[Comparative study of patients hospitalized for SARS-CoV-2 infection in two consecutive waves in Tunisia]. / Étude comparative de patients hospitalisés pour une infection SARS-CoV-2 au cours de deux vagues consécutives en Tunisie.

Introduction: Since December 2019, a novel coronavirus (SARS-CoV-2) has triggered a global pandemic with a heavy medical and societal-economic toll. The health consequences were not similar during the successive waves that affected several countries. The aim of our study was to compare the sociodemographic, clinical and evolutionary features of COVID-19 patients hospitalized at the Military Hospital of Tunis (HMPIT) during the 2nd and 3rd waves that affected the country. Patients and methods: Observational prospective study involving 1,527 COVID-19 patients hospitalized at HMPIT over 11 months, divided into two periods: from July 2020 to December 2020 called the second wave (V2) and from January 2021 to May 2021 called the third wave (V3). We compared the epidemiological data, the clinical form and the evolution of the patients for each period. Results: The number of hospitalized patients was 636 during V2 compared to 891 during V3. Average age was 63.5 ± 15.3 years during V2 versus 65.8 ± 17.8 years during V3 (P = not significant [NS]). The percentage of young adults [18-40 years] was 6.5% during V2 compared to 6.7% during V3 (P = NS). The gender ratio (M/F) was 1.59 for V2 and 1.42 for V3 (P = NS). Comorbidities were present in 65% of V2 patients and 66.3% of V3 patients (P = NS), with hypertension being the most prevalent one in both groups (47.2% for V2 versus 44.9% for V3; P = NS), followed by overweight, dyslipidemia and diabetes (33% for V2 versus 39.3% for V3; P = 0.012). The median duration between symptoms onset and hospitalization was 7 days [5-10] during V2 versus 8.5 days during V3 [5-12] (P = 0.0004). The severe clinical form was present in 49% of patients admitted during V2 compared to 34.8% during V3 (P < 10-3). The critical form represented 18.6% of cases during V2 against 16.8% during V3 (P = NS). The average hospital length of stay in COVID units (outside of intensive care unit) was 8.4 ± 5.4 days during V2 and 9.8 ± 5.7 days during V3. The average length of stay was significantly longer for the intensive care unit (11.3 ± 3.4 days for V2 versus 13.8 ± 3.9 days for V3; P = 0.01). The case fatality rate was 24.5% during V2 and 20.7% during V3 (P = NS). Median age of death was 70.2 years [42-88] during V2 and 70.4 years [22-96] during V3 with 2 patients less than 40 years of age (1%) for the latter period. The gender ratio (M/F) of deceased patients was 3.21 for V2 and 1.5 for V3 (P = 0.001). The case fatality rate was higher in the intensive care unit (65.4% for V2 versus 69.7% for V3; P = NS). Causes of death were dominated by ARDS (acute respiratory distress syndrome) for both periods (55.1% for V2 versus 70.8% for V3; P = 0.002), followed by septic shock (12.8% for V2 versus 10.8% for V3; P = NS) and multi-organ failure (9.6% for V2 versus 7.0% for V3; P = NS). Conclusion: This study revealed a decrease in severe and critical clinical forms during the 3rd wave, as well as a decrease in the case fatality rate compared to the previous wave, due to improved management and vaccination. On the other hand, the percentage of ARDS was significantly higher during this wave probably related to the beginning of circulation in our country of the Delta variant causing more severe clinical cases.

Whole Genome Sequencing of a Citrobacter freundii Strain Isolated from the Hospital Environment: An Extremely Multiresistant NDM-1 and VIM-48 Coproducing Isolate.

Citrobacter freundii has acquired resistance to several antimicrobial drugs, including last-resort antibiotics affecting, therefore, clinical efficacy and causing high rates of mortality. In this study, we investigate the whole genome sequence of a carbapenem-resistant C. freundii strain isolated from the hospital environment in Tunisia. A total of 210 samples were taken using sterile swabs, from inanimate surfaces, medical devices, and care staff, during the period extended between March and April 2019. After the microbiological analysis of samples and antimicrobial susceptibility testing, only one strain identified as C. freundii showing resistance to carbapenems was selected for the whole genome sequencing. The genome analysis revealed a high-level resistance to most antibiotics. Interestingly, we have noted the coexistence of blaNDM-1 and blaVIM-48 metallo-ß-lactamase (MBL) encoding genes conferring resistance to carbapenems. Other ß-lactamases encoding genes have also been detected, including blaTEM-1, blaCMY-48, and blaOXA-1. Moreover, genes conferring resistance to aminoglycoside [aac(3)-IId, ant(3″)-Ia, aadA, aac(6')-Ib], macrolide [mph(A)], sulfonamide (sul1), trimethoprim (dfrA1), tetracycline [tet(D)], chloramphenicol [cat(B3)], rifamycin (arr-3), and quinolone (qnrB) have been revealed. The multi-locus sequence typing analysis showed that this isolate could not be assigned to an existing sequence type (ST), but it is almost identical to ST22. The plasmid investigation revealed the presence of five plasmids belonging to diverse incompatibility groups (IncFII, IncHI1A, IncHI1B, IncN, and IncX3). To the best of our knowledge, our findings report the first detection of NDM-1 and VIM-48 coproducing C. freundii in Tunisia and the second detection in the world of the blaVIM-48.

