Epidemiology of bacteraemia in Hamad general hospital, Qatar: a one year hospital-based study.

We conducted a one-year observational study from July 2007 to June 2008 to describe the epidemiology of bacteraemia at Hamad general hospital. During this period, a total of 452 episodes of bacteraemia occurred, which corresponds to a rate of 19/1000 hospital admissions. Most patients 58.8% (266/452) had community acquired bacteraemia, and primary bacteraemia accounted for 62.2% (281/452) of the cases. The most common source of bacteraemia was intravenous catheterization in 19.2% (87/452) but no source was identified in 42.9% (194/452) of the episodes. Gram-negative organisms were isolated in 63.1% (285/452) episodes with Escherichia coli being the most frequent 21.5% (97/452). Multidrug resistance was observed in 33.3% (7/21) of all Pseudomonas aeruginosa isolates, 50% (6/12) of Acinetobacter isolates and 28.6% (6/21) of Enterobacter isolates, whereas all ESBL producing Klebsiella spp. and E. coli were multiresistant. The percentages of oxacillin resistant coagulase negative Staphylococci isolates and methicillin-resistant Staphylococcus aureus isolates were 81.8% (27/33) and 13.2% (7/53) respectively. In hospital mortality was 22.5% (102/452), and inadequate treatment and septic shock were found to be independent predictors of mortality. Therefore, bloodstream infection surveillance is crucial to produce meaningful guidelines for prevention (e.g., catheter-related) and empirical treatment of bacteraemia in Qatar.

Campylobacter peritonitis complicating continuous ambulatory peritoneal dialysis: report of three cases and review of the literature.

BACKGROUND: The micro-organisms involved in continuous ambulatory peritoneal dialysis (CAPD) peritonitis are usually gram-positive cocci of cutaneous origin. Campylobacter species are rarely implicated as a cause of CAPD peritonitis. METHODS: A retrospective review of 100 consecutive episodes of peritonitis was carried out in patients undergoing CAPD or automated PD in our hospital from June 2004 to December 2007. Collection of dialysate and microbial examination was done according to ISPD guidelines. Identification of the organism was made on the basis of Gram smear morphology, positive oxidase test, and biochemical reactions using API Campi (BioMérieux, Marcy l'Etoile, France). Susceptibility testing was performed using E-test (AB Biodisc, Solna, Sweden) and confirmation was done by molecular techniques. RESULTS: The causative organisms in 23 of these episodes were gram-negative bacteria, 3 of which were identified as Campylobacter species using special culture techniques. The clinical presentation in our patients with Campylobacter peritonitis (CP) was different from that of patients with peritonitis from other organisms in that all 3 had diarrhea at presentation. Among patients with CP, no subspecies-specific feature was identified. Good response to the antibiotic treatment was observed; there was no relapse/recurrence of peritonitis, catheter loss, or death. CONCLUSION: Incidence of CP remains low and, regardless of the subtype, clinical outcomes are better than those seen with other gram-negative bacteria such as Pseudomonas. The presence of diarrhea at presentation and the finding of curved or spiral gram-negative bacilli in the Gram smear of peritoneal dialysis effluent should make one think of CP. The use of appropriate microbiology techniques in this situation will increase the isolation of this organism.

A rare and unsuspected complication of Clostridium difficile infection.

OBJECTIVE: To report the occurrence of abdominal compartment syndrome (ACS) due to infection with Clostridium difficile. DESIGN: Case report. SETTING: Trauma intensive care unit (TICU) of Hamad General Hospital, a teaching hospital in Doha, Qatar. PATIENT: A 36-year-old man involved in a motor vehicle accident had severe traumatic brain injury and received ceftriaxone. On day 7, he developed severe abdominal distension and diarrhoea followed by paralytic ileus with oliguria, hyperkalaemia, and intra-abdominal hypertension. The patient's stool sample was positive for C. difficile toxin A and B MEASUREMENTS AND RESULTS: An ACS was diagnosed. The patient was successfully treated in the TICU by stopping the offending antibiotic and starting metronidazole plus neostigmine as a prokinetic agent. The fluid status was guided by pulse-induced continuous cardiac output, and frusemide was added to the treatment. With this aggressive management the abdominal pressure decreased and the renal function improved, with full recovery of renal function by day 21. Unfortunately the patient's Glasgow coma score (GCS) deteriorated, so percutaneous tracheostomy was performed. He was transferred to the neurosurgical ward on day 35. A week later he was shifted to the rehabilitation unit for further management. CONCLUSIONS: C. difficile colitis can cause intra-abdominal hypertension (IAH) and ACS. Rapid diagnosis, early aggressive supportive care, metronidazole and prokinetics are necessary to lower the morbidity and mortality of C. difficile colitis associated with IAH and ACS.

