Health care-associated infections, including device-associated infections, and antimicrobial resistance in Iran: The national update for 2018

Introduction. Surveillance of health care-associated infections (HAIs) is an essential part of an efficient healthcare system. This study is an update on incidence and mortality rates of HAIs in Iran in 2018. Methods. Almost all hospitals across the country (940 hospitals) entered the data of HAIs and denominators to the Iranian Nosocomial Infections Surveillance (INIS) software. Statistics were derived from INIS. Results. From 9,607,213 hospitalized patients, 127,953 suffered from HAI, 15.65% of whom died. The incidence rate of HAI was calculated as 4.2 per 1000 patient-days. Considering relative frequencies among HAIs, Pneumonia (29.1%) and UTIs (25.6%) were the most common types of infection. Ventilator-associated pneumonia (VAP) was the most frequent device-associated infection (DAI) 25.66 per 1000 ventilator-days, and had the highest mortality rate (43.08%). Incidence density of other DAIs was 5.43 for catheter-associated UTI and 2.86 for catheter-associated BSI per 1000 device-days. Medical ICUs had the highest incidence and percentage of deaths (15.35% and 37.63%, respectively). The most causative organisms were Escherichia coli, Acinetobacter baumannii, and Klebsiella pneumonia. The rate of methicillin-resistance Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Klebsiella pneumoniae carbapenemase (KPC)-producing bacteria was about 49%, 57%, and 58% respectively. Conclusion. The findings indicate that HAIs in Iran require special attention, and further studies are needed to evaluate them more accurately, identify risk factors and preventive interventions

Clonal Relationship and Resistance Profiles Among ESBL-Producing Escherichia coli

AmpC β-lactamases hydrolyze all β-lactams except cefepime and carbapenems. The study of AmpC-producing E. coli has high priority for the infection control committee. This research is aimed to investigate the resistant urinary AmpC-generating E. coli isolates and identify their genetic variety. Some 230 E. coli isolates from patients suffering urinary tract infection symptoms were studied in 2017–2018 to assess their susceptibility toward antimicrobial agents. AmpC gene was evaluated by PCR and molecular typing using the 10-loci MLVA method. MLVA images were examined by BioNumerics 6.6 software through the use of the UPGMA algorithms. Thirty-eight AmpC-generating E. coli isolates were detected. The most abundant determinant was blaCIT and blaEBC, blaFOX, and blaDHA had the next ranks, respectively. Six major clusters and a singleton were identified by MLVA. AmpC beta-lactamases in urinary isolates of E. coli in the hospital under study and high rate of additional resistance to gentamicin, cotrimoxazole and ciprofloxacin. The most frequent gene determinant of AmpC beta-lactamase was blaCIT and vary depending on time and geographical location

Priority Setting for Improvement of Cervical Cancer Prevention in Iran

Background: Cervical cancer is the fourth most common cancer among women worldwide. Organized cervical screening and vaccination against human papilloma virus (HPV) have been successful interventions for prevention of invasive cervical cancer (ICC). Because of cultural and religious considerations, ICC has low incidence in Iran and many other Muslim countries. There is no organized cervical screening in these countries. Therefore, ICC is usually diagnosed in advanced stages with poor prognosis in these countries. We performed a priority setting exercise and suggested priorities for prevention of ICC in this setting. Methods: We invited experts and researchers to a workshop and asked them to list important suggestions for ICC prevention in Iran. After merging similar items and removing the duplicates, we asked the experts to rank the list of suggested items. We used a strategy grid and Go-zone analysis to determine final list of priorities for ICC prevention in Iran. Results: From 26 final items suggested as priorities for prevention of ICC, the most important priorities were developing national guidelines for cervical screening and quality control protocol for patient follow-up and management of precancerous lesions. In addition, we emphasized considering insurance coverage for cervical screening, public awareness, and research priorities, and establishment of a cervical screening registry. Conclusion: A comprehensive approach and implementation of organized cervical screening program is necessary for prevention of ICC in Iran and other low incidence Muslim countries. Because of high cost for vaccination and low incidence of cervical cancer, we do not recommend HPV vaccination for the time being in Iran

The Mechanism of Resistance in AmpC-Producing Escherichia coli Isolated from Urinary Tract Infections: Mechanism of Resistance in AmpC-Producing

