Long-form investigative health story featured on website and teased on broadcast show.
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.
But this superbug continues to present myriad challenges for field hospitals where the bacteria easily grow and cross-contaminate other patients and test results are often slower than the rate of treatment and transfer. Combat support hospitals and longer-term tertiary care hospitals like Landstuhl in Germany may not know for several days or weeks that a patient has acquired an acinetobacter infection. With the speed of the transfer along the transport chain, constant vigilance is required.
“My concern is that we have a Level I trauma center that spreads out 8,500 miles,” Hospenthal said. “In our system, when you get injured you get transferred and handed off many, many, many times and you get transported across long distances and that just increases the opportunity for nosocomial transmission or cross contamination, so I think we always have to be worried about that.”
For soldiers injured in Afghanistan or Iraq, the evacuation process takes them through an emergency room that spans several continents.
Acinetobacter has infected more than 3,300 U.S. injured troops in military hospitals, between 2003, when it was first recognized as a problem, and 2009, the last time the Department of Defense made statistics public. However, these statistics only include wounded service members who happen to have been tested for the bacteria. At various points of acinetobacter outbreak during that period, observed rates were as high as 20 percent of wounded soldiers in military hospitals.
The Oversight Committee of the House Armed Service Committee called a hearing to discuss multidrug resistant bacteria, especially acinetobacter, and their role in the military healthcare system last fall. The 112th Congress chose not revisit the issue. Military-based research funding for superbugs was decreased from $14 million in 2010 to $2 million in 2011. The Department of Defense did not request additional funds and Congress did not allocate any. Some research on acinetobacter continues through other programs like Brooke Army Medical Center’s burn studies. But, the NIH, not the Department of Defense, now oversees funding for most acinetobacter studies and those dollars could be in danger due to budget cuts made in the recent debt-ceiling agreement.
Creeping into civilian hospitals?
With the withdrawal of 33,000 troops from Afghanistan over the next year and the majority of the 50,000 troops from Iraq by the end of this year, there are questions about how infections in the military hospitals might affect the U.S. healthcare system. The non-profit group Institute of Federal Health Care concluded in June 2009, “Gram-negative infections [including acinetobacter] constitute a threat to health care facilities in the U.S. from returning troops, posing issues of how much followup is feasible, for how long and at what cost?” The remarks were part of a round table discussion called “Emerging Infectious Diseases In-Theater: Risks and Mitigation,” with more than two-dozen military and private health care representatives.
But doctors interviewed for this piece, both military and civilian, are unsure if there’s any reason for concern. “There were other non-deployed very sick people in the ICUs at Walter Reed that did have very similar strains of acinetobacter, the implications being that they did get cross-contamination and probably infection from acinetobacter that was brought back by returning troops,” said Hospenthal, referring to a 2007 study at Walter Reed Medical Center. “Based on that I would say, yes, there’s a threat. Now, has that threat proven significant? I have not seen any data for that. We were certainly concerned that it would spread through the VA system.”
The Department of Veterans Affairs contends that its rates of acinetobacter are low when compared to civilian hospitals, with about 28,000 cases of acinetobacter last year out of 5.5 million veterans treated. Roughly 415,000 of that group were service members returning from Iraq or Afghanistan who did not have traumatic injuries and, thus, were less likely to have acinetobacter infections. Injured troops are, for the most part, still treated in the military healthcare system at Walter Reed Medical Center, National Naval Medical Center or Brooke Army Medical Center, so any acinetobacter infections they might have would be counted in the military’s numbers, not the VA hospitals’.
Many civilian doctors say that the risk from returning troops isn’t the main concern at this point, because acinetobacter is already rampant in U.S. hospitals. According to Dr. Brad Spellberg, associate professor of medicine at UCLA, who worked with the Infectious Disease Society to campaign for new drugs that treat multidrug resistant organisms, most medical centers are, “already saturated with this stuff.” He added that, most of his colleagues in academic medical centers, “have experienced this organism with fairly alarming frequency … any place you find sophisticated medical technology, you’re going to find this organism.”
As large and spread out as the military healthcare system may be, it has the advantage of central oversight and strict enforcement once policies are set. In contrast, most civilian hospitals do not share information, compliance standards or strategies for combating acinetobacter. Added to the fact that acinetobacter has no official tracking code from the CDC, it can be difficult for civilian facilities to identify and safeguard against the superbug.
In smaller, city hospitals like Nashville General, outbreaks of acinetobacter can cripple the ICU. Dr. L. Leon Dent is director of surgical care at Maherry Medical College and has authored studies on the outbreaks and prevention at the hospital. He agrees that antibiotic resistance and the ability to change itself are some of the biggest problems with treating acinetobacter. For smaller hospitals with limited funds and staff, it’s also difficult to discover the bacteria before they spread through the ICU and even harder to eradicate once there.
“I’m very afraid of this organism,” he said. “It has the potential to cause a lot of havoc in our hospitals. We’re doing a better job at hand hygiene and other things. But, we’re by no means close to solving the problem. We have to keep working on it. It’s a very sobering thing.”
Controlling acinetobacter infections
As hard as it is to kill as acinobacter, most doctors agree that the easiest way to prevent infections is stricter hygiene compliance and limiting antibiotic exposure, both in military and civilian hospitals. At the University of Maryland Medical Center, several studies are in progress on what level of hygiene measures, like increased hand cleaning and gown changing, can reduce infection. While that may seem like an easy fix, it requires a major investment for any hospital. Ensuring that hospital staff comply with infection control tactics and thoroughly clean equipment and surfaces to eradicate the bacteria requires time and money that many hospitals don’t have.
“We need new antibiotics, we also need better infection control — infection control interventions can be expensive,” said Dr. Anthony Harris, who has done several NIH funded research studies on acinetobacter at the University of Maryland Medical Center. “When nurses and doctors go in and out of a patient’s room 100 times a day, we don’t know how high their hand hygiene compliance has to be to limit the spread. Obviously, if it has be 100 percent, it may not be feasible.”
Although overuse of antibiotics helped create the superbug version of acinetobacter, finding new antibiotics is one important key to controlling it, doctors believe. The problem is their options are very limited; they need new varieties to keep the bacteria guessing. The only antibiotics that usually work against multidrug resistant acinetobacter are colistin and sometimes refampin or tigecycline, all of which are highly toxic. Colistin, the most commonly used agent for acinetobacter, can cause severe kidney and neurological damage and is considered an antibiotic of last resort.
A bill was introduced to Congress in July to provide incentive funding for the development of new antibiotics to treat these drug-resistant bacteria, including acinetobacter. The bill has won the support of the Infectious Disease Society, which has been lobbying for the funds with its “Bad Bugs, No Drugs,” campaign, and many other companies. But it’s got a long way to go in Congress and any new drug research must go through a 10 to 20 year approval process.
“There is no solution. There are many ways to address the problem,” said Spellberg. “It isn’t a choice of antibiotics or infection control prevention or immunotherapy or environmental decontamination. It’s all of the above.”
