Promoting cross-regional collaboration in antimicrobial stewardship: Findings of an infectious diseases working group survey in Arab countries of the Middle East.

Abstract Background Antimicrobial resistance is a significant global issue that presents an increasing threat to patients' wellbeing. Although a global concern, the emergence of multi-drug resistant organisms is of particular significance in the Middle East. In recent years, this region has seen an alarming increase in antimicrobial resistance presenting a major challenge to physicians managing various infectious diseases. Methods A Working Group comprising experts in infectious diseases from Arab countries of Middle East assembled to review similarities and differences in antimicrobial practices and management of multi-drug resistant organisms across the region and assess the barriers to achieving cross-regional collaboration. The Working Group conducted an anonymous online survey to evaluate current practice and understanding of management of multi-drug resistant organisms across the region. Results A total of 122 physicians from Arab countries of the Middle East responded to the survey. Their responses demonstrated heterogeneity between countries in awareness of local epidemiology, management of multi-drug resistant organisms and antimicrobial stewardship practices. The Working Group recognized similarities and differences in the management of multi-drug resistant organisms across the region, and these were validated by the data collected in the survey. Overall, the similarities across the region reflect several key issues that can have an impact on the management of multi-drug resistant organisms and the prevention of antimicrobial resistance. Conclusions This paper highlights the urgency of addressing antimicrobial resistance in Arab countries of the Middle East. The Working Group identified key barriers to effective management which may guide the development of future coherent strategies to promote effective antimicrobial stewardship in the region. Here, we outline a call to action for the region, with a need to focus on training and education, capacity building, infrastructure, regional research, and regional surveillance

Low Rate of Bacterial Coinfections and Antibiotic Overprescribing During COVID-19 Pandemic: A Retrospective Study from Oman

Objectives: The recommended treatment for COVID-19 includes antiviral drugs, corticosteroids, immunomodulatory drugs, low molecular weight heparin, as well as antibiotics. Although COVID-19 is a viral disease, many studies indicate that antibiotics are prescribed frequently, mainly to treat suspected bacterial coinfection. At the same time, the prevalence of bacterial coinfections during COVID-19 is rather low indicating the significant antibiotic overuse in these patients. It is well known that this can trigger antibiotic bacterial resistance, and once it emerges the reversal of resistance is a complex and long-lasting process. The aims of this study were to estimate the prevalence of bacterial coinfections during the COVID-19 and to analyze the antibiotic treatment justification during this pandemic in Oman. Methods: This retrospective analysis was conducted using the Royal Hospital COVID-19 Registry Database. The study analyzed demographic and clinical characteristics, as well as laboratory parameters and antibiotic treatment of hospitalized patients. Results: During the study period, 584 patients were enrolled in the analysis. Coinfection was rare as it was confirmed in 0.9% of patients. Superinfections were present in 15.2% of patients. Gram-negative bacteria were isolated in 95 (69.9%) samples, gram-positive bacteria in 25 (18.4%) samples, while Candida spp. was found in 16 (11.8%) samples. On admission, empirical antibiotic treatment was started in 543 (93.0%) patients. Conclusions: During COVID-19, coinfections are rarely seen and the overuse of antibiotics is not justified. The incidence of superinfections is the same as in other patients in healthcare settings caused by the same resistant microorganisms, which implies the use of even more

It is time to define an organizational model for the prevention and management of infections along the surgical pathway : a worldwide cross-sectional survey

