Acute rhinosinusitis during Hajj season 2014: Prevalence of bacterial infection and patterns of antimicrobial susceptibility

doi:10.1016/j.tmaid.2016.11.004

Travel Medicine and Infectious Disease

Volume 14, Issue 6, November–December 2016, Pages 583-587

https://doi.org/10.1016/j.tmaid.2016.11.004 Get rights and content

Abstract

Background

The presence of large number of pilgrims during Hajj in Makkah region increases the risk of respiratory diseases. In this study, we aimed to assess the bacteriology of acute rhinosinusitis (ARS) during Hajj season and to demonstrate the antimicrobial susceptibility patterns that should guide the clinicians towards more appropriate antibiotic use.

Methods

Patients with ARS presenting during Hajj season of 2014 were prospectively enrolled. According to EPOS2012 criteria. Sampling of sinus secretions was performed from the middle meatus adjacent to the maxillary sinus ostium via endoscopic guidance. Over all, the study has covered all ENT, emergency and outpatient departments in Hajj.

Results

Two hundred and twenty six patients with ARS were enrolled in the study. Pathogenic bacteria were identified in 93 (41.2%) patients. Of the 93 patients with bacterial ARS, Staphylococcus aureus was isolated in 46 (49.5%) patients, out of which 13 (28.3%) were methicillin-resistant Staphylococcus aureus (MRSA).The second most common group of bacterial isolates was Enterobacteriaceae such as Escherichia coli, and various Klebsiella species. Antibiotic sensitivity showed that methicillin-sensitive Staphylococcus aureus (MSSA) was also sensitive to cephalosporins, quinolones and clindamycin, while exhibiting relatively less sensitivity rates to amoxicillin-clavulinic acid and macrolides.

Conclusion

Our study demonstrates the importance of assessing the bacteriology of ARS to help implement guidelines for proper treatment and prevention protocols during Hajj season.

Introduction

Hajj is one of the five pillars of Islam and the largest annual gatherings of humans hosted in Makkah, Saudi Arabia. The presence of large number of pilgrims in a small area at a specific time increases the risk of introducing potentially harmful communicable diseases with subsequent fast magnification [1].

Changes in routine healthy activities (lack of sleep, bad hygiene, physiological habits and malnutrition, etc.) as well as fatigue and anxiety resulting from traveling, performing pilgrimage ceremonies and overcrowding [2], [3], make the pilgrims even more susceptible to diseases [4].

Respiratory diseases are very prevalent during Hajj [5]. The exact incidence of upper respiratory tract infections (URTI) among pilgrims is not known. In previous study, it was reported that about 20% of pilgrims will experience respiratory symptoms [6].

Alherabi reported that a total of 78.5% of the patients presenting to the Emergency Departments, or to the Ear, Nose and Throat Clinics, in Hajj season of 2009, had URTI including pharyngitis, viral URTI, and tonsillitis between the hours of 12pm to 12am during Hajj days [5]. Many patients develop one form of respiratory tract infection or another during Hajj season and this leads to high morbidity, imposes high costs on the health system, and is among the major obstacles for pilgrims to perform Hajj duties [7].

In this study, we aimed to assess the bacteriology of acute rhinosinusitis (ARS) during Hajj season and to demonstrate the antimicrobial susceptibility patterns that should guide the clinicians towards more appropriate antibiotic use.

Section snippets

Patient selection

Study protocol was approved by our Institutional Review Board (IRB) prior to commencement of the study. This paper had the final approval from the committee of bio-medical ethics, Umm al Qura University. The study was conducted in Alnoor Specialized Hospital, a 500-bed tertiary care facility in Makkah. The hospital also provided primary health care services to all pilgrims during the Hajj season. Three hundred forty three patients presenting to the emergency or outpatient departments at this

Results

According to EPOS2012 diagnostic criteria, 229 patients were diagnosed as ARS (66.8% of the screened patients); 3 patients declined to participate in the study, and the remaining 226 patients were enrolled. Age ranged from 9 to 77 years (Mean ± SD; 34.6 ± 13.9). Of all ARS patients, 176 (77.9%) were males. The percentages of patients from each geographical location are summarized in Table 1.

The most common presenting symptom was nasal obstruction followed by nasal discharge and facial pain.

Discussion

ARS is one of the most common infections worldwide and is usually bacterial or viral in origin. The incidence of bacterial infections varies and may depend on patients' immune status, previous vaccinations, hospitalization, geographical distribution, and specific environmental conditions [12], [13]. A recent systematic review showed that bacterial pathogens were identified in 53.7% of 9595 patients with ARS reported in 29 studies [14]. In our study, bacterial pathogens were identified in 41.2%

Conclusion

The present study updates our knowledge about the prevalence of bacterial infections in patients presenting with ARS during Hajj season. It also highlights the increasing role of S. aureus, MRSA and Enterobacteriaceae in bacterial ARS during Hajj, and the current trends in antimicrobial resistance and susceptibility. It is important to conduct similar studies on a larger scale and on annual basis to further establish guidelines for selecting the proper antibiotics for treatment and hopefully

Financial disclosures

This research was supported by a research grant from the Institute of Scientific Research and Revival of Islamic Heritage, Umm Al-Qura University, Makkah, Saudi Arabia.

