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Malak Salman Alharbi et al, 2020;4(2):513–517.

International Journal of Medicine in Developing Countries

Antimicrobial resistance in general ICUs in Saudi Arabia; a systematic review

Malak Salman Alharbi1*, Yasir Abdullah Alharbi2, Abdulrahman Waleed Bagar3, Alaa Abbas Kurdi3, Ethar Ahmad Boudal3, Fahad Hatem Aman4, Malak Salman Alharbi5, Khalid Ghalilah6

Correspondence to: Malak Salman Alharbi

*Taibah University, Saudi Arabia.

Email: malaksnal22 [at] gmail.com

Full list of author information is available at the end of the article.

Received: 12 December 2019 | Accepted: 26 December 2019


ABSTRACT

Critically ill patients admitted to the Intensive care unit (ICU) have demonstrated an increased incidence of antimicrobial resistance compared to other hospitalized patients. Therefore, efforts should be exerted to reveal the contributing epidemiological factors for antimicrobial resistance to reduce mortality as well as health care costs. This study aims to explore the literature to evaluate the epidemiology of antimicrobial resistance in general ICU in Saudi Arabia. The literature was reviewed through the PubMed database in the duration between 2009 and 2019. Search terms included a combination of antimicrobial resistance, general ICU and Saudi. The findings were then filtered to include original research articles investigating antimicrobial resistance in general ICUs in Saudi Arabia. A total of 89 articles were retrieved. Following the exclusion of articles on animals and including trials only on humans, 23 articles appeared. A total of six articles were considered as eligible, published between 2009 and 2019, covering a total of 10,071 bacterial isolates from general ICUs in Saudi Arabia. The trials included respiratory tract, urinary tract, and bloodstream infections. The study concludes that the incidence of antimicrobial resistance in general ICUs in Saudi Arabia is high and alarming. Future studies should focus on exploring solutions for this critical problem in Saudi Arabia.


Keywords:

Antimicrobial resistance, intensive care, ICU, nosocomial infections.


Introduction

Antimicrobial resistance is regarded as a significant factor in predicting patient outcomes and overall resource utilization following infections in ICUs [1]. ICUs are facing an emergency and spreading antibiotic-resistant bacterial strains all over the world. Moreover, some resistant bacterial strains have few treatment options [2].

Previous epidemiological trials focused mainly on two frequent Gram-positive antimicrobial-resistant strains, namely, Methicillin-resistant Staph aureus (MRSA) and Vancomycin-resistant Enterococcus (VRE) in different sites of infections [3].

Some reports illustrated that multidrug resistance (MDR) within Gram-negative bacteria is becoming an increasing threat in healthcare organizations [4]. Some bacterial strains also have no sensitivity against any available antibiotic therapy, such as multidrug-resistant Acinetobacter and extended-spectrum β-lactamase producing Gram-negative bacteria [5].

The awareness of healthcare professionals toward this emerging threat deserves more consideration to improve the prescription of empirical antibiotics [6]. In Europe, there is a wide range of protocols that focuses on resistance patterns of nosocomial or ICU infections, as well as the etiology of infections [7].

The development of MDR bacterial strains is an emerging problem, especially in healthcare-associated infections in ICUs [8]. This is mainly due to increased morbidity and mortality of severe infections, in addition to the increased healthcare costs due to therapy failure and prolonged hospital stay [9].

The major influencers of the treatment and prevention of MDR bacterial strains include single-use tools for each patient, rational antibiotics prescription, hand hygiene, isolation of infected patients, and environmental cleaning [10].

Therefore, the goal of this systematic review is to examine the literature for the epidemiological figures for antimicrobial resistance in general ICUs in Saudi Arabia.


Materials and Methods

This systemic review of the literature was done on the PubMed database in the duration between 2009 and 2019 to evaluate the epidemiology of antimicrobial resistance in general ICU in Saudi Arabia. Search terms included a combination of antimicrobial resistance, general ICU, and Saudi.

All the titles in addition to abstracts that appeared from this search were reviewed thoroughly. The results were then filtered to include original research articles investigating antimicrobial resistance figures in general ICUs in Saudi Arabia. Additionally, the selected trials mentioned the type of infection in addition to the type of bacterial isolate under investigation. Only trials published in the English language were classified as related articles, which can be further evaluated in the second step.

