BackgroundThe 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.MethodsGNB 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.ResultsThe 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.ConclusionHealthy 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.

hWe describe a 22-year-old soldier with 19% total body surface area burns, polytrauma, and sequence-and culture-confirmed Pythium aphanidermatum wound infection. Antemortem histopathology suggested disseminated Pythium infection, including brain involvement; however, postmortem PCR revealed Cunninghamella elegans, Lichtheimia corymbifera, and Saksenaea vasiformis coinfection. The utility of molecular diagnostics in invasive fungal infections is discussed. CASE REPORT In August 2013, a 22-year-old U.S. soldier was injured by an improvised explosive device (IED) while on foot patrol in Bamyan Province, central Afghanistan, which propelled him into a nearby stream. He sustained 19% total body surface area (TBSA) partial-and full-thickness burns, including superficial burns to the penis and multiple skin and soft tissue injuries. These injuries extended from the distal right medial thigh to the right midcalf and from the left gluteus to the left thigh, involving portions of the scrotum. Open fractures of the right tibia/fibula and left proximal femur were noted in addition to comminuted, minimally displaced fractures of the left pelvic girdle complicated by intra-and retroperitoneal hematomas. Soft tissue wounds from IED fragments without bony injury were observed in the left posterior upper arm. He was evacuated to Craig Joint Theater Hospital (CJTH) in Bagram in north-central Afghanistan.Upon arrival at CJTH, he received a massive transfusion of packed red blood cells (PRBC; 18 units within the first 24 h from injury), fresh frozen plasma (20 units), platelets (3 units apheresis platelets), and cryoprecipitate (20 units) and underwent irrigation and debridement of all soft tissue wounds with external fixation of the right tibia/fibula and left femoral fractures. The minimally displaced fractures of the left pelvic girdle were treated nonoperatively. The patient was medically evacuated to Landstuhl Regional Medical Center (LRMC) in Germany. Despite serial irrigation and debridement of each of these injuries (except the pelvic girdle injuries) over the next 48 h, progressive wound infection in the proximal open left femur fracture necessitated a left hip disarticulation on day 4 after injury (PDOI 4). Intraoperative cultures of the left lower extremity (the site was not further specified) revealed 2 isolates of multidrug-resistant (MDR) Escherichia coli. A prior fungal culture from the left lower extremity (PDOI 2) grew three separate molds (Aspergillus species, Geotrichum species, and Alternaria species) and an unspecified yeast, whereas a fungal culture from this site on PDOI 4 became overgrown with bacteria and could not be further evaluated. No additional operative cultures were obtained at LRMC. To minimize fecal contamination of the left hip wound, an open laparotomy was performed, with placement of a diverting colostomy and evacuation of a retroperitoneal hematoma.On PDOI 12, the patient was transferred to the Burn Intensive Care Unit at San Antonio Military Medical Center (SAMMC) for continued treatment. He ...

Given the changing epidemiology of infecting pathogens in combat casualties, we evaluated bacteria and fungi in acute traumatic wounds from Afghanistan. From January 2013 to February 2014, 14 mangled lower extremities from 10 explosive-device injured casualties were swabbed for culture at Role 3 facilities. Bacteria were recovered from all patients on the date of injury. Pathogens recovered during routine patient care were recorded. The median injury severity score was 29, median initial Role 3/4 blood product support was 32 units, and median evacuation time was 42 minutes to first surgical care. Gram-positive bacteria were found in some wounds but not methicillin-resistant Staphylococcus aureus or vancomycin-resistant Enterococcus. Most wounds were colonized with low-virulence, environmental gram-negative bacteria, and not recovered again during therapy, reflecting wound contamination. Only one wound had the same bacteria (E. cloacae) throughout care at the Role 3, 4, and 5 facilities. Three cultures from two patients had multidrug-resistant bacteria (E. cloacae, E. coli), all detected at Role 5 facilities. Molds were not detected at Role 3, whereas one patient had a mold at Role 4 and 5. Mangled lower extremity injuries have a high contamination rate with environmental organisms, which are not typically associated with infections during the course of the patient's care.

BackgroundStaphylococcus 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.MethodsColonization 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).Results4 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).ConclusionMRSA 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.

The overall 3% MRSA colonization rate is consistent with historical reports, but the oropharynx-only colonization supports more recent findings. In addition, the use of deodorant/anti-perspirant invalidated axillary PCR samples, limiting its utility. Defining MRSA positivity by PCR/ESI-TOF-MS is complicated by co-colonization of S. aureus with CoNS, which can also carry mecA.