Carbapenem Resistance in Gram-Negative Bacteria: A Hospital-Based Study in Egypt.

Background and Objectives: The global spread of carbapenem resistance and the resulting increase in mortality forced the World Health Organization (WHO) to claim carbapenem-resistant enterobacteriaceae (CRE) as global priority pathogens. Our study aimed to determine the prevalence of carbapenemase-encoding genes and major plasmid incompatibility groups among Gram-negative hospital-based isolates in Egypt. Material and Methods: This cross-sectional study was carried out at Mansoura University Hospitals over 12 months, from January to December 2019. All the isolates were tested for carbapenem resistance. The selected isolates were screened by conventional polymerase chain reaction (PCR) for the presence of carbapenemase genes, namely blaKPC, blaIMP, blaVIM, and blaNDM-1. PCR-based plasmid replicon typing was performed using the commercial PBRT kit. Results: Out of 150 isolates, only 30 (20.0%) demonstrated carbapenem resistance. Klebsiella pneumoniae was the most resistant of all isolated bacteria, and blaNDM was the predominant carbapenemases gene, while the most prevalent plasmid replicons were the F replicon combination (FIA, FIB, and FII) and A/C. Plasmids were detected only in Klebsiella pneumoniae, Escherichia coli, Enterobacter cloacae, and Pseudomonas aeruginosa. Remarkably, we found a statistically significant association between carbapenemase genes and plasmid replicons, including blaNDM, IncA/C, and IncX. Conclusions: Our study demonstrated an alarming rise of plasmid-mediated carbapenem-resistant bacteria in our locality. The coexistence of resistance genes and plasmids highlights the importance of a targeted antibiotic surveillance program and the development of alternative therapeutic options at the local and international levels. Based on our results, we suggest a large-scale study with more Enterobacteriaceae isolates, testing other carbapenemase-encoding genes, and comparing the replicon typing method with other plasmid detection methods. We also recommend a national action plan to control the irrational use of antibiotics in Egypt.

Susceptibility tests of oropharyngeal Candida albicans from egyptian patients to fluconazole determined by three methods.

Candida albicans frequently cause oropharyngeal candidiasis in immunocompromised patients. As some of these isolates show resistance against azoles, the clinician is wary of initiating therapy with fluconazole (FZ) until a final susceptibility report is generated. We aimed to evaluate the efficacy of rapid flow cytometry (FCM) and disc diffusion (DD) methods in comparison to reference microdilution (MD) of Clinical and Laboratory Standards Institute (CLSI) method for FZ. Thirty seven Candida albicans isolates were tested by the three methods. By both MD and FCM, 26/37 (70.3%) were sensitive with minimal inhibitory concentration (MIC) ≤ 8µg/ml, 5/37 (13.5%) were susceptible dose dependant (S-DD) with MIC 16-32 µg/ml and 6/37 (16.2%) were resistant with MIC ≥64µg/ml. More than 92% of isolates susceptible to FZ by the MD were susceptible by the DD methods with good agreement (81.08%, P = 0.000). However, 4/5 isolates diagnosed as S-DD by MD were resistant by DD. Interestingly, the MIC by FCM at 4 h showed excellent agreement (95.59%, P = 0.000) to that obtained by MD method at 24 h. Overall, FCM antifungal susceptibility testing provided rapid, reproducible results that are valuable alternative to MD. The DD test is recommended as a simple and reliable screening test for the detection of susceptible Candida albicans isolates to FZ.

Adherence and Effectiveness of HBV Vaccination among Healthcare Workers in Egypt.

