{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,29]],"date-time":"2026-10-29T22:03:25Z","timestamp":1793311405356,"version":"4.5.0"},"reference-count":44,"publisher":"Oxford University Press (OUP)","issue":"Supplement_2","funder":[{"DOI":"10.13039\/100000002","name":"NIH","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2022,5,4]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n               <jats:sec>\n                  <jats:title>Introduction<\/jats:title>\n                  <jats:p>Extremity trauma is the most common battlefield injury, resulting in a high frequency of combat-related extremity wound infections (CEWIs). As these infections are associated with substantial morbidity and may impact wounded warriors long after initial hospitalization, CEWIs have been a focus of the Infectious Disease Clinical Research Program (IDCRP). Herein, we review findings of CEWI research conducted through the IDCRP and discuss future and ongoing analyses.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>Military personnel with deployment-related trauma sustained between 2009 and 2014 were examined in retrospective analyses through the observational Trauma Infectious Disease Outcomes Study (TIDOS). Characteristics of wounded warriors with \u22651 open extremity wound were assessed, focusing on injury patterns and infection risk factors. Through a separate trauma-associated osteomyelitis study, military personnel with combat-related open fractures of the long bones (tibia, femur, and upper extremity) sustained between 2003 and 2009 were examined to identify osteomyelitis risk factors.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Among 1,271 wounded warriors with \u22651 open extremity wound, 16% were diagnosed with a CEWI. When assessed by their most severe extremity injury (i.e., amputation, open fracture, or open soft-tissue wound), patients with amputations had the highest proportion of infections (47% of 212 patients with traumatic amputations). Factors related to injury pattern, mechanism, and severity were independent predictors of CEWIs during initial hospitalization. Having a non-extremity infection at least 4 days before CEWI diagnosis was associated with reduced likelihood of CEWI development. After hospital discharge, 28% of patients with extremity trauma had a new or recurrent CEWI during follow-up. Risk factors for the development of CEWIs during follow-up included injury pattern, having either a CEWI or other infection during initial hospitalization, and receipt of antipseudomonal penicillin for \u22657 days. A reduced likelihood for CEWIs during follow-up was associated with a hospitalization duration of 15-30 days. Under the retrospective osteomyelitis risk factor analysis, patients developing osteomyelitis had higher open fracture severity based on Gustilo\u2013Anderson (GA) and the Orthopaedic Trauma Association classification schemes and more frequent traumatic amputations compared to open fracture patients without osteomyelitis. Recurrence of osteomyelitis was also common (28% of patients with open tibia fractures had a recurrent episode). Although osteomyelitis risk factors differed between the tibia, femur, and upper extremity groups, sustaining an amputation, use of antibiotic beads, and being injured in the earlier years of the study (before significant practice pattern changes) were consistent predictors. Other risk factors included GA fracture severity \u2265IIIb, blast injuries, foreign body at fracture site (with\/without orthopedic implant), moderate\/severe muscle damage and\/or necrosis, and moderate\/severe skin\/soft-tissue damage. For upper extremity open fractures, initial stabilization following evacuation from the combat zone was associated with a reduced likelihood of osteomyelitis.