Infection control practices in blood banks of Pakistan

Background: Implementation of infection control standards in blood banks is important to prevent transmission of blood-borne infections such as HIV, hepatitis B and Hepatitis C. No study from Pakistan evaluated the infection control practices in the blood banks of Pakistan.

Aims: This study aimed to evaluate infection control practices with reference to safe blood supply, staff safety and waste disposal practices in blood banks of Karachi, Pakistan.

Methods: This was a cross-sectional study. Infection control practices of all blood banks working in Karachi were determined through a structured questionnaire followed by an educational intervention. Mean scores for overall infection control practices and specific practices regarding safe blood supply, staff safety and waste disposal were calculated and compared with different factors using statistical tools.

Results: Patient safety scores of 49 (92.5%) blood banks were within the satisfactory range but staff safety and waste disposal scores of only 26 (49.1%) and 4 (7.5%) blood banks were satisfactory. Significantly lower infection control (IC) scores were observed for stand-alone blood banks and those working in the absence of a haematologist (P-value < 0.001). Availability of written standard operating procedures (SOPs) and IC guidelines correlated positively (P-value < 0.001) with mean IC scores.

Conclusions: Blood banks in Karachi lack implementation of IC standards particularly with reference to staff safety and waste management and disposal. Sindh blood transfusion authority (SBTA) should take measures to increase IC compliance within blood banks

Clinical, laboratory and bacterial profile of spontaneous bacterial peritonitis in chronic liver disease patients

To determine the clinical and laboratory features, bacterial profile and antibiotic sensitivity pattern of Spontaneous Bacterial Peritonitis [SBP] in Chronic Liver Disease [CLD] patients presenting at a tertiary care hospital of Karachi. Cross-sectional study. PMRC Centre for Gastroenterology and Hepatology and Jinnah Postgraduate Medical Centre, Karachi, from April 2010 to March 2012. CLD patients with ascites were recruited from PMRC Centre for Gastroenterology and Hepatology and Jinnah Postgraduate Medical Centre, Karachi. Basic demographics, symptoms and clinical signs of patients were recorded. Patients with the history of antibiotic use within last 3 days or any intra-abdominal source of infection were excluded. Diagnostic paracentesis was done for ascitic fluid detailed report [D/R] and culture. Blood sample was collected for total leukocyte count, serum proteins and billirubin levels. Out of a total 152 CLD patients, 38 [25%] were diagnosed with SBP. Eight [24.2%] patients presented with classical SBP, 20 [52.6%] had culture negative neutrocytic ascites and 10 [26%] had bacterascites. Fever, abdominal tenderness and constipation were common in SBP patients. Ascitic fluid culture was positive in 19 [50%] patients. E. coli [65%] was the predominant pathogen followed by Enterococcus species [15%]. Resistance was high against cephalosporins [78%] and fluoroquinolones [69.6%] and least against amikacin [13%] and meropenem [12%]. Ascitic fluid D/R and culture together can lead to the accurate diagnosis of SBP and can guide for the right antibiotic choice as resistance to commonly prescribed antibiotic is common in such patients

Long term follow up of interferon treated chronic HCV patients in responders and non-responders

Interferon with ribavirin is the recommended treatment for chronic hepatitis C with a response rate ranging from 50-80% in different countries. Although sustained response is comparable to clinical cure, but whether interferon therapy slows down the disease process in non-responders and relapsers is not known. To determine the long term outcome of chronic HCV patients who have completed the interferon therapy and compare results between responders, relapsers and non-responders. Retrospective case record analysis of chronic hepatitis C patients who were treated with conventional interferon and ribavirin for 6 months during 1998 to 2002 and their follow up till 2011 were included. Depending upon the response they were divided into three groups i.e. responders, non responders and relapsers. A total of 175 patients were included. There were 126 [72%] males and 49 [28%] females, whose ages ranged from 11 to 70 years [mean 35.8 +/- 10.3]. After interferon therapy, 109 were sustained responders, 33 were relapsers and 33 non responders. Mean age of the responders [32.4 +/- 8.8 years] was significantly less as compared to non responders [40.4 +/- 12.0 years] and relapsers [42.4 +/- 8.0 years], [p < 0.05]. Responders had a much better follow up i.e four years as compared to non responders which was statistically significant[p <0.05]. During 10 years follow up, cirrhosis developed in 3 [2.8%] sustained responders, 6 [18.2%] non responders and 8 [24.2%] relapsers. During yearly followup, sustained responders had significantly lower mean ALT and AFP levels as compared to non responders and relapsers [p < 0.05] while non responders and relapsers had lower albumin levels as compared to the responders [p < 0.05]. Majority of the sustained responders had disease eradication, but non responders and relapsers should be followed for any evidence of cirrhosis

