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1.  Drug-resistant ventilator associated pneumonia in a tertiary care hospital in Saudi Arabia 
Annals of Thoracic Medicine  2014;9(2):104-111.
There is a wide geographic and temporal variability of bacterial resistance among microbial causes of ventilator-associated pneumonia (VAP). The contribution of multi-drug resistant (MDR) pathogens to the VAP etiology in Saudi Arabia was never studied. We sought to examine the extent of multiple-drug resistance among common microbial causes of VAP.
We conducted a retrospective susceptibility study in the adult intensive care unit (ICU) of King Abdulaziz Medical City, Riyadh, Saudi Arabia. Susceptibility results of isolates from patients diagnosed with VAP between October 2004 and June 2009 were examined. The US National Healthcare Safety Network definition of MDR was adopted.
A total of 248 isolates including 9 different pathogens were included. Acinetobacter spp. was highly (60-89%) resistant to all tested antimicrobials, including carbapenems (three- and four-class MDR prevalence were 86% and 69%, respectively). Pseudomonas aeruginosa was moderately (13-31%) resistant to all tested antimicrobials, including antipseudomonal penicillins (three- and four-class MDR prevalence were 13% and 10%, respectively). With an exception of ampicillin (fully resistant), Klebsiella spp. had low (0-13%) resistance to other tested antimicrobials with no detected MDR. Staphylococcus aureus was fully susceptible to vancomycin with 42% resistance to oxacillin. There were significant increasing trends of MDR Acinetobacter spp. however not P. aeruginosa during the study. Resistant pathogens were associated with worse profile of ICU patients but not patients’ outcomes.
Acinetobacter in the current study was an increasingly resistant VAP-associated pathogen more than seen in many parts of the world. The current finding may impact local choice of initial empiric antibiotics.
PMCID: PMC4005156  PMID: 24791174
Acinetobacter; antimicrobial resistance; microbiology; Saudi Arabia; ventilator-associated pneumonia
2.  Prospective study of incidence and predictors of peripheral intravenous catheter-induced complications 
Although intravenous therapy is one of the most commonly performed procedures in hospitalized patients, it remains susceptible to infectious and noninfectious complications. Previous studies investigated peripheral intravenous catheter (PIVC) complications mainly in pediatrics, but apparently none were investigated among Saudi adult populations. The aim of this study was to assess the pattern and complications of PIVCs at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia.
An observational prospective cohort study investigated PIVCs pattern and complications among adults with PIVCs, admitted to various wards at KAMC. PIVCs-related clinical outcomes (pain, phlebitis, leaking, and others) were recorded in 12-hour intervals, using the Visual Inspection Phlebitis scale. Density incidence (DI) and cumulative incidence (CI) of complications and their relative risks (RRs) were calculated. Regression analyses were applied and significance limits were set at P<0.05.
During the study period, 359 adults were included, mounting to 842 PIVCs and 2,505 catheter days. The majority of patients, 276 (76.9%), had medical, chief admission complaints, whereas 83 (23.1%) were trauma/surgical and infectious cases. Complicated catheters were found in 141 (39.3%) patients, with 273 complications (32.4/100 catheters), in 190 complicated catheters (CI =22.56/100 catheters and DI =75.84/1,000 catheter days). Phlebitis ranked first among complications, 148 (CI =17.6%), followed by pain 64 (CI =7.6%), leaking 33 (CI =3.9%), dislodgement 20 (CI =2.4%), and extravasations and occlusion 4 (CI =0.5% each). Phlebitis was predicted with female sex (P<0.001), insertion in fore/upper arm (P=0.024), and infusion of medication (P=0.02). Removal time for PIVCs insertion was not a significant predictor of phlebitis (RR =1.46, P=0.08).
Incidence of complications in this study was significantly higher than rates in previous studies. Better insertion techniques may be sought to lower the incidences of PIVC complications, thus extending their onset beyond day 3. Changing catheters is recommended when clinically indicated rather than routinely post-72 hours.
