Retrospective analysis of Acinetobacter baumannii bacteraemia risk factors, complications, and mortality in a tertiary university hospital in Saudi Arabia
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Introduction. There are many multidrug-resistant isolates of the nosocomial pathogen, Acinetobacter baumannii causing severe healthcare-acquired infections in terminally ill patients with high mortality and morbidity rates. Aim. This study aimed to retrospectively analyse Acinetobacter baumannii bacteraemia (ABB) cases in Saudi Arabia where the information is sparse regarding the prevalence, risk factors, clinical disease, antibiotic regimen, antibiotic susceptibility, treatment outcomes, and mortality associated with this infection. Methods. A retrospective chart review was conducted between January 1st, 2015, and December 31st, 2022, to identify all patients 14 years and above with ABB. Demographic and clinical data, as well as results from laboratory analyses, were collected from patients’ electronic charts. Statistical analyses were performed on the data to identify factors associated with 90-day mortality. Results. Of the 122 ABB cases, 71 (63.4%) died. The factors that were found to be associated with 90-day mortality were the Charlson comorbidity score, Pitt bacteremia score, quick Sequential Organ Failure Assessment (qSOFA) score (p < 0.001 for each), hospital ward (p < 0.02), short duration of antibiotic treatment (p < 0.01), and higher age (p < 0.05). The most common source of infection was Central Line-associated Bloodstream Infection in 52.7%. Also associated with mortality were inappropriate antimicrobial therapy (p < 0.02) and empirical use of colistin (p < 0.05). In many patients, ABB was caused by carbapenem-resistant A. baumannii (CRAB) (69.6%), and 74.4% of those patients died. Conclusion. To prevent ABB-associated mortality, an appropriate regimen and duration of treatment are necessary. Hospitals should also practice proper hygiene to prevent the spread of ABB. CRAB is a growing threat in hospitals in Saudi Arabia especially in the critical care setting and carries a very high risk of mortality.
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All required changes have been made and this manuscript is now suitable for publication.
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Thank you for addressing the majority of the reviewers comments. One reviewer comment remains unresolved. Comment 4 from Reviewer 1; The reviewer asked that you change a statement in line 65 listing carbapenems as a first-line agent for A. baumannii treatment. In your rebuttal you have stated that this doesn't need amending as you are referring to another study. I disagree and having checked the study referenced- the authors do not list carbapenems as a first-line antibiotic in their study either. Please amend this line in your manuscript so that carbapenems are not listed as a first line treatment option. Two other editing issues also need to be resolved; Line 123- you have instructions to "[add specifications]" - please resolve this in the text. Figure 1- your axis are not labelled. Additionally, please consider if this is the …
Thank you for addressing the majority of the reviewers comments. One reviewer comment remains unresolved. Comment 4 from Reviewer 1; The reviewer asked that you change a statement in line 65 listing carbapenems as a first-line agent for A. baumannii treatment. In your rebuttal you have stated that this doesn't need amending as you are referring to another study. I disagree and having checked the study referenced- the authors do not list carbapenems as a first-line antibiotic in their study either. Please amend this line in your manuscript so that carbapenems are not listed as a first line treatment option. Two other editing issues also need to be resolved; Line 123- you have instructions to "[add specifications]" - please resolve this in the text. Figure 1- your axis are not labelled. Additionally, please consider if this is the best way to represent this data- if you need numerical data labels above the bars, is the chart not clear enough and why does it need this information in addition to what should be read from the the axis? Please carefully recheck your manuscript before resubmission.
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Both reviewers have mentioned the lack of connection between your stated aims and the conclusions drawn- please pay close attention to this during your revisions. Please respond to each reviewer comment point by point.
