Cracking the Code: Unveiling the Diversity of Carbapenem-Resistant Klebsiella pneumoniae Clones in the Arabian Peninsula through Genomic Surveillance.

The rise of antimicrobial resistance is a global challenge that requires a coordinated effort to address. In this study, we examined the genetic similarity of carbapenem-resistant Klebsiella pneumoniae (CRKP) in countries belonging to the Gulf Cooperation Council (GCC) to gain a better understanding of how these bacteria are spreading and evolving in the region. We used in silico genomic tools to investigate the occurrence and prevalence of different types of carbapenemases and their relationship to specific sequence types (STs) of CRKP commonly found in the region. We analyzed 720 publicly available genomes of multi-drug resistant K. pneumoniae isolates collected from six GCC countries between 2011 and 2020. Our findings showed that ST-14 and ST-231 were the most common STs, and 51.7% of the isolates carried blaOXA-48-like genes. Additionally, we identified rare carbapenemase genes in a small number of isolates. We observed a clonal outbreak of ST-231 in Oman, and four Saudi isolates were found to have colistin resistance genes. Our study offers a comprehensive overview of the genetic diversity and resistance mechanisms of CRKP isolates in the GCC region that could aid in developing targeted interventions to combat this pressing global issue.

Etiology and Antibiotic Susceptibility Patterns of Urinary Tract Infections in Children in a General Hospital in Kuwait: A 5-Year Retrospective Study.

OBJECTIVE: The aim of this study was to determine the bacterial profile and prevalence of antibiotic resistance patterns of uropathogens, as well as to evaluate the problem with extended-spectrum ß-lactamases (ESBLs)-producing isolates, causing urinary tract infections (UTIs) in children in Al-Amiri Hospital, Kuwait, over a 5-year period. MATERIALS AND METHODS: Significant isolates from symptomatic pediatric patients with UTIs from January 2017 to December 2021 were identified by conventional methods and by the VITEK 2 identification card system. Antimicrobial susceptibility testing was performed by the disk diffusion method for Gram-positive organisms and an automated VITEK 2 system for Gram-negative organisms. ESBL-producing Enterobacterales were detected by the double-disk diffusion method and VITEK 2 system. RESULTS: Significant bacteriuria was detected in 13.7% of the 9,742 urine samples. Escherichia coli accounted for 67.3% of these, followed by Klebsiella pneumoniae (8.9%), Proteus spp. (5.7%), and Enterococcus spp. (7.4%), respectively. High resistance rates were observed among the Enterobacterales against ampicillin, cephalothin, nitrofurantoin, amoxicillin/clavulanic acid, and trimethoprim-sulfamethoxazole. The prevalence of ESBL-producing E. coli and K. pneumoniae was 26% and 55%, respectively. The most sensitive among the antibiotics tested for Gram-negative organisms were meropenem, amikacin, gentamicin, and piperacillin/tazobactam, while the antibiotics tested for Gram-positive organisms were vancomycin, ampicillin, linezolid, and nitrofurantoin. CONCLUSION: E. coli remains the most common uropathogen. A high percentage of uropathogens causing UTI in children were highly resistant to the first- and second-line antibiotics for the therapy of UTI. ESBL-producing bacteria were highly prevalent in children in our hospital. Local antibiograms should be used to assist with empirical UTI treatment.

Seroprevalence of toxocariasis among allergic patients in Kuwait and its association with eosinophilia.

Toxocariasis is a worldwide helminthic infection which is transmitted from infected dogs and cats and has been associated with peripheral blood eosinophilia. The Centers for Disease Control and Prevention (CDC) placed toxocariasis among the top 6 parasitic diseases in the USA which are prioritized for public health action. To our knowledge, there are no reports on human toxocariasis in Kuwait or in the other Gulf Cooperation Council (GCC) countries. This study aims at investigating the seroprevalence of toxocariasis among allergic patients in Kuwait and its association with eosinophilia, age, gender, nationality, and history of direct contact with dogs or cats. From September to December 2021, the laboratory records of allergic patients referred to Al-Rashed Allergy Hospital, Kuwait were reviewed and a total of 400 serum samples were selected: 200 samples from patients with normal eosinophil count (< 500 cells/µl) and 200 samples from patients with eosinophilia (> 500 cells/µl). The sera were screened for anti-Toxocara canis IgG antibodies via antibody enzyme-linked immunosorbent assay (Ab-ELISA). The seropositive patients were asked about their history of direct contact with dogs or cats. Statistical analyses were performed using Microsoft Excel® Analysis ToolPak software. Toxocariasis seropositivity was detected in 10 out of 400 (2.5%) allergic patients. Five patients had eosinophilia while 5 had normal eosinophil count. There was no difference in mean age or gender between Toxocara-seropositive and seronegative patients (p > 0.05). The seroprevalence rate was lower-than-expected among Kuwaiti patients (2/307, 0.7%) in comparison with non-Kuwaiti patients (8/57, 14.0%) (χ2 = 33.603, df = 1, p < 0.001) who originated from endemic South/Southeast Asian countries. Seven out of 8 (87.5%) seropositive patients had a history of direct contact with cats, dogs, or both. The seroprevalence rate of toxocariasis among allergic patients in Kuwait was 2.5%. Raising awareness and early deworming treatment/prophylaxis for juvenile dogs and cats remain crucial for toxocariasis prevention.

