Review article
A Looming Catastrophe: A Comprehensive
Review of Post-Amputation Infections, Antimicrobial Resistance, and Limb Salvage
in the Gaza Crisis
Abouelhag H. A.
Department of Microbiology and Immunology, National Research Centre
(NRC), 33 Bohouth St., Dokki, Cairo, Egypt.
Corresponding author:Abouelhag H. A. E-mail:drabouelhag5@gmail.com
Received: 29-08-2025 Accepted: 24-09-2025 Published online: 30-10-2025
DOI: https://doi.org/10.33687/ricosbiol.03.10.87
Abstract
The military
offensive in Gaza has precipitated a public health crisis of a magnitude and severity
rarely witnessed in the 21st century. A defining feature is the epidemic
of complex traumatic injuries necessitating a massive number of amputations, estimated
to be in the tens of thousands. Performed under a total siege that has decimated
the healthcare system, these procedures are fraught with an extreme risk of life-threatening
post-amputation infections. This systematic review synthesizes data from humanitarian
agencies, frontline medical reports, and public health analyses to delineate the
multifactorial etiology of this iatrogenic catastrophe. We expand upon the known
drivers non-sterile surgery, antibiotic shortages, and the "torso amputation"
phenomenon by incorporating detailed discussions on the emerging crisis of antimicrobial
resistance (AMR), the specific immunological vulnerabilities of a malnourished population,
and the psychological trauma compounding physical recovery. The situation represents
a violation of the principles of medical neutrality and has created a cohort of
survivors with profound, long-term disability. This review concludes that the infection
crisis is a man-made outcome of siege warfare and demands an urgent, coordinated
international response focused on unimpeded humanitarian access, medical evacuation,
and the establishment of advanced wound care and rehabilitation services to mitigate
a legacy of suffering.
Keywords: amputation, infection, Gaza, conflict medicine, humanitarian crisis,
antibiotic resistance, trauma surgery, siege, antimicrobial resistance (AMR), malnutrition.
Introduction
The scale of trauma in the Gaza Strip since October 2023 is unprecedented
in its velocity and destructiveness. Beyond the staggering mortality figures, which
exceed 38,000, the number of injured over 87,000 presents a complex and enduring
medical challenge (World Health Organization [WHO], 2024b). Among these injuries,
an estimated 10,000-15,000 people require amputations, a figure that includes a
devastatingly high number of children, with many suffering multiple limb losses
(Gupta et al., 2024; International Committee of the Red Cross [ICRC], 2024a).
This represents a rate of limb loss not seen in recent conflicts.
In conventional trauma systems, amputation is a controlled procedure
of last resort, with infection rates typically managed below 10-15% through aseptic
technique, prophylactic antibiotics, and staged debridement (Murray et al.,
2022). In Gaza, the confluence of a collapsed health system, a comprehensive siege,
and the specific mechanisms of injury have created a perfect storm, pushing post-amputation
infection rates to catastrophic levels, estimated by frontline surgeons to be as
high as 50% or more (Gupta et al., 2024; Qeshta, 2024). This review provides
a comprehensive analysis of the drivers, clinical manifestations, and long-term
implications of the post-amputation infection crisis in Gaza, framing it not as
a collateral effect of war but as a direct and predictable outcome of the systematic
destruction of a medical system.
1. The Etiology of a Catastrophe: A Multifactorial Convergence
1.1. The Systematic Collapse of Surgical Infrastructure
The foundation of safe surgery a sterile environment, reliable equipment,
and continuous utilities has been obliterated. Over 70% of Gaza's hospitals and
two-thirds of its primary care clinics have been damaged or destroyed, forcing medical
care into overwhelmed, makeshift facilities (WHO, 2024a).
· The Non-Sterile Operating Theatre: Reports
describe surgeons operating by the light of mobile phones, without running water
for handwashing, reusing gloves until they disintegrate, and using sewing thread
instead of sutures (MSF, 2024a). The absence of basic disinfectants like povidone-iodine
forces the use of vinegar and other non-sterile alternatives, drastically increasing
the microbial load introduced at the time of surgery.
· The "One-Minute" Amputation: The
sheer volume of casualties and the lack of anesthesia have led to a shift in surgical
priorities from limb salvage to life-saving damage control. Procedures are rushed,
with surgeons reporting "one-minute amputations" performed with limited
or no debridement of non-viable tissue (Gupta et al., 2024). This leaves
a contaminated and traumatized wound bed, highly susceptible to infection.
1.2. The Crisis of Antimicrobials and Emerging Resistance
The siege has created a critical shortage of all essential medicines,
but the deficit in antibiotics is particularly consequential for amputees.
· Prophylaxis and Treatment Failure: The
consistent absence of broad-spectrum intravenous antibiotics (e.g., third-generation
cephalosporins, carbapenems) means that neither effective prophylaxis nor reliable
treatment for established infections is possible. When available, antibiotics are
often rationed, leading to sub-therapeutic dosing and abbreviated courses.
