Multidrug resistance among uropathogenic clonal group A E. Coli isolates from Pakistani women with uncomplicated urinary tract infections.

OBJECTIVE: Multi-drug resistance (MDR) has notably increased in community acquired uropathogens causing urinary tract infections (UTIs), predominantly Escherichia coli. Uropathogenic E. coli causes 80% of uncomplicated community acquired UTIs, particularly in pre-menopausal women. Considering this high prevalence and the potential to spread antimicrobial resistant genes, the current study was conducted to investigate the presence of clinically important strains of E. coli in Pakistani women having uncomplicated cystitis and pyelonephritis. Women belonging to low-income groups were exclusively included in the study. Seventy-four isolates from urine samples were processed, phylotyped, and screened for the presence of two Single Nucleotide Polymorphisms (SNPs) particularly associated with a clinically important clonal group A of E. coli (CgA) followed by antibiotic susceptibility testing and genome sequence analysis. RESULTS: Phylogroup B2 was most prevalent in patients and 44% of isolates were positive for the presence of CgA specific SNPs in Fumarate hydratase and DNA gyrase subunit B genes. Antibiotic susceptibility testing showed widespread resistance to trimethoprim-sulfamethoxazole and extended-spectrum beta-lactamase production. The infection analysis revealed the phylogroup B2 to be more pathogenic as compared to the other groups. The genome sequence of E. coli strain U17 revealed genes encoding virulence, multidrug resistance, and host colonization mechanisms. CONCLUSIONS: Our research findings not only validate the significant occurrence of multidrug-resistant clonal group A E. coli (CgA) in premenopausal Pakistani women suffering from cystitis and pyelonephritis but also reveal the presence of genes associated withvirulence, and drug efflux pumps. The detection of highly pathogenic, antimicrobial-resistant phylogroup B2 and CgA E. coli strains is likely to help in understanding the epidemiology of the pathogen and may ultimately help to reduce the impact of these strains on human health. Furthermore, the findings of this study will particularly help to reduce the prevalence of uncomplicated UTIs and the cost associated with their treatment in women belonging to low-income groups.

The Utility of Frequent Laboratory Monitoring for Patients on Tumor Necrosis Factor-Alpha Inhibitors in Dermatology.

Introduction: Tumor necrosis factor-alpha inhibitors (TNF-ai) are becoming increasingly common to use among patients with skin disease. To safely take these medications, it is recommended to monitor laboratory values routinely; however, the utility of this practice and the risk-benefit of frequent laboratory monitoring has not been explored fully in patients with skin disease. The purpose of this study was to evaluate the necessity of routine laboratory monitoring in patients taking a TNF-ai with a dermatological disease. Methods: Retrospective chart review evaluated laboratory abnormalities (complete blood counts and liver function tests) in adult patients who took a TNF-ai for a dermatologic disease at The University of Kansas Hospital. Results: There were 27 patients included for a total of 45 entries. The most common skin disease was hidradenitis suppurativa (23/45) and infliximab (22/45) was most the commonly used medication. Of the 45 entries, there were only seven patients that developed abnormal monitoring laboratory values related to initiation of TNF-ai. These abnormalities were transient and most frequently occurred after 12 months, with 2 of the 45 resulting in no discontinuation or dose reduction of TNF-ai. One patient discontinued medication due to anemia that did not improve after medication withdrawal. Conclusions: Laboratory abnormalities due to TNF-ai were infrequent and when they did occur were transient and mild. The study was limited by the small sample size of patients, and larger prospective studies are needed to evaluate these findings fully. However, dermatologists may be able to employ less frequent laboratory monitoring safely for patients on TNF-ai.

Can an amino acid mixture alleviate gastrointestinal symptoms in neuroendocrine tumor patients?

BACKGROUND: Neuroendocrine tumors, although relatively rare in incidence, are now the second most prevalent gastrointestinal neoplasm owing to indolent disease biology. A small but significant sub-group of neuroendocrine tumor patients suffer from diarrhea. This is usually secondary to carcinoid syndrome but can also be a result of short gut syndrome, bile acid excess or iatrogenic etiologies. Recently, an amino acid based oral rehydration solution (enterade® Advanced Oncology Formula) was found to have anti-diarrheal properties in preclinical models. METHODS: A retrospective chart review of all NET patients treated with enterade® AO was performed after IRB approval. RESULTS: Ninety-eight NET patients who had received enterade® AO at our clinic from May 2017 through June 2019 were included. Patients (N = 49 of 98) with follow up data on bowel movements (BMs) were included for final analysis. Eighty-four percent of patients (41/49) had fewer BMs after taking enterade® AO and 66% (27/41) reported more than 50% reduction in BM frequency. The mean number of daily BMs was 6.6 (range, 3-20) at baseline before initiation of therapy, while the mean number of BMs at 1 week time point post enterade® AO was 2.9 (range, 0-11). CONCLUSIONS: Our retrospective observations are encouraging and support prospective validation with appropriate controls in NET patients. This is first published report of the potential anti-diarrheal activity of enterade® AO in NET patients.

