Phylodynamic signatures in the emergence of community-associated MRSA.

Community-associated, methicillin-resistant Staphylococcus aureus (MRSA) lineages have emerged in many geographically distinct regions around the world during the past 30 y. Here, we apply consistent phylodynamic methods across multiple community-associated MRSA lineages to describe and contrast their patterns of emergence and dissemination. We generated whole-genome sequencing data for the Australian sequence type (ST) ST93-MRSA-IV from remote communities in Far North Queensland and Papua New Guinea, and the Bengal Bay ST772-MRSA-V clone from metropolitan communities in Pakistan. Increases in the effective reproduction number (Re) and sustained transmission (Re > 1) coincided with spread of progenitor methicillin-susceptible S. aureus (MSSA) in remote northern Australian populations, dissemination of the ST93-MRSA-IV genotype into population centers on the Australian East Coast, and subsequent importation into the highlands of Papua New Guinea and Far North Queensland. Applying the same phylodynamic methods to existing lineage datasets, we identified common signatures of epidemic growth in the emergence and epidemiological trajectory of community-associated S. aureus lineages from America, Asia, Australasia, and Europe. Surges in Re were observed at the divergence of antibiotic-resistant strains, coinciding with their establishment in regional population centers. Epidemic growth was also observed among drug-resistant MSSA clades in Africa and northern Australia. Our data suggest that the emergence of community-associated MRSA in the late 20th century was driven by a combination of antibiotic-resistant genotypes and host epidemiology, leading to abrupt changes in lineage-wide transmission dynamics and sustained transmission in regional population centers.

Pathways to prevention: insights on stemming HIV outbreaks in Larkana, Pakistan.

In the past two decades, Pakistan has faced multiple human immunodeficiency virus outbreaks, with Larkana appearing to be the hub of such outbreaks. While the previous Larkana outbreaks happened in high-risk populations, the alarming outbreak in 2019 occurred in a low-risk paediatric population, raising several concerning questions. Human immunodeficiency virus infections spilling into the general population is indicative of a steady increase in the number of cases, and the failure of control strategies to stem the concentrated epidemic from evolving. Although several causative factors have been identified from previous outbreaks, the one that occurred in 2019 may have been influenced by an additional, hitherto unexplored factor; child sexual abuse. The current narrative review was planned to summarise human immunodeficiency virus risk factors and causes identified in previous Larkana epidemics, to explore potential reasons for the outbreaks in children, and to discuss possible steps needed for stemming human immunodeficiency virus outbreaks in Pakistan.

Interleukin-6 (IL-6) as a Predictor of Clinical Outcomes in Patients with COVID-19.

BACKGROUND: Interleukin-6 (IL-6) has been known to be involved in immune regulation, inflammatory response, and metabolism. It is also recognized as the major cause to underscore the pathology of severe COVID-19 patients. However, it remains to be seen if IL-6 is superior to other inflammatory biomarkers in ascertaining clinical severity and mortality rate for COVID-19. This study aimed to determine the value of IL-6 as a predictor of severity and mortality in COVID-19 patients and compare it with other pro-inflammatory biomarkers in the South Asian region. METHODS: An observational study was conducted, including all adult SARS-CoV-2 patients who had undergone IL-6 testing from December 2020 to June 2021. The patients' medical records were reviewed to collect demographic, clinical, and biochemical data. Other pro-inflammatory biomarkers apart from IL-6 included Neutrophils to Lymphocyte Ratio (NLR), D-dimer, C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), and procal-citonin for analysis. SPSS version 22.0 was utilized. RESULTS: Out of the 393 patients who underwent IL-6 testing, 203 were included in the final analysis with a mean (SD) age of 61.9 years (12.9) and 70.9% (n = 144) were male. Fifty-six percent (n = 115) subjects had critical disease. IL-6 levels were elevated (> 7 pg/mL) in 160 (78.8%) patients. Levels of IL-6 significantly correlated with age, NLR, D-dimer, CRP, ferritin, LDH, length of stay, clinical severity, and mortality. All the inflammatory markers were significantly increased in critically ill and expired patients (p < 0.05). The receiver operator curve showed that IL-6 had the best area under the curve (0.898) compared to other pro-inflammatory biomarkers for mortality with comparable results for clinical severity. CONCLUSIONS: Study findings show that though IL-6 is an effective marker of inflammation and can be helpful for clinicians in recognizing patients with severe COVID-19. However, we still need further studies with larger sample size.

