Exploring drivers and challenges influencing antibiotic prescribing in outpatient settings and possible mitigation strategies in the United Arab Emirates: a qualitative study.

Objectives: Healthcare institutions implement antimicrobial stewardship (AMS) programmes to optimize the use of antibiotics. The focus is often on inpatient rather than outpatient settings. We aimed to explore perceptions of AMS stakeholders on effective interventions for appropriate antibiotic use in outpatient settings, and the role of clinical pharmacists in the AMS multidisciplinary team. Methods: A qualitative semi-structured interview study using thematic analysis by two researchers independently. Participants that practice AMS programmes were recruited from healthcare facilities in the United Arab Emirates (UAE). Interviews were conducted face to face or online and transcribed verbatim. Results: Four themes emerged: (i) Perceived factors leading to unnecessary or inappropriate antibiotic prescribing and their impact on patients and the community; (ii) current outpatient AMS activities and perceived barriers and facilitators for their sustainability; (iii) suggested outpatient AMS strategies to be implemented in outpatient settings; and (iv) perceived future AMS implementation barriers and suggested mitigation strategies. Conclusions: Several AMS interventions, together with the presence of a clinical pharmacist, may be effective in improving antibiotic use in UAE outpatient settings. Future research should investigate the most appropriate AMS strategy considering barriers and possible mitigation strategies to ensure sustainability.

Exploring Antimicrobial Stewardship Influential Interventions on Improving Antibiotic Utilization in Outpatient and Inpatient Settings: A Systematic Review and Meta-Analysis.

Antimicrobial stewardship interventions are targeted efforts by healthcare organizations to optimize antimicrobial use in clinical practice. The study aimed to explore effective interventions in improving antimicrobial use in hospitals. Literature was systemically searched for interventional studies through PubMed, CINAHL, and Scopus databases that were published in the period between January 2010 to April 2022. A random-effects model was used to pool and evaluate data from eligible studies that reported antimicrobial stewardship (AMS) interventions in outpatient and inpatient settings. Pooled estimates presented as proportions and standardized mean differences. Forty-eight articles were included in this review: 32 in inpatient and 16 in outpatient settings. Seventeen interventions have been identified, and eight outcomes have been targeted. AMS interventions improved clinical, microbiological, and cost outcomes in most studies. When comparing non-intervention with intervention groups using meta-analysis, there was an insignificant reduction in length of stay (MD: -0.99; 95% CI: -2.38, 0.39) and a significant reduction in antibiotics' days of therapy (MD: -2.73; 95% CI: -3.92, -1.54). There were noticeable reductions in readmissions, mortality rates, and antibiotic prescriptions post antimicrobial stewardship multi-disciplinary team (AMS-MDT) interventions. Studies that involved a pharmacist as part of the AMS-MDT showed more significant improvement in measured outcomes than the studies that did not involve a pharmacist.

Score Gains on the NBME Subject Examinations in Internal Medicine Among Clerkship Students: a Two-Year Longitudinal Study from the United Arab Emirates.

Background: The impact of clinical proficiency on individual student scores on the National Board of Medical Examiners (NBME) Subject Examinations remains uncertain. We hypothesised that increasing the length of time spent in a clinical environment would augment students' performance. Methods: Performance on the NBME Subject Examination in Internal Medicine (NBME-IM) of three student cohorts was observed longitudinally. Scores at the end of two unique internal medicine clerkships held at the third and fourth years were compared. The score differences between the two administrations were compared using paired t-tests, and the effect size was measured using Cohen's d. Moreover, linear regression was used to assess the correlation between the NBME-IM score gains and performance on a pre-clinical Comprehensive Basic Science Examination (CBSE). A two-tailed p-value <0.05 was considered significant. Results: Of the 236 students enrolled during the third year, age, gender, CBSE, and NBME-IM scores were similar across all cohorts. The normalised score gain on the NBME-IM at the fourth year was 9.5% (range -38 to +45%) with a Cohen's d of 0.47. However, a larger effect size with a Cohen's d value of 0.96 was observed among poorly scoring students. Performance on the CBSE was a significant predictor of score gain on the NBME-IM (R 0.51, R 2 0.26, p-value < 0.001). Conclusions: Despite the increased length of clinical exposure, modest improvement in students' performance on repeated NBME-IM examination was observed. Medical educators need to reconsider how the NBME-IM is used in clerkship assessments.

