Infection Control Measures in a Combat Zone
Abstract & Commentary
By Dean L. Winslow, MD, FACP, FIDSA, Chief, Division of AIDS Medicine, Santa Clara Valley Medical Center; Clinical Professor, Stanford University School of Medicine, is Associate Editor for Infectious Disease Alert.
Synopsis: High rates of ventilator-associated pneumonia (VAP) have been seen in field hospitals in Iraq. Application of infection control measures in the intensive care unit (ICU) of the largest field hospital in theater resulted in a significant reduction in VAP.
Source: Landrum ML, Murray CK. Ventilator-associated pneumonia in a military deployed setting: the impact of an aggressive infection control program. J Trauma. 2008;64:S123-S128.
All patients admitted to the ICU at the Air Force Theater Hospital (Balad, Iraq) were followed prospectively for the development of VAP. There were 475 patients admitted to the ICU from May 2006 through August 2006. The baseline rate of VAP determined in May 2006 was 60.6 per 1000 ventilator days. After institution of infection control interventions (hand hygiene, contact barrier precautions, patient and staff cohorting, chlorhexidine oral care, and reducing the duration and spectrum of surgical antimicrobial prophylaxis), the rates of VAP progressively declined. The rates fell to 31.6 in June, 21.3 in July, and 11.1 in August. Targeted surveillance repeated in November and December revealed rates of VAP of 11.6 and 9.7, respectively. Reduced antimicrobial resistance of Acinetobacter (the most common pathogen implicated in VAP in this hospital) was also noted after the interventions.
Commentary
Rapid evacuation of casualties from the battlefields of Afghanistan and Iraq to surgical hospitals, as well as surgical innovations and the wearing of individual body armor by coalition forces, have resulted in unprecedented rates of survival of severely wounded soldiers. During the US Civil War (1861-1865), as many as 50% of soldiers died from their wounds. The rate of survival increased in subsequent conflicts. By the 1960s, during the Vietnam War, the mortality rate of battlefield wounds fell to approximately 20% (mainly due to the widespread use of helicopter MedEvac), and is 10% in our ongoing conflicts in Southwest Asia (Afghanistan and Iraq).
Medical care of wounded US and coalition soldiers begins on the battlefield where, in addition to highly trained combat medics embedded with operational units, virtually every soldier is now trained as a combat lifesaver. The skill and sophistication of this first level of care (along with individual body armor, which does an excellent job protecting the chest and thorax from penetrating trauma) is an under-recognized component of the improved survival of wounded in our current wars. Initial casualty evacuation (CASEVAC) to a Level II Combat Support Hospital (CSH) is handled by either tactical vehicle (Humvee, etc.) or helicopter, depending on distance. At these Level II facilities, general and orthopedic surgical capabilities are present and life-saving surgery is performed. Numerous CSHs and smaller Forward Surgical Teams (FSTs) are present throughout Iraq. The single Level III facility in Iraq is the large Air Force Theater Hospital (AFTH) located in Balad, approximately 50 miles north of Baghdad. In addition to having all the capabilities of the lower level facilities, it is the center for excellence in theater for neurosurgery and head and neck cases. In addition to treating coalition soldiers, as many as one third of patients, at any given time, are Iraqi soldiers, police, and civilians. Since US personnel are generally aerovaced by fixed wing aircraft to Landstuhl, Germany, or even back to the United States within 48 hours, many of the long-term patients in the ICU at AFTH are Iraqis for whom adequate care often does not exist at present in the civilian sector in Iraq. Consequently, it is likely that the majority (if not all) of the cases of VAP seen in the AFTH were non-US personnel. The high baseline rates of VAP seen prior to the infection control interventions may, in part, be related to the medical severity of the patients who spent long stays in the ICU, as well as the likelihood that many of these were head and neck cases.
While the two Army CSHs located in Baghdad operate out of fixed facilities, the AFTH was operating out of a "rabbit warren" of interconnected tents on a large concrete pad during the period of this study, and did so until just a few months ago. These tent hospitals are notoriously difficult to keep clean and are always dusty. Interestingly, an earlier paper describing the epidemiology of Acinetobacter infections in US military personnel demonstrated no significant difference in the infection rates of personnel treated in tent or fixed facilities (the latter always seemed a lot cleaner — I've worked in both types) and identified this pathogen in the hospital environment of both types of structures.1 It should be noted that as part of the "full court press" of infection control measures instituted at the AFTH, they also incorporated closing one ICU tent on a rotating basis periodically, and accomplished thorough cleaning and disinfection.
The bottom line I derived from reading this paper is that broad and aggressive infection control measures do work, even in field conditions.
(As a brief editorial note, I am back in Iraq serving at a small Air Force EMEDS hospital as this issue of Infectious Disease Alert goes to press. Despite what feelings the readers may have about the war in Iraq, Americans should be justifiably proud of the good work our soldiers, airmen, sailors, and marines are doing over here. Just about every single American serviceman or woman with whom I have served during my 4 tours in Iraq since 2003, takes their job very seriously and desires to make a positive difference during their tour of duty. The doctors, nurses, medics, and all the other professionals serving on the military health care teams are also doing wonderful work by providing first rate medical care for US, coalition, and host nation soldiers, as well as frequently performing humanitarian work "outside the wire.")
References
- Scott P, et al. An outbreak of multi-drug resistant Acinetobacter baumannii-calcoaceticus complex infections in the U.S. military health-care system associated with military operations in Iraq. Clin Infect Dis 2007;44:1577-1584.
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