Efficacy and safety of Artemisinin Combination Therapy for the treatment of uncomplicated Plasmodium falciparum malaria across international borders of India.

BACKGROUND OBJECTIVES: Malaria due to Plasmodium falciparum (Pf) remains a major public threat in India. Artemisinin-based combination therapy (ACT) has been the country's first-line drug for uncomplicated Pf malaria. In 2013-2014, Artesunate plus sulfadoxine (AS+SP) was replaced by Artemether Lumefantrine (AL) as the first- line antimalarial in North East (NE) states of the country which are endemic for Pf malaria. Regular monitoring of antimalarial drugs is of utmost importance to achieve the goal of elimination. This study aimed to assess the efficacy and safety of ACT for treating uncomplicated Pf malaria in the NE states of India. METHODS: A prospective study of 28-day follow-up was conducted to monitor the efficacy and safety of AL from 2018-2019 in four districts, Udalgiri, Meghalaya, Lawngtlai, and Dhalai of NE, India. The clinical and parasitological response and the polymorphism analysis of the Pfdhps, P/dhfr, and Pfkelch 13 gene were evaluated. RESULTS: A total of 234 patients were enrolled in the study out of 216 patients who completed the follow-up to 28 days. One-hundred percent adequate clinical and parasitological responses (ACPR) were observed with polymerase chain reaction (PCR) correction. The genotype results suggest no recrudescence in the treatment-failure patients. The classical single nucleotide polymorphisms (SNP) in the Pfdhfr gene was S108N (94.9%), followed by C59R (91.5%), whereas, in the Pfdhps gene, the common SNP was A437G (79.6%), followed by S3436A. No associated or validated mutations were found in the propeller region of the PfKelch13 gene. INTERPRETATION CONCLUSION: AL was efficacious and safe in uncomplicated P. falciparum malaria in North East India. In contrast, mutations in the genes responsible for sulfadoxine and pyrimethamine resistance have been fixed in northeast India's population.

Comparison of NEWS2 and PSI as mortality predictors in patients with community acquired pneumonia.

In the West, National Early Warning Score 2 (NEWS2) is commonly applied to predict the severity of illness using only bedside variables unlike the extensive Pneumonia Severity Index (PSI). The objective of this study was to compare these scores as mortality predictors in patients admitted with community acquired pneumonia (CAP). This cross-sectional study was conducted in Jinnah Postgraduate Medical Centre, Karachi, Pakistan, for six months in 2020 on 116 patients presenting with CAP. Cases of aspiration pneumonia, hospital acquired pneumonia, pulmonary tuberculosis, pulmonary embolism, and pulmonary oedema were excluded. In-hospital mortality was taken as the outcome of this study. The mean age of the participants was 46.9±20.5 years. The in-hospital mortalities were 45(38.8%). NEWS2 was 97.8% sensitive but only 15.5% specific in predicting the outcome, whereas PSI was less sensitive (68.9%) but more specific (50.7%), which showed that in comparison with PSI, NEWS2 is a more sensitive mortality predicting score among hospitalised CAP patients.

Quality assurance of malaria rapid diagnostic tests: An aid in malaria elimination.

Background & objectives: India targets malaria elimination by 2030 in a phased manner, so malaria's assured diagnosis is crucial. Introduction of rapid diagnostic kits in India in 2010 has revolutionized malaria surveillance. The storage temperature of rapid diagnostic tests (RDTs), kit components and handling in transportations impact the results of RDTs. Therefore, quality assurance (QA) is required before it reaches end-users. The Indian Council of Medical Research-National Institute of Malaria Research (ICMR-NIMR) has a World Health Organization (WHO) recognized lot-testing laboratory facility to assure the quality of RDTs. Methods: The ICMR-NIMR receives RDTs from different manufacturing companies as well as various agencies such as National and State Programmes and Central Medical Services Society. The WHO standard protocol is followed to conduct all the tests, including long-term and post-dispatch testing. Results: A total of 323 lots tested during January 2014-March 2021 were received from different agencies. Amongst them, 299 lots passed the quality of test and 24 failed. In long-term testing, 179 lots were tested and only nine failed. A total of 7741 RDTs were received from end-users for post-dispatch testing of which 7540 qualified the QA test with a score of 97.4 per cent. Interpretation & conclusions: RDTs received for quality testing showed compliance with QA evaluation of malaria RDTs based on the protocol recommended by the WHO. However, continuous monitoring of the quality of RDTs is required under QA programme. Quality-assured RDTs have a major role, especially in areas where low parasitaemia of parasites persists.

