Hydatid disease: the Lebanese contribution

Hydatid disease [HD] or cystic echinococcosis [CE] has been an important zoonotic disease causing medical, economic and public health problems in many parts of the world, including South America, North Africa, Turkey, and Middle Eastern countries. Humans as well as animals, primarily sheep and cattle, are infected by the ingestion of food, usually leafy vegetables, contaminated with the eggs [oncospheres] of the dog tapeworm Echinococcus granulosus. Hydatid cysts, which are the larval stage of the parasite, are located mostly in the liver and lungs of the infected host. Because of its chronic endemicity in Lebanon and neighboring countries, this disease has constituted an integral part of research studies conducted by medical doctors and researchers in Lebanon, mostly spearheaded by those at the American University of Beirut [AUB] and its medical center [AUBMC] since the early turn of the last century [1920s]. Over 130 wide ranging studies were published; some were innovative e.g. the introduction of the once famous Indirect Haemagglutination [IHA] test for serodiagnosis, and the use of dilute cetrimide as a protoscolicidal agent during surgery. Although the incidence of HD is decreasing in our country, it has acquired increasing public health concern and is considered as an emerging or re-emerging disease in many parts of the world. In this review, we shed light on the numerous studies/publications done in Lebanon as a tribute to those researchers who have impacted the literature of HD in many aspects. The latter include epidemiology and ways of transmission, clinical features and radiological tools for diagnosis, serodiagnosis and immunology, and investigation of different therapeutic modalities for different aspects of the disease. Moreover, consolidating these studies in this review would hopefully represent the historic foundation for interested researchers and investigators, especially in this country, to pursue and build on such studies. The advances in technology, and the availability and utilization of new methodologies will hopefully help find more reliable and efficient ways for the diagnosis, and management of this disease

Reflection on bacterial resistance to antimicrobial agents at a major tertiary care center in Lebanon over a decade

Antimicrobial resistance has been inflecting deleterious health and economic consequences locally and globally. This study addresses the patterns and trends of bacterial resistance to antimicrobial agents over a decade, at a major tertiary care center in Beirut. Data on bacterial susceptibility patterns at the CAP accredited Clinical Microbiology Laboratory is analyzed from January 2000 to November 2011, along with related different studies conducted during this period. Increasing rates of ESBL-producing isolates were noted for Escherichia coli, Klebsiella pneumoniae, Salmonella spp. and Shigella spp. Resistance to carbapenems remains problematic in Acinetobacter spp. and Pseudomonas aeruginosa, and started emerging in E. coli and K. pneumoniae. Tigecycline and colistin maintained excellent activity against most ESBL and carbapenem resistant bacteria relevant to the treatment by these agents. Resistance to quinolones is being encountered in Streptococcus pneumoniae, Haemophilus influenzae, Salmonella spp. and Shigella spp. Methicillin resistant Staphylococcus aureus [MRSA], though remaining relatively high, showed decreasing trends of resistance, while vancomycin maintain uniform activity. Rare and sporadic vancomycin resistant strains in enterococci are encountered. Macrolide and clindamycin increasing rates of resistance is noted in S. pneumoniae, group A streptococci, S. aureus, viridans streptococci and some others. Physicians should be aware of the local epidemiology of antimicrobial resistance to properly guide the initial therapy. These resistance problems can be attributed to uncontrolled use of antimicrobial agents, thus, highlighting the need for antimicrobial stewardship to curb this threat

In vitro activity of fosefomycin and other antimicrobials against uropathogenic Escherichia coli and klebsiella pneumonia at a tertiary care center in Lebanon

