Implementation and long-term efficacy of a multifaceted intervention to reduce central line-associated bloodstream infections in intensive care units of a low-middle-income country.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) pose a significant risk to critically ill patients, particularly in intensive care units (ICU), and are a significant cause of hospital-acquired infections. We investigated whether implementation of a multifaceted intervention was associated with reduced incidence of CLABSIs. METHODS: This was a prospective cohort study over nine years. We implemented a bundled intervention approach to prevent CLABSIs, consisting of a comprehensive unit-based safety program (CUSP). The program was implemented in the Neonatal ICU, Medical ICU, and Surgical ICU departments at the Aga Khan University Hospital in Pakistan. RESULTS: The three intervention ICUs combined were associated with an overall 36% reduction in CLABSI rates and a sustained reduction in CLABSI rates for > a year (5 quarters). The Neonatal ICU experienced a decrease of 77% in CLABSI rates lasting ∼1 year (4 quarters). An attendance rate above 88% across all stakeholder groups in each CUSP meeting correlated with a better and more sustained infection reduction. CONCLUSIONS: Our multifaceted approach using the CUSP model was associated with reduced CLABSI-associated morbidity and mortality in resource-limited settings. Our findings suggest that a higher attendance rate (>85%) at meetings may be necessary to achieve sustained effects post-intervention.

Daptomycin MICs by Broth Microdilution Method Against Staphylococcus aureus in Clinical Specimens: A Cross-Sectional Study from Pakistan.

OBJECTIVE: To explore the distribution of daptomycin (DAP) minimum inhibitory concentrations (MICs) in Staphylococcus aureus isolated from complicated skin, soft tissue, and bloodstream infections collected from the Pakistani population using broth microdilution (BMD). STUDY DESIGN: Descriptive, cross-sectional study. Place and Duration of the Study: Department of Pathology and Laboratory Medicine, The Aga Khan University Hospital, from May to October 2021. METHODOLOGY: Through consecutive sampling techniques, 169 Staphylococcus aureus (S. aureus) isolated from clinical specimens including pus, tissue, and blood were collected. Patients' data including age, gender, geographical location, specimen site, and methicillin susceptibility were collected from the laboratory data. BMD was used to determine MICs of clinical isolates and S. aureus ATCC 29213. DAP MIC ≤1.0 µg/ml was considered susceptible according to the Clinical and Laboratory Standards Institute M100. RESULTS: Among all the clinical isolates, 144 (85%) and 25 (15%) were from skin and soft tissue and blood, respectively. All isolates were susceptible to DAP with MIC50, MIC90, and MIC range of 0.25 µg/ml, 0.5 µg/ml, and 0.06 - 0.5 µg/ml, respectively. CONCLUSION: These study findings demonstrated low in-vitro MICs for DAP against S. aureus in tested isolates from a diverse variety of patient specimens from across Pakistan. KEY WORDS: Daptomycin, Staphylococcus aureus, Broth microdilution, Minimum inhibitory concentrations.

Placental inflammation and pregnancy outcomes: A prospective, observational study in South Asia: The PURPOSe study.

