Prevalence of drug resistant Enterobacteriaceae in a Nepalese tertiary care hospital.

Antimicrobial resistance in Enterobacteriaceae is an emerging global public health problem. Numerous studies have reported community-acquired AmpC beta-lactamase and extended spectrum beta-lactamase (ESBL) producing Enterobacteriaceae in Nepal. However, there are limited data on community-acquired Metallo-beta-lactamase (MBL) producing Enterobacteriaceae. A hospital-based descriptive cross-sectional study was conducted using 294 Enterobacteriaceae isolates from a total of 2,345 different clinical specimens collected from patients attending a tertiary care hospital in Nepal. Bacteria were isolated using standard microbiological growth media and identified using biochemical tests. For antimicrobial susceptibility testing, Kirby-Bauer disc diffusion technique was used. AmpC, ESBL, and MBL productions were detected by using combined disc method. AmpC, ESBL, and MBL productions were detected in 19.4%, 29.6%, and 8.5% of total Enterobacteriaceae isolates respectively. Higher rates of beta-lactamases production were seen among the isolates from in-patients in comparison with those from out-patients. However, 11.6%, 25%, and 3.7% of the total isolates from out-patients were AmpC, ESBL, and MBL producers respectively. The co-production of the beta-lactamases was also detected, with two Klebsiella pneumoniae isolates producing all three beta-lactamases. One MBL producing Proteus vulgaris isolate that was pan-resistant with no remaining treatment options was also isolated. Prevalence of drug resistant Enterobacteriaceae in our study was very high. Detection of AmpC, ESBL, and MBL positive isolates from out-patients, who did not have recent history of hospital visit, indicated the community dissemination of the drug resistant bacteria. This is a matter of great concern and an immediate attention to formulate strategies to prevent further development and spread of antibiotic resistance is required.

Mean Bone Density in Interadicular Areas of Maxilla among Patients Visiting Dental Unit of a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: A close relationship occurs between the type of bone density and the success of orthodontic mini-implant. The aim of this study was to find out the mean bone density in interradicular areas of the maxilla among patients visiting dental unit of a tertiary care centre. Methods: A descriptive cross-sectional study was performed at the Department of Orthodontics and Dentofacial Orthopedics at a tertiary care centre from 15 January 2022 to 28 June 2022 after taking ethical approval from the Institutional Review Committee (Reference number: UCMS/IRC/175/21). Data was collected from scan reports obtained with a computed tomography scanner. Bone density was measured at 6 mm height from the alveolar crest. Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated. Results: Out of 70 patients, mean bone density at interradicular areas of maxilla was 992.31±204.20 HU (944.46-1040.13, 95% Confidence Interval). Between central and lateral incisor 50 (71.44%) had D2 type of bone density. Conclusions: The mean bone density in inter radicular areas of the maxilla among patients visiting the dental outpatient department was similar to other studies done in similar settings. Keywords: bone density; prevalence; prostheses and implants.

Knowledge and DdeI Based Confirmation of Sickle Cell Anemia Among the Tharu Community.

BACKGROUND: Sickle cell anemia is an inherited blood disorder caused due to a point mutation at the sixth codon of the ?-globin gene of both alleles. Sickle cell traits occur when the mutation is in one of the two alleles of the ?-globin genes. This study was carried out in the Tharu community, which is an indigenous and minority group mostly residing in the Terai region of Nepal. They are also considered as the most vulnerable group for inheriting Sickle cell anemia. METHODS: Purposive sampling, which included 130 Tharu individuals of Kanchanpur district of Nepal, was considered for the study. The survey was conducted using a descriptive questionnaire that contained relevant information including the family history of Sickle cell anemia. This was followed by the analysis of blood samples to determine the prevalence of Sickle cell anemia and Sickle cell traits. Primer-mediated enzymatic amplification of target sequences in genomic DNA followed by restriction endonuclease assay with an enzyme DdeI was carried out for the confirmation. RESULTS: Among 130 individuals, only 55.4% had basic knowledge about Sickle cell anemia. After screening for sickle cell anemia from 60 participants, 27 (45%) of them were found to be in the heterozygous state (carrier, Hb AS) and 28 (46.7%) were in the homozygous (normal, AA Hb) state with 5 (8.3%) having the diseased hemoglobin (Hb SS) variant of Sickle cell anemia. CONCLUSIONS: This study demonstrated a high prevalence of Sickle cell anemia and Sickle cell traits in the Tharu community. This study may be beneficial for concerned personnel policymakers to reduce sickle cell cases by improving genetic literacy among the Tharu community.

