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Al Dabbagh M, Alghounaim M, Almaghrabi RH, Dbaibo G, Ghatasheh G, Ibrahim HM, Aziz MA, Hassanien A, Mohamed N. A Narrative Review of Healthcare-Associated Gram-Negative Infections Among Pediatric Patients in Middle Eastern Countries. Infect Dis Ther 2023; 12:1217-1235. [PMID: 37071349 DOI: 10.1007/s40121-023-00799-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/28/2023] [Indexed: 04/19/2023] Open
Abstract
INTRODUCTION Gram-negative bacteria (GNB) have become prominent across healthcare and community settings due to factors including lack of effective infection control and prevention (ICP) and antimicrobial stewardship programs (ASPs), GNB developing antimicrobial resistance (AMR), and difficulty treating infections. This review summarizes available literature on healthcare-associated infections (HAIs) in Middle Eastern pediatric patients. METHODS Literature searches were performed with PubMed and Embase databases. Articles not reporting data on GNB, HAIs, pediatric patients, and countries of interest were excluded. RESULTS The searches resulted in 220 publications, of which 49 met the inclusion criteria and 1 additional study was identified manually. Among 19 studies across Egypt reporting GNB prevalence among pediatric patients, Klebsiella species/K. pneumoniae and Escherichia coli were typically the most common GNB infections; among studies reporting carbapenem resistance and multidrug resistance (MDR), rates reached 86% and 100%, respectively. Similarly, in Saudi Arabia, Klebsiella spp./K. pneumoniae and E. coli were the GNB most consistently associated with infections, and carbapenem resistance (up to 100%) and MDR (up to 75%) were frequently observed. In other Gulf Cooperation Council countries, including Kuwait, Oman, and Qatar, carbapenem resistance and MDR were also commonly reported. In Jordan and Lebanon, E. coli and Klebsiella spp./K. pneumoniae were the most common GNB isolates, and AMR rates reached 100%. DISCUSSION This review indicated the prevalence of GNB-causing HAIs among pediatric patients in Middle Eastern countries, with studies varying in reporting GNB and AMR. Most publications reported antimicrobial susceptibility of isolated GNB strains, with high prevalence of extended-spectrum beta-lactamase-producing K. pneumoniae and E. coli isolates. A review of ASPs highlighted the lack of data available in the region. CONCLUSIONS Enhanced implementation of ICP, ASPs, and AMR surveillance is necessary to better understand the widespread burden of antimicrobial-resistant GNB and to better manage GNB-associated HAIs across Middle Eastern countries.
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Affiliation(s)
- Mona Al Dabbagh
- King Abdulaziz Medical City, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | | | | | - Ghassan Dbaibo
- Center for Infectious Diseases Research, American University of Beirut, Beirut, Lebanon.
| | | | - Hanan M Ibrahim
- Pediatric Department, Children's Hospital, Ain Shams University Hospital, Cairo, Egypt
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Dai R, Wu H, Liu G, Shen L, Geng Y, Zhang S, Zhou H, Jiang C, Gong J, Fan X, Ji C. Investigation of bacterial and fungal population structure on environmental surfaces of three medical institutions during the COVID-19 pandemic. Front Microbiol 2023; 14:1089474. [PMID: 36970696 PMCID: PMC10033641 DOI: 10.3389/fmicb.2023.1089474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/15/2023] [Indexed: 03/11/2023] Open
Abstract
ObjectivesTo evaluate the population structure of environmental bacteria and fungi in three different types of medical institutions and the potential risks due to antibiotic resistance during the coronavirus disease 2019 (COVID-19) pandemic.MethodsOne hundred twenty-six environmental surface samples were collected from three medical institutions during the COVID-19 pandemic. A total of 6,093 and 13,514 representative sequences of 16S and ITS ribosomal RNA (rRNA) were obtained by amplicon sequencing analysis. The functional prediction was performed using the Phylogenetic Investigation of Communities by Reconstruction of Unobserved States tool based on the Greengenes database and the FAPROTAX database.ResultsOn environmental surfaces in three medical institutions during the COVID-19 pandemic, Firmicutes (51.6%) and Bacteroidetes (25%) were the dominant bacteria, while Ascomycota (39.4%) and Basidiomycota (14.2%) were the dominant fungi. A number of potential bacterial and fungal pathogens were successfully identified by the metagenomic approach. Furthermore, compared with the bacterial results, the fungi showed a generally closer Bray Curtis distance between samples. The overall ratio of Gram-negative bacteria to Gram-positive bacteria was about 3:7. The proportion of stress-tolerant bacteria in medical institutions A, B and C reached 88.9, 93.0 and 93.8%, respectively. Anaerobic bacteria accounted for 39.6% in outdoor environments, 77.7% in public areas, 87.9% in inpatient areas and 79.6% in restricted areas. Finally, the β-Lactam resistance pathway and polymyxin resistance pathway were revealed through functional prediction.ConclusionWe described the microbial population structure changes in three different types of medical institutions using the metagenomic approach during the COVID-19 pandemic. We found that the disinfection measures performed by three healthcare facilities may be effective on the “ESKAPE” pathogens, but less effective on fungal pathogens. Moreover, emphasis should be given to the prevention and control of β-lactam and polymyxin antibiotics resistance bacteria during the COVID-19 pandemic.
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Affiliation(s)
- Rongchen Dai
- School of Public Health, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Hanting Wu
- School of Public Health, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Guiming Liu
- Beijing Agro-Biotechnology Research Center, Beijing Academy of Agriculture and Forestry Sciences, Beijing, China
| | - Linlai Shen
- China Academy of Chinese Medical Sciences, Beijing, China
| | - Yuanyuan Geng
- State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- Department of Infectious Diseases and Clinical Microbiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shu Zhang
- State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- Department of Infectious Diseases and Clinical Microbiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Haijian Zhou
- State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Canran Jiang
- State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- Department of Infectious Diseases and Clinical Microbiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jie Gong
- State Key Laboratory of Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- Department of Infectious Diseases and Clinical Microbiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xin Fan
- Department of Infectious Diseases and Clinical Microbiology, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- *Correspondence: Xin Fan, ; Conghua Ji,
| | - Conghua Ji
- School of Public Health, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
- *Correspondence: Xin Fan, ; Conghua Ji,
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Multidrug-Resistant Acinetobacter baumannii Infections in the United Kingdom versus Egypt: Trends and Potential Natural Products Solutions. Antibiotics (Basel) 2023; 12:antibiotics12010077. [PMID: 36671278 PMCID: PMC9854726 DOI: 10.3390/antibiotics12010077] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 01/03/2023] Open
Abstract
Acinetobacter baumannii is a problematic pathogen of global concern. It causes multiple types of infection, especially among immunocompromised individuals in intensive care units. One of the most serious concerns related to this pathogen is its ability to become resistant to almost all the available antibiotics used in clinical practice. Moreover, it has a great tendency to spread this resistance at a very high rate, crossing borders and affecting healthcare settings across multiple economic levels. In this review, we trace back the reported incidences in the PubMed and the Web of Science databases of A. baumannii infections in both the United Kingdom and Egypt as two representative examples for countries of two different economic levels: high and low-middle income countries. Additionally, we compare the efforts made by researchers from both countries to find solutions to the lack of available treatments by looking into natural products reservoirs. A total of 113 studies reporting infection incidence were included, with most of them being conducted in Egypt, especially the recent ones. On the one hand, this pathogen was detected in the UK many years before it was reported in Egypt; on the other hand, the contribution of Egyptian researchers to identifying a solution using natural products is more notable than that of researchers in the UK. Tracing the prevalence of A. baumannii infections over the years showed that the infections are on the rise, especially in Egypt vs. the UK. Further concerns are linked to the spread of antibiotic resistance among the isolates collected from Egypt reaching very alarming levels. Studies conducted in the UK showed earlier inclusion of high-throughput technologies in the tracking and detection of A. baumannii and its resistance than those conducted in Egypt. Possible explanations for these variations are analyzed and discussed.
