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Resourcing and Practicing Clinical Microbiology in Austere Environments: Iraq 2006-2007. LTC Steve Mahlen, PhD, D(ABMM) Medical Director, Microbiology, Madigan Army Medical Center Current Chief, Laboratory, 21 st CSH, Abu Ghraib /Camp Cropper, Iraq MAY 2006 – APR 2007 - PowerPoint PPT Presentation
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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
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
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