Clinical and therapeutic features of brucellosis: An 11-year study at a tertiary care hospital in Riyadh, Saudi Arabia.

To study the varying presentations, risk factors, and treatment outcomes among patients with physician-diagnosed brucellosis. This retrospective analysis evaluated all cases of brucellosis reported at King Khalid University Hospital during 2003-2013. Data were retrieved from patient records and a laboratory information system. Descriptive statistics were generated to summarize the study variables. Fisher's exact test or Pearson's chi-square test was used to compare categorical variables. Out of 163 patients identified with brucellosis, 76.7% of patients were culture positive. Fever was the most frequent symptom (85.9%), followed by arthralgia (46.6%). The most common clinical signs was splenomegaly (12.9%), followed by hepatomegaly (11.0%). Laboratory investigations revealed lymphocytosis and anemia in 66.3% and 55.2% of the patients, respectively. Approximately half of the patients (47.8%) had high erythrocyte sedimentation rates, and 56.4% had neutrophilia. Raw milk consumption and direct contact with animals were reported by 45.4% and 16.0% of patients, respectively. Treatment failure and relapse were observed in 8 (5.7%) cases. All treatment failures and relapses occurred among children <= 10 years of age or adults > 45 years old (11.0% vs. 0%; p = 0.006). Our findings demonstrate that raw milk consumption can be a substantial factor in brucellosis prevention in Saudi Arabia. Laboratory findings, along with the observed pattern in clinical signs and symptoms, can potentially mean underdiagnosis of mild cases. Age was the only factor associated with unfavorable treatment outcomes.

Childhood brucellosis: a study of 102 cases.

One hundred two children, 45 days to 14 years of age, with proven brucellosis were studied to illustrate the epidemiologic, clinical and laboratory findings and to assess the outcome of antimicrobial therapy. The main source of infection was the consumption of raw milk in 80% of the patients. The predominant presenting symptoms and signs were fever, arthralgia, malaise, weight loss, arthritis, hepatosplenomegaly and lymphadenopathy. Brucella melitensis was isolated from 75% of 87 patients. Diverse hematologic and biochemical abnormalities were found. Different durations and combinations of trimethoprim-sulfamethoxazole or tetracycline plus streptomycin or rifampin were used for therapy. Eight-five patients were followed for an average of 14 months. Twelve (85.7%) of 14 patients treated with two-antibiotic combinations for 3 weeks relapsed, as did 5 (8%) of 62 patients treated for at least 6 weeks (P less than 0.001). No relapses occurred in 9 patients treated with trimethoprim-sulfamethoxazole and rifampin for 8 to 12 weeks plus streptomycin for the first 3 weeks. Longer duration and combination of antibiotic therapy seem warranted to improve outcome and to prevent relapses.

Antimicrobial susceptibility and serogroups of Salmonella isolates from Riyadh, Saudi Arabia.

The antimicrobial susceptibility and serogroups of 153 Salmonella strains isolated during a period of 22 months from both children and adults at a major teaching hospital in Riyadh, Saudi Arabia were studied. Antimicrobial susceptibility testing by comparative disc method and MIC determination by E-test method were performed on selected antimicrobial agents. For nalidixic acid and trimethoprim only the comparative disc method was used. Discrepancy between the two methods were noticed only in 1.3% of isolates. The majority of isolates from children (41%) were serogroup B, while those from adults (43%) were serogroup C1. The overall resistance was 16% to ampicillin and ampicillin/sulbactam, 13% to nalidixic acid, and 11% to chloramphenicol and trimethoprim/sulphamethoxazole. The resistance of Salmonella isolates to the so-called first line anti-Salmonella agents, i.e. ampicillin, chloramphenicol and trimethoprim/sulphamethoxazole, has increased compared to that reported 4 years ago from this Institution. Almost all isolates were susceptible to the second, and third generation cephalosporins, fluoroquinolones, aztreonam, mecillinam and gentamicin. Multiple drug resistance to two or more drugs was noticed in 16% of isolates, most of which were serogroup B. The majority of these multiple drug resistant isolates (96%) were ampicillin resistant and beta-lactamase producers. Although these isolates showed reduced MICs to ampicillin/sulbactam, their MICs were still higher than the susceptibility breakpoint for this combination. The nalidixic acid-resistant isolates showed higher MICs to the fluoroquinolones compared to the nalidixic acid-sensitive isolates. Isolates from children showed higher resistance to some of the antimicrobial agents compared to those from adults.

Penicillin-resistant Streptococcus pneumoniae in Riyadh, Saudi Arabia.

