Compassionate Nursing Care for COVID-19 Patients in the ICU in the Western Region of Saudi Arabia: A Lived Experience Study.

INTRODUCTION: The rapid spread and the severity of symptoms of COVID-19 led to an increasing number of critical cases that need to be admitted to intensive care units (ICUs) worldwide. Compassion is a principle of nursing practice and indicates the meaning of providing high-quality care in all units, especially in the ICU. It means that nurses know what is important to patients and when they should be there for them when it is needed. There is a paucity of literature from Saudi Arabia that explores how critical care nurses perceive compassionate care during COVID-19. OBJECTIVES: The aim of this study was to investigate the lived experiences of critical care nurses providing compassionate care to COVID-19 patients at King Abdulaziz Medical City, Jeddah, Saudi Arabia. METHODS: A prospective, cross-sectional, descriptive phenomenological approach was utilized in this study. Data were collected from 13 ICU nurses through interviews. Collected data were transcribed and analyzed using Colaizzi's data analysis method. RESULTS:  Eleven out of the 13 ICU nurses hold a Bachelor of Science in Nursing (BSN) and have more than five years of experience. Despite all the challenges surrounding the care for critically ill COVID-19 patients, nurses provide compassion in different ways to show personal interest to the patients. Data analysis revealed five themes: (1) contemporary meaning and competencies for compassionate nursing care, including communication and the inability to freely use touch; (2) physical symptoms, including discomfort, body aches and headaches, and sleep disturbances; (3) emotional turmoil, where three sub-themes emerged, including fear and anxiety, uncertainty, and isolation and loneliness; (4) role changing, including frequent guidelines change, additional roles and responsibilities, and altruism; (5) professionalism, including cultural facets of care, teamwork, and support. DISCUSSION: The COVID-19 pandemic has caused major changes in nurses' working environment and so their experience. The results of this study indicated that nurses working in the ICU experienced remarkable and massive physical, psychological, and emotional symptoms during the COVID-19 pandemic. The nurses extended the relationships to the patients' families as they are at high risk of stress, anxiety, and depression. In addition, they were able to support them in dealing with the fear associated with the uncertainty of COVID-19. Also, results revealed that remote therapeutic relationships and psychotherapy can be credible and trustworthy alternatives to in-person care. CONCLUSIONS: The results of this study indicated that ICU nurses provide compassionate care despite experiencing unprecedented and immense physical, psychological, and emotional symptoms during the COVID-19 pandemic. RECOMMENDATIONS: Further study is recommended using other research methodologies. It is also recommended to conduct the same study in different cities for better generalization.

An Interdisciplinary Approach to the Management of Individuals With Tracheostomy.

BACKGROUND: Study objectives were to identify the proportion of tracheostomy subjects with successful decannulation, time to decannulation after ICU discharge, and predictors of long-term tracheostomy based on an interdisciplinary team approach. METHODS: This retrospective cohort study recruited all adult tracheostomy patients admitted between January 2016 and December 2018. Long-term tracheostomy patients with recurrent admissions and compromised airway and patients with neck tumors obstructing the airway were excluded. Data regarding subjects' demographics, comorbidities, Glasgow coma score (GCS), feeding, ICU discharge date, decannulation date, and outcome were collected. The interdisciplinary team members included tracheostomy resource nurse; respiratory therapist; speech clinician; ear, nose, and throat specialist; and rehab medicine specialist. RESULTS: Of the 221 subjects followed during the study period, 16% (36/221) were excluded, and the remaining 84% (185/221) underwent the decannulation protocol. Subjects who failed capping multiple times 114/185 (62%) were labeled long term and did not progress to decannulation. We successfully decannulated 71/185 subjects (38%), and none developed decannulation failure. Forty deaths occurred during hospitalization, but none was due to tracheostomy complications. The median time to decannulation after ICU discharge was 47 d. Predictors of long-term tracheostomy were GCS < 11 (odds ratio [OR] 5.6 [95% CI 2.7-12.0]), age ≥ 65 y (OR 4.5 [95% CI (2.1-10.0]), comorbidities ≥ 2 (OR 4.0 [95% CI 1.5-11.2]), and female sex (OR 3.0 [95% CI 1.3-7.4]). The proportion of subjects with long-term tracheostomy significantly increased with the total number of predictors (Fisher exact test, P < .001). CONCLUSIONS: Long-term tracheostomy was a common outcome among subjects with a tracheostomy. Older age, low GCS, female gender, and the number of comorbidities were significant long-term tracheostomy predictors. Further studies to assess outcomes and predictors of tracheostomy are needed.

