Adherence to Antimicrobial Prophylaxis

All facilities responsible for trauma care should monitor adherence to antimicrobial prophylaxis regimens.14 Special situation: care of combat injured secondary to suicide bomber/blast injury

Blast injuries, especially those related to suicide bomber attacks, present a unique bloodborne pathogen risk if an impaled body part is introduced into the trauma patient. There have been reported cases of Hepatitis B virus (HBV)-positive impaled bone fragments recovered from suicide bomber victims in Israel.15,16 This prompted the Israeli Ministry to provide post-exposure HBV vaccination as a practice. Since the initiation of the vaccine, HBV impaled fragments have been reported but no disease transmission.17

Prior to deployment, U.S. forces are required to receive a three-dose vaccine series, but 5-14% of vaccinated patients fail to achieve immunity (anti HBs <10 mlU/ml) which places them at increased risk of transmission.18,19 Thus we recommend attempting to verify anti-HBV status in those who are combat injured secondary to a suicide bomber and provide HBV immunoglobulin (HBIG) and HBV vaccine for those incompletely vaccinated with unknown titers or anti-HBs<10 mlU/ml. Recombinant Hepatitis B vaccine may be considered in those who have failed to respond to conventional Hepatitis B vaccine.

The risk of transmission for human immunodeficiency virus (HIV) is considered very low after blast injury and generally warrants no action.17 However, in the case of penetrating blast injury in a highly endemic region, expert teleconsultation should be obtained to discuss case specifics. Specific recommendations can be obtained via email (usarmy.jbsa.medcom-rhc-c.list.amedd-ic-consult@health.mil) or the AD.VI.S.OR hotline found at https://prolongedfieldcare.org/telemed-resources-for-us-mil/ or with infection prevention or infectious disease consultants (usarmy.jbsa.medcom-rhc-c.list.amedd-ic-consult@health.mil) or with infectious disease consultants through the AD.VI.S.OR hotline. Hepatitis C (HCV) prophylaxis is not recommended, but testing can be considered in penetrating blast injury at the time of injury and at two, four, and six months.20

- Healthcare Bloodborne Pathogen Exposure: Staff caring for patients with combat wounds are at risk for blood borne pathogens (HBV, HIV and HCV).20 At risk activities include security personnel searching patients (for example, patting down patients who are injection drug users, needle sticks, break in surgical technique and blood splatters to non-intact skin, eyes or mucosa).
- Source testing should be obtained for HBV, HIV and HCV: Testing for HBV and HIV should be obtained at time of exposure and up to six months post-exposure.21 There is no post-exposure treatment for HCV, although excellent and well-tolerated regimens to cure HCV do exist for patients who become infected.
  - For HBV, treatment is based on the source’s HBV surface antigen (HBsAg) status and the exposed patient’s vaccine completion and post-vaccine titer (anti-HBs >10 mlU/ml. Refer to the 2018 CDC Prevention of Hepatitis B virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices: A summary of the MMWR report.22
  - For high risk HIV exposure, 28 days of post-exposure prophylaxis with antiretroviral therapy should be administered within 1-2 hours but no later than 72 hours post-exposure. Refer to Updated S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for post-exposure prophylaxis.21