Rehab H. El-Sokkary

Occurrence of classes I and II integrons in Enterobacteriaceae collected from Zagazig University Hospitals, Egypt

Integrons are genetic units characterized by the ability to capture and incorporate gene cassettes, thus can contribute to the emergence and transfer of antibiotic resistance. The objectives of this study were: (1) to investigate the presence and distribution of class I and class II integrons and the characteristics of the gene cassettes they carry in Enterobacteriaceae isolated from nosocomial infections at Zagzig University Hospital in Egypt, (2) to determine their impact on resistance, and (3) to identify risk factors for the existence of integrons. Relevant samples and full clinical history were collected from 118 inpatients. Samples were processed; isolated microbes were identified and tested for antibiotic susceptibilities. Integrons were detected by polymerase chain reaction (PCR) and were characterized into class I or II by restriction fragment length polymorphism (RFLP). Integron-positive isolates were subjected to another PCR to detect gene cassette, followed by gene cassette sequencing. Risk factors were analyzed by logistic regression analysis. Seventy-six Enterobacteriaceae isolates were recognized, 41 of them (53.9%) were integron-positive; 39 strains carried class I and 2 strains carried class II integrons. Integrons had gene cassettes encoding different combinations and types of resistance determinants. Interestingly, blaOXA129 gene was found and ereA gene was carried on class I integrons. The same determinants were carried within isolates of the same species as well as isolates of different species. The presence of integrons was significantly associated with multidrug resistance (MDR). No risk factors were associated for integron carriage. We conclude that integrons carrying gene cassettes encoding antibiotic resistance are significantly present among Enterobacteriaceae causing nosocomial infection in our hospital. Risk factors for acquisition remain to be identified.

The course of spinal tuberculosis (Pott disease): results of the multinational, multicentre Backbone-2 study

We aimed to describe clinical, laboratory, diagnostic and therapeutic features of spinal tuberculosis (ST), also known as Pott disease. A total of 314 patients with ST from 35 centres in Turkey, Egypt, Albania and Greece were included. Median duration from initial symptoms to the time of diagnosis was 78 days. The most common complications presented before diagnosis were abscesses (69%), neurologic deficits (40%), spinal instability (21%) and spinal deformity (16%). Lumbar (56%), thoracic (49%) and thoracolumbar (13%) vertebrae were the most commonly involved sites of infection. Although 51% of the patients had multiple levels of vertebral involvement, 8% had noncontiguous involvement of multiple vertebral bodies. The causative agent was identified in 41% of cases. Histopathologic examination was performed in 200 patients (64%), and 74% were consistent with tuberculosis. Medical treatment alone was implemented in 103 patients (33%), while 211 patients (67%) underwent diagnostic and/or therapeutic surgical intervention. Ten percent of the patients required more than one surgical intervention. Mortality occurred in 7 patients (2%), and 77 (25%) developed sequelae. The distribution of the posttreatment sequelae were as follows: 11% kyphosis, 6% Gibbus deformity, 5% scoliosis, 5% paraparesis, 5% paraplegia and 4% loss of sensation. Older age, presence of neurologic deficit and spinal deformity were predictors of unfavourable outcome. ST results in significant morbidity as a result of its insidious course and delayed diagnosis because of diagnostic and therapeutic challenges. ST should be considered in the differential diagnosis of patients with vertebral osteomyelitis, especially in tuberculosis-endemic regions. Early establishment of definitive aetiologic diagnosis and appropriate treatment are of paramount importance to prevent development of sequelae.

Comparison of brucellar and tuberculous spondylodiscitis patients: results of the multicenter "Backbone-1 Study".