The following step was determining the inclusion criteria to choose the studies that will be considered in the systematic review. Abstracts were revised manually to choose the appropriate abstracts to be considered. The inclusion criteria were the presence of sufficient details on the method of analysis and examined the type of infection and type of bacterial isolate. Moreover, only trials recruiting patients in Saudi Arabia were included.

Furthermore, references of selected trials were revised to define any related articles. Finally, the required data sets were collected from the final record of eligible articles and summarized.

There was no need to obtain informed consent as the study is not involving any interventions to patients.


Results

A total of 89 articles were retrieved by searching PubMed using the combination of the three terms, including antimicrobial resistance, general ICU, and Saudi. Following the exclusion of articles on animals and including trials only on humans, 23 articles appeared.

After searching the abstracts and checking for the eligibility criteria in identified potential abstracts, a total of six articles [1116] were considered as eligible to be included in our systematic review that was published between 2009 and 2019, covering a total of 10,071 bacterial isolates from different sites of infections.

Out of the 10,071 bacterial isolates, five studies [1115] included isolates from the respiratory tract, where two of them [12,13] were from ventilator acquired pneumonia. Also, two studies [14,16] were focusing on bloodstream infections, while one of them [16] was mainly considering the hospital-acquired bloodstream infections. As for urinary tract infections, only one study [15] had isolated from urinary tract infections.

Turning to study design, three studies had a prospective design [13,14,16], where all of them were prospective observational studies. The other three studies [11,12,15] had a retrospective design.

According to extracted results, different types of bacterial isolates were identified. However, Acinetobacter was described as the most resistant bacterial strain in two studies [12,13], while the other studies [11,1416] demonstrated that Gram-negative bacilli, in general, showed a high level of resistance. The included trials are discussed in detail in Table 1.


Discussion

Antimicrobial resistance is a universal threat that requires assertive and immediate actions [6]. It is expected that by the year 2050, the mortality due to antimicrobial resistance will be higher than mortality due to cancer and cardiovascular diseases collectively [8]. Therefore, it’s mandatory to understand the etiology and epidemiology of antimicrobial resistance to find a solution to minimize the antimicrobial resistance [11].

The present review examined the medical literature to explore an updated figure of antimicrobial resistance in general ICUs in Saudi Arabia. The review revealed that Gram-negative bacilli were the most frequent bacterial strain in ICUs in Saudi Arabia, with Acinetobacter being described as the most resistant strain in all Gram-negative strains [12,13].

The review also revealed that the most common site of infections in patients admitted to general ICUs is respiratory tract [11,14,15], followed by urinary tract infections [15] and bloodstream infections [14,16]. While ventilator acquired pneumonia was described as the most common nosocomial infections in ICU patients [12,13].

Other important bacterial strains were also illustrated in the included studies. Klebsiella pneumonia and Pseudomonas aeruginosa were the most common Gram-negative bacilli strains with a high level of resistance following Acinetobacter spp. E. coli was also reported in bacterial isolated from urinary and respiratory tracts [15].

Regarding Gram-positive bacterial strains, they were mainly reported in bloodstream infections, especially the hospital-acquired type [14,16]. The most resistant Gram-positive cocci strains were reported to be MRSA, and VRE, which was mainly reported in ventilator acquired infections [13].

In spite of the different sites of infections and different bacterial isolates, all the included studies [1116] strongly recommended the development of assertive and emergent protocols to regulate the prescription of empirical antibiotics therapy. This should be applied in parallel to the implementation of infection prevention and control standards [1116].

However, the present review has some limitations that should be considered in any future studies. Most of the studies examining antimicrobial resistance in Saudi Arabia are retrospective in nature, which affects the internal validity of the study. Also, all the studies were single-center studies that may question the reliability of the outcomes of these studies.

Table 1. Summary of the specifications and results of included studies.

