Prevalence of Extended Spectrum ß-Lactamase Producers (ESBLs) with antibiotic resistance pattern of Gram negative pathogenic bacteria isolated from door handles in hospitals of Pokhara, Western Nepal.

BACKGROUND: The presence of drug-resistant Gram-negative pathogenic bacteria and Extended Spectrum ß-Lactamase Producers (ESBLs) in hospital associated fomites like door handles can serve as vehicles in transmission and may be the key factor in epidemiology of ESBL producing bacterial infection not only in a hospital setting but also in the community. The aim of this study was to determine the prevalence of ESBLs and antibiotic resistance of Gram-Negative pathogenic Bacteria isolated from door-handles in two selected hospitals in Pokhara Metropolitan City, Nepal. The study was conducted in selected hospitals in Pokhara Metropolitan City, Western Nepal. A cross-sectional study design was used. The hospitals were selected randomly. A total of 100 swab samples were taken from door-handles. Isolation and identification of bacteria were done using standard microbiological procedures. An antibiotic susceptibility test, screening and confirmation of ESBLs were performed using the Clinical Laboratory Standard Institute's guidelines. RESULTS: Out of the 100 swab samples cultured, 96 (96%) showed bacterial growth. A total of one hundred and forty isolates were isolated in this study which were further identified based on cultural, morphological and biochemical characteristics. The study also found that door handles/knobs had higher level of contamination in Outpatient Departments (OPDs), Emergency, Laboratory, General wards and Toilets, in that order as compared to Radiology Room, Staff rooms, Intensive Care Unit and Operation Theatre which were lower. The level of contamination varies depending on the traffic exposure and the environment. The most prevalent Gram-negative bacteria identified was Escherichia coli 28.85%, followed by Klebsiella spp 21.15%, Pseudomonas aeruginosa 15.38%, Proteus spp 11.54%, Enterobacter spp 9.62%, Acenetobacter spp 7.69%, Citrobacter spp 5.77%. The most effective drug of choice was Amikacin, Nitrofurantoin, Norfloxacin, Ciprofloxacin, Tetracycline and Imipenem for many Gram-negative isolates. The overall prevalence of ESBLs in this study was 27.14%. Out of total 15 Escherichia coli isolated, 11(73.3%), Klebsiella spp 9/11 (81.8%); Pseudomonas spp 7/8 (87.5%), Proteus spp 4/6 (66.6%); Enterobacter spp 3/5 (60%), Acenetobacter spp 3/4 (75%) and Citrobacter spp 1/3 (33.3%) were found to be Extended ß-Lactamase Producers (ESBLs). CONCLUSION: The isolation of of pathogenic Gram-negative bacteria and ESBLs in hospital environments and subsequent detection of high drug resistance patterns indicates a potentially serious public health challenge that strengthens the need for the effective and routine cleaning of door-handles in hospitals.

Determination of causes of adult deaths using minimally invasive tissue sampling in Gandaki province of Nepal: a multicenter hospital-based study.

BACKGROUND: Minimally Invasive Tissue Sampling (MITS) has been successfully used to establish the cause of death in low- and middle-income countries, mostly in stillbirths and neonates. The objective of this study was to determine the causes of death among adults using MITS in the Gandaki province of Nepal and to find out the contribution of MITS to identify the causes of death. METHODS: A multicentric hospital-based pilot study was conducted to enroll 100 cases of adult deaths. The specimens of cerebrospinal fluid, blood, brain, lungs, and liver tissue were collected utilizing MITS. These specimens underwent standard histopathological, serological, and microbiological analyses. The findings from MITS, and if available, clinical records and forensic autopsy findings were compiled and the cause of death panel identified the causes of death. The final cause of death allocated to each case was based on the WHO International Medical Certificate of Death. RESULTS: Among a total of 100 cases enrolled during the study period, infectious cause attributed to the immediate cause of death in 77 (77%), cardiovascular in 10 (10%), neurological in 8 (8%), malignancy in two (2%), and gastrointestinal and hepatobiliary cause in one (1%) case. The mean age of the cases was 50.8 ± 15.9 years and 76 (76%) were males. MITS established the cause of death in the causal chain of events in 81(81%) cases and identified the cause of death significantly more with infectious than non-infectious causes (p < 0.001). CONCLUSIONS: MITS was useful in establishing the cause of death in the majority of adult deaths and the most common cause was infectious disease. Our findings suggest that MITS can be a valuable and alternative tool for mortality surveillance in low-resource settings, where complete diagnostic autopsies are less accepted or less prioritized.

Burden of Serious Bacterial Infections and Multidrug-Resistant Organisms in an Adult Population of Nepal: A Comparative Analysis of Minimally Invasive Tissue Sampling Informed Mortality Surveillance of Community and Hospital Deaths.

