Antimicrobial Resistance Profiles of Pseudomonas aeruginosa in the Arabian Gulf Region Over a 12-Year Period (2010-2021).

OBJECTIVES: To evaluate literature from a 12-year period (2010-2021) on the antimicrobial resistance profile of Pseudomonas aeruginosa from the Arabian Gulf countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates). METHODS: An electronic literature search was conducted for articles on antimicrobial resistance in P. aeruginosa and associated phenotypes, covering the period of 1st January 2010 to 1st December 2021. RESULTS: Antimicrobial resistance in the Arabian Gulf was highest to meropenem (10.3-45.7%) and lowest to colistin (0.0-0.8%), among the agents tested. Annual data showed that ceftazidime resistance (Kuwait), piperacillin-tazobactam non-susceptibility (Qatar), and aztreonam, imipenem, and meropenem resistance (Saudi Arabia) increased by 12-17%. Multiple mechanisms of carbapenem resistance were identified and multiple clones were detected, including high-risk clones such as ST235. The most common carbapenemases detected were the VIM-type metallo-ß-lactamases. CONCLUSIONS: Among P. aeruginosa in the Arabian Gulf countries, resistance to meropenem was higher than to the other agents tested, and meropenem resistance increased in Saudi Arabia during the study period. Resistance to colistin, a classic antibiotic used to treat Pseudomonas spp. infections, remained low. The VIM-type ß-lactamase genes were dominant. We recommend local and regional antimicrobial resistance surveillance programs to detect the emergence of resistance genes and to monitor antimicrobial resistance trends in P. aeruginosa.

A national, multicentre, web-based point prevalence survey of antimicrobial use and quality indices among hospitalised paediatric patients across South Africa.

OBJECTIVES: Data on antimicrobial consumption among the paediatric population in public hospitals in South Africa are limited. This needs to be addressed to improve future antimicrobial use and reduce antimicrobial resistance rates. This study aimed to quantify antimicrobial usage and to identify and classify which antimicrobials are used in the paediatric population in public sector hospitals in South Africa according to the World Health Organization (WHO) AWaRe list of antimicrobials. METHODS: A point prevalence survey was conducted among 18 public sector hospitals from nine provinces using a newly developed web-based application. Data were analysed according to the WHO AWaRe list to guide future quality improvement programmes. RESULTS: A total of 1261 paediatric patient files were reviewed, with 49.7% (627/1261) receiving at least one antimicrobial and with 1013 antimicrobial prescriptions overall. The top five antimicrobials included ampicillin (16.4%), gentamicin (10.0%), amoxicillin/enzyme inhibitor (9.6%), ceftriaxone (7.4%) and amikacin (6.3%). Antimicrobials from the 'Access' classification were the most used (55.9%), with only 3.1% being from the 'Reserve' classification. The most common infectious conditions for which an antimicrobial was prescribed were pneumonia (14.6%; 148/1013) and clinical sepsis (11.0%; 111/1013). Parenteral administration (75.6%; 766/1013) and prolonged surgical prophylaxis (66.7%; 10/15) were common concerns. Only 28.0% (284/1013) of prescribed antimicrobials had cultures requested; of which only 38.7% (110/284) of culture results were available in the files. CONCLUSION: Overall, antimicrobial prescribing is common among paediatric patients in South Africa. Interventions should be targeted at improving antimicrobial prescribing, including surgical prophylaxis, and encouraging greater use of oral antibiotics.

A point prevalence survey of antimicrobial utilisation patterns and quality indices amongst hospitals in South Africa; findings and implications.

