scholarly journals 502. Klebsiella variicola Infections in Service Members Who Sustained Trauma in Iraq and Afghanistan

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S243-S244
Author(s):  
John L Kiley ◽  
Katrin Mende ◽  
Miriam Beckius ◽  
Susan Kaiser ◽  
M Leigh Carson ◽  
...  
Keyword(s):  
Injury Severity ◽  
Length Of Hospital Stay ◽  
Patient Characteristics ◽  
Invasive Disease ◽  
Multidrug Resistant ◽  
Trauma Patients ◽  
Disease Outcomes ◽  
Military Trauma ◽  
Pcr Targeting ◽  
Selection Of

Abstract Background Recent work has argued that genus Klebsiella is best divided into 3 clades: K. pneumoniae (Kp), K. quasipneumoniae (Kq), and K. variicola (Kv). Kv has drawn attention from reports of higher mortality and virulence. We evaluated a previously defined group of military trauma patients with Klebsiella infections for the presence of Kv, described clinical and isolate characteristics, and compared Kv and Kp groups. Methods All initial and serial (≥7 days from prior isolate) infecting Kp isolates (identified by clinical laboratories without the ability to speciate Kq and Kv) were collected from the Trauma Infectious Disease Outcomes Study (6/09–12/14). Additionally, a previously defined group of colonizing isolates linked to the infecting isolates and a selection of random colonizers were included from groin swabs. DNA extraction and PCR targeting Kv per published methods was performed. Antimicrobial susceptibilities were determined using the BD Phoenix Automated Microbiology System and CLSI criteria. Multidrug resistance was defined as either resistance to ≥3 classes of aminoglycosides, β-lactams, carbapenems and/or fluoroquinolones or production of ESBL or KPC. Results Of 237 archived Kp isolates (from 122 patients), 10 (4%) were identified as Kv by PCR (from 8 [7%] patients). The Kv sources were 4 from blood (40%), 1 intra-abdominal (10%) and 5 from groin (50%). Six (3%) isolates were identified as Kq (4 from groin and 2 from respiratory specimens). The Kv and Kp patients were all males, with a median age of 25 (IQR 21–46) and 23 (IQR 21–28), length of hospital stay of 24 days (IQR: 5–106) and 53 days (IQR 36–74), and Injury Severity Score of 21 (IQR: 10–50) and 38 (IQR: 30–45), respectively. There were no deaths in the Kv group compared with 4 with Kp. Infecting Kv isolates were more likely to be from blood compared with Kp (80% vs. 17%, P = 0.04). No infecting Kv isolates were multidrug-resistant compared with 70% of infecting Kp isolates (P < 0.01). Conclusion Kv represented 4% of the previously identified Kp isolates in this population. Patient characteristics were similar in both groups. While Kv was less resistant than Kp, it was more likely to be associated with invasive disease in this group. Disclosures All authors: No reported disclosures.

scholarly journals 1184. Resistance Patterns and Susceptibility Analysis of Klebsiella pneumoniae Infections in Service Members Who Sustained Trauma in Iraq and Afghanistan

2018 ◽  
Vol 5 (suppl_1) ◽  
pp. S357-S358
Author(s):  
John Kiley ◽  
Katrin Mende ◽  
Susan J Kaiser ◽  
Leigh Carson ◽  
Dan Z Lu ◽  
...  
Keyword(s):  
Klebsiella Pneumoniae ◽  
Common Species ◽  
Multidrug Resistant ◽  
Trauma Patients ◽  
Disease Outcomes ◽  
Antibiotic Susceptibilities ◽  
Military Trauma ◽  
Resistance Patterns ◽  
Outcomes Study ◽  
Susceptibility And Resistance

