Antibiotic Resistance in Palestine: An Emerging Part of a Larger Crisis
Since March 30th, Palestinians have been holding weekly demonstrations along the fence between Gaza and Israel in commemoration of the 70th anniversary of the “Nakba,” the 1948 event that saw nearly 750,000 flee what is now Israel. The response of Israeli forces has been extremely violent: Since demonstrations began, over 4,100 protesters have been injured by live ammunition. On May 14-15th alone, 62 Palestinians were killed (including one healthcare worker) and 3,414 were injured, including 147 with critical, life-threatening conditions and 271 children. From April to mid-July, Médecins Sans
Frontières (MSF) facilities received over 1,600 trauma patients.
MSF has been providing surgical care (debridement, closure, grafts, flaps, and orthopedic surgery), as well as comprehensive post-operative physical therapy in 4 clinics in Gaza during this time. 90% of those admitted had lower limb injuries due to gunshot wounds. Among those with fractures, 70% needed external fixation and 80% had some degree of bone loss. “Dirty wounds,” those contaminated during trauma or with active infection or significant devitalized tissue, were common. Many arrived at MSF facilities after previous surgeries in hospitals with limited infection control procedures, stressed by
repeated mass casualty events. Wound break down, tibial non-union, and osteomyelitis will affect substantial numbers. Amputation will be unavoidable for many patients.
Even in well-resourced settings, 20-40% of patients with these kinds of injuries develop deep bone infections (1-3). In Gaza, the rate of infectious complications will likely be higher, and multi-drug resistant polymicrobial infections are a near certainty. The Middle East is a known hotspot for antibiotic resistance (ABR). In Gaza, ABR has been documented across inpatient and outpatient settings: ESBLs (Extended-spectrum β-lactamase), MRSA (Methicillin-resistant Staphylococcus aureus), and carbapenamase-producing pathogens have all been found (4-11). Yet, research to date is of inconsistent
quality, and establishing overall Palestinian ABR rates is not possible. However, MSF’s experience in the Middle East may be instructive. Multi-drug resistant pathogens were found in 50% of similarly conflict affected Syrian, Iraqi, and Yemeni patients at the MSF reconstructive surgical hospital in Jordan.
In Palestine, antibiotics are poorly regulated and available on the private market without a prescription. In health facilities, antibiotics are overused and often inappropriately prescribed (4). MSF recently evaluated public and private laboratories and found, despite the encouraging presence of robust data collection systems, many labs were lacking basic reagents for identifying bacteria, forcing technicians to identify them visually without biochemical confirmation. There was a lack of support for technicians interpreting results, few guidelines in place for antibiotic sensitivity testing (AST), and no quality control procedures. There was also a lack of experience processing bone/tissue cultures, a necessary part of infectious complication management in orthopedic trauma. In this setting - where the health system was already in crisis before the most recent violence - adding an overwhelming number of surgical cases to hospitals risks creating an epidemic of ABR infection.
There are some technical solutions to this emerging crisis: strengthening laboratory capacity in Gaza by improving the supply chain, training technicians to process bone/tissue samples, implementing internal quality controls, standardizing AST methods, making guidelines more available for he technicians who identify resistance mechanisms, and strengthening ABR surveillance to inform the empiric treatment in critically unwell patients would all help. Meanwhile, samples should also be sent to reference laboratories outside of Gaza in Tel Aviv or Jerusalem for AST. Rational antibiotic use should be
promoted, based on reliable microbiology results, and the need for surgical expertise and infection control support should not be underestimated.
Beyond technical solutions, other steps would avert ABR. Medical professionals must be permitted to access training opportunities in Israel, Egypt, or Jordan. Importantly, patients should be transferred outside of Gaza when the complexity of their injuries exceeds the ability of local hospitals to treat them. Authorizations to refer Palestinian patients are not granted routinely by Israeli authorities. The WHO has stated that 49% of transfers were denied as of July 3rd, 2018, a significant increase compared to the 9% denial rate previously established (12). In the current group of injuries, primarily among young men, authorization is even less likely to be granted.
ABR is a significant part of this evolving medical humanitarian crisis. Gaza is facing a generation of young adults whose injuries will result in lifelong disability due to the Israeli military’s response. The volume of civilian casualties is overwhelming the health system, and there are ongoing injuries as demonstrations continue. Complex care service expertise (including surgical, pain management, mental health, physiotherapy, nursing) is needed to manage the immediate and longer-term consequences of this unique trauma. The enormous surgery, rehabilitation, and infection management needs will require
both external support to optimally manage these patients as well as urgent, on-site support.
1. Sathiyakumar V, Thakore RV, Stinner DJ, Obremskey WT, Ficke JR, Sethi MK.
Gunshot-induced fractures of the extremities: a review of antibiotic and debridement practices.
Curr Rev Musculoskelet Med. 2015;8(3):276-89.
2. Ktistakis I, Giannoudi M, Giannoudis PV. Infection rates after open tibial fractures: are
they decreasing? Injury. 2014;45(7):1025-7.
