Mahmoud S. Abed

Decreasing ventilator-associated pneumonia in adult intensive care units using the Institute for Healthcare Improvement bundle

BACKGROUND Ventilator-associated pneumonia (VAP) increases in-hospital mortality of ventilated patients to 46%, compared with 32% for ventilated patients who do not develop VAP. In addition, VAP prolongs time spent on the ventilator, length of intensive care unit (ICU) stay, and length of hospital stay. METHODS In this study, we implemented VAP bundle to decrease the rate of VAP infection. This is a pre- and postintervention trial beginning in 2006 to decrease the rate of VAP in adult ICUs after initiation of the Institute for Healthcare Improvement (IHI) VAP bundle compared with the VAP rate for the preceding 12 months. The study was conducted at a private general hospital in Saudi Arabia. The study included all adult patients who were on mechanical ventilation from 2006 to 2008. An interdisciplinary performance improvement team was formed. The team implemented an evidence-based VAP bundle adopted from the IHI. RESULTS The implementation of the VAP prevention bundle resulted in the reduction of VAP rates from a mean of 9.3 cases per 1000 ventilator-days in fiscal year 2006 to 2.3 cases per 1000 ventilator-days in 2007 and to 2.2 in 2008 (P < .001). It is estimated that each VAP case increases the hospital length of stay attributable by 10 days and the mean hospital cost by

Promoting and sustaining a hospital-wide, multifaceted hand hygiene program resulted in significant reduction in health care-associated infections.

40,000. Thus, the potential decrease in hospital cost is

Attitudes towards influenza vaccination of multi-nationality health-care workers in Saudi Arabia.

780,000 annually. CONCLUSION Implementing the IHI VAP bundle significantly resulted in the reduction of the VAP rate with potential great cost avoidance.

Clostridium difficile-associated disease among patients in Dhahran, Saudi Arabia

BACKGROUND Hand hygiene is the single most important intervention to combat infections in any health care setting. However, adherence to hand hygiene practice remains low among health care workers. OBJECTIVES Our objective was to assess compliance with hand hygiene over time utilizing a multifaceted approach to hand hygiene. In addition, we assessed the rate of device-associated infections. METHODS This is a descriptive time series study with a multitude of interventions from October 2006 to December 2011 set in a 350-bed community hospital in Saudi Arabia. We utilized a multimodal program to promote hand hygiene activities. We also calculated device-associated infection rates as outcome measures. RESULTS Over the study, the overall hand hygiene compliance rate increased from a baseline of 38% in second quarter 2006 to 65% in 2010 and then to 85% in 2011 (P < .001). The compliance rates increased among all professions and different hospital units. The compliance rates were 87% for physicians, 89% for nursing staff, and 93% for nutritionist. The rate of health care-associated methicillin-resistant Staphylococcus aureus per 1,000 patient-days decreased from 0.42 in 2006 to 0.08 in 2011. Ventilator-associated infection rates decreased from 6.12 to 0.78, central line-associated bloodstream infections rates decreased from 8.23 to 4.8, and catheter-associated urinary tract infection rates decreased from 7.08 to 3.5. CONCLUSION This intervention used a multitude of interventions and resulted in an institution-wide increase and sustained improvement in compliance rates.

Antimicrobial resistance rates of Enterobacter spp.: a seven-year surveillance study.