Case Report: Neonatal Multi-System Inflammatory Syndrome Associated With SARS-CoV-2 Exposure in Two Cases From Saudi Arabia.

Background: Vertical transmission of SARS-CoV-2 is under investigation. A few reports suggest the possibility of SARS-CoV-2 transmission from mothers to their neonates. Most neonates have mild symptoms, but some develop multisystem involvement and shock. Case Presentation: We report two cases of possible SARS-CoV-2 vertical transmission from mothers to their neonates. The first case shows maternal infection with SARS-CoV-2 in the second trimester followed by recurrent infection in the third trimester right before the delivery. The infant demonstrated respiratory distress soon after delivery along with myocardial dysfunction and multi-organ system involvement. The second case shows maternal infection with SARS-COV-2 at the time of delivery with preterm labor secondary to placental abruption, with that delivery resulting in the preterm neonate requiring non-invasive ventilation with multisystem involvement in the context of persistently positive SARS-COV-2 PCR in the neonate. Both neonates were treated with IVIG along with steroids. Both neonates recovered fully and were discharged and allowed to go home. Conclusion: In neonates, COVID-19 usually presents as an asymptomatic or mild illness; some may develop a more severe course. Our two cases, however, demonstrate that multisystem involvement, although rare, is possible. This report also supports the current evidence of possible vertical transmission from mothers to their neonates. This multisystem involvement might be underreported and should be considered in neonates with respiratory distress when born to mothers suffering of COVID-19. Clinical Trial Registration: [KSUMC], identifier [No#98763298].

Effects of the Coronavirus disease 2019 pandemic on routine pediatric immunization coverage rates at the main University Hospital in Saudi Arabia.

OBJECTIVES: To investigate whether the coronavirus disease-2019 pandemic has had any effects on pediatric vaccination rates at the main university hospital in Saudi Arabia. METHODS: A retrospective study conducted at King Saud University Medical City, Riyadh, Saudi Arabia using electronic health records. The vaccination statuses of all children who were scheduled for vaccinations at birth and at 2, 4, 6, 9, and 12 months during March, April and May between 2017 and 2020 were included in the study with total sample of 15,870 children, and comparisons between the cohorts were performed. RESULTS: All vaccination visits during April and May 2020 were below the lower extremes except for the birth vaccinations. In March, April, and May 2020 there were respective drops in vaccination visits of 49.93%, 71.90% and 68.48% compared with the mean numbers of vaccination visits during the same months from 2017 to 2019. In comparisons of mean numbers of visits from March 2017 to May 2019 and March to May in 2020, the respective reductions in visits for birth and 2, 4, 6, 9 and 12-month vaccinations were 16.5%, 80.5%, 74.7%, 72.9%, 80.0% and 74.1%. CONCLUSIONS: The huge impact of the coronavirus disease-2019 pandemic on childhood vaccinations will require urgent vaccination recovery plans with innovative approaches and future action plans to maintain vaccination coverage during any subsequent pandemics.

Pediatric brucellosis. An update review for the new millennium.

Brucellosis remains the most common bacterial zoonotic infection in many countries worldwide. Despite being long recognized and controllable, the disease still causes substantial morbidity, affecting especially the young population. The aim of this review is to provide insight to the epidemiology, etiology, clinical features, diagnosis, and management of childhood brucellosis.

Optimizing Vancomycin Monitoring in Pediatric Patients.

