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Background Community-acquired pneumonia (CAP) is a significant cause of morbidity and mortality, especially for the elderly and people who suffer from chronic conditions. This study was conducted to assess the clinical and microbiological characteristics and disease outcomes associated with the occurrence of CAP. Methods This retrospective chart review was conducted at King Abdulaziz Medical City, Jeddah, Saudi Arabia. Cases with documented clinical diagnosis of CAP during the period from 2016 to 2019 were included. Data were collected on demographic, clinical, and microbiological characteristics, used antimicrobials and patients’ outcomes, including length of hospital stay, intensive care unit admission, and mortality. Multivariate regression analysis was performed to identify risk factors for increased length of hospital stay. Results A total of two hundred and eighteen CAP episodes were identified. Patients had a median age of 64.5 years, and 54.1% were males. Microbiological diagnosis was established in 33 patients (15.1%). Admission to ICU and diagnosis of a neurological disease were significantly associated with longer hospital stay (>7 days). An average of 2.7 antimicrobials were used per patient, and the most common antibiotics used were Piperacillin/Tazobactam (46.3%), Doxycycline (44%), then Ceftriaxone (42.7%). Four patients (1.8%) died during hospital stay. Conclusions This retrospective analysis of CAP cases identified a lack of microbiological diagnosis and increased burden associated with disease severity and the need for hospitalization. The ability to identify CAP at an earlier stage will be a cornerstone to mitigate its impact on the healthcare system and ICU units.

Assessing the effectiveness of antibiotics and communicating the problem of resistance are essential when devising antimicrobial stewardship programs (ASPs) in hospital settings. The Drug Resistance Index (DRI) is a useful tool that combines antibiotic consumption and bacterial resistance into a single measure. In this study, we used the DRI to assess the impact of introducing a new antibiotic restriction form on antibiotic effectiveness for the treatment of Gram-negative infections in the intensive care unit (ICU).This was an observational study to assess and evaluate the antibiotic susceptibility of Gram-negative bacteria and antibiotic prescribing rates for the antibiotics indicated for Gram-negative bacteria following the introduction of a new antibiotic restriction form. The study was conducted from 2015 to 2017 at King Abdulaziz Medical City, a tertiary care facility in Jeddah, Saudi Arabia. Changes in antibiotic effectiveness before and after the introduction of the form were evaluated by calculating the DRI for four of the most common Gram-negative pathogens and eight commonly used antibiotic classes.The overall DRI for the adult ICU was higher (59.45) in comparison to the hospital-wide DRI (47.96). A higher DRI was evident for carbapenems and antipseudomonal penicillins + beta-lactamase inhibitors.The DRI is a useful tool for tracking the effectiveness of antibiotics over time. The results of our study are significant in the way that it highlights the importance of having an effective antibiotic stewardship program in healthcare settings and regular feedback of antibiotic consumption data to the stakeholders to keep the antibiotic prescriptions in check, thereby ensuring their sustained effectiveness.

This study was supported by baseline funding (BAS/1/1020-01-01) from King Abdullah University of Science and Technology to AP.

