Travel Medicine and Infectious Disease (2012) 10, 157e161

Available online at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals / tmid

CASE REPORT

Microbiological findings from the Haiti disaster

Alexandre Rodrigues Marra a,*, Marines Dalla Valle Martino b,Mauro Ricardo Ribas a, Carlos Rodriguez-Taveras c,Oscar Fernando Pavao dos Santos a

a Intensive Care Unit, Hospital Israelita Albert Einstein, Sao Paulo, BrazilbClinical Pathology, Hospital Israelita Albert Einstein, Sao Paulo, Brazilc Infectious Diseases Division, Hospital Central de Las Fuerzas Armadas, Santo Domingo, Dominican Republic

Received 27 September 2011; received in revised form 14 March 2012; accepted 20 March 2012Available online 20 April 2012

KEYWORDSMicrobiology;Disaster;Haiti;Resistant;Gram-negativebacteria

* Corresponding author. Av. AlbertCare Unit, 5th floor Morumbi, Sao Paþ55 37471500; fax: þ55 37473561.

E-mail address: alexmarra@einstei

1477-8939/$ - see front matter ª 201doi:10.1016/j.tmaid.2012.03.007

Summary There are few data regarding microbiological findings from the disaster situationin Haiti. A rapid and accurate diagnosis of infection is necessary for the optimal efficacy ofantimicrobial therapy, considering the antimicrobial spectrum and the duration of treatment.Furthermore, understanding the microorganisms and their susceptibility profiles is necessary toimplement appropriate infection control policies and to contain the emergence and dissemina-tion of Gram-negative multidrug-resistant pathogens.ª 2012 Elsevier Ltd. All rights reserved.

Introduction

On January 12, 2010, an earthquake measuring 7.0 on theMoment magnitude scale (Mw) occurred approximately25 km (16 miles) west of Port-au-Prince, Haiti’s capital.1 Anestimated three million people were affected by the quake,which caused more than three-hundred-thousand people todie, three-hundred-thousand people to be injured and onemillion people to become homeless.1

Einstein, 627/701 Intensiveulo 05651-901, Brazil. Tel.:

n.br (A.R. Marra).

2 Elsevier Ltd. All rights reserved

Many countries responded to appeals for humanitarianaid and medical teams.1,2 On February 5 the Hospital Isra-elita Albert Einstein in Sao Paulo, Brazil, sent a team towork with the Harvard Humanitarian Initiative1 in anorphanage in Fond Parisien, Haiti. There was no microbio-logical support to assist the doctors in choosing antimicro-bial therapy. Therefore, we decided to collect culturesfrom patients who were earthquake victims with infectedwounds and to analyse the cultured pathogens and theirantibiotic susceptibility patterns.

Methodology

The participants of the Brazilian team included five doctors(specialising in infectious diseases, orthopaedics, paediatrics,

.

158 A.R. Marra et al.

obstetrics and anaesthesiology), six nurses, two laboratorytechnicians, one pharmacist and an electrical engineer. Thismission team travelled to a large displacement camp in anorphanage (“Love a Child”, or “Renmen yon Timoun” in theCreole language) in Fond Parisien on the Haitian side of thecountry’s border with the Dominican Republic. The camp wascreated to accommodate several hundred injured Haitianearthquake victims.

Upon arrival, the team discovered that Haiti was defi-cient in reliable facilities for microbiological study ofinfected wounds; thus, the wounds were empiricallytreated with antibiotics. We believed that the microbiologyof wound infections occurring after major disasters wouldbe different from that of routine wound infections in hos-pitalised patients. Therefore, due to the limited resourcesof the operating room (tents), the nature of the injuries,and the lack of post-operative care (hand hygiene), wedecided to collect cultures from the infected wounds usingAmies agar gel with charcoal swabs (Copan Italia, S.p.A,Brescia, Italy). Ten days after collection, the swab speci-mens were sent to a private microbiology laboratory in theDominican Republic. The samples were plated onto bloodagar, chocolate agar and MacConkey agar and were thenincubated at 35e37 �C to identify non-fastidious aerobicbacteria. The bacterial growth was identified by automatedmethods (Vitek 2 system). Antimicrobial susceptibilitytesting of the bacterial isolates was performed using thesame automated method described above. Interpretationcriteria for susceptibility or resistance were followedaccording to the Clinical and Laboratory Standards Institute(CLSI) guidelines.3 There was no permission to transportthese biological materials to a microbiology laboratory inBrazil, as would have been required by international laws.

