strategic plan for combating antimicrobial resistance in Gulf Cooperation Council States

The Gulf Cooperation Council Center for Infection Control [GCC-IC] has placed the emergence of antimicrobial resistance [AMR] on the top of its agenda for the past four years. The board members have developed the initial draft for the GCC strategic plan for combating AMR in 2014. The strategic plan stems from the WHO mandate to combat AMR at all levels. The need for engaging a large number of stakeholders has prompted the GCC-IC to engage a wider core of professionals in finalizing the plan. A multi-disciplinary group of more than 40 experts were then identified. And a workshop was conducted in Riyadh January 2015 and included, for the first time, representation of relevant ministries and agencies as well as international experts in the field. Participants worked over a period of two and a half days in different groups. International experts shared the global experiences and challenges in addressing human, food, animal, and environmental aspects of controlling AMR. Participants were then divided into 4 groups each to address the human, animal, microbiological and diagnostic, or the environmental aspect of AMR. At the end of the workshop, the strategic plan was revised and endorsed by all participants. The GCC-IC board members then approved it as the strategic plan for AMR. The document produced here is the first GCC strategic plan addressing AMR, which shall be adopted by GCC countries to develop country-based plans and related key performance indicators [KPIs]. It is now the role of each country to identify the body that will be accountable for implementing the plan at the country level

Preventing healthcare-associated transmission of the Middle East Respiratory Syndrome [MERS]: Our Achilles heel

Middle East Respiratory Syndrome [MERS] coronavirus is the most recent among the Coronaviridae family to jump species and infect humans. Major health-care associated MERS outbreaks have occurred in the Middle East and Korea that affected both patients and healthcare workers. These outbreaks were characterized by intra and inter-hospital spread and were exacerbated specifically by overcrowding, delayed diagnosis and appropriate use of personal protective equipment. Recent experience with this virus emphasizes the importance of compliance with infection control practices and with other interventions addressing patient triage, placement and flow within and between healthcare facilities. Our Achilles heel remains compliance with the best infection prevention practices and their harmonization with patient flow. Both infection prevention compliance and maintenance of patient flow are critical in preventing healthcare-associated transmission of many of these emerging infectious diseases, including MERS

Pre-employment screening of latent tuberculosis infection among healthcare workers using tuberculin skin test and QuantiFERON-TB Gold test at a tertiary care hospital in Saudi Arabia

To assess the agreement between the tuberculin skin test [TST] and the QuantiFERON-TB Gold test [QFT-G] as pre-employment screening tests for latent tuberculosis infection [LTBI] among healthcare workers. A retrospective cross-sectional study was conducted among 1412 healthcare workers who were screened for LTBI during the period from August 2009 to May 2011 at a tertiary-care hospital in the Kingdom of Saudi Arabia [KSA]. The studied population was screened for LTBI using both TST and QFT-G simultaneously. The agreement between both tests was quantified using the Kappa coefficient [k]. Comparing the results of QFT-G with TST, the tests had a significant overall agreement of 73.7% [1040/1412; k = 0.33; p < 0.01]. Negative concordance comprised 60.1% of the results, and positive concordance comprised 13.5%. However, positive TST but negative QFT comprised 16.3% of the results, and negative TST but positive QFT-G comprised 10.1%. Concordance was significantly associated with young age, female gender, Saudi-born nationals, and early career but not job type [clinical versus non-clinical] nor status of Bacillus Calmette-Guerin [BCG] vaccination. This study demonstrated 73.7% overall agreement between TST and QFT-G results among healthcare workers during pre-employment screening for LTBI. The results need to be confirmed in future studies before recommending QFT-G as a pre-employment screening test for LTBI

Association of compliance of ventilator bundle with incidence of ventilator-associated pneumonia and ventilator utilization among critical patients over 4 years

