purulence, or wound) (Davis et al. 2005). Of blood, urine, wound, or sputum specimens obtained from March 2003 to May 2004, 145 of 24,114 (0.6%) were positive for Acinetobacter spp. Among those sampled were 237 active-duty patients with injuries, 151 of whom had been deployed to OEF or OIF. Blood, wound, sputum, urine, and skin cultures were obtained on 84 of those deployed soldiers, and 48 of them (32%) were Acinetobacter spp.-positive. Thirty of the 237 patients were judged to have either wound injuries or related osteomyelitis; the wound or bone infections represented 63% of the culture positives, 36% of all OEF- or OIF-deployed men who were cultured and hospitalized, and 20% of all those with injuries who had been deployed to OEF or OIF. Those results demonstrate that Acinetobacter spp. is a common cause of wound infection or related osteomyelitis in men hospitalized for their war-related injuries from OEF and OIF. That no soldier had more than 12 days between injury and infection is informative, although a larger series would be needed to assess more accurately what a maximal incubation period might be.

Another contemporaneous case series of 102 patients with A. baumannii bacteremia was published; the cases presented in 2002-2004 at the Landstuhl Regional Medical Center (which accounted for about 78% of the patients), Walter Reed Army Medical Center (WRAMC), Brooke Army Medical Center (BAMC), National Naval Medical Center, and the US Navy hospital ship Comfort (Joly-Guillou 2005). The typical patient was a male soldier who experienced a traumatic injury in Iraq. In this multihospital series and the BAMC series, A. baumannii bacteremia was common in OEF and OIF returnees who were hospitalized for injuries, but it was rare before the start of OEF and OIF (CDC 2004; Davis et al. 2005; Zapor and Moran 2005). No late manifestations (months after injury) were reported in either case series (CDC 2004; Davis et al. 2005).

Death from A. baumannii is unusual. The only four deaths at WRAMC from 2003 to 2004 attributable to A. baumannii were in immunosuppressed patients whose ages were 35 years (renal transplantation and nosocomial pneumonia), 72 years (prolonged hospitalization with congestive heart failure), 78 years (diabetes and prior malignancy), and 84 years (in nursing home, mental status changes, and nosocomial pneumonia) (Zapor and Moran 2005). Fifty-three multiple-drug-resistant A. baumannii cases were seen at WRAMC in the 2003-2004 period, 34 in civilians and 19 in active-duty personnel. Zapor and Moran assert that successful reduction of risk to noncombatants and combatants alike who share hospital wards with infected combatants will require more rigorous universal precautions with thorough education of staff, patients, and family members.

Emerging infectious diseases, by definition, may arise from unanticipated sources. A previously unrecognized Acinetobacter-like organism from dog and cat bites was reported in 2002 (Kaiser et al. 2002). It is possible that organisms will emerge from southwest and south-central Asia that are not recognized as threats to soldiers or civilians. Hospital-based microbiologic and epidemiologic surveillance should be conducted on newly recognized organisms, as was done with the reports of drug-resistant A. baumannii in US military hospitals (CDC 2004; Davis et al. 2005).

Other Wound Infections

Nearly any war-theater injury, whether combat-derived or otherwise, may result in infection. The risk of infection is inherent in military service, training, readiness activities, transport, or combat (Zapor and Moran 2005). Men and women deployed to OEF and OIF face the risk of being injured by explosive devices of many types, including improvised explosives,

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