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Appelbaum RD, Farrell MS, Gelbard RB, Hoth JJ, Jawa RS, Kirsch JM, Mandell S, Nohra EA, Rinderknecht T, Rowell S, Cuschieri J, Stein DM. Antibiotic prophylaxis in injury: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document. Trauma Surg Acute Care Open 2024; 9:e001304. [PMID: 38835634 PMCID: PMC11149135 DOI: 10.1136/tsaco-2023-001304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 04/11/2024] [Indexed: 06/06/2024] Open
Affiliation(s)
- Rachel D Appelbaum
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael S Farrell
- Department of Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Rondi B Gelbard
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - J Jason Hoth
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Randeep S Jawa
- Department of Surgery, Stony Brook University, Stony Brook, New York, USA
| | - Jordan M Kirsch
- Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Samuel Mandell
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Eden A Nohra
- Department of Surgery, University of Colorado, Denver, Colorado, USA
| | | | - Susan Rowell
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois, USA
| | - Joseph Cuschieri
- Department of Surgery at ZSFG, University of California San Francisco, San Francisco, California, USA
| | - Deborah M Stein
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland, USA
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Zurawski DV, Serio AW, Black C, Pybus B, Akers KS, Deck DH, Johnson S, Chattagul S, Noble SM, Raynor M, Lanteri CA. A Review of Omadacycline for Potential Utility in the Military Health System for the Treatment of Wound Infections. Mil Med 2024; 189:e1353-e1361. [PMID: 37963013 PMCID: PMC11110612 DOI: 10.1093/milmed/usad417] [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: 12/23/2022] [Revised: 08/21/2023] [Accepted: 10/10/2023] [Indexed: 11/16/2023] Open
Abstract
INTRODUCTION Combat-related wound infections complicate the recovery of wounded military personnel, contributing to overall morbidity and mortality. Wound infections in combat settings present unique challenges because of the size and depth of the wounds, the need to administer emergency care in the field, and the need for subsequent treatment in military facilities. Given the increase in multidrug-resistant pathogens, a novel, broad-spectrum antibiotic is desired across this continuum of care when the standard of care fails. Omadacycline was FDA-approved in 2018 for treatment of adults with acute bacterial skin and skin structure infections (ABSSSI), as well as community-acquired bacterial pneumonia (CABP). It is a broad-spectrum antibiotic with activity against gram-positive, gram-negative, and atypical bacterial pathogens, including multidrug-resistant species. Omadacycline can overcome commonly reported tetracycline resistance mechanisms, ribosomal protection proteins, and efflux pumps, and is available in once-daily intravenous or oral formulations. In this review, we discuss the potential role of omadacycline, which is included in the Department of Defense Formulary, in the context of combat wound infections. MATERIALS AND METHODS A literature review was undertaken for manuscripts published before July 21, 2023. This included a series of publications found via PubMed and a bibliography made publicly available on the Paratek Pharmaceuticals, Inc. website. Publications presenting primary data published in English on omadacycline in relation to ESKAPEE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Escherichia coli, and Enterobacter species) pathogens and Clostridioides difficile, including in vitro, in vivo, and clinical data were included. RESULTS Of 260 identified records, 66 were included for evidence review. Omadacycline has in vitro activity against almost all the ESKAPEE pathogens, apart from P. aeruginosa. Importantly, it has activity against the four most prevalent bacterial pathogens that cause wound infections in the military healthcare system: S. aureus, including methicillin-resistant S. aureus, A. baumannii, K. pneumoniae, and E. coli. In vivo studies in rats have shown that omadacycline is rapidly distributed in most tissues, with the highest tissue-to-blood concentration ratios in bone mineral. The clinical efficacy of omadacycline has been assessed in three separate Phase 3 studies in patients with ABSSSI (OASIS-1 and OASIS-2) and with CABP (OPTIC). Overall, omadacycline has an established safety profile in the treatment of both ABSSSI and CABP. CONCLUSIONS Omadacycline has broad-spectrum activity, the option to be orally administered and an established safety profile, making it a potentially attractive replacement for moxifloxacin in the military individual first aid kit, especially when accounting for the increasing resistance to fluoroquinolones. Further studies and clinical evaluation are warranted to support broader use of omadacycline to treat combat wound infections in the military healthcare system.
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Affiliation(s)
- Daniel V Zurawski
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Alisa W Serio
- Paratek Pharmaceuticals, King of Prussia, PA 19406, USA
| | - Chad Black
- Experimental Therapeutics Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Brandon Pybus
- Experimental Therapeutics Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Kevin S Akers
- Combat Wound Care Research Team (CRT4), U.S. Army Institute of Surgical Research, San Antonio, TX 78234, USA
| | - Daniel H Deck
- Paratek Pharmaceuticals, King of Prussia, PA 19406, USA
| | - Sheila Johnson
- Experimental Therapeutics Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Supaksorn Chattagul
- Experimental Therapeutics Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Schroeder M Noble
- Wound Infections Department, Bacterial Diseases Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Malik Raynor
- Experimental Therapeutics Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Charlotte A Lanteri
- Experimental Therapeutics Branch, Center for Infectious Diseases Research, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
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Karp MC, April MD, Newberry RK, Schauer SG. Associations with Prehospital Antibiotic Receipt among Combat Casualties with Open Wounds: A Department of Defense Trauma Registry Study. Mil Med 2024; 189:e606-e611. [PMID: 37647617 DOI: 10.1093/milmed/usad323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 07/24/2023] [Accepted: 08/03/2023] [Indexed: 09/01/2023] Open
Abstract
INTRODUCTION Current Tactical Combat Casualty Care (TCCC) guidelines recommend antibiotic administration for all open wounds to prevent infection. We identified associations between demographics, procedures, and medicines with the receipt of prehospital antibiotics among combat casualties. MATERIALS AND METHODS We used a series of emergency department procedure codes to identify adult subjects within the Department of Defense Trauma Registry from January 2007 to August 2016 who sustained open wounds. We compared demographics, procedures, and medicines administered among casualties receiving prehospital wound prophylaxis versus casualties not receiving antibiotic prophylaxis. We controlled for confounders with multivariable logistical regression. RESULTS We identified 18,366 encounters meeting inclusion criteria. Antibiotic recipients (n = 2384) were comparable to nonrecipients (n = 15,982) with regard to age and sex. Antibiotic recipients were more likely to sustain injuries from firearms and undergo all procedures examined related to hemorrhage control, airway management, pneumothorax treatment, and volume replacement except for intraosseous access. Antibiotic recipients were less likely to sustain injuries from explosives. Antibiotic recipients had a modestly higher survival than nonrecipients (97.4% versus 96.0%). Associations with prehospital antibiotic receipt in multivariable logistic regression included non-North Atlantic Treaty Organization military force affiliation (odds ratio (OR) 4.65, 95% CI, 1.0-20.8), tachycardia (OR 3.4, 95% CI, 1.1-10.5), intubation (OR 2.0, 95% CI, 1.1-3.8), and administration of tranexamic acid (OR 5.6, 95% CI, 1.2-26.5). CONCLUSIONS The proportion of combat casualties with open wounds receiving prehospital antibiotics was low despite published recommendations for early antibiotics in patients with open wounds. These findings highlight the ongoing need for additional educational and quality assurance initiatives to continue improving adherence to TCCC guidelines with regard to prehospital antibiotic administration. Future studies are necessary to determine reasons for suboptimal TCCC guideline compliance.
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Affiliation(s)
- Marissa C Karp
- Adjutant General Captains Career Course, Fort Jackson, SC 29207, USA
| | - Michael D April
- 14th Field Hospital, Fort Stewart, GA, USA
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Ryan K Newberry
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Steven G Schauer
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Departments of Anesthesiology and Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado 80045, USA
- Center for Combat and Battlefield (COMBAT) Research, University of Colorado School of Medicine, Aurora, Colorado 80045, USA
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Roumieh Z, Mansour H, Assaad RA, Dimassi H, Husni R, Zoghby S, Mokhbat JE. Impact of the 4th of August Beirut explosion mass casualty incident on a university hospital microbial Flora. BMC Infect Dis 2024; 24:48. [PMID: 38178025 PMCID: PMC10765836 DOI: 10.1186/s12879-023-08818-4] [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: 05/26/2023] [Accepted: 11/13/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Following the Beirut explosion, our university hospital received at least 350 casualties. Subsequently, infection control standard practices were compromised. Concerns for Multi-Drug Resistant Organisms (MDROs) infections in injured patients and a resulting hospital outbreak were raised. The objectives of the study were to compare the rate of hospital growing MDROs 6 months before and 6 months after the Beirut explosion, to identify emerging microorganisms and to evaluate the change in surgical infection prevention practices. METHODS This is a retrospective chart review of patients with hospital acquired infections (HAI) admitted to the hospital before and after the Beirut explosion. The study was conducted between February 4, 2020 and January 4, 2021. Excluded patients were those transferred from other hospitals and those with community acquired infections. The primary outcome was to identify the rate of growing MDROs post explosion. The secondary outcomes were identifying antibiotics used for surgical prophylaxis in patients requiring surgeries and patients diagnosed with a HAI. Therefore, patients were divided in three groups. Control group included patients admitted with explosion-related injuries on that same day. Patients admitted and between February 4 and August 4 and diagnosed with HAI were compared to those admitted post August 4 with explosion-related HAI and to patients diagnosed with non-explosion-related HAI between August 4 and January 4, 2021. An estimated rate of 18-22% MDRO was needed to achieve a statistical significance with 80% power and 0.05 α. Pearson Chi square test was used to analyze the primary outcome. RESULTS A total of 82 patients with 150 cultures were included in this study. Data showed an increase in the rate of MDRO after the explosion with 37.1% of the cultures taken before the explosion and 53.1% after the explosion (p = 0.05). When comparing the types of HAI in both groups, culture sites were significantly different between pre- and post-explosion patients (p = 0.013). However, both groups had similar types of microbes (p = 0.996) with an increase in candida related infections. CONCLUSION These findings confirmed that the Beirut explosion impact on antimicrobial resistance was similar to combat zone incidence, where an increase in MDROs rate such as Escherichia coli (E.Coli) and Stenotrophomonas maltophilia, in addition to the increase in candida related infections.