Guillain-Barré syndrome associated with Salmonella paratyphi A.

A 31-year-old Nepali man was admitted to the intensive care unit with a 3-day history of fever associated with four-limb weakness, followed by difficulty in swallowing. The patient came from Nepal 20 days before admission. On examination the patient was conscious and appeared ill, with a temperature of 38.0 degrees C. His four limbs were weak (grades 2-3) and he was areflexic with mild facial weakness and absent gag reflex. Brain CT and MRI were normal. Cerebrospinal fluid analysis showed high protein. A neurophysiologic study showed data consistent with motor axonal polyradiculopathy. The patient was diagnosed with Guillain-Barré syndrome (GBS), and intravenous immunoglobulin (0.4 g/kg day for 5 days) was administered. On the third hospitalization day, the patient developed respiratory failure for which he was intubated and mechanically ventilated. On the same day, blood samples grew Salmonella paratyphi A (S. paratyphi A), which was sensitive to ceftriaxone. The patient was then diagnosed with GBS associated with S. paratyphi A, and treated with ceftriaxon (2 g administered intravenously, daily for 10 days). On the eleventh hospitalization day the patient was weaned from ventilator and extubated successfully. Subsequently, the patient improved, his fever subsided, and he regained muscle power satisfactorily.

Irreversible papillitis and ophthalmoparesis as a presenting manifestation of neurobrucellosis.

A 35-year-old man presented with a meningeal syndrome and acute onset of visual blurring. Clinical investigations revealed bacterial meningitis with bilateral papillitis and ophthalmoparesis. Serum and cerebrospinal fluid serology confirmed the diagnosis of chronic active neurobrucellosis. Following therapy there was no improvement and he developed optic atrophy. Extensive literature review revealed, one case of bilateral irreversible papillitis resulting from neurobrucellosis. However no cases of neurobrucellosis have been reported with meningitis, irreversible papillitis and ophthalmoparesis. This case demonstrates that in endemic areas, acute meningitis is a potential manifestation of neurobrucellosis and that bilateral irreversible papillitis with ophthalmoparesis can be a potential serious complication.

Acute bacterial meningitis in Qatar.

OBJECTIVE: To study the changes in the epidemiology, clinical and bacteriological profiles of bacterial meningitis in the era of the Haemophilus influenzae type b (Hib)vaccine and pneumococcus resistance. METHODS: This is a retrospective study of children aged <12 years admitted to the Hamad Medical Corporation, Qatar between January 1998 through December 2002 with positive cerebrospinal fluid culture. RESULTS: We described 64 patients with culture proven bacterial meningitis. In infants <3 months (n=29 [45%]), the most common organism was Group B Streptococcus (GBS) (20%). Children >3 months (n=35 [55%]); Hib (25%) and Streptococcus pneumoniae (STP) (20%) were the most common organisms before introduction of Hib vaccination. A significant drop of Hib infections were noticed after introduction of the vaccine. Fever, neck stiffness, seizure, vomiting, and bulging fontanel were the most frequent presenting features. Group B Streptococcus were sensitive to ampicillin and cefotaxime with no resistance detected. Forty percent of STP isolates were resistant to penicillin and 12% were resistant to ceftriaxone. Fifty percent of Hib were resistant to ampicillin; while none of Hib were resistant to ceftriaxone. No case of Listeria monocytogenes meningitis was diagnosed. Morbidity was 28%, and one patient expired (2%) after Klebsiella pneumoniae meningitis. Streptococcus pneumoniae was associated with the highest morbidity (62%) while Hib had zero morbidity in our patients. CONCLUSION: Bacterial meningitis is a serious illness with a significant morbidity and mortality. Haemophilus influenzae type b infection decreased which indicated an effective vaccination. As there is 12% bacterial resistance of STP reported against ceftriaxone; We recommend Cefotaxime for infants <3 months while ceftriaxone plus vancomycin as empiric therapy for older patients with community acquired bacterial meningitis. A pneumococcal vaccination may further decrease the incidence of meningitis in our community. A continuos surveillance to detect changes in the microbiology of organisms causing bacterial meningitis or their sensitivity in our community is essential to update these recommendations.

