Antimicrobial resistance is closely linked to antimicrobial use and is a growing concern worldwide. Antimicrobial resistance increases healthcare costs substantially in many countries, including Lebanon. National data from Lebanon have, in the most part, been limited to a few academic hospitals. The Lebanese Society of Infectious Diseases conducted a retrospective study to better describe the antimicrobial susceptibility patterns of bacterial isolates in Lebanon. Data were based on records retrieved from the bacteriology laboratories of 16 different Lebanese hospitals between January 2011 and December 2013. The susceptibility results of a total 20684 Gram-positive and 55594 Gram-negative bacteria were analyzed. The prevalence rate of methicillin-resistant Staphylococcus aureus was 27.6% and of vancomycin-resistant Enterococcus spp was 1%. Streptococcus pneumoniae had susceptibilities of 46% to oxacillin, 63% to erythromycin, and 98% to levofloxacin. Streptococcus pyogenes had susceptibilities of 94% to erythromycin and 95% to clindamycin. The mean ampicillin susceptibility of Haemophilus influenzae, Salmonella spp, and Shigella spp isolates was 79%, 81.3%, and 62.2%, respectively. The extended-spectrum beta-lactamase production rate for Escherichia coli was 32.3% and for Klebsiella spp was 29.2%. Acinetobacter spp showed high resistance to most antimicrobials, with low resistance to colistin (17.1%). Pseudomonas spp susceptibilities to piperacillin-tazobactam and imipenem were lower than 80% (79.7% and 72.8%, respectively). This study provides population-specific data that are valuable in guiding antimicrobial use in Lebanon and neighbouring countries and will help in the establishment of a surveillance system for antimicrobial resistance following the implementation of a nationwide standardization of laboratory methods and data entry.

Staphylococcus aureus is an important human pathogen and is a growing public health concern. In this study, 130 S. aureus, 93 methicillin-resistant S. aureus (MRSA) and 37 methicillin-sensitive S. aureus (MSSA), clinical isolates recovered from Lebanon were typed by protein A gene (spa) sequencing and multi-locus sequence typing (MLST). Forty-eight different spa types were identified and clustered into 30 different groups. MLST revealed 10 sequence types (STs) among the isolates. There were eight major MRSA clones defined as isolates with the same ST and the same SCCmec type. The majority of the PVL-positive isolates (53%) were ST80-MRSA-IVc. Systematic surveillance of both hospital and community isolates in Lebanon together with measures designed to limit the spread are required.

Aim:  To study the prevalence and molecular basis of antimicrobial resistance in UPEC. Methods and Results:  PCR was used to detect the presence of the Class I integron variable region (VR). The VR amplicons were then characterized by partial sequencing and restriction digestion with AluI. VR negative isolates showed more antibiotic susceptibility than VR positive isolates. 30% of the isolates were positive for the VR and carried the genes dfrA7, dfrA17‐aadA5, dfrA1‐aadA1, dfrA12‐orf5‐aadA2 and blaOXA‐30‐aadA1. Five restriction patterns were detected and isolates with the same VR amplicon size had the same restriction pattern. Conclusions:  Our data demonstrated that Class I integrons are widely disseminated in Lebanon and showed their importance for the occurrence and transmission of multidrug resistance. Significance and Impact of the Study:  These findings will facilitate greater understanding of the factors that contribute to the presence and transfer of integron‐associated antibiotic resistance genes in UPEC.

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Sphingomonads comprise a physiologically versatile group many of which appear to be adapted to oligotrophic environments, but several also had features in their genomes indicative of host associations. In this study, the extent variability of the 16S–23S rDNA intergenic spacer (ITS) sequences of 14 ATCC reference sphingomonad strains and 23 isolates recovered from drinking water was investigated through PCR amplification and sequencing. Sequencing analysis of the 16S–23S rRNA gene ITS region revealed that the ITS sizes for all studied isolates varied between 415 and 849 bp, while their G+C content was 42.2–57.9 mol%. Five distinct ITS types were identified: ITSnone (without tRNA genes), ITSAla(TGC), ITSAla(TGC)+Ile(GAT), ITSIle(GAT)+Ala(TGC), and ITS Ile(GAT)+Pseudo. All of the identified tRNAAla(TGC) molecules consisted of 73 bases, and all of the tRNAIle(GAT) molecules consisted of 74 bases. We also detected striking variability in the size of the ITS region among the various examined isolates. Highest variability was detected within the ITS-2. The importance of this study is that this is the first comparison of the 16S–23S rDNA ITS sequence similarities and tRNA genes from sphingomonads. Collectively the data obtained in this study revealed the heterogeneity and extent of variability within the ITS region compared to the 16S rRNA gene within closely related isolates. Sequence and length polymorphisms within the ITS region along with the ITS types (tRNA-containing or lacking and the type of tRNA) and ITS-2 size and sequence similarities allowed us to overcome the limitation we previously encountered in resolving closely related isolates based on the 16S rRNA gene sequence.

