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Karp MC, April MD, Newberry RK, Schauer SG. Associations with Prehospital Antibiotic Receipt among Combat Casualties with Open Wounds: A Department of Defense Trauma Registry Study. Mil Med 2024; 189:e606-e611. [PMID: 37647617 DOI: 10.1093/milmed/usad323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 07/24/2023] [Accepted: 08/03/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Current Tactical Combat Casualty Care (TCCC) guidelines recommend antibiotic administration for all open wounds to prevent infection. We identified associations between demographics, procedures, and medicines with the receipt of prehospital antibiotics among combat casualties. MATERIALS AND METHODS We used a series of emergency department procedure codes to identify adult subjects within the Department of Defense Trauma Registry from January 2007 to August 2016 who sustained open wounds. We compared demographics, procedures, and medicines administered among casualties receiving prehospital wound prophylaxis versus casualties not receiving antibiotic prophylaxis. We controlled for confounders with multivariable logistical regression. RESULTS We identified 18,366 encounters meeting inclusion criteria. Antibiotic recipients (n = 2384) were comparable to nonrecipients (n = 15,982) with regard to age and sex. Antibiotic recipients were more likely to sustain injuries from firearms and undergo all procedures examined related to hemorrhage control, airway management, pneumothorax treatment, and volume replacement except for intraosseous access. Antibiotic recipients were less likely to sustain injuries from explosives. Antibiotic recipients had a modestly higher survival than nonrecipients (97.4% versus 96.0%). Associations with prehospital antibiotic receipt in multivariable logistic regression included non-North Atlantic Treaty Organization military force affiliation (odds ratio (OR) 4.65, 95% CI, 1.0-20.8), tachycardia (OR 3.4, 95% CI, 1.1-10.5), intubation (OR 2.0, 95% CI, 1.1-3.8), and administration of tranexamic acid (OR 5.6, 95% CI, 1.2-26.5). CONCLUSIONS The proportion of combat casualties with open wounds receiving prehospital antibiotics was low despite published recommendations for early antibiotics in patients with open wounds. These findings highlight the ongoing need for additional educational and quality assurance initiatives to continue improving adherence to TCCC guidelines with regard to prehospital antibiotic administration. Future studies are necessary to determine reasons for suboptimal TCCC guideline compliance.
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Affiliation(s)
- Marissa C Karp
- Adjutant General Captains Career Course, Fort Jackson, SC 29207, USA
| | - Michael D April
- 14th Field Hospital, Fort Stewart, GA, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Ryan K Newberry
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Steven G Schauer
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Departments of Anesthesiology and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado 80045, USA
- Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, Colorado 80045, USA
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Baumgartner H, Schüll D, Kolbenschlag J, Mederake M. [Reconstruction of posttraumatic deformities and defects]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:738-745. [PMID: 37606652 DOI: 10.1007/s00132-023-04422-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/10/2023] [Indexed: 08/23/2023]
Abstract
The reconstruction of posttraumatic defects of bone and soft tissue, as well as residual deformities of the bone is often a lengthy and complicated procedure. Multiple surgical interventions are necessary to reconstruct the affected extremity and restore its functionality. To achieve an optimal result it often takes months or years and requires great patience and compliance of the patient. This treatment should be carried out in centers with the appropriate instrumental and human resources. Since the pathologies are often complex with bony deformities or loss of bone, as well as infections and soft tissue defects, the treatment should be carried out by very experienced surgeons to successfully manage these complex reconstructions. This often requires interdisciplinary cooperation, especially with experienced plastic surgeons. A soft tissue reconstruction for better blood circulation in the exposed bony structures, as well as the bony defects themselves, can be reconstructed at the same time.
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Affiliation(s)
- Heiko Baumgartner
- BG Unfallklinik Tübingen, Klinik für Unfall- und Wiederherstellungschirurgie, Eberhard-Karls-Universität Tübingen, Tübingen, Deutschland
| | - Daniel Schüll
- BG Unfallklinik Tübingen, Klinik für Unfall- und Wiederherstellungschirurgie, Eberhard-Karls-Universität Tübingen, Tübingen, Deutschland.
