Epidemiology and clinical characteristics of Morganella morganii infections: A multicenter retrospective study.

BACKGROUND: Morganella morganii is a Gram-negative, opportunistic pathogen that can cause a variety of infections, including bloodstream infections, especially in those with compromised immune systems. It is often resistant to antibiotics, making it a difficult organism to treat. Limited studies have addressed M. morganii, but the organism is becoming increasingly recognized as a public health threat. More research is needed to understand the epidemiology and virulence factors of M. morganii in Saudi Arabia, as well as to develop effective treatment strategies. METHODS: This retrospective study included all M. morganii bloodstream infections patients admitted to five tertiary care hospitals in Saudi Arabia between 2015 and 2022. RESULTS: The study population included 75 patients (45 males and 30 females) between the age of 53-72 with a 54% ICU admission rate. The most comorbidities were hypertension followed by diabetes. The most common symptoms were fever, cough, shortness of breath, vomiting, and fatigue. The study also found that M. morganii was often resistant to multiple antibiotics, including ciprofloxacin, trimethoprim/sulfamethoxazole, gentamicin, amoxicillin, nitrofurantoin, and colistin. The most common treatment for M. morganii bacteremia was carbapenems, followed by aminoglycosides, ciprofloxacin, and colistin. Source control measures, such as surgery, line removal, drainage, and tissue removal, were also used in some cases. The study found that the in-hospital mortality rate for M. morganii bacteremia was 41%. The risk of mortality was increased in patients who were admitted to the ICU, who were older than 65 years, and who had Klebsiella pneumoniae co-infection. CONCLUSION: M. morganii bacteremia is a serious infection that is often resistant to antibiotics. Elderly patients and patients with comorbidities are at increased risk of mortality. Source control measures and appropriate antibiotic therapy are important for improving outcomes.

Not every skin rash in a returning adult male traveler is monkeypox.

In May 2022, several European countries including Spain reported cluster of monkeypox cases with no apparent travel to endemic areas. We report a suspected case of monkeypox in Saudi Arabia in a healthy 30-year-old man who returned from Spain and the Netherlands with fever and rash for six days duration during the same time period of the outbreak, he was suspected to have monkeypox but was ultimately diagnosed with chickenpox.

Factors associated with poor outcomes among hospitalized patients with COVID-19: Experience from a MERS-CoV referral hospital.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has resulted in millions of deaths, including more than 6000 deaths in the Kingdom of Saudi Arabia (KSA). Identifying key predictors of intensive care unit (ICU) admission and mortality among infected cases would help in identifying individuals at risk to optimize their care. We aimed to determine factors of poor outcomes in hospitalized patients with COVID-19 in a large academic hospital in Riyadh, KSA that serves as a Middle East Respiratory Syndrome coronavirus (MERS-CoV) referral center. METHODS: This is a single-center retrospective cohort study of hospitalized patients between March 15 and August 31, 2020. The study was conducted at King Saud University Medical City (KSUMC). COVID-19 infection was confirmed using real-time reverse transcriptase polymerase chain reaction (RT-PCR) for SARS-COV-2. Demographic data, clinical characteristics, laboratory, radiological features, and length of hospital stay were obtained. Poor outcomes were, admission to ICU, need for invasive mechanical ventilation (IMV), and in-hospital all-cause mortality. RESULTS: Out of 16,947 individuals tested in KSUMC, 3480 (20.5%) tested positive for SARS-CoV-2 and of those 743 patients (21%) were hospitalized. There were 62% males, 77% were younger than 65 years. Of all cases, 204 patients (28%) required ICU admission, 104 (14%) required IMV, and 117 (16%) died in hospital. In bivariate analysis, multiple factors were associated with mortality among COVID-19 patients. Further multivariate analysis revealed the following factors were associated with mortality: respiratory rate more than 24/min and systolic blood pressure <90 mmHg in the first 24h of presentation, lymphocyte count <1 × 109/L and aspartate transaminase level >37 units/L in the first 48 h of presentation, while a RT-PCR cycle threshold (Ct) value ≤24 was a predictor for IMV. CONCLUSION: Variable factors were identified as predictors of different outcomes among COVID-19 patients. The only predictor of IMV was a low initial Ct values of SARS-CoV-2 PCR. The presence of tachypnea, hypotension, lymphopenia, and elevated AST in the first 48h of presentation were independently associated with mortality. This study provides possible independent predictors of mortality and invasive mechanical ventilation. The data may be helpful in the early identification of high-risk COVID-19 patients in areas endemic with MERS-CoV.

