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Abstract Objectives/Hypothesis To assess the efficacy of 0.23% povidone-iodine (PVP-I) nasal rinses and mouth washes on detectability of the coronavirus disease 2019 (COVID-19) virus and cycle threshold (Ct) values in nasopharyngeal swabs. Study design This was an open-label, prospective, randomized, placebo-controlled clinical trial. Setting The study was conducted in King Saud University Medical City, Riyadh, Saudi Arabia, from August 2021 to July 2022. Methods Participants diagnosed with SARS-CoV-2 were randomly assigned to one of three groups, with participants receiving either 0.23% PVP-I, 0.9% normal saline (NS) nasal rinses and mouth washes, or no intervention (control group). Nasopharyngeal swabs were taken 4, 8, 12, and 18 days after the first swab to measure the detectability of the virus and the Ct. Results A total of 19 participants were involved in this study. The mean viral survival was 9.8, 12, and 12.6 days for the PVP-I, NS, and control groups, respectively, with a statistically significant difference (p = 0.046). The Ct mean values were 23 ± 3.4, 23.5 ± 6.3, and 26.3 ± 5.9 at the time of recruitment and 25.2 ± 3.5, 15 ± 11.7, and 26.9 ± 6.4 after 4 days for the PVP-I, NS, and control groups, respectively. Conclusions When used continuously at a concentration of 0.23%, PVP-I showed promising results in terms of decreasing the pandemic burden by reducing the period of infectiousness and viral load. However, the use of PVP-I did not result in significantly different changes in the quality-of-life parameters in recently vaccinated and mild COVID-19 patients.

Carbapenem-resistant Enterobacterales (CRE) pose a significant public health concern. CRE could be carbapenamse producers or non-producers. In the Kingdom of Saudi Arabia, blaOXA-48 and blaNDM represent the majority of carbapenemase isolates. There are very limited treatment options for carbapenemase-producing CRE caused by blaNDM. Ceftazidime-avibactam plus aztreonam (CZA-ATM) or cefiderocol as monotherapy are considered the treatment of choice for these infections. Here, we report a case of a 70-year-old man presented with surgical site infection of above knee amputation stump. The cultures revealed carbapenem-resistant Klebsiella pneumoniae positive for blaNDM and blaOXA-48 resistant to CZA-ATM therapy and intermediate susceptibility to tigecycline. He was started on CZA-ATM both adjusted for renal function, and high dose tigecycline with daily wound dressing and irrigation. By day 20 of the antibiotic regimens, he had clinical and microbiological cure based on repeated wound cultures. This case identifies a rare incidence of CRE skin and soft tissue infection positive for blaNDM and blaOXA-48 resistant to CZA-ATM in a background of limited targeted options, but successfully treated with CZA-ATM and high-dose tigecycline. Such therapeutic approach might be useful in few circumstances when no other antibiotic options are available to treat extensively drug-resistant Klebsiella pneumoniae.

Abstract Background Disseminated nocardiosis still causes significant morbidity and mortality and is often caused by Nocardia asteroides, N. basiliensis, and N. farcinica and are often treated with trimethoprim–sulfamethoxazole (TMP–SMX). Nocardia otitidiscaviarum (N. otitidiscaviarum) rarely causes disseminated disease and resistance to TMP–SMX is even more rare. Case presentation A 37-year-old woman with metastatic breast cancer and right ear deafness with recent occupational gardening and manipulating soil, presented to the hospital with first time seizure and multiple skin nodules. Magnetic resonance imaging (MRI) showed ring enhancing lesions, biopsy of the skin and brain lesions grew N. otitidiscaviarum. She was empirically treated with TMP–SMX and Imipenem–Cilastatin, however, almost three weeks into therapy, susceptibility results revealed it to be resistant to both antimicrobials, she was subsequently changed to Amikacin, Linezolid, Moxifloxacin, and Doxycycline but ultimately died. Conclusions This case report highlights the importance of suspecting a rare Nocardia species in patients at risk with proper occupational exposure, moreover, TMP–SMX resistance should be suspected with lack of clinical response, this may have important implications on clinical practice when facing similar infections.

Background: Coronavirus disease 2019 (COVID-19) has resulted in millions of deaths, including more than 6000 deaths in the Kingdom of Saudi Arabia (KSA). Identifying key predictors of intensive care unit (ICU) admission and mortality among infected cases would help in identifying individuals at risk to optimize their care. We aimed to determine factors of poor outcomes in hospitalized patients with COVID-19 in a large academic hospital in Riyadh, KSA that serves as a Middle East Respiratory Syndrome coronavirus (MERS-CoV) referral center. Methods: This is a single-center retrospective cohort study of hospitalized patients between March 15 and August 31, 2020. The study was conducted at King Saud University Medical City (KSUMC). COVID-19 infection was confirmed using real-time reverse transcriptase polymerase chain reaction (RT-PCR) for SARS-COV-2. Demographic data, clinical characteristics, laboratory, radiological features, and length of hospital stay were obtained. Poor outcomes were, admission to ICU, need for invasive mechanical ventilation (IMV), and in-hospital all-cause mortality. Results: Out of 16,947 individuals tested in KSUMC, 3480 (20.5%) tested positive for SARS-CoV-2 and of those 743 patients (21%) were hospitalized. There were 62% males, 77% were younger than 65 years. Of all cases, 204 patients (28%) required ICU admission, 104 (14%) required IMV, and 117 (16%) died in hospital. In bivariate analysis, multiple factors were associated with mortality among COVID-19 patients. Further multivariate analysis revealed the following factors were associated with mortality: respiratory rate more than 24/min and systolic blood pressure 37 units/L in the first 48 h of presentation, while a RT-PCR cycle threshold (Ct) value ≤24 was a predictor for IMV. Conclusion: Variable factors were identified as predictors of different outcomes among COVID-19 patients. The only predictor of IMV was a low initial Ct values of SARS-CoV-2 PCR. The presence of tachypnea, hypotension, lymphopenia, and elevated AST in the first 48 h of presentation were independently associated with mortality. This study provides possible independent predictors of mortality and invasive mechanical ventilation. The data may be helpful in the early identification of high-risk COVID-19 patients in areas endemic with MERS-CoV.

Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae have been isolated from human patients in many countries across the globe but rarely in Saudi Arabia. Here we provide the genomic characterization of the first KPC-producing K. pneumoniae isolated from the urine of a patient in Riyadh, Saudi Arabia, who had a recent travel history to Egypt involving a medical procedure. Presence of KPC-encoding gene initially detected with the Xpert Carba-R assay was confirmed by traditional PCR. Susceptibility testing using the VITEK 2 system, E-test and microbroth dilution methods showed that the K. pneumoniae isolate, namely SA01_KPC-2, was resistant to all antibiotics except colistin and ceftazidime/avibactam. Whole-genome sequencing (WGS), performed on the Illumina Miseq instrument, identified the isolate as sequence type (ST) 383 and serotype KL30-D1 O1v2. Genome assembly of SA01_KPC-2 indicated the presence of two plasmids. Plasmid pSA01_KPC-2, of approximately 45.9 kb in size, harbored the blaKPC-2 flanked by ISKpn27 and ISKpn6 and had a backbone similar to published KPC-carrying IncX6 plasmids. The second plasmid pSA01_incHIB1, a derivative of published 372-kb plasmid pKpvST383, carried genes encoding virulence factors and resistance to five classes of antibiotics. The isolation of the first KPC producer in Saudi Arabia requires high attention and rapid interventions to prevent further spread. Keywords: Carbapenem-resistant enterobacteriaceae (CRE), Klebsiella pneumoniae carbapenemase (KPC), IncX6 plasmids, ST383, Saudi Arabia

Ecthyma gangrenosum (EG) is a well-recognized dermatological condition classically associated with Pseudomonas aeruginosa infection, however, the association with other bacteria, especially gram positive, is rare. There are only a few reported cases of EG caused by staphylococcal infection. Here, we report a case in a young patient with chronic kidney disease (CKD) presenting with EG secondary to Methicillin Resistant Staphylococcus aureus.

Background: The Kingdom of Saudi Arabia (KSA) reported 170,639 cases and 1430 deaths from COVID-19 since the first case emerged in the country on March 2 through June 25, 2020. The objective of this report is to describe the characteristics and outcome observed among 99 hospitalized COVID-19 patients in the largest academic hospital in KSA, and assess co-infection with the Middle East Respiratory Syndrome Coronavirus (MERS-CoV). Methods: This single-center case series data included select epidemiological, clinical, radiological features and laboratory findings of all confirmed hospitalized cases of COVID-19 in King Saud University Medical City (KSUMC), Riyadh, KSA, from March 22 until May 31, 2020, followed through June 6, 2020. We conducted retrospective analysis of listed data from 99 hospitalized patients and present characteristics and factors associated with severity in percentages and univariate odds ratios. Cases were confirmed using nasopharyngeal or throat swab by real-time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and MERS-CoV by RT-PCR. Results: The 99 hospitalized COVID-19 patients included in this analysis constitute 16% of 632 positive SARS-CoV-2 among 6633 persons who were tested at the KSUMC (positivity rate, 9.4%). MERS-CoV PCR was negative in all 99 patients tested. The majority of these 99 hospitalized patients were males (66%), had a mean age of 44 years (range, 19–87), and a quarter (25.3%) were health care workers. Patients with comorbid conditions accounted for 52.5% of patients including the 8.1% who were asymptomatic; diabetes mellitus being the most frequent (31.3%), followed by hypertension (22.2%). The most common presenting symptoms were fever (67.7%), cough (60.6%), dyspnea (43.4%), upper respiratory symptoms (27.3%), fatigue (26.3%), diarrhea (19.2%) and loss of smell (9.1%). The clinical conditions among these 99 patients included upper respiratory tract infection (47.5%), abnormal chest X-ray, lymphopenia, high inflammatory markers a fifth (21%) of patients had moderate pneumonia, while 7% had severe pneumonia with 22.2% requiring admission to the intensive care unit and 12.1% died. Late presentation with severe disease, an abnormal chest X-ray, lymphopenia, high inflammatory markers (C-reactive protein, ferritin, and procalcitonin), and end organ damage (high creatinine or high aspartate aminotransferase) were predictors for admission to critical care unit or died. Conclusion: We observed no MERS-CoV co-infection in this early cohort of hospitalized COVID-19 patients who were relatively young, more than half had comorbid conditions, presented with fever and/or cough, an abnormal chest X-ray, lymphopenia, and high inflammatory markers. Given MERS-CoV endemicity in the country, co-monitoring of MERS-CoV and SARS-CoV-2 coinfection is critical.