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. 2017 Apr;18(3):357-367.
doi: 10.1089/sur.2017.002. Epub 2017 Feb 24.

Multi-Drug-Resistant Gram-Negative Infections in Deployment-Related Trauma Patients

Wesley R Campbell  1 , Ping Li  2   3 , Timothy J Whitman  4 , Dana M Blyth  5 , Elizabeth R Schnaubelt  6 , Katrin Mende  2   3   5 , David R Tribble  2
Affiliations

Multi-Drug-Resistant Gram-Negative Infections in Deployment-Related Trauma Patients

Wesley R Campbell et al. Surg Infect (Larchmt). 2017 Apr.

Abstract

Background: The contribution of multi-drug-resistant gram-negative bacilli infections (MDRGN-I) in patients with trauma is not well described. We present characteristics of MDRGN-Is among military personnel with deployment-related trauma (2009-2014).

Patients and methods: Data from the Trauma Infectious Disease Outcomes Study were assessed for infectious outcomes and microbial recovery. Infections were classified using standardized definitions. Gram-negative bacilli were defined as multi-drug-resistant if they showed resistance to ≥3 antibiotic classes or were producers of extended-spectrum β-lactamase or carbapenemases.

Results: Among 2,699 patients admitted to participating U.S. hospitals, 913 (33.8%) experienced ≥1 infection event, of which 245 (26.8%) had a MDRGN-I. There were 543 MDRGN-I events (24.6% of unique 2,210 infections) with Escherichia coli (48.3%), Acinetobacter spp. (38.6%), and Klebsiella pneumoniae (8.4%) as the most common MDRGN isolates. Incidence of MDRGN-I was 9.1% (95% confidence interval [CI]: 8.0-10.2). Median time to MDRGN-I event was seven days with 75% occurring within 13 days post-trauma. Patients with MDRGN-Is had a greater proportion of blast injuries (84.1% vs. 62.5%; p < 0.0001), traumatic amputations (57.5% vs. 16.3%; p < 0.0001), and higher injury severity (82.0% had injury severity score ≥25 vs. 33.7%; p < 0.0001) compared with patients with either no infections or non-MDRGN-Is. Furthermore, MDRGN-I patients were more frequently admitted to the intensive care unit (90.5% vs. 48.5%; p < 0.0001), colonized with a MDRGN before infection (58.0% vs. 14.7%; p < 0.0001), and required mechanical ventilation (78.0% vs. 28.8% p < 0.0001). Antibiotic exposure before the MDRGN-I event was significantly higher across antibiotic classes except first generation cephalosporins and tetracyclines, which were very commonly used with all patients. Regarding outcomes, patients with MDRGN-Is had a longer length of hospitalization than the comparator group (53 vs. 18 days; p < 0.0001).

Conclusions: We found a high rate of MDRGN-I in our population characterized by longer hospitalization and greater injury severity. These findings inform treatment and infection control decisions in the trauma patient population.

Keywords: gram-negative bacilli; multi-drug–resistant organisms; trauma-related infections.

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Conflict of interest statement

No competing financial interests exist.

The views expressed are those of the authors and does not necessarily reflect the official views of the Uniformed Services University of the Health Sciences, Henry M. Jackson Foundation for the Advancement of Military Medicine, National Institutes of Health or the Department of Health and Human Services, Walter Reed National Military Medical Center, Landstuhl Regional Medical Center, Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of Defense or the Departments of the Army, Navy or Air Force. Mention of trade names, commercial products, or organization does not imply endorsement by the U.S. Government.'

Figures

<b>FIG. 1.</b>
FIG. 1.
Flow diagram of study population and infection incidence. MDRGN-I = multi-drug–resistant gram-negative infection.
<b>FIG. 2.</b>
FIG. 2.
Time (days) from injury to first multi-drug–resistant gram-negative culture per patient, stratified by injury severity score (ISS), which is a standardized trauma assessment tool for grading aggregate anatomic severity of injury. ISS was calculated within 15 days of injury. ISS 0–9 are mild injuries, 10–14 are moderate injuries, 15–24 are severe injuries, and ≥25 are critical injuries.
<b>FIG. 3.</b>
FIG. 3.
Proportion of antibiotic classes received by patients with multi-drug–resistant Gram-negative infections (MDRGN-I; n = 245) and either no infection or a non-MDRGN-I (n = 2,454). Data are restricted to antibiotic classes prescribed within the first two weeks post-injury: (A) Days 0–7 post-injury and (B) days 8–14 post-injury. Gen = generation; PCN = penicillin.
<b>FIG. 4.</b>
FIG. 4.
Distribution of number of antibiotic class combinations that were received for at least two days by patients with a multi-drug–resistant gram-negative infection (MDRGN-I) or no infection/non-MDRGN-I (columns). Antifungal agents, anti-parasitic agents, and topical agents are excluded. For each antibiotic class distribution, the percentage of patients out of the total number of MDRGN-I (n = 245) and no-infection/non-MDRGN-I patients (n = 2,454) is presented (lines).
<b>FIG. 5.</b>
FIG. 5.
Distribution of infection syndrome. (A) Stratified by multi-drug–resistant gram-negative (MDRGN) status. Proportion of infection events with either a MGRGN infection (MDRGN-I) or a non-MDRGN-I is listed next to each column. (B) Stratified by bacterial organism. SSTI = skin and soft-tissue infections; BSI = blood stream infections; UTI = urinary tract infections; CNS = central nervous system infections; PNA = pneumonia; osteo = osteomyelitis.
See this image and copyright information in PMC

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