The prevalence of antimicrobial resistance in clinical isolates from Gulf Corporation Council countries

Self-medication with antibiotics in Saudi Arabia

Introduction

Despite of the global dilemma of antibiotics resistance, this issue is more worsen in developing countries or places where the antibiotics can be dispensed or purchased without prescription such as in Saudi Arabia. Most health awareness campaigns and published studies regarding the self-medication with antibiotics in Saudi Arabia are conducted within hospitals. The prevalence and reasons of self-medication with antibiotics were not well studied from community perspective in Saudi Arabia. This study was conducted to investigate the prevalence of self-medication with antibiotics in Saudi Arabia.

Methodology

A cross-sectional study using online survey and snowball technique was conducted during the period from January 2017 to May 2017 targeting people who are living in Saudi Arabia.

Results

A total of 1264 respondent completed the questionnaire and included in the study. About 34% of respondents have used antibiotic without a prescription, and 81.3% of them knew that it might be harmful to health. The most antibiotic used for self-medication was Amoxicillin/clavulanic acid (45.1%) followed by amoxicillin (39.9%). The most common illness and reasons for seeking antibiotic without prescription were tonsillitis (76.7%) and the previous experience of using a particular antibiotic (52.1%) respectively. The major source of self-medication with antibiotic was previous doctor's prescription (36.6%).

Conclusion

The relative high prevalence of self-medication with antibiotics necessitates taking serious steps by health authorities to implement the law of forbidding the sale of antibiotics without prescription.

Bioactive Constituents, Radical Scavenging, and Antibacterial Properties of the Leaves and Stem Essential Oils from Peperomia pellucida (L.) Kunth

Background:

Peperomia pellucida is an annual herbaceous ethnomedicinal plant used in the treatment of a variety of communicable and noncommunicable diseases in the Amazon region.

Objective:

The study aimed at profiling the bioactive constituents of the leaves and stem essential oils (LEO and SEO) of P. pellucida, their in vitro antibacterial and radical scavenging properties as probable lead constituents in the management of oxidative stress and infectious diseases. Materials and

Methods:

The EOs were obtained from the leaves and stem P. pellucida using modified Clevenger apparatus and characterized by a high-resolution gas chromatography-mass spectrometry, while the radicals scavenging and antibacterial effects on four oxidants and six reference bacteria strains were examined by spectrophotometric and agar diffusion techniques, respectively.

Results:

The EOs exhibited strong antibacterial activities against six bacteria (Escherichia coli [180], Enterobacter cloacae, Mycobacterium smegmatis, Listeria ivanovii, Staphylococcus aureus, Streptococcus uberis, and Vibrio paraheamolyticus) strains. The SEO antibacterial activities were not significantly different (P < 0.05) from the LEO against most of the test bacteria with minimum inhibitory concentration ranging between 0.15 and 0.20 mg/mL for both EOs. The two oils were bactericidal at 0.20 mg/mL against S. aureus while the minimum bactericidal concentration (0.15 mg/mL) of LEO against L. ivanovii was lower than of SEO (0.20 mg/mL) after 24 h. The LEO IC₅₀ value (1.67 mg/mL) revealed more radical scavenging activity than the SEO (2.83 mg/mL) and reference compounds against 2,2-diphenyl-1-picrylhydrazyl radical. The EOs also scavenged three other different radicals (2,2’-azino-bis (3-ethylbenzothiazoline-6-sulfonic acid) diammonium salt radical, lipid peroxyl radical, and nitric oxide radical) in concentration-dependent manner.

Conclusion:

Our results suggest that apart from the indigenous uses of the plant extracts, the EO contains strong bioactive compounds with antibacterial and radicals scavenging properties and may be good alternative candidates in the search for novel potent antibiotics in this present era of increasing multidrug-resistant bacterial strains as well as effective antioxidants agents.

SUMMARY

Established gas chromatography-mass spectrometry technique was applied to quantitatively and qualitatively analyze the volatile constituents in Peperomia pellucida essential oil (EO)

The Clinical and Laboratory Standards Institute (2014) guidelines were employed to evaluate the antibacterial effects of the EOs

Among the known prominent bioactive terpenoids, linalool 17.09%, limonene 14.25%, β-caryophyllene 12.52%, and linalyl acetate 10.15% were the main constituents of the EOs in this current study

The leaf and stem EOs were bactericidal at a concentration below 0.23 mg/mL against three multidrug-resistant bacteria and significantly scavenged known free radicals reported to be associated with contagious and oxidative stress-related disorders.

