Isoniazid Resistance in Mycobacterium tuberculosis Is a Heterogeneous Phenotype Composed of Overlapping MIC Distributions with Different Underlying Resistance Mechanisms.

MIC testing using the Bactec mycobacteria growth indicator tube system 960 of 70 phylogenetically diverse, isoniazid-resistant clinical strains of Mycobacterium tuberculosis revealed a complex pattern of overlapping MIC distributions. Whole-genome sequencing explained most of the levels of resistance observed. The MIC distribution of strains with only inhA promoter mutations was split by the current concentration endorsed by the Clinical and Laboratory Standards Institute to detect low-level resistance to isoniazid and is, consequently, likely not optimally set.

Use of nanotechnology for infectious disease diagnostics: application in drug resistant tuberculosis.

BACKGROUND: The increased transmission of multidrug-resistant (MDR) tuberculosis (TB) poses a challenge to tuberculosis prevention and control in Sri Lanka. Isoniazid (INH) is a key element of the first line anti tuberculosis treatment regimen. Resistance to INH may lead to development of MDR TB. Therefore, early detection of INH resistance is important to curb spread of resistance. Due to the limited availability of rapid molecular methods for detection of drug resistance in Sri Lanka, this study was aimed at developing a simple and rapid gold nanoparticle (AuNP) based lateral flow strip for the simultaneous detection of the most common INH resistance mutation (katG S315 T, 78.6%) and Mycobacterium tuberculosis (MTb). METHODS: Lateral flow strip was designed on an inert plastic backing layer containing a sample pad, nitrocellulose membrane and an absorption pad. Biotin labeled 4 capture probes which separately conjugated with streptavidin were immobilized on the nitrocellulose. The test sample was prepared by multiplex PCR using primers to amplify codon 315 region of the katG gene and MTb specific IS6110 region. The two detection probes complementary to the 5' end of each amplified fragment was conjugated with gold nanoparticles (20 nm) and coupled with the above amplified PCR products were applied on the sample pad. The hybridization of the amplified target regions to the respective capture probes takes place when the sample moves towards the absorption pad. Positive hybridization is indicated by red colour lines. RESULTS: The three immobilized capture probes on the strip (for the detection of TB, katG wild type and mutation) were 100 and 96.6% specific and 100 and 92.1% sensitive respectively. CONCLUSION: The AuNP based lateral flow assay was capable of differentiating the specific mutation and the wild type along with MTb identification within 3 h.

Detection of bacterial pathogens from clinical specimens using conventional microbial culture and 16S metagenomics: a comparative study.

BACKGROUND: Infectious disease is the leading cause of death worldwide, and diagnosis of polymicrobial and fungal infections is increasingly challenging in the clinical setting. Conventionally, molecular detection is still the best method of species identification in clinical samples. However, the limitations of Sanger sequencing make diagnosis of polymicrobial infections one of the biggest hurdles in treatment. The development of massively parallel sequencing or next generation sequencing (NGS) has revolutionized the field of metagenomics, with wide application of the technology in identification of microbial communities in environmental sources, human gut and others. However, to date there has been no commercial application of this technology in infectious disease diagnostic settings. METHODS: Credence Genomics Rapid Infection Detection™ test, is a molecular based diagnostic test that uses next generation sequencing of bacterial 16S rRNA gene and fungal ITS1 gene region to provide accurate identification of species within a clinical sample. Here we present a study comparing 16S and ITS1 metagenomic identification against conventional culture for clinical samples. Using culture results as gold standard, a comparison was conducted using patient specimens from a clinical microbiology lab. RESULTS: Metagenomics based results show a 91.8% concordance rate for culture positive specimens and 52.8% concordance rate with culture negative samples. 10.3% of specimens were also positive for fungal species which was not investigated by culture. Specificity and sensitivity for metagenomics analysis is 91.8 and 52.7% respectively. CONCLUSION: 16S based metagenomic identification of bacterial species within a clinical specimen is on par with conventional culture based techniques and when coupled with clinical information can lead to an accurate diagnostic tool for infectious disease diagnosis.

Seroprevalence of Bordetella pertussis specific Immunoglobulin G antibody levels among asymptomatic individuals aged 4 to 24 years: a descriptive cross sectional study from Sri Lanka.

