PER-8, a Novel Extended-Spectrum ß-Lactamase PER Variant, from an Acinetobacter baumannii Clinical Isolate in Nepal.

A novel PER-type extended-spectrum ß-lactamase, PER-8, was identified in an Acinetobacter baumannii clinical isolate obtained in Nepal. The amino acid sequence of PER-8 has a substitution at position 39 (Gly to Glu) compared with that of PER-7. The kcat/Km ratio of PER-8 for aztreonam was lower than that of PER-7, while the kcat/Km ratio of PER-8 for imipenem was higher than that of PER-7. The genomic environment surrounding blaPER-8 was intI1 blaPSE-1qacEDI sulI ISCR1-blaPER-8gts sulI orfX on a 100-kb plasmid.

Pseudomonas aeruginosa Clinical Isolates in Nepal Coproducing Metallo-ß-Lactamases and 16S rRNA Methyltransferases.

A total of 11 multidrug-resistant Pseudomonas aeruginosa clinical isolates were obtained in Nepal. Four of these isolates harbored genes encoding one or more carbapenemases (DIM-1, NDM-1, and/or VIM-2), and five harbored genes encoding a 16S rRNA methyltransferase (RmtB4 or RmtF2). A novel RmtF variant, RmtF2, had a substitution (K65E) compared with the same gene in RmtF. To our knowledge, this is the first report describing carbapenemase- and 16S rRNA methyltransferase-coproducing P. aeruginosa clinical isolates in Nepal.

Identification of a novel NDM variant, NDM-13, from a multidrug-resistant Escherichia coli clinical isolate in Nepal.

A novel New Delhi metallo-ß-lactamase, NDM-13, was identified in a carbapenem-resistant Escherichia coli clinical isolate obtained from the urine of a patient in Nepal. The enzymatic activity of NDM-13 against ß-lactams was similar to that of NDM-1. However, NDM-13 displayed significantly higher k cat/Km ratios for cefotaxime. The genetic environment of bla NDM-13 was determined to be tnpA-IS30-bla NDM-13-ble MBL-trpF-dsbC-cutA-groES-groL, with bla NDM-13 located within the chromosome.

NDM-12, a novel New Delhi metallo-ß-lactamase variant from a carbapenem-resistant Escherichia coli clinical isolate in Nepal.

A novel New Delhi metallo-ß-lactamase variant, NDM-12, was identified in a carbapenem-resistant Escherichia coli clinical isolate obtained from a urine sample from a patient in Nepal. NDM-12 differed from NDM-1 by two amino acid substitutions (M154L and G222D). The enzymatic activities of NDM-12 against ß-lactams were similar to those of NDM-1, although NDM-12 showed lower kcat/Km ratios for all ß-lactams tested except doripenem. The blaNDM-12 gene was located in a plasmid of 160 kb.

Identification of a novel 6'-N-aminoglycoside acetyltransferase, AAC(6')-Iak, from a multidrug-resistant clinical isolate of Stenotrophomonas maltophilia.

Stenotrophomonas maltophilia IOMTU250 has a novel 6'-N-aminoglycoside acetyltransferase-encoding gene, aac(6')-Iak. The encoded protein, AAC(6')-Iak, consists of 153 amino acids and has 86.3% identity to AAC(6')-Iz. Escherichia coli transformed with a plasmid containing aac(6')-Iak exhibited decreased susceptibility to arbekacin, dibekacin, neomycin, netilmicin, sisomicin, and tobramycin. Thin-layer chromatography showed that AAC(6')-Iak acetylated amikacin, arbekacin, dibekacin, isepamicin, kanamycin, neomycin, netilmicin, sisomicin, and tobramycin but not apramycin, gentamicin, or lividomycin.

NDM-1 Metallo-ß-Lactamase and ArmA 16S rRNA methylase producing Providencia rettgeri clinical isolates in Nepal.

