Source Tracing of Leishmania donovani in Emerging Foci of Visceral Leishmaniasis, Western Nepal.

We sequenced Leishmania donovani genomes in blood samples collected in emerging foci of visceral leishmaniasis in western Nepal. We detected lineages very different from the preelimination main parasite population, including a new lineage and a rare one previously reported in eastern Nepal. Our findings underscore the need for genomic surveillance.

Detection of blaNDM-1,mcr-1 and MexB in multidrug resistant Pseudomonas aeruginosa isolated from clinical specimens in a tertiary care hospital of Nepal.

INTRODUCTION: Pseudomonas aeruginosa is an opportunistic pathogen, which causes healthcare-associated infections in immunosuppressed patients. They exhibit resistance to multiple classes of antibiotics via various mechanisms such as the over-expression of efflux pumps, decreased production of the outer membrane protein (D2 porin), over-expression of the chromosomally encoded AmpC cephalosporinase, modification of drugs, and mutation(s) at the target site of the drug. The bacteria also develop antibiotic resistance through the acquisition of resistance genes carried on mobile genetic elements. Limited data on phenotypic as well as genotypic characterization of MDR P. aeruginosa in Nepal infers the needs for this study. This study was carried out to determine the prevalence rate of metallo-ß-lactamase (MBL-producer) as well as colistin resistant multidrug resistant (MDR) P. aeruginosa in Nepal and also to detect MBL, colistin resistance, and efflux pump encoding genes i.e. blaNDM-1, mcr-1 and MexB respectively in MDR P. aeruginosa isolated from clinical samples. METHODS/METHODOLOGY: A total of 36 clinical isolates of P. aeruginosa were collected. All bacterial isolates were phenotypically screened for antibiotic susceptibility using Kirby Bauer Disc Diffusion method. All the multidrug resistant P. aeruginosa were phenotypically screened for MBL producer by Imipenem-EDTA combined disc diffusion test (CDDT). Similarly, MIC value for colistin was also determined by broth microdilution method. Genes encoding carbapenemase (blaNDM-1), colistin resistant (mcr-1) and efflux pump activity (MexB) were assayed by PCR. RESULTS: Among 36 P. aeruginosa, 50% were found to be MDR among which 66.7% were found to be MBL producer and 11.2% were found to be colistin resistant. Among MDR P. aeruginosa, 16.7%, 11.2% and 94.4% were found to be harbouring blaNDM-1, mcr-1 and MexB genes respectively. CONCLUSION: In our study, carbapenemase production (encoded by blaNDM-1), colistin resistant enzyme production (encoded by mcr-1), and expression of efflux pump (encoded by MexB) are found to be one of the major causes of antibiotic resistance in P. aeruginosa. Therefore, periodic phenotypic as well as genotypic study in Nepal on P. aeruginosa would provide the scenario of resistance pattern or mechanisms in P. aeruginosa. Furthermore, new policies or rules can be implemented in order to control the P. aeruginosa infections.

Molecular detection of plasmid mediated blaTEM, blaCTX-M,and blaSHV genes in Extended Spectrum ß-Lactamase (ESBL) Escherichia coli from clinical samples.

BACKGROUND: Extended spectrum ß-lactamases (ESBLs) are a group of beta-lactamase enzymes that confer resistance to the oxyimino-cephalosporins and monobactams. The emergence of ESBL - producing genes possesses a serious threat for treating infections since it is associated with multi-drug resistance. This study was focused to identify the ESBLs producing genes from Escherichia coli isolates from clinical samples from a referral-level tertiary care hospital in Lalitpur. METHODS: This was a cross-sectional study conducted from September 2018 to April 2020 at the Microbiology Laboratory of Nepal Mediciti Hospital. Clinical samples were processed, and culture isolates were identified and characterized following standard microbiological techniques. An antibiotic susceptibility test was performed by a modified Kirby-Bauer disc diffusion method as recommended by Clinical and Laboratory Standard Institute guidelines.Extended -spectrum beta-lactamases were phenotypically confirmed by the combined disc method. The ESBL-producing genes blaTEM, blaCTX-M and blaSHV were confirmed by PCR. RESULTS: Of the 1449 total E. coli isolates, 22.29% (323/1449) isolates were multi-drug resistant (MDR). Among the total MDR E. coli isolates, 66.56% (215/323) were ESBL producers. The maximum number of ESBL E. coli was isolated from urine 90.23% (194) followed by sputum 5.58% (12), swab 2.32% (5), pus 0.93% (2), and blood 0.93% (2). The antibiotic susceptibility pattern of ESBL E. coli producers showed the highest sensitivity toward tigecycline (100%) followed by polymyxin b, colistin and meropenem. Out of 215 phenotypically confirmed ESBL E. coli, only 86.51% (186) isolates were found to be positive by PCR for either blaTEM or blaCTX-M genes. Among the ESBL genotypes, the most common were blaTEM 63.4% (118) followed by blaCTX-M 36.6% (68). CONCLUSION: The emergence of MDR and ESBL - producing E. coli isolates with high antibiotic - resistant rates to commonly used antibiotics and increased predominance of major gene types blaTEM is a serious concern to the clinicians and microbiologists. Periodic monitoring of antibiotic susceptibility and associated genes would help guide the rationale use of antibiotics for treating the predominant pathogen E. coli in the hospitals and healthcare facilities of the communities.