BACKGROUND: In Sri Lanka pertussis continues to circulate in the community and cases among adolescents and adults have been reported despite 95% coverage of the four dose pertussis vaccination during early childhood. Waning of immunity following natural infection or immunization may contribute to the persistent circulation. An adolescent booster dose is not included in the national immunization schedule of Sri Lanka, although this is routine practice in many countries. Therefore information on immunity to pertussis in the adolescent group is needed prior to considering vaccination schedule changes. METHODS: The quantitative determination of specific Immunoglobulin G antibodies to Bordetella pertussis toxin was done using a commercially available validated ELISA method. The antibody values were categorized into groups according to the interpretive criteria provided by the manufacturer. The values were <55 IU/mL, negative; 55-<60 IU/mL, borderline; 60-125 IU/mL, positive; >125, strongly positive respectively. Sera of 385 asymptomatic individuals aged 4 to 24 years admitted to surgical units of Lady Ridgeway Hospital, Colombo and Colombo South Teaching Hospital were used for the study. Mann-Whitney U and Kruskal-Wallis tests were used in analysis of results and p ≤0.05 was considered as statistically significant. Details of epidemiological variables were collected using a questionnaire and correlation with significant levels of pertussis antibodies was determined. RESULTS: Median age of the study population was 12 years with 212 (55.1%) females. The median anti PT antibody level was 3.31 IU/mL and 352 (91%) had anti PT levels ≤55 IU/mL. Median of anti PT levels were 3.18 IU/mL for 4-7 years, 1.43 IU/mL (IQR 0.336-6.27) for 8-11 years, 4.28 IU/mL (IQR 0.978-13.39) for 12-15 years, 6.14 IU/mL for 16-19 years and 4.89 IU/mL for 20-24 years and the differences were statistically significant (p = 0.000). Females (p < 0.003) and those having a sibling aged ≥12 years (p = 0.017) had significantly higher anti PT levels. CONCLUSIONS: The majority of the study population, especially 8 to 11 year age group had low anti PT IgG levels. The higher antibody titers in the 12-15 year age group seem to indicate infection in early adolescence. A booster dose of acellular pertussis vaccine need to be considered.

Role Models and Teachers: medical students perception of teaching-learning methods in clinical settings, a qualitative study from Sri Lanka.

BACKGROUND: Medical education research in general, and those focusing on clinical settings in particular, have been a low priority in South Asia. This explorative study from 3 medical schools in Sri Lanka, a South Asian country, describes undergraduate medical students' experiences during their final year clinical training with the aim of understanding the teaching-learning experiences. METHODS: Using qualitative methods we conducted an exploratory study. Twenty eight graduates from 3 medical schools participated in individual interviews. Interview recordings were transcribed verbatim and analyzed using qualitative content analysis method. RESULTS: Emergent themes reveled 2 types of teaching-learning experiences, role modeling, and purposive teaching. In role modelling, students were expected to observe teachers while they conduct their clinical work, however, this method failed to create positive learning experiences. The clinical teachers who predominantly used this method appeared to be 'figurative' role models and were not perceived as modelling professional behaviors. In contrast, purposeful teaching allowed dedicated time for teacher-student interactions and teachers who created these learning experiences were more likely to be seen as 'true' role models. Students' responses and reciprocations to these interactions were influenced by their perception of teachers' behaviors, attitudes, and the type of teaching-learning situations created for them. CONCLUSIONS: Making a distinction between role modeling and purposeful teaching is important for students in clinical training settings. Clinical teachers' awareness of their own manifest professional characterizes, attitudes, and behaviors, could help create better teaching-learning experiences. Moreover, broader systemic reforms are needed to address the prevailing culture of teaching by humiliation and subordination.

Descriptive cross sectional study on prevalence, perceptions, predisposing factors and health seeking behaviour of women with stress urinary incontinence.

