Epidemiology of bacteraemia in Hamad general hospital, Qatar: a one year hospital-based study

Evaluation of the Appropriateness of Piperacillin-Tazobactam Prescription in Community-Acquired Pneumonia: A Tertiary-Center Experience

Background Antimicrobial resistance (AMR) has been designated a public health crisis by the World Health Organization. AMR can lead to escalated healthcare costs, higher mortality rates, increased morbidity, and more frequent hospitalizations. This study aimed to retrospectively evaluate the appropriateness of Tazocin prescription for community-acquired pneumonia (CAP). Methodology We conducted a retrospective analysis of patients aged ≥18 years who were admitted with a diagnosis of CAP and administered intravenous Tazocin between November 2021 and October 2022. The primary objective was to assess the appropriateness of Tazocin prescriptions in patients with CAP. Results A total of 39 patients with CAP were included, with a mean age of 61 ± 17.36 years. Overall, 24 (61%) patients were male. The rate of inappropriate prescriptions of Tazocin was 66.6%. The incidence of inappropriate Tazocin prescription varied significantly among different medical specialties, with the highest rate observed in the oncology-palliative specialty (90%; p = 0.033). Conclusions Our study affirms the inclination of physicians to prescribe Tazocin for CAP without justifiable indications and highlights the unwarranted use of Tazocin for CAP across various medical specialties. This is evidenced by the notably high rate of inappropriate empirical prescriptions.

The epidemiology and microbiological characteristics of infections caused by Gram-negative bacteria in Qatar: national surveillance from the Study for Monitoring of Antimicrobial Resistance Trends (SMART): 2017 to 2019

Background

The global Study of Monitoring Antimicrobial Resistance Trends (SMART) is a surveillance program for evaluation of antimicrobial resistance (AMR) in Gram-negative bacteria (GNB) from different regions including Gulf countries.

Objectives

To evaluate AMR in GNB from various clinical specimens including microbiological and genetic characteristics for existing and novel antimicrobials.

Methods

A prospective study was conducted on clinical specimens from Hamad Medical Corporation, Qatar, between 2017 and 2019 according to the SMART protocol. Consecutive GNB from different sites were evaluated including lower respiratory, urinary tract, intrabdominal and bloodstream infections.

Results

Over the 3 years study period, 748 isolates were evaluated from the specified sites comprising 37 different GNB outlining four key pathogens: Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Stenotrophomonas maltophilia.For the two major pathogens E. coli and K. pneumoniae, phenotypic ESBL was identified in 55.77% (116/208) compared to 39% (73/187), while meropenem resistance was 3.8% compared to 12.8% and imipenem/relebactam resistance was 2.97% compared to 11.76%, respectively. The overall ceftolozane/tazobactam resistance for E. coli was 9.6% (20/208) compared to 14.97% (28/187) for K. pneumoniae while resistance for ceftazidime/avibactam was 3.65% (5/137) and 5.98% (10/117), respectively. Genomic characteristics of 70 Enterobacterales including 48 carbapenem-resistant, revealed prevalence of β-lactamases from all classes, predominated by blaCXM-15 while carbapenem resistance revealed paucity of blaKPC and dominance of blaOXA-48 and blaNDM resistance genes.

Conclusions

Surveillance of GNB from Qatar showed prevalence of key pathogens similar to other regions but demonstrated significant resistance patterns to existing and novel antimicrobials with different underlying resistance mechanisms.

Estimation of Prevalence of Hospital-Acquired Blood Infections among Patients Admitted at a Tertiary Hospital in Oman over a Period of Five Years: A Cross-Sectional Study

Background

Data from developed/developed countries have shown that hospital-acquired blood infections (HA-BSIs) are one of the most severe nosocomial infections and constitute 20%-60% of hospitalization-related deaths. Despite the high morbidity and mortality rates and the enormous burden of health care costs associated with HA-BSIs, to our knowledge, there are few published reports on HA-BSI prevalence estimates in Arab countries, including Oman.

Objectives

This study aims to explore the HA-BSI prevalence estimates over selected sociodemographic characteristics among admitted patients at a tertiary hospital in Oman over five years of follow-up. The regional variations in Oman were also examined in this study.

Methods

This hospital-based cross-sectional study reviewed reports of hospital admissions over 5 years of retrospective follow-ups at a tertiary hospital in Oman. HA-BSI prevalence estimates were calculated over age, gender, governorate, and follow-up time.

Results

In total, 1,246 HA-BSI cases were enumerated among a total of 139,683 admissions, yielding an overall HA-BSI prevalence estimate of 8.9 cases per 1000 admissions (95% CI: 8.4, 9.4). HA-BSI prevalence was higher among males compared to females (9.3 vs. 8.5). HA-BSI prevalence started as relatively high in the group aged 15 years or less (10.0; 95% CI 9.0, 11.2) and then declined as age increased from 36 to 45 years (7.0; 95% CI 5.9, 8.3) when it started to increase steadily with increasing age in the group aged 76 or more (9.9; 95% CI 8.1, 12.1). The governorate-specific estimate of HA-BSI prevalence was the highest among admitted patients who resided in Dhofar governorate, while the lowest estimate was reported from the Buraimi governorate (5.3).

Conclusion

The study provides supportive evidence for a steady increase in HA-BSI prevalence over age categories and years of follow-up. The study calls for the timely formulation and adoption of national HA-BSI screening and management programs centered on surveillance systems based on real-time analytics and machine learning.

Effects of Inappropriate Administration of Empirical Antibiotics on Mortality in Adults With Bacteraemia: Systematic Review and Meta-Analysis

Introduction

Bloodstream infections are associated with high mortality rates and contribute substantially to healthcare costs, but a consensus on the prognostic benefits of appropriate empirical antimicrobial therapy (EAT) for bacteraemia is lacking.

Methods

We performed a systematic search of the PubMed, Cochrane Library, and Embase databases through July 2021. Studies comparing the mortality rates of patients receiving appropriate and inappropriate EAT were considered eligible. The quality of the included studies was assessed using Joanna Briggs Institute checklists.