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Dawadi P, Khadka C, Shyaula M, Syangtan G, Joshi TP, Pepper SH, Kanel SR, Pokhrel LR. Prevalence of metallo-β-lactamases as a correlate of multidrug resistance among clinical Pseudomonas aeruginosa isolates in Nepal. THE SCIENCE OF THE TOTAL ENVIRONMENT 2022; 850:157975. [PMID: 35964754 DOI: 10.1016/j.scitotenv.2022.157975] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/07/2022] [Accepted: 08/08/2022] [Indexed: 06/15/2023]
Abstract
Pseudomonas aeruginosa is an opportunistic human pathogen that has developed antibiotic resistance (AR) and causes a range of illnesses, including respiratory pneumonia, gastrointestinal infections, keratitis, otitis media and bacteremia in patients with compromised immune system. The production of metallo-β-lactamases (MBLs) is one of the major mechanisms of AR in this bacterium with ensuing infections difficult to treat. The main goal of this study was to provide a quantitative estimate of MBLs producing clinical P. aeruginosa isolates among the Nepalese patients and determine if MBL correlates with multi-drug resistance (MDR). Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline was followed for meta-analysis of relevant literature using PubMed, Research4Life, and Google Scholar. The prevalence of MBLs in P. aeruginosa from clinical samples was determined using R 4.1.2 for data pooled from studies published until 2021. The meta-analysis of a total of 19 studies selected (of 6038 studies for which titles and abstracts were reviewed) revealed the prevalence of MBLs producing P. aeruginosa (MBL-PA) was 14 % (95 % CI: 0.10-0.19) while MDR isolates among P. aeruginosa was 42 % (95 % CI: 0.30-0.55) in Nepal. Combined Disc Test was predominantly used phenotypic method for confirming MBLs phenotypes among the studies. Sputum was the most common specimen from which MBL-PA was recovered. A significant positive correlation was observed between MDR and MBL production in P. aeruginosa. We conclude that MBL producing strains are widespread among the clinical isolates of P. aeruginosa in Nepal and responsible for emerging MDR strains. It is paramount that antibiotics prescription against the bacterium should be monitored closely and alternative therapeutic modalities against MBL-PA explored.
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Affiliation(s)
- Prabin Dawadi
- Faculty of Science, Nepal Academy of Science and Technology, Khumaltar, Lalitpur 44700, Bagmati, Nepal; Central Department of Microbiology, Tribhuvan University, Kathmandu 44618, Bagmati, Nepal
| | - Christina Khadka
- Central Department of Microbiology, Tribhuvan University, Kathmandu 44618, Bagmati, Nepal
| | - Manita Shyaula
- Central Department of Microbiology, Tribhuvan University, Kathmandu 44618, Bagmati, Nepal
| | - Gopiram Syangtan
- Central Department of Microbiology, Tribhuvan University, Kathmandu 44618, Bagmati, Nepal
| | - Tista Prasai Joshi
- Faculty of Science, Nepal Academy of Science and Technology, Khumaltar, Lalitpur 44700, Bagmati, Nepal
| | - Samantha H Pepper
- Department of Heath Education and Promotion, College of Health and Human Performance, East Carolina University, Greenville, NC 27858, USA
| | - Sushil R Kanel
- Department of Chemistry, Wright State University, Dayton, OH 45435, USA
| | - Lok R Pokhrel
- Department of Public Health, The Brody School of Medicine, East Carolina University, Greenville, NC 27834, USA.
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Ramadan RA, Bedawy AM, Negm EM, Hassan TH, Ibrahim DA, ElSheikh SM, Amer RM. Carbapenem-Resistant Klebsiella pneumoniae Among Patients with Ventilator-Associated Pneumonia: Evaluation of Antibiotic Combinations and Susceptibility to New Antibiotics. Infect Drug Resist 2022; 15:3537-3548. [PMID: 35833009 PMCID: PMC9271681 DOI: 10.2147/idr.s371248] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022] Open
Abstract
Background Carbapenemase-producing Gram-negative bacteria, particularly Klebsiella pneumoniae (K. pneumoniae), are at the forefront of the list of causative agents of ventilator-associated pneumonia (VAP). The treatment options for such infections are limited, and various antimicrobial combinations have been suggested as alternatives in clinical practice. New antibiotics, such as ceftazidime/avibactam, ceftolozane/tazobactam and cefiderocol, have shown advantages in both in vitro and clinical studies. Purpose To evaluate the in vitro effect of meropenem–ciprofloxacin and meropenem–colistin combinations on carbapenem-resistant (CR) K. pneumoniae VAP isolates and to determine their susceptibility to new antibiotics. Methods Seventy-three K. pneumoniae isolates from 176 endotracheal samples from VAP cases were studied. Antibiotic susceptibility testing and phenotypic detection of extended-spectrum β lactamase (ESBL) and carbapenemase production were done. CR K. pneumoniae isolates were tested for the five predominant carbapenemase genes (blaKPC, blaOXA-48, blaNDM,blaVIM, and blaIMP). In vitro evaluation of meropenem–ciprofloxacin and meropenem–colistin combinations was done by MIC test strips. Susceptibility to new antibiotics was tested by disk diffusion method. Results Sixty-three (86.3%) of the isolates were ESBL producers and 52 (71.2%) were carbapenem resistant. BlaNDM was the most prevalent carbapenemase gene (50%), followed by blaOXA-48, (36.5%) then blaKPC in (11.5%). BlaVIM and blaIMP were not detected. Meropenem–ciprofloxacin combination showed indifferent effect on all isolates, while meropenem–colistin combination showed 25% synergism, 15.4% addition and 59.6% indifference. All (100%) CR K. pneumoniae isolates were resistant to ceftolozane/tazobactam and 79% were resistant to ceftazidime/avibactam, while 96% were sensitive to cefiderocol. Conclusion A high rate of carbapenem resistance exists among VAP K. pneumoniae isolates. Meropenem–colistin combination and cefiderocol appear to be potential treatment options for infections caused by CR K. pneumoniae. Resistance to the tested new β-lactam/β-lactamase inhibitors was high, signifying a major threat.
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Affiliation(s)
- Raghdaa A Ramadan
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Aya M Bedawy
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Essamedin M Negm
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Tarek H Hassan
- Department of Chest Diseases, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Dalia A Ibrahim
- Department of Chest Diseases, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Somia M ElSheikh
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Rania M Amer
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Abstract
PURPOSE OF REVIEW Critical care registries are synonymous with measurement of outcomes following critical illness. Their ability to provide longitudinal data to enable benchmarking of outcomes for comparison within units over time, and between units, both regionally and nationally is a key part of the evaluation of quality of care and ICU performance as well as a better understanding of case-mix. This review aims to summarize literature on outcome measures currently being reported in registries internationally, describe the current strengths and challenges with interpreting existing outcomes and highlight areas where registries may help improve implementation and interpretation of both existing and new outcome measures. RECENT FINDINGS Outcomes being widely reported through ICU registries include measures of survival, events of interest, patient-reported outcomes and measures of resource utilization (including cost). Despite its increasing adoption, challenges with quality of reporting of outcomes measures remain. Measures of short-term survival are feasible but those requiring longer follow-ups are increasingly difficult to interpret given the evolving nature of critical care in the context of acute and chronic disease management. Furthermore, heterogeneity in patient populations and in healthcare organisations in different settings makes use of outcome measures for international benchmarking at best complex, requiring substantial advances in their definitions and implementation to support those seeking to improve patient care. SUMMARY Digital registries could help overcome some of the current challenges with implementing and interpreting ICU outcome data through standardization of reporting and harmonization of data. In addition, ICU registries could be instrumental in enabling data for feedback as part of improvement in both patient-centred outcomes and in service outcomes; notably resource utilization and efficiency.
