Infectious Complications of Damage Control Orthopedics in War Trauma

Mody, Rupal; Zapor, Michael; Hartzell, Joshua D.; Robben, Paul M.; Waterman, Paige; Wood‐Morris, Robert N.; Trotta, Richard F.; Andersen, Romney C.; Wortmann, Glenn

doi:10.1097/ta.0b013e3181af6aa6

Cited by 91 publications

(60 citation statements)

References 8 publications

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“…A. baumannii was more likely to be recovered during original episodes of osteomyelitis than during recurrences, whereas SA was more likely to be isolated during recurrences than during the initial episode of osteomyelitis [21]. Another retrospective chart review again highlighted the polymicrobial nature of combat-related osteomyelitis, but found Gram-negative rods like A. baumannii were more common than Gram-positive organisms such as SA during early and late infections [14]. These observations shed no light on a potential interaction between these two organisms.…”

Section: Discussionmentioning

confidence: 99%

Acinetobacter baumannii is not Associated with Osteomyelitis in a Rat Model: A Pilot Study

Collinet-Adler¹,

Castro²,

Ledonio³

et al. 2011

Clinical Orthopaedics &Amp; Related Research

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Background Multidrug resistant Acinetobacter baumannii (MDR AB) with and without Staphylococcus aureus (SA) is a commonly isolated organism in infected segmental bone defects in combat-related trauma in Iraq and Afghanistan. Although MDR AB in visceral infections is a therapeutic challenge, control of infection appears more common for combat-related osteomyelitis.Questions/purposes Using a rat model, we explored the virulence of MDR AB in segmental bone defects alone and in combination with SA. Methods Segmental defects in 60 rat femurs were created, stabilized, and inoculated with MDR AB alone and 60 with MDR AB and SA. We performed qualitative and quantitative bacteriology and radiographic assessments at 2, 4, and 8 weeks for MDR AB and at 1, 2, and 3 weeks for MDR AB and SA. Results Quantitative bacteriology revealed a 3-to 5-log decrease in MDR AB from the initial inoculum. After polymicrobial inoculation, only 10 of 60 animals had positive cultures for MDR AB, whereas 59 of 60 animals had positive cultures for SA. Recovered SA were 2 to 5 log greater than the initial inoculum, while there again was a 3-to 5-log decrease in MDR AB. MDR AB alone did not cause bony lysis, but there was radiographic evidence of new bone formation in 67% of the segmental defects. Osteolysis was noted with MDR AB and SA. Conclusions MDR AB did not appear to cause or contribute to clinically apparent osteomyelitis in this pilot study. Clinical Relevance Resolution of infections in combatrelated segmental bone defects inoculated with MDR AB may be attributable to low virulence.

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Section: Discussionmentioning

confidence: 99%

Acinetobacter baumannii is not Associated with Osteomyelitis in a Rat Model: A Pilot Study

Collinet-Adler¹,

Castro²,

Ledonio³

et al. 2011

Clinical Orthopaedics &Amp; Related Research

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“…14 In addition to MRSA, there is also an increasing concern about other antibiotic-resistant bacteria, including Acinetobacter, Klebsiella, Pseudomonas, and Enterobacter, which are present in open fractures 23 and are known to be potentially infectious agents of open wounds. [24][25][26] Notably, pan-resistant strains of the significant hospital pathogen A. baumannii have emerged, developing resistance to colistin, the drug of last resort. 27 Antibiotic-susceptible and -resistant A. baumannii infections have continued to increase in prevalence over the past decades, both in military and civilian settings.…”

Section: Discussion Current Concepts In Open Fracture Care and Infectmentioning

confidence: 99%

Current Concepts and Ongoing Research in the Prevention and Treatment of Open Fracture Infections