Several studies showed that the implementation of the Institute for Healthcare Improvement [IHI] ventilator bundle alone or with other preventive measures are associated with reducing Ventilator-Associated Pneumonia [VAP] rates. However, the association with ventilator utilization was rarely examined and the findings were conflicting. The objectives were to validate the bundle association with VAP rate in a traditionally high VAP environment and to examine its association with ventilator utilization. The study was conducted at the adult medical-surgical intensive care unit [ICU] at King Abdulaziz Medical City, Saudi Arabia, between 2010 and 2013. VAP data were collected by a prospective targeted surveillance as per Centers for Disease Control and Prevention [CDC]/National Healthcare Safety Network [NHSN] methodology while bundle data were collected by a cross-sectional design as per IHI methodology. Ventilator bundle compliance significantly increased from 90% in 2010 to 97% in 2013 [P for trend < 0.001]. On the other hand, VAP rate decreased from 3.6 [per 1000 ventilator days] in 2010 to 1.0 in 2013 [P for trend = 0.054] and ventilator utilization ratio decreased from 0.73 in 2010 to 0.59 in 2013 [P for trend < 0.001]. There were negative significant correlations between the trends of ventilator bundle compliance and VAP rate [cross-correlation coefficients -0.63 to 0.07] and ventilator utilization [cross-correlation coefficients -0.18 to -0.63]. More than 70% improvement of VAP rates and approximately 20% improvement of ventilator utilization were observed during IHI ventilator bundle implementation among adult critical patients in a tertiary care center in Saudi Arabia. Replicating the current finding in multicenter randomized trials is required before establishing any causal link

Drug-resistant ventilator associated pneumonia in a tertiary care hospital in Saudi Arabia

There is a wide geographic and temporal variability of bacterial resistance among microbial causes of ventilator-associated pneumonia [VAP]. The contribution of multi-drug resistant [MDR] pathogens to the VAP etiology in Saudi Arabia was never studied. We sought to examine the extent of multiple-drug resistance among common microbial causes of VAP. We conducted a retrospective susceptibility study in the adult intensive care unit [ICU] of King Abdulaziz Medical City, Riyadh, Saudi Arabia. Susceptibility results of isolates from patients diagnosed with VAP between October 2004 and June 2009 were examined. The US National Healthcare Safety Network definition of MDR was adopted. A total of 248 isolates including 9 different pathogens were included. Acinetobacter spp. was highly [60-89%] resistant to all tested antimicrobials, including carbapenems [three- and four-class MDR prevalence were 86% and 69%, respectively]. Pseudomonas aeruginosa was moderately [13-31%] resistant to all tested antimicrobials, including antipseudomonal penicillins [three- and four-class MDR prevalence were 13% and 10%, respectively]. With an exception of ampicillin [fully resistant], Klebsiella spp. had low [0-13%] resistance to other tested antimicrobials with no detected MDR. Staphylococcus aureus was fully susceptible to vancomycin with 42% resistance to oxacillin. There were significant increasing trends of MDR Acinetobacter spp. However not P. aeruginosa during the study. Resistant pathogens were associated with worse profile of ICU patients but not patients' outcomes. Acinetobacter in the current study was an increasingly resistant VAP-associated pathogen more than seen in many parts of the world. The current finding may impact local choice of initial empiric antibiotics.

Comparison of the tuberculin skin test and Quanti-FERON-TB Gold In-Tube [QFT-G] test for the diagnosis of latent tuberculosis infection in dialysis patients

Dialysis patients are more likely than the general population to develop active tuberculosis [TB]. In these patients, the availability of a highly sensitive and specific test to diagnose latent TB will ensure earlier treatment and decreased progression to active disease. In the current study, the Quanti-FERON-TB Gold In-Tube [QFT-G] test was compared with the tuberculin skin test [TST] for the diagnosis of latent tuberculosis infection [LTBI] among 200 hemodialysis patients and 15 confirmed TB disease cases in a tertiary care center in Saudi Arabia. Among the LTBI cases, 26 [13%] were TST positive, and 65 [32.5%] were positive by the QTF-G test, with an overall agreement between the 2 tests of 75.5% [k = 0.34] being observed. Among the confirmed tuberculosis disease cases, none were positive by TST, and 10 [66.7%] were positive by the QTF-G test, resulting in an overall agreement of 33.3% [k = 0]. A comparison between the TST and the QTF-G test was performed based on the sensitivity, specificity, and area under the curve [AUC] obtained for the tests. The QTF-G test was more sensitive and less specific than the TST in predicting the confirmed TB disease cases. When we tested the correspondence of the AUC values between the 2 diagnostic modalities, the obtained p-value was 0.0003. In conclusion, the AUCs of the examined diagnostic modalities are significantly different in predicting LTBI and tuberculosis

