Comparison of the Brucella Standard Agglutination Test with the ELISA IgG and IgM in patients with Brucella bacteremia.

The presumptive diagnosis of Brucellosis is based on a high or rising antibody titer measured by the Brucella Standard Agglutination Test (SAT). This tests does not discriminate between the immunoglobulin classes (IgG and IgM). The purpose of this study was to compare the diagnostic value of SAT with Brucella Enzyme Linked Immunosorbent Assay (ELISA) IgG and IgM tests in patients with Brucella bacteremia. Over a one-year period, we had 68 patients with clinical features suggestive of Brucellosis who had positive blood cultures for Brucella species. Sera were obtained from all of the patients as well as a control group of 70 healthy military personnel who were blood donors and had no symptoms of Brucellosis. Patients and blood donors originated from the same referral population. All the sera were tested by SAT and ELISA. All the 70 controls had a negative SAT. The sensitivity and specificity of the SAT test for the bacteremic patients were 95.6% and 100.0% respectively, while that of the ELISA IgG were 45.6% and 97.1%, and that of the ELISA IgM were 79.1% and 100.0% respectively. The sensitivity and specificity of either IgG or IgM positivity were 94.1% and 97.1% respectively. Assuming that the population prevalence of active Brucellosis in Saudi Arabia (SAT >or=1:320) is 5%, the positive and negative predictive values of SAT were 100% and 99.7% respectively; of ELISA IgG they were 45.2% and 97.1%; and of ELISA IgM they were 100% and 98.9%. When both the ELISA IgG and IgM were combined, the positive and negative predictive values were 63% and 99.6% respectively. In patients with Brucella bactremia, the sensitivity of either ELISA IgM or IgG were lower than SAT, however, combining IgM and IgG had similar sensitivity and specificity to SAT. The positive predictive value of SAT and IgM is satisfactory.

Outbreak of Acinetobacter baumannii in an intensive care unit associated with tracheostomy.

A case-control study was conducted to determine risk factors for acquisition of an epidemic strain of Acinetobacter baumannii in an intensive care unit. The epidemic strain was identified by pulsed-field gel electrophoresis and was isolated from tracheal secretions in 13 (87%) of 15 patients. In a logistic regression analysis, presence of a tracheostomy was an independent risk for Acinetobacter sp acquisition (odds ratio, 421; 95% confidence interval, 13.8-12925; P =.001) and the strength of the association was inversely related to the duration of mechanical ventilation. The outbreak coincided with the introduction of a policy of early percutaneous tracheostomy in the intensive care unit and probably resulted from inadequate infection control practices during respiratory care. No environmental reservoir was found. Institution of contact precautions, enhanced handwashing, and staff education was associated with resolution of the outbreak.

A randomized clinical trial to compare the effects of a heat and moisture exchanger with a heated humidifying system on the occurrence rate of ventilator-associated pneumonia.

BACKGROUND: The purpose of this study was to compare the performance of heat and moisture exchanger filters with heated humidifying systems in the mechanical ventilator circuit on the incidence of ventilator-associated pneumonia (VAP) and bacterial colonization. METHOD: Two hundred and forty-three consecutive patients who required mechanical ventilation for 48 hours or more in the adult intensive care unit were randomized to either a heat and moisture exchanger (HME) or a heated humidifying breathing circuit. RESULTS: The VAP rate among the group with HME was 11.4%; the rate among the group with heated humidifying system (HHS) was 15.8%. The difference was not statistically significant. Approximately 68% of the patients in the HME group had no pathogen isolated compared with 50% of the patients in the HHS group. This difference was statistically significant (P =.006). However, the distribution of the pathogens among those patients who had the isolated pathogens was mostly identical in the 2 groups. CONCLUSION: Even though the study did not find HME to be significantly advantageous over the HHS, in as much as VAP rate is concerned, other advantages such as reduced nurses workload, reduced financial cost, and better safety made HME a more favorable device for use in our adult intensive care unit.

Impact of antibiotic prophylaxis on wound infection after cesarean section in a situation of expected higher risk.

