Empiric Antibiotic Therapy in the Treatment of Community-acquired Pneumonia in a General Hospital in Saudi Arabia.

BACKGROUND: Guideline-based empiric antimicrobial therapy is recommended for the treatment of community-acquired pneumonia (CAP). In this study, we evaluate the pattern of empiric antibiotics of CAP patients. MATERIALS AND METHODS: Patients with CAP were retrieved from the health information unit using the International Classification of Diseases, Ninth Revision. The electronic pharmacy database was used to retrieve prescribed antibiotics and the duration of therapy for each antibiotic. RESULTS: A total of 1672 adult patients were included in the study and 868 (52%) were male. Of all the patients, 47 (2.8%) were admitted to the intensive care unit (ICU). The most frequently used antibiotics were levofloxacin (68.12%), ceftriaxone (37.7%), imipenem-cilastatin (32.5%), and azithromycin (20.6%). The mean days of therapy of each of these antibiotics were 3.2, 2.8, 4.4, and 2.9, respectively. A combination therapy of levofloxacin and imipenem-cilastatin was prescribed for 355 (21.8%) of non-ICU patients versus 20 (60.6%) of ICU patients (P = 0.0007). Imipenem-cilastatin was prescribed for 518 (31.8%) of non-ICU patients versus 25 (56.8%) of ICU patients (P = 0.0009). Levofloxacin was prescribed for 1106 (68%) of non-ICU patients versus 33 (75%) of ICU patients (P = 0.412). Ceftriaxone use decreased significantly from 40.9% in 2013 to 25.9% in 2016 (P = 0.034). In addition, levofloxacin use increased from 63.7% to 75% (P = 0.63). CONCLUSION: The most commonly used antibiotics were levofloxacin, ceftriaxone, imipenem-cilastatin, and azithromycin. The data call for further refinement and prospective audit of antibiotic use in CAP, especially in non-ICU settings.

Epidemiology and source of infection in patients with febrile neutropenia: A ten-year longitudinal study.

OBJECTIVES: No recent studies are available from Saudi Arabia on the etiology of febrile neutropenia. The objective of this study was to describe the characteristics of patients with febrile neutropenia and to calculate the rate of occurrence of bacteremia in these patients. METHODS: This is a hospital-based study of patients admitted with febrile neutropenia from 2006 to 2015. RESULTS: A total of 372 distinct episodes of febrile neutropenia representing 231 patients were included. Hematologic malignancies constituted 56.6% of the episodes. Positive blood cultures were reported in 13.5% with equal frequency of Gram-negative bacilli and gram positive cocci. The most commonly suspected sites of infection were blood 10.8% and pulmonary 9.2%, and the majority (72.5%) was thought to have no identifiable source of infection. Of all the episode, 32% had central venous catheters. The most frequently used single antimicrobial agents were imipenem (38%) and ceftazidime (7.5%). The mortality rate was 11.2% and it was significantly associated with the presence of bacteremia 24.4% versus 12.4% (P=0.016). Mortality was not significantly association with age, type of malignancy, presence of central venous catheter, or the severity of neutropenia. Compared to patients with hematological malignancy, patients with solid organ malignancy were more likely to be female 62% versus 14.9% (P<0.001) and were less likely to have bacteremia 8.7% versus 17.1%, P=0.042, respectively. CONCLUSION: We had shown that febrile neutropenia in this study has a low rate of bacteremia and that about 45% received the recommended initial empiric therapy.

The calm before the storm: clinical observations of Middle East respiratory syndrome (MERS) patients.

BACKGROUND: Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection emerged in 2012. The majority of cases occurred in the Kingdom of Saudi Arabia and the disease carries a high case fatality rate. METHODS: We present three MERS-CoV cases and highlight the salient clinical features and laboratory, and radiographic characteristics. RESULTS: Although all nasopharyngeal samples were negative, MERS CoV infection was confirmed by reverse transcription-polymerase chain reaction of the E gene (UpE) and open reading frame (ORF1b) on sputum samples. The Ct value of the ORF1 gene was 24.8-29.11. One patient had been on immune suppressive agent and two patients had diabetes mellitus. The average length of hospital stay was 10.6 days. Two patients received ribavirin and IFN-a2b in addition to supportive management. The clinical course for these patients started with a febrile period lasting five days, a reduction in fever was coinciding with increased respiratory rate and oxygen requirements. All patients were discharged home. None of the 50 contacts tested positive for MERS-CoV. CONCLUSION: Resolution of the fever was accompanied by an increase in oxygen requirements and respiratory rate also lasting several days. This was followed by resolution of all symptoms and return to normal.