Health screening strategies in Maghreb countries: Situation Analysis and perspectives.

BACKGROUND: The aim of screening is to improve individual health through an early detection of diseases at a stage where the prognosis of disease could be significantly. However, this kind of intervention is costly and it's necessary to respect criteria in selection of targeted diseases and screening tests. OBJECTIVE: The objective of this study was to describe public health screening policy in the Maghreb countries in order to identify the main barriers to the development of this type of intervention. METHODOLOGY: This study is a literature review of screening practices and policy in Maghreb countries. For this purpose, we conducted a global search in MEDLINE, as well as in the websites of the Ministries of Health of Maghreb countries; we also asked also key persons in the different countries to provide us useful t information concerning screening in their countries. RESULTS: Antenatal and neonatal screening is generally limited to a few pilot experiments such as screening for congenital hypothyroidism and phenylketonuria and deafness. Regarding school population, screening of certain diseases such as dental disorders, infectious diseases including tuberculosis, overweight and obesity, visual impairment, is carried out during periodic medical visits. Among adults, screening is often opportunist; it is performed in patients who use primary care health centers; the main targeted diseases are cervical, breast cancer and colorectal cancer, pulmonary tuberculosis. Screening coverage, especially for cancers, remains relatively low; for example, in Tunisia, this coverage was 12.7% for at least one cervical smear in the last five years; while for an annual clinical breast examination, this proportion was 33.2%. CONCLUSIONS: It is strongly recommended to improve coverage by screening, especially for cancers through educational actions of the population highlighting the high chances of cure in case of early detection, training of care staff and improvement, access to screening benefits.

Multidrug-resistant enterococci in the hospital environment: detection of novel vancomycin-resistant E. faecium clone ST910.

INTRODUCTION: The role of the hospital environment as a reservoir of resistant bacteria in Tunisia has been poorly investigated; however, it could be responsible for the transmission of multidrug-resistant bacteria. The objective was to study the prevalence of Enterococcus in the environment of a Tunisian hospital and the antibiotic resistance phenotype/genotype in recovered isolates, with special reference to vancomycin resistance. METHODOLOGY: A total of 300 samples were taken (March-June, 2013) and inoculated in Slanetz-Bartley agar plates supplemented or not supplemented with 8 µg/mL of vancomycin. Antibiotic resistance genes were tested by polymerase chain reaction (PCR). The clonal relatedness of the vanA isolates was assessed using pulsed-field gel electrophoresis (PFGE) and multilocus sequence testing (MLST). RESULTS: Enterococci were recovered in 33.3% of tested samples inoculated in SB medium. E faecium was the most prevalent species, followed by E. faecalis and E. casseliflavus. Antimicrobial resistance genes detected were as follows (number of isolates): erm(B) (71), tet(M) (18), aph(3')-IIIa (27), ant(6)-Ia (15), cat(A) (4), and van(C2) (6). Vancomycin-resistant-enterococci (VRE) were recovered from 14 samples (4.7%), when tested in SB-VAN. The 14 VRE (one per positive sample) were identified as E. faecium and contained the van(A),erm(B), tet(M), ant(6)-Ia, and aph(3')-IIIa genes. Thirteen of the VRE strains were ascribed by PFGE and MLST to a novel clone (new ST910), and only one VRE strain was typed as ST80 included in CC17. CONCLUSIONS: The emergence and spread of new clones of VRE, especially in the hospital environment in this country, could become particularly problematic.

Characterization of extended-spectrum ß-lactamase (ESBL)-producing Klebsiella, Enterobacter, and Citrobacter obtained in environmental samples of a Tunisian hospital.