Cryptococcal meningitis in people living with human immunodeficiency virus in Nepal: Perspectives from resource limited setting.

Early diagnosis of cryptococcal meningitis among people living with HIV (PLHIV) is crucial for its therapeutic success. The objective of this study was to diagnose cryptococcal meningitis in PLHIV cases using the available laboratory techniques for its confirmation in resource limited setting. This cross-sectional prospective study was conducted among 72 PLHIV with clinical suspicion of meningitis. Each cerebrospinal fluid (CSF) sample received at the National Public Health Laboratory, Kathmandu was processed for India ink staining, cryptococcal antigen lateral flow assay, and fungal culture following standard protocols. The laboratory-confirmed cryptococcal meningitis cases were between 24 and 69 years of age (median age 39 years) with 87.5% (12/14) of cases being male. Cryptococcus was detected in 22.22% (16/72) by any of the three tests, 19.44% (14/72) by cryptococcal antigen lateral flow assay, 16.66% (12/72) by India ink staining, and 8.33% (6/72) by culture. High percentage of cryptococcal meningitis among PLHIV warrants early microbiological diagnosis for better case management. Cryptococcal antigen detection immunoassay should be the priority test for laboratory diagnosis of cryptococcal meningitis in PLHIV. Alternatively, very simple and economic India ink staining of CSF specimens could be used in resource limited settings.

Burden of human metapneumovirus infections among children with acute respiratory tract infections attending a Tertiary Care Hospital, Kathmandu.

BACKGROUND: Acute respiratory infections (ARIs) are one of the most common causes of mortality and morbidity worldwide. Every year millions of children suffer from viral respiratory tract infections (RTIs) ranging from mild to severe illnesses. Human Metapneumovirus (HMPV) is among the most frequent viruses responsible for RTIs. However, HMPV infections and their severity among children have not been explored yet in Nepal. PURPOSE: Therefore, the study was focused on HMPV infections and other potential viral etiologies or co-infections using multiplex PCR among children attending Kanti Children's Hospital and assessed the clinical characteristics of the infections as well as found the co-infections. A hospital-based cross-sectional study was designed and a convenience sampling method was used to enroll children of less than 15 years with flu-like symptoms from both outpatients and inpatients departments over three months of the study period. RESULTS: HMPV infection (13.3%) was the most predominant infection among the different viral infections in children with ARIs in Kanti Children's Hospital. The HMPV was more prevalent in the age group less than three years (21.8%). Cough and fever were the most common clinical features present in all children infected with HMPV followed by rhinorrhea, sore throat, and wheezing. HMPV-positive children were diagnosed with pneumonia (42.9%), bronchiolitis (28.5%), upper respiratory tract infections (14.3%), and asthma (14.3%). The prevalence of HMPV was high in late winter (14.3%) followed by early spring (13.5%). CONCLUSIONS: This study provides the baseline information on HMPV and associated co-infection with other respiratory viruses for the differential diagnosis based on molecular methods and also the comparison of clinical presentations among the different respiratory syndromes.

Visceral leishmaniasis in new foci areas of Nepal: Sources and extent of infection.

