stateside medical staff if the troops have not been disbursed; if they have been, the nosocomial origin of the condition might be masked by the “isolated” cases seen by many practitioners.

Other causes of nosocomial infections in OEF- and OIF-deployed troops and civilian military employees include those familiar in civilian settings, such as infections caused by methicillin-resistant Staphylococcus aureus (LaMar et al. 2003) and anaerobes (Brook and Frazier 1993). The origin of those infections (southwest and south-central Asia) is evident from the temporal association with deployment, as was the case in the 1991 Gulf War with Irish troops (Humphreys et al. 1988) and in the present conflicts among US troops (CDC 2004; Davis et al. 2005; Zapor and Moran 2005).

Returning soldiers may serve as a nidus of organisms that can infect others in the same hospital or rehabilitation unit. A number of prevention research projects have evaluated colonization rates, including those among family members of returning soldiers (Fishbain et al. 2003; Kenner et al. 2003). Unrecognized sources of contamination of the hands of hospital workers are also being investigated, for example, computer keyboards in an ICU (Bures et al. 2000). Nosocomial risks that have been recognized in US military facilities also may be of importance in the field setting, depending on the specific circumstances of the field hospital or clinic (Blatt et al. 1993; Conger et al. 2004; Cumberland and Jones 1987; John 1977; Lamarque et al. 1992).

Given the rarity of chronic infections related to wounds, the committee believes that unrecognized wound or nosocomial infections will pose a diagnostic dilemma for returning veterans only in the most unusual circumstances, such as a late-presenting osteomyelitis. A penetrating injury of an extremity (from stepping on a pressure-detonated mine) resulted in chronic osteomyelitis and later squamous-cell carcinoma in a Vietnam veteran in 1987 (Coy 1994). Cultures taken 20 years after the injury (and after 18 years of draining of a sinus tract) grew Bacteroides fragilis, Proteus vulgaris, P. aeruginosa, and Enterococcus faecalis; the patient had been treated with cleocin, erythromycin, and tobramycin (no culture sensitivity results were presented) (Coy 1994). No details were given as to why those complications were manifest and so unsuccessfully managed.

Regional Experiences in Non-Americans

A number of reports of A. baumannii and other wound infections have come from countries neighboring Iraq or Afghanistan. The reports may provide lessons that inform the care of US troops, especially in the evolution of antibiotic resistance in environmentally acquired A. baumannii.

In 2002, A. baumannii infection occurred in 21 patients in a trauma ICU in Qatar; the outbreak was attributed to poor infection-control management and environmental contamination (El Shafie et al. 2004). The organism was sensitive only to amikacin among 17 antibiotics tested, including the carbapenems (El Shafie et al. 2004). In a series of 36 patients infected with 38 strains of A. baumannii in January 2000-August 2001 in a Turkish teaching hospital, only the carbapenems and colistin were fully efficacious against all strains in the laboratory (Ayan et al. 2003). A devastating earthquake in the Marmara region of Turkey in 1999 resulted in the hospitalization of 630 trauma victims at one hospital, of whom 240 were hospitalized for more than 48 hours. Of the 240, 41 patients (17%) had 43 nosocomial infection episodes that resulted in analysis of 143 culture specimens. In the 48 specimens with positive results (34% of specimens), A. baumannii was most common (31%), followed by S. aureus (19%), P. aeruginosa (15%), E. coli (13%), Klebsiella pneumoniae (13%), other Pseudomonas spp. (6%),

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