Is Antimicrobial Resistance Pattern of Enteric Fever Changing in Kathmandu Valley.

Introduction: Enteric fever is a public health problem in developing countries including Nepal. Antimicrobial sensitivity pattern of Salmonella sp causing enteric fever is changing over time and also differs according to geographical location. Periodic surveillance of antimicrobial resistance of Salmonella sp is mandatory for management of enteric fever rationally. The objective of this study was to analyze the resistance pattern of Salmonella sp to commonly used antimicrobials. Materials and Methods: This was a retrospective study undertaken reviewing the records of blood isolates of Salmonella sp over one year period at Kanti Children’s Hospital, Nepal. Antimicrobial sensitivity testing was done following Kirby Bauer’s disk diffusion technique using Muller Hinton agar. Results: Salmonella typhi was found to be 100% resistance to ampicillin and resistance to nalidixic acid and ciprofloxacin was also high. The resistance to chloramphenicol and ofloxacin was low. No resistance was found to amoxicillin, ceftriaxone, cefotaxime and amikacin. However, among the sensitive isolates of Salmonella typhi intermediate sensitivity to ceftriaxone and ceftazidime was reported to be high. Among the isolates of S paratyphi A, the resistance to nalidixic acid was 100% followed by 75% to ciprofloxacin. No resistance was found to chloramphenicol, ceftriaxone, cefixime, amikacin and low resistance to amoxicillin and ofloxacin. Among the sensitive isolates of S paratyphi A, majority of them were only moderately sensitive to cefotaxime and ceftazidime and about 1/3 of the organisms had only intermediate sensitivity to ceftriaxone. Conclusiion: Commonly used parenteral third generation cephalosporins, first line drugs like chloramphenicol and amoxicillin and ofloxacin among fluoroquinolones were found to be effective in vitro in treating enteric fever. However, Salmonella typhi was found to be highly resistant to the most frequently used drugs like ciprofloxacin and cefixime and Salmonella paratyphi A to ciprofloxacin. A comparative chart of antimicrobial sensitivity of enteric fever in children over 10 year period from different hospitals of Kathmandu valley is also presented in the study.

Clinical Analysis, Management and Outcome of Intussusception in Children.

Introduction: Intussusception is the commonest cause of bowel obstruction in infancy and childhood. Early diagnosis and management is essential to reduce morbidity and mortality. The objective was to To review the diagnostic criteria of intussusception in infants and children to increase awareness of attending personnel for effective management decrease the rate of operative treatment and complications. Materials and Methods: The data collected of all 38 patients admitted in Kanti Childrens Hospital between 2008 September to 2009 September were studied prospectively. Each patient was evaluated in regard to age at presentation, sex, signs and symptoms, diagnostic method, treatment (operative, non-operative). Results: During study period of one year there were a total of 20 (52%) males and 18 (48%) females of age 3 months to 6 years. Pain abdomen was seen in 25(66%), vomiting 16(42%), diarrhea 15(40%), blood mixed with stool 10(26%). These symptoms were seen in different combination. X-ray erect abdomen was done in 15 and ultrasound in all 38 cases. Ten out of 15 (66.6%) patients with early presentation and diagnosis had successful barium enema reduction.10 (66.6%) had successful reduction and admitted to our hospital. 28(74%) patients were undergone laparatomy. Among 28 (74%) patents that had lapartotomy, manual reduction was successful in 18 and 10 required bowel resection and anastomosis. Conclusion: The awareness of early features of intussusception is important for early referral to tertiary centers for successful non-operative barium reduction and reduce the need of laparotomies in children.

Metachromatic Leucodystrophy: A Case Report.

Metachromatic leukodystrophy (MLD) is an autosomal recessive neurodegenerative disorder characterized by deficient activity of the enzyme arylsulfatase-A. Deficiency of this enzyme results in intralysosomal storage of sphingolipid cerebroside 3-sulfates (sulfatides), which are abundant in myelin and neurons. A pathological hallmark of MLD is demyelination and neurodegeneration, causing various and ultimately lethal neurological symptoms. Its frequency is estimated to be 1/40,000 live births. The disease encompasses three clinical subtypes: late infantile (40% of the patients with MLD), juvenile (40%), and adult (20%).

Bacteriological Profile of Neonatal Sepsis: A Hospital Based Study.

