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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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Granata G, Petersen E, Capone A, Donati D, Andriolo B, Gross M, Cicalini S, Petrosillo N. The impact of armed conflict on the development and global spread of antibiotic resistance: a systematic review. Clin Microbiol Infect 2024:S1198-743X(24)00160-5. [PMID: 38556213 DOI: 10.1016/j.cmi.2024.03.029] [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: 02/01/2024] [Revised: 03/19/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Scant data are available on the link between armed conflicts and the development and spread of antimicrobial resistance. OBJECTIVES We performed a systematic review with the aim to summarize the available data on the prevalence and features of antibiotic resistance and the causes of antibiotic resistance development during armed conflicts in the 21st century. METHODS Data sources: PubMed and SCOPUS databases were searched from 1 January 2000 to 30 November 2023. STUDY ELIGIBILITY CRITERIA Original articles reporting data on armed conflicts and antimicrobial resistance were included in this systematic review. No attempt was made to obtain information from unpublished studies. No language restriction was applied. Methods of data synthesis: Both quantitative and qualitative information were summarized by means of textual descriptions. PARTICIPANTS Patients or soldiers deployed in armed conflict zones. TESTS culture-dependent antibiotic sensitivity testing or molecular detection of the genetic determinants of antibiotic resistance after a confirmed diagnosis of bacterial infection. Assessment of risk of bias: To evaluate the quality of the included studies, we adapted the tool recommended by the Joanna Briggs Institute. RESULTS Thirty-four studies were identified, published between November 2004 and November 2023. The quality of included studies was high and medium in 47% and 53% of the studies, respectively. The included studies reported high infection and colonization rates of multidrug-resistant bacteria. Studies performed during the Eastern Ukraine conflict reported high rates of New Delhi metallo-β-lactamase producers. DISCUSSION Our findings confirm that wars lead to a large pool of multidrug-resistant infections that could potentially spread. Infection control in healthcare facilities in conflict zones and proper antimicrobial stewardship are crucial.
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Affiliation(s)
- Guido Granata
- Systemic and Immune Depression-Associated Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", Istituto di Ricovero e Cura a Carattere Scientifico, Roma, Italy.
| | - Eskild Petersen
- PandemiX Center of Excellence, Roskilde University, Roskilde, Denmark; European Society for Clinical Microbiology and Infectious Diseases Emerging Infections Subcommittee. European Society of Clinical Microbiology and Infectious Diseases, Basel, Switzerland
| | - Alessandro Capone
- Systemic and Immune Depression-Associated Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", Istituto di Ricovero e Cura a Carattere Scientifico, Roma, Italy
| | - Daniele Donati
- Infection Prevention & Control/Infectious Disease Service, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Benedetta Andriolo
- Systemic and Immune Depression-Associated Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", Istituto di Ricovero e Cura a Carattere Scientifico, Roma, Italy
| | - Maya Gross
- Systemic and Immune Depression-Associated Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", Istituto di Ricovero e Cura a Carattere Scientifico, Roma, Italy
| | - Stefania Cicalini
- Systemic and Immune Depression-Associated Infection Unit, National Institute for Infectious Diseases "L. Spallanzani", Istituto di Ricovero e Cura a Carattere Scientifico, Roma, Italy
| | - Nicola Petrosillo
- Infection Prevention & Control/Infectious Disease Service, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy; European Society for Clinical Microbiology and Infectious Diseases International Affairs SubCommittee. European Society of Clinical Microbiology and Infectious Diseases, Basel, Switzerland
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Sun H, Dong D, Zhao M, Jian J. Infection with multi‑drug resistant organisms in patients with limb fractures: Analysis of risk factors and pathogens. Biomed Rep 2024; 20:28. [PMID: 38259588 PMCID: PMC10801349 DOI: 10.3892/br.2023.1716] [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: 03/20/2023] [Accepted: 10/17/2023] [Indexed: 01/24/2024] Open
Abstract
Infection with multi-drug resistant organisms (MDROs) has emerged as a global problem in medical institutions. Overuse of antibiotics is the main cause of drug resistance. Notably, the incidence of infection with MDROs increases in patients with limb fractures who have undergone invasive surgery. The present study aimed to analyze the risk factors for postoperative MDROs infection in a cohort of patients with limb fractures. A retrospective study was performed on the data of patients with fractures between January 2020 and August 2022. Postoperative surgical site infection occurred in 114 patients in total, of which 47 were infected with MDROs. Univariate logistic regression analysis and multivariate binary logistic regression were used to confirm the associations between independent risk factors and MDRO infection. A total of 155 bacteria were collected from patients with MDROs infection and patients with non-MDROs infection, of which 66.5% were gram-positive bacteria and 33.5% were gram-negative. Staphylococcus aureus accounted for 26.5% of the 155 pathogens. MDROs, such as methicillin-resistant S. aureus and extended-spectrum β-lactamases-positive gram-negative bacillus, were detected after antibiotic treatment. Univariate analysis indicated that the number of antibiotics administered, being bedridden, repeat infection, operative time and repeated operation were different in the two groups. In addition, univariate logistic analysis indicated that being bedridden (OR, 3.98; P=0.001), administration of >2 antibiotics (OR, 2.42; P=0.026), an operative time of >3 h (OR, 3.37; P=0.003), repeated infection (OR, 3.08; P=0.009) and repetition of procedures (OR, 2.25; P=0.039) were individual risk factors for MDRO infection. Multivariate analysis showed that being bedridden (OR, 2.66; P=0.037), repeated infection (OR, 4.00; P=0.005) and an operative time of >3 h (OR, 2.28; P=0.023) were risk factors of MDRO infection. In conclusion, constrained antibiotic use, shortened operative time and increased activity duration can effectively prevent surgical-site infection with MDROs in patients with fractures.
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Affiliation(s)
- Honggang Sun
- Clinical Laboratory, Bayi Orthopedic Hospital, Chengdu, Sichuan 610052, P.R. China
| | - Dagao Dong
- Clinical Laboratory, Bayi Orthopedic Hospital, Chengdu, Sichuan 610052, P.R. China
| | - Min Zhao
- Clinical Laboratory, Bayi Orthopedic Hospital, Chengdu, Sichuan 610052, P.R. China
| | - Jie Jian
- Clinical Laboratory, Bayi Orthopedic Hospital, Chengdu, Sichuan 610052, P.R. China
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Moon AY, Bailey EJ, Polanco JA, Kurata WE, Pierce LM. Antibacterial Efficacy of a Chitosan-Based Hydrogel Modified With Epsilon-Poly-l-Lysine Against Pseudomonas aeruginosa in a Murine-Infected Burn Wound Model. Mil Med 2023; 188:52-60. [PMID: 37948238 DOI: 10.1093/milmed/usad013] [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: 10/04/2022] [Revised: 01/03/2023] [Accepted: 01/09/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Because antibiotic resistance is increasing worldwide and the leading cause of death in burn patients is an infection, an urgent need exists for nonantibiotic approaches to eliminate multidrug-resistant bacteria from burns to prevent their systemic dissemination and sepsis. We previously demonstrated the significant antibiofilm activity of a chitosan (CS) hydrogel containing the antimicrobial peptide epsilon-poly-l-lysine (EPL) against multidrug-resistant Pseudomonas aeruginosa using ex vivo porcine skin. In this study, we evaluated the in vivo antibacterial efficacy of a CS/EPL hydrogel against P. aeruginosa in a murine burn wound infection model. MATERIALS AND METHODS Full-thickness burns were created on the dorsum using a heated brass rod and were inoculated with bioluminescent, biofilm-forming P. aeruginosa (Xen41). Mice were treated with CS/EPL, CS, or no hydrogel applied topically 2 or 24 hours after inoculation to assess the ability to prevent or eradicate existing biofilms, respectively. Dressing changes occurred daily for 3 days, and in vivo bioluminescence imaging was performed to detect and quantitate bacterial growth. Blood samples were cultured to determine systemic infection. In vitro antibacterial activity and cytotoxicity against human primary dermal fibroblasts, keratinocytes, and mesenchymal stem cells were also assessed. RESULTS CS/EPL treatment initiated at early or delayed time points showed a significant reduction in bioluminescence imaging signal compared to CS on days 2 and 3 of treatment. Mice administered CS/EPL had fewer bloodstream infections, lower weight loss, and greater activity than the untreated and CS groups. CS/EPL reduced bacterial burden by two orders of magnitude in vitro and exhibited low cytotoxicity against human cells. CONCLUSION A topical hydrogel delivering the antimicrobial peptide EPL demonstrates in vivo efficacy to reduce but not eradicate established P. aeruginosa biofilms in infected burn wounds. This biocompatible hydrogel shows promise as an antimicrobial barrier dressing for the sustained protection of burn wounds from external bacterial contamination.
