Deployed antimicrobial stewardship: an audit of antimicrobial use at Role 3

Fletcher, Tom; Hutley, E; Adcock, Chris; Martin, Nathaniel I.; Wilson, David E.

doi:10.1136/jramc-2013-000116

Cited by 5 publications

(5 citation statements)

References 14 publications

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“…This discord was a reflection of not only disagreement in clinical practice between the JTS trauma team members, but also the controversy that existed in the civilian literature regarding the use of Gram-negative coverage in the setting of Type III open fractures. 1,2,16,22–25 The primary goal of the 2011 CPG and follow-on internal 2012 JTS guidance was to standardize care and reduce variability in practice in the fast moving and austere environment which complicates combat trauma care. 13,14 Overall, our analysis of antimicrobial usage patterns over a five-year period highlights an increasing trend toward compliance (in accordance with the 2011 published CPG) from 2009–2010 to 2013–2014.…”

Section: Discussionmentioning

confidence: 99%

“…Although not available in the United States, intravenous amoxicillin-clavulanate was the first-line choice for post-injury antimicrobial prophylaxis by the British military, in accordance with their published guidelines. 22 As a portion of wounded U.S. military personnel were treated by coalition forces in the combat zone, use of amoxicillin-clavulanate as a substitute for cefazolin and cefazolin/metronidazole (in the case of penetrating abdomen injury) was deemed to be compliant. Furthermore, use of vancomycin with any injury category was also not considered compliant.…”

Section: Methodsmentioning

confidence: 99%

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

et al. 2017

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In 2008, a clinical practice guideline (CPG) was developed for the prevention of infections among combat casualties and was later revised in 2011. We evaluated utilization of antimicrobials within 48 hours following injury in the combat zone over a five-year period (June 2009–May 2014) with regard to number of regimens, type of antimicrobial, and adherence to the 2011 CPG. The study population consisted of 5196 wounded military personnel. Open fractures and skin and soft-tissue injuries were the most frequent injuries. Closed injuries had the highest overall compliance (83%), while open fractures and maxillofacial injuries had significant improvement in compliance from 2009–2010 (34% and 50%, respectively) to 2013–2014 (73% and 76%; p<0.05). Part of the improvement with open fractures was a significant reduction of expanded Gram-negative coverage (61% received it in 2009–2010 compared to 7% in 2013–2014; p<0.001). Use of Gram-negative coverage with maxillofacial injuries also significantly declined (37% to 12%; p=0.001). Being injured during 2011–2014 compared to 2009–2010 was associated with CPG compliance (p<0.001), while high injury severity scores (≥10) and admission to the intensive care unit in Germany were associated with noncompliance (p<0.001). Our analysis demonstrates an increasing trend toward CPG compliance with significant reduction of expanded Gram-negative coverage.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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

et al. 2017

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“…Antibiotic resistance is one of the main problems of the team dealing with nosocomial infections [ 1 , 2 , 9 ].…”

Section: Discussionmentioning

confidence: 99%

“…There is a wide range of worrisome pathogens that are becoming resistant and many pathogens that may soon be untreatable. The decreasing effectiveness of antibiotics in treating common infections has quickened in recent years, and with the arrival of untreatable strains of carbapenem resistant Enterobacteriaceae , we are at the dawn of a postantibiotic era [ 1 , 2 , 3 ].…”

Section: Introductionmentioning

confidence: 99%

Antibiotic treatment and resistance in chronic wounds of vascular origin

Tzaneva

Mladenova

Todorova

et al. 2016

Medicine and Pharmacy Reports

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Background and aimThe problem of antibiotic resistance is worldwide and affects many types of pathogens. This phenomenon has been growing for decades and nowadays we are faced with a wide range of worrisome pathogens that are becoming resistant and many pathogens that may soon be untreatable. The aim of this study was to determine the resistance and antibiotic treatment in chronic wounds of vascular origin.MethodsWe performed a cross sectional study on a sample of patients with chronic vascular wounds, hospitalized between October 2014 and August 2015, in the Clinic of Vascular Surgery in Trakia Hospital Stara Zagora. The statistical analysis of data was descriptive, considering the p value of ≤0.05, the threshold of statistical significance.ResultsIn the group of 110 patients, the significantly most frequent chronic wound (p<0.001) was peripheral arteriopathy (47.3%, CI95%: 38.19–56.54). Among 159 strains, 30% of patients having multiple etiology, the species most frequently isolated were Staphylococcus aureus, E.coli, Enterococcus faecalis, Pseudomonas aeruginosa and Proteus mirabilis with a significant predominance (p<0.05) of the Gram negative (55.1%). The spectrum of strains resistance included the Beta-lactams (36.4%, p<0.001), Macrolides (20%), Tetracyclines (9.1%), Aminoglycosides (8.2%) and Fluoroquinolones (4.5%).ConclusionsGram negative microorganisms were the main isolates in patients with vascular chronic wound. Significantly predominant was the resistance to the beta-lactam antibiotics.

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“…This reflected the disagreement on the need for EGN coverage between the Joint Trauma System trauma team members and mirrored the controversy in the civilian trauma literature regarding the use of EGN post-trauma antibiotic prophylaxis in the management of Type III open fractures. 1,4,5,24–27 The 2011 CPG 12 (and follow-on internal 2012 Joint Trauma System guidance 13 ) standardized recommendations for Joint Trauma System trauma providers with the goal of reducing practice variability in the fast-moving and austere environment, which complicates combat trauma care.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2017

J Trauma Acute Care Surg

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Background We examined combat-related open extremity fracture infections as a function of whether post-trauma antimicrobial prophylaxis included expanded Gram-negative (EGN) coverage. Methods Military personnel with open extremity fractures sustained in Iraq and Afghanistan (2009–2014) who transferred to participating hospitals in the United States were assessed. The analysis was restricted to patients with a U.S. hospitalization period of ≥7 days. Prophylaxis was classified as narrow (e.g., IV cefazolin, clindamycin, or amoxicillin-clavulanate) or EGN, if the prophylactic regimen included fluoroquinolones and/or aminoglycosides. Results The study population included 1044 patients, of which 585 (56%) and 459 (44%) received narrow and EGN coverage, respectively (p<0.001). Skin and soft-tissue infections (SSTIs) were more common among patients who received narrow prophylaxis compared to EGN coverage (28% versus 22%; p=0.029), while osteomyelitis rates were comparable between regimens (8%). Similar findings were noted when endpoints were measured at two and four weeks post-injury. There was no significant difference related to length of hospitalization between narrow and EGN regimens (median: 34 and 32 days, respectively) or operation room visits (median: 5 and 4). A higher proportion of EGN coverage patients had Gram-negative organisms isolated that were not susceptible to fluoroquinolones and/or aminoglycosides (49% versus 40%; p<0.001). In a Cox proportional model, narrow prophylaxis was independently associated with an increased risk of extremity SSTIs (Hazard Ratio: 1.41; 95% confidence interval: 1.09–1.83). Discussion Despite seeing a small benefit with EGN coverage related to a reduction of SSTIs, it does not decrease the risk of osteomyelitis and there appears to be a cost of increased antibiotic resistance associated with use. Overall, our findings support the current post-combat trauma antibiotic prophylaxis guidelines, which recommend use of cefazolin or clindamycin with open fractures. Level of Evidence Prognostic/Epidemiological Level I

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Deployed antimicrobial stewardship: an audit of antimicrobial use at Role 3

Cited by 5 publications

References 14 publications

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

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

Antibiotic treatment and resistance in chronic wounds of vascular origin

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

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