Assessment of Proinflammatory Cytokines Among Patients with Middle East Respiratory Syndrome Coronavirus Infection.

Middle East respiratory syndrome coronavirus (MERS-CoV) is associated with significant morbidity and mortality. This study was performed to assess the proinflammatory cytokines profile among MERS-CoV patients. A total of 46 MERS-CoV-infected patients (27 symptomatic and 19 asymptomatic) were assessed and compared with 52 normal healthy controls for plasma levels of interleukin (IL)-1ß, tumor necrosis factor (TNF)-α, IL-17, IL-7, IL-6, interferon (IFN)-α, and IL-15 using a customized luminex kit. Whereas asymptomatic MERS-CoV patients and controls were no different; the mean plasma levels among MERS-CoV symptomatic patients were significantly higher than the normal controls: IL-1ß (16.89 ± 1.23 vs. 12.80 ± 0.59 pg/mL; p < 0.001), TNF-α (14.04 ± 0.93 vs. 10.35 ± 0.29 pg/mL; p < 0.0001), IL-17 (14.3 ± 0.89 vs. 11.47 ± 0.61 pg/mL; p < 0.001), IL-7 (21.56 ± 1.00 vs. 16.31 ± 0.30 pg/mL; p < 0.0001), IL-6 (156.5 ± 37.90 vs. 18.60 ± 1.59 pg/mL; p < 0.0001), and IFN-α (68.73 ± 13.06 vs. 23.57 ± 1.05 pg/mL; p < 0.0001). The mean plasma levels of IL-7 (24.81 ± 1.63 vs. 19.79 ± 0.94 pg/mL; p < 0.01), IL-6 (312.7 ± 94.67 vs. 101.2 ± 25.67 pg/mL; p < 0.01), and IFN-α (89.00 ± 18.97 vs. 51.05 ± 8.68 pg/mL; p < 0.05) were significantly elevated among MERS-CoV symptomatic patients with fatal outcome compared with MERS-CoV symptomatic patients who survived. Only IL-7 was found to have a higher risk ratio of mortality (4.76, 95% confidence interval: 1.5-14.94; p < 0.01). No differences were observed in IL-15 levels among the groups. Significantly elevated proinflammatory cytokines among symptomatic MERS-CoV-infected patients may contribute to manifestations of cytokine storm frequently observed among critically ill MERS-CoV patients and IL-7 may serve as a marker for disease activity.

Early postictal temperature changes in patients presenting to the emergency department.

OBJECTIVE: Understanding the elevations in body temperature after a seizure helps detect etiologies and monitor for complications. We aim to determine the proportion of patients who develop elevated temperatures after a seizure and to examine the trend in temperature change over time. We also seek to examine the effects that an infection or impaired ambulatory status might have on body temperature course, as well as the effect of elevated temperature on the length of hospital stay. METHODS: A retrospective chart review was conducted at King Saud University Medical City. The included patients were individuals older than 12 years of age who presented to the emergency department with seizures between May 2015 and August 2018. Temperature recordings were documented from 18 four-hour time intervals (0-72 h from presentation). Information about age, gender, seizure duration, seizure type, polytherapy, anti-seizure medication, infection, ambulatory status, and length of stay were collected. Logistic regression and a mixed-effects model were used to determine which variables were associated with temperatures of 37.5 °C or higher in the first 12 h of presentation and to estimate the change in temperature over the ensuing time intervals. RESULTS: 416 encounters were identified. The presence of an infection was significantly associated with developing temperature elevation, with an odds ratio (OR) of 2.8 (95% CI [1.54, 5.32]). Ambulatory patients were less likely to have elevations compared to non-ambulatory patients (OR = 0.33; 95% CI [0.18, 0.6]). Temperatures were highest within the first hours of presentation and gradually decreased with each interval by 0.03 °C (p < 0.0001), which increased to 0.12 °C (p = 0.005) if a patient was ambulatory. Temperatures substantially increased across the intervals in patients with infections by 0.21 °C (p < 0.0001). Elevated temperatures were significantly associated with longer hospital stays (p < 0.0001). CONCLUSION: Elevated temperatures can occur after seizures in general, and subside over the ensuing 72 h in the absence of an infection. Physicians should still conduct thorough evaluations in patients with temperatures of 37.5 °C or higher to rule out an underlying infection. The absence of an elevated temperature is favorable and associated with a shorter hospital stay.

COVID-19 Vaccine Acceptance among Health Care Workers in the Kingdom of Saudi Arabia.

