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Background: During the conflicts in Iraq and Afghanistan, more than 52,000 U.S. military members were wounded in action. The battlefield mortality rate was lower than in past conflicts, however, those surviving often had complex soft tissue and bone injuries requiring multiple surgeries. This report describes the rates, types, and risks of infections complicating the care of combat casualties.Patients and Methods: Infection and microbiology data obtained from the Trauma Infectious Disease Outcomes Study (TIDOS), a prospective observational study of infections complicating deployment-related injuries, were used to determine the proportion of infection, types, and associated organisms. Injury and surgical information were collected from the Department of Defense Trauma Registry. Multivariable Cox proportional hazards and logistic regression models were used to evaluate potential factors associated with infection.Results: From 2009-2012, 1,807 combat casualties were evacuated to U.S. TIDOS-participating hospitals. Among the 1,807 patients, the proportion of overall infections from time of injury through initial U.S. hospitalization was 34% with half being skin, soft tissue, or bone infections. Infected wounds most commonly grew Enterococcus faecium, Pseudomonas aeruginosa, Acinetobacter spp. or Escherichia coli. In the multivariable model, amputation, blood transfusions, intensive care unit admission, injury severity scores, mechanical ventilation, and mechanism of injury were associated with risk of infection.Conclusions: One-third of combat casualties from Iraq and Afghanistan develop infections during their initial hospitalization. Amputations, blood transfusions, and overall injury severity are associated with risk of infection, whereas more easily modifiable factors such as early operative intervention or antibiotic administration are not. [ABSTRACT FROM AUTHOR]

The article offers the author's view on the healthcare of the U.S. military personnel. The author states that military healthcare is more risky and emotionally charged. The author notes that the concept of prolonged filed care may start on the front lines has implications for level of evacuation and treatment. The author mentions the need of the U.S Army medicine to maintain situational understanding.

The article discusses the monitoring of the health and Ebola virus exposure of U.S. military personnel deployed to Liberia to build treatment units and train health care workers in its fight against the disease. Topics include the twice daily monitoring of military units and standard screening assessment of personnel exhibiting exposure symptoms, and prevalent health issues as gastrointestinal and respiratory concerns. The background for the Ebola epidemic in West Africa is also discussed.

Background The United States introduced human T-lymphotropic virus Type I ( HTLV- I) screening of blood donors in 1988. The US military uses freshly collected blood products for life-threatening injuries when available stored blood components in theater have been exhausted or when these components are unsuccessful for resuscitation. These donors are screened after donation by the Department of Defense ( DoD) retrospective testing program. All recipients of blood collected in combat are tested according to policy soon after and at 3, 6, and 12 months after transfusion. Case Report A 31-year-old US Army soldier tested positive for HTLV- I 44 days after receipt of emergency blood transfusions for severe improvised explosive device blast injuries. One donor's unit tested HTLV- I positive on the DoD-mandated retrospective testing. Both the donor and the recipient tested reactive with enzyme immunoassay and supplemental confirmation by HTLV- I Western blot. The donor and recipient reported no major risk factors for HTLV- I. Phylogenetic analysis of HTLV- I sequences indicated Cosmopolitan subtype, Subgroup B infections. Comparison of long terminal repeat and env sequences revealed molecular genetic linkage of the viruses from the donor and recipient. Conclusion This case is the first report of transfusion transmission of HTLV- I in the US military during combat operations. The emergency fresh whole blood policy enabled both the donor and the recipient to be notified of their HTLV- I infection. While difficult in combat, predonation screening of potential emergency blood donors with Food and Drug Administration-mandated infectious disease testing as stated by the DoD Health Affairs policy should be the goal of every facility engaged with emergency blood collection in theater. [ABSTRACT FROM AUTHOR]

Background: Staphylococcus aureus [methicillin-resistant and methicillin-susceptible (MRSA/MSSA)] is a leading cause of infections in military personnel, but there are limited data regarding baseline colonization of individuals while deployed. We conducted a pilot study to screen non-deployed and deployed healthy military service members for MRSA/MSSA colonization at various anatomic sites and assessed isolates for molecular differences. Methods: Colonization point-prevalence of 101 military personnel in the US and 100 in Afghanistan was determined by swabbing 7 anatomic sites. US-based individuals had received no antibiotics within 30 days, and Afghanistan-deployed personnel were taking doxycycline for malaria prophylaxis. Isolates underwent identification and testing for antimicrobial resistance, virulence factors, and pulsed-field type (PFT). Results: 4 individuals in the US (4 isolates- 3 oropharynx, 1 perirectal) and 4 in Afghanistan (6 isolates- 2 oropharynx, 2 nare, 1 hand, 1 foot) were colonized with MRSA. Among US-based personnel, 3 had USA300 (1 PVL+) and 1 USA700. Among Afghanistan-based personnel, 1 had USA300 (PVL+), 1 USA800 and 2 USA1000. MSSA was present in 40 (71 isolates-25 oropharynx, 15 nare) of the US-based and 32 (65 isolates- 16 oropharynx, 24 nare) of the Afghanistan-based individuals. 56 (79%) US and 41(63%) Afghanistan-based individuals had MSSA isolates recovered from extra-nare sites. The most common MSSA PFTs were USA200 (9 isolates) in the US and USA800 (7 isolates) in Afghanistan. MRSA/MSSA isolates were susceptible to doxycycline in all but 3 personnel (1 US, 2 Afghanistan; all were MSSA isolates that carried tetM). Conclusion: MRSA and MSSA colonization of military personnel was not associated with deployment status or doxycycline exposure. Higher S. aureus oropharynx colonization rates were observed and may warrant changes in decolonization practices. [ABSTRACT FROM AUTHOR]

Background: The US military has seen steady increases in multidrug-resistant (MDR) gram-negative bacteria (GNB) infections in casualties from Iraq and Afghanistan. This study evaluates the prevalence of MDR GNB colonization in US military personnel. Methods: GNB colonization surveillance of healthy, asymptomatic military personnel (101 in the US and 100 in Afghanistan) was performed by swabbing 7 anatomical sites. US-based personnel had received no antibiotics within 30 days of specimen collection, and Afghanistan-based personnel were receiving doxycycline for malaria chemoprophylaxis at time of specimen collection. Isolates underwent genotypic and phenotypic characterization. Results: The only colonizing MDR GNB recovered in both populations was Escherichia coli (p=0.01), which was seen in 2% of US-based personnel (all perirectal) and 11% of Afghanistan-based personnel (10 perirectal, 1 foot+groin). Individuals with higher off-base exposures in Afghanistan did not show a difference in overall GNB colonization or MDR E. coli colonization, compared with those with limited off-base exposures. Conclusion: Healthy US- and Afghanistan-based military personnel have community onset-MDR E. coli colonization, with Afghanistan-based personnel showing a 5.5-fold higher prevalence. The association of doxycycline prophylaxis or other exposures with antimicrobial resistance and increased rates of MDR E. coli colonization needs further evaluation. [ABSTRACT FROM AUTHOR]

Trauma-related invasive mold infections are an emerging threat among US military personnel. Early identification of suspicious wounds, based on injury profile and tissue-based diagnosis, require aggressive surgical and empiric antifungal therapy (liposomal amphotericin B and voriconazole pending histopathology and cultures).Background. Major advances in combat casualty care have led to increased survival of patients with complex extremity trauma. Invasive fungal wound infections (IFIs) are an uncommon, but increasingly recognized, complication following trauma that require greater understanding of risk factors and clinical findings to reduce morbidity.Methods. The patient population includes US military personnel injured during combat from June 2009 through December 2010. Case definition required wound necrosis on successive debridements with IFI evidence by histopathology and/or microbiology (Candida spp excluded). Case finding and data collected through the Trauma Infectious Disease Outcomes Study utilized trauma registry, hospital records or operative reports, and pathologist review of histopathology specimens.Results. A total of 37 cases were identified: proven (angioinvasion, n = 20), probable (nonvascular tissue invasion, n = 4), and possible (positive fungal culture without histopathological evidence, n = 13). In the last quarter surveyed, rates reached 3.5% of trauma admissions. Common findings include blast injury (100%) during foot patrol (92%) occurring in southern Afghanistan (94%) with lower extremity amputation (80%) and large volume blood transfusion (97.2%). Mold isolates were recovered in 83% of cases (order Mucorales, n = 16; Aspergillus spp, n = 16; Fusarium spp, n = 9), commonly with multiple mold species among infected wounds (28%). Clinical outcomes included 3 related deaths (8.1%), frequent debridements (median, 11 cases), and amputation revisions (58%).Conclusions. IFIs are an emerging trauma-related infection leading to significant morbidity. Early identification, using common characteristics of patient injury profile and tissue-based diagnosis, should be accompanied by aggressive surgical and antifungal therapy (liposomal amphotericin B and a broad-spectrum triazole pending mycology results) among patients with suspicious wounds. [ABSTRACT FROM AUTHOR]

The article presents information on an observational study which evaluates trends in the incidence rates of Staphylococcus aureus bacteremia and skin and soft tissue infections (SSTIs) and the proportion due to methicillin-resistant Staphylococcus aureus (MRSA). It provides information that Spearman rank correlation test and the Mantel-Haenszel chi-square test for linear trend was used in the study. It concludes that the rates of both community-onset and hospital-onset MRSA bacteremia have decreased in parallel. It reports that the proportion of community-onset SSTIs due to MRSA has declined during 2005-2010 in the U.S.

