Three distinct clones of carbapenem-resistant Acinetobacter baumannii with high diversity of carbapenemases isolated from patients in two hospitals in Kuwait

This study was undertaken to investigate the clonal relatedness of multidrug-resistant [MDR] Acinetobacter baumannii isolates collected from patients in two teaching hospitals in Kuwait. Clinically significant consecutive isolates of A. baumannii obtained from patients in the Mubarak [36] and Adan [58] hospitals over a period of 6 months were studied. These isolates were identified using molecular methods, and their antimicrobial susceptibility was determined by the Etest method. The mechanism of resistance to carbapenem was investigated by PCR, and pulsed-field gel electrophoresis [PFGE] was used to determine the clonal relatedness of MDR isolates. Of the 94 isolates investigated, 80 [85.1%] were multidrug resistant [MDR]. The A. baumannii PFGE clone A and subclone A1 were the most prevalent in patients infected with MDR isolates. Fifty-five [94.8%] and 15 [41.7%] of the MDR isolates from the Adan and Mubarak hospitals, respectively, belonged to PFGE clone A; isolates in this group showed higher resistance rates to antibiotics than isolates form other groups. Of the 94 isolates, 40 [42.6%] were resistant to either imipenem or meropenem or to both [CRAB]. Most CRAB isolates [29/40 or 72.5%] carried bla genes, which code for MBL [VIM-2 and IMP-1] enzymes. Two isolates harbored bla[OXA]23- Three distinct clones of CRAB were isolated, providing evidence of a high diversity of carbapenemases among our geographically related isolates. 2011 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved

Sequence analysis of bla [CTX-M] genes carried by clinically significant Escherichia coli isolates in Kuwait hospitals

To investigate the extent, distribution and sequence analysis of bla[CTX-M] genes carried by Escherichia coli isolated from patients admitted to all government hospitals in Kuwait. Extended-spectrum beta-lactamase [ESBL]-producing E. coli isolates were collected from the 8 major hospitals in Kuwait. CTX-M ESBLs were analyzed by PCR and sequenced. Clonality of the positive isolates was determined for genetic relatedness using pulsed-field gel electrophoresis [PFGE] with XbaI digestion of the genomic DNA. Of the 136 ESBL-positive isolates, 106 [77.9%] harbored bla[CTX-M] genes. Among these, bla[CTX-M-15] was the most frequent with a prevalence rate of 84.1%, followed by bla[CTX-M-14] [6.8%], bla[CTX-M-14b] [5.7%] and bla[TOHO-1] [3.4%]. Ninety-three [87.7%] were isolated from Kuwaiti [35.9%], Egyptian [31.1%] and Indian [20.8%] nationals; the majority of isolates positive for bla[CTX-M-15] were mainly from these 3 nationalities. PFGE analysis did not demonstrate any clustering of positive isolates in any particular hospital. This study confirms an explosive emergence of CTX-M-15 beta-lactamase among E. coli isolates in Kuwait and shows that the strains were clonally heterogeneous with no evidence of inter- or intra-hospital spread. Thus Kuwait may represent an important source of CTX-M-15-positive E. coli

prevalence of chlamydia trachomatis and neisseria gonorrhoeae infections among men with urethritis in Kuwait

Chlamydial non-gonococcal urethritis and gonorrhoea are the most common sexually transmitted bacterial infections worldwide. Data on these infections are scanty in the Islamic world, especially Kuwait. The objective of this study was to establish the prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae among men with symptomatic urethritis in Kuwait. Men with urethral discharge seen and managed at eight governmental hospitals were recruited into the study. A pair of urethral swab and first-voided urine sample were taken from the patients and sent immediately to the laboratory where they were processed using strand displacement nucleic acid amplification kits [SDA; Probe Tec, Becton Dickinson]; one pair per patient was studied. A total of 426 symptomatic men were studied, out of whom 155 [36.4%] were infected by either C. trachomatis or N. gonorrhoeae, or both. The overall prevalence rates of C. trachomatis and N. gonorrhoeae were 12.4% and 23.9%, respectively. There was no significant difference in chlamydial and gonococcal prevalence between Kuwaiti men and non-Kuwaitis [P > 0.05]. Infection rates were much lower in married men than unmarried men. Men in the age range of 21-35 years were more vulnerable to both infections. The findings show that N. gonorrhoeae and, to a lesser extent, C. trachomatis are common in men with urethritis in Kuwait. Appropriate preventive strategies that conform to Islamic rules and values should be of highest priority of the policymakers

Comparative in vitro activity of tigecycline and other antimicrobial agents against Shigella species from Kuwait and the United Arab of Emirates

