Expert Commentary & Five-year View
Penetrating trauma, particularly HE injuries, are likely to increase in the future as military assault weapons are increasingly penetrating the civilian sector via the illegal narcotics trade, and terrorist bombings are becoming more commonplace. The actual cause of infection in penetrating trauma injury remains unclear but is likely multifactorial, to include impaired host immune response, the environment of the injury, mechanism of injury and anatomic location. A prospective trial is not feasible in military patients owing to dangerous conditions of injury but a trial examining infection pathogenesis and bacterial pathogen-specific outcomes by evaluating host immune response using modern genomic and proteomic molecular techniques would provide valuable information and could be carried out at a large academic trauma center.
Gram-positive organisms, for example, Streptococcus pyogenes and S. aureus, historically were major causes of morbidity and mortality following penetrating trauma in the pre-antibiotic era and remain initial pathogens for many infection types. As a result, prophylactic antibiotic regimens are mandatory during penetrating trauma surgical management and must prevent these organisms. While multidrug-resistant infections are clearly on the rise, the cause remains unclear. Surgical providers should be cognizant that infections in this population are inevitable, and numerous studies prove the use of broader spectrum agents or prolonging prophylactic therapy does not further mitigate infection risk. Unfortunately, prophylactic antibiotic use asserts selective pressure on host and hospital flora, leading to resistance. An excellent example is the recent demonstration of substantially higher ampicillin/sulbactam resistance in a center where abdominal trauma patients repeatedly received ampicillin/sulbactam. Utilizing practice guidelines will help minimize this phenomenon. Over time, we may see first-generation cephalosporins lose their prophylactic effect in traumatic injury. Novel nonantibiotic approaches such as immunoaugmentation with antibodies, or limiting antimicrobials to topical applications might reduce selective pressure to develop antibiotic resistance in the host microbiome that is currently thought to be caused by perioperative agents.
Duration of prophylactic antibiotic therapy remains problematic. There are few quality studies comparing duration to any objective measures of infection. Prospective randomized trials to find the best prophylactic agent and duration to reduce penetrating injury infections of all the areas we examined (CNS, maxillofacial, thorax, abdomen and orthopedic) are desperately needed and could easily be performed at large trauma centers. Trials optimizing timing of antibiotic administration with regard to known antimicrobial pharmacokinetic/pharmacodynamic properties (e.g., prolonging infusion times of β-lactams to reduce bacterial resistance) should also assist in improving outcomes in penetrating traumatic infections, which are increasingly antibiotic resistant.
In summary, large advances in morbidity and mortality have been achieved by coupling antimicrobial therapy with aggressive surgical management following penetrating traumatic injury, however, many exciting opportunities exist for providers in the field to improve care and outcomes for patients suffering these terrible injuries.
The authors would like to thank Diana Temple for her assistance in preparation of the manuscript.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
Expert Rev Anti Infect Ther. 2011;9(1):81-96. © 2011 Expert Reviews Ltd.
Cite this: Prophylaxis and Treatment of Infections Associated with Penetrating Traumatic Injury - Medscape - Jan 01, 2011.