Identification and treatment of infections in multiply traumatized patients

Trauma is the leading cause of death among young adults, and infection is a leading complication in multiply traumatized patients. All antibiotic use and all infections among 1,009 patients admitted to the Maryland Institute for Emergency Medical Services Systems over a six-month period were reviewed. The vast majority of patients had sustained high-speed automobile trauma and had blunt injuries. All antibiotics were given by the infectious diseases consultants under predetermined protocols. During this time period, 175 infections and 76 bacteremias were identified. Thirty-three percent of the antibiotic use was for prophylaxis. Prophylactic antibiotics were used for open fractures, in which a cephalosporin was used; for abdominal trauma, in which an aminoglycoside and clindamycin or cefoxitin alone was used; and for penetrating open fractures of the oral cavity, in which penicillin was used. As therapy, the aminoglycosides were used in 25 percent, the cephalosporins in 21 percent, the penicillins in 39 percent, and other antibiotics in 15 percent of the cases. The organisms identified as causing infection were Staphylococcus aureus (25 percent), Escherichia coli (18 percent), Enterobacter species (17 percent), Pseudomonas species (12 percent), and Klebsiella species (11 percent). The sites of infections were primary bacteremia (11 percent), vascular lines (21 percent), the central nervous system (3 percent), the lower respiratory tract (13 percent), the paranasal sinuses (6 percent), the urinary tract (19 percent), surgical wounds (11 percent), the abdomen (7 percent), and other sites (9 percent). More than 82 percent of the infections that occurred were nosocomial in origin and were related to the various procedures used for monitoring and therapy in these critically ill patients. Infections of the abdominal cavity and the lower respiratory tract accounted for eight of the 10 infection-related deaths in these patients.