ANTIBIOTICS IN TACTICAL COMBAT CASUALTY CARE (TCCC)

1. ANTIBIOTICS IN TACTICAL COMBAT CASUALTY CARE (TCCC) Infections and sepsis are a late cause of morbidity and mortality in combat trauma patients. Recommendations for and commentary on early administration of antibiotics in the combat casualty have been recorded since WWII.

2. ANTIBIOTICS IN TCCC All wounds sustained on the battlefield should receive antibiotics. But at a minimum, any patient presenting with penetrating abdominal trauma, massive soft tissue damage, a grossly contaminated wound, open fracture, or a long delay in CASEVAC/MEDVAC should receive prophylactic antibiotics.

3. ANTIBIOTICS IN TCCC • War wound antibiotics need to be simple, practical, effective, have a good safety profile, and a broad spectrum of activity. • Treatment should start immediately and continue at least until surgical debridement has occurred. • Coverage should be appropriate for the organisms implicated in combat wound infections.

4. ANTIBIOTICS IN TCCC • Consideration should be made as to how far forward the BN PA/MD want to push antibiotic supplies and release authority. This will depend on several factors: • Supply/Re-supply • Education and training level of Medics, Combat Life Savers, and Laymen • Mission and Unit priority

5. PILL AND PARENTAL PACKS • Pill Packs may be available thru the hospital Pharmacy/MedLog, or if stocks are plentiful can be assembled and packaged at the BAS. • Parental Packs could also be assembled and used by the medics as directed; particularly if their CASEVAC may by-pass the BAS en-route to the FST. • PAs/MDs must educate and emphasize judicious use particularly of p.o. antibiotics to decrease development of resistant organisms.

6. ORAL PROPHYLAXIS • Decrease the logistical burden of carrying, reconstitution and injection of parental medications • Simple, light, durable, and easily administered • Single agent DOC is #1Gatifloxacin followed by #2Moxifloxacin • More realistic choices would be Levofloxacin or Ciprofloxacin alone or in combination with Metronidazole or Clindamycin

7. PARENTAL ANTIBIOTICS • Should be used in unconscious casualties, patients in shock, and penetrating abdominal trauma • Does not lessen the importance of rapid transit to definitive care and surgical treatment • Successful regimes include: • Single Agents #1Cefoxitin 1-2 Gms TID IV/IM. If IV push over 3-5 minutes. #2. Ertapenum 1Gm qd IV/IM. If IV, it must be given over 30 minutes. If IM, it should be mixed with 3.2cc of 1% Lidocaine without Epinephrine. • Combinations: #1Gentamicin and Clindamycin, #2Tobramycin and Clindamycin. • What you’ll probably have and use most will be Cefazolin and Ciprofloxacin.

8. P.O. Antibiotics Pen VK Clindamycin Cephalexin Doxycycline Augmentin Metronidazole Ciprofloxacin Azithromycin Gatifloxacin Sulfamethoxazole Parental Antibiotics Ceftriaxone Cefazolin MES SICKCALL

9. P.O. Antibiotics Gatifloxacin Parental Antibiotics Cefazolin Ciprofloxacin MES TRAUMA

10. AS SOON AS YOU ARRIVE • Perform an inventory. • Differentiate NEED and “nice to have” • Speak with: Div Surgeon/PA, Pharmacy Chief, MEDLOG, Returning or Sister Units, and Inter-theater MEDLOG via email to determine what is available, possible, impossible, and surplus to guide you on your request • Be prepared to barter, do favors, and kiss-up to get what you want

11. PRIOR TO MISSION • Request and or prepare Pill Packs and Parental Packs for the BAS, Platoon Medics, Combat Life Savers, and Laymen as supplies, training, mission, and confidence dictate. • Pre-think drug protocols and combinations. • Place orders to MEDLOG/Pharmacy ASAP! • Don’t break the bank on “Pet Drugs”.

12. DURING MISSION • BE AGGRESSIVE. • Don’t be afraid to go “Old School”. • Safeguard your “Z-Packs”. • Resist using Cipro for every soft stool. • Use good wound care and frequent re-eval to optimize AB effect. • Anticipate shortages, and order early!!!

13. QUESTIONS??? POC: Shon Compton W# (210) 221-4734 C# (210) 488-8695 Email scompton1@satx.rr.com shon.compton@amedd.army.mil