Al-Amiri Hospital Research Articles

Delay in diagnosing a patient with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome who presented with status epilepticus and lactic acidosis: a case report

BackgroundMitochondrial encephalomyopathy, lactic acidosis, and stroke-like episode syndrome is a rare mitochondrial genetic disorder that can present with a variety of clinical manifestations, including stroke, hearing loss, seizures, and lactic acidosis. The most common genetic mutation associated with this syndrome is M.3243A>G. The main underlying mechanism of the disease relates to protein synthesis, energy depletion, and nitric oxide deficiency. Controlling disease complications and improving patient quality of life are the primary aims of treatment options.Case presentationA 28-year-old Arabic female visited Al-Amiri Hospital in Kuwait. The patient was newly diagnosed with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episode syndrome following her admission as a case of status epilepticus requiring further investigation. The patient’s seizures were controlled, and she was evaluated to rule out the most serious complications by carrying out appropriate clinical, laboratory, and radiological imaging. The patient was discharged from the hospital after 2 weeks with a follow-up plan.ConclusionThis case report emphasizes the importance of considering mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episode syndrome as a potential cause of status epilepticus with lactic acidosis in a young female patient with a past history of stroke-like episodes. It also stresses the most important workup to rule out every possible life-threatening complication to improve patients’ lives.

Multicenter Study for the Effect of COVID-19 Lockdown on Patients With Sacral Neuromodulation Implants

IntroductionThe massive spread of COVID-19 affected many aspects of medical and surgical services. Many patients with sacral neuromodulation (SNM) devices needed integrated follow-up and close communication regarding the programming of the device. In this study, we aimed to explore the effect of COVID-19 lockdown on patients with SNM devices. Materials and MethodsThis was a multicenter study designed and conducted in four centers performing SNM (Toronto Western Hospital, Toronto, Canada; King Abdulaziz University Hospital, Jeddah, Saudi Arabia; Al-Amiri Hospital, Kuwait City, Kuwait; and Austin and Western Health, University of Melbourne, Australia). An online questionnaire was created through Google Forms and circulated among patients with SNM devices in all four mentioned centers. The questionnaire was sent to patients during the forced lockdown period in each country. ResultsA total of 162 responses were received by September 2020. Data showed that most patients had their device implanted before the lockdown period (92.5%, 150/162). Most patients did not experience any contact difficulties (91.9%, 149/162). When patients were requested for their preference of programming, 89.5% (145/162) preferred remote programming. Correlation analysis did not show any significant relation between patient diagnosis and COVID-19–related difficulties or preferences. ConclusionThe difficulties with access to care experienced during the pandemic and the patient’s expressed willingness to participate in virtual care should provide impetus for manufacturers of SNM devices to move forward with developing remote programming capabilities.

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 β-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.

Clinical Characteristics, Incidence, and Outcomes of Transcatheter Aortic Valve Implantation Stratified by New-onset Left Bundle Branch Block

Background: Clinical outcomes after transcatheter aortic valve implantation (TAVI) patients have not been reported in the Gulf region. Objectives: To define the baseline electrocardiographic (ECG), echocardiographic, and computed tomographic findings of patients undergoing TAVI and analyze the predictors of developing new-onset persistent left bundle branch block (LBBB). Methods: Patients with severe aortic stenosis who underwent TAVI between 2013 and 2021 at the Sabah Al-Ahmed Cardiac Centre in Al-Amiri Hospital in the state of Kuwait were included in this study. Baseline characteristics, electrocardiography (ECG), echocardiography, and preprocedural computed tomography data were extracted. The primary outcome was new-onset LBBB. Results: A total of 61 patients were included (65.6% females; mean age: 73.5 ± 9 years; baseline ejection fraction: 55.5% ± 9.7%). Of these, 18 developed new-onset LBBB. Those who developed LBBB tended to have lower ejection fraction (52.5 ± 9.6 vs. 56.8% ± 9.5%; P = 0.116). Those who developed LBBB were more likely to develop 1st degree atrioventricular block post-TAVI (P = 0.001). Conclusion: The incidence of new-onset LBBB post-TAVI was 29.5%. The new-onset LBBB group was more likely to develop conduction abnormalities requiring permanent pacemaker implantation.