OBJECTIVE: To examine inflammatory lesions in placentas of stillbirths, preterm neonatal deaths and term controls in India and Pakistan. DESIGN: Prospective, observational study. SETTING: Three hospitals in India and a large maternity hospital in Pakistan. POPULATION: The enrolled participants with placentas available for histology evaluation included stillbirths (n = 814), preterm live births who died within 28 days of birth (n = 618) and term live birth controls (n = 201). From this same population, polymerase chain reaction (PCR) analysis for pathogens was performed on 809 stillbirth placentas, 614 neonatal death placentas and the placentas of 201 term controls. Placentas from preterm infants who lived beyond day 28 (n = 1432) were only available from India. METHODS: A prospective observational study of placental inflammatory lesions defined by the Amsterdam criteria and on the same placentas, multiplex PCR evaluation for 75 pathogens using TaqMan Array Cards. MAIN OUTCOME MEASURES: Any placental inflammatory lesions, including chorioamnionitis, funisitis, villitis and intervillitis and their association with various pathogens. RESULTS: In the Indian liveborn preterm infants, placental inflammation of any kind was present in 26.2% of those who died versus 16.6% of those who lived (p = 0.0002). Chorioamnionitis was present in 25.8% of those who died versus 16.3% of those who lived (p = 0.0002) and funisitis was present in 4.1% of those who died versus 1.5% of those who lived, (p = 0.005). Across all three sites, in the placentas of the 201 term controls, 18.9% had any inflammation, 16.9% had chorioamnionitis, 5.5% had funisitis, 0.5% had intervillitis and none had villitis. Overall, for stillbirths, any inflammation was observed in 30.2%, chorioamnionitis in 26.9%, funisitis in 5.7%, intervillitis in 6.0% and villitis in 2.2%. For the neonatal deaths, any inflammation was present in 24.9%, chorioamnionitis in 23.3%, funisitis in 8.1%, intervillitis in 1.9% and villitis in 0.5%. Compared with the placentas of term controls, in neonatal deaths, only chorioamnionitis was significantly increased (23.3% versus 16.9%, p = 0.05). Among stillbirths, the rates of any inflammation, chorioamnionitis, intervillitis and villitis were similar across the birthweight groups. However, funisitis was more common in the placentas of stillborn fetuses weighing 2500 g or more (13.8%) compared with 1.0% for those weighing less than 1000 g and 4.8% for stillborn fetuses weighing 1000-2499 g. In the PCR studies, Ureaplasma spp. were by far the most common pathogens found and generally were more commonly found in association with inflammatory lesions. CONCLUSIONS: Chorioamnionitis was the most common type of placental inflammatory lesion regardless of whether the placentas evaluated were from term controls, stillbirths or neonatal deaths. For stillbirths, inflammation in each inflammation category was more common than in the term controls and significantly more so for any inflammation, chorioamnionitis, intervillitis and villitis. For neonatal deaths, compared with the placentas of term controls, all inflammation categories were more common, but only significantly so for chorioamnionitis. Ureaplasma spp. were the most common organisms found in the placentas and were significantly associated with inflammation.

Prevalence of familial hypercholesterolemia in a country-wide laboratory network in Pakistan: 10-year data from 988, 306 patients.

INTRODUCTION: Familial hypercholesterolemia (FH) is a modifiable risk factor for premature coronary heart disease but is poorly diagnosed and treated. We leveraged a large laboratory network in Pakistan to study the prevalence, gender and geographic distribution of FH. METHODOLOGY: Data were curated from the Aga Khan University Hospital clinical laboratories, which comprises of 289 laboratories and collection points spread over 94 districts. Clinically ordered lipid profiles from 1st January 2009 to 30th June 2018 were included and data on 1,542,281 LDL-C values was extracted. We used the Make Early Diagnosis to Prevent Early Death (MEDPED) criteria to classify patients as FH and reported data on patients with low-density liporotein -cholesterol (LDL-C) ≥ 190 mg/dL. FH cases were also examined by their spatial distribution. RESULTS: After applying exclusions, the final sample included 988,306 unique individuals, of which 24,273 individuals (1:40) had LDL-C values of ≥190 mg/dL. Based on the MEDPED criteria, 2416 individuals (1:409) had FH. FH prevalence was highest in individuals 10-19 years (1:40) and decreased as the patient age increased. Among individuals ≥40 years, the prevalence of FH was higher for females compared with males (1:755 vs 1:1037, p < 0.001). Median LDL-C for the overall population was 112 mg/dL (IQR = 88-136 mg/dL). The highest prevalence after removing outliers was observed in Rajan Pur district (1.23% [0.70-2.10%]) in Punjab province, followed by Mardan (1.18% [0.80-1.70%]) in Khyber Pakhtunkhwa province, and Okara (0.99% [0.50-1.80%]) in Punjab province. CONCLUSION: There is high prevalence of actionable LDL-C values in lipid samples across a large network of laboratories in Pakistan. Variable FH prevalence across geographic locations in Pakistan may need to be explored at the population level for intervention and management of contributory factors. Efforts at early diagnosis and treatment of FH are urgently needed.

