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Girona‐Alarcón M, Fresán E, Garcia‐Garcia A, Bobillo‐Perez S, Balaguer M, Felipe A, Esteban ME, Jordan I. Device-associated multidrug-resistant bacteria surveillance in critically ill children: 10 years of experience. Acta Paediatr 2021; 110:203-209. [PMID: 32383199 DOI: 10.1111/apa.15342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 04/21/2020] [Accepted: 05/04/2020] [Indexed: 12/21/2022]
Abstract
AIM Multidrug-resistant bacterial infections are a public health problem worldwide. However, most of the information available refers to adults. The main objectives were to determine the incidence, risk factors, and outcomes for device-associated infections, especially those involving multidrug-resistant bacteria. METHODS This is a prospective, observational study. Children aged ≥1 month and <18 years admitted to the paediatric intensive care unit from 2008 to 2017, with a device-associated infection microbiologically confirmed were included. Patients infected with resistant bacteria were compared with those who had a drug-susceptible infection. RESULTS The study included 213 patients. Out of all the device-associated infections, 22% (48 patients) were caused by multidrug-resistant bacteria. The most frequent were extended-spectrum beta-lactamase (ESBL)-producing enterobacteria. Cardiovascular diseases, age under 1year, comorbidity, prolonged use of invasive device, and length of stay until infection were risk factors for resistant bacteria, but not specifically for ESBL-producing bacteria. Length of stay and mortality was increased in patients with multidrug-resistant bacteria. CONCLUSION Being under 1-year-old and having a cardiovascular disease were the two major risk factors for resistant bacterial infection. ESBL-producing bacteria were the most frequent multidrug-resistant agents. However, patients with ESBL-producing bacteria did not have any additional risk factors, so they may have been colonised in the community.
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Affiliation(s)
- Mònica Girona‐Alarcón
- Paediatric Intensive Care Unit Institut de Recerca Hospital Sant Joan de Déu University of Barcelona Barcelona Spain
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group Institut de Recerca Hospital Sant Joan de Déu, Hospital Sant Joan de Déu Barcelona Spain
| | - Elena Fresán
- Paediatric Intensive Care Unit Institut de Recerca Hospital Sant Joan de Déu University of Barcelona Barcelona Spain
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group Institut de Recerca Hospital Sant Joan de Déu, Hospital Sant Joan de Déu Barcelona Spain
| | - Ana Garcia‐Garcia
- Immunology Department Hospital Sant Joan de Déu‐Clínic University of Barcelona Barcelona Spain
| | - Sara Bobillo‐Perez
- Paediatric Intensive Care Unit Institut de Recerca Hospital Sant Joan de Déu University of Barcelona Barcelona Spain
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group Institut de Recerca Hospital Sant Joan de Déu, Hospital Sant Joan de Déu Barcelona Spain
| | - Monica Balaguer
- Paediatric Intensive Care Unit Institut de Recerca Hospital Sant Joan de Déu University of Barcelona Barcelona Spain
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group Institut de Recerca Hospital Sant Joan de Déu, Hospital Sant Joan de Déu Barcelona Spain
| | - Aida Felipe
- Paediatric Intensive Care Unit Institut de Recerca Hospital Sant Joan de Déu University of Barcelona Barcelona Spain
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group Institut de Recerca Hospital Sant Joan de Déu, Hospital Sant Joan de Déu Barcelona Spain
| | - Maria Esther Esteban
- Zoology and Anthropology Section Department of Evolutionary Biology, Ecology and Environmental Sciences Faculty of Biology GREAB‐ Biological Anthropology Research Group Institut de Recerca de la Biodiversitat (IRBio) University of Barcelona Barcelona Spain
| | - Iolanda Jordan
- Paediatric Intensive Care Unit Institut de Recerca Hospital Sant Joan de Déu University of Barcelona Barcelona Spain
- Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group Institut de Recerca Hospital Sant Joan de Déu, Hospital Sant Joan de Déu Barcelona Spain
- Paediatric Intensive Care Unit CIBERESP, Hospital Sant Joan de Déu‐Clínic University of Barcelona Barcelona Spain
