scholarly journals 449. Epidemiology of Combat-Related Deep Soft-Tissue Wound Infections

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S221-S221
Author(s):  
Laveta Stewart ◽  
Ping Li ◽  
Dana M Blyth ◽  
Dana M Blyth ◽  
Joseph Petfield ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Antibiotic Treatment ◽  
Injury Severity ◽  
Delayed Diagnosis ◽  
Multidrug Resistant ◽  
Military Hospital ◽  
Deep Soft Tissue ◽  
Post Injury ◽  
Empiric Antibiotic ◽  
Combat Casualties

Abstract Background Deep soft-tissue infections (DSTIs) are a common complication of combat-related extremity trauma. We present an epidemiologic assessment of combat-related DSTIs among wounded military personnel. Methods Wounded personnel were included in the analysis if they sustained an open combat-related extremity wound (2009–2014), were admitted to a participating US military hospital, had a DSTI as the first confirmed extremity wound infection (within 30 days post-injury), started antibiotics ±3 days of DSTI diagnosis, and received ≥5 days of directed antibiotic treatment. Results Among 1961 combat casualties with open extremity wounds, 259 had a DSTI diagnosis with 173 (67%) having only 1 index DSTI and 86 (33%) having >1 index DSTI diagnosed on the same day. Nearly all patients (95%) were injured via a blast mechanism. Patients with >1 index DSTI were more severely injured (median injury severity score: 35 vs. 33; P = 0.009) and required large volume blood transfusions within 24 hours of injury (median units: 23 vs. 17; P < 0.001). Initial empiric antibiotic treatment largely involved carbapenem and vancomycin (77% and 72% of patients, respectively). For diagnosis timing, 130 (50%) patients had an early DSTI diagnosis (≤7 days post-injury), while the remaining 129 (50%) patients had a delayed diagnosis (>7 days post-injury). Patients with early DSTI diagnoses more often had >1 index DSTI (47% vs. 19% with delayed DSTI; P < 0.001). Polymicrobial DSTIs were common (73% of early DSTIs; 58% of delayed DSTIs) with Enterococcus spp. most frequently identified (56% of early DSTIs; 31% of delayed DSTIs) as well as Enterobacter spp., Escherichia coli, Pseudomonas aeruginosa, and Acinetobacter spp. Moreover, 26% and 39% of early and delayed DSTIs had multidrug-resistant Gram-negative bacteria. Receipt of >20 units of blood within 24 hours of injury and having >1 index DSTI were independently associated with an early DSTI diagnosis (odds ratio [OR]: 3.21; 95% CI: 1.47–7.02 and OR: 2.98; 95% CI: 1.63–5.42, respectively). Conclusion Multiple index DSTIs and massive blood transfusion requirement are associated with early infection onset post-injury. Awareness of wound microbiology findings relative to DSTI onset provides guidance on empiric antimicrobial therapy. Disclosures All authors: No reported disclosures.

scholarly journals HMGB1 Inhibition to Ameliorate Organ Failure and Increase Survival in Trauma

2021 ◽  
Author(s):  
Zhangsheng Yang ◽  
Milomir O Simovic ◽  
Peter R Edsall ◽  
Bin Liu ◽  
Tomas S Cancio ◽  
...  
Keyword(s):  
Inflammatory Mediators ◽  
Plasma Levels ◽  
Injury Severity ◽  
Inflammatory Responses ◽  
High Mobility ◽  
Organ Damage ◽  
Blast Injury ◽  
Military Hospital ◽  
Remote Organ ◽  
Combat Casualties