BACKGROUND: To measure rates of incisional surgical site infection (ISSI) after cesarean section (CS) and to assess risks for infection. METHODS: Prospective surveillance for ISSI at a 540-bed hospital in Saudi Arabia by using Centers for Disease Control and Prevention definitions for infection and the National Nosocomial Infections Surveillance (NNIS) system risk index. RESULTS: Seven hundred thirty-five CSs were studied from September 1998 to July 1999; 72% were emergency procedures, despite a 95% rate of antenatal care. The overall ISSI rate was 2.8% (95% confidence interval [CI], 1.7%-4.3%). The rate for NNIS risk category 0 was 2.4% (95% CI, 1.3%-4.2%; n = 536) and for category 1 was 4.1% (95% CI, 1.8%-8.6%; n = 170). In the multivariate analysis, the only independent risks for ISSI were duration of surgery (OR = 1.01; 95% CI, 1.00-1.03; P =.02) and no antibiotic prophylaxis (OR = 3.09; 95% CI, 1.10-9.11; P =.04). Antibiotic prophylaxis was inconsistently administered among both emergency and elective CS. Infection control procedures were inadequate in the obstetric suite operating room. CONCLUSIONS: Despite deficient infection control practices in the setting described, ISSI rates after CS were judged "acceptable" compared with NNIS benchmark rates. This was attributed to prescribing antibiotic prophylaxis for patients at low risk as well as high risk of infection.

Brucellosis in pregnant women.

Brucella species occasionally cause spontaneous human abortion, but theories regarding whether they do so more frequently than do other infectious pathogens remain controversial. We reviewed 92 pregnant women who presented with acute brucellosis at a Saudi Arabian hospital. From 1983 through 1995, the cumulative incidence of pregnancy and brucellosis was 1.3 cases per 1000 delivered obstetrical discharges. The incidence of spontaneous abortion in the first and second trimesters was 43%, and the incidence of intrauterine fetal death in the third trimester was 2%. Antepartum antimicrobial therapy with cotrimoxazole or cotrimoxazole/rifampin was protective against spontaneous abortion (relative risk, 0.14; 95% confidence interval, 0.06--0.37; P<.0001). The beneficial effect of treatment occurred in women with febrile illness; vaginal bleeding at presentation usually led to spontaneous abortion. This study demonstrated that the incidence of spontaneous abortion among pregnant women with brucellosis is high and that these women should receive prompt therapy with antimicrobial agents when they present for medical care.

Are Saudi Arabian hospitals prepared for the threat of biological weapons?

The use of biological weapons has been recorded repeatedly in history. Until recently, biological terrorism had been little discussed or written about. However, events over the past 12 to 18 months have made it clear that likely perpetrators already envisage every possible scenario. Nations and dissident groups exist that have both the motivation and access to utilize biological weapons. In April 1994, a Russian biological weapons expert presented the conclusions of the Russian experts as to the agents most likely to be used: smallpox, anthrax, and plague. Health care workers in the Kingdom of Saudi Arabia (physicians, nurses, and emergency medical technicians) need to be aware of the seriousness of the threat of biological weapons, and to have an approach for the early identification, triage, and management of biological weapons victims. Clues to the occurrence of a bioterrorism attack include the abrupt onset of a large number of cases of a similar disease or syndrome, the occurrence of diseases with unusual geographic or seasonal distribution, and epidemics of non-endemic diseases. Health care workers must maintain a high index of suspicion, involve the hospital epidemiologist or infectious diseases specialist, identify a clear administrative chain-of-command to minimize confusion, and rely on existing networks such as the hospital disaster-and-safety committee to ensure a multidisciplinary response. Maximum readiness can be achieved by periodic readiness drills.

Brucellosis in laboratory workers at a Saudi Arabian hospital.

BACKGROUND: Saudi Arabia is hyperendemic for brucellosis, with more than 8000 cases reported each year to public health authorities. During 1998, brucellosis ranked as the No. 1 reportable communicable disease (22.5%) in Saudi Arabian National Guard communities. King Fahad Hospital is the major referral center for National Guard personnel in the nation's central region. METHODS AND RESULTS: From 1991 to 2000, brucellosis developed in 7 expatriate hospital employees. Six employees were bacteriology technologists, and one was a pathologist. Each had a clinical syndrome compatible with brucellosis (headache, fever, rigors, sweats, and myalgias) plus elevated Brucella sp serum agglutinin titers > or = 1:1280; one patient also had positive blood cultures. All patients responded to anti-Brucella therapy. Two patients had relapses, and complications occurred in four patients (septic endophlebitis of the leg, infected prosthesis, epididymoorchitis, and lumbar spondylitis). In all these employees except the pathologist, the infection was associated with processing Brucella sp cultures. CONCLUSION: Despite the enforcement of stringent infection control measures including the use of a class II biosafety hood in the laboratory, the problem of nosocomial brucellosis persists because of the large number of infected specimens handled by the laboratory (17,500 specimens per year). Ultimately, risk reduction depends on efforts to reduce disease endemicity in the country. In the meantime, conversion of the laboratory to biosafety level 3 is under way.

