Discussion

The Kahramanmaraş earthquake is one of the most destructive earthquakes in history. Due to the damage to the highways, the accumulation of snow on the roads caused by the winter season, and the high density of civilian vehicles, it was not possible to reach the earthquake zone on the first day of the earthquake. In the early period, despite the development of various alternative routes, transportation remained unavailable. On February 12, 2023, the repair of the broken runway at Hatay Airport in the region was completed, and it opened to civilian flights. However, it did not cause any damage that would prevent flights at other airports. Military helicopters transferred medical personnel from Adana Incirlik Air Base to other disaster-affected regions. The transportation of health workers to disaster areas was the most frequently mentioned problem on the first day of the disaster. A total of 145km of road and tunnel damage in the region, damage to 1,204km of railway network, and the fire that broke out at the Iskenderun Port brought transportation and dispatch operations to a standstill. ^6,7 Out of all the patients who presented to the Akdeniz University ED, 1,669 (91.05%) arrived by their own means; 1,186 (91.65%) of the adult patients applied on their own. While 118 (86.13%) of the hospitalized patients arrived by their own means and private vehicles, 19 (18.86%) patients were transported by ambulance. In the study conducted by Eyler, et al after the October 30, 2022 Izmir earthquake, only 13% of the applications were made by ambulance, due to the low number of patient admissions to the emergency services, the relative distance of their hospitals to the region most affected by the earthquake, the difficulty of transportation due to the panic experienced after the earthquake, and the fact that there is a university hospital very close to the earthquake area. ^{Reference Eyler, Ty, Duman Atilla and Berksoy8}

During the first three days, 113 (8.73%) of the patients presented to the ED were admitted, and within the first week, 414 (31.99%) were admitted. Within the first three days, 30 (21.89%) of the inpatients were completed, and by the end of the first week, 82 (59.85%) were completed. In the study by Sever, et al, 423 (70.1%) of the patients applied to reference hospitals in the first three days of the disaster. By the end of the first week, the hospitals admitted 562 patients, accounting for 93.2% of all patients. ^{Reference Sever, Erek and Vanholder9} Seventy-five percent of the injured were hospitalized for the first three days after the 1995 Hanshin-Awaji earthquake, and the number of those who got sick continued to increase during the 15-day period after the earthquake. ^{Reference Tanaka, Oda and Iwai10} In this study, the rates were similar, and most of the applications were completed within the first seven days. When focusing on the provinces where earthquake victims came from, Hatay ranks first with 573 (44.28%) patients in all EDs, followed by Kahramanmaraş with 260 (20.09%) patients. Evaluation of hospitalized earthquake victims according to their province of origin, Hatay ranks first with 68 (49.63%) patients, followed by Kahramanmaraş with 22 (16.05%) patients and Gaziantep with 18 (13.11%) patients. The hospitalization of the patients after admission was orthopedics in the first place with 38 (27.73%) patients, internal medicine, especially nephrology with 25 (18.24%) patients, and intensive care with 20 (14.59%) patients.

There were eight university hospitals, 12.5% of the hospitals affiliated with the Ministry of Health, and 17.5% of the primary health care facilities within the earthquake zone. Within the earthquake zone, 16.5% of the total specialists and general practitioners serving in the hospitals affiliated with the Ministry of Health in Türkiye, as well as 15.5% of the other health employees, were working in the 11 affected provinces. ⁷ The influx of injured in Malatya, Adıyaman, Kahramanmaraş, and Hatay, heavily affected by the earthquake, caused an insufficient number of health workers. The loss of lives, families, and homes prevented many health workers from actively working, leading to deficiencies in the first days. The lack of coordination in disaster areas and the arrival of the winter season delayed the arrival of health workers from outside the disaster areas. ⁶

It is well-known that trauma patients have a high risk of developing infections and that in-hospital infection-related mortality increases in the presence of trauma. During the study period from August 17, 1999 through September 25, 1999, Öncel, et al observed that patients spent varying amounts of time under debris, ranging from six to 135 hours. Of the 143 culture samples taken, 48 were positive. Acinetobacter baumannii (31.2%) was in first place with 15 patients, followed by Staphylococcus aureus (18.7%) with nine growths and Pseudomonas aeruginosa (14.6%) with seven growths. ^{Reference Oncül, Keskin and Hv11} Tao, et al conducted a study where 58.5% of the 775 cultured patients had positive results in pus and/or wound culture, with Gram-negative bacilli being the most frequently isolated pathogens. ^{Reference Tao, Kang and Chen12} Forty-four of the patients admitted in this study had a history of being under debris. The longest time under debris was 145 hours and the shortest was 15 minutes; the average duration of the wreckage was 14.17 hours. The duration of the wreck was not risky for mortality or in-hospital infection development (P = .154; P = .489). In patients with in-hospital infection, the mortality rate was calculated as three (18.8%), which is consistent with the literature. Researchers detected microbial proliferation in 67 (60.0%) of the samples in the study conducted on patients with crush syndrome after the Marmara earthquake. Researchers isolated 67% Gram-negative bacilli, 17% Gram-positive cocci, 12% Enterobacteriaciae, and four percent yeast-like fungi from the wound samples. The main bacterial isolates for wound infections were Acinetobacter and Pseudomonas aeruginosa. ^{Reference Kazancioglu, Cagatay and Calangu13}