ObjectivesThe present study was conducted to estimate the seroprevalence of antibody to pertussis toxin among adult populations in western Saudi Arabia.DesignA cross-sectional study.SettingKing Abdulaziz Medical City, Jeddah, western Saudi Arabia. A tertiary care teaching hospital.ParticipantsA total of 1200 participants (400 healthcare workers, 400 military recruits and 400 blood donors) were included. The majority were male (79.3%), and the mean (±SD) age was 27.2 (±6.7) years old.InterventionsThe study included the analysis of serum blood samples using commercial ELISA. A consecutive sampling technique was applied.Primary outcome measuresSeropositivity of antipertussis toxin immunoglobulin G (anti-PT IgG) ≥62.5 IU/mL.ResultsAntibody titres ≥62.5 IU/mL, indicating exposure to Bordetella pertussis infection within the last year, were identified in 12.0% (95% CI 10.2% to 14.0%) of the participants. Titres ≥125 IU/mL, suggesting recent infection, were detected in 3.5% (95% CI 2.5% to 4.7%). Seroprevalence of positive IgG antibody titres (≥62.5 IU/mL) was highest among the healthcare workers (HCWs) (14%), then the military recruits (13.5%) and blood donors (8.5%; p=0.03). The multivariate regression analysis showed association between participants group (HCWs and military), male gender and younger age (ConclusionsHigh pertussis seropositivity was associated with participants’ occupation (ie, healthcare workers and military recruits), and anti-PT IgG titre was negatively correlated with age. A substantial deficiency in pertussis reporting in Saudi Arabia has been suggested, with potential increased risk to the most vulnerable populations (ie, infants and elderly). Enhancing the booster dose of pertussis vaccine for adolescents and adults is crucial to minimise the burden of pertussis.

The authors have requested that this preprint be removed from Research Square.

Background The life expectancy of people living with HIV is markedly increasing with the introduction of effective antiretroviral medications. However, these patients face an increased risk of developing multi-morbidities-especially with advanced age. This study was conducted to assess the prevalence of and risk factors associated with the occurrence of chronic comorbidities among patients diagnosed with HIV infection. Methods A retrospective chart review was conducted on the medical records of patients with HIV diagnoses from 2000 to 2018. Data were collected on age, sex, date of diagnosis, associated co-morbidities, antiretroviral medications (ART) and status at time of data collection (alive or deceased). Only adult patients 18 years or above were studied. Results A total of 130 confirmed HIV cases were included. Patient ages ranged from 23 to 86 years old (mean ± SD 50.1 ± 12.6). Almost half of the patients (48.5%) had at least one associated comorbidity. The most common chronic comorbidity was diabetes mellitus (15.4%), followed by dyslipidemia (10.8%), hypertension (10.8%) and lymphoma (10.0%). Comorbidity proportions increased with advanced patient age (p = 0.047). Three or more comorbidities were reported in 40.7% of patients aged 60 years old or above. Using logistic regression analysis, only patients aged 50 years old or above were more likely to have at least one comorbidity (OR = 7.59, 95%CI = 2.25, 25.61). Conclusions The burden of chronic comorbidities among people diagnosed with HIV is high, especially among older age individuals, with an increasing number of comorbidities per patient. Proper counseling for HIV patients is highly recommended-not only for prevention of other infectious diseases (e.g., vaccination) but also for lifestyle modification and self-management for those with chronic conditions.

A point prevalence survey was conducted on May 11, 2017, among inpatients at 6 hospitals in Saudi Arabia. The overall point prevalence was 6.8% (114 of 1,666). The most common types of infections were pneumonia (27.2%), urinary tract infections (20.2%), and bloodstream infections (10.5%). Approximately 19.2% of healthcare-associated infections were device associated.

Objectives: There is local and regional deficiency in the data examining the contribution of resistant pathogens to device-associated healthcare-associated infections (DA-HAIs). We examined such data in a multihospital system in Saudi Arabia in comparison with the US NHSN reports. Methods: Surveillance of DA-HAIs was prospectively conducted between 2008 and 2016 in 4 hospitals of Ministry of National Guard Health Affairs. Consecutive NHSN reports were used for comparison. Definitions and methodology of DA-HAIs and bacterial resistance were based on the NHSN reports. Results: In total, 1,260 pathogens causing 1,141 DA-HAI events were included. Gram-negative pathogens (GNPs) were responsible for 62.5% of DA-HAIs, with significantly higher Klebsiella, Pseudomonas, Acinetobacter, and Enterobacter than NHSN hospitals. Approximately 28.3% of GNPs and 23.5% of gram-positive pathogens (GPPs) exhibited some type of resistance. Nearly 34.3% of Klebsiella were cephalosporin-resistant; 4.8% of Enterobacteriaceae were carbapenem-resistant (CRE); 24.4% of Staphylococcus aureus were methicillin-resistant (MRSA; and 21.9% of Enterococci were Vancomycin-resistant (VRE). The multidrug resistance (MDR) rates were 65.0% for Acinetobacter, 26.4% for Escherichia coli, 23.0% for Klebsiella, and 14.9% for Pseudomonas. Resistant GNPs including cephalosporin-resistant Klebsiella, MDR Klebsiella, and MDR Escherichia coli were significantly more frequent than in NHSN hospitals, whereas resistant GPPs including MRSA and VRE were significantly less frequent than in NHSN hospitals. Conclusion: Compared with American hospitals, GNPs that contribute to DA-HAIs in Saudi hospitals show more resistance. The higher resistance rates in Klebsiella and Escherichia coli are alarming and call for effective antimicrobial stewardship programs.Funding: NoneDisclosures: None