Pathogens identified in the internal tissues and placentas of stillbirths: results from the prospective, observational PURPOSe study.

OBJECTIVE: To examine internal organ tissues and placentas of stillbirths for various pathogens. DESIGN: Prospective, observational study. SETTINGS: Three study hospitals in India and a large maternity hospital in Pakistan. POPULATION: Stillborn infants delivered in a study hospital. METHODS: A prospective observational study. MAIN OUTCOME MEASURES: Organisms identified by pathogen polymerase chain reaction (PCR) in internal organs and placental tissues of stillbirths. RESULTS: Of 2437 stillbirth internal tissues, 8.3% (95% CI 7.2-9.4) were positive. Organisms were most commonly detected in brain (12.3%), cerebrospinal fluid (CSF) (9.5%) and whole blood (8.4%). Ureaplasma urealyticum/parvum was the organism most frequently detected in at least one internal organ (6.4% of stillbirths and 2% of all tissues). Escherichia coli/Shigella was the next most common (4.1% one or more internal organ tissue sample and 1.3% of tissue samples), followed by Staphylococcus aureus in at least one internal organ tissue (1.9% and 0.9% of all tissues). None of the other organisms was found in more than 1.4% of the tissue samples in stillbirths or more than 0.6% of the internal tissues examined. In the placenta tissue, membrane or cord blood combined, 42.8% (95% CI 40.2-45.3) had at least one organism identified, with U. urealyticum/parvum representing the most commonly identified (27.8%). CONCLUSIONS: In about 8% of stillbirths, there was evidence of a pathogen in an internal organ. Ureaplasma urealyticum/parvum was the most common organism found in the placenta and in the internal tissues, especially in the fetal brain.

Community-acquired meningoencephalitis due to concomitant infection caused by Naegleria fowleri and Streptococcus pneumoniae from Karachi, Pakistan: A Case Report.

Naegleria fowleri causes acute fatal primary amoebic meningoencephalitis in adults and children with a history of exposure to aquatic activities. However, several cases of Primary Amoebic Meningoencephalitis (PAM) have been reported from Karachi with no history of aquatic recreational activities suggesting the presence of N. fowleri in domestic water. This study reports a case of co-infection of N. fowleri with Streptococcus pneumoniae in an elderly hypertensive male.

Pathogens Identified by Minimally Invasive Tissue Sampling in India and Pakistan From Preterm Neonatal Deaths: The PURPOSE Study.

BACKGROUND: We identified pathogens found in internal organs and placentas of deceased preterm infants cared for in hospitals in India and Pakistan. METHODS: Prospective, observational study conducted in delivery units and neonatal intensive care units. Tissue samples from deceased neonates obtained by minimally invasive tissue sampling and placentas were examined for 73 different pathogens using multiplex polymerase chain reaction (PCR). RESULTS: Tissue for pathogen PCR was obtained from liver, lung, brain, blood, cerebrospinal fluid, and placentas from 377 deceased preterm infants. Between 17.6% and 34.1% of each type of tissue had at least 1 organism identified. Organism detection was highest in blood (34.1%), followed by lung (31.1%), liver (23.3%), cerebrospinal fluid (22.3%), and brain (17.6%). A total of 49.7% of the deceased infants had at least 1 organism. Acinetobacter baumannii was in 28.4% of the neonates compared with 14.6% for Klebsiella pneumoniae, 11.9% for Escherichia coli/Shigella, and 11.1% for Haemophilus influenzae. Group B streptococcus was identified in only 1.3% of the neonatal deaths. A. baumannii was rarely found in the placenta and was found more commonly in the internal organs of neonates who died later in the neonatal period. The most common organism found in placentas was Ureaplasma urealyticum in 34% of the samples, with no other organism found in >4% of samples. CONCLUSIONS: In organ samples from deceased infants in India and Pakistan, evaluated with multiplex pathogen PCR, A. baumannii was the most commonly identified organism. Group B streptococcus was rarely found. A. baumannii was rarely found in the placentas of these deceased neonates.

