Infection with high proportion of multidrug-resistant bacteria in conflict-related injuries is associated with poor outcomes and excess resource consumption: a cohort study of Syrian patients treated in Jordan

Bullet-related bacterial wound infections among injured personnel at emergency site hospitals in Bahir Dar: prevalence, antimicrobial susceptibility and associated factors

BACKGROUND

Bullet-related bacterial wound infection can be caused by high-velocity bullets and shrapnel injuries. In Ethiopia, significant injuries were reported that may cause severe wound infections, persistent systemic infections and may lead to amputation and mortality. The magnitude, antimicrobial susceptibility profiles, and factors associated with bacterial wound infections among patients with bullet-related injuries are not yet studied particularly at health facilities in Bahir Dar, Northwest Ethiopia. Therefore, this study was aimed to determine the prevalence, bacterial profiles, antimicrobial susceptibility profiles, and factors associated with bacterial infections among patients with bullet-related injuries at referral health facilities in Bahir Dar, Northwest Ethiopia.

METHODS

A Hospital-based cross-sectional study was conducted among patients with bullet-related injuries at three referral health facilities in Bahir Dar from May 25 to July 27, 2022. A total of 384 patients with bullet-related injuries were included in the study. Sociodemographic and clinical data were collected using a structured questionnaire. Wound swabs were collected aseptically and cultured on Blood and MacConkey agar following bacteriological standards. Biochemical tests were performed to differentiate bacteria for positive cultivation and antimicrobial susceptibility profiles of the isolates were done on Muller Hinton agar using the Kirby-Bauer disk diffusion technique according to the 2021 Clinical Laboratory Standard Institute (CLSI) guideline. The data were entered using Epi-Info version 7.3 and analyzed using SPSS version 25. Descriptive data were presented using frequency, percentages, figures, and charts. Logistic regression was carried out to identify factors associated with bacterial wound infections. P-value < 0.05 was considered statistically significant.

RESULTS

The prevalence of bullet-related bacterial wound infection among three referral hospitals in Bahir Dar city was 54.7%. The most commonly isolated Gram-negative organism was Klebsiella spps 49 (23.3%) while among Gram-positive organism, Staphylococcus aureus 58 (27.6%) and coagulase-negative staphylococci (CONS) 18 (8.6%). Contamination, hospitalization and smoking habit were significantly associated with the presence of bullet-related bacterial wound infections. Over 97% multidrug resistant (MDR) bacterial isolates were identified and of theses, E. coli, Proteus species, Citrobactor, and Staphylococcus aureus were highly drug resistant.

CONCLUSION

Increased prevalence of bullet-related bacterial wound infection was noticed in this study. S. aureus followed by Klebsiella species were most commonly isolated bacteria. High frequency of resistance to Ampicillin, Oxacillin, Cefepime, Ceftriaxone, Ceftazidime, Vancomycin, and Norfloxacin was observed. Therefore, proper handling of bullet injuries, prompt investigation of bacterial infections, monitoring of drug sensitivity patterns and antibiotic usage are critical.

Optimization and Validation of an FTIR-based, All-in-one System for Viable MDR Bacteria Detection in Combat-related Wound Infection

INTRODUCTION

The U.S. Military members experiencing combat-related injuries have a higher chance of developing infections by multidrug-resistant (MDR) bacteria at admission to military hospitals. MDR wound infections result in higher amputation rates and greater risks for subsequent or chronic infections that require readmission or extended stay in the hospital. Currently, there is no FDA-clear, deployable early diagnostic system for suitable field use.We are reporting our efforts to improve a previously developed Rapid Label-free Pathogen Identification (RAPID) system to detect viable MDR bacteria in wound infections and perform antibiotic susceptibility testing (AST). Specifically, we added multiplex and automation capability and significantly simplified the sample preparation process. A functional prototype of the improved system was built, and its performance was validated using a variety of lab-prepared spiked samples and real-world samples.

MATERIALS AND METHODS

To access the baseline performance of the improved RAPID system in detecting bacteria presence, we selected 17 isolates, most of them from blood or wound infections, and prepared mono-strain spiked samples at 104 to 106 cfu/mL concentration. These samples were processed and analyzed by the RAPID system. To demonstrate the AST capability of the system, we selected 6 strains against 6 different antibiotics and compared the results from the system with the ones from the gold standard method.To validate the system's performance with real-world samples, we first investigated its performance on 3 swab samples from epicutaneous methicillin-resistant Staphylococcus aureus-exposed mouse model. The AST results from our system were compared with the ones from the gold standard method. All animal experiments were approved by the Johns Hopkins University Animal Care and Use Committee (Protocol No. MO21M378). Then, we obtained swab samples from 7 atopic dermatitis (AD) patients and compared our AST results with the ones from the gold standard method. The human subject protocol was approved by the Johns Hopkins Medicines Institutional Review Boards (Study No. CR00043438/IRB00307926) and by USAMRDC (Proposal Log Number/Study Number 20000251).

RESULTS

High-quality data were obtained from the spiked samples of all 17 strains. A quantitative analysis model built using these data achieved 94% accuracy in predicting the species ID in 8 unknown samples. The AST results on the spiked samples had shown 100% matching with the gold standard method. Our system successfully detects the presence/absence of viable bacteria in all 3 mouse and 7 AD patient swab samples. Our system shows 100% and 85.7% (6 out of 7) accuracy when compared to the oxacillin susceptibility testing results for the mouse and the AD patient swabs, respectively.