Abstract Background Klebsiella pneumoniae was the third most common species of multidrug-resistant (MDR) Gram-negative organism in military trauma patients injured in Iraq and Afghanistan (2009–2014). This study aims to characterize the antimicrobial susceptibility and resistance patterns of K. pneumoniae isolates in these patients. Methods All infecting K. pneumoniae isolates (IKpI) archived by the Trauma Infectious Disease Outcomes Study (TIDOS) and 96 colonizing isolates (CKpI) from groin swabs were included (6/09-12/14). All CKpI linked with IKpI were included; the remainder to total 50 MDR and 46 non-MDR CKpI were chosen randomly. Antimicrobial identification and susceptibilities were determined by CLSI criteria using the BD Phoenix Automated Microbiology System. 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 archived isolates, 237 isolates were included in the analysis (141 IKpI and 96 CKpI). IKpI sources were 40% wound, 22% respiratory, 20% blood, 9% urine, and 9% other. Antibiotic susceptibilities for IKpI were: cefazolin (CFZ) 20%, ceftriaxone 30%, levofloxacin 62%, piperacillin–tazobactam (PTZ) 41%, meropenem 96%, and amikacin 89%. MDR IKpI and CKpI were more likely to have had prior fluoroquinolone (82% vs. 18%, P &lt; 0.01) or anti-pseudomonal penicillin (53% vs. 47%, P &lt; 0.01) exposure. Seventeen patients had CKpI cultured at a median of 5 days (IQR 2–17) before a subsequent IKpI with 11 (65%) having MDR CKpI. All IKpI isolated after MDR CKpI were also MDR. Among IKpI recovered after non-MDR CKpI, new resistance was noted in 1 IKpI to gentamicin (200 days post-CKpI), 1 IKpI to ertapenem (7 days post-CKpI), two IKpI to CFZ (10 days and 17 days, respectively), and 1 IKpI to PTZ (19 days post-CKpI). Serial isolates of IKpI had similar MDR status (63% initial IKpI were MDR, whereas 76% of subsequent IKpI were MDR). Conclusion K. pneumoniae isolates in military trauma patients from Iraq and Afghanistan had challenging resistance patterns. Prior exposure to fluoroquinolones and anti-pseudomonal penicillins were associated with MDR K. pneumoniae isolation. MDR status of CKpI predicted subsequent IKpI MDR status. Disclosures All authors: No reported disclosures.

scholarly journals A retrospective cohort study of 27,049 polytraumatized patients age 60 and above: identifying changes over 16 years

2021 ◽  
Author(s):  
Y. Kalbas ◽  
M. Lempert ◽  
F. Ziegenhain ◽  
J. Scherer ◽  
V. Neuhaus ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Injury Severity ◽  
Descriptive Analysis ◽  
Patient Characteristics ◽  
Severe Trauma ◽  
Diagnostic Tools ◽  
Trauma Patients ◽  
Treatment Algorithms ◽  
Injured Patients ◽  
Over Time

Abstract Purpose The number of severely injured patients exceeding the age of 60 has shown a steep increase within the last decades. These patients present with numerous co-morbidities, polypharmacy, and increased frailty requiring an adjusted treatment approach. In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017. Methods A descriptive analysis of the data from the TraumaRegister DGU® (TR-DGU) was performed. Patients admitted to a level one trauma center in Germany, Austria and Switzerland between 2002 and 2017, aged 60 years or older and with an injury severity score (ISS) over 15 were included. Patients were stratified into subgroups based on the admission: 2002–2005 (1), 2006–2009 (2), 2010–2013 (3) and 2014–2017 (4). Trauma and patient characteristics, diagnostics, treatment and outcome were compared. Results In total 27,049 patients with an average age of 73.9 years met the inclusion criteria. The majority were males (64%), and the mean ISS was 27.4. The proportion of patients 60 years or older [(23% (1) to 40% (4)] rose considerably over time. Trauma mechanisms changed over time and more specifically low falls (< 3 m) rose from 17.6% (1) to 40.1% (4). Altered injury patterns were also identified. Length-of-stay decreased from 28.9 (1) to 19.5 days (4) and the length-of-stay on ICU decreased from 17.1 (1) to 12.7 days (4). Mortality decreased from 40.5% (1) to 31.8% (4). Conclusion Length of stay and mortality decreased despite an increase in patient age. We ascribe this observation mainly to increased use of diagnostic tools, improved treatment algorithms, and the implementation of specialized trauma centers for older patients allowing interdisciplinary care.

