Nosocomial Pathogens--A Single Center Study in Saudi Arabia.
Nosocomial infections are commonly transmitted due to lack of effective infection control because the hospital staffs do not follow a correct hygiene maintenance plan regularly. As the staff in the hospital commonly moves from one place to another and from one patient to another, they may serve as a vector for transmission of infection. Additionally, the visitors to the admitted patients are also an active vector for transmitting the nosocomial infections. Additionally, increased use of out-patient treatment in recent time means that a greater percentage of people who are hospitalized today are likely to be seriously ill with more weakened immune systems than in the past (10). Moreover, some medical procedures bypass the body's natural protective barriers and cause some serious infections. Nosocomial pathogens have shifted away from easily treatable bacteria towards more resistant bacteria because of extensive use of large number of antimicrobial agents (11). The burden of healthcare-associated infections and increased morbidity and mortality due to nosocomial bacteria acquired during hospital stay has been reported worldwide (12-15).
In order to control and reduce the prevalence of nosocomial pathogens within healthcare settings, it becomes imperative to acquire the knowledge about the source and transmission of these difficult to treat pathogens. The aim of this study was to screen the patients, staff and the environment of Maternity Hospital in northern part of Saudi Arabia.
MATERIALS AND METHODS
In this study, 821 swabs were collected from the Hail Maternity Hospital, Saudi Arabia between March and April 2013. Swabs were collected from a range of body sites including, nose, rectal, umbilical, throat, skin and wound infections; from patients (365), hospital staff (414), and from the hospital environment like walls, beds, taps, computer keyboards and ventilator surfaces (42). The swabs were processed in the Microbiology Laboratory and the bacterial isolates were cultured during 24-48 h at 37[degrees]C on 5% sheep blood agar, chocolate agar, and Mac-Conkey agar. Growing colonies were checked for mixed cultures, transferred to a new plate and the isolates growing in pure culture were subsequently conserved in at 80[degrees]C until use.
Identification of Pure Bacterial Colonies by Biochemical methods
After Gram staining and determination of catalase and oxidase activities, bacterial isolates were identified using PHOENIXH identification cards (BD Diagnostics, Sparks, MD, USA) or APIH identification strips (bioMe'rieux, Lyon, France), both according to the manufacturer's instructions. Additionally, Slidex Staph Plus (bioMe'rieux, Lyon, France) was used for Staphylococcus aureus identification.
All bacterial strains were examined by MALDI-TOF-MS (16) using a Microflex LT instrument (Bruker Daltonics, Germany), Flex control 3.0 software and the Biotyper 2.0 database (Bruker Daltonics). These instruments were used to calculate and process the analytical data according to the manufacturer's instructions. In this method, a fresh colony material was smeared on a polished steel target plate (Bruker Daltonics) using a toothpick, overlaid with 1 il of a saturated a-cyano-4-hydroxy-cinnamic acid (HCCA) matrix solution in 50% acetonitrile-2.5% trifluoroacetic acid (Bruker Daltonics), and air dried at room temperature. For the direct transfer-formic acid method, 1 il of 70% formic acid was added to the bacterial spot and allowed to air dry before the matrix solution was added. The Bruker bacterial test standard (Bruker Daltonics) was used for calibration according to the instructions of the manufacturer. For each strain, two preparations of colony/sample material were analyzed. Standard Bruker interpretative criteria were applied to compare the data obtained with reference data base. Briefly, scores of e"2.0 were accepted for species assignment and scores of e"1.7 but <2.0 for identification to the genus level. Scores below 1.7 were considered unreliable.
Microscan walkaway (Siemens Healthcare Diagnostics, Sacramento, CA, USA) is an automated system used for bacterial identification and antibiotic susceptibility test. A small portion of a well isolated colony was taken and added to a Gram-positive or a Gram-negative Microscan combo panel. The panel was loaded into the Microscan walkaway machine according to the manufacturer's protocol. Results were available after 24- 48 hrs.