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Affiliation(s)
- Andrea Y Moon
- Department of General Surgery, Tripler Army Medical Center, Tripler AMC, HI 96859, USA
| | - Emily J Bailey
- Department of Clinical Investigation, Tripler Army Medical Center, Tripler AMC, HI 96859, USA
| | - Jonilee A Polanco
- Department of Clinical Investigation, Tripler Army Medical Center, Tripler AMC, HI 96859, USA
| | - Wendy E Kurata
- Department of Clinical Investigation, Tripler Army Medical Center, Tripler AMC, HI 96859, USA
| | - Lisa M Pierce
- Department of Clinical Investigation, Tripler Army Medical Center, Tripler AMC, HI 96859, USA
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Soderstrom MA, Blyth DM, Carson ML, Campbell WR, Yabes JM, Shaikh F, Stewart L, Tribble DR, Murray CK, Kiley JL. Seasonality of Microbiology of Combat-Related Wounds and Wound Infections in Afghanistan. Mil Med 2023; 188:304-310. [PMID: 37948254 PMCID: PMC10637295 DOI: 10.1093/milmed/usad115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/02/2023] [Accepted: 03/28/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Battlefield-related wound infections are a significant source of morbidity among combat casualties. Seasonality of these infections was demonstrated in previous conflicts (e.g., Korea) but has not been described with trauma-related health care-associated infections from the war in Afghanistan. METHODS The study population included military personnel wounded in Afghanistan (2009-2014) medevac'd to Landstuhl Regional Medical Center and transitioned to participating military hospitals in the United States with clinical suspicion of wound infections and wound cultures collected ≤7 days post-injury. Analysis was limited to the first wound culture from individuals. Infecting isolates were collected from skin and soft-tissue infections, osteomyelitis, and burn soft-tissue infections. Data were analyzed by season (winter [ December 1-February 28/29], spring [March 1-May 31], summer [June 1-August 31], and fall [September 1-November 30]). RESULTS Among 316 patients, 297 (94.0%) sustained blast injuries with a median injury severity score and days from injury to initial culture of 33 and 3.5, respectively. Although all patients had a clinical suspicion of a wound infection, a diagnosis was confirmed in 198 (63%) patients. Gram-negative bacilli (59.5% of 316) were more commonly isolated from wound cultures in summer (68.1%) and fall (67.1%) versus winter (43.9%) and spring (45.1%; P < .001). Multidrug-resistant (MDR) Gram-negative bacilli (21.8%) were more common in summer (21.8%) and fall (30.6%) versus winter (7.3%) and spring (19.7%; P = .028). Findings were similar for infecting Gram-negative bacilli (72.7% of 198)-summer (79.5%) and fall (83.6%; P = .001)-and infecting MDR Gram-negative bacilli (27.3% of 198)-summer (25.6%) and fall (41.8%; P = .015). Infecting anaerobes were more common in winter (40%) compared to fall (11%; P = .036). Gram-positive organisms were not significantly different by season. CONCLUSION Gram-negative bacilli, including infecting MDR Gram-negative bacilli, were more commonly recovered in summer/fall months from service members injured in Afghanistan. This may have implications for empiric antibiotic coverage during these months.
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Affiliation(s)
- Matthew A Soderstrom
- Infectious Disease Service, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, TX 78234, USA
| | - Dana M Blyth
- Infectious Disease Service, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - M Leigh Carson
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Wesley R Campbell
- Infectious Disease Service, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Joseph M Yabes
- Infectious Disease Service, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, TX 78234, USA
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Clinton K Murray
- Infectious Disease Service, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, TX 78234, USA
| | - John L Kiley
- Infectious Disease Service, Brooke Army Medical Center, Joint Base San Antonio, Fort Sam Houston, TX 78234, USA
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Bennett W, Mende K, Campbell WR, Beckius M, Stewart L, Shaikh F, Rahman A, Tribble DR, Yabes JM. Enterobacter cloacae infection characteristics and outcomes in battlefield trauma patients. PLoS One 2023; 18:e0290735. [PMID: 37643169 PMCID: PMC10464967 DOI: 10.1371/journal.pone.0290735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 08/14/2023] [Indexed: 08/31/2023] Open
Abstract
Enterobacter cloacae is a Gram-negative rod with multidrug-resistant potential due to chromosomally-induced AmpC β-lactamase. We evaluated characteristics, antibiotic utilization, and outcomes associated with battlefield-related E. cloacae infections (2009-2014). Single initial and serial E. cloacae isolates (≥24 hours from initial isolate from any site) associated with a clinical infection were examined. Susceptibility profiles of initial isolates in the serial isolation group were contrasted against last isolate recovered. Characteristics of 112 patients with E. cloacae infections (63 [56%] with single initial isolation; 49 [44%] with serial isolation) were compared to 509 patients with bacterial infections not attributed to E. cloacae. E. cloacae patients sustained more blast trauma (78%) compared to non-E. cloacae infections patients (75%; p<0.001); however, injury severity scores were comparable (median of 34.5 and 33, respectively; p = 0.334). Patients with E. cloacae infections had greater shock indices (median 1.07 vs 0.92; p = 0.005) and required more initial blood products (15 vs. 14 units; p = 0.032) compared to patients with non-E. cloacae infections. Although E. cloacae patients had less intensive care unit admissions (80% vs. 90% with non-E. cloacae infection patients; p = 0.007), they did have more operating room visits (5 vs. 4; p = 0.001), longer duration of antibiotic therapy (43.5 vs. 34 days; p<0.001), and lengthier hospitalizations (57 vs. 44 days; p<0.001). Patients with serial E. cloacae had isolation of infecting isolates sooner than patients with single initial E. cloacae (median of 5 vs. 8 days post-injury; p = 0.046); however, outcomes were not significantly different between the groups. Statistically significant resistance to individual antibiotics did not develop between initial and last isolates in the serial isolation group. Despite current combat care and surgical prophylaxis guidelines recommending upfront provision of AmpC-inducing antibiotics, clinical outcomes did not differ nor did significant antibiotic resistance develop in patients who experienced serial isolation of E. cloacae versus single initial isolation.
