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Florek CA, Cozzone E, Williams DL, Armbruster DA. A controlled release antibiotic wound protectant gel formulated for use in austere environments. J Biomed Mater Res B Appl Biomater 2024; 112:e35455. [PMID: 39177322 DOI: 10.1002/jbm.b.35455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 06/10/2024] [Accepted: 07/08/2024] [Indexed: 08/24/2024]
Abstract
Battlefield wounds are at high risk of infection due to gross contamination and delays in evacuation from forward-deployed locations. The aim of this study was to formulate an antibiotic wound gel for application by a field medic in austere environments to protect traumatic wounds from infection during transport. Formulation development was conducted over multiple phases to meet temperature, handling, in vitro elution, and in vivo tissue response requirements. Thermal properties were evaluated by vial inversion, DSC, and syringe expression force in a temperature range of 4-49°C. Handling was evaluated by spreading onto blood-contaminated tissue and irrigation resistance. Controlled antibiotic release was evaluated by a modified USP immersion cell dissolution method. Local tissue effects were evaluated in vivo by subcutaneous implantation in rats for 7 and 28 days. An oleogel composition of cholesterol, hydrogenated castor oil, soybean oil, and glyceryl monocaprylocaprate met the target performance criteria. Peak expression force from a 5 mL syringe at 4°C was 48.3 N, the dropping point temperature was 68°C, and the oleogel formulation could be spread onto blood-contaminated tissue and resisted aqueous irrigation. The formulation demonstrated sustained release of tobramycin in PBS at 32°C for 5 days. Implantation in a rat dorsal pocket demonstrated a slight tissue reaction after 7 days with minimal to no reaction after 28 days, comparable to a commercial hemostat control. Material resorption was evident after 28 days. The formulation met target characteristics and is appropriate for further evaluation in a large animal contaminated blast wound model.
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Affiliation(s)
| | | | - Dustin L Williams
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah, USA
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
- Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Tran P, Abidi N, Bergfeld N, Shashtri M, Reid TW. Selenium Bandages and Cotton Cloth That Kill Microorganisms in Wounds. Mil Med 2024; 189:179-183. [PMID: 39160845 DOI: 10.1093/milmed/usae069] [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: 12/11/2023] [Revised: 01/27/2024] [Accepted: 02/27/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION The material of a bandage plays an important role in wound management. Microorganisms can colonize the dressing and release toxins, which create dead cells in the wound. This allows the microorganisms to bind the dead cells and infect the wound. Thus, a dressing is needed that kills bacteria in the bandage. To combat health care-associated infections, antimicrobial treatment of medical textiles, such as gauze, uniforms, curtains, bed sheets, gowns, and masks, is required. Besides, antimicrobial resistance is another major problem of this century. Antibacterial overuse has contributed to drug-resistant bacteria. To combat these two problems, we synthesized new organo-selenium compounds that can be attached to the cotton of the dressing. We then used an in vivo wound model, which allowed us to measure the effectiveness of selenium attached to a cotton dressing, to prevent bacteria from infecting a wound. MATERIALS AND METHODS Organo-selenium was attached to cotton fabric, resulting in a fabric with 0.1% selenium covalently attached to it. Staphylococcus aureus (as well as methicillin-resistant S. aureus [MRSA]), Stenotrophomonas maltophilia, Enterococcus faecalis, Staphylococcus epidermidis, and Pseudomonas aeruginosa were chosen for the wound infection study. All the bacteria were enumerated in the wound dressing and in the wound tissue under the dressing. Wounds were made on the backs of mice. The material was used as a bandage over the wound. Bacteria were injected into the wound under the bandage. The amount of bacteria in the wound after 5 days was determined. A similar study was performed using dressing material that was soaked in phosphate buffered saline at 37 °C for 3 months before use. RESULTS Cotton dressing with selenium attached showed complete inhibition (7 logs, as compared with control dressing) of different bacterial strains, in both the dressing and "the tissue" of the wound. Similar results were obtained using selenium cotton dressing that was soaked for 3 months before use. Control cotton with no selenium showed complete infiltration of bacteria into the wound and the dressing. In addition, a study was performed under Food and Drug Administration standard methods to show the ability of the selenium to kill bacteria in the fabric, using material that was washed 5 times in detergent. This also showed complete killing of bacteria in the fabric. CONCLUSIONS The results show that the selenium remains in the dressing after washing and is able to completely protect the wound from bacterial infection. In the selenium bandage, no bacteria were found in the bandage or the wound after 5 days.
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Affiliation(s)
- Phat Tran
- Ophthalmology and Visual Science, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Fiber Institute, New American Fabric LLC, Lubbock, TX 79415, USA
| | - Noureddine Abidi
- Fiber Institute, New American Fabric LLC, Lubbock, TX 79415, USA
- Honors College, Texas Tech University, Lubbock, TX 79409, USA
| | - Nicholas Bergfeld
- Fiber Institute, New American Fabric LLC, Lubbock, TX 79415, USA
- Honors College, Texas Tech University, Lubbock, TX 79409, USA
| | | | - Ted W Reid
- Ophthalmology and Visual Science, Texas Tech University Health Sciences Center, Lubbock, TX 79430, USA
- Fiber Institute, New American Fabric LLC, Lubbock, TX 79415, USA
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Geringer MR, Stewart L, Shaikh F, Carson ML, Lu D, Cancio LC, Gurney JM, Tribble DR, Kiley JL. Epidemiology and timing of infectious complications from battlefield-related burn injuries. Burns 2024:S0305-4179(24)00204-3. [PMID: 39341778 DOI: 10.1016/j.burns.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/28/2024] [Accepted: 07/04/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Infections are the most frequent complication and cause of mortality in burn patients. We describe the epidemiology and outcomes of infections among deployed U.S. military personnel with burns. METHODS Military personnel who sustained a burn injury in Iraq or Afghanistan (2009-2014) and were admitted to the Burn Center at U.S. Army Institute of Surgical Research at Brooke Army Medical Center were included in the analysis. RESULTS The study population included 144 patients who were primarily young (median 24 years) males (99 %) with combat-related burns (62 %) sustained via a blast (57 %), resulting in a median total body surface area burned (TBSA) of 6 % (IQR 3-14 %). Twenty-six (18 %) patients developed infections, with pneumonia being the predominant initial infection (= 16), followed by skin and soft-tissue infections (SSTI, = 6), bloodstream infections (BSI, = 3), and intra-abdominal infections (IAI, = 1). Initial infections were diagnosed at a median of 4 days (IQR 3-5) post-injury for pneumonia, 7 days (IQR 4-12) for SSTIs, 7 days (IQR 6-7) for BSI, and 17 days for IAI. Patients with infections were more severely injured with greater TBSA (median 31 % vs 5 %), more inhalation injury (38 % vs 12 %), and longer time to definitive surgical management (median of 34 days vs 9) compared to those who did not develop infections (p < 0.001). Among patients with inhalation injury, a higher proportion developed pneumonia (42 %) compared to those without inhalation injury (5 %; p < 0.001). Five patients developed an invasive fungal infection. Gram-negative bacilli were most frequently recovered, with 32 % of Gram-negative isolates being multidrug-resistant. Four patients died, of whom all had ≥ 4 infections. CONCLUSIONS Military personnel with burn injuries who developed infections were more severely injured with greater TBSA and inhalation injury. Improved understanding of risk factors for burn-related infections in combat casualties is critical for effective management.
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Affiliation(s)
- Matthew R Geringer
- Infectious Disease Service, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, United States.
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD 20817, United States
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD 20817, United States
| | - M Leigh Carson
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD 20817, United States
| | - Dan Lu
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD 20817, United States
| | - Leopoldo C Cancio
- US. Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234, United States
| | - Jennifer M Gurney
- US. Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234, United States; Joint Trauma System, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234, United States
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States
| | - John L Kiley
- Infectious Disease Service, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, United States
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Tigabu E, Melese A, Mekonen F, Siraj Y. Bullet-related bacterial wound infections among injured personnel at emergency site hospitals in Bahir Dar: prevalence, antimicrobial susceptibility and associated factors. BMC Microbiol 2024; 24:166. [PMID: 38755533 PMCID: PMC11097502 DOI: 10.1186/s12866-024-03324-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 05/09/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Bullet-related bacterial wound infection can be caused by high-velocity bullets and shrapnel injuries. In Ethiopia, significant injuries were reported that may cause severe wound infections, persistent systemic infections and may lead to amputation and mortality. The magnitude, antimicrobial susceptibility profiles, and factors associated with bacterial wound infections among patients with bullet-related injuries are not yet studied particularly at health facilities in Bahir Dar, Northwest Ethiopia. Therefore, this study was aimed to determine the prevalence, bacterial profiles, antimicrobial susceptibility profiles, and factors associated with bacterial infections among patients with bullet-related injuries at referral health facilities in Bahir Dar, Northwest Ethiopia. METHODS A Hospital-based cross-sectional study was conducted among patients with bullet-related injuries at three referral health facilities in Bahir Dar from May 25 to July 27, 2022. A total of 384 patients with bullet-related injuries were included in the study. Sociodemographic and clinical data were collected using a structured questionnaire. Wound swabs were collected aseptically and cultured on Blood and MacConkey agar following bacteriological standards. Biochemical tests were performed to differentiate bacteria for positive cultivation and antimicrobial susceptibility profiles of the isolates were done on Muller Hinton agar using the Kirby-Bauer disk diffusion technique according to the 2021 Clinical Laboratory Standard Institute (CLSI) guideline. The data were entered using Epi-Info version 7.3 and analyzed using SPSS version 25. Descriptive data were presented using frequency, percentages, figures, and charts. Logistic regression was carried out to identify factors associated with bacterial wound infections. P-value < 0.05 was considered statistically significant. RESULTS The prevalence of bullet-related bacterial wound infection among three referral hospitals in Bahir Dar city was 54.7%. The most commonly isolated Gram-negative organism was Klebsiella spps 49 (23.3%) while among Gram-positive organism, Staphylococcus aureus 58 (27.6%) and coagulase-negative staphylococci (CONS) 18 (8.6%). Contamination, hospitalization and smoking habit were significantly associated with the presence of bullet-related bacterial wound infections. Over 97% multidrug resistant (MDR) bacterial isolates were identified and of theses, E. coli, Proteus species, Citrobactor, and Staphylococcus aureus were highly drug resistant. CONCLUSION Increased prevalence of bullet-related bacterial wound infection was noticed in this study. S. aureus followed by Klebsiella species were most commonly isolated bacteria. High frequency of resistance to Ampicillin, Oxacillin, Cefepime, Ceftriaxone, Ceftazidime, Vancomycin, and Norfloxacin was observed. Therefore, proper handling of bullet injuries, prompt investigation of bacterial infections, monitoring of drug sensitivity patterns and antibiotic usage are critical.
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Affiliation(s)
- Enanu Tigabu
- Department of Medical Laboratory Sciences, GAMBY Medical and Business College, Bahir Dar, Ethiopia.
| | - Addisu Melese
- Department of Medical Laboratory Sciences, School of Health Sciences, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Feleke Mekonen
- Department of Medical Laboratory Sciences, School of Health Sciences, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Yesuf Siraj
- Department of Medical Laboratory Sciences, School of Health Sciences, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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Zhao X, Huang Y, Li Z, Chen J, Luo J, Bai L, Huang H, Cao E, Yin Z, Han Y, Guo B. Injectable Self-Expanding/Self-Propelling Hydrogel Adhesive with Procoagulant Activity and Rapid Gelation for Lethal Massive Hemorrhage Management. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024; 36:e2308701. [PMID: 37971104 DOI: 10.1002/adma.202308701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 11/09/2023] [Indexed: 11/19/2023]
Abstract
Developing hydrogels that can quickly reach deep bleeding sites, adhere to wounds, and expand to stop lethal and/or noncompressible bleeding in civil and battlefield environments remains a challenge. Herein, an injectable, antibacterial, self-expanding, and self-propelling hydrogel bioadhesive with procoagulant activity and rapid gelation is reported. This hydrogel combines spontaneous gas foaming and rapid Schiff base crosslinking for lethal massive hemorrhage. Hydrogels have rapid gelation and expansion rate, high self-expanding ratio, excellent antibacterial activity, antioxidant efficiency, and tissue adhesion capacity. In addition, hydrogels have good cytocompatibility, procoagulant ability, and higher blood cell/platelet adhesion activity than commercial combat gauze and gelatin sponge. The optimized hydrogel (OD-C/QGQL-A30) exhibits better hemostatic ability than combat gauze and gelatin sponge in rat liver and femoral artery bleeding models, rabbit volumetric liver loss massive bleeding models with/without anticoagulant, and rabbit liver and kidney incision bleeding models with bleeding site not visible. Especially, OD-C/QGQL-A30 rapidly stops the bleedings from pelvic area of rabbit, and swine subclavian artery vein transection. Furthermore, OD-C/QGQL-A30 has biodegradability and biocompatibility, and accelerates Methicillin-resistant S. aureus (MRSA)-infected skin wound healing. This injectable, antibacterial, self-expanding, and self-propelling hydrogel opens up a new avenue to develop hemostats for lethal massive bleeding, abdominal organ bleeding, and bleeding from coagulation lesions.