Effect of educational Guidelines Intervention regarding COVID -19 on nurses knowledge and precautionary practices in gastrointestinal endoscopes

Background: COVID-19 pandemic affected the global population, and infection is a high risk among nurses in the gastrointestinal endoscopy unit. Endoscopy is a diagnostic procedure that involves inserting a flexible fiber-optic tube into the esophagus, stomach, or upper small intestine, depending on the degree of suspected lesions. This study aimed to evaluate the effect of educational guidelines intervention regarding COVID -19 on nurses' knowledge and precautionary practices in gastrointestinal (GIT) endoscopes. Design: A quasi-experimental design was used. Setting: The study was carried out at the gastrointestinal endoscopy unit affiliated with General Portsaid Hospitals (Al-Mabarrah Hospital, Al-Amiri Hospital, Al-Zohour Hospital, Port Fouad Hospital, and Al-Tadamon Hospital). Sample: The study included a convenient sample of all endoscopy nursing personnel (30 nurses). Three tools for data collection: (1) Demographic structured interview sheet, (2) Nurses’ Covid-19 Knowledge Questionnaire, and (3) Nurses’ Covid- 19 Precautionary Practices Checklists. Results: More than one-third of the studied nurses received training courses regarding COVID-19 before. Almost three-quarters of the studied nurses reported that their main source of information about knowledge regarding COVID-19 was doctors. There was an improvement with a highly statistically significant difference between nurse's knowledge regarding COVID -19 pre/post one month of educational intervention (P<0.001), with improved their precautionary practices score after one month. A statistically significant positive relation was found between the total mean score of studied nurses' COVID-19 knowledge and precautionary practice one month after the educational intervention. Conclusion: The study concluded that educational guidelines intervention for nurses in the GIT endoscopy unit greatly helps in improving COVID-19 levels of knowledge and precautionary practices with significant differences immediately and two months following an educational guidelines intervention. Recommendation: Continues designing and implementation in-service training program for nurses in the GIT endoscopy unit to improve their knowledge and precautionary practices

Microbiological and clinical characteristics of sternal wound infections following cardiac surgery in a teaching hospital in Kuwait: A 5-year retrospective study

Background: Sternal wound infections (SWI) following cardiac surgery are health-care-associated infections which have to be prevented as the morbidity and mortality attributed to SWI are high. Objective: The aim is to study incidence, microbial etiology, risk factors, and outcome of SWI that followed cardiac surgery in our hospital. Methods: A retrospective, single-center study involving 833 patients who underwent cardiac surgery from January 2012 to December 2016 was conducted in Al-Amiri hospital in collaboration with the Cardiac Coronary Care Unit, Sabah Al Ahmed Cardiac Centre, Kuwait. Microbiological data were retrieved from laboratory computers, and clinical details from patient files. Age, sex, microbial etiology, risk factors, and outcome were analyzed. A statistical study was done using the SPSS statistical package. Results: The incidence of SWI was 2.1%. Predominant microorganisms isolated were Staphylococcus epidermidis (27.7%) and Pseudomonas aeruginosa (27.7%). The most common risk factor was diabetes mellitus, 88.9% cases. About 50% cases were obese and 72.2% cases had a hospital stay for more than 10 days, with the median length of stay being 13.50 days. 30-day mortality outcome was zero. Conclusion: SWI lead to bacteremia, sepsis and extended hospital stay placing the patient at risk of further hospital acquired infections, and increased cost. Preoperative blood sugar control and weight reduction are important. Infection control measures such as nasal screen for Staphylococcus aureus and rectal screen for multidrug-resistant Gram-negative bacilli have to be considered. Based on the most common organisms isolated, ceftazidime with vancomycin could be a better option for surgical antibiotic prophylaxis in our center.

