A review of the Royal Perth Hospital Bali experience: an infection control perspective

Development of a Mobile Laboratory for Sudden Onset Disasters

OBJECTIVES

Clinical diagnostics in sudden onset disasters have historically been limited. We set out to design, implement, and evaluate a mobile diagnostic laboratory accompanying a type 2 emergency medical team (EMT) field hospital.

METHODS

Available diagnostic platforms were reviewed and selected against in field need. Platforms included HemoCue301/WBC DIFF, i-STAT, BIOFIRE FILMARRAY multiplex rt-PCR, Olympus BX53 microscopy, ABO/Rh grouping, and specific rapid diagnostic tests. This equipment was trialed in Katherine, Australia, and Dili, Timor-Leste.

RESULTS

During the initial deployment, an evaluation of FilmArray tests was successful using blood culture identification, gastrointestinal, and respiratory panels. HemoCue301 (n = 20) hemoglobin values were compared on Sysmex XN 550 (r = 0.94). HemoCue WBC DIFF had some variation, dependent on the cell, when compared with Sysmex XN 550 (r = 0.88-0.16). i-STAT showed nonsignificant differences against Vitros 250. Further evaluation of FilmArray in Dili, Timor-Leste, diagnosed 117 pathogens on 168 FilmArray pouches, including 25 separate organisms on blood culture and 4 separate cerebrospinal fluid pathogens.

CONCLUSION

This mobile laboratory represents a major advance in sudden onset disaster. Setup of the service was quick (< 24 hr) and transport to site rapid. Future deployment in fragmented health systems after sudden onset disasters with EMT2 will now allow broader diagnostic capability.

Synergistic effect of Myrtus communis L. essential oils and conventional antibiotics against multi-drug resistant Acinetobacter baumannii wound isolates

Acinetobacter baumannii is a rapidly emerging, highly resistant clinical pathogen with increasing prevalence. In recent years, the limited number of antimicrobial agents available for treatment of infections with multi-drug resistant (MDR) strains reinforced tendency for discovery of novel antimicrobial agents or treatment strategies. The aim of the study was to determine antimicrobial effectiveness of three Myrtus communis L. essential oils, both alone and in combination with conventional antibiotics, against MDR A. baumannii wound isolates. The results obtained highlighted the occurrence of good antibacterial effect of myrtle oils when administered alone. Using checkerboard method, the combinations of subinhibitory concentrations of myrtle essential oils and conventional antibiotics, i.e. polymixin B and ciprofloxacine were examined. The results proved synergism among M. communis L. essential oils and both antibiotics against MDR A. baumannii wound isolates, with a FIC index under or equal 0.50. Combination of subinhibitory concentrations of essential oils and ciprofloxacin most frequently reduced bacterial growth in synergistic manner. The similar has been shown for combination with polymyxin B; furthermore, the myrtle essential oil resulted in re-sensitization of the MDR wound isolates, i.e. MICs used in combination were below the cut off for the sensitivity to the antibiotic. Time-kill curve method confirmed efficacy of myrtle essential oil and polymyxin B combination, with complete reduction of bacterial count after 6h. The detected synergy offers an opportunity for future development of treatment strategies for potentially lethal wound infections caused by MDR A. baumannii.

Burn Disasters—An Audit of the Literature

All events that result in disasters are unique, and it is impossible to become fully prepared. However, through thorough planning and preparedness, it is possible to gain a better understanding of the typical injury patterns and problems that arise from a variety of hazards. Such events have the potential to claim many lives and overwhelm local medical resources. Burn disasters vary in scope of injury and procedures required, and are much more labor and resource intensive than non-burn disasters.

This review of the literature should help determine whether, despite each event having its own unique features, there still are common problems disaster responders face in the prehospital and hospital phases, what recommendations were made from these disasters, and whether these recommendations have been implemented into practice and the current disaster planning processes.

The objective of this review was to assess: (1) prehospital and hospital responses used during past burn disasters; (2) problems faced during those disaster responses; (3) recommendations made following those disasters; (4) whether these recommendations were integrated into practice; and (5) the key characteristics of burn disasters and how they differ from other disasters. This review is important to determine why, despite having disaster plans, things still go wrong.

Country-to-country transfer of patients and the risk of multi-resistant bacterial infection

Management of patients with a history of healthcare contact in multiple countries is now a reality for many clinicians. Leisure tourism, the burgeoning industry of medical tourism, military conflict, natural disasters, and changing patterns of human migration may all contribute to this emerging epidemiological trend. Such individuals may be both vectors and victims of healthcare-associated infection with multiresistant bacteria. Current literature describes intercountry transfer of multiresistant Acinetobacter spp and Klebsiella pneumoniae (including Klebsiella pneumoniae carbapenemase- and New Delhi metallo-β-lactamase-producing strains), methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and hypervirulent Clostridium difficile. Introduction of such organisms to new locations has led to their dissemination within hospitals. Healthcare institutions should have sound infection prevention strategies to mitigate the risk of dissemination of multiresistant organisms from patients who have been admitted to hospitals in other countries. Clinicians may also need to individualize empiric prescribing patterns to reflect the risk of multiresistant organisms in these patients.