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Affiliation(s)
- Abi Beane
- Mahidol Oxford Tropical Medicine Research Unit, Oxford University, UK
| | - Jorge I.F. Salluh
- D’Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
- Postgraduate program, Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rashan Haniffa
- Mahidol Oxford Tropical Medicine Research Unit, Oxford University, UK
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Jawad I, Rashan S, Sigera C, Salluh J, Dondorp AM, Haniffa R, Beane A. A scoping review of registry captured indicators for evaluating quality of critical care in ICU. J Intensive Care 2021; 9:48. [PMID: 34353360 PMCID: PMC8339165 DOI: 10.1186/s40560-021-00556-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/23/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Excess morbidity and mortality following critical illness is increasingly attributed to potentially avoidable complications occurring as a result of complex ICU management (Berenholtz et al., J Crit Care 17:1-2, 2002; De Vos et al., J Crit Care 22:267-74, 2007; Zimmerman J Crit Care 1:12-5, 2002). Routine measurement of quality indicators (QIs) through an Electronic Health Record (EHR) or registries are increasingly used to benchmark care and evaluate improvement interventions. However, existing indicators of quality for intensive care are derived almost exclusively from relatively narrow subsets of ICU patients from high-income healthcare systems. The aim of this scoping review is to systematically review the literature on QIs for evaluating critical care, identify QIs, map their definitions, evidence base, and describe the variances in measurement, and both the reported advantages and challenges of implementation. METHOD We searched MEDLINE, EMBASE, CINAHL, and the Cochrane libraries from the earliest available date through to January 2019. To increase the sensitivity of the search, grey literature and reference lists were reviewed. Minimum inclusion criteria were a description of one or more QIs designed to evaluate care for patients in ICU captured through a registry platform or EHR adapted for quality of care surveillance. RESULTS The search identified 4780 citations. Review of abstracts led to retrieval of 276 full-text articles, of which 123 articles were accepted. Fifty-one unique QIs in ICU were classified using the three components of health care quality proposed by the High Quality Health Systems (HQSS) framework. Adverse events including hospital acquired infections (13.7%), hospital processes (54.9%), and outcomes (31.4%) were the most common QIs identified. Patient reported outcome QIs accounted for less than 6%. Barriers to the implementation of QIs were described in 35.7% of articles and divided into operational barriers (51%) and acceptability barriers (49%). CONCLUSIONS Despite the complexity and risk associated with ICU care, there are only a small number of operational indicators used. Future selection of QIs would benefit from a stakeholder-driven approach, whereby the values of patients and communities and the priorities for actionable improvement as perceived by healthcare providers are prioritized and include greater focus on measuring discriminable processes of care.
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Affiliation(s)
- Issrah Jawad
- National Intensive Care Surveillance-MORU, Borella, Colombo, Western Province 08 Sri Lanka
| | - Sumayyah Rashan
- National Intensive Care Surveillance-MORU, Borella, Colombo, Western Province 08 Sri Lanka
| | - Chathurani Sigera
- National Intensive Care Surveillance-MORU, Borella, Colombo, Western Province 08 Sri Lanka
| | - Jorge Salluh
- Department of Critical Care and Graduate Program in Translational Medicine, D’Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Arjen M. Dondorp
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Central Thailand 10400 Thailand
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Rashan Haniffa
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Central Thailand 10400 Thailand
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Abi Beane
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Central Thailand 10400 Thailand
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Maebed AZM, Gaber Y, Bakeer W, Dishisha T. Microbial etiologies of ventilator-associated pneumonia (VAP) in intensive care unit of Beni-Suef University's Hospital. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2021; 10:41. [PMID: 34341765 PMCID: PMC8319904 DOI: 10.1186/s43088-021-00130-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 07/17/2021] [Indexed: 11/22/2022] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is a major health problem for people intubated in intensive care units (ICUs), leading to increased mortality rates, hospital stay, and treatment costs. In the present study, the core pathogens causing VAP in Beni-Suef University's Hospital, Egypt, was investigated over a study period of 2 years (2017–2019). Results Of a total of 213 patients subjected to mechanical ventilation, 60 have developed VAP during their stay in the ICU. The mortality rate reached 41.7% among VAP patients. Sixty bacteria were isolated from an endotracheal aspirate of hospitalized patients. The different isolates were cultured followed by running biochemical tests, sensitivity assays, and automated VITEK®2 System analysis. Unexpectedly, all the isolates were Gram-negative bacteria. Klebsiella pneumoniae were the main pathogen encountered (27/60 isolates) followed by Acientobacter baumannnii (7/60) and other microorganisms belonging to the genera Moraxella, Escherichia, and Pseudomonas (11/60). Antibiotic sensitivity testing was performed via the VITEK®2 System using up to 16 different antibiotics representing 8 different antibiotic classes and subclasses (aminoglycosides, carbapenems, fluoroquinolones, penicillin/β-lactamase inhibitor, extended-spectrum cephalosporins, aminopenicillins, aminopenicillins/β-lactamase inhibitor, folic acid synthesis inhibitor). Majority of the isolates (28/60) showed a remarkable extensive drug resistance (XDR) pattern, while 15 isolates were multi-drug resistant (MDR) and only 6 were pan-drug resistant (PDR) with regard to antibiotics under evaluation. Conclusion The association of VAP with multi-drug-resistant bacteria is alarming, and rapid management is crucial. Identification of core pathogens is essential for identifying the most appropriate technique for infection control.
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Affiliation(s)
- Al Zahraa M Maebed
- Department of Microbiology and Immunology, Faculty of Pharmacy, Nahda University, Beni Suef, Egypt
| | - Yasser Gaber
- Department of Microbiology and Immunology, Faculty of Pharmacy, Beni-Suef University, Beni Suef, Egypt.,Department of Pharmaceutics and Pharmaceutical Technology, College of Pharmacy, Mutah University, Kerak, 61710 Jordan
| | - Walid Bakeer
- Department of Microbiology and Immunology, Faculty of Pharmacy, Beni-Suef University, Beni Suef, Egypt
| | - Tarek Dishisha
- Department of Microbiology and Immunology, Faculty of Pharmacy, Beni-Suef University, Beni Suef, Egypt
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El-Kholy A, El-Mahallawy HA, Elsharnouby N, Abdel Aziz M, Helmy AM, Kotb R. Landscape of Multidrug-Resistant Gram-Negative Infections in Egypt: Survey and Literature Review. Infect Drug Resist 2021; 14:1905-1920. [PMID: 34079301 PMCID: PMC8163635 DOI: 10.2147/idr.s298920] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/26/2021] [Indexed: 12/19/2022] Open
Abstract
Purpose This article is the first to review published reports on the prevalence of multidrug-resistant (MDR) gram-negative infections in Egypt and gain insights into antimicrobial resistance (AMR) surveillance and susceptibility testing capabilities of Egyptian medical centers. Materials and Methods A literature review and online survey were conducted. Results The online survey and literature review reported high prevalence of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae (19–85.24% of E. coli, and 10–87% of K. pneumoniae), carbapenem-resistant Enterobacteriaceae (35–100% of K. pneumoniae and 13.8–100% of E. coli), carbapenem-resistant Acinetobacter baumannii (10–100%), and carbapenem-resistant Pseudomonas aeruginosa (15–70%) in Egypt. Risk factors for MDR Gram-negative infections were ventilated patients (67.4%), prolonged hospitalization (53.5%) and chronic disease (34.9%). Although antimicrobial surveillance capabilities were deemed at least moderate in most centers, lack of access to rapid AMR diagnostics, lack of use of local epidemiological data in treatment decision-making, lack of antimicrobial stewardship (AMS) programs, and lack of risk prediction tools were commonly reported by respondents. Conclusion This survey has highlighted the presence of knowledge gaps as well as limitations in the surveillance and monitoring capabilities of AMR in Egypt, with most laboratories lacking rapid diagnostics and molecular testing. Future efforts in Egypt should focus on tackling these issues via nationwide initiatives, including understanding the AMR trends in the country, capacity building of laboratories and their staff to correctly and timely identify AMR, and introducing newer antimicrobials for targeting emerging resistance mechanisms in Gram-negative species.