Background The objectives of the study were to investigate the organizational characteristics of acute care facilities worldwide in preventing and managing infections in surgery; assess participants' perception regarding infection prevention and control (IPC) measures, antibiotic prescribing practices, and source control; describe awareness about the global burden of antimicrobial resistance (AMR) and IPC measures; and determine the role of the Coronavirus Disease 2019 pandemic on said awareness. Methods A cross-sectional web-based survey was conducted contacting 1432 health care workers (HCWs) belonging to a mailing list provided by the Global Alliance for Infections in Surgery. The self-administered questionnaire was developed by a multidisciplinary team. The survey was open from May 22, 2021, and June 22, 2021. Three reminders were sent, after 7, 14, and 21 days. Results Three hundred four respondents from 72 countries returned a questionnaire, with an overall response rate of 21.2%. Respectively, 90.4% and 68.8% of participants stated their hospital had a multidisciplinary IPC team or a multidisciplinary antimicrobial stewardship team. Local protocols for antimicrobial therapy of surgical infections and protocols for surgical antibiotic prophylaxis were present in 76.6% and 90.8% of hospitals, respectively. In 23.4% and 24.0% of hospitals no surveillance systems for surgical site infections and no monitoring systems of used antimicrobials were implemented. Patient and family involvement in IPC management was considered to be slightly or not important in their hospital by the majority of respondents (65.1%). Awareness of the global burden of AMR among HCWs was considered very important or important by 54.6% of participants. The COVID-19 pandemic was considered by 80.3% of respondents as a very important or important factor in raising HCWs awareness of the IPC programs in their hospital. Based on the survey results, the authors developed 15 statements for several questions regarding the prevention and management of infections in surgery. The statements may be the starting point for designing future evidence-based recommendations. Conclusion Adequacy of prevention and management of infections in acute care facilities depends on HCWs behaviours and on the organizational characteristics of acute health care facilities to support best practices and promote behavioural change. Patient involvement in the implementation of IPC is still little considered. A debate on how operationalising a fundamental change to IPC, from being solely the HCWs responsibility to one that involves a collaborative relationship between HCWs and patients, should be opened.Peer reviewe

It is time to define an organizational model for the prevention and management of infections along the surgical pathway: a worldwide cross-sectional survey

Background The objectives of the study were to investigate the organizational characteristics of acute care facilities worldwide in preventing and managing infections in surgery; assess participants' perception regarding infection prevention and control (IPC) measures, antibiotic prescribing practices, and source control; describe awareness about the global burden of antimicrobial resistance (AMR) and IPC measures; and determine the role of the Coronavirus Disease 2019 pandemic on said awareness. Methods A cross-sectional web-based survey was conducted contacting 1432 health care workers (HCWs) belonging to a mailing list provided by the Global Alliance for Infections in Surgery. The self-administered questionnaire was developed by a multidisciplinary team. The survey was open from May 22, 2021, and June 22, 2021. Three reminders were sent, after 7, 14, and 21 days. Results Three hundred four respondents from 72 countries returned a questionnaire, with an overall response rate of 21.2%. Respectively, 90.4% and 68.8% of participants stated their hospital had a multidisciplinary IPC team or a multidisciplinary antimicrobial stewardship team. Local protocols for antimicrobial therapy of surgical infections and protocols for surgical antibiotic prophylaxis were present in 76.6% and 90.8% of hospitals, respectively. In 23.4% and 24.0% of hospitals no surveillance systems for surgical site infections and no monitoring systems of used antimicrobials were implemented. Patient and family involvement in IPC management was considered to be slightly or not important in their hospital by the majority of respondents (65.1%). Awareness of the global burden of AMR among HCWs was considered very important or important by 54.6% of participants. The COVID-19 pandemic was considered by 80.3% of respondents as a very important or important factor in raising HCWs awareness of the IPC programs in their hospital. Based on the survey results, the authors developed 15 statements for several questions regarding the prevention and management of infections in surgery. The statements may be the starting point for designing future evidence-based recommendations. Conclusion Adequacy of prevention and management of infections in acute care facilities depends on HCWs behaviours and on the organizational characteristics of acute health care facilities to support best practices and promote behavioural change. Patient involvement in the implementation of IPC is still little considered. A debate on how operationalising a fundamental change to IPC, from being solely the HCWs responsibility to one that involves a collaborative relationship between HCWs and patients, should be opened

Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial

Background Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage. Methods In this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Participants, care givers, and those assessing outcomes were masked to allocation. We originally planned to enrol 15 000 women with a composite primary endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore increased the sample size from 15 000 to 20 000 women in order to estimate the effect of tranexamic acid on the risk of death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283. Findings Between March, 2010, and April, 2016, 20 060 women were enrolled and randomly assigned to receive tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036 and 9985, respectively, were included in the analysis. Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008). All other causes of death did not differ significantly by group. Hysterectomy was not reduced with tranexamic acid (358 [3·6%] patients in the tranexamic acid group vs 351 [3·5%] in the placebo group, RR 1·02, 95% CI 0·88–1·07; p=0·84). The composite primary endpoint of death from all causes or hysterectomy was not reduced with tranexamic acid (534 [5·3%] deaths or hysterectomies in the tranexamic acid group vs 546 [5·5%] in the placebo group, RR 0·97, 95% CI 0·87-1·09; p=0·65). Adverse events (including thromboembolic events) did not differ significantly in the tranexamic acid versus placebo group. Interpretation Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset. Funding London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation

Ten golden rules for optimal antibiotic use in hospital settings: the WARNING call to action

Antibiotics are recognized widely for their benefits when used appropriately. However, they are often used inappropriately despite the importance of responsible use within good clinical practice. Effective antibiotic treatment is an essential component of universal healthcare, and it is a global responsibility to ensure appropriate use. Currently, pharmaceutical companies have little incentive to develop new antibiotics due to scientific, regulatory, and financial barriers, further emphasizing the importance of appropriate antibiotic use. To address this issue, the Global Alliance for Infections in Surgery established an international multidisciplinary task force of 295 experts from 115 countries with different backgrounds. The task force developed a position statement called WARNING (Worldwide Antimicrobial Resistance National/International Network Group) aimed at raising awareness of antimicrobial resistance and improving antibiotic prescribing practices worldwide. The statement outlined is 10 axioms, or “golden rules,” for the appropriate use of antibiotics that all healthcare workers should consistently adhere in clinical practice

Amebic Liver Abscess: A disease native to Oman?

Objective: Amebic liver abscess (ALA) is endemic to many areas of the world. In this study we sought to investigate the epidemiology, presentation, laboratory tests and imaging characteristics related to ALA in Oman and ultimately determine whether ALA is native to Oman or is it imported from abroad. Methods: This case series study was conducted at Royal Hospital Muscat, Oman. Patient data was extracted from the Royal Hospital patient database and included patients older than 13 years of age, discharged with the discharge diagnosis of ALA from January 2013 to December 2017. Results: 22 patients were included in the study. The results showed 18 Omani patients and 4 expatriates. Only two Omanis had history of travel abroad. 15 patients were male and 7 females. The average age was 45.2. The most common presentation was abdominal pain seen in 17 patients. Fever was seen in 13 patients. Alanine transferase was found to be elevated in 13 patients. 90% of patients had no symptomatic infections prior to developing ALA. Conclusion: The data suggests that ALA is endemic to Oman given the higher number of local patients and the lack of travel abroad in this population. As the number of treated ALA patients is rather small, it can be concluded that the occurrence of ALA is much lower in Oman as compared to other endemic areas. The majority of patients had no prior symptomatic infections and thus a method of control would be to screen and prevent amebic spread. Keywords: Amebic liver abscess, Amebiasis, liver abscess, Entamoeba histolytica, Royal Hospital, Oma

COVID-19 amongst cancer patients: an experience from Oman

Introduction: The pandemic of coronavirus has no parallel in recent history. Human Life has completely transformed. There are no approved standard therapies. Patients with comorbidities, old age, immunocompromised, and cancer are at higher risk of complicated course and higher mortality. Patients and Methods: This study is an analysis of Cancer patients who got COVID-19 infection to assess the rate, demographics, laboratory data, and mortality. The data was compared, with normal non-cancer COVID-19 infected patients.  Results: The overall number of COVID-19 positive cancer patients was low (0.47%) compared to normal population (2.17%). The mortality in COVID-19 Positive cancer patients was 35.1% vs 1.03%. Diabetic, hypertensive and cardiac patients are more likely to get COVID-19.  Among Normal subjects, ratio of expatriate patients was higher.  Septicemia was more frequent in cancer patients. Non-cancerous patients were more commonly ventilated.  Leucocytosis, renal impairment, Hypocalcemia, high Troponin, high D-dimer, and high transaminases were seen more in non-cancerous patients. A high Lactate dehydrogenase was more common in cancer patients. The mortality from COVID-19 was higher in cancer patients 25% vs 15.7%. Around 72.8% cancer patients received active treatment with in past 4 weeks before COVID-19 infection. Discussion and Conclusions: There are very few reports of COVID-19 infection in cancer patients. The number of patients is small with limited information and capacity of the healthcare system. Oncologists should consider to tailor cancer clinical management. The cancer patients must practice social distancing, and seek early evaluation for symptoms suspicious for COVID-19, testing for virus and chest radiography. Contintuous..