BACKGROUND: Bacterial diseases are the leading cause of mortality globally, and due to haphazard use of antibiotics, antimicrobial resistance has become an emerging threat. METHODS: This cross-sectional observational study utilized a minimally invasive tissue sampling procedure to determine the cause of death among an adult population. Bacterial cultures (blood, cerebrospinal fluid, lung tissue) and antibiotic susceptibility were evaluated, and the results were compared between community and hospital deaths. RESULTS: Of 100 deceased persons studied, 76 (76%) deaths occurred in the community and 24 (24%) in the hospital. At least 1 bacterial agent was cultured from 86 (86%) cases; of these, 74 (86%) had a bacterial disease attributed as the primary cause of death, with pneumonia (35, 47.3%), sepsis (33, 44.6%), and meningitis (3, 4.1%) most common. Of 154 bacterial isolates (76.6% from the community and 23.4% from the hospital) detected from 86 culture-positive cases, 26 (16.8%) were multidrug-resistant (MDR). Klebsiella species were the most common (13 of 26) MDR organisms. The odds of getting an MDR Klebsiella infection was 6-fold higher among hospital deaths compared with community deaths (95% confidence interval [CI], 1.37-26.40; P = .017) and almost 23-fold higher (CI, 2.45-213.54; P = .006) among cases with prior antibiotic use compared to those without. CONCLUSIONS: High incidence of serious bacterial infections causing death of adults in the community, with most MDR organisms isolated from hospitalized cases, calls for robust surveillance mechanisms and infection prevention activities at the community level and evidence-driven antibiotic stewardship in healthcare settings.

Disseminated cryptococcosis in a deceased with HIV-1 diagnosed by minimally invasive tissue sampling technique.

Minimal invasive tissue sampling (MITS) technique detected HIV infection and disseminated cryptococcosis in an adult female with sudden death. A proper autopsy is essential to diagnose the exact cause of death and MITS can suffice in natural deaths.

Rapid response calls in inpatient psychiatric units.

OBJECTIVE: To assess the rates of serious medical issues on psychiatry wards by determining the rate, indication and outcomes of rapid response calls. METHOD: Using retrospective file review, information regarding rapid response calls during an 8-month period was analysed. RESULTS: Seventy-two rapid response calls were recorded; 7.5% of the admissions involved a rapid response call. Of patients who required a rapid response call, 88.6% had medical comorbidities. Also, 29.2% of rapid response calls required transfer to another ward. CONCLUSIONS: Patients on psychiatry wards frequently require urgent medical intervention. Improved collaboration and service planning between general medical and psychiatric service is required to improve clinical care and outcomes for this high-risk group.

Efficacy of Topical Cyclosporine 0.05% the Treatment of Vernal Keratoconjunctivitis.

INTRODUCTION: Vernal Keratoconjunctivitis is a chronic bilateral seasonally exacerbated allergy affecting the conjunctiva and cornea of children. As technology has advanced, newer medications have been developed for the control of the disease. PURPOSE: To assess the effectiveness of an immunomodulator, cyclosporine, in the treatment of vernal keratoconjunctivitis. MATERIALS AND METHODS: Fifty patients of moderate, severe to very severe vernal keratoconjunctivitis were selected for the study. They were given cyclosporine 0.05% eye drops in loading dose followed by gradual tapering. Symptoms and signs were recorded at presentation, after two weeks, after four weeks, after two months and after three months. RESULTS: Vernal keratoconjunctivitis, being a chronic disease showed marked improvement with immunomodulator therapy. There was significant improvement in the symptom and sign score initially, at the first follow up itself with symptom score reduction from median of mean of 2.4 to 0.6 (p=0.00) and a similar sign score reduction from 1.75 to 0.625 (p=0.00). There was gradually more improvement as therapy continued and the beneficial effects were maintained till the end point of the study at three months where median of mean symptom score was 0.4 (p=0.00) and similar sign score of 0.375 (p= 0.000). CONCLUSION: Topical cyclosporine proved to be an effective and safe treatment strategy to treat cases of moderate, severe and very severe vernal keratoconjunctivitis.

Safety, Efficacy and Acceptability of Early First Trimester Abortion using Oral Mifepristone and Sublingual Misoprostol.

