Antimicrobial Stewardship Challenges in the Deployed Setting

Army Health Systems Doctrine and Training in Relation to Antibiotics: A Systematic Review

INTRODUCTION

In the early 2000s when Tactical Combat Casualty Care was developed, the adoption of prophylactic antibiotic use was not mainstream. Back then, guidelines were derivative of civilian trauma guidelines which did not include widespread prophylactic antibiotic use. Current protocols across the DoD have embraced the use of prophylactic antibiotic use before reaching a military treatment facility as evidenced by Tactical Combat Casualty Care guidelines and several Joint Trauma System Clinical Practice Guidelines.This review intends to find trends associated with the use of antibiotics in the military setting and answer the research question: Do current Army doctrine and practices address these issues and how can they be reworked to address them if needed?

MATERIALS AND METHODS

Methods were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary author utilized four databases to locate articles: MEDLINE (EBSCOhost), Cochrane Central Register of Controlled Trials (Wiley), CINAHL Complete (EBSCOhost), and Embase (Elsevier). The following keywords were utilized: "Combat casualty," "antibiotic," "trauma," and "prehospital." This ultimately led to 19 articles included in the review.

RESULTS

Nineteen articles were included in the final review and placed into one of the following categories: Overall antibiotic use, guideline adherence and practices, strains, and infection risk factors. Overall, the Army Health System has shown that there is room for improvement in terms of antibiotic stewardship and training regarding antibiotics.

CONCLUSION

Infectious diseases pose a substantial risk to combat wounded. The Army Health System must anticipate encountering challenges with delivering care to patients suffering infections in addition to serious combat injuries. A systematic review of the literature highlights several areas for improvement, primarily areas involving pathogen surveillance, treatment of pediatric populations, and the Army's operational domain of training.

A Multidisciplinary Approach to Improvements in Perioperative Antibiotic Prophylaxis at a Military Treatment Facility

INTRODUCTION

Surgical site infections complicate 2%-5% of surgeries. According to the Centers for Disease Control and Prevention, half of all surgical site infections are preventable. Adherence to published recommendations regarding perioperative antibiotic administration decreases the incidence of surgical site infections. Members of the Department of Anesthesia noticed casual observations of inaccurate prescribing of antibiotics at our institution, Brooke Army Medical Center, and approached the Antimicrobial Stewardship Program to collaborate on this issue.

MATERIALS AND METHODS

A team of anesthesiologists, clinical pharmacists, and infectious disease specialists collaborated with the Department of Surgery to improve this effort as part of a multiyear project from 2018 to 2021. We first assessed adherence to recommended perioperative antibiotic use to establish a baseline and next, noticing gaps, created a project with the goal to improve compliance to >90% across surveyed measures. Our key interventions included educational initiatives, creation of facility-specific guidelines, peer benchmarking, updating order sets, interdisciplinary collaboration, creation of intraoperative reminders and visual aids, and tailored presentations to selected services.

RESULTS

Of 292 charts (2.3% of cases from January to October 2018) reviewed pre-intervention, compliance rates were 84% for antibiotic choice, 92% for dose, 65% for redosing, and 71% for postoperative administration. Of doses, 100% were timed correctly, and thus, this variable was not targeted. Post-intervention, our review of 387 charts (10% of cases from May to November 2020) showed no change in correct antibiotic choice (84%) and statistical improvement to 96% for correct dose, 95% for correct redosing, and 85% for correct postoperative administration (P < .05 for all).

CONCLUSIONS

Our multidisciplinary approach of collaboration with multiple departments, creating guidelines and providing feedback, improved compliance with perioperative antibiotic administration recommendations.

Resistance patterns and clinical outcomes of Klebsiella pneumoniae and invasive Klebsiella variicola in trauma patients

Recent reclassification of the Klebsiella genus to include Klebsiella variicola, and its association with bacteremia and mortality, has raised concerns. We examined Klebsiella spp. infections among battlefield trauma patients, including occurrence of invasive K. variicola disease. Klebsiella isolates collected from 51 wounded military personnel (2009-2014) through the Trauma Infectious Disease Outcomes Study were examined using polymerase chain reaction (PCR) and pulsed-field gel electrophoresis. K. variicola isolates were evaluated for hypermucoviscosity phenotype by the string test. Patients were severely injured, largely from blast injuries, and all received antibiotics prior to Klebsiella isolation. Multidrug-resistant Klebsiella isolates were identified in 23 (45%) patients; however, there were no significant differences when patients with and without multidrug-resistant Klebsiella were compared. A total of 237 isolates initially identified as K. pneumoniae were analyzed, with 141 clinical isolates associated with infections (remaining were colonizing isolates collected through surveillance groin swabs). Using PCR sequencing, 221 (93%) isolates were confirmed as K. pneumoniae, 10 (4%) were K. variicola, and 6 (3%) were K. quasipneumoniae. Five K. variicola isolates were associated with infections. Compared to K. pneumoniae, infecting K. variicola isolates were more likely to be from blood (4/5 versus 24/134, p = 0.04), and less likely to be multidrug-resistant (0/5 versus 99/134, p<0.01). No K. variicola isolates demonstrated the hypermucoviscosity phenotype. Although K. variicola isolates were frequently isolated from bloodstream infections, they were less likely to be multidrug-resistant. Further work is needed to facilitate diagnosis of K. variicola and clarify its clinical significance in larger prospective studies.