Bullet-related bacterial wound infections among injured personnel at emergency site hospitals in Bahir Dar: prevalence, antimicrobial susceptibility and associated factors.

BACKGROUND: Bullet-related bacterial wound infection can be caused by high-velocity bullets and shrapnel injuries. In Ethiopia, significant injuries were reported that may cause severe wound infections, persistent systemic infections and may lead to amputation and mortality. The magnitude, antimicrobial susceptibility profiles, and factors associated with bacterial wound infections among patients with bullet-related injuries are not yet studied particularly at health facilities in Bahir Dar, Northwest Ethiopia. Therefore, this study was aimed to determine the prevalence, bacterial profiles, antimicrobial susceptibility profiles, and factors associated with bacterial infections among patients with bullet-related injuries at referral health facilities in Bahir Dar, Northwest Ethiopia. METHODS: A Hospital-based cross-sectional study was conducted among patients with bullet-related injuries at three referral health facilities in Bahir Dar from May 25 to July 27, 2022. A total of 384 patients with bullet-related injuries were included in the study. Sociodemographic and clinical data were collected using a structured questionnaire. Wound swabs were collected aseptically and cultured on Blood and MacConkey agar following bacteriological standards. Biochemical tests were performed to differentiate bacteria for positive cultivation and antimicrobial susceptibility profiles of the isolates were done on Muller Hinton agar using the Kirby-Bauer disk diffusion technique according to the 2021 Clinical Laboratory Standard Institute (CLSI) guideline. The data were entered using Epi-Info version 7.3 and analyzed using SPSS version 25. Descriptive data were presented using frequency, percentages, figures, and charts. Logistic regression was carried out to identify factors associated with bacterial wound infections. P-value < 0.05 was considered statistically significant. RESULTS: The prevalence of bullet-related bacterial wound infection among three referral hospitals in Bahir Dar city was 54.7%. The most commonly isolated Gram-negative organism was Klebsiella spps 49 (23.3%) while among Gram-positive organism, Staphylococcus aureus 58 (27.6%) and coagulase-negative staphylococci (CONS) 18 (8.6%). Contamination, hospitalization and smoking habit were significantly associated with the presence of bullet-related bacterial wound infections. Over 97% multidrug resistant (MDR) bacterial isolates were identified and of theses, E. coli, Proteus species, Citrobactor, and Staphylococcus aureus were highly drug resistant. CONCLUSION: Increased prevalence of bullet-related bacterial wound infection was noticed in this study. S. aureus followed by Klebsiella species were most commonly isolated bacteria. High frequency of resistance to Ampicillin, Oxacillin, Cefepime, Ceftriaxone, Ceftazidime, Vancomycin, and Norfloxacin was observed. Therefore, proper handling of bullet injuries, prompt investigation of bacterial infections, monitoring of drug sensitivity patterns and antibiotic usage are critical.

Mycobacterium abscessus Soft Tissue Infection: Review of Published Cases and Challenges in Treatment.

We report the first case of Mycobacterium abscessus soft tissue infection following a firearm injury. We summarize previous published cases of M. abscessus soft tissue infection and review the current evidence on management.

Evaluation of infection rates with narrow versus broad-spectrum antibiotic regimens in civilian gunshot open-fracture injury.

INTRODUCTION: Civilian gunshot open-fracture injuries portray a significant health burden to patients. Use of antibiotics is endorsed by guideline recommendations for the prevention of post-traumatic infections, however, antimicrobial selection and their associated outcomes remains unclear. Therefore, we sought to compare infectious and other clinical outcomes between three antimicrobial cohorts in patients with gunshot-related fractures requiring operative intervention. MATERIALS AND METHODS: Patients were identified by retrospectively querying the University of Kentucky Trauma Registry for gunshot wound victims. A narrow regimen, an expanded gram-negative regimen, and a regimen containing a fluoroquinolone antimicrobial were identified for comparison. The primary outcome was a composite of infections at or before 14 days of hospitalization. Secondary endpoints included hospital length of stay, incidence of multidrug resistant bacteria and methicillin-resistant Staphylococcus aureus colonization, number of drug-related adverse events, number of Clostridium difficile infections, and 30-day mortality. RESULTS: 252 patients were selected for inclusion: 126 in the narrow regimen, 49 in the expanded gram-negative regimen, and 77 in the fluoroquinolone-based regimen. There were no statistical differences in the primary endpoint of early infectious outcomes between groups (p = 0.1797). The expanded gram-negative regimen was associated with increased hospital length of stay, and increased incidence of multi-drug resistant bacteria and methicillin-resistant Staphylococcus aureus colonization. There were no statistically significant differences in any of the remaining secondary endpoints. CONCLUSION: In this study evaluating civilian gunshot trauma, broad spectrum antibiotic coverage was not associated with improvements in post-traumatic infections. A randomized trial is needed to confirm these results.