A rapid method for DNA Isolation from blood, dried blood spots and rapid diagnosis test.

Background & objectives: Malaria is a parasitic disease spread by Plasmodium parasite. Microscopy, lateral flow devices such as the Rapid Diagnostic Test (RDT), molecular methods such as Polymerase Chain Reaction (PCR), isothermal methods such as Loop-mediated isothermal amplification (LAMP), and other diagnostic methods are available for malaria. On the other hand, the accuracy of molecular diagnosis is dependent on genomic DNA isolation. A quick method for isolating and subjectively determining the presence of genomic DNA from blood, dried blood spot (DBS), and rapid diagnostic test (RDT), was identified. Methods: We have developed a protocol for isolating DNA from blood, DBS, and RDTs using the HUDSON Buffer (TCEP and EDTA). Isolated genomic DNA was seen with SYBR Safe DNA stain (1X) under a UV transilluminator without running in 0.8 percent gel electrophoresis or using a spectrophotometer. Results: The technique for DNA isolation was accurate for the presence of malaria parasite genomic DNA from positive samples confirmed by microscopy with a sensitivity of 76% and specificity of 78.67% and RDT with a sensitivity of 88% and specificity of 66%. The requirements were minimal, and the process took 30 minutes for a hundred sample processing. Interpretation & conclusion: Finding a fast and reliable method of separating nucleic acids from many samples is crucial. This approach extracts intact genomic DNA in under ten minutes, making it ideal for large-scale investigations.

Risk Factors Of Idiopathic Pulmonary Fibrosis In Pakistani Population: A Matched Case-Control Studyy.

OBJECTIVE: To evaluate the factors associated with idiopathic pulmonary fibrosisrisk. Methods: The case-controlstudywas conductedfromJanuary 5, 2017,toSeptember 4, 2018, attheprivate-sectorAga Khan University Hospital and the public-sector Jinnah Postgraduate Medical Centre, two large tertiary care centres in Karachi, andcomprisedadultpatientsof eithergenderwithdiagnosedidiopathicpulmonary fibrosis, asdefinedby the IndianChest Registry. Subjects without idiopathic pulmonary fibrosis but registered with the department of pulmonology of the two hospitalswere enrolledas controls.Datawas collectedusinga structuredquestionnaire, andanthropometricmeasurements were noted for each subject. Gastroesophageal reflux disease was assessed using GerdQ. This wasfollowed by serological evaluations and spirometry. Data was analysed using SPSS 21. RESULTS: Of the 459 subjects, 154(33.6%)were cases and305(66.4%)were controls.Amongthe cases, 81(52.6%)were females and 73(47.4%) were males with mean age 66.1±10.9 years. Among the controls, 162(53.1%) were females and 143(46.9%) were males with mean age 64.6±11.1 years(p>0.05.)The most common ethnicity wasUrdu-speaking; 89(58%) among the cases and 150(49%) among the controls (p<0.05). Ethnicity, number of persons in the household per room, and type of house were significantly associated with the risk of developing idiopathic pulmonary fibrosis(p<0.05). CONCLUSIONS: Ethnicity,type of house and the number of personsin a household perroom were found to be the significant risk factorsfor idiopathic pulmonary fibrosisIPF.

The case report of a non-resident Indian with Plasmodium ovale curtisi from Kerala, India.

