Opportunities and Obstacles in the Prevention of Skin and Soft-Tissue Infections Among Military Personnel

Risk for exertional heat illness among US army enlistees: climate indexes, intrinsic factors and their interactions

OBJECTIVES

To characterise intrinsic and extrinsic (climatic) risks for mild and severe exertional heat illness (EHI) among first-year army enlistees.

METHODS

We examined 337 786 soldiers who enlisted between 2012 and 2019. Survival models were used to predict incident EHI from intrinsic factors (demographics, healthcare utilisation, chronic conditions, body mass index (BMI), Army Physical Fitness Test (APFT), upper/lower respiratory tract infections (URTI and LRTI), skin and soft-tissue infections (SSTI), extrinsic factors (geographical region, daily mean Universal Thermal Climate Index (UTCI), wet bulb globe temperature (WBGT)) and interactions.

RESULTS

There were 1390 cases of mild and 359 cases of severe EHI. Females had a higher risk for mild (adjusted OR (aOR) 1.78; 95% CI 1.57 to 2.02) but a lower risk for severe (aOR 0.61; 95% CI 0.38 to 0.87) EHI. Obesity was associated with severe EHI (aOR: 1.76; 95% CI 1.09 to 2.84) but not mild EHI (aOR: 1.03; 95% CI 0.76 to 1.39). URTI was associated with severe (aOR: 2.44; 95% CI 1.12 to 5.30) and mild (aOR 3.72, 95% CI 2.84 to 4.87) EHI, as were LRTI (severe, aOR: 11.40; 95% CI 6.09 to 21.32; mild, aOR 2.06; 95% CI 1.22 to 3.46), but not SSTI. UTCI outperformed WBGT in predicting EHI. Outside the Southern USA, EHI risk was elevated at lower UTCI. Associations varied over climate conditions and generally did not increase with climatic heat stress.

CONCLUSIONS

Respiratory infections were associated with the highest risk for EHI in soldiers. Risk mitigation strategies may include monitoring prevention and recovery from respiratory infections. Female sex and obesity may have different associated risks over climate conditions.

Diagnostic and Therapeutic Challenges in a Military Recruit Training Center of the Hellenic Navy: A Retrospective Analysis of the Poros Registry Serving as a Quality Improvement Project for Medical Officers

INTRODUCTION

Basic military training (BMT) has been associated with increased morbidity burden. Nevertheless, the exact epidemiology of the encountered cases in the BMT of Greek recruits has never been assessed. The aim of this quality improvement project was to investigate for the first time the clinical patterns, rates, and severity of symptoms leading recruits to visit the infirmary of a recruit training center and use this knowledge to provide a practical guidance for the physicians in charge.

MATERIALS AND METHODS

All medical cases which were consecutively examined for the time range from November 2021 to September 2022 at the infirmary of the Hellenic Naval recruit training center in Poros, Greece, were retrospectively analyzed. Logistic regression analyses were performed to identify independent predictors of "severe clinical status" (i.e., overnight sick bay confinement and/or transfer to a tertiary hospital within 24 h) and absence from BMT for at least 1 day.

RESULTS

A total of 2,623 medical cases were examined during four recruit seasons from November 2021 to September 2022. Upper respiratory tract infections (URTIs) and musculoskeletal injuries were the most frequent reasons for a recruit's visit to the infirmary (33.9% and 30.2%, respectively). 6.7% of the total cases were identified as having "severe clinical status." Specifically, in psychiatric, urological, and cardiovascular cases, febrile events were all independently associated with increased risk of "severe clinical status." There was a positive association between training week and absence from BMT, while febrile events and spring recruit season were also independently linked with increased probability of absence from BMT for at least 1 day.

CONCLUSIONS

URTIs and musculoskeletal complaints were the primary reasons for recruits' presentation at the infirmary of a Greek recruit training center, leading to severe rates of attrition. Further registries and quality improvement projects are warranted to reach specific conclusions and reduce BMT-related morbidity and its subsequent implications.

Doxycycline Prophylaxis for Skin and Soft Tissue Infections in Naval Special Warfare Trainees, United States1

In 2015, several severe cases of skin and soft tissue infection (SSTI) among US Naval Special Warfare trainees prompted the introduction of doxycycline prophylaxis during the highest-risk portion of training, Hell Week. We performed a retrospective analysis of the effect of this intervention on SSTI incidence and resulting hospital admissions during 2013-2020. In total, 3,371 trainees underwent Hell Week training during the study period; 284 SSTIs were diagnosed overall, 29 of which led to hospitalization. After doxycycline prophylaxis was introduced, admission rates for SSTI decreased from 1.37 to 0.64 admissions/100 trainees (p = 0.036). Overall SSTI rates remained stable at 7.42 to 8.86 SSTIs/100 trainees (p = 0.185). Hospitalization rates per diagnosed SSTI decreased from 18.4% to 7.2% (p = 0.009). Average length of hospitalization decreased from 9.01 days to 4.33 days (p = 0.034). Doxycycline prophylaxis was associated with decreased frequency and severity of hospitalization for SSTIs among this population.

Skin Swabbing for Staphylococcus aureus-Targeting Phages

INTRODUCTION

Staphylococcus aureus (SA) is a major human bacterial pathogen increasingly refractory to antibiotics. Given the dearth of novel antibiotics in the developmental pipeline, we require concerted efforts at optimizing novel antimicrobial approaches. One promising option is the utilization of bacteriophage (phage) therapy, which has been resurrected as a viable clinical therapeutic. Specifically, an expanded library of phages targeting SA is desired. We surmised that SA-targeting phages would be readily accessible as a major component of the cutaneous microbiome. Specifically, we sought to discern if easily accessible (convenient) and discrete anatomic locations, including the nares, axilla, fingernails, toenails, and web spaces, could provide intact phages via a noninvasive, expedient procedure involving swabbing.

