Pattern of internet use, anxiety, and depression among professional students of Tripura, India: an analysis

Introduction: In this era of technology we cannot imagine our lives without internet. However, excessive internet use may bring curse in life. Aims and objectives: The present study was an attempt to examine the pattern and prevalence of internet use among medical and engineering students. It was also aimed at comparing pattern of internet use, anxiety, and depression of professional students. Further, it was also intended to study the level of anxiety and depression across the subgroups of internet users. Methodology: The study was carried out among 1100 professional students, selected randomly from five institutions of Tripura, India. Out of 1100 students, 659 were medial students and 441 were engineering students. All of them were in the age group of 18-25 years. Internet Addiction Test, Hamilton Anxiety Rating Scale, and Hamilton Depression Rating Scale were used for assessing pattern of internet use, anxiety, and depression respectively among the professional students. Data was collected from the subjects following group administration method and was analysed quantitatively with the help of Statistical Package for the Social Sciences version 25 (SPSS v25). Results: The prevalence of excessive internet use among professional students of Tripura was 7.4%. Medical and engineering students did not differ significantly with respect to their pattern of internet use (except ‘average’ use of internet), anxiety, and depression. However, a significant difference in each of anxiety and depression had been noted across the different patterns of internet use of the study subjects.

Kimura's disease involving bilateral lacrimal glands and extraocular muscles along with ipsilateral face: A unique case report

A 23 year female presented with bilateral recurrent swelling of eyelids along with ptosis and proptosis for last 3 years. She also had swellings over the right cheek, parotid gland, and retro auricular area along with regional lymphadenopathy. Systemic laboratory workup revealed raised serum IgE and a high peripheral eosinophil count. Computed tomography and magnetic resonance imaging showed bilateral enlargement of extraocular muscles, lacrimal glands, and ipsilateral parotid gland. Excision biopsy of the retro-auricular lymph node was suggestive of Kimura's disease (KD). The patient responded well to systemic corticosteroid. KD rarely affects orbit, but it should be included in the differential diagnosis of inflammatory diseases of the orbit. To our knowledge, this is the first reported case of KD from India involving the orbit, lacrimal gland, extraocular muscles, parotid gland and buccal area.

Diverse aminoglycoside phosphotransferase types conferring aminoglycoside resistance in Enterobacteriaceae: A single-centre study from Northeast India

The present study investigates the molecular basis of aph-mediated aminoglycoside resistance and their transmission dynamics in a tertiary care hospital of Northeast India. Two hundred forty one isolates (230 Escherichia coli and 11 Klebsiella pneumoniae) were collected and screened for aminoglycoside resistance genes. Various aph types were amplified using polymerase chain reaction (PCR) assay. Plasmid incompatibilty, horizontal transferability and ERIC-PCR based typing were carried out for all the positive isolates. Among them, 67 isolates showed the presence of aph gene. Aph (3“)-IIIa and aph (3')-Via were predominant and horizontally transferable. All the plasmids were of incompatibility I1 group. Twenty-eight different haplotypes of E. coli were found harbouring aph gene types. This study was able to identify diverse aph types in a single centre and their corresponding phenotypic trait.

Profiling of major biochemical compounds for identification of nutritionally rich genotypes in mango

Aim: Mango is a major fruit crop grown in India with wide variability for fruit colour, size, shape and fruit quality. The main objective of this study was profiling of mango genotypes and their genetic estimates for major biochemical compounds to identify superior genotypes as parents for developing nutritionally rich hybrids in future. Methodology: Fifty mango varieties were analysed for biochemical compounds such as total antioxidants, total phenols, total flavonoids and total carotenoids. The L*, a*, b* values were recorded for pulp colour, and genetic estimates were also worked for genetic parameters such as genotypic variance, phenotypic variance, GCV, PCV, heritability and genetic advance. Correlation matrix for major biochemical compounds and L*, a*, b* values were also calculated. Results: The present study revealed the presence of wide genetic variability in mango gene pool for biochemical compounds and pulp colour. The total phenolics ranged from 24.44 to 148.33 mg 100g-1 of pulp, total flavonoids 10.33-49 mg 100g-1, total carotenoids 0.48-7.50 mg 100g-1 and total antioxidants 0.14-1.59 µmol Trolox 100g-1 of pulp. The future genetic estimates showed that the phenotypic coefficient of variation (PCV) for all the characters was slightly higher than genotypic coefficient of variation (GCV), indicating the presence of environmental influence to some degree in the phenotypic expression of characters. However, the difference between PCV and GCV for all the traits was narrow suggesting that the traits were less influenced by environment. The broad sense heritability (H2b) for all the compounds was high which indicates the phenotype of that trait strongly reflects its genotype. Interpretation: High values of PCV, GCV and heritability for total antioxidants, total phenols, total flavonoids and total carotenoids indicated high genetic variability and better scope for selection and improvement through hybridization.

