Impact of an antimicrobial stewardship programme on reducing broad-spectrum antibiotic use and its effect on carbapenem-resistant Acinetobacter baumannii (CRAb) in hospitals in Jordan.

OBJECTIVES: To evaluate the impact of an antimicrobial stewardship programme (ASP) on reducing broad-spectrum antibiotic use and its effect on carbapenem-resistant Acinetobacter baumannii (CRAb) in hospitalized patients. METHODS: The study was a retrospective, ecological assessment in a tertiary teaching hospital over 6 years (January 2014 to December 2019). The intervention involved the implementation of an ASP in February 2018, which remains in effect today. This ASP consists of several components, including education, antibiotic guidelines, antibiotic restriction policy with prior approval, audit of compliance to the restriction policy and feedback. Restricted antibiotics were imipenem/cilastatin, ertapenem, meropenem, vancomycin, teicoplanin, tigecycline, colistin, amikacin, piperacillin/tazobactam, levofloxacin and ciprofloxacin. The intervention was evaluated by time-series methods. RESULTS: Statistically significant decreases in the level of antibiotic use, after the introduction of the ASP, were observed for the following antibiotics: imipenem/cilastatin (P = 0.0008), all carbapenems (P = 0.0001), vancomycin (P = 0.0006), colistin (P = 0.0016) and third-generation cephalosporins (P = 0.0004). A statistically significant decrease in the slope, after the introduction of the ASP, for ertapenem (P = 0.0044) and ciprofloxacin (P = 0.0117) was observed. For piperacillin/tazobactam, there was a significant increasing trend (P = 0.0208) before the introduction of the ASP. However, this increased trend was halted post-introduction of the ASP (P = 0.4574). The introduction of the ASP was associated with a significant impact on reducing the levels of CRAb (P = 0.0237). CONCLUSIONS: The introduced antimicrobial stewardship interventions contributed to a reduction in the use of several broad-spectrum antibiotics, reversed the trends of increasing use of other antibiotics and were associated with a significant reduction in CRAb.

Identification of thresholds in relationships between specific antibiotic use and carbapenem-resistant Acinetobacter baumannii (CRAb) incidence rates in hospitalized patients in Jordan.

BACKGROUND: Antibiotic resistance is a major threat to public health worldwide. The relationship between the intensity of antibiotic use and resistance might not be linear, suggesting that there might be a threshold of antibiotic use, beyond which resistance would be triggered. OBJECTIVES: To identify thresholds in antibiotic use, below which specific antibiotic classes have no significant measurable impact on the incidence of carbapenem-resistant Acinetobacter baumannii (CRAb), but above which their use correlates with an increase in the incidence of CRAb. METHODS: The study took place at a tertiary teaching hospital in Jordan. The study was ecological in nature and was carried out retrospectively over the period January 2014 to December 2019. The outcome time series for this study was CRAb cases. The primary explanatory variables were monthly use of antibiotics and the use of alcohol-based hand rub (ABHR). Non-linear time-series methods were used to identify thresholds in antibiotic use. RESULTS: Non-linear time-series analysis determined a threshold in third-generation cephalosporin and carbapenem use, where the maximum use of third-generation cephalosporins and carbapenems should not exceed 8 DDD/100 occupied bed days (OBD) and 10 DDD/100 OBD, respectively. ABHR had a significant reducing effect on CRAb cases even at lower usage quantities (0.92 L/100 OBD) and had the most significant effect when ABHR exceeded 3.4 L/100 OBD. CONCLUSIONS: The identification of thresholds, utilizing non-linear time-series methods, can provide a valuable tool to inform hospital antibiotic policies through identifying quantitative targets that balance access to effective therapies with control of resistance. Further studies are needed to validate the identified thresholds, through being prospectively adopted as a target for antimicrobial stewardship programmes, and then to evaluate the impact on reducing CRAb incidence.

Correction to: Public health impact and cost effectiveness of routine childhood vaccination for hepatitis a in Jordan: a dynamic model approach.

Following publication of the original article1, the authors noted the following.

