Prevalence of Entamoeba histolytica, Giardia lamblia, and Cryptosporidium spp. in Libya: 2000-2015.

INTRODUCTION: The intestinal protozoa Entamoeba histolytica, Giardia lamblia, and Cryptosporidium spp. are the causative agents of giardiasis, amebiasis, and cryptosporidiosis, respectively. Adequate knowledge of the geographical distribution of parasites and the demographic variables that influence their prevalence is important for effective control of infection in at-risk populations. METHODS: The data were obtained by an English language literature search of Medline and PubMed for papers using the search terms 'intestinal parasites and Libya, G. lamblia and Libya, E. histolytica and Libya and Cryptosporidium and Libya' for the period 2000-2015. RESULTS: The data obtained for the period 2000-2015 showed prevalence rates of 0.8-36.6% (mean 19.9%) for E. histolytica/dispar, 1.2-18.2% (mean 4.6%) for G. lamblia and 0.9-13% (mean 3.4%) for Cryptosporidium spp. among individuals in Libya with gastroenteritis (GE). On the other hand, prevalence rates of 0.8-16.3% (mean 8.3%), 1.8-28.8% (mean 4.8%), and 1.0-2.5% (mean=2.4), respectively, were observed for individuals without GE. The mean prevalence rate of E. histolytica/dispar was significantly higher among individuals with GE compared with those without GE (p<0.0000001, OR=2.74). No significant difference in prevalence rate of the three organisms was found according to gender, but most of infections were observed in children aged 10 years or younger. CONCLUSION: The reviewed data suggest that E. histolytica, G. lamblia, and Cryptosporidium spp. may play a minor role in GE in Libya. The observed high prevalence rates of E. histolytica/dispar reported from Libya could be due mainly to the non-pathogenic E. dispar and E. moshkovskii. However, more studies are needed in the future using E. histolytica-specific enzyme immunoassays and/or molecular methods to confirm this observation.

Aeromonas in Arab countries: 1995-2014.

The aim of this review is to provide information on the prevalence, clinical syndromes, and antimicrobial resistance and therapy of Aeromonas spp. infections in Arab countries. The data were obtained by an English language literature search from 1995 to 2014 of Medline and PubMed for papers using the search terms "Aeromonas+name of Arab country (i.e. Algeria, Egypt, etc.)". Additional data were obtained from a Google search using the aforementioned terms. The organisms have been reported from diarrheal children, patients with cholera-like diarrhea, an outbreak of acute gastroenteritis and from different types of animals, foods and water source in several Arab countries in the Middle East and North Africa with predominance of A. hydrophila, A. caviae and A. sobria. Using molecular techniques few studies reported genes encoding several toxins from aeromonads isolated from different sources. Among the antimicrobials examined in the present review third generation cephalosporins, fluoroquinolones and aminoglycosides showed excellent activity and can be employed in the treatment of Aeromonas-associated human infections in Arabic countries. Whenever possible, treatment should be guided by the susceptibility testing results of the isolated organism. In the future, studies employing molecular testing methods are required to provide data on circulating genospecies and their modes of transmission in the community, and on their mechanisms of resistance to antimicrobials. Microbiology laboratories and research centers are encouraged to look for these organisms in clinical, food and water sources to attain a better understanding of the public health risks from these organisms in Arab countries.

Genospecies and virulence factors of Aeromonas species in different sources in a North African country.

INTRODUCTION: Aeromonads of medical importance have been reported from numerous clinical, food, and water sources, but identification of genospecies and virulence factors of Aeromonas species from countries in North Africa and the Middle East are few. METHODS: In total 99 Aeromonas species isolates from different sources (diarrheal children [n=23], non-diarrheal children [n=16], untreated drinking water from wells [n=32], and chicken carcasses [n=28]) in Tripoli, Libya, were included in the present investigation. Genus identification was confirmed by biochemical analysis, and genospecies were determined using a combination of 16S rDNA variable region and gyrB sequence analysis. Polymerase chain reaction (PCR) was used to detect genes encoding toxins from 52 of the isolates. RESULTS: We identified 44 isolates (44%) as A. hydrophila (3 [3.0%] subspecies anaerogenes, 23 [23%] subspecies dhakensis, and 18 [18%] subspecies ranae); 27 isolates (27%) as A. veronii; 23 isolates (23%) as A. caviae; and 5 isolates (5.0%) as other genospecies. The genes encoding aerolysin (aer), cytolytic enterotoxin (act), and A. hydrophila isolate SSU enterotoxin (ast) were detected in 45 (87%), 4 (7.7%), and 9 (17%) of the 52 isolates tested, respectively. The gene encoding an extracellular lipase (alt) was not detected. CONCLUSION: The majority of aeromonads from Libya fall within three genospecies (i.e. A. hydrophila, A. veronii, and A. caviae), and genes coding for toxin production are common among them.