BACKGROUND CONTEXT No direct comparison between brucellar spondylodiscitis (BSD) and tuberculous spondylodiscitis (TSD) exists in the literature. PURPOSE This study aimed to compare directly the clinical features, laboratory and radiological aspects, treatment, and outcome data of patients diagnosed as BSD and TSD. STUDY DESIGN A retrospective, multinational, and multicenter study was used. PATIENT SAMPLE A total of 641 (TSD, 314 and BSD, 327) spondylodiscitis patients from 35 different centers in four countries (Turkey, Egypt, Albania, and Greece) were included. OUTCOME MEASURES The pre- and peri- or post-treatment spinal deformity and neurologic deficit parameters, and mortality were carried out. METHODS Brucellar spondylodiscitis and TSD groups were compared for demographics, clinical, laboratory, radiological, surgical interventions, treatment, and outcome data. The Student t test and Mann-Whitney U test were used for group comparisons. Significance was analyzed as two sided and inferred at 0.05 levels. RESULTS The median baseline laboratory parameters including white blood cell count, C-reactive protein, and erythrocyte sedimentation rate were higher in TSD than BSD (p<.0001). Prevertebral, paravertebral, epidural, and psoas abscess formations along with loss of vertebral corpus height and calcification were significantly more frequent in TSD compared with BSD (p<.01). Surgical interventions and percutaneous sampling or abscess drainage were applied more frequently in TSD (p<.0001). Spinal complications including gibbus deformity, kyphosis, and scoliosis, and the number of spinal neurologic deficits, including loss of sensation, motor weakness, and paralysis were significantly higher in the TSD group (p<.05). Mortality rate was 2.22% (7 patients) in TSD, and it was 0.61% (2 patients) in the BSD group (p=.1). CONCLUSIONS The results of this study show that TSD is a more suppurative disease with abscess formation requiring surgical intervention and characterized with spinal complications. We propose that using a constellation of constitutional symptoms (fever, back pain, and weight loss), pulmonary involvement, high inflammatory markers, and radiological findings will help to differentiate between TSD and BSD at an early stage before microbiological results are available.

Reprocessing practices for gastrointestinal endoscopes: a multicentre study in Egyptian university hospitals

The aim of this study was to assess the practices of health care workers during gasterointestinal endoscope reprocessing, evaluate their knowledge about reprocessing, and verify their compliance with laboratory and microbiological tests in endoscopy units at Zagazig University and Fayoum University hospitals. All nursing staff on duty from 10 endoscopy units, with 16 flexible endoscopes, were included. Knowledge and practice were assessed by a questionnaire and a checklist. The mean knowledge score was 7.5 (SD 1.9), which was poor. Compliance was 90% for disinfection and 74% for endoscope processing after disinfection. Before reuse after cleaning, no organisms were detected in 5 endoscopes, while 8 colony forming units were found in 2. Pseudomonas aeruginosa was the most common organism isolated. Strict implementation of the reprocessing guidelines are needed, especially the pre-cleaning stage and leak testing. Repeating high level disinfection after storage and before use must be followed.

Prevention of Ventilator Associated Pneumonia in an Emergency Intensive Care Unit: An Intervention Study

Background: Ventilator-associated pneumonia is the most frequent hospital acquired infection in ICU among mechanically ventilated patients. The objective of this study was to examine the effect of a series of interventions on VAP rate, MDR rate, antibiotic susceptibility pattern and health care providers’ practices. Methodology: A quasi-experimental study was conducted in three phases: A pre-intervention phase (phase I) including VAP epidemiologic surveillance program, an intervention phase (phase II) including the implementation of a comprehensive infection control program and a post-intervention phase (phase III) including assessment of the effect of the selected interventions. Results: After intervention, VAP rate per one thousand ventilator days showed reduction from 48.8 to 40. There was a significant improvement in the infection control practice of health care providers; the mean percentage of change in total practice was 14.02%. The most common isolated pathogen was Klebsiella, its prevalence decreased from 43% to 37.2% after intervention. During phase (I) 81.4% of isolates were found to be MDR, which decreased to 74.6% in phase III. Conclusion: the study showed a significant reduction in VAP rates with evidence based prevention strategies. Klebsiella was the most prevalent MDR pathogen responsible for VAP. Multifaceted intervention is a key strategy to prevent VAP.

