Results from the Survey of Antibiotic Resistance (SOAR) 2015-17 in the Middle East (Kuwait, Lebanon and Saudi Arabia): data based on CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints

OBJECTIVES

To determine antibiotic susceptibility of Streptococcus pneumoniae and Haemophilus influenzae isolates from community-acquired respiratory tract infections (CA-RTIs) collected in 2015-17 from Kuwait, Lebanon and Saudi Arabia.

METHODS

MICs were determined by CLSI broth microdilution and susceptibility was assessed using CLSI, EUCAST (dose-specific) and pharmacokinetic/pharmacodynamic (PK/PD) breakpoints.

RESULTS

A total of 139 S. pneumoniae isolates were collected from four centres in Kuwait, Lebanon and Saudi Arabia in 2015-17 and 55 H. influenzae isolates were collected and analysed from Saudi Arabia over the same time period. Pneumococci from all three countries were commonly non-susceptible to penicillin based on CLSI oral or low-dose IV penicillin using EUCAST breakpoints (39% in Kuwait to 57.1% in Lebanon) but by CLSI IV and EUCAST high-dose breakpoints most isolates were susceptible (∼90% in Kuwait and Saudi Arabia, and 100% in Lebanon). Isolates from Lebanon were highly susceptible to most other antibiotics (>90%) except cefaclor, oral cefuroxime and cefpodoxime (EUCAST breakpoints only). Overall, susceptibility was significantly lower in Kuwait and Saudi Arabia than Lebanon. Although all H. influenzae isolates (Saudi Arabia only) were β-lactamase negative, 3.6% and 12.7% were ampicillin resistant by CLSI and EUCAST breakpoints, respectively. Otherwise susceptibility was high in H. influenzae. The application of different EUCAST breakpoints for low and higher doses for some of the antibiotics (amoxicillin, amoxicillin/clavulanic acid, ampicillin, penicillin, ceftriaxone, clarithromycin, erythromycin, levofloxacin and trimethoprim/sulfamethoxazole) allowed, for the first time in a SOAR study, the effect of raising the dosage on susceptibility to be quantified.

CONCLUSIONS

Relatively low antibiotic susceptibility was observed in S. pneumoniae from Kuwait and Saudi Arabia in contrast to Lebanon, where rates of susceptibility were generally higher. Isolates of H. influenzae from Saudi Arabia were susceptible to most antibiotics. These factors are important in decision making for empirical therapy of CA-RTIs.

Molecular detection of carbapenem resistance genes in rectal swabs from patients in Gulf Cooperation Council hospitals

BACKGROUND

Gram-negative organisms harbouring carbapenem resistance genes (CRGs) are spreading globally, including in Gulf Cooperation Council (GCC) countries. However, relatively few data are available about carriage of CRGs in hospitalized patients in this region.

AIM

To determine prevalence of CRG carriage and risk factors for colonization among patients in GCC hospitals.

METHODS

Rectal swabs were obtained from ∼50 intensive care unit (ICU) patients from each of 11 hospitals in five GCC countries between March and November 2019. The swabs were tested for the presence of bla_KPC, bla_NDM, bla_VIM, bla_IMP, and bla_OXA-48 CRG using a commercial polymerase chain reaction test. Data on risk factors for colonization were collected and analysed.

FINDINGS

Of 529 specimens screened, 138 (26.1%) were positive for one or more CRGs. The positivity rates among the hospitals ranged from 8.0% to 67.3%; ∼20% of the positive specimens harboured ≥2 CRGs. The most common CRG detected was bla_OXA-48, which was present in 82 specimens (15.5%). Additional CRGs included bla_NDM, bla_VIM, bla_KPC, and bla_IMP either alone or in combination. Overall, 31.1% of patients on antibiotics on admission to the ICU were positive for CRGs compared to 16.5% not on antibiotic therapy (P < 0.001). CRG detection was also more common among patients aged >65 years (P = 0.027) and increased with hospital length of stay (P = 0.025).

CONCLUSION

The rate of CRGs detected in hospitalized patients in GCC countries varied considerably. Prior antibiotic exposure, increasing age, and prolonged length of stay were associated with CRG detection.