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Affiliation(s)
- Xin Zhao
- State Key Laboratory for Mechanical Behavior of Materials, and Frontier Institute of Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China
| | - Ying Huang
- State Key Laboratory for Mechanical Behavior of Materials, and Frontier Institute of Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China
| | - Zhenlong Li
- State Key Laboratory for Mechanical Behavior of Materials, and Frontier Institute of Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China
| | - Jueying Chen
- State Key Laboratory for Mechanical Behavior of Materials, and Frontier Institute of Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China
| | - Jinlong Luo
- State Key Laboratory for Mechanical Behavior of Materials, and Frontier Institute of Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China
| | - Lang Bai
- Department of Orthopaedics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Heyuan Huang
- School of Aeronautics, Northwestern Polytechnical University, Xi'an, 710072, China
| | - Ertai Cao
- School of Aeronautics, Northwestern Polytechnical University, Xi'an, 710072, China
| | - Zhanhai Yin
- Department of Orthopaedics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Yong Han
- State Key Laboratory for Mechanical Behavior of Materials, and Frontier Institute of Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China
- Department of Orthopaedics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Baolin Guo
- State Key Laboratory for Mechanical Behavior of Materials, and Frontier Institute of Science and Technology, Xi'an Jiaotong University, Xi'an, 710049, China
- Department of Orthopaedics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
- Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, College of Stomatology, Xi'an Jiaotong University, Xi'an, 710049, China
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Chen Y, Leung A, Wang Y, Archer NK. Optimization and Validation of an FTIR-based, All-in-one System for Viable MDR Bacteria Detection in Combat-related Wound Infection. Mil Med 2024:usae068. [PMID: 38516949 DOI: 10.1093/milmed/usae068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/08/2024] [Accepted: 02/18/2024] [Indexed: 03/23/2024] Open
Abstract
INTRODUCTION The U.S. Military members experiencing combat-related injuries have a higher chance of developing infections by multidrug-resistant (MDR) bacteria at admission to military hospitals. MDR wound infections result in higher amputation rates and greater risks for subsequent or chronic infections that require readmission or extended stay in the hospital. Currently, there is no FDA-clear, deployable early diagnostic system for suitable field use.We are reporting our efforts to improve a previously developed Rapid Label-free Pathogen Identification (RAPID) system to detect viable MDR bacteria in wound infections and perform antibiotic susceptibility testing (AST). Specifically, we added multiplex and automation capability and significantly simplified the sample preparation process. A functional prototype of the improved system was built, and its performance was validated using a variety of lab-prepared spiked samples and real-world samples. MATERIALS AND METHODS To access the baseline performance of the improved RAPID system in detecting bacteria presence, we selected 17 isolates, most of them from blood or wound infections, and prepared mono-strain spiked samples at 104 to 106 cfu/mL concentration. These samples were processed and analyzed by the RAPID system. To demonstrate the AST capability of the system, we selected 6 strains against 6 different antibiotics and compared the results from the system with the ones from the gold standard method.To validate the system's performance with real-world samples, we first investigated its performance on 3 swab samples from epicutaneous methicillin-resistant Staphylococcus aureus-exposed mouse model. The AST results from our system were compared with the ones from the gold standard method. All animal experiments were approved by the Johns Hopkins University Animal Care and Use Committee (Protocol No. MO21M378). Then, we obtained swab samples from 7 atopic dermatitis (AD) patients and compared our AST results with the ones from the gold standard method. The human subject protocol was approved by the Johns Hopkins Medicines Institutional Review Boards (Study No. CR00043438/IRB00307926) and by USAMRDC (Proposal Log Number/Study Number 20000251). RESULTS High-quality data were obtained from the spiked samples of all 17 strains. A quantitative analysis model built using these data achieved 94% accuracy in predicting the species ID in 8 unknown samples. The AST results on the spiked samples had shown 100% matching with the gold standard method. Our system successfully detects the presence/absence of viable bacteria in all 3 mouse and 7 AD patient swab samples. Our system shows 100% and 85.7% (6 out of 7) accuracy when compared to the oxacillin susceptibility testing results for the mouse and the AD patient swabs, respectively. CONCLUSIONS Our system has achieved excellent performance in detecting viable bacteria presence and in performing AST in a multiplex, automated, and easy-to-operate manner, on both lab-prepared and real samples. Our results have shown a path forward to a rapid (sample-to-answer time ≤3 hours), accurate, sensitive, species-specific, and portable system to detect the presence of MDR combat-related wound infections in the field environment. Our future efforts involve ruggedizing the RAPID system and evaluating performance under relevant environmental conditions.
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Affiliation(s)
- Ying Chen
- Optowares, Inc., Woburn, MA 01801, USA
| | | | - Yulia Wang
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD 21231, USA
| | - Nathan K Archer
- Department of Dermatology, Johns Hopkins School of Medicine, Baltimore, MD 21231, USA
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Legesse AY, Hadush Z, Teka H, Berhe E, Abera BT, Amdeselassie F, Abraha HE, Gebre D, Bazzano AN. Lived experience of healthcare providers amidst war and siege: a phenomenological study of Ayder Comprehensive Specialized Hospital of Tigray, Northern Ethiopia. BMC Health Serv Res 2024; 24:292. [PMID: 38448988 PMCID: PMC10916075 DOI: 10.1186/s12913-024-10655-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/29/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Most wars are fought in poor countries and result in significant proportions of disabilities and mortalities. The consequences of wars and political instability on health workers and access to healthcare remain under-studied. This study aimed to explore the lived experience of healthcare providers amidst war and siege, in a teaching hospital in northern Ethiopia. METHODS The study was conducted between February 2022 to March 2022. A qualitative phenomenological study was conducted between February to March 2022 with 20 healthcare providers working in Ayder Comprehensive and Specialized Hospital (ACSH), Tigray, Ethiopia, during the Tigray War. The study employed in-depth interviews. RESULTS The main themes identified included the consequences of the siege on health service delivery at ACSH, personal survival threats posed by the siege, immediate health consequences of the siege among care providers, and consequences of the siege on the motivation and energy of health professionals. CONCLUSIONS Health workers are exposed to a range of direct and indirect impacts of war, emphasizing the need to amend the conditions in which they live and work.
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Affiliation(s)
- Awol Yemane Legesse
- College of Health Sciences, Department of Obstetrics and Gynecology, Mekelle University, Tigray, Ethiopia.
| | - Znabu Hadush
- College of Health Sciences, School of Public Health, Mekelle University, Tigray, Ethiopia
| | - Hale Teka
- College of Health Sciences, Department of Obstetrics and Gynecology, Mekelle University, Tigray, Ethiopia
| | - Ephrem Berhe
- College of Health Sciences, Department of Internal Medicine, Mekelle University, Tigray, Ethiopia
| | - Bisrat Tesfay Abera
- College of Health Sciences, Department of Internal Medicine, Mekelle University, Tigray, Ethiopia
| | - Fasika Amdeselassie
- College of Health Sciences, Department of Surgery, Mekelle University, Tigray, Ethiopia
| | - Hiluf Ebuy Abraha
- Ayder Comprehensive Specialized Hospital, Mekelle University, Quality Office, Tigray, Ethiopia
- University of South Carolina, Arnold School of Public Health, Columbia, SC, USA
| | - Daniel Gebre
- Ayder Comprehensive Specialized Hospital, Mekelle University, Labor ward, Tigray, Ethiopia
| | - Alessandra N Bazzano
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
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Soderstrom MA, Blyth DM, Carson ML, Campbell WR, Yabes JM, Shaikh F, Stewart L, Tribble DR, Murray CK, Kiley JL. Seasonality of Microbiology of Combat-Related Wounds and Wound Infections in Afghanistan. Mil Med 2023; 188:304-310. [PMID: 37948254 PMCID: PMC10637295 DOI: 10.1093/milmed/usad115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/02/2023] [Accepted: 03/28/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Battlefield-related wound infections are a significant source of morbidity among combat casualties. Seasonality of these infections was demonstrated in previous conflicts (e.g., Korea) but has not been described with trauma-related health care-associated infections from the war in Afghanistan. METHODS The study population included military personnel wounded in Afghanistan (2009-2014) medevac'd to Landstuhl Regional Medical Center and transitioned to participating military hospitals in the United States with clinical suspicion of wound infections and wound cultures collected ≤7 days post-injury. Analysis was limited to the first wound culture from individuals. Infecting isolates were collected from skin and soft-tissue infections, osteomyelitis, and burn soft-tissue infections. Data were analyzed by season (winter [ December 1-February 28/29], spring [March 1-May 31], summer [June 1-August 31], and fall [September 1-November 30]). RESULTS Among 316 patients, 297 (94.0%) sustained blast injuries with a median injury severity score and days from injury to initial culture of 33 and 3.5, respectively. Although all patients had a clinical suspicion of a wound infection, a diagnosis was confirmed in 198 (63%) patients. Gram-negative bacilli (59.5% of 316) were more commonly isolated from wound cultures in summer (68.1%) and fall (67.1%) versus winter (43.9%) and spring (45.1%; P < .001). Multidrug-resistant (MDR) Gram-negative bacilli (21.8%) were more common in summer (21.8%) and fall (30.6%) versus winter (7.3%) and spring (19.7%; P = .028). Findings were similar for infecting Gram-negative bacilli (72.7% of 198)-summer (79.5%) and fall (83.6%; P = .001)-and infecting MDR Gram-negative bacilli (27.3% of 198)-summer (25.6%) and fall (41.8%; P = .015). Infecting anaerobes were more common in winter (40%) compared to fall (11%; P = .036). Gram-positive organisms were not significantly different by season. CONCLUSION Gram-negative bacilli, including infecting MDR Gram-negative bacilli, were more commonly recovered in summer/fall months from service members injured in Afghanistan. This may have implications for empiric antibiotic coverage during these months.
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Affiliation(s)
- Matthew A Soderstrom
- Infectious Disease Service, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, TX 78234, USA
| | - Dana M Blyth
- Infectious Disease Service, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - M Leigh Carson
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Wesley R Campbell
- Infectious Disease Service, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Joseph M Yabes
- Infectious Disease Service, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, TX 78234, USA
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Clinton K Murray
- Infectious Disease Service, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, TX 78234, USA
| | - John L Kiley
- Infectious Disease Service, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, TX 78234, USA
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Dhillon NS, Jeon N, Gurkan UA, Gupta AS, Bonomo RA, Drummy LF, Zhang M, Chance MR. Military Medicine and Medical Research as a Source of Inspiration and Innovation to Solve National Security and Health Challenges in the 21st Century. Pathog Immun 2023; 8:51-63. [PMID: 37799210 PMCID: PMC10550252 DOI: 10.20411/pai.v8i1.596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/07/2023] [Indexed: 10/07/2023] Open
Abstract
The history of military medicine and research is rife with examples of novel treatments and new approaches to heal and cure soldiers and others impacted by war's devastation. In the 21st century, new threats, like climate change, are combined with traditional threats, like geopolitical conflict, to create novel challenges for our strategic interests. Extreme and inaccessible environments provide heightened risks for warfighter exposure to dangerous bacteria, viruses, and fungi, as well as exposure to toxic substances and extremes of temperature, pressure, or both providing threats to performance and eroding resilience. Back home, caring for our veterans is also a health-care priority, and the diseases of veterans increasingly overlap with the health needs of an aging society. These trends of climate change, politics, and demographics suggest performance evaluation and resilience planning and response are critical to assuring both warfighter performance and societal health. The Cleveland ecosystem, comprising several hospitals, a leading University, and one of the nation's larger Veteran's Health Administration systems, is ideal for incubating and understanding the response to these challenges. In this review, we explore the interconnections of collaborations between Defense agencies, particularly Air Force and Army and academic medical center-based investigators to drive responses to the national health security challenges facing the United States and the world.