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Affiliation(s)
- William Bennett
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, United States of America
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
| | - Katrin Mende
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, United States of America
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - Wesley R. Campbell
- Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
| | - Miriam Beckius
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, United States of America
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - Azizur Rahman
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - David R. Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
| | - Joseph M. Yabes
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, United States of America
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America
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Acquisition of extended-spectrum cephalosporin-resistant Gram-negative bacteria: epidemiology and risk factors in a 6-year cohort of 507 severe trauma patients. J Glob Antimicrob Resist 2022; 31:363-370. [PMID: 36334873 DOI: 10.1016/j.jgar.2022.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/05/2022] [Accepted: 10/09/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Severe trauma patients are at higher risk of infection and often exposed to antibiotics, which could favor acquisition of antimicrobial resistance. In this study, we aimed to assess prevalence, acquisition, and factors associated with acquisition of extended-spectrum cephalosporin-resistant Gram-negative bacteria (ESCR-GNB) in severe trauma patients. METHODS We conducted a retrospective monocentric cohort study in a French level one Regional Trauma Centre between 01 January 2010and 31 December 2015. Patients admitted for ≥ 7 days, with an Injury Severity Score ≥ 15, and ≥ 1 microbiological sample were included in the analysis. Prevalence and acquisition rate of ESCR-GNB were determined then, factors associated with ESCR-GNB acquisition were assessed using a Cox model. RESULTS Of 1873 patients admitted during the study period, 507 were included (median Injury Severity Score = 29 [22-34] and median intensive care unit length of stay = 16 days [10-28]). Most of them (450; 89%) had an antimicrobial therapy. Prevalence of ESCR-GNB increased from 13% to 33% during intensive care unit stay, bringing the ESCR-GNB acquisition rate to 29%. Acquisition of ESCR-GNB was mainly related to AmpC beta-lactamase Enterobacterales and was independently associated with mechanical ventilation needs (hazard ratio [HR] = 6.39; 95% confidence interval [CI] [1.51-27.17]; P = 0.01), renal replacement therapy needs (HR = 2.44; 95% CI [1.24-4.79]; P = 0.01), exposure to cephalosporins (HR = 1.06; 95% CI [1.01-1.12]; P = 0.02), and/or combination therapy with non-beta-lactam antibiotics such as vancomycin, linezolid, clindamycin, or metronidazole (HR = 1.03; 95% CI [1.01-1.06]; P = 0.02). CONCLUSIONS Acquisition of ESCR-GNB was prevalent in severe trauma patients. Our results suggest selecting antibiotics with caution, particularly in the most severely ill.
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McCarthy SL, Stewart L, Shaikh F, Murray CK, Tribble DR, Blyth DM. Prognostic Value of Sequential Organ Failure Assessment (SOFA) Score in Critically-Ill Combat-Injured Patients. J Intensive Care Med 2022; 37:1426-1434. [PMID: 35171072 PMCID: PMC9378752 DOI: 10.1177/08850666221078196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Infection is a frequent and serious complication after combat-related trauma. The Sequential Organ Failure Assessment (SOFA) score has been shown to have predictive value for outcomes, including sepsis and mortality, among various populations. We evaluated the prognostic ability of SOFA score in a combat-related trauma population. Methods: Combat casualties (2009-2014) admitted to Landstuhl Regional Medical Center (LRMC; Germany) intensive care unit (ICU) within 4 days post-injury followed by transition to ICUs in military hospitals in the United States were included. Multivariate logistic regression was used to determine predictive effect of selected variables and receiver operating characteristic (ROC) curve analysis was used to evaluate overall accuracy of SOFA score for infection prediction. Results: Of the 748 patients who met inclusion criteria, 436 (58%) were diagnosed with an infection (32% bloodstream, 63% skin and soft tissue, and 40% pulmonary) and were predominantly young (median 24 years) males. Penetrating trauma accounted for 95% and 86% of injuries among those with and without infections, respectively (p < 0.001). Median LRMC admission SOFA score was 7 (interquartile range [IQR]: 4-9) in patients with infections versus 4 (IQR: 2-6) in patients without infections (p < 0.001). Thirty-day mortality was 2% in both groups. On multivariate regression, LRMC SOFA score was independently associated with infection development (odds ratio: 1.2; 95% confidence interval: 1.1-1.3). The ROC curve analysis revealed an area under the curve of 0.69 for infection prediction, and 0.80 for mortality prediction. Conclusions: The SOFA scores obtained up to 4 days post-injury predict late onset infection occurrence. This study revealed that for every 1 point increase in LRMC SOFA score, the odds of having an infection increases by a factor of 1.2, controlling for other predictors. The use of SOFA score in admission assessments may assist clinicians with identifying those at higher risk of infection following combat-related trauma.
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Affiliation(s)
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | | | - David R. Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Dana M. Blyth
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA
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Metagenomic features of bioburden serve as outcome indicators in combat extremity wounds. Sci Rep 2022; 12:13816. [PMID: 35970993 PMCID: PMC9378645 DOI: 10.1038/s41598-022-16170-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 07/05/2022] [Indexed: 11/09/2022] Open
Abstract
Battlefield injury management requires specialized care, and wound infection is a frequent complication. Challenges related to characterizing relevant pathogens further complicates treatment. Applying metagenomics to wounds offers a comprehensive path toward assessing microbial genomic fingerprints and could indicate prognostic variables for future decision support tools. Wound specimens from combat-injured U.S. service members, obtained during surgical debridements before delayed wound closure, were subjected to whole metagenome analysis and targeted enrichment of antimicrobial resistance genes. Results did not indicate a singular, common microbial metagenomic profile for wound failure, instead reflecting a complex microenvironment with varying bioburden diversity across outcomes. Genus-level Pseudomonas detection was associated with wound failure at all surgeries. A logistic regression model was fit to the presence and absence of antimicrobial resistance classes to assess associations with nosocomial pathogens. A. baumannii detection was associated with detection of genomic signatures for resistance to trimethoprim, aminoglycosides, bacitracin, and polymyxin. Machine learning classifiers were applied to identify wound and microbial variables associated with outcome. Feature importance rankings averaged across models indicated the variables with the largest effects on predicting wound outcome, including an increase in P. putida sequence reads. These results describe the microbial genomic determinants in combat wound bioburden and demonstrate metagenomic investigation as a comprehensive tool for providing information toward aiding treatment of combat-related injuries.
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Winskel-Wood B, Padula MP, Marks DC, Johnson L. Cold storage alters the immune characteristics of platelets and potentiates bacterial-induced aggregation. Vox Sang 2022; 117:1006-1015. [PMID: 35579630 DOI: 10.1111/vox.13293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/13/2022] [Accepted: 04/20/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Cold-stored platelets are currently under clinical evaluation and have been approved for limited clinical use in the United States. Most studies have focused on the haemostatic functionality of cold-stored platelets; however, limited information is available examining changes to their immune function. MATERIALS AND METHODS Two buffy-coat-derived platelet components were combined and split into two treatment arms: room temperature (RT)-stored (20-24°C) or refrigerated (cold-stored, 2-6°C). The concentration of select soluble factors was measured in the supernatant using commercial ELISA kits. The abundance of surface receptors associated with immunological function was assessed by flow cytometry. Platelet aggregation was assessed in response to Escherichia coli and Staphylococcus aureus, in the presence and absence of RGDS (blocks active conformation of integrin α2 β3 ). RESULTS Cold-stored platelet components contained a lower supernatant concentration of C3a, RANTES and PF4. The abundance of surface-bound P-selectin and integrin α2 β3 in the activated conformation increased during cold storage. In comparison, the abundance of CD86, CD44, ICAM-2, CD40, TLR1, TLR2, TLR4, TLR3, TLR7 and TLR9 was lower on the surface membrane of cold-stored platelets compared to RT-stored components. Cold-stored platelets exhibited an increased responsiveness to E. coli- and S. aureus-induced aggregation compared to RT-stored platelets. Inhibition of the active conformation of integrin α2 β3 using RGDS reduced the potentiation of bacterial-induced aggregation in cold-stored platelets. CONCLUSION Our data highlight that cold storage changes the in vitro immune characteristics of platelets, including their sensitivity to bacterial-induced aggregation. Changes in these immune characteristics may have clinical implications post transfusion.