During a period of ten months, minimum inhibitory concentrations (MICs) to seven antimicrobial agents of 150 clinical isolates of Streptococcus pneumoniae were determined at a teaching hospital in Riyadh, Saudi Arabia. Twenty-two (14.7%) isolates showed relative resistance to penicillin. High-level resistance to penicillin was not observed in any of the isolate. Seventeen (11.3%) isolates were resistant to erythromycin, and 31 (20.7%) to tetracycline. Multiple resistance was observed in 21 (14%) isolates. Decreased resistance to ceftriaxone was also found in two (1.3%) isolates. Isolates with relative resistance to penicillin were significantly associated with higher rates of resistance to other antibiotics than were penicillin-susceptible isolates. This was also true for multiple resistance encountered in both groups.

An outbreak of infection due to Staphylococcus aureus phage type 52 in a neonatal intensive care unit.

An outbreak of infection due to Staphylococcus aureus phage-type 52, resistant only to penicillin, occurred in children's wards primarily in a neonatal intensive care unit. The outbreak involved 86 infants; the majority presented with conjunctivitis, wound infections, boils, omphalitis and otitis externa. Seven per cent of these infants (six of 86) also had septicaemia. In addition, 6% (five of 86) were colonized by this phage type and the most common site of carriage was the umbilicus. The outbreak was contained by eradication of nasal carriage among the staff members and also by standard infection control measures.

Septicaemia in febrile neutropenic children with cancer in Saudi Arabia.

The pattern of sepsis among 56 children admitted for various forms of cancer to the King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia during a 6-year period, was retrospectively reviewed. A total of 148 febrile neutropenic episodes occurred and 55 of these, in 40 patients, were associated with positive blood cultures. The isolates were Gram-positive bacteria in 54% of instances, Gram-negative bacteria in 39.4% and Candida in 6.6% and polymicrobial sepsis occurred in five patients. Profound neutropenia (neutrophil counts less than 0.1 x 10(9) l-1) significantly predisposed to Gram-negative sepsis (P less than 0.02), which was responsible for about one-third of deaths in this series. Central venous catheters were present prior to 49% of the septicaemic episodes, but were not significantly associated with either increased Gram-negative or Gram-positive bacterial sepsis. However, all four cases of candidaemia occurred in patients with a central venous catheter in situ, and it is recommended that early empirical treatment for candida be considered in all febrile neutropenic cancer patients with central venous catheters.

Brucellosis in Riyadh, Saudi Arabia. A microbiological and clinical study.

During a period of two years, 30 cases of brucellosis were positively diagnosed from a total of 209 patients who reported with prolonged fever for investigation. Diagnosis was made both by blood culture and serological tests. The latter included slide and tube agglutination in all cases and an enzyme linked immunosorbent assay (ELISA) in 16. 11 cases (36.7%) gave negative results by the slide-agglutination screening test used at the recommended single serum dilution of 1:80. This was due to the prozone phenomenon as they gave positive results upon further dilution in the tube agglutination test. 13 of the 16 tested by ELISA were positive for both IgM and IgG and three were positive for IgG only. Of the six cases that were positive by culture, five grew Brucella melitensis and one B. abortus.

Isolation of Streptococcus milleri from clinical specimens.

During a period of 26 months, 80 strains of Streptococcus milleri were isolated from 80 patients with clinical evidence of infection. More than a third of the isolates were from lesions related to the gastro-intestinal tract and a quarter from abscesses of various other sites. The haemolytic activity and group antigenic profile of these isolates are discussed. In addition, the clinical significance of S. milleri isolated from various sites is evaluated.

Evaluation of a Brucella enzyme immunoassay test (ELISA) in comparison with bacteriological culture and agglutination.

An ELISA test for IgG and IgM antibrucella antibodies was found to be effective in diagnosis of human brucellosis. Assays for IgG and IgM in 30 culture-positive cases gave significant ELISA values. By the standard agglutination test, 10% of these cases gave readings less than 1:160. These are considered insignificant, taking 1:160 as the accepted cut-off value. Moreover, in an extra 135 samples from suspected brucella cases, where only serology was requested (77.6% of all cases), 7.4% were found to have IgM brucella antibodies by ELISA. In all of these, the corresponding agglutination titres were less than 1:80 and hence reported as insignificant. We report the detection of IgG and IgM antibodies in samples from patients with both acute and chronic disease. In few patients with acute disease, only IgM was detected. These findings are discussed in comparison with earlier studies. Finally, the ELISA test, in addition to measuring antibody classes directly, also detects incomplete antibodies. By this, it can efficiently replace the 2 mercaptoethanol test (2ME) and the Coomb's antihuman-globulin test. This saves considerable laboratory cost and time.

Shigella flexneri bacteraemia.