BACKGROUND: Stress urinary incontinence (SUI) leads to considerable physical and psychological morbidity. The highest prevalence reported was found in Caucasian Americans (range 23% -67%) and the lowest in Singaporean females (4.8%). The study assessed the prevalence, perceptions, predisposing factors and health seeking behaviour of women with SUI in an Asian setting which may have different sociocultural implications. METHODS: 400 consecutive women >20 years of age attending the outpatient department of a tertiary care hospital in Sri Lanka, for non-urinary conditions were studied over a 3 week period using an interviewer administered questionnaire. SUI was diagnosed on clinical history alone when leakage of urine occurred either with coughing, sneezing, walking or lifting heavy objects. The severity was graded using the Finnish Gynaecological Society's Urinary Incontinence Severity Score (UISS). Data were analysed using SPSS version 20. Odds ratios were calculated using univariate and multivariate analysis. RESULTS: Ninety three (23.33%) had SUI and only 12 (12.9%) had sought treatment. The prevalence among women >50 years of age was 34.71% ( n = 121) compared to 18.28% (n = 279) in those ≤50 years. 25 (26.88%) had mild SUI, 66 (70.97%) moderate and 2 (2.15%) severe as per UISS. SUI was perceived as an illness by 210 (52.5%). SUI was significantly associated with pregnancy, parity, vaginal delivery, complicated labour, diabetes mellitus, chronic cough, constipation and faecal incontinence (p < 0.05).Among those affected main reasons for not seeking medical advice included; being embarrassed (n = 27, 33.33%), not knowing that it is remediable (n = 23, 28.40%), perceiving SUI to be a normal consequence of childbirth (n = 19, 23.46%) and having to attend to needs of the family (n = 12, 14.81%). None who had been pregnant (n = 313) had received advice on postnatal pelvic floor exercises. SUI interfered with social activities (71;76.34%), sexual function (21; 22.58%) and resulted in despair (67; 72.09%). It was associated with clinically diagnosed candidiasis (50; 53.76%) and soreness in the perineal region (49; 52.69%). CONCLUSIONS: SUI is a common and neglected gynaecological problem with poor healthcare seeking behaviour. Community based education may help to minimize the occurrence and improve the quality of life of those affected.

Novel and highly lethal NKX2.5 missense mutation in a family with sudden death and ventricular arrhythmia.

To date, several disease-related mutations in NKX2-5, a cardiac-specific homeobox gene, have been documented in patients with a variety of congenital heart diseases (CHDs). The most commonly reported phenotypes are secundum atrial septal defect (ASD) and atrioventricular conduction disease (AVCD). Reports of sudden cardiac death (SCD) have been attributed to progressive conduction disease preventable with pacemaker therapy. A retrospective chart review of individuals from three generations of a family with a novel NKX2-5 mutation associated with CHD, ventricular arrhythmias, and SCD despite pacemaker therapy was conducted. The review documented NKX2-5 Gln181His missense mutation in 11 phenotypically affected members of a single family with a strong family history of SCD, CHD, and AVCD. Before genotyping, four family members died suddenly, two despite pacemaker therapy. The ages at SCD were respectively 23, 29, 44, and 45 years. Observed phenotypic characteristics of genotype-positive patients included ASD, ventricular septal defect, aortic coarctation, tricuspid atresia, supraventricular tachycardia, progressive AVCD, and ventricular tachycardia documented on implantable cardiac defibrillator (ICD) recording. The age at presentation ranged from 5 months to 44 years, and AVCD was seen as early as infancy. Four phenotypically unaffected family members tested negative for the mutation. The findings of this review strongly suggest a new association of this NKX2-5 mutation with SCD from ventricular arrhythmia. This observation has significant implications for the choice of therapy for affected individuals, specifically the use of ICDs, and broadens the observed phenotypic spectrum of NKX2-5 mutations.

Validation and Cultural Adaptation of the Sinhala Translation of the Cardiff Acne Disability Index (CADI).

