The grades of evidence (I-III) and levels of recommendations (I-III) are defined at the end of the "Major Recommendations" field.
Level I
There are insufficient data to support a Level I recommendation for this topic.
Level II
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.
Level III
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.
Summary
Good clinical practice recommends that ventriculostomies and other intracranial pressure (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 cerebrospinal fluid (CSF) infections.
There is no support for use of prolonged antibiotics for systemic prophylaxis in intubated traumatic brain injury (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.
Definitions:
Grades of Evidence
Class I - Good quality randomized controlled trial (RCT)
Class II - Moderate quality RCT, good quality cohort, good quality, or case-control
Class III - Poor quality RCT; moderate or poor quality cohort; moderate or poor case-control; case series, databases or registries
Levels of Recommendation
Levels of recommendation are Level I, II, and III, derived from Class I, II, and III evidence, respectively.
Level I - recommendations are based on the strongest evidence for effectiveness, and represent principles of patient management that reflect a high degree of clinical certainty.
Level II - recommendations reflect a moderate degree of clinical certainty.
Level III - recommendations for which the degree of clinical certainty is not established.