CONCLUSIONS

Our system has achieved excellent performance in detecting viable bacteria presence and in performing AST in a multiplex, automated, and easy-to-operate manner, on both lab-prepared and real samples. Our results have shown a path forward to a rapid (sample-to-answer time ≤3 hours), accurate, sensitive, species-specific, and portable system to detect the presence of MDR combat-related wound infections in the field environment. Our future efforts involve ruggedizing the RAPID system and evaluating performance under relevant environmental conditions.

Multidrug Resistance among Patients with Surgical Site Infection in a Tertiary Care Centre

Introduction

Infections at surgical sites are a major problem all over the world. Pathogens linked to postoperative infections are becoming increasingly resistant to antibiotics, which presents a significant therapeutic challenge for surgeons and raises the financial burden placed on patients. The study aimed to find the prevalence of multidrug resistance among patients with surgical site infections in a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted from 3 November 2022 to 2 May 2023 among post-operative patients with surgical site infection after receiving ethical approval from the Institutional Review Committee. Swab samples were sent for antimicrobial susceptibility testing. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Among 147 patients with surgical site infection, the prevalence of multi-drug resistance was 95 (64.63%) (56.90-72.36, 95% Confidence Interval). Among them, 51 (53.68%) patients were in the 21-40 years age group and most of them were male 53 (55.79%).

Conclusions

The prevalence of multidrug-resistant cases was similar to other studies done in similar settings.

Keywords

antimicrobial drug resistance; multidrug resistance; Staphylococcus aureus; surgical site infection.

Antimicrobial analysis of honey against Staphylococcus aureus isolates from wound, ADMET properties of its bioactive compounds and in-silico evaluation against dihydropteroate synthase

BACKGROUND

One of the main challenges of wound healing is infection with multi-drug resistant (MDR) bacteria such as Staphylococcus aureus. The spectrum of antibiotics used to treat them is declining; thus, there is a need for alternatives. Our study was designed to evaluate the antimicrobial properties of honey, its pharmacokinetics (ADMET) properties and in-silico analysis of its bioactive compounds against dihydropteroate synthase of S. aureus using trimethoprim as control.

METHODS

Standard protocols were employed in collection and preparation of samples, generation of canonical strings, and conduction of microbiological analyses. Bioactive compounds' ADMET properties were evaluated using the SWISSADME and the MCULE toxicity checker tools. The MCULE one-click docking tool was used in carrying out the dockings.

RESULTS

The gas chromatography-mass spectrophotometry revealed twenty (20) bioactive compounds and was dominated by sugars (> 60%). We isolated a total of 47 S. aureus isolates from the wound samples. At lower concentrations, resistance to trimethoprim (95.74 to 100.00%) was higher than honey (70.21 to 96.36%). Only seven (7) isolates meet Lipinski's rule of five and ADMET properties. The docking scores of the bioactive compounds ranged from -3.3 to -4.6 while that of trimethoprim was -6.1, indicating better binding or interaction with the dihydropteroate synthase. The bioactive compounds were not substrates to P450 cytochrome enzymes (CYP1A2, CYP2CI9 and CYP2D6) and p-glycoprotein, indicating better gastrointestinal tract (GIT) absorption.

CONCLUSION

The favourable docking properties shown by the bioactive compounds suggest they could be lead compounds for newer antimetabolites for management of MDR S. aureus.

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

BACKGROUND

Iraq has suffered unrest and conflicts in the past decades leaving behind a weakened healthcare system. In 2018, Médecins Sans Frontières (MSF) opened a tertiary orthopaedic care centre in Mosul providing reconstructive surgery with access to microbiological analysis.

METHODS

A retrospective cross-sectional analysis of microbiological and clinical data of patients admitted between April 2018 - December 2019.

RESULTS

There were 174 patients who were included in this study; there were more males than females (135 to 38 respectively), and the mean age was 32.6 years. Of the 174 patients, the majority had more than one bacterial isolate detected (n= 122, 70.1%); 141 (81.0%) had at least one multi-drug resistant (MDR) isolate detected during their hospital stay. Staphylococcus aureus (n=197, 48.2%) was the most common organism isolated. Overall, most isolates detected were MDR (n=352, 86%), mostly MRSA (n=186, 52.8%) or ESBL-producing Enterobacterales (n=117, 33.2%). Among patients admitted to the Operating Department (n=111, 63.7%), 81.1% (n=90) were admitted for violent trauma injuries. Patients who had more than one procedure performed per surgery had significantly increased odds of having at least one MDR organism isolated (OR 8.66, CI 1.10-68.20, p=0.03).

CONCLUSION

This study describes a high prevalence of antibiotic resistance in patients with trauma-related wounds in Mosul, Iraq. It highlights the importance of microbiological analysis and ongoing surveillance to provide optimal treatment. Additionally, it underscores the importance of infection prevention and control measures and antibiotic stewardship.

