Variation in Postinjury Antibiotic Prophylaxis Patterns Over Five Years in a Combat Zone

Abstract

In 2008, a clinical practice guideline (CPG) was developed for the prevention of infections among combat casualties and was later revised in 2011. We evaluated utilization of antimicrobials within 48 hours following injury in the combat zone over a 5-year period (June 2009 through May 2014) with regard to number of regimens, type of antimicrobial, and adherence to the 2011 CPG. The study population consisted of 5,196 wounded military personnel. Open fractures and skin and soft-tissue injuries were the most frequent injuries. Closed injuries had the highest overall compliance (83%), whereas open fractures and maxillofacial injuries had significant improvement in compliance from 2009-2010 (34 and 50%, respectively) to 2013-2014 (73 and 76%, respectively; p < 0.05). Part of the improvement with open fractures was a significant reduction of expanded Gram-negative coverage (61% received it in 2009-2010 compared to 7% in 2013-2014; p < 0.001). Use of Gram-negative coverage with maxillofacial injuries also significantly declined (37-12%; p = 0.001). Being injured during 2011-2014 compared to 2009-2010 was associated with CPG compliance (p < 0.001), while high injury severity scores (≥10) and admission to the intensive care unit in Germany were associated with noncompliance (p < 0.001). Our analysis demonstrates an increasing trend toward CPG compliance with significant reduction of expanded Gram-negative coverage.

Figure 1

Proportion of wounded military personnel who received expanded Gram-negative coverage by injury pattern. Each time period began in June and ended in May. Overall total patients who received expanded Gram-negative coverage per injury pattern was: open fractures = 703; skin and soft-tissue injuries = 175; closed = 18; and maxillofacial = 133. All injury patterns had significant difference in proportion across the study years with p-values of <0.001 for skin and soft-tissue injuries and open fractures, p=0.007 for closed injuries, and p=0.001 for maxillofacial injuries. The 2008 CPG did not recommend use of Gram-negative agents in open fractures of maxillofacial injuries. The 2010 JTS guidance document recommended use of Gram-negative agents in contaminated open fractures and some maxillofacial injuries. The 2011 CPG recommended against use of Gram-negative coverage in all injuries except for penetrating abdomen where cefazolin/metronidazole or ertapenem was recommended