Ali M. Somily

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.

Molecular characterization of methicillin-resistant Staphylococcus aureus in nosocomial infections in a tertiary-care facility: emergence of new clonal complexes in Saudi Arabia

Changes in the molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) continue to be reported. This study was carried out to characterize MRSA isolates in Saudi Arabia. MRSA isolates causing nosocomial infections (n = 117) obtained from 2009–2015 at a tertiary-care facility in Riyadh, Saudi Arabia, were studied. Molecular characterization of isolates was carried out using the StaphyType DNA microarray (Alere Technologies, Jena, Germany). Fourteen clonal complexes (CC) were identified, with the most common being CC80 (n = 35), CC6 (n = 15), CC5 (n = 13) and CC22 (n = 12). With the exception of nine ST239 MRSA-III isolates, all others were of community-associated MRSA lineages. The following strains are identified for the first time in Saudi Arabia: ST8-MRSA-IV [PVL+/ACME+], USA300 (n = 1); ST72-MRSA-IV USA700 (n = 1); CC5-MRSA-IV, [PVL+/edinA+], WA MRSA-121 (n = 1); CC5-MRSA-V+SCCfus, WA MRSA-14/109 (n = 2), CC97-MRSA-IV, WA MRSA-54/63; CC2250/2277-MRSA-IV and WA MRSA-114. CC15-MRSA (n = 3) was identified for the first time in clinical infection in Saudi Arabia. None of the isolates harboured vancomycin resistance genes, while genes for resistance to mupirocin and quaternary ammonium compounds were found in one and nine isolates respectively. Fifty-seven isolates (48.7%) were positive for Panton-Valentine leukocidin genes. While the staphylokinase (sak) and staphylococcal complement inhibitor (scn) genes were present in over 95% of the isolates, only 37.6% had the chemotaxis-inhibiting protein (chp) gene. Increasing occurrence of community-acquired MRSA lineages plus emergence of pandemic and rare MRSA strains is occurring in our setting. Strict infection control practices are important to limit the dissemination of these MRSA strains.

Nosocomial transmission of community-acquired methicillin-resistant Staphylococcus aureus in a well-infant nursery of a teaching hospital

Background:  Infection due to community‐acquired strains of methicillin‐resistant Staphylococcus aureus (CA‐MRSA) has been reported with increasing frequency. Herein is described the nosocomial transmission of CA‐MRSA involving 13 neonates and two mothers in a well‐infant nursery in a teaching hospital in Saudi Arabia.

Detection of Salmonella typhi agglutinins in sera of patients with other febrile illnesses and healthy individuals

BACKGROUND AND PURPOSE Widal test is frequently applied for the detection of Salmonella agglutinins to diagnose Salmonella enterica serotype Typhi infection. There are however a number of controversies challenging the diagnostic utility of this test. This study was performed to determine the prevalence of Salmonella agglutinins in patients with other febrile illnesses and healthy blood donors. MATERIALS AND METHODS Sera from 50 healthy blood donors were compared for the presence of Salmonella agglutinins in various groups of patients with other febrile illnesses using Widal test in the division of Serology and Immunology at King Khalid University Hospital, Riyadh. The patient groups of other febrile illnesses included infections with Beta-hemolytic streptococcus (n = 50), Brucella (n = 46), Helicobacter pylori (n = 24), Treponema pallidum (n = 30), Toxoplasma (n = 44), and other parasites (n = 20). RESULTS Majority of the patients and normal individuals were tested positive for Widal test at dilution of less than 1 : 40 both for the O (62.5%) and H (64.6%) antigen. A decreasing trend in Widal reactivity was observed with increasing dilutions of the serum samples. At 1 : 160 titer, which is generally considered as a cut off point for positive Widal test, 6.4 and 11% individuals had positive Widal test for O and H Salmonella antigens, respectively. CONCLUSION Detection of a significant number of positive Widal tests in conditions where it is expected to be nonreactive appears to be a serious problem in making a correct diagnosis of typhoid fever, thus challenging the diagnostic utility of the Widal test.

Evaluation of GeneXpert MTB/RIF for detection of Mycobacterium tuberculosis complex and rpo B gene in respiratory and non-respiratory clinical specimens at a tertiary care teaching hospital in Saudi Arabia

