Disengagement Does Not Apply to Bacteria: A High Carriage Rate of Antibiotic-Resistant Pathogens Among Syrian Civilians Treated in Israeli Hospitals

To the Editor—Three years of civil war in Syria have caused the deaths of >100 000 people including 11 000 children, with many more wounded [1]. The healthcare system in Syria is severely compromised and polio cases have been detected [2, 3]. Soon after the 1973 war, Syria and Israel signed an agreement on disengagement; no formal relations exist between the 2 countries. Despite the disengagement, the Israeli army has been providing humanitarian aid to wounded Syrian civilians by emergency medical care in a field hospital near the border and by transferring wounded civilians for medical care in northern Israeli hospitals. Due to incomplete medical history of the Syrian patients and polio in Syria, contact isolation and screening cultures for multidrug-resistant (MDR) bacteria are conducted upon their admission to Israeli hospitals. Here we report a high carriage rate of MDR pathogens among Syrian patients treated in 2 Israeli hospitals, Baruch Padeh Medical Center in Poriya and Galilee Medical Center in Nahariya. Twenty-nine Syrian children (aged 1 day to 16 years) were treated at Galilee Medical Center, and 60 adult Syrian patients were treated at Baruch Padeh Medical Center. Among children, 21 MDR isolates were detected in 19 patients (19/29 [66%]). Extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae comprised 20 of 21 MDR isolates (19/20 were Escherichia coli); 1 isolate was methicillin-resistant Staphylococcus aureus (MRSA). Among the adult patients, 28 of 60 (47%) carried MDR bacteria. In adults, however, the types of MDR isolates differed: carbapenem-resistant Enterobacteriaceae (CRE) carriage was noted (5 patients, 2 with New Delhi metallo-β-lactamase), as well as MRSA (n = 11), MDR Acinetobacter baumannii (n = 5), and ESBL (n = 7). This extremely high rate of ESBL carriage among children, not previously reported, may represent a high rate of community-acquired carriage of MDR isolates among the Syrian pediatric population, which could be caused by injudicious use of antimicrobials (both in humans and livestock) and inadequate sanitation [4, 5]. Indeed, most of the Syrian children we treated had no previous illnesses or admissions to Syrian hospitals. Carriage of MDR bacteria among the adult patients (especially CRE, MRSA, and MDR A. baumannii) can also imply acquisition of resistant bacteria in Syrian hospitals seriously affected by the prolonged war, as described in other areas of conflict [6]. Wounded Syrian patients are being treated in additional countries in the region, such as Turkey and Jordan. Due to this alarmingly high carriage rate of MDR isolates, we feel that contact isolation of Syrian patients, until carriage of MDR isolates is ruled out, is paramount to prevent further spread of these pathogens. Additionally, screening cultures on admission for MDR isolates have an utmost importance in providing the clinician valuable data about antibiotic susceptibilities, thus improving empiric antibiotic treatment when sepsis is suspected. Potential conflicts of interest. All authors: No potential conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.