Application of ventilator care bundle and its impact on ventilator associated pneumonia incidence rate in the adult intensive care unit.

OBJECTIVE: To reduce ventilator associated pneumonia (VAP) incidence rate, lessen the cost of care, and correlate VAP bundles compliance with VAP incidence rate. METHODS: This study was a prospective longitudinal study conducted on adult intensive care unit (ICU) patients at Hera General Hospital, Makkah, Kingdom of Saudi Arabia from January to December 2010. The following Institute for Healthcare Improvement VAP prevention bundle was applied: head-of-bed elevation; daily sedation-vacation along with a readiness-to-wean assessment; peptic ulcer disease (PUD) prophylaxis; and deep venous thrombosis (DVT) prophylaxis. RESULTS: Among a total of 2747 patients, the bundle compliance rate in January 2010 was 30%, and reached to 100% in December 2010, while the overall rate was 78.9%. The individual bundle compliance rates were as follows: head-of-bed elevation - 99.9%; daily sedation vacation - 88.9%; PUD prophylaxis - 94.9%; and DVT prophylaxis - 85.7%. At the beginning, VAP rate was 2.5/1000 ventilator days, and reduced to 0.54 in the next month. The overall VAP incidence rate in 2010 was found to be 1.98 with a reduction of 1.41 by comparing with the same data of year 2009 collected retrospectively. The total reduction cost in one year was $154,930. A significant correlation was found between the VAP rate and its bundle compliance (p=0.001). Most frequent pathogens found were Pseudomonas aeruginosa (30.8% of all isolates) followed by Acinetobacter baumannii (27.7%), and methicillin-resistant Staphylococcus aureus (15.4%). CONCLUSION: Application of VAP prevention bundle reduced the VAP incidence rate and lowered the cost of care.

Hand hygiene compliance rate among healthcare professionals.

OBJECTIVE: To motivate healthcare professionals, with a focus on improving hand hygiene compliance. METHODS: An observational, prospective, longitudinal study was conducted on the evaluation of hand hygiene compliance at Hera General Hospital, Makkah, Kingdom of Saudi Arabia from May 2009 to May 2010. Four components to improve hand hygiene compliance were implied; daily audit, monthly staff education; quarterly workshops of hand hygiene, and education material distribution. The compliance rate was calculated by its adherence with number of opportunities. RESULTS: Of total 163 healthcare professionals were surveyed for hand hygiene compliance; 57 (35%) were doctors, 92 (56.4%) nurses, and 14 (8.6%) patient care technicians. The overall compliance rate was 50.3%, and its distribution among staff was as follows; doctors 49.1%, nurses 52.2%, and technicians 42.8%. The highest compliance rate among doctors and nurses was found in surgical units. A low compliance in high intensity patient care area was observed such as in the emergency room and out patient department. The patient care technicians showed highly variable results, as their compliance rate was 100% in medical units while 0% in various other clinical areas. CONCLUSION: The overall hand hygiene compliance rate of healthcare professionals reached 50% after a long education campaign, and was highest among the nurses. Further study is needed to explore the reasons for non-compliance.

Profile of bacterial pneumonia during Hajj.

BACKGROUND & OBJECTIVES: The congregation of a large number of people during Hajj seasons from different parts of the world in overcrowded conditions within a confined area for a long period of time presents many public health challenges and health risks. One of the main health problems of the crowding is ease transmission of pneumonia by air droplets. This study was aimed to determine the most common causes of bacterial pneumonia during the 2005 Hajj season and to relate the findings with clinical conditions. METHODS: A total of 141 patients with suspected pneumonia from the three main tertiary care hospitals in Makkah, Saudi Arabia, were investigated during Hajj season, 2005. Sputum and serum samples were collected and investigated for the possible presence of typical or atypical causative agents. RESULTS: Of the 141 clinically suspected pneumonia cases, 76 (53.9%) were confirmed positive by microbiological tests. More than 94 per cent of the confirmed cases were in the age group >50 yr, and 56.6 per cent of the cases were men. The most frequent isolates were Candida albicans (28.7%) and Pseudomonas aeruginosa (21.8%), followed by Legionella pneumophila (14.9%) and Klabsiella pneumoniae (9.2%). More than one causative pathogens were isolated in 15 patients (16.3%), and 55 per cent of patients were diabetic. INTERPRETATION & CONCLUSIONS: Clinicians should be aware that typical pneumonia treatment regimens may not work well during the Hajj season due to the wide variety of isolated organisms. This necessitates taking a sputum sample before starting treatment for identification and sensitivity testing. Special precautions need to be taken for >50 yr old patients.

Multi-drug resistant Ewingella americana.

We report a case of pneumonia due to multi-drug resistant Ewingella americana in a young patient admitted in the Intensive Care Unit of Hera General Hospital, Makkah, Saudi Arabia with severe head injury in a road traffic accident. He was an Indonesian pilgrim who had traveled to the Kingdom of Saudi Arabia to perform Hajj in December 2007. Ewingella americana was identified to be the pathogen of pneumonia with clinical signs and symptoms along with positive radiological findings.

