Distribution of MecA and Erm Genes among Methicillin-resistant Staphylococcus Aureus with Inducible Resistance to Clindamycin.

BACKGROUND: The emergence of Methicillin-resistant Staphylococcus aureus and its ability to confer cross-resistance to macrolide-lincosamide-streptogramin B has complicated the treatment against it. Gene-based studies among phenotypic methicillin-resistant isolates with inducible resistance to clindamycin are less available in Nepal. This work was undertaken to detect the mecA and erm genes among such phenotypes isolated from clinical samples. METHODS: S. aureus isolated from different clinical samples was identified by standard microbiological procedures (Gram-staining, colony morphology, and different biochemical tests). Methicillin-resistant and inducible resistant to clindamycin phenotypes were detected by using cefoxitin disc (30 µg) and a double disk diffusion test according to the Clinical and Laboratory Standards Institute guidelines and mecA and erm genes were detected by polymerase chain reaction. RESULTS: Among 120 S. aureus isolates, 51.67% (n=62) were MRSA, and the prevalence of inducibly-resistant, constitutively-resistant and Macrolide-Streptogramin phenotypes were 15.83% (n=19), 28.33% (n=34) and 15.83% (n=19) respectively. While 35.84% (n=43) of isolates showed sensitivity to both antibiotics, erythromycin and clindamycin. Out of 14 inducibly-resistant phenotypes, 57.14% (n=8) were found carrying ermC and 28.57% (n=4) phenotypes contained both ermA and ermC. All phenotypes were positive for the mecA gene. CONCLUSIONS: Macrolides-Lincosamide-Streptogramin B resistance was predominant among methicillin-resistant S. aureus. While all isolates with inducible clindamycin resistance harbored mecA gene, most of them also harbored ermC gene. The higher prevalence of inducible-resistant to clindamycin indicated the need for rational use of antimicrobial agents.

Detection of blaoxa-23 Gene from Carbapenem-resistant Acinetobacter Baumannii.

BACKGROUND: Antibiotic resistance is a great concern for public health and Acinetobacter baumannii-associated infections are increasing in many parts of the world, including Nepal. However, limited data is available on the prevalence of A. baumannii harboring blaOXA-23 from Nepal. METHODS: A hospital-based cross-sectional study was designed to detect the blaOXA-23 gene from carbapenem-resistant A. baumannii isolates in Nepal. A total of 380 clinical specimens were collected and processed following standard microbiological procedures. Antibiotic susceptibility test was performed as per the protocol of the Kirby-Bauer disk diffusion technique and the CLSI guidelines, while screening of carbapenemase production was assessed by the Modified Hodge Test using meropenem (10µg) disc. The presence of the blaOXA-23 gene in carbapenemase-positive A. baumannii was confirmed by PCR. RESULTS: Among 380 specimens analyzed, 210 (55.3%) samples were positive for bacterial growth, where 33(15.7% of total growth) of the isolates were A. baumannii, and most of them were isolated from the ICU patients (20/33, 60.6%) and sputum (16/33, 48.5%). Thirty-two isolates (97%) were colistin sensitive, while only four (12.1%) isolates were sensitive to meropenem and imipenem. Twenty-three (69.7%) of A. baumannii were carbapenemase positive as revealed by the Modified Hodge Test test, and 19 of them (57.6% of total A. baumannii) harbored the blaOXA-23 gene. CONCLUSIONS: A high prevalence of the blaOXA-23 gene among carbapenem-resistant A. baumannii isolates were found. Systematic network surveillance should be established to check the spread of such isolates, especially in the intensive care units of tertiary care hospitals in Nepal.

Contrast-induced Nephropathy among Patients Administered with Contrast Material at a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Administration of an intravenous contrast medium, which is used in various routine hospital procedures, can lead to the development of nephropathy in some patients. This contrast-induced nephropathy is one of the most common reasons for hospital-acquired acute kidney injury. This study aimed to find out the prevalence of contrast-induced nephropathy among patients administered with contrast material at a tertiary care centre. Methods: This descriptive cross-sectional study was conducted from 4 March 2022 to 23 May 2022 at a tertiary care centre after taking ethical approval from the Institutional Review Committee (Reference number: 0812202106). Patients administered with an intravenous contrast medium for diagnostic imaging were included in the study. Data including sociodemographic variables and renal function test results were collected. A convenience sampling method was used. Point estimate was done and 95% Confidence Interval was calculated. Results: Among 174 participants, contrast-induced nephropathy was found in 86 (48.31%) (48.24-48.39, 95% Confidence Interval). Conclusions: The study showed that the prevalence of contrast-induced nephropathy was higher than findings from other studies done in a similar setting. Keywords: contrast material; kidney disease; prevalence.