Cutaneous mucormycosis postcosmetic surgery: A case report and review of the literature

BACKGROUND

Mucormycosis is a rare, aggressive, and life-threatening infection that is caused by organisms belonging to the order Mucorales. It is usually acquired through direct means and virtually always affects immunocompromised patients with the port of entry reflecting the site of infection, in this case, cutaneous. Unlike other mucormycoses, patients affected by Apophysomyces elegans (A elegans) are known to be immunocompetent. This locally aggressive disease penetrates through different tissue plains invading adjacent muscles, fascia, and even bone causing extensive morbidity and may prove fatal if treated inadequately. Cutaneous mucormycosis is associated with disruption of cutaneous barriers such as trauma. However, rarely, it may be iatrogenic. No cases have been previously reported postcosmetic surgery, especially one that is so commonly performed, lipofilling.

CASE REPORT

The patient is a, previously healthy, 41-year-old middle-eastern female who was admitted to the plastic surgery department 17 days after undergoing cosmetic surgery. She suffered from extensive tissue inflammation and necrosis in both gluteal regions. Following admission, she was initially started on empirical antimicrobial therapy which was changed to an antifungal agent, voriconazole, when preliminary microbiological results showed filamentous fungi. This was discontinued and liposomal amphotericin B was commenced when further mycological analysis identified A elegans. Furthermore, she underwent a total of 10 sessions of extensive debridement to the extent that portions of the sacrum and left femoral head became exposed. Her clinical status and wounds improved with the appropriate management and she remained an inpatient for 62 days. Subsequently, she had defects in both gluteal regions which required reconstructive surgery.

CONCLUSION

A elegans is an uncommon cause of iatrogenic cutaneous mucormycosis. A high index of clinical suspicion is required, especially in the absence of clinical improvement despite conventional methods of treatment, so that early diagnosis can be reached and the appropriate management instigated promptly in order to mitigate morbidity and mortality. Reversal of predisposing risk factors, regular extensive surgical debridement, and antifungal therapy remain the cornerstones of therapy for this life-threatening condition.

In vitro activity of tigecycline against isolates collected from complicated skin and skin structure infections and intra-abdominal infections in Africa and Middle East countries: TEST 2007-2012

Complicated skin and skin structure infections (cSSSIs) and intra-abdominal infections (IAIs) are problematic due to decreasing therapeutic options available against multidrug-resistant pathogens common among these types of infections. A total of 2245 isolates from African and the Middle Eastern (AfME) countries were collected to determine in vitro activity for tigecycline and comparators during 2007-2012 as part of the Tigecycline Evaluation Surveillance Trial program. Tigecycline was launched in the AfME in 2007 and remains active against a wide range of targeted pathogens worldwide. Isolates were recovered from cSSSI (1990) and IAI (255) from 38 sites in 11 AfME countries. Staphylococcus aureus was the most common species from cSSSI (27.9%), and the methicillin-resistant S. aureus rate was 25%. Enterococcus spp. (7.1%) and Streptococcus agalactiae (2.9%) were other common Gram-positive pathogens represented. Enterobacter spp. (14.5%), Pseudomonas aeruginosa (13.9%), Escherichia coli (11.4%), Klebsiella spp. (10.9%), and Acinetobacter spp. (7.2 %) were the most common Gram-negative species collected. Tigecycline MIC(90) values were 0.25 μg/mL against S. aureus. E. coli and Enterobacter spp. had tigecycline MIC(90) values of 1 and 2 μg/mL, respectively. E. coli was the most frequently collected species from IAI (28.3%), followed by Klebsiella spp. (20.8%), Enterococcus spp. (11.8%), and Stenotrophomonas maltophilia (6.3%). Isolates collected from IAI had the following tigecycline MIC(90) values: E. coli (1 μg/mL), Klebsiella spp. and other Enterobacteriaceae (2 μg/mL), Enterococcus spp. (0.25 μg/mL), and S. maltophilia (1 μg/mL). Tigecycline in vitro activity was observed against a broad spectrum of bacterial species, including strains resistant to other antimicrobial classes.

In VitroActivity of Linezolid and Other Antibiotics Against Gram-Positive Bacteria from the Major Teaching Hospitals in Kuwait

Multidrug-resistant Gram-positive bacteria are an increasingly pressing problem in the clinic. Consequently, linezolid, a recently introduced oxazolidinone with Gram-positive activity, was tested in comparison with 10 other antibiotics against 8103 clinically significant Gram-positive cocci by Etest, disk diffusion and Vitek methods. Linezolid demonstrated excellent activities against all isolates. Vancomycin and teicoplanin demonstrated equally excellent activity against almost all isolates. The methicillin-resistant Staphylococcus aureus (MRSA) strains were all susceptible to the glycopeptides and linezolid, but resistant to erythromycin (96%), fusidic acid (91.5%), gentamicin (84%) and clindamycin (73%). Forty one and 39% of the Streptococcus pneumoniae isolates were resistant to penicillin (MIC >0.5 microg/ml) and erythromycin (MIC >1 microg/ml), respectively. S. agalactiae susceptibility was 9% and 10% resistant to clindamycin and erythromycin, respectively. In conclusion, all the Gram-positive isolates tested were susceptible to linezolid. With its oral bioavailability profiles, it obviously holds great promise. Our data should be a useful addition to the literature from the Middle East.