Background & objectives: The successful elimination program of visceral leishmaniasis (VL) in Nepal decreased the incidence to less than 1 per 10,000 population leading to the consolidation phase. However, new VL cases have been recorded from new districts, threatening the elimination goal. This study monitors the geographical spread of VL and identifies potential risk factors. Methods: VL data of 2017-2020 were obtained from the Epidemiology and Disease Control Division (EDCD) of Nepal and mapped. Telephonic interviews with 13 VL patients were conducted. Results: The incidence maps indicate that VL is spreading to new areas. The target incidence exceeded four times in hilly and twice in mountainous districts. VL cases occurred in 64 of 77 districts in all three regions (mountainous, hilly and Terai). Interviews showed a correlation between travel history (private, commercial and for studies) and the spread of VL cases to new foci. Interpretation & conclusion: One major challenge of VL elimination in the maintenance phase is the spread of infection through travelers to new foci areas, which needs to be under continuous surveillance accompanied by vector control activities. This should be confirmed by a large-scale analytical study.

Multidrug-resistant bacteria with ESBL genes: a growing threat among people living with HIV/AIDS in Nepal.

BACKGROUND: Bacterial opportunistic infections are common in people living with HIV/AIDS (PLHA). Besides HIV-TB co-infection, lower respiratory tract infections (LRTIs) due to multidrug-resistant (MDR) bacteria cause significant morbidity and mortality among PLHA. This study identified bacterial co-infection of the lower respiratory tract and detected plasmid-mediated blaTEM and blaCTX-M genes among Extended-Spectrum ß-Lactamase (ESBL) producing isolates from sputum samples in PLHA. METHODS: A total of 263 PLHA with LRTIs were enrolled in this study, out of which, 50 were smokers, 70 had previous pulmonary tuberculosis, and 21 had CD4 count < 200 cells/µl. Sputum samples collected from PLHA were processed with standard microbiological methods to identify the possible bacterial pathogens. The identified bacterial isolates were assessed for antibiotic susceptibility pattern using modified Kirby Bauer disk diffusion method following Clinical Laboratory Standard Institute (CLSI) guidelines. In addition, plasmid DNA was extracted from MDR and ESBL producers for screening of ESBL genes; blaCTX-M and blaTEM by conventional PCR method using specific primers. RESULTS: Of 263 sputum samples, 67 (25.48%) showed bacterial growth. Among different bacterial pathogens, Klebsiella pneumoniae, (17; 25.37%) was the most predominant, followed by Haemophillus influenzae, (14; 20.90%) and Escherichia coli, (12; 17.91%). A higher infection rate (4/8; 50%) was observed among people aged 61-70 years, whereas no infection was observed below 20 years. About 30.0% (15/50) of smokers, 32.86% (23/70) cases with previous pulmonary tuberculosis, and 52.38% (11/21) with CD4 count < 200 cells/µl had bacterial LRTIs. Among 53 bacterial isolates excluding H. influenzae, 28 isolates were MDR and 23 were ESBL producers. All ESBL producers were sensitive to colistin and polymyxin B. Among ESBL producers, 47.83% (11/23) possessed blaCTX-M, 8.6% (2/23) were positive for blaTEM gene, and 43.48% (10/23) possessed both ESBL genes. CONCLUSION: The increasing rate of MDR bacterial infections, mainly ESBL producers of LRTIs causes difficulty in disease management, leading to high morbidity and mortality of PLHA. Hence, it is crucial to know the antibiogram pattern of the isolates to recommend effective antimicrobial therapy to treat LRTIs in PLHA.

Detection of NDM-1 and VIM Genes in Carbapenem-Resistant Klebsiella pneumoniae Isolates from a Tertiary Health-Care Center in Kathmandu, Nepal.

