First data on latent tuberculosis infection in Syrian refugees with diabetes in Lebanon.

OBJECTIVE: The association between diabetes mellitus and tuberculosis is a health-threatening double trouble. Vulnerable populations such as refugees and conflict-displaced populations may be at higher risk of both diseases. Here, we examined the prevalence of latent tuberculosis infection (LTBI) and its associated risk factors in a population of Syrian refugees with diabetes in North Lebanon. STUDY DESIGN: This is a cross-sectional study. METHODS: A total of 87 Syrian refugees with diabetes were enrolled. Demographic and clinical data were collected using a structured questionnaire, and a blood sample was obtained from each patient. LTBI was examined using the last generation QuantiFERON-TB Gold Plus assay. RESULTS: The mean age of the study population was 54.1 ± 10.5 years, and the majority were women (79.3%). LTBI was found in 1 in 5 (17/87; 19.5%) enrolled patients, with the majority being originated from Aleppo (47.05%). Infection was significantly associated only with age (P = 0.009), and its risk was 4-fold higher in patients aged ≥60 years (odds ratio: 4.1, confidence interval: 1.4-12.5, P = 0.018). CONCLUSION: This study highlights the need to implement effective tuberculosis control strategies among refugees with diabetes, with particular attention to those at older age.

The epidemiology of Candida species in the Middle East and North Africa.

In recent decades, the epidemiology of invasive candidiasis (IC) has progressively changed worldwide. This notably includes emergence of several Candida species. Although some surveillance programs provided global trends in IC epidemiology, data from countries from the Middle East and North Africa (MENA) remain scarce. In this manuscript, we reviewed the existing available data on the epidemiology of Candida species associated with IC, particularly candidemia, in MENA region regarding species distribution. As witnessed worldwide, an evident shift of Candidaalbicans towards non-albicansCandida (NAC) has been observed in the MENA region. The worrying emergence of multi-drug resistant Candida species in MENA calls for a better understanding of their epidemiology. This represents an essential prerequisite for the implementation of effective infection control strategies and surveillance systems to prevent IC among high-risk patients.

First Lebanese Antibiotic Awareness Week campaign: knowledge, attitudes and practices towards antibiotics.

Antibiotic resistance (ABR) is a major global health threat that increases the risk of treatment failure and increases medical costs. One of the most common factors contributing to the spread of ABR is self-medication. The public, as well as workers in clinical and veterinary sectors, commit false practices towards appropriate antibiotic use, favouring the spread of resistance. As such, the first Lebanese Antibiotic Awareness Week campaign was initiated with a human-centred and interactive approach. The data showed a strikingly low level of antibiotic awareness. Cooperation between relevant stakeholders, policy-makers and health actors is crucial to control and overcome the problem of ABR.

First data on Pneumocystis jirovecii colonization in patients with respiratory diseases in North Lebanon.

Pneumocystis colonization may play a role in transmission and local inflammatory response. It was explored in patients with respiratory diseases in North Lebanon. Overall prevalence reached only 5.2% (95% CI 2.13-10.47) but it was higher (17.3%) in the subpopulation of patients with chronic obstructive pulmonary disease (COPD). COPD was the only factor associated with a significantly increased risk of colonization. mtLSU genotyping revealed predominance of genotype 2, identified in five patients (71.4%), including one patient who had co-infection with genotype 3. These first data in North Lebanon confirm Pneumocystis circulation among patients with respiratory diseases and the potential for transmission to immunocompromised patients.

Characterization of resistance genes in 68 ESBL-producing Klebsiella pneumonia in Lebanon.

AIM: We studied 68 ESBL-producing Klebsiella pneumoniae strains isolated in Lebanon, determined their profile of resistance to antibiotics, and identified 6 ESBL genes. METHODOLOGY: The susceptibility to antibiotics was determined by the disk diffusion method. The MIC of carbapenems and cefepime was determined by the agar dilution method. ESBL genes were detected by PCR. RESULTS: A percentage of 88.2% and 86.7% of isolates carried the SHV and CTX-M gene respectively; combinations of more than 1 gene of resistance were detected in several isolates. Five strains were resistant to carbapenems; 4/5 carried the OXA-48 gene. CONCLUSION: Our study revealed the emergence of K. pneumoniae ESBL (+) strains carrying several types of genes involved in this phenotype; we also identified carbapenem-resistant strains due to the OXA-48 gene, which are a real threat for public health, especially in Lebanon.