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Affiliation(s)
- Nanak S. Dhillon
- Department of Nutrition, School of Medicine, Case Western Reserve University, Cleveland, OH
- Center for Proteomics and Bioinformatics, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Nayeon Jeon
- Department of Nutrition, School of Medicine, Case Western Reserve University, Cleveland, OH
- Center for Proteomics and Bioinformatics, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Umut A. Gurkan
- Department of Mechanical and Aerospace Engineering, Case School of Engineering, Case Western Reserve University, Cleveland, Ohio
| | - Anirban Sen Gupta
- Department of Biomedical Engineering, School of Medicine, Case School of Engineering, Case Western Reserve University, Cleveland, Ohio
| | - Robert A. Bonomo
- Center for Proteomics and Bioinformatics, School of Medicine, Case Western Reserve University, Cleveland, Ohio
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center; Case Western Reserve University, Cleveland, OH; VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES); Departments of Medicine, Pharmacology, Molecular Biology and Microbiology, and Biochemistry, Case Western Reserve University, Cleveland, Ohio
| | - Lawrence F. Drummy
- Materials and Manufacturing Directorate, Air Force Research Laboratory, Dayton, Ohio
| | - Mei Zhang
- Department of Biomedical Engineering, School of Medicine, Case School of Engineering, Case Western Reserve University, Cleveland, Ohio
| | - Mark R. Chance
- Department of Nutrition, School of Medicine, Case Western Reserve University, Cleveland, OH
- Center for Proteomics and Bioinformatics, School of Medicine, Case Western Reserve University, Cleveland, Ohio
- Department of Biomedical Engineering, School of Medicine, Case School of Engineering, Case Western Reserve University, Cleveland, Ohio
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Bennett W, Mende K, Campbell WR, Beckius M, Stewart L, Shaikh F, Rahman A, Tribble DR, Yabes JM. Enterobacter cloacae infection characteristics and outcomes in battlefield trauma patients. PLoS One 2023; 18:e0290735. [PMID: 37643169 PMCID: PMC10464967 DOI: 10.1371/journal.pone.0290735] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 08/14/2023] [Indexed: 08/31/2023] Open
Abstract
Enterobacter cloacae is a Gram-negative rod with multidrug-resistant potential due to chromosomally-induced AmpC β-lactamase. We evaluated characteristics, antibiotic utilization, and outcomes associated with battlefield-related E. cloacae infections (2009-2014). Single initial and serial E. cloacae isolates (≥24 hours from initial isolate from any site) associated with a clinical infection were examined. Susceptibility profiles of initial isolates in the serial isolation group were contrasted against last isolate recovered. Characteristics of 112 patients with E. cloacae infections (63 [56%] with single initial isolation; 49 [44%] with serial isolation) were compared to 509 patients with bacterial infections not attributed to E. cloacae. E. cloacae patients sustained more blast trauma (78%) compared to non-E. cloacae infections patients (75%; p<0.001); however, injury severity scores were comparable (median of 34.5 and 33, respectively; p = 0.334). Patients with E. cloacae infections had greater shock indices (median 1.07 vs 0.92; p = 0.005) and required more initial blood products (15 vs. 14 units; p = 0.032) compared to patients with non-E. cloacae infections. Although E. cloacae patients had less intensive care unit admissions (80% vs. 90% with non-E. cloacae infection patients; p = 0.007), they did have more operating room visits (5 vs. 4; p = 0.001), longer duration of antibiotic therapy (43.5 vs. 34 days; p<0.001), and lengthier hospitalizations (57 vs. 44 days; p<0.001). Patients with serial E. cloacae had isolation of infecting isolates sooner than patients with single initial E. cloacae (median of 5 vs. 8 days post-injury; p = 0.046); however, outcomes were not significantly different between the groups. Statistically significant resistance to individual antibiotics did not develop between initial and last isolates in the serial isolation group. Despite current combat care and surgical prophylaxis guidelines recommending upfront provision of AmpC-inducing antibiotics, clinical outcomes did not differ nor did significant antibiotic resistance develop in patients who experienced serial isolation of E. cloacae versus single initial isolation.
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Affiliation(s)
- William Bennett
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, United States of America
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Katrin Mende
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, United States of America
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - Wesley R. Campbell
- Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
| | - Miriam Beckius
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, United States of America
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - Azizur Rahman
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - David R. Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
| | - Joseph M. Yabes
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, United States of America
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
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Vlok M, Maloney T, Dilkes-Hall IE, Oktaviana AA, Setiawan P, Priyatno AAD, Ririmasse M, Geria IM, Effendy MAR, Istiawan B, Atmoko FT, Adhityatama S, Moffat I, Joannes-Boyau R, Brumm A, Aubert M. Reply to: Common orthopaedic trauma may explain 31,000-year-old remains. Nature 2023; 615:E15-E18. [PMID: 36922613 PMCID: PMC10017509 DOI: 10.1038/s41586-023-05757-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Affiliation(s)
- Melandri Vlok
- Sydney Southeast Asian Centre, University of Sydney, Sydney, New South Wales, Australia.
| | - Tim Maloney
- Griffith Centre for Social and Cultural Research, Griffith University, Gold Coast, Queensland, Australia.
- Australian Research Centre for Human Evolution, Griffith University, Nathan, Queensland, Australia.
- Research into Deer Genetics and Environment, RIDGE Group Inc, Ascot, Western Australia, Australia.
| | - India Ella Dilkes-Hall
- Archaeology, School of Social Sciences, University of Western Australia, Crawley, Western Australia, Australia
| | - Adhi Agus Oktaviana
- School of Humanities, Languages and Social Science, Griffith University, Gold Coast, Queensland, Australia
- BRIN, OR Arkeologi, Bahasa dan Sastra, Pusat Riset Arkeometri, Jakarta, Indonesia
| | - Pindi Setiawan
- Faculty of Art and Design, Bandung Institute of Technology, Bandung, Indonesia
| | | | - Marlon Ririmasse
- BRIN, OR Arkeologi, Bahasa dan Sastra, Pusat Riset Arkeometri, Jakarta, Indonesia
| | - I Made Geria
- BRIN, OR Arkeologi, Bahasa dan Sastra, Pusat Riset Arkeometri, Jakarta, Indonesia
| | | | - Budy Istiawan
- Balai Pelestarian Cagar Budaya Kalimantan Timur, Samarinda, Indonesia
| | | | - Shinatria Adhityatama
- School of Humanities, Languages and Social Science, Griffith University, Gold Coast, Queensland, Australia
| | - Ian Moffat
- Archaeology, College of Humanities, Arts and Social Sciences, Flinders University, Bedford Park, South Australia, Australia
| | - Renaud Joannes-Boyau
- Geoarchaeology and Archaeometry Research Group (GARG), Southern Cross University, Lismore, New South Wales, Australia
- Palaeo-Research Institute, University of Johannesburg, Johannesburg, South Africa
| | - Adam Brumm
- Australian Research Centre for Human Evolution, Griffith University, Nathan, Queensland, Australia
| | - Maxime Aubert
- Griffith Centre for Social and Cultural Research, Griffith University, Gold Coast, Queensland, Australia
- Australian Research Centre for Human Evolution, Griffith University, Nathan, Queensland, Australia
- Geoarchaeology and Archaeometry Research Group (GARG), Southern Cross University, Lismore, New South Wales, Australia
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12
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Jennings BM, Ransom JC, Hopkinson SG. The Influence of Time and Place on the Experiences of US Military Nurses in Vietnam. Nurs Outlook 2022; 70:S104-S114. [PMID: 36585057 DOI: 10.1016/j.outlook.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 08/18/2022] [Accepted: 08/18/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although the conflict in Vietnam (usually referred to as the Vietnam War) ended almost 50 years ago, few research-based publications of nurses' experiences in Vietnam exist. PURPOSE The purpose of this study was to expand what is known about the experiences of US military nurses who served in Vietnam. METHODS This secondary analysis used qualitative description to examine interview data from 15 nurses who served in-country (within Vietnam) and in-theater supporting Vietnam (e.g., Guam, the Philippines) between 1965 and 1972. FINDINGS We found that nurses' experiences varied based on time deployed and place deployed (land, sea, or air; in-country or in-theater). The influence of time and place on US military nurses' experiences in Vietnam are illustrated through findings pertaining to danger, daily life, and work. The most prominent differences were between nurses assigned in-country and those assigned in-theater. DISCUSSION The findings illustrate ways research of more recent and future conflicts might be strengthened.
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Affiliation(s)
- Bonnie Mowinski Jennings
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA; Colonel, US Army (retired).
| | - Jeffrey C Ransom
- US Army Nurse Corps, Center for Nursing Science & Clinical Inquiry, Madigan Army Medical Center, Tacoma, WA; Major, US Army
| | - Susan G Hopkinson
- Nursing & Health Studies, University of Wisconsin, Green Bay, WI; Colonel, US Army (retired)
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McCarthy SL, Stewart L, Shaikh F, Murray CK, Tribble DR, Blyth DM. Prognostic Value of Sequential Organ Failure Assessment (SOFA) Score in Critically-Ill Combat-Injured Patients. J Intensive Care Med 2022; 37:1426-1434. [PMID: 35171072 PMCID: PMC9378752 DOI: 10.1177/08850666221078196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Infection is a frequent and serious complication after combat-related trauma. The Sequential Organ Failure Assessment (SOFA) score has been shown to have predictive value for outcomes, including sepsis and mortality, among various populations. We evaluated the prognostic ability of SOFA score in a combat-related trauma population. Methods: Combat casualties (2009-2014) admitted to Landstuhl Regional Medical Center (LRMC; Germany) intensive care unit (ICU) within 4 days post-injury followed by transition to ICUs in military hospitals in the United States were included. Multivariate logistic regression was used to determine predictive effect of selected variables and receiver operating characteristic (ROC) curve analysis was used to evaluate overall accuracy of SOFA score for infection prediction. Results: Of the 748 patients who met inclusion criteria, 436 (58%) were diagnosed with an infection (32% bloodstream, 63% skin and soft tissue, and 40% pulmonary) and were predominantly young (median 24 years) males. Penetrating trauma accounted for 95% and 86% of injuries among those with and without infections, respectively (p < 0.001). Median LRMC admission SOFA score was 7 (interquartile range [IQR]: 4-9) in patients with infections versus 4 (IQR: 2-6) in patients without infections (p < 0.001). Thirty-day mortality was 2% in both groups. On multivariate regression, LRMC SOFA score was independently associated with infection development (odds ratio: 1.2; 95% confidence interval: 1.1-1.3). The ROC curve analysis revealed an area under the curve of 0.69 for infection prediction, and 0.80 for mortality prediction. Conclusions: The SOFA scores obtained up to 4 days post-injury predict late onset infection occurrence. This study revealed that for every 1 point increase in LRMC SOFA score, the odds of having an infection increases by a factor of 1.2, controlling for other predictors. The use of SOFA score in admission assessments may assist clinicians with identifying those at higher risk of infection following combat-related trauma.
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Affiliation(s)
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | | | - David R. Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Dana M. Blyth
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA
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Tribble DR, Spott MA, Shackleford SA, Gurney JM, Murray BCK. Department of Defense Trauma Registry Infectious Disease Module Impact on Clinical Practice. Mil Med 2022; 187:7-16. [PMID: 35512379 DOI: 10.1093/milmed/usac050] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/03/2022] [Accepted: 02/14/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The Joint Trauma System (JTS) is a DoD Center of Excellence for Military Health System trauma care delivery and the DoD's reference body for trauma care in accordance with National Defense Authorization Act for Fiscal Year 2017. Through the JTS, evidence-based clinical practice guidelines (CPGs) have been developed and subsequently refined to standardize and improve combat casualty care. Data are amassed through a single, centralized DoD Trauma Registry to support process improvement measures with specialty modules established as the registry evolved. Herein, we review the implementation of the JTS DoD Trauma Registry specialty Infectious Disease Module and the development of infection-related CPGs and summarize published findings on the subsequent impact of the Infectious Disease Module on combat casualty care clinical practice and guidelines. METHODS The DoD Trauma Registry Infectious Disease Module was developed in collaboration with the Infectious Disease Clinical Research Program (IDCRP) Trauma Infectious Disease Outcomes Study (TIDOS). Infection-related information (e.g., syndromes, antibiotic management, and microbiology) were collected from military personnel wounded during deployment June 1, 2009 through December 31, 2014 and medevac'd to Landstuhl Regional Medical Center in Germany before transitioning to participating military hospitals in the USA. RESULTS To support process improvements and reduce variation in practice patterns, data collected through the Infectious Disease Module have been utilized in TIDOS analyses focused on assessing compliance with post-trauma antibiotic prophylaxis recommendations detailed in JTS CPGs. Analyses examined compliance over three time periods: 6 months, one-year, and 5 years. The five-year analysis demonstrated significantly improved adherence to recommendations following the dissemination of the 2011 JTS CPG, particularly with open fractures (34% compliance compared to 73% in 2013-2014). Due to conflicting recommendations regarding use of expanded Gram-negative coverage with open fractures, infectious outcomes among patients with open fractures who received cefazolin or expanded Gram-negative coverage (cefazolin plus fluoroquinolones and/or aminoglycosides) were also examined in a TIDOS analysis. The lack of a difference in the proportion of osteomyelitis (8% in both groups) and the significantly greater recovery of Gram-negative organisms resistant to aminoglycosides or fluoroquinolones among patients who received expanded Gram-negative coverage supported JTS recommendations regarding the use of cefazolin with open fractures. Following recognition of the outbreak of invasive fungal wound infections (IFIs) among blast casualties injured in Afghanistan, the ID Module was refined to capture data (e.g., fungal culture and histopathology findings, wound necrosis, and antifungal management) needed for the TIDOS team to lead the DoD outbreak investigation. These data captured through the Infectious Disease Module provided support for the development of a JTS CPG for the prevention and management of IFIs, which was later refined based on subsequent TIDOS IFI analyses. CONCLUSIONS To improve combat casualty care outcomes and mitigate high-consequence infections in future conflicts, particularly in the event of prolonged field care, expansion, refinement, and a mechanism for sustainability of the DoD Trauma Registry Infectious Disease Module is needed to include real-time surveillance of infectious disease trends and outcomes.