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Affiliation(s)
- Ben Winskel-Wood
- Research and Development, Australian Red Cross Lifeblood, Alexandria, New South Wales, Australia.,School of Life Sciences, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Matthew P Padula
- School of Life Sciences, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Denese C Marks
- Research and Development, Australian Red Cross Lifeblood, Alexandria, New South Wales, Australia.,Sydney Medical School, The University of Sydney, Camperdown, New South Wales, Australia
| | - Lacey Johnson
- Research and Development, Australian Red Cross Lifeblood, Alexandria, New South Wales, Australia.,School of Life Sciences, University of Technology Sydney, Sydney, New South Wales, Australia
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11
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Tribble DR. IDCRP Trauma-Related Infection Research. Mil Med 2022; 187:2-6. [PMID: 35512373 DOI: 10.1093/milmed/usab508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 11/23/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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12
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Mende K, Akers KS, Tyner SD, Bennett JW, Simons MP, Blyth DM, Li P, Stewart L, Tribble DR. Multidrug-Resistant and Virulent Organisms Trauma Infections: Trauma Infectious Disease Outcomes Study Initiative. Mil Med 2022; 187:42-51. [PMID: 35512375 DOI: 10.1093/milmed/usab131] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/24/2021] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION During the wars in Iraq and Afghanistan, increased incidence of multidrug-resistant (MDR) organisms, as well as polymicrobial wounds and infections, complicated the management of combat trauma-related infections. Multidrug resistance and wound microbiology are a research focus of the Trauma Infectious Disease Outcomes Study (TIDOS), an Infectious Disease Clinical Research Program, Uniformed Services University, research protocol. To conduct comprehensive microbiological research with the goal of improving the understanding of the complicated etiology of wound infections, the TIDOS MDR and Virulent Organisms Trauma Infections Initiative (MDR/VO Initiative) was established as a collaborative effort with the Brooke Army Medical Center, Naval Medical Research Center, U.S. Army Institute of Surgical Research, and Walter Reed Army Institute of Research. We provide a review of the TIDOS MDR/VO Initiative and summarize published findings. METHODS Antagonism and biofilm formation of commonly isolated wound bacteria (e.g., ESKAPE pathogens-Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.), antimicrobial susceptibility patterns, and clinical outcomes are being examined. Isolates collected from admission surveillance swabs, as part of infection control policy, and clinical infection workups were retained in the TIDOS Microbiological Repository and associated clinical data in the TIDOS database. RESULTS Over the TIDOS study period (June 2009 to December 2014), more than 8,300 colonizing and infecting isolates were collected from military personnel injured with nearly one-third of isolates classified as MDR. At admission to participating U.S. military hospitals, 12% of wounded warriors were colonized with MDR Gram-negative bacilli. Furthermore, 27% of 913 combat casualties with ≥1 infection during their trauma hospitalization had MDR Gram-negative bacterial infections. Among 335 confirmed combat-related extremity wound infections (2009-2012), 61% were polymicrobial and comprised various combinations of Gram-negative and Gram-positive bacteria, yeast, fungi, and anaerobes. Escherichia coli was the most common Gram-negative bacilli isolated from clinical workups, as well as the most common colonizing MDR secondary to extended-spectrum β-lactamase resistance. Assessment of 479 E. coli isolates collected from wounded warriors found 188 pulsed-field types (PFTs) from colonizing isolates and 54 PFTs from infecting isolates without significant overlap across combat theaters, military hospitals, and study years. A minority of patients with colonizing E. coli isolates developed subsequent infections with the same E. coli strain. Enterococcus spp. were most commonly isolated from polymicrobial wound infections (53% of 204 polymicrobial cultures). Patients with Enterococcus infections were severely injured with a high proportion of lower extremity amputations and genitourinary injuries. Approximately 65% of polymicrobial Enterococcus infections had other ESKAPE organisms isolated. As biofilms have been suggested as a cause of delayed wound healing, wound infections with persistent recovery of bacteria (isolates of same organism collected ≥14 days apart) and nonrecurrent bacterial isolates were assessed. Biofilm production was significantly associated with recurrent bacteria isolation (97% vs. 59% with nonrecurrent isolates; P < 0.001); however, further analysis is needed to confirm biofilm formation as a predictor of persistent wound infections. CONCLUSIONS The TIDOS MDR/VO Initiative provides comprehensive and detailed data of major microbial threats associated with combat-related wound infections to further the understanding of wound etiology and potentially identify infectious disease countermeasures, which may lead to improvements in combat casualty care.
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Affiliation(s)
- Katrin Mende
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA.,Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Kevin S Akers
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
| | - Stuart D Tyner
- Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Jason W Bennett
- Multidrug-Resistant Organisms Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Mark P Simons
- Naval Medical Research Center, Silver Spring, MD 20910, USA
| | - Dana M Blyth
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Ping Li
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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13
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Hocking L, Ali GC, d’Angelo C, Deshpande A, Stevenson C, Virdee M, Guthrie S. A rapid evidence assessment exploring whether antimicrobial resistance complicates non-infectious health conditions and healthcare services, 2010-20. JAC Antimicrob Resist 2021; 3:dlab171. [PMID: 34806009 PMCID: PMC8599069 DOI: 10.1093/jacamr/dlab171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Antimicrobial resistance (AMR) is one of the greatest public health threats at this time. While there is a good understanding of the impacts of AMR on infectious diseases, an area of less focus is the effects AMR may be having on non-communicable health conditions (such as cancer) and healthcare services (such as surgery). Therefore, this study aimed to explore what impact AMR is currently having on non-communicable health conditions, or areas of health services, where AMR could be a complicating factor impacting on the ability to treat the condition and/or health outcomes. To do this, a rapid evidence assessment of the literature was conducted, involving a systematic approach to searching and reviewing the evidence. In total, 101 studies were reviewed covering surgery, organ transplants, cancer, ICUs, diabetes, paediatric patients, immunodeficiency conditions, liver and kidney disease, and physical trauma. The results showed limited research in this area and studies often use a selective population, making the results difficult to generalize. However, the evidence showed that for all health conditions and healthcare service areas reviewed, at least one study demonstrated a higher risk of death for patients with resistant infections, compared with no or drug-susceptible infections. Poor health outcomes were also associated with resistant infections in some instances, such as severe sepsis and failure of treatments, as well as a greater need for invasive medical support. While there are gaps in the evidence base requiring further research, efforts are also needed within policy and practice to better understand and overcome these challenges.
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Affiliation(s)
- Lucy Hocking
- RAND Europe, Westbrook Centre, Milton Road, Cambridge, UK
- Corresponding author. E-mail:
| | | | | | | | | | - Mann Virdee
- RAND Europe, Westbrook Centre, Milton Road, Cambridge, UK
| | - Susan Guthrie
- RAND Europe, Westbrook Centre, Milton Road, Cambridge, UK
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14
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Higgins PG, Kniel M, Rojak S, Balczun C, Rohde H, Frickmann H, Hagen RM. Molecular Epidemiology of Carbapenem-Resistant Acinetobacter baumannii Strains Isolated at the German Military Field Laboratory in Mazar-e Sharif, Afghanistan. Microorganisms 2021; 9:microorganisms9112229. [PMID: 34835355 PMCID: PMC8622437 DOI: 10.3390/microorganisms9112229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/22/2021] [Accepted: 10/22/2021] [Indexed: 11/20/2022] Open
Abstract
The study was performed to provide an overview of the molecular epidemiology of carbapenem-resistant Acinetobacter baumannii in Afghanistan isolated by the German military medical service during the Afghanistan conflict. A total of 18 isolates were collected between 2012 and 2018 at the microbiological laboratory of the field hospital in Camp Marmal near Mazar-e Sharif, Afghanistan, from Afghan patients. The isolates were subjected to phenotypic and genotypic differentiation and antimicrobial susceptibility testing as well as to a core genome multi-locus sequence typing (cgMLST) approach based on whole-genome next-generation sequence (wgNGS) data. Next to several sporadic isolates, four transmission clusters comprising strains from the international clonal lineages IC1, IC2, and IC9 were identified. Acquired carbapenem resistance was due to blaOXA-23 in 17/18 isolates, while genes mediating resistance against sulfonamides, macrolides, tetracyclines, and aminoglycosides were frequently identified as well. In conclusion, the assessment confirmed both the frequent occurrence of A. baumannii associated with outbreak events and a variety of different clones in Afghanistan. The fact that acquired carbapenem resistance was almost exclusively associated with blaOXA-23 may facilitate molecular resistance screening based on rapid molecular assays targeting this resistance determinant.
