Nosocomial infections: Epidemiology, prevention, control and surveillance

Nosocomial infections or healthcare associated infections occur in patients under medical care.These infections occur worldwide both in developed and developing countries.Nosocomial infections accounts for 7％ in developed and 10％ in developing countries,As these infections occur during hospital stay,they cause prolonged stay,disability,and economic burden.Frequently prevalent infections include central line-associated bloodstream infections,catheter-associated urinary tract infections,surgical site infections and ventilator-associated pneumonia.Nosocomial pathogens include bacteria,viruses and fungal parasites.According to WHO estimates,approximately 15％ of all hospitalized patients suffer from these infections.During hospitalization,patient is exposed to pathogens through different sources environment,healthcare staff,and other infected patients.Transmission of these infections should be restricted for prevention.Hospital waste serves as potential source of pathogens and about 20％-25％ of hospital waste is termed as hazardous.Nosocomial infections can be controlled by practicing infection control programs,keep check on antimicrobial use and its resistance,adopting antibiotic control policy.Efficient surveillance system can play its part at national and international level.Efforts are required by all stakeholders to prevent and control nosocomial infections.

Diagnostic yield of bronchoalveolar lavage gene xpert in smear-negative and sputum-scarce pulmonary tuberculosis

To measure the diagnostic yield of Bronchoalveolar Lavage [BAL] gene Xpert [Xpert MTB/RIF assay], to detect Mycobacterium tuberculosis [MTB] and rifampicin resistance and compare it with that of mycobacterial cultures in a suspected case of pulmonary tuberculosis. An analytical study. Department of Pulmonology, Fauji Foundation Hospital [FFH], Rawalpindi, from December 2012 to August 2013. BAL specimens of 93 patients with suspected pulmonary tuberculosis with smear-negative or sputumscarce disease, who presented to the Department of Pulmonology, FFH, Rawalpindi were inducted. A smear-negative case was one in whom three consecutive early morning sputum samples did not reveal acid fast bacilli when examined by microscopy with Zeihl Nelson [ZN] stain. Patients who had sputum amount less than 1 ml were defined to have sputumscarce disease. The same was evaluated with ZN stain, gene Xpert and mycobacterial cultures. Sensitivity analysis was carried out using culture as the gold standard. The frequency of positive mycobacterial cultures was 85 [91.4%]. The sensitivity, specificity, positive predictive value and negative predictive values of BAL gene Xpert to detect Mycobacterium tuberculosis were 91.86%, 71.42%, 97.53% and 41.66% respectively. Xpert MTB/RIF assay had a sensitivity and specificity of 83.33% and 100% to detect rifampicin resistance. Bronchoalveolar lavage gene Xpert had a superior diagnostic yield in patients with either smear-negative or sputum-scarce pulmonary tuberculosis. Hence a positive Xpert MTB/RIF assay may be a useful adjunct to diagnosis and detection of MDR-TB in bronchoalveolar lavage specimens

Therapeutic bronchoalveolar lavage with conventional treatment in allergic bronchopulmonary aspergillosis

To establish the role of therapeutic bronchoalveolar lavage in addition to conventional treatment among two groups, with allergic bronchopulmonary aspergillosis, in terms of regression in serum IgE levels and clinical recurrence at 3 and 6 months of follow-up. A quasi-experimental study. Department of Pulmonology, Fauji Foundation Hospital, Rawalpindi, from July 2010 to December 2013. The study was carried out on 132 patients who fulfilled the Greenberger and Patterson criteria and underwent a chest X-ray, an HRCT chest and classified radiologically as with Central Bronchiectasis [CB], High Attenuation Mucus [HAM] or Other Radiological Features [ORF]. Baseline serum IgE levels were noted. All patients were given treatment including prednisolone and antifungal agent itraconazole for 4 months. Patients with ORF on HRCTchest and just received the medical treatment were labeled as conventional group. Those patients who had CB or HAM radiological features also underwent bronchoscopy with therapeutic Bronchoalveolar Lavage [BAL], labeled as BAL group. Clinical recurrence and serum IgE levels were noted at 3 and 6 months. Values were compared using chi-square and Mann-Whitney tests respectively. Around 78 [59.1%] of patients underwent bronchoscopy with therapeutic bronchoalveolar lavage to remove the mucus plugs. The mean serum IgE levels at baseline were 3312.04 +/- 2526.217 and 3486.15 +/- 2528.324 IU/ml in the BAL and conventional groups respectively. There was a statistically significant reduction in the mean serum IgE levels at 3 [p < 0.00] and 6 months [p < 0.001] of follow-up in BAL as compared to conventional group. There was no significant difference in the clinical recurrence rate in both the groups [p=0.078 at 3 and 0.343 at 6 months respectively]. Therapeutic bronchoalveolar lavage may be a useful adjunct to treatment in patients with allergic bronchopulmonary aspergillosis, serum in terms of IgE level reduction

