Patterns of fluoroquinolone utilization and resistance in a tertiary care hospital: a retrospective cross-sectional analysis study from a developing country.

BACKGROUND: Fluoroquinolones are the most commonly prescribed antibiotics. Because of their known tendency to drive antimicrobial resistance, their prescribing patterns need to be more restricted. This study aimed to describe the clinical practice of fluoroquinolone prescription, dose adjustments for renal impairment patients and bacterial resistance profiles, eventually providing evidence-based recommendations to optimize antibiotic prescribing practices in the local population. METHODS: This retrospective, cross-sectional study was conducted at An-Najah National University Hospital in Palestine. The data were collected from admitted patients who were given ciprofloxacin or levofloxacin from July 2021 to June 2023. Data from 692 inpatients across various hospital departments were examined (409 for levofloxacin and 283 for ciprofloxacin). Statistical analysis was performed via IBM SPSS version 23.0 to summarize the demographic, clinical, and epidemiological data. RESULTS: The sociodemographic profile revealed diverse age distributions, with 25.4% and 39% older than 50 years for ciprofloxacin and levofloxacin, respectively. Ciprofloxacin was predominantly used in the oncology department (28.2%), with surgical prophylaxis (22.6%) and febrile or afebrile neutropenia (21.1%) being the most common indications. Levofloxacin was predominantly used in the medical ward (45.7%), mainly for lower respiratory tract infection (58.8%) and prophylaxis for bone marrow transplantation (16.5%). Enterococcus and methicillin-resistant Staphylococcus aureus were the most commonly isolated pathogens, with 62.5% of the isolates demonstrating resistance to ciprofloxacin. Moreover, extended-spectrum beta-lactamase-producing Enterobacterales were the most common pathogen isolated, with 33.3% being resistant to levofloxacin. Statistical analysis revealed a significant association between the choice of antibiotic and the approach to therapy. Levofloxacin was significantly more likely than ciprofloxacin to be used as empiric therapy (p < 0.001), whereas ciprofloxacin was more likely to be used as targeted therapy (p < 0.001). CONCLUSIONS: This study investigated prescribing practices and resistance to levofloxacin and ciprofloxacin in a large hospital in a developing country. According to the bacterial resistance profiles, we conclude that there is a need for hospital departments to exercise greater restraint on the use of these antibiotics. To this end, further studies addressing the clinical efficacy of fluoroquinolones against the current treatment guidelines to evaluate their appropriateness should be carried out.

Blood culture contamination in a tertiary care hospital: a retrospective three-year study.

BACKGROUND: Bloodstream infections (BSI) are a leading cause of morbidity and mortality in hospitalized patients worldwide. A blood culture is the primary tool for determining whether a patient has BSI and requires antimicrobial therapy, but it can result in an inappropriate outcome if the isolated microorganisms are deemed contaminants from the skin. Despite the development of medical equipment and technology, there is still a percentage of blood culture contamination. The aims of this study were to detect the blood culture contamination (BCC) rate in a tertiary care hospital in Palestine and to identify the departments with the highest rates along with the microorganisms isolated from the contaminated blood samples. METHOD: Blood cultures that were taken at An-Najah National University Hospital between January 2019 and December 2021 were evaluated retrospectively. Positive blood cultures were classified as either true positives or false positives based on laboratory results and clinical pictures. Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) version 21. A p-value of less than 0.05 was considered statistically significant for all analyses. RESULTS: Out of 10,930 blood cultures performed in the microbiology laboratory from 2019 to 2021, 1479 (13.6%) were identified as positive blood cultures that showed microbial growth. Of these, 453 were blood culture contaminations, representing 4.17% of total blood cultures and 30.63% of the positive blood culture samples. The highest rate of contamination was in the hemodialysis unit (26.49%), followed by the emergency department (15.89%). Staphylococcus epidermidis was the most prevalent (49.2%), followed by Staphylococcus hominis (20.8%) and Staphylococcus haemolyticus (13.2%). The highest annual contamination rate was observed in 2019 (4.78%) followed by 2020 (3.95%) and the lowest was in 2021 (3.79%). The rate of BCC was decreasing, although it did not reach statistically significant levels (P value = 0.085). CONCLUSION: The rate of BCC is higher than recommended. The rates of BCC are different in different wards and over time. Continuous monitoring and performance improvement projects are needed to minimize blood culture contamination and unnecessary antibiotic use.

Nosocomial infections in the surgical intensive care unit: an observational retrospective study from a large tertiary hospital in Palestine.