Clinical patterns, epidemiology and risk factors of community-acquired urinary tract infection caused by extended-spectrum beta-lactamase producers: a prospective hospital case-control study.

PURPOSE: To assess incidence rate, risk factors and susceptibility patterns associated with extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli or Klebsiella pneumoniae in community-acquired urinary tract infections (CA-UTIs). METHODS: A prospective, case-control study was conducted at a tertiary teaching hospital from Jan 2015 to Dec 2016. The results of microbiology cultures were initially screened to include only patients with positive E. coli or K. pneumoniae urine cultures. Afterwards, clinical symptoms were assessed to confirm the UTI. To investigate the risk factors, patients with a positive urine culture for ESBL-producing isolates were assigned as cases, while patients with non-ESBL were assigned as controls. RESULTS: Out of 591 patients included in this study, 57.5% (n = 340) were included in the control group and 42.5% (n = 251) were in the case group. The incidence rate of ESBL-producing isolates was 3.465 cases per 1000-patient hospital admissions. Male gender (OR = 1.856, 95% CI = 1.192-2.889, p = 0.006), pediatrics (OR = 1.676, 95% CI = 1.117-2.517, p = 0.013), patients with comorbidity (OR = 1.542, 95% CI = 1.029-2.312, p = 0.036) and UTI in the previous 12 months (OR = 1.705, 95% CI = 1.106-2.628, p = 0.016) were independently associated with a higher risk of infection. The resistance rate for most commonly prescribed antibiotics was high. CONCLUSIONS: Our results suggest that the incidence of ESBL producers among CA-UTIs is high. Male gender, pediatrics, comorbidity and UTI in the previous 12 months were associated with a higher risk for infection. Continuous surveillance and prudent antibiotic use by healthcare professionals are important factors for effective control of ESBL associated infections.

Public health impact and cost effectiveness of routine childhood vaccination for hepatitis a in Jordan: a dynamic model approach.

BACKGROUND: As the socioeconomic conditions in Jordan have improved over recent decades the disease and economic burden of Hepatitis A has increased. The purpose of this study is to assess the potential health and economic impact of a two-dose hepatitis A vaccine program covering one-year old children in Jordan. METHODS: We adapted an age-structured population model of hepatitis A transmission dynamics to project the epidemiologic and economic impact of vaccinating one-year old children for 50 years in Jordan. The epidemiologic model was calibrated using local data on hepatitis A in Jordan. These data included seroprevalence and incidence data from the Jordan Ministry of Health as well as hospitalization data from King Abdullah University Hospital in Irbid, Jordan. We assumed 90% of all children would be vaccinated with the two-dose regimen by two years of age. The economic evaluation adopted a societal perspective and measured benefits using the quality-adjusted life-year (QALY). RESULTS: The modeled vaccination program reduced the incidence of hepatitis A in Jordan by 99%, 50 years after its introduction. The model projected 4.26 million avoided hepatitis A infections, 1.42 million outpatient visits, 22,475 hospitalizations, 508 fulminant cases, 95 liver transplants, and 76 deaths over a 50 year time horizon. In addition, we found, over a 50 year time horizon, the vaccination program would gain 37,502 QALYs and save over $42.6 million in total costs. The vaccination program became cost-saving within 6 years of its introduction and was highly cost-effective during the first 5 years. CONCLUSION: A vaccination program covering one-year old children is projected to be a cost-saving intervention that will significantly reduce the public health and economic burden of hepatitis A in Jordan.

Hepatitis A virus age-specific sero-prevalence and risk factors among Jordanian children.