Remarkable Recovery in a Patient with Lethal Dose Paraquat Poisoning: A Case Report.

Paraquat emerges as a formidable medical dilemma in Southeast Asia, its toxic effects attributed to the generation of free radicals and oxidative stress, with a specific predilection for diverse tissues, most notably the lungs. The scarcity of effective treatment modalities in resource-constrained settings magnifies the magnitude of the paraquat poisoning predicament. This report outlines the successful management of a 25-year-old man who ingested a lethal dose of paraquat. The patient presented solely with dysphagia devoid of accompanying symptoms, regardless of ingesting a fatal quantity of paraquat. The diagnosis was made based on history and a thorough clinical examination. Early, aggressive treatment with pulse therapy of steroids and antioxidants led to unexpected and quirky recovery. The case stresses the importance of prompt management and highlights the need for more research and public education to prevent future cases. Keywords: antioxidants; case reports; corrosive; paraquat; steroids.

Methicillin-resistant Staphylococcus aureus nasal colonization in people living with HIV and healthy people in Kathmandu, Nepal.

AIM: This study aimed to compare methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization in people living with HIV (PLHIV) and healthy people from Kathmandu. METHODS: MRSA isolated from 400 nasal swabs was screened using a cefoxitin disc and confirmed by the presence of the mecA gene. RESULTS: MRSA nasal carriers among the PLHIV and control cohorts were 3.5% (7 out of 200) and 5.0% (10 out of 200), respectively. All the MRSA from PLHIV and most of MRSA from healthy controls were PVL positive. Longer duration of antiretroviral therapy significantly reduces the risk of MRSA nasal colonization in PLHIV. CONCLUSION: There is no significant difference in MRSA nasal colonization in PLHIV and healthy controls in this study region.

Antimicrobial Resistance in Salmonella Typhi Isolated From a Referral Hospital of Kathmandu, Nepal.

PURPOSE: The morbidity and mortality due to typhoid fever can be significantly reduced with the use of effective antibiotics. At present, fluoroquinolones, third generation cephalosporins, and azithromycin are widely used to treat typhoid fever. However, changing antibiotic susceptibility among Salmonella Typhi and Salmonella Paratyphi poses a particular challenge to the therapeutic management of enteric fever. The objective of this study was to assess the antibiotic susceptibility pattern of Salmonella Typhi isolates. PATIENTS AND METHODS: A total of 706 blood specimens were collected from febrile patients attending the outpatient department of Kathmandu Model Hospital during June to September, 2018. The antibiotic susceptibility testing for 11 different antibiotics (nalidixic acid, ciprofloxacin, ofloxacin, levofloxacin, cefixime, ceftriaxone, cefotaxime, azithromycin, cotrimoxazole, chloramphenicol, and amoxicillin) was performed by disk diffusion method. Furthermore, minimum inhibitory concentration (MIC) values of ciprofloxacin, ofloxacin, and azithromycin were determined by agar dilution method. Mutation at gyrA ser83 associated with reduced susceptibility to fluoroquinolones was determined by PCR-RFLP. RESULTS: Out of 706 blood samples, 6.94% (n = 49) were culture positive for Salmonella enterica (S. Typhi, n = 46). It was revealed that 97.8% S. Typhi isolates were susceptible to conventional first-line antibiotics (ampicillin, chloramphenicol, and cotrimoxazole), 97.3% to cephalosporins and 95.7% to azithromycin. S. Typhi were either resistant or intermediately susceptible to fluoroquinolones: 97.8% to ciprofloxacin, 91.3% to ofloxacin, and 89.1% to levofloxacin. The MIC of ciprofloxacin, ofloxacin, and azithromycin for S. Typhi ranged from 0.008 to 32, 0.03 to 16, and 2 to 8 µg/mL, respectively. Out of 46 S. Typhi isolates, 44 (95.65%) had gyrA ser83 mutation. CONCLUSION: Fluoroquinolones have poor activity against Salmonella Typhi. The trends of increasing azithromycin MIC value among S. Typhi might limit its use for the treatment of typhoid fever. Effectiveness of conventional first-line antibiotics in vitro suggests considering their clinical use after large-scale studies.