Diagnostic value of bronchoscopy in Sars-Cov-2 infection: A systematic review.

OBJECTIVE: To investigate the diagnostic performance of bronchoscopy in patients with coronavirus disease 2019 infection. METHODS: The systematic review was conducted in April 2021 and comprised search of published articles and preprint servers for original articles assessing diagnostic performance of bronchoscopy in patients with suspected coronavirus disease 2019 infection. The primary outcome of interest was diagnostic sensitivity of bronchoalveolar lavage in the patients. The quality of each study was assessed using the Quality Assessment, Data Abstraction and Synthesis-2 tool. RESULTS: Of the 29 full-text articles assessed for eligibility, 4(13.8%) were included collectively comprising 209 patients who had undergone bronchoalveolar lavage. Mean sensitivity of bronchoalveolar lavage was 83.5% ± 10.63 (range: 68.2-940%). Overall, the 4 studies had an unclear or low risk of bias. CONCLUSIONS: Limited data suggested that bronchoscopy with bronchoalveolar lavage did not have reliably higher diagnostic sensitivity than that reported for either nasopharyngeal or oropharyngeal swabs.

Country data on AMR in Pakistan in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome.

BACKGROUND: Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action. OBJECTIVES: To review the current situation with respect to AMR in Pakistan and initiatives addressing it. Identifying areas where more information is required will provide a call to action to minimize any further rises in AMR and improve patient outcomes. METHODS: National AMR initiatives, antibiotic use and prescribing in Pakistan, and availability of susceptibility data, in particular for the key community-acquired respiratory tract infection (CA-RTI) pathogens (Streptococcus pneumoniae and Haemophilus influenzae) were identified. National and international antibiotic prescribing guidelines for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) commonly used locally were also reviewed, plus local antibiotic availability. Insights from a local clinician and clinical microbiologist were sought to contextualize this information. CONCLUSIONS: Pakistan is active in developing initiatives to address AMR such as compiling a National Action Plan. However, antibiotic consumption is high and although there is legislation in place prohibiting over-the-counter purchase of antibiotics, this is still possible. Healthcare professionals use local and international antibiotic prescribing guidelines for CA-RTIs when managing patients. As highlighted by the clinical microbiologist's expert comments, surveillance of AMR in locally prevalent microorganisms is lacking. A more standardized inclusive approach in developing local guidelines, using up-to-date local surveillance data of isolates from community-acquired infections, could make management guideline use more locally relevant for clinicians. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development and improve clinical outcomes for patients.

Latent M. tuberculosis infection is associated with increased inflammatory cytokine and decreased suppressor of cytokine signalling (SOCS)-3 in the diabetic host.

Tuberculosis (TB) outcomes are worsened by type II diabetes mellitus (DM). Protective immunity against Mycobacterium tuberculosis (MTB) is driven by cytokines. Latent TB (LTBi) is common but its effect on the diabetic host is not well understood. We investigated mycobacterial antigen-stimulated responses in peripheral blood mononuclear cell (PBMC) isolated from healthy endemic controls (EC), those with LTBi, DM groups with and without LTBi, as compared with TB patients. Cytokines were measured using a Luminex-based assay. Gene expression was determined by RT-PCR. In DM-LTBi cases, PPD-stimulated proinflammatory cytokines; IFN-γ, IL-6, IL-2, TNF-α and GM-CSF and anti-inflammatory cytokines, IL-5 and IL-13 were raised as compared with EC. DM-LTBi PPD-stimulated IFN-γ, IL-6 and TNF-α mRNA titres were found raised in DM-LTBi, whilst suppressor of cytokine signalling (SOCS)-3 expression was lowered. Within DM cases, stratification based on HbA1c levels revealed raised IFN-γ but lowered IL-6 gene expression in those with controlled levels as compared with uncontrolled glycaemic levels. Further, SOCS1 expression levels were found higher in DM cases with controlled glycaemia when compared with EC. Overall, we show that diabetics with LTBi manifest raised levels of inflammatory and anti-inflammatory cytokines concomitant with reduced SOCS3 mRNA expression. Reduced glycaemic control results in further inflammatory dysregulation impacting conversing impacting IFN-γ and IL-6 activation. These results suggest that dysregulated immune activation in diabetes is exacerbated by LTBi, lack of glycaemic control may further compromise immunity against MTB infection.