BACKGROUND: Klebsiella pneumoniae is one of the leading causes of nosocomial infections. Carbapenems are used as the last resort for the treatment of multidrug resistant Gram-negative bacterial infections. In recent years, resistance to these lifesaving drugs has been increasingly reported due to the production of carbapenemase. The main objective of this study was to detect the carbapenem-resistant genes blaNDM-1 and blaVIM in K. pneumoniae isolated from different clinical specimens. METHODS: A total of 585 clinical specimens (urine, pus, sputum, blood, catheter tips, and others) from human subjects attended at Annapurna Neurological Institute and Allied Sciences, Kathmandu were obtained in the period between July 2018 and January 2019. The specimens were isolated and identified for K. pneumoniae. All K. pneumoniae isolates were processed for antimicrobial susceptibility testing (AST) using the disk diffusion method. The isolates were further phenotypically confirmed for carbapenemase production by the modified Hodge test (MHT) using imipenem (10 µg) and meropenem (10 µg) discs. Thus, confirmed carbapenemase-producing isolates were further screened for the production of blaNDM-1 and blaVIM using conventional polymerase chain reaction (PCR). RESULTS: Among the clinical isolates tested, culture positivity was 38.29% (224/585), and the prevalence of K. pneumoniae was 25.89% (58/224). On AST, K. pneumoniae exhibited resistance toward carbapenems including ertapenem, meropenem, and imipenem, while it showed the highest susceptibility rate against to tigecycline (93.1%; 54/58). Overall, AST detected 60.34% (35/58) carbapenem-resistant isolates, while the MHT phenotypically confirmed 51.72% (30/58) isolates as carbapenemase-producers and 48.28% (28/58) as carbapenemase nonproducers. On subsequent screening for resistant genes among carbapenemase-producers by PCR assay, 80% (24/30) and 3.33% (1/30) isolates were found to be positive for blaNDM-1 and blaVIM, respectively. In the same assay among 28 carbapenem nonproducing isolates, 9 (32.14%) isolates were positive for blaNDM-1 gene while none of them were tested positive for blaVIM gene. CONCLUSIONS: Molecular detection of resistant genes provides greater specificity and sensitivity than those with conventional techniques, thus aiding in accurate identification of antimicrobial resistance and clinical management of the disease.

Co-infection with Campylobacter and rotavirus in less than 5 year old children with acute gastroenteritis in Nepal during 2017-2018.

BACKGROUND: Diarrhoea, although easily curable, is a global cause of death for a half million children every year. Rotavirus and Campylobacter are the most common etiological agents of diarrhoea in children less than 5 years of age. However, in Nepal, these causative agents are not routinely examined for the diagnosis and treatment. The main objective of this study was to determine Campylobacter co-infection associated with rotavirus diarrhoea in children less than 5 years of age. METHODS: A cross-sectional study was conducted at Kanti Children's Hospital (KCH), Kathmandu, Nepal from November 2017 to April 2018. A total of 303 stool specimens from children affected with diarrhoea were processed to detect rotavirus using a rapid rotavirus antigen detection test kit, and Campylobacter by microscopy, culture and biochemical tests. Antibiotic susceptibility tests of Campylobacter isolates were performed according to European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines 2015. RESULTS: Of 303 samples, 91 (30.0%) were positive for co-infection with rotavirus and Campylobacter. Rotavirus mono-infection was detected in 61 (20.1%), and Campylobacter mono-infection was detected in 81 (26.7%) samples. Patient's age, month of infection, untreated water and frequent soil contact were the major risk factors for infections. Clinical features such as > 9 loose motions per day, fever, vomiting, mild to moderate dehydration, diarrhea persisting 6-9 days and presence of mucus in stool were significant (p < 0.05) clinical features, and were more severe in coinfection compared to mono-infections in multivariate analysis. CONCLUSION: The study shows a high rate of rotavirus and Campylobacter coinfection in children with diarrhoea. Diagnosis based management of diarrhoeal cases can guide the specific treatment.

Efficacy of Primaquine in Preventing Short- and Long-Latency Plasmodium vivax Relapses in Nepal.

BACKGROUND: Plasmodium vivax is the main cause of malaria in Nepal. Relapse patterns have not been characterized previously. METHODS: Patients with P. vivax malaria were randomized to receive chloroquine (CQ; 25 mg base/kg given over 3 days) alone or together with primaquine (PQ; 0.25 mg base/kg/day for 14 days) and followed intensively for 1 month, then at 1- to 2-month intervals for 1 year. Parasite isolates were genotyped. RESULTS: One hundred and one (49%) patients received CQ and 105 (51%) received CQ + PQ. In the CQ + PQ arm, there were 3 (4.1%) recurrences in the 73 patients who completed 1 year of follow-up compared with 22 of 78 (28.2%) in the CQ-only arm (risk ratio, 0.146 [95% confidence interval, .046-.467]; P < .0001). Microsatellite genotyping showed relatively high P. vivax genetic diversity (mean heterozygosity, 0.843 [range 0.570-0.989] with low multiplicity of infection (mean, 1.05) reflecting a low transmission preelimination setting. Of the 12 genetically homologous relapses, 5 (42%) occurred in a cluster after 9 months, indicating long latency. CONCLUSIONS: Although there may be emerging CQ resistance, the combination of CQ and the standard-dose 14-day PQ regimen is highly efficacious in providing radical cure of short- and long-latency P. vivax malaria in Nepal.