Objectives: Antimicrobial use is growing, driven mainly by rising demands in developing countries. Knowing how antimicrobials are prescribed is important. Consequently, we undertook a point prevalence survey (PPS) quantifying antimicrobial consumption among 18 public sector hospitals across South Africa.Method: A purpose-built web-based application was used to collect PPS data.Results: Out of 4407 adult patients surveyed, 33.6% were treated with an antimicrobial. The most frequently prescribed groups were a combination of penicillins including ß-lactamase inhibitors. Amoxicillin combined with an enzyme inhibitor accounted for 21.4% total DDDs. In the medical and surgical wards, Access antimicrobials (54.1%) were mostly used, while in the ICU, Watch antimicrobials (51.5%) were mostly used. Compliance with the South African Standard Treatment Guidelines and Essential Medicines List was 90.2%; however, concerns with extended use of antimicrobials for surgical prophylaxis (73.2% of patients).Conclusion: The web-based PPS tool was easy to use and successful in capturing PPS data since the results were comparable to other PPS studies across Africa. High use of amoxicillin combined with an enzyme inhibitor, possibly because it was among the broad-spectrum antimicrobials in the Access group. The findings will assist with future targets to improve antimicrobial prescribing among public sector hospitals in South Africa.

Development of a web-based application to improve data collection of antimicrobial utilization in the public health care system in South Africa.

OBJECTIVE: Determining antimicrobial utilization patterns in hospitals can be a challenge given personnel and resource constraints with paper-based systems. A web-based application (APP) was developed in South Africa to address this, building on a recent point prevalence survey (PPS) using a paper-based system. Consequently, there was a need to test and evaluate the ease of use of a newly developed app and potential time saving versus paper-based methods for PPS. The findings can be used to further refine the APP. METHODS: The developed app was tested in a large academic public hospital in a PPS in South Africa. During data collection, the app was evaluated for functionality on 35 variables and subsequently refined. After data collection, the app was evaluated in terms of its time-saving potential and ease of use. RESULTS: 181 patient's files were surveyed across 13 wards in the hospital, with the antimicrobial usage findings similar to the previous paper-based study in the same hospital. The median age for males was 45.5 years and 42 years for females. Overall 80 out of 181 (44%) patients received antibiotics. Whilst 38% (12 out of 31) of patients in the adult surgical ward received antimicrobials, the prevalence was the highest (78%) in the pediatric medical wards. All the data collectors were confident in using the app after training and found the tool is not complex at all to use. In addition, the time taken to plan for the study and to collect data was considerably reduced. Reduced time spent in data collection and analysis is important for timely instigation of quality improvement programs in resource limited settings. CONCLUSIONS: All data collectors would recommend the app for future PPSs. Several concerns with data entry were identified, which have now been addressed. The app development has been successful and is now being deployed across South Africa as part of a national PPS as well as wider.

Validity of World Health Organisation prescribing indicators in Namibia's primary healthcare: findings and implications.

OBJECTIVE: World Health Organization/International Network of Rational use of Drugs (WHO/INRUD) indicators are widely used to assess medicine use. However, there is limited evidence on their validity in Namibia's primary health care (PHC) to assess the quality of prescribing. Consequently, our aim was to address this. DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS: An analytical cross-sectional survey design was used to examine and validate WHO/INRUD indicators in out-patient units of two PHC facilities and one hospital in Namibia from 1 February 2015 to 31 July 2015. The validity of the indicators was determined using two-by-two tables against compliance to the Namibian standard treatment guidelines (NSTG). The receiver operator characteristics for the WHO/INRUD indicators were plotted to determine their accuracy as predictors of compliance to agreed standards. A multivariate logistic model was constructed to independently determine the prediction of each indicator. MAIN OUTCOMES AND RESULTS: Out of 1243 prescriptions; compliance to NSTG prescribing in ambulatory care was sub-optimal (target was >80%). Three of the four WHO/INRUD indicators did not meet Namibian or WHO targets: antibiotic prescribing, average number of medicines per prescription and generic prescribing. The majority of the indicators had low sensitivity and/or specificity. All WHO/INRUD indicators had poor accuracy in predicting rational prescribing. The antibiotic prescribing indicator was the only covariate that was a significant independent risk factor for compliance to NSTGs. CONCLUSION: WHO/INRUD indicators showed poor accuracy in assessing prescribing practices in ambulatory care in Namibia. There is need for appropriate models and/or criteria to optimize medicine use in ambulatory care in the future.

Statin use in Brazil: findings and implications.

