Of the 294,274 patients in the JTDB from 2004 to 2017, 227,462 adult patients with blunt or penetrating trauma who were admitted to the intensive care unit or a general ward were identified. After eliminating those who met the exclusion criteria, the remaining 150,948 patients were included in this study (Fig. 1).
Of those patients, 10,172 (6.7%) with infection were identified. A total of 1,130 (11.1%) patients had sepsis. The demographic characteristics among the patients with and without infection are shown in Table 1. Patients with infection were older than those without [71 (53–82) vs. 67 (47–80) years, p < 0.01]. Patients with infection had more comorbidities [6,806 (66.9%) vs. 80,565 (57.2%), p < 0.01, see Additional file 1]. Patients with infection received more emergency procedures [5,233 (51.4%) vs. 38,954 (27.7%), p < 0.01] and transfusions [3,100 (31.0%) vs. 19,139 (13.9%), p < 0.01] than those without infection. The use of steroids or immunosuppressants did not differ between the patients with or without infection [48 (0.5%) vs. 532 (0.4%), p = 0.14, and 18 (0.2%) vs. 204 (0.1%), p = 0.42, respectively]. The severity of trauma was greater in patients with infection than those without [mild, 3,837 (37.7%) vs. 84,106 (59.7%); moderate, 4,518 (44.4%) vs. 47,809 (34.0%); severe, 1,817 (17.9%) vs. 8,861 (6.3%), p < 0.01].
Table 1
Characteristics of trauma patients with and without infection
| Non-infection | Infection | P-value |
Number | 140,776 (93.3) | 10,172 (6.7) | |
Age | 67 (47–80) | 71 (53–82) | < 0.01 |
Gender (Male) | 81,294 (57.7) | 6,764 (66.5) | < 0.01 |
Mechanism of Injury | | | 0.04 |
Blunt | 136,591 (97.0) | 9,906 (97.4) |
Penetrating | 4,185 (3.0) | 266 (2.6) |
Injury site (AIS ≥ 3) | | | |
Head | 38,844 (27.6) | 4,031 (39.6) | < 0.01 |
Face | 1,008 (0.7) | 99 (1.0) | < 0.01 |
Neck | 469 (0.3) | 57 (0.6) | < 0.01 |
Thorax | 29,143 (20.7) | 2,807 (27.6) | < 0.01 |
Abdomen and Pelvis | 8,208 (5.8) | 960 (9.4) | < 0.01 |
Spine | 14,752 (10.5) | 1,596 (15.7) | < 0.01 |
Upper extremity | 7,390 (5.2) | 464 (4.6) | < 0.01 |
Lower extremity | 53,600 (38.1) | 3,850 (37.8) | 0.65 |
Others | 35 (0.0) | 9 (0.1) | < 0.01 |
ISS | | | < 0.01 |
Mild (< 15) | 84,106 (59.7) | 3,837 (37.7) |
Moderate (15–29) | 47,809 (34.0) | 4,518 (44.4) |
Severe (≥ 30) | 8,861 (6.3) | 1,817 (17.9) |
Number of comorbidities | | | < 0.01 |
0 | 60,211 (42.8) | 3,366 (33.1) |
42,852 (30.4) | 3,155 (31.0) |
22,344 (15.9) | 1,942 (19.1) |
9,995 (7.1) | 1,038 (10.2) |
≥ 4 | 5,374 (3.8) | 671 (6.6) |
Medication | | | |
Steroid | 532 (0.4) | 48 (0.5) | 0.14 |
Immunosuppressant | 204 (0.1) | 18 (0.2) | 0.42 |
Anticoagulant | 2,637 (1.9) | 296 (2.9) | < 0.01 |
Vital signs at emergency department | | | |
GCS | 15 (14–15) | 14 (11–15) | < 0.01 |
SBP | 138 (119–159) | 134 (110–158) | < 0.01 |
HR | 82 (71–95) | 86 (73–102) | < 0.01 |
Temperature | 36.5 (36.0–37.0) | 36.4 (35.8–36.9) | < 0.01 |
RR | | | < 0.01 |
≤ 17 (quartile 1) | 31,202 (25.9) | 1,923 (21.2) |
18–23 (quartile 2–3) | 54,125 (44.9) | 3,678 (40.5) |
