Infection with high proportion of multidrug-resistant bacteria in conflict-related injuries is associated with poor outcomes and excess resource consumption: a cohort study of Syrian patients treated in Jordan

Background: In spite of the evident general negative effects of armed conflict on countries’ health systems and populations’ health outcomes, little is known about similar impacts of conflicts on the spread of antimicrobial resistances (AMR). This review was to address this evidence gap and describe:1. Patterns of AMR in the Middle East (ME) and resistance profiles of pathogens included in the Global AMR Surveillance System (GLASS) supported by the World Health Organization;2. Differences in proportions of AMR isolates between conflict and non-conflict countries. Methods: A systematic literature review was conducted following PRISMA guidelines and searching five electronic databases. Subject heading and free text were searched for “antimicrobial resistances” and “Middle East”, to identify observational studies on AMR published from January 2011 to June 2018. Data were extracted from included articles on a predefined set of variables. Percentages of AMR were analysed as median and interquartile ranges. Risk of bias was assessed using the Newcastle-Ottawa Scale. Results: A total of 132 articles met the inclusion criteria. Included studies showed heterogeneity in study design, laboratory methods and standards for interpretation of results, and an overall high risk of bias. Main findings were the following:1. High proportions of carbapenem resistance in Acinetobacter spp. (median 74.2%: range), and both carbapenem resistance (median 8.1% and 15.4% for E. coli and K. pneumoniae respectively) and ESBL-production (median 32.3% and 27.9% for E. coli and K. pneumoniae respectively) amongst Enterobacteriaceae. S. aureus isolates showed a median methicillin resistance percentage of 45.1%, while vancomycin resistance was almost absent. A median of 50% of the strains of S. pneumoniae showed non-susceptibility to penicillin. 2. Similar trends were observed in conflict and non-conflict affected countries.Conclusions: There is a lack of standardization in the methodological approach to AMR research in the Middle East. The proportion of antibiotic resistances among specific GLASS pathogens is high, particularly among Acinetobacter spp.

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“…4 Clinical management of conflict-related extremity wounds is challenging, requiring substantial resources, and it is often complicated by infection. [5][6][7] Wound complications can result in prolonged treatment times and increased risk of morbidity and mortality.…”

Section: Introductionmentioning

confidence: 99%

Negative pressure wound therapy versus standard treatment in patients with acute conflict-related extremity wounds: a pragmatic, multisite, randomised controlled trial

Älgå

¹

,

Haweizy

²

,

Bashaireh

³

et al. 2020

The Lancet Global Health

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Background In armed conflict, injuries among civilians are usually complex and commonly affect the extremities. Negative pressure wound therapy (NPWT) is an alternative to standard treatment of acute conflict-related extremity wounds. We aimed to compare the safety and effectiveness of NPWT with that of standard treatment. MethodsIn this pragmatic, randomised, controlled superiority trial done at two civilian hospitals in Jordan and Iraq, we recruited patients aged 18 years or older, presenting with a conflict-related extremity wound within 72 h after injury. Participants were assigned (1:1) to receive either NPWT or standard treatment. We used a predefined, computer-generated randomisation list with three block sizes. Participants and their treating physicians were not masked to treatment allocation. The primary endpoint was wound closure by day 5. The coprimary endpoint was net clinical benefit, defined as a composite of wound closure by day 5 and freedom from any bleeding, wound infection, sepsis, or amputation of the index limb. Analysis was by intention to treat. The trial is registered with ClinicalTrials. gov, number NCT02444598, and is closed to accrual.Findings Between June 9, 2015, and Oct 24, 2018, 174 patients were randomly assigned to either the NPWT group (n=88) or the standard treatment group (n=86). Five patients in the NPWT group and four in the standard treatment group were excluded from the intention-to-treat analysis. By day 5, 41 (49%) of 83 participants in the NPWT group and 49 (60%) of 82 participants in the standard treatment group had closed wounds, with an absolute difference of 10 percentage points (95% CI -5 to 25, p=0·212; risk ratio [RR] 0·83, 95% CI 0·62 to 1·09). Net clinical benefit was seen in 33 (41%) of 81 participants in the NPWT group and 34 (44%) of 78 participants in the standard treatment group, with an absolute difference of 3 percentage points (95% CI -12 to 18, p=0·750; RR 0·93, 95% CI 0·65 to 1·35). There was one in-hospital death in the standard treatment group and none in the NPWT group. The proportion of participants with sepsis, bleeding leading to blood transfusion, and limb amputation did not differ between groups.Interpretation NPWT did not yield superior clinical outcomes compared with standard treatment for acute conflictrelated extremity wounds. The results of this study not only question the use of NPWT, but also question the tendency for new and costly treatments to be introduced into resource-limited conflict settings without supporting evidence for their effectiveness. This study shows that high-quality, randomised trials in challenging settings are possible, and our findings support the call for further research that will generate context-specific evidence.