Background. Adenovirus serotype 14 (Ad-14) recently emerged as a respiratory pathogen in the United States, with studies suggesting higher morbidity and mortality. This study was conducted to determine whether Ad-14 is associated with clinical outcomes in otherwise healthy patients with pneumonia.Methods. Medical records of military trainees hospitalized with pneumonia during an outbreak of Ad-14 infection were reviewed. Clinical, radiographic, and laboratory parameters were compared on the basis of Ad-14 infection.Results. Two hundred thirty-four trainees received a diagnosis of pneumonia, and 83(35%) were hospitalized. Sixty-one percent of patients with pneumonia were Ad-14 positive; 43% of patients with Ad-14 pneumonia were hospitalized (83% of female patients and 40% of male patients; P = .04), compared with 40% of patients with Ad-14 negative cases. Ad-14 infection was associated with higher admission temperature (38.3oC [interquartile range, (IQR) 37.7, 39.4] vs 37.3oC [IQR (36.7, 38.5)]; P < .01) and lower white blood cell count (8.3 × 1000 cells/μL [IQR, 5.7, 12.4] vs 13 × 1000 cells/μL [IQR, 7.5, 12.9]; P = .01), neutrophil count (6.7 × 1000 cells/μL [IQR, 2.8, 9.7] vs 9.7 × 1000 cells/μL [IQR, 5.6, 12.1]; P = .02), lymphocyte count (0.9 × 1000 cells/μL [IQR, 0.8, 1.1] vs 1.3 × 1000 cells/μL [IQR, 1, 1.9]; P = .001), and platelet count (210 × 1000 cells/μL [IQR, 145, 285] vs 261 × 1000 cells/μL [IQR, 238, 343]; P < .01). Ad-14 pneumonia was not associated with specific radiographic findings, pneumonia severity score, intensive care unit admission, longer hospitalization, or 30-day mortality.Conclusions. During an outbreak of Ad-14 infection, Ad-14 infection was not associated with excess overall morbidity or mortality. Ad-14 infection was associated with specific laboratory and clinical parameters and higher hospitalization rates in female trainees. These data provide new insight to the epidemiology of Ad-14 infection. [ABSTRACT FROM PUBLISHER]

International infectious disease surveillance has been conducted by the United States (U.S.) Department of Defense (DoD) for many years and has been consolidated within the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) since 1998. This includes activities that monitor the presence of antimicrobial resistance among pathogens. AFHSC-GEIS partners work within DoD military treatment facilities and collaborate with host-nation civilian and military clinics, hospitals and university systems. The goals of these activities are to foster military force health protection and medical diplomacy. Surveillance activities include both community-acquired and health care-associated infections and have promoted the development of surveillance networks, centers of excellence and referral laboratories. Information technology applications have been utilized increasingly to aid in DoD-wide global surveillance for diseases significant to force health protection and global public health. This section documents the accomplishments and activities of the network through AFHSC-GEIS partners in 2009. [ABSTRACT FROM AUTHOR]

U.S. combat casualties from Iraq and Afghanistan continue to develop infections with multidrug-resistant (MDR) bacteria. This study assesses the infection control database and clinical microbiology antibiograms at a single site from 2005 to 2007, a period when all Operation Iraqi Freedom (OIF)/Operation Enduring Freedom (OEF) casualties admitted to the facility underwent initial isolation and screening for MDR pathogens. During this 3-year period, there were 2,242 OIF/OEF admissions: 560 in 2005, 724 in 2006, and 958 in 2007. The most commonly recovered pathogens from OIF/OEF admission screening cultures were methicillin- resistant Staphyhlococcus aureus (MRSA), Klebsiella pneumoniae and Acinetobacter. The yearly nosocomial infection rate of these three pathogens among OIF/OEF admissions ranged between 2 and 4%. There were remarkable changes in resistance profiles for Acinetobacter, K. pneumoniae, and S. aureus over time. Despite aggressive infection control procedures, there is continued nosocomial transmission within the facility and increasing antimicrobial resistance in some pathogens. Novel techniques are needed to control the impact of MDR bacteria in medical facilities. [ABSTRACT FROM AUTHOR]

The article presents a study about the strategies used to prevent morbidity and mortality associated with combat-related injuries. It investigates infectious disease complications of combat-related injuries of the U.S. military acquired from wars in Iraq and Afghanistan. Results of such study show that there is a need to concentrate more on the advancement in military medicine.

We describe the types of medical problems encountered at a U.S. Army echelon II medical facility during Operation Iraqi Freedom in the period after completion of major ground combat operations, a time of nation restructuring and intermittent, intense, armed conflict. A total of 4.831 patients were assessed between October 1, 2003 and June 30, 2004, 74% with disease and nonbattle injury presentations, 19% with dental complaints, and 7% wounded in action (WIA). Disease and nonbattle injury evaluations were predominantly musculoskeletal. Improvised explosive devices or mortars caused 78% of the WIA casualties. The most frequent dental evaluations were for restorations (47%). Thirty-eight individuals were admitted to holding beds, most commonly to receive intravenous antibiotic treatment for cellulitis (29%). Three hundred forty-one individuals were evacuated, including 150 WIA. Determining the types of casualties seen at forward echelons of medical care during different phases of conflict can aid medical planning and help predict the type of medical resources required. [ABSTRACT FROM AUTHOR]

Abstract: Bacterial infections are a common cause of mortality in burn patients and viral infections, notably herpes simplex virus (HSV) and cytomegalovirus (CMV) have also been associated with mortality. This study is a retrospective review of all autopsy reports from patients with severe thermal burns treated at the US Army Institute of Research (USAISR) burn unit over 12 years. The review focused on those patients with death attributed to a bacterial or viral cause by autopsy report. Of 3751 admissions, 228 patients died with 97 undergoing autopsy. Death was attributed to bacteria for 27 patients and to virus for 5 patients. Bacterial pathogens associated with mortality included Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae and Staphylococcus aureus. This association with mortality was independent of % total body surface area burn, % full-thickness burn, inhalation injury, and day of death post-burn. Bloodstream infection was the most common cause of bacteria related death (50%), followed by pneumonia (44%) and wound infection (6%). Time to death following burn was ≤7 days in 30%, ≤14 days in 59% and ≤21 days in 67%. All of the viral infections associated with mortality involved the lower respiratory tract, HSV for 4 and CMV for 1. Four of these 5 patients had evidence of inhalation injury by bronchoscopy, all had facial and neck burns, and 2 had concomitant Staphylococcus pneumonia. Time to death following burn ranged from 14 to 42 days for the 5 patients. Despite advances in care, gram negative bacterial infections and infection with S. aureus remain the most common cause of bacteria related mortality early in the hospital course. Viral infections are also associated with mortality and numbers have remained stable when compared to data from prior years. [ABSTRACT FROM AUTHOR]