BACKGROUND: Nosocomial infections or hospital-acquired infections are a growing public health threat that increases patient morbidity and mortality. Patients at the highest risk are those in intensive care units. Therefore, our objective was to provide a pattern analysis of nosocomial infections that occurred in an adult surgical intensive care unit (ICU). METHODS: This study was a retrospective observational study conducted in a 6-bed surgical intensive care unit (SICU) at An-Najah National University Hospital (NNUH) to detect the incidence of nosocomial infections from January 2020 until December 2021. The study group included 157 patients who received antibiotics during their stay in the SICU. RESULTS: The incidence of nosocomial infections, either suspected or confirmed, in the SICU was 26.9% (95 out of 352 admitted patients). Pneumonia (36.8%) followed by skin and soft tissue infections (35.8%) were the most common causes. The most common causative microorganisms were in the following order: Pseudomonas aeruginosa (26.3%), Acinetobacter baumannii (25.3%), extended-spectrum beta lactamase (ESBL)-Escherichia coli (23.2%) and Klebsiella pneumonia (15.8%). The average hospital stay of patients with nosocomial infections in the SICU was 18.5 days. CONCLUSIONS: The incidence of nosocomial infections is progressively increasing despite the current infection control measures, which accounts for an increased mortality rate among critically ill patients. The findings of this study may be beneficial in raising awareness to implement new strategies for the surveillance and prevention of hospital-acquired infections in Palestinian hospitals and health care centers.

Epidemiology and clinical characteristics of patients with carbapenem-resistant enterobacterales infections: experience from a large tertiary care center in a developing country.

BACKGROUND: Carbapenem-resistant Enterobacterales (CREs) are a significant source of healthcare-associated infections. These bacteria are difficult to treat and have a high mortality rate due to high rates of antibiotic resistance. These pathogens are also linked to major outbreaks in healthcare institutions especially those with limited resources in infection prevention and control (IPC). Therefore, our study aimed to describe the epidemiology and clinical characteristics of patients with carbapenem-resistant Enterobacteriaceae in a referral hospital in a developing country. METHODS: This was a retrospective cross-sectional study that included 218 patients admitted to An-Najah National University Hospital between January 1, 2021, and May 31, 2022. The target population was all patients with CRE infection or colonization in the hospital setting. RESULTS: Of the 218 patients, 135 had CR-Klebsiella pneumoniae (61.9%), and 83 had CR-Escherichia coli (38.1%). Of these, 135 were male (61.9%) and 83 were female (38.1%), with a median age of 51 years (interquartile range 24-64). Malignancy was a common comorbidity in 36.7% of the patients. Approximately 18.3% of CRE patients were obtained from patients upon admission to the emergency department, the largest percentage among departments. Most CRE pathogens were isolated from rectal swabs, accounting for 61.3%. Among the 218 patients, colistin was the most widely used antimicrobial agent (13.3%). CR- E. coli showed resistance to amikacin in 23.8% of the pathogens tested and 85.7% for trimethoprim/sulfamethoxazole compared to CR- K. pneumonia, for which the resistance to trimethoprim/sulfamethoxazole was 74.1%, while for amikacin it was 64.2%. Regarding meropenem minimum inhibitory concentration, 85.7% of CR- E. coli were greater than 16 µg/mL compared to 84% of CR- K. pneumonia isolates. CONCLUSION: This study found that CRE is frequently reported in this tertiary care setting, implying the presence of selective pressure and transmission associated with healthcare setting. The antibiotics tested showed a variety of resistance rates, with CR-K. pneumoniae being more prevalent than CR-E. coli, and exhibiting an extremely high resistance pattern to the available therapeutic options.

Epidemiology and source of infection in cancer patients with febrile neutropenia: an experience from a developing country.

