Carriage of Extended-Spectrum-ß-Lactamase- and AmpC-ß-Lactamase-Producing Enterobacteriaceae (ESBL-PE) in Healthy Community and Outpatient Department (OPD) Patients in Nepal.

BACKGROUND: Extended-spectrum ß-lactamase (ESBL)- and AmpC-ß-lactamase (ESBL)- and AmpC-Enterobacteriaceae have recently emerged as a public threat in the treatment of nosocomial as well as community-acquired infections. Very little information is currently available about its existence in Nepal. We, therefore, aim to determine the prevalence of ESBL and AmpC-ß-lactamase (ESBL)- and AmpC-Enterobacteriaceae have recently emerged as a public threat in the treatment of nosocomial as well as community-acquired infections. Very little information is currently available about its existence in Nepal. We, therefore, aim to determine the prevalence of ESBL and AmpC. METHODS: During a 6-month period (November 2014-April 2015), a total of 190 stool specimens from 190 participants were obtained from different population. Of the total 260 fecal isolates, 152 from outpatient department (OPD) and 108 from healthy volunteer were collected. Stool specimens were cultured and enterobacterial isolates were subjected to antimicrobial susceptibility tests according to the standard microbiologic guidelines. ESBL was screened using ceftazidime (CAZ, 30 µg) and cefotaxime (CTX, 30 µg) and cefotaxime (CTX, 30 ß-lactamase (ESBL)- and AmpC. RESULTS: The prevalence of ESBL, AmpC-ß-lactamase (ESBL)- and AmpC-ß-lactamase (ESBL)- and AmpC-Enterobacteriaceae have recently emerged as a public threat in the treatment of nosocomial as well as community-acquired infections. Very little information is currently available about its existence in Nepal. We, therefore, aim to determine the prevalence of ESBL and AmpC-E. coli was 70.2% followed by K. pneumoniae (12.7%), and among AmpC-ß-lactamase (ESBL)- and AmpC-E. coli was 70.2% followed by E. coli was 70.2% followed by K. pneumoniae (12.7%), and among AmpC-K. pneumoniae (12.7%), and among AmpC-C. freundii 2/7 (28.57%) were detected highest among AmpC-ß-lactamase (ESBL)- and AmpC. CONCLUSION: Our study revealed a high prevalence of ESBL- and AmpC-ß-lactamase-producing enteric pathogen in Nepalese OPD and healthy population. The significant increase of these isolates and increased rate of drug resistance indicates a serious threat that stress the need to implement the surveillance system and a proper control measure so as to limit the spread of ESBL-producing Enterobacteriaceae (ESBL-PE) in both OPD as well as in community. Therefore, healthcare providers need to be aware that ESBL- and AmpC-ß-lactamase-producing strains are not only circulating in hospital environments but also in the community and should be dealt with accordingly.ß-lactamase (ESBL)- and AmpC-Enterobacteriaceae have recently emerged as a public threat in the treatment of nosocomial as well as community-acquired infections. Very little information is currently available about its existence in Nepal. We, therefore, aim to determine the prevalence of ESBL and AmpC-ß-lactamase (ESBL)- and AmpC.

Molecular epidemiology of Rotavirus causing diarrhea among children less than five years of age visiting national level children hospitals, Nepal.

BACKGROUND: Rotaviruses are the major cause of diarrhea among the infants and young children all over the world causing over 500,000 deaths and 2.4 million hospitalizations each year. In Nepal Rotavirus infection positivity rates ranges from 17.0 to 39.0% among children less than 5 years. However, little is known about the molecular genotypes of Rotavirus prevailing. The objective of this study was to estimate the burden of Rotavirus gastroenteritis and determine the genotypes of Rotavirus among children less than 5 years. METHODS: The cross sectional study was conducted from January to November 2014 among children less than 5 years old visiting Kanti Children's Hospital and Tribhuvan University Teaching Hospital. Rotavirus antigen detection was performed by Enzyme Linked Immunosorbent Assay (ELISA) using ProSpecT Rotavirus Microplate Assay. Among the Rotavirus antigen positive samples, 59 samples were used for Rotavirus RNA extraction. Multiplex PCR was performed to identify G type comprising G1-G4, G8-G10 and G12 and P type comprising P[4], P[6], P[8], P[9], P[10], and P[11]. RESULTS: A total of 717 diarrheal stool samples were collected from patients ranging from 10 days to 59 months of age. Rotavirus antigen positive was found among (N = 164)22.9% of patients. The highest number of the diarrhea was seen in January. Molecular analysis of Rotavirus genotypes revealed that the predominant G-Type was G12 (36%) followed by G9 (31%), G1 (21%), G2 (8.6%). The predominant P- type was P6 (32.8%) followed by P8 (31%), P10 (14.8%), P4 (14.8%). A total of seven G/P type combinations were identified the most common being G12P [6] (35.8%), G1P [8] (15.1%), G9P [8] (15.1%). CONCLUSION: Rotavirus diarrhea is, mostly affecting children from 7 to 24 months in Nepal, mostly occurring in winter. The circulating genotypes in the country are found to be primarily unusual genotypes and predominance of G12P[6]. It is recommended to conduct genotyping of Rotavirus on large samples before starting vaccination in the country.

