Pre-Hospital Antibiotic Administration

The Israeli Defense Forces Point of Injury Antimicrobial Treatment Protocol - A New Protocol and Review of the Literature

INTRODUCTION

Combat wound infection is a common and serious complication, leading to significant morbidity and mortality. In 2005, a point of injury antimicrobial protocol was published by the Israel Defense Forces, in which Moxifloxacin was chosen. During 2016-2017, a revision of this protocol was performed and concluded with the publication of an updated protocol. The purpose of this report is to present this process and the revised protocol, together with a review of the literature.

METHODS

We searched "Medline" and "Google Scholar" for studies dealing with antimicrobial prophylaxis in trauma, for militaries' point of injury antimicrobial protocol protocols and for established surgical antimicrobial prophylaxis protocols.

RESULTS

Point of injury antimicrobial protocol is aimed at preventing early infection and its complications. The choice of Moxifloxacin for this purpose may not be optimal since Moxifloxacin spectrum might be overly broad, there is scant evidence supporting it for this indication, and the available preparation does not meet distinctive technical requirements. Contrarily, Ceftriaxone seemed to have suitable microbiological, pharmacological and technical features.

CONCLUSION

Point of injury antimicrobial protocol should be used especially when evacuation and definitive surgical treatment are delayed. According to present scientific data and operational needs, Ceftriaxone was chosen for most penetrating injuries, with Metronidazole addition for penetrating abdominal and cranial trauma.

For debate: on-the-person battlefield antibiotics

Wound infection has always been an important contributor to mortality and morbidity on the battlefield. On-the-person antibiotics have long been suggested as one way to help combat this, which have already been implemented by some North Atlantic Treaty Organization partners. This paper is an up-to-date review of the evidence of the efficacy of on-the-person antibiotics and whether the British military should look to use them in the near future.

Antibiotic Prophylaxis With Cefuroxime: Influence of Duration on Infection Rate With Staphylococcus aureus in a Contaminated Open Fracture Model

OBJECTIVES

The optimal duration of perioperative antibiotic prophylaxis (PAP) for open fractures remains controversial because of heterogeneous or unclear guidelines and highly variable prophylactic regimens in clinical practice. We aimed at testing different PAP durations under controlled conditions in a contaminated rabbit fracture model.

METHODS

A complete humeral osteotomy in 18 rabbits was fixed with a 7-hole locking compression plate and inoculated with Staphylococcus aureus. Cefuroxime was administered in a weight-adjusted dosage equivalent to human medicine (18.75 mg/kg). PAP was administered as a single shot only; for 24 hours; or for 72 hours in separate groups of rabbits (n = 6 per group). Infection was assessed after 2 weeks by quantitative bacteriological evaluation of the tissues and hardware.

RESULTS

Postoperative duration of PAP had a significant impact on the success of antibiotic prophylaxis in this model. Whereas the single-shot regimen completely failed to prevent infection, the 24-hour regimen showed a reduced infection rate (1 of 6 rabbits infected), but only the 72-hour course was able to prevent fracture-related infection in all animals in our model.

CONCLUSIONS

When contamination with high bacterial loads is likely (eg, in an open fracture situation), a 72-hour course of intravenous cefuroxime seems to be superior in preventing fracture-related infection in our rabbit model compared with a single-shot or 24-hour antibiotic regimen.

Field Wound Care: Prophylactic Antibiotics

Adequate management of wounds requires numerous interventions, one of which is the appropriate use of antimicrobials to attempt to minimize the risk of excess morbidity or mortality without increasing toxicity or multidrug resistant bacterial acquisition. There are numerous recommendations and opinions for not only the use of systemic prophylactic antimicrobials, but also the agent, dose, route, and duration. To best address the implementation of systemic antimicrobials in a field scenario, one must weigh the factors that go into that decision and then determine the best agents possible. The epidemiologic triangle (ie, the host, the agent, and the environment) forms the basis for selecting the correct prophylactic antibiotic for field wound care. Extreme conditions can be encountered in both military and nonmilitary systems, requiring a unique selection process to make the right antibiotic choice. A modifiable weighted matrix, recommended previously for point of injury combat casualty care, assists in selecting the best oral and intravenous/intramuscular agent based on the epidemiologic risk determination.

Infection and combat injuries

Blast and ballistic weapons used on the battlefield cause devastating injuries rarely seen outside armed conflict. These extremely high-energy injuries predominantly affect the limbs and are usually heavily contaminated with soil, foliage, clothing and even tissue from other casualties. Once life-threatening haemorrhage has been addressed, the military surgeon’s priority is to control infection.

Combining historical knowledge from previous conflicts with more recent experience has resulted in a systematic approach to these injuries. Urgent debridement of necrotic and severely contaminated tissue, irrigation and local and systemic antibiotics are the basis of management. These principles have resulted in successful healing of previously unsurvivable wounds. Healthy tissue must be retained for future reconstruction, vulnerable but viable tissue protected to allow survival and avascular tissue removed with all contamination.

While recent technological and scientific advances have offered some advantages, they must be judged in the context of a hard-won historical knowledge of these wounds. This approach is applicable to comparable civilian injury patterns. One of the few potential benefits of war is the associated improvement in our understanding of treating the severely injured; for this positive effect to be realised these experiences must be shared.