Elucidating the virulence genes harboured by carbapenemase- and non-carbapenemase-producing carbapenem-resistant Klebsiella pneumoniae rectal isolates from patients admitted to intensive care units using whole-genome sequencing in Kuwait.

Introduction. Klebsiella pneumoniae is a Gram-negative pathogen responsible for community- and nosocomial-acquired infections. The presence of an accessory genome determines the bacterial pathogenicity and the host immune response, and thus indicates multidrug-resistant strains or more virulent groups. Little is known about the virulence genes in K. pneumoniae in Kuwait.Hypothesis/Gap Statement. The diversity of virulence genes and capsule loci in K. pneumoniae isolates warrants further genomic studies to better understand their transmission within the hospitals in Kuwait.Aim. We aimed to investigate the virulence genes harboured by K. pneumoniae isolated from rectal swabs of intensive care unit (ICU) patients in two Kuwaiti teaching hospitals.Methodology. Six isolates from patients in the ICUs of Al Razi and Mubarak hospitals, designated RZH144, RZH132 RZH108 and RZH173, and MKH381 and MKH347, respectively, were subjected to whole-genome sequencing (WGS) assays. RZH144 and RZH132 were non-carbapenemase-producing K. pneumoniae (NCKP) isolates negative for genes encoding carbapenemase production by PCR assays, and the remaining four were carbapenemase-producing K. pneumoniae (CPKP) isolates. Isolates were characterized by phenotypic, PCR and WGS methods. Susceptibility testing was performed by E test and clonality by multilocus sequence typing. Analysis of the isolates' assembled contigs was carried out using Kleborate (https://pathogen.watch).Results. An NCPE RZH132 K. pneumoniae isolate belonged to ST231-wzi104 and harboured gene clusters encoding the biosynthesis of the siderophore aerobactin (iuc5) on 62-3LV. The capsular locus variants were KL51 and O locus O1v2. Another NCPKP RZH144 isolate was confirmed as ST43-wzi412 and harboured KL61 and O1v1. The four CPKP isolates harboured two virulence loci - ybt14 and iuc5 - encoding the siderophores yersiniabactin and aerobactin, respectively. They belonged to ST231-wzi104 and harboured yersiniabactin on ICEKp5. The sequence type of ybt was YbST145-1LV. Strain RZ108 was devoid of virulence loci. Its sequence type was ST15-wzi151 and harboured KL48 and O1V1. ST231 clonal lineage isolates shared common virulence plasmid variants.Conclusion. The CPKP ST231 had the highest virulence score and contained iuc5, which was found for the first time in ST231-CPKP isolates in Kuwait.

Epidemiology, Serogroups and Resistance of Salmonella During a 15-Year Period (2006-2020) in Kuwait.