Antibiotic prescribing pattern in a medical intensive care unit in Qatar.

OBJECTIVES: The primary objectives were to evaluate the current usage of anti-microbial agents in the Medical Intensive Care Unit (MICU) of Hamad Medical Corporation (HMC) in Doha, State of Qatar and to correlate this with: a) the infectious disease pattern, b) the isolated microorganisms and their sensitivity pattern, and, importantly, c) the patient's clinical outcome. A secondary objective was to evaluate the influence of the use of steroid therapy on the development of fungal infections. METHODS: A prospective study covering a 2-month period from February through April 2004, including all patients admitted to the MICU for a minimum of 48 hours, and receiving a systemic antibiotic. RESULTS: From the 71 eligible patients admitted, 54 (76%) were treated for presumed or proven infections and received antibiotics, corresponding with 280 (89%) of the 313 patient days. Respiratory infections accounted for 57%. A total of 159 antibiotics (134 intravenously and 25 orally) were administered to the 54 patients during their stay in the MICU, corresponding with an average of almost 3 antibiotics per patient. Ceftriaxone was prescribed in 31 patients (57%) as initial therapy. Throughout the study period, a total of 385 microbiology samples for culturing were taken, corresponding with almost one sample per patient per day. Fifty-two percent of patients had a microbiologically proven infection (MPI): 18% with community-acquired pneumonia (CAP), 18% ventilated-acquired pneumonia (VAP), and 11% with hospital-acquired pneumonia (HAP). In the group of bacterial MPI, sensitivity pattern resulted in change in empirical antibiotic therapy in 12 of 23 patients (52%). In the group of patients with non-MPI, antibiotherapy was changed in 5 of the 26 patients (19%). Yeast infections developed in 13 of 30 (43%) patients receiving steroids (with 3 out of 9 patients (33%) receiving steroids for severe sepsis, and septic shock) compared to 5 of 24 (21%) patients receiving no steroids. CONCLUSION: This study highlights the urgent need for updated empiric and treatment guidelines as well as the monitoring of the antibiotic usage.

Rapidly progressive lung disease in a patient with cystic fibrosis on long-term azithromycin: possible role of mycoplasma infection.

Macrolides is effective therapy in patients with cystic fibrosis (CF). We describe a girl with CF given long-term azithromycin who died of rapidly progressive lung disease. She was found to have rising titers of mycoplasma serology, suggesting a possible causative role of a resistant mycoplasma infection. Mycoplasma infection should be considered in CF patients who are deteriorating, even if they are being treated with macrolides, to which these organisms are usually susceptible.

Clinical presentation of acute bacterial meningitis in Qatar.

OBJECTIVE: To study the changes in the epidemiology of bacterial meningitis in the era of the Hemophilus influenzae (H. influenzae) type b vaccine and pneumoccous resistance. METHODS: Retrospective study which included patients admitted to Hamad Medical Corporation, Doha, Qatar between January 1998 through to December 2000 with positive cerebrospinal fluid culture. RESULTS: Thirty-seven patients with culture proven bacterial meningitis were described. Streptococcus pneumoniae (S. pneumoniae) and H. influenzae were the most common organisms, accounting for 30% and 24% of cases. Fever, neck stiffness, vomiting, and bulging fontanel were the most frequent presenting features. Fifty four percent of S. pneumoniae isolates were resistant to penicillin, and 22% of H. influenzae were resistant to ampicillin, but both were sensitive to ceftriaxone. No cases of Listeria monocytogenes meningitis were diagnosed. Morbidity was 32%, and mortality 5%. Poor outcome was associated with altered mental status on admission. CONCLUSION: Bacterial meningitis is a serious illness in our community with significant morbidity and mortality. Streptococcus pneumoniae and H. influenzae are the most frequent pathogens causing meningitis in our community. As there is no bacterial resistance (S. pneumoniae and H. influenzae) reported against ceftrixone, we recommend ceftriaxone alone as empiric therapy for patients with no comorbid conditions presenting with community acquired bacterial meningitis. A continuous surveillance for changes in the microbiology of organisms causing bacterial meningitis or their sensitivity in our community is essential to update these recommendations.