Insurgents

copyright 2008, Proceedings, u.s. naval Institute, Annapolis, Maryland (410) 268-6110 www.usni.org

in the

Bloodstream
By Captain Chas Henry, U.S. Marine Corps (Retired)

A bacterial outbreak of historic proportions threatens wounded troops when theyre most vulnerable.

ts why I lost my leg, so it sucks. The assessment, from a 22-year-old Marine toughing out physical therapy on two prosthetic limbs, is laconic, matter-of-fact. Sergeant David Emery lost one leg in February 2007 when a suicide bomber assaulted the checkpoint near Haditha, Iraq, where he and fellow Marines stood guard. Military surgeons were forced to remove his remaining leg when it became infected with acinetobacter baumanniia strain

of highly resistant bacteria that since U.S. forces began fighting in Iraq and Afghanistan has threatened the lives, limbs, and organs of hundreds wounded in combat. They could have saved it, says Emery. They had a rod in it, but then the bacteria was in too bad and my white blood cell count was up to 89,000and they told my mom on a Friday that they had to take it. Emerys mother recalls that the hazard was not confined to her sons limbs. He ended up getting it in his stomach, says Connie Emery, and they tried to close his stomach back up, but when they did, the stitches ended up pulling away because the infection was taking over. An Army infectious disease physician says the germ has spread rapidly since the wars in Afghanistan and Iraq began. Prior to the war, we were seeing one to two cases of acinetobacter infection per year, remembers Lieutenant Colonel Kimberly Moran, deputy director for tropical public health at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Now thats much different. Weve had hundreds of positive cultures over the last four years. And the toll has been serious, observes Army Colonel Glenn Wortmann, acting chief of infectious disease at Walter Reed Army Medical Center in Washington, D.C. Of the infectious disease problems that have come out of the conflict, notes Dr. Wortmann, it is the most important complication weve seen.
courtesy oF Kyle Petersen

Found MYSTERY MICRoBE Commander Kyle Petersen, shown here examining a plate of acinetobacter colonies under a magnifying loupe, first noticed the dangerous effects of the drug-resistant bacteria while serving on board the hospital ship uSnS Comfort (T-AH-20) in April 2003.

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The persistence of the outbreak has pushed it to momentous proportions. I believe this is the largest in-hospital acinetobacter outbreak in history, asserts Dr. Timothy Endy, a retired Army colonel now teaching infectious disease medicine at the State University of New York, Upstate Medical University. Endy battled the bacteria while attending to patients at Walter Reed.

Where did it Come From?

Researchers say they dont know exactly how acinetobacter baumannii first made its way into frontline treatment facilities. Early suspicions pointed to the possibility that the germs, mixed with soil, were blown deep into penetrating wounds. Some physicians speculated that bacteria residing in the combat zone had settled onto the skin of service memberslying dormant until open wounds allowed the bugs to create havoc. Small-sample testing, however, has indicated little or no evidence of problemcausing acinetobacter in Iraqi soil. And the only Iraq or Afghanistan veterans so far showing signs of acinetobacter colonization on their skin are those who have spent time in casualty treatment centers. Moreover, say scientists, nothing in the character of the outbreak would indicate that it originated as a result of intentional biological attack. The bugs dangerous effects were first noticed just weeks into the March 2003 assault on Iraq. During April of that year, then-Lieutenant Commander Kyle Petersen, a Navy physician treating battle casualties on board the Comfort, observed a number of not-easily-explained patient deaths. He contacted fellow infectious disease specialists via online message boards, describing his American and Iraqi patients symptomsand, when they were eventually available, their lab results. The interaction helped rapidly identify the problem and initiated testing of frontline medical facilities. There were bacteria, recalls Moran, acinetobacter bacteria, on hospital surfaces like in operating rooms, on ventilator machines, or on light surfaces or environmental control units.