Background and Aim: AmpC β-lactamases are capable of hydrolyzing all β-lactams except cefepime and carbapenems. The detection of AmpC-producing Escherichia coli has a high priority in infection management. This research is aimed to investigate the resistant AmpC- generating E. coli isolates and identify their genetic variety. Methods: In this study, 230 E. coli isolates from patients having urinary tract infection symptoms were investigated in 2017-2018 to assess their susceptibility toward antimicrobial agents. AmpC genes were evaluated by PCR and molecular typing using the 10-loci MLVA method. MLVA images were examined by BioNumerics 6.6 software through the use of the UPGMA algorithms. Results: The highest frequencies of susceptibility among E. coli isolates were to meropenem 96.08%, piperacillin-tazobactam 90.43%, followed by gentamicin 66.54%, ceftazidime 50%, ciprofloxacin 48.26%, ceftriaxone 41.74%. All E. coli isolates were resistant to amoxicillin-clavulanate. Thirty-eight AmpC-generating E. coli isolates were detected. The most abundant determinant was CIT and EBC, FOX, and DHA had the next ranks, respectively. Six major clusters and a singleton were identified by MLVA. Conclusion: AmpC-generation ability is an effective feature in the resistance of E. coli isolates and its investigation is of crucial significance in infection management. The major mechanisms of AmpC beta-lactamase vary depending on time and geographical location. *Corresponding Author: Mohammad Rahbar; Email: [email protected] Please cite this article as: Dolatyar Dehkharghani A, Haghighat S, Rahnamaye Farzami M, Rahbar M. The Mechanism of Resistance in AmpC-Producing Escherichia coli Isolated from Urinary Tract Infections. Arch Med Lab Sci. 2020;6:1-9 (e6). https://doi.org/10.22037/amls.v6.3257

Correlation of Maternal Age, Weight, Pregnancy - associated Plasma Protein A, Free Beta-human Chorionic Gonadotropin, Fetal Crown-rump Length, and Fetal Gender with Fetal DNA Fraction in Non-invasive Prenatal Testing: An Experiment on Iranian Pregnant Women

Background: Non-invasive prenatal testing (NIPT) as a novel screening method has been widely proposed to screen for common fetal chromosomal aneuploidies. The aim of the present study was to examine the possible effects of maternal age, maternal weight, fetal crown-rump length (CRL), serum pregnancy-associated plasma protein A (PAPP-A), free beta-human chorionic gonadotropin (free β-hCG), and fetal gender on cell-free fetal DNA (cffDNA) percentage fluctuations. Methods: In the present cross-sectional study, 308 singleton pregnant women aged 20-47 years at 11+0 to 13+6 weeks of pregnancy referring to the DeNA Laboratory in Tehran, Iran, for NIPT test during a one-month period between July 2018 and August 2018 were selected randomly. The cffDNA was extracted from maternal plasma. Whole exome sequencing by a ion semiconductor sequencer using cffDNA was applied for all participants. The PAPP-A and free β-hCGas biochemical biomarkers were assessed using a closed chemilumine scence immunoassay analyzer. The Shapiro-Wilk test, Pearson analysis, beta regression analysis, and Mann-Whitney U test were performed to analyze the data. Results: In the screening population, the cffDNA percentage showed no significant correlation with CRL and maternal age (P=0.096 and P=0.881, respectively). However, the cffDNA percentage correlated well with maternal weight, PAPP-A, and free β-hCG (P=0, P=0.009, and P=0.001, respectively). Beta regression between cffDNA percentage and maternal weight, free β-hCG, and PAPP-A was significant (P<0.001). The mean cffDNA percentage between male and female fetal groups showed a significant difference (P<0.001). Conclusion: This study demonstrated that the cffDNA percentage in the first trimester of pregnancy had a negative correlation with maternal weight and a positive correlation with PAPP-A and free β-hCG values. Furthermore, the cffDNA percentage in male fetuses was higher than that in female fetuses

The Frequency of Integrons and OXA Genes in Uropathogenic Isolates of Klebsiella pneumoniae: Transmission of antimicrobial resistance in Klebsiella pneumoniae