High Frequency of Isolation of Antibiotic-Resistant Oral Viridans Streptococci from Children in Kuwait

Antimicrobial resistance among the Viridans group of streptococci (VGS) has emerged as a hindrance to effective antibiotic therapy. Our objective was to evaluate the prevalence of antibiotic-resistant VGS in healthy children. Plaque samples were collected from tooth and tongue surfaces of 102 healthy subjects. Serially diluted samples were inoculated onto BHI agar plates and Mitis Salivarius Agar (MSA) plates and incubated as appropriate. Representative colonies were identified to species level by standard methods. Susceptibility of the VGS was performed by determining the minimum inhibitory concentrations (MICs) of 11 antibiotics using Etest. Of the 540 VGS isolates from both sites, 58% were from the tooth surfaces and 42% from the tongue. The most prevalent were S. salivarius (21.5%) and S. sanguis (16.3%). Imipenem and vancomycin had excellent activities. Resistance rates to trimethoprim, amoxicillin, piperacillin, erythromycin, cefuroxime and cephalothin, were 60.7, 40.8, 34.7, 32.6, 27.5 and 25.3%, respectively. Resistance rates to penicillin and clindamycin were 15.9% and 15.4%, respectively. The majority of the erythromycin-resistant isolates were from the tongue; 41% versus 29%. At the species level, 26% and 23% of S. salivarius and 23% and 14% of S. mutans from the tooth and tongue, respectively were resistant to penicillin. The data show species-related and site-related variations in the susceptibility pattern and an emerging high prevalence of antibiotic-resistant VGS. The difference in the susceptibilities between the species underscores the importance of accurate-identification and the need for surveillance of antimicrobial resistance among clinical isolates in our hospitals.

Value of (1-3)-β-d-glucan, Candida mannan and Candida DNA detection in the diagnosis of candidaemia

This study determined the value of (1,3)-β-d-glucan (BDG), Candida mannan (MN) and Candida species-specific DNA as surrogates for diagnosis of candidaemia. Thirty-nine patients yielding Candida species in blood cultures were investigated for presence of BDG, MN and Candida species-specific DNA in serum samples. The Candida spp. bloodstream isolates included C. albicans (n = 16), C. tropicalis (n = 10), C. parapsilosis (n = 7), C. glabrata (n = 3) and C. dubliniensis (n = 3). Positivity of the three markers was as follows: Candida DNA for corresponding Candida species, 100%; BDG, 87%; MN, 59%. Despite varying sensitivities of these biomarkers, they provided a useful adjunct to the diagnosis of candidaemia.

Performance comparison of four methods for detecting multidrug-resistant Mycobacterium tuberculosis strains

SETTING

National Tuberculosis Reference Laboratory, Kuwait.

OBJECTIVE

To compare Genotype MTBDRplus (gMTBDR(+)), INNO-LiPA Rif.TB (INNO-LiPA), polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and DNA sequencing for detecting rifampicin (RMP) and/or isoniazid (INH) resistance-associated mutations in the rpoB hot-spot region (HSR-rpoB), the katG codon 315 (katG315) and the inhA regulatory region (inhA-RR) among multidrug-resistant Mycobacterium tuberculosis (MDR-TB) isolates.

DESIGN

A total of 82 MDR-TB and 43 pansusceptible M.tuberculosis BACTEC 460-characterised isolates were processed using molecular techniques and the Mycobacterial Growth Indicator Tube (MGIT) 960 system.