BACKGROUND The compliance with influenza vaccination among health-care workers (HCWs) is known to be low. A multi-nationality survey to explore the reasons for such poor compliance has not been studied in depth. MATERIALS AND METHODS An epidemiologic survey to evaluate the compliance rates with influenza vaccination and possible associated reasons for compliance. RESULTS A total of 450 survey sheets were distributed and 244 (54.2%) were completed. Of the total respondents, 51 (20.9%) were Saudi, 114 (46.7%) were other Arabs, 21 (4%) were North American, 21 (8.6%) were from UK or South Africa and 48 (19.7%) did not indicate their nationalities. There were 32 (13.1%) physicians, and 132 (54.1%) nurses. The overall influenza vaccination rate was 41% in the preceding year and 69% in the preceding 5 years, and 49.2% (n=110) of the latter group received one to three vaccines. Of the total respondents, 156 (63.9%) report that the influenza vaccine was important, 86 (35%) report that they were not at risk of influenza, 163 (66.8%) report that the influenza vaccine was not safe and 152 (62.3%) report that influenza was not a serious illness. In a multivariate analysis, the following factors were important in choosing vaccinations: being a male, other Arab nationality, and knowing that influenza vaccine is important (P<or=0.01). Feeling at risk of influenza, and not using any vaccine alternatives, and that the vaccine is important for self and the patients protection, were statistically important factors as well (P<or=0.05). CONCLUSION Important factors associated with increasing influenza vaccine acceptance include being a male, other Arab nationality, and knowing that influenza vaccine is important. In addition, feeling at risk of influenza, and not using any vaccine alternatives, and that the vaccine is important for self and the patients protection, were statistically important factors as well. Thus, efforts to increase the acceptance rates should take these factors in consideration.

Pandemic influenza A (2009 H1N1) in hospitalized patients in a Saudi Arabian hospital: Epidemiology and clinical comparison with H1N1-negative patients

Clostridium difficile-associated diarrhea (CDAD) is an important healthcare-associated infection. However, there are no data from Saudi Arabia on this disease. A two-year prospective, observational study on the incidence of CDAD in a hospital in Saudi Arabia was carried out. Stool analysis for C. difficile toxins A and B was carried out by an enzyme-linked immunosorbent assay. Medical and laboratory records were reviewed. Of the total number of patients, there were 53.3% male and the mean age was 44.6 ± 27.2 years. Of the 913 specimens, only 42 (4.6%) were positive for C. difficile toxins. The annual incidence rates of C. difficile were 1.2 and 0.9 per 1000 discharges, and 2.4 and 1.7 per 10,000 patient days in 2007 and 2008, respectively. Of the total number of cases, 52.4% were with onset in the hospital, 38.1% were with onset in the community and 9.5% were community-onset but healthcare facility-associated CDAD. Of the cases, 16 (39%) patients did not have exposure to antimicrobial drugs in the 3 months prior to the test date. The remaining patients received antimicrobial drug therapy. Cephalosporin and fluoroquinolone were the most common antimicrobial drugs used. Overall, the prevalence of C. difficile-associated diarrhea was low; further studies are required in Saudi Arabia to elucidate the true prevalence of the disease.

Peripherally inserted central catheter bloodstream infection surveillance rates in an acute care setting in Saudi Arabia

Objective: The aim of the study was to evaluate the trends of antimicrobial resistance of Enterobacter spp. over time in a Saudi Arabian hospital. Materials and Methods: This is an in vitro surveillance study of the antibiotic susceptibility pattern among Enterobacter spp. recovered from outpatient and nosocomial isolates over a 7-year period from 2000 to 2006. Only a single isolate per patient was included. Results: A total of 1,394 nonrepetitive isolates were analyzed during the study period. Enterobactercloacae and Enterobacteraerogenes constituted 60 and 33% of the isolates, respectively. Overall, there was no statistically significant increase in the resistance rates over time for the outpatient and nosocomial isolates of Enterobacter. For E.cloacae, nosocomial isolates were statistically more resistant than outpatient isolates to ceftriaxone (17.5 vs. 5.5%), ciprofloxacin (9.5 vs. 4.7%), ticarcillin (42.8 vs. 25.4%) and ticarcillin-clavulanic acid (23 vs. 9.3%). For E.aerogenes, the nosocomial isolates were also more resistant to ceftriaxone and ciprofloxacin than the outpatient isolates (9.2 vs. 2.4% and 9.6 vs. 3%, respectively). In addition, nosocomial isolates of E.aerogenes were more resistant to piperacillin (25 vs. 15.6%) and ticarcillin-clavulanic acid (32 vs. 10.2%) than outpatient isolates. The most active antimicrobial agents were imipenem, amikacin and gentamicin against Enterobacter. Resistance rate to ≥3 classes of antibiotics was present in 2.5% of nosocomial and 1.7% of outpatient isolates (p = 0.78). Conclusion: The resistance rate for the outpatient and nosocomial isolates of Enterobacter had remained relatively stable over the study period. The most active antimicrobial agents were imipenem, amikacin and gentamicin.