Abbreviations used: GC-MS: Gas chromatography-mass spectrometry, DPPH: 2,2-diphenyl-1-picrylhydrazyl, ABTS: 2,2-azino-bis (3-ethylbenzothiazoline-6-sulfonic acid) diammonium salt, DMSO: Dimethyl sulfoxide, LP^•: Lipid peroxide radical, NO^•: Nitric oxide radical, LEO: Leaf essential oil, SEO: Stem essential oil, RC: Reference compound, TBARS: Thiobarbituric acid

Microbiological and molecular identification of bacterial species isolated from nasal and oropharyngeal mucosa of fuel workers in Riyadh, Saudi Arabia

This study aimed to determine the bacterial species colonizing the nasal and oropharyngeal mucosa of fuel workers in Central Riyadh, Saudi Arabia on a microbiological and molecular level. Throat and nasal swab samples were obtained from 29 fuel station attendants in the period of time extending from March to May 2014 in Riyadh, Saudi Arabia. Microbiological identification techniques were utilized to identify the bacterial species isolated. Antibiotic sensitivity was assessed for each of the bacterial isolates. Molecular identification techniques based on PCR analysis of specific genomic sequences was conducted and was the basis on which phylogeny representation was done for 10 randomly selected samples of the isolates. Blood was drawn and a complete blood count was conducted to note the hematological indices for each of the study participants. Nineteen bacterial species were isolated from both the nasal cavity and the oropharynx including Streptococcus thoraltensis, alpha-hemolytic streptococci, Staphylococcus hominis, coagulase-negative staphylococci, Leuconostoc mesenteroides, Erysipelothrix rhusiopathiae and several others. We found 100% sensitivity of the isolates to ciprofloxacin, cefuroxime and gentamicin. Whereas cefotaxime and azithromycin posted sensitivities of 85.7% and 91.4%, respectively. Low sensitivities (<60% sensitivity) to the antibiotics ampicillin, erythromycin, clarithromycin and norfloxacin were observed. Ninety-seven percent similarity to the microbial bank species was noted when the isolates were compared to it. Most hematological indices recorded were within the normal range. In conclusion, exposure to toxic fumes and compounds within fuel products may be a contributing factor to bacterial colonization of the respiratory tract in fuel workers.

Comparison of antimicrobial activity between ceftolozane-tazobactam and ceftazidime-avibactam against multidrug-resistant isolates of Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa

OBJECTIVE

This study compared the activity of ceftolozane-tazobactam and ceftazidime-avibactam against 120 bacterial strains, including extended-spectrum beta-lactamase (ESBL) producers, carbapenem-resistant Enterobacteriaceae (CRE), and Pseudomonas aeruginosa, isolated from patients admitted to Cleveland Clinic Abu Dhabi, United Arab Emirates.

METHODS

In vitro susceptibility was tested using the Etest strip minimum inhibitory concentration (MIC) method, and PCR was used to characterize the carbapenemase enzymes produced by CRE strains.

RESULTS

All 29 ESBL isolates were susceptible to ceftazidime-avibactam (MIC₅₀ 0.125μg/ml), whereas all but one were susceptible to ceftolozane-tazobactam (MIC₅₀ 0.38μg/ml). Twenty-seven (45%) CRE isolates were susceptible to ceftazidime-avibactam (MIC₅₀ ≥256μg/ml), whereas only six (10%) isolates were susceptible to ceftolozane-tazobactam (MIC₅₀ ≥256μg/ml). Very few NDM-1 isolates were susceptible to ceftazidime-avibactam, whereas the majority of OXA-48 isolates were susceptible. Twenty-nine (94%) P. aeruginosa isolates were susceptible to ceftazidime-avibactam (MIC₅₀ 1.5μg/ml), whereas 30 (97%) isolates were susceptible to ceftolozane-tazobactam (MIC₅₀ 0.75μg/ml).

CONCLUSIONS

Ceftolozane-tazobactam and ceftazidime-avibactam showed comparable activity against ESBL and P. aeruginosa, with ceftazidime-avibactam having lower MICs against ESBL isolates and ceftolozane-tazobactam having lower MICs against P. aeruginosa. Ceftazidime-avibactam showed better activity against all CRE isolates except for those carrying the NDM-1 enzyme.

