Heather C. Yun
Intensivist and Infectious Disease Consultant, Craig Joint Theater Hospital, Bagram Air Field, Afghanistan, 2011
Clinton K. Murray
Senior Medical Officer, Medical Company, 1st Infantry Division, 1st Brigade Combat Team, 101st Forward Support Battalion, Ar Ramadi, Iraq, 2003–2004
ID/Infection Control Subject Matter Expert In-theater Review of Role 2 and 3 US, Coalition and Afghanistan National Facilities, CENTCOM, 2012
Team Leader, Graduate Medical Education Subject Matter Expert In-theater Consultant to Afghan National Army ID/Preventive Medicine Residency Training Program, CENTCOM, NATO Training Mission-Afghanistan (NTM-A), Kabul, Afghanistan, 2013
Expeditionary Surgical Assessment Team-Forward Surgical Team/Golden Hour Off-Set Treatment-Mission Review, Special Operations Command, Afghanistan, 2015
“Every operation in surgery is an experiment in bacteriology.”
Berkeley Moynihan (1865–1936)
BLUF Box (Bottom Line Up Front)
- 1.
Evacuate to surgical care as soon as possible.
- 2.
Aggressively debride wounds with the removal of all necrotic tissue and foreign bodies easily reached except in the eye, brain, and spine.
- 3.
Irrigate wounds until clean with normal saline or sterile water without additives under low pressure (less than 14 PSI).
- 4.
Deliver antibiotics within 3 h of injury; avoid overly broad spectrum antibiotics and minimize duration; antibiotic activity should reflect the most contaminated site; IV infusion of antibiotics is preferred.
- 5.
Give tetanus immunoglobulin and toxoid as appropriate.
- 6.
Obtain cultures only when there is clinical evidence of infection.
- 7.
Extremity wounds should undergo delayed primary closure; skin should not be closed if there is a colon injury or extensive devitalized tissue due to excessive infectious complications.
- 8.
If no evacuation at 3–5 days, consider closing wounds if no evidence of infection.
- 9.
Forward hospitals are breeding grounds for resistant bacteria. It is not the soil or the projectiles or the water; assume it is your facility! Standard infection control procedures reduce infection rates even in austere environments.
Introduction
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.
Prevention of Infection
Care at Point of Injury (Level I)
Initial care provided in the combat zone near or at the time of injury should emphasize the safety of the patient and the personnel caring for the patient, controlling hemorrhage, and stabilization of breathing and airway per TCCC guidelines (available online at http://www.naemt.org/education/TCCC/guidelines_curriculum). Wound care at this point consists of wound coverage with sterile bandage and stabilizing bony structures with rapid evacuation to a surgeon as soon as is feasible. If evacuation to surgical care is expected to be longer than 3 h, antibiotics should be provided to the casualty as soon as possible (Table 37.1). The selection of these agents is based on spectrum, ease of administration, stability, and storage limitations. These antibiotic recommendations are not applicable to patients who can be rapidly removed from the battlefield or to those who have reached care at established medical facilities such as a battalion aid station (BAS) or combat support hospitals (CSH) . Based on mission, oral moxifloxacin has been placed into some personal medical kits (the Improved First Aid Kit or IFAK; these also hold individual use items such as tourniquets, bandages, and pain medications) along with medic/corpsman medical kits.
Table 37.1
Antimicrobial therapy for the prevention of infection in combat-related trauma during the care of casualties under tactical situations when evacuation is expected to be delayed (>3 h), as suggested by the Tactical Combat Casualty Care Committee
Injury |
Preferred agent |
Alternate agent |
Duration |
---|---|---|---|
Point-of-injury/delayed evacuation
Expected delay to reach surgical care |
Moxifloxacin 400 mg PO × 1 dose. Ertapenem 1 g IV or IM if penetrating abdominal injury, shock, or unable to tolerate PO medications |
Levofloxacin 500 mg PO × 1 dose. Cefotetan 2 g IV or IM q12 h if penetrating abdominal injury, shock,
or unable to tolerate PO medications |
Single-dose therapy |
Professional Medical Care Without Surgical Support (Levels I and IIa)
Care at a BAS (level I) is typically provided by a physician assistant and/or a general medical officer with no patient-holding capability. Patients were evacuated from these facilities within 1–2 h of injury in Iraq, with slightly longer delays early during the conflict in Afghanistan. In 2009, a mandate for prehospital evacuation times of <60 min further reduced this to an average of 43 min in the years since. Although enhanced casualty care can be provided, the primary goal for most injuries is stabilization and evacuation to a surgeon within 6 h of injury. Primary wound management consists of hemostasis, wound irrigation, and removal of gross contamination. Wounds should be bandaged with a sterile dressing and underlying bony structures stabilized to prevent further injury. Antibiotics, typically intravenous, should be given within 3 h of injury (Table 37.2). The agent of choice should reflect the injury site requiring the broadest spectrum of bacterial activity, avoiding excessively broad empiric antimicrobial therapy. Tetanus immunoglobulin or toxoid should be given as indicated. It is acceptable to leave small, retained metal fragments in soft tissues; however, x-ray evaluation is necessary to adequately determine location and extent of injury.
Table 37.2
Selection and duration of antimicrobial therapy for the prevention of infection in combat-related trauma
Injury |
Preferred agent(s)
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