Infections in Combat-Related Wounds

 

Military/civilian

Study sample

Site

Infection rate

Outcome

Most common organism

Study

Iraq

British Military

48

Open femur fractures

8.33%

4% underwent amputation

S. aureus

[31]

US Military

300

Lower extremity amputations

27%

53% underwent reoperation

N/Sa

[32]

British Military

182

Chest

10.44%

4.9% overall mortality

N/S

[33]

US Military

192

Diaphyseal tibia fractures

27%

22% underwent amputation

ABC (Surveillance)

[29]

S. aureus (Infected)

US Military

16,742

Variable

5.5%

0.6% overall mortality

Gram negatives

[13]

Civilian

137

Chronic osteomyelitis

78%

N/S

S. aureus

[34]

Military and civilian

211

Variable

26.5%

3.57% mortality among infected

ABC

[35]

US Military

49

Variable

49%

N/S

Coagulase-negative Staphylococcus

[36]

Syria

Civilian

100

Variable

12%

2% overall mortality

N/S

[3]

Military and civilian

66

Cranial trauma

10.6%

4.5% overall mortality

N/S

[37]

Military and civilian

345

Variable

18%

N/S

P. aeruginosa

[15]

Military and civilian

186

Cranial trauma

6.45%

31.7% overall mortality

N/S

[38]

Israel

Civilian

21

Variable

30% with Candida

43% mortality with candidemia

Candida

[39]

Military

Group 1982: 184

30.5%

Group 1982: 30.5%

N/S

P. aeruginosa

[40]

Group 1973: 130

30.5%

Group 1973: 31.5%

Military and civilian

41

Burns

58.53%

14.61% overall mortality

P. aeruginosa

[41]

Military

420

Variable

22%

1.90% overall mortality1.20% mortality from infection

P. aeruginosa

[42]

Military and civilian

142

Chest trauma

4.9%

7.75% overall mortality

N/S

[43]

Military

624

Variable

12.5%

6 cases of bacterial sepsis

P. aeruginosa

[44]

Lebanon

Military and civilian

350

Total body cluster munitions

19.4%

0.85% bacteremia

P. aeruginosa

[45]

Military and civilian

272

Cranial trauma

11.39%

N/S

N/S

[46]

Military and civilian

1021

Head and neck injuries

12%

N/S

S. aureus

[47]


a N/S not stated



Microbiology results of wound infections from recent Middle Eastern conflicts are compatible with previous data from conflict zones. ABC, a common and serious culprit of wound infections in current time Middle Eastern conflicts, was recognized as early as the Korean War where it was isolated from blood cultures of injured individuals [48]. Pathogens infecting wounds within 8 h of injury included Clostridium species along with other gram-positive and gram-negative pathogens [48]. In attempt to prevent clostridium infections during the Korean War, large doses of penicillin in combination with streptomycin and tetanus toxoid were administered routinely to the wounded [49, 50]. Despite its potential benefits, early administration of antibiotics resulted in an increased proportion of resistant bacteria among infected war wounds 3–5 days following injury [5052]. Similarly, bacteria recovered in Japan from evacuated U.S. soldiers 7 days after injury, had a predominance of P. aeruginosa and S. aureus followed by Enterobacter species [53]. The presence of these pathogens remained in wounds upon arrival in the United States, thus highlighting the importance of war injuries in transmitting pathogens across borders and continents.

Wound infection rate during the Vietnam War was 4% among American soldiers [54]. Blood cultures primarily grew gram-negative organisms including Pseudomonas and Klebsiella species [55]. Despite conflicting reports, ABC had an unclear role during the Vietnam conflict [56]. In a 1972 report, ABC were the predominant gram-negative bacteria among 30 U.S. Marines with 63 extremity wounds [51]. Other common gram-negative bacteria in this group of injured soldiers included P. aeruginosa and Enterobacter species. Two larger studies conducted on injured American soldiers during the Vietnam War did not reveal any role of ABC in the microbial etiology of war-related infections. The first study analyzed 1531 wound cultures taken from injured U.S. soldiers during the Vietnam War and managed in Japan between 1967 and 1968 showed that P. aeruginosa, Proteus species, E. coli, Aerobacter aerogenes, and Klebsiella pneumonia were the most frequently encountered gram-negative bacteria while infection with ABC was not reported [57]. The second report from Brooke General Hospital describes 100 tissue samples from injured U.S. soldiers during the Vietnam War revealed also that P. aeruginosa, Proteus species, Klebsiella-Enterobacter group, and E. coli were the predominant gram-negative bacteria identified [53].