The incidence of urinary tract infections [UTIs] caused by extended-spectrum-?lactamase [ESBL] producing Escherichia coli [ESBLEC] and Klebsiella pneumoniae [ESBL-KP] has been on the rise limiting oral treatment options. Fosfomycin was reported to be highly efficacious against these organisms, however, data is lacking in Lebanon and the Middle East. To determine the in vitro activity of fosfomycin against ESBL and non-ESBL-producing E. coli and K. pneumoniae uropathogens in Lebanon. A total of 542 consecutive non-duplicate isolates of ESBL-producing E. coli [n = 374] and K. pneumoniae [n = 168], and 291 isolates of non-ESBLproducing E. coli [n = 236] and K. pneumoniae [n = 55] were recovered from urine specimens of patients tested at the American University of Beirut Medical Center [AUBMC] during 2010. Each isolate was tested against a battery of 13 antimicrobials by disk diffusion according to the guidelines of CLSI testing and result interpretation criteria. The fosfomycin susceptibility for ESBLproducing vs. non-ESBL-producing isolates was 86% vs. 97% for E. coli and 62% vs. 78% for K. pneumoniae. This activity of fosfomycin among ESBL-EC and ESBL-KP was generally higher than cefepime [26% and 30%], ciprofloxacin [24% and 41%], Trimeth/sulfa [26% and 19%], Pip/taz [75% and 45%], gentamicin [45% and 42%], and tobramycin [32% and 26%]. On the other hand, higher activity against both species of ESBLproducing bacteria was shown by amikacin [96% and 79%] and imipenem [99.7% and 98.8%]. Nitroflurantoin was highly active against ESBL-EC [95%] but not against ESBL-KP [29%]. Fosfomycin shows good activity, being higher against ESBL-producing E. coli than K. pneumoniae uropathogens in Lebanon

Emergence of fluoroquinolone-resistant Streptococcus pneumoniae in Lebanon: a report of three cases

The global emergence of Streptococcus pneumoniae resistance to fluoroquinolones is alarming and has grown to be a cause for significant concern worldwide. We report the first three cases of levofloxacin resistant S. pneumoniae isolates in a tertiary medical center in Beirut, Lebanon. Judicious use of antimicrobial agents is imperative to limit the spread of such resistant strains

Prevalence of hepatitis B in a presumably healthy Lebanese population

Policy makers need data on the prevalence of infection with HBV in order to determine the cost effectiveness of universal immunization against hepatitis B. This study aims at determining the prevalence rate of infection with HBV in a basically healthy group of Lebanese adults. Sera from 2634 presumably healthy Lebanese individuals, mean age 32.1 years, obtained between 1995-1997, were tested for hepatitis B surface antigen [HBsAg]. The sample was composed of subjects residing in different areas in Lebanon. Detection of HBsAg was performed utilizing the ELISA technique. The analysis took place in the Clinical Microbiology Laboratory, Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon. Chi-square test was used to examine statistical associations. The prevalence of HBsAg among the samples was 1.6%. Blue-collar employees, smokers and those living in the South of Lebanon were significantly more likely to be infected with hepatitis B virus. The data presented indicates that Lebanon has a low prevalence of HBV infection. Cost-effective studies are needed to justify universal immunization against hepatitis B especially in countries where budgets are tight

[Efficacy of bactec TB in the rapid confirmatory diagnosis of mycobacterial infections. A lebanese tertiary care center experience]

