Molecular epidemiology of carbapenem-resistant Acinetobacter baumannii isolates in the Gulf Cooperation Council States: dominance of OXA-23-type producers.

The molecular epidemiology and mechanisms of resistance of carbapenem-resistant Acinetobacter baumannii (CRAB) were determined in hospitals in the states of the Cooperation Council for the Arab States of the Gulf (Gulf Cooperation Council [GCC]), namely, Saudi Arabia, United Arab Emirates, Oman, Qatar, Bahrain, and Kuwait. Isolates were subjected to PCR-based detection of antibiotic resistance genes and repetitive sequence-based PCR (rep-PCR) assessments of clonality. Selected isolates were subjected to multilocus sequence typing (MLST). We investigated 117 isolates resistant to carbapenem antibiotics (either imipenem or meropenem). All isolates were positive for OXA-51. The most common carbapenemases were the OXA-23-type, found in 107 isolates, followed by OXA-40-type (OXA-24-type), found in 5 isolates; 3 isolates carried the ISAba1 element upstream of blaOXA-51-type. No OXA-58-type, NDM-type, VIM-type, or IMP-type producers were detected. Multiple clones were detected with 16 clusters of clonally related CRAB. Some clusters involved hospitals in different states. MLST analysis of 15 representative isolates from different clusters identified seven different sequence types (ST195, ST208, ST229, ST436, ST450, ST452, and ST499), as well as three novel STs. The vast majority (84%) of the isolates in this study were associated with health care exposure. Awareness of multidrug-resistant organisms in GCC states has important implications for optimizing infection control practices; establishing antimicrobial stewardship programs within hospital, community, and agricultural settings; and emphasizing the need for establishing regional active surveillance systems. This will help to control the spread of CRAB in the Middle East and in hospitals accommodating transferred patients from this region.

Molecular characterization of carbapenemase-producing Escherichia coli and Klebsiella pneumoniae in the countries of the Gulf cooperation council: dominance of OXA-48 and NDM producers.

The molecular epidemiology and mechanisms of resistance of carbapenem-resistant Enterobacteriaceae (CRE) were determined in hospitals in the countries of the Gulf Cooperation Council (GCC), namely, Saudi Arabia, United Arab Emirates, Oman, Qatar, Bahrain, and Kuwait. Isolates were subjected to PCR-based detection of antibiotic-resistant genes and repetitive sequence-based PCR (rep-PCR) assessments of clonality. Sixty-two isolates which screened positive for potential carbapenemase production were assessed, and 45 were found to produce carbapenemase. The most common carbapenemases were of the OXA-48 (35 isolates) and NDM (16 isolates) types; 6 isolates were found to coproduce the OXA-48 and NDM types. No KPC-type, VIM-type, or IMP-type producers were detected. Multiple clones were detected with seven clusters of clonally related Klebsiella pneumoniae. Awareness of CRE in GCC countries has important implications for controlling the spread of CRE in the Middle East and in hospitals accommodating patients transferred from the region.

The Management of Patients at High Risk of Serious COVID-19 Disease: Optimising the Patient Pathway in the Middle East, Africa, and Eastern Europe.

Introduction For patients at high risk of severe COVID-19 disease, antiviral therapeutic options are available to reduce the risk of hospitalization or death. Although many countries have developed national guidelines for COVID-19 management that include use of antiviral agents, it is unclear how these guidelines are used in daily clinical practice. This study aims to assess the management of high-risk COVID-19 patients in the Middle East, Africa, and Eastern Europe, with a focus on understanding current practices, challenges, and potential strategies for improvement. Methods Healthcare professionals (HCPs) from the Middle East, Africa, and Eastern Europe came together at a regional summit in February 2023 to share perspectives on the therapeutic management of patients at high risk of serious COVID-19 disease in the community. Summit participants represented diverse medical specialties, geographical regions, and healthcare settings. Key insights gathered during the summit were supplemented with evidence from the published literature via a non-systematic literature search of MEDLINE and online sources such as government reports since the start of 2020 to identify articles on disease burden, unmet needs, treatment access, antiviral therapy, guidelines related to individuals with COVID-19 at high-risk for poor outcomes in low- and middle-income countries (LMICs). Together, these sources were used by the authors to generate their recommendations for future priorities and optimal care pathways globally. Results Specific insights gathered from the summit were that participants reported that primary care is the first point of contact for high-risk patients, but the role of primary care physicians (PCPs) in treatment is uncertain. Additionally, participants highlighted that between-country differences in the care pathway for high-risk patients are due to variations in local treatment practices, healthcare system structures, and resourcing. In line with the published literature, participants agreed that HCP education is needed to support the identification, counseling, and appropriate management of high-risk patients and that pharmacists have a critical role to play in identifying clinically important potential interactions with antiviral treatment and recommending appropriate adjustments. Furthermore, patient hesitancy can result in late presentation, delayed treatment, and potential progression of symptoms. HCPs should proactively counsel high-risk patients, so they are aware of their risk and its implications and understand what to do if they experience symptoms of COVID-19. Targeted educational initiatives for patients are needed to mitigate reluctance to undergo COVID-19 testing and counter COVID-19 misinformation. Conclusion Collaboration among stakeholders is essential to optimize COVID-19 management for high-risk patients globally, ensuring effective implementation of guidelines and improving outcomes.

