1. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010 Genesis of Clinical Microbiology in the CSH - Afghanistan 2002 LTC John M. Scherer Ph.D., M.T. (ASCP) Ph.D., M.T. (ASCP)

2. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010 HISTORY May 2002 Outbreak of unknown illness among British soldiers Unknown etiology Critically ill Spreading person-to-person 44 th MEDCOM responsible for HCO Currently no CSH in Afghanistan Concern over inability to ID any infectious diseases 520 th TAML had the capability but not all the components Three-person team deployed July 2002 met up with 339 th CSH in August

3. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010 MISSION To deploy the developmental M403 Microbiology Augmentation Set to Bagram Air Force Base in Afghanistan, work out supply issues, train the 339 th CSH in its use, and redeploy back to COUNS for future deployment to Kuwait.

4. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010 CAPABILITIES Culture: Wounds, Blood, Stools, Urine, Respiratory, Fluids, etc. Antibiotic Susceptibilities: GNR & GPC (- Strep pneumo) RAPID tests: Group A Strep, Influenza, Strep pneumo, some Protozoa O&P Direct Fungal Staining Malaria Staining

5. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010 Mycobacterium staining or culture Anaerobe identification Fungal identification ITEMS NOT PART OF THE KIT

6. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010

7. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010

8. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010

9. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010 Isolates and Susceptibility Patterns

10. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010 Coagulase test

11. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010

12. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010 SpecimenLocal NationalUS/CoalitionTotal Sputum58260 Wound10823131 Stool57984 Blood10815123 Urine6736103 STD42731 Throat/Nasal23537 CSF12820 O&P45660 Total368281649 Demographics of Microbiology Workload 452nd Combat Support Hospital, Bagram Afghanistan (April 1, 2003 to Mar 15, 2004)

13. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010 Top Organisms isolated* E. coli30 K. pneumoniae19 A. baumannii17 E. cloacae16 Staph not aureus16 P. aeruginosa11 Shigella sp10 S. aureus10 Klebsiella other8 Enterobacter aerogenes8 Proteus sp6 Haemophilus sp5 Total156 Most commonly isolated organisms from 452nd Combat Support Hospital, Bagram Afghanistan (April 1, 2003 to Mar 15, 2004). *These 12 organisms account for approximately 85% of the total number of positive cultures.

14. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010 SourceOrganismNumber Positive BloodEnterobacter aerogenes5 Acinetobacter baumannii 3 SputumAcinetobacter baumannii 10 Klebsiella pneumoniae6 StoolShigella species9 UrineE. coli14 Klebsiella pneumoniae5 Enterobacter cloacae5 WoundE. coli12 Enterobacter cloacae9 Staphylococcus aureus8 Most common isolated organisms based on culture type 452nd Combat Support Hospital, Bagram Afghanistan (April 1, 2003 to Mar 15, 2004).

15. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010 Slide 15 AfghanistanUS E. coli 43%4% K. pneumoniae 79%12%/21% E. cloacae 75%43%*/75% *Enterobacter species P. aeruginosa 55%23%/55% ESBL activity as measured by Ceftazidime resistance Annals of Clinical Microbiology and Antimicrobials 2004; 3:7 Journal of Antimicrobial Chemotherapy 2000; 45: 295-303

16. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010 Slide 16 AfghanistanUS Ampicillin7%52%/60% Cephalothin20%62%/70% Ciprofloxacin60%87%/96% Nitrofurantoin80%98% SXT37%75%/81% E. Coli Susceptibility Pattern Annals of Clinical Microbiology and Antimicrobials 2004; 3:7 Antimicrobial Agents and Chemotherapy 2001; 1402–1406

17. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010 Overall, the set performed exceptionally well Susceptibility patterns are different than those observed in the US Some tests will not provide the same performance as they do in the US Gram negative rods were frequently isolated from blast wounds (not Acinetobacter) CLINICAL CONCLUSIONS

18. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010 Maintain soldiers with local knowledge in theater Decreases casualty movement/decreased logistical burden Mission readiness - Bacterial versus viral meningitis IMPACT BEYOND PATIENT CARE

19. UNCLASSIFIED LTC John M. Scherer/(301) 619-8837/john.scherer@us.army.mil 1 March 2010 Questions Special Thanks to CPT Scott Cvecko for the data from the 452nd CSH