Hemorrhage Rates in Pediatric Patients Receiving Postoperative Steroids After Tonsillectomy.

Importance. Developing a safe postoperative pain regimen after tonsillectomy is important. While postoperative steroids may provide an analgesic benefit, it is not known whether steroids increase the bleeding risk after tonsillectomy. Objective. To determine whether postoperative steroids increase the risk of hemorrhage after tonsillectomy in children. Design. Retrospective cohort study. Setting. Tertiary referral academic medical center. Participants. An age- and indication-matched cohort was randomly selected from tonsillectomy patients ≤12 years old from 2012 to 2017. Intervention. Prednisolone, 0.5 mg/kg (maximum dose 20 mg/day) qAM × 3 days postoperatively. Main Outcome. Postoperative hemorrhage requiring operative intervention. Results. A total of 1358 patients were included in this study, 679 of which received postoperative steroids. The steroid group had a similar of operative intervention for post-tonsillectomy hemorrhage of 1.8% versus 2.2% in the nonsteroid group (P = .560). Conclusion and Relevance. Post-tonsillectomy steroid use is not associated with an increase in operative intervention for postoperative hemorrhage.

Post FDA approval analysis of 200 gallium-68 DOTATATE imaging: A retrospective analysis in neuroendocrine tumor patients.

Gallium-68 DOTATATE provides physiologic imaging and assists in disease localization for somatostatin receptor (SSTR) positive neuroendocrine tumor (NET) patients. However, questions regarding usefulness of gallium- 68 DOTATATE imaging in identifying the primary site in neuroendocrine tumors (NETS) of unknown primary, correlation of NET grade with median Standardized Uptake Value (SUV) and effects of long acting somatostatin analog on gallium-68 DOTATATE imaging quality needs to be evaluated. A single institution retrospective review of the first 200 NET patients with gallium-68 DOTATATE imaging from Dec 2016 to Dec 2017 was conducted. Questions related to NETs of unknown primary, correlation of Standardized Uptake Value (SUV) to Ki-67 (which signifies proliferation rate), the effects of long-acting systemic somatostatin analog (SSA) on SUV were part of our data analysis. From these 200 patients, 59.5% (119) were females, 40.5% (81) were males; the median age was 62 years. The following primary tumor sites were identified: small bowel-37.5%; pancreas-18.5%; bronchial-14%; colon-3.5%; rectum-2%; appendix-1.5%; adrenal-0.5%; prostate-0.5%; others-3% and unknown primary-19%. Mean hepatic SUV of the lesion with the greatest radiolabeled uptake in 96 patients was similar irrespective to exposure to long acting SSA. Patients exposed to long acting SSA had mean SUV of 31.3 vs 27.8 for SSA naïve patients. The difference was not statistically significant. Gallium-68 DOTATATE imaging seems to distinguished G3 NET from G1/G2 based on mean SUV, and also identified the primary tumor site in 17 of 38 (45%) patients with unknown primary. Systemic exposure to long acting SSA does not appear to influence mean SUV of gallium-68 DOTATATE scan.

Transmission of multidrug-resistant Campylobacter jejuni to children from different sources in Pakistan.

OBJECTIVES: Due to the rapid emergence of multidrug-resistant isolates, Campylobacter jejuni (C. jejuni) has been classified as a member of the priority pathogens group. This study aimed to determine the prevalence, antibiotic resistance patterns and source tracking of clinical C. jejuni isolates from paediatric diarrhoeal patients in Pakistan. METHODS: A total of 150 stool samples from children were processed for the presence of C. jejuni using culture, biochemical tests and species-specific PCR. Antibiotic susceptibility of the isolates was determined by the disc diffusion method, and metallo-ß-lactamase (MBL) producers were detected using gene-specific PCR. Source tracking was performed using source-predictive PCR. RESULTS: C. jejuni was present in 54.6% of the processed samples. More than 80% of the isolated strains were resistant to seven of 12 tested antibiotics. High levels of susceptibility were observed against imipenem (12.2%) and TGC (9.7%). Six isolates (7.3%) were MBL producers and positive for at least one of the five MBL genes. Source tracking showed that 57.3% of the isolates belonged to livestock-associated clusters (C1-C6) and 42.8% were assigned to non-livestock/environmental clusters (C7-C9). Isolates belonging to livestock clusters had a high Multiple Antibiotic Resistance (MAR) index (P < 0.001) as compared with non-livestock. CONCLUSION: A high prevalence of multidrug-resistant C. jejuni among paediatric diarrhoeal patients was observed. Moreover, the association of these isolates to livestock clades suggests transmission to human populations via the food chain. The presence of imipenem-resistant MBL-producing C. jejuni can lead to serious public health concerns.

