The Saudi Thoracic Society pneumococcal vaccination guidelines-2016.

Streptococcus pneumoniae (pneumococcus) is the leading cause of morbidity and mortality worldwide. Saudi Arabia is a host to millions of pilgrims who travel annually from all over the world for Umrah and the Hajj pilgrimages and are at risk of developing pneumococcal pneumonia or invasive pneumococcal disease (IPD). There is also the risk of transmission of S. pneumoniae including antibiotic resistant strains between pilgrims and their potential global spread upon their return. The country also has unique challenges posed by susceptible population to IPD due to people with hemoglobinopathies, younger age groups with chronic conditions, and growing problem of antibiotic resistance. Since the epidemiology of pneumococcal disease is constantly changing, with an increase in nonvaccine pneumococcal serotypes, vaccination policies on the effectiveness and usefulness of vaccines require regular revision. As part of the Saudi Thoracic Society (STS) commitment to promote the best practices in the field of respiratory diseases, we conducted a review of S. pneumoniae infections and the best evidence base available in the literature. The aim of the present study is to develop the STS pneumococcal vaccination guidelines for healthcare workers in Saudi Arabia. We recommend vaccination against pneumococcal infections for all children <5 years old, adults ≥50 years old, and people ≥6 years old with certain risk factors. These recommendations are based on the presence of a large number of comorbidities in Saudi Arabia population <50 years of age, many of whom have risk factors for contracting pneumococcal infections. A section for pneumococcal vaccination before the Umrah and Hajj pilgrimages is included as well.

Antibiotic utilization pattern in a general medical ward of a tertiary medical center in Saudi Arabia.

To assess the pattern of antibiotic utilization and outcome of patients with bacteremia in a General Medical Ward, all positive blood cultures (BC) over a 12-month period from January 1994 to December 1995 were retrospectively reviewed. Fifty-two positive BC were recorded in 43 patients (63% males, 37% females; mean age 65.9 ± 16.6). 72% of the patients received antibiotics before or soon after obtaining the BC, and ceftriaxone was the most frequently-prescribed antibiotic (41.93%), either alone or in combination with other antibiotics. The bacteremia was due to gram-positive cocci in 60.46% of cases, gram-negative rods in 30.23%, and gram-positive rods in 9.30%. Positive BC due to contamination were not included. The most common gram-positive cocci were Staphylococcus epidermidis, followed by S. aureus, while the most common gram-negative bacilli were Brucella species, Proteus mirabilis, and Klebsiella sp. The suspected sources of the bacteremia were respiratory (21.2%), urinary (19.2%), or skin (19.2%). A subsequent change in the antibiotics regimen was done in 69.76% cases after BC results became available with no apparent effect on the outcome. Adding vancomycin and clindamycin was the most frequent change done (19.4% for each equally). Complications developed in 69.76% of patients, with 88.66% of them suffering from sepsis/shock. 69.23% of the patients improved and 30.77% expired; death was related to infection in 87.5% of cases. In conclusion, most bacteremia in the medical ward of the hospital were due to gram-positive cocci, which should be considered in antibiotic selection prior to BC. Risk factors for acquiring Brucellosis should always be obtained.

Information disclosure and decision-making: the Middle East versus the Far East and the West.

OBJECTIVES: to assess physicians' and patients' views in Saudi Arabia (KSA) towards involving the patient versus the family in the process of diagnosis disclosure and decision-making, and to compare them with views from the USA and Japan. DESIGN: A self-completion questionnaire (used previously to study these issues in Japan and the USA) was translated to Arabic and validated. PARTICIPANTS: Physicians (n = 321) from different specialties and ranks and patients (n = 264) in a hospital or attending outpatient clinics from 6 different regions in KSA. RESULTS: In the case of a patient with incurable cancer, 67% of doctors and 51% of patients indicated that they would inform the patient in preference to the family of the diagnosis (p = 0.001). Assuming the family already knew, 56% of doctors and 49% of patients would tell the patient even if family objected (p NS). However, in the case of HIV infection, 59% of physicians and 81% of patients would inform the family about HIV status without the patient's consent (p = 0.001). With regards to withholding ventilatory support, about 50% of doctors and over 60% of patients supported the use of mechanical ventilation in a patient with advanced cancer, regardless of the wishes of the patient or the family. Finally, the majority of doctors and patients (>85%) were against assisted suicide. CONCLUSIONS: Although there was more recognition for a patient's autonomy amongst physicians, most patients preferred a family centred model of care. Views towards information disclosure were midway between those of the USA and Japan. Distinctively, however, decisions regarding life prolonging therapy and assisted suicide were not influenced to a great extent by wishes of the patient or family, but more likely by religious beliefs.

Post-neurosurgical meningitis due to multidrug-resistant Acinetobacter baumanii treated with intrathecal colistin: case report and review of the literature.

Intrathecal colistin (Polymxin E) is becoming an important option for the treatment of post-neurosurgical meningitis caused by multidrug resistant (MDR) Acinetobacter baumannii. We report a case of 28-year-old man who developed meningitis due to MDR A. baumannii associated with an external ventricular drain. The patient was cured using a 4-week course of intrathecal colistin 3.2 mg via external ventricular drain (EVD) daily without any serious side effects.