PMCID: PMC4266329  PMID: 25525365
catheter-induced complications; peripheral venous catheter; phlebitis; thrombo-phlebitis; incidence; prospective study
3.  Molecular Characterization of Carbapenemase-Producing Escherichia coli and Klebsiella pneumoniae in the Countries of the Gulf Cooperation Council: Dominance of OXA-48 and NDM Producers 
The molecular epidemiology and mechanisms of resistance of carbapenem-resistant Enterobacteriaceae (CRE) were determined in hospitals in the countries of the Gulf Cooperation Council (GCC), namely, Saudi Arabia, United Arab Emirates, Oman, Qatar, Bahrain, and Kuwait. Isolates were subjected to PCR-based detection of antibiotic-resistant genes and repetitive sequence-based PCR (rep-PCR) assessments of clonality. Sixty-two isolates which screened positive for potential carbapenemase production were assessed, and 45 were found to produce carbapenemase. The most common carbapenemases were of the OXA-48 (35 isolates) and NDM (16 isolates) types; 6 isolates were found to coproduce the OXA-48 and NDM types. No KPC-type, VIM-type, or IMP-type producers were detected. Multiple clones were detected with seven clusters of clonally related Klebsiella pneumoniae. Awareness of CRE in GCC countries has important implications for controlling the spread of CRE in the Middle East and in hospitals accommodating patients transferred from the region.
PMCID: PMC4068443  PMID: 24637692
4.  The inevitable! An emergence of a new influenza virus 
Annals of Thoracic Medicine  2009;4(3):109-110.
PMCID: PMC2714562  PMID: 19641639
5.  Association of compliance of ventilator bundle with incidence of ventilator-associated pneumonia and ventilator utilization among critical patients over 4 years 
Annals of Thoracic Medicine  2014;9(4):221-226.
Several studies showed that the implementation of the Institute for Healthcare Improvement (IHI) ventilator bundle alone or with other preventive measures are associated with reducing Ventilator-Associated Pneumonia (VAP) rates. However, the association with ventilator utilization was rarely examined and the findings were conflicting. The objectives were to validate the bundle association with VAP rate in a traditionally high VAP environment and to examine its association with ventilator utilization.
The study was conducted at the adult medical-surgical intensive care unit (ICU) at King Abdulaziz Medical City, Saudi Arabia, between 2010 and 2013. VAP data were collected by a prospective targeted surveillance as per Centers for Disease Control and Prevention (CDC)/National Healthcare Safety Network (NHSN) methodology while bundle data were collected by a cross-sectional design as per IHI methodology.
Ventilator bundle compliance significantly increased from 90% in 2010 to 97% in 2013 (P for trend < 0.001). On the other hand, VAP rate decreased from 3.6 (per 1000 ventilator days) in 2010 to 1.0 in 2013 (P for trend = 0.054) and ventilator utilization ratio decreased from 0.73 in 2010 to 0.59 in 2013 (P for trend < 0.001). There were negative significant correlations between the trends of ventilator bundle compliance and VAP rate (cross-correlation coefficients −0.63 to 0.07) and ventilator utilization (cross-correlation coefficients −0.18 to −0.63).
More than 70% improvement of VAP rates and approximately 20% improvement of ventilator utilization were observed during IHI ventilator bundle implementation among adult critical patients in a tertiary care center in Saudi Arabia. Replicating the current finding in multicenter randomized trials is required before establishing any causal link.
PMCID: PMC4166069  PMID: 25276241
Bundle; health-care-associated infection; Institute for Healthcare Improvement; quality improvement; ventilator-associated pneumonia; ventilator utilization
6.  β-Lactamase Production in Key Gram-Negative Pathogen Isolates from the Arabian Peninsula 
Clinical Microbiology Reviews  2013;26(3):361-380.
