Prevalence and susceptibility pattern of methicillin resistant staphylococcus aureus [MRSA]

To determine the prevalence and susceptibility pattern of MRSA isolated at a single tertiary care hospital at Rawalpindi and to compare MRSA susceptibility pattern with MSSA [Methicillin sensitive Staphylococcus aureus]. Descriptive cross sectional data based study. The study was conducted at department of microbiology, Pakistan Railways Hospital Rawalpindi, from January 2012 to March 2014. Culture reports data were retrospectively collected from microbiology laboratory. The antibiotic susceptibility patterns of all staphylococcal strains were determined by modified Kirby Bauer antibiotic sensitivity method. The data was analyzed on the basis of antimicrobial susceptibility pattern, location of the patient [OPD, ward patients] and specimen type [wound swab, pus, HVS and effusions]. A total of 167 isolates were used in the study. Among these isolates 55 [33%] were MRSA and 112 [67%] were MSSA. The majority of S.aureus isolates were obtained from patients with skin and soft tissue infections. All [100%] strains of MRSA isolated during study period were found to be sensitive to Vancomycin, and linezolid and 95% to Teicoplanin, as well as they showed higher susceptibility against chloramphenicol [88%],Fusidic acid [70%] and Rifampin [48%] while MSSA showed higher susceptibility to Gentamicin [92%],Erythromycin [86%] and Ciprofloxacin [71%] as compared to MRSA. This study showed a high prevalence of MRSA in this tertiary care hospital of Rawalpindi. Present study conclusively shows that Vancomycin, Linezolid and Teicoplanin remain the first choice of treatment for MRSA infections. Still alternative antibiotics like chloramphenicol, Fusidic acid, and Rifampin are available to maintain and reserve the efficacy of Vancomycin, Teicoplanin and Linezolid in treating life threatening illnesses

Dissection of ascending aorta after aortic valve replacement and reduction Aortoplasty

A case of Debakey type-II [Stanford type-A] dissecting aortic aneurysm, after aortic valve replacement and reduction aortoplasty, is reported. The patient was 35 years male who was diagnosed of severe aortic regurgitation along with aortic root dilatation of 7 cm. He underwent aortic valve replacement with 27-A St Jude's mechanical aortic valve along with reduction aortoplasty. Nine months later, he was admitted to our hospital with complaint of severe sudden anterior chest pain. Computed tomography with aortic enhancement showed dilatation and dissection of ascending aorta. Successful operation of aortic root replacement with composite graft was performed and patient was discharged without any postoperative complication. The aortic diameter at the time of aortic valve replacement is an independent risk factor for the late aortic dissection

Evaluation of laboratory request forms for culture and sensitivity testing of pus specimen

To evaluate the awareness among health care professionals about the importance of various components of request form through their form completion behavior in a teaching hospital at Rawalpindi. Retrospective study. All lab request forms accompanying pus specimen for culture and sensitivity received in the laboratory of Islamic International Medical College Trust Pakistan Railways Hospital during the calendar year of 2010 were analyzed. A total of 525 Laboratory [Lab] Request forms for pus culture and sensitivity were received. These were analyzed for completion of all the provided information spaces. The results were entered in Microsoft access sheet and analyzed. Most of the specimens [55%] originated from Department of Gynecology and Obstetrics, followed by Departments of Surgery 23%, Orthopedics 11%, Pediatrics 2%, Medicine 1%, ICU and ER 1%, ENT 1%. Department was not mentioned in 6% forms. Most of these forms were signed by Post Graduate Trainees [44%], followed by Medical officers 18%, Consultants 11%, House Officers 9%, Ward Representatives 8%, Registrars 4% and signed without designation 1%. Five percent forms were received unsigned. In the Patient Identification part of the form Father / husband's name was written only in 38%. Patient's ward, bed number, age, gender and Registration No. were missing from 5.7%, 30.7%, 15.2%, 10.5% and 14% respectively. Although clinical notes were given in 90.3% but diagnosis was stated in 26.5% and history of antibiotic therapy only in 2,3% forms. Important information like site of pus collection and type of wound were missing from 20.4% and 27.6% of the forms. The type of test required was stated in 81% whereas the date was missing from vast majority [81.7%] of forms. The study indicates lack of awareness about the importance of components of Lab Request form among Health Professionals. Serious omissions are made even in patient identification information. The frequently neglected important parameters included history of antibiotic therapy, date of sample collection, and site of pus. The study highlights the need for attention to teaching and training laying emphasis on this issue and conducting CME lectures for both graduate and postgraduate levels

