Page 78 - 2022 Spring JSOM

Efficacy of Vancomycin Powder in Mitigating Infection of

Open Penetrating Trauma Wounds on the Battlefield
An Evidence-Based Review

Brett R. TerBeek *; Paul E. Loos ; Timothy B. Pekari ; David J. Tennent, MD 4
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ABSTRACT
Background: Open penetrating trauma wounds to the extrem- environment. Several types of gram-positive bacteria are com-
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ities remain the most common injuries encountered in com- monly inoculated during this period and ultimately may lead
bat and are frequently complicated by bacterial infections. to infection. Special Operations Combat Medics are frequently
These infections place a heavy burden on the Servicemember confronted with austere conditions and greater wait times for
and the healthcare system as they often require multiple ad- medical evacuation. This results in time for these inoculated
ditional procedures and can frequently cause substantial de- pathogens to establish a more pervasive infection. When con-
bility. Previous studies have shown that vancomycin powder sidering future conflicts, near-peer wars will not have the lux-
has demonstrated efficacy in decreasing infection risks in clean ury of rapid evacuation times and prolonged field care may
and contaminated orthopedic surgical wounds. Methods: This be a reality. Current antibiotic administration guidelines for
review evaluates the most prevalent organisms cultured post- TCCC advises systemic delivery of oral broad-spectrum an-
trauma, the current Tactical Combat Casualty Care (TCCC) timicrobials or intravenous, if oral is not possible. This evi-
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guidelines for antibiotic prophylaxis, and relevant research of dence-based approach should not be changed.
vancomycin’s prophylactic use. Results: Results from previous
studies have shown a time-dependent reduction in bacterial Prophylactic, local, intrawound antibiotic administration has
load when vancomycin powder is introduced early post injury been studied and has demonstrated a reduction in infections
in traumatic orthopedic wounds. Furthermore, perioperative during orthopedic surgery. In post-amputation wound closure,
application affords a cost-effective method to prevent infection local application of vancomycin has demonstrated a reduction
with minimal adverse effects. Discussion: The current TCCC in deep tissue infections. Additionally, when post-wound in-
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guidelines advocate for the use of antibiotics at the point of fections do occur, they place a massive financial burden on the
injury. When vancomycin powder is used in synergy with these Department of Defense (DoD), in both additional treatment
guidelines, it can contribute a timely and powerful antibiotic expenses as well as in delayed return to duty. Locally-applied
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to prevent infection. Conclusion: The prophylactic use of van- vancomycin provides the benefit of high antibiotic concentra-
comycin powder is a promising adjunctive agent to current tion without the systemic toxicity found through high levels of
Clinical Practice Guidelines (CPG), but it cannot be conclu- intravenous (IV) vancomycin. Extrapolating this clinical use
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sively determined to be effective without further research into to the battlefield could offer the exact adjunctive, prophylactic
its application in traumatic combat wounds. agent that combat injuries require. Clinical use has demon-
strated reduced amputation revision surgeries and reduced
Keywords: vancomycin; trauma; combat; TCCC; prehospital; os- post-operative infection. The addition of point of injury
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teomyelitis; infection topical antibiotics may further enhance the already reduced
infection rates provided by the systemic antibiotic adminis-
tration in the TCCC guidelines. Many of these wounds are
associated with vascular injuries and may not have sufficient
Introduction
vascular flow to allow the systemic antibiotics to effectively
America’s wars in Iraq and Afghanistan have shown an in- treat bacterial wound contaminants. This evidence-based re-
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crease in survivable open extremity trauma wounds from var- view explores the efficacy of the prophylactic application of
ious mechanisms of injury. These injuries are most commonly vancomycin powder in mitigating infection from open-pene-
caused by improvised explosive devices (IEDs) or gunshot trating trauma wounds on the battlefield.
wounds. Extremities have historically been the most vulner-
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able to wounding and that still persist in today’s conflicts. An
issue plaguing the recovery of these Servicemembers is the oc- Methods
currence of wound site infections. These infections often lead PubMed was reviewed for clinical literature, using the follow-
to the development of deep tissue infections and osteomyelitis ing search terms, “vancomycin powder,” “combat trauma,”
resulting in morbidity and less frequent mortality. This dis- “infection,” “TCCC AND antibiotics,” “vancomycin AND
proportionately affects soldiers involved in dismounted blast orthopaedic AND surgery,” “bacteria AND combat AND
injuries. During the initial blast, penetrating trauma wounds trauma,” and “osteomyelitis.” This research also examined
are always contaminated with the aerosolized mire of the literature identifying the microbiology of trauma wounds
*Correspondence to brett.terbeek@gmail.com

1 Brett R. TerBeek is a physician assistant and former Special Forces Operations and intelligence sergeant affiliated with 1/25 SBCT, Fort Wain-
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wright, AK. Paul E. Loos is a Special Forces medical sergeant affiliated with 1st SFC(A), Fort Bragg, NC. Timothy B. Pekari is a physician
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assistant and Dr David J. Tennent is an orthopedic surgeon affiliated with Evans Army Community Hospital, Fort Carson, CO.
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