Clinical characteristics and outcomes of hospitalized COVID-19 patients in a MERS-CoV referral hospital during the peak of the pandemic.

OBJECTIVE: To describe the clinical characteristics and outcomes of hospitalized coronavirus disease 2019 (COVID-19) patients in a middle east respiratory syndrome coronavirus (MERS-CoV) referral hospital during the peak months of the pandemic. DESIGN: A single-center case series of hospitalized individuals with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in King Saud University Medical City (KSUMC), an academic tertiary care hospital in Riyadh, Saudi Arabia. Clinical and biochemical markers were documented. Risks for ventilatory support, intensive care unit (ICU) admission and death are presented. RESULTS: Out of 12,688 individuals tested for SARS-CoV-2 by real time reverse transcriptase polymerase reaction (RT-PCR) from June 1 to August 31, 2020, 2,683 (21%) were positive for COVID-19. Of the latter, 605 (22%) patients required hospitalization with a median age of 55, 368 (61%) were male. The most common comorbidities were hypertension (43%) and diabetes (42%). Most patients presented with fever (66%), dyspnea (65%), cough (61%), elevated IL-6 (93.5%), D-dimer (90.1%), CRP (86.1%), and lymphopenia (41.7%). No MERS-CoV co-infection was detected. Overall, 91 patients (15%) died; risk factors associated with mortality were an age of 65 years or older OR 2.29 [95%CI 1.43-3.67], presence of two or more comorbidities OR 3.17 [95%CI 2.00-5.02], symptoms duration of seven days or less OR 3.189 [95%CI (1.64 - 6.19]) lymphopenia OR 3.388 [95%CI 2.10-5.44], high CRP OR 2.85 [95%CI 1.1-7.32], high AST OR 2.95 [95%CI 1.77-4.90], high creatinine OR 3.71 [95%CI 2.30-5.99], and high troponin-I OR 2.84 [95%CI 1.33-6.05]. CONCLUSION: There is a significant increase in severe cases of COVID-19. Mortality was associated with older age, shorter symptom duration, high CRP, low lymphocyte count, and end-organ damage.

Clinical Characteristics and Outcome of Hospitalized COVID-19 Patients in a MERS-CoV Endemic Area.

BACKGROUND: The Kingdom of Saudi Arabia (KSA) reported 170,639 cases and 1430 deaths from COVID-19 since the first case emerged in the country on March 2 through June 25, 2020. The objective of this report is to describe the characteristics and outcome observed among 99 hospitalized COVID-19 patients in the largest academic hospital in KSA, and assess co-infection with the Middle East Respiratory Syndrome Coronavirus (MERS-CoV). METHODS: This single-center case series data included select epidemiological, clinical, radiological features and laboratory findings of all confirmed hospitalized cases of COVID-19 in King Saud University Medical City (KSUMC), Riyadh, KSA, from March 22 until May 31, 2020, followed through June 6, 2020. We conducted retrospective analysis of listed data from 99 hospitalized patients and present characteristics and factors associated with severity in percentages and univariate odds ratios. Cases were confirmed using nasopharyngeal or throat swab by real-time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and MERS-CoV by RT-PCR. RESULTS: The 99 hospitalized COVID-19 patients included in this analysis constitute 16% of 632 positive SARS-CoV-2 among 6633 persons who were tested at the KSUMC (positivity rate, 9.4%). MERS-CoV PCR was negative in all 99 patients tested. The majority of these 99 hospitalized patients were males (66%), had a mean age of 44 years (range, 19-87), and a quarter (25.3%) were health care workers. Patients with comorbid conditions accounted for 52.5% of patients including the 8.1% who were asymptomatic; diabetes mellitus being the most frequent (31.3%), followed by hypertension (22.2%). The most common presenting symptoms were fever (67.7%), cough (60.6%), dyspnea (43.4%), upper respiratory symptoms (27.3%), fatigue (26.3%), diarrhea (19.2%) and loss of smell (9.1%). The clinical conditions among these 99 patients included upper respiratory tract infection (47.5%), abnormal chest X-ray, lymphopenia, high inflammatory markers a fifth (21%) of patients had moderate pneumonia, while 7% had severe pneumonia with 22.2% requiring admission to the intensive care unit and 12.1% died. Late presentation with severe disease, an abnormal chest X-ray, lymphopenia, high inflammatory markers (C-reactive protein, ferritin, and procalcitonin), and end organ damage (high creatinine or high aspartate aminotransferase) were predictors for admission to critical care unit or died. CONCLUSION: We observed no MERS-CoV co-infection in this early cohort of hospitalized COVID-19 patients who were relatively young, more than half had comorbid conditions, presented with fever and/or cough, an abnormal chest X-ray, lymphopenia, and high inflammatory markers. Given MERS-CoV endemicity in the country, co-monitoring of MERS-CoV and SARS-CoV-2 coinfection is critical.

