Molecular epidemiology and outcome of carbapenem-resistant Enterobacterales in Saudi Arabia

Carbapenem-resistant Enterobacteriaceae in the livestock, humans and environmental samples around the globe: a systematic review and meta-analysis

Carbapenem-resistant Enterobacteriaceae (CRE) have diminished treatment options causing serious morbidities and mortalities. This systematic review and meta-analysis assessed the prevalence and associated factors of Enterobacteriaceae infections in clinical, livestock and environmental settings globally. The population intervention comparison and outcome strategy was used to enroll studies using the preferred reporting system for systematic review and meta-analysis to include only cross-sectional studies. Search engines used to retrieve articles included journal author name estimator, PubMed, Google Scholar and African Journals Online (AJOL). The Newcastle-Ottawa scale was used to assess the quality of studies. Sixteen articles from 2013 to 2023 in Africa, Asia, Europe and South America were studied. The pooled prevalence of CRE was 43.06% (95% CI 21.57-66.03). Klebsiella pneumoniae (49.40%), Escherichia coli (26.42%), and Enterobacter cloacae (14.24%) were predominant. Klebsiella pneumoniae had the highest resistance with the blaKPC-2 in addition to blaNDM, blaOXA-48, blaIMP and blaVIM. The blaKPC-2 genes occurrence was associated with environmental (P-value < 0.0001) and South American studies (P-value < 0.0001), but there was no difference in the trends over time (P-value = 0.745). This study highlights the high rates of CRE infections, particularly within blaKPC production. Monitoring and surveillance programs, research and infection control measures should be strengthened. Additionally, further studies are needed to explore the mechanisms driving the predominance of specific bacterial species and the distribution of resistance genes within this bacterial family.

Clinical Characteristics and Molecular Insights of Carbapenem-Resistant Klebsiella pneumoniae Isolates from Patients in Intensive Care Units

Background: Carbapenem-resistant Klebsiella pneumoniae (CRKP), a significant worldwide public health threat, is common in patients in intensive care units. Methods: A retrospective study was conducted over a period of 22 months to assess the risk factors associated with infection caused by CRKP isolates. Strain identification was performed using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), and antimicrobial sensitivity was assessed using the micro broth dilution method and Kirby-Bauer test. The genes blaKPC, blaOXA-48, blaNDM, blaVIM, and blaGES were amplified using polymerase chain reaction (PCR), followed by sequencing of the PCR products. The polymerase hypermucoviscosity phenotype was determined using the string test. Capsular serotypes (K1, K2) and presence of the virulence gene (rmpA) in positive isolates were investigated using phenotypic tests followed by PCR. Results: Length of hospitalization and use of carbapenems were associated with CRKP infection. CRKP isolates exhibited extensive drug resistance, but retained sensitivity to colistin and ceftazidime-avibactam (CZA). The main gene detected in 35 CRKP isolates was blaKPC-2. In addition, 11 strains were positive in the string test, and two of these strains carried rmpA. Conclusions: Prolonged hospitalization and carbapenem exposure increased the risk of CRKP infection in intensive care unit (ICU) patients. The prevalence of CRKP carrying the blaKPC-2 gene was high, and suspected hypervirulent carbapenem-resistant K. pneumoniae isolates were scattered.

Treatment of a challenging NDM and OXA-48-producing Klebsiella pneumoniae causing skin and soft tissue infection and exhibiting resistance to the combination of Ceftazidime-Avibactam and Aztreonam: A case report

Carbapenem-resistant Enterobacterales (CRE) pose a significant public health concern. CRE could be carbapenamse producers or non-producers. In the Kingdom of Saudi Arabia, bla OXA-48 and bla NDM represent the majority of carbapenemase isolates. There are very limited treatment options for carbapenemase-producing CRE caused by bla NDM. Ceftazidime-avibactam plus aztreonam (CZA-ATM) or cefiderocol as monotherapy are considered the treatment of choice for these infections. Here, we report a case of a 70-year-old man presented with surgical site infection of above knee amputation stump. The cultures revealed carbapenem-resistant Klebsiella pneumoniae positive for bla NDM and bla OXA-48 resistant to CZA-ATM therapy and intermediate susceptibility to tigecycline. He was started on CZA-ATM both adjusted for renal function, and high dose tigecycline with daily wound dressing and irrigation. By day 20 of the antibiotic regimens, he had clinical and microbiological cure based on repeated wound cultures. This case identifies a rare incidence of CRE skin and soft tissue infection positive for bla NDM and bla OXA-48 resistant to CZA-ATM in a background of limited targeted options, but successfully treated with CZA-ATM and high-dose tigecycline. Such therapeutic approach might be useful in few circumstances when no other antibiotic options are available to treat extensively drug-resistant Klebsiella pneumoniae.