Burn wounds infected by contaminated water: case reports, review of the literature and recommendations for treatment

First-aid education for the management of burns advocates cool running water over burnt skin to limit soft tissue damage. However, the water used may itself constitute a risk. We report three cases of severe invasive and necrotizing infection in patients who used or immersed themselves in contaminated water in an attempt to extinguish the fire following acute major burns. Wound cultures from all patients yielded Aeromonas hydrophila and two yielded Bacillus cereus. One patient had a complex polymicrobial infection, including zygomycosis with Rhizomucor variabilis. All patients were treated aggressively with wound débridement, including one patient who required bilateral lower limb amputations to control progressive infection. All infections were successfully treated and all patients survived their burn injuries. We review the management of burns complicated by exposure to contaminated water leading to burn wound infections. We describe commonly reported organisms from various water sources, the appropriate initial empirical antimicrobial chemotherapy and present the clinician with a proposed algorithm for managing these serious infections.

Multi-drug resistant Acinetobacter infections in critically injured Canadian forces soldiers

Background

Military members, injured in Afghanistan or Iraq, have returned home with multi-drug resistant Acinetobacter baumannii infections. The source of these infections is unknown.

Methods

Retrospective study of all Canadian soldiers who were injured in Afghanistan and who required mechanical ventilation from January 1 2006 to September 1 2006. Patients who developed A. baumannii ventilator associated pneumonia (VAP) were identified. All A. baumannii isolates were retrieved for study patients and compared with A. baumannii isolates from environmental sources from the Kandahar military hospital using pulsed-field gel electrophoresis (PFGE).

Results

During the study period, six Canadian Forces (CF) soldiers were injured in Afghanistan, required mechanical ventilation and were repatriated to Canadian hospitals. Four of these patients developed A. baumannii VAP. A. baumannii was also isolated from one environmental source in Kandahar – a ventilator air intake filter. Patient isolates were genetically indistinguishable from each other and from the isolates cultured from the ventilator filter. These isolates were resistant to numerous classes of antimicrobials including the carbapenems.

Conclusion

These results suggest that the source of A. baumannii infection for these four patients was an environmental source in the military field hospital in Kandahar. A causal linkage, however, was not established with the ventilator. This study suggests that infection control efforts and further research should be focused on the military field hospital environment to prevent further multi-drug resistant A. baumannii infections in injured soldiers.

Impact of multi-drug-resistant Acinetobacter baumannii on clinical outcomes

We conducted a retrospective matched cohort study to examine the impact of isolation of multi-drug-resistant (MDR) Acinetobacter baumannii on patient outcomes. Cases from whom MDR A. baumannii was isolated in a clinical culture (n = 118) were compared with controls from whom MDR A. baumannii was not isolated (n = 118). Cases and controls were matched according to ward, calendar month of hospitalization, and duration of hospitalization before culture. The following outcomes were compared in multivariable analysis: in-hospital mortality, length of stay, need for mechanical ventilation, and functional status at discharge. MDR A. baumannii was determined to be a pathogen in 72% of cases. In 36% of cases, the patient died, versus 21% of controls (odds ratio [OR] 2.21, 95% confidence interval [CI] 1.17-4.16, P = 0.014). Median length of stay for surviving cases was 17 days, versus 11 for surviving controls (multiplicative effect 1.55, 95% CI 0.99-2.44, P = 0.057). Fifty-two percent of cases required mechanical ventilation, versus 25% of controls (OR 3.72, 95% CI 1.91-7.25, P<0.001); 60% of surviving cases were discharged with reduced functional status, versus 38% of controls (OR 4.4, 95% CI 1.66-11.61, P = 0.003). In multivariable analysis, clinical isolation of MDR A. baumannii remained a significant predictor of mortality (OR 6.23, 95% CI 1.31-29.5, P = 0.021), need for mechanical ventilation (OR 7.34, 95% CI 2.24-24.0, P<0.001), and reduced functional status on discharge (OR 7.93, 95% CI 1.1-56.85, P = 0.039). Thus, MDR A. baumannii acquisition is associated with severe adverse outcomes, including increased mortality, need for mechanical ventilation, and reduced functional status.

Trauma-related infections in battlefield casualties from Iraq

OBJECTIVE

To describe risks for, and microbiology and antimicrobial resistance patterns of, war trauma associated infections from Operation Iraqi Freedom.

BACKGROUND

: The invasion of Iraq resulted in casualties from high-velocity gunshot, shrapnel, and blunt trauma injuries as well as burns. Infectious complications of these unique war trauma injuries have not been described since the 1970s.

METHODS

Retrospective record review of all trauma casualties 5 to 65 years of age evacuated from the Iraqi theatre to U.S. Navy hospital ship, USNS Comfort, March to May 2003.War trauma-associated infection was defined by positive culture from a wound or sterile body fluid (ie, blood, cerebrospinal fluid) and at least two of the following infection-associated signs/symptoms: fever, dehiscence, foul smell, peri-wound erythema, hypotension, and leukocytosis. A comparison of mechanisms of injury, demographics, and clinical variables was done using multivariate analysis.