Birth Prevalence of Orofacial Clefts in Kuwait From Hospital-Based Registration: Retrospective Study.

Cleft lip and palate (CLAP) are the most common craniofacial anomalies and birth defects globally. Despite the fact that a tertiary care registry of clefts has existed in Kuwait since 2008, to date there is no published data regarding the prevalence of orofacial clefts in this population. To tabulate the pattern of orofacial clefts from tertiary care center registration during 2009 through 2014 and to estimate the prevalence and trend using population-based records. Data from all CLAP cases (born in Kuwait) registered in the central cleft center registry of the Al-Amiri hospital, Kuwait City, Kuwait, from January 2009 to December 2014 were obtained. Data regarding the type, severity, gender as well as nationality, parental consanguinity, and associated syndrome were obtained from medical records. Birth prevalence was tabulated against the population statistics for the period obtained from the central department of statistics. A total of 202 CLAP patients were recorded in the study period with a mean birth prevalence of 0.57 per 1000 live births (95% confidence interval [CI] .57 ± .23). The registry recorded 108 (53.2%) males and 94 (47.8%) females. Children born to Kuwaitis represented 53.7% of cases while those born to non-Kuwaitis represented 45.3%. The most common oral cleft was CLAP (47.3%), followed by cleft palate (30.5%), cleft lip (20.2%), and other facial clefts (2%). Other congenital anomalies were recognized in 33% of all cases. There were no statistically significant differences in oral cleft prevalence across gender or nationality. The prevalence of oral cleft in Kuwait appears to be similar to those of other Middle Eastern populations.

Evaluation of Nutritional Status Post Laparoscopic Sleeve Gastrectomy-5-Year Outcomes.

Obesity is considered a public health problem and has led to advancements in bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) had become the most performed procedure worldwide; however, its consequences on nutritional status in the short and long term are of concern. A retrospective analysis of medical records and bariatric database of patients who underwent LSG from October 2008-September 2015 at Al-Amiri Hospital, Kuwait, was performed. Data regarding nutritional status along with demographic data were collected over a 5-year follow-up period. One thousand seven hundred ninety-three patients comprising of 74% females and 26% males were included. The greatest % total body weight loss (%TBWL) was at 18months post-LSG (33%), corresponding to a % excess weight loss (%EWL) of 73.8%. With regard to nutritional status, vitamin B1 showed a significant drop at 3-5years post-op in comparison to pre-op value, but stayed within the normal range throughout the study. Red blood cells count, hemoglobin, and hematocrit also showed a significant drop starting from 6months post-op until the fifth year of follow-up. On the other hand, vitamins B6 and B12 showed a significant increase at 6months post-op and decreased afterwards, but did not reach pre-op values. Vitamin D also showed a significant increase throughout the study period from deficient value at the pre-op time, but remained insufficient. Albumin, transferrin, folate, ferritin, iron, and vitamin B2 showed no significant changes at 5years post-LSG compared to pre-op values. Little is known about the nutritional status and optimal nutritional care plan post-LSG, especially in the longer term. Nutritional deficiencies were prevalent prior and post-LSG. Some of the nutritional parameters improved and even reached the abnormal high level post-LSG. These observations highlight the importance of pre- and post-operative nutritional assessment and tailored supplementation to ensure optimal nutritional status.

Population structure and molecular genetic characterization of clinical Candida tropicalis isolates from a tertiary-care hospital in Kuwait reveal infections with unique strains.

