Resistance patterns among multidrug-resistant tuberculosis patients: a multi-center study from Pakistan

Background: the high burden of multi-drug resistance tuberculosis [MDR TB] is a matter of great concern. The increasing resistance to anti tuberculosis drugs has been the area of growing concern and are posing threats to TB control. The aim of this study was to evaluate the drug resistance patterns for the first line and second line anti-Tuberculosis drugs in multiple drug resistant tuberculosis [MDR-TB] patients

Method: the study was retrospective, observational, employing purposive, non-random sampling technique for data collection conducted at the TB Clinic- of the different healthcare centers in the provinces of Pakistan Sindh and Baluchistan from December 2010 to May 2016. All bacteriologically confirmed TB patients who were found to be Rifampin Resistant [RR] on Genotypic drug susceptibility testing [GXP], or detected to be drug resistant on phenotypic Universal drug susceptibility testing were enrolled into the study

Results: out of total 3776 patients, 96.3% were resistant to Rifampicin and 94.7% were resistant to Isoniazid. 25.5% isolates were resistant to all five first line drugs. Resistances against Pyrazinamide and Ethambutol was 54.2% and 51.6% respectively. 36.3% patients were resistant to Fluoroquinolones [FQ], 9.7% were resistant to Ethionamide [Eto] and 4.1% were resistant to both FQ and Eto. 33.5% patients were MDR plus resistant to FQ. However, the resistance to both FQ plus Aminogycosides was quite low, 2.7%

Conclusion: the drug resistance rates are quiet high in MDR-TB for both first line and second line drugs. The standardized MDR TB regimen needs to be updated, based on the prevalence of drug resistance patterns in the community for the effective management of drug resistant TB

Developing local guidelines for management of sepsis in adults: sepsis guidelines for Pakistan [SGp] endorsed by global sepsis alliance

The purpose of developing [Sepsis Guidelines for Pakistan] [SGP] is to provide clinicians practicing in local hospitals with a framework to aid timely recognition and management of adult patients in sepsis by adopting evidence-based recommendations of Surviving Sepsis Campaign [SSC] tailored to available resources. These recommendations are not meant to replace the SSC Guidelines. SGP is an initiative of Pakistan Society of Critical Care Medicine [PSCCM]. Four key decision points to be addressed in the guidelines were identified by a thirteen member multidisciplinary committeei.e., grading the hospitals in the country, recognition of sepsis and associated organ dysfunction, essential interventions to manage sepsis, and general measures for provision of a comprehensive care to patients in sepsis according to the level of education and training of healthcare providers and facilities and resources available in different levels of hospitals. The draft was presented at the 3[rd] Sepsis Symposium held on13[th] September, 2014 in Karachi. The final document was approved by a panel of experts from across the country, representatives of relevant societies and Global Sepsis Alliance [GSA]. Hospitals are divided into basic, intermediate and tertiary depending on the availability of diagnostic facilities and training of the medical personnel. Modified definitions of sepsis,severe sepsis, and septic shock are used given the lack of facilities to diagnose sepsis according to international definitions and criteria in Pakistan. Essential interventions include fluid resuscitation,vasopressors to support the circulation, maintaining oxygen saturation >/= 90% with oxygen, non-invasive ventilation or mechanical ventilation with lung protective strategies, prompt administration of antibiotics as recommended by the Medical Microbiology and Infectious Diseases Society of Pakistan [MMIDSP] and early source control. It is recommended to avoid starvation, keep an upper blood glucose 7.20, avoid fresh frozen plasma in the absence of bleeding, transfuse platelets if indicated, not use intravenous immunoglobulins and avoid neuromuscular blocking agents [NMBAs] in the absence of ARDS, target specific titration endpoints when continuous or intermittent sedation is required in mechanically ventilated patients and use continuous renal replacement therapy [CRRT] to facilitate management of fluid balance in hemodynamically unstable septic patients in tertiary care centers. In addition a comprehensive, meticulous and multidisciplinary general care is required to improve outcome of sepsis by reinforcing hand hygiene and other infection control measures, adequate monitoring and documentation tailored to the available resources. Goals of care and prognosis should be discussed with patients and families early and either shifting the patient to a hospital with better facilities or limiting or withdrawing therapy in case of poor prognosis should be considered

BCG vaccination is associated with decreased severity of tuberculosis in Pakistan

Vaccination with Bacille Calmette-Guerin [BCG] is given at birth to protect against tuberculosis [TB] in Pakistan. The country ranks 6th amongst high-burden countries worldwide and has an incidence of 231/100,000 population. This was a cross-sectional multi-center hospital-based study. TB patients [n = 218] with pulmonary [PTB, n = 120] or extrapulmonary [ETB, 98] were recruited, and the presence of a BCG vaccination scar was documented. Cases were further classified into minimal, moderate and advanced PTB or less severe [LETB] or severe disseminated [D-ETB] disease. The association of age, gender and severity of TB infections with BCG vaccination of the individual TB cases was investigated. No difference was found of the BCG vaccination status of PTB and ETB cases, or in relation to age or gender. Patients under 29 years of age comprised the largest group. There were more females with ETB than PTB. The largest group within ETB comprised those with tuberculous lymphadenitis [LNTB, 39%]. A significantly greater number of LNTB cases had received BCG vaccinations than had those with pleural [unilateral] TB [p = 0.004], and tuberculous meningitis [p = 0.027] groups. Also, there were more immunized patients with pulmonary as compared with pleural disease [p = 0.001]. LNTB represents localized granulomatous disease and the observation of higher vaccination rates in this group suggests that BCG has protected against more severe forms of TB in this high-burden region.