[Anti-tetanus immunity among university students and health staff in North Lebanon and administration of anti-tetanus serums in two hospitals]. / Immunité antitétanique chez des étudiants universitaires et personnels de santé au Liban-Nord et administration de serum antitétanique dans deux hôpitaux.

Tetanus is a serious illness that kills about one million people a year globally. This study aimed to i) evaluate immunity against tetanus (by antibodies titres in blood) among health staff and students at the Public Health Faculty, Lebanese University, ii) explore the determinants of the anti-tetanus immunity by a questionnaire and iii) estimate anti-tetanic serum use in the emergency departments of two hospitals (1 private, 1 public) in Tripoli. Most of the participants (76.6%) had anti-tetanus antibody titres ≥ 0.1 UI/mL. There was no association between immune status and gender (P = 0.614) but more participants ≤ 25 years were immunized than those > 25 years (P < 0.001) and more students were immunized than employees (P = 0.032). There was an inverse association between anti-tetanus immunity and having visited a physician in the past year (P = 0.009). In 2011, 1037 people received anti-tetanus immunoglobulins at the hospitals, 73% at the private hospital. Vaccination campaigns targetting adults > 25 years may be warranted to assure good anti-tetanus protection and avoid administration of anti-tetanus immunoglobulins in emergency departments.

Prevalence of type b Haemophilus influenzae and antibiotic resistance in 52 clinical isolates in north Lebanon.

The aim of this study was to determine the capsular typing and type b prevalence of clinical Haemophilus influenzae strains in north Lebanon in both invasive and non-invasive disease and to determine the susceptibility pattern and the mechanism of resistance to ß-lactams [ß-lactamase-producing strains and ß-lactamase-negative ampicillin resistant (BLNAR) strains]. Fifty-two strains of clinical H. influenzae were isolated from 312 clinical specimens; the resistance pattern to ß-lactams of these strains was determined by using the disc diffusion and E-test methods followed by molecular methods such as PCR of blaTEM et blaROB genes. Nine (17.4%) of the 52 strains were resistant to ampicillin; all of them produced type TEM-1 ß-lactamase. In the susceptible strains 15.3% were not fully susceptible to ß-lactams or considered low BLNAR strains. Slide agglutination serotyping showed that 30.7% of the strains were type b.

Carbapenemase and virulence factors of Enterobacteriaceae in North Lebanon between 2008 and 2012: evolution via endemic spread of OXA-48.

OBJECTIVES: To investigate the resistance to carbapenems in Enterobacteriaceae and the underlying resistance mechanisms in North Lebanon between 2008 and 2012. METHODS: A total of 2767 Enterobacteriaceae isolates recovered from clinical samples collected in Nini Hospital (North Lebanon) were screened for a decrease in susceptibility or resistance to ertapenem (MIC >0.25 mg/L). Enterobacteriaceae were similarly screened from 183 faecal samples obtained from non-hospitalized patients. The bacterial isolates were assigned to clonal lineages by PFGE and multilocus sequence typing. Carbapenemase genes, their genetic environment and virulence genes were characterized by molecular approaches. RESULTS: The rate of Enterobacteriaceae exhibiting a decrease in susceptibility or resistance to ertapenem increased from 0.4% in 2008-10 to 1.6% in 2012 for the clinical isolates recovered from hospitalized patients. Of these isolates, scattered among seven enterobacterial species, 88% produced OXA-48 carbapenemase. However, Escherichia coli represented 73% of the OXA-48-producing Enterobacteriaceae collected in 2012 at this hospital. During the faecal carriage study performed in non-hospitalized patients, E. coli was the only species producing OXA-48. The bla(OXA-48) gene was mainly found within Tn1999.2-type transposons inserted into E. coli chromosomes or in ∼50, ∼62 or ∼85 kb plasmids. The plasmids and chromosomal inserts were related to pOXA-48a. Molecular typing of the isolates revealed clonal diversity of E. coli and Klebsiella pneumoniae producing OXA-48. OXA-48 was observed in all major E. coli phylogroups, including D and B2, and isolates harbouring virulence genes of extra-intestinal pathogenic E. coli. Although not belonging to highly virulent capsular genotypes, the OXA-48-producing K. pneumoniae harboured genes associated with virulence or host colonization. CONCLUSIONS: Horizontal transfer of related plasmids has facilitated the spread of the bla(OXA-48) gene into several Enterobacteriaceae species, including virulent E. coli. Their clonal diversity and the presence of faecal carriers in the community suggest an endemic spread of OXA-48.