Latent tuberculosis infection among health-care workers using Quantiferon-TB Gold-Plus in a country with a low burden for tuberculosis: prevalence and risk factors.

BACKGROUND: Health-care workers (HCW) are susceptible to latent tuberculosis infection (LTBI). The prevalence of LTBI in HCW in Saudi Arabia has not been reported using the fourth-generation interferon gamma release assay QuantiFERON-TB Gold Plus (QFT-Plus). OBJECTIVE: Determine the prevalence of LTBI in a large heterogeneous HCW population and assess risk factors for LTBI. DESIGN: Cross-sectional and case-control study. SETTING: Tertiary academic hospital, Riyadh, Saudi Arabia. PATIENTS AND METHODS: Medical records of HCWs who had QFT-Plus performed between January to December 2018 were reviewed and included in the cross-sectional study. In a subset analysis, randomly selected positive QFT-Plus cases were compared with controls selected from the same areas of work. Univariate and binary logistic regression analyses were performed to assess the significance of other factors to QFT-PLus positivity. MAIN OUTCOME MEASURES: Prevalence of LTBI in HCWs and potential risk factors for LTBI. SAMPLE SIZE: 3024 HCWs in the cross-sectional analysis; 294 cases and 294 controls in the case-control analysis. RESULTS: Twenty-four percent (n=733) of the HCWs had a positive QFT-Plus. The median (interquartile range) age was 34.0 (31.0-37.1) years, 71% were female, and only 24.8% were of Saudi nationals. Nursing represented 57.7% of HCWs, and 24.7% were working in a non-clinical area. Only 20.3% worked in TB-related departments. A higher risk of LTBI was present in HCWs who were older than 50 years (OR=1.95), from either Philippines (OR=4.7) or the Indian subcontinent (OR=4.1), working as a nurse (OR=2.7), allied health profession (OR=2.1), radiology technician (OR=3.1), or in the emergency room (OR=2.4) or intensive care unit (OR=2.1). In the binary logistic regression, independent predictors for positive QFT-Plus were age group older than 50 years (aOR=2.96), known TB exposure (aOR=1.97), and not receiving BCG at birth (aOR=3.08). LIMITATION: Single-center, retrospective, possible recall bias for BCG vaccination. CONCLUSION: The high prevalence of LTBI among HCW emphasizes the need to continue pre-employment screening, especially for employed personnel from high endemic areas, with targeted annual screening for the same group and other identified high-risk groups. These findings can aid in the development of national screening guidelines for LTBI in HCW. CONFLICT OF INTEREST: None.

Nosocomial outbreak of the Middle East Respiratory Syndrome coronavirus: A phylogenetic, epidemiological, clinical and infection control analysis.

