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

A comparative study of laparoscopic (LC) vs. open cholecystectomy (OC) in a medical school of Bihar, India

Background: Gallstone disease is a significant health problem world over (in both developing and developed nations). The incidence of gallstone disease increases after age of 40years and it becomes 4-10 times more common in old age. As many as 16% and 29% of women above the age of 40-49 years and 50-59 years, respectively, had gall stones. Laparoscopic cholecystectomy introduced in 1985 has become the procedure of choice for surgical removal of the gallbladder. The aim is to compare laparoscopic cholecystectomy and open cholecystectomy in patients of cholelithiasis by measuring parameters such as use of post-operative analgesia, operative time, post-operative hospital stays, morbidity, mortality and patient satisfaction.Methods: It is a prospective randomized study of 120 patients of cholelithiasis aged between 20years to 80years operated during 2015-2018 at of Anugrah Narayan Magadh Medical College and Hospital, Gaya, Bihar, India. They were divided into open and laparoscopic Cholecystectomy groups by drawing a lottery.Results: The median (range) operation time for laparoscopic cholecystectomy was 55-155 min (mean=102 min) and 40-105 min (mean=72 min) for open cholecystectomy (p <0.001). Form LC group 5 cases had to be converted to OC. Rate of conversion was 5/60=8.3% which is within limits of worldwide laparoscopic cholecystectomy conversion rate of 5% to 10%. LC was found to be superior to OC.Conclusions: Laparoscopic cholecystectomy is better than open cholecystectomy However, open cholecystectomy is preferable in cases of complicated cholecystectomy.

High MDR and ESBL Producing Escherichia coli and Klesbiella pneumoniae from Urine, Pus and Sputum Samples.

Aims: This study was done to assess the prevalence of multidrug resistance and extended spectrum β-lactamase producing E. coli, K. pneumoniae in urine, pus and sputum. Place and Duration of Study: This study was done to assess the prevalence of MDR and ESBL producing E. coli and Klebsiella in urine, pus and sputum from March 2013 to April 2014 at KIST Medical College, Lalitpur, kathmandu, Nepal. Methodology: E. coli and K. pneumoniae were isolated from urine, pus and sputum samples in KIST Medical College, Lalitpur, Nepal. Antibiotic susceptibility test was performed by using disk diffusion method. MDR isolates which were suspected as ESBL producers were confirmed by using double disk synergy test and combined disk diffusion test for same isolates. Results: Out of 580 urine samples, (87/580) 15% showed significant growth of E. coli and K. pneumoniae while in 97 pus and 124 sputum (16/221) 7% showed significant growth of E. coli and K. pneumoniae. From the sputum among 9 isolates, 3 were E. coli and 6 were K. pneumoniae whereas in pus among 7 isolates, 6 were E. coli and one was K. pneumoniae. Out of E. coli (77) isolates from urine, (74/77) 96.10% were MDR and of K. pneumoniae (10) isolates from urine 90% were MDR. Among E. coli (74) MDR isolates 52/74 (70.27%) were ESBL producers whereas all MDR K. pneumoniae isolates from urine were ESBL producers. All the isolates of E. coli and K. pneumoniae from pus and sputum were MDR which were resistant to tested third generation cephalosporins. Among the isolates E. coli (55.55%) and K. pneumoniae (42.85%) isolates were ESBL producers. Conclusions: The high prevalence of MDR E. coli and K. pneumoniae was observed in urine, pus and sputum. The resistance pattern was alarmingly higher to all the antibiotics used except imipenem and amikacin. The prevalence of ESBL was higher so necessary step should be taken to prevent the spread and emergence of resistance.

Correlation of Multidrug Resistance and Plasmid Profile in Extended Spectrum Beta Lactamase Producing Escherichia coli Isolated from Patients Suspected of Urinary Tract Infection.

Aims: To determine the prevalence of extended spectrum beta lactamase producing Escherichia coli (ESBL E. coli) strains among the total isolates and study the association between the antibiotic resistance and plasmid profiles of the isolates. Methodology: A total of 1258 urine samples were collected. Identification of Bacterial isolates was done using standard biochemical tests, antibiotic susceptibility pattern was determined using the Kirby - Bauer’s disk diffusion method and confirmation of the ESBL E. coli was done following CLSI guidelines. Isolation of Plasmid DNA of ESBL positive strains was done by alkaline lysis method. Results: Out of 303 isolates, 198 were E. coli. The isolates were tested for antibiotic sensitivity, MDR, ESBL and plasmid profiles. 59.09% of the E. coli isolates exhibited multi-drug resistance. 41(58.57%) out of 76 ESBL E. coli isolates possessed plasmids. Few isolates possessed single plasmid while other had multiple plasmids with different size ranged from 1 kb to 10 kb. Conclusions: High prevalence of ESBL E. coli was found with good association between the antibiotic resistance and plasmid profiles of the isolates.