Rapid detection of Mycobacterium tuberculosis [MTB], especially multidrug-resistant strains, is of importance for prompt clinical management and initiation of public health control measures. Culture remains the "gold" standard in the confirmatory laboratory diagnosis of mycobacterial infections. The reliability of the automated radiometric BACTEC 460 TB [BAC:, TEC] system for the rapid detection of mycobacteria in clinical specimens was evaluated and compared to the conventional culture on Lowenstein-Jensen [LJ] medium. All clinical specimens submitted for mycobacterial culture were processed and simultaneously cultured on both BACTEC broth medium and Li solid medium. Acid-fast bacilli [AFB] smears were also performed on the sediments. Differentiation of mycobacterial isolates as MTB or Mycobacterium sp. other than tuber-culosis [MOTT] was based on the BACTEC NAP test. All positive culture findings recovered between January 1997 and December 2003 were analyzed in this study.A total of 3300 specimens were tested of which 355 [10.7%] yielded positive cultures consisting of 233 [65.6%] MTB and 122 [34.4%] MOTT. The percentages of AFB smear-positive were 45% and 49% in clinical speci-mens yielding MTB and MOTT, respectively. Though several types of specimens were cultured, most isolates [72% of MTB and 91% of MOTT] were recovered from respiratory specimens. Overall, the BACTEC showed significantly higher mycobacteria recovery rate [91%] than LJ [77%]. In terms of times to detection, BACTEC showed significantly shorter detection time of isolates than L.1 for the overall [mean 9.6 days for BACTEC vs 22.8 days for Li] and for each category of AFB smear finding. The detection time is shortened for BACTEC with the increasing grade of smear positivity. BACTEC is substantially more sen-sitive, efficient and rapid than LJ in the laboratory diagnosis of mycobacterial infections. This system also provides rapid differentiation of MTB from MOTT and susceptibility test results on MTh. However, the simultaneous use of BACTEC and LJ is recommended to provide maximum optimal recovery of isolates from clinical specimens. The time-saving in BACTEC provides an excellent facility for physicians in patient management and to public health personnel for prompt initiation of infection control measures

Etiologic agents of dermatophyte infection in Lebanon

Dermatophytes are common and cause important human fungal infections in many parts of the world, including Lebanon. The prevalence of these fungi, however, tends to vary with time and geographic location. In our region, studies on the prevalence of dermatophytoses and the distribution of the various dermatophyte species involved are rare. In Lebanon, only one study was published on this subject over the last forty years. This study was undertaken to shed light on the types and prevalence of dermatophytes recovered at the American University of Beirut Medical Center [AUBMC], and to compare the findings with those of the only study from the same hospital published in the early 1960s. Records from the clinical microbiology section were reviewed for the patients on whom dermatophyte cultures were requested between 1996 and 2002. All positive cultures were identified and analyzed. Among 1631 submitted specimens for culture [one per patient], 208 [12.7%] yielded 11 species of dermatophytes, dominated by Trichophyton spp. [89.9%], followed by Microsporum spp. [9.1%], Epidermophyton floccosum [0.4%] and Trichosporum beigelii [0.4%]. The male to female ratio was almost 1:1, and the age range was 1 to 77 yrs for both sexes 14% were children [

Glycopeptide and oxacillin activity against Staphylococcus aureus isolates at a tertiary care center in Lebanon

Worldwide reports have noted the emergence of glycopeptides-intermediate Staphylococcus aureus [GISA]. However, data from Lebanon is lacking. We conducted a study to determine the minimum inhibitory concentrations [MICs] for oxacillin [OXA], vancomycin [VAN] and teicoplanin [TEC] against consecutive clinical isolates of S. aureus at a tertiary care center in Lebanon. The categorization of isolates as susceptible, intermediately-resistant, or resistant was based on the OXA agar screen plate [OS] and the 1 /micro g OXA disk diffusion [OD] according to the National Committee for Clinical Laboratory Standards [NCCLS] guidelines. The MICs of OXA, VAN and TEC against these isolates were determined using the E-test. We tested 147 S. aureus isolates, 108 of which were methicillin-resistant [MRSA] and 39 methicillin-susceptible [MSSA]. The rar ges of MICS [micro g/ml] among MRSA and MSSA isolates respectively were: OXA 1.5 >/= 256 and 0.19-3; VAN 1-3 and 1.5-3; TEC 0.094-3 and 0.19-2. The MIC50/90 [micro g/ml] for MRSA versus MSSA isolates were, respectively 24/

Intestinal parasites among presumably healthy individuals in Lebanon.