Seroprevalence and Clinical Features of Scrub Typhus among Febrile Patients Attending a Referral Hospital in Kathmandu, Nepal.

(1) Background: Scrub typhus (ST) is endemic to Nepal. It is often underdiagnosed and misdiagnosed due to non-specific clinical presentation coupled with limited microbiological facilities, leading to adverse clinical outcomes. This study aimed to assess the seroprevalence of scrub typhus in febrile patients attending Sukraraj Tropical and Infectious Disease Hospital (STIDH), Nepal, from August 2018 to April 2019. (2) Materials and Method: Blood/serum samples and clinical and demographic data of adult febrile patients (≥19 years) who attended or were referred to the hospital were collected after obtaining written informed consent from the participants excluding immunocompromised individuals. Collected blood/serum samples were subjected to hematological, biochemical, and serological tests. A serological test for scrub typhus was performed using the ImmuneMed scrub typhus rapid diagnostic test kit. Data generated were analyzed using SPSS software version 24.0. (3) Results: Amongst the 2070 febrile patients, 462 (22.3%) were seropositive to at least one etiological agent of febrile illnesses (scrub typhus: 253 cases, dengue: 101 cases, leptospirosis: 9, brucellosis: 52, malaria: 9 and kala-azar: 20 cases). Scrub typhus accounted for 12.2% (n = 253) of total febrile illnesses followed by dengue (4.9%, n = 101). Mixed seropositivity of scrub typhus with dengue, brucellosis, and typhoid was found in 12 (0.6%), 9 (0.4%), and 5 (0.2%) cases, respectively. Among 253 scrub typhus patients, 53.4% were female. Among the 154 patients, the most common symptoms were fever (100%), headache (79.2%), sweating (70.1%), breathing difficulty (51.3%), redness of the eye (43.5%), and pathognomonic eschar was observed in 9.1% patients. Fifty percent of scrub typhus patients had low platelet count and >30% of patients had an elevated level of liver enzymes (such as serum glutamic oxaloacetic transaminase (SGPT) and serum glutamic pyruvic transaminase (SGOT). (4) Conclusion: Scrub typhus is a considerable cause of febrile illness in Nepal. Females apparently have a higher chance of acquiring scrub typhus. ST presents nonspecific clinical presentation. The diagnostic dilemma of typhus patients can be minimized by the early monitoring of ST-associated symptoms. The country's health system needs to be strengthened for early outbreak detection, and immediate response actions against scrub typhus to control the future outbreak of ST.

Assessment of Preparedness of Government of Nepal in COVID Designated Hospitals and Clinics for Pandemic Response.

BACKGROUND: Preparedness, readiness, and response status of any country is integral in identifying, managing, and preventing COVID-19 pandemic. The objective of this study is to assess the status of the Government of Nepal designated COVID hospitals and COVID clinics to respond against COVID-19. METHODS: A cross sectional study was conducted with the focal persons of COVID hospitals and COVID clinics using a semi-structured questionnaire from April 26, 2020 to May 27, 2020 via face to face interview with onsite observation and telephonic interview in few unreachable health facilities.  Results: Government of Nepal designated COVID hospitals and COVID clinics demonstrated efforts in establishing preparedness plans and committees such as COVID management core team (96.7% and 86%), provision of coordination with the government authority (both 100% ), preparedness response plan (93.3% and 84%), and infection prevention and control committee (63.3% and 65.6%) to respond to COVID-19 respectively. The participants reported differences in training provided to their health care workers with maximum COVID hospitals (80%) providing training on use of personal protective equipment and least (43.3%) on handling dead bodies. Only half of the COVID clinics (49.5%) had provision of triage systems. CONCLUSIONS: COVID hospitals and COVID clinics in Nepal demonstrated different status of COVID pandemic preparedness and readiness. In case of surge, Nepalese hospitals would struggle due to lack of trained workforce and infrastructure.  Interdisciplinary, multi-sectoral collaboration with various focused strategies, including in-service training to staff, is paramount to increase preparedness and readiness.  Keywords: COVID-19; Nepal; preparedness; readiness.