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Schmidt P, Hasan C, Simon A, Geffers C, Wager J, Zernikow B. Multidrug-resistant bacteria in a paediatric palliative care inpatient unit: results of a one year surveillance. GMS HYGIENE AND INFECTION CONTROL 2020; 15:Doc03. [PMID: 32269914 PMCID: PMC7105757 DOI: 10.3205/dgkh000338] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Aim: Nosocomial infections (NIs) and multidrug resistant (MDR) pathogens are an important paediatric healthcare issue. In vulnerable patients such as children with life-limiting conditions, MDR infections can be life-threatening. Additionally, these children have a significantly increased risk for colonisation with MDR pathogens. Therefore, it is vital to prevent new colonisations with MDR pathogens in this vulnerable patient group. However, little is known about colonisation with MDR pathogens and NIs in inpatient units for paediatric palliative care (PPC). The aim of this study was to investigate the prevalence of colonisation with MDR pathogens and the incidence of NIs in a PPC unit. Methods: Evaluation of surveillance data of a PPC unit. All patients admitted to a PPC unit from 1st April 2012 to 31st March 2013 were screened for MDR pathogens upon admission. Patients who exhibited clinical signs of an infection during their inpatient stay were screened again. Results: During the study period, 198 cases were admitted to the unit. Those cases represent 118 patients. 18% of the patients were colonised with MDR pathogens. The most common MDR pathogens were E. coli (8.1%) and Pseudomonas ssp. (8.1%). In addition, 58% of patients with tracheostomy had MDR pathogens in their tracheal secretions. The incidence density of NIs was 0.99 per 1000 inpatient treatment days with no NI caused by MDR pathogens. Conclusion: Due to a high prevalence, it is reasonable to screen PPC patients for MDR pathogen colonisation before or during admission. Special attention must be given to patients with tracheostomy. Our results provide preliminary evidence that participation in social activities in a PPC unit for patients colonised with MDR pathogens is safe if hygiene concepts are applied.
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Affiliation(s)
- Pia Schmidt
- Witten/Herdecke University, Faculty of Health, School of Medicine, Department of Children's Pain Therapy and Paediatric Palliative Care, Datteln, Germany.,Paediatric Palliative Care Centre, Children's and Adolescents' Hospital Datteln, Datteln, Germany
| | - Carola Hasan
- Witten/Herdecke University, Faculty of Health, School of Medicine, Department of Children's Pain Therapy and Paediatric Palliative Care, Datteln, Germany.,Paediatric Palliative Care Centre, Children's and Adolescents' Hospital Datteln, Datteln, Germany
| | - Arne Simon
- Saarland University Medical Center and Saarland University Faculty of Medicine, Department of Paediatric Haematology and Oncology, Homburg/Saar, Germany
| | - Christine Geffers
- Institute of Hygiene and Environmental Medicine, Charité - University Medicine in Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - Julia Wager
- Witten/Herdecke University, Faculty of Health, School of Medicine, Department of Children's Pain Therapy and Paediatric Palliative Care, Datteln, Germany.,Paediatric Palliative Care Centre, Children's and Adolescents' Hospital Datteln, Datteln, Germany
| | - Boris Zernikow
- Witten/Herdecke University, Faculty of Health, School of Medicine, Department of Children's Pain Therapy and Paediatric Palliative Care, Datteln, Germany.,Paediatric Palliative Care Centre, Children's and Adolescents' Hospital Datteln, Datteln, Germany
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Del Puente F, Giacobbe DR, Salsano A, Maraolo AE, Ong DSY, Yusuf E, Tutino S, Marchese A, Santini F, Viscoli C. Epidemiology and outcome of Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae (KPC-KP) infections in cardiac surgery patients: a brief narrative review. J Chemother 2019; 31:359-366. [PMID: 31701842 DOI: 10.1080/1120009x.2019.1685794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae (KPC-KP) is a difficult-to-treat pathogen due to its multidrug-resistant phenotype. Cardiac surgery patients are at increased risk of developing KPC-KP infections compared to other populations, with previous KPC-KP colonization being a critical factor in influencing the risk of subsequent infection. Two different pieces of information are essential to comprehensively assess the local characteristics of KPC-KP colonization in cardiac surgery patients: (i) the local prevalence of colonization; (ii) the timing of colonization. Treatment of KPC-KP infections in cardiac surgery patients is a complex task, but more effective treatment options have recently become available. Nonetheless, implementation and full adherence to infection-control measures remain of pivotal importance for reducing the burden of KPC-KP infections in this peculiar population. The aim of this narrative review is to summarize the available literature on the epidemiology and outcome of KPC-KP infections in cardiac surgery patients.