Awareness about rabies post exposure prophylaxis in Pakistan among patients and health care workers: results from an Asian rabies expert bureau study

To identify the gaps in information on rabies and post exposure prophylaxis [PEP] in relation to categorization of wound severity, wound washing and appropriate use of vaccine and rabies immunoglobulin after exposure, and define actions that should be taken at dog bite management centres for prevention of rabies occurring after animal bites. Cross-sectional survey. A multicentre study across Pakistan conducted from 1st July 2007 to 31st January 2008. A pre-tested questionnaire was distributed to the respective medical officers in 6 dog bite management centres across Pakistan from 1st July 2007 to 31st January 2008. Information was obtained about demographics of dog bite victims, the timing and type of PEP administered and their responses to the injury. Out of 519 completed questionnaires the mean age of dog bite victims was 24 years. Over one-third were less than 18 years of age; male/female ratio was 4.9:1; 43% lived in rural Pakistan; 67.8% were classified as lower socioeconomic class; 98% animal bites were from dogs, of which 92.5% were first time bites. 45.5% wounds were classified as Category I [no risk], 42.7%, Category II [moderate risk] and 11.9% Category III [severe risk]. Tissue culture vaccine [TCV] was used 54% by intramuscular route and 45% by intradermal route. Only 118 [22.9%] patients received rabies immunoglobulin [RIG]. Critical analysis of the results reveals serious gaps in understanding of wound severity classification and correct application of PEP with vaccine and RIG. There is a dire need for improved awareness and understanding of dog bite management among health care givers in order to prevent rabies deaths

Dengue fever outbreak in Karachi, 2005-A clinical experience

Dengue Fever is the most common arboviral disease in the world, and presents cyclically in tropical and subtropical regions of the world. In Pakistan there has been at least one confirmed outbreak in 1994. This is a series of 72 cases seen between September and December 2005 that were diagnosed as dengue fever, the case definition being acute fever with thrombocytopenia, leukopenia and high ALT, and with or without overt bleeding. There was no other explanation for the clinical and lab. investigations. Young adults were affected, males more often than females. Clinical presentation was fever, vomiting, abdominal pain, myalgia and minor to severe bleeding from the nose, gums, gastro intestinal tract or into the skin. Low platelets and TLC, and raised ALT were the salient laboratory features. Management consisted of judicious fluid replacement and fever reduction. Most patients recovered completely, except one young patient who presented with hypovolemic shock, and died of hemorrhage. Dengue viral infection must be regarded as a public health problem, and serious efforts undertaken for public awareness, surveillance and vector control

Spectrum of opportunistic infections in patients with HIV/AIDS: experience of two Teaching Hospitals in Karachi, Pakistan

Human immunodeficiency virus [HIV] infection and acquired immunodeficiency syndrome [AIDS] is being increasingly reported from various regions in Pakistan. With the unavailability and financial restriction of antiretroviral therapy, most patients will develop opportunistic infections in the course of their disease. Knowledge and recognition of these opportunistic infections has both individual and public health consequences. A retrospective descriptive study was conducted on all HIV positive patients presenting to Liaquat National Hospital and one outpatient clinic at Aga Khan University Hospital, Karachi from November 1991 to July 2003. Demographic data and risk factors were recorded and detailed information was collected regarding the presence and characteristics of opportunistic infections in this population. A total of 85 patients were included in the study, of which 61 [71.8%] were male and 24 [28.2%] were female. Majority of the patients [50, 58.8%] were in the 31-45 year age group. At the time of presentation 65 [76.5%] of the patients were symptomatic. The gastrointestinal tract was the most commonly affected system [n = 69, 81%]. This was followed by pulmonary [n = 26, 40%], central nervous system [n = 13, 20%], and skin infections [n = 11, 15.3%]. Overall, oral candidiasis was the most common opportunistic infection diagnosed. This study shows that a wide spectrum of opportunistic infections occur in our population of patients with HIV/AIDS. A higher index of suspicion and improved availability of diagnostic tests are required to identify these infections. In addition, better access to antiretroviral therapy is needed to reduce the morbidity and mortality associated with this disease

Clinical experience with patients of HIV/AIDS in two hospitals in Karachi

The clinical course of 67 patients with HIV/AIDS is analysed The number of cases between 2001-2002 almost doubled compared with the number between 1991-2000 Previous reports from Pakistan described cases in heterosexual men who had either lived or traveled to countries with high HIV prevalence and exposed to commercial sex workers Our report shows a rise in the number of cases acquired within Pakistan which includes wives and neonates Highly active retroviral therapy is available but at a prohibitive cost and hence most patients are deprived of its benefits The majority of patients are treated symptomatically for opportunistic infections Most cases are diagnosed late because of ignorance on the part of patients and physicians There is a great need for early diagnosis in order to improve quality of the and limit its spread Public awareness and physician training in the subject must be stressed