Reporting of mycetoma cases from skin and soft tissue biopsies over a period of ten years: A single center report and literature review from Pakistan.

BACKGROUND: Mycetoma is an important neglected tropical disease associated with debilitation, disfigurement and death if not diagnosed and treated adequately. In Pakistan, mycetoma cases have frequently been diagnosed in histopathology and microbiology laboratories. However, there is scarcity of published data from this country. Therefore, the objectives of this study were to evaluate the frequency and type of mycetoma reported in skin and soft tissue biopsies from a single center over 10 years and review of published literature from Pakistan. METHOD: This descriptive observational retrospective study was conducted at the Aga Khan University Hospital laboratory, Karachi, Pakistan. Laboratory data from 2009-2018 of skin and soft tissue biopsies with positive findings of mycetoma were retrieved from hospital information system. The variables for statistical analysis were age and gender of patient, anatomical site of lesion, residence of patient (geographical location) in the country, etiologic agents of mycetoma and significant gross and microscopic histopathological findings. The data was entered, and descriptive epidemiologic assessment was carried out using MS excel 2013. Geographical information system was used for mapping the location. Literature review of mycetoma cases reported from Pakistan was done on PubMed, Google search and PakMediNet from 1980 till April 2019. RESULT: During ten years of study period, 89 skin and soft tissue biopsies were reported as mycetoma, majority were eumycetoma [n = 66/89 (74%)] followed by actinomycetoma [n = 23/89 (26%)]. Involvement of lower limb was predominantly observed [n = 74/89 (83%)] in which foot had significant contribution [n = 65/74 (88%)]. Only 18 specimens were submitted for microbiological assessment and six grew agents of mycetoma, with Madurella mycetomatis reported in only three. Well-formed granuloma formation was observed in only 26%[n = 23/89] of cases. Specific geographical location was not identified, and cases were reported from across the country. From Pakistan, only two original papers and 7 case reports were available in published literature. CONCLUSION: This single center study reports a handful of cases of mycetoma from Pakistan. We conclude that the index of suspicion should remain high among treating surgeons and physicians and clinical laboratories should improve their diagnostic capacity and skills. This will have a great impact on disease outcome and patient's life.

Lung Findings in Minimally Invasive Tissue Sampling (MITS) Examinations of Fetal and Preterm Neonatal Deaths: A Report From the PURPOSe Study.

BACKGROUND: Complete diagnostic autopsy (CDA) is considered to be the gold-standard procedure that aids in determination of cause of death in stillbirths and neonatal deaths. However, CDA is not routinely practiced in South Asian countries due to religious beliefs, lack of expertise, and lack of resources. Minimally invasive tissue sampling (MITS) has been recommended as a less mutilating and less expensive alternative to CDA for obtaining tissues for analysis. The present study aims to evaluate the yield of lung tissue and histological findings using MITS as part of a cause of death analysis for stillborns and preterm neonatal deaths. METHODS: Data were collected during an observational multicenter prospective study called the Project to Understand and Research Preterm birth and Stillbirth (PURPOSe) conducted in India and Pakistan. After obtaining written informed consent from parents, the eligible stillbirths and neonatal deaths were subjected to MITS using a standard protocol. The tissues were obtained from both lungs for histological and microbiological analysis. RESULTS: At both sites, a total of 453 stillbirths and 352 neonatal deaths underwent MITS. For stillbirths and neonatal deaths, the yield of lung tissue using MITS was high (92%). Intrauterine fetal distress and respiratory distress syndrome were the leading lung pathologies reported in stillbirths and neonatal deaths, respectively. CONCLUSIONS: MITS appears to be a reasonable alternative to CDA in obtaining and evaluating lung tissue to inform accurate cause of death analysis in stillbirth and preterm deaths.