We included only the 14 wound-infection patients whohad purulent discharges. Because translators were onlyavailable to translate from Creole to English or to Spanish,but not to Portuguese, obtaining information directly fromeach patient was limited. However, data on gender, type ofsurgery, site of surgery, infectious microorganisms andantimicrobial susceptibilities were adequately collected(see Table 1).

Results

All 14 patients had developed wound infections in theaftermath of the earthquake, and 93% of the wounds werein their lower limbs. All of these patients received oralciprofloxacin as an empirical antimicrobial therapy. Almostone-half of the patients (42.5%, 6/14) were submitted toa surgical procedure, such as amputation or the externalfixation or surgical fixation of fractures (Table 1).

As presented in Table 1, the majority of the isolatedmicroorganisms were Gram-negative (80%, 8/10), includingAcinetobacter baumannii, Enterobacter cloacae, Escher-ichia coli, Klebsiella pneumoniae and Pseudomonas aerugi-nosa. Interestingly, only a single type of organism waspresent in each culture, even after collecting more than onesample in some patients. Of these Gram-negative bacteria,three-quarter were resistant to trimethoprim/sulphame-thoxazole (75.0%, 6/8); furthermore, more than one-third(37.7%, 3/8) were resistant to the cephalosporins, including

ceftriaxone, ceftazidime and cefepime. One case (12.5%, 1/8) was not susceptible to ciprofloxacin even though thepatient had not previously received this antimicrobialtherapy (Table 1). An X-raymachine was not available duringthe visit of thefirst Brazilian team; thus, itwas not possible toconfirm the presence of osteomyelitis in these cases.

Discussion

The devastation of the 2010 earthquake in Haiti com-pounded the intractable problems of poverty, deforestationand the loss of the country’s microbiotic ecosystem.4 Thereare not many reports that recommend procedures medicalstaff should follow in these situations for taking care ofpatients and avoiding the spread of infectious diseases.5e7

It is known that the majority of infections during disas-ters are caused by Gram-negative aerobic bacteria7,8 andassociated with increased mortality9 when complicated bysepsis.7 Most of the earthquake victims suffered injurieswith tissue damage and open wounds, which could beheavily contaminated with soil and debris.8,10

During our stay in Found Parisien, Haiti, there was noaccess to microbiological methods for guiding the initialtreatment of infected patients; moreover, there wereearthquake victims with serious injuries that still neededsurgical care or basic care such as local dressings. The onlyavailable antibiotic for the treatment of these patients wasciprofloxacin with easy dosing (twice a day); previousreports had revealed that cephalosporins are not the mostsuitable for use due to possible infections by Gram-negativebacteria that are resistant to this class of drugs (e.g.,extended-spectrum beta-lactamases, ESBL).5,8,11

Pathogens that thrive in Haiti’s warm groundwater areflushed out by heavy rains and hurricanes, enabling theorganisms to spread and cause new disease outbreaks.4 Thisfact can corroborate the findings that the majority of theinfected wounds are caused by Gram-negative bacteria.Associated with this comment, the following factors allcontributed to the development of some multidrug-resistant Gram-negative infections: the presence of devi-talised tissue; fluid collections; clots in the wounds; theabsence of contact barrier precautions; poor hand hygiene,surgical technique and sterilisation of materials; environ-mental microorganism reservoirs; and the positioning ofpatients on the bare ground inside the tents.5,11 Pathogenssuch as Acinetobacter, Pseudomonas and Klebsiella cancontaminate traumatic wounds and are common inhabi-tants of soil and water.5