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Affiliation(s)
- Zeinab Roumieh
- School of Pharmacy department of pharmacy practice, Lebanese American University, Byblos, Lebanon
| | - Hanine Mansour
- School of Pharmacy department of pharmacy practice, Lebanese American University, Byblos, Lebanon
| | - Rawad Abi Assaad
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Hani Dimassi
- School of Pharmacy, Lebanese American University, Beirut, Lebanon
- School of Pharmacy department of pharmaceutical sciences, Lebanese American University, Byblos, Lebanon
| | - Rola Husni
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Sanaa Zoghby
- Infection control, Lebanese American University Medical Center-Rizk Hospital (LAUMC-RH), Beirut, Lebanon
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Dehne LM, Foertsch MJ, Droege CA, Makley AT, Mosher DR, Philpott CD, Sagi HC, Mueller EW, Droege ME. Antibiotic Duration Following Abdominal Gunshot Injuries With Associated Pelvis or Spine Involvement: A 20-Year Single-Center Experience. J Surg Res 2023; 291:97-104. [PMID: 37354706 DOI: 10.1016/j.jss.2023.05.025] [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: 09/12/2022] [Revised: 05/04/2023] [Accepted: 05/15/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION Optimal antimicrobial prophylaxis duration following gunshot wounds (GSW) to the abdomen with an associated orthopedic fracture is unknown. This study evaluated the safety and efficacy of short versus long courses of prophylactic antibiotics following penetrating hollow viscus injury with communicating orthopedic fracture. METHODS This retrospective study included adult patients admitted to the trauma service over a 20-y period who sustained an abdominal GSW with hollow viscus injury and communicating spine or pelvic fractures. Patients were stratified into cohorts based on prophylactic antibiotic duration: short course (SC, ≤48 h) and long course (>48 h). The primary outcome was the incidence of osteomyelitis and meningitis up to 1-y postinjury. Secondary outcomes included hospital length of stay and the incidence of multidrug-resistant organisms and Clostridioides difficile infections. Risk factors for osteomyelitis and meningitis were determined. RESULTS A total of 125 patients were included with 45 (36%) in the SC group. Median prophylactic antibiotic durations were SC, 1 (interquartile range [IQR], 1-2) versus long course, 7 (IQR, 5-7) d (P < 0.001). There was no difference in osteomyelitis and meningitis incidence (2 [4.4%] versus 4 [5%], P = 0.77). Median hospital length of stay (7 [IQR, 6-11] versus 9 [IQR, 6-15] d, P = 0.072) and incidence of multidrug-resistant organisms (6 [13.3%] versus 13 [16.3%], P = 0.86) and Clostridioides difficile infections (0 [0%] versus 1 [1.3%], P = 0.77) were similar between groups. There were no independent risk factors identified for osteomyelitis or meningitis. CONCLUSIONS A shorter course of antibiotic prophylaxis ≤48 h may be adequate following abdominal GSW that traverses a hollow viscus and results in pelvic fracture or spinal column injury.
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Affiliation(s)
- Lauren Michelle Dehne
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio.
| | - Madeline Jane Foertsch
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Christopher Allen Droege
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Amy Teres Makley
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Carolyn Dosen Philpott
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Henry Claude Sagi
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Eric William Mueller
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
| | - Molly Elizabeth Droege
- Department of Pharmacy Services, UC Health - University of Cincinnati Medical Center, Cincinnati, Ohio; University of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, Ohio
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Abd Allah FM, Elhosiny AM, Mohamed HF, Farrag AA, Elmeleigy MA. Enhanced antimicrobial activity of lactic acid bacteria through genome shuffling and genetic variability among shuffled strains. World J Microbiol Biotechnol 2023; 39:114. [PMID: 36913158 DOI: 10.1007/s11274-023-03556-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 02/24/2023] [Indexed: 03/14/2023]
Abstract
In this investigation, lactic acid bacteria (LAB) isolated from milk were tested for their antibacterial properties and improved the antimicrobial activity of these isolates using genome shuffling. A total of sixty-one isolates were found in eleven samples, which were then tested using the agar diffusion method for their antibacterial activity against Staphylococcus aureus, Escherichia coli, Salmonella typhimurium, and Pseudomonas aeruginosa. Thirty-one strains exhibited antibacterial activity against at least one of the tested pathogens, with an inhibitory zone's diameter varying between 15.0 and 24.0 mm. Two isolates that showed the highest antimicrobial activity were identified as Lactobacillus plantarum CIP 103151 and Lactobacillus plantarum JCM 1149 according to 16S rRNA analysis. In the present study, applying genome shuffling approach significantly enhanced the antibacterial activity of L. plantarum. The initial populations were obtained via ultraviolet irradiation and were treated using the protoplast fusion method. The ideal condition for the production of protoplasts was 15 mg/ml of lysozyme and 10 μg/ml of mutanolysin. After two rounds of fusion, ten recombinants exhibited a significant increase in the inhibition zones versus S. aureus, S. typhimurium, P. aeruginosa, and E. coli, reaching up to 1.34, 1.31, 1.37, and 1.37-fold increase in inhibitory zone respectively. Random Amplified Polymorphic DNA results showed clear differences in DNA banding patterns among the wild strain of L. plantarum CIP 103151 and the three selected shuffled strains using primers 1283 & OPA09. On the other hand, no change was obtained using primers OPD03 neither among the wild strain and the three recombinant strains nor among the three shuffled strains.
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Affiliation(s)
- Fatema M Abd Allah
- Botany & Microbiology Department (Girls Branch), Faculty of Science, Al-Azhar University, Cairo, Egypt
| | - Asmaa M Elhosiny
- Botany & Microbiology Department (Girls Branch), Faculty of Science, Al-Azhar University, Cairo, Egypt
| | - Hala F Mohamed
- Botany & Microbiology Department (Girls Branch), Faculty of Science, Al-Azhar University, Cairo, Egypt. .,Third Institute of Oceanography, Ministry of Natural Resources, Xiamen, 361005, People's Republic of China.
| | - Ayman A Farrag
- Al-Azhar Centre for Fermentation Biotechnology & Applied Microbiology, Al-Azhar University, Cairo, Egypt.,Botany & Microbiology Department (Boys Branch), Faculty of Science, Al-Azhar University, Cairo, Egypt
| | - Magda A Elmeleigy
- Botany & Microbiology Department (Girls Branch), Faculty of Science, Al-Azhar University, Cairo, Egypt.
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Yang L, Guo J, He J, Shao J. Skin grafting treatment of adolescent lower limb avulsion injury. Front Surg 2022; 9:953038. [PMID: 36189402 PMCID: PMC9521200 DOI: 10.3389/fsurg.2022.953038] [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: 05/25/2022] [Accepted: 08/30/2022] [Indexed: 11/25/2022] Open
Abstract
Background Under the influence of various factors, the number of lower extremity avulsion injuries in adolescents is increasing year by year. The main modality of treatment is skin grafting. There are many types of skin grafting. Although many studies on skin grafting after avulsion injuries have been published in the past few decades, there are differences in the treatment options for adolescents with post avulsion injuries. Main body Thorough debridement and appropriate skin grafts are essential for the surgical management of avulsion injuries for optimal prognosis. In the acquisition of grafts, progress has been made in equipment for how to obtain different depths of skin. The severity of the avulsion injury varies among patients on admission, and therefore the manner and type of skin grafting will vary. Especially in adolescents, graft survival and functional recovery are of great concern to both patients and physicians. Therefore, many efforts have been made to improve survival rate and activity. Conclusion This review summarizes the principles of treatment of avulsion injuries, the historical development of skin grafts, and the selection of skin grafts, hoping to be helpful for future research.
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Whitely ME, Helms SM, Muire PJ, Lofgren AL, Lopez RA, Wenke JC. Preclinical evaluation of a commercially available biofilm disrupting wound lavage for musculoskeletal trauma. J Orthop Surg Res 2022; 17:347. [PMID: 35840981 PMCID: PMC9284756 DOI: 10.1186/s13018-022-03199-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment of open fractures remains a significant challenge in trauma care as these fractures are accompanied by extensive soft tissue damage, exposing the wound site to contaminants and increasing infection risk. Formation of biofilm, a capsule-like environment that acts as a barrier to treatment, is a primary mode by which infecting pathogens persist at the wound site. Therefore, a pressing need exists to identify irrigation methods that can disrupt biofilm and expose pathogens to treatment. This study aims to evaluate the antibiofilm wound lavage, Bactisure™, in comparison with saline for care of severe musculoskeletal wounds and elucidate potential effects on antibiotic treatment success. METHODS UAMS-1 Staphylococcus aureus biofilms were formed in vitro and treated with Bactisure™ wound lavage or sterile normal saline, alone, or in combination with sub-biofilm inhibitory levels of vancomycin. Characterization methods included quantification of biofilm biomass, quantification of viable biofilm bacteria, and biofilm matrix imaging. For in vivo assessment, a delayed treatment model of contaminated open fracture was used wherein a critical-sized defect was created in a rat femur and wound site inoculated with UAMS-1. Following a 6 h delay, wounds were debrided, irrigated with lavage of interest, and antibiotic treatments administered. Bacterial enumeration was performed on bone and hardware samples after two weeks. RESULTS An immediate reduction in biofilm biomass was observed in vitro following antibiofilm lavage treatment, with a subsequent 2- to 3- log reduction in viable bacteria achieved after 24 h. Furthermore, biofilms treated with antibiofilm lavage in combination with vancomycin exhibited a minor, but statistically significant, decrease in viable bacteria compared to irrigation alone. In vivo, a minor, not statistically significant, decrease in median bioburden was observed for the antibiofilm lavage compared to saline when used in combination with antibiotics. However, the percentage of bone and hardware samples with detectable bacteria was reduced from 50 to 38%. CONCLUSIONS These results suggest that the antibiofilm wound lavage, Bactisure™, may hold promise in mitigating infection in contaminated musculoskeletal wounds and warrants further investigation. Here, we proposed multiple mechanisms in vitro by which this antibiofilm lavage may help mitigate infection, and demonstrate this treatment slightly outperforms saline in controlling bioburden in vivo.
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Affiliation(s)
- Michael E Whitely
- Combat Wound Care Department, US Army Institute of Surgical Research, 3698 Chambers Pass, Building 3611, JBSA-Fort Sam Houston, San Antonio, TX, 78234, USA.
| | - Sarah M Helms
- Combat Wound Care Department, US Army Institute of Surgical Research, 3698 Chambers Pass, Building 3611, JBSA-Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Preeti J Muire
- Combat Wound Care Department, US Army Institute of Surgical Research, 3698 Chambers Pass, Building 3611, JBSA-Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Alicia L Lofgren
- Combat Wound Care Department, US Army Institute of Surgical Research, 3698 Chambers Pass, Building 3611, JBSA-Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Rebecca A Lopez
- Combat Wound Care Department, US Army Institute of Surgical Research, 3698 Chambers Pass, Building 3611, JBSA-Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Joseph C Wenke
- Combat Wound Care Department, US Army Institute of Surgical Research, 3698 Chambers Pass, Building 3611, JBSA-Fort Sam Houston, San Antonio, TX, 78234, 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: 2] [Impact Index Per Article: 1.0] [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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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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11
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Barsoumian AE, Roth AL, Solberg SL, Hanhurst AS, Funari TS, Crouch H, Florez C, Murray CK. Antimicrobial Stewardship Challenges in the Deployed Setting. Mil Med 2021; 185:e818-e824. [PMID: 31786601 DOI: 10.1093/milmed/usz412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Up to 34% of combat trauma injuries are complicated by infection with multidrug-resistant organisms. Overutilization of antibiotics has been linked to increased multidrug-resistant organisms in combat-injured patients. Antimicrobial stewardship efforts at deployed medical treatment facilities have been intermittently reported; however; a comprehensive assessment of antimicrobial stewardship practices has not been performed. MATERIALS AND METHODS A survey tool was modified to include detailed questions on antimicrobial stewardship practices at medical treatment facilities. A Joint Service, multidisciplinary team conducted on-site assessments and interviews to assess the status of antimicrobial stewardship best practices, with particular emphasis on antibiotic prophylaxis in combat injured, in the U.S. Central Command operational theaters. Limitations to implementing stewardship to the national standards were explored thematically. RESULTS Nine Role 1, 2, and 3 medical facilities representing the range of care were assessed on-site. A total of 67% of the sites reported a formal antimicrobial stewardship program and 56% of the sites had an assigned head of antimicrobial stewardship. No military personnel in theater received training on antimicrobial stewardship and laboratory assets were limited. Personnel at these sites largely had access to Joint Trauma System guidelines describing antimicrobial prophylaxis for combat injured (89%), yet infrequently received feedback on their implementation and adherence to these guidelines (11%). CONCLUSIONS Antimicrobial stewardship programs in theater are in the early stages of development in theater. Areas identified for improvement are access to expertise, development of a focus on high-impact lines of effort, laboratory support, and the culture of antimicrobial prescribing. Risks can be mitigated through theater level formalization of efforts, expert mentoring through telehealth, and a focus on implementation and adherence and feedback to national guidelines.