BACKGROUND: Febrile neutropenia (FN) is a life-threatening complication that predisposes cancer patients to serious infections. This study aims to describe the epidemiology and source of infection in cancer patients with FN in a tertiary care hospital. METHODS: A hospital-based retrospective study was conducted in a large tertiary care hospital from January 2020 to December 2021. Data on cancer patients with FN were collected from the hospital information system. RESULTS: 150 cancer patients with FN were identified during the study period. Most patients were males (98; 65.3%), and the mean age of participants was 42.2 ± 16.0 years. Most patients (127; 84.7%) had hematologic malignancies, and acute myeloid leukemia was the most common diagnosis (42; 28%), followed by acute lymphocytic leukemia (28; 18.7%) and Hodgkin's lymphoma (20; 13.3%). Fifty-four (36%) patients had a median Multinational Association for Supportive Care in Cancer (MASCC) scores greater than 21. Regarding the outcome, nine (6%) died, and 141(94%) were discharged. The focus of fever was unknown in most patients (108; 72%). Among the known origins of fever were colitis (12; 8%), pneumonia (8; 5.3%), cellulitis (6; 4%), bloodstream infections (7; 4.6%), perianal abscess (2; 1.3%) and others. The median duration of fever was two days, and the median duration of neutropenia was seven days. Sixty-three (42%) patients had infections: 56 (73.3%) were bacterial, four (2.6%) were viral, two (1%) were fungal and 1 (0.7%) was parasitic. Among the bacterial causes, 50 cases (89.2%) were culture-positive. Among the culture-positive cases, 34 (68%) were gram-positive and 22 (44%) were gram-negative. The most frequent gram-positive bacteria were E. faecalis (9; 18% of culture-positive cases), and the most frequent gram-negative organisms were Klebsiella pneumoniae (5; 10%). Levofloxacin was the most commonly used prophylactic antibiotic (23; 15.33%), followed by acyclovir (1610.7%) and fluconazole in 15 patients (10%). Amikacin was the most popular empiric therapy, followed by piperacillin/tazobactam (74; 49.3%), ceftazidime (70; 46.7%), and vancomycin (63; 42%). One-third of E. faecalis isolates were resistant to ampicillin. Approximately two-thirds of Klebsiella pneumoniae isolates were resistant to piperacillin/tazobactam and ceftazidime. Amikacin resistance was proven in 20% of isolates. CONCLUSIONS: The majority of patients suffered from hematologic malignancies. Less than half of the patients had infections, and the majority were bacterial. Gram-positive bacteria comprised two-thirds of cases. Therefore, empiric therapy was appropriate and in accordance with the antibiogram of the isolated bacteria.

Microbial spectrum and drug resistance profile in solid malignancies in a large tertiary hospital from Palestine.

BACKGROUND: Since the available data for bloodstream infections in solid malignancy tumors are somewhat limited in Palestine, prevention of infection before the occurrence, controlling it when it occurs, and implementing stewardship programs are important ways in the whole therapy of solid tumor patients, which is becoming challenging recently with the evolution of more antimicrobial drug-resistant pathogens. Therefore, our study aims to assess the microbial spectrum and antimicrobial sensitivity and the overall outcome related to many clinical risk factors in patients with solid tumor patients seeking care in a referral hospital as an experience from a developing country. METHODS: From the onset of 2018 to the end of 2020, a total of 116 episodes with positive blood cultures were retrospectively studied and analyzed in 96 patients who had solid tumors in a referral hospital in Palestine. RESULTS: We identified 116 positive blood cultures in 96 patients with a male to female ratio of 1:1. The mean age was 58 years. Breast cancer was the tumor most frequently recorded (13.5%), followed by urinary tract tumors (10.4%). The most common source of episodes with positive blood culture was catheter-related. Gram-positive bacteria accounted for 52.6% of blood cultures with the predomination of Staphylococcus species. On the contrary, Gram-negative bacteria were documented in 39.7% of the cultures, with E. coli being the most frequent bacteria. Regarding fungi that were only Candida species, it was isolated in 15.5% of the cultures.28.4% of patients started on a single antimicrobial as an initial regimen, the remaining started combination antimicrobial therapy. The initial antimicrobials used most frequently were aminoglycosides in 29.3% of the episodes. All species of Staphylococcus were sensitive to vancomycin. Enterococcus species were fully resistant to ciprofloxacin. In the case of E. coli, the isolates were 100% sensitive to imipenem, meropenem, and amikacin and were mostly resistant to ampicillin, where the sensitivity was only about 19.5%. P.aeruginosa was sensitive in 83.3% of cultures to both piperacillin-tazobactam and gentamicin, but highly resistant to imipenem, in which sensitivity decreased to 50%. The isolates of Klebsiella species were 72.2% sensitive to gentamicin, meropenem, and imipenem and 100% resistant to ampicillin. A. baumannii was 50% sensitive to trimethoprim-sulfamethoxazole. Candida species showed high sensitivity to both caspofungin and flucytosine (83.3%), followed by 77.8% sensitivity to voriconazole. Death was reported in 27.6% of the episodes and there was a significant relationship between shock at presentation and death (p = 0.010). CONCLUSIONS: The findings of this investigation confirm the prevalent BSI seen in patients with solid malignancies and demonstrate a significant percentage of antibiotic resistance. Therefore, stewardship programs that dig deep before using any type of antimicrobials will help reduce the risk of resistance to antibiotics. In addition, the implementation of infection control surveillance plays an important role in decreasing the risk of contamination.