Susceptibility to Vancomycin of Biofilm Producing Staphylococci Isolated from Tertiary Care Hospital of Nepal / Susceptibilidad a la vancomicina de estafilococos productores de biopelículas aislados del hospital de atención terciaria de Nepal

Background: Methicillin resistance and biofilm-producing Staphylococci are emerging as multidrug-resistant strains narrowing the efficacy of antimicrobial therapy. Although vancomycin is used as the drug of choice to treat such isolates, different studies worldwide have documented the emergence of strains that are intermediately susceptible or resistant to this antibiotic. Objective: The study aimed to determine the minimum inhibitory concentration of vancomycin to methicillin-resistant and biofilm-producing staphylococci isolated from different clinical specimens. Methods: 375 staphylococci isolated from different clinical specimens over one year were included in the study. Biofilm formation was determined by the Tissue culture plate method (TCP), and ica genes were identified by Polymerase Chain Reaction (PCR). Antibiotic susceptibility and methicillin resistance were done following Clinical and Laboratory Standards Institute (CLSI) guidelines. The minimum inhibitory concentration (MIC) of vancomycin in all isolates was determined by the agar dilution method. Results:Among 375 Staphylococci studied, 43% and 57% represented S. aureus and Coagulase-Negative Staphylococci (CNS), respectively. The rate of Methicillin-Resistant S. aureus (MRSA) and Methicillin-Resistant Coagulase Negative Staphylococci (MRCNS) were 81.4% and 66.8% respectively and determined by the disc diffusion method. The most potential antibiotics were tetracycline and chloramphenicol showing sensitivity to more than 90% isolates. The Minimum Inhibitory Concentration (MIC) value of oxacillin for staphylococci ranged from 0.125-32 µg/ml. Oxacillin agar diffusion method showed 51.6% and 79.9% isolates as MRSA and MRCNS, respectively, revealing a very high percentage of S. aureus and CNS isolates as methicillin-resistant. All isolates had susceptible vancomycin MICs that ranged from 0.125-2 µg/ml. Two S. aureus isolated from Central Venous Catheter (CVC) and catheter specimens were detected with intermediate susceptibility to vancomycin. Similarly, three CNS isolated from blood, CVC, and wound/pus (w/p) were intermediately susceptible to vancomycin. Strong biofilm formation was observed in 22.1% of clinical isolates, and the ica gene was detected among 22.9% of isolates. Only one S. aureus detected as a biofilm producer by the TCP method was found to have intermediate susceptibility to vancomycin. Conclusions: The increment in vancomycin MIC among methicillin-resistant and biofilm-producing staphylococci is alarming. Strict control measures to prevent methicillin-resistant isolates spread and routine surveillance for vancomycin-resistant isolates must be incorporated in hospitals to prevent antimicrobial treatment failure

