As the Syrian civil war continues, at least 4 million people have fled the country and 220,000 people are estimated to have been killed over the last four years . There has been widespread destruction of infrastructure, including devastation of healthcare services, resulting in the resurgence of communicable diseases such as polio and leishmaniasis , and a lack of basic surgical care. Over the last two and a half years, Ziv Medical Center, a 320 bed hospital, in Northern Israel, close to the border with Lebanon and Syria has received over 450 Syrian casualties of the civil war. An alarming finding has been the culture of various Multi-Drug Resistant (MDR) bacteria from Syrian patients admitted to several hospitals in Israel . These bacteria include Methicillin-resistant Staphylococcus aureus (MRSA), MDR Acinetobacter sp., Extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae and Carbapenem-resistant Enterobacteriaceae (CRE). Of the first 306 patients admitted to Ziv Medical Center between February 2013 and May 2014, 40.8% patients were found to have MDR (including ESBL) from bacterial cultures (including surveillance cultures for MDR) taken within 3 days of admission, and 70% of patients had MDR (including ESBL) from all cultures during their period of admission to Ziv. The consequences to individual patients suffering life-threatening infections, to admitting health facilities in all countries neighbouring Syria and to countries receiving refugees more widely, including Europe, is an alarming clinical and public health threat.
Preliminary results from the Galilee (Nahariya) and Baruch Padeh (Poriya) Medical Centers in Israel  indicate an approximately 40% carriage rate amongst Syrian adults of various multi-drug resistant organisms including MRSA, MDR A. baumannii, carbapenem-resistant Enterobacteriaceae; and, an approximately 70% carriage rate of Extended-spectrum beta-lactamases (ESBL) among Syrian children. Quoting Peretz et al. , 19 out of 29 children (66%) treated at the hospitals were found to have MDR. “ESBL comprised 20 of 21 MDR isolates (19/20 were Escherichia coli); 1 isolate was MRSA. Among the adult patients, 28 of 60 (47%) carried MDR bacteria. In adults, however, the types of MDR isolates differed: CRE carriage was noted (5 patients, 2 with New Delhi metallo-β-lactamase), as well as MRSA”.
Much needs to be done in order to discover the origins and mechanisms of antibiotic resistance, but initial findings indicate high rates of ESBL carriage amongst children (most of whom have not been previously hospitalised in Syria) and who are likely, therefore, to have community-acquired carriage of resistant organisms [3-5].
Research within Syria has shown the alarming level of antibiotic resistance there before the present civil conflict began [6,7]. Causes of resistance include the liberal use of antibiotics from poor prescribing where clinical indications are weak, to over-the-counter distribution of drugs without medical prescriptions [8-10]. In addition, the industrial use of antibiotics, in farming, for example, facilitates the development and propagation of resistance [11,12]. Syrian scientific literature indicates that this has been a cause of concern for some time . It is possible, that this has been further compounded by the collapse of large sections of the Syrian healthcare system.
The purpose of this paper is to outline infection control measures necessary within the hospital taken in order to reduce the incidence and duration of infections amongst the patients from Syria, to prevent cross infection and to form a cohesive plan of action across multiple departments under challenging circumstances.
Routine infection control measures in Ziv Medical Center include the isolation of all patients transferred to the hospital from other health facilities, with microbiological screening cultures taken at admission. Policy then dictates that patients are kept in isolation. This has been a major challenge with Syrian patients, not simply because of the volume of patients received in the hospital, but also because all hospital departments, including the pediatric and adult intensive care units, have been involved in the care of the patients and almost all the patients have required surgery.
Some patients arrived after receiving basic paramedical care or medical treatment in a field hospital. Others arrived up to five days after initial injury, with infected wounds that had been sutured primarily after trauma in Syrian health facilities, with improvised, soiled dressings and dirty clothes and blankets. The number of septic complications amongst the first 100 patients admitted to Ziv Medical Center is shown in table 1. Table 2 shows the causative organisms of infections amongst the first 100 patients treated in Ziv Medical Centre. Twenty two patients were found to have MDR bacteria, including ESBL, MRSA, CRE and Acinetobacter.
Clinical and epidemiological data is essential in order to understand the scale of antibiotic resistance within Syria and the Middle East. It stands to reason that the disruption of health services in Syria is likely to have further compounded the spread of multi-drug resistance and efforts to monitor and contain this are important. Strict infection control policies are notoriously difficult to enforce and their effectiveness warrants regular evaluation. Physical isolation compounds emotional isolation and the effects of infection control measures that affect social contact and social well-being need to be studied.
As further data emerges about the pathogens involved in infections amongst these patients, the origins of regional multi-drug resistance, carriage rates of resistant organisms and practices that increase resistance in these communities, clinical and public health measures will need to be addressed. Measures are necessary to control the spread of resistance amongst populations that, of necessity, have fled their homes and are in constant movement across the world.
Citation: Biswas S, Hadary A, Aladdin S, Rechnitzer H, Kassis S, et al. (2015) Infection Control Measures in an Israeli District Hospital Receiving Syrian Civil War Casualties Colonized with Multi-Drug Resistant Bacteria. J Infect Non Infect Dis 1: 004.
Copyright: © 2015 Seema Biswas, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.