Introduction: Neonatal sepsis is a major cause of mortality and morbidity in newborn. There are many factors that contribute to neonatal sepsis. The organisms responsible for early onset and late onset sepsis are different. Objective: This study was conducted to analyze the organisms responsible for early onset and late onset neonatal sepsis. Materials and Methods: A prospective hospital based study over the period of one year was conducted at neonatal intermediate care unit of Kanti Children’s Hospital, Maharajgunj, Kathmandu, Nepal. Results: Organisms were isolated in 6.1% of the collected blood samples. The male female ratio of culture proven sepsis was 1.9:1. Escherichia coli were found to be the most common organism in both early onset and late onset sepsis. Staphylococcus aureus was more common in late onset sepsis than early onset sepsis. Conclusion: Escherichia coli were the most common organism in both early onset and late onset sepsis. Staphylococcal aureus was significantly more common in late onset sepsis than early onset sepsis.

Bacteriological Analysis and Antibiotic Sensitivity Pattern of Blood Culture Isolates in Kanti Children Hospital.

Introduction: As antibiotic sensitivity pattern to common pathogen has been changing day by day, so it has been necessary to study about bacteriological analysis and antibiotic sensitivity pattern. Therefore, the purpose of this study was to analyze on data on bacteremia in children, the pathogen involved and sensitivity pattern. Objectives: The aim of this study was to determine the bacteriological profile and antibiotic sensitivity pattern of blood culture isolates from Kanti Children Hospital. Method: All blood culture reports (n=9856) during one year period (April 2007 to March 2008) included in the study were analyzed and the sensitivity pattern were recorded. In this retrospective study, we reviewed records of patients from Kanti Children Hospital from April 2007 to March 2008. Results: The positivity of blood culture was 4.2% (414/9856). Out of them, 269 (65%) were positive for Staphylococcus aures, 121(29.3%) E coli, 13(3.1%) Klebsiella pneumonia, 6(1.4%) Streptococcus pneumonia and 5(1.2%) Streptococcus viridence. Staphylococcus aureus was found most sensitive to Chloramphenicol (88.8%) followed by Amikacin (87.5%), Ofloxacin (76.5%), Ciprofloxacin (72%) and least sensitive to Ampicillin, Cloxacillin and Penicillin. E.coli was found most sensitive to Amikacin (74.7%) followed by Ofloxacin (69.9%), Ciprofloxacin (56.4%) and least sensitive to Cephalexin, Gentamycin and Ampicillin. Klebsiella pneumoniae was found most sensitive to Amikacin (91.7%) followed by Ofloxacin (87.5%), Chloramphenical (81.8%) and least sensitive to Cotrimoxazole and Gentamycin. It is 100% resistance to Ampicillin and Erythromycin. Streptococcus pneumoniae was most sensitive to Penicillin, Chloramphenical (100%) followed by Ampicillin and Erythromycin (83.3%) and least sensitive to Cotrimoxazole. Streptococcus viridence was most sensitive to Chloramphenical (100%) followed by Erythromycin (80%), Penicillin (75%) and least sensitive to Cotrimoxazole. Conclusion: This highlights the variable nature of antibiotic susceptibility patterns both in time and location around different geographical locations and within the same country as well. Therefore, it is advisable to continuously evaluate the sensitivity-resistance pattern of isolates so as to make a rational use of antibiotics.

Wilm’s Tumor Ten Year Experience at Kanti Children’s Hospital.

Introduction: Wilm's tumor is the second most common abdominal tumor in children. It arises from the kidney. The survival of children with Wilm's tumor has improved over the past 25 years. Objectives: To study the clinical presentation of Wilm’s tumor and evaluate the ten year survival. Materials and Methods: A retrospective hospital based study was conducted at Kanti Children's Hospital from March 1998 to February 2008. A total of 60 histopathologically diagnosed children below 14 yr of age were included in the study. Results: About 2/3rd (66.5%) presented with abdominal swelling followed by abdominal pain (16.5%) and fever (13.5%). A few children manifested with red colored urine (3.5%). The age of children ranged from one month to 13 years with the mean age of 36 months. Males were affected more than the females (M:F=3:1). Most affected age group was 2 to 5 yrs (41.5%) followed by 1 to 2 yrs (25.0%). Most of the cases were in stage III (36.5%) followed by stage II (33.5%). SIOP protocol was used to treat these children and overall 10 year survival rate was 50.0%. One fifth (20%) of the cases died, 16.5% relapsed and 13.5% lost to follow up. Conclusion: Despite severe resource limitations, paediatric oncology unit at Kanti Children’s Hospital has been successfully treating Wilm's tumor with the success rate of 50.0%.

Causative agents of urinary tract infections in children and their antibiotic sensitivity pattern: a hospital based study.