CONTEXT: Healthcare workers (HCWs) face a potential risk of acquiring different bloodborne pathogens, by occupational exposure to contaminated blood and body fluids. Hepatitis B vaccine is a safe, effective method of conferring long-term protection against HBV infection. AIMS: The study aimed to assess the adherence and effectiveness of HBV vaccination among HCWs at Gastrointestinal Surgical Center, Mansoura University, Egypt. SETTINGS AND DESIGN: A prospective descriptive study was carried out between June 2019 and December 2019 at Gastrointestinal Surgical Center, Mansoura University, Egypt. METHODS AND MATERIAL: All HCWs with anti-HBs levels below 10 mIU/mL were advised to receive 3 doses of recombinant HBV vaccine, at 0, 1, and 6 months. The anti-HBs levels were checked 3 months after the third dose of the HBV vaccine. STATISTICAL ANALYSIS USED: Data was analyzed using the Statistical Package of Social Science (SPSS) program for windows (version 16). RESULTS: A total of 442 healthcare providers were included. Most of them completed the 3 doses of the vaccine (81.7%), 10.2% refused the vaccine, while 0.9% and 7.2% received 1 and 2 doses, respectively. Odds of vaccination were the highest (88.1%, 273/310) among nurses (OR, 4.7; 95% CI, 2.6-5.2; P ≤ 0.001). The overall anti-HBs positivity of 97% (350/361) was observed. The main reasons for not being vaccinated included the fear of vaccine side effects 25/81 (30.9%) and lack of trust in the vaccine effectiveness 18/81 (22.2%). CONCLUSIONS: The outcome of the present study emphasizes the need to apply alternative and innovative measures to build a positive attitude toward the HBV vaccine among HCWs.

Extensive drug resistant Acinetobacter baumannii: a comparative study between non-colistin based combinations.

Background The Gastrointestinal Surgery Center (GISC)-Mansoura University, faced a series of extensive drug resistant (XDR) A. baumannii cases, that were microbiologically resistant to penicillins, cephalosporins, fluoroquinolones, aminoglycosides, carbapenems and tigecycline. Colistin would have been a last resort therapy in such situation, however, intravenous polymyxins E (colistin) is relatively unavailable in Egypt. Many practitioners tried to form antibiotic combinations from the available antibiotics to overcome the resistance mechanisms of the pathogen. Objective Evaluate the clinical outcomes of these combinations retrospectively. Setting The study took place at the GISC, which is an academic specialized center affiliated with Mansoura University-Egypt. Method Clinical data were collected from the patients' files, where the subjects were classified into two major groups according to the therapeutic intervention. Group 1 included 24 patients divided into 4 subgroups. The first was treated by a Cephalosporin with a Fluoroquinolone (1A), The second was treated by a Carbapenem with a Fluoroquinolone (1B), The third was treated by a B-lactam with an Aminoglycoside (1C) and the fourth was treated by Carbapenem with a Glycylcycline (1D). Group 2 included 6 patients, treated with Tigecycline and Ampicillin-Sulbactam. Main outcome measure Primary outcomes are the A. baumannii microbiological culture negativity after 14 days of therapy and the 30 days' survival after the antibiotic course, while the secondary outcomes are the expected therapies' side effects. Results Group 2 is associated with significant higher primary outcomes without a significant difference regarding the secondary outcomes. Conclusion The combination of Tigecycline and Ampicillin-Sulbactam, appears to be a clinically effective therapy against XDR A. baumannii, despite each agent being resistant alone, without alerting adverse effects.

An overview of healthcare-associated infections in a tertiary care hospital in Egypt.

BACKGROUND: Healthcare-associated infection (HAI) is a major problem in healthcare facilities and is associated with increased morbidity and mortality and prolonged hospital stay. This study aims to determine the incidence rate, risk factors, and bacterial aetiology of HAI in a tertiary care hospital in Mansoura, Egypt. METHODS: This is a prospective observational study carried out over 12 months in different departments of Mansoura New General Hospital (MNGH). Data were collected from patient's records and laboratory results of the ongoing HAI surveillance program. RESULTS: The incidence of HAI was 3.7% among 6912 patients studied. The independent predictors of HAI were multiple devices (AOR=88.1), central venous catheter (CVC) (AOR=34), urinary catheter (AOR=28.9) and length of stay >20 days (AOR=3.1). Surgical site infections (SSI) were the most frequent (24%) followed by catheter associated urinary tract infections (CAUTI) (20%). The most frequently isolated pathogens were Klebsiella spp. (27.2%), and E. coli (18%). CONCLUSIONS: HAI is a significant problem in MNGH. Klebsiella spp. were the predominant causative organisms of HAI, as has been described in other studies from developing countries.

Genotypic detection of rifampicin and isoniazid resistant Mycobacterium tuberculosis strains by DNA sequencing: a randomized trial.

