Aiman El-Saed

The results of a 6-year epidemiologic surveillance for ventilator-associated pneumonia at a tertiary care intensive care unit in Saudi Arabia.

BACKGROUND Ventilator-associated pneumonia (VAP) prevention is an important patient safety initiative. We describe the impact of a multidisciplinary surveillance program on VAP rates in a tertiary medical-surgical-trauma intensive care unit (ICU). METHODS An epidemiologic surveillance program was established in 2003 as a joint project between ICU and Infection Prevention and Control Department to regularly report VAP rates to guide evidence-based VAP preventive strategies. VAP cases were diagnosed according to predefined criteria and prospectively recorded by a research physician. VAP microbiology, risk factors, and outcomes were noted. RESULTS Of 2,812 ventilated patients, 433 (15.4%) developed VAP corresponding to 15.9 episodes per 1,000 ventilator-days. The rate decreased from 19.1 in 2003 to 6.3 per 1,000 ventilator-days in 2009. On multivariate analysis, VAP was associated with accidental extubation (hazard ratio [HR], 4.11; 95% confidence interval [CI]: 1.93-8.73), trauma versus medical diagnosis (HR, 2.59; 95% CI: 2.07-3.23), chronic obstructive pulmonary disease (HR, 1.55; 95% CI: 1.08-2.22), and neuromuscular blockade (HR, 1.39; 95% CI: 1.07-1.81). The most common isolated pathogens were Gram-negative organisms. VAP patients had longer mechanical ventilation duration, ICU and hospital length of stay, but similar ICU and hospital mortality compared with non-VAP patients. CONCLUSION The study showed a reduction in VAP rates with active surveillance, reporting and evidence-based preventive strategies and identified several modifiable risk factors, which should be the focus of additional interventions.

Acinetobacter is the most common pathogen associated with late-onset and recurrent ventilator-associated pneumonia in an adult intensive care unit in Saudi Arabia.

BACKGROUND The guidelines for initial empiric antimicrobial therapy for ventilator-associated pneumonia (VAP) are highly dependent on the type of causative pathogen and the time of diagnosis. The objective of this study was to examine the microbial causes of VAP and describe any variability by the timing of VAP onset and over time. METHODS A prospective surveillance study was conducted in the adult general intensive care unit of a tertiary care hospital in Riyadh, Saudi Arabia. Microbial isolates obtained from blood and different respiratory specimens of patients diagnosed with VAP (using the US Centers for Disease Control and Prevention definition) between August 2003 and June 2009 were included. RESULTS A total of 457 pathogens were identified during the study; 380 (83.2%) were associated with primary VAP and 77 (16.8%) were associated with recurrent VAP. Of primary VAP pathogens, 159 (41.8%) were associated with early-onset (<5 days) and 221 (58.2%) were associated with late-onset (≥5 days) VAP. The most common pathogen identified was Acinetobacter spp (26.5%), followed by Pseudomonas aeruginosa (21.7%), Staphylococcus aureus including methicillin-resistant S. aureus (MRSA) (15.3%), Klebsiella spp (6.8%), Haemophilus spp (6.1%), and Enterobacter spp (5.0%). Acinetobacter spp and MRSA were significantly associated with late-onset VAP while Haemophilus spp and Streptococcus pneumoniae were significantly associated with early-onset VAP. Acinetobacter spp was the only pathogen associated with recurrent VAP and its incidence showed a significant increasing trend during the study period. Acinetobacter spp was significantly associated with prolonged ventilation, sedation, and nasogastric intubation. CONCLUSIONS Acinetobacter baumannii is the most common and increasingly important pathogen associated with VAP in our patients, especially late-onset and recurrent VAP.

Description of a Hospital Outbreak of Middle East Respiratory Syndrome in a Large Tertiary Care Hospital in Saudi Arabia.

BACKGROUND Since the first isolation of Middle East respiratory syndrome coronavirus (MERS-CoV) in Saudi Arabia in 2012, sporadic cases, clusters, and sometimes large outbreaks have been reported. OBJECTIVE To describe the recent (2015) MERS-CoV outbreak at a large tertiary care hospital in Riyadh, Saudi Arabia. METHODS We conducted an epidemiologic outbreak investigation, including case finding and contact tracing and screening. MERS-CoV cases were categorized as suspected, probable, and confirmed. A confirmed case was defined as positive reverse transcription polymerase chain reaction test for MERS-CoV. RESULTS Of the 130 suspected cases, 81 (62%) were confirmed and 49 (38%) were probable. These included 87 patients (67%) and 43 healthcare workers (33%). Older age (mean [SD], 64.4 [18.3] vs 40.1 [11.3] years, P<.001), symptoms (97% vs 58%, P<.001), and comorbidity (99% vs 42%, P<.001) were more common in patients than healthcare workers. Almost all patients (97%) were hospitalized whereas most healthcare workers (72%) were home isolated. Among 96 hospitalized cases, 63 (66%) required intensive care unit management and 60 (63%) required mechanical ventilation. Among all 130 cases, 51 (39%) died; all were patients (51 [59%]) with no deaths among healthcare workers. More than half (54%) of infections were believed to be caught at the emergency department. Strict infection control measures, including isolation and closure of the emergency department, were implemented to interrupt the chain of transmission and end the outbreak. CONCLUSION MERS-CoV remains a major healthcare threat. Early recognition of cases and rapid implementation of infection control measures are necessary. Infect Control Hosp Epidemiol 2016;1–9

Epidemiology of H1N1 (2009) Influenza among Healthcare Workers in a Tertiary Care Center in Saudi Arabia: A 6-Month Surveillance Study

BACKGROUND Certain emerging infections, such as severe acute respiratory syndrome and avian influenza, represent a great risk to healthcare workers (HCWs). There are few data about the epidemiology of H1N1 influenza among HCWs. METHODS We conducted a prospective surveillance study for all HCWs at King Abdulaziz Medical City (Riyadh, Saudi Arabia) who were confirmed positive for H1N1 influenza by polymerase chain reaction (PCR) from June 1 through November 30, 2009. RESULTS During 6 months of surveillance, 526 HCWs were confirmed positive for H1N1 influenza. The distribution of these cases showed 2 clear outbreaks: an initial outbreak (peak at early August) and a shorter second wave (peak at end of October). Among all PCR-confirmed cases, the attack rate was significantly higher in clinical HCWs than in nonclinical HCWs (6.0% vs 4.3%; P < .001) and in HCWs in emergency departments than in HCWs in other hospital locations (17.4% vs 5.0%, P < .001). The percentage of HCWs who received regular influenza vaccination was greater for clinical HCWs than for nonclinical HCWs (46.2% vs 24.6%; P < .001). The majority of HCWs with confirmed H1N1 influenza were young (mean age + or - standard deviation, 34.5 + or - 9.5 years), not Saudi (58.4%), female (55.1%), and nurses (36.1%). Approximately 4% of women who were less than 50 years old were pregnant. Reported exposures included contact with a case (41.0%), contact with a sick household member (23.8%), and recent travel history (13.3%). Respiratory symptoms (98.0%), including cough (90.1%), were the most frequently reported symptoms, followed by muscle aches (66.2%), fever (62.5%), headache (57.9%), diarrhea (16.5%), and vomiting (9.8%). None of these HCWs died, and all recovered fully without hospital admission. CONCLUSIONS The results confirm the vulnerability of HCWs, whether clinical or nonclinical, to emerging H1N1 influenza.

The strategic plan for combating antimicrobial resistance in Gulf Cooperation Council States.