Emerging Antimicrobial Resistance


The emergence of MDR organisms is a major problem facing both military and civilian facilities handling causalities of war. Increasing bacterial resistance in conflict injuries has been described in previous wars including the Vietnamese and Korean wars [5052, 57]. More recently, the first carbapenemase-producing K. pneumonia ST11 in Ukraine was reported from a patient injured during the Maidan revolution [58].

The free movement of injured fighters and civilians has facilitated the transmission of MDR pathogens. Nosocomial transmission has been reported to be a greater contributing factor to wound infection over environmental contamination at the time of injury [5961]. For this reason, strict infection control practices and techniques must be implemented to reduce nosocomial transmission of MDR organisms. They include patient contact isolation upon admission, hand hygiene, wearing of gloves when in contact patients, masks and eye protection as needed, avoiding unnecessary empiric use of broad-spectrum antibiotics, and limiting the duration of antibiotic administration. The use of local antibiograms is encouraged, as it is helpful in assessing local epidemiology and antibiotic resistance. Separation of patients as per length of hospital stay (longer or shorter than 72 h) should be encouraged [54].


Prophylaxis and Management of War-Related Injuries


The use of prophylactic antibiotics in war-related trauma is common practice despite being a subject of significant controversy [62, 63]. Current evidence suggests that the use of broad-spectrum antimicrobial agents at the time of injury should be discouraged since it may be a potential cause of antimicrobial resistance. There is strong recommendation against the early use of aminoglycosides or fluoroquinolones to cover for gram-negative bacteria and against the early administration of penicillin to prevent gas gangrene or infections caused by Streptococci [64]. In severe trauma patients broad-spectrum antibiotic coverage against MDR pathogens is not needed at the time of injury and the administration of antimicrobials for more than 24 h do not affect mortality or confer additional protection against serious infectious complications including sepsis. It is believed that prolonged administration of broad spectrum antibiotics increases the probability of infection with MDR pathogens [62, 63].

The Infectious Disease Society of America (IDSA) and the Surgical Infection Society (SIS) produced joint guidelines for the prevention of infections associated with combat-related injuries. These guidelines advocate the administration of systemic antibiotics within 3 h following injury to prevent infectious complications including sepsis. The choice of antibiotics depends on the location of the wound with Cefazolin (first-generation cephalosporin) being preferred in the extremity, central nervous system, and thoracic wounds, while metronidazole (an antimicrobial with anti-anaerobic activity) to be used in abdominal wounds. Topical agents such as silver sulfadiazine and mafenide acetate are suggested for burn trauma patients [64]. Other guidelines have similar recommendations [54, 65]. The French Armed Forces recommend the use of 2 g of amoxicillin–clavulanic acid intravenously 3 times daily for all injuries as first-line antibiotic prophylaxis. Gentamicin 400 mg once-daily dose for 3 days is added for gram-negative coverage in type III open fracture (particularly, type IIIb and IIIc) and abdominal trauma with perforation of a hollow viscera [66]. Table 19.2 describes the various recommendations for antibiotic prophylaxis as suggested by the IDSA/SIS, French military, and Petersen and Waterman review in penetrating combat-related trauma [6466].


Table 19.2
First-line recommended antibiotic prophylaxis of combat-related injuries according to location




















 
IDSA/SIS

Petersen and Waterman review

French military

Extremity (including skin, soft tissue, and bone)

With or without open fracture

Cefazolin 2 g IV q6–8h for 1–3 days

Penicillin 2–4 million units q4h OR Cefazolin 1 g IV q8h for 1–5 days

Amoxicillin-clavulanate 2 g TID + Gentamicin 400 mg once-daily dose (for IIIb and IIIc) for 1 day

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Nov 17, 2017 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Infections in Combat-Related Wounds
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