Infections due to Gram-negative bacilli (GNB) are a leading cause of morbidity and mortality worldwide. The extent of antibiotic resistance in GNB in countries of the Gulf Cooperation Council (GCC), namely, Saudi Arabia, United Arab Emirates, Kuwait, Qatar, Oman, and Bahrain, has not been previously reviewed. These countries share a high prevalence of extended-spectrum-β-lactamase (ESBL)- and carbapenemase-producing GNB, most of which are associated with nosocomial infections. Well-known and widespread β-lactamases genes (such as those for CTX-M-15, OXA-48, and NDM-1) have found their way into isolates from the GCC states. However, less common and unique enzymes have also been identified. These include PER-7, GES-11, and PME-1. Several potential risk factors unique to the GCC states may have contributed to the emergence and spread of β-lactamases, including the unnecessary use of antibiotics and the large population of migrant workers, particularly from the Indian subcontinent. It is clear that active surveillance of antimicrobial resistance in the GCC states is urgently needed to address regional interventions that can contain the antimicrobial resistance issue.
PMCID: PMC3719487  PMID: 23824364
7.  Spread, Circulation, and Evolution of the Middle East Respiratory Syndrome Coronavirus 
mBio  2014;5(1):e01062-13.
The Middle East respiratory syndrome coronavirus (MERS-CoV) was first documented in the Kingdom of Saudi Arabia (KSA) in 2012 and, to date, has been identified in 180 cases with 43% mortality. In this study, we have determined the MERS-CoV evolutionary rate, documented genetic variants of the virus and their distribution throughout the Arabian peninsula, and identified the genome positions under positive selection, important features for monitoring adaptation of MERS-CoV to human transmission and for identifying the source of infections. Respiratory samples from confirmed KSA MERS cases from May to September 2013 were subjected to whole-genome deep sequencing, and 32 complete or partial sequences (20 were ≥99% complete, 7 were 50 to 94% complete, and 5 were 27 to 50% complete) were obtained, bringing the total available MERS-CoV genomic sequences to 65. An evolutionary rate of 1.12 × 10−3 substitutions per site per year (95% credible interval [95% CI], 8.76 × 10−4; 1.37 × 10−3) was estimated, bringing the time to most recent common ancestor to March 2012 (95% CI, December 2011; June 2012). Only one MERS-CoV codon, spike 1020, located in a domain required for cell entry, is under strong positive selection. Four KSA MERS-CoV phylogenetic clades were found, with 3 clades apparently no longer contributing to current cases. The size of the population infected with MERS-CoV showed a gradual increase to June 2013, followed by a decline, possibly due to increased surveillance and infection control measures combined with a basic reproduction number (R0) for the virus that is less than 1.
MERS-CoV adaptation toward higher rates of sustained human-to-human transmission appears not to have occurred yet. While MERS-CoV transmission currently appears weak, careful monitoring of changes in MERS-CoV genomes and of the MERS epidemic should be maintained. The observation of phylogenetically related MERS-CoV in geographically diverse locations must be taken into account in efforts to identify the animal source and transmission of the virus.
PMCID: PMC3944817  PMID: 24549846
8.  Transmission and evolution of the Middle East respiratory syndrome coronavirus in Saudi Arabia: a descriptive genomic study 
Lancet  2013;382(9909):1993-2002.
Since June, 2012, Middle East respiratory syndrome coronavirus (MERS-CoV) has, worldwide, caused 104 infections in people including 49 deaths, with 82 cases and 41 deaths reported from Saudi Arabia. In addition to confirming diagnosis, we generated the MERS-CoV genomic sequences obtained directly from patient samples to provide important information on MERS-CoV transmission, evolution, and origin.
Full genome deep sequencing was done on nucleic acid extracted directly from PCR-confirmed clinical samples. Viral genomes were obtained from 21 MERS cases of which 13 had 100%, four 85–95%, and four 30–50% genome coverage. Phylogenetic analysis of the 21 sequences, combined with nine published MERS-CoV genomes, was done.
