Alternatives Therapeutic Approaches to Conventional Antibiotics: Advantages, Limitations and Potential Application in Medicine.

Resistance to antimicrobials and particularly multidrug resistance is one of the greatest challenges in the health system nowadays. The continual increase in the rates of antimicrobial resistance worldwide boosted by the ongoing COVID-19 pandemic poses a major public health threat. Different approaches have been employed to minimize the effect of resistance and control this threat, but the question still lingers as to their safety and efficiency. In this context, new anti-infectious approaches against multidrug resistance are being examined. Use of new antibiotics and their combination with new ß-lactamase inhibitors, phage therapy, antimicrobial peptides, nanoparticles, and antisense antimicrobial therapeutics are considered as one such promising approach for overcoming bacterial resistance. In this review, we provide insights into these emerging alternative therapies that are currently being evaluated and which may be developed in the future to break the progression of antimicrobial resistance. We focus on their advantages and limitations and potential application in medicine. We further highlight the importance of the combination therapy approach, wherein two or more therapies are used in combination in order to more effectively combat infectious disease and increasing access to quality healthcare. These advances could give an alternate solution to overcome antimicrobial drug resistance. We eventually hope to provide useful information for clinicians who are seeking solutions to the problems caused by antimicrobial resistance.

Antibiotic Resistance Pattern of Extended Spectrum Beta Lactamase Producing Escherichia coli Isolated From Patients With Urinary Tract Infection in Morocco.

Extended-spectrum ß-lactamases producing Escherichia coli (ESBL-EC) lend resistance to most ß-lactam antibiotics. Because of limited treatment options, ESBL-EC infections are generally more difficult to treat, leading to higher hospital costs, reduced rates of microbiological and clinical responses, and a threat to the patient's life. This study aimed to determine the antibiotic resistance pattern of ESBL-EC isolated from patients with urinary tract infection in Morocco. This retrospective laboratory-based study was conducted at Cheikh Khalifa International University Hospital, Casablanca, from January 2016 to June 2019. A total of 670 urine samples were collected from urinary tract infection patients and processed by standard microbiological methods. In vitro susceptibility testing to different antibiotics of all identified isolates of Escherichia coli (E. coli) was performed following Kirby-Bauer's disc diffusion method on Mueller-Hinton Agar according to the EUCAST standards. The reviewing of ESBL-EC was confirmed by the appearance of a characteristically shaped zone referred to as a "champagne cork" using the Combined Disk Test. Among a total of 438 E. coli isolated from nonrepetitive urine samples, two hundred fifty-nine (59%) were ESBL-EC, of which 200 (77%) were isolated from adult patients (over the age of 50) and the majority were female. All ESBL-EC isolates were resistant to third-generation cephalosporin and quinolones and sensitive to carbapenem and fosfomycin. Knowledge of antimicrobial resistance patterns in ESBL-EC, the major pathogen associated with urinary tract infection, is indispensable as a guide in choosing empirical antimicrobial treatment.

A laboratory-based study of COVID-19 in Casablanca, Morocco.

Given the spread of coronavirus disease 2019 (COVID-19) and its impact on human health, laboratory confirmation of diagnosis is essential. This study examined the contribution of laboratory diagnosis to the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the diagnosis of COVID-19, taking into account patient risk of exposure to SARS-CoV-2, clinical symptoms and comorbidities. A cross-sectional, laboratory-based study was carried out from 1 April 2020 to 30 April 2020 at the National Reference Laboratory in Morocco using nasopharyngeal samples from patients admitted to the Cheikh Khalifa International University Hospital or other hospitals in Casablanca. A one-step reverse transcription real-time polymerase chain reaction (RT-PCR) was used to detect the presence of the SARS-CoV-2 genome. A national epidemiological investigation form was used to analyze patient exposure risk, clinical symptoms and comorbidities. A total of 793 samples from 375 patients were analyzed and 1150 RT-PCR tests were conducted; 116 patients (30.93%) were COVID-19 positive. Travel to a risk zone, contact with a confirmed COVID-19 case and contact with a person who had been in a risk zone were significantly associated with being positive for COVID-19. Fever and cough were the main symptoms; 7.76 % of positive patients were asymptomatic. This is the first laboratory-based study in Morocco for the diagnosis of COVID-19. Laboratory diagnosis of COVID-19 by RTPCR associated with knowledge of exposure risk factors and clinical symptoms and comorbidities remains essential for clinicians for early, appropriate medical management COVID-19 patients.

