Page 88 - JSOM Winter 2025

• What is the best timing for antibiotic administration? fixation hardware after 14 days. In this study, administration
• Do antibiotic recommendations change if invasive proce- of antibiotics at 2 hours reduced the infection rate versus at
dures are performed? 6 and 24 hours, and reduced the harm with delaying surgery
• Should topical administration of antibiotics be included in from 2 to 6 to 24 hours. 7
TCCC?
• Do the antibiotic choices need to be updated? Finally, it is known that the time to antibiotic administration
in patients with sepsis is independently related to risk of pro-
Question 1: What is the best timing for antibiotic gression to septic shock. Whiles et al. conducted a retrospective
administration? cohort study in a large urban academic center. They found that
a. Background: Since the introduction of penicillin into battle- in their cohort of 3929 patients with severe sepsis and overall
field medicine in 1943, the utilization of antibiotics to treat mortality of 12.8%, those who progressed to septic shock had
wounds of war has been well established to reduce morbid- longer time to antibiotics versus those who did not (3.77 vs.
ity and mortality. Further, once infection has become well 2.76, P<.001). Additionally, each hour of delay in antibiotic
established in the patient or has involved necrotic or devi- administration has been associated with an 8% increase in risk
talized tissue, the impact of systemic antimicrobials is dras- of progression to septic shock. In summary, though we un-
8
tically reduced. Antibiotic administration is currently in- derstand that TCCC interventions are performed in a kinetic
4
cluded in TCCC guidelines as part of the MARCH PAWS* environment and delaying antibiotic administration presents a
framework, where MARCH represents initial stabilization possible ease of task saturation in this setting, the existing evi-
and the second “A” represents “antibiotics” after initial sta- dence suggests that such a delay would risk worsened casualty
bilization. Full review of this topic included whether the outcomes, including reduced survival.
emphasis on early antibiotic administration truly merited
its known logistical challenges in the TCCC setting, or if it c. Recommendation: Antibiotic prophylaxis should be admin-
can be deferred to consideration in the Prolonged Casualty istered as soon as practical following initial stabilization (in
Care (PCC) or Role-1 or 2 environments. line with current MARCH PAWS timing, no change).
b. Update: Early antibiotic administration has been a feature
of every previous iteration of the TCCC guidelines. This Question 2: Do antibiotic recommendations change if
practice was not based on controlled trials but rather on invasive procedures are performed?
pragmatic observations and expert opinion, later supported a. Background: Current TCCC guidelines only address an-
by various observational cohort studies. Given concurrent tibiotics for combat wounds but do not address planned
improvement in battle wound survivability achieved since or emergent invasive procedures (e.g., cricothyroidotomy,
the implementation of early antibiotic administration, we thoracostomy, etc.) in the TCCC setting.
sought to find any literature that would suggest either b. Update: Current CDC guidelines classify surgical wounds
harm or noninferiority of delayed antibiotics. No such lit- as “clean,” “clean-contaminated,” “contaminated,” or
erature was found. To the contrary, we reviewed data that “dirty.” Recent review articles have demonstrated infec-
suggested that early antibiotic administration does confer tion rates of 1%–5%, 3%–11%, 10%–27%, and >27%,
various benefits, including lower infection rates and lower respectively. 9,10 Antibiotic prophylaxis is typically recom-
mortality. Classen et al. examined the timing of antibi- mended in “clean-contaminated” wounds or higher. “Con-
otic administration in 2847 patients undergoing elective taminated” wounds involve a major break in sterile tech-
“clean” or “clean-contaminated” surgical procedures at a nique and, by extension, would include all trauma-related
single large community hospital. They found that preoper- wounds. As such, it seems reasonable that any invasive pro-
ative (<2 hours before incision) and perioperative (<3 hours cedure in the TCCC setting, even unrelated to direct com-
after incision) antibiotic administration had low risks of bat trauma, would be at least “contaminated” and warrant
surgical wound infections (0.6% preoperative; 1.4% peri- antibiotic prophylaxis. This also aligns with our goal for
operative). Meanwhile, post-operative (>3 hours and <24 simplicity in these guidelines: dermal penetration should
hours after incision) antibiotic administration resulted in lead to antibiotic administration.
surgical wound infections in 3.3% of patients (RR 5.8, c. Recommendation: Antibiotic prophylaxis for invasive pro-
P<.0001). In a retrospective review of the Department of cedures within TCCC should be administered as for any
5
Defense Trauma Registry, Karp et al. examined the effect penetrating wound.
of prehospital antibiotics in trauma patients in Iraq and
Afghanistan. Patients who received prehospital antibiot- Question 3: Should topical administration of antibiotics
ics had a small but statistically significant survival benefit be included in TCCC?
(97.4% vs. 96%, P<.001). 6 a. Background: There is no recommendation for topical anti-
biotics in the current TCCC guidelines. Furthermore, a
Although controlled studies are lacking, in vivo animal mod- formal examination of the evidence (or lack thereof) ad-
els support these observational findings. Penn-Barwell et al. dressing this question has not been included in prior change
investigated the relationship between the timing of antibiotic papers.
administration and surgery in a rat femur model infected with b. Update: Many recent papers have examined the use of topi-
Staphylococcus aureus. In their study, the authors introduced a cal antibiotics in preventing surgical infections in a hospital
standard defect to rat femurs and introduced a standard inoc- setting. In general, a theoretical benefit of topical antibiotic
ulum of S. aureus. They then administered cefazolin and per- use is the circumvention of needing intact circulation to
formed surgical debridement at 2, 6, and 24 hours. They then deliver antibiotics to the wound area, though many limita-
measured the presence and burden of bacteria in the bone and tions also exist.
*Massive Hemorrhage/MASCAL; Airway; Respirations; Circulation; Communications; Hypo/Hyperthermia & Head Injuries; Pain Control;
Antibiotics; Wounds (including Nursing and Burns); Splinting.

86 | JSOM Volume 25, Edition 4 / Winter 2025