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Affiliation(s)
- Filippo Del Puente
- Department of Health Sciences, University of Genoa, Genoa, Italy.,Clinica Malattie Infettive, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy
| | - Daniele R Giacobbe
- Department of Health Sciences, University of Genoa, Genoa, Italy.,Clinica Malattie Infettive, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy
| | - Antonio Salsano
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate (DISC), University of Genoa, Genoa, Italy.,Division of Cardiac Surgery, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy
| | - Alberto E Maraolo
- Section of Infectious Diseases, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - David S Y Ong
- Department of Medical Microbiology and Infection Control, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands.,Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Erlangga Yusuf
- Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Stefania Tutino
- Department of Health Sciences, University of Genoa, Genoa, Italy.,Clinica Malattie Infettive, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy
| | - Anna Marchese
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate (DISC), University of Genoa, Genoa, Italy.,Microbiology Unit, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy
| | - Francesco Santini
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate (DISC), University of Genoa, Genoa, Italy.,Division of Cardiac Surgery, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy
| | - Claudio Viscoli
- Department of Health Sciences, University of Genoa, Genoa, Italy.,Clinica Malattie Infettive, Ospedale Policlinico San Martino - IRCCS, Genoa, Italy
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Będzichowska A, Przekora J, Stapińska-Syniec A, Guzek A, Murawski P, Jobs K, Wróblewska B, Kalicki B. Frequency of infections caused by ESBL-producing bacteria in a pediatric ward - single-center five-year observation. Arch Med Sci 2019; 15:688-693. [PMID: 31110535 PMCID: PMC6524197 DOI: 10.5114/aoms.2017.72407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 03/09/2017] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Infections caused by Enterobacteriaceae producing extended-spectrum β-lactamases (ESBLs) are a serious therapeutic and clinical problem. An increasing role of ESBL(+) pathogens is observed in both community- and hospital-acquired infections. The aim of the study was to assess the incidence and the risk factors for ESBL(+) bacteria infection in a pediatric ward during a 5-year period. MATERIAL AND METHODS The medical documentation data of patients hospitalized in the Department of Pediatrics, Pediatric Nephrology and Allergology between 2011 and 2015 were subjected to a retrospective analysis. Cases of ESBL(+) bacterial infections were analyzed in detail. RESULTS 0.57% (46) of all the hospitalizations (8015) during the 5-year observation period in our department were caused by ESBL (+) pathogens. It constituted 8.5% of all positive microbiological cultures obtained. The analysis revealed an increasing trend in the number of ESBL (+) infections throughout the observed period. 43.5% of patients were only asymptomatic carriers. In 71.7% urinary tract structural and functional abnormalities were present. 76.1% of patients had been hospitalized previously and 60.9% had undergone urinary tract invasive procedures. CONCLUSIONS The results confirm the rising trend of ESBL (+) infections during the observed period. ESBL (+) bacteria were isolated primarily in previously hospitalized children with particular reference to urinary tract invasive procedures during hospitalizations. Moreover, the study showed that patients with urogenital disorders and non-urinary chronic diseases are more susceptible to these priority pathogen infections.
