Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2018 Jan;19(1):95-103.
doi: 10.1089/sur.2017.157. Epub 2017 Dec 20.

Association of Enterococcus spp. with Severe Combat Extremity Injury, Intensive Care, and Polymicrobial Wound Infection

Rae A Heitkamp  1 , Ping Li  2   3 , Katrin Mende  2   3   4 , Samandra T Demons  1 , David R Tribble  2 , Stuart D Tyner  1
Affiliations

Association of Enterococcus spp. with Severe Combat Extremity Injury, Intensive Care, and Polymicrobial Wound Infection

Rae A Heitkamp et al. Surg Infect (Larchmt). 2018 Jan.

Abstract

Background: Combat-related extremity wound infections can complicate the recovery of injured military personnel. The Enterococcus genus contains both commensal and pathogenic bacteria found in many combat wounds. We describe the patient population susceptible to Enterococcus infection, the characteristics of Enterococcus spp. isolated from combat-related wounds, and the microbiological profile of Enterococcus-positive wounds.

Methods: Patient and culture data were obtained from the Trauma Infectious Disease Outcomes Study. Subjects were divided into a case group with enterococcal extremity wound infections and a comparator group with wound infections caused by other micro-organisms.

Results: Case and comparator subjects had similar patterns of injury and infection. Case subjects had higher Injury Severity Scores (33 vs. 30; p < 0.001), longer hospitalization at U.S. facilities (55 vs. 40 days; p = 0.004), and required more large-volume blood transfusions (>20 units) within 24 h post-injury (53% vs. 30%; p < 0.001). Approximately 60% of case subjects had three or more infections, and 91% had one or more polymicrobial infections, compared with 43% and 50%, respectively, in the comparator group. The thigh was the most common site of Enterococcus spp. isolation, contributing 50% of isolates. Enterococcus faecium was the predominant species isolated from case-group infections overall (66%), as well as in polymicrobial infections (74%). Frequent co-colonizing microbes in polymicrobial wound infections with Enterococcus were other ESKAPE pathogens (64%) (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae [and Escherichia coli], Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.) and fungi (35%).

Conclusions: The specific pathogenicity of Enterococcus relative to other pathogens in polymicrobial wounds is unknown. Identifying strain-specific outcomes and investigating the interactions of Enterococcus strains with other wound pathogens could provide additional tools and strategies for infection mitigation in combat-related wounds.

Keywords: ESKAPE pathogens; Enterococcus faecalis; Enterococcus faecium; combat-trauma–related infections.

PubMed Disclaimer

Conflict of interest statement

No competing financial interests exist. All material has been reviewed by the Walter Reed Army Institute of Research and the Uniformed Services University of the Health Sciences. They had no objection to its publication.

The views expressed herein are those of the authors and do not reflect the official policy or position of Uniformed Services University of the Health Sciences, Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., the National Institutes of Health or the Department of Health and Human Services, Brooke Army Medical Center, the Walter Reed Army Institute of Research, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Air Force, the Department of the Navy, the Department of the Army, the Department of Defense, or the U.S. Government.

All work involving human subjects was approved by the Uniformed Services University of Health Sciences Infectious Disease Institutional Review Board (IRB No. 351767).

Figures

<b>FIG. 1.</b>
FIG. 1.
Flowchart of inclusion criteria for subjects and infections. Subjects are a subset of the Department of Defense and Veterans Affairs Trauma Infectious Disease Outcomes Study (TIDOS) population with combat-related extremity injuries and extremity wound infections (skin or soft-tissue infection or osteomyelitis). The cohort was divided into a case group of subjects with at least one Enterococcus culture associated with a wound infection and a comparator group of subjects with wound cultures positive for any other microorganism. The total number of infections and the number of wound infections were determined for the case and comparator group.
See this image and copyright information in PMC

References

    1. Holcomb JB, Stansbury LG, Champion HR, et al. . Understanding combat casualty care statistics. J Trauma 2006;60:397–401 - PubMed
    1. Cross JD, Ficke JR, Hsu JR, et al. . Battlefield orthopaedic injuries cause the majority of long-term disabilities. J Am Acad Orthop Surg 2011;19:S1–S7 - PubMed
    1. Masini BD, Waterman SM, Wenke JC, et al. . Resource utilization and disability outcome assessment of combat casualties from Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma 2009;23:261–266 - PubMed
    1. Tribble DR, Conger NG, Fraser S, et al. . Infection-associated clinical outcomes in hospitalized medical evacuees after traumatic injury: Trauma Infectious Disease Outcome Study. J Trauma 2011;71:S33–S42 - PMC - PubMed
    1. Murray CK, Wilkins K, Molter NC, et al. . Infections in combat casualties during Operations Iraqi and Enduring Freedom. J Trauma 2009;66:S138–S144 - PubMed

MeSH terms

LinkOut - more resources