Antifungal susceptibility profile of invasive Candida glabrata isolates (2009-2020) from a tertiary care hospital laboratory in Pakistan.

Introduction. Invasive infections with Candida glabrata are a global concern due to poor clinical outcomes and propensity to acquire resistance to antifungal agents. Hypothesis/Gap Statement. Monitoring emerging resistance and trends in Candida glabrata, an important agent of candidemia in Pakistan, is critical for patient management; data that is missing from Pakistan. Aim. Thus, this study evaluated antifungal resistance and MICs) distribution in invasive C. glabrata isolates from Pakistan. Methods. This cross-sectional and retrospective study was conducted from January 2009 to March 2020 at a clinical laboratory in Pakistan that has a nation-wide network. Antifungal susceptibility data of 277 candidemia, deep organ and soft tissue (invasive) C. glabrata sensu lato isolates against fluconazole, itraconazole, voriconazole, posaconazole, anidulafungin, micafungin, caspofungin and amphotericin B was retrieved. Susceptibility testing was performed using colorimetric broth microdilution and interpreted using CLSI criteria. Demographics, clinical history and outcome were studied. Chi-square test was used to demonstrate association between antifungal resistance and clinical characteristics of the patients. Results. We identified 277 patients with invasive C. glabrata infection. Of which 48 (18.4%) isolates were resistant to fluconazole (MIC ≥64 mg l-1), one isolate each was resistant to amphotericin (MIC=2 mg l-1), anidulafungin (MIC=1 mg l-1) and micafungin (MIC=0.5 mg l-1). MIC90 for fluconazole was 64 mg l-1 and other triazoles 2 mg l-1, caspofungin 0.12 mg l-1, anidulafungin 0.06 mg l-1, micafungin 0.03 mg l-1 and amphotericin 0.5 mg l-1. Fluconazole MIC ≥64 mg l-1, caspofungin MIC >0.06 mg l-1 and amphotericin MIC >0.25 mg l-1 (above MIC50) were significantly associated with patient being alive at the time of reporting, no use of healthcare devices, nor infection with other fungi. Fluconazole resistance was significantly associated with prior antifungal use by the patient. Conclusion. Surveillance data of antifungal resistance among common Candida species should be monitored closely for identification of resistant strains.

Comparative analysis of N95 respirators fit testing with commercially available and in house reagent.

BACKGROUND: Due to COVID-19, thousands of healthcare workers have been affected and have lost their lives in the line of duty. For the protection of healthcare workers, WHO and CDC have made standard guidelines and requirements for PPE use. N95 masks are amongst the most readily used PPE by healthcare professionals and it is highly recommended by OSHA that every make and model of N95 should go through a fit test at least once in a year. METHOD: A total of 30 randomly selected healthcare professionals (who were a regular user of N95 respiratory masks) were subjected to assess in-house (saccharin sodium benzoate) reagent for use for standard qualitative fit testing in our hospital. Threshold testing with the in-house reagent at three different concentrations was performed prior to establish participants' sensitivity to the reagent. After successful completion of threshold testing, fit test was performed on participants wearing an N95 mask. RESULTS: All the participants included in the study passed the sensitivity testing with three concentrations of the reagents, while it was concluded that the concentration of the in-house reagent that was well suited for the sensitivity testing was a concentration of 1g/dl saccharin with 10g/dl sodium benzoate. For fit testing 12g/dl was found to be more appropriate. DISCUSSION: Our study provided a low cost solution to ensure safety of healthcare workers who are regular users of N95 masks following guidelines implemented by OSHA and CDC. CONCLUSION: The in-house test solution prepared was found to be equally sensitive to its commercially available counterpart.