Sub-inhibitory concentration of ertapenem induces overexpression of regulator of antibiotic resistance A in Escherichia coli

AcrAB-TolC is a tripartite efflux pump system constitutively expressed which functions as an intrinsic-resistant mechanism found to be responsible for conferring resistance towards dyes, detergents and different compounds including various classes of antibiotics. One global regulator belonging to AraC-type regulator family, regulator of antibiotic resistance A (RarA) up-regulates the expression of AcrAB-TolC encoded in Klebsiella pneumoniae, Enterobacter sp. 638, Serratia proteamaculans 568 and Enterobacter cloacae resulting in multidrug-resistant phenotypes. The present work was initiated to find out the transcriptional response of RarA in clinical isolates of Escherichia coli against concentration gradient carbapenem stress. A total of 22 clinical isolates of E. coli and expression level of regulators were analysed via quantitative real-time polymerase chain reaction with and without carbapenem stress. As a result, a strong correlation between the expressional levels of RarA in AcrAB overexpressed isolates of E. coli and elevated expression was observed when exposed under concentration gradient ertapenem stress. The clones containing pRar showed reduction in the zone of inhibition towards carbapenem, indicating the active participation of RarA in AcrAB overexpressed isolates of E. coli conferring resistance towards carbapenems.

Transcriptional response of AcrEF-TolC against fluoroquinolone and carbapenem in Escherichia coli of clinical origin

Introduction: Efflux pump systems constitute a major means of intrinsic resistance in Escherichia coli. AcrEF-TolC pump is known to exhibit higher expression level in quinolone resistant isolates. However, the transcriptional response of this pump is yet to be known when exposed to quinolone and other group of antibiotics. Objective: The present study analyses the transcriptional response of AcrEF-TolC in the presence of quinolones and carbapenems. Methodology: A total of 167 non-duplicate clinical isolates from Silchar medical college and Hospital, Silchar, India were included in this study. Of which 27 were devoid of any carbapenemase activity and among them 13 isolates showed overexpression of AcrE and AcrF gene. Transcriptional response of AcrE was directly proportional to increasing concentration of levofloxacin and ofloxacin. However, the response of AcrE and AcrF was inconsistent with carbapenems. Result: The study isolates showed susceptibility towards amikacin (68.4%), gentamicin (59.6%), cefepime (52.7%) and pipercillin/tazobactam (48.3%). The present investigation highlights that apart from qnr genes and mutational changes in gyr region, AcrEF-TolC plays a major role in fluoroquinolone resistance in this part of the world. Conclusion: Upregulation of AcrE in the presence of levofloxacin and ofloxacin warrants further investigation to establish their active role in efflux of this drug.

Occurrence of II and V staphylococcal cassette chromosome mec types among coagulase-negative staphylococci from Northeastern part of India

Introduction: Coagulase Negative Staphylococci, the most commonly isolated pathogen are becoming emerging threats to the community as well as to the nosocomial environment. The present study underscores the distribution of Staphylococcal cassette chromosome mec (SCCmec) types among Methicillin resistant Coagulase Negative Staphylococci from the environmental origin. Methods and Materials: Environmental and food sample (n = 460) from different location of northeastern region of India were collected for a period of one year and were phenotypically and genotypically screened using cefoxitin disc and PCR techniques for mecA and mecC gene detection. All the MR-CoNS isolates possessing mecA gene were subjected to 16srDNA sequencing for species identification. SCCmec typing was determined by evaluating using primer sets from type I to type V. Antibiotic susceptibility testing was performed for all the isolates. Statistical analysis with chi-square test using SPSS-21 statistical software. Results: Methicillin resistance shown by one hundred forty three isolates were carried out for molecular analysis, among them 53.84% serves as mecA carrier. Distribution of Staphylococcus haemolyticus was more frequent and was found that SCCmec types II and V were predominant among the study isolates. Linezolid was the drug of choice for the CoNS isolates. Statistical analysis showed an insignificant result for the tested antibiotics and SCCmec types. Conclusion: This study therefore interprets the relative importance of SCCmec types among MR-CoNS isolates.