Barriers of Visceral Leishmaniasis reporting and surveillance in Nepal: comparison of governmental VL-program districts with non-program districts.

OBJECTIVES: At the time when Nepal is on the verge of reaching the maintenance phase of the Visceral Leishmaniasis (VL) elimination program, the country is facing new challenges. The disease has expanded to 61 of the country's 75 districts including previously non-endemic areas where there is no control or patient management program in place. This study aimed to assess which elements of the surveillance and reporting systems need strengthening to identify cases at an early stage, prevent further transmission and ensure sustained VL elimination. METHODS: In a cross-sectional mixed-method study, we collected data from two study populations in VL program and non-program districts. From February to May 2016, structured interviews were conducted with 40 VL patients, and 14 in-depth and semi-structured interviews were conducted with health managers. RESULTS: The median total delay from onset of symptoms to successful reporting to the Ministry of Health was 68.5 days in the VL-program and 83 days in non-program districts. The difference in patient's delay from the onset of symptoms to seeking health care was 3 days in VL-program and 20 days in non-program districts. The diagnostic delay (38.5 days and 36 days, respectively), treatment delay (1 vs. 1 days) and reporting delay (45 vs. 36 days) were similar in program and non-program districts. The diagnostic delay increased three-fold from 2012, while treatment and reporting delay remained unchanged. The main barriers to surveillance were: (i) lack of access and awareness in non-program districts; (ii) growing private sector not included in and not participating to referral, treatment and reporting; (iii) lack of cooperation and coordination among stakeholders for training and deployment of interventions; (iv) insufficient validation, outreach and process optimisation of the reporting system. CONCLUSIONS: Corrective measures are needed to maintain the achievements of the VL elimination campaign and prevent resurgence of the disease in Nepal. A clear patient referral structure, reinforcement of report notification and validation and direct relay of data by local hospitals and the private sector to the district health offices are needed to ensure prompt treatment and timely and reliable information to facilitate a responsive system of interventions.

Designing malaria surveillance strategies for mobile and migrant populations in Nepal: a mixed-methods study.

BACKGROUND: As malaria cases have declined throughout Nepal, imported cases comprise an increasing share of the remaining malaria caseload, yet how to effectively target mobile and migrant populations (MMPs) at greatest risk is not well understood. This formative research aimed to confirm the link between imported and indigenous cases, characterize high-risk MMPs, and identify opportunities to adapt surveillance and intervention strategies to them. METHODS: The study used a mixed-methods approach in three districts in far and mid-western Nepal, including (i) a retrospective analysis of passive surveillance data, (ii) a quantitative health facility-based survey of imported cases and their MMP social contacts recruited by peer-referral, and (iii) focus group (FG) discussions and key informant interviews (KIIs) with a subset of survey participants. Retrospective case data were summarised and the association between monthly indigenous case counts and importation rates in the previous month was investigated using Bayesian spatio-temporal regression models. Quantitative data from structured interviews were summarised to develop profiles of imported cases and MMP contacts, including travel characteristics and malaria knowledge, attitudes and practice. Descriptive statistics of the size of cases' MMP social networks are presented as a measure of potential programme reach. To explore opportunities and barriers for targeted malaria surveillance, data from FGs and KIIs were formally analysed using a thematic content analysis approach. RESULTS: More than half (54.1%) of malaria cases between 2013 and 2016 were classified as imported and there was a positive association between monthly indigenous cases (incidence rate ratio (IRR) 1.02 95% CI 1.01-1.03) and the previous month's case importation rate. High-risk MMPs were identified as predominantly adult male labourers, who travel to malaria endemic areas of India, often lack a basic understanding of malaria transmission and prevention, rarely use ITNs while travelling and tend not to seek treatment when ill or prefer informal private providers. Important obstacles were identified to accessing Nepali MMPs at border crossings and at workplaces within India. However, strong social connectivity during travel and while in India, as well as return to Nepal for large seasonal festivals, provide opportunities for peer-referral-based and venue-based surveillance and intervention approaches, respectively. CONCLUSIONS: Population mobility and imported malaria cases from India may help to drive local transmission in border areas of far and mid-western Nepal. Enhanced surveillance targeting high-risk MMP subgroups would improve early malaria diagnosis and treatment, as well as provide a platform for education and intervention campaigns. A combination of community-based approaches is likely necessary to achieve malaria elimination in Nepal.