INTRODUCTION AND OBJECTIVES: Statins have become an integral part of treatment to reduce cardiac events in patients with cardiovascular disease. However, their use within the public healthcare system in Brazil is unknown. Consequently, we sought to determine and characterize statin use in primary healthcare delivered by the public health system (SUS) in Brazil and evaluate associated patient factors to improve future use. METHODS: Cross-sectional study with a national representative sample from five Brazilian regions, derived from the National Survey on Access, Use and Promotion of Rational Use of Medicines using a multi-stage complex sampling plan. Patients over 18 years old were interviewed from July 2014 to May 2015. The prevalences of statin use and self-reported statin adherence were determined amongst medicine users. The associations between statin use and sociodemographic/health condition variables were assessed using logistic regression. RESULTS: A total of 8803 patients were interviewed, of whom 6511 were medicine users. The prevalence of statin use was 9.4% with simvastatin (90.3%), atorvastatin (4.7%) and rosuvastatin (1.9%) being the most used statins. Poor adherence was described by 6.5% of patients. Statin use was significantly associated with age ≥65 years old, higher educational level, residence in the South, metabolic and heart diseases, alcohol consumption and polypharmacy. CONCLUSIONS: This is the first population based study in Brazil to assess statin use in SUS primary healthcare patients. Addressing inequalities in access and use of medicines including statins is an important step in achieving the full benefit of statins in Brazil, with the findings guiding future research and policies.

Integrated Kidney Exosome Analysis for the Detection of Kidney Transplant Rejection.

Kidney transplant patients require life-long surveillance to detect allograft rejection. Repeated biopsy, albeit the clinical gold standard, is an invasive procedure with the risk of complications and comparatively high cost. Conversely, serum creatinine or urinary proteins are noninvasive alternatives but are late markers with low specificity. We report a urine-based platform to detect kidney transplant rejection. Termed iKEA (integrated kidney exosome analysis), the approach detects extracellular vesicles (EVs) released by immune cells into urine; we reasoned that T cells, attacking kidney allografts, would shed EVs, which in turn can be used as a surrogate marker for inflammation. We optimized iKEA to detect T-cell-derived EVs and implemented a portable sensing system. When applied to clinical urine samples, iKEA revealed high level of CD3-positive EVs in kidney rejection patients and achieved high detection accuracy (91.1%). Fast, noninvasive, and cost-effective, iKEA could offer new opportunities in managing transplant recipients, perhaps even in a home setting.

Ventricular tachycardia during microdebrider-assisted turbinectomy: An electrocardiographic artifact.

Interference of monitored electrocardiogram is common during different surgical procedures using electrical equipment. The electrical devices used induce artifacts in the electrocardiographic tracing, which may resemble serious arrhythmia. We describe a case of electrocardiographic artifact resembling ventricular tachycardia with the use of a Storz unidrive microdebrider during inferior turbinectomy under general anesthesia. This case report highlights the importance of knowledge of various equipment-related electrocardiographic artifacts in avoiding unnecessary and harmful therapeutic interventions.

Teenage pregnancy.

OBJECTIVE: To study the frequency of teenage pregnancy and its complications as compared to controls. METHODS: A retrospective case record analysis of 2522 pregnancies, aged below 25 years was carried out, in the Department of Obstetrics, Riyadh Armed Forces Hospital during the period 1 January 1999 to 31st December 1999. RESULTS: The incidence of teenage pregnancy for 1999 was 6%. Three hundred and eighty five (76%) were carrying their first pregnancy while 42 (8%) mothers had 2 or more previous pregnancies and deliveries. The birth weight was less than 2.5 kg in 109 (21.5%) adolescents, as compared to 187 (9%) of the controls. The rate of instrumental deliveries and cesarean section in adolescents was 9% and 6% as compared to 5% and 10% in the controls. Seventy nine (16%) of adolescents delivered prematurely as compared to 216 (11%) of the controls. Forty seven (9%) of adolescents were unbooked compared to 133 (7%) who were controlled. The incidence of pre-eclampsia and preterm delivery in adolescents was 2% and 16% as compared to 1% and 11% in the controls. CONCLUSION: Teenage pregnancy, which showed a steady decline from 18% in 1979 to 6% in 1999 was associated with a significantly higher risk of preterm delivery, pre-eclampsia, low birth weight and instrumental delivery.

Changing trends in perinatal deaths at the Armed Forces Hospital, Riyadh, Saudi Arabia.