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Affiliation(s)
- Agata Będzichowska
- Department of Pediatrics, Pediatric Nephrology and Allergology, Military Institute of Medicine, Warsaw, Poland
| | - Jędrzej Przekora
- Department of Pediatrics, Pediatric Nephrology and Allergology, Military Institute of Medicine, Warsaw, Poland
| | - Angelika Stapińska-Syniec
- Students’ Academic Club at the Department of Pediatrics, Pediatric Nephrology and Allergology, Military Institute of Medicine, Warsaw, Poland
| | - Aneta Guzek
- Department of Medical Diagnostics, Military Institute of Medicine, Warsaw, Poland
| | - Piotr Murawski
- Information and Communication Technology Department, Military Institute of Medicine, Warsaw, Poland
| | - Katarzyna Jobs
- Department of Pediatrics, Pediatric Nephrology and Allergology, Military Institute of Medicine, Warsaw, Poland
| | - Barbara Wróblewska
- Department of Immunology and Food Microbiology, Institute of Animal Reproduction and Food Research of the Polish Academy of Sciences, Olsztyn, Poland
| | - Bolesław Kalicki
- Department of Pediatrics, Pediatric Nephrology and Allergology, Military Institute of Medicine, Warsaw, Poland
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Jaworski R, Haponiuk I, Irga-Jaworska N, Steffens M, Chojnicki M, Paczkowski K, Zielinski J. Monitoring both procalcitonin and C-reactive protein in the early period after tetralogy of Fallot correction in children promotes rational antibiotic use. Adv Med Sci 2018; 63:112-118. [PMID: 29111402 DOI: 10.1016/j.advms.2017.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/20/2017] [Accepted: 10/17/2017] [Indexed: 01/04/2023]
Abstract
PURPOSE This retrospective cohort study aimed to identify the early postoperative kinetics of C-reactive protein (CRP) and procalcitonin (PCT) in children undergoing tetralogy of Fallot (ToF) correction. The ability of these inflammatory markers to guide rational antibiotic usage was also determined. MATERIALS AND METHODS All consecutive children who underwent ToF correction in 2009-2016 in our referral pediatric cardiac surgery clinic in Gdansk, Poland and did not exhibit infection signs on early postoperative days (POD) were identified. All patients received 48h antibiotic prophylaxis. Antibiotic treatment was extended or empirical antibiotic therapy was introduced if the clinician considered it necessary. CRP and PCT levels were measured on POD1-4 and 1-3, respectively. RESULTS Of the 60 eligible children, 44 underwent CRP testing only. The remaining 16 patients underwent both CRP and PCT testing. All patients had abnormally high CRP values after surgery. All patients who also underwent PCT testing also displayed elevated PCT levels. The CRP and PCT levels peaked on POD2 (median=99.8mg/L) and POD1 (median=4.08ng/mL), respectively. In the CRP-alone patients, antibiotic prophylaxis was prolonged or empirical antibiotic therapy was started in 59%; in the CRP and PCT group, this was 25% (p<0.05). CONCLUSIONS The children had elevated CRP and PCT levels after ToF correction, with peaks observed on POD2 and POD1, respectively. Monitoring both CRP and PCT in the early postoperative period may guide antibiotic therapy, thus reducing unnecessary treatment, additional toxicity, and adverse drug interactions without increasing treatment failure. Rational antibiotic treatment may also reduce antibiotic resistance.
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Silvetti S, Ranucci M, Isgrò G, Villa V, Costa E. Preoperative colonization in pediatric cardiac surgery and its impact on postoperative infections. Paediatr Anaesth 2017; 27:849-855. [PMID: 28504326 DOI: 10.1111/pan.13169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with congenital heart defects are frequently hospitalized before surgery. This exposes them to a high risk for pathogen colonization. There are limited data on colonization prevalence in the pediatric cardiac population, and limited data concerning its potential role in the risk of developing infections after cardiac surgery. AIM This study aimed to verify the impact of preoperative colonization on postoperative infections in a population of pediatric cardiac surgery patients coming from Italy and developing countries. METHODS This was a retrospective study conducted in all the patients aged ≤18 years who underwent pediatric open-heart surgery in the year 2015. Clinical data were retrieved from the institutional database for cardiac surgery patients. Data on swab cultures were retrieved from the laboratory database. Swab colonization was tested for association with infection and other outcomes. RESULTS Among 169 children who performed the screening for pathogen colonization, 50% had at least one positive swab. Italian patients were (P=.001) less likely to be colonized with respect to foreign patients (relative risk 0.17, 95% CI 0.09-0.35). Postoperative infections in colonized patients occurred at a similar rate as in noncolonized patients (relative risk 1.24, 95% CI 0.64-2.39; P=.532). Colonized patients had a preoperative stay (P=.021) longer than noncolonized patients (mean difference 2 days, 95% CI 0.3-3.8 days). CONCLUSION The results of our study suggest that the impact of preoperative colonization on outcome and postoperative infections may be negligible; larger series are required to clearly define this issue.