Introduction: Quality of life (QoL) is impaired in patients with acne vulgaris. The Cardiff Acne Disability Index (CADI) that assesses QoL of acne patients was initially developed in English and is being currently used widely after being validated in different languages. This study was conducted to validate the CADI in Sinhala, a language used by the majority of Sri Lanka. Materials and Methods: The CADI was translated into Sinhala, and lingually validated as per published guidelines. This CADI-Sinhala version and the Sinhala version of the Dermatology Life Quality Index (DLQI) were simultaneously administered to 150 Sinhala-speaking young adults with acne. The clinical severity of acne was assessed using the Global Acne Grading System (GAGS). The Cronbach's alpha and Spearman correlation coefficients were used to determine the internal consistency, reliability, and validity of the CADI-Sinhala. Construct validity was examined using a factor analysis. Results: The study included 90% females and their mean age was 23 (SD, 2.5) years. The majority (97.3%) had acne of mild to moderate severity when measured by the GAGS. The CADI-Sinhala Scale showed a Cronbach's alpha coefficient of 0.819 indicating high internal consistency and reliability. The mean item-total correlation coefficient was 0.74 (range, 0.42-0.87) with CADI Q3 having the lowest correlation. CADI Sinhala showed a strong and highly significant correlation with the Sinhala DLQI (Spearman's rho = 0.66; P< 0.001) indicating concurrent validity. The correlation with GAGS was of low intensity, although it was statistically significant (p < 0.01). Conclusion: The CADI-Sinhala is a reliable and valid tool for assessing the QoL of Sinhala-speaking acne patients. This five-item tool will help clinicians to provide holistic treatment through improved understanding of patient's perspectives.

Efficacy and safety of Link Natural Sudarshana, an Ayurvedic herbal preparation in COVID-19 patients: A phase II multicenter double-blind randomized placebo-controlled trial.

ETHNOPHARMACOLOGICAL RELEVANCE: In vitro and in vivo studies have shown anti-viral and immunomodulatory actions in components of many traditional medicines. Various constituents of traditional medicines have been found to be effective against coronavirus disease (COVID-19) in several clinical trials and in-silico studies. Sudarshana cúrna, a polyherbal Ayurvedic medicine, has been used over thousands of years for a variety of infectious fevers. AIMS OF THE STUDY: This study aimed to evaluate the efficacy and safety of Link Natural Sudarshana (LNS) tablets, in patients with COVID 19 disease. LNS is a polyherbal preparation comprising 49 medicinal plants included in the Sudarshana cúrna. MATERIALS AND METHODS: A randomized parallel-group double-blind placebo-controlled multi-center phase II clinical trial was conducted in patients with mild to moderate COVID-19 disease. They were randomly allocated to intervention and control groups. The intervention group received LNS tablets whereas the control group received placebo tablets for 10 days or until the patient was discharged from the hospital. All patients received standard symptomatic treatment. The primary outcome, a reduction in mean log viral load was assessed at day 5 of treatment. The secondary outcomes, clinical progression and safety, were assessed by, monitoring changes in symptoms daily on a Likert scale ranging from 1 to 4 and laboratory tests respectively. RESULTS: A total of 171 patients (treatment group 83, control group 88) completed the trial. There were no significant differences between the baseline status of the two groups except that body mass index was significantly higher in the placebo group. The mean log viral load reduction at day 5 was higher in the treatment group (2.20 ± 1.67) compared to the placebo group (1.93 ± 1.80), with a mean difference of -0.278. This difference was not statistically significant at the 5% significant level. Reduction of mean cumulative symptom score, which included 16 symptoms graded according to severity, was higher in the treatment group compared to the placebo group. This difference was not statistically significant. None of the study participants developed hypoxia. Among the 7 lymphopenia patients in the placebo group, 3 continued to have lymphopenia at day 10, whereas 9 lymphopenia patients in the treatment group, reverted to normal counts. C reactive proteins (CRP) showed a greater reduction in the treatment group. None reported adverse effects. No significant changes occurred in hematological and biochemical parameters that assessed safety. CONCLUSIONS: LNS is safe to use in COVID-19 patients and accelerated the decline in viral load, relieved symptoms, reduced CRP levels and reversed lymphopenia earlier, when compared to the placebo.

ICU care through NGS - Based identification of infectious agents: A comparative study.