≥ 24 (quartile 4) | 35,089 (29.1) | 3,490 (38.4) |
Number of emergency procedures | | | < 0.01 |
0 | 101,822 (72.3) | 4,939 (48.6) |
1 | 26,297 (18.7) | 1,992 (19.6) |
2 | 7,223 (5.1) | 1,382 (13.6) |
≥ 3 | 5,434 (3.9) | 1,859 (18.3) |
Emergency procedures | | | |
Intubation | 11,877 (8.4) | 3,217 (31.6) | < 0.01 |
Ventilator use or assisted ventilation | 9,494 (6.7) | 2,443 (24.0) | < 0.01 |
REBOA | 293 (0.2) | 103 (1.0) | < 0.01 |
Chest drainage | 8,176 (5.8) | 1,111 (0.9) | < 0.01 |
Craterization | 655 (0.5) | 295 (2.9) | < 0.01 |
Emergency TAE | 4,071 (2.9) | 809 (8.0) | < 0.01 |
Central venous line use | 4,277 (3.0) | 1,439 (14.1) | < 0.01 |
Vasopressor use | 1,491 (1.1) | 508 (5.0) | < 0.01 |
Open bone traction | 10,250 (7.3) | 824 (8.1) | < 0.01 |
External skeletal fixation | 4,130 (2.9) | 592 (5.8) | < 0.01 |
Other emergency bone fixation | 5,434 (3.9) | 438 (4.3) | 0.03 |
Blood transfusion | 19,139 (13.9) | 3,100 (31.0) | < 0.01 |
Any operation | 80,308 (57.0) | 6,761 (66.5) | < 0.01 |
Continuous variables were compared using the Mann–Whitney U test. Categorical variables were compared using the Chi-square test. |
Missing: GCS = 13,085, SBP = 2,281, HR = 5,577, Temperature = 15,926, RR = 21,441, Blood transfusion = 3,421 |
AIS: Abbreviated Injury Scale, ISS: Injury Severity Score, COPD: Chronic obstructive pulmonary disease, DM: Diabetes mellitus, HD: Hemodialysis, GCS: Glasgow coma scale, SBP: Systolic blood pressure, HR: Heart rate, RR: Respiratory rate, REBOA: Resuscitative endovascular balloon occlusion of the aorta, TAE: Transcatheter arterial embolization, UTI; Urinary tract infection, SSI: Surgical site infection |
Patients with infection had more concomitant complications than patients without infection (Table 2). Specifically, atelectasis [1,041 (10.2%) vs. 913 (0.6%), p < 0.01], higher brain dysfunction [944 (9.3%) vs. 2,539 (1.8%), p < 0.01], and disseminated intravascular coagulation and coagulation disorder [751 (7.4%) vs. 713 (0.5%), p < 0.01] were more common in patients with infection than in those without infection.
Table 2
Concomitant complications in patients with and without infection
| Non-infection | Infection | P-value |
Number | 140,776 (93.3) | 10,172 (6.7) | |
Number of concomitant complications | | | < 0.01 |
0 | 129,290 (91.8) | 5,022 (49.4) |
1 | 9,257 (6.6) | 2,656 (26.1) |
2 | 1,678 (1.2) | 1,132 (11.1) |
3 | 378 (0.3) | 550 (5.4) |
≥ 4 | 173 (0.1) | 812 (8.0) |
Central nervous system | | | |
Diabetes insipidus | 195 (0.1) | 115 (1.1) | < 0.01 |
Hydrocephalus | 211 (0.1) | 164 (1.6) | < 0.01 |
Fat embolism | 87 (0.1) | 149 (1.5) | < 0.01 |
Cerebrospinal fluid leakage | 237 (0.2) | 113 (1.1) | < 0.01 |
Higher brain dysfunction | 2,539 (1.8) | 944 (9.3) | < 0.01 |
Mental disorders (PTSD, etc.) | 597 (0.4) | 201 (2.0) | < 0.01 |
Others | 1,544 (1.1) | 503 (4.9) | < 0.01 |
Circulation | | | |
Acute coronary syndrome | 63 (0.0) | 38 (0.4) | < 0.01 |
Refractory shock | 223 (0.2) | 174 (1.7) | < 0.01 |
Acute kidney injury | 187 (0.1) | 266 (2.6) | < 0.01 |