METHODS

One hundred subjects participated in systematic skin swab specimen collections. Pooled samples were subject to phage harvesting utilizing the soft agar overlay technique. The approval was secured from the Naval Medical Research Center Institutional Review Board (NMRC 2018.0004 FWA00000152). We utilized the same procedures from known samples containing SA-targeting phages. As another positive control, we employed the same swab and acquired samples from an active wound infection.

RESULTS

As anticipated, there were no adverse events, and the procedure was successfully implemented within the projected 10-minute duration. No phages were identified exploiting this methodology. Positive controls from various environmental samples identified SA-targeting phages as did the wound effluent sample.

CONCLUSIONS

Skin swabbing at multiple anatomic sites from 100 adults yielded insufficient biomass for phage recovery. The negative results provide helpful information for future phage isolation attempts. The lessons learned on why this study failed to isolate phages can be easily utilized by others. With a desire to increase our SA-targeting phage library in pursuit of future clinical trials, and acknowledging the paucity of these phages accessible via traditional recovery from environmental sources, we will next acquire large volumes of wound effluent from confirmed infected wounds with SA to optimize the biomass for phage recovery.

Skin problems of Korean military personnel changes in the use of cosmetics and differences in preference according to different characteristics: Focused on comparison pre- and post-enlistment

BACKGROUND

Recently, men's interest and participation in cosmetology have increased, and the number of "grooming" men who are exorbitantly investing in fashion and looks has increased, further increasing the growth potential of men's cosmetics.

OBJECTIVES

The purpose of this study was to analyze the skin diseases of men in their 20s and 30s in Korea, focusing on the comparison before and after enlistment, and to study the changes in cosmetic use and the difference in cosmetic preference according to the military service problem of Korean men.

METHODS

We enrolled 450 people, after excluding 50 dishonest respondents. Statistical data processing collected with the data analysis method were analyzed using the Statistical Package for Social Science (SPSS) WIN25.0 statistical package program through data coding and cleaning.

RESULTS

A total of 217 (48.2%) people preferred the cosmetic type of skin/lotion preferred by the private sector, and the cosmetic type required by the military was a complex skin lotion (48.2%) with 216 people (48.2%). All-in-one products were the most common products. The P-value was P < .001 or more.

CONCLUSION

The results of this comprehensive study indicated skin problems of Korean military personnel changes in the use of cosmetics and differences in preference according to different characteristics focused on comparison pre- and post-enlistment was assessed.

Emerging Infectious Diseases and Antimicrobial Resistance (EIDAR)

Introduction

The Infectious Disease Clinical Research Program’s (IDCRP) Emerging Infectious Diseases and Antimicrobial Resistance (EIDAR) Research Area is a Department of Defense (DoD) clinical research capability that is responsive and adaptive to emerging infectious disease (EID) threats to US military readiness. Among active-duty and other Military Health System (MHS) beneficiaries, EIDAR research is largely focused on evaluating the incidence, risk factors, and acute- and long-term health effects of military-relevant EIDs, especially those caused by high-consequence pathogens or are responsible for outbreaks among US military populations. The EIDAR efforts also address Force Health Protection concerns associated with antimicrobial resistance and antimicrobial stewardship practices within the MHS.

Methods

The EIDAR studies utilize the approach of: (1) Preparing for emergent conditions to systematically collect clinical specimens and data and conduct clinical trials to assist the military with a scientifically appropriate response; and (2) Evaluating burden of emergent military-relevant infectious diseases and assessing risks for exposure and development of post-infectious complications and overall impact on military readiness.

Results

In response to the Ebola virus epidemic in West Africa, the IDCRP partnered with the National Institutes of Health in developing a multicenter, randomized safety and efficacy study of investigational therapeutics in Ebola patients. Subsequently, the EIDAR team developed a protocol to serve as a contingency plan (EpICC-EID) to allow clinical research activities to occur during future outbreaks of viral hemorrhagic fever and severe acute respiratory infections among MHS patients. The EIDAR portfolio recently expanded to include studies to understand exposure risks and impact on military readiness for a diversity of EIDs, such as seroincidence of non-Lyme disease borreliosis and Coccidioides fungal infections among high-risk military populations. The team also launched a new prospective study in response to the recent Zika epidemic to conduct surveillance for Zika and other related viruses among MHS beneficiaries in Puerto Rico. Another new study will prospectively follow U.S. Marines via an online health assessment survey to assess long-term health effects following the largest DoD Shiga Toxin-Producing Escherichia coli outbreak at the U.S. Marine Corps Recruit Depot-San Diego. In cooperation with the Trauma-Related Infections Research Area, the EIDAR Research Area is also involved with the Multidrug-Resistant and Virulent Organisms Trauma Infections Initiative, which is a collaborative effort across DoD laboratories to characterize bacterial and fungal isolates infecting combat-related extremity wounds and link lab findings to clinical outcomes. Furthermore, the EIDAR team has developed an Antimicrobial Resistance and Stewardship Collaborative Clinical Research Consortium, comprised of Infectious Disease and Pharmacy specialists.

Conclusions

The EIDAR Research Area is responsive to military-relevant infectious disease threats that are also frequently global public health concerns. Several new EIDAR efforts are underway that will provide Combatant Command Surgeons, Infectious Diseases Service Chiefs, and other Force Health Protection stakeholders with epidemiological information to mitigate the impact of EIDs and antimicrobial resistance on the health of U.S. military service members and their dependents.