The emergence of highly resistant and hypervirulent Klebsiella pneumoniae CC14 clone in a tertiary hospital over 8 years.

BACKGROUND: Klebsiella pneumoniae is a major bacterial and opportunistic human pathogen, increasingly recognized as a healthcare burden globally. The convergence of resistance and virulence in K. pneumoniae strains has led to the formation of hypervirulent and multidrug-resistant strains with dual risk, limiting treatment options. K. pneumoniae clones are known to emerge locally and spread globally. Therefore, an understanding of the dynamics and evolution of the emerging strains in hospitals is warranted to prevent future outbreaks. METHODS: In this study, we conducted an in-depth genomic analysis on a large-scale collection of 328 multidrug-resistant (MDR) K. pneumoniae strains recovered from 239 patients from a single major hospital in the western coastal city of Jeddah in Saudi Arabia from 2014 through 2022. We employed a broad range of phylogenetic and phylodynamic methods to understand the evolution of the predominant clones on epidemiological time scales, virulence and resistance determinants, and their dynamics. We also integrated the genomic data with detailed electronic health record (EHR) data for the patients to understand the clinical implications of the resistance and virulence of different strains. RESULTS: We discovered a diverse population underlying the infections, with most strains belonging to Clonal Complex 14 (CC14) exhibiting dominance. Specifically, we observed the emergence and continuous expansion of strains belonging to the dominant ST2096 in the CC14 clade across hospital wards in recent years. These strains acquired resistance mutations against colistin and extended spectrum ß-lactamase (ESBL) and carbapenemase genes, namely blaOXA-48 and blaOXA-232, located on three distinct plasmids, on epidemiological time scales. Strains of ST2096 exhibited a high virulence level with the presence of the siderophore aerobactin (iuc) locus situated on the same mosaic plasmid as the ESBL gene. Integration of ST2096 with EHR data confirmed the significant link between colonization by ST2096 and the diagnosis of sepsis and elevated in-hospital mortality (p-value < 0.05). CONCLUSIONS: Overall, these results demonstrate the clinical significance of ST2096 clones and illustrate the rapid evolution of an emerging hypervirulent and MDR K. pneumoniae in a clinical setting.

Common Resistance Patterns in the Burn Unit of a Tertiary Care Center: A Retrospective Observational Study.

Background Nosocomial bacterial infections have been one of the major concerns in the healthcare system. Burn patients, specifically severe cases, are at a high risk of developing bacterial infections compared to others. The most frequent cultures among burn patients are Staphylococcus aureus, Pseudomonas aeruginosa,and Acinetobacter baumannii. There is a scarcity of local data showing the most common infections in burn patients. This research aimed to determine the most common organisms that cause infections in burn unit patients and the antibiotic sensitivity and resistance patterns in King Abdulaziz Medical City (KAMC) in Jeddah. Methodology In this cross-sectional study, data were collected from patients' files into a data collection sheet. All patients in the burn unit with a positive culture were included in the study using a convenient sampling technique from Best-Care, KAMC electronic medical records. Burn patients with negative culture results and patients who were admitted to the plastic surgery ward for reasons other than burns were excluded. For sample size calculation, convenience sampling of 109 patient medical charts, over the study period from June 2016 to November 2021, was selected for data extraction, analysis, and reporting. Results Pseudomonas aeruginosa was the leading cause of infection in burn patients comprising 33.9% of the cases. Enterobacter cloacae was the second most frequent cause of infection among burn patients (27.5%). Klebsiella pneumoniae was the third most frequent cause of infection (26.6%) while Acinetobacter baumannii was the fourth most frequent cause of infection in burn patients (22.9%). Conclusions Understanding the local epidemiology of bacterial infections will be crucial for the development of treatment guidelines designed to standardize initial antibiotic use, reduce hospital-acquired infections, and reduce drug resistance. More attention should be paid to gram-negative bacteria, specifically Pseudomonas aeruginosa and Enterobacter Cloacae.

Evidence-Based Interventions to Reduce the Incidence of Common Multidrug-Resistant Gram-Negative Bacteria in an Adult Intensive Care Unit.