Impact of Multidisciplinary Team Escalating Approach on Antibiotic Stewardship in the United Arab Emirates.

Antimicrobial stewardship programs (ASP) are an essential strategy to combat antimicrobial resistance. This study aimed to measure the impact of an ASP multidisciplinary team (MDT) escalating intervention on improvement of clinical, microbiological, and other measured outcomes in hospitalised adult patients from medical, intensive care, and burns units. The escalating intervention reviewed the patients' cases in the intervention group through the clinical pharmacists in the wards and escalated complex cases to ID clinical pharmacist and ID physicians when needed, while only special cases required direct infectious disease (ID) physicians review. Both non-intervention and intervention groups were each followed up for six months. The study involved a total of 3000 patients, with 1340 (45%) representing the intervention group who received a total of 5669 interventions. In the intervention group, a significant reduction in length of hospital stay (p < 0.01), readmission (p < 0.01), and mortality rates (p < 0.01) was observed. Antibiotic use of the WHO AWaRe Reserve group decreased in the intervention group (relative rate change = 0.88). Intravenous to oral antibiotic ratio in the medical ward decreased from 4.8 to 4.1. The presented ASP MDT intervention, utilizing an escalating approach, successfully improved several clinical and other measured outcomes, demonstrating the significant contribution of clinical pharmacists atimproving antibiotic use and informing antimicrobial stewardship.

Importation of Entamoeba histolytica and predominance of Klebsiella pneumoniae in liver abscesses: a 7-year retrospective cohort study from the United Arab Emirates.

BACKGROUND: There is a dearth of information on liver abscesses in the United Arab Emirates. Herein, we describe the clinical features of liver abscesses and determine their incidence rates and clinical outcomes. METHODS: We retrospectively reviewed the clinical charts of adult patients with a primary diagnosis of liver abscess at a major hospital over a 7-year period. RESULTS: Amongst 45 patients, 82.2% (37/45) had a pyogenic liver abscess (PLA) and 17.8% (8/45) had amoebic liver abscesses (ALA). Overall, patients were young (median age 42 years, IQR 35-52), mostly males (77.8%, 35/45) from the Indian subcontinent (55.6%, 25/45), presented with fever (88.9%, 40/45) and abdominal pain (88.9%, 40/45), and had a solitary abscess on imaging (71.1% (32/45). Crude annual incidence rates were 35.9/100,000 hospital admissions (95% CI 26.2-48.0) and 5.9/100,000 inhabitants (95% CI 4.3-7.9). All ALA patients were from the Indian subcontinent (100%, 8/8). Klebsiella pneumoniae was the most frequent pathogen in PLA (43.2% [16/37], 95% CI 27.1-60.5%). The hospital stay was shorter in ALA (7.5 days, IQR 7-8.5) than in PLA (14 days, IQR 9-17). No deaths were recorded within 30 days of hospitalisation. CONCLUSIONS: ALA was exclusively seen in migrants from the Indian subcontinent, suggesting importation. Further research to characterise K. pneumoniae isolates and assess potential risk factors is needed.

Admission levels of Soluble Urokinase Plasminogen Activator Receptor (suPAR) are Associated with the Development of Severe Complications in Hospitalised COVID-19 Patients: A Prospective Cohort Study.

