Narrative Review of the Epidemiology of Hospital-Acquired Pneumonia and Ventilator-Associated Pneumonia in Gulf Cooperation Council Countries.

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are the most common healthcare-associated infections, with rates varying between countries. Antimicrobial resistance (AMR) among common HAP/VAP pathogens has been reported, and multidrug resistance (MDR) is of further concern across Middle Eastern countries. This narrative review summarizes the incidence and pathogens associated with HAP/VAP in hospitals across Gulf Cooperation Council (GCC) countries. A PubMed literature search was limited to available data on HAP or VAP in patients of any age published within the past 10 years. Reviews, non-English language articles, and studies not reporting HAP/VAP data specific to a GCC country were excluded. Overall, 41 articles, a majority of which focused on VAP, were selected for inclusion after full-text screening. Studies conducted over multiple years showed a general reduction in VAP rates over time, with Gram-negative bacteria the most commonly reported pathogens. Gram-negative isolates reported across GCC countries included Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae. Rates of AMR varied widely among studies, and MDR among A. baumannii, K. pneumoniae, Escherichia coli, P. aeruginosa, and Staphylococcus aureus isolates was commonly reported. In Saudi Arabia, between 2015 and 2019, rates of carbapenem resistance among Gram-negative bacteria were 19-25%; another study (2004-2009) reported antimicrobial resistance rates in Acinetobacter species (60-89%), P. aeruginosa (13-31%), and Klebsiella species (100% ampicillin, 0-13% other antimicrobials). Although limited genotype data were reported, OXA-48 was found in ≥ 68% of patients in Saudi Arabia with carbapenem-resistant Enterobacteriaceae infections. Ventilator utilization ratios varied across studies, with rates up to 0.9 reported in patients admitted to adult medical/surgical intensive care units in both Kuwait and Saudi Arabia. VAP remains a burden across GCC countries albeit with decreases in rates over time. Evaluation of prevention and treatment measures and implementation of a surveillance program could be useful for the management of HAP and VAP.

Variability of Steroid Prescription for COVID-19 Associated Pneumonia in Real-Life, Non-Trial Settings.

The RECOVERY study documented lower 28-day mortality with the use of dexamethasone in hospitalized patients on invasive mechanical ventilation or oxygen with COVID-19 Pneumonia. We aimed to examine the practice patterns of steroids use, and their impact on mortality and length of stay in ICU. We retrospectively examined records of all patients with confirmed Covid 19 pneumonia admitted to the ICU of Dubai hospital from January 1st, 2020 - June 30th, 2020. We assigned patients to four groups (No steroids, low dose, medium dose, and high dose steroids). The primary clinical variable of interest was doses of steroids. Secondary outcomes were 28-day mortality and length of stay in ICU". We found variability in doses of steroid treatment. The most frequently used dose was the high dose. Patients who survived were on significantly higher doses of steroids and had significantly longer stays in ICU. The prescription of steroids in Covid-19 ARDS is variable. The dose of steroids impacts mortality rate and length of stay in ICU, although patients treated with high dose steroids seem to stay more days in ICU.

Promoting cross-regional collaboration in antimicrobial stewardship: Findings of an infectious diseases working group survey in Arab countries of the Middle East.

