{"_asset":{"@search.score":2.9951413,"Name":"Extensively antibiotic-resistant bacterial infections in trauma cases managed at the Médecins Sans Frontières tertiary orthopaedic center in Mosul, Iraq: A case series","AlternateTitleCommaDelimited":"","Id":"8911","AssetLocationUri":null,"Abstract":"

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.

","PublicationOrPresentationDate":"2024-07-08T00:00:00Z","LastModifiedDate":"2024-08-06T21:34:44.646Z","IsDeleted":false,"DigitalObjectIdentifier":"10.1093/ofid/ofae379","ContentTypeName":"Research","ParentContentTypeName":"Journal Article","JournalName":"Open Forum Infectious Diseases","ContentType":"Journal Article > Research","AvailabilityTypeId":1,"AvailabilityType":"Full Text","JournalIssue":"8","JournalVolume":"11","JournalPages":"ofae379","JournalAbbreviation":"Open Forum Infect Dis","Conference":null,"ConferenceStartDate":null,"ConferenceEndDate":null,"content":"\nExtensively Antibiotic-Resistant \nBacterial Infections in Trauma Cases \nManaged at the Médecins Sans \nFrontières Tertiary Orthopaedic Center \nin Mosul, Iraq: A Case Series\nHisham Abdulrahman Ahmed,1,2,3 Humam Hasheem Mahmood,1,2\n\nHaitham Hosam Aldin Sami,1 Abdullah Natiq Taher,1,2 Pilar Garcia-Vello,4,5 Engy Ali,6\n\nErnestina Repetto,7 Anita Williams,4,5, Fabiola Gordillo Gomez,4,8\n\nand Krystel Moussally4,\n\n1Tertiary Orthopaedic Center, Operational Centre Brussels, Médecins Sans Frontières, East \nMosul, Iraq, 2Ministry of Public Health, Ninawa Governorate, Iraq, 3Macquarie University \nHospital, Australian Orthopaedic Association, Sydney, Australia, 4MSF Lebanon Branch Office, \nMiddle East Medical Unit, Operational Centre Brussels, Médecins Sans Frontières, Beirut, \nLebanon, 5Luxembourg Operational Research Unit, Medical Department, Operational Centre \nBrussels, Médecins Sans Frontières, Luxembourg, 6Directorate of Health, Ministry of Health \nLuxembourg, Luxembourg, 7Infectious Diseases Service, Saint Pierre University Hospital, \nBrussels, Belgium, and 8Medical Department, Operational Centre Brussels, Médecins \nSans Frontières, Brussels, Belgium\n\nThe Médecins Sans Frontières Tertiary Orthopaedic Care center \nin Mosul, Iraq, provides reconstructive surgery, microbiological \nanalysis, integrated infection prevention and control, and \nantibiotic stewardship services. Between May 2018 and \nFebruary 2020, we recorded soft tissue and/or bone infections \ncaused by gram-negative extensively drug-resistant (XDR) \nbacteria in 4.9% (13/266) of the admitted patients. The XDR \nbacteria identified among 12 patients in this case series \nwere extended-spectrum β-lactamase–producing Klebsiella \npneumoniae (n = 5, 41.7%) with intermediate sensitivity or \nresistance to imipenem and/or meropenem, Acinetobacter spp \n(n = 3, 25.0%; 2 Acinetobacter baumannii strains) resistant \nto imipenem and/or meropenem, Pseudomonas aeruginosa \n(n = 2, 16.7%) resistant to imipenem and meropenem, and \nextended-spectrum β-lactamase–producing Proteus mirabilis \n(n = 2, 16.7%) resistant to meropenem. Most XDR isolates \nwere sensitive only to colistin or polymyxin B, neither of \nwhich is available in Iraq. Therefore, the only treatment option \nwas multiple rounds of surgical debridement and wound care. \nThe infection was deemed cured before discharge in 7 patients \n(58.3%). Meanwhile, 4 patients (33.3%) were discharged with \n\nunhealed wounds, and outpatient follow-up was planned. One \npatient died in the intensive care unit of a referral hospital \nafter developing septicemia postsurgery. XDR bacteria pose \nsubstantial health risks in Iraq. Thus, improving antimicrobial \nstewardship and accessibility to essential antibiotics is critical \nto address this issue.