To determine the prevalence period of intestinal parasites among presumably healthy subjects in Lebanon. One stool specimen from 2634 presumably healthy Lebanese subjects, mean age 32.1 years with a range of 14-71 years, resident of different areas in Lebanon was examined for the presence of parasites. The analysis took place in the Clinical Microbiology Laboratory, Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon, over 25-months between 1995-1997. The prevalence of intestinal parasites was 12.4%. The most common parasites identified were Entamoeba coli [3.8%], Giardia lamblia [3.1%] and Entamoeba histolytica [2.3%]. The data presented shows the need to improve hygienic conditions to contain the problem of intestinal infections with parasites in Lebanon

Molecular fingerprinting of multidrug-resistant mycobacterium tuberculosis strains in Beirut reveals genetic diversity and father to daughter transmission

The typing of six consecutive multidrug-resistant Mycobacterium tuberculosis strains isolated from patients with tuberculosis [TB] at the American University of Beirut Medical Center, was performed by touchdown double-repetitive-element [DRE]-PCR. The isolates exhibited four distinct patterns in DRE-PCR with three isolates exhibiting unique patterns and three isolates yielded similar DNA fragment patterns [cluster pattern]. Only two of the three cluster isolates exhibited identical patterns as revealed by restriction fragment length polymorphism [RFLP] targeting specific mutations in the rpoB and katG genes that confer resistance to rifampin and isoniazid, respectively. A direct epidemiological linkage for the two isolates exhibiting genotypic relatedness was also established as the isolates were recovered from a 33-year-old man and his 8-year-old daughter. The data show that transmission of multidrug-resistant M. tuberculosis strains is contributing to the emergence of drug-resistant TB in Beirut. Combining DRE-PCR with RFLP at the rpo B and katG genes could provide a powerful means for investigating the spread of multidrug-resistant M. tuberculosis strains in Lebanon

current status of hepatitis B in Lebanon

The current status of hepatitis B infection in Lebanon is unknown due to the scarcity of published studies on the subject. This study was conducted to summarize the available information on hepatitis B in lebanon since 1966, as well as to determine the current status of the problem, by analyzing the prevalence of positive hepatitis B surface antigen [HBsAg] reported from different laboratories of major hospitals covering the six districts of Lebanon in the year 2000. The overall HBsAg carrier rate among 61,271 tested individuals was 2.2%, being 13% among 30,809 blood donors, and 3.6% among 13,669 tested individuals in serology laboratories. There were marked geographical variations in the HBsAg carrier rate being 0.8% in Mount Lebanon, 1.9% in each of Bekaa and greater Beirut, 2.2% in north Lebanon, 2.4% in Nabatiyeh, reaching up to 4.7% in south Lebanon. These findings are comparable to the previously reported studies on pregnant women and children, thus confirming that Lebanon is moderately endemic for hepatitis B. Such information stresses the urgent need for efficient national public health surveillance campaigns, and mass vaccination programs. In addition, the universal screening of pregnant women for HBsAg, and the implementation of universal newborn vaccination against hepatitis B virus [HBV] should be the standard of medical care for the control and eradication of HBV in Lebanon

Tuberculous epididymo-orchitis following intravesical BCG for superficial bladder cancer

A seventy-two-year-old man with transitional cell carcinoma of the bladder received intra-vesical Bacillus Calmette-Guerin [BCG] following which he developed left testicular pain and swelling that partially resolved with conservative treatment. Six months later a second course of BCG was given for recurrent disease. Ten months later, he developed left testicular swelling and severe induration along with a draining scrotal sinus. Tuberculous orchitis was suspected and a left orchiectomy was performed. Pathology showed caseating granulomatous orchitis and epididymitis with numerous acid fast bacilli on Ziehl-Neelson stain. The patient received a six-month course of antituberculous therapy. This case highlights a rare but serious complication of intravesical BCG