Glycopeptide intermediate Staphylococcus aureus and prevalence of the luk-PV gene in clinical isolates, in Northern Lebanon.

OBJECTIVES: The aim of our study was to confirm the identification of 113 meticillin-resistant Staphylococcus aureus (MRSA) strains by pyrosequencing, to determine the susceptibility of these clinical isolates to various classes of antibiotics, to determine the minimum inhibitory concentration (MIC) to glycopeptides, and to detect mecA and luk-PV genes. METHODOLOGY: The Staphylococcus species was identified by pyrosequencing of the variable region (V3) of the 16SrRNA. The susceptibility of these 113 strains of MRSA to antibiotics was determined by the disk diffusion method on Mueller-Hinton agar. The MIC of glycopeptides was determined by using the dilution method on solid media. mecA gene and luk-PV gene were detected by PCR. RESULTS: The disk diffusion method proved full susceptibility to vancomycin, teicoplanin, and linezolid; whereas MIC (dilution method) indicated that 5/113 strains were resistant to teicoplanin, giving a probability of having heterogeneous glycopeptide intermediate S. aureus (hGISA) strains. The mecA gene was detected in all MRSA strains ruling out the probability of having new variants of this gene in the tested strains. The luk-PV gene was detected in 28 out of 113 MRSA strains (24.8%). CONCLUSION: The originality of this study was the detection of hGISA strains knowing that they were susceptible to glycopeptides according to the diffusion method. Thus it is necessary to check the level of susceptibility of MRSA clinical isolates to glycopeptides for immunodeficient patients, by determining the MIC.

Panton-Valentine leukocidin producing Staphylococcus aureus nasal carriage, in North-Lebanon.

OBJECTIVES: We investigated the prevalence and the risk factors of nasal carriage of Staphylococcus aureus carrying Panton-Valentine leukocidin genes [Sa PVL(+)] in pupils. STUDY POPULATION AND METHODS: Two hundred and fifty-seven pupils were screened by nasal swabbing. The detection of 16S rRNA, mecA and luk-PV genes was performed by PCR and the risk factors were assessed with the statistical analysis of a questionnaire. RESULTS: Thirty-one percent of pupils were colonized, with 16.4% of isolates carrying the luk-PV gene and 8.8% the mecA gene. Children aged 7years or more and living in a boarding school were the factors promoting nasal carriage 60% of children who presented with an abscess in the previous year were carriers of luk-PV gene Sa. CONCLUSION: The study revealed a high prevalence of luk-PV gene among methicillin-susceptible strains and a statistically significant correlation between the presence of this gene and presenting with an abscess.

[Preliminary study on the prevalence of Campylobacter in childhood diarrhoea in north Lebanon]. / Etude préliminaire sur la prévalence de Campylobacter dans les diarrhées infantiles au nord du Liban.