\n\nKeywords. access to antibiotics; extensive antibiotic \nresistance; Iraq; surgical management; trauma.\n\nReceived 27 March 2024; editorial decision 11 June 2024; accepted 04 July 2024; \npublished online 8 July 2024\n\nCorrespondence: Krystel Moussally, MSc, MSF Lebanon Branch Office, Middle East Medical \nUnit, Médecins Sans Frontières, Domtex building, Hamra street, Beirut, Lebanon (Krystel. \nmoussally@msf.org); Hisham Abdulrahman Ahmed, MD, Macquarie University Hospital, \nAustralian Orthopaedic Association, 201 Kent St, Sydney, NSW 2000, Australia \n(alhabbarhisham@gmail.com).\n\nOpen Forum Infectious Diseases® \n\n© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases \nSociety of America. This is an Open Access article distributed under the terms of the \nCreative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which \npermits unrestricted reuse, distribution, and reproduction in any medium, provided the original \nwork is properly cited. \nhttps://doi.org/10.1093/ofid/ofae379\n\nAntimicrobial resistance (AMR), an increasing global health \nthreat [1, 2], is prevalent in patients with surgical trauma \nwounds in conflict-affected settings such as Mosul, Iraq [3– \n6]. Patients with surgical trauma, particularly those in low- \nresource and conflict-affected areas, face severe consequences \nwhen wounds become infected by drug-resistant bacteria, as in-\nfection leads to increased mortality, prolonged hospital stay, \nand severe economic losses for the patient and health systems \n[7–9]. A high prevalence of multidrug-resistant (MDR) infec-\ntions has been identified in patients with trauma-related \nwounds [10]. In particular, extensively drug-resistant (XDR) \nbacteria represent a major concern. XDR infections have fewer \ntreatment options, and such treatments are not easily accessible \nin low-resource settings [11].\n\nEvidence on XDR infections in Iraq is scarce, with no reports \nfrom Mosul regarding the population with conflict-associated \nwounds [12, 13]. Therefore, this case series described the char-\nacteristics, clinical management, and outcomes of patients ad-\nmitted with conflict-associated wounds complicated by XDR \ninfections to the Médecins Sans Frontières (MSF) Tertiary \nOrthopaedic Care (TOC) center in East Mosul, Iraq, between \nMay 2018 and February 2020.\n\nMATERIALS AND METHODS\n\nSetting\n\nMosul, which has been heavily affected by decades of conflict \n(most recently in 2017), has a deteriorated public health system \n[14]. MSF has been performing free orthopedic and reconstruc-\ntive surgery since May 2018 at the TOC in East Mosul, adopting \na multidisciplinary approach including surgery, physiotherapy, \nmental health care, and wound care. Infection prevention and \ncontrol (IPC) measures, access to microbiology diagnostics, \nand antibiotic stewardship programs were established in re-\nsponse to the significant burden of MDR.\n\nStudy Design and Population\n\nThis retrospective case series investigated the clinical and mi-\ncrobiological characteristics of patients admitted to MSF \nTOC in Mosul who were diagnosed with XDR infection be-\ntween May 2018 and February 2020.\n\nBRIEF REPORT • OFID • 1\n\nOpen Forum Infectious Diseases \n\nB R I E F R E P O R T\nDownloaded from https://academic.oup.com/ofid/article/11/8/ofae379/7709362 by guest on 06 August 2024\n\nhttps://orcid.org/0000-0002-5295-8451\nhttps://orcid.org/0000-0002-1260-0690\nmailto:Krystel.moussally@msf.org\nmailto:Krystel.moussally@msf.org\nmailto:alhabbarhisham@gmail.com\nhttps://creativecommons.org/licenses/by/4.0/\nhttps://doi.org/10.1093/ofid/ofae379\n\n\nDefinition of XDR\n\nXDR was defined as nonsusceptibility to at least 1 agent in all but \n≤2 antimicrobial categories per the corresponding antibiogram, \nas stipulated by the international expert proposal