Haiti: Facing a hidden emergency

Antibiotic-resistant infections are a growing problem for burn patients

Jackson Joseph, a physiotherapist, helps a patient regain the use of a limb through a joint exercise at MSF's Drouillard Hospital in Haiti.
Haiti 2018 © Scott Streble
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The accident happened in a flash. A three-year-old boy was playing at home when he collided with his grandmother, who was carrying a pot of soup. The hot liquid spilled all over his head, scalding him terribly.

"He screamed, and his grandmother did too because she did not know what to do," the boy's mother explains.

The family could not afford private medical care, so they took a motorcycle from their neighborhood to the Doctors Without Borders/Médecins Sans Frontières (MSF) hospital on the other side of Haiti's capital, Port-au-Prince. Since 2015, MSF has run Haiti's only specialized hospital for burns. Located in the Cité Soleil slum, it frequently receives patients from the most crowded and impoverished areas of the city. Families here struggle to make ends meet, and household fires, cooking accidents, and gas explosions related to living in close quarters are all too common.

Recovering from a severe burn is a long and difficult process. Weekslong hospital stays involve repeated dressing changes, physiotherapy sessions, pain management, psychological care, and surgeries such as skin grafts. Outpatient care often continues for months, as many burn patients suffer long-term consequences of their injuries that must be carefully managed.

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Most urgently, they must survive. The greatest risks come from dehydration, which can lead to death, and infections that can emerge as the body's defenses are compromised. The skin is the immune system's outer wall; when large areas of skin are destroyed by a burn, bacteria can enter the bloodstream, creating a life-threatening systemic infection called sepsis.

A young patient in Drouillard Burn Hospital
Bradley, a three-year-old patient at MSF’s Drouillard hospital in Haiti, sits next to his mother, Judeline.
Haiti 2018 © Scott Streble

"It's a whole fight to keep the patient living because sepsis is a very challenging thing with burn patients," says Wesly Michel Toussaint, an MSF doctor responsible for the antibiotic stewardship program in the hospital. "For each hour of sepsis, the patient's chances of survival go down, and they can go into multiorgan dysfunction syndrome. The kidneys stop working, the lungs stop working, the whole body stops working well, and the person can go into shock and die."

Further complicating matters, antibiotic-resistant infections are a growing problem for burn patients in Haiti, as in many other health care settings around the world.

"For health care facilities, it's a big challenge," says MSF's medical coordinator Dr. Gabriel Kabilwa. "It's becoming ever more challenging for burn patients, because they are more susceptible to infection.

Treating Burn and Trauma Victims in Haiti
Shnider Avril, a patient at MSF’s Drouillard hospital in Haiti, receives care for severe burns caused by a propane tank explosion.
Haiti 2018 © Spencer Platt/Getty Images

Choosing the right treatment

Prevention is the first tool in the fight against infections. Wound dressings are regularly changed by surgeons in sterilized operating rooms. Wards are rigorously cleaned, patients are separated from each other by barriers and partitions, and hands are washed again and again.

Diagnosing an infection, however, presents many challenges. A fever could be the body's inflammatory response to the trauma of a burn, or it could be the symptom of an infection. The crucial questions are what bacteria are present and which antibiotics should be administered. 

"Before starting antibiotics, we systematically take blood samples," Dr. Kabilwa says. "Once we have the result, we move to the antibiotic that is most effective."

In some cases, bacteria that are normally treatable with certain antibiotics show signs of resistance, requiring lab tests to determine which other antibiotics will be effective. Using an antibiotic can lead to greater antibiotic resistance, so each decision to start or stop an antibiotic must be made carefully.

Drouillard Burn Hospital / Centre de Brûlés de Drouillard
Montina Duperval, a physiotherapist, works with a patient to recover mobility after a serious burn.
Haiti 2018 © Scott Streble

"Sometimes you have one infection that is covered by the antibiotic and you have another bacteria that is not covered, so you have to find the antibiotic that covers the bacteria," Dr. Toussaint says. "Sometimes you change the antibiotic because it is not working, while you await the lab result."

When a multidrug-resistant infection is diagnosed, a patient is transferred to the hospital's isolation ward. Dressing changes are done on a special rotation in the operating room to reduce the risk of transmission to other patients.

Patients with antibiotic-resistant infections typically require longer hospital stays, and their chances of survival are lower, Dr. Toussaint says. In difficult cases, a patient's blood must be tested repeatedly and their treatment adapted until the correct antibiotics are identified. Recently, a 78-year-old patient being treated for a burn covering nearly 15 percent of his skin surface was struggling with an infection. He had an elevated heart rate and a low fever and was dependent on oxygen. After putting him on an initial treatment of first-line antibiotics, doctors ordered repeated blood tests and closely monitored the patient for days. Finally they were able to identify the right antibiotics to treat his methicillin-resistant Staphylococcus aureus (MRSA) infection, and he recovered.

Drouillard Burn Hospital / Centre de Brûlés de Drouillard
Jesulène Tégé, a nurse, provides follow-up care to a patient who was severely burned.
Haiti 2018 © Scott Streble

Antibiotic stewardship is focused on achieving the best outcomes for each patient while minimizing the unintended consequences of antibiotic use.

Dr. Wesly Michel Toussaint, an MSF doctor responsible for the antibiotic stewardship program in the hospital

Adapting to the needs

In December 2018, MSF completed a major expansion of the burn hospital in Cité Soleil, with additional space between patient beds and three operating rooms. The staff inaugurated the building with a new name, Douvanjou, a Haitian Creole word for daybreak. 

"We chose Douvanjou because the hospital is where a person can find care rapidly, any time of day or night," explains the hospital's medical director, Dr. Erneau Mondesir. "If you are burned, the risk of infection is lower if the patient comes right away."

For the staff, some of the biggest challenges occur when severely burned patients arrive in groups. Explosions of cooking gas can strike multiple members of a household, and the staff often must stabilize five, six, or seven patients in the emergency room before admitting them. Major burns may require months of round-the-clock care with careful attention to hydration and nutrition to keep a patient strong enough to recover from a burn and fight infection. 

Following the ups and downs of each patient can be a long process. Recently, the hospital treated a young girl with a severe burn who began treatment in the intensive care unit and later developed an antibiotic-resistant infection that required treatment in the isolation ward. After skin grafts and multiple courses of antibiotics, she was finally successfully discharged after 147 days.

"For me, my best moment is when the patient is discharged," Dr. Toussaint says. 

As difficult as it can be to treat antibiotic-resistant infections, so far the hospital has not encountered an infection that is resistant to all antibiotics, Dr. Toussaint says. Yet with antibiotics widely used without a prescription in Haiti—sometimes even sold on the streets— there is concern that such extensively drug-resistant infections may appear.

In MSF's hospital the most powerful antibiotics are used judiciously, after careful discussions with multiple specialists. The staff follow protocols based on the principles of antibiotic stewardship, aiming to ensure that no patient develops an infection that is impossible to treat.

"Antibiotic stewardship is focused on achieving the  best outcomes for each patient while minimizing  the unintended consequences of antibiotic use," Dr. Toussaint says. 

In Haiti MSF is testing a new technology initiative, known as the MiniLab, to address the problem of a lack of laboratories and trained microbiology staff in many of the places where our teams work.