Outcomes of post-traumatic osteomyelitis in a conflict setting: a retrospective cohort study in Gaza

AIM

Assess the microbiology and treatment outcomes of post-traumatic osteomyelitis (PTO) patients in Medecins Sans Frontieres (MSF) supported reconstructive surgical facilities in Gaza, pre-October 7, 2023, and identify recurrence risk factors.

BACKGROUND

PTO is common among war-wounded in conflict-affected settings in the Middle East. The ongoing war in Gaza since October 2023, has severely disrupted healthcare, increasing suspected and sub-optimally treated PTO, and related literature is scarce.

METHODS

Two-centre retrospective cohort study including PTO patients diagnosed by microbiological confirmation via bone biopsy and treated between December 6, 2018 and September 8, 2021, with follow-up until January 31, 2022. Differences between multi-drug resistant (MDR) and non-MDR, polymicrobial and monomicrobial PTO were assessed. Predictors of recurrence were identified using cox proportional hazards multivariate regression.

RESULTS

202 patients with 275 PTO episodes and 441 isolates were included. MDR was present in 53% of episodes; 43% episodes were polymicrobial; recurrence occurred in 26%. Twenty patients (10%) underwent amputation. Staphylococcus aureus was the most prevalent (35%) isolate (62% methicillin-resistant), followed by 13% Enterobacterales (59% extended-spectrum beta-lactamase producers), 10% Pseudomonas aeruginosa and 3% Acinetobacter species. The 6-month survival (recurrence-free) probability was 79% (95% CI: 73-86) decreasing to 56% (95% CI: 47 - 68) by 24 months. Significant risk factors of recurrence included up to 3 procedures, fibula fractures, PTO with Enterobacter cloacae or Staphylococcus aureus.

CONCLUSIONS

Managing PTO in Gaza is complex. Rebuilding the healthcare system, strengthening local capacities, ensuring access to necessary resources are essential for the long-term management of PTO in Gaza.