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Affiliation(s)
- David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Mary Ann Spott
- Joint Trauma System, JBSA Fort Sam Houston, TX 78234, USA
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15
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McDonald J, Liang SY, Li P, Stewart L, Tribble DR. DoD-VA Trauma Infection Research Collaboration. Mil Med 2022; 187:17-24. [PMID: 35512378 DOI: 10.1093/milmed/usab482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/28/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In the aftermath of wars, there is a surge in the number of wounded service members who leave active duty and become eligible for healthcare through the Department of Veterans Affairs (VA). Collaborations between the Department of Defense (DoD) and VA are crucial to capture comprehensive data and further understand the long-term impact of battlefield trauma. We provide a summary of the development, methodology, and status of an effective collaboration between the Infectious Disease Clinical Research Program and the St. Louis VA Health Care System with the multicenter, observational Trauma Infectious Disease Outcomes Study (TIDOS), which examines the short- and long-term outcomes of deployment-related trauma. METHODS As part of TIDOS, wounded service members who transitioned to participating military hospitals in the United States (2009-2014) were given the opportunity to enroll in a prospective follow-up cohort study to continue to capture infection-related data after their hospital discharge. Enrollees in the TIDOS cohort who left military service and received health care through the VA also had the option of consenting to have relevant VA medical records abstracted and included with the study data. Infections considered to be complications resulting from the initial trauma were examined. RESULTS Among 1,336 TIDOS enrollees, 1,221 (91%) registered and received health care through the VA with 633 (47%) consenting to follow-up using VA records and comprising the TIDOS-VA cohort. Of the first 337 TIDOS-VA cohort enrollees, 38% were diagnosed with a new trauma-related infection following hospital discharge (median: 88 days; interquartile range: 18-351 days). Approximately 71% of the infections were identified through DoD sources (medical records and follow-up) and 29% were identified through VA electronic medical records, demonstrating the utility of DoD-VA collaborations. The TIDOS DoD-VA collaboration has also been utilized to assess intermediate and long-term consequences of specific injury patterns. Among 89 TIDOS-VA cohort enrollees with genitourinary trauma, 36% reported sexual dysfunction, 21% developed at least one urinary tract infection, 14% had urinary retention/incontinence, and 8% had urethral stricture. The rate of urinary tract infections was 0.05/patient-year during DoD follow-up time and 0.07/patient-year during VA follow-up time. CONCLUSIONS Wider capture of infection-related outcome data through the DoD-VA collaboration provided a clearer picture of the long-term infection burden resulting from deployment-related trauma. Planned analyses include assessment of osteomyelitis among combat casualties with amputations and/or open fractures, evaluation of mental health and social factors related to injury patterns, and examination of health care utilization and cost in relation to infectious disease burdens.
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Affiliation(s)
- Jay McDonald
- Infectious Diseases Section, Veterans Affairs St. Louis Health Care System, St. Louis, MO 63106, USA.,Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Stephen Y Liang
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Ping Li
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Ford MB, Mende K, Kaiser SJ, Beckius ML, Lu D, Stam J, Li P, Stewart L, Tribble DR, Blyth DM. Clinical Characteristics and Resistance Patterns of Pseudomonas aeruginosa Isolated From Combat Casualties. Mil Med 2022; 187:426-434. [PMID: 34196358 PMCID: PMC8963144 DOI: 10.1093/milmed/usab259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/06/2021] [Accepted: 06/21/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Multidrug-resistant (MDR) Gram-negative infections complicate care of combat casualties. We describe the clinical characteristics, resistance patterns, and outcomes of Pseudomonas aeruginosa infections in combat casualties. METHODS Combat casualties included in the Trauma Infectious Disease Outcomes Study with infections with and without P. aeruginosa isolation during initial hospitalization were compared. Pseudomonas aeruginosa from initial wound, blood, and serial isolates (≥7 days from previous isolate) collected from June 2009 through February 2014 was subjected to antimicrobial susceptibility testing, pulsed-field gel electrophoresis, and whole genome sequencing for assessing clonality. Multidrug resistance was determined using the CDC National Healthcare Safety Network definition. RESULTS Of 829 combat casualties with infections diagnosed during initial hospitalization, 143 (17%) had P. aeruginosa isolated. Those with P. aeruginosa were more severely injured (median Injury Severity Score 33 [interquartile range (IQR) 27-45] vs 30 [IQR 18.5-42]; P < .001), had longer hospitalizations (median 58.5 [IQR 43-95] vs 38 [IQR 26-56] days; P < .001), and higher mortality (6.9% vs 1.5%; P < .001) than those with other organisms. Thirty-nine patients had serial P. aeruginosa isolation (median 2 subsequent isolates; IQR: 1-5), with decreasing antimicrobial susceptibility. Ten percent of P. aeruginosa isolates were MDR, associated with prior exposure to antipseudomonal antibiotics (P = .002), with amikacin and colistin remaining the most effective antimicrobials. Novel antimicrobials targeting MDR Gram-negative organisms were also examined, and 100% of the MDR P. aeruginosa isolates were resistant to imipenem/relabactam, while ceftazidime/avibactam and ceftolozane/tazobactam were active against 35% and 56% of the isolates, respectively. We identified two previously unrecognized P. aeruginosa outbreaks involving 13 patients. CONCLUSIONS Pseudomonas aeruginosa continues to be a major cause of morbidity, affecting severely injured combat casualties, with emergent antimicrobial resistance upon serial isolation. Among MDR P. aeruginosa, active antimicrobials remain the oldest and most toxic. Despite ongoing efforts, outbreaks are still noted, reinforcing the crucial role of antimicrobial stewardship and infection control.
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Affiliation(s)
- Mary B Ford
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Katrin Mende
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- Infectious Disease Clinical Research Program, Department ofPreventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Susan J Kaiser
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- Infectious Disease Clinical Research Program, Department ofPreventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Miriam L Beckius
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Dan Lu
- Infectious Disease Clinical Research Program, Department ofPreventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Jason Stam
- Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Ping Li
- Infectious Disease Clinical Research Program, Department ofPreventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Department ofPreventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department ofPreventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Dana M Blyth
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
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Bergmann-Leitner ES, Bobrov AG, Bolton JS, Rouse MD, Heyburn L, Pavlovic R, Garry BI, Alamneh Y, Long J, Swierczewski B, Tyner S, Getnet D, Sajja VS, Antonic V. Blast Waves Cause Immune System Dysfunction and Transient Bone Marrow Failure in a Mouse Model. Front Bioeng Biotechnol 2022; 10:821169. [PMID: 35392409 PMCID: PMC8980552 DOI: 10.3389/fbioe.2022.821169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/23/2022] [Indexed: 11/29/2022] Open
Abstract
Explosive devices, either conventional or improvised, are common sources of injuries during combat, civil unrest, and terror attacks, resulting in trauma from exposure to blast. A blast wave (BW), a near-instantaneous rise in pressure followed by a negative pressure, propagates through the body in milliseconds and can affect physiology for days/months after exposure. Epidemiological data show that blast-related casualties result in significantly higher susceptibility to wound infections, suggesting long-lasting immune modulatory effects from blast exposure. The mechanisms involved in BW-induced immune changes are poorly understood. We evaluated the effects of BW on the immune system using an established murine model. Animals were exposed to BWs (using an Advanced Blast Simulator), followed by longitudinally sampling for 14 days. Blood, bone marrow, and spleen were analyzed for changes in the 1) complete blood count (CBC), and 2) composition of bone marrow cells (BMC) and splenocytes, and 3) concentrations of systemic cytokines/chemokines. Our data demonstrate that BW results in transient bone marrow failure and long-term changes in the frequency and profile of progenitor cell populations. Viability progressively decreased in hematopoietic stem cells and pluripotent progenitor cells. Significant decrease of CD4+ T cells in the spleen indicates reduced functionality of adaptive immune system. Dynamic changes in the concentrations of several cytokines and chemokines such as IL-1α and IL-17 occurred potentially contributing to dysregulation of immune response after trauma. This work lays the foundation for identifying the potential mechanisms behind BW’s immunosuppressive effects to inform the recognition of this compromised status is crucial for the development of therapeutic interventions for infections to reduce recovery time of wounded patients injured by explosive devices.
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Affiliation(s)
- Elke S. Bergmann-Leitner
- Biologics Research and Development, Walter Reed Army Institute of Research, Silver Spring, MD, United States
- *Correspondence: Elke S. Bergmann-Leitner, ; Venkatasivasai S. Sajja, ; Vlado Antonic,
| | - Alexander G. Bobrov
- Wound Infections Department, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Jessica S. Bolton
- Biologics Research and Development, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Michael D. Rouse
- Wound Infections Department, Naval Research Medical Center, Silver Spring, MD, United States
- Henry M. Jackson Foundation, Rockville, MD, United States
| | - Lanier Heyburn
- Blast Induced Neurotrauma Branch, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Radmila Pavlovic
- Wound Infections Department, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Brittany I. Garry
- Wound Infections Department, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Yonas Alamneh
- Wound Infections Department, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Joseph Long
- Blast Induced Neurotrauma Branch, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Brett Swierczewski
- Bacterial Disease Branch, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Stuart Tyner
- Military Infectious Diseases Research Program, Frederick, MD, United States
| | - Derese Getnet
- Wound Infections Department, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Venkatasivasai S. Sajja
- Blast Induced Neurotrauma Branch, Walter Reed Army Institute of Research, Silver Spring, MD, United States
- *Correspondence: Elke S. Bergmann-Leitner, ; Venkatasivasai S. Sajja, ; Vlado Antonic,
| | - Vlado Antonic
- Wound Infections Department, Walter Reed Army Institute of Research, Silver Spring, MD, United States
- *Correspondence: Elke S. Bergmann-Leitner, ; Venkatasivasai S. Sajja, ; Vlado Antonic,
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Oley MH, Oley MC, Wewengkang LAW, Kepel BJ, Langi FLFG, Setiadi T, Aling DMR, Gunawan DF, Tulong MT, Faruk M. Bactericidal effect of hyperbaric oxygen therapy in burn injuries. Ann Med Surg (Lond) 2022; 74:103314. [PMID: 35145678 PMCID: PMC8819012 DOI: 10.1016/j.amsu.2022.103314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/14/2022] [Accepted: 01/23/2022] [Indexed: 12/20/2022] Open
Abstract
Introduction Burn injuries are frequently encountered in emergency cases and often become the port of entry for pathogens. More than 450,000 burn injuries occur annually causing nearly 3,400 deaths in the United States. The prevalence of burn injury in Indonesia is 0.7% in 2013. More than half of these According to several studies on the use of patients were treated for bacterial infections, some of which were resistant to certain antibiotics. Using hyperbaric oxygen therapy (HBOT) to treat burns has several positive effects including managing bacterial infections, as well as accelerating the wound healing process. Therefore, this study aims to prove the effectiveness of HBOT in inhibiting bacterial growth. Methods This is an experimental research study in rabbits using a post-test control group design. 38 rabbits were given second-degree burns on the shoulder region with a metal iron plate that has been previously heated for 3 min. Bacterial cultures were taken on days 5 and 10 after exposure to the burns. The samples were divided into two groups, HBOT and control. Statistical analyses were performed using the Mann-Whitney U method. Results Gram-negative bacteria were the most frequently found pathogen in both groups. Citrobacter freundi was the most common Gram-negative bacteria (34%) found in the culture results of both groups. In contrast to the control group, there was no bacterial growth found in the HBOT group's culture results, (0%) vs (58%). A significant reduction of bacterial growth was observed in the HBOT group (69%) compared with the control group (5%). Bacterial levels stagnated in 6 rabbits (31%) in the HBOT group and 7 rabbits (37%) in the control group. Overall, there was significantly less bacterial growth in the HBOT treatment group compared with the control group (p < 0.001). Conclusion HBOT administration can significantly reduce bacterial growth in burn injuries. Hyperbaric oxygen therapy (HBOT) to treat burns has several positive effects including managing bacterial infections. HBOT influence the extent of a bacterial infection based on reduced bacterial counts after receiving HBOT. The bactericidal effects of HBOT are obtained by inducing the release of reactive oxygen species.
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Affiliation(s)
- Mendy Hatibie Oley
- Plastic Reconstructive and Aesthetic Surgery Division, Department of Surgery, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
- Plastic Reconstructive and Aesthetic Surgery Division, Department of Surgery, R. D. Kandou Hospital, Manado, Indonesia
- Hyperbaric Centre Siloam Hospital, Manado, Indonesia
- Corresponding author. Reconstructive & Aesthetic Plastic Surgery Division, Department of Surgery, Faculty of Medicine, University Sam Ratulangi, Jalan Raya Tanawangko No.56, Malalayang Satu Barat, Malalayang, Manado City, North Sulawesi, 95162, Indonesia.
| | - Maximillian Christian Oley
- Hyperbaric Centre Siloam Hospital, Manado, Indonesia
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
- Division of Neurosurgery, Department of Surgery, R. D. Kandou Hospital, Manado, Indonesia
| | | | - Billy Johnson Kepel
- Department of Chemistry, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
| | - Fima Lanra Fredrik G. Langi
- Department Epidemiology and Biostatistics, Public Health Faculty, Sam Ratulangi University, Manado, Indonesia
| | - Taat Setiadi
- Department of Surgery, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
- Department of Surgery, R. D. Kandou Hospital, Manado, Indonesia
| | | | | | | | - Muhammad Faruk
- Department of Surgery, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
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Bobrov AG, Getnet D, Swierczewski B, Jacobs A, Medina-Rojas M, Tyner S, Watters C, Antonic V. Evaluation of Pseudomonas aeruginosa pathogenesis and therapeutics in military-relevant animal infection models. APMIS 2021; 130:436-457. [PMID: 34132418 DOI: 10.1111/apm.13119] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/21/2021] [Indexed: 01/02/2023]
Abstract
Modern combat-related injuries are often associated with acute polytrauma. As a consequence of severe combat-related injuries, a dysregulated immune response results in serious infectious complications. The gram-negative bacterium Pseudomonas aeruginosa is an opportunistic pathogen that often causes life-threatening bloodstream, lung, bone, urinary tract, and wound infections following combat-related injuries. The rise in the number of multidrug-resistant P. aeruginosa strains has elevated its importance to civilian clinicians and military medicine. Development of novel therapeutics and treatment options for P. aeruginosa infections is urgently needed. During the process of drug discovery and therapeutic testing, in vivo testing in animal models is a critical step in the bench-to-bedside approach, and required for Food and Drug Administration approval. Here, we review current and past literature with a focus on combat injury-relevant animal models often used to understand infection development, the interplay between P. aeruginosa and the host, and evaluation of novel treatments. Specifically, this review focuses on the following animal infection models: wound, burn, bone, lung, urinary tract, foreign body, and sepsis.
