Infectious Complications After Battlefield Injuries: Epidemiology, Prevention, and Treatment
Purpose of Review
Recent conflicts have resulted in an unprecedented proportion of survivors of complex battlefield injuries. These patients are predisposed to infectious complications with multidrug-resistant organisms (MDROs). The epidemiology, prevention, and treatment of these infections are described, with emphasis on recent literature.
Data from the Trauma Infectious Disease Outcomes Study (TIDOS) cohort have revealed a 27% rate of infectious complications in those evacuated after traumatic injury; this increases to 50% in the intensive care unit. Acinetobacter baumannii-calcoaceticus was common in casualties injured in Iraq, but was replaced by other extended-spectrum beta-lactamase-producing Enterobacteriaceae as well as fungi in casualties from Afghanistan. Prevention of infections includes short courses of narrow-spectrum prophylactic antimicrobials and infection control; the mainstay of wound infection prevention is debridement and irrigation. Treatment of many infections is primarily surgical and antimicrobial therapy directed against expected and recovered pathogens.
Infections after combat trauma are common and complex, requiring a multidisciplinary approach to prevention and care.
KeywordsCombat trauma Military medicine Trauma Infection Infection prevention Drug-resistant organism
Compliance with Ethical Standards
Conflict of Interest
The authors declare no conflicts of interest and no funding source was used in the preparation of this manuscript.
The views expressed herein are those of the authors and do not reflect the official policy or position of Brooke Army Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Air Force, the Department of the Army, or the Department of Defense or the US Government.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 2.Centers for Disease C, Prevention. Acinetobacter baumannii infections among patients at military medical facilities treating injured U.S. service members, 2002–2004. MMWR Morb Mortal Wkly Rep. 2004;53(45):1063–6.Google Scholar
- 5.Whitman TJ, Qasba SS, Timpone JG, Babel BS, Kasper MR, English JF, et al. Occupational transmission of Acinetobacter baumannii from a United States serviceman wounded in Iraq to a health care worker. Clin Infect Dis Off Publ Infect Dis Soc Am. 2008;47(4):439–43. doi: 10.1086/589247.CrossRefGoogle Scholar
- 6.Keen EF 3rd, Mende K, Yun HC, Aldous WK, Wallum TE, Guymon CH, et al. Evaluation of potential environmental contamination sources for the presence of multidrug-resistant bacteria linked to wound infections in combat casualties. Infect Control Hosp Epidemiol Off J Soc Hosp Epidemiol Am. 2012;33(9):905–11. doi: 10.1086/667382.CrossRefGoogle Scholar
- 10.• Scott P, Deye G, Srinivasan A, Murray C, Moran K, Hulten E, et al. An outbreak of multidrug-resistant Acinetobacter baumannii-calcoaceticus complex infection in the US military health care system associated with military operations in Iraq. Clin Infect Dis Off Publ Infect Dis Soc Am. 2007;44(12):1577–84. doi: 10.1086/518170. Epidemiologic investigation demonstrating clonal spread of Acinetobacter across multiple military medical facilities. CrossRefGoogle Scholar
- 13.Sutter DE, Bradshaw LU, Simkins LH, Summers AM, Atha M, Elwood RL, et al. High incidence of multidrug-resistant gram-negative bacteria recovered from Afghan patients at a deployed US military hospital. Infect Control Hosp Epidemiol Off J Soc Hosp Epidemiol Am. 2011;32(9):854–60. doi: 10.1086/661284.CrossRefGoogle Scholar
- 17.Hospenthal DR, Crouch HK, English JF, Leach F, Pool J, Conger NG, et al. Multidrug-resistant bacterial colonization of combat-injured personnel at admission to medical centers after evacuation from Afghanistan and Iraq. J Trauma. 2011;71(1 Suppl):S52–7. doi: 10.1097/TA.0b013e31822118fb.CrossRefPubMedGoogle Scholar
- 19.• Warkentien T, Rodriguez C, Lloyd B, Wells J, Weintrob A, Dunne JR, et al. Invasive mold infections following combat-related injuries. Clin Inf Dis Off Publ Infect Dis Soc Am. 2012;55(11):1441–9. doi: 10.1093/cid/cis749. Initial description of emerging trend of invasive fungal infections in combat casualties evacuated from Afghanistan. CrossRefGoogle Scholar
- 20.Lloyd B, Weintrob AC, Rodriguez C, Dunne JR, Weisbrod AB, Hinkle M, et al. Effect of early screening for invasive fungal infections in U.S. service members with explosive blast injuries. Surg Infect. 2014; doi: 10.1089/sur.2012.245.
- 21.Rodriguez CJ, Weintrob AC, Shah J, Malone D, Dunne JR, Weisbrod AB, et al. Risk factors associated with invasive fungal infections in combat trauma. Surg Infect. 2014; doi: 10.1089/sur.2013.123.