Background: Assessing the effectiveness of antibiotics and communicating the problem of resistance is essential when devising antimicrobial stewardship programs in hospital settings. The drug resistance index (DRI) is a useful tool that combines antibiotic consumption and bacterial resistance into a single measure. In this study, we used the DRI to assess the impact of introducing a new antibiotic restriction form on antibiotic effectiveness for the treatment of gram-negative infections in the intensive care unit (ICU). Methods: We conducted a before-and-after intervention study from 2015 to 2017 at King Abdulaziz Medical City, a tertiary-care facility in Jeddah, Saudi Arabia. The antibiotic susceptibility of gram-negative bacteria and antibiotic prescribing rates for antibiotics indicated for gram-negative bacteria were assessed to evaluate the impact of a new antibiotic restriction form introduced in the ICU in July 2016. Changes in antibiotic effectiveness before and after the intervention were evaluated by calculating the DRI for 4 of the most common gram-negative pathogens and 8 commonly used antibiotic classes. Results: The overall DRI for the adult ICU (59.45) was higher than the hospital-wide DRI (47.96). A higher DRI was evident for carbapenems and antipseudomonal penicillins + β-lactamase inhibitors. A. baumannii had the highest DRI, followed by K. pneumoniae in both the adult ICU and hospital-wide. After implementation of antibiotic restriction in the adult ICU, the DRI for carbapenems was significantly lower in the postintervention phase, from 31.61 to 26.05 (P = 0.031). Conclusions: DRI is a useful tool for tracking the effectiveness of antibiotics over time. The results highlight the importance of having effective antibiotic stewardship program in healthcare settings as well as regular feedback of antibiotic consumption data to the stakeholders to keep the antibiotic prescriptions in check, thereby ensuring their sustained effectiveness.Funding: NoneDisclosures: None

Objectives There is local and regional deficiency in the data examining the contribution of resistant pathogens to device-associated healthcare-associated infections (DA-HAIs). The objective was to examine such data in a multi-hospital system in Saudi Arabia in comparison with the US National Health Surveillance Network (NHSN). Methods Surveillance of DA-HAIs was prospectively conducted between 2008 and 2016 in four hospitals of Ministry of National Guard Health Affairs. Consecutive NHSN reports were used for comparisons. Definitions and methodology of DA-HAIs and bacterial resistance were based on NHSN. Results A total 1260 pathogens causing 1141 DA-HAI events were included. Gram negative pathogens (GNPs) were responsible for 62.5% of DA-HAIs, with a significantly higher Klebsiella, Pseudomonas, Acinetobacter, and Enterobacter than NHSN hospitals. Approximately 28.3% of GNPs and 23.5% of gram positive pathogens (GPPs) had some type of resistance. Nearly 34.3% of Klebsiella were resistant to third/fourth generation cephalosporins, 4.8% of Enterobacteriaceae were carbapenem-resistant (CRE), 24.4% of Staphylococcus aureus were methicillin-resistant (MRSA), and 21.9% of Enterococci were vancomycin-resistant (VRE). Multidrug resistance (MDR) was 65.0% in Acinetobacter, 26.4% in Escherichia coli, 23.0% in Klebsiella, and 14.9% in Pseudomonas. Resistant GNPs including cephalosporin-resistant Klebsiella, MDR Klebsiella, and MDR Escherichia coli were significantly more frequent while resistant GPPs including MRSA and VRE were significantly less frequent than NHSN hospitals. Conclusion The current findings showed heavier and more resistant contribution of GNPs to DA-HAIs in Saudi hospitals compared with American hospitals. The higher resistance rates in Klebsiella and Escherichia coli are alarming and call for effective antimicrobial stewardship programs.