Several preclinical and clinical reports have demonstrated that levels of circulating high mobility group box 1 protein (HMGB1) are increased early after trauma and are associated with systemic inflammation and clinical outcomes. However, the mechanisms of the interaction between HMGB1 and inflammatory mediators that lead to the development of remote organ damage after trauma remain obscure. HMGB1 and inflammatory mediators were analyzed in plasma from 54 combat casualties, collected on admission to a military hospital in Iraq, and at 8 and 24 hours after admission. Forty-five (83%) of these patients had traumatic brain injury (TBI). Nine healthy volunteers were enrolled as controls. HMGB1 plasma levels were significantly increased in the first 8 hours after admission, and were found to be associated with systemic inflammatory responses, injury severity score, and presence of TBI. These data provided the rationale for designing experiments in rats subjected to blast injury and hemorrhage, to explore the effect of HMGB1 inhibition by CX-01. Animals were cannulated, then recovered for 5-7 days before blast injury in a shock tube and volume-controlled hemorrhage. Blast injury and hemorrhage induced an early increase in HMGB1 plasma levels that coincided with severity of tissue damage and mortality. CX-01 inhibited systemic HMGB1 release, decreased local and systemic inflammatory responses, significantly reduced tissue and organ damage, and tended to increase survival. These data suggest that CX-01 has potential as an adjuvant treatment for traumatic hemorrhage.

scholarly journals HMGB1 Inhibition to Ameliorate Organ Failure and Increase Survival in Trauma

Biomolecules ◽  
2022 ◽  
Vol 12 (1) ◽  
pp. 101
Author(s):  
Zhangsheng Yang ◽  
Milomir O. Simovic ◽  
Peter R. Edsall ◽  
Bin Liu ◽  
Tomas S. Cancio ◽  
...  
Keyword(s):  
Inflammatory Mediators ◽  
Plasma Levels ◽  
Injury Severity ◽  
Inflammatory Responses ◽  
High Mobility ◽  
Organ Damage ◽  
Blast Injury ◽  
Military Hospital ◽  
Remote Organ ◽  
Combat Casualties

Several preclinical and clinical reports have demonstrated that levels of circulating high mobility group box 1 protein (HMGB1) are increased early after trauma and are associated with systemic inflammation and clinical outcomes. However, the mechanisms of the interaction between HMGB1 and inflammatory mediators that lead to the development of remote organ damage after trauma remain obscure. HMGB1 and inflammatory mediators were analyzed in plasma from 54 combat casualties, collected on admission to a military hospital in Iraq, and at 8 and 24 h after admission. In total, 45 (83%) of these patients had traumatic brain injury (TBI). Nine healthy volunteers were enrolled as controls. HMGB1 plasma levels were significantly increased in the first 8 h after admission, and were found to be associated with systemic inflammatory responses, injury severity score, and presence of TBI. These data provided the rationale for designing experiments in rats subjected to blast injury and hemorrhage, to explore the effect of HMGB1 inhibition by CX-01 (2-O, 3-O desulfated heparin). Animals were cannulated, then recovered for 5–7 days before blast injury in a shock tube and volume-controlled hemorrhage. Blast injury and hemorrhage induced an early increase in HMGB1 plasma levels that coincided with severity of tissue damage and mortality. CX-01 inhibited systemic HMGB1 activity, decreased local and systemic inflammatory responses, significantly reduced tissue and organ damage, and tended to increase survival. These data suggest that CX-01 has potential as an adjuvant treatment for traumatic hemorrhage.

scholarly journals Clinical Characteristics and Resistance Patterns of Pseudomonas aeruginosa Isolated From Combat Casualties

2021 ◽  
Author(s):  
Mary B Ford ◽  
Katrin Mende ◽  
Susan J Kaiser ◽  
Miriam L Beckius ◽  
Dan Lu ◽  
...  
Keyword(s):  
Pseudomonas Aeruginosa ◽  
Antimicrobial Susceptibility ◽  
Clinical Characteristics ◽  
Injury Severity ◽  
Multidrug Resistant ◽  
Severely Injured ◽  
Gram Negative ◽  
Resistance Patterns ◽  
Initial Hospitalization ◽  
Combat Casualties

