Trauma-related Infections in Battlefield Casualties From Iraq

Sir William Osler writing on the difficulties of casualty care in 1914 stated: This is an artillery war in which shrapnel do the damage, tearing flesh, breaking bones and always causing jagged irregular wounds. And here comes in the great tragedy – sepsis everywhere, unavoidable sepsis!..The surgeons are back in the pre-Listerian days and have wards filled with septic wounds. the wound of shrapnel and shell is a terrible affair, and infection is well nigh inevitable.1 Ninety years later, his quote remains pertinent. War wounds are distinct from peacetime traumatic injuries because these higher velocity projectiles and/or blast devices cause a more severe injury and accompanying wounds are frequently contaminated by clothing, soil, and environmental debris2 (Figure 1). Recent advances in aeromedical evacuation and trauma care have resulted in significantly lower mortality rates among battlefield casualties,3 but since the Vietnam War era4,5 there have been no published descriptions of risks for and morbidity of combat wound infections. FIGURE 1. Typical war injury from Iraq offensive in 2003. Note clothing fiber and dirt and necrotic material deep in the wound bed. Current battlefield casualty management starts at time of wounding (Figure 2). Initially, buddy/self-care is performed to include hemorrhage control and pain management. The casualty is immediately evacuated to an Echelon II facility: Forward Resuscitative Surgical System for Marines or Forward Surgical Team for Army personnel for surgical hemostasis and perioperative antibiotics. During the assault phase of Operation Iraqi Freedom, these surgical teams were embedded in front line units and therefore were immediately available to receive casualties, but they had limited ability to provide prolonged perioperative care. Once stabilized, casualties are evacuated to Echelon III facilities. These facilities are staffed with surgical subspecialists and can provide extended perioperative care due to increased bed capacity.6 FIGURE 2. Aeromedical evacuation process for casualties in initial phases of Operation Iraqi Freedom. USNS Comfort (TAH-20), a 1000-bed hospital ship, was the largest Echelon III facility in theater for the initial phases of Operation Iraqi Freedom in 2003 (Figure 3). USNS Comfort initially received all wounded coalition forces from the Basrah region, but as combatants moved further inland and Medevac routes became longer, it was used more for its theater-unique neurosurgical, angiography, CT scan, and burn care capabilities, allowing for stabilization prior to Medevac to the Echelon IV facilities in Europe. In addition, it became the preferred site for receiving injured Iraqi patients, particularly enemy combatants due to its isolated location in the Persian Gulf. Military and civilian casualties were evacuated from several sources including 2 Army Combat Support Hospitals, several Forward Resuscitative Surgical System and Forward Surgical Teams, 1 Navy Fleet Hospital, and a British Hospital Ship. FIGURE 3. USNS Comfort (TAH-20) underway. Inset: ICU #2 at height of operations, over 30 ventilated patients with multiple traumatic casualties were managed in relatively tight quarters. During the height of casualty evacuations in April 2003, USNS Comfort experienced a cluster of multidrug resistant Acinetobacter baumanii infection on its wards and ICUs.7 A comprehensive investigation failed to locate a common environmental point source on the ship, and a frequency distribution of date of infection showed a propensity to positive culture in the first 48 hours of hospitalization. Battlefield casualties themselves were postulated to be the source of infection with acquisition occurring prior to admission to our hospital ship. In light of this, we sought to describe war trauma associated infection (WTAI), define the factors associated with acquisition of WTAI, and further characterize the causal WTAI microorganisms, including antimicrobial resistance patterns.