- 22.•• Tribble DR, Conger NG, Fraser S, Gleeson TD, Wilkins K, Antonille T, et al. Infection-associated clinical outcomes in hospitalized medical evacuees after traumatic injury: trauma infectious disease outcome study. J Trauma. 2011;71(1 Suppl):S33–42. doi: 10.1097/TA.0b013e318221162e. Prospective observational study describing clinical infectious disease complications in combat casualties. CrossRefPubMedPubMedCentralGoogle Scholar
- 28.•• Hospenthal DR, Murray CK, Andersen RC, Bell RB, Calhoun JH, Cancio LC, et al. Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society. J Trauma. 2011;71(2 Suppl 2):S210–34. doi: 10.1097/TA.0b013e318227ac4b. Most recent guideline for preventing infections in combat casualties. CrossRefPubMedGoogle Scholar
- 29.•• Hospenthal DR, Murray CK, Andersen RC, Blice JP, Calhoun JH, Cancio LC, et al. Guidelines for the prevention of infection after combat-related injuries. J Trauma. 2008;64(3 Suppl):S211–20. doi: 10.1097/TA.0b013e318163c421. Seminal guideline for prevention of infection after combat injury. CrossRefPubMedGoogle Scholar
- 33.Weintrob AC, Weisbrod AB, Dunne JR, Rodriguez CJ, Malone D, Lloyd BA, et al. Combat trauma-associated invasive fungal wound infections: epidemiology and clinical classification. Epidemiol Infect. 2014:1–11. doi: 10.1017/S095026881400051X.
- 35.Yun HC, Murray CK. Infection prevention in the deployed environment. US Army Med Dep J. 2016;2–16:114–8.Google Scholar
- 36.• Landrum ML, Murray CK. Ventilator associated pneumonia in a military deployed setting: the impact of an aggressive infection control program. J Trauma. 2008;64(2 Suppl):S123–7. doi: 10.1097/TA.0b013e31816086dc. discussion S7–8. Description of success of basic infection prevention procedures in a deployed hospital. CrossRefPubMedGoogle Scholar
- 37.• Hospenthal DR, Green AD, Crouch HK, English JF, Pool J, Yun HC, et al. Infection prevention and control in deployed military medical treatment facilities. J Trauma. 2011;71(2 Suppl 2):S290–8. doi: 10.1097/TA.0b013e318227add8. Guideline for appropriate infection prevention in deployed hospitals. CrossRefPubMedGoogle Scholar
- 38.• Investigators F, Bhandari M, Jeray KJ, Petrisor BA, Devereaux PJ, Heels-Ansdell D, et al. A trial of wound irrigation in the initial management of open fracture wounds. N Engl J Med. 2015;373(27):2629–41. doi: 10.1056/NEJMoa1508502. Multicenter randomized controlled trial of wound irrigation using high, low, and very low pressure and with castile soap vs saline. CrossRefGoogle Scholar
- 40.• Weber D, Dulai SK, Bergman J, Buckley R, Beaupre LA. Time to initial operative treatment following open fracture does not impact development of deep infection: a prospective cohort study of 736 subjects. J Orthop Trauma. 2014;28(11):613–9. doi: 10.1097/BOT.0000000000000197. Prospective observational study demonstrating no association between time to debridement and infection. CrossRefPubMedGoogle Scholar
- 44.Joint Theater Trauma System Clinical Practice Guideline. Treatment of suspected invasive fungal infection in war wounds. 2012. http://www.usaisr.amedd.army.mil/assets/cpgs/Invasive_Fungal_Infection_in_War_Wounds_1_Nov_12.pdf. Accessed July 9 2014.
- 45.• Joint Theater Trauma System Clinical Practice Guideline. Invasive fungal infection in war wounds. 2016. Most recent guideline for preventing, diagnosing and treating IFI in combat casualties. http://www.usaisr.amedd.army.mil/cpgs/Invasive_Fungal_Infection_04_Aug_2016.pdf. Accessed 2 July 2017.
- 52.Joint Trauma System Clinical Practice Guideline. Frozen and deglycerolized red blood cells. 2016. http://www.usaisr.amedd.army.mil/assets/cpgs/Fresh_Whole_Blood_Transfusion_24_Oct_12.pdf. Accessed 2 July 2017.
- 53.Joint Theater Trauma System Clinical Practice Guideline. Fresh whole blood (fwb) transfusion. 2012. http://www.usaisr.amedd.army.mil/assets/cpgs/Fresh_Whole_Blood_Transfusion_24_Oct_12.pdf. Accessed July 9 2014.
- 59.Chang D, Garcia RA, Akers KS, Mende K, Murray CK, Wenke JC et al. Activity of gallium meso- and protoporphyrin IX against biofilms of multidrug-resistant Acinetobacter baumannii isolates. Pharmaceuticals (Basel). 2016;9(1). doi: 10.3390/ph9010016.
- 60.Wang Y, Wu X, Chen J, Amin R, Lu M, Bhayana B, et al. Antimicrobial blue light inactivation of gram-negative pathogens in biofilms: in vitro and in vivo studies. J Infect Dis. 2016;213(9):1380–7. doi: 10.1093/infdis/jiw070.
- 66.Blyth DM, Mende K, Weintrob AC, Beckius ML, Zera WC, Bradley W, et al. Resistance patterns and clinical significance of Candida colonization and infection in combat-related injured patients from Iraq and Afghanistan. Open Forum Infect Dis. 2014;1(3):ofu109. doi: 10.1093/ofid/ofu109.CrossRefPubMedPubMedCentralGoogle Scholar