A Race Against Time: Early vs Late Infection After Severe Trauma

Authors:
Amin Dehghan, Marina Eguchi, Fabiana Sanchez, Marco Henriquez, Ricardo Fonseca, Melissa Canas, Grant V. Bochicchio

Body of Abstract:
Introduction: Infections are a significant source of morbidity and prolonged hospitalization among severe injured trauma patients. When an infection is suspected or diagnosed (early versus late) may reflect distinct pathophysiologic mechanisms, patient factors, and injury patterns, influencing outcomes and management strategies. Our goal was to describe the incidence and compare characteristics of early vs. late infection based on when infection was suspected in a Level 1 trauma cohort.

Methods: We retrospectively analyzed a prospectively trauma registry on Level I trauma patients (2019–2024) with de-identified patient data. Collected variables included demographics, comorbidities, injury mechanism, clinical severity (ISS, GCS, APACHE II), MTP activation and blood products transfusion, airway interventions, and infection data. The blood transfusion score was calculated: whole blood units ×2 plus packed RBC, FFP, TXA, platelets, and cryoprecipitate units ×1. Time to infection was measured from ED arrival. Descriptive statistics summarized characteristics; t-tests and chi-square tests compared groups.

Results: Among 599 Level 1 trauma patients, 102 (17%) were diagnosed with infection. Based on a median 90-hour interval to initial suspicion, infections were classified as early (51, 50%) or late (51, 50%). Pneumonia had a median onset of 87 [20–160] hours, UTI 77 [12–211] hours, and other infections 140 [12–251] hours post-admission (Fig. 1).

The mean age was significantly higher in the early infection group (52.8 ± 21.1 vs 40.5 ± 18.0 years, p = 0.002) and the mean ISS was significantly higher in the late infection group (27.4 ± 13.6 vs 20.1 ± 12.6, p = 0.022); While GCS (10.5 ± 5.3 vs 10.7 ± 5.2, p = 0.89), blood transfusion score (6.5 ± 11.5 vs 9.9 ± 12.0, p = 0.15), and APACHE II score (18.7 ± 8.3 vs 19.8 ± 9.5, p = 0.54) did not differ. In the patients with late infection, MTP activation rate and substance use disorder were more common (39.2% vs 19.6%, p=0.03, 72.5% vs 51.0%, p=0.025, respectively). There were no significant differences in race (p = 0.10), sex (p = 0.097), prehospital airway intervention (p = 0.562), ED airway intervention (p = 0.282), NPPV use (p = 1.0), or mechanism of injury (penetrating, blunt, burn; p = 0.057).

Gram negative pathogens were more common in the late infection (61.5 % vs 41.8%, p=0.046). Early infections included 15 Gram-positive, 18 Gram-negative, 7 viral, and 3 fungal cases, while late infections included 13 Gram-positive, 24 Gram-negative, and 2 fungal cases. Although the pseudomonas infection rate was higher in late infections (15.4% vs 4.7%), it was not statistically significant due to sample size (p = 0.142).

Conclusion: In critically injured level 1 trauma patients, one should be highly suspicious and on alert for the diagnosis of early infection. Also, the clinical team should remain alert for Gram-negative infections, particularly after 90 hours.