Antimicrobial resistance landscape and COVID-19 impact in Egypt, Iraq, Jordan, and Lebanon: A survey-based study and expert opinion.

OBJECTIVES: The objective of this study was to assess the antimicrobial resistance (AMR) landscape and the impact of COVID-19 on AMR in Egypt, Iraq, Jordan, and Lebanon, and to gather expert opinions on the barriers to the implementation of antimicrobial stewardship (AMS) initiatives in the region. METHODS: A cross-sectional questionnaire survey was used to assess the current AMR landscape, existing AMS initiatives, barriers to implementing AMS initiatives, and the impact of COVID-19 on AMR in the four countries. RESULTS: The survey was completed by 204 physicians from Egypt (n = 82), Lebanon (n = 49), Iraq (n = 43), and Jordan (n = 30). Previous antibiotic use and previous bacterial colonization were perceived as the most common risk factors for an increase in AMR. According to the survey, multidrug-resistant (MDR) gram-negative bacteria were most common in lower respiratory tract infections, and Klebsiella pneumoniae and Escherichia coli were the most commonly identified gram-negative bacteria in hospital-acquired infections. Only 14.8% of pediatric physicians and 28.6% of adult physicians reported that target pathogen genotyping and phenotyping were done in hospitals, and the most commonly reported reasons for the lack of testing were technological and resource constraints. These constraints, coupled with the scarcity and high cost of newer antibiotics, have been identified as the most significant barriers to the successful management of MDR gram-negative bacterial infections in the region. It was reported that the spectrum of activity and safety of the antibiotic, the site of infection, the presence of comorbidities, and published guidelines and local antibiograms determined the choice of empirical antibiotic therapy for patients in the region. The four countries experienced a significant rise in AMR due to several factors during the COVID-19 pandemic, including an increase in hospital occupancy, a shift in priorities away from AMR surveillance, and changes in AMR epidemiology. Additionally, the large volumes of unnecessary and unsubstantiated antibiotic prescriptions during the COVID-19 pandemic has led to subsequent antibiotic shortages and significant increases in AMR in the region. Physicians also noted that the majority of COVID-19 patients were already on antibiotics before visiting the healthcare facility. MDR gram-negative bacteria were found in the majority of COVID-19 patients admitted to the intensive care unit. Despite the fact that various AMS initiatives have been implemented, they are not standardized across the region. Some of the main barriers to AMS implementation in the region are a lack of adequately trained AMS staff, lack of AMS knowledge and training among healthcare professionals, financial constraints, and the lack of AMR surveillance systems. CONCLUSION: These survey results provide valuable insights into the existing AMR and AMS landscape in the region, as well as the barriers that impede efficient AMS and AMR management. Based on these findings, the authors developed a call to action that suggests ways for each country in the region to address these challenges.

Renal involvement in childhood-onset systemic lupus erythematosus in Egypt.

Lupus nephritis has been described as the most serious complication of systemic lupus erythematosus (SLE) and the strongest predictor of poor outcome. While the incidence of childhood SLE is relatively low, renal involvement appears to be more common and more severe in childhood SLE. This study aims to characterize the features and outcome of renal involvement in childhood-onset SLE based on a study of 100 Egyptian patients (mean age at diagnosis 10.1 years, range 2-17 years). Initial data regarding disease manifestations and biopsy findings were reviewed. Disease activity was assessed using SLEDAI scores. Follow-up data (mean duration 6 years) were noted regarding specific treatment, response, complications and renal survival. Initial renal involvement was present in 78 patients, including 66 with hypertension and 23 with renal impairment. Pathologically, class IV nephropathy was found in 18 patients, class V in 9 and low-grade lesions (class II-III) in 49. Twenty patients required follow-up biopsy, and all transformations were observed. SLEDAI scores significantly decreased from initial (mean ± SD) of 21.4 ± 7.3 to 13.4 ± 7.8, in association with response to therapy (P < 0.0001). Poor response was associated with initial hypertension and renal impairment but not with initial SLEDAI score or pathological class. The projected renal survival was 82.4 and 64.7% 5 and 10 years from diagnosis. Early renal involvement in childhood SLE is common, serious and requires proper evaluation and management.

Profile of patients visiting the pediatric emergency service in an Egyptian university hospital.

BACKGROUND: The emergency department (ED) is an essential component of the medical service offered in any hospital. Yet, the published information about patients' profile and utilization of emergency services in both developing and developed countries is scarce. AIM: This study aimed to characterize the presentation and outcome of patients visiting the ED of a university-based tertiary pediatric hospital. METHODS: This is a descriptive study reporting the profile of patients visiting the ED for 1 year. RESULTS: The total number of patients visiting the hospital was 249,552, with a monthly average of 20,046 patients, including 3639 monthly ED visits. "Treat-and-release" cases represented 46.7% and infants represented the largest age group (44.4%). The main presentation was respiratory distress (24.4%) and wheezy chest (17.3%), followed by convulsions (15%) and then pallor (10.7%). Long-term illnesses were predominantly congenital heart diseases, cerebral palsy, chronic hemolytic anemia, and asthma. The overall mortality rate was 0.8%. CONCLUSIONS: Appropriate and ongoing data collection and analysis could guide more efficient utilization of pediatric emergency services to achieve better outcomes.

