Eman Farid

Neonatal Sepsis 1991–2001: Prevalent Bacterial Agents and Antimicrobial Susceptibilities in Bahrain

Objectives: To investigate the organisms causing neonatal sepsis and their modifications over an extended period, to assess their changing sensitivities to antibiotics and to verify whether the policy for screening pregnant women for group B streptococci (GBS) carriage is desirable in our settings. Subjects and Methods: Medical records of all infants with positive blood culture from the Neonatal Intensive Care Unit at Salmaniya Medical Complex between 1991 and 2001 and Bahrain Defense Force Hospital between 1999 and 2001 were reviewed. Results: Of the 7,978 neonates in both hospitals 335 (4.19%) had culture-proven bacteremia. Gram-positive bacteria were isolated at constant rate over the 11-year period. The main agents isolated were coagulase-negative Staphylococcus (CoNS) in 138 cases (41%), Staphylococcus aureus in 28 newborns (8%) and GBS in 26 patients (7.8%, 0.2/1,000 live births). All of them were sensitive to penicillin G, erythromycin and clindamycin. Gram-negative bacteria were declining but Escherichia coli was isolated in 35 cases (10%). Of special concern is the increasing percentage (5.7%) of Candida isolation. No clear trend toward increasing resistance was observed, although a major difference among the two institutions was evident. Klebsiella and Enterobacter spp. showed resistance to many of the antibiotics tested, thereby posing difficult therapeutic choices. Conclusion: Good quality specimens are essential to evaluate the role of CoNS. The increasing threat of fungal infection must be carefully tackled. Specifically tailored policies for GBS prevention must be defined according to the local epidemiology.

Efficacy and safety of early tacrolimus conversion to sirolimus after kidney transplantation: Long-term results of a prospective randomized study

We report a prospective, open-label, randomized study to evaluate the safety and efficacy of converting patients with a stable renal function from tacrolimus (Tac)-based regimen to a sirolimus (SRL)-based regimen after kidney transplantation. Fifty-eight low-risk renal allograft recipients who receiving Tac 6 months posttransplant, were randomly assigned to continue Tac (n = 29) or convert to SRL (n = 29). We evaluated the 3-year outcomes including patient and graft survival, graft function, and safety profile. Three-year patient and graft survival in SRL and Tac groups were 93.1% versus 100% (P = 0.32), and 89.7% versus 100% (P = 0.11), respectively. However, the SRL group had a significantly better renal function, from the 2nd year posttransplant until the last follow-up. Four (13.8%) patients in the SRL group and 3 (10.3%) in the Tac group (P = 0.5) developed biopsy-proven acute rejection. Mean urinary protein excretion increased significantly after SRL conversion. Diastolic blood pressure was significantly lower at the end of the study in patients who eliminated Tac (80.4 vs. 75.6 mmHg in Tac and SRL group, respectively) (P = 0.03). Mean hemoglobin concentrations decreased after SRL conversion and remained significantly lower from 12 months to 36 months (P = 0.01). The mean serum cholesterol (540 ± 44 mg/dl) and triglyceride (177 ± 27 mg/dl) increased significantly in the SRL group, compared to Tac group (487 ± 62 mg/dl) (P = 0.03) and (141 ± 26 mg/dl) (P = 0.04). Our experience demonstrates that conversion to SRL from calcineurin inhibitors-based therapy may result in better renal function and blood pressure control in renal transplant recipients without an increased risk of acute rejection. However, these benefits have not resulted in a growing advantage in graft or patient survival.

Immunological aspects of biopsy-proven lupus nephritis in Bahraini patients with systemic lupus erythematosus

Lupus nephritis (LN) is a frequent and potentially serious complication of systemic lupus erythematosus (SLE) that may influence morbidity and mortality. Immunological investigations are aiding tools to the kidney biopsy findings in early diagnosis, in addition to monitoring the effect of therapy. The aim of the present study is to highlight the role of these investigations in a group of Bahraini patients and to determine whether there is any positive association between these findings and the outcome of LN. The current study is a retrospective case-control study of randomly selected 88 SLE patients, 44 with biopsy-proven LN and 44 without, acting as controls. All renal biopsies performed during the period from 1996 to 2012 were classified according to the World Health Organization classification. Immunological investigations analyzed are: Antinuclear antibodies (ANA), anti-ds DNA, anti-ENA, anti-cardiolipin antibodies (abs) and complement components C3, C4. Human leukocyte antigen (HLA) typing class II was performed on selected cases. All patients had positive ANA (100%). A significantly high frequency of anti-Smith abs among the non-LN group (43.18%) compared with the LN group (18.18%) was found (P <0.001). On the other hand, the anti-Ro/SSA abs in the non-LN group was also found at a statistically higher frequency (20.45%) compared with that in the LN group (4.54%) (P <0.01). Anti-ds-DNA abs were found to be higher in the LN group (84.09%) compared with the non-LN group (70.45%), but the difference was not statistically significant (P = 0.082). There was a positive association of ANA positivity and low C3 and or C4 in the studied group. In our study, 88.2% of the HLA typed patients had HLADR2, DR3 or both. In conclusion, in our Arabic Bahraini SLE patients, the presence of anti-Smith, anti-Ro/SSA and anti-RNP antibodies and the absence of anti-dsDNA antibodies are independent predictive markers for renal involvement. However, more prospective studies with a larger number of patients are essential to ascertain those findings.