BACKGROUND: Middle East Respiratory Syndrome coronavirus (MERS-CoV) continues to cause intermittent community and nosocomial outbreaks. Obtaining data on specific source(s) and transmission dynamics of MERS-CoV during nosocomial outbreaks has been challenging. We performed a clinical, epidemiological and phylogenetic investigation of an outbreak of MERS-CoV at a University Hospital in Riyadh, Kingdom of Saudi Arabia. METHODS: Clinical, epidemiological and infection control data were obtained from patients and Healthcare workers (HCWs). Full genome sequencing was conducted on nucleic acid extracted directly from MERS-CoV PCR-confirmed clinical samples and phylogenetic analysis performed. Phylogenetic analysis combined with published MERS-CoV genomes was performed. HCWs compliance with infection control practices was also assessed. RESULTS: Of 235 persons investigated, there were 23 laboratory confirmed MERS cases, 10 were inpatients and 13 HCWs. Eight of 10 MERS inpatients died (80% mortality). There were no deaths among HCWs. The primary index case assumed from epidemiological investigation was not substantiated phylogenetically. 17/18 MERS cases were linked both phylogenetically and epidemiologically. One asymptomatic HCW yielded a MERS-CoV genome not directly linked to any other case in the investigation. Five HCWs with mild symptoms yielded >75% full MERS-CoV genome sequences. HCW compliance with use of gowns was 62.1%, gloves 69.7%, and masks 57.6%. CONCLUSIONS: Several factors and sources, including a HCW MERS-CoV 'carrier phenomenon', occur during nosocomial MERS-CoV outbreaks. Phylogenetic analyses of MERS-CoV linked to clinical and epidemiological information is essential for outbreak investigation. The specific role of apparently healthy HCWs in causing nosocomial outbreaks requires further definition.

Utility of Stimulated Thyroglobulin in Reclassifying Low Risk Thyroid Cancer Patients' Following Thyroidectomy and Radioactive Iodine Ablation: A 7-Year Prospective Trial.

Context: Following total thyroidectomy and radioactive iodine (RAI) ablation, serum thyroglobulin levels should be undetectable to assure that patients are excellent responders and at very low risk of recurrence. Objective: To assess the utility of stimulated (sTg) and non-stimulated (nsTg) thyroglobulin levels in prediction of patients outcomes with differentiated thyroid cancer (DTC) following total thyroidectomy and RAI ablation. Method: A prospective observational study conducted at a University Hospital in Saudi Arabia. Patients diagnosed with differentiated thyroid cancer and were post total thyroidectomy and RAI ablation. Thyroglobulin levels (nsTg and sTg) were estimated 3-6 months post-RAI. Patients with nsTg <2 ng/ml were stratified based on their levels and were followed-up for 5 years and clinical responses were measured. Results: Of 196 patients, nsTg levels were <0.1 ng/ml in 122 (62%) patients and 0.1-2.0 ng/ml in 74 (38%). Of 122 patients with nsTg <0.1 ng/ml, 120 (98%) had sTg levels <1 ng/ml, with no structural or functional disease. sTg levels >1 occurred in 26 (35%) of patients with nsTg 0.1-2.0 ng/ml, 11 (15%) had structural incomplete response. None of the patients with sTg levels <1 ng/ml developed structural or functional disease over the follow-up period. Conclusion: Suppressed thyroglobulin (nsTg < 0.1 ng/ml) indicates a very low risk of recurrence that does not require stimulation. Stimulated thyroglobulin is beneficial with nsTg 0.1-2 ng/ml for re-classifying patients and estimating their risk for incomplete responses over a 7 years follow-up period.

Miliary tuberculosis with delayed-onset total knee arthroplasty Mycobacteria tuberculosis infection successfully treated with medical therapy alone: A case report and literature review.

Tuberculosis (TB) affecting a prosthetic knee is an unusual and diagnostically challenging presentation of this disease. This study reported a case of an 80-year-old man with a left total knee arthroplasty (TKA) performed eight years before his presentation. He presented with left knee swelling and pain for one month. Knee X-rays showed a normal joint space with no loosening of his prosthesis. His chest X-ray showed miliary disease, and microbiological studies of his sputum and synovial fluid aspirate grew Mycobacteria tuberculosis complex. He was successfully medically treated with anti-tuberculous therapy alone for one year. His knee hardware was retained, and he did not require debridement, resection, or revision. It is believed that this is the first reported case of miliary TB with delayed-onset TKA prosthetic joint infection (PJI) in which the prosthesis was successfully retained. Thirty-eight published TB TKA PJI cases in medical literature were also reviewed.