A retrospective study was conducted to find out the causative agents of urinary tract infection (UTI) in children and their antibiotic sensitivity pattern among Nepalese children. This was done at Kanti Children's Hospital in Kathmandu (Nepal) by analyzing the records of urine samples collected for culture and sensitivity tests over a period of six months (April to November, 2007). Of the total 1878 mid-stream urine samples collected from suspected cases of UTI, 538 (28.6%) were positive for pathogenic organisms. There was no significant difference in growth positive rate in two genders (M: 51.7% and F: 48.3%). Of the various pathogenic organisms isolated, Escherichia coli constituted for 93.3% followed by Proteus sp, Klebsiella sp, Citrobacter sp, Staphylococcus aureus and others. E. coli was found to be most sensitive to amikacin, chloramphenicol, nitrofurantoin and ofloxacin and least sensitive to most commonly used drugs like cephalexin, nalidixic acid, cotrimoxazole and norfloxacin.

Lipid profile of adult Nepalese population.

Dyslipidemia is one of the major risk factors of coronary artery disease. Present study was aimed to find out the lipid profile of non-diabetic adult Nepalese population (n = 454; M: 180 and F: 274; Mean age: 42.8+/-15.5 years). The mean +/- SD (mg/dl) level of total cholesterol (TC), triglyceride (TG), low density lipoprotein (LDL) and high density lipoprotein (HDL) was 184+/-50.7, 147.4+/-79.9, 111.9+/-42.0 and 45.0+/-11.7, respectively. All lipid levels except LDL were higher among 41 to 60 years age group while LDL was higher among participants aged >60 years. Desirable TC level (<200 mg/dl) was found in 78.0% of the total population while the normal TG (<150 mg/dl) and LDL (<129 mg/dl) was found in 61.5% and 72.0%, respectively. High TC (> or =240 mg/dl) and very high TG (> or =500 mg/dl) and LDL (> or =190 mg/dl) were found in 8.8%, 2.6% and 5.8% of participants, respectively. Higher HDL level (40 mg/dl) was seen in 60.0% of the total population. Higher percentage of women than men (65.3% vs 52.2%) had >40 mg/dl HDL level. Nornal lipid profile (TC <200 mg/dl, TG <150 mg/dl, LDL <129 mg/dl, HDL >40 mg/dl) was seen in 26.7% of participants, and was higher in females (32.1%) than in males (18.3%). The overall mean cholesterol level was within normal limit. Mean LDL level showed increasing trend with age and about one fourth of participants had normal lipid profile.

Seasonal distribution of enteropathogens detected from diarrheal stool and water samples collected in Kathmandu, Nepal.

A total of 334 diarrheal fecal samples (from 210 males and 124 females) collected in Kathmandu, Nepal, were studied for various kinds of enteropathogens. Overall, 33% (111/334) fecal samples were positive for one or more enteropathogens. There was no difference in detection rates between males and females. Enteropathogen detection rates in summer, winter, spring, and autumn were 61% (40/66), 52% (45/87), 31% (25/81), and 25% (25/100), respectively. Altogether eight species of bacteria, three genera of viruses, and five species of protozoan parasites were detected with considerable seasonal variations. Among the bacterial isolates, enteropathogenic Escherichia coli topped the list followed by Vibrio sp. Only one sample had Shigella (S. sonnei). Rotavirus type A was the most frequently detected among the enteric viruses, followed by human enterovirus and human adenovirus, respectively. Among the enteric protozoan parasites, Giardia intestinalis was the most frequently detected followed by Cryptosporidium parvum. Detection of bacterial and protozoan pathogens showed a slightly high tendency in the summer season compared with that in the other seasons (p>0.05), whereas the detection of viruses was significantly high in the winter season (p<0.05). Of the total 57 water samples, 43 (75%) showed one or more bacterial species out of which 51% (22/43) were E. coli. Among the E. coli isolates, 68% were EPEC. Enterohemorrhagic E. coli (O157) was not detected.

Role of cytokines in experimental and clinical uveitis.

Uveitis is a major cause of visual impairment. Experimental autoimmune uveitis mimics the clinical conditions of posterior uveitis in many ways. T-cells (particularly CD4+ helper-T-cells) have been shown to play an important role in pathogenesis of experimental and clinical uveitis. Based on the pattern of cytokine they secrete, CD4+ helper cells have been divided into Th1 and Th2 subsets. Various Th1 and Th2 cytokines appear to be involved in the pathogenesis and/or recovery from uveitis. This article discusses in detail the uveitopathogenic and therapeutic potential of Th1 and Th2 cytokines in experimental and clinical uveitis.

Contamination of soil with helminth parasite eggs in Nepal.

