Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1.         The manuscript repeatedly highlights regional and global MDRO patterns without clear differentiation. Consider condensing overlapping sections.

2.         While the discussion mentions national and regional trends, it lacks a direct correlation to actionable recommendations tailored to Oman’s healthcare system.

3.         The discussion extensively attributes changes in MDRO prevalence to COVID-19 but does not provide sufficient molecular or clinical data to substantiate these claims.

4.         The manuscript could benefit from deeper analysis of the specific factors driving MDRO trends in Oman, such as local antibiotic prescribing habits or infection control policies.

5.         No detailed information on the genetic or molecular mechanisms of resistance in MDROs is provided, which could be critical for understanding and addressing the issue.

6.         Comparisons to other regions, such as Europe or the USA, are too broad and lack contextual relevance to Oman’s healthcare infrastructure.

7.         The findings are from a single hospital, which limits generalizability. Emphasize the need for broader studies involving multiple centers.

8.         The manuscript mentions inconsistencies in sample nomenclature. This issue could undermine the reliability of conclusions drawn from the data.

9.         While some statistical tests are mentioned, the manuscript could provide more comprehensive statistical analyses, such as multivariate analyses or trend modeling, to strengthen conclusions.

10.       The significant association between COVID-19 and VRE cases is mentioned but lacks detailed analysis to support causal inference.

11.       Recommendations such as "genomic epidemiology" or "clinical outcome studies" are generic. Provide more specific goals or frameworks for these future studies.

12.       The manuscript calls for national infection control measures but does not outline practical steps or strategies for implementation.

13.       There is limited discussion on how to effectively implement or improve antibiotic stewardship programs in Oman.

14.       The manuscript briefly mentions diagnostic limitations but does not explore their impact on MDRO detection and management in depth.

15.       Insufficient Focus on Candida auris and Rare Pathogens, While these are mentioned, they are not discussed in detail, missing an opportunity to highlight the importance of fungal infections and uncommon pathogens.

16.       The manuscript uses similar phrasing across sections, which can make the content feel repetitive and less engaging.

17.       Some sentences are excessively long and complex, which may confuse readers. Simplify sentence structure for better readability.

18.       Consider adding more graphs, charts, or tables to visually represent key findings, such as trends in MDRO prevalence or COVID-19 associations.

19.       The manuscript does not discuss how socioeconomic or cultural factors in Oman might influence MDRO trends, which could add depth to the discussion.

Author Response

Reviewer 1

Dear Esteemed Reviewer,

We sincerely appreciate the time and effort you invested in providing such a thorough and insightful review of our manuscript (1-19). Your valuable comments have been instrumental in guiding our revisions and strengthening the overall quality of our work.

We've addressed your comments by:

• Rewriting the discussion to provide clearer differentiation between regional and global MDRO patterns and emphasizing the direct correlation to actionable recommendations for Oman's healthcare system.
• Including additional graphs, summary tables, and shifting redundant tables to the supplementary file to improve clarity and visual representation of key findings.

Providing more specific details about the current AMR and ASP systems in Oman, acknowledging limitations, and emphasizing the pressing need for improvement at the governmental level. We understand this requires infrastructure changes and increased focus on infectious diseases and AMR in Oman's research priorities and funding cycles. One of the major issues is that AMR and infectious diseases ae not even listed in the priority of research in Oman and it is not there in the funding cycles funded by MoH and MoHERI. These major issues limit research advancement in the field.  References: https://mohcsr.gov.om/wp-content/uploads/2020/12/HRP-Oman_2ndEd_National.pdf

https://www.mohcsr.gov.om/moheri/srp-2023/

We have long advocated for the update of the second edition of Health Research Priorities published by the Centre of Studies and Research (CSR) in Oman to incorporate a dedicated section for AMR. We completely agree that this is a crucial step. As a member of the CSR, I have personally witnessed the need for this inclusion. Furthermore, I have consistently advocated for the prioritization of infectious diseases and AMR within Oman's strategic research funding cycles during various meetings and conferences. Unfortunately, these critical areas are currently underrepresented in research funding priorities.

We believe that this manuscript, along with the valuable lessons learned from the COVID-19 pandemic, will serve as a catalyst for change, prompting the government to recognize the urgent need to address the growing threat of infectious diseases and AMR.

We acknowledge the limitations of our study, particularly the cross-sectional design. We are actively working on obtaining funding for future cohort studies and establishing a protected registry database. This manuscript serves as a call to action for these improvements, aligning with the recommendations we have been advocating for within the CSR.

