Hospital-acquired infection poses significant clinical and economic burden worldwide.  In the Kingdom of Saudi Arabia, infection control is a young, rapidly growing specialty.  An infrastructure to expedite the growth of this important discipline is fast being established.  The Kingdom faces unique challenges when addressing infection control. Much of the policy-making in domestic infection control is driven by the preventive medicine concerns of the annual pilgrimage (Hajj) to Mecca, which are unparalleled.

 

The Saudi Ministry of Health acts to contain and control public health risks at this gathering of 2 million. Infectious hazards at the Hajj include meningococcal meningitis, respiratory tract infections, blood borne diseases, and zoonotic diseases, all of which have international ramifications as pilgrimaging Muslims return home. In the wake of the extraordinary pace of modernization in Saudi Arabia, deficiencies in infection control remain, which are slowly being redressed.

 

Saudi Arabia seeks increasing international partnership in the area of infection control and preventive medicine. The Saudi health care system was formed on the basis of Western models to resounding success. Saudi Arabia is now in a position to provide experience and knowledge in return. International dialogue in the infection control arena is of mutual value. Important public health progress is afoot in this young kingdom, and these advances translate both regionally and on the international platform.

 

Antimicrobial resistance (AMR) in bacteria is emerging and spreading rapidly worldwide. This phenomenon is nowadays affecting public and animal health dramatically on a global level. Unfortunately, the current dependence on antibiotics – whether to treat, prevent, or stimulate food animal growths – have exponentially increased this resistance. When antibiotics are used, selective pressure is created, and possibly forcing the exposed bacteria to mutate or acquire pieces of DNA to become antibiotic resistant. The selection pressure resulting from the overwhelming use and misuse of antibiotics is exponentially supporting the AMR phenomenon. The multidrug-resistant (MDR) pathogens are spreading rapidly in many parts of the world causing severe medical and economic consequences. It is estimated that at least every 10 minutes a patient dies in the USA or Europe because of fatal infections caused by antibiotic-resistant bacteria.

 

The Goal of the WHO Global action plan is to ensure, for if possible, continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality-assured, used in a responsible way, and accessible to all who need them.

 

In May 2015 World Health Assembly adopted a global action plan on antimicrobial resistance with five objectives.

 

Objective 1: Improve awareness and understanding of antimicrobial resistance through effective communication, education, and training

 

Objective 2: Strengthen the knowledge and evidence base through surveillance and research

 

Objective 3: Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures

 

Objective 4: Optimize the use of antimicrobial medicines in human and animal health

 

 Objective 5: Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions

 

The Kingdom Saudi Arabia AMR action plan underscores the need for effective “one health economy” approach involving coordination among numerous international sectors and actors, including human and veterinary medicine, agriculture, finance, environment, and well-informed consumers. The action plan recognizes and addresses both the variable resources nations must combat antimicrobial resistance and the economic factors that discourage the development of replacement products by the pharmaceutical industry.

 

The objectives of WHO were also adopted by The Kingdom of Saudi Arabia. Recent studies showed a substantial increase in the rate of carbapenem-resistant GNB in Saudi Arabia over the last decade in comparison with the rates of the 1990s. It also documented the increasing prevalence of extended spectrum beta-lactamase (ESBL) producing isolates from Saudi Arabia, where some institutions had 29% ESBL rates among Escherichia coli (E. coli) and 65% ESBL rates among Klebsiella pneumoniae (K. pneumoniae). Thus, these increasing rates have been associated with many reported outbreaks and mortality that ranged between 11-40%. A Saudi national surveillance on Gram-positive cocci demonstrated that 32% of Staphylococcus aureus (S. aureus) are methicillin-resistant (MRSA), and 33% of Streptococcus pneumoniae are resistant penicillin G and 26% are resistant to erythromycin. Several factors are associated with the increasing emergence and spread of MDR bacteria in Saudi Arabia.

 

It is evident that the unoptimized use of antibiotics is a major factor for AMR development. A hospital in Riyadh has well demonstrated the overuse of antimicrobial agents from 4 adult ICUs in 2010, where the highest use was meropenem (33.2 defined daily doses [DDD] per 100 bed-days), followed by piperacillintazobactam (16.0 DDD/100 bed-days). On the other hand, the DDD/100 bed-days in 37 ICUs in the United States was 3.75 for carbapenems and 7.08 for antipseudomonal penicillins. Over-the-counter antibiotics without prescription in Saudi community pharmacies is another issue that is driving the improper use of antibiotics. Only one out of 88 pharmacists in Eastern province refused to sell antibiotics without a prescription, and 77.6% of the pharmacies in Riyadh dispensed antibiotics without a prescription.

 

Heavy international travel activities are occurring due to the large population of expatriates and to pilgrimage the Holy cities. A recent study showed that returned travellers from Hajj had acquired MDR A. baumannii and NDM-producing E. coli during the Hajj event. Previous data from 2 major hospitals in Makkah showed that ceftazidime resistance is evident in 24.6% of E. coli, 34.4% of K. pneumoniae, and 52.7% of P. aeruginosa. Another issue that can contribute to the spread of AMR is the challenge related to the adherence of infection control practices. The hand hygiene compliance rate in a hospital in Makkah in 2011 was 50.3%. The effectiveness of hand hygiene compliance was well demonstrated in controlling a nosocomial outbreak caused by carbapenem-resistant K. pneumoniae in Riyadh.

 

There hasn’t been a structured national plan on laboratory surveillance and preventive measures to circumvent the ongoing surge in microbial resistance. A survey of 20 MOH laboratories survey done in 2015 has shown that 18 out 20 hospitals reported antibiograms with current CLSI reference. They have AMR policy and quality assurance, it was found that 60% of staph aureus were resistant to oxacillin, and 50% of E Coli were resistant to 3rd generation cephalosporins,60% of Acinetobacter resistant to Amikacin AND Colistin 40%). Although detection and reporting happen at the institutional level, but coordination between health institutions was not established. No data exist on incidence, mortality and economic impact. Now through the National AMR program, a systematic approach toward the problem is established in guidance with WHO and GHSA action.