In this study, 878 swabs were collected from a range of body sites from patients, staff and from the hospital environment. The identification from the positive samples showed, 157 different bacterial strains were isolated including, S. aureus (32.48%), E. coli (19.74%), K. pneumoniae (32.48%), Enterobacter spp. (5.73%), Citrobacter (0.63%) and P. aeruginosa (8.9%) as presented in Table 1. Among these bacterial isolates, 41.4% were found to be in staff, 56.6% in patients and 1.9% in hospital environment respectively. The antibiotic susceptibility results revealed that, among 157 bacterial isolates, 19% (30/157) were found to be MRSA, 12% (21/157) MSSA, 17% (26/157) E. coli-ESBL-positive, 3% (5/157) E. coli-ESBL-negative, 30% (46/157) K. pneumoniae-ESBL-positive and 3% (5/157) K. Pneumoniae-ESBL-negative isolates, respectively. Furthermore, the distribution of resistant strains among patients, staff and environment are shown in Figure 1. The results of resistant bacterial strain distribution showed that, 57% of MRSA were found among staff members and 43% MRSA were found to be present among patients respectively. However, 94%, 3% and 3% MSSA were found to be present in staff, patients and environment respectively. All (100%) Extended spectrum a-lactamase (ESBL) positive E. coli and 91% ESBL positive K. pneumoniae were found among patients respectively.
Nosocomial infections are on the rise and they pose a serious threat to patients and the healthcare professionals. Staphylococcus aureus, Coagulase-Negative Staphylococci (CoNS), Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Clostridium difficile, Enterobacter spp., Enterococcus spp., and Acinetobacter spp. are common bacterial pathogens capable of causing nosocomial infections (3-5). The results of current study showed a high prevalence of nosocomial bacterial isolates among the patients and hospital staff in Ha'il Maternity hospital. In this study, 878 swabs were collected from a range of body sites from patients, staff and from the hospital environment. The identification from the positive samples showed, 157 different bacterial strains were isolated including, S. aureus (32.48%), E. coli (19.74%), K. pneumoniae (32.48%), Enterobacter spp. (5.73%), Citrobacter (0.63%) and P. aeruginosa (8.9%). The results of our study were slightly different compared to a study conducted as one year surveillance in a military hospital in Saudi Arabia by Moataz et al. 2005. In his study, MRSA was found to be the most common (10.2%) (17). Additionally in another study from the KSA, the most prevalent nosocomial pathogen was found to be MRSA (31.7%) (15). Nosocomial pathogens are slowly becoming difficult to treat organisms due to the appearance of highly resistant strains, because of higher number of antibiotic usage in the hospitalized patients (11). Methicillin resistant S. aureus and ESBL positive E. coli and K. pneumoniae are at rise among the hospitalized patients. The antibiotic profiling of the nosocomial pathogens in the current study showed a high prevalence of MRSA from both hospital staff as well as from the patients. 57% of MRSA in our study were found to be among the hospital staff and 43% among the patients. The results of our study were in agreement with a study from India in which 55% of MRSA were reported from the hospital staff and 45% from the patients (18).
Extended spectrum [beta]-lactamases (ESBLs) positive K. pneumoniae and E. coli have emerged as most prevalent nosocomial pathogens among the Gram-negative rods (GNR) worldwide. These pathogens have been reported from the patients, hospital staff as well as from the hospital environment. In our study, 46% K. pneumoniae and 26% E. coli were found to be ESBL positive. Furthermore, the distribution of these ESBL positive strains showed that 100% ESBL-E. coli and 90% ESBL-K. pneumoniae were from the patients and 9% ESBL-K. pneumoniae were from the hospital staff.
The results of our study showed a high prevalence of nosocomial pathogens from patients, hospital staff as well as from the hospital environment in Maternity hospital, Hail, Saudi Arabia. Furthermore, highly resistant strains like MRSA and ESBL-positive E. coli and K. pneumoniae in our study confirms that the hospital workers may be acting as a vector for the transmission of these difficult to treat pathogens in the hospital settings. In order to control the nosocomial infections, the surveillance strategies along with the antibiotic prescription guidelines as well as the efficient infection control programs should be implemented.