3. Prodromidis AD, Charalambous CP. The 6-Hour Rule for Surgical Debridement of Open
Tibial Fractures: A Systematic Review and Meta-Analysis of Infection and Nonunion Rates. J
Orthop Trauma. 2016;30(7):397-402.
4. Alyacoubi S, Abuowda Y, Albarqouni L, Bottcher B, Elessi K. Inpatient management of
community-acquired pneumonia at the European Gaza Hospital: a clinical audit. Lancet.
2018;391 Suppl 2:S40.
5. Elmanama AA, Laham NA, Tayh GA. Antimicrobial susceptibility of bacterial isolates
from burn units in Gaza. Burns. 2013;39(8):1612-8.
6. Astal Z. Susceptibility patterns in Pseudomonas aeruginosa causing nosocomial
infections. J Chemother. 2004;16(3):264-8.
7. Astal Z, El-Manama A, Sharif FA. Antibiotic resistance of bacteria associated with
community-acquired urinary tract infections in the southern area of the Gaza Strip. J Chemother.
2002;14(3):259-64.
8. Chen L, Al Laham N, Chavda KD, Mediavilla JR, Jacobs MR, Bonomo RA, et al. First
report of an OXA-48-producing multidrug-resistant Proteus mirabilis strain from Gaza,
Palestine. Antimicrob Agents Chemother. 2015;59(7):4305-7.
9. Al Laham N, Mediavilla JR, Chen L, Abdelateef N, Elamreen FA, Ginocchio CC, et al.
MRSA clonal complex 22 strains harboring toxic shock syndrome toxin (TSST-1) are endemic
in the primary hospital in Gaza, Palestine. PLoS One. 2015;10(3):e0120008.
10. Al Jarousha AM, El Jadba AH, Al Afifi AS, El Qouqa IA. Nosocomial multidrugresistant
Acinetobacter baumannii in the neonatal intensive care unit in Gaza City, Palestine. Int
J Infect Dis. 2009;13(5):623-8.
11. Aila E. Nasal carriage of methicillin resistant Staphylococcus aureus among health care
workers at Al Shifa hospital in Gaza Strip. BMC Infect Dis. 2017;17(28).
12. WHO. Situation Report: Occupied Palestinian Territory, Gaza (23 June-4 July 2018)2018 4 July 2018. Available from: http://healthclusteropt.org/admin/file_manager/uploads/files/shares/Docu....
Competing interests:
No competing interests
04 September 2018
Rupa Kanapathipillai
Infectious Diseases Physician
Nada Malou, Kate Baldwin, Pascale Marty, Clair Mills, Camille Rodaix, Patrick Herard, Malika Saim
Rapid Response:
Antibiotic Resistance in Palestine: An Emerging Part of a Larger Crisis
Since March 30th, Palestinians have been holding weekly demonstrations along the fence between Gaza and Israel in commemoration of the 70th anniversary of the “Nakba,” the 1948 event that saw nearly 750,000 flee what is now Israel. The response of Israeli forces has been extremely violent: Since demonstrations began, over 4,100 protesters have been injured by live ammunition. On May 14-15th alone, 62 Palestinians were killed (including one healthcare worker) and 3,414 were injured, including 147 with critical, life-threatening conditions and 271 children. From April to mid-July, Médecins Sans
Frontières (MSF) facilities received over 1,600 trauma patients.
MSF has been providing surgical care (debridement, closure, grafts, flaps, and orthopedic surgery), as well as comprehensive post-operative physical therapy in 4 clinics in Gaza during this time. 90% of those admitted had lower limb injuries due to gunshot wounds. Among those with fractures, 70% needed external fixation and 80% had some degree of bone loss. “Dirty wounds,” those contaminated during trauma or with active infection or significant devitalized tissue, were common. Many arrived at MSF facilities after previous surgeries in hospitals with limited infection control procedures, stressed by
repeated mass casualty events. Wound break down, tibial non-union, and osteomyelitis will affect substantial numbers. Amputation will be unavoidable for many patients.
Even in well-resourced settings, 20-40% of patients with these kinds of injuries develop deep bone infections (1-3). In Gaza, the rate of infectious complications will likely be higher, and multi-drug resistant polymicrobial infections are a near certainty. The Middle East is a known hotspot for antibiotic resistance (ABR). In Gaza, ABR has been documented across inpatient and outpatient settings: ESBLs (Extended-spectrum β-lactamase), MRSA (Methicillin-resistant Staphylococcus aureus), and carbapenamase-producing pathogens have all been found (4-11). Yet, research to date is of inconsistent
quality, and establishing overall Palestinian ABR rates is not possible. However, MSF’s experience in the Middle East may be instructive. Multi-drug resistant pathogens were found in 50% of similarly conflict affected Syrian, Iraqi, and Yemeni patients at the MSF reconstructive surgical hospital in Jordan.