Antecedentes: Los estafilococos resistentes a la meticilina y productores de biopelículas están surgiendo como cepas multirresistentes que reducen la eficacia del tratamiento antimicrobiano. Aunque la vancomicina se utiliza como fármaco de elección para tratar dichos aislados, diferentes estudios realizados en todo el mundo han documentado la aparición de cepas intermedias susceptibles o resistentes a este antibiótico. Objetivo: El estudio tenía como objetivo determinar la concentración mínima inhibitoria de la vancomicina para los estafilococos resistentes a la meticilina y productores de biofilm aislados de diferentes muestras clínicas. Métodos: Se incluyeron en el estudio 375 estafilococos aislados de diferentes muestras clínicas durante un año. La formación de biopelículas se determinó mediante el método de la placa de cultivo de tejidos (TCP), y los genes ica se identificaron mediante la reacción en cadena de la polimerasa (PCR). La susceptibilidad a los antibióticos y la resistencia a la meticilina se realizaron siguiendo las directrices del Clinical and Laboratory Standards Institute (CLSI). La concentración inhibitoria mínima (MIC) de vancomicina en todos los aislados se determinó por el método de dilución en agar. Resultados:Entre los 375 estafilococos estudiados, el 43% y el 57% representaban S. aureus y estafilococos coagulasa-negativos (ECN), respectivamente. La tasa de S. aureus resistente a la meticilina (SARM) y de estafilococos coagulasa negativos resistentes a la meticilina (ECNM) fue del 81,4% y el 66,8%, respectivamente, y se determinó por el método de difusión de discos. Los antibióticos más potenciales fueron la tetraciclina y el cloranfenicol, que mostraron una sensibilidad superior al 90% de los aislados. El valor de la concentración inhibitoria mínima (CIM) de la oxacilina para los estafilococos osciló entre 0,125-32 µg/ml. El método de difusión en agar de la oxacilina mostró que el 51,6% y el 79,9% de los aislados eran SARM y MRCNS, respectivamente, lo que revela que un porcentaje muy elevado de los aislados de S. aureus y CNS son resistentes a la meticilina. Todos los aislados tenían MIC de vancomicina susceptibles que oscilaban entre 0,125-2 µg/ml. Se detectaron dos S. aureus aislados de muestras de catéteres venosos centrales (CVC) y catéteres con una susceptibilidad intermedia a la vancomicina. Del mismo modo, tres S. aureus aislados de sangre, CVC y herida/pus (w/p) fueron intermedianamente susceptibles a la vancomicina. Se observó una fuerte formación de biopelículas en el 22,1% de los aislados clínicos, y se detectó el gen ica en el 22,9% de los aislados. Sólo un S. aureus detectado como productor de biopelículas por el método TCP resultó tener una susceptibilidad intermedia a la vancomicina. Conclusiones: El incremento de la MIC de vancomicina entre los estafilococos resistentes a la meticilina y productores de biofilm es alarmante. Para evitar el fracaso del tratamiento antimicrobiano, deben incorporarse en los hospitales medidas de control estrictas para prevenir la propagación de los aislados resistentes a la meticilina y una vigilancia rutinaria de los aislados resistentes a la vancomicina

Inducible Clindamycin Resistance and Biofilm Production among Staphylococci Isolated from Tertiary Care Hospitals in Nepal.

Resistance to antibiotics, biofilm formation and the presence of virulence factors play important roles in increased mortality associated with infection by staphylococci. The macrolide lincosamide streptogramin B (MLSB) family of antibiotics is commonly used to treat infections by methicillin-resistant isolates. Clinical failure of clindamycin therapy has been reported due to multiple mechanisms that confer resistance to MLSB. This study aims to find the incidence of different phenotypes of MLSB resistance and biofilm production among staphylococci. A total of 375 staphylococci were isolated from different clinical samples, received from two tertiary care hospitals in Nepal. Methicillin resistance was detected by cefoxitin disc diffusion method and inducible clindamycin resistance by D test, according to CLSI guidelines. Biofilm formation was detected by the tissue culture plate method and PCR was used to detect ica genes. Of the total staphylococci isolates, 161 (42.9%) were Staphylococcus aureus, with 131 (81.4%) methicillin-resistant strains, and 214 (57.1%) isolates were coagulase-negative staphylococci, with 143 (66.8%) methicillin-resistant strains. The overall prevalence of constitutive MLSB (cMLSB) and inducible MLSB (iMLSB) phenotypes was 77 (20.5%) and 87 (23.2%), respectively. Both iMLSB and cMLSB phenotypes predominated in methicillin-resistant isolates. The tissue culture plate method detected biofilm formation in 174 (46.4%) isolates and ica genes in 86 (22.9%) isolates. Among biofilm producing isolates, cMLSB and iMLSB phenotypes were 35 (20.1%) and 27 (15.5%), respectively. The cMLSB and iMLSB were 11 (12.8%) and 19 (22.1%), respectively, in isolates possessing ica genes. Clindamycin resistance in the form of cMLSB and iMLSB, especially among MRSA, emphasizes the need for routine D tests to be performed in the lab.

Phytochemical analysis of medicinal plants of Nepal and their antibacterial and antibiofilm activities against uropathogenic Escherichia coli.