India's target of malaria elimination by 2030 may not be achieved solely by detecting Plasmodium falciparum and P. vivax, the two common Plasmodium species causing infections in humans. Sporadic reports have been documented on other Plasmodium species in the country, associated mostly with travel history. A febrile patient of Indian origin (Non-resident Indian (NRI)) was diagnosed with an infection of Plasmodium ovale curtisi malaria on his arrival from Sudan. A case report from Kerala was published in December 2020 and this is second report. Due to the inaccessibility of molecular techniques for routine diagnosis, this neglected non-falciparum malaria goes undetected. For an accurate diagnosis, suspected malaria cases should be tested using PCR and other advanced methods.

Comparison of DECAF (dysponea, eosinopenia, consolidation, acidaemia, and atrial fibrillation) and APACHE II (acute physiology and chronic health evaluation ii) scoring system to predict mortality among patients with acute exacerbation of chronic obstructive pulmonary disease.

OBJECTIVES: To compare the diagnostic accuracy of two systems in predicting mortality among patients with acute exacerbation of chronic obstructive pulmonary disease. METHODS: The cross-sectional study was conducted from November 2017 to June 2018 in the Department of Chest Medicine, Jinnah Postgraduate Medical Centre, Karachi, and comprised patients with acute exacerbation of chronic obstructive pulmonary disease. Dyspnoea-eosinopenia-consolidation-acidaemia-atrial fibrillation system was compared with acute physiology and chronic health evaluation II scoring system after mortality scores were calculated for each patient. Data was analysed using SPSS 21. RESULTS: Of the 210 patients, 147(70%) were males and 63(30%) were females. Overall, 59(28.1%) patients died during hospital stay. The mean dyspnoea-eosinopenia-consolidation-acidaemia-atrial fibrillation score was 2.31±0.93 while the mean acute physiology and chronic health evaluation II score was 15.8±7.2. A decision threshold of dyspnoea-eosinopenia-consolidation-acidaemia-atrial fibrillation score >2 had a sensitivity of 84.6% and specificity of 82.3% while acute physiology and chronic health evaluation II score had sensitivity of 53.9% and specificity of 76.5%. CONCLUSIONS: Both scoring systems were found to be good predictors of mortality, but dyspnoea-eosinopenia-consolidationacidaemia-atrial fibrillation score was a simpler and effective clinical tool.

Epidemiology and Clinico-radiological features of Interstitial Lung Diseases.

OBJECTIVE: The literature on interstitial lung diseases is limited. The aim of this research was to make this entity of diseases more understandable to clinicians and general population of the region of Pakistan. METHODS: We conducted a cross-sectional study on 253 Pakistani subjects who are a part of the hospital-based registry of JPMC. We performed statistical analyses on SPSS version 22.0. We included patients above 15 years of age who exhibited clinical clues and radiological signs of ILD during March 2016 through February 2018 and excluded those who were on tuberculosis treatment, suspected to be suffering from post-infection bronchiectasis, expectant females or had failed to follow-up. RESULTS: There was a 2:3 male to female ratio. Mean age was 49.0±13.2 years. Majority were non-smokers. Idiopathic Pulmonary Fibrosis (IPF) was the commonest ILD (38.8%) followed by Non-Specific Interstitial Pneumonitis (NSIP) (15.1%). Most patients presented with dyspnea and dry cough and about half were clubbed (47.3%). Substantial IPF cases (52.6%) were suffering from GERD symptoms. CONCLUSION: IPF and NSIP were the major ILDs, GERD was the only predictor of IPF. This entity of lung diseases needs to be explored further to identify patterns of presentation and to make diagnosis at a manageable stage.

One-pot synthesis of 1,5-diketones from 3-acetyl-4-hydroxycoumarin and effective cyclization to unexpected 3,4-dihydropyridines.