OBJECTIVE: To examine the association between plasma levels of the soluble urokinase plasminogen activator receptor (suPAR) and the incidence of severe complications of COVID-19. METHODS: 403 RT-PCR-confirmed COVID-19 patients were recruited and prospectively followed-up at a major hospital in the United Arab Emirates. The primary endpoint was time from admission until the development of a composite outcome, including acute respiratory distress syndrome (ARDS), intensive care unit (ICU) admission, or death from any cause. Patients discharged alive were considered as competing events to the primary outcome. Competing risk regression was used to quantify the association between suPAR and the incidence of the primary outcome. RESULTS: 6.2% of patients experienced ARDS or ICU admission, but none died. Taking into account competing risk, the incidence of the primary outcome was 11.5% (95% confidence interval [CI], 6.7-16.3) in patients with suPAR levels >3.91 ng/mL compared to 2.9% (95% CI, 0.4-5.5) in those with suPAR ≤3.91 ng/mL. Also, an increase by 1 ng/mL in baseline suPAR resulted in a 58% rise in the hazard of developing the primary outcome (hazard ratio 1.6, 95% CI, 1.2-2.1, p = 0.003). CONCLUSION: suPAR has an excellent prognostic utility in predicting severe complications in hospitalised COVID-19 patients.

Impact of Ethnicity and Underlying Comorbidity on COVID-19 Inhospital Mortality: An Observational Study in Abu Dhabi, UAE.

BACKGROUND: The UAE reported its first cluster of COVID 2019 in a group of returned travellers from Wuhan in January 2020. Various comorbidities are associated with worse disease prognosis. Understanding the impact of ethnicity on the disease outcome is an important public health issue but data from our region is lacking. AIM: We aim to identify comorbidities among patients hospitalized for COVID-19 that are associated with inhospital death. Also, to assess if ethnicity is correlated with increased risk of death. Patients and Method. The study is a single-centre, observational study in Shaikh Shakhbout Medical City, Abu Dhabi. Patients admitted with COVID-19, between 1st of March and the end of May, were enrolled. Records were studied for demography, comorbidity, and ethnicity. Ethnicity was divided into Arabs (Gulf, North Africa, and the Levant), South Asia (India, Pakistan, Bangladesh, Nepal, and Afghanistan), Africans, the Philippines, and others. The study was approved by the Department of Health of Abu Dhabi. RESULTS: 1075 patients (972 males) were enrolled. There were 24 nationalities under 5 ethnicity groups. Mean (average) age was 51 years (20-81). 101 (9.4%) died with deceased patients being significantly older. Death risk was not significantly influenced by sex. Duration of hospitalization among survivors was 6.2 days (0.2-40.4) with older patients and men staying longer (P < 0.01). Comorbidities of diabetes, hypertension, cardiovascular disease, chronic renal disease, liver disease, and malignancy were associated with higher risk of mortality univariate, but only liver disease reached statistical significance after adjustment for age. The highest percentage of death was seen in Arab Levant (21.2) followed by the Asian Afghan (18.8); however, differences among ethnicities did not reach statistical significance (P = 0.086). CONCLUSION: COVID-19 outcome was worse in older people and those with comorbidities. Men and older patients required longer hospitalization. Ethnicity is not seen to impact the risk of mortality.

Seroprevalence of maternal HIV, hepatitis B, and syphilis in a major maternity hospital in North Kordofan, Sudan.

Routine infectious diseases screening of Sudanese pregnant women has been patchy due to scarcity of healthcare resources and social stigma. We sought to determine the seroprevalence of HIV, hepatitis B, and syphilis among pregnant women attending antenatal care (ANC) at El Obeid Maternity Hospital in western Sudan. We also explored the association between these infections and a set of socio-demographic and maternal variables. Unlinked anonymous testing for HIV-1/2 antibodies, hepatitis B surface antigen, and Treponema pallidum antibodies was performed on residual blood samples collected during routine ANC (August 2016-March 2017). Seroprevalence of HIV was 1.13% (5/444; 95% CI 0.37-2.61%), hepatitis B 2.93% (13/444; 95% CI 1.57-4.95%), and syphilis 7.43% (33/444; 95% CI 5.17-10.28%). On bivariate analysis, there were no statistically significant associations between hepatitis B, syphilis, or a composite outcome including any of the three infections and age, stage of pregnancy, gravidity, parity, previous mode of delivery, history of blood transfusion, or husband polygamy. Urgent action is needed to scale up routine maternal screening for HIV, hepatitis B, and syphilis on an opt-out basis. Further research into the socio-demographic and behavioural determinants of these infections as well as their clinical outcomes is needed.