A total of 104522 babies were delivered at the Riyadh Armed Forces Hospital between 1979 and 1998, including 807 stillbirths and 658 neonatal deaths. The 20-year period was divided into four 5-yearly intervals for comparative purposes. The overall Perinatal Mortality Rate (PMR) for infants weighing 500 grams or more ranged between 20.2 per 1000 in 1979 and 13 per 1000 in 1998. The lowest PMR of 10.3 per 1000 was recorded in 1985. Thirty-one per cent of the perinatal deaths were unbooked. The corrected neonatal death rate (excluding congenital anomalies) dropped from 10.1 per 1000 in 1979 to 1.7 per 1000 live births in 1998 - The corrected stillbirth rate dropped from 12.1 per 1000 births in 1979 to six per 1000 in 1998. Of the 807 stillbirths, 24.1% had lethal congenital anomalies while 29.5% were unexplained, 4% had hydrops fetalis, 2% died as a consequence of toxaemia of pregnancy, 7.5% were associated with antepartum haemorrhage, 7.9% were mechanical, related to cord accident and ruptured uterus, 9.8% died as a consequence of maternal disease, 5.4% of intrapartum asphyxia and 6.4% placental insufficiency. Of the 658 neonatal deaths, 47.5% had lethal congenital anomalies, 2% had hydrops fetalis, 7.6% died as a result of intrapartum asphyxia, 38% died as a result of prematurity with its complications of severe respiratory dysfunction and intraventricular and pulmonary haemorrhage, 4.1% died in NICU of secondary infection and 0.7% were unclassified. The overall PMR for infants weighing 500 grams or more was 14.1 per thousand. Congenital anomalies and low birth weight/prematurity accounted for 85.5% of the neonatal deaths. Congenital anomalies and unexplained deaths accounted for 53% of total stillbirths while maternal disease was responsible for 9.8% of total stillbirths. Reducing congenital anomalies and preventing prematurity and provision of good antenatal care will help in reducing PMR still further.

Problems of Parkinson`s disease in the Arab world.

Problems of Parkinson`s Disease within the Arab world are discussed and a number of solutions are presented that will help in the management of Idiopathic Parkinson`s Disease. The problems discussed are problems related to the diagnosis whereby no individual clinical feature has sufficient sensitivity and specificity to serve as the sole basis for distinguishing Parkinson`s disease from other diseases with Parkinsonian features. Problems related to the Unified Parkinson`s Disease Rating Scale are also discussed and convey a multitude of problems culturally distinct to the Arab world. Problems related to the medical treatment, selection of patients for surgery, the surgery itself and the surgeon, programming and rehabilitation are discussed in detail.

Can the rate of cesarean section be reduced?

OBJECTIVE: To look into all cases with previous one cesarean section who were cared for and delivered at Armed Forces Hospital, Riyadh, between January 1990 and December 1998, to determine its prevalence, final method of delivery, and outline measures of reducing its incidence. METHODS: Retrospective analysis of hospital records of all women with previous one cesarean section who had either a repeat cesarean section or delivered vaginally after cesarean section. RESULTS: Between 1990 and 1998, 61,060 mothers were delivered. Two thousand five hundred and seventy eight patients had one previous cesarean section. They represented 3.5% of the total number of deliveries. Nine hundred and sixty eight (37.5%) cases had repeat cesarean section. Of the 1610 (62.5%) mothers who achieved vaginal delivery, 102 (6%) had ventouse, 42 (3%) had forceps and 22 (1%) had an assisted breech delivery. Rupture of uterine scar was reported in 15 cases. There were no maternal or perinatal deaths. CONCLUSION: Patients with one previous cesarean section are three times more likely to have a cesarean section as compared to mothers with unscarred uterus. Reducing the overall cesarean section rate is possible through a closer look at the primary indication for the first cesarean section. A protocol is needed to allow more cases with one or more previous cesarean section to have trial of vaginal delivery under close monitoring and involve the senior staff more in the diagnosis and management of cases of dystocia and the use of Oxytocin when indicated.

[Serologic and virologic investigations on the presence of BLV infection in a dairy herd in Syria]. / Serologische und virologische Untersuchungen über das Vorkommen der BLV-Infektion in einer Milchviehherde in Syrien.