Molecular characterisation of Panton-Valentine leucocidin-producing methicillin-resistant Staphylococcus aureus clones isolated from the main hospitals in Taif, KSA

INTRODUCTION

Panton-Valentine leucocidin (PVL) is a bicomponent pore-forming cytolytic toxin encoded by the lukF-PV and lukS-PV genes. Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) may carry the pvl genes which may be related to increased disease severity. This study aimed to characterise the PVL-producing MRSA recovered from different Taif Hospitals, Saudi Arabia.

METHODS

The study included 45 hospital-acquired-MRSA (HA-MRSA) and 26 CA-MRSA strains which were identified from 445 S. aureus strains isolated from different clinical samples. MRSA strains were identified by standard oxacillin salt agar screening procedure and by the detection of the mecA gene by the polymerase chain reaction (PCR). Detection of the S. aureus-specific femA, mecA and pvl genes was performed by multiplex PCR. PCR-restriction fragment length polymorphism (PCR-RFLP) analysis was done for coagulase (coa) gene.

RESULTS

The staphylococcal cassette chromosome mec types of the 45 HA-MRSA strains were Type I (n = 24), Type II (n = 7) and Type III (n = 14) whereas the 26 CA-MRSA strains were Type IV (n = 14), Type V (n = 11) and one isolate was non-typeable. All the HA-MRSA and six CA-MRSA strains were PVL-negative PCR-RFLP analysis of coa gene showed that PVL-positive MRSA (n = 20) isolates showed six different patterns, and five patterns were shared by PVL-positive methicillin-susceptible S. aureus (MSSA). The eighth pattern was the most frequent in both MRSA and MSSA.

CONCLUSION

PVL is more frequent among CA-MRSA than MSSA. All the HA-MRSA and 25% of CA-MRSA strains were negative for PVL. The pvl gene was related to the severity of infection but not related to coa gene RFLP pattern.

Antibacterial and Antioxidant Properties of the Leaves and Stem Essential Oils of Jatropha gossypifolia L

Antibacterial and antioxidant properties of the leaves and stem essential oils (EOs) of Jatropha gossypifolia and their efficacies against infectious and oxidative stress diseases were studied in vitro. The EOs obtained using Clevenger modified apparatus were characterized by high resolution GC-MS, while their antioxidant and antibacterial properties were examined by spectrophotometric and agar diffusion techniques, respectively. The EOs exhibited strong antibacterial activity against Escherichia coli, Enterococcus faecium, and Staphylococcus aureus. The stem essential oil (SEO) was more active than the leaf essential oil (LEO) against test bacteria with minimum inhibition concentration (MIC) ranging from 0.025 to 0.05 mg/mL and the LEO from 0.05 to 0.10 mg/mL. The SEO was bactericidal at 0.025 and 0.05 mg/mL against S. aureus and E. faecium, respectively, and the LEO was bacteriostatic against the three bacteria at 0.05 and 0.10 mg/mL. The SEO IC50 (0.07 mg/mL) showed that the antiradical strength was superior to LEO (0.32 mg/mL) and β-carotene (1.62 mg/mL) in scavenging 2, 2-diphenyl-1-picrylhydrazyl radicals (DPPH•). The oils effectively reduced three other oxidants to neutral molecules in concentration dependent manner. Findings from this study suggest that, apart from the traditional uses of the plant extracts, the EOs have strong bioactive compounds with noteworthy antibacterial and antiradical properties and may be good candidates in the search for lead compounds for the synthesis of novel potent antibiotics.

Antibiotic Consumption During a 4-year Period in a Community Hospital with an Antimicrobial Stewardship Program

OBJECTIVES

We sought to evaluate the trend of antibiotic consumption in patients admitted to a community hospital in Qatar with an antimicrobial stewardship program.

METHODS

This observational study was carried out in a 75-bed facility in Western Qatar over a 4-year period (2012-2015). The monitoring of antimicrobial consumption from inpatient wards was performed from the pharmacy records and presented as defined daily dose (DDD) divided by the patient days and expressed as 100 bed-days (DBD).

RESULTS

The consumption of antimicrobials in 2012 was 171.3 DBD, and increased to 252.7 DBD in 2013, 229.1 DBD in 2014, and 184.7 DBD in 2015. Cephalosporins use reduced from 98.2 DBD in 2013 to 51.5 DBD in 2015 while the consumption of penicillins increased during the beginning of 2014 with a slight decrease in 2015. Carbapenems consumption during 2014-2015 was lower than previous years, and vice-versa for aminoglycosides. Fluoroquinolones had a sustained increase with 37.1% increased consumption in 2015 compared to the two previous years. There was an increase in the use of intravenous (IV) (108.5%) and oral azithromycin (55.1%) and the use of oral (152.8%) and IV moxifloxacin (22.9%).

