Epidemiology and clinical characteristics of patients with healthcare-acquired multidrug-resistant Gram-negative bacilli: a retrospective study from a tertiary care hospital.

The numbers of infections caused by Gram-negative bacteria (GNB) that produce extended-spectrum beta-lactamases (ESBLs) and those that are carbapenem resistant, especially Escherichia coli (E. coli) and Klebsiella pneumoniae (K. pneumoniae), are increasing, and these infections are becoming a global public health problem. The aim of this study was to assess the prevalence of infections caused by ESBL-producing and carbapenem-resistant Gram-negative bacilli in patients hospitalized at An-Najah National University Hospital in Nablus, Palestine, and to provide healthcare workers with valuable information on the treatment of these infections. A retrospective cross-sectional investigation was conducted at a large tertiary care teaching hospital. The study included patients admitted to the hospital between January and December 2021, from whom ESBL-producing and carbapenem-resistant Gram-negative bacilli were isolated. The patients' clinical and demographic information was obtained from the hospital information system. In addition, information regarding the bacterial isolates and antibiotic resistance was obtained from the hospital's microbiology laboratory. This study included a total of 188 patients-91 males (48.4%) and 97 females (51.6%). The general surgical ward accounted for the highest proportion of infections (30.9%), followed by the surgical ICU (12.2%). The most common infections were caused by ESBL-producing E. coli, which accounted for 62.8% of the cases. Among them, urinary tract infections caused by this microorganism were the most prevalent (44.7% of patients). Over 50% of the patients (54.2%) had a history of antibiotic use, and 77.8% had been hospitalized within the past three months. ESBL-producing E. coli was significantly isolated from blood cultures (p-value = 0.000), and CR-K. pneumoniae was significantly isolated from endotracheal isolates (p-value = 0.001). This study emphasizes the concerning frequency of healthcare-acquired infections caused by ESBL-producing and carbapenem-resistant GNB in a tertiary care hospital. The substantial prevalence of antibiotic resistance presents considerable obstacles to the successful administration of routinely employed antibiotics. The results highlight the immediate need for improved antimicrobial stewardship and the implementation of infection control strategies to reduce the effects of multidrug-resistant GNB on patient well-being and public health.

Nosocomial infections in the surgical intensive care unit: an observational retrospective study from a large tertiary hospital in Palestine.

BACKGROUND: Nosocomial infections or hospital-acquired infections are a growing public health threat that increases patient morbidity and mortality. Patients at the highest risk are those in intensive care units. Therefore, our objective was to provide a pattern analysis of nosocomial infections that occurred in an adult surgical intensive care unit (ICU). METHODS: This study was a retrospective observational study conducted in a 6-bed surgical intensive care unit (SICU) at An-Najah National University Hospital (NNUH) to detect the incidence of nosocomial infections from January 2020 until December 2021. The study group included 157 patients who received antibiotics during their stay in the SICU. RESULTS: The incidence of nosocomial infections, either suspected or confirmed, in the SICU was 26.9% (95 out of 352 admitted patients). Pneumonia (36.8%) followed by skin and soft tissue infections (35.8%) were the most common causes. The most common causative microorganisms were in the following order: Pseudomonas aeruginosa (26.3%), Acinetobacter baumannii (25.3%), extended-spectrum beta lactamase (ESBL)-Escherichia coli (23.2%) and Klebsiella pneumonia (15.8%). The average hospital stay of patients with nosocomial infections in the SICU was 18.5 days. CONCLUSIONS: The incidence of nosocomial infections is progressively increasing despite the current infection control measures, which accounts for an increased mortality rate among critically ill patients. The findings of this study may be beneficial in raising awareness to implement new strategies for the surveillance and prevention of hospital-acquired infections in Palestinian hospitals and health care centers.

Assessment of practices and awareness regarding the disposal of unwanted pharmaceutical products among community pharmacies: a cross-sectional study in Palestine.