We believe these revisions effectively address your comments and significantly strengthen the manuscript.

Sincerely,

Mohammed Al-Shhoumi

Corresponding Author

 

 

 

 

1. The manuscript repeatedly highlights regional and global MDRO patterns without clear differentiation. Consider condensing overlapping sections.

Corrected.

2. While the discussion mentions national and regional trends, it lacks a direct correlation to actionable recommendations tailored to Oman’s healthcare system.

Corrected.

 

3. The discussion extensively attributes changes in MDRO prevalence to COVID-19 but does not provide sufficient molecular or clinical data to substantiate these claims. Corrected.

 

4. The manuscript could benefit from deeper analysis of the specific factors driving MDRO trends in Oman, such as local antibiotic prescribing habits or infection control policies. Corrected.

 

5. No detailed information on the genetic or molecular mechanisms of resistance in MDROs is provided, which could be critical for understanding and addressing the issue. Corrected.

 

6. Comparisons to other regions, such as Europe or the USA, are too broad and lack contextual relevance to Oman’s healthcare infrastructure. Corrected.

 

7. The findings are from a single hospital, which limits generalizability. Emphasize the need for broader studies involving multiple centers. Corrected.

 

8. The manuscript mentions inconsistencies in sample nomenclature. This issue could undermine the reliability of conclusions drawn from the data. Corrected.

 

9. While some statistical tests are mentioned, the manuscript could provide more comprehensive statistical analyses, such as multivariate analyses or trend modeling, to strengthen conclusions. Corrected.

 

10. The significant association between COVID-19 and VRE cases is mentioned but lacks detailed analysis to support causal inference. Corrected.

 

11. Recommendations such as "genomic epidemiology" or "clinical outcome studies" are generic. Provide more specific goals or frameworks for these future studies. Corrected.

 

12. The manuscript calls for national infection control measures but does not outline practical steps or strategies for implementation. Corrected.

 

13. There is limited discussion on how to effectively implement or improve antibiotic stewardship programs in Oman. Corrected.

 

14. The manuscript briefly mentions diagnostic limitations but does not explore their impact on MDRO detection and management in depth. Corrected.

 

15. Insufficient Focus on Candida auris and Rare Pathogens, While these are mentioned, they are not discussed in detail, missing an opportunity to highlight the importance of fungal infections and uncommon pathogens. Corrected.

 

16. The manuscript uses similar phrasing across sections, which can make the content feel repetitive and less engaging. Corrected.

 

17. Some sentences are excessively long and complex, which may confuse readers. Simplify sentence structure for better readability. Corrected.

 

18. Consider adding more graphs, charts, or tables to visually represent key findings, such as trends in MDRO prevalence or COVID-19 associations. Corrected.

 

19. The manuscript does not discuss how socioeconomic or cultural factors in Oman might influence MDRO trends, which could add depth to the discussion. Corrected.

 

 

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript is acceptable after major revisions. Below are my comments:

1. The formatting should be consistent, as noted in lines 49, 165-168, and 216.

2. From my perspective, the authors have provided too many tables, which can easily distract from the main focus. I suggest keeping only the summary tables in the main text and placing the remaining tables in the supplementary information.

3. Have the authors collected any data post-2022?

4. There are few references to recently published articles, especially after 2023; almost none are cited. I recommend that the authors include more recently published articles to enhance the credibility of this study.

5. The format of the references needs to be standardized.

6. This paper seems more like a summary of existing cases. Could the authors elaborate on the innovative aspects of this paper?

Author Response

Reviewer 2

Dear Esteemed Reviewer,

We sincerely appreciate the time and effort you invested in providing such a thorough and insightful review of our manuscript (1-6). Your valuable comments have been instrumental in guiding our revisions and strengthening the overall quality of our work.

We've addressed your comments by:

• Rewriting the discussion to provide clearer differentiation between regional and global MDRO patterns and emphasizing the direct correlation to actionable recommendations for Oman's healthcare system.
• Including additional graphs, summary tables, and shifting redundant tables to the supplementary file to improve clarity and visual representation of key findings.