Candida tropicalis is a frequently isolated yeast species causing bloodstream, urinary tract and other infections particularly in patients admitted to intensive care units (ICUs) and those requiring prolonged urinary catheterization (UC) or receiving broad-spectrum antibiotics (BSA). This study investigated clinical characteristics and genetic relatedness among C. tropicalis strains isolated from patients at Al-Amiri Hospital in Kuwait. C. tropicalis strains (n = 63) isolated from blood, genito-urinary, respiratory (RT) and digestive (GIT) tracts and wound sites from 54 patients were used. All isolates were phenotypically identified and tested against six antifungal drugs by using Vitek 2 system. Molecular identification was performed by PCR amplification of rDNA. Fingerprinting was achieved by 6-loci-based multilocus sequence typing (MLST) and data were analyzed by BioNumerics software for phylogenetic relationships. Patients mean age was >65 years and >20% patients were hospitalized in ICUs. Most patients had underlying conditions that included UC, BSA, diabetes and RT/GIT abnormalities. Most candiduria cases had UC, ureteric stent or suprapubic catheters. All isolates were identified as C. tropicalis by Vitek 2 and by species-specific PCR. Sixty-two isolates were susceptible to all tested antifungal drugs. MLST identified 59 diploid sequence types (DSTs) including 54 newly-identified DSTs. C. tropicalis isolates from multiple sites of same patient usually belonged to different DSTs. Interestingly, 56 of 57 isolates from 48 patients belonged to unique genotypes. Only six isolates from six patients belonged to three DSTs (clusters), however, C. tropicalis strains in each cluster were isolated >3 months apart. Our data show diverse origins of C. tropicalis infections in Kuwait as most isolates were unique strains. There was no obvious correlation between cluster isolates with time of isolation and/or hospital ward of their origin. This study presents the first MLST analysis of C. tropicalis isolates from Middle East and may be useful for studying genetic relationships among global C. tropicalis strains.

Efficacy of intragastric balloon for the management of obesity: experience from Kuwait.

Traditional methods of treating obesity have shown only limited efficacy. Intragastric balloon (BIB) is considered a new potential alternative method in the management of obesity. There is limited information in the literature about the outcome of BIB in the region of the Arabian Gulf. This study examined the efficacy and satisfaction of BIB in obese patients in Al-Amiri Hospital in Kuwait. A retrospective review of BIB in patients from October 2009 through December 2012 at Al-Amiri Hospital, Kuwait, included 179 patients. Weight loss, complications, satisfaction level, and weight gain after removal of the balloon were assessed. The weight loss was analyzed further according to different demographic groups. A total of 179 patients were included in the study. Their data were collected, and the pre-insertion and post-removal body mass index (BMI) was calculated. Before insertion of the BIB, there was a mean weight of 99.7 kg (SD 26.7); after removal, they showed a mean weight of 88.9 kg (SD 25). There was a mean weight loss of 10.9 kg (SD 8). The patients experienced a median excess weight loss of 38.5%. There was no significant variation in the weight loss according to age, gender, and nationality. There was a satisfaction level of 44% among the patients. Weight gain after removal was experienced by 34.7% of patients. BIB seems to be an effective method of significant weight reduction with little complications, making it a good alternative in the management of obesity in females with lower BMI.

The educational environment of the undergraduate medical curriculum at Kuwait University.

BackgroundEducational environment of an institution affects the quality of learning. We aim to assess the educational environment of the undergraduate curriculum of Faculty of Medicine, Kuwait University (FOMKU).MethodsA cross-sectional study was carried out during April 2014. The validated Dundee Ready Education Environment Measure (DREEM) questionnaire was e-mailed to 607 students. Mean scores of the main domains of the questionnaire, and for each item, were calculated, and their association with the students’ background information was measured using Student’s t-test (P-value of ≤0.05 was considered as the cut-off level of significance).ResultsOf 607 students, 117 (19.3%) completed the questionnaire. The total mean score for DREEM was 108.7/200 (54.3%). The mean score for students’ perception of teaching, perception of teachers, academic self-perception, perception of atmosphere, and social self-perception were 25.2/48 (52.5%), 24.6/44 (55.9%), 18.4/32 (57.5%), 26.2/48 (54.5%), and 14.3/28 (51.0%), respectively. The highest mean score for an item of DREEM questionnaire was for “my accommodation is pleasant” (3.48±0.75), while the lowest was for “there is a good support system for students who get stressed” (0.88±0.86). The total mean score was not significantly different between the two phases of the curriculum, or among males and females; however, few significant differences among the main domains and items were noted.ConclusionBased on the learners’ perspectives, the educational environment of FOMKU, was suboptimal. Medical educators in Kuwait should improve this environment in order to advance the quality of the delivered curriculum.