Prevalence, antimicrobial resistance and serotype distribution of group B streptococcus isolated among pregnant women and newborns in Rabat, Morocco.

Purpose. Group B streptococcus (GBS) is an important cause of neonatal sepsis worldwide. Data on the prevalence of maternal GBS colonization, risk factors for carriage, antibiotic susceptibility and circulating serotypes are necessary to tailor adequate locally relevant public health policies.Methodology. A prospective study including pregnant women and their newborns was conducted between March and July 2013 in Morocco. We collected clinical data and vagino-rectal and urine samples from the recruited pregnant women, together with the clinical characteristics of, and body surface samples from, their newborns. Additionally, the first three newborns admitted every day with suspected invasive infection were recruited for a thorough screening for neonatal sepsis. Serotypes were characterized by molecular testing.Results. A total of 350 pregnant women and 139 of their newborns were recruited. The prevalence of pregnant women colonized by GBS was 24 %. In 5/160 additional sick newborns recruited with suspected sepsis, the blood cultures were positive for GBS. Gestational hypertension and vaginal pruritus were significantly associated with a vagino-rectal GBS colonization in univariate analyses. All of the strains were susceptible to penicillin, while 7 % were resistant to clindamycin and 12 % were resistant to erythromycin. The most common GBS serotypes detected included V, II and III.Conclusion. In Morocco, maternal GBS colonization is high. Penicillin can continue to be the cornerstone of intrapartum antibiotic prophylaxis. A pentavalent GBS vaccine (Ia, Ib, II, III and V) would have been effective against the majority of the colonizing cases in this setting, but a trivalent one (Ia, Ib and III) would only prevent 28 % of the cases.

Streptococcus pneumoniae carriage among healthy and sick pediatric patients before the generalized implementation of the 13-valent pneumococcal vaccine in Morocco from 2010 to 2011.

Nasopharyngeal carriage studies provide insights into the local prevalence of circulating pneumococcal serotypes. These data are critical to vaccination monitoring, as they allow for the prediction and assessment of impact. Very little data are available on the carriage of pneumococcal serotypes in Morocco. Here, we describe the prevalence of Streptococcus pneumoniae carriage and serotype distribution among 697 pediatric patients with ages ranging from 2 to 59 months who were admitted to a Moroccan hospital with severe pneumonia, as well as 195 healthy infants and young children who were recruited at a vaccination clinic. Carriage rates were 40.5% (79/195) for healthy children and 22.8% (159/697) for sick children. The most commonly observed circulating serotypes included 6A, 6B and 19F, all of which are included in the current 13-valent anti-pneumococcal conjugate vaccine that was recently introduced in Morocco. Monitoring of circulating serotypes remains necessary after vaccine introduction to assess whether serotype replacement is occurring.

Rhinovirus C is associated with wheezing and rhinovirus A is associated with pneumonia in hospitalized children in Morocco.

Human rhinovirus (RV) is commonly associated with severe acute lower respiratory infections (ALRI) in children. We aimed to describe the distribution of RV species and associations between RV species and clinical features in children hospitalized with clinically severe pneumonia (CSP) in Morocco. Nasopharyngeal aspirates (NPAs) were collected from 700 children, 2-59 months of age, admitted with CSP to the Hôpital d'Enfants de Rabat in Morocco. At least one respiratory virus was identified in 92% of children, of which RV was the most common (53%). PCR assays, sequencing, and phylogenetic tree analyses were carried out on 183 RV-positive NPAs to determine RV species and genotypes. Of 157 successfully genotyped NPAs, 60 (38.2%) were RV-A, 8 (5.1%) were RV-B, and 89 (56.7%) were RV-C. Wheezing and cyanosis were more common in RV-C-positive than RV-A-positive children (80.9% vs. 56.7%; P = 0.001 for wheezing and 10.1% vs. 0%; P = 0.011 for cyanosis). Physician's discharge diagnosis of pneumonia was more frequent among RV-A-positive (40.0%) than RV-C-positive children (20.2%; P = 0.009). RV-A and RV-C showed distinct seasonal patterns. Our findings suggest that RV-C is associated with wheezing illness while RV-A is associated with pneumonia. J. Med. Virol. 89:582-588, 2017. © 2016 Wiley Periodicals, Inc.

