After theLushan earthquake, the Chinese government and various departments responded quickly. Theemergency responseplanswereimmediatelyactivated.The experts in intensivecare, orthopedics, neurosurgery, thoracic surgery, infectious disease,nephrology,clinical pharmacology and rehabilitation from west China hospital and across China assessed patients' conditionandmadeclinicaltreatmentstrategies together daily.The condition of severe wounded were reported twiceaday.

Methods

ThestudywasapprovedbytheEthicsCommitteeofWestChinaHospital,Sichuan University,whichwaivedtheneedforinformedconsent,asallthedataandsampleswerecollectedaspartofnormalcareindailyclinicalpractice,accordingto thecurrent guidelines.

We retrospectively reviewed the medical records of the 81 critical patients. All data were verified bytwo authors independently.

Clinicalspecimenswereobtained from blood, sputum, wound, urine, stool, intravenousand intraurethralcatheters in patients with fever or signs of infections. All samples were collectedunder sterile conditions and blood samples were collected in more than two sets of aerobic and anaerobic.Bacterial identification and minimal inhibitory concentrations(MICs) ofantibacterial agents against bacteria were performed by the VITEK-2COMPACTautomated microbiologysystem(BioMerieux).Theantimicrobialsusceptibilityresultswere interpreted according to Clinical and Laboratory Standards Institute (CLSI) guidelines. Patientshaddefinitivediagnosesofinfection complicationsaccording to medical history, clinical findings, laboratory and imagingtests.

Stringent infection control measures were implemented to preventhospitalinfections. First, entry into ICUwasrestricted including visitation, thenumberof healthworkersand hospitalcleaners, placement of obvious warningsnear the bed units, improvementsinhand hygienecompliance, the use of disposable gloves, masksandcaps, increase the number of disinfection of surroundings. Enhanced antimicrobialstewardship including the choiceofantibiotic and dosage regimen were introduced. Based on consideration of the patient's clinical course, procalcitonin(PCT) was used for early diagnosis,monitoringof treatment responses to reduce inappropriate use of antibiotics[1].

Before admissiontoICU, somepatients were treated with active surgical procedures such as craniotomy, debridement,fasciotomyand amputation. The treatmentsofdrainage subarachnoidlumbarspacecontinuouslywereappliedto the patients with severecraniocerebraltraumaafter craniotomy. The treatmentsofvacuumsealingdrainagedressing(VSD)were appliedto the patients withopenfracturesofextremitieswithskinandsoft tissuedefectafter surgery. Wound dressings were changed daily or twicea day according tosituationofpatients.Some patients were received the secondoperationfor removal of theinfectedfocitoimprove infection control.

Statistical analysis: Data were analyzed by SPSS version 17.0 software package. A normality test was performed for all quantitative variables. Continuous variables with normal distributions were presented as mean±standard deviation.The comparison of group differences for continuous variables was performed using Student’s t-test and one-way ANOVA. LSD-t test was used for multiple comparison. A two-tailed P < 0.05 was considered statistically significant.

Results

Clinical characteristics of 81 critically ill patients with earthquake related trauma

A total of 81 critically ill patients (mean age: 54.83 ± 25.13 yr; 47 male)were included in the study.Children younger than 16 years accounted for 7.4% and those older than 80 years accounted for 24.7% of the patients.APACHE II(Acute Physiology and Chronic Health Evaluation II)and Sequential Organ Failure Assessment (SOFA)[2]were applied within 24 hours of admission of each patient to our ICU.There were significant differences in the scores of APACHE IIand SOFA among different causes of injury groups(P < 0.01).

Infections

A 14.81% proportion of the trauma patients had no infection and 85.19% (69/81) had infectious complicationduringstayinginICU. There were59 casesof community acquiredinfections when admissiontoICU,however, 5ofwhom (8.47%, 5/59)had nosocomialinfections when leaving the ICU.Elevencasessuffered frommulti-siteinfections.

A total of 421clinical specimens were collected.Pathogens identified from69 hospitalizedpatients with infections were shown in Table S1.Acinetobacter baumannii,Klebsiella pneumoniaeand Pseudomonas aeruginosa were the most frequent pathogensisolated from patients with nosocomial infections, and the most frequently isolated pathogen from patients with community acquired infections wasStaphylococcusaureus.There were 54caseswithpositiveculture results. Infectionscaused bygram-negative bacteria (34/54, 63.0%) were morecommon, predominantlyKlebsiella pneumoniae (24.1%, 13/54), followed byAcinetobacter baumannii (20.4%, 11/54). Gram-positive bacteria caused 37.0% (20/54) of infections, predominantly Staphylococcus aureus (6/54, 11.1%) and Staphylococcus epidermidis (9.3%, 5/54). Mixedinfections were present in12episodes.

Antimicrobial drug susceptibility testing results for the 5 most common pathogens were shown in TableS2. All the Staphylococcusaureus were sensitive to vancomycin and tigecycline, followed by rifampicin, oxacillin andclindamycin.Most of Acinetobacter baumannii were multiresistant strains, which sensitive topolymix and resistant to other antibacterial drugs in varying degrees. It was worthnoting that the resistance of Acinetobacter baumannii toimipenemwas88.2%. Thecandida albicans was sensitiveto amphotericinB,fluconazole, itraconazole and 5-fluorocytosine.