Comparison of sensitivity of quantiFERON-TB gold test and tuberculin skin test in active pulmonary tuberculosis

To compare the sensitivity of tuberculin skin test [TST] and quantiFERON-TB gold test [QFT-G] in active pulmonary tuberculosis. Analytical study. Department of Pulmonology, Fauji Foundation Hospital, Rawalpindi, from July 2011 to January 2012. QuantiFERON-TB gold test [QFT-G] was evaluated and compared it with tuberculin skin test [TST] in 50 cases of active pulmonary tuberculosis, in whom tuberculous infection was suspected on clinical, radiological and microbiological grounds. Sensitivity was determined against postive growth for Mycobacterium tuberculosis. Out of 50 cases, 43 were females and 7 were males. The mean age was 41.84 +/- 19.03 years. Sensitivity of QFT-G was 80% while that of TST was 28%. QFT-G has much higher sensitivity than TST for active pulmonary tuberculosis. It is unaffected by prior BCG administration and prior exposure to atypical mycobacteria. A positive QFT-G result can be an adjunct to diagnosis in patients having clinical and radiological data compatible with pulmonary tuberculosis

Enteric fever in Karachi: current antibiotic susceptibility of salmonellae isolates

To determine the current sensitivity and resistance profile of Salmonellae [S.] isolates in a laboratory setting. An observational study. Dr. Essa's Laboratory and Diagnostic Centre, Karachi, Pakistan, from November 2008 - October 2010. Isolates from blood culture specimens of 481 bacteraemic patients were identified using conventional biochemical tests. Salmonellae was confirmed with specific antisera and their antibiograms determined by Kirby-Bauer Disc Diffusion method using 12 relevant antibiotics. Inclusions of the study were bacteraemia documented in all blood samples positive for S. typhi, S. paratyphi-A and B. Exclusions were all samples other than blood and blood samples negative for S. typhi and S. paratyphi-A and B during the same period. Multidrug resistance [MDR] of isolates was defined as the isolates showing resistance to all conventional anti-typhoid medicines i.e., Chloramphenicol, Ampicillin and Co-trimoxazole. Specimens [n=217] yielded 131 Salmonellae typhi [60.36%], 71 S. paratyphi-A [32.71%], and 15 S. paratyphi-B [6.9%]; these were sensitive to the Quinolones [Enoxacin: 94.96% [n=91], Ciprofloxacin, 96.47% [n=182], Ofloxacin: 95.74% [n=203]], and Cephalosporins [Cefixime: 96.62% [n=202], Cefotaxime: 99.17% [n=206], Ceftriaxone: 98.79% [n=208]]. Resistance to Amoxicillin was 96.48% [n=128] and 29.91% [n=78] to Co-trimoxazole. About 62.64% [n=136] of the isolates were MDR strains. Ciprofloxacin is currently a suitable empirical choice in presumed enteric fever cases, but culture and sensitivity analysis should be encouraged and results incorporated in prescription strategy. Increasing frequency of S. paratyphi-A isolates possibly suggests incomplete coverage employing monovalent vaccine

Current Bacteriological profile in Fire-burn victims and their associated mortality at the Burns Centre, Karachi Pakistan