Clinical and epidemiological characteristics of multi-drug resistant Enterobacterales isolated from King Fahad Hospital of the University, AlKhobar, Saudi Arabia

Multi-drug resistant (MDR) Enterobacterales remain a major clinical problem. Infections caused by carbapenem-resistant strains are particularly difficult to treat. This study aimed to assess the clinical and epidemiological characteristics of MDR Enterobacterales isolates. A total of 154 non-repetitive clinical isolates, including Escherichia coli (n = 66), Klebsiella pneumoniae (n = 70), and other Enterobacterales (n = 18), were collected from the Diagnostic Microbiology Laboratory at King Fahad Hospital of the University. Most E. coli isolates were collected from urine specimens (n = 50, 75.8%) and resistance against the third and fourth-generation cephalosporins (ceftriaxone, ceftazidime, cefixime, and cefepime) and fluoroquinolones (ciprofloxacin and levofloxacin) was assessed. Clonal relatedness analysis using enterobacterial repetitive intergenic consensus polymerase chain reaction (ERIC-PCR) revealed two clones (E. coli A and B), each comprising two strains. Most K. pneumoniae samples were collected from respiratory specimens (27.1%, 20 samples), and the strains showed overall resistance to most of the antimicrobials tested (54%‒100%). Moreover, clonal-relatedness analysis using ERIC-PCR revealed seven major clones of K. pneumoniae. These findings suggest nosocomial transmission among some identical strains and emphasize the importance of strict compliance with infection prevention and control policies and regulations. Environmental reservoirs could facilitate this indirect transmission, which needs to be investigated.

Molecular Screening of Carbapenem-Resistant K. pneumoniae (CRKP) Clinical Isolates for Concomitant Occurrence of Beta-Lactam Genes (CTX-M, TEM, and SHV) in the Kingdom of Bahrain

The emergence of extended-spectrum β-lactamase-producing Klebsiella pneumoniae, including CRKP infections, has resulted in significant morbidity and mortality worldwide. We aimed to explore the presence of bla genes (CTX-M, TEM, and SHV) in CRKP isolates. A total of 24 CRKP isolates were randomly selected from the Salmaniya Medical Complex Microbiology Laboratory. These isolates, which were positive for carbapenemases, were further explored for CTX-M, TEM, and SHV genes using PCR. All the CTX-M PCR amplicons were sent for sequencing. To determine genetic relatedness, molecular typing by ERIC-PCR was performed. The bla gene testing demonstrated that a significant proportion of these isolates harbored SHV, CTX-M, and TEM genes (100%, 91.6%, and 45.8%), respectively. Bioinformatic analyses confirmed CTX-M-15 in these isolates. ERIC-PCR analysis showed three clusters demonstrating genetic relatedness. The study findings reveal the concomitant carriage of the SHV and CTX-M-15 and a comparatively lower carriage of TEM genes in CRKP isolates. Our findings highlight the significance of routinely reporting the presence of antibiotic resistance genes along with regular antibiotic sensitivity reports, as this will aid clinicians in prescribing appropriate antibiotics.

Klebsiella pneumoniae bacteraemia epidemiology: resistance profiles and clinical outcome of King Fahad Medical City isolates, Riyadh, Saudi Arabia

BACKGROUND AND OBJECTIVES

Klebsiella pneumoniae (K. pneumoniae) is the second leading cause of community-acquired and hospital-acquired gram-negative bloodstream infection (BSI). This study aimed to assess the epidemiological and microbial-resistance characteristics and clinical factors associated with K. pneumoniae BSI in Saudi Arabia.

MATERIALS AND METHODS

Data of 152 K. pneumoniae isolates diagnosed between January 2019 and January 2020 at King Fahad Medical City, Riyadh, Saudi Arabia were evaluated retrospectively. Clinical records of the patients were collected and analysed statistically.

RESULTS

In total, 152 cases of K. pneumoniae BSI were identified. Adult patients (66.4%) were at a higher risk of developing the infection than paediatric patients (33.6%). The rate of infection was slightly higher in women than in men. Neurological disorders were the predominant underlying conditions for the acquisition of K. pneumoniae BSI, at all ages. Most of the deceased patients were adults with multi-organ dysfunction. Klebsiella pneumoniae showed disturbing resistance to amoxicillin-clavulanate and cefuroxime (72.4%), ceftazidime (67.8), cephalothin (76.3%), and to Carbapenems (36.1%).

CONCLUSIONS

The impact of K. pneumoniae BSI was seen not only at the patient level, but also at the community level, and was related to multi-drug resistant infection. These findings provide a better understanding of microbial resistance and its association with patient clinical outcomes.