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Forthcoming studies will examine the effectiveness of common antibiotic regimens for managing extremity deep soft-tissue infections to improve clinical outcomes of combat casualties and support development of clinical practice guidelines for CEWI treatment. The long-term impact of extremity trauma and resultant infections will be further investigated through both Department of Defense and Veterans Affairs follow-up, as well as examination of the impact on comorbidities and mental health\/social factors.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/milmed\/usab065","type":"journal-article","created":{"date-parts":[[2022,5,5]],"date-time":"2022-05-05T21:35:33Z","timestamp":1651786533000},"page":"25-33","source":"Crossref","is-referenced-by-count":36,"title":["IDCRP Combat-Related Extremity Wound Infection Research"],"prefix":"10.1093","volume":"187","author":[{"given":"Joseph L","family":"Petfield","sequence":"first","affiliation":[{"name":"Landstuhl Regional Medical Center , Landstuhl 19180, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Louis R","family":"Lewandowski","sequence":"additional","affiliation":[{"name":"Walter Reed National Military Medical Center , Bethesda, MD 20852, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laveta","family":"Stewart","sequence":"additional","affiliation":[{"name":"Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences , Bethesda, MD 20814, USA"},{"name":"Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. , Bethesda, MD 20817, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Clinton K","family":"Murray","sequence":"additional","affiliation":[{"name":"Brooke Army Medical Center , JBSA Fort Sam Houston, TX 78234, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David R","family":"Tribble","sequence":"additional","affiliation":[{"name":"Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences , Bethesda, MD 20814, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2022,5,5]]},"reference":[{"issue":"1","key":"2022071313545255300_R1","first-page":"204","article-title":"Incidence and epidemiology of combat injuries sustained during \u201cthe surge\u201d portion of Operation Iraqi Freedom by a U.S. Army Brigade Combat Team","volume":"68","author":"Belmont","year":"2010","journal-title":"J Trauma"},{"issue":"6","key":"2022071313545255300_R2","doi-asserted-by":"crossref","first-page":"341","DOI":"10.5435\/JAAOS-D-15-00123","article-title":"Musculoskeletal injuries in Iraq and Afghanistan: epidemiology and outcomes following a decade of war","volume":"24","author":"Belmont","year":"2016","journal-title":"J Am Acad Orthop Surg"},{"issue":"4","key":"2022071313545255300_R3","doi-asserted-by":"crossref","first-page":"254","DOI":"10.1097\/BOT.0b013e31802f78fb","article-title":"Characterization of extremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom","volume":"21","author":"Owens","year":"2007","journal-title":"J Orthop Trauma"},{"issue":"2","key":"2022071313545255300_R4","doi-asserted-by":"crossref","first-page":"287","DOI":"10.1097\/TA.0b013e31829a0970","article-title":"The nature and extent of war injuries sustained by combat specialty personnel killed and wounded in Afghanistan and Iraq, 2003-2011","volume":"75","author":"Schoenfeld","year":"2013","journal-title":"J Trauma Acute Care Surg"},{"issue":"6 Suppl 5","key":"2022071313545255300_R5","doi-asserted-by":"crossref","first-page":"S438","DOI":"10.1097\/TA.0b013e318275469c","article-title":"Ten years at war: comprehensive analysis of amputation trends","volume":"73","author":"Krueger","year":"2012","journal-title":"J Trauma Acute Care Surg"},{"issue":"7","key":"2022071313545255300_R6","doi-asserted-by":"crossref","first-page":"1439","DOI":"10.1016\/j.injury.2017.05.022","article-title":"Extremity injuries sustained by the UK military in the Iraq and Afghanistan conflicts: 2003-2014","volume":"48","author":"Chandler","year":"2017","journal-title":"Injury"},{"issue":"1","key":"2022071313545255300_R7","doi-asserted-by":"crossref","first-page":"101","DOI":"10.1302\/0301-620X.95B1.30580","article-title":"Severe open tibial fractures in combat trauma: management and preliminary outcomes","volume":"95-B","author":"Penn-Barwell","year":"2013","journal-title":"Bone Joint