Evaluation of an adjusted MEWS (Modified Early Warning Score) for COVID-19 patients to identify risk of ICU admission or death in the Kingdom of Bahrain.

BACKGROUND: While most COVID-19 cases have uncomplicated infection, a small proportion has the potential to develop life-threatening disease, as such development of a prediction tool using patients baseline characteristics at the time of diagnosis should aid in early identification of high-risk groups and devise pertinent management. Hence, we set up this retrospective study to determine preadmission triaging tool to predict the development of severe COVID-19 in the Kingdom of Bahrain MATERIALS AND METHODS: A retrospective study was conducted from 1 September 2020 to 30 November 2020 with enrolment of all SARS-CoV-2 PCR-confirmed persons aged ≥ 14 years who attended Al-Shamil Field Hospital (SFH) in the Kingdom of Bahrain for triaging and assessment with recording of the following parameters: systolic blood pressure, heart rate, respiratory rate, temperature, the alert, verbal, pain, unresponsive neurological score, age, oxygen saturation, comorbidities, Body Mass Index (BMI), duration of symptoms and living with immunocompromised populations to develop our local adjusted MEWS as predictor for ICU admission & for consideration of suitable isolation at home. Follow up data of all patients was obtained from the electronic medical records system including CXR findings, treatments/medications received, need of oxygen supplements /intubation, needs of ICU care, and the outcome (death /discharged alive) IBM SPSS statistic version 21 program was used for data analysis. RESULTS: Our study showed that using the locally developed adjusted MEWS score, there was an significant association between high value of this adjusted MEWS score and abnormal radiographic finding (49.7 % Vs. 17 % for patients with high score Vs. those with low score respectively). Out of the 181 patients with high scores on adjusted MEWS; 38.7 % required oxygen via nasal cannula, 14.4 % required face mask and 8.3 % non-rebreather mask; this proportion was significantly higher than their counterpart patients who score low on adjusted MEWS (20.9 %, 7.7 %, 4.8 %respectively) with statistically significance difference between the two groups (p value of 0.00, 0.00,.004 respectively) Requirement of ICU admission was significantly higher among patients with high score in comparison to those with low score (14.4 % vs. 3 %) with significant p value (0.00) But higher score value was not associated significantly with increase mortality rate among COVID patients. CONCLUSION: Development of our new Adjusted MEWS score system by adding the additional elements of age, oxygen saturation, comorbidities, Body Mass Index (BMI) and duration of symptoms found to be very useful predictor tool for preadmission triaging of COVID patients based on their risk assessment to help clinician to decide on the appropriate placement to different level of isolation facilities.

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.

COVID-19 in the Gulf Cooperation Council Member States: An Evidence of Effective Response.

OBJECTIVES: The World Health Organization (WHO) published a global strategic response plan in February 2020 aiming to mitigate the impact of the novel coronavirus disease 2019 (COVID-19) outbreak. It identified immediate activities required for global preparedness and response to the outbreak and set eight priority areas (pillars) essential for scaling up countries' operational readiness and response. Despite a semi-annual progress report on implementing the Global Strategic Plan in June 2020, there is limited granular information available on the extent of the national plan's content and implementation, particularly in the Member States of the Gulf Cooperation Council (GCC). Therefore, we sought to review the preparedness and responsiveness towards the COVID-19 outbreak in the GCC in the first phase of the pandemic and to document lessons learned for improving the ongoing response efforts and preparedness for future pandemics. METHODS: A rapid appraisal was conducted in June 2020 according to the WHO Strategic Preparedness and Response Plan and the accompanying Operational Planning Guidelines. The survey was administered to public health professionals or/and infectious disease experts in the states. The findings were cross-triangulated with secondary data that was publicly available for each country. RESULTS: The preparedness and response efforts of Bahrain, Saudi Arabia, and the UAE were fully compliant with all 11 (100%) pillars of the modified strategic response measures. Kuwait, Oman, and Qatar complied with eight of the pillars. The component on conducting COVID-19 related research was the lowest-performing across all the six states. CONCLUSIONS: All GCC states demonstrated an effective response to the pandemic, enhanced existing infrastructures, and accelerated reforms that would have otherwise taken longer. The lessons learned through the early phase of the pandemic continue to steer the states in realigning their strategies and resetting their goals of controlling the outbreak, particularly in the current context of vaccine introduction and increasing preparedness capacities for future pandemics.