Background Hepatitis B viral infection represents a major public health problem worldwide. Despite being considered a vaccine- preventable disease; prevalence is still high in many regions. Most people are unaware that they are infected, and are frequently diagnosed during routine screening or as a work-up of advanced hepatic disease. The current study aimed to evaluate the proportion of the population currently infected, with past infection, or non-infected, and to determine the proportion of the population that is immunized. Methods A retrospective descriptive study was done, reviewing the serological markers for hepatitis B requested among the population who attended the MNGHA, Jeddah. Data from people screened between 2016 and 2018 were included in this study. Serological markers for hepatitis B included hepatitis B surface antigen (HBsAg), hepatitis B core antibodies (HBcAbs), and hepatitis B surface antibodies (HBsAbs). Results Among 8370 people screened for hepatitis B, 312 (3.72%) individuals were found to be infected with hepatitis B (HBsAg/HBcAb positive, or at least HBsAg positive). The majority (92.34%, n=7729) was not infected (HBsAg negative/HBcAb negative, or HBsAg negative/HBcAb positive/HBsAb positive as past infection, and HBcAb negative/HBsAb positive as immune). Serological status of infection of the remaining 3.93% was unknown (only HBsAb negative tested, or isolated core: HBcAb positive/HBsAg negative/HBsAb negative [possible occult infection], or only HBcAb positive tested). Among subjects screened for HBsAbs (n=5619), 3382 (60.19%) were immune (HBsAb >10 IU/mL). Of 4960 individuals tested for HBcAbs, 862 (17.38%) were found to be positive, exposed to hepatitis B virus (active, occult, or past infection). The majority of infected individuals were Saudi (94.6%) and 57.6% were male; however, 75% of the population screened were Saudi, with 4.66% of infection among Saudis. Regarding the population exposed to hepatitis B (HBcAbs positive tested), 22.28% were Saudis, 20.08% from the Philippines, 16.90% from Pakistan, 14.52% from Egypt, and 9.55% from India, from the most frequently exposed nationalities. Among immune people, 54.3% were Saudi and 58.5% were female. Conclusion Despite the available vaccination for hepatitis B virus, more than 3% of the population screened was infected, and more than 17% had been exposed to the virus (HBcAbs positive). Screening for hepatitis B virus, early identification of infected individuals, and vaccination for the non-immune population must be encouraged.

Background Hepatitis C virus (HCV) is one of the three major bloodborne infections. HCV infection has a devastating outcome, yet is a curable disease. The World Health Organization (WHO) targets elimination of the disease by 2030. This target cannot be achieved without screening and case detection. This retrospective study aimed to investigate the prevalence of HCV infection among people tested at King Abdulaziz Medical City, Jeddah (KAMC-J), during 2018. Methods Results of the HCV antibody enzyme-linked immunosorbent assay (ELISA) tests conducted during 2018 at KAMC-J were obtained from the Electronic Medical System (BestCare). The HCV RNA test results were reviewed through the HCV surveillance database available in the Infection Prevention and Control Department. Data were also collected on demographic variables (age, sex, and nationality). Statistical analysis was done with IBM SPSS version 24. Results A total of 5425 HCV antibody tests were performed in 2018. More than half of the samples were for females (54.4%, n=2953). The overall prevalence of positive HCV antibodies among the tested population was 1.5% (n=82). Reactive HCV antibodies were higher among females (1.6%, n=46) than males (1.5%, n=36). The prevalence significantly increased with age from 0.3% (n=6) among people younger than 25 years up to 6.2% (n=42) among those older than 70 years. HCV positive antibody prevalence was significantly higher among Saudi (1.8%, n=79) than non-Saudi (0.3%, n=3) populations. Of the 82 cases with positive HCV antibodies, 49 (59.8%) cases were newly diagnosed, of which 30.6% (n=15) had reactive HCV RNA. Only two people were HCV/HBV co-infected. Conclusion This study demonstrates the importance of HCV screening of high-risk populations, including military personnel, and the need for early intervention in order to achieve the WHO target of eliminating the disease by 2030.

