Guest blog by Dr. Richard Murphy, Infectious Diseases Referent, and Oliver Yun, Medical Editor, Médecins Sans Frontières/Doctors Without Borders, New York, NY
A major challenge in Haiti in the aftermath of the January 12th earthquake has been, and will continue to be, the management of infected wounds. Untreated wounds have progressed to gangrene and sepsis among some patients who have received inadequate or late initial care. After the earthquake, we sent additional guidance to our medical staff in Haiti for recognizing and treating infected wounds.
Opportunities to prevent wound infections were likely missed in many patients who could not access care or received delayed care after the earthquake. This is unfortunate because it is known that some common types of injuries seen after the earthquake, including open fractures, benefit from early aggressive management. Open fractures, which are fractures in which the skin and soft tissue have also been compromised, have far better outcomes when early antibiotic prophylaxis and surgical wash-out (debridement) are delivered. We expect to see many patients in the weeks and months to come with infectious complications of open fractures and other contaminated injuries.
Past earthquakes have provided some important lessons about the types of infections to expect. After the 2005 earthquake in Pakistan, polymicrobial infections were observed with a prominence of difficult-to-treat pathogens such as Pseudomonas aeruginosa and Acinetobacter spp. The same was true after the 2008 Wenchuan earthquake in China. Oddly, the classic pathogens in skin and soft tissue infections, Staphylococcus aureus and Streptococcus spp, were rarely encountered after the earthquakes in Pakistan and China.
What are the implications? Since we will not have the benefit of a microbiology laboratory to guide our antibiotic choices in Haiti, we will have to base our initial treatment strategies on our best predictions, making use of the experiences from Pakistan and China. In addition to antibiotics, other steps are critical in the management of infected wounds including debridement and tetanus prophylaxis.
We prioritized tetanus vaccine and immunoglobulin in our initial medical-supply shipments to the earthquake zone. Tetanus is a potentially deadly complication of contaminated wounds that we expect to see in Haiti. The existing level of protection to tetanus in the general population is inadequate with only about half of Haitians appropriately vaccinated.
In unvaccinated persons, wound contamination with dirt, saliva, or faeces brings a high risk of infection with tetanus bacteria. Clostridium tetani spores are ubiquitous in the environment and germinate under low oxygen tensions, which are present in closed wounds. As the disease develops, patients develop lockjaw or stiff neck. The syndrome can quickly progress to critical illness requiring intensive medical support.
Prevention is clearly the preferred option and we have urged our staff to ensure that all patients with tetanus-prone wounds receive, at minimum, tetanus toxoid vaccine, with the addition, in some cases, of tetanus immunoglobulins. Because the median incubation period is about a week to 10 days after exposure, we are concerned that a spike in tetanus could occur any time now in Haiti.