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

Abstract

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.

Challenges and Opportunities in Reporting Trauma-Related Research: A Case Study from Syria

“…3 Injuries caused by shrapnel are polluted injuries and analysis of shrapnel injuries might give an opportunity to study the efficacy of antibiotics used in wound infection control and prophylaxis, especially because guidelines concerning the administration of antimicrobials for trauma infections were designed mostly based on studies in civilian settings. 4 The scarcity of the data constituted a barrier in extracting knowledge on the effect of antimicrobial drug use in the Syrian combat settings.…”

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

“…This finding concurs with previously published TIDOS analysis showing prophylaxis durations in excess of guideline recommendations. 14 Duration also varied between treatment groups with the EGN treatment group having a longer duration of use of narrow-spectrum antibiotics. However, while longer prophylaxis duration of narrow-spectrum antibiotics decreased SSTI risk, there was no effect on the risk of developing osteomyelitis with use of longer prophylaxis durations.…”

“…As previously described, 14,20 antibiotic usage was determined through prospective medical record review. Antibiotic prophylaxis regimens were classified as narrow or EGN for the analysis.…”

“…Specifically, the proportion of wounded military personnel with open fractures who received EGN coverage as part of post-traumatic antibiotic prophylaxis decreased from above 50% to less than 10% in 2013–2014. 14 This marked change in practice patterns allowed us to retrospectively evaluate infectious outcomes in patients with comparable injury severity who sustained open extremity fractures based on whether they did or did not receive EGN coverage (i.e., fluoroquinolones or aminoglycosides).…”

Antimicrobial Prophylaxis with Combat-Related Open Soft-Tissue Injuries

“…For example, approximately 20% of patients with open soft-tissue injuries received EGN coverage between 2009 and 2011. 10 The reason for this deviation from guideline recommendations is unclear, but it likely reflected concern for inoculation of Gram-negative bacteria in grossly contaminated wounds. Of note, use of EGN coverage was also common in other types of injuries.…”