BACKGROUND: The improper disposal of pharmaceutical preparations substantially threatens human health and environmental safety. Pharmacists are responsible for properly disposing of unwanted medications and educating patients about how to do so themselves. This study aimed to assess community pharmacists' knowledge, determine their views on how to dispose of unwanted pharmaceuticals, and assess the extent to which they realize that it is their responsibility to guide patients toward the safe disposal of expired medications. METHODS: A descriptive cross-sectional study was conducted between December 2021 and April 2022 among 400 practicing pharmacists who were chosen to participate by random cluster sampling. Community pharmacists' practices, awareness, and beliefs about disposing of unused drugs were evaluated. The Statistical Package for Social Sciences (IBM-SPSS) version 21 was used for data entry and analysis. RESULTS: Of 400 pharmacists, 348 stated that they did not participate in courses on the safe disposal of unwanted medications. Disposal of drugs in the garbage, an unsafe method, was very frequently recommended by pharmacists to patients, especially regarding inhalers, antibiotics, hormonal drugs, and solid and semisolid drugs. However, many pharmacists advised patients to return their hormonal, category B, and category C drugs to the pharmacy. A total of 61.3% of pharmacists agreed and 26% strongly agreed that unsafe disposal of drugs negatively affects the environment. A total of 54.3% of the participants agreed that improper disposal of antibiotics might be a reason for increased antimicrobial resistance, and 54.5% of them agreed that improper disposal of hormonal drugs might contribute to the development of certain cancers. A total of 80.3% of the participants perceived that most unwanted drugs in pharmacies were those returned from patients. A total of 97.3% of the participants supported establishing a drug disposal system, with 77.5% choosing to have the district health board responsible for funding this system. A total of 48.5% of the participants indicated that a lack of education and awareness on the issue of getting rid of unused drugs constitutes a challenge to the safe disposal of medicines, and 66% of them said that a lack of law enforcement constitutes another challenge. A total of 95.5% of the participants agreed or strongly agreed that good training for health sector workers and organizing workshops to develop knowledge on this subject would improve practices. A total of 93.3% supported distributing educational brochures, and 92.8% supported placing special containers in every pharmacy to collect unwanted drugs. CONCLUSIONS: Most pharmacists in our study returned drugs to manufacturing companies and stores, and few followed the correct methods of incineration and return of drugs to the Ministry of Health. Current data emphasize the issue of improper disposal of medicine in Palestine and the need for improved education among healthcare workers.

Impact of an antibiotic stewardship program on antibiotic utilization, bacterial susceptibilities, and cost of antibiotics.

Antimicrobial misuse is a worldwide issue, and antimicrobial resistance is considered the most challenging aspect of health care. It has been reported that as much as 30-50% of antimicrobials prescribed in hospitals are deemed unnecessary or inappropriate. Antibiotic stewardship programs (ASPs) include policies that apply continuous management of judicious anti-infectious treatment in the clinical setting. Therefore, the objectives of this study were to evaluate the effect of ASPs on antibiotic consumption, the costs of antibiotic expenditure, and the sensitivity of antimicrobials. A retrospective, quasi-experimental study was performed to assess the effect of ASP at An-Najah National University Hospital, a tertiary care hospital in the West Bank, Palestine, over a period of 20 months before and 17 months after the implementation of the ASP. Data on antibiotic consumption were reported monthly as days of therapy per 1000 patient-days and monthly costs (USD/1000 patient-days). A total of 2367 patients who received one or more of the targeted antibiotics (meropenem, colistin and tigecycline) during their hospital stay were included in the study. They have split into two groups: 1710 patients in the pre-ASP group, and 657 patients in the post ASP group. The most significant reduction in DOT per 1000 patient-days was seen with tigecycline, with a percentage of change of - 62.08%. Furthermore, the mean cost of the three antibiotics decreased significantly by 55.5% in the post-ASP phase compared to the pre-ASP phase. After the implementation of ASP, there was a statistically significant increase in susceptibility to meropenem, piperacillin and piperacillin/tazobactam with respect to Pseudomonas aeruginosa. However, changes in mortality rates were not statistically significant (p = 0.057). ASP positively reduced costs and antimicrobial consumption, with no statistically significant effect on the overall mortality rate. However, a long-term evaluation of the ASP's impact is needed to conclude its lasting impact on infection-related mortality and antimicrobial susceptibility pattern.

Patterns of microbial resistance in bloodstream infections of hemodialysis patients: a cross-sectional study from Palestine.

