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Intervention Review

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Prophylactic antibiotics for penetrating abdominal trauma

  1. Martin Brand1,*,
  2. Jacque Goosen2,
  3. Andrew Grieve3

Editorial Group: Cochrane Injuries Group

Published Online: 7 OCT 2009

Assessed as up-to-date: 13 JAN 2009

DOI: 10.1002/14651858.CD007370.pub2


How to Cite

Brand M, Goosen J, Grieve A. Prophylactic antibiotics for penetrating abdominal trauma. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD007370. DOI: 10.1002/14651858.CD007370.pub2.

Author Information

  1. 1

    Melville, South Africa

  2. 2

    University of the Witwatersrand, Trauma Surgery, Johannesburg, Gauteng, South Africa

  3. 3

    University of the Witwatersrand, General Surgery/Trauma Unit, Johannesburg, Gauteng, South Africa

*Martin Brand, PO Box 291429, Melville, 2109, South Africa. martinbrand78@gmail.com.

Publication History

  1. Publication Status: New
  2. Published Online: 7 OCT 2009

SEARCH

This is not the most recent version of the article. View current version (18 NOV 2013)

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

Penetrating abdominal trauma occurs when the peritoneal cavity is breached. Routine laparotomy for penetrating abdominal injuries began in the 1800s, but the discovery of penicillin in 1928 by Alexander Fleming allowed antibiotics to be used in the second World War to combat septic complications (Poole 1944). This practice was marked by a reduction in sepsis related mortality and morbidity. This was later ratified during the Korean war when casualties were given prophylactic antibiotics while awaiting transfer to hospital for further management (Scott 1954). Whether prophylactic antibiotics are required in the prevention of infective complications following penetrating abdominal trauma today is controversial as no randomised, placebo controlled trials have been published to date. Now, with the use of new sterilisation techniques for both surgical instruments and surgical field, and a change in thinking with regard to hollow viscus perforation management, there may be a shift in the need for antibiotic usage in penetrating abdominal trauma.

There has also been debate about the timing of antibiotic prophylaxis. In 1972 Fullen noted a 7% to 11% post-surgical infection rate with pre-operative antibiotics, a 33% to 57% infection rate with intra-operative antibiotic administration and a 30% to 70% infection rate with only post-operative antibiotic administration (Fullen 1972). According to current guidelines there is sufficient class I evidence to support the use of a single pre-operative broad spectrum antibiotic dose with aerobic and anaerobic cover (Thadepalli 1972; Thadepalli 1973), with continuation (up to 24 hours) only in the event of a hollow viscus perforation found at exploratory laparotomy (Luchette 2000).

The aim of this review was to assess the benefits or harms of prophylactic antibiotics administered for penetrating abdominal injuries in terms of reducing the incidence of septic complications, such as septicaemia, intra-abdominal abscesses and wound infections.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

To assess whether there was a reduction in the incidence of infective complications following the administration of prophylactic antibiotics in penetrating abdominal trauma (wounds that enter the peritoneal cavity).

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms
 

Criteria for considering studies for this review

 

Types of studies

Randomised controlled trials.

 

Types of participants

Patients who had an isolated penetrating abdominal wound, were not on antibiotics, and had no evidence of intra-abdominal sepsis or any other focus of infection.

 

Types of interventions

  • Prophylactic antibiotic administration at the time of presentation to the emergency department, or perioperatively.
  • Placebo or no antibiotic.

Trials would have been included regardless of the type, dose or route of administration of the antibiotic(s).

 

Types of outcome measures

 

Primary outcomes

  • Septic complications, including intra-abdominal abscesses and wound infections.

 

Secondary outcomes

  • Mortality.
  • Septicaemia.

 

Search methods for identification of studies

Searches were not restricted by date, language or publication status.

We searched the following electronic bibliographic databases:

Cochrane Injuries Group Specialised Register (searched 3 Sept 2008),
CENTRAL (The Cochrane Library 2008 Issue 3),
MEDLINE (Ovid) (1954 to Aug (week 3) 2008),
EMBASE (Ovid) (1980 to Sept 2008),
ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to Sept 2008),
ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) (1990 to Sept 2008),
PubMed (searched 4 Sept 2008: limited to last 180 days).

We also checked the reference lists of all relevant studies and reviews.

The search strategy can be found in Appendix 1.

