Prevention of combat-related infections: Antimicrobial therapy in battlefield and barrier measures in French military medical treatment facilities

doi:10.1016/j.tmaid.2014.04.013

Travel Medicine and Infectious Disease

Volume 12, Issue 4, July–August 2014, Pages 318-329

https://doi.org/10.1016/j.tmaid.2014.04.013 Get rights and content

Summary

Infection is a major complication associated with combat-related injuries. Beside immobilization, wound irrigation, surgical debridement and delayed coverage, post-injury antimicrobials contribute to reduce combat-related infections, particularly those caused by bacteria of the early contamination flora. In modern warfare, bacteria involved in combat-related infections are mainly Gram-negative bacteria belonging to the late contamination flora. These bacteria are frequently resistant or multiresistant to antibiotics and spread through the deployed chain of care. This article exposes the principles of war wounds antimicrobial prophylaxis recommended in the French Armed Forces and highlights the need for high compliance to hygiene standard precautions, adapted contact precautions and judicious use of antibiotics in French deployed military medical treatment facilities (MTF).

Introduction

Since World War II, advances in the personal protective equipment, in field medicalization (self-aid, transportation, damage control, forward resuscitative and stabilization surgical care, rapid evacuation) as well as the systematic use of antimicrobials have contributed to an improved survival of soldiers injured on the battlefield [1]. However, the more numerous surviving soldiers, with complex and destructive wounds, are exposed to potentially lethal infections. In modern conflicts, the overall incidence of wound infections is estimated between 5.5% and 30%, depending on the study and the localization and severity of wounds [2], [3], [4], [5], [6]. It can reach 40% for critically ill patients. Thus, war wound infections remain a frequent cause of morbidity and the second cause of death in combat after multiorgan failure by haemorragic shock. In contemporary warfare (Vietnam, the Yom Kippur War, Iraq and Afghanistan), the typology of combat-related infectious complications gradually changed with: 1) an increase of limb injuries characterized by multiple lesions due to explosive munitions [7], 2) the emergence of infections by multidrug-resistant organisms [8], [9], [10], [11], [12] and more recently, 3) the emergence of invasive fungal infections [13], [14]. Infection prevention of combat-related injuries in the French Armed Forces relies, as in some other NATO medical services, on three interrelated and complementary strategies:

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rapid surgical management with large debridement of necrotic tissue and irrigation,
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rapid delivery of antibiotics after injury,
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control of direct and indirect transmissions in deployed military medical treatment facilities (MTFs).

Control and prevention of combat-related infections require standardized protocols, personnel emphasis and compliance at each level of the deployed French military MTFs. When a French soldier is wounded in a conflict area, a chain of support is deployed, according to two principles: bringing medical and surgical means closer to the wounded and repatriating him as soon as possible to the French military hospitals. At the point-of-injury, closer to the wounded, emergency care is provided by medical posts and by mobile medical teams (Role 1). The military surgical team, devoted to the first vital emergency surgical procedures, constitutes the light manoeuvre Role 2 facilities. The Role 3 facilities are organised on a modular basis in a medical and surgical combat support hospital, with a capacity of 2 surgical areas and 50 hospital beds. The 9 armed forces teaching hospitals located in France represent the Role 4 facilities, offering specialized units and rehabilitation program.

Section snippets

Early contamination

Any war wound is by definition contaminated at the time of the injury by the endogenous flora (skin, oropharyngeal or gastrointestinal flora depending on the type of lesion). Skin flora is essentially composed of Gram-positive bacteria, as coagulase-negative or coagulase-positive staphylococci, corynebacteria, streptococci including Streptococcus pyogenes [15]. A lesion of the hollow viscera is a source of contamination by intestinal flora (enterobacteria, enterococci, and anaerobic bacteria

Surgical management

The precocity of the surgical management is a major factor in preventing infections [38]. The surgical procedure that combines emergency debridement and aggressive surgical debridement limits the favourable biological conditions for bacterial growth by removing necrotic tissue, blood clots and foreign bodies. However, excision of potentially viable tissue should be avoided in order not to unnecessarily enlarge the wound. Wounds must be largely irrigated with antiseptic solutions or sterile

