Thursday, August 04, 2005

Festering wounds of Iraq

Maybe the bird flu chickens haven't come home to roost yet, but the Iraq ones sure have. The Iraqi soil, as if in retribution, has produced an antibiotic resistant organism that has infected several hundred returning soldiers with a potentially fatal drug resistant bacterium, Acinetobacter baumannii. A report today in Forbes highlights the problem, but it isn't new. In November of 2004 CDC reported the ongoing struggle the military was having with this dangerous source of wound infections:
Acinetobacter baumannii is a well known but relatively uncommon cause of health-care--associated infections. Because the organism has developed substantial antimicrobial resistance, treatment of infections attributed to A. baumannii has become increasingly difficult (1). This report describes an increasing number of A. baumannii bloodstream infections in patients at military medical facilities in which service members injured in the Iraq/Kuwait region during Operation Iraqi Freedom (OIF) and in Afghanistan during Operation Enduring Freedom (OEF) were treated. The number of these infections and their resistance to multiple antimicrobial agents underscore 1) the importance of infection control during treatment in combat and health-care settings and 2) the need to develop new antimicrobial drugs to treat these infections.
At the time of that report there were 102 cases of blood culture positive Acinetobacter infection. The number of infections is now much larger, totalling more than 280, according to reporting in Forbes:
Doctors worry not only about soldiers who are already infected but also those who are carrying Acinetobacter on their skin even though they themselves are not infected. Lt. Cmdr. Kyle Petersen, an infectious disease specialist at National Naval Medical Center (NNMC) in Bethesda, Md.,says his hospital treated 396 patients who had been wounded in Iraq between May 2003 and February 2005. About 10% were infected and another 20% were found to have Acinetobacter bacteria on their skin but were not infected. The rate of appearance of the bacteria has "been flat-out steady," says Petersen.

The same has been true at Army hospitals that include Walter Reed Medical Center in Washington, D.C., Tripler Medical Center inHawaii and Brooke Army Medical Center in San Antonio, where there has been a total of about 240 cases of patients infected, while another 500 have carried the bacteria, according to Col. Bruno Petrucelli, director of epidemiology and disease surveillance for the U.S. Army Center for Health Promotion and Preventive Medicine.

Petrucelli says the five patients who died were at Army hospitals—most of them at Walter Reed. They were already suffering from serious health problems before they contracted the bacteria. "These were the sickest of the sick," says Petrucelli. The infections are split evenly among wound infections, respiratory infections and a mix of bloodstream and other infections. (Matthew Herper in Forbes)
A. baumannii likes to hang out in the environment, chiefly soil and water. A likely source of the bacteria in these patients is contamination at time of injury, but it is also possible that it can occur during emergency treatment or in field hospitals, where it has also taken up residence. Hospital infection with this organism is not rare stateside and there is evidence it is increasing. The influx of many wound-infected patients into the domestic hospital environment is likely to increase it further.

A. baumannii infections are nasty, primarily because of their antibiotic resistance. They often take up residence in bone, where eradication is very difficult. Only three drugs are left to treat them.
But other patients have been less fortunate, as they have suffered from infections of the bone, the bloodstream or of internal organs, which have complicated their care. Lt. Cmdr. Petersen says that NNMC's annual bill for the kind of antibiotics [one patient] received has increased tenfold to $200,000.

Besides [intravenous] imipenem, which carries a risk of seizure, two other drugs have worked. Another is amikacin, which does not work for bone infections and has not been effective against some strains of the bacteria. A third is colistin, an antibiotic doctors had stopped using because of its toxic effects on the kidneys.

"It is a scary thing about any drug-resistant bacteria, when you grow it for the very first time out of a patient and you've only got three antibiotics, one so old that we had to bring it back from the archives," says Col. Joel Fishbain, chairman of the infection-control committee at Walter Reed.
Scary, yes, And just another little reminder (reminders are always needed) that the costs of the Iraq Debacle will need to be paid for decades by innocent people in Iraq and the US and the UK. Paid for in painful and tragic ways. Only the perpetraitors [sic] will get off scott free, at least in their lifetimes. History will have to do what is necessary to their reputations.