Influenza is more common than Middle East Respiratory Syndrome Coronavirus (MERS-CoV) among hospitalized adult Saudi patients.

BACKGROUND: Since the initial description of Middle East Respiratory Syndrome Coronavirus (MERS-CoV), we adopted a systematic process of screening patients admitted with community acquired pneumonia. Here, we report the result of the surveillance activity in a general hospital in Saudi Arabia over a four year period. MATERIALS AND METHODS: All admitted patients with community acquired pneumonia from 2012 to 2016 were tested for MERS-CoV. In addition, testing for influenza viruses was carried out starting April 2015. RESULTS: During the study period, a total of 2657 patients were screened for MERS-CoV and only 20 (0.74%) tested positive. From January 2015 to December 2016, a total of 1644 patients were tested for both MERS-CoV and influenza. None of the patients tested positive for MERS-CoV and 271 (16.4%) were positive for influenza. The detected influenza viruses were Influenza A (107, 6.5%), pandemic 2009 H1N1 (n = 120, 7.3%), and Influenza B (n = 44, 2.7%). Pandemic H1N1 was the most common influenza in 2015 with a peak in peaked October to December and influenza A other than H1N1 was more common in 2016 with a peak in August and then October to December. CONCLUSIONS: MERS-CoV was a rare cause of community acquired pneumonia and other viral causes including influenza were much more common. Thus, admitted patients are potentially manageable with Oseltamivir or Zanamivir therapy.

Performance of CURB-65 in predicting mortality of patients with community-acquired pneumonia in Saudi Arabia.

INTRODUCTION: Various objective scoring systems were developed to standardize the approach to the designation of severity of community-acquired pneumonia (CAP). There is limited data on the use of CURB-65 among admitted CAP patients in Saudi Arabia.  METHODOLOGY: The retrospective study included CAP patients, admitted to a general hospital in Eastern Saudi Arabia. The CURB-65 was extracted from the available medical records. RESULTS: During the study period, from 2013 to 2016, a total of 1786 adults were admitted with a mean age of 63.9 ± 21.7 (range 14-108 years). The majority of the patients (51.7%) had CURB-65 score 0 or 1 followed by the score 2, 3 and 4/5 (29%, 15.2%, and 4.1%, respectively).  The mean CURB-65 was 1.4 ± 1.12 for those who survived and 2.27 ± 1.03 for those who died (p < 0.001). The mean age was 63.01± 21.9 years for survived patients and 75.1 ± 15.58 years for fatal cases (p < 0.001). The overall 30-day crude mortality rate was 7.6%. The mortality rates for CURB-65 scores 0, 1, 2, 3, and 4/5 were 1.8%, 4.3%, 10.2%, 14%, and 21.9%, respectively. CONCLUSIONS: The mortality rates of admitted patients with CAP did not differ from those reported in the literature. However, the utilization of CURB-65 score was low and there is a need for wider implementation of pneumonia severity index for patients presenting with CAP.

Systematic review of the prevalence of Mycobacterium tuberculosis resistance in Saudi Arabia.

AIM: To quantitatively estimate the prevalence of resistance of Mycobacterium tuberculosis (TB) to first line agents in Saudi Arabia. METHODS: The overall prevalence of M. tuberculosis resistance was calculated using meta-analysis. RESULTS: We included 22 studies from Saudi Arabia that were published from 1979 to 2013.A high degree of heterogeneity among studies was observed. Based on random effect methodology, the prevalence (and 95% CI) of the resistance rates were: INH 10.13 (8.13-12.11), rifampicin 5.41 (4.21-6.61), ethambutol 1.29 (1.83-2.37) and streptomycin 6.5 (4.9-8.1), and multi-drug resistant was 6.7 (5.1-8.3). CONCLUSION: The prevalence of resistance to anti-tuberculous agents was highest for INH followed by streptomycin and rifampicin. Multi-drug resistant tuberculosis remains at 6.7%. The data support the recommendations to use four anti-tuberculous agents as empiric therapy.

Vancomycin-induced acute tubular necrosis.

OBJECTIVES: To report nephrotoxicity in the form of acute tubular necrosis (ATN) related to vancomycin. METHODS: This study was conducted at Johns Hopkins Aramco Healthcare, Saudi Aramco, Dharan, Saudi Arabia between June and August 2013. All patients who received intravenous vancomycin as a part of the hospital's vancomycin stewardship program were monitored for the development of ATN. RESULTS: A total of 89 patients received vancomycin over a 3-month period. Three patients developed ATN attributed to high levels of vancomycin, with an incidence of 3.4%. CONCLUSION: Intravenous vancomycin is nephrotoxic and can lead to ATN. The medical community must be aware of the potential risks of vancomycin associated nephrotoxicity. Renal function and vanomycin drug levels should be closely monitored.