Rapid, label-free pathogen identification system for multidrug-resistant bacterial wound infection detection on military members in the battlefield

US military service members experiencing combat-related wounds have higher risk of infection by multidrug-resistant bacteria. The gold standard culture-based antimicrobial susceptibility testing (AST) is not feasible in the battlefield environment. Thus, a rapid deployable system for bacteria identification and AST directly from wound sample is urgently needed. We report the potential of a Rapid, Label-free Pathogen Identification (RAPID) diagnostic system based on ATR-FTIR method to detect and distinguish multi-drug resistant strains for six different species in the ESKAPEE group. Our RAPID system combines sample processing on-broad to isolate and enrich bacteria cells from wound sample, ATR-FTIR measurement to detect antimicrobial-induced bacterial cell spectral changes, and machine learning model for automated, objective, and quantitative spectral analysis and unknown sample classification. Based on experimental results, our RAPID system is a promising technology for label-free, sensitive (104 cfu/mL from mixture), species-specific (> 95% accuracy), rapid (< 10 min for identification, ~ 4 hours for AST) bacteria detection directly from wound samples.

Antibiotic resistance among bacteria isolated from war-wounded patients at the Weapon Traumatology Training Center of the International Committee of the Red Cross from 2016 to 2019: a secondary analysis of WHONET surveillance data

Background

A substantial body of evidence has recently emphasized the risks associated with antibiotic resistance (ABR) in conflicts in the Middle East. War-related, and more specifically weapon-related wounds can be an important breeding ground for multidrug resistant (MDR) organisms. However, the majority of available evidence comes from the military literature focused on risks and patterns of ABR in infections from combat-related injuries among military personnel. The overall aim of this study is to contribute to the scarce existing evidence on the burden of ABR among patients, including civilians with war-related wounds in the Middle East, in order to help inform the revision of empirical antibiotic prophylaxis and treatment protocols adopted in these settings. The primary objectives of this study are to: 1) describe the microbiology and the corresponding resistance profiles of the clinically relevant bacteria most commonly isolated from skin, soft tissue and bone biopsies in patients admitted to the WTTC; and 2) describe the association of the identified bacteria and corresponding resistance profiles with sociodemographic and specimen characteristics.

Methods

We retrospectively evaluated the antibiograms of all consecutive, non-duplicate isolates from samples taken from patients admitted to the ICRC WTTC between 2016 and 2019, limited to skin and soft tissue samples and bone biopsies. We collected data on socio-demographic characteristics from patient files and data on specimens from the WHONET database. We ran univariate and multivariable logistic regression models to test the association between bacterial and resistance profiles with sociodemographic and specimen characteristics.

Results

Patients who were admitted with war-related trauma to the ICRC reconstructive surgical project in Tripoli, Lebanon, from 2016 to 2019, presented with high proportion of MDR in the samples taken from skin and soft tissues and bones, particularly Enterobacterales (44.6%), MRSA (44.6%) and P. aeruginosa (7.6%). The multivariable analysis shows that the odds of MDR isolates were higher in Iraqi patients (compared to Syrian patients) and in Enterobacterales isolates (compared to S. aureus isolates).

Conclusions

Our findings stress the importance of regularly screening patients who present with complex war-related injuries for colonization with MDR bacteria, and of ensuring an antibiotic-sensitivity testing-guided antimicrobial therapeutic approach.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07253-1.

Application of berberine-loaded albumin nanoparticles in infections of traumatic wounds

In recent years, the morbidity of infections in traumatic wounds has been on the increase. There are not many kinds of drugs for clinical treatment of infections, and their efficacy and safety are limited. Plant antimicrobial drugs are increasingly popular in mainstream medicine due to the challenges of traditional antibiotics abuse. Berberine has a scavenging effect on infections, however, berberine was restricted from using as a drug preparation with poor stability and bioavailability. Due to the low toxicity of nanoparticles, the green-synthetic, size-controlled approach of nanoparticles has been paid more attention. Therefore, based on the intermolecular disulfide bond network platform built earlier, we designed and developed a strategy to assemble molecular bovine serum albumin into large-sized nanostructures through the reconstructed intermolecular disulfide bond and hydrophobic interaction, and berberine with poor water solubility was encapsulated in it. Nanoassembly with bovine serum albumin increased biostability of berberine and significantly improved its activity against Staphylococcus Aureus (S.aureus) activity, which gives some new insights into the preparation and development of anti-infectives for Chinese medicine.

Cost analysis of negative-pressure wound therapy versus standard treatment of acute conflict-related extremity wounds within a randomized controlled trial

Background

Clinical outcomes after negative-pressure wound therapy (NPWT) and standard treatment of conflict-related extremity wounds are similar. In resource-limited settings, cost affects the choice of treatment. We aimed to estimate treatment-related costs of NPWT in comparison with standard treatment for conflict-related extremity wounds.

Methods

We derived outcome data from a randomized, controlled superiority trial that enrolled adult (≥ 18 years) patients with acute (≤ 72 h) conflict-related extremity wounds at two civilian hospitals in Jordan and Iraq. Primary endpoint was mean treatment-related healthcare costs (adjusted to 2019 US dollars).

Results

Patients were enrolled from June 9, 2015, to October 24, 2018. A total of 165 patients (155 men [93.9%]; 10 women [6.1%]; and median [IQR] age, 28 [21–34] years) were included in the analysis. The cost per patient treated with NPWT was $142 above that of standard treatment. Overall, results were robust in a sensitivity analysis.

Conclusions

With similar clinical outcomes compared to standard care, our results do not support the use of NPWT in routine treatment of conflict-related extremity wounds at civilian hospitals in resource scarce settings.

Trial registration NCT02444598.

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.

Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: a qualitative study

Background

Healthcare associated infections (HAIs) are the most frequent adverse outcome in healthcare delivery worldwide. In conflict-affected settings HAIs, in particular surgical site infections, are prevalent. Effective infection prevention and control (IPC) is crucial to ending avoidable HAIs and an integral part of safe, effective, high quality health service delivery. However, armed conflict and widespread violence can negatively affect the quality of health care through workforce shortages, supply chain disruptions and attacks on health facilities and staff. To improve IPC in these settings it is necessary to understand the specific barriers and facilitators experienced locally.

Methods

In January and February of 2020, we conducted semi-structured interviews with hospital staff working for the International Committee of the Red Cross across eight conflict-affected countries (Central African Republic, South Sudan, Democratic Republic of the Congo, Mali, Nigeria, Lebanon, Yemen and Afghanistan). We explored barriers and facilitators to IPC, as well as the direct impact of conflict on the hospital and its’ IPC programme. Data was analysed thematically.

Results

We found that inadequate hospital infrastructure, resource and workforce shortages, education of staff, inadequate in-service IPC training and supervision and large visitor numbers are barriers to IPC in hospitals in this study, similar to barriers seen in other resource-limited settings. High patient numbers, supply chain disruptions, high infection rates and attacks on healthcare infrastructures, all as a direct result of conflict, exacerbated existing challenges and imposed an additional burden on hospitals and their IPC programmes. We also found examples of local strategies for improving IPC in the face of limited resources, including departmental IPC champions and illustrated guidelines for in-service training.

Conclusions

Hospitals included in this study demonstrated how they overcame certain challenges in the face of limited resources and funding. These strategies present opportunities for learning and knowledge exchange across contexts, particularly in the face of the current global coronavirus pandemic. The findings are increasingly relevant today as they provide evidence of the fragility of IPC programmes in these settings. More research is required on tailoring IPC programmes so that they can be feasible and sustainable in unstable settings.

Observational Study of Hand Hygiene Compliance at a Trauma Hospital in Iraqi Kurdistan

Healthcare-associated infections, commonly caused by poor hand hygiene, represent a significant source of disease and economic burden for healthcare systems, especially those in resource-limited settings. The few existing studies on hand hygiene compliance in resource-limited hospital settings suggest that compliance is insufficient. The difference in compliance rates between units in resource-limited trauma hospitals is largely unknown. We aimed to assess hand hygiene compliance rates among healthcare workers at a trauma hospital in Iraqi Kurdistan and compare the levels of compliance between the emergency room (ER), the intensive care unit (ICU), and the acute care ward (ACW). We carried out overt observations in 2018 using the validated World Health Organization ‘five moments for hand hygiene’ observational tool. We observed a total of 622 hand hygiene opportunities performed by 149 healthcare workers. Hand hygiene compliance was defined as handwashing with soap and water or the use of alcohol-based hand rub, in accordance with the ‘five moments for hand hygiene’ concept. Overall, the hand hygiene compliance rate was found to be 6.8% (95% confidence interval 5.0–9.1). Compliance was significantly lower in the ER (1.0%), compared with the ICU (8.1%) (p = 0.0012), and the ACW (11.1%) (p < 0.0001). In all three units, the availability of alcohol-based hand rub and handwashing sinks was insufficient in relation to the number of patient beds. We conclude that the overall level of hand hygiene compliance was low, with the lowest level of compliance in the ER. Our findings call for improved resource allocation and strengthened hand hygiene routines. These relatively simple measures could potentially lower the incidence of healthcare-associated infections and improve the mortality and morbidity of patients in already overburdened healthcare systems.

Emerging Status of Multidrug-Resistant Bacteria and Fungi in the Arabian Peninsula

Simple Summary

The incidence and developing status of multidrug-resistant bacteria and fungi, as well as their related mortality, is reviewed by a systematic published literature search from nine countries in the Arabian Peninsula. In order to analyse the emerging status and mortality, a total of 382 research articles were selected from a comprehensive screening of 1705 papers. More than 850 deaths reported since 2010 in the Arabian Peninsula due to the infection of multidrug-resistant bacteria and fungi. Multidrug-resistant bacteria Acinetobacter baumannii, Mycobacterium tuberculosis, Staphylococcus aureus, and fungi Candida auris are the most prevalent and causing high deaths. To control these infections and associated deaths in the Arabian Peninsula, continuous preventive measures, accurate methods for early diagnosis of infection, active surveillance, constant monitoring, developing vaccines, eradicating multidrug resistance modulators, and data sharing among countries are required.

Abstract

We aimed to identify the prevalence and emerging status of multidrug-resistant bacteria and fungi and their associated mortality in nine countries in the Arabian Peninsula. Original research articles and case studies regarding multidrug-resistant bacteria and fungi in the Arabian Peninsula, published during the last 10 years, were retrieved from PubMed and Scopus. A total of 382 studies were included as per the inclusion and exclusion criteria, as well as the PRISMA guidelines, from a thorough screening of 1705 articles, in order to analyse the emerging status and mortality. The emerging nature of >120 multidrug-resistant (MDR) bacteria and fungi in the Arabian Peninsula is a serious concern that requires continuous monitoring and immediate preventive measures. More than 50% (n = 453) of multidrug-resistant, microbe-associated mortality (n = 871) in the Arabian Peninsula was due to MDR Acinetobacter baumannii, Mycobacterium tuberculosis and Staphylococcus aureus infection. Overall, a 16.51% mortality was reported among MDR-infected patients in the Arabian Peninsula from the 382 articles of this registered systematic review. MDR A. baumannii (5600 isolates) prevailed in all the nine countries of the Arabian Peninsula and was one of the fastest emerging MDR bacteria with the highest mortality (n = 210). A total of 13,087 Mycobacterium tuberculosis isolates were reported in the region. Candida auris (580 strains) is the most prevalent among the MDR fungal pathogen in the Arabian Peninsula, having caused 54 mortalities. Active surveillance, constant monitoring, the development of a candidate vaccine, an early diagnosis of MDR infection, the elimination of multidrug resistance modulators and uninterrupted preventive measures with enhanced data sharing are mandatory to control MDR infection and associated diseases of the Arabian Peninsula. Accurate and rapid detection methods are needed to differentiate MDR strain from other strains of the species. This review summarises the logical relation, prevalence, emerging status and associated mortality of MDR microbes in the Arabian Peninsula.