Background: Sepsis claims 1 in 5 lives annually as per global statistics. Sepsis incidence in recent studies represents at least 35 % of all ICU admissions and has a high mortality rate, especially in the presence of co-existing morbidities. The challenge has been to accurately diagnose the causative organism, considering factors such as possible polymicrobial infections, commensals and environmental contaminants. Legacy techniques such as culture, automated culture systems or even newer species-specific PCR or film array these challenges difficult to overcome. The Bactfast® and Fungifast® assays along with the integrated workflow is based on next generation sequencing and have the ability to demarcate infecting pathogen from contamination and commensal. The unique ability to pinpoint the exact pathogen, considering the commensal and contamination in a variety of samples, with an extremely high sensitivity could lead it to be a tool of diagnostic choice for non-resolving ICU sepsis due to its comprehensive coverage and speed. The aim of this study was to evaluate the use of Bactfast® and Fungifast® as a last mile diagnostic tool in a ICU setting. Method: This study was carried out considering access to four intensive care units (ICU). Legacy testing, mostly done on culture, was conducted at the various integrated microbiology facilities of the hospitals where the ICUs were located, in Chennai, India. NABL accredited laboratory Micro Genomics (India) Pvt Ltd, was established as the central processing facility for next generation sequencing to run the Bactfast® and Fungifast® assay. Co-relation of results for 490 samples was done retrospectively by a multi-disciplinary team of consultants which comprised of microbiologists, and infectious disease physicians. Result: The diagnostic workflow established with the Bactfast® assay provided a sensitivity of 94.1 % and specificity of 86.6 %. Identification of pathogens in Bactfast® was better when compared to the data published in 2017, as reflected by positive co-relation with clinical confirmation. Although the Fungifast® specificity was high, at 99.4 %, only 12 samples were positive on fungal culture out of 490 samples. Therefore, it was concluded a further study for fungi based on multiple technologies with more true positive samples is required to evaluate the test. Conclusion: Bactfast® can identify pathogens in a sample without any bias. Its introduction as diagnostic modality in life threatening ICU sepsis could reduce mortality and morbidity. Although the initial results of Fungifast® are encouraging a further research is required for more information on test sensitivity.

ASVAC2022 : 8th Asian Vaccine Conference.

Aiming to further the Immunization Partners in Asia Pacific (IPAP)'s vision of a world where no one suffers from a vaccine preventable disease, the 8th Asian Vaccine Conference (ASVAC 2022) was held in Colombo, Sri Lanka and virtually from 15 to 18, September 2022 (www.asianvaccine.com). This conference followed those held in Siem Reap, Cambodia (2009), Manila, Philippines (2010), Jakarta, Indonesia (2011), Cebu, Philippines (2013), Hanoi, Vietnam (2015), Singapore (2017) and Naypyidaw and Yangon, Myanmar (2019). The ASVAC2022 themed "Immunization: in Era of Pandemics," commenced with the EPI Managers' Workshop, followed by pre-conference workshops and Vaccinology Masterclass, followed by the main conference featuring 5 plenary lectures, 6 partner-led symposia, free paper and poster presentations, and industry-supported lunch and evening sessions. There were over 1830 registered participants, with 112 attending in person and 998 virtually from 63 countries. The conference was organized by IPAP and hosted by the Vaccine and Infectious Disease Forum of Sri Lanka, Sri Lanka College of Pediatricians, Sri Lanka College of Microbiologists and College of General Practitioners of Sri Lanka, with the support of the Ministry of Health, Sri Lanka. The 9th ASVAC is scheduled to be held in Davao City, Philippines in late 2023.

Changing trends in antimicrobial resistance and serotypes of Streptococcus pneumoniae isolates in Asian countries: an Asian Network for Surveillance of Resistant Pathogens (ANSORP) study.