Background and Aim: One of the most critical concerns in Klebsiella pneumoniae isolated from nosocomial infections is antibiotic resistance due to transferable resistance genes. This study aims to investigate the relationship and role of integrons in the transport of OXA-type genes in the production of carbapenem-resistant isolates. Methods: In this study, 270 isolates of K. pneumoniae were isolated from patients with urinary tract infection symptoms hospitalized at Milad hospital of Tehran during 2017-2018. The biochemical methods confirmed K. pneumoniae isolates. Also, antimicrobial susceptibility testing was performed using an E-test method. Carbapenem-resistant isolates were confirmed using an automated antimicrobial susceptibility testing system (Phenix BD USA). The presence of OXA genes, integron, and its class were determined by PCR method. Results: According to our findings, the most effective antibiotics against uropathogenic K. pneumoniae isolates were piperacillin-tazobactam and meropenem, respectively. Out of the 270 isolates, 27 (10%) were detected as carbapenem-resistant K. pneumoniae isolates. Moreover, 47.2%, 40.1%, 39.2%, and 36.4% of K. pneumoniae isolates were resistant to ceftriaxone, ceftazidime, trimethoprim-sulfamethoxazole, and amoxicillin/clavulanate, respectively. A significant proportion of isolates had class I integron. Meaningful differences in OXA-51, 58, and 24 genes were found in carbapenem-resistant and carbapenem-susceptible K. pneumoniae isolates. No significant relationship was observed between class 1 and 2 integrons and other studied gene determinants of antimicrobial resistance. Conclusion: According to the observed results, OXA-23, OXA-24, OXA-58, and OXA-51-like groups were the most prevalent genes in carbapenem-resistant K. pneumoniae isolates, respectively. Also, 97.9% of carbapenem-susceptible K. pneumoniae isolates had class 1 integron. *Corresponding Author: Dr. Mohammad Rahbar; Email: [email protected] ORCID: https://orcid.org/0000-0003-2292-3175 Please cite this article as: Pourbaghi E, Hosseini Doust R, Rahbar M, Rahnamaye Farzami M. The Frequency of Integrons and OXA Genes in Uropathogenic Isolates of Klebsiella pneumoniae. Arch Med Lab Sci. 2021;7:1-8 (e23). https://doi.org/10.22037/amls.v7.3517

First-trimester Combined Screening for Trisomies 21, 18, and 13 by Three Closed Chemiluminescence Immunoassay Analyzers (an Experiment on Iranian Pregnant Women)

Background: Pregnancy-associated plasma protein-A (PAPP-A) and free β-human chorionic gonadotropin (free β-hCG) as valuable biochemical biomarkers are used to screen down syndrome, Edwards syndrome, and Patau syndrome in the first trimester of pregnancy. Closed immunoassay analyzers are regarded as sophisticated platforms to measure biochemical biomarkers. This study compared the performance of three chemiluminescence analyzers when used for combined screening.Methods: The present cross-sectional study was conducted on 371 pregnant women within the age range of 20-47 years during 11+0 to 13+6 weeks of pregnancy referring to Dena laboratory in Tehran, Iran, during July 2018 and August 2018 using random selection. The biochemical biomarkers of PAPP-A and free β-hCG were assayed on Cobas, Immulite, and Maglumi analyzers. Benetech software as a commercial screening software was used to calculate the risks of trisomy 21 (T21), trisomy 18 (T18), and trisomy 13 (T13). Deming regression, nonparametric spearman analysis, analysis of variance, and Chi-square test were performed to analyze the data.Results: For the screening population, although the three systems well correlated to PAPP-A and free β-hCG, the values of Maglumi were slightly higher than those reported for Cobas and Immulite. The multiples of the median (MoM) of PAPP-A and free β-hCG had a significant correlation on three platforms. There were no significant differences between the calculated risks of T21, T18, and T13 on the three systems. The sensitivity for all systems was reported as 50%. In addition, specificity and negative predictive value (NPV) were higher than 99% and 95%, respectively. Positive predictive value (PPV) was reported as less than 50%.Conclusion: The obtained results of the present study demonstrated that there were significant correlations between three different systems in terms of PAPP-A and free β-hCG values and MoMs. The sensitivity of all systems for all trisomies was 50%; however, the specificity of all systems was almost the same. The best PPV and NPV for T21 were on Cobas, Immulite, and Maglumi, respectively. The PPV and NPV of all systems for T18/13 were almost the same