for standard \ndefinitions for acquired resistance [15]. In microorganisms \nwith intrinsic resistance to an antibiotic or antibiotic class, the \nantibiotic or class was removed prior to applying the XDR defi-\nnition criteria. Only antibiotic families available within the coun-\ntry were tested. Therefore, the susceptibility of organisms to \nantibiotics that are not available in Iraq was not considered in \nthe assessment of XDR resistance. This approach ensured that \nthe classification of XDR was applicable and relevant to the treat-\nments available in Iraq. If an antibiotic class was not tested, no \nassumption was made regarding bacterial susceptibility.\n\nMicrobiological and Clinical Procedures\n\nAntibiotic sensitivity testing was performed with the Kirby-Bauer \ndisk diffusion method [16]. No other tests were performed. The \ninterpretation was based on the guidelines of the Clinical and \nLaboratory Standards Institute [17] and performed in an external \nmicrobiology laboratory in Erbil (>80 km from Mosul). \nExtended-spectrum β-lactamase (ESBL) production was deter-\nmined by detecting the synergy between clavulanic acid and a \nthird-generation cephalosporin indicator. Testing was per-\nformed for all antibiotic classes available in Iraq. The guidelines \ndo not have a breakpoint zone diameter for interpreting poly-\nmyxin B and colistin. In Iraq, testing for colistin was not available.\n\nOn admission, patients with signs of infection underwent bi-\nopsy at least 1 week after antibiotic washout following the MSF \nguidelines with clinical, blood, and radiologic examinations. In \naddition to the clinical assessment of the wound, the severity of \nthe infection was assessed weekly by measuring C-reactive pro-\ntein levels and the erythrocyte sedimentation rate. The techni-\ncal procedures for debridement, wound care, and final suture \nafter infection resolution followed the MSF guidelines [18].\n\nData Collection\n\nInformation on XDR isolates was retrospectively collected from \nthe WHONET microbiology laboratory database, which is rou-\ntinely used in the TOC. Sociodemographic and clinical data \nwere extracted from our routine database and patients’ medical \nrecords.\n\nPatient outcomes were categorized as cured (no clinical in-\nfection signs, complete wound healing with no pus discharge, \nand normal C-reactive protein and erythrocyte sedimentation \nrate levels), uncured (outpatient follow-up required), or de-\nceased at discharge.\n\nRESULTS\n\nBetween May 2018 and February 2020, 266 patients with a micro-\nbiologically confirmed infection were admitted to the MSF TOC \n\nin Mosul. More than half of these infections were caused by gram- \npositive bacteria (135/266, 50.8%), whereas the remainder were \ncaused by gram-negative bacteria (131/266, 49.2%). Among the \ngram-negative bacteria, 67.9% (89/131) were ESBL producers. \nIn total, 126 of 131 gram-negative bacteria were tested for carba-\npenem resistance with imipenem or meropenem, revealing that \n23.8% of the isolates (30/126) were carbapenem resistant. Of \nthe total patient cohort, 4.9% (13/266) were infected by an \nXDR organism, comprising 9.9% (13/131) of all gram-negative \ninfections, and all of these organisms were gram negative. \nTwelve patients were included in this case series, and their char-\nacteristics are presented in Table 1. One patient was excluded be-\ncause of incomplete records.\n\nThe median age of patients in the case series was 29.5 years \n(IQR, 15.5–38). They were predominantly male (n = 9, 75.0%). \nSix patients (50.0%) reported comorbidities. The median hos-\npital stay was 37 days (IQR, 21–58.5), and patients underwent \na median of 4 operations (IQR, 3–7.5) during their stay. All pa-\ntients presented with clinical signs of infection on admission. \nMost injuries (n = 9, 75.0%) resulted from nonviolent trauma, \nwhereas 3 (25.0%) resulted from violent trauma, namely blast \ninjuries. The limbs were the most prevalent site of injury \n(n = 7, 58.3%). Most patients had soft tissue infections (n = 7, \n58.3%), and 5 (41.7%) also had bone involvement (Table 1).