High-level aminoglycoside resistance in Acinetobacter baumannii recovered from Intensive Care Unit patients in Northeastern India

Background: Acinetobacter baumannii has emerged as an important nosocomial pathogen, its ability to acquire resistance to carbapenems and aminoglycosides, has complicated their treatment regimen. The present study investigates the prevalence and diversity of aminoglycoside-modifying enzymes and 16S methyltransferases in A. baumannii isolates recovered from patients admitted in Intensive Care Unit (ICU) of a tertiary referral hospital in Northeastern India. Materials and Methods: We investigated the high-level aminoglycoside-resistance (HLAR) (gentamicin and amikacin minimum inhibitory concentration ? 512 ?g/ml) among 164 multidrug-resistant A. baumannii obtained from ICU. Genes encoding aminoglycoside-modifying enzymes, 16S methyltransferase and coexisting beta-lactamases were amplified. Horizontal transferability, plasmid stability and elimination assays were performed. Clonality and sequence types were evaluated by repetitive extragenic palindromic-polymerase chain reaction and multilocus sequence typing (MLST) respectively. Results: A total of 130 (79.2%) isolates were found to exhibit HLAR, with acquired aminoglycoside-resistance genes in 109 (83.8%) isolates along with coexisting extended-spectrum beta-lactamases and metallo-beta-lactamases. Genes aph (3') I, aph (3') VIa and armA were predominant and horizontally transferable. Plasmids were eliminated with single sodium dodecyl sulphate treatment. Seventeen haplotypes were found responsible for the infection. MLST revealed circulation of ST583 and ST188 in ICU. Conclusions: This study reveals the presence of aminoglycoside-resistance genes in combination with blaCTXM and blaNDM, which are highly stable and not frequently reported from this geographical region. Further, the study could predict limited treatment option and need for formulating infection control strategy.

Observation of a new pattern of mutations in gyrA and parC within Escherichia coli exhibiting fluroquinolone resistance

Therapeutic options with quinolones are severely compromised in infections caused by members of Enterobacteriaceae family. Mutations in chromosomal region are one of the major reasons for bacterial resistance towards this group of antibiotic. The aim of the study is to detect the mutations in gyr A and par C responsible for quinolone resistance among clinical isolates of Escherichia coli. A total of 96 quinolone-resistant clinical isolates of E. coli were collected from a tertiary care hospital of North-east India during March 2015 to August 2015. All the quinolone-resistant E. coli strains were investigated for mutations in the topoisomerases genes gyrA and parC by amplifying and sequencing the quinolone resistance determining regions. Among the 96 E. coli isolates, 83.3% were resistant to nalidixic acid and 80.2%, 66.6%, 23.9% and 50% to ciprofloxacin, norfloxacin, levofloxacin and ofloxacin, respectively. Several alterations were detected in gyrA and parC genes. Three new patterns of amino acid substitution are reported in E. coli isolates. The findings of this study warrant a review in quinolone-based therapy in this region of the world to stop or slow down the irrational use this drug.

Association of glycerol kinase gene with class 3 integrons: A novel cassette array within Escherichia coli

Background: Integrons are genetic elements which are known for their role in capturing and spreading of antibiotic resistance determinants among Gram-negative bacilli. So far, there is no study regarding Class 3 integron and their genetic organisation in India. Objective: This study investigates the occurrence of Class 3 integron and their gene cassette array among Escherichia coli. Materials and Methods: In this study, a total of 200 E. coli isolates were collected from indoor and outdoor patients from Silchar Medical College and Hospital during September 2015 to February 2016. Detection of the integrase genes and gene cassettes within the Class 3 integron was performed by polymerase chain reaction which was further analysed by sequencing. Results: Twenty-seven isolates were found to harbour Class 3 integron. Sequencing of the gene cassettes and whole Class 3 integron revealed the presence of nine different types of cassettes array, out of which the arrangement with glycerol kinase gene cassette was found to be the most prevalent. Arrangement with blaCTX-Mgene cassette was also detected in few isolates. Conclusion: This study provides epidemiological profiling of Class 3 integrons in this geographical area. The data generated in this study are helpful in infection control programme, anti-infective research and search for epidemiological markers.