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Affiliation(s)
- Paul G. Higgins
- Institute for Medical Microbiology, Immunology, and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50935 Cologne, Germany;
- German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, 50935 Cologne, Germany
| | - Meret Kniel
- Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, 56070 Koblenz, Germany; (M.K.); (S.R.); (C.B.)
| | - Sandra Rojak
- Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, 56070 Koblenz, Germany; (M.K.); (S.R.); (C.B.)
| | - Carsten Balczun
- Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, 56070 Koblenz, Germany; (M.K.); (S.R.); (C.B.)
| | - Holger Rohde
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf (UKE), 20251 Hamburg, Germany;
| | - Hagen Frickmann
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, 20359 Hamburg, Germany; or
- Institute for Medical Microbiology, Virology and Hygiene, University Medicine Rostock, 18057 Rostock, Germany
| | - Ralf Matthias Hagen
- Department of Microbiology and Hospital Hygiene, Bundeswehr Central Hospital Koblenz, 56070 Koblenz, Germany; (M.K.); (S.R.); (C.B.)
- Correspondence: ; Tel.: +49-261-896-77200
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15
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Kiley JL, Mende K, Beckius ML, Kaiser SJ, Carson ML, Lu D, Whitman TJ, Petfield JL, Tribble DR, Blyth DM. Resistance patterns and clinical outcomes of Klebsiella pneumoniae and invasive Klebsiella variicola in trauma patients. PLoS One 2021; 16:e0255636. [PMID: 34339473 PMCID: PMC8328492 DOI: 10.1371/journal.pone.0255636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/20/2021] [Indexed: 12/20/2022] Open
Abstract
Recent reclassification of the Klebsiella genus to include Klebsiella variicola, and its association with bacteremia and mortality, has raised concerns. We examined Klebsiella spp. infections among battlefield trauma patients, including occurrence of invasive K. variicola disease. Klebsiella isolates collected from 51 wounded military personnel (2009-2014) through the Trauma Infectious Disease Outcomes Study were examined using polymerase chain reaction (PCR) and pulsed-field gel electrophoresis. K. variicola isolates were evaluated for hypermucoviscosity phenotype by the string test. Patients were severely injured, largely from blast injuries, and all received antibiotics prior to Klebsiella isolation. Multidrug-resistant Klebsiella isolates were identified in 23 (45%) patients; however, there were no significant differences when patients with and without multidrug-resistant Klebsiella were compared. A total of 237 isolates initially identified as K. pneumoniae were analyzed, with 141 clinical isolates associated with infections (remaining were colonizing isolates collected through surveillance groin swabs). Using PCR sequencing, 221 (93%) isolates were confirmed as K. pneumoniae, 10 (4%) were K. variicola, and 6 (3%) were K. quasipneumoniae. Five K. variicola isolates were associated with infections. Compared to K. pneumoniae, infecting K. variicola isolates were more likely to be from blood (4/5 versus 24/134, p = 0.04), and less likely to be multidrug-resistant (0/5 versus 99/134, p<0.01). No K. variicola isolates demonstrated the hypermucoviscosity phenotype. Although K. variicola isolates were frequently isolated from bloodstream infections, they were less likely to be multidrug-resistant. Further work is needed to facilitate diagnosis of K. variicola and clarify its clinical significance in larger prospective studies.
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Affiliation(s)
- John L. Kiley
- Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, United States of America
| | - Katrin Mende
- Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, United States of America
- Department of Preventive Medicine and Biostatistics, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - Miriam L. Beckius
- Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, United States of America
| | - Susan J. Kaiser
- Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, United States of America
- Department of Preventive Medicine and Biostatistics, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - M. Leigh Carson
- Department of Preventive Medicine and Biostatistics, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - Dan Lu
- Department of Preventive Medicine and Biostatistics, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, United States of America
| | - Timothy J. Whitman
- Walter Reed National Military Medical Center, Bethesda, Maryland, United States of America
| | | | - David R. Tribble
- Department of Preventive Medicine and Biostatistics, Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States of America
| | - Dana M. Blyth
- Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas, United States of America
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16
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Ford MB, Mende K, Kaiser SJ, Beckius ML, Lu D, Stam J, Li P, Stewart L, Tribble DR, Blyth DM. Clinical Characteristics and Resistance Patterns of Pseudomonas aeruginosa Isolated From Combat Casualties. Mil Med 2021; 187:426-434. [PMID: 34196358 DOI: 10.1093/milmed/usab259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/06/2021] [Accepted: 06/21/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Multidrug-resistant (MDR) Gram-negative infections complicate care of combat casualties. We describe the clinical characteristics, resistance patterns, and outcomes of Pseudomonas aeruginosa infections in combat casualties. METHODS Combat casualties included in the Trauma Infectious Disease Outcomes Study with infections with and without P. aeruginosa isolation during initial hospitalization were compared. Pseudomonas aeruginosa from initial wound, blood, and serial isolates (≥7 days from previous isolate) collected from June 2009 through February 2014 was subjected to antimicrobial susceptibility testing, pulsed-field gel electrophoresis, and whole genome sequencing for assessing clonality. Multidrug resistance was determined using the CDC National Healthcare Safety Network definition. RESULTS Of 829 combat casualties with infections diagnosed during initial hospitalization, 143 (17%) had P. aeruginosa isolated. Those with P. aeruginosa were more severely injured (median Injury Severity Score 33 [interquartile range (IQR) 27-45] vs 30 [IQR 18.5-42]; P < .001), had longer hospitalizations (median 58.5 [IQR 43-95] vs 38 [IQR 26-56] days; P < .001), and higher mortality (6.9% vs 1.5%; P < .001) than those with other organisms. Thirty-nine patients had serial P. aeruginosa isolation (median 2 subsequent isolates; IQR: 1-5), with decreasing antimicrobial susceptibility. Ten percent of P. aeruginosa isolates were MDR, associated with prior exposure to antipseudomonal antibiotics (P = .002), with amikacin and colistin remaining the most effective antimicrobials. Novel antimicrobials targeting MDR Gram-negative organisms were also examined, and 100% of the MDR P. aeruginosa isolates were resistant to imipenem/relabactam, while ceftazidime/avibactam and ceftolozane/tazobactam were active against 35% and 56% of the isolates, respectively. We identified two previously unrecognized P. aeruginosa outbreaks involving 13 patients. CONCLUSIONS Pseudomonas aeruginosa continues to be a major cause of morbidity, affecting severely injured combat casualties, with emergent antimicrobial resistance upon serial isolation. Among MDR P. aeruginosa, active antimicrobials remain the oldest and most toxic. Despite ongoing efforts, outbreaks are still noted, reinforcing the crucial role of antimicrobial stewardship and infection control.