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Affiliation(s)
- Alice E Barsoumian
- Infectious Disease Service, Department of Medicine, Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
| | - Amanda L Roth
- U.S. Army Medical Materiel Development Activity, 1430 Veterans Drive, Fort Detrick, MD 21702
| | - 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
| | - Tamara S Funari
- U.S. Central Command HQ, Surgeon Division, 7115 South Boundary Blvd., MacDill AFB, FL 33621
| | - Helen Crouch
- Infection Prevention and Control, Quality and Safety Center, U.S. Army Medical Command Headquarters, 2748 Worth Rd. STE 26, JBSA 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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12
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Lee GJ, Kyoung KH, Kim KH, Kim N, Sul YH, Lim KH, Hong SK, Cho H. Current status of initial antibiotic therapy and analysis of infections in patients with solitary abdominal trauma: a multicenter trial in Korea. Ann Surg Treat Res 2021; 100:119-125. [PMID: 33585356 PMCID: PMC7870430 DOI: 10.4174/astr.2021.100.2.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/08/2020] [Accepted: 12/11/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose Proper use of antibiotics during emergency abdominal surgery is essential in reducing the incidence of surgical site infection. However, no studies have investigated the type of antibiotics and duration of therapy in individuals with abdominal trauma in Korea. We aimed to investigate the status of initial antibiotic therapy in patients with solitary abdominal trauma. Methods From January 2015 to December 2015, we retrospectively analyzed the medical records of patients with solitary abdominal trauma from 17 institutions including regional trauma centers in South Korea. Both blunt and penetrating abdominal injuries were included. Time from arrival to initial antibiotic therapy, rate of antibiotic use upon injury mechanism, injured organ, type, and duration of antibiotic use, and postoperative infection were investigated. Results Data of the 311 patients were collected. The use of antibiotic was initiated in 96.4% of patients with penetrating injury and 79.7% with blunt injury. Initial antibiotics therapy was provided to 78.2% of patients with solid organ injury and 97.5% with hollow viscus injury. The mean day of using antibiotics was 6 days in solid organ injuries, 6.2 days in hollow viscus. Infection within 2 weeks of admission occurred in 36 cases. Infection was related to injury severity (Abbreviated Injury Scale of >3), hollow viscus injury, operation, open abdomen, colon perforation, and RBC transfusion. There was no infection in cases with laparoscopic operation. Duration of antibiotics did not affect the infection rate. Conclusion Antibiotics are used extensively (84.2%) and for long duration (6.2 days) in patients with abdominal injury in Korea.
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Affiliation(s)
- Gil Jae Lee
- Department of Traumatology, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Kyu-Hyouck Kyoung
- Department of Surgery and Trauma Center, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Ki Hoon Kim
- Department of General Surgery, Haeundae Paik Hospital, Inje University, Busan, Korea
| | - Namryeol Kim
- Department of Trauma Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Young Hoon Sul
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Kyoung Hoon Lim
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Suk-Kyung Hong
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hangjoo Cho
- Department of Trauma Surgery, Uijeongbu St. Mary Hospital, College of Medicine, The Catholic University of Korea., Seoul, Korea
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13
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Rouse MD, Stanbro J, Roman JA, Lipinski MA, Jacobs A, Biswas B, Regeimbal J, Henry M, Stockelman MG, Simons MP. Impact of Frequent Administration of Bacteriophage on Therapeutic Efficacy in an A. baumannii Mouse Wound Infection Model. Front Microbiol 2020; 11:414. [PMID: 32256472 PMCID: PMC7090133 DOI: 10.3389/fmicb.2020.00414] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 02/27/2020] [Indexed: 01/21/2023] Open
Abstract
The spread of multidrug antibiotic resistance (MDR) is a widely recognized crisis in the treatment of bacterial infections, including those occurring in military communities. Recently, the World Health Organization published its first ever list of antibiotic-resistant “priority pathogens” – a catalog of 12 families of bacteria that pose the greatest threat to human health with A. baumannii listed in the “Priority 1: Critical” category of pathogens. With the increasing prevalence of antibiotic resistance and limited development of new classes of antibiotics, alternative antimicrobial therapies are needed, with lytic bacteriophage (phage) specifically targeted against each of the high priority bacterial infections as a potential approach currently in development toward regulatory approval for clinical use. Balb/c mice were prophylactically administered PBS or phage selected against A. baumannii strain AB5075. After 3 weeks, mice were anesthetized, wounded (dorsal), and challenged topically with AB5075. Following infection, mice were subsequently treated with PBS or phage for three consecutive days, and evaluated for 3 weeks to assess the safety and efficacy of the phage treatment relative to the control. We assessed mortality, bacterial burden, time to wound closure, systemic and local cytokine profiles, alterations in host cellular immunity, and finally presence of neutralizing antibodies to the phage mixture. In our study, we found that prophylactic phage administration led to a significant reduction in monocyte-related cytokines in serum compared to mice given PBS. However, we detected no significant changes to circulating blood populations or immune cell populations of secondary lymphoid organs compared to PBS-treated mice. Following prophylactic phage administration, we detected a marked increase in total immunoglobulins in serum, particularly IgG2a and IgG2b. Furthermore, we determined that these antibodies were able to specifically target phage and effectively neutralize their ability to lyse their respective target. In regards to their therapeutic efficacy, administration of phage treatment effectively decreased wound size of mice infected with AB5075 without adverse effects. In conclusion, our data demonstrate that phage can serve as a safe and effective novel therapeutic agent against A. baumannii without adverse reactions to the host and pre-exposure to phage does not seem to adversely affect therapeutic efficacy. This study is an important proof of concept to support the efforts to develop phage as a novel therapeutic product for treatment of complex bacterial wound infections.
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Affiliation(s)
- Michael D Rouse
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States.,Naval Medical Research Center, Silver Spring, MD, United States
| | - Joshua Stanbro
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States.,Naval Medical Research Center, Silver Spring, MD, United States
| | - Jessica A Roman
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States.,Naval Medical Research Center, Silver Spring, MD, United States
| | - Michelle A Lipinski
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States.,Naval Medical Research Center, Silver Spring, MD, United States
| | - Anna Jacobs
- Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Biswaijt Biswas
- Biological Defense Research Directorate, Naval Medical Research Center, Fort Detrick, MD, United States
| | | | - Matthew Henry
- Naval Medical Research Center, Silver Spring, MD, United States.,Biological Defense Research Directorate, Naval Medical Research Center, Fort Detrick, MD, United States
| | | | - Mark P Simons
- Naval Medical Research Center, Silver Spring, MD, United States
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14
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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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15
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Chalela JA, Britell PE. Tactical Neurocritical Care. Neurocrit Care 2020; 30:253-260. [PMID: 29589329 DOI: 10.1007/s12028-018-0524-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Neurocritical care is usually practiced in the comfort of an intensive care unit within a tertiary care medical center. Physicians deployed to the frontline with the US military or allied military are required to use their critical care skills and their neurocritical skills in austere environments with limited resources. Due to these factors, tactical critical care and tactical neurocritical care differ significantly from traditional critical care. Operational constraints, the tactical environment, and resource availability dictate that tactical neurocritical care be practiced within a well-defined, mission-constrained framework. Although limited interventions can be performed in austere conditions, they can significantly impact patient outcome. This review focuses on the US Army approach to the patient requiring tactical neurocritical care specifically point of injury care and care during transportation to a higher level of care.
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Affiliation(s)
- Julio A Chalela
- Neurology and Neurosurgery, Medical University of South Carolina, 1-151, AV BN, SCARNG, Charleston, USA.
| | - Patrick E Britell
- Anesthesiology and Neurosurgery, Medical University of South Carolina, 75th CSH, USAR, Charleston, USA
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16
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Stewart L, Li P, Blyth MDM, Campbell WR, Petfield JL, Krauss M, Greenberg L, Tribble DR. Antibiotic Practice Patterns for Extremity Wound Infections among Blast-Injured Subjects. Mil Med 2020; 185:628-636. [PMID: 32074316 DOI: 10.1093/milmed/usz211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 06/30/2019] [Accepted: 07/03/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION We examined antibiotic management of combat-related extremity wound infections (CEWI) among wounded U.S. military personnel (2009-2012). METHODS Patients were included if they sustained blast injuries, resulting in ≥1 open extremity wound, were admitted to participating U.S. hospitals, developed a CEWI (osteomyelitis or deep soft-tissue infections) within 30 days post-injury, and received ≥3 days of relevant antibiotic (s) for treatment. RESULTS Among 267 patients, 133 (50%) had only a CEWI, while 134 (50%) had a CEWI plus concomitant non-extremity infection. In the pre-diagnosis period (4-10 days prior to CEWI diagnosis), 95 (36%) patients started a new antibiotic with 28% of patients receiving ≥2 antibiotics. During CEWI diagnosis week (±3 days of diagnosis), 209 (78%) patients started a new antibiotic (71% with ≥2 antibiotics). In the week following diagnosis (4-10 days after CEWI diagnosis), 121 (45%) patients started a new antibiotic with 39% receiving ≥2 antibiotics. Restricting to ±7 days of CEWI diagnosis, patients commonly received two (35%) or three (27%) antibiotics with frequent combinations involving carbapenem, vancomycin, and fluoroquinolones. CONCLUSIONS Substantial variation in antibiotic prescribing patterns related to CEWIs warrants development of combat-related clinical practice guidelines beyond infection prevention, to include strategies to reduce the use of unnecessary antibiotics and improve stewardship.
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Affiliation(s)
- Laveta Stewart
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Suite 100, Bethesda, MD 20817
| | - Ping Li
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Suite 100, Bethesda, MD 20817
| | - Maj Dana M Blyth
- Infectious Disease Service, Brooke Army Medical Center, 3551 Roger Brooke Drive #3600, Fort Sam Houston, TX 78234
| | - Wesley R Campbell
- Infectious Disease Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889
| | | | - Margot Krauss
- Westat, 1600 Research Boulevard, Rockville, MD 20850
| | | | - 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
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17
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Naylor JF, April MD, Hill GJ, Schauer SG. Pediatric Prehospital Wound Prophylaxis in Iraq and Afghanistan. Mil Med 2020; 185:73-76. [PMID: 32074367 DOI: 10.1093/milmed/usz285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 07/23/2019] [Accepted: 07/23/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Infectious complications of war wounds are a significant source of mortality and morbidity. Tactical Combat Casualty Care (TCCC) guidelines recommend prehospital moxifloxacin, ertapenem, or cefotetan for "all open combat wounds." We describe the prehospital administration of antibiotics to pediatric trauma patients. METHODS We queried the Department of Defense Trauma Registry for all pediatric subjects admitted to United States and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. RESULTS During this time, there were 3,439 pediatric encounters which represented 8.0% of all admissions. Prehospital providers administered a total of 216 antibiotic doses to 210 subjects. Older children received antibiotics more frequently than younger children, were more likely to be male, located in Afghanistan, and injured by explosive with the majority surviving to hospital discharge. Cefazolin and ceftriaxone were the most frequently utilized antibiotics. CONCLUSIONS The most frequently administered antibiotics were cephalosporins. TCCC recommended agents for adult prehospital wound prophylaxis were infrequently administered to pediatric casualties. Administration rates of pediatric prehospital wound prophylaxis may be improved with pediatric-specific TCCC guidelines recommending cephalosporins as first-line agents, fielding of a TCCC-oriented Broselow tape, and training prehospital providers on administration of antimicrobials.