Does Alcohol Intoxication Protect Patients from Severe Injury and Reduce Hospital Mortality? The Association of Alcohol Consumption with the Severity of Injury and Survival in Trauma Patients

2013 ◽  
Vol 79 (12) ◽  
pp. 1289-1294 ◽  
Author(s):  
Chi-Hsun Hsieh ◽  
Li-Ting Su ◽  
Yu-Chun Wang ◽  
Chih-Yuan Fu ◽  
Hung-Chieh Lo ◽  
...  
Keyword(s):  
Alcohol Consumption ◽  
Hospital Stay ◽  
Brain Injuries ◽  
Injury Severity ◽  
Motor Vehicle ◽  
Length Of Hospital Stay ◽  
Trauma Patients ◽  
Prolonged Hospital Stay ◽  
Severe Injuries ◽  
Prolonged Hospital

Alcohol-related motor vehicle collisions are a major cause of mortality in trauma patients. This prospective observational study investigated the influence of antecedent alcohol use on outcomes in trauma patients who survived to reach the hospital. From 2005 to 2011, all patients who were older than 18 years and were admitted as a result of motor vehicle crashes were included. Blood alcohol concentration (BAC) was routinely measured for each patient on admission. Patients were divided into four groups based on their BAC level, which included nondrinking, BAC less than 100, BAC 100 to 200, and BAC 200 mg/dL or greater. Patient demographics, physical status and injury severity on admission, length of hospital stay, and outcome were compared between the groups. Odds ratios of having a severe injury, prolonged hospital stay, and mortality were estimated. Patients with a positive BAC had an increased risk of sustaining craniofacial and thoracoabdominal injuries. Odds ratios of having severe injuries (Injury Severity Score [ISS] 16 or greater) and a prolonged hospital stay were also increased. However, for those patients whose ISS was 16 or greater and who also had a brain injury, risk of fatality was significantly reduced if they were intoxicated (BAC 200 mg/dL or greater) before injury. Alcohol consumption does not protect patients from sustaining severe injuries nor does it shorten the length of hospital stay. However, there were potential survival benefits related to alcohol consumption for patients with brain injuries but not for those without brain injuries. Additional research is required to investigate the mechanism of this association further.

Clinical Characteristics of Trauma Patients Requiring Hydrocortisone Treatment for Refractory Hypotension

2017 ◽  
Vol 83 (8) ◽  
pp. 821-824
Author(s):  
Gina Kim ◽  
Jeffrey Young
Keyword(s):  
Hospital Mortality ◽  
Injury Severity ◽  
Traumatic Injury ◽  
Patient Characteristics ◽  
Data Repository ◽  
Trauma Patients ◽  
Lower Blood ◽  
Refractory Hypotension ◽  
The University ◽  
Stress Dose

Corticosteroids play an important role in responding to physiologic stress in the human body. However, its application in critical care remains heavily debated. The purpose of this study was to identify patient characteristics associated with receiving stress-dose steroids during the intensive care unit stay after traumatic injury and its effect on in-hospital mortality. Patients admitted to the University of Virginia trauma center between January 1, 2011, and December 31, 2015, were identified using our Trauma Registry. Stress dose steroids were defined as 100 mg IV hydrocortisone every eight hours. Patients who received stress-dose steroids were identified using the Clinical Data Repository. Patient characteristics associated with increased likelihood of receiving stress-dose steroids during admission were age >65, diabetes mellitus, congestive heart failure, burn injuries, Injury Severity Score >15, lower blood pressure (141/80 vs 125/76 mm Hg), and higher heart rate (87 vs 94/min). Patients who received stress-dose steroids were found to have increased mortality but not after controlling for the aforementioned patient factors associated with increased likelihood of receiving stress-dose steroids. The use of stress-dose steroids in critically ill patients with refractory hypotension does not appear to affect in-hospital mortality.