ABSTRACT Introduction Multidrug-resistant (MDR) Gram-negative infections complicate care of combat casualties. We describe the clinical characteristics, resistance patterns, and outcomes of Pseudomonas aeruginosa infections in combat casualties. Methods Combat casualties included in the Trauma Infectious Disease Outcomes Study with infections with and without P. aeruginosa isolation during initial hospitalization were compared. Pseudomonas aeruginosa from initial wound, blood, and serial isolates (≥7 days from previous isolate) collected from June 2009 through February 2014 was subjected to antimicrobial susceptibility testing, pulsed-field gel electrophoresis, and whole genome sequencing for assessing clonality. Multidrug resistance was determined using the CDC National Healthcare Safety Network definition. Results Of 829 combat casualties with infections diagnosed during initial hospitalization, 143 (17%) had P. aeruginosa isolated. Those with P. aeruginosa were more severely injured (median Injury Severity Score 33 [interquartile range (IQR) 27-45] vs 30 [IQR 18.5-42]; P &lt; .001), had longer hospitalizations (median 58.5 [IQR 43-95] vs 38 [IQR 26-56] days; P &lt; .001), and higher mortality (6.9% vs 1.5%; P &lt; .001) than those with other organisms. Thirty-nine patients had serial P. aeruginosa isolation (median 2 subsequent isolates; IQR: 1-5), with decreasing antimicrobial susceptibility. Ten percent of P. aeruginosa isolates were MDR, associated with prior exposure to antipseudomonal antibiotics (P = .002), with amikacin and colistin remaining the most effective antimicrobials. Novel antimicrobials targeting MDR Gram-negative organisms were also examined, and 100% of the MDR P. aeruginosa isolates were resistant to imipenem/relabactam, while ceftazidime/avibactam and ceftolozane/tazobactam were active against 35% and 56% of the isolates, respectively. We identified two previously unrecognized P. aeruginosa outbreaks involving 13 patients. Conclusions Pseudomonas aeruginosa continues to be a major cause of morbidity, affecting severely injured combat casualties, with emergent antimicrobial resistance upon serial isolation. Among MDR P. aeruginosa, active antimicrobials remain the oldest and most toxic. Despite ongoing efforts, outbreaks are still noted, reinforcing the crucial role of antimicrobial stewardship and infection control.

scholarly journals 1198. Clinical Characteristics and Outcomes of Klebsiella pneumoniae Infections in Service Members Who Sustained Trauma in Iraq and Afghanistan

2018 ◽  
Vol 5 (suppl_1) ◽  
pp. S362-S363
Author(s):  
John Kiley ◽  
Katrin Mende ◽  
Susan J Kaiser ◽  
Leigh Carson ◽  
Dan Z Lu ◽  
...  
Keyword(s):  
Klebsiella Pneumoniae ◽  
Injury Severity ◽  
Common Species ◽  
Multidrug Resistant ◽  
Clinical Aspects ◽  
Trauma Patients ◽  
Combat Casualties ◽  
Improvised Explosive ◽  
Explosive Devices ◽  
Time From Injury

Abstract Background Klebsiella pneumoniae infections present a challenge to the clinician due to increasing resistance. K. pneumoniae was the third most common species of multidrug-resistant (MDR) Gram-negative organism in trauma patients sustaining injuries in Iraq and Afghanistan from 2009 to 2014. This study aims to elucidate the epidemiology of these infections by characterizing clinical aspects, risk for MDR infections, and outcomes. Methods All initial and serial (≥7 days from prior isolate) infecting K. pneumoniae isolates were collected from the Trauma Infectious Disease Outcomes Study (TIDOS) (6/09-12/14). Antimicrobial susceptibilities were determined using the BD Phoenix Automated Microbiology System and CLSI criteria. MDR was defined as either resistance to ≥3 classes of aminoglycosides, β-lactams, carbapenems and/or fluoroquinolones or production of an ESBL or KPC. Results Of 588 K. pneumoniae isolates in the TIDOS registry, 141 infecting isolates (98 initial) from 51 patients met inclusion criteria. Initial isolates were respiratory (31%), wound (25%), blood (20%), urine (10%), intra-abdominal (8%) and other (6%). All patients were male with a median age of 23 years (IQR 21–28). The majority of patients (82%) suffered blast injuries; of which, 88% were from improvised explosive devices. Patients had a median injury severity score (ISS) of 38 (IQR 30–45) and time from injury to first infecting K. pneumoniae isolate was 15 days (IQR 8–31). The median hospital stay was 49 days (IQR 28–70) and four patients died. All patients had received antibiotics prior to diagnosis. Twenty-three (46%) patients had initial isolates classified as MDR. There was no difference in age, ISS, or time from injury to first isolation among those who did and did not have initial MDR isolates. Sixteen patients had 64 serial isolates, of which 24 were wound, 20 respiratory, 14 blood and six urine. Three of these 16 patients died compared with 1 of 35 patients without serial isolates. Conclusion K. pneumoniae infections are common among combat casualties. Patients with K. pneumoniae infections were severely injured and almost half of initial infecting isolates were MDR, complicating treatment. Disclosures All authors: No reported disclosures.