Resistance patterns and clinical outcomes of Klebsiella pneumoniae and invasive Klebsiella variicola in trauma patients

Recent reclassification of the Klebsiella genus to include Klebsiella variicola, and its association with bacteremia and mortality, has raised concerns. We examined Klebsiella spp. infections among battlefield trauma patients, including occurrence of invasive K. variicola disease. Klebsiella isolates collected from 51 wounded military personnel (2009-2014) through the Trauma Infectious Disease Outcomes Study were examined using polymerase chain reaction (PCR) and pulsed-field gel electrophoresis. K. variicola isolates were evaluated for hypermucoviscosity phenotype by the string test. Patients were severely injured, largely from blast injuries, and all received antibiotics prior to Klebsiella isolation. Multidrug-resistant Klebsiella isolates were identified in 23 (45%) patients; however, there were no significant differences when patients with and without multidrug-resistant Klebsiella were compared. A total of 237 isolates initially identified as K. pneumoniae were analyzed, with 141 clinical isolates associated with infections (remaining were colonizing isolates collected through surveillance groin swabs). Using PCR sequencing, 221 (93%) isolates were confirmed as K. pneumoniae, 10 (4%) were K. variicola, and 6 (3%) were K. quasipneumoniae. Five K. variicola isolates were associated with infections. Compared to K. pneumoniae, infecting K. variicola isolates were more likely to be from blood (4/5 versus 24/134, p = 0.04), and less likely to be multidrug-resistant (0/5 versus 99/134, p<0.01). No K. variicola isolates demonstrated the hypermucoviscosity phenotype. Although K. variicola isolates were frequently isolated from bloodstream infections, they were less likely to be multidrug-resistant. Further work is needed to facilitate diagnosis of K. variicola and clarify its clinical significance in larger prospective studies.

Diabetic foot infections: Profile and antibiotic susceptibility patterns of bacterial isolates in a tertiary care hospital of Oman

BACKGROUND

In diabetic foot infections (DFIs), the diversity of microbial profile and ever-changing antibiotic-resistance patterns emphasize accurate characterization of microbial profile and antibiotic susceptibility pattern. The aim of the study was to investigate the pathogens associated with DFI and their antibiotic susceptibility patterns.

MATERIALS AND METHODS

A cross-sectional retrospective study was conducted at a tertiary-care hospital, Oman. The socio-demographic and microbiological profile and antibiotic susceptibility patterns of pathogens isolated from patients with DFIs from January 2013 to December 2018 were reviewed. Quantitative and qualitative variables were expressed as mean ± standard deviation and percentages, respectively. A Chi-square test was used for testing the association between multidrug-resistant (MDR) organisms and variables.

RESULTS

In total, 233 isolates recovered from 133 clinical specimens with an average of 1.8 organisms per specimen were included in the study. Fifty-six and forty-four percent of specimens showed monomicrobial and polymicrobial growth of two or more organisms, respectively. The frequency of isolation was predominant among males (65%). Aerobic Gram-negative rods were predominantly (75%) isolated compared to Gram-positive organisms (25%). Staphylococcus aureus and Pseudomonas aeruginosa were the most frequently isolated Gram-positive and Gram-negative bacteria, respectively. Thirty-eight percent of them were MDR strains. Gram-negative organisms showed fairly good susceptibility ranging from 75% to 100% to carbapenems, aminoglycosides, and piperacillin-tazobactam. While doxycycline and trimethoprim-sulfamethoxazole showed good susceptibility toward Gram-positive organisms.

CONCLUSION

DFIs are often polymicrobial with a predominance of Gram-negative pathogens. This study recommends the use of carbapenems and doxycycline for empirical therapy of Gram-negative and Gram-positive bacterial DFIs, respectively.

Antimicrobial resistance in the protracted Syrian conflict: halting a war in the war

The Syrian conflict has damaged key infrastructure and indirectly affected almost all parts of the Middle East and Europe, with no end in sight. Exhausting conditions created by the Syrian crisis and related massive displacement promote the emergence of numerous public health problems that fuel antimicrobial resistance (AMR) development. Here, we explore the current situation of the Syrian displaced population, and AMR inside Syria and among refugees in host countries. We then suggest a roadmap of selected key interventions and strategies to address the threat of AMR in the context of the Syrian crisis. These recommendations are intended to urge health policy-makers in governments and international health organizations to optimize and push for implementing an effective policy taking into consideration the current obstacles.

Prevalence of multidrug-resistant bacteria in Ethiopia: a systematic review and meta-analysis

OBJECTIVES

Multidrug-resistant (MDR) bacteria are a significant public-health threat worldwide, especially in low- and middle-income countries. Comprehensive data are important to understand the magnitude of multidrug resistance (MDR), however these are not available in Ethiopia.