Course and Outcome of Renal Transplant Recipients Admitted to the Intensive Care Unit (ICU): Long Term Follow-up

Background The goal of this study was to evaluate the course and outcome of renal transplant recipients admitted to ICU and to analyze factors determining prognosis and mortality. Methods We reviewed the data of all adult renal transplant recipients who were admitted to the ICU at our center, between 1997 and 2017 which included the demographic features, data admission characteristics, and ICU courses. Among 379 consecutive kidney transplants followed up in our center, 60 patients were re-admitted to ICU and were categorized to early (during first 3 months; n=28); intermediate (3–12 months; n=7); and late (12 months and afterwards, n=25). Results The mean age was 48.3 ± 12.6 years and 68% were males. The causes of ICU admissions were surgical complication (71%) and infection (18%) in early phase, infection (57%) and cardiovascular complications (28%) in intermediate phase, and infection (68%) and respiratory complications (12%) in late phase. Mortality after discharge was significantly higher in late admission (78.6%) (p=0.002). Twenty patients during their ICU stay required ventilator. When compared to kidney transplant patients not admitted to ICU, only 35% vs 74% still have functioning grafts at the last follow-up (p=0.0001) and main cause of graft loss was death with function grafts (36.7% vs 13.7%). The overall graft survival rates were 97%, 80%, and 74% at 1 year, 3 years, and 5 years, respectively. Patient survival rates at these times were 86%, 82%, and 74%, respectively. In multivariate analysis, we found only the age and need for ventilator during the ICU as an independent risk factor for mortality (P < 0.02). Conclusion We found in this study that the main reason for ICU admissions among renal transplant recipients was infections. Mortality rates for this particular population are relatively high and are primarily linked to need for ventilators.

Trends of Mortality Among Renal Transplant Patients in Bahrain

Background The aim of this study was to analyze the trends in mortality of renal allograft recipients at our centre and if the pattern has changed over the last 30 years. Methods We reviewed patients who underwent transplantation and died between 1980 and 2017. We compared the causes of death for three decades: 1980 to 1989, 1990 to 1999, and 2000 to 2017. Results Out of 357 kidney transplants followed-up in our center, 90 patients (25.2%). There was 52 male (57.8%) and the mean ages was 52.3 ± 12.4 (range: 58). Basic kidney diseases were, diabetic nephropathy (28.9%) and chronic glomerulonephritis (10.2%). For the three periods, 3, 10, and 77 patients died, respectively. Sepsis mainly due to pneumonia was the main cause of death over the three periods (66.7%, 40% and 66.2%, respectively) and cardiovascular diseases accounted for (33.3%, 20% and 27.3%, respectively) with no significant change (P>0.05). Most of these patients died after the first year post transplant with no significant difference (P=0.26), (100%, 60% and 79%, respectively). Death with a functioning graft increased from 33.3% to 60% to 68.8%, respectively with significant difference (p=0.02). We found only by multivariate analysis that mean recipient age (43.2 ±18.1, 60.2 ± 12.2 and 51.9 ± 11.9 years, respectively) (P=0.045), pre-transplant hypertension (0%, 70% and 58.4%, respectively) (P=0.044) and use of induction antibody therapy (33.3%, 40% and 90%, respectively) (P= 0.012) have increase the risk for death over the three decades. When compared to live kidney transplant recipients during the same study period, we found that those who died exhibited significant differences in recipients age (median 52 years vs 48 years, P=0.001), hemoglobin at 1-month (median 10.2 vs 11.3 gm%, p= 0.008) and serum creatinine at 1-year (median 111 vs 104 mmol/l, P=0.002). Conclusion The causes of graft loss and death have not changed over the last three decades. The main causes of death was infection and cardiac disease. Death with functioning graft is of concern. Advanced recipient age, early level of hemoglobin, is associated with increased risk for death after kidney transplantation.

Opportunistic infections in HIV positive patients in Bahrain in 4 years study 2009-2013

Results CD4% and absolute CD4 count in HIV patients with associated infections was significantly lower than in those without associated infections (P< 0.001) but there was no significant difference in CD4/CD8 Ratio between the two groups. Infection with Staphylococcus aureus was the commonest encountered infections and present in 9.8% % of total AIDS patients and 28.7% of AIDS patient group who had OIs; followed by yeast infections (9.2% and 27.2% respectively). Mycobacterium tuberculosis was present in 3.6% of total AIDS patients and 10.6% of the group with OIs while Mycobacterium Other Than Tuberculosis (MOTT) was present in 2.5% and 7.5% respectively. Pneumocystis jirovecii pneumonia (PCP) was observed in 5.1% and 15.1% respectively. The least bacterial infections observed were Streptococcus penumoniae, Streptococcus melleri, Stenotrophomonas maltophilia, & Citrobacter species. Herpes simplex II (HSV-II) was the commonest OIs observed while Cytomegalovirus antigenemia was only present in 2% and 6% respectively. Conclusion Studying the pattern of OIs in HIV-infected patients in Bahrain is of paramount importance due to scarcity of data in the Arab worlds. This help to improve physician’s awareness to improve care of AIDS patients.