BACKGROUND: Drug-resistant Providencia rettgeri producing metallo-ß-lactamase and 16S rRNA methylase has been reported in several countries. We analyzed P. rettgeri clinical isolates with resistance to carbapenems and aminoglycosides in a hospital in Nepal. METHODS: Five clinical isolates of multidrug-resistant P. rettgeri were obtained in a hospital in Nepal. Antimicrobial susceptibilities were determined using the microdilution method and entire genomes were sequenced to determine drug-resistant genes. Epidemiological analysis was performed by pulsed-field gel electrophoresis. RESULTS: Four of the 5 isolates were resistant to carbapenems (imipenem and meropenem), with MICs ≥16 mg/L, with the remaining isolate showing intermediate resistance to imipenem, with an MIC of 2 mg/L and susceptibility to meropenem with an MIC ≤1 mg/L. All 5 isolates had blaVEB-1. Of the 4 carbapenem-resistant strains, 3 had blaNDM-1 and 1 had blaOXA-72. All isolates were highly resistant to aminoglycosides (MICs ≥1,024 mg/L) and harbored armA. As the result of pulsed-field gel electrophoresis pattern analysis in the 5 P. rettgeri isolates, 4 had identical PFGE patterns and the fifth showed 95.7% similarity. CONCLUSIONS: This is the first report describing multidrug-resistant P. rettgeri strains harboring blaNDM-1 or blaOXA-72 and armA isolated from patients in Nepal.

NDM-8 metallo-ß-lactamase in a multidrug-resistant Escherichia coli strain isolated in Nepal.

A novel metallo-ß-lactamase, NDM-8, was identified in a multidrug-resistant Escherichia coli isolate, IOMTU11 (NCGM37), obtained from the respiratory tract of a patient in Nepal. The amino acid sequence of NDM-8 has substitutions at positions 130 (Asp to Gly) and 154 (Met to Leu) compared with NDM-1. NDM-8 showed enzymatic activities against ß-lactams similar to those of NDM-1.

Distribution of antibody titer against Salmonella enterica among healthy individuals in nepal.

BACKGROUND: Enteric fever is an endemic problem in Nepal and Widal agglutination test is widely used for its diagnosis but a normal baseline titer in healthy population and cutoff values have not been established. METHODS: We measured average baseline antibody titers against "O" and "H" antigens of Salmonella enterica serotype Typhi and "H" antigens of serotypes Paratyphi A and Paratyphi B among apparently healthy blood donors in Nepal. The antibody titers were measured using Standard Widal Confirmatory Quantitative Tube test. RESULTS: Among the 100 blood samples collected from healthy volunteers, 62 individuals had significant antibody titers (> or = 1:20) against one of the four antigens against S. enterica. Among 54 samples with an anti-O titer against serotype Typhi, 15 and 36 samples had titers of > or = 1:60 and > or = 1:40, respectively. A significant proportion (12% of all) had anti-O titer of > or = 1:80. Similarly, among the 59 samples demonstrating anti-H titers of > or = 1:20 to S. enterica serotype Typhi, 29 had a titer of > or = 1:80 and 12 had 1:160. For S. enterica serotypes Paratyphi A and B, anti-H titers of > or = 1:20 were found only in 12% and 3%, respectively, of all samples tested. CONCLUSION: When a single Widal agglutination titer is used for the diagnosis of enteric fever, it will be more appropriate to change the currently used cutoff levels against S. enterica serotype Typhi to > 1:80 for anti-O and > 1:160 for anti-H titers for Nepal.

A Novel 6'-N-Aminoglycoside Acetyltransferase, AAC(6')-Ial, from a Clinical Isolate of Serratia marcescens.

Serratia marcescens IOMTU115 has a novel 6'-N-aminoglycoside acetyltransferase-encoding gene, aac(6')-Ial. The encoded protein AAC(6')-Ial has 146 amino acids, with 91.8% identity to the amino acid sequence of AAC(6')-Ic in S. marcescens SM16 and 97.3% identity to the amino acid sequence of AAC(6')-Iap in S. marcescens WW4. The minimum inhibitory concentrations of aminoglycosides for Escherichia coli expressing AAC(6')-Ial were similar to those for E. coli expressing AAC(6')-Ic or AAC(6')-Iap. Thin-layer chromatography showed that AAC(6')-Ial, AAC(6')-Ic, or AAC(6')-Iap acetylated all the aminoglycosides tested, except for apramycin, gentamicin, and lividomycin. Kinetics assays revealed that AAC(6')-Ial is a functional acetyltransferase against aminoglycosides. The aac(6')-Ial gene was located on chromosomal DNA.

Fact-finding Survey of Nosocomial Infection Control in Hospitals in Kathmandu, Nepal-A Basis for Improvement.

