Gaza bombardment worsens superbug outbreaks

Content warning: This story contains graphic images and descriptions of injuries

There is a growing and dire public health crisis taking place in Gaza. Israeli blockades and hospital bombings are fuelling a superbug emergency, with civilians who survive starvation and injury later facing untreatable, life-threatening infections.

Doctors on the ground told the Bureau of Investigative Journalism (TBIJ) they were treating wounds infested with maggots and using vinegar to fight infections.

“Wounds are left open much longer [and the] injured are delayed in receiving proper care or not able to get care at all, which increases the risk of infections and emergence of antimicrobial resistance [AMR],” says Krystel Moussally, an epidemiologist monitoring the situation for Doctors without Borders (MSF).

The infections are so severe that they don’t respond to many of the antibiotics that are designed to treat them. Badly infected wounds can lead to limb amputations and, in some cases, death.

Medical organisations, including MSF and Medical Aid Palestine, say that targeted bombings of hospitals and humanitarian aid blockades are restricting access to healthcare in Gaza, exacerbating infections that don’t respond to essential medicines.

In some cases, doctors have run tests to discover that infections can be fought with certain antibiotics – but have not been able to get their hands on the life-saving drugs.

‘I’ve never seen these types of cases before’

As explosions sound in the background, Dr Alaa Alshurafa tries to relay her day-to-day experience treating superbug infections in Gaza city. Over a WhatsApp call that keeps cutting out, she conveys the damage these drug-resistant infections are inflicting in the war zone.

Dr Alaa, 30, was forced to flee her home in northern Gaza with her family after the war began. Despite this, she is serving as a doctor at one of the medical points set up by The International Federation of Red Cross and Red Crescent Societies (IFRC) in Gaza city.

Every morning, before she leaves for work, she checks that no one on her route has reported a warning from the Israeli Defense Force of a potential airstrike. The clinic is a 15-minute walk from where she lives. She has to do the journey on foot, leaving her exposed to a potential attack by drone, air or sniper.

Once she does arrive at the clinic, the medical point is flooded with more than a hundred patients a day.

When she spoke to TBIJ, she was facing an outbreak of impetigo, a highly contagious bacterial skin infection most common in children. It causes blisters and itchy sores and is usually treated with an antibiotic cream.

“I’ve never seen these types of cases before,” Dr Alaa said. “It’s a very severe form of impetigo, an extensive form which includes faces and the whole body. We don’t have sufficient antibiotics.”

What little medicine is available is extremely expensive and while it does work sometimes, it is not always effective. “I’ve seen many cases that come again and again because of failure of treatment,” she said. “The rate of reinfection [could be] because of overcrowding and maybe misuse of antibiotics or nonadherence to the antibiotic regime plays a role.”

The most common type of bacteria that leads to impetigo is Staphylococcus aureus. A drug-resistant variant of this bacteria is behind the MRSA superbug.

MRSA infections are resistant to many common antibiotics, making them severe and even potentially fatal.

Moussally, the MSF epidemiologist, said: “It might be that this type of infection is difficult to treat not only because of [lack of] access to oral antibiotics, but more so because of a high resistance of the Staphylococcus bacteria causing it.”

Without adequate laboratory testing it is hard to say if the bacteria has developed stronger resistance.

Moussally’s work tracking drug-resistant bacteria in Gaza dates back to before 7 October and the start of the war. Then, MSF could monitor infections through labs at Nasser and Al-Awda Hospitals in Gaza. But over the course of the war, both hospitals have been besieged and attacked, making lab tests extremely challenging.

However, data collected by MSF at the hospitals from 2019 to 2023 showed that more than 70% of Staphylococcus aureus in wounded patients was the MRSA superbug strain.

Even before the war, superbugs were already a problem in Gaza; TBIJ reported on the issue as far back as 2018.

Open wounds left to fester

Content warning: graphic imagery below

In Gaza’s remaining hospitals, surgeons are overwhelmed by critical cases. Patients with open, but not initially deadly, wounds that need reconstructive surgery are lower priority, and often forced to wait or seek help at Red Cross and Red Crescent medical points.

Any length of time a person spends with their flesh or, in many cases, bone exposed raises the risk of superbugs and – as multiple doctors report – maggots.

“It is not uncommon to see explosive injury patients with limb injuries and open fractures to develop infections either from the wound itself or from… operations,” says Dr Abdulwhhab Abu Alamrain, who currently works in the orthopaedic department of a government hospital.

Pseudomonas aeruginosa is another highly drug-resistant bacteria. It can infect wound dressings, causing bandages to turn green and smell like mown grass. Doctors in Dr Abdulwhhab’s orthopaedic department have seen cases; tests, available at a few private labs still operating in Gaza and seen by TBIJ, show some Pseudomonas infections don’t respond to any antibiotics at all.

Dr Abdulwhhab said: “This results in two options, either amputation or refusal [of an amputation] and face death. Unfortunately, we have seen many cases that have died either because of refusal or because they accept [the amputation] at the last moment [and die] waiting for surgery or on the operation table.”

Lessons from history

This is not the first time war has worsened a superbug crisis. During the war in Iraq, a lethal strain of the drug-resistant bacteria Acinetobacter baumannii infected American soldiers. Media at the time called it ‘Iraqibacter’.

The superbug infections weren’t confined to the borders of Iraq. Injured soldiers lost limbs, suffered sepsis, and some died back home in US hospitals after their wounds became infected with the bacteria.

The emergence of this strain of Acinetobacter baumannii was detected after its spread in the US hospitals. But due to the lack of testing capacity in Iraq, the extent to which it affected Iraqi civilians at the time is unknown.

“Iraq is a lesson about what war has done and why we have an ongoing crisis of AMR in a place like Iraq. We need to learn these lessons,” said Dr Omar Dewachi, an Iraqi medical anthropologist who narrates the touring exhibit The Pathogen of War.

Acinetobacter baumannii infections have also been reported in Gaza.

Using vinegar as medicine

With so many patients and so few drugs, some doctors report resorting to using vinegar to disinfect and treat wounds.

Moussally said: “Partially functioning hospitals are overcrowded with a huge caseload of injuries, lack of basic supplies needed to treat infections and do proper wound care management and are functioning with sub-standard infection prevention and control measures being the best they can do under the conditions they face. All of this drives AMR.”

Dr Khaled al Shawwa came home to Gaza city from Jerusalem to visit his family for the weekend on 5 October 2023 – two days before the Hamas attacks. He has been in Gaza ever since. He was previously a GP and had just completed his surgical qualification in Jerusalem.

He now works in the outpatient department at a clinic set up by MSF. There he deals with 80-130 patients a day. He told TBIJ: “We see Pseudomonas very frequently and sometimes we use vinegar, we apply it on the wounds. Nurses have a bottle of vinegar on the wound-dressing shelf.”

The World Health Organization has repeatedly raised concerns about drug-resistant strains of Pseudomonas.

The best practice to prevent bacteria gaining resistance to even more antibiotics is to treat infections carefully with specific drugs, preferably after lab testing to make sure the medicine will work. In Gaza, however, doctors have to work with what they have.

“Drugs are not always available. We are guided by the availability of the drugs and availability of the tests. Where I work, the drugs come in shipments and donations. In some shipments you have one or two types of antibiotics. You don’t have many options … It’s not your decision,” Dr Khaled said.

Despite the limited resources, he and his colleagues at the local pharmacies have concocted a mixture of available antibiotics and steroids to try to treat difficult infections. “You have to do anything. You can’t just leave the patients alone.”

Israel Defense Forces did not respond to TBIJ’s request for comment.