Symptoms 6 months following SARS-CoV-2 infection in Nepali women.

In Nepal, over 1 million individuals have tested positive for SARS-CoV-2. We sought to describe the frequency of nonrecovery from this infection at 6 months and associated symptoms. We conducted a retrospective cohort study of 6142 women who had positive and negative PCR tests for this infection 6 months previously at 3 institutions in Kathmandu. In telephone interviews women provided information on 22 symptoms and their intensities, health status and history, and functional status. Of 3732 women who had tested PCR positive, 630 (16.9%) reported that they were unrecovered. These 630 unrecovered women were distinguished statistically from the 3102 recovered women by more frequent histories of allergies, rheumatoid disease, BCG immunization, Covid vaccination, strep throat and recent URIs, and both weight gain and weight losses of more than 5 kg in the 6 months following testing, and stressful events in the preceding year. Fatigue, pain, difficulty remembering, shortness of breath, heat and cold intolerance and unrefreshing sleep were reported in 41.9% to 10.5% of these 630 unrecovered women. Six months after confirmed SARS-CoV-2 infection 16.9% of Nepali women have long-COVID manifested as an immune, metabolic, and hormonal systems disruptive and dysfunction syndrome.

Has Data Quality of an Antimicrobial Resistance Surveillance System in a Province of Nepal Improved between 2019 and 2022?

An operational research study was conducted in 2019 to assess the quality of data submitted by antimicrobial resistance (AMR) surveillance sites in the Bagmati Province of Nepal to the National Public Health Laboratory for Global Antimicrobial Resistance and Use Surveillance System (GLASS). Measures were implemented to enhance the quality of AMR surveillance by strengthening capacity, improving infrastructure, implementing data sharing guidelines, and supervision. The current study examined reports submitted by surveillance sites in the same province in 2022 to assess whether the data quality had improved since 2019. The availability of infrastructure at the sites was assessed. Of the nine surveillance sites in the province, seven submitted reports in 2022 versus five in 2019. Completeness in reporting improved significantly from 19% in 2019 to 100% in 2022 (p < 0.001). Timely reports were received from two sites in 2019 and only one site in 2022. Specimen-pathogen consistency in accordance with the GLASS guidelines for urine, feces, and genital swab specimens improved, with ≥90% consistency at all sites. Overall, the pathogen-antibacterial consistency improved significantly for each GLASS priority pathogen. The study highlights the importance of dedicated infrastructure and institutional arrangements for AMR surveillance. Similar assessments covering all provinces of the country can provide a more complete country-wide picture.

Phenotypic detection of methicillin resistance, biofilm production, and inducible clindamycin resistance in Staphylococcus aureus clinical isolates in Kathmandu, Nepal.

INTRODUCTION: Methicillin resistance, inducible clindamycin resistance (ICR), biofilm production, and increased minimum inhibitory concentration (MIC) of vancomycin in Staphylococcus aureus are major causes of antibiotic treatment failure and increased morbidity and mortality. The surveillance of such isolates and the study of their antimicrobial pattern are essential in managing the infections caused by these isolates. This study aimed to determine methicillin resistance, biofilm production, and ICR in S. aureus isolates from a tertiary care hospital in Kathmandu, Nepal. MATERIALS AND METHODS: A total of 217 S. aureus isolated from different samples were processed following standard laboratory procedures. Antibiotic susceptibility testing was performed by the Kirby-Bauer disk diffusion technique. Methicillin-resistant S. aureus (MRSA) were identified by the cefoxitin disk diffusion test, and biofilm producers were examined using the microtiter plate technique. D-test and E-test were performed to determine inducible clindamycin resistance and minimum inhibitory concentration of vancomycin, respectively. RESULTS: Among the 217 S. aureus isolates, 78.3% were multidrug-resistant (MDR), 47.0% were MRSA, 62.2% were biofilm producers, and 50.7% showed ICR. All MRSA isolates exhibited MIC levels of vancomycin within the susceptible range. Biofilm producers and MRSA isolates showed elevated antimicrobial resistance. MRSA was significantly associated with MDR. Biofilm-producing and multidrug-resistant MRSA isolates showed significantly higher MIC levels of vancomycin (p = 0.0013 and < 0.0001, respectively), while ICR was significantly higher in MDR (p = 0.0001) isolates. CONCLUSION: High multidrug resistance, MRSA, and ICR in this study call for routine evaluation of antibiotic susceptibility patterns of S. aureus. Vancomycin can be used to treat serious staphylococcal infections. Clindamycin should be prescribed only after performing the D-test. Drugs like teicoplanin, chloramphenicol, doxycycline, amikacin, and levofloxacin can treat MRSA infections.