Providing more specific details about the current AMR and ASP systems in Oman, acknowledging limitations, and emphasizing the pressing need for improvement at the governmental level. We understand this requires infrastructure changes and increased focus on infectious diseases and AMR in Oman's research priorities and funding cycles. One of the major issues is that AMR and infectious diseases ae not even listed in the priority of research in Oman and it is not there in the funding cycles funded by MoH and MoHERI. These major issues limit research advancement in the field.  References: https://mohcsr.gov.om/wp-content/uploads/2020/12/HRP-Oman_2ndEd_National.pdf

https://www.mohcsr.gov.om/moheri/srp-2023/

We have long advocated for the update of the second edition of Health Research Priorities published by the Centre of Studies and Research (CSR) in Oman to incorporate a dedicated section for AMR. We completely agree that this is a crucial step. As a member of the CSR, I have personally witnessed the need for this inclusion. Furthermore, I have consistently advocated for the prioritization of infectious diseases and AMR within Oman's strategic research funding cycles during various meetings and conferences. Unfortunately, these critical areas are currently underrepresented in research funding priorities.

We believe that this manuscript, along with the valuable lessons learned from the COVID-19 pandemic, will serve as a catalyst for change, prompting the government to recognize the urgent need to address the growing threat of infectious diseases and AMR.

We acknowledge the limitations of our study, particularly the cross-sectional design. We are actively working on obtaining funding for future cohort studies and establishing a protected registry database. This manuscript serves as a call to action for these improvements, aligning with the recommendations we have been advocating for within the CSR.

We've addressed your additional comments as follows:

Formatting Consistency (Lines 49, 165-168, 216)

We have carefully reviewed the manuscript and ensured consistent formatting throughout.

Tables (Summary Tables in Main Text, Others in Supplementary Material)

We have incorporated your suggestion regarding the tables. Only the essential summary tables are now included in the main text, while the remaining tables have been moved to the supplementary information for better readability and focus.

Data Post-2022

You are correct in pointing out the lack of post-2022 data. Unfortunately, we were unable to collect data beyond 2022 due to limitations in funding and resource availability. We acknowledge this limitation and will strive to include more recent data in future studies.

References (Recent Publications, Standardized Format)

We have comprehensively reviewed our references and incorporated more recent articles, particularly those published after 2023. This will enhance the credibility and timeliness of our study. Additionally, we have ensured that all references adhere to a standardized format.

Innovative Aspects

We appreciate your inquiry regarding the manuscript's innovative aspects. Unlike previous studies that focused on specific MDRO strains, our research provides a broader overview of the overall MDRO burden by collecting data for all clinical samples. This comprehensive approach offers valuable insights into the scope of the problem in Oman.

Furthermore, we highlight the unique challenges posed by Oman's infrastructure limitations, particularly the lack of emphasis on infectious diseases and AMR in research funding cycles. The current focus on cardiovascular disorders and health leadership, while important, overshadows the pressing need to address AMR. We emphasize the absence of infectious diseases and AMR as a designated research priority within Oman's national research priorities document.

Despite these limitations, we believe our study offers a valuable call to action. It sheds light on the critical issue of AMR in Oman and advocates for dringend improvements in research focus and funding allocation.

We believe these revisions effectively address your comments and significantly strengthen the manuscript.

Sincerely,

Mohammed Al-Shhoumi Corresponding Author

 

 

 

 

 

 

 

 

1. The formatting should be consistent, as noted in lines 49, 165-168, and 216. Corrected
2. From my perspective, the authors have provided too many tables, which can easily distract from the main focus. I suggest keeping only the summary tables in the main text and placing the remaining tables in the supplementary information. Corrected
3. Have the authors collected any data post-2022? No
4. There are few references to recently published articles, especially after 2023; almost none are cited. I recommend that the authors include more recently published articles to enhance the credibility of this study. Corrected
5. The format of the references needs to be standardized. Corrected
6. This paper seems more like a summary of existing cases. Could the authors elaborate on the innovative aspects of this paper? Corrected

 

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

The researchers aimed to investigate changes in the epidemiology of multidrug-resistant bacteria over 6 years in a hospital in Oman. Although this is an interesting study from a region with limited epidemiological data, the confusion in presenting the results makes the article very difficult to follow. The fact that no statistical method was used to make comparisons between years reduces the scientific value of the comparisons. Other limitations of the article include the lack of information on the infection prevention and control practices and antibiotic use policies of the hospital where the study was conducted and the lack of differentiation between community-acquired and hospital-acquired isolates. 

Author Response

Reviewer 3

Dear Esteemed Reviewer,

We sincerely appreciate the time and effort you invested in providing such a thorough and insightful review of our manuscript. Your valuable comments have been instrumental in guiding our revisions and strengthening the overall quality of our work.

