Page 55 - JSOM Summer 2018

Prehospital Administration of Antibiotic Prophylaxis
for Open Combat Wounds in Afghanistan: 2013–2014

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Steven G. Schauer, DO, MS *; Andrew D. Fisher, MPAS, PA-C, LP ; Michael D. April, MD, PhD ;
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Katherine A. Stolper, DO ; Cord W. Cunningham, MD ; Robert Carter III, PhD, MPH ;
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Jessie Renee D. Fernandez, BS ; James A. Pfaff, MD 8
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ABSTRACT
Background: Military operations place injured Servicemem- dramatic increase in blast injuries, most commonly from im-
bers at high risk for open wounds. Austere environments and provised explosive devices (IEDs). These operations have had
initial wound contamination increase the risk for infection. the highest proportion of blast injuries seen in any large-scale
Wound infections continue to cause significant morbidity conflict. The current injury patterns for combat wounds in-
among injured Servicemembers. Limited evidence suggests clude head and neck (34%), thorax (6%), abdomen (11%),
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that early antibiotic therapy for open wounds reduces infec- and extremity (54%). The majority of combat wounds pri-
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tion rates. Methods: We obtained data from the Prehospital marily result in injury to the extremities. Blast mechanisms
Trauma Registry (PHTR) from January 2013 through Septem- often result in severe orthopedic injuries and open wounds.
ber 2014. This database includes data from Tactical Combat
Casualty Care (TCCC) cards, Department of Defense 1380 Studies of open tibial shaft fractures sustained during Opera-
forms, and after-action reports to provide near–real-time tion Iraqi Freedom and Operation Enduring Freedom found
feedback to units on prehospital medical care. We evaluated infection rates of 23% to 27%, with approximately 22% ulti-
whether patients with open wounds received antibiotics in ac- mately requiring amputation. In several studies, Staphylococ-
cordance with TCCC guidelines. Low adherence was defined cus aureus was the most common organism contributing to
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at less than 80%. Results: In this data set, overall, prefixed fa- recurrent infection. However, studies also have reported iso-
cility providers administered antibiotics to 54.0% of patients lation of multidrug resistant gram-negative organisms, notably
with an open combat wound. Of the antibiotics given, 11.1% Acinetobacter calcoaceticus-baumannii complex, Pseudomo-
were within TCCC guidelines. The relatively low administra- nas aeruginosa, and Klebsiella pneumoniae, from the wounds
tion and adherence rates persisted across subgroup analyses. of Operation Iraqi Freedom and Operation Enduring Freedom
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Conclusion: Overall, relatively few patients with open combat casualties. Although there was no association between injury
wounds receive antibiotic administration as recommended by severity and degree of bone loss in these studies, there was an
TCCC guidelines. In the group that received antibiotics, few association between infection and bone loss.
received the specific antibiotics recommended by TCCC guide-
lines. The development of strategies to improve adherence to It is common practice to give antibiotic prophylaxis to pa-
these TCCC recommendations is a research priority. tients with open fractures. Early prophylactic antibiotic ad-
ministration in contaminated orthopedic injuries is especially
Keywords: prehospital; antibiotics; wound; prophylaxis; com- important; clinical and preclinical models have shown reduced
bat; emergency; tactical; casualty infection rates and development of osteomyelitis with anti-
biotic administration within 3 hours compared with after 3
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hours. Limited evidence from military studies suggests that
early antibiotic administration for open combat wounds re-
Introduction
duces infection rates. 8,9
Battlefield wounds from blast and high-velocity projectiles are
often complex and heavily contaminated with soil, weapon Battlefield first responder (BFR) is the first phase of out-of-hos-
fragments, or debris from other casualties, placing them at pital care and encompasses a brief but high-impact phase of
high risk for infections. Wound infections continue to cause self-aid and buddy aid. All deploying Soldiers receive training
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significant morbidity in injured Servicemembers and is the in BFR before deployment and aid bags are equipped with all
leading cause for fracture nonunion and limb amputation. 2 the necessary equipment and medications to successfully fol-
low Tactical Combat Casualty Care (TCCC) guidelines for
The wound patterns and mechanisms currently seen in Op- the BFR stage. TCCC encompasses BFR and the entire gamut
eration Iraqi Freedom and Operation Enduring Freedom dif- of prehospital care in the tactical setting. The current TCCC
fer from those in prior conflicts, most notably because of the recommendations for antibiotic administration include 400mg
*Correspondence to 3698 Chambers Pass Road, Fort Sam Houston, TX 78234; or steven.g.schauer.mil@mail.mil.
1 MAJ Schauer is with the US Army Institute for Surgical Research and San Antonio Military Medical Center, Joint Base San Antonio, Fort Sam
Houston, TX. MAJ Fisher is with the 197th Special Troops Support Company (SO) (A), Camp Bullis, TX. MAJ April is with the San Antonio
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Military Medical Center. CPT Stolper is with the San Antonio Military Medical Center. LTC Cunningham is with the US Army Institute for
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Surgical Research. LTC Carter is with the US Army Institute for Surgical Research and Medical Simulation, Program Executive Office for Simu-
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lation, Training, and Instrumentation, Orlando, FL. Ms Fernandez is with the US Army Institute for Surgical Research. COL (Ret) Pfaff is with
the San Antonio Military Medical Center.
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