Three distinct MERS-CoV genotypes were identified in Riyadh. Phylogeographic analyses suggest the MERS-CoV zoonotic reservoir is geographically disperse. Selection analysis of the MERS-CoV genomes reveals the expected accumulation of genetic diversity including changes in the S protein. The genetic diversity in the Al-Hasa cluster suggests that the hospital outbreak might have had more than one virus introduction.
We present the largest number of MERS-CoV genomes (21) described so far. MERS-CoV full genome sequences provide greater detail in tracking transmission. Multiple introductions of MERS-CoV are identified and suggest lower R0 values. Transmission within Saudi Arabia is consistent with either movement of an animal reservoir, animal products, or movement of infected people. Further definition of the exposures responsible for the sporadic introductions of MERS-CoV into human populations is urgently needed.
Saudi Arabian Ministry of Health, Wellcome Trust, European Community, and National Institute of Health Research University College London Hospitals Biomedical Research Centre.
PMCID: PMC3898949  PMID: 24055451
9.  Physician ‘defiance’ towards hand hygiene compliance: Is there a theory–practice–ethics gap? 
The theory–practice gap has always existed [1,2]. This gap is often cited as a culmination of theory being idealistic and impractical, even if practical and beneficial, is often ignored. Most of the evidence relating to the non-integration of theory and practice assumes that environmental factors are responsible and will affect learning and practice outcomes, hence the gap. Therefore, the author believes that to ‘bridge the gap’ between theory and practice, an additional dimension is required: ethics. A moral duty and obligation ensuring theory and practice integrate. In order to effectively implement new practices, one must deem these practices as worthy and relevant to their role as healthcare providers (HCP). Hence, this introduces a new concept which the author refers to as the theory–practice–ethics gap. This theory–practice–ethics gap must be considered when reviewing some of the unacceptable outcomes in healthcare practice [3]. The literature suggests that there is a crisis of ethics where theory and practice integrate, and healthcare providers are failing to fulfill our duty as patient advocates.
Physician hand hygiene practices and compliance at King Abdulaziz Cardiac Centre (KACC) are consistent with those of other physicians in the global healthcare arena. That is one of noncompliance to King Abdulaziz Medical City (KAMC) organizational expectations and the World Health Organization (WHO) requirements?
An observational study was conducted on the compliance of cardiac surgeons, cardiologists and nurses in the authors’ cardiac center from January 2010 to December 2011. The hand hygiene (HH) compliance elements that were evaluated pertained to the WHO’s five moments of HH recommendations. The data was obtained through direct observation by KAMC infection prevention and control practitioners.
Physician hand hygiene compliance at KACC was consistently less than 60%, with nurses regularly encouraging physicians to be diligent with hand hygiene practices in the clinical area.
Hand hygiene compliance will not improve unless evidence-based recommendations are adopted and endorsed by all healthcare professionals and providers.
PMCID: PMC3809478  PMID: 24174860
Theory; Practice; Ethics; Hand hygiene; Healthcare associated infection; Physician
10.  Improvement of the low knowledge, attitude and practice of hepatitis B virus infection among Saudi national guard personnel after educational intervention 
BMC Research Notes  2012;5:597.
Although the risk of hepatitis B virus (HBV) was reported to be higher in military personnel than the general population in Saudi Arabia (SA), there is lack of studies assessing HBV awareness among them. The objective was to evaluate the knowledge, attitude and practice (KAP) of HBV infection among military personnel.
An intervention design with pre- and post-education KAP questionnaire was completed among National Guard soldiers working in Jeddah during January 2009. Educational intervention was provided through educational leaflets, group and individual discussions, visual show, and a lecture. A score was created from the correct answers to 58 questions.