BACKGROUND: Antimicrobial resistance is a significant global issue that presents an increasing threat to patients' wellbeing. Although a global concern, the emergence of multi-drug resistant organisms is of particular significance in the Middle East. In recent years, this region has seen an alarming increase in antimicrobial resistance presenting a major challenge to physicians managing various infectious diseases. METHODS: A Working Group comprising experts in infectious diseases from Arab countries of Middle East assembled to review similarities and differences in antimicrobial practices and management of multi-drug resistant organisms across the region and assess the barriers to achieving cross-regional collaboration. The Working Group conducted an anonymous online survey to evaluate current practice and understanding of management of multi-drug resistant organisms across the region. RESULTS: A total of 122 physicians from Arab countries of the Middle East responded to the survey. Their responses demonstrated heterogeneity between countries in awareness of local epidemiology, management of multi-drug resistant organisms and antimicrobial stewardship practices. The Working Group recognized similarities and differences in the management of multi-drug resistant organisms across the region, and these were validated by the data collected in the survey. Overall, the similarities across the region reflect several key issues that can have an impact on the management of multi-drug resistant organisms and the prevention of antimicrobial resistance. CONCLUSIONS: This paper highlights the urgency of addressing antimicrobial resistance in Arab countries of the Middle East. The Working Group identified key barriers to effective management which may guide the development of future coherent strategies to promote effective antimicrobial stewardship in the region. Here, we outline a call to action for the region, with a need to focus on training and education, capacity building, infrastructure, regional research, and regional surveillance.

Management of infections caused by WHO critical priority Gram-negative pathogens in Arab countries of the Middle East: a consensus paper.

Antimicrobial resistance is an important global issue that impacts the efficacy of established antimicrobial therapy. This is true globally and within the Arab countries of the Middle East, where a range of key Gram-negative pathogens pose challenges to effective therapy. There is a need to establish effective treatment recommendations for this region given specific challenges to antimicrobial therapy, including variations in the availability of antimicrobials, infrastructure and specialist expertise. This consensus provides regional recommendations for the first-line treatment of hospitalized patients with serious infections caused by World Health Organization critical priority Gram-negative pathogens Acinetobacter baumannii and Pseudomonas aeruginosa resistant to carbapenems, and Enterobacteriaceae resistant to carbapenems and third-generation cephalosporins. A working group comprising experts in infectious disease across the region was assembled to review contemporary literature and provide additional consensus on the treatment of key pathogens. Detailed therapeutic recommendations are formulated for these pathogens with a focus on bacteraemia, nosocomial pneumonia, urinary tract infections, skin and soft tissue infections, and intra-abdominal infections. First-line treatment options are provided, along with alternative agents that may be used where variations in antimicrobial availability exist or where local preferences and resistance patterns should be considered. These recommendations take into consideration the diverse social and healthcare structures of the Arab countries of the Middle East, meeting a need that is not filled by international guidelines. There is a need for these recommendations to be updated continually to reflect changes in antimicrobial resistance in the region, as well as drug availability and emerging data from clinical trials.

Salmonella typhi Meningitis in an Immunocompetent Asian Adult.

Enteric salmonella infections are common in the United States though nonenteric salmonella infections in immunocompetent adults are exceedingly rare in the United States, and meningitis is one of the least common extra-intestinal sites. In addition, it is very unusual for a patient with bacterial meningitis to present with meningitis signs and symptoms of >72 h duration like aseptic meningitis.  A 25-year-old Indian male, without any past medical history brought by friends to the ER had fever and irritability for a week. He became increasingly somnolent and confused three days back. Physical exam reveals signs of meningitis and laboratory showed cerebrospinal fluid (CSF) studies suggestive of bacterial meningitis. Culture of CSF grew Salmonella typhi and later on blood culture also grew S. typhi. The patient became worse with cerebral edema and hydrocephalous suspected by change in neurological status and confirmed by ultrasound of eye ball examining optic nerve sheath diameter and CT scan of brain. The patient required neurosurgical intervention and hence external ventricular drain was placed. The patient was also placed on mechanical ventilation. Subsequently he developed ventilator associated pneumonia (VAP) with carbapenem-resistant Pseudomonas aeruginosa. The patient underwent tracheostomy and successfully completed treatment of VAP and was transferred to his home country after four months. Thus we describe a rare case of salmonella meningitis in an immunocompetent adult.

Clinical Predictors of Adherence to Low Tidal Volume Ventilation Practice: Is it Different on Weekend and Night Shifts?