PURPOSE: The aim of the study was to investigate the changing pattern in serogroup distribution and antimicrobial resistance of all Salmonella spp. isolated from patients attending the Mubarak Al Kabeer Hospital (MAK), Kuwait from 2006 to 2020. PATIENTS AND METHODS: A retrospective study of all enrolled patients attending the MAK with culture-positive Salmonella spp. was undertaken. Data on age, gender, culture sample and serogroup were obtained from the laboratory information system. A prospective antimicrobial susceptibility of all stock isolates was carried out using E test. The trend rates of Salmonella serogroups and antimicrobial resistance were compared among 5 periods: 2006-2008, 2009-2011, 2012-2014, 2015-2017, and 2018-2020. RESULTS: A total of 700 isolates were identified. The majority of the isolates were from the stool (77.6%), followed by the blood (16.4%). The most common serogroups were serogroup D (37.6%) and B (23.4%). There was a significant rise in ciprofloxacin resistance from 32.2% during 2006-2008 to 54.3% during 2018-2020 and from 32.5% during 2009-2011 to 54.3% during 2018-2020 (P=0.0001, respectively). The resistance trend to cefotaxime was at relatively low levels ranging from 0% to 3.4% through 2006-2008 to 2018-2020. There was a significant drop of the resistance to ampicillin from 23.6% in 2015-2017 to 12.3% in 2006-2008 to 2018-2020 (P=0.03). Trimethoprim/sulfamethoxazole resistance dropped significantly from 14.5 to 3.6% (P=0.002) during 2006-2008 to 2018-2020 and then from 13.5 to 3.6% (P=0.02) during 2015-2017 to 2018-2020. One hundred and seventeen (16.7%) isolates were multidrug-resistant. CONCLUSION: Continuous surveillance of Salmonella and its antimicrobial resistance is important for antibiotic policy formulation for invasive Salmonella infections.

Molecular characterization of rectal isolates of carbapenemase-negative carbapenem-resistant enterobacterales obtained from ICU patients in Kuwait by whole-genome sequencing.

Introduction. Carbapenem-resistant enterobacterales (CRE) are listed among the most urgent antibiotic resistance threats.Hypothesis. Previous studies on the mechanisms of CRE in Kuwait have focused on carbapenemases. There have been no studies on non-carbapenemase-producing CRE in Kuwait.Aim/Gap Statement. The aim of this study was to investigate the genetic characteristics of non-carbapenemase-producing carbapenem-resistant enterobacterales (NCPE) isolates using whole-genome sequencing (WGS).Methodology. Fourteen confirmed NCPE isolates that were negative for genes encoding carbapenemase production by polymerase chain reaction (PCR) assays using rectal swabs from intensive care unit patients were characterized using phenotypic, PCR and WGS methods. Susceptibility testing was performed via Etest and clonality via multi-locus sequence typing (MLST).Results. All of the isolates were resistant to ertapenem; 78.6 % were resistant to imipenem, meropenem and trimethoprim-sulfamethoxazole. Resistance to the other antibiotics was variable, ranging from 28.5 (colistin) through 50 (tigecycline) and 64.3 (amikacin) up to 85.7 % against both amoxicillin-clavulanic acid and ciprofloxacin. WGS detected several resistance genes mediating the production of ß-lactamases, genes encoding an outer-membrane porin permeability mutation resulting in reduced susceptibility to ß-lactams, including carbapenems, and genes for multidrug-resistant (MDR) efflux pumps. The isolates also possessed global activator protein MarA, which mediated reduced permeability to ß-lactams. The existence of ß-lactamase genes, overexpression of MDR efflux pumps and reduced permeability mediated by the porin genes were responsible for carbapenem resistance.Conclusions. This finding reflects the superior detection capabilities offered by WGS analysis, which can be used to complement traditional methods and overcome their limited resolution in clinical settings.

Molecular characterization of metronidazole resistant Bacteroides strains from Kuwait.

Eleven metronidazole resistant Bacteroides and one newly classified Phocaeicola dorei strain from Kuwait were investigated for their resistance mechanisms and the emergence of their resistant plasmids. All but one strain harbored nimE genes on differently sized plasmids. Of the 11 nimE genes, 9 were preceded by full copies of the prototype ISBf6 insertion sequence element, one carried a truncated ISBf6 and one was activated by an additional copy of IS612B. Nucleotide sequencing results showed that the nimE ISBf6 distances were constant and all five different plasmids shared a common region, suggesting that (i) the nimE-ISBf6 configuration was inserted into an undisclosed common genetic element, (ii) over time, this common element was mutated by insertions and deletions, spreading the resultant plasmids. Of the 10 B. fragilis strains in this collection, 6 were also cfiA-positive, one with full imipenem resistance, indicating a tendency for multidrug resistance (MDR) among such isolates. The significant number of metronidazole resistant Bacteroides spp. and P. dorei strains with the MDR phenotype warns of difficulties in treatment and suggests promoting adherence to antibiotic stewardship recommendations in Kuwait.

Evaluation of the in vitro activity of ceftaroline, ceftazidime/avibactam and comparator antimicrobial agents against clinical isolates from paediatric patients in Kuwait: ATLAS data 2012-19.