A total of 400 male soldiers with mean age 30.7 ± 6.1 years completed both questionnaires. The majority had school education (96.8%) and in the lower military ranks (66.0%). Only 19.5% of soldiers reported HBV vaccine intake. The low median and inter-quartile range of the pre-intervention score (16, 6–26) markedly increased after education (to 53, 50–55, p<0.001). The overall improvement of mean KAP score (204%) was also observed in all its component scores; disease nature (272%), methods of transmission (206%), prevention and control (109%), attitude (155%), and practice (192%). The improvement was evident irrespective of socio-demographic characteristics and history of HBV vaccine. KAP scores were significantly associated with higher educational levels, higher monthly income, administrative jobs, and higher job ranks.
We are reporting a low level of HBV awareness among Saudi military population. The study confirms the need and effectiveness of focused multifaceted educational campaigns among the military population.
PMCID: PMC3532195  PMID: 23111118
Hepatitis B virus; Knowledge; Attitude and Practice; Military; Saudi Arabia
11.  The prevalence of antimicrobial resistance in clinical isolates from Gulf Corporation Council countries 
The burden of antimicrobial resistance worldwide is substantial and is likely to grow. Many factors play a role in the emergence of resistance. These resistance mechanisms may be encoded on transferable genes, which facilitate the spread of resistance between bacterial strains of the same and/or different species. Other resistance mechanisms may be due to alterations in the chromosomal DNA which enables the bacteria to withstand the environment and multiply. Many, if not most, of the Gulf Corporation Council (GCC) countries do not have clear guidelines for antimicrobial use, and lack policies for restricting and auditing antimicrobial prescriptions.
The aim of this study is to review the prevalence of antibiotic resistance in GCC countries and explore the reasons for antibiotic resistance in the region.
The PubMed database was searched using the following key words: antimicrobial resistance, antibiotic stewardship, prevalence, epidemiology, mechanism of resistance, and GCC country (Saudi Arabia, Qatar, Bahrain, Kuwait, Oman, and United Arab Emirates).
From January1990 through April 2011, there were 45 articles published reviewing antibiotic resistance in the GCC countries. Among all the GCC countries, 37,295 bacterial isolates were studied for antimicrobial resistance. The most prevalent microorganism was Escherichia coli (10,073/44%), followed by Klebsiella pneumoniae (4,709/20%), Pseudomonas aeruginosa (4,287/18.7%), MRSA (1,216/5.4%), Acinetobacter (1,061/5%), with C. difficile and Enterococcus representing less than 1%.
In the last 2 decades, E. coli followed by Klebsiella pneumoniae were the most prevalent reported microorganisms by GCC countries with resistance data.
PMCID: PMC3436690  PMID: 22958584
Antibiotics/antimicrobials; Resistance; GCC; (Saudi Arabia, Qatar, Bahrain, Kuwait, Oman, and United Arab Emirates) Gram negative; Gram positive; Anaerobes; Pathogens; Infection; Resistance mechanisms; Molecular typing
12.  Increased prevalence of rotavirus among children associated gastroenteritis in Riyadh Saudi Arabia 
Virology Journal  2011;8:548.
The aim of this study is to assess the epidemiology along with the molecular structure of rotavirus causing pediatric diarrhea among Saudi patients. However, in this report we sited the epidemiological reflect coming from our project.
One thousand and seven diarrheal stool samples had been collected between Jan1st, 2008 and OCT 31st, 2010 from hospitalized patients below the age of 5 year. Samples were then examined using Enzyme-linked immunosorbent assay (ELISA). Demographic data were collected including age, sex, date of admission and discharge. Finally, the chi-squire test, α level of significance was used to test the variables in the data.
Of these 1007 stool samples, rotavirus was detected in 65.5% (660/1007 samples). We observed that children who are 1 year of age or less had more infection with rotavirus 81% (534/660) than those who is over 1 year of age (19%,126/660) (P = 0.000). Infections occur throughout the year with no clear significant seasonal peaks. The difference between males (57.5%, 380/660) and females (42.4%, 280/660) in terms of rotavirus positivity is statistically significant.