Post-injury antibiotic prophylaxis

In civilian practice, antibiotics have been showed to reduce early infections in open fractures of the limbs [46]. The scientific evidence base for antibiotic prophylaxis in combat-related injuries is limited, because of the lack of control studies. According to military data during 1973 Yom Kippur War [47], [48], as well as during the 1982 Falkland Islands conflict [49] and the 1993 Mogadishu battle in Somalia [50], post-injury war wound antibiotic prophylaxis is recommended by many military

Infection control practices in the French MTFs

Rapid surgical management and early delivery of intravenous antibiotics soon after the injury are key-points of the initial management of war wounds. However, nosocomial transmission plays a major role in MDRO spread throughout the chain of care, which is from the point of injury to the home-nation Role 4 facilities, including aeromedical evacuation. This highlights the importance of maintaining high levels of compliance to basic rules of hygiene in deployed health facilities [86].

Conclusion

The increasingly complex war wounds especially explained by the involvement of explosive devices, the difficult working conditions in the battlefield, the diffusion of MDRO not only in the healthcare facilities but also in the community, the suboptimal architecture of deployed medical care facilities regarding infection control, the high rate of personnel turnover, make the prevention of combat-related infections a challenge. Beside standardized protocols, deployed military medical personnel

Conflict of interest

None.

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Prevention of combat-related infections: Antimicrobial therapy in battlefield and barrier measures in French military medical treatment facilities

Summary

Introduction

Section snippets

Early contamination

Surgical management

Post-injury antibiotic prophylaxis

Infection control practices in the French MTFs

Conclusion

Conflict of interest

Lancet Infect Dis

Lancet

Clin Microbiol Infect

Clin Microbiol Infect

Curr Opin Microbiol

J Infect Public Health

Orthop Traumatol Surg Res

Pathol Biol

Anaerobe

Anaerobe

J Hosp Infect

J Hosp Infect

Am J Infect Control

Am J Infect Control

Lancet Infect Dis

History of infections associated with combat-related injuries

J Trauma

Prevention of infections associated with combat-related extremity injuries

J Trauma

Infectious complications of combat-related mangled extremity injuries in the British military

J Trauma

Microbiology and injury characteristics in severe open tibia fractures from combat

J Trauma Acute Care Surg

Infectious complications of damage control orthopedics in war trauma

J Trauma

Epidemiology of infections associated with combat-related injuries in Iraq and Afghanistan

J Trauma

Combat wounds in operation Iraqi freedom and operation enduring freedom

J Trauma

Multidrug-resistant organisms in military war wounds from Iraq and Afghanistan

Clin Orthop Relat Res

Multidrug-resistant Acinetobacter extremity infections in soldiers

Emerg Infect Dis

Multi-drug resistant Acinetobacter infections in critically injured Canadian force soldiers

BMC Infect Dis

An outbreak of multidrug-resistant Acinetobacter baumannii-calcoaceticus complex infection in the US military health care system associated with military operations in Iraq

Clin Infect Dis

Invasive mold infections following combat-related injuries

Clin Infect Dis

Invasive fungal infections following combat-related injury

Mil Med

Septic complications of war wounds

J Am Med Assoc

Bacteriology of war wounds at the time of injury

Mil Med

Microbiologic flora contaminating open fractures: its significance in the choice of primary antibiotic agents and the likelihood of deep wound infection

J Orthop Trauma

Association of bacterial colonization at the time of presentation to a combat support hospital in a combat zone with subsequent 30-day colonization or infection

Mil Med

Infectious complications of open type III tibial fractures among combat casualties

Clin Infect Dis

Osteomylistis in military personnel wounded in Iraq and Afghanistan

J Trauma

Combat surgery in a communication zone. I war wounds and bacteriology (preliminary report)

Mil Med

Microbial flora of orthopaedics war wounds

Mil Med

Trauma-related infections in battlefield casualties from Iraq

Ann Surg

Bacterial infections in wounded French soldiers repatriated from former Yugoslavia

Médecine Armées

Multidrug-resistant bacteria from personnel with combat injury at a French military medical center

J Trauma Acute Care Surg

Global spread of carbapenemase-producing Enterobacteriaceae

Emerg Infect Dis

Emergence of Enterobacteriaceae producing extended-spectrum beta-lactamases (ESBLs) in the community

J Antimicrob Chemother

High incidence of multidrug-resistant Gram-negative bacteria recovered from Afghan patients at a deployed US military hospital

Infect Control Hosp Epidemiol

Factors associated with recovery of A. baumannii in a combat support hospital