Shigella species isolated from stool samples of symptomatic patients of all age groups at the Mubarak Al Kabir Hospital and Infectious Diseases Hospital, Kuwait and Tawam Hospital, UAE during a 2-year period were investigated for their susceptibility to tigecycline and several other antibiotics by determining the minimum inhibitory concentrations [MICs] using the E test method. A total of 100 and 42 strains were collected from UAE and Kuwait, respectively. The extent of drug resistance in the Shigella spp. isolates from these two countries was analyzed by criteria recommended by the Clinical and Laboratory Standards Institute [CLSI]. Amikacin, cefotaxime, cefuroxime, ciprofloxacin, imipenem, meropenem, piperacillin-tazobactam and tigecycline had excellent activities against all isolates from UAE and Kuwait with MIC[90s] of 12, 0.094, 4, 0.012, 0.25, 0.032, 3 and 0.25micro g/ml and 4, 1, 4, 0.125, 0.38, 0.19, 3 and 0.25 micro g/ml, respectively. Half of all isolates from both countries were resistant to ampicillin. None of the isolates in Kuwait was resistant to amoxicillin-clavulanic acid compared with 22% in UAE. Resistance to chloramphenicol was recorded in 50 and 36% of the isolates in Kuwait and UAE, respectively. The percentages of non-susceptibility to trimethoprim-sulfamethoxazole and tetracycline were very high in Kuwait and UAE [76% vs. 92% and 76% vs. 98%, respectively]. Notably, one isolate, S. flexneri, from UAE had reduced susceptibility to ciprofloxacin [MIC, 0.25 micro g/ml]. Four [2.8%] of the isolates were ESBL producers by the E test ESBL method but could not be confirmed by PCR using primers for bla[tem], BLA [SHV] and- bla[tem]. In conclusion, Shigella spp. isolated from symptomatic patients in Kuwait and the UAE demonstrated high

case of community-onset meningitis caused by hospital methicillin-resistant staphylococcus aureus successfully treated with linezolid and rifampicin

To report a relatively rare presentation of methicillin-resistant Staphylococcus aureus [MRSA] meningitis in a previously healthy boy in Kuwait. A 14-year-old boy presented with a 2 weeks' history of headache and fever with increasing severity. He developed photophobia and double vision 2 days prior to his hospital visit and received ceftriaxone for 6 days prior to admission to the hospital. There was no history of head trauma or neurosurgical operation. Lumbar puncture revealed a slightly turbid cerebrospinal fluid with pleocytosis and greatly reduced glucose, elevated protein level and on culture grew MRSA. Staphylococcal chromosome cassette mec [SCCmec] typing revealed that it belonged to SCCmec type III and sequence type 238 [ST238-SCCmec-lll]. Polymerase chain reaction screening for the presence of Panton-Valen-tine leukocidin [PVL] genes yielded a negative result; all these findings were consistent with hospital-acquired MRSA. He was treated with intravenous linezolid and rifampicin for 2 weeks, made good response and was discharged home fully recovered and well. Hospital MRSA should be considered in the differential diagnosis of the causative agents of community-onset meningitis in healthy patients even without predisposing factor

Antibiotic therapeutic options for infections caused by drug-resistant Gram-positive cocci

Serious infections caused by Gram-positive bacteria are currently difficult to treat because many of these pathogens are now resistant to standard antimicrobial agents. As a result of the emergence and spread of multidrug-resistant Gram-positive pathogens, new antimicrobial agents are urgently needed for clinical use. In recent years, there has been an increase in the number of drugs that have activity against these Gram-positive pathogens. Daptomycin, tigecycline, linezolid, quinupristin/dalfopristin and dalbavancin are five antimicrobial agents that are useful for the treatment of infections due to drug-resistant Gram-positive cocci. This review focuses on their mechanism of action, pharmacokinetics, spectrum of activity, clinical effectiveness, drug interaction and safety. These antimicrobial agents provide the clinician with additional treatment options among the limited therapies for resistant Gram-positive bacterial infection

Surveillance of antibacterial resistance in Staphylococcus aureus isolated in Kuwaiti hospitals