METHODS

Five electronic databases and grey literature of Addis Ababa University Repository were searched for data regarding the prevalence of MDR bacteria in Ethiopia. OpenMetaAnalyst R1.3 was used for analysis using a random-effects model to determine the effect size. Heterogeneity among articles was checked using the inconsistency index (I²). Funnel plot was used to check for publication bias. The quality of each article was checked using the Newcastle-Ottawa checklist adapted for cross-sectional studies.

RESULTS

Through database searching, 2094 articles were identified, of which 37 fulfilled the study inclusion criteria. This review comprises 6856 bacteria, of which 4949 isolates were MDR. The overall pooled prevalence of MDR was 70.5% (95% CI 64.9-76.1%), with considerable heterogeneity (I² = 97.48%, P < 0.001). Funnel plot revealed no publication bias. Sidama (81.7%) had the highest MDR and Tigray (51.1%) the lowest. The greatest source of MDR was from multiple sites of infection (MSI) (76.8%); the least was from bloodstream infections (62.9%). MDR was higher in studies conducted on hospital-acquired infections (72.1%) compared with both hospital- and community-acquired infections (69.8%).

CONCLUSION

Our study indicates a high prevalence of MDR in Ethiopia. Sidama region, MSI and hospital-acquired infections showed the highest MDR in subgroup analysis. Regional hospitals should implement infection prevention and proper use of antibiotics in the community.

The socioeconomic burden of antibiotic resistance in conflict-affected settings and refugee hosting countries: a systematic scoping review

Background

Antibiotic resistance (ABR) is a major global threat. Armed and protracted conflicts act as multipliers of infection and ABR, thus leading to increased healthcare and societal costs. We aimed to understand and describe the socioeconomic burden of ABR in conflict-affected settings and refugee hosting countries by conducting a systematic scoping review.

Methods

A systematic search of PubMed, Medline (Ovid), Embase, Web of Science, SCOPUS and Open Grey databases was conducted to identify all relevant human studies published between January 1990 and August 2019. An updated search was also conducted in April 2020 using Medline/Ovid. Independent screenings of titles/abstracts followed by full texts were performed using pre-defined criteria. The Newcastle-Ottawa Scale was used to assess study quality. Data extraction and analysis were based on the PICOS framework and following the PRISMA-ScR guideline.

Results

The search yielded 8 studies (7 publications), most of which were single-country, mono-center and retrospective studies. The studies were conducted in Lebanon (n = 3), Iraq (n = 2), Jordan (n = 1), Palestine (n = 1) and Yemen (n = 1). Most of the studies did not have a primary aim to assess the socioeconomic impact of ABR and were small studies with limited statistical power that could not demonstrate significant associations. The included studies lacked sufficient information for the accurate evaluation of the cost incurred by antibiotic resistant infections in conflict-affected countries.

Conclusion

This review highlights the scarcity of research on the socioeconomic burden of ABR on general populations in conflict-affected settings and on refugees and migrants in host countries, and lists recommendations for consideration in future studies. Further studies are needed to understand the cost of ABR in these settings to develop and implement adaptable policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-021-00357-6.

A pH-sensitive oxidized-dextran based double drug-loaded hydrogel with high antibacterial properties

Delayed healing or non-healing of wounds caused by bacterial infection is still a difficult medical problem. Nowadays, the topical application of antibiotics is a common treatment for infections. However, subinhibitory concentrations or high dose of antibiotics leads to the antibacterial effect counterproductive. So it's necessary to put forward an on-demand drug delivery to solve this tough issue. In this paper, a pH-responsive hydrogel was prepared by oxidized dextran (Dex-CHO), sulfadiazine (SD) and tobramycin (TOB). The hydrogel was designed by the environment in the early immature stage of biofilm (pH 5.0). Schiff bases can release drugs in slightly acidic environment. The hydrogel showed injectable, pH-sensitive drug release, and great biocompatibility. Released SD and TOB exhibited a synergistic effect therefore the hydrogel showed high antibacterial activity. This study provides an easy and promising strategy to develop smart hydrogels that aim at topical administration of antibiotics and come up with a new treatment of local bacterial infections.

Antimicrobial resistance among GLASS pathogens in conflict and non-conflict affected settings in the Middle East: a systematic review

BACKGROUND

In spite of the evident general negative effects of armed conflict on countries' health systems and populations' health outcomes, little is known about similar impacts of conflicts on the spread of antimicrobial resistances (AMR). This review was to address this evidence gap and describe: 1. Patterns of AMR in the Middle East (ME) and resistance profiles of pathogens included in the Global AMR Surveillance System (GLASS) supported by the World Health Organization; 2. Differences in proportions of AMR isolates between conflict and non-conflict countries.

METHODS

A systematic literature review was conducted following PRISMA guidelines and searching five electronic databases. Subject heading and free text were searched for "antimicrobial resistances" and "Middle East", to identify observational studies on AMR published from January 2011 to June 2018. Data were extracted from included articles on a predefined set of variables. Percentages of AMR were analysed as median and interquartile ranges. Risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

A total of 132 articles met the inclusion criteria. Included studies showed heterogeneity in study design, laboratory methods and standards for interpretation of results, and an overall high risk of bias. Main findings were the following: 1. High proportions of carbapenem resistance in Acinetobacter spp. (median 74.2%), and both carbapenem resistance (median 8.1 and 15.4% for E. coli and K. pneumoniae respectively) and ESBL-production (median 32.3 and 27.9% for E. coli and K. pneumoniae respectively) amongst Enterobacteriaceae. S. aureus isolates showed a median methicillin resistance percentage of 45.1%, while vancomycin resistance was almost absent. A median of 50% of the strains of S. pneumoniae showed non-susceptibility to penicillin. 2. Similar trends were observed in conflict and non-conflict affected countries.