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Affiliation(s)
- Amani El-Kholy
- Department of Clinical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hadir A El-Mahallawy
- Clinical Pathology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Noha Elsharnouby
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | | | - Ramy Kotb
- Pfizer Africa & Middle East Medical Affairs, Dubai, United Arab Emirates
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Saharman YR, Karuniawati A, Severin JA, Verbrugh HA. Infections and antimicrobial resistance in intensive care units in lower-middle income countries: a scoping review. Antimicrob Resist Infect Control 2021; 10:22. [PMID: 33514432 PMCID: PMC7844809 DOI: 10.1186/s13756-020-00871-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 12/22/2020] [Indexed: 01/18/2023] Open
Abstract
Background Intensive care units (ICUs) in lower-middle income countries (LMICs) are suspected to constitute a special risk for patients of acquiring infection due to multiple antibiotic resistant organisms. The aim of this systematic scoping review was to present the data published on ICU-acquired infections and on antimicrobial resistance observed in ICUs in LMICs over a 13-year period. A systematic scoping review was conducted according to the PRISMA extension guideline for scoping reviews and registered in the Open Science Framework.
Main body of the abstract Articles were sought that reported on ICU-acquired infection in LMICs between 2005 and 2018. Two reviewers parallelly reviewed 1961 titles and abstracts retrieved from five data banks, found 274 eligible and finally included 51. Most LMICs had not produced reports in Q1 or Q2 journals in this period, constituting a large gap in knowledge. However, from the reported evidence it is clear that the rate of ICU-acquired infections was comparable, albeit approximately 10% higher, in LMICs compared to high income countries. In contrast, ICU mortality was much higher in LMICs (33.6%) than in high income countries (< 20%). Multidrug-resistant Gram-negative species, especially Acinetobacter baumannii and Pseudomonas aeruginosa, and Klebsiella pneumoniae played a much more dominant role in LMIC ICUs than in those in high income countries. However, interventions to improve this situation have been shown to be feasible and effective, even cost-effective. Conclusions Compared to high income countries the burden of ICU-acquired infection is higher in LMICs, as is the level of antimicrobial resistance; the pathogen distribution is also different. However, there is evidence that interventions are feasible and may be quite effective in these settings. Protocol Registration The protocol was registered with Open Science Framework (https://osf.io/c8vjk)
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Affiliation(s)
- Yulia Rosa Saharman
- Department of Clinical Microbiology, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia.,Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Anis Karuniawati
- Department of Clinical Microbiology, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Juliëtte A Severin
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Henri A Verbrugh
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
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Iordanou S, Papathanassoglou E, Middleton N, Palazis L, Timiliotou-Matsentidou C, Raftopoulos V. Device-associated health care-associated infections: The effectiveness of a 3-year prevention and control program in the Republic of Cyprus. Nurs Crit Care 2020; 27:602-611. [PMID: 33314424 DOI: 10.1111/nicc.12581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Device-associated health care-associated infections (DA-HAIs) are a major threat to patient safety, particularly in the Intensive Care Unit (ICU). This study aimed to evaluate the effectiveness of a bundle of infection control measures to reduce DA-HAIs in the ICU of a General Hospital in the Republic of Cyprus, over a 3-year period. METHODS We studied 599 ICU patients with a length of stay (LOS) for at least 48 hours. Our prospective cohort study was divided into three surveillance phases. Ventilator-associated pneumonia (VAP), central line-associated blood-stream infections (CLABSI), and catheter-associated blood-stream infections (CAUTI) incidence rates, LOS, and mortality were calculated before, during, and after the infection prevention and control programme. RESULTS There was a statistically significant reduction in the number of DA-HAI events during the surveillance periods, associated with DA-HAIs prevention efforts. In 2015 (prior to programme implementation), the baseline DA-HAIs instances were 43: 16 VAP (10.1/1000 Device Days), 21 (15.9/1000DD) CLABSIs, and 6 (2.66/1000DD) CAUTIs, (n = 198). During the second phase (2016), CLABSIs prevention measures were implemented and the number of infections were 24: 14 VAP (12.21/1000DD), 4 (4.2/1000DD) CLABSIs, and 6 (3.22/1000DD) CAUTIs, (n = 184). During the third phase (2017), VAP and CAUTI prevention measures were again implemented and the rates were 6: (3 VAP: 12.21/1000DD), 2 (1.95/1000DD) CLABSIs, and 1 (0.41/1000DD) CAUTIs, (n = 217). There was an overall reduction of 87% in the total number of DA-HAIs instances for the period 1 January 2015 to 31 December 2017. CONCLUSIONS The significant overall reduction in DA-HAI rates indicates that a comprehensive infection control programme can affect DA-HAI rates.
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Affiliation(s)
- Stelios Iordanou
- Intensive Care Unit, Limassol General Hospital, Limassol, Cyprus
| | | | - Nicos Middleton
- Department of Nursing, Cyprus University of Technology, Limassol, Cyprus
| | - Lakis Palazis
- Nicosia General Hospital, Intensive Care Unit, Nicosia, Cyprus
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Nahla KS, Manal IS, Gehan MA. Central line-related bloodstream infections and microbiological study in an Egyptian Ministry of Health Hospital. Afr Health Sci 2020; 20:158-167. [PMID: 33402904 PMCID: PMC7750073 DOI: 10.4314/ahs.v20i1.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Central line-associated bloodstream infections continue to be one of the most important health problems in ICU. OBJECTIVES To identify the central line-related bloodstream infections and their microbiological characteristics Specific objectives to the identify the incidence, predisposing factors of central line-related bloodstream Infections and study the antibiotic sensitivity patterns of the isolated organisms. MATERIAL AND METHODS Patients' demographic, clinical data, central venous catheter related data,and blood culture specimen collection data were collected utilizing a descriptive exploratory design from a purposive sample of 120 ICU patients underwent insertion central venous catheter. RESULTS out of 120 central line catheters sent for culture from patients immediately and seven days after insertion., 13(10.83%) were positive seven days after insertion. Of the 13 infection cases, 10 cases were Staphylococcus epidermis and the others were Staphylococcus aureus. In addition, most infected patients were overweight and obese, diabetic, had sub-clavian route, and their length of hospital stayed more than7 days. CONCLUSION 10.83 % developed bacterial blood stream infection 7 days after insertion of central venous catheters, and most of bacterial isolates were Staphylococcus epidermis and were sensitive to Vancomycin and Amikain.