- BG Klinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland.
| | - Jonas Kolbenschlag
- BG Unfallklinik Tübingen, Klinik für Hand‑, Plastische, Rekonstruktive und Verbrennungschirurgie, Eberhard-Karls-Universität Tübingen, Tübingen, Deutschland
| | - Moritz Mederake
- BG Unfallklinik Tübingen, Klinik für Unfall- und Wiederherstellungschirurgie, Eberhard-Karls-Universität Tübingen, Tübingen, Deutschland
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Buckman SA, Forrester JD, Bessoff KE, Parli SE, Evans HL, Huston JM. Surgical Infection Society Guidelines: 2022 Updated Guidelines for Antibiotic Use in Open Extremity Fractures. Surg Infect (Larchmt) 2022; 23:817-828. [DOI: 10.1089/sur.2022.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Sara A. Buckman
- Division of Acute and Critical Care Surgery, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Joseph D. Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Kovi E. Bessoff
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Sara E. Parli
- Department of Pharmacy Services, University of Kentucky, Lexington, Kentucky, USA
| | - Heather L. Evans
- Division of General and Acute Care Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jared M. Huston
- Departments of Surgery and Science Education, Zucker School of Medicine, Northwell Health, Manhasset, New York, USA
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Kobata SI, Teixeira LEM, Fernandes SOA, Faraco AAG, Vidigal PVT, Araújo IDD. Prevention of bone infection after open fracture using a chitosan with ciprofloxacin implant in animal model. Acta Cir Bras 2020; 35:e202000803. [PMID: 32901680 PMCID: PMC7478494 DOI: 10.1590/s0102-865020200080000003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/06/2020] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To evaluate different concentrations of ciprofloxacin to prevent infection after open fracture contaminated with S. aureus in rats using absorbable local delivery system. METHODS Fifty-two Wistar rats were assigned to six groups. After 4 weeks, all animals underwent 99mTc-ceftizoxima scintigraphy evaluation, callus formation measurement and histological analysis. ANOVA, t-Student and Kruskal Wallis were used for quantitative variables statistical analysis, whereas qui square and exact Fisher were used for qualitative variables. RESULTS Treatment using 25% and 50% of ciprofloxacin incorporated at the fracture fixation device were effective in preventing bone infection compared to control group (p<0.05). Chitosan were not effective in preventing bone infection when used alone compared to control group (p>0.05). Histological findings demonstrated bone-healing delay with 50% of ciprofloxacin. No difference in callus formation were observed (p>0.05). CONCLUSION Local delivery treatment for contaminated open fracture using chitosan with ciprofloxacin is effective above 25%.
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Willy C, Stichling M, Müller M, Gatzer R, Kramer A, Back DA, Vogt D. [Acute therapeutic measures for limb salvage Part 2 : Debridement, lavage techniques and anti-infectious strategies]. Unfallchirurg 2017; 119:388-99. [PMID: 27160730 DOI: 10.1007/s00113-016-0178-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The quality of the primary care of Gustilo-Anderson (GA) type IIIB and IIIC extremity injuries is crucial to the success of the limb salvage procedure. This article provides a compilation of consistent, but often controversially discussed aspects of initial debridement, modern techniques of lavage and wound closure, in addition to current issues on the application of antibiotics and antiseptics, based on our own experiences and the latest literature. The following points should be stressed. Severe extremity injuries with gross contamination (GA IIIA, B, and C) will still be associated with an infection rate of up to 60 %. The initial debridement should be performed as soon as an experienced trauma surgeon is available. Tissue that is definitely avital will have to be removed, whereas traumatized but potentially surviving tissue will have to be re-evaluated during a second-look operation after 36-48 h. Given a high enough level of contamination, biofilms will form after as few as 6 h. The perioperative antibiotic prophylaxis has to be initiated early and should be continued for at least 24 h (GA I/II) or up to 5 days (GA III). In cases of bacterial contamination, wound irrigation will be useful with additives such as polyhexanide, octenidine or superoxidized water. Rinsing of the wound should be performed with 3-9 L and only slight manual pressure (no jet lavage). The definitive primary closure of a wound should be achieved in the initial operation, but only in the case of certain "decontamination" and overall vitality of the wound (GA I and II). In the presence of high-grade injuries, a temporary vacuum sealing technique can be used until the earliest possible definitive plastic surgical wound closure.
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Affiliation(s)
- C Willy
- Abteilung Unfallchirurgie und Orthopädie, Septisch-Rekonstruktive Chirurgie, Forschungs- und Behandlungszentrum Rekonstruktion von Defektwunden, Exzellenz-Zentrum zur Versorgung von Verwundeten aus Kriegs- und Krisengebieten, Bundeswehrkrankenhaus Berlin, Scharnhorststr. 13, 10115, Berlin, Deutschland.