Critical care medicine in Saudi Arabia.

Critical care medicine remains underdeveloped in many parts of the world. In Saudi Arabia, there have been major developments in the past 2-3 decades. The purpose of this review is to give an account of the current status of critical care practice (including services provided during the haj season) and training in Saudi Arabia using examples of primary, secondary and tertiary care hospitals. The future needs of the profession are also addressed.

Critical care medicine in Saudi Arabia

Critical care medicine remains underdeveloped in many parts of the world. In Saudi Arabia, there have been major developments in the past 2-3 decades. The purpose of this review is to give an account of the current status of critical care practice [including services provided during the haj season] and training in Saudi Arabia using examples of primary, secondary and tertiary care hospitals. The future needs of the profession are also addressed

Pulmonary changes in liver transplant candidates with hepatitis C cirrhosis.

OBJECTIVE: Several studies have shown that pulmonary abnormalities are common in patients with end-stage liver disease. However, most of these studies were conducted on patients with heterogeneous etiologies. Therefore, we studied these changes in a homogenous group of hepatitis C cirrhotic patients who were potential candidates for liver transplantation. METHODS: The charts of 81 patients from King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia with hepatitis C cirrhosis who were evaluated for liver transplantation were reviewed. The following data was retrieved: echocardiography with micro-bubble study, arterial blood gases, and pulmonary function tests of 81 candidates and reviewed over 3 years from 1994 to 1997. RESULTS: The mean age was 53 (+/-9) years with male to female ratio of 1.4:1. Echocardiographic micro-bubble study, revealed 4 of 62 (7%) had an intrapulmonary shunt. Arterial blood gases results were pH of 7.44 (+/-0.4), partial arterial tension of carbon dioxide of 33 mm Hg (+/-4), partial arterial tension of oxygen of 84 mm Hg (+/-12), and alveolar-arterial gradient of 30 mm Hg (+/-10). Eleven percent had obstructive airway disease, 17% had restrictive lung impairment, and 43% had reduced diffusion capacity. Seventy five percent of patients with reduced diffusion capacity had normal lung volumes. Various pulmonary function test abnormalities did not lead to significant differences in arterial blood gases. CONCLUSION: Pulmonary changes were frequent in liver transplant candidates with hepatitis C virus cirrhosis with reduced diffusion capacity being the most. Apart from the effect of hepatopulmonary syndrome on arterial oxygenation, other pulmonary abnormalities were not significantly different.

Clinical aspects of miliary tuberculosis in Saudi adults.

OBJECTIVE: To review all cases of miliary tuberculosis (MT) over a period of 7 years in a Saudi Arabian population, to determine the clinical and laboratory characteristics and diagnostic methods, and to compare our data with others reported in the literature. DESIGN: A retrospective case review. RESULTS: Of 780 cases of active tuberculosis seen over period of 7 years, 47 (6%) had MT. The majority of the patients were aged over 60 years (68%). The most common symptoms were fever and weight loss. Risk factors were present in 70% of cases, mainly diabetes mellitus, history of prior tuberculosis, chronic liver and renal disease, immunosuppressive drug therapy and malignancy. Miliary pattern on chest radiography was seen in 89%. The most common laboratory abnormalities were anemia (66%), lymphopenia (89%), low albumin (87%), and high alkaline phosphatase (80%). Fiberoptic bronchoscopy was diagnostic in 7/10 (70%), bone marrow examination in 8/11 (73%), and liver biopsy in 14/16 (88%). High alkaline phosphatase and lymphopenia were associated with high yield of liver biopsies and bone marrow examination: 13/14 (93%) and 7/8 (88%), respectively. Death occurred in 10/47 (21%); all of these had radiological evidence of miliary pattern, and 80% had comorbid conditions. CONCLUSION: These data confirm and extend the results of other studies and suggest that MT is a disease of the elderly and immunocompromised, and is associated with high mortality. A high index of suspicion is required for diagnosis.

Complications of carbon monoxide poisoning.

OBJECTIVE: Acute carbon monoxide poisoning is a common problem that occurs during winter and leads to serious complications. METHODS: We retrospectively studied 24 consecutive cases admitted with the aim of finding the causes and outcome of acute carbon monoxide poisoning. RESULTS: The source of poisoning was charcoal in 71% of patients, motor gasoline in 21%, and other causes in 8%. Immediate complications included altered consciousness level in 54% of patients, metabolic acidosis in 46%, pneumonia in 42%, cardiac arrhythmia in 29% and rhabdomyolysis in 25%. Late neurological complications occurred in 17% of patients. All the patients received 100% oxygen. Eleven patients (46%) required mechanical ventilation. Ultimately, 19 patients (79%) recovered completely, 4 (17%) had neurological or cardiac disorders, and 1 (4%) died. CONCLUSION: Immediate and late complications are common in carbon monoxide poisoning cases admitted to the hospital especially when they arrive late. Time lapse between exposure and presentation may have a role in predicting the outcome.