The purpose of this study was to investigate the actual conditions of nosocomial infection control in Kathmandu City, Nepal as a basis for the possible contribution to its improvement. The survey was conducted at 17 hospitals and the methods included a questionnaire, site visits and interviews. Nine hospitals had manuals on nosocomial infection control, and seven had an infection control committee (ICC). The number of hospitals that met the required amount of personal protective equipment preparation was as follows: gowns (13), gloves (13), surgical masks (12). Six hospitals had carried out in-service training over the past one year, but seven hospitals responded that no staff had been trained. Eight hospitals were conducting surveillance based on the results of bacteriological testing. The major problems included inadequate management of ICC, insufficient training opportunities for hospital staff, and lack of essential equipment. Moreover, increasing bacterial resistance to antibiotics was recognized as a growing issue. In comparison with the results conducted in 2003 targeting five governmental hospitals, a steady improvement was observed, but further improvements are needed in terms of the provision of high quality medical care. Particularly, dissemination of appropriate manuals, enhancement of basic techniques, and strengthening of the infection control system should be given priority.

Medical students' characteristics as predictors of career practice location: retrospective cohort study tracking graduates of Nepal's first medical college.

OBJECTIVE: To determine, in one low income country (Nepal), which characteristics of medical students are associated with graduate doctors staying to practise in the country or in its rural areas. DESIGN: Observational cohort study. SETTING: Medical college registry, with internet, phone, and personal follow-up of graduates. PARTICIPANTS: 710 graduate doctors from the first 22 classes (1983-2004) of Nepal's first medical college, the Institute of Medicine. MAIN OUTCOME MEASURES: Career practice location (foreign or in Nepal; in or outside of the capital city Kathmandu) compared with certain pre-graduation characteristics of medical student. RESULTS: 710 (97.7%) of the 727 graduates were located: 193 (27.2%) were working in Nepal in districts outside the capital city Kathmandu, 261 (36.8%) were working in Kathmandu, and 256 (36.1%) were working in foreign countries. Of 256 working abroad, 188 (73%) were in the United States. Students from later graduating classes were more likely to be working in foreign countries. Those with pre-medical education as paramedics were twice as likely to be working in Nepal and 3.5 times as likely to be in rural Nepal, compared with students with a college science background. Students who were academically in the lower third of their medical school class were twice as likely to be working in rural Nepal as those from the upper third. In a regression analysis adjusting for all variables, paramedical background (odds ratio 4.4, 95% confidence interval 1.7 to 11.6) was independently associated with a doctor remaining in Nepal. Rural birthplace (odds ratio 3.8, 1.3 to 11.5) and older age at matriculation (1.1, 1.0 to 1.2) were each independently associated with a doctor working in rural Nepal. CONCLUSIONS: A cluster of medical students' characteristics, including paramedical background, rural birthplace, and lower academic rank, was associated with a doctor remaining in Nepal and with working outside the capital city of Kathmandu. Policy makers in medical education who are committed to producing doctors for underserved areas of their country could use this evidence to revise their entrance criteria for medical school.

Phenotypic characterization of nosocomial isolates of Staphylococcus aureus with reference to MRSA.

BACKGROUND: Apart from being a major cause of mortality, nosocomial infections due to Staphylococcus aureus have been imposing a burden on patients, hospitals and health care systems. The present study was designed to determine the prevalence of methicillin resistant S. aureus (MRSA) among nosocomial isolates along with their phenotypic characterization. METHODOLOGY: MRSA and methicillin sensitive S. aureus (MSSA) were determined by performing four different tests viz: disc diffusion, oxacillin screen agar test, MRSA latex agglutination test, and MIC of oxacillin by E test. RESULTS: Of the 149 S. aureus nosocomial isolates, 44.9% were MRSA, which included 82.1% of homogeneous MRSA and 17.9% of heterogeneous MRSA. Association of MRSA infection was found to be significantly higher in skin and lower respiratory tract infections. Of the MRSA isolates, 65 were multiresistant oxacillin resistant Staphylococcus aureus (MORSA) and 2 were nonmultiresistant oxacillin resistant Staphylococcus aureus (NORSA). D tests performed on 136 isolates showed that Inducible macrolide-lincosamide-streptogramin B (MLSB) and constitutive MLSB resistance were found to be associated with MRSA. On the contrary, susceptibility to both erythromycin and clindamycin was found to be associated with MSSA. However, MSB (macrolide-streptogramin B) resistance was not found associated either with MRSA or MSSA. Furthermore, both inducible and constitutive MLSB were found to be associated with only homogenous MRSA. CONCLUSION: D tests may be made mandatory in all S. aureus isolates as inducible MLSB resistance cannot be detected in routine susceptibility test unless erythromycin and clindamycin are placed 15-26 mm apart.