How Well the Government of Nepal Is Responding to COVID-19? An Experience From a Resource-Limited Country to Confront Unprecedented Pandemic.

COVID-19, caused by SARS-CoV-2, was first reported in Wuhan, China and is now a pandemic affecting over 218 countries and territories around the world. Nepal has been severely affected by it, with an increasing number of confirmed cases and casualties in recent days, even after 8 months of the first case detected in China. As of 26 November 2020, there were over 227,600 confirmed cases of COVID in Nepal with 209,435 recovered cases and 1,412 deaths. This study aimed to compile public data available from the Ministry of Health and Population (MoHP), Government of Nepal (GoN) and analyse the data of 104 deceased COVID-19 patients using IBM SPSS (Version 25.0). Additionally, this study also aimed to provide critical insights on response of the GoN to COVID-19 and way forward to confront unprecedented pandemic. Figures and maps were created using the Origin Lab (Version 2018) and QGIS (Version 3.10.8). Most of the reported cases were from Bagmati Province, the location of Nepal's capital city, Kathmandu. Among deceased cases, >69% of the patients were male and patients ≥54 years accounted for 67.9% (n = 923). Preliminary findings showed respiratory illness, diabetes, and chronic kidney diseases were the most common comorbid conditions associated with COVID-19 deaths in Nepal. Despite some efforts in the 8 months since the first case was detected, the government's response so far has been insufficient. Since the government eased the lockdown in July 2020, Nepal is facing a flood of COVID-19 cases. If no aggressive actions are taken, the epidemic is likely to result in significant morbidity and mortality in Nepal. The best way to curb the effect of the ongoing pandemic in a resource-limited country like Nepal is to increase testing, tracing, and isolation capacity, and to set up quality quarantine centers throughout the nation. A comprehensive health literacy campaign, quality care of older adults and those with comorbidity will also result in the effective management of the ongoing pandemic.

Acute Acquired Methemoglobinemia Following Nitrobenzene Poisoning.

Nitrobenzene is an aromatic compound commonly used in agricultural fertilizers. It is capable of inducing methemoglobinemia when ingested in sufficient quantities. Methemoglobinemia impairs oxygen transport by dual mechanism of impaired oxygen binding and diminished oxygen unloading. We report a case of nitrobenzene poisoning accompanied by methemoglobinemia and later complicated by unconjugated hyperbilirubinemia secondary to hemolysis. Prompt treatment with intravenous methylene blue based on a clinical diagnosis in view of dropping SpO2 unresponsive to oxygen with chocolate cyanosis and paradoxically elevated PaO2 enabled favorable patient outcome. Other recommended modalities of treatment in acquired acute methemoglobinemia include vitamin C, hyperbaric oxygen and exchange transfusions. Keywords: Methemoglobinemia; methylene blue; nitrobenzene; nitroboom.

Knowledge, Attitude and Practice of healthcare workers Towards Coronavirus Disease 2019 (COVID-19) Pandemic.

BACKGROUND: The emergence of SARS-CoV 2 pandemic is the greatest public health concern of the century. Healthcare workers are the front liners of pandemic management. Their knowledge, attitudes and practices can influence the outcome of pandemic. The study aims to determine the knowledge, attitude and practices among healthcare workers. METHODS: Knowledge, attitude and practice related questionnaire based online survey through Google forms was conducted from Healthcare workers, following ethical approval from NHRC (ERB protocol registration number: 297/2020 P). Online forms were disseminated via Facebook, Instagram, Whatsapp, Viber and personal messaging. Responses containing anonymized data was collected analyzed in using SPSS-version 26, (Year: 2019). The results were interpreted in terms of percentage response, knowledge score, and practice and discussed on the possible solutions in improving the infection prevention and control practice. RESULTS: 473 HCWs responded to the questionnaire, out of which 426 responses met inclusion criteria which is 90% of the total responses. The mean score for knowledge was 3.20 + 1.15 out of maximum seven; with 45.7% correct answers. 70.4 % (300) participants felt that Nepal will be unable to contain the pandemic, 64 % of the total employed participants felt that there was inadequate institutional preparedness to protect HCWs from exposure. 91% participants reported practicing hand hygiene after every patient encounter; whereas 31.7% (77) and 22.1% (59) participants did not know how to check sealing of the N95 masks and use personal protective equipment's respectively. CONCLUSIONS: The survey findings showed deficiencies in knowledge and appropriate practice among the HCWs, in prevention of SARS-CoV-2 transmission. Attitudes towards COVID19 were a mix of both positive and negative viewpoints. Even in health care workers with access to internet, there is significant gap in universal infection prevention and control practices required for self-protection and limiting untoward transmission.

