thedrifter
03-11-07, 08:09 AM
Wounded troops face new enemy: bacteria
Strides in care help more soldiers survive, but their weakened state makes them vulnerable.
By JEAN HELLER
Published March 11, 2007
TAMPA - Jonathan Gadsden's mother understood how horribly he had been injured. Roadside bombs in Iraq inflict grievous wounds.
But two months after the August 2004 blast under his Humvee, the 20-year-old Marine showed enough improvement to be transferred to the James A. Haley Medical Center here for rehabilitation.
Then, in a weekend, Gadsden went over a medical cliff. He died Oct. 22 of an infection that has become the invisible scourge of modern warfare.
Gadsden's doctors overlooked earlier results from two blood cultures that revealed a devastating strain of bacteria in the system of the 21-year-old from Charleston, S.C.
An autopsy by the Hillsborough County medical examiner also missed it.
It was not until June 2005 that a federal inquiry disclosed that Gadsden had fallen victim to the bacteria, well-known to medical science but insidious in its threat to wounded military personnel in Iraq and Afghanistan. It is hard to treat, highly contagious, and potentially lethal.
And its victims include civilians who found themselves on the same hospital ward with those infected.
Hundreds of Army and Marine personnel have been attacked by the bacteria. No one is certain how many have died because, like Gadsden, it often is assumed that death is the result of wartime injuries.
The cruel irony: Major improvements in battlefield medicine are saving lives that might have been lost in earlier wars. Yet those improvements also leave more soldiers and Marines vulnerable to the bacteria because they are so seriously weakened and must spend more time in environments where the bacteria thrive.
The situation has left Zeada Gadsden, Jonathan's mother, grasping for answers the Army isn't providing.
"At first they told me he died as a result of his head wounds," Zeada said from her home in Charleston, S.C. "I asked for the autopsy because I couldn't understand how he could have died. He was doing so well."
The medical examiner concluded he died from meningitis due to blast injuries to the head.
Then Zeada's dentist told her that a newspaper said her son died of a bacterial infection.
"I can't get closure because I can't get answers," Zeada said.
The inspector general's investigation said if doctors hadn't overlooked two blood cultures, Gadsden might have been saved.
Stubborn killer
Its formal name is Acinetobacter baumannii, an organism born resistant to most modern antibiotics. It is not aggressive, but it is opportunistic. Healthy people often carry colonies of A. baumannii on their skin to no ill effect. But when it gets into sick and badly injured bodies, it takes over.
A few treatments exist, but if they don't put down the infection in two weeks, A. baumannii will have learned to resist them, too.
It preys on the most vulnerable: patients in intensive care, on ventilators, in operating rooms, or those seriously torn up in battlefield conditions.
A. baumannii can survive 20 days on a hospital countertop, a computer keyboard or a cell phone.
Some medical experts believe it lives in soil around the world. Explosions hurl dirt into the air that lands in open wounds.
Others point to evidence that the wounded contract it in the medical facilities trying to save their lives: combat hospitals in Baghdad, the medical center at Landstuhl, Germany, and military and veterans hospitals.
When the wounded arrive at combat hospitals, the instinct of the medical staff is to administer antibiotics against infection. That, some experts say, gives A. baumannii a better chance to take hold.
"As broad-spectrum antibiotics are administered, they kill both good and bad bacteria, but they don't touch the acinetobacter," said Dr. Douglas Holt, an infections disease specialist at the University of South Florida and director of the Hillsborough County Health Department.
"The acinetobacter is then able to take advantage of the nutrition and housing that became available when all the neighbors were evicted."
In Gadsden's case, the Armed Forces Institute of Pathology found evidence that he died of bacterial meningitis enabled by an A. baumannii infection.
"A more thorough Infectious Diseases Section consultation would have included obtaining and reviewing all prior treatment records" and would have discovered the two earlier findings of the acinetobacter, the inspector general's report said.
Such knowledge, it concluded, "should have altered the diagnostic evaluation and treatment plan and may have changed the clinical outcome in this case."
Col. Duane Hospenthal, chief of infectious diseases at Brooke Army Medical Center at Fort Sam Houston, Texas, and a consultant to the Army surgeon general, said aggressive infection control measures at Brooke cut the number of A. baumannii cases from 141 in 2004 to 78 in 2005 and 83 last year.
Returning wounded are screened routinely for that bacteria and other multi-drug-resistant organisms, such as staph. Patients are put on "contact precaution" status in private rooms. Personnel treating them must wear gloves. Gowns are required around open wounds.
