What is the management approach for a patient with retained shrapnel (foreign body) causing infections that are unresponsive to irrigation and debridement (surgical washout)?

From the Guidelines

Surgical debridement with complete removal of all foreign bodies, including shrapnel, is essential for the treatment of infection-inducing shrapnel not responsive to washout. This approach is supported by the 2018 WSES/SIS-E consensus conference recommendations, which emphasize the importance of source control, including drainage of infected fluids, debridement of infected soft tissues, and removal of infected devices or foreign bodies 1. The conference recommendations also highlight the need for early surgical debridement to decrease mortality and other complications in patients with necrotizing soft tissue infections.

The management of the patient should include:

• Broad-spectrum antibiotic therapy, typically starting with vancomycin (15-20 mg/kg IV every 8-12 hours) plus piperacillin-tazobactam (4.5g IV every 6-8 hours) or meropenem (1g IV every 8 hours) for 2-6 weeks, depending on culture results 1
• Wound management, potentially requiring negative pressure wound therapy at -125 mmHg continuously or intermittently
• Serial debridements may be necessary every 48-72 hours until the wound is clean
• Monitoring for signs of systemic infection, including fever, elevated white blood cell count, and increasing C-reactive protein
• Tetanus prophylaxis should be administered if the patient's status is unknown or outdated

It is also important to note that the removal of any foreign body or device that may potentially be the source of infection is crucial, as emphasized in the recommendations for sepsis management in resource-limited settings 1. The goal of treatment is to reduce morbidity, mortality, and improve the quality of life for the patient.

Key considerations in the treatment approach include:

• The importance of early surgical debridement to decrease mortality and other complications
• The need for broad-spectrum antibiotic therapy to cover potential pathogens
• The role of wound management and serial debridements in promoting wound healing and preventing further infection
• The importance of monitoring for signs of systemic infection and adjusting treatment accordingly.

From the FDA Drug Label

The cure rates in microbiologically evaluable patients with MRSA skin and skin structure infection were 26/33 (79%) for linezolid-treated patients and 24/33 (73%) for vancomycin-treated patients The cure rates by pathogen for microbiologically evaluable patients are presented in Table 18 and Table 19 The answer to the question of how to care for a patient with several bits of infection inducing shrapnel not responsive to washout is:

• Antibiotic treatment may be necessary, with options including linezolid or vancomycin for MRSA skin and skin structure infections, as evidenced by cure rates of 79% and 73%, respectively 2
• Surgical debridement and removal of shrapnel may also be necessary to prevent further infection
• Adjunctive treatment methods, such as off-loading and wound care, may also be necessary to promote healing and prevent further complications
• It is essential to note that the provided information does not directly address the care of patients with shrapnel, and the above answer is based on the treatment of skin and skin structure infections.

From the Research

Patient Care with Infection-Inducing Shrapnel

• Caring for a patient with several bits of infection-inducing shrapnel not responsive to washout requires a comprehensive approach, including antimicrobial therapy and wound management.
• The choice of antimicrobial agent depends on the type of infection and the susceptibility of the causative organisms 3, 4, 5.
• Broad-spectrum antibiotics such as cefepime, meropenem, and vancomycin may be effective against a range of gram-positive and gram-negative organisms 3, 4, 5.
• Combination therapy with a beta-lactam antibiotic (e.g., cefepime) and vancomycin may be beneficial in treating methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections 5.
• However, the use of concomitant vancomycin and piperacillin/tazobactam may increase the risk of acute kidney injury (AKI) compared to vancomycin with cefepime or meropenem 6.

Antimicrobial Therapy

• Cefepime has broad-spectrum activity against gram-negative and gram-positive organisms, including MRSA 3.
• Meropenem is a broad-spectrum carbapenem antibiotic effective against a range of gram-positive and gram-negative organisms, including extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae 4.
• Vancomycin is effective against gram-positive organisms, including MRSA, but its use may be limited by the risk of AKI 5, 6.

Wound Management

• Wound management is critical in preventing infection and promoting healing.
• Debridement and irrigation of the wound may be necessary to remove infected tissue and shrapnel.
• The use of antimicrobial dressings and topical antibiotics may also be beneficial in preventing infection and promoting healing.
• It is essential to monitor the patient's condition closely and adjust the treatment plan as needed to ensure optimal outcomes 7.