High isolation rates of multidrug-resistant bacteria from water and carpets of mosques.

OBJECTIVE: There is little information regarding the isolation of antimicrobial-resistant potentially pathogenic bacteria from water and carpets of mosques worldwide. The objective of the present investigation is to determine the bacteriological quality of water and carpets of mosques in Elkhomes city in Libya. METHODS: Potentially pathogenic bacteria were isolated from water samples (n=44) and dust samples from carpets (n=50) of 50 mosques in Elkhomes city, Libya, using standard bacteriological procedures. Susceptibility of isolated bacteria to antimicrobial agents was determined by the disc-diffusion method. RESULTS: Of the water samples examined, 12 (27.3%) were positive for Escherichia coli, 10 (22.7%) for Klebsiella spp., and 15 (34.1%) for other enteric bacteria. Of the dust samples of carpets examined, 6 (12%) were positive for E. coli, 33 (66%) for Klebsiella spp., and 30 (60%) for Staphylococcus spp. Multidrug resistance (MDR, resistance to three or more antimicrobial groups) was found among 48.7% (19/37) and 46.9% (30/64) of the examined enterobacteria from water and carpets, respectively, and among 66.7% (20/30) of Staphylococcus spp. from carpets. In addition, methicillin-resistant Staphylococcus aureus (MRSA) was isolated from a carpet of one mosque. CONCLUSION: Presence of multidrug-resistant potentially pathogenic bacteria in examined water and carpets indicate that mosques as communal environments may play a role in the spread of multidrug-resistant bacteria in the community and pose a serious health risk to worshipers.

Enteroaggregative Escherichia coli in diarrheic children in Egypt: molecular characterization and antimicrobial susceptibility.

INTRODUCTION: Little information is available regarding the significance of enteroaggregative Escherichia coli (EAEC) in pediatric diarrhea in Egypt. METHODOLOGY: Escherichia coli was isolated from stool samples of 62 diarrheic and 43 non-diarrheic (control) Egyptian children. Samples were screened for genes specific for enteroaggregative E. coli (EAEC), enteropathogenic E. coli (EPEC), enterotoxigenic E. coli (ETEC), Shiga toxin-producing E. coli (STEC), and enteroinvasive E. coli (EIEC) using polymerase chain reaction (PCR). Diarrheagenic E. coli were grouped phylogenetically using PCR and tested for their susceptibility to antibiotics using the disk diffusion method. Isolates designated as EAEC were examined for eight virulence factors (VFs) using PCR. RESULTS: EAEC was detected in 19 (30.7%) and 4 (9.3%), EPEC in 2 (3.2%) and 1 (2.3%), and ETEC in 2 (3.2%) and 0 (0.0%) diarrheic and control children, respectively; STEC and EIEC were not detected. Only EAEC was significantly isolated from diarrheic children compared with controls (p < 0.01, OR = 4.31).Three or more VFs (multivirulent isolates) were found in 52.6% and 50% of EAEC isolated from diarrheic children and controls, respectively. More than 73% (17/23) of EAEC isolates were identified as belonging to phylogenetic group D. Multiple-antibiotic resistance (resistance to three or more drugs) was observed in more than 91% of EAEC. CONCLUSIONS: Multivirulent EAEC is a significant causative agent of pediatric diarrhea in Egypt, with the majority of isolated EAEC belong to phylogenetic group D. Multiple-antibiotic resistance among EAEC has the potential to be a serious public health problem for the country.

Nasal carriage of multi-drug resistant Panton-Valentine leucocidin-positive methicillin-resistant Staphylococcus aureus in children in Tripoli-Libya.

