Bacterial and Fungal Coinfection in Critically Ill COVID-19 Cases and Predictive Role of Procalcitonin During the First Wave at an Academic Health Center.

BACKGROUND: Coinfection at various sites can complicate the clinical course of coronavirus disease of 2019 (COVID-19) patients leading to worse prognosis and increased mortality. We aimed to investigate the occurrence of coinfection in critically ill COVID-19 cases, and the predictive role of routinely tested biomarkers on admission for mortality. METHODS: This is a retrospective study of all SARS-CoV-2-infected cases, who were admitted to King Fahad Hospital of the University between March 2020 and December 2020. We reviewed the data in the electronic charts in the healthcare information management system including initial presentation, clinical course, radiological and laboratory findings and reported all significant microbiological cultures that indicated antimicrobial therapy. The mortality data were reviewed for severely ill patients who were admitted to critical care units. RESULTS: Of 1091 admitted patients, there were 70 fatalities (6.4%). 182 COVID-19 persons were admitted to the critical care service, of whom 114 patients (62.6%) survived. The in-hospital mortality was 13.4%. Coinfection was noted in 67/68 non-survivors, and Gram-negative pathogens (Enterobacterales, Pseudomonas aeruginosa, and Acinetobacter baumanni) represented more than 50% of the etiological agents. We noted that the serum procalcitonin on admission was higher for non-survivors (Median = 1.6 ng/mL ± 4.7) than in survivors (Median = 0.2 ng/mL ± 4.2) (p ≤ 0.05). CONCLUSION: Coinfection is a serious complication for COVID-19 especially in the presence of co-morbidities. High levels of procalcitonin on admission may predict non-survival in critically ill cases in whom bacterial or fungal co-infection is likely.

The Environmental Deposition of Severe Acute Respiratory Syndrome Coronavirus 2 in Nosocomial Settings: Role of the Aerosolized Hydrogen Peroxide.

BACKGROUND: Data on the role of aerosolized hydrogen peroxide (AHP) systems in the control of the COVID-19 pandemic are still emerging. This study provides evidence of the environmental shedding of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the hospital environment, and the efficacy of AHP to eliminate it. METHODS: A total of 324 environmental sites (224 surfaces and 100 air samples) belonging to 54 patient rooms were contextually collected and tested for genes of SARS-CoV-2 using RT-PCR assays and Xpert® Xpress SARS-CoV-2. RESULTS: The SARS-CoV-2 viral genome was detected in seven sites (2.5%) of three patients' rooms, including six highly touched surfaces and one air sample. Viral shedding was directly related to the distance from the patient, with 1, 1.9, and 3.5% of samples testing positive at 3, 2, and 1 meter, respectively (P-value=0.02). None of the sites showed the viral genome following application of 6% AHP. Of note, the viral genome was detected at 2 meters of a mildly symptomatic case on a face mask in the absence of aerosol generating procedures. CONCLUSION: Our data support the possible role of the hospital environment as a source of infection, and the efficacy of AHP to eliminate the virus. Further studies are needed to address the viability of the pathogen in these nosocomial sites and the cost-effectiveness of routine hospital disinfection procedures using AHP for SARS-CoV-2.

Metagenomic study on the composition of culturable and non-culturable bacteria in tap water and biofilms at intensive care units.

Bacterial community diversity of bulk water and corresponding biofilms of four intensive care units' (ICUs) drinking water systems were studied and compared using 16S rRNA gene amplicons and next generation sequencing. Proteobacteria, mainly Alphaproteobacteria and Betaproteobacteria were dominant in the bulk water and biofilms. Principal component analysis showed different bacterial communities characterizing each of the bulk water and the biofilms in three of the studied ICUs. Taxonomic classification and comparison of different genera between samples highlighted the dominance of Aquabacterium (80%) and Novosphingobium (72%) in bulk water while biofilms harbored different bacteria affiliated to Pelomonas (97%) and Caulobacter (96%), Porphyrobacter (78%) and Staphylococcus (74%). Staphylococcus aureus was the only possible pathogen found with low percentage (2.32%) in three of the ICUs' biofilm and only in one of the ICU's bulk water. This study sheds light on the prevalence of unculturable bacterial flora in the biofilm ignored by the microbiological standard methods. This study was performed on tap and bulk water from ICUs; however, it indicates the need for further studies to investigate the function and activity of the microbial diversity in order to assess the real risk presented by this water microflora on patients' health.

Prevalence of digestive tract colonization of carbapenem-resistant Acinetobacter baumannii in hospitals in Saudi Arabia.

Carbapenem-resistant Acinetobacter baumannii is a major health problem worldwide, especially in intensive care units (ICUs). This study aimed to detect the prevalence of A. baumannii colonization of the gastrointestinal tract of patients admitted to the ICU in two hospitals in Saudi Arabia. In addition, it aimed to characterize the molecular mechanisms of carbapenem resistance in these isolates. From January to June 2014, 565 rectal swab specimens were screened for Acinetobacer strains and carbapenem resistance using CHROMagar Acinetobacter and CHROMagar KPC agar plates, respectively. Organism identification and susceptibility were detected using the Vitek 2 system. A total of 47 Acinetobacter spp. were detected, and 35 were resistant to carbapenem, making the prevalence of Acinetobacter spp. 8.3% (47/565) and carbapenem resistance (6.2%, 35/565). The 47 strains showed remarkable clonal diversity as revealed by PFGE. Using PCR, OXA-51, a chromosomal marker for A. baumannii, was detected in 46 strains. OXA-23 ß-lactamase was detected in all 35 carbapenem-resistant A. baumannii. No IMP, VIM, SPM, SIM, GIM, KPC or NDM ß-lactamases were detected in these isolates. Thus, OXA-23 was the main mechanism of carbapenem resistance in these isolates. To the best of our knowledge, this is the first study to detect the prevalence of Acinetobacter colonization in the digestive tract of ICU patients in Saudi Arabia. This study revealed the importance of having well-established protocols for early identification of these multidrug-resistant organisms, optimizing infection-control strategies and having active surveillance studies to reduce morbidity, mortality and cost.

Increasing threat of community-acquired methicillin-resistant Staphylococcus aureus.

INTRODUCTION: Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a serious problem in the community. The objective of this prospective study was to report the frequency of community-acquired MRSA (CA-MRSA) isolates at King Fahd Hospital of the University in the Eastern Province of Saudi Arabia, to describe the spectrum of disease observed in patients infected with CA-MRSA and to study the antibiotic susceptibility profile. METHODS: Isolates of CA-MRSA from King Fahd Hospital of the University were reviewed prospectively during an 8-year period, from January 2001 to December 2008. RESULTS: The prevalence of CA-MRSA infections increased from 9.9 per 10,000 admissions in 2001 to 67 per 10,000 admissions in 2008 (P < 0.001). The number of CA-MRSA increased from 67 isolates in the first part of the study (2001-2004) to 176 cases in the second period of the study (2005-2008), and the percentage of CA-MRSA/of the total MRSA isolates rose from 20% in the first period to 59% in the second period of the study (P < 0.001). Soft tissue infections accounted for 198 (81%) of the 243 cases of CA-MRSA infections and invasive infections in 14 (7%) patients. The antibiotic susceptibility pattern has also changed with increasing levels of resistance to erythromycin, tetracycline, clindamycin, ciprofloxacin and gentamicin. CONCLUSION: Continued emergence of MRSA in the community is a public-health problem that demands increased vigilance in the diagnosis and management of suspected and confirmed staphylococcal infections.

A review of community-acquired methicillin-resistant Staphylococcus aureus for primary care physicians.

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections among young people without healthcare-associated risk factors have emerged during the past decade. Reported prevalence rates of CA-MRSA vary widely among studies, largely because of the different definitions employed and different settings in which the studies have been performed. Although the majority of CA-MRSA infections are mild skin and soft tissue infections, severe life-threatening cases have been reported. CA-MRSA infections have mostly been associated with staphylococcal strains bearing the staphylococcal cassette chromosome mec type IV element and Panton-Valentine leukocidin genes. These strains are more frequently susceptible to a variety of non-beta-lactam antibiotics. Clinicians must be aware of the wide spectrum of disease caused by CA-MRSA. Continued emergence of MRSA in the community is a public health problem, and therefore warrants increased vigilance in the diagnosis and management of suspected and confirmed staphylococcal infections.

Osteoarticular tuberculosis: how often is it missed?

This study was carried out to analyze the clinical presentations and outcomes of osteoarticular tuberculosis (OAT) at a university hospital in AlKhobar, Saudi Arabia. A prospective observational study was carried out between 1 January 1998 and 31 December 2007. Patients demographic characteristics were recorded, including age, gender, nationality, clinical manifestation, delay in diagnosis, laboratory results, findings on imaging studies, histological and bacteriological studies of biopsy specimens, treatment modalities, surgical interventions and final outcomes. Fifty-two patients were diagnosed with OAT during the study period. The majority were males (64%), about half were below age 30 years. The mean age at diagnosis was 33 years. There were 32 Saudis (64%), and 18 non-Saudis (36%). Pyrexia, loss of appetite and night sweats were the presenting symptoms in 44, 38 and 36%, respectively. The average time from onset of symptoms to diagnosis was 185 days (7-730 days). On admission, the average erythrocyte sedimentation rate (ESR) was 68 mm/h (4-142). A Mantoux test was performed, in 48 patients the results were positive. The vertebral column was the site of infection in 88% of patients. All patients were managed with standard antituberculous therapy. Forty-two patients (84%) had a favorable outcome.

Breast infections in non-lactating women.

BACKGROUND: Breast infection in lactating mothers is a common entity which in the majority of cases can be explained by ascending infections. However, it has been noticed that the number of non lactating women presenting with breast abscesses is rising. This study attempts to explore the sensitivity pattern of organisms and underlying cause of breast infections in non-lactating women. MATERIALS AND METHODS: This review was undertaken at King Fahd of the University, Alkhobar, Saudi Arabia between 1991-2003. All patients presenting with breast infections were included. Medical records, operative notes, cultures, histopathology reports and outcome were reviewed. RESULTS: The number of patients presenting with breast infections accounted for 179(3.5%) out of the total number of patients 6314 with variable breast complaints. Infection occurred in 136(76%) lactating women (Group I) ,while Non lactating (Group II) breast infections accounted for 43(24%). Age ranged from 24 years to 52 years. Underlying clinical conditions were found in 26 patients(60%) in Group II namely granulomatous mastitis13(50%), duct ectasia4 (15.3%), pregnancy3(11.5%), fat necrosis1(3.8%), diabetes3 (11.5%) and breast cancer 2(7.6%). The pattern of culture results was different in the two groups, from differing causative organisms namely staphylococcus aureus as the commonest organism in both groups, in comparison to such uncommon organisms as Klebsiella pneumonae, Peptococcus magnus, Streptococcus group B, Entro-bacter cloacae, Methicillin resistant staphylococcus aureus (MRSA) and Mycobacterium tuberculosis occurring in group II only. Fortunately, all organisms were sensitive to antimicrobial therapy. CONCLUSION: Breast infection in non-lactating women is an infrequent but recognized clinical entity that deserves special attention. An underlying clinical condition should always be sought and treated. Indeed, in addition to cultures, radiological modalities such as ultrasonographic imaging may provide specific diagnosis and aid the management.

Bacterial contamination of stethoscopes.

BACKGROUND: A stethoscope, an essential tool of the medical profession, can become a source of nosocomial infection. OBJECTIVE: To determine the frequency of bacterial contamination of stethoscopes as well as the practices used for cleaning them. METHODS: Cultures were taken from 100 stethoscopes used by different medical personnel in different hospital services. The stethoscopes were collected while the staff filled in a questionnaire. RESULTS: Thirty (30%) out of the 100 stethoscopes surveyed were contaminated with microorganisms. The majority of organisms isolated were gram-positive bacteria (gram positive bacilli 12%, gram-negative bacteria 9%, gram-positive cocci 9%). None of the stethoscopes grew methicillin-resistant staphylococcus aureus. Overall, 21% of the health personnel cleaned their stethoscopes daily, 47% weekly, and 32% yearly. None of the health care workers cleaned their stethoscopes after every patient. Nurses cleaned their stethoscopes more often than physicians and medical students. CONCLUSION: Stethoscopes may be important in the spread of infectious agents. Their regular disinfection after use on each patient should be considered, particularly in such areas of the hospital, as the critical care units, and oncology units which house many patients with antibiotic-resistant organisms.

Gastroesophageal reflux in bronchial asthma patients. A clinical note.

OBJECTIVE: The objective is to correlate the symptoms of gastroesophageal reflux with the results of esophageal reflux with the results of esophageal pH metry in asthmatic patients. METHODS: A prospective study was carried out in King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia (KSA), during the period January 2000 through to February 2001, whereby 50 patients (34 females and 16 females) with primary diagnosis of bronchial asthma were consecutively enrolled, their mean age + SD was 38.01 + 9.8 years. Twenty-two subjects who were not suffering from asthma or gastroesophageal reflux (GER) (13 females and 9 males) constituted the control group. A questionnaire was administered to all participants and demographic data; asthma and GER symptoms were obtained. Esophageal manometry was performed, whereby the location, length and resting pressure of the lower esophageal sphincter (LES) were determined, pH catheter was inserted nasogastrically, and ambulatory pH data over 24 hours were collected. Pulmonary function tests were also performed. RESULTS: Twenty-two (44%) patients with asthma had a Demeester score greater than 14.7 and were therefore diagnosed as having pathological GER. Accordingly, the asthma patients were divided into 2 groups, asthma patients with GER (n=22) and those without GER (n=28). Multiple logistic regression analysis revealed that age did not significantly influence occurrence of GER, but it indicated that hoarseness of voice and nocturnal symptoms were significant predictors for the presence of GER in asthmatic patients, hence, the probability of having GER in an asthma patient is nearly 8 times if he/she has nocturnal symptoms and about 7 times if they have hoarseness of voice. However 36.4% of asthmatic patients diagnosed by esophageal ph metry as having GER did not complain of heartburn and hoarseness of voice; such as the reflux was silent. CONCLUSION: The frequency of GER among 50 patients with asthma reporting to KFHU, Al-Khobar, KSA is 44%. The presence of nocturnal symptoms and hoarseness of voice are significant clinical predictors of GER in asthmatic patients. Patients with difficult to treat asthma should be subjected to esophageal pH metry since a substantial proportion of them may have silent reflux.