Physician 'defiance' towards hand hygiene compliance: Is there a theory-practice-ethics gap?

The theory-practice gap has always existed. This gap is often cited as a culmination of theory being idealistic and impractical, even if practical and beneficial, is often ignored. Most of the evidence relating to the non-integration of theory and practice assumes that environmental factors are responsible and will affect learning and practice outcomes, hence the gap. Therefore, the author believes that to 'bridge the gap' between theory and practice, an additional dimension is required: ethics. A moral duty and obligation ensuring theory and practice integrate. In order to effectively implement new practices, one must deem these practices as worthy and relevant to their role as healthcare providers [HCP]. Hence, this introduces a new concept which the author refers to as the theory-practice-ethics gap. This theory-practice-ethics gap must be considered when reviewing some of the unacceptable outcomes in healthcare practice [3]. The literature suggests that there is a crisis of ethics where theory and practice integrate, and healthcare providers are failing to fulfill our duty as patient advocates. Physician hand hygiene practices and compliance at King Abdulaziz Cardiac Centre [KACC] are consistent with those of other physicians in the global healthcare arena. That is one of noncompliance to King Abdulaziz Medical City [KAMC] organizational expectations and the World Health Organization [WHO] requirements? An observational study was conducted on the compliance of cardiac surgeons, cardiologists and nurses in the authors' cardiac center from January 2010 to December 2011. The hand hygiene [HH] compliance elements that were evaluated pertained to the WHO's five moments of HH recommendations. The data was obtained through direct observation by KAMC infection prevention and control practitioners. Physician hand hygiene compliance at KACC was consistently less than 60%, with nurses regularly encouraging physicians to be diligent with hand hygiene practices in the clinical area. Hand hygiene compliance will not improve unless evidence-based recommendations are adopted and endorsed by all healthcare professionals and providers

Hepatitis B virus among Saudi national guard personnel: seroprevalence and risk of exposure

Data on HBV prevalence among active military personnel in Saudi Arabia [SA] are lacking. In addition, the work-related risk of exposure is unclear. The objective of this study was to estimate the seroprevalence of HBV and the risk of HBV exposure among SA National Guard [SANG] soldiers. A cross-sectional study was performed and included 400 male SANG soldiers working in Jeddah during January 2009. All soldiers completed a questionnaire to assess their risk of exposure and gave a blood sample to test for hepatitis serology markers. A total of 16 [4.0%] soldiers were positive for HbsAg, 53 [13.2%] were positive for anti-HBc, and 230 [57.5%] were positive for anti-HBs. None of the soldiers had acute HBV infection, but 15 [3.8%] were chronic HBV carriers. A total of 152 [38.0%] soldiers were susceptible to HBV infection, and 230 [57.5%] were immune to HBV infection, primarily [84.3%] due to HBV vaccination. Compared with those who were negative for anti-HBc [never exposed], soldiers who were positive for anti-HBc were more likely to be older, have a lower education level, have a higher income, have a longer service duration, have a household member with HBV disease, have undergone surgery, or have undergone endoscopy. In the multivariate logistic regression model, older age, presence of a household member with HBV disease and previous endoscopy were independent predictors of HBV exposure. We report a 4% prevalence of HBsAg in the Saudi military population. This HBV prevalence was higher than those in the general Saudi population and military populations from Western countries. Both work-related and community-related risk factors for exposure are suggested

Benchmarking local healthcare-associated infections: available benchmarks and interpretation challenges