BACKGROUND: Several studies have reported that trough levels may not be optimal for monitoring vancomycin therapy, because of overexposure and nephrotoxicity risks. Therefore, we developed a population pharmacokinetic model to optimize vancomycin dosing and monitoring in pediatrics. METHODS: Data were retrospectively collected on 76 pediatric patients 1-12 years of age, admitted to general pediatric wards or intensive care units at King Saud University Medical City, Riyadh, Saudi Arabia. The predictability of 3 methods for calculating the area under the curve (AUC) at steady state was assessed for optimum vancomycin therapy monitoring. The 3 methods were simple linear regression, Bayesian approach and the 2-sample pharmacokinetic equation method. We also used Monet Carlo simulations to evaluate the dosing of vancomycin. RESULTS: A 1-compartment model adequately described the data. A strong correlation occurred between the observed and predicted AUC from 0 to 24 hours (AUC0-24h) calculated using the Bayesian approach with a trough sample only or pharmacokinetic equations based on 2 measured samples (R = 0.93 and 0.92, respectively). For the simple linear regression method with a trough sample only, the predicted AUC0-24h at steady state with vancomycin trough levels of 10, 15 and 20 µg/mL were 413, 548 and 714 µg·hour/mL, respectively. The target AUC0-24h above 400 was achieved in 46% and 95% of individuals with trough values of 7-11 and 11-15 µg/mL, respectively. Monte Carlo simulations showed that 60-80 mg/kg/d doses are needed to optimize vancomycin therapy. CONCLUSIONS: In conclusion, targeting vancomycin trough levels above 15 µg/mL in pediatrics would overshoot the target AUC0-24h above 400 and expose them to unnecessary adverse events.

Emergence of carbapenem-resistant Enterobacteriaceae isolated from patients in a university hospital in Saudi Arabia. Epidemiology, clinical profiles and outcomes.

Carbapenemase-producing Enterobacteriaceae have been steadily spreading worldwide during the last decade. Nine patients were identified prospectively and were followed during their hospitalization course to identify the epidemiology, clinical profiles and outcomes. These patients had one or more cultures positive for a CRE isolate, contributing to a total of eleven positive cultures from various sites without including duplicates of isolates obtained from the same site. Isolates from these patients included five Klebseilla pneumoniae, three Escherichia coli, and one Enterobacter aerogenes. Five isolates were grown from blood cultures, three from wound cultures, one from urine cultures, one from respiratory cultures and one from an abscess collection. Five survived the hospital course. The other five patients died due to severe sepsis, septic shock or multi-organ failure. Of the nine isolates of CRE identified for which molecular analysis were available, four K. pneumonia were confirmed as blaNDM and one as OXA-48. For the purpose of controlling the spread of CRE in our institution, we recommend considering active surveillance cultures and screening patients transferred from other hospitals or coming from highly endemic settings at admission for these organisms.

Emergence of Vancomycin-resistant Enterococci at a Teaching Hospital, Saudi Arabia.

BACKGROUND: Vancomycin-resistant enterococci (VRE) are a major and emerging hospital-acquired pathogen associated with high mortality, particularly among the critically ill and Intensive Care Units (ICUs) patients. This study aimed to determine the prevalence and demographic and clinical characteristics of VRE among patients admitted to a university hospital in Riyadh, Saudi Arabia. METHODS: A study was conducted during the period from September 2014 to November 2015 at King Khalid University Hospital, a tertiary care hospital in Riyadh, Saudi Arabia, including in-patients with VRE infection. Data were collected using laboratory results and the medical records of admitted patients and were analyzed using SPSS version 19.0 statistical software. RESULTS: In a one-year period, 231 enterococci were isolated from blood, urine, exudates, sputum, stool, and body fluid. There were 191 (82.7%) vancomycin-sensitive enterococci (VSE) and 40 (17.3%) isolates were VRE. The Enterococcus species included E. faecalis 168 (72.7%), E. faecium, 53 (22.8%) E. gallinarum 5 (2.2%), and E. avium 5 (2.2%). VRE were more significant from blood specimens (P< 0.0001) while VSE were significantly more predominant from urine specimens (P< 0.0001). VRE were more commonly isolated from patients in ICUs and oncology unit (P = 0.0151 and P< 0.001, respectively) while VSE were more predominant in the medical and surgical areas (P = 0.0178 and P = 0.0178, respectively). CONCLUSIONS: This study highlights the high prevalence of VRE in the hospital and the association of enterococcal infections with high-risk areas and oncology units, which warrant more studies looking for better management of these infections.