Refeeding Syndrome.

Refeeding syndrome is a potentially fatal alteration in serum electrolytes occurring in patients refed after a period of starvation. Its actual incidence is not established due to lack of universally acceptable definitions. 88 years lady presented with negligible food intake for 15 days,mild dehydration and a BMI of 16.8kg/m2. Rigorous refeeding was started and patient developed hypophosphatemia, hypomagnesemia and ventricular premature contractions. Patient was diagnosed with refeeding syndrome and treatment was started. She recovered uneventfully and was discharged with nasogastric tube in situ on day 10 of admission. Refeeding syndrome is commonly encountered but mostly overlooked diagnosis and is a significant cause of nutritional morbidity and mortality in patients with chronic malnourishment. Keywords: Hypophosphatemia; refeeding; refeeding syndrome.

Percutaneous Renal Biopsy: Comparison of Blind and Real-time Ultrasound Guided Technique.

BACKGROUND: Percutaneous renal biopsy is performed for diagnosis and prediction of prognosis of renal diseases. Adequacy of tissue and clinically significant bleeding are the main issues of the procedure. We aimed to compare these issues in renal biopsy by blind and real time ultrasound guided technique. METHODS: It was a cross sectional, randomized study conducted between June 2016 to December 2016. In blind technique, marking for biopsy was done by ultrasound. Two attempts were performed for all and more if tissue was inadequate. Patients kept in bed rest for 24 hours, observed for post procedure hematuria and ultrasound done at 6 hours and 24 hours to diagnose perinephric hematoma. RESULTS: Total 75 biopsies (blind = 37 and Ultrasound -guided = 38) were evaluated. Blind and Ultrasound-guided technique had significant difference of number of attempt (mean±SD) 2.4±0.6 and 2.1±0.3 (p<0.01) respectively with no difference of number of glomeruli in light microscopy. Bleeding complications were macroscopic hematuria (11(30%)vs15(40%)) and perinephric hematoma ( 5(13.5%)vs3(7.9%)) in blind and Ultrasound-guided technique respectively with no significant difference. Those patients who developed perinephric hematoma was observed in all at 6 hours. CONCLUSIONS: Ultrasound-guided technique of percutaneous renal biopsy is superior with fewer attempts and equivalent in adequacy of tissue and bleeding complication than blind technique.

Performance analysis of different rice-based cropping systems in tropical region of Nepal.

Energy inputs, environmental impacts and economic outputs are the main concerns in today's agricultural production systems. The current study investigated the energy, environmental and financial performances of different rice-based cropping systems (CSs). The CSs studied were: Rice-Wheat-Fallow (R-W-F), Rice-Wheat-Maize (R-W-M), Rice-Wheat-Mungbean (R-W-Mu), Rice-Lentil-Maize (R-L-M), Rice-Lentil-Mungbean (R-L-Mu), Rice-Garlic (R-G) and Rice-Onion (R-O). Primary data were collected from 210 randomly selected farms by using structured questionnaire. In this study, Data Envelopment Analysis (DEA) was used to analyze the technical efficiencies of the farms in order to estimate their energy inputs saving potential, under different CSs. Among the studied systems, R-W-M, R-L-M and R-W-Mu were found energy efficient, R-L-Mu, R-W-F and R-W-Mu were efficient considering their greenhouse gas emissions, and R-G, R-O and R-L-M were more profitable systems. Based on the combined energy, environmental and economic criteria, we conclude that R-L-M, R-L-Mu and R-W-M are the most energy, environmentally and economically efficient CSs as compared to other systems in the study. The mean technical efficiency scores of farms indicated a considerable potential of reducing energy inputs (18-34%), without compromising the economic return of the majority farms under different CSs. The results of this study support eco-efficient CSs with modern production technologies.