Results

We ultimately assessed 198 studies of 89,962 total patients. The pooled odds ratio (OR) for the prognostic impacts of inappropriate EAT was 2.06 (P < 0.001), and the funnel plot was symmetrically distributed. Among subgroups without between-study heterogeneity (I² = 0%), those of patients with severe sepsis and septic shock (OR, 2.14), Pitt bacteraemia scores of ≥4 (OR, 1.88), cirrhosis (OR, 2.56), older age (OR, 1.78), and community-onset/acquired Enterobacteriaceae bacteraemia infection (OR, 2.53) indicated a significant effect of inappropriate EAT on mortality. The pooled adjusted OR of 125 studies using multivariable analyses for the effects of inappropriate EAT on mortality was 2.02 (P < 0.001), and the subgroups with low heterogeneity (I² < 25%) exhibiting significant effects of inappropriate EAT were those of patients with vascular catheter infections (adjusted OR, 2.40), pneumonia (adjusted OR, 2.72), or Enterobacteriaceae bacteraemia (adjusted OR, 4.35). Notably, the pooled univariable and multivariable analyses were consistent in revealing the negligible impacts of inappropriate EAT on the subgroups of patients with urinary tract infections and Enterobacter bacteraemia.

Conclusion

Although the current evidence is insufficient to demonstrate the benefits of prompt EAT in specific bacteraemic populations, we indicated that inappropriate EAT is associated with unfavorable mortality outcomes overall and in numerous subgroups. Prospective studies designed to test these specific populations are needed to ensure reliable conclusions.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021270274.

Prevalence of Multidrug-Resistant Methicillin-Resistant Staphylococcus aureus in Northeastern Saudi Hospitals

Methicillin-resistant Staphylococcus aureus (MRSA) is responsible for serious threats to human health, causing various syndromes worldwide. Here, our purpose was to estimate the prevalence of nosocomial MRSA among isolates from King Khalid Hospital (KKH) and Maternity and Children Hospital (MCH) at Hafar Al-Batin Governorate, Saudi Arabia, and to determine the resistance of these isolates to common antibiotics used for treatment. One-hundred clinical specimens were collected from admitted patients during a six month period, and subjected to MRSA screening using traditional microbiological techniques. Antimicrobial susceptibility testing (AST) was also performed and confirmed by the VITEK2 automated system. Among the 37 S. aureus strains isolated from KKH, 23 (62.16%) were identified as MRSA. In MCH, 38 (60.31%) out 63 isolated strains were identified as MRSA. According to AST, few MRSA strains were resistant to teicoplanin, fosfomycin, linezolid, and mupirocin in both hospitals. Vancomycin resistance was not detected in any of the MRSA strains. Twelve MRSA strains from KKH and 17 strains from MCH were considered multidrug resistant (MDR). In conclusion, prevention is critical to reduce the high prevalence of MRSA.

Rhamnolipid Nano-Micelles versus Alcohol-Based Hand Sanitizer: A Comparative Study for Antibacterial Activity against Hospital-Acquired Infections and Toxicity Concerns

Hospital-acquired infections (HAIs) are considered to be a major global healthcare challenge, in large part because of the development of microbial resistance to currently approved antimicrobial drugs. HAIs are frequently preventable through infection prevention and control measures, with hand hygiene as a key activity. Improving hand hygiene was reported to reduce the transmission of healthcare-associated pathogens and HAIs. Alcohol-based hand sanitizers are commonly used due to their rapid action and broad spectrum of microbicidal activity, offering protection against bacteria and viruses. However, their frequent administration has been reported to be associated with many side effects, such as skin sensitivity, skin drying, and cracks, which promote further skin infections. Thus, there is an essential need to find alternative approaches to hand sanitation. Rhamnolipids are glycolipids produced by Pseudomonas aeruginosa, and were shown to have broad antimicrobial activity as biosurfactants. We have previously demonstrated the antimicrobial activity of rhamnolipid nano-micelles against selected drug-resistant Gram-negative (Salmonella Montevideo and Salmonella Typhimurium) and Gram-positive bacteria (Staphylococcus aureus, Streptococcus pneumoniae). To the best of our knowledge, the antimicrobial activity of rhamnolipid nano-micelles in comparison to alcohol-based hand sanitizers against microorganisms commonly causing HAIs in Egypt—such as Acinetobacter baumannii and Staphylococcus aureus—has not yet been studied. In the present work, a comparative study of the antibacterial activity of rhamnolipid nano-micelles versus alcohol-based hand sanitizers was performed, and their safety profiles were also assessed. It was demonstrated that rhamnolipid nano-micelles had a comparable antibacterial activity to alcohol-based hand sanitizer, with a better safety profile, i.e., rhamnolipid nano-micelles are unlikely to cause any harmful effects on the skin. Thus, rhamnolipid nano-micelles could be recommended to replace alcohol-based hand sanitizers; however, they must still be tested by healthcare workers in healthcare settings to ascertain their antimicrobial activity and safety.

Microbiological Spectrum and Antibiogram of Urinary Tract Infection in a Tertiary Care Center from the Kingdom of Bahrain

Urinary tract infection is the second-most common after respiratory infections. This is a single-center retrospective study conducted in Bahrain Specialist Hospital, Bahrain. Urine culture data from November 2011 until December 2020 was obtained from the hospital database. Out of 28082, 4849 (17.3%) cultures were positive. One hundred and thirty-four (2.8%) showed the growth of multiple organisms. The male-to-female ratio was 3.7. Most of the patients [1872 (39.7%)] were 20-40 years. Men and women were 53.84 ± 25.85 and 43.41 ± 23.89 years, respectively; P <0.001. 4118/4715 (87.3%) were Gram-negative. Five hundred and sixty-four (11.9 %) and 33 (0.7%) were Gram-positive cocci and fungi, respectively. Escherichia coli (E. coli) was the most common and Klebsiella species were second-most common, accounting for 2916 (61.8%) and 586 (12.4%), respectively. 30.2% of all E. coli and 130 (22.2%) of all Klebsiella species were extended-spectrum beta-lactamase (ESBL) producers. ESBL Klebsiella pneumoniae, Pseudomonas aeruginosa, and Enterococcus faecalis were present more in inpatients (P <0.001). P. aeruginosa was found more in women (P <0.001). E. coli was resistant to cotrimoxazole, ciprofloxacin, and levofloxacin in 28%, 17.3%, and 18.1%, respectively. ESBL E. coli and ESBL K. pneumoniae were resistant to amoxicillin-clavulanate, cotrimoxazole, ciprofloxacin, and levofloxacin in 73.8%, 62.3%, 62.4%, 58.4% and 68.2%, 62.6%, 55.7%, and 41.8% respectively. There is a high incidence of ESBL E. coli and ESBL K. pneumoniae. There is alarmingly increased resistance of P. aeruginosa to carbapenems. Amoxicillin-clavulanate, cefixime, and cefuroxime are suitable oral antibiotics for empirical treatment. For sick patients, piperacillin-tazobactam, aminoglycosides, and carbapenems should be considered. Antibiotic stewardship is the need of an hour.