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Affiliation(s)
- Jason F Naylor
- Madigan Army Medical Center, 9040 Jackson Avenue, Joint Base Lewis-McChord, Tacoma, WA 98431
| | - Michael D April
- San Antonio Military Medical Center, 3551 Roger Brooke Drive, Joint Base San Antonio, San Antonio, TX 78234
| | - Guyon J Hill
- Carl R. Darnall Army Medical Center, 36065 Santa Fe Avenue, Fort Hood, TX 76544
| | - Steven G Schauer
- Madigan Army Medical Center, 9040 Jackson Avenue, Joint Base Lewis-McChord, Tacoma, WA 98431.,US Army Institute of Surgical Research, 3698 Chambers Pass Suite B, Joint Base San Antonio, San Antonio, TX 78234.,59th Medical Wing, 1100 Wilford Hall Loop, Joint Base San Antonio, San Antonio, TX 78236
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18
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Lloyd BA, Murray CK, Shaikh F, Carson ML, Blyth DM, Schnaubelt ER, Whitman TJ, Tribble DR. Antimicrobial Prophylaxis with Combat-Related Open Soft-Tissue Injuries. Mil Med 2019; 183:e260-e265. [PMID: 29447384 DOI: 10.1093/milmed/usx125] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/08/2017] [Accepted: 11/30/2017] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION All Department of Defense (DoD) guidance documents recommend cefazolin or clindamycin as post-trauma antibiotic prophylaxis for open soft-tissue injuries. Although not advocated, some patients with open soft-tissue injuries also received expanded Gram-negative coverage (EGN) prophylaxis based on the judgment of front-line trauma providers. During the study period, revised guidelines in 2011/2012 re-emphasized recommendations for using cefazolin or clindamycin, and stewardship efforts in the DoD trauma community aimed to reduce the practice of adding EGN to guideline-recommended antibiotic prophylaxis. Our objective was to examine antibiotic utilization among wounded military personnel with open extremity soft-tissue injuries over a 5-yr period and assess the impact on infectious outcomes in patients who received EGN prophylaxis versus guideline-directed prophylaxis. METHODS The study population included military personnel with open extremity soft-tissue injuries sustained in Iraq and Afghanistan (2009-2014) who transferred to participating hospitals in the USA following medical evacuation. The analysis was restricted to patients who were hospitalized for at least seven days at a U.S. facility and excluded those who sustained open fractures. Post-trauma antibiotic prophylactic regimens were defined as narrow if they followed recommended guidance (e.g., IV cefazolin or clindamycin) or EGN coverage when the narrow regimen also included fluoroquinolones and/or aminoglycosides. Intravenous amoxicillin-clavulanate, which is commonly used at non-U.S. coalition theater hospitals, was also classified as narrow because it conformed to coalition antibiotic prophylaxis guidelines. This study was approved by the Infectious Disease Institutional Review Board of the Uniformed Services University of the Health Sciences. RESULTS A total of 287 wounded personnel with open soft-tissue injuries were assessed, of which 212 (74%) received narrow prophylaxis and 75 (26%) received EGN coverage (p < 0.001). Among patients in the narrow prophylaxis group, 81% were given cefazolin and/or clindamycin, while 19% received amoxicillin-clavulanate. In the EGN group, 88% and 12% received a fluoroquinolone and aminoglycoside, respectively. Use of EGN coverage significantly declined during the study period from 39% in 2009-2010 to 11% in 2013-2014 (p < 0.001). Approximately 3% of patients who received a narrow regimen developed an extremity skin and soft-tissue infection, while there were no skin and soft-tissue infections among patients in the EGN coverage group. Nonetheless, this was not a significant difference (p = 0.345). In addition, the proportion of non-extremity infections was not significantly different between narrow and EGN regimen groups (11% and 15%, respectively). There were also no significant differences between the narrow and EGN regimen groups related to duration of hospitalization (median of 19 versus 20 d). CONCLUSION Use of non-guideline directed EGN-based post-trauma antibiotic prophylaxis does not improve infectious outcomes nor does it shorten hospital stay.
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Affiliation(s)
- Bradley A Lloyd
- San Antonio Military Medical Center, 3551 Roger Brooke Drive #3600, Fort Sam Houston, TX
| | - Clinton K Murray
- San Antonio Military Medical Center, 3551 Roger Brooke Drive #3600, Fort Sam Houston, TX
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Suite 100, Bethesda, MD
| | - M Leigh Carson
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Suite 100, Bethesda, MD
| | - Dana M Blyth
- San Antonio Military Medical Center, 3551 Roger Brooke Drive #3600, Fort Sam Houston, TX
| | | | - Timothy J Whitman
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD
| | - 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
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19
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Tribble DR, Murray CK, Lloyd BA, Ganesan A, Mende K, Blyth DM, Petfield JL, McDonald J. After the Battlefield: Infectious Complications among Wounded Warriors in the Trauma Infectious Disease Outcomes Study. Mil Med 2019; 184:18-25. [PMID: 31778199 PMCID: PMC6886670 DOI: 10.1093/milmed/usz027] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/04/2019] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION During recent wars in Iraq and Afghanistan, improved survivability in severe trauma corresponded with a rise in the proportion of trauma-related infections, including those associated with multidrug-resistant organisms (MDROs). Significant morbidity was reported in association with the infections. There is also concern regarding potential long-term impacts of the trauma-related infectious complications. Therefore, to meet the critical need of prospective collection of standardized infection-related data to understand the disease burden and improve outcomes of wounded personnel, the Trauma Infectious Disease Outcomes Study (TIDOS) was developed. Herein, we review accomplishments and key peer-reviewed findings of TIDOS. METHODS The TIDOS project is a multicenter observational study of short- and long-term infectious complications following deployment-related trauma. Wounded military personnel medevac'd to Landstuhl Regional Medical Center (LRMC; Germany) before transfer to a participating US military hospital between June 2009 and December 2014 were eligible for inclusion. An infectious disease module to supplement the Department of Defense Trauma Registry by collecting infection-related data from all trauma patients admitted to participating hospitals was developed. Specimens from trauma patients were also collected and retained in a microbiological isolate repository. During the initial hospitalization, patients were given the opportunity to enroll in a prospective follow-up cohort study. Patients who received Department of Veterans Affairs (VA) care were also given the opportunity to consent to ongoing VA follow-up. RESULTS A total of 2,699 patients transferred to participating military hospitals in the USA, of which 1,359 (50%) patients enrolled in the TIDOS follow-up cohort. In addition, 638 enrolled in the TIDOS-VA cohort (52% of TIDOS enrollees who entered VA healthcare). More than 8,000 isolates were collected from infection control surveillance and diagnostic evaluations and retained in the TIDOS Microbiological Repository. Approximately 34% of the 2,699 patients at US hospitals developed a trauma-related infection during their initial hospitalization with skin and soft-tissue infections being predominant. After discharge from the US hospitals, approximately one-third of TIDOS cohort enrollees developed a new trauma-related infection during follow-up and extremity wound infections (skin and soft-tissue infections and osteomyelitis) continued to be the majority. Among TIDOS cohort enrollees who received VA healthcare, 38% developed a new trauma-related infection with the incident infection being diagnosed a median of 88 days (interquartile range: 19-351 days) following hospital discharge. Data from TIDOS have been used to support the development of Joint Trauma System clinical practice guidelines for the prevention of combat-related infections, as well as the management of invasive fungal wound infections. Lastly, due to the increasing proportion of infections associated with MDROs, TIDOS investigators have collaborated with investigators across military laboratories as part of the Multidrug-Resistant and Virulent Organisms Trauma Infections Initiative with the objective of improving the understanding of the complex wound microbiology in order to develop novel infectious disease countermeasures. CONCLUSIONS The TIDOS project has focused research on four initiatives: (1) blast-related wound infection epidemiology and clinical management; (2) DoD-VA outcomes research; (3) Multidrug- Resistant and other Virulent Organisms Trauma Infections Initiative; and (4) Joint Trauma System clinical practice guidelines and antibiotic stewardship. There is a continuing need for longitudinal data platforms to support battlefield wound research and clinical practice guideline recommendation refinement, particularly to improve care for future conflicts. As such, maintaining a research platform, such as TIDOS, would negate the lengthy time needed to initiate data collection and analysis.
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Affiliation(s)
- 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
| | - Clinton K Murray
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
- Current affiliation is 1st Area Medical Laboratory, Aberdeen Proving Ground, MD
| | - Bradley A Lloyd
- Landstuhl Regional Medical Center, Landstuhl, Germany, CMR 402, APO, AE, 09180
- Current affiliation is Wright Patterson Medical Center, OH
| | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
- Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20852
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720 A Rockledge Drive, Bethesda, MD 20817
| | - Katrin Mende
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720 A Rockledge Drive, Bethesda, MD 20817
| | - Dana M Blyth
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234
| | - Joseph L Petfield
- Landstuhl Regional Medical Center, Landstuhl, Germany, CMR 402, APO, AE, 09180
| | - Jay McDonald
- Veterans Affairs St. Louis Health Care System, 915 N Grand Blvd, St. Louis, MO 63106
- Washington University School of Medicine, 660 Euclid Ave, St. Louis, MO 63110
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20
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CORR Insights®: Union Rates and Reported Range of Motion Are Acceptable After Open Forearm Fractures in Military Combatants. Clin Orthop Relat Res 2019; 477:2329-2331. [PMID: 31135535 PMCID: PMC6999934 DOI: 10.1097/corr.0000000000000750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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21
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Depcinski SC, Nguyen KH, Ender PT. Cefazolin and an aminoglycoside compared with cefazolin alone for the antimicrobial prophylaxis of type III open orthopedic fractures. Int J Crit Illn Inj Sci 2019; 9:127-131. [PMID: 31620351 PMCID: PMC6792399 DOI: 10.4103/ijciis.ijciis_7_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/13/2019] [Accepted: 08/05/2019] [Indexed: 12/16/2022] Open
Abstract
Context Uncertainty of antibiotic prophylaxis of type III open orthopedic fractures still exists. Controversy remains as using cefazolin as a single agent or the addition of an aminoglycoside for broader coverage to prevent infection. Aims The aim of the study was to determine if the combination of cefazolin and an aminoglycoside reduced infections compared with cefazolin alone. Subjects and Methods This was a retrospective study inclusive of patients with type III open fracture admitted between January 1, 2010, and August 31, 2014 at a level 1 trauma center, who were prophylactically treated with cefazolin alone or cefazolin and an aminoglycoside. Statistical Analysis Used All analyses were performed using Microsoft Excel 2010. Chi-square or Fisher's exact tests were used for categorical data and Wilcoxon rank-sum test for skewed continuous data. Logistic regression analysis was performed on all confounding variables with P < 0.1. Results A significantly higher percentage in the combination group developed infection (6/15 [40%] vs. 8/53 [15.1%], P = 0.035). There was a trend toward a higher odds of infection in the combination group (odds ratio: 2.99, 95% confidence interval: 0.79-11.33, P = 0.107). Infection rates due to multidrug-resistant bacteria were statistically higher with the combination group (3/15 [20%] vs. 1/53 [1.9%], P = 0.046). There were no statistically significant differences in 30-day mortality, 1-year readmission rates due to fracture complication, or length of hospital stay. Conclusions The results suggest that the addition of an aminoglycoside to cefazolin may not be necessary to prevent infection.