A facile synthesis of 1,5-diketones from 3-acetyl-4-hydroxycoumarin, aldehydes and cyclic-ketones via a one-pot aldol condensation and subsequent Michael addition reaction in the presence of a single catalyst of l-proline under mild reaction conditions has been developed. Novel 1,5-diketones were further cyclized to unexpected 3,4-dihydropyridines rather than generally formed pyridine analogues with ammonium acetate in acetic acid. One pot, high yields (72-92%) for novel 1,5-diketones and (70-90%) for the 3,4-dihydropyridine adducts, easy work-up and purification of products are the key advantages of this method.

Highly selective and sensitive coumarin-triazole-based fluorometric 'turn-off' sensor for detection of Pb2+ ions.

Exposure to even very low concentrations of Pb2+ is known to cause cardiovascular, neurological, developmental, and reproductive disorders, and affects children in particular more severely. Consequently, much effort has been dedicated to the development of colorimetric and fluorescent sensors that can selectively detect Pb2+ ions. Here, we describe the development of a triazole-based fluorescent sensor L5 for Pb2+ ion detection. The fluorescence intensity of chemosensor L5 was selectively quenched by Pb2+ ions and a clear color change from colorless to yellow could be observed by the naked eye. Chemosensor L5 exhibited high sensitivity and selectivity towards Pb2+ ions in phosphate-buffered solution [20 mM, 1:9 DMSO/H2 O (v/v), pH 8.0] with a 1:1 binding stoichiometry, a detection limit of 1.9 nM and a 6.76 × 106  M-1 binding constant. Additionally, low-cost and easy-to-prepare test strips impregnated with chemosensor L5 were also produced for efficient of Pb2+ detection and proved the practical use of this test.

Synthesis, estrogen receptor binding affinity and molecular docking of pyrimidine-piperazine-chromene and -quinoline conjugates.

Substituted 2-amino-7-((6-(4-(2-hydroxyethyl) piperazin-1-yl)-2-methylpyrimidin-4-yl)oxy)-4-phenyl-4H-chromene-3-carbonitriles and 2-amino-7-((6-(4-(2-hydroxyethyl)piperazin-1-yl)-2-methylpyrimidin-4-yl)oxy)-4-phenyl-1,4-dihydroquinoline-3-carbonitriles were synthesized via an efficient multi-component one pot synthesis under mild conditions. These compounds 1-20 were evaluated against human breast cancer cell lines (MCF-7) and human embryonic kidney cells (HEK293) for cytotoxic activities. Among them, compounds 6, 7, 15, 17 and 19 showed better anti-proliferative activities as (IC50 value 48±1.70, 65±1.13, 92±1.18, 30±1.17 and 16±1.10µM) than curcumin drug (48±1.11µM). Molecular docking was also performed with active compounds 6, 7 and 15 against Bcl-2 protein which gave good binding affinity (ΔG=-9.08, -8.29 and -7.70kcal/mol) respectively. Furthermore, the structure-activity relationship (SAR) analysis revealed that the chromene and quinoline moieties, when attached with pyrimide and piperazine moieties, enhanced anti-proliferative activities.

Degradation of aldrin and endosulfan in rotary drum and windrow composting.

Removal efficiencies, kinetics and degradation pathways of aldrin, endosulfan α and endosulfan ß in vegetable waste were evaluated during rotary drum and conventional windrow composting. The highest percentage removal of aldrin, endosulfan α and endosulfan ß in rotary drum composting was 86.8, 83.3 and 85.3% respectively, whereas in windrow composting, it was 66.6%, 77.7% and 67.2% respectively. The rate constant of degradation of aldrin, endosulfan α and endosulfan ß during rotary drum composting ranged from 0.410-0.778, 0.057-0.076 and 0.009-0.061 day(-1) respectively. The pathways of degradation of these pesticides in composting process were proposed. Metabolites dieldrin and 1 hydroxychlorodene formed during composting of aldrin in the vegetable waste indicated the occurrence of epoxidation reaction and oxidation of bridge carbon of aldrin containing the methylene group. Formation of chloroendic acid and chloroendic anhydride during composting of endosulfan containing vegetable waste support the occurrence of endosulfan sulfate and dehydration reaction respectively.

