Infection control practices in blood banks of Pakistan

Background: Implementation of infection control standards in blood banks is important to prevent transmission of blood-borne infections such as HIV, hepatitis B and Hepatitis C. No study from Pakistan evaluated the infection control practices in the blood banks of Pakistan.

Aims: This study aimed to evaluate infection control practices with reference to safe blood supply, staff safety and waste disposal practices in blood banks of Karachi, Pakistan.

Methods: This was a cross-sectional study. Infection control practices of all blood banks working in Karachi were determined through a structured questionnaire followed by an educational intervention. Mean scores for overall infection control practices and specific practices regarding safe blood supply, staff safety and waste disposal were calculated and compared with different factors using statistical tools.

Results: Patient safety scores of 49 (92.5%) blood banks were within the satisfactory range but staff safety and waste disposal scores of only 26 (49.1%) and 4 (7.5%) blood banks were satisfactory. Significantly lower infection control (IC) scores were observed for stand-alone blood banks and those working in the absence of a haematologist (P-value < 0.001). Availability of written standard operating procedures (SOPs) and IC guidelines correlated positively (P-value < 0.001) with mean IC scores.

Conclusions: Blood banks in Karachi lack implementation of IC standards particularly with reference to staff safety and waste management and disposal. Sindh blood transfusion authority (SBTA) should take measures to increase IC compliance within blood banks

Pattern of cesarean delivery in Bolan medical complex hospital Quetta

Objective: To analyze contemporary practices of cesarean section [CS] at a public sector hospital

Study design: A retrospective study

Place and Duration of study: A Department of Obstetrics and Gynecology Unit-4, Bolan Medical Complex Hospital Quetta, from January 2011 to December 2015

Methodology: In this study clinical records of all the patients who underwent cesarean section were reviewed. This included booked, un-booked or referred cases. Data regarding the indications, type of cesarean deliveries and demographic features as well as outcome were noted

Results: Out of 27791 total births, 2951 were cesarean deliveries, giving a cesarean section rate of 10.6%. The highest number of CSs were performed in multigravidas [54%] followed by primigravida [28.5%] and grand multigravida [17.5%]. The commonest indication for CS was previous cesarean section [50.1%] in which previous one LSCS was 29.9% and previous two or more LSCS were 20.2%. Other common indications were obstructed labor [12.1%], cephalo-pelvic disproportion [CPD - 6.1%], placenta previa [5%], labor dystocia [4.7%] and breech presentation [4.7%]

Conclusions: Previous ceserean section was the commonest indication for CS. Multigravida ranked highest among women who underwent CS. The ceserean section rate in this study was 10.6 indicating better obstetric care

Synergistic effect of antibiotics against bacterial pathogens causing diarrhea isolated from children <5 years of age

Background: Infant mortality rate due to diarrhea is high in Pakistan. The alarming increase in antimicrobial resistance of bacterial pathogens causing diarrhea has made the treatment more complicated. This study was designed to determine the in vitro synergistic [combined] effect of different antibiotics against these pathogens in order to determine whether the combined antibiotic therapy may be used to treat diarrhea

Objectives: To study the antibiotic resistance pattern of bacterial pathogens causing diarrhea isolated from children <5 years. To study the synergistic effect of antibiotics against bacterial pathogens causing diarrhea. Study design, settings and duration: A cross sectional study conducted at Pakistan Health Research Council [PHRC], Jinnah Postgraduate Medical Center and National Institute of Child Health, Karachi over a period of twenty months

Materials and Methods: Bacterial pathogens including Salmonella, Shigella, Vibrio, Escherichia coli and Aeromonas causing diarrhea were collected. Their sensitivity and resistance pattern was performed by disk diffusion method and combined the effect of existing antibiotics including ampicillin [AMP], cefotaxime [CTX], Cefixime [CFM], Co-trimoxazole [SXT] and Ofloxacin [OFX] was performed by checkerboard method. The study was approved by Ethical Review Board of National Institute of Child Health, Karachi

Results: Most of the combinations showed indifferent and antagonistic activity against bacterial pathogens causing diarrhea. But only AMP-SXT and CFM-OFX yielded synergistic activity against Vibrio and Aeromonas respectively. AMP-CFM and AMP-OFX exhibit synergistic effect against Escherichia coli while no combination of antibiotics proved as synergistic for Salmonella and Shigella

Conclusion: Little synergistic activity of different antibiotic combinations was observed against diarrheal isolates and most of the combinations exhibited indifferent and antagonistic activity. Hence this can be concluded that single antibiotics are effective than combination

Clinical, laboratory and bacterial profile of spontaneous bacterial peritonitis in chronic liver disease patients