Treating sleeve gastrectomy leak with endoscopic stenting: the Kuwaiti experience and review of recent literature.

Obesity today is a leading cause of global morbidity and mortality, and bariatric surgeries such as laparoscopic sleeve gastrectomy (LSG) are increasingly playing a key role in its management. Such operations, however, carry many difficult and sometimes fatal complications, including leaks. This study aims at evaluating the effectiveness of endoscopic stenting in treating gastric leaks post-LSG. A retrospective study was conducted to the patients who were admitted with post-LSG gastric leak at Al-Amiri Hospital Kuwait from October 2008 to December 2012 and were subsequently treated with stenting. The patients were stented endoscopically with self-expandable metal stent (SEMS), and a self-expandable plastic stent (SEPS) was used to facilitate stent removal. A total of 17 patients with post-LSG leaks underwent endoscopic stenting. The median age was 34 years (range 19-56), 53% of the patients were male, and mean body mass index (BMI) was 43 kg/m(2). The median duration of SEMS placement per patient was 42 days (range 28-84). The SEPS-assisted retrieval process took a median duration of 11 days (range 14-35). Successful treatment of gastric leak was evident in 13 (76%) patients, as evident by gastrografin swallow 1 week after stent removal. In addition, a shorter duration between the LSG and the time of stent placement was associated with a higher success rate of leak seal. The use of SEMS appears to be a safe and effective method in the treatment of post-LSG leaks, with a success rate of 76%. The time frame of intervention after surgery is critical, as earlier stent placement is associated with favorable outcomes. Finally, SEPS is often required to facilitate SEMS removal, and further modification of stents and its delivery system may improve results.

Biopsied Oral Soft Tissue Lesions in Kuwait: A Six-Year Retrospective Analysis

Objectives: The aim of this study was to determine the relative frequency of biopsied oral soft tissue lesions in Kuwait. Materials and Methods: Biopsy records and microscopic sections of all oral soft tissue biopsies seen in the Department of Histopathology at Al-Amiri Hospital, Kuwait, between January 2004 and December 2009 were reviewed. The biopsies were divided into two major groups; group 1: nonneoplastic lesions, and group 2: neoplastic lesions. Group 1 was subdivided into reactive, inflammatory, cyst/cyst-like, dysplastic, and pigmented lesions. Group 2 was subdivided into epithelial and mesenchymal lesions, and also into benign and malignant lesions. Results: Of the 858 biopsies, 732 (85.3%) were nonneoplastic while the remaining 126 (14.7%) were neoplastic. In group 1, more than half of the lesions were within the reactive subgroup (n = 386; 52.7%) while in group 2, 94 (74.6%) lesions were epithelial in origin and 32 (25.4%) were mesenchymal. In addition, 70 (55.6%) lesions were malignant and 56 (44.4%) were benign. Of the 858 biopsies, the most common lesions were fibrous hyperplasias: 178 (20.7%); mucoceles: 110 (12.8%); pyogenic granulomas: 94 (11.0%); squamous cell carcinomas: 56 (6.5%), and lichenoid mucositis: 49 (5.7%). Conclusions: The majority of the lesions were nonneoplastic and were related to local irritation or trauma. Most neoplastic lesions were epithelial in origin. Oral squamous cell carcinoma was one of the most prevalent oral lesions highlighting the importance of prevention, early detection and diagnosis of oral cancer.

