Page 107 - JSOM Spring 2023

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Appropriate Antibiotic Usage and prescribed today were discovered during this period. Since
Timing Are Essential the 1970s, very few new classes of antibiotics have been
found, and there are even fewer new antibiotics in clinical
Churchill observed that the use of topical sulfonamides did not trials. This comes when antibiotic resistance seems to be on
appear to offer any advantages for combat wounds that were the rise because of what Stuart B. Levy calls the “antibiotic
managed with early surgical attention. He also commented that paradox,” whereby the more antibiotics are used, the less ef-
penicillin is unnecessary for the routine treatment of “soft-part fective they become. Developing an effective strategy for the
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wounds,” but rather that it should be used for complicated continued development of novel antibiotics will be an import-
wounds or those with established infection. It is important to ant focus for both civilian and military medicine over the next
note that Churchill’s observations reflect the first widespread decade(s).
application of antibiotics in the combat setting. The most appro-
priate timing, dosing, and perioperative length of administration Anecdotally, ground medics do not always focus on using the
were all areas yet to be fully defined. During combat operations aseptic technique for procedures that are generally performed
throughout Operation Iraqi Freedom/Operation Enduring Free- in the hospital. Contaminated dressings or medical equipment
dom (OIF/OEF), these same issues would again require scrutiny. that has not been maintained in a sterile setting are sometimes
The complex wounding nature of improvised explosive devices used as a pragmatic solution. It has been suggested by some
(IEDs), as well as rapid evacuation with open wounds across the that cleanliness is difficult on the battlefield and unnecessary
theater toward Germany, posed the same challenges of observa- because “antibiotics will handle that.” Churchill dismissed
tion and review by the Joint Trauma System. these concepts with his careful and fastidious practice of at-
tention to wound care nearly 80 years ago in his manuscript.
It is also important to note that Churchill and fellow combat Medics need to hold each other accountable to ensure that
surgeons were not able to culture most wounds, nor was there appropriate technique is used in caring for their casualties.
recognition of the importance of identifying which bacterial Although antibiotics have helped prevent major infections,
organisms were responsible for the wound infection. The pro- proper aseptic—or, when appropriate, sterile—technique and
cess of bacterial culturing and associated identification of anti- appropriate wound management, including dressing changes
biotic efficacy against specific strains of organisms was still in and debridement in prolonged field-care situations, are main-
evolution. To this present day, the ability to accurately identify tained to prevent worse outcomes.
the causative organism of infection in a timely manner requires
a level of microbiologic support that is not readily available in
most forward locations (i.e., Role 2). Then and now, the un- Lest We Forget
guided application of broad-spectrum antibiotics may provide We have come out on the back side of the 20 years of con-
some degree of control of an ongoing wound infection but also flict. Antibiotic usage has been cemented into protocols by the
creates many secondary issues of bacterial resistance. Committee on Tactical Combat Casualty Care, and we are at a
time when the survival of war injuries is at an all-time high.
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Where Do We Go from Here? However, there is still room for growth. Medics need to con-
tinue to train for the next conflict, fight against complacency
Today, antibiotics are used everywhere, from the point of in- resulting from contemporary advances, and grow more vigi-
jury on the battlefield (as recommended by the Committee lant in the appropriate care of war wounds.
on Tactical Combat Casualty Care) to hospitals worldwide.
It is estimated that antibiotic usage in the United States saves (Authors’ note: The recent conflict in the Ukraine has dramat-
200,000 lives per year. At the time of the writing of the manu- ically emphasized this need to remember the past to prepare
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script by Churchill, antibiotic resistance was not widely recog- for the future. One author (JAJ) recently completed a brief
nized. Antibiotic resistance poses a significant health concern stint in the Ukraine and observed that basic wound care and
for treating infections today and in the future. It is estimated techniques there are much closer to those of WWII than to the
that 2.8 million Americans acquired infection by resistant mi- recent advances of OIF/OEF).
crobes—with 35,000 deaths— according to the CDC’s 2019
Antibiotic Resistance Threats report. It is easy to visualize an The authors encourage all military medics to continue to re-
impending post-antibiotic world. 9,10 turn to the basics and ensure that a foundation for consid-
eration of casualties include lessons learned from patients in
One of the authors (JAJ) was deployed at Bagram Air Base past wars so that future patients do not suffer the same conse-
and the Heathe N. Craig Theater Hospital during the final quences. Those privileged to care for those in harm’s way owe
year of operations. Over the almost 15 years of medical oper- it to their brothers and sisters in arms, for those who are still
ations at Craig Theater, the widespread and aggressive use of with us and those who are not. Lest we forget.
broad- spectrum antibiotics had resulted in the emergence of a
constantly evolving strain of multiply resistant Acinetobacter References
baumanii. During this final year, there were no effective anti- 1. Churchill ED. The surgical management of the wounded in the
biotic agents capable of controlling this CRAB (carbapenem- Mediterranean theater at the time of the fall of Rome. Ann Surg.
resistant Acinetobacter baumanii) organism (Johannigman JA, 1944;120(3):268–283.
personal record and communication as Deputy Commander 2. American Chemical Society International Historic Chemical Land-
of Clinical Services, Craig Theater Hospital, Bagram Air Base, marks. Discovery and Development of Penicillin. https://www.acs.
2021.). org/education/whatischemistry/landmarks/flemingpenicillin.html.
Accessed 13 February 2023.
3. Mailer JS Jr, Mason B. Penicillin: Medicine’s wartime wonder
Antibiotic discovery peaked during the “Golden Age” from drug and its production at Peoria, Illinois. https://www.lib.niu.edu/
the 1940s to 1960s. Many of the same antibiotics regularly 2001/iht810139.html. Accessed 13 February 2023.

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