To investigate the prevalence of antibiotic resistance among Staphylococcus aureus isolated in Kuwaiti hospitals. S. aureus were isolated and identified following standard microbiological methods. Antibacterial susceptibility test was performed by disk diffusion and the measurement of minimum inhibitory concentration with E-test strips. A total of 1,846 S. aureus isolates were analyzed from 13 hospitals between 1 March and 30 October 2005. They were isolated from 1,765 [95.6%] inpatients and 81 [4.4%] outpatients. Methicillin resistance was detected in 588 [32.0%] of the isolates. The methicillin-resistant S. aureus [MRSA] consisted of 461 [78%] multiresistant and 127 [22%] nonmultiresistant isolates. The non-multiresistant MRSA consisted of epidemic MRSA-15 and community-associated MRSA. The community-associated MRSA was detected in all hospitals with MRSA, indicating its establishment in Kuwaiti hospitals. The proportion of isolates resistant to gentamicin, kanamycin, erythromycin, tetracycline, ciprofloxacin, fusidic acid and trimethoprim was higher among MRSA than methicillin-susceptible S. aureus [MSSA] isolates. Twenty-four and 22% of MRSA and MSSA isolates, respectively, expressed reduced susceptibility to vancomycin [minimum inhibitory concentration = 3-4 mg/l]. The study revealed the presence of methicillin resistance in 32% of S. aureus isolated in Kuwaiti hospitals and revealed an increase in the number of MRSA and MSSA with reduced susceptibility to vancomycin

Comparative evaluation of BacT/ALERT 3D and BACTEC systems for the recovery of pathogens causing bloodstream infections

To compare BacT/ALERT [BTA] and BACTEC 9240 [BAC], two continuously monitoring automated blood culture systems, for the recovery of bloodstream pathogens and standard media available for these systems. Blood samples from 100 adults and 50 paediatric patients suspected of having bloodstream infections were inoculated at the bedside into non-vented BTA and BAC standard blood culture bottles and incubated in their respective instruments. The time to growth detection [TD] was recorded for each bottle that became positive. A quantitative assay was also carried out with 5 standard bloodstream pathogens to assess TD of each pathogen as well as the quantity of organisms recovered. A total of 23 isolates representing true infections were recovered by both BTA and BAC bottles, indicating ablood culture positivity rate of 15.3%, 18 [78.3%] by BTA bottles and 13 [56.5%] by BAC. Proteus mirabilis, Pseudomonas aeruginosa and Clostridium perfringens were recovered only by the BTA system. The average TDs were 19.0 and 24.6 h for BTA and BAC, respectively. Analysis of the quantitative growth of known pathogens in both systems was more or less the same for Staphylococcus aureus, Escherichia coli and P. aeruginosa but slightly different for Haemophilus influenzae and Streptococcus pneumoniae. The anaerobic bottle ofthe BTA did not support the growth of H. influenzae below an inoculum of 10[10] CFU/ml whereas the BAC did so at a lower inoculum of 10[8] CFU/ml. TD for S. pneumoniae in the BTA was about half of that in the BAC. The BTA system appears to be more efficient in detecting common bloodstream pathogens asa higher inoculum is needed for the BAC system to detect the same organism

Spectrum and antibiotic resistance of uropathogens isolated from hospital and community patients with urinary tract infections in two large hospitals in Kuwait

To determine the spectrum of microbial etiology and antibiotic resistance pattern of the uropatho-gens that cause urinary tract infections in 2 large teaching hospitals in Kuwait over a period of 1 year. The Vitek identification card system was used to identify the Uropathogens. Susceptibility of the isolates against 18 antibiotics was performed by the mi-crobroth dilution method using the Vitek automated system. In addition, gram-positive bacteria were tested in parallel by the disk diffusion technique. The six overall most common isolates were: Escherichia coli, accounting for 47% of isolates in both hospitals, followed by Candida spp. [10.8%], Klebsiella pneumoniae [9.6%], Streptococcus agalactiae [GBS; 9.5%], Enterococcus fae-calis [4,2%] and Pseudomonas aeruginosa [4.1%]. Ami-kacin provided the widest coverage amongst all the antibiotics tested followed by ciprofloxacin, gentamicin and piperacillin-tazobactam. For the gram-negatives, high resistance [26-63%] to the p-lactam antibiotics was noted, especially to ampicillin, amoxicillin-clavulanicacid, cephalothin and cefuroxime. Resistance to trimethoprim-sulfamethoxazole was also high. None of the enterococci was resistant to the glycopeptides, but 38-60% of the Staphylococcus haemolyticuswere resistant to vancomycin or teicoplanin. These data show the high level of antimicrobial resistance amongst the Uropathogens causing urinary tract infection in the two hospitals studied

Listeria monocytogenes meningitis in an immunocompetent adult patient

To report an interesting case of meningitis caused by Listeria monocytogenes in an immunocompetent adult. Patient and A previously healthy 25-year-old man presented with typical clinical features of meningitis. Cerebrospinal fluid [CSF] was obtained on the day of admission for biochemical and microbiological investigations. In addition, blood was also taken for culture and hematological studies. Antibiotic susceptibility test was performed using the Etest method. Microscopic examination of the CSF showed pleocytosis, which was predominantly lymphocytic, while the biochemical investigation revealed raised concentrations of protein and lactic acid as well as decreased glucose concentration. A 24-hour culture yielded pure growth of gram-positive bacilli identified by standard methods as L. monocytogenes. It was susceptible to ampicillin and trimethoprim-sulfamethoxazole. The patient was treated with intravenous ampicillin combined with gentamicin and made a complete recovery. This presentation describes an unusual case of meningitis caused by L. monocytogenes in a previously healthy young adult with no risk factor. Only a few similar cases have been reported in the literature.