CONCLUSIONS

We observed a decrease in antibiotic use in patients admitted to a community hospital with an antimicrobial stewardship program, but the increase in fluoroquinolones consumption is a concern that requires focused strategies.

High prevalence of the PER-1 gene among carbapenem-resistant Acinetobacter baumannii in Riyadh, Saudi Arabia

The prevalence of carbapenem-resistant Acinetobacter baumannii in Saudi Arabia and their resistance genetic mechanisms are yet to be identified. We studied the prevalence and genetic diversity of extended-spectrum beta-lactamase genes, particularly the PER-1 gene, among carbapenem-resistant A. baumannii strains from patients at a tertiary care hospital in Riyadh, Saudi Arabia between 2006 and 2014. Fresh subcultured samples were tested for antimicrobial susceptibility minimum inhibitory concentration (MIC). Total genomic DNA was extracted from each isolate and further used for polymerase chain reaction (PCR) genotyping, sequence-based typing (SBT) of PER-1 and OXA-51-like gene, and multilocus sequence typing (MLST) of positive isolates. Randomly selected clinical isolates (n = 100) were subjected to MLST. A total of 503 isolates were characterized as multidrug-resistant (MDR) using the MIC. Isolates were further PCR tested for bla _-TEM and bla _-PER-1 resistance genes (n = 503). The genotyping results showed that 68/503 (14 %) isolates were positive to bla TEM. The genotyping results of PER-1-like genes showed that 384/503 (76.3 %) were positive among MDR Acinetobacter isolates. Based on SBT, the majority of these isolates were clustered into three main groups including isolates harboring PER-1: AB11 (bla _-PER-1), isolate AB16 (bla _-PER-1), and, finally, the plasmid pAB154 (bla _-PER-7). Remarkably, many isolates were concealing the PER-1 gene and harboring the TEM resistance genes as well. MLST results for selected isolates (n = 100) identified four main sequence types (STs: 2, 19, 20, and 25) and four novel isolates (ST 486-489). We report 76.3 % prevalence of the PER-1 resistance gene among Acinetobacter clinical isolates from Riyadh, Saudi Arabia. Further work is needed to explore the clinical risks and patient outcome with such resistance related to healthcare-associated infections and investigate the genetic and molecular mechanisms that confer the MDR phenotype.

Race Against Antimicrobial Resistance Requires Coordinated Action - An Overview

Resistance developed by microbes is challenging success stories of treatment of infectious diseases with anti-microbials. Developing new antimicrobials against these resistant organisms does not progress at the same speed. In an effort to address this key issue, this work overviews the role of different stakeholders and discusses preventative and control measures for effective management of available resources. Roles and concerns of physicians, pharmacists and the public are also discussed. More than anything, this situation requires immediate action to establish antimicrobial stewardship program, control over the counter sale and promote public awareness. The paper also confronts the idea of curbing the use of antimicrobials using mass media, while detailing the consequences of non-therapeutic use. The role of policy makers in taking global action is essential to establishing authority or agency for formulating national guidelines and regulations for prudently using antimicrobials. To do this, this paper recommend the establishment of a global fund. In conclusion, the race against resistance is a collective responsibility requiring coordinated action at local, national, regional and international levels to ensure sustained utilization of antimicrobials.

Multidrug Resistant and Extensively Drug Resistant Bacteria: A Study

Background and Objective. Antimicrobial resistance is now a major challenge to clinicians for treating patients. Hence, this short term study was undertaken to detect the incidence of multidrug-resistant (MDR), extensively drug-resistant (XDR), and pandrug-resistant (PDR) bacterial isolates in a tertiary care hospital. Material and Methods. The clinical samples were cultured and bacterial strains were identified in the department of microbiology. The antibiotic susceptibility profile of different bacterial isolates was studied to detect MDR, XDR, and PDR bacteria. Results. The antibiotic susceptibility profile of 1060 bacterial strains was studied. 393 (37.1%) bacterial strains were MDR, 146 (13.8%) strains were XDR, and no PDR was isolated. All (100%) Gram negative bacterial strains were sensitive to colistin whereas all (100%) Gram positive bacterial strains were sensitive to vancomycin. Conclusion. Close monitoring of MDR, XDR, or even PDR must be done by all clinical microbiology laboratories to implement effective measures to reduce the menace of antimicrobial resistance.

