Crush Syndrome Related Infections: A Retrospective Analysis of Wound Infections in a University Hospital After the 2023 Earthquake in Turkey

Öz

Infection is one of the complications affecting morbidity and mortality after Crush syndrome in earthquake victims. The aim of our study was to determine the frequency and antibiotic susceptibility pattern of microorganisms in wound cultures of earthquake victims admitted to our hospital with post-earthquake trauma-related injuries. For wound cultures, identification and antibiotic susceptibility of bacteria isolated from wound swabs and tissue samples were performed with BD Phoenix (Becton Dickinson, USA). Q scoring was used for the evaluation of wound cultures. A total of 552 patients were admitted to our hospital with earthquake-related injuries. Of these, 186 were hospitalised. The mean age of 14 earthquake survivors (11 females, 3 males) was 36.5 years (2-83) and the mean duration of stay in the rubble was 23.5 hours (8-120 hours). Fasciotomies were performed in 12 of the patients and amputations were performed in 4 of them. A total of 30 microorganisms were isolated from 24 cultures, while 6 cultures were negative. It was found that 30% of the wound infections were polymicrobial and Gram-negative agents were isolated firstly and Gram-positive agents were isolated secondly. The most common agent was Acinetobacter baumanii 56.7% (n:17); the others were Pseudomonas aureginosa 10% (n:3), Enterobacter cloace 10% (n:3), Enterococcus faecium 10% (n:3), Klebsiella pneumoniae 6.7% (n:2), Escherchia coli 6.7% (n:2). Multiple antibiotic resistance was observed in Acinetobacter baumanii, Pseudomonas aureginosa and Klebsiella pneumoniae isolates and nosocomial infection was considered. Generally, multidrug resistant microorganisms are reported after natural disasters. Crush syndrome poses a risk for nosocomial infections and early and appropriate prophylactic antibiotic treatment is important in the prognosis of patients.

Anahtar Kelimeler

• Earhquake
• Crush syndrome
• healthcare-associated infections (HAI);
• Gram negative

Crush Sendromu İlişkili Enfeksiyonlar: 2023 Türkiye Depremi Sonrasında Bir Üniversite Hastanesinde Görülen Yara Enfeksiyonlarının Retrospektif Analizi

Öz

Depremzedelerde meydana gelen Crush sendromu sonrasında enfeksiyon morbidite ve mortaliteyi etkileyen komplikasyonlardan biridir. Çalışmamızın amacı, deprem sonrası travma ilişkili yaralanma ile hastanemize başvuran depremzedelerin yara kültürlerinde mikroorganizmaların sıklığını ve antibiyotik duyarlılık paternini belirlemektir. Yara kültürleri için yara yerlerinden alınan sürüntü ve doku örneklerinden izole edilen bakterilerin tanımlanma ve antibiyotik duyarlılıkları BD Phoenix (Becton Dickinson, ABD) ile yapıldı. Yara kültürlerinin değerlendirilmesinde Q skorlaması kullanıldı. Hastanemize deprem ilişkili yaralanma şikayetiyle toplam 552 hasta başvurdu. Bunlardan 186’sının yatışı yapıldı. Depremzede 14 hastanın (11 kadın, 3 erkek) yaş ortalaması 36,5 (2-83), ortalama enkazda kalma süresi 23,5 saatti (8-120 saat). Hastaların 12’sine fasyotomi uygulanırken, 4’ünün çeşitli uzuvlarına ampütasyon yapılmıştır. Üremesi olan 24 kültürden toplam 30 mikroorganizma izole edilirken; 6 kültürde üreme olmadı. Yara enfeksiyonların %30’u polimikrobiyal olup ilk sırada Gram negatif etkenler ikinci sırada ise Gram pozitif etkenlerin ürediği saptanmıştır. En sık görülen etken Acinetobacter baumanii %56,7 (n:17) iken; diğerleri Pseudomonas aureginosa %10 (n:3), Enterobacter cloace %10 (n:3), Enterococcus faecium %10 (n:3), Klebsiella pneumoniae %6,7 (n:2) Escherchia coli %6,7 (n:2) olarak saptanmıştır. Acinetobacter baumanii, Pseudomonas aureginosa ve Klebsiella pneumoniae izolatlarında çoklu antibiyotik direnci olduğu izlenmiş olup hastane bakımı ilişkili enfeksiyon olduğu düşünülmüştür. Genellikle doğal afetlerden sonra çoklu ilaca dirençli mikroorganizmalar rapor edilmektedir. Crush sendromu hastane enfeksiyonlar için risk oluştururken, erken ve uygun profilaktik antibiyotik tedavisi hastaların prognozunda önem taşımaktadır.