Prevalence of extended -spectrum beta -lactamases in enterobacteriaceae, Pseudomonas and stenotrophomonas as determined by VITEK2 and Etest syptems in Kuwait teaching hospital

To determine the prevalence of extended-spectrum beta-lactamase [ESBL]-producing members of the Enterobacteriaceae using VITEK 2 and E test systems. A total of 3,592 consecutive gram-negative isolates [single isolate per patient] of the family of Enterobacteriaceae and Pseudomonas adjudged to be clinically relevant to the patient's infection were studied for ESBL production over a period of 1 year at Mubarak Al-Kabeer Hospital, Kuwait. Two methods were used: the automated VITEK 2 system and E test ESBL, a manually manipulated plastic strip containing various gradients of beta-lactam antibiotics. These tests and interpretative criteria for the results were performed according to the manufacturer's instructions. Of the 3,592 bacterial isolates, 264 [7.5%] and 185 [5.2%] were positive for ESBL production by the VITEK 2 and E test, respectively. All the ESBL-producing Pseudomonas aeruginosa identified by VITEK 2 gave indeterminate results by E test. Prevalent ESBL producers, identified by the VITEK 2 versus E test, respectively, were: Citrobacter spp. [15 vs. 3.2%], K. pneumoniae [12.2 vs. 11.4%], Enterobacter spp. [12 vs. 3%], E. coli [6.5 vs. 5.6%], P. aeruginosa [6.5 vs. 0%] and Morganella spp. [2 vs. 1%]. The most common infection associated with ESBL-producing pathogens was urinary tract infection [68.2%], followed by wound infection [14.4%] and bloodstream infection [6.1%]. The result of this study showed a relatively high prevalence of clinically significant ESBL producers among the Enterobacteriaceae and Pseudomonas spp. at our teaching hospital. The VITEK 2 identified a higher prevalence of ESBL strains than the E test

Molecular characterization of nitroimidazole resistance in metronidazole - resistant bacteroides species isolated from hospital patients in Kuwait

The aim of this study was to screen for infections caused by metronidazole [MTZ]-resistant Bacteroides spp., and to characterize the genes that encode the MTZ resistance. Materials and A total of 7 MTZ-resistant Bacteroides spp. were isolated from 5 patients with MTZ-resistant infections. These organisms were investigated for carriage of genes that encode MTZ resistance. The presence of these genes was investigated by PCR and the PCR products were subjected to PCR-RFLP analysis. The strains were MTZ-resistant with minimum inhibitory concentrations of >32 micro g/ml. The presence of nim genes was indicated by PCR in all 7 strains. PCR-RFLP analysis of the nim gene products demonstrated two of the five reported resistance genes, nimA-nimE. These two resistance genes were nimE in 5 of the 7 isolates and nimA in 2 strains. MTZ-resistant Bacteroides spp. have been isolated from patients in Kuwait. Nim genes, specifically nimE and nimA, mediate the drug resistance in these isolates. The methods used in detecting these genes are rapid, accurate and relatively inexpensive and could be adopted easily to help in monitoring emergence of MTZ resistance determinants in Kuwait