Patterns of Antimicrobial Prescribing in a Tertiary Care Hospital in Oman

OBJECTIVES

Antimicrobial stewardship programs have been designed to measure and improve the use of antimicrobials to achieve optimal clinical outcomes and reduce bacterial resistance. The aim of this study was to review patterns of antimicrobial prescribing for hospitalized patients in the acute care setting and assess the appropriateness of antimicrobial use among prescribers in a tertiary care hospital in Oman.

METHODS

We conducted a retrospective audit of the appropriateness of antimicrobial prescribing in patients admitted to acute care settings in a tertiary care hospital in Oman over a four-week period (1 November to 28 November 2012). The data of all discharged patients were retrieved from the department databases. Patient records and prescriptions were reviewed by an infectious disease consultant. The rationality of antimicrobial use was evaluated, analyzed, and judged based on local standard guidelines and the experience of the evaluating consultant.

RESULTS

There were 178 patients discharged from acute medical teams over the study period. Sixty-four percent of the patients received a total of 287 antimicrobial agents during admission. The average number of antimicrobials prescribed per patient in those prescribed antimicrobials was 2.5±1.1. The most commonly prescribed antimicrobial agent was piperacillin/tazobactam. Most patients had infections from gram-negative organisms, and high rates of extended spectrum beta-lactamase producing organisms were observed. Cultures were obtained before antimicrobial initiation in 25% of patients. Variability in antimicrobial selection for common infections was observed.

CONCLUSIONS

National guidelines for the management of common infections are needed to minimize the overuse and misuse of antimicrobial agents in tertiary care hospitals. A large surveillance study on antimicrobial prescribing appropriateness in different hospital settings is warranted.

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

Methicillin-Resistant Staphylococcus Aureus in Saudi Arabia: Genotypes Distribution Review

Methicillin-resistant Staphylococcus Aureus (MRSA) infections in hospital have obviously imposed a significant burden of morbidity and mortality, and strain on healthcare resources. Here, we review the genotype distribution of these pathogens in the Kingdom of Saudi Arabia (KSA). A PubMed literature search (until May 2014) specified 12 articles that characterized MRSA clones in KSA. Only two regions (Riyadh and Damamm) were represented in ten articles. Data from these articles showed that the pandemic Vienna/Hungarian/Brazilian clone (CC8/ST239-III) is the most frequent in Saudi regions (Riyadh and Damamm). Several other clones such as Barnim/UK-EMRSA-15 (CC22-IV), Southwest Pacific clone (ST30-IV) and European community-associated-MRSA clone (CC80-IV) have been detected in the Riyadh region. A variety of MRSA clones is beginning to circulate in Saudi hospitals. Continued collection and molecular characterization of MRSA is crucial for the effective prevention and treatment.

Antimicrobial resistance: one world, one fight!

The lack of new antibiotic classes calls for a cautious use of existing agents. Yet, every 10 min, almost two tons of antibiotics are used around the world, all too often without any prescription or control. The use, overuse and misuse of antibiotics select for resistance in numerous species of bacteria which then renders antimicrobial treatment ineffective. Almost all countries face increased antimicrobial resistance (AMR), not only in humans but also in livestock and along the food chain. The spread of AMR is fueled by growing human and animal populations, uncontrolled contamination of fresh water supplies, and increases in international travel, migration and trade. In this context of global concern, 68 international experts attending the fifth edition of the World HAI Resistance Forum in June 2015 shared their successes and failures in the global fight against AMR. They underlined the need for a “One Health” approach requiring research, surveillance, and interventions across human, veterinary, agricultural and environmental sectors. This strategy involves concerted actions on several fronts. Improved education and increased public awareness are a well-understood priority. Surveillance systems monitoring infections need to be expanded to include antimicrobial use, as well as the emergence and spread of AMR within clinical and environmental samples. Adherence to practices to prevent and control the spread of infections is mandatory to reduce the requirement of antimicrobials in general care and agriculture. Antibiotics need to be banned as growth promoters for farm animals in countries where it has not yet been done. Antimicrobial stewardship programmes in animal husbandry have proved to be efficient for minimising AMR, without compromising productivity. Regarding the use of antibiotics in humans, new tools to provide highly specific diagnoses of pathogens can decrease diagnostic uncertainty and improve clinical management. Finally, infection prevention and control measures – some of them as simple as hand hygiene – are essential and should be extended beyond healthcare settings. Aside from regulatory actions, all people can assist in AMR reduction by limiting antibiotic use for minor illnesses. Together, we can all work to reduce the burden of AMR.

