There are insufficient data to support a Level I recommendation for this topic.

Periprocedural antibiotics for intubation should be administered to reduce the incidence of pneumonia. However, it does not change length of stay or mortality.

Early tracheostomy should be performed to reduce mechanical ventilation days. However, it does not alter mortality or the rate of nosocomial pneumonia.

Routine ventricular catheter exchange or prophylactic antibiotic use for ventricular catheter placement is not recommended to reduce infection.

Early extubation in qualified patients can be done without increased risk of pneumonia.

In severe traumatic brain injury (TBI) patients, the incidence of infection is increased with mechanical ventilation and invasive monitoring techniques. Infections contribute to morbidity, mortality, and increased hospital length of stay. For example, as many as 70% of mechanically ventilated patients can develop pneumonia and ICP monitoring infection rates can be as high as 27%. While there is no current evidence that short-term use of ICP monitors leads to increased morbidity and mortality, health care costs can increase with device reinsertion and administration of antibiotics. Infection prophylaxis for TBI can be divided into several aspects of care, including external ventricular drainage (EVD) and other ICP monitoring devices, and prophylaxis to prevent nosocomial systemic infections.

For this new topic, Medline was searched from 1966 through April of 2006 (see Appendix B for search strategy). A second search was conducted using the key words tracheostomy and TBI. Results were supplemented with literature recommended by peers or identified from reference lists. Of 54 potentially relevant studies, 7 were included as evidence for this topic (Evidence Tables I and II).

The incidence of infection for ICP devices is reported to be 1%-27%, but this incidence also depends upon the method of ascertaining infection. Ventriculostomy colonization is easier to detect because of CSF sampling. Few studies have actually sent ICP devices for culture after usage. When ICP device bacterial colonization is compared, ventricular (by CSF culturing) has an average infection rate of 8% and parenchymal (by culturing the device tip) has an infection rate of 14%. Several factors have been identified that may affect the risk of EVD infection: duration of monitoring; use of prophylactic parenteral antibiotics; presence of concurrent other systemic infections; presence of intraventricular or subarachnoid hemorrhage; open skull fracture, including basilar skull fractures with CSF leak; leakage around the ventriculostomy catheter; and flushing of the ventriculostomy tubing.

In studies of patients with neurological processes other than or including TBI, contradictory results were found when analyzing infection risk factors for EVD. Mayhall et al. published a sentinel, prospective, observational study of 172 patients with 213 ventriculostomies. The authors found that the cumulative infection risk increased if monitoring duration exceeded five days. However, no increased infection risk was noted if patients had multiple catheters, leading to the conclusion that routine, prophylactic catheter exchanges at 5 days would potentially lower the overall infection rate. Winfield et al. challenged the analysis of cumulative risk in terms of infection and catheter duration. In 184 monitors over a 12-year period, they found the daily infection rate to be less than 2% through the monitoring period. No correlation was noted between daily infection rate and monitoring duration. Age, hospital site of monitor placement, and diagnosis (trauma vs. non-trauma) had no effect on infection rate. The authors concluded that prophylactic catheter exchange was not substantiated.

In a cohort of 584 severe TBI patients, Holloway et al reevaluated the EVD infection rate and monitoring duration at the same institution as Mayhall. The authors included patients from the multi-centered Traumatic Coma Data Bank. They found that the risk of EVD infections rose over the first 10 days, but, thereafter, decreased significantly. There was no difference in the infection rate in patients who had catheter exchange prior to or after 5-day intervals, concluding that routine catheter exchange offered no benefit. EVD infection was positively associated with systemic infection and ventricular hemorrhage.

Good clinical practice recommends that ventriculostomies and other ICP monitors should be placed under sterile conditions to closed drainage systems, minimizing manipulation and flushing. There is no support for routine catheter exchanges as a means of preventing CSF infections.

There is no support for use of prolonged antibiotics for systemic prophylaxis in intubated TBI patients, given the risk of selecting for resistant organisms. However, a single study supports the use of a short course of antibiotics at the time of intubation to reduce the incidence of pneumonia. Early tracheostomy or extubation in severe TBI patients have not been shown to alter the rates of pneumonia, but the former may reduce the duration of mechanical ventilation.

There is a lack of RCTs with sufficient numbers of TBI patients to study the effect of prophylactic antibiotics for external ventricular drains and other ICP devices. Due to the preponderance of Class III evidence and continued clinical uncertainty, such trials, including those with antibiotic impregnated catheters, would be both ethical and useful.