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© Jacob Burns/MSF
19 Nov 19 11 Dec 19

Why bacteria love war wounds: Antibiotic resistance in the Middle East

Bacteria are all around us, on us and even in us. In fact, they are everywhere. Most are harmless, some are useful, and some can be really dangerous if they end up in the wrong part of the body.

Until the first antibiotic was discovered about a century ago, many people died of complications from mild diseases or small wounds, because doctors had no tools to tackle bacterial infections. The discovery of antibiotics brought about a complete revolution in the field of medicine. But today, their efficiency is declining fast, as bacteria become increasingly resistant to antibiotics.

Risk of becoming resistant to antibiotics

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Bacteria, like all living things, adapt to new environments. Every time they are exposed to antibiotics, there is a small chance that they will adapt and survive. And with the widespread use of antibiotics over recent decades, bacteria have had a lot of opportunities to increase their resistance. This has become a very serious problem, as well as a very complex one. In different locations, different types of bacteria have grown resistant to different types of antibiotics. In places where there is violent conflict – such as many locations in the Middle East where MSF works – the problem is even more complex.

The impact of a bullet, an explosion or a collapsing wall on the human body can be major. It can cause significant internal damage, often requiring surgery to put it right.

“A war wound has enormous potential for bacterial infection,” says Dr Jorgen Stassijns, who is coordinating MSF’s efforts to get a grip on the problem of antibiotic resistance.

“A bullet or a piece of shrapnel rips the skin apart and rips the flesh open, allowing bacteria to get in, while if you step on a landmine, lots of dirt will be blown into the fresh wound immediately. The risk of infection is huge.”

Take Waleed, a patient in MSF’s reconstructive surgery hospital in Amman, Jordan. In 2016, he was walking down the street in the Yemeni town of Ibb when an aircraft opened fire at the building next to him. A wall collapsed, severely injuring his jaw and leg.

The impact of a bullet, an explosion or a collapsing wall on the human body can be major. It can cause significant internal damage, often requiring surgery to put it right. Complex bone fractures, for instance, may require multiple surgical interventions, increasing the risk of a bone becoming infected – if it was not already infected when the body was first injured.

Today, Waleed has still not recovered fully. This is not because of the damage inflicted by the collapsing wall, but because his wounds were infected by bacteria that became resistant to the very drugs that were supposed to heal him.

Difficult to get proper treatment in times of war

In times of war, health systems often break down, making it difficult for patients to get proper treatment, as happened to Waleed in war-torn Yemen. “I was treated in Ibb, but received poor medical care,” he says. “Then I moved to the capital, Sana’a, for further treatment. I had a number of surgeries, but the medical care was still poor.”

The improper use of antibiotics stimulates the rise of antibiotic resistance in bacteria. Waleed was eventually admitted to MSF’s hospital in Amman, where doctors discovered he had a severe infection in his bones, caused by bacteria that were resistant to the antibiotics normally used to treat this condition. “The doctors at MSF told me that I got this because of the misuse of antibiotics,” says Waleed. “Many doctors had given me a lot of antibiotics, and that’s what caused the antibiotic-resistant bacteria.”

Testing the bacteria in the laboratory

How do you treat a patient who has a bacterial infection that cannot be treated by antibiotics? Fortunately, there are different types of antibiotics, and resistance to one type does not necessarily mean that another type will not work. A laboratory can determine the exact type of bacteria causing an infection, as well as which antibiotics it is resistant to. The reconstructive surgery hospital in Amman is one of the few MSF hospitals in the region with such a laboratory.

“Most of the cases we treat in this hospital are antibiotic-resistant,” says May Al Asmar, laboratory supervisor at MSF’s hospital in Amman. “That’s because all of our patients come from warzones, where they didn’t get the right antibiotics. We do reconstructive surgery, so most samples we process are bone or soft tissue from infected parts. We follow the right steps until we can determine the right antibiotic for an infection and help the doctors decide on the right dosage.”

Setting up a laboratory for microbiology tests is not easy in places affected by violence. While the necessary equipment is not particularly expensive or complex, the space must be very well organised. Laboratories like this also need highly trained staff, because processing the samples requires specialist knowledge and exceptionally rigorous protocols. Contaminating a sample with other bacteria has to be avoided at all costs. Equally important is that the bacteria from the sample do not escape, as potentially they are very dangerous.

MSF is currently trying to set up more of these laboratories, as well as expanding its collaboration with external laboratories. Not only is finding the right antibiotic treatment crucial for treating infections with resistant bacteria, but it is also crucial for preventing bacteria from becoming resistant in the first place. A more effective course of antibiotics will eliminate more bacteria, thereby decreasing the chance that resistance will develop. An ineffective course, on the other hand, can strongly stimulate the bacteria’s resistance.

To prevent this, MSF has started to train its medical staff in the region in the optimal use of antibiotics. Doctors clearly need to know how to prescribe the correct antibiotics, but given the very complex situation of antibiotic resistance, knowing which drugs to prescribe and when is not that simple. Antibiotic stewardship programmes are key to improving the use of antibiotics in hospitals.

