Adherence to Published Antimicrobial Prophylaxis Guidelines for Wounded Service Members in the Ongoing Conflicts in Southwest Asia

Lloyd, Bradley A.; Weintrob, Amy; Hinkle, Mary; Fortuna, Gerald R.; Murray, Clinton K.; Bradley, William P.; Millar, Eugene V.; Shaikh, Faraz; Vanderzant, Kristen; Gregg, Stacie; Lloyd, Gina; Stevens, Julie E.; Carson, M. Leigh; Aggarwal, Deepak; Tribble, David R.

doi:10.7205/milmed-d-13-00424

Cited by 21 publications

(23 citation statements)

References 21 publications

(28 reference statements)

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“…In brief, AIS is an anatomically-based injury severity scoring system, which allows for the categorization of distinct injury types (e.g., blunt force and penetrating trauma) by specific body regions. Trauma patients were classified into one of the five established injury categories 18 based on their pattern of injury as well as their antibiotic prophylaxis requirement in a stepwise fashion using the highest level of antibiotic coverage required. Patients not meeting an injury criteria requiring antibiotic prophylaxis were placed in the “closed” injury category.…”

Section: Methodsmentioning

confidence: 99%

“…15,16 In two prior publications, we evaluated antimicrobial prophylaxis compliance with the 2008 CPG over a six-month and one-year period among injured United States (U.S.) military personnel medically evacuated to Landstuhl Regional Medical Center (LRMC). 17,18 Although the six-month analysis was comprehensive at the time, methodological limitations restricted applicability of the results. Therefore, a revised methodology based on Abbreviated Injury Scale (AIS) codes for injury categorization, rather than International Classification of Disease (9 th edition) diagnostic codes, and improved antibiotic regimen coding were applied to a subsequent one-year cohort, resulting in rates of overall CPG compliance of 75%.…”

Section: Introductionmentioning

confidence: 99%

“…Similarly, 27% of “compliant” maxillofacial injury patients received Gram-negative coverage. 18 Furthermore, in both the six-month and one-year analyses, 17,18 vancomycin was allowed as a substitution for Gram-positive prophylaxis despite not being recommended by either the 2008 CPG or 2010 JTS guidance.…”

Section: Introductionmentioning

confidence: 99%

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Variation in Postinjury Antibiotic Prophylaxis Patterns Over Five Years in a Combat Zone

et al. 2017

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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 five-year period (June 2009–May 2014) with regard to number of regimens, type of antimicrobial, and adherence to the 2011 CPG. The study population consisted of 5196 wounded military personnel. Open fractures and skin and soft-tissue injuries were the most frequent injuries. Closed injuries had the highest overall compliance (83%), while open fractures and maxillofacial injuries had significant improvement in compliance from 2009–2010 (34% and 50%, respectively) to 2013–2014 (73% and 76%; 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% to 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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Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Variation in Postinjury Antibiotic Prophylaxis Patterns Over Five Years in a Combat Zone

et al. 2017

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“…As previously described, 14,20 antibiotic usage was determined through prospective medical record review. Antibiotic prophylaxis regimens were classified as narrow or EGN for the analysis.…”

Section: Methodsmentioning

confidence: 99%

“…Antimicrobial prophylaxis was assessed in the period immediately following injury up to 48 hours (i.e., day of injury and day after the injury) to account for the potential of documentation omissions and multiple transitions of care associated with combat trauma care/medical evacuation. 20,22 Antibiotics provided immediately after injury prior to admission to combat support hospitals were not included in the analysis.…”

Section: Methodsmentioning

confidence: 99%

Early infectious outcomes after addition of fluoroquinolone or aminoglycoside to posttrauma antibiotic prophylaxis in combat-related open fracture injuries

et al. 2017

J Trauma Acute Care Surg

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Background We examined combat-related open extremity fracture infections as a function of whether post-trauma 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, or amoxicillin-clavulanate) or EGN, if the prophylactic regimen included fluoroquinolones and/or aminoglycosides. Results The study population included 1044 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% versus 22%; p=0.029), while osteomyelitis rates were comparable between regimens (8%). Similar findings were noted when endpoints were measured at two and four weeks post-injury. There was no significant difference related to length of hospitalization between narrow and EGN regimens (median: 34 and 32 days, respectively) or operation 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% versus 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 appears 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 use of cefazolin or clindamycin with open fractures. Level of Evidence Prognostic/Epidemiological Level I

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Tranexamic acid in life-threatening military injury and the associated risk of infective complications

Lewis

Stewart

et al. 2016

British Journal of Surgery

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Background Tranexamic acid (TXA) has been shown to reduce mortality from severe hemorrhage. Although recent data suggest that TXA has anti-inflammatory properties, few analyses have investigated the impact of TXA on infectious complications in trauma patients. We examined the association between TXA administration and infection risk among injured military personnel. Methods Patients administered TXA were matched by injury severity score to patients who did not receive TXA. Conditional logistic regression was used to examine risk factors associated with infections within 30 days. A Cox proportional analysis evaluated risk factors in a time-to-first infection model. Results A total of 335 TXA recipients were matched to 626 patients not administered TXA. A greater proportion of TXA recipients had an infection compared to the comparative group (P <0.001). The univariate analysis estimated an unadjusted odds ratio (OR) of 2.5 (95 per cent confidence interval [CI]: 1.8–3.4) for the association of TXA with infection risk; however, upon multivariable analysis, TXA administration was not significant (OR: 1.3; CI: 0.8–1.9). Blast injuries, intensive care unit (ICU) admission, and receipt of ≥10 units of blood within 24 hours post-injury were independently associated with infection risk. The Cox proportional model confirmed association with ICU admission and blood transfusions. Moreover, traumatic amputations were also significantly associated with a reduced time-to-first infection. Conclusion In life-threatening military injuries matched for injury severity, TXA recipients did not have a higher risk for infections nor was time to developed infections shorter than in non-recipients. Extent of blood loss, blast injuries, extremity amputations, and intensive care stay were associated with infections.

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Adherence to Published Antimicrobial Prophylaxis Guidelines for Wounded Service Members in the Ongoing Conflicts in Southwest Asia

Cited by 21 publications

References 21 publications

Variation in Postinjury Antibiotic Prophylaxis Patterns Over Five Years in a Combat Zone

Variation in Postinjury Antibiotic Prophylaxis Patterns Over Five Years in a Combat Zone

Early infectious outcomes after addition of fluoroquinolone or aminoglycoside to posttrauma antibiotic prophylaxis in combat-related open fracture injuries

Tranexamic acid in life-threatening military injury and the associated risk of infective complications

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