Microbiology of War Wounds - Dr. Bizri - cpb-eu-w2.wpmucdn.com€¦ · MicrobiologyofWar*Wounds AUBMC**Experience Abdul&Rahman Bizri MD&MSc Division&of&Infectious&Diseases&...

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


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


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


Trauma-‐related infections due to cluster munitions Lebanon

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


Trauma-‐related infections due to cluster munitions Lebanon (I


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



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

Microbiology of War Wounds - Dr. Bizri - cpb-eu-w2.wpmucdn.com€¦ · Microbiology*of*War*Wounds AUBMC**Experience Abdul&Rahman Bizri MD&MSc Division&of&Infectious&Diseases&...

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Microbiology of War Wounds - Dr. Bizri - cpb-eu-w2.wpmucdn.com€¦ · MicrobiologyofWar*Wounds AUBMC**Experience Abdul&Rahman Bizri MD&MSc Division&of&Infectious&Diseases&...