Risk factors of mortality in nosocomial infected traumatic patients in a trauma referral center in south of Iran

The immune suppressive properties of damage associated molecular patterns in the setting of sterile traumatic injury

Associated with the development of hospital-acquired infections, major traumatic injury results in an immediate and persistent state of systemic immunosuppression, yet the underlying mechanisms are poorly understood. Detected in the circulation in the minutes, days and weeks following injury, damage associated molecular patterns (DAMPs) are a heterogeneous collection of proteins, lipids and DNA renowned for initiating the systemic inflammatory response syndrome. Suggesting additional immunomodulatory roles in the post-trauma immune response, data are emerging implicating DAMPs as potential mediators of post-trauma immune suppression. Discussing the results of in vitro, in vivo and ex vivo studies, the purpose of this review is to summarise the emerging immune tolerising properties of cytosolic, nuclear and mitochondrial-derived DAMPs. Direct inhibition of neutrophil antimicrobial activities, the induction of endotoxin tolerance in monocytes and macrophages, and the recruitment, activation and expansion of myeloid derived suppressor cells and regulatory T cells are examples of some of the immune suppressive properties assigned to DAMPs so far. Crucially, with studies identifying the molecular mechanisms by which DAMPs promote immune suppression, therapeutic strategies that prevent and/or reverse DAMP-induced immunosuppression have been proposed. Approaches currently under consideration include the use of synthetic polymers, or the delivery of plasma proteins, to scavenge circulating DAMPs, or to treat critically-injured patients with antagonists of DAMP receptors. However, as DAMPs share signalling pathways with pathogen associated molecular patterns, and pro-inflammatory responses are essential for tissue regeneration, these approaches need to be carefully considered in order to ensure that modulating DAMP levels and/or their interaction with immune cells does not negatively impact upon anti-microbial defence and the physiological responses of tissue repair and wound healing.

Evaluation of the Risk Factors of Nosocomial Pneumonia and the Prevalence of Antibiotic Resistance in Trauma Patients in Need of Immediate Intervention

Background: Pneumonia is the most common nosocomial infection reported worldwide in intensive care units. This study aimed to evaluate the risk factors of nosocomial pneumonia and the frequency of antibiotic resistance in trauma patients who need immediate intervention. Patients and Methods: This prospective cohort study was conducted in Shahid Rajaei Trauma Hospital in Shiraz between 2020 and 2021. All the trauma patients who needed immediate intervention (levels 1 and 2 based on the Canadian Emergency Department Triage and Acuity Scale) and had no symptoms of infection were included. Patients who were discharged or died before 48 hours were excluded. Results: The results demonstrated that major trauma (Injury Severity Score [ISS] ≥16), intubation, and use of invasive mechanical ventilation increase nosocomial pneumonia and death rate. The most common causes of nosocomial infections were Acinetobacter baumannii (23%) and coagulase-negative staphylococcus (18.5%). The highest levels of antibiotic resistance were related to cefoxitin, erythromycin, ciprofloxacin, and trimethoprim-sulfamethoxazole. Conclusions: Major trauma, intubation, and invasive mechanical ventilation were the effective factors in the development of nosocomial pneumonia. Continuous monitoring for mentioned risk factors and strict surveillance of antibiotic prescription can decrease the prevalence of nosocomial infections and subsequent deaths.

Evaluation of critical care burden following traumatic injury from two randomized controlled trials

Trauma resuscitation practices have continued to improve with new advances targeting prehospital interventions. The critical care burden associated with severely injured patients at risk of hemorrhage has been poorly characterized. We aim to describe the individual and additive effects of multiorgan failure (MOF) and nosocomial infection (NI) on delayed mortality and resource utilization. A secondary analysis of harmonized data from two large prehospital randomized controlled trials (Prehospital Air Medical Plasma (PAMPer) Trial and Study of Tranexamic Acid during Air and Ground Medical Prehospital Transport (STAAMP) Trial) was conducted. Only those patients who survived beyond the first 24 hours post-injury and spent at least one day in the ICU were included. Patients were stratified by development of MOF only, NI only, both, or neither and diagnosis of early (≤ 3 days) versus late MOF (> 3 days). Risk factors of NI and MOF, time course of these ICU complications, associated mortality, and hospital resource utilization were evaluated. Of the 869 patients who were enrolled in PAMPer and STAAMP and who met study criteria, 27.4% developed MOF only (n = 238), 10.9% developed NI only (n = 95), and 15.3% were diagnosed with both MOF and NI (n = 133). Patients developing NI and/or MOF compared to those who had an uncomplicated ICU course had greater injury severity, lower GCS, and greater shock indexes. Early MOF occurred in isolation, while late MOF more often followed NI. MOF was associated with 65% higher independent risk of 30-day mortality when adjusting for cofounders (OR 1.65; 95% CI 1.04-2.6; p = 0.03), however NI did not significantly affect odds of mortality. NI was individually associated with longer mechanical ventilation, ICU stay, hospital stay, and rehabilitation requirements, and the addition of MOF further increased the burden of inpatient and post-discharge care. MOF and NI remain common complications for those who survive traumatic injury. MOF is a robust independent predictor of mortality following injury in this cohort, and NI is associated with higher resource utilization. Timing of these ICU complications may reveal differences in pathophysiology and offer targets for continued advancements in treatment.