BACKGROUND: With the legalization of medical abortion in Nepal, mifepristone-misoprostol combination via different routes has been widely used for early abortion. This study aims to evaluate the efficacy and acceptability of 200 milligrams mifepristone orally followed by 800 micrograms sublingual misoprostol in outpatient setting. METHODS: It was an open-label prospective study conducted in outpatient department of a tertiary hospital over a period of 13 months. Clients upto nine weeks of pregnancy were enrolled. 200 milligrams of mifepristone orally followed by 800 micrograms of misoprostol sublingually 36 to 48 hours later were prescribed. They were followed up in 14 days sonologically or verbally through telephone. Side effects and satisfaction to the regimen were assessed through acceptability questionnaire. Mann-Whitney U test was used for analyzing categorical data. RESULTS: A total of 47 clients were enrolled. The mean age and gestational age were 29.38 years (SD+5.914) and 6.2 weeks (SD+1.28) respectively. The commonest indications for termination were completed family and unwanted pregnancy (40.4% each). The average duration of bleeding was 5.76 days (SD +3.61). Abdominal cramping was the most common side effect (95.7%). The least acceptable parameter was the bleeding time (80.9%). For 97.9% clients, the adverse effects were acceptable. The overall success rate of the regimen was 87.2%. CONCLUSIONS: With a comparable success rate to vaginal use, home based sublingual use of misoprostol in low resource settings offers an acceptable and cost effective alternative for medical abortion upto nine weeks of pregnancy. Lesser gestational age is a useful predictor for successful abortion.

Constructing Item Banks for Measuring Quality of Life in Refractive Error.

SIGNIFICANCE: Existing patient-reported outcome instruments in refractive error are paper-based questionnaires. They are not comprehensive and psychometrically robust. This study has identified the content of the refractive error-specific item banks that aim to provide comprehensive and scientific measurement of refractive error-specific quality of life. PURPOSE: The purpose of this study was to identify minimally representative, optimally informative, and efficient sets of items for measuring quality of life in people with refractive error. METHODS: First, items were identified from existing patient-reported outcome instruments. Second, items were developed from qualitative studies with people with refractive error (48 and 101 in-depth interviews in Australia and Nepal, respectively). Third, classification and selection of items were done based on a set of systematic criteria using an iterative process of binning and winnowing. The resulting items underwent cognitive testing with people with refractive error in Australia and in Nepal. Each step was guided by an expert panel consensus. RESULTS: We retrieved 792 items from the existing patient-reported outcome instruments. From the interviews conducted in Australia, a total of 2367 comments were coded into 807 initial items. Similarly, from the interviews conducted in Nepal, 3477 comments were coded into 914 initial items. After binning and winnowing, followed by cognitive testing, a final set of items comprising 337 items for the Item-pool (Australia) and 308 items for the Item-pool (Nepal), both spanning 12 domains, was obtained. Forty-seven percent of items were common across the two item pools. In the Item-pool (Nepal), 65% items were common for corrected and uncorrected refractive error. CONCLUSIONS: We identified the content of two different sets of item banks to comprehensively measure the impact of refractive error on quality of life for people in Australia and Nepal, which may be applicable to high-income country settings and low- and middle-income country settings, respectively. Future work aims to develop computer-adaptive testing system to administer the item banks, resulting in useful measurement tools for researchers, clinicians, and policy planners.

A case of acute postoperative keratitis after deep anterior lamellar keratoplasty by multidrug resistant Klebsiella.

A healthy lady of 42 years underwent deep anterior lamellar keratoplasty for granular dystrophy. The very next day, it was complicated by development of infectious keratitis. The organism was identified as multidrug resistant Klebsiella pneumoniae. Donor corneal button may be implicated in the transmission of infection in an otherwise uneventful surgery and follow-up. Nosocomial infections are usually severe, rapidly progressive and difficult to treat. Finally, the lady had to undergo therapeutic penetrating keratoplasty for complete resolution of infection.

Intestinal parasitosis in school children of Lalitpur district of Nepal.

BACKGROUND: Enteric parasites are the most common cause of parasitic diseases and cause significant morbidity and mortality, particularly in developing countries like Nepal. The objective of this study was to estimate the prevalence and risk factors of intestinal parasitic infections among school going children of Lalitpur district of Nepal. METHODS: A total of 1392 stool samples were collected from school children of two government, two private and two community schools of the same district. The stool samples were examined for evidence of parasitic infections by direct microscopy and confirmed by concentration methods (formal ether sedimentation technique or floatation technique by using Sheather's sugar solution). Modified Ziehl-Neelsen (ZN) staining was performed for the detection of coccidian parasites. RESULTS: Prevalence of intestinal parasitosis was found to be 16.7%. The highest prevalence rate was seen with Giardia lamblia (7.4%) followed by Entamoeba histolytica (3.4%) and Cyclospora cayetanensis (1.6%). Children aged 11-15 years and the ones belonging to family of agriculture workers were most commonly affected. Hand washing practice and type of drinking water also showed significant difference. CONCLUSIONS: The burden of parasitic infections among the school children, coupled with the poor sanitary conditions in the schools, should be regarded as an issue of public health priority and demands for effective school health programs involving periodic health education and screening.