Evaluation of Shigella Species Azithromycin CLSI Epidemiological Cutoff Values and Macrolide Resistance Genes.

Azithromycin (AZM) has been recommended by the American Academy of Pediatrics for the treatment of shigellosis in children. In this study, 502 Shigella species isolated between 2004 and 2014 were tested for AZM epidemiological cutoff values (ECV) by disk diffusion. AZM MICs and the presence of the macrolide resistance genes [erm(A), erm(B), erm(C), ere(A), ere(B), mph(A), mph(B), mph(D), mef(A), and msr(A)] were determined for all 56 (11.1%) isolates with an AZM disk diffusion zone diameter of ≤15 mm. The distribution of AZM ECV MICs was also determined for 186 Shigella isolates with a disk zone diameter of ≥16 mm. Finally, pulsed-field gel electrophoresis (PFGE) was performed on 15 Shigella flexneri isolates with an AZM disk zone diameter of <16 mm from different years and geographic locations. Serotyping the 502 Shigella species isolates revealed that 373 (74%) were S. sonnei, 119 (24%) were S. flexneri, and 10 (2%) were S. boydii Of the 119 Shigella flexneri isolates, 48 (42%) isolates had an AZM disk diffusion zone diameter of ≤15 mm and a MIC of ≥16 µg/ml. With the exception of one isolate, all were positive for the macrolide resistance gene mph(A). S. flexneri PFGE showed four distinct patterns, with patterns I and II presenting with 92.3% genetic similarity. On the other hand, 2 (0.5%) of the 373 S. sonnei isolates had the AZM non-wild-type (NWT) ECV phenotype (those with acquired or mutational resistance), as the AZM MICs were ≥32 µg/ml and the isolates were positive for the mph(A) gene. Overall, our S. flexneri results are in concordance with the CLSI AZM ECV, but isolates with an AZM disk diffusion zone diameter between 14 and 15 mm should be carefully evaluated, as the S. flexneri AZM MIC for NWT isolates may need adjustment to 32 µg/ml. Our data on S. sonnei support that the AZM NWT ECV should be 11 mm for the disk diffusion zone diameter and ≥32 µg/ml for the MICs.

Tigecycline-induced pancreatitis in a patient with recurrent malignancy: a case report and literature review.

Introduction and importance: Drug-induced pancreatitis is an important health issue that makes a minority of causes of acute pancreatitis. Tigecycline-induced pancreatitis is a rare condition with poorly understood mechanism and has a small incident compared to other causes of pancreatitis. Case presentation: The authors present a case of a 39-year-old female patient with acute pancreatitis. Tigecycline was the suspected culprit by exclusion. The patient was managed by keeping her nill per os, rehydration, pain management and discontinuation of the drug. The patient improved gradually. Clinical discussion: Tigecycline-induced acute pancreatitis is a rare but known complication that is mostly seen in patients with chronic renal insufficiency combined with high dose of administration. Onset is usually within 14 days of initiation. Discontinuation of the drug is the most effective intervention in addition to supportive management. Conclusion: Acute pancreatitis should be suspected in any patient presenting with vomiting, abdominal pain and acidosis while on tigecycline. Monitoring of amylase and lipase can be beneficial especially in those with chronic renal insufficiency or those receiving a high dose.

Spectrum and antibiotic resistance in community- and hospital-acquired urinary tract infections among adults: Experience from a large tertiary care center in a developing country.

