Page 89 - JSOM Winter 2025

i. TerBeek et al. reviewed multiple articles regarding Question 4: Do the antibiotic choices need to
the use of vancomycin powder as an adjunct to usual be updated?
debridement and irrigation in preventing orthopedic a. Background:
surgical infections, although these were limited to rat i. Current guidelines recommend moxifloxacin 400mg
models and perioperative use in elective total hip re- orally once daily if the patient is conscious and able
placements in the civilian setting. While overall peri- to take oral medications, while ertapenem 1g parenter-
operative infections, particularly S. aureus infections, ally (intravenous/intraosseous/intramuscular) is recom-
were generally decreased, one study noted an increase mended otherwise. In a 2004 study of 49 soldiers in the
in polymicrobial and Gram-negative infections. It was second Iraq War with 61 open war wounds (primarily
concluded that, while promising, further research extremities) cultured near the time of injury, Murray
needed to be done, particularly regarding open, pene- et al. reported a predominance of gram- positive bac-
trating trauma in the battlefield setting, before vanco- teria isolates (93%, mostly skin commensals). Out of
mycin powder could be recommended as an adjunct to the 31 bacterial isolates, only 2 were drug-resistant
current TCCC antibiotic recommendations. 11 (both MRSA); none of the Gram-negative isolates were
ii. Wang et al. conducted a single-center retrospective co- multidrug-resistant. 14
hort study involving 243 patients with high-risk tibial ii. Keen et al. evaluated bacterial isolates at the point of
plateau fractures undergoing surgery and randomized definitive care in San Antonio at Brooke Army Medical
them 1:1 to preoperative IV cephalosporin and intra- Center in patients admitted from January 2001 to
wound vancomycin powder to preoperative IV ceph- December 2008, including and compared to patients
alosporin alone. There was a significant difference in who had deployed overseas to local military and civil-
fracture-related infection after 12 months of follow-up ian trauma patients. They found an increase in MDR
between the two groups (3.8% with intrawound Acinetobacter baumannii isolates (from 4% to 55%)
vancomycin powder vs. 10.9% in the control group; and MDR Pseudomonas aeruginosa isolates (from 2%
P=.041), and the number of gram-positive infections in to 8%) over the study period. Notably, there was a
the control group (12/14) was higher than the vanco- difference in isolation of MDR A. baumannii between
mycin group (1/4). This was limited by the study being patients who had been deployed overseas and local pa-
retrospective and single-center, and the patients receiv- tients (52% vs. 20%) but no difference between these
ing definitive surgery for a specific orthopedic injury in groups in MDR Pseudomonas aeruginosa isolation.
a hospital setting. 12 Also of note, 49% of the MDR A. baumannii isolates
iii. Waterbrook et al. reviewed four randomized trials were recovered from the respiratory tract but only
on the use of topical antibiotics alone versus placebo 24% from wounds. Some of this increase over time is
15
for acute, minor, uncomplicated soft tissue wounds likely related to nosocomial transmission, whether at
in the emergency department setting. In general, top- that facility or others along the way from the point of
ical antibiotics across the studies included bacitracin, injury in theater. While this is part of a global trend of
mupirocin, and a triple antibiotic ointment (bacitra- increasing antibiotic resistance, other factors may ex-
cin, neomycin, polymyxin B); placebo consisted of a plain this rising trend beyond the use of prophylactic
carrier ointment without antibiotics or was not speci- antibiotics (e.g., ertapenem) in TCCC.
fied. Infection rates in the placebo groups ranged from iii. Ljungquist et al. reported on bacterial infections in war
12%–17% versus 4%–5% in the various antibiotic wounds in patients admitted to hospitals in the war
groups and were statistically significant in each study, in Ukraine from February 2022 to September 2022.
suggesting a benefit to topical antibiotics in these mi- The included patients required ICU-level care or emer-
nor, uncomplicated wounds. However, there was no gency surgery. Sources of infection included soft tissue
difference between various topical antibiotics when from burns or wounds, as well as venous catheter tips
compared within each study. 13 and tracheobronchial aspirates in ventilated patients.
iv. Overall, it is difficult to extrapolate from these orthope- Of the 156 isolates from 141 patients, 133 were from
dic and emergency medicine studies to the combat en- adults with combat-related injuries. Of the isolates that
vironment and various types of combat wounds. There underwent antimicrobial resistance testing, 89/154
may be some benefit to certain forms of topical antibiot- (58%) were resistant to meropenem. Of those carbap-
ics in specific orthopedic or minor injuries. However, the enem-resistant isolates that underwent extended anti-
diagnostic reasoning and nuance required to effectively microbial resistance testing, 52/107 (49%) were also
discern when this would be appropriate likely exceeds resistant to cefiderocol and 10/107 (9%) resistant to
the scope of TCCC providers (e.g., all service members colistin. Of the 61 Enterobacterales and Pseudomonas
serving in combat). From a practical standpoint, the use aeruginosa isolates tested, >80% were resistant to ei-
of powders or creams in the TCCC environment also ther ceftazidime-avibactam, ceftolozane-tazobactam,
poses significant challenges, compared to the controlled, imipenem-relebactam, or meropenem-vaborbactam,
operating room or ED setting in which the available evi- with 9 Klebsiella pneumoniae isolates (6%) resistant
dence exists. As such, there is not enough evidence for to all tested antibiotics. 16
a blanket recommendation for the use of topical anti- iv. Granzer et al. had looked at the molecular epidemiology
biotics alone or as an adjunct in the TCCC guidelines. of carbapenem-resistant Acinetobacter baumannii iso-
However, we do note that this is a promising area of lates in patients injured in the previous Ukraine conflict
further research based on available data. that were treated at German Armed Forces hospitals in
c. Recommendation: No recommendation for inclusion of 2014-2015. They analyzed 32 carbapenem- and fluoro-
topical antibiotics alone or as an adjunct in this change pa- quinolone-resistant isolates from 21 patients and found
per. We support continued research for future consideration. that they represented only 4 major clonal clusters, but

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