Etiology, clinical characteristics, and outcome of infective endocarditis: 10-year experience from a tertiary care center in Pakistan.

This study was conducted to assess the clinical characteristics, causative agents, complications, and outcomes of infective endocarditis (IE) among patients presenting to our tertiary care center over the last decade. This retrospective cohort study included all adult patients admitted to the Aga Khan University Hospital with the diagnosis of IE over a ten-year period from 2010 to 2020.  Outcomes variables included complications during hospitalization, surgical intervention, mortality, and length of stay. We identified a total of 305 cases out of which 176 (58%) were males and 129 (42%) were females. The mean age of the patients was 46.9±18.8 years. 95 (31%) had prosthetic valves in place. Staphylococcus aureus was isolated in 54 (39%) patients followed by coagulase-negative Staphylococcus in 23 (17%). Echocardiography revealed vegetations and abscesses in 236 (77%) and 4 (1%) patients, respectively. The most common valvular complication was mitral valve regurgitation found in 26 (9%) patients, followed by tricuspid valve regurgitation in 13 (4%) patients and aortic valve regurgitation in 11 (3%) patients. Furthermore, 81 (27%) patients suffered from heart failure and 66 (22%) from a stroke during hospitalization. The mean hospital length of stay was 10.4 ± 10.6 days. 64 (21%) patients required surgical repair and the overall mortality rate was 25%. Prosthetic valve endocarditis (OR = 3.74, 95% CI = 2.15-6.50, p<0.001), chronic kidney disease (OR = 2.51, 95% CI = 1.15-5.47, p=0.036), previous stroke (OR = 2.42, 95% CI = 1.18-4.96, p=0.026), and ischemic heart disease (OR = 3.04, 95% CI = 1.50-6.16, p=0.003) were significantly associated with an increased risk of mortality. In conclusion, our study provided valuable data on the clinical characteristics and outcomes of patients with IE in a developing country. S. aureus was the most common causative agent. Heart failure and stroke were the most common complications. The presence of prosthetic valves, history of chronic kidney disease, ischemic heart disease and previous stroke were associated with a significantly increased risk of mortality. Surgical management was not associated with improved outcomes.

Association of Chest Xray (CXR) findings with outcomes in COVID-19 Patients.

Objective: To investigate chest radiography findings in suspected coronavirus disease-2019 patients in a tertiary care setting. METHODS: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of coronavirus disease-2019 cases admitted to the tertiary care centre from March 1 to March 30, 2020. A predesigned proforma was used to gather data, including demographics, like age and gender, co-morbidities, presenting symptoms and chest radiography findings during the admission. Length of stay and mortality were the outcome measures. Data was analysed using SPSS 22. RESULTS: Of the 154 suspected cases, 46(29.8%) tested positive for coronavirus disease-2019; 29(63%) males and 17(37%) females with a mean age of 50.7±19.1 years. Abnormal chest radiography was noted in 25(54.3%) cases, with bilateral pulmonary infiltrates being the most common finding 19(41.3%). Mortality was the outcome in 7(28%) of these cases, and the mean length of hospital stay was 9.3±7.3 days. Abnormal chest radiography findings were associated with an increased risk of mortality (p=0.009) and a longer hospital stay (p=0.017). Conclusion: Abnormal chest radiography findings were frequently seen in coronavirus disease-2019 patients and were also associated with increased risk of mortality and prolonged hospital stay.

Risk factors for intensive care unit admission and mortality among adult meningitis patients.

