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Military superbug, quiet civilian epidemic

US Army Sgt. Matthew Miller, left, of Pasadena, Maryland, leads a team of soldiers loading a wounded soldier onto his Medevac near Tikrit, Iraq, Aug. 25, 2005. Photo: AP/Jacob Silberberg

A thick layer of dust covers the blazing hot combat fields of Afghanistan and Iraq, getting under soldiers’ helmets, chalking up their fatigues and covering exposed skin. When enemy fire hits, troops often sustain severe burns and open wounds with shredded surrounding skin. Medical aid is generally faster than in any other U.S. wars, thanks to technology and a transport chain designed for high speed. When medics come, there’s an efficient process of lifting wounded troops onto open transport vehicles, prodding them with devices to assess vitals, wrapping their wounds and giving them fluids and blood. But during all that activity, the dust, the many hands and bandages, open wounds and needle punctures give other enemies — microscopic superbugs — an opportunity to attack from the inside.

For troops wounded in the wars in Iraq and Afghanistan, one of the most prolific superbugs has been an almost exclusively hospital-bred strain of bacteria known as “Iraqibacter,” a mutated version of the common acinetobacter baumannii. While military hospitals have waged a somewhat successful internal battle against the bacteria, for civilian hospitals in the U.S. and around the world, these bugs are a formidable foe.

“The data we were seeing shocked us into action,” said Colonel Dr. Duane Hospenthal, Infectious Diseases Consultant for the U.S. Army Surgeon General.  In fall 2008, the military expanded its infection monitoring and control system, also known as GEIS (Global Emerging Infectious Surveillance), to include acinetobacter and other multidrug-resistant organisms. This overhaul followed a spate of high-profile stories in Wired magazine and on the PBS program “Nova” about the prevalence of acinetobacter at Walter Reed Medical Center.

Acinetobacter isn’t new, but its current offspring are superbugs that are much more dangerous than the original bacteria. The current versions have thousands of mutants that grow stronger with antibiotic exposure, resist most treatments, thrive in the jagged wounds made by modern weapons and can survive in ICUs of any kind for weeks on hard surfaces like counters and equipment with no food. The consequence of acquiring an acinetobacter infection ranges from a few more weeks in the hospital to severe suppression of the immune system that can exacerbate other illnesses and lead to death. Unless they are screening for it routinely, doctors may not even know if a patient has been infected with the superbug.

In the Korean and Vietnam Wars, service members infected with acinetobacter were mostly confined to single field hospitals and these infections could be successfully treated with a range of antibiotics. But, modern acinetobacter resists almost all the potent antibiotics administered in hospital ICUs and it has adapted to the complex evacuation chain that brings wounded troops through a series of up to 10 locations. Though the military has made some successful changes to combat the bugs, it’s an ongoing challenge.

“If you look at the trauma scores, we do a lot better job of keeping folks alive,” said Hospenthal, drawing a comparison to past wars. “There’s a lot of open wounds, a lot of critically ill folks getting massively transfused. All these things put them at risk to be colonized and then to be immune-compromised…and they are at risk for these infections.”

What’s changed?

Dealing with antibiotic-resistant bacteria, especially acinetobacter, has put an enormous strain on the military healthcare system, which has spurred major procedural changes and an increased cost of care.

In its own surveillance report of hospital infections released in March of this year, the military healthcare system concluded that, “Compared to past wars, the acquisition of multidrug-resistant isolates appears to be significantly increased…These infections plague DoD and Veterans Affairs medical treatment facilities and contribute to prolonged hospital stays. Outbreaks of acinetobacter infections are becoming increasingly common among patients in ICUs, surgical units and burn units.”

Thanks to growing public awareness of the issue and heightened pressure to address it, some of the military’s strategies for dealing with acinetobacter infections have proven successful. Though the numbers of infected are still much higher than wars that preceded those in Afghanistan and Iraq, the overall rates since 2003 have been on the decline, according to the Department of Defense statistics presented at a House oversight committee on the subject last fall.

This can be attributed, in part, to the changes that have been implemented in the military healthcare system, which now perform routine screening and have stricter hygiene codes to combat acinetobacter and other drug-resistant bacteria. New measures include testing at several stages of the transport chain, limiting antibiotic use, placing infection control officers at many of the trauma centers and increasing the use of electronic medical records to track a patient’s history of infection.