Microbiology of War Wounds AUBMC Experience Abdul Rahman Bizri MD MSc Division of Infectious Diseases Department of Internal Medicine AUBMC Conflict Medicine Program - AUB
Current Middle- East Geopolitical Map
Current Middle- East Geopolitical Map
Lebanon- Syria: Unique Geopolitics
Relevance The Arab Israeli conflict and resulting wars and armed conflicts The Lebanese civil war The Arab uprisings and the war on terror The strong association between military conflicts and infectious diseases MDR pathogens Iraqibacter Z. T. Sahli, A. R. Bizri & G. S. Abu- Sittah. Epidemiol. Infect. (2016), 144, 2848 2857 MMWR, vol 53, pg 1063-1066, (2004). JAMA 2004; 292:2964-6, (2004) Virulence 3:3, 243 250; May/June 2012
Operation Iraqi Freedom / Operation Enduring Freedom Political ramifications!! Microbiological consequences Ø Multi Drug Resistant Bacteria (MDR bacteria) Wound bacteriology: (USA & Germany military hospitals) Acinetobacter baumannii calcoaceticus (MDR- XDR) Klebsiella pneumoniae & E coli (ESBL) Pseudomonas aeruginosa (MDR) Staphylococcus aureus (MRSA) Crit Care Med 2008 Vol. 36, No. 7 (Suppl.)
Epidemiologic Source of MDR Bacteria in Hypothesis(s): Wound Infections Multi- factorial and situation specific Colonizing the casualty s skin Inoculated into the wound at the time of the injury through dirt & debris Nosocomial transmission Medical care Evacuation Heavy metals (munition/ordinance) ± environment Other factors Crit Care Med 2008 Vol. 36, No. 7 (Suppl.) BMC International Health and Human Rights (2010), 10(1). doi:10.1186/1472-698x- 10-17.
Summary of published reports describing microbiology of war wound infections in Iraq, Syria, Israel, & Lebanon Z. T. Sahli, A. R. Bizri, G. S. ABU- Sittah; Epidemiol. Infect., 2016 Mar 2:1-10
Summary of published reports describing microbiology of war wound infections in Iraq, Syria, Israel, & Lebanon Country Number % infection Pathogen Iraq 17861 5-49% Staphylococcus aureus ABC (Iraqibacter) Syria 697 6-12% Pseudomonas aeruginosa Israel 796 22-58% Pseudomonas aeruginosa Candida spp. Lebanon 1643 5-39% Staphylococcus aureus Pseudomonas aeruginosa Z. T. Sahli, A. R. Bizri, G. S. ABU- Sittah; Epidemiol. Infect., 2016 Mar 2:1-10
The Lebanese Experience Lebanon has been plagued by wars and military conflicts since 1975 Civil war Military confrontations with Israel Both civilians and military affected Few published reports In recent times: Lebanese hospitals are referral centers for war casualties from Syria and Iraq + Lebanese nationals involved Winslow C. Lebanon: War and Politics in a Fragmented Society. New York: Routledge, 1996, pp. 360. Z. T. Sahli, A. R. Bizri & G. S. Abu- Sittah. Epidemiol. Infect. (2016), 144, 2848 2857
Summary of published reports describing the microbiology of war wound infections- Middle East Z. T. Sahli, A. R. Bizri & G. S. Abu- Sittah. Epidemiol. Infect. (2016), 144, 2848 2857
The Lebanese Experience (AUBMC) Intracranial infection after missile injuries to the brain (Civil war + Israeli war) 30 intracranial infections (ICIs) 600 penetrating head injuries from missiles AUBMC (1981 and 1988) 16 brain abscess 9 cerebritis 2 infected intracerebral hematoma 5 meningitis Infection developed 4 days to 7 years after the initial debridement Incidence of ICI in patients with postoperative retention of bone: 4% no scalp wound dehiscence 84.6% wound dehiscence present Taha JM, Haddad FS, Brown JA. Neurosurgery 1991; 29: 864 868.
The Lebanese Experience (AUBMC) Intracranial infection after missile injuries to the brain: Organisms cultured Organism Dehisced wound (%) Intracranial infection (%) Gram positive 2 (10) 11 (36) Gram negative 12 (57) 12 (40) Mixed (+/- ) 7 (33) 2 (7) Negative culture 0 5 (17) Total 21 30 Taha JM, Haddad FS, Brown JA. Neurosurgery 1991; 29: 864 868.
The Lebanese Experience (AUBMC) Intracranial infection after missile injuries to the brain: organisms cultured & risk factors Infection Single organism Multiple organisms Dehisced Wound (%) Intracranial Infection (%) 9 (43) 22 (88) 12 (57) 3 (12) Total 21 25 Risk Factors Extensive brain injury Coma Trajectory through an air sinus Cerebrospinal fluid fistula Inadequate initial debridement Incomplete dural closure Taha JM, Haddad FS, Brown JA. Neurosurgery 1991; 29: 864 868.