Brucella bacteraemia: clinical and laboratory observations in 160 patients.

OBJECTIVES: To describe the clinical, serological, and prognostic features of bacteraemic brucellosis in an endemic region. METHODS: Retrospective case series of 160 patients admitted from 1983 to 1995 to a hospital providing secondary and tertiary level medical care in Saudi Arabia. All patients had positive blood cultures for Brucella species, predominantly Brucella melitensis. RESULTS: Bacteraemia was documented in 38% of 545 cases of brucellosis admitted to our institution during the study period. The main clinical syndromes were febrile illness alone (44%) or fever with arthritis (42%). Of 68 isolates that were speciated, 93% were Brucella melitensis. Initial agglutinating antibody titre was > or =1:320 in 96% of the patients. Antimicrobial resistance of B.melitensis isolates was: co-trimoxazole, 29%; rifampicin, 3.5%; streptomycin, 0.6%; and tetracycline, 0.6%. No increase in resistance was noted over the 13-year study period. Commonly used antimicrobial regimens consisted of streptomycin plus tetracycline or rifampicin plus doxycycline given for 6 weeks. Seven patients (5%) had relapse of their symptoms after antimicrobial therapy. Three of these had infective endocarditis with repeated bacteraemia. These patients required aortic valve replacement and recovered after surgery. The remaining four patients responded to a second course of therapy. CONCLUSIONS: Brucella bacteraemia is an acute febrile disease often associated with rheumatologic complaints. Most patients have an agglutinating antibody titre > or =1:320 and respond well to standard chemotherapy regimens with low mortality.

Clinico-diagnostic experience with tuberculous lymphadenitis in Saudi Arabia.

OBJECTIVES: To describe the diagnosis and outcomes of tuberculous lymphadenitis in a low HIV-seroprevalence population at a hospital in Riyadh, Saudi Arabia. METHODS: Retrospective case series of tuberculous lymphadenitis from 1983 to 1998 were examined. RESULTS: There were 99 cases with a median age of 38 years and a female preponderance (female/male ratio of 1.3 : 1). Eighty per cent had cervical involvement and 36% had systemic symptoms. Eighty-nine per cent had their lymphadenopathy for more than 1 month. The diagnostic yield of tuberculin skin testing was 83%, of chest X-ray was 27%, of fine-needle aspiration was 46%, and of excisional lymph node biopsy was 97%. Only one-third of patients received a tuberculin test. There was no significant difference in outcome between 6 and 9 months of chemotherapy, and paradoxical enlargement of nodes occurred in only 6%. CONCLUSIONS: Tuberculous lymphadenitis in our study population was predominantly cervical in location. The diagnostic yield of FNA was lower than that reported in the literature, and might be improved by more frequent tuberculin skin testing, multiple aspirations of lymph nodes, or use of excisional biopsy as the initial diagnostic procedure. Most patients responded well to chemotherapy, with few complications.

Antibiotic resistance. An impending crisis.

The global emergence of antimicrobial resistance has become a pre-eminent concern in medicine and public health. Antimicrobial resistance is of particular concern because the problem is widespread, the causative factors are uncontrolled, and national strategies to address the problem are lacking. The persisting burden of infectious diseases makes elimination of antibiotic use unethical, but dramatic overuse and misuse of antimicrobial agents around the world must be reduced to extend the useful lifetimes of these drugs. Population genetic models suggest that resistance emerges rapidly under the selective pressure of antibiotics, but decays slowly once that pressure is removed. Hence, measures to prevent the emergence of resistance must be implemented urgently. A multiplicity of factors drive antibiotic resistance, and solutions require the collaboration of governmental agencies, the pharmaceutical companies, healthcare providers, and consumers. Leadership in the form of a national steering committee on antimicrobial resistance is needed in the Kingdom of Saudi Arabia to guide collective action to control the threat of antibiotic resistance.

Pediatric status epilepticus: a perspective from Saudi Arabia.

The purpose of this study was to assess risk factors and management of status epilepticus and non-status epilepticus seizures at a community hospital in Saudi Arabia. The research design was a prevalence study of a convenience sample of pediatric seizure episodes admitted to a 350-bed hospital from 1992 to 1997. The mean age at presentation was 2 years, 10 months, 43% of patients had no history of seizures, and 17% were transferred from other hospitals. Fifty-nine (28%) of 212 seizure episodes were status epilepticus (SE). These SE episodes were significantly more likely than non-SE episodes to be associated with a history of seizures, prior antiepileptic drug (AED) therapy, the presence of an acute etiology, and prolonged duration of seizures before hospitalization. SE episodes were also significantly more likely than non-SE episodes to receive an inappropriate AED, to require intensive care unit admission, to suffer morbidity, and to have SE recurrence at follow-up; however, the difference in mortality was not significant. In conclusion, children with SE were more likely than those with non-SE seizures to have a history of seizures and acute brain insults, prolonged seizure duration before hospitalization, and less optimal management and outcomes. Management of SE in this referral population can be improved by more rapid access to appropriate medical care.