Author(s) Year Study design Sample size Type of infection Bacterial isolate Objective Result
Ibrahim et al. [11] 2018 Retrospective 3,736 Respiratory tract infections Acinetobacter, Klebsiella pneumonia, Pseudomonas aeruginosa To determine the distribution and resistance patterns of Gram-negative bacteria (GNB) in ICUs at King Abdullah Hospital in Bisha, Saudi Arabia. Elevated antimicrobial resistance with an increased incidence of MDR patterns was found among GNB from ICUs. Comprehensive surveillance programs are required to track the origins and emergence pathways of resistant strains.
Balkhy et al. [12] 2014 Retrospective 248 Ventilator acquired pneumonia (VAP) Acinetobacter spp. Pseudomonas aeruginosa, Klebsiella spp., Staphylococcus aureus To explore the level of multi-drug resistance among common bacterial causes of VAP Acinetobacter is an increasingly resistant VAP-associated bacteria in general ICUs in Saudi Arabia. The present outcome may influence the local primary empirical antibiotic choice.
El Saed et al. [13] 2013 Prospective observational 457 Ventilator acquired pneumonia Acinetobacter spp., Pseudomonas aeruginosa, Staphylococcus aureus including MRSA, Klebsiella spp. (Haemophilus spp. and Enterobacter spp. To evaluate the microbial causes of VAP and describe any changes in the timing of VAP onset. Acinetobacter baumannii is the most common and increasingly significant bacteria linked to VAP, especially with late-onset and recurrent VAP.
Khan [14] 2012 Prospective observational 335 Respiratory infections and bloodstream infection Acinetobacter spp., Klebsiella species and Pseudomonas species, Gram-Negative isolates, Staph. aureus and Coagulase-negative staphylococci (CoNS) To examine the susceptibility pattern and microbiological spectrum of bacterial strains in the ICU and intermediate care unit in a single medical center. The high incidence of reduced antibiotic susceptibility among Gram-negative bacteria in ICUs proposes that more effective protocols are required to minimize the selection and spreading of resistant bacterial strains.
Al Johani et al. [15] 2010 Retrospective 4,192 Respiratory infections and urinary tract infection Acinetobacter baumannii, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumonia, Stenotrophomonas maltophilia, and Enterobacter. To explore patterns of antimicrobial susceptibility in gram-negative isolates
to commonly prescribed antibiotics in an ICU at a tertiary care hospital in Riyadh, Saudi Arabia
Antimicrobial resistance is an emerging problem in the KFNGH ICU, suggesting new more restrictive
Antibiotic prescription guidelines. Continuous monitoring of antimicrobial susceptibility and tight adherence to infection prevention standards are crucial to prevent major outbreaks from the occurrence.
Al tawfiq et al. [16] 2009 Prospective survey 1,103 Hospital-acquired bloodstream infection Coagulase-negative staphylococcus was the leading
Staphylococcus aureus
and Escherichia coli, Klebsiella pneumonia, Pseudomonas aeruginosa
To examine the figures of healthcare-associated bloodstream infection (HA-BSI) at Saudi Aramco Medical Services Organization. The incidence of secondary BSI remained relatively stable over the study period. Yet, primary BSI and CLABSI increased over time. Coagulase-negative staphylococcus, Staphylococcus aureus, and Escherichia coli were the most common bacterial strains.

Finally, to our knowledge, this is the first systematic review to give an updated insight from the literature during the last ten years on the figures of antimicrobial resistance in general ICUs in Saudi Arabia.


Conclusion

From this review, it is concluded that there is a high incidence of antimicrobial resistance in ICUs. Further trials are necessary to evaluate the level of knowledge and attitude of healthcare professionals toward antimicrobial resistance in Saudi Arabia. Also, Universities and hospitals should take initiatives to develop awareness and education programs to the medical staff as well as the public to highlight the hazards of antimicrobial resistance.


List of Abbreviations

GNB Gram-negative bacteria
ICU ICU
MRSA Methicillin-resistant Staph aureus
VAP Ventilator acquired pneumonia
VRE Vancomycin-resistant Enterococcus

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Not applicable.


Ethical approval

Not applicable.


