Prevalence of Carbapenem-Resistant Enterobacteriaceae in Western Saudi Arabia and Increasing Trends in the Antimicrobial Resistance of Enterobacteriaceae.

PURPOSE:  The aim of the study is to estimate the prevalence rate of carbapenem-resistant Enterobacteriaceae (CRE) and to determine the types of carbapenemase genes present in patients admitted to King Abdulaziz Medical City (KAMC-J) and King Abdulaziz University Hospital (KAUH), both in Jeddah, Saudi Arabia. METHODS:  A total of 180 isolates were analyzed which were included on the basis of retrospective chart review of patients from KAMC-J and KAUH between 1st April 2017 to 30th March 2019. The prevalence of carbapenemase genes ( blaIMP, blaVIM, blaKPC, blaNDM-1, and blaOXA-48) was evaluated by Xpert® Carba-R (Cepheid, Sunnyvale, CA, USA). We assessed the CRE prevalence and described their susceptibility to antimicrobial agents based on antibiogram reports.  Results: Klebsiella pneumoniae showed a higher frequency of bla OXA-48 (79%) than bla NDM (11.7%) genes (p=0.007). The CRE prevalence in KAUH was 8% in 2017 and increased to 13% in 2018. In KAMC-J, the prevalence was 57% in 2018 and 61% in 2019. K. pneumoniae was found to be the most frequently isolated causative organism followed by Escherichia coli . The  bla OXA-48 (76.1%) gene was predominant among overall isolates followed by bla NDM (13.9%); both genes coexisted in 6.1% of the isolates. CONCLUSION:  During the study period, the prevalence of CRE considerably rose in the two tertiary care institutions from western Saudi Arabia. In the CRE isolates, bla OXA-48 was discovered to be the most common gene. We recommend an antimicrobial resistance surveillance system to detect the emergence of resistant genes through use of new rapid diagnostic tests and monitor antimicrobial use in order to improve clinical outcomes of CRE infections given the severity of infection associated with the CRE isolates as well as the limited treatment options available.

Assessing the Effectiveness of Antibiotic Therapy Against Common Gram-Negative Bacteria in a Saudi Arabian Hospital Using the Drug Resistance Index.

INTRODUCTION: Assessing the effectiveness of antibiotics and communicating the problem of resistance are essential when devising antimicrobial stewardship programs (ASPs) in hospital settings. The Drug Resistance Index (DRI) is a useful tool that combines antibiotic consumption and bacterial resistance into a single measure. In this study, we used the DRI to assess the impact of introducing a new antibiotic restriction form on antibiotic effectiveness for the treatment of Gram-negative infections in the intensive care unit (ICU). METHODS: This was an observational study to assess and evaluate the antibiotic susceptibility of Gram-negative bacteria and antibiotic prescribing rates for the antibiotics indicated for Gram-negative bacteria following the introduction of a new antibiotic restriction form. The study was conducted from 2015 to 2017 at King Abdulaziz Medical City, a tertiary care facility in Jeddah, Saudi Arabia. Changes in antibiotic effectiveness before and after the introduction of the form were evaluated by calculating the DRI for four of the most common Gram-negative pathogens and eight commonly used antibiotic classes. RESULTS: The overall DRI for the adult ICU was higher (59.45) in comparison to the hospital-wide DRI (47.96). A higher DRI was evident for carbapenems and antipseudomonal penicillins + beta-lactamase inhibitors. Acinetobacter baumannii had the highest DRI followed by Klebsiella pneumoniae in both the adult ICU and hospital-wide. After the implementation of antibiotic restriction in the adult ICU, the DRI for carbapenems was significantly lower in the post-intervention phase (from 31.61 to 26.05) (p = 0.031). CONCLUSION: The DRI is a useful tool for tracking the effectiveness of antibiotics over time. The results of our study are significant in the way that it highlights the importance of having an effective antibiotic stewardship program in healthcare settings and regular feedback of antibiotic consumption data to the stakeholders to keep the antibiotic prescriptions in check, thereby ensuring their sustained effectiveness.

Vascular endothelial growth factor-C in patients with breast cancer.

