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.
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.
Quality orthopaedic care in sudden-onset disasters: suggestions from Médecins Sans Frontières-France
As a result, MSF has created a multifaceted, context-adapted, field experience-based, approach to ABR in hospitals in Middle Eastern conflict settings. We focus on three pillars: (1) infection prevention and control (IPC); (2) microbiology and surveillance; and (3) antibiotic stewardship.