 

Data collection and analysis

 

Selection of studies

A total of 741 references were retrieved by the search. MAB and ANG independently screened the search results to identify relevant trials. None of the references found met the inclusion criteria. We also screened the reference lists of all relevant material. No trials were identified for inclusion in the review.

 

Data extraction and management

Had suitable studies been found, MAB and ANG would have independently extracted the following data from identified trials:

  • year and language of publication;
  • year of study;
  • inclusion and exclusion criteria;
  • sample size;
  • mechanism of injury;
  • type, dose and route of prophylactic antibiotic; and
  • incidence of complications.

 

Assessment of risk of bias in included studies

MAB and ANG would have assessed the risk of bias of each trial independently. MAB and ANG would have recorded whether or not the trial authors performed their analysis using an intention-to-treat method. We would have clarified any unclear or missing information through contact with the trial report authors. We would have resolved differences in opinion between the review authors during extraction of data through discussion. JAG was to have served as arbitrator, should differences in opinion have persisted.

MAB and ANG would have assessed the risk of bias of the trials independently, without masking trial names. The review authors would have followed the instructions given in the Cochrane Handbook for Systematic Reviews of Interventions (Handbook 2008). Due to the risk of biased overestimation of intervention effects in randomised trials that are of inadequate methodological quality (Kjaergard 2001; Moher 1998; Schulz 1995), the review authors would have looked at the influence of the methodological quality of the trials on the results by evaluating the reported randomisation and follow-up procedures in each trial. Where information was not available in the published trial reports, MAB and ANG would have contacted the authors in order to assess the trials correctly.

The review authors would have assessed generation of allocation sequence, allocation concealment, blinding and follow up. We would have presented this information in the 'Risk of bias' table in the review.

 

Allocation concealment

We would have judged allocation concealment as follows.

  • Adequate: if performed by means of centralised or pre-numbered containers administered serially to patients, or an on-site computer with allocations in a locked unreadable file, or sequentially-numbered, sealed, opaque envelopes.
  • Unclear: if the trial is described as randomised, but the trial report fails to describe the method of allocation concealment.
  • Inadequate: if a completely transparent procedure was used, e.g. case record numbers, dates of birth, or an open list of random numbers.

 

Allocation sequence generation

We would have judged allocation sequence generation as follows.

  • Adequate: if a computer-generated or random-number table was used.
  • Unclear: if the trial is described as randomised, but the trial report fails to describe the method of allocation sequence.
  • Inadequate: if patients were allocated according to names, dates, admittance numbers, etc. Trials using these methods are known as quasi-randomised trials, and would have been excluded from the review.

 

Blinding

We would have judged blinding as follows.

  • Adequate: if the trial was described as double blind, and the method of blinding was described.
  • Unclear: if the trial was described as double blind, but the method of blinding was not described.
  • Not performed: if the trial was not double blind.

 

Follow up

We would have judged follow up as follows.

  • Adequate: if the numbers and reasons for drop-outs and withdrawals in all intervention groups were described, or if it was specified that there were no drop-outs or withdrawals.
  • Unclear: if the trial report gave the impression that there had been no drop-outs or withdrawals, but this was not specifically stated.
  • Inadequate: if the numbers or reasons for drop-outs and withdrawals were not described.

MAB and ANG would have recorded sample sizes and durations of follow up.

The authors would have used a funnel plot to explore bias (Macaskill 2001). We would have performed the linear regression approach described by Egger et al to determine funnel plot asymmetry (Egger 1997).

 

Measures of treatment effect

We would have analysed dichotomous data for relative risk (RR) and odds ratio (OR), and measured the absolute effects with risk differences (RD). We would have calculated confidence intervals (CIs) at 95% for these measures of effect. We would also have considered treatment effect by intention-to-treat analysis, using available case analysis and analysis by imputation. We would not have used the Mantel-Haenszel method for the meta-analysis (Greenland 1985; Mantel 1959). We would have presented results as a forest plot. We would have used the Cochrane Collaboration's Review Manager software for data analysis (Review Manager 2008).

