Patrick Herard

Antimicrobial drug-resistant bacteria isolated from Syrian war-injured patients, August 2011-March 2013.

To the Editor: Soft-tissue injuries sustained during wars are subject to environmental contamination and, thus, to a high risk for infection. Efforts to describe the epidemiology of war-associated infections are complicated by difficult access to patients, limited availability of microbiology support, and widespread empirical antimicrobial drug use. Nevertheless, identifying the relevant pathogens is critical because war-associated injuries commonly become infected and antimicrobial drug–resistant bacteria are well-described in these injuries, including those in the Middle East (1–3). The Medecins Sans Frontieres (MSF) surgical project in Amman, Jordan, was initially developed for war-injured Iraqis needing surgical reconstruction or management of chronic osteomyelitis. Infection management is based on organism-directed antimicrobial agents and wide surgical resection of involved tissue. The proximity of this project to the Syrian conflict provided an opportunity to describe microbiologic features of infections caused by war-associated injuries in Syrians, who may be at increased risk for infection-associated complications because of exclusion from care in official health systems. We describe a cross-sectional series of 61 Syrian orthopedic patients who had suspected infections, as determined on the basis of surgical samples obtained intraoperatively. Syrian patients admitted to the MSF clinic underwent initial surgical exploration of wounds; if infection was suspected, >3 intraoperative samples (bone, fibrous tissue, fluid) were obtained for culture and transported (at 4°–8°C) within 2 h to the laboratory at Ibn al-Haytham Hospital in Amman. Patients who were treated with antimicrobial drugs within 2 weeks before admission were excluded from analysis. We retrospectively reviewed data for patients admitted during August 1, 2011–March 31, 2013. Data were collected from databases and individual charts in Amman and analyzed by using Stata 12 (http://www.stata.com/stata12/). This study was deemed exempt from additional ethical approval by the MSF review board because it involved routinely collected data. We defined a multidrug-resistant (MDR) isolate as 1) extended-spectrum β-lactamase–expressing Enterobacteriaceae; 2) Pseudomonas aeruginosa and Acinetobacter baumannii isolates resistant to at least 1 agent in 3 antimicrobial categories typically used for treatment; or 3) methicillin-resistant Staphylococcus aureus (MRSA). Pathogen identification was conducted by using conventional methods and the API system (bio-Merieux, Durham, NC, USA). Antimicrobial drug susceptibility testing was conducted by using the MicroScan Walk-Away System (Dade Behring, West Sacramento, CA, USA). During the study period, 870 patient consultations were conducted, of which 345 (40%) were for patients from Syria. At the initial operating room evaluation, infection was suspected in 61 (18%) Syrians. These patients had a median age of 26 years (interquartile range 22–34); 98% were male. The median time from injury to admission was 5 months (interquartile range 1.2–8.1), but for 27 (44%) patients, the time from injury to admission was >6 months. The 2 most common injuries were gunshot wounds (32 patients [52%]) and wounds from explosions (20 patients [33%]). The dominant injury was located in an upper extremity in 14 (23%) patients and a lower extremity in 47 (77%) patients. For the 61 patients, a total of 67 bacterial isolates were identified from cultures of surgical specimens. Overall, 45 (74%) patients had at least 1 positive culture, and 6 (13%) patients had polymicrobial results. Gram-negative organisms represented 24 (56%) of 43 isolates; 10 (23%) were P. aeruginosa, 8 (19%) were E. coli, and 6 (14%) were A. baumannii. Gram-positive bacteria, including MRSA, represented 19 (44%) of 43 isolates (Table). Overall, 31 (69%) of 45 patients with confirmed infection were positive for MDR organisms. Within this group, MRSA represented 8 (42%) of 19 staphylococcal isolates. Table Antimicrobial drug resistance among frequently isolated bacterial isolates from Syrian patients with war-associated wound infections, August 2011–March 2013* Patients who had experienced delayed definitive management were frequently positive for MDR organisms, especially gram-negative pathogens and MRSA. For a humanitarian surgical project, infection with MDR organisms leads to formidable diagnostic, treatment, and control challenges. For example, treatment of MDR infections requires ongoing access to high-quality clinical microbiology support; late-generation antimicrobial drugs, which are typically given parenterally for up to 6 weeks; trained personnel; and sufficient hospital space to isolate patients with resistant strains. Our findings support the previously reported linkage between war-associated injuries and infection with antimicrobial drug–resistant organisms (1–4) and the implications for patient management. The source of antimicrobial drug–resistant organisms in war-associated injuries remains uncertain; possibilities include nosocomial transmission (5), particularly through prior contact with severely compromised health systems (6). Another possibility is fecal colonization with extended-spectrum β-lactamase–producing gram-negative bacteria. (7,8). Another likely contributor in Syria is the wide availability of antimicrobial drugs without a prescription (9). This study has limitations. Although measures were taken to ensure that positive cultures represented clinical infection rather than colonization, we cannot exclude colonization as a possible source of some recovered organisms. In neglected war-associated injuries, multiple pathogens are potentially present, but every strain is not necessarily clinically relevant (10). Furthermore, complete patient histories are difficult to obtain in crisis settings, limiting our ability to describe all prior interventions. Study strengths included partnership with a high-quality culture laboratory, which is uncommon in programs treating war injuries; systemic sampling of patients with suspected infection; and use of intraoperative samples for culture. Further research needed in this neglected area includes prospective studies to determine the effect of MDR isolates on patient outcomes and randomized clinical trials of antimicrobial drug strategies to inform treatment protocols.