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.

Prevalence of infections and antimicrobial use in the acute-care hospital setting in the Middle East: Results from the first point-prevalence survey in the region.

OBJECTIVES: Community-acquired (CAIs) and healthcare-associated (HAIs) infections are associated with significant morbidity and mortality. Data related to the epidemiology of these infections in the Middle East is scarce. The aim of this study is to estimate the prevalence of infections and antimicrobial use in the acute hospital setting in this region. METHODS: A multicentre Point-Prevalence Survey was conducted in seven Middle Eastern countries: Egypt, Kingdom of Saudi Arabia, United Arab Emirates, Lebanon, Oman, Kuwait and Bahrain. Data were collected by the infection control and infectious diseases teams of the respective hospitals. Study surveys were completed in one day (03 April 2018). RESULTS: The overall point prevalence of infection was 28.3%; HAI and CAI point prevalence was 11.2% and 16.8%, respectively. The majority of patients with an infection (98.2%) were receiving antimicrobial therapy. There were high levels of resistance to antimicrobials among Acinetobacter baumannii, Enterobacter cloacae, Klebsiella pneumoniae and other Klebsiella sp. CONCLUSIONS: Our findings indicate that the point prevalence of both HAI and CAI is high in a sample of Middle Eastern countries. These findings along with the increased use of antimicrobials represent a significant public health problem in the region; particularly in light of the growing regional antimicrobial resistance.

Identification of carbapenem-resistant Pseudomonas aeruginosa in selected hospitals of the Gulf Cooperation Council States: dominance of high-risk clones in the region.

PURPOSE: The molecular epidemiology and resistance mechanisms of carbapenem-resistant Pseudomonas aeruginosa (CRPA) were determined in hospitals in the countries of the Gulf Cooperation Council (GCC), namely, Saudi Arabia, the United Arab Emirates, Oman, Qatar, Bahrain and Kuwait. METHODOLOGY: Isolates were screened for common carbapenem-resistance genes by PCR. Relatedness between isolates was assessed using previously described genotyping methods: an informative-single nucleotide polymorphism MassARRAY iPLEX assay (iPLEX20SNP) and the enterobacterial repetitive intergenic consensus (ERIC)-PCR assay, with selected isolates being subjected to multilocus sequence typing (MLST). Ninety-five non-repetitive isolates that were found to be resistant to carbapenems were subjected to further investigation.Results/Key findings. The most prevalent carbapenemase-encoding gene, blaVIM-type, was found in 37/95 (39 %) isolates, while only 1 isolate (from UAE) was found to have blaIMP-type. None of the CRPA were found to have blaNDM-type or blaKPC-type. We found a total of 14 sequence type (ST) clusters, with 4 of these clusters being observed in more than 1 country. Several clusters belonged to the previously recognized internationally disseminated high-risk clones ST357, ST235, ST111, ST233 and ST654. We also found the less predominant ST316, ST308 and ST823 clones, and novel MLST types (ST2010, ST2011, ST2012 and ST2013), in our collection. CONCLUSION: Overall our data show that 'high-risk' CRPA clones are now detected in the region and highlight the need for strategies to limit further spread of such organisms, including enhanced surveillance, infection control precautions and further promotion of antibiotic stewardship programmes.

Evolution of genotypic resistance algorithms and their impact on the interpretation of clinical trials: an OPTIMA trial substudy.

PURPOSE: The outdated rules of older HIV genotypic resistance algorithms can affect virologic responses. This study was designed to determine how often these incorrect resistance interpretations affect analyses of long-term clinical trials, antiretroviral (ARV) choices, and HIV disease progression rates. METHOD: Baseline VIRCO virtual phenotypes (VVP) from patients screened in 2001-2002 for OPTIMA were compared to 2005 Stanford HIV resistance database algorithm (HIVDB-10/05, version 4.1.4) interpretations of the HIV-1 pol sequences. Drugs were called discordant if resistant by one algorithm and sensitive by the other. RESULTS: Of 2,341 drug comparisons, 501 (21.4%) were discordant, affecting 140 (86.4%) of 162 screened patients. NRTI/NtRTIs were more discordant than NNRTIs and PIs (38.6% vs. 4.3% vs. 12.8%; p < .0001). Sixty-nine (53%) patients were placed on 2 drugs reported as sensitive by VVP but resistant by HIVDB-10/05; they had higher than expected rates of disease progression and a similar time to first event or death as patients on ARVs classified as resistant by both algorithms (p = .61). CONCLUSIONS: Underestimation of drug resistance by older genotypic algorithms resulted in using ARVs incorrectly thought to be sensitive and in higher than expected rates of HIV disease progression. The use of older genotypes to interpret long-term clinical trials should account for this underestimation, because results may be different if viral sequences are interpreted with newer algorithms.