RESULTS

Of 211 patients, 56 met criteria for infection. Infections were more common in blast injuries, soft tissue injuries, >3 wound sites, loss of limb, abdominal trauma, and higher Injury Severity Score (ISS). Wound infections accounted for 84% of cases, followed by bloodstream infections (38%). Infected were more likely to have had fever prior to arrival, and had higher probability of ICU admission and more surgical procedures. Acinetobacter species (36%) were the predominant organisms followed by Escherichia coli and Pseudomonas species (14% each).

CONCLUSIONS

Similar to the Vietnam War experience, gram-negative rods, particularly Acinetobacter species, accounted for the majority of wound infections cared for on USNS Comfort during Operation Iraqi Freedom. Multidrug resistance was common, with the exception of the carbapenem class, limiting antibiotic therapy options.

First response, rehabilitation, and outcomes of hand and upper limb function: survivors of the bali bombing disaster. A case series report

In October 2002, two bombs exploded in Bali injuring hundreds, and killing 202 people. The purpose of this paper is to report the organization of the first response, rehabilitation strategies, and outcome of a series of patients evacuated to the Royal Perth Hospital (RPH), a civilian hospital in Australia. The initial medical response in Bali was primarily conducted by holidaying health professionals supporting the hospital on the island. The Australian Defence Force was primarily responsible for the ongoing acute clinical management during the evacuation and repatriation of survivors to all major burn units in Australia. At the RPH, hospital adaptations included novel staffing and treatment strategies to sustain a team effort beyond the acute phase of the disaster to manage the surge of 28 patients (15% of yearly admissions) in 7 days. Data collected were related to service delivery and patient outcomes (shoulder active range of motion, grip strength, and the Burns Specific Health Scale). Data were compared to baseline, similar data collected during normal practice and population norms. Bali patients received 3.2% more therapy treatment sessions and 6.8% less contact hours than usual protocols. Shoulder AROM recovered to normal limits by 3 months postdischarge. Grip strength for women was shown to reach population norms by 1 month after discharge and by 6 months for males. Self-rated physical recovery exceeded major burn population norms at 6 months postdischarge. Physical therapy outcome measures demonstrated upper limb recovery as usual in the Bali group, despite a mass casualty situation. To achieve this required support from the multidisciplinary team, in combination with community, government, and hospital administrative assistance.

Comparison of Acinetobacter baumannii isolates from the United Kingdom and the United States that were associated with repatriated casualties of the Iraq conflict

Acinetobacter isolates associated with casualties from the Iraq conflict from the United States were compared with those from the United Kingdom by pulsed-field gel electrophoresis and integron analysis. Representatives of the main outbreak strain associated with casualties from both countries were indistinguishable in DNA profile. Two further outbreak strains were common to both sets of isolates.

Infection in acute burn wounds following the Bali bombings: a comparative prospective audit

INTRODUCTION

Bacterial colonisation and invasive bacterial infection remain the major causes of mortality and morbidity following severe burn thus ongoing surveillance of patients and monitoring of infection facilitates early intervention to minimise the risk of sepsis. The circumstances of the Bali bombings in October 2002, provided an opportunity to analyse the ramifications of lengthy transfer times, delayed resuscitation and topical treatment, on the primary incidence of burn wound infection (BWI).

METHOD

This prospective clinical audit investigated the primary incidence of BWI between the usual burn patients admitted to the Burn Unit at Royal Perth Hospital, Western Australia, and a number of survivors from the Bali bombings during a 3-month audit period in 2002. BWI was identified using the Peck et al. proposed definitions for the surveillance of burn wound infections. These include impetigo, surgical wound related infection, cellulitis and invasive infection of unexcised wounds.

RESULTS

The incidence of primary BWI in the Bali-tourist group (68.2%) compared with the standard WA group (18.2%) was significant (p=0.001).

CONCLUSION

Sensitive assessment criteria allowed for early identification of wound infection. A clinically significant difference in the Bali-tourist group is probably related to the circumstances of their injury.

The epidemiology and control of Acinetobacter baumannii in health care facilities

Acinetobacter baumannii is a ubiquitous pathogen capable of causing both community and health care-associated infections (HAIs), although HAIs are the most common form. This organism has emerged recently as a major cause of HAI because of the extent of its antimicrobial resistance and its propensity to cause large, often multifacility, nosocomial outbreaks. The occurrence of outbreak is facilitated by both tolerance to desiccation and multidrug resistance, contributing to the maintenance of these organisms in the hospital environment. In addition, the epidemiology of A. baumannii infection is often complex, with the coexistence of epidemic and endemic infections, the latter of which often is favored by the selection pressure of antimicrobials. The only good news is that potentially severe A. baumannii infection, such as bacteremia or pneumonia in patients in the intensive care unit who are undergoing intubation, do not seem to be associated with a higher attributable mortality rate or an increased length of hospital stay.