| | - M Stichling
- Sektion Gefäß- und Thoraxchirurgie der Abteilung Unfallchirurgie und Orthopädie, Septisch-Rekonstruktive Chirurgie, Bundeswehrkrankenhaus Berlin, Scharnhorststr. 13, 10115, Berlin, Deutschland
| | - M Müller
- Abteilung I/Laborgruppe Med. Mikrobiologie, Zentrales Institut des Sanitätsdienstes, der Bundeswehr Kiel/Berlin, Berlin, Deutschland
| | - R Gatzer
- Abteilung I/Laborgruppe Med. Mikrobiologie, Zentrales Institut des Sanitätsdienstes, der Bundeswehr Kiel/Berlin, Berlin, Deutschland
| | - A Kramer
- Institut für Hygiene und Umweltmedizin, Universitätsmedizin Greifswald, Greifswald, Deutschland
| | - D A Back
- Abteilung Allgemein- und Viszeralchirurgie, Bundeswehrkrankenhaus Berlin, Scharnhorststr. 13, 10115, Berlin, Deutschland
| | - D Vogt
- Abteilung Unfallchirurgie und Orthopädie, Septisch-Rekonstruktive Chirurgie, Forschungs- und Behandlungszentrum Rekonstruktion von Defektwunden, Exzellenz-Zentrum zur Versorgung von Verwundeten aus Kriegs- und Krisengebieten, Bundeswehrkrankenhaus Berlin, Scharnhorststr. 13, 10115, Berlin, Deutschland
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A Descriptive Study of Open Fractures Contaminated by Seawater: Infection, Pathogens, and Antibiotic Resistance. BIOMED RESEARCH INTERNATIONAL 2017; 2017:2796054. [PMID: 28303249 PMCID: PMC5337837 DOI: 10.1155/2017/2796054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 01/31/2017] [Indexed: 01/21/2023]
Abstract
Aims. In this work, the main objectives were to investigate the clinical characteristics and bacterial spectrum present in open fractures contaminated by seawater. Methods. We conducted a retrospective cohort study and included all patients with open fractures from 1st January, 2012, to 31st December, 2015, in our hospital. Patients were grouped based on the presence of seawater contamination in wounds. We compared the infection rate, bacterial spectrum, and antibiotic resistance between the two groups. Results. We totally included 1337 cases of open fracture. Wounds from 107 cases (8.0%) were contaminated by seawater. The wound infection rate of seawater-contaminated group was significantly higher in patients with Gustilo-Anderson Type II and Type III open fractures. The bacterial spectrum from seawater-contaminated wounds was remarkably different from that of the remaining. Antibiotic sensitivity tests revealed that more than 90% of infecting pathogens in seawater-contaminated wounds were sensitive to levofloxacin and ciprofloxacin. Conclusion. Cephalosporin in combination with quinolone was recommended in the early-stage management of open fractures contaminated by seawater.
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Otchwemah R, Grams V, Tjardes T, Shafizadeh S, Bäthis H, Maegele M, Messler S, Bouillon B, Probst C. Bacterial contamination of open fractures - pathogens, antibiotic resistances and therapeutic regimes in four hospitals of the trauma network Cologne, Germany. Injury 2015; 46 Suppl 4:S104-8. [PMID: 26542854 DOI: 10.1016/s0020-1383(15)30027-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The bacterial contamination of soft tissues and bone in open fractures leads to an infection rate of up to 50%. Pathogens and their resistance against therapeutic agents change with time and vary in different regions. In this work, our aims were to characterize the bacterial spectrum present in open fractures, analyze the bacterial resistance to antibiotic agents and question the EAST guideline recommendations for antibiotic prophylaxis after open fractures in a German Trauma Network. MATERIALS AND METHODS We conducted a retrospective cohort study and included all patients with open fractures from 1(st) of January 2011 until the 31(st) of December 2014 in four hospitals of the trauma network cologne. Soft tissue damage was classified according to the Gustilo Anderson classification. RESULTS We included 123 patients. Forty-five injuries (37%) were classified I°, 45 (37%) as II° and 33 (27%) as III°. Lower leg (34%) was the most commonly injured location. An antibiotic prophylaxis was administered to 109 patients (89%). In 107 of them (98%) a cephalosporin or cephalosporin combination was given. In 35 of the patients (28%), microbiological samples were taken of the fracture site. Wound cultures were positive in 21 patients (60%). Fifty percent of the bacterial detections occurred in III° fractures. Coagulase negative Staphylococci (COST) were the most frequent pathogens. In II° open fractures one gram-negative strain was isolated. Fewest resistances were seen against quinolones and co-trimoxazole. DISCUSSION The recommended EAST guideline prophylaxis would have covered all but one bacterium (97% of positive cultures). One Escherichia coli was found in a II° open fracture and would have been missed. One of the isolated Staphylococci epidermidis and an Enterococcus faecium were resistant against gentamycin and first- and second-generation-cephalosporin's which were used as prophylaxis frequently. However, a regional adaption of the EAST guidelines seems not justified due to the rather low number of cases in our study. CONCLUSION The EAST guideline seems to be adequate in a high percentage of cases (97%) in the setting of the trauma network cologne. Further research should be guided at identification of initial open fracture pathogens to improve the efficiency of antibiotic prophylaxis.