Distribution of Class II integrons and their contribution to antibiotic resistance within Enterobacteriaceae family in India.

Background: Integrons are the main contributors to the development of multidrug resistance (MDR) among Gram‑negative bacilli. There is a lack of knowledge about the molecular relation between gene cassettes and antibiotic resistance in India. Objective: In this study, we have investigated the occurrence of Class II integron and their cassette array among Enterobacteriaceae. Materials and Methods: A total of 268 MDR non‑duplicate strains of Enterobacteriaceae were collected from Silchar Medical College and Hospital, Silchar, Assam, India, during June 2012 to May 2013. Polymerase chain reaction was performed for detection of the integrase genes and gene cassettes within the Class II integron which were further analysed by sequencing. Results: Class II integron was observed in 47 isolates. Four different gene cassette arrangements were detected: dfrA1‑sat2‑aadA1; dfrA1‑sat2‑aadA1‑orfX‑ybeA‑ybfA‑ybfB‑ybgA; dfrA12‑sat2‑aadA1; and dfrA1‑linF‑aadA1. The most prevalent cassette combination was dfrA1‑sat2‑aadA1. This study has also identified a set of gene cassette associated with linF gene instead of sat2 gene. Conclusion: Further investigation is required to determine the current situation and important reservoir of Class II integron for the transmission of drug resistance among Enterobacteriaceae and their contribution to antimicrobial resistance in hospital environment.

Development and validation of a questionnaire to measure preferences and expectations of patients undergoing palliative chemotherapy: EXPECT questionnaire.

OBJECTIVE: The objective was to design and validate the questionnaire for capturing palliative chemotherapy‑related preferences and expectations. DESIGN: Single arm, unicentric, prospective observational study. METHODS: EXPECT questionnaire was designed to capture preferences and expectations of patients undergoing palliative chemotherapy. This questionnaire underwent a linguistic validation and then was tested in patients. Ten patients are undergoing chemotherapy for solid tumors who fulfilled the inclusion and exclusion criteria self‑administered the EXPECT questionnaire in regional language. After filling this questionnaire, they self‑administered quick questionnaire‑10 (QQ‑10). SPSS version 16 (IBM New York) was used for analysis. Completion rate of EXPECT questionnaire was calculated. The feasibility, face validity, utility and time taken for completion of EXPECT questionnaire was also assessed. RESULTS: The completion rate of this questionnaire was 100%. All patients completed questionnaire within 5 min. The QQ‑10 tool confirmed the feasibility, face validity and utility of the questionnaire. CONCLUSION: EXPECT questionnaire was validated in the regional language, and it’s an effective tool for capturing patient’s preferences and expectation from chemotherapy.

An audit of cytoreductive surgeries in ovarian cancer from a rural based cancer center.

BACKGROUND AND OBJECTIVE: Ovarian cancers are frequently seen at an advanced stage in our center. This audit was planned to see the morbidity and efficacy of different types of cytoreductive surgeries (radical vs. ultra‑radical) done in such patients. METHODS: This was a retrospective analysis of all ovarian cancer patients who underwent cytoreductive surgery at our center from January 2009 to August 2013. The case records of these patients were reviewed and the demographic, disease‑related and treatment‑related data were extracted. RESULTS: Fifty‑fivepatients were identified. Ten (18.2%) patients underwent primary cytoreduction while 45 patients had (81.8%) interval cytoreduction. The resections achieved were optimal in 50 patients (90.9%) and suboptimal in five patients (9.1%). The postoperative median blood loss was 400 (350–600) mL. The median time interval for surgery was 4.0 h (3–5 h). The type of resection achieved (optimal vs. suboptimal) was the only factor affecting the progression free survival (PFS) (Hazard ratio = 0.08 95% confidence interval 0.02–0.3). There was no significant difference in postoperative morbidity in patients undergoing the ultra‑radical surgery as compared to those who underwent radical surgery. CONCLUSION: Optimal cytoreduction may improve PFS in advanced ovarian cancer patients and needs to be done even if it mandates an ultra‑radical surgery.

Tolerance of weekly paclitaxel and carboplatin as neoadjuvant chemotherapy in advanced ovarian cancer patients who are unlikely to tolerate 3 weekly paclitaxel and carboplatin.