Incidence of metallo-beta-lactamase-producing Klebsiella pneumoniae isolates from hospital setting in Pakistan.

The aim of this study was monitoring and surveillance in different wards of the PIMS hospital, Islamabad, to understand emerging challenges of antibiotic resistance in particular association with most virulent serotypes of Klebsiella pneumoniae. The study was conducted during March 2015 to September 2015. The study showed that rate of isolation of K. pneumoniae was 37% (103 positives out of a total of 277 clinical samples) and 7.7% (8) were phenotypically and genotypically confirmed to be metallo-ß-lactamase resistant (carbapenem resistant) and all of them were multidrug resistant (MDR). These carbapenem-resistant isolates were isolated from blood, endotracheal tubes, and pus. Molecular screening for the presence of integrons indicated that distribution of class I integrons (87.5% of carbapenem-resistant K. pneumoniae isolates) was higher than class II integrons (1.25%) among given isolates. The study indicated that exposure of metallo-beta-lactamase-producing strains through hospitalizations increases the chances of spread of MDR pathogens. There is an urgent need for effective surveillance and monitoring strategies to control the spread of extremely resistant K. pneumoniae implicated in nosocomial infections leading to the increased health burden and enforcement of policy guideline on appropriate antibiotics usage.

Resistance patterns of diversified phylogroups of Escherichia coli associated with mothers having history of preterm births in Pakistan.

OBJECTIVE: Urinary tract infections (UTIs) are caused by extraintestinal pathogenic Escherichia coli (ExPEC), and are one of the key predictors of preterm births. In the light of this fact, present study was conducted to determine the predominant Escherichia coli (E. coli) phylotypes and their associated antibiotic susceptibility patterns, isolated from pregnant mothers with the history of preterm births. METHODS: Forty seven E. coli strains were isolated out of a total of 80 urine samples of pregnant women. The isolates were phylotyped and further screened for the presence of Clonal group A. Moreover, Antimicrobial susceptibility testing and screening for Extended Spectrum Beta Lactamase (ESBL) producing strains were also performed. RESULTS: Among the 47 isolates, phylogroup B2 was found to be highly prevalent (45%), followed by group D (23%), B1 (10.64%), A (6.38%), E (6.38%), cryptic clade I (4.25%) and F (2.13%). Two isolates belonged to CgA and 41 (87.23%) isolates were found to be multidrug-resistant. Out of nine antibiotics tested in the study, the isolates displayed high resistance to Ampicillin (82.6%), Sulphamethoxazole (65.22%), Nalidixic acid (60.87%), Sulphamethoxazole-Trimethoprim, Doxycycline and Erythromycin (56.52% each). In total, 8 (17.02%) of the isolates were found to be ESBL positive. CONCLUSIONS: The prevalence of infections caused by virulent and highly drug resistant E. coli isolates constitute a risk of developing preterm birth complications in pregnant women and requires the selection of appropriate antibiotics for the treatment of infections caused during pregnancy.

Characterization of enteropathogenic Escherichia coli of clinical origin from the pediatric population in Pakistan.

BACKGROUND: Enteropathogenic Escherichia coli (EPEC) is one of the leading causes of watery diarrhea among children. METHODS: In this study EPEC isolates from the pediatric population of Pakistan (2010-2012) were subjected to phylotyping, antibiotic susceptibility, extended-spectrum beta-lactamase (ESBL) profiling and evaluation of one representative strain from each panel of phylotypesin Galleria mellonella, infection model. RESULTS: A total of 46/225 (20.4%) stool samples were positive for EPEC. Isolates mainly belong to D phylogroup (18, 39%) followed by nontypeable (10, 22%), B1 (9, 20%), B2 (8, 17%) and A (1, 2%). High resistance was observed for ampicillin (42, 91%), erythromycin (41, 89%), cefaclor (37, 80%), trimethoprim/sulfamethoxazole (36, 78%), tetracycline (36, 78%). Among nalidixic acid resistant isolates 13 (28%) showed presence of single nucleotide polymorphism (SNP) in parC (C330-T330) whereas 1 (2%) isolate showed gyrB (A660-T660) SNP. Furthermore, 27 (59%) isolates were ESBL producers. Representative isolates of phlyotypes A and B2 showed enhance killing of G. mellonella compared to ones belonging to phylotypes B1 and D. CONCLUSIONS: Non-typeable EPEC strains were frequently observed. ESBL production in ESBL producers was found to be plasmid mediated. No significant association of antibiotic resistance profile with specific phylogroup of EPEC was found, however G. mellonella infection model differentiated representative phylotypes.