Objectives: To report antimicrobial resistance data for Gram-positive and Gram-negative pathogens isolated from paediatric patients in three hospitals in Kuwait during 2012-19. Methods: In vitro activity of antimicrobials against isolates from documented infections was determined using CLSI broth microdilution method and breakpoints at a central laboratory. Enterobacterales and Pseudomonas aeruginosa isolates were screened for ß-lactamases using multiplex PCR assays. Phenotypic determination of resistance in Haemophilus influenzae and Gram-positive isolates was performed using standard methodologies. Results: Among 515 Enterobacterales isolates, 29.3% were ESBL-positive; susceptibility was highest to amikacin, ceftazidime/avibactam and meropenem (≥97.4%), regardless of ESBL status. CTX-M-15 was identified in 87.1% of ESBL-positive Escherichia coli and 84.2% of ESBL-positive Klebsiella pneumoniae isolates. Of 111 P. aeruginosa isolates, 9.9% were MDR and 12.6% meropenem-resistant (MEM-R). Amikacin and ceftazidime/avibactam had the highest susceptibility rates in the overall group (≥92.8%), with reduced rates among MDR and MEM-R isolates. All 269 MRSA and 180 MSSA isolates were susceptible to daptomycin, linezolid, teicoplanin, tigecycline and vancomycin. All MSSA and 99.3% of MRSA were ceftaroline susceptible. All 168 pneumococcal isolates were susceptible to ceftaroline, linezolid, tigecycline and vancomycin. H. influenzae and Streptococcus pyogenes ceftaroline susceptibility rates were ≥93.3% and ≥95.6%. Conclusions: Most isolates of Enterobacterales (including resistant phenotypes) and P. aeruginosa from Kuwait during 2012-19 were susceptible to ceftazidime/avibactam. Ceftaroline was active against most Gram-positive isolates, including resistant phenotypes, and ESBL-negative Enterobacterales. These results indicate that novel antibiotics such as ceftazidime/avibactam and ceftaroline represent valuable treatment options for paediatric infections, including those caused by MDR organisms.

Prevalence of carbapenem-resistant Enterobacteriaceae and emergence of high rectal colonization rates of blaOXA-181-positive isolates in patients admitted to two major hospital intensive care units in Kuwait.

BACKGROUND: Fecal colonization by carbapenem-resistant Enterobacteriaceae (CRE) can be the main reservoir for transmission of these resistant organisms especially in the Intensive Care Units (ICUs). AIM: This study was conducted to evaluate the rate of rectal carriage and molecular characterization of CRE in patients hospitalized in the ICUs of 2 major hospitals (Adan and Mubarak Al Kabeer Hospitals) in Kuwait. MATERIALS AND METHODS: Rectal swabs were collected from all patients at admission, 48 h after admission and once weekly from April 2017- March 2018. Initial CRE screening was carried out on MacConkey agar on which meropenem disc 10µg was placed. Identification of isolates was by API 20E. Susceptibility testing was performed using the E-test method. Polymerase chain reaction (PCR) was used to detect the carbapenemase-encoding genes. Clonal relationship was investigated by pulsed-field electrophoresis (PFGE). Genes of blaOXA-181 and blaNDM-5-carrying plasmids were detected in some strains. RESULTS: A total of 590 patients were recruited into the study. Of these, 58 were positive for CRE, giving a prevalence of 9.8%; 25/320 (7.8%) in Adan and 33/270 (12.2%) in Mubarak Al Kabeer Hospitals. All isolates were resistant to multiple antibiotics. Resistance rates to colistin and tigecycline were 17% and 83%, respectively. Single genes of blaOXA-181 were detected in isolates from 38 (65.5%) out of 58 patients and in 5 patients colonized by blaOXA-48-positive CRE. A combination of 2 genes was detected in 12 isolates; 5 blaKPC-2 and blaOXA-181, 4 blaVIM-1 and blaOXA-181, and 3 blaNDM-5 and blaOXA-181. PFGE showed an overall level of similarity of 38%. Southern hybridization studies localized the blaOXA-181 and blaNDM-5 genes to a large plasmid of 200kb in 3 K. pneumoniae isolates and a small plasmid of 80kb in 2 E. coli isolates, respectively. CONCLUSION: The prevalence of CRE colonization in the 2 hospital ICUs was relatively high and the emergence of blaOXA-181-mediated CRE is a cause for concern as there is the possibility of rapid horizontal spread among hospital patients in Kuwait. Active surveillance of CRE in the ICUs is highly recommended to stem its spread.