Considering the flora of the hospital, the growths in the group that were considered community-acquired infections were incompatible with hospital flora, while the growths that were considered nosocomial infections were partially compatible. Recently, the most common agents encountered in this hospital flora are gram-negative bacilli: Klebsiella pneumoniae is in the first place (14%), Pseudomonas aeruginosa is in the second place (12%), and Acinetobacter baumanii is in the third place (10%). As seen in this study, the most common pathogenic microorganisms in hospitals were the main cause of infections thought to be nosocomial. This was especially true for repeated tracheal and wound pus cultures. Resistant gram-positive agents such as MRSA or Vancomycin-resistant Enterococcus (VRE) Faecium were rarely encountered in the hospital flora or in the growths in the study.

When the culture growths in the group considered as community-acquired infection were evaluated, some resistant microorganisms that were not expected to be encountered in community-acquired infections were encountered. Escherichia coli is the most common cause of community-acquired urinary tract infections detected in the urine culture taken in the first 48 hours. However, E. faecium and P. aeruginosa, which are the factors expected in nosocomial urinary tract infections, were encountered in the culture growths taken in the first 48 hours of the study. In the cultures taken after 48 hours, Candida albicans and non-Albican Candida come to the fore, especially due to long-term Foley catheter use, which is an expected situation. It has been revealed that Klebsiella species and Citrobacter fruendii, which produce Extended Spectrum Beta-Lactamase (ESBL) enzymes, which are frequently induced especially due to the empirical use of ceftriaxone, are resistant to third-generation cephalosporins compatible with hospital flora.

M. catharalis and H. influenza, which are the most common gram-positive and gram-negative agents in community-acquired pneumonia, were encountered in the samples taken from respiratory tract isolates. However, MRSA growth, which was expected to be the cause of nosocomial pneumonia, occurred in some patients. Although community-acquired MRSA is not very common, comorbidities such as diabetes, hemodialysis, and immunosuppression are also risk factors. ^{Reference Masters14}

When the patients in the study were examined, it was seen that the patient with MRSA growth was 80 years old and had diabetes and laryngeal cancer, which are among the risk factors for community-acquired MRSA. It was observed that the growths in the respiratory isolates taken 48 hours later were compatible with the hospital flora and had similar resistance rates.

Staphylococci and streptococci come to the fore in community-acquired wound infections. In this study, although it was initially thought that patients would have Staphylococcus infections, the presence of hospital-acquired wound infection agents such as S. malthophilia and P. aeruginosa was found to be greater than expected. Patients coming from the community with trauma such as penetrating or gunshot wounds, burns, crushing, or freezing may encounter gram-negative factors such as P. aeruginosa. ^{Reference Swartz, Pasternack, Bennett, Dolin and Blaser15} Cultures taken after 48 hours are generally postoperative cultures and non-fermentative grams-negative bacilli are common and compatible with hospital flora.

Community-acquired MRSA was encountered when evaluating blood and catheter cultures in this group, but these factors are generally expected in both groups. Klebsiella pneumoniae, which is encountered in the hospital flora, especially in catheters that are not changed for more than seven days in the femoral region, is an expected factor and was the most common catheter-related infection agent in the study. The presence of Candida glabrata was detected in the cultures taken 48 hours after the patient, who had been catheterized for a long time, received Total Parenteral Nutrition (TPN), and had a history of abdominal surgery. Hospital flora generally includes Candida albicans, which is sensitive to azoles. Although azoles were not used, azole-resistant Candida glabrata was an unexpected agent.

While the mortality rate in the first seven days was two (1.45%) in the admitted patients, the 30-day mortality was eight (5.83%). This rate was 19.3% (43/223) in the study of Keven, et al, and the mortality rate was 8.6% (527) in the study of Tanaka, et al. ^{Reference Tanaka, Oda and Iwai10,Reference Keven, Ates and Sever16} After the Great Marmara earthquake, 5,302 hospitalized patients were involved in a study conducted in 35 reference hospitals, which reported a mortality rate of 4.3% (425). ^{Reference Sever, Erek and Vanholder9} In this study, while the mortality rate was two (1.45%) people in seven days, the mortality rate was five (3.64%) people at the end of 28 days. Of the patients who died, the cause of death was sepsis due to respiratory tract diseases in three, peptic ulcer perforation in one, and massive pulmonary embolism in one. A high incidence of pneumonia was observed among the elderly in the Hanshin-Awaji earthquake; this was probably due to a sharp deterioration in living conditions, sanitation, and hygiene due to the earthquake, as well as dust inhalation from collapsed buildings. ^{Reference Tanaka, Oda and Iwai10} The causes of death are similar, but the low number of multiple traumas and the absence of severe crush syndrome patients affect the results. The death rates in the study were quite low in the disaster that caused such great destruction. The main reason for the low death rates is the distance to the earthquake zone and the presence of large and fully equipped hospitals close to the earthquake zone. It is concluded that the treatment of patients in critical condition is provided in hospitals close to earthquake areas. Many patients arrived at these regions using their own means and with the help of their relatives. This suggests that the patients are in good condition in many respects.