Most striking about the problem is that men and women wounded in combat have acquired the bacteria in the very hospitals where aggressive surgery has, in many cases, saved their lives. The outbreak, acknowledges a Defense Department fact sheet, appears to have started during the care of patients (both U.S. military and non-U.S.) in the combat support hospitals of Iraq and Afghanistan. They go to whats called far forward surgical outfits where the main concern is keeping them alive, explains Dr. Rox Anderson of Harvard Medical School, and in the process theres not a hundred percent of the [anti-contamination] controls. Despite a great effort by the military medical people, theres a high risk of infection anyway. Once established at frontline surgical sites, the bacteria began traveling with patients or on patients, says Dr. Moran, from Iraq all the way back to Walter Reed, with stops along the way through the evacuation chain and getting into our hospitals. There, she adds, it was spread from patient to patient through various means, just being on surfaces and having one person come in a room after another person has left. Most evidence of the bacteria has been confirmed at military hospitals in Germany, the Washington, D.C. area, and Texasthough cases have also been confirmed on board the hospital ship USNS Comfort (T-AH-20) and at Tripler Army Medical Center in Hawaii. After Canadian soldiers injured in Afghanistan began testing positive for acinetobacter infection, public health officials began warning Canadian hospitals to take precautions against spread of the germs if they treated anyone who had been wounded overseas. (As Proceedings went to press, the Baltimore Sun reported an outbreak of acinetobacter baumannii infections at the University of Maryland Medical Center.)
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Putting up a Heavy Resistance

At first glance, acinetobacter baumannii does not seem particularly fiendish. It is neither intensely virulent nor remarkably energetic. Its name, in fact, derives from the Greek word akinetos, meaning unable to move. But, as hundreds of those wounded in combat have learned, it exhibits one particularly troubling genius. Noteworthy even among better-known, more-feared microorganisms, it is able to steal resistance capabilities from other bacteria with which it comes into contact. Its this smart, says Moran, that it could put together this resistance island that makes it resistant to almost every antibiotic we have available.
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Defense Department recordsprovided in response to a December 2007 query from Proceedingsindicate that from March 2003 to March 2005 acinetobacter infections attacked more than 250 patients at U.S. military healthcare facilities. As of June 2006, the same documents say, seven deaths had been linked to acinetobacter-related complications. The records did not contain figures for the bacterias impact during the remainder of 2006 and 2007. While the majority of those fighting acinetobacter infection in military hospitals have been deployed to Iraq or Afghanistan, up to a third have notinfants and the elderly among those apparently acquiring the bacteria in armed forces healthcare centers. Those hit hardest are typically the weakest of the weak. In the case of men and women hurt on the battlefield, observes Anderson, those with complex wounds, combination of burns, blast injury, and lacerations. A lot of patients are colonized with acinetobacter, EASY ACCESS Lieutenant (junior grade) John Gore examines the stomach wound of a serviceman in the adds Commander Eric Elintensive care unit of the hospital ship uSnS Comfort (T-AH-20) in April 2003. That was the month a physician ster, a Navy surgeon inon board the Comfort first determined that the acinetobacter germ, which can easily enter the body through volved in combat wound rewounds such as those in the stomach, can cause severe infections that sometimes lead to amputation. search, but its the patients that have additional injuries, prove infection take days. So a doctor may have to wait theyre very systemically ill, they have an associated arteup to 72 hours to learn if bacteria have colonized on a rial injury, an associated abdominal injurythose are the patients skin or, more dangerously, insinuated themselves patients that run into trouble and become infected from a into a wound. bug like acinetobacter. Is my patient infected, or just colonized? asks PeOf the seven people the Defense Department actersen, recalling the dilemma faced when suspecting that knowledges to have died because of acinetobacter-reacinetobacter is threatening a patient. If [the persons lated complications, five were non-active duty patients skin] is colonized and I over-treat him, I could damage being treated in the same hospital as infected service his kidneys. If hes infected, and I ignore that and say hes memberspatients already weakened by such problems colonized, he could die. as organ failure, immune system deficiency, or multiple The infection, if it goes on, notes Anderson, traumatic wounds. sometimes will lead to amputation, so these are tough There have, however, been frighteningly dissimilar choices. cases. An apparently healthy nurse at the National Naval Even when some degree of amputation is required Medical Center in Bethesda, for instance, spent months to rid a patient of quickly spreading infection, military near death after being exposed.
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u.s. nAvy (shAne t. Mccoy)

Facing a bug able to counter many commonly used antibiotics, doctors and patients are sometimes forced to turn to increasingly toxic medications that might kill the bacteria but risk additional harm to a patients health. Were having to dig old ones out of the closet, says Petersen, medications that were not so good in the 1960s, and use those because theyre the only effective treatment. One such antibiotic is colistin. It hadnt been used really since the 1970s, says Walter Reeds Wortmann. I had never used iteveruntil the last couple years. And the concern with colistin was that it would cause kidney damage or nerve damage. In addition to agonizing over what treatment to use, physicians worry about when they should bring medications to bear. This is particularly difficult since tests to

surgeons face the challenge of trying to remove only infected tissueto get rid of the devitalized tissue, explains Moran, without taking too much in the way of good viable tissue and preserving limb length for a prosthetic.