This study attempts to document the current bacteriological profile from pertinent specimens of fire burn victims in our setting with respect to the time related variations in the isolation of microbial species, extent of their burn injury and their effect on mortality rate. During a three year period [Jan 2008 to Dec 2010], a prospective study was conducted on 477 fire burn victims at the Burns Centre of Civil Hospital, Karachi, with the exclusions of electrical, chemical and other forms of burn injury. Blood, pus, urine and wound biopsy samples were collected and cultured according to standard laboratory protocols. The data was analyzed according to the age, gender, time related changes, percentage of burn surface and the mortality rate. Total 477 patients were included in our study. Multiple specimens were collected [n=732] of which 649 [88.7%] cultures were positive for different organisms. Staphylococcus aureus was the commonest organism isolated in fire burn patients. During 1[st] week S. aureus was predominant [31.6%] followed by Pseudomonas. After 1[st] week S. aureus [24.6%] and Pseudomonas [25.5%] isolation rate became similar. Mortality rate due to infections was 18.9% in the subjects. S.aureus was the commonest cause of infection in fire burn patients in our setting followed by Pseudomonas. These suggests that hygiene should strictly be maintained around burn patients to avoid opportunistic infections

Pulmonary embolism in soldiers serving at high altitude

To determine the frequency of different risk factors for pulmonary embolism with particular reference to high altitude as one of the factors. Cross sectional, analytical study. Department of Pulmonology, Military Hospital Rawalpindi, from December 2006 to December 2007. A total of 50 serving soldiers suspected of pulmonary embolism were enrolled. A detailed history and physical examination was carried out to ascertain the risk factors of the disease. Screening profile was performed for connective tissue and infectious diseases, thrombophilic disorders and plasma homocystein levels. If soldiers were evacuated from high altitude, their approximate height from sea level was noted. Pulmonary embolism was confirmed on spiral CT scan of chest and/or ventilation-perfusion lung scan. Results were analyzed by SPSS version 11. About 86% of patients were between 20-40 years of age. Dyspnea was the commonest symptom [40%] while tachypnea was the commonest clinical finding in these soldiers. D-dimer value was<250 in only 10% of patients. Pleural effusion was the commonest radiological abnormality[40%] while non-specific T-wave inversions were noted as the most frequent ECG change[44%]. Ventilation-perfusion [V/Q] scan was confirmatory in 80% of patients and spiral CT chest in 56%. When the frequency of risk factors of pulmonary embolism were analyzed, 50% of patients had high altitude as the only risk factor. Hereditary thrombophilic disorder was found in 14%, connective tissue disorder/infections in 20% and miscellaneous others in 16%. Pulmonary embolism occurs at an increased frequency in soldiers working at high altitude, without any other co-existent risk factor

Post-tuberculous chronic obstructive pulmonary disease

To determine the frequency of chronic obstructive pulmonary disease [COPD] as a sequel of treated pulmonary tuberculosis. A case series. Department of Pulmonology, Military Hospital, Rawalpindi, from April to November 2007. Forty seven adults, previously treated for pulmonary tuberculosis and presenting subsequently with chronic exertional dyspnoea for which no other alternate cause was found were included. Those having a probability of re-activated TB, having history of current or previous smoking or occupational exposure, asthmatics and cases of interstitial lung disease and ischemic heart disease were excluded. Pre- and post-dilator FVC, FEV1 and FEV1/FVC were recorded in each case through simple spirometry on Spirolab-II - MIR S/N 507213. Stage and pattern of COPD was recorded. There were 76.5% [n=36] males. Mean age was 56.4 and 44.2 years in males and females respectively. Twenty six [55.3%] were found to have an obstructive ventilatory defect of different degrees: severe/stage III in 69.2% [n=18], moderate/stage II in 23.0% [n=6] and mild/stage I in 5.9% [n=2]. Fourteen [29.7%] were found to have a restrictive pattern and 7 [14.8%] revealed a mixed obstructive and restrictive pattern. Chronic obstructive pulmonary disease can occur as one of the chronic complications of pulmonary tuberculosis and the obstructive ventilatory defect appears more common among various pulmonary function derangements

Diffuse consolidation form of bronchoalveolar carcinoma

This case report describes a patient with diffuse consolidation form of bronchoalveolar carcinoma [BAC] which is a rare type of adenocarcinoma of lung. He was diagnosed on the basis of findings on X-ray and high resolution CT [HRCT] chest later confirmed by open lung biopsy and immuno-histochemical staining. Only supportive treatment could be provided and the patient expired during the subsequent month of follow-up. Traditionally, diffuse consolidation is the radiological presentation in only 20% of patients with bronchoalveolar carcinoma