To determine the clinical and laboratory features, bacterial profile and antibiotic sensitivity pattern of Spontaneous Bacterial Peritonitis [SBP] in Chronic Liver Disease [CLD] patients presenting at a tertiary care hospital of Karachi. Cross-sectional study. PMRC Centre for Gastroenterology and Hepatology and Jinnah Postgraduate Medical Centre, Karachi, from April 2010 to March 2012. CLD patients with ascites were recruited from PMRC Centre for Gastroenterology and Hepatology and Jinnah Postgraduate Medical Centre, Karachi. Basic demographics, symptoms and clinical signs of patients were recorded. Patients with the history of antibiotic use within last 3 days or any intra-abdominal source of infection were excluded. Diagnostic paracentesis was done for ascitic fluid detailed report [D/R] and culture. Blood sample was collected for total leukocyte count, serum proteins and billirubin levels. Out of a total 152 CLD patients, 38 [25%] were diagnosed with SBP. Eight [24.2%] patients presented with classical SBP, 20 [52.6%] had culture negative neutrocytic ascites and 10 [26%] had bacterascites. Fever, abdominal tenderness and constipation were common in SBP patients. Ascitic fluid culture was positive in 19 [50%] patients. E. coli [65%] was the predominant pathogen followed by Enterococcus species [15%]. Resistance was high against cephalosporins [78%] and fluoroquinolones [69.6%] and least against amikacin [13%] and meropenem [12%]. Ascitic fluid D/R and culture together can lead to the accurate diagnosis of SBP and can guide for the right antibiotic choice as resistance to commonly prescribed antibiotic is common in such patients

Comparison of rapid test with ELISA for the detection of hepatitis B surface antibodies

To compare the sensitivity and specificity of a rapid ICT test with ELISA for the detection of Hepatitis B surface antibody. Cross sectional comparative study conducted at PMRC Specialized Centre for gastroenterology and hepatology JPMC, Karachi from April 2012 - March 2013. A total of 206 apparently healthy adults were selected from a rural community. After taking informed consent, 5 ml blood was collected sera separated and tested for hepatitis B surface antibody [anti-HBs] by a rapid immuno-chromatographic test developed by Korea [Humasis] and ELISA simultaneously. As per manufacturer's guidelines, the rapid ICT test is interpreted as positive if antibody liters are > 30 mIU/ml and negative if the titers are <30 mIU/ml. For ELISA, the CDC interprets antibody titers > 10 mlU/ml as positive or prolective and < 10 mlU/ml as negative and recommends a booster dose. The results of ELISA [gold standard] were compared with rapid test using SPSS version 17.0. Out of 206 sera, using ELISA, anti-HBs was positive in 91[44.2%] sera and negative in 115[55.8%] sera. Using ICT, anti-HBs was positive in 85[41.3%] and negative in 121[58.7%] and the sensitivity and specificity of rapid test ICT was 83.5% and 92.2% respectively with overall accuracy of 88.5%. These figures fell to 70.8% sensitivity and 94.6% specificity with 81.5% accuracy when CDC cut off of 10 mlU/ml was used. The ICT kit gave good results in samples having high liters [> 100 mlU/ml] but had a limited sensitivity for cases having titers between 10 mlU/ml-100 mlU/ml, thus limiting its use and creating unnecessary demand for booster dose of vaccine. The rapid ICT for anti-HBs is not as sensitive as ELISA but can still be used for rapid decision making especially in OPD setups and remote areas

Management of patients with uterine rupture

To find out the frequency, predisposing factors, maternal and fetal outcomes and mode of management of uterine rupture at a tertiary care hospital. Descriptive case series. Department of Obstetrics and Gynaecology Unit-4, Bolan Medical Complex Hospital Quetta, from January 2001 to December 2012. All patients who presented with ruptured uterus during labor were included in the study. Data on various variables were recorded. This included patient related demography, obstetrical history of previous and present pregnancy and care during labor, hospital course, surgical procedure performed and maternal and fetal outcome. Out of 38,747 deliveries, 201 cases of ruptured uterus were dealt with. This constitutes a frequency of ruptured uterus as 1 in 193 deliveries. Predisposing factors noted were lack of antenatal care [n=180, 90%], grand multiparity [n=100, 49.7%], injudicious use of oxytocin or misoprostol [62.7%], uterine scar [n=74, 36.8%] and residing more than 100 km from tertiary care hospital [n=69, 34.3%]. Of the total 41 [20.4%] patients had subtotal abdominal hysterectomy, 60 [29.8%] had repair of ruptured uterus with bilateral tubal ligation and 93 [46.3%] had repair of uterus only. Bladder repair was done in 7 [3.5%] patients. Eighteen maternal deaths occurred in this series. Perinatal mortality was 86.7% [n=185]. Uterine rupture remained one of the major causes of maternal and newborn morbidity and mortality. Use of oxytocin, misoprostol and herbs during labor and lack of monitoring were important observations

