Antimicrobial susceptibility and molecular profiles of acinetobacter baumannii in Makkah hospitals, and the potential use of bacteriophage as a treatment option

frequently causes infections especially in intensive care settings worldwide including Saudi Arabia. This organism is known to acquire resistant to almost all clinically available antimicrobial agents. To understand the magnitude of A. baumannii acquisition in local settings, 895 isolates were collected from King Abdullah Medical City Makkah, Al Noor Hospital and Al Zahir Hospital of Makkah from 2013-2019. Vitek2® system was used for identification of the organism and antimicrobial susceptibility test. Thirty MDR A. baumannii isolates from King Abdullah Medical City Makkah and seven from Al Noor Hospital were selected for whole genome sequencing. To study the role of bacteriophage, sewage water from King Abdullah Medical City Makkah and Al Noor Hospital were screened for clinical isolates A. baumannii lytic phenomenon. A few bacteriophage candidates were found, but the subsequent lytic tests were negative. This phenomenon was studied by reviewing the bacteriophage genomes integrated in the bacterial nucleic acids. In this study, 70-80% of A. baumannii isolated from Makkah hospitals were found to be resistant to commonly used antibiotics in intensive care units. There are increasing trends of resistance to agents that been reserved to treat carbapenem-resistant A. baumannii i.e. tigecycline and colistin. The sequence type (ST)-195 was the predominant sequence type, contributed to 48.6% of A. baumannii isolations in Makkah hospitals. There were three novel sequence types that associated with 18.9% of infections that need further characterization. Among the β-lactamase resistant mutations, this study found blaADC-25 and blaOXA-66 were the most common with 86.5% and 83.8% respectively, followed by blaOXA-23 and blaTEM-1D, both at 37.8%. This study also found 75.7% and 73.0% of the tested MDR A. baumannii isolated from Makkah hospitals acquired mph(E) and msr(E) macrolides resistant genes respectively. The aminoglycosides resistance was encoded mainly by aminoglycoside phosphor-transferase gene, aph(3′′)-Ib at 83.8% and aminoglycoside O-phosphotransferase aph(6)-Id at 70.3%. Besides, these MDR isolates were also acquired of sulphonamide resistant genes of sul1 (32.4%) and sul2 (18.9%). Part of the core of this project was to find the potential bacteriophage that has capability to infect and lyse A. baumannii cells. After extensive searching for bacteriophage from sewage water of two tertiary care hospitals in Makkah, several bacteriophage candidates were shortlisted, however these bacteriophages failed to perform lytic phenomenon consistently. Almost one-fourth of MDR A. baumannii were found to acquire intact bacteriophage genomes, indicated prophages condition. The whole genome sequence of two MDR A. baumannii isolates (AB417 and AB552) were studied before and after bacteriophage treatment indicated additional intact bacteriophage genomes were added in isolate AB552. Three genomes of non-Acinetobacter bacteriophages was found to be integrated in these MDR Acinetobacter series. In conclusion, this study found the resistant rate of A. baumannii were more than 80% in Makkah hospitals which may lead to treatment failure in clinical practice. Searching for a non-pharmacological approach by means of using bacteriophage therapy showed inconsistent outcomes. With few treatment options available, robust infection control strategies and antibiotic stewardship programs are critical for preventing the spread of these resistant strains. Further research is very critical to find alternative agents to treat MDR A. baumannii

Tackling antimicrobial resistance in primary care facilities across Pakistan : current challenges and implications for the future

Antibiotics are gradually becoming less effective against bacteria worldwide, and this issue is of particular concern in economically-developing nations like Pakistan. We undertook a scoping review in order to review the literature on antimicrobial use, prescribing, dispensing and the challenges associated with antimicrobial resistance in primary care (PC) settings in Pakistan. Furthermore, this review aims to identify potential solutions to promote appropriate use of antimicrobials in Pakistan. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) checklist, a comprehensive scoping review was conducted to review the literature of antimicrobials used, prescribed and dispensed in PC settings in Pakistan. Google Scholar and Pub-Med were searched for the period 2000–2023. Papers were analyzed on the basis of eligibility i.e., included antimicrobial use, prescribing and dispensing practices by general population at homes, by prescribers in outpatient departments of hospitals and by pharmacists/dispensers in community pharmacies, respectively. Two researchers analyzed the articles thoroughly and disagreements were resolved through discussion with a third reviewer. Both quantitative and qualitative research studies were eligible for inclusion. Additionally, the selected papers were grouped into different themes. We identified 4070 papers out of which 46 studies satisfied our eligibility criteria. The findings revealed limited understanding of antimicrobial resistance (AMR) by physicians and community pharmacists along with inappropriate practices in prescribing and dispensing antibiotics. Moreover, a notable prevalence of self-medication with antibiotics was observed among the general population, underscoring a lack of awareness and knowledge concerning proper antibiotic usage. Given the clinical and public health implications of AMR, Pakistan must prioritize its policies in PC settings. Healthcare professionals (HCPs) need to reduce inappropriate antibiotic prescribing and dispensing, improve their understanding of the AWaRe (access, watch and reserve antibiotics) classification and guidance, monitor current usage and resistance trends, as well as implement antimicrobial stewardship (ASP) activities starting in targeted locations