Growing numbers of healthcare facilities are routinely collecting standardized data on healthcare-associated infection [HAI], which can be used not only to track internal performance but also to compare local data to national and international benchmarks. Benchmarking overall [crude] HAI surveillance metrics without accounting or adjusting for potential confounders can result in misleading conclusions. Methods commonly used to provide risk-adjusted metrics include multivariate logistic regression analysis, stratification, indirect standardization, and restrictions. The characteristics of recognized benchmarks worldwide, including the advantages and limitations are described. The choice of the right benchmark for the data from the Gulf Cooperation Council [GCC] states is challenging. The chosen benchmark should have similar data collection and presentation methods. Additionally, differences in surveillance environments including regulations should be taken into consideration when considering such a benchmark. The GCC center for infection control took some steps to unify HAI surveillance systems in the region. GCC hospitals still need to overcome legislative and logistic difficulties in sharing data to create their own benchmark. The availability of a regional GCC benchmark may better enable health care workers and researchers to obtain more accurate and realistic comparisons

Impact of infection control educational activities on rates and frequencies of percutaneous injuries [PIs] at a tertiary care hospital in Saudi Arabia

To study the impact of educational activities on the rates and frequencies of percutaneous injuries [PIs] at a tertiary care hospital in Saudi Arabia. PI surveillance is a routine activity in King Abdulaziz Medical City [a 900-bed teaching tertiary health care hospital] in Riyadh using the Exposure Prevention Information Network [EPINet] data collection tool. From 2001 through 2003, educational activities were conducted for health care workers [HCWs] to prevent PIs. The education included lectures on the risk of unsafe practices that may lead to PIs and how to avoid them. Data from before [1997-2000] and after [2004-2008] the intervention were imported from our surveillance system and statistically analyzed. The total overall rate of PIs per 1000 HCWs was significantly lower in the post-intervention period than in the pre-intervention period [14 vs. 32.8/1000 HCWs, respectively]. The rates of PIs among nurses and housekeepers showed a significant decrease [15 vs. 37.6/1000 HCWs and 10 vs. 34.5/1000 HCWs, respectively]. The frequency of PIs in the emergency department [ED] and intensive care units [ICUs] showed a significant decrease [3.4% for both vs. 12.4% and 13.7%, respectively]. PIs associated with devices, such as needles on IV lines, IV catheters, lancets and suture needles, showed a significant decrease. PIs occurring during device disassembly and from inappropriately discarded devices also decreased significantly. The educational program reduced some categories of PIs, including the overall rate, the rate among nurses and housekeepers, the frequency in the ED and ICUs and the frequency among needles on IV lines, IV catheters, lancets and suture needles. Other PI categories did not change significantly

Carriage of staphylococcus aureus among Hajj pilgrims

To evaluate the prevalence of methicillin resistant Staphylococcus aureus [MRSA] carriage among a cohort of pilgrims during 2004 Hajj season. Pilgrims attending the 2004 Hajj season were recruited and screened for carriage of MRSA. Standard microbiological techniques were used to screen for the presence of MRSA. Out of 411 individuals screened, 85 [20.6%] were positive for Staphylococcus aureus [S. aureus] of which only 6 [1.46%] were MRSA. Four individuals [4.6%] had the S. aureus organism in both nasal and axillary swabs, while 7 individuals [8%] had the organism in their axillae only. The other 74 individuals [87.1%] had the organism in their nares only. The 6 MRSA isolates were positive for the mecA gene by polymerase chain reaction method. None of the pilgrims examined had any risk factors for community-acquired methicillin resistant S. aureus [CAMRSA]. Overall, the prevalence of MRSA in the population of pilgrims examined was found to be low [1.46%] in comparison with most community based studies. A low rate of MRSA carriage was noticed among the screened cohort. Physicians treating patients suspected of S. aureus infection during the Hajj pilgrimage should bear in mind the possibility of community acquired - MRSA and should obtain appropriate samples for bacterial cultures and susceptibility testing so that antimicrobial agents could be introduced when necessary at a later stage