Clostridium difficile Occurrence, Toxin Profile and Antibiotic Susceptibility: An Egyptian Center Experience

Background: Clostridium difficile (C. difficile) infection (CDI) is of concern in healthcare facilities. The role of binary toxin alone is controversial. Resistance to antibiotic therapy has emerged. Objectives: to determine the occurrence of C. difficile, their toxigenicity, antibiotic susceptibility pattern and the effect of binary toxin gene. Methodology: A cross section study, stools samples were collected from 211 patients. Strains were identified, antibiogram was determined using ATB TM ANA, and E-test for vancomycin. A multiplex PCR assay for (tpi), tcdA and tcdB genes, followed by a duplex PCR for cdtA and cdtB genes were done. Results: C. difficile was isolated from 29 samples (13.7%).. One strain was resistant to metronidazole, and three had intermediate susceptibility. All isolates were positive for (tpi) gene. Fifteen isolates (51.7%) were non toxigenic and 14 (48.2%) were toxigenic. Three toxigenic isolates harbored binary toxin genes. It was not possible to identify any impact of binary toxin due to small number found to harbor it. Conclusions : C. difficile is not a major problem in our locality. Further studies are needed to detect the role of binary toxin. Proper infection control measures and rationale use of antimicrobials are mandatory to prohibit further exaggeration of the problem.

Association of incretin receptors genetic polymorphisms with type 2 diabetes mellitus in Egyptian patients

Incretins have opened a new era in type 2 diabetes mellitus (T2DM) pathogenesis. The present study aimed to assess whether there is an association between GIPR rs2302382, GIPR rs1800437 and GLP‐1R rs367543060 polymorphisms with T2DM or not and also to determine the effect of these polymorphisms on gastric inhibitory polypeptide (GIP) and glucagon‐like peptide‐1 (GLP‐1) levels.

Detection of hepatitis C virus (HCV) among health care providers in an Egyptian university hospital: different diagnostic modalities

Background Hepatitis C virus (HCV) infection has received much attention and is placed at the core of the infection control agenda. It is considered as a major public health problem in Egypt, where the highest prevalence of HCV exists. The great risk of exposure to infection of health care providers (HCPs) has highlighted the urgent need for implementing an infection control program. Objective The purpose of this study was to detect the prevalence of HCV infection among HCPs in Zagazig University Hospitals and to assess the performance of different diagnostic modalities. Methodology Blood, polymerase chain reaction (PCR), enzyme-linked immunosorbent assay (ELISA), and saliva tests were performed in enrolled HCPs. Results This study compared HCV diagnosis Hepanostika HCV Ultra ELISA as a screening test and PCR as gold standard test, which resulted in 40.6% positive results by ELISA compared to 34.8% by PCR (p<0.0001), while OraQuick HCV rapid antibody compared to PCR shows that 37.7% of the participants were positive by OraQuick HCV rapid antibody test. Application of standard precautions while dealing with blood has negative significant correlation with HCV infection (rs =-0.265, p=0.03). Conclusion HCPs at Zagazig University Hospitals are at high risk for HCV infection. Lack of compliance and awareness of prevention and control of the infection are associated cofactors. Serum HCV-Ab detection by Hepanostika HCV Ultra ELISA and OraQuick HCV rapid antibody test are sensitive and specific serologic assays for diagnosis with correspondent results to that obtained by quantitative real-time PCR.

Multidrug-resistant bacteria among patients with ventilator-associated pneumonia in an emergency intensive care unit, Egypt

Ventilator-associated pneumonia (VAP) is the most common hospital-acquired infection among mechanically ventilated patients. Our objectives were to determine the incidence of VAP, isolate multidrug-resistant bacteria, identify the most prevalent resistant strains and identify their antibiotic susceptibility pattern. The VAP rate was calculated. The isolated microbes were identified and tested for antibiotic susceptibilities. The minimum inhibitory concentrations were determined of imipenem, meropenem and ertapenem for Klebsiella isolates. Klebsiella isolates resistant to carbapenems were tested for the presence of the blaKPC gene. The VAP incidence density rate was 48.8 incidences/1 000 ventilator days. The most common Gram-positive organism was Staphylococcus aureus, of which 86.6% of isolates were resistant to cefoxitin , but 100% were sensitive to teicoplanin, linezolid and tigecycline. The most common Gram-negative bacillus was Klebsiella, of which 94.6% of isolates were resistant to cefotaxime, 70.2% to imipenem, and 64.9% to ertapenem, but 100% were sensitive to colistin and 94.6% were sensitive to tigecycline. Of the carbapenem-resistant Klebsiella strains, 23.1% had the blaKPC gene. The high rates of VAP and the high rates of resistance among isolated organisms point to improper implementation of infection control programmes.