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Affiliation(s)
- Alexander G Bobrov
- Wound Infections Department, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Derese Getnet
- Wound Infections Department, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Brett Swierczewski
- Wound Infections Department, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Anna Jacobs
- Wound Infections Department, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Maria Medina-Rojas
- Wound Infections Department, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Stuart Tyner
- US Army Medical Research and Development Command Military Infectious Diseases Research Program, Frederick, Maryland, USA
| | - Chase Watters
- Naval Medical Research Unit-3, Ghana Detachment, Accra, Ghana
| | - Vlado Antonic
- Wound Infections Department, Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
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Velasco JM, Valderama MT, Margulieux K, Diones PC, Peacock T, Navarro FC, Liao C, Chua D, Macareo L, Crawford J, Swierczewski B. Comparison of Carbapenem-Resistant Microbial Pathogens in Combat and Non-combat Wounds of Military and Civilian Patients Seen at a Tertiary Military Hospital, Philippines (2013-2017). Mil Med 2021; 185:e197-e202. [PMID: 31247085 DOI: 10.1093/milmed/usz148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/31/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Bacterial wound infections are a danger to both military and civilian populations. The nature of injury and infection associated with combat related wounds are important in guiding antibiotic prophylaxis and empiric treatment guidelines. MATERIALS AND METHODS The isolates were screened for drug-resistance by the MicroScan Walkaway Plus System using either the Negative Breakpoint Combo Panel (NBCP) 30 or 34 or Positive Breakpoint Combo Panel (PBPC) 20 or 23. Isolates with a minimum inhibitory concentration (MIC) of ≥8 μg/mL to imipenem and/or meropenem were tested for both carbapenemase production using the CarbaNP test and real-time PCR to determine molecular resistance mechanisms. Plasmid conjugation analysis was performed to define potential for horizontal gene transfer. RESULTS We characterized 634 bacterial wound isolates collected from September 2013 to December 2017 from patients seen at a Philippine military tertiary hospital presenting with combat or non-combat injuries [354 (military) and 280 (civilians)]. Staphylococcus aureus was the most predominant bacterial species isolated from wounds in both populations (104/634, 16%). A variety of Gram-negative bacterial species comprised 442/634 (70%) of the isolates identified, with the most prevalent shown to be Pseudomonas aeruginosa, Enterobacter cloacae, Klebsiella pneumoniae, Escherichia coli, and Acinetobacter sp. Carbapenemase production was detected in 34/442 (8%) Gram-negative isolates. Testing for molecular resistance mechanisms showed 32/34 (17 military, 15 civilian) wound isolates were blaNDM positive and 2 were blaVIM positive, with the two blaVIM isolates found in the civilian population. Plasmid conjugation of 14 blaNDM and 2 blaVIM positive wound isolates representatives showed 2/16 (13%) produced E. coli J53 transconjugants (E. coli from a civilian; E. cloacae from a military). CONCLUSION We describe in this study the wound bacterial and antibiotic resistance profile in the military (combat vs non-combat associated) and civilian population. We observed that, with the exception of Acinetobacter sp., resistance of prevalent Gram-negative bacterial species to imipenem or meropenem were not significantly different between the military and civilian populations. We also presented data on the prevalent bacterial species isolated from both combat and non-combat wounds in a military tertiary care hospital setting as well as the carbapenemase-encoding gene primarily responsible for carbapenem resistance as well as evidence of horizontal transfer via mobile genetic elements. Clinicians may use this information to guide empiric antibiotic coverage for the predominant organisms if wound culture results are not readily available.A prospective, longitudinal evaluation of the wound bacterial profile documenting the changing bacterial flora using higher resolution molecular strategies can provide a more comprehensive understanding of the diversity, composition, and abundance of bacterial composition of the wound microbial community from the time of injury, during the course of evacuation from the field to higher level of care facilities, and up to wound resolution.
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Affiliation(s)
- John Mark Velasco
- Department of Virology, U.S. Army Medical Directorate - Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand 10400.,University of the Philippines Manila, Ermita, Manila, Philippines 1000
| | - Ma Theresa Valderama
- Department of Virology, U.S. Army Medical Directorate - Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand 10400
| | - Katie Margulieux
- Department of Bacterial and Parasitic Diseases, U.S. Army Medical Directorate - Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand 10400
| | - Paula Corazon Diones
- Department of Virology, U.S. Army Medical Directorate - Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand 10400
| | - Trent Peacock
- Department of Bacterial and Parasitic Diseases, U.S. Army Medical Directorate - Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand 10400
| | - Fatima Claire Navarro
- V Luna Medical Center, Armed Forces of the Philippines Health Service Command, V Luna Ave., Quezon City, Philippines 0840
| | - Cynthia Liao
- V Luna Medical Center, Armed Forces of the Philippines Health Service Command, V Luna Ave., Quezon City, Philippines 0840
| | - Domingo Chua
- V Luna Medical Center, Armed Forces of the Philippines Health Service Command, V Luna Ave., Quezon City, Philippines 0840
| | - Louis Macareo
- Department of Virology, U.S. Army Medical Directorate - Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand 10400
| | - John Crawford
- University of the Philippines Manila, Ermita, Manila, Philippines 1000
| | - Brett Swierczewski
- Bacterial Disease Branch, Walter Reed Army Institute of Research, MD 20910-7500
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Bozzay JD, Walker PF, Schechtman DW, Shaikh F, Stewart L, Tribble DR, Bradley MJ. Outcomes of Exploratory Laparotomy and Abdominal Infections Among Combat Casualties. J Surg Res 2021; 257:285-293. [PMID: 32866669 PMCID: PMC7736445 DOI: 10.1016/j.jss.2020.07.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/09/2020] [Accepted: 07/11/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Abdominal injuries historically account for 13% of battlefield surgical procedures. We examined the occurrence of exploratory laparotomies and subsequent abdominal surgical site infections (SSIs) among combat casualties. METHODS Military personnel injured during deployment (2009-2014) were included if they required a laparotomy for combat-related trauma and were evacuated to Landstuhl Regional Medical Center, Germany, before being transferred to participating US military hospitals. RESULTS Of 4304 combat casualties, 341 (7.9%) underwent laparotomy. Including re-explorations, 1053 laparotomies (median, 2; interquartile range, 1-3; range, 1-28) were performed with 58% occurring within the combat zone. Forty-nine (14.4%) patients had abdominal SSIs (four with multiple SSIs): 27 (7.9%) with deep space SSIs, 14 (4.1%) with a deep incisional SSI, and 12 (3.5%) a superficial incisional SSI. Patients with abdominal SSIs had larger volume of blood transfusions (median, 24 versus 14 units), more laparotomies (median, 4 versus 2), and more hollow viscus injuries (74% versus 45%) than patients without abdominal SSIs. Abdominal closure occurred after 10 d for 12% of the patients with SSI versus 2% of patients without SSI. Mesh adjuncts were used to achieve fascial closure in 20.4% and 2.1% of patients with and without SSI, respectively. Survival was 98% and 96% in patients with and without SSIs, respectively. CONCLUSIONS Less than 10% of combat casualties in the modern era required abdominal exploration and most were severely injured with hollow viscus injuries and required massive transfusions. Despite the extensive contamination from battlefield injuries, the SSI proportion is consistent with civilian rates and survival was high.
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Affiliation(s)
- Joseph D Bozzay
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland.
| | - Patrick F Walker
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Matthew J Bradley
- Department of Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, Maryland
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Designed Antimicrobial Peptides Against Trauma-Related Cutaneous Invasive Fungal Wound Infections. J Fungi (Basel) 2020; 6:jof6030184. [PMID: 32971819 PMCID: PMC7559897 DOI: 10.3390/jof6030184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 01/22/2023] Open
Abstract
Cutaneous invasive fungal wound infections after life-threatening dismounted complex blast injury (DCBI) and natural disasters complicate clinical care. These wounds often require aggressive repeated surgical debridement, can result in amputations and hemipelvectomies and have a 38% mortality rate. Given the substantial morbidity associated with cutaneous fungal wound infections, patients at risk need immediate empiric treatment mandating the use of rapidly acting broad-spectrum antimicrobials, acting on both fungi and bacteria, that are also effective against biofilm and can be administered topically. Designed antimicrobial peptides (dAMPs) are engineered analogues of innate antimicrobial peptides which provide the first line of defense against invading pathogens. The antifungal and antibacterial effect and mammalian cytotoxicity of seven innovative dAMPs, created by iterative structural analog revisions and physicochemical and functional testing were investigated. The dAMPs possess broad-spectrum antifungal activity, in addition to being effective against Gram-negative and Gram-positive bacteria, which is crucial as many wounds are polymicrobial and require immediate empiric treatment. Three of the most potent dAMPs—RP504, RP556 and RP557—possess limited mammalian cytotoxicity following 8 h incubation. If these encouraging broad-spectrum antimicrobial and rapid acting results are translated clinically, these novel dAMPs may become a first line empiric topical treatment for traumatic wound injuries.
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Barsoumian AE, Solberg SL, Hanhurst AS, Roth AL, Funari TS, Cruz-Fehr MCE, Crouch H, Florez C, Murray CK. Status Update on Infection Prevention and Control at Deployed Medical Treatment Facilities. Mil Med 2020; 185:451-460. [PMID: 31681959 DOI: 10.1093/milmed/usz359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Infections with multidrug resistant organisms that spread through nosocomial transmission complicate the care of combat casualties. Missions conducted to review infection prevention and control (IPC) practices at deployed medical treatment facilities (MTFs) previously showed gaps in best practices and saw success with targeted interventions. An IPC review has not been conducted since 2012. Recently, an IPC review was requested in response to an outbreak of multidrug resistant organisms at a deployed facility. MATERIALS AND METHODS A Joint Service team conducted onsite IPC reviews of MTFs in the U.S. Central Command area of operations. Self-assessments were completed by MTF personnel in anticipation of the onsite assessment, and feedback was given individually and at monthly IPC working group teleconferences. Goals of the onsite review were to assist MTF teams in conducting assessments, review practices for challenges and successes, provide on the spot education or risk mitigation, and identify common trends requiring system-wide action. RESULTS Nine deployed MTFs participated in the onsite assessments, including four Role 3, three Role 2 capable of surgical support, and two Role 1 facilities. Seventy-eight percent of sites had assigned IPC officers although only 43% underwent required predeployment training. Hand hygiene and healthcare associated infection prevention bundles were monitored at 67% and 29% of MTFs, respectively. Several challenges including variability in practices with turnover of deployed teams were noted. Successes highlighted included individual team improvements in healthcare associated infections and mentorship of untrained personnel. CONCLUSIONS Despite successes, ongoing challenges with optimal deployed IPC were noted. Recommendations for improvement include strengthening IPC culture, accountability, predeployment training, and stateside support for deployed IPC assets. Variability in IPC practices may occur from rotation to rotation, and regular reassessment is required to ensure that successes are sustained through times of turnover.
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Affiliation(s)
- Alice E Barsoumian
- Infectious Disease Service, Department of Medicine, San Antonio Military Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
| | - Steffanie L Solberg
- United States Air Forces Central Command, Command Surgeon Cell, 524 Shaw Drive, Suite B-15, Shaw Air Force Base, SC 29152
| | - Ashley S Hanhurst
- Main Operating Room, Department of Surgical Services, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889
| | - Amanda L Roth
- US Army Medical Materiel Development Activity, 1430 Veterans Drive, Fort Detrick, MD 21702
| | - Tamara S Funari
- U.S. Central Command HQ, Surgeon Division, 7115 South Boundary Blvd., MacDill AFB, FL 33621
| | - Maria Cristina E Cruz-Fehr
- 60th Medical Group, Infection Prevention and Control Office, David Grant Medical Center, 101 Bodin Circle, Travis Air Force, CA 94535
| | - Helen Crouch
- Infection Prevention and Control, Quality and Safety Center U.S. Army Medical Command Headquarters, 2748 Worth Rd. STE 26, Ft Sam Houston, TX 78234
| | - Christopher Florez
- United States Air Force Infection Prevention Consultant to the Surgeon General, 3488 Garden Avenue, JBSA Fort Sam Houston, TX 78234
| | - Clinton K Murray
- 1st Area Medical Laboratory, 6745 Plum Point Drive, Aberdeen Proving Ground, MD 21005
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Neff JA, Bayramov DF, Patel EA, Miao J. Novel Antimicrobial Peptides Formulated in Chitosan Matrices are Effective Against Biofilms of Multidrug-Resistant Wound Pathogens. Mil Med 2020; 185:637-643. [PMID: 32074338 PMCID: PMC7029774 DOI: 10.1093/milmed/usz222] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Infection frequently complicates the treatment of combat-related wounds, impairs healing, and leads to worse outcomes. To better manage wound infections, antimicrobial therapies that are effective against biofilm and designed for direct wound application are needed. The primary objective of this work was to evaluate a chitosan matrix for delivery of two engineered antimicrobial peptides, (ASP)-1 and ASP-2, to treat biofilm-associated bacteria. A secondary objective was to determine whether replacing the levorotatory (L) form amino acids in ASP-2 with dextrorotatory (D) form amino acids would impact peptide activity. MATERIALS AND METHODS Chitosan gels loaded with antimicrobial peptides were evaluated for peptide release over 7 days and tested for efficacy against biofilms grown both in vitro on polymer mesh and ex vivo on porcine skin. RESULTS When delivered via chitosan, 70% to 80% of peptides were released over 7 days. Gels eradicated biofilms of gram-positive and gram-negative, drug-resistant bacteria in vitro and ex vivo. Under the conditions tested, no meaningful differences in peptide activity between the L and D forms of ASP-2 were detected. CONCLUSIONS Chitosan serves as an effective delivery platform for ASP-1 and ASP-2 to treat biofilm-embedded bacteria and warrants further development as a topical treatment.
