Due to the large
population of expatriate workers, the gulf region concentrates infectious
strains from all around the word. In addition, the booming of the
touristic sector in several of these countries, and the hosting of over 4
million pilgrims every year to Mecca and Madinah in the Kingdom of Saudi Arabia,
lead to the emergence of new MDR strains by genes exchange among strains from
different places. Another factor, is that high numbers of citizens seek medical
care in hospitals abroad and therefore might get infections from those medical
centers (Balkhy et al., 2016). Therefore, The Gulf Cooperation Council
Center for Infection Control (GCC-IC) has put the emergence of antimicrobial
resistance (AMR) on the top of its last four years agenda, and they have
developed a unified infection control manual as a reference for those countries
on best practices in infection control. The manual was the result of hard work
of representatives from Infectious Disease Societies, Food and Drug
Authorities, Ministries of Health, Ministries of Agriculture, Academic and
Research Centers, from all GCC countries in Riyadh on January 2015 (Balkhy et
Five strategic aims are identified as the
pillars of the GCC AMR strategic plan. The five aims can be summarized as
GCC Countries must
understand the magnitude of AMR in their countries among humans and animals, as
well as in agriculture and in the environment.
GCC Countries must
restrict the usage of effective antimicrobials to preserve their efficiency.
GCC Countries should
develop early identification methods for emerging MDR microorganisms.
GCC Countries should
limit the spread of resistant pathogens among patients, animals, and in agriculture.
Finally, GCC countries
must encourage collaborative research activities regarding AMR in humans,
animals, and the environment with all academic and research institutions (Balkhy
et al., 2016).
Our study aims to work on clinical MDR
isolates in the state of Qatar to help putting limits to this life threatening
issue. In the following pages of this introduction, studies about MDR bacteria
conducted in the GCC countries in particular and worldwide briefly will be
described. The main objective is to understand the exact situation, and to
answer important questions before designing our study. The questions include,
but are not limited to: 1- What is being done currently in Qatar to understand
the problem and fight against it? 2- What are the areas that require further investigations?
3- Which bacterial types are acquiring MDR infections? 4- Where do those
bacteria come from? 5- Via what mechanisms they are getting MDR? As it is the
case always in science, the first step in curing a disease is understanding it,
and our study aims to explain at the physiological and molecular level the
causative factors of the increased level of MDR in Qatar.
Medical Corporation (HMC) is Qatar’s main not-for-profit healthcare provider
and under its umbrella lies many hospitals and medical health centers. Among
the first studies conducted at Hamad hospital was one about gram negative
bacilli in 1998. One hundred eight consecutive aerobic gram negative bacilli
were isolated from patients 72 hours after admission to the ICU. The isolates
include: P. aeruginosa. Klebsiella, E. Coli, Stenotrophomonas
maltophilia, enterobacter, acinetobacter, and others. MDR was detected with
the highest percentages of resistance isolate shown with Stenotrophomonas
maltophilia followed by P. aeruginosa. The author claimed that MDR
could be due to the excessive use of antimicrobials, as 70% of the patients in
the study were under antimicrobial treatment by the time of the culture (El
Shafie et al., 2005).
Between January and June 2002, an A. baumannii outbreak had occurred
in a trauma intensive care unit (TICU) at HMC in Qatar and it was studied.
Twenty one patients were involved in the outbreak, their infections were
hospital acquired. All 21 strains of A. baumannii were proven resistant
to all tested antimicrobial agents except amikacin. A. baumannii was
also isolated from the TICU environment including staff hands and equipment which
proves further the nosocomial origin. This study emphasized on the important
role of strict infection control measures in hospitals to avoid the
dissemination of strains that might survive for long time on surfaces such as A.
baumannii (El Shafie et al., 2004).
Another study conducted at HMC considered
452 episodes of bacteraemia that had happened during one year between July 2007
and June 2008. The various sources of isolates are IV catheter, urinary system,
respiratory system, gastrointestinal tract, wounds and others. Both gram
negative and gram positive bacteria were isolated and studied. Cases were
divided into community acquired (58.8% of the patients) and nosocomial acquired
bacteremia (41.2% of the patients). Gram-negative bacteria were isolated from
63.1% (285/452) of the individuals with E. coli being the most frequently
isolated type 21.5% (97/452). The most common source of bacteraemia was found
to be the IV catheterization 19.2% with E. coli being also the most
frequent bloodstream isolate 21.5% (97/452), followed by S. aureus 11.7%
(53/452). The most frequent pathogenic bacteria isolated from nosocomial bacterial
infections were S. aureus 16.1% (30/186). Multidrug resistance was
encountered in 50% (6/12) of Acinetobacter isolates, 33.3% (7/21) of all Pseudomonas
aeruginosa isolates, and 28.6% (6/21) of Enterobacter isolates. In
addition, the highest percentages of isolated bacteria with ESBL production was
detected within MDR E. coli and Klebsiella spp. strains with
27.8% (27/97) and 17.9% (7/39). Overall,
E. coli and S. aureus as the most frequent infectious bacteria
isolated. Finally, ESBL producing bacteria were shown to be horizontally
transmitted from patient to patient which highlight the importance of the
control of such outbreaks in our hospitals (Khan et al., 2010).