Bacterial infection during wars, conflicts and post-natural disasters in Asia and the Middle East: a narrative review

Healthcare workers' perceptions of postoperative care and implementation challenges in conflict-affected northwest Syria: a mixed-methods analysis

Introduction

Protracted violent conflict has severely reduced healthcare provision in northwest Syria (NWS), and this is especially concerning for postoperative care as conflict-related injuries have further compounded this strain. Without sufficient postoperative care, minor complications can evolve into life-threatening events. In this study, we aim to understand healthcare workers' attitudes, practices and perceptions regarding postoperative care in NWS and identify key barriers to postoperative care.

Methods

Individuals with experience in health leadership positions in NWS were identified using purposive and snowball sampling and interviewed using a semistructured interview guide. Interview summaries were analysed using a standardised codebook to identify potential themes. In addition to these interviews, an online survey on hospital practices was sent to hospital administrators and non-governmental organisation leadership who disseminated the survey to all employees engaging in clinical work.

Results

Eighteen key informants were interviewed, and 466 survey responses from doctors (39%), nurses (37%), medical technicians (13%) and administrators (11%) were recorded. Through key informant interviews, we demonstrate several barriers to postoperative care, including health system fragmentation, limited healthcare workforce, insufficient resources due to conflict, disinterest, and lack of clinical documentation and discharge standards. Survey respondents reported poor patient compliance (66%), lack of routine follow-up visits (42%) and non-sterile operating room instruments (42%) as primary reasons for postoperative complications. Identified pathways to improve postoperative care included increased staffing and training, improved operating room sterilisation, and enhanced patient follow-up and discharge processes.

Conclusion

In conclusion, the health system in NWS is extremely overburdened from over a decade of violent conflict, increased demand for health services and insufficient resources. This has made implementing consistent and adequate postoperative care nearly impossible, contributing to unnecessary complications and mortality. Solutions to address postoperative complications in NWS must account for these complex realities and the broader context in which this system exists.

Evaluating a research training programme for frontline health workers in conflict-affected and fragile settings in the middle east

BACKGROUND

Health Research Capacity Building (HRCB) is key to improving research production among health workers in LMICs to inform related policies and reduce health disparities in conflict settings. However, few HRCB programmes are available in the MENA region, and few evaluations of HRCB globally are reported in the literature.

METHODS

Through a qualitative longitudinal design, we evaluated the first implementation of the Center for Research and Education in the Ecology of War (CREEW) fellowship. Semi-structured interviews were conducted with fellows (n = 5) throughout the programme at key phases during their completion of courses and at each research phase. Additional data was collected from supervisors and peers of fellows at their organizations. Data were analysed using qualitative content analysis and presented under pre-identified themes.

RESULTS

Despite the success of most fellows in learning on how to conduct research on AMR in conflict settings and completing the fellowship by producing research outputs, important challenges were identified. Results are categorized under predefined categories of (1) course delivery, (2) proposal development, (3) IRB application, (4) data collection, (5) data analysis, (6) manuscript write-up, (7) long-term effects, and (8) mentorship and networking.

CONCLUSION

The CREEW model, based on this evaluation, shows potential to be replicable and scalable to other contexts and other health-related topics. Detailed discussion and analysis are presented in the manuscript and synthesized recommendations are highlighted for future programmes to consider during the design, implementation, and evaluation of such programmes.

Molecular Epidemiology of Escherichia coli with Resistance against Third-Generation Cephalosporines Isolated from Deployed German Soldiers-A Retrospective Assessment after Deployments to the African Sahel Region and Other Sites between 2007 and 2016

