and Stenotrophomonas (now called Xanthomonas) maltophilia (4%) (Oncul et al. 2002). Mortality was high, and antibiotic resistance was common, including methicillin resistance in all nine S. aureus strains and resistance to all tested antibiotics, such as carbapenems, in two A. baumannii strains and one P. aeruginosa strain (Oncul et al. 2002).
In a 1999 outbreak, 12 of 170 (7%) ICU patients in a Turkish hospital acquired A. baumannii infection; of 25 strains isolated, all were carbapenem-resistant, and the ICU had to be closed and disinfected because of environmental contamination and continuing transmission (Aygun et al. 2002). Wound infections in a Saudi Arabian hospital were assessed in the hot summer months of an unspecified year, possibly 1994 or 1995; of 2331 wounds, 193 (8%) were infected with 283 bacterial strains, and the most prevalent organisms were S. aureus (35% of strains), E. coli (31%), P. aeruginosa (25%), and Klebsiella spp. (10%) (Abussaud 1996). Neonatal ICUs have also experienced multiple-drug-resistant Acinetobacter spp. infections in the Middle East; one series of seven Saudi neonates (of whom three died) demonstrated sensitivity only to imipenem and resistance to 12 other antibiotics tested (probably in 2002 or 2003) (Manzar 2004).
One hundred and fifty-seven patients (96% men) at a military hospital in Turkey in 1994-1999 were admitted because of maxillofacial fractures (Ortakoglu et al. 2004). The precipitating events were from traffic accidents (44%), combat (27%), falls (17%), work accidents (10%), and sports (3%). Infectious complications occurred in local wounds and with osteomyelitis due to delayed primary treatment or delayed evacuation. Organisms of concern were not detailed, nor were the treatment experiences of the infected patients.
In two ICUs in Saudi Arabia and Kuwait where gram-negative bacterial isolates were studied in 1994-1995, A. baumannii isolates made up 42 of 207 isolates from 172 patients; they were much more common in Kuwaiti isolates (33%) than in Saudi isolates (8%) (Rotimi et al. 1998). Detailed susceptibility testing suggested that all 42 A. baumannii isolates were sensitive to imipenem (both sites) and that all 33 isolates in Kuwait were sensitive to ciprofloxacin and 89% (eight of nine isolates) in Saudi Arabia (Rotimi et al. 1998).
War in Lebanon in 1984 was associated with A. baumannii infection in 36 patients with isolates obtained from sputum, wounds, blood, urine, ulcer swab, or vaginal swab (Matar et al. 1992); the organisms were largely sensitive to minocycline, imipenem, and ciprofloxacin at that time.
Osteomyelitis was common in 210 patients with maxillofacial injuries seen at the Mostafa-Khomeini Hospital in Tehran, Iran, during the 1981-1986 Iran-Iraq war (Akhlaghi and Aframian-Farnad 1997). Missile or blast hits accounted for 94% of cases, and motor-vehicle accidents 6%. Twenty-four persons (11%) had infectious complications: eight with mandibular and one with maxillary osteomyelitis, one with cervical abscess, six with foreign-body infections (four in silicone implants), and eight with other infections. The authors attributed the high incidence of osteomyelitis to the inability to evacuate and promptly treat patients with wounds, something that will occur only rarely in US military troops (such as in capture after injury with later release). No organisms or treatment approaches were presented in the Iranian series, although the surgical antibiotics used were limited to cephalotin, gentamycin, ampicillin, and penicillin.
Afghan guerrilla combatants and civilians seen in a Pakistani hospital in 1985-1987 also had very high wound- and bone-infection rates, which were attributed to the long time between injury and medical attention (Bhatnagar et al. 1992). In 1274 patient records reviewed, about 50% of the patients had musculoskeletal injuries. Comminuted fractures and foreign bodies were