BACKGROUND: It is important to note that the causative agents and patterns of antibiotic resistance vary between urinary tract infections (UTIs) acquired in the community and those acquired in a hospital setting. Therefore, the aim of this study was to compare the types of organisms and patterns of antibiotic resistance in adult patients with community-acquired urinary tract infections (CA-UTIs) and hospital-acquired urinary tract infections (HA-UTIs). METHODS: Retrospectively, we collected urine samples from patients at An-Najah National University Hospital who experienced nonrecurring urinary tract infections (UTIs) between January 2019 and December 2020. The data were subsequently analyzed using IBM-SPSS® 21.0 software to determine the distribution of microorganisms and evaluate the rates of antibiotic resistance. RESULTS: A total of 798 nonrepetitive UTI patients were included in our study, in which more than half of the UTIs occurred in female patients (472; 59.1%), and most of the UTIs were of community origin (611; 76.6%). Both community-acquired urinary tract infections (CA-UTIs) and hospital-acquired urinary tract infections (HA-UTIs) were more common in female patients (45.6% and 13.5%, respectively). Escherichia coli was the most commonly isolated urinary pathogen in both the CA-UTIs and HA-UTIs. The five most common isolated urinary pathogens were E. coli, Klebsiella pneumoniae, Enterococcus faecalis, E. faecium, and Pseudomonas aeruginosa. Among the isolated bacteria, 28.2% were extended-spectrum beta-lactamase (ESBL)-producing bacteria, 4.1% were carbapenem-resistant Enterobacterales (CRE), and 6.5% were vancomycin-resistant Enterococci. The most commonly isolated urinary pathogens from HA-UTIs showed higher resistance rates against all the tested antibiotics except for E. faecium, which showed greater resistance to tetracycline (42.5%) and quinupristin/dalfopristin (17.5%) in CA-UTIs. CONCLUSIONS: There are similarities in the etiological profiles of CA-UTI and HA-UTI, but the resistance rates are high, and urine culture is essential for the correct treatment of individual cases, even in primary care.

Epidemiology and clinical characteristics of patients with healthcare-acquired multidrug-resistant Gram-negative bacilli: a retrospective study from a tertiary care hospital.

The numbers of infections caused by Gram-negative bacteria (GNB) that produce extended-spectrum beta-lactamases (ESBLs) and those that are carbapenem resistant, especially Escherichia coli (E. coli) and Klebsiella pneumoniae (K. pneumoniae), are increasing, and these infections are becoming a global public health problem. The aim of this study was to assess the prevalence of infections caused by ESBL-producing and carbapenem-resistant Gram-negative bacilli in patients hospitalized at An-Najah National University Hospital in Nablus, Palestine, and to provide healthcare workers with valuable information on the treatment of these infections. A retrospective cross-sectional investigation was conducted at a large tertiary care teaching hospital. The study included patients admitted to the hospital between January and December 2021, from whom ESBL-producing and carbapenem-resistant Gram-negative bacilli were isolated. The patients' clinical and demographic information was obtained from the hospital information system. In addition, information regarding the bacterial isolates and antibiotic resistance was obtained from the hospital's microbiology laboratory. This study included a total of 188 patients-91 males (48.4%) and 97 females (51.6%). The general surgical ward accounted for the highest proportion of infections (30.9%), followed by the surgical ICU (12.2%). The most common infections were caused by ESBL-producing E. coli, which accounted for 62.8% of the cases. Among them, urinary tract infections caused by this microorganism were the most prevalent (44.7% of patients). Over 50% of the patients (54.2%) had a history of antibiotic use, and 77.8% had been hospitalized within the past three months. ESBL-producing E. coli was significantly isolated from blood cultures (p-value = 0.000), and CR-K. pneumoniae was significantly isolated from endotracheal isolates (p-value = 0.001). This study emphasizes the concerning frequency of healthcare-acquired infections caused by ESBL-producing and carbapenem-resistant GNB in a tertiary care hospital. The substantial prevalence of antibiotic resistance presents considerable obstacles to the successful administration of routinely employed antibiotics. The results highlight the immediate need for improved antimicrobial stewardship and the implementation of infection control strategies to reduce the effects of multidrug-resistant GNB on patient well-being and public health.

Evaluation of COVID-19 rapid antigen test against polymerase chain reaction test in immunocompromised patients.

On the 11th of March 2020, the world faced a new global pandemic, COVID-19 which is a disease caused by the novel coronavirus, it had multiple devastating outcomes on multiple sectors along with significant rates of mortality. These challenges encouraged the development of multiple testing methods, as well as anti-viral medications such as Molnupiravir, as well as evaluating the efficacy of available medications against it, like; Azithromycin, Ritonavir and Hydroxychloroquine. Vaccination against COVID-19 forged into a significant challenge, few months ensuing the first case of SARS-CoV-2, which was diagnosed in December 2019, in Wuhan-China, thus, multiple vaccines were approved for use around the world to combat this pandemic. Our study includes a sample of 556 oncology patients at Augusta Victoria Hospital in Jerusalem, all patients were tested using Panbio rapid antigen test and Allplex PCR Assay. The main objective was to study the sensitivity and specificity of Rapid antigen test, which contributes to a faster isolation call and management of infected patients, thus decreasing the risk on spread to other patients and health care. Patients were categorized based on two factors: Ct range and age group and studying their possible effect on false-negative results. Patients with Ct value less than 20, had the highest detection rate which is consistent with other studies in the literature. The sensitivity and specificity of Panbio Rapid Antigen testing were of 69.9% and 100%, respectively. A correlation between age group and false negative results could not be made, but a correlation between Ct value and false negative result was noticed, Ct value was directly related to false negative results. P-value of 0.007 indicated that results were statistically significant where PCR test is considered more sensitive compared to rapid antigen test.