RESULTS

All susceptible strains contained wild-type sequences in target genes. RMP resistance was detected in respectively 78, 77 and 79 MDR-TB strains by gMTBDR(+), INNO-LiPA and HSR-rpoB sequencing. Two isolates with Ins514TTC mutation were detected as RMP-resistant by gMTBDR(+) but as RMP-susceptible by INNO-LiPA. One isolate with L533P mutation, detected as RMP-susceptible by gMTBDR(+), was detected as RMP-resistant by INNO-LiPA. Two of three isolates detected as RMP-susceptible by gMTBDR(+), INNO-LiPA, HSR-rpoB sequencing and the MGIT 960 system contained a I572F mutation that is outside HSR-rpoB. INH resistance was detected in respectively 76, 60, 60 and 22 MDR-TB strains by gMTBDR(+), katG315 PCR-RFLP, katG315 sequencing and inhA-RR sequencing.

CONCLUSIONS

Although gMTBDR(+) accurately detected ∼ 88% of MDR-TB strains, some rpoB mutations were either missed or were outside the region of analysis of the gMTBDR(+) assay.

Invasive pulmonary aspergillosis due to Aspergillus terreus: value of DNA, galactomannan and (1→3)-β-d-glucan detection in serum samples as an adjunct to diagnosis

A case of invasive pulmonary aspergillosis caused by Aspergillus terreus is described. The diagnosis was based on demonstration of branched septate hyphae in a sputum specimen and isolation of the fungus in culture. The diagnosis was further supported by detection of A. terreus-specific DNA, galactomannan (GM) and (1→3)-β-d-glucan (BDG) in consecutive serum specimens. The patient was treated for about 10 weeks with voriconazole. The decreasing levels of GM and BDG in serum samples were accompanied by symptomatic and radiological improvement. The report highlights the value of surrogate markers in the diagnosis and for monitoring the course of invasive aspergillosis during therapy.

Secular trends in susceptibility patterns of Mycobacterium tuberculosis isolates in Kuwait, 1996-2005

OBJECTIVE

To determine the incidence and trends of drug resistance among all Mycobacterium tuberculosis strains isolated during a 10-year period in Kuwait.

DESIGN

Drug susceptibility data for M. tuberculosis isolates recovered from all pulmonary and extra-pulmonary tuberculosis (TB) patients in Kuwait from January 1996 to December 2005 were collected and analysed. Patients were divided into Kuwaiti nationals and expatriates. Prior treatment status was not recorded.

RESULTS

From 1996 to 2005, 5399 non-repetitive culture-positive TB cases (56% from pulmonary sites and 44% from extra-pulmonary sites) among 917 (17%) Kuwaiti nationals and 4482 (83%) expatriates were identified throughout Kuwait. Overall resistance rates were as follows: any drug 12.5%, isoniazid (INH) 9.1%; rifampicin (RMP) 1.1%, ethambutol (EMB) 2.0%, streptomycin 4.3% and multidrug resistance (MDR) 0.9%. The resistance rates over the 10-year period remained nearly same. However, significant differences were noted in resistance rates for RMP and MDR among pulmonary vs. extra-pulmonary cases and for any drug, INH and EMB among isolates from Kuwaiti vs. expatriate patients.

CONCLUSIONS

Moderate and stable single drug resistance (<10%) and low MDR rates (<1%) were found among TB cases in Kuwait. These findings highlight the importance of ongoing control measures to limit the development and spread of drug-resistant M. tuberculosis in Kuwait.

Emergence and trends of penicillin non-susceptible Streptococcus pneumoniae in Saudi Arabia and Kuwait - perspective and outstanding issues

For many years in the past Streptococcus pneumoniae was uniformly susceptible to penicillin until the sudden and unexpected emergence of clinical infections caused by penicillin-resistant S. pneumoniae (PRSP) in 1967. Within the following decade, reports of nosocomial and community outbreaks of infections due to PRSP became widespread all over the world. Recent reports suggest that the incidence of resistance rates is rising in many countries although there are geographical variations in the prevalence and patterns of resistance between countries. The problem of antibiotic resistance is further compounded by the emergence of resistance to many beta-lactam antibiotics. The first report of PRSP in Saudi Arabia was in 1991. Barely a year after, PRSP infection was reported in Kuwait in 1992. Since then, studies from various parts of these countries have recorded prevalence rates ranging from 6.2% in Riyadh to 34% in Jeddah and 20% to 56% in neighboring Kuwait. These suggest considerable variation in the prevalence of PRSP in different cities in the Saudi Kingdom and Kuwait. The mechanism of resistance is due to chromosomally mediated alteration of penicillin-binding proteins (PBPs), which are target sites for beta-lactam antibiotics. It would appear that the spread of PRSP strains in Saudi Arabia is driven by the selective pressure created by excessive use and misuse of antimicrobial agents made possible by the easy availability of these agents, often frequently obtainable over the counter. In Kuwait, irrational and misguided use of antibiotics may be the major driving force favoring the spread of PRSP. The serotypes of strains encountered in Saudi Arabia and Kuwait are almost identical, with serotypes 19, 6, 15, 14 and 23 being the most common; together they constitute about 70% of the isolates circulating in these countries. In general, almost 90% of the serotypes included in the 23-polyvalent vaccine are present in the general population. However, a much lower percentage of these serotypes is found in the conjugated vaccines, which are more relevant to our communities. This paper reviews the emergence and the steady increase in the prevalence of penicillin-resistant pneumococcal strains in Saudi Arabia and Kuwait during the last 10 years. It discusses the trends, mechanisms of resistance and factors associated with the emergence, dissemination, and colonization of resistant organisms and suggests options available to clinicians for management of infections due to PRSP.