The effect of high fat dietary modification and nutritional status on the outcome of critically ill ventilated children: single-center study.

BACKGROUND: Ventilator dependency constitutes a major problem in the intensive care setting. Malnutrition is considered a major determinant of extubation failure, however, attention has been attracted to modulating carbon dioxide production through decreasing carbohydrate loading and increasing the percent of fat in enteral feeds. The detected interrelation between substrate oxidation and ventilation outcome became the base of several research to determine the appropriate composition of the nonprotein calories of diet in ventilated patients. PURPOSE: We aimed to assess the effect of high-fat dietary modification and nutritional status on ventilatory and final outcomes of pediatric intensive care. METHODS: Fifty-one ventilated children (1 month to 12 years of age) with pulmonary disease who could be enterally fed, in the Cairo University Pediatric intensive care unit, were divided into 2 groups: group A included 25 patients who received isocaloric high-fat, low-carbohydrate diet; group B included 26 patients who received standard isocaloric diet. Comprehensive nutritional assessment was done for all patients. RESULTS: Group A had a significant reduction in carbon dioxide tension, but no similar reduction in the duration or level of ventilatory support. Assisted minute ventilation was predicted by weight-for-age and caloric intake rather than the type of diet. Poor nutritional status was associated with higher mortality and lower extubation rates. Mild hypertriglyceridemia and some gastrointestinal intolerance were significant in group A, with no impact on the adequacy of energy or protein delivery. CONCLUSION: The high-fat enteral feeding protocol may contribute to reducing carbon dioxide tension, with mild hypertriglyceridemia and negligible gastrointestinal intolerance as potential adverse effects. Optimization of nutritional status rather than dietary modification may improve ventilatory and survival outcomes in critically ill-ventilated children.

Central venous catheters as a vascular access modality for pediatric hemodialysis.

BACKGROUND: The use of hemodialysis catheters is an essential component of dialysis practice. Children are particularly likely to require multiple courses of dialysis over their lifetime, hence the repeated need for vascular access. These catheters remain a significant source of morbidity and mortality. METHODS: All catheters inserted for hemodialysis at the Center of Pediatric Nephrology and Transplantation, Cairo University over a period of 40 months were studied. Patient data as well as data of catheter insertion, dwell, cause of removal and complications were reported. RESULTS: A total of 195 uncuffed central venous catheters were used for temporary access in 131 patients for a mean duration of 35.7 days. Of attempted insertions, 87.4% achieved successful access, of which 56% remained for the required period, 8.9% were accidentally dislodged, and 35.1% were removed due to complications--mostly infection. The overall rate of possible catheter-related bacteremia was 9.6 episodes/ 1,000 catheter days. Infection increased with longer catheter dwell. Nineteen cuffed tunneled catheters were surgically inserted and used for up to 11 months (mean 117 days). Loss of these catheters was attributed mainly to infection (ten episodes) and catheter thrombosis (six episodes). During the study, 317 femoral catheters were inserted. CONCLUSION: Uncuffed central venous catheters are both needed and useful for short-term hemodialysis. Vascular access for extended durations may be provided by cuffed tunneled catheters. Infection is the major serious concern with both uncuffed and cuffed catheters.

Role of online hemodiafiltration in improvement of inflammatory status in pediatric patients with end-stage renal disease.

INTRODUCTION: Patients with end-stage renal disease are known to suffer from chronic inflammation as the result of an ongoing subacute cytokine induction, which may contribute considerably to dialysis-related long-term morbidity and mortality. In order to assess the inflammatory risk associated with online hemodiafiltration compared to conventional hemodialysis, we compared the cytokine induction profile of pediatric patients during treatment with each these modalities of dialysis. MATERIALS AND METHODS: Thirty pediatric patients on regular hemodialysis for at least 6 months were shifted to online hemodiafiltration. We collected serum samples before and 6 months after initiation of online hemodiafilration. The target pro-inflammatory cytokines selected were interleukin-6, tumor necrosis factor-α, and high-sensitivity C-reactive protein. RESULTS: High-sensitivity C-reactive protein decreased significantly on hemodiafiltration. The mean C-reactive protein level after 6 months was 3.41 µg/mL in the online hemodiafilration as compared to 7.98 µg/mL in the hemodialysis group (P = .01). Plasma interleukin-6 and tumor necrosis factor-α and tumor necrosis factor-α also decreased significantly on hemodiafiltration and the values were 100.44 pg/mL versus 168.40 pg/mL (P = .002) and 11.45 pg/mL versus 15.70 pg/mL (P = .008), respectively, for the hemodiafilration and hemodialysis groups. CONCLUSIONS: Online hemodiafiltration is associated with dampened pro-inflammatory cytokine profile compared to conventional hemodialysis in children with end-stage renal disease.