The challenge of antibiotic resistance in post-war Mosul, Iraq: An analysis of 20 months microbiological samples from a tertiary orthopaedic care centre

Conflict-associated wounds and burns infected with GLASS pathogens in the Eastern Mediterranean Region: A systematic review

BACKGROUND

While the relationship between conflict-associated injuries and antimicrobial resistance is increasingly being elucidated, data concerning civilian casualties is sparse. This systematic review assesses literature focused on Global Antimicrobial Resistance Surveillance System (GLASS) Priority Pathogens causing infections in civilian wounds and burns in conflict-affected countries within the World Health Organisation's Eastern Mediterranean Region Office (EMRO).

METHODS

A systematic literature review was conducted following Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Five databases and grey literature were searched, identifying studies published from January 2010 to June 2024. Search terms included "wounds", "burns," "antimicrobial resistance", and the twelve countries of interest. Included studies reported resistance of GLASS pathogens. Two reviewers used Covidence to assess papers for inclusion. Data were extracted into a spreadsheet for analysis. Where quantitative data were available, medians, interquartile ranges and percentages were calculated by pathogen and country.

RESULTS

621 records were identified; 19 studies met inclusion criteria. Nine of the papers were from Iraq, three from Libya, three from Lebanon, one each from Yemen and Gaza; two reported on conflict affected refugees in Jordan. A total of 1,942 distinct microbiological isolates were reported, representing all four critical and high priority GLASS pathogen categories. Among the isolates, Staphylococcus aureus was the most prevalent (36.3%). Median resistances identified: Methicillin resistant Staphylococcus aureus (n = 680): 55.6% (IQR:49.65-90.3%); carbapenem resistant Pseudomonas aeruginosa (n = 372): 22.14% (7.43-52.22%); carbapenem resistant Acinetobacter baumannii (n = 366): 60.3% (32.1-85%); carbapenem resistant Klebsiella pneumoniae (n = 75): 12.65% (9.73-34.25%); ceftriaxone resistant Escherichia coli (n = 63): 76% (69-84.65%); ceftriaxone resistant Klebsiella pneumoniae (n = 40): 81.45% (76.73-86.18%). Only three studies had a low risk of bias.

DISCUSSION

Findings imply high rates of GLASS priority pathogens among wounded civilians in conflict-affected EMRO countries. However, evidence was heterogeneous, low quality and sparse in certain countries, highlighting the necessity of effective surveillance including standardised data collection. Improving primary data will facilitate the production of large, high-quality studies throughout the EMRO, including under-represented countries.

CONCLUSION

Laboratory diagnostic capacity building and improved surveillance in conflict-affected settings in the Eastern Mediterranean Region are required to assess the burden of GLASS priority pathogens in vulnerable non-combatant populations.

Extensively Antibiotic-Resistant Bacterial Infections in Trauma Cases Managed at the Médecins Sans Frontières Tertiary Orthopaedic Center in Mosul, Iraq: A Case Series

The Médecins Sans Frontières Tertiary Orthopaedic Care center in Mosul, Iraq, provides reconstructive surgery, microbiological analysis, integrated infection prevention and control, and antibiotic stewardship services. Between May 2018 and February 2020, we recorded soft tissue and/or bone infections caused by gram-negative extensively drug-resistant (XDR) bacteria in 4.9% (13/266) of the admitted patients. The XDR bacteria identified among 12 patients in this case series were extended-spectrum β-lactamase-producing Klebsiella pneumoniae (n = 5, 41.7%) with intermediate sensitivity or resistance to imipenem and/or meropenem, Acinetobacter spp (n = 3, 25.0%; 2 Acinetobacter baumannii strains) resistant to imipenem and/or meropenem, Pseudomonas aeruginosa (n = 2, 16.7%) resistant to imipenem and meropenem, and extended-spectrum β-lactamase-producing Proteus mirabilis (n = 2, 16.7%) resistant to meropenem. Most XDR isolates were sensitive only to colistin or polymyxin B, neither of which is available in Iraq. Therefore, the only treatment option was multiple rounds of surgical debridement and wound care. The infection was deemed cured before discharge in 7 patients (58.3%). Meanwhile, 4 patients (33.3%) were discharged with unhealed wounds, and outpatient follow-up was planned. One patient died in the intensive care unit of a referral hospital after developing septicemia postsurgery. XDR bacteria pose substantial health risks in Iraq. Thus, improving antimicrobial stewardship and accessibility to essential antibiotics is critical to address this issue.

The impact of armed conflict on the development and global spread of antibiotic resistance: a systematic review

BACKGROUND

Scant data are available on the link between armed conflicts and the development and spread of antimicrobial resistance.

OBJECTIVES

We performed a systematic review with the aim to summarize the available data on the prevalence and features of antibiotic resistance and the causes of antibiotic resistance development during armed conflicts in the 21st century.

METHODS

Data sources: PubMed and SCOPUS databases were searched from 1 January 2000 to 30 November 2023.

STUDY ELIGIBILITY CRITERIA

Original articles reporting data on armed conflicts and antimicrobial resistance were included in this systematic review. No attempt was made to obtain information from unpublished studies. No language restriction was applied. Methods of data synthesis: Both quantitative and qualitative information were summarized by means of textual descriptions.