Successful Autologous Bone Marrow Transplantation in Active COVID-19 Patients: Case Report.

BACKGROUND: Patients with hematologic malignancies are considered at high risk for COVID-19 infection either from the disease or the treatment. Hematopoietic stem cell transplantation, one of the approved therapies for hematologic malignancies, was performed worldwide during the COVID-19 era with some regulations, such as COVID-19 testing, before proceeding with transplantation or cellular therapy. To the authors' knowledge, none have reported the result of autologous hematopoietic stem cell transplantation in an active COVID-19 patient. CASE PRESENTATION: We describe a successful clinical course of autologous bone marrow transplantation for 2 lymphoma patients who tested positive for COVID-19. A thorough discussion was conducted between multidisciplinary hemato-oncology, intensive care, and infectious diseases teams. The decision was to proceed toward bone marrow transplantation with some modifications in the transplantation protocol and close patient monitoring. CONCLUSION: Our cases lend credence that successful autologous bone marrow transplantation is possible among active COVID-19 patients. The obstacles we faced could be overcome with collaboration between a highly qualified multidisciplinary team. Despite the potential complications, the benefits of bone marrow transplantation among patients with a high risk of relapse and who are still COVID-19-positive outweigh the risks. However, further studies are still recommended to support our inference.

Impact of an antibiotic stewardship program on antibiotic utilization, bacterial susceptibilities, and cost of antibiotics.

Antimicrobial misuse is a worldwide issue, and antimicrobial resistance is considered the most challenging aspect of health care. It has been reported that as much as 30-50% of antimicrobials prescribed in hospitals are deemed unnecessary or inappropriate. Antibiotic stewardship programs (ASPs) include policies that apply continuous management of judicious anti-infectious treatment in the clinical setting. Therefore, the objectives of this study were to evaluate the effect of ASPs on antibiotic consumption, the costs of antibiotic expenditure, and the sensitivity of antimicrobials. A retrospective, quasi-experimental study was performed to assess the effect of ASP at An-Najah National University Hospital, a tertiary care hospital in the West Bank, Palestine, over a period of 20 months before and 17 months after the implementation of the ASP. Data on antibiotic consumption were reported monthly as days of therapy per 1000 patient-days and monthly costs (USD/1000 patient-days). A total of 2367 patients who received one or more of the targeted antibiotics (meropenem, colistin and tigecycline) during their hospital stay were included in the study. They have split into two groups: 1710 patients in the pre-ASP group, and 657 patients in the post ASP group. The most significant reduction in DOT per 1000 patient-days was seen with tigecycline, with a percentage of change of - 62.08%. Furthermore, the mean cost of the three antibiotics decreased significantly by 55.5% in the post-ASP phase compared to the pre-ASP phase. After the implementation of ASP, there was a statistically significant increase in susceptibility to meropenem, piperacillin and piperacillin/tazobactam with respect to Pseudomonas aeruginosa. However, changes in mortality rates were not statistically significant (p = 0.057). ASP positively reduced costs and antimicrobial consumption, with no statistically significant effect on the overall mortality rate. However, a long-term evaluation of the ASP's impact is needed to conclude its lasting impact on infection-related mortality and antimicrobial susceptibility pattern.

Global trends in research related to the links between microbiota and antibiotics: a visualization study.

The scientific community widely acknowledges that the gut microbiota plays a critical role in maintaining host health and can be altered by a range of factors, such as antibiotic use, diet, stress, and infections. Therefore, this study utilized bibliometric analysis to thoroughly investigate research trends in the microbiota and antibiotics. Scopus was used to extract papers linked to microbiota and antibiotics published between 2002 and 2021, and both Microsoft Excel and VOSviewer were used to conduct the analysis of the data. A total of 2,816 publications discussed the connection between the microbiota and antibiotics. Growth occurred in two stages: the first (2002-2015) was characterized by fairly slow publication production, while the second (2016-2021) saw a rapid increase in publishing progress. The United States has the most publications, 654, representing 23.22% of the total. China came second with 372 publications (13.21%), followed by the United Kingdom with 161 publications (5.72%) and India with 157 publications (5.58%). In addition, publications on 'altered intestinal microbiota composition with antibiotic treatment' were introduced after 2017, while 'gut microbiota and antimicrobial resistance' and 'probiotics as an alternative antimicrobial therapy' were introduced before 2017. Based on these results, this study provides an in-depth look at key moments in the history of microbiota and antibiotic research, as well as possible directions for future research in different areas of microbiota and antibiotic research. Therefore, it is suggested that more attention should be given to the latest promising hotspots, such as how antibiotic treatment changes the composition of the gut microbiota.