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most prevalent human enzyme deficiency. affecting an estimated 400 million people worldwide. G6PD deficiency increases erythrocyte vulnerability to oxidative stress and may precipitate episodes of hemolysis when individuals are exposed to triggering agents. Although central retinal vein occlusion (CRVO) does occur in G6PD-deficient individuals. G6PD-deficient individuals exposed to oxidative stressors have not been previously reported to have an increase in CRVO incidence. This is a case of an Army Ranger who deployed to Afghanistan with unrecognized G6PD deficiency and was placed on primaquine following his return to the United States and subsequently developed CRVO. Primaquine is a well-recognized cause of hemolysis in individuals with G6PD deficiency. Hemolytic anemia may contribute to thrombosis as a result of increased erythrocyte aggregation and erythrocyte--endothelium interaction. This case underscores the continued need for routine G6PD screening and avoidance of known triggers in G6PD-deficient individuals. [ABSTRACT FROM AUTHOR]

Introduction: This study was conducted to identify and understand the current factors affecting recruitment, job satisfaction, and retention of U.S. Army Medical Corps officers and provide historical background to understand if the current factors are dissimilar.Materials and Methods: An anonymous, voluntary questionnaire was sent to U.S. Army Medical Corps officers, and responses were tabulated and analyzed. Historical research was conducted and historical analysis applied.Results: Recruiting, job satisfaction, and retention among Army Medical Corps Officers have been problematic throughout the 50-year history of the all-volunteer force. Recruiting has largely been of medical students, with very limited numbers of direct accessions. At times, satisfactory overall numbers have camouflaged shortages in key go-to-war specialties. Also, satisfactory numbers in a specialty have sometimes camouflaged problems in depth of experience. Satisfaction has been seen as a problem but apparently only studied informally and/or episodically. Retention has largely been addressed through service obligations, followed by monetary bonuses, although these have to be across the Department of Defense, limiting service flexibility. There has never been consistent, longitudinal sampling of opinion among Medical Corps Officers to allow senior leaders to influence the Department of Defense policy. A recent (2016) study provides substantial data but should be repeated rather than being isolated.Conclusion: As the situation in the Department of Defense and Army Medical Department changes, with more focus on go-to-war specialties, the Army needs to better measure opinion among Medical Corps Officers to inform policy. These studies should be conducted regularly to generate reliable information on trends and allow prioritization of effort to areas that hamper recruiting, undermine satisfaction, and prevent retention. [ABSTRACT FROM AUTHOR]

Introduction: Tactical Combat Casualty Care (TCCC) is the execution of prehospital trauma skills in the combat environment. TCCC was recognized by the 2018 Department of Defense Instruction on Medical Readiness Training as a critical wartime task. This study examines the training, understanding, and utilization of TCCC principles and guidelines among US Army medical providers and examines provider confidence of medics in performing TCCC skills.Materials and Methods: A cross-sectional survey, developed by members of the Committee on TCCC, was distributed to all US Army Physicians and Physician Assistants via anonymous electronic communication.Results: A total of 613 completed surveys were included in the analyses. Logistic regression analyses were conducted on: TCCC test score of 80% or higher, confidence with medic utilization of TCCC, and medic utilization of ketamine in accordance with TCCC.Conclusions: <60% of respondents expressed confidence in the ability of the medics to perform all TCCC skills. Supervising providers who that believed 80 to 100% of their medics had completed TCCC training had more confidence in their medic's TCCC abilities. With TCCC, a recognized lifesaver on the battlefield, continued training and utilization of TCCC concepts are paramount for deploying personnel. [ABSTRACT FROM AUTHOR]

Introduction: In 2013, the U.S. Army Surgeon General implemented the Performance Triad (P3), an educational initiative to improve health-related behaviors of soldiers throughout the U.S. Army. The components of P3 are Sleep, Activity, and Nutrition with tenet behaviors for each component. This study reports the results of the 2015 U.S. Army Medical Corps survey regarding physician knowledge and adherence to the tenet behaviors of P3.Methods: In 2015, an anonymous survey was sent to all active duty U.S. Army physicians to assess demographic information, work hours, and knowledge of and adherence to P3. The survey assessed the tenets of P3 with questions about the following topics: obtaining 8 h of sleep per day; performing at least 2 d of resistance training and 1 day of agility training per week; re-fueling 30-60 min after exercise; incorporating at least 150 min of moderate and 75 min of vigorous aerobic exercise per week; going caffeine free 6 h before bedtime; eating at least 8 servings of fruits and vegetables per day; and getting 15,000 steps per day. For each question, there were four response options which ranged from "Always" to "Never." A positive response to the questionnaire was defined as answering frequently or always. The responses were analyzed by comparison of several physician categories utilizing descriptive statistics and multivariable analysis.Results: Surveys were completed by 1,003 of approximately 4,500 U.S. Army physicians. 79.1% of the respondents were male. Staff physicians made up 834 (83.6%) of the respondents compared with 164 (16.4%) physicians in training. Overall 25% of respondents were adherent to the sleep tenet, 45% to the exercise tenet, and 38% to the nutrition tenet. Reported work hours were significantly higher in physicians in training compared with staff physicians (p < 0.001). About 28.4% of staff reported a positive response to obtaining at least 8 h of sleep per night, compared with 12.7% of residents/fellows. In multivariable analyses, better sleep was associated with being a staff physician [odds ratio 2.4 (95% confidence interval 1.40-4.13)], working fewer hours per week [1.75 (1.37-2.25)], and belief in supervisor adherence to P3 [2.04 (1.59-2.56)]. Increased exercise was associated with male gender [2.09 (1.45-3.02)], being a staff physician [1.63 (1.09-2.43)], and belief in supervisor adherence to P3 [1.43 (1.18-1.75)]. Positive response to the nutrition tenet was associated with belief in supervisor adherence to P3 [1.23 (1.01-1.49)].Conclusion: Overall, U.S. Army physicians are most adherent to the exercise tenet and least adherent to the sleep tenet of P3; this is consistent with the military culture. Work hours seem to affect wellness behaviors. Specifically, physicians who work fewer hours are more likely to report obtaining 8 h of sleep per day and exercise on a regular basis. Importantly, belief in supervisor adherence to P3 was associated with better adherence to P3, suggesting that physician leadership has a positive effect on wellness behaviors. This suggests a role for similar wellness programs in civilian healthcare institutions. Future research should also include changes in health system policies to motivate physician wellness behaviors. [ABSTRACT FROM AUTHOR]

The Trauma Infectious Disease Outcomes Study began in June 2009 as combat operations were decreasing in Iraq and increasing in Afghanistan. Our analysis examines the rate of infections of wounded U.S. military personnel from operational theaters in Iraq and Afghanistan admitted to Landstuhl Regional Medical Center between June 2009 and December 2013 and transferred to a participating U.S. hospital. Infection risk factors were examined in a multivariate logistic regression analysis (expressed as odds ratios [OR]; 95% confidence intervals [CI]). The study population includes 524 wounded military personnel from Iraq and 4,766 from Afghanistan. The proportion of patients with at least one infection was 28% and 34% from the Iraq and Afghanistan theaters, respectively. The incidence density rate was 2.0 (per 100 person-days) for Iraq and 2.7 infections for Afghanistan. Independent risk factors included large-volume blood product transfusions (OR: 10.68; CI: 6.73-16.95), high Injury Severity Score (OR: 2.48; CI: 1.81-3.41), and improvised explosive device injury mechanism (OR: 1.84; CI: 1.35-2.49). Operational theater (OR: 1.32; CI: 0.87-1.99) was not a risk factor. The difference in infection rates between operational theaters is primarily a result of increased injury severity in Afghanistan from a higher proportion of blast-related trauma during the study period. [ABSTRACT FROM AUTHOR]

The Army Knowledge Online provides an e-mail service to assist deployed health care providers with specialty consultation. This performance improvement project evaluated the impact and utility of the infectious disease Army Knowledge Online teleconsultation service. Health care providers using the service from January 2010 through December 2010 were emailed a 9-question survey. The survey sought to determine if teleconsultation changed care or evacuation plan, and if responses were timely and clear. 123 consults were received, primarily from Afghanistan (58) and Iraq (26), and primarily regarding U.S. service members: (Army-36, Navy-18, Air Force-10, and Marines-3). Consults were answered on average in 3.3 hours. Completed surveys were obtained from 87 of the total 123 consultations. Responses to survey questions were as follows [scored on a 5-point scale from 1 (no, not at all) to 5 (yes, absolutely)l: Response Helpful (4.6), Response Changed Care (3.3), Response Changed Evacuation Plan (1.8), If Evacuation Plan Changed; was Evacuation Prevented (2.4), Response Timely (4.8), Response Verbose (I.1), Recommendations Clear (4.6), Too Many Recommendations (1.2), and Response Answered Your Question (4.8). The infectious disease teleconsultation service provides timely, helpful, and relevant feedback and plays an important role in influencing patient evacuation plan. [ABSTRACT FROM AUTHOR]