The antimicrobial stewardship program in Gulf Cooperation Council (GCC) states: insights from a regional survey

OBJECTIVES

The purpose of the current study is to describe the prevalence and characteristics of antimicrobial stewardship programs (ASP) in Gulf Cooperation Council (GCC) states to explore opportunities and overcome barriers to effective ASP implementation.

METHODS

A cross-sectional questionnaire survey was used to evaluate the current status of ASP: major stewardship components, barriers of implementation and program impact in acute care hospitals of GCC states.

RESULTS

Forty-seven healthcare professionals responded from four GCC states, the majority from Saudi Arabia (81%). Twenty-nine (62%) participating hospitals had ASP in place. Of these established programs, 35 (75%) reported lack of funding and personnel as major barriers to program implementation. The top three objectives cited for the hospital ASP were to reduce resistance (72.3%), improve clinical outcomes (70.2%) and reduce costs (44.7%). The reported impact of existing ASP was reduction of inappropriate prescribing (68%), reduction of broad spectrum antibiotic use (63.8%), reduction of healthcare-associated infections (61.7%), reduction of length of stay or mortality metrics (59.6%), reduction in direct antibiotic cost (57.4%) and reduction of reported antibiotic resistance (55.3%).

CONCLUSION

Survey participants from GCC states who have implemented ASP report significant impacts in the reduction of broad spectrum antibiotic use, hospital-acquired infection, inappropriate prescribing and antimicrobial resistance. These findings suggest a promising opportunity to enhance existing ASP through sharing of best practices and support the development of regional guidelines across GCC states.

Assessing the Groundwater Quality at a Saudi Arabian Agricultural Site and the Occurrence of Opportunistic Pathogens on Irrigated Food Produce

This study examines the groundwater quality in wells situated near agricultural fields in Saudi Arabia. Fruits (e.g., tomato and green pepper) irrigated with groundwater were also assessed for the occurrence of opportunistic pathogens to determine if food safety was compromised by the groundwater. The amount of total nitrogen in most of the groundwater samples exceeded the 15 mg/L permissible limit for agricultural irrigation. Fecal coliforms in densities > 12 MPN/100 mL were detected in three of the groundwater wells that were in close proximity to a chicken farm. These findings, coupled with qPCR-based fecal source tracking, show that groundwater in wells D and E, which were nearest to the chicken farm, had compromised quality. Anthropogenic contamination resulted in a shift in the predominant bacterial phyla within the groundwater microbial communities. For example, there was an elevated presence of Proteobacteria and Cyanobacteria in wells D and E but a lower overall microbial richness in the groundwater perturbed by anthropogenic contamination. In the remaining wells, the genus Acinetobacter was detected at high relative abundance ranging from 1.5% to 48% of the total groundwater microbial community. However, culture-based analysis did not recover any antibiotic-resistant bacteria or opportunistic pathogens from these groundwater samples. In contrast, opportunistic pathogenic Enterococcus faecalis and Pseudomonas aeruginosa were isolated from the fruits irrigated with the groundwater from wells B and F. Although the groundwater was compromised, quantitative microbial risk assessment suggests that the annual risk incurred from accidental consumption of E. faecalis on these fruits was within the acceptable limit of 10⁻⁴. However, the annual risk arising from P. aeruginosa was 9.55 × 10⁻⁴, slightly above the acceptable limit. Our findings highlight that the groundwater quality at this agricultural site in western Saudi Arabia is not pristine and that better agricultural management practices are needed alongside groundwater treatment strategies to improve food safety.

Nosocomial Infections and Epidemiology of Antibiotic Resistance in Teaching Hospitals in South East of Iran

Aim:

Antibiotic resistance as one of the most serious health threats worldwide leading to a high rate of morbidity and mortality. The aim of present study was to examine the prevalence of nosocomial infections (NIs) and pattern of antibiotic resistance in teaching hospitals in Iran

Methods:

This cross-sectional descriptive study was conducted in a period of one year in three teaching hospitals and all patients with suspected NIs symptoms were chooses. Among these patients who showed antibiotic resistance were included in the study. The samples for clinical test in laboratory were obtained with using standard methods and aseptic technique by trained personnel. Antibiotic susceptibility testing was performed by Kirby-Bauer’s disk diffusion method on Muller-Hinton agar (Hi Media, Mumbai, India) in accordance with the standards of the Clinical Laboratory Standards Institute.