Conflict of interest

None.

Acknowledgement

We would like to acknowledge our group of medical students for their valuable help with patients' counseling and sampling. These include: Abdulwahab K. Neyazi, Ahmed G. Al-ahdal, Ahmed H. Al-Abbasi, Elham A. Hasan, Bayan Z. Hafiz, Abdullah A. Al-Erinan, Fatmah M. Hawsawi, Lujain S. Babker, Mohammed A. Khan, Hashem M. Bin Samman, Waed S. Jameel, Moayad A. Al-Manabri, Salman A. Turkastani, Feras K. Al-Jabri, Anas A. Al-Khotani, Basel A. Dahlawi, and Ahmed A. Mirza.

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Citation Excerpt :
The 3GC-resistant A. baumannii were observed at 91% during the 2014 Hajj [21] and 77% in ill pilgrims during the 2015 Hajj [24]. Overall, imipenem-resistant bacteria were reported during the 2014–2015 Hajj at a rate ranging from 1 to 90% in A. baumannii, E. coli, K. pneumoniae, and P. aeruginosa [21,23,24]. Salmonella enterica which were resistant to ceftriaxone, gentamycin and colistin were isolated from two pilgrims [16].
Hajj is the annual mass gathering of Muslims, and is a reservoir and potential source of bacterial transmission. The emergence of bacterial transmission, including multi-drug resistance (MDR) bacteria, during Hajj has not been systematically assessed.
Articles in Pubmed, Scopus, and Google scholar were identified using controlled words relating to antibiotic resistance (AR) at the Hajj from January 2002 to January 2017. Eligible studies were identified by two researchers. AR patterns of bacteria were obtained for each study.
We included 31 publications involving pilgrims, Hajj workers or local patients attending hospitals in Mecca, Mina, and the Medina area. Most of these publications provided antibiotic susceptibility results. Ten of them used the PCR approach to identify AR genes. MRSA carriage was reported in pilgrims and food handlers at a rate of 20%. Low rates of vancomycin-resistant gram-positive bacteria were reported in pilgrims and patients. The prevalence of third-generation cephalosporin-resistant bacteria was common in the Hajj region. Across all studies, carbapenem-resistant bacteria were detected in fewer than 10% of E.coli isolates tested but up to 100% in K. pneumoniae and A. baumannii. Colistin-resistant Salmonella enterica, including mcr-1 colistin-resistant E.coli and K.pneumoniae were only detected in the pilgrim cohorts.
This study provides an overview of the prevalence of MDR bacteria at the Hajj. Pilgrims are at high risk of AR bacterial transmission and may carry and transfer these bacteria when returning to their home countries. Thus, pilgrims should be instructed by health care practitioners about hygiene practices aiming at reducing traveler's diarrhea and limited use of antibiotics during travel in order to reduce the risk of MDR bacterial transmission.
Arbaeen public health concerns: A pilot cross-sectional survey
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Cholera has previously been associated with mass gatherings, such as the outbreak in Senegal in 2005, which was linked to the Grand Magal of Touba [7]. Additionally, studies from the Hajj suggest that such mass gathering events pose a risk for the spread of resistant bacterial infections both locally and globally [8–10]. This is a major concern, especially given the poor awareness of pilgrims on the appropriate use of antibiotics that has been recorded in the Hajj [11].
Arbaeen is an annual religious procession in Iraq with an estimated 17–20 million participants. Public health risks associated with such a mass gathering can be serious at both local and global levels. This is the first quantitative examination of risk factors for, and symptoms of, infectious disease among Arbaeen participants.
A cross-sectional survey was conducted of a convenience sample of 191 Arbaeen participants in 2017. Interviewers administered a structured questionnaire. Questions included food sources, preventive measures used and symptoms of infectious diseases during the procession.
Data were collected for 191 participants (143 males, 58 females). The most prevalent symptoms were respiratory (runny nose: 22.6%, cough: 22.5%). Diarrhoea was reported by 12.6% of participants, with a strong association with high-income country origin and eating (commercial) street food (odds ratios 6.1 and 4.1, respectively, p < 0.05). All symptoms investigated, except breathlessness, were more prevalent in high-income country participants (p < 0.05).
Street food and high-income country origin were independent risk factors for respiratory or gastrointestinal infection symptoms in this sample of Arbaeen participants. However, these results cannot be generalised due to possible selection bias. Further studies are required to inform policy development and health system preparedness to reduce Arbaeen-associated health risks.
Bacterial respiratory carriage in French Hajj pilgrims and the effect of pneumococcal vaccine and other individual preventive measures: A prospective cohort survey
2019, Travel Medicine and Infectious Disease
Citation Excerpt :