OBJECTIVES: The purpose of our study was to assess COVID-19 vaccine acceptance among health care workers (HCWs) in the Kingdom of Saudi Arabia (KSA) and identify: 1) vaccine acceptance barriers; 2) demographic differences; and 3) the most trusted COVID-19 sources of information. METHODS: Between October and December 2020, all registered HCWs in the KSA were emailed a survey questionnaire, using Qualtrics® and Google Forms®, evaluating their acceptance of a COVID-19 vaccine. RESULTS: Of the 23,582 participants surveyed, 15,299 (64.9%) said they would accept a COVID-19 vaccine. Vaccine acceptance among HCWs differed by several demographic characteristics, with males (69.7%), Christians (71.9%), and Pakistanis (81.6%) most likely to accept a COVID-19 vaccine. Of the 8,202 (35.1%) who said they would not accept a COVID-19 vaccine, the main reason reported was fear of potential side effects (58.5%). Participants reported health officials (84.6%) as the most reliable source of COVID-19 information. Additionally, participants reported the highest confidence in the KSA Ministry of Health (88.5%). CONCLUSIONS: Overall, these findings provide KSA health care authorities with the information needed to develop public health messaging campaigns for HCWs to best address COVID-19 vaccine concerns-especially as the country prepares to vaccinate its general population.

Prevalence and outcome of isoniazid-monoresistant tuberculosis at a university hospital in Saudi Arabia.

OBJECTIVES: To determine the prevalence and outcome in patients with isoniazid-monoresistant Mycobacterium tuberculosis complex and compare them to those in patients with non-isoniazid-monoresistant Mycobacterium tuberculosis. METHODS: This cross-sectional analytical study was conducted at King Khalid University Hospital, Riyadh, Saudi Arabia. The data were retrospectively collected from the electronic medical records of patients who tested positive for Mycobacterium tuberculosis between May 2015 and April 2019. RESULTS: We identified 105 patients infected with Mycobacterium tuberculosis. The prevalence proportion of isoniazid-monoresistant tuberculosis was 8.6% (n=9). Five patients with isoniazid-monoresistant tuberculosis (55.6%) were successfully treated, while one patient died. In the nonresistant population, 51 (53.1%) patients were successfully treated. However, 12 (12.5%) patients with no isoniazid resistance had an unsuccessful treatment outcome. The resistant group had a longer treatment duration with a mean of 12 months compared to the non-isoniazid-resistant group, with a mean treatment duration of 9.5 months. Twenty-eight patients (26.7%) had adverse events, with the majority of them being in the non-isoniazid-resistant group. CONCLUSION: Isoniazid monoresistance is the most common form of drug resistance found in our population. Our study has not shown any significance in the outcome of isoniazid-resistant cases compared to non-isoniazid-resistant cases. This may be due to the low number of isoniazid-monoresistant cases in our population.

Knowledge, Attitude, and Barriers Influencing Seasonal Influenza Vaccination Uptake.

BACKGROUND: Seasonal influenza is an acute respiratory infection caused by influenza viruses that are highly contagious and circulate in all parts of the world. It gives rise to an estimated 3 to 5 million cases of severe illness and about 250,000 to 500,000 deaths globally each year. Influenza tends to cause epidemics with serious illness and death among high-risk groups such as children aged 5 years and younger, pregnant women, elderly ≥65 years of age, and with chronic medical conditions. According to the Centers for Disease Prevention and Control (CDC), all people who are 6 months old and above are recommended to receive the seasonal influenza vaccine annually. Despite the fact that influenza vaccine is readily available, and the severity of the disease is known to adversely affect the individual's quality of life and well-being, vaccination uptake rates are still low, contributing to the increased burden of the disease worldwide. OBJECTIVES: To measure the influenza vaccine uptake among residents of Riyadh Province, Saudi Arabia, that determines their attitude, knowledge, and beliefs regarding the vaccine. METHODS: A cross-sectional study was conducted using a self-administered structured questionnaire distributed online targeting residents of Riyadh Province, Saudi Arabia, from 1st of August 2019 till 30th of September 2019. Participants were selected through volunteer sampling. The questionnaire included demographic data including age, gender, occupation, education level, marital status, and comorbidities. It also included questions regarding knowledge, attitude, and beliefs regarding influenza vaccine. After collection of data, statistical analyses were conducted by using Statistical Package for Social Sciences (SPSS) version 19.0. A P value of <0.05 was considered statistically significant. RESULTS: Our study included 503 participants, with age ranging from 18 to 65 years old and 324 (64%) were females. 100 participants (19.9%) had comorbid conditions, and 223 (44.3%) have been vaccinated against influenza in the past. A large portion of participants (41.2%) were familiar with seasonal influenza vaccination from the media. The knowledge part of the questionnaire showed that 302 (60%) participants knew how often they should receive the vaccine and 313 (62.2%) participants knew that the vaccine is provided freely in all of Saudi Arabia. In terms of belief and attitude, 371 participants (73.8%) thought they were susceptible to the disease and 365 (73.8%) believed that influenza vaccine is beneficial, while 446 participants (88.7%) thought that the general public need more knowledge and awareness on the scientific facts of influenza vaccine. Regarding barriers, 295 participants (58.6%) wanted to avoid vaccines and 252 (50.1%) were concerned about the vaccine's adverse effects. Participants with frequent health checkups and those who had previous knowledge on the availability of the vaccine for free were more likely to be vaccinated. Vaccinated participants (44.3%) were asked if they were willing to take the vaccine again when it is due, 158 (70.9%) answered yes. Those who elicited symptomatic reaction to the vaccine (26.0%) were less inclined to take it again (P = 0.035). CONCLUSION: We concluded that there is a low influenza vaccine uptake rate among our study population, considering that the barriers most commonly chosen by participants are solvable with health education and campaigns oriented towards delivering facts about the vaccine and dispelling misinformation; such measures are highly recommended and are postulated to carry a great benefit that should target common misconceptions identified in this study.