Susceptibility pattern and epidemiology of Mycobacterium tuberculosis in a Saudi Arabian hospital: a 15-year study from 1989 to 2003.

BACKGROUND AND OBJECTIVES The World Health Organization (WHO) declared that pandemic influenza A (H1N1) was a public health emergency of international concern in April 2009. Herein, we describe the characteristics of patients in a Saudi Arabian hospital with and without H1N1 infection. METHODS We reviewed the records of patients admitted with influenza-like illness and compared confirmed pandemic H1N1 cases to the H1N1-negative patients admitted to the hospital. Infections due to the novel H1N1 virus were confirmed using real-time reverse transcriptase polymerase chain reaction (rRT-PCR). RESULTS During the study period, a total of 165 patients were admitted with influenza-like illness and underwent rRT-PCR testing. Of these patients, 47 (28.4%) had confirmed novel H1N1 virus infection. Thus, the hospitalization incidence rate was 13.4 cases per 100,000 persons. The remaining patients had negative H1N1 rRT-PCR test results. The mean age±SD of the H1N1-positive patients was 30.3±28.5 years compared with 25.3±23 years for the H1N1-negative group (P=0.28). Severe obesity was observed in 6.7% and 8.5% of H1N1-positive and H1N1-negative patients, respectively (P=0.74). The clinical picture was similar between the two groups, except for the higher prevalence of nausea (25.5% vs. 11%) and diarrhea (21.3% vs. 7.6%) in the H1N1-positive group than in the H1N1-negative group (P=0.03) The mortality rate was low in both groups. CONCLUSION The clinical presentation and outcome are insufficient to differentiate between influenza-like illness (ILI) caused by H1N1 and that cause by other pathogens. In general, both groups had mild disease in this cohort of patients in Saudi Arabia.

Clinical Investigations: INFECTIONSusceptibility Pattern and Epidemiology of Mycobacterium tuberculosis in a Saudi Arabian Hospital: A 15-Year Study From 1989 to 2003

BACKGROUND AND OBJECTIVE Peripherally inserted central venous catheters (PICCs) are alternatives to short-term central venous catheters and provide intravenous access in the acute hospital setting. In this study, we describe the rate of PICC-associated bloodstream infections (BSI). DESIGN AND SETTING Prospective cohort study using data on PICC lines reviewed from January to December 2009. METHODS The infection control team was responsible for prospective BSI case findings. The infection rate was calculated per 1000 device-days. RESULTS During the study period, 92 PICC lines were inserted with a total of 3336 device-days of prospective surveillance. The most frequent reasons for the insertion of the PICC lines were chemotherapy (n=19, 20.7%), intravenous antimicrobial therapy (n=34, 37%), and for patients in the medical intensive care unit (ICU) (n=16, 17.4%). The overall BSI rate was 4.5/1000 PICC days. The PICC line–associated BSI rates for a specific indication were as follows: chemotherapy 6.6/1000 device-days, intravenous antimicrobial therapy 1.2/1000 device-days, medical ICU 7.3/1000 device-days, surgical ICU 4.6/1000 device-days, and total parental nutrition patients 2.4/1000 device-days (P<.001). The rates were not adjusted for patient severity of illness. CONCLUSIONS Our data suggest that underlying conditions and indications for the PICC line use may play an important role in the development of BSI.