Antibiotic resistance profiles and associated factors of Pseudomonas Infections among patients admitted to large tertiary care hospital from a developing country.

BACKGROUND: Pseudomonas infections are among the most common infections encountered in hospitalized patients, especially those with chronic illnesses or an immunocompromised state. Management of these infections has become challenging due to increased antibiotic resistance. Therefore, this study examines the antibiotic resistance profiles of Pseudomonas spp. and the associated factors among patients admitted to a large tertiary hospital in a developing country. METHODS: This retrospective observational chart review study assessed patients admitted to a large tertiary hospital in a developing country with a positive culture growth of Pseudomonas from anybody site. Antibiotic susceptibility of the isolated Pseudomonas and patient characteristics were studied from the start of 2021 to the end of 2022. The study ground consisted of 185 patients. RESULTS: The study included 185 patients with positive Pseudomonas isolates. Males constituted 54.6% of the sample, while 45.4% were females. The median age of the patients was 53 years. Patient comorbidities and risk factors for Pseudomonas infection and multidrug resistance were assessed. Antibiotic resistance to the Pseudomonas regimens showed the highest resistance to meropenem and ciprofloxacin (23.4%, similarly) among isolates of Pseudomonas aeruginosa. Multidrug resistance (MDR) was found in 108 (58.4%) isolates. The most commonly used antibiotic for treatment was piperacillin-tazobactam, accounting for 33.3% of cases, followed by aminoglycosides at 26.6%. CONCLUSIONS: Pseudomonas aeruginosa isolates were resistant to meropenem and ciprofloxacin. Over half of the isolates were multidrug-resistant, which was worrying. Piperacillin-tazobactam and aminoglycosides were the most often utilized antibiotics, highlighting the significance of susceptibility testing. Implementing antimicrobial stewardship programs and infection control measures can help reduce drug resistance and improve outcomes in Pseudomonas infections.

A cross-sectional evaluation of knowledge, attitudes, practices, and perceived challenges among Palestinian pharmacists regarding COVID-19.

OBJECTIVES: This study aims to evaluate knowledge, attitudes, practices, and perceived challenges regarding coronavirus disease 2019 among pharmacists in Palestine. METHODS: An online method was used to collect the data. Three hundred sixty-four pharmacists participated in the study from all areas in the Palestinian territories. The questionnaire consisted of three sections: sociodemographics; knowledge, attitudes, practices regarding coronavirus disease 2019; and barriers that prevent the implementation of infection control measures. The Statistical Package for the Social Sciences program Version 21 was used to analyze the data. Variables were expressed as frequencies, percentages, mean, and median. The chi-square test, Kruskal-Wallis test, Mann-Whitney U test, and Pearson's test were applied, along with logistic regression analysis. RESULTS: The median age of the participants was 29 years old, and most of them were female (70.9%). The analysis found that 76.4% of pharmacists had good knowledge regarding coronavirus disease 2019, and 52.7% had good practices. The median attitude score recorded by the participants was 32 points [Q1-Q3: 30-34] out of 35. Notably, the level of concern regarding coronavirus disease 2019 was significantly associated with all three tools of measurement; knowledge (p = 0.001), attitudes (p = 0.001), and practices (p = 0.001). It also appears that more years of experience had higher odds (3-5 years of experience: odds ratio, 2.560; 95% confidence interval, 1.413-4.639; p = 0.002, more than 5 years: odds ratio, 2.931; 95% confidence interval, 1.188-7.232; p = 0.020) of good practice. CONCLUSION: Although an acceptable level of knowledge was found, it might be considered inadequate. Moreover, there is a lack of appropriate adherence to safety measures from pharmacists. Therefore, we recommend the responsible authorities generate an organized training program to expand pharmacists' knowledge and experience regarding coronavirus disease 2019.

