Resourcing and Practicing Clinical Microbiology in Austere Environments: Iraq 2006-2007 LTC Steve Mahlen, PhD, D(ABMM) LTC Steve Mahlen, PhD, D(ABMM) Medical.

Resourcing and Practicing Clinical Resourcing and Practicing Clinical Microbiology in Austere Microbiology in Austere

Environments: Iraq 2006-2007Environments: Iraq 2006-2007 LTC Steve Mahlen, PhD, D(ABMM)LTC Steve Mahlen, PhD, D(ABMM)

Medical Director, Microbiology, Madigan Army Medical Medical Director, Microbiology, Madigan Army Medical CenterCenter

CurrentCurrent Chief, Laboratory, 21Chief, Laboratory, 21stst CSH, Abu Ghraib/Camp Cropper, CSH, Abu Ghraib/Camp Cropper,

IraqIraq MAY 2006 – APR 2007MAY 2006 – APR 2007

This talk contains material taken from the 2008 This talk contains material taken from the 2008 ASM Sunrise Seminar “Resourcing and Practicing ASM Sunrise Seminar “Resourcing and Practicing Clinical Microbiology in Austere Environments”Clinical Microbiology in Austere Environments” COL David Craft, LTC Steven Mahlen, CPT Dan ErwinCOL David Craft, LTC Steven Mahlen, CPT Dan Erwin

ObjectivesObjectives

Describe the challenges of establishing a Describe the challenges of establishing a clinical microbiology lab in an austere clinical microbiology lab in an austere environment.environment.

Define the personnel, analytical systems, Define the personnel, analytical systems, information systems and logistical support information systems and logistical support required for public health and clinical laboratory required for public health and clinical laboratory operations in an austere environment.operations in an austere environment.

Discuss the standardization of protocols, Discuss the standardization of protocols, validation, proficiency testing and other validation, proficiency testing and other regulatory requirements associated with regulatory requirements associated with testing, result reporting and consulting in an testing, result reporting and consulting in an austere environment.austere environment.

CaseCase

Detainee, age ?, shot by U.S. Soldier Detainee, age ?, shot by U.S. Soldier while attempting to set bomb off by a while attempting to set bomb off by a roadroad L tib/fib fractureL tib/fib fracture

Several wound washoutsSeveral wound washouts Hardware placed (external fixator)Hardware placed (external fixator) A week later:A week later:

Increasing leg painIncreasing leg pain Worse after another washoutWorse after another washout

CaseCase

Started on imipenem and amikacinStarted on imipenem and amikacin A day later:A day later:

Purulent dischargePurulent discharge Low-grade feverLow-grade fever CBC: high WBCCBC: high WBC

Blood cultures positiveBlood cultures positive

CultureCulture Moist bacterial Moist bacterial

coloniescolonies Grayish whiteGrayish white

Oxidase negativeOxidase negative Non-lactose-Non-lactose-

fermenter on fermenter on MacConkey agarMacConkey agar

Antibiotic Susceptibility Antibiotic Susceptibility ProfileProfile

Amikacin: RAmikacin: R Imipenem: RImipenem: R Gentamicin: RGentamicin: R Tobramycin: RTobramycin: R Cefepime: RCefepime: R Ceftazidime: SCeftazidime: S Ceftriaxone: RCeftriaxone: R Levofloxacin: RLevofloxacin: R Amp/sulbactam: SAmp/sulbactam: S

ResultResult Taken back to ORTaken back to OR

All hardware removedAll hardware removed Area debridedArea debrided

RecoveredRecovered

Challenges of micro in an Challenges of micro in an austere environmentaustere environment

LogisticsLogistics EnvironmentEnvironment Equipment Equipment

maintenancemaintenance PersonnelPersonnel CommunicationCommunication Quality controlQuality control

VBCVBC

Ibn Sina

Camp Cropper

LogisticsLogistics

Abu GhraibAbu Ghraib Difficult to get supplies: convoy or Difficult to get supplies: convoy or

helicopterhelicopter Priority of lab reagents over other Priority of lab reagents over other

critical itemscritical items Cold-chain itemsCold-chain items

Camp CropperCamp Cropper Easier to get supplies: near BIAPEasier to get supplies: near BIAP