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Affiliation(s)
- Mary B Ford
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Katrin Mende
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA.,Infectious Disease Clinical Research Program, Department ofPreventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Susan J Kaiser
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA.,Infectious Disease Clinical Research Program, Department ofPreventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Miriam L Beckius
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Dan Lu
- Infectious Disease Clinical Research Program, Department ofPreventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Jason Stam
- Multidrug-Resistant Organism Repository and Surveillance Network, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
| | - Ping Li
- Infectious Disease Clinical Research Program, Department ofPreventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - Laveta Stewart
- Infectious Disease Clinical Research Program, Department ofPreventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD 20817, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department ofPreventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Dana M Blyth
- Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
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Molecular Epidemiology of Carbapenem-Resistant Acinetobacter baumannii Isolates from Northern Africa and the Middle East. Antibiotics (Basel) 2021; 10:antibiotics10030291. [PMID: 33799540 PMCID: PMC8002098 DOI: 10.3390/antibiotics10030291] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 02/06/2023] Open
Abstract
At the Bundeswehr Hospitals of Hamburg and Westerstede, patients repatriated from subtropical war and crisis zones of Northern Africa and the Middle East were medically treated, including microbiological assessment. Within a six-year interval, 16 Acinetobacter spp. strains, including 14 Acinetobacter baumannii (Ab) isolates with resistance against carbapenems and origins in Afghanistan (n = 4), Iraq (n = 2), Libya (n = 2), and Syria (n = 8) were collected. While clonal relationships of Libyan and Syrian strains had been assessed by superficial next generation sequencing (NGS) and “DiversiLab” repetitive elements sequence-based (rep-)PCR so far, this study provides core genome-based sequence typing and thus more detailed epidemiological information. In detail, sequencing allowed a definitive species identification and comparison with international outbreak-associated Ab strains by core genome multi locus sequence typing (cgMLST) and the identification of MLST lineages, as well as the identification of known resistance genes. The sequence analysis allowed for the confirmation of outbreak-associated clonal clusters among the Syrian and Afghan Ab isolates, indicating likely transmission events. The identified acquired carbapenem resistance genes comprised blaOXA-23, blaOXA-58, blaNDM-1, and blaGES-11, next to other intrinsic and acquired, partly mobile resistance-associated genes. Eleven out of 14 Ab isolates clustered with the previously described international clonal lineages IC1 (4 Afghan strains), IC2 (6 Syrian strains), and IC7 (1 Syrian strain). Identified Pasteur sequence types of the 14 Ab strains comprised ST2 (Syrian), ST25 (Libyan), ST32 (Iraqi), ST81 (Afghan), ST85 (Libyan), and ST1112 (Syrian), respectively. In conclusion, the study revealed a broad spectrum of resistance genes in Ab isolated from war-injured patients from Northern Africa and the Middle East, thereby broadening the scarcely available data on locally abundant clonal lineages and resistance mechanisms.
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18
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Coles C, Ottolini MG. Infectious Disease Clinical Research Program: Building the Bench. Mil Med 2020; 184:66-70. [PMID: 31778195 DOI: 10.1093/milmed/usz094] [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: 02/14/2019] [Revised: 03/15/2019] [Indexed: 11/13/2022] Open
Abstract
The role of physicians in the U.S. Armed Forces is diverse, encompassing a wide array of skills and responsibilities to provide superior healthcare to their patients and to advance military medicine. In addition to healthcare delivery and medical education, military physicians are engaged in public health, operational medicine, and cutting-edge medical research. Thus, clinical research is a crucial component of Graduate Medical Education (GME) and supports critical thinking (knowledge, skills, and abilities) and the development of leadership skills among U.S. military physicians. The Infectious Disease Clinical Research Program (IDCRP) education mission was established in 2005 with the overall goal of supporting the development and training of the next generation of clinical researchers in infectious diseases and related public health disciplines in the Armed Forces using several strategies, including didactic learning, mentored research, and research engagement. Through involvement in the IDCRP, infectious disease fellows, residents (e.g., surgical, internal medicine, and pediatrics), and Master of Public Health (MPH) students have continued their education and gained valuable skills related to clinical research. Trainees either conduct research with IDCRP mentors or participate in IDCRP-led practicum experiences, with research projects ranging from epidemiologic studies to microbiological assessments. Consistent with the needs of the Military Health System (MHS), and in accordance with Accreditation Council for Graduate Medical Education goals, the IDCRP provides opportunities for medical and graduate students, residents, and infectious disease fellows to conduct mentored research within the MHS, as well as gain important leadership skills in the conduct of clinical research. Overall, IDCRP continues to further infectious disease research through the support and education of the next generation of active-duty infectious disease researchers in the MHS.
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Affiliation(s)
- Christian Coles
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD 20817
| | - Martin G Ottolini
- Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814
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19
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Yang S, Li X, Liu P, Zhang M, Wang C, Zhang B. Multifunctional Chitosan/Polycaprolactone Nanofiber Scaffolds with Varied Dual-Drug Release for Wound-Healing Applications. ACS Biomater Sci Eng 2020; 6:4666-4676. [PMID: 33455179 DOI: 10.1021/acsbiomaterials.0c00674] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Electrospinning-based wound dressings with multifunctional properties, including hemostasis-promoting, antibacterial, drug release, and therapeutic effects, are of great interest in military and civilian trauma healthcare. Herein, we designed lidocaine hydrochloride (LID) and mupirocin-loaded chitosan/polycaprolactone (CSLD-PCLM) scaffolds with multiple functions as wound dressings. Through the dual spinneret electrospinning technique, the scaffolds achieved a nanofiber structure, which enhanced the interfacial interaction between the scaffold and blood cells and showed excellent blood coagulation capacity. In particular, the scaffolds loaded with LID and mupirocin exhibited rapid release of LID and sustained release of mupirocin. The CSLD-PCLM scaffold containing mupirocin exhibited outstanding antibacterial activity. Moreover, the scaffold significantly enhanced the wound healing process with complete re-epithelialization as well as collagen deposition in a full-thickness skin defect model. Thus, CSLD-PCLM nanofibrous scaffolds may ideally meet the various requirements of the wound healing process and are promising candidates for wound dressings in future clinical applications.
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Affiliation(s)
- Shuang Yang
- Institute of Biomedical Engineering, Chongqing Engineering Laboratory of Nano/Micro Biological Medicine Detection Technology, Chongqing University of Science and Technology, Chongqing 401331, China
| | - Xiaoming Li
- Department of Military Traffic Injury Prevention, State Key Lab of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Ping Liu
- Department of Military Traffic Injury Prevention, State Key Lab of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Army Medical University, Chongqing 400042, China
| | - Maolan Zhang
- Institute of Biomedical Engineering, Chongqing Engineering Laboratory of Nano/Micro Biological Medicine Detection Technology, Chongqing University of Science and Technology, Chongqing 401331, China
| | - Chao Wang
- Department of Pediatric Intensive Care Unit, Ministry of Education Key Laboratory of Child Development and Disorders, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
| | - Bo Zhang
- Department of Military Traffic Injury Prevention, State Key Lab of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Army Medical University, Chongqing 400042, China
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Clostridioides difficile infections complicating combat-injured patients from Iraq and Afghanistan. Infect Control Hosp Epidemiol 2020; 41:1100-1102. [PMID: 32600498 DOI: 10.1017/ice.2020.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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21
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Yabes JM, Stewart L, Shaikh F, Robben PM, Petfield JL, Ganesan A, Campbell WR, Tribble DR, Blyth DM. Risk of Acute Kidney Injury in Combat-Injured Patients Associated With Concomitant Vancomycin and Extended-Spectrum β-Lactam Antibiotic Use. J Intensive Care Med 2020; 36:818-827. [PMID: 32508215 DOI: 10.1177/0885066620930994] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Multidrug-resistant infections complicating combat-related trauma necessitate the use of broad-spectrum antimicrobials. Recent literature posits an association between vancomycin (VANC) and piperacillin-tazobactam (VPT) combination therapy and acute kidney injury (AKI). We examined whether therapy with VPT was associated with an increased risk of AKI compared to VANC and other broad-spectrum β-lactam antibiotics (VBL) following combat-related injuries. METHODS Patients within the Trauma Infectious Disease Outcomes Study (TIDOS) who received ≥48 hours concomitant VPT or VBL started within 24 hours of each other were assessed. Exclusion criteria were receipt of renal replacement therapy and baseline creatinine >1.5 mg/dL. Acute kidney injury was defined by meeting any of the Risk, Injury, Failure, Loss, End Stage Renal Disease (RIFLE), AKIN, or VANC consensus guidelines criteria 3 to 7 days after therapy initiation. Variables significantly associated with AKI were used in inverse probability treatment weighting to perform univariate and subsequent logistic regression multivariate modeling to determine significant risk factors for AKI. RESULTS Sixty-one patients who received VPT and 207 who received VBL were included. Both groups had a median age of 24 years and initial median creatinine of 0.7 mg/dL. The VBL patients were more likely to have sustained blast injuries (P = .001) and received nephrotoxic agents (amphotericin [P = .002] and aminoglycosides [P < .001]). In the VBL group, AKI incidence was 9.7% compared to 13.1% in the VPT group (P = .438). Multivariate analysis identified a relative risk of 1.727 (95% CI: 1.027-2.765) for AKI associated with VPT exposure. Acute kidney injury severity generally met RIFLE Risk criteria and was 1 day in duration. Only 1 patient had persistent renal dysfunction 30 days after therapy completion. CONCLUSION In this young and previously healthy, severely ill combat-injured population, VPT was associated with nearly twice the risk of AKI compared to VBL. Nevertheless, AKI was of low severity, short duration, and had high rates of renal recovery.