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Affiliation(s)
- Jennifer A Neff
- Allvivo Vascular, Inc., 20914 Bake Parkway, Suite 100, Lake Forest, CA 92630
| | - Danir F Bayramov
- Allvivo Vascular, Inc., 20914 Bake Parkway, Suite 100, Lake Forest, CA 92630
| | - Esha A Patel
- Allvivo Vascular, Inc., 20914 Bake Parkway, Suite 100, Lake Forest, CA 92630
| | - Jing Miao
- Allvivo Vascular, Inc., 20914 Bake Parkway, Suite 100, Lake Forest, CA 92630
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Patterson SB, Mende K, Li P, Lu D, Carson ML, Murray CK, Tribble DR, Blyth DM. Stenotrophomonas maltophilia infections: Clinical characteristics in a military trauma population. Diagn Microbiol Infect Dis 2019; 96:114953. [PMID: 31791809 DOI: 10.1016/j.diagmicrobio.2019.114953] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/29/2019] [Accepted: 11/09/2019] [Indexed: 01/27/2023]
Abstract
Stenotrophomonas maltophilia is a pathogen with unique resistance patterns. We assessed 70 combat casualties with S. maltophilia clinical isolates to examine its role as a nosocomial pathogen in critically-ill trauma patients. Incidence density was 0.36 S. maltophilia infections per 100 patient-days (95% CI: 0.29-0.44). Patients predominantly had blast trauma (97%) and were critically injured (injury severity score [ISS] >25; 80%). Restricting to patients with ISS >15, 50 patients with S. maltophilia infections were compared to 441 patients with infections attributed to other gram-negative bacilli. Patients with S. maltophilia infections had significantly more operating room visits prior to isolation, traumatic or early surgical amputations, longer hospitalization (median 71 vs 47 days), and higher overall mortality (10% vs 2%; P = 0.01). Initial and serial (≥7 days between initial and subsequent isolation) S. maltophilia isolates had high susceptibility to trimethoprim-sulfamethoxazole and minocycline. Evaluation of newer agents awaiting CLSI breakpoints, including moxifloxacin, showed promising results.
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Affiliation(s)
- Shane B Patterson
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, USA.
| | - Katrin Mende
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, USA; Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD, USA
| | - Ping Li
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD, USA
| | - Dan Lu
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD, USA
| | - M Leigh Carson
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD, USA
| | - Clinton K Murray
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Dana M Blyth
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, USA
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Woodburn KW, Jaynes JM, Clemens LE. Evaluation of the Antimicrobial Peptide, RP557, for the Broad-Spectrum Treatment of Wound Pathogens and Biofilm. Front Microbiol 2019; 10:1688. [PMID: 31396193 PMCID: PMC6667648 DOI: 10.3389/fmicb.2019.01688] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/09/2019] [Indexed: 12/31/2022] Open
Abstract
The relentless growth of multidrug resistance and generation of recalcitrant biofilm are major obstacles in treating wounds, particularly in austere military environments where broad-spectrum pathogen coverage is needed. Designed antimicrobial peptides (dAMPs) are constructed analogs of naturally occurring AMPs that provide the first line of defense in many organisms. RP557 is a dAMP resulting from iterative rational chemical structural analoging with endogenous AMPs, human cathelicidin LL-37 and Tachyplesin 1 and the synthetic D2A21 used as structural benchmarks. RP557 possesses broad spectrum activity against Gram-positive and Gram-negative bacteria and fungi, including recalcitrant biofilm with substantial selective killing over bacterial cells compared to mammalian cells. RP557 did not induce resistance following chronic passages of Pseudomonas aeruginosa and Staphylococcus aureus at subinhibitory concentrations, whereas concurrently run conventional antibiotics, gentamycin, and clindamycin, did. Furthermore, RP557 was able to subsequently eliminate the generated gentamycin resistant P. aeruginosa and clindamycin resistant S. aureus strains without requiring an increase in minimum inhibitory concentration (MIC) concentrations. RP557 was evaluated further in a MRSA murine wound abrasion infection model with a topical application of 0.2% RP557, completely eliminating infection. If these preclinical results are translated into the clinical setting, RP557 may become crucial for the empirical broad-spectrum treatment of wound pathogens, so that infections can be reduced to a preventable complication of combat-related injuries.
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Affiliation(s)
| | - Jesse M Jaynes
- Integrative Biosciences, Tuskegee University, Tuskegee, AL, United States
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Glick Y, Furer A, Glick K, Yitzhak A, Brosh T. The Israeli Defense Forces Point of Injury Antimicrobial Treatment Protocol - A New Protocol and Review of the Literature. Mil Med 2019; 184:78-82. [PMID: 30901438 DOI: 10.1093/milmed/usy292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/26/2018] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Combat wound infection is a common and serious complication, leading to significant morbidity and mortality. In 2005, a point of injury antimicrobial protocol was published by the Israel Defense Forces, in which Moxifloxacin was chosen. During 2016-2017, a revision of this protocol was performed and concluded with the publication of an updated protocol. The purpose of this report is to present this process and the revised protocol, together with a review of the literature. METHODS We searched "Medline" and "Google Scholar" for studies dealing with antimicrobial prophylaxis in trauma, for militaries' point of injury antimicrobial protocol protocols and for established surgical antimicrobial prophylaxis protocols. RESULTS Point of injury antimicrobial protocol is aimed at preventing early infection and its complications. The choice of Moxifloxacin for this purpose may not be optimal since Moxifloxacin spectrum might be overly broad, there is scant evidence supporting it for this indication, and the available preparation does not meet distinctive technical requirements. Contrarily, Ceftriaxone seemed to have suitable microbiological, pharmacological and technical features. CONCLUSION Point of injury antimicrobial protocol should be used especially when evacuation and definitive surgical treatment are delayed. According to present scientific data and operational needs, Ceftriaxone was chosen for most penetrating injuries, with Metronidazole addition for penetrating abdominal and cranial trauma.
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Affiliation(s)
- Yuval Glick
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Military POB 02149 Tel Hashomer, Ramat Gan, Military Postal Code, Israel
| | - Ariel Furer
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Military POB 02149 Tel Hashomer, Ramat Gan, Military Postal Code, Israel
| | - Karina Glick
- Internal Medicine Department "A', Assuta Ashdod University Hospital, 7 Ha-Refua St., Ashdod, Israel
| | - Avraham Yitzhak
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Military POB 02149 Tel Hashomer, Ramat Gan, Military Postal Code, Israel
| | - Tal Brosh
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Military POB 02149 Tel Hashomer, Ramat Gan, Military Postal Code, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Ben-Gurion Blvd., Be'er-Sheva, Israel.,Infectious Diseases Unit, Assuta Ashdod University Hospital, 7 Ha-Refua St., Ashdod, Israel
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Rogers E, Wright C. For debate: on-the-person battlefield antibiotics. BMJ Mil Health 2018; 166:175-178. [PMID: 30530792 DOI: 10.1136/jramc-2018-001033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/19/2018] [Accepted: 11/21/2018] [Indexed: 11/04/2022]
Abstract
Wound infection has always been an important contributor to mortality and morbidity on the battlefield. On-the-person antibiotics have long been suggested as one way to help combat this, which have already been implemented by some North Atlantic Treaty Organization partners. This paper is an up-to-date review of the evidence of the efficacy of on-the-person antibiotics and whether the British military should look to use them in the near future.
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Affiliation(s)
- Edward Rogers
- Army Medical Services Support Unit, Robertson House, RMAS, Camberly, UK .,Department of Anaesthesia, Frimley Park NHS Foundation Trust, Frimley, UK
| | - C Wright
- Emergency Department, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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Älgå A, Karlow Herzog K, Alrawashdeh M, Wong S, Khankeh H, Stålsby Lundborg C. Perceptions of Healthcare-Associated Infection and Antibiotic Resistance among Physicians Treating Syrian Patients with War-Related Injuries. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15122709. [PMID: 30513739 PMCID: PMC6313556 DOI: 10.3390/ijerph15122709] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 11/22/2018] [Accepted: 11/29/2018] [Indexed: 12/11/2022]
Abstract
Healthcare-associated infections (HAIs) constitute a major contributor to morbidity and mortality worldwide, with a greater burden on low- and middle-income countries. War-related injuries generally lead to large tissue defects, with a high risk of infection. The aim of this study was to explore how physicians in a middle-income country in an emergency setting perceive HAI and antibiotic resistance (ABR). Ten physicians at a Jordanian hospital supported by Médecins Sans Frontières were interviewed face-to-face. The recorded interviews were transcribed verbatim and analyzed by qualitative content analysis with an inductive and deductive approach. The participants acknowledged risk factors of HAI and ABR development, such as patient behavior, high numbers of injured patients, limited space, and non-compliance with hygiene protocols, but did not express a sense of urgency or any course of action. Overuse and misuse of antibiotics were reported as main contributors to ABR development, but participants expressed no direct interrelationship between ABR and HAI. We conclude that due to high patient load and limited resources, physicians do not see HAI as a problem they can prioritize. The knowledge gained by this study could provide insights for the allocation of resources and development of hygiene and wound treatment protocols in resource-limited settings.
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Affiliation(s)
- Andreas Älgå
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, 11883 Stockholm, Sweden.
- Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden.
| | - Karin Karlow Herzog
- Department of Public Health Sciences, Karolinska Institutet, 17177 Stockholm, Sweden.
| | | | - Sidney Wong
- Médecins Sans Frontières, Operational Centre Amsterdam, 1018 DD Amsterdam, The Netherlands.
| | - Hamidreza Khankeh
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, 11883 Stockholm, Sweden.
- Health in Emergency and Disaster Research Centre, University of Social Welfare and Rehabilitation Sciences, Tehran 1985713834, Iran.
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Aurora A, Le TD, Akers KS, Blyth DM, Graybill JC, Clemens MS, Chung KK, Rizzo JA. Recurrent bacteremia: A 10-year retrospective study in combat-related burn casualties. Burns 2018; 45:579-588. [PMID: 30385059 DOI: 10.1016/j.burns.2018.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/27/2018] [Accepted: 10/04/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Surviving the first episode of bacteremia predisposes burn casualties to its recurrence. Herein, we investigate the incidence, mortality, bacteriology, and source of infection of recurrent bacteremia in military burn casualties admitted to the U.S. Army Institute of Surgical Research Burn Center over a 10year period. METHODS Bacteremia was defined as the growth of Gram-positive or Gram-negative organisms in a blood culture that excluded probable skin contaminants. Recurrent bacteremia was defined as a subsequent episode of bacteremia ≥7 days after the first episode. Polymicrobial bacteremia was the presence of more than one pathogen in the same blood culture. Bacteremia was attributed to UTI, pneumonia, or wound sepsis. All other bacteremias were considered non-attributable bloodstream infections. Univariate and multivariate analyses determined factors predictive of clinical outcome. RESULTS Out of 952 combat-related burn casualties screened, 166 cases were identified; 63% (non-recurrent) and 37% (recurrent) with median time to recurrence of 20 days. Univariate and multivariate analysis showed that the mortality rate was two and nine-fold, respectively, higher with recurrent bacteremia. Univariate analysis found that except for urinary tract infection, large burn size (>20%), 3rd degree burns, increased injuiry severity, perineal burns, and mechanical ventilator days were independent factors predictive of recurrence of bacteremia as well as increased mortality in the recurrent bacteremia cohort. Acinetobacter baumannii complex (63%) was prevalent in the non-recurrent group, while Klebsiella pneumoniae (46% vs. 30%) and Pseudomonas aeruginosa (35% vs. 26%) were prevalent in recurrent bacteremia. Half of the recurrent bacteremia cases were polymicrobial, compared to 9% in non-recurrent bacteremia. Pneumonia was prevalent in non-recurrent bacteremia (38%) and a combination of pneumonia and wound sepsis (29%) in recurrent bacteremia casualties. CONCLUSIONS Recurrent bacteremia increases mortality in military burn casualties. Additional research is needed to address and mitigate the underlying causes, thereby improving survival.