Shigellosis is usually a non-invasive enteric disease, rarely accompanied by extra-intestinal manifestations. Shigella septicaemia is therefore reported in a child aged 10 months. In the laboratory the organism was resistant to ampicillin and only moderately susceptible to chloramphenicol. The patient responded well to cotrimoxazole to which the organism isolated was susceptible in vitro. We recommend that blood as well as faeces should be cultured in exceptionally ill patients with suspected or otherwise confirmed shigella infection.

Antimicrobial resistance and prevalence of extended spectrum beta-lactamase among clinical isolates of gram-negative bacteria in Riyadh.

The activity of ciprofloxacin, imipenem and 12 other commonly used antibiotics was evaluated against 106 documented clinical isolates from a medical Intensive Care Unit (ICU). The resistance rates to ceftriaxone, cefotaxime, aztreonam and ceftazidime were 42, 25, 24 and 21%, respectively. Apart from Pseudomonas aeruginosa, all isolates were sensitive to ciprofloxacin and imipenem. Complete cross resistance among tested beta-lactam groups was uniformly evident in Enterobacter cloacae, Citrobacter freundii and P. aeruginosa. On the other hand, penicillins and second generation cephalosporins showed cross resistance among Escherichia coli and Klebseilla pneumoniae isolates. Induction experiments indicate that 70 and 62% of P. aeruginosa and E. cloacae or C. freundii produce class I cephalosporinase, respectively. Among all tested isolates, plasmid mediated extended spectrum beta-lactamase (ESBL) was detected in one isolate of K. pneumoniae. The plasmid mediated beta-lactamase is transferable and inhibited by beta-lactamase inhibitors. The transconjugates not only expressed resistance to extended spectrum beta-lactams and aztreonam but also toward tested aminoglycoside antibiotics, with the exception of gentamicin. The obtained transconjugates conferred high level resistance to ceftazidime and aztreonam but considerably low resistance to ceftriaxone and cefotaxime. The isoelectric point for the extended-spectrum beta-lactamase is 8.2.

Helicobacter pylori infection in children in Saudi Arabia.

20 children with suspected Helicobacter pylori (H. pylori) infection are presented. The mean age of the children was 9.4 years (range 4-13 years). The mean H. pylori IgG and IgA antibodies were 677 units and 760.7 units respectively. Antral biopsy cultures were positive in five children. Histopathology of the gastric antral and duodenal biopsies showed H. pylori gastritis in 11 children, duodenitis and gastritis in five, normal histology in three and one child had normal histology with H. pylori like organism on the surface of the antral mucosa. From this study, we conclude that serology is a good diagnostic test for H. pylori infection in Saudi Arabia.

High level resistance to aminoglycosides in enterococci from Riyadh.

Enterococci with high level of aminoglycosides resistance are being reported from different parts of the world with increasing frequency. Treatment of infections caused by such isolates is associated with a high incidence of failure or relapse. This is attributed to the loss of the synergetic effect of aminoglycosides and cell wall active agents against isolates exhibiting this type of resistance. To determine the prevalence of enterococci with high level resistance to aminoglycosides in Riyadh, Saudi Arabia, 241 distinct clinical isolates were examined by disk diffusion method using high content aminoglycosides disks. Seventy-four isolates (30%) were resistant to one or more of the aminoglycosides tested. The most common pattern of resistance was that to streptomycin and kanamycin. Of the 241 isolates tested, 29 (12%) were resistant to high levels of gentamicin, 35 (15%) to tobramycin, 65 (27%) to kanamycin and 53 (22%) to streptomycin. The highest rate of resistance to a high level of gentamicin was found among enterococcal blood isolates (30%). Eighteen of the isolates were identified as Enterococcus faecium, 13 (72%) of these showed high level resistance to two or more of the aminoglycosides tested.

Enteric fever due to multi-resistant Salmonella typhi.

Five cases of enteric fever due to multi-resistant Salmonella typhi are reported. Four of these patients most probably contracted the disease in India and the fifth in Egypt. All of them were successfully treated either with ceftriaxone or ciprofloxacin.

Non-group A streptococci: are they pathogens in the throat?

A total of 3,184 paediatric patients with sporadic pharyngitis was studied at King Khalid University Hospital in Riyadh, Saudi Arabia. In addition, 478 children without pharyngitis who were matched for age and sex were included as controls. Group A beta-haemolytic streptococci (beta HS) were detected significantly more often among the children with pharyngitis than among the controls (8.4% vs 2.3%; p < 0.0001). In contrast, total non-group A and group C beta HS were isolated at lower frequency from the sick than control children (0.9% vs 2.5% and 0.2% vs 1.2% respectively; p < 0.01) while other non-group A beta HS such as groups B, G and F were each isolated in similar frequency from both the sick and control children. We conclude that non-group A beta HS appear not to be as important as aetiological agents of sporadic pharyngitis in these children.