Characterization of Vaginal Escherichia coli Isolated from Pregnant Women in Two Different African Sites.

The relevance of vaginal colonization of pregnant women by Escherichia coli is poorly understood, despite these strains sharing a similar virulence profile with other extraintestinal pathogenic E. coli producing severe obstetric and neonatal infections. We characterized the epidemiology, antimicrobial susceptibility and virulence profiles of 84 vaginal E. coli isolates from pregnant women from Rabat (Morocco) and Manhiça (Mozambique), two very distinct epidemiological settings. Low levels of antimicrobial resistance were observed to all drugs tested, except for trimethoprim-sulfamethoxazole in Manhiça, where this drug is extensively used as prophylaxis for opportunistic HIV infections. The most prevalent virulence factors were related to iron acquisition systems. Phylogroup A was the most common in Rabat, while phylogroups E and non-typeable were the most frequent in Manhiça. Regardless of the apparently "low virulence" of these isolates, the frequency of infections is higher and the outcomes more devastating in constrained-resources conditions, especially among pregnant women and newborns.

Knowledge gaps on paediatric respiratory infections in Morocco, Northern Africa.

BACKGROUND: The burden of acute respiratory infections (ARI) among Moroccan children remains significant. However, scarce information is available regarding trends in its epidemiology and etiology, or regarding its associated prognostic factors. The purpose of this work was to review available data on the burden of ARI among children under five years of age in Morocco. METHODS: A systematic review was conducted for the period 1997-2014 using the PRISMA proposed methodology. Various online databases were screened, in addition to physical libraries of Moroccan medical schools, and official reports of the Moroccan Ministry of Health. Search queries in English and French languages included: Respiratory Tract Infections, pneumonia, epidemiology, etiology, microbiology, mortality and Morocco. The documents were included for analysis when they reported original data on the incidence, distribution, or a clinical description of the diseases or their etiology or described clinical management or national preventive strategies. RESULTS: Thirty-two documents were included in the final analysis. 21 of which had been published. In 2012, ARI caused 13% of paediatric deaths, half of the consultations at health facilities and third of the paediatric admissions. The microorganisms more frequently identified among hospitalized children were Streptococcus pneumoniae (38%) and Haemophilus influenza type b (Hib) (15%). The MOH introduced Hib vaccines into the national immunization program (PNI) in 2007and the 13-valent vaccine against pneumococcus in 2010. The national first line antibiotics recommended for non-severe ambulatory treatment is Amoxicillin. Studies of antibiotic resistance showed from 1998 to 2008 a 22% increase in the rate of penicillin non-susceptibility among Streptococcus pneumoniae isolates. Viral respiratory infections and the role attributed to air pollution in the incidence of ARI have been poorly characterized. CONCLUSIONS: Further efforts should be made towards the development of adequate surveillance programs to better clarify the epidemiology, etiology, antimicrobial susceptibility patterns and the effectiveness of the preventives and curatives strategies in place against paediatric ARIs in Morocco. Additionally, a holistical approach should be used to identify the heath determinants of ARIs among children.

First report of a Klebsiella pneumoniae ST466 strain causing neonatal sepsis harbouring the blaCTX-M-15 gene in Rabat, Morocco.

