Clinton K. Murray

OBJECTIVE: To determine whether intrawound vancomycin changes the bacteriology of surgical site infection pathogens and investigate the emergence of antibiotic-resistant pathogens. METHODS: Design: Secondary analysis of phase III, prospective, randomized clinical trial. Setting: Thirty-six US trauma centers. Patient Selection Criteria: Patients who became infected after fixation of tibial plateau or pilon fracture. Outcome Measures and Comparisons: Pathogen types and bacterial susceptibilities as determined from routine clinical culture in the operating room. RESULTS: Seventy-four patients were studied who were 67.5% male with a mean age of 48.6 years. A lower proportion of gram-positive cocci was observed in the vancomycin powder compared with the standard-of-care group (3.7% vs. 8.0%, P = 0.01). Methicillin-resistant Staphylococcus aureus infection incidence was comparable in both the vancomycin powder and the standard-of-care groups, but rates of methicillin-susceptible S. aureus infections were lower in the treatment group (1.4% vs. 4.8%, P = 0.01). The incidence of coagulase-negative Staphylococci and gram-negative rod infections were similar in both groups. There was no significant difference in susceptibilities between groups in rates of vancomycin-resistant enterococcus. CONCLUSIONS: Topical vancomycin powder decreases the likelihood of gram-positive infections consistent with the biologic activity of vancomycin. Fewer methicillin-susceptible S. aureus and coagulase-negative Staphylococci infections were observed in the group treated with vancomycin powder. An effect of vancomycin powder on methicillin-resistant S. aureus infection risk was not detected given the low incidence in both the intrawound vancomycin and the standard-of-care groups. There was no emergence of gram-negative rod infections or increased resistance patterns observed. Use of topical vancomycin powder does not seem to produce infections in these patients with greater antibiotic resistance than would have occurred without its use. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Serological assessment of SARS-CoV-2 specific responses are an essential tool for determining the prevalence of past SARS-CoV-2 infections in the population especially when testing occurs after symptoms have developed and limited contact tracing is in place. The goal of our study was to test a new 10-plex electro-chemiluminescence-based assay to measure IgM and IgG responses to the spike proteins from multiple human coronaviruses including SARS-CoV-2, assess the epitope specificity of the SARS-CoV-2 antibody response against full-length spike protein, receptor-binding domain and N-terminal domain of the spike protein, and the nucleocapsid protein. We carried out the assay on samples collected from three sample groups: subjects diagnosed with COVID-19 from the U.S. Army hospital at Camp Humphreys in Pyeongtaek, South Korea; healthcare administrators from the same hospital but with no reported diagnosis of COVID-19; and pre-pandemic samples. We found that the new CoV-specific multiplex assay was highly sensitive allowing plasma samples to be diluted 1:30,000 with a robust signal. The reactivity of IgG responses to SARS-CoV-2 nucleocapsid protein and IgM responses to SARS-CoV-2 spike protein could distinguish COVID-19 samples from non-COVID-19 and pre-pandemic samples. The data from the three sample groups also revealed a unique pattern of cross-reactivity between SARS-CoV-2 and SARS-CoV-1, MERS-CoV, and seasonal coronaviruses HKU1 and OC43. Our findings show that the CoV-2 IgM response is highly specific while the CoV-2 IgG response is more cross-reactive across a range of human CoVs and also showed that IgM and IgG responses show distinct patterns of epitope specificity. In summary, this multiplex assay was able to distinguish samples by COVID-19 status and characterize distinct trends in terms of cross-reactivity and fine-specificity in antibody responses, underscoring its potential value in diagnostic or serosurveillance efforts.

Up to 50% of combat injured patients from recent conflicts have suffered infectious complications, predominantly with multidrug-resistant (MDR) bacteria acquired nosocomially in the chain of tactical combat casualty care. These bacteria have ranged from MDR Acinetobacter baumannii-calcoaceticus associated with Operation Iraqi Freedom (OIF), to extended spectrum beta-lactamase producing Enterobacteriaceae from operations in Afghanistan. Experience from interventions at Level III facilities demonstrate that basic infection control (IC) procedures, such as improvements in hand hygiene, use of ventilator associated pneumonia bundles, and antimicrobial stewardship, can improve outcomes even in austere environments. While some systematic interventions have been implemented to mitigate this risk, including development of the Deployed Infection Control Course, the Multidrug-Resistance Surveillance Network, and the Trauma Infectious Disease Outcomes Study, ongoing vulnerabilities remain. Deployed microbiology capabilities should be strengthened, theater-level IC standard operating procedures should be implemented, and a joint, theater-level expert IC consultant should be appointed to be responsible for directing IC activities from Levels I to IV.

Background. Orthopedic injuries predominate during wartime, often complicated by deep soft tissue or bone infections. Among long bones, tibia injuries typically have the highest infection rates therefore we focused on osteomyelitis risk factors in open tibia fractures sustained in combat.

Background. Penetrating wounds with environmental contamination are associated with a range of infectious complications, including fungus. This is the first study to examine the epidemiology, resistance patterns, and outcomes of Candida infections and colonization in United States military patients injured in Iraq and Afghanistan. Methods. Clinical information associated with initial unique and serial Candida isolates collected from patients (June 2009–October 2013) through the Trauma Infectious Disease Outcomes Study (TIDOS) was evaluated. Susceptibilities were performed using Sensititre YeastOne (YO-9) plates and interpreted by Clinical Laboratory and Standards Institute (CLSI) and adjusted-European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria. Results. The analysis included 127 patients with 131 unique Candida isolates, of which 102 were Candida albicans and 29 non-albicans Candida spp. Overall, 99% of patients were male with a median age of 23 and an injury severity score of 22. Injuries were primarily due to blasts (77%) and sustained among personnel serving in Afghanistan (89%). There was a median of 7 days from injury to Candida isolation, and 74 isolates were associated with infection. In the multivariate analysis, non-albicans Candida spp were associated with prior antifungal exposure, blood isolates, and wound isolates (P < .01). Nonsusceptibility by CLSI and EUCAST criteria was associated with non-albicans Candida spp (P < .05). Patients with Candida isolation had a 7.1% mortality rate, compared with 1.4% from the overall TIDOS population. Conclusions. Candida isolation from patients with penetrating war injuries may identify a population at higher risk for death. Prospective studies are needed to determine whether targeted antifungals and surgical management will affect this mortality rate.

A total of 102 methicillin-resistant Staphylococcus aureus (MRSA) isolates collected from 50 injured service members (June 2009 to December 2011) at U.S. military treatment facilities were analyzed for the conventional mecA gene and mecC homologue by using standard PCR-based methods. The prevalence of the mecC homologue was zero.