Phenotypic and genotypic characterization of enteroaggregative Escherichia coli isolates from pediatric population in Pakistan.

Enteroaggregative Escherichia coli (EAEC) are a leading cause of diarrhea among children. The objective of this study was to define the frequency of EAEC among diarrheal children from flood-affected areas as well as sporadic cases, determine multidrug resistance, and evaluation of virulence using an in vivo model of pathogenesis. Stool samples were collected from 225 diarrheal children from 2010 to 2011 from flood-affected areas as well as from sporadic cases in Pakistan. Identified EAEC isolates were characterized by phylogrouping, antibiotic resistance patterns including the extended-spectrum beta lactamase spectrum, single nucleotide polymorphism detection in gyrA and parC, and virulence potential using wax worm, G. mellonella. A total of 35 (12.5%) confirmed EAEC isolates were identified among 225 E. coli isolates. EAEC isolates displayed high resistance to tetracycline, ampicillin, and cefaclor. A total of 34.28% were ESBL positive. Single nucleotide polymorphism detection revealed 37.14% and 68.57% isolates were positive for SNPs in gyrA (A660 -T660 ) and parC (C330 -T330 ), respectively. Phylogrouping revealed that B2 phylogroup was more prevalent among all EAEC isolates tested followed by D, A, B1, and non-typeable (NT). Infection of G. mellonella with EAEC showed that killing infective dose was 100% higher than E. coli DH5 alpha control. EAEC are prevalent among Pakistani children with diarrhea, they are highly resistant to antibiotics, and predominantly fall into B2 phylogroup. Epidemiologic surveillance of EAEC and other E. coli pathotypes is critical to assess not only the role of these pathogens in diarrheal disease but also to determine the extent of multidrug resistance among the population.

Draft Genome Sequence of the Enteropathogenic Bacterium Campylobacter jejuni Strain cj255.

The enteropathogen Campylobacter jejuni is a global health disaster, being one of the leading causes of bacterial gastroenteritis. Here, we present the draft genome sequence of C. jejuni strain cj255, isolated from a chicken source in Islamabad, Pakistan. The draft genome sequence will aid in epidemiological studies and quarantine of this broad-host-range pathogen.

Antibiotic susceptibility profiling and virulence potential of Campylobacter jejuni isolates from different sources in Pakistan.

OBJECTIVE: To determine antibiotic resistance patterns and virulence potential of Campylobacter jejuni (C. jejuni) isolates from clinical human diarrheal infections, cattle and healthy broilers. METHODS: Antibiotic sensitivity patterns of C. jejuni isolates were determined by Kirby Bauer Disc Diffusion assay. These isolates were then subjected to virulence profiling for the detection of mapA (membrane-associated protein), cadF (fibronectin binding protein), wlaN (beta-l,3-galactosyltransferase) and neuAB (sialic acid biosynthesis gene). Further C. jejuni isolates were grouped by random amplification of polymorphic DNA (RAPD) profiling. RESULTS: A total of 436 samples from poultry (n=88), cattle (n=216) and humans (n=132) from different locations were collected. Results revealed percentage of C. jejuni isolates were 35.2% (31/88), 25.0% (54/216) and 11.3% (15/132) among poultry, cattle and clinical human samples respectively. Antibiotic susceptibility results showed that similar resistance patterns to cephalothin was ie. 87.0%, 87.1% and 89%among humans, poultry and cattle respectively, followed by sulfamethoxazole+trimethoprim 40.0%, 38.7% and 31.0% in humans, poultry and cattle and Ampicillin 40%, 32% and 20% in humans, poultry and cattle respectively. Beta-lactamase activity was detected in 40.00% humans, 20.37% cattle and 32.25% in poultry C. jejuni isolates. CadF and mapA were present in all poultry, cattle and human C. jejuni isolates, wlaN was not detected in any isolate and neuAB was found in 9/31 (36%) poultry isolates. RAPD profiling results suggested high diversity of C. jejuni isolates. CONCLUSIONS: Detection of multidrug resistant C. jejuni strains from poultry and cattle is alarming as they can be potential hazard to humans. Moreover, predominant association of virulence factors, cadF and mapA (100% each) in C. jejuni isolates from all sources and neuAB (36%) with poultry isolates suggest the potential source of transmission of diverse types of C. jejuni to humans.