Prevalence and antimicrobial susceptibility of enterotoxigenic extra-intestinal Bacteroides fragilis among 13-year collection of isolates in Kuwait.

BACKGROUND: Some strains of Bacteroides fragilis species are associated with diarrhea as a result of enterotoxin production (bft or fragilysin). Fragilysin is activated by C11 protease (fpn) and together with C10 protease (bfp) play a significant role in its invasiveness. The objectives of this study were to investigate the proportion of clinical isolates from extra-intestinal sources that are toxin producers and characterize the genes mediating toxin production. Clinical isolates submitted to our reference laboratory over the last 13 years were screened for toxin production using PCR technique. All stool isolates were excluded. The isolates were tested for their susceptibility to 8 antimicrobial agents by E test. Carbapenem resistance gene cfiA was detected by PCR. RESULTS: A total of 421 B. fragilis isolates were viable. Out of these, bft was detected in 210 (49.9%) isolates. Of the 210 bft-positive isolates, 171 (81.4%), 33 (15.7%) and 6 (2.8%) harbored bft-1, bft-2, and bft-3 genes, respectively. Twenty (9.5%) of the bft-positive strains originated from bloodstream infections. Twenty-five, 20 and 9 strains harbored bfp-1, bfp-2 and bfp-3 gene, respectively. Two, 3, 4 bfp isotypes were detected simultaneously in some of strains. The resistance rates against amoxicillin-clavulanic acid was 32%, clindamycin 62%, cefoxitin 26%, imipenem 11%, meropenem 17%, metronidazole 4%, piperacillin 61% and tigecycline 14%. A chromosomally located cfiA gene that encode metallo-ß-lactamase was identified in only 34 isolates (16.2%). CONCLUSIONS: The prevalence of enterotoxin-producing B. fragilis was high among the extra-intestinal isolates. Metronidazole was the most active agent against all isolates. There was no statistically significance difference between resistance rates among bft-positive and bft-negative isolates except for clindamycin.

Comparative in vitro activity of ceftaroline and comparator agents against nosocomial Gram-negative and Gram-positive clinically significant bacterial isolates from patients in a teaching hospital in Kuwait.

The objective was to test the in vitro activities of ceftaroline and comparator agents against clinical isolates of Gram-negative and Gram-positive bacteria. Isolates were identified with VITEK II. Susceptibility testing was with E test. A total of 1264 isolates were tested. Compared to other cephalosporins, ceftaroline demonstrated excellent in vitro activities (MIC90, ≤0.5 mg/L) against Escherichia coli, Salmonella spp. and Haemophilus influenzae. When matched with the comparator cephalosporins, ceftaroline demonstrated the greatest activity against methicillin-susceptible Staphylococcus aureus (MSSA), with MIC90 of 0.25 mg/L. Ceftaroline's MIC90s against both community-associated methicillin-resistant S. aureus (MRSA) and hospital-acquired MRSA were 0.5 and 1 mg/L, respectively. Major discrepancies were noted between E test and disc diffusion tests for ceftaroline only against 16 Gram-negative and 16 Gram-positive isolates. Ceftaroline demonstrated an excellent in vitro activity against the majority of clinically significant Gram-negative and Gram-positive isolates obtained from proven cases of bacterial infections.

Overwhelming Streptococcus pyogenes sepsis in an elderly patient with septic arthritis.

INTRODUCTION: The signs of Streptococcus pyogenes, group A streptococci (GAS) bacteremia are non-specific and patients can have wide presentations ranging from flu-like symptoms to life-threatening toxic-shock syndrome in just a few hours. CASE PRESENTATION: We report a case of fulminant S. pyogenes sepsis in an elderly woman with septic arthritis and remarkable past medical history/risk factors. She was febrile, hypotensive and had a swollen and tender right knee. Multiple blood cultures and the synovial fluid culture yielded S. pyogenes. Despite adequate antimicrobial therapy with penicillin and clindamycin the patient succumbed to her infection within 4days of presentation in our hospital. CONCLUSION: GAS remains penicillin sensitive most of the time but prompt appropriate antibiotic therapy is very crucial to survival.

Contribution of horizontal gene transfer to the emergence of VIM-4 carbapenemase producer Enterobacteriaceae in Kuwait.