Prevalence of Helicobacter pylori infection in patients with peptic ulcer diseases.

OBJECTIVE: To determine the prevalence of Helicobacter pylori (H. pylori) infection among patients presenting with peptic ulcer disease (PUD) and to establish the relationship between H. pylori infection and its diverse pathology. Secondly, we aimed to examine the effect of age, gender, and geographical distribution on the prevalence of the disease. METHODS: The study included patients with PUD who underwent upper gastrointestinal endoscopy at Hera General Hospital, Makkah, Kingdom of Saudi Arabia between January 2003 and February 2004. We tested the biopsies for the detection of H. pylori by Campylobacter like organism (CLOTM) test, histopathology, immunoglobulin G (IgG) antibodies, culture, and antimicrobial susceptibility testing. RESULTS: The overall prevalence rate of H. pylori infection among 132 patients with PUD was 63%, while it was high among females (70%) as compared with males (58%). The H. pylori were mainly found in chronic active gastritis (89%) and severe active gastritis (96%). Helicobacter pylori were documented by CLOTM test in 73 (55.3%) cases, histopathology in 69 (52.3%) cases, microbiological culture in 59 (44.7%) cases, and IgG antibodies in 61 (46.2%) cases. The highest resistance (31%) was found in metronidazole, while lowest the (3%) in tetracycline and erythromycin. CONCLUSION: The highest prevalence of H. pylori was found in the younger age group with female preponderance. The leading causes of multifocal pathology were chronic and severe active gastritis secondary to H. pylori infection.

Accuracy of current oxacillin sensitivity tests routinely used in hospitals in Western Saudi Arabia.

OBJECTIVE: To determine the accuracy of the current oxacillin resistant Staphylococcus aureus (S. aureus) detection test used in Makkah hospitals in comparison with the National Committee for Clinical Laboratory Standards (NCCLS) method. METHODS: A total of 500 S. aureus clinical isolates and it's oxacillin sensitivity patterns were collected from the 4 main hospitals in Makkah, Kingdom of Saudi Arabia between April 2003 and January 2004. The oxacillin sensitivity of these clinical isolates were re-examined using the NCCLS standard method and confirmed using polymerase chain reaction (PCR) technique. RESULTS: Of 500 clinical isolates, 103 (20.6%) were resistant to oxacillin using NCCLS standard method but they were sensitive according to the current hospital routine sensitivity test method. The PCR technique confirmed the presence of mecA gene in 88/103 isolates appeared to be methicillin-resistant S. aureus (MRSA) using NCCLS standard technique. CONCLUSION: A significant percentage of MRSA are currently misdiagnosed in accordance with the current routine sensitivity method. In addition, some mecA negative and oxacillin resistant strains (according to the NCCLS standard method) can be misdiagnosed by using PCR technique. These findings emphasis the urgent need to comply with the recommended NCCLS guidelines for detection of oxacillin resistance. Moreover, the PCR technique can not be used as a single diagnostic tool for detection of MRSA.

Pyoderma among Hajj Pilgrims in Makkah.

OBJECTIVE: Bacterial skin infections have been considered as a possible health problem of the Hajj pilgrims. Significant increase in the rate of resistance to commonly used antibiotics against gram positive organisms has been observed. The present study was planned to obtain the microbiological profile of bacterial skin infections and their susceptibility to antimicrobials. METHODS: Pyodermas were investigated clinically and bacteriologically by a prospective study conducted on patients attending the dermatology clinic at the King Faisal Hospital, Makkah, Kingdom of Saudi Arabia during 2 Hajj periods (2000 - 2001). RESULTS: Of a total of 80 pyoderma patients, 52.5% were primary and 47.5% secondary. The leading cause of primary pyoderma was found to be impetigo in 28.8% cases, and of secondary pyoderma was infected eczema in 18.8% cases. Positive cultures were found in 87.5% cases. The organisms responsible for primary pyoderma were: Staphylococcus aureus (65.6%), Streptococcus pyogenes (28.1%) or both (6.4%) while in secondary pydermas were: Staphylococcus aureus (44.7%), Streptococcus pyogenes (15.8%), or both (18.4%), and gram negative bacilli (21.1%). The resistant pattern of antimicrobials against Staphylococcus aureus was as follows: penicillin 80.85%, tetracycline 10.6%, gentamicin 6.4%, erythromycin 4.3% and cotrimoxazole [corrected] 4.3%. Oxacillin and cephalothin were found least resistant (2.1%). CONCLUSION: Pyoderma appeared as one of the common health hazard of our Hajj pilgrims. Penicillin and tetracycline are found ineffective in treating skin infections caused by Staphylococcus aureus while oxacillin is recommended as first line of treatment.