Middle East respiratory syndrome coronavirus: a case-control study of hospitalized patients.

BACKGROUND: There is a paucity of data regarding the differentiating characteristics of patients with laboratory-confirmed and those negative for Middle East respiratory syndrome coronavirus (MERS-CoV). METHODS: This is a hospital-based case-control study comparing MERS-CoV-positive patients (cases) with MERS-CoV-negative controls. RESULTS: A total of 17 case patients and 82 controls with a mean age of 60.7 years and 57 years, respectively (P = .553), were included. No statistical differences were observed in relation to sex, the presence of a fever or cough, and the presence of a single or multilobar infiltrate on chest radiography. The case patients were more likely to be overweight than the control group (mean body mass index, 32 vs 27.8; P = .035), to have diabetes mellitus (87% vs 47%; odds ratio [OR], 7.24; P = .015), and to have end-stage renal disease (33% vs 7%; OR, 7; P = .012). At the time of admission, tachypnea (27% vs 60%; OR, 0.24; P = .031) and respiratory distress (15% vs 51%; OR, 0.15; P = .012) were less frequent among case patients. MERS-CoV patients were more likely to have a normal white blood cell count than the control group (82% vs 52%; OR, 4.33; P = .029). Admission chest radiography with interstitial infiltrates was more frequent in case patients than in controls (67% vs 20%; OR, 8.13; P = .001). Case patients were more likely to be admitted to the intensive care unit (53% vs 20%; OR, 4.65; P = .025) and to have a high mortality rate (76% vs 15%; OR, 18.96; P < .001). CONCLUSIONS: Few clinical predictors could enhance the ability to predict which patients with pneumonia would have MERS-CoV. However, further prospective analysis and matched case-control studies may shed light on other predictors of infection.

Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin outcome study.

The purpose of this study was to determine if ambulatory blood pressure measurement predicted total and cardiovascular mortality over and beyond clinic blood pressure measurement and other cardiovascular risk factors; 5292 untreated hypertensive patients referred to a single blood pressure clinic who had clinic and ambulatory blood pressure measurement at baseline were followed up in a prospective study of mortality outcome. Multiple Cox regression was used to model time to total and cause-specific mortality for ambulatory blood pressure measurement while adjusting for clinic blood pressure measurement and other risk factors at baseline. There were 646 deaths (of which 389 were cardiovascular) during a median follow-up period of 8.4 years. With adjustment for gender, age, risk indices, and clinic blood pressure, higher mean values of ambulatory blood pressure were independent predictors for cardiovascular mortality. The relative hazard ratio for each 10-mm Hg increase in systolic blood pressure was 1.12 (1.06 to 1.18; P<0.001) for daytime and 1.21 (1.15 to 1.27; P<0.001) for nighttime systolic blood pressure. The hazard ratios for each 5-mm Hg increase in diastolic blood pressure were 1.02 (0.99 to 1.07; P=NS) for daytime and 1.09 (1.04 to 1.13; P<0.01) for nighttime diastolic pressures. The hazard ratios for nighttime ambulatory blood pressure remained significant after adjustment for daytime ambulatory blood pressure. These results have 2 important clinical messages: ambulatory measurement of blood pressure is superior to clinic measurement in predicting cardiovascular mortality, and nighttime blood pressure is the most potent predictor of outcome.

Ambulatory blood pressure measurement as a predictor of outcome in an Irish population: methodology for ascertaining mortality outcome.

BACKGROUND: Ambulatory blood pressure monitoring (ABPM) has proven to be a superior predictor of morbid events when compared to clinic or office blood pressure measurement (CBPM). The purpose of this study was to evaluate the predictive value of ABPM in a sample of 14 414 people referred for management of cardiovascular risk. METHODS: In this paper we describe the methodology required to examine mortality outcome in the absence of a national unique identifier. RESULTS: Using a computerized database of deaths we were able to establish that 1348 people had died by the end of the follow-up period (30 September 2002). Sixty-four percent of deaths were cardiovascular and in 207 subjects who had post-mortem examinations, 78% were cardiovascular. CONCLUSIONS: The accurate identification of the cause of death in a large population will allow comparison of the relative predictive power of APBM and CBPM in an Irish population.