The high rate of positivity, are at variance with previously published reports of rotavirus infection in Saudi Arabia since 2005 which reported a major decrease year by year in the incidence of rotavirus over; 2005, 2006 and 2008 with percentage of; 25%, 10%, 6% respectively explained by improvements in public health introduced in recent years. Our increasing rate result (65.5%) may suggest emerging of unusual serotypes, not been represent to our country earlier.
PMCID: PMC3273455  PMID: 22176997
13.  Acceptance and Adverse Effects of H1N1 Vaccinations Among a Cohort of National Guard Health Care Workers during the 2009 Hajj Season 
BMC Research Notes  2011;4:61.
The H1N1 influenza pandemic had garnered a large amount of attention. Currently, the most effective preventive measure available is the H1N1 vaccine. We aimed to assess the willingness of our study participants to receive the H1N1 vaccination prior to the annual Hajj season. If any participant declined, we investigated the reasons for vaccine rejection.
We conducted a prospective cohort study of National Guard employees during the 1430 (2009) Hajj season. A survey was used as the primary method for data collection. Participants were vaccinated one to two weeks prior to their trip to Mona, and any side effects reported at the time of injection and three weeks post vaccination were recorded.
There were 100 male and 26 female participants in the study. In total, 66.7% (n = 84) of the participants were health care workers (HCWs) and 33.3% (n = 42) were non-health care workers (non-HCWs). Less than half of the respondents (46.8%, n = 59) accepted the vaccination. The vaccination acceptance rate was higher among non-HCWs, at a rate of 71.4% (n = 30); HCWs only accepted at a rate of 34.5% (n = 29) (OR 1.103, 95% CI [0.488-2.496]). The most common reason for vaccine refusal was the impression that the disease was not fatal (25.4%, n = 32). Finally, all participants reported pain at the injection site and 18.3% (n = 11) reported swelling. All other side effects were reported in less than 15% of the participants.
Despite fears of the new H1N1 vaccine, there was a reasonable rate of vaccine acceptance among our study participants. Early health education may increase the rate of acceptance of the H1N1 vaccine. Furthermore, additional research is needed on long-term adverse effects of the H1N1 vaccine.
PMCID: PMC3063226  PMID: 21396123
14.  Authors’ reply 
Annals of Thoracic Medicine  2010;5(4):250-251.
PMCID: PMC2954388
16.  Awareness, attitudes, and practices related to the swine influenza pandemic among the Saudi public 
During an infectious disease outbreak, it is critical to learn as much as possible about the concerns, knowledge, attitudes, and behavior of the public. Such information can be crucial to the improvement of communication efforts by public health officials and clinicians. The aim of this study was to identify awareness, attitudes, and practices related to influenza A (H1N1) among the Saudi public.
A cross-sectional study of 1,548 adult subjects recruited from various shopping malls in Riyadh and Jeddah was conducted. All of the subjects were interviewed using a questionnaire that tested their knowledge, attitudes, and use of precautionary measures in relation to the H1N1 influenza pandemic.
More than half (54.3%, 840/1548) of the participants showed high concern, 43.7%(677/1548) showed a low level of knowledge, and 60.8%(941/1548) had taken minimal or no precautionary measures. After adjusting for other variables, education level was the only significant predictor of the level of concern (p < 0.001), while greater precautionary measures were taken by participants who were male (p < 0.001), older (p = 0.047), better educated (p = 0.04), and more knowledgeable (p < 0.001). More than one-third (38.3%) of participants were not convinced that the MOH reports about the disease were true, and only 16.1% of the participants reported receiving information from health providers.
High concern did not translate into a higher compliance with precautionary recommendations, possibly due to the low level of knowledge about the disease among the public. Frequent communication between physicians and the public is recommended to help dispel myths about the disease and to spread better information about the role that the public can play in limiting the spread of the disease.
PMCID: PMC2844401  PMID: 20187976

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