Comparison of rapid test with ELISA for the detection of hepatitis B surface antibodies

To compare the sensitivity and specificity of a rapid ICT test with ELISA for the detection of Hepatitis B surface antibody. Cross sectional comparative study conducted at PMRC Specialized Centre for gastroenterology and hepatology JPMC, Karachi from April 2012 - March 2013. A total of 206 apparently healthy adults were selected from a rural community. After taking informed consent, 5 ml blood was collected sera separated and tested for hepatitis B surface antibody [anti-HBs] by a rapid immuno-chromatographic test developed by Korea [Humasis] and ELISA simultaneously. As per manufacturer's guidelines, the rapid ICT test is interpreted as positive if antibody liters are > 30 mIU/ml and negative if the titers are <30 mIU/ml. For ELISA, the CDC interprets antibody titers > 10 mlU/ml as positive or prolective and < 10 mlU/ml as negative and recommends a booster dose. The results of ELISA [gold standard] were compared with rapid test using SPSS version 17.0. Out of 206 sera, using ELISA, anti-HBs was positive in 91[44.2%] sera and negative in 115[55.8%] sera. Using ICT, anti-HBs was positive in 85[41.3%] and negative in 121[58.7%] and the sensitivity and specificity of rapid test ICT was 83.5% and 92.2% respectively with overall accuracy of 88.5%. These figures fell to 70.8% sensitivity and 94.6% specificity with 81.5% accuracy when CDC cut off of 10 mlU/ml was used. The ICT kit gave good results in samples having high liters [> 100 mlU/ml] but had a limited sensitivity for cases having titers between 10 mlU/ml-100 mlU/ml, thus limiting its use and creating unnecessary demand for booster dose of vaccine. The rapid ICT for anti-HBs is not as sensitive as ELISA but can still be used for rapid decision making especially in OPD setups and remote areas

Comparison of different ICT kits for HBsAg and anti HCV using gold standard ELISA

To compare rapid tests [ICT] with 4[th] generation ELISA [gold standard] for hepatitis B and C infection. Biochemistry and Serology Laboratory of the Pakistan Medical Research Council, Research Centre, Jinnah Post Graduate Medical Centre, Karachi. Study was done over six months. ELISA confirmed 200 samples for HBsAg and 200 for Anti-HCV were selected, making a total of 400 samples. Out of 400 samples, 200 were positive and 200 negative on ELISA. These samples were further tested on three different brands of most frequently used rapid ICT Kits for HBsAg and Anti HCV. The sensitivity, specificity, negative predictive value, positive predictive value and cost effectiveness were compared using 4[th] generation ELISA as gold standard. The Rapid kits for HBsAg that were analysed included Acon [USA], Determine [Abbott] and Intec [China] and for Anti HCV they were Acon [USA], Membrane [Canada] and Nobis [Germany]. Out of 100 positive and 100 negative tests for HBsAg confirmed on ELISA, all rapid kits showed comparable results with ELISA. The sensitivity and negative predictive value of Intec China [98%] and Determine Abbot [98%] were similar to each other however, these were higher when compared to Acon USA [95%]. The rapid kit by Intec China was cheaper to the other two rapid kits and was therefore, the most cost effective rapid kit. The specificity and positive predictive value of all three HBsAg ICT kits was 100% and in agreement with ELISA. Out of 100 HCV positive and 100 HCV negative cases confirmed on ELISA, the rapid test by Acon USA showed maximum sensitivity. The sensitivity and negative predictive values of Acon USA were higher [93%] as compared to Membrane - Canada [89%] and Nobis- Germany [86%]. The specificity and positive predictive values of Acon were comparatively lower [93%] but did not significantly vary when compared with Membrane Canada [97%] and Nobis German [96%]. The rapid ICT Kits for HbsAg and anti HCV were equally sensitive and specific when compared with ELISA. These rapid kits are cheaper and easy to perform and their use should be encouraged especially in rural setting. ELISA confirmed rapid HBV, HCV kits being cheaper but sensitive and specific should be used for screening cases especially in rural setting