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Affiliation(s)
- Shawn C Depcinski
- Department of Pharmacy, St. Luke's University Health Network, PA, USA
| | | | - Peter T Ender
- Department of Medicine, Section of Infectious Diseases, St. Luke's University Health Network, Bethlehem, PA, USA
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22
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Pace LR, Harrison ZL, Brown MN, Haggard WO, Jennings JA. Characterization and Antibiofilm Activity of Mannitol-Chitosan-Blended Paste for Local Antibiotic Delivery System. Mar Drugs 2019; 17:md17090517. [PMID: 31480687 PMCID: PMC6780707 DOI: 10.3390/md17090517] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/23/2019] [Accepted: 08/28/2019] [Indexed: 12/16/2022] Open
Abstract
Mannitol, a polyalcohol bacterial metabolite, has been shown to activate dormant persister cells within bacterial biofilm. This study sought to evaluate an injectable blend of mannitol, chitosan, and polyethylene glycol for delivery of antibiotics and mannitol for eradication of Staphylococcal biofilm. Mannitol blends were injectable and had decreased dissociation and degradation in the enzyme lysozyme compared to blends without mannitol. Vancomycin and amikacin eluted in a burst response, with active concentrations extended to seven days compared to five days for blends without mannitol. Mannitol eluted from the paste in a burst the first day and continued through Day 4. Eluates from the mannitol pastes with and without antibiotics decreased viability of established S. aureus biofilm by up to 95.5% compared to blends without mannitol, which only decreased biofilm when loaded with antibiotics. Cytocompatibility tests indicated no adverse effects on viability of fibroblasts. In vivo evaluation of inflammatory response revealed mannitol blends scored within the 2–4 range at Week 1 (2.6 ± 1.1) and at Week 4 (3.0 ± 0.8), indicative of moderate inflammation and comparable to non-mannitol pastes (p = 0.065). Clinically, this paste could be loaded with clinician-selected antibiotics and used as an adjunctive therapy for musculoskeletal infection prevention and treatment.
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Affiliation(s)
- Leslie R Pace
- Department of Biomedical Engineering, Herff College of Engineering, University of Memphis, Memphis, TN 38152, USA
| | - Zoe L Harrison
- Department of Biomedical Engineering, Herff College of Engineering, University of Memphis, Memphis, TN 38152, USA
| | - Madison N Brown
- Department of Biomedical Engineering, Herff College of Engineering, University of Memphis, Memphis, TN 38152, USA
| | - Warren O Haggard
- Department of Biomedical Engineering, Herff College of Engineering, University of Memphis, Memphis, TN 38152, USA
| | - J Amber Jennings
- Department of Biomedical Engineering, Herff College of Engineering, University of Memphis, Memphis, TN 38152, USA.
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Woolum JA, Bailey AM, Dugan A, Agrawal R, Baum RA. Evaluation of infection rates with narrow versus broad-spectrum antibiotic regimens in civilian gunshot open-fracture injury. Am J Emerg Med 2019; 38:934-939. [PMID: 31402235 DOI: 10.1016/j.ajem.2019.158358] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/18/2019] [Accepted: 07/20/2019] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Civilian gunshot open-fracture injuries portray a significant health burden to patients. Use of antibiotics is endorsed by guideline recommendations for the prevention of post-traumatic infections, however, antimicrobial selection and their associated outcomes remains unclear. Therefore, we sought to compare infectious and other clinical outcomes between three antimicrobial cohorts in patients with gunshot-related fractures requiring operative intervention. MATERIALS AND METHODS Patients were identified by retrospectively querying the University of Kentucky Trauma Registry for gunshot wound victims. A narrow regimen, an expanded gram-negative regimen, and a regimen containing a fluoroquinolone antimicrobial were identified for comparison. The primary outcome was a composite of infections at or before 14 days of hospitalization. Secondary endpoints included hospital length of stay, incidence of multidrug resistant bacteria and methicillin-resistant Staphylococcus aureus colonization, number of drug-related adverse events, number of Clostridium difficile infections, and 30-day mortality. RESULTS 252 patients were selected for inclusion: 126 in the narrow regimen, 49 in the expanded gram-negative regimen, and 77 in the fluoroquinolone-based regimen. There were no statistical differences in the primary endpoint of early infectious outcomes between groups (p = 0.1797). The expanded gram-negative regimen was associated with increased hospital length of stay, and increased incidence of multi-drug resistant bacteria and methicillin-resistant Staphylococcus aureus colonization. There were no statistically significant differences in any of the remaining secondary endpoints. CONCLUSION In this study evaluating civilian gunshot trauma, broad spectrum antibiotic coverage was not associated with improvements in post-traumatic infections. A randomized trial is needed to confirm these results.
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Affiliation(s)
- Jordan A Woolum
- Department of Pharmacy, West Virginia University, Morgantown, WV, United States.
| | - Abby M Bailey
- Department of Pharmacy, University of Kentucky, Lexington, KY, United States
| | - Adam Dugan
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, United States
| | - Rahul Agrawal
- Department of Business Intelligence, University of Kentucky HealthCare Information Technology, Lexington, KY, United States
| | - Regan A Baum
- Department of Pharmacy, University of Kentucky, Lexington, KY, United States
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Chaudhry SB, Veve MP, Wagner JL. Cephalosporins: A Focus on Side Chains and β-Lactam Cross-Reactivity. PHARMACY 2019; 7:E103. [PMID: 31362351 PMCID: PMC6789778 DOI: 10.3390/pharmacy7030103] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/24/2019] [Accepted: 07/26/2019] [Indexed: 12/13/2022] Open
Abstract
Cephalosporins are among the most commonly prescribed antibiotic classes due to their wide clinical utility and general tolerability, with approximately 1-3% of the population reporting a cephalosporin allergy. However, clinicians may avoid the use of cephalosporins in patients with reported penicillin allergies despite the low potential for cross-reactivity. The misdiagnosis of β-lactam allergies and misunderstanding of cross-reactivity among β-lactams, including within the cephalosporin class, often leads to use of broader spectrum antibiotics with poor safety and efficacy profiles and represents a serious obstacle for antimicrobial stewardship. Risk factors for cephalosporin allergies are broad and include female sex, advanced age, and a history of another antibiotic or penicillin allergy; however, cephalosporins are readily tolerated even among individuals with true immediate-type allergies to penicillins. Cephalosporin cross-reactivity potential is related to the structural R1 side chain, and clinicians should be cognizant of R1 side chain similarities when prescribing alternate β-lactams in allergic individuals or when new cephalosporins are brought to market. Clinicians should consider the low likelihood of true cephalosporin allergy when clinically indicated. The purpose of this review is to provide an overview of the role of cephalosporins in clinical practice, and to highlight the incidence of, risk factors for, and cross-reactivity of cephalosporins with other antibiotics.
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Affiliation(s)
- Saira B Chaudhry
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ 08854, USA
- Department of Infectious Diseases, Jersey Shore University Medical Center, Neptune, NJ 07753, USA
| | - Michael P Veve
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Knoxville, TN 37920, USA.
| | - Jamie L Wagner
- Department of Pharmacy Practice, School of Pharmacy, University of Mississippi, Jackson, MS 39216, USA
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25
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Apelqvist J, Willy C, Fagerdahl AM, Fraccalvieri M, Malmsjö M, Piaggesi A, Probst A, Vowden P. EWMA Document: Negative Pressure Wound Therapy. J Wound Care 2019; 26:S1-S154. [PMID: 28345371 DOI: 10.12968/jowc.2017.26.sup3.s1] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.1 NPWT has been described as a effective treatment for wounds of many different aetiologies2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,4-6 dehisced sternal wounds following cardiac surgery7,8 and as a valuable agent in complex non-healing wounds.9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.11 While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.
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Affiliation(s)
- Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, 205 02 Malmö, Sweden and Division for Clinical Sciences, University of Lund, 221 00 Lund, Sweden
| | - Christian Willy
- Department of Trauma & Orthopedic Surgery, Septic & Reconstructive Surgery, Bundeswehr Hospital Berlin, Research and Treatment Center for Complex Combat Injuries, Federal Armed Forces of Germany, 10115 Berlin, Germany
| | - Ann-Mari Fagerdahl
- Department of Clinical Science and Education, Karolinska Institutet, and Wound Centre, Södersjukhuset AB, SE-118 83 Stockholm, Sweden
| | - Marco Fraccalvieri
- Plastic Surgery Unit, ASO Città della Salute e della Scienza of Turin, University of Turin, 10100 Turin, Italy
| | | | - Alberto Piaggesi
- Department of Endocrinology and Metabolism, Pisa University Hospital, 56125 Pisa, Italy
| | - Astrid Probst
- Kreiskliniken Reutlingen GmbH, 72764 Reutlingen, Germany
| | - Peter Vowden
- Faculty of Life Sciences, University of Bradford, and Honorary Consultant Vascular Surgeon, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, United Kingdom
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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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Wells CM, Beenken KE, Smeltzer MS, Courtney HS, Jennings JA, Haggard WO. Ciprofloxacin and Rifampin Dual Antibiotic-Loaded Biopolymer Chitosan Sponge for Bacterial Inhibition. Mil Med 2019; 183:433-444. [PMID: 29635619 DOI: 10.1093/milmed/usx150] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 01/05/2018] [Indexed: 12/22/2022] Open
Abstract
Complex extremity wounds in Wounded Warriors can become contaminated with microbes, which may cause clinical outcomes resulting in amputation, morbidity, or even fatality. Local delivery of multiple or broad-spectrum antibiotics allows practicing clinicians treatment solutions that may inhibit biofilm formation. Propagation of vancomycin-resistant Staphylococcus aureus is also a growing concern. The development of vancomycin-resistant S. aureus has become a critical challenge in nosocomial infection prevention in the USA, but to date has seen little occurrence in osteomyelitis. As an alternative, locally delivered ciprofloxacin and rifampin were investigated in a preclinical model for the prevention of biofilm in complex extremity wounds with implanted fixation device. In vitro assays demonstrated ciprofloxacin and rifampin possess an additive effect against Gram-negative Pseudomonas aeruginosa and were actively eluted from a chitosan sponge based local delivery system. In an in vivo orthopedic hardware-associated polymicrobial model (S. aureus and Escherichia coli) the combination was able to achieve complete clearance of both bacterial strains. E. coli was detected in bone of untreated animals, but did not form biofilm on wires. Results reveal the clinical potential of antibiotic-loaded chitosan sponges to inhibit infection through tailored antibiotic selection at desired concentrations with efficacy towards biofilm inhibition.