237 cattle of a dairy herd in Syria were tested for anti-BLV antibody by the ELISA. 194 animals were additionally examined by the agar gel immunodiffusions test (AGID) on BLV antibodies and 100 by polymerase chain reaction (PCR) for BLV provirus. BLV specific antibodies were determined by means of AGID and ELISA at 62.9% and 69.2% of the examined animals, respectively. Using the PCR method the BLV provirus was detected in 89% of the investigated cattle. Only one ELISA seropositive animal was negative for BLV provirus. The results show the high BLV contamination of this herd and lead to the presumption of wide spread enzootic bovine leukosis in Syria. In the case of the diagnosis of BLV-infection, the PCR-technique compared to the serological tests proved to be much more sensitive. By the detection of BLV antibody, the ELISA showed a higher sensitivity than the AGID and in this way, is advisable as a method of choice for screening investigations. Restriction enzyme and sequence analysis of PCR-amplificates demonstrate that different BLV provirus variants (A, B and C) in the examined herd occur, where the variant C which a high similarity to an Australian BLV provirus isolates showed, occurred most frequently at 92.5%.

Intrapartum rupture of the gravid uterus.

Full text is available as a scanned copy of the original print version.

Emergency peripartum hysterectomy.

A total of 54 166 mothers delivered at the Riyadh Armed Forces Hospital between 1990 and 1997, including 6119 (11.3%) caesarean sections. Emergency peripartum hysterectomy for obstetric haemorrhage was carried out in 16 cases (0.3/1000 deliveries). The operation followed major degrees of placenta praevia in 12 (75%) cases and atonic postpartum haemorrhage in four (25%). All patients required blood transfusion. There was one neonatal death and no maternal deaths. Although the operation was straightforward, bladder injury occurred in five (31%) cases which was repaired with no residual damage. Placenta accreta was confirmed histologically in 12 (75%) patients. In conclusion, all obstetricians should be aware of the strong association between a scarred uterus, placenta praevia and placenta accreta which can be very adherent and difficult to remove causing bleeding and necessitating hysterectomy. The operation should be performed by an experienced obstetrician before the patient's condition is extreme.

Epidemiology of multiple sclerosis in Arabs in Jordan: a comparative study between Jordanians and Palestinians.

In a 2-year hospital-based study in Jordan 131 Arab multiple sclerosis patients were identified including 84 Palestinians and 36 Jordanians. Based on MS/ALS case ratio, multiple sclerosis was found to be twice as common among Palestinians than Jordanians. Other than the less marked female preponderance among Jordanian patients, the disease had the same clinical and paraclinical characteristics in both groups. It was more likely for Palestinian and Jordanian patients to originate from the northern parts of their countries, to be Rh negative and to be HLA-DR2 positive than their controls. Palestinians (patients and controls) did not show significant differences from Jordanians (patients and controls) in relation to their eye color, ABO and Rh blood groups distribution nor the HLA-DR or HLA-DQ (apart from HLA-DQ3) epitopes frequency, thus not offering any significant difference in the genetic-racial markers studies to explain the difference in the observed disease susceptibility. Previous studies demonstrated that 2 racially different populations sharing the same environment can have different risk of developing multiple sclerosis, but this study has shown that this can also be true for 2 racially similar populations sharing the same environment.

Multiple sclerosis in Arabs in Jordan.

In a 2-year hospital-based study (1992 and 1993), there were 131 multiple sclerosis patients attending 2 large referral hospitals in Jordan. Based on MS/ALS case ratios an overall rate of 32.1 (95% CI 19.7-55.2) was estimated. There were 126 Arabs of whom 84 were Palestinians and 36 indigenous Jordanians. Comparison of these subgroups, which had a similar age distribution revealed that the disease was twice as frequent in Palestinians (estimated 42.0/100,000 (CI 2.8-90.8)) among Jordanians (estimated 20.0/100,000 (CI 9.5-47.2)). Clinical presentation, pattern of disease, disability and HLA association were similar to that in the disease reported in Caucasians in the West. All investigations including neurophysiology and imaging were also very similar to Western reports.