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Affiliation(s)
- Robin Otchwemah
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany.
| | - Volker Grams
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany
| | - Thorsten Tjardes
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany
| | - Sven Shafizadeh
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany
| | - Holger Bäthis
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany
| | - Marc Maegele
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany
| | - Sabine Messler
- Institute for Hygiene, Cologne-Merheim Medical Center, Germany
| | - Bertil Bouillon
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany
| | - Christian Probst
- Department of Traumatology and Orthopedic Surgery, Cologne-Merheim Medical Center, Germany
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Klüter T, Fitschen-Oestern S, Weuster M, Fickenscher H, Seekamp A, Lippross S. Toxic-shock-Syndrom nach offener Sprunggelenkverletzung. Unfallchirurg 2014; 118:643-6. [DOI: 10.1007/s00113-014-2659-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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C L O, M M, N M J. Controversies in the management of open fractures. Open Orthop J 2014; 8:178-84. [PMID: 25067972 PMCID: PMC4110387 DOI: 10.2174/1874325001408010178] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 03/21/2014] [Accepted: 04/06/2014] [Indexed: 11/22/2022] Open
Abstract
Open fractures are a common problem encountered by orthopaedic surgeons and comprise a broad spectrum of trauma. Management is guided by principle-based steps aimed at reducing the risk of gas gangrene or suppurative infections, whilst maintaining viability in a favourable soft tissue environment to reduce the risk of delayed or non-union of bone. Aspects of these principles, however, create discussion around several areas of controversy. The specific antimicrobial regimen and its duration are questions that have been evaluated for decades. Like the ever-evolving nature of the bacterial pathogens, the answer to this is dynamic and changing. The “six-hour rule” is a hotly debated topic with fervent perseverance of this dogma despite a gross lack of support from the literature. The most appropriate soft tissue management approach for open fractures – immediate definitive soft tissue closure versus leaving wounds open for delayed closure or definitive management – is also an area of debate. Exploration of these controversies and consideration for the historical context of the supporting literature furthers our understanding of the critical elements.
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Affiliation(s)
- O'Brien C L
- Division of Orthopaedic Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Menon M
- Division of Orthopaedic Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
| | - Jomha N M
- Division of Orthopaedic Surgery, Department of Surgery, University of Alberta, Edmonton, Canada
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Siskind E, Huntoon K, Shah K, Villa M, Blood AJ, Lumerman L, Fishbane L, Goncharuk E, Oropallo A, Bhaskaran M, Sachdeva M, Jhaveri KD, Calderon K, Nicastro J, Coppa G, Molmenti EP. Partial closure of skin wounds after kidney transplantation decreases the incidence of postoperative wound infections. Int J Angiol 2013; 21:85-8. [PMID: 23730135 DOI: 10.1055/s-0032-1315797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Wound infections are a major cause of morbidity after kidney transplantation. The purpose of our study was to evaluate an improved technique of wound closure. Data corresponding to 104 consecutive live donor kidney recipients were prospectively collected and analyzed. Our routine standard technique involved closure of the abdominal wall muscle and fascia in one layer with interrupted nonabsorbable full thickness sutures. No drains were used. The skin was closed with interrupted 2-0 nylon sutures 4 to 5 cm apart, leaving the skin and subcutaneous tissue in between partially open. Patients were allowed to shower starting on the first postoperative day. Examination of the wounds was continued for at least 1 month postoperatively, and then routinely as needed. All patients were thoroughly informed preoperatively of our technique. There were no immediate postoperative wound infections. There were no instances of dehiscence, evisceration, or need for revision. All patients were able to continue with their routine daily activities. Cosmetic results were satisfactory in all cases. We did not experience any patient complaints with respect to our technique. Patient satisfaction scores conducted by Press Ganey and Associates ranked in the 99 percentile with respect to peers undergoing kidney transplantation. Three patients returned six months postoperatively with suture granulomas which were treated nonoperatively. Partial closure of the skin wound with no associated drains is an effective and cosmetically desirable way to decrease the incidence of postoperative infections in kidney transplantation.
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Affiliation(s)
- Eric Siskind
- Department of Transplantation, Hofstra North Shore-Long Island Jewish School of Medicine, Manhasset, New York
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