Qualitative analysis of sputum specimens submitted for acit fast bacilli [AFB] microscopy to a teaching hospital at Rawalpindi

To find out the quality of sputum specimens submitted for AFB microscopy, to categorize these specimens on the basis of their quality and to compare the frequency of AFB positive smears in each category of these specimens. Five hundred and seventy convenient sputum samples from patients referred for AFB microscopy of sputum were examine after Ziehi Neelsen staining. Based on Heinman and Radano's criteria for sputum, all the sputa under study were divided into sputum and non-sputum categories. The non-sputum category was sub-divided into saliva and mixed samples based on the ratio of pus cells and epithelial cells. All the smears for qualitative categorization and for AFB were examined by the qualified microbiologist. The frequency of AFB positive smears in each category was calculated. Out of 570 specimens submitted, only 110 [19%] were found to be sputum specimens, while 324 [57%] were saliva and 136 [24%] were declared as mixed. The frequency of AFB positive smears was the highest in samples categorized as sputum, 23.6% [26 out of 110] followed by mixed samples 7.35% [10 out of 136], and saliva 0.31% [1 out of 324]. The overall frequency of AFB positive smears was 6.49% [37 out of 570]. Quality of sputum specimen plays a major role in the detection of AFB from the sputum smears. As evident from this study, the frequency of AFB positive smears in the sputum was found to be much higher as compared to saliva and mixed samples

Comparison of intravenous ketorolac with diclofenac for postoperative analgesia

To compare analgesic effect and complications of non - steroidal anti-inflammatory drugs [NASIDs], ketorolac versus diclofenic in prevention of pain after laparoscopic cholecystectomy. Quasi-experimental study. The Department of Anesthesiology and Surgical Intensive Care Unit, Dow Medical College, Karachi from March 2003 to March 2004. Sixty patients, ASA physical status I and II were selected to received either ketorolac 30 mg intravenous [group A] or diclofenic 75 mg intravenous [group B], after general anesthesia induction and before surgical incision. In ketorolac group same dose repeated three times daily for 24 hours. The diclofenic group received diclofenic 75mg 12 hourly for 24 hours. Analgesic effect assessed by intensity of pain postoperatively using visual analogue scale, 0 mean no pain and 10 most severe pain. Rescue analgesic nalbuphine was administered if needed. Both groups required rescue analgesic 0.1mg/kg nalbuphine boluses postoperatively. Higher nalbuphine consumption was noted compared to diclofenic group until 12 hours, which is statistically significant [P value < 0.05]. Side effects were almost similar in both groups. Ketorolac and diclofenic are insufficient alone for analgesia after laparoscopic cholecystectomy; the total nalbuphine consumption was less in ketorolac group

assessment of risk factors for postoperative nausea and vomiting

To determine the risk factors for postoperative nausea and vomiting. Quasi-experimental study with prospective data collection. The study was conducted at Dow Medical College University and Civil Hospital, Karachi from January to December 2004. Data on patients' characteristic, anesthesia, surgery and postoperative nausea and vomiting was collected in operating theatre, postanesthesia care unit and wards. During postoperative 24 hours period, 60 out of a total of 200 patients experienced nausea and vomiting. The factors associated with an increased risk of Postoperative Nausea and Vomiting [PONV] were gender [female odds ratio 3], patients with previous history of nausea and vomiting or motion sickness [odds ratio 4], laparoscopic cholecystectomy [odds ratio 3.5] and eye surgery [odds ratio 3.9], all of these were statistically significant [p < 0.05]. No statistically significant difference was found between the other parameters. The incidence of PONV was found significantly higher in female gender, patients with previous history of nausea and vomiting or motion sickness, patient undergoing laparoscopic cholecystectomy and eye surgery

Prevalence of hepatitis b and hepatitis c among cardiac surgery patients in relation to postoperative recovery

Background: hepatitis B and C are becoming a common occurrence in patients who are admitted for major surgical procedures and associated with significant morbidity and mortality. We evaluated the prevalence of hepatitis B and C admitted for different procedures in the cardiac surgery ward in relation to their postoperative recovery