Pattern of bacterial pathogens in postoperative wounds and their sensitivity patterns

To identify the common bacterial pathogens involved in postoperative wound infections and their sensitivity patterns. Cross-sectional study. Surgical ward 2, Jinnah Postgraduate Medical Centre Karachi, from December 15, 2008 to December 14, 2009. Wound swabs were collected for patients who developed surgical site infection during the study period. Infected cases were identified using Centre for Disease Control [CDC] definition for surgical site infections. Culture and sensitivity were performed using American Society of Microbiology [ASM] guidelines. During the study period, 82 [7.3%] patients developed postoperative wound infection in the selected ward. The most commonly isolated pathogens were E.coli [33.8%], Pseudomonas aeruginosa [16.9%] and Staphylococcus aureus [15.5%]. Resistance pattern of E.coli isolates showed 100%, 93%, 32% and 12% resistance to ceftriaxone, ofloxacin, amikacin and meropenem respectively. Pseudomonas aeruginosa isolates were 100% resistant to tetracyclin and ceftazidime, 91.6% to ofloxacin, 83.3% to meropenem and 66.7% to amikacin. Staphylococcus aureus exhibited maximum resistance to cloxacillin [100%] followed by ofloxacin [90.9%], tetracyclin [45.5%], amikacin [45.5%], chloramphenicol [36.4%] and vancomycin [0%]. Gram negative organisms were frequently associated with postoperative wound infections in general surgery ward and resistance to multiple drugs was noted

Comparison of healing of duodenal ulcer with herbal medicine versus allopathic medicine

Proton pump inhibitors heal over 90% cases of duodenal ulcer but these are expensive. Many patients are reluctant to use allopathic treatment and therefore, use alternate herbal medicines to achieve the same results. There is no head to head comparison of the efficacy of herbal treatment with standard allopathic treatment available in the literature. To compare the healing rates of duodenal ulcer using either herbal drugs [Andamali + Susi + Qarheen] or allopathic medicines [proton pump inhibitor]. Endoscopically diagnosed cases of duodenal ulcer were assigned to two groups where one group received herbal medicine and the other received proton pump inhibitor for 4 weeks [Clarithromycin and Amoxicillin were added for a week for Helicobacter pylori positive cases]. Healing was checked on endoscopy at the completion of therapy. Complete blood count, liver function tests, urea and creatinine were done initially and at the end of therapy to see any adverse effects of the therapy. Other side effects were also noted during the study. A total of 42 endoscopically proven cases of duodenal ulcer were included in the study, 22 patients received proton pump inhibitor [group A] and 20 received herbal medicine [group B]. Seven cases [5 in group A and 2 in group B] were lost to follow up and were thus excluded from the study. Thirty-five cases [17 group A, 18 group B] completed the study. Out of these 35 cases, 29[82.85%] were males and 6[17.1%] females. Helicobacter pylori was present in 19[54.3%] cases [10 in group A and 9 in group B]. After 4 weeks of therapy, 16[94%] cases healed with proton pump inhibitors and 13[72%] healed in herbal medicine group. The difference in healing rates was not significant. Using proton pump inhibitors along with 2 antibiotics in the Helicobacter pylori positive cases, 9 out of 10[90%] showed healing of ulcer, while 7 out of 9[78%] cases in herbal medicine group who were positive for Helicobacter pylori, but did not receive antibiotics also showed healing. Regarding adverse effects, bitter taste in mouth was reported in 5[29%] and diarrhea in 2[12%] patients, receiving triple regimen in group 'A' against only 2[11%] patients who had similar complaints with herbal medicine. No significant change was observed in the hematological and biochemical parameters like CP, LFTs, urea and creatinine from the baseline to the end of therapy in both groups. Healing of duodenal ulcer is almost similar with both herbal and standard allopathic drugs; however, adverse effects were more common with allopathic drugs. Herbal medicine can be used to treat duodenal ulcer

Is raised helicobacter pylori antibody titre enough to decide retreatment?