Hepatitis A Virus (HAV) has been a significant cause of infections among the children and adolescents of Jordan. Availability of safe vaccines made it necessary to identify the ill-defined temporal immunity trends for HAV and possible age-specific prevalence transitions. This community-based cross sectional study was conducted during the period July-August 2008 on 3,066 recruited subjects from the 12 governorates of Jordan, with pre-defined criteria. Several households were chosen at random within each selected block to enroll the subjects. They were interviewed and data were collected. Their sera were tested for total antibodies against HAV. A multivariate model was then performed to identify the possible risk factors. The HAV sero-prevalence rates among the age categories-second year, 2-4 years, 5-9 years, 10-14 years, 15-19 years, and those above 20 years were 26%, 32%, 44%, 63%, 78%, and 94%, respectively. The model revealed the association of several risk factors for higher HAV sero-prevalence rates: (i) older age groups; (ii) lower maternal education levels; (iii) residing in certain governorates; (iv) using public net drinking water; and (v) avoiding use of public net sewage system. This study provided strong evidence for continuous transition of HAV epidemiology towards intermediate endemicity in Jordan, with more susceptible adolescents and adults. Following the World Health Organization (WHO) recommendations for countries with intermediate endemicity, large-scale hepatitis A vaccination is recommended for children in Jordan. This is strengthened by the availability of effective and safe HAV vaccines, improving the socio-economic status of the Jordanians, and increasing life expectancy among Jordanians.

Utilization of multidisciplinary surgical techniques to successfully manage 20 brain abscesses in a child.

PURPOSE: This study describes a case of multiple brain abscesses in a four-year-old boy who presented with a history of fever and disorientation. METHODS: Medical investigations revealed severe leukocytosis and the presence of 20 hypodense lesions in the boy's cerebrum. Initial medical treatment included intravenous antibiotics, antiepileptics, and dexamethasone. The boy underwent five surgical interventions within a period of 5 weeks that included frameless stereotactic craniotomies for aspiration and resection of the abscesses. RESULTS: At the 3-month follow-up, the boy displayed no neurological deficits and no lesions were detected in his brain. CONCLUSIONS: This study reveals the importance of instituting a standardized protocol to determine the urgency of surgical intervention in cases of brain abscess so that surgical treatment can be applied in the appropriate time period. This case also shows that rewarding results can be obtained in treating brain abscesses in children when the proper treatment method is initiated in the appropriate amount of time.

Disseminated Histoplasmosis Presenting as Obstructive Jaundice.

Gastrointestinal manifestations in systemic fungal infection are not uncommon; however, obstructive jaundice due to lymphadenopathy is considered rare. We present a case of a 16-year-old male patient who presented with painless jaundice. Laboratory tests revealed direct hyperbilirubinemia with cholestatic liver injury. Chest and abdominal computed tomography showed mediastinal and porta hepatis lymphadenopathy, with severe biliary ductal dilatation proximal to an obstructing lymph node near the head of the pancreas. Endoscopic ultrasound showed a 22 × 35-mm lymph node with a mass effect on the common bile duct leading to obstructive jaundice. Infectious workup confirmed the diagnosis of disseminated histoplasmosis.

Prevalence of Extended-Spectrum ß-Lactamases in Multidrug-Resistant Klebsiella pneumoniae Isolates in Jordanian Hospitals.

The increase in the prevalence of infections caused by certain bacteria, such as Klebsiella pneumonia (K. pneumoniae), is a global health concern. Bacterial production of an enzyme called extended-spectrum beta-lactamase (ESBL) can generate resistance to antimicrobial therapeutics. Therefore, between 2012 and 2013, we investigated K. pneumoniae that produce ESBLs with the prevalence of individual genes including blaSHV, blaCTX-M, blaTEM, and blaOXA isolated from clinical samples. A total of 99 variable diagnostic samples including blood from hematological malignancies (n = 14) or other clinical sources including sputum, pus, urine, and wound (n = 85) were analyzed. All samples' bacterial type was confirmed and their susceptibility to antimicrobial agents was established. Polymerase chain reaction (PCR) amplification was carried out to ascertain presence of specific genes that included blaSHV, blaCTX-M, blaTEM, and blaOXA. Plasmid DNA profiles were determined to assess significance between resistance to antimicrobial agents and plasmid number. It was found that among non-hematologic malignancy isolates, the highest rate of resistance was 87.9% to imipenem, with lowest rate being 2% to ampicillin. However, in hematologic malignancy isolates, the highest microbial resistance was 92.9% to ampicillin with the lowest rate of resistance at 28.6% to imipenem. Among collected isolates, 45% were ESBL-producers with 50% occurrence in hematologic malignancy individuals that were ESBL-producers. Within ESBL-producing isolates from hematologic malignancy individuals, blaSHV was detected in 100%, blaCTX-M in 85.7%, and blaTEM and blaOXA-1 at 57.1% and 27.1%, respectively. In addition, blaSHV, blaCTX-M, and blaOXA were found in all non-hematological malignancy individuals with blaTEM detected in 55.5% of samples. Our findings indicate that ESBLs expressing blaSHV and blaCTX-M genes are significantly prevalent in K. pneumoniae isolates from hematologic malignancy individuals. Plasmid analysis indicated plasmids in isolates collected from hematological malignancy individuals. Furthermore, there was a correlation between resistance to antimicrobial agents and plasmids within two groups analyzed. This study indicates an increase in incidence of K. pneumoniae infections displaying ESBL phenotypes in Jordan.