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Affiliation(s)
- Carlos M Wells
- Department of Biomedical Engineering, University of Memphis, 3796 Norriswood Avenue, Memphis, TN 38111
| | - Karen E Beenken
- The Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205
| | - Mark S Smeltzer
- The Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205
| | - Harry S Courtney
- Department of Medicine, University of Tennessee Health Science Center, 956 Court Avenue, Memphis, TN 38163
| | - Jessica A Jennings
- Department of Biomedical Engineering, University of Memphis, 3796 Norriswood Avenue, Memphis, TN 38111
| | - Warren O Haggard
- Department of Biomedical Engineering, University of Memphis, 3796 Norriswood Avenue, Memphis, TN 38111
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Boles LR, Awais R, Beenken KE, Smeltzer MS, Haggard WO, Jessica AJ. Local Delivery of Amikacin and Vancomycin from Chitosan Sponges Prevent Polymicrobial Implant-Associated Biofilm. Mil Med 2019; 183:459-465. [PMID: 29635622 DOI: 10.1093/milmed/usx161] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 12/27/2017] [Indexed: 01/01/2023] Open
Abstract
Military personnel have high risk for infection, particularly those with combat-related extremity trauma. Administration of multiple or broad-spectrum antibiotics provides clinicians with a strategy for preventing biofilm-based medical device infections. Selection of effective antibiotic combinations based on common pathogens may be used to improve chitosan wound dressing sponge-based local antibiotic delivery systems. In vitro assays in this study demonstrate that vancomycin and amikacin have a synergistic relationship against a strain of osteomyelitis-producing Gram-positive Staphylococcus aureus, although an indifferent relationship was observed against Gram-negative Pseudomonas aeruginosa. In an in vivo model of orthopedic hardware-associated polymicrobial (S. aureus and Escherichia coli) biofilm, chitosan sponges loaded with a combination of vancomycin and amikacin at 5 mg/mL each showed a greater percentage of complete clearance, 50%, than either antibiotic alone, 8.33%. Doubling the loading concentration of the combination achieved a complete clearance rate of 100%, a four log-fold reduction of S. aureus on the wire and a six log-fold reduction in bone. E. coli was detected in bone of untreated animals but did not form biofilm on wires. Results demonstrate the clinical potential of chitosan sponges to prevent infection and illustrates antibiotic selection and loading concentrations necessary for effective biofilm prevention.
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Affiliation(s)
- Logan R Boles
- Department of Biomedical Engineering, University of Memphis, 3796 Norriswood Avenue, Memphis, TN 38111
| | - Rukhsana Awais
- Department of Biomedical Engineering, University of Memphis, 3796 Norriswood Avenue, Memphis, TN 38111
| | - Karen E Beenken
- Department of Microbiology and Immunology University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205
| | - Mark S Smeltzer
- Department of Microbiology and Immunology University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205
| | - Warren O Haggard
- Department of Biomedical Engineering, University of Memphis, 3796 Norriswood Avenue, Memphis, TN 38111
| | - Amber Jennings Jessica
- Department of Biomedical Engineering, University of Memphis, 3796 Norriswood Avenue, Memphis, TN 38111
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Zong ZW, Qin H, Chen SX, Yang JZ, Yang L, Zhang L, Du WQ, Zhong X, Zhou RJ, Tan D, Wu H. Chinese expert consensus on the treatment of modern combat-related spinal injuries. Mil Med Res 2019; 6:6. [PMID: 30786926 PMCID: PMC6381715 DOI: 10.1186/s40779-019-0196-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 02/07/2019] [Indexed: 12/12/2022] Open
Abstract
The battlefield treatments of spinal and spinal cord injury vary from civilian settings. However, there is no unified battlefield treatment guidelines for spine trauma in PLA. An expert consensus is reached, based on spine trauma epidemiology and the concepts of battlefield treatment combined with the existing levels of military medical care in modern warfare. Since the specialized treatment for spine trauma are no significant difference between civilian settings and modern war, the first aid, emergency treatment and early treatment of spine trauma are introduced separately in three levels in this consensus. In Level I facilities, the fast and accurate evaluation of spine trauma followed by fixation and stabilization are recommended during the first-aid stage. Re-evaluation, further treatment for possible hemorrhagic shock, dyspnea and infection are recommended at Level II facilities. At Level III facilities, it is recommended to strengthen the intensive care and the prevention of urinary system and lung infection for the wounded with severe spinal injury, however, spinal surgery is not recommended in a battlefield hospital. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.
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Affiliation(s)
- Zhao-Wen Zong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China.
| | - Hao Qin
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Si-Xu Chen
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Jia-Zhi Yang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Lei Yang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Lin Zhang
- Department of Tactical Health Service, NCO School of Army Medical University, Shijiazhuang, 050000, China
| | - Wen-Qiong Du
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Xin Zhong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, Chongqing, 400038, China
| | - Ren-Jie Zhou
- Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Dan Tan
- Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
| | - Hao Wu
- Xinqiao Hospital, Army Medical University, Chongqing, 400037, China
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Blake DP. Key Ways to Prevent Infection When There Is No "Building": Aspects for the Field. Surg Infect (Larchmt) 2019; 20:115-118. [PMID: 30676276 DOI: 10.1089/sur.2018.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Infection control is a critical aspect in the continuum of surgical care. Much of what is outlined in the literature pertains to hospital-based practice, with only recent attention paid to the more austere environments, particularly those faced during humanitarian or combat operations. OBJECTIVE This manuscript provides a brief historical review of the development of infection control practices and further identifies and outlines several aspects necessary to successful program applications in austere environments. RESULTS Hand hygiene remains the simplest form of infection control. Use of alcohol-based hand sanitizer is a logistically reasonable option for most circumstances, mitigating the requirement for clean running water to facilitate more traditional "soap and water" methods of hand disinfection. Environmental decontamination, patient cohorting, and patient isolation based on existing colonization/infection also has demonstrated efficacy in controlling cross-contamination and is feasible in most austere environments. Finally, senior leadership engagement with deliberate planning, antimicrobial stewardship, and vigorous quality and process improvement algorithms have resulted in reduced rates of critical infections in these settings. CONCLUSIONS Basic tenets of infection control can be achieved even in resource-poor environments. Meticulous attention to adhering to these principles, with support from senior medical and operational leadership, facilitates improvements in infection control outcomes. There remains, however, a need for additional robust outcomes data regarding best practices in these environments.
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Affiliation(s)
- David P Blake
- Division of Acute Care Surgery, Department of Surgery, Hartford Hospital, Hartford, Connecticut and Department of Surgery, Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine, Bethesda, Maryland
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Jang JY, Kang WS, Keum MA, Sul YH, Lee DS, Cho H, Lee GJ, Lee JG, Hong SK. Antibiotic use in patients with abdominal injuries: guideline by the Korean Society of Acute Care Surgery. Ann Surg Treat Res 2018; 96:1-7. [PMID: 30603627 PMCID: PMC6306503 DOI: 10.4174/astr.2019.96.1.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/17/2018] [Accepted: 10/05/2018] [Indexed: 11/30/2022] Open
Abstract
Purpose A task force appointed by the Korean Society of Acute Care Surgery reviewed previously published guidelines on antibiotic use in patients with abdominal injuries and adapted guidelines for Korea. Methods Four guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II instrument. Five topics were considered: indication for antibiotics, time until first antibiotic use, antibiotic therapy duration, appropriate antibiotics, and antibiotic use in abdominal trauma patients with hemorrhagic shock. Results Patients requiring surgery need preoperative prophylactic antibiotics. Patients who do not require surgery do not need antibiotics. Antibiotics should be administered as soon as possible after injury. In the absence of hollow viscus injury, no additional antibiotic doses are needed. If hollow viscus injury is repaired within 12 hours, antibiotics should be continued for ≤ 24 hours. If hollow viscus injury is repaired after 12 hours, antibiotics should be limited to 7 days. Antibiotics can be administered for ≥7 days if hollow viscus injury is incompletely repaired or clinical signs persist. Broad-spectrum aerobic and anaerobic coverage antibiotics are preferred as the initial antibiotics. Second-generation cephalosporins are the recommended initial antibiotics. Third-generation cephalosporins are alternative choices. For hemorrhagic shock, the antibiotic dose may be increased twofold or threefold and repeated after transfusion of every 10 units of blood until there is no further blood loss. Conclusion Although this guideline was drafted through adaptation of other guidelines, it may be meaningful in that it provides a consensus on the use of antibiotics in abdominal trauma patients in Korea.
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Affiliation(s)
- Ji Young Jang
- Trauma Center, Department of Surgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Wu Seong Kang
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Min-Ae Keum
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Young Hoon Sul
- Department of Trauma Surgery, Chungbuk National University Hospital, Cheongju, Korea
| | - Dae-Sang Lee
- Department of Trauma Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hangjoo Cho
- Department of Trauma Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gil Jae Lee
- Department of Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Jae Gil Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Suk-Kyung Hong
- Division of Acute Care Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Management of non-missile penetrating spinal injury. Neurosurg Rev 2018; 42:791-798. [DOI: 10.1007/s10143-018-01057-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 10/22/2018] [Accepted: 11/21/2018] [Indexed: 01/01/2023]
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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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Shiels SM, Tennent DJ, Wenke JC. Topical rifampin powder for orthopedic trauma part I: Rifampin powder reduces recalcitrant infection in a delayed treatment musculoskeletal trauma model. J Orthop Res 2018; 36:3136-3141. [PMID: 29781552 DOI: 10.1002/jor.24055] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 05/15/2018] [Indexed: 02/04/2023]
Abstract
Open fractures become infected despite meticulous debridement and care. Locally applied antibiotics, commonly embedded in polymethylmethacrylate, deliver high doses of drug directly to the fracture site. Direct application of antibiotic powder, which is being applied prophylactically in spine surgery, is a recent interest in the trauma sector, where bacterial biofilms are more prevalent. Traditional antibiotics, such as vancomycin, are poor performers against bacterial biofilms thus are ineffective in delayed treatment. Rifampin is an effective eradicator of Staphylococcal biofilms. Here, a rat model of musculoskeletal trauma was used to evaluate the utility of locally applied rifampin powder for reducing established orthopedic Staphylococcal infections in a delayed treatment scenario that previously indicated the limited use of local vancomycin. By applying rifampin powder directly to the contaminated segmental defect, the number of bacteria, as well as clinical indications of infection, were significantly reduced compared to vancomycin and daptomycin. Considering the Infectious Disease Society of America's recommendation to use rifampin in combination with another antibiotic to reduce the onset of rifampin resistance, rifampin powder was also applied in combination with vancomycin or daptomycin with insignificant changes in eradication performance. No indications of rifampin resistance were identified. Clinical Significance: The use of locally applied rifampin is a promising therapy for mature and tolerant musculoskeletal infections. Published 2018. This article is a U.S. Government work and is in the public domain in the USA. J Orthop Res 36:3136-3141, 2018.