Management and Outcomes of Traumatic Colon Injury in Civilian and Military Patients

2011 ◽  
Vol 77 (12) ◽  
pp. 1685-1691 ◽  
Author(s):  
Chitra N. Sambasivan ◽  
Samantha J. Underwood ◽  
Reed B. Kuehn ◽  
S. D. Cho ◽  
Laszlo N. Kiraly ◽  
...  
Keyword(s):  
United States ◽  
Injury Severity ◽  
Primary Repair ◽  
Patient Characteristics ◽  
The United States ◽  
Trauma Patients ◽  
Colon Injury ◽  
Initial Management ◽  
Civilian Trauma ◽  
Level I

Divergent injury patterns may indicate the need for differing strategies in combat and civilian trauma patients. This study aims to compare outcomes of colon injury management in these two populations. Parallel retrospective reviews were conducted comparing warfighters (n = 59) injured downrange and subsequently transferred to the United States with civilians (n = 30) treated at a United States Level I trauma center. Patient characteristics, mechanisms of injury, treatment course, and complications were compared. The civilian (CP) and military (MP) populations did not differ in Injury Severity Score (MP 20 vs CP 26; P = 0.41). The MP experienced primarily blast injuries (51%) as opposed to blunt trauma (70%; P < 0.01) in the CP. The site of colon injury did not differ between groups ( P = 0.15). Initial management was via primary repair (53%) and resection and anastomosis (27%) in the CP versus colostomy creation (47%) and stapled ends (32%) in the MP ( P < 0.001). Ultimately, the CP and MP experienced equivalent continuity rates (90%). Overall complications (MP 68% vs CP 53%; P = 0.18) and mortality (MP 3% vs CP 3%; P = 0.99) did not differ between the two groups. The CP and MP experience different mechanisms and initial management of colon injury. Ultimately, continuity is restored in the majority of both populations.

scholarly journals 543. Biocide Resistance Genes in Klebsiella spp. Infections from Trauma Patients in Iraq and Afghanistan

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S259-S259
Author(s):  
John L Kiley ◽  
Dana M Blyth ◽  
Dana M Blyth ◽  
Miriam Beckius ◽  
Susan Kaiser ◽  
...  
Keyword(s):  
Resistance Genes ◽  
Efflux Pump ◽  
Multidrug Resistant ◽  
Trauma Patients ◽  
Biocide Resistance ◽  
Military Trauma ◽  
High Incidence ◽  
Integral Role ◽  
Rising Incidence ◽  
Klebsiella Spp

Abstract Background Biocides play an integral role in infection control. Paralleling concern about rising incidence of multidrug-resistant (MDR) organisms is a concern for resistance to biocides. In small studies, several genes involved in the production of efflux pump proteins have been identified as markers of biocide resistance in Klebsiella spp., namely cepA, qacA, qacE, qac∆E, and acrA. This study aimed to analyze the Klebsiella spp. isolates of a previously defined military trauma group with a high incidence of MDR organisms for the presence of these genes and their correlation with other resistance. Methods All infecting K. pneumoniae, K. variicola, and K. quasipneumoniae isolates archived by the Trauma Infectious Disease Outcomes Study (June 2009–December 2014) were selected. Additionally, all colonizing isolates linked with infecting isolates were included; the remainder to total 50 MDR and 46 non-MDR colonizing isolates were chosen randomly. Antimicrobial identification and susceptibilities were determined by CLSI criteria using the BD Phoenix Automated Microbiology System. PCR according to published methods for cepA, qacA, qacE, qac∆E, and acrA was accomplished in duplicate. 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 A total of 237 isolates (221 K. pneumoniae, 10 K. variicola, 6 K. quasipneumoniae) met inclusion criteria, of which 149 (63%) were MDR. All isolates had been exposed to antimicrobials prior to isolation. Of all isolates, 234 (98%) carried cepA: 218 (98%) K. pneumoniae carried cepA, 10 (100%) K. variicola carried cepA, and 6 (100%) of K. quasipneumoniae carried cepA. In addition, 148 (62%) isolates with cepA were MDR. One (10%) K. variicola isolate carried qacE along with cepA. This isolate was the only MDR K. variicola. None of the isolates carried qacA, qac∆E, or acrA. Conclusion We confirmed the near universal presence of the cepA biocide resistance gene in Klebsiella spp. isolated from trauma patients in Iraq and Afghanistan. In the largest evaluation of biocide resistance genes in Klebsiella spp. to our knowledge, the presence of qacA, qacE, qac∆E, and acrA was less common than has been reported elsewhere. Disclosures All authors: No reported disclosures.