Abdominal compartment syndrome | 33 (0.0) | 37 (0.4) | < 0.01 |
Others | 762 (0.5) | 325 (3.2) | < 0.01 |
Respiratory | | | |
Lung edema | 124 (0.1) | 163 (1.6) | < 0.01 |
Atelectasis | 913 (0.6) | 1,041 (10.2) | < 0.01 |
Pulmonary embolism | 294 (0.2) | 490 (4.8) | < 0.01 |
ARDS and respiratory failure | 346 (0.2) | 615 (6.0) | < 0.01 |
Others | 461 (0.3) | 197 (1.9) | < 0.01 |
Gastroenterology and hepato-biliary | | | |
Ulcer and upper GI bleeding | 428 (0.3) | 322 (3.2) | < 0.01 |
Ileus | 226 (0.2) | 152 (1.5) | < 0.01 |
Pancreatitis | 68 (0.0) | 49 (0.5) | < 0.01 |
Cholecystitis | 166 (0.1) | 102 (1.0) | < 0.01 |
Hyperbilirubinemia and liver failure | 116 (0.1) | 160 (1.6) | < 0.01 |
Others | 572 (0.4) | 333 (3.3) | < 0.01 |
Bone and joint | | | |
Compartment syndrome | 220 (0.2) | 345 (3.4) | < 0.01 |
Refracture | 62 (0.0) | 342 (3.4) | < 0.01 |
Pseudoarthrosis | 57 (0.0) | 377 (3.7) | < 0.01 |
Others | 382 (0.3) | 159 (1.6) | < 0.01 |
Coagulation | | | |
DIC and coagulation disorder | 713 (0.5) | 751 (7.4) | < 0.01 |
Thrombopenia (< 50000) | 291 (0.2) | 341 (3.4) | < 0.01 |
Others | 357 (0.3) | 107 (1.1) | < 0.01 |
Others | | | |
Wound disruption | 179 (0.1) | 319 (3.1) | < 0.01 |
Decubitus | 405 (0.3) | 407 (4.0) | < 0.01 |
Hypothermia (< 35 °C) | 206 (0.1) | 138 (1.4) | < 0.01 |
Drug allergy | 117 (0.1) | 75 (0.7) | < 0.01 |
Others | 1,130 (0.8) | 421 (4.1) | < 0.01 |
PTSD: Post trauma stress disorder, ARDS: Acute respiratory destress syndrome, GI: Gastrointestinal, DIC: Disseminated intravascular coagulopathy |
Patients with infection had higher in-hospital mortality [1,079 (10.6%) vs. 2,904 (2.1%), p < 0.01], a longer hospital stay [42 (25–70) vs. 23 (14–38) days, p < 0.01], and less discharge at home [2,433 (23.9%) vs. 61,738 (43.9%), p < 0.01] than patients without infection (Table 3).
Table 3
Outcome of trauma patients with and without infection
| Non-infection | Infection | P-value |
Number | 140,776 (93.3) | 10,172 (6.7) | |
Admission | | | < 0.01 |
ICU | 80,076 (56.9) | 7,205 (70.8) |
General ward | 60,700 (43.1) | 2,967 (29.2) |
In-hospital mortality | 2,904 (2.1) | 1,079 (10.6) | < 0.01 |
Place after discharge | | | < 0.01 |
Home | 61,738 (43.9) | 2,433 (23.9) |
Transfer | 72,949 (51.9) | 6,416 (63.1) |
Other | 2,933 (2.1) | 233 (2.3) |
LOS | 23 (14–38) | 42 (25–70) | < 0.01 |
Continuous variables were compared using the Mann–Whitney U test. Categorical variables were compared using the Chi-square test. |
Missing: place after discharge = 263 |
ICU: Intensive care unit, LOS: Length of hospital stay |
Figure 2 shows the effect of infection on trauma patients according to trauma severity. The in-hospital mortality rate between trauma patients with infection and those without infection differed according to trauma severity [16.7% (95% CI; 14.6–18.8%) vs. 3.6% (95% CI; 3.3–3.9%), p < 0.01, in patients with mild trauma; 12.3% (95% CI; 11.0–13.6%) vs. 7.3% (95% CI; 6.9–7.7%), p < 0.01, in patients with moderate trauma; and 12.0% (95% CI; 9.8–14.2%) vs. 11.1% (95% CI; 9.8–12.4%), p = 0.41, in patients with severe trauma].