Biofilm Formation by Pathogens Causing Ventilator-Associated Pneumonia at Intensive Care Units in a Tertiary Care Hospital: An Armor for Refuge.

BACKGROUND: Emerging threat of drug resistance among pathogens causing ventilator-associated pneumonia (VAP) has resulted in higher hospital costs, longer hospital stays, and increased hospital mortality. Biofilms in the endotracheal tube of ventilated patients act as protective shield from host immunity. They induce chronic and recurrent infections that defy common antibiotics. This study intended to determine the biofilm produced by pathogens causing VAP and their relation with drug resistance. METHODS: Bronchoalveolar lavage and deep tracheal aspirates (n = 70) were obtained from the patients mechanically ventilated for more than 48 hours in the intensive care units of Tribhuvan University Teaching Hospital, Kathmandu, and processed according to the protocol of the American Society for Microbiology (ASM). Antibiotic susceptibility testing was done following Clinical and Laboratory Standards Institute (CLSI) 2017 guidelines. Biofilm formation was determined using the microtiter plate method described by Christensen and modified by Stepanovoic et al. RESULTS: Significant microbial growth was seen in 78.6% of the total samples with 52.7% monomicrobial, 45.5% polymicrobial, and 1.8% fungal infection. Among the 71 isolates obtained, bulk was gram-negative (n = 64, 90.1%). Pseudomonas aeruginosa (31.0%) was the predominant isolate followed by Acinetobacter calcoaceticus baumannii complex (16.9%), Klebsiella pneumoniae (16.9%), Citrobacter freundii (15.5%), Staphylococcus aureus (7.0%), Escherichia coli (5.6%), Citrobacter koseri (2.8%), Enterococcus faecalis (1.4%), Burkholderia cepacia complex (1.4%), and Candida albicans (1.4%). Of the total isolates, 56.3% were biofilm producers. Multidrug-resistant (MDR) organisms, extended-spectrum ß-lactamase (ESBL), and metallo-ß-lactamase (MBL) producers were preeminent among the biofilm producers. The highest producer of biofilm was P. aeruginosa (19.7%). Among gram-negative biofilm producers, 42.2% were MDR, 21.9% were ESBL producers, and 7.8% were MBL producers. CONCLUSION: Gram-negative nonfermenter bacteria account for the bulk of nosocomial pneumonia. MDR, ESBL, and MBL production was preponderant among the biofilm producers. The rampant spread of drug resistance among biofilm producers is summoning novel interventions to combat multidrug resistance.

Quality Assessment of an Antimicrobial Resistance Surveillance System in a Province of Nepal.

Antimicrobial resistance (AMR) is a global problem, and Nepal is no exception. Countries are expected to report annually to the World Health Organization on their AMR surveillance progress through a Global Antimicrobial Resistance Surveillance System, in which Nepal enrolled in 2017. We assessed the quality of AMR surveillance data during 2019-2020 at nine surveillance sites in Province 3 of Nepal for completeness, consistency, and timeliness and examined barriers for non-reporting sites. Here, we present the results of this cross-sectional descriptive study of secondary AMR data from five reporting sites and barriers identified through a structured questionnaire completed by representatives at the five reporting and four non-reporting sites. Among the 1584 records from the reporting sites assessed for consistency and completeness, 77-92% were consistent and 88-100% were complete, with inter-site variation. Data from two sites were received by the 15th day of the following month, whereas receipt was delayed by a mean of 175 days at three other sites. All four non-reporting sites lacked dedicated data personnel, and two lacked computers. The AMR surveillance data collection process needs improvement in completeness, consistency, and timeliness. Non-reporting sites need support to meet the specific requirements for data compilation and sharing.

Detection of Pan drug resistance OXA-48 producing Providencia in an ICU patient for the first time in Nepal.

