Skip to main content Accessibility help

Evaluation of Potential Environmental Contamination Sources for the Presence of Multidrug-Resistant Bacteria Linked to Wound Infections in Combat Casualties

  • Edward F. Keen (a1), Katrin Mende (a1) (a2), Heather C. Yun (a1) (a3), Wade K. Aldous (a4), Timothy E. Wallum (a5), Charles H. Guymon (a5), David W. Cole (a6), Helen K. Crouch (a1), Matthew E. Griffith (a1) (a3), Bernadette L. Thompson (a1), Joel T. Rose (a4) and Clinton K. Murray (a1) (a3)...



To determine whether multidrug-resistant (MDR) gram-negative organisms are present in Afghanistan or Iraq soil samples, contaminate standard deployed hospital or modular operating rooms (ORs), or aerosolize during surgical procedures.


Active surveillance.


US military hospitals in the United States, Afghanistan, and Iraq.


Soil samples were collected from sites throughout Afghanistan and Iraq and analyzed for presence of MDR bacteria. Environmental sampling of selected newly established modular and deployed OR high-touch surfaces and equipment was performed to determine the presence of bacterial contamination. Gram-negative bacteria aerosolization during OR surgical procedures was determined by microbiological analysis of settle plate growth.


Subsurface soil sample isolates recovered in Afghanistan and Iraq included various pansusceptible members of Enterobacteriaceae, Vibrio species, Pseudomonas species, Acinetobacter Iwojfii, and coagulase-negative Staphylococcus (CNS). OR contamination studies in Afghanistan revealed 1 surface with a Micrococcus luteus. Newly established US-based modular ORs and the colocated fixed-facility ORs revealed no gram-negative bacterial contamination prior to the opening of the modular OR and 5 weeks later. Bacterial aerosolization during surgery in a deployed fixed hospital revealed a mean gram-negative bacteria colony count of 12.8 colony-forming units (CFU)/dm2/h (standard deviation [SD], 17.0) during surgeries and 6.5 CFU/dm2/h (SD, 7.5; P = .14) when the OR was not in use.


This study demonstrates no significant gram-negative bacilli colonization of modular and fixed-facility ORs or dirt and no significant aerosolization of these bacilli during surgical procedures. These results lend additional support to the role of nosocomial transmission of MDR pathogens or the colonization of the patient themselves prior to injury.


Corresponding author

Infectious Disease Service, San Antonio Military Medical Center, Brooke Army Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234 (