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Affiliation(s)
- Amit Aurora
- U.S. Army Institute of Surgical Research, JBSA, Fort Sam Houston, TX, United States
| | - Tuan D Le
- U.S. Army Institute of Surgical Research, JBSA, Fort Sam Houston, TX, United States
| | - Kevin S Akers
- U.S. Army Institute of Surgical Research, JBSA, Fort Sam Houston, TX, United States; Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Dana M Blyth
- Brooke Army Medical Center, JBSA, Fort Sam Houston, TX, United States
| | - John C Graybill
- U.S. Army Institute of Surgical Research, JBSA, Fort Sam Houston, TX, United States
| | - Michael S Clemens
- U.S. Army Institute of Surgical Research, JBSA, Fort Sam Houston, TX, United States
| | - Kevin K Chung
- U.S. Army Institute of Surgical Research, JBSA, Fort Sam Houston, TX, United States; Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Julie A Rizzo
- U.S. Army Institute of Surgical Research, JBSA, Fort Sam Houston, TX, United States; Uniformed Services University of the Health Sciences, Bethesda, MD, United States.
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Skube ME, Mallery Q, Lusczek E, Elterman J, Spott MA, Beilman GJ. Characteristics of Combat-Associated Small Bowel Injuries. Mil Med 2018; 183:e454-e459. [PMID: 29546406 PMCID: PMC6136988 DOI: 10.1093/milmed/usy009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 11/27/2017] [Accepted: 01/18/2018] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Although there are multiple studies regarding the management and outcomes of colonic injuries incurred in combat, the literature is limited with regard to small bowel injuries. This study seeks to provide the largest reported review of the characteristics of combat-associated small bowel injuries. MATERIALS AND METHODS The Department of Defense Trauma Registry was queried for U.S. Armed Forces members who sustained hollow viscus injuries in the years 2007-2012 during Operations Enduring Freedom, Iraqi Freedom, and New Dawn. Concomitant injuries, procedures, and complications were delineated. Fisher's exact test was used to analyze the relationship of bowel injury pattern to rates of repeat laparotomy, fecal diversion, and complications. RESULTS One hundred seventy-one service members had small bowel injuries. The mean age was 25.8 ± 6.6 yr with a mean injury severity score of 27.9 ± 12.4. The majority of injuries were penetrating (94.2%, n = 161) as a result of explosive devices (61.4%, n = 105). The median blood transfusion requirement in the first 24 h was 6.0 units (interquartile range 1.0-17.3 units). The most frequent concomitant injuries were large bowel (64.3%, n = 110), pelvic fracture (35.7%, n = 61), and perineal (26.3%, n = 45). Fifty patients (29.2%) had a colostomy, and nine patients (5.3%) had an ileostomy; 62.6% (n = 107) of soldiers underwent more than one laparotomy. The mortality rate was 1.8% (n = 3). The most common complications were pneumonia (15.2%, n = 26), deep vein thrombosis (14.6%, n = 25), and wound infection (14.6%, n = 25). The need for repeat laparotomy and fecal diversion was found to be significantly associated with injury pattern (p = 0.00052 and p < 0.0001, respectively). CONCLUSION We found that two-thirds of service members with small bowel injuries also had a large bowel injury. One-third of the patients required diversion and two-thirds had more than one laparotomy. The pattern of bowel injury significantly affected the need for repeat laparotomy and fecal diversion.
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Affiliation(s)
- Mariya E Skube
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN
| | - Quinn Mallery
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN
| | - Elizabeth Lusczek
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN
| | - Joel Elterman
- Department of Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH
| | - Mary A Spott
- U.S. Army Institute of Surgical Research, 3698 Chambers Pass Ste B, JBSA Ft Sam Houston, TX
| | - Greg J Beilman
- Department of Surgery, University of Minnesota, 420 Delaware St SE, Minneapolis, MN
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Sani R, Adamou H, Daddy H, Amodou MI, Adoulaye MB, James LD, Garba I, Idé K, Hama Y, Sanoussi S. INJURIES OF BOKO HARAM INSURGENCY IN SOUTH-EAST NIGER REPUBLIC. JOURNAL OF THE WEST AFRICAN COLLEGE OF SURGEONS 2018; 8:22-44. [PMID: 32754455 PMCID: PMC7368572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Currently, wounds of wars, terrorism and criminality are increasing and constitute major public health problem worldwide. AIM To present the epidemiological, clinical and therapeutic characteristics of the wounds observed during the Boko Haram (BH) insurgency in the South-east of the Republic of Niger. METHODOLOGY This was a cross-sectional study from December 2014 to December 2016 at Diffa Regional Hospital, Diffa, Niger of individuals whose injuries were as a result of Boko Haram insurgency. RESULTS In the period of this study, 573 injuries from Boko Haram insurgency were managed at the Regional Hospital at Diffa. The majority, 513(89.5%), were males while females constituted 60(10.5%) with a male/female ratio of 8.55. The mean age was 30,94(SD24,91) years (range 1 to 97 years). Civilian victims accounted for 379 (66.1%) while Nigerien soldiers accounted for 160(27.9%) and 34 (5.9%) were Boko Haram fighters. Firearms and explosives accounted for injuries in 489 (85.3%) and 7(1.2%) of patients respectively; 42 (7.3%) suffered injuries from a variety of traditional weapons. Injuries to limbs accounted for 361(63%) of cases and polytrauma in 65(11.34%). The main surgical management included wound debridement in 409 (71.4%), external bone fixation in 38 (6.6%), laparotomy in 30 (5.2%), thoracic drainage in 27 (4.7%), and major limb amputations in 13 (2.3%) cases.Postoperative follow-up was uneventful in 460 (80.28%) of cases; there were 29 deaths, giving a mortality rate of 5.1%. Predictors of death after injuries of Boko Haram terrorism in this study included: being civilian patients (OR = 3.38 [1.15-9.85], p=0.018), injuries to head, neck, trunk or spine (OR 3.45[1.58-7.58], p= 0.001) or the presence of polytrauma on admission (OR = 17.30 [7.72-38.80], p<0.0001). CONCLUSION This study has shown that injuries sustained in Boko Haram insurgency in Niger were mainly firearm injuries and injuries from the use of traditional weapons, affecting mostly young civilian males. The part of the body most commonly involved were the extremities, with mainly soft tissue injuries. Wound debridement was the commonest surgical procedure performed and the mortality rate was 5.1%. Predictors of mortality were being civilian patients, injuries of head, neck, trunk or spine and polytrauma. The ICRC has played a major role in strengthening our hospital for the task of caring for the victims, in terms of provision of material resources and in the further training of our personnel.
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Affiliation(s)
- R Sani
- Department of Surgery and Surgical specialties, Niamey National Hospital, Faculty of Health Sciences, Abdou Moumouni University of Niamey, Niger
| | - H Adamou
- Department of Surgery, Zinder National Hospital, Faculty of Health Sciences, University of Zinder, Niger
| | - H Daddy
- Department of Anesthesia and Critical Care, Faculty of Health Sciences, Abdou Moumouni University of Niamey, Niger
| | - Magagi I Amodou
- Department of Surgery, Zinder National Hospital, Faculty of Health Sciences, University of Zinder, Niger
| | - M B Adoulaye
- Department of Surgery, Diffa regional Hospital, Niger
| | - L Didier James
- Department of Surgery and Surgical specialties, Niamey National Hospital, Faculty of Health Sciences, Abdou Moumouni University of Niamey, Niger
| | - I Garba
- Department of Surgery and Surgical specialties, Niamey National Hospital, Faculty of Health Sciences, Abdou Moumouni University of Niamey, Niger
| | - K Idé
- Department of Surgery and Surgical specialties, Niamey National Hospital, Faculty of Health Sciences, Abdou Moumouni University of Niamey, Niger
| | - Y Hama
- Department of Surgery and Surgical specialties, Niamey National Hospital, Faculty of Health Sciences, Abdou Moumouni University of Niamey, Niger
| | - S Sanoussi
- Department of Surgery and Surgical specialties, Niamey National Hospital, Faculty of Health Sciences, Abdou Moumouni University of Niamey, Niger
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Älgå A, Karlow Herzog K, Alrawashdeh M, Wong S, Khankeh H, Stålsby Lundborg C. "Reality rarely looks like the guidelines": a qualitative study of the challenges hospital-based physicians encounter in war wound management. Scand J Trauma Resusc Emerg Med 2018; 26:52. [PMID: 29945644 PMCID: PMC6020423 DOI: 10.1186/s13049-018-0517-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 06/11/2018] [Indexed: 11/21/2022] Open
Abstract
Background Globally, armed conflict is a major contributor to mortality and morbidity. The treatment of war-associated injuries is largely experience-based. Evidence is weak due to difficulty in conducting medical research in war settings. A qualitative method could provide insight into the specific challenges associated with providing health care to injured civilians. The aim of this study was to explore the challenges hospital-based physicians encounter in war wound management, focusing on surgical intervention and antibiotic use. Methods Semi-structured, face-to-face interviews were conducted with physicians at a Jordanian hospital supported by Médecins Sans Frontières. The interviews were recorded, transcribed verbatim and analysed using content analysis with an inductive and deductive approach. Results We found that challenges in war wound management primarily relate to protocol adherence. Protocols for the management of acute war wounds were adhered to on areas that could be considered commonly agreed principles of war wound surgery, such as the use of wound debridement and the evaluation of the systemic condition of the patient before initiating antibiotic treatment. We identified limitations imposed on the physicians that complicate or even hinder protocol adherence. Additionally, we identified factors associated with conscious deviations from the protocols. Conclusions We conclude that adherence to established protocols around the management of acute war wounds is difficult. We present aspects that may be considered when establishing clinical projects in similar contexts. The knowledge gained by this study could provide insights for the development of protocols or guidelines for wound management and antibiotic use in an unstable setting, such as a hospital in close proximity to armed conflict. We suggest the use of a grounded theory approach to further study the discrepancy between guideline recommendations and actual practice.
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Affiliation(s)
- Andreas Älgå
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden. .,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
| | - Karin Karlow Herzog
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | | | - Sidney Wong
- Médecins Sans Frontières, Operational Centre Amsterdam, Amsterdam, The Netherlands
| | - Hamidreza Khankeh
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
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Resistant Gram-Negative Bacteria and Diagnostic Point-of-Care Options for the Field Setting during Military Operations. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9395420. [PMID: 30009178 PMCID: PMC6020508 DOI: 10.1155/2018/9395420] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/07/2018] [Accepted: 05/20/2018] [Indexed: 12/16/2022]
Abstract
The spread of multidrug-resistant bacteria in resource-poor settings affects the military medical service in case of deployments of soldiers to war and crisis zones. Patients with war injuries are prone to colonization or infection with multidrug-resistant bacteria. Resistant Gram-negative bacteria play a dominant role in military wound infections. Problematic hygiene conditions on deployment facilitate exposition of soldiers with subsequent colonization. Although colonizing strains are frequently cleared from their hosts after returning from deployment, transmission to close contacts of the soldiers in the home country cannot be excluded and therapeutic options are reduced if colonization progresses to invasive infection. Since sophisticated culture-based diagnostic approaches are typically not available in the field setting on deployment, molecular rapid diagnostic test systems are an option for transmission control if the locally prevalent molecular resistance mechanisms are known. Efforts for global resistance surveillance can contribute to better understanding of resistance distribution and spread at deployment sites. This review summarizes experience of the military medical services with multidrug resistance on deployment and with the influx of resistant strains to the home country and discusses potential use of available molecular rapid test systems as an option for the field setting.
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Älgå A, Wong S, Shoaib M, Lundgren K, Giske CG, von Schreeb J, Malmstedt J. Infection with high proportion of multidrug-resistant bacteria in conflict-related injuries is associated with poor outcomes and excess resource consumption: a cohort study of Syrian patients treated in Jordan. BMC Infect Dis 2018; 18:233. [PMID: 29788910 PMCID: PMC5964734 DOI: 10.1186/s12879-018-3149-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 05/15/2018] [Indexed: 11/30/2022] Open
Abstract
Background Armed conflicts are a major contributor to injury and death globally. Conflict-related injuries are associated with a high risk of wound infection, but it is unknown to what extent infection directly relates to sustainment of life and restoration of function. The aim of this study was to investigate the outcome and resource consumption among civilians receiving acute surgical treatment due to conflict-related injuries. Patients with and without wound infections were compared. Methods We performed a cohort study using routinely collected data from 457 consecutive Syrian civilians that received surgical treatment for acute conflict-related injuries during 2014–2016 at a Jordanian hospital supported by Médecins Sans Frontières. We defined wound infection as clinical signs of infection verified by a positive culture. We used logistic regression models to evaluate infection-related differences in outcome and resource consumption. Results Wound infection was verified in 49/457 (11%) patients. Multidrug-resistance (MDR) was detected in 36/49 (73%) of patients with infection. Among patients with infection, 11/49 (22%) were amputated, compared to 37/408 (9%) without infection, crude relative risk = 2.62 (95% confidence interval 1.42–4.81). Infected patients needed 12 surgeries on average, compared to five in non-infected patients (p < .00001). Mean length of stay was 77 days for patients with infection, and 35 days for patients without infection (p = .000001). Conclusions Among Syrian civilians, infected conflict-related wounds had a high prevalence of MDR bacteria. Wound infection was associated with poor outcomes and high resource consumption. These results could guide the development of antibiotic protocols and adaptations of surgical management to improve care for wound infections in conflict-related injuries. Trial registration ClinicalTrials.gov (NCT02744144). Registered April 13, 2016. Retrospectively registered.