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Affiliation(s)
- Simona Silvetti
- Department of CardioVascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Piazza Edmondo Malan, Milan, Italy
| | - Marco Ranucci
- Department of CardioVascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Piazza Edmondo Malan, Milan, Italy
| | - Giuseppe Isgrò
- Department of CardioVascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Piazza Edmondo Malan, Milan, Italy
| | - Valentina Villa
- Hospital Health Direction, IRCCS Policlinico San Donato, Piazza Edmondo Malan, Milan, Italy
| | - Elena Costa
- Chemistry Laboratory, IRCCS Policlinico San Donato, Piazza Edmondo Malan, Milan, Italy
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Mycobacterium chimaera - a new threat for cardiac surgical patients? POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2017; 14:22-26. [PMID: 28515744 PMCID: PMC5404123 DOI: 10.5114/kitp.2017.66925] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 03/09/2017] [Indexed: 11/17/2022]
Abstract
An outbreak of invasive Mycobacterium chimaera infections associated with "heater-cooler" devices in patients treated with cardiac surgery has been described worldwide. The authors summarize the current state of knowledge regarding the epidemiology, diagnostics, treatment, and prevention of Mycobacterium chimaera infections in patients after cardiothoracic surgery.
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Cheikh A, Belefquih B, Chajai Y, Cheikhaoui Y, El Hassani A, Benouda A. Enterobacteriaceae producing extended-spectrum β-lactamases (ESBLs) colonization as a risk factor for developing ESBL infections in pediatric cardiac surgery patients: "retrospective cohort study". BMC Infect Dis 2017; 17:237. [PMID: 28356079 PMCID: PMC5372307 DOI: 10.1186/s12879-017-2346-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 03/25/2017] [Indexed: 11/29/2022] Open
Abstract
Background Children with cardiac defects need many hospitalizations and repetitive antibiotic therapies, with an increasing risk of colonization with multidrug-resistant bacteria (MDRB) such as extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) Post-operative infections with these bacteria in paediatric cardiac surgery are life threatening. This article aims to study the prevalence of ESBL colonization among paediatric cardiac surgery patients, and to compare occurrence of post-operative infections with and without ESBL colonization. We also aim to study the correlation between the onset of postoperative infection and other parameters such as age, length of stay and preoperative antibiotic therapy. Methods A retrospective cohort study included paediatric cardiac surgery patients in Cheikh Zaid hospital in Rabat, Morocco, between the 1st of January 2011 and 31 December 2014. A screening for ESBL colonization was requested for children who had a risk factor (previous hospitalization and/or taking antibiotics) at admission. Swabs were collected from three sites (throat, nose and anus). Two groups were compared – patients colonized and not colonized with ESBLs. Statistical analysis was performed using R software. Results ESBL colonization screening was performed in 111 patients. Positive colonization was detected in 17 cases (15%). Klebsiella pneumoniae (KP): 9 (53%) was the most frequently isolated species. Among the 17 patients, 23.5% (4/17) developed a postoperative infection due to ESBLs versus only one patient without colonization (1%). There was a statically significant difference in terms of occurrence of postoperative infection between the two groups (p = 0.001). Relative risk of developing a postoperative infection with positive colonization was 22 (95% CI, 8.37–58.5). Conclusions The analysis of colonization with multidrug-resistant bacteria and the prevention of nosocomial infections appear to be important challenges for paediatric cardiac surgery. Systematic screening of ESBL colonization for cardiac surgery could have a significant contribution, on one hand to guide prophylactic antibiotic therapy of patients, and on the other, to prevent spread of those infections.
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Affiliation(s)
- Amine Cheikh
- Department of pharmacy, Abulcasis University, Cheikh Zaid Hospital, Rabat, Morocco.
| | - Bouchra Belefquih
- Department of Microbiology, Faculty of Medicine, Mohammed VI University of Health Sciences, Microbiology Unit, National Reference Laboratory, Casablanca, Morocco
| | - Younes Chajai
- Department of Intensive care, Abulcasis University, Cheikh Zaid Hospital, Rabat, Morocco
| | - Younes Cheikhaoui
- Department of pediatric cardiac surgery, Cheikh Zaid Hospital, Rabat, Morocco
| | - Amine El Hassani
- Department of pediatrics, Mohammed V University, Cheikh Zaid Hospital, Rabat, Morocco
| | - Amina Benouda
- Department of Microbiology, Cheikh Zaid Hospital, Rabat, Morocco
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