\n\nOf the episodes, 9 (75.0%) were polymicrobial and 3 (25.0%) \nwere monomicrobial. At least 1 XDR isolate was identified in \neach episode. In addition to other transmission-based precau-\ntions, all patients were placed in single-bed isolation rooms.\n\nThe most prevalent XDR organism was ESBL-producing \nKlebsiella pneumoniae (n = 5, 41.7%), exhibiting resistance or \nintermediate sensitivity to imipenem and/or meropenem. \nOther XDR isolates included Acinetobacter spp (n = 3, \n25.0%), with resistance to imipenem and/or meropenem; \nPseudomonas aeruginosa (n = 2, 16.7%), showing resistance \nto imipenem and meropenem; and ESBL-producing Proteus \nmirabilis (n = 2, 16.7%), with meropenem resistance \n(Figure 1). All isolated XDR organisms were gram negative. \nIn polymicrobial episodes, additional pathogens included \nmethicillin-resistant Staphylococcus aureus, Enterococcus spp, \nEscherichia coli, viridans streptococci, and Burkholderia \ncepacia.\n\nAntibiotic susceptibility testing identified colistin and poly-\nmyxin B as the only potential treatments for XDR infections; \nhowever, neither drug is available in the country. Tigecycline \nresistance was noted in 71.4% (5/7) of tested isolates. Newer \nantibiotics, such as ceftazidime-avibactam or meropenem- \nvaborbactam, are not on MSF’s essential medications list \nbecause of economic barriers and a lack of local efficacy data, \nresulting in reliance on surgical management, primarily de-\nbridement and subsequent wound care.\n\nSeven patients (58.3%) were treated solely by surgical de-\nbridement. All patients who received antibiotics had \n\n2 • OFID • BRIEF REPORT\nDownloaded from https://academic.oup.com/ofid/article/11/8/ofae379/7709362 by guest on 06 August 2024\n\n\n\nBRIEF REPORT • OFID • 3\nTable 1. Demographics and Clinical Characteristics of Patients With Extensively Drug-Resistant Infections Admitted May 2018–February 2020 in Mosul, Iraq\n\nNo. Sex Age, y\n\nOPD \nAdmission, \n\nNo.\nNature of \n\nInjury Site of Injury Infection Type Antibiotics Provided (All IV)\nTreatment \nDuration, d Comorbidities Radiology\n\nLOS, \nd\n\nDebridement, \nNo. Outcome\n\n1 M 24 10 Road traffic \ninjury\n\nLower limb Polymicrobial Vancomycin, 1 g; imipenem, \n1 g; gentamycin, 280 mg; \n\ncolistin, \n9 000 000-IU loading dose \n\nswitched to 4 500 000\n\n8 None Osteomyelitis 30 14 Cured\n\n2 M 30 NA Bedsore Back Polymicrobial Levofloxacin, 500 mg; \namikacin, 750 mg\n\n13 None No bone \ninvolvement\n\n45 3 Uncured\n\n3 M 32 NA Bedsore Back Polymicrobial Amikacin, 1 g; ceftriaxone, 2 \ng\n\n78 Neurologic \ndisordera\n\nNo bone \ninvolvement\n\n120 3 Died\n\n4 F 69 NA Diabetic \nfoot\n\nFoot Polymicrobial Gentamycin, 160 mg; \ncefazolin, 1 g; metronidazole, \n\n500 mg; ceftriaxone, 2 g\n\n…b Diabetes Osteomyelitis 44 8 Cured\n\n5 M 14 NA Bedsore Lumbar area Monomicrobial None … None No bone \ninvolvement\n\n72 4 Uncured\n\n6 F 34 1 Suicidal \nattempt\n\nForearm Polymicrobial None … None No fracture or \nosteomyelitis\n\n18 4 Cured\n\n7 F 52 2 Blast injury Iliac region Polymicrobial None … Diabetes and \nhypertension\n\nOsteomyelitis 22 2 Cured\n\n8 M 17 NA Shell injury Sacrococcygeal Polymicrobial Imipenem, 500 mg; \nvancomycin, 1 g; amikacin, 1 \n\ng\n\n8 Neurologic \ndisordera\n\nNo bone \ninvolvement\n\n20 2 Uncured\n\n9 M 29 8 Electrical \nburn\n\nHand Polymicrobial None … None Foot amputation; \nno bone \n\ninvolvement\n\n45 5 