Injured Libyan combatant patients: both vectors and victims of multiresistance bacteria?

T he emergence of multidrug resistant bacteria is a global health problem (1Á3), affecting the management and outcomes of a wide spectrum of infections particularly in hospitals. Resistance contributes to mortality and compromises the healthcare security of nations. Moreover, resistant pathogens are spread between countries by human travel (4Á8), including the medical transfer and evacuation of combat casualties. Over 30,000 young patients injured during the recent conflict in Libya were transferred directly or indirectly to hospitals in North Africa, the Middle East, and Europe for treatment. Many of those transferred to Europe were found to be colonized or infected with multiresistant organisms, including methicillin-resistant Staphylococcus aureus (MRSA), extended-spectrum b-lactamase (ESBL) Á and/or Enterobacteriaceae, Acinetobacter baumannii, and Pseudomonas aeruginosa. In Germany, Klebsiella pneumoniae harboring OXA-48, CTX-M-15, and a DHA-1 AmpC-b-lactamases was recovered from 17 Libyan injured patients along with A. baumannii carrying OXA-23 and NDM-1 carbapene-mases. It was suggested that the bacteria with these carbapenemases were acquired while the patients were hospitalized in Libya (9). Most recently, 45 patients admitted to Danish hospitals were found to be carriers of K. pneumonia with OXA-48 carbapenemase; three had A. baumannii with OXA-23 enzyme, one had A. baumannii with NDM-1, and five carried MRSA. MRSA t037-III was found in two of the patients and is a rare spa type in Denmark, while the isolates with OXA-48-producing and NDM-1 enzymes were the first producers of these enzymes to be recorded in Denmark (10). Similarly, the first OXA-48-positive-K. pneumoniae to be documented in Slovenia was obtained from an injured Libyan combatant (11). The United Kingdom has also reported several isolations of OXA-48-positive K. pneu-moniae from patients transferred for treatment following combat injuries in Libya (12). Even before these reports, the European Centre for Disease Prevention and Control (ECDC) circulated a rapid risk assessment on October 31, 2011, stating that the provision of healthcare to patients transferred from Libya to the European Union presents a high risk of introducing multiresistant bacteria (13). This, along with other ECDC risk assessments specifically relating to carbape-nemase-producing Enterobacteriaceae, was distributed to institutions accepting Libyan patients and their micro-biological laboratories (14). Several local studies have reported widespread multi-resistant organisms in Libya itself. Recently, Franka et al. found multiresistance rates exceeding 50% among Gram-negative bacilli which were recovered from screening specimens of 36 combatant patients treated at three hospitals in Tripoli, Libya (15), whilst 144 of 498 (29.8%) patients admitted to Tripoli Medical …