Médecins Sans Frontières Experience in Orthopedic Surgery in Postearthquake Haiti in 2010

INTRODUCTION During January 2010, a 7.0 magnitude earthquake struck Haiti, resulting in death and destruction for hundreds of thousands of people. This study describes the types of orthopedic procedures performed, the options for patient follow-up, and limitations in obtaining outcomes data in an emergency setting. PROBLEM There is not a large body of data that describes larger orthopedic cohorts, especially those focusing on internal fixation surgeries in resource-poor settings in postdisaster regions. This article describes 248 injuries and over 300 procedures carried out in the Médecins Sans Frontières-Orthopedic Centre Paris orthopedic program. METHODS Surgeries described in this report were limited to orthopedic procedures carried out under general anesthesia for all surgical patients. Exclusion factors included simple fracture reduction, debridement, dressing changes, and removal of hardware. This data was collected using both prospective and retrospective methods; prospective inpatient data were collected using a data collection form designed promptly after the earthquake and retrospective data collection was performed in October 2010. RESULTS Of the 264 fractures, 204 were fractures of the major long bones (humerus, radius, femur, tibia). Of these 204 fractures of the major long bones, 34 (16.7%) were upper limb fractures and 170 (83.3%) were lower limb fractures. This cohort demonstrated a large number of open fractures of the lower limb and closed fractures of the upper limb. Fractures were treated according to their location and type. Of the 194 long bone fractures, the most common intervention was external fixation (36.5%) followed by traction (16.7%), nailing (15.1%), amputation (14.6%), and plating (9.9%). CONCLUSION The number of fractures described in this report represents one of the larger orthopedic cohorts of patients treated in a single center in the aftermath of the 2010 earthquake in Haiti. The emergent surgical care described was carried out in difficult conditions, both in the hospital and the greater community. While outcome and complication data were limited, the proportion of patients attending follow-up most likely exceeded expectations and may reflect the importance of the rehabilitation center. This data demonstrates the ability of surgical teams to perform highly-specialized surgeries in a disaster zone, and also reiterates the need for access to essential and emergency surgical programs, which are an essential part of public health in low- and medium-resource settings.

Amputation in emergency situations: indications, techniques and Médecins Sans Frontières France's experience in Haiti

PurposeThe decision to amputate is always difficult but becomes even harder in emergency situations, which usually present extra complicating factors.MSF ExperienceThese include human factors (related to both the surgeon and the patient); poor or nonexistent medical facilities, especially in war conditions or resource-poor countries; and cultural and religious considerations. Médecins Sans Frontières (MSF) has developed a quick medical and logistical response that relies on surgical protocols adapted to emergency situations, together with complete “kits” of medical equipment, supplies and inflatable facilities.ConclusionOur response to Haiti’s 2010 earthquake relied on these tools but also highlighted the need to develop more detailed protocols that will help our teams on the ground.