scholarly journals Spread of community-acquired meticillin-resistant Staphylococcusaureus skin and soft-tissue infection within a family: implications forantibiotic therapy and prevention

2010 ◽  
Vol 59 (4) ◽  
pp. 489-492 ◽  
Author(s):  
N. H. Amir ◽  
A. S. Rossney ◽  
J. Veale ◽  
M. O'Connor ◽  
F. Fitzpatrick ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Antibiotic Treatment ◽  
Soft Tissue Infection ◽  
Clinical Presentation ◽  
Tissue Infection ◽  
Recurrent Infections ◽  
Family Cluster ◽  
Empiric Antibiotic ◽  
Empiric Antibiotic Treatment

Outbreaks or clusters of community-acquired meticillin-resistant Staphylococcusaureus (CA-MRSA) within families have been reported. We describea family cluster of CA-MRSA skin and soft-tissue infection where CA-MRSA wassuspected because of recurrent infections which failed to respond to flucloxacillin.While the prevalence of CA-MRSA is low worldwide, CA-MRSA should be consideredin certain circumstances depending on clinical presentation and risk assessment.Surveillance cultures of family contacts of patients with MRSA should be consideredto help establish the prevalence of CA-MRSA and to inform the optimal choiceof empiric antibiotic treatment.

scholarly journals Hand tumors: A review of 186 patients at a single institute

2021 ◽  
Vol 29 (1) ◽  
pp. 230949902199399
Author(s):  
Taketsugu Fujibuchi ◽  
Hiroshi Imai ◽  
Joji Miyawaki ◽  
Teruki Kidani ◽  
Hiroshi Kiyomatsu ◽  
...  
Keyword(s):  
Soft Tissue ◽  
Clinical Features ◽  
Malignant Tumors ◽  
Proximal Phalanx ◽  
Delayed Diagnosis ◽  
Ring Finger ◽  
Soft Tissue Tumors ◽  
Body Parts ◽  
Maximal Diameter ◽  
Benign Soft Tissue Tumors

Purpose: The spectrum of diagnoses and clinical features of hand tumors differ from those of tumors in other body parts. However, only a few reports have comprehensively referenced the diagnosis and clinical features of hand tumors. This study aimed to elucidate the diagnostic distribution and the clinical features of hand tumors undergone surgery in our institute. Patients and methods: A total of 235 lesions in 186 patients diagnosed with hand tumors between 1978 and 2020 were reviewed. Age at surgery, gender, chief complaint, tumor location, and pathological diagnosis were analyzed. Results: There were 121 benign bone tumors, 98 benign soft tissue tumors, and 16 malignant tumors. Chondroma and tenosynovial giant cell tumor were common benign bone and soft tissue tumors at the proximal phalanx of the ring finger and the palm, respectively. Meanwhile, chondrosarcoma and synovial sarcoma were common malignant tumors at the dorsal part of the hand. Local pain and painless mass were the chief complaints in patients with benign bone and soft tissue tumors, respectively. Most patients with malignant tumors were referred after unplanned resection. When patients were classified into two categories by tumor size according to maximal diameter, tumors larger than 19 mm had a significantly higher risk of malignant ( p = 0.031) despite being smaller than other tumors in different body parts. Conclusion: When a tumor malignancy is suspected, the patient should be referred to a specialist to avoid unplanned resection or delayed diagnosis due to misdiagnosis. Knowing the distribution and clinical features should help in diagnosing hand tumors.

scholarly journals Thalamic abscess in a patient with hereditary hemorrhagic telangiectasia successfully treated with an empiric antibiotic regime: case report and review of the literature

