Field Wound Care: Prophylactic Antibiotics

Abstract

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.

Bacteriophages for Chronic Wound Treatment: From Traditional to Novel Delivery Systems

“…Many other systemic drugs (e.g., aspirin, flavonoids, thromboxane alpha-2 agonists, sulodexide) improve the wound environment [94][95][96][97]. However, caution in the use of this latter treatment is needed to evaluate if the benefits overcome their associated risks: antimicrobial resistance, allergic reactions, drug toxicities (cardiac, hepatic, renal, and hematopoietic), and drug interactions [98].…”

For debate: on-the-person battlefield antibiotics

“…There is difficulty identifying the best antimicrobial for POI use. Despite Gram-negative bacteria being predominate in infected combat wounds, studies have also shown Gram-positive infective wounds including methicillin-resistant Staphylococcus aureus 3 27 32 33. Therefore, a POI antibiotic cannot have purely Gram-negative activity.…”

“…Therefore, a POI antibiotic cannot have purely Gram-negative activity. Recent research has shown that the US military POI antibiotic, moxifloxacin, has poor P. aeruginosa cover and has actually resulted in increased drug resistance of Bacteroides sp 33–35. There is even some evidence to suggest that wound infections usually occur in patients while in hospital and not at POI.…”

“…Antibiotics may offer false assurance. Alexander Fleming stated during the Great War that ‘all the great success of primary wound treatment have been due to efficient surgery, and it seems a pity that the surgeon should wish to share his glory with a chemical antiseptic of more than doubtful utility.’35 During World War II, efficient debridement of wounds was replaced by an over-reliance of topical sulfanilamide powder in the US military, which led to increased infection rates and the need to re-educate healthcare professionals 33. The International Committee of the Red Cross, as recently as 2010, stated, ‘the best antibiotic is good surgery.’36 These observations have been supported by a small study comparing prophylactic antibiotic use and wound irrigation in US combat wounded in Iraq.…”

“…Finally, the added logistical burden needs to be addressed. The current cost of moxifloxacin is £1.65 per day33 and so is relatively low, however, this cost could be considerably more if the MOD was to choose a different, more effective antibiotic. The current stability of oral fluoroquinolones is 15–30° and so is unsuitable for some of the environments where the British military is currently working.…”