Emerging Status of Multidrug-Resistant Bacteria and Fungi in the Arabian Peninsula

Simple Summary

The incidence and developing status of multidrug-resistant bacteria and fungi, as well as their related mortality, is reviewed by a systematic published literature search from nine countries in the Arabian Peninsula. In order to analyse the emerging status and mortality, a total of 382 research articles were selected from a comprehensive screening of 1705 papers. More than 850 deaths reported since 2010 in the Arabian Peninsula due to the infection of multidrug-resistant bacteria and fungi. Multidrug-resistant bacteria Acinetobacter baumannii, Mycobacterium tuberculosis, Staphylococcus aureus, and fungi Candida auris are the most prevalent and causing high deaths. To control these infections and associated deaths in the Arabian Peninsula, continuous preventive measures, accurate methods for early diagnosis of infection, active surveillance, constant monitoring, developing vaccines, eradicating multidrug resistance modulators, and data sharing among countries are required.

Abstract

We aimed to identify the prevalence and emerging status of multidrug-resistant bacteria and fungi and their associated mortality in nine countries in the Arabian Peninsula. Original research articles and case studies regarding multidrug-resistant bacteria and fungi in the Arabian Peninsula, published during the last 10 years, were retrieved from PubMed and Scopus. A total of 382 studies were included as per the inclusion and exclusion criteria, as well as the PRISMA guidelines, from a thorough screening of 1705 articles, in order to analyse the emerging status and mortality. The emerging nature of >120 multidrug-resistant (MDR) bacteria and fungi in the Arabian Peninsula is a serious concern that requires continuous monitoring and immediate preventive measures. More than 50% (n = 453) of multidrug-resistant, microbe-associated mortality (n = 871) in the Arabian Peninsula was due to MDR Acinetobacter baumannii, Mycobacterium tuberculosis and Staphylococcus aureus infection. Overall, a 16.51% mortality was reported among MDR-infected patients in the Arabian Peninsula from the 382 articles of this registered systematic review. MDR A. baumannii (5600 isolates) prevailed in all the nine countries of the Arabian Peninsula and was one of the fastest emerging MDR bacteria with the highest mortality (n = 210). A total of 13,087 Mycobacterium tuberculosis isolates were reported in the region. Candida auris (580 strains) is the most prevalent among the MDR fungal pathogen in the Arabian Peninsula, having caused 54 mortalities. Active surveillance, constant monitoring, the development of a candidate vaccine, an early diagnosis of MDR infection, the elimination of multidrug resistance modulators and uninterrupted preventive measures with enhanced data sharing are mandatory to control MDR infection and associated diseases of the Arabian Peninsula. Accurate and rapid detection methods are needed to differentiate MDR strain from other strains of the species. This review summarises the logical relation, prevalence, emerging status and associated mortality of MDR microbes in the Arabian Peninsula.

Epidemiology of Methicillin-Resistant Staphylococcus Aureus in Arab Countries of the Middle East and North African (MENA) Region

Available data suggest a high burden of methicillin-resistant staphylococcus aureus (MRSA) in Arab countries of the Middle East and North Africa (MENA). To review the MRSA rates and molecular epidemiology in this region, we used PubMed search engine to identify relative articles published from January 2005 to December 2019. Great heterogeneity in reported rates was expectedly seen. Nasal MRSA colonization ranged from 2%–16% in Gulf Cooperation Council (GCC), 1–9% in the Levant, and 0.2%–9% in North African Arab states. Infective MRSA rates ranged from 9%–38% in GCC, 28%–67% in the Levant, and 28%–57% in North African states. Studies demonstrated a wide clonal diversity in the MENA. The most common molecular types belonged to 5 clonal complexes (CC) known to spread worldwide: CC5, CC8, CC22, CC30, and CC80. The most prevalent strains had genotypes related to the European community-acquired MRSA (CA-MRSA), Brazilian/Hungarian hospital-acquired MRSA (HA-MRSA), UK-EMRSA-15 HA-MRSA, and USA300 CA-MRSA. Finally, significant antimicrobial resistance was seen in the region with variation in patterns depending on location and clonal type. For a more accurate assessment of MRSA epidemiology and burden, the Arab countries need to implement national surveillance systems.

Rodent-Related Zoonotic Pathogens at the Human-Animal-Environment Interface in Qatar: A Systematic Review and Meta-Analysis