Cured\n\n10 M 8 20 Road traffic \ninjury\n\nFoot Monomicrobial None … None No fracture or bone \ninvolvement\n\n22 7 Cured\n\n11 M 42 19 Diabetic \nfoot\n\nThigh Monomicrobial None … Diabetes and \nhypertension\n\nNo bone \ninvolvement\n\n189 9 Cured\n\n12 M 13 7 Bedsore Lumber back Polymicrobial None … Neurologic \ndisordera\n\nOsteomyelitis 9 3 Uncured\n\nAbbreviations: d, days; F, female; IV, intravenous; LOS, length of stay; M, male; NA, not applicable; OPD, outpatient department; y, years. \naParaplegia or spinal cord injury. \nbDuration of antibiotic treatment missing for patient 4.\nDownloaded from https://academic.oup.com/ofid/article/11/8/ofae379/7709362 by guest on 06 August 2024\n\n\n\npolymicrobial infections. Antibiotics included ceftriaxone, \namikacin, levofloxacin, gentamycin, and imipenem, and they \nwere provided as slow infusions coupled with renal and liver \nmonitoring to prevent side effects. One case required amputa-\ntion of the lower limb.\n\nThe wounds of 7 patients (58.3%) were healed before dis-\ncharge, and 4 patients (33.3%) were discharged with unhealed \nwounds and ongoing outpatient follow-up. One patient trans-\nferred to intensive care died from postoperative septicemia.\n\nDISCUSSION\n\nOur study highlights the challenges of XDR infections in \nMosul, Iraq, where specific antibiotic treatment options remain \nscarce [19], contributing to the global burden of AMR [20].\n\nData paucity on XDR infections in conflict-affected areas such \nas the Middle East [10, 21]—worsened by conflict-driven AMR \ncontributors, such as collapsed health systems, limited staff train-\ning, restricted availability and misuse of antibiotics, inadequate \nIPC measures, and poor diagnostic capacity—exacerbates \nAMR issues [21–23]. This series highlighted the imminent threat \nof XDR gram-negative bacteria, recognized as critical pathogens \nof global health priority according to the World Health \nOrganization, in Mosul, Iraq [24].\n\nOf particular concern is the impact of XDR infections on \nthe young study population, potentially resulting in pro-\nlonged disability during their peak productive years, thereby \nemphasizing the urgent need for (1) strengthened AMR sur-\nveillance in Iraq to address the emergence of XDR infections \nand contain transmission, (2) context-adapted IPC measures, \nand (3) improved diagnostic capabilities for better antimicro-\nbial stewardship.\n\nIn Mosul, colistin and polymyxin B were often the only \ntreatment options for some XDR infections. Regarding \n\nnon–Pseudomonas aeruginosa infections, tigecycline, which is \noften not available for testing in external laboratories, was an op-\ntion; however, it was not accessible because of supply shortages. \nThe scarcity of these drugs alongside tigecycline resistance se-\nverely restricted therapeutic options. Therefore, access to essen-\ntial antibiotics such as colistin and tigecycline [11, 25], which are \nrecognized as last-resort antibiotics against MDR pathogens \n[26], is critical for the treatment of XDR infections caused by \ngram-negative bacteria in Iraq [27]. Novel antibacterial agents \nsuch as β-lactam/β-lactamase inhibitor combinations, represent-\ning promising alternatives against MDR and XDR infections \n[28], have not yet been added to MSF’s essential medication \nlist because the local resistance patterns, which are critical for se-\nlecting relevant antibiotics, have not been clarified. The high \ncosts associated with these new antibiotics, which are up to \n20-fold more expensive than older alternatives for carbapenem- \nresistant Enterobacterales, MDR Pseudomona aeruginosa, and \ncarbepenem-resistant Acinetobacter baumannii [29], represent \na significant barrier to accessibility. Despite potential availability \nthrough MSF support, ensuring a continuous and sustainable \nsupply of these expensive drugs in low-resource settings remains \nchallenging. Considering the growing issue of AMR worldwide, \nthere is a pressing need to ensure access to established and \nemerging antibiotics in low-resource settings to effectively man-\nage infections and save lives.