Imported dengue fever in East London: a 6-year retrospective observational study.

Background: Dengue fever (DF) is a frequently imported arthropod-borne infection in the United Kingdom but its broad range of clinical presentations makes it potentially unrecognized by clinicians. Methods: We conducted a 6-year retrospective case note review of laboratory confirmed DF patients in East London in the period from 1 January 2010 through 31 December 2015. Epidemiological, clinical and laboratory features of imported DF were described. Risk factors associated with viraemic DF presentations were assessed. Results: Forty-four patients (4 from primary care clinics and 40 from three acute hospitals) were confirmed to have DF through RNA and/or IgM detection. In total, 86.4% (38/44) had primary infection compared to 13.6% (6/44) with secondary infection. Viraemic DF presentations accounted for 59.1% (26/44) of cases. The median age was 34 years (IQR 25-43). Most patients were males (68.2%, 30/44) and of non-white ethnicity (81.8%, 36/44). South Asia was the most frequent travel destination (52.3%, 23/44) followed by Southeast Asia (20.5%, 9/44). July-September was the peak season of presentation (43.2%, 19/44). The median interval between arrival in the UK and laboratory testing was 7 days (IQR 4-13). Arriving from abroad ≤ 7 days before molecular testing (age-adjusted odds ratios [OR] 16.98, 95% CI 2.43-118.75, P = 0.004) and travel to South or Southeast Asia regions (age-adjusted OR 4.41, 95% CI 1.07-18.21, P = 0.040) were associated with detectable viraemia at presentation. Only one DF patient met the WHO severity criteria. HIV serostatus was determined in 61.4% (27/44) of cases. Conclusion: Clinicians need to improve DF recognition as well as rates of HIV testing in tropical travellers. Region of travel and time since arrival from DF endemic settings may help clinicians optimize requests for molecular testing. Further research on the clinical and public health aspects of imported DF is needed.

Epidemiology and clinical features of imported malaria in East London.

BACKGROUND: Malaria is the most common imported tropical disease in the United Kingdom (UK). The overall mortality is low but inter-regional differences have been observed. METHODS: We conducted a 2-year retrospective review of clinical and laboratory records of patients with malaria attending three acute hospitals in East London from 1 April 2013 through 31 March 2015. Epidemiological and clinical characteristics of imported malaria were described and risk factors associated with severe falciparum malaria were explored. RESULTS: In total, 133 patients with laboratory-confirmed malaria were identified including three requiring critical care admission but no deaths. The median age at presentation was 41 years (IQR 30-50). The majority of patients were males (64.7%, 86/133) and had Black or Black British ethnicity (67.5%, 79/117). West Africa was the most frequent region of travel (70.4%, 76/108). Chemoprophylaxis use was poor (25.3%, 20/79). The interval between arriving in the UK and presenting to hospital was short (median 10 days; IQR 5-15.5, n = 84). July-September was the peak season of presentation (34.6%, 46/133). Plasmodium falciparum was the commonest species (76.7%, 102/133) and 31.4% (32/102) of these patients had parasitaemia >2%. Severe falciparum malaria was documented in 36.3% (37/102) of patients and the October-March season presentation was associated with an increased risk of severity (OR 3.00; 95% CI 1.30-6.93). Black patients appeared to have reduced risk of severe falciparum malaria (OR 0.46; 95% CI 0.16-1.35) but this was not statistically significant. HIV sero-status was determined in only 27.1% (36/133) of cases. Only 8.5% (10/117) of all malaria patients were treated as outpatients. CONCLUSION: Clinicians need to raise awareness on malaria prevention strategies, improve rates of HIV testing in tropical travellers, and familiarise themselves with ambulatory management of malaria. The relationship between season of presentation, ethnicity and severity of falciparum malaria should be explored further.

Extreme elevation of ferritin and creatine kinase in primary infection with HIV-1.