Rodents are one of the most diversified terrestrial mammals, and they perform several beneficial activities in nature. These animals are also important as carriers of many pathogens with public health importance. The current systematic review was conducted to formulate a true depiction of rodent-related zoonoses in Qatar. Following systematic searches on PubMed, Scopus, Science Direct, and Web of Science and a screening process, a total of 94 published articles were selected and studied. The studied articles reported 23 rodent-related zoonotic pathogens that include nine bacterial, eleven parasitic, and three viral pathogens, from which the frequently reported pathogens were Mycobacterium tuberculosis (32 reports), Escherichia coli (23), and Salmonella spp. (16). The possible pathway of entry of the rodent-borne pathogens can be the land port, seaports, and airport of Qatar through carrier humans and animals, contaminated food, and agricultural products. The pathogens can be conserved internally by rodents, pets, and livestock; by agricultural production systems; and by food marketing chains. The overall estimated pooled prevalence of the pathogens among the human population was 4.27% (95%CI: 4.03–4.51%; p < 0.001) with significant heterogeneity (I² = 99.50%). The top three highest prevalent pathogens were M.tuberculosis (30.90%; 22.75–39.04%; p < 0.001; I² = 99.70%) followed by Toxoplasma gondii (21.93%; 6.23–37.61%; p < 0.001; I² = 99.30%) and hepatitis E virus (18.29%; 11.72–24.86%; p < 0.001; I² = 96.70%). However, there is a knowledge gap about the listed pathogens regarding the occurrence, transmission pathways, and rodent role in transmission dynamics at the human–animal–environment interface in Qatar. Further studies are required to explore the role of rodents in spreading zoonotic pathogens through the One Health framework, consisting of zoologists, ecologists, microbiologists, entomologists, veterinarians, and public health experts in this country.

Measures used to assess the burden of ESBL-producing Escherichia coli infections in humans: a scoping review

Background

ESBL-producing bacteria pose a serious challenge to both clinical care and public health. There is no standard measure of the burden of illness (BOI) of ESBL-producing Escherichia coli (ESBL-EC) in the published literature, indicating a need to synthesize available BOI data to provide an overall understanding of the impact of ESBL-EC infections on human health.

Objectives

To summarize the characteristics of BOI reporting in the ESBL-EC literature to (i) describe how BOI associated with antimicrobial resistance (AMR) is measured and reported; (ii) summarize differences in other aspects of reporting between studies; and (iii) highlight the common themes in research objectives and their relation to ESBL-EC BOI.

Methods and results

Two literature searches, run in 2013 and 2018, were conducted to capture published studies evaluating the BOI associated with ESBL-EC infections in humans. These searches identified 1723 potentially relevant titles and abstracts. After relevance screening of titles and abstracts and review of full texts, 27 studies were included for qualitative data synthesis. This review identified variability in the reporting and use of BOI measures, study characteristics, definitions and laboratory methods for identifying ESBL-EC infections.

Conclusions

Decision makers often require BOI data to make science-based decisions for the implementation of surveillance activities or risk reduction policies. Similarly, AMR BOI measures are important components of risk analyses and economic evaluations of AMR. This review highlights many limitations to current ESBL-EC BOI reporting, which, if improved upon, will ensure data accessibility and usefulness for ESBL-EC BOI researchers, decision makers and clinicians.

Evaluation of the health and healthcare system burden due to antimicrobial-resistant Escherichia coli infections in humans: a systematic review and meta-analysis

BACKGROUND

Assessment of the burden of disease due to antimicrobial-resistant Escherichia coli infections facilitates understanding the scale of the problem and potential impacts, and comparison to other diseases, which allows prioritization of research, surveillance, and funding. Using systematic review and meta-analysis methodology, the objectives were to evaluate whether humans with antimicrobial-resistant E. coli infections experience increases in measures of health or healthcare system burden when compared to susceptible E. coli infections.

METHODS

Comprehensive literature searches were performed in four primary and seven grey literature databases. Analytic observational studies of human E. coli infections that assessed the impact of resistance to third/fourth/fifth-generation cephalosporins, resistance to quinolones, and/or multidrug resistance on mortality, treatment failure, length of hospital stay and/or healthcare costs were included. Two researchers independently performed screening, data extraction, and risk of bias assessment. When possible, random effect meta-analyses followed by assessment of the confidence in the cumulative evidence were performed for mortality and length of hospital stay outcomes, and narrative syntheses were performed for treatment failure and healthcare costs.

RESULTS

Literature searches identified 14,759 de-duplicated records and 76 articles were included. Based on 30-day and all-cause mortality meta-analyses, regardless of the type of resistance, there was a significant increase in the odds of dying with resistant E. coli infections compared to susceptible infections. A summary mean difference was not presented for total length of hospital stay meta-analyses due to substantial to considerable heterogeneity. Since small numbers of studies contributed to meta-analyses for bacterium-attributable mortality and post-infection length of hospital stay, the summary results should be considered with caution. Studies contributing results for treatment failure and healthcare costs had considerable variability in definitions and reporting.

CONCLUSIONS

Overall, resistant E. coli infections were associated with significant 30-day and all-cause mortality burden. More research and/or improved reporting are necessary to facilitate quantitative syntheses of bacterium-attributable mortality, length of hospital stay, and hospital costs. Protocol Registration PROSPERO CRD42018111197.

Prevalence of infections and antimicrobial use in the acute-care hospital setting in the Middle East: Results from the first point-prevalence survey in the region

OBJECTIVES

Community-acquired (CAIs) and healthcare-associated (HAIs) infections are associated with significant morbidity and mortality. Data related to the epidemiology of these infections in the Middle East is scarce. The aim of this study is to estimate the prevalence of infections and antimicrobial use in the acute hospital setting in this region.

METHODS

A multicentre Point-Prevalence Survey was conducted in seven Middle Eastern countries: Egypt, Kingdom of Saudi Arabia, United Arab Emirates, Lebanon, Oman, Kuwait and Bahrain. Data were collected by the infection control and infectious diseases teams of the respective hospitals. Study surveys were completed in one day (03 April 2018).

RESULTS

The overall point prevalence of infection was 28.3%; HAI and CAI point prevalence was 11.2% and 16.8%, respectively. The majority of patients with an infection (98.2%) were receiving antimicrobial therapy. There were high levels of resistance to antimicrobials among Acinetobacter baumannii, Enterobacter cloacae, Klebsiella pneumoniae and other Klebsiella sp.

CONCLUSIONS

Our findings indicate that the point prevalence of both HAI and CAI is high in a sample of Middle Eastern countries. These findings along with the increased use of antimicrobials represent a significant public health problem in the region; particularly in light of the growing regional antimicrobial resistance.