On the other hand, our study showed a significantly increased carriage of S. pneumoniae, H. influenzae and K. pneumoniae following participation in Hajj, confirming previous results obtained from cohort studies conducted among French pilgrims [17,18] and from a large cohort study enrolling pilgrims from 13 countries [15]. Such bacterial acquisition is worrying since these pathogens are frequently responsible for Hajj-associated pneumonia [8–10] or may be responsible for acute rhinosinusitis [11]. We demonstrate here that vaccination against IPD with a conjugate vaccine had a significant protective effect against pneumococcal carriage following participation in the Hajj.
Viral respiratory tract infections are known to be common in Hajj pilgrims while the role of bacteria is less studied.
Clinical follow-up, adherence to preventive measures and PCR-based pharyngeal bacterial carriage pre- and post-Hajj, were assessed in a cohort of 119 French Hajj pilgrims.
55% had an indication for pneumococcal vaccination. Occurrence of respiratory symptoms was 76.5%, with cough (70.6%) and sore throat (44.5%) being the most frequent; fever was reported by 38.7% pilgrims and 42.0% took antibiotics. Respiratory symptoms, fever and antibiotic intake were significantly more frequent in pilgrims with indication for vaccination against pneumococcal infection. The prevalence of S. pneumoniae carriage (1.8% pre-, 9.8% post-Hajj), H. influenzae carriage (0.9%, 45.4%) and K. pneumoniae (2.8%, 9.8%) significantly increased post-Hajj. Pilgrims vaccinated with conjugate pneumococcal vaccine were seven time less likely to present S. pneumoniae carriage post-Hajj compared to those not vaccinated (3.2% vs. 18.0%, OR = 0.15; 95% CI [0.03–0.74], p = 0.02).
Pilgrims at risk for pneumococcal disease are more likely to suffer from febrile respiratory symptoms at the Hajj despite being immunized against pneumococcal disease and despite lowered S. pneumoniae carriage and should be targeted for reinforced prevention against respiratory infections.
Knowledge, attitude and practice (KAP) survey regarding antibiotic use among pilgrims attending the 2015 Hajj mass gathering
2019, Travel Medicine and Infectious Disease
Overuse and misuse of antibiotics have been reported in Hajj. However, little is known about Knowledge, Attitude and Practice (KAP) of pilgrims themselves in relation to these agents.
Adult pilgrims from seven countries attending the 2015 Hajj were interviewed using a structured KAP questionnaire.
KAP information was collected from 1476 pilgrims. Misconceptions regarding antibiotics included that they: cure all diseases (24.6%); cure common cold and flu (63.0%); are used to stop fever (47.3%); have no side effects (43.2%). Negative attitudes included prophylactic use (50%), self-medication (43.2%), non-compliance with therapy (63.5%) and storage of left-overs for future use (54.1%). In practice, 87.3% of pilgrims admitted to using non-prescribed antibiotics, only 19.3% use antibiotic as directed by their doctor and 54% do not usually check the expiry date of antibiotics before use. Over 60% brought antibiotics from their home country to KSA and 39.2% acquired non-prescribed antibiotics in Saudi Arabia. KAP scores were higher among the younger age group (≤43 years old) and among those with healthcare-related work or education and increased with increasing levels of education.
Multifaceted and multidisciplinary approaches, both in KSA and in pilgrims' countries of origin, are needed to address antibiotic misuse during Hajj.
Nasal Microbiota and Sensitivity Pattern in Rhinosinusitis
2024, Indian Journal of Otolaryngology and Head and Neck Surgery
Bacterium detected by gram stain and drug sensitivity in Chinese children with acute sinusitis
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Original articleAcute rhinosinusitis during Hajj season 2014: Prevalence of bacterial infection and patterns of antimicrobial susceptibility

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Patient selection

Results

Discussion

Conclusion

Financial disclosures

Conflict of interest

Acknowledgement

Travel Ned Infet Dis

Travel Men Infect Dis

J Infect Public Health

Otolaryngol–Head Neck Surg

Braz J Otorhinolaryngol

Otolaryngol Head Neck Surg

Int J PediatrOtorhinolaryngol

Otolaryngol Head Neck Surg

Otolaryngol Head Neck Surg

Hajj and the risk of influenza

BMJ

Road map of an ear, Nose, and Throat clinic during the 2008 Hajj in Makkah, Saudi Arabia

Saudi Med J

Influenza a common viral infection among Hajj pilgrims: time for routine surveillance and vaccination

J Travel Med

Pattern of admission to hospitals during Muslim pilgrimage (Hajj)

Saudi Med J

European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists

Rhinology

The introduction and validation of a modified Arabic Sino-Nasal outcome test (MA-SNOT)

PAN Arab J Rhinol

Microbiology and antimicrobial susceptibility patterns of commensal flora in the middle nasal meatus

Ann Otol Rhinol Laryngol

Original article
Acute rhinosinusitis during Hajj season 2014: Prevalence of bacterial infection and patterns of antimicrobial susceptibility