In general, a rapid and accurate diagnosis of infection iscritical for effective antimicrobial therapy, considering theantimicrobial spectrum and the duration of the treatment.Furthermore, an understanding of the types of bacteriainvolved and their susceptibility profiles are essential forimplementing appropriate infection control policies and forcontaining the emergence and dissemination of Gram-negative multidrug-resistant pathogens.3,4

Ready access to a microbiology laboratory would beadvantageous for the management of not only woundinfections but also other infections in the triage areas or inthe patient tents e infections such as pneumonia, urinarytract infections or sepsis.

Table 1 Characteristics of 14 wound-infection patients.

No. Sex Woundlocation

Surgicalprocedure

Days from woundoccurrence toswab collection

Cultureresults

AST susceptible (MIC) AST res tant (MIC) Antimicrobialtherapy

Clinicaloutcome

1 F Left lowerlimb

No 27 S. aureus Methicillin (�0.2) e Ciprofloxacin(oral)

CureCiprofloxacin (�0.5)Clindamycin (�0.2)Vancomycin (�1)

2 M Left lowerlimb

No 29 E. coli Trimethoprim-sulphamethoxazole(�20)

Ciprofloxacin(oral)

Amikacin (�2) Ceftria ne (�64) CureCiprofloxacin (�0.2) ceftazi me (�64)Imipenem (�1) cefepim (�64)

3 F Right lowerlimb

Yes(externalfixator)

27 Candidaalbicans

e e Ciprofloxacin(oral)

Cure

4a M Right lowerlimb

Yes(amputation)

29 No growth e e Ciprofloxacin(oral)

Cure

5 M Left lowerlimb

No 27 E. coli Amikacin (�2) Trimeth prim/sulpham thoxazole(�320)

Ciprofloxacin(oral)

CureCiprofloxacin (�0.2)Ceftazidime (�1)Cefepime (�1)Imipenem (�1)Piperacillin-tazobactam(�4)

6 M Right lowerlimb

No 27 P. aeruginosa Amikacin (�2) e Ciprofloxacin(oral)

CureCiprofloxacin (1)Ceftazidime (�1)Cefepime (8)Imipenem (�1)Piperacillin-tazobactam(�1)

7 F Right lowerlimb

Yes(amputation)

27 A. baumannii Ampicillin-sulbactam (8) Amikac (�32) Ciprofloxacin(oral)

Failure;continuedpurulent secretion;changed totrimethoprim-sulphamethoxazolewith dehiscence

Imipenem (�1) Ceftria ne (32)Cefepim (32)Ciproflo acin (4)Trimeth prim/sulpham thoxazole(�320)

8 M Right lowerlimb

No 30 No growth e e Ciprofloxacin(oral)

Cure

(continued on next page)

Micro

biology

inHaiti

159

is

xodie

oe

inxoexoe

Table 1 (continued )

No. Sex Woundlocation

Surgicalprocedure

Days from woundoccurrence toswab collection

Cultureresults

AST susceptible (MIC) AS t (MIC) Antimicrobialtherapy

Clinicaloutcome

9b F Left upper limb No 41 K. pneumoniae Amikacin (�2) Tri /sul oxazole(�

Ciprofloxacin(oral)

CureCiprofloxacin (2)Ceftriaxone (�1)Ceftazidime (�1)Cefepime (�1)Imipenem (�1)

10c F Left lowerlimb þ gluteo

No 39 P. aeruginosa Amikacin (�2) e Ciprofloxacin(oral)

CureCiprofloxacin (�0.2)Ceftazidime (4)Cefepime (2)Imipenem (�1)Piperacillin-tazobactam (8)