Background Measles, rubella, and varicella-zoster are vaccine-preventable diseases that have the potential of transmission in healthcare settings. Healthcare professionals are at high risk of exposure to these viral diseases and should be immunized. Screening and vaccination of newly recruited healthcare workers (HCWs) is considered a cost effective intervention. All newly recruited HCWs are required to have physical and serological assessment before they start working. Serology screening covers several vaccine-preventable diseases including measles, rubella, and varicella. This study aimed to identify the immune status to these diseases among the newly recruited HCWs at King Abdulaziz Medical City, Jeddah (KAMC-J). Methods A retrospective review of the employees’ medical records was conducted. Data were extracted from the electronic medical records and database of pre-employment assessment. Data were collected on demographic data (age, sex, and nationality) and IgG antibodies of measles, rubella, and varicella-zoster virus. Results During the study period, 673 newly recruited HCWs were screened. The mean age was 26.5 (SD 5.5) years, and two-thirds (63%) of the participants were female. The majority of participants were immune against measles (87.3%), rubella (87.8%), and varicella (93.2%). Immunity (positive IgG) against measles, rubella, and varicella was higher in females than in males. Similarly, measles and rubella IgG was higher in older participants (older than 25 years of age); however, varicella IgG was higher among younger participants (25 years old or younger). Measles-positive IgG ranged from 78.9% to 96.9%; the lowest was among non-clinical HCWs and the highest was among nurses. Rubella-positive IgG ranged from 85.7% to 93.8%; the lowest was among allied health staff and the highest was among nurses. Varicella-positive IgG ranged from 91.2% to 95.5%, the lowest was among allied health staff and the highest was among physicians. Among the new Saudi employees, prevalence rates of IgG for measles, rubella, and varicella were 85.1%, 86.7%, and 93.1%, respectively, which were lower than those for non-Saudi HCWs. Conclusion This study revealed good immunity coverage for measles, rubella, and varicella among newly recruited HCWs; however, the allied health staff and non-clinical HCWs should receive more attention to optimize their vaccination status. Immunization of new HCWs should be enhanced as an essential component of workers’ protection to reduce the risk of transmission and burden on the healthcare system.