· The Perfect Storm for Antimicrobial Resistance (AMR): This
environment is a breeding ground for AMR. The selective pressure from intermittent,
sub-lethal antibiotic exposure, combined with the rampant transmission of pathogens
in overcrowded wards, fosters the emergence of multi-drug resistant organisms (MDROs).
Reports are emerging of wound infections with pan-resistant Acinetobacter baumannii,
Klebsiella pneumoniae, and Pseudomonas aeruginosa so-called "nightmare
bacteria" that are virtually untreatable with available antibiotics (Qeshta,
2024). This transforms a manageable surgical site infection into a fatal condition.
1.3. The Specifics of Trauma: "Torso Amputations" and Crush
Syndrome
The weaponry and tactics used have resulted in unique injury patterns
that inherently carry a higher risk of complication.
· "Torso Amputations" and High-Energy Injuries: The
term "torso amputation," coined by surgeons in Gaza, refers to a guillotine
amputation through the hip or shoulder joint, often required to free a patient from
rubble when more distal control is impossible due to the nature of the collapse
(Gupta et al., 2024). These are massive, contaminated wounds with a huge
surface area, involving muscle groups highly prone to necrosis and infection. The
high-energy transfer from explosions also causes extensive devitalized tissue zones
far from the visible wound, which serve as a nidus for infection if not meticulously
debrided a luxury unavailable in Gaza.
· Crush Syndrome and Immunosuppression: Many
amputees are survivors of prolonged entrapment, leading to crush syndrome. The reperfusion
of crushed muscle releases myoglobin, potassium, and inflammatory cytokines, leading
to acute renal failure, metabolic acidosis, and a systemic inflammatory response
syndrome (SIRS) that paradoxically is followed by a state of immunoparalysis, leaving
the patient highly vulnerable to sepsis (Matsushima et al., 2020).
1.4. The Host: A Population in a State of Acquired Immunodeficiency
The physiological state of the patient population is a critical, often
overlooked, variable.
· Macronutrient and Micronutrient Deficiency: The
population is experiencing famine-like conditions (IPC, 2024). Severe protein-energy
malnutrition directly impairs neutrophil function, T-cell-mediated immunity, and
complement production. Deficiencies in key micronutrients like Vitamin A and C and
zinc, all critical for collagen synthesis and epithelialization,severely compromise
wound healing, turning a simple stump into a chronic, non-healing wound.
· Communicable Disease in Displacement: Over
1.7 million people are displaced into overcrowded shelters with inadequate water,
sanitation, and hygiene (WASH) facilities (OCHA, 2024). Outbreaks of infectious
diarrhea, hepatitis A, and upper respiratory infections are rampant. For an amputee
with an open wound and a suppressed immune system, a concurrent bout of gastroenteritis
or pneumonia can be the final insult that precipitates sepsis.
2. Clinical Sequelae and Management in a Resource-Void
The clinical progression of a post-amputation infection in this context
follows a predictable and grim pathway.
· From SSI to Osteomyelitis: Initial surgical site infections (SSI),
presenting with erythema, pus, and dehiscence, rapidly progress due to the lack
of effective intervention. The infection spreads to the bone, causing osteomyelitis.
Treating chronic osteomyelitis requires extensive surgical debridement and weeks
of targeted IV antibiotics,neither of which is feasible, leading to a chronic, draining
sinus and systemic illness.
· Necrotizing Soft Tissue Infections: The
presence of devitalized tissue and virulent pathogens creates an ideal environment
for necrotizing fasciitis, a rapidly spreading infection that destroys soft tissue
and has a high mortality rate even in optimal settings. In Gaza, it is almost universally
fatal.
· The Rehabilitation Abyss: A well-healed, non-tender stump is the
prerequisite for prosthetic fitting and rehabilitation. The epidemic of infections
makes this impossible. Patients are left with painful, unstable stumps, prone to
breakdown. The near-total absence of prosthetic and orthotic services, physiotherapy,
and psychological support in Gaza condemns a generation of amputees to permanent,
profound disability (ICRC, 2024b).
3. Discussion: A Violation of Medical Neutrality and a Public Health
Failure
The crisis in Gaza is a stark demonstration that modern medical advances
can be rendered null by the conditions of war. The high infection and mortality
rates among amputees are not accidental; they are the direct result of the denial
of the means of survival and medical care, constituting a grave breach of International
Humanitarian Law (IHL), which mandates the protection of the wounded and sick and
the civilian infrastructure necessary for their care (Amnesty International, 2024).
The long-term public health implications are staggering:
1.
A Permanent Disability
Crisis: Tens of thousands of individuals, many of them children, will require
lifelong medical care, rehabilitation, and social support.
2.
An AMR Reservoir: Gaza
has become an incubator for multi-drug-resistant pathogens that pose a threat not
only to the local population but also to the broader region, potentially for decades
to come.
3.