Klebsiella pneumoniae is one of the Gram-negative bacilli most commonly found in urine of pregnant women and causing neonatal sepsis. The aim of this study was to analyse in terms of epidemiology and antimicrobial resistance of 23 K. pneumoniae isolates collected from vaginal swabs or urine of pregnant women, from pharyngeal and ear swabs of apparently healthy newborns and from peripheral cultures and hemocultures of newborns with suspected invasive neonatal infection in Rabat, Morocco. The prevalence of K. pneumoniae was 0.6 and 0.9% among pregnant women and neonates, respectively. These strains showed lower antimicrobial resistance levels regarding the developed countries. Thus, only one strain from a neonate presented an ESBL. This is the first report of a K. pneumoniae strain causing neonatal sepsis harbouring the blaCTX-M-15 gene in an IncFII plasmid and belonging to ST466 in this area.

Aetiology, epidemiology and clinical characteristics of acute moderate-to-severe diarrhoea in children under 5 years of age hospitalized in a referral paediatric hospital in Rabat, Morocco.

The objective of the study was to describe the aetiology, epidemiology and clinical characteristics of the principal causes of acute infectious diarrhoea requiring hospitalization among children under 5 years of age in Rabat, Morocco. A prospective study was conducted from March 2011 to March 2012, designed to describe the main pathogens causing diarrhoea in hospitalized children >2 months and less than 5 years of age. Among the 122 children included in the study, enteroaggregative Escherichia coli (EAEC) and rotavirus were the main aetiological causes of diarrhoea detected. Twelve (9.8 %) children were referred to an intensive care unit, while two, presenting infection by EAEC, and EAEC plus Shigella sonnei, developed a haemolytic uraemic syndrome. Additionally, six (4.9 %) deaths occurred, with EAEC being isolated in four of these cases. Diarrhoeagenic E. coli and rotavirus play a significant role as the two main causes of severe diarrhoea, while other pathogens, such as norovirus and parasites, seem to have a minimal contribution. Surveillance and prevention programmes to facilitate early recognition and improved management of potentially life-threatening diarrhoea episodes are needed.

Risk factors for a poor outcome among children admitted with clinically severe pneumonia to a university hospital in Rabat, Morocco.

OBJECTIVES: Data on prognostic factors among children with severe pneumonia are scarce in middle-income countries. We investigated prognostic factors for an adverse outcome among children admitted to the Hôpital d'Enfants de Rabat, Morocco with World Health Organization-defined clinically severe pneumonia (CSP). METHODS: Children aged 2-59 months admitted to the hospital and fulfilling the CSP definition were recruited into this 13-month prospective study. A poor prognosis was defined as death, a need for intensive care, or a Respiratory Index of Severity in Children (RISC) score ≥3. Multivariate logistic regression was performed to ascertain independent predictive factors for a poor prognosis. RESULTS: Of the 689 children included in this analysis, 55 (8.0%) required intensive care and 28 died (4.0%). Five hundred and two (72.8%) children were classified as having a good prognosis and 187 (27.2%) as having a poor prognosis. A history of prematurity (odds ratio (OR) 2.50, 95% confidence interval (CI) 1.24-5.04), of fever (OR 2.25, 95% CI 1.32-3.83), living in a house with smokers (OR 1.79, 95% CI 1.18-2.72), impaired consciousness (OR 10.96, 95% CI 2.88-41.73), cyanosis (OR 2.09, 95% CI 1.05-4.15), pallor (OR 2.27, 95% CI 1.34-3.84), having rhonchi on auscultation (OR 2.45, 95% CI 1.58-3.79), and human metapneumovirus infection (OR 2.13, 95% CI 1.13-4.02) were all independent risk factors for an adverse outcome, whereas a history of asthma (OR 0.46, 95% CI 0.25-0.84) was the only independent risk factor for a positive outcome. CONCLUSIONS: The early identification of factors associated with a poor prognosis could improve management strategies and the likelihood of survival of Moroccan children with severe pneumonia.

The epidemiology and aetiology of infections in children admitted with clinical severe pneumonia to a university hospital in Rabat, Morocco.

