The burden of infection in severely injured trauma patients and the relationship with admission shock severity.
BACKGROUND
Infection following severe injury is common and has a major impact on patient outcomes. The relationship between patient, injury, and physiologic characteristics with subsequent infections is not clearly defined. The objective of this study was to characterize the drivers and burden of all-cause infection in critical care trauma patients.


METHODS
A prospective cohort study of severely injured adult patients admitted to critical care was conducted. Data were collected prospectively on patient and injury characteristics, baseline physiology, coagulation profiles, and blood product use. Patients were followed up daily for infectious episodes and other adverse outcomes while in the hospital.


RESULTS
Three hundred patients (Injury Severity Score [ISS] >15) were recruited. In 48 hours or less, 29 patients (10%) died, leaving a cohort of 271. One hundred forty-one patients (52%) developed at least one infection. Three hundred four infections were diagnosed overall. Infection and noninfection groups were matched for age, sex, mechanism, and ISS. Infection rates were greater with any degree of admission shock and threefold higher in the most severely shocked cohort (p < 0.01). In multivariate analysis, base deficit (odds ratio [OR], 1.78, 95% confidence interval [CI], 1.48-1.94; p < 0.001) and lactate (OR, 1.36; 95% CI, 1.10-1.69; p = 0.05) were independently associated with the development of infection. Outcomes were significantly worse for the patients with infection. In multivariate logistic regression, infection was the only factor independently associated with multiple-organ failure (p < 0.001; OR, 15.4; 95% CI, 8.2-28.9; r = 0.402), ventilator-free days (p < 0.001; β, -4.48; 95% CI, -6.7 to -2.1; r = 0.245), critical care length of stay (p < 0.001; β, 13.2; 95% CI, 10.0-16.4; r = 0.466), and hospital length of stay (p < 0.001; β, 31.1; 95% CI, 24.0-38.2; r = 0.492).


CONCLUSIONS
Infectious complications are a burden for severely injured patients and occur early in the critical care stay. Severity of admission shock was predictive of infection and represents an opportunity for interventions to improve infectious outcomes. The incidence of infection may also have utility as an end point for clinical trials in trauma hemorrhage given the relationship with patient-experienced outcomes.


METHODS
Prognostic/epidemiologic study, level II.
From the Centre for Trauma Sciences (E.C., R.D., K.B.), Blizard Institute, Queen Mary University of London, London; and Department of Orthopaedic Trauma Surgery (K.W.), University of Oxford, Oxford, United Kingdom.
Elaine
E
Cole
Ross
R
Davenport
Keith
K
Willett
Karim
K
Brohi
D000328:Adult; D005260:Female; D006801:Humans; D007239:Infections / Q000209:etiology* / Q000382:microbiology; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D012774:Shock, Traumatic / Q000150:complications* / Q000382:microbiology; D014947:Wounds and Injuries / Q000150:complications* / Q000382:microbiology