scholarly journals Antifungal Resistance Patterns in Molds Isolated from Wounds of Combat-Related Trauma Patients

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S78-S79 ◽  
Author(s):  
Nicholas Keaton ◽  
Katrin Mende ◽  
Miriam Beckius ◽  
Aaron Farmer ◽  
Julie Rizzo ◽  
...  
Keyword(s):  
Fungal Infections ◽  
Medical Center ◽  
Trauma Patients ◽  
Broth Microdilution ◽  
Fusarium Spp ◽  
Post Injury ◽  
Disease Outcomes ◽  
Military Trauma ◽  
Resistance Patterns ◽  
Outcomes Study

Abstract Background An outbreak of trauma-related invasive fungal infections (IFI) occurred in US service members injured in Afghanistan. Empiric treatment included voriconazole (VORI) and amphotericin (AMB) and aggressive surgical debridement. Antifungal susceptibilities (AS) and relation to outcomes are yet to be described. Methods Between 2009 and 2013, military trauma patients with initial unique and serial (&gt;3 days after initial isolation) molds isolated from wounds and admitted to Brooke Army Medical Center as part of the Trauma Infectious Disease Outcomes Study were assessed. The AS to AMB, VORI, posaconazole (POSA), isavuconazole (ISA), itraconazole, and caspofungin were determined by broth microdilution with CLSI breakpoint interpretations for Aspergillus spp. and mucormycetes (MM). Results Included are 18 patients with 28 initial mold isolates with 72% of IFI diagnosed via histopathology. All patients were male with a median of eight operations. There was a median of 11 days post-injury to mold culture. Initial isolates were five Aspergillus spp., three MM, three Fusarium spp., and combinations of three Aspergillus and MM, two Aspergillus and Fusarium, one Aspergillus and Bipolaris, one MM and Fusarium. A. flavus (AFL) and A. fumigatus (AFU) were all susceptible to AMB and POSA and 25% of AFL were intermediate to VORI. Four A. terreus (AT) isolates had MICs to AMB of 0.25, 1, 2, and 4, and were susceptible to VORI. ISA MIC50 and 90 were one and two for Aspergillus spp. Fusarium spp. MICs were &gt;16 for VORI, POSA, and ISA, with AMB MIC50/90 of two and three. Among MM isolates, 86% were susceptible to AMB and 29% to POSA, and ISA MIC50 and MIC90 were 8 and &gt;16. Five patients had serial isolates. One with serial AFL and AFU received no antifungal therapy, one with AT was treated with VORI, AMB, and POSA, and one with AFL was treated with AMB with no new resistance. The patient with serial MM was treated with AMB and VORI and remained resistant to POSA, but susceptible to AMB. Serial A. elegans acquired new POSA and AMB resistance and ISA MIC increased from 4 to 16 after AMB and VORI exposure. Conclusion Antifungal exposure to AMB and VORI was not associated with new resistance within Aspergillus spp., but 50% of MM exposed to this combination developed POSA and AMB resistance. Despite resistance of Fusarium, it was not isolated on subsequent debridements. Disclosures All authors: No reported disclosures.

scholarly journals Trauma Embolic Scoring System in military trauma: a sensitive predictor of venous thromboembolism

2019 ◽  
Vol 4 (1) ◽  
pp. e000367 ◽  
Author(s):  
Patrick F Walker ◽  
Seth Schobel ◽  
Joseph D Caruso ◽  
Carlos J Rodriguez ◽  
Matthew J Bradley ◽  
...  
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Scoring System ◽  
Injury Severity ◽  
Univariate Analysis ◽  
Trauma Patients ◽  
Military Trauma ◽  
Support Tools ◽  
Combat Casualties