In trauma, expect the unexpected: a rare case of post-traumatic pancreatitis associated with salmonellosis and enterocolitis.

A 16-year-old Hispanic man was transferred to our level I paediatric trauma centre with pancreatitis. Ten days prior, he had sustained a gunshot wound to the abdomen requiring an exploratory laparotomy for repair of a traumatic left diaphragmatic injury. Additional injuries included gastric, renal, liver and pancreatic lacerations as well as a T12 burst fracture that resulted in paraplegia. Conservative management of pancreatitis was unsuccessful over the next 10 days, resulting in progressive symptoms of severe unresolved pain, nausea, emesis and rising lipase. Workup for post-traumatic, biliary and drug-associated causes of pancreatitis was negative, and no anatomical abnormalities were found on imaging. A fever workup on hospital day 10 revealed a urinary tract infection with non-typhoid Salmonella sp, and subsequent stool and imaging studies revealed salmonellosis associated with right-sided colitis and Clostridium difficile infection. Pancreatitis resolved within 48 hours following treatment of salmonellosis and Clostridium.

In Vivo Fitness Adaptations of Colistin-Resistant Acinetobacter baumannii Isolates to Oxidative Stress.

The loss of fitness in colistin-resistant (CR) Acinetobacter baumannii was investigated using longitudinal isolates from the same patient. Early CR isolates were outcompeted by late CR isolates for growth in broth and survival in the lungs of mice. Fitness loss was associated with an increased susceptibility to oxidative stress since early CR strains had reduced in vitro survival in the presence of hydrogen peroxide and decreased catalase activity compared to that of late CR and colistin-susceptible (CS) strains.

[CHARACTERISTICS OF ANTIBIOTICORESISTANCE OF MICROFLORA IN A COMBAT (THE GUN-SHOT ANO THE MINE-EXPLOSION) WOUNDS OF THE EXTREMITIES].

Abstract Results of bacteriological investigations of a gun-shot and a mine-explosion woundings of the extremities were analyzed in Military-Medical Clinical Centres (MMCC) of Kyiv, Lviv and Vinnytsya. Spectrum of the allotted microorganisms and profile of their antibioticoresistance were disclosed. The patterns of resistance were determined in accordance to offering of international experts of European Committee on Antimicrobial Susceptibility Testing (EUCAST). Dominating microflora in a Chief MMCC (Kyiv) and MMCC of a Western Region (Lviv) were various species of the Enterobacteriaceae and P. aeruginosa families, while in MMCC of a Central Region (Vinnytsya)--a gramm-negative non-fermentative bacilli of the Acinetobacter genus and Pseudomonas genus. The majority (79.5%) of isolates were characterized by polyresistance for antibiotics. Maximal quantity of strains with a widened spectrum of resistance was revealed in 2 - 3 weeks after a wounding--in 71.4 and 96.9% accordingly.

Liver allografts from donors with peritoneal contamination: report of two cases.

Organs from deceased donors with traumatic abdominal injury, peritoneal contamination and open abdomen are usually discarded due to risks of transmission of severe infections to the recipient. There are no specific recommendations regarding organ utilization from these donors, but they might be an unexplored source able to attenuate organ shortage. Herein, the first successful report of a case involving liver transplantation using a liver allograft procured from a deceased donor with an open abdomen is outlined. This donor was a young trauma patient in which peritoneal contamination had occurred following a gunshot wound. Also included in this the report is liver transplant from a donor, who also was a trauma victim with an enteric perforation. The decision-making process to accept liver allografts from donors with a greater risk of peritoneal infection involved the absence of uncontrolled sepsis or visible contamination of the cavity. Appropriate donor-recipient matching and adequate anti-infectious management might have contributed to a favorable outcome, which suggest that these donors can be used as alternatives to reduce organ shortage.

[APPLICATION OF BACTERIOPHAGES IN COMPLEX OF TREATMENT OF A SHOT-GUN WOUNDS OF SOFT TISSUES IN THE PATIENTS, SUFFERING MULTIPLE ALLERGY FOR ANTIBIOTICS].

The results of complex therapy of the injured persons, suffering shot-gun wound of soft tissues in multiple allergy to antibiotics, using local bacteriophagotherapy, were analyzed.

An alarming presentation of Creutzfeldt-Jakob disease following a self-inflicted gunshot wound to the head.