Colonization and infection with bacteria with acquired antibiotic resistance are among the risks for soldiers on international deployments. Enterobacterales with resistance against third-generation cephalosporines are amongst the most frequently imported microorganisms. To contribute to the scarcely available epidemiological knowledge on deployment-associated resistance migration, we assessed the molecular epidemiology of third-generation cephalosporine-resistant Escherichia coli isolated between 2007 and 2016 from German soldiers after deployments, with a particular focus on the African Sahel region. A total of 51 third-generation cephalosporine-resistant E. coli isolated from 51 military returnees from deployment collected during the assessment period between 2007 and 2016 were subjected to short-read next-generation sequencing analysis. Returnees from the Sahel region (Djibouti, Mali, South Sudan, Sudan, Sudan, and Uganda) comprised a proportion of 52.9% (27/51). Repeatedly isolated sequence types according to the Warwick University scheme from returnees from the Sahel region were ST38, ST131, and ST648, confirming previous epidemiological assessments from various sub-Saharan African regions. Locally prevalent resistance genes in isolates from returnees from the Sahel region associated with third-generation resistance were bla_CTX-M-15, bla_CTX-M-27, bla_CTX-M-1, bla_TEM-169, bla_CTX-M-14, bla_CTX-M-99-like, bla_CTX-M-125, bla_SHV-12, and bla_DHA-1, while virulence genes were east1, sat, and tsh in declining order of frequency of occurrence each. In line with phenotypically observed high resistance rates for aminoglycosides and trimethoprim/sulfamethoxazole, multiple associated resistance genes were observed. A similar, slightly more diverse situation was recorded for the other deployment sites. In summary, this assessment provides first next-generation sequencing-based epidemiological data on third-generation cephalosporine-resistant E. coli imported by deployed German soldiers with a particular focus on deployments to the Sahel region, thus serving as a small sentinel. The detected sequence types are well in line with the results from previous epidemiological assessments in sub-Saharan Africa.

Predicting the impact of environmental factors on citrus canker through multiple regression

Climatic conditions play a significant role in the development of citrus canker caused by Xanthomonas citri pv. citri (Xcc). Citrus canker is regarded as one of the major threats being faced by citrus industry in citrus growing countries of the world. Climatic factors exert significant impacts on growth stage, host susceptibility, succulence, vigor, survival, multiplication rate, pathogen dispersion, spore penetration rate, and spore germination. Predicting the impacts of climatic factors on these traits could aid in the development of effective management strategies against the disease. This study predicted the impacts of environmental variables, i.e., temperature, relative humidity, rainfall, and wind speed the development of citrus canker through multiple regression. These environmental variables were correlated with the development of canker on thirty (30) citrus varieties during 2017 to 2020. Significant positive correlations were noted among environment variables and disease development modeled through multiple regression model (Y = +24.02 + 0.5585 X1 + 0.2997 X2 + 0.3534 X3 + 3.590 X4 + 1.639 X5). Goodness of fit of the model was signified by coefficient determination value (97.5%). Results revealed the optimum values of environmental variables, i.e., maximum temperature (37°C), minimum temperature (27°C), relative humidity (55%), rainfall (4.7-7.1 mm) and wind speed (8 Km/h), which were conducive for the development of citrus canker. Current study would help researchers in designing better management strategies against citrus canker disease under changing climatic conditions in the future.

Efficacy of topical honey compared to systemic gentamicin for treatment of infected war wounds in a porcine model: A non-inferiority experimental pilot study

BACKGROUND

In armed conflicts, infected wounds constitute a large portion of the surgical workload. Treatment consists of debridements, change of dressings, and antibiotics. Many surgeons advocate for the use of honey as an adjunct with the rationale that honey has bactericidal and hyperosmotic properties. However, according to a Cochrane review from 2015 there is insufficient data to draw any conclusions regarding the efficacy of honey in treatment of wounds. We, therefore, decided to evaluate if honey is non-inferior to gentamicin in the treatment of infected wounds in a highly translatable porcine wound model.

MATERIAL AND METHODS

50 standardized wounds on two pigs were infected with S. aureus and separately treated with either topically applied Manuka honey or intramuscular gentamicin for eight days. Treatment efficacy was evaluated with quantitative cultures, wound area measurements, histological, immunohistochemical assays, and inflammatory response.

RESULTS

Topically applied Manuka honey did not reduce bacterial count or wound area for the duration of treatment. Intramuscular gentamicin initially reduced bacterial count (geometric mean 5.59*¸0.37 - 4.27*¸0.80 log10 (GSD) CFU/g), but this was not sustained for the duration of the treatment. However, wound area was significantly reduced with intramuscular gentamicin at the end of treatment (mean 112.8 ± 30.0-67.7 ± 13.2 (SD) mm2). ANOVA-analysis demonstrated no variation in bacterial count for the two treatments but significant variation in wound area (p<0.0001). The inflammatory response was more persistent in the pig with wounds treated with topically applied Manuka honey than in the pig treated with intramuscular gentamicin.

CONCLUSION

At the end of treatment S. aureus count was the same with topically applied Manuka honey and intramuscular gentamicin. The wound area was unchanged with topically applied Manuka honey and decreased with intramuscular gentamicin. Topically applied Manuka honey could consequently be non-inferior to intramuscular gentamicin in reducing S. aureus colonization on the wound's surface, but not in reducing wound size. The use of Manuka honey dressings to prevent further progression of a wound infection may therefore be of value in armed conflicts, where definite care is not immediately available.