Comparison of ß-D-Glucan levels between Candida auris and other Candida species at the time of candidaemia: a retrospective study.

OBJECTIVES: To compare serum ß-D-glucan (BDG) levels in candidaemia with different Candida species, especially C. auris. METHODS: Aga Khan University clinical laboratory database was retrospectively reviewed from January 2015 to December 2019. Blood culture positive cases with any Candida species and concomitant BDG level were included. RESULTS: Among the 192 cases included in our study, 48 were C. albicans, 54 C. auris, eight C. glabrata, 32 C. parapsilosis, 43 C. tropicalis and seven other Candida species. The level of BDG was significantly lower in C. auris (median 62.43, interquartile range (IQR) 12.80-182.94 pg/mL) compared to C. albicans (median 266.83, IQR 66.29-523.43 pg/mL) and C. tropicalis (median 324.41, IQR 105.20-523.44 pg/mL). The sensitivity of serum BDG was significantly lower for C. auris (43.75%, 95% CI 29.5-58.8%) than C. tropicalis (79.07%, 95% CI 64.0-90.0%). DISCUSSION: Serum BDG has lower sensitivity in patients with suspected C. auris candidaemia in our setting. Considering that C. auris has higher morbidity and mortality than other species, a more sensitive test is required.

Extraintestinal Seeding of Salmonella enterica Serotype Typhi, Pakistan.

We evaluated Salmonella enterica serotype Typhi strains isolated from all body sites in Pakistan during 2013-2018. Despite an increase in overall number of localized, extensively drug-resistant Salmonella Typhi in organ infections during 2018, there was no increase in the proportion of such isolates in comparison with non-extensively drug-resistant isolates.

Increase in Penicillin and multidrug resistance in Streptococcus pneumoniae (1993-2016): Report from a tertiary care hospital laboratory, Pakistan.

OBJECTIVE: To determine the trend of resistance to antimicrobials in Streptococcus pneumoniae infections, and the impact of new Clinical and Laboratory Standards Institute guidelines on 1211 among meningeal isolates. METHODS: The descriptive observational retrospective study was conducted at the Aga Khan University Hospital laboratory in Karachi, and comprised Streptococcus pneumoniae isolation and antimicrobial susceptibility data over a period of 24 years, from 1993 to 2016, which was compared in terms of pre-2008 and post-2008 data, which was analysed using SPSS 19. RESULTS: Of the 7415 non-duplicate isolates identified, 4700(63.4%) were from male patients and 2,715(36.6%) were from female patients. The overall mean age of the patients was 38±27 years. Penicillin resistance in non-meningeal isolates during the two periods was not significantly different (p>0.05), but a significant rise in penicillin resistance in meningeal isolates was observed in the second period (p<0.05). High resistance rates were observed for co-trimoxazole, tetracycline and erythromycin, and an increased trend of multi-drug resistant strains was also noted from 1999 {n=35/317(11%)} to 2016 {n=110/314 (36%)}. CONCLUSIONS: The emergence of multi-drug resistant strains was evident. The spike in penicillin-resistant Streptococcus pneumoniae in meningeal isolates may have been due to the revised guidelines by the Clinical and Laboratory Standards Institute.

Outbreak investigation of Candida auris at a tertiary care hospital in Karachi, Pakistan.