Campylobacter species are a major cause of human diarrhoeal disease worldwide. In Lebanon, the true prevalence of Campylobacter infections and the species distribution in childhood diarrhoea are not known. This study in 2010 investigated the prevalence of Campylobacter species and its possible etiologic role in childhood diarrhoea in north Lebanon. A total of 90 stool samples from children (aged 1 month to 10 years) presenting with diarrhoea were collected from 5 hospitals. A polymerase chain reaction technique (PCR) was used for each sample forthe amplification of all Campylobacter species followed by 5 PCR reactions for the amplification of C. jejuni, C. hyointestinalis, C. coli, C. fetus and C. upsaliensis. Of the 90 samples, 10 were positive for Campylobacterspecies (11.1%):1 for C.coli, 1 for C. jejuni, 2 for both C. jejuni and C. coli, and 6 could not be identified to the species level with the available primers. Campylobacter species is frequently associated with childhood diarrhoea in north Lebanon but Campylobacter infection may be significantly underdiagnosed because the search for Campylobacter is not part of the routine stool culture.

Preliminary study on the prevalence of Campylobacter in childhood diarrhoea in north Lebanon

Campylobacter species are a major cause of human diarrhoeal disease worldwide. In Lebanon, the true prevalence of Campylobacter infections and the species distribution in childhood diarrhoea are not known. This study in 2010 investigated the prevalence of Campylobacter species and its possible etiologic role in childhood diarrhoea in north Lebanon. A total of 90 stool samples from children [aged 1 month to 10 years] presenting with diarrhoea were collected from 5 hospitals. A polymerase chain reaction technique [PCR] was used for each sample for the amplification of all Campylobacter species followed by 5 PCR reactions for the amplification of C. jejuni, C. hyointestinalis, C. coli, C. fetusand C. upsaliensis. Of the 90 samples, 10 were positive for Campylobacter species [11.1%]: 1 for C .coli, 1 for C. jejuni, 2 for both C. jejuni and C. coli, and 6 could not be identified to the species level with the available primers. Campylobacter species is frequently associated with childhood diarrhoea in north Lebanon but Campylobacter infection may be significantly underdiagnosed because the search for Campylobacteria not part of the routine stool culture

[Infections with respiratory syncytial virus in North Lebanon--prevalence during winter 2008]. / Les infections à virus respiratoire syncytial au Nord du Liban--prévalence au cours de l'hiver 2008.

Between 1 December 2007 and 31 May 2008, we analysed 120 nasopharyngeal swabs for the presence respiratory syncytial virus (RSV) infection in 120 children aged 15 days to 6 years, hospitalized in 2 hospitals in North Lebanon. Of the 120 samples, 32 were positive (26.7%) for RSV. There was a peak in January which progressively disappeared from February to May. Being positive for RSV was significantly associated with the presence of rhinorrhoea and dyspnoea as clinical symptoms and the absence of pneumonia signs on chest X-ray and the diagnosis of bronchitises or bronchiolitis. Testing for RSV is important in cases of respiratory infections in children as it may limit unnecessary prescription of antibiotics.

[Infections with respiratory syncytial virus in North Lebanon-prevalence during winter 2008]

Between 1 December 2007 and 31 May 2008, we analysed 120 nasopharyngeal swabs for the presence respiratory syncytial virus [RSV] infection in 120 children aged 15 days to 6 years, hospitalized in 2 hospitals in North Lebanon. Of the 120 samples, 32 were positive [26.7%] for RSV. There was a peak in January which progressively disappeared from February to May. Being positive for RSV was significantly associated with the presence of rhinorrhoea and dyspnoea as clinical symptoms and the absence of pneumonia signs on chest X-ray and the diagnosis of bronchitises or bronchiolitis. Testing for RSV is important in cases of respiratory infections in children as it may limit unnecessary prescription of antibiotics

[Biological analysis of workers in the food sector in north Lebanon]. / Analyses biologiques réalisées chez des travailleurs dans le secteur alimentaire au nord du Liban.

We investigated the prevalence of bacterial and parasitic infections among workers in a pastry factory in North Lebanon in 2004. We found 39% of the workers (n = 196) had nasal carriage of Staphylococcus aureus. Resistance of S. aureus isolates was 98.7% to penicillin G, 24.7% to fusidic acid, 14.3% to pefloxacine and tetracycline, 11.7% to erythromycin, 6.5% to oxacillin and amoxicillin-clavulanate. Salmonella typhi was not found in any of the workers. Prevalence of intestinal parasites was 57.8% (n = 308). Amoebae comprised 72.5% (68.3% Entamoeba coli, 15.5% E. histolytica), followed by flagellates (18.0 %) (37.5% Dientamoeba fragilis, 31.3% Giardia lamblia) and nematodes (7.8%) (only Ascaris lumbricoides). The tuberculin test was positive in 16.3% of the workers (n = 301).