BACKGROUND: A biofilm is an extracellular polymeric substance (EPS) composed of polysaccharides, proteins, nucleic acids, and lipids that impede antibiotics and immune cells, thus providing a shielded environment for bacterial growth. Due to biofilm formation, some microbes can show up to 1000 fold increased resistance towards the antibiotics than the normal planktonic forms. The study was conducted to screen the crude extracts of medicinal plants used in Nepal for their in vitro antibiofilm activities. METHODS: Total phenolic and total flavonoid contents were determined by using a Folin-Ciocalteau reagent and aluminium trichloride method, respectively. Resazurin assay was used to determine the minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC). The initial antibiofilm activities and their inhibitory concentration (IC50) values were determined by the microtiter based modified crystal violet staining method. RESULTS: Out of 25 different plant extracts were used for the study, methanolic extracts of 20 plants showed a biofilm inhibition activity against five different strong biofilm producing Escherichia coli strains. Calotropis gigantea exhibited inhibition against all five different E. coli strains with IC50 values ranging from 299.7 ± 20.5 to 427.4 ± 2.7 µg/mL. Apart from that, Eclipta prostrata also showed biofilm formation inhibition, followed by Eupatorium adenophorum, Moringa oleifera, Ocimum tenuifolium, Oxalis lantifolia, Prunus persica, and Urtica parviflora. The extracts of C. gigantea, E. prostrata, Mangifera indica, O. tenuifolium, P. persica, and U. parviflora exhibited a moderate to poor MIC value ranging from 625 to 2500 µg/mL. The highest amount of phenolic content (TPC) was found in Acacia catechu followed by Morus alba, which was 38.9 and 25.1 mg gallic acid equivalents, respectively. The highest amount of flavonoid content was found in A. catechu followed by M. indica, which was 27.1 and 20.8 mg quercetin equivalents, respectively. CONCLUSION: Extracts of C. gigantea, E. prostrata, P. persica, U. parviflora, and O. tenuifolium showed antibacterial as well as antibiofilm activity against pathogenic and strong biofilm producing E. coli. Thus, extracts or the pure compound from these medicinal plants could be used as antibiotics in the future.

Sex Predictability by Using Mandibular Canine Index.

BACKGROUND: Canines are known for their higher resistance to trauma and pathological alterations when compared to other teeth. Among all the teeth, canines show highest sexual dimorphism. METHODS: This descriptive cross-sectional study was commenced from January 2019 to April 2019 after the ethical approval from Institutional Review Committee. The maximum mesio-distal widths of right and left mandibular canines and mandibular inter-canine arch width were measured on the cast with the help of a divider and digital vernier callipers. Mandibular canine index was calculated by dividing the mesio-distal width of each mandibular canine with inter-canine arch width. Data was entered and analyzed using Statistical Package for the Social Sciences version 21. RESULTS: Sex predictability by using mandibular canine index in the present study showed poor sex predictability (57.5% - 62.5%). CONCLUSIONS: Sex determination should be done by other methods and mandibular canine index should be used cautiously in Nepalese population.

Extended spectrum ß-lactamase producing uropathogenic Escherichia coli and the correlation of biofilm with antibiotics resistance in Nepal.

BACKGROUND: Urinary tract infection (UTI) is one of the frequently diagnosed infectious diseases which is caused mainly by Escherichia coli. E. coli confers resistance against the two major classes of antibiotics due to the production of extended spectrum ß-lactamase enzymes (ESBL), biofilm, etc. Biofilm produced by uropathogenic E. coli (UPEC) protects from host immune system and prevent entry of antimicrobial compounds. The main objective of this cross-sectional study was to determine the correlation of biofilm production and antibiotic resistance as well as to characterize the pgaA and pgaC genes responsible for biofilm formation among uropathogenic ESBL producing E. coli. METHODS: A total of 1977 mid-stream urine samples were examined and cultured for bacterial strain identification. ESBL was detected by combined disc method following CLSI whereas biofilm formation was analyzed by semi-quantitative method. Furthermore, the pgaA and pgaC genes responsible for biofilm formation in UPEC were detected by multiplex PCR. All the statistical analyses were done via IBM SPSS Statistics 21 where Pearson's correlation test were used to determine correlation (-1 ≥ r ≤ 1). RESULTS: E. coli was the predominant causative agent, which accounted 159 (59.3%) of the Gram-negative bacteria, where 81 (50.9%) E. coli strains were found to be ESBL producers. In addition, 86 (54.1%) E. coli strains were found to be biofilm producers. Both the pgaA and pgaC genes were detected in 45 (93.7%) the UPEC isolates, which were both biofilm and ESBL producers. Moreover, there was a positive correlation between biofilm and ESBL production. CONCLUSION: The analyses presented weak positive correlation between biofilm and ESBL production in which biofilm producing UPEC harbors both pgaA and pgaC genes responsible for biofilm formation.