Reevaluation of the impact of methicillin-resistance on outcomes in patients with Staphylococcus aureus bacteremia and endocarditis

BACKGROUND/AIMS

Methicillin-resistant Staphylococcus aureus (MRSA) is highly prevalent in hospitals, and has recently emerged in the community. The impact of methicillin-resistance on mortality and medical costs for patients with S. aureus bacteremia (SAB) requires reevaluation.

METHODS

We searched studies with SAB or endocarditis using electronic databases including Ovid-Medline, Embase-Medline, and Cochrane Library, as well as five local databases for published studies during the period January 2000 to September 2011.

RESULTS

A total of 2,841 studies were identified, 62 of which involved 17,563 adult subjects and were selected as eligible. A significant increase in overall mortality associated with MRSA, compared to that with methicillin-susceptible S. aureus (MSSA), was evidenced by an odds ratio (OR) of 1.95 (95% confidence interval [CI], 1.73 to 2.21; p < 0.01). In 13 endocarditis studies, MRSA increased the risk of mortality, with an OR of 2.65 (95% CI, 1.46 to 4.80). When three studies, which compared mortality rates between CA-MRSA and CA-MSSA, were combined, the risk of methicillin-resistance increased 3.23-fold compared to MSSA (95% CI, 1.25 to 8.34). The length of hospital stay in the MRSA group was 10 days longer than that in the MSSA group (95% CI, 3.36 to 16.70). Of six studies that reported medical costs, two were included in the analysis, which estimated medical costs to be $9,954.58 (95% CI, 8,951.99 to 10,957.17).

CONCLUSION

MRSA is still associated with increased mortality, longer hospital stays and medical costs, compared with MSSA in SAB in studies published since the year 2000.

Exploring bacterial resistance in Northern Oman, a foundation for implementing evidence-based antimicrobial stewardship program

BACKGROUND

Increasing rate of resistant infections is a challenge to healthcare negatively impacting therapeutic and financial outcomes. Targeted antimicrobial stewardship interventions are needed to counteract this global crisis. On large scale, we sought to identify the prevalence of resistant pathogens and their susceptibility pattern in Northern Oman.

MATERIAL AND METHOD

Retrospective analysis of all isolates processed by Suhar Hospital microbiology laboratory between Jan1st, 2016 and Dec31st, 2017. Organism identification, susceptibility and phenotyping were performed following CLSI standards and duplicate isolates were excluded. Pertinent microbiological data were collected and analyzed.

RESULTS

Of 15,733 samples included, Gram-negative bacteria predominate by 67.76%, Gram-positive (29%) and Candida species (2.63%). Frequently isolated Gram-negative bacteria were Escherichia coli (32.39%), Pseudomonas aeruginosa (22.16%), Klebsiellapneumoniae (19.97%) and Acinetobacter baumannii (5.22%), there was virtually no resistance to colistin and tigecycline, while a growing resistance toward ciprofloxacin and meropenem was observed. Resistant E. coli and K. pneumoniae were isolated from bloodstream infection (12%). While Gram-positives were MSSA (27.23%), Streptococcus agalactiae (25.36%), MRSA (16.10%) and CoNS (12.1 %), they were almost universally susceptible to daptomycin and linezolid with low resistance (8˜20%) to clindamycin. Approximately, 50% of Staphylococci (MRSA and CoNS) required vancomycin treatment.

CONCLUSION

Study findings should guide targeted stewardship interventions to optimize antibiotic prescriptions. Empirical treatment options should be revised, drug-bug match therapy instituted promptly and newer agents considered. Prescribing restriction of formulary antimicrobials that still retain their activity towards bugs - like colistin, linezolid and tigecycline- is a mandatory action. Review empiric use of ciprofloxacin and meropenem to counteract growing resistance.

Epidemiology of common resistant bacterial pathogens in the countries of the Arab League

No uniformly organised collection of data regarding antimicrobial resistance has occurred in the countries of the Arab League. 19 countries of the Arab League have published data for antimicrobial susceptibility for the WHO priority organisms, and seven of 14 of these organisms are included in this Review (Escherichia coli, Klebsiella spp, Pseudomonas aeruginosa, Acinetobacter baumannii, Salmonella spp, Staphylococcus aureus, and Streptococcus pneumoniae). Although E coli and Klebsiella spp resistance to third-generation cephalosporins is common in all countries, with prevalence reaching more than 50% in Egypt and Syria, carbapenem resistance is emerging, albeit with a prevalence of less than 10%. Conversely, a large amount of carbapenem resistance has been reported for P aeruginosa and A baumannii across the Arab League, reaching 50% and 88% of isolates in some countries. As for Salmonella spp, the prevalence of fluoroquinolone resistance has exceeded 30% in several areas. With regards to the Gram-positive pathogens, the prevalence of meticillin resistance in S aureus is reported to be between 20% and 30% in most countries, but exceeds 60% in Egypt and Iraq. The prevalence of penicillin non-susceptibility among pneumococci has reached more than 20% in Algeria, Egypt, Morocco, Saudi Arabia, and Tunisia. These findings highlight the need for structured national plans in the region to target infection prevention and antimicrobial stewardship.

Prevalence of antibiotic resistant Escherichia coli isolates from fecal samples of food handlers in Qatar

Background

It is well documented that food handlers harbor and shed enteric foodborne pathogens causing foodborne disease outbreaks. However, little known on enteric antibiotic resistant (AR) bacteria carriage in food handlers. The objective of this study was to establish a baseline prevalence of fecal AR E. coli among food handlers in Qatar.

Methods

Fecal samples were collected from 456 migrant food handlers of different nationalities arriving in Qatar on a work permit between January 2015 and December 2016. These samples (25 g each) were collected based on the availability and examination schedule at the Medical Commission facility from those consented to participate. Isolated E. coli bacteria were tested for antibiotic susceptibility against nine antibiotics using the E-test method and Double Disc Synergy Test (DDST) for extended-spectrum beta-lactamase (ESBL) production.

Results

From the 78 E. coli positive samples (17.1%, n = 456), 60% of the isolates were resistant to at least one antibiotic, whereas, 27% were multi-drug resistant (MDR). Seven isolates (9%, n = 78) were ESBL producers of which five were MDR. Individual AR E. coli frequencies to the nine antibiotics were not significantly (P > 0.05) different by nationality.