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Xavier A. Santander ◽  
Anwar Saab ◽  
Juan Manuel Revuelta-Barbero ◽  
Elena Múñez
Keyword(s):  
Antibiotic Treatment ◽  
Hereditary Hemorrhagic Telangiectasia ◽  
Diagnostic Yield ◽  
Neurological Complications ◽  
Clinical Aspects ◽  
Complete Disappearance ◽  
Empiric Antibiotic ◽  
Dominant Disease ◽  
Antibiotic Regime ◽  
Stereotaxic Biopsy

Abstract Background Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant disease associated with neurological complications, including cerebral abscesses (CA). They tend to be unique, supratentorial and lobar. While the surgical intervention is a rule of thumb when treating and diagnosing the etiology of these lesions, this is not always possible due to dangerous or inaccessible locations. We report the case of a patient solely treated with empiric antibiotics without stereotaxic intervention and satisfactory results. Case presentation We present the case of a 21-year-old patient with a right thalamic abscess due to HHT and pulmonary arteriovenous malformations, previously embolized, treated solely with antibiotics. At first, we contemplated the possibility of a stereotaxic biopsy, but the high-risk location and the fact that our patient received a previous full course of antibiotic treatment (in another center), made us discard this intervention because of the low diagnostic yield. We started an empiric antibiotic regime. We followed up very closely the clinical and radiological evaluation the next weeks, adjusting our antibiotic treatment when necessary. The results were favorable from both the radiological and clinical aspects and 6 months after the diagnosis the images show its almost complete disappearance. Conclusion Carefully tailored antibiotic-only regime and vigilance of its adverse effects and close radiological following is a good treatment approach when surgery is not an option.

scholarly journals Zebrafish Blunt-Force TBI Induces Heterogenous Injury Pathologies That Mimic Human TBI and Responds with Sonic Hedgehog-Dependent Cell Proliferation across the Neuroaxis

Biomedicines ◽  
2021 ◽  
Vol 9 (8) ◽  
pp. 861
Author(s):  
James Hentig ◽  
Kaylee Cloghessy ◽  
Manuela Lahne ◽  
Yoo Jin Jung ◽  
Rebecca A. Petersen ◽  
...  
Keyword(s):  
Cell Proliferation ◽  
Proliferative Response ◽  
Injury Severity ◽  
Granule Cell Layer ◽  
Dependent Manner ◽  
Adult Zebrafish ◽  
Post Injury ◽  
Blunt Force ◽  
Shh Pathway ◽  
Wide Range

Blunt-force traumatic brain injury (TBI) affects an increasing number of people worldwide as the range of injury severity and heterogeneity of injury pathologies have been recognized. Most current damage models utilize non-regenerative organisms, less common TBI mechanisms (penetrating, chemical, blast), and are limited in scalability of injury severity. We describe a scalable blunt-force TBI model that exhibits a wide range of human clinical pathologies and allows for the study of both injury pathology/progression and mechanisms of regenerative recovery. We modified the Marmarou weight drop model for adult zebrafish, which delivers a scalable injury spanning mild, moderate, and severe phenotypes. Following injury, zebrafish display a wide range of severity-dependent, injury-induced pathologies, including seizures, blood–brain barrier disruption, neuroinflammation, edema, vascular injury, decreased recovery rate, neuronal cell death, sensorimotor difficulties, and cognitive deficits. Injury-induced pathologies rapidly dissipate 4–7 days post-injury as robust cell proliferation is observed across the neuroaxis. In the cerebellum, proliferating nestin:GFP-positive cells originated from the cerebellar crest by 60 h post-injury, which then infiltrated into the granule cell layer and differentiated into neurons. Shh pathway genes increased in expression shortly following injury. Injection of the Shh agonist purmorphamine in undamaged fish induced a significant proliferative response, while the proliferative response was inhibited in injured fish treated with cyclopamine, a Shh antagonist. Collectively, these data demonstrate that a scalable blunt-force TBI to adult zebrafish results in many pathologies similar to human TBI, followed by recovery, and neuronal regeneration in a Shh-dependent manner.

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