In Palestine, antibiotics are poorly regulated and available on the private market without a prescription. In health facilities, antibiotics are overused and often inappropriately prescribed (4). MSF recently evaluated public and private laboratories and found, despite the encouraging presence of robust data collection systems, many labs were lacking basic reagents for identifying bacteria, forcing technicians to identify them visually without biochemical confirmation. There was a lack of support for technicians interpreting results, few guidelines in place for antibiotic sensitivity testing (AST), and no quality control procedures. There was also a lack of experience processing bone/tissue cultures, a necessary part of infectious complication management in orthopedic trauma. In this setting - where the health system was already in crisis before the most recent violence - adding an overwhelming number of surgical cases to hospitals risks creating an epidemic of ABR infection.
There are some technical solutions to this emerging crisis: strengthening laboratory capacity in Gaza by improving the supply chain, training technicians to process bone/tissue samples, implementing internal quality controls, standardizing AST methods, making guidelines more available for he technicians who identify resistance mechanisms, and strengthening ABR surveillance to inform the empiric treatment in critically unwell patients would all help. Meanwhile, samples should also be sent to reference laboratories outside of Gaza in Tel Aviv or Jerusalem for AST. Rational antibiotic use should be
promoted, based on reliable microbiology results, and the need for surgical expertise and infection control support should not be underestimated.
Beyond technical solutions, other steps would avert ABR. Medical professionals must be permitted to access training opportunities in Israel, Egypt, or Jordan. Importantly, patients should be transferred outside of Gaza when the complexity of their injuries exceeds the ability of local hospitals to treat them. Authorizations to refer Palestinian patients are not granted routinely by Israeli authorities. The WHO has stated that 49% of transfers were denied as of July 3rd, 2018, a significant increase compared to the 9% denial rate previously established (12). In the current group of injuries, primarily among young men, authorization is even less likely to be granted.
ABR is a significant part of this evolving medical humanitarian crisis. Gaza is facing a generation of young adults whose injuries will result in lifelong disability due to the Israeli military’s response. The volume of civilian casualties is overwhelming the health system, and there are ongoing injuries as demonstrations continue. Complex care service expertise (including surgical, pain management, mental health, physiotherapy, nursing) is needed to manage the immediate and longer-term consequences of this unique trauma. The enormous surgery, rehabilitation, and infection management needs will require
both external support to optimally manage these patients as well as urgent, on-site support.
1. Sathiyakumar V, Thakore RV, Stinner DJ, Obremskey WT, Ficke JR, Sethi MK.
Gunshot-induced fractures of the extremities: a review of antibiotic and debridement practices.
Curr Rev Musculoskelet Med. 2015;8(3):276-89.
2. Ktistakis I, Giannoudi M, Giannoudis PV. Infection rates after open tibial fractures: are
they decreasing? Injury. 2014;45(7):1025-7.
3. Prodromidis AD, Charalambous CP. The 6-Hour Rule for Surgical Debridement of Open
Tibial Fractures: A Systematic Review and Meta-Analysis of Infection and Nonunion Rates. J
Orthop Trauma. 2016;30(7):397-402.
4. Alyacoubi S, Abuowda Y, Albarqouni L, Bottcher B, Elessi K. Inpatient management of
community-acquired pneumonia at the European Gaza Hospital: a clinical audit. Lancet.
2018;391 Suppl 2:S40.
5. Elmanama AA, Laham NA, Tayh GA. Antimicrobial susceptibility of bacterial isolates
from burn units in Gaza. Burns. 2013;39(8):1612-8.
6. Astal Z. Susceptibility patterns in Pseudomonas aeruginosa causing nosocomial
infections. J Chemother. 2004;16(3):264-8.
7. Astal Z, El-Manama A, Sharif FA. Antibiotic resistance of bacteria associated with
community-acquired urinary tract infections in the southern area of the Gaza Strip. J Chemother.
2002;14(3):259-64.
8. Chen L, Al Laham N, Chavda KD, Mediavilla JR, Jacobs MR, Bonomo RA, et al. First
report of an OXA-48-producing multidrug-resistant Proteus mirabilis strain from Gaza,
Palestine. Antimicrob Agents Chemother. 2015;59(7):4305-7.
9. Al Laham N, Mediavilla JR, Chen L, Abdelateef N, Elamreen FA, Ginocchio CC, et al.
MRSA clonal complex 22 strains harboring toxic shock syndrome toxin (TSST-1) are endemic
in the primary hospital in Gaza, Palestine. PLoS One. 2015;10(3):e0120008.
10. Al Jarousha AM, El Jadba AH, Al Afifi AS, El Qouqa IA. Nosocomial multidrugresistant
Acinetobacter baumannii in the neonatal intensive care unit in Gaza City, Palestine. Int
J Infect Dis. 2009;13(5):623-8.
11. Aila E. Nasal carriage of methicillin resistant Staphylococcus aureus among health care
workers at Al Shifa hospital in Gaza Strip. BMC Infect Dis. 2017;17(28).
12. WHO. Situation Report: Occupied Palestinian Territory, Gaza (23 June-4 July 2018)2018 4 July 2018. Available from:
http://healthclusteropt.org/admin/file_manager/uploads/files/shares/Docu....
Competing interests: No competing interests