Background Clostridium difficile is a gram-positive, anerobic, toxin-producing bacillus that mainly causes diarrhea and colitis. A recent meta-analysis reported an overall rate of 3.54 per 10,000 patient-days per year for C difficile infection (CDI). The highest incidence was observed in intensive care units (ICUs). In the USA, C difficile caused an estimated half a million infections and 29,000 deaths in 2012. More than 80% of these deaths occurred in individuals aged 65 years or older. The approximate cost of CDI treatment in the USA was US$ 5.4–6.3 billion per year. For the countries in the Arabian Peninsula including Jordan, Kuwait, Qatar, Saudi Arabia, Egypt, and Lebanon, the prevalence rates range from 4.6% to 23.6% for CDI isolates. Saudi Arabia has the lowest rate (4.6%) among these countries. A remarkable increase in nosocomial CDI cases in the adult ICU at King Abdulaziz Medical City was observed between 18 January and 11 March 2018.The aim of our study was to decrease the incidence of CDI in adult ICUs by implementing evidence-based interventions. Methods Cluster investigations were done; a time, place, and person table created, brain storming to identify the possible risk factors was evoked by the investigative team, a root cause analysis/fishbone diagram was pulled, and corrective actions were formulated. Clinicians: hand hygiene (soap and water), use of gloves, barrier precautions, prompt identification and early treatment of CDI cases were applied. Environmental: proper cleaning, housekeeping protocol review, and types of disinfectants used were highlighted. Surveillance: outcome surveillance of CDI cases was added to the patient safety annual report plan. Administration: antibiotic stewardship program (ASP), managing staff shortage, and reinforcement of the guidelines were essential. Results In the first quarter, the rate of CDI was 2.1 per 1000 patient-days, which dropped to 0.9, 0.4, and 0.4 per 1000 patient-days, respectively, in the second, third, and fourth quarters of 2018. Conclusion There was a significant reduction in the number of CDI cases after timely and appropriate actions were taken. However, maintaining a zero rate was challenging. Continuous monitoring, ongoing data collection, and education were considered key to reducing CDI.

We wish to thank members of the Infectious Disease Department and the Pathology Laboratory at King Khaled hospital in the Ministry of the National Guards – Health Affairs Western region for their support of our research. We also wish to acknowledge the Bioscience core laboratory at KAUST for their help with the sequencing operations. We thank Malak Haidar from KAUST Pathogen Genomics Laboratory for the technical help. We also acknowledge help from the team of curators at the Institut Pasteur MLST system (Paris, France) for importing novel alleles, profiles, and/or isolates at http://bigsdb.pasteur.fr.

Background: Studying temporal changes in resistant pathogens causing healthcare-associated infections (HAIs) is crucial in improving local antimicrobial and infection control practices. We analyzed 10-year trends in resistance in pathogens causing HAIs in a tertiary-care setting in Saudi Arabia and we compared such trends with those of the US NHSN. Methods: We performed a pooled analysis of surveillance data that were prospectively collected between 2007 and 2016 in 4 hospitals of the Ministry of National Guard Health Affairs. Definitions and methodology of HAIs and antimicrobial resistance were based on NHSN methods. Consecutive NHSN reports were used for comparisons. Results: In total, 1,544 pathogens causing 1,531 HAI events were included. Gram-negative pathogens (GNPs) were responsible for 63% of HAIs, with a significant increasing trend in Klebsiella spp and a decreasing trend in Acinetobacter spp. Methicillin-resistant Staphylococcus aureus (27.0%) was consistently less frequent than NHSN reports. Vancomycin-resistant Enterococci (20.3%) more than doubled during the study, closing the gap with the NHSN. Carbapenem resistance was highest for Acinetobacter (68.3%) and Pseudomonas (36.8%). Increasing trends of carbapenem resistance were highest for Pseudomonas and Enterobacteriaceae, closing the initial gaps with the NHSN. With the exception of Klebsiella and Enterobacter, multidrug-resistant (MDR) GNPs generally decreased, mainly due to the decreasing resistance to cephalosporins, fluoroquinolones, and aminoglycosides. Conclusions:The current trends probably reflect multiple local interventions to reduce HAIs and MDR as well as the heavy use of carbapenems and vancomycin. Our main challenge remains to further enhance the newly launched antimicrobial stewardship practices.Funding: NoneDisclosures: None

We describe the clinical and genetic characteristics of multi-drug resistant tuberculosis (MDR-TB) in a family cluster in the western region of Kingdom of Saudi Arabia diagnosed between 2012 and 2016. All cases had risk factors for tuberculosis acquisition and they were not household contacts of the index case. Genetic analysis detected both MDR-TB and pre-extensively drug-resistant tuberculosis (pre-XDR TB) strains in the index case and confirmed tuberculosis transmission between two cases. Lack of early diagnosis of MDR-TB by molecular testing and lack of extended contact tracing contributed to the transmission of MDR-TB among this family cluster over four years. Keywords: Multidrug resistant tuberculosis, Family cluster