J"},{"issue":"1","key":"2022071313545255300_R8","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1007\/s11751-016-0250-x","article-title":"Factors influencing infection in 10 years of battlefield open tibia fractures","volume":"11","author":"Penn-Barwell","year":"2016","journal-title":"Strategies Trauma Limb Reconstr"},{"issue":"6 Suppl 5","key":"2022071313545255300_R9","doi-asserted-by":"crossref","first-page":"S520","DOI":"10.1097\/TA.0b013e31827559da","article-title":"Dismounted complex blast injury report of the army dismounted complex blast injury task force","volume":"73","author":"Ficke","year":"2012","journal-title":"J Trauma Acute Care Surg"},{"issue":"2 Suppl","key":"2022071313545255300_R10","first-page":"S163","article-title":"Osteomyelitis in military personnel wounded in Iraq and Afghanistan","volume":"64","author":"Yun","year":"2008","journal-title":"J Trauma"},{"issue":"3 Suppl 2","key":"2022071313545255300_R11","doi-asserted-by":"crossref","first-page":"S194","DOI":"10.1097\/TA.0000000000000364","article-title":"Infection reduces return-to-duty rates for soldiers with Type III open tibia fractures","volume":"77","author":"Napierala","year":"2014","journal-title":"J Trauma Acute Care Surg"},{"issue":"1 Suppl","key":"2022071313545255300_R12","first-page":"S47","article-title":"Infectious complications and soft tissue injury contribute to late amputation after severe lower extremity trauma","volume":"71","author":"Huh","year":"2011","journal-title":"J Trauma"},{"issue":"1 Suppl","key":"2022071313545255300_R13","first-page":"S33","article-title":"Infection-associated clinical outcomes in hospitalized medical evacuees after traumatic injury: Trauma Infectious Disease Outcome Study","volume":"71","author":"Tribble","year":"2011","journal-title":"J Trauma"},{"issue":"Suppl 2","key":"2022071313545255300_R14","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1093\/milmed\/usz027","article-title":"After the battlefield: infectious complications among wounded warriors in the Trauma Infectious Disease Outcomes Study","volume":"184","author":"Tribble","year":"2019","journal-title":"Mil Med"},{"issue":"9","key":"2022071313545255300_R15","doi-asserted-by":"crossref","first-page":"e344","DOI":"10.1097\/BOT.0000000000001225","article-title":"Osteomyelitis risk factors related to combat trauma open tibia fractures: a case-control analysis","volume":"32","author":"Tribble","year":"2018","journal-title":"J Orthop Trauma"},{"issue":"Suppl 2","key":"2022071313545255300_R16","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1093\/milmed\/usab131","article-title":"Multidrug-Resistant and Virulent Organisms (MDR\/VO) trauma infections: TIDOS initiative","volume":"187","author":"Mende","year":"2022","journal-title":"Mil Med"},{"issue":"Suppl 1","key":"2022071313545255300_R17","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1093\/milmed\/usy336","article-title":"Combat-related extremity wounds: injury factors predicting early onset infections","volume":"184","author":"Stewart","year":"2019","journal-title":"Mil Med"},{"issue":"5","key":"2022071313545255300_R18","doi-asserted-by":"crossref","first-page":"494","DOI":"10.1089\/sur.2017.241","article-title":"Epidemiology of trauma-related infections among a combat casualty cohort after initial hospitalization: the Trauma Infectious Disease Outcomes Study","volume":"19","author":"Tribble","year":"2018","journal-title":"Surg Infect (Larchmt)"},{"issue":"10","key":"2022071313545255300_R19","doi-asserted-by":"crossref","first-page":"1258","DOI":"10.7205\/MILMED-D-15-00368","article-title":"Impact of operational theater on combat and noncombat trauma-related infections","volume":"181","author":"Tribble","year":"2016","journal-title":"Mil Med"},{"issue":"5","key":"2022071313545255300_R20","doi-asserted-by":"crossref","first-page":"803","DOI":"10.1097\/01.sla.0000251707.32332.c1","article-title":"Trauma-related infections in battlefield casualties from Iraq","volume":"245","author":"Petersen","year":"2007","journal-title":"Ann