11 F Right lowerlimb

Yes(surgicalfixation offracture)

35 No growth e e Ciprofloxacin(oral)

Cure

12c M Left lowerlimb

No 39 E. cloacae Ciprofloxacin (Z2) Tri im/sul oxazole(�

Ciprofloxacin(oral)

Cure

Piperacillin-tazobactam (32) Ce (�64)Amikacin (8) Ce 32)Imipenem (�1)

13 M Right lowerlimb

Yes (surgicalfixation offracture)

35 No growth e e Ciprofloxacin(oral)

Cure

14b M Right lowerlimb

Yes (surgicalfixation offracture)

39 E. cloacae Amikacin (�2) Tri im/sul oxazole(�

Ciprofloxacin(oral)

CureCeftriaxone (�1)Ceftazidime (8)Cefepime (�1)Ciprofloxacin (0.5)Piperacillin-Tazobactam (�4)Imipenem (�1)

AST Z antimicrobial susceptibility test; MIC Z minimum inhibitory concentration (mg/mL).a Four samples with the same culture result.b Two samples with the same culture result and AST.c Three samples with the same culture result and AST.

160A.R.Marra

etal.

T resistan

metoprimphameth320)

methoprphameth320)ftriaxonefepime (

methoprphameth320)

Microbiology in Haiti 161

Author’s contributions

AM and MRR participated in the data collection andanalysis. AM, MDVM, CRT and OFPS participated in thestudy design and coordination and helped to draft themanuscript.

All authors read and approved the final manuscript.

Conflict of interest

None declared.

Acknowledgements

We thank the Harvard Humanitarian Initiative for their keycontribution as a partner in the management of the Haitianwound-infection patients.

We also thank the Hospital Israelita Albert Einsteinhealthcare volunteers and the people of Haiti for theirwarm welcome of our team. We all learned a great dealabout human caring and solidarity.

References

1. Harvard Humanitarian Initiative. (Accessed at http://www.hhi.harvard.edu, March 25, 2011).

2. Kidder T. Recovering from disaster-partners in health and theHaitian earthquake. N Engl J Med 2010;362:769e72.

3. Clinical Laboratory Standards Institute. Performance standardsfor antimicrobial susceptibility testing: twentieth informa-tional supplement. Wayne, PA: M100-S20; 2010. CLSI document.

4. Wampler P. Pick sanitation over vaccination in Haiti. Nature2011;470:175.

5. Uckay I, Sax H, Harbarth S, Bernard L, Pittet D. Multi-resistantin repatriated patients after natural disasters: lessons learnedfrom the 2004 tsunami for hospital infection control. J HospInfect 2008;68:1e8.

6. Murray CK. Infectious diseases complications of combat-related injuries. Crit Care Med 2008;36:358e64.

7. Keven K, Ates K, Sever MS, Yenicesu M, Canbakan B, Arinsoy T,et al. Infectious complications after mass disasters: the Mar-mara earthquake experience. Scand J Infect Dis 2003;35:110e3.

8. Tao C, Kang M, Chen Z, Xie Y, Fan H, Qin L, et al. Microbiologicstudy of the pathogens isolated from wound culture amongWenchuan earthquake survivors. Diagn Microbiol Infect Dis2009;63:268e70.

9. Wen J, Shi YK, Li YP, Wang L, Cheng L, Gao Z, et al. Risk factorsof earthquake inpatient death: a case control study. Crit Care2009;13:R24.

10. Centers for Disease Control and Prevention. Fact sheet aboutEmergency wound care after an earthquake. Available at:[acessed 23.02.12], http://www.bt.cdc.gov/disasters/earthquakes/haiti/haitiwoundcare.asp; 2010.

11. Kiani QH, Amir M, Ghazanfar MA, Iqbal M. Microbiology ofwound infections among hospitalised patients following the2005 Pakistan earthquake. J Hosp Infect 2009;73:71e8.