Dr Marwa Qasim Mohammed is one of a group of doctors trained in antibiotic stewardship after joining the team in MSF’s hospital in Aden, Yemen. “Before working with MSF, we prescribed antibiotics to the patient not according to the type of infection, but based on the principle that this antibiotic should always be given after surgery for one week to 10 days or even two weeks,” says Dr Marwa. “We didn’t follow a specific protocol and we never relied on lab results.” But that has all changed. “Now we’ve learned to follow a protocol that defines the type of antibiotic that should be used for different infections,” she says. “We received specialised training courses on resistant bacteria – about choosing the right antibiotic for the right type of bacteria.”

Also vital in hospitals are infection prevention and control (IPC) measures. Even if rigorous rules on the use of antibiotics can help prevent bacteria from becoming resistant in the hospital itself, some patients will already be infected with resistant bacteria when they are admitted to hospital. And it is crucial that these resistant bacteria do not infect anybody else.

“The main principle of IPC is hygiene,” says Fatima Salim Younis, in charge of infection prevention and control in MSF’s post-operative care hospital in Mosul, Iraq. Two years after a violent battle was fought over the city, the lack of proper medical care is still impacting large numbers of people. Many patients in MSF’s hospital suffer from infections caused by antibiotic-resistant bacteria. “The main aim of our IPC programme is to protect the staff, the other patients and visiting family members from contracting bacteria from these patients,” says Fatima.

Challenges to applying the procedures

But putting in place proper IPC measures is easier said than done, especially in a place affected by violence. “Applying these procedures in Mosul’s hospitals presents challenges,” she adds. “Hospital capacity in Mosul is limited, yet the city is faced with a growing number of patients. It’s almost impossible to apply the correct procedures in an overcrowded environment. Additionally, in many hospitals, procedures aren’t clear or aren’t applied properly, there’s a lack of supplies and a lack of awareness among medical staff.”

One of the biggest challenges involves the patients themselves, who are often unused to following strict protocols. “Patients are used to different lifestyles outside the hospital, but once they are inside, they have to adhere to the IPC procedures,” says Fatima.

Before being admitted to hospital, patients may have their own ideas about their treatment, or even have taken it into their own hands. Antibiotics are sold over the counter without a prescription in many countries, particularly in the Middle East, which feeds the problem of antibiotic resistance. “Many people think that suffering from a wound or infection means they need any kind of antibiotic from the pharmacy, without a doctor’s prescription,” says Amal Abed, a health promoter in one of MSF’s hospitals in Gaza.

This hospital in Gaza almost exclusively treats patient shot during protests at the border with Israel. Their gunshot wounds are precisely the type of injury that require a very considered use of antibiotics. “Many patients will complain if they’re not continuously receiving antibiotic prescriptions,” says Amal. “I always explain that antibiotics should only be prescribed when they are really useful for your body.”

The role of health promoters in MSF projects is a vital one, both for helping patients understand the treatment and for helping them accept the necessary infection prevention and control measures. Some measures can seem quite drastic to patients, such as being isolated for several weeks at a time in a single room rather than staying in a large shared ward.

“When patients are told they need to be isolated because their infections are caused by resistant bacteria, they start to worry,” says Amal. “But we tell them that they can still go about their normal lives and people can come to visit them – there are just a few precautions to be taken. When they realise that everything is normal – that they can leave their room with a gown on after using hand sanitiser, for example – they accept it.”

Amal can see the impact of health promotion activities on patients. “I’ve noticed that, after attending health promotion sessions, patients will approach and explain things to new patients,” she says. “It makes me very happy when patients spread the messages in their own communities and share them with other wounded people.”

Spreading the word about antibiotic resistance is important, because the problem is not limited to MSF’s hospitals, or even to healthcare facilities in general; it is a problem for society as a whole.

“Thanks to God and the efforts of the doctors, I am now 90 per cent cured,” say Waleed, back in Amman. For more than three years he has suffered from a bone infection, and it has taken months of specialist care in MSF’s hospital to reach this stage of recovery.

Waleed’s treatment has been a success, but the challenges of tackling antibiotic resistance extend far beyond MSF’s hospital wards. “MSF can only try to address a small part of the problem of antibiotic resistance,” says Dr Jorgen. “We have very little influence on private healthcare providers, which make up the biggest part of the healthcare system in many countries. And the vast majority of antibiotics are not even used in medicine, but in livestock breeding and agriculture, over which we have no say. What we’re trying to do across MSF projects can make a big difference in our own facilities, but much more is needed to tackle the problem of antibiotic resistance as a whole.”

Despite the complexity of antibiotic resistance, and despite the many challenges we face, MSF is trying to play its part in the worldwide battle against antibiotic resistance and is committed to doing more in the coming years. Antibiotics are just too important – to our patients and to our doctors – for us to lose this fight.