Open Access Open Badges Research article

Biofilms and persistent wound infections in United States military trauma patients: a case–control analysis

Kevin S Akers12*, Katrin Mende23, Kristelle A Cheatle3, Wendy C Zera3, Xin Yu3, Miriam L Beckius4, Deepak Aggarwal3, Ping Li3, Carlos J Sanchez1, Joseph C Wenke1, Amy C Weintrob35, David R Tribble3, Clinton K Murray2 and the Infectious Disease Clinical Research Program Trauma Infectious Disease Outcomes Study Group

Author Affiliations

1 Extremity Trauma and Regenerative Medicine Task Area, United States Army Institute of Surgical Research, JBSA Fort Sam, Houston, TX, USA

2 Department of Medicine, Infectious Disease Service, Brooke Army Medical Center, JBSA Fort Sam, Houston, TX, USA

3 Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD, USA

4 Department of Clinical Investigation, Brooke Army Medical Center, JBSA Fort Sam, Houston, TX, USA

5 Walter Reed National Military Medical Center, Bethesda, MD, USA

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BMC Infectious Diseases 2014, 14:190  doi:10.1186/1471-2334-14-190

Published: 8 April 2014



Complex traumatic injuries sustained by military personnel, particularly when involving extremities, often result in infectious complications and substantial morbidity. One factor that may further impair patient recovery is the persistence of infections. Surface-attached microbial communities, known as biofilms, may play a role in hindering the management of infections; however, clinical data associating biofilm formation with persistent or chronic infections are lacking. Therefore, we evaluated the production of bacterial biofilms as a potential risk factor for persistent infections among wounded military personnel.


Bacterial isolates and clinical data from military personnel with deployment-related injuries were collected through the Trauma Infectious Disease Outcomes Study. The study population consisted of patients with diagnosed skin and soft-tissue infections. Cases (wounds with bacterial isolates of the same organism collected 14 days apart) were compared to controls (wounds with non-recurrent bacterial isolates), which were matched by organism and infectious disease syndrome. Potential risk factors for persistent infections, including biofilm formation, were examined in a univariate analysis. Data are expressed as odds ratios (OR; 95% confidence interval [CI]).


On a per infected wound basis, 35 cases (representing 25 patients) and 69 controls (representing 60 patients) were identified. Eight patients with multiple wounds were utilized as both cases and controls. Overall, 235 bacterial isolates were tested for biofilm formation in the case–control analysis. Biofilm formation was significantly associated with infection persistence (OR: 29.49; CI: 6.24-infinity) in a univariate analysis. Multidrug resistance (OR: 5.62; CI: 1.02-56.92), packed red blood cell transfusion requirements within the first 24 hours (OR: 1.02; CI: 1.01-1.04), operating room visits prior to and on the date of infection diagnosis (OR: 2.05; CI: 1.09-4.28), anatomical location of infected wound (OR: 5.47; CI: 1.65-23.39), and occurrence of polymicrobial infections (OR: 69.71; CI: 15.39-infinity) were also significant risk factors for persistent infections.


We found that biofilm production by clinical strains is significantly associated with the persistence of wound infections. However, the statistical power of the analysis was limited due to the small sample size, precluding a multivariate analysis. Further data are needed to confirm biofilm formation as a risk factor for persistent wound infections.

Biofilm; Risk factors; Trauma-related infections; Persistent infections; Chronic infections; Extremity wound infections