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Affiliation(s)
- Andreas Älgå
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden. .,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
| | - Sidney Wong
- Médecins Sans Frontières, Operational Centre Amsterdam, Amsterdam, The Netherlands
| | | | - Kalle Lundgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Christian G Giske
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Johan von Schreeb
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Malmstedt
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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Tribble DR, Krauss MR, Murray CK, Warkentien TE, Lloyd BA, Ganesan A, Greenberg L, Xu J, Li P, Carson ML, Bradley W, Weintrob AC. Epidemiology of Trauma-Related Infections among a Combat Casualty Cohort after Initial Hospitalization: The Trauma Infectious Disease Outcomes Study. Surg Infect (Larchmt) 2018; 19:494-503. [PMID: 29717911 DOI: 10.1089/sur.2017.241] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Trauma Infectious Disease Outcomes Study (TIDOS) cohort follows military personnel with deployment-related injuries in order to evaluate short- and long-term infectious complications. High rates of infectious complications have been observed in more than 30% of injured patients during initial hospitalization. We present data on infectious complications related to combat trauma after the initial period of hospitalization. PATIENTS AND METHODS Data related to patient care for military personnel injured during combat operations between June 2009 and May 2012 were collected. Follow-up data were captured from interviews with enrolled participants and review of electronic medical records. RESULTS Among 1,006 patients enrolled in the TIDOS cohort with follow-up data, 357 (35%) were diagnosed with one or more infection during their initial hospitalization, of whom 160 (45%) developed a trauma-related infection during follow-up (4.2 infections per 10,000 person-days). Patients with three or more infections during the initial hospitalization had a significantly higher rate of infections during the follow-up period compared with those with only one inpatient infection (incidence rate: 6.6 versus 3.1 per 10,000 days; p < 0.0001). There were 657 enrollees who did not have an infection during initial hospitalization, of whom 158 (24%) developed one during follow-up (incidence rate: 1.6 per 10,000 days). Overall, 318 (32%) enrolled patients developed an infection after hospital discharge (562 unique infections) with skin and soft-tissue infections being predominant (66%) followed by osteomyelitis (16%). Sustaining an amputation or open fracture, having an inpatient infection, and use of anti-pseudomonal penicillin (≥7 d) were independently associated with risk of an extremity wound infection during follow-up, whereas shorter hospitalization (15-30 d) was associated with a reduced risk. CONCLUSIONS Combat-injured patients have a high burden of infectious complications that continue long after the initial period of hospitalization with soft-tissue and osteomyelitis being predominant. Further research on the long-term impact and outcomes of combat-associated infection is needed.
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Affiliation(s)
- David R Tribble
- 1 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | | | - Clinton K Murray
- 3 San Antonio Military Medical Center , JBSA Fort Sam Houston, Texas
| | | | | | - Anuradha Ganesan
- 1 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,4 Walter Reed National Military Medical Center , Bethesda, Maryland.,6 The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland
| | | | | | - Ping Li
- 1 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,6 The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland
| | - M Leigh Carson
- 1 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,6 The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland
| | - William Bradley
- 1 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,6 The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland
| | - Amy C Weintrob
- 1 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,4 Walter Reed National Military Medical Center , Bethesda, Maryland.,6 The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland
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38
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Field Wound Care: Prophylactic Antibiotics. Wilderness Environ Med 2018; 28:S90-S102. [PMID: 28601215 DOI: 10.1016/j.wem.2016.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 12/19/2016] [Accepted: 12/20/2016] [Indexed: 12/28/2022]
Abstract
Adequate management of wounds requires numerous interventions, one of which is the appropriate use of antimicrobials to attempt to minimize the risk of excess morbidity or mortality without increasing toxicity or multidrug resistant bacterial acquisition. There are numerous recommendations and opinions for not only the use of systemic prophylactic antimicrobials, but also the agent, dose, route, and duration. To best address the implementation of systemic antimicrobials in a field scenario, one must weigh the factors that go into that decision and then determine the best agents possible. The epidemiologic triangle (ie, the host, the agent, and the environment) forms the basis for selecting the correct prophylactic antibiotic for field wound care. Extreme conditions can be encountered in both military and nonmilitary systems, requiring a unique selection process to make the right antibiotic choice. A modifiable weighted matrix, recommended previously for point of injury combat casualty care, assists in selecting the best oral and intravenous/intramuscular agent based on the epidemiologic risk determination.
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Heitkamp RA, Li P, Mende K, Demons ST, Tribble DR, Tyner SD. Association of Enterococcus spp. with Severe Combat Extremity Injury, Intensive Care, and Polymicrobial Wound Infection. Surg Infect (Larchmt) 2017; 19:95-103. [PMID: 29261091 DOI: 10.1089/sur.2017.157] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Combat-related extremity wound infections can complicate the recovery of injured military personnel. The Enterococcus genus contains both commensal and pathogenic bacteria found in many combat wounds. We describe the patient population susceptible to Enterococcus infection, the characteristics of Enterococcus spp. isolated from combat-related wounds, and the microbiological profile of Enterococcus-positive wounds. METHODS Patient and culture data were obtained from the Trauma Infectious Disease Outcomes Study. Subjects were divided into a case group with enterococcal extremity wound infections and a comparator group with wound infections caused by other micro-organisms. RESULTS Case and comparator subjects had similar patterns of injury and infection. Case subjects had higher Injury Severity Scores (33 vs. 30; p < 0.001), longer hospitalization at U.S. facilities (55 vs. 40 days; p = 0.004), and required more large-volume blood transfusions (>20 units) within 24 h post-injury (53% vs. 30%; p < 0.001). Approximately 60% of case subjects had three or more infections, and 91% had one or more polymicrobial infections, compared with 43% and 50%, respectively, in the comparator group. The thigh was the most common site of Enterococcus spp. isolation, contributing 50% of isolates. Enterococcus faecium was the predominant species isolated from case-group infections overall (66%), as well as in polymicrobial infections (74%). Frequent co-colonizing microbes in polymicrobial wound infections with Enterococcus were other ESKAPE pathogens (64%) (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae [and Escherichia coli], Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.) and fungi (35%). CONCLUSIONS The specific pathogenicity of Enterococcus relative to other pathogens in polymicrobial wounds is unknown. Identifying strain-specific outcomes and investigating the interactions of Enterococcus strains with other wound pathogens could provide additional tools and strategies for infection mitigation in combat-related wounds.
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Affiliation(s)
- Rae A Heitkamp
- 1 Bacterial Diseases Branch, Walter Reed Army Institute of Research , Silver Spring, Maryland
| | - Ping Li
- 2 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,3 Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland
| | - Katrin Mende
- 2 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,3 Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland.,4 San Antonio Military Medical Center , Joint Base San Antonio, Fort Sam Houston, Texas
| | - Samandra T Demons
- 1 Bacterial Diseases Branch, Walter Reed Army Institute of Research , Silver Spring, Maryland
| | - David R Tribble
- 2 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Stuart D Tyner
- 1 Bacterial Diseases Branch, Walter Reed Army Institute of Research , Silver Spring, Maryland
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40
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Riddle CAPTMS, Martin GJ, Murray COLCK, Burgess CAPTTH, Connor CP, Mancuso COLJD, Schnaubelt MER, Ballard LCTP, Fraser J, Tribble DR. Management of Acute Diarrheal Illness During Deployment: A Deployment Health Guideline and Expert Panel Report. Mil Med 2017; 182:34-52. [PMID: 28885922 PMCID: PMC5657341 DOI: 10.7205/milmed-d-17-00077] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Acute diarrheal illness during deployment causes significant morbidity and loss of duty days. Effective and timely treatment is needed to reduce individual, unit, and health system performance impacts. METHODS This critical appraisal of the literature, as part of the development of expert consensus guidelines, asked several key questions related to self-care and healthcare-seeking behavior, antibiotics for self-treatment of travelers' diarrhea, what antibiotics/regimens should be considered for treatment of acute watery diarrhea and febrile diarrhea and/or dysentery, and when and what laboratory diagnostics should be used to support management of deployment-related travelers' diarrhea. Studies of acute diarrhea management in military and other travelers were assessed for relevance and quality. On the basis of this critical appraisal, guideline recommendations were developed and graded by the Expert Panel using good standards in clinical guideline development methodology. RESULTS New definitions for defining the severity of diarrhea during deployment were established. A total of 13 graded recommendations on the topics of prophylaxis, therapy and diagnosis, and follow-up were developed. In addition, four non-graded consensus-based statements were adopted. CONCLUSIONS Successful management of acute diarrheal illness during deployment requires action at the provider, population, and commander levels. Strong evidence supports that single-dose antimicrobial therapy is effective in most cases of moderate to severe acute diarrheal illness during deployment. Further studies are needed to address gaps in available knowledge regarding optimal therapies for treatment, prevention, and laboratory testing of acute diarrheal illness.
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Affiliation(s)
- CAPT Mark S. Riddle
- Enteric Disease Department, Naval Medical Research Center, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA
| | - Gregory J. Martin
- Chief, Tropical Medicine-Infectious Diseases, Bureau of Medical Services, US Department of State, 2401 E St NW L209, Washington DC 20037, USA
| | - COL Clinton K. Murray
- Deputy Medical Corps Chief, Medical Corps Specific Branch Proponent Officer, Infectious Disease Consultant to the Army Surgeon General, Brooke Army Medical Center, 3551 Roger Brooke Dr, JBSA Fort Sam Houston, TX 78234, USA
| | - CAPT Timothy H. Burgess
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Col Patrick Connor
- Military Enteric Disease Group, Academic Department of Military Medicine, Birmingham Research Park, Vincent Drive, Birmingham B15 2SQ, United Kingdom
| | - COL James D. Mancuso
- Department of Preventive Medicine & Biostatistics, The F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Maj Elizabeth R. Schnaubelt
- Infectious Disease Service, Landstuhl Regional Medical Center, Landstuhl, Germany, CMR 402, APO, AE, 19180, USA [Current Affiliation: Division of Global HIV and TB, Centers for Disease Control and Prevention, 1600 Clifton Rd, Atlanta, GA 30333, USA]
| | - Lt Col Timothy P. Ballard
- Operational Medicine, Defense Institute for Medical Operations, 1320 Truemper St, Bldg 9122, JBSA-Lackland, TX 78236, USA
| | - Jamie Fraser
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Dr #100, Bethesda, MD 20817, USA
| | - David R. Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
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Campbell WR, Li P, Whitman TJ, Blyth DM, Schnaubelt ER, Mende K, Tribble DR. Multi-Drug-Resistant Gram-Negative Infections in Deployment-Related Trauma Patients. Surg Infect (Larchmt) 2017; 18:357-367. [PMID: 29173084 DOI: 10.1089/sur.2017.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The contribution of multi-drug-resistant gram-negative bacilli infections (MDRGN-I) in patients with trauma is not well described. We present characteristics of MDRGN-Is among military personnel with deployment-related trauma (2009-2014). PATIENTS AND METHODS Data from the Trauma Infectious Disease Outcomes Study were assessed for infectious outcomes and microbial recovery. Infections were classified using standardized definitions. Gram-negative bacilli were defined as multi-drug-resistant if they showed resistance to ≥3 antibiotic classes or were producers of extended-spectrum β-lactamase or carbapenemases. RESULTS Among 2,699 patients admitted to participating U.S. hospitals, 913 (33.8%) experienced ≥1 infection event, of which 245 (26.8%) had a MDRGN-I. There were 543 MDRGN-I events (24.6% of unique 2,210 infections) with Escherichia coli (48.3%), Acinetobacter spp. (38.6%), and Klebsiella pneumoniae (8.4%) as the most common MDRGN isolates. Incidence of MDRGN-I was 9.1% (95% confidence interval [CI]: 8.0-10.2). Median time to MDRGN-I event was seven days with 75% occurring within 13 days post-trauma. Patients with MDRGN-Is had a greater proportion of blast injuries (84.1% vs. 62.5%; p < 0.0001), traumatic amputations (57.5% vs. 16.3%; p < 0.0001), and higher injury severity (82.0% had injury severity score ≥25 vs. 33.7%; p < 0.0001) compared with patients with either no infections or non-MDRGN-Is. Furthermore, MDRGN-I patients were more frequently admitted to the intensive care unit (90.5% vs. 48.5%; p < 0.0001), colonized with a MDRGN before infection (58.0% vs. 14.7%; p < 0.0001), and required mechanical ventilation (78.0% vs. 28.8% p < 0.0001). Antibiotic exposure before the MDRGN-I event was significantly higher across antibiotic classes except first generation cephalosporins and tetracyclines, which were very commonly used with all patients. Regarding outcomes, patients with MDRGN-Is had a longer length of hospitalization than the comparator group (53 vs. 18 days; p < 0.0001). CONCLUSIONS We found a high rate of MDRGN-I in our population characterized by longer hospitalization and greater injury severity. These findings inform treatment and infection control decisions in the trauma patient population.
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Affiliation(s)
- Wesley R Campbell
- 1 Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Ping Li
- 2 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,3 Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland
| | | | - Dana M Blyth
- 5 San Antonio Military Medical Center , Fort Sam Houston, Texas
| | | | - Katrin Mende
- 2 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,3 Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland.,5 San Antonio Military Medical Center , Fort Sam Houston, Texas
| | - David R Tribble
- 2 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland
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