Methicillin-resistant Staphylococcus aureus (MRSA) colonized children are at an increased risk of developing infections than methicillin-sensitive S. aureus colonized children. Nasal specimens from inpatient children, mothers of inpatient children, healthcare workers, and outpatient children at Tripoli Children Hospital (TCH) were examined for MRSA by chromogenic MRSA ID medium. Susceptibility of MRSA isolates to antibiotics was determined by the disc diffusion method. The nasal carriage rate of MRSA among inpatient children (8.3%, 24 of 289), their mothers (11%, 22 of 200), and healthcare workers (12.4%, 22 of 178) was significantly higher than among outpatient children (2.2%, 2 of 91) (P < 0.05, P < 0.02, and P < 0.006, respectively). Of the examined MRSA isolates (N = 35) 10 (28.6%) were positive for Panton-Valentine leucocidin genes by polymerase chain reaction. Multidrug resistance was found in 24.3% (17 of 70) of MRSA isolates. Nasal carriage of multidrug-resistant Panton-Valentine leucocidin-positive MRSA is not uncommon among inpatient children and their mothers in Tripoli.

Antimicrobial resistance in Libya: 1970-2011.

Resistance to antimicrobial agents is a major health problem that affects the whole world. Providing information on the past state of antimicrobial resistance in Libya may assist the health authorities in addressing the problem more effectively in the future. Information was obtained mainly from Highwire Press (including PubMed) search for the period 1970-2011 using the terms 'antibiotic resistance in Libya', 'antimicrobial resistance in Libya', 'tuberculosis in Libya', and 'primary and acquired resistance in Libya' in title and abstract. From 1970 to 2011 little data was available on antimicrobial resistance in Libya due to lack of surveillance and few published studies. Available data shows high resistance rates for Salmonella species in the late 1970s and has remained high to the present day. High prevalence rates (54-68%) of methicillin-resistant Staphylococcus aureus (MRSA) were reported in the last decade among S. aureus from patients with burns and surgical wound infections. No reports were found of vancomycin-resistant S. aureus (VRSA) or vancomycin-intermediate-resistant S. aureus (VISA) using standard methods from Libya up to the end of 2011. Reported rates of primary (i.e. new cases) and acquired (i.e. retreatment cases) multidrug-resistant tuberculosis (MDR-TB) from the eastern region of Libya in 1971 were 16.6 and 33.3% and in 1976 were 8.6 and 14.7%, in western regions in 1984-1986 were 11 and 21.5% and in the whole country in 2011 were estimated at 3.4 and 29%, respectively. The problem of antibiotic resistance is very serious in Libya. The health authorities in particular and society in general should address this problem urgently. Establishing monitoring systems based on the routine testing of antimicrobial sensitivity and education of healthcare workers, pharmacists, and the community on the health risks associated with the problem and benefits of prudent use of antimicrobials are some steps that can be taken to tackle the problem in the future.

Cryptosporidium in countries of the Arab world: the past decade (2002-2011).

INTRODUCTION: Cryptosporidium is the causative agent of cryptosporidiosis. The disease is self-limited in immunocompetent persons but potentially life-threatening in immunocompromised individuals. METHODS: The data included in the present review were obtained mainly from a Highwire Press (including PubMed) search for the period 2002-2011. RESULTS: Information on cryptosporidiosis is lacking in some Arab countries; however available data show prevalence rates of <1-43% (mean = 8.7%) of Cryptosporidium infection in diarrheic immunocompetent pediatrics and <1-82% (mean 41%) in immunocompromised patients (including children and adults). Infection rate with Cryptosporidium species among pediatrics in rural and semiurban areas was higher than in urban areas. Cryptosporidium-associated diarrhea occurs mainly in younger children and inversely correlates with age, being more prevalent in children aged 1 year or less, particularly in rural and suburban regions. Although most Arab countries are characterized by a hot summer and a mild winter, infection with Cryptosporidium appears to occur at a higher rate of incidence during the rainy months that are usually associated with the cold season of the year. Contact with animals and contaminated waters are the main modes of transmission of cryptosporidia. Reports of C. hominis from the region indicate that person-to-person transmission is also important. Foreign housekeepers in oil-rich countries may be a source of Cryptosporidium. CONCLUSION: Cryptosporidium species, mainly C. parvum, are important causes of diarrhea in countries of the Arab world, particularly in children. In addition to educational programs that promote personal, household, as well as food hygiene, improving water treatment processes and protection of treated waters from contamination should be implemented by the health and environmental authorities in each country. More studies employing molecular testing methods are needed in the future to provide data on circulating species/genospecies and subtypes and their modes of transmission in the community.

