Resourcing and Practicing Clinical
Microbiology in Austere Environments:
Iraq 2006-2007
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LTC Steve Mahlen, PhD, D(ABMM)
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Medical Director, Microbiology, Madigan Army Medical Center
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Chief, Laboratory, 21st CSH, Abu Ghraib/Camp Cropper, Iraq
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Current
MAY 2006 – APR 2007
This talk contains material taken from the 2008 ASM
Sunrise Seminar “Resourcing and Practicing Clinical
Microbiology in Austere Environments”
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COL David Craft, LTC Steven Mahlen, CPT Dan Erwin
Objectives
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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.
Case
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Detainee, age ?, shot by U.S. Soldier while
attempting to set bomb off by a road
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L tib/fib fracture
Several wound washouts
Hardware placed (external fixator)
A week later:
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Increasing leg pain
Worse after another washout
Case
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Started on imipenem and amikacin
A day later:
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Purulent discharge
Low-grade fever
CBC: high WBC
Blood cultures positive
Culture
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Moist bacterial
colonies
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Grayish white
Oxidase negative
Non-lactosefermenter on
MacConkey agar
Antibiotic Susceptibility Profile
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Amikacin: R
Imipenem: R
Gentamicin: R
Tobramycin: R
Cefepime: R
Ceftazidime: S
Ceftriaxone: R
Levofloxacin: R
Amp/sulbactam: S
Result
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Taken back to OR
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All hardware removed
Area debrided
Recovered
Challenges of micro in an
austere environment
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Logistics
Environment
Equipment
maintenance
Personnel
Communication
Quality control
VBC
Ibn Sina
Camp
Cropper
Logistics
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Abu Ghraib
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Difficult to get supplies: convoy or helicopter
Priority of lab reagents over other critical
items
Cold-chain items
Camp Cropper
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Easier to get supplies: near BIAP
Logistics
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Media and reagents
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Temp sensitive items
Short shelf-life
Re-supply delays
Set up a monthly
standing order if
possible
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Shipping
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No overnight deliveries
Incoming reference
tests
Send-out testing
Environmental Challenges
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Environmental conditions
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Temp ranges
Dust storms
Dust Outside
Dust Inside
Facilities and Equipment
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ISO shelters
Fixed facilities
Utilities
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Power
Water
Air conditioning
Phone/internet
Equipment
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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
Personnel
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2 minimum
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Experience
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Application of "oldschool" methods
Flexibility
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Clinical microbiologist
Micro competent MT
Performs all area's of ID
diagnostic lab (bact,
mycology, parasitology,
etc)
Competence
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SME
Test Menu
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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)
Interactions with Clinical Staff
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Experience level of the microbiologist
Other duties for the microbiologist
What is the makeup of the clinical staff?
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Infectious Disease physician(s)
Experience level of staff
6-month rotations for some specialties
Organism data, antibiograms
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Own medical facility
Theater-wide
Make sure:
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You can ID most common bacteria by
glancing at plates
You can discuss antibiotic-related issues
with clinical staff
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Maintain antibiograms year to year
Test Reporting Challenges
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Issues
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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?
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No social security number
Often difficult to obtain any identification data
Regulatory Requirements
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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
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Regulatory Requirements
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Limited!
When possible:
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Run QC
Avoid expired
reagents/media
Use FDA-approved
methodology
Use standardized SOPs
Standardize validations
Proficiency testing
Summary
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There are significant challenges to establishing
and running a clinical microbiology lab in an
austere environment
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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