The diagnosis of primary HIV-1 infection can be challenging, especially in the absence of reported risks or when presenting features are unusual and uncommon. We report an atypical case of primary HIV-1 infection with HIV-1 subtype C in a 61-year old Caucasian man who presented with extreme hyperferritinaemia without iron overload and marked elevation of serum creatine kinase without rhabdomyolysis. In view of his symptomatic seroconversion and low baseline CD4+ T-lymphocyte count, the patient was treated promptly with combination antiretroviral therapy. Subsequently, he made good clinical improvement on treatment and no opportunistic infections were diagnosed at presentation or as part of a later immune reconstitution syndrome. This novel case highlights the importance of clinical suspicion of HIV and suggests that primary HIV-1 infection should be considered in patients presenting with severe hyperferritinaemia or markedly elevated creatine kinase levels. Further studies are required to explain the causative biological mechanisms underlying this rare presentation.

An unusual cause for a relatively common radiographic abnormality.

A 59-year-old Indian woman presented to the respiratory clinic with chest pains, long-standing swallowing difficulties and a chest radiograph, which was reported as showing a shadow in the right paratracheal region. A CT scan was obtained and was reported as demonstrating a right-sided paratracheal lymph node and varicosities adjacent to the inferior vena cava. Histology from an endobronchial ultrasound-guided biopsy revealed a heavily blood-stained sample but showed no evidence of granulomas or malignancy. Subsequently, the images were reviewed, with the conclusion that they were actually of an engorged azygos vein compressing the oesophagus. MRI confirmed the absence of mediastinal lymphadenopathy and the presence of a prominent hemiazygos vein compressing the oesophagus. This case highlights the importance of including anatomical abnormalities in the differential diagnosis and reassessing patients when the history and investigations do not correlate.

Real-life outcomes of maraviroc-based regimens in HIV-1-infected individuals.

PURPOSE: The use of maraviroc in our unit was reviewed with regard to efficacy and safety and also reviewed with regard to how our experience reflects the data presented in clinical trials. METHODS: We utilized the pharmacy dispensary system to identify any patient dispensed maraviroc and conducted a case note review. RESULTS: We identified 27 patients who have been prescribed maraviroc as part of their antiretroviral treatment. In all, 81% were men and 81% were white British. There were 26 treatment-experienced patients and 1 treatment-naive patient. At the time of switching to maraviroc, 17 patients had detectable HIV viral loads and 10 had HIV RNA levels <40 copies/mL. At completion, 6 undetectable patients maintained undetectability and 10 viremically detectable patients achieved viral suppression. Maraviroc was discontinued in 18.5% of patients and the only adverse drug reaction reported was a rash. CONCLUSIONS: The experience of using maraviroc by our study participants shows similarity in terms of efficacy and safety to the MERIT and MOTIVATE clinical trials.

Does interferon-sparing tenofovir disoproxil fumarate-based therapy have a role in the management of severe acute hepatitis delta superinfection?

Infection with hepatitis delta virus (HDV) always occurs in association with hepatitis B virus (HBV) and is a cause of significant morbidity and mortality. We present a case of severe acute HDV infection superimposed on a previously unrecognized HBV infection, in which an interferon-sparing antiviral therapy consisting of tenofovir disoproxil fumarate (TDF) and lamivudine was initiated and subsequently maintained. Evidence of successful suppression of HDV ribonucleic acid (RNA) was obtained after 65 weeks of TDF-based treatment. This was mirrored by a significant reduction in the levels of HBV DNA and HBV surface antigen. HDV RNA subsequently rebounded after our patient stopped antiviral therapy of his own accord. Interferon-sparing TDF-based antiviral therapy was safe and effective in achieving HDV RNA suppression in acute HDV superinfection. Further research into the utility of interferon-sparing TDF-based regimes in the treatment of acute HDV infection is needed.

Seroprevalence of the human immunodeficiency virus (HIV) among pregnant women in eastern Sudan.