Helicobacter pylori infection causes a rise in its antibodies which take almost a year to come to baseline following successful eradication treatment. Checking these values in between a year may give falsely high values and many patients may thus be over treated. Aims: To serially determine Helicobacter pylori antibody titres in patients after giving them triple therapy for H. pylori eradication and see how these values drop over time. Longitudinal study conducted in Department of Gastroenterology and Hepatology, Pakistan Medical Research Council, Research Centre, Jinnah Post Graduate Medical Centre, Karachi, from May 2006 to April 2010. Over the period of four years, 186 patients who were found positive for campylobacter like organism test during endoscopy were further tested for anti H. pylori IgG titre before being treated for H.pylori. Patients were given triple therapy comprising of Omeprazole [20mg twice daily], Amoxicillin [1gm twice daily] and Clarythromycin [500mg twice daily] for a week and were followed at 1, 3, 6 and 12 months to check symptomatic relief and they were tested again for H. Pylori antibody titres. Data was collected on pre-designed proforma which included patient's demography, symptoms and diagnosis. Out of 186 patients who had a positive campylobacter like organism test, 173 patients consented to participate in the study. Serology for H. Pylori was positive in 119[68%] cases. A decline in mean antibody titres was observed as 11%, 21.5%, 54.7% and 59.2% at 1, 3, 6 and 12 months respectively. Sensitivity of serology for diagnosing H. pylori infection is good but using these as a tool for monitoring response to treatment is doubtful. A slow drop in H. pylori antibodies was seen over 12 months and therefore, physicians are cautioned not to retreat the already treated cases till about one year post treatment. H. pylori antibodies should be checked on regular basis to diagnose new cases but it should not be used in previously treated patients to retreat

experience of polypectomy in children and adults in Karachi

To see the morphological types of polyps, the acceptability of the procedure and the complications following polypectomy. Out patients department of Gastroenterology at PMRC, Research Centre, Jinnah Postgraduate Medical Centre, Karachi. All patients [children and adults] referred with history of bleeding per rectum underwent flexible sigmoidoscopy or colonoscopy without sedation or analgesia. Bowel cleansing was done using a laxative the night before the procedure and an enema on the morning of the procedure. The site, size and number of polyps were noted and polypectomy performed using Olympus PSD 10 cautry and a snare. Polyp was retrieved with a basket for histological examination. Post polypectomy patients were asked to report if there were any signs of bleed or abdominal distension. Over 3 years, 126 colonic polyps were seen [60 children and 66 adults]. The ages of the patients ranged from 2 - 82 years. The main presenting feature was rectal bleeding and the site of polyp was mostly the recto sigmoid area or the descending colon. Of 60 children, 13 were less than 5 years of age and 47 were between 5 - 15 years. The polyp was mostly single pedunculated cherry red in color. Five children had multiple polyps of whom 3 had polyposis coli. In adults majority had single polyp in the rectum or sigmoid and 11 had multiple polyps with 3 having polyposis coli. In adults most polyps had an ulcerated surface and a short pedicle. Post polypectomy 3 cases had a bleed within 24 hours, [1 child and 2 adults]. Both were admitted and transfused blood. On repeat examination the bleeding was seen from the base of the stalk which was electro coagulated with a hot biopsy forceps. None required surgery. On histology 58 polyps were hyperplasic and 51 hamartomatous including juvenile polyps. Only one adult had a tub-villous adenoma. Biopsy was not done in 9 adults and 7 children. All patients tolerated the procedure well and none required anesthesia or analgesia. Majority of the polyps in children and adults were hyperplasic or hamartomatous with only one adult having tubovillous adenoma. Only 3 [2.4%] had a post polypectomy bleed which was managed by electro coagulation of the stump