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Affiliation(s)
- Khalil Shaaban Nahla
- Critical Care and Emergency Nursing Department, Faculty of Nursing, Cairo University, Egypt
| | - Ismaeel Sayed Manal
- Critical Care and Emergency Nursing Department, Faculty of Nursing, British University in Egypt
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13
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Collin SM, Shetty N, Guy R, Nyaga VN, Bull A, Richards MJ, van der Kooi TI, Koek MB, De Almeida M, Roberts SA, Lamagni T. Group B Streptococcus in surgical site and non-invasive bacterial infections worldwide: A systematic review and meta-analysis. Int J Infect Dis 2019; 83:116-129. [DOI: 10.1016/j.ijid.2019.04.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 04/15/2019] [Accepted: 04/18/2019] [Indexed: 12/15/2022] Open
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Kayingo G. Bacteria and Viruses. PHYSICIAN ASSISTANT CLINICS 2019; 4:323-332. [PMID: 32289089 PMCID: PMC7140249 DOI: 10.1016/j.cpha.2018.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Gerald Kayingo
- Betty Irene Moore School of Nursing, Physician Assistant Program, University of California, Davis, 2450 48th Street, #2120, Sacramento, CA 95817, USA
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15
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Moghnieh RA, Kanafani ZA, Tabaja HZ, Sharara SL, Awad LS, Kanj SS. Epidemiology of common resistant bacterial pathogens in the countries of the Arab League. THE LANCET. INFECTIOUS DISEASES 2018; 18:e379-e394. [PMID: 30292478 DOI: 10.1016/s1473-3099(18)30414-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 06/03/2018] [Accepted: 06/18/2018] [Indexed: 12/12/2022]
Abstract
No uniformly organised collection of data regarding antimicrobial resistance has occurred in the countries of the Arab League. 19 countries of the Arab League have published data for antimicrobial susceptibility for the WHO priority organisms, and seven of 14 of these organisms are included in this Review (Escherichia coli, Klebsiella spp, Pseudomonas aeruginosa, Acinetobacter baumannii, Salmonella spp, Staphylococcus aureus, and Streptococcus pneumoniae). Although E coli and Klebsiella spp resistance to third-generation cephalosporins is common in all countries, with prevalence reaching more than 50% in Egypt and Syria, carbapenem resistance is emerging, albeit with a prevalence of less than 10%. Conversely, a large amount of carbapenem resistance has been reported for P aeruginosa and A baumannii across the Arab League, reaching 50% and 88% of isolates in some countries. As for Salmonella spp, the prevalence of fluoroquinolone resistance has exceeded 30% in several areas. With regards to the Gram-positive pathogens, the prevalence of meticillin resistance in S aureus is reported to be between 20% and 30% in most countries, but exceeds 60% in Egypt and Iraq. The prevalence of penicillin non-susceptibility among pneumococci has reached more than 20% in Algeria, Egypt, Morocco, Saudi Arabia, and Tunisia. These findings highlight the need for structured national plans in the region to target infection prevention and antimicrobial stewardship.
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Affiliation(s)
- Rima A Moghnieh
- Division of Infectious Diseases, Department of Internal Medicine, Makassed General Hospital, Beirut, Lebanon
| | - Zeina A Kanafani
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Hussam Z Tabaja
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Sima L Sharara
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Lyn S Awad
- Pharmacy Department, Makassed General Hospital, Beirut, Lebanon
| | - Souha S Kanj
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.
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Iordanou S, Middleton N, Papathanassoglou E, Raftopoulos V. Surveillance of device associated infections and mortality in a major intensive care unit in the Republic of Cyprus. BMC Infect Dis 2017; 17:607. [PMID: 28877671 PMCID: PMC5586002 DOI: 10.1186/s12879-017-2704-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 08/23/2017] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Device-associated health care-associated infections (DA-HAI) pose a threat to patient safety, particularly in the intensive care unit. The aim of this study was to assess the incidence of DA-HAIs, mortality and crude excess mortality at a General Hospital's Intensive Care Unit (ICU) in the Republic of Cyprus for 1 year period. METHODS A prospective cohort, active DA-HAIs surveillance study with the use of Health Acquired Infections (HAIs) ICU Protocol (v1.01 standard edition) as provided by ECDC/NHSN for the active DA-HAIs surveillance study was conducted. The study sample included 198 ICU patients admitted during the research period and hospitalized for over 48 h. The Ventilator-Associated Pneumonia (VAP), Central Line-Associated Bloodstream Infection (CLABSI), and Catheter-Associated Urinary Tract Infection (CAUTI) rates, length of stay (LOS), mortality, and crude excess mortality were calculated. RESULTS CLABSI was the most frequent DA-HAI with 15.9 incidence rate per 1000 Central Venus Catheter (CVC) days. The VAP rate, was 10.1 per 1000 ventilator days and the CAUTI rate was 2.7 per 1000 urinary catheter days. Device associated infections were found to be significantly associated with the length of ICU stay (p < 0.001), the CVC days (p < 0.001), ventilator days (p < 0.001), and urinary catheter days (p < 0.001). The excess mortality was 22.1% for those who acquired a DA-HAI (95% CI, 2-42.2%) compared to the patients who remained DA-HAI free. Mortality of patients with VAP infection was 2.3 times higher (RR = 2.33 95% CI, 1.07-5.05) than those patients admitted without a HAI and subsequently did not acquire a DA-HAI. The most frequently isolated pathogen was Staphylococcus epidermidis (13.9%) and Candida albicans (13.9%). CONCLUSIONS Higher DA-HAIs rates and device utilization than the international benchmarks were found in this study, calling into question the safety of preventative practices employed in this unit.
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Affiliation(s)
- Stelios Iordanou
- Nursing Department, General Hospital of Limassol, Cyprus University of Technology, Limassol, Cyprus
| | - Nicos Middleton
- Nursing Department, Cyprus University of Technology, 15, Vragadinou Str, 3041 Limassol, Cyprus
| | | | - Vasilios Raftopoulos
- Nursing Department, Cyprus University of Technology, 15, Vragadinou Str, 3041 Limassol, Cyprus
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Parajuli NP, Acharya SP, Dahal S, Singh JP, Mishra SK, Kattel HP, Rijal BP, Pokhrel BM. Epidemiology of device-associated infections in an intensive care unit of a teaching hospital in Nepal: A prospective surveillance study from a developing country. Am J Infect Control 2017; 45:1024-1029. [PMID: 28431848 DOI: 10.1016/j.ajic.2017.02.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 02/28/2017] [Accepted: 02/28/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND Device-associated health care-acquired infections (DA-HAIs) in intensive care unit patients are a major cause of morbidity, mortality, and increased health care costs. METHODS A prospective, structured clinicomicrobiological surveillance was carried out for 3 common DA-HAIs: ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI) present in the patients of an intensive care unit of a teaching hospital in Nepal. DA-HAIs were identified using the Centers for Disease Control and Prevention definitions, and their rates were expressed as number of DA-HAIs per 1,000 device-days. RESULTS Overall incidence rate of DA-HAIs was 27.3 per 1,000 patient-days occurring in 37.1% of patients. The device utilization ratio for mechanical ventilation, central line catheter, and urinary catheter was 0.83, 0.63, and 0.78, respectively. The rates of VAP, CLABSI, and CAUTI were 21.40, 8.64, and 5.11 per 1,000 device-days, respectively. Acinetobacter spp (32.7%), Klebsiella spp (23.6%), Burkholderia cepacia complex (12.7%), and Escherichia coli (10.9%) were the common bacterial pathogens. Most of the bacterial isolates associated with DA-HAIs were found to be multidrug-resistant. CONCLUSIONS Incidence of DA-HAIs in the study intensive care unit was high compared with that of developed countries. Formulation and implementation of standard infection control protocols, active surveillance of DA-HAIs, and antimicrobial stewardship are urgently needed in our country.