Carbapenem-resistant Enterobacteriaceae encountered in countries of the Arabian Peninsula usually produce OXA-48-like and New Delhi metallo-beta-lactamases (NDM) carbapenemases. However, a temporary increase in VIM-4-producing, clonally unrelated Enterobacteriaceae strains was described earlier in a Kuwaiti hospital. We investigated the genetic support of blaVIM-4 in six Klebsiella pneumoniae strains, one Escherichia coli, and one Enterobacter cloacae strain and compared it to that of VIM-4-producing isolates from other countries of the region. Five K. pneumoniae strains and the E. coli strain from Kuwait carried an ~165 kb IncA/C-type plasmid indistinguishable by restriction fragment length polymorphism. The complete sequence of one of them (pKKp4-VIM) was established. pKKp4-VIM exhibited extensive similarities to episomes pKP-Gr642 carrying blaVIM-19 encountered in Greece and to the partially sequenced pCC416 harboring blaVIM-4 detected in Italy. In other countries of the region, the only similar plasmid was the one detected in the isolate from the UAE. In all Kuwaiti strains, irrespective of the species and their VIM plasmids, the blaVIM-4 gene was located within the same integron structure (In416), different from those of other countries of the region. Our data show that the spread of this IncA/C plasmid and particularly that of the In416 integron caused a considerable, albeit temporary, increase in the rate of mostly clonally unrelated VIM-producing Enterobacteriaceae strains of multiple species. Monitoring of such events is of high importance as the interference with the spread of mobile genetic elements may represent a formidable challenge to infection control.

Characterization of NDM-7 Carbapenemase-Producing Escherichia coli Isolates in the Arabian Peninsula.

AIM: The purpose of this study was to characterize the New Delhi metallo-beta lactamase (NDM)-7-producing Enterobacteriaceae isolated in the Arabian Peninsula. METHODS: Enterobacteriaceae identified to carry blaNDM-7 in a collection of 157 NDM-producing isolates from Kuwait, Oman, Saudi Arabia, and the United Arab Emirates (UAE) were investigated for their antibiotic and disinfectant susceptibility, and resistance gene content. The virulence profile, phylogenetic and sequence types of the isolates were also determined. The plasmids carrying the blaNDM-7 were transferred, and their complete nucleotide sequence was determined. RESULTS: Four NDM-7-producing Escherichia coli isolated in Kuwait, Oman, and the UAE, respectively, were identified. They were clonally unrelated, carried a few virulence determinants only, and belonged to clonal complexes CC10 and CC23, or ST448. They were all multi-drug resistant but remained susceptible to fosfomycin, tigecycline, and colistin. In all isolates, blaNDM-7 was located on IncX3 type plasmids of a variable size, not harboring any further resistance genes. The plasmids exhibited a high degree of similarity to each other and to pKpN01-NDM7 from Canada, with various size deletions and insertions. CONCLUSIONS: Our findings show that IncX3 type plasmids play an important role in the spread of the currently rare NDM-7 variant in the Arabian Peninsula. This association of blaNDM-7 with the IncX3-type plasmid is particularly worrisome, as this type of plasmid was proved to spread other carbapenemases in various species of Enterobacteriaceae worldwide at a high efficiency.

Surveillance of Antibiotic Resistance among Hospital- and Community-Acquired Toxigenic Clostridium difficile Isolates over 5-Year Period in Kuwait.

Clostridium difficile infection (CDI) is a leading and an important cause of diarrhea in a healthcare setting especially in industrialized countries. Community-associated CDI appears to add to the burden on healthcare setting problems. The aim of the study was to investigate the antimicrobial resistance of healthcare-associated and community-acquired C. difficile infection over 5 years (2008-2012) in Kuwait. A total of 111 hospital-acquired (HA-CD) and 35 community-acquired Clostridium difficile (CA-CD) clinical isolates from stool of patients with diarrhoea were studied. Antimicrobial susceptibility testing of 15 antimicrobial agents against these pathogens was performed using E test method. There was no evidence of resistance to amoxicillin-clavulanic acid, daptomycin, linezolid, piperacillin-tazobactam, teicoplanin and vancomycin by both HA-CD and CA-CD isolates. Metronidazole had excellent activity against CA-CD but there was a 2.9% resistance rate against HA-CD isolates. Ampicillin, clindamycin, levofloxacin and imipenem resistance rates among the HC-CD vs. CA-CD isolates were 100 vs. 47.4%; 43 vs. 47.4%; 100 vs. 100% and 100 vs. 89%, respectively. An unexpected high rifampicin resistance rate of 15.7% emerged amongst the HA-CD isolates. In conclusion, vancomycin resistance amongst the HA-CD and CA-CD isolates was not encountered in this series but few metronidazole resistant hospital isolates were isolated. High resistance rates of ampicillin, clindamycin, levofloxacin, and imipenem resistance were evident among both CA-CD and HA-CD isolates. Rifampicin resistance is emerging among the HA-CD isolates.

