Infections have complicated the care provided to those wounded in war throughout recorded history. During Operation Iraqi Freedom (OIF ) and Operation Enduring Freedom (OEF ), approximately one-third of casualties developed an infectious complication, and sepsis was the fourth most common cause of reversible mortality. Infectious risks associated with combat-related injuries include those from initial wound contamination and from nosocomial infections associated with long-term care. The latter often involve multiple drug-resistant bacteria (multidrug-resistant organisms (MDROs )) such as the gram-negative bacteria Acinetobacter baumannii (primarily associated with injury in Iraq), Pseudomonas aeruginosa , extended spectrum beta-lactamase-producing Escherichia coli and Klebsiella pneumoniae (commonly found after injury in Afghanistan), and the gram-positive bacteria methicillin-resistant Staphylococcus aureus (MRSA ). Invasive fungi also emerged in the Afghanistan theater of operations as a significant cause of wound infections.

The most comprehensive treatment strategies for managing combat-related injury infections can be found in the 2011 Guidelines for Prevention of Infections Associated with Combat Trauma. These were developed as an update to the earlier 2008 guidelines and were endorsed by the Surgical Infection Society and the Infectious Diseases Society of America. These highlight strategies for infection prevention with different injury patterns, with evidence-based weighting of recommendations. The suggestions provided in this chapter for preventing and treating combat-related infections are obtained from those guidelines along with current recommendations by the Tactical Combat Casualty Care (TCCC ) committee and published as Joint Theater Trauma System Clinical Practice Guidelines. Of note, the recommendations are not for managing nosocomial infections. In addition, it is vital to recognize the importance of infection control – even in a combat setting – and that it begins during the initial stages of stabilizing a patient. Overall, surgeons should aim to replicate standard US surgical care with dedicated operating rooms, good hand hygiene, wear of clean scrubs with hats and shoe covers in the OR, cohort of long-term vs rapidly evacuated patients, protocols for disinfection and/or sterilization of patient care equipment, and appropriate environmental cleaning.

The primary method to prevent the development of infection in penetrating trauma is rapid surgical evaluation and management without relying on antimicrobial therapy to “sterilize” the wound. This is a lesson that has been repeatedly relearned since antibiotics have been available on the battlefield. Treatment strategies vary by anatomical location; however, overall treatment strategies include an emphasis on irrigation, debridement, antimicrobial therapy, coverage of wounds, and stabilization of underlying bony structures. Other interventions of secondary importance include minimizing blood transfusion, controlling hyperglycemia, minimizing hypothermia, and providing adequate oxygenation. In addition, antibiotic stewardship/control programs should be put in place in the combat zone to limit duration and spectrum of antimicrobial agents. It is critical to get the entire hospital team involved in infection control measures and to understand that “appropriate” antibiotic use often means narrowing the coverage or stopping antibiotics altogether.