Internal podalic version still has a role in the management of transverse lie

To analyze the cases of undiagnosed transverse lie presented in labour room of BMCH which were managed by IPV or LSCS, thus emphasizing the continuing importance of IPV in the developing countries. To study the role of internal podalic version in the management of undiagnosed transverse lie presenting in active labour. Retrospective case series study. This study was carried out at the Department of Obstetrics and Gynecology Unit-I, Bolan Medical Complex Hospital Quetta, Baluchistan, from January 2001 to December 2012. This is a retrospective case series study of 144 cases of transverse lie who presented in active labour. The relevant data of 11 years was collected from the labour ward register and was analyzed. There were total 144 cases of undiagnosed transverse lie that came to hospital out of which 74[51.38%] were managed by internal podalic version and cesarean section was performed in 70[48.62%] cases. None of them had any form of antenatal care. 44[30.55%] of them were 2[nd] twin. Internal podalic version still has a role in the management of transverse lie. It is almost always successful in the delivery of second twin but singleton pregnancies can also be delivered with this skill if proper patient selection is done. It has shown a good maternal and fetal outcome

Pattern of bacterial pathogens in postoperative wounds and their sensitivity patterns

To identify the common bacterial pathogens involved in postoperative wound infections and their sensitivity patterns. Cross-sectional study. Surgical ward 2, Jinnah Postgraduate Medical Centre Karachi, from December 15, 2008 to December 14, 2009. Wound swabs were collected for patients who developed surgical site infection during the study period. Infected cases were identified using Centre for Disease Control [CDC] definition for surgical site infections. Culture and sensitivity were performed using American Society of Microbiology [ASM] guidelines. During the study period, 82 [7.3%] patients developed postoperative wound infection in the selected ward. The most commonly isolated pathogens were E.coli [33.8%], Pseudomonas aeruginosa [16.9%] and Staphylococcus aureus [15.5%]. Resistance pattern of E.coli isolates showed 100%, 93%, 32% and 12% resistance to ceftriaxone, ofloxacin, amikacin and meropenem respectively. Pseudomonas aeruginosa isolates were 100% resistant to tetracyclin and ceftazidime, 91.6% to ofloxacin, 83.3% to meropenem and 66.7% to amikacin. Staphylococcus aureus exhibited maximum resistance to cloxacillin [100%] followed by ofloxacin [90.9%], tetracyclin [45.5%], amikacin [45.5%], chloramphenicol [36.4%] and vancomycin [0%]. Gram negative organisms were frequently associated with postoperative wound infections in general surgery ward and resistance to multiple drugs was noted

Is raised helicobacter pylori antibody titre enough to decide retreatment?

Helicobacter pylori infection causes a rise in its antibodies which take almost a year to come to baseline following successful eradication treatment. Checking these values in between a year may give falsely high values and many patients may thus be over treated. Aims: To serially determine Helicobacter pylori antibody titres in patients after giving them triple therapy for H. pylori eradication and see how these values drop over time. Longitudinal study conducted in Department of Gastroenterology and Hepatology, Pakistan Medical Research Council, Research Centre, Jinnah Post Graduate Medical Centre, Karachi, from May 2006 to April 2010. Over the period of four years, 186 patients who were found positive for campylobacter like organism test during endoscopy were further tested for anti H. pylori IgG titre before being treated for H.pylori. Patients were given triple therapy comprising of Omeprazole [20mg twice daily], Amoxicillin [1gm twice daily] and Clarythromycin [500mg twice daily] for a week and were followed at 1, 3, 6 and 12 months to check symptomatic relief and they were tested again for H. Pylori antibody titres. Data was collected on pre-designed proforma which included patient's demography, symptoms and diagnosis. Out of 186 patients who had a positive campylobacter like organism test, 173 patients consented to participate in the study. Serology for H. Pylori was positive in 119[68%] cases. A decline in mean antibody titres was observed as 11%, 21.5%, 54.7% and 59.2% at 1, 3, 6 and 12 months respectively. Sensitivity of serology for diagnosing H. pylori infection is good but using these as a tool for monitoring response to treatment is doubtful. A slow drop in H. pylori antibodies was seen over 12 months and therefore, physicians are cautioned not to retreat the already treated cases till about one year post treatment. H. pylori antibodies should be checked on regular basis to diagnose new cases but it should not be used in previously treated patients to retreat