Conclusions

Based on our findings, we revealed that individual resistant E. coli and MDR resistant E. coli were common in fecal samples of food handlers in Qatar. This may indicate that food handlers can potentially contaminate foods with AR E. coli, a possible public health concern.

Antibiotic Resistance Profile of Commensal Escherichia coli Isolated from Broiler Chickens in Qatar

Antibiotic resistance (AR) is a growing public health concern worldwide, and it is a top health challenge in the 21st century. AR among Enterobacteriaceae is rapidly increasing, especially in third-generation cephalosporins and carbapenems. Further, strains carrying mobilized colistin resistance ( mcr) genes 1 and 2 have been isolated from humans, food-producing animals, and the environment. The uncontrolled use of antibiotics in food-producing animals is a major factor in the generation and spread of AR. No studies have been done to evaluate AR in the veterinary sector of Qatar. This study aimed at establishing primary baseline data for the prevalence of AR among food-producing animals in Qatar. Fecal samples (172) were obtained from two broiler farms and one live bird market in Qatar, and 90 commensal Escherichia coli bacteria were isolated and subjected to susceptibility testing against 16 clinically relevant antibiotics by using the E-test method. The results found that 81 (90%) of 90 isolates were resistant to at least one antibiotic, 14 (15.5%) of 90 isolates were colistin resistant, 2 (2.2%) of 90 isolates were extended-spectrum β-lactamase producers, and 2 (2.2%) of 90 isolates were multidrug resistant to four antibiotic classes. Extended-spectrum β-lactamase-producing E. coli and colistin-resistant isolates were confirmed by using double-disc susceptibility testing and PCR, respectively. Such a high prevalence of antibiotic-resistant E. coli could be the result of a long application of antibiotic treatment, and it is an indicator of the antibiotic load in food-producing animals in Qatar. Pathogens carrying AR can be easily transmitted to humans through consumption of undercooked food or noncompliance with hygiene practices, mandating prompt development and implementation of a stewardship program to control and monitor the use of antibiotics in the community and agriculture.

Molecular surveillance of chloroquine drug resistance markers (Pfcrt and Pfmdr1) among imported Plasmodium falciparum malaria in Qatar

Imported malaria has been a great challenge for public health in Qatar due to influx of large number of migrant workers. Antimalarial drug resistance has emerged as one of the greatest challenges facing malaria control today. Monitoring parasite haplotypes that predict susceptibility to major antimalarial can guide treatment policies. This study aimed to determine molecular drug resistance pattern in imported malaria cases in Qatar. Blood samples from the uncomplicated P. falciparum malaria patients were collected at Hamad General Hospital, HMC, Doha, Qatar. The samples were further confirmed by nested-polymerase chain reaction (PCR) for P. falciparum. Molecular markers of chloroquine (Pfcrt and Pfmdr1) were analyzed by using nested PCR- RFLP method to determine the key point mutations associated with chloroquine (CQ) drug resistance. A total 118 blood samples were positive for P. falciparum. Overall, by RFLP, 72% harboured wild type allele (N86) of Pfmdr1 gene. The prevalence of Pfcrt mutant (T76), WT (K76) and mixed alleles (K76T) was 63.6% (n = 75), 22.9% (n = 27) and 13.5% (n = 16), respectively. Mean parasitaemia level was higher among the wild type alleles of Pfcrt gene as compared to the mixed/mutant alleles whereas mixed alleles of Pfmdr1 gene having high parasitaemia. Molecular surveillance strategy based on imported malaria cases can be used to detect and track CQ drug-resistant malaria. The data presented here might be helpful for enrichment of molecular surveillance of antimalarial resistance and will be useful for developing and updating antimalarial guidance for non-immune imported cases in Qatar.

Distribution of Mutations Associated with Antifolate and Chloroquine Resistance among Imported Plasmodium vivax in the State of Qatar

Plasmodium vivax is the most prevalent parasite worldwide, escalating by spread of drug resistance. Currently, in Qatar, chloroquine (CQ) plus primaquine are recommended for the treatment of P. vivax malaria. The present study examined the prevalence of mutations in dihydrofolate reductase (dhfr), dihydropteroate synthase (dhps) genes and CQ resistance transporter (crt-o) genes, associated with sulphadoxine-pyrimethamine (SP) and chloroquine resistance, among imported P. vivax cases in Qatar. Blood samples were collected from patients positive for P. vivax and seeking medical treatment at Hamad General Hospital, Doha, during 2013-2016. The Sanger sequencing method was performed to examine the single nucleotide polymorphisms in Pvdhfr, Pvdhps, and Pvcrt-o genes. Of 314 examined P. vivax isolates, 247 (78.7%), 294 (93.6%) and 261 (83.1%) were successfully amplified and sequenced for Pvdhfr, Pvdhps, and Pvcrt-o, respectively. Overall, 53.8% (N = 133) carried mutant alleles (58R/117N) in Pvdhfr, whereas 77.2% (N = 227) and 90% (N = 235) isolates possessed wild type allele in Pvdhps and Pvcrt-o genes, respectively. In addition, a total of eleven distinct haplotypes were detected in Pvdhfr/Pvdhps genes. Interestingly, K10 insertion in the Pvcrt-o gene was observed only in patients originating from the Indian subcontinent. The results suggested that CQ remains an acceptable treatment regimen but further clinical data are required to assess the effectiveness of CQ and SP in Qatar to support the current national treatment guidelines. In addition, limited distribution of genetic polymorphisms associated with CQ and SP resistance observed in imported P. vivax infections, necessitates regular monitoring of drug resistant P. vivax malaria in Qatar.