Metastatic spread of tumours is the major cause of death in patients with breast cancer. Despite the importance of the lymphatic system in tumour metastasis, little is known about the role of lymphangiogenesis in tumour growth and metastasis. This study was undertaken to evaluate the potential usefulness of plasma levels of lymphanagiogenesis factor, vascular endothelial cell growth factor-C (VEGF-C) as a prognostic factor in 122 patients with breast cancer. There was no significant difference between plasma levels of VEGF-C in patients with early (n =81), advanced (n =32) or inflammatory breast cancer (n =9) and 64 age matched healthy controls. We found no significant correlation between VEGF-C with age, tumour size, tumour grade, or disease-free and over-all survival. Plasma VEGF-C levels did not significantly differ in patients with positive oestrogen, progesterone, and Her-2 neu compared to those who were negative for these parameters. In conclusion our study has failed to show any prognostic value for plasma VEGF-C level in patients with breast cancer.

Plasma CD105, TGFbeta-1, TGFbeta-3 and the ligand/receptor complexes in children with acute lymphoblastic leukaemia.

The role of angiogenesis in solid tumours is well recognised, but its importance in haematological malignancies is less well understood. In leukaemia, mainly the determination of microvascular density utilising immunohistochemistry in the bone marrow trephines and the measurement of soluble angiogenic factors have led to the recognition that angiogenesis may be important in leukaemia as well. In this study, the soluble form of the endothelial cell activation/proliferation (i.e., angiogenesis) marker CD105 and its ligands TGFbeta-1 and -3, as well as the ligand/receptor complexes in plasma from children with acute lymphoblastic leukaemia (ALL) were quantified. The plasma level of CD105 was significantly higher in patients with common ALL compared to controls, while the TGFbeta-3 level was lower in patients. Neither the CD105 or TGFbeta-3 levels were of prognostic value, nor did they correlate with any of the known prognostic indicators, such as white blood cell counts. There were no significant differences between the plasma levels of any of the other parameters, such as TGFbeta-1 or the ligand receptor complexes, in children with leukaemia compared to controls. Our results support the role of angiogenesis in leukaemia and suggest that anti-angiogenesis may be a therapeutic target in leukaemia.

Candidemia and the susceptibility pattern of Candida isolates in blood.

OBJECTIVE: Candida species has become one of the most common blood isolates as well as one of the leading causes of nosocomial bloodstream infections. The purpose of our study was to determine the prevalence of Candida species among our bloodstream infecting organisms and the susceptibility pattern of the Candida isolates to antifungal agents. METHODS: A prospective study was carried out in the Division of Microbiology, King Khalid National Guard Hospital, Jeddah, Kingdom of Saudi Arabia of all positive blood cultures for Candida species. The study took place from 1st January 1998 to March 2002. Identification and susceptibility pattern of isolates were determined by the Candifast technique to amphotericin B, fluconazole, nystatin, Flucytosine, econazole, ketoconazole and miconazole. RESULTS: Over a 2-year period, 17,916 blood cultures were performed in our hospital. There were 2,972 positive cultures, of which 83 (2.8%) patients had Candida species isolated from their bloodstream. Of these, 38 (46%) were Candida albicans (C.albicans). The remaining 45 strains were made up of Candida tropicalis 9 (10.8%); Candida parapsilosis 9 (10.8%); Candida species 9 (10.8%); Candida guilliermondi 6 (7.2%); Candida krusei 5 (6%); Candida glabrata 4 (4.8%); Candida pseudotropicalis 2 (2.4%) and Trichosporon species 1 (1.2%). All Candida species were susceptible to amphotericin B. However, only 18 (47%) out of 38 C.albicans were susceptible to fluconazole, while only 8 (17.7%) of 45 non-C.albicans strains were susceptible to this drug. CONCLUSION: The susceptibility of C.albicans to fluconazole in our hospital using the Candifast method is very low (47%). These results need to be confirmed by carrying out the Etest or the NCCLS M27-A method to confirm the true susceptibilities of Candida strains in our locality.

Enterococcus faecalis endocarditis.

The increasing usage of cephalosporins, to which the enterococci are resistant, has resulted in the rising number of enterococcal infections worldwide. Enterococci are a normal part of the flora of the human gastrointestinal tract, buccal cavity, perineal skin, vagina, urethra and gallbladder, but may occur as pathogens in a number of sites causing urinary tract infections, intra-abdominal infections, fatal bacteremia, meningitis and endocarditis. A Saudi male who developed enterococcal endocarditis with vegetations on both aortic and mitral valves required mitral and aortic valve replacement. The attention of physicians is drawn to the increasing frequency of enterococcus as a cause of nosocomial infections, the risk factors, and antibiotic resistance pattern including resistance to vancomycin as well as its potential for virulence.