Outcomes

Noneof the81 patientsincluded in this study died during the hospital stay. One patientautomaticallydischarged forpersonalreasons inthe fifth dayafter admission.He suffered seriouscraniocerebralinjury and receivedcardiopulmonaryresuscitation before admissiontoICU. Three patients withunderlyingdiseasesdischarged voluntarily because the generalconditionof them graduallydeteriorated. The rest of the patients survived with positive outcomes.

Discussion

Earthquake is the most harmful natural disasters because it can cause heavycasualtiesandproperty losses.China is an earthquake-prone nation.The 1976 Tangshan earthquakeresulted inmore than240 000 deaths and 165 000 injuries, the 2008 Wenchuan earthquakecaused more than 69000 deaths and 374000 injuries.Peoplehad sufferedsevereinjuryin theearthquake, thesubsequentincreasingininfectiouscomplicationhas a major impact on patient outcomes[3].Manyfactorscan cause infection in earthquakevictimsincludeopen wounds, insufficient wound debridement,invasiveprocedures,useofvenous and urinary catheters,the functionaldisordersofimmunesystem, etc.

The patients in our ICU all had severemultipletrauma, the most common types of injury were bone fractures, craniocerebral injuries, and chest injuries, which was similar to the resultsof theepidemiologicalinvestigation of this earthquake and the previous earthquakes[4-6].Crushing injuries were more serious than damages from other causes in this study. Previousstudies have alsofound that severe crushing injury was morelikely tohave complications andresulted in death [7,8]. There were less crush injury patients, and only one of them had crushsyndrome. It was possible that because the earthquake occurred in theremotearea and no tall buildingscollapsed, timely and effectively emergency rescue based on experiences and lessons of Wenchuan earthquake. Thatwas may beone reason that the critical ill patients in our ICU had betterclinicaloutcome.

Similartopreviousreports[4,9-10], pulmonaryinfectionwas the most common infectiouscomplicationinthe patients.The high incidence of pulmonary infections after the earthquake mightbe related to overcrowding and the severedamagein infrastructure and health-care systems.Intracranial infection was another common infectiouscomplicationinpatients in our ICU.Craniotomy, most of the severecraniocerebraltraumapatientsinICUunderwentit,immunefunctionconstantlydisorderafter severe injuries andcontinuousterminalcistern drainagemightbe thereasons forhigh susceptibility to craniocerebral infection.

Acinetobacter baumannii and Klebsiella pneumoniaewerethemajorpathogens.They also were common isolates inour hospital. All severely injured patients were transported from the earthquake zone, some patients were treated with surgical procedures and received antimicrobial agentsin local hospital with poor conditions and the absence of essential surgical equipment and infectioncontrol measures,necessaryinvasive procedures such as venouscatheter,tracheal intubation, indwelling catheter were performed in some patients.The above factors might cause nosocomial diseases.

Only one patient complicatedwithfungal infection, which were lessthanpreviouslyreported[11].Thefungiwere accounted for 9.7%of the isolated pathogens from the victims in the 2008 Wenchuan earthquake[12]. Manyfactors might be related to thelowerincidenceoffungalinfectioninthe patients,such asenhanced antimicrobial stewardship,strictinfectioncontrolmeasuresandaggressiveimmunesupportivetreatment.

Noneof the patients in ICU died during the hospital stay.We summarized someexperiences withinfection control in Lushan earthquake injuries. First, empiric antimicrobialdrugs selection were based on infectionsites, thepossible pathogens,pathogens spectrum of the hospital, etc.It is important to change effective antibiotics to control infection in a timely manner according to the patient's clinical course and the microbiological data. Second, PCT was used to guide the use of antimicrobials.Because many studies had shown that PCT had abilities to early detect bacterial infectionand assess the clinical efficacy of the empirical antibiotic therapy[13-14].Third, Meropenem (2 g every 8 hour) was given when intracranialinfectionswere diagnosed following Infectious Disease Society ofAmerican(IDSA) guidelines[15].Fosfomycin has maintained its bactericidal activity against anaerobic pathgeons, many gram-positive, gram-negative bacterial and multi-resistant pathogens over theyears. Inaddition, fosfomycin has minimal side effects and it can act as an immunomodulator and protect human cells fromcertainmedications'toxicities[16-17]. Therefore, the combined treatment with fosfomycin and other antibacterialagents were used to treat infectionscaused byMDRpathogens.Fourth,targetedimmune-enhancing therapywas veryimportant for patientswith serious infections. Studies suggested thatmultipleimmunedefectsoccur insepsis, immune-enhancing therapysuch as thymosin alpha 1, immunoglobulins,granulocyte macrophage colony stimulating factor can improvethe prognosis[18-21].Fifth,Stringentinfection control measures were implementedtopreventthespread of infection.Our hospital managers often use multimodalstrategies toraise the theconsciousness of infection prevention and controlamongdifferent grades of staff, such as administrative support, motivation, free availability of hand disinfectants, training and intensive education of medical workers.Therefore, we arealreadyusedtocarry outcontrolinfectionmeasures.And our hospital won the Asia Pacific Hand HygieneExcellence Award(2012/2013).