Pituitary abscess.

Pituitary abscess is an uncommon pituitary lesion. Its clinical diagnosis can be difficult to distinguish from other pituitary lesions. This pathology is characterised by vague symptoms of headaches, generalised tiredness and hypopituitarism manifestations. A history of recent meningitis, paranasal sinusitis or head surgery can be a suggestive of the source of infection.A 20-year-old man was admitted to neurosurgery department with complain of headache, fatigue, polyuria, polydipsia, blurred vision and sexual dysfunction. MRI of the head revealed a suprasellar mass that was centrally hyperintense lesion on T2-weighted images with peripheral hypointensity and isointense centrally on T1 images with peripheral hyperintensity images. Treatment of this lesion pituitary abscess was surgical drainage of the pituitary area through a trans-sphenoidal approach and broad spectrum antibiotic therapy with ceftriaxone, metronidazole and vancomycin for 6 weeks. The patient continues to have pituitary insufficiency and treated with oral hydrocortisone.Although pituitary abscess is a rare condition, it should always be kept in mind when evaluating a patient with hypopituitarism. After the diagnosis, the surgery and antibiotics should be commenced rapidly. The outcome is usually good with proper treatment.

Tetanus in an unvaccinated laborer in Bahrain.

Mr. M.D.S., a 27-year-old Indian male, presented with complaints of diffuse body pain and spasms, 7 days after a needle penetrated his right foot at his place of work. He was diagnosed clinically with tetanus. The patient was electively intubated to protect the airway and transferred to an intensive care unit. In addition to his tetanus, he developed multiple hospital-acquired infections. After 34 days, he was successfully extubated and extensive physiotherapy commenced. He was discharged 10 days after extubation.

Fever in sickle cell disease patients in the Kingdom of Bahrain.

Sickle cell disease (SCD) is a hereditary blood disorder characterized by abnormal red blood cell shape (sickling). The incidence of the disease in the Kingdom of Bahrain is approximately 2.1%. Patients with SCD are prone to multiple health complications, some of which are fatal. A retrospective study was conducted at the Salmaniya Medical Complex in the Kingdom of Bahrain from June, 2012 to December, 2012 to assess the incidence of fever among the SCD in-patients at that institution. The study also assessed the antibiotics administered, type of organisms isolated and patient outcome. The results showed that a total of 59 patients developed fever and 33 of those with fever had a positive culture result (55.93%). The most common isolate was gram-positive bacteria, most commonly Staphylococcus epidermidis (42.86%), and ceftriaxone was the most commonly prescribed antimicrobial. In conclusion, there was a low rate of hospital acquired infection and special attention needs to be paid to the infection control measures for SCD patients. For most of the SCD fever cases, there was no clear cause of the fever even after extensive diagnostic evaluations; thus, those fevers may have been of a non-infectious etiology in this population. Fortunately, none of the patients had any of the common preventable infections as a result of the high vaccination coverage and strong vaccination program in place in the Kingdom of Bahrain.

Infection in long term care facility in the kingdom of Bahrain.

Infections in long term care facilities (LTCF) are common and are considered a major cause of mortality and morbidity. Endemic infections and outbreaks are observed in LTCF. Of particular concern is the growth of multi-drug resistant organisms. A study was conducted in the Kingdom of Bahrain concerning infections among the residents in a LTCF. The aim was to define the rate, type and outcomes of institutional infections. The different treatment modalities and antimicrobials used were evaluated. Our facility cares for the elderly and a heterogeneous group of patients from different populations (e.g., mentally retarded, bedbound due to various disabilities and other forms of consciousness impairment such as post stroke disability, cerebral palsy and anoxic brain damage). The initial span of six months was changed to seven months to increase the sample size and improve the data analysis. This was a prospective study conducted in Muharaq Geriatric Hospital in the Kingdom of Bahrain. The study was conducted over seven months from January 2013 to July 2013 on 104 patients. During that period, patients with new positive cultures from different sites were included. The clinical features, microbiological features and outcomes of the bacteremic episodes were included. The information was collected by a questionnaire created by the research team. From a total of 104 patients staying in the LTFC, 19 had positive cultures from different sites at different times. The study showed that infections are common, especially urinary tract infections.

Renal malakolpkia followed by chronic myelogenous leukaemia: treatment challenges case report and literature review.

Malakoplakia is a rare granulomatous disorder of unknown aetiology and usually affects patients with underlying immunosuppression. This disorder usually involves the genitourinary tract but has been reported in a wide array of anatomical sites. We are presenting, what is to our knowledge, the first case in the literature in which a patient was diagnosed with malakoplakia and after his successful management; he was diagnosed with chronic meylomoncytic leukaemia. All cases of malakoplakia reported in the literature were either preceded or accompanied by an immunosuppressive state.