The intestinal epithelial cell differentiation marker intestinal alkaline phosphatase (ALPi) is selectively induced by histone deacetylase inhibitors (HDACi) in colon cancer cells in a Kruppel-like factor 5 (KLF5)-dependent manner.

The histone deacetylase inhibitor (HDACi) sodium butyrate promotes differentiation of colon cancer cells as evidenced by induced expression and enzyme activity of the differentiation marker intestinal alkaline phosphatase (ALPi). Screening of a panel of 33 colon cancer cell lines identified cell lines sensitive (42%) and resistant (58%) to butyrate induction of ALP activity. This differential sensitivity was similarly evident following treatment with the structurally distinct HDACi, MS-275. Resistant cell lines were significantly enriched for those harboring the CpG island methylator phenotype (p = 0.036, Chi square test), and resistant cell lines harbored methylation of the ALPi promoter, particularly of a CpG site within a critical KLF/Sp regulatory element required for butyrate induction of ALPi promoter activity. However, butyrate induction of an exogenous ALPi promoter-reporter paralleled up-regulation of endogenous ALPi expression across the cell lines, suggesting the presence or absence of a key transcriptional regulator is the major determinant of ALPi induction. Through microarray profiling of sensitive and resistant cell lines, we identified KLF5 to be both basally more highly expressed as well as preferentially induced by butyrate in sensitive cell lines. KLF5 overexpression induced ALPi promoter-reporter activity in resistant cell lines, KLF5 knockdown attenuated butyrate induction of ALPi expression in sensitive lines, and butyrate selectively enhanced KLF5 binding to the ALPi promoter in sensitive cells. These findings demonstrate that butyrate induction of the cell differentiation marker ALPi is mediated through KLF5 and identifies subsets of colon cancer cell lines responsive and refractory to this effect.

Comparison of semi-continuous and interrupted suture techniques for mitral valve replacement.

OBJECTIVE: To compare the efficacy of semi-continuous technique and interrupted suture technique for mitral valve replacement in early post-operative period. METHODS: The randomised prospective study was conducted at Chaudhry Pervaiz Elahi Institute of Cardiology, Multan, Pakistan, from December 2012 to December 2014 The patients were divided into two equal groups: Group I patients underwent semi-continuous technique for mitral valve replacement, and Group II underwent interrupted technique. Data was analysed using SPSS 16. RESULTS: The 100 patients were divided into two equal groups of 50(50%) each. There was no significant difference in terms of age, gender and pre-operative echocardiographic characteristics (p>0.05 each). Total bypass and cross-clamp times were significantly higher in Group II (p<0.0001 and p<0.0001). The incidence of peri-prosthetic leakage was low in Group II compared to Group I but it was not significantly different (p=0.64). CONCLUSIONS: Semi-continuous technique was found to be a safe and reliable method of mitral valve replacement.

Benefits of Lot Testing to Improve the Quality of Malaria Rapid Diagnostic Tests in India.

Since 2010, malaria rapid diagnostic tests (RDTs) are widely used to detect malaria. The Indian Council of Medical Research-National Institute of Malaria Research performed lot testing (LT) according to WHO procedures since 2016. Lot testing is performed to evaluate the lot-to-lot variation in performance of malaria RDTs. Four sets of positive quality control (QC) panels for P. falciparum (Pf) and P. vivax (Pv) and 10 negative panels tested RDTs. RDTs were reported as pass, failed, or deferred on the basis of WHO criteria. In the past 5 years, 275 lots containing 15,488 RDT kits for malaria diagnosis were subjected to LT. The monovalent RDTs (n = 1,216), based on either Pf histidine rich protein 2 (HRP2) or Pan-Plasmodium lactate dehydrogenase (Pan-pLDH) antigens, showed 90.4% sensitivity and 100% specificity, whereas RDTs based on HRP2 + Pan-pLDH or HRP2 + pLDH (n = 13,924) had sensitivity 95.6% and specificity 99.5%, respectively. RDTs based on PfHRP2 + Pv-pLDH + Pan-pLDH (n = 348) had 100% sensitivity and specificity. In a comparison between HRP2 + pLDH or HRP2 + Pan-pLDH to HRP2 + pLDH + Pan-pLDH RDTs, it was found that the sensitivity of PfHRP2 with Pan-pLDH RDTs (n = 2,382) was only 83%. Of the 275 lots analyzed, 15 lots of PfHRP2 with Pan-pLDH were deferred. The QC panel for Pf revealed a faint Pan band in the tested lots, which is a cause for concern. The results of deferred lots were reported to concerned government agencies. Quality-compromised RDTs may lead to an incorrect diagnosis. It is critical to have a QC system in place for effective malaria management.

