Antibiotics / Infection

#### ANTIBIOTICS / INFECTION

Surv Ophthalmol. 2018 Sep - Oct;63(5):677-693. doi:10.1016/j.survophthal.2018.02.003. Epub 2018 Feb 15.

# Management of bacterial postoperative endophthalmitis and the role of vitrectomy.

Clarke B, Williamson T, Gini G, Gupta B

Management of postoperative bacterial endophthalmitis was explored in the Endophthalmitis Vitrectomy Study37 in 1995, which has underpinned the core protocols in treatment ever since. While surgical techniques have continued to evolve, little has changed in the overall clinical management as no further large randomized controlled trials have taken place. We review the literature addressing the incidence of endophthalmitis, pathogens, antibiotic therapies, and the role of vitrectomy. We suggest an update to management protocols based on available evidence. While vitreous culture remains the gold standard for diagnosis, new techniques allow bacterial identification after antibiotic administration, so injection should be initiated immediately. Current antibiotic regimes are comprehensive and do not need changing. Intravitreal antibiotics should not be repeated at 48 hours after initial treatment. Vitrectomy should be considered instead if the clinical picture is not improving.

J Spec Oper Med. Summer 2018;18(2):53-56.

# Prehospital administration of antibiotic prophylaxis for open combat wounds in Afghanistan 2013-2014.

Schauer SG, Fisher AD, April MD, Stolper KA, Cunningham CW, Carter R 3rd, Fernandez JRD, Pfaff JA.

BACKGROUND: Military operations place injured Servicemembers at high risk for open wounds. Austere environments and initial wound contamination increase the risk for infection. Wound infections continue to cause significant morbidity among injured Servicemembers. Limited evidence suggests that early antibiotic therapy for open wounds reduces infection rates.

METHODS: We obtained data from the Prehospital Trauma Registry (PHTR) from January 2013 through September 2014. This database includes data from Tactical Combat Casualty Care (TCCC) cards, Department of Defense 1380 forms, and after-action reports to provide near-real-time feedback to units on prehospital medical care. We evaluated whether patients with open wounds received antibiotics in accordance with TCCC guidelines. Low adherence was defined at less than 80%.

RESULTS: In this data set, overall, prefixed facility providers administered antibiotics to 54.0% of patients with an open combat wound. Of the antibiotics given, 11.1% were within TCCC guidelines. The relatively low administration and adherence rates persisted across subgroup analyses.

CONCLUSION: Overall, relatively few patients with open combat wounds receive antibiotic administration as recommended by TCCC guidelines. In the group that received antibiotics, few received the specific antibiotics recommended by TCCC guidelines. The development of strategies to improve adherence to these TCCC recommendations is a research priority.

Surg Infect (Larchmt). 2018 Apr;19(3):286-297

# Early infections complicating the care of combat casualties from Iraq and Afghanistan.

Weintrob A, Murray C, Xu J, Krauss M, Bradley W, Warkentien T, Lloyd B, Tribble D

BACKGROUND: During the conflicts in Iraq and Afghanistan, more than 52,000 U.S. military members were wounded in action. The battlefield mortality rate was lower than in past conflicts, however, those surviving often had complex soft tissue and bone injuries requiring multiple surgeries. This report describes the rates, types, and risks of infections complicating the care of combat casualties.

PATIENTS AND METHODS: Infection and microbiology data obtained from the Trauma Infectious Disease Outcomes Study (TIDOS), a prospective observational study of infections complicating deployment-related injuries, were used to determine the proportion of infection, types, and associated organisms. Injury and surgical information were collected from the Department of Defense Trauma Registry. Multivariable Cox proportional hazards and logistic regression models were used to evaluate potential factors associated with infection.

RESULTS: From 2009-2012, 1,807 combat casualties were evacuated to U.S. TIDOS-participating hospitals. Among the 1,807 patients, the proportion of overall infections from time of injury through initial U.S. hospitalization was 34% with half being skin, soft tissue, or bone infections. Infected wounds most commonly grew Enterococcus faecium, Pseudomonas aeruginosa, Acinetobacter spp. Or Escherichia coli. In the multivariable model, amputation, blood transfusions, intensive care unit admission, injury severity scores, mechanical ventilation, and mechanism of injury were associated with risk of infection.

CONCLUSIONS: One-third of combat casualties from Iraq and Afghanistan develop infections during their initial hospitalization. Amputations, blood transfusions, and overall injury severity are associated with risk of infection, whereas more easily modifiable factors such as early operative intervention or antibiotic administration are not.