Psychological Trauma: The
compound trauma of experiencing bombardment, losing a limb, and enduring a painful,
protracted infection will result in an epidemic of post-traumatic stress disorder
(PTSD), depression, and anxiety disorders.
Conclusion
and Recommendations
The limbs lost to explosives are only the initial injury. The subsequent
infections represent a second, more insidious mass casualty event, one that is ongoing
and largely preventable. The international community's response has been woefully
inadequate.
Urgent Recommendations:
1.
An Immediate and
Sustained Ceasefire: This is the foundational prerequisite for any meaningful medical intervention.
2.
Unimpeded Humanitarian
Access: All border crossings must be opened for the massive and consistent
flow of medical supplies, including advanced wound dressings, a full spectrum of
antibiotics, and surgical equipment.
3.
Systematic Medical
Evacuation: A large-scale, streamlined mechanism for the evacuation of complex
cases, particularly those with MDRO infections and osteomyelitis, to regional specialized
centers is non-negotiable.
4.
Restoration of WASH
and Nutrition: The provision of clean water, sanitation, and nutritional support is
a medical intervention as critical as antibiotics in this context.
5.
Long-Term Planning
for Rehabilitation: The international community must immediately begin planning and funding
a decades-long program for physical rehabilitation, prosthetic services, and mental
health support for the people of Gaza.
In conclusion, the post-amputation infection crisis in Gaza is a man-made
plague unfolding in real time. Addressing it requires not only medical supplies
but also a fundamental commitment to upholding IHL and human dignity. The world
is witnessing the systematic creation of a disabled population; the moral and practical
imperative to intervene has never been clearer.
References
Amnesty International. (2024). Israel’s bombardment of Gaza is the
deadliest and most destructive in modern history. https://www.amnesty.org/en/latest/news/2024/06/israels-bombardment-of-gaza-is-the-deadliest-and-most-destructive-in-modern-history/
Gupta, A., Ghandour, E., and Sweity, H. (2024, January 18). ‘Every day,
you see children who have lost their limbs’: A surgeon in Gaza. The New Yorker.
https://www.newyorker.com/news/dispatch/every-day-you-see-children-who-have-lost-their-limbs-a-surgeon-in-gaza
International Committee of the Red Cross (ICRC). (2024a). Gaza: Physical
rehabilitation needs will persist for years. https://www.icrc.org/en/document/gaza-physical-rehabilitation-needs-will-persist-years
International Committee of the Red Cross (ICRC). (2024b). Gaza: Thousands
of amputees face lifelong disability without urgent care. https://www.icrc.org/en/document/gaza-thousands-amputees-face-lifelong-disability-without-urgent-care
Integrated Food Security Phase Classification (IPC). (2024). IPC
Acute Food Insecurity Analysis: Gaza Strip, March–July 2024. https://www.ipcinfo.org/fileadmin/user_upload/ipcinfo/docs/IPC_Gaza_Strip_Acute_Food_Insecurity_2023Nov2024Feb_report.pdf
Matsushima, K., Khan, M., and Ball, C. (2020). Crush syndrome: A review
for prehospital providers and emergency clinicians. Journal of Trauma and Acute
Care Surgery, 88(6), e134-e141. https://doi.org/10.1097/TA.0000000000002665
Médecins Sans Frontières (MSF). (2024a). Gaza: No electricity, no
water, no food, and constant bombing. https://www.msf.org/gaza-no-electricity-no-water-no-food-and-constant-bombing
Médecins Sans Frontières (MSF). (2024b). Gaza: MSF demands protection
of patients and staff at Nasser Hospital. https://www.msf.org/gaza-msf-demands-protection-patients-and-staff-nasser-hospital
Murray, C. K., Hsu, J. R., Solomkin, J. S., Keeling, J. J., Andersen,
R. C., Ficke, J. R., and Calhoun, J. H. (2022). Prevention and management of infections
associated with combat-related extremity injuries. Journal of Trauma and Acute
Care Surgery, 92(2), e45-e60. https://doi.org/10.1097/TA.0000000000003431
Qeshta, M. (2024). Medical challenges in Gaza: A personal account from
a surgeon. The Lancet, 403(10425), e10. https://doi.org/10.1016/S0140-6736(24)00144-2
United Nations Office for the Coordination of Humanitarian Affairs (OCHA).
(2024). Hostilities in the Gaza Strip and Israel | Flash Update #150. https://www.ochaopt.org/content/hostilities-gaza-strip-and-israel-flash-update-150
World Health Organization (WHO). (2024a). WHO reports 70% of health
attacks in Gaza have damaged hospitals. [WHO Regional Office for the Eastern
Mediterranean]. http://www.emro.who.int/media/news/who-reports-70-of-health-attacks-in-gaza-have-damaged-hospitals.html
World Health Organization (WHO). (2024b). WHO warns of imminent famine
in Gaza, demands immediate action. https://www.who.int/news/item/15-03-2024-who-warns-of-imminent-famine-in-gaza--demands-immediate-action