Multidrug-resistant Chronic Osteomyelitis Complicating War Injury in Iraqi Civilians

BACKGROUND War-related orthopedic injury is frequently complicated by environmental contamination and delays in management, placing victims at increased risk for long-term infectious complications. We describe, among Iraqi civilians with war-related chronic osteomyelitis, the bacteriology of infection at the time of admission. METHODS In the Médecins Sans Frontières Reconstructive Surgery Project in Amman, Jordan, we retrospectively reviewed baseline demographics and results of initial intraoperative surgical cultures among Iraqi civilians with suspected osteomyelitis. RESULTS One hundred thirty-seven patients (90% male; median age, 35 years [interquartile range {IQR}, 28-46]; median time since initial injury, 19 months [IQR, 10-35]) were admitted with suspected chronic osteomyelitis after war-related injury. One hundred seven patients had a positive intraoperative culture. Before arrival, patients had undergone a median of 4 (IQR, 2-6) surgical procedures in Iraq. Fifty-nine (55%) of 107 patients with confirmed osteomyelitis had a multidrug-resistant (MDR) organism isolated at admission: cefepime-resistant Enterobacteriaceae (n = 40), methicillin-resistant Staphylococcus aureus (n = 16), and MDR Acinetobacter baumannii (n = 3). An association of borderline significance existed between a history of more than two prior surgical procedures in Iraq and an MDR isolate at program entry (multivariate: odds ratio, 5.3; 95% confidence interval, 0.9-30.6; p = 0.064). CONCLUSION Health care actors, including Iraqi health facilities and humanitarian medical organizations, must be aware of the link between chronic war injury and antimicrobial drug resistance in this region and should be prepared for the management challenges involved with the treatment of chronic drug-resistant osteomyelitis.

Reconstruction of Nonunion Tibial Fractures in War-Wounded Iraqi Civilians, 2006-2008: Better Late Than Never

Objective: To describe medical care and surgical outcome after functional reconstructive surgery in late-presenting patients who already had at least one prior operation. Design: Retrospective review of medical care and surgical outcome from August 2006 to December 2008 using patient records for initial data with active follow-up for the latest outcome information. Setting: Médecins sans Frontières surgical programme in Jordan Red Crescent Hospital, Amman, Jordan. Patients: Sixty-two civilians with nonunion tibial fractures caused by war-related trauma in Iraq; 53 completed follow-up. Intervention: Amputation and/or reconstruction. Main Outcome Measurements: Late surgical complications (after the patients return to Iraq) were analyzed for infection recurrence, bone union, and functional condition (defined using the Short Musculoskeletal Functional Assessment score). Results: Almost three fourths of patients arrived with infected injuries, 9 of whom had amputation as the initial surgery; the rest, and all uninfected patients, had reconstruction. Excluding loss to follow-up, only 4 of 53 (8%) patients who arrived with an infected injury had infection recurrence. Excluding loss to follow-up and amputation, 2 of 14 (14%) patients in the uninfected and 5 of 30 (17%) in the infected injury group did not achieve successful tibial union. Mean Dysfunctional and Bothersome Indices overall were 27.1 and 29.8, respectively, with similar results for all 3 groups (amputations, uninfected, and infected injuries). Conclusions: Our study shows that patients with infected and uninfected injuries surgically treated in Amman achieved similar outcomes. Despite late presentation, our patients had a comparable outcome to other studies dealing with early reconstruction. Reconstruction for the infected group required longer treatment time. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical Care of Pediatric Patients in the Humanitarian Setting The Médecins Sans Frontières Experience, 2012-2013