A Study of the Microbiology of Breast Abscess in a Teaching Hospital in Kuwait

Objectives: To determine the microbiological profile of breast abscess and assess the antibiotic susceptibility of the causative agents. Materials and Methods: Data obtained from cases of breast abscess over a period of 3.5 years, June 2006 to December 2009, were retrospectively analyzed. Specimens were cultured using optimal aerobic and anaerobic microbiological techniques. The antibiotic susceptibility test was carried out using the methods recommended by the Clinical and Laboratory Standards Institute. One specimen per patient was analyzed. Results: Of the 114 patients, 107 (93.8%) non-lactating and 7 (6.1%) lactating women were diagnosed with breast abscess during this period. Of the 114 specimens, 83 (73%) yielded bacterial growth. Of these, 115 pathogens were isolated with an average of 1.4 pathogens per abscess. Eighteen (22%) of the 83 specimens yielded mixed bacterial growth. There were more Gram-positive pathogens (60, 52%) than anaerobes (32, 28%) and Gram-negative pathogens (22, 19%). The predominant organisms were methicillin-susceptible Staphylococcus aureus (37, 32%), methicillin-resistant S. aureus (MRSA; 11, 10%), Bacteroides spp. (16, 14%), anaerobic streptococci (14, 12%) and Pseudomonas aeruginosa (9, 8%). Of the 48 S. aureus, MRSA accounted for 11 (23%). All MRSA isolates were susceptible to trimethoprim-sulfamethoxazole and vancomycin. Conclusion:S. aureus was the most common pathogenic organism isolated in breast abscesses at Al-Amiri Hospital, Kuwait, of which 23% were MRSA. Nearly a third of the cases were caused by anaerobes, particularly B. fragilis. The data present a basis for the formation of empirical antimicrobial therapeutic policy in the management of breast abscess.

Interventional radiology in billiary diseases: A non-surgical therapeutic option

PurposeThis study was undertaken to report our experience in Al-Amiri Hospital in Kuwait in the different billiary interventional procedures used for management of billiary diseases. Patients and methodsThe study was conducted from March 2007 until September 2009 on 64 patients suffering from obstructive jaundice and/or billiary diseases due to different causes. ResultsAccording to the patient’s diagnosis and the interventional procedure applied, our patients were classified into four groups: (I) patients with malignant obstructive jaundice who had decompression of the obstructed billiary tree; encountered in 44 patients (68.75%). (II) Patients with benign billiary strictures encountered in 9 patients (14.06%), where successful balloon dilatation was encountered in 6 patients (9.37%). (III) Patients with bile duct stones who had stone removal; encountered in 8 patients (12.5%), with successful stones elimination in all of the 8 patients. (IV) Patients with bile leak due to bile duct defect and leakage who had billiary stenting till sealing of the bile leak; encountered in 3 patients (4.68%). Technical and clinical success rate in this patient series was high and comparable with the results of the others. ConclusionPercutaneous transhepatic billiary interventional techniques could be done as an alternative management to surgical interference in patients with billiary diseases, with low morbidity and mortality rates and favorable outcome (high clinical success rates).

Etiology and Antibiotic Susceptibility Patterns of Community- and Hospital-Acquired Urinary Tract Infections in a General Hospital in Kuwait