Transmissible spongiform encephalopathies (TSE), also known as prion diseases, are characterized by rapid and fatal neurological decline. They not only detrimentally affect the patient, but also present additional challenges to healthcare systems due to the infectivity of the tissues and the difficulty of inactivating the prion. The most common TSE is Creutzfeldt-Jakob disease (CJD), which can occur after familial, spontaneous or acquired transmission. TSEs received more attention after the development of variant CJD (vCJD), also known as Mad Cow Disease, in the UK during the mid-1990s. Unlike familial or spontaneous CJD, this variant was connected to consumption of cattle contaminated with the prion disease, bovine spongiform encephalopathy.This development increased interest in the etiology of CJD and other TSEs and the risk it presents as an infectious disease. The following details the case of a 59-year-old male infected with CJD presented to our level II trauma center for treatment following a self-inflicted gunshot wound to the head.

Trauma and wound management: gunshot wounds in horses.

Bullet wounds in horses can cause a wide array of injuries, determined by the type of projectile, the energy of the bullet on entry, and the type of tissue the bullet encounters. Treatment includes identification of all structures involved, debridement of the permanent cavity, and establishing adequate drainage. Bullet wounds should be treated as contaminated, and broad-spectrum antibiotics, including those with an anaerobic spectrum, are indicated. Although musculoskeletal injuries resulting from gunshots are most common in horses, they carry a good prognosis for survival and return to function.

Prospective randomised controlled trial of nanocrystalline silver dressing versus plain gauze as the initial post-debridement management of military wounds on wound microbiology and healing.

INTRODUCTION: Recent conflicts have been characterised by the use of improvised explosive devices causing devastating injuries, including heavily contaminated wounds requiring meticulous surgical debridement. After being rendered surgical clean, these wounds are dressed and the patient transferred back to the UK for on-going treatment. A dressing that would prevent wounds from becoming colonised during transit would be desirable. The aim of this study was to establish whether using nanocrystalline silver dressings, as an adjunct to the initial debridement, would positively affect wound microbiology and wound healing compared to standard plain gauze dressings. METHODS: Patients were prospectively randomised to receive either silver dressings, in a nanocrystalline preparation (Acticoat™), or standard of care dressings (plain gauze) following their initial debridement in the field hospital. On repatriation to the UK microbiological swabs were taken from the dressing and the wound, and an odour score recorded. Wounds were followed prospectively and time to wound healing was recorded. Additionally, patient demographic data were recorded, as well as the mechanism of injury and Injury Severity Score. RESULTS: 76 patients were recruited to the trial between February 2010 and February 2012. 39 received current dressings and 37 received the trial dressings. Eleven patients were not swabbed. There was no difference (p=0.1384, Fishers) in the primary outcome measure of wound colonisation between the treatment arm (14/33) and the control arm (20/32). Similarly time to wound healing was not statistically different (p=0.5009, Mann-Whitney). Wounds in the control group were scored as being significantly more malodorous (p=0.002, Mann-Whitney) than those in the treatment arm. CONCLUSIONS: This is the first randomised controlled trial to report results from an active theatre of war. Performing research under these conditions poses additional challenges to military clinicians. Meticulous debridement of wounds remains the critical determinant in wound healing and infection and this study did not demonstrate a benefit of nanocrystaline silver dressing in respect to preventing wound colonisation or promoting healing, these dressings do however seem to significantly reduce the unpleasant odour commonly associated with battlefield wounds.

An unusual etiology of post-traumatic meningitis.

Clostridium perfringens and related species are well-known culprits of post-traumatic soft tissue and bone infection. However, central nervous system involvement with these organisms spontaneously or subsequent to trauma is unusual. The authors reported a case of post-traumatic meningitis in which both C perfringens and Enterococcus faecium were isolated.

A new model for the characterization of infection risk in gunshot injuries: technology, principal consideration and clinical implementation.

INTRODUCTION: The extent of wound contamination in gunshot injuries is still a topic of controversial debate. The purpose of the present study is to develop a model that illustrates the contamination of wounds with exogenous particles along the bullet path. MATERIAL AND METHODS: To simulate bacteria, radio-opaque barium titanate (3-6 µm in diameter) was atomized in a dust chamber. Full metal jacket or soft point bullets caliber .222 (n = 12, v0 = 1096 m/s) were fired through the chamber into a gelatin block directly behind it. After that, the gelatin block underwent multi-slice CT in order to analyze the permanent and temporary wound cavity. RESULTS: The permanent cavity caused by both types of projectiles showed deposits of barium titanate distributed over the entire bullet path. Full metal jacket bullets left only few traces of barium titanate in the temporary cavity. In contrast, the soft point bullets disintegrated completely, and barium titanate covered the entire wound cavity. DISCUSSION: Deep penetration of potential exogenous bacteria can be simulated easily and reproducibly with barium titanate particles shot into a gelatin block. Additionally, this procedure permits conclusions to be drawn about the distribution of possible contaminants and thus can yield essential findings in terms of necessary therapeutic procedures.

Debriding effect of bromelain on firearm wounds in pigs.