BACKGROUND: Tuberculosis is a growing international health concern. It is the biggest killer among the infectious diseases in the world today. Early detection of drug resistance allows starting of an appropriate treatment. Resistance to drugs is due to particular genomic mutations in specific genes of Mycobacterium tuberculosis(MTB). The aim of this study was to identify the presence of Isoniazid (INH) and Rifampicin(RIF) drug resistance in new and previously treated tuberculosis (TB) cases using DNA sequencing. METHODS: This study was carried out on 153 tuberculous patients with positive Bactec 460 culture for acid fast bacilli. RESULTS: Of the 153 patients, 105 (68.6%) were new cases and 48 (31.4%) were previously treated cases. Drug susceptibility testing on Bactec revealed 50 resistant cases for one or more of the first line antituberculous. Genotypic analysis was done only for rifampicin resistant specimens (23 cases) and INH resistant specimens (26 cases) to detect mutations responsible for drug resistance by PCR amplification of rpoB gene for rifampicin resistant cases and KatG gene for isoniazid resistant cases. Finally, DNA sequencing was done for detection of mutation within rpoB and KatG genes. Genotypic analysis of RIF resistant cases revealed that 20/23 cases (86.9%) of RIF resistance were having rpoB gene mutation versus 3 cases (13.1%) having no mutation with a high statistical significant difference between them (P < 0.001). Direct sequencing of Kat G gene revealed point mutation in 24/26 (92.3%) and the remaining 2/26 (7.7%) had wild type KatG i.e. no evidence of mutation with a high statistical significant difference between them (P < 0.001). CONCLUSION: We can conclude that rifampicin resistance could be used as a useful surrogate marker for estimation of multidrug resistance. In addition, Genotypic method was superior to that of the traditional phenotypic method which is time-consuming taking several weeks or longer.

TNF-α gene polymorphisms and expression.

Tumor necrosis factor alpha (TNF-α) is a proinflammatory cytokine with an important role in the pathogenesis of several diseases. Its encoding gene is located in the short arm of chromosome 6 in the major histocompatibility complex class III region. Most of the TNF-α gene polymorphisms are located in its promoter region and they are thought to affect the susceptibility and/or severity of different human diseases. This review summarizes the data related to the association between TNF-α gene and its receptor polymorphisms, and the development of autoimmune diseases. Among these polymorphisms the -308G/A TNF-α promotor polymorphism has been associated several times with the the development of autoimmune diseases, however some discrepant results have been recorded. The other TNF-α gene polymorphisms had little or no association with autoimmune diseases. Current results about the molecules controlling TNF-α expression are also presented. The discrepancy between different records could be related partly to either the differences in the ethnic origin or number of the studied individuals, or the abundance and activation of other molecules that interact with the TNF-α promotor region or other elements.

A study of the treatment of cutaneous fungal infection in animal model using photoactivated composite of methylene blue and gold nanoparticle.

BACKGROUND: Onychomycosis is a widespread public health problem, in which T. rubrum and T. mentagrophytes is the commenest causative organisms. Current medical therapy has many drawbacks and side effects. Methylene blue (m.b) photodynamic therapy (pdt) proved efficacy but with lengthy sessions. OBJECTIVES: Optimizing methylene blue photodynamic therapy by combination of methylene blue photosensitizer and gold nanoparticles (aunps) in a composite as gold nanoparticles are efficient delivery systems and efficient enhancers of photosensitizers for antifungal photodynamic therapy. MATERIALS AND METHODS: Eighty newzealand rabbit (Oryctolagus cuniculus) were used and categorized in eight equal groups as follows; healthy and infection control, composite photodynamic therapy and five comparative groups. Photodynamic therapy was initiated at day three to five post inoculation, for four sessions forty eight hours apart. Each group divided and light exposure at two fluencies; 80J and 100J. All groups were investigated macroscopically and microscopically (histopathology and scanning electron microscope) also flowcytometry assessment for cell death and X-ray analysis for gold nanoparticles accumulation in brain and liver tissues were determined. RESULTS: Recovery from infection approaching 96% in gold nanoparticles+light group, around 40% in methylene blue photodynamic therapy and 34% in composite photodynamic therapy. The observed findings confirmed by apparent decrease of apoptosis, however small amounts of gold nanoparticles detected in brain and liver. CONCLUSION: Light stimulated gold nanoparticles is a promising tool in treatment of onychomycosis.