Surg"},{"issue":"1 Suppl","key":"2022071313545255300_R21","first-page":"S62","article-title":"Infections complicating the care of combat casualties during Operations Iraqi Freedom and Enduring Freedom","volume":"71","author":"Murray","year":"2011","journal-title":"J Trauma"},{"issue":"4 Suppl","key":"2022071313545255300_R22","first-page":"S138","article-title":"Infections in combat casualties during Operations Iraqi and Enduring Freedom","volume":"66","author":"Murray","year":"2009","journal-title":"J Trauma"},{"issue":"2 Suppl 2","key":"2022071313545255300_R23","first-page":"S210","article-title":"Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society","volume":"71","author":"Hospenthal","year":"2011","journal-title":"J Trauma"},{"issue":"3","key":"2022071313545255300_R24","first-page":"S211","article-title":"Guidelines for the prevention of infection after combat-related injuries","volume":"64","author":"Hospenthal","year":"2008","journal-title":"J Trauma"},{"key":"2022071313545255300_R25","article-title":"Infection prevention in combat-related injuries (CPG ID: 24)","volume-title":"Joint Trauma System","author":"Saeed","year":"2016"},{"issue":"Suppl 2","key":"2022071313545255300_R26","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1093\/milmed\/usy077","article-title":"Infection prevention in combat-related injuries","volume":"183","author":"Saeed","year":"2018","journal-title":"Mil Med"},{"issue":"S1","key":"2022071313545255300_R27","doi-asserted-by":"crossref","first-page":"346","DOI":"10.7205\/MILMED-D-16-00040","article-title":"Variation in postinjury antibiotic prophylaxis patterns over five years in a combat zone","volume":"182","author":"Lloyd","year":"2017","journal-title":"Mil Med"},{"issue":"5","key":"2022071313545255300_R28","doi-asserted-by":"crossref","first-page":"854","DOI":"10.1097\/TA.0000000000001609","article-title":"Early infectious outcomes following addition of fluoroquinolone or aminoglycoside to post-trauma antibiotic prophylaxis in combat-related open fracture injuries","volume":"83","author":"Lloyd","year":"2017","journal-title":"J Trauma Acute Care Surg"},{"issue":"9-10","key":"2022071313545255300_R29","doi-asserted-by":"crossref","first-page":"e260","DOI":"10.1093\/milmed\/usx125","article-title":"Antimicrobial prophylaxis with combat-related open soft-tissue injuries","volume":"183","author":"Lloyd","year":"2018","journal-title":"Mil Med"},{"key":"2022071313545255300_R30","article-title":"CDC\/NHSN surveillance definitions for specific types of infections","author":"Centers for Disease Control and Prevention","year":"2019"},{"issue":"4","key":"2022071313545255300_R31","doi-asserted-by":"crossref","first-page":"453","DOI":"10.2106\/00004623-197658040-00004","article-title":"Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses","volume":"58","author":"Gustilo","year":"1976","journal-title":"J Bone Joint Surg Am"},{"issue":"10 Suppl","key":"2022071313545255300_R32","doi-asserted-by":"crossref","first-page":"S1","DOI":"10.1097\/00005131-200711101-00001","article-title":"Fracture and dislocation classification compendium\u20142007: Orthopaedic Trauma Association classification, database and outcomes committee","volume":"21","author":"Marsh","year":"2007","journal-title":"J Orthop Trauma"},{"issue":"8","key":"2022071313545255300_R33","doi-asserted-by":"crossref","first-page":"457","DOI":"10.1097\/BOT.0b013e3181c7cb6b","article-title":"A new classification scheme for open fractures","volume":"24","author":"Orthopaedic Trauma Association: Open Fracture Study Group","year":"2010","journal-title":"J Orthop Trauma"},{"issue":"4","key":"2022071313545255300_R34","doi-asserted-by":"crossref","first-page":"e110","DOI":"10.1097\/BOT.0000000000001397","article-title":"Osteomyelitis risk factors related to combat trauma open femur fractures: a case-control analysis","volume":"33","author":"Lewandowski","year":"2019","journal-title":"J Orthop Trauma"},{"issue":"12","key":"2022071313545255300_R35","doi-asserted-by":"crossref","first-page":"e475","DOI":"10.1097\/BOT.0000000000001593","article-title":"Osteomyelitis