Bacteraemia in Intensive Care Unit: Clinical, Bacteriological, and Prognostic Prospective Study

Objectives. We conducted a one-year observational study from December 2012 to November 2013 to describe the epidemiology of bacteraemia in intensive care units (ICU) of Mohammed V Military Teaching Hospital of Rabat (Morocco). Methods. The study consisted of monitoring all blood cultures coming from intensive care units and studying the bacteriological profile of positive blood cultures as well as their clinical significance. Results. During this period, a total of 46 episodes of bacteraemia occurred, which corresponds to a rate of 15,4/1000 patients. The rate of nosocomial infections was 97% versus 3% for community infections. The most common source of bacteraemia was the lungs in 33%, but no source was identified in 52% of the episodes. Gram negative organisms were isolated in 83,6% of the cases with Acinetobacter baumannii being the most frequent. Antibiotic resistance was very high with 42,5% of extended-spectrum beta-lactamases (ESBLs) in Enterobacteriaceae and 100% of carbapenemase in Acinetobacter baumannii. The antibiotherapy introduced in the first 24 hours was adequate in 72% of the cases. Conclusions. Bloodstream infections in ICU occur most often in patients over 55 years, with hypertension and diabetes. The bacteria involved are mainly Gram negative bacteria multiresistant to antibiotics. Early administration of antibiotics significantly reduces patients mortality.

Acinetobacter Infections among Adult Patients in Qatar: A 2-Year Hospital-Based Study

This retrospective study was conducted at Hamad General Hospital, Qatar, to describe the demographic data, clinical features underlying diseases, antimicrobial susceptibility, and outcome of A. baumannii infection. It involved all adult patients 15 years of age or older who were managed at Hamad General Hospital for A. baumannii infection from January 1, 2012, to December 31, 2013. We identified a total of 239 patients with A. baumannii infection, of which 182 (76.2%) were males. The mean age was 49.10 ± 19.57 years. The majority of the episodes (25.1%) occurred in elderly patients (≥65 years) and the most commonly identified site of A. baumannii infection was the respiratory tract, 117 (48.9%). Most episodes of infection, 231 (96.7%), were hospital-acquired and high rate of nosocomial infections occurred in the medical intensive care unit, 66 (28.6%). All patients had underlying medical conditions. Maximum resistance was seen to cefotaxime, 147 (58.3%), and minimum resistance was seen to colistin, 2 (1.4%). Of the 239 isolates, 102 (42.7%) were susceptible and 137 (57.3%) were multidrug-resistant. The in-hospital mortality in our study was 31%. Male gender, multidrug resistance, and septic shock were found to be independent mortality predictors.

Emergence of multidrug-resistant Acinetobacter baumannii producing OXA-23 Carbapenemase in Qatar

The objective of our study was to describe the molecular support of carbapenem resistance from randomly selected clinical isolates of multidrug-resistant (MDR) Acinetobacter baumannii as a pilot study from the Hamad Medical Corporation (HMC), Qatar. Results of our report will be used to study carbapenemases using molecular techniques in all isolated MDR A. baumannii. Forty-eight MDR A. baumannii were randomly selected from isolates preserved at HMC. Identification of all isolates was confirmed by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Antibiotic resistance was tested phenotypically by Phoenix and confirmed by Etest. The molecular support of carbapenemases (bla OXA-23, bla OXA-24, bla OXA-58, bla NDM) was investigated by real-time PCR. The epidemiologic relatedness of the isolates was verified by phylogenetic analysis based on partial sequences of CsuE and bla OXA-51 genes. All 48 isolates were identified as A. baumannii and were confirmed to be resistant to most antibiotics, especially meropenem, imipenems, ciprofloxacin, levofloxacin, amikacin, gentamicin and most of the β-lactams; they were sensitive to colistin. All the isolates were positive for bla OXA-23 and negative for the other tested carbapenemase genes. Clonality analysis demonstrated that different lineages were actually circulating in Qatar; and we suggest that an outbreak occurred in the medical intensive care unit of HMC between 2011 and 2012. Here we report the emergence of MDR A. baumannii producing the carbapenemase OXA-23 in Qatar.

Epidemiology and clinical outcomes of multidrug-resistant, gram-negative bloodstream infections in a European tertiary pediatric hospital during a 12-month period

BACKGROUND

Bloodstream infections caused by multidrug-resistant, Gram-negative (MDRGN) bacteria represent a significant cause of morbidity and mortality. Prompt diagnosis and appropriate empiric treatment are the most important determinants of patient outcome. The objective of our study was to assess the epidemiology and clinical outcome of MDRGN sepsis in a tertiary-care pediatric hospital during a 12-month period.

METHODS

It was a retrospective, observational study of MDRGN bacteremia including all patients <18 years of age, hospitalized during 2011, with documented bacteremia caused by Enterobacteriaceae or non-fermentative bacteria.

RESULTS

Overall, 136 blood cultures in 119 patients were included. The median age of patients was 1.1 years; 86.3% of patients had an underlying disease. The cumulative incidence of Gram-negative bloodstream infections was 5.4/1000 hospital admissions and the infection rate was 0.65/1000 hospital days. Most frequently isolated strains were Klebsiella pneumoniae, Escherichia coli and Pseudomonas aeruginosa; 67.6% of infections were hospital acquired. The percentage of multidrug-resistant (MDR) organisms among isolated species was 39%. The crude rate of mortality was 16% and sepsis-related mortality was 9.2%. The mortality rate among patients with an antibiotic-resistant isolate was 22.6%. Factors significantly associated with sepsis-related mortality were antibiotic resistance (odds ratio: 4.26, 95% confidence interval: 1.07-16.9) and hospital acquisition of infection (odds ratio: 1.13, 95% confidence interval: 1.05-1.22).

CONCLUSIONS

This study demonstrates the high mortality of hospital-acquired MDRGN bacteremia in children. International networks focusing on clinical management and outcomes of MDRGN in children are required. Study of novel antibiotics active against Gram-negative bacteria should include children early in the clinical trial development programs.

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.

Community-acquired, healthcare-associated and hospital-acquired bloodstream infection definitions in children: a systematic review demonstrating inconsistent criteria

BACKGROUND

Historically, bacterial infections were categorized as either community-acquired (CA) or hospital-acquired (HA). However, the CA/HA dichotomy no longer adequately reflects patterns of emerging healthcare-associated (HCA) infections in complex patients managed between hospital and the community. Studies trying to define this evolving epidemiology often excluded children.