OBJECTIVE: To assess the risk factors for intensive care unit admission and inpatient all-cause mortality among adult meningitis patients. METHODS: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised of patients of either gender aged ≥18 years diagnosed with bacterial, viral, or tuberculous meningitis between July 2010 and June 2019. Multivariable logistic regression analyses were used to explore independent predictors of inpatient mortality and intensive care unit admission. Data was analysed using SPSS 24. RESULTS: Of the 929 patients with suspected meningitis, 506(54.5%) had confirmatory diagnosis. Of them, 303(59.9%) were males. The overall median age of the sample was 47.0 years (interquartile range: 33.0 years). The most common aetiology was bacterial meningitis 324(64%), followed by viral meningitis 141(27.9%). Incidence of inpatient mortality was 53(10.5%), while 75(14.8%) patients required intensive care unit admission. Tuberculous aetiology, intensive care unit admission, concurrent encephalitis, hydrocephalus, inpatient neurosurgery, and longer length of hospital stay were predictors of mortality (p<0.05). Non-indication of blood culture was found to be associated with reduced risk of mortality (p<0.05). For intensive care unit admission, diabetes mellitus, presentation with seizure, imaging suggestive of meningitis, and inpatient neurosurgery were associated with higher risk of admission, while hypertension, presentation with headache, viral aetiology and non-indication of blood culture reduced the risk (p<0.05). CONCLUSIONS: Adult meningitis patients tend to have poor expected outcomes, and their management strategies should be planned accordingly.

Progression of Acute Kidney Injury to Chronic Kidney Disease in Sepsis Survivors: 1-Year Follow-Up Study.

BACKGROUND: Despite the fact that septic acute kidney injury (AKI) is considered to be reversible, it can result in permanent kidney damage. Unfortunately, there is a scarcity of long-term follow-up studies highlighting progression to chronic kidney disease (CKD) in sepsis survivors. To address this issue, we conducted this study to assess the development of CKD in sepsis patients with AKI, and to identify risk factors associated with its development. METHODS: This retrospective cohort study evaluated medical records of patients admitted at the Aga Khan University Hospital between January-December 2017 with the diagnosis of sepsis and subsequent development of acute kidney injury (AKI). One-year follow-up data was then analyzed to determine whether the AKI resolved or progressed to chronic kidney disease. RESULTS: 1636 sepsis patients were admitted during the study period, out of which 996 (61%) met the inclusion criteria. 612 (61%) developed AKI during the admission. Mortality rate in the AKI group was 44% (n = 272). After 1 year, 47 (19%) patients eventually went on to develop CKD and 81% (n = 195) recovered fully. Risk factors for development of CKD were age ≥ 60 years (p = <0.001), diabetes (p = <0.001), hypertension (p = 0.001) and history of ischemic heart disease (p = <0.001). CONCLUSION: Mortality rates in sepsis are alarmingly high and even those patients who manage to survive are at risk of developing permanent organ dysfunction. Our study revealed that almost one fifth of all septic AKI survivors went on to develop chronic kidney disease within 1 year, even when AKI was not severe. We recommend that clinicians focus on early recovery of renal function, irrespective of AKI severity, and ensure robust follow-up monitoring to reduce long term morbidity and mortality associated with this devastating illness.

Knowledge and attitude towards identification and management of sepsis among resident physicians in a tertiary care teaching hospital in Pakistan.

This study was conducted to determine the compliance and knowledge of sepsis guidelines among resident physicians in a tertiary care hospital of a developing country. A self-structured validated questionnaire was prepared to evaluate compliance and knowledge of the Surviving Sepsis Campaign (SSC) guidelines. A total of 76 resident physicians completed the questionnaire; out of these, 51 (67%) were from Internal Medicine department and 25 (33%) were from Emergency Medicine department of the Aga Khan University Hospital, Karachi. A total of 71 (93%) participants claimed to be aware of the SSC guidelines but only 20 (26%) considered themselves very knowledgeable on the subject. Thirty-five (46%) physicians claimed that they were using the guidelines regularly. We concluded that the overall knowledge and compliance of sepsis guidelines was suboptimal. This emphasises the need for increased awareness and teaching of sepsis and SSC guidelines to improve patient outcomes in developing countries.