This study reveals a high percentage of prevalence of nosocomial pathogens from patients, hospital staff as well as from the hospital environment in Maternity hospital, Hail, Saudi Arabia. Furthermore, highly resistant strains like MRSA and ESBL-positive E. coli and K. pneumoniae in our study confirms that the hospital workers may be acting as a vector for the transmission of these difficult to treat pathogens in the hospital settings. This study highlights the need for strengthening nosocomial infection prevention and control programs, monitoring antibiotic prescription policies at each facility, and implementation of surveillance and effective infection control programs in the hospitals across the Saudi Arabia.
(Received: 10 August 2018; accepted: 26 September 2018)
This study was funded by a research grant from Ha'il University.
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Mushtaq A. Khan  *, Khalid A. Al-Motair , Mohammed M. Alenezi , Ahmed S. Altheban , Sahar A. Hammam  and Mohammed S. Al-Mogbel 
 Molecular Diagnostic and Personalized Therapeutics Unit, College of Applied Medical Sciences, University of Ha'il, Kingdom of Saudi Arabia,  College of Nursing, University of Ha'il, Kingdom of Saudi Arabia,  Ha'il Maternity Hospital, Kingdom of Saudi Arabia.
* To whom all correspondence should be addressed. Tel.: +966 531521860; Fax: +966 65317027 E-mail: firstname.lastname@example.org
Table 1. Results of 157 nosocomial bacterial isolates collected from Hospital staff, Patients and hospital environment of Maternity hospitaal in Hail region of Saudi Arabia Bacterial isolate From From staff patients MRSA 12 9 MSSA 28 1 E. coli-ESBL (P) -- 26 K. pneumoniae- 4 42 ESBL (P) E. coli-ESBL (N) 5 -- K. pneumoniae- 3 -- ESBL (N) Enterobacter. Spp. 1 -- ESBL (P) Enterobacter. Spp. 8 -- ESBL (N) Citrobacter 1 -- P. aeruginosa 3 11 Total 65 (41.4%) 89 (56.6%) Bacterial isolate From Total environment MRSA -- 21 (13.3%) MSSA 1 30 (19.1%) E. coli-ESBL (P) -- 26 (16.5%) K. pneumoniae- -- 46 (29.2%) ESBL (P) E. coli-ESBL (N) -- 5 (3.8%) K. pneumoniae- 2 5 (3.8%) ESBL (N) Enterobacter. Spp. -- 1 (0.3%) ESBL (P) Enterobacter. Spp. -- 8 (5.1%) ESBL (N) Citrobacter -- 1 (0.3%) P. aeruginosa -- 14 (8.9%) Total 3 (1.9%) 157 *MRSA: methicillin resistant Staphylococcus aureus, *MSSA: methicillin sensitive Staphylococcus aureus, *ESBL: extended- spectrum [beta]-lactamase, *P: positive, *N: negative Fig. 1. Antibiotic susceptibility of 157 bacterial isolates from staff, patients and environment staff patient environment MRSA 57 43 0 MSSA 94 3 3 E. coli-ESBL(P) 0 100 0 K. pne-ESBL(P) 9 91 0 E. coli-ESBL(N) 60 0 40 Ent. ESBL (P) 100 0 0 Ent. ESBL (N) 100 0 0 CITROBACTER 100 0 0 PA 21 79 0 *MRSA: methicillin resistant Staphylococcus aureus, *MSSA: methicillin sensitive Staphylococcus aureus, *ESBL: extended- spectrum a-lactamase, *P: positive, *N: negative, *K. pne: K. pneumoniae, *ENT: Enterobacter, *PA: P. aeruginosa Note: Table made from bar graph.
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|Author:||Khan, Mushtaq A.; Motair, Khalid A. Al-; Alenezi, Mohammed M.; Altheban, Ahmed S.; Hammam, Sahar A.;|
|Publication:||Journal of Pure and Applied Microbiology|
|Date:||Sep 1, 2018|
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