Antimicrobial resistance in Streptococcus pneumoniae remains a serious concern worldwide, particularly in Asian countries, despite the introduction of heptavalent pneumococcal conjugate vaccine (PCV7). The Asian Network for Surveillance of Resistant Pathogens (ANSORP) performed a prospective surveillance study of 2,184 S. pneumoniae isolates collected from patients with pneumococcal infections from 60 hospitals in 11 Asian countries from 2008 to 2009. Among nonmeningeal isolates, the prevalence rate of penicillin-nonsusceptible pneumococci (MIC, ≥ 4 µg/ml) was 4.6% and penicillin resistance (MIC, ≥ 8 µg/ml) was extremely rare (0.7%). Resistance to erythromycin was very prevalent in the region (72.7%); the highest rates were in China (96.4%), Taiwan (84.9%), and Vietnam (80.7%). Multidrug resistance (MDR) was observed in 59.3% of isolates from Asian countries. Major serotypes were 19F (23.5%), 23F (10.0%), 19A (8.2%), 14 (7.3%), and 6B (7.3%). Overall, 52.5% of isolates showed PCV7 serotypes, ranging from 16.1% in Philippines to 75.1% in Vietnam. Serotypes 19A (8.2%), 3 (6.2%), and 6A (4.2%) were the most prominent non-PCV7 serotypes in the Asian region. Among isolates with serotype 19A, 86.0% and 79.8% showed erythromycin resistance and MDR, respectively. The most remarkable findings about the epidemiology of S. pneumoniae in Asian countries after the introduction of PCV7 were the high prevalence of macrolide resistance and MDR and distinctive increases in serotype 19A.

The manual mycobacteria growth indicator tube and the nitrate reductase assay for the rapid detection of rifampicin resistance of M. Tuberculosis in low resource settings.

BACKGROUND: Tuberculosis (TB) is a disease of poverty that contributes significantly to ill-health in developing countries. Drug resistant TB is a major challenge to disease control. Early diagnosis and rapid determination of drug sensitivity is of paramount importance in eradication of TB. Although automated liquid culture based methods are available for rapid detection of drug resistance, the high cost of these tests prevent them from being used routinely in low resource settings. This study compares two phenotypic methods, the manual Mycobacteria Growth Indicator Tube (MGIT) and the Nitrate Reductase Assay (NRA) in liquid medium, with the agar proportion method (APM), the gold standard for susceptibility testing of Mycobacterium tuberculosis. METHODOLOGY: Fourteen day old M. tuberculosis strains (n=373) grown on solid media were used for drug susceptibility testing by APM, NRA and the manual MGIT method. Rifampicin free and rifampicin incorporated (final concentration, 1 µg/ml) media were inoculated with the recommended concentrations of mycobacterial suspensions and incubated at 37°C in 5% CO2. In the APM, the proportion of colonies in the drug containing medium was determined. In the NRA, the colour change in the medium was compared with a standard colour series after day 6 and day 12 of incubation. Growth in the MGIT was detected using the manual MGIT reader from day 2 onwards. The 2 methods were compared with the gold standard, APM to determine sensitivity and specificity and agreement between the methods was calculated using kappa statistics. RESULTS: Thirty one (31) rifampicin resistant isolates were identified. When compared with the APM, the sensitivity of detection of rifampicin resistance was 85% for the NRA and 93% for the manual MGIT and the specificity was 99% and 100% respectively. Both assays, NRA (κ=0.86) and manual MGIT method (κ= 0.94) were in excellent agreement with the APM. The mean turnaround time for manual MGIT method and NRA were 08 days and 10 days respectively. CONCLUSION: The NRA in liquid medium and manual MGIT are useful alternatives to APM for drug susceptibility testing of M. tuberculosis in low resource settings.

Spread of methicillin-resistant Staphylococcus aureus between the community and the hospitals in Asian countries: an ANSORP study.

OBJECTIVES: Methicillin-resistant Staphylococcus aureus (MRSA) is highly prevalent in hospitals in many Asian countries. Recent emergence of community-associated (CA) MRSA worldwide has added another serious concern to the epidemiology of S. aureus infections. To understand the changing epidemiology of S. aureus infections in Asian countries, we performed a prospective, multinational surveillance study with molecular typing analysis. METHODS: We evaluated the prevalence of methicillin resistance in S. aureus isolates in CA and healthcare-associated (HA) infections, and performed molecular characterization and antimicrobial susceptibility tests of MRSA isolates. RESULTS: MRSA accounted for 25.5% of CA S. aureus infections and 67.4% of HA infections. Predominant clones of CA-MRSA isolates were ST59-MRSA-SCCmec type IV-spa type t437, ST30-MRSA-SCCmec type IV-spa type t019 and ST72-MRSA-SCCmec type IV-spa type t324. Previously established nosocomial MRSA strains including sequence type (ST) 239 and ST5 clones were found among CA-MRSA isolates from patients without any risk factors for HA-MRSA infection. CA-MRSA clones such as ST59, ST30 and ST72 were also isolated from patients with HA infections. CONCLUSIONS: Our findings confirmed that MRSA infections in the community have been increasing in Asian countries. Data also suggest that various MRSA clones have spread between the community and hospitals as well as between countries.