Results:

During one year study, 561 patients with nosocomial infections were recognized and among them 340 patients (60.6%) showed some level of antibiotic resistance. The most common cause of NIs in present study was Acinetobacter and the most type of infection was respiratory system infections (52.7%). The highest resistance rate was against Ciprofloxacin (61.8%) followed by Imipenem (50.3%).

Conclusion:

Rate of NIs and antibiotics resistance is high in Iranian hospital. So Iranian health ministry should provide guideline and suitable programs for prevention of NIs and antibiotic therapy in hospitals.

Removal of bacterial contaminants and antibiotic resistance genes by conventional wastewater treatment processes in Saudi Arabia: Is the treated wastewater safe to reuse for agricultural irrigation?

This study aims to assess the removal efficiency of microbial contaminants in a local wastewater treatment plant over the duration of one year, and to assess the microbial risk associated with reusing treated wastewater in agricultural irrigation. The treatment process achieved 3.5 logs removal of heterotrophic bacteria and up to 3.5 logs removal of fecal coliforms. The final chlorinated effluent had 1.8 × 10(2) MPN/100 mL of fecal coliforms and fulfils the required quality for restricted irrigation. 16S rRNA gene-based high-throughput sequencing showed that several genera associated with opportunistic pathogens (e.g. Acinetobacter, Aeromonas, Arcobacter, Legionella, Mycobacterium, Neisseria, Pseudomonas and Streptococcus) were detected at relative abundance ranging from 0.014 to 21 % of the total microbial community in the influent. Among them, Pseudomonas spp. had the highest approximated cell number in the influent but decreased to less than 30 cells/100 mL in both types of effluent. A culture-based approach further revealed that Pseudomonas aeruginosa was mainly found in the influent and non-chlorinated effluent but was replaced by other Pseudomonas spp. in the chlorinated effluent. Aeromonas hydrophila could still be recovered in the chlorinated effluent. Quantitative microbial risk assessment (QMRA) determined that only chlorinated effluent should be permitted for use in agricultural irrigation as it achieved an acceptable annual microbial risk lower than 10(-4) arising from both P. aeruginosa and A. hydrophila. However, the proportion of bacterial isolates resistant to 6 types of antibiotics increased from 3.8% in the influent to 6.9% in the chlorinated effluent. Examples of these antibiotic-resistant isolates in the chlorinated effluent include Enterococcus and Enterobacter spp. Besides the presence of antibiotic-resistant bacterial isolates, tetracycline resistance genes tetO, tetQ, tetW, tetH, tetZ were also present at an average 2.5 × 10(2), 1.6 × 10(2), 4.4 × 10(2), 1.6 × 10(1) and 5.5 × 10(3) copies per mL of chlorinated effluent. Our study highlighted that potential risks associated with the reuse of treated wastewater arise not only from conventional fecal indicators or known pathogens, but also from antibiotic-resistant bacteria and genes.

Knowledge, attitude and practice towards antibiotic use among the public in Kuwait

Background

The emergence and spread of bacterial resistance to antibiotics is a growing problem worldwide, which presents a significant threat to public health globally in the 21^st century. A substantial evidence has shown that the general community plays a role in the increase and spread of antibiotic resistance. The present study was designed to determine knowledge, attitude and practice towards antibiotic use.

Methods

A cross-sectional survey was performed using a pretested self-administered questionnaire on a sample of 770 randomly selected Kuwaiti individuals. Descriptive and multivariate logistic regression analysis were used in data analysis.

Results

The response rate was 88.3%. Nearly three-quarters (72.8%) of respondents had been prescribed antibiotics within 12 months prior to the study period, and 36% of them had not finished the course of treatment. Over one-quarter (27.5%) were self-medicated with antibiotics to treat mainly common cold, sore throat and cough. Self-medication was more prevalent among those who were prescribed antibiotics and those who had attitudes towards using and accessing antibiotic inappropriately. Almost 47% of participants had low knowledge regarding action, use, safety and resistance of antibiotics. Forty one percent of respondents had attitudes towards using and accessing antibiotic inappropriately. Better knowledge was found to be a predictor for positive attitude. Respondents level of agreement that doctors often prescribe antibiotics to meet the patient’s expectation, and that doctors often take time to consider carefully the need for an antibiotic were 52.7% and 35.3%, respectively.

Conclusions

These findings will aid in the assessment of the adequacy of present public educational campaigns. Also, it will provide further insight in designing future multifaceted interventions to promote specific messages to rationalize antibiotic use, and compensate for knowledge and attitude gaps as an effort towards preventing development of antibiotic resistance.

