Infections complicating battlefield trauma, particularly those with multidrug-resistant (MDR) and novel pathogens, adversely impact the health and recovery of wounded warriors. Community-associated skin and soft-tissue infections (SSTIs) also impose a high burden on the health of military personnel living in close quarters (e.g., recruits), as well as affecting frontline readiness through lost duty and/or training days.
The overarching aim of the Wound Infections Research Area is to mitigate the infection burden among military personnel by supporting improvements in evidence-based clinical practice guidelines (CPGs) and identifying effective prevention and treatment strategies for battlefield-related wound infections and community-associated SSTIs.
Through the Trauma Infectious Disease Outcomes Study (TIDOS), led by Dr. David Tribble, recently completed analyses examined outcomes with penetrating and closed cranial injuries and burns, as well as evaluated the performance of a real-time commercial Mucorales assay to support trauma-related fungal infection diagnosis. A TIDOS follow-up cohort collected infection-related data after the initial hospitalization, and in collaboration with Dr. Jay McDonald of the Veterans Affairs St. Louis Health Care System, characterization of long-term impacts of battlefield trauma and trauma-related infections is underway, to include opioid use and post-traumatic stress disorder. Led by Dr. Katrin Mende and in collaboration with multiple DoD laboratories, wound microbiology has been assessed through the TIDOS MDR and Other Virulent Organisms (MDR/VO) Trauma Infections Initiative. Current analyses are assessing the epidemiology and resistance characteristics of wound infections with Acinetobacter baumannii and Staphylococcus aureus.
Other TIDOS initiatives are focused on supporting the refinement and development of evidence-based CPGs and wartime preparedness. In collaboration with the University of Minnesota (UMN) and University of Michigan Medicine, data from military and civilian trauma patients are being utilized to assess outcomes with different post-trauma prophylactic strategies and examine the effectiveness of antimicrobial treatment of extremity wound infections. Findings from these analyses, with a systematic review conducted by the UMN Evidence-Based Practice Center, will provide an evidence base for use by a consensus panel to refine existing and develop new Joint Trauma System (JTS) CPGs for the prevention and treatment of battlefield-related wound infections.
In collaboration with the U.S. Army Institute of Surgical Research (USAISR) and U.S. Army’s Telemedicine and Advanced Technology Research Center (TATRC), machine learning algorithms are being developed to support a clinical decision support tool to aid infection risk stratification of combat casualties in the prehospital setting, particularly with prolonged field care, and offer diagnostic support with enhanced precision following hospital admission. A Wartime Infection, Control and Prevention Knowledge, Attitudes, and Practices (KAP) Survey is being developed to identify areas where additional training and education of frontline providers may be needed regarding the management of infectious diseases during deployment. Through another initiative, technical recommendations and scientific/regulatory frameworks are being developed to inform a next-generation JTS DoD Trauma Registry Infectious Disease (ID) Module and Wartime Specimen and Isolate Repositories. ‘On-the-shelf’ clinical trial protocols for activation during future conflicts to examine the effectiveness of battlefield wound infection prevention and management strategies and products are being developed in collaboration with the George Washington University Biostatistics Center. Discussions are underway with the JTS and other stakeholders regarding potential research questions and interventions for assessment with the protocols.
Community-associated SSTIs, generally S. aureus, have been examined in congregate military populations through multiple IDCRP protocols and pooling the data and specimens from those protocols into the new SSTI Repository Protocol is nearing completion. Analysis of data in the repository, combined with a systematic review, will identify evidence gaps related to the prevention of community-associated SSTIs and inform potential prevention strategies and/or products for future prospective evaluation.
During 2024, analyses were completed for the DoD Antimicrobial Stewardship Program (ASP) study, which is the first IDCRP protocol to examine ASPs within the Military Health System (MHS). An enterprise-wide framework analysis of the structure and outcomes of DoD ASPs was conducted in relation to the Centers for Disease Control and Prevention (CDC) Core Elements and findings were compared against national hospital results.
For 2025, collaborative initiatives designed to address gaps in combat casualty care will remain priorities. Building on the foundation of TIDOS, and endorsed by the JTS, a new Military Trauma Infections – Southwest Asia Conflicts Cohort protocol is being developed to expand data collection for the full period of the wars in Iraq and Afghanistan to include recent conflicts (2001-2023), which will allow examination of outcomes with different polytraumatic injury patterns, operational theaters, wound microbiology, and time periods (e.g., practice pattern changes). Comparative analyses of combat casualty data in collaboration with the United Kingdom Ministry of Defence and data collection through the Wartime Infection, Control and Prevention KAP Survey are also expected to occur in the coming year.
Military Impact
Initiatives of the Wound Infections Research Area remain aligned with priorities of the Defense Health Agency (DHA) Military Infectious Diseases, JTS, and the MHS by addressing gaps in combat casualty care to support wartime preparedness and informing the development of a research infrastructure for future conflicts. The Wartime Infection, Control and Prevention KAP Survey will evaluate the familiarity of frontline providers with combat casualty care and infectious disease guidelines. The TIDOS team is also providing support for prospective, observational studies of Ukraine war-related wound infections conducted by the University of Colorado and in collaboration with the Walter Reed Army Institute of Research, Multidrug-Resistant Organism Repository and Surveillance Network (WRAIR MRSN). Through the DoD ASP Study, recommendations for areas where ASPs could be improved in military hospitals as compared to national standards were included in a technical report submitted to the DHA Antimicrobial Stewardship Committee. Findings from the Antibiotic-Resistant Bloodstream Infection (BSI) Study on BSI trends, resistance patterns, and mortality over a decade in MHS beneficiaries will help inform patient care.