PARTICIPANTS

Patients or soldiers deployed in armed conflict zones.

TESTS

culture-dependent antibiotic sensitivity testing or molecular detection of the genetic determinants of antibiotic resistance after a confirmed diagnosis of bacterial infection. Assessment of risk of bias: To evaluate the quality of the included studies, we adapted the tool recommended by the Joanna Briggs Institute.

RESULTS

Thirty-four studies were identified, published between November 2004 and November 2023. The quality of included studies was high and medium in 47% and 53% of the studies, respectively. The included studies reported high infection and colonization rates of multidrug-resistant bacteria. Studies performed during the Eastern Ukraine conflict reported high rates of New Delhi metallo-β-lactamase producers.

DISCUSSION

Our findings confirm that wars lead to a large pool of multidrug-resistant infections that could potentially spread. Infection control in healthcare facilities in conflict zones and proper antimicrobial stewardship are crucial.

Antibiotic susceptibility patterns at the Médecins Sans Frontières (MSF) Acute Trauma Hospital in Aden, Yemen: a retrospective study from January 2018 to June 2021

Background

Antimicrobial resistance (AMR) is an urgent global health concern, especially in countries facing instability or conflicts, with compromised healthcare systems. Médecins Sans Frontières (MSF) established an acute trauma hospital in Aden, Yemen, treating mainly war-wounded civilians, and implemented an antimicrobial stewardship (AMS) programme. This study aimed to describe clinical characteristics and identify antibiotic susceptibility patterns representative of patients treated with antibiotics.

Methods

Retrospective cross-sectional study using routinely collected data from all patients treated with antibiotics in the MSF-Aden Acute Trauma hospital between January 2018 and June 2021. Routine clinical data from patients' files was entered into an AMS electronic database and microbiological data were entered into WHONET. Both databases were imported and merged in REDCap and analysed using RStudio.

Results

Three hundred and sixty-three of 481 (75%) included patients were injured by violence-related trauma. Most were men aged 19-45 years (n = 331; 68.8%). In total, 598 infections were diagnosed and treated. MDR organisms were identified in 362 (60.5%) infections in 311 (65%) patients. Skin and soft-tissue infections (SSTIs) (n = 143; 24%) were the most common, followed by osteomyelitis (n = 125; 21%) and intra-abdominal-infections (IAIs) (n = 116; 19%), and 111 (19%) secondary bloodstream infections were identified. Escherichia coli was the most frequently identified pathogen, causing IAI (n = 87; 28%) and SSTI (n = 43; 16%), while Staphylococcus aureus caused mainly osteomyelitis (n = 84; 19%). Most Gram-negatives were ESBL producers, including E. coli (n = 193; 81.4%), Klebsiella pneumoniae (n = 72; 77.4%) and Enterobacter cloacae (n = 39; 50%) while most S. aureus were methicillin resistant (n = 93; 72.6%).

Conclusions

High rates of MDR were found. This information will facilitate a comprehensive review of the empirical antibiotic treatment guidelines.

A three years antimicrobials consumption in Ethiopia from 2017 to 2019: A cross- sectional study

BACKGROUND

The widespread use and misuse of antimicrobials are the major driving factor for antimicrobial resistance (AMR) that threatens the health of human beings globally. Thus, monitoring antimicrobial consumption at national level is crucial to prevent and contain AMR. Nevertheless, there is no well-established system for recording and reporting of antimicrobial consumption in Ethiopia. Hence, the national antimicrobial consumption survey was conducted to generate evidence for decision-making on the appropriate use of antimicrobials in Ethiopia and tackle AMR.

METHODS

All imported and locally manufactured antimicrobials from 2017 to 2019 were from the Ethiopian Food and Drug Authority and local manufacturers database, respectively. Data were collected and analyzed descriptively in accordance with the World Health Organization (WHO) Anatomical Therapeutic Chemical (ATC) and defined daily doses (DDD) classification and methodology.

RESULTS

The average DDD/1,000 inhabitants for all antimicrobials was 15.36. The DDD/1,000 inhabitants fell down sharply from 37.03 in 2017 to 4.30 in 2018, before slightly rising to 4.75 in 2019. The majority of the consumed antimicrobials were comprised of oral antimicrobials (98.6%), while parenteral antimicrobials made up 1.4%. Tetracyclines (35.81%), fluoroquinolones (20.19%), macrolides (13.92%), antiretrovirals (10.57%), and cephalosporins (9.63%) were the most frequently consumed classes of antimicrobials during the three years period. About 75.83% of the consumed antimicrobials fall under the WHO AWaRe classification and 67.87% of antimicrobial consumption was from the WHO Access class medications, with Watch and Reserve classes accounting for 32.13% and <1%, respectively. Similarly, about 86.90% of the antimicrobials fall under the Ethiopian AWaRe classification, with Access, Watch, and Reserve accounting for 87.73%, 12.26%, and <1%, respectively.

CONCLUSION

Due to the peculiarities of our settings, our findings may have some similarities and differences with similar studies from other countries. Hence, we recommend for all concerned bodies to work collaboratively to improve monitoring of antimicrobial consumption at different levels of the Ethiopian healthcare tier system. Future work is necessary to establish a strong system of reporting of antimicrobial consumption patterns in Ethiopia.