BACKGROUND: Wound excision is the standard treatment for firearm wounds. However, achieving a satisfactory curative effect is difficult because of the traumatic mechanism of high-velocity projectiles. We propose a new therapy by using topical bromelain as a supplement to wound incision for the debridement of firearm wounds. We clarified the debriding effect of bromelain on firearm wounds in pigs. METHODS: In vitro, muscle tissues around the wound track and normal muscle were incubated in bromelain solutions of different concentrations. Tissue hydrolization was estimated by measuring tissue weight and the release of total amino acids. In vivo, the hind limbs of 15 pigs were wounded with high-velocity projectiles. Five groups were classified as follows: wound excision (E), wound incision (I), bromelain (B), incision + bromelain (IB), and control (C). Debriding effectiveness was estimated using bacterial content, histopathologic examination, and wound healing time. RESULTS: In vitro, hydrolization of wound tissue was significantly more intensive than that of normal tissue. Bromelain solution (10 mg/mL) hydrolyzed wound tissue rapidly with minimal proteolysis of normal tissue. In vivo, the wound-track bacterial content of group IB was similar to that of group E and was significantly lower than that of groups I, B, and C. The wound healing time of group IB was also shorter. CONCLUSIONS: Bromelain is effective in the debridement of uncomplicated firearm wounds if used as a supplement to simple wound incision. This new therapy shows notable advantages over conventional surgical debridement as it greatly simplifies the procedures.

Survival of a patient with trauma-induced mucormycosis using an aggressive surgical and medical approach.

BACKGROUND: Mucormycosis is a deadly angioinvasive fungal infection that is increasing in incidence. Gastrointestinal and abdominal involvement is rare, has higher mortality rates, and is frequently diagnosed late. METHODS: We report a patient who sustained multiple gunshot wounds to the chest and abdomen and subsequently developed omental and hepatic mucormycosis. He underwent 14 abdominal washouts and several liver debridements, and he received combination therapy with amphotericin B and micafungin. RESULTS: The patient survived the disease, with negative cultures and pathology at the last washout, and underwent skin grafting. He is clinically improved and remains on oral antifungals as an outpatient. CONCLUSIONS: Mucormycosis should be considered in trauma patients with persistent signs of infection after lavage and antibiotics, especially when necrosis or atypical wound presentations are noted. Approaches such as ours using aggressive surgical management and intensive antifungal administration should be instituted once the diagnosis is suspected.

[Microbiological aspects and antibiotic treatment of abdominal gunshot injury].

Abdominal gunshot injury is a life-threatening condition that requires urgent and complex measures: control of hemorrhage and source of infection through a surgical intervention; prophylaxis and antibiotic therapy of the infectious complications; intensive care for cardiology and pulmonary support. First phase in infection process (diffuse peritonitis and bacteremia), is governed by Escherichia coli, Enterococcus spp, Bacteroides fragilis group, while the second (development of abscess)--by anaerobes. Application of antibiotic prophylaxis or therapy depends on the time since the incidence together with the score evaluating severity of patient'status. Empiric antibiotic therapy should be broad-spectrum and rapidly bactericidal.

Acinetobacter baumannii skin and soft-tissue infection associated with war trauma.

BACKGROUND: Acinetobacter baumannii is usually associated with nosocomial pneumonia or bacteremia. Reports of A. baumannii skin and soft-tissue infection (SSTI) are uncommon. METHODS: We performed a retrospective review of 57 inpatients admitted to a naval hospital ship and identified 8 patients with A. baumannii-associated SSTI. Demographic and clinical characteristics were compared between these patients and 49 patients with A. baumannii infections that were not SSTIs. We also reviewed 18 cases of A. baumannii-associated SSTI from the literature. RESULTS: Our 8 cases of A. baumannii-associated SSTI were associated with combat trauma wounds. The median age of the patients was 26 years. Although not statistically significant, A. baumannii-associated SSTIs were more likely to be associated with gunshot wounds (75% vs. 55%) or external fixators (63% vs. 29%), compared with A. baumannii infections that were not SSTIs. Use of a central venous catheter and total parenteral nutrition was also more common for patients with SSTI. Our cases of A. baumannii-associated SSTI presented as cellulitis with a "peau d'orange" appearance with overlying vesicles and, when untreated, progressed to necrotizing infection with bullae (hemorrhagic and nonhemorrhagic). In our case series, all isolates were multidrug resistant, and clinical success was achieved for 7 of 8 patients with debridement and carbapenem therapy. CONCLUSIONS: A. baumannii-associated SSTI is an emerging infection in patients who experience trauma. Clinicians should be aware of the potential role of A. baumannii as a multidrug-resistant pathogen causing hospital-acquired SSTI, particularly when associated with previous trauma or use of invasive devices. It should be suspected in patients who experience trauma and have edematous cellulitis with overlying vesicles. Early empirical coverage for drug-resistant species (e.g., with carbapenem therapy), combined with debridement, is usually curative.