Spitzoid neoplasms pose diagnostic difficulties because their morphology is not consistently predictive of their biological potential. Recent advances in the molecular characterization of these tumours provides a framework by which they can now begin to be categorized. In particular, spitzoid lesions with ALK rearrangement have been specifically associated with a characteristic plexiform growth pattern of intersecting fascicles of amelanotic spindled melanocytes. We report the case of an 87-year-old man with a 3-cm nodule on his mid-upper back comprised of an intradermal proliferation of fusiform amelanotic melanocytes arranged in intersecting fascicles with occasional peritumoral clefts. Immunohistochemical studies demonstrated diffuse, strong expression of SOX10 and S100 by the tumour cells and diffuse, weak-to-moderate cytoplasmic positivity for anaplastic lymphoma kinase (ALK), suggestive of ALK rearrangement. Fluorescence in situ hybridization revealed no ALK rearrangements but instead revealed at least three intact ALK signals in 36% of the tumour cells, confirming ALK copy number gain. To our knowledge, this is the first reported case of a plexiform spitzoid neoplasm exhibiting ALK copy number gain instead of ALK rearrangement. This case suggests that ALK copy number gain is a novel mechanism of ALK activation but with the same characteristic histopathological growth pattern seen among ALK-rearranged spitzoid neoplasms.

Introduction: Approximately 80% of diabetes-related lower extremity amputations are preceded by a foot ulcer. Global studies on the epidemiology of diabetic foot ulcer (DFU) infections and guidelines detailing the most common pathogens and their respective antimicrobial susceptibilities are available. While Gram-positive cocci, mainly Staphylococcus species (spp.), were the most common organisms cultured from DFU in the United States, the Gram-negative Pseudomonas spp. were found to be the most common in some Middle Eastern countries. In Lebanon, however, such studies remain scarce. This study, conducted in Lebanon, investigated the most common organisms in DFU infections and their antimicrobial profiles. Methodology: We collected data from all documented diabetic foot infections between January 2015 and March 2016, 128 participants total, from 5 different hospitals in various regions of Lebanon. Results: Among all isolates, Enterobacteriaceae (42%), Pseudomonas spp. (18.6%) and methicillin-sensitive Staphylococcus aureus (MSSA) (15.3%) were the most frequent bacteria. In addition, 72% of Pseudomonas spp. were susceptible to ciprofloxacin and 63.6% of Enterobacteriaceae were susceptible to either amoxicillin/clavulanate or ciprofloxacin, 91% were susceptible to piperacillin/tazobactam. Methicillin-resistant Staphylococcus aureus (MRSA) was only found in hospitalized patients or those who received prior antibiotics. Polymicrobial infections were documented in only 38% of patients. Conclusion: In Lebanon, the most appropriate empirical oral outpatient treatment would be a combination of amoxicillin/clavulanate and ciprofloxacin. As for admitted patients who have failed the oral regimen, piperacillin/tazobactam would then be the treatment of choice.

Epithelioid cells with foamy cytoplasm (histiocytoid features) are typical histopathologic findings among benign and malignant histiocytic neoplasms such as xanthoma and atypical fibroxanthoma. However, these changes are unusual in melanoma, which is typically composed of nested and variably pigmented atypical epithelioid cells. Here, we report a patient with metastatic melanoma in lymph nodes presenting with prominent balloon cell/histiocytoid features expressing melanocytic markers, after treatment with nivolumab. This report suggests that the spectrum of neoplasms with histiocytoid features should be expanded to include melanoma, a pattern that, to the best of our knowledge, is uncommon, especially in the setting of post-neoadjuvant therapy.