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Introduction: We examined antibiotic management of combat-related extremity wound infections (CEWI) among wounded U.S. military personnel (2009-2012)., Methods: Patients were included if they sustained blast injuries, resulting in ≥1 open extremity wound, were admitted to participating U.S. hospitals, developed a CEWI (osteomyelitis or deep soft-tissue infections) within 30 days post-injury, and received ≥3 days of relevant antibiotic (s) for treatment., Results: Among 267 patients, 133 (50%) had only a CEWI, while 134 (50%) had a CEWI plus concomitant non-extremity infection. In the pre-diagnosis period (4-10 days prior to CEWI diagnosis), 95 (36%) patients started a new antibiotic with 28% of patients receiving ≥2 antibiotics. During CEWI diagnosis week (±3 days of diagnosis), 209 (78%) patients started a new antibiotic (71% with ≥2 antibiotics). In the week following diagnosis (4-10 days after CEWI diagnosis), 121 (45%) patients started a new antibiotic with 39% receiving ≥2 antibiotics. Restricting to ±7 days of CEWI diagnosis, patients commonly received two (35%) or three (27%) antibiotics with frequent combinations involving carbapenem, vancomycin, and fluoroquinolones., Conclusions: Substantial variation in antibiotic prescribing patterns related to CEWIs warrants development of combat-related clinical practice guidelines beyond infection prevention, to include strategies to reduce the use of unnecessary antibiotics and improve stewardship., (Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2020.)

Multidisciplinary trauma care systems have been shown to improve patient outcomes. Medical care in support of the global war on terror has provided opportunities to refine these systems. We report on the multidisciplinary trauma care system at the Role III Hospital at Kandahar Airfield, Afghanistan. We reviewed the Joint Trauma System Registry, Kandahar database from 1 October 2009 to 31 December 2010 and extracted data regarding patient demographics, clinical variables and outcomes. We also queried the operating room records from 1 January 2009 to 31 December 2010. In the study period of 1 October 2009 to 31 December 2010, 2599 patients presented to the trauma bay, with the most common source of injury being from Improvised Explosive Device (IED) blasts (915), followed by gunshot wounds (GSW) (327). Importantly, 19 patients with triple amputations as a result of injuries from IEDs were seen. 127 patients were massively transfused. The in-hospital mortality was 4.45%. From 1 January 2010 to 31 December 2010, 4106.24 operating room hours were logged to complete 1914 patient cases. The mean number of procedures per case in 2009 was 1.27, compared to 3.11 in 2010. Multinational, multidisciplinary care is required for the large number of severely injured patients seen at Kandahar Airfield. Multidisciplinary trauma care in Kandahar is effective and can be readily employed in combat hospitals in Afghanistan and serve as a model for civilian centres., (Published by Elsevier Ltd.)

Little is known about the utilization of central nervous system (CNS) and musculoskeletal (MS) medications in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans with blast-related injuries (BRIs). We followed prescription drug use among a cohort of 133 OIF/OEF veterans with BRIs by using the Joint Theatre Trauma Registry, the Tampa Polytrauma Registry, and electronic medical records. We extracted 12 months of national medication records from the Veterans Health Administration Decision Support System and analyzed them with descriptive statistics. Over the 12-month period (fiscal year 2007), CNS medications comprised 27.9% (4,225/15,143) of total prescriptions dispensed to 90.2% (120/133) of our cohort. Approximately one-half (48.9%) of the 133 patients were treated with opioid analgesics. Nearly 60% received antidepressants. More than one-half (51.1%) of patients were treated with anticonvulsants. Benzodiazepines and antipsychotics were dispensed to 17.3% and 15.8%, respectively. For MS medicines, 804 were prescribed for 48.1% (64/133) of veterans. Nearly one-fourth (24.8%) were treated with skeletal muscle relaxants. The CNS and MS medications, in general, were continuously prescribed over the 12-month study period. This study provides insight into the complex medical management involved in the care of veterans with BRIs.

Background: Little is known about the utilization and costs of central nervous system (CNS) and musculoskeletal medications in veterans with blast injuries., Methods: Two years of national medication records of Operations Enduring Freedom and Iraqi Freedom veterans with blast injuries were extracted from the Veterans Health Administration Decision Support System and analyzed with descriptive statistics., Results: Over the 2-year period, there was a total of 23,795 pharmacy claims (various drug classes) for 60 patients with blast injuries with a 2-year drug acquisition cost of $111,535 (mean per patient = $1,858; median per patient = $960). There were 6,471 CNS pharmacy claims or 4.5 CNS pharmacy claims per patient per month. Over four (81.6%) of five veterans were prescribed opioid analgesics; 75.0% (45 of 60) received antidepressants; 68.3% (41 of 60) received anticonvulsants; 40% (24 of 60) received antipsychotics; and 41.6% (25 of 60) received sedative hypnotics. The drug acquisition cost of all CNS medications was $46,384 ($7.17 per claim) and accounted for over 41% of total medication spending. For musculoskeletal medications, there were 1,253 pharmacy claims for 32 patients or 53% of the cohort costing $5,015 ($4.00 per claim), which accounted for 4.5% ($5,015 of $111,535) of total medication spending., Conclusions: The analysis suggests that these combat-wounded veterans were discharged on CNS medications with potential side effects, although the magnitude of these side effects, if any, remains unknown.

Burn patients with extensive involvement of body surface area (BSA >30%) represent a challenge in wound treatment. Multiple topical agents may be used for cleansing, barrier protection, and antimicrobial control leading to complications of contact and/or irritant dermatitis, which may further complicate re-epithelization and eventual wound healing. We present 4 patients who sustained extensive burns during Operation Iraqi Freedom/Operation Enduring Freedom and later developed contact dermatitis to mafenide acetate, a common topical antimicrobial used in burn care treatment, also known as Sulfamylon (alpha-amino-p-toluenesulfonamide monoacetate). All patients who were patch tested to mafenide acetate 7% solution were positive. A rechallenge with mafenide acetate resulted in recrudescence of the eruption in 2 out of the 4 patients. Though cutaneous reactions to mafenide acetate were reported by Yaffe and Dressler in 1969, the most recent case reports are from 1995. This paper presents more recent examples of cutaneous reactions to mafenide acetate, while also reviewing the literature.