Frequency of embB codon 306 mutations in ethambutol-susceptible and -resistant clinical Mycobacterium tuberculosis isolates in Kuwait

SETTING

Recent reports of embB306 mutations in ethambutol-resistant and ethambutol-susceptible drug-resistant strains of Mycobacterium tuberculosis have questioned the significance of these mutations in conferring resistance to ethambutol (EMB).

OBJECTIVE

To determine the occurrence of embB306 mutations in all EMB-resistant and -susceptible drug-resistant M. tuberculosis strains isolated during a specified period at a single geographical location.

DESIGN

Twenty-five pansusceptible, all EMB-resistant and -susceptible M. tuberculosis strains resistant to other first-line drugs isolated in Kuwait during 2000-2003 were analyzed. The embB306 mutations were detected by PCR-restriction fragment length polymorphism and DNA sequencing. The PCR-based methods were also used for determining strain relatedness.

RESULTS

None of the pansusceptible M. tuberculosis strains contained a mutation at embB306. Fifteen of 50 (30%) EMB-resistant strains but only three of 122 (2%) EMB-susceptible isolates resistant to other first-line drugs contained a mutated embB306. The EMB-susceptible isolates with embB306 mutation were resistant to isoniazid plus other drug(s). The isolates carrying similar mutations were genotypically distinct strains.

CONCLUSIONS

The frequency of embB306 mutations in EMB-resistant strains compared to EMB-susceptible M. tuberculosis isolates resistant to other drugs was 15 times higher. Association of embB306 mutations in EMB-susceptible strains with isoniazid resistance and inherent problems associated with phenotypic EMB susceptibility testing suggest that these strains may actually be EMB-resistant.

Sunflower seed husk agar: a new medium for the differentiation of Candida dubliniensis from Candida albicans

A sunflower (Helianthus annuus) seed husk agar medium has been developed and evaluated for differentiation of Candida dubliniensis from Candida albicans on the basis of colony morphology and chlamydospore production. All C. dubliniensis isolates (n=40) produced rough colonies with hyphal fringes and abundant chlamydospores whereas 101 of 105 (96.2%) C. albicans isolates produced smooth colonies with no evidence of chlamydospore production. Since this medium is free from oil droplets, chlamydospores can be examined with greater clarity by Dalmau plate technique. This medium provides a simple and cost-effective tool for the presumptive differentiation of C. dubliniensis from C. albicans and is particularly suited for clinical microbiology laboratories where biochemical or molecular methods for the differentiation of these two species are not available.

Rapid detection of ethambutol-resistant Mycobacterium tuberculosis strains by PCR-RFLP targeting embB codons 306 and 497 and iniA codon 501 mutations

Mutations at embB gene codons 306 and 497 and iniA gene codon 501 occur frequently in ethambutol (EMB)-resistant Mycobacterium tuberculosis strains worldwide. The identification of these mutations in resistant strains has been achieved by labor-intensive DNA sequencing or by tedious amplification protocols followed by restriction endonuclease digestion. In this report, we describe PCR-restriction fragment length polymorphism (RFLP)-based methods for determining substitutions at embB codons 306 and 497 and iniA codon 501 directly in BACTEC cultures of M. tuberculosis isolates. The wild-type and mutant alleles are revealed by easily interpretable and different RFLP patterns. The methods optimized initially on reference strains were tested directly on BACTEC cultures of 25 randomly selected clinical M. tuberculosis isolates, seven of which were determined to contain EMB-resistant strains by phenotypic drug susceptibility testing. The PCR-RFLP methods identified mutations in four of seven EMB-resistant strains with three isolates containing mutated embB codon 306 and one isolate containing mutated embB codon 497. The results of PCR-RFLP were confirmed by DNA sequencing. The worldwide prevalence figures for mutations at embB codons 306 and 497 and iniA codon 501 suggest that nearly half of EMB-resistant M. tuberculosis strains could be identified within one working day even in developing countries equipped with simple PCR technology instead of weeks required for phenotypic drug susceptibility testing. Further, since EMB resistance is also associated with multiple-drug resistance from some geographical locations, detection of EMB resistance may also lead to rapid identification of multidrug-resistant strains of M. tuberculosis.

