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Investigating Antibiotic Resistance among trauma patients in Aden, Yemen

MSF Aden Trauma Centre Emergency Room (ER)

A recently published retrospective cross-sectional study investigated infections among patients admitted to Aden Acute Trauma Hospital and treated with antibiotics from January 2018 to June 2021, revealing high rates of multidrug-resistant (MDR) infections. In 2017, an Antimicrobial Stewardship program was introduced in the hospital to ensure proper antibiotic use and safety. An empirical treatment guideline was adopted in 2018 and will be updated to reflect the findings of this study. 

Of the 481 patients included in the study, 88% were male, aged between 19 and 45 years old (68.8%). The primary cause of admission was violence-related trauma, mainly from gunshots (64%). Penetrating wounds, particularly to the abdomen and lower limbs, were the most common injuries. A total of 598 infections were diagnosed, with the most common being skin and soft-tissue infections, osteomyelitis, and intra-abdominal infections. 65% of the patients were diagnosed with MDR infections. The study identified a range of bacterial species responsible for infections among trauma patients. The distribution of these bacteria varied depending on the type of infection. Secondary bloodstream infections were observed in 111 out of 598 infections, especially in the case of intra-abdominal or skin and soft-tissue infections.  

Observed antibiotic resistance patterns confirm the need to review empirical treatment guidelines by taking into consideration that: 

  • Most Gram-negatives were ESBL producers, including Escherichia coli (n = 193; 81.4%), Klebsiella pneumoniae (n = 72; 77.4%) and Enterobacter cloacae (n = 39; 50%). Empiric guidelines may have to consider escalated treatments such as carbapenems. 
  • Most Staphylococcus aureus were methicillin-resistant (n = 93; 72.6%). Escalated treatments such as vancomycin or linezolid should be considered and made available. 
  • Acinetobacter baumannii display alarming levels of carbapenem- resistance and limited susceptibility to amikacin, making it necessary to seek alternative treatment strategies.   Despite high susceptibility, colistin can bring about significant side effects for the patients and its effectiveness varies depending on the infection site. 

Better access to microbiology laboratory will contribute to better diagnosis and tailored treatments, reducing the use of reserved antibiotics and broad-spectrum antibiotics. When adapting empiric guidelines to stronger antibiotics, de-scalation strategies need to be in place: the administration of broad-spectrum ("stronger") antibiotics should be discontinued upon availability of laboratory results, allowing for the selection of targeted antibiotics. Lastly, together with better access to microbiology and antibiotic stewardship, effective infection prevention and control measures need to be ensured to decrease infections and prevent the spread of muti-drug resistant bacteria.