Antimicrobial resistance and carbapenemase dissemination in Pseudomonas aeruginosa isolates from Libyan hospitals: a call for surveillance and intervention

Pseudomonas aeruginosa is a multidrug-resistant bacterium capable of forming biofilms. This study aimed to assess resistance of clinical isolates from Libyan hospitals to antipseudomonal antibiotics, the prevalence of selected extended-spectrum β-lactamases and carbapenemase genes among these isolates, and the microorganisms' capacity for alginate and biofilm production. Forty-five isolates were collected from four hospitals in Benghazi and Derna, Libya. Antimicrobial susceptibility was determined using agar disc diffusion. The presence of resistance genes (blaCTXM, blaTEM, blaSHV-1, blaGES-1, blaKPC, and blaNDM) was screened using PCR. Biofilm formation was quantified via the crystal violet assay, while alginate production was measured spectrophotometrically. Resistance to antipseudomonal antibiotics ranged from 48.9% to 75.6%. The most prevalent resistance gene was blaNDM (26.7%), followed by blaGES-1 (17.8%). Moreover, all isolates demonstrated varying degrees of biofilm-forming ability and alginate production. No statistically significant correlation was found between biofilm formation and alginate production. The dissemination of resistant genes in P. aeruginosa, particularly carbapenemases, is of great concern. This issue is compounded by the bacteria's biofilm-forming capability. Urgent intervention and continuous surveillance are imperative to prevent further deterioration and the catastrophic spread of resistance among these formidable bacteria.

Phenotypic ESBL and non-phenotypic ESBL isolates of Klebsiella pneumoniae exhibit differing responses to induced antimicrobials resistance and subsequent antibiotic cross-resistance

AIM

To investigate the effect of adapting Klebsiella pneumoniae clinical isolates harboring ESBL genes to cetrimide (CT) in terms of subsequent cross-resistance to other biocides and antibiotics, and to investigate changes to virulence markers, such as biofilm formation and efflux activity. The changes between phenotypic extended spectrum β-lactamases (pESBL) expressing isolates and non-phenotypic ESBL (npESBL) isolates was compared.

METHODS AND RESULTS

Kl. pneumoniae isolates (14 pESBL and 17 npESBL) were adapted to increasing concentrations of CT, until 4 × MIC was reached. The MIC of the adapted isolates was tested against chloroxylenol (CX) and chlorhexidine. Disk diffusion techniques were used to determine the susceptibility of the isolates to different antibiotics. Biofilm formation was assessed for the isolates using the crystal violet method and efflux pump activity was studied using the ethidium bromide assay. After CT adaptation, 100% of npESBL isolates and 85.7% of pESBL isolates showed increase in CT MIC after CT adaptation. While 41.2% of npESBL and 57.1% of the pESBL isolates showed a cross-resistance with chlorhexidine. CT adaptation resulted in a significant decrease in the susceptibility of npESBL isolates to aztreonam and cefotaxime compared to pESBL isolates, which could be linked to the increase in efflux activity of npESBL compared to pESBL. Biofilm formation was significantly increased after CT adaptation regardless of the type of isolate.

CONCLUSIONS

The extensive use of biocides in the environment can induce cross-resistance to other biocides and antibiotics, and can increase the ability of bacteria to form biofilms. The response of bacteria to biocide adaptation differs between pESBL and npESBL isolates, although the effect is strain specific.

Changes in drug demand when a pandemic coincides with other outbreaks in a war zone country: a cross-sectional pilot study

BACKGROUND

Yemen's health system has severely deteriorated due to the ongoing civil war accompanied by the COVID-19 pandemic which coincided with other outbreaks of endemic infections. Many health institutions closed due to insufficient equipment and supplies. Consequently, pharmacists became the available healthcare provider on the frontlines. This study aimed to evaluate the pattern of demand for prescription and nonprescription drugs during the pandemic based on the pharmacist's perspective in Yemen, a conflict zone country.

METHODS

An online survey was developed, validated, and distributed among pharmacists. The questionnaire was composed of two sections: (1) demographic characteristics of the participants and (2) changes in the demand for different drug categories. Chi-square test and Fisher's exact test were used to find statistical associations.

RESULTS

Responses (330) were received from pharmacists working in 12 out of 22 governorates in Yemen. During the pandemic, there was an increase in the demand for prescription drugs such as antibiotics, antimalarials, and sedatives (95%, 90%, and 71%, respectively) and an increase in the demand for nonprescription drugs such as vitamins (93%) and paracetamol (> 90%). Some of these drugs could have serious side effects if taken without medical advice, and others could result in severe effects if taken concomitantly. In addition, there was an increase in the demand for prescription drugs without a prescription, which was reported by 50% of the participants. No statistical difference was seen between the frontline districts and major cities in terms of requesting these drugs without a prescription. On the other hand, most participants (75.2%) did not attend any training or workshop during the last 6 months of conducting this survey.

CONCLUSION

COVID-19 has increased the demand for many prescription and nonprescription drugs, where the irrational use of these drugs may lead to devastating health effects. In war zone areas hit by a pandemic, policymakers and public health organizations should focus on training and educating pharmacists as important health care and medicine providers for the public.

Prevalence and predictors of self-medication drugs to prevent or treat COVID-19: Experience from a Middle Eastern country

BACKGROUND

The lack of definitive cure for COVID-19 and the late introduction of a vaccine were responsible to push the general public to look for a remedy to treat or prevent COVID-19. The objective of this study was to evaluate patterns and factors that affect self-medication practices in Jordan during the pandemic.

METHODS

This was a cross-sectional study using an online questionnaire that was developed, piloted and distributed to the general public via various social media platforms. The questionnaire assessed the type of drugs and treatments used to self-medicate, the reasons behind their self-medication, and the factors affecting their practices.

RESULTS

A total of 1179 participants (females 46.4%) with a mean age of 32 (SD = 12.5) completed the questionnaire. The overall prevalence of the use of at least one product to treat or prevent COVID-19 was 80.4%. The most commonly used products to self-medicate were vitamin C (57.6%), followed by paracetamol (51.9%), zinc (44.8%) and vitamin D (32.5%). Female gender (odds ratio [OR]) = 1.603, working in the medical field (OR = 1.697), and history of COVID-19 infection (OR = 2.026) were variables associated with self-medication. The most common sources of participants' information about drugs to prevent or treat COVID-19 were newspapers (n = 519, 44.0%), followed by pharmacists (43.4%), friends (33.8%) and internet searching such as Google (30.7%).

CONCLUSION

This study identified the main drugs and supplements used during COVID-19 and the motives behind their use. It also identified the most influential source of information on the public during the pandemic. Self-medication can lead to worsening of the patient's health and delay seeking medical advice from healthcare professionals. Efforts should be done to help mitigate risks of self-medications by active involvement of pharmacists and other members of healthcare team to refute false claims about drug, especially in the media.

Before and after case reporting: A comparison of the knowledge, attitude and practices of the Jordanian population towards COVID-19

Coronavirus disease- 2019 (COVID-19) is an emerging contagious infectious disease. It is pandemic and has affected more than 21 million people and resulted in more than 750,000 deaths worldwide (https://www.worldometers.info/coronavirus/#countries; 14/08/20). Our research group initiated a study to ascertain the knowledge, attitude and practices (KAP) of Jordanians toward COVID-19 prior to any initial case report in Jordan. This project was underway when the first Jordanian case was reported. We extended our study to identify how case reporting would alter public KAP towards COVID-19. This cross-sectional study randomly selected and recruited 2104 Jordanian adults. A four-section questionnaire was devised to address the sociodemographic characteristics of the subjects and their KAP toward COVID-19. The mean knowledge score for the study population was 15.9 ± 2.2 (out of the 20 knowledge questions), with 60.9% of the participants having good knowledge about COVID-19. Participants’ practices to prevent transmission of COVID-19 were adequate in more than 60% of participants. Most participants had positive attitudes regarding their role in preventing COVID-19 and many of the participants’ attitudes and practices changed to more appropriate ones after reporting the first case of COVID-19 in Jordan. The percentage of participants who trust the government in confronting COVID-19 increased significantly (p value < 0.001). However, one alarming and unexpected finding was that the prevention practice score of participants working in the medical field was similar to those from the general population. This may necessitate stricter training and guidelines for this group who will be in the frontline in combating the disease. Impact of this study: The data generated from this study shows that when cases of disease were reported, the public’s attitudes and practices improved in many aspects, and that confidence in the government to contain the disease was boosted. We believe that this study is important in allowing other, international governments to develop an understanding of public KAP during pandemic disease outbreaks.

COVID-19: Between Past and Present

Since the WHO declared coronavirus disease 2019 (COVID-19) as a pandemic, huge efforts were made to understand the disease, its pathogenesis, and treatment. COVID-19 is caused by severe acute respiratory syndrome (SARS) coronavirus-2 (SARS-CoV2), which is closely related to SARS-associated coronavirus (SARS-CoV). This article attempts to provide a timely and comprehensive review of the coronaviruses over the years, and the epidemics they caused in this century with a focus on the current pandemic COVID-19. It also covers the basics about the disease immunopathogenesis, diagnosis, prognosis, and treatment options. Although almost every single week new clinical findings are published, which change our understanding of COVID-19, this review explores and explains the disease and the treatment options available so far. In summary, many therapeutic options are being investigated to treat and/or ameliorate the symptoms of COVID-19, but none is registered and no sufficient data to support immune-based therapy beyond the context of clinical trials. For that, strengthening our immune system is the best defense at this time.

Investigating possible association between multidrug resistance and isolate origin with some virulence factors of Escherichia coli strains isolated from infant faeces and fresh green vegetables

AIMS

In this study, the association between multidrug resistance (MDR) and the expression of some virulence factors were evaluated in Escherichia coli strains isolated from infant faeces and fresh green vegetables. The effect of isolate origin on associated virulence factors was evaluated. In addition, genetic fingerprinting of a sample of these isolates (10 isolates from each group) was studied in order to detect any genetic relatedness among these isolates.

METHODS AND RESULTS

Escherichia coli isolates were divided into four groups based on their origin (human faeces or plant) and their antibiotic resistance (multiresistance or susceptible). PCR was used to investigate heat-labile and heat-stable enterotoxin genes, and four siderophore genes (aerobactin, enterobactin, salmochelin and yersiniabactin). Genetic fingerprinting of the isolates was performed using enterobacterial repetitive intergenic consensus PCR. Siderophore production was measured by a colorimetric method. Biofilm formation was evaluated by a crystal violet assay. The results of the study showed that the expression of MDR is not significantly associated with an increase in these virulence factors or with biofilm formation. However, the origin of isolates had a significant association with siderophore gene availability and consequently on the concentrations of siderophores released. Genetic fingerprinting indicated that human and plant isolates have the same clonal origin, suggesting their circulation among humans and plants.

CONCLUSION

Antibiotic-susceptible strains of E. coli may be as virulent as MDR strains. Results also suggest that the environment can play a potential role in selection of strains with specific virulence factors.

SIGNIFICANCE AND IMPACT OF THE STUDY

Antibiotic-susceptible isolates of Escherichia coli from plant or human origin can be as virulent as the multidrug resistance (MDR) ones. Genetic relatedness was detected among the isolates of plant and human origin, indicating the circulation of these bacteria among human and plants. This could imply a potential role for environmental antimicrobial resistant bacteria in human infection.

Evaluation of antibiotic dispensing practice in community pharmacies in Jordan: A cross sectional study

It is well known that the emergence of antibiotic resistance is linked to the misuse and overuse of antibiotics. Misuse includes self-medication and the inappropriate use of antibiotics because of improper dosage or improper duration than recommended. This study investigated three patterns of dispensing antibiotics in a sample of community pharmacies in Jordan. This included dispensing antibiotics by prescription or over-the-counter either by direct request or upon a pharmacist’s recommendation. The antibiotics dispensed were evaluated in terms of indication, appropriateness of dose, and duration of treatment based on the empirical treatment suggested by selected references: Lexicomp (2017) and UptoDate (2017) and the manufacturer’s recommendations. Of the 457 antibiotics dispensed, almost one third were without prescription. Of the antibiotics dispensed with prescription or without prescription, 31.5% and 24.6% respectively were appropriate dosage and duration (p = 0.002). In the three patterns of dispensing, beta lactam antibiotics were the most commonly dispensed. In addition, it was noticed that there was a tendency to prescribe or dispense higher generations of antibiotics to cases that could have been treated with lower generation or safer antibiotics. Furthermore, 12.2% of the antibiotics were dispensed to treat infections that are not indicated for them. In conclusion, a significant proportion of antibiotics are dispensed without prescription in Jordan. Moreover, a considerable proportion of prescribed antibiotics were inappropriate for the conditions concerned. This indicates the importance of enforcing the Jordanian regulations prohibiting the dispensing of nonprescription antibiotics and the implementation of continuous education to physicians and pharmacists to increase awareness about the emergence of antibiotic resistance.