AIM

To identify what criteria have been used to distinguish between CA, HCA and HA bloodstream infections (BSIs) in children, and the proportional distribution of CA, HCA and HA among total BSIs and by organism.

METHODS

We systematically reviewed published literature from PubMed, UK Department of Health and US Centers for Disease Control and Prevention websites.

FINDINGS

Results from 23 studies and the websites highlighted the use of inconsistent criteria. There were 13 and 15 criteria variations for CA and HA BSI respectively, although a 48h cut-off for cultures sampled post admission was most commonly reported. Five studies used variable clinical criteria to define HCA. The mean proportion of paediatric CA BSI in nine studies was 50%. Only four BSI organisms from five studies were predominantly CA (Streptococcus pneumoniae, Salmonella spp.) or HA (coagulase-negative staphylococci, Enterococcus spp.), whereas Pseudomonas spp., Klebsiella spp. and Enterobacter spp. did not clearly fit into either category.

CONCLUSIONS

Our study reveals inconsistent use of criteria, and a lack of evidence upon which to base them, to distinguish between CA, HCA and HA BSI in children. Criteria for CA, HCA and HA BSI need to be developed using population-based studies that consider patients' clinical characteristics, recent healthcare exposure as well as isolated organism species.

Infectious diseases in the Arabian Peninsula and Egypt

Infectious diseases are important causes of morbidity and mortality globally. Epidemiologically, differences in the patterns of infectious diseases and antimicrobial resistance exist across diverse geographical regions. In this review on infectious diseases in the Arabian Peninsula and Egypt, the epidemiology of tuberculosis, malaria and human immunodeficiency virus (HIV) infections will be addressed. The challenges of the hepatitis C epidemic in Egypt and the epidemiology of this infection across the region will be reviewed. In recent years, we have seen dengue endemicity become established, with major outbreaks in parts of the region. Emerging data also indicate that, across the region, there is an increasing burden of antibiotic resistance, with endemicity in healthcare settings and dissemination into the community. New challenges include the emergence of the Alkhurma haemorrhagic fever virus in Saudi Arabia. The annual Hajj pilgrimage in Saudi Arabia serves as a model for the control of infectious disease in mass gatherings. As most of these countries constantly experience a uniquely dynamic population influx in the form of expatriate workers, tourists, or pilgrims, concerted regional and international collaboration to address these public health concerns in a region that lies at the crossroads for the global spread of infectious pathogens is imperative.

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

Background

The burden of antimicrobial resistance worldwide is substantial and is likely to grow. Many factors play a role in the emergence of resistance. These resistance mechanisms may be encoded on transferable genes, which facilitate the spread of resistance between bacterial strains of the same and/or different species. Other resistance mechanisms may be due to alterations in the chromosomal DNA which enables the bacteria to withstand the environment and multiply. Many, if not most, of the Gulf Corporation Council (GCC) countries do not have clear guidelines for antimicrobial use, and lack policies for restricting and auditing antimicrobial prescriptions.

Objective

The aim of this study is to review the prevalence of antibiotic resistance in GCC countries and explore the reasons for antibiotic resistance in the region.

Methodology

The PubMed database was searched using the following key words: antimicrobial resistance, antibiotic stewardship, prevalence, epidemiology, mechanism of resistance, and GCC country (Saudi Arabia, Qatar, Bahrain, Kuwait, Oman, and United Arab Emirates).

Results

From January1990 through April 2011, there were 45 articles published reviewing antibiotic resistance in the GCC countries. Among all the GCC countries, 37,295 bacterial isolates were studied for antimicrobial resistance. The most prevalent microorganism was Escherichia coli (10,073/44%), followed by Klebsiella pneumoniae (4,709/20%), Pseudomonas aeruginosa (4,287/18.7%), MRSA (1,216/5.4%), Acinetobacter (1,061/5%), with C. difficile and Enterococcus representing less than 1%.

Conclusion

In the last 2 decades, E. coli followed by Klebsiella pneumoniae were the most prevalent reported microorganisms by GCC countries with resistance data.

Evaluation of the use of piperacillin/tazobactam (Tazocin) at Hamad General Hospital, Qatar: are there unjustified prescriptions?

Objectives

The aim of this study was to evaluate the appropriateness of piperacillin/tazobactam (Tazocin^®; Pfizer, New York, NY) usage in our hospital.

Subjects and methods

This retrospective study was designed to involve all patients admitted to Hamad General Hospital and prescribed piperacillin/tazobactam as an empiric therapy from January 1 to March 31, 2008. The medical records of such patients were retrospectively reviewed and studied.

Results

During this period, 610 prescriptions were ordered for 596 patients. The main indication for initiation of Tazocin was sepsis (207/610; 34%). The overall rate of appropriateness of empirical therapy was 348/610 (57%). Most of the inappropriate prescriptions were in cases of aspiration pneumonia and abdominal infections, with inappropriate prescriptions found mostly in surgical wards (86%) and the surgical intensive care unit (66.7%). Septic work-up results showed positive cultures in 57% (345/610) of cases. There were 198/254 prescriptions (78%) where antibiotics were changed according to the sensitivity data to narrow-spectrum antimicrobials. In 56/254 (22%) cases, pathogens were susceptible to narrow-spectrum antibiotics even though piperacillin/tazobactam was continued.

Conclusion

Our study showed that there was an injudicious use of piperacillin/tazobactam at our hospital, evidenced by the significant number of inappropriate empiric prescriptions and inappropriate drug modifications, based on the results of microbial cultures and antibiograms.

Nosocomial postneurosurgical Acinetobacter baumannii meningitis: a retrospective study of six cases admitted to Hamad General Hospital, Qatar

This article reports six cases of nosocomial Acinetobacter baumannii meningitis in patients who had undergone neurosurgical procedures with placing of external ventricular drains. The mean time between surgery and onset of infection was 27 days [standard deviation (SD) 14] Multi-drug resistance was observed in three cases (50%) and carbapenem resistance was noted in two cases (33%). All patients had received empirical antibiotics and these were appropriate in five cases (83%). The mean duration of antimicrobial treatment was 12.5 (SD 2.4) days. Two of the six patients (33%) died in hospital.