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“…The study design was clearly stated in 29 out of the 132 articles included ( Only one study reported sample size calculation and employed representative population although not powered for the prevalence detected nor for the comparison between the sub-groups performed (95). Measures of sampling variation in the results were reported by only four studies (95,161,165,168).…”

Section: Assessment Of Risk Of Biasmentioning

confidence: 99%

“…Only three studies described the use of multivariate analysis -usually logistic regressionto control for confounding (45,147,168). None of the studies took missing data into account in the analysis nor in the discussion, and similarly limitations and potential sources of bias were never mentioned in the discussion, with the exception of one surveillance study performed in Lebanon The cohort studies included in the review (52,131,161) showed overall lower risk of bias compared to other study designs. Two out of the three studies (52,131) lacked detailed description of the statistical methods employed, in particular if and how control for confounding was performed and how losses to follow up were dealt with.…”

Section: Assessment Of Risk Of Biasmentioning

confidence: 99%

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Antimicrobial resistance and conflict in the Middle East: A systematic review

Truppa¹,

Abo‐Shehada²

2020

Preprint

0

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Background: In spite of the evident general negative effects of armed conflict on countries’ health systems and populations’ health outcomes, little is known about similar impacts of conflicts on the spread of antimicrobial resistances (AMR). This review was to address this evidence gap and describe:1. Patterns of AMR in the Middle East (ME) and resistance profiles of pathogens included in the Global AMR Surveillance System (GLASS) supported by the World Health Organization;2. Differences in proportions of AMR isolates between conflict and non-conflict countries. Methods: A systematic literature review was conducted following PRISMA guidelines and searching five electronic databases. Subject heading and free text were searched for “antimicrobial resistances” and “Middle East”, to identify observational studies on AMR published from January 2011 to June 2018. Data were extracted from included articles on a predefined set of variables. Percentages of AMR were analysed as median and interquartile ranges. Risk of bias was assessed using the Newcastle-Ottawa Scale. Results: A total of 132 articles met the inclusion criteria. Included studies showed heterogeneity in study design, laboratory methods and standards for interpretation of results, and an overall high risk of bias. Main findings were the following:1. High proportions of carbapenem resistance in Acinetobacter spp. (median 74.2%: range), and both carbapenem resistance (median 8.1% and 15.4% for E. coli and K. pneumoniae respectively) and ESBL-production (median 32.3% and 27.9% for E. coli and K. pneumoniae respectively) amongst Enterobacteriaceae. S. aureus isolates showed a median methicillin resistance percentage of 45.1%, while vancomycin resistance was almost absent. A median of 50% of the strains of S. pneumoniae showed non-susceptibility to penicillin. 2. Similar trends were observed in conflict and non-conflict affected countries.Conclusions: There is a lack of standardization in the methodological approach to AMR research in the Middle East. The proportion of antibiotic resistances among specific GLASS pathogens is high, particularly among Acinetobacter spp.

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Infection with high proportion of multidrug-resistant bacteria in conflict-related injuries is associated with poor outcomes and excess resource consumption: a cohort study of Syrian patients treated in Jordan

Cited by 58 publications

References 26 publications

Antimicrobial resistance among GLASS pathogens in conflict and non-conflict affected settings in the Middle East: A systematic review

Antimicrobial resistance among GLASS pathogens in conflict and non-conflict affected settings in the Middle East: A systematic review

Negative pressure wound therapy versus standard treatment in patients with acute conflict-related extremity wounds: a pragmatic, multisite, randomised controlled trial

Antimicrobial resistance and conflict in the Middle East: A systematic review

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