Design, synthesis, molecular docking and anti-proliferative activity of novel phenothiazine containing imidazo[1,2-a]pyridine derivatives against MARK4 protein.

A series of novel phenothiazine-containing imidazo[1,2-a]pyridine derivatives were designed and synthesized under metal-free conditions in excellent yield. These derivatives were effectively transformed further into N-alkyl, sulfoxide, and sulfone derivatives. Derivatives were deployed against human microtubule affinity regulating kinase (MARK4), some molecules play crucial roles in cell-cycle progression such as G1/S transition and regulator of microtubule dynamics. Hence, molecules have shown excellent MARK4 inhibitory potential. Molecules with excellent IC50 values were selected for further studies such as ligand interactions using fluorescence quenching experiments for the binding constant. The highest binding constant was calculated as K = 0.79 × 105 and K = 0.1 × 107 for compounds 6a and 6h, respectively. Molecular docking, cell cytotoxicity, mitochondrial reactive oxygen species measurement and oxidative DNA damage were also studied to understand the mechanism of action of the molecules on cancer cells. It was found that the designed and synthesized compounds played anti-cancer roles by binding and inhibiting MARK4 protein.

Obstructive jaundice expands intrahepatic regulatory T cells, which impair liver T lymphocyte function but modulate liver cholestasis and fibrosis.

Although obstructive jaundice has been associated with a predisposition toward infections, the effects of bile duct ligation (BDL) on bulk intrahepatic T cells have not been clearly defined. The aim of this study was to determine the consequences of BDL on liver T cell phenotype and function. After BDL in mice, we found that bulk liver T cells were less responsive to allogeneic or syngeneic Ag-loaded dendritic cells. Spleen T cell function was not affected, and the viability of liver T cells was preserved. BDL expanded the number of CD4(+)CD25(+)Foxp3(+) regulatory T cells (Treg), which were anergic to direct CD3 stimulation and mediated T cell suppression in vitro. Adoptively transferred CD4(+)CD25(-) T cells were converted into Treg within the liver after BDL. In vivo depletion of Treg after BDL restored bulk liver T cell function but exacerbated the degrees of inflammatory cytokine production, cholestasis, and hepatic fibrosis. Thus, BDL expands liver Treg, which reduce the function of bulk intrahepatic T cells yet limit liver injury.

Phytochemical, Geographical, and Pharmacological Retrospect of Genus Torilis.

BACKGROUND: Genus Torilis (Apiaceae) known as hedge parsley, encompasses 11-13 species distributed worldwide and shows potential pharmacological uses. Its phytochemical pattern is highly diversified including many phenolic and terpenic compounds. OBJECTIVE: This research-review provides new highlighting of structural organizations, structure-activity trends, taxonomical, tissue and geographical distribution of phytocompounds of Torilis genus from extensive statistical analyses of available data. METHODS: In extenso, exploration of documented literature and statistical data analyses were applied to update the phytochemical pool of the genus under several aspects including structural diversity, geographical distribution, biological compartmentations and pharmacological activities. RESULTS: Phytoconstituents were classified into homogeneous clusters that revealed to be associated with chemical constitutions (aglycone types, chemical groups) and distributions (through species, tissues, geographical). About bioactivities, terpenes were studied from a pharmacological point of view with relatively high frequencies for antifungal, antibacterial, cytotoxic and anti-inflammatory activities. Preliminary structure-activity relationships were highlighted implying opposite effects between hydroxylation and methylation in favor of different activities. Crude extracts and isolated compounds have shown several biological activities (antibacterial, anticancer, antiangiogenic, antiproliferative, etc.), thus providing authentic scientific proof for their diverse uses in folk medicines. CONCLUSION: The phytochemistry of the genus Torilis promises important perspectives in matters of pharmacological activities. These perspectives call for further investments in pharmacology because of (i) unbalance between phenolic and terpenic compounds according to the countries and (ii) more advanced current states of structural elucidations compared to biological evaluations.

