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Prevention of Infection and Antibiotic Use in the Management of Armed Conflict Injuries to the Extremities

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Armed Conflict Injuries to the Extremities

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Abstract

Despite the development of improved protective personal equipment, orthopedic injury patterns remained unchanged from World War I. Orthopedic trauma comprises the vast majority of war injuries, as 70% of casualties involve the musculoskeletal system and extremity injuries represent the most common type. Factors influencing the development of wound infections in a combat theater include wound type and severity, the presence of embedded foreign material, evacuation time from point of injury to medical care, initiation of antimicrobial agents, adequacy of initial wound debridement, immediate wound care, definitive surgical care, rehabilitative care, prior antimicrobial pressure, and the presence of nosocomial pathogens, especially multidrug resistant (MDR) pathogens at treatment facilities. With the possible exception of Acinetobacter baumannii–calcoaceticus complex (ABC), the bacteria infecting combat-related wounds in the past decade are similar to those described in wars of previous periods. The incidence of osteomyelitis in combat-related extremity injuries is between 2% and 15%. Early and aggressive management of extremity wounds starting with interventions near the battlefield have resulted in improved outcomes. The use of antibiotic prophylaxis in an attempt to diminish the rate of infective complications has been considered standard for the last 30 years. However, two major areas of controversies are the use of the best agent and the duration of prophylaxis. Despite its enormous contribution for the understanding and management of open fractures, the Gustilo and Anderson classification has also limitations and recent reviewed data support at least two important and practical conclusions: (1) a short course of first-generation cephalosporins, begun as soon as possible after injury, significantly lowers the risk of infection when used in combination with prompt, modern orthopedic fracture wound management; (2) there is insufficient evidence to support prolonged courses or repeated short courses of antibiotics, the use of antibiotic coverage to gram-negative bacilli or clostridial species, or the use of local antibiotic therapies such as beads. Guidelines recommend the early use of cefazolin or another intravenous first generation cephalosporin at Level I/IIa medical care in the combat zone for all extremity injuries (AII). At Level IV/V medical care, antibiotics should include those agents started earlier in the evacuation chain, but these should be stopped after 24–72 h if there is no evidence of infection upon evaluation of the wound. Level IV/V should be treating only infected wounds and using periprocedure antibiotics as part of routine care.

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  1. Rambam Health Care Campus, Israel Institute of Technology, 9602, Haifa, 31096, Israel

    Renato Finkelstein

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Correspondence to Renato Finkelstein .

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  1. Ziv Medical Center, Str. Rambam 1, Zefat, 13100, Israel

    Alexander Lerner

  2. Faculty of Medicine, Deptartment of Orthopaedic Surgery, Rambam Medical Center, Haaliyah Street 8, Haifa, 31096, Israel

    Michael Soudry

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Finkelstein, R. (2011). Prevention of Infection and Antibiotic Use in the Management of Armed Conflict Injuries to the Extremities. In: Lerner, A., Soudry, M. (eds) Armed Conflict Injuries to the Extremities. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-16155-1_10

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  • DOI: https://doi.org/10.1007/978-3-642-16155-1_10

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