Molecular characterization of diarrheagenic Escherichia coli from Libya.

Diarrheagenic Escherichia coli (DEC) are important enteric pathogens that cause a wide variety of gastrointestinal diseases, particularly in children. Escherichia coli isolates cultured from 243 diarrheal stool samples obtained from Libyan children and 50 water samples were screened by polymerase chain reaction (PCR) for genes characteristic of enteroaggregative E. coli (EAEC), enteropathogenic E. coli (EPEC), enterotoxigenic E. coli (ETEC), enterohemorrhagic E. coli (EHEC), and enteroinvasive E. coli (EIEC). The DEC were detected in 21 (8.6%) children with diarrhea; 10 (4.1%) cases were identified as EAEC, 3 (1.2%) as EPEC, and 8 (3.3%) were ETEC; EHEC, and EIEC were not detected. All DEC were grouped phylogenetically by PCR with the majority (> 70%) identified as phylogenetic groups A and B1. The EAEC isolates were also tested for eight genes associated with virulence using PCR. Multi-virulence (≥ 3 virulence factors) was found in 50% of EAEC isolates. Isolated EAEC possessed different virulence traits and belonged to different phylogenetic groups indicating their heterogeneity.

Methicillin-resistant Staphylococcus aureus (MRSA) in a tertiary surgical and trauma hospital in Benghazi, Libya.

INTRODUCTION: Methicillin resistant Staphylococcus aureus (MRSA) is a multidrug resistant organism that threatens the continued effectiveness of antibiotics worldwide and causes a threat almost exclusively in hospitals and long-term care settings. This study investigated the prevalence of MRSA strains and their sensitivity patterns against various antibiotics used for treating hospitalized patients in a major tertiary surgical hospital in Benghazi, Libya. METHODOLOGY: We investigated 200 non-duplicate S. aureus strains isolated from different clinical specimens submitted to the Microbiology Laboratory at Aljala Surgical and Trauma Hospital, Benghazi, Libya from April to July 2007. Isolates were tested for methicillin resistance by the oxacillin disc-diffusion assay according to Clinical and Laboratory Standards Institute guidelines. MRSA strains were tested for antimicrobial resistance (i.e., vancomycin, ciprofloxacin, erythromycin, chloramphenicol and fusidic acid) using commercial discs. Information on patient demographics and clinical disease was also collected. RESULTS: Of the isolates examined 31% (62/200) were MRSA. No significant differences were observed in the prevalence of MRSA among S. aureus from females or males or from different age groups. Most MRSA were isolated from burns and surgical wound infections. Antibiotic resistance patterns of 62 patients with MRSA to vancomycin, ciprofloxacin, fusidic acid, chloramphenicol and erythromycin were 17.7%, 33.9%, 41.9%, 38.7% and 46.8% of cases, respectively. CONCLUSION: MRSA prevalence in our hospital was high and this may be the case for other hospitals in Libya. A sound surveillance program of nosocomial infections is urgently needed to reduce the incidence of infections due to MRSA and other antimicrobial-resistant pathogens in Libyan hospitals.

Enteric pathogens associated with childhood diarrhea in Tripoli-Libya.

Stool samples from children < 5 years of age with diarrhea (N = 239) were examined for enteric pathogens using a combination of culture, enzyme-immunoassay, and polymerase chain reaction methods. Pathogens were detected in 122 (51%) stool samples; single pathogens were detected in 37.2% and co-pathogens in 13.8% of samples. Norovirus, rotavirus, and diarrheagenic Escherichia coli (DEC) were the most frequently detected pathogens (15.5%, 13.4%, and 11.2%, respectively); Salmonella, adenovirus, and Aeromonas were detected less frequently (7.9%, 7.1%, and 4.2%). The most commonly detected DEC was enteroaggregative E. coli (5.4%). Resistance to ≥ 3 antimicrobials was observed in 60% (18/30) of the bacterial pathogens. Salmonella resistance to ciprofloxacin (63.1%) has become a concern. Enteric viral pathogens were the most significant causative agents of childhood diarrhea in Tripoli. Bacterial pathogens were also important contributors to pediatric diarrhea. The emergence of ciprofloxacin-resistant Salmonella represents a serious health problem that must be addressed by Libyan health authorities.