Objectives To assess the performance of Xpert MTB/RIF, an automated molecular test for Mycobacterium tuberculosis (MTB) and resistance to rifampin (RIF), against smear microscopy and culture method for diagnosis of MTB infection. Methods This is a retrospective analysis of 103 respiratory and 137 non-respiratory patient specimens suspected of tuberculosis at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia performed between April 2014 and March 2015. Each sample underwent smear microscopy, mycobacterial culture, and GeneXpert MTB/RIF test. Results Fifteen out of 103 respiratory samples were smear and culture positive, whereas 9 out of 137 non-respiratory samples were smear positive. Out of 9 smear positive specimens, 8 were also culture positive. All 15 culture positive respiratory samples were detected by Xpert MTB/RIF (sensitivity and positive predictive value [PPV]=100%). Similarly, all 8 culture positive non-respiratory specimens were identified by Xpert MTB/RIF (sensitivity 100%; PPV 88.8%). The Xpert MTB/RIF detected only one false positive result in 88 smear negative respiratory specimens (specificity 98.9%; negative predictive value [NPV]= 100%). All 125 smear negative non-respiratory specimens tested negative by culture and Xpert MTB/RIF (sensitivity, specificity, PPV, NPV= 100%). Conclusion The performance of Xpert MTB/RIF was comparable to the gold standard culture method for identification of MTB in both respiratory and non-respiratory clinical specimens.

Phenotypic and genotypic characterization of extended-spectrum b-lactamases producing Escherichia coli and Klebsiella pneumoniaein a tertiary care hospital in Riyadh, Saudi Arabia.

BACKGROUND AND OBJECTIVES Extended-spectrum beta-lactamase (ESBL)-producing pathogens remain a public health concern, with limited data on the molecular characterization of isolates. We aimed to determine the molecular characterization of ESBL-producers circulating in our setting and correlate the molecular types with the minimal inhibitory concentration (MIC) to third-generation cephalosporins. DESIGN AND SETTING Retrospective study conducted during the period from January to June 2013 at King Khalid University hospital, a tertiary-care hospital in Riyadh, Saudi Arabia. MATERIALS AND METHODS All Escherichia coli and Klebsiella pneumoniae confirmed to be ESBL producers were included. The MICs of ceftriaxone and ceftazidime were determined by the E-test. Molecular characterization of ESBL-genes was performed using the Check-MDR-CT102 DNA microarray. RESULT Of 77 isolates comprising 50 (65%) E coli and 27 (35%) K pneumoniae, the majority (n=63; 81%) were from urine. Most isolates were blaCTX-M gene positive (n=72/77; 93.5%) comprising blaCTX-M1 (n=62), blaCTX-M9 (n=9) and blaCTX-M25 (n=1). Two or more ESBL genes were present in 45% of isolates with blaSHV predominating in K pneumoniae and blaTEM in E coli. Two isolates were positive for blaOXA-48 carried in combination with blaCTX-M9 and blaTEM in E coli and blaCTX-M1/CTX-M9 in K pneumoniae. Ceftriaxone MIC50 and MIC90 of ≥256 μg/mL were seen in E coli and K pneumoniae harboring blaCTX-M alone or in combination with blaSHV or blaTEM. For ceftazidime the highest MIC50 and MIC90 was seen in K pneumoniae harboring blaCTX-M+blaSHV and E coli with blaCTX-M+blaTEM combinations. CONCLUSION A preponderance of blaCTX-M suggests dissemination of the gene in our setting. The MIC for ceftriaxone and ceftazidime correlate well with molecular characterization of ESBL-producing Enterobacteriaceae.

Accuracy of Detecting Resistance to Carbapenems among Gram Negative Rods: Comparison of Three Methods

Abstract Objective To compare the results of imipenem and meropenem susceptibility testing among multi-drug resistant (MDR) isolates of Acinetobacter spp., Pseaudomonas aeruginosa (P.aeruginosa) and members of the Enterobacteriacae. Methods Three methods used for susceptibility testing of 210 isolates: disk diffusion (a reference method), MicroScan (MicroScan Walk Away 96 System, Dade Behring Inc. West Sacramento CA 95691, USA) and Etest (AB Biodisk Solna, Sweden). Results Of the 210 isolates, Acinetobacter spp. accounted for the majority of isolates [110(52.4%)] followed by P.aeruginosa, 79 (37.6%). These isolates were more prevalent from respiratory specimens 98 (46.7%), Acinetobacter spp. 60(28.6%) and P.aeruginosa 34(16.2%). The study has demonstrated discrepant results for carbapenems tested by MicroScan and Etest. For imipenem, the MicroScan exhibited 2.8 % very major error, major error was 10.1% but 3.9% by Etest for Acinetobacter spp., Other discrepant results (minor errors) were 28.7% and 33% for MicroScan and Etest, respectively. For meropenem, minor errors were higher by MicroScan (13.6%) and Etest (21%). For P.aeruginosa, very major error (1.6%) was exhibited by imipenem Etest but major errors were 23% and 30.5% for both drugs by MicroScan, respectively. Minor errors were higher for both drugs by both methods (MicroScan: 15.3% to 20.8% and Etest : 34.9% to 34.2%). Conclusion Microbiology laboratories should consider the use of an additional confirmatory test for carbapenem susceptibility testing of clinical isolates of Acinetobacter spp. and P.aeruginosa and members of the Enterobacteriacae.