The increased incidence of sexually transmitted infections has historically been associated with military personnel at war. The incidence of gonorrhea and Chlamydia in personnel deployed in the current wars in Iraq and Afghanistan has not been reported. An electronic records' review of testing done from January 2004 to September 2009 revealed higher rates of Chlamydia than gonorrhea, especially among females who deploy to Iraq. Additionally, increasing Chlamydia rates were noted over the study. Overall, the rates of gonorrhea and Chlamydia were the same or lower than age- and year-matched U.S. rates reported by the Center for Disease Control and Prevention. Ongoing education with emphasis on prevention and treatment are needed, as are development of specific projects to define the risk factors and timing of acquisition of sexually transmitted infections in combat zones. [ABSTRACT FROM AUTHOR]

Abstract: Background: Topical antimicrobials are employed for prophylaxis and treatment of burn wound infections despite no established susceptibility breakpoints, which are becoming vital in an era of multidrug-resistant (MDR) bacteria. We compared two methods of determining topical antimicrobial susceptibilities. Methods: Isolates of Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), extended spectrum beta-lactamase (ESBL) producing Klebsiella pneumoniae, and Acinetobacter baumanii-calcoaceticus (ABC) from burn patients were tested using broth microdilution and agar well diffusion to determine minimum inhibitory concentrations (MICs) and zones of inhibition (ZI). Isolates had systemic antibiotic resistance and clonality determined. MDR included resistance to antibiotics in three or more classes. Results: We assessed 22 ESBL-producing K. pneumoniae, 20 ABC (75% MDR), 20 P. aeruginosa (45% MDR), and 20 MRSA isolates. The most active agents were mupirocin for MRSA and mafenide acetate for the gram-negatives with moderate MICs/ZI found with silver sulfadiazene, silver nitrate, and honey. MDR and non-MDR isolates had similar topical resistance. There was no clonality associated with resistance patterns. Conclusion: Despite several methods to test bacteria for topical susceptibility, no defined breakpoints exist and standards need to be established. We recommend continuing to use silver products for prophylaxis against gram-negatives and mafenide acetate for treatment, and mupirocin for MRSA. [Copyright &y& Elsevier]

Specialty teleconsultation is being provided to deployed healthcare providers in the current wars in Iraq and Afghanistan through the use of the Army Knowledge Online (AKO) e-mail service. We reviewed 374 teleconsults received by the infectious disease (ID) service between January 2005 and June 2008. The patients were 65% male, 12% female, 33% the gender was not stated or the consult did not involve an individual, and 41% were U.S. Army. The average response time was under 5 hours. Ninety-one percent of consults originated from the U.S. Central Command area of responsibility. Consults included questions pertaining to therapy (42%), diagnosis (21%), prevention (13%), or mixed categories (24%). Bacterial infections were the most common (32%), followed by parasitic infections (16%). Tuberculosis and methicillin-resistant Staphylococcus aureus accounted for 13% and 8% of consults, respectively. Data from this program should be useful in focusing predeployment provider training. It also provides the military ID community situational awareness of problems encountered in theater. [ABSTRACT FROM AUTHOR]

U.S. casualties have developed multidrug-resistant (MDR) bacterial infections. A surveillance project to evaluate U.S. military patients for the presence of MDR pathogens from wounding through the first 30 days of care in the military healthcare system (MHS) was performed. U.S. military patients admitted to a single combat support hospital in Iraq during June-July of 2007 had screening swabs obtained for the detection of MDR bacteria and a subsequent retrospective electronic medical records review for presence of colonization or infection in the subsequent 30 days. Screening of 74 U.S. military patients in Iraq found one colonized with methicillin-resistant Staphylococcus aureus. Fifty-six patients of these were screened for Acinetobacter in Germany and one found colonized. Of patients evacuated to the U.S., 9 developed infections. Carefully obtained screening cultures immediately after injury combined with look-back monitoring supports the role of nosocomial transmission. Consistent infection control strategies are needed for the entire MHS. [ABSTRACT FROM AUTHOR]

Introduction: Battlefield-related wound infections are a significant source of morbidity among combat casualties. Seasonality of these infections was demonstrated in previous conflicts (e.g., Korea) but has not been described with trauma-related health care-associated infections from the war in Afghanistan., Methods: The study population included military personnel wounded in Afghanistan (2009-2014) medevac'd to Landstuhl Regional Medical Center and transitioned to participating military hospitals in the United States with clinical suspicion of wound infections and wound cultures collected ≤7 days post-injury. Analysis was limited to the first wound culture from individuals. Infecting isolates were collected from skin and soft-tissue infections, osteomyelitis, and burn soft-tissue infections. Data were analyzed by season (winter [ December 1-February 28/29], spring [March 1-May 31], summer [June 1-August 31], and fall [September 1-November 30])., Results: Among 316 patients, 297 (94.0%) sustained blast injuries with a median injury severity score and days from injury to initial culture of 33 and 3.5, respectively. Although all patients had a clinical suspicion of a wound infection, a diagnosis was confirmed in 198 (63%) patients. Gram-negative bacilli (59.5% of 316) were more commonly isolated from wound cultures in summer (68.1%) and fall (67.1%) versus winter (43.9%) and spring (45.1%; P < .001). Multidrug-resistant (MDR) Gram-negative bacilli (21.8%) were more common in summer (21.8%) and fall (30.6%) versus winter (7.3%) and spring (19.7%; P = .028). Findings were similar for infecting Gram-negative bacilli (72.7% of 198)-summer (79.5%) and fall (83.6%; P = .001)-and infecting MDR Gram-negative bacilli (27.3% of 198)-summer (25.6%) and fall (41.8%; P = .015). Infecting anaerobes were more common in winter (40%) compared to fall (11%; P = .036). Gram-positive organisms were not significantly different by season., Conclusion: Gram-negative bacilli, including infecting MDR Gram-negative bacilli, were more commonly recovered in summer/fall months from service members injured in Afghanistan. This may have implications for empiric antibiotic coverage during these months., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Introduction: The coronavirus disease 2019 (COVID-19) is a viral respiratory illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has led to one of the world's largest infectious disease outbreaks. COVID-19 first emerged in Wuhan, Hubei, China, in December 2019, and the emergence was especially concerning to the U.S. Forces Korea (USFK) stationed in the Republic of Korea (ROK, South Korea), which remains vital to peace and security of the East Asian region. The first wave of cases emerged in South Korea from China before a globally established response, which forced USFK into a challenging position to combat a novel virus with countless unknowns regarding effective control and portended impact., Materials and Methods: As cases began to emerge in South Korea, USFK in early February began to proactively formulate peninsula-wide preventative health measures to protect the force. Eventually, USFK spearheaded a uniquely proactive Operation Kill the Virus that targeted COVID-19 as an enemy that must be rigorously defended against. Through the operation, USFK systematically employed eight key principles to successfully combat the pandemic, which are documented in this article., Results: The operation's eight principles focused on (1) Treat it like a combat operation, (2) Protect the force to protect the mission, (3) Stay one step ahead of the curve by exercising an abundance of caution, (4) Use predictive analysis, (5) Maintain open and transparent dialog with the community every day, (6) Be empathetic but prepare the community for lifestyle and culture changes, (7) Follow and enforce rules, and finally (8) Keep your foot on the gas and fight complacency. By closely collaborating with the ROK government, especially the Korean Centers for Disease Control and Prevention, USFK effectively limited the number of locally acquired cases, including service members, families, and civilians, to 24 by April 2020. Vital to that success was ensuring a sufficient capability and capacity to test, trace, treat, and logistically support with personal protective equipment and sufficient infrastructure for quarantine and isolation. As the pandemic shifted to the USA and Europe, new cases in the ROK shifted from locally acquired to imported from international travelers. Fundamental to USFK's sustained preservation of readiness and training included aggressive quarantine and testing of all arrivals from the United States of America (USA), identification of hotspots in all installations, and perpetual fine-tuning of the operation's principles in collaboration with the ROK's aggressive approach to eradicate COVID-19 from the peninsula., Conclusions: In successfully executing the operation, USFK imparts three main lessons for future outbreaks. First, a military command should execute a health response similar to how it executes combat operations against a battlefield enemy. Second, the command should maintain flexibility to new changes or risks that alter courses of action. And finally, engagement with the local community, host nation, and international partners should not be compromised when formulating strategies. The USFK's immediate recognition of the public health threat by all levels of leadership and medical personnel enabled a unique and highly effective Operation Kill the Virus that engaged all members of the community, both local and international., (© Crown copyright 2021.)