Does the serum testosterone level have a relation to coronary artery disease in elderly men?

Background. The low serum level of testosterone in the elderly subjects may contribute to coronary artery disease (CAD). Our aim is to study serum levels of free testosterone in elderly men with CAD. Subjects and Methods. This study was conducted on 100 elderly males with CAD, one half of them was presented with ACS (with mean age 69.6 ± 2.44 year), and the other half was presented with stable CAD (with mean age 69.42 ± 2.14 year), in addition to 50 apparently healthy elderly males (with mean age 69.06 ± 1.64 year) as a control group. We detected the levels of serum free testosterone, cortisol, fibrinogen, plasminogen activator inhibitor-1(PAI-1), high sensitive C-reactive protein(hsCRP), interleukin-6(IL-6). Results. Cases with CAD had significant lower values of free testosterone and HDL-c, but they had significant higher values of cortisol, fibrinogen, PAI-1, IL-6, hsCRP, in comparison to control group. Cases with ACS had significant higher values of cortisol, hsCRP, IL-6, fibrinogen, PAI-1, total cholesterol and BMI more than those with stable CAD. The free testosterone had significant negative correlation with fibrinogen, PAI-1, hsCRP and IL-6 in both groups of patients. Conclusion. The lower value of serum free testosterone in elderly male subjects may contribute to CAD.

Relation of Cag-A-positive Helicobacter pylori strain and some inflammatory markers in patients with ischemic heart diseases.

Recently, a potential link between infectious agents and athero-sclerosis has been suggested. H. pylori strains bearing the cytotoxin associated gene A (Cag-A) provoked a heightened inflammatory response in vivo and showed stronger relation to gastric complication of this infection. The association between Cag-A positive strain and vascular diseases producing conflicting results. So, the present study aimed to estimate the seroprevalence of H. pylori Cag-A positive strains as a risk factor among different groups of ischemic heart disease and to study its interaction with high sensitivity CRP (hs-CRP) and IL6 as inflammatory host responses. The present study was conducted on anti H. pylori IgG positive 60 ischemic heart disease (IHD) patients and 20 apparently healthy individuals as a control group. IHD patients were classified into 3 groups: (group I) with acute myocardial infarction, unstable angina pectoris patients (group II), chronic stable angina pectoris patients (group III). For all patients and control groups serum anti Cag-A IgG, IL6, hs-CRP, CK, CKMB, LDH, AST and Lipid profile were estimated. IL6 and hs-CRP levels were increased in groups I, II and III as compared with group IV (P < 0.001) with positive correlation between IL6 and hs-CRP in groups I, II and III (P < 0.05). The percentage of anti Cag-A positive cases was similar among the patient groups, but significantly higher than in the control group. Thus, infection with Cag-A positive H. pylori strain may play a role as a risk factor in development of ischemic heart diseases through provocation of high inflammatory response or through other mechanism. Therefore eradication of this infection is important as it is much less expensive than long term treatment of the other risk factors.

IL-18 level correlates with development of sepsis in surgical patients.

Interleukin 18 may play an important role in sepsis. We measured circulating IL-18 levels in 47 patients with surgical wounds, 27 of them had clinical and laboratory evidences of sepsis. The patients had significantly higher IL-18 levels than healthy control (p1 = 0.001), patients with local infection (p4 = 0.001) and patients with clean surgical wound (p5 = 0.001) both at admission and after 48 hours. Serial observations revealed that in all patients, IL-18 levels increased significantly especially in patients with sepsis after 48 h (p = 0.007). IL-18 levels appeared to correlate significantly with leucocytes counts (p = 0.001) and with C-RP (p = 0.007). These results suggest that IL-18 levels are increased in patients with sepsis and correlate with CRP and leukocyte counts suggesting that IL-18 may play a role in sepsis. We suggest that IL-18 could be used as a collaborative evidence of surgical sepsis.