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Affiliation(s)
- Stefanie M Shiels
- US Army Institute of Surgical Research, 3698 Chambers Pass, Fort Sam Houston 78234, Texas
| | - David J Tennent
- US Army Institute of Surgical Research, 3698 Chambers Pass, Fort Sam Houston 78234, Texas.,Department of Orthopaedics, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Joseph C Wenke
- US Army Institute of Surgical Research, 3698 Chambers Pass, Fort Sam Houston 78234, Texas
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35
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Willy C, Scheuermann-Poley C, Stichling M, von Stein T, Kramer A. [Importance of wound irrigation solutions and fluids with antiseptic effects in therapy and prophylaxis : Update 2017]. Unfallchirurg 2018. [PMID: 28643098 DOI: 10.1007/s00113-017-0375-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Despite the use of modern antibiotics as well as complex perioperative, intraoperative and postoperative prophylactic measures, the rate of surgical site infections (SSI) could not be significantly reduced. The introduction of biocompatible antiseptic drugs with a high microbiocidal effect provided a successful alternative for infection prevention and therapy, particularly in a time of increasing occurrence of multi-drug resistant pathogens. Hence, questions about the risk-benefit ratio of antiseptic wound irrigation solutions, the prophylactic use of wound irrigation solutions for the reduction of SSI and the effect of negative pressure wound therapy combined with instillation (NPWTi) need to be answered. METHOD Against the background of our own experiences with the use of antiseptic wound irrigation solutions, a literature analysis (e.g. computer-supported MEDLINE, EMBASE and Cochrane database research as of April 2017) was performed. RESULTS Antiseptic fluids can be used both prophylactically and therapeutically, in acute and chronic, clean, contaminated and infected wounds to reduce the posttraumatic and postoperative wound infection rates. The antiseptic solutions that are commonly used in orthopedic and trauma surgery (e.g. PVP-iodine, octenidine, polyhexanide, sodium hypochlorite/hypochlorous acid and acetic acid), have in common that no development of resistance has so far been shown and that when the contraindications are taken into account, the antiseptic effect can develop without any clinically significant local and systemic side effects. As a rule the biocompatibility index is higher than 1 for the substances mentioned. In addition, they show an antiseptic effect against biofilms and multi-drug resistant pathogens. These antiseptic solutions can also be used for NPWTi with some limitations for octenidine. CONCLUSION As the basic equipment in trauma surgery, a selection of three different antiseptic wound irrigation solutions for the reduction of the rates of posttraumatic and SSI can be recommended. The use of antiseptics should be reviewed on an ongoing basis in the daily clinical routine and particular attention should be paid to unwanted effects in the course of the healing process. After application of 7-14 days, the indications for continuing the use of the antiseptic solutions must be carefully re-evaluated.
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Affiliation(s)
- Christian Willy
- Klinik für Unfallchirurgie, Orthopädie, septisch-rekonstruktive Chirurgie, Forschungs- und Behandlungszentrum septische Defektwunden, Bundeswehrkrankenhaus Berlin, Scharnhorststraße 13, 10115, Berlin, Deutschland.
| | - Catharina Scheuermann-Poley
- Klinik für Unfallchirurgie, Orthopädie, septisch-rekonstruktive Chirurgie, Forschungs- und Behandlungszentrum septische Defektwunden, Bundeswehrkrankenhaus Berlin, Scharnhorststraße 13, 10115, Berlin, Deutschland
| | - Marcus Stichling
- Klinik für Unfallchirurgie, Orthopädie, septisch-rekonstruktive Chirurgie, Forschungs- und Behandlungszentrum septische Defektwunden, Bundeswehrkrankenhaus Berlin, Scharnhorststraße 13, 10115, Berlin, Deutschland
| | - Thomas von Stein
- Abteilung für Septische und Rekonstruktive Chirurgie, BG Unfallklinik Murnau, Prof.-Küntscher-Straße 8, 82418, Murnau, Deutschland
| | - Axel Kramer
- Institut für Hygiene und Umweltmedizin, Universitätsmedizin Greifswald, Walter-Rathenau-Straße 49A, 17475, Greifswald, Deutschland
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Saeed O, Tribble DR, Biever KA, Crouch HK, Kavanaugh M. Infection Prevention in Combat-Related Injuries. Mil Med 2018; 183:137-141. [DOI: 10.1093/milmed/usy077] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Indexed: 11/12/2022] Open
Affiliation(s)
- Omar Saeed
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - David R Tribble
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Kimberlie A Biever
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Helen K Crouch
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
| | - Michael Kavanaugh
- Joint Trauma System, 3698 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, TX
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Tribble DR, Lewandowski LR, Potter BK, Petfield JL, Stinner DJ, Ganesan A, Krauss M, Murray CK. Osteomyelitis Risk Factors Related to Combat Trauma Open Tibia Fractures: A Case-Control Analysis. J Orthop Trauma 2018; 32:e344-e353. [PMID: 29878946 PMCID: PMC6103838 DOI: 10.1097/bot.0000000000001225] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We assessed osteomyelitis risk factors in US military personnel with combat-related open tibia fractures (2003-2009). METHODS Patients with open tibia fractures who met the diagnostic criteria of osteomyelitis were identified as cases using Military Health System data and verified through medical record review. Controls were patients with open tibia fractures who did not meet osteomyelitis criteria. The Gustilo-Andersen fracture classification scheme was modified to include transtibial amputations (TTAs) as the most severe level. Logistic regression multivariable odds ratios [ORs; 95% confidence intervals (CI)] were assessed. RESULTS A total of 130 tibia osteomyelitis cases and 85 controls were identified. Excluding patients with TTAs, osteomyelitis cases had significantly longer time to radiographic union compared with controls (median: 210 vs. 165 days). Blast injuries, antibiotic bead utilization, ≥ Gustilo-Andersen-IIIb fractures [highest risk with TTA (OR: 15.10; CI: 3.22-71.07)], and foreign body at the fracture site were significantly associated with developing osteomyelitis. In a separate model, the Orthopaedic Trauma Association Open Fracture Classification muscle variable was significant with increasing risk from muscle loss (OR: 5.62; CI: 2.21-14.25) to dead muscle (OR: 8.46; CI: 3.31-21.64). When TTAs were excluded, significant risk factors were similar and included sustaining an injury between 2003 and 2006. CONCLUSIONS Patients with severe blast trauma resulting in significant muscle damage are at the highest risk for osteomyelitis. The period association coincides with a time frame when several trauma system practice changes were initiated (eg, increased negative pressure wound therapy, decreased high-pressure irrigation, and reduced crystalloid use). LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- David R. Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Louis R. Lewandowski
- Department of Surgery, Uniformed Services University - Walter Reed National Military Medical Center, Bethesda, MD
| | - Benjamin K. Potter
- Department of Surgery, Uniformed Services University - Walter Reed National Military Medical Center, Bethesda, MD
| | | | | | - Anuradha Ganesan
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD
- Infectious Disease, Walter Reed National Military Medical Center, Bethesda, MD
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. Bethesda, MD
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Lachiewicz AM, Hauck CG, Weber DJ, Cairns BA, van Duin D. Bacterial Infections After Burn Injuries: Impact of Multidrug Resistance. Clin Infect Dis 2018; 65:2130-2136. [PMID: 29194526 DOI: 10.1093/cid/cix682] [Citation(s) in RCA: 194] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 08/11/2017] [Indexed: 12/14/2022] Open
Abstract
Patients who are admitted to the hospital after sustaining a large burn injury are at high risk for developing hospital-associated infections. If patients survive the initial 72 hours after a burn injury, infections are the most common cause of death. Ventilator-associated pneumonia is the most important infection in this patient population. The risk of infections caused by multidrug-resistant bacterial pathogens increases with hospital length of stay in burn patients. In the first days of the postburn hospitalization, more susceptible, Gram-positive organisms predominate, whereas later more resistant Gram-negative organisms are found. These findings impact the choice of empiric antibiotics in critically ill burn patients. A proactive infection control approach is essential in burn units. Furthermore, a multidisciplinary approach to burn patients with a team that includes an infectious disease specialist and a pharmacist in addition to the burn surgeon is highly recommended.
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Affiliation(s)
- Anne M Lachiewicz
- Division of Infectious Diseases, University of North Carolina at Chapel Hill
| | - Christopher G Hauck
- Division of Infectious Diseases, University of North Carolina at Chapel Hill
| | - David J Weber
- Division of Infectious Diseases, University of North Carolina at Chapel Hill
| | - Bruce A Cairns
- Department of Surgery, University of North Carolina at Chapel Hill.,North Carolina Jaycee Burn Center, Chapel Hill
| | - David van Duin
- Division of Infectious Diseases, University of North Carolina at Chapel Hill
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Zong ZW, Chen SX, Qin H, Liang HP, Yang L, Zhao YF. Chinese expert consensus on echelons treatment of pelvic fractures in modern war. Mil Med Res 2018; 5:21. [PMID: 29970166 PMCID: PMC6029371 DOI: 10.1186/s40779-018-0168-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/13/2018] [Indexed: 01/18/2023] Open
Abstract
The characteristics and treatment of pelvic fractures vary between general conditions and modern war. An expert consensus has been reached based on pelvic injury epidemiology and the concepts of battlefield treatment combined with the existing levels of military medical care in modern warfare. According to this consensus, first aid, emergency treatment and early treatment of pelvic fractures are introduced in three separate levels. In Level I facilities, simple triage and rapid treatment following the principles of advanced trauma life support are recommended to evaluate combat casualties during the first-aid stage. Re-evaluation, further immobilization and fixation, and hemostasis are recommended at Level II facilities. At Level III facilities, the main components of damage control surgery are recommended, including comprehensive hemostasis, a proper resuscitation strategy, the treatment of concurrent visceral and blood vessel damage, and battlefield intensive care. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.
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Affiliation(s)
- Zhao-Wen Zong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, ChongQing, 400038, China.
| | - Si-Xu Chen
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, ChongQing, 400038, China
| | - Hao Qin
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, ChongQing, 400038, China
| | - Hua-Ping Liang
- First Department, Research Institute of Surgery, Daping Hospital, Army Medical University, Chongqing, 400042, China
| | - Lei Yang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department of War Wound Rescue Skills Training, Base of Army Health Service Training, Army Medical University, ChongQing, 400038, China
| | - Yu-Feng Zhao
- Department of Trauma Surgery, Daping Hospital, Army Medical University, ChongQing, 400042, China
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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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Larréché S, Bousquet A, Soler C, Mac Nab C, de Briel D, Delaune D, Bigaillon C, Pasquier P, Dubost C, Demoures T, Malgras B, Ausset S, de Rudnicki S, Leclerc T, de Loynes B, Bonnet S, Mocellin N, Ficko C, Haus R, Hersan O, Rigal S, Mérens A. Microbiology of French military casualties repatriated from overseas for an open traumatic injury. Med Mal Infect 2018; 48:403-409. [PMID: 29709404 DOI: 10.1016/j.medmal.2018.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 03/27/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND This study aimed to describe the microbiological epidemiology of repatriated French soldiers with an open traumatic injury, and to measure the proportion of multidrug-resistant bacteria (MDRB). METHODS Retrospective study including all French soldiers repatriated in 2011 and 2012 in Parisian military hospitals for open traumatic injury. Results of clinical samples and MDRB screening were collected. The antibiotic susceptibility was assessed using the agar disk diffusion method. Characterization of resistance mechanisms was performed using PCR. Genotyping of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) isolates was performed using rep-PCR. RESULTS A total of 139 patients were included; 70% of them were repatriated from Afghanistan. At admission, 24/88 were positive for MDRB (28%), mainly ESBL-E but no carbapenemase-producing Enterobacteriaceae and vancomycin-resistant Enterococcus faecium were identified. Forty-five patients had lesion sample collection, and 28/45 had a positive culture. The most frequently isolated pathogens were Enterobacter cloacae, Pseudomonas aeruginosa, and Escherichia coli. For eight patients, a MDRB was isolated from the wound, mainly ESBL-E (7/8) but also one methicillin-resistant Staphylococcus aureus and one imipenem-resistant Acinetobacter baumannii. Among ESBL-E, the PCR evidenced the high prevalence of CTX-M15 enzymes. Rep-PCR performed on the 23 ESBL-producing E. coli isolates highlighted numerous profiles. CONCLUSIONS Controlling the spread of ESBL-E is currently challenging for French Armed Forces. Despite any evidence of an epidemic clone, a high-level compliance with hygiene precautions is required throughout the chain of care to avoid cross contamination.