The assessment of the hospital environment as a reservoir of ESBL-producing Enterobacteriaceae in Tunisian hospitals is scarcely analyzed, except for Escherichia coli. The aim of this study was to evaluate the presence of ESBL-producing non-E. coli Enterobacteriaceae (ESBL-EbNoEc) in 300 samples of abiotic surfaces and the hands of patients and staff of a Tunisian Hospital, and to characterize the ESBL genes of the recovered isolates. ESBL-EbNoEc were recovered in 28 of 300 (9.3%) analyzed samples and were identified as Klebsiella pneumoniae (n= 11), Enterobacter cloacae (n=11), Citrobacter freundii (n=4) and Klebsiella oxytoca (n=2). The bla genes identified by PCR and sequencing among the strains were as follows: 11 K.pneumoniae strains [blaCTX-M-15+ blaTEM-1+ blaSHV-11 (n=6); blaCTX-M-15+ blaTEM-1+ blaSHV-28 (n=3); blaCTX-M-15+ blaTEM-1+ blaSHV-1 (n=2)], 11 E. cloacae strains [blaCTX-M-15 (n=6); blaCTX-M-15+ blaTEM-1b (n=2); blaCTX-M-15+ blaTEM-1b+ blaOXA-1 (n=1);blaCTX-M-15+ blaOXA-1 (n=1);blaSHV-12 (n=1)], 4 C. freundii strains [blaCTX-M-15] and 2 K. oxytoca strains [blaCTX-M-15 (n=1); blaSHV-12 (n=1)]. The ISEcp1 and orf477 sequences were identified upstream and downstream of the blaCTX-M-15 gene, respectively, in 3 K. pneumoniae and 3 E. cloacae isolates. The PFGE analysis demonstrated three unrelated pulsotypes in K. pneumoniae strains and five pulsotypes in E. cloacae. The uncontrolled dissemination of ESBL-producing bacteria, even in the hospital environment, has become a real problem and new strategies and hygienic rules are needed to stop this bacterial dissemination.

High prevalence of Staphylococcus haemolyticus and Staphylococcus saprophyticus in environmental samples of a Tunisian hospital.

The purpose of this study was to evaluate the rate of detection of coagulase negative staphylococci (CoNS) in environmental samples of 17 services in a Tunisian hospital, determining the antimicrobial resistance phenotypes and genotypes of recovered isolates. To our knowledge, this is the first study that determines the prevalence of CoNS with correlation of antibiotic resistance in the hospital environment in Tunisia. CoNS were obtained from 83 of the 200 tested samples (41.5%). Staphylococcus haemolyticus was the most prevalent species (45.8%), followed by S. saprophyticus (36.1%). The remaining CoNS species detected were S. epidermidis, S. cohnii, S. warneri, S. sciuri, S. simulans, S. pasteuri, S. arlettae, and S. xilosus. Methicillin-resistant CoNS were detected in 20 of the 200 tested samples (10%), and the mecA gene was demonstrated in 18 S. haemolyticus, one S. epidermidis and one S. saprophyticus isolates. Methicillin susceptible isolates were detected in 63 samples (31.5%). Antimicrobial resistance genes detected were as follows (number of isolates): erythromycin [msr(A) (n = 32); erm(C) (n = 8)], tetracycline [tet(K) and/or tet(M) (n = 21)], gentamicin [aac(6')-Ie-aph(2″)-Ia (n = 16)], kanamycin [(aph(3')-IIIa (n = 19)], tobramycin [ant(4')-Ia (n = 14)], and streptomycin [ant(6')-Ia (n = 3)]. The high frequency of detection of multi-drug-resistant CoNS in the hospital environment, especially S. haemolyticus and S. saprophyticus, is of relevance and could be due to cross-transmission between patients, staff, and environment.

Detection of CTX-M-15-Producing Escherichia coli Isolates of Lineages ST131-B2 and ST167-A in Environmental Samples of a Tunisian Hospital.

To investigate the possible role of the hospital environment in the dissemination of extended-spectrum-beta-lactamase (ESBL)-producing Escherichia coli isolates, 300 samples were taken during 2013 from abiotic surfaces (n = 250), healthcare worker hands (n = 27), and hands of patients (n = 23) in a Tunisian Hospital. ESBL-producing E. coli isolates were recovered in 3.7% of analyzed samples (4% abiotic surfaces; 4.3% hands of patients; 0% in healthcare worker hands), and one isolate/sample was further studied. The characterization of beta-lactamase genes, as well as the genetic environment of blaCTX-M gene, was performed by PCR and sequencing. The ESBL genes found were as follows: blaCTX-M-15 (eight isolates), blaCTX-M-15+blaSHV-12 (two isolates), and blaSHV-12 (one isolate). The blaTEM-1b gene was detected in seven ESBL-positive isolates. The orf477 was found downstream of blaCTX-M-15 gene in 10 strains, whereas the ISEcp1 sequence was identified upstream of this gene in two isolates. The analysis of class 1 integrons by PCR and sequencing revealed five positive isolates with the following gene cassette arrangements: dfrA1-aadA1 (two isolates), aadA1 (two isolates), and aadA2 (one isolate). The virulence-encoding genes aer, eae, bfp, and hly were detected by PCR in six, four, four, and three isolates, respectively. The following sequence types and associated phylogroups were detected among ESBL-producing strains: ST167-phylogroup-A (six isolates) and ST131-phylogroup-B2 (two isolates). In conclusion, the hospital environment could be a reservoir of multiresistant bacteria, including ESBL-positive E. coli isolates, which could be acquired by the patient population, and strict control measures should be established to minimize this problem.