OBJECTIVE: There are little data regarding safety and effectiveness of neoadjuvant chemotherapy (NACT) in patients who are considered unfit for receiving 3 weekly paclitaxel and carboplatin. The aim of this study was to study the toxicity and response rates of weekly paclitaxel and carboplatin as NACT in such cohort of patients. METHODS: Study population included advanced ovarian cancer patients who were unlikely to tolerate 3 weekly paclitaxel and carboplatin and hence received weekly paclitaxel (80 mg/m2) and carboplatin AUC‑2 as NACT. The data regarding the baseline characteristics, chemotherapy tolerance, completion rates, toxicity (CTCAE version 4.02), and radiological response rates are presented. SPSS version 16 was used for analysis. Descriptive statistics is presented. RESULT: Eleven patients received this schedule. Nine patients completed nine cycles of NACT. Except one, all patients completed NACT with an average relative dose intensity of >0.8. There was no chemotherapy‑related mortality. Grade 3–4 life‑threatening complications were seen in two patients. The post NACT response rate was 100%. CONCLUSION: Weekly paclitaxel and carboplatin chemotherapy is safe and efficacious in patients who are unsuitable for 3 weekly paclitaxel and carboplatin chemotherapy schedules.

Efficacy of second‑line erlotinib in patients postprogression of first‑line chemotherapy in head and neck cancers.

BACKGROUND: Oral tyrosine kinase inhibitor (gefitinib and erlotinib) have been used in the palliative treatment of head and neck cancers with limited success. In this report, we aim to quantify the symptomatic benefit, progression‑free survival (PFS) and overall survival (OS) when erlotinib is given as second‑line treatment in Head and neck cancers. METHODS: This was a post‑hoc retrospective analysis of a randomized study comparing metronomic chemotherapy with cisplatin. A patient who progressed on chemotherapy and had a PS0‑2 were offered second‑line chemotherapy. Patients who had received erlotinib (150 mg PO OD) as second line treatment were selected for this analysis. Erlotinib was discontinued in case of either progression of disease or if the patient had intolerable side effects. Patient were monitored 1‑week after the start of erlotinib and subsequently at monthly intervals. The toxicity was recorded in accordance with CTCAE version 4.02 (NCI,USA) and the response were graded in accordance with RECIST version 1.1. All of these patients were followed‑up till death. RESULTS: Twenty‑three patients were identified. The median age of these patients at the start of the second line was 47 years (interquartile range 40.5–51.75 years). The primary site of distribution was oral cavity primary in 17 patients (77.3%) and nonoral cavity primary in 05 (22.7%) patients. The immediate last chemotherapy regimen received was cisplatin in 9 patients (40.9%) and metronomic chemotherapy in 13 patients (59.1%). Symptomatic benefits post second‑line erlotinib was seen in 18 patients (81.8%). The most common adverse events (any grade) seen were anemia in 20 patients (90.9%), rash in 10 patients (45.5%) and diarrhea in 7 patients (31.8%).The best radiological response documented were a partial response in 04 patients (19.2%). The median estimated PFS and OS were 110 days (95% confidence interval [CI]: 61–175 days) and 156 days (95% CI: 126–185 days) respectively. CONCLUSION: Erlotinib single agent has promising activity in the second line and needs to be explored in future studies.

Predictivity of human papillomavirus positivity in advanced oral cancer.