bacteriology of the supragingival plaque of child dental patients in Kuwait

To investigate the bacterial flora of the gingival plaques of pediatric dental patients in order to establish baseline data for future studies on the complex microbiota of the oral cavity of this group of child dental patients. Subjects and Forty subjects, aged 3-12 years, were enrolled and investigated after informed consent was obtained. During the patients' first visit to the dental clinic supragingival plaque samples were collected from the gingival area of buccal and lingual tooth surfaces of all primary and permanent molar teeth using sterile curettes. Serially diluted samples were inoculated onto a set of selective and nonselective media and then incubated at the appropriate atmospheric conditions and temperatures. Representative colonies of isolates were identified by standard methods, including hemolytic characteristics on blood agar and profiling on API 20S and API 20A as appropriate. A total of 183 isolates [123 aerobes and 60 anaerobes] were recovered from the 40 patients with a mean count of 3 per sample of aerobes compared to 1.5 per sample for the anaerobes. Streptococcus sanguis was the predominant aerobic species [23.6%] isolated from 29 [72.5%] of the 40 patients, followed by Streptococcus mitis, 19.5 and 60%, Streptococcus salivarius, 17.1 and 52.5% and Streptococcus mutans, 17.1 and 52.5%. The frequency of isolation of anaerobic bacteria was Prevotella spp. 50% from 30 [75%] of the 40 patients, Fusobacterium spp., 18.3 and 27.5%, Bacteroides spp., Porphyromonas spp. and Peptostreptococcus spp., 6.7 and 10%, 6.7 and 10%, and 5 and 7.5%, respectively. Prevotella intermedia was the single most common species. The results show that there were more aerobic/facultative anaerobic bacteria than the obligate anaerobes in the dental plaque of the pediatric dental patients in Kuwait. The high prevalence of the pioneering streptococci as well as black-pigmented Prevotella spp. and Fusobacterium spp. indicates that the dental plaques of the children were in the developing stage, a precursor to the development of periodontal diseases

Comparative evaluation of anoxomat and conventional anaerobic gaspak jar systems for the isolation of anaerobic bacteria

To evaluate the performance of the Anoxomat, in comparison with the conventional anaerobic GasPak jar system, for the isolation of obligate anaerobes. Method: Anoxomat, model WS800, and anaerobic GasPak jar system [Oxoid] were evaluated. Anoxomat system utilized a gas mixture of 80% N2, 10% CO2 and 10% H2, while the GasPak used a gas mixture of 90% H2 and 10% CO2. An anaerobic indicator within the jars monitored anaerobiosis. A total of 227 obligate anaerobic bacteria comprising 116 stock strains, 5 ATCC reference strains and 106 fresh strains, representing different genera, were investigated for growth on anaerobic agar plates and scored for density, colony sizes, susceptibility zones of antibiotic inhibition and the speed of anaerobiosis [reducing the indicator]. The results demonstrate that the growth of anaerobic bacteria is faster inside the Anoxomat jar than in the anaerobic GasPak jar system. Of the 227 strains tested, the colonies of 152 [67%] were larger [by size range of 0.2-2.4 mm] in the Anoxomat at 48 h than in the GasPak jar compared with only 21% [range 0.1-0.3 mm] that were larger in the GasPak than in the Anoxomat. The remaining 12% were equal in their sizes. There was no measurable difference in the colony sizes of the reference strains. The Porphyromonas asaccharolytica strains failed to grow within the GasPak system but grew inside the Anoxomat. With the Anoxomat, anaerobiosis was achieved about 35 min faster than in the GasPak system. The density of growth recorded for 177 [78%] strains was heavier in the Anoxomat than in the GasPak jar. The zones of inhibition of the antibiotics tested were not different in the two systems. The Anoxomat system provided superior growth, in terms of density and colony size, and achieved anaerobiosis more rapidly. Evidently, the Anoxomat method is more reliable and appears to support the growth of strict anaerobes better

Methicillin-resistant staphylococcus aureus

The last decade has witnessed a remarkable rise in the number of reported outbreaks of hospital-acquired infections caused by Methicillin-resistant Staphylococcus aureus [MRSA] world-wide. A notable feature of these bacterial strains is the ease with which they acquired resistance to many antibiotics, spread within an Institution and the uniform problem of control and limited choice of effective treatment of the serious infections that they cause. Immunocompromised, debilitated patients and patients with open wounds, particularly burn patients, are at risk of infection by these strains and a number of relatively high mortality rates have been reported amongst those with MRSA septicaemia during outbreaks. The reservoir of MRSA in outbreaks of hospital-acquired infection include, infected and colonized patients, ambulant patient-carriers, health-care providers and sometimes, the inanimate hospital environment. Breach of infection control practices by doctors and nurses, lack of facilities to implement infection control policies and excessive use of antimicrobial agents play significant roles in the occurrence of outbreaks within a hospital. The main sites of MRSA colonization in a hospital setting include skin, mucous membranes and respiratory secretions while the most common MRSA infections include wound and skin infections, bacteraemia, pneumonia and urinary tract infection. Unfortunately, the antimicrobial agents that are available against MRSA are often potentially toxic, limited in number, difficult to administer and expensive. There are also uncertainties in the efficacy of topical antibiotic and antiseptic preparations, although results with mupirocin seem to be good. There is no consensus regarding which control measures are most appropriate and many different approaches, depending on local resources and interest of the authorities, are often used when hospitals encounter patients with MRSA