Antimicrobial Drug–Resistant Bacteria Isolated from Syrian War–Injured Patients, August 2011–March 2013

Day NP, et al. Activities of daily living associated with acquisition of melioi-dosis in northeast Thailand: a matched case–control study. Variability of Burkholderia pseudomallei strain sensitivities to chlorine disinfection. To the Editor: Soft-tissue injuries sustained during wars are subject to environmental contamination and, thus, to a high risk for infection. Efforts to describe the epidemiology of war-associated infections are complicated by difficult access to patients, limited availability of microbiology support, and widespread empirical antimicrobial drug use. Nevertheless, identifying the relevant pathogens is critical because war-associated injuries commonly become infected and antimicrobial drug–re-sistant bacteria are well-described in these injuries, including those in the Middle East (1–3). The Médecins Sans Frontières (MSF) surgical project in Amman, Jordan, was initially developed for war-injured Iraqis needing surgical reconstruction or management of chronic osteomyelitis. Infection management is based on organism-directed antimicrobial agents and wide surgical resection of involved tissue. The proximity of this project to the Syr-ian conflict provided an opportunity to describe microbiologic features of infections caused by war-associated injuries in Syrians, who may be at increased risk for infection-associated complications because of exclusion from care in official health systems. We describe a cross-sectional series of 61 Syrian orthopedic patients who had suspected infections, as determined on the basis of surgical samples obtained intraoperatively. Syrian patients admitted to the MSF clinic underwent initial surgical exploration of wounds; if infection was suspected, >3 intraopera-tive samples (bone, fibrous tissue, fluid) were obtained for culture and transported (at 4°–8°C) within 2 h to the laboratory at Ibn al-Haytham Hospital in Amman. Patients who were treated with antimicrobial drugs within 2 weeks before admission were excluded from analysis. We retrospectively reviewed data for patients admitted during August 1, 2011–March 31, 2013. Data were collected from databases and individual charts in Amman and analyzed by using Stata 12 (http://www.stata.com/ stata12/). This study was deemed exempt from additional ethical approval by the MSF review board because it involved routinely collected data. We defined a multidrug-resistant (MDR) isolate as 1) extended-spectrum β-lactamase–expressing Entero-bacteriaceae; 2) Pseudomonas aeru-ginosa and Acinetobacter baumannii isolates resistant to at least 1 agent in 3 antimicrobial categories typically used for treatment; or 3) methicillin-resistant Staphylococcus aureus (MRSA). Pathogen identification was conducted by using conventional methods and the API system (bio-Mérieux, Dur-ham, NC, USA). Antimicrobial drug susceptibility testing was conducted by using the MicroScan Walk-Away System (Dade Behring, West Sacra-mento, CA, USA). During the study period, 870 patient consultations …