CONCLUSIONS

There is a lack of standardization in the methodological approach to AMR research in the Middle East. The proportion of antibiotic resistances among specific GLASS pathogens is high, particularly among Acinetobacter spp.

Negative pressure wound therapy versus standard treatment in patients with acute conflict-related extremity wounds: a pragmatic, multisite, randomised controlled trial

BACKGROUND

In armed conflict, injuries among civilians are usually complex and commonly affect the extremities. Negative pressure wound therapy (NPWT) is an alternative to standard treatment of acute conflict-related extremity wounds. We aimed to compare the safety and effectiveness of NPWT with that of standard treatment.

METHODS

In this pragmatic, randomised, controlled superiority trial done at two civilian hospitals in Jordan and Iraq, we recruited patients aged 18 years or older, presenting with a conflict-related extremity wound within 72 h after injury. Participants were assigned (1:1) to receive either NPWT or standard treatment. We used a predefined, computer-generated randomisation list with three block sizes. Participants and their treating physicians were not masked to treatment allocation. The primary endpoint was wound closure by day 5. The coprimary endpoint was net clinical benefit, defined as a composite of wound closure by day 5 and freedom from any bleeding, wound infection, sepsis, or amputation of the index limb. Analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT02444598, and is closed to accrual.

FINDINGS

Between June 9, 2015, and Oct 24, 2018, 174 patients were randomly assigned to either the NPWT group (n=88) or the standard treatment group (n=86). Five patients in the NPWT group and four in the standard treatment group were excluded from the intention-to-treat analysis. By day 5, 41 (49%) of 83 participants in the NPWT group and 49 (60%) of 82 participants in the standard treatment group had closed wounds, with an absolute difference of 10 percentage points (95% CI -5 to 25, p=0·212; risk ratio [RR] 0·83, 95% CI 0·62 to 1·09). Net clinical benefit was seen in 33 (41%) of 81 participants in the NPWT group and 34 (44%) of 78 participants in the standard treatment group, with an absolute difference of 3 percentage points (95% CI -12 to 18, p=0·750; RR 0·93, 95% CI 0·65 to 1·35). There was one in-hospital death in the standard treatment group and none in the NPWT group. The proportion of participants with sepsis, bleeding leading to blood transfusion, and limb amputation did not differ between groups.

INTERPRETATION

NPWT did not yield superior clinical outcomes compared with standard treatment for acute conflict-related extremity wounds. The results of this study not only question the use of NPWT, but also question the tendency for new and costly treatments to be introduced into resource-limited conflict settings without supporting evidence for their effectiveness. This study shows that high-quality, randomised trials in challenging settings are possible, and our findings support the call for further research that will generate context-specific evidence.

FUNDING

The Stockholm County Council, the Swedish National Board of Health and Welfare, and Médecins Sans Frontières.

Syrian Civil War: a systematic review of trauma casualty epidemiology

BACKGROUND

The Syrian Civil War has caused over 400 000 traumatic deaths. Understanding the nature of war casualties is crucial to deliver healthcare improvement. Historic regional conflicts and Syrian mortality data have been characterised by blast injuries. The aim of this novel review is to assess the trauma epidemiology of Syrian Civil War casualties from the perspective of healthcare facilities.

METHODS

This review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method. Studies addressing Syria, trauma and war were investigated. Eligibility criteria included being conducted from a healthcare facility, published in English and peer reviewed. The outcomes were demography, mechanism of injury and anatomical injury site.

RESULTS

38 papers satisfied the eligibility criteria. 13 842 casualties were reported across the entire data set. Casualties were 88.8% male (n=4035 of 4544). Children contributed to 16.1% of cases (n=398 of 2469). Mortality rate was 8.6% (n=412 of 4774). Gunshot wound was the most common mechanism of injury representing 66.3% (n=7825 of 11799). Head injury was the most common injured site at 26.6% (n=719 of 2701).

CONCLUSIONS

This conflict has a distinct trauma profile compared with regional modern wars. The prevalence of gunshot wounds represents a marked change in mechanism of injury. This may be related to higher mortality rate and proportion of head injuries identified. This review cannot correlate mechanism of injury, demographics or injuries sustained to outcomes. The quality of data from the included studies lacked standardisation; future research and consistent reporting tools are required to enable further analysis.

Epidemiology of Trauma Patients from the Mosul Offensive, 2016-2017: Results from a Dedicated Trauma Center in Erbil, Iraqi Kurdistan

INTRODUCTION

Most epidemiological studies from conflicts are restricted to either combatants or civilians. It is largely unknown how the epidemiology differs between the two groups. In 2016, an Iraqi-led coalition began retaking Mosul from the terrorist group Islamic State of Iraq and Syria. One key institution that received trauma patients from Mosul was Emergency Management Center (EMC) in Erbil, 90 km away. The aim of this study was to describe the epidemiology, morbidity, and mortality of civilians and combatants admitted during the ongoing conflict.

