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.
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.
BACKGROUND
The history of conflicts in the Middle East has resulted in a high burden of complications from conflict-related wounds like posttraumatic osteomyelitis (PTO). This is particularly challenging to manage in settings like Mosul, Iraq and Gaza, Palestine, where healthcare systems are weakened. In nonconflict settings, PTO caused by Pseudomonas aeruginosa (PAPTO) can lead to >20% of treatment failures. We aim to describe the clinical characteristics, outcomes, and management, in PAPTO patients admitted to Médecins Sans Frontières (MSF) facilities in Mosul and Gaza between 1 April 2018 and 31 January 2022.
METHODS
We conducted a retrospective cohort study on patients with PAPTO diagnosed with culture of intraoperative bone biopsy, using routinely collected data.
RESULTS
Among 66 PAPTO episodes from 61 enrolled patients, 37.9% had a multidrug-resistant Pseudomonas aeruginosa, with higher antibiotic resistance in Gaza. Polymicrobial infections were prevalent (74.2%), mainly involving Staphylococcus aureus (74.1%), being predominantly methicillin-resistant (95.0%). Overall, 81.7% received appropriate antibiotic treatment, with monotherapy used in 60.6% of episodes and a median treatment duration of 45.5 days. Recurrence was observed in 24.6% of episodes within a median of 195 days (interquartile range, 64-440 days). No significant differences were found in recurrence rates based on the type of antibiotic treatment (mono- or dual therapy) or episode (mono- or polymicrobial).
CONCLUSIONS
Management of PAPTO in the conflict-affected, low-resource settings of Mosul and Gaza achieved a recurrence rate aligned with global reports through appropriate and targeted antibiotic use, primarily in monotherapy, provided over a mean treatment duration of 45.5 days.
Since 7 October 2023, large-scale military operations in the Gaza Strip have resulted in an escalating public health crisis. Residents of Gaza are mostly displaced from their homes and living in overcrowded conditions with insufficient access to water, sanitation, and food, and health services have been considerably disrupted. To inform humanitarian and decision-making efforts, we aimed to estimate the project excess mortality from traumatic injuries, infectious diseases, maternal and newborn complications, and non-communicable diseases (NCDs) under different future scenarios.
METHODS
We used five different models to project excess deaths from February to August 2024, considering three scenarios: (1) an immediate and permanent ceasefire; (2) the status quo, reflecting conditions from mid-October 2023 to mid-January 2024; and (3) a further escalation of the conflict. Using publicly available data and expert consultations, our analysis projected excess deaths resulting under each scenario. A model was developed to determine increased malnutrition (as an underlying cause).
RESULTS
Without epidemics, the ceasefire scenario would result in 6550 excess deaths, rising to 58,260 under the status quo, and 74,290 under escalation. With epidemics, these projections rise to 11,580, 66,720, and 85,750, respectively. Under the ceasefire scenario, infectious diseases would be the main cause of excess deaths (1,520 excess deaths without epidemics and 6,550 with epidemics). Traumatic injuries followed by infectious diseases would be the main causes of excess deaths in both the status quo (53,450 due to traumatic injuries; 2,120 due to infectious diseases without epidemics and 10,590 including epidemics) and escalation scenarios (68,650 due to traumatic injuries; 2,720 due to infectious diseases without epidemics and 14,180 with epidemics). Our projections indicate that, even in the best-case ceasefire scenario, thousands of excess deaths would continue to occur, mainly due to the time it would take to improve water, sanitation, shelter conditions, and malnutrition, and restore functioning healthcare services in Gaza. While the total number of estimated excess deaths from maternal and neonatal causes are relatively small (100–330 excess deaths), every loss of a mother has severe consequences for family health and wellbeing. NCDs are projected to cause more deaths (1,680 (ceasefire) –2,680 (escalation) excess deaths) due to a heavily disrupted specialised health services and impeded access to treatment and medications.
CONCLUSION
These projections underscore the critical and urgent need for an immediate ceasefire to mitigate the alarming excess mortality in Gaza. The severity of the ceasefire scenario cannot be understated, with over 6–11 thousand excess deaths projected. Decision-makers must act swiftly to prevent further loss of life and address the dire humanitarian situation in Gaza.
Limb salvage by ortho-plastic teams is the standard protocol for treating open tibial fractures in high-income countries, but there’s limited research on this in conflict settings like the Gaza Strip. This study assessed the clinical impact of gunshot-related open tibial fractures, compared patient management by orthopedic and ortho-plastic teams, and identified the risk factors for bone non-union in this context.
METHODS
A retrospective review of medical records was conducted on Gaza Strip patients with gunshot-induced-open tibial fractures from March 2018 to October 2020. Data included patient demographics, treatments, and outcomes, with at least one year of follow-up. Primary outcomes were union, non-union, infection, and amputation.
RESULTS
The study included 244 injured individuals, predominantly young adult males (99.2%) with nearly half (48.9%) having Gustilo-Anderson type IIIB fractures and more than half (66.8%) with over 1 cm of bone loss. Most patients required surgery, including rotational flaps and bone grafts with a median of 3 admissions and 9 surgeries. Ortho-plastic teams managed more severe muscle and skin injuries, cases with bone loss > 1 cm, and performed less debridement compared to other groups, though these differences were not statistically significant. Non-union occurred in 53% of the cases, with the ortho-plastic team having the highest rate at 63.6%. Infection rates were high (92.5%), but no significant differences in bone or infection outcomes were observed among the different groups. Logistic regression analysis identified bone loss > 1 cm, vascular injury, and the use of a definitive fixator at the first application as predictors of non-union.
CONCLUSIONS
This study highlights the severity and complexity of such injuries, emphasizing their significant impact on patients and the healthcare system. Ortho-plastic teams appeared to play a crucial role in managing severe cases. However, further research is still needed to enhance our understanding of how to effectively manage these injuries.
To assess colorectal cancer (CRC) awareness and its influence on attitudes toward colonoscopy in Palestine.
MATERIALS AND METHODS
Convenience sampling was used to recruit Palestinian adults from hospitals, primary health care centers, and public spaces across 11 governorates. To evaluate the awareness of CRC signs/symptoms, risk factors, and mythical causes, the Bowel Cancer Awareness Measure and Cancer Awareness Measure-Mythical Causes Scale were used after translation into Arabic. For each correctly recognized item, one point was given. The total awareness score of each domain was calculated and categorized into tertiles; the top tertile was considered high awareness, and the other two tertiles were considered low awareness.
RESULTS
A total of 4,623 questionnaires were included. Only 1,849 participants (40.0%) exhibited high awareness of CRC signs/symptoms. High awareness of CRC symptoms was associated with higher likelihood of showing positive attitudes toward colonoscopy (odds ratio [OR], 1.21 [95% CI, 1.07 to 1.37]). A total of 1,840 participants (38.9%) demonstrated high awareness of CRC risk factors. Participants with high awareness of CRC risk factors were more likely to display positive attitudes toward colonoscopy (OR, 1.20 [95% CI, 1.07 to 1.37]). Only 219 participants (4.7%) demonstrated high awareness of CRC causation myths. There was no association between awareness of CRC causation myths and positive attitudes toward colonoscopy.
CONCLUSION
Awareness of CRC was poor with less than half of the study participants demonstrating high awareness of CRC signs/symptoms and risk factors, and a minority (<5%) displaying high awareness of CRC causation myths. High awareness of CRC signs/symptoms and risk factors was associated with greater likelihood of demonstrating positive attitudes toward colonoscopy. Educational initiatives are needed to address knowledge gaps and dispel misconceptions surrounding CRC.