We conducted a cross-sectional survey to determine the prevalence of the human immunodeficiency virus (HIV) among pregnant women attending a major hospital in Kassala state, eastern Sudan. Unlinked anonymous testing of residual blood specimens, which were originally collected for other routine clinical purposes, was performed using rapid immunochromatographic assays. In total, 430 residual blood specimens were consecutively collected over a 6-week period (April-May 2010). Specimens from the antenatal clinic (ANC) constituted 50.7% (218/430) of the total whereas specimens from the labour ward accounted for the remaining 49.3% (212/430). The median age of pregnant women was 29 years (range 16-40). The prevalence of HIV-1 infection was 0.23% (1/430) [95% confidence interval=0.01-1.29%]. The only reactive specimen came from a 20-year-old ANC attendee. We report low HIV prevalence among pregnant women in eastern Sudan but further research is needed to confirm our findings. An integrated framework to diagnose and treat maternal HIV infection should be developed in order to prevent transmission to infants.

Mycobacterium avium complex suppurative parotitis in a patient with human immunodeficiency virus infection presenting with immune reconstitution inflammatory syndrome.

Restoration of the immune system following initiation of antiretroviral therapy can result in an adverse phenomenon known as immune reconstitution inflammatory syndrome (IRIS). Herein, we report a case of Mycobacterium avium complex (MAC) suppurative parotitis associated with IRIS in a patient with advanced human immunodeficiency virus disease. To the best of our knowledge, this is the first reported case of MAC parotitis in the setting of IRIS and clinicians should be aware of this condition.

Paediatric HIV in central Sudan: high sero-prevalence and poor performance of clinical case definitions.

BACKGROUND: Paediatric clinical case definitions (CCDs) for the human immunodeficiency virus (HIV) have been proposed as screening tools in resource-limited countries. OBJECTIVES: We assessed the performance of the World Health Organisation CCD (WHO-CCD), the Bloemfontein CCD (B-CCD) and a locally modified version of the Bloemfontein CCD (MB-CCD) in comparison with HIV serology in acutely hospitalised children aged 1.5-14 years. We also determined the HIV sero-prevalence among this group of children. STUDY DESIGN: A cohort of 106 consecutive acute paediatric admissions to a major teaching hospital in central Sudan was recruited over a 3-month period. RESULTS: The WHO-CCD, B-CCD, and MB-CCD were relatively specific with estimates of 96.0% (95% confidence interval [CI] 90.1-98.9), 88.0% (95% CI 80.0-93.6), and 74.0% (95% CI 64.3-82.3), respectively. However, corresponding sensitivities were poor with estimates of 16.7% (95% CI 0.4-64.1), 33.3% (95% CI 4.3-77.7), and 66.7% (95% CI 22.3-95.7), respectively. The HIV sero-prevalence was high at 5.7% (95% CI 2.1-11.9). CONCLUSIONS: CCDs performed poorly against HIV serology in acutely hospitalised children aged 1.5-14 years in central Sudan and, therefore, we advocate improving access to serological diagnostic tools. The high HIV sero-prevalence rate among this group of children poses serious challenges to policy makers and warrants further research.

Utility of lymph node aspiration in the diagnosis of visceral leishmaniasis in Sudan.

We evaluated lymph node aspiration (LNA) as a simple diagnostic procedure for visceral leishmaniasis (VL). Lymph node aspiration was compared with the direct agglutination test (DAT) using a diagnostic titer > or = 1:6,400 in 7,880 suspected VL patients in eastern Sudan. Compared with DAT, LNA had a sensitivity of 65.1% (95% confidence interval = 63.5-66.6%). Parasite density in LNA correlated strongly with DAT titers (P < 0.0001), and low parasite density accounted for 78.1% of positive LNA results with DAT titers < 1:6,400 (n = 782). Risk factors predictive of a positive LNA result were an age of 1-29 years, male sex, a hemoglobin level < 10.0 g/dL, a DAT titer > or = 1:800, and a location with a higher prevalence of VL. Lymph node and splenic aspirations were similarly accurate as tests of cure after treatment of 50 VL patients in southern Sudan. Pre-treatment LNA results were negative in 20 cases of severe post kala-azar dermal leishmaniasis.