Objective: Our purpose was to determine the bacterial profile and prevalence of antibiotic resistance patterns of uropathogens, as well as evaluate the problem with extended-spectrum β-lactamase (ESBL) producing isolates, causing urinary tract infections (UTIs) in Al-Amiri Hospital, Kuwait, over a 3-year period. Materials and Methods: Isolates (56,505) from symptomatic UTI cases from January 2005 to December 2007 were identified by conventional methods and the VITEK identification card system. Antimicrobial susceptibility testing was performed by disk diffusion method for Gram-positive organisms and an automated VITEK 2 machine for Gram-negative organisms. ESBL production by the Enterobacteriaceae was detected by the double-disk diffusion method and VITEK-2 system. Results: Significant bacteriuria was detected in 15,064 (26.6%) of the 56,505 urine samples. Escherichia coli accounted for 4,876 (54.9%) from community-acquired UTI (CA-UTI) and 2,253 (36.4%) from hospital-acquired UTI (HA-UTI), followed by Streptococcus agalactiae (1,129, 12.7%) and Klebsiella pneumoniae (962, 10.8%) from CA-UTI cases. Candida spp. (973, 15.7%) and K. pneumoniae (747, 12.1%) were the second and third most prevalent isolates, respectively, in HA-UTI. High resistance rates were observed among the Enterobacteriaceae against ampicillin, cephalothin, ciprofloxacin, piperacillin and trimethoprim-sulfamethoxazole. About 855 (12%) and 291 (17%) of E. coli and K. pneumoniae, respectively, were resistant to ≧4 antibiotics. The prevalence of ESBL-producing E. coli and K. pneumoniae in CA-UTI was 12 and 17% and in HA-UTI 26 and 28%, respectively. Conclusion: A high percentage of the uropathogens causing UTI in the Al-Amiri Hospital setting was highly resistant to the first- and second-line antibiotics for the therapy of UTI. ESBL-producing bacteria are highly prevalent in our hospital.

Value of Kidney-Ureter-Bladder Radiography in the Erect Position in Addition to Standard Intravenous Urography Examination

Objectives: To determine if additional kidney-ureter-bladder radiography in the erect position can improve the diagnostic yield of standard intravenous urography (IVU) examination. Subjects and Methods: This prospective study was conducted from March to July 2007 on 108 consecutive patients (65 males and 43 females, age ranging from 20 to 50 years) who were referred to the Department of Radiology, Al-Amiri Hospital, Kuwait, for IVU examinations. After 15 min, a film was done in the erect position in addition to the routine IVU protocol. Results: Additional information was demonstrated in the erect radiograph as follows: detecting nephroptosis in 18 (17%) patients, improved visualization of the ureters in 58 (54%) patients, and differentiation between phleboliths and ureteric stone was possible in 12 (11%) patients. Conclusions: Our study demonstrated significant additional findings in the erect position (at 15 min) compared to the supine position.

Clinical Pharmacokinetics of Gentamicin

Objectives: The objectives of this study were to: (1) derive equations for estimating gentamicin clearance (Cl_gent) and volume of distribution (V_d) based on the local population attending Al-Amiri Hospital, Kuwait; (2) independently evaluate these equations by comparison with other published methods in their predictive ability to estimate Cl_gent and V_d. Materials and Methods: Cl_gent and V_d were calculated in 47 patients (group 1) using the Sawchuk-Zaske method. Regression analysis was used to derive a correlation between creatinine clearance (Cl_cr) and Cl_gent, V_d and actual body weight (ABW). Based on actual Cl_gent and V_d values, the predictive ability of the estimated parameters from the regression equations was validated and compared with 4 published methods using mean error (ME), i.e. bias, and mean squared error (MSE) and root mean squared error (RMSE), i.e. precision. All equations were also evaluated in an independent second group (group 2) of 23 patients. Results: The mean ± SD values of Cl_gent and V_d were 4.0 ± 1.8 l·h^–1 and 16.8 ± 6.7 liters, respectively. The derived equations were: Cl_gent = (0.760) (Cl_cr) + 1.117 (r = 0.701) and V_d = (0.165) (ABW) + 5.604 (r = 0.532). In comparison to the 4 published methods, the derived equations were less biased (ME = 0.00) and more precise (MSE = 1.68, RMSE = 1.02) in predicting Cl_gent (p < 0.05), and less biased (ME = –0.01) with no difference in precision (MSE = 36.22, RMSE = 4.59) in predicting V_d (p > 0.05). This precision was confirmed in the second group of 23 patients, where the derived equations were less biased (ME = –0.1) and more precise (MSE = 3.22, RMSE = 1.48) in predicting Cl_gent (p < 0.05), whilst no difference was found for prediction of V_d (p > 0.05). Conclusion: The equations developed in this study provided a reliable estimation of Cl_gent and V_d. It is planned to use them at Kuwait Hospitals to help provide more individualized patient dosing information to physicians.