Hannigan

Pulos

Grice

et al. 2015

Advances in Wound Care

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Significance: Open fractures are fractures in which the bone has violated the skin and soft tissue. Because of their severity, open fractures are associated with complications that can result in increased lengths of hospital stays, multiple operative interventions, and even amputation. One of the factors thought to influence the extent of these complications is exposure and contamination of the open fracture with environmental microorganisms, potentially those that are pathogenic in nature. Recent Advances: Current open fracture care aims to prevent infection by wound classification, prophylactic antibiotic administration, debridement and irrigation, and stable fracture fixation. Critical Issues: Despite these established treatment paradigms, infections and infection-related complications remain a significant clinical burden. To address this, improvements need to be made in our ability to detect bacterial infections, effectively remove wound contamination, eradicate infections, and treat and prevent biofilm formation associated with fracture fixation hardware. Future Directions: Current research is addressing these critical issues. While culture methods are of limited value, culture-independent molecular techniques are being developed to provide informative detection of bacterial contamination and infection. Other advanced contamination-and infection-detecting techniques are also being investigated. New hardware-coating methods are being developed to minimize the risk of biofilm formation in wounds, and immune stimulation techniques are being developed to prevent open fracture infections. SCOPE AND SIGNIFICANCEOpen fractures occur when bone is exposed through skin as a result of bone breaking through skin or wound penetration with fractured bone exposure. While multiple factors may influence open fracture rate, a recent study reported an incidence of 30.7/ 10 5

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“…6,7 It is generally accepted that antibiotic prophylaxis in grade I and II fractures should not be administered for > 24 hours. 5,6,8 However, the minimum duration for grade III fractures varies between one and ten days, 1,3,5,6,[8][9][10][11][12][13] or even several weeks. 7 Guidelines based on expert opinion and common sense advocate a maximum of 48 hours 6 to 72 hours 3 for grade III fractures.…”

mentioning

confidence: 98%

Short duration of antibiotic prophylaxis in open fractures does not enhance risk of subsequent infection

Dunkel

Pittet

Tovmirzaeva

et al. 2013

The Bone & Joint Journal

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We undertook a retrospective case-control study to assess the clinical variables associated with infections in open fractures. A total of 1492 open fractures were retrieved; these were Gustilo and Anderson grade I in 663 (44.4%), grade II in 370 (24.8%), grade III in 310 (20.8%) and unclassifiable in 149 (10.0%). The median duration of prophylaxis was three days (interquartile range (IQR) 1 to 3), and the median number of surgical interventions was two (1 to 9). We identified 54 infections (3.6%) occurring at a median of ten days (IQR 5 to 20) after trauma. Pathogens intrinsically resistant to the empirical antibiotic regimen used (enterococci, Enterobacter spp, Pseudomonas spp) were documented in 35 of 49 cases (71%). In multivariable regression analyses, grade III fractures and vascular injury or compartment syndrome were significantly associated with infection. Overall, compared with one day of antibiotic treatment, two to three days (odds ratio (OR) 0.6 (95% confidence interval (CI) 0.2 to 2.0)), four to five days (OR 1.2 (95% CI 0.3 to 4.9)), or > five days (OR 1.4 (95% CI 0.4 to 4.4)) did not show any significant differences in the infection risk. These results were similar when multivariable analysis was performed for grade III fractures only (OR 0.3 (95% CI 0.1 to 3.4); OR 0.6 (95% CI 0.2 to 2.1); and OR 1.7 (95% CI 0.5 to 6.2), respectively). Infection in open fractures is related to the extent of tissue damage but not to the duration of prophylactic antibiotic therapy. Even for grade III fractures, a one-day course of prophylactic antibiotics might be as effective as prolonged prophylaxis.

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Infectious Complications of Damage Control Orthopedics in War Trauma

Abstract: Infection was associated with 40% of DCO-associated intramedullary nails. Blast injury was a predictor of infection. Despite infection, fracture union and nail retention rates were high, suggesting a good outcome.

Cited by 91 publications

References 8 publications

Acinetobacter baumannii is not Associated with Osteomyelitis in a Rat Model: A Pilot Study

Acinetobacter baumannii is not Associated with Osteomyelitis in a Rat Model: A Pilot Study

Current Concepts and Ongoing Research in the Prevention and Treatment of Open Fracture Infections

Short duration of antibiotic prophylaxis in open fractures does not enhance risk of subsequent infection

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