Assessing maternal and neonatal near-miss reviews in rural Nepal: an implementation research study to inform scale-up.

AIM: To understand how maternal and neonatal near-miss reviews could be implemented and scaled-up in rural communities through the existing district health system in Nepal. METHODS: Mixed methods with a modified time series evaluation design were used. The World Health Organization maternal and neonatal near-miss criteria used in multicountry surveys were adapted and used to define maternal and neonatal near-miss cases. RESULTS: The World Health Organization near-miss criteria were mainly applicable at the district hospital setting, but further adaptations were needed for community-level birthing centres, as organ dysfunction and critical intervention criteria were not found appropriate. In birthing centres, disease-based criteria were applicable for maternal near-miss review, and danger and clinical sign-based and condition at birth criteria were applicable for neonatal near-miss review. Primary barriers to implementation were attrition of trained staff due to the frequent transfer of healthcare providers, and time constraints of district hospital medical doctors for case-by-case reviews as they were often busy in hospital and in their private clinics. CONCLUSION: Adapted maternal and neonatal near-miss review process implementation in Nepal is feasible through the existing government health system.

Prevalence and risk factors of hepatitis B infection among mothers and children with hepatitis B infected mother in upper Dolpa, Nepal.

BACKGROUND: Hepatitis B Virus (HBV) infection is a worldwide public health problem. In Nepal, the prevalence of HBV is found to be low (0.9%), although high prevalence (≥8%) of HBV infection is depicted among subgroup/population in the mountain region by various studies. This study assessed the prevalence and the risk of HBV infection among mothers, as well as among the youngest child under 5 years old living with hepatitis B positive mothers in Dolpa, the most remote mountain district of Nepal. METHODS: The cross sectional study survey was conducted between June and July 2014. All mothers with their youngest child under 5 years old were invited to participate in the survey and tested for hepatitis B surface antigen (HBsAg). The HBsAg positive mothers were further tested by 5-panel HBV test card. Children living with HBsAg positive mothers were also tested for HBsAg. RESULTS: One hundred fifty-one mothers, comprising 37% of the total study population in the selected Village Development Committees (VDCs), were surveyed in the mobile health camps. The seroprevalence of HBsAg among mothers and their youngest child under 5 years old living with HBsAg positive mothers were 17% (95% CI, 11.01-22.99%) and 48% (95%CI, 28.42-67.58%) respectively. The majority of HBV infected mothers were indigenous (84%) followed by Dalit (4%) and other castes (12%). Among HBV infected mothers, 40% were hepatitis B envelope antigen (HBeAg) positive. The prevalence of HBsAg was higher among children living with HBeAg positive mothers as compared to HBeAg negative (60% vs 40%) and male children compared to female (60% vs 33%). Thirty-six percent of children were vaccinated with a full course of the hepatitis B vaccine. Of these vaccinated children, 56% were HBsAg sero-positive. CONCLUSIONS: The HBV infection rate is high among mothers and children living with HBsAg positive mothers in the indigenous population of the most remote mountain community of Nepal.

Prevalence of congenital defects including selected neural tube defects in Nepal: results from a health survey.

BACKGROUND: In resource-limited nations like Nepal, congenital defects, including neural tube defects (NTDs), have great public health impact. NTDs and a few other congenital defects can be prevented by micronutrient supplementation. Without proper research regarding such defects, it is difficult to assess the damage made to health and productivity. This study aims to investigate different congenital defects among children in Nepal. METHODS: Household surveys and health camps were conducted from 2011 to 2012. Physical examination of women of reproductive age (15 to 49 years) was done in selected Village Development Committees of nine districts in three ecological regions of Nepal. Congenital defects, including NTDs, were examined in children (age 0 to 5 years) who were alive at the time of the survey. Data entry and analysis was performed by using SPSS version 11.5. RESULTS: 21,111 women were interviewed and 27,201 children born to them were assessed. The prevalence of congenital defects was 52.0 (95% CI: 44.0-61.0) per 10,000 children. The prevalence of selected NTDs was 4.0 (95% CI: 2.0-7.0) per 10,000 children. Among the neural tube defects, encephalocele, myelomeningocele and dermal sinus were the major ones, having almost the same prevalence in the Hill and Terai regions. The majority of children with genital abnormalities (17.0 per 10,000 children; 95% CI: 10.0-28.0) and limb deformities (14.0 per 10,000 children; 95% CI: 8.0-24.0) were found in the Terai. The rate of congenital birth defects was higher in the regions where women were in poor health. CONCLUSION: There is high prevalence of congenital defects in Nepal. Since such defects add a burden to families and society, it is imperative that health policies addressing programs like supplementation, fortification and dietary diversification be implemented.