Background Multidrug-resistant Gram-negative bacteria (MDR-GNB) present a significant and escalating hazard to healthcare globally. Context-specific interventions have been implemented for the prevention and control of MDR-GNB in several healthcare facilities. The objective of this study was to implement and evaluate the effectiveness of evidence-based interventions in the incidence and dissemination of MDR-GNB. Methods This was a pre-and post-intervention study conducted in three phases at King Abdulaziz Medical City Jeddah, Saudi Arabia. During Phase-1, the data on each of the four MDR-GNB (Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli) were collected prospectively. Genomic fingerprinting was performed on isolates using enterobacterial repetitive intergenic consensus-polymerase chain reaction (ERIC-PCR) to determine clonality and establish a link between different strains within and between the hospital wards/units. In the second phase, targeted interventions were implemented in the adult intensive care unit (ICU) based on previously determined risk factors and included the education of healthcare workers on hand hygiene, disinfection of patients' surrounding, daily chlorhexidine baths, and disinfection rooms on discharge with hydrogen peroxide fogging after MDR-GNB patients were discharged. An antibiotic restriction protocol was simultaneously implemented as part of the hospital antibiotic stewardship program. In the third phase, the effectiveness of the interventions was evaluated by comparing the incidence rate and clonality (using ERIC-PCR genetic fingerprints) of MDR-GNB before and after the intervention. Results A significant reduction of MDR-GNB was observed in Phase-2 and Phase-3 compared with Phase-1. The mean incidence rate of MDR-GNB per 1000 patient days in Phase-1 (pre-intervention) was 11.08/1000, followed by 6.07 and 3.54/1000 in Phase-2 and Phase-3, respectively. A statistically significant reduction was observed in the incidence rate of MDR-GNB in the adult ICU (P=0.007), whereas no statistically significant decrease (P=0.419) was observed in areas other than the adult ICU. Two A. baumannii strains appear to be circulating within the ICU environment with reduced frequency in Phase-2 and Phase-3 compared to Phase-1. Conclusion  There was a significant reduction in the incidence of MDR-GNB in the adult ICU due to the successful implementation of both infection control and stewardship interventions, albeit challenging to ascertain the relative contribution of each.

Risk Factors for Infection With Multidrug-Resistant Gram-Negative Bacteria in a Tertiary Care Hospital in Saudi Arabia: A Case-Control Study.

Background The increase in the incidence of multidrug-resistant (MDR) organisms especially Gram-negative bacteria (GNB) in healthcare facilities is a serious cause of concern. This study identified risk factors for the infection with these MDR GNB, such as Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli to inform healthcare workers about strategies for their containment. Methods A case-control study was carried out at a tertiary care hospital where 100 patients with healthcare-associated infections (infections arising 48 hours after admission) caused by MDR GNB were compared with two control groups, i.e., 100 patients with healthcare-associated infections caused by non-MDR GNB (not meeting the criteria of MDR) and 100 patients without infection caused by GNB. MDR bacteria were defined as the ones that were non-susceptible to at least one antibiotic in three or more classes of antibiotics. The data were analyzed using descriptive statistics (frequency and percentage of categorical variables). Multivariate regression analysis was undertaken to identify significant predictors of MDR GNB. Odds ratios with 95% confidence intervals were calculated, and the level of significance was determined at p-value < 0.05. Results A total of 388 organisms were isolated during four months (January-April 2015) from 332 patients. Fifty-six (17%) of the patients were infected with more than one organism. Among the MDR bacteria, the most dominant MDR organism was A. baumannii (38%), followed by K. pneumoniae (31%), P. aeruginosa (20%), and E. coli (11%). Among the non-MDR organisms, the most dominant was P. aeruginosa (47%), followed by E. coli (32%), K. pneumoniae (18%), and A. baumannii (3%). Patients with MDR organisms compared with the first control group (patients with non-MDR organisms) showed that prior antibiotic use (p-value: 0.001), intensive care unit (ICU) admission (p-value: 0.001), and indwelling medical devices (p-value: 0.005) were significant risk factors for MDR infections. It was also found that the risk factors for MDR GNB infection were the same in the second control group (patients without infection): prior antibiotic use (p-value: 0.002), ICU admission (p-value: 0.001), and indwelling medical devices (p-value: 0.03). Based on the comparison of the two control groups, prolonged hospital stays of more than five days (p-value: 0.001), immunosuppressive therapy (p-value: 0.02), and over 60 years of age (p-value: 0.02) were significant risk factors for non-MDR infection. Conclusion  The risk factors identified in our study provide guidance to healthcare workers for the prevention and containment of MDR GNB.