Anahtar Kelimeler

• Deprem
• Crush sendromu
• Sağlık hizmeti ilişkili enfeksiyonlar (SHİE);
• Gram negatif

Kaynakça

1. 1. Yılmaz S, Karakayali O, Yilmaz S, Çetin M, Eroglu SE, Dikme O, et al. Emergency Medicine Association of Turkey Disaster Committee Summary of Field Observations of February 6th Kahramanmaraş Earthquakes. Prehospital and disaster medicine. 2023;38(3):415-8.
2. 2. Kuwagata Y, Oda J, Tanaka H, Iwai A, Matsuoka T, Takaoka M, et al. Analysis of 2,702 traumatized patients in the 1995 Hanshin-Awaji earthquake. J Trauma. 1997;43(3):427-32.
3. 3. Michaelson M. Crush injury and crush syndrome. World J Surg. 1992;16(5):899-903.
4. 4. Testing TECoAS. Breakpoint tables for interpretation of MICs and zone diameters Version 12.0, 2022 [Available from: https://www.eucast.org/clinical_breakpoints.
5. 5. Matkoski C, Sharp SE, Kiska DL. Evaluation of the Q Score and Q234 Systems for Cost-Effective and Clinically Relevant Interpretation of Wound Cultures. Journal of Clinical Microbiology. 2006;44(5):1869-72.
6. 6. Kuwagata Y, Oda J, Tanaka H, Iwai A, Matsuoka T, Takaoka M, et al. Analysis of 2,702 Traumatized Patients in the 1995 Hanshin-Awaji Earthquake. Journal of Trauma and Acute Care Surgery. 1997;43(3):427-32.
7. 7. Bartels SA, VanRooyen MJ. Medical complications associated with earthquakes. Lancet. 2012;379(9817):748-57.
8. 8. Keven K, Ates K, Sever MS, Yenicesu M, Canbakan B, Arinsoy T, et al. Infectious Complications after Mass Disasters: The Marmara Earthquake Experience. Scandinavian Journal of Infectious Diseases. 2003;35(2):110-3.

9. 9. Weigelt JA. Risk of wound infections in trauma patients. Am J Surg. 1985;150(6):782-4.
10. 10. Ran Y-C, Ao X-X, Liu L, Fu Y-L, Tuo H, Xu F. Microbiological study of pathogenic bacteria isolated from paediatric wound infections following the 2008 Wenchuan earthquake. Scandinavian Journal of Infectious Diseases. 2010;42(5):347-50.
11. 11. Wang T, Li D, Xie Y, Kang M, Chen Z, Chen H, et al. The microbiological characteristics of patients with crush syndrome after the Wenchuan earthquake. Scandinavian Journal of Infectious Diseases. 2010;42(6-7):479-83.
12. 12. Oncül O, Keskin O, Acar HV, Küçükardali Y, Evrenkaya R, Atasoyu EM, et al. Hospital-acquired infections following the 1999 Marmara earthquake. J Hosp Infect. 2002;51(1):47-51.
13. 13. Kazancioglu R, Cagatay A, Calangu S, Korular D, Turkmen A, Aysuna N, et al. The characteristics of infections in crush syndrome. Clin Microbiol Infect. 2002;8(4):202-6.
14. 14. Bekçibaşı M, Hoşoğlu S, Deveci Ö, Dayan S. Therapy for wound infections after earthquakes requires inclusion of drugs targeting Gram-negative bacteria. Infectious Diseases. 2017;49(11-12):862-4.
15. 15. Miskin IN, Nir-Paz R, Block C, Merin O, Burshtein S, Pirogovsky S, et al. Antimicrobial therapy for wound infections after catastrophic earthquakes. N Engl J Med. 2010;363(26):2571-3.
16. 16. Eryilmaz-Eren E, Yalcin S, Ozan F, Saatci E, Suzuk-Yildiz S, Ture Z, et al. An outbreak analysis of wound infection due to Acinetobacter baumannii in earthquake-trauma patients. Am JInfect Control. 2023.
17. 17. Özdemir G, Karlıdağ T, Bingöl O, Sarıkaya B, Çağlar C, Bozkurt İ, et al. Systematic triage and treatment of earthquake victims: Our experience in a tertiary hospital after the 2023 Kahramanmaras earthquake. Jt Dis Relat Surg. 2023;34(2):480-7.
18. 18. Özkaya U, Yalçın MB. Deprem yaralanmalı hastada kompartman sendromu ve ezilme (crush) sendromu ayrımı: Fasyotomi kime ve ne zaman. TOTBİD Dergisi.2022;21(3):312-5.
19. 19. Chen X, Zhong H, Fu P, Hu Z, Qin W, Tao Y. Infections incrush syndrome: a retrospective observational study after the Wenchuan earthquake. Emerg Med J. 2011;28(1):14-7.
20. 20. Akgun E, Emet A, Sibar K, Çatma FM, Kocyigit IA, Şahin A, et al. Risk Factors for Surgical Site Infections Following Fasciotomy in Patients With Acute Compartment Syndrome: AStudy on the February 2023 Kahramanmaraş Earthquake. Cureus. 2023;15(10):e46880.