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Affiliation(s)
- Narayan Prasad Parajuli
- Department of Clinical Microbiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal; Department of Laboratory Medicine, Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal.
| | - Subhash Prasad Acharya
- Department of Anesthesiology and Critical Care, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Santosh Dahal
- Department of Clinical Microbiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Jaya Prasad Singh
- Department of Laboratory Medicine, Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
| | - Shyam Kumar Mishra
- Department of Clinical Microbiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Hari Prasad Kattel
- Department of Clinical Microbiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Basista Prasad Rijal
- Department of Clinical Microbiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Bharat Mani Pokhrel
- Department of Clinical Microbiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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Maraolo AE, Cascella M, Corcione S, Cuomo A, Nappa S, Borgia G, De Rosa FG, Gentile I. Management of multidrug-resistant Pseudomonas aeruginosa in the intensive care unit: state of the art. Expert Rev Anti Infect Ther 2017; 15:861-871. [PMID: 28803496 DOI: 10.1080/14787210.2017.1367666] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Alberto Enrico Maraolo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Marco Cascella
- Division of Anesthesia, Department of Anesthesia and Pain Medicine, Istituto Nazionale Tumori – IRCCS - Fondazione G. Pascale, Naples, Italy
| | - Silvia Corcione
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Arturo Cuomo
- Division of Anesthesia, Department of Anesthesia and Pain Medicine, Istituto Nazionale Tumori – IRCCS - Fondazione G. Pascale, Naples, Italy
| | - Salvatore Nappa
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Guglielmo Borgia
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | | | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
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Amanati A, Karimi A, Fahimzad A, Shamshiri AR, Fallah F, Mahdavi A, Talebian M. Incidence of Ventilator-Associated Pneumonia in Critically Ill Children Undergoing Mechanical Ventilation in Pediatric Intensive Care Unit. CHILDREN-BASEL 2017; 4:children4070056. [PMID: 28671616 PMCID: PMC5532548 DOI: 10.3390/children4070056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 06/21/2017] [Accepted: 06/27/2017] [Indexed: 12/03/2022]
Abstract
Background: Among hospital-acquired infections (HAIs) in children, ventilator-associated pneumonia (VAP) is the most common after blood stream infection (BSI). VAP can prolong length of ventilation and hospitalization, increase mortality rate, and directly change a patient’s outcome in Pediatric Intensive Care Units (PICU). Objectives: The research on VAP in children is limited, especially in Iran; therefore, the identification of VAP incidence and mortality rate will be important for both clinical and epidemiological implications. Materials and Methods: Mechanically ventilated pediatric patients were assessed for development of VAP during hospital course on the basis of clinical, laboratory and imaging criteria. We matched VAP group with control group for assessment of VAP related mortality in the critically ill ventilated children. Results: VAP developed in 22.9% of critically ill children undergoing mechanical ventilation. Early VAP and late VAP were found in 19.3% and 8.4% of VAP cases, respectively. Among the known VAP risk factors that were investigated, immunodeficiency was significantly greater in the VAP group (p = 0.014). No significant differences were found between the two groups regarding use of corticosteroids, antibiotics, PH (potential of hydrogen) modifying agents (such as ranitidine or pantoprazole), presence of nasogastric tube and total or partial parenteral nutrition administration. A substantial number of patients in the VAP group had more than four risk factors for development of VAP, compared to those without VAP (p = 0.087). Mortality rate was not statistically different between the VAP and control groups (p = 0.477). Conclusion: VAP is still one of the major causes of mortality in PICUs. It is found that altered immune status is a significant risk factor for acquiring VAP. Also, occurrence of VAP was high in the first week after admission in PICU.
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Affiliation(s)
- Ali Amanati
- Pediatric Infections Research Center, Shahid Beheshti University of Medical Sciences, Tehran 1551415468, Iran.
| | - Abdollah Karimi
- Pediatric Infections Research Center, Shahid Beheshti University of Medical Sciences, Tehran 1551415468, Iran.
| | - Alireza Fahimzad
- Pediatric Infections Research Center, Shahid Beheshti University of Medical Sciences, Tehran 1551415468, Iran.
| | - Ahmad Reza Shamshiri
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran 1439955991, Iran.
| | - Fatemeh Fallah
- Pediatric Infections Research Center, Shahid Beheshti University of Medical Sciences, Tehran 1551415468, Iran.
| | - Alireza Mahdavi
- Pediatric anesthesiologists and intensivist, Mofid children's hospital, Shahid Beheshti Medical University, Tehran 1551415468, Iran.
| | - Mahshid Talebian
- BS of Nursery, Head Nurse of Pediatric Intensive Care Unit, Mofid children's hospital, Shahid Beheshti University of Medical Sciences, Tehran 1551415468, Iran.
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Tawfik DM, Ahmad TA, Sheweita SA, Haroun M, El-Sayed LH. The detection of antigenic determinants of Acinetobacter baumannii. Immunol Lett 2017; 186:59-67. [PMID: 28427887 DOI: 10.1016/j.imlet.2017.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 04/07/2017] [Accepted: 04/09/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Acinetobacter baumannii continues to pose a threat to burdened patients in ICUs all around the world. Lately, infection control techniques are not sufficient to curb A. baumannii's progression and chemotherapeutics are losing their potency against it. Thus, immunization became a key player in providing an ideal solution to the dilemma. None of the vaccines under investigation have reached the market and the search for a tailored vaccine remains a challenge. The notion of unravelling the bacterial antigens to design a novel epitope-based vaccine proved its merits. METHODS In this work, the propitious polysaccharide and protein antigenic determinants of A. baumannii were mapped by mimicking the infection. The immune response was evaluated by western blot, ELISA, and cellular proliferation assay techniques. RESULTS The screening showed that OMPs induced the most eminent sustained IgG response. In addition, OMP gave the highest cellular proliferation and a fold increase in ELISA that reached up to 10-fold by week 6. Whilst, the LPS gave a rapid IgM response, that reached 5-fold and the response was visible from week 1 in the western blot. The OMPs had a more pronounced effect in eliciting a cellular immune response. CONCLUSION The results elaborated the valuable role of using pure OMPs and detoxified LPS together; as a major cornerstone in designing an ideal vaccine against A. baumannii.