Table S1.Pathogens identified from69 hospitalized patients with infections

Pathogens / Infection sites
Wound secretion / blood / Respiratory secretion / urine / Cerebrospinal fluid / stool / Total(%)
Acinetobacter baumannii / 13 / 3 / 25 / 4 / 6 / - / 51(38.1)
Klebsiella pneumoniae / 7 / 1 / 16 / 3 / 1 / - / 28(20.9)
Pseudomonas aeruginosa / 4 / 8 / 1 / - / - / 13(9.7)
Escherichia coli / 5 / 3 / 1 / 2 / - / - / 11(8.2)
Enterobacter cloacae / 1 / 1 / - / 1 / - / - / 3(2.2)
Burkholderia cepacia / - / - / 1 / - / - / - / 1(0.7)
proteusmirabilis / - / - / 1 / - / - / 1(0.7)
Staphylococcus aureus / 7 / - / 1 / - / - / - / 8(6.0)
Staphylococcushaemolyticus / 5 / 2 / - / - / - / - / 7(5.2)
Enterococcusfaecium / 2 / 1 / - / - / 1 / - / 4(3.0)
Streptococcus pneumoniae / - / - / 1 / - / - / - / 1(0.7)
Staphylococcusepidermidis / 1 / - / - / - / - / - / 1(0.7)
Candidaalbicans / - / - / 2 / 3 / - / - / 5(3.7)
Total(%) / 45(33.6) / 11(8.2) / 56(41.8) / 14(10.4) / 8(6.0) / - / 134

“-” meansthat bacteria were not found inthe cultures.

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Table S2. Antimicrobial susceptibility of the 5 most common pathogens isolated from patients injured during earthquake, Lushan,China, 2013

Organism / No. (%) the resistance ofpathogens to antibacterials
No. / IMP / MEM / TZP / AMP / ZOX / AMK / AZT / CAZ / SAM / FEP / PB / CIP / SMZ / GM / LEV / TGC / DA / OX / RD / VA
A. baumannii / 51 / 45(88.2) / 48(94.1) / 47(92.2) / 51(100) / 51(100) / 45(88.2) / 50(98.0) / 45(88.2) / 33(64.7) / 47(92.2) / 0(0) / 48(94.1) / 36(70.6) / 48(94.1) / 21(41.2) / 4(7.8) / - / - / - / -
K.pneumoniae / 28 / 0(0) / 0(0) / 1(3.5) / 28(100) / 18(64.3) / 13(46.4) / 15(53.6) / 15(53.6) / 2(7.1) / 13(46.4) / 0(0) / 13(46.4) / 5(17.9) / 5(17.9) / 13(46.4) / 0(0) / - / - / - / -
P. aeruginosa / 13 / 6(46.2) / 6(46.2) / 1(7.7) / 13(100) / 12(92.3) / 0(0) / 8(61.5) / 1(7.7) / 0(0) / 0(0) / 0(0) / 0(0) / 1(7.7) / 0(0) / 0(0) / 0(0) / - / - / - / -
E.coli / 11 / 0(0) / 0(0) / 0(0) / 6(54.5) / 6(54.5) / 0(0) / 5(45.5) / 3(27.3) / 0(0) / 3(27.3) / 0(0) / 0(0) / 2(18.2) / 2(18.2) / 0(0) / 0(0) / - / - / - / -
S. aureus / 8 / - / - / - / - / - / - / - / - / - / - / - / 2(25) / 2(25) / 4(50.0) / 2(25.0) / 0(0) / 6(75) / 4(50) / 2(25) / 0(0)
S.haemolyticus / 7 / - / - / - / - / - / - / - / - / - / - / - / 6(85.7) / 3(42.9) / 6(85.7) / 6(85.7) / 0(0) / 5(71.4) / 7(100) / 1(14.3) / 0(0)

MEM, Meropenem; TZP, tazobactam/piperacillin; AMP, ampicillin; ZOX, ceftizoxime; AMK, amikacin; AZT, Aztreonam; CAZ, Ceftazidime; SAM, Cefperazone-Sulbactam; FEP, Cefepime; PB, polymyxin B; CIP, ciprofloxacin; SMZ, sulfamethoxazole/trimethoprim; GM, gentamicin; LEV, levofloxacin; TGC, Tigecycline; DA, clindamycin; OX, Oxacillin; RD, rifampicin; VA, vancomycin; A. baumannii, Acinetobacter baumannii; P. aeruginosa, Pseudomonas aeruginosa; K. pneumoniae, Klebsiella pneumoniae; E.coli, Escherichia coli; S. aureus, Staphylococcus aureus; S.haemolyticus, Staphylococcushaemolyticus.

“-”, not available.

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