Abstract The MIRACLE trial (MERS-CoV Infection tReated with A Combination of Lopinavir/ritonavir and intErferon-β1b) investigates the efficacy of a combination therapy of lopinavir/ritonavir and recombinant interferon-β1b provided with standard supportive care, compared to placebo provided with standard supportive care, in hospitalized patients with laboratory-confirmed MERS. The MIRACLE trial is designed as a recursive, two-stage, group sequential, multicenter, placebo-controlled, double-blind randomized controlled trial. The aim of this article is to describe the statistical analysis plan for the MIRACLE trial. The primary outcome is 90-day mortality. The primary analysis will follow the intention-to-treat principle. The MIRACLE trial is the first randomized controlled trial for MERS treatment. Trial registration ClinicalTrials.gov, NCT02845843. Registered on 27 July 2016.

Introduction Influenza can cause mild to severe illnesses and serious outcomes can result in hospitalisation or death. Clinical presentation and management of influenza cases in Saudi Arabia have been tackled especially during 2009 H1N1 pandemic, however, available data on influenza related hospital stay and determining factors in the country is limited. This study aims to assess factors that determine the length of stay (LOS) among hospitalised influenza confirmed cases in King Abdulaziz Medical City – western Saudi Arabia. Methods A retrospective review of laboratory-confirmed influenza cases admitted to King Abdulaziz Medical City during the period from January to December 2016 was conducted. Identified variables included age, gender, influenza strains and associated comorbidities. Results Among the 556 laboratory-confirmed influenza cases during the study period, 157 patients were admitted (28.2%). More than half (52.2%) of the admitted patients were females, 20.4% were ≤5 years old, 51.6% were >5–65 years old and 28.0% were >65 years old. Healthcare workers represented 3.2% of the admitted patients. Influenza A-non H1N1 represented 65.6% followed by influenza B (36.3%) and influenza A-H1N1 (10.8%). Some patients have more than one episode of influenza. Most patients (65.0%) were admitted for more than 2 days (41.4% for 2–5 days and 23.6% for more than 5 days). Length of stay was significantly longer among elderly patients (>65 years old) and patients with DM, cardiac, chronic respiratory, immune deficiency diseases and with increased number of co-morbidities, however, no statistical significant association was reported according to influenza strains. Conclusion Significant number of patients were admitted because of influenza for duration more than 2 days. Length of stay was associated with chronic morbidities and old age. Enhancement of immunisation programs especially for high risk patients is essential for reducing burden of influenza on patients and healthcare system.

Objectives: To determine the impact of applying the best available clinical evidence on the preventive measures to reduce the rate of catheter-associated urinary tract infections (CAUTI) in adult intensive care units (ICU). Methods : Data were collected from adult ICUs (28 beds) from 2008 to 2016. The proper use of silicon catheter, aseptic insertion technique, emptying bag three-fourth via close circuit, the use of appropriate size catheter, securing the draining tube on the thigh to keep catheter bag below patient’s bladder level and removal of the catheter as early as possible were ensured in all patients. Results : Rate of UTI and urinary catheter utilization ratios were reviewed during the study period. There was a mean of 6,175 catheter days/year for ICU. Despite the overall rise in the urinary catheterization ratio over these years; we observed a significant reduction in the UTI rate per 1000 Urinary catheter days; from 2.3 in 2010 to 0.3 in 2011 and it was sustained through 2016. Conclusion : The monthly rates of CAUTI significantly declined after the enforcement of agreed strategies and interventions to prevent CAUTI rates in adult ICU. Saudi Med J 2018; Vol. 39 (1): 97-102 doi: 10.15537/smj.2018.1.20999 How to cite this article: Al-Hameed FM, Ahmed GR, AlSaedi AA, Bhutta MJ, Al-Hameed FF, AlShamrani MM. Applying preventive measures leading to significant reduction of catheter-associated urinary tract infections in adult intensive care unit. Saudi Med J . 2018 Jan;39(1):97-102. doi: 10.15537/smj.2018.1.20999.