Decadal Analysis of ESBL-Escherichia coli Antibiotic Resistance Patterns in Urine Samples from Nepal: A Systematic Review and Meta-Analysis.

BACKGROUND: This systematic review aimed to determine the antimicrobial resistance pattern of the extended-spectrum ß-lactamases producing Escherichia coli (ESBL-EC) in urine samples in Nepal. METHODS: Systematic literature review was conducted to locate all articles reporting ESBL-EC in urine samples published between January 2012 to December 2022. The Egger's weighted regression analysis was done to assess the publication bias. A random-effects model was used to calculate the pooled prevalence and corresponding 95% confidence interval due to significant between-study heterogeneity. The strength of correlation between multidrug resistance and ESBL production in E.coli strains was determined using Pearson's correlation coefficient. The data were analyzed using R-language 4.2.2. software. RESULTS: The combined prevalence of E.coli in urine samples was found to be 14 % (95% CI, 11-18), while the overall pooled prevalence of ESBL E.coli and MDR E.coli were 30% (95% CI, 20-42) and 70% (95% CI, 38-90) respectively. A strong positive correlation of 0.99 (95% CI, 0.89-1.0) was found between ESBL production and MDR among E.coli isolates. Imipenem was the drug of choice against ESBL-E.coli in urine specimens. CONCLUSIONS: Our analyses showed the overall ESBL-EC and MDR-EC burden in Nepal is considerably high. Likewise, the study also infers an increasing trend of antibiotic resistance pattern of ESBL-EC in urine samples.

Antibiotic Susceptibility of Staphylococcus Aureus with VanA and MecA Genes.

BACKGROUND: Staphylococcus aureus (S.aureus) is an emerging antibiotic resistant bacterium responsible for various infections in human. Resistance to methicillin and vancomycin are of prime concern in S. aureus. The study aims to determine the minimum inhibitory concentration (MIC) of Vancomycin and evaluate the existence of mecA and vanA genes, associated with antibiotic resistance. METHODS: Clinical specimens from three Kathmandu hospitals were processed and S. aureus was identified using conventional microbiological procedures. MRSA was phenotypically identified with cefoxitin (30µg) disc diffusion, while vancomycin susceptibility was assessed using the Ezy MICTM stripes. The mecA and vanA genes were detected by polymerase chain reaction (PCR). RESULTS: Out of 266 S. aureus samples from various clinical specimen subjected for analysis, 77 (28.9%) were found methicillin-resistant (MRSA) and 10 (3.8%) were observed vancomycin-resistant (VRSA). Vancomycin resistant isolates showed a significant correlation between resistance to ampicillin, chloramphenicol, and cefoxitin. The mecA gene was found in 39 of the MRSA isolates, having 50.64% of MRSA cases, while the vanA gene was detected in 4 of the VRSA cases, constituting 40% of VRSA occurrences. CONCLUSIONS: The strains with higher vancomycin minimum inhibitory concentration values (≥ 1.5 µg/ml) displayed increased resistance rates to various antibiotics compared to strains with lower minimum inhibitory concentration values (< 1.5 µg/ml). The presence of vanA genes was strongly associated (100%) with vancomycin resistance, while the 10.3% mecA gene was identified from MRSA having resistance towards vancomycin also.

Application of Pediatric Risk of Mortality (PRISM) III Score in Predicting Mortality Outcomes.