Infection control and hospital epidemiology in the Kingdom: the right discipline in the right place at the right time.

Full text is available as a scanned copy of the original print version.

The use of a quality-improvement approach to reduce needlestick injuries in a Saudi Arabian hospital.

OBJECTIVE/DESIGN: An increase was noted in the incidence of needlestick injuries in our institution. A retrospective study was carried out analyzing the accident reports and medical records of needle-stick injuries from January 1995 to July 1996. Study variables included monthly incidence; location; injury site; mechanism; staff vocational status; source virological status; staff immunity; and serological conversion to hepatitis B and C viruses and the human immunodeficiency virus (HIV). SETTING: 350-bed general hospital in Western Saudi Arabia employing 2,083 employees of many different nationalities. RESULTS: 126 injuries were identified. Thirty percent of injuries occurred in the operating room and 28% on general wards. Twenty-five injuries occurred during a surgical procedure in the operating room, 22 injuries were caused by undisposed sharps, 11 occurred during suturing, 11 occurred during injection, and 10 occurred while disposing of refuse. At least 38% of the injuries were avoidable. Sixty percent of those injured were nurses, 30% were medical staff, and 6% were housekeeping staff. Nine of the identifiable sources were hepatitis B surface antigen-positive, nine were hepatitis C antibody-positive, and none were anti-HIV positive. Eighty-nine percent of injuries involved the hands. None of our injured employees had seroconverted at 3, 6, or 9 months follow-up to HIV, hepatitis C, or hepatitis B. Eighty-four percent of injured staff were hepatitis B immune. CONCLUSION: Steps taken to reduce the future incidence of injuries included the provision of readily accessible sharps boxes, a hospitalwide education program focusing on safe handling and disposal of sharps, and the development of clear policies and procedures for dealing with sharps injuries. A further study will be conducted 12 months after the introduction of these measures.

An epidemic of primary tuberculosis in a Canadian aboriginal community.

In 1987, an outbreak of primary tuberculosis occurred in a Canadian aboriginal community of 350 people. The source case was a young woman who had been symptomatic for four months with smear positive cavitary pulmonary tuberculosis. Her 17 siblings and their families were frequent close contacts. Among the 626 persons surveyed in the community and environs, 35 additional active cases of tuberculosis were identified. The mean age of cases was 13 years and the median age 10 years. The method of diagnosis was bacteriological in 20 and radiological in 16. There were 257 positive tuberculin reactors of whom 120 had no previous record of a positive skin test. Isoniazid prophylaxis was recommended to all new reactors, close household contacts, reactors under the age of 35 years and reactors with lung scars. One late case was identified at one year of follow-up in a contact who had refused prophylaxis. The rates of infection and disease were higher in the family (65% and 46%, respectively) than in the community and environs (19% and 5.6%, respectively). This report illustrates the nature of a point source epidemic of primary tuberculosis in a susceptible community with a predictable reservoir of infection. The delay in diagnosis of the source case allowed numerous new infections to occur. However, prompt aggressive contact follow-up was successful in containing the epidemic. To prevent future outbreaks, the reservoir of infected persons must be identified and administered chemoprophylaxis.

Polymicrobial endocarditis with eight pathogens in an intravenous drug abuser.

A 17-year-old intravenous drug abuser with tricuspid endocarditis required valvulectomy for refractory infection due to 8 different bacterial pathogens. Only one organism was isolated from blood cultures in the first 48 h, and subsequent organisms were not isolated until 9-13 days after hospitalization. The spectrum of pathogens in this patient strengthens previous clinico-bacteriologic observations made in the literature, and emphasizes the need for empiric coverage of oropharyngeal flora in addition to the usual skin flora involved in drug-addict associated endocarditis.

Idiopathic pulmonary hemosiderosis, complete heart block and celiac disease.

A 24-year-old male with recurrent hemoptysis due to idiopathic pulmonary hemosiderosis and celiac sprue developed infranodal heart block necessitating implantation of a pacemaker. A possible common underlying mechanism is discussed.