Increased antimicrobial resistance against azithromycin during COVID: role of irrational utilization.

Objectives: To assess the use of azithromycin during coronavirus disease-2019 pandemic and its impact on antimicrobial resistance in an urban setting. METHODS: The retrospective, cross-sectional study was conducted on two different data sets. The first data set was of inpatients (N = 300) during the first wave of COVID 19 i.e. January to December, 2020. Data was collected from tertiary care hospitals in Karachi between October 2021 and November 2022 after approval from the ethics review committee of Ziauddin University, Karachi. Drug utilisation evaluation was done using a structured and validated tool. The treatment protocols were evaluated by comparing against the coronavirus disease-2019 treatment protocol 2020 and the guidelines issued by the Medical Microbiology and Infectious Diseases Society of Pakistan. Second data set comprised of the consumption data (obtained from pharmacies for both inpatients and outpatients) as well as the antimicrobial resistance, (obtained from antibiogram collected from the microbiology departments of the participating hospitals). This data was taken for the period of three years i.e. 2019 (Pre-COVID) to 2021 (Post-first wave of COVID) to establish trends of both consumption and antibiotic resistance. Data was analysed using SPSS 20. RESULTS: Of the 300 patients, 207(69%) were males and 93(31%) were females. There were 162(54%) adults with mean age 40.06±10.48 years, followed by 120(40%) geriatrics with mean age 70.37±6.94 years, 18(6%) paediatrics with mean age 13.5±3.60 years. All patients were given Azithromycin empirically followed by culture sensitivity test in 21% cases only. Comparison with COVID treatment protocols revealed the non-compliance of just 3%. However, in case of Community Acquired Pneumonia (CAP), sinusitis, typhoid and urethritis, comparison with MMIDSP guidelines revealed non-compliance of 95%, 22%, 75% and 100% respectively. Moreover, in 11% of patients, it was administered for conditions not recommended by guidelines. Furthermore, the Antibiogram exhibited percent increase in resistance against azithromycin. CONCLUSIONS: Enhanced consumption and irrational use of azithromycin during the coronavirus disease-2019 pandemic most likely contributed to increase in antimicrobial resistance.

Increasing Frequency of New Delhi Metallo-beta-Lactamase and Klebsiella pneumoniae Carbapenemase Resistant Genes in a Set of Population of Karachi.

OBJECTIVE: To determine the frequency of Klebsiella pneumoniae Carbapenemase (blaKPC) and New Delhi Metallo-Beta-Lactamase (blaNDM) resistant genes among clinical isolates of Enterobacterales in a set of Karachi population. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Department of Microbiology, Dr. Ziauddin University Hospital, Karachi, Pakistan, from January 2019 to December 2020. METHODOLOGY: A total of 2100 clinical isolates of Enterobacterales were collected. All isolates of Carbapenem-Resistant Enterobacterales (CRE) (Escherichia coli, Enterobacter and Klebsiella species) on the basis of Meropenem screening test positivity were included in the study. DNA was extracted and PCR was performed for resistant genes detection. Frequencies and percentages were computed for categorical variables and mean values and standard deviation for quantitative variables. RESULTS: Among 2100 isolates of Enterobacterales, the majority were E. coli 1260 (60%), followed by Klebsiella species 462 (22%), and Enterobacter species 210 (10%). The sources of CRE isolates included 34 (25%) from respiratory (tracheal aspirate, pleural fluid, and gastric lavage); 33 (24.26%) urine, 32 (25.53%) pus, 15 (11.03%) blood, and 20 (14.7%) others (ascitic fluid, stents, and tissue). All isolates of CRE were sensitive (100%) to Colistin, Tigecycline and Fosfomycin. Biochemically confirmed CRE 136 (6.5%) isolates, (79 (58%) males and 57 (42%) females), were selected for detecting resistant genes. The PCR showed 32 (23.52%) positive for both NDM and KPC resistant genes, 28 (20.58%) for NDM and 19 (13.97%) for KPC alone. Out of 79 followed up patients, 58 (73.4%) expired while 21 (26.6%) were discharged. CONCLUSION: The frequency of blaNDM and blaKPC resistant genes in CRE isolates depicted increasing trend. Colistin, Fosfomycin, and Tigecycline showed high antimicrobial sensitivities in vitro. Further measures need to be applied for CRE with comprehensive resistant genes detection to curtail antimicrobial resistance. KEY WORDS:  Frequency, KPC, NDM, Klebsiella species, Carbapenemases, Enterobacterales E.coli.

Effect of denture cleansers on the color stability of heat cure acrylic resin.

OBJECTIVE: To compare the color stability of heat cure acrylic resin after immersion in distilled water and denture cleansers. STUDY DESIGN: In-vitro experimental study. PLACE AND DURATION OF STUDY: Dr. Ishrat-ul-Ebad Khan Institute of Oral Health Sciences, Dow University of Health Sciences and Al-Karam Textiles, Karachi, from January to April 2012. METHODOLOGY: Seventy two rectangular shaped specimens; 18 specimens were measured at baseline (control group) of the study (0 day), 18 specimens were immersed in distilled water. Eighteen (18) in Fittydent denture cleanser tablets for 10 minutes and eighteen (18) in Dentipur denture cleanser tablets for 10 minutes. Specimens were polished and stored in istilled water for 24 hours prior to experiment. After 60 days of immersion, the specimens were tested for color changes with spectrophotometer. SPSS 16 was used for statistical analysis. RESULTS: There was statistically significant difference in the color change (ΔE) among all groups (p < 0.001) after 60 days of immersion. At baseline (0 day), trace amount of color change was observed whereas when specimens were immersed in Fittydent denture cleansers tablets for 60 days noticeable change in color was observed. Very slight change in color was bserved when specimens were immersed in distilled water and dentipur denