Ali M. Bazzi

Overview of Zika infection, epidemiology, transmission and control measures

The current Zika virus outbreak in the Americas and the proposed link to increases in microcephaly and neurological disorders have prompted the World Health Organization to declare a Public Health Emergency of International Concern on February 1, 2016. The virus is transmitted by Aedes mosquitoes and potentially by transfusion, perinatal and sexual transmission. The potential for spread into countries where Aedes mosquitoes are endemic is high. Previously, cases tended to be sporadic and associated with mild, non-specific symptoms. Prior outbreaks occurred in Yap Island in Micronesia in 2007, the first time Zika arose outside of Africa and Asia, and in French Polynesia in 2013. A birth data review has confirmed that the latter outbreak was followed by an increase in microcephaly cases. A coordinated international response is needed to address mosquito control; expedite development of diagnostic tests, vaccines and specific treatments for Zika; and address the proposed link to microcephaly and neurological diseases.

Prevalence of Panton-Valentine leukocidin-positive methicillin- susceptible Staphylococcus aureus infections in a Saudi Arabian hospital

Panton-Valentine leukocidin (PVL) is a two-component toxin associated with the toxicity and virulence of Staphylococcus aureus. The presence of PVL is well documented in community-acquired methicillin-resistant S. aureus (CA-MRSA) and is observed in methicillin-susceptible S. aureus (MSSA) with variable prevalence. We assessed the prevalence of PVL in a sample of 93 MSSA patients in a healthcare facility in Eastern Saudi Arabia using real-time PCR for lukSF-PV genes. The presence or absence of PVL was correlated with age, gender, hospitalization status, infection site and antibiotic resistance. PVL was detected in 28 (30%) patient samples. PVL was associated with a greater likelihood of resistance to trimethoprim-sulfamethoxazole (a resistance of 39.2% of PVL-positive isolates compared to 6.1% of PVL-negative isolates) (p < 0.0007). These results suggest a significant prevalence of PVL expression in MSSA strains in the study population and call for monitoring of and surveillance programs for PVL status and the selection of appropriate antibiotic treatments.

Comparison among four proposed direct blood culture microbial identification methods using MALDI-TOF MS

Matrix-assisted laser desorption-ionization time-of-flight (MALDI-TOF) mass spectrometry facilitates rapid and accurate identification of pathogens, which is critical for sepsis patients. In this study, we assessed the accuracy in identification of both Gram-negative and Gram-positive bacteria, except for Streptococcus viridans, using four rapid blood culture methods with Vitek MALDI-TOF-MS. We compared our proposed lysis centrifugation followed by washing and 30% acetic acid treatment method (method 2) with two other lysis centrifugation methods (washing and 30% formic acid treatment (method 1); 100% ethanol treatment (method 3)), and picking colonies from 90 to 180min subculture plates (method 4). Methods 1 and 2 identified all organisms down to species level with 100% accuracy, except for Streptococcus viridans, Streptococcus pyogenes, Enterobacter cloacae and Proteus vulgaris. The latter two were identified to genus level with 100% accuracy. Each method exhibited excellent accuracy and precision in terms of identification to genus level with certain limitations.

A review of candidate therapies for Middle East respiratory syndrome from a molecular perspective

Abstract There have been 2040 laboratory‐confirmed cases of Middle East respiratory syndrome coronavirus (MERS‐CoV) in 27 countries, with a mortality rate of 34.9%. There is no specific therapy. The current therapies have mainly been adapted from severe acute respiratory syndrome (SARS‐CoV) treatments, including broad‐spectrum antibiotics, corticosteroids, interferons, ribavirin, lopinavir‐ritonavir or mycophenolate mofetil, and have not been subject to well‐organized clinical trials. The development of specific therapies and vaccines is therefore urgently required. We examine existing and potential therapies and vaccines from a molecular perspective. These include viral S protein targeting; inhibitors of host proteases, including TMPRSS2, cathepsin L and furin protease, and of viral M(pro) and the PL(pro) proteases; convalescent plasma; and vaccine candidates. The Medline database was searched using combinations and variations of terms, including ‘Middle East respiratory syndrome coronavirus’, ‘MERS‐CoV’, ‘SARS’, ‘therapy’, ‘molecular’, ‘vaccine’, ‘prophylactic’, ‘S protein’, ‘DPP4’, ‘heptad repeat’, ‘protease’, ‘inhibitor’, ‘anti‐viral’, ‘broad‐spectrum’, ‘interferon’, ‘convalescent plasma’, ‘lopinavir ritonavir’, ‘antibodies’, ‘antiviral peptides’ and ‘live attenuated viruses’. There are many options for the development of MERS‐CoV‐specific therapies. Currently, MERS‐CoV is not considered to have pandemic potential. However, the high mortality rate and potential for mutations that could increase transmissibility give urgency to the search for direct, effective therapies. Well‐designed and controlled clinical trials are needed, both for existing therapies and for prospective direct therapies.

Direct identification and susceptibility testing of positive blood cultures using high speed cold centrifugation and Vitek II system

Compared to routine isolated colony-based methods, direct testing of bacterial pellets from positive blood cultures reduces turnaround time for reporting of antibiotic susceptibility. The aim of this study was to compare the accuracy, and precision, of a rapid method for direct identification and susceptibility testing of blood cultures with the routine method used in our laboratory, using Vitek 2. A total of 60 isolates were evaluated using the candidate and the routine method. The candidate method had 100% accuracy for the identification of Gram negative bacteria, Staphylococcus and Enterococcus, 50% for Streptococcus and 33.3% for Corynebacterium species. Susceptibility testing of Gram negative isolates yielded 98-100% essential agreement. For Staphylococcus and Enterococcus isolates, essential agreement was 100% for 17 antibiotics except for moxifloxacin. Direct testing of blood culture samples with Vitek 2 produced reliable identification and susceptibility results 18-24h sooner for aerobic/anaerobic facultative Gram-negative bacteria and Gram-positive Staphylococcus and Enterococcus strains.

Questionnaire-based analysis of infection prevention and control in healthcare facilities in Saudi Arabia in regards to Middle East Respiratory Syndrome

Abstract Effective implementation of infection prevention and control in healthcare facilities depends on training, awareness and compliance of healthcare workers. In Saudi Arabia recent significant hospital outbreaks, including Middle East Respiratory Syndrome Coronavirus (MERS-CoV), have resulted from lack of, or breakdown in, infection prevention and control procedures. This study was designed to assess attitudes to, and awareness of, infection prevention and control policies and guidelines among healthcare workers of different professions and institution types in Saudi Arabia. A questionnaire was administered to 607 healthcare workers including physicians (n=133), nurses (n=162), laboratory staff (n=233) and other staff (n=79) in government hospitals, private hospitals and poly clinics. Results were compared using Chi square analysis according to profession type, institution type, age group and nationality (Saudi or non-Saudi) to assess variability. Responses suggested that there are relatively high levels of uncertainty among healthcare workers across a range of infection prevention and control issues, including institution-specific issues, surveillance and reporting standards, and readiness and competence to implement policies and respond to outbreaks. There was evidence to suggest that staff in private hospitals and nurses were more confident than other staff types. Carelessness of healthcare workers was the top-cited factor contributing to causes of outbreaks (65.07% of total group), and hospital infrastructure and design was the top-cited factor contributing to spread of infection in the hospital (54.20%), followed closely by lack and shortage of staff (53.71%) and no infection control training program (51.73%). An electronic surveillance system was considered the most effective by staff (81.22%). We have identified areas of concern among healthcare workers in Saudi Arabia on infection prevention and control which vary between institutions and among different professions. This merits urgent multi-factorial actions to try to ensure outbreaks such as MERS-CoV can be minimized and contained.