BACKGROUND: Children admitted in a pediatric intensive care unit have a high risk of mortality. Pediatric risk of mortality III score in first 24 hours of admission has increasingly been used to predict mortality. The objective of this study was to evaluate the validity of Pediatric risk of mortality score in prediction of mortality among the patient admitted in pediatric intensive care unit. METHODS: This prospective observational study was conducted at pediatric intensive care unit of a government pediatric hospital from January to June 2021. Patients between 1 month to 14 years of age and meeting the inclusion criteria were enrolled. Pediatric risk of mortality III score was calculated within 24 hours of admission. Patients were followed up for outcome measure as survivors and non survivors. Chi square test and logistic regression analysis were used to find the association of predictors and the score. RESULTS: The mean Pediatric risk of mortality III score was lower in survivors than in non-survivors (4.67 ± 3.8 versus 14.10 ± 6.07; p<0.001). Those requiring inotropic and ventilator support have significantly higher mortality [49.4 versus 0.6 (p<0.001) and 81.8 versus 1.5 (p<0.001) respectively]. Minimum systolic blood pressure, abnormal pupillary reflex, increased blood urea nitrogen and decreased platelet were the significant (p<0.001) risk factors. The area under the Receiver Operating Characteristic curve was 0.916±0.024 (p<0.001) and goodness-of-fit test showed no significant difference between observed and expected mortalities (p=0.186). CONCLUSIONS: The Pediatric risk of mortality score constitutes a useful prognostic tool in predicting the mortality. KEY WORDS: Mortality; pediatrics; pediatric intensive care unit; risk score.

Extended Spectrum Beta Lactamase Escherichia Coli in Bagmati River, Kathmandu Valley.

BACKGROUND: Antimicrobial resistance organisms in the peripheral communities of an environment can be predicted by the presence of extended-spectrum beta-lactamase Escherichia coli in that environment. The close connectivity between humans and water sources can facilitate the entry of antimicrobial resistant organisms into the human ecosystem. The aim of this study was to assess beta lactamase producing Escherichia coli from Bagmati river within Kathmandu valley. METHODS: In the year 2020, a cross-sectional study was conducted on water samples collected from 66 locations along the Bagmati River. Coliforms were isolated by five tubes dilution method and identified by cultural and biochemical tests. Further Escherichia coli was isolated in eosin methylene blue agar at 44.5 °C. Antibiotic susceptibility test was performed by Kirby Bauer disk diffusion methods. Beta lactamase gene types were detected by using conventional multiplex polymerase chain reaction. RESULTS: A total of 615 bacterial isolates were identified among which 39 % (n=241) were Escherichia coli. Extended spectrum beta lactamase producing Escherichia coli was confirmed in 16.6 % (40/241) of total Escherichia coli isolates. Among 66 sites this isolate was detected in 26 (40 %) sampling sites excluding upstream regions. All the Escherichia coli isolates were multidrug resistance showing higher percentage (>99 %) of resistant for penicillin, tetracycline and erythromycin antibiotics. There were significant differences in resistance rate for cefotaxime and ceftazidime by extended spectrum beta lactamase producing and non-producing Escherichia coli (p<0.05). CONCLUSIONS: Presence of multidrug resistance extended spectrum beta lactamase producing Escherichia coli in river streams suggests the chances of circulating within river system and hence transmitting in human community. KEY WORDS: Bagmati river; drug resistance; escherichia coli; human.

Efficacy of Native Bacillus thuringiensis against Mosquito Vector.

BACKGROUND: Larval source management is an effective measure to control mosquito-borne diseases. Bacillus thuringiensis produces specific insecticidal crystal proteins toxic to mosquito larvae. In many parts of the South East Asian region, Bacillus thuringiensis is used for larval source management. In Nepal, larvicidal Bacillus thuringiensis is not available. The study aims to isolate larvicidal Bacillus thuringiensis from soil samples of Nepal to control mosquitoes. METHODS: Native Bacillus thuringiensis was obtained from soil samples by the acetate selection method. It was identified by observing crystal protein with Coomassie Brilliant Blue stain in a light microscope. The mosquito larvae were collected from different breeding habitats. A preliminary bioassay was performed by inoculating three loopful of 48 hours culture of spherical crystal protein producing Bacillus thuringiensis in a plastic cup containing 25 larvae and 100 ml of sterile distilled water. The cup was incubated at room temperature for 24 hours to observe the mortality of larvae. Further selective bioassay was performed with the isolate which showed 100% mortality, as described above in four replicates along with the negative and positive control. RESULTS: Out of 1385 Bacillus thuringiensis obtained from 454 soil samples, 766 (55.30%) were spherical crystal protein producers, among them, a single strain (14P2A) showed 100% mortality against mosquito larvae. The lethal concentration doses required to kill 50% and 90% of the larval population were 32.35 and 46.77 Parts per million respectively. CONCLUSIONS: The native Bacillus thuringiensis produces the crystal protein effective in killing mosquito larvae. The native Bacillus thuringiensis should be included as a tool to control mosquito-borne diseases in Nepal.