Implementation of central venouscatheter bundle in an intensive care unitin Kuwait: Effect on centralline-associated bloodstream infections

Central line-associated bloodstream infection [CLABSIs] is an importanthealthcare-associated infection in the critical care units. It causes substantial mor-bidity, mortality and incurs high costs. The use of central venous line [CVL] insertionbundle has been shown to decrease the incidence of CLABSIs.Our aim was to study the impact of CVL insertion bundle on incidence of CLABSIand study the causative microbial agents in an intensive care unit in Kuwait.Surveillance for CLABSI was conducted by trained infection control team usingNational Health Safety Network [NHSN] case definitions and device days measure-ment methods. During the intervention period, nursing staff used central line carebundle consisting of [1] hand hygiene by inserter [2] maximal barrier precautionsupon insertion by the physician inserting the catheter and sterile drape from headto toe to the patient [3] use of a 2% chlorohexidine gluconate [CHG] in 70% ethanolscrub for the insertion site [4] optimum catheter site selection. [5] Examination ofthe daily necessity of the central line.During the pre-intervention period, there were 5367 documented catheter-daysand 80 CLABSIs, for an incidence density of 14.9 CLABSIs per 1000 catheter-days. After implementation of the interventions, there were 5052 catheter-days and 56CLABSIs, for an incidence density of 11.08 per 1000 catheter-days. The reduction inthe CLABSI/1000 catheter days was not statistically significant [P = 0.0859].This study demonstrates that implementation of a central venous catheter post-insertion care bundle was associated with a reduction in CLABSI in an intensive carearea setting

Point-surveillance of antibiotic resistance in enterobacteriaceae isolates from patients in a Lagos teaching hospital, Nigeria

This study was carried out to determine a point prevalence of drug resistance and extended-spectrum Beta -lactamase [ESBL] among members of the family Enterobacteriaceae. Consecutive clinically significant non-repetitive isolates obtained from both hospitalized patients and outpatients' samples were studied. The isolates were identified using VITEK 2 while susceptibility testing was performed against 16 antibiotics using the E-test strips. Phenotypic production of ESBL was detected by E-test ESBL method. Positive isolates were confirmed by PCR. Of a total of 102 isolates studied, 43 [42.2%] were Escherichia coli and 32 [31.4%] Klebsiella pneumoniae. These isolates demonstrated remarkable high rates of resistance to the Beta -lactam antibiotics, except the carbapenems and piperacillin-tazobactam. Fifty-two [51%] were resistant to >/= 3 classes of drugs and 29 [28.4%] to >/= 5 drugs. Thirty-eight [37.3%] were ESBL producers. Of these, 21 [55.3%] were E. coli and 12 [31.6%] K. pneumoniae. Thus, the overall prevalence of ESBL-producing E. coli was 20.6% and K. pneumoniae 11.8%. This study showed an alarmingly high prevalence of antibiotic resistance in invasive Enterobacteriaceae isolates and a high prevalence of ESBL producers in the study center. Antibiotic stewardship and other preventive strategies are recommended to reduce the high rate of resistant bacteria in this hospital

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

Comparative efficacy of two methods of skin preparation of the perineal and genital skin of male urological patients

To compare the efficacy of two methods of skin antiseptic preparations of the genitalia and perineum in male urological patients. Prospective study. Mubarak Hospital, Kuwait. Adult male patients of two study groups numbering 114 [group-1] and 117 [group-2] admitted for cystoscopic procedures. The perineum and genitalia of patients in both groups were prepared by applying chlorhexidine-cetrimide mixture [CCM] and CCM plus povidone-iodine solution respectively. Swab specimens were obtained from the perineum and genitalia, before cleaning and disinfection [specimen A], after disinfection and draping [specimen B] and after the completion of the operative procedure [specimen C]. Specimens were cultured on appropriate media and representative colonies identified by standard methods. In groups 1 and 2, the A specimen yielded bacterial growth in 35.1 and 63% of patients, respectively. The commonest isolates in both groups were Gram-positive bacteria [89.2%] while Gram-negative bacteria accounted for only 10.8%. The B and C specimens in group-1 yielded positive bacterial culture in 7.1 and 11.4% patients respectively. In group-2, specimens B and C yielded bacterial growth in 5.1 and 2.6% patients respectively. In both groups, there was a significant reduction of patients with culture-positive B specimens after skin disinfection [p < 0.001]. The isolation rate of bacteria in specimen C in group-2 was significantlylower than group-1 patients [p < 0.001]. The addition of povidone-iodine to the CCM based regimen of perineal skin antiseptic preparation is associated with longer and more effective skin disinfection in male urological patients

Mycobacterium tuberculosis breast infection mimicking pyogenic abscesses in Kuwait

To present 2 cases of primary breast abscesses caused by Mycobacterium tuberculosis mimicking pyogenic abscesses in healthy young females. Two young non-lactating Indonesian and Indian women, aged 27 and 29 years old, respectively, presented with breast abscesses caused by M. tuberculosis. The breasts presented as huge, swollen, hot, tender masses with a discharge at the subareolar site. Surgical drainage revealed deep abscess with copious amount of pus, samples of which were positive for acid-fast bacilli [AFB] and later confirmed as M. tuberculosis by positive cultures in Becton Dickinson BBL Migit and BACTEC 12B media. The initial therapies with clindamycin were changed to 4 anti-tuberculous drugs as soon as the smears showed the presence of AFB. The patients were discharged a week later, but both were lost to follow-up. Mammary tuberculosis should be considered in the differential diagnosis of breast lesion, especially in patients from endemic areas

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

Epididymo-orchitis and testicular abscess caused by salmonella enteritidis in immunocompromised patients in Kuwait

To report relatively uncommon presentations of epididymo-orchitis and testicular abscess caused by Salmonella spp. in 2 immunocompromised patients. A 56-year-old man, a known case of systemic lupus erythematosus on azathioprine and prednisolone therapy, developed urinary tract infection followed by bacteremia and epididymo-orchitis. Both urine and blood cultures yielded Salmonella enteritidis strains, which were demonstrated by pulsed-field gel electrophoresis typing method to be genotypically identical. The second patient, a 55-year-old diabetic [type II], presented with a testicular abscess from which a pure culture of S. enteritidis was obtained. Both were treated with intravenous piperacillin and amikacin followed by oral ciprofloxacin, responded well to the therapeutic regimen and were discharged home well. Their follow-ups were uneventful. This report shows that it is important to consider Salmonella infection in the differential diagnosis of inflamed and tender testis in immunocompromised patients and to include blood, urine and stool cultures in all cases

Infant botulism due to consumption of contaminated commercially prepared honey

To report the first case of infant botulism in Arabian Gulf States. A 6-week-old infant, presenting with signs of sepsis, was intubated and ventilated due to progressive weakness. Infant botulism was suspected with acute flaccid paralysis and a history of honey consumption. An electromyogram showed decreased amplitude of compound muscle action potential in all motor nerves, preserved sensory responses; the motor terminal latencies and motor conduction velocities were normal. Blood, stool and honey samples were sent for culture. Stool and honey cultures showed two identical strains of Clostridium botulinum.This case shows that the infant botulism occurred from the ingested contaminated honey. Hence vigilance should be maintained when a baby is fed honey and shows signs of progressive weakness because the disease can quickly progress to respiratory failure

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

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

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