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Multidrug-Resistant Chronic Osteomyelitis Complicating War Injury in Iraqi Civilians

Murphy, Richard A. MD, MPH; Ronat, Jean-Baptiste MS; Fakhri, Rasheed M. MD; Herard, Patrick MD; Blackwell, Nikki MBBS; Abgrall, Sophie MD, PhD; Anderson, Deverick J. MD, MPH

The Journal of Trauma: Injury, Infection, and Critical Care: July 2011 - Volume 71 - Issue 1 - p 252-254
doi: 10.1097/TA.0b013e31821b8622
Brief Report

Background: War-related orthopedic injury is frequently complicated by environmental contamination and delays in management, placing victims at increased risk for long-term infectious complications. We describe, among Iraqi civilians with war-related chronic osteomyelitis, the bacteriology of infection at the time of admission.

Methods: In the Médecins Sans Frontières Reconstructive Surgery Project in Amman, Jordan, we retrospectively reviewed baseline demographics and results of initial intraoperative surgical cultures among Iraqi civilians with suspected osteomyelitis.

Results: One hundred thirty-seven patients (90% male; median age, 35 years [interquartile range {IQR}, 28–46]; median time since initial injury, 19 months [IQR, 10–35]) were admitted with suspected chronic osteomyelitis after war-related injury. One hundred seven patients had a positive intraoperative culture. Before arrival, patients had undergone a median of 4 (IQR, 2–6) surgical procedures in Iraq. Fifty-nine (55%) of 107 patients with confirmed osteomyelitis had a multidrug-resistant (MDR) organism isolated at admission: cefepime-resistant Enterobacteriaceae (n = 40), methicillin-resistant Staphylococcus aureus (n = 16), and MDR Acinetobacter baumannii (n = 3). An association of borderline significance existed between a history of more than two prior surgical procedures in Iraq and an MDR isolate at program entry (multivariate: odds ratio, 5.3; 95% confidence interval, 0.9–30.6; p = 0.064).

Conclusion: Health care actors, including Iraqi health facilities and humanitarian medical organizations, must be aware of the link between chronic war injury and antimicrobial drug resistance in this region and should be prepared for the management challenges involved with the treatment of chronic drug-resistant osteomyelitis.

From the Médecins Sans Frontières/Doctors Without Borders (R.A.M.), New York, New York; Médecins Sans Frontières (J.-B.R., P.H.), Paris, France; Médecins Sans Frontières (R.M.F.), Amman, Jordan; University of Queensland (N.B.), Brisbane, Australia; Division of Infectious Diseases (S.A.), Avicenne Hospital, Bobigny, France; and Division of Infectious Diseases (D.J.A.), Duke University Medical Center, Durham, North Carolina.

Submitted for publication December 2, 2010.

Accepted for publication March 21, 2011.

Address for reprints: Richard A. Murphy, MD, MPH, Médecins Sans Frontières/Doctors Without Borders, 333 Seventh Avenue, 2nd Floor, New York, NY 10001; email:

© 2011 Lippincott Williams & Wilkins, Inc.