LogisticsLogistics

Media and Media and reagentsreagents Temp sensitive Temp sensitive

itemsitems Short shelf-lifeShort shelf-life Re-supply delaysRe-supply delays Set up a monthly Set up a monthly

standing order if standing order if possiblepossible

ShippingShipping No overnight No overnight

deliveriesdeliveries Incoming reference Incoming reference

teststests Send-out testingSend-out testing

Environmental ChallengesEnvironmental Challenges

Environmental conditionsEnvironmental conditions Temp rangesTemp ranges Dust stormsDust storms

Dust OutsideDust Outside

Dust InsideDust Inside

Facilities and EquipmentFacilities and Equipment

ISO shelters ISO shelters Fixed facilitiesFixed facilities UtilitiesUtilities

PowerPower WaterWater Air conditioningAir conditioning Phone/internetPhone/internet

EquipmentEquipment

Equipment breaks down on Equipment breaks down on deployments!deployments!

May be difficult to get hold of technical May be difficult to get hold of technical repsreps

Make sure you have technical and Make sure you have technical and operation manuals before deploymentoperation manuals before deployment

Med maintenance may not be able to Med maintenance may not be able to helphelp

PersonnelPersonnel

2 minimum2 minimum Clinical microbiologistClinical microbiologist Micro competent MTMicro competent MT

ExperienceExperience Application of "old-Application of "old-

school" methods school" methods FlexibilityFlexibility

Performs all area's of Performs all area's of ID diagnostic lab ID diagnostic lab (bact, mycology, (bact, mycology, parasitology, etc)parasitology, etc)

CompetenceCompetence SMESME

Test MenuTest Menu

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

Interactions with Clinical Interactions with Clinical StaffStaff

Experience level of the microbiologistExperience level of the microbiologist Other duties for the microbiologistOther duties for the microbiologist What is the makeup of the clinical staff?What is the makeup of the clinical staff?

Infectious Disease physician(s)Infectious Disease physician(s) Experience level of staffExperience level of staff 6-month rotations for some specialties6-month rotations for some specialties

Organism data, antibiogramsOrganism data, antibiograms Own medical facilityOwn medical facility Theater-wideTheater-wide

Make sure:Make sure:

You can ID most common bacteria by You can ID most common bacteria by glancing at platesglancing at plates

You can discuss antibiotic-related You can discuss antibiotic-related issues with clinical staffissues with clinical staff Maintain antibiograms year to yearMaintain antibiograms year to year

Test Reporting ChallengesTest Reporting Challenges IssuesIssues

Lots of systems (CHCS, AHLTA-T, MEDWEB, Lots of systems (CHCS, AHLTA-T, MEDWEB, JPTA)!JPTA)!

No interoperability in theater of operationNo interoperability in theater of operation No interoperability with medical treatment No interoperability with medical treatment

facilities in the U.S. and other sites (Germany)facilities in the U.S. and other sites (Germany) How are foreign nationals/detainees How are foreign nationals/detainees

identified?identified? No social security numberNo social security number Often difficult to obtain any identification dataOften difficult to obtain any identification data

Regulatory RequirementsRegulatory Requirements Accrediting agencies not in Accrediting agencies not in

combat zones:combat zones: CCollege of ollege of AAmerican merican PPathologists – athologists –

CAPCAP JJoint oint CCommission on ommission on AAccreditation of ccreditation of

HHealth ealth CCare are OOrganization – rganization – JCAHOJCAHO CCommission on ommission on OOffice ffice LLaboratory aboratory

AAccreditation (ccreditation (COLACOLA)) FFood and ood and DDrug rug AAdministration dministration – FDA– FDA

Regulatory RequirementsRegulatory Requirements

Limited!Limited! When possible:When possible:

Run QCRun QC Avoid expired Avoid expired

reagents/mediareagents/media Use FDA-approved Use FDA-approved

methodologymethodology Use standardized Use standardized

SOPsSOPs Standardize Standardize

validationsvalidations Proficiency testingProficiency testing

SummarySummary

There are significant challenges to There are significant challenges to establishing and running a clinical establishing and running a clinical microbiology lab in an austere microbiology lab in an austere environmentenvironment Ensure personnel are trained properlyEnsure personnel are trained properly Establish appropriate information systems and Establish appropriate information systems and

logistical support (crucial!)logistical support (crucial!) Standardize protocols, validation, Standardize protocols, validation,

proficiency testing and other regulatory proficiency testing and other regulatory requirements associated with testing, requirements associated with testing, result reporting and consultingresult reporting and consulting