Susceptibility tests of oropharyngeal Candida albicans from Egyptian patients to fluconazole determined by three methods

Candida albicans frequently cause oropharyngeal candidiasis in immunocompromised patients. As some of these isolates show resistance against azoles, the clinician is wary of initiating therapy with fluconazole (FZ) until a final susceptibility report is generated. We aimed to evaluate the efficacy of rapid flow cytometry (FCM) and disc diffusion (DD) methods in comparison to reference microdilution (MD) of Clinical and Laboratory Standards Institute (CLSI) method for FZ. Thirty seven Candida albicans isolates were tested by the three methods. By both MD and FCM, 26/37 (70.3%) were sensitive with minimal inhibitory concentration (MIC) ¡Ü 8¦Ìg/ml, 5/37 (13.5%) were susceptible dose dependant (S-DD) with MIC 16-32 ¦Ìg/ml and 6/37 (16.2%) were resistant with MIC ¡Ý64¦Ìg/ml. More than 92% of isolates susceptible to FZ by the MD were susceptible by the DD methods with good agreement (81.08%, P = 0.000). However, 4/5 isolates diagnosed as S-DD by MD were resistant by DD. Interestingly, the MIC by FCM at 4 h showed excellent agreement (95.59%, P = 0.000) to that obtained by MD method at 24 h. Overall, FCM antifungal susceptibility testing provided rapid, reproducible results that are valuable alternative to MD. The DD test is recommended as a simple and reliable screening test for the detection of susceptible Candida albicans isolates to FZ.

Prevalence of low positive anti-HCV antibodies in blood donors: Schistosoma mansoni co-infection and possible role of autoantibodies.

Patients infected with schistosoma frequently show a high seroprevalence of anti-hepatitis C virus (anti-HCV) antibodies. The aim of this study was to find the underlying reason for this phenomenon, and to examine a possible involvement of autoantibodies. Out of 2,400 Egyptian blood donors, 192 (8%) were anti-HCV positive by ELISA. They were 133 males and 59 females with age ranging from 27 to 48 years. According to optical density ratio (ODR) of anti-HCV antibodies, 96 cases were low positive (LP) with ODR (1-2) designated as group I, and 96 were high positive (HP) with ODR (> or =2) (group II). Both groups were examined for quantitative HCV core antigen (HCVcAg), liver function (Albumin, ALT, AST) and anti-Schistosoma mansoni(anti-Sm) IgG. Group I cases were HCVcAg negative with normal liver function tests, and 44 of them were anti-Sm positive. Ninety cases (93.75%) of group II were HCVcAg positive with markedly affected liver function tests and 72 cases were anti-Sm positive. All group I cases were examined for autoimmune markers (ANA, AMA, SMA and LKM). In group I, 33 (75%) of anti-Sm positive cases were positive for one or more of the autoimmune markers examined, while none of anti-Sm negative was positive for any marker with significant difference between the two groups (P < 0.0001). Our results primarily on blood donors indicate that LP anti-HCV frequently represents false-positive reactivity with a possible role of Sm-induced autoantibodies in this phenomenon.

The Bcl-2 and TGF-beta1 levels in patients with chronic hepatitis C, liver cirrhosis and hepatocellular carcinoma.

Relatively little is known about the biochemical mechanisms controlling proliferation and neoplastic transformation of Hepatocellular carcinoma (HCC). The aim of study was to determine the level of the oncoproteins Bcl-2, transforming growth factor-beta1 (TGF-beta1) and alpha fetoprotein (AFP) in serum of patients with chronic hepatitis C (CHC), and liver cirrhosis (LC) as compared to HCC as a biomarkers of malignant transformation and early detection of suspected patients. A total of forty-three patients were included, 30 of them were males and 13 females, their ages ranged from 29-66 years (49.37 +/- 8.35). Increased levels of Bcl-2 were found in liver cirrhosis and HCC groups as compared to CHC and control groups (P < 0.001). The level of Bcl-2 was higher in CHC than control but the difference was insignificant (P > 0.05). Serum TGF-beta1 was significantly increased in CHC and liver cirrhosis groups as compared to HCC and control groups (p < 0.001). However, there was no significant difference between TGF-beta1 in HCC and control group (P > 0.05). The AFP level was significantly increased in HCC than CHC and liver cirrhosis. No significant difference was detected in AFP between CHC and LC patients (P > 0.05) or between CHC and healthy control (P > 0.05). A positive correlation was found between Bcl-2, and AFP in LC and HCC groups. It is concluded that the increased level of Bcl-2 in HCC may be involved in hepatocacingenesis. TGF-beta1 may be the primary marker to start the process of carcinogenesis, however, low level of TGF-beta1 may be needed to the progress of malignancy.