Bloodstream infections (BSIs) are a prominent cause of death and hospitalization among hemodialysis (HD) patients. The emergence of multidrug-resistant organisms (MDRO) is making the management of these infections more challenging. This study describes the clinical characteristics, microbial profiles and antibiotic resistance patterns in patients with BSIs. A retrospective cross-sectional study was conducted at An-Najah National University Hospital from January 2019 to December 2020. Clinical and demographic data regarding BSIs were collected from the hospital information system. Data regarding bacterial isolates and the antimicrobial resistance of BSIs were collected from the microbiology lab. Data were entered and analyzed using version 21 of the Statistical Package for Social Sciences program (IBM-SPSS). 111 BSIs occurred during the study period, with a rate of 1.5 infections per 100 patient-months. These patients had been on HD for the median duration of 747 (360, 1825) days and 62.2% had already had a BSI before the study period. 118 microorganisms were isolated; 99 (83.89%) were gram-positive and 19 (16.1%) were gram-negative. Among the gram-positive isolates, coagulase-negative staphylococci (CoNS) (88, 74.57%) were predominant. As for the gram-negative isolates, the most frequent were both Stenotrophomonas maltophilia and Escherichia coli, with five (4.23%) positive cultures each. Among the latter, two were Extended-Spectrum Beta-Lactamase producing (ESBL) (1.69%). The most frequently used empiric antibiotics were a combination of vancomycin and gentamicin (27%), followed by vancomycin alone (24.3%). Regarding gram-positive isolates, vancomycin was the most frequently used and effective antibiotic after cultures, whereas for gram-negative bacteria, it was found to be gentamicin. MDROs were defined as those resistant to at least one agent in three or more antimicrobial categories. 89 (75.4%) isolates were found to be MDRO, 85 (85.85%) gram-positive bacteria and 4 (21%) gram-negative bacteria. When comparing patients according to the type of vascular access, 66 (75%) infections with MDRO were found among patients with central venous catheters (CVCs). However, no statistically significant relationship was found between the type of vascular access and infection with MDRO (p = 0.523). MDRO cause a remarkably high proportion of BSIs in Palestinian patients. The results of this study support the empiric use of vancomycin and gentamicin to treat these infections. It is vital that health care providers prevent these infections via instituting and adhering to infection control policies in hemodialysis centers and providing proper antibiotic therapy of limited use and duration when necessary to avoid breeding resistance.

Frequency of microbial isolates and pattern of antimicrobial resistance in patients with hematological malignancies: a cross-sectional study from Palestine.

BACKGROUND: Infections are the main cause of death in patients with hematologic malignancies. This study aims to determine the microbial profile of infections in patients with hematologic malignancies and to determine the antimicrobial resistance patterns for these pathogens. METHODS: A retrospective descriptive cross-sectional study was conducted from January 2018 to December 2019 at a large hematological center in Palestine. The medical data of hematologic malignancy patients with positive cultures were collected from the hematology/oncology department using the hospital information system, and data regarding the microbial isolates and their antimicrobial resistance were collected from the microbiology laboratory. RESULTS: A total of 144 isolates were identified from different types of specimens, mostly blood samples. Of all isolates, 66 (45.8%) were gram-negative bacteria (GNB), 57 (39.6%) were gram-positive bacteria (GPB), and 21 (14.6%) were fungal isolates. The GNB that were most frequently isolated were Pseudomonas aeruginosa (27, 40.9%), followed by Escherichia coli (E. coli) (20, 30.3%). Fourteen isolates (24.6%) of GPB were Staphylococcus epidermidis followed by Enterococcus faecium (10, 17.5%) and Staphylococcus hemolyticus (10, 17.5%). The most frequent fungal pathogens were Candida species (20, 95.2%). GNB were found to be resistant to most antibiotics, mainly ampicillin (79.3%). Pseudomonas aeruginosa exhibited high resistance to ciprofloxacin (60%) and imipenem (59.3%). Among GPB, high resistance rates to oxacillin (91.1%) and amikacin (88.8%) were found. All isolated strains of Staphylococcus epidermidis were resistant to cephalosporins and oxacillin. Approximately half of the GNB isolates (34, 51.5%) were multi-drug resistant organisms (MDRO), and 16.7% (11 isolates) were difficult-to-treat resistance (DTR). Furthermore, 68.4% (39 isolates) of GPB were MDRO. The proportion of staphylococci (CoNS and S. aureus) resistant to oxacillin was 91.7%, while 88.6% of enterococci were resistant to vancomycin. CONCLUSIONS: The findings of this study confirm the predominant microorganisms seen in patients with hematologic malignancies, and show a high percentage of antibiotic resistance. Policies regarding antibiotic use and proper infection control measures are needed to avert the ever-growing danger of antimicrobial resistance. This may be achieved by developing antibiotic stewardship programs and local guidelines based on the hospital's antibiogram.