Background: Resistance to antimicrobial agents of pathogenic bacteria has become a major problem in routine medical practices. Carbapenem resistance has long been increasing. The production of carbapenem- hydrolysing ß-lactamases (carbapenamases), which include NDM, KPC, OXA-48, IMP-1 and VIM is the most common mechanism. Case presentation: A 56 years old male presented with fever and mental changes with progressively decreasing sensorium for the last 3 days. He was admitted to Intensive care unit (ICU) with a diagnosis of meningoencephalitis. On day seven, he developed ventilator associated pneumonia due Klebsiella pnemoniae and Acinetobacter baumannii. He was on meropenem, but the isolates were susceptible to colistin, tigecyclin and amikacin solely. Hence, amikacin was started with addition of intravenous and nebulized colistin. Subsequently, vital signs improved with resolution of fever. However, on day 18, he developed fever once again with a drop in blood pressure. Inotropic support was maintained, and echinocandins and tigecycline were added to the regimen.Repeat blood and urine culture grew Providencia species, which were resistant to most of the drugs on phenotypic Kirby-Bauer disk diffusion method and are intrinsically resistant to colistin and tigecycline. Phenotypic detection of ESBL (combined disk method), MBL, KPCs, AmpC and co-producer were tested according to updated CLSI guideline and all were negative. But the Modified Hodges test was found to be positive. Consequenty, OXA-48 drug resistance pattern was brought into action by blank disc method according to A Tsakris et al., which revealed indentation of growth toward both EDTA and EDTA/PBA disk indicating production of OXA-48 carbapenamase. To confirm the resistance pattern we processed the isolated colonies for Xpert Carba-R (Cepheid) assay, which detected blaOXA-48 gene and confirmed the OXA-48 drug resistance pattern. Hence, the infecting organism was not susceptible to any of the antibiotics. The patient was kept under isolation and on 31th day of admission, he died of septic shock. Conclusions: Carbapenamase production along with intrinsic colistin resistance in infecting bacterial pathogens can cause fatal outcomes in the resource limited countries like Nepal where new antibiotic combinations ceftazidime+ Avibactam, or aztreonam +avibactam are not available. Drug resistance patterns including OXA 48 producer should be characterized in all cases by standard phenotypic methods or by Xpert Carba-R assay and larger studies are required to know the exact burden of OXA 48 producer in Nepal.

Human fascioliasis by Fasciola hepatica: the first case report in Nepal.

BACKGROUND: Fascioliasis is a zoonotic disease caused by Fasciola species. Patient may be asymptomatic or presents with jaundice and biliary colic or right hypochondriac pain due to bile duct obstruction with gastrointestinal symptoms. CASE PRESENTATION: We report a case of human fascioliasis in a 45 years old female presented to Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal on August, 2015 with fever, right hypochondriac pain, jaundice and occasional vomiting with anorexia for 4 months whose alkaline phosphatase was elevated and peripheral blood smear revealed eosinophilia. The patient also gives the history of consumption of water-cress. Endoscopic Retrograde Cholagiopancretography (ERCP) showed the presence of a flat worm resembling Fasciola hepatica and stool routine examination revealed ova of F. hepatica. The patient was treated with nitazoxanide by which she got improved. Repeat stool examination 2 weeks after treatment revealed no ova of F. hepatica. CONCLUSIONS: Patient with fascioliasis can be simply diagnosed with stool routine microscopy and treated with nitazoxanide. So patient with right hypochondriac pain, sign and symptoms of obstructive jaundice, eosinophilia and history of water-cress consumption should be suspected for fascioliasis and investigated and treated accordingly.

Epidemiology of device-associated infections in an intensive care unit of a teaching hospital in Nepal: A prospective surveillance study from a developing country.

BACKGROUND: Device-associated health care-acquired infections (DA-HAIs) in intensive care unit patients are a major cause of morbidity, mortality, and increased health care costs. METHODS: A prospective, structured clinicomicrobiological surveillance was carried out for 3 common DA-HAIs: ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI) present in the patients of an intensive care unit of a teaching hospital in Nepal. DA-HAIs were identified using the Centers for Disease Control and Prevention definitions, and their rates were expressed as number of DA-HAIs per 1,000 device-days. RESULTS: Overall incidence rate of DA-HAIs was 27.3 per 1,000 patient-days occurring in 37.1% of patients. The device utilization ratio for mechanical ventilation, central line catheter, and urinary catheter was 0.83, 0.63, and 0.78, respectively. The rates of VAP, CLABSI, and CAUTI were 21.40, 8.64, and 5.11 per 1,000 device-days, respectively. Acinetobacter spp (32.7%), Klebsiella spp (23.6%), Burkholderia cepacia complex (12.7%), and Escherichia coli (10.9%) were the common bacterial pathogens. Most of the bacterial isolates associated with DA-HAIs were found to be multidrug-resistant. CONCLUSIONS: Incidence of DA-HAIs in the study intensive care unit was high compared with that of developed countries. Formulation and implementation of standard infection control protocols, active surveillance of DA-HAIs, and antimicrobial stewardship are urgently needed in our country.