Lebanese civil war experience - AUBMC Head and neck war injuries: 10- year experience (AUBMC) 1021 Lebanese patients (1975 1984) Infection rate (12%) Most common organisms: S. aureus P. aeruginosa E. coli Proteus mirabilis Anaerobes: B. fragilis, Peptococcus, Peptostreptococcus Zaytoun G, Shikhani A, Salman S. Laryngoscope 1986; 96: 899 903.
Lebanese civil war experience - AUBMC 1975-1986 30,000 casualties managed at AUBMC Disaster plan implementation (> 25/1hr) 1420 operated upon within 6 hours (711 within 1 st hour) Mortality 130 (8.7%) {highest gunshot wounds 9.5%} Major causes of mortality: Hemorrhage (3.7%) Sepsis (2.1%) ARDS (1.2%) Nassoura Z, et al. Journal of Trauma and Acute Care Surgery 1991; 31: 1596 1599.
Lebanese civil war experience AUBMC (1975-1986) Complications of Surgery Complication No. of patients % Wound infection 172 11.5 Pneumonia 68 4.5 Septicemia 52 3.5 Intraabdominal collection 45 3 Post- operative bleed 41 2.7 Urinary tract infection 39 2.6 Enterocutaneous fistula 32 2.1 Pulmonary embolus 9 0.6 Others 6 0.4 Nassoura Z, et al. Journal of Trauma and Acute Care Surgery 1991; 31: 1596 1599.
Trauma- related infections due to cluster munitions- Lebanon (Israeli War) Journal of Infection and Public Health (2013) 6, 482 486
Trauma- related infections due to cluster munitions Lebanon Journal of Infection and Public Health (2013) 6, 482 486
Trauma- related infections due to cluster munitions- Lebanon (Israeli Wars) Journal of Infection and Public Health (2013) 6, 482 486
Trauma- related infections due to cluster munitions Lebanon (I Trauma- related infections due to cluster munitions- Lebanon (Israeli Wars) Journal of Infection and Public Health (2013) 6, 482 486
Epidemiological data of the 4 carbapenem- resistant Acinetobacter baumannii carrying the blandm- 1 gene isolated in Lebanon from Syrian war casualties R. Rafei et al. / International Journal of Infectious Diseases 21 (2014) 21 2322
Acinetobacter baumannii isolates from Aleppo- Syria 260 isolates tested - January 2008 and July 2011 - % susceptibility Antibiotic Aleppo AUBMC* Aztreonam 1.5 3 Pip/Tazo 13.4 10 Amoxi/Clav 6.8 Cefuroxime 4.7 Cefoxitin 5 Cefotaxime 8.6 10 Cefepime 15.3 10 Caftazidime 19.4 Meropenem 29.5 Antibiotic Aleppo AUBMC* Imipenem 35.4 12 Nitrofurantoin 3.6 Ciprofloxacin 18.8 8 Gentamicin 17.3 15 Amikacin 21.7 12 Cotrimoxazole 25.9 9 Tetracycline 31.7 Colistin 93.1 99 Tigecycline NT 99 A.R. Hamzeh et al. / American Journal of Infection Control 40 (2012) 776-7 *G. F. Araj & G S Zaatari AUBMC July 1,2011 June 30, 2012
The microbiology of war wounds in the Middle East: The experience of a regional tertiary medical center Academic tertiary care university medical center Receives patients from all over the country and acts as a regional referral medical center Recent Middle- East crises o War injuries (military and civilians) o Lebanon, Syria, Iraq, Palestine, Conflict Medicine Program (AUB) o Global Health Initiative Conflict Medicine Program AUB 2017
Characteristics and hospital stay of patients with blast and gunshot injuries
Characteristics and hospital stay of patients with blast and gunshot injuries
MDR pathogens and distribution by country of injury, injury type and mechanism of injury Acinetobacter baumanii Pseudomonas aeruginosa MDR E. coli
Non- MDR pathogens and distribution by country of injury, injury type and mechanism of injury Staphylococcus species Enterococcus species Enterobacter species Klebsiella pneumoniae
Effect of variables on MDR among infected persons with culture growth (bivariate analysis) * Statistically significant
Multivariate analysis of Risk Factors for MDR Infection
Bone cultures from war- wounded civilians in the Middle East Staphylococcus aureus Staphylococcus species CoN E. coli Pseudomonas aeruginosa International Orthopaedics (SICOT) Jan 2017
War related osteomyelitis total cultures Conflict Medicine Program AUB 2017
War related osteomyelitis acute phase isolates Conflict Medicine Program AUB 2017
War related osteomyelitis chronic phase isolates
Concluding remarks Association between war and infectious diseases Wound infections resulting from war related trauma AUBMC is a referral center (local & regional) Conflict Medicine Program + partnership with others (MSF ICRC ) Need for additional data Need multi- disciplinary approach Ø Better experience Ø Better outcomes