METHOD

This retrospective cohort study utilized routinely collected data on patients with conflict-related injuries who were admitted to EMC between October 16, 2016, and July 10, 2017. Data processing and analysis was carried out using JMP 13. Categorical variables were compared using Fisher's exact test.

RESULTS

The analysis included 1725 patients, out of which 46% were civilian. Ordnance accounted for most injuries (68%), followed by firearms (18%) and improvised explosive devices (IEDs) (14%). The proportion of IED-related injuries among combatants were almost three times that of civilians. The proportions of abdominal injuries, need for surgery, laparotomies, and amputations were significantly higher among civilians than among combatants. The mortality rate was 0.5%.

DISCUSSION

The fact that civilians had greater surgical needs than combatants may be explained by several factors including a lack of ballistic protection. The extremely low mortality rate indicates significant gaps in prehospital care and transport. Our results may provide useful information to guide medical preparedness and response during future conflicts. CLINICALTRIALS.

GOV ID

NCT03358758.

Perceptions of Healthcare-Associated Infection and Antibiotic Resistance among Physicians Treating Syrian Patients with War-Related Injuries

Healthcare-associated infections (HAIs) constitute a major contributor to morbidity and mortality worldwide, with a greater burden on low- and middle-income countries. War-related injuries generally lead to large tissue defects, with a high risk of infection. The aim of this study was to explore how physicians in a middle-income country in an emergency setting perceive HAI and antibiotic resistance (ABR). Ten physicians at a Jordanian hospital supported by Médecins Sans Frontières were interviewed face-to-face. The recorded interviews were transcribed verbatim and analyzed by qualitative content analysis with an inductive and deductive approach. The participants acknowledged risk factors of HAI and ABR development, such as patient behavior, high numbers of injured patients, limited space, and non-compliance with hygiene protocols, but did not express a sense of urgency or any course of action. Overuse and misuse of antibiotics were reported as main contributors to ABR development, but participants expressed no direct interrelationship between ABR and HAI. We conclude that due to high patient load and limited resources, physicians do not see HAI as a problem they can prioritize. The knowledge gained by this study could provide insights for the allocation of resources and development of hygiene and wound treatment protocols in resource-limited settings.

Negative-Pressure Wound Therapy Versus Standard Treatment of Adult Patients With Conflict-Related Extremity Wounds: Protocol for a Randomized Controlled Trial

Background

In armed conflict, injuries commonly affect the extremities and contamination with foreign material often increases the risk of infection. The use of negative-pressure wound therapy has been described in the treatment of acute conflict-related wounds, but reports are retrospective and with limited follow-up.

Objective

The objective of this study is to investigate the effectiveness and safety of negative-pressure wound therapy use in the treatment of patients with conflict-related extremity wounds.

Methods

This is a multisite, superiority, pragmatic randomized controlled trial. We are considering for inclusion patients 18 years of age and older who are presenting with a conflict-related extremity wound within 72 hours after injury. Patients are block randomly assigned to either negative-pressure wound therapy or standard treatment in a 1:1 ratio. The primary end point is wound closure by day 5. Secondary end points include length of stay, wound infection, sepsis, wound complications, death, and health-related quality of life. We will explore economic outcomes, including direct health care costs and cost effectiveness, in a substudy. Data are collected at baseline and at each dressing change, and participants are followed for up to 3 months. We will base the primary statistical analysis on intention-to-treat.

Results

The trial is ongoing. Patient enrollment started in June 2015. We expect to publish findings from the trial by the end of 2019.

Conclusions

To the best of our knowledge, there has been no randomized trial of negative-pressure wound therapy in this context. We expect that our findings will increase the knowledge to establish best-treatment strategies.

Trial Registration

ClinicalTrials.gov NCT02444598; http://clinicaltrials.gov/ct2/show/NCT02444598 (Archived by WebCite at http://www.webcitation.org/72hjI2XNX)

International Registered Report Identifier (IRRID)

DERR1-10.2196/12334

"Reality rarely looks like the guidelines": a qualitative study of the challenges hospital-based physicians encounter in war wound management

Background

Globally, armed conflict is a major contributor to mortality and morbidity. The treatment of war-associated injuries is largely experience-based. Evidence is weak due to difficulty in conducting medical research in war settings. A qualitative method could provide insight into the specific challenges associated with providing health care to injured civilians. The aim of this study was to explore the challenges hospital-based physicians encounter in war wound management, focusing on surgical intervention and antibiotic use.

Methods

Semi-structured, face-to-face interviews were conducted with physicians at a Jordanian hospital supported by Médecins Sans Frontières. The interviews were recorded, transcribed verbatim and analysed using content analysis with an inductive and deductive approach.

Results

We found that challenges in war wound management primarily relate to protocol adherence. Protocols for the management of acute war wounds were adhered to on areas that could be considered commonly agreed principles of war wound surgery, such as the use of wound debridement and the evaluation of the systemic condition of the patient before initiating antibiotic treatment. We identified limitations imposed on the physicians that complicate or even hinder protocol adherence. Additionally, we identified factors associated with conscious deviations from the protocols.

Conclusions

We conclude that adherence to established protocols around the management of acute war wounds is difficult. We present aspects that may be considered when establishing clinical projects in similar contexts. The knowledge gained by this study could provide insights for the development of protocols or guidelines for wound management and antibiotic use in an unstable setting, such as a hospital in close proximity to armed conflict. We suggest the use of a grounded theory approach to further study the discrepancy between guideline recommendations and actual practice.