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.

Current status of long-term antibiotic prophylaxis for urinary tract infections in children: An antibiotic stewardship challenge.

Recurrent urinary tract infections (UTIs) in children are associated with development of pyelonephritis and renal scarring. Traditionally, continuous antibiotic prophylaxis (CAP) has been used to prevent recurrent UTI. Recent studies have challenged the efficacy of CAP for preventing renal scarring and have raised concerns about inducing bacterial resistance. This review focuses on studies published between January 2000 and April 2019 and evaluates the use of CAP in children for avoiding recurrent UTIs and renal scarring. A systematic literature search was carried out using the following search terms and related medical subject headings in the MEDLINE electronic database: 'urinary tract infection', 'antimicrobial/antibiotic prophylaxis', and 'children/pediatrics'. Randomized clinical trials (RCTs), original research articles, guidelines, systematic reviews, and meta-analyses describing antibiotic prophylaxis for UTIs were included. A total of 34 RCTs, 9 systematic reviews, and 3 guidelines describing antibiotic prophylaxis were included in this review. The efficacy of CAP for preventing recurrent UTI remains unclear due to non-generalizability of results obtained from suboptimally designed clinical trials. CAP has not been proven as beneficial for preventing new renal scarring in children. Additionally, CAP is associated with increased risk of multidrug resistant infections in children. No conclusive evidence can be drawn from the available clinical data to support routine use of CAP for prevention of renal scarring. Accumulation of evidence from additional well designed studies may result in different conclusions in the future. It is important to identify specific risks for recurrent UTI and ensuing renal injury to ensure more judicious use of CAP.

Evaluation of GeneXpert MTB/RIF for detection of Mycobacterium tuberculosis complex and rpo B gene in respiratory and non-respiratory clinical specimens at a tertiary care teaching hospital in Saudi Arabia.

OBJECTIVES: To assess the performance of Xpert MTB/RIF, an automated molecular test for Mycobacterium tuberculosis (MTB) and resistance to rifampin (RIF), against smear microscopy and culture method for diagnosis of MTB infection. Methods: This is a retrospective analysis of 103 respiratory and 137 non-respiratory patient specimens suspected of tuberculosis at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia performed between April 2014 and March 2015. Each sample underwent smear microscopy, mycobacterial culture, and GeneXpert MTB/RIF test. Results: Fifteen out of 103 respiratory samples were smear and culture positive, whereas 9 out of 137 non-respiratory samples were smear positive. Out of 9 smear positive specimens, 8 were also culture positive. All 15 culture positive respiratory samples were detected by Xpert MTB/RIF (sensitivity  and positive predictive value [PPV]=100%). Similarly, all 8 culture positive non-respiratory specimens were identified by Xpert MTB/RIF (sensitivity 100%; PPV 88.8%). The Xpert MTB/RIF detected only one false positive result in 88 smear negative respiratory specimens (specificity 98.9%; negative predictive value [NPV]= 100%). All 125 smear negative non-respiratory specimens tested negative by culture and Xpert MTB/RIF (sensitivity, specificity, PPV, NPV= 100%). Conclusion: The performance of Xpert MTB/RIF was comparable to the gold standard culture method for identification of MTB in both respiratory and non-respiratory clinical specimens.

Tuberculosis incidence trends in Saudi Arabia over 20 years: 1991-2010.

OBJECTIVE: To evaluate tuberculosis (TB) incidence rates and trends over a period of 20 years (1991-2010) and assess the impact of the National TB Control Program (NTP) on incidence trends. METHODS: This is a retrospective study of TB surveillance data reported by the Ministry of Health. We evaluated TB incidence data by nationality, age, and region of the country and assessed incidence trends over 20 years of study. Chi-squared test was used to assess trend change and its significance. RESULTS: There were a total of 64,345 reported TB cases over the study period. Of these 48% were Non-Saudis. TB annual incidence rate ranged between 14 and 17/100,000. For Saudis, the rate ranged between 8.6 and 12.2/100,000. Non-Saudis had 2-3 times higher incidence. Disease trend was rising over the first 10 years of the study period then it started to fall slightly. The incidence increased with age, but only people older than 45 years showed a declining trend. Regional variations were observed. Makkah and Jazan regions had the highest incidence rates. Disease trends were rising over the last 10 years in Makkah and Central regions. CONCLUSION: TB control seems to be facing some challenges in several regions of the Kingdom. NTP needs to evaluate and improve TB control strategies in order to reduce disease incidence to elimination levels.