War Wounds

Question 1

Definition of soft tissue wound infection

Answer 1

Must meet at least 1 of the following criteria:

• Organisms cultured from tissue/drainage site
• Purulent drainage
• Abscess or other evidence of infection
• At least 2 of the following:
  
  • Localized pain/tenderness
  • Redness
  • Swelling
  • Heat

Question 2

What 3 major organisms are found in the majority of wounds?

Answer 2

Acinetobacter

E. Coli

Pseudomonas

(Think “guerilla warfare”… gorilla = A.P.E)

Question 3

What happens to the type of bacteria that infect a wound as time goes on?

Answer 3

As the injury progresses, it goes from a gram (+) problem to a gram (-) one

Exception = recurrent MRSA infections

Question 4

What did widespread treatment of Acinetobacter do?

Answer 4

Lead to the development of multi-drug resistant strains

Question 5

Early lessons from Iraq

aka Microbiology take home points

Answer 5

• Organisms change over time
  
  • Gram (-) rods are the predominant problem
  • Appear to travel w/ wounded patients
  • Result in nosocomial spread
• No indication for pre/post procedure cultures
• If something doesn’t look infected, don’t culture it
• 30% of wounds become infected
  
  • 20% of these patients experience multiple repeat infections after discharge
• Recent appreciation for invasive fungal infections

Question 6

Comparative toxicities of antifungal agents (mainly Amphotericin B vs Fluconazole)

Answer 6

AmB is highly nephrotoxic

Flu is slightly hepatotoxic

Question 7

Recent trends in war wounds

Answer 7

• Atypical mycobacterial wound infections
  
  • requires months of triple drug therapy
  • all from blast patients during OEF (operation enduring freedom)
• Colistin resistant Acinetobacter
  
  • most strains have been sensitive to minocycline
  • fortunately, colistin-resistance acinetobacter are not very virulent

Question 8

Difference between OIF and OEF

Answer 8

Iraq:

hot, arid desert

blast injuries inside vehicles

acinetobacter largest concern

Afghanistan:

lush, heavy vegetation in some regions

blast injuries while walking

invasive fungal infections were significant concern

Question 9

Empiric Treatment Options when Wounds Appear Infected

Answer 9

Meropenem

Vancomycin

Antifungals

Always send tissue or pus for culture (swab is not as good); send tissue for histopathology if fungi are a concern

Question 10

Measures to prevent infection

Answer 10

• Adequate debridement
  
  • fluid lavage of open wounds
  • repeat washouts critical
• Negative Pressure Wound Therapy

Question 11

When to consult ID

Answer 11

• what you’re doing isn’t working
• renal problems or drug allergies limit selection of Abx
• you’re thinking of starting an Abx or Antifungal you’re not familiar with

Question 12

How did nosocomial spread of acinetobactor kill people?

Answer 12

Gave elderly people pneumonia