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Comments to Author
Title and Abstract Line 20-21: The abstract should provide a brief background, methods, results, and conclusion. Consider rephrasing to make it more concise and focused. Introduction Line 56-57: Clarify the significance of the pathogen in the hospital setting. Line 70-73: Provide more context on the high mortality rates mentioned by citing specific studies or reports. Methods Line 95-97: Specify the criteria used to identify Acinetobacter-positive blood cultures. Line 104: Provide more details on the ethical review process and how patient confidentiality was maintained. Line 115-124: The process for identifying and testing Acinetobacter isolates could be detailed further to enhance replicability. Line 131-136: Clarify the statistical methods used, especially how the confidence intervals and p-values …
Comments to Author
Title and Abstract Line 20-21: The abstract should provide a brief background, methods, results, and conclusion. Consider rephrasing to make it more concise and focused. Introduction Line 56-57: Clarify the significance of the pathogen in the hospital setting. Line 70-73: Provide more context on the high mortality rates mentioned by citing specific studies or reports. Methods Line 95-97: Specify the criteria used to identify Acinetobacter-positive blood cultures. Line 104: Provide more details on the ethical review process and how patient confidentiality was maintained. Line 115-124: The process for identifying and testing Acinetobacter isolates could be detailed further to enhance replicability. Line 131-136: Clarify the statistical methods used, especially how the confidence intervals and p-values were determined. Results Line 138-139: Include more demographic details to give a fuller picture of the study population. Line 147-149: Explain why only the location variable was significantly associated with mortality. Line 157: Specify the statistical significance of higher age and lower antibiotic duration more clearly. Line 163-164: Provide more details on the clinical signs and symptoms to better understand their relevance. Line 170-173: Explain the significance of the p-values for comorbidities and risk factors. Discussion Line 221-223: Summarize the key findings more clearly and relate them back to the study objectives. Line 228-229: Expand on why the high mortality rates for CRAB are not surprising. Line 238-240: Discuss the implications of the study findings in the context of other similar studies. Line 269-273: Elaborate on the choice of antibiotics used and how this aligns with current treatment guidelines.
Please rate the manuscript for methodological rigour
Satisfactory
Please rate the quality of the presentation and structure of the manuscript
Satisfactory
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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Comments to Author
This Saudi Arabian study adds to the global evidence on antimicrobial susceptibility, clinical features and mortality of patients with Acinetobacter baumannii bacteraemia and strengthens that evidence by its similar findings to those in other countries. This is useful to readers involved in the prevention and management of these infections. As a general comment, the conclusion in both the abstract and the main article do not clearly answer the aims or clearly reflect the data collected and should be rewritten. Specific comments / suggestions as follows: Lines 46-49: The abstract conclusion focuses on CRAB and suggesting new methods of prevention and therapies. The study did not assess CRAB exclusively, nor did it assess prevention measures. While it did assess treatment provided and sensitivities, …
Comments to Author
This Saudi Arabian study adds to the global evidence on antimicrobial susceptibility, clinical features and mortality of patients with Acinetobacter baumannii bacteraemia and strengthens that evidence by its similar findings to those in other countries. This is useful to readers involved in the prevention and management of these infections. As a general comment, the conclusion in both the abstract and the main article do not clearly answer the aims or clearly reflect the data collected and should be rewritten. Specific comments / suggestions as follows: Lines 46-49: The abstract conclusion focuses on CRAB and suggesting new methods of prevention and therapies. The study did not assess CRAB exclusively, nor did it assess prevention measures. While it did assess treatment provided and sensitivities, these were not listed as aims of the study. The conclusion should comment accurately on the findings of the study as pertaining to the aims. Line 50: "authors" implies more than one. In the version I received for review there is only one author listed. Please correct to "author" or list additional authors. Line 66-67; The author includes carbapenems in "first line agents" for treatment. As carbapenem restriction for the purposes of preventing spread of carbapenemases is a worldwide practice, if this is different in Saudi Arabia the author should add some local clarification as to why carbapenems are first line agents and for what infections. Otherwise change to second or third line as appropriate. Line 184: What is meant by "respiratory fluid"? Please clarify if bronchoalveolar lavage, endotracheal aspirate, pleural fluid etc. Line 218: The author refers the reader to Table 5 to view the data pertaining to empiric colistin use. This is in fact represented in Table 4. Line 297; "confirms resistance". Should that read "confers resistance"? Lines 299-302: The author states that antimicrobial resistance is on the rise in Acinetobacter baumannii. This is not determined by or explained by the study as the resistance to certain antibiotics, specifically carbapenems is reflected as a percentage of all isolates in one period and is similar to the resistance rates published elsewhere quoted in the article. Similarly the author states that CRAB is a growing threat in Saudi Arabia. This is true if considered over the 14 years for which the author has other references discussed in the discussion lines 248-255 but those lines of the discussion may need to be rewritten to demonstrate the increased resistance over time such that the author can make the conclusion. Once the scene is set with these two, then I would suggest the author concludes on their own findings of interest based on the aims of the study e.g. mortality and key contributors to round out their paper with what they actually concluded from their own work.
Please rate the manuscript for methodological rigour
Satisfactory
Please rate the quality of the presentation and structure of the manuscript
Poor
To what extent are the conclusions supported by the data?
Partially support
Do you have any concerns of possible image manipulation, plagiarism or any other unethical practices?
No
Is there a potential financial or other conflict of interest between yourself and the author(s)?
No
If this manuscript involves human and/or animal work, have the subjects been treated in an ethical manner and the authors complied with the appropriate guidelines?
Yes
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