[The prehospital use of antibiotics in military operations]

War wounds usually show abundant devitalized tissue and often contain foreign material (environmental matter, shrapnels, and bullets). Thus, they are particularly prone to infection. Moreover, evacuation to a medical treatment facility and surgical debridement are often delayed due to tactical constraints. Thus, the early administration of an antibiotic on the ground in a prehospital setting seems justified to slow bacterial growth and the development of early infection. However, antibiotics are never a substitute for surgical treatment. The mix of microorganisms expected in war wounds is highly variable and determines the choice of the antibacterial agent. In a prehospital setting and in the absence of medical or paramedical personnel, the antibiotic must be administered orally (combat pill pack). In view of the antibacterial activity as well as pharmacokinetic and pharmaceutical properties, a combination of a fluoroquinolone active against Pseudomonas and a lincomycine with a high oral bioavailability at high doses seems to be a rational choice (ciprofloxacine 750 mg or alternatively levofloxacine 500 mg+clindamycine 600 mg tablets). If oral administration is excluded (unconsciousness, penetrating abdominal trauma, shock), the parenteral administration will be delayed until the patient has been taken in charge by medical or paramedical personnel. In that case, the intravenous administration of an association of an ureidopenicilline with antibacterial activity against Pseudomonas and a ß-lactamase-inhibitor at high doses could be a rational choice (piperacilline 4 g+tazobactam 0.5 g) (Tazocilline®). An antibiotic treatment beyond the time of surgery may become necessary in individual patients depending on the local features of the wound and should be prescribed by the medical officer in charge of the patient on a case-by-case basis.

Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society

Despite advances in resuscitation and surgical management of combat wounds, infection remains a concerning and potentially preventable complication of combat-related injuries. Interventions currently used to prevent these infections have not been either clearly defined or subjected to rigorous clinical trials. Current infection prevention measures and wound management practices are derived from retrospective review of wartime experiences, from civilian trauma data, and from in vitro and animal data. This update to the guidelines published in 2008 incorporates evidence that has become available since 2007. These guidelines focus on care provided within hours to days of injury, chiefly within the combat zone, to those combat-injured patients with open wounds or burns. New in this update are a consolidation of antimicrobial agent recommendations to a backbone of high-dose cefazolin with or without metronidazole for most postinjury indications, and recommendations for redosing of antimicrobial agents, for use of negative pressure wound therapy, and for oxygen supplementation in flight.

Critical care at Role 4

This descriptive paper focuses on the sequence of events that occur during the admission and ongoing management of the Military Polytrauma patient to Critical Care, Area B, Queen Elizabeth Hospital Birmingham (QEHB). It is intended to inform new clinical staff, the wider DMS, and potentially other NHS intensive care units which may be called upon to manage such patients during a military surge or following a U.K. domestic major incident.

Improvised explosive devices: pathophysiology, injury profiles and current medical management

The improvised explosive device (IED), in all its forms, has become the most significant threat to troops operating in Afghanistan and Iraq. These devices range from rudimentary home made explosives to sophisticated weapon systems containing high-grade explosives. Within this broad definition they may be classified as roadside explosives and blast mines, explosive formed pojectile (EFP) devices and suicide bombings. Each of these groups causeinjury through a number of different mechanisms and can result in vastly different injury profiles. The "Global War on Terror" has meant that incidents which were previously exclusively seen in conflict areas, can occur anywhere, and clinicians who are involved in emergency trauma care may be required to manage casualties from similar terrorist attacks. An understanding of the types of devices and their pathophysiological effects is necessary to allow proper planning of mass casualty events and to allow appropriate management of the complex poly-trauma casualties they invariably cause. The aim of this review article is to firstly describe the physics and injury profile from these different devices and secondly to present the current clinical evidence that underpins their medical management.

Infectious complications of combat-related mangled extremity injuries in the British military

BACKGROUND

During the wars in Iraq and Afghanistan, extremity injuries have predominated; however, no systematic review of field and stabilization care with subsequent infectious complications exists. This study evaluates the infectious complications and possible risk factors of British military casualties with mangled extremities, highlighting initial care and infections.

METHODS

This is a retrospective cohort study of British military casualties in Iraq and Afghanistan between August 2003 and May 2008. Casualties with mangled extremities undergoing limb salvage were evaluated for management strategies at the time of injury through evacuation back to the United Kingdom and subsequent infections.

RESULTS

There were 84 casualties with 85 extremities (20 infected and 65 uninfected). Infected extremities had more Gustilo Classification IIIb. There were no differences by Injury Severity Score, age, durations from injury to evacuation, or surgery, or arrival in England, use of clotting materials, or method of extremity stabilization between infected and uninfected extremity injuries. Tourniquet use in the field and fasciotomy were associated with infections. Antimicrobial coverage was associated with infections. Staphylococcus aureus were recovered later in casualties' clinical course in contrast to early recovery of Acinetobacter. On multivariate analysis, tourniquet in the field, antibiotics during evacuation and in the operating room, and fasciotomy were associated with infection as were certain bacteria, notably, Pseudomonas aeruginosa.

CONCLUSION

Infections occurred in 24% of those with mangled extremities including 6% with osteomyelitis. Certain procedures, likely reflective of injury severity, were associated with infections along with certain bacteria, P. aeruginosa and possibly S. aureus. Continued clarification is required for antimicrobial coverage (penicillin-based regimens vs. additional anaerobic coverage) and certain surgical procedures to improve casualty care.