Knowledge of health care workers regarding COVID-19 pandemic response plan; A study from a university affiliated hospital in Jordan.

BACKGROUND: The education and training of healthcare workers (HCWs) about pandemic response plans, infection control protocols (ICP), and precautions are critical for breaking the virus transmission chain. This study aimed to assess the knowledge of HCWs regarding the COVID-19 pandemic response plan and the ICP. Concomitantly, evaluating the effectiveness and impact of institutional measures, policies, and training programs. METHODS: A cross-sectional study using an electronic questionnaire was used to collect data from 267 HCWs at a University-affiliated-hospital during April 2020. RESULTS: In this study, 90.7% of participants were nurses and 66% were females. 60.3% of participants received specific training about caring for COVID-19 patients while at least 94.3% reviewed the pandemic response plan and ICP for COVID-19. 47.5% and 29.2% of participants provided direct care for suspected or confirmed COVID-19 patients, respectively. Between 85.7% and 100% of the participants answered all items correctly regarding the COVID-19 pandemic response plan, measures, and precautions. Furthermore, the correct answers were above 95% for each item. CONCLUSION: HCWs have a high level of knowledge about the COVID-19 pandemic response plan and ICP. Training and disseminating updated plans and protocols in different methods such as an intranet and onsite training in addition to regular methods were very effective.

Prevalence estimates of drug addiction among high-school students and its association with violence, and school behaviors: A cross-sectional study from Jordan.

INTRODUCTION: This study aims to estimate the prevalence of drug addiction among high-school students and its association with violence and school behavior. The present study provides baseline data focusing specifically on the extent of drug addiction and violence. METHODS: A cross-sectional study design was used. The questionnaire covered students' demographic profiles, including age, gender, and academic branch, and statements related to violent behaviors and school-related factors. A urine sample was collected from each participant to test for drugs and was analyzed by Multi-Drug Rapid Test Cup. RESULTS: Out of 440 students, a total of 414 were included in this study. Positive drug use via urine sample was confirmed in 70 students (16.9%), with 80% being males. Violent behaviors were common, including used to write on the walls (118, 28.5%), had problems with teachers (107, 25.9%) or peers (267, 64.5%), or using abusive language with school staff (63, 15.2%). There were no significant associations between drug addiction and these violent behaviors (p > 0.05). Students who had no respect for the teachers were significantly more in the addicted group (31.4%) than the non-addicted group (14%) (p = 0.004). CONCLUSION: High school should be identified as a critical period at risk for drug use and violent actions. This study points to the importance of early detection of drug addiction among vulnerable young people, enabling the development of educational programs to prevent abuse and dependence on substances.

A case-control study of risk factors for hepatitis B virus infection in North Jordan.

Jordan is a country with intermediate endemicity for hepatitis B virus (HBV) infection where risk factors for viral transmission and their relative contributions are not well known. A case-control study of 100 hepatitis B virus seropositive patients and another 100 seronegative controls was conducted. Univariate analysis and logistic regression model were performed to examine probable risk factors for acquisition of hepatitis B virus infections. Logistic-regression analysis showed that significant risk factors for acquisition of hepatitis B virus infection were sharing toothbrushes (odds ratio = 10.167; 95% confidence interval, 1.181-87.509), unhygienic dental care (odds ratio = 2.455; 95% confidence interval, 1.294-4.658), and living abroad for at least 1 year (odds ratio = 20.018; 95% confidence interval, 2.268-176.685). The presence of these risk factors emphasizes the need for both increasing the use of hepatitis B vaccines and risk-targeted public health education. Development and enforcement of appropriate infection control guidelines for dental care services are also necessary to curtail HBV transmission. Further research that controls for confounding factors is needed to assess the relative contribution of the identified risk factors in the Jordanian community.

