| Extremity wound infections (EWIs) |
Comprehensive 6-year studies of osteomyelitis risk factors with open fractures of tibia, femur, and upper extremities; high risk with fracture severity and amputations, substantial muscle damage, and extensive degloving7–9 Personnel with amputations as their most severe extremity injury had highest proportion of EWIs10 Assessment of antibiotic practice patterns in period surrounding EWI diagnosis date identified substantial variation with frequent receipt of multiple antibiotics11 Use of expanded Gram-negative coverage with open fractures did not have benefit with reducing osteomyelitis compared to use of cefazolin, supporting JTS CPG recommendations12
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| Invasive fungal wound infections (IFIs) |
DoD IFI Outbreak Investigation (TIDOS led) provided recommendations for early diagnosis and surgical/medical management13 Findings from IFI Outbreak Investigation and subsequent TIDOS IFI analyses supported development and refinement of JTS CPG for the management of IFIs in war wounds14 Adverse impact of IFIs on wound healing confirmed (longer time to wound closure)15; pathogenicity of fungi of order Mucorales also confirmed (longer time to wound closure vs non-Mucorales fungi)16 Proposed trauma-related IFI definitions, which provide a framework to support clinical decision-making and reduce practice variation A panfungal polymerase chain reaction-based assay was 99% specific at identifying filamentious fungi in surgical pathology specimens, but not as sensitive (63%); sensitivity improved in specimens from sites with angioinvasion17
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| Combat wound microbiology |
>8,300 isolates collected from surveillance swabs and clinical infection work-ups in TIDOS Microbiology Repository Collaborative network with DoD laboratories established to assess microbiology with a focus on MDR and virulent organisms18 Cefazolin use prior to isolate collection associated with risk of MDR Gram-negative colonization among trauma patients19 Doxycycline use as antimalarial prophylaxis not associated with increase in Staphylococcus aureus tetracycline resistance20 27% of patients with ≥1 infection had an infection with a MDR Gram-negative bacilli; 58% of these patients were colonized with a MDR Gram-negative bacilli prior to infection21
Enterococcus infections largely polymicrobial with ESKAPE pathogens being co-cultured from the majority of infections22 Gram-negative bacteria predominant among EWIs: 57% of monomicrobial EWIs and 86% of polymicrobial EWIs23
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| Long-term outcomes |
Successful research collaboration between the DoD and the VA St. Louis Health Care System 38% of veterans in the TIDOS-VA cohort developed a trauma-related infection during follow-up24 28% of patients with tibia osteomyelitis during their hospitalization had a recurrence during follow-up25 21% of TIDOS-VA enrollees with genitourinary trauma developed an UTI (75% of UTI events diagnosed during follow-up)26
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| Miscellaneous |
TIDOS analyses supported refinement of JTS CPG for the prevention of combat trauma-related infections27 Examination of patients who received blood products with/without TXA found no significant association with infections on mulitvariable analysis; high proportion of infections among TXA recipients likely attributed to greater injury severity28 Infections not restricted to combat trauma; 15% of personnel with deployment-related non-combat injuries had ≥1 infection29 Adherence to JTS CPG post-trauma prophylactic recommendations showed increased over 5-year period, particularly with reduction in use of expanded Gram-negative coverage with open fractures30 14% of personnel who underwent combat-related exploratory laparotomy developed an abdominal surgical site infection31 13% of patients who received vancomycin plus piperacillin-tazobactam developed acute kidney injury; however, severity was low and duration was short32
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