\n\nAlthough we advocate for improved antibiotic access, we em-\nphasize the need for alternative strategies such as surgical debride-\nment and subsequent wound care for managing AMR infections \nin extreme situations in which necessary antibiotics are unavail-\nable. Although this approach provides effective wound healing, \nas presented in this study, aiming at definitive source control \nmight be insufficient to treat complex infections such as osteomy-\nelitis [30], in which concurrent targeted antibiotic therapy is often \nnecessary to prevent early relapse and complications. This study \n\nFigure 1. Type and proportion of bacteria isolated in bone biopsies from patients with extensively drug-resistant infections in Mosul, Iraq, May 2018−February 2020.\n\n4 • OFID • BRIEF REPORT\nDownloaded from https://academic.oup.com/ofid/article/11/8/ofae379/7709362 by guest on 06 August 2024\n\n\n\ndid not monitor whether cured patients who were released with-\nout further antibiotic therapy later experienced relapse.\n\nBeyond antibiotic treatment and surgery, quality IPC mea-\nsures such as placing patients in single-room isolation are es-\nsential in this context to prevent XDR transmission within \nthe facilities. The identification of XDR cases in an MSF facility \nhighlights the broader public health concern of XDR pathogen \ncirculation in the community and other facilities in Mosul, par-\nticularly when surgical care is the only option amid limited an-\ntibiotic accessibility.\n\nCONCLUSION\n\nXDR infection poses a substantial challenge in Mosul, Iraq. \nXDR infection management in this setting highlights the criti-\ncal role of surgical management in a context in which access to \nessential antibiotics is problematic. Although larger studies are \nneeded to clarify the actual prevalence of XDR infection in \nMosul, improved accessibility to older and newer antibiotics \nis necessary to ensure appropriate XDR infection management \nand prevent further transmission.\n\nNotes\nAcknowledgments. We thank the MSF TOC staff for their continuous \n\nwork toward improving patients’ outcomes, as well as our patients who \ntrusted us throughout their clinical management. This series report was \nproduced as part of the activities of the TOC center of MSF in Mosul, \nIraq, which is maintained with MSF funding.\n\nAuthor contributions. E. A. and K. M. conceptualized the idea. All au-\nthors contributed to the write-up of the study protocol, including design \nand methodology. H. A. A., H. H. M., H. H. A. S., and A. N. T. supported \nthe collection of the data. H. A. A. and K. M. were responsible of data cu-\nration. Analysis of the results was done by H. A. A. with the support and \nvalidation of A. W. and K. M. All authors discussed and supported the in-\nterpretation of the results. H. A. A. drafted the original manuscript with the \nsupport of P. G.-V. and K. M. K. M. supervised the project. All authors re-\nviewed the results and approved the last version of the manuscript.\n\nData availability. Data presented in this study are not available publicly \nbut upon request to interested researchers due to confidentiality and con-\ntextual privacy concerns.