Available laboratory tests to guide antimicrobial therapy

Physicians are encountering more difficulties in treating and managing patients with infectious diseases due to the continued emergence of single and multi-drug resistant organisms. This emphasizes the need of laboratory tests that are of help in predicting or monitoring response to therapy.Several conventional, special, automated and molecular antimicrobial susceptibility tests are available including the disk diffusion test, determination of the minimal inhibitory concentration, the E test, serum bactericidal titers, and determination of antimicrobial levels in blood. This article addresses these and other antimicrobial tests to update and enlighten the physicians in selecting the most relevant test[s] that will help guiding the therapy of infections caused by different bacterial etiologic agents

Current status and changing trends of antimicrobial resistance in Lebanon

Antimicrobial resistance among microorganisms has been on the rise worldwide including Lebanon. Several surveillance programs have been initiated to monitor the patterns of resistance due to the deleterious consequences on patients management.Thus, knowledge about the local antimicrobial resistance patterns is essential for epidemiologic aspects as well as clinical practice. In this context, the current status and changing trends of antimicrobial resistance in Lebanon are addressed covering the most relevant bacterial, mycobacterial and fungal pathogens

Post immunization Hib antigen detection in the CSF of a patient with meningococcal meningitis

We report a case of meningococcal meningitis where the cerebrospinal fluid was negative for neisseria meningitidis but positive for haemophilus influenzae type b by rapid antigen detection test. We believe that this was due to prior immunization with haemophilus influenzae type b vaccine. We recommend caution in interpretation of the rapid antigen detection tests especially in patients who had been vaccinated against organisms screened by these tests

Prevalence and etiology of intestinal parasites in Lebanon

As there no studies done on the prevalence of intestinal parasites in Lebanon since 1967, this study was undertaken to reveal the current patterns of intestinal parasitic infestations in Lebanese patients from two geographic regions: Beirut and Tripoli. Analysis was based on 33,253 stool specimens examined at the American university of Beirut Medical Center [AUH] and 11,611 specimens examined at the Islamic Hospital [IH] in Tripoli over five and three years, respectively. The prevalence of intestinal parasites at AUH and IH were 8.47% and 45.35% respectively [overall 18%]. The prevalence in males vs females was almost the same being 8.23% vs 8.74% and 44.67%% vs 45.88% at AUH and IH, respectively. Although 18 different types of parasites were encountered the most common pathogenic parasites found at AUHvs IHwere: Giardia Lamblia [20.7% vs 10.5% of parasites found] Entamoeba histolyica [10.41% vs 1.25%] Taenia spp. [6.03% vs 4.08%] and ascaris lumbricoides [2.09% vs 46.97%]. the overall yearly or monthly prevalence of parasites recovered from both hospitals did not show clear seasonal patterns. Compared to developed countries, Lebanon still suffers from a high prevalence and a wide spectrum of intestinal parasites

Hepatitis C virus: prevalence in Lebanese blood donors and brief overview of the disease

Hepatitis C virus [HCV] is recognized as the major cause of non-A, non-B hepatitis. Its prevalence in different patient populations and blood donors has been reported worldwide but not yet from Lebanon. This study was performed to determine the prevalence of HCV antibodies in 536 random Lebanese blood donors using three enzyme immunoassay kits: ETI-AB-HCVK [Sorin, Biomedica, Italy], UBI HCV EIA [Organon Teknika, Netherlands] and ORTHO HCV 2.0 ELISA [Ortho Diagnostic Systems, USA]. The latter was also used as an arbitrator test. Though ETI-AB-HCVK and UBI HCV EIA kits gave higher initial positive results [5.8% and 3.7%, respectively] than ORTHO HCV 2.0 ELISA [1.1%], the over all prevalence of HCV antibody in these blood donors was 0.7%. A brief review of the HCV virus, its epidemiology, clinical features and diagnostic aspects is also presented. A similar testing approach was carried out on additional 3643 blood donors. Confirmatory testing based on CHIRON RIBA HCV 2.0 strip immunoblot assay [Ortho] revealed that the HCV antibody seroprevalence in random Lebanese blood donors is 0.11% and not 0.7% as found by ELISAs alone