Mycoplasma pneumoniae-associated mucositis syndrome: A rare and clinically challenging disease in a Saudi child.

Mycoplasma pneumoniae-associated mucositis (MPAM) is an extra-pulmonary manifestation of M. pneumoniae infection and may present as isolated mucosal lesions (e.g., ocular, oral, and urogenital) or as a combination of mucosal and minimal cutaneous lesions. MPAM is a rare entity that lies on the spectrum of erythema multiform (EM) major and Stevens-Johnson syndrome (SJS). We present a 12-year-old boy who presented with classical clinical manifestations of MPAM and strongly positive M. pneumoniae PCR results. The patient was treated with antimicrobial therapy and had an uneventful recovery. Physicians should be aware of this rare entity and manage patients accordingly.

Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak perceptions of risk and stress evaluation in nurses.

INTRODUCTION: Saudi Arabia was affected by an outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV). We aimed to determine the perception of risk and level of stress among nurses. METHODOLOGY: A questionnaire survey was administered to determine the perceptions of risk of MERS-CoV infection. RESULTS: The majority of the participants were females (332; 86.0%), and there were 54 (14.0%) males. Of the 386 respondents, nurses constituted the majority of the respondents (293; 75.9%), and there were 34 doctors (8.8%). The percentage of exposure was found to be greater in those who were working in the intensive care unit (ICU) (89; 23%). There was a significant difference in the worry and fear scale of contracting the MERS-CoV infection between participants who worked in isolation areas, ICUs, and emergency rooms (mean: 3.01±1.1) compared to participants who worked in areas that are less likely to admit and have MERS-CoV suspected or positive cases (mean: 2.77±1.1; p = 0.031. Females were significantly more worried and fearful of contracting the virus compared to males (mean: 2.92±1.1 versus 2.61±1.0, respectively; p = 0.045). CONCLUSIONS: MERS-CoV caused a relatively significant level of distress among nurses. There was a difference in the worry and fear scale of contracting the MERS-CoV infection between participants who worked in areas likely to admit and have MERS-CoV suspected or positive cases. After the campaign, the level of confidence got higher and the participants were more adherent to the infection control precautions.

Prevalence and risk factors of Gram-negative bacilli causing blood stream infection in patients with malignancy.

OBJECTIVES: To evaluate the epidemiology, risk factors, and antibiotic resistance of Gram negative bacteria (GNB) in patients with hematologic or solid organ malignancies.   METHODS: This is a retrospective study of 61 episodes of GNB bacteremia occurring in 56 patients with malignancy admitted to the Oncology Units in King Khalid University Hospital, Riyadh. Kingdom of Saudi Arabia during the period from January 2013 to October 2015. Data were retrieved from the computerized database of the microbiology laboratory and the patient's medical records.   RESULTS:  Hematological malignancies accounted for 30 (54%) and solid tumors accounted for 26 (46%). The most common hematological malignancies were leukemia 23 (77%), followed by lymphoma 6 (20%). Among solid tumors, colorectal cancer 9 (34.6) and breast cancer 6 (23%) were the most common. The most predominant pathogen was Escherichia coli (E. coli) (29.5%) followed by Acinetobacter baumannii (A. baumannii) (18%). The extended-spectrum beta-lactamases producers rate of E. coli and Klebsiella pneumonia was (34.6%). Imipenem resistance among Pseudomonas aeruginosa/ A. baumannii was high (52.4%). The multi-resistant organisms rate was (43.5%). Risk factors associated with the bacteremia were ICU admission (32.1%), post-surgery (23.2%), and placement of central line (21.4%). The overall 30-day mortality rate of the studied population was high (32.1%).  CONCLUSION: In light of the high resistant rate among the GNB isolated from malignancy patients from our institution, careful selection of antimicrobial treatment based on antimicrobial susceptibility testing is recommended.

Viral agents causing acute lower respiratory tract infections in hospitalized children at a tertiary care center in Saudi Arabia.