Extended-Spectrum β-lactamase-Producing Escherichia coli Isolated in the Al-Amiri Hospital in 2003 and Compared with Isolates from the Farwania Hospital Outbreak in 1994-96 in Kuwait

Extended-spectrum -lactamases (ESBLs) are a major problem in Kuwait and an accurate method for their detection is essential. This study was designed to evaluate the efficacy of the commercial system (Vitek 2) to identify ESBLs in clinical isolates of Escherichia coli and relate this to their identification by agar dilution methods for use in a diagnostic laboratory. The presence of the major ESBLs parental enzyme groups was confirmed by PCR and the similarity of the strains was determined by pulsed field gel electrophoresis (PFGE) on DNA, cleaved using XbaI endonuclease, to identify clonal spread.Seventy-one separate E. coli isolates from 65 patients were tested. Sixty-two isolates were from 56 patients from the Al-Amiri Hospital and nine isolates from neonates from Farwania Hospital. The isolates were screened for ESBL activity by the Vitek 2 system. Isolates showing positive results were further tested with Etest ESBL strips and by the disc approximation methods. All the isolates were flagged as ESBL-positive by the Vitek 2 advanced expert system (AES). Isolates from all the 65 patients were detected as ESBL positive by the Etest, only if both ESBL strips were used. The double disc approximation test using five different antibiotics could detect ESBL presence in isolates from only 46 patients. In this test, the synergy with cefepime was the most sensitive in ESBL detection, showing their presence in 41 isolates. PCR with primers for blaTEM and blaSHV demonstrated that one or both of these enzymes in all isolates. PFGE revealed that many different clones were present amongst the isolates.The epidemiology of ESBL E. coli in Kuwait is complex. Many distinct strains are already present in the population, as shown by the results of PFGE. Several testing methods may be required to detect all strains harboring ESBLs.

Therapeutic Drug Monitoring of Gentamicin: Evaluation of Five Nomograms for Initial Dosing at Al-Amiri Hospital in Kuwait

Objective: To compare five published nomograms (Thomson guidelines, Mawer nomogram, rule of eights, Hull-Sarubbi table and Dettli method) for calculating the initial gentamicin dosage regimen in a Kuwaiti population. Materials and Methods: Based on measured peak and trough gentamicin concentrations, the elimination rate constant and volume of distribution of gentamicin were calculated for each patient (n = 56), using a modified two-point Sawchuk-Zaske method. The calculated individual set of pharmacokinetic parameters and the initial dose regimen recommended by each of the five methods were used to predict the steady-state peak and trough of gentamicin concentrations. Results: The Thomson guidelines produced consistent results in predicting gentamicin concentrations within the target ranges of peak plus trough, peak only and trough only (63, 75 and 75%, respectively). The Mawer nomogram, Hull-Sarubbi table and Dettli methods achieved similar percentages of patients (46–50%) within the target ranges (5–10 mg · l^–1 for peak and 0.5–2 for trough), whereas empirical dosing and the rule of eights showed the lowest percentages of patients within the peak plus trough target range (25 and 37%, respectively). However, with respect to the underdosing target range (predicted concentration <5 mg · l^–1), the Thomson guidelines showed that 21% of patients were underdosed. Conclusion: The results show that a large number of patients (37–63%) were outside the target ranges in all initial gentamicin dosing methods evaluated in this study. Therefore, serum concentration measurement can be advised to assist in the optimization of gentamicin dose selection.