Page 91 - JSOM Winter 2025

compared to cefadroxil and cephalexin, as well as retrospective study of the U.S. and U.K military Joint
higher cost. As a result of this in-depth comparison, we Theatre Trauma Registries between March 2003 and
recommend changing the oral antibiotic option from October 2011 that there had been 3,201 open globe
moxifloxacin to cefadroxil (preferred) or cephalexin injuries identified. Despite the prevalence of open
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(alternative). globe eye injuries seen in the recent Middle East con-
v. The results of our matrix for parenteral antibiotic op- flicts, however, Weichel and Colyer reported in 2008
tions resulted in a clear first-tier option in ceftriaxone that there had been no cases of endophthalmitis en-
with 35 points (see Table 4). The second-line option countered in U.S. casualties in Iraq and Afghanistan. 24
was cefazolin at 37 points. Ceftriaxone has clear ben- ix. The previous TCCC antibiotics, specifically the moxi-
efits over cefazolin in its once-daily dosing, broader floxacin, were selected with endophthalmitis preven-
Gram-negative coverage, and some limited anaerobic tion considered as a factor. 25,26 The lack of reported
coverage. This was considered both acceptably broad cases of endophthalmitis might be considered as ev-
while narrower than the previous recommendation idence of success for TCCC antibiotic prophylaxis;
of ertapenem (42 points in our matrix) from a stew- however, when one considers that Karp and her col-
ardship perspective. It also has excellent clinical expe- leagues found that only 13% of casualties with an
rience and tolerable side effect profiles, good supply indication for TCCC antibiotics actually received
chain reliability, and can be administered via IV, IM, them, and of those only 2.6% received moxifloxacin,
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and IO routes. As a result of this in-depth comparison, the benefit provided seems less certain. 6
we recommend changing the parenteral antibiotic op- x. However, consideration of systemic levofloxacin or
tion to ceftriaxone. moxifloxacin administration to casualties with open
vi. The previous antibiotic choices of moxifloxacin and globe injury in the PCC or Role2/3 context seems a
ertapenem have very low rates of life-threatening ana- prudent consideration.
phylactic reactions, with no such incidents reported c. Recommendation:
in Iraq and Afghanistan. A reasonable question is i. We recommend changing the oral antibiotic option
whether cephalosporins would increase the risk of from moxifloxacin to cefadroxil 1000mg once daily
anaphylaxis following these proposed changes, par- (preferred) or cephalexin 500mg orally four times a
ticularly in service members with documented peni- day (alternative).
cillin allergies. Most antibiotic recipients in Iraq and ii. We recommend changing the parenteral antibiotic op-
Afghanistan actually received cefazolin beyond the tion from ertapenem to ceftriaxone 2g intramuscularly/
care phase of TCCC (e.g., as peri-operative antibi- intravenously/intraosseously once daily.
otics for definitive surgery). A beta-lactam allergy is iii. To maintain simplicity and consistency among our up-
also side-chain specific. For example, cefadroxil and dates, we also recommend updating a related section
cephalexin share similar side chains with penicillin and regarding antibiotics for penetrating eye injury.
amoxicillin, making cross-reactivity possible, unlike
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ceftriaxone. However, penicillin allergy is frequently Summary
dubious, with studies showing that a very high per- This review reaffirmed the importance of early antibiotic
centage of individuals reporting penicillin allergy are administration and recommended antibiotic prophylaxis for
not actually allergic upon evaluation. Specifically, a any invasive procedure in the TCCC setting. Perhaps most
study among Marine recruits in San Diego found that impactfully, we have proposed changing the oral antibiotic to
out of 402 with self-reported penicillin allergies who cefadroxil (preferred) or cephalexin (alternative) and the par-
were included for amoxicillin challenge, only 5 (1.2%) enteral antibiotic to ceftriaxone.
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had an objective challenge reaction. Therefore, while
acknowledging potential allergy as a downside, we did Proposed Changes
not consider it a significant enough drawback to alter
these recommendations. Further investigations into Current wording (as of April 2025) in the TCCC Guidelines:
the validity and impact of charted penicillin allergies 9. Penetrating Eye Trauma
in the warfighter are needed with delisting as an ulti- a. If a penetrating eye injury is noted or suspected:
mate goal. • Perform a rapid field test of visual acuity and docu-
vii. A related issue is the intravitreal penetration of these ment findings.
antibiotics for penetrating eye injury in TCCC. A well- • Cover the eye with a rigid eye shield (NOT a pressure
known review by Brockhouse indicates that agents like patch).
meropenem, linezolid, and moxifloxacin achieve thera- • Ensure that the 400mg moxifloxacin tablet in the
peutic levels in the vitreous, while ceftriaxone reaches Combat Wound Medication Pack (CWMP) is taken
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levels justifying its use in specific situations. Another if possible and that IV/IO/IM antibiotics are given as
study by Sharir notes that ceftriaxone has been shown outlined below if oral moxifloxacin cannot be taken.
to penetrate the vitreous humor, even with intramuscu- 12. Antibiotics
lar (IM) administration. There are currently no studies a. Antibiotics recommended for all open combat
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examining the intravitreal penetration of oral cefadroxil wounds.
or cephalexin, though this represents an absence of evi- b. If able to take PO medications:
dence as opposed to evidence against their use. • Moxifloxacin (from the Combat Wound Medica-
viii. Bacterial endophthalmitis as a sequela to open globe tion Pack), 400mg PO once a day.
combat eye injuries was rare to absent among Ameri- c. If unable to take PO medications (shock,
can combat casualties during the wars in Iraq and unconsciousness):
Afghanistan. Breeze and colleagues reported in a • Ertapenem, 1g IV/IO/IM once a day.

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