1. Copyright © Medical Technology Department Vancomycin Resistant Enterococci (VRE) among Non–Hospitalized Individuals in Gaza City, Palestine Rasha R. Rashed (B. Sc Medical Technology) Baha' Sh. Mosabbih (B. Sc Medical Technology) Dr. Abdelraouf A. Elmanama (Ph. D microbiology)

2. Copyright © Medical Technology Department, Islamic University-Gaza Introduction Enterococci are gram-positive cocci which often occur in pairs (diplococci) Two species are common commensal organisms in the intestines of humans: E. faecalis and E. faecium Enterococci occur almost everywhere, including soil, food, water, plants, animals, birds, and insects they inhabit in humans and other animal's gastrointestinal tract and the female genital tract

3. Copyright © Medical Technology Department, Islamic University-Gaza Intro (cont.) Enterococci are amongst the most antibiotic resistant bacteria isolated from humans. Minor infections can usually be treated by antibiotics such as penicillins, macrolides or tetracyclines, However, only penicillins, or teicoplanin and vancomycin are reliably effective against serious enterococcal infections such as endocarditis or meningitis. Serious infections often need prolonged treatment, usually with several antibiotics being given together by injection.

4. Copyright © Medical Technology Department, Islamic University-Gaza Intro. (cont.) Enterococcus spp. is now the third most common pathogen among hospitalized patients, accounting for nearly 12% of nosocomial infections in 1986 the first vancomycin-resistant enterococcus (VRE) was found in France and a year later the first strain was isolated in the UK. Infection with vancomycin-resistant enterococci (VRE) is a growing problem in health care systems. The Centers for Disease Control and Prevention (CDC) reported that 28.5% of enterococcal isolates from patients in intensive care units (ICUs) from January through December 2003 in the United States (NNIS System) were vancomycin-resistant, with an increase of 12% comparing with 1998 through 2002.1

5. Copyright © Medical Technology Department, Islamic University-Gaza Objectives This study is considered as the first study in Gaza strip to investigate the occurrence of VRE among non– hospitalized individuals. We also attempted to assess the public awareness on antibiotic resistance issue and to examine the possible risk factors of acquiring VRE.

6. Copyright © Medical Technology Department, Islamic University-Gaza Materials & Methods

7. Copyright © Medical Technology Department, Islamic University-Gaza Test subjects One hundred, randomly selected healthy subjected (36 females and 64 males) were interviewed and either a stool or rectal swab samples were collected. They were asked to fill out a brief questionnaire and submit a rectal swab, which was either performed by the participants themselves or by one of the investigators. The questionnaire consisted of both open and close ended questions dealing with personal, socioeconomic data, and attitude toward diagnosis and treatment of illness with antibiotics. The study started Jan 15- 1 and lasted to June 6, 2006.

8. Copyright © Medical Technology Department, Islamic University-Gaza Microbiological examination Rectal swabs or 1 g of stool specimen were placed in tubes containing 5 ml of Brain Heart Infusion Both (BHIB) and transported to the laboratory. Subcultures were made onto the surface of freshly prepared Slanetz & Bartley Agar (oxoid) and Bile Esculine Agar (HiMedia) with no antibiotics. Plates were incubated at 37 oC for 48-72 hours. Colonies growing on agar with morphologically resembling Enterococci were primarily identified by Gram staining, catalse test and by growth in 6.5% NaCl broth. Species identification was performed with the API 20 STREP system (bioMe´rieux, Marcy l’Etoile, France).

9. Copyright © Medical Technology Department, Islamic University-Gaza Susceptibility testing Resistance to vancomycin was screened by the modified Kirby-Bauer disk diffusion assay. An inoculum with a turbidity equivalent to that of a no. 1 McFarland standard and Mueller-Hinton agar were used. Vancomycin disks (30 µg) were placed on the surface of the plate. The plates were read after incubation at 37°C for 24 h.

10. Copyright © Medical Technology Department, Islamic University-Gaza Data analysis Data obtained from microbiological investigation & from the questionnaire survey were uploaded to (spss version 11) software and analyzed using cross tabulating & chi square test.

11. Copyright © Medical Technology Department, Islamic University-Gaza Results Distribution of Enterococcus positive stool culture according to age and sex

12. Copyright © Medical Technology Department, Islamic University-Gaza Distribution of VRE according to sex

13. Copyright © Medical Technology Department, Islamic University-Gaza Distribution of Enterococcus positive stool culture according to age

14. Copyright © Medical Technology Department, Islamic University-Gaza Distribution of VRE according to age

15. Copyright © Medical Technology Department, Islamic University-Gaza Public awareness Age and having info about Antibiotic resistance

16. Copyright © Medical Technology Department, Islamic University-Gaza Gender and having info about Antibiotic resistance