Influenza Vaccination Coverage Rates, Knowledge, Attitudes, and Beliefs in Jordan: A Comprehensive Study

Influenza vaccination is the most effective method in preventing influenza and its complications. This study's objectives were to investigate the vaccination coverage and frequency and to assess knowledge, attitudes, and practices toward influenza vaccination in Jordan during the year 2012 and the 5 years preceding it. Additionally, it aimed at identifying the barriers and motivations to receive the vaccine and the factors contributing to its uptake. In May 2012, a self-administered cross-sectional survey was distributed to 3,200 adults conveniently selected across Jordan to explore influenza vaccination status, knowledge, attitudes, and practices toward the influenza vaccine. The survey response rate was 98.3%. The overall coverage rate of seasonal influenza vaccination ranged from 9.9% to 27.5%. Results of the univariate analysis revealed that males, participants older than 45 years, business owners, and university students or graduates were more likely to take the vaccine. Healthcare workers (HCW) showed higher rates than non-HCW and those with concomitant chronic diseases were more committed to receive the vaccine. Knowledge about the influenza vaccine is considered high in the Jordanian population. Fear from side effects was the major barrier, while the fear of the virus spread and outbreak was the major reason to receive the vaccine. The coverage rates were low in Jordan compared to other countries. The need for influenza vaccine campaigns and on-going education in Jordan health schools is crucial to increase the rate and remove misconceptions and negative attitudes toward vaccination.

Antimicrobial and anti-inflammatory potential therapy for opportunistic microorganisms

Introduction: Methanolic extracts of six plants (Arbutus andrachne, Chrysanthemum coronarium, Inula viscosa, Origanum syriacum, Punica granatum, and Rosmarinus officinalis) used in traditional medicine for the treatment of bacterial and fungal infections were evaluated. The present study was conducted to evaluate the antimicrobial and anti-inflammatory activity of some medicinal plants in lowering the risk of opportunistic infections of the oral cavity caused by Staphylococcus aureus, Pseudomonas aeruginosa, and Candida albicans. Extracts were evaluated separately and in a mixture. Methodology: The methanolic plant extracts were tested against three opportunistic microorganisms by determining the minimum inhibitory concentration (MIC). They were also evaluated for their ability to suppress the release of the pro-inflammatory cytokine IL-6 while not suppressing the release of the anti-inflammatory cytokine IL-10 from peripheral blood mononuclear cells using ELISA. Results: All extracts showed both antimicrobial and anti-inflammatory activities. However, O. syriacum exhibited the highest antimicrobial activity for the three microorganisms among all of the tested extracts (MIC S. aureus: 1 mg/mL; P. aeruginosa: 2 mg/mL; and C. albicans: 1 mg/mL). The extracts inhibited the expression of the pro-inflammatory cytokine IL-6 with apparent dose-dependent responses while they attenuated the secretion of the anti-inflammatory cytokine IL-10. The mixture of O. syriacum and R. officinalis showed an anti-inflammatory effect, with a synergistic antimicrobial effect. Conclusion: These findings support the idea that a diet rich in plants and herbs may contribute to the reduction of inflammation and microbial growth and may also be preventive against various infections, including those related to the oral cavity.

Occupational exposure of pharmaceutical workers to drug actives and excipients and their effect on Staphylococcus spp. nasal carriage and antibiotic resistance

BACKGROUND

Pharmaceutical manufacturing workers are exposed to significant amounts of product ingredients, including antibiotics. Such exposure could affect their nasal microflora.

OBJECTIVE

To assess the effect of exposure to various unidentified pharmaceutical ingredients in cephalosporin-manufacturing and non-cephalosporin plants on the nasal carriage of Staphylococcus spp. and their antibiotic resistance.

METHODS

Nasal swab samples were collected from 39 workers in both plants on three different occasions. Staphylococci were isolated and identified to genus level. Antibiotic resistance profiles were determined and subsequent identification to species level was performed.

RESULTS

There was complete absence of S. aureus in the samples collected from workers in both facilities. Multiple drug resistant coagulase-negative staphylococci (MDR CONS) prevalence rates were higher in the non-cephalosporin plant than in the cephalosporin plant, with resistance towards six classes of antibiotics. S. epidermidis was the prevalent species in the non-cephalosporin plant and S. haemolyticus prevailed in the cephalosporin-producing plant.