Patients and Methods: one hundred and twenty six patients admitted during July to December 2007, 23.8% [n=30] were found to be seropositive. Data of 23 patients were available 65.2% [n=15] were male. The mean age of the subjects was 41 years, 56.5% [n=13] were seropositive for hepatitis B whereas 43.5% [n=10] for hepatitis C., 26% [n=6] had deranged preoperative LFT's. Post operatively 6 patients [26.1%] developed abnormal LFTs. Poor left ventricular function was present in 2[8.7%] patients, hypertension was present in 17.4%[n=4], 1 patient[4.3%] was Diabetic and obese, 2 patients[8.6%] have creatinine level more than 2 mg/dl

Results: the overall mortality was only 8.7% [n=2]. Altogether 60.9% [n=14] patients developed morbidities that comprised of: arrhythmias 13%[n=3], re-exploration 30.4%[n=7], wound dehiscence 4.3%[n=1] and in 10 cases [43.5%], morbidities other than these were seen that included: cardiac tamponade, disorientation, cough with hematemesis, infective endocarditis, renal failure, raised BP, delayed chest wound healing with persistent fever, bone pain and failure of saphenous graft. The mean time for bypass; 87 min and time for x-clamp; 58 min, 52% [n=12] patients needed inotropic support postoperatively with mean duration of 15 hrs. mean extubating time was 9.3 hrs. whereas mean time for removal of drain was 30.28 hrs. Bleeding recorded at 6hrs was 515 ml, at 24hrs; 903 ml and 422 ml on 2nd POD. The mean duration for ICU stay came out to be 3 days and ward stay was 4 days

Conclusions: * Approximately ¼ of the patients admitted during the 6 months period came out to be seropositive for hepatitis B and hepatitis C. * The number of affected males was greater than females. * Incidence of hepatitis B was greater than hepatitis C. * Practice of getting shave or hair cut from street barbers and needle prick injuries were popular source of infections particularly for hepatitis B virus, whereas blood transfusion and previous surgery got more response among hepatitis C seropositive. * Morbidity and mortality were high among these patients * Awareness regarding the above among general population and doctors should be created via public mass education

Comparison of fentanyl / isoflurane versus nalbuphine/isoflurane in patients undergoing elective coronary artery bypass surgery

To compare hemodynamic stability, efficacy and extubation time by using fentanyl / isoflurane versus nalbuphine / Isoflurane for coronary artery bypass surgery. Intervention experimental study. The Department of Anesthesiology and Surgical Intensive Care Unit, Dow Medical College and Civil Hospital, Karachi from April 2003 to April 2004. Sixty patients, both sexes, with ejection fraction not less than 40%, elective coronary artery bypass surgery were randomly allocated to receive either fentanyl / isoflurane or albuphine. Hemodynamic stability, drugs supplemented and extubation time were recorded. During intubation, skin incision and sternotomy systolic blood pressure was 126, 47 +/- 7.45, 127.97 +/- 7.58 and 127.03 +/- 7. 10 in group A fentanyl/isoflurane] and 167.60 +/- 14.41, 169.50 +/- 12.99 and 165.83 +/- 11.79 in group B nalbuphine/isoflurane] respectively with [p < 0.05] which is significant. To maintain hemodynamic stability in group B, supplementation with propofol and glyceryltrinitrate infusion was required. Extubation time in group A was 8.2113.87, and in group B was 6.15 +/- 3.41 with [p<0.05] which is significant. Fentanyl/isoflurane provides better hemodynamic stability than nalbuphine / isoflurane, but nalbuphme / isoflurane leads to earlier tracheal extubation than fentanyl / isoflurane group

Daycare cardiothoracic surgery

OBJECTIVE: The implications of Day Care Cardio Thoracic procedures in a developing country like Pakistan. DESIGN: Observational and prospective study. It was conducted at the Cardiac Surgery Unit, Civil Hospital Karachi, from July 1999 to December 2000. 35 patients with different methods of surgery were selected and the procedures performed on them were anterior mediastinotomy, permanent pace maker insertions, cervical sympathectomy, patent ductus arteriosus ligation, and eloiser's flaps. Out of 35 patients, only 3 were detained for over 24 hours solely for logistic reasons. All of them had been told to report back after 10 days and none of them had any wound infection or chest complication. Based on our experience, we found our protocol safe and effective in a selected group of patients. We recommend that quite a number of procedures can be done safely with economic advantages and better utilization of hospital resources without sacrifying the quality of health services