Proactive Innovation in a Prolonged Conflict Setting: Facing COVID-19 in a Specialized Cancer Hospital in Palestine.

The prolonged ongoing conflict in Palestine exacerbated socioeconomic conditions and weakened the health system, complicating the management of COVID-19 pandemic, especially for cancer patients who are doubly-at risk. Augusta Victoria Hospital (AVH) is Palestine's only specialized cancer hospital, receiving patients from the Gaza Strip and the West Bank for oncology, nephrology, hematology, and radiotherapy. AVH's preparedness measures enabled its agile response. These proactive and innovative preparedness measures included: implementing a facility-level preparedness and response plan; utilizing multidisciplinary team-based and evidence-informed approaches to decision making; prioritizing health workers' safety and education; establishing in-house PCR testing to scale up timely screenings; and accommodating health workers, patients, and their relatives at hospital hotels, to maintain daily, continuous and critical health care for cancer patients and limit the spread of infection. At the facility-level, the biggest challenge faced by AVH was continuing essential and daily care for immunocompromised patients while protecting them from potential infection from relatives, hospital staff and other suspected patients. At the national level, the lack of preparedness, inequalities in vaccine distribution, political instability, violence, delays in obtaining medical exit permits to reach Jerusalem, weakened AVH's response. AVH's flexible financing, hospital accreditation, and strong leadership and coordination enabled its agility and resilience. Despite compiling challenges, the hospital's proactive and innovative interventions minimized the risk of infection among two high-risk groups: the immunocompromised patients and their health workers, providing invaluable lessons for health facilities in other fragile-and-conflict-affected settings.

Characteristics, Risk Factors, and Prevalence of Clostridioides difficile Among Hospitalized Patients in a Tertiary Care Hospital in Palestine.

PURPOSE: Clostridioides difficile is one of the most important nosocomial infection pathogens. It is linked with many risk factors. Unfortunately, many studies have been conducted in different countries to address the Clostridioides difficile infections (CDI), and no studies have been conducted in Palestine. This study aims to identify the prevalence and possible risk factors associated with CDI. PATIENTS AND METHODS: This was a retrospective descriptive study conducted at the An-Najah National University Hospital (NNUH) in Palestine. Data were collected for patients diagnosed with CDI who tested positive for GDH, toxins A and B between January 2018 and April 30, 2021. In addition, patient characteristics and risk factors associated with CDI were analyzed. RESULTS: A total of 593 participants were included in the study; 53% had hospital-acquired CDI. There was an insignificant association between participant age and CDI risk. Most patients had mild to moderate infections. Sixty-three percent of the participants were immunocompromised. About 58.5% used an antibiotic agent two weeks before CDI, and 67% were on a proton pump inhibitor (PPI). About 61.3% of patients were treated according to IDSA 2017 guidelines, and 94% responded adequately to the treatment provided. CONCLUSION: There was an increased prevalence of community-acquired CDI, with a prevalence almost equal to that of hospital-acquired. In addition, most of the participants were immunocompromised. The risk factors for CDI, such as antibiotics and PPI use, were also observed with high prevalence among positive patients. Antimicrobial stewardship and the appropriate use of acid suppressors are warranted.

Acceptance of COVID-19 vaccines in Palestine: a cross-sectional online study.

INTRODUCTION: In Palestine (West Bank and Gaza), there have been more than 320 890 known cases of COVID-19, resulting in 3452 deaths. The detrimental effects of the virus can be seen in the nation's health, economy and government operations, leading to radical uncertainty that is exacerbated by the absence of any definitive treatment or vaccines. The level of knowledge about and trust in treatment and vaccination varies worldwide. This study aims to assess the willingness of Palestinians to receive a COVID-19 vaccine and their knowledge about such vaccines. METHODS: An online survey of adults over 18 years old (n=1080) was conducted in Palestine in October 2020. Using multivariate logistic regression, we identified correlates of participants' willingness to get a COVID-19 vaccine. RESULTS: We found that about 63% of participants were willing to get a COVID-19 vaccine. However, acceptance varied with the specific demographic variables that were investigated. Women, married participants and those aged 18-24 years are more likely to take the vaccine. Further, participants with good knowledge about the vaccine and its side effects are more willing to get the vaccine. CONCLUSION: The availability of a safe and effective COVID-19 vaccine in Palestine is crucial to decrease the burden of COVID-19 morbidity and mortality. In addition, to ensure a high vaccination rate, health awareness campaigns should target those who are not willing to get the vaccine, especially those who are more vulnerable and the elderly.