Simplified sunflower (Helianthus annuus) seed agar for differentiation of Candida dubliniensis from Candida albicans

This study evaluated sunflower (Helianthus annuus) seed agar (SSA) for differentiation of Candida dubliniensis from Candida albicans on the basis of colony characteristics and chlamydospore production. Simplified SSA without creatinine and KH(2)PO(4) was also used. On both media, C. dubliniensis isolates (n = 25) developed rough colonies and formed abundant chlamydospores after incubation for 24-48 h at 28 degrees C, while C. albicans isolates (n = 53) showed smooth colonies with no evidence of chlamydospore formation. Cryptococcus neoformans isolates (n = 10) formed brown colonies on both media. Simplified SSA offers a simple and inexpensive tool for presumptive differentiation of C. dubliniensis from C. albicans in clinical microbiology laboratories.

The prevalence and clonal diversity of penicillin-resistant Streptococcus pneumoniae in Kuwait

Penicillin-resistant Streptococcus pneumoniae (PRSP) is widespread all over the world, including countries previously free of PRSP. This study was undertaken to determine the prevalence, the common serotypes and the clonality of PRSP isolated over a period of 1 year, from various clinical samples from three major hospitals in Kuwait. Strains were identified by standard methods and their antibiotic susceptibility was determined by the agar dilution method. The clonality of the isolates was determined by repetitive extragenic palindromic sequence polymerase chain reaction (REP-PCR) genomic profiling and pulsed field gel electrophoresis (PFGE). Serotyping was done by Quellung reaction using specific antisera. We found that 55% of the S. pnuemoniae were resistant to penicillin (46% and 9% exhibited intermediate and full resistance, respectively). Nearly 41% were resistant to sulfamethoxazole-trimethoprim, 9% to cefotaxime and ceftriaxone, 15% to amoxycillin-clavulanate, 17% to cefuroxime, 77 % to cefaclor, and 14% to clindamycin. The commonest serotypes among the PRSPs were 6A, 6B, 14, 19F, 23F and nontypable. PFGE and REP-PCR patterns showed a large diversity of genetic clones of the PRSP. Serotypes 6B, 14, 19F and 23F were more clonally related than the others. Our data showed that the prevalence of PRSP was high, the serotypes were diversified and different genetic clones make up the population of circulating PRSP in Kuwait.

Staphylococcal septicaemia in burns

This study analyses staphylococcal septicaemia in a series of 1516 burn patients who were admitted to the burn unit of the Al-Babtain Centre for Burns and Plastic Surgery, Ibn Sina Hospital, Kuwait over a period of 6.5 years (1 June 1992-31 December 1998). One hundred and nine patients (7.2%) developed clinically and microbiologically proven septicaemia, of which 80 (73.4%) showed one or the other type of Staphylococcus in their blood. Fifty (62.5%) of them were males and 30 (37.5%) females, with a mean age of 26 years and the mean total body surface area of burns (TBSA) of 45% (range 1-93%). Preschool age children comprised 27.5% of the patients. Flame was the dominant (80%) cause of burn. Of the 80 patients who had 91 episodes of septicaemia, 52 (65%) had MRSA, 8 (10%) MSSA, 11 (13.8%) MRSE and 5 (6.2%) MSSE and 4 (5%) others had mixed organisms. Only the patients with MRSA had multiple episodes. Eight patients (10%) showed septicaemic episodes within only 48 h of admission; however, the majority of the patients (77.5%) had a septicaemic attack within 2 weeks postburn. Of the 52 MRSA septicaemic cases, 39 (75%) survived and 13 (25%) died. Four patients with septicaemia due to mixed infections died. A total of 19 patients were intubated, 14 due to inhalation injury and 5 because of septicaemia; all in the former group died. Glycopeptide therapy (vancomycin/teicoplanin) was instituted immediately following the detection of staphylococci in the blood. No significant difference was noted in relation to mortality amongst the septicaemic patients, whether or not on prophylactic antibiotic. Fifty-six (70%) of the 80 patients had 139 sessions of skin grafting and survived. Of the 52 MRSA patients, 40 had 101 sessions of skin grafting and 33 of them survived. The apparent low mortality was probably due to early detection of the organism, appropriate antibiotic therapy, care for nutrition and early wound cover. This study indicates a high incidence of staphylococcal septicaemia (especially due to MRSA) in the burn unit. A surface wound is the likely source of entry to the blood stream in these immunocompromised patients. The organism could be detected in blood as early as 48 h postburn and in as little TBSA burn as 1% in this MRSA endemic unit. Inhalation injury with major burns and added staphylococcal septicaemia invariably proved to be fatal.