Author details

Malak Salman Alharbi1, Yasir Abdullah Alharbi2, Abdulrahman Waleed Bagar3, Alaa Abbas Kurdi3, Ethar Ahmad Boudal3, Fahad Hatem Aman4, Malak Salman Alharbi5, Khalid Ghalilah6

  1. Resident Internal Medicine, Madinah General Hospital, Madinah, Saudi Arabia
  2. Resident General Surgery, Ohud Hospital, Madinah, Saudi Arabia
  3. Resident ER, Madinah General Hospital, Madinah, Saudi Arabia
  4. Medical Intern, College of Medicine, Imam Mohammad Ibn Saud University, Riyadh, Saudi Arabia
  5. Medical Intern, Central South University, Saudi Arabia
  6. Head of the Department of Internal Medicine in MGH, ID Consultant, Saudi Arabia

References

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How to Cite this Article
Pubmed Style

Alharbi MS, Alharbi YA, Bagar AW, Kurdi AA, Boudal EA, Aman FH, Alharbi MS, Ghalilah K. Antimicrobial resistance in general ICUs in Saudi Arabia; a systematic review. IJMDC. 2020; 4(2): 513-517. doi:10.24911/IJMDC.51-1576135858


Web Style

Alharbi MS, Alharbi YA, Bagar AW, Kurdi AA, Boudal EA, Aman FH, Alharbi MS, Ghalilah K. Antimicrobial resistance in general ICUs in Saudi Arabia; a systematic review. https://www.ijmdc.com/?mno=77698 [Access: October 15, 2021]. doi:10.24911/IJMDC.51-1576135858


AMA (American Medical Association) Style

Alharbi MS, Alharbi YA, Bagar AW, Kurdi AA, Boudal EA, Aman FH, Alharbi MS, Ghalilah K. Antimicrobial resistance in general ICUs in Saudi Arabia; a systematic review. IJMDC. 2020; 4(2): 513-517. doi:10.24911/IJMDC.51-1576135858



Vancouver/ICMJE Style

Alharbi MS, Alharbi YA, Bagar AW, Kurdi AA, Boudal EA, Aman FH, Alharbi MS, Ghalilah K. Antimicrobial resistance in general ICUs in Saudi Arabia; a systematic review. IJMDC. (2020), [cited October 15, 2021]; 4(2): 513-517. doi:10.24911/IJMDC.51-1576135858



Harvard Style

Alharbi, M. S., Alharbi, . Y. A., Bagar, . A. W., Kurdi, . A. A., Boudal, . E. A., Aman, . F. H., Alharbi, . M. S. & Ghalilah, . K. (2020) Antimicrobial resistance in general ICUs in Saudi Arabia; a systematic review. IJMDC, 4 (2), 513-517. doi:10.24911/IJMDC.51-1576135858



Turabian Style

Alharbi, Malak Salman, Yasir Abdullah Alharbi, Abdulrahman Waleed Bagar, Alaa Abbas Kurdi, Ethar Ahmad Boudal, Fahad Hatem Aman, Malak Salman Alharbi, and Khalid Ghalilah. 2020. Antimicrobial resistance in general ICUs in Saudi Arabia; a systematic review. International Journal of Medicine in Developing Countries, 4 (2), 513-517. doi:10.24911/IJMDC.51-1576135858



Chicago Style

Alharbi, Malak Salman, Yasir Abdullah Alharbi, Abdulrahman Waleed Bagar, Alaa Abbas Kurdi, Ethar Ahmad Boudal, Fahad Hatem Aman, Malak Salman Alharbi, and Khalid Ghalilah. "Antimicrobial resistance in general ICUs in Saudi Arabia; a systematic review." International Journal of Medicine in Developing Countries 4 (2020), 513-517. doi:10.24911/IJMDC.51-1576135858



MLA (The Modern Language Association) Style

Alharbi, Malak Salman, Yasir Abdullah Alharbi, Abdulrahman Waleed Bagar, Alaa Abbas Kurdi, Ethar Ahmad Boudal, Fahad Hatem Aman, Malak Salman Alharbi, and Khalid Ghalilah. "Antimicrobial resistance in general ICUs in Saudi Arabia; a systematic review." International Journal of Medicine in Developing Countries 4.2 (2020), 513-517. Print. doi:10.24911/IJMDC.51-1576135858



APA (American Psychological Association) Style

Alharbi, M. S., Alharbi, . Y. A., Bagar, . A. W., Kurdi, . A. A., Boudal, . E. A., Aman, . F. H., Alharbi, . M. S. & Ghalilah, . K. (2020) Antimicrobial resistance in general ICUs in Saudi Arabia; a systematic review. International Journal of Medicine in Developing Countries, 4 (2), 513-517. doi:10.24911/IJMDC.51-1576135858