Background It had been more than 5 years since the first case of Middle East Respiratory Syndrome coronavirus infection (MERS-CoV) was recorded, but no specific treatment has been investigated in randomized clinical trials. Results from in vitro and animal studies suggest that a combination of lopinavir/ritonavir and interferon-β1b (IFN-β1b) may be effective against MERS-CoV. The aim of this study is to investigate the efficacy of treatment with a combination of lopinavir/ritonavir and recombinant IFN-β1b provided with standard supportive care, compared to treatment with placebo provided with standard supportive care in patients with laboratory-confirmed MERS requiring hospital admission. Methods The protocol is prepared in accordance with the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) guidelines. Hospitalized adult patients with laboratory-confirmed MERS will be enrolled in this recursive, two-stage, group sequential, multicenter, placebo-controlled, double-blind randomized controlled trial. The trial is initially designed to include 2 two-stage components. The first two-stage component is designed to adjust sample size and determine futility stopping, but not efficacy stopping. The second two-stage component is designed to determine efficacy stopping and possibly readjustment of sample size. The primary outcome is 90-day mortality. Discussion This will be the first randomized controlled trial of a potential treatment for MERS. The study is sponsored by King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. Enrollment for this study began in November 2016, and has enrolled thirteen patients as of Jan 24-2018. Trial registration ClinicalTrials.gov, ID: NCT02845843. Registered on 27 July 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2427-0) contains supplementary material, which is available to authorized users.

Central venous catheters (CVCs) are life-saving and the majority of patients in intensive care units (ICUs) have them placed in order to receive medicine and fluids. However, the use of these catheters can result in serious bloodstream infections. The rate of Central Line Associated Blood Stream Infection (CLABSI) in Adult Intensive Care Units (ICUs) at King Abdulaziz Medical City Jeddah (KAMC-J) at the start of the project was 2.0/1000 line days in 2008. The Central Line (CL) Bundle by the Institute of Healthcare Improvement (IHI) was implemented at the same time with monitoring of compliance to the CL Bundle. The compliance to CL Bundle was very low at 37% in the same period. A multidisciplinary team was created to improve the compliance to the CL bundle which was expected to have an impact on the rate of CLABSI to achieve zero CLABSI events. The team continued to monitor and evaluate the progress on the compliance to the bundle as well as monitoring the CLABSI events using National Healthcare Safety Network diagnostic criteria. The real reduction in the rate of CLABSI was achieved in 2010 with 0.7/1,000 device days when the compliance to CL Bundle reached up to 98% in that year and 100% in the next two subsequent years. The project still continued and the rate continued to drop and the ultimate target of zero CLABSI was achieved in the year 2014 and maintained in the year 2015 with a sustained compliance of 100% to the CL Bundle. Successful implementation of CL Bundle can help in reducing the rates of CLABSI and achieving zero CLABSI events for a sustained period.

Background. Hypermucoviscous Klebsiellapneumoniae (HMVKP) emerged as a cause of invasive infections in South-East (SE) Asia. It has become the most common cause of liver abscess in that region, and it is a significant causative organism in endogenous endophthalmitis and meningitis. During the past decade, cases of this uniquely virulent organism have been reported outside of SE Asia, with a propensity to affect individuals of SE Asian descent. Cases have been reported from North America including Canada. Methods. We report a case of a patient of Filipino descent living in Canada who presented with recurrent HMVKP bacteremia in the absence of pyogenic liver abscess or other localized metastatic Klebsiella infection. Results. Investigations identified an immunoglobulin (Ig)G2 deficiency and low IgM indicating potential common variable immunodeficiency, and administration of intravenous immunoglobulins was associated with prevention of further recurrences. Conclusions. To our knowledge, this is the first report of HMVKP associated with predisposing antibody deficiency.