Antibiotics in tactical combat casualty care 2002

Military Medicine, Nov 2003 by O'Connor, Kevin, Butler, Frank

Care of casualties in the tactical combat environment should include the use of prophylactic antibiotics for all open wounds. Cefoxitin was the antibiotic recommended in the 1996 article "Tactical Combat Casualty Care in Special Operations." The present authors recommend that oral gatifloxacin should be the antibiotic of choice because of its ease of carriage and administration, excellent spectrum of action, and relatively mild side effect profile. For those casualties unable to take oral antibiotics because of unconsciousness, penetrating abdominal trauma, or shock, cefotetan is recommended because of its longer duration of action than cefoxitin.

Introduction

Infections are an important cause of late morbidity and mortality in combat trauma. The need for early administration of antibiotics was recognized 50 years ago, when Poole1 stated that "the greatest lesson learned from World War II may have been the benefit of the use of penicillin prophylactically in the surgical units closest to the front." Scott2 commented after the Korean War that "In any tactical situation where the casualty cannot reach the aid station until 4 or 5 hours or longer after wounding, antibiotic therapy by the aidman in the field is most desirable." Sepsis was the major cause of mortality in rear echelon hospitals during the Vietnam conflict, particularly in the setting of extensive burns or penetrating trauma to the head or central nervous system.3 Hell4 states that "a single injection of a broadspectrum drug with a long half-life should be given prophylactically to personnel on the battlefield to provide bactericidal coverage from the earliest moment after injury occurs." Civilian trauma care also includes the use of prophylactic antibiotics. One standard surgical text notes that "All injured patients undergoing an operation should receive preemptive antibiotic therapy."5

Despite these observations and the lessons of past conflicts however, as recently as the 1993 Mogadishu action, antibiotics were not being used by U.S. combat medics.6 Mabry et al.6 reported that four of the five open fractures of the tibia from gunshot wounds sustained in this battle became infected. Both open fractures of the femur also became infected. In all, there were 15 wound infections in 58 casualties. Mabry noted that "current U.S. Army doctrine on prehospital care does not call for antibiotic administration by medics in the field." Why has this seemingly simple step in battlefield trauma care been so difficult to implement?

One reason that the military has been slow to adopt the practice of using battlefield antibiotics is that antibiotics are not routinely given in civilian prehospital trauma care. One text notes that "Antibiotics are widely utilized for the prophylaxis of infections in trauma care. It is emphasized that they should be applied early, before an operation is carried out, to be of any use. So far, however, their prehospital use has not been validated."7 The current edition of the American College of Surgeons-sponsored Prehospital Trauma Life Support Manual contains no mention of prehospital antibiotics in civilian care.8 This practice is quite reasonable given the short transport times to the hospital in most urban trauma centers.

Combat medical personnel who provide prehospital care for their wounded teammates on the battlefield, however, do so under conditions profoundly different from those found in civilian emergency medical systems. The treatment strategies that they use need to take into account the prolonged delays to evacuation commonly encountered in combat operations. There was a 15-hour delay to definitive care for most casualties in Mogadishu.6 Because of these differences, there has been a renewed call for antibiotics to be included in the care provided by combat medics when there is penetrating abdominal trauma, massive soft tissue damage, a grossly contaminated wound, an open fracture, or when a long delay until Casualty Evacuation is anticipated.9 In acknowledgment of the differences between the civilian and the military prehospital settings, this recommendation has now been included in the Prehospital Trauma Life Support Manual for battlefield trauma, and it is clear that battlefield antibiotics should be added to the care provided by combat medics.10

For prophylaxis with antibiotics to be practical and effective, the regimen chosen must be as simple as possible, and the antibiotic should be administered as soon as possible after the injury occurs. The antibiotic coverage has to be maintained at least until surgical debridement has been performed.4 Coverage must be appropriate for the organisms implicated in combat wound infections. Klein et al.11 noted that combatants in the Yom Kippur War were treated with penicillin. The most common organism found in wound infections in that conflict was Pseudomonas, comprising 25.6% of clinical isolates. Gram-negative bacilli were found to be 70.2% of isolates overall.11 Mabry et al.6 also found that Pseudomonas and polymicrobial infections were a significant cause of morbidity after the Mogadishu action. Reports from the Russian experience in Afghanistan stated that clostridial species remain an important pathogen on the modern battlefield.12,13