BACKGROUND: From September 2014, a tertiary care hospital in Karachi, Pakistan, started diagnosing 3-5 cases/month of a yeast locally identified as Saccharomyces spp. resistant to fluconazole. US Centers for Disease Control and Prevention identified the isolates as Candida auris. The Pakistan Field Epidemiology and Laboratory Training Program (FELTP) and the hospital investigated the outbreak from April 2015 to January 2016. OBJECTIVE: The aim of the outbreak investigation was to determine the risk factors and to inform measures to limit the spread of the organism in the hospital. METHODS: Medical records, nursing schedules and infection control practices were reviewed. Sixty-two age- and sex-matched hospital controls from the same wards were identified. RESULTS: Thirty cases (17 males) were identified (mean age = 51.6 years, age range = 2-91 years), case fatality was 53%. Multivariate logistic regression showed that a history of surgery within 90 days of diagnosis, admission to the emergency department and history of chronic kidney disease were significantly associated with C. auris infection. DISCUSSION: This is the report of the outbreak investigation that triggered a global exploration of C. auris as a newly identified multidrug-resistant nosocomial organism, spreading within the hospital, especially among patients with invasive procedures. Unfortunately, we could not identify any specific source of the outbreak nor stop the transmission of the organism.

Screening for triazole resistance in clinically significant Aspergillus species; report from Pakistan.

BACKGROUND: Burden of aspergillosis is reported to be significant from developing countries including those in South Asia. The estimated burden in Pakistan is also high on the background of tuberculosis and chronic lung diseases. There is concern for management of aspergillosis with the emergence of azole resistant Aspergillus species in neighbouring countries in Central and South Asia. Hence the aim of this study was to screen significant Aspergillus species isolates at the Microbiology Section of Aga Khan Clinical Laboratories, Pakistan, for triazole resistance. METHODS: A descriptive cross-sectional study, conducted at the Aga Khan University Laboratories, Karachi, from September 2016-May 2019. One hundred and fourteen, clinically significant Aspergillus isolates [A. fumigatus (38; 33.3%), A. flavus (64; 56.1%), A. niger (9; 7.9%) A. terreus (3; 2.6%)] were included. The clinical spectrum ranged from invasive aspergillosis (IA) (n = 25; 21.9%), chronic pulmonary aspergillosis (CPA) (n = 58; 50.9%), allergic bronchopulmonary aspergillosis (ABPA) (n = 4; 3.5%), severe asthma with fungal sensitization (SAFS) (n = 4; 3.5%), saprophytic tracheobronchial aspergillosis (n = 23; 20.2%). Screening for triazole resistance was performed by antifungal agar screening method. The minimum inhibitory concentration (MIC) of 41 representative isolates were tested and interpreted according to the Clinical and Laboratory Standards Institute broth microdilution method. RESULTS: All the isolates were triazole-susceptible on agar screening. MICs of three azole antifungals for 41 tested isolates were found to be ≤1 ml/L; all isolates tested were categorized as triazole-susceptible, including 4 isolates from patients previously on triazole therapy for more than 2 weeks. The minimum inhibitory concentration required to inhibit the growth of 90% organisms (MIC90) of itraconazole, voriconazole and posaconazole of the representative Aspergillus isolates was 1 mg/L, 1 mg/L and 0.5 mg/L, respectively. CONCLUSION: Triazole resistance could not be detected amongst clinical Aspergillus isolates from the South of Pakistan. However, environmental strains remain to be tested for a holistic assessment of the situation. This study will set precedence for future periodic antifungal resistance surveillance in our region on Aspergillus isolates.

Use of pefloxacin as a surrogate marker to detect ciprofloxacin susceptibility in Salmonella enterica serotypes Typhi and Paratyphi A.

OBJECTIVE: To determine the use of pefloxacin as a surrogate marker to detect fluoroquinolone (ciprofloxacin) susceptibility against Salmonella enterica serotypes Typhi and Paratyphi A. METHODS: The prospective, descriptive cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, from September 2016 to March 2018, and comprised Salmonella Typhi and Paratyphi A isolates of blood cultures. Disk susceptibility tests and broth microdilution to test minimum inhibitory concentration were performed as per standard guidelines. Data was analysed using SPSS 21. RESULTS: Of the 138 isolates, 91(66%) were intermediate resistant to ciprofloxacin but were resistant to pefloxacin, 42(30%) were resistant to both ciprofloxacin and pefloxacin, and 5(4%) were susceptible to both ciprofloxacin and pefloxacin. Of the isolates that were intermediate resistant to ciprofloxacin, 85(93%) had minimum inhibitory concentration range0.12-0.5mg\L, while 6(7%) had MIC>1mg\L (p<0.0001). CONCLUSIONS: Pefloxacin disk diffusion test was found to be reliable in detecting fluoroquinolone resistance among enteric fever causing Salmonella.