Antibiotic utilization patterns for different wound types among surgical patients : findings and implications

Antimicrobial prophylaxis is effective in reducing the rate of surgical site infections (SSIs) post operatively. However, there are concerns with the extent of extend prophylaxis post-operatively especially among low- and middle-income countries (LMICs). This increases antimicrobial re-sistance (AMR), which is a key issue in Pakistan. Consequently, we conducted an observational cross-sectional study among 583 patients undergoing surgery at a leading teaching hospital in Pakistan with respect to the choice, time and duration of antimicrobials to prevent SSIs. Identi-fied varables included post-op prophylactic antimicrobials given to all patients in all surgical procedures. In addition, cephalosporins were frequently used for all surgical procedures and among these, the use of third generation cephalosporins was common. The duration of post-operative prophylaxis was 3-4 days, appreciably longer than guideline suggestions, with most patients prescribed antimicrobials up to discharge. The inappropriate choice of antimicrobials combined with prolonged post-operative antibiotic administration post-operatively need to be addressed. This includes appropriate interventions, including antimicrobial stewardship pro-grams, which have been successful in other LMICs to improve antibiotic utilization associated with SSIs and reduce AM

Antibiotic susceptibility surveillance in the Punjab Province of Pakistan : findings and implications

Background and Objectives: The increase in antimicrobial resistance (AMR) across countries has seriously impacted the effective management of infectious diseases, with subsequent impact on morbidity, mortality and costs. This includes Pakistan. Antimicrobial surveillance activities should be mandatory to continually assess the extent of multidrug-resistant bacteria and the implications for future empiric prescribing. The objective of this retrospective observational study was to monitor the susceptibility pattern of microbes in Pakistan. Materials and Methods: Clinical samples from seven laboratories in Punjab, Pakistan were collected between January 2018 and April 2019, with Punjab being the most populous province in Pakistan. The isolates were identified and their antimicrobial susceptibility was tested using the Kirby-Bauer disc diffusion assay and micro broth dilution methods. The antibiotics assessed were those typically prescribed in Pakistan. Results: In total, 2523 bacterial cultural reports were studied. The most frequently isolated pathogens were Staphylococcus aureus (866, 34.3%), followed by Escherichia coli (814, 32.2%), Pseudomonas aeruginosa (454, 18.0%) and Klebsiella pneumoniae (269, 10.7%). Most pathogens were isolated from pus (1464, 58.0%), followed by urine (718, 28.5%), blood (164, 6.5%) and sputum (81, 3.2%). Conclusions: The findings suggest that current antimicrobial options are severally restricted in Pakistan due to the emergence of multidrug-resistant pathogens. This calls for urgent actions including initiating antimicrobial stewardship programs to enhance prudent prescribing of antibiotics. This includes agreeing on appropriate empiric therapy as part of agreed guidelines, in line with the WHO EML and AWaRe book, whilst awaiting culture reports. This is alongside other measures to reduce inappropriate antimicrobial prescribing and reverse the threat of rising AMR

Ongoing strategies to improve antimicrobial utilization in hospitals across the Middle East and North Africa (MENA) : findings and implications

Antimicrobial resistance (AMR) is an increasing global concern, increasing costs, morbidity, and mortality. National action plans (NAPs) to minimize AMR are one of several global and national initiatives to slow down rising AMR rates. NAPs are also helping key stakeholders understand current antimicrobial utilization patterns and resistance rates. The Middle East is no exception with high AMR rates. Antibiotic point prevalence surveys (PPS) provide a better understanding of existing antimicrobial consumption trends in hospitals, and assist with the subsequent imple-mentation of antimicrobial stewardship programs (ASPs). These are important NAP activities. We examined current hospital consumption trends across the Middle East along with documented ASPs. A narrative assessment of 24 PPS studies in the Region found that, on average, more than 50% of in-patients received antibiotics, with Jordan having the highest rate at 98.1%. Published studies ranged in size from single to 18 hospitals. The most prescribed antibiotics were ceftriax-one, metronidazole, and penicillin. In addition, significant postoperative antibiotic prescribing lasting up to five days or longer was common to avoid surgical site infections. These findings have resulted in a variety of suggested short-, medium-, and long-term actions among key stakehold-ers, including governments and healthcare workers, to improve and sustain future antibiotic prescribing in order to decrease AMR throughout the Middle East