IMPORTANCE Little is known about the scope of practice and outcomes in pediatric surgery performed by humanitarian organizations in resource-poor settings and conflict zones. This study provides the largest report to date detailing such data for a major nongovernmental organization providing humanitarian surgical relief support in these settings. OBJECTIVE To characterize pediatric surgical care provision by a major nongovernmental organization in specialized humanitarian settings and conflict zones. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted from August 15, 2014, to March 9, 2015, of 59,928 surgical interventions carried out from January 1, 2012, to December 31, 2013, by the Médecins Sans Frontières Operational Centre Paris (MSF-OCP) program in 20 locations, including South Sudan, Yemen, Syria, Gaza, Pakistan, Nigeria, Central African Republic, Democratic Republic of Congo, and the Philippines. Surgical interventions were primarily for general surgical, traumatic, and obstetric emergencies and were categorized by mechanism, type of intervention, American Society of Anesthesia risk classification, and urgency of intervention. MAIN OUTCOMES AND MEASURES Operative indications, type of intervention, and operative case mortality. RESULTS Among all age groups, 59,928 surgical interventions were performed in dedicated trauma, obstetric, and reconstructive centers for 2 years. Nearly one-third of interventions (18,040 [30.1%]) involved preteen patients (aged <13 years) and 4571 (7.6%) involved teenaged patients (aged 13-17 years). The proportion of violence-related injuries in the preteen group was significantly lower than in the teenage group (4.8% vs 17.5%; P < .001). Burns (50.1%), other accidental injuries (16.4%), and infections (23.4%) composed the bulk of indications in the preteen group. Interventions in the teenage group were principally caused by trauma-related injuries (burns, 22.9%; traffic accidents, 10.1%; gunshot wounds, 8.0%). Crude perioperative case mortality rates were 0.07% in the preteen group, 0.15% in the teenage group, and 0.22% in the adult group (>17 years) (P = .001). One-third of the cases (33.4%) were deemed urgent, while most of the remaining cases (57.7%) were deemed semielective (surgical intervention to be performed within 48 hours). CONCLUSIONS AND RELEVANCE When examining surgical interventions in a population of pediatric patients cared for in the specialized setting of humanitarian aid and conflict zones, burns, other accidental injuries, and infection composed the bulk of indications in the preteen group; interventions in the teenage group were principally caused by trauma-related injuries. Crude perioperative case mortality rates in the preteen group were significantly lower than in the adult group. Further work is needed to examine long-term outcomes of pediatric operations in these settings and to guide context-specific surgical program development.

Triage in surgery: from theory to practice, the Medecins Sans Frontières experience

Establishing triage is necessary in mass casualty events. If the concept of triage itself is easy, its application in the field encounters many difficulties at times unforseen. MSF offers a list of the main obstacles encountered when establishing an efficient triage system.

Quality orthopaedic care in sudden-onset disasters: suggestions from Médecins Sans Frontières-France.

A huge change is needed in the conception and implementation of surgical care during sudden-onset disasters (SOD). The inadequate surgical response mounted by the majority of foreign medical teams (FMT) after Haiti’s earthquake is a striking example of the need for a structured professional approach. Logistical capacity already exists to provide safe, timely, effective, efficient, equitable and ethical patient-centred care with minimum standards. However, knowledge, skills and training in the fields of general, orthopaedic and plastic surgery need further clarification. Surgical activity data and clinical examples from several Médecins Sans Frontières–France (MSF) projects are used here to describe the skill set and experience essential for surgeons working in SOD contexts.

Bone cultures from war-wounded civilians in the Middle East: a surgical prospective

PurposeHidden infections in a reconstructive surgery program are frequently underestimated.MethodsA retrospective study was undertaken of 1,891 civilian war-wounded patients from Iraq, Syria, Yemen and Gaza treated in Amman from August 2006 to January 2016. One thousand three hundred and fifty-three underwent surgical interventions for previous bone injury and had systematic bone cultures.ResultsAmong patients (167) without any clinical, biological or radiological signs of infection, 46% demonstrated infection based on bone cultures. We conclude that bone culture should become a prerequisite for any reconstruction in such contexts.

Antibiotic resistance in Palestine: an emerging part of a larger crisis

Supporting previous letters published in The BMJ about the violent response of Israeli forces to Palestinian protestors in Gaza,123 Medecins Sans Frontieres (MSF) has received 2228 trauma patients from April to September. The total number of injured has now reached 20 833, with 191 deaths.4 About 90% of Palestinian patients seeking care from MSF have had lower limb injuries from gunshot wounds, …