Eighteen months ago, when the sharp increase in A. baumannii infections was noted in returning military wounded, the Department of Veterans Affairs directed that all patients in VA facilities who tested positive for the bacteria be isolated, said Linda Brady, infection control coordinator at Bay Pines Medical Center in St. Petersburg.
The incidence of the acinetobacter at Haley has significantly dropped, said Edward Cutolo, the chief of staff.
"We have one or two positive cases ... per month among our patients," Cutolo said. "While this sounds like a large number, this is significantly less than what we encountered earlier in the conflict."
Still, Hospenthal said it's difficult to know how many military patients are affected. "Because of ... the often severe nature of our patients' other problems, it is difficult to even tell when infection exists."
Victims of success
It is not lost on doctors familiar with this type of bacteria that the better medicine gets at saving wartime wounded, the more jeopardy they're in.
"In some respect, we're victims of our successes," said Dr. Arjun Srinivasan, a medical epidemiologist with the Centers for Disease Control and Prevention in Atlanta. "People are surviving who are more severely injured than ever before, and they're staying in hospitals longer, increasing the risk of infections there."
One way to attack the bacteria is to minimize antibiotics to limit resistance build up. Another is to better sterilize hospital environments.
But in hospitals that churn wounded in and out in great numbers, where medical workers are stretched thin and exhausted, some standard housekeeping procedures slip by, doctors say.
Civilian hospitals also report outbreaks in increasing numbers since infected military personnel began returning from Iraq and Afghanistan.
"Once it emerges, it can spread from person to person, so you get outbreaks," Holt said. "It causes terrible infections in those already sick."
Acinetobacter baumannii
Common infection sites: spinal fluid, between the membranes lining the abdominal wall, urinary tract.
Treatment: Several antibiotics can be effective in the first two weeks, until bacteria becomes resistant.
Last resort: Colistin, one of the oldest antibiotics known to medicine. Highly toxic. Can cause kidney and nervous system damage.
Victims: The very sick and seriously injured, commonly in hospital intensive care, surgery areas, on respirators, or with catheters, surgical drains and multiple IV lines. Prolonged hospitalization or antibiotic therapy predisposes a patient to A. baumannii colonization, though not necessarily to infection.
Source: WebMD
Ellie
Strides in care help more soldiers survive, but their weakened state makes them vulnerable.
By JEAN HELLER
Published March 11, 2007
TAMPA - Jonathan Gadsden's mother understood how horribly he had been injured. Roadside bombs in Iraq inflict grievous wounds.
But two months after the August 2004 blast under his Humvee, the 20-year-old Marine showed enough improvement to be transferred to the James A. Haley Medical Center here for rehabilitation.
Then, in a weekend, Gadsden went over a medical cliff. He died Oct. 22 of an infection that has become the invisible scourge of modern warfare.
Gadsden's doctors overlooked earlier results from two blood cultures that revealed a devastating strain of bacteria in the system of the 21-year-old from Charleston, S.C.
An autopsy by the Hillsborough County medical examiner also missed it.
It was not until June 2005 that a federal inquiry disclosed that Gadsden had fallen victim to the bacteria, well-known to medical science but insidious in its threat to wounded military personnel in Iraq and Afghanistan. It is hard to treat, highly contagious, and potentially lethal.
And its victims include civilians who found themselves on the same hospital ward with those infected.
Hundreds of Army and Marine personnel have been attacked by the bacteria. No one is certain how many have died because, like Gadsden, it often is assumed that death is the result of wartime injuries.
The cruel irony: Major improvements in battlefield medicine are saving lives that might have been lost in earlier wars. Yet those improvements also leave more soldiers and Marines vulnerable to the bacteria because they are so seriously weakened and must spend more time in environments where the bacteria thrive.
The situation has left Zeada Gadsden, Jonathan's mother, grasping for answers the Army isn't providing.
"At first they told me he died as a result of his head wounds," Zeada said from her home in Charleston, S.C. "I asked for the autopsy because I couldn't understand how he could have died. He was doing so well."
The medical examiner concluded he died from meningitis due to blast injuries to the head.
Then Zeada's dentist told her that a newspaper said her son died of a bacterial infection.
"I can't get closure because I can't get answers," Zeada said.
The inspector general's investigation said if doctors hadn't overlooked two blood cultures, Gadsden might have been saved.