A cross-sectional evaluation of knowledge, attitudes, practices, and perceived challenges among Palestinian pharmacists regarding COVID-19.

OBJECTIVES: This study aims to evaluate knowledge, attitudes, practices, and perceived challenges regarding coronavirus disease 2019 among pharmacists in Palestine. METHODS: An online method was used to collect the data. Three hundred sixty-four pharmacists participated in the study from all areas in the Palestinian territories. The questionnaire consisted of three sections: sociodemographics; knowledge, attitudes, practices regarding coronavirus disease 2019; and barriers that prevent the implementation of infection control measures. The Statistical Package for the Social Sciences program Version 21 was used to analyze the data. Variables were expressed as frequencies, percentages, mean, and median. The chi-square test, Kruskal-Wallis test, Mann-Whitney U test, and Pearson's test were applied, along with logistic regression analysis. RESULTS: The median age of the participants was 29 years old, and most of them were female (70.9%). The analysis found that 76.4% of pharmacists had good knowledge regarding coronavirus disease 2019, and 52.7% had good practices. The median attitude score recorded by the participants was 32 points [Q1-Q3: 30-34] out of 35. Notably, the level of concern regarding coronavirus disease 2019 was significantly associated with all three tools of measurement; knowledge (p = 0.001), attitudes (p = 0.001), and practices (p = 0.001). It also appears that more years of experience had higher odds (3-5 years of experience: odds ratio, 2.560; 95% confidence interval, 1.413-4.639; p = 0.002, more than 5 years: odds ratio, 2.931; 95% confidence interval, 1.188-7.232; p = 0.020) of good practice. CONCLUSION: Although an acceptable level of knowledge was found, it might be considered inadequate. Moreover, there is a lack of appropriate adherence to safety measures from pharmacists. Therefore, we recommend the responsible authorities generate an organized training program to expand pharmacists' knowledge and experience regarding coronavirus disease 2019.

Prevalence and Risk Factors of Group B Streptococcus Colonization in Pregnant Women: A Pilot Study in Palestine.

BACKGROUND: Maternal Streptococcus agalactiae (Group B Streptococcus (GBS)) colonization is an important cause of complications in mothers and neonates during gestation and after delivery. The data regarding GBS colonization among pregnant women in Palestine is scarce. The aim of this study is to determine the prevalence of GBS colonization, its associated risk factors, and the antibiotic sensitivity patterns in Nablus, West Bank, Palestine. METHODS: A cross-sectional, single center study conducted at Rafidia Governmental Hospital in Nablus, West Bank, Palestine. Samples were collected between November 2019 and January 2020. Vaginal swabs from 200 pregnant women (≥35 weeks of gestation) attending the labor and delivery department were plated directly on CHROMagarTM StrepB (CHROM agar, France) and placed in an incubator at 35-37°C. After 24 and 48 hours, the plates were checked for growth and classified into three categories: growth of GBS with mauve colonies on chromogenic media, no growth, or other growth. The identification of the mauve colonies was confirmed by the CAMP test. Identified GBS isolates were tested for susceptibility to vancomycin, ampicillin, clindamycin, cefotaxime, erythromycin, and levofloxacin using the disc diffusion method. Clinical and demographic information were collected using a questionnaire. RESULT: The overall prevalence of GBS colonization was 12%. The median age of the study population was 27 years. GBS colonization was significantly associated with age (p=0.013), history of previous preterm delivery (p=0.013), and parity (p=0.015). No association was noted with smoking, previous abortion, previous history of fetal demise, vaginitis, or urinary tract infection. Resistance to ampicillin, vancomycin, cefotaxime, erythromycin, clindamycin, and levofloxacin was found to be 91.7%, 54.2%, 45.8%, 29.2%, 25%, and 8.3%, respectively. CONCLUSION: The prevalence of vaginal GBS in this study was 12% from Nablus, West Bank. Further research is needed to determine the GBS serotypes common in West Bank and the burden they cause on the health system. Moreover, this study also highlights the need to establish a screening program suited to a developing country with low control on the antibiotic's prescription protocols.