Comparison of clinical associations and laboratory abnormalities in children with moderate and severe dehydration.

OBJECTIVES: To search for possible early clinical associations and laboratory abnormalities in children with severe dehydration in northern Jordan. PATIENTS AND METHODS: We prospectively evaluated 251 children with acute gastroenteritis. Dehydration assessment was done following a known clinical scheme. Probable clinical associations and laboratory abnormalities were examined against the preassigned dehydration status. RESULTS: Children with severe dehydration had significantly more hypernatremia and hyperkalemia, less isonatremia, and higher mean levels of urea, creatinine, and glucose (P < 0.005). Receiver operating characteristic curves showed statistically significant area under the curve values for laboratory variables. These area under the curve values were 0.991 (95% confidence interval [CI] 0.980-1.001) for serum urea, 0.862 (95% CI 0.746-0.978) for sodium, 0.850 (95% CI 0.751-0.949) for creatinine, 0.69 (95% CI 0.555-0.824) for potassium, and 0.684 (95% CI 0.574-0.795) for glucose (P < 0.05 for all). Certain independent serum cutoff levels of urea, creatinine, sodium, glucose, and potassium had high negative predictive value (100%), whereas other cutoff values for each, except potassium, had high positive predictive value (100%) for severe dehydration. Historic clinical characteristics of patients did not correlate to dehydration degree. CONCLUSIONS: Serum urea, creatinine, sodium, potassium, and glucose were useful independently in augmenting clinical examination to diagnose the degree of dehydration status among children presenting with gastroenteritis. Serum urea performed the best among all. On the contrary, none of the examined historical clinical patterns could be correlated to the dehydration status. Larger and multicenter studies are needed to validate our results and to examine their impact on final outcomes.

Multidisciplinary team management and cesarean delivery for a Jordanian woman infected with SARS-COV-2: A case report.

The SARS-COV-2 virus appears to have originated in Hubei Province in China towards the end of 2019 and has spread worldwide. Currently, there is little literature on COVID-19, and even less on its effect on pregnant mothers and infants. At this time, there are no clear recommendations specific to pregnant women with COVID-19. We report the multidisciplinary team management of a cesarean delivery for a woman infected with SARS-COV-2, including her pre-delivery care, intraoperative considerations, and post-delivery recommendations for the mother and baby. We also discuss the currently available recommendations and guidelines on the management of such cases.

COVID-19 outbreak in Jordan: Epidemiological features, clinical characteristics, and laboratory findings.

BACKGROUND: In March 2020, an outbreak of coronavirus 19 (COVID-19) was detected in the North of Jordan. This retrospective study is the first from Jordan to report the epidemiologic, clinical, laboratory, and radiologic characteristics of COVID-19 infected patients. METHODS: All patients with laboratory-confirmed COVID-19 infection by RT-PCR in the North of Jordan admitted between March 15 and April 2, 2020 were included. The clinical features, radiological, and laboratory findings were reviewed. RESULTS: Of 81 patients affected, 79 (97.5%) shared a common exposure to four recent travelers from endemic areas. The mean age was 40 years. Although about half (44 [54.3%]) were females, symptomatic patients were mostly females (75%). The most common presenting symptoms were nasal congestion, sore throat and dry cough. Less than one-third (31%) had chronic diseases. Although 84% of patients reported receiving Bacille Calmette-Guérin (BCG) vaccination, more asymptomatic patients had BCG than symptomatic (p = 0.017). Almost all patients (97.5%) had an elevated D-dimer level. Erythrocyte sedimentation rate (ESR) and c-reactive protein were elevated in 50% and 42.7% of patients, respectively. High ESR found to be the predictor of abnormal chest radiograph observed in 13 (16%) patients with OR of 14.26 (95% CI 1.37-147.97, p = 0.026). CONCLUSIONS: An outbreak of COVID-19 infection in northern Jordan affected more females and relatively young individuals and caused mainly mild illnesses. The strict outbreak response measures applied at early stages probably contributed to the lenient nature of this outbreak, but the contribution of other factors to such variability in COVID-19 presentation is yet to be explained.