Serological assessment of SARS-CoV-2 specific responses are an essential tool for determining the prevalence of past SARS-CoV-2 infections in the population especially when testing occurs after symptoms have developed and limited contact tracing is in place. The goal of our study was to test a new 10-plex electro-chemiluminescence-based assay to measure IgM and IgG responses to the spike proteins from multiple human coronaviruses including SARS-CoV-2, assess the epitope specificity of the SARS-CoV-2 antibody response against full-length spike protein, receptor-binding domain and N-terminal domain of the spike protein, and the nucleocapsid protein. We carried out the assay on samples collected from three sample groups: subjects diagnosed with COVID-19 from the U.S. Army hospital at Camp Humphreys in Pyeongtaek, South Korea; healthcare administrators from the same hospital but with no reported diagnosis of COVID-19; and pre-pandemic samples. We found that the new CoV-specific multiplex assay was highly sensitive allowing plasma samples to be diluted 1:30,000 with a robust signal. The reactivity of IgG responses to SARS-CoV-2 nucleocapsid protein and IgM responses to SARS-CoV-2 spike protein could distinguish COVID-19 samples from non-COVID-19 and pre-pandemic samples. The data from the three sample groups also revealed a unique pattern of cross-reactivity between SARS-CoV-2 and SARS-CoV-1, MERS-CoV, and seasonal coronaviruses HKU1 and OC43. Our findings show that the CoV-2 IgM response is highly specific while the CoV-2 IgG response is more cross-reactive across a range of human CoVs and also showed that IgM and IgG responses show distinct patterns of epitope specificity. In summary, this multiplex assay was able to distinguish samples by COVID-19 status and characterize distinct trends in terms of cross-reactivity and fine-specificity in antibody responses, underscoring its potential value in diagnostic or serosurveillance efforts., Competing Interests: The authors have declared that no competing interests exist.

Objective: To determine risk factors for osteomyelitis in US military personnel with combat-related, extremity long bone (humerus, radius, and ulna) open fractures., Design: Retrospective observational case-control study., Setting: US military regional hospital in Germany and tertiary care military hospitals in the United States (2003-2009)., Patients/participants: Sixty-four patients with open upper extremity fractures who met diagnostic osteomyelitis criteria (medical record review verification) were classified as cases. Ninety-six patients with open upper extremity fractures who did not meet osteomyelitis diagnostic criteria were included as controls., Intervention: Not applicable., Main Outcome Measurements: Multivariable odds ratios (ORs; 95% confidence interval [CI])., Results: Among patients with surgical implants, osteomyelitis cases had longer time to definitive orthopaedic surgery compared with controls (median: 26 vs. 11 days; P < 0.001); however, there was no significant difference with timing of radiographic union. Being injured between 2003 and 2006, use of antibiotic beads, Gustilo-Anderson [GA] fracture classification (highest with GA-IIIb: [OR: 22.20; CI: 3.60-136.95]), and Orthopaedic Trauma Association Open Fracture Classification skin variable (highest with extensive degloving [OR: 15.61; CI: 3.25-74.86]) were independently associated with osteomyelitis risk. Initial stabilization occurring outside of the combat zone was associated with reduced risk of osteomyelitis., Conclusions: Open upper extremity fractures with severe soft-tissue damage have the highest risk of developing osteomyelitis. The associations with injuries sustained 2003-2006 and location of initial stabilization are likely from evolving trauma system recommendations and practice patterns during the timeframe., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: During recent wars in Iraq and Afghanistan, improved survivability in severe trauma corresponded with a rise in the proportion of trauma-related infections, including those associated with multidrug-resistant organisms (MDROs). Significant morbidity was reported in association with the infections. There is also concern regarding potential long-term impacts of the trauma-related infectious complications. Therefore, to meet the critical need of prospective collection of standardized infection-related data to understand the disease burden and improve outcomes of wounded personnel, the Trauma Infectious Disease Outcomes Study (TIDOS) was developed. Herein, we review accomplishments and key peer-reviewed findings of TIDOS., Methods: The TIDOS project is a multicenter observational study of short- and long-term infectious complications following deployment-related trauma. Wounded military personnel medevac'd to Landstuhl Regional Medical Center (LRMC; Germany) before transfer to a participating US military hospital between June 2009 and December 2014 were eligible for inclusion. An infectious disease module to supplement the Department of Defense Trauma Registry by collecting infection-related data from all trauma patients admitted to participating hospitals was developed. Specimens from trauma patients were also collected and retained in a microbiological isolate repository. During the initial hospitalization, patients were given the opportunity to enroll in a prospective follow-up cohort study. Patients who received Department of Veterans Affairs (VA) care were also given the opportunity to consent to ongoing VA follow-up., Results: A total of 2,699 patients transferred to participating military hospitals in the USA, of which 1,359 (50%) patients enrolled in the TIDOS follow-up cohort. In addition, 638 enrolled in the TIDOS-VA cohort (52% of TIDOS enrollees who entered VA healthcare). More than 8,000 isolates were collected from infection control surveillance and diagnostic evaluations and retained in the TIDOS Microbiological Repository. Approximately 34% of the 2,699 patients at US hospitals developed a trauma-related infection during their initial hospitalization with skin and soft-tissue infections being predominant. After discharge from the US hospitals, approximately one-third of TIDOS cohort enrollees developed a new trauma-related infection during follow-up and extremity wound infections (skin and soft-tissue infections and osteomyelitis) continued to be the majority. Among TIDOS cohort enrollees who received VA healthcare, 38% developed a new trauma-related infection with the incident infection being diagnosed a median of 88 days (interquartile range: 19-351 days) following hospital discharge. Data from TIDOS have been used to support the development of Joint Trauma System clinical practice guidelines for the prevention of combat-related infections, as well as the management of invasive fungal wound infections. Lastly, due to the increasing proportion of infections associated with MDROs, TIDOS investigators have collaborated with investigators across military laboratories as part of the Multidrug-Resistant and Virulent Organisms Trauma Infections Initiative with the objective of improving the understanding of the complex wound microbiology in order to develop novel infectious disease countermeasures., Conclusions: The TIDOS project has focused research on four initiatives: (1) blast-related wound infection epidemiology and clinical management; (2) DoD-VA outcomes research; (3) Multidrug- Resistant and other Virulent Organisms Trauma Infections Initiative; and (4) Joint Trauma System clinical practice guidelines and antibiotic stewardship. There is a continuing need for longitudinal data platforms to support battlefield wound research and clinical practice guideline recommendation refinement, particularly to improve care for future conflicts. As such, maintaining a research platform, such as TIDOS, would negate the lengthy time needed to initiate data collection and analysis., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Objectives: To identify the risk factors for osteomyelitis development in US military personnel with combat-related, open femur fractures?, Design: Retrospective observational case-control study., Setting: US military regional hospital in Germany and tertiary care hospitals in United States (2003-2009)., Patients/participants: One hundred three patients with open femur fractures who met diagnostic osteomyelitis criteria (medical record review verification) were classified as cases. Sixty-four patients with open femur fractures who did not meet osteomyelitis diagnostic criteria were included as controls., Main Outcome Measurements: The main outcome measurements were multivariable odds ratios (ORs) and 95% confidence interval (CI)., Results: Among patients with surgical implants, osteomyelitis cases had significantly longer time to definitive orthopaedic surgery compared with controls (median: 21 vs. 13 days). Independent predictors for osteomyelitis risk were Gustilo-Anderson classification (transfemoral amputation OR: 19.3; CI: 3.0-123.0) and Orthopaedic Trauma Association Open Fracture Classification for muscle loss (OR: 5.7; CI: 1.3-25.1) and dead muscle (OR: 32.9; CI: 5.4-199.1). Being injured between 2003 and 2006, antibiotic bead use, and foreign body plus implant(s) at fracture site were also risk factors., Conclusions: Patients with open femur fractures resulting in significant muscle damage have the highest osteomyelitis risk. Foreign body contamination was only significant when an implant was present. Increased risk with antibiotic bead use is likely a surrogate for clinical suspicion of contamination with complex wounds. The timeframe association is likely due to changing trauma system patterns around 2006-2007 (eg, increased negative pressure wound therapy, reduced high-pressure irrigation, decreased crystalloid use, and delayed definitive internal fixations)., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Infectious complications related to deployment trauma significantly contribute to the morbidity and mortality of wounded service members. The Trauma Infectious Disease Outcomes Study (TIDOS) collects data on US military personnel injured in Iraq and Afghanistan in an observational cohort study of infectious complications. Patients enrolled in TIDOS may also consent to follow-up through the Department of Veterans Affairs (VA). We present data from the first 337 TIDOS enrollees to receive VA healthcare., Methods: Data were collected from the Department of Defense (DoD) Trauma Registry, TIDOS infectious disease module, DoD and VA electronic medical records, and telephone interview. Cox proportional hazard analysis was performed to identify predictors of post-discharge infections related to deployment trauma., Results: Among the first 337 TIDOS enrollees who entered VA healthcare, 111 (33%) had 244 trauma-related infections during their initial trauma hospitalization (2.1 infections per 100 person-days). Following initial discharge, 127 (38%) enrollees had 239 trauma-related infections (170 during DoD follow-up and 69 during VA time). Skin and soft-tissue infections and osteomyelitis were predominant during and after the initial trauma hospitalization. In a multivariate model, a shorter time to development of a new infection following discharge was independently associated with injury severity score ≥10 and occurrence of ≥1 inpatient infection during initial trauma hospitalization., Conclusions: Incident infections related to deployment trauma continue well after initial hospital discharge and into VA healthcare. Overall, 38% of enrolled patients developed a new trauma-related infection after their initial hospital discharge, with 29% occurring after the patient left military service.