Predictors of mortality in hospitalized patients with influenza: a five-year experience from a tertiary care centre in Pakistan.

Influenza outbreaks are associated with significant morbidity. Our aim was to determine the factors associated with increased mortality in hospitalized patients admitted with diagnosis of influenza, at a tertiary care center in Pakistan. This study included all adult patients with an influenza infection, confirmed by realtime reverse-transcriptase polymerase-chain-reaction (RT-PCR) at Aga Khan University Hospital Pakistan. In our study, 112 patients with laboratory-confirmed influenza virus infection were admittedat our hospital from the 1st of January 2013 to the 31st of December 2018. Eighty-nine patients (79.46%) were managed in ward or special care units and 23 patients (20.5%) received treatment in intensive care unit (ICU). The overall mortality in our study was 15/112 (13.4%) with the mortality rate of ICU patients being 47.8% while the mortality rate of patients treated in special care units and wards was only 4.5%. The mean age of patients with influenza infection was 58.1 years (±16.6). Influenza virus type A was found in 87 patients (77.6%), while influenza type B was present in only 25 (22.4%) patients. Out of the 15 non-survivors, 14 had influenza A. Only 17 patients (15.2%) were found to have positive culture of respiratory specimen, out of which 3 were non-survivors and 14 were survivors. Our analysis identified septic shock (odds ratio 45.24; 95%, confidence interval 6.20-330; p<0.001), renal failure (odds ratio 10.88; 95%, confidence interval 1.61-73.52; p=0.01) and ICU stay (odds ratio 17.22; 95%, confidence interval 2.68-110.5; p=0.003) as independent risk factors associated with in-hospital mortality.

Clinical features, diagnosis and management of COVID-19 patients in the outdoor setting.

In a brief span of a few months, coronavirus disease (COVID-19) pandemic has brought a major paradigm shift in operation of clinical services around the world. Infection may be mild, moderate or severe; many remain asymptomatic. High burden of non-communicable and communicable diseases theoretically puts Pakistani population at increased risk of severe COVID-19 infection. Considering the universal risk of infection, the outpatient services in Pakistan need to be redesigned. Starting with risk assessment of the facility and provision of a dedicated telephone connection, structure and workflow need to be redesigned in order to minimise risk of exposure to healthcare professionals, staff and patients. Patients with COVID-19 patients should be identified before they arrive in the facility and should be served expeditiously, in an environment which prevents cross-transmission of infection. Tele-consultation is assuming an important role. Changes which are taking place in response to Covid-19 pandemic will have far reaching effects on clinical services in Pakistan.

Detection and Molecular Characterization of Staphylococci from Eggs of Household Chickens.

Eggs are a healthy and nutritious food source, but may be contaminated by bacteria. Previous studies have reported the presence of staphylococci in eggs of farmed chickens, but no study has evaluated the staphylococcal population of eggs from household chickens. In this study, staphylococci from eggs (n = 275) of household chickens collected from November 2016 to March 2017 from different villages of Khyber Pakhtunkhwa province, Pakistan, were characterized. Seven species of staphylococci were identified from 65 eggs, including the predominant species, Staphylococcus xylosus (49/275; 17.8%). S. xylosus isolates (n = 73) were tested for antimicrobial susceptibility, presence of resistance genes, genetic relatedness, and inhibitory activity against other bacteria. The majority of isolates were resistant to oxacillin (83.6%) and tetracycline (24.7%), but also exhibited resistance to daptomycin and linezolid (5.5% each). Of the 10 resistance genes tested, isolates were only positive for mecA (35.6%; 26/73), mecC/C1 (2.7%; 2/73), and tet(K) (14/73; 19%). Using pulsed-field gel electrophoresis (PFGE), nine clusters had identical PFGE patterns. Isolates produced inhibitory activity against a broad spectrum of bacteria; 20.5%, 19.2%, 17.8%, and 16.4% of S. xylosus were able to inhibit growth of Salmonella enterica serotype Typhi, methicillin-susceptible Staphylococcus aureus, Escherichia coli, and methicillin-resistant Staphylococcus aureus, respectively. This study demonstrated the presence of genetically related antimicrobial-resistant S. xylosus from eggs from household chickens. Like table eggs, eggs of household chickens also contain staphylococci that may be resistant to antimicrobials used to treat human infections. These data will allow comparison between staphylococci from eggs from different sources and may indicate the relative safety of eggs from household chickens. Further study of these egg types and their microbial composition is warranted.