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Affiliation(s)
- Dina M Tawfik
- Biotechnology Department, Institute of Graduate Studies and Research, Alexandria University, Alexandria, Egypt; SeptivaK Research Group, Immunology Department, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Tarek A Ahmad
- SeptivaK Research Group, Immunology Department, Medical Research Institute, Alexandria University, Alexandria, Egypt; Special Projects Department, Bibliotheca Alexandrina, Alexandria, Egypt.
| | - Salah A Sheweita
- Biotechnology Department, Institute of Graduate Studies and Research, Alexandria University, Alexandria, Egypt
| | - Medhat Haroun
- Biotechnology Department, Institute of Graduate Studies and Research, Alexandria University, Alexandria, Egypt
| | - Laila H El-Sayed
- SeptivaK Research Group, Immunology Department, Medical Research Institute, Alexandria University, Alexandria, Egypt; Immunology and Allergy Department, Medical Research Institute, Alexandria University, Alexandria, Egypt
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Talaat M, El-Shokry M, El-Kholy J, Ismail G, Kotb S, Hafez S, Attia E, Lessa FC. National surveillance of health care-associated infections in Egypt: Developing a sustainable program in a resource-limited country. Am J Infect Control 2016; 44:1296-1301. [PMID: 27339791 DOI: 10.1016/j.ajic.2016.04.212] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND Health care-associated infections (HAIs) are a major global public health concern. The lack of surveillance systems in developing countries leads to an underestimation of the global burden of HAI. We describe the process of developing a national HAI surveillance program and the magnitude of HAI rates in Egypt. METHODS The detailed process of implementation of a national HAI surveillance program is described. A 3-phase surveillance approach was implemented in intensive care units (ICUs). This article focuses on results from the phase 2 surveillance. Standard surveillance definitions were used, clinical samples were processed by the hospital laboratories, and results were confirmed by a reference laboratory. RESULTS Ninety-one ICUs in 28 hospitals contributed to 474,544 patient days and 2,688 HAIs. Of these, 30% were bloodstream infections, 29% were surgical site infections, 26% were pneumonia, and 15% were urinary tract infections. Ventilator-associated pneumonia had the highest incidence of device-associated infections (4.3/1,000 ventilator days). The most common pathogens reported were Klebsiella spp (28.7%) and Acinetobacter spp (13.7%). Of the Acinetobacter spp, 92.8% (157/169) were multidrug resistant, whereas 42.5% (151/355) of the Klebsiella spp and 54% (47/87) of Escherichia coli were extended-spectrum β-lactamase producers. CONCLUSIONS Implementation of a sustainable surveillance system in a resource-limited country was possible following a stepwise approach with continuous evaluation. Enhancing infection prevention and control programs should be an infection control priority in Egypt.
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Affiliation(s)
- Maha Talaat
- Global Disease Detection Center, US Centers for Disease Control and Prevention, Cairo, Egypt; US Naval Medical Research Unit, No. 3, Cairo, Egypt.
| | - Mona El-Shokry
- Global Disease Detection Center, US Centers for Disease Control and Prevention, Cairo, Egypt; US Naval Medical Research Unit, No. 3, Cairo, Egypt; Ain Shams University Hospitals, Cairo, Egypt
| | | | | | - Sara Kotb
- Global Disease Detection Center, US Centers for Disease Control and Prevention, Cairo, Egypt; US Naval Medical Research Unit, No. 3, Cairo, Egypt
| | - Soad Hafez
- Alexandria University Hospitals, Alexandria, Egypt
| | - Ehab Attia
- Ministry of Health and Population, Cairo, Egypt
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El Zowalaty ME, Gyetvai B. Effectiveness of Antipseudomonal Antibiotics and Mechanisms of Multidrug Resistance in Pseudomonas aeruginosa. Pol J Microbiol 2016. [DOI: 10.5604/17331331.1197272] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Perceived versus Observed Patient Safety Measures in a Critical Care Unit from a Teaching Hospital in Southern Colombia. Crit Care Res Pract 2016; 2016:2175436. [PMID: 26989508 PMCID: PMC4775773 DOI: 10.1155/2016/2175436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 01/24/2016] [Indexed: 11/17/2022] Open
Abstract
Introduction. Patient safety is an important topic. The purpose of this study is to evaluate the perceived versus observed patient safety measures (PSM) in critically ill patients in a teaching hospital in Latin America. Materials and Methods. The level of perceived patient safety was evaluated with the patient safety hospital survey. Three months later, a qualitative study was conducted, including video recording of procedures, graded according to adherence to PSM. Levels of adherence were scored during patient mobilization (PM), placement of central catheters (PCC), other invasive procedures (OIP), infection control (IC), and endotracheal intubation (ETI). Results. The perceived adherence of PSM in the prestudy survey was considered fair by 89.1% of the ICU staff. After the survey, 829 ICU procedures were video-recorded. Mean observed adherence for fair patient safety measures was 20.8%. Perceived adherence was higher than the real patient safety protocol measures observed in the videos. Conclusion. Perception of PSM was higher than observed in the management of critically ill patients in a teaching hospital in southern Colombia.
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Zorgani A, Abofayed A, Glia A, Albarbar A, Hanish S. Prevalence of Device-associated Nosocomial Infections Caused By Gram-negative Bacteria in a Trauma Intensive Care Unit in Libya. Oman Med J 2015; 30:270-5. [PMID: 26366261 DOI: 10.5001/omj.2015.54] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES Device-associated nosocomial infections (DANIs) have a major impact on patient morbidity and mortality. Our study aimed to determine the distribution rate of DANIs and causative agents and patterns of antibiotic resistance in the trauma-surgical intensive care unit (ICU). . METHODS Our study was conducted at Abusalim Trauma Hospital in Tripoli, Libya. All devices associated with nosocomial infections, including central venous catheters (CVC), endotracheal tubes (ETT), Foley's urinary catheters, chest tubes, nasogastric tubes (NGT), and tracheostomy tubes, were removed aseptically and examined for Gram-negative bacteria (GNB). . RESULTS During a one-year study period, 363 patients were hospitalized; the overall mortality rate was 29%. A total of 79 DANIs were identified, the most common site of infection was ETT (39.2%), followed by urinary catheters (19%), NGTs (18%), tracheostomy tubes (11%), CVCs (10%), and chest tubes (3%). The most frequently isolated organisms were Klebsiella pneumonia, Acinetobacter baumannii, and Pseudomonas aeruginosa (30%, 20%, and 14%, respectively). Extremely high resistance rates were observed among GNB to ampicillin (99%), cefuroxime (95%), amoxicillin-clavulante (92%), and nitrofurantoin (91%). Lower levels of resistance were exhibited to amikacin (38%), imipenem (38%), and colistin (29%). About 39% of the isolates were defined as multi-drug resistant (MDR). Overall, extended spectrum β-lactmase producers were expressed in 39% of isolates mainly among K. pneumonia (88%). A. baumannii isolates exhibited extremely high levels of resistance to all antibiotics except colistin (100% sensitive). In addition, 56.3% of A. baumannii isolates were found to be MDR. P. aeruginosa isolates showed 46%-55% effectiveness to anti-pseudomonas antibiotics. . CONCLUSION High rates of DANI's and the emergence of MDR organisms poses a serious threat to patients. There is a need to strengthen infection control within the ICU environment, introduce surveillance systems, and implement evidence-based preventive strategies.
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Abstract
PURPOSE OF REVIEW Compared with adults, neonatal and pediatric populations are especially vulnerable patients who have specific diagnostic and therapeutic differences; therefore, the standard infection control practices designed for adults are sometimes not effective or need modifications to work. This review focuses on the recent literature addressing the challenges and successes in preventing healthcare-associated infections (HAIs) in children. RECENT FINDINGS Improving the implementation of pediatric versions of preventive bundles focusing on proper catheter insertion and maintenance, mainly as a part of a larger multimodal strategy, is effective in reducing the central-line-associated bloodstream infections in neonatal and pediatric populations including oncology patients. Appropriate feeding, antimicrobial stewardship, and infection control measures should be combined in reducing necrotizing enterocolitis in preterm neonates. Implementing a multimodal bundle strategy adapted for pediatric population is successful in preventing ventilator-associated pneumonia. Appropriate use of antimicrobial prophylaxis remains the cornerstone for preventing surgical-site infections irrespective of age, with few additional effective adjuvant preventive practices in specific pediatric patients. SUMMARY Several evidence-based practices are effective in reducing the incidence and the impact of HAIs in children; however, proper implementation remains a challenge. Additionally, several adult preventive practices are still unestablished in children and need further thorough examination.