High Prevalence of New Delhi Metallo-ß-Lactamase-1 (NDM-1) Producers among Carbapenem-Resistant Enterobacteriaceae in Kuwait.

The aim of the study was to determine the prevalence of New Delhi metallo-ß lactamase-1 (NDM-1) producing Enterobacteriaceae in Kuwait over a one year period. Consecutive Enterobacteriaceae isolates with reduced susceptibility to carbapenems were collected from four government hospitals in Kuwait from January-December 2014. Their susceptibility to 18 antibiotics was performed by determining the minimum inhibitory concentration. Isolates resistant to carbapenems were tested by PCR for resistant genes. Finger printing of the positive isolates was done by DiversiLab®. Clinical data of patients harboring NDM-1 positive isolates were analyzed. A total of 764 clinically significant Enterobacteriaceae isolates were studied. Of these, 61 (8%) were carbapenem-resistant. Twenty one out of these 61 (34.4%) were NDM-1-producers. All patients positive for NDM-1-carrying bacteria were hospitalized. About half were females (11/21 [52.3%]), average age was 53.3 years and the majority were Kuwaitis (14/21 [66.6%]). Six patients (28.5%) gave a history of travel or healthcare contact in an endemic area. Mortality rate was relatively high (28.6%). The predominant organism was Klebsiella pneumoniae (14 [66.6%]) followed by E. coli (4 [19%]). All NDM-1-positive isolates were resistant to meropenem, ertapenem, cefotaxime, cefoxitin and ampicillin, while 95.2% were resistant to imipenem, cefepime, and piperacillin-tazobactam. They were multidrug resistant including resistance to tigecycline, but 90% remained susceptible to colistin. About two-thirds of isolates (61.9%) co-produced-extended spectrum ß-lactamases. During the study period, an outbreak of NDM-1 positive K. pneumoniae occurred in one hospital involving 3 patients confirmed by DiversiLab® analysis. In conclusion, NDM-1-producing Enterobacteriaceae is a growing healthcare problem with increasing prevalence in Kuwait, especially in hospitalized patients, leaving few therapeutic options. A high prevalence of NDM-1 necessitates the implementation of strict infection control to prevent the spread of these organisms.

Implementation of central venous catheter bundle in an intensive care unit in Kuwait: Effect on central line-associated bloodstream infections.

Central line-associated bloodstream infection (CLABSIs) is an important healthcare-associated infection in the critical care units. It causes substantial morbidity, mortality and incurs high costs. The use of central venous line (CVL) insertion bundle has been shown to decrease the incidence of CLABSIs. Our aim was to study the impact of CVL insertion bundle on incidence of CLABSI and study the causative microbial agents in an intensive care unit in Kuwait. Surveillance for CLABSI was conducted by trained infection control team using National Health Safety Network (NHSN) case definitions and device days measurement methods. During the intervention period, nursing staff used central line care bundle consisting of (1) hand hygiene by inserter (2) maximal barrier precautions upon insertion by the physician inserting the catheter and sterile drape from head to toe to the patient (3) use of a 2% chlorohexidine gluconate (CHG) in 70% ethanol scrub for the insertion site (4) optimum catheter site selection. (5) Examination of the daily necessity of the central line. During the pre-intervention period, there were 5367 documented catheter-days and 80 CLABSIs, for an incidence density of 14.9 CLABSIs per 1000 catheter-days. After implementation of the interventions, there were 5052 catheter-days and 56 CLABSIs, for an incidence density of 11.08 per 1000 catheter-days. The reduction in the CLABSI/1000 catheter days was not statistically significant (P=0.0859). This study demonstrates that implementation of a central venous catheter post-insertion care bundle was associated with a reduction in CLABSI in an intensive care area setting.

Sequence analysis of genes mediating extended-spectrum beta-lactamase (ESBL) production in isolates of Enterobacteriaceae in a Lagos Teaching Hospital, Nigeria.