Objectives: We assessed osteomyelitis risk factors in US military personnel with combat-related open tibia fractures (2003-2009)., Methods: Patients with open tibia fractures who met the diagnostic criteria of osteomyelitis were identified as cases using Military Health System data and verified through medical record review. Controls were patients with open tibia fractures who did not meet osteomyelitis criteria. The Gustilo-Andersen fracture classification scheme was modified to include transtibial amputations (TTAs) as the most severe level. Logistic regression multivariable odds ratios [ORs; 95% confidence intervals (CI)] were assessed., Results: A total of 130 tibia osteomyelitis cases and 85 controls were identified. Excluding patients with TTAs, osteomyelitis cases had significantly longer time to radiographic union compared with controls (median: 210 vs. 165 days). Blast injuries, antibiotic bead utilization, ≥ Gustilo-Andersen-IIIb fractures [highest risk with TTA (OR: 15.10; CI: 3.22-71.07)], and foreign body at the fracture site were significantly associated with developing osteomyelitis. In a separate model, the Orthopaedic Trauma Association Open Fracture Classification muscle variable was significant with increasing risk from muscle loss (OR: 5.62; CI: 2.21-14.25) to dead muscle (OR: 8.46; CI: 3.31-21.64). When TTAs were excluded, significant risk factors were similar and included sustaining an injury between 2003 and 2006., Conclusions: Patients with severe blast trauma resulting in significant muscle damage are at the highest risk for osteomyelitis. The period association coincides with a time frame when several trauma system practice changes were initiated (eg, increased negative pressure wound therapy, decreased high-pressure irrigation, and reduced crystalloid use)., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Level of Evidence: Observational/retrospective/historic controls, level IV.

Combat trauma wounds with invasive fungal infections (IFIs) are often polymicrobial with fungal and bacterial growth, but the impact of the wound microbiology on clinical outcomes is uncertain. Our objectives were to compare the microbiological features between IFI and non-IFI wounds and evaluate whether clinical outcomes differed among IFI wounds based upon mold type. Data from U.S. military personnel injured in Afghanistan with IFI wounds were examined. Controls were matched by the pattern/severity of injury, including blood transfusion requirements. Wound closure timing was compared between IFI and non-IFI control wounds (with/without bacterial infections). IFI wound closure was also assessed according to mold species isolation. Eighty-two IFI wounds and 136 non-IFI wounds (63 with skin and soft tissue infections [SSTIs] and 73 without) were examined. The time to wound closure was longer for the IFI wounds (median, 16 days) than for the non-IFI controls with/without SSTIs (medians, 12 and 9 days, respectively; P < 0.001). The growth of multidrug-resistant Gram-negative rods was reported among 35% and 41% of the IFI and non-IFI wounds with SSTIs, respectively. Among the IFI wounds, times to wound closure were significantly longer for wounds with Mucorales growth than for wounds with non-Mucorales growth (median, 17 days versus 13 days; P < 0.01). When wounds with Mucorales and Aspergillus spp. growth were compared, there was no significant difference in wound closure timing. Trauma wounds with SSTIs were often polymicrobial, yet the presence of invasive molds (predominant types: order Mucorales, Aspergillus spp., and Fusarium spp.) significantly prolonged the time to wound closure. Overall, the times to wound closure were longest for the IFI wounds with Mucorales growth., (Copyright © 2015, American Society for Microbiology. All Rights Reserved.)

Background: An outbreak of invasive fungal infections (IFI) began in 2009 among United States servicemen who sustained blast injuries in Afghanistan. In response, the military trauma community sought a uniform approach to early diagnosis and treatment. Toward this goal, a local clinical practice guideline (CPG) was implemented at Landstuhl Regional Medical Center (LRMC) in early 2011 to screen for IFI in high-risk patients using tissue histopathology and fungal cultures., Methods: We compared IFI cases identified after initiation of the CPG (February through August 2011) to cases from a pre-CPG period (June 2009 through January 2011)., Results: Sixty-one patients were screened in the CPG period, among whom 30 IFI cases were identified and compared with 44 pre-CPG IFI cases. Demographics between the two study periods were similar, although significantly higher transfusion requirements (p<0.05) and non-significant trends in injury severity scores and early lower extremity amputation rates suggested more severe injuries in CPG-period cases. Pre-CPG IFI cases were more likely to be associated with angioinvasion on histopathology than CPG IFI cases (48% versus 17%; p<0.001). Time to IFI diagnosis (three versus nine days) and to initiation of antifungal therapy (seven versus 14 days) were significantly decreased in the CPG period (p<0.001). Additionally, more IFI patients received antifungal agent at LRMC during the CPG period (30%) versus pre-CPG period (5%; p=0.005). The CPG IFI cases were also prescribed more commonly dual antifungal therapy (73% versus 36%; p=0.002). There was no statistical difference in length of stay or mortality between pre-CPG and CPG IFI cases; although a non-significant reduction in crude mortality from 11.4% to 6.7% was observed., Conclusions: Angioinvasive IFI as a percentage of total IFI cases decreased during the CPG period. Earlier diagnosis and commencement of more timely treatment was achieved. Despite these improvements, no difference in clinical outcomes was observed compared with the pre-CPG period.

Background: Infection is a potentially devastating complication following severe lower extremity trauma, but its impact on the outcomes of combat casualties remains unclear. We hypothesize that orthopedic infectious complications will have a negative impact on holistic patient outcome as measured by return-to-duty (RTD) and disability ratings among wounded soldiers., Methods: We reviewed the medical records for 115 wounded soldiers who sustained a Type III open tibia fracture and tabulated the prevalence of infectious complications. We searched the Physical Evaluation Board database to determine the disability ratings of soldiers with and without an infection and how many of each group was able to return to active duty service. The average percent disability rating and RTD rates between groups were compared using an unpaired t test and χ test, respectively., Results: Overall, 40% of our cohort had an infectious complication of their fractured limb. Twenty-one soldiers were able to RTD, while 94 could not and were medically retired. Of those medically retired, 44% had an infection. The average percent disability among soldiers with infection was 55%, compared with 47% for those who were not infected (p = 0.1407). Soldiers who experienced any type of infectious complication (p = 0.0470) and having osteomyelitis (p = 0.0335) had a lower chance of RTD compared with those who had no infection. Having a deep soft tissue infection alone showed a strong trend toward decreased RTD rate (p = 0.0558)., Conclusion: Infectious complications following severe lower extremity trauma significantly decrease the rate of RTD. In addition, the presence of infectious complications demonstrates a trend toward higher disability ratings in the combat wounded., Level of Evidence: Prognostic study, level III.

