Antimicrobial Management of Complicated Skin and Soft Tissue Infections in an Era of Emerging Multi-Drug Resistance: Perspectives from 5 Gulf Countries

The number of complicated skin and soft tissue infections (cSSTIs) in the Arabian Gulf region has risen in recent years, particularly those caused by multi-drug resistant (MDR) pathogens. The high prevalence of diabetes, obesity, and associated cardio-metabolic comorbidities in the region renders medical and surgical management of cSSTI patients with MDR infections challenging. An experienced panel of international and regional cSSTI experts (consensus group on cSSTIs) was convened to discuss clinical considerations for MDR infections from societal, antimicrobial stewardship, and cost perspectives, to develop best practice recommendations. This article discusses antibiotic therapies suitable for treating MDR cSSTIs in patients from the Gulf region and recommends that these should be tailored according to the local bacterial ecology by country and region. The article highlights the need for a comprehensive patient treatment pathway and defined roles of each of the multidisciplinary teams involved with managing patients with MDR cSSTIs. Aligned and inclusive definitions of cSSTIs for clinical and research purposes, thorough and updated epidemiological data on cSSTIs and methicillin-resistant Staphylococcus aureus in the region, clearcut indications of novel agents and comprehensive assessment of comparative data should be factored into decision-making are necessary.

Adult cases of H1N1 influenza dmitted from 2015 to 2016

Background: The clinical characteristics, risk factors and outcomes of H1N1 influenza cases in Bahrain have not been reported

Objective: To evaluate personal and clinical characteristics, risk factors, and outcomes in adults with confirmed H1N1 infection

Setting: Salmaniya medical complex, Bahrain

Design: A retrospective observational study

Method: All H1N1-confirmed-patients admitted between 1 September 2015 and 31 March 2016 were reviewed. Personal and clinical characteristics, risk factors, and outcomes were documented. The analyses were performed using STATA software, version 12 and P-value of <.05 was considered significant

Result: Twenty-six confirmed H1N1 cases were admitted and reviewed. Eight [30.7%] were admitted to the intensive care unit and 5 [19.2%] died. None of the patients received flu vaccine.The age range was 24 to 83 years.The presence of comorbid conditions and smoking were common among the study population; however, it was not statistically significant. A significant association was discovered between mortality and the need for vasopressors [all patients requiring vasopressors died compared to only one among other patients, P-value<.005]

Conclusion: In our study of the flu season of 2015-2016, 5 patients died. We recommend vaccination, especially for high risk groups. The study is limited by the small study-population size and one missing file

Antibiotic appropriateness for urinary tract infection in the emergency room

Background: Urinary Tract Infections [UTI] are a common cause of emergency room [ER] visits and antibiotic misuse

Objective: To evaluate the characteristics of UTI attending ER and to assess antibiotic prescription and inappropriate treatment implications

Design: A Prospective Study

Setting: Salmaniya Medical Complex, Bahrain

Method: Patients aged more than 14 years who presented to the ER with UTI from 1 July 2014 to 31 July 2014 were reviewed. Data was obtained from patients' emergency records and classified according to the type of UTI as complicated, uncomplicated or UTI in pregnancy. Antibiotic treatment was considered appropriate if it followed the Local or International Guidelines

Result: A total of 239 patients were included in the study; 83 [34.7%] were males, 75 [31.4%] were pregnant females and 81 [33.9%] were non-pregnant females, the mean age was 37.56 years. One hundred forty-five [60.7%] patients had complicated UTI. The most prescribed antibiotics were cefuroxime and ciprofloxacin. Seventy-two [30.1%] of inappropriate antibiotics prescription were mostly due to improper duration. Inappropriate antibiotic treatment was significantly more common among males, 43 [17.9%] P-value <0.001; complicated UTI were 63 [26.4%], P-value <0.001. One hundred thirty-three [55.6%] prescriptions were written by emergency doctors, P- value <0.001. There was no significance among the different age groups

Conclusion: High rate of inappropriate antibiotics use in UTI patients mostly in complicated UTI and in patients treated by emergency doctors physicians

Fever in sickle cell disease patients in the Kingdom of Bahrain

Sickle cell disease [SCD] is a hereditary blood disorder characterized by abnormal red blood cell shape [sickling]. The incidence of the disease in the Kingdom of Bahrain is approximately 2.1%. Patients with SCD are prone to multiple health complications, some of which are fatal. A retrospective study was conducted at the Salmaniya Medical Complex in the Kingdom of Bahrain from June, 2012 to December, 2012 to assess the incidence of fever among the SCD in-patients at that institution. The study also assessed the antibiotics administered, type of organisms isolated and patient outcome. The results showed that a total of 59 patients developed fever and 33 of those with fever had a positive culture result [55.93%]. The most common isolate was gram-positive bacteria, most commonly Staphylococcus epidermidis [42.86%], and ceftriaxone was the most commonly prescribed antimicrobial. In conclusion, there was a low rate of hospital acquired infection and special attention needs to be paid to the infection control measures for SCD patients. For most of the SCD fever cases, there was no clear cause of the fever even after extensive diagnostic evaluations; thus, those fevers may have been of a non-infectious etiology in this population. Fortunately, none of the patients had any of the common preventable infections as a result of the high vaccination coverage and strong vaccination program in place in the Kingdom of Bahrain