Antimicrobial stewardship capacity and manpower needs in the Asia Pacific.

OBJECTIVES: Antimicrobial stewardship is a strategy to combat antimicrobial resistance in hospitals. Given the burden and impact of antimicrobial resistance in the Asia Pacific, it is important to document capacity and gaps in antimicrobial stewardship programmes (ASP). We aimed to understand existing capacities and practices, and define the resources needed to establish antimicrobial stewardship where it is lacking. METHODS: An anonymous online survey, consisting of questions on antimicrobial control at country, hospital and programme levels, was circulated to healthcare providers in the field of infectious diseases and microbiology through Asian Network for Surveillance of Resistant Pathogens, ReAct Group and the Australasian Society for infectious Diseases. RESULTS: 139 participants from 16 countries or regions completed the survey. The majority of participants were adult infectious diseases physicians (61/139, 43.9%) and microbiologists (31/139, 22.3%). Participants from 7 countries reported that antimicrobials can be obtained without prescriptions. Despite the high percentage (75.5%) of respondents working in large hospitals, only 22/139 participants (15.8%) from Australia, China, Singapore, Taiwan, Thailand and Vietnam reported having more than 10 infectious diseases physicians. Hospital empiric antimicrobial guidelines for common infections were available according to 110/139 (79.1%) participants. Pre-authorisation of antimicrobials was reported by 88/113 (77.9%) respondents while prospective audit and feedback was reported by 93/114 (81.6%). Automatic stop orders and culture-guided de-escalation were reported by only 52/113 (46.0%) and 27/112 (24.1%) respectively. CONCLUSION: The survey reveals a wide range of ASP development in Asia Pacific. Establishing national workgroups and guidelines will help advance antimicrobial stewardship in this diverse region.

The use of objective structured self-assessment and peer-feedback (OSSP) for learning communication skills: evaluation using a controlled trial.

Feedback is essential to guide students towards expected performance goals. The usefulness of teacher feedback on improving communication skills (CS) has been well documented. It has been proposed that self-assessment and peer-feedback has an equally important role to play in enhancing learning. This is the focus of this study. Objectively structured self-assessment and peer feedback (OSSP) was incorporated into small group CS teaching sessions of a group of semester one medical students who were learning CS for the first time, to minimise the influence of previous educational interventions. A control group matched for academic performance, gender and age was used to enable parallel evaluation of the innovation. A reflective log containing closed and open ended questions was used for OSSP. Facilitators and simulated patients provided feedback to students in both groups during CS learning as per routine practice. Student perceptions on OSSP and acceptability as a learning method were explored using a questionnaire. CS were assessed in both groups using objective structured clinical examination (OSCE) as per routine practice and assessors were blinded as to which group the student belonged. Mean total score and scores for specific areas of interview skills were significantly higher in the experimental group. Analysis of the questionnaire data showed that students gained fresh insights into specific areas such as empathy, addressing patients' concerns and interview style during OSSP which clearly corroborated the specific differences in scores. The free text comments were highly encouraging as to acceptability of OSSP, in spite of 67% being never exposed to formal self- and peer-assessment during pre-university studies. OSSP promotes effective CS learning and learner acceptability is high.

High rate of reduced susceptibility to ciprofloxacin and ceftriaxone among nontyphoid Salmonella clinical isolates in Asia.

This multinational study from Asia revealed that reduced susceptibility to ciprofloxacin (MIC, 0.125 to 1 microg/ml) in nontyphoid Salmonella isolates was common in Taiwan (48.1%) and Thailand (46.2%) and in S. enterica serotype Choleraesuis (68.8%) and S. Virchow (75.0%) from all countries. Reduced susceptibility to ceftriaxone (MIC, 2 to 8 microg/ml) remained uncommon in Asia, except in Taiwan (38.0%) or in S. Typhimurium (25.0%) from all countries.

Training simulated patients: evaluation of a training approach using self-assessment and peer/tutor feedback to improve performance.