Diagnostic yield of transbronchial needle aspiration analysis of 30 cases

In our clinical set up transbonchial needle aspiration of lymph node and parenchymal lesions is an underutilized technique. This study was done to highlight the usefulness of this technique in the pulmonologists armamentarium. Thirty procedures were performed on patients with intrathoracic lymphadenopathy or parenchymal lung lesions in this study from October, 2006 to April, 2007. Patients with an easily accessible peripheral lymph node, bleeding diathesis and an already confirmed diagnosis were excluded from the study as were patients with a well visualized biopsiable endobronchial lesion. Nineteen patients [63.3%] on whom transbonchial needle aspirations were performed had intrathoracic lymphadenopathy while 11 [36.6%] had parenchymal lesions without endobronchial lesions which could be biopsied. Adequate samples were obtained in 23 patients [76.6%] chronic granulomatous inflammations which was diagnosed as tuberculosis in corroboration with other clinical and laboratory evidence was seen in 3 cases [10%]. Carcinoma was diagnosed in 6 cases [20%]. Thirteen cases [43%] were reported as normal and inadequate samples were obtained in 7 cases [23%]. Transbronchial Needle Aspiration [TBNA] is an effective method of obtaining cytological material from intrathoracic lymph nodes and parenchymal lesions and can provide a safe alternative to invasive mediastinotomy/mediastinoscopy and open lung biopsya

Swyer-james-macleod syndrome

This case report describes a patient with Swyer-James-MacLeod Syndrome [SJMS] in an adult male diagnosed on the basis of findings on X-ray chest, high resolution CT [HRCT] of chest and radionuclide perfusion lung scan. This rare syndrome is considered to be an acquired disease due to repeated pneumonias in early childhood

Case report of halofantrine induced QT interval prolongation with subsequent ventricular arrhythmias

A 45 years old lady, presented in emergency department of NICVD with 2 days history of high grade fever with rigors followed by severe vertigo. There was no previous history of any cardiac ailment nor she was hospitalized for any major illness. No family history of cardiac disease. No past history of palpitations or vertigo. She was prescribed antimalarial "halofantrine" in a dose of 500 mg 6 hourly [3 doses], a day prior to admission in NICVD. On examination, middle-aged lady appeared anxious and tachypnic. Apart from irregularly irregular pulse and relative hypotention rest of the examination was unremarkable. ECG:Initial ECG showed prolongation of QT interval, i.e., 0.48 seconds. QTc, 0.6 seconds. She developed unstable Torsade De pointes and then subsequent ECGs showed recurrent intermittent ventricular tachycardia. Management : Patient was cardioverted initially at 200 Joules, followed by i/v bolus of lignocaine; as she failed to respond, i/v magnesium sulphate was tried, as intermittent VT continued, temporary pacemaker was implanted and overdrive pacing successfully maintained normal sinus rhythm. Patient`s intrinsic heart rate was 80b/m, QT 0.48 sec. QTc, 0.6 see, while overdrive pacing was done at 120b/m, with QT 0.36 see, QTc 0.46 sec Investigations: All routine hemotological and biochemical investigations were found normal including [CBC, ESR, RBS, Urea. Creatinene, Electrolytes, Cholesterol, UrineD/R, LFTs], Chest XRay and echocardiagraphy reports were also normal. Course in the Hospital:Subsequently, temporary Pacemaker was switched off after few days. Serial ECGs showed normalization of QT interval. Last ECG showed QT of 0.4 seconds, QTc, 0.5 seconds. She was discharged after a week without any medication

Gastro intestinal stromal tumor of stomach a case report

Gastro intestinal stromal tumors [GISTs] are a subset ofGI mesenchymal tumors of varying differentiation. With the advent of immune histochemical staining techniques now available in Pakistan, they are recognized as a distinct group of mesenchymal tumors. This case demonstrates that rare stromal neoplasms have to be taken into account in the differential diagnosis of gastrointestinal tumors even ifendoscopic biopsies are negative for neoplastic changes. Because of the uncertain biological behavior of the GISTs an early surgical intervention is recommended