Prevalence of positive COVID-19 among asymptomatic health care workers who care patients infected with the novel coronavirus: A retrospective study.

BACKGROUND: Limited information is available about COVID-19 infections among health care workers. Sensitive detection of COVID-19 cases in health care workers is crucial for hospital infection prevention policy, particularly for those who work with vulnerable patients. The aim of this study is to describe the prevalence of positive COVID-19 among asymptomatic health care workers who took care of patients with COVID-19 during the pandemic. METHODS: This retrospective study included all health care workers at King Abdullah University Hospital who take care of patients infected with COVID-19 patients from March 18, 2020 to April 29, 2020. They were tested for COVID-19 infection by use of real-time reverse-transcriptase rRT-PCR on samples from nasopharyngeal swabs. RESULTS: A total number of 370 health care workers were screened. The majority were nurses followed by physicians and other personnel. This study showed that all asymptomatic health care workers were tested negative for COVID-19Q. CONCLUSION: Unexpectedly, the prevalence of positive COVID-19 among asymptomatic health care workers who take care of patients infected with the novel coronavirus was 0%. This result must be cautiously interpreted. Further studies are needed in order to find effective strategy of screening health care workers to insure a safe working environment.

First report of clinical, functional, and molecular investigation of chronic granulomatous disease in nine Jordanian families.

INTRODUCTION: Chronic granulomatous disease is a rare inherited immunodeficiency syndrome caused by mutations in four genes encoding essential nicotinamide adenine dinucleotide phosphate (NADPH) oxidase complex components. MATERIAL AND METHODS: Clinical, functional, and molecular investigations were conducted in 15 Jordanian CGD patients from nine families. RESULTS AND DISCUSSION: Fourteen patients were children of consanguineous parents and suffered from autosomal recessive (AR) CGD forms with mutations in the CYBA, NCF1, and NCF2 genes encoding p22phox, p47phox, and p67phox proteins, except for one patient in whom the mutation's location was not found. One patient had an extremely rare X(+)CGD subtype resulting from a novel missense mutation (G1234C) in exon 10 of CYBB. We found a genetic heterogeneity in the Jordanian families with a high frequency of rare ARCGD, probably because consanguineous marriages are common in Jordan. No clear correlation between the severity of the clinical symptoms and the CGD types could be established.

Hepatitis B virus genotypes and lamivudine resistance mutations in Jordan.

AIM: To investigate and identify prevalent hepatitis B virus (HBV) genotypes and to explore lamivudine-resistant mutations among treated and untreated patients in Jordan. METHODS: A total of 107 cases with chronic hepatitis B were recruited from different medical centers in Jordan. Serological tests were preformed for all cases using a microparticle enzyme immunoassay. HBV Genotyping was performed for 70 cases using Line probe genotyping assay. The YMDD mutations were explored for 20 cases (4 were lamivudine naive) using the INNO-LiPA HBV DR assay. RESULTS: Genotype D was the only detected genotype. A total of 6 YMDD mutations were detected in 5 treated patients (31%) while one mutation was detected in the naive patients. Seventeen percent of cases were positive for HBeAg and had statistically significant higher levels of serum aminotransferases. CONCLUSION: HBV genotype D appears to be the only circulating type in Jordanian patients. The YMDD mutations were detected in 31% of lamivudine-treated cases with similar patterns to those found in the literature. We also found a relatively low prevalence of HBeAg expression among examined cases (17%). Awareness of these serologic, genotypic and resistance patterns might help in the formulation of management plans and for predicting clinical outcomes. Further larger scale studies are needed to confirm our results and to examine possible associations among clinical, serologic, and genetic patterns of HBV infections in Jordan.