BACKGROUND: Most medical schools use simulated patients (SPs) for teaching. In this context the authenticity of role play and quality of feedback provided by SPs is of paramount importance. The available literature on SP training mostly addresses instructor led training where the SPs are given direction on their roles. This study focuses on the use of peer and self evaluation as a tool to train SPs. METHODS: SPs at the medical school participated in a staff development and training programme which included a) self-assessment of their performance while observing video-tapes of their role play using a structured guide and b) peer group assessment of their performance under tutor guidance. The pre and post training performance in relation to authenticity of role play and quality of feedback was blindly assessed by students and tutors using a validated instrument and the scores were compared. A focus group discussion and a questionnaire assessed acceptability of the training programme by the SPs. RESULTS: The post-training performance assessment scores were significantly higher (p < 0.05) than the pre-training scores. The degree of improvement in the quality of feedback provided to students was more when compared to the improvement of role play. The acceptability of the training by the SPs was very satisfactory scoring an average of 7.6 out of 10. The majority of the SPs requested the new method of training to be included in their current training programme as a regular feature. CONCLUSION: Use of structured self-reflective and peer-interactive, practice based methods of SP training is recommended to improve SP performance. More studies on these methods of training may further refine SP training and lead to improvement of SP performance which in turn may positively impact medical education.

Antimicrobial susceptibility of Shigella isolates in eight Asian countries, 2001-2004.

BACKGROUND AND PURPOSE: Shigellosis is a major health problem in developing countries, causing 91 million episodes and 414,000 deaths in Asia annually. Because of increasing trends towards drug resistance, this study was undertaken to monitor local resistance patterns of Shigella isolates from 8 Asian countries. METHODS: Ninety eight Shigella isolates collected from 8 centers in 8 Asian countries from July 2001 to July 2004 were analyzed in terms of serogroup distribution and antimicrobial susceptibility. RESULTS: The most common serogroup of Shigella isolates was Shigella flexneri (49/98, 50%), followed by Shigella sonnei (44/98, 45%). The highest resistance rate was found for trimethoprim-sulfamethoxazole (81%), followed by tetracycline (74%) and ampicillin (53%). Overall, 76 Shigella isolates (78%) were multidrug-resistant strains; S. flexneri had a higher multidrug resistance rate than S. sonnei (74% vs 23%). Increasing ciprofloxacin and ceftriaxone resistance was observed; approximately 10% and 5% of isolates were resistant to ciprofloxacin and ceftriaxone, respectively. Five ceftriaxone-non-susceptible strains (from Taiwan [3], Hong Kong [1] and The Philippines [1]) and 10 ciprofloxacin-non-susceptible strains (from Hong Kong [2], The Philippines [1], Korea [2], Vietnam [4] and Sri Lanka [1]) were isolated. CONCLUSIONS: High rates of multidrug resistance and steady increases in ceftriaxone and ciprofloxacin resistance of Shigella are serious pubic health concerns in Asian countries. Continuous monitoring of resistance patterns among Shigella isolates is necessary.

Formative feedback to students: the mismatch between faculty perceptions and student expectations.

BACKGROUND: Formative assessments and other learning tools are ineffective in the absence of formative feedback. METHODS: A study was carried out on preclinical students and teachers using mixed methods approach that included questionnaire surveys, focus group discussions and post survey discussions to determine perceptions and expectations of students on feedback and those of teachers. RESULTS: Students expected formative feedback to be incorporated into all teaching activities from the beginning of the course in medicine to promote self regulated and self directed learning. Students stated that provision of model answers and grades in assessments are inadequate but require teacher student dialogue sessions to clarify issues. Students considered immediate feedback or feedback within two weeks on a written activity, simple but focused, by a content expert would be the best form. In contrast, the teachers perceived the feedback provided using a model answer by a non content expert to be acceptable. Students also believed that formative feedback is of particular importance in salvaging poor performers. CONCLUSIONS: There is a need to create awareness among teachers on the usefulness of this tool in higher education and for moulding teaching practices by including training on this aspect of teaching-learning, in routine faculty development activities. The study showed the importance of including feedback as a generic feature in all learning activities, and this may require incorporating into institutional policy for successful implementation.