Perceptions of health professionals regarding minimally invasive tissue sampling (MITS) to identify the cause of death in stillbirths and neonates: results from a qualitative study.

BACKGROUND: Pakistan is considered to be one of the riskiest places in the world for childbirth as measured by its high stillbirth and neonatal mortality rates. Complete diagnostic autopsy remains the gold standard to determine the cause of death (CoD); however, it is not routinely implemented due to religious objections, sociocultural beliefs, limited resources and low demand from physicians and families. Recently, minimally invasive tissue sampling (MITS) using needle biopsies of multiple tissues to obtain tissue for histological examination and organism identification with PCR has been developed and promoted to determine CoD in low-resource areas. To ensure successful implementation of MITS, it is important to understand health professionals' attitudes and perceptions related to MITS. METHODS: A qualitative study was conducted at the National Institute of Child Health (NICH), Karachi, Pakistan. Focus group discussions (FGDs) and Key-informant interviews (KIIs) were conducted with health professionals including doctors, nurses, trainees, clinicians, bioethics experts and public health experts to explore their perceptions and views on acceptability of MITS. Data were analyzed using NVivo 10 software. RESULTS: A total of 12 interviews (FGDs = 4; KIIs = 8) were conducted. Four overarching themes were identified: (I) acceptability of MITS; (II) perceived benefits of the MITS procedure; (III) factors facilitating the implementation of MITS; and (IV) health system requirements for implementing the MITS procedure. Generally, MITS was considered as a positive development for the health system. Diagnostic accuracy and identification of less common causes of death were highlighted as two main benefits of the MITS procedure. The study highlighted a number of facilitators for the acceptability of MITS including effective counseling, building trust with parents, fast procedure time, and approaching families within a few hours of death. In addition, lack of skilled staff, poorly equipped healthcare facilities and the potential high cost to conduct MITS were identified as challenges for the implementation of MITS. CONCLUSIONS: This formative research provided a unique opportunity to explore health professionals' views and attitudes towards the MITS procedure. Such insights are crucial to ensure successful implementation and integration of a new technique into the existing health system. The research identified the factors influencing the acceptability of MITS among health professionals in Pakistan. The study also informed factors that could help facilitate the implementation of the MITS procedures in the context of Pakistan and similar settings.

Methicillin resistant Staphylococcus aureus outbreak in a neonatal intensive care unit.

The global and national burden of communicable and noncommunicable diseases continues to rise, thus making access to Healthcare workers (HCWs) colonized with methicillin-resistant Staphylococcus aureus (MRSA) may pose transmission risk to vulnerable patients including neonates. This study reports an MRSA outbreak in a level-II neonatal intensive care unit (NICU) of a secondary care hospital in Pakistan. Once identified, an infection control team from the parent hospital visited the facility, risk factors were listed and infection control measures taken to control the outbreak. Screening cultures of NICU staff and environmental cultures from NICU were obtained for the presence of MRSA. Five neonates were positive for MRSA; one HCW was found to be colonized with MRSA, the antibiogram pattern of which matched with that of the outbreak strain. Decolonization of colonized HCWs and re-deployment from NICU to outpatient department were taken and the outbreak was declared over once no further MRSA cases were identified. Identification of an outbreak situation is the cornerstone for its control and multiple measures taken simultaneously help in curbing the outbreak. Although an epidemiological link was established with the HCW, a molecular link could not be proven.