Health care response to CCHF in US soldier and nosocomial transmission to health care providers, Germany, 2009.

In 2009, a lethal case of Crimean-Congo hemorrhagic fever (CCHF), acquired by a US soldier in Afghanistan, was treated at a medical center in Germany and resulted in nosocomial transmission to 2 health care providers (HCPs). After his arrival at the medical center (day 6 of illness) by aeromedical evacuation, the patient required repetitive bronchoscopies to control severe pulmonary hemorrhage and renal and hepatic dialysis for hepatorenal failure. After showing clinical improvement, the patient died suddenly on day 11 of illness from cerebellar tonsil herniation caused by cerebral/cerebellar edema. The 2 infected HCPs were among 16 HCPs who received ribavirin postexposure prophylaxis. The infected HCPs had mild or no CCHF symptoms. Transmission may have occurred during bag-valve-mask ventilation, breaches in personal protective equipment during resuscitations, or bronchoscopies generating infectious aerosols. This case highlights the critical care and infection control challenges presented by severe CCHF cases, including the need for experience with ribavirin treatment and postexposure prophylaxis.

Infection prevention and control in deployed military medical treatment facilities.

Infections have complicated the care of combat casualties throughout history and were at one time considered part of the natural history of combat trauma. Personnel who survived to reach medical care were expected to develop and possibly succumb to infections during their care in military hospitals. Initial care of war wounds continues to focus on rapid surgical care with debridement and irrigation, aimed at preventing local infection and sepsis with bacteria from the environment (e.g., clostridial gangrene) or the casualty's own flora. Over the past 150 years, with the revelation that pathogens can be spread from patient to patient and from healthcare providers to patients (including via unwashed hands of healthcare workers, the hospital environment and fomites), a focus on infection prevention and control aimed at decreasing transmission of pathogens and prevention of these infections has developed. Infections associated with combat-related injuries in the recent operations in Iraq and Afghanistan have predominantly been secondary to multidrug-resistant pathogens, likely acquired within the military healthcare system. These healthcare-associated infections seem to originate throughout the system, from deployed medical treatment facilities through the chain of care outside of the combat zone. Emphasis on infection prevention and control, including hand hygiene, isolation, cohorting, and antibiotic control measures, in deployed medical treatment facilities is essential to reducing these healthcare-associated infections. This review was produced to support the Guidelines for the Prevention of Infections Associated With Combat-Related Injuries: 2011 Update contained in this supplement of Journal of Trauma.

Multidrug-resistant bacterial colonization of combat-injured personnel at admission to medical centers after evacuation from Afghanistan and Iraq.

BACKGROUND: Multidrug-resistant organism (MDRO) infections, including those secondary to Acinetobacter (ACB) and extended spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae (Escherichia coli and Klebsiella species) have complicated the care of combat-injured personnel during Operations Iraqi Freedom and Enduring Freedom. Data suggest that the source of these bacterial infections includes nosocomial transmission in both deployed hospitals and receiving military medical centers (MEDCENs). Admission screening for MDRO colonization has been established to monitor this problem and effectiveness of responses to it. METHODS: Admission colonization screening of injured personnel began in 2003 at the three US-based MEDCENs receiving the majority of combat-injured personnel. This was extended to Landstuhl Regional Medical Center (LRMC; Germany) in 2005. Focused on ACB initially, screening was expanded to include all MDROs in 2009 with a standardized screening strategy at LRMC and US-based MEDCENs for patients evacuated from the combat zone. RESULTS: Eighteen thousand five hundred sixty of 21,272 patients admitted to the 4 MEDCENs in calendar years 2005 to 2009 were screened for MDRO colonization. Average admission ACB colonization rates at the US-based MEDCENs declined during this 5-year period from 21% (2005) to 4% (2009); as did rates at LRMC (7-1%). In the first year of screening for all MDROs, 6% (171 of 2,989) of patients were found colonized at admission, only 29% (50) with ACB. Fifty-seven percent of patients (98) were colonized with ESBL-producing E. coli and 11% (18) with ESBL-producing Klebsiella species. CONCLUSIONS: Although colonization with ACB declined during the past 5 years, there seems to be replacement of this pathogen with ESBL-producing Enterobacteriaceae.

Response to infection control challenges in the deployed setting: Operations Iraqi and Enduring Freedom.

BACKGROUND: Infections caused by multidrug-resistant organisms (MDROs), including Acinetobacter, have complicated the care of military personnel injured in Operations Iraqi and Enduring Freedom. Cumulative data suggest that nosocomial transmission of MDROs in deployed medical treatment facilities (MTFs) has contributed to these infections. A 2008 review of deployed MTFs identified multiple factors impeding the performance of infection prevention and control (IC) practices. In response, efforts to emphasize IC basics, improve expertise, and better track MDRO colonization were pursued. METHODS: Efforts to increase awareness and enhance IC in deployed MTFs were focused on educating leaders and deploying personnel, producing deployed IC resources, and standardizing level IV and V admission screening for MDRO colonization. A repeat mission in 2009 reviewed interval progress. RESULTS: Increased awareness and the need for emphasis on basic IC practice, including hand hygiene, use of transmission-based (isolation) precautions, and cohorting of patients, were imparted to leaders and deploying personnel through briefings, presentations, and an All Army Activities message. Enhancement of IC expertise was implemented through increased standardization of IC practice, establishment of a predeployment IC short course, an IC teleconsultation service, and dedicated Internet resources. Standardization of admission colonization screening of personnel evacuated from the combat theater was established to better define and respond to the MDRO problem. A repeat review of the deployed MTFs found overall improvement in IC practice, including clear command emphasis in the Iraqi theater of operations. CONCLUSIONS: Maintaining a strong IC effort in the deployed setting, even in a stabilized operational environment, is difficult. Use of innovative strategies to enhance expertise and practice were implemented to reduce MDRO infections.