Hide All
1. Boucher, HW, Talbot, GH, Bradley, JS, et al. Bad bugs, no drugs: no ESKAPE! an update from the Infectious Diseases Society of America. Clin Infect Dis 2009;48(1):112.
2. Amundson, D, Dadekian, G, Etienne, M, et al. Practicing internal medicine onboard the USNS Comfort in the aftermath of the Haitian earthquake. Ann Intern Med 2010;152(11):733737.
3. Elston, JW, Bannan, CL, Chih, DT, Boutlis, CS. Acinetobacter spp. in gunshot injuries. Emerg Infect Dis 2008;14(1):178180.
4. Öncül, O, Keskin, Ö, Acar, HV, et al. Hospital-acquired infections following the 1999 Marmara earthquake. J Hosp Infect 2002;51(1):4751.
5. Hussey, SM, Dukette, PJ, Dunn, SH, et al. The 2010 Haiti earthquake: a pathology perspective aboard the USNS Comfort . Arch Pathol Lab Med 2011;135(4):417421.
6. Moellering, RC Jr. NDM-1: a cause for worldwide concern. N Engl J Med 2010;363(25):23772379.
7. Walsh, TR, Weeks, J, Livermore, DM, Toleman, MA. Dissemination of NDM-1 positive bacteria in the New Delhi environment and its implications for human health: an environmental point prevalence study. Lancet Infect Dis 2011;11(5):355362.
8. Tângdén, T, Cars, O, Melhus, A, Löwdin, E. Foreign travel is a major risk factor for colonization with Escherichia coli producing CTX-M-type extended-spectrum beta-lactamases: a prospective study with Swedish volunteers. Antimicrob Agents Chemother 2010;54(9):35643568.
9. Murray, CK. Epidemiology of infections associated with combat-related injuries in Iraq and Afghanistan. J Trauma 2008;64(suppl 3):S232S238.
10. Murray, CK, Hinkle, MK, Yun, HC. History of infections associated with combat-related injuries. J Trauma 2008;64(suppl 3): S221S231.
11. Scott, P, Deye, G, Srinivasan, A, et al. An outbreak of multidrug-resistant Acinetobacter baumannii-calcoaceticus complex infection in the US military health care system associated with military operations in Iraq. Clin Infect Dis 2007;44(12):15771584.
12. Ake, J, Scott, P, Wortmann, G, et al. Gram-negative multidrug-resistant organism colonization in a US military healthcare facility in Iraq. Infect Control Hosp Epidemiol 2011;32(6):545552.
13. Sutter, DE, Bradshaw, LU, Simkins, LH, et al. High incidence of multidrug-resistant gram-negative bacteria recovered from Afghan patients at a deployed US military hospital. Infect Control Hosp Epidemiol 2011;32(9):854860.
14. Griffith, ME, Lazarus, DR, Mann, PB, Boger, JA, Hospenthal, DR, Murray, CK. Acinetobacter skin carriage among US Army soldiers deployed in Iraq. Infect Control Hosp Epidemiol 2007;28(6):720722.
15. Kaspar, RL, Griffith, ME, Mann, PB, et al. Association of bacterial colonization at the time of presentation to a combat support hospital in a combat zone with subsequent 30-day colonization or infection. Mil Med 2009;174(9):899903.
16. Mende, K, Sutter, DE, Beckius, ML, Murray, CK, Hospenthal, DR. Recovery of multidrug-resistant bacteria from swabs stored for 1 and 4 weeks to mimic long-distance shipping conditions. Paper presented at: 49th annual meeting of the Infectious Diseases Society of America, October 20-23, 2011, Boston, MA.
17. The National Healthcare Safety Network (NHSN) Manual. Patient safety component: protocol: multidrug-resistant organism (MDRO) and Clostridium dijficile-associated disease (CDAC) module. Division of Healthcare Quality Promotion, National Center for Preparedness, Detection and Control of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA. 2008.
18. Centers for Disease Control and Prevention (CDC). Acinetobacter baumannii infections among patients at military medical facilities treating injured U.S. service members, 2002-2004. MMWR Morb Mortal Wkly Rep 2004;53(45):10631066.
19. Murray, CK, Horvath, LL. An approach to prevention of infectious diseases during military deployments. Clin Infect Dis 2007;44(3):424430.
20. Griffith, ME, Gonzalez, RS, Holcomb, JB, Hospenthal, DR, Wortmann, GW, Murray, CK. Factors associated with recovery of Acinetobacter baumannii in a combat support hospital. Infect Control Hosp Epidemiol 2008;29(7):664666.
21. Yun, HC, Murray, CK, Roop, SA, Hospenthal, DR, Gourdine, E, Dooley, DP. Bacteria recovered from patients admitted to a deployed U.S. military hospital in Baghdad, Iraq. Mil Med 2006;171(9):821825.
22. Riesenfeld, CS, Goodman, RM, Handelsman, J. Uncultured soil bacteria are a reservoir of new antibiotic resistance genes. Environ Microbiol 2004;6(9):981989.
23. Donato, JJ, Moe, LA, Converse, BJ, et al. Metagenomic analysis of apple orchard soil reveals antibiotic resistance genes encoding predicted bifunctional proteins. Appi Environ Microbiol 2010;76(13):43964401.
24. Vane, EAP, Drost, E, Elder, D, Heib, Y. Behind the scenes: patient safety in the operating room and central materiel service during deployments. In: Henriksen, K, Battles, JB, Marks, ES, Lewin, DI, eds. Advances in Patient Safety: From Research to Implementation. Vol 3. Implementation Issues. Rockville, MD: Agency for Healthcare Research and Quality (US), 2005:469482.
25. Dansby, W, Purdue, G, Hunt, J, et al. Aerosolization of methicillin-resistant Staphylococcus aureus during an epidemic in a burn intensive care unit. J Burn Care Res 2008;29(2):331337.
26. Bernard, HR, Speers, R Jr, O'Grady, FW, Shooter, RA. Airborne bacterial contamination: investigation of human sources. Arch Surg 1965;91(3):530533.
27. Daistrom, DJ, Venkatarayappa, I, Manternach, AL, Palcie, MS, Heyse, BA, Prayson, MJ. Time-dependent contamination of opened sterile operating-room trays. J Bone Joint Surg Am 2008;90(5):10221025.
28. D'Avignon, LC, Chung, KK, Saffle, JR, Renz, EM, Cancio, LC, Prevention of Combat-Related Infections Guidelines Panel. Prevention of infections associated with combat-related burn injuries. J Trauma 2011;71(suppl 2):S282S289.
29. Keen, EF III, Robinson, BJ, Hospenthal, DR, et al. Prevalence of multidrug-resistant organisms recovered at a military burn center. Burns 2010;36(6):819825.
30. Aldous, WK, Co, E-MA. Factors associated with recovery of multidrug-resistant bacteria in a combat support hospital in Iraq. Infect Control Hosp Epidemiol 2010;31(4):425427.
31. Keen, EF III, Murray, CK, Robinson, BJ, Hospenthal, DR, Co, EMA, Aldous, WK. Changes in the incidences of multidrug-resistant and extensively drug-resistant organisms isolated in a military medical center. Infect Control Hosp Epidemiol 2010;31(7):728732.
32. Hospenthal, DR, Green, AD, Crouch, HK, et al. Infection prevention and control in deployed military medical treatment facilities. J Trauma 2011;71(suppl 2):S290S298.
33. Hospenthal, DR, Murray, CK, Andersen, RC, et al. Guidelines for the prevention of infections associated with combat-related injuries: 2011 update: endorsed by the Infectious Diseases Society of America and the Surgical Infection Society. J Trauma 2011;71(suppl 2):S210S234.


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed