Changing epidemiology of pediatric Streptococcus pneumoniae isolates before vaccine introduction in Casablanca (Morocco).

The objective of this study was to describe the evolution over time of serotypes and antimicrobial resistance of Streptococcus pneumoniae isolates responsible for invasive pneumococcal disease (IPD) in children ≤5 years in Casablanca (Morocco), before vaccine introduction. Isolates recovered from cases of IPD in children ≤5 years during two study periods (1994-2001 and 2006-2010) were compared in terms of serotypes and antimicrobial susceptibility. Serogrouping was done using Pneumotest Kit and serotyping was done by the Quellung capsular swelling. Antibiotic susceptibility pattern was determined by Etest method. The theoretical coverages of the 7-, 10- and 13-valent pneumococcal vaccines were determined. A total of 85 and 102 isolates were studied for the two periods, respectively. During the first period, the most prevalent serogroups/serotypes were 5, 7, 1, 14, 6, 23, 19, 2, 15 and 18, whereas during the second study period, the most frequent were 19, 14, 6, 23, 5, 1 and 18. From 2006 to 2010, serotype 19A accounted for 7.8% of the isolates, whereas serogroups 33 and 22 were rarely isolated (1% each). Assuming cross protection among serogroups, the respective coverage rates for the first vs. second periods reached 40% vs. 53.9% for PCV7, 74.1% vs. 71.6% for PCV10 and 75.3% vs. 82.4% for PCV13. The prevalence of penicillin-nonsusceptibility increased (22.4% vs. 48.5%) as well as the levels of penicillin-resistance (5.9% vs. 15.8%). Penicillin-nonsusceptibility was relatively low across both study periods in serogroups 7, 15, 1 and 5, whereas it was high in serogroups 14, 19 and 23. In conclusion, serotype fluctuations and increases in antibiotic resistance of S. pneumoniae occurred in Casablanca before vaccine introduction. Both of these variations are probably linked to the increase in antibiotic use that has occurred in Casablanca over time. There is a need for a continuous surveillance to assess the vaccine formulations, monitor vaccine impact and to guide treatment recommendations.

Eleven-year surveillance of antibiotic resistance in Streptococcus pneumoniae in Casablanca (Morocco).

OBJECTIVE: To analyze trends of antibiotic resistance rates in Streptococcus pneumoniae from 1998 to 2008 in Casablanca (Morocco). METHODS: The antibiotic resistance levels of 955 consecutive nonduplicate isolates were studied using E test and disc diffusion methods. Results were interpreted following Clinical and Laboratory Standards Institute guidelines (2005). Analysis was done according to three periods (1998-2001; 2002-2005; 2006-2008), age, and site of infection. RESULTS: Penicillin nonsusceptibility (PNS) increased significantly over time (15.6%, 17.8%, and 24.8%; p=0.003). Levels of PNS have changed as well: in 2006-2008, 9.1% of the isolates had an MIC ≥2 µg/ml versus 7.7% in 2002-2005 and 3.4% in 1998-2001. The PNS increase was particularly marked in pediatric isolates (21.4%, 25.5%, and 43.3%; p=0.001). There was no significant difference between the rates of PNS in invasive and noninvasive isolates from children, whereas in adults noninvasive isolates were more penicillin nonsusceptible. Amoxicillin and ceftriaxone nonsusceptible isolates were very rare. An increase of resistance rates was also noticed for erythromycin (9.4%, 12.2%, and 14.4%), tetracycline (20%, 18.6%, and 30.5%), and chloramphenicol (5.6%, 5.6%, and 8.1%). Trimethoprim-sulfamethoxazole resistance rates remained stable (22.8%, 20%, and 23.8%). Proportions of dual nonsusceptibility to penicillin and erythromycin, increased from 5.6% to 8.9%. Multiple drug resistance (resistance to 3 or more antibiotic classes) was found in 0%, 2.4%, and 7.7% of all isolates, respectively. CONCLUSION: The results reported here maybe useful for guiding update of treatment recommendations and suggest the need for continuous surveillance. Increase of antibiotic resistance correlated with antibiotic consumption, stressing the need for elaboration of antibiotic policy in Morocco.

Health care worker perceptions of hand hygiene practices and obstacles in a developing region.

A structured self-assessment questionnaire was distributed to 8 southern and eastern Mediterranean hospitals to identify perceived obstacles to hand hygiene (HH). An insufficient number of sinks and alcohol handrub stations was rated by the vast majority of respondents as the most critical impediment, whereas improved availability of HH products was deemed the key intervention to increase compliance. The least importance and relevance were given to HH auditing and collegial reminders. While initiatives to improve HH compliance clearly must address infrastructural inadequacies, sociocultural issues also need to be considered when transposing initiatives found to be successful in Western countries to less-developed regions, to ensure that campaigns are not compromised by perceptual undercurrents.

Self-protection as a driver for hand hygiene among healthcare workers.

A total of 2,725 healthcare workers in 8 Mediterranean countries replied to a self-assessment questionnaire that assessed their perceptions on hand hygiene. Responses revealed that rates of hand hygiene compliance before patient contact were significantly less than rates after patient contact (P < .001) and that use of soap and water was preferred over use of alcohol-based hand rub. These findings suggest that self-protection could be a major subliminal driver for performance of hand hygiene.

Colistin and rifampicin in the treatment of nosocomial infections from multiresistant Acinetobacter baumannii.

INTRODUCTION: The increased incidence of nosocomial infections by multi-drug resistant Acinetobacter baumannii creates demand on the application of some combinations of older antimicrobials on that species. We conducted the present observational study to evaluate the efficacy of intravenous and aerosolized colistin combined with rifampicin in the treatment of critically patients with nosocomial infections caused by multiresistant A. baumannii. PATIENTS AND METHODS: Critically ill patients with nosocomial infections caused by A. baumannii resistant to all antibiotics except colistin in a medical intensive care unit. Diagnosis of infection was based on clinical data and isolation of bacteria. The bacterial susceptibilities to colistin were tested. Clinical response to colistin+rifampicin was evaluated. RESULTS: Twenty-six patients (43.58+/-18.29 years, Acute Physiology and Chronic Health Evaluation II Score (APACHE II): 6.35+/-2.99), of whom 16 cases of nosocomial pneumonia treated by aerosolized colistin (1x10(6) IU three times/day) associated with intravenous rifampicin (10 mg/kg every 12h), nine cases of bacteraemia treated by intravenous colistin (2x10(6)IU three times/day) associated with intravenous rifampicin (10 mg/kg every 12h) in which three cases associated with ventilator associated pneumonia and one case of nosocomial meningitis treated by intrathecal use of colistin associated with intravenous rifampicin. The clinical evolution was favourable for all ill patients. Concerning side effects, we have noticed a moderate hepatic cytolysis in three patients. CONCLUSION: This is the first clinical report of colistin combined with rifampicin for treatment of A. baumannii infection. Despite the lack of a control group and the limited number of patients, the results seem to be encouraging.

[Germs that produce the extended spectrum betalactamases]. / Les germes producteurs de bêta lactamases à spectre étendu: épidémie dans un service d'Hémato-Oncologie.

This retrospective study analyses an epidemic with germs ESBL that supervenes at the department of hematology and pediatric oncology in UHC Ibn Rochd of Casablanca. The responsible germ is the ESBL Escherichia coli. Six patients have been infected during the same period that 2 are female and 4 are male. Five patients had acute lenkemia, one patient had a non Hodgkin's disease. All the patients were in the stage of a deep postchermotherapy neutropenia. The picture of all the patients represented a severe infection with suffered fever and acute diarrhea. Five patients died with apicture of septic shock in the 48 to 72 hours after the beginning of the infection and before the identification of the germ. Their treatment consisted in the third generation of cephalosporin and aminoside. One patient who use the imipeneme more the aminoside has been apyrexized the epidemic and severe situation led to the closing of the unit during a week in order to do a disinfection. After 12 monthes of recession, few isolate episodes of infections with enterobacteries ESBL have observed and controlled. The factors that determine the increase and the diffusion of the ESBL germ are numerous and some of them are still not identified, the means of prevention consisted in: the fight against the selection of the resistant germs, the fight against the colonization of the patients by these germs and their transmission between the patients, this requires measures of hygiene and particularly the washing of the hands.

Are there regional variations in the diagnosis, surveillance, and control of methicillin-resistant Staphylococcus aureus?

OBJECTIVE: To assess the way healthcare facilities (HCFs) diagnose, survey, and control methicillin-resistant Staphylococcus aureus (MRSA). DESIGN: Questionnaire. SETTING: Ninety HCFs in 30 countries. RESULTS: Evaluation of susceptibility testing methods showed that 8 laboratories (9%) used oxacillin disks with antimicrobial content different from the one recommended, 12 (13%) did not determine MRSA susceptibility to vancomycin, and 4 (4.5%) reported instances of isolation of vancomycin-resistant S. aureus but neither confirmed this resistance nor alerted public health authorities. A MRSA control program was reported by 55 (61.1%) of the HCFs. The following isolation precautions were routinely used: hospitalization in a private room (34.4%), wearing of gloves (62.2%), wearing of gowns (44.4%), hand washing by healthcare workers (53.3%), use of an isolation sign on the patient's door (43%), or all four. When the characteristics of HCFs with low incidence rates (< 0.4 per 1,000 patient-days) were compared with those of HCFs with high incidence rates (> or = 0.4 per 1,000 patient-days), having a higher mean number of beds per infection control nurse was the only factor significantly associated with HCFs with high incidence rates (834 vs 318 beds; P = .02). CONCLUSION: Our results emphasize the urgent need to strengthen the microbiologic and epidemiologic capacities of HCFs worldwide to prevent MRSA transmission and to prepare them to address the possible emergence of vancomycin-resistant S. aureus.

Plasmid-mediated TEM-3 extended-spectrum beta-lactamase production in Salmonella typhimurium in Casablanca.

Isolates of extended-spectrum beta-lactamase (ESBL)-producing Salmonella typhimurium were recovered from children admitted to the IbnRochd University Hospital of Casablanca in 1994. These isolates produced TEM-3 as shown by PCR, isoelectric focusing and sequencing. Production of TEM-3 and resistance to gentamicin were encoded by a 10 kb plasmid that could be transferred by conjugation and transformation. This report extends the list of ESBLs produced by S. typhimurium and stresses the need for continuous surveillance of non-typhoidal Salmonella to adapt antibiotic treatment and preventive measures.