Nosocomial Infections in Patients with Traumatic Brain Injury: A Hospital-Based Study from North India

Background Traumatic brain injury (TBI) is a major global health concern, it being a leading cause of morbidity and mortality in young adults. Infections acquired in the hospital setting are one of many risk factors that are associated with higher mortality in this population. Despite significant impact on the overall outcome, infections in TBI patients are largely understudied and underreported. The purpose of this study was to study the profile of infectious complications in patients with TBI and impact of these infections on the hospital outcome of these patients.

Materials and Methods The medical records of all the patients with a diagnosis of TBI admitted in our hospital from January 2017 to January 2020 were reviewed. They were screened for presence of any predefined infection acquired at any time during their hospital stay. Data regarding demographics, focus of infection, results of various cultures, and hospital outcome was recorded.

Results A total of 60 patients with TBI who had developed nosocomial infections were included in this observational study. Patients were mostly young, with a mean age of 36.6 years. Majority (66.6%) of patients who developed infectious complications had Glasgow coma scale (GCS) score of less than 10. Respiratory tract and urinary tract were the most common sites of infections in these patients. Burkholderia cepecia and Acinetobacter baumannii were the two most common isolated organisms. All-cause mortality in this population was 23.3%.

Conclusions Most TBI patients are young, in their productive period of lives, and do not have major comorbidities. Invariably, they have low GCS scores and encounter a breach of their surface immunity due to catheters, procedures, and intubation. Such patients make an extremely significant impact on hospital resources as well as poor economic outcomes.

What factors affect length of hospital stay among trauma patients? A single-center study, Southwestern Iran

PURPOSE

Trauma is a major health concern. Length of hospital stay (LOS) has been targeted as an important metric to assess trauma care. This study aims to evaluate the risk factors that affect LOS among trauma patients in a trauma center in Southwestern Iran.

METHODS

This cross-sectional study was conducted on patients admitted to Rajaee Trauma Center, Shiraz, Iran between January 1, 2018 and December 30, 2018. The inclusion criteria were age above 15 years and having traffic accident injuries, including car, motorcycle and pedestrian injury mechanisms. The exclusion criteria were existing diseases including cardiovascular, cerebral, renal, and pulmonary diseases prior to this study, dead upon arrival or within 48 h after admission, and stay at the hospital for less than 6 h. The risk variables analyzed for prolonged LOS were age, gender, mechanism of traffic accident injury, infection during hospital stay, type of injury, injury severity score, surgery during hospitalization, and survival. Poisson regression was performed to evaluate the partial effects of each covariate on trauma hospitalization (≥3 days as longer stay).

RESULTS

This study was conducted on 14,054 patients with traffic accident injury and the mean age was (33.89 ± 15.78) years. Additionally, 74.35% of the patients were male, with male to female ratio of 2.90. The result of Poisson regression indicated that male patients, higher age, combination of thoracic injuries, onset of infected sites, and surgery patients were more susceptible to have a longer LOS. Considering the site of injury, patients with face injuries followed by those with thorax injuries had the highest means of LOS (3.74 days and 3.36 days, respectively). Simultaneous existence of surgical intervention and infection in a patient had the greatest impact on prolonged LOS.

CONCLUSION

This study identified that age, gender, mechanism of injury, infection, type of injury, survival, and ISS could lead to prolongation of LOS, but the affect can be reduced by eliminating modifiable risk factors.

A Comparative Study of Injury Severity Scales as Predictors of Mortality in Trauma Patients: Which Scale Is the Best?

Objective:

To compare the injury severity scales as predictors of mortality in trauma patients to search for the best scale.

Methods:

In a prospective cohort study and systematical random sampling conducted from March to September 2017, trauma patients over the age of 13 years were enrolled. The investigated variables were age, gender, systolic blood pressure, heart rate, respiratory rate, injured body region, Glasgow Coma Scale (GCS), injury severity score (ISS), revised trauma score (RTS), trauma injury severity score (TRISS) and the outcome.

Results:

Totally, 1410 trauma patients were followed up, out of which 68.5% were male. The participants’ mean age was 43.5±20.88 years. After adjusting the confounding effects, age over 60 years (OR=7.38, CI [3.91-13.93]), GCS<8 (OR=6.5, CI [2.38-18.16]), RTS<7.6 (OR=6.04, CI [2-13.7]), and TRISS<0.9 (OR=3.09, CI [1.39-6.88]) were determined as the most significant predictor variables for in-hospital mortality. The results of Receiver Operating Characteristic (ROC) curve revealed that TRISS had the highest area under the curve in comparison to other tests that were evaluated. Furthermore, TRISS had the highest sensitivity and specificity for scores higher than 96.15. By contrast, the sensitivity and specificity of GCS decreased for scores higher than 5.5.

Conclusion:

Our results showed that TRISS, RTS, GCS, and ISS were all very effective approaches for evaluating prognosis, mortality and probable complications in trauma patients; thus, these systems of injury evaluation and scoring are recommended to facilitate treatment. TRISS, RTS, and ISS had almost the same sensitivity that was higher than GCS, but GCS had the most specificity. Finally, TRISS was selected as the most efficient scale for predicting mortality.