Microbiology  of  War  WoundsAUBMC    Experience

Abdul  Rahman Bizri MD  MScDivision  of  Infectious  Diseases  

Department  of  Internal  MedicineAUBMC

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”

MMWR,  vol  53,  pg  1063-­‐1066,  (2004).  JAMA  2004;  292:2964-­‐6,  (2004)Virulence  3:3,  243–250;  May/June  2012

Z.  T.  Sahli,  A.  R.  Bizri  &  G.  S.  Abu-­‐Sittah.  Epidemiol.  Infect.  (2016),  144,  2848–2857

Operation  Iraqi  Freedom  /  Operation  Enduring  Freedom

Political  ramifications  …  !!• Microbiological  consequences  …  

ØMulti  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  Wound  Infections

Hypothesis(s):  • 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.

Multi-­‐factorial  and  situation  specific  

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  aureusABC  (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  

Z.  T.  Sahli,  A.  R.  Bizri  &  G.  S.  Abu-­‐Sittah.  Epidemiol.  Infect.  (2016),  144,  2848–2857Winslow  C.  Lebanon:  War  and  Politics  in  a  Fragmented  Society.  New  York:  Routledge,  1996,  pp.  360.

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

• 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

The  Lebanese  Experience  (AUBMC)Intracranial  infection  after  missile  injuries  to  the  brain

(Civil  war  +  Israeli  war)

Taha JM,  Haddad  FS,  Brown  JA.  Neurosurgery  1991;  29:  864–868.

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

The  Lebanese  Experience  (AUBMC)Intracranial  infection  after  missile  injuries  to  the  brain:

Organisms  cultured  

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   DehiscedWound(%)

IntracranialInfection  

(%)Single  organism

9  (43) 22  (88)

Multiple  organisms

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.

• 1975-­‐1986• 30,000  casualties  managed  at  AUBMC• Disaster  plan  implementation  (>  25/1hr)• 1420  operated  upon  within  6  hours  (711  within    1st hour)• Mortality  130  (8.7%)  {highest  gunshot  wounds  9.5%}• Major  causes  of  mortality:• Hemorrhage  (3.7%)• Sepsis  (2.1%)• ARDS  (1.2%)  

Lebanese  civil  war  experience  -­‐ AUBMC

Nassoura Z,  et  al.  Journal  of  Trauma  and  Acute  Care  Surgery  1991;  31:  1596–1599.

Complication No.  of  patients   %Wound  infection 172 11.5Pneumonia   68 4.5Septicemia     52 3.5Intraabdominal   collection   45 3Post-­‐operative   bleed 41 2.7Urinary   tract  infection   39 2.6Enterocutaneous fistula   32 2.1Pulmonary  embolus   9 0.6Others   6 0.4

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

Trauma-­‐related   infections  due  to  cluster  munitions-­‐Lebanon  (Israeli  War)

Journal  of  Infection  and  Public  Health  (2013)  6,  482—486

Journal  of  Infection  and  Public  Health  (2013)  6,  482—486

Trauma-­‐related  infections  due  to  cluster  munitions  Lebanon

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

Journal  of  Infection  and  Public  Health  (2013)  6,  482—486

Trauma-­‐related   infections  due  to  cluster  munitions-­‐Lebanon  (Israeli  Wars)  

Epidemiological   data  of  the  4 carbapenem-­‐resistant   Acinetobacter  baumanniicarrying  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

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

260  isolates   tested  -­‐ January   2008  and   July  2011  -­‐ %  susceptibility

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  baumaniiPseudomonas  aeruginosaMDR  E.  coli

Non-­‐MDR  pathogens  and  distribution  by  country  of  injury,  injury  type  and  mechanism  of  injury

Staphylococcus  species  Enterococcus  species  Enterobacter  speciesKlebsiella  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  CoNE.  coliPseudomonas  aeruginosa   International  Orthopaedics (SICOT)  Jan  2017

War  related  osteomyelitis  total  cultures

Conflict  Medicine  Program  AUB  2017

Conflict  Medicine  Program  AUB  2017

War  related  osteomyelitis  acute  phase  isolates

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  approachØ Better  experience  Ø Better  outcomes