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Affiliation(s)
- Joseph M Yabes
- Brooke Army Medical Center, JBSA, Fort Sam Houston, TX, USA
| | - Laveta Stewart
- 231653Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Faraz Shaikh
- 231653Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Paul M Robben
- 8395Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | - Anuradha Ganesan
- 231653Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA.,8395Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | - David R Tribble
- 231653Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Dana M Blyth
- Brooke Army Medical Center, JBSA, Fort Sam Houston, TX, USA
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22
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Zemke JN, Sanchez JL, Pang J, Gray GC. The Double-Edged Sword of Military Response to Societal Disruptions: A Systematic Review of the Evidence for Military Personnel as Pathogen Transmitters. J Infect Dis 2020; 220:1873-1884. [PMID: 31519020 DOI: 10.1093/infdis/jiz400] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 08/02/2019] [Indexed: 11/12/2022] Open
Abstract
Given their lack of immunity and increased exposure, military personnel have the potential to serve as carriers or reservoirs for infectious diseases into or out of the deployment areas, but, to our knowledge, the historical evidence for such transmission events has not previously been reviewed. Using PubMed, we performed a systematic review of published literature between 1955 and 2018, which documented evidence for military personnel transporting infectious pathogens into or out of deployment areas. Of the 439 articles screened, 67 were included for final qualitative and quantitative review. The data extracted from these articles described numerous instances in which thousands of military service members demonstrated potential or actual transmission and transportation of multiple diverse pathogens. These data underscore the immense importance preventive medical professionals play in mitigating such risk, how their public health efforts must be supported, and the importance of surveillance in protecting both military and civilian populations.
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Affiliation(s)
- Juliana N Zemke
- Duke Global Health Institute, Duke University, Durham, North Carolina.,Division of Infectious Diseases, Duke University, Durham, North Carolina
| | - Jose L Sanchez
- Department of Defense, Defense Health Agency, Public Health Division, Armed Forces Health Surveillance Branch, Silver Spring, Maryland
| | - Junxiong Pang
- Duke Global Health Institute, Duke University, Durham, North Carolina.,Centre for Infectious Disease Epidemiology & Research, Saw Swee Hock School of Public Health, National University of Singapore
| | - Gregory C Gray
- Duke Global Health Institute, Duke University, Durham, North Carolina.,Division of Infectious Diseases, Duke University, Durham, North Carolina.,Emerging Infectious Disease Program, Duke-National University of Singapore Medical School, Singapore.,Global Health Research Center, Duke-Kunshan University, Kunshan, China
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23
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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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24
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Patterson SB, Mende K, Li P, Lu D, Carson ML, Murray CK, Tribble DR, Blyth DM. Stenotrophomonas maltophilia infections: Clinical characteristics in a military trauma population. Diagn Microbiol Infect Dis 2019; 96:114953. [PMID: 31791809 DOI: 10.1016/j.diagmicrobio.2019.114953] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/29/2019] [Accepted: 11/09/2019] [Indexed: 01/27/2023]
Abstract
Stenotrophomonas maltophilia is a pathogen with unique resistance patterns. We assessed 70 combat casualties with S. maltophilia clinical isolates to examine its role as a nosocomial pathogen in critically-ill trauma patients. Incidence density was 0.36 S. maltophilia infections per 100 patient-days (95% CI: 0.29-0.44). Patients predominantly had blast trauma (97%) and were critically injured (injury severity score [ISS] >25; 80%). Restricting to patients with ISS >15, 50 patients with S. maltophilia infections were compared to 441 patients with infections attributed to other gram-negative bacilli. Patients with S. maltophilia infections had significantly more operating room visits prior to isolation, traumatic or early surgical amputations, longer hospitalization (median 71 vs 47 days), and higher overall mortality (10% vs 2%; P = 0.01). Initial and serial (≥7 days between initial and subsequent isolation) S. maltophilia isolates had high susceptibility to trimethoprim-sulfamethoxazole and minocycline. Evaluation of newer agents awaiting CLSI breakpoints, including moxifloxacin, showed promising results.
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Affiliation(s)
- Shane B Patterson
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, USA.
| | - Katrin Mende
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, USA; Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD, USA
| | - Ping Li
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD, USA
| | - Dan Lu
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD, USA
| | - M Leigh Carson
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., 6720A Rockledge Drive, Bethesda, MD, USA
| | - Clinton K Murray
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, USA
| | - David R Tribble
- Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Dana M Blyth
- Brooke Army Medical Center, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234, USA
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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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Medical evacuations of members of the French armed forces for infectious diseases in foreign operations. Med Mal Infect 2019; 50:545-554. [PMID: 31672468 DOI: 10.1016/j.medmal.2019.09.011] [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: 03/18/2018] [Revised: 11/15/2018] [Accepted: 09/13/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Medical evacuations from foreign settings are a major health and strategic problem for the armed forces. This work aimed to study the characteristics of French military evacuations due to infectious diseases. PATIENTS AND METHODS We performed a retrospective study based on the registers of the French operational military staff for health to assess the characteristics of the strategic medical evacuation of French armed forces members on missions abroad between January 1, 2011 and December 31, 2016. RESULTS Out of 4633 included cases, 301 medical evacuations (6.5%) were carried out due to infectious situations. More than half of patients were repatriated to surgical wards (162 patients, 54%), 108 patients (36%) to medical wards, 21 patients (7%) to intensive care units, six patients (2%) to an armed forces medical center, and four files (1%) were incomplete. Among infectious emergencies, malaria led to 30 evacuations (10%) including 11 to intensive care units and one death before evacuation. Infectious diseases requiring medical evacuation were most often mild and community-acquired. Most soldiers were evacuated without medical assistance. CONCLUSIONS Infectious diseases during missions and medical repatriations carried out for infectious reasons are important epidemiological indicators to monitor. They make it possible to adapt preventive measures, training, and diagnostic and therapeutic tools which can be made available to front-line military physicians.
