• The Syrian crisis has not only affected the physical health of refugees, but has also had a drastic effect on their mental health
• Wadi Khaled, a rural district in the north of Lebanon, hosts about 36,000 displaced Syrians, and is one of most under-served and marginalized areas of Lebanon
• Médecins Sans Frontières (MSF) has been providing mental health services to Syrian refugees and the Lebanese host population in Akkar, Wadi Khaled since 2016.
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.
Inappropriate use of antibiotics is widespread, and one of the main drivers for antimicrobial resistance (AMR). In pregnant women with suspected urinary tract infection (UTI), studies have suggested antibiotic over-use in up to 96%; use may be particularly high in settings with limited diagnostic resources and where reliant on symptomatic approaches. In south Beirut, specifically within camps where refugees settle and living conditions are poor, MSF has been operational since 2014 as the main provider of free primary healthcare services as well as sexual and reproductive health (SRH) care. Current MSF protocols operational in this setting recommend the use of urine dipsticks for UTI screening in pregnant women, followed by empirical antibiotic treatment for those with a positive result (positive for nitrites and/or leucocytes).
METHODS
In 2021, around 6,300 (24%) of the total 26,300 antenatal care (ANC) consultations conducted had a suspected UTI, based on urine dipstick results, and all those suspected with UTI were prescribed antibiotics. A prospective study was conducted between April and July 2022, to determine if adding urine
culture, following positive urine dipstick, to the protocol would reduce the use of unnecessary antibiotics. We used descriptive statistics to describe the population and compare positive and negative urine cultures. We calculated the proportion of patients receiving appropriate or inappropriate antibiotics.
ETHICS
This study was approved by the MSF Ethics Review Board, and by the ethics committee of the Lebanese American University.
RESULTS
A total of 449 pregnant women with suspected UTI were included in this study; all received urine culture. 81 (18%) were culture-positive. Under usual practice, 368 women (82%) would have been overprescribed antibiotics, based solely on urine dipstick results. 197 (44%) of the cohort were symptomatic, and were given empirical antibiotic treatment, with cefixime administered to 42 (21%) women and fosfomycin to 155 (79%). Escherichia coli (79%) was the most common bacterial species isolated, followed by Proteus (11%). In addition, among the 81 positive cultures, 4 (5%) were found resistant to fosfomycin and 39 (48%) to cefixim
CONCLUSION
These study findings reinforce concern around potential over prescription of unnecessary antibiotics in such populations, which could contribute to a potential rise in AMR. In addition, resistance to cefixime, one of the recommended antibiotics to treat UTI’s, is relatively high in this community. In contexts where urine culture is feasible, not costly, accessible, and results rapidly available, particularly with large cohorts of patients, urine culture should be the main method used to diagnose UTI; treatment should be based on microbiology/antibiotic sensitivity results.
CONFLICTS OF INTEREST
None declared.
Between 2009 and 2012, malaria cases diagnosed in a Médecins sans Frontières programme have increased fivefold in Baraka, South Kivu, Democratic Republic of the Congo (DRC). The cause of this increase is not known. An in vivo drug efficacy trial was conducted to determine whether increased treatment failure rates may have contributed to the apparent increase in malaria diagnoses.
METHODS
In an open-randomized non-inferiority trial, the efficacy of artesunate-amodiaquine (ASAQ) was compared to artemether-lumefantrine (AL) for the treatment of uncomplicated falciparum malaria in 288 children aged 6-59 months. Included children had directly supervised treatment and were then followed for 42 days with weekly clinical and parasitological evaluations. The blood samples of children found to have recurring parasitaemia within 42 days were checked by PCR to confirm whether or not this was due to reinfection or recrudescence (i.e. treatment failure).
RESULTS
Out of 873 children screened, 585 (67%) were excluded and 288 children were randomized to either ASAQ or AL. At day 42 of follow up, the treatment efficacy of ASAQ was 78% before and 95% after PCR correction for re-infections. In the AL-arm, treatment efficacy was 84% before and 99.0% after PCR correction. Treatment efficacy after PCR correction was within the margin of non-inferiority as set for this study. Fewer children in the AL arm reported adverse reactions.
CONCLUSIONS
ASAQ is still effective as a treatment for uncomplicated malaria in Baraka, South Kivu, DRC. In this region, AL may have higher efficacy but additional trials are required to draw this conclusion with confidence. The high re-infection rate in South-Kivu indicates intense malaria transmission.
Trial registration NCT02741024.
The Médecins Sans Frontières Tertiary Orthopaedic Care center in Mosul, Iraq, provides reconstructive surgery, microbiological analysis, integrated infection prevention and control, and antibiotic stewardship services. Between May 2018 and February 2020, we recorded soft tissue and/or bone infections caused by gram-negative extensively drug-resistant (XDR) bacteria in 4.9% (13/266) of the admitted patients. The XDR bacteria identified among 12 patients in this case series were extended-spectrum β-lactamase–producing Klebsiella pneumoniae (n = 5, 41.7%) with intermediate sensitivity or resistance to imipenem and/or meropenem, Acinetobacter spp (n = 3, 25.0%; 2 Acinetobacter baumannii strains) resistant to imipenem and/or meropenem, Pseudomonas aeruginosa (n = 2, 16.7%) resistant to imipenem and meropenem, and extended-spectrum β-lactamase–producing Proteus mirabilis (n = 2, 16.7%) resistant to meropenem. Most XDR isolates were sensitive only to colistin or polymyxin B, neither of which is available in Iraq. Therefore, the only treatment option was multiple rounds of surgical debridement and wound care. The infection was deemed cured before discharge in 7 patients (58.3%). Meanwhile, 4 patients (33.3%) were discharged with unhealed wounds, and outpatient follow-up was planned. One patient died in the intensive care unit of a referral hospital after developing septicemia postsurgery. XDR bacteria pose substantial health risks in Iraq. Thus, improving antimicrobial stewardship and accessibility to essential antibiotics is critical to address this issue.