Contamination of soil with helminth eggs in Kathmandu Valley (n=122) and outside of Valley (n=34) in Nepal was investigated with the use of centrifugal floatation technique using sucrose solution (sp gr 1.200). The overall soil contamination rate was 36.5% (57/156). The prevalence was uniform in Kathmandu Valley (36.9%) and outside of the valley (35.3%). A mean of six helminth eggs per sample were detected out of which more than half were embryonated (potentially infective). In Kathmandu Valley, soil contamination rate was higher (48.3%) during wet season compared with that observed in dry season (33.3%) but without significant difference (p>0.05). Multiple species of helminth eggs were detected in 22.8% of total positive samples (n=57). Altogether five species of nematoda (Ascaris lumbricoides, Toxocarta sp, Trichuris trichiura, Capillaria sp and Trichostrongylus sp) and two species of cestoda (Hymenolepis nana and H. diminuta) were recovered. A. lumbricoides was predominant in Kathmandu Valley while Trichostrongylus was the commonest one in outside of valley.

Modulation of antigenicity of mycelial antigens during developmental cycle of Karnal bunt (Tilletia indica) of wheat.

Indirect enzyme linked immunosorbent assays (ELISA) were developed using polyclonal antibodies against soluble cytoplasmic (SCA) and insoluble cell wall antigens (ICWA) for monitoring modulation of mycelial antigens during growth cycle of T. indica. With SCA, continuous decrease in ELISA reactivity was observed in maturing fungus cultures, suggesting that SCA were expressed predominantly during early vegetative phase and their decreasing role was apparent as the fungus matures possibly towards sporogenous mycelium. In case of ICWA, the reaction profile showed an increase up to exponential phase of growth probably due to increase in the cell division and branching of mycelium. But later, ICWA antibody reactivity was decreased which may be due to conversion of mycelial phase to sporogenous phase, a quiescent stage of growth. Characterization of changes in antigenic configuration during developmental cycle of Tilletia indica by these antibodies could prove to be useful in identification of developmentally related and virulence marker(s).

Toxoplasma antibody prevalence in Nepalese pregnant women and women with bad obstetric history.

Sera from randomly selected 345 pregnant Nepalese women aged 16-36 years and 13 women with bad obstetric history (BOH) were tested for the presence of Toxoplasma antibodies using microlatex agglutination (MLA) and ELISA methods. The overall prevalence was 55.4% (191/345). Prevalence was slightly higher (59.0%) in older age-group (27-36 years) compared with younger age-group (16-26 years) (52.2%). No significant difference in antibody prevalence in women belonging to two different ethnic-groups (Tibeto-Burmans 57.8%, Indo-Aryans 52.7%) was observed (p>0.05). MLA antibody titer ranged from 1:16 to 1:2,048. Over three-fourth of the women showed either high (1:510 or over) or low (1:16 or 1:32) antibody titer. Three percent (6/191) of MLA antibody positive subjects had Toxoplasma IgM antibodies by IgM-ELISA. All six IgM antibody positive pregnant women had MLA antibody titer of over 1:510. Of the total 13 women with BOH, 5 (38.5%) had Toxoplasma antibodies of which 2 (40.0%) were positive for Toxoplasma-IgM antibodies.

Continuous hyperfractionated accelerated radiotherapy in advanced head and neck malignancies.

58 patients of advanced head and neck cancer were treated by continuous hyperfractionated accelerated radiotherapy (study group) or conventional radiotherapy (control group). The study group of 29 patients had 26/29 (89%) of patients of stage T3 and T4 with 12/29 (41% 0) > N2 disease. The schedule employed was 1.5 Gy 3 times a day in 36 fractions on 12 treatment days without stopping for weekends. The spinal dose has been kept at 40.5 Gy and interfraction interval has been strictly kept at 6 hrs. Clinical, as well as radiological assessment has been encouraging with 23/29 (79.13%) of patients achieving complete regression of the primary tumor and nodal disease. Compared to the conventionally treated controls this value has been significant (P value < 0.001). In stage III disease tumor control has been in 9/10 (90%) cases, while in stage IV disease in 14/19 (73.68%) cases. The acute mucosal reactions have been found to be severe in these cases with 18/29 i.e. 62.06% suffering from grade III reactions. Nasogastric feeding was required in 25.92% of patients.

Effectiveness of beta-exotoxin of Bacillus thuringiensis var. thuringiensis on the ability of Meloidogyne sp. from brinjal (Solanum melongena L.) to survive.

Beta-exotoxin produced by Bacillus thuringiensis var. thuringiensis grown in the acid hydrolysates of wheat and rice brans caused 95% and 85% mortality respectively of Meloidogyne sp. as against 72% of ß-exotoxin produced on farm yard manure within 7 days. Acid hydrolysate of wheat or rice bran and solid farm yard manure proved to be the best media for growth of B. thuringiensis var. thuringiensis.