OBJECTIVES: Scarce and limited epidemiological, clinical and microbiological data are available regarding paediatric respiratory tract infections in the Kingdom of Morocco, a middle-income country in northwestern Africa. The results of hospital-based surveillance aiming at describing the aetiology and epidemiology of respiratory distress among children <5 years of age are presented. METHODS: Children admitted to the Hôpital d'Enfants de Rabat, Morocco, and meeting the World Health Organization clinical criteria for severe pneumonia were recruited over a period of 14 months and were thoroughly investigated to ascertain a definitive diagnosis. RESULTS: In total, 700 children were recruited for the study. Most frequent clinical diagnoses included wheezing-related conditions (bronchitis/asthma, 46%; bronchiolitis, 15%), while typical bacterial pneumonia was infrequent (only 19% of the cases). Invasive bacterial disease detected by classical microbiology or molecular methods was also uncommon, affecting only 3.5% of the patients, and with an overall low detection of pneumococcal or Haemophilus influenzae type b disease. Conversely, coverage of respiratory viral detection in the nasopharynx was almost universal among cases (92%), with the three most frequent viruses detected being rhinovirus (53%), respiratory syncytial virus (18%) and adenovirus (17%). The overall case fatality rate (CFR) among recruited patients with a known outcome was 4.1% (28/690). CONCLUSIONS: In Morocco, the epidemiological profile of paediatric acute respiratory infections is markedly shifted towards wheezing-related diseases and thus resembles that of high-income countries. However, the high associated CFRs found in this study call for an improvement in preventive and clinical management strategies.

Detection of Streptococcus pneumoniae and Haemophilus influenzae type B by real-time PCR from dried blood spot samples among children with pneumonia: a useful approach for developing countries.

BACKGROUND: Dried blood spot (DBS) is a reliable blood collection method for storing samples at room temperature and easily transporting them. We have previously validated a Real-Time PCR for detection of Streptococcus pneumoniae in DBS. The objective of this study was to apply this methodology for the diagnosis of S. pneumoniae and Haemophilus influenzae b (Hib) in DBS samples of children with pneumonia admitted to two hospitals in Mozambique and Morocco. METHODS: Ply and wzg genes of S. pneumoniae and bexA gene of Hib, were used as targets of Real-Time PCR. 329 DBS samples of children hospitalized with clinical diagnosis of pneumonia were tested. RESULTS: Real-Time PCR in DBS allowed for a significant increase in microbiological diagnosis of S. pneumoniae and Hib. When performing blood bacterial culture, only ten isolates of S. pneumoniae and none of Hib were detected (3·0% positivity rate, IC95% 1·4-5·5%). Real-Time PCR from DBS samples increased the detection yield by 4x fold, as 30 S. pneumoniae and 11 Hib cases were detected (12·4% positivity rate, IC95% 9·0-16·5%; P<0·001). CONCLUSION: Real-Time PCR applied in DBS may be a valuable tool for improving diagnosis and surveillance of pneumonia caused by S. pneumoniae or Hib in developing countries.

Antibiotic Usage Prior and During Hospitalization for Clinical Severe Pneumonia in Children under Five Years of Age in Rabat, Morocco.

Scarce and limited epidemiological, clinical and microbiological data are available regarding pediatric respiratory tract infections in the Kingdom of Morocco, a middle-income country in Northwestern Africa. Data on antibiotic usage for such infections are also scarce. A good understanding of pre-admission and intra-hospital usage of antibiotics in children with respiratory infections linked with an adequate surveillance of the antibiotic susceptibility from circulating pathogens could help policy makers improve their recommendations on management of respiratory infections. We hereby present data on antibiotic usage prior and during admission and antibiotic susceptibility of major circulating respiratory pathogens in children under five years of age admitted to the Hôpital d'Enfants de Rabat, Morocco, with a diagnosis of clinical severe pneumonia (using World Health Organization (WHO) standardized case definitions) during a period of 14 months (November 2010-December 2011), as part of a larger hospital-based surveillance study designed to understand the etiology and epidemiology of severe pneumonia cases among children.