Septic Abortion Secondary to Peptoniphilus asaccharolyticus Complicated by Bacteremia: A Case Report and Review of Literature.

Peptoniphilus species are gram-positive anaerobic coccus (GPAC) that are found in the human flora, such as the skin, gastrointestinal tract, and genitourinary tract, and can be pathogenic. Septic abortion caused by Peptoniphilus species has been reported only three times in the literature. Here, we present a case of Peptoniphilus asaccharolyticus (P. asaccharolyticus) bacteremia as a complication of septic abortion.

Leclercia adecarboxylata Bacteremia without a Focus in a Non-Immunosuppressed Patient.

BACKGROUND Leclercia adecarboxylata is a gram-negative rod, which is normally found in water and food. It is an emerging pathogen that affects immunocompromised patients, including patients with hematological malignancies or those receiving chemotherapy. Generally, L. adecarboxylata is considered a low-virulence pathogen with an excellent susceptibility profile, but some strains may be resistant to multiple antibiotics, such as b-lactams. Moreover, L. adecarboxylata is usually isolated as a part of polymicrobial cultures in immunocompetent individuals, but there have been cases where it was the only isolate. CASE REPORT A 74-year-old woman who was non-immunosuppressed and had multiple comorbidities was admitted with acute decompensated heart failure due to pneumonia. She was treated with multiple courses of antibiotics including amoxicillin-clavulanate and ciprofloxacin for pneumonia, but her infection worsened, and she had cardiopulmonary arrest. After resuscitation, she was stable for several days but suddenly became confused and hypotensive. The septic screen showed L. adecarboxylata bacteremia without a clear source, which was treated successfully with meropenem for 14 days. After the meropenem course, the patient developed diarrhea and was found to have severe Clostridium difficile infection. She did not respond to oral vancomycin and intravenous metronidazole and died. CONCLUSIONS This case illustrated an infection in a non-immunosuppressed individual by an organism that is considered an opportunistic pathogen, mainly affecting immunocompromised patients. The patient's blood culture grew L. adecarboxylata, which was sensitive to all antibiotics but resolved with meropenem treatment. Owing to increasing L. adecarboxylata infections, we recommend further studies to understand the organism's pathogenesis, risk factors, and resistance pattern.

A Patient With Dengue Fever and COVID-19: Coinfection or Not?

Co-epidemics can create a burden on healthcare systems in the affected areas. The world, at present, is facing the pandemic of coronavirus disease. Nonetheless, many areas worldwide suffer from endemics that are not of less danger than the current pandemic. We presented a case of a patient diagnosed with dengue fever and was also found to have coronavirus through nasal swab, but immunoglobulin M and G were undetectable. Our case brings to notice the alarming probability of two co-epidemics happening simultaneously. However, through the presented case, our theory is that the dengue virus may cause a false-positive detection of severe acute respiratory syndrome coronavirus 2.

Changes in Hematological Indices and Lymphocyte Subsets in Response to Platelet Apheresis Donation.

BACKGROUND: Platelet apheresis is a technique in which whole blood is collected from a donor followed by platelet (PLT) separation. Platelet apheresis has a significant impact on some biochemical indices after donation. This study aimed to investigate the impact of platelet apheresis on complete blood count (CBC) and lymphocyte subsets over a typical interdonation interval. METHODS: Healthy male subjects (n = 10) were recruited to study changes in CBC and lymphocyte subsets before and at three intervals following platelet apheresis. Repeated measures ANOVA was used to compare quantitative variables between different visits. RESULTS: Following platelet apheresis, platelet count decreased 30% at 24 hours after donation (p < 0.001) compared to the baseline count with significant repeated ANOVA across different visits (p < 0.001, Eta = 0.558). No changes were observed in other variables of CBC. The lymphocyte subsets including CD4, CD8, and CD4/CD8 ratio were decreased at 24 hours after donation (-0.6%, -0.4% and -0.7%, respectively) but none was significant. At 24 hours, the proportion of CD19 and CD16-56 were slightly increased (1.6%, 3.3%, p > 0.05, respectively). CONCLUSIONS: The significant reduction in PLT count after 24 hours of plateletpheresis may have adverse health effects on PLT donors. Platelet apheresis has no significant effect on lymphocyte subsets of the donor.