We've addressed your comments by:

• Rewriting the discussion to provide clearer differentiation between regional and global MDRO patterns and emphasizing the direct correlation to actionable recommendations for Oman's healthcare system.
• Including additional graphs, summary tables, and shifting redundant tables to the supplementary file to improve clarity and visual representation of key findings.

Providing more specific details about the current AMR and ASP systems in Oman, acknowledging limitations, and emphasizing the pressing need for improvement at the governmental level. We understand this requires infrastructure changes and increased focus on infectious diseases and AMR in Oman's research priorities and funding cycles. One of the major issues is that AMR and infectious diseases ae not even listed in the priority of research in Oman and it is not there in the funding cycles funded by MoH and MoHERI. These major issues limit research advancement in the field.  References: https://mohcsr.gov.om/wp-content/uploads/2020/12/HRP-Oman_2ndEd_National.pdf

https://www.mohcsr.gov.om/moheri/srp-2023/

We have long advocated for the update of the second edition of Health Research Priorities published by the Centre of Studies and Research (CSR) in Oman to incorporate a dedicated section for AMR. We completely agree that this is a crucial step. As a member of the CSR, I have personally witnessed the need for this inclusion. Furthermore, I have consistently advocated for the prioritization of infectious diseases and AMR within Oman's strategic research funding cycles during various meetings and conferences. Unfortunately, these critical areas are currently underrepresented in research funding priorities.

We believe that this manuscript, along with the valuable lessons learned from the COVID-19 pandemic, will serve as a catalyst for change, prompting the government to recognize the urgent need to address the growing threat of infectious diseases and AMR.

We acknowledge the limitations of our study, particularly the cross-sectional design. We are actively working on obtaining funding for future cohort studies and establishing a protected registry database. This manuscript serves as a call to action for these improvements, aligning with the recommendations we have been advocating for within the CSR.

We appreciate your specific feedback regarding the limitations of our study design and data presentation.

• Cross-Sectional Design and Statistical Methods: You are absolutely right that our cross-sectional design is limited in its ability to establish causality. Our primary aim was to assess the current burden of MDROs in Oman's healthcare system, and a cross-sectional study design is well-suited to this purpose. Future research will incorporate longitudinal studies to explore trends and risk factors associated with MDROs. We will also strive to employ more robust statistical methods in future studies to make stronger comparisons between different time periods.
• Infection Prevention and Control Practices and Antibiotic Use Policies: We acknowledge that our manuscript did not comprehensively address infection prevention and control practices or antibiotic use policies within the hospital. These are important factors that can influence MDRO prevalence. The updated version includes that as it was corrected upon your insightful guidance.
• Community- vs. Hospital-Acquired Isolates: The differentiation between community-acquired and hospital-acquired MDRO isolates is an important distinction that we were unable to address in this study. This is yet another area we will focus on in future research endeavors.

We believe that this initial cross-sectional study has effectively served its purpose of highlighting the concerning prevalence of MDROs in Oman's healthcare system. The limitations you have identified underscore the need for further investigation, and we are committed to addressing these issues in future research projects. We are confident that our findings will serve as a springboard for further inquiry and, more importantly, will bring about the necessary changes to Oman's healthcare infrastructure, including dringend improvements in research funding allocation and a revision of the national research priorities to include infectious diseases and AMR.

We believe these revisions effectively address your comments and significantly strengthen the manuscript.

Sincerely,

Mohammed Al-Shhoumi

Corresponding Author

 

 

 

 

 

 

 

 

 

 

 

 

Reviewer 3

The researchers aimed to investigate changes in the epidemiology of multidrug-resistant bacteria over 6 years in a hospital in Oman. Although this is an interesting study from a region with limited epidemiological data, the confusion in presenting the results makes the article very difficult to follow. The fact that no statistical method was used to make comparisons between years reduces the scientific value of the comparisons. Other limitations of the article include the lack of information on the infection prevention and control practices and antibiotic use policies of the hospital where the study was conducted and the lack of differentiation between community-acquired and hospital-acquired isolates. 

 

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Authors successfully answered all the queries. Congratulations for the effort made by them during revision. I accept this manuscript in current form. 

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript can be acceptable.

Reviewer 3 Report

Comments and Suggestions for Authors

The authors revised the paper according to the reviewer's recommendations where possible.