Esophageal motility disorders in diabetics

To see the presence of esophageal motor disorders in diabetic patients and compare it with controls at the Department of Medicine Ziauddin Medical University Hospital, Karachi. Diabetic patients admitted at Ziauddin Medical University Hospital, Karachi were taken as study subjects, whereas age and sex matched healthy volunteers not suffering from any disease neither taking any medication for dyspepsia were taken as controls Esophageal manometry was done to see the motility disorders in diabetic patients and controls. Resting pressure of the lower esophageal sphincter in diabetics was similar to controls. Percentage of relaxation of the lower esophageal sphincter was low in diabetics. Amplitude of esophageal peristalsis and duration of contraction was similar in both the groups. Propulsive velocity of peristalsis was slower in diabetics. Parameters of upper esophageal sphincter were similar in diabetics and controls. Abnormal peristaltic waves like aperistalsis of the esophageal body, high amplitude and broader waves, absent contraction and hypertensive lower esophageal sphincter were seen in diabetics only. Poor relaxation of the lower esophageal sphincter and slow propulsive velocity were noted in diabetics. Abnormal peristaltic waves like aperistalsis of the esophageal body, high amplitude and broader waves, absent contraction and hypertensive lower esophageal sphincter were seen in diabetics only

Helicbacter pylori clearance and eradication with triple therapy in duodenal ulcer patients

Triple therapy was given to 49 chronic helicobacter pylori positive chronic duodenal ulcer cases to see its efficacy in H. pylori clearance, eradication and ulcer healing. H. pylori clearance and eradication rates at weeks 5 and 8 were 87.8 percent and 81.5 percent while ulcer healing rates 68.2 percent and 81.5 percent respectively. Seven [18 percent] cases failed to clear H. pylori and were classified as non-responders. Histologically 60 percent showed post-treatment regression of gastritis. Tolerance to drugs was excellent with a good compliance rate

Triple therapy in duodenal ulcer healing: a follow-up study

Thirty nine Helicobacter pylori [HP] positive chronic duodenal ulcer patients completed the 4 weeks treatment of triple therapy [Denol, Metronidazole and Amoxil]. Of these 29 showed healed duodenal ulcer and negative CLO test at 8 weeks [eradication]. They were followed at 3.6 and 12 months and at each follow-up, endoscopy and CLO testing were repeated. At 12 weeks, 54% showed a healed ulcer and negative CLO and these figures reached to 69 and 66% at 6 and 12 months respectively. Thirty percent relapsed within 1 year. The present study indicates a prolonged remission of duodenal ulcer following HP eradication

Healing and relapse rates of duodenal ulcer with omeprazole Vs ranitidine

The efficacy of omeprazole 20 mg a day was assessed against ranitidine 150 mg twice a day in the healing and relapse of duodenal ulcer. Forty three endoscopically verified cases were allocated to 2 weeks of treatment, which was extended to 4 weeks, if the ulcer persisted on day 15. Two cases were excluded due to deviation from the protocol. Of 41 evaluable cases, 21 received omeprazole and 20 ranitidine. Healing rates with omeprazole and ranitidine at 2 weeks were 71% and 70% respectively which rose to 100% and 90% at 4 weeks [N.S.]. There was no significant difference in pain relief in two groups. Follow-up endoscopies, in 33 healed cases revealed 100% relapse at 3 months in omeprazole and 79% in ranitidine treated cases [P<0.05]

Famotidine 40mg BID in the treatment of reflux oesophagitis

To assess the efficacy of famotidine in the healing of reflux oesophagitis, 25 endoscopically proven cases were treated with famotidine 40 mg B.I.D. for 6 to 12 weeks. Six patient were lost to follow-up, of the 19 cases analysed, 16 [84.2%] healed at 6 weeks and 17 [89.5%] at 12 weeks. Twelve cases [63%] became asymtomatic within six weeks of treatment. In conclusion famotidine 40 mg B.I.D. is effective in the healing of reflux oesophagitis

Endoscopic lesions in chronic renal failure

To determine the frequency and type of upper gastrointestinal lesions in patients with chronic renal failure [CRF], upper G.I. endoscopy was done in 101 cases. Of the various mucosal lesions, inflammatory changes were seen maximally [40], followed by erosions [16] and ulcers [7]. Other changes included atrophic gastro-duodenal folds [17], pale mucosa [11] and moniliasis [6] which was only seen in patients with end stage CRF. Lesions were more frequent in those who were in advanced stage of CRF [81%] and those undergoing dialysis [79%], reflecting a positive correlation of upper G.I. lesions with the severity of CRF