\n\nPatient consent statement. This research was approved by the MSF \nEthics Review Board under protocol 2086 (16/12/2020) and by the \nMinistry of Health and Environment of the Nineveh Health Directorate \nin Iraq under protocol number 31210 (08/12/2020). All patient data used \nin this study were pseudoanonymized and did not include direct patient \nidentifiers. Written consent from patients was waived by the MSF and local \nethics committees following the nature of the study design.\n\nFinancial support. This study did not receive any funding. The work was \nsupported by Médecins Sans Frontières.\n\nPotential conflicts of interest. All authors: No reported conflicts.\n\nReferences\n1. World Health Organization. Antimicrobial resistance. 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Available at: http://www.ncbi.nlm.nih.gov/books/NBK532250/. Accessed 6 \nFebruary 2024.\n\nBRIEF REPORT • OFID • 5\nDownloaded from https://academic.oup.com/ofid/article/11/8/ofae379/7709362 by guest on 06 August 2024\n\nhttps://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance\nhttps://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance\nhttps://dgpi.de/wp-content/uploads/2022/12/AWaRe-Antibiotic-Book_WHO_Dez2022.pdf\nhttps://dgpi.de/wp-content/uploads/2022/12/AWaRe-Antibiotic-Book_WHO_Dez2022.pdf\nhttps://hmu.edu.krd/images/Medicine/Conference/2-5.pdf\nhttps://hmu.edu.krd/images/Medicine/Conference/2-5.pdf\nhttps://annd.org/uploads/publications/Right_to_health_in_Iraq_Fragile_structures_and_growing_challenges_Muntather_Hassan_En.pdf\nhttps://annd.org/uploads/publications/Right_to_health_in_Iraq_Fragile_structures_and_growing_challenges_Muntather_Hassan_En.pdf\nhttps://clsi.org/media/2663/m100ed29_sample.pdf\nhttps://clsi.org/media/2663/m100ed29_sample.pdf\nhttps://medicalguidelines.msf.org/en/viewport/CG/english/treatment-of-a-simple-wound-18482379.html\nhttps://medicalguidelines.msf.org/en/viewport/CG/english/treatment-of-a-simple-wound-18482379.html\nhttps://www.who.int/publications-detail-redirect/WHO-EMP-IAU-2017.12\nhttps://www.who.int/publications-detail-redirect/WHO-EMP-IAU-2017.12\nhttps://iris.who.int/bitstream/handle/10665/371090/WHO-MHP-HPS-EML-2023.02-eng.pdf?%20sequence=1\nhttps://iris.who.int/bitstream/handle/10665/371090/WHO-MHP-HPS-EML-2023.02-eng.pdf?%20sequence=1\nhttp://www.ncbi.nlm.nih.gov/books/NBK532250/\n\n\tExtensively Antibiotic-Resistant Bacterial Infections in Trauma Cases Managed at the Médecins Sans Frontières Tertiary Orthopaedic Center in Mosul, Iraq: A Case Series\n\tMATERIALS AND METHODS\n\tSetting\n\tStudy Design and Population\n\tDefinition of XDR\n\tMicrobiological and Clinical Procedures\n\tData Collection\n\n\tRESULTS\n\tDISCUSSION\n\tCONCLUSION\n\tNotes\n\tReferences\n\n\n","UrlSlug":"extensively-antibiotic-resistant-bacterial-infections-trauma-cases-managed-médecins-sans-frontières-tertiary-orthopaedic-center-mosul-iraq-case-series","collections":[],"countries":[{"Name":"Iraq","Id":105}],"asset_languages":[{"AlternateTitle":null,"language":[{"Id":1,"Name":"English"}],"contentTranslation":[],"contentLocation":[]}],"creators":[{"Name":"Moussally K","Id":17270,"ac":[{"Order":9}]},{"Name":"Ali E","Id":18940,"ac":[{"Order":5}]},{"Name":"Williams A","Id":25450,"ac":[{"Order":7}]},{"Name":"Gordillo Gomez F","Id":32855,"ac":[{"Order":8}]},{"Name":"Repetto E","Id":34104,"ac":[{"Order":6}]},{"Name":"Abdulrahman Ahmed H","Id":34835,"ac":[{"Order":0}]},{"Name":"Hasheem Mahmood H","Id":34836,"ac":[{"Order":1}]},{"Name":"Hosam Aldin Sami H","Id":34837,"ac":[{"Order":2}]},{"Name":"Natiq Taher A","Id":34838,"ac":[{"Order":3}]},{"Name":"Garcia-Vello P","Id":34839,"ac":[{"Order":4}]}],"keywords":[{"Name":"antibiotic resistance","Id":1},{"Name":"surgery & trauma care","Id":39},{"Name":"antimicrobial resistance","Id":72}]}}

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Extensively antibiotic-resistant bacterial infections in trauma cases managed at the Médecins Sans Frontières tertiary orthopaedic center in Mosul, Iraq: A case series