Reflection and Reaction http://infection.thelancet.com Vol 6 June 2006 317 *Jonathan R Iredell, Vitali Sintchenko Centre for Infectious Diseases and Microbiology, Institute of Clinical Pathology and Medical Research, Sydney West Area Health Service, Sydney, Australia joni@icpmr.wsahs.nsw.gov.au 1 Soothill JS, Lock PE. Screening for carbapenem-resistant bacteria. Lancet Infect Dis 2005; 5: 597–98. 2 Boyce JM, Cookson B, Christiansen K, et al. Meticillin-resistant Staphylococcus aureus. Lancet Infect Dis 2005; 5: 653–63. 3 Playford EG, Craig JC, Simpson J, Iredell J. Carbapenem-resistant Acinetobacter baumannii (CR-AB): risk factors for acquisition and infection amongst ICU patients. 43rd Interscience Conference on Antimicrobial Agents and Chemotherapy; Chicago, IL, USA; Sept 14–17, 2003. 4 Naas T, Levy M, Hirschauer C, Marchandin H, Nordmann P. Outbreak of carbapenem-resistant Acinetobacter baumannii producing the carbapenemase OXA-23 in a tertiary care hospital of Papeete, French Polynesia. J Clin Microbiol 2005; 43: 4826–29. 5 Espedido B, Iredell J, Thomas L, Zelynski A. Wide dissemination of a carbapenemase plasmid among gram-negative bacteria: implications of the variable phenotype. J Clin Microbiol 2005; 43: 4918–19. 6 Walsh TR, Toleman MA, Poirel L, Nordmann P. Metallo-β-lactamases: the quiet before the storm? Clin Microbiol Rev 2005; 18: 306–25. 7 Borriello G, Werner E, Roe F, Kim AM, Ehrlich GD, Stewart PS. Oxygen limitation contributes to antibiotic tolerance of Pseudomonas aeruginosa in biofilms. Antimicrob Agents Chemother 2004; 48: 2659–64. 8 Sintchenko V, Iredell JR, Gilbert GL, Coiera E. Handheld computer- based decision support reduces patient length of stay and antibiotic prescribing in critical care. J Am Assoc Med Inform 2005; 12: 398–402. Acinetobacter baumannii is a Gram-negative bacterium that causes nosocomial outbreaks of infections, often with problematic antibiotic resistance. 1 In the UK there are ongoing problems with two multidrug-resistant clones—“SE clone” and OXA-23 clone 1 2–4 —that are widespread, particularly in London and southeast England. OXA-23 clone 1 is resistant to virtually all antibiotics including carbapenems; 4 many representatives of the SE clone are also carbapenem resistant. 3 Since March 2003, casualties from the Iraq conflict have been admitted to UK NHS hospitals. Several of these hospitals have reported clusters of multidrug-resistant A baumannii infections to the Health Protection Agency, and a notice requesting information was published in the Communicable Disease Report in October 2003. 5 Outbreaks have also been reported at receiving hospitals in Germany, 6,7 and reports from the USA describe an increasing number of clinically significant A baumannii infections in military medical facilities in the Iraq/Kuwait region during the conflicts in Iraq and Afghanistan. 8–10 In some cases, the organism has been isolated from wounds within 2 hours of hospital admission. 11 We surveyed the 30 NHS Trusts that had received patients directly from Iraq between March and October 2003. 11 had problems with multidrug- resistant Acinetobacter spp before receiving patients from Iraq and most cases were unrelated to Iraq; the remaining 19 did not have substantial problems with acinetobacter infections. Nevertheless, several problem strains have been isolated from patients who have been transferred from Iraq. One NHS Trust in the Midlands received a patient from Iraq from whom the first known UK representative of an acinetobacter strain now known as “T strain” was isolated. This isolate was sent to the Laboratory for Healthcare Associated Infection (Health Protection Agency Centre for Infections, London) for comparison with other isolates by pulsed-field gel electrophoresis (PFGE) because its antibiogram distinguished it from other acinetobacter in the unit where it was found. Subsequently, the strain was identified in further patients admitted to the Trust from Iraq, and in others with no such link. The suspected index case of a large intensive therapy unit outbreak of multidrug-resistant acinetobacter in a Trust in southeast England had been injured in Iraq. However, the patient had spent 4 weeks in a hospital outside the UK, receiving multiple courses of antibiotics, and was hospitalised in the UK for over 1 week before the organism was isolated, meaning that it was not possible to attribute his infection to importation from Iraq. Moreover, PFGE revealed that this clone (OXA-23 clone 2) had previously been found in three other hospitals in southern England without any apparent connection with Iraq. A further strain (Midlands 2) was isolated from soldiers from two geographically distant hospitals, both of which had received military casualties from Iraq. In summary, the isolates of Acinetobacter spp from casualties returning from Iraq represent a number Importation of multidrug-resistant Acinetobacter spp infections with casualties from Iraq