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Souza ES, Belei RA, Carrilho CMDDM, Matsuo T, Yamada-Ogatta SF, Andrade G, Perugini MRE, Pieri FM, Dessunti EM, Kerbauy G. Mortality and risks related to healthcare-associated infection. TEXTO & CONTEXTO ENFERMAGEM 2015. [DOI: 10.1590/0104-07072015002940013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Healthcare-associated infections are a major cause of morbidity-mortality among hospitalized patients. The aim of this epidemiological study was to determine mortality and risks related to death in adult patients with healthcare-associated infections admitted to a teaching hospital in one year. Patient data were collected from infection medical reports. The mortality rate associated with infections was 38.4%, and it was classified as a contributing factor to deaths in 87.1% of death cases. The correlation between healthcare-associated infection and death was statistically significant among clinical patients (41.3%) presenting comorbidities related to the diagnosis (55.8%), cardiovascular infection (62.2%), pneumonia (48.9%), developing sepsis (69.0%), as well as patients who had been colonized (45.2%) and infected (44.7%) by multidrug resistance microorganisms.
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Bukhari S, Banjar A, Baghdadi S, Baltow B, Ashshi A, Hussain W. Central line associated blood stream infection rate after intervention and comparing outcome with national healthcare safety network and international nosocomial infection control consortium data. Ann Med Health Sci Res 2014; 4:682-6. [PMID: 25328774 PMCID: PMC4199155 DOI: 10.4103/2141-9248.141499] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Benchmarking of central line associated blood stream infection (CLABSI) rates remains a problem in developing countries due to the variations in surveillance practices and/or infection risk as non-availability of national data. Aim: The aim of the following study was to find out the CLABSI rate before and after central line (CL) bundle intervention and compare the outcome with international surveillance data. Subjects and Methods: This prospective longitudinal cohort study on adult intensive care unit patients was conducted at Hera General Hospital, Makkah Saudi Arabia from January 1 to December 31, 2012. Five key components of bundle were selected; hand hygiene, maximal barrier precautions upon insertion, skin antisepsis, optimum site selection and daily review of line necessity with prompt removal of unnecessary lines. Post-intervention CLABSI rate was compared with National Healthcare Safety Network (NHSN) and International Nosocomial Infection Control Consortium (INICC) rates. Statistical Package for the Social Sciences (SPSS) 14.0 software (SPSS Inc., 233 South Wacker Drive, 11th floor Chicago, USA) was used for statistical analysis included regression analysis for correlation. Statistical significance was set at P < 0.05. Results: CLABSI rate was reduced from 10.1 to 6.5 per 1000 CL days after interventions and had significant correlation with overall bundle compliance rate 87.6% (P = 0.02) On benchmarking, CLABSI rate after the intervention was similar to mean pool value of INICC (6.8) while higher than NHSN (3.1). The most common microorganisms isolated were; methicillin-resistant Staphylococcus aureus (30.8%), Acinetobacter baumanii (23.3%) and Enterococcus faecalis (15.4%). Conclusion: We found that INICC data was a better benchmarking tool comparative to NHSN because it represents the countries that are developing the surveillance system. A multicenter national study is recommended.
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Affiliation(s)
- Sz Bukhari
- Department of Infection Prevention and Control, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia
| | - A Banjar
- Department of Pediatrics, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia
| | - Ss Baghdadi
- Department of Obstetrics and Gynecology, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia
| | - Ba Baltow
- Department of Laboratory, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia
| | - Am Ashshi
- Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia
| | - Wm Hussain
- Department of Rheumatology, Hera General Hospital, Makkah, Kingdom of Saudi Arabia
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Aelami MH, Lotfi M, Zingg W. Ventilator-associated pneumonia in neonates, infants and children. Antimicrob Resist Infect Control 2014. [DOI: 10.1186/2047-2994-3-30] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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El-Mahdy TS. Identification of a Novel Metallo-^|^beta;-Lactamase VIM-28 Located within Unusual Arrangement of Class 1 Integron Structure in Pseudomonas aeruginosa Isolates from Egypt. Jpn J Infect Dis 2014. [DOI: 10.7883/yoken.67.382] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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See I, Lessa FC, ElAta OA, Hafez S, Samy K, El-Kholy A, El Anani MG, Ismail G, Kandeel A, Galal R, Ellingson K, Talaat M. Incidence and pathogen distribution of healthcare-associated infections in pilot hospitals in Egypt. Infect Control Hosp Epidemiol 2013; 34:1281-8. [PMID: 24225613 PMCID: PMC4697449 DOI: 10.1086/673985] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To report type and rates of healthcare-associated infections (HAIs) as well as pathogen distribution and antimicrobial resistance patterns from a pilot HAI surveillance system in Egypt. METHODS Prospective surveillance was conducted from April 2011 through March 2012 in 46 intensive care units (ICUs) in Egypt. Definitions were adapted from the Centers for Disease Control and Prevention's National Healthcare Safety Network. Trained healthcare workers identified HAIs and recorded data on clinical symptoms and up to 4 pathogens. A convenience sample of clinical isolates was tested for antimicrobial resistance at a central reference laboratory. Multidrug resistance was defined by international consensus criteria. RESULTS ICUs from 11 hospitals collected 90,515 patient-days of surveillance data. Of 472 HAIs identified, 47% were pneumonia, 22% were bloodstream infections, and 15% were urinary tract infections; case fatality among HAI case patients was 43%. The highest rate of device-associated infections was reported for ventilator-associated pneumonia (pooled mean rate, 7.47 cases per 1,000 ventilator-days). The most common pathogens reported were Acinetobacter species (21.8%) and Klebsiella species (18.4%). All Acinetobacter isolates tested (31/31) were multidrug resistant, and 71% (17/24) of Klebsiella pneumoniae isolates were extended-spectrum β-lactamase producers. CONCLUSIONS Infection control priorities in Egypt should include preventing pneumonia and preventing infections due to antimicrobial-resistant pathogens.
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Affiliation(s)
- Isaac See
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA
| | - Fernanda C. Lessa
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Omar Abo ElAta
- Infection Control Unit, Global Disease Detection and Response Program, US Naval Medical Research Unit No. 3, Cairo, Egypt
| | - Soad Hafez
- Department of Infection Control, Alexandria University Hospitals, Alexandria, Egypt
| | - Karim Samy
- Infection Control Unit, Global Disease Detection and Response Program, US Naval Medical Research Unit No. 3, Cairo, Egypt
| | - Amani El-Kholy
- Infection Control Unit, Clinical Pathology and Pediatric Departments, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mervat Gaber El Anani
- Infection Control Unit, Clinical Pathology and Pediatric Departments, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ghada Ismail
- Department of Clinical Pathology, Ain Shams University Hospitals, Egypt
| | - Amr Kandeel
- Ministry of Health and Population, Cairo, Egypt
| | - Ramy Galal
- Ministry of Health and Population, Cairo, Egypt
| | - Katherine Ellingson
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Maha Talaat
- Infection Control Unit, Global Disease Detection and Response Program, US Naval Medical Research Unit No. 3, Cairo, Egypt
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