An Overview of Antimicrobial Resistance in Saudi Arabia (2013-2023) and the Need for National Surveillance

Antimicrobial resistance (AMR) is a well-recognized global threat. The World Health Organization (WHO) issued a report ranking the critical types of bacterial resistance that need to be monitored. Several studies from individual institutions in Saudi Arabia have reported rates of antimicrobial resistance using automated methods. However, no national surveillance study has been conducted to date using gold standard methods for antimicrobial susceptibility testing. This review summarizes AMR rates for major bacterial pathogens in Saudi Arabia and provides a justification for the need for a national surveillance project. In Saudi Arabia, AMR rates for both Gram-positive and Gram-negative bacteria are on the rise. Surveillance studies help identify AMR trends and emergence of outbreaks. The WHO has started a program, the Global Antimicrobial Resistance Surveillance System (GLASS), encouraging its member states, including Saudi Arabia, to conduct antimicrobial surveillance studies to estimate AMR rates worldwide. Of the microbiological methods used to test antimicrobial susceptibility, only broth microdilution (BMD) is considered the "gold standard." As AMR studies in Saudi Arabia are sparse, mostly limited to single centers and were conducted using automated methods, a national AMR surveillance project is needed to evaluate the current status and to inform stewardship decisions.

Infectious diseases pharmacy practice, education, and research in Saudi Arabia: A review and future perspectives by the Infectious Diseases Pharmacy Specialty Network at the Saudi Society of Clinical Pharmacy

Background

Infectious diseases (ID) pharmacy is one of the rapidly evolving clinical pharmacy specialties in the Kingdom of Saudi Arabia (KSA). There are gaps in the literature on ID pharmacy status in KSA. This review aimed to provide an update on the current status of several areas related to ID pharmacy in KSA, including practice, education, and research, and make pertinent recommendations for future development to achieve the KSA Vision, 2030, KSA Vision, 2030.

Methods

This review was developed by a group of ID pharmacists working in different sectors under the umbrella of the ID Pharmacy Specialty Network (PSN) of the Saudi Society of Clinical Pharmacy (SSCP). The authors evaluated domains related to ID pharmacy in KSA and searched the literature for relevant articles. Based on the experts' assessment of the current gaps and challenges, recommendations were made for future improvement.

Results

Several aspects of ID pharmacy in KSA were evaluated, including history and development, antimicrobial resistance (AMR), antimicrobial stewardship programs (ASP), roles of ID pharmacists, ID pharmacy education, and research. The biggest challenges include AMR, the varying levels of ASP implementation, and the low number of ID-trained pharmacists, especially in non-major cities. Several recommendations for improvement were discussed.

Conclusion

Infectious diseases pharmacy has sustained remarkable progress in KSA in several areas. However, more efforts are needed to increase ASP implementation, increase the number of ID-trained pharmacists, and encourage ID pharmacists in publishing and participating in practice guidelines, which will eventually help achieve the KSA Vision, 2030, KSA Vision, 2030.

Molecular Epidemiology of Carbapenem-Resistant K. pneumoniae Clinical Isolates from the Adult Patients with Comorbidities in a Tertiary Hospital, Southern Saudi Arabia

Hospitalized patients are likely to have chronic illnesses and are at an increased risk of mortality due to infection caused by MDR bacteria. We aimed to identify carbapenem-resistant genes carrying Klebsiella pneumoniae (K. pneumoniae) isolates and their risk factors recovered from adult patients with comorbidities. A cross-sectional study was carried out between April 2021 and December 2021 at King Abdullah Hospital (KAH) in Bisha province, Saudi Arabia. Seventy-one multi-drug resistant K. pneumoniae recovered from clinical samples and screened for carbapenemase genes of blaOXA-48-like, blaNDM-1, blaKPC, blaVIM, and blaIMP. Of 71 MDR K. pneumoniae examined, 47 (66.2%) isolates harbored various carbapenemase genes. The most prevalent single resistance gene was blaOXA-48-like (62.5%; n = 25), and 33.3% of them were recovered from sputum isolates. The blaNDM-1 gene was detected in 12 (30.0%) isolates, and eight of them were recovered from urine (n = 4) and blood (n = 4). Two (5.0%) single blaKPC genes were recovered from the sputum (n = 1) and blood (n = 1) isolates. In contrast, no blaIMP- and blaVIM-carrying isolates were detected. The co-existence of two resistance genes between blaOXA-48-like and blaNDM-1 was found in six strains, whereas only one strain was found to be produced in the three genes of blaNDM-1, blaKPC, and blaOXA-48-like. There were statistically significant associations between the presence of carbapenem-gene-carrying K. pneumoniae and patients' gender (χ2(1) = 5.94, p = 0.015), intensive care unit admission (χ2(1) = 7.649, p = 0.002), and chronic obstructive pulmonary disease (χ2(1) = 4.851, p = 0.028). The study highlighted the existence of carbapenemase-producing K. pneumoniae, particularly blaOXA-48-like and blaNDM-1, in patients with comorbidities. Our findings emphasize the importance of the molecular characterization of resistance-determinant-carrying bacterial pathogens as a part of infection control and prevention in hospital settings.