Maternal and neonatal seroprevalence of Hepatitis B surface antigen (HBsAg) in Tripoli, Libya.

BACKGROUND: Pregnant women with Hepatitis B virus HBV represent a major reservoir of the virus in the community. Data regarding the prevalence of HBV in pregnant women and maternal transmission of the virus in Libya are lacking. METHODOLOGY: Hepatitis blood samples from 1,500 pregnant women and 1,500 cord blood samples of their neonates delivered at Tripoli Medical Center, Tripoli, were tested for HBsAg by ELISA technique. HBsAg-positive samples were also tested for HBeAg. RESULTS: HBsAg was detected in 1.5% (23/1,500) pregnant women and in 0.9% (14/1,500) neonates. Although HBsAg was detected at higher rate in pregnant women aged > 25 years [1.8% (22/1,235)] than in pregnant women aged < 25 years [0.4% (1/265)], the difference was not statistically significant (P > 0.05). All HBsAg-positive neonates were born to HBsAg-positive mothers with a rate of maternal transmission at 60.9% (14/23). HBeAg was detected in 21.7% (5/23) and in 7.1% (1/14) of HBsAg-positive pregnant women and neonates, respectively. CONCLUSIONS: Because of the high risk of developing chronic HBV infection at birth among infants born to HBsAg-positive mothers, administration of HBIG in combination with hepatitis B vaccine as post-exposure prophylaxis for such infants is of paramount importance. In addition, universal HBsAg screening of all pregnant women will greatly assist in reducing the maternal transmission of HBV in the country.

Enteric fever in Mediterranean north Africa.

Typhoid fever is endemic in the Mediterranean North African countries (Morocco, Algeria, Tunisia, Libya, and Egypt) with an estimated incidence of 10-100 cases per 100,000 persons. Outbreaks caused by Salmonella enterica serovar Typhi are common and mainly due to the consumption of untreated or sewage-contaminated water. Salmonella enterica Paratyphi B is more commonly involved in nosocomial cases of enteric fever in North Africa than expected and leads to high mortality rates among infants with congenital anomalies. Prevalence among travellers returning from this region is low, with an estimate of less than one per 100,000. Although multidrug resistant strains of Salmonella Typhi and Paratyphi are prevalent in this region, the re-emergence of chloramphenicol- and ampicillin-susceptible strains has been observed. In order to better understand the epidemiology of enteric fever in the Mediterranean North African region, population-based studies are needed. These will assist the health authorities in the region in preventing and controlling this important disease.

Uropathogens from diabetic patients in Libya: virulence factors and phylogenetic groups of Escherichia coli isolates.

Urinary tract infections (UTIs) in patients with diabetes mellitus (DM) are reported mainly from developed countries. In addition to this underreporting from developing countries, there is a lack of information pertaining to the virulence factors (VFs) and phylogenetic grouping of uropathogenic Escherichia coli (UPEC) from DM and non-DM patients in developing countries. Between July 2005 and June 2006, urine specimens were collected from 135 DM and 164 non-DM patients, all with clinically diagnosed UTIs, attending Elkhadra Hospital and the Diabetic Center in Tripoli, Libya. Specimens were examined for different uropathogens using standard microbiological procedures. Isolated uropathogens were tested for their susceptibility to antimicrobial agents by a disc diffusion method. In addition, UPEC was grouped phylogenetically by PCR and subsequently tested for 19 VFs. Uropathogens were isolated from 77 (57 %) of the DM group and from 110 (67 %) of the non-DM group (P >0.05). E. coli was isolated from 18 (13 %) and 29 (18 %), Klebsiella species from 18 (13 %) and 23 (14 %), and Staphylococcus aureus from 12 (9 %) and 12 (7 %) of the DM and non-DM groups, respectively (P >0.05). Age, gender, education level and marital status had no significant influence on the isolation rates of different organisms from the DM group compared with the non-DM group. With very few exceptions, no differences were observed in the antimicrobial resistance profiles of uropathogens from the DM and non-DM patients. In addition, UPEC from the DM patients was significantly less virulent and was associated with phylogenetic group A, whilst UPEC from the non-DM patients was significantly more virulent and was associated with group D. The results of our surveillance of UTI infections in DM patients agree, in general, with observations reported previously from several developed countries.