First report of Klebsiella quasipneumoniae harboring blaKPC-2 in Saudi Arabia.

Background: Nosocomial infections caused by multi-drug resistant Enterobacteriaceae are a global public health threat that ought to be promptly identified, reported, and addressed accurately. Many carbapenem-resistant Enterobacteriaceae-associated genes have been identified in Saudi Arabia but not the endemic Klebsiella pneumoniae carbapenemases (KPCs), which are encoded by blaKPC-type genes. KPCs are known for their exceptional spreading potential. Methods: We collected n = 286 multi-drug resistant (MDR) Klebsiella spp. isolates as part of screening for resistant patterns from a tertiary hospital in Saudi Arabia between 2014 and 2018. Antimicrobial susceptibility testing was carried out using both VITEK II and the broth microdilution of all collected isolates. Detection of resistance-conferring genes was carried out using Illumina whole-genome shotgun sequencing and PacBio SMRT sequencing protocols. Results: A Carbapenem-resistant Enterobacteriaceae (CRE) Klebsiella quasipneumoniae subsp. similipneumoniae strain was identified as a novel ST-3510 carrying a blaKPC-2 carbapenemase encoding gene. The isolate, designated as NGKPC-421, was obtained from shotgun Whole Genome Sequencing (WGS) surveillance of 286 MDR Klebsiella spp. clinical isolates. The NGKPC-421 isolate was collected from a septic patient in late 2017 and was initially misidentified as K. pneumoniae. The sequencing and assembly of the NGKPC-421 genome resulted in the identification of a putative ~ 39.4 kb IncX6 plasmid harboring a blaKPC-2 gene, flanked by transposable elements (ISKpn6-blaKPC-2-ISKpn27). Conclusion: This is the first identification of a KPC-2-producing CRE in the Gulf region. The impact on this finding is of major concern to the public health in Saudi Arabia, considering that it is the religious epicenter with a continuous mass influx of pilgrims from across the world. Our study strongly highlights the importance of implementing rapid sequencing-based technologies in clinical microbiology for precise taxonomic classification and monitoring of antimicrobial resistance patterns.

Response to imatinib therapy in adult patients with chronic myeloid leukemia in Saudi population: a single-center study.

No study has been published yet in the Arab world regarding response and outcome of imatinib in patients with chronic myeloid leukemia (CML). This study evaluated a total of 122 patients with CML treated with imatinib between 2001 and 2012. Survival, hematologic, cytogenetic and molecular responses and adverse events were assessed. The 5-year overall survival (OS), event free survival (EFS) and progression-free survival (PFS) rates were: 95.4 ± 2.3%, 81.4 ± 4.6% and 90.8 ± 3.2%, respectively. Significant differences in OS (p = 0.001), EFS (p = 0.001) and PFS (p = 0.001) were noted when patients were stratified by cytogenetic response. Survival by Sokal risk groups was not significant (p = 0.293). Complete hematologic response was achieved in 94 patients (93.1%), cytogenetic response in 84 (83.2%), major molecular response in 62 (61.4%) and complete molecular response in 34 (33.7%). This article presents the first evidence on the effectiveness of imatinib in patients with CML from Saudi Arabia and highlights similarities and differences in response patterns in published studies.

Hepatitis B virus among Saudi National Guard personnel: seroprevalence and risk of exposure.