Pseudomonas aeruginosa septicaemia in burns

Out of 1415 patients treated as inpatients at Al-Babtain Center for Burns and Plastic Surgery, Ibn Sina Hospital, Kuwait spanning over a period of 6 years from June 1992 to June 1998, 102 developed clinically and microbiologically proven septicaemia. Only 15 out of them had either single or multiple episodes of septicaemia due to Pseudomonas aeruginosa and were studied during their stay in the hospital. Five of them were males and 10 females, with a mean age of 26 years (range 3-51 years) and mean total body surface area of burns (TBSA) of 66% (range 25-90%). All of them had flame burns and resuscitation was found to be difficult in eight patients either due to delayed hospitalization or accompanied inhalation injury. Seven patients were intubated, four due to inhalation injury and three for septicaemic complications. Among the 15 patients under study, a total of 36 septicaemic episodes were detected of which 21 were due to P. aeruginosa. This organism was found in the first episodes in nine patients, in second episodes in six, in third episodes in three and fourth, fifth and sixth episodes in one patient, each at a variable postburn day. Ten patients had 38 sessions of excision and skin grafting, six of them survived. Nine of the 15 patients under study died due to septicaemia, but only six of them had P. aeruginosa as the last isolate. Except for one, all patients had > 40% TBSA burn, two had difficult resuscitation and four were intubated. The day of death varied between 3 to 52 days postburn (mean 19 days). This study showed that females with flame burns are susceptible to P. aeruginosa septicaemia. Difficult resuscitation and intubation also proved to be important risk factors. Septicaemia could occur quite early in the postburn days and the mortality due to this organism was quite high. Early excision and grafting with other effective management may result in a better outcome.

Rifampicin as an adjunct to vancomycin therapy in MRSA septicaemia in burns

Rifampicin has been successfully used as an adjunct to vancomycin therapy in several clinical conditions of MRSA infections such as endocarditis, ventriculoperitoneal shunts and septicaemia. However, very little information is available in the literature regarding its use in MRSA septicaemia in burns. The present prospective study was conducted to evaluate the efficacy of rifampicin as an adjunct therapy in burn cases with MRSA septicaemia not responding well to vancomycin. Fourteen out of 36 MRSA septicaemia patients with burns who either did not or only partially responded to therapeutic doses of vancomycin within 5-6 days were treated with rifampicin as an adjunct therapy (600 mg, i.v., o.d) for 5 days during the study period between January 1995 to December 1998. All the patients had burns due to flame and the TBSA varied between 20-90% with a mean of 64%. Eleven patients had deep and three had mixed burns. MRSA septicaemic episodes usually followed 2 3 days of detection of the organism in burn wounds. All the isolates were sensitive to vancomycin with an MIC of < or = 1.0 mg/L and were treated with vancomycin, (500 mg, i.v., 6 hourly). The serum vancomycin levels in all the patients were within the therapeutic range. However, blood cultures still remained positive even after 5-6 days of therapy. Institution of rifampicin, as an adjunct to vancomycin therapy to which the MRSA isolates were susceptible, showed a dramatic clinical response and survival of grafts. Thirteen patients survived and one died who had 70% deep burns and blood cultures revealed a multiresistant Acinetobacter in addition to MRSA. The present study thus confirms the efficacy of clinical use of rifampicin as an adjunct in vancomycin nonresponding cases of MRSA septicaemia in burns.

