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.
Iraq has suffered unrest and conflicts in the past decades leaving behind a weakened healthcare system. In 2018, Médecins Sans Frontières (MSF) opened a tertiary orthopaedic care centre in Mosul providing reconstructive surgery with access to microbiological analysis.
METHODS
A retrospective cross-sectional analysis of microbiological and clinical data of patients admitted between April 2018 - December 2019.
RESULTS
There were 174 patients who were included in this study; there were more males than females (135 to 38 respectively), and the mean age was 32.6 years. Of the 174 patients, the majority had more than one bacterial isolate detected (n= 122, 70.1%); 141 (81.0%) had at least one multi-drug resistant (MDR) isolate detected during their hospital stay. Staphylococcus aureus (n=197, 48.2%) was the most common organism isolated. Overall, most isolates detected were MDR (n=352, 86%), mostly MRSA (n=186, 52.8%) or ESBL-producing Enterobacterales (n=117, 33.2%). Among patients admitted to the Operating Department (n=111, 63.7%), 81.1% (n=90) were admitted for violent trauma injuries. Patients who had more than one procedure performed per surgery had significantly increased odds of having at least one MDR organism isolated (OR 8.66, CI 1.10-68.20, p=0.03).
CONCLUSION
This study describes a high prevalence of antibiotic resistance in patients with trauma-related wounds in Mosul, Iraq. It highlights the importance of microbiological analysis and ongoing surveillance to provide optimal treatment. Additionally, it underscores the importance of infection prevention and control measures and antibiotic stewardship.
We analysed the concordance of rectal swab isolates and blood culture for Gram-negative bacteria (GNB) isolates in neonates with a suspicion of neonatal sepsis admitted to a neonatal care unit in Haiti.
METHODS
We matched pairs of blood and rectal samples taken on the date of suspected sepsis onset in the same neonate. We calculated the proportion of rectal isolates in concordance with the blood isolates by species and genus. We calculated the negative predictive value (NPV) for GNB and extended-spectrum β-lactamase (ESBL)-producing GNB for all rectal and blood isolate pairs in neonates with suspected sepsis.
RESULTS
We identified 238 blood and rectal samples pairs, with 238 blood isolate results and 309 rectal isolate results. The overall concordance in genus and species between blood and rectal isolates was 22.3% [95% confidence interval (CI) 17.4-28.0%] and 20.6% (95% CI 16.0-26.2%), respectively. The highest concordance between blood and rectal isolates was observed for samples with no bacterial growth (65%), followed byKlebsiella pneumoniae (18%) and Klebsiella oxytoca (12%). The NPV of detecting GNB bacterial isolates in rectal samples compared with those in blood samples was 81.6% and the NPV for ESBL-positive GNB was 92.6%.
CONCLUSIONS
The NPV of rectal swab GNB isolates was high in all patient groups and was even higher for ESBL-positive GNB. Clinicians can use the results from rectal swabs when taken simultaneously with blood samples during outbreaks to inform the (de-)escalation of antibiotic therapy in those neonates that have an ongoing sepsis profile.