OBJECTIVE: To determine the load and importance of respiratory viruses in hospitalized Saudi children with acute lower respiratory tract infections (ALRIs). METHODS: A retrospective study was performed at the Departments of Pediatrics, Pathology/Microbiology, King Khalid University Hospital, Kingdom of Saudi Arabia from January 2005 to December 2010. Nasopharyngeal aspirates were collected from 643 children with ALRI. Viruses were detected by direct immunofluorescence, respiratory syncytial virus (RSV), adenovirus (ADV), type 1 to 3 parainfluenza viruses (PIV), and type A and B influenza virus (flu). RESULTS: Of the 643 children with ALRI, viruses were detected in 309 (48.1%) specimens. The viruses that were identified included RSV (n=295, 95.5%), PIV (n=8, 1.2%), ADV (n=2, 0.3%), flu A (n=2, 0.3%), and flu B (n=2, 0.3%). The RSV was predominated in 231 (75%) children less than one year of age. Only younger age and male gender were associated with severe illness. The peak frequency of the viruses detected was in the winter. Of the 309 virus positive samples, bronchiolitis was detected in 81.2% (n=251), and pneumonia in 14.2% (n=44) (p<0.0001). CONCLUSION: Viruses are an important cause of ALRIs in Saudi children constituting approximately 48.1% of the total cases. The RSV is the most common pathogen (95.5%) causing ALRIs. Most of the children were younger than one year of age, and were more likely to present with bronchiolitis than pneumonia.

Clinical and laboratory profiles of urinary tract infections caused by extended-spectrum beta-lactamase-producing Escherichia coli in a tertiary care center in central Saudi Arabia.

OBJECTIVE: To study the clinical and laboratory characteristics of urinary tract infections (UTIs) caused by extended-spectrum beta-lactamase (ESBL) producing Escherichia coli (E. coli). METHODS: A retrospective clinical and laboratory study was performed at the Bacteriology Unit, Department of Pathology/Microbiology, King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia from June 2009 to June 2011. A total of 339 adults and pediatric patients with UTI was included in the study. Two groups of patients (ESBL E. coli UTI and non-ESBL E. coli UTI) were studied. Symptoms and signs of illness, comorbidities, outcomes, and urine analysis results were analyzed. RESULTS: There was 339 episodes of culture-verified UTI, 113 (33.3%) cases were caused by ESBL E. coli, and 226 (66.7%) cases were caused by non-ESBL E. coli. Non-ESBL E. coli UTI was more commonly found in children, and ESBL E. coli was more predominant in female patients. Identified risk factors for acquisition of ESBL E. coli UTI included patients who had underlying renal disease and renal transplant (p=0.017), children with vesicoureteric reflux (p=0.044), surgical intervention, recurrent UTI (p<0.004), and in inpatients. Non-ESBL E. coli patients are more likely to present with UTI. The ESBL E. coli uropathogen are resistant to antibiotics, including the third generation cephalosporin, gentamicin, and ciprofloxacin, whereas the non-ESBL E. coli were more resistant to antibiotics Ampicillin and cotrimoxazole. CONCLUSION: Identifying the risk factors and the antimicrobial resistance patterns associated with ESBL producing E. coli UTI is necessary for the development of an appropriate empirical antibiotic treatment.

Fatal Streptococcus melleri meningitis complicating missed infected intramedullary dermoid cyst secondary to dermal sinus in a Saudi child.

A spinal intramedullary abscess secondary to an infected dermoid cyst is rare, and it has a poor prognosis, unless diagnosed and treated promptly. We report a 12-month-old patient with a spinal intramedullary abscess with secondary to a dermoid cyst resulting from a dermal sinus, despite a clearly defined opening at the lower back with discharge of a purulent material from a dermal sinus tract seen on the lower back before the patient had become symptomatic and showed meningeal signs. The patient was managed as a case of meningitis until he had complications that endangered his life, and then further radiological evaluation was done to delineate the underlying pathology. This case illustrates the importance of the recognition and evaluation of skin markers because of the potential for intradural extension and a frequent association with other dysraphic abnormalities. It also emphasizes the importance of early diagnosis and treatment of spinal intramedullary abscess.