BACKGROUND: Data on HBV prevalence among active military personnel in Saudi Arabia (SA) are lacking. In addition, the work-related risk of exposure is unclear. The objective of this study was to estimate the seroprevalence of HBV and the risk of HBV exposure among SA National Guard (SANG) soldiers. METHODS: A cross-sectional study was performed and included 400 male SANG soldiers working in Jeddah during January 2009. All soldiers completed a questionnaire to assess their risk of exposure and gave a blood sample to test for hepatitis serology markers. RESULTS: A total of 16 (4.0%) soldiers were positive for HbsAg, 53 (13.2%) were positive for anti-HBc, and 230 (57.5%) were positive for anti-HBs. None of the soldiers had acute HBV infection, but 15 (3.8%) were chronic HBV carriers. A total of 152 (38.0%) soldiers were susceptible to HBV infection, and 230 (57.5%) were immune to HBV infection, primarily (84.3%) due to HBV vaccination. Compared with those who were negative for anti-HBc (never exposed), soldiers who were positive for anti-HBc were more likely to be older, have a lower education level, have a higher income, have a longer service duration, have a household member with HBV disease, have undergone surgery, or have undergone endoscopy. In the multivariate logistic regression model, older age, presence of a household member with HBV disease and previous endoscopy were independent predictors of HBV exposure. CONCLUSION: We report a 4% prevalence of HBsAg in the Saudi military population. This HBV prevalence was higher than those in the general Saudi population and military populations from Western countries. Both work-related and community-related risk factors for exposure are suggested.

Improvement of the low knowledge, attitude and practice of hepatitis B virus infection among Saudi national guard personnel after educational intervention.

BACKGROUND: Although the risk of hepatitis B virus (HBV) was reported to be higher in military personnel than the general population in Saudi Arabia (SA), there is lack of studies assessing HBV awareness among them. The objective was to evaluate the knowledge, attitude and practice (KAP) of HBV infection among military personnel. METHODS: An intervention design with pre- and post-education KAP questionnaire was completed among National Guard soldiers working in Jeddah during January 2009. Educational intervention was provided through educational leaflets, group and individual discussions, visual show, and a lecture. A score was created from the correct answers to 58 questions. RESULTS: A total of 400 male soldiers with mean age 30.7 ± 6.1 years completed both questionnaires. The majority had school education (96.8%) and in the lower military ranks (66.0%). Only 19.5% of soldiers reported HBV vaccine intake. The low median and inter-quartile range of the pre-intervention score (16, 6-26) markedly increased after education (to 53, 50-55, p<0.001). The overall improvement of mean KAP score (204%) was also observed in all its component scores; disease nature (272%), methods of transmission (206%), prevention and control (109%), attitude (155%), and practice (192%). The improvement was evident irrespective of socio-demographic characteristics and history of HBV vaccine. KAP scores were significantly associated with higher educational levels, higher monthly income, administrative jobs, and higher job ranks. CONCLUSION: We are reporting a low level of HBV awareness among Saudi military population. The study confirms the need and effectiveness of focused multifaceted educational campaigns among the military population.

Perinatal cytomegalovirus hepatitis in Saudi infants: a case series.

BACKGROUND/AIM: Cytomegalovirus (CMV) is the most common congenital viral infection, occurring in 0.4%-2.3% of all live births. The clinical manifestations of CMV are multiorgan involvement. Currently, the numbers of studies of hepatic CMV infection in immunocompetent infants are insufficient and little information exists in the medical literature about the hepatic manifestations and complications of CMV. PATIENTS AND METHODS: Nine infants diagnosed with hepatic CMV infection were included in the study. The diagnosis was based on the presence of IgM anti-CMV antibodies titer in serum and detection of CMV-DNA in blood. The authors identified clinical characteristics, biochemical characteristics, immunologic markers, and the outcome of hepatic CMV with or without treatment. RESULTS: Jaundice was the most common clinical feature of CMV infection in infancy (100%). Hepatic abnormalities in the form of cholestasis (defined as a serum conjugated bilirubin concentration greater than 17.1 µmol/L or greater than 20% of the total serum bilirubin) were found in all patients (100%), hepatitis (77%), hypoalbuminemia (55%), elevated alkaline phosphatase, and gamma-glutamyltransferase (77%). Other findings showed hepatosplenomegaly (44%), thrombocytopenia (22%) and low birth weight (11%) The treatment of hepatic CMV infection was indicated in 66% and was not indicated in 33%. Both of them had resolved cholestasis and hepatitis. CONCLUSION: Jaundice and cholestasis were the most common clinical features of hepatic CMV infections. Hepatic CMV infection in young infants is often a self-limited illness that does not require antiviral therapy. Most of the patients with hepatic CMV infection had a favorable outcome.