The Gulf Cooperation Council Center for Infection Control (GCC-IC) has placed the emergence of antimicrobial resistance (AMR) on the top of its agenda for the past four years. The board members have developed the initial draft for the GCC strategic plan for combating AMR in 2014. The strategic plan stems from the WHO mandate to combat AMR at all levels. The need for engaging a large number of stakeholders has prompted the GCC-IC to engage a wider core of professionals in finalizing the plan. A multi-disciplinary group of more than 40 experts were then identified. And a workshop was conducted in Riyadh January 2015 and included, for the first time, representation of relevant ministries and agencies as well as international experts in the field. Participants worked over a period of two and a half days in different groups. International experts shared the global experiences and challenges in addressing human, food, animal, and environmental aspects of controlling AMR. Participants were then divided into 4 groups each to address the human, animal, microbiological and diagnostic, or the environmental aspect of AMR. At the end of the workshop, the strategic plan was revised and endorsed by all participants. The GCC-IC board members then approved it as the strategic plan for AMR. The document produced here is the first GCC strategic plan addressing AMR, which shall be adopted by GCC countries to develop country-based plans and related key performance indicators (KPIs). It is now the role of each country to identify the body that will be accountable for implementing the plan at the country level.

Benchmarking local healthcare-associated infections: Available benchmarks and interpretation challenges

Growing numbers of healthcare facilities are routinely collecting standardized data on healthcare-associated infection (HAI), which can be used not only to track internal performance but also to compare local data to national and international benchmarks. Benchmarking overall (crude) HAI surveillance metrics without accounting or adjusting for potential confounders can result in misleading conclusions. Methods commonly used to provide risk-adjusted metrics include multivariate logistic regression analysis, stratification, indirect standardization, and restrictions. The characteristics of recognized benchmarks worldwide, including the advantages and limitations are described. The choice of the right benchmark for the data from the Gulf Cooperation Council (GCC) states is challenging. The chosen benchmark should have similar data collection and presentation methods. Additionally, differences in surveillance environments including regulations should be taken into consideration when considering such a benchmark. The GCC center for infection control took some steps to unify HAI surveillance systems in the region. GCC hospitals still need to overcome legislative and logistic difficulties in sharing data to create their own benchmark. The availability of a regional GCC benchmark may better enable health care workers and researchers to obtain more accurate and realistic comparisons.

Drug-resistant ventilator associated pneumonia in a tertiary care hospital in Saudi Arabia

BACKGROUND: There is a wide geographic and temporal variability of bacterial resistance among microbial causes of ventilator-associated pneumonia (VAP). The contribution of multi-drug resistant (MDR) pathogens to the VAP etiology in Saudi Arabia was never studied. We sought to examine the extent of multiple-drug resistance among common microbial causes of VAP. MATERIALS AND METHODS: We conducted a retrospective susceptibility study in the adult intensive care unit (ICU) of King Abdulaziz Medical City, Riyadh, Saudi Arabia. Susceptibility results of isolates from patients diagnosed with VAP between October 2004 and June 2009 were examined. The US National Healthcare Safety Network definition of MDR was adopted. RESULTS: A total of 248 isolates including 9 different pathogens were included. Acinetobacter spp. was highly (60-89%) resistant to all tested antimicrobials, including carbapenems (three- and four-class MDR prevalence were 86% and 69%, respectively). Pseudomonas aeruginosa was moderately (13-31%) resistant to all tested antimicrobials, including antipseudomonal penicillins (three- and four-class MDR prevalence were 13% and 10%, respectively). With an exception of ampicillin (fully resistant), Klebsiella spp. had low (0-13%) resistance to other tested antimicrobials with no detected MDR. Staphylococcus aureus was fully susceptible to vancomycin with 42% resistance to oxacillin. There were significant increasing trends of MDR Acinetobacter spp. however not P. aeruginosa during the study. Resistant pathogens were associated with worse profile of ICU patients but not patients’ outcomes. CONCLUSION: Acinetobacter in the current study was an increasingly resistant VAP-associated pathogen more than seen in many parts of the world. The current finding may impact local choice of initial empiric antibiotics.