Real-Time Assay as A Tool for Detecting lytA Gene in Streptococcus pneumoniae Isolates

Objective: In-time diagnosis of Streptococcus pneumoniae (S. pneumonia) can play a significant role in decreasing morbidity and mortality rate. Applying molecular methods has gained popularity due to the existing limits of routine diagnostic methods. Examining the expression of different genes of this bacterium through different molecular methods suggests that lytA gene has a higher sensitivity and specificity in diagnosis of Streptococcus pneumoniae. The aim of this study was to evalutate lytA gene expression in diagnosis of invasive S. pneumonia in culture positive specimens by real-time polymerase chain reaction (PCR). Materials and Methods: IIn this a descriptive study, All received specimens were isolated to identify S. pneumoniae. DNA was then extracted and after optimizing the test and determining the detection limit, samples were tested by real-time PCR using lytA gene primers. Results: Twenty seven isolates were diagnosed as S. pneumoniae. In all, the extracted DNA was positive in real-time method. The electrophoresis of the products also confirmed the presence of single product b along with the 53 base pair fragment. The detection limit of the test was less 6 colony forming unit (CFU). Conclusion: Real-Time PCR seems to provide reliable and rapid results. We suggest that this test should be conducted on the preliminary isolated specimens, since applying various biochemical tests need one extra working day

Real-Time Assay as A Tool for Detecting lytA Gene in Streptococcus pneumoniae Isolates Citation

Abstract Objective: In-time diagnosis of Streptococcus pneumoniae (S. pneumonia) can play a significant role in decreasing morbidity and mortality rate. Applying molecular methods has gained popularity due to the existing limits of routine diagnostic methods. Examining the expression of different genes of this bacterium through different molecular methods suggests that lytA gene has a higher sensitivity and specificity in diagnosis of Streptococcus pneumoniae. The aim of this study was to evalutate lytA gene expression in diagnosis of invasive S. pneumonia in culture positive specimens by real-time polymerase chain reaction (PCR). Materials and Methods: IIn this a descriptive study, All received specimens were isolated to identify S. pneumoniae. DNA was then extracted and after optimizing the test and determining the detection limit, samples were tested by real-time PCR using lytA gene primers. Results: Twenty seven isolates were diagnosed as S. pneumoniae. In all, the extracted DNA was positive in real-time method. The electrophoresis of the products also confirmed the presence of single product b along with the 53 base pair fragment. The detection limit of the test was less 6 colony forming unit (CFU). Conclusion: Real-Time PCR seems to provide reliable and rapid results. We suggest that this test should be conducted on the preliminary isolated specimens, since applying various biochemical tests need one extra working day

Priority Setting for Improvement of Cervical Cancer Prevention in Iran

Background Cervical cancer is the fourth most common cancer among women worldwide. Organized cervical screening and vaccination against human papilloma virus (HPV) have been successful interventions for prevention of invasive cervical cancer (ICC). Because of cultural and religious considerations, ICC has low incidence in Iran and many other Muslim countries. There is no organized cervical screening in these countries. Therefore, ICC is usually diagnosed in advanced stages with poor prognosis in these countries. We performed a priority setting exercise and suggested priorities for prevention of ICC in this setting. Methods We invited experts and researchers to a workshop and asked them to list important suggestions for ICC prevention in Iran. After merging similar items and removing the duplicates, we asked the experts to rank the list of suggested items. We used a strategy grid and Go-zone analysis to determine final list of priorities for ICC prevention in Iran. Results From 26 final items suggested as priorities for prevention of ICC, the most important priorities were developing national guidelines for cervical screening and quality control protocol for patient follow-up and management of precancerous lesions. In addition, we emphasized considering insurance coverage for cervical screening, public awareness, and research priorities, and establishment of a cervical screening registry. Conclusion A comprehensive approach and implementation of organized cervical screening program is necessary for prevention of ICC in Iran and other low incidence Muslim countries. Because of high cost for vaccination and low incidence of cervical cancer, we do not recommend HPV vaccination for the time being in Iran