Epidemiology and detection of acinetobacter using conventional culture and in-house developed PCR based methods

Active surveillance cultures for multidrug-resistant (MDR) gram-negative bacteria is one strategy to control outbreaks. The objectives of the study are to evaluate the prevalence of Acinetobacter colonization and to compare conventional culture and in-house developed PCR based method. Swabs were collected from patients transferred from another organization or were admitted to the intensive care units. Swabs were cultured by conventional method and were tested using in-house LightCycler® 2.0 real-time PCR method. Of 449 tested samples, the majority came from cardiac step down unit (188, 42%), male medical floor (80; 18%), and coronary care unit (66; 13.4%). Of the total specimens, 14 (3%) were positive by PCR and 12 (2.6%) were positive by routine cultures. The positivity rates among wounds, respiratory, perineal, and nasal samples were 3.2%, 9.7%, 4.6% and 0.8% respectively. Two positive samples by PCR were negative by routine culture. The overall concordance rate was 99.5% and the positive concordance rate was 85.7%. The current study revealed a low prevalence of MDR Acinetobacter among the studied population. The LightCycler® 2.0 PCR produced comparable positive results to routine cultures.

Molecular aspects of MERS-CoV

Middle East respiratory syndrome coronavirus (MERS-CoV) is a betacoronavirus which can cause acute respiratory distress in humans and is associated with a relatively high mortality rate. Since it was first identified in a patient who died in a Jeddah hospital in 2012, the World Health Organization has been notified of 1735 laboratory-confirmed cases from 27 countries, including 628 deaths. Most cases have occurred in Saudi Arabia. MERS-CoVancestors may be found in OldWorld bats of the Vespertilionidae family. After a proposed bat to camel switching event, transmission of MERS-CoV to humans is likely to have been the result of multiple zoonotic transfers from dromedary camels. Human-to-human transmission appears to require close contact with infected persons, with outbreaks mainly occurring in hospital environments. Outbreaks have been associated with inadequate infection prevention and control implementation, resulting in recommendations on basic and more advanced infection prevention and control measures by the World Health Organization, and issuing of government guidelines based on these recommendations in affected countries including Saudi Arabia. Evolutionary changes in the virus, particularly in the viral spike protein which mediates virus-host cell contact may potentially increase transmission of this virus. Efforts are on-going to identify specific evidence-based therapies or vaccines. The broad-spectrum antiviral nitazoxanide has been shown to have in vitro activity against MERS-CoV. Synthetic peptides and candidate vaccines based on regions of the spike protein have shown promise in rodent and non-human primate models. GLS-5300, a prophylactic DNA-plasmid vaccine encoding S protein, is the first MERS-CoV vaccine to be tested in humans, while monoclonal antibody, m336 has given promising results in animal models and has potential for use in outbreak situations.

Influenza A(H1N1)pdm09 epidemiology in the Eastern Province of Saudi Arabia

Abstract Objectives The influenza A(H1N1)pdm09 virus caused a worldwide pandemic in 2009–2010 and has since remained in seasonal circulation. This study was conducted to determine any variations in the influenza A(H1N1)pdm09 status according to sex, age group, sample type, or location within the Eastern Province of the Kingdom of Saudi Arabia. Methods Samples from 749 patients with suspected Middle East respiratory coronavirus who presented to Johns Hopkins Aramco Healthcare facilities in the Eastern Province of Saudi Arabia were tested reflexively for influenza A/H1N1 2009 by the Ministry of Health using the RealTime ready Influenza A/H1N1 Detection Set for real-time PCR. The sample types included nasopharyngeal swabs (n=677), expectorated deep cough sputum (n=32), induced sputum (n=17), and tracheal aspirates (n=23). Results The incidence of influenza A(H1N1)pdm09 was higher among younger patients; 27.94% of patients in the 0–19-year age group tested positive compared to only 3.51% of patients in the ≥80-year age group. The incidence of influenza A(H1N1)pdm09 was higher in Ras Tanura city compared to other locations in the Eastern Province. Conclusions Younger individuals in the Eastern Province of the Kingdom of Saudi Arabia had a relatively higher risk of influenza A(H1N1)pdm09 infection. Additionally, an outbreak of influenza A(H1N1)pdm09 may have occurred in Ras Tanura city between April 2015 and February 2016.

Fusarium Infection in a Kidney Transplant Recipient Successfully Treated with Voriconazole

Fusarium infections in solid-organ transplant recipients are rare and carry high mortality. We report a case of a kidney transplant recipient who developed infection with Fusarium species. The patient received treatment with oral voriconazole for five months with good response.