BACKGROUND: Extended-spectrum ß-lactamases (ESBLs) in Gram-negative organisms is now a major concern in Enterobacteriaceae worldwide. This study determined a point-prevalence and genetic profiles of ESBL-producing isolates among members of the family Enterobacteriaceae in Lagos State University Teaching Hospital Ikeja, Nigeria. METHODS: Consecutive non-repetitive invasive multidrug-resistant isolates of the family Enterobacteriaceae obtained over a period of 1 month (October 2011) were studied. The isolates were identified using VITEK-2/VITEK MS Systems. Susceptibility testing was performed using E test technique; results were interpreted according to the criteria recommended by the Clinical and Laboratory Standards Institute (CLSI, 2012). ESBL production was detected by E test ESBL method and confirmed by polymerase chain reaction (PCR). RESULTS: During the one-month study period, 38 isolates with ESBL phenotypic characteristics were identified and confirmed by PCR. Of these, 21 (55.3 %) were E. coli, 12 (31.6 %) K. pneumoniae, 3 (7.9 %) Proteus spp., 1 (2.6 %) each M. morganii and C. freundii. Thirty (79 %) harbored bla CTX-M genes. Sequence analysis revealed that they were all bla CTX-M-15 genes. Twenty-nine (96.7 %) of these, also harbored bla TEM genes simultaneously. All the CTX-M-15-producing isolates carried insertion sequence bla ISEcP1 upstream of bla CTX-M-15 genes. The E. coli isolates were genetically heterogeneous, while the K. pneumoniae had 98 % homology. CONCLUSIONS: Our point-prevalence surveillance study revealed a high prevalence of Enterobacteriaceae isolates harboring bla CTX-M-15 in the Hospital. Urgent implementation of antibiotic stewardship and other preventive strategies are necessary at this time in our hospital.

A prospective study of community-associated Clostridium difficile infection in Kuwait: Epidemiology and ribotypes.

Clostridium difficile infection (CDI) is increasingly recognized as a significant community acquired pathogen that causes disease in the community. The aim of the study was to investigate prospectively the incidence of community-acquired-CDI (CA-CDI) in Kuwait. Of the 2584 patients with diarrhea, 16 (0.62%) were confirmed cases of CA-CDI. The other notable pathogens were Salmonella spp. (0.39%) and Campylobacter spp. (0.23%). The mean age was 39 years and the CDI was mild. Exposure to antibiotics in the previous 12 weeks, contact with infant aged <2 years and history of foreign travel was significantly associated with CA-CDI (P < 0.001; P < 0.0001; P < 0.002, respectively). Detected PCR ribotypes were 139 (n = 4) and 014, 056, 070, 097 and 179 (each n = 2). CA-CDI in Kuwait is more likely to occur in younger age and associated with ribotype 139. CA-CDI is not a common problem in Kuwait however extra vigilance must be maintained to detect it in the community even without traditional predisposing factors.

Characterization of Carbapenem-Resistant Enterobacteriaceae with High Rate of Autochthonous Transmission in the Arabian Peninsula.

To establish the role of local transmission versus possible pathogen import due to previous foreign exposure in infections caused by carbapenem non-susceptible Enterobacteriaceae in the Arabian Peninsula, 200 independent isolates collected in 16 hospitals of Saudi Arabia, Kuwait, Oman and the United Arab Emirates were studied. All strains were multidrug resistant; 42.5% of them also qualified as extremely drug resistant. The frequency of various carbapenemases varied according to the participating countries, but in the collection, as a whole, blaNDM-1 was the most frequently encountered carbapenemase gene (46.5%) followed by blaOXA-48-like gene (32.5%). A comparatively high rate (8.9%) of multi-clonal strains carrying both blaNDM and blaOXA-48-like genes in the United Arab Emirates, representing the most resistant subgroup, was encountered. No KPC-expressing isolates were detected. Three major clones of blaNDM-1 carrying Klebsiella pneumoniae of ST152 (n = 22, Saudi Arabia), ST14 (n = 7, United Arab Emirates) and ST147 types (n = 9, Oman) were identified, the latter two clones carrying similar, but not identical HI1b incompatibility type plasmids of >170 kb. While from 78.6% of the cases with documented foreign hospitalization blaNDM positive strains were isolated, these strains formed only 25.6% of all the isolates expressing this enzyme. In fact, 56.8% of the NDM, 75.7% of OXA-48-like and 90.9% of VIM positive strains were recovered from patients without documented foreign exposure, neither in the form of travel or prior hospitalization abroad, suggesting a high rate of autochthonous infections. This, considering the extensive links of these countries to the rest of the world, predicts that trends in the local epidemiology of carbapenem resistant strains may increasingly affect the spread of these pathogens on the global scale. These results call for improved surveillance of carbapenem resistant Enterobacteriaceae in the countries of the Arabian Peninsula.