Epidemiology of invasive pneumococcal infection in children aged five years and under in Saudi Arabia: a five-year retrospective surveillance study

BACKGROUND The epidemiology of invasive pneumococcal disease (IPD) in children aged <or=5 years in Saudi Arabia has not been described. We conducted a retrospective surveillance study to describe the epidemiology of IPD in the population of children aged <or=5 years served by the National Guard Health Affairs hospitals in central and western regions of Saudi Arabia. METHODS We reviewed the medical records of children <or=5 years old admitted to the King Abdulaziz Medical City hospitals in Riyadh and Jeddah with pneumococcal infections for the period January 1999 through December 2003. Only microbiologically confirmed IPD cases (meningitis or bacteremia) were included in the analysis. RESULTS A total of 82 IPD cases, 19 (23.2%) meningitis and 63 (76.8%) bacteremia, were diagnosed during the five-year period. Of these, 12.2% (10/82) died, with a case-fatality slightly but insignificantly higher in cases of meningitis (15.8%) than bacteremia (11.1%). The average annual IPD incidence was 17.4 per 100,000 (4.0 for meningitis and 13.4 for bacteremia). The incidence was roughly similar in males and females (18.3 and 16.6, respectively; p=0.663) and was almost 4-fold higher in the first year of life compared to the next four years (40.6 and 11.5, respectively; p<0.001). The average annual IPD mortality was 2.1 per 100,000 and was higher in the first year of life compared to the next four years (5.2 and 1.3 , respectively; p=0.043). CONCLUSIONS In the pre-vaccination era (1999-2003) in Saudi Arabia, IPD incidence was comparable to the pre-vaccination incidence rates from many industrialized countries, with children aged <or=1 year suffering the highest IPD risk among those aged <or=5 years.

Identified Transmission Dynamics of Middle East Respiratory Syndrome Coronavirus Infection During an Outbreak: Implications of an Overcrowded Emergency Department

Abstract A total 130 cases of Middle East respiratory syndrome coronavirus were identified during a large hospital outbreak in Saudi Arabia; 87 patients and 43 healthcare workers. The majority (80%) of transmission was healthcare-acquired (HAI) infection, with 4 generations of HAI transmission. The emergency department was the main location of exposure.

The impact of onset time on the isolated pathogens and outcomes in ventilator associated pneumonia

Several guidelines base the empirical therapy of ventilator-associated pneumonia (VAP) on the time of onset. However, there is emerging evidence that the isolated microorganisms may be similar regardless of onset time. This study evaluated the characteristics and outcomes of VAP with different onset times. All of the mechanically ventilated patients admitted to the ICU of a 900-bed tertiary-care hospital between 01/08/2003 and 31/12/2010 were prospectively followed for VAP development according to the National Healthcare Safety Network criteria. The patients were categorized into four groups: EO if VAP occurred within 4 days of intubation and hospital admission; LO if VAP occurred after 4 days of admission; EL if VAP occurred within 4 days of intubation, but after the fourth hospitalization day; and LL if VAP occurred after the fourth day of intubation and hospitalization. Out of the 394 VAP episodes, 63 (16%) were EO episodes, 331 (84.0%) were LO episodes, 40 (10.1%) were EL episodes and 291 (73.1%) were LL episodes. The isolated microorganisms were comparable among the four groups, with a similar rate of potentially multidrug resistant organisms in the EO-VAP (31.7%), LO-VAP (40.8%), EL-VAP (37.5%) and LL-VAP (43.3%) samples. The hospital mortality was 24% for EO-VAP cases, 28% for LO-VAP cases, 40% for EL-VAP cases and 49% for LL-VAP cases. However, in the adjusted multivariate analysis, neither LO-VAP, EL-VAP nor LL-VAP was associated with an increased risk of hospital mortality compared with EO-VAP (OR, 0.86 95% CI, 0.34-2.19; 1.22; 95% CI, 0.41-3.68, and 0.95; 95% CI, 0.43-2.10, respectively). In this study, the occurrence of potential multidrug resistant pathogens and the mortality risk were similar regardless of VAP timing from hospital admission and intubation. The bacterial isolates obtained from the VAP cases did not follow an early vs. late-onset pattern, and thus, these terms may not be clinically helpful.