Malaria chemoprophylaxis is used as a preventive measure in military personnel deployed to malaria-endemic countries. However, limited information is available on compliance with chemoprophylaxis among trauma patients during hospitalization and after discharge. Therefore, we assessed antimalarial primary chemoprophylaxis and presumptive antirelapse therapy (primaquine) compliance among wounded United States military personnel after medical evacuation from Afghanistan (June 2009-August 2011) to Landstuhl Regional Medical Center in Landstuhl, Germany, and then to three U.S. military hospitals. Among admissions at Landstuhl Regional Medical Center, 74% of 2,540 patients were prescribed primary chemoprophylaxis and < 1% were prescribed primaquine. After transfer of 1,331 patients to U.S. hospitals, 93% received primary chemoprophylaxis and 33% received primaquine. Of 751 trauma patients with available post-admission data, 42% received primary chemoprophylaxis for four weeks, 33% received primaquine for 14 days, and 17% received both. These antimalarial chemoprophylaxis prescription rates suggest that improved protocols to continue malaria chemoprophylaxis in accordance with force protection guidelines are needed., (© The American Society of Tropical Medicine and Hygiene.)

In 2008, a clinical practice guideline (CPG) was developed for the prevention of infections among military personnel with combat-related injuries. Our analysis expands on a prior 6-month evaluation and assesses CPG adherence with respect to antimicrobial prophylaxis for U.S. combat casualties medically evacuated to Landstuhl Regional Medical Center over a 1-year period (June 2009 through May 2010), with an eventual goal of continuously monitoring CPG adherence and measuring outcomes as a function of compliance. We classified adherence to the CPG as receipt of recommended antimicrobials within 48 hours of injury. A total of 1106 military personnel eligible for CPG assessment were identified and 74% received antimicrobial prophylaxis. Overall, CPG compliance within 48 hours of injury was 75%. Lack of antimicrobial prophylaxis contributed 2 to 22% to noncompliance varying by injury category, whereas receipt of antibiotics other than preferred was 11 to 30%. For extremity injuries, antimicrobial prophylaxis adherence was 60 to 83%, whereas it was 80% for closed injuries and 68% for penetrating abdominal injuries. Overall, the results of our analysis suggest an ongoing need to improve adherence, monitor CPG compliance, and assess effectiveness., (Reprint & Copyright © 2014 Association of Military Surgeons of the U.S.)

Emergency whole blood transfusions may increase the risk of transmitting bloodborne pathogens, including human T-lymphotropic viruses (HTLVs). U.S. military personnel with any medical encounter for HTLV infection during 2000-2013;2008 were identified from surveillance data. Using both inclusive and restrictive case definitions, the incidence of diagnoses of HTLV infection was analyzed in relation to demographic factors and prior deployment. There were 247 "possible" cases of HTLV infection identified, or 1.88 cases per 100,000 person-years (p-yrs) (95% CI 1.66, 2.13). Seventy of these met the restrictive definition, translating to a rate of 0.53 per 100,000 p-yrs (95% CI 0.42, 0.67). Under the restrictive definition, a higher rate was noted among females versus males (RR 2.37; 95% CI 1.41, 3.98), service members with a healthcare occupation versus those who are primarily trained to engage in combat (RR 2.54; 95% CI 1.06, 6.10), and service members with any deployment experience (RR 8.98; 95% CI 5.61, 14.37). These findings, and a prior military case report of transfusion-transmitted HTLV-I, suggest a need to better define the epidemiology of HTLV in U.S. military personnel to further ensure emergency transfusion safety.

Background: In 2009, pandemic H1N1 influenza virus (2009 H1N1) emerged worldwide, causing morbidity and mortality that disproportionately affected young adults. Upper respiratory infection (URI), largely due to adenovirus, is an endemic cause of morbidity in military training. Whether clinical presentations differ or excess morbidity results from coinfection is unclear., Methods: The Center for Advanced Molecular Detection evaluates epidemiology and rapid diagnostics of respiratory pathogens in trainees with URI. From May 1, 2009, to November 30, 2009, demographic, clinical, and PCR data from throat and nasal specimens for adenovirus and 2009 H1N1 were prospectively collected., Results: 375 trainees with URI enrolled and were tested for both adenovirus and 2009 H1N1 by PCR (median age 20; 89% male). Adenovirus PCR was positive in 72% (96% serotype E-4) and 2009 H1N1 in 20%. Males were more likely to have adenovirus and females more likely to have 2009 H1N1 (p  =  0.047). Subjects with 2009 H1N1 presented an average of 1 week earlier in training, had shorter illness duration before enrollment, less sore throat, diarrhea, and fewer abnormal findings on throat exam. Coryza and cough were more common with 2009 H1N1 compared to adenovirus. Subjects with 2009 H1N1 were less likely to have adenovirus than those without, despite persistently high frequencies of adenovirus detections during peak 2009 H1N1 weeks (15% vs. 83%, p < 0.01). Coinfection with adenovirus and 2009 H1N1 was rare (4%). Rates of hospitalization and pneumonia did not differ between the adenovirus, 2009 H1N1, or coinfected groups., Conclusion: Military trainees with 2009 H1N1 vs. adenovirus have differing clinical presentations, and males are more likely to have adenovirus. Despite high frequencies of adenovirus infection, coinfection with adenovirus and 2009 H1N1 is rare and apparently does not result in increased morbidity.

A total of 102 methicillin-resistant Staphylococcus aureus (MRSA) isolates collected from 50 injured service members (June 2009 to December 2011) at U.S. military treatment facilities were analyzed for the conventional mecA gene and mecC homologue by using standard PCR-based methods. The prevalence of the mecC homologue was zero.

In response to the high rates of colonization and infection by multidrug-resistant gram-negative bacilli (MDR GNB), many military treatment facilities (MTFs) have implemented additional infection control practices, such as active surveillance cultures for asymptomatic colonization. Results of surveillance cultures (June 2009 - May 2012) collected from patients at Landstuhl Regional Medical Center (Landstuhl RMC), Germany, and three U.S. MTFs were analyzed to evaluate trends in MDR GNB colonization over time and across facilities. At Landstuhl RMC, 6.6 percent of patients were colonized on admission with MDR GNB compared to 12.4 percent of patients admitted to the participating U.S. MTFs. Escherichia coli was the predominant organism, representing 82.4 percent of MDR isolates at Landstuhl RMC and 67.1 to 83.3 percent at U.S. MTFs. Other common MDR GNB included Acinetobacter calcoaceticus-baumannii complex and Klebsiella pneumoniae. Although Pseudomonas aeruginosa was often isolated from the surveillance cultures, it was never multidrug-resistant. Annual rates of MDR GNB colonization were not significantly different over the three-year period. Ongoing research includes assessment of predictive factors for MDR GNB colonization and the relationship between colonization and infection.

Objective: Occupational exposures to blood and other bodily fluids occur in approximately 5 per 100 persons every year in US hospitals. Since the provision of health care in the deployed environment poses unique challenges to hospital personnel, it is important to characterize the rates of occupational exposures and understand the prevalence of blood-borne pathogens (BBPs) in host nations., Methods: A retrospective review of public health and laboratory records at a US military trauma center in Afghanistan from October 1, 2010, to March 31, 2012., Results: A total of 65 occupational exposures were reported, including 47 (72%) percutaneous and 18 (28%) mucocutaneous, with a yearly rate of 8.6 exposures per 100 persons. During 6-month deployment cycles, the majority of exposures (46.2%) occurred in the first 2 months after arrival in Afghanistan. Physicians reported the most exposures (26%), and the operating room (48%) was the most common hospital location. The prevalence of hepatitis B and hepatitis C among local national source patients ([Formula: see text]) was 8.9% and 2.3%, respectively, with no cases of HIV or syphilis detected. In contrast, there were no BBPs detected in coalition source ([Formula: see text]) or exposed ([Formula: see text]) patients., Conclusions: The characteristics of occupational exposures in this deployed environment were comparable to those of US-based hospitals. Standard practices used to reduce occupational exposures, such as use of personal protective equipment and safety devices, should continue to be prioritized in the deployed setting. Although BBP rates are not well defined in Afghanistan, our results were consistent with those of prior epidemiologic studies.