A case report of late treatment failure in Plasmodium falciparum malaria in a traveler from the Democratic Republic of the Congo to India.

A young male returned from the Democratic Republic of the Congo (DRC) to India after four months during his official work. Within a week of his arrival, he developed a high-grade fever with nausea and was hospitalized in a private hospital in New Delhi. He was diagnosed with malaria, treated with an artesunate injection as antimalarial, and discharged on day 5th from the hospital. A week later, he was diagnosed with malaria and dengue positive at ICMR-National Institute of Malaria Research, New Delhi. Artesunate with sulphadoxine and pyrimethamine (AS+SP) was administered following India's malaria treatment policy. However, high-grade fever, along with the asexual stage of the P. falciparum parasite, was observed within 28 days of treatment with AS+SP, signifying late treatment failure (LTF). Further, the molecular analysis from both the days of episodes was analyzed using genomic DNA from dried blood spots, revealing resistance to sulphadoxine-pyrimethamine with mutations at codons pfdhfr 51I, pfdhfr 59 R, pfdhfr 108 N, pfdhps 437 A, pfdhps 581 G. No functional mutation associated was found in pfKelch13, but interestingly the sensitive codons to chloroquine (CQ) (wild type pfcrtK76 and pfmdrN86) revealed the probably reversible CQ sensitivity in the sample from DRC.

Antibiotic resistance, bacterial transmission and improved prediction of bacterial infection in patients with antibody deficiency.

Background: Antibody-deficient patients are at high risk of respiratory tract infections. Many therefore receive antibiotic prophylaxis and have access to antibiotics for self-administration in the event of breakthrough infections, which may increase antimicrobial resistance (AMR). Objectives: To understand AMR in the respiratory tract of patients with antibody deficiency. Methods: Sputum samples were collected from antibody-deficient patients in a cross-sectional and prospective study; bacteriology culture, 16S rRNA profiling and PCR detecting macrolide resistance genes were performed. Bacterial isolates were identified using MALDI-TOF, antimicrobial susceptibility was determined by disc diffusion and WGS of selected isolates was done using Illumina NextSeq with analysis for resistome and potential cross-transmission. Neutrophil elastase was measured by a ProteaseTag immunoassay. Results: Three hundred and forty-three bacterial isolates from sputum of 43 patients were tested. Macrolide and tetracycline resistance were common (82% and 35% of isolates). erm(B) and mef(A) were the most frequent determinants of macrolide resistance. WGS revealed viridans streptococci as the source of AMR genes, of which 23% also carried conjugative plasmids linked with AMR genes and other mobile genetic elements. Phylogenetic analysis of Haemophilus influenzae isolates suggested possible transmission between patients attending clinic.In the prospective study, a negative correlation between sputum neutrophil elastase concentration and Shannon entropy α-diversity (Spearman's ρ = -0.306, P = 0.005) and a positive relationship with Berger-Parker dominance index (ρ = 0.502, P < 0.001) were found. Similar relationships were noted for the change in elastase concentration between consecutive samples, increases in elastase associating with reduced α-diversity. Conclusions: Measures to limit antibiotic usage and spread of AMR should be implemented in immunodeficiency clinics. Sputum neutrophil elastase may be a useful marker to guide use of antibiotics for respiratory infection.