BACKGROUND AND OBJECTIVE: Human papillomavirus (HPV) is a known prognostic factor world over in patients of carcinoma oropharynx. The role of HPV in oral cancers has not been investigated adequately. We tried to identify standard clinicopathological features in oral cancer, which would predict HPV‑positivity. METHODS: This was a retrospective analysis of 124 cases of T4 oral cancer patients at our center. HPV‑positive was defined in accordance with positive p16 immunohistochemistry done on pretreatment local tumor site biopsy. Age, sex, habits (smoking history and oral tobacco), Eastern Cooperative Oncology Group performance status (ECOG PS), T stage, N stage, grade, and site were selected, for testing of prediction for HPV‑positivity. The analysis was performed by R studio version 3.1.1. Two‑sample test for equality of proportions with continuity correction was used to identify factors predicting for HPV‑positivity. P = 0.05 was considered as significant. RESULTS: Of 124 patients, 16 patients (12.9%) were HPV‑positive. The median age of the whole cohort was 43 years (interquartile range 37–52 years) with 15 females (12.1%). All had squamous cell carcinoma (100%). The grade of the tumor was well differentiated in 9 patients (7.2%), moderately differentiated in 98 patients (79.1%), and poorly differentiated in 17 patients (13.7%). The ECOG PS 0 in 19 patients (15.3%), 1 in 104 patients (83.9%), and 2 in 1 patient (0.8%). The subsite of the tumor was buccal mucosa in 74 patients (59.7%), anterior two‑third of tongue in 33 patients (26.6%), and others in 17 patients (13.7%). None of the tested factors except the use of oral tobacco were statistically significantly associated with HPV‑positivity. History of tobacco usage had a statistical trend toward ability to predict HPV‑positivity. The proportion of patients with HPV‑positive oral cancer in patients without history usage of oral tobacco was 31.3% while it was 10.2% in patients with previous history of tobacco use (P = 0.03). CONCLUSION: Standard clinicopathological variables could not predict for HPV‑positivity. Negative history of tobacco (smokeless) usage showed statistical trends toward ability to predict HPV‑positivity in oral cancer patients.

Head and neck cancer in geriatric patients: Analysis of the pattern of care given at a tertiary cancer care center.

BACKGROUND AND AIM: The percentage of elderly people with head and neck cancers (HNC) is on the rise. This makes HNC in this group of patients an important issue for healthcare providers. The present study was planned to analyze the patterns of care given to the geriatric patients and to identify the factors influencing the decision making process. MATERIALS AND METHODS: Data of all the elderly patients (≥65 years) registered in the year 2012, with histologically proven HNC (all sites, stages, histopathological types, except lymphoma, sarcoma and cervical metastasis of unknown origin) receiving treatment (definitive/palliative) were collected. RESULTS: A total of 270 patients were included in this study. The median age was 72 years (range: 65–101), with predominant male population (70%, n = 190). Oral cavity squamous cell carcinoma (SCC) was the most common cancer (57%, n = 154). Eastern Co‑Operative Oncology Group performance status (PS) of 0–2 was seen in 91% of the patients. Co‑morbidities were present in 139 (51.5%) patients. 50% (n = 134) of the patients received palliative intent treatment, 45% (n = 123) definitive treatment, whereas in 5% (n = 13) the intent was not mentioned. Age, a clinical stage and PS significantly influenced the decision making on the intent of treatment. 208 (77%) patients completed their treatment irrespective of the intent. Age was the only factor influencing treatment completion irrespective of the intent. CONCLUSION: Geriatric HNC patients frequently present with advanced disease, having multiple co‑morbidities. Hence, a multidisciplinary team management of these patients is essential, also taking into account of the social and financial support available to these patients.

Contribution of efflux pumps in fluroquinolone resistance in multi-drug resistant nosocomial isolates of Pseudomanas aeruginosa from a tertiary referral hospital in north east India.

Background: Pseudomonas aeruginosa is one of the leading opportunistic pathogen and its ability to acquire resistance against series of antimicrobial agents confi ne treatment option for nosocomial infections. Increasing resistance to fl uroquinolone (FQ) agents has further worsened the scenario. The major mechanism of resistance to FQs includes mutation in FQs target genes in bacteria (DNA gyrase and/or topoisomerases) and overexpression of antibiotic effl ux pumps. Objective: We have investigated the role of effl ux pump mediated FQ resistance in nosocomial isolates of P. aeruginosa from a tertiary referral hospital in north eastern part of India. Materials and Methods: A total of 234 non-duplicate, consecutive clinical isolates of P. aeruginosa were obtained from a tertiary referral hospital of north-east India. An effl ux pump inhibitor (EPI), carbonyl cyanide m-chlorophenylhydrazone (CCCP) based method was used for determination of effl ux pump activity and multiplex polymerase chain reaction (PCR) was performed for molecular characterisation of effl ux pump. Minimum inhibitory concentration (MIC) reduction assay was also performed for all the isolates. Results and Conclusion: A total number of 56 (23%) have shown effl ux mediated FQ resistance. MexAB-OprM effl ux system was predominant type. This is the fi rst report of effl ux pump mediated FQ resistance from this part of the world and the continued emergence of these mutants with such high MIC range from this part of the world demands serious awareness, diagnostic intervention, and proper therapeutic option.