risk factors related to combat trauma open upper extremity fractures: a case-control analysis","volume":"33","author":"Warkentien","year":"2019","journal-title":"J Orthop Trauma"},{"issue":"4","key":"2022071313545255300_R36","doi-asserted-by":"crossref","first-page":"789","DOI":"10.1097\/CORR.0000000000000411","article-title":"Is bone loss or devascularization associated with recurrence of osteomyelitis in wartime open tibia fractures?","volume":"477","author":"Petfield","year":"2019","journal-title":"Clin Orthop Relat Res"},{"issue":"3 Suppl","key":"2022071313545255300_R37","first-page":"S239","article-title":"Prevention and management of infections associated with combat-related extremity injuries","volume":"64","author":"Murray","year":"2008","journal-title":"J Trauma"},{"issue":"7","key":"2022071313545255300_R38","article-title":"Negative pressure wound therapy for open traumatic wounds","volume":"7","author":"Iheozor-Ejiofor","year":"2018","journal-title":"Cochrane Database Syst Rev"},{"issue":"10","key":"2022071313545255300_R39","doi-asserted-by":"crossref","first-page":"1965","DOI":"10.1007\/s00264-017-3556-5","article-title":"Risk factors for infectious complications after open fractures; a systematic review and meta-analysis","volume":"41","author":"Kortram","year":"2017","journal-title":"Int Orthop"},{"issue":"9","key":"2022071313545255300_R40","doi-asserted-by":"crossref","first-page":"904","DOI":"10.1001\/jamasurg.2014.940","article-title":"Changing patterns of in-hospital deaths following implementation of damage control resuscitation practices in US forward military treatment facilities","volume":"149","author":"Langan","year":"2014","journal-title":"JAMA Surg"},{"issue":"5","key":"2022071313545255300_R41","doi-asserted-by":"crossref","first-page":"651","DOI":"10.1007\/s00068-016-0725-y","article-title":"The Gustilo\u2013Anderson classification system as predictor of nonunion and infection in open tibia fractures","volume":"43","author":"Thakore","year":"2017","journal-title":"Eur J Trauma Emerg Surg"},{"key":"2022071313545255300_R42","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1097\/01.blo.0000150345.51508.74","article-title":"Host classification predicts infection after open fracture","volume":"433","author":"Bowen","year":"2005","journal-title":"Clin Orthop Relat Res"},{"issue":"3","key":"2022071313545255300_R43","doi-asserted-by":"crossref","first-page":"149","DOI":"10.1097\/BOT.0000000000000488","article-title":"Factors associated with development of nonunion or delayed healing after an open long bone fracture: a prospective cohort study of 736 subjects","volume":"30","author":"Westgeest","year":"2016","journal-title":"J Orthop Trauma"},{"issue":"Suppl 1","key":"2022071313545255300_R44","doi-asserted-by":"crossref","first-page":"628","DOI":"10.1093\/milmed\/usz211","article-title":"Antibiotic practice patterns for extremity wound infections among blast-injured subjects","volume":"185","author":"Stewart","year":"2020","journal-title":"Mil Med"}],"container-title":["Military Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/milmed\/article-pdf\/187\/Supplement_2\/25\/44855585\/usab065.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/milmed\/article-pdf\/187\/Supplement_2\/25\/44855585\/usab065.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,7,13]],"date-time":"2022-07-13T13:55:47Z","timestamp":1657720547000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/milmed\/article\/187\/Supplement_2\/25\/6580958"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,5,1]]},"references-count":44,"journal-issue":{"issue":"Supplement_2","published-online":{"date-parts":[[2022,5,5]]},"published-print":{"date-parts":[[2022,5,4]]}},"URL":"https:\/\/doi.org\/10.1093\/milmed\/usab065","relation":{},"ISSN":["0026-4075","1930-613X"],"issn-type":[{"value":"0026-4075","type":"print"},{"value":"1930-613X","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2022,5,1]]},"published":{"date-parts":[[2022,5,1]]}}}