infection control and hospital epidemiology september 2011, vol. 32, no. 9 original article High Incidence of Multidrug-Resistant Gram-Negative Bacteria Recovered from Afghan Patients at a Deployed US Military Hospital Deena E. Sutter, MD; 1 Linda U. Bradshaw, MD; 1 Lucas H. Simkins, BBA; 2 Amy M. Summers, BS; 3 Michael Atha, MD; 4 Robert L. Elwood, MD; 1 Janelle L. Robertson, MD; 5 Clinton K. Murray, MD; 6 Glenn W. Wortmann, MD; 7 Duane R. Hospenthal, MD, PhD 6 objective. To investigate potential sources and risks associated with multidrug-resistant (MDR) bacteria in a deployed US military hospital. design. Retrospective analysis of factors associated with recovery of MDR bacteria, supplemented by environmental sampling. setting. The largest US military hospital in Afghanistan. patients. US and Afghan patients with positive bacterial culture results, from September 2007 through August 2008. methods. Microbiologic, demographic, and clinical data were analyzed. Potential risk factors included admission diagnosis or mechanism of injury, length of stay, gender, age, and nationality (US or Afghan). Environmental sampling of selected hospital high-touch surfaces and equipment was performed to help elucidate whether environmental MDR bacteria were contributing to nosocomial spread. results. A total of 266 patients had 411 bacterial isolates that were identified during the study period, including 211 MDR bacteria (51%). Gram-negative bacteria were common among Afghan patients (241 [76%] of 319), and 70% of these were classified as MDR. This included 58% of bacteria recovered from Afghan patients within 48 hours of hospital admission. The most common gram-negative bacteria were Escherichia coli (53% were MDR), Acinetobacter (90% were MDR), and Klebsiella (63% were MDR). Almost one-half of potential extended-spectrum b-lactamase (ESBL) producers were community acquired. Of 100 environmental swab samples, 18 yielded MDR bacteria, including 10 that were Acinetobacter, but no potential ESBL-producing bacteria. conclusions. Gram-negative bacteria from Afghan patients had high rates of antimicrobial resistance. Patients experiencing complex trauma and prolonged hospital stays likely contribute to the presence of MDR bacteria in this facility. However, many of these patients had community-acquired cases, which implies high rates of colonization prior to hospital admission. Infect Control Hosp Epidemiol 2011;32(9):854-860 Affiliations: 1. Department of Pediatrics, Wilford Hall Medical Center, Lackland Air Force Base, Texas; 2. 507th Medical Squadron, Tinker Air Force Base, Oklahoma; 3. Department of Pathology and Area Laboratory Support, Department of Medicine, Walter Reed Army Medical Center, Washington, DC; 4. Department of Medicine, Travis Air Force Base, California; 5. Department of Medicine, Elgin Hospital, Elgin Air Force Base, Florida; 6. Infectious Disease Service, San Antonio Military Medical Center, Fort Sam Houston, Texas; 7. Infectious Disease Service, Department of Medicine, Walter Reed Army Medical Center, Washington, DC. Received March 3, 2011; accepted April 15, 2011; electronically published July 27, 2011. This article is in the public domain, and no copyright is claimed. 0899-823X/2011/3209-0004. DOI: 10.1086/661284 Reports from the developing world of infections with mul- tidrug-resistant (MDR) bacteria have increased over the past decade. The recent identification and spread of the New Delhi metallo-beta-lactamase 1 (NDM-1) in infections with Entero- bacteriaceae serves as an alarming example of this trend. 1 Spread of these MDR bacteria to the Western world has been documented in patients who have obtained medical care in India and Pakistan, 1 as well as asymptomatically among lei- sure travelers. 2 Despite the country’s geographic proximity, there is a paucity of epidemiological data on bacterial resis- tance rates from Afghanistan. MDR bacterial infections, including those with MDR Aci- netobacter baumannii, in combat-injured US military per- sonnel returning from Iraq and Afghanistan have been re- ported since early in these conflicts. 3,4 Cross-contamination from local national patients who are cared for in deployed US hospitals has been postulated as a source of these MDR bacteria. 4,5 Pediatric patients comprise up to 10% of admis- sions to deployed US hospitals. 6 Mortality rates in children have been reported to exceed those of adults, and infection is a common cause of death. 6,7 Although Iraq has been the focus of multiple epidemiologic studies, little is known about