WASHINGTON, DC—Preventing the spread of infection from multidrug resistant organisms (MDROs) is a battle being fought, not just in civilian healthcare settings worldwide, but in the military healthcare system as well.
Described by military officials to a House subcommittee in September 2010 as having “complicated” the care of injured servicemembers returning from Iraq and Afghanistan, military healthcare officials continue to monitor and take action against the spread of these infections. “I think we have made great progress in responding to the problem,” said Dr Duane Hospenthal, infectious disease consultant to the Army Surgeon General. “There is research money now being pushed into this to help with it [and] we continue to monitor infection control in the deployed setting.”
These infections emerged early in the current military conflict, when military physicians began seeing a number of unexplained infections in wounded servicemembers returning from Iraq that were eventually determined to be caused by a type of gram-negative bacteria called Acinetobacter baumannii.
It is thought that much of these bacteria and other MDRO causing infections, such as extended-spectrum beta-lactamase producing enterobacteriaceae, MDR Pseudomonas aeruginosa, and methicillin-resistant Staphylococcus aureus (MRSA) are likely spread nosocomially both in the combat theater, during the journey back, and within military medical centers in the US.
The opportunities for the spread of these bacteria in servicemembers from the point of injury through their return home are widespread. Hospenthal pointed out that in the military trauma system there are “a lot more hands and a lot more distance” that an injured military personnel in theater encounters during the continuum of care, compared to a civilian who is injured in a car accident in their hometown.
Performing simple tasks such as hand washing is critical in addressing the problem. “The battle in infection control in the military and civilian setting is mostly battling over getting people to do the common and simple things over and over again, each and every time,” said Hospenthal.
Addressing Infection Control
In addition to guidelines that have been published focusing on limiting antibiotic overuse and basic infection control interventions, the Army conducted a review of infection control practices and challenges in the combat theater hospitals in 2008 and 2009. The reviews identified areas that needed to be strengthened in infection control practices in its Level 3 facilities.
For the deployed setting, a protocol was developed to address the problem of cross-contamination of injured troops from longer staying patients, such as local nationals. The protocol recommends medical personnel to cohort patients who will be at their facilities greater than 72 hours from patients who will be there less than 72 hours.
In order to increase expertise of infection control officers, a short course was developed for those who are leading infection control efforts in deployed hospitals. The course became an official AMEDD Center and School course.
Recently, a new Army requirement has also been added that requires a trained dedicated infection control officer at every combat support hospital (CSH) location. “The current status is that the combat support hospitals rarely go and deploy to one place,” said Hospenthal. “Even if they had an infection control officer, when they get to Iraq or Afghanistan and they break into two, three, or four locations, you really need someone on the ground at each location. So that official [execute order] at the Department of Army level makes
it a requirement of all deployed CSHs to identify and train up infection control officers for each slice of every CSH location.”
Military hospitals receiving combat injured patients from theater also made some changes. While admission MDRO colonization screening had been established at Landstuhl Regional Medical Center, Walter Reed Army Medical Center, National
Naval Medical Center, and Brooke Army Medical Center, the hospitals were screening only for Acinetobacter baumannii. Now these hospitals screen for all MDROs and the hospitals have standardized their screening protocols allowing comparable data on infection rates to be collected at the facilities.
While infection control remains a major challenge, Hospenthal said that research indicates that the number of Acinetobacter infections appear to have declined in servicemembers over five years of study. Acinetobacter infections, however, are not the only ones that officials continue to monitor and worry about. Other gram-negative MDRO infections, including extended-spectrum ß-lactamase (ESBL)-producing enterobacteriaceae, like Escherichia coli (E coli) and Klebsiella pneumoniae continue to be a concern.
The military is eager for more data on MDRO infections in servicemembers to help inform its prevention efforts and is collecting data through a variety of avenues. The Joint Theater Trauma Registry recently added an infectious disease module that collects data on what antibiotics were used for infections, for example.
Another program, the Infectious Diseases Clinical Research Program’s Trauma Infectious Diseases Outcomes Study, has been established to study interventions and outcomes in combat-wounded who develop MDRO infections and began enrollment of patients in June 2009.
A repository to collect and study MDRO has also been established and is supported by the Army Medical Research and Materiel Command. The MDRO Repository and Surveillance Network system collects and characterizes bacterial isolates and provides support for epidemiologic study of the MDRO problem across the MHS, including in the combat theater.