Krait Snake Bite Presenting as a Cerebral Salt Wasting.

How to cite this article: Keyal NK, Shrestha R, Thapa S, Adhikari P. Krait Snake Bite Presenting as a Cerebral Salt Wasting. Indian J Crit Care Med 2019;23(7):347-348.

Prevalence of Selected Non-Metric Dental Traits in Indo-Nepalese and Tibeto-Nepalese Ethnic Groups of Western Hilly Region.

INTRODUCTION: Additional anatomic features present on teeth are called non-metric dental traits. Carabelli's cusp and shovelling are such traits which are mostly evaluated for identification of ethnicity. The present study aims to determine the prevalence of Carabelli's cusp and shovelling among Indo-Nepalese and Tibeto-Nepalese ethnic group. METHODS: A descriptive cross-sectional study was conducted in a tertiary hospital from March 22 to June 22 2019 after obtaining ethical approval from the institutional review committee. The study was conducted among 274 patients and convenient sampling method was applied. Data were analyzed by the help of Statistical Package for Social Sciences version 21. RESULTS: Among 274 cases, 153 (55.84%) cases were Indo-Nepalese and 121 (44.16%) were TibetoNepalese. Carabelli's cusp (16/26) was noticed in 87 (56.86%) of Indo-Nepalese and 45 (37.19%) of Tibeto-Nepalese. Shovelling (11, 12, 21, 22) was present in 47 (30.71%) Indo-Nepalese and 79 (65.28%) of Tibeto-Nepalese. Further, Carabelli's cusp (16/26) was found in 77 (53.10%) females and 55 (55.12%) males. Shovelling was present in 75 (51.72%) females and 51 (39.53%) males. Bilateralism with respect to Carabelli's cusp was present in 82 (62.2%) cases. Presence of bilateral shovelling on upper central incisors and lateral central incisors were among 117 (94.35%) and 56 (91.80%) respectively. CONCLUSIONS: Carabelli's cusps are frequently found in Indo-Nepalese ethnic group and shovelling of teeth most commonly present in Tibeto-Nepalese population. Further, bilaterism for shovelling of teeth is more common than bilaterism for cusp of Carabelli.

Simulating Colour Vision Deficiency from a Spectral Image.

People with colour vision deficiency (CVD) have difficulty seeing full colour contrast and can miss some of the features in a scene. As a part of universal design, researcher have been working on how to modify and enhance the colour of images in order to make them see the scene with good contrast. For this, it is important to know how the original colour image is seen by different individuals with CVD. This paper proposes a methodology to simulate accurate colour deficient images from a spectral image using cone sensitivity of different cases of deficiency. As the method enables generation of accurate colour deficient image, the methodology is believed to help better understand the limitations of colour vision deficiency and that in turn leads to the design and development of more effective imaging technologies for better and wider accessibility in the context of universal design.

Spectrogenic imaging: a novel approach to multispectral imaging in an uncontrolled environment.

Increasing the number of imaging channels beyond the conventional three has been shown to be beneficial for a wide range of applications. However, it is mostly limited to imaging in a controlled environment, where the capture environment (illuminant) is known a priori. We propose here a novel system and methodology for multispectral imaging in an uncontrolled environment. Two images of a scene, a normal RGB and a filtered RGB are captured. The illuminant under which an image is captured is estimated using a chromagenic based algorithm, and the multispectral system is calibrated automatically using the estimated illuminant. A 6-band multispectral image of a scene is obtained from the two RGB images. The spectral reflectances of the scene are then estimated using an appropriate spectral estimation method. The proposed concept and methodology is generic one, as it is valid in whatever way we acquire the two images of a scene. A system that can acquire two images of a scene can be realized, for instance in two shots using a digital camera and a filter, or in a single shot using a stereo camera, or a custom color filter array design. Simulation experiments using a stereo camera based system confirms the effectiveness of the proposed method. This could be useful in many imaging applications and computer vision.