Whos At Risk?

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Good Antibiotics, Bad Antibiotics

Youre looking two or three years down the road. And Two key issues seem behind the persistence of the out- thats if the ideas pan out. break. A number of infectious disease specialists point to In mid-2007, a group of military infectious disease phydifficulties in completely ridding hospital environments of sicians convened in San Antonio to discuss the outbreak. acinetobacter. Doing so, they say, requires more stringent They plan to write a medical journal article including reccleaning than that typically sufficient to kill other bacte- ommendations for dealing with the problem. ria. Additionally, several express concern that policies on Policies on infection control and antibiotic use, meanantibiotic use differ at commands and hospitals along the time, remain essentially unchanged from those in place casualty evacuation chain. when the war began. There are Sometimes trying to err on the guidelines, says Wortmann, and side of caution, doctors on the sort of loose oversight of the pracFour years into the fight, frontline prescribe wide-spectrum ticing patterns of the physicians, antibiotics prior to determining if but there is no one person that up to 20 percent of those a patient is actually carrying acisays, Doctor Jones in Baghdad, returning wounded still face you must do this. netobacter. In the long term, this has created problems. Timothy Endy, the former Walbiological onslaught by this I think antibiotic use is probter Reed physician, is among those bloodstream insurgent. ably driving some of this, suggests who believe that, in some measure, Petersen of the Comfort, because there should be. He urges defense when you keep people on prolonged leaders to bring a more systemantibiotics unnecessarily, it lets them be colonized with atic approach to the fightacross military service lines worse and worse bacteria. and command structuresciting lessons that should be In 2006, doctors at Walter Reed began successfully learned from this outbreak but have not been implemented curbing acinetobacter infections using an antibiotic called to my knowledge. imipenem. Soon thereafter, Endy recalls, frontline surgeons A key reform he feels necessary, and past due: creating began using imipenem as a prophylactic antibioticinfus- the means for military services and the Department of ing it into injured service members even when it was not Veterans Affairs to gather and share real-time information clear the bacteria had colonized on the patients skin or on antibiotic-resistant infections in medical centers. invaded their wounds. The result, he says: We started to He also recommends application of unified policies on see increasing resistance to this antibiotic, resulting in the infection control and prophylactic use of antibioticsand use of the more toxic drug, colistin. advocates that the services most senior medical officers, Wortmann at Walter Reed understands the urge of front- employing a more global view than physicians at single line providers to break out the big guns right away, par- points along casualty evacuation routes, be afforded auticularly when they know their facilities are contaminated thority to order clinical practice guidelines for infection with acinetobacter. But he counsels caregivers to first use control. antibiotics targeted toward more common bacteria, treating Most important, he adds, in order for treatment rules for acinetobacter only when tests show a patient has been to work more swiftly than fast-adapting bacteria, such colonized or infected. When you give an antibiotic, he guidelines must be executed in the war theater without says, youll kill most of the bacteria thats on that pa- delay. tient, but if a bacteria either is resistant to that antibiotic Endy also counsels that hospitals treating the combat or is able to rapidly become resistant to that antibiotic, wounded be afforded space and staff to keep acinetothen it will grow because all the other bacteria have been bacter-positive patients isolated from other patients, and killed off. that attention be paid to preventing warehoused medical equipment from becoming breeding grounds for contamiA Bacterial Long War? nation. Researchers in military laboratories and elsewhere are During 2004, the outbreaks worst point so far, some 30 exploring better means of fighting acinetobacter. Some percent of all patients returning from Iraq and Afghanistan are examining possible uses of radiation. At Harvard, An- tested positive for acinetobacter. Four years into the fight, derson is experimenting with a dye painted onto open up to 20 percent of those returning wounded still face wounds then activated with light. Even the worst strains biological onslaught by this bloodstream insurgent. that are resistant to multiple antibiotics, he says, will Thats what really held me back, says Marine Sersuccumb to the light-activated dye approach. geant Emery. Thats why I was laid up in the hospital Another idea: creating tests to more quickly determine for so long. or rule out infection. This would allow faster closing of non-infected woundsreducing contamination risk. But officer. He now covers dethese technologies are not ready for prime time as of to- Captain Henry was a Marine public affairsfor Washington, d.C. televifense, intelligence, and homeland security morrow, cautions Elster. Clinical trials take a while. sion outlets ABC7 and newsChannel 8.
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