 

Subgroup analysis and investigation of heterogeneity

We would have tested statistical heterogeneity using the I2 test (Higgins 2002) and the Chi2 test, with a P value of 0.10 representing statistical significance. If heterogeneity was identified, we would have considered performing subgroup analyses. Subgroups that would then have been considered include: injury severity scores, time to surgical intervention, organs injured, different antibiotics and trials with a low risk of bias (adequate generation of allocation sequence, allocation concealment, blinding and follow up) compared to trials with a high risk of bias (one or more of the four components of methodological quality judged as being inadequate or unclear). If the results in the fixed-effect and random-effects models did not differ, we would have reported the fixed-effect model. Otherwise, we would have reported the results of both models.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms
 

Description of studies

The search resulted in 561 potentially relevant references. There were no randomised controlled trials that fulfilled our inclusion criteria.

 

Risk of bias in included studies

We included no trials in this review.

 

Effects of interventions

There were no trials included in this review.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

Since the discovery of penicillin in 1928 there has been a marked reduction in post-operative septic complications. This is especially true during war situations with prolonged extraction times, and delay to surgical intervention (Scott 1954). Antibiotics were introduced in the trauma setting almost 100 years ago (Poole 1944) with little thought as to their appropriate use. Improved surgical technique and equipment, together with surgical site preparation, post-operative care and the concept of expedient management has resulted in further improvement in mortality and morbidity figures.

We asked the question of whether or not we should be using prophylactic antibiotics with penetrating abdominal trauma, however we were not able to include any studies in this review, and thus cannot draw any conclusions which answer this question.

This review has illustrated the fact that prophylactic antibiotic guidelines for penetrating abdominal trauma are based on expert opinion rather than firm evidence.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

 

Implications for practice

There is no evidence upon which to base the use of prophylactic antibiotics in patients with penetrating abdominal injury.

 
Implications for research

With the emergence of multiple-drug resistant organisms the use of antibiotics should be carefully considered. A placebo controlled, randomised, double blind study is required to illicit which patients, if any, would benefit from antibiotic prophylaxis in penetrating abdominal trauma.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

To the Cochrane Injuries Group for editorial support.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

This review has no analyses.

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms
 

Appendix 1. Search strategy

Cochrane Injuries Group Specialised Register (searched 3 Sept 2008)
(abdominal or abdomen or thorax or thoracic or splenic or spleen or stomach or gastric) and (injur* or trauma* or perforat* or penetrat* or rupture or burst* or stab* or gunshot or shot or wound*) and (Antibiotic or Prophylaxis or Gentamicin* or Cefazolin* or prophylactic* or premedication* or Cefazolin or cephazolin or cefamezine or cephamezine or ancef or cefamedin or gramaxin or kefzol or totacef or Tazobactam or piperacillin or tazocin or Gentamicin* or gentamycin* or gemyticin or gimyticin or gentacycol or gentavet or genticin or garamycin* or "co-amoxiclavulanic acid" or augmentin)

CENTRAL (The Cochrane Library 2008 Issue 3)
#1 MeSH descriptor Abdominal Injuries explode all trees
#2 MeSH descriptor Thoracic Injuries explode all trees
#3 (abdominal or abdomen or thorax or thoracic) near3 (injur* or trauma* or perforat* or penetrat*)
#4 (splenic or spleen) near3 rupture*
#5 (stomach or gastric) near3 (rupture or perforation or injur* or burst*)
#6 (stab* or gunshot or shot or penetrat* wound*) near3 (abdomen* or abdominal or stomach or splenic or spleen or thorax or thoracic)
#7 MeSH descriptor Wounds, Stab explode all trees
#8 MeSH descriptor Wounds, Gunshot explode all trees
#9 MeSH descriptor Rupture explode all trees
#10 abdomen* or abdominal or stomach or splenic or spleen or thorax or thoracic
#11 (#7 OR #8 OR #9)
#12 (#10 AND #11)
#13 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #12)
#14 MeSH descriptor Antibiotic Prophylaxis explode all trees
#15 MeSH descriptor Gentamicins explode all trees
#16 MeSH descriptor Cefazolin explode all trees
#17 (antibiotic*) near5 (prophylaxis or prophylactic* or remedication*)
#18 Cefazolin or cephazolin or cefamezine or cephamezine or ancef or cefamedin or gramaxin or kefzol or totacef or Tazobactam piperacillin or tazocin or Gentamicin* or gentamycin* or g-myticin or gmyticin or gentacycol or gentavet or genticin or garamycin* or co-amoxiclavulanic acid* or augmentin
#19 (#14 OR #15 OR #16 OR #17 OR #18)
#20 (#13 AND #19)

MEDLINE (Ovid) (1954 to Aug (week 3) 2008)
1.exp Abdominal Injuries/
2.exp Thoracic Injuries/
3.((abdominal or abdomen or thorax or thoracic) adj3 (injur* or trauma* or perforat* or penetrat*)).ab,ti.
4.((splenic or spleen) adj3 rupture*).ab,ti.
5.((stomach or gastric) adj3 (rupture or perforation or injur* or burst*)).ab,ti.
6.((stab* or gunshot or shot or penetrat* wound*) adj3 (abdomen* or abdominal or stomach or splenic or spleen or thorax or thoracic)).ab,ti.
7.exp Wounds, Stab/
8.exp Wounds, Gunshot/
9.exp Rupture/
10.7 or 8 or 9
11.(abdomen* or abdominal or stomach or splenic or spleen or thorax or thoracic).ti,ab.
12.10 and 11
13.1 or 2 or 3 or 4 or 5 or 6 or 12
14.exp Antibiotic Prophylaxis/
15.exp Gentamicins/
16.exp Cefazolin/
17.(antibiotic* adj5 (prophylaxis or prophylactic* or premedication*)).ab,ti.
18.(Cefazolin or cephazolin or cefamezine or cephamezine or ancef or cefamedin or gramaxin or kefzol or totacef or Tazobactam piperacillin or tazocin or Gentamicin* or gentamycin* or g?myticin or gmyticin or gentacycol or gentavet or genticin or garamycin* or co?amoxiclavulanic acid* or augmentin).ab,ti.
19.14 or 15 or 16 or 17 or 18
20.13 and 19
21.(randomised or randomized or randomly or random order or random sequence or random allocation or randomly allocated or at random or controlled clinical trial$).tw,hw.
22.clinical trial.pt.
23.randomized controlled trial.pt.
24.randomized controlled trial.pt.
25.controlled clinical trial.pt.
26.placebo.ab.
27.clinical trials as topic.sh.
28.trial.ti.
29.21 or 22 or 23 or 24 or 25 or 26 or 27 or 28
30.humans.sh.
31.29 and 30
32.20 and 31

EMBASE (Ovid) (1980 to 4 September 2008)
1.exp Abdominal Injury/
2.exp bite wound/ or exp gunshot injury/ or exp knife cut/ or exp missile wound/ or exp stab wound/
3.(abdomen* or abdominal or stomach or splenic or spleen or thorax or thoracic).ti,ab.
4.2 and 3
5.exp spleen rupture/ or exp aorta rupture/ or exp liver rupture/ or exp stomach rupture/ or exp thorax organ rupture/ or exp urogenital tract rupture/ or exp diaphragm injury/ or exp thorax penetrating trauma/
6.1 or 4 or 5
7.((abdominal or abdomen or thorax or thoracic) adj3 (injur* or trauma* or perforat* or penetrat*)).ab,ti.
8.((splenic or spleen) adj3 rupture*).ab,ti.
9.((stomach or gastric) adj3 (rupture or perforation or injur* or burst*)).ab,ti.
10.((stab* or gunshot or shot or penetrat* wound*) adj3 (abdomen* or abdominal or stomach or splenic or spleen or thorax or thoracic)).ab,ti.
11.6 or 7 or 8 or 9 or 10
12.exp Antibiotic Prophylaxis/
13.exp Gentamicin/
14.exp Cefazolin/
15.(antibiotic* adj5 (prophylaxis or prophylactic* or premedication*)).ab,ti.
16.(Cefazolin or cephazolin or cefamezine or cephamezine or ancef or cefamedin or gramaxin or kefzol or totacef or Tazobactam piperacillin or tazocin or Gentamicin* or gentamycin* or g?myticin or gmyticin or gentacycol or gentavet or genticin or garamycin* or co?amoxiclavulanic acid* or augmentin).ab,ti.
17.12 or 13 or 14 or 15 or 16
18.11 and 17
19.exp animal model/
20.Animal Experiment/
21.exp ANIMAL/
22.exp Experimental Animal/
23.19 or 20 or 21 or 22
24.Human/
25.23 not 24
26.(randomised or randomized or randomly or random order or random sequence or random allocation or randomly allocated or at random or controlled clinical trial* or placebo).tw,hw.
27.exp clinical trial/
28.exp Randomized Controlled Trial/
29.26 or 27 or 28
30.29 not 25
31.18 and 30

ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to Sept 2008),
ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) (1990 to Sept 2008)

1.Topic=(abdominal or abdomen or thorax or thoracic or splenic or spleen or stomach or gastric)
2.Topic=(injur* or trauma* or perforat* or penetrat* or rupture or burst* or stab* or gunshot or shot or penetrat* wound*)
3.Topic=(Antibiotic or Prophylaxis or Gentamicin* or Cefazolin* or prophylactic* or premedication* or Cefazolin or cephazolin or cefamezine or cephamezine or ancef or cefamedin or gramaxin or kefzol or totacef or Tazobactam piperacillin or tazocin or Gentamicin* or gentamycin* or gemyticin or gimyticin or gentacycol or gentavet or genticin or garamycin* or co-amoxiclavulanic acid* or augmentin)
4.Topic=(randomised or randomized or randomly or random order or random sequence or random allocation or randomly allocated or at random or placebo) OR Title=(trial or controlled)
5.1 and 2 and 3 and 4

PubMed (searched 4 Sept 2008: limited to last 180 days)
1.(abdominal OR abdomen OR thorax OR thoracic OR splenic OR spleen OR stomach OR gastric) AND (injur* OR trauma OR traumatic OR perforat* OR penetrat* OR rupture OR burst* OR stab OR stabbed OR stabbing* OR gunshot OR shot OR wound*) AND (Antibiotic OR Prophylaxis OR Gentamicin* OR Cefazolin* OR prophylactic* OR premedication* OR Cefazolin OR cephazolin OR cefamezine OR cephamezine OR ancef OR cefamedin OR gramaxin OR kefzol OR totacef OR Tazobactam OR piperacillin OR tazocin OR Gentamicin* OR gentamycin* OR gemyticin OR gimyticin OR gentacycol OR gentavet OR genticin OR garamycin* OR "co-amoxiclavulanic acid" OR augmentin)
2.randomised OR randomized OR randomly OR random order OR random sequence OR random allocation OR randomly allocated OR at random OR placebo Field: Title/Abstract
3.trial OR controlled Field: Title

 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

Protocol first published: Issue 4, 2008
Review first published: Issue 4, 2009

 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

MAB and ANG independently collected the referenced studies. MAB and ANG analysed studies for inclusion independently. MAB and ANG met to discuss the results, and any discrepancies were mediated by JAG. MAB wrote the initial manuscript, which was ratified by ANG and JAG. JAG supervised the review process.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Index terms

None known.

References

Additional references

  1. Top of page
  2. Abstract摘要
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Additional references
Egger 1997
  • Egger M, Davey SA, Schneider M, Minder C. Bias in a meta-analysis detected by a simple, graphical test. BMJ (Clinical Research Edition) 1997;315(7109):629-34.
Fullen 1972
Greenland 1985
Handbook 2008
  • Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions. Version 5.0.1 [updated September 2008]. The Cochrane Collaboration, 2008. Available from www.cochrane-handbook.org.
Higgins 2002
Kjaergard 2001
  • Kjaergard LL, Villumsen J, Gluud C. Reported methodological quality and discrepancies between large and small randomised trials in meta-analyses. Annals of Internal Medicine 2001;135:982-9.
Luchette 2000
  • Luchette FA, Borzotta AP, Croce MA, O'Neill PA, Whittmann DH, Mullins CD, et al. Practice management guidelines for prophylactic antibiotic use in penetrating abdominal trauma: the EAST Practice Management Guidelines Work Group. Journal of Trauma 2000;48(3):508-18.
Macaskill 2001
Mantel 1959
Moher 1998
Poole 1944
  • Poole LT. Army progress with penicillin. British Journal of Surgery 1944;32:110-1.
    Direct Link:
Review Manager 2008
  • The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). 5.0 for Windows. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2008.
Schulz 1995
  • Schulz KF, Chalmers I, Hayers RJ, Altman DG. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273:408-12.
Scott 1954
  • Scott R. Care of the battle casualty in advance of the aid station. Walter Reed Army Medical Centre Conference on recent advances in medicine and surgery. 19 April 1954.
Thadepalli 1972
  • Thadepalli H, Gorbach SL, Broido P, Norsen J. A prospective study of infections in penetrating abdominal trauma. American Journal of Clinical Nutrition 1972;25(12):1405-8.
Thadepalli 1973