Burn septicaemia: an analysis of 79 patients

Out of 943 patients treated from June 92 to May 96 at the burns unit of the Al-Babtain Centre for Plastic Surgery and Burns, Kuwait, 280 (30%) required admission to the burns intensive care unit (ICBU) and were studied retrospectively. Seventy-nine (28.2%) developed clinically and microbiologically proven septicaemia. Forty-four (56%) were males, 35 (44%) females with a mean age of 26 years (range 45 days to 75 years) and mean total body surface area burn (TBSA) of 46% (range 10-90%). Sixty-two had flame burns, 16 a scald and one had an electric burn. These 79 patients had a total of 118 septicaemic episodes. Sixty (76%) had only one and 19 (24%) had multiple episodes of septicaemia. Fifty-four (68%) had their first episode within 2weeks, though the maximum number of episodes was between 6 and 10 days postburn. Septicaemia was also observed in 13% of patients within 3 days postburn. Out of the 118 episodes, 48 were due to methicillin resistant Staphylococcus aureus (MRSA), 17 due to methicillin resistant Staphylococcus epidemidis (MRSE), 15 to Pseudomonas, 12 to Acinetobacter, four to Streptococcus, another four to Enterococci, two to Klebsiella, one due to Serratia and 15 to more than one organism. Once the septicaemia was diagnosed appropriate therapy was instituted. Fifty-six (71%) patients had 143 sessions of skin grafting and the mortality was low in operated patients. Twenty-three (29.1%) patients died. The low mortality rate was probably due to factors such as continuous clinical and microbiological surveillance leading to quick detection of aetiology, appropriate antibiotic therapy, care for nutrition and early wound cover. This study suggests that flame burn patients are more vulnerable to sepsis. Onset of septicaemia may be as early as 3 days and commonly within 2 weeks. A surface wound is the likely source of entry to the blood stream. Gram positive organisms are dominant in the aetiology. Early detection and appropriate treatment including wound coverage result in a better outcome.

In vitro activity of piperacillin/tazobactam versus other broad-spectrum antibiotics against nosocomial gram-negative pathogens isolated from burn patients

Burn patients are at high risk for nosocomial infections due to multiresistant bacteria, a large proportion of which are gram-negative. Tazobactam, a potent inhibitor of beta-lactamases, extends the spectrum of piperacillin to include many beta-lactamase producing bacteria. Consequently, it was decided to evaluate the activity of piperacillin/tazobactam in comparison with that of eight other antibiotics that are usually used for therapy against gram-negative bacterial infections in our burn unit. All consecutive gram-negative isolates from wounds, blood, respiratory tract, urine etc. from burn patients considered to be clinically significant were tested for their susceptibility to piperacillin/tazobactam, piperacillin, ceftazidime, cefotaxime, ceftriaxone, ciprofloxacin, gentamicin, amikacin and imipenem, determined by disk diffusion test. The zone inhibition was interpreted according to NCCLS recommendations. A total of 948 strains, isolated during the period of July, 1994 to September, 1995, made up of Pseudomonas spp (326), Acinetobacter spp (268) and Enterobacteriaceae (354), were tested. Overall piperacillin/tazobactam showed superior activity over the other antibiotics except for imipenem. Of the 948 isolates, 87% were susceptible to the combination, 56% to the three third generation cephalosporins, 69% to ciprofloxacin, 59% to the aminoglycosides and 97% to imipenem. Piperacillin/tazobactam showed strikingly superior activity over piperacillin alone against Acinetobacter spp followed by Enterobacteriaceae and the least against Pseudomonas. The emergence of Acinetobacter spp as a dominant gram-negative pathogen in burn patients and its high level of resistance against most of the antibiotics tested except piperacillin/tazobactam (87%) and imipenem (100%) were significant in light of the epidemiology of burn infections and treatment. This study suggests that piperacillin/tazobactam holds good promise against gram-negative infections in burn patients.

Endocarditis due to Aspergillus flavus

Fungal endocarditis has emerged as an important complication of patients undergoing cardiovascular surgery. Our patient had no past history of cardiac surgery, intravenous drug abuse or immunosuppressive therapy. He had received broad-spectrum antibiotics for varying periods, which might have predisposed him to this infection. The diagnosis was based on the demonstration of hyaline, septate branched fungal elements in the infected valvular tissue and isolation of Aspergillus flavus in culture. The delay in establishing the ante-mortem diagnosis because of repeatedly negative blood cultures, presence of disseminated intravascular coagulopathy and rapidly deteriorating kidney function were the major factors contributing to his poor prognosis and death, despite surgical removal of infected valves and antifungal therapy. This is the first report of endocarditis due to A. flavus from the Middle East.