Identification of Bacterial and Fungal Pathogens in Patients with Post-Laparoscopic Sleeve Gastrectomy Leakage

BackgroundPost-laparoscopic sleeve gastrectomy (LSG) leak leads to serious complications, and death may occur. The microbial pattern should be established in order to plan empirical antimicrobial therapy. The intra-abdominal leaks post-LSG were cultured and reviewed.MethodsMicrobial cultures collected from all post-sleeve leakage cases managed at the King Khalid University Hospital (KKUH) from May 2011 until April 2016 were reviewed.ResultsA total of 31 patients with positive leak post-LSG were included. The mean presentation time was postoperative day 12. Computed tomography (CT) was done for all patients on presentation with CT-guided aspiration and drainage next day. Samples from the collection were aspirated first for culture then a pigtail drain was kept in place. The average time of drain removal was on the 75th postoperative day. A total of 28 patients (90.3%) had positive culture results. Candida species were the most common organism isolated from 19 patients (61.2%), among them, 10 (32.2%) were positive for Candida species only. Positive bacterial cultures were found in 18 patients (58%). Majority of which single bacterial pathogen isolate, only seven patients had two organisms, and four patients had three organisms. Klebsiella pneumoniae was the most frequent isolated bacteria [8 patients (44.4%)] followed by Streptococcus and Pseudomonas species. Candida albicans was the most common Candida species isolated, 13 patients (68.4%).ConclusionFungal microbes isolated from post-LSG leak collection are common and could be considered in the primary empirical therapy. The antibiotic choice for the leak should cover Klebsiella, Streptococcus, and Pseudomonas until definitive culture results are obtained.

New Delhi Metallo-β-Lactamase 1 (NDM 1) Klebsiella Pneumoniae in Saudi Arabia: First Case Report and Literature Review

Our patient is a 56 years old Indian gentleman who presented to our hospitals emergency department with right upper quadrant pain which started three hours earlier, the pain was colicky and moderately severe, there was none of the following: radiation, nausea, vomiting, fever nor jaundice. He was hemodynamically stable, on physical exam he had mild tenderness over the right upper quadrant, no guarding nor rigidity, bowel sounds were audible, liver function tests were sent and all the enzymes and bilirubin were within normal range. No ultrasound was done at this time; he was given intramuscular scopolamine, and was prescribed ranitidine daily. He remained symptom free for the next 4 months, when he developed sudden onset of fever, chills and rigors, with no other symptoms, he again presented to our hospitals emergency department, the emergency physician assessment couldnt find a focus of infection for his fever, a blood culture was drawn, and he was discharged on acetaminophen. That same night the blood culture grew a gram negative bacilli, he was called back to the emergency department, where intravenous ceftriaxone was started, the gram negative was later identified as E. coli, which was an extended spectrum Lactamase (ESBL) producer, it was only susceptible to imipenem.

Molecular typing of ST239-MRSA-III from diverse geographic locations and the evolution of the SCCmec III element during its intercontinental spread

ST239-MRSA-III is probably the oldest truly pandemic MRSA strain, circulating in many countries since the 1970s. It is still frequently isolated in some parts of the world although it has been replaced by other MRSA strains in, e.g., most of Europe. Previous genotyping work (Harris et al., 2010; Castillo-Ramírez et al., 2012) suggested a split in geographically defined clades. In the present study, a collection of 184 ST239-MRSA-III isolates, mainly from countries not covered by the previous studies were characterized using two DNA microarrays (i) targeting an extensive range of typing markers, virulence and resistance genes and (ii) a SCCmec subtyping array. Thirty additional isolates underwent whole-genome sequencing (WGS) and, together with published WGS data for 215 ST239-MRSA-III isolates, were analyzed using in-silico analysis for comparison with the microarray data and with special regard to variation within SCCmec elements. This permitted the assignment of isolates and sequences to 39 different SCCmec III subtypes, and to three major and several minor clades. One clade, characterized by the integration of a transposon into nsaB and by the loss of fnbB and splE was detected among isolates from Turkey, Romania and other Eastern European countries, Russia, Pakistan, and (mainly Northern) China. Another clade, harboring sasX/sesI is widespread in South-East Asia including China/Hong Kong, and surprisingly also in Trinidad & Tobago. A third, related, but sasX/sesI-negative clade occurs not only in Latin America but also in Russia and in the Middle East from where it apparently originated and from where it also was transferred to Ireland. Minor clades exist or existed in Western Europe and Greece, in Portugal, in Australia and New Zealand as well as in the Middle East. Isolates from countries where this strain is not epidemic (such as Germany) frequently are associated with foreign travel and/or hospitalization abroad. The wide dissemination of this strain and the fact that it was able to cause a hospital-borne pandemic that lasted nearly 50 years emphasizes the need for stringent infection prevention and control and admission screening.