Stubborn killer
Its formal name is Acinetobacter baumannii, an organism born resistant to most modern antibiotics. It is not aggressive, but it is opportunistic. Healthy people often carry colonies of A. baumannii on their skin to no ill effect. But when it gets into sick and badly injured bodies, it takes over.
A few treatments exist, but if they don't put down the infection in two weeks, A. baumannii will have learned to resist them, too.
It preys on the most vulnerable: patients in intensive care, on ventilators, in operating rooms, or those seriously torn up in battlefield conditions.
A. baumannii can survive 20 days on a hospital countertop, a computer keyboard or a cell phone.
Some medical experts believe it lives in soil around the world. Explosions hurl dirt into the air that lands in open wounds.
Others point to evidence that the wounded contract it in the medical facilities trying to save their lives: combat hospitals in Baghdad, the medical center at Landstuhl, Germany, and military and veterans hospitals.
When the wounded arrive at combat hospitals, the instinct of the medical staff is to administer antibiotics against infection. That, some experts say, gives A. baumannii a better chance to take hold.
"As broad-spectrum antibiotics are administered, they kill both good and bad bacteria, but they don't touch the acinetobacter," said Dr. Douglas Holt, an infections disease specialist at the University of South Florida and director of the Hillsborough County Health Department.
"The acinetobacter is then able to take advantage of the nutrition and housing that became available when all the neighbors were evicted."
In Gadsden's case, the Armed Forces Institute of Pathology found evidence that he died of bacterial meningitis enabled by an A. baumannii infection.
"A more thorough Infectious Diseases Section consultation would have included obtaining and reviewing all prior treatment records" and would have discovered the two earlier findings of the acinetobacter, the inspector general's report said.
Such knowledge, it concluded, "should have altered the diagnostic evaluation and treatment plan and may have changed the clinical outcome in this case."
Col. Duane Hospenthal, chief of infectious diseases at Brooke Army Medical Center at Fort Sam Houston, Texas, and a consultant to the Army surgeon general, said aggressive infection control measures at Brooke cut the number of A. baumannii cases from 141 in 2004 to 78 in 2005 and 83 last year.
Returning wounded are screened routinely for that bacteria and other multi-drug-resistant organisms, such as staph. Patients are put on "contact precaution" status in private rooms. Personnel treating them must wear gloves. Gowns are required around open wounds.
Eighteen months ago, when the sharp increase in A. baumannii infections was noted in returning military wounded, the Department of Veterans Affairs directed that all patients in VA facilities who tested positive for the bacteria be isolated, said Linda Brady, infection control coordinator at Bay Pines Medical Center in St. Petersburg.
The incidence of the acinetobacter at Haley has significantly dropped, said Edward Cutolo, the chief of staff.
"We have one or two positive cases ... per month among our patients," Cutolo said. "While this sounds like a large number, this is significantly less than what we encountered earlier in the conflict."
Still, Hospenthal said it's difficult to know how many military patients are affected. "Because of ... the often severe nature of our patients' other problems, it is difficult to even tell when infection exists."
Victims of success
It is not lost on doctors familiar with this type of bacteria that the better medicine gets at saving wartime wounded, the more jeopardy they're in.
"In some respect, we're victims of our successes," said Dr. Arjun Srinivasan, a medical epidemiologist with the Centers for Disease Control and Prevention in Atlanta. "People are surviving who are more severely injured than ever before, and they're staying in hospitals longer, increasing the risk of infections there."
One way to attack the bacteria is to minimize antibiotics to limit resistance build up. Another is to better sterilize hospital environments.
But in hospitals that churn wounded in and out in great numbers, where medical workers are stretched thin and exhausted, some standard housekeeping procedures slip by, doctors say.
Civilian hospitals also report outbreaks in increasing numbers since infected military personnel began returning from Iraq and Afghanistan.
"Once it emerges, it can spread from person to person, so you get outbreaks," Holt said. "It causes terrible infections in those already sick."
Acinetobacter baumannii
Common infection sites: spinal fluid, between the membranes lining the abdominal wall, urinary tract.
Treatment: Several antibiotics can be effective in the first two weeks, until bacteria becomes resistant.
Last resort: Colistin, one of the oldest antibiotics known to medicine. Highly toxic. Can cause kidney and nervous system damage.
Victims: The very sick and seriously injured, commonly in hospital intensive care, surgery areas, on respirators, or with catheters, surgical drains and multiple IV lines. Prolonged hospitalization or antibiotic therapy predisposes a patient to A. baumannii colonization, though not necessarily to infection.
Source: WebMD
Ellie