title: Multidrug-resistant chronic osteomyelitis complicating war injury in Iraqi civilians.
abstract: 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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Médecins Sans Frontières/Doctors Without Borders, New York, NY, USA. richard.murphy@newyork.msf.org
authors.forename: Richard A
authors.initials: RA
authors.lastname: Murphy
authors.forename: Jean-Baptiste
authors.initials: JB
authors.lastname: Ronat
authors.forename: Rasheed M
authors.initials: RM
authors.lastname: Fakhri
authors.forename: Patrick
authors.initials: P
authors.lastname: Herard
authors.forename: Nikki
authors.initials: N
authors.lastname: Blackwell
authors.forename: Sophie
authors.initials: S
authors.lastname: Abgrall
authors.forename: Deverick J
authors.initials: DJ
authors.lastname: Anderson
mesh_terms: D000328:Adult; D002908:Chronic Disease; D024901:Drug Resistance, Multiple, Bacterial; D005260:Female; D006801:Humans; D015994:Incidence; D054542:Iraq War, 2003-2011; D008297:Male; D008875:Middle Aged; D008889:Military Personnel; D010019:Osteomyelitis / Q000188:drug therapy / Q000453:epidemiology* / Q000209:etiology; D012189:Retrospective Studies; D014481:United States / Q000453:epidemiology; D014947:Wounds and Injuries / Q000150:complications* / Q000453:epidemiology