CONCLUSIONS

The observed prevalence of CONS in both production plants was the same. However, exposure to intermittent non-cephalosporin pharmaceuticals results in higher prevalence of MDR CONS compared to continuous exposure to cephalosporin.

Anti-cancer, anti-inflammatory and anti-microbial activities of plant extracts used against hematological tumors in traditional medicine of Jordan

ETHNOPHARMACOLOGICAL RELEVANCE

Mercurialis annua L., Bongardia chrysogonum L., and Viscum cruciatum Sieb have been traditionally used by local herbalists in Jordan for the treatment of hematopoietic neoplasms.

AIM OF THE STUDY

To determine the anti-cancer, anti-inflammatory and anti-microbial potentials of the three extracts against two of the most common hematopoietic malignancies in the Jordanian populations; Burkitt's lymphoma and Multiple myeloma.

MATERIALS AND METHODS

The anti-cancer activity was tested against the two cell lines (BJAB Burkitt's lymphoma and U266 multiple myeloma) using the MTT and trypan blue assays. The agar dilution assay was used to study the anti-microbial activity against Gram-positive bacteria, Gram-negative bacteria, anaerobic bacteria and yeast. The pro-inflammatory cytokines interleukin (IL) -1β, IL-8 and tumor necrosis factor-α (TNF-α) were measured in the pretreated cell lines using ELISA assay to determine the anti-inflammatory activity of Viscum cruciatum Sieb against the two cell lines.

RESULTS

The results show no evidence of stimulation of tumor growth by any of the three extracts comprising cell lines from hematological malignancies, but Viscum cruciatum Sieb showed a selective anticancer activity against BJAB cells, with IC(50) value of 14.21μg/ml. The antimicrobial effect was only noticed with Viscum cruciatum extract by inhibiting Staphylococcus aureus, Candida albicans and Propionibacterium acne, but not Pseudomonas aeruginosa at MIC of 1.25, 1.25, 0.625 and <5mg/ml, respectively. The highest activity was against the anaerobic bacteria Propionibacterium acne. Viscum cruciatum Sieb extract showed an inhibitory effect on the pro-inflammatory cytokine IL-8, but it increased TNF-α and IL-1β secretions in BJAB cells. Whereas, it had an inhibitory effect on TNF-α and IL-1β cytokines while it enhanced IL-8 secretions in U266 cells.

CONCLUSION

Among the three tested herbal extracts used in the traditional medicine in Jordan, only Viscum cruciatum Sieb showed high anti-cancer and anti-microbial potentials. They also had an anti-inflammatory effect. These observations raise the prospects of using Viscum cruciatum Sieb for treatment of diseases associated with some bacterial and fungal infections, for imbalanced cytokine production and for enhancing cancer and other immunotherapies.

Preparation of Silver- and Zinc-Doped Mullite-Based Ceramics Showing Anti-Bacterial Biofilm Properties

Zinc- and silver-doped mullite ceramic discs were prepared and tested as potentially resistant materials against bacterial adhesion and biofilm formation. Elemental analysis and X-ray diffraction studies showed that zinc ions were incorporated in the structural framework of the mullite, while silver ions remained outside the mullite crystal lattice, which allowed their slow (0.02 ppm/24 hours) leaching into the surrounding aqueous environment. In agreement with this behavior, silver-doped mullite showed potent resistance against surface attachment of Pseudomonas aeruginosa, while on the other hand, zinc-doped mullite failed to stop bacterial attachment.

Multiple drug resistance and strength of attachment to surfaces in Pseudomonas aeruginosa isolates

AIMS

To investigate the presence of a relationship between the strength of attachment of Pseudomonas aeruginosa to stainless steel surfaces and their observed multiple drug resistance.

METHODS AND RESULTS

Multiple drug resistance of clinical and environmental isolates of Ps. aeruginosa was evaluated using disc diffusion method. The blot succession technique was used to quantify the strength of attachment of Ps. aeruginosa isolates. Different multiple drug-resistant Ps. aeruginosa isolates exhibited variable attachment strength. Although the highest multiple drug-resistant clinical isolate was shown to have the least attachment strength among clinical isolates, a weak correlation was found between attachment strength and multiple resistance among our investigated Ps. aeruginosa isolates.

CONCLUSIONS

There is a weak correlation between multiple drug resistance and strength of attachment to stainless steel surfaces.

SIGNIFICANCE AND IMPACT OF THE STUDY

Even low-resistant Ps. aeruginosa could have the potential of attaching firmly to surfaces and forming biofilm.