Susceptibility pattern of tracheal tube isolates from Intensive Care Unit of Fauji Foundation Hospital Rawalpindi.

OBJECTIVE: To determine the prevalence of resistant pathogens and their antimicrobial susceptibility pattern in an intensive care unit. METHODS: The cross-sectional observational study was conducted at Foundation Hospital, Rawalpindi, Pakistan, from May to September 2016, and comprised tracheal tubes which were collected in sputum culture bottles from patients with clinical findings of ventilator associated pneumonia. The tubes were cultured to locate the resistant pathogens. RESULTS: A total of 113 different strains of bacteria were isolated from 80 patients. The main isolated bacteria was acinetobacter baumannii 45(39.8%) followed by klebsiella pneumonia 14(12.3%) and methicillin-resistant staphylococcus aureus 13(11.5%). Polymyxin B was the most appropriate drug for treating patients infected with acinetobacter baumannii with a sensitivity of 64% while vancomycin and linez oli dhad 100% sensitivity for methicill in - resistant staphylococcusaureus. CONCLUSIONS: Acinetobacter baumannii was the most prevalent strain in tracheal tubes and polymyxin B was the most effective medicine.

Mycobacterium tuberculosis infection and resistance to rifampicin with GeneXpert®MTB/RIF: a single-center experience on bronchoalveolar lavage samples in renal failure patients.

Patients with end-stage renal disease (ESRD) are immunocompromised and are more at risk to develop and acquire Mycobacterium tuberculosis (MTB) infection. However, risk assessment is uncertain. The objective of current research was to study the frequency of MTB infection in ESRD patients . For this purpose, bronchoalveolar lavage (BAL) samples were evaluated for the presence of MTB by using GeneXpert®MTB/RIF test. We analysed 350 clinical samples of BAL collected from a tertiary care hospital in Pakistan, from September, 2015 to July, 2016. We performed the GeneXpert®test on each sample. According to our results prevalence of MTB was observed in 1.7% of bronchoalveolar lavage (BAL) samples taken from patients with chronic kidney diseases. All the positive samples were susceptible to rifampicin. There is a low prevalence of MTB infec tion (pulmonar y tuberculosis) in patients with chronic kidney disease in our setup. Suspected patients can be diagnosed by using GeneXpert®MTB/RIF testing on bronchoalveolar lavage samples.

Factors pivotal for designing of nanoantimicrobials: an exposition.

Understanding the interplay between bacterial pathogens and antimicrobials is a key to realize the control over infections causing morbidity and mortality. An important current issue of contemporary medicine and microbiology is the search for new strategies for adequate therapy of infectious diseases associated with rapidly emerging multidrug-resistant (MDR) pathogens. Recently, a great deal of progress has been made in the field of nanobiotechnology towards the development of various nanoantimicrobials (NAMs) as novel therapeutic solution. Current microbiological studies, employing either synthetic antibiotics or natural antimicrobial, have demonstrated the ability of NAMs to tackle the issue of MDR by reverting the mechanisms of resistance. The present review critically discusses the various factors that can contribute to modulate the effects of NAMs on microbes. It includes essential features of NAMs including but not limited to composition, surface charge, loading capacity, size, hydrophobicity/philicity, controlled release and functionalization. In contrast, how microbial structural differences, biofilm formation, persister cells and intracellular pathogens contribute towards sensitivity or resistance towards antimicrobials is comprehensively analysed. These multilateral factors should be considered earnestly in order to make NAMs a successful alternative of the conventional antibiotics.

Hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) from Pakistan: molecular characterisation by microarray technology.

The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in Pakistan is known to be high, but very few studies have described the molecular epidemiology of the different MRSA clones circulating in the country. Forty-four MRSA isolates were collected from two tertiary care hospitals of the Rawalpindi district of Pakistan. All strains were identified by a conventional phenotypic method and then subjected to genotyping by microarray hybridisation. Six clonal complexes (CCs) and 19 strains were identified. The most commonly identified strains were: (i) Panton-Valentine leucocidin (PVL)-positive CC772-MRSA-V, "Bengal Bay Clone" (ten isolates; 22.3%), (ii) ST239-MRSA [III + ccrC] (five isolates) and (iii) a CC8-MRSA-IV strain, as well as CC6-MRSA-IV (both with four isolates; 9.1% each). Several of the strains detected indicated epidemiological links to the Middle Eastern/Arabian Gulf region. Further studies are needed to type MRSA from countries with less known epidemiology and to monitor the distribution and spread of strains, as well as possible links to global travel, migration and commerce.

Detection and Molecular Characterization of Methicillin-Resistant Staphylococcus aureus from Table Eggs in Haripur, Pakistan.

Table eggs are nutritionally important food consumed globally. Despite being protected inside the hard shell and a semipermeable membrane, the egg contents may be contaminated with microbes and thus become a possible carrier of infectious agents to humans. A number of medically significant bacterial species such as Salmonella enterica, Listeria monocytogenes, and Yersinia enterocolitica have already been reported from table eggs. More important is the presence of antimicrobial-resistant bacterial strains in this food source. The present study was aimed at detection and characterization of Staphylococcus aureus from table eggs collected from different retail shops in Haripur city of Pakistan. Staphylococci were isolated from 300 eggs collected from December 2015 to May 2016. S. aureus isolates were tested for antimicrobial susceptibility using broth microdilution and characterized using pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), staphylococcal cassette chromosome mec (SCCmec) typing, and spa typing. The presence of Panton-Valentine leukocidin and antimicrobial resistance genes were detected using PCR. Staphylococci were isolated from 21.3% (64/300) of the table eggs tested. Of those, 59% (38/64) were identified as S. aureus, of which 33 (86.8%) were positive for mecA (MRSA, methicillin-resistant S. aureus). All MRSA were multidrug resistant (resistant to two or more antimicrobial classes), contained aac-aph (encoding aminoglycosides), and were pvl+. Using MLST, spa typing, and SCCmec typing, three genotypic patterns were assigned: ST8-t8645-MRSA-IV, associated with USA300; and ST772-t657-MRSA-IV and ST772-t8645-MRSA-IV, both characteristic of the Bengal Bay community-associated MRSA clone. Molecular typing by PFGE revealed that the bacterial population was highly homogenous with only two patterns observed. This study is the first report of detection of human-associated pvl+ MRSA from table eggs. The genetic similarities of MRSA present in the eggs to that of humans may suggest human to poultry transmission of MRSA via contamination.

Multidrug resistance in Gram-negative pathogens isolated from patients with chronic kidney diseases and renal transplant.

Multidrug resistance (MDR) in gram-negative pathogens is the emerging threat to clinicians. The current study was designed to determine the prevalence and pattern of multidrug resistance in gram-negative clinical isolates. It was conducted at the COMSATS Institute of Information Technology, Islamabad, Pakistan, from June to October 2014. Of the 8, 300 samples collected, 729(8.8%) clinically important gram-negative pathogens were retrieved. These pathogens were subjected to phenotypic and biochemical detection and were further processed for multidrug resistance pattern. It was observed that gram-negative pathogens were simultaneously resistant to many antibiotics. The prevalence of extended spectrum b-lactamase phenomenon was 220(100%) in Klebsiella pneumoniae, 195(75%) in Escherichia coli. Resistance to carbapenem was 174(79%) in Klebsiella pneumoniae and 14(5.4%) in Escherichia coli. Resistance against fluoroquinolones also displayed an escalating trend. The current study found that resistance against antibiotics was displaying a drastic increase in chronic renal patients.