Objective: To determine whether multidrug-resistant (MDR) gram-negative organisms are present in Afghanistan or Iraq soil samples, contaminate standard deployed hospital or modular operating rooms (ORs), or aerosolize during surgical procedures., Design: Active surveillance., Setting: US military hospitals in the United States, Afghanistan, and Iraq., Methods: Soil samples were collected from sites throughout Afghanistan and Iraq and analyzed for presence of MDR bacteria. Environmental sampling of selected newly established modular and deployed OR high-touch surfaces and equipment was performed to determine the presence of bacterial contamination. Gram-negative bacteria aerosolization during OR surgical procedures was determined by microbiological analysis of settle plate growth., Results: Subsurface soil sample isolates recovered in Afghanistan and Iraq included various pansusceptible members of Enterobacteriaceae, Vibrio species, Pseudomonas species, Acinetobacter lwoffii, and coagulase-negative Staphylococcus (CNS). OR contamination studies in Afghanistan revealed 1 surface with a Micrococcus luteus. Newly established US-based modular ORs and the colocated fixed-facility ORs revealed no gram-negative bacterial contamination prior to the opening of the modular OR and 5 weeks later. Bacterial aerosolization during surgery in a deployed fixed hospital revealed a mean gram-negative bacteria colony count of 12.8 colony-forming units (CFU)/dm(2)/h (standard deviation [SD], 17.0) during surgeries and 6.5 CFU/dm(2)/h (SD, 7.5; [Formula: see text]) when the OR was not in use., Conclusion: This study demonstrates no significant gram-negative bacilli colonization of modular and fixed-facility ORs or dirt and no significant aerosolization of these bacilli during surgical procedures. These results lend additional support to the role of nosocomial transmission of MDR pathogens or the colonization of the patient themselves prior to injury.

Drug-resistant Acinetobacter baumannii-calcoaceticus complex, Klebsiella pneumoniae, and methicillin-resistant Staphylococcus aureus colonize and infect combat casualties from Iraq and Afghanistan. We retrospectively evaluated relatedness, by pulsed-field gel electrophoresis and antibiotic susceptibility testing, of isolates colonizing and infecting casualties over 2 years. Colonizing organisms were unrelated to isolates producing later infection in up to 27% of cases; most isolates underwent change in antibiotic susceptibilities. The same is true for serial infecting isolates recovered during hospitalization., (Published by Mosby, Inc.)

Objective: To investigate potential sources and risks associated with multidrug-resistant (MDR) bacteria in a deployed US military hospital., Design: Retrospective analysis of factors associated with recovery of MDR bacteria, supplemented by environmental sampling., Setting: The largest US military hospital in Afghanistan., Patients: US and Afghan patients with positive bacterial culture results, from September 2007 through August 2008., Methods: Microbiologic, demographic, and clinical data were analyzed. Potential risk factors included admission diagnosis or mechanism of injury, length of stay, gender, age, and nationality (US or Afghan). Environmental sampling of selected hospital high-touch surfaces and equipment was performed to help elucidate whether environmental MDR bacteria were contributing to nosocomial spread., Results: A total of 266 patients had 411 bacterial isolates that were identified during the study period, including 211 MDR bacteria (51%). Gram-negative bacteria were common among Afghan patients (241 [76%] of 319), and 70% of these were classified as MDR. This included 58% of bacteria recovered from Afghan patients within 48 hours of hospital admission. The most common gram-negative bacteria were Escherichia coli (53% were MDR), Acinetobacter (90% were MDR), and Klebsiella (63% were MDR). Almost one-half of potential extended-spectrum β-lactamase (ESBL) producers were community acquired. Of 100 environmental swab samples, 18 yielded MDR bacteria, including 10 that were Acinetobacter, but no potential ESBL-producing bacteria., Conclusions: Gram-negative bacteria from Afghan patients had high rates of antimicrobial resistance. Patients experiencing complex trauma and prolonged hospital stays likely contribute to the presence of MDR bacteria in this facility. However, many of these patients had community-acquired cases, which implies high rates of colonization prior to hospital admission.

Since the beginning of military operations in Iraq and Afghanistan, multidrug-resistant bacteria have been noted to be infecting and colonizing combat casualties. Studies suggest the primary source of these bacteria is nosocomial transmission. A focus area for improvement has been to enhance infection control (IC) at hospitals in the combat theater. A 5-day IC course was developed and implemented to provide just-in-time training to those personnel who have been identified to lead IC efforts while deployed. Twenty-nine students have attended the first 6 offerings of this course. A pre- and post-course test showed an average 21% improvement in knowledge. A follow-up questionnaire provided to those students who deployed found the course had enhanced performance of their IC duties. We describe the deployment-unique training developed to provide basic IC, emphasizing the unique challenges found in the combat setting.

Infections caused by multidrug-resistant (MDR) pathogens are associated with significant morbidity and mortality in patients with burn injuries. We performed a 6-year antibiotic susceptibility records review from January 2003 to December 2008 to assess the prevalence of MDR isolates by pathogen at the US Army Institute of Surgical Research Burn Center. During the study period Acinetobacter baumannii (780 isolates [22%]) was the most prevalent organism recovered, followed by Pseudomonas aeruginosa (703 isolates [20%]), Klebsiella pneumoniae (695 isolates [20%]), and Staphylococcus aureus (469 isolates [13%]). MDR prevalence rates among these isolates were A. baumannii 53%, methicillin-resistant S. aureus (MRSA) 34%, K. pneumoniae 17% and P. aeruginosa 15%. Two isolates, 1 A. baumannii and 1 P. aeruginosa, were identified as resistant to all 4 classes of antibiotics tested plus colistin. A. baumannii isolates recovered from patients with burns greater than 30% of total body surface area (TBSA) were more likely to be MDR (61%) with no significant difference for P. aeruginosa and K. pneumoniae. A higher proportion of MDR P. aeruginosa isolates were recovered from respiratory specimens compared to blood specimens (24% vs. 9%) while the opposite was true for MRSA (35% vs. 54%). A comparison of A. baumannii recovered during hospitalization days 1-5 and 15-30 revealed higher MDR levels as length of stay increased (48% vs. 75%) while no significant trends were observed for P. aeruginosa and K. pneumoniae. A similar pattern was observed for MDR A. baumannii levels for the facility between 2003 and 2005 and 2006-2008 (39% vs. 70%), with no significant increase in MDR P. aeruginosa and MDR K. pneumoniae. Increasing antibiotic resistance patterns of the most prevalent isolates recovered during extended hospitalization, impact of % TBSA and other clinical parameters may affect empirical antimicrobial therapy and patient management decisions during treatment., (Published by Elsevier Ltd.)

Background: Staphylococcus aureus infections complicate care of combat-related injuries and can independently result in skin and soft-tissue infections during deployments or training. Community-associated methicillin-resistant S. aureus (CA-MRSA) strains seem to produce severe disease but retain susceptibility to many oral antimicrobials. This study characterizes 84 MRSA isolates recovered from wound cultures at a combat support hospital in Iraq., Methods: MRSA strains recovered from December 2007 through March 2009 were analyzed. Antimicrobial resistance testing was determined by broth microdilution and the BD Phoenix Automated Microbiology System. The genotypic pattern was analyzed by pulsed-field gel electrophoresis and polymerase chain reaction identification of resistance and virulence genes., Results: No MRSA isolates from wound cultures were resistant to vancomycin. The most active oral antistaphylococcal agents were tetracycline (95% susceptibility), trimethoprim-sulfamethoxazole (94%), and clindamycin (94%). Of agents not typically recommended as monotherapy, 98% of isolates were susceptible to rifampin, 91% to moxifloxacin, and 60% to levofloxacin. The most common pulsed-field type (PFT) was USA300 (79%). The typical staphylococcal cassette chromosome mec IV elements carrying the CA-MRSA resistance genes were present in 88% of the isolates. Panton-Valentine leukocidin virulence genes were identified in 88% of isolates, including 100% of PFT USA300. The virulence gene associated with an arginine catabolic mobile element was present in 75% of isolates, including 94% of PFT USA300., Conclusion: This study is the first genotypic and phenotypic characterization of CA-MRSA recovered from wound cultures in a deployed combat hospital. The pattern noted was similar to that seen in soldiers stationed in the United States.