[Biological analysis of workers in the food sector in north Lebanon]

We investigated the prevalence of bacterial and parasitic infections among workers in a pastry factory in North Lebanon in 2004. We found 39% of the workers [n = 196] had nasal carriage of Staphylococcus aureus. Resistance of S. aureus isolates was 98.7% to penicillin G, 24.7% to fusidic acid, 14.3% to pefloxacine and tetracycline, 11.7% to erythromycin, 6.5% to oxacillin and amoxicillin-clavulanate. Salmonella typhi was not found in any of the workers. Prevalence of intestinal parasites was 57.8% [n = 308]. Amoebae comprised 72.5% [68.3% Entamoeba coli, 15.5% E. histolytica], followed by flagellates [18.0 %] [37.5% Dientamoeba fragilis, 31.3% Giardia lamblia] and nematodes [7.8%] [only Ascaris lumbricoides]. The tuberculin test was positive in 16.3% of the workers [n = 301]

[Retrospective study of bacteremia diagnosed in an emergency department: frequency, susceptibility of microorganisms, and impact on therapeutic management]. / Etude rétrospective des bactériémies diagnostiquées aux urgences: fréquence, sensibilité des microorganismes et intérêt dans la prise en charge thérapeutique.

OBJECTIVE: The authors had for aim to determine the prevalence of bacteremia diagnosed in an emergency department (ED), the susceptibility of microorganisms to antibiotics, and the impact on therapeutic management. DESIGN: A retrospective analysis was made on patient features, microbiological ecology, susceptibility to antibiotics, and modalities of antimicrobial therapy in the Georges Pompidou European hospital ED of Hôpital, between 1 November 2001 and 30 June 2002. RESULTS: One thousand four hundred and thirty two blood cultures were obtained from 1069 patients. The rate of positive cultures was 12%, but only 8.7% (n = 125) were proved as true bacteremia. The most frequently identified organisms were: Enterobacteriaceae (n = 63, 39.4%) with a predominance of Escherichia coli (n = 48, 30%), and Streptococcus pneumoniae (n = 16, 10%). Forty two cases of pyelonephritis and 34 of prostatitis both due to E. coli were diagnosed. 76.5% of these were resistant to amoxicillin, 64.7% to amoxicillin-clavulanic acid, 11.8% to ciprofloxacin, and 44% to cotrimoxazole. No resistance to third generation cephalosporin was detected in E. coli isolates. Fourteen S. pneumoniae pneumonia cases were diagnosed. 57.1% of isolates presented with a decreased susceptibility to penicillin (CMI > 0.1 mg/l). Susceptibility to amoxicillin and cefotaxim was 85.7% and 92.9% respectively. Blood culture was the only exam available for bacterial diagnosis in 51.5% of true bacteremia. 1.6% of blood cultures from ED samples had an impact on therapeutic management. CONCLUSIONS: Blood culture is a relevant exam for the diagnosis of infection in patients admitted to the ED.

Fulminant invasive pulmonary aspergillosis in immunocompetent patients--a two-case report.

Two cases of invasive aspergillosis (IA) in immunocompetent patients with a fulminant fatal outcome are reported. Both patients were elderly and had a history of chronic lung disease treated with prolonged inhaled corticosteroids and a short course of systemic corticosteroids. They presented with dyspnea and fever, their respiratory function deteriorated rapidly, and they died 7 days after admission. Aspergillus fumigatus was cultured from respiratory samples. IA was confirmed in one case by necropsy that showed diffuse bilateral necrotizing pneumonitis and myocarditis. In the other case, IA diagnosis was established by thoracic CT scan plus detection of Aspergillus antigen in two blood samples. These two cases demonstrate that short-term corticosteroid therapy in immunocompetent patients with underlying chronic lung conditions is a risk factor for IA, and that its evolution can be fulminant.