Antimicrobial susceptibility pattern of Shigella spp. isolated from children under 5 years of age attending tertiary care hospitals, Nepal along with first finding of ESBL-production.

BACKGROUND: Shigella is an important cause of bacterial gastroenteritis in resource-poor countries. The treatment of shigellosis mostly requires antibiotics. However, the increase of multidrug resistance along with emergence of extended-spectrum ß-lactamase and ciprofloxacin resistance among Shigella spp. has challenged the situation. This study was conducted to determine the distribution of species and antibiotic susceptibility pattern of Shigella species isolated from stool specimen among children less than 5 years of age in Nepal. RESULTS: Out of total 717 stool samples collected, 15 cases of Shigella spp. was isolated which includes 12 S. flexneri and 3 S. sonnei. Multidrug resistance was found among 13(86%) of the isolates. One of the isolates of S. flexneri was found to be ESBL-producer with MIC >256 mg/L for cefixime. CONCLUSION: The high occurrence of multidrug resistance among Shigella spp. along with a case of ESBL-production for the first time in Nepal alarms the concerns about dissemination of the resistant isolates. So, systemic monitoring of the antimicrobial susceptibility pattern of Shigella spp. is becoming crucial to guide therapy.

Isolation, speciation and antifungal susceptibility testing of Candida isolates from various clinical specimens at a tertiary care hospital, Nepal.

BACKGROUND: Candida species are responsible for various clinical infections ranging from mucocutaneous infection to life threatening invasive diseases along with increased resistance to antifungal drugs has made a serious concern. Resistance to antifungal agents has increased during the last decade. Thus, identification of Candida up to species level and its antifungal susceptibility testing has a paramount significance in the management of Candidal infections. The aim of the study was to speciate Candida species and to determine antifungal susceptibility pattern of Candida species to antifungal agents. METHODS: A total of 100 consecutive Candida species were isolated from 1248 clinical specimens over 7 months period. Growths on Sabouraud dextrose agar were evaluated for colony appearance, macroscopic examination, Gram staining, germ tube test and urea hydrolysis test. Further, they were processed for Candida speciation on CHROMagar. Antifungal susceptibility testing was performed as recommended by Clinical and Laboratory Standards Institute (CLSI) M44-A document. RESULTS: Out of 100 Candida isolates, Candida albicans (56%) was the most common species. Among the non-albicans Candida species, Candida tropicalis (20%) was the predominant isolate followed by Candida glabrata (14%). Regarding antifungal susceptibility pattern, Candida species were more susceptible to clotrimazole (82%) followed by fluconazole (64%) and miconazole (44%). CONCLUSIONS: Candida albicans was the predominant species responsible for various Candidal infections. Among commonly used antifungal drugs clotrimazole, miconazole and fluconazole were most effective.

Characterization of rotavirus causing acute diarrhoea in children in Kathmandu, Nepal, showing the dominance of serotype G12.

Diarrhoeal diseases are a major problem in developing countries. Though precise data on childhood mortality associated with diarrhoeal diseases in Nepal are not available, it has been estimated that approximately 25 % of child deaths are associated with diarrhoeal disease, particularly acute diarrhoea. The purpose of this study was to assess the incidence of rotavirus causing acute diarrhoea in children less than 5 years of age. A total of 525 children with acute diarrhoea in a children's hospital of Kathmandu, Nepal, were enrolled between April and September 2011. The incidence of acute diarrhoea due to rotavirus was 25.9 % (136/525) as determined by ELISA. The percentage of rotavirus-infected males was higher (64.5 %) than females (35.5 %). The frequency of rotavirus cases was higher in children less than 2 years of age, among which the majority of cases (80.2 %) were in children between 6 and 24 months old (P<0.01). Genotypic characterization by RT-PCR revealed that the serotype G12 represented 55.9 % of cases in this study associated with P-types of either P[6], P[4] or P[8]. Further to this, a total of eight G/P combinations were identified, G12P[6] being the most common strain type of rotavirus in Nepal, with a prevalence rate of 46.4 %. The aim of this study was to find out the major genotypes of rotavirus causing acute diarrhoea in children.