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Frickmann H, Hahn A, Berlec S, Ulrich J, Jansson M, Schwarz NG, Warnke P, Podbielski A. On the Etiological Relevance of Escherichia coli and Staphylococcus aureus in Superficial and Deep Infections - A Hypothesis-Forming, Retrospective Assessment. Eur J Microbiol Immunol (Bp) 2019; 9:124-130. [PMID: 31934364 PMCID: PMC6945993 DOI: 10.1556/1886.2019.00021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 09/08/2019] [Indexed: 02/07/2023] Open
Abstract
Introduction Escherichia coli and Staphylococcus aureus are important causes of severe diseases like blood stream infections. This study comparatively assessed potential differences in their impact on disease severity in local and systemic infections. Methods Over a 5-year interval, patients in whom either E. coli or S. aureus was detected in superficial or primary sterile compartments were assessed for the primary endpoint death during hospital stay and the secondary endpoints duration of hospital stay and infectious disease as the main diagnosis. Results Significance was achieved for the impacts as follows: Superficial infection with S. aureus was associated with an odds ratio of 0.27 regarding the risk of death and of 1.42 regarding infectious disease as main diagnosis. Superficial infection with E. coli was associated with a reduced duration of hospital stay by –2.46 days and a reduced odds ratio of infectious diseases as main diagnosis of 0.04. The hospital stay of patients with E. coli was increased due to third-generation cephalosporin and ciprofloxacin resistance, and in the case of patients with S. aureus due to tetracycline and fusidic acid resistance. Conclusions Reduced disease severity of superficial infections due to both E. coli and S. aureus and resistance-driven prolonged stays in hospital were confirmed, while other outcome parameters were comparable.
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Affiliation(s)
- Hagen Frickmann
- Department of Microbiology and Hospital Hygiene, Bundeswehr Hospital Hamburg, Hamburg, Germany.,Institute for Medical Microbiology, Virology, and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Andreas Hahn
- Institute for Medical Microbiology, Virology, and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Stefan Berlec
- Institute for Medical Microbiology, Virology, and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Johannes Ulrich
- Institute for Medical Microbiology, Virology, and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Moritz Jansson
- Institute for Medical Microbiology, Virology, and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Norbert Georg Schwarz
- Infectious Disease Epidemiology, Bernhard Nocht Institute for Tropical Medicine Hamburg, Hamburg, Germany
| | - Philipp Warnke
- Institute for Medical Microbiology, Virology, and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Andreas Podbielski
- Institute for Medical Microbiology, Virology, and Hygiene, University Medicine Rostock, Rostock, Germany
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Lundin JG, McGann CL, Weise NK, Estrella LA, Balow RB, Streifel BC, Wynne JH. Iodine binding and release from antimicrobial hemostatic polymer foams. REACT FUNCT POLYM 2019. [DOI: 10.1016/j.reactfunctpolym.2018.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Resistant Gram-Negative Bacteria and Diagnostic Point-of-Care Options for the Field Setting during Military Operations. BIOMED RESEARCH INTERNATIONAL 2018; 2018:9395420. [PMID: 30009178 PMCID: PMC6020508 DOI: 10.1155/2018/9395420] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/07/2018] [Accepted: 05/20/2018] [Indexed: 12/16/2022]
Abstract
The spread of multidrug-resistant bacteria in resource-poor settings affects the military medical service in case of deployments of soldiers to war and crisis zones. Patients with war injuries are prone to colonization or infection with multidrug-resistant bacteria. Resistant Gram-negative bacteria play a dominant role in military wound infections. Problematic hygiene conditions on deployment facilitate exposition of soldiers with subsequent colonization. Although colonizing strains are frequently cleared from their hosts after returning from deployment, transmission to close contacts of the soldiers in the home country cannot be excluded and therapeutic options are reduced if colonization progresses to invasive infection. Since sophisticated culture-based diagnostic approaches are typically not available in the field setting on deployment, molecular rapid diagnostic test systems are an option for transmission control if the locally prevalent molecular resistance mechanisms are known. Efforts for global resistance surveillance can contribute to better understanding of resistance distribution and spread at deployment sites. This review summarizes experience of the military medical services with multidrug resistance on deployment and with the influx of resistant strains to the home country and discusses potential use of available molecular rapid test systems as an option for the field setting.
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31
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Kielmann M, Prior C, Senge MO. Porphyrins in troubled times: a spotlight on porphyrins and their metal complexes for explosives testing and CBRN defense. NEW J CHEM 2018. [DOI: 10.1039/c7nj04679k] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A critical perspective on (metallo)porphyrins in security-related applications: the past, present and future of explosives detection, CBRN defense, and beyond.
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Affiliation(s)
- Marc Kielmann
- School of Chemistry
- SFI Tetrapyrrole Laboratory
- Trinity Biomedical Sciences Institute
- Trinity College Dublin
- The University of Dublin
| | - Caroline Prior
- School of Chemistry
- SFI Tetrapyrrole Laboratory
- Trinity Biomedical Sciences Institute
- Trinity College Dublin
- The University of Dublin
| | - Mathias O. Senge
- Medicinal Chemistry
- Trinity Translational Medicine Institute
- Trinity Centre for Health Sciences
- Trinity College Dublin
- The University of Dublin
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Heitkamp RA, Li P, Mende K, Demons ST, Tribble DR, Tyner SD. Association of Enterococcus spp. with Severe Combat Extremity Injury, Intensive Care, and Polymicrobial Wound Infection. Surg Infect (Larchmt) 2017; 19:95-103. [PMID: 29261091 DOI: 10.1089/sur.2017.157] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Combat-related extremity wound infections can complicate the recovery of injured military personnel. The Enterococcus genus contains both commensal and pathogenic bacteria found in many combat wounds. We describe the patient population susceptible to Enterococcus infection, the characteristics of Enterococcus spp. isolated from combat-related wounds, and the microbiological profile of Enterococcus-positive wounds. METHODS Patient and culture data were obtained from the Trauma Infectious Disease Outcomes Study. Subjects were divided into a case group with enterococcal extremity wound infections and a comparator group with wound infections caused by other micro-organisms. RESULTS Case and comparator subjects had similar patterns of injury and infection. Case subjects had higher Injury Severity Scores (33 vs. 30; p < 0.001), longer hospitalization at U.S. facilities (55 vs. 40 days; p = 0.004), and required more large-volume blood transfusions (>20 units) within 24 h post-injury (53% vs. 30%; p < 0.001). Approximately 60% of case subjects had three or more infections, and 91% had one or more polymicrobial infections, compared with 43% and 50%, respectively, in the comparator group. The thigh was the most common site of Enterococcus spp. isolation, contributing 50% of isolates. Enterococcus faecium was the predominant species isolated from case-group infections overall (66%), as well as in polymicrobial infections (74%). Frequent co-colonizing microbes in polymicrobial wound infections with Enterococcus were other ESKAPE pathogens (64%) (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae [and Escherichia coli], Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.) and fungi (35%). CONCLUSIONS The specific pathogenicity of Enterococcus relative to other pathogens in polymicrobial wounds is unknown. Identifying strain-specific outcomes and investigating the interactions of Enterococcus strains with other wound pathogens could provide additional tools and strategies for infection mitigation in combat-related wounds.
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Affiliation(s)
- Rae A Heitkamp
- 1 Bacterial Diseases Branch, Walter Reed Army Institute of Research , Silver Spring, Maryland
| | - Ping Li
- 2 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,3 Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland
| | - Katrin Mende
- 2 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland.,3 Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, Maryland.,4 San Antonio Military Medical Center , Joint Base San Antonio, Fort Sam Houston, Texas
| | - Samandra T Demons
- 1 Bacterial Diseases Branch, Walter Reed Army Institute of Research , Silver Spring, Maryland
| | - David R Tribble
- 2 Infectious Disease Clinical Research Program, Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences , Bethesda, Maryland
| | - Stuart D Tyner
- 1 Bacterial Diseases Branch, Walter Reed Army Institute of Research , Silver Spring, Maryland
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