Characteristics of Pyogenic Liver Abscess: Experience of a Single Centre in Oman

Objectives: Liver abscess can develop as a complication of hepatobiliary disease or other intraabdominal infections, but more recently it is associated with primary and secondary liver malignancies and their treatment. The goal of this study was to analyze the epidemiology, etiology and clinical characteristics of pyogenic liver abscess in Oman. The intention was to obtain the information needed for the adequate liver abscess empirical treatment. Methods: This retrospective study took place in a tertiary hospital. Consecutive patients treated for the liver abscess during the five years period, from January 2013 until the end of 2017, were enrolled. Their demographic and clinical data were used to study the characteristics of pyogenic liver abscess in Oman. Results: Fifty-three patients with pyogenic liver abscess were enrolled in the study. They were predominantly male and younger than 60 years. Klebsiella pneumoniae was the most usual bacteria causing the liver abscess. Clinical presentation was unspecific and the abdominal pain and high fever were the most usual symptoms. Conclusion: The majority of pyogenic liver abscesses are caused by K. pneumoniae so the empirical treatment should be started with antibiotic directed against it. Further studies are needed to establish the local role of anaerobic bacteria in pyogenic liver abscess as well as to monitor the presence of hypervirulent K. pneumoniae in Oman. Keywords: Pyogenic liver abscess; Etiology; Epidemiology; Klebsiella pneumoniae

The Impact of Demographic, Clinical Characteristics and the Various COVID-19 Variant Types on All-Cause Mortality: A Case-Series Retrospective Study

(1) Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has rapidly evolved into a pandemic affecting virtually every country in the world. We evaluated the demographic, clinical, laboratory, and all-cause mortality of moderate and severe COVID-19 patients admitted to a tertiary care hospital in Oman during the different COVID-19 waves and variant types. (2) Methods: A case-series retrospective study was carried out between 12 March 2020 and 30 June 2022. All adults over the age of 18 with laboratory-confirmed COVID-19 were enrolled. Analyses were performed using univariate and multivariate statistics. (3) Results: A total of 1462 confirmed cases enrolled with the mean age of the cohort was 55 ± 17 years with significant differences among the groups (p = 0.006). A total of 63% and 80% of the patients were males and citizens of Oman, respectively. Patients infected with the Alpha COVID-19 variant type were more likely to have acute respiratory distress syndrome (ARDS) (p p p p p = 0.001) compared with other COVID-19 variant types. The Delta (adjusted odds ratio (aOR), 1.8; 95% confidence interval (CI): 1.22–2.66; p = 0.003) and Omicron (aOR, 1.88; 95% CI: 1.09–3.22; p = 0.022) COVID-19 variant types were associated with higher all-cause mortality when compared to the initial COVID-19 variant. Old age (aOR, 1.05; 95% CI: 1.04–1.06; p p = 0.04), ICU admission (aOR, 3.41; 95% CI: 2.16–5.39; p p = 0.004), and ARDS (aOR, 5.75; 95% CI: 3.69–8.98; p p = 0.012). (4) Conclusions: Alpha and Delta variants were associated with a longer hospital stay, need for intensive care, mechanical ventilation, and increased mortality. Old age, cardiac renal dysfunction were commonly associated with Omicron variants. Large-scale national studies to further assess the risk factors for mortality related to COVID-19 waves are warranted