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Affiliation(s)
- S Larréché
- Microbiologie, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France.
| | - A Bousquet
- Microbiologie, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - C Soler
- Microbiologie, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - C Mac Nab
- Microbiologie, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - D de Briel
- Microbiologie, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France; Microbiologie, hôpitaux civils de Colmar, 39, avenue de la Liberté, 68024 Colmar, France
| | - D Delaune
- Microbiologie, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - C Bigaillon
- Microbiologie, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - P Pasquier
- Anesthésie-réanimation, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France; Anesthésie-réanimation, Hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France; École du Val-de-Grâce, 1, place Alphonse-Laveran, 75005, Paris, France
| | - C Dubost
- Anesthésie-réanimation, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - T Demoures
- Chirurgie orthopédique, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - B Malgras
- École du Val-de-Grâce, 1, place Alphonse-Laveran, 75005, Paris, France; Chirurgie viscérale, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - S Ausset
- Anesthésie-réanimation, Hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France; École du Val-de-Grâce, 1, place Alphonse-Laveran, 75005, Paris, France
| | - S de Rudnicki
- Anesthésie-réanimation, Hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - T Leclerc
- École du Val-de-Grâce, 1, place Alphonse-Laveran, 75005, Paris, France; Centre de traitement des brulés, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - B de Loynes
- Chirurgie orthopédique, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - S Bonnet
- École du Val-de-Grâce, 1, place Alphonse-Laveran, 75005, Paris, France; Chirurgie viscérale, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France; Chirurgie viscérale, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - N Mocellin
- Chirurgie viscérale, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - C Ficko
- Maladies infectieuses et tropicales, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France
| | - R Haus
- Direction centrale du service de santé des armées, 158, cours des Maréchaux, 94300 Vincennes, France
| | - O Hersan
- Direction centrale du service de santé des armées, 158, cours des Maréchaux, 94300 Vincennes, France
| | - S Rigal
- École du Val-de-Grâce, 1, place Alphonse-Laveran, 75005, Paris, France; Chirurgie orthopédique, hôpital d'instruction des armées Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France
| | - A Mérens
- Microbiologie, hôpital d'instruction des armées Bégin, 69, avenue de Paris, 94160 Saint-Mandé, France; École du Val-de-Grâce, 1, place Alphonse-Laveran, 75005, Paris, France
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Lloyd BA, Murray CK, Bradley W, Shaikh F, Aggarwal D, Carson ML, Tribble DR. Variation in Postinjury Antibiotic Prophylaxis Patterns Over Five Years in a Combat Zone. Mil Med 2018; 182:346-352. [PMID: 28291497 DOI: 10.7205/milmed-d-16-00040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
In 2008, a clinical practice guideline (CPG) was developed for the prevention of infections among combat casualties and was later revised in 2011. We evaluated utilization of antimicrobials within 48 hours following injury in the combat zone over a 5-year period (June 2009 through May 2014) with regard to number of regimens, type of antimicrobial, and adherence to the 2011 CPG. The study population consisted of 5,196 wounded military personnel. Open fractures and skin and soft-tissue injuries were the most frequent injuries. Closed injuries had the highest overall compliance (83%), whereas open fractures and maxillofacial injuries had significant improvement in compliance from 2009-2010 (34 and 50%, respectively) to 2013-2014 (73 and 76%, respectively; p < 0.05). Part of the improvement with open fractures was a significant reduction of expanded Gram-negative coverage (61% received it in 2009-2010 compared to 7% in 2013-2014; p < 0.001). Use of Gram-negative coverage with maxillofacial injuries also significantly declined (37-12%; p = 0.001). Being injured during 2011-2014 compared to 2009-2010 was associated with CPG compliance (p < 0.001), while high injury severity scores (≥10) and admission to the intensive care unit in Germany were associated with noncompliance (p < 0.001). Our analysis demonstrates an increasing trend toward CPG compliance with significant reduction of expanded Gram-negative coverage.
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Affiliation(s)
- Bradley A Lloyd
- San Antonio Military Medical Center, 3551 Roger Brooke Drive Building 3600, Fort Sam Houston, TX 78234
| | - Clinton K Murray
- San Antonio Military Medical Center, 3551 Roger Brooke Drive Building 3600, Fort Sam Houston, TX 78234
| | - William Bradley
- 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
| | - 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
| | - Deepak Aggarwal
- 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
| | - 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
| | - 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
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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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Yang L, Broomhead M, Nuutila K, Proppe K, Eriksson E. Topically Delivered Minocycline Penetrates a Full-Thickness Burn Eschar and Reduces Tissue Bacterial Counts. J Burn Care Res 2017; 39:790-797. [DOI: 10.1093/jbcr/irx051] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Lu Yang
- Applied Tissue Technologies LLC, Hingham, MA
| | | | | | - Karl Proppe
- Applied Tissue Technologies LLC, Hingham, MA
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Abbara A, Al-Harbat N, Karah N, Abo-Yahya B, El-Amin W, Hatcher J, Gabbar O. Antimicrobial Drug Resistance among Refugees from Syria, Jordan. Emerg Infect Dis 2017; 23:885-886. [PMID: 28418320 PMCID: PMC5403049 DOI: 10.3201/eid2305.170117] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Early infectious outcomes after addition of fluoroquinolone or aminoglycoside to posttrauma antibiotic prophylaxis in combat-related open fracture injuries. J Trauma Acute Care Surg 2017; 83:854-861. [PMID: 28570348 DOI: 10.1097/ta.0000000000001609] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND We examined combat-related open extremity fracture infections as a function of whether posttrauma antimicrobial prophylaxis included expanded Gram-negative (EGN) coverage. METHODS Military personnel with open extremity fractures sustained in Iraq and Afghanistan (2009-2014) who transferred to participating hospitals in the United States were assessed. The analysis was restricted to patients with a U.S. hospitalization period of ≥7 days. Prophylaxis was classified as narrow (e.g., IV cefazolin, clindamycin, and/or amoxicillin-clavulanate) or EGN, if the prophylactic regimen included fluoroquinolones and/or aminoglycosides. RESULTS The study population included 1,044 patients, of which 585 (56%) and 459 (44%) received narrow and EGN coverage, respectively (p < 0.001). Skin and soft-tissue infections (SSTIs) were more common among patients who received narrow prophylaxis compared to EGN coverage (28% vs. 22%; p = 0.029), whereas osteomyelitis rates were comparable between regimens (8%). Similar findings were noted when endpoints were measured at 2 and 4 weeks postinjury. There was no significant difference related to length of hospitalization between narrow and EGN regimens (median: 34 and 32 days, respectively) or operating room visits (median: 5 and 4). A higher proportion of EGN coverage patients had Gram-negative organisms isolated that were not susceptible to fluoroquinolones and/or aminoglycosides (49% vs. 40%; p < 0.001). In a Cox proportional model, narrow prophylaxis was independently associated with an increased risk of extremity SSTIs (hazard ratio: 1.41; 95% confidence interval: 1.09-1.83). DISCUSSION Despite seeing a small benefit with EGN coverage related to a reduction of SSTIs, it does not decrease the risk of osteomyelitis, and there seems to be a cost of increased antibiotic resistance associated with use. Overall, our findings support the current post-combat trauma antibiotic prophylaxis guidelines, which recommend the use of cefazolin or clindamycin with open fractures. LEVEL OF EVIDENCE Prognostic/Epidemiological, Level II; Therapy, level IV.
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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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49
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Infectious Complications After Battlefield Injuries: Epidemiology, Prevention, and Treatment. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0102-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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50
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Tribble DR, Li P, Warkentien TE, Lloyd BA, Schnaubelt ER, Ganesan A, Bradley W, Aggarwal D, Carson ML, Weintrob AC, Murray CK. Impact of Operational Theater on Combat and Noncombat Trauma-Related Infections. Mil Med 2017; 181:1258-1268. [PMID: 27753561 DOI: 10.7205/milmed-d-15-00368] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The Trauma Infectious Disease Outcomes Study began in June 2009 as combat operations were decreasing in Iraq and increasing in Afghanistan. Our analysis examines the rate of infections of wounded U.S. military personnel from operational theaters in Iraq and Afghanistan admitted to Landstuhl Regional Medical Center between June 2009 and December 2013 and transferred to a participating U.S. hospital. Infection risk factors were examined in a multivariate logistic regression analysis (expressed as odds ratios [OR]; 95% confidence intervals [CI]). The study population includes 524 wounded military personnel from Iraq and 4,766 from Afghanistan. The proportion of patients with at least one infection was 28% and 34% from the Iraq and Afghanistan theaters, respectively. The incidence density rate was 2.0 (per 100 person-days) for Iraq and 2.7 infections for Afghanistan. Independent risk factors included large-volume blood product transfusions (OR: 10.68; CI: 6.73-16.95), high Injury Severity Score (OR: 2.48; CI: 1.81-3.41), and improvised explosive device injury mechanism (OR: 1.84; CI: 1.35-2.49). Operational theater (OR: 1.32; CI: 0.87-1.99) was not a risk factor. The difference in infection rates between operational theaters is primarily a result of increased injury severity in Afghanistan from a higher proportion of blast-related trauma during the study period.
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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, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Ping Li
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Tyler E Warkentien
- Infectious Disease, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889
| | - Bradley A Lloyd
- Infectious Disease Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive No. 3600, Fort Sam Houston, San Antonio, TX 78234
| | - Elizabeth R Schnaubelt
- Infectious Disease, Landstuhl Regional Medical Center, CMR 402, Box 1559, APO AE 09180, Landstuhl, Germany
| | - Anuradha Ganesan
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Suite 100, Bethesda, MD 20817
| | - William Bradley
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Deepak Aggarwal
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - M Leigh Carson
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Amy C Weintrob
- Infectious Disease Clinical Research Program, Preventive Medicine and Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
| | - Clinton K Murray
- Infectious Disease Service, San Antonio Military Medical Center, 3551 Roger Brooke Drive No. 3600, Fort Sam Houston, San Antonio, TX 78234
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