Clinical practice guidelines for the management of invasive candida infections in adults in the Middle East region: expert panel recommendations

Invasive Candida infections contribute to significant morbidity and mortality in patients with healthcare-associated infections. They represent a major burden on the public health system, and are challenging to diagnose and treat. A multidisciplinary expert panel critically reviewed available evidence to provide consensus recommendations for the management of invasive Candida infections in the Middle East. Based on diagnosis, recommendations were provided for the management of Candida infections in non-neutropenic and neutropenic patients. Polyenes [amphotericin B-deoxycholate [AmB-d] and lipid formulations amphotericin B [LFAmB]], triazoles [fluconazole, itraconazole and voriconazole], echinocandins [caspofungin, anidulafungin, and micafungin] and flucytosine are the recommended categories of antifungal agents for treatment of Candida infections. Echinocandins are preferred for treatment of proven and suspected Candida infections, especially in critically ill patients or those with previous exposure to azoles. Recommendations were also provided for infections caused by specific Candida species as well as management of different disease conditions. The experts highlighted that the guidelines should be used along with clinical judgment. Given the paucity of published data from the region, research in the form of randomized clinical trials should be given priority

Clinical practice guidelines for the treatment of invasive aspergillus infections in adults in the Middle East region: expert panel recommendations

The incidence of invasive Aspergillus infections in the Middle East continues to rise with the increase in the number of immunocompromised patients, and carries significant morbidity and mortality. A panel of experts analysed the evidence from the most recent international guidelines and relevant published literature to reach consensus and develop clear clinical practice guidelines to aid diagnosis and treatment of invasive Aspergillus infections in the Middle East. Disease-specific recommendations were provided for the management of invasive aspergillosis. The expert panel acknowledged that these guidelines should be followed as closely as possible but used alongside clinical judgement

Tetanus in an unvaccinated laborer in Bahrain

Mr. M.D.S., a 27-year-old Indian male, presented with complaints of diffuse body pain and spasms, 7 days after a needle penetrated his right foot at his place of work. He was diagnosed clinically with tetanus. The patient was electively intubated to protect the airway and transferred to an intensive care unit. In addition to his tetanus, he developed multiple hospital-acquired infections. After 34 days, he was successfully extubated and extensive physiotherapy commenced. He was discharged 10 days after extubation

Antibiotics surveillance in pediatrics in-patients, a point prevalence comparative study between kingdom of Bahrain and the European Union

To determine the variation in drug, dose and indications of antimicrobial prescription in children admitted in the hospital and compare the results with the European countries. Point Prevalence Survey [PPS]. All existing pediatric and neonatal wards [medical, surgical, PICU, NICU] within Salmaniya Medical Complex. Data collection was performed using pediatric department and NICU forms. Essential data collected were the patient's biographical data and details about the antibiotics used. The pattern of antibiotics choice and use in Bahrain and the European Union was almost similar in pediatric units. Almost all antibiotics prescribed were on empirical basis. There is a high rate of use of intravenous broad spectrum antibiotics in the pediatric services in Salmaniya Medical Complex for surgical prophylaxis and for medical reasons compared to European Union Centers. The decision to prescribe antimicrobial agents should always be clinically justified and the reasons should be recorded in the patient's medical record. It is important not to prescribe antibiotics on "just in case" basis

Trends of empiric antibiotic usage in an accident and emergency department in a secondary care hospital

Several strategies to optimize the use of antibiotics have been developed. Most of these interventions can be classified as educational or restrictive. Restrictive measures are considered to be more effective, but the enforcement of these measures may be difficult and may lead to conflicts with prescribers. Any intervention should be aimed at targets with the highest impact on antibiotic prescribing. To evaluate the current practices of prescribing antibiotics at the time of admission and to assess the adequacy of empiric antibiotic use and to identify risk factors for inadequate treatment and targets for intervention. A prospective observational study. Salmaniya Medical Complex. From November 2007 to March 2008, patients admitted in the medical department through the emergency and who received antibiotic therapy within 24 hours were included. Antibiotic therapy was considered adequate if the spectrum of coverage, dose, application mode and duration of therapy were appropriate according to local recommendations or published international guidelines. Two hundred admitted patients were evaluated. One hundred nineteen patients' records were traced and evaluated after patients were discharged. Twenty [16.8%] patients received antibiotics within 4 hours: 99 [83.2%] had their first dose of antibiotics within 24 hours of admissions. Empirical antibiotic therapy was inadequate in 14 [11.8%] patients. Initial therapy was adjusted in 61 [51.3%] patients. We found a high rate of inappropriate empiric antibiotic use in our institution, which is similar to other studies. A well-structured and organized antimicrobial team has to be established to implement antimicrobial management program in the hospital. that will ultimately improve the rate of inadequate antibiotic use

Brucellosis with spondylitis

We are reporting what we think is probably the first case of brucellosis in a Bahraini patient. Our patient was a 54 year old Bahraini who presented with a history of fever of three weeks and back pain. He has elevated liver enzymes, highly positive brucella serology and his spinal MRI revealed multilevel spondylitis. He was diagnosed as having Brucellar spondylitis and was treated with two courses of antibiotics over a period of 8 months. He improved dramatically and was discharged from the hospital in March 2007 and since then he had no recurrence