IntroductionClinical decision support tools capable of predicting which patients are at highest risk for venous thromboembolism (VTE) can assist in guiding surveillance and prophylaxis decisions. The Trauma Embolic Scoring System (TESS) has been shown to model VTE risk in civilian trauma patients. No such support tools have yet been described in combat casualties, who have a high incidence of VTE. The purpose of this study was to evaluate the utility of TESS in predicting VTE in military trauma patients.MethodsA retrospective cohort study of 549 combat casualties from October 2010 to November 2012 admitted to a military treatment facility in the USA was performed. TESS scores were calculated through data obtained from the Department of Defense Trauma Registry and chart reviews. Univariate analysis and multivariate logistic regression were performed to evaluate risk factors for VTE. Receiver operating characteristic (ROC) curve analysis of TESS in military trauma patients was also performed.ResultsThe incidence of VTE was 21.7% (119/549). The median TESS for patients without VTE was 8 (IQR 4–9), and the median TESS for those with VTE was 10 (IQR 9–11). On multivariate analysis, Injury Severity Score (ISS) (OR 1.03, p=0.007), ventilator days (OR 1.05, p=0.02), and administration of tranexamic acid (TXA) (OR 1.89, p=0.03) were found to be independent risk factors for development of VTE. On ROC analysis, an optimal high-risk cut-off value for TESS was ≥7 with a sensitivity of 0.92 and a specificity of 0.53 (area under the curve 0.76, 95% CI 0.72 to 0.80, p<0.0001).ConclusionsWhen used to predict VTE in military trauma, TESS shows moderate discrimination and is well calibrated. An optimal high-risk cut-off value of ≥7 demonstrates high sensitivity in predicting VTE. In addition to ISS and ventilator days, TXA administration is an independent risk factor for VTE development.Level of evidenceLevel III.

scholarly journals Resistance patterns and clinical outcomes of Klebsiella pneumoniae and invasive Klebsiella variicola in trauma patients

PLoS ONE ◽  
2021 ◽  
Vol 16 (8) ◽  
pp. e0255636
Author(s):  
John L. Kiley ◽  
Katrin Mende ◽  
Miriam L. Beckius ◽  
Susan J. Kaiser ◽  
M. Leigh Carson ◽  
...  
Keyword(s):  
Bloodstream Infections ◽  
Multidrug Resistant ◽  
Trauma Patients ◽  
Blast Injuries ◽  
Chain Reaction ◽  
Disease Outcomes ◽  
String Test ◽  
Resistance Patterns ◽  
Outcomes Study ◽  
Polymerase Chain

Recent reclassification of the Klebsiella genus to include Klebsiella variicola, and its association with bacteremia and mortality, has raised concerns. We examined Klebsiella spp. infections among battlefield trauma patients, including occurrence of invasive K. variicola disease. Klebsiella isolates collected from 51 wounded military personnel (2009–2014) through the Trauma Infectious Disease Outcomes Study were examined using polymerase chain reaction (PCR) and pulsed-field gel electrophoresis. K. variicola isolates were evaluated for hypermucoviscosity phenotype by the string test. Patients were severely injured, largely from blast injuries, and all received antibiotics prior to Klebsiella isolation. Multidrug-resistant Klebsiella isolates were identified in 23 (45%) patients; however, there were no significant differences when patients with and without multidrug-resistant Klebsiella were compared. A total of 237 isolates initially identified as K. pneumoniae were analyzed, with 141 clinical isolates associated with infections (remaining were colonizing isolates collected through surveillance groin swabs). Using PCR sequencing, 221 (93%) isolates were confirmed as K. pneumoniae, 10 (4%) were K. variicola, and 6 (3%) were K. quasipneumoniae. Five K. variicola isolates were associated with infections. Compared to K. pneumoniae, infecting K. variicola isolates were more likely to be from blood (4/5 versus 24/134, p = 0.04), and less likely to be multidrug-resistant (0/5 versus 99/134, p<0.01). No K. variicola isolates demonstrated the hypermucoviscosity phenotype. Although K. variicola isolates were frequently isolated from bloodstream infections, they were less likely to be multidrug-resistant. Further work is needed to facilitate diagnosis of K. variicola and clarify its clinical significance in larger prospective studies.

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