Antimicrobial Prescribing Practices Following Publication of Guidelines for the Prevention of Infections Associated With Combat-Related Injuries

Abstract

Background Timely and limited antibiotic prophylaxis (postinjury antimicrobial therapy) targeting specific traumatic injuries is a well-recognized measure to lessen posttraumatic infection. Modern military combat injuries raise significant challenges because of complex multiple injuries and limited data derived directly from well-controlled trials to base recommendations. Expert consensus review of available evidence led to published guidance for selection and duration of antimicrobial therapy for combat-related trauma infection prevention. This analysis evaluates antibiotic-prescribing practices by military physicians in the operational theater relative to the published guidance. Methods Trauma history and infectious disease-specific inpatient care information is captured through the Joint Theater Trauma Registry along with a supplemental infectious disease module. Injury patterns are classified based on documented International Classification of Diseases-9th Revision codes with a composite assessment of each patient’s injury pattern. Antimicrobial use categorized as prophylaxis is prescribed within the first 48 hours postinjury. Adherence to published guidance is reported along with patient characteristics and injury severity to assess for potential explanations of nonadherence. Results During June to November 2009, 75% of the 610 eligible trauma patients received antimicrobial prophylaxis. Adherence to the recommended antibiotic agent on the day of injury was in the range of 46% to 50% for the most common extremity injury patterns and 10% in penetrating abdominal injuries. Antibiotics were given in 39% of patients sustaining injuries that are recommendations to not receive antimicrobial prophylaxis. Conclusions This first evaluation of combat trauma-related antibiotic prophylaxis shows adherence levels comparable or superior to reported rates in civilian settings despite the austere, frequently mass casualty environment. Areas for interval surveillance and education-based strategies for improved adherence to practice guidance are identified.

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

“…15 Antimicrobial prescribing adherence was 64 to 79% for extremity injuries, 73% for maxillofacial soft-tissue injuries and/or fractures, and 10% for penetrating abdominal injuries requiring antibiotic prophylaxis. Compliance for closed injuries (required no antibiotic prophylaxis) was 52%.…”

“…As possible explanations for noncompliance, it was noted that the CPG only became available 6 months before the analysis, other published recommendations conflicted with the CPG’s guidance, and the study’s methodology (i.e., use of International Classification of Disease 9 th edition [ICD-9] injury code characterization) may not have been fully adequate to assess clinical decision making regarding antibiotic utilization. 15,16 We recommended further evaluation utilizing a larger sample size over a longer time period to improve precision. 15 …”

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

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

Modern Military Trauma

“…Moxifloxacin is available in oral form and has been shown to be very efficacious against a wide variety of gram positive and negative bacteria as well as anaerobic and aerobic bacteria [38,39]. This training has led to increased adherence with timely antibiotic administration reaching nearly 80 % [40]. Increased adherence has led to infection rates as low as 26.6 % including pneumonia [41].…”