BACKGROUND: Low tidal volume ventilation (LTVV) strategy improves outcomes; however, despite recommended by guidelines, adherence to this practice is not high. METHODS: Tidal volume for mechanically ventilated patients were recorded for each 12-hour shift, day and night shifts for consecutive 101 patients. Adherence was determined by comparing these tidal volumes to standard low tidal volumes of 6 ml/kg of ideal body weight. Adherence rates were calculated and adherence rates of daytime shifts were compared to those of night time shifts. Adherence rates for weekday shifts were compared with those of weekend shifts. Clinical variables were recorded to analyze predictors of adherence pattern. RESULTS: The sample size was 101 patients with 870 patient-ventilator days with 1734 patient ventilator shifts. Shift adherence was only 47.5%. There was no significant difference between day and night shifts or weekday and weekend shifts. Stepwise multiple regression analysis shows that age, gender, body mass index (BMI), and partial pressure of carbon dioxide (PCO2) have significant correlation with adherence to LTVV practice. CONCLUSION: The study found that adherence to lung protective low tidal volume mechanical ventilation practice is low. Practice adherence is not different over weekend or night shifts. Age, gender, BMI, and PCO2 have significant correlation with adherence to LTVV practice.

Invasive candidiasis in critical care setting, updated recommendations from "Invasive Fungal Infections-Clinical Forum", Iran.

Invasive candidiasis (IC) bears a high risk of morbidity and mortality in the intensive care units (ICU). With the current advances in critical care and the use of wide-spectrum antibiotics, invasive fungal infections (IFIs) and IC in particular, have turned into a growing concern in the ICU. Further to blood cultures, some auxiliary laboratory tests and biomarkers are developed to enable an earlier detection of infection, however these test are neither consistently available nor validated in our setting. On the other hand, patients' clinical status and local epidemiology data may justify the empiric antifungal approach using the proper antifungal option. The clinical approach to the management of IC in febrile, non-neutropenic critically ill patients has been defined in available international guidelines; nevertheless such recommendations need to be customized when applied to our local practice. Over the past three years, Iranian experts from intensive care and infectious diseases disciplines have tried to draw a consensus on the management of IFI with a particular focus on IC in the ICU. The established IFI-clinical forum (IFI-CF), comprising the scientific leaders in the field, has recently come up with and updated recommendation on the same (June 2014). The purpose of this review is to put together literature insights and Iranian experts' opinion at the IFI-CF, to propose an updated practical overview on recommended approaches for the management of IC in the ICU.

Assessment of venous thromboembolism risk and adequacy of prophylaxis in selected acute care medical centres in Arabian Gulf States: results from the ENDORSE study.

OBJECTIVES: To assess the prevalence of venous thromboembolism (VTE) risk in acutely ill surgical and medical patients in selected acute care centres in the Arabian Gulf States, and to determine the proportion of at-risk patients who received effective prophylaxis in accordance with 2004 American College of Chest Physicians (ACCP) guidelines. MATERIALS AND METHODS: Eight hospitals from 3 countries (Kuwait, Kingdom of Saudi Arabia, and United Arab Emirates) contributed to the global ENDORSE (Epidemiological International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting) study. Medical records were reviewed for all the in-patients aged ≥40 years admitted to medical wards, and in patients aged ≥18 admitted to surgical wards. The VTE risk and recommended prophylaxis were assessed according to the 2004 ACCP guidelines. RESULTS: Of 1,291 evaluable patients, 801 were considered at risk of VTE; 391 (48.8%) surgical patients and 410 (51.2%) medical patients. Of the 801 patients, 322 (40.2%) received ACCP-recommended VTE prophylaxis; 159 (40.7%) of surgical patients and 163 (39.8%) of medical patients. CONCLUSIONS: The data showed that VTE prophylaxis was underutilized in high-risk hospitalized patients. We recommend that active measures should be implemented in acute care centres in these Arabian Gulf countries to ensure identification of patients at risk of VTE and institute the appropriate prophylaxis.