War Wounds

Question 1

What are the criteria to define a wound infection?

Answer 1

at least one of:

1. Patient has organisms cultured from tissue/drainage from affected site
2. patient has purulent drainage at affected site
3. patient has an abscess or other evidence of infection seen during an infasive procedure of histoplathologic examination
4. patient has 2+ signs/symptoms: tenderness, redness, pain, swelling, heat

Question 2

What is the general trend in appearance of bacteria in war wounds? How has our regiment of treatment affected this progression?

Answer 2

gram + appear first, then gram -.

However, as we give broad gram + antibiotics when they are first treated, we are now seeing less gram + and more gram - stuff after a few days. however within months, gram + stuff reappear.

Question 3

Why don’t we give broad gram + and gram - coverage right away?

Answer 3

RESISTANCE

Question 4

What is the major bug that we are now worried about in our returning soldiers?

Answer 4

Multidrug resistant acinetobacter baumannii-calcoaceticus infection: because it is in the OR tables, sinks, patient peds, heating units, tent walls. => worry about brining it back to the US and potentially seeing our civilian and military hospitals (nosocomial spread)

Question 5

If something doesn’t look infected… do you culture?

Answer 5

NO

Question 6

How do you treat against invasive fungi infections?

Answer 6

• continual debriement
• negative wound pressure
• repeat washouts!

Question 7

Emperic treatment of gram +? gram -? fungals?

Answer 7

Gram +: Meropenem (ertapenem, colistin)
Gram -: Vancomycin (daptomycin, linezolid)
Antifungals: liposomal amphotericin B, Voriconazole

ALWAYS SEND TISSUE/PUS FOR CULTURE => focus antibiotics on these results.

Question 8

What are some key infection prevention steps that can be done?

Answer 8

1. HAND WASHING (Not just the alcohol stuff)
2. ICU cleaning
3. Isolation procedures
4. cohorting
5. antibiotic control/stewarding