Resourcing and Practicing Clinical Microbiology in Austere Environments: Iraq 2006-2007

1. Resourcing and Practicing Clinical Microbiology in Austere Environments: Iraq 2006-2007 • LTC Steve Mahlen, PhD, D(ABMM) • Medical Director, Microbiology, Madigan Army Medical Center • Current • Chief, Laboratory, 21st CSH, Abu Ghraib/Camp Cropper, Iraq • MAY 2006 – APR 2007 • This talk contains material taken from the 2008 ASM Sunrise Seminar “Resourcing and Practicing Clinical Microbiology in Austere Environments” • COL David Craft, LTC Steven Mahlen, CPT Dan Erwin

2. Objectives Describe the challenges of establishing a clinical microbiology lab in an austere environment. Define the personnel, analytical systems, information systems and logistical support required for public health and clinical laboratory operations in an austere environment. Discuss the standardization of protocols, validation, proficiency testing and other regulatory requirements associated with testing, result reporting and consulting in an austere environment.

3. Case • Detainee, age ?, shot by U.S. Soldier while attempting to set bomb off by a road • L tib/fib fracture • Several wound washouts • Hardware placed (external fixator) • A week later: • Increasing leg pain • Worse after another washout

4. Case • Started on imipenem and amikacin • A day later: • Purulent discharge • Low-grade fever • CBC: high WBC • Blood cultures positive

6. Culture Moist bacterial colonies Grayish white Oxidase negative Non-lactose-fermenter on MacConkey agar

7. Antibiotic Susceptibility Profile Amikacin: R Imipenem: R Gentamicin: R Tobramycin: R Cefepime: R Ceftazidime: S Ceftriaxone: R Levofloxacin: R Amp/sulbactam: S

8. Result Taken back to OR All hardware removed Area debrided Recovered

9. Challenges of micro in an austere environment • Logistics • Environment • Equipment maintenance • Personnel • Communication • Quality control

10. Mosul Tikrit Balad Airbase Al Asad Airbase Camp Cropper/VBC Ibn Sina Camp Bucca

11. VBC Ibn Sina Camp Cropper

12. Logistics • Abu Ghraib • Difficult to get supplies: convoy or helicopter • Priority of lab reagents over other critical items • Cold-chain items • Camp Cropper • Easier to get supplies: near BIAP

13. Logistics • Media and reagents • Temp sensitive items • Short shelf-life • Re-supply delays • Set up a monthly standing order if possible • Shipping • No overnight deliveries • Incoming reference tests • Send-out testing

14. Environmental Challenges Environmental conditions Temp ranges Dust storms

15. Dust Outside

16. Dust Inside

17. Facilities and Equipment • ISO shelters • Fixed facilities • Utilities • Power • Water • Air conditioning • Phone/internet

18. Equipment • Equipment breaks down on deployments! • May be difficult to get hold of technical reps • Make sure you have technical and operation manuals before deployment • Med maintenance may not be able to help

19. Personnel • 2 minimum • Clinical microbiologist • Micro competent MT • Experience • Application of "old-school" methods • Flexibility • Performs all area's of ID diagnostic lab (bact, mycology, parasitology, etc) • Competence • SME

20. Test Menu Blood (Septi-Chek) Urine (bi-plates) Wounds/fluids (aerobic/anaerobic) Respiratory Stools (TCBS, EIA’s) AFB (Kinyoun) Mycology (direct exam and culture) Parasitology (O&P's, EIA’s, blood parasites)

21. Interactions with Clinical Staff • Experience level of the microbiologist • Other duties for the microbiologist • What is the makeup of the clinical staff? • Infectious Disease physician(s) • Experience level of staff • 6-month rotations for some specialties • Organism data, antibiograms • Own medical facility • Theater-wide

22. Make sure: • You can ID most common bacteria by glancing at plates • You can discuss antibiotic-related issues with clinical staff • Maintain antibiograms year to year

23. Test Reporting Challenges Issues Lots of systems (CHCS, AHLTA-T, MEDWEB, JPTA)! No interoperability in theater of operation No interoperability with medical treatment facilities in the U.S. and other sites (Germany) How are foreign nationals/detainees identified? No social security number Often difficult to obtain any identification data

24. Regulatory Requirements Accrediting agencies not in combat zones: College of American Pathologists – CAP Joint Commission on Accreditation of Health Care Organization – JCAHO Commission on Office Laboratory Accreditation (COLA) Food and Drug Administration – FDA

25. Limited! When possible: Run QC Avoid expired reagents/media Use FDA-approved methodology Use standardized SOPs Standardize validations Proficiency testing Regulatory Requirements

26. Summary • There are significant challenges to establishing and running a clinical microbiology lab in an austere environment • Ensure personnel are trained properly • Establish appropriate information systems and logistical support (crucial!) • Standardize protocols, validation, proficiency testing and other regulatory requirements associated with testing, result reporting and consulting