Environmental Staphylococcus aureus contamination in a Tunisian hospital.

One hundred hospital environment samples were obtained in 2012 in a Tunisian hospital and tested for Staphylococcus aureus recovery. Antimicrobial resistance profile and virulence gene content were determined. Multilocus-sequence-typing (MLST), spa-typing, agr-typing and SmaI-pulsed-field gel electrophoresis (PFGE) were performed. Two methicillin-resistant S. aureus (MRSA) isolates typed as: ST247-t052-SCCmecI-agrI were recovered from the intensive care unit (ICU). Ten samples contained methicillin-susceptible S. aureus (MSSA) and these samples were collected in different services, highlighting the presence of the tst gene encoding the toxic shock syndrome toxin as well as the lukED, hla, hlb, hld and hlgv virulence genes in some of the isolates. In conclusion, we have shown that the hospital environment could be a reservoir contributing to dissemination of virulent S. aureus and MRSA.

Homocysteine and inflammatory biomarkers plasma levels, and severity of acute coronary syndrome.

Recently, homocysteine and new inflamatory biomarkers are demonstrated to be involved in cardiovascular diseases. These risk factors are not well studied in acute coronary syndrome. We investigated the distribution of homocysteine and inflammatory markers in patients with acute coronary syndrome and evaluated the association between these parameters and severity of the disease. One hundred and twenty-two patients with acute coronary syndrome were recruited in the cardiac intensive unit care of military hospital of Tunis. Classic risk factors, lipid parameters, total homocysteine, HsCRP, IL-6 and TNFα were determined for all participants. We investigated the distribution of these parameters according to the number of diseased vessels in patients with acute coronary syndrome. Patients with three affected vessels showed significant elevated homocysteine, HsCRP, IL-6, TNF-α, total cholesterol, LDL-cholesterol and Lp (a) compared to those with one and those with two affected vessels. Homocysteine (OR = 1.14; 95%IC: 1.04-1.25; P = 0.006), TNF-α (OR = 1.27; 95%IC: 1.13-1.44; P = 10(-3)), HsCRP (OR = 1.09; 95%IC:1.03-1.16; P = 0.005) and IL-6 (OR = 1.15; 95%IC: 1.06-1.25; P = 0.001) were significant predictors of severity of the disease. We conclude that homocysteine and inflammatory biomarkers appear to enhance the degree of affected arteries and so the severity of coronary artery disease.

[Knowledge and attitudes of medical students at the end of their curriculum, towards breast and cervical cancer screening]. / Connaissances et attitudes des étudiants en fin d'études médicates vis-à-vis des dépistages des cancers du col utérin et du sein.

This study assesses knowledge and attitudes of medical students of the faculty of medicine of Tunis, at the end of their medical curriculum, towards breast and cervical cancer screening. Among the 644 medical students at the end of their curriculum, 592 answered to anonymous questionnaire (response rate = 92%). Results show that 34.1% have proposed systematic cervical cancer screening. This proportion was 61.0% for clinical breast cancer examination. The majority of students (70.2%) proposed to start this cervical screening since the first sexual activities. As for the periodicity of this screening, 44.2% are favourable for a yearly periodicity, 39.2% for every three years, 7.2% for every five years and 9.4% for a periodicity at least once in life. 94.1% of students declared to have learned clinical breast examination, contrarily to pap smear, for which this proportion was only 55.1%. Breast and cervical cancer control training, in the faculty of medicine of Tunis, is insufficient and should be improved and restructured.

[Attitude to cervical cancer screening of women residing in two regions of northern Tunisia]. / Recours au depistage du cancer du col utérin chez des femmes residant dans deux regions du Nord de la Tunisie.

The objective of this survey to describe knowledge, attitudes and behaviours of women residing in two regions of the North of Tunisia, towards cervical cancer screening methods. 936 women residing to the Ariana (urbanized region) and 993 women residing to Zaghouan (region to farming predominance) were included; they were chosen according to the method of quotas while taking like criteria's, the of area residence (urban or rural), age and the level of education. Every woman should have answered to a questionnaire. Data collected were related to women perception of the severity of the cervical cancer, of their vulnerability for this cancer, of screening efficiency and the recourse of women to this service. The recourse to the cervical cancer screening was significantly more frequent in Ariana (24,6% vs. 13,8% p <0,001); the half of women is optimistic towards the therapeutic progress recorded in Tunisia in the domain of cancer. A better organization of cervical cancer screening including the individual invitations of women and a better sensitization and implication of physicians of the first line in the two sectors public and private, are indispensable to improve the frequency of recourse to cervical cancer screening.