Prevalence of 16S rRNA methylase genes among β-lactamase-producing Enterobacteriaceae clinical isolates in Saudi Arabia

BACKGROUND

Co production of 16S rRNA methylases gene and β-Lactamase gene among Enterobacteriaceae isolates conferring resistance to both therapeutic options has serious implications for clinicians worldwide.

METHODS

To study co existence of 16S rRNA methylases (armA, rmtA, rmtB, rmtC, rmtD, and npmA) and β-Lactamase (blaTEM-1, blaSHV-12, blaCTX-M-14) genes, we screened all phenotypic positive β-Lactamase producing enterobacteriaceae by polymerase chain reaction (PCR) targeting above genes. A total of 330 enterobacteriaceae strains were collected during study period out of that 218 isolates were identified phenotypically as β-Lactamase producers, which include 50 (22.9%) Escherichia coli; 92 (42.2%) Klebsiella pneumoniae, 44 (20.2%), Citrobactor freundii and 32 (14.7%) Enterobacter spp.

RESULTS

Among this 218, only 188 isolates harbored the resistant gene for β-Lactamase production. Major β-Lactamase producing isolates were blaTEM-1 type. 122 (56 %) isolates were found to produce any one of the 16S rRNA methylase genes. A total of 116 isolates co produced b-Lactamase and at least one 16S rRNA methylases gene Co production of armA gene was found in 26 isolates with rmtB and in 4 isolates with rmtC. The rmtA and rmtD genes were not detected in any of the tested isolates. Six isolates were positive for a 16S rRNA methylase gene alone.

CONCLUSION

β-Lactamase producing isolates appears to coexist with 16S rRNA methylase predominantly armA and rmtB genes in the same isolate. We conclude the major β-Lactamase and 16S rRNA methylases co-producer was K. pneumoniae followed by E. coli. We suggest further work on evaluating other β-lactamases types and novel antibiotic resistance mechanisms among Enterobacteriaceae.

Epidemiology of multi-drug resistant organisms in a teaching hospital in oman: a one-year hospital-based study

Background. Antimicrobial resistance is increasingly recognized as a global challenge. A few studies have emerged on epidemiology of multidrug resistant organisms in tertiary care settings in the Arabian Gulf. Aim. To describe the epidemiology of multi-drug resistant organisms (MDRO) at Sultan Qaboos University Hospital, a tertiary hospital in Oman. Methods. A retrospective review of MDRO records has been conducted throughout the period from January 2012 till December 2012. Organisms were identified and tested by an automated identification and susceptibility system, and the antibiotic susceptibility testing was confirmed by the disk diffusion method. Results. Out of the total of 29,245 admissions, there have been 315 patients registered as MDRO patients giving an overall prevalence rate of 10.8 (95% CI 9.3, 12.4) MDRO cases per 1000 admissions. In addition, the prevalence rate of MDRO isolates was 11.2 (95% CI 9.7, 12.9) per 1000 admissions. Overall, increasing trends in prevalence rates of MDRO patients and MDRO isolates were observed throughout the study period. Conclusion. Antimicrobial resistance is an emerging challenge in Oman. Continuous monitoring of antimicrobial susceptibility and strict adherence to infection prevention guidelines are essential to prevent proliferation of MDRO. Along such quest, stringent antibiotic prescription guidelines are needed in the country.

β-Lactamase production in key gram-negative pathogen isolates from the Arabian Peninsula

SUMMARY Infections due to Gram-negative bacilli (GNB) are a leading cause of morbidity and mortality worldwide. The extent of antibiotic resistance in GNB in countries of the Gulf Cooperation Council (GCC), namely, Saudi Arabia, United Arab Emirates, Kuwait, Qatar, Oman, and Bahrain, has not been previously reviewed. These countries share a high prevalence of extended-spectrum-β-lactamase (ESBL)- and carbapenemase-producing GNB, most of which are associated with nosocomial infections. Well-known and widespread β-lactamases genes (such as those for CTX-M-15, OXA-48, and NDM-1) have found their way into isolates from the GCC states. However, less common and unique enzymes have also been identified. These include PER-7, GES-11, and PME-1. Several potential risk factors unique to the GCC states may have contributed to the emergence and spread of β-lactamases, including the unnecessary use of antibiotics and the large population of migrant workers, particularly from the Indian subcontinent. It is clear that active surveillance of antimicrobial resistance in the GCC states is urgently needed to address regional interventions that can contain the antimicrobial resistance issue.