Infection Control in Multiple Trauma

1. Infection Control in Multiple Trauma Tin M. Do, M.D.

2. Why control infection in trauma? • Causes of death in severe trauma patients: #1. Head injury #2. Infection complications • Those with infection have: • Higher outpatient care needed • Worse functional status outcome • Prolonged hospital stay • Inreased mortality • Higher rate of emotional distress • Most common cause of late death from trauma is SEPSIS

3. Risk Factors for infection in trauma patients • Risk factors for infection: • Hypotension • Blood transfusion (more units of blood = higher infection rate) • Prolonged ventilatory support • Multiple surgeries • Brain and Spinal cord injuries • Other risk factors: • Degree of nutrition status • Underlying chronic medical problems (diabetes, heart disease, etc) • Immunologic depression • Stress reaction from trauma

4. Infection complications after trauma • Wounds (clean vs. contaminated) • Surgical sites • Central lines • Urinary catheter • Ventilator-associated respiratory infections • Decubitus ulcers • The more severe the injuries, the higher the age, the more days of ventilatory support  the higher the risk of infection.

5. Prevention of infection • Close surveillance of wounds, vital signs • Hand washing • Optimal nutrition status • Appropriate antibiotics should be guided by cultures and sensitivities • Check all invasive lines and catheters • Prevent ventilator-associated pneumonia • Trauma patients have higher risk of pneumonia than non-trauma patients (18% vs. 3%)

6. Prevention of Ventilator-associated pneumonia • Elevate patient’s head (about 30-45°) • Suctioning of airway • Decrease number of days of intubation • Nurse cleans patient’s mouth every 2 hours • Use of germicidal mouthwash (Chlorhexadine), brushing teeth • Preventing aspiration from enteral feeding • Gastric ulcer prophylaxis (ranitidine, omeprazole, etc)

7. Prophylactic Antibiotic use • 1 Antibiotic for short-term (1-2 days) post-trauma is sufficient • Antibiotic during surgery is acceptable • Problems with prophylactic administration with 1 or more antibiotic (for more than 24 hours) following severe trauma: • No additional protection against sepsis, organ failure, and death • Increases the probability of antibiotic-resistant infections

8. Prophylactic Antibiotic use in Open Fractures • Osteomyelitis can be a result of open fractures • Start a short-course (~48 hrs) of Cephalosporin +/- Aminoglycoside antibiotic as soon as possible once open fracture is identified • Contaminated/dirty wounds: consider treating for Anaerobic pathogens (PCN,Clindamycin, Metronidazole) • No evidence to support long-term antibiotic treatment in open fractures

9. Immunomodulator treatmentin trauma • Hyperinflammation from trauma causes tissue injury • New area of research for treatment in trauma • Many immunomodulators decrease SIRS/inflammatory response, but NOT infection rate Recent Metanalysis of randomized-control trials (2010): • Only 3 have shown improvements in infection, organ failure, mortality in trauma • Immunomglobulin (IG) • Interferon-γ • Glucan

10. Surgical wound infections • Infection rate of surgical incision/traumatic wounds (if no Antibiotic use) • <3% clean wounds • 10% clean-contaminated wounds (ex. Appendectomy) • 20-25% contaminated wounds (ex. penetrating wounds < 4hr, perioperative spillage from GI tract) • 40% dirty infected wounds (ex. Penetrating wounds > 4hr, pre-operative spillage of GI tract) -- based on National Nosocomial Infections Surveillance (NNIS) System • Contaminated wounds, consider: • Delayed primary closure • Healing by secondary intention • Topical antibiotic use

11. Hospital-acquired infection in trauma patients • Total 5,537 trauma patients studied • Most common infection sites: • Urine • Respiratory (31% from ventilatory support) • Most common pathogens: • Gram+ cocci (Staph) • Only 0.3% of studied patients had Methicillin-Resistant Staph Aureus infection • Incidence of hospital-acquired infection = 9.1% • Risk factors: • Older age • More severely injured A Six-Year Descriptive Study of Hospital-Associated Infection in Trauma Patients: Demographics, Injury Features, and Infection Patterns. Harrison et al., Surgical Infections, Aug 2007.

12. History of injury/trauma isimportant! • This helps in determining the pathogen and therefore, the kind of antibiotic to use !! • Also to help rule out any foreign body in the wound (ex. broken glass, teeth, etc) • Tetanus status • Presence of contamination with soil, water • Risks factors: • Diabetes, liver disease, HIV, cancer, immunocompromised • Recent use of antibiotics • Chronic venous stasis, lymphedema • IV drug use

13. Wounds & Minor Trauma • Antibiotic of choice: Penicillin or Cephalosporin • Must consider tetanus in ALL wounds • Skin and Soft Tissue infections are mostly from: • Staphylococcus aureus • Group A Streptococcus • Deeper infections (and in immunocompromised patients) • Gram Negative • Anaerobic organisms • Mixed organisms

14. Tetanus & Prophylaxis • Tetanus status • Treat appropriately with tetanus toxoid and/or immunoglobulin • Antibiotic prophylaxis for deep and penetrating wounds or wounds contaminated with soil, dirt, etc. • Rabies prophylaxis for all feral animals and wild animal bites • Human bites: • Consider screening for HIV, hepatitis

15. Tetanus Prophylaxis Time sinceType of WoundTetanus ToxoidTetanus IG Vaccination AT LEAST 3 DOSES OF TETANUS TOXOID <5 yr All wounds -- -- 5-10 yr Clean minor wound -- -- All other yes -- >10 yr All wounds yes -- UNCERTAIN VACCINATION, OR <3 DOSES OF TETANUS TOXOID Clean minor wound yes -- All other wounds yes yes

16. References • Morgan AS: Risk factors for infection in the trauma patient. J Natl Med Assoc 1992; 84; 1019-23. • Infection in hospitalized trauma patients: incidence, risk factors, and complications. Papia G, McLellan BA, El-Helou P, Louie M, Rachlis A, Szalai JP, Simor AE. J Trauma. 1999 Nov;47(5):923-7. • Surgical Infection Society guideline: prophylactic antibiotic use in open fractures: an evidence-based guideline. Hauser CJ, Adams CA Jr, Eachempati SR, Council of the Surgical Infection Society. Surg Infect (Larchmt). 2006 Aug; 7(4):379-405. • Late outcomes of trauma patients with infections during index hospitalization. Czaja AS, Rivara FP, Wang J, Koepsell T, Nathens AB, Jurkovich GJ, Mackenzie E. J Trauma. 2009 Oct;67(4):805-14. • Severe trauma is not an excuse for prolonged antibiotic prophylaxis. Velmahos GC, Toutouzas KG, Sarkisyan G, Chan LS, Jindal A, Karaiskakis M, Katkhouda N, Berne TV, Demetriades D. Arch Surg. 2002 May;137(5):537-41. • Guide to the elimination of ventilator-associated pneumonia. An APIC Guide, 2009. Greene L, Sposato K. • A systematic review of randomized controlled trials exploring the effect of immunomodulative interventions on infection, organ failure, and mortality in trauma patients. Spruijt NE, Visser T, Leenen LP. Crit Care. 2010; 14(4):R150. Epub 2010 Aug 5. • National Nosocomial Infections Surveillance (NNIS) System. NNIS report, data summary from October 1986-April 1996, issued May 1996. A report from the NNIS System. Am J Infect Control. Oct 1996;24(5):380-8. • Textbook of Adult Emergency Medicine, 3rd ed, 2009. Cameron P, et al.