Using culture sensitivity reports to optimize antimicrobial therapy : findings and implications of antimicrobial stewardship activity in a hospital in Pakistan

Background: There are concerns with inappropriate prescribing of antibiotics in hospitals especially broad spectrum in Pakistan and the subsequent impact on antimicrobial resistance rates. One recognized way to reduce inappropriate prescribing is for empiric therapy to be adjusted according to the result of culture sensitivity reports. Objective: Using culture sensitivity reports to optimize antibiotic prescribing in a teaching hospital in Pakistan. Methods: A retrospective observational study was undertaken in Ghurki Trust Teaching Hospital. A total of 465 positive cultures were taken from patients during the study period (May 2018 and December 2018). The results of pathogen identification and susceptibility testing from patient-infected sites were assessed. Additional data was collected from the patient’s medical file. This included demographic data, sample type, causative microbe, antimicrobial treatment, and whether empiric or definitive treatment as well as medicine costs. Antimicrobial data was assessed using World Health Organization’s Defined Daily Dose methodology. Results: A total of 497 isolates were detected from the 465 patient samples as 32 patients had polymicrobes, which included 309 g-negative rods and 188 g-positive cocci. Out of 497 isolates, the most common Gram-positive pathogen isolated was Staphylococcus aureus (Methicillin-sensitive Staphylococcus aureus) (125) (25.1%) and the most common Gram-negative pathogen was Escherichia coli (140) (28.1%). Most of the gram-negative isolates were found to be resistant to ampicillin and co-amoxiclav. Most of the Acinetobacter baumannii isolates were resistant to carbapenems. Gram-positive bacteria showed the maximum sensitivity to linezolid and vancomycin. The most widely used antibiotics for empiric therapy were cefoperazone plus sulbactam, ceftriaxone, amikacin, vancomycin, and metronidazole whereas high use of linezolid, clindamycin, meropenem, and piperacillin + tazobactam was seen in definitive treatment. Empiric therapy was adjusted in 220 (71.1%) cases of Gram-negative infections and 134 (71.2%) cases of Gram-positive infections. Compared with empiric therapy, there was a 13.8% reduction in the number of antibiotics in definitive treatment. The average cost of antibiotics in definitive treatment was less than seen with empiric treatment (8.2%) and the length of hospitalization also decreased. Conclusions: Culture sensitivity reports helped reduced antibiotic utilization and costs as well as helped select the most appropriate treatment. We also found an urgent need for implementing antimicrobial stewardship programs in hospitals and the development of hospital antibiotic guidelines to reduce unnecessary prescribing of broad-spectrum antibiotics

Impact of the International Nosocomial Infection Control Consortium (INICC)’s multidimensional approach on rates of ventilator-associated pneumonia in intensive care units in 22 hospitals of 14 cities of the Kingdom of Saudi Arabia

To analyze the impact of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Approach (IMA) and use of INICC Surveillance Online System (ISOS) on ventilator-associated pneumonia (VAP) rates in Saudi Arabia from September 2013 to February 2017. A multicenter, prospective, before–after surveillance study on 14,961 patients in 37 intensive care units (ICUs) of 22 hospitals. During baseline, we performed outcome surveillance of VAP applying the definitions of the CDC/NHSN. During intervention, we implemented the IMA and the ISOS, which included: (1) a bundle of infection prevention practice interventions, (2) education, (3) outcome surveillance, (4) process surveillance, (5) feedback on VAP rates and consequences and (6) performance feedback of process surveillance. Bivariate and multivariate regression analyses were performed using generalized linear mixed models to estimate the effect of intervention. The baseline rate of 7.84 VAPs per 1000 mechanical-ventilator (MV)-days―with 20,927 MV-days and 164 VAPs―, was reduced to 4.74 VAPs per 1000 MV-days―with 118,929 MV-days and 771 VAPs―, accounting for a 39% rate reduction (IDR 0.61; 95% CI 0.5–0.7; P 0.001). Implementing the IMA was associated with significant reductions in VAP rates in ICUs of Saudi Arabia

Students' participation in collaborative research should be recognised

Letter to the editor