Page 87 - JSOM Winter 2025

Antibiotics in Tactical Combat Casualty Care 2025

TCCC Change 25-1

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Piotr Wisniewski, MD *; Yusof A. J. Becker, MD ; Derek T. Larson, DO ;
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Jason M. Blaylock, MD ; Frank K. Butler, MD ; Robert J. Cybulski, PhD ; Travis G. Deaton, MD ;
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Kellye A. Donovan, PharmD, PhD ; Paul C. F. Graf, PhD ; Jacob R. King, PharmD ;
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Louis R. Lewandowski, MD ; Ryan C. Maves, MD ; Richard D. Neading ;
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Matthew K. O’Shea, MBChB, DPhil ; Roseanne A. Ressner, DO ; James D. Wallace, MD ;
Wells L. Weymouth, MD ; Clinton K. Murray, MD 17
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ABSTRACT
Tactical Combat Casualty Care (TCCC) guidelines have his- original TCCC guidelines due to its broad spectrum, low cost,
torically recommended antibiotics for combat wounds due to and ability to be delivered intravenously (IV), intraosseously
potential delays in evacuation and wound contamination. The (IO), or intramuscularly (IM). The antibiotics recommended
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currently recommended agents, moxifloxacin (oral) and ertap- in TCCC have been modified several times in the last three
enem (parenteral), have not been recently reviewed. This paper decades, and the currently recommended agents are moxiflox-
documents the findings of a multidisciplinary panel convened acin in casualties able to tolerate per os (PO) medications, and
in 2023 to re-evaluate TCCC antibiotic recommendations con- ertapenem if the IV, IO, or IM routes need to be used.
sidering current antibiotic options, emerging data regarding
multi-drug resistance (MDR), and evolving combat wound These two recommendations have not been recently reviewed
microbiology. The panel addressed four key questions through and need to be re-evaluated in light of the currently avail-
literature review and expert discussion: the optimal timing for able antibiotic options, the evolving microbiology of combat
antibiotic administration, whether recommendations change wounds, and emerging data regarding potential adverse effects
for invasive procedures, the inclusion of topical antibiotics, and due to the administration of moxifloxacin and ertapenem.
the need to update antibiotic choices. The review reaffirmed the
importance of early antibiotic administration, recommended The choice of antibiotics in TCCC should be based on their
antibiotic prophylaxis for any invasive procedure in the TCCC effectiveness across a broad range of potential bacterial patho-
setting, found insufficient evidence to recommend topical an- gens, the incidence and severity of side effects, environmental
tibiotics at this time, and proposed updates to the antibiotic stability, simplicity of dosing regimens, and overall cost. 3
choices based on factors like spectrum, side effects, stability,
dosing, and cost. The panel recommends changing the oral Background
antibiotic to cefadroxil (preferred) or cephalexin (alternative)
and the parenteral antibiotic to ceftriaxone. In light of these In 2023, as part of the regular review of Tactical Combat Ca-
changes in TCCC antibiotics, considerations should be made sualty Care (TCCC) guidelines by the Joint Trauma System
within Prolonged Casualty Care guidelines for the narrower and Committee on TCCC (CoTCCC), a multidisciplinary ad
spectrum of antibiotics and surveillance for unanticipated in- hoc panel was assembled to address questions on antibiotic
creases in specific injury patterns such as post-traumatic en- administration in TCCC. This panel included a mix of mili-
dophthalmitis, open fractures, or abdominal injuries. tary and civilian infectious diseases physicians, general/trauma
surgeons, orthopedic surgeons, emergency medicine physi-
Keywords: TCCC; antibiotics; infectious disease cians, independent duty corpsmen, medical logisticians, epi-
demiologists, microbiologists, and pharmacists. The CoTCCC
proposed a set of questions to guide literature review and dis-
cussion. This change paper is the result of the multidisciplinary
Proximate Reason for this Change
review process, taking into account the existing medical liter-
Antibiotics are not typically administered in the prehospital ature, projections of future armed conflicts and their potential
phase of care for civilian trauma patients. However, in tactical implications on combat wounds and infections, and the expert
combat settings, there may be delays of many hours in the opinions of the working group members.
evacuation of the casualty to a facility with surgical capabil-
ities, and combat wounds are often contaminated with soil Discussion
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or other foreign material by the wounding mechanism. Thus,
combat medical personnel must be prepared to administer an- The following four questions were suggested by the CoTCCC
tibiotics to their casualties. Cefoxitin was recommended in the for this review:

*Author affliations can be found on page 93.

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