Panton-Valentine leukocidin Staphylococcus aureus osteomyelitis of the femur in a Saudi child.

Staphylococcus aureus producing Panton-Valentine leukocidin (PVL) is well recognized to cause severe skin and soft tissue infections. Recently, it has been increasingly recognized as causing life-threatening musculoskeletal infection. We reported previously 3 children who had osteomyelitis caused by methicillin resistant Staphylococcus aureus. We report and discuss a case of Methicillin sensitive staphylococcus aureus encoding the PVL genes isolated from a child with acute osteomyelitis from Saudi Arabia.

Outbreak of Bacille Calmette-Guérin-related lymphadenitis in Saudi children at a university hospital after a change in the strain of vaccine.

BACKGROUND AND OBJECTIVES: Bacille Calmette-Guérin (BCG) vaccination is part of the expanded program of vaccination in Saudi Arabia. Lymphadenitis is the most common complication of the BCG vaccine. We observed an increase in the rate of BCG lymphadenitis that coincided with the introduction of a new strain of BCG vaccine. The aim of this study was to determine the incidence and the possible causes of BCG lymphadenitis at a university hospital in Riyadh, Saudi Arabia. DESIGN AND SETTING: Retrospective chart review and prospective follow up of infants who received BCG vaccine. METHODS: We studied all infants presenting with suppurative or nonsuppurative adenopathy with nodes age;2 cm seen at the infectious diseases clinic at KKUH. The study duration was divided into two periods. The first period reviewed infants who received different BCG vaccine strains between January 2002 and December 2007. The second study period was conducted after close evaluation of the BCG administration technique of the vaccinating staff and reviewed infants who received the BCG SSI Danish strain 1331 between January 2008 and December 2010. RESULTS: During the study period from January 2002 to December 2007, 19 402 infants received four different BCG vaccine strains. Eight infants developed BCG lymphadenitis, and all were associated with the BCG SSI vaccine. The incidence rate in 2007 was 1.96 per 1000. In the second period, 66 of 9921 infants who received the BCG SSI vaccine developed BCG lymphadenitis between January 2008 and December 2010. The incidence rate was 10.14 per 1000 in 2010. CONCLUSION: We conclude that receipt of the BCG SSI vaccine might have contributed to the increased incidence of lymphadenitis in these children. Hence, caution should be exercised in switching from one vaccine to another, as is often done in developing countries.

Severe community-acquired infection caused by methicillin-resistant Staphylococcus aureus in Saudi Arabian children.

Community acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infection has become a major pathogen causing significant infection in children in Saudi Arabia. It has emerged as a frequent cause of skin and soft tissue infections and can be associated with life-threatening complications such as necrotizing pneumonia and sepsis. Between January 2005 and March 2008, 5 (6%) previously healthy children with invasive CA-MRSA infections were identified from 80 children with community-onset MRSA infections. Three children had osteomyelitis, with one patient presenting a fulminant and extensive soft tissue and bone destruction complicated by deep vein thrombosis and pathological fracture. One child had deep-seated infection, and one infant had severe orbital cellulitis and bilateral orbital abscess complicated by subdural empyema. The median age was 4-years (range 3 months to 17 years). Only one patient had a risk factor. Two patients were initially treated with ineffective antimicrobial therapy (beta-lactam). One isolate showed inducible clindamycin resistance. The recovery was uneventful in all patients. This report should increase the awareness of clinicians regarding severe CA-MRSA infections and highlight the challenges encountered in the choice of therapy of serious infections caused by this organism.

First case of extensive spinal cord infection with Aspergillus nidulans in a child with chronic granulomatous disease.

Chronic granulomatous disease (CGD) is characterized by a defect in phagocytic cells that lead to recurrent bacterial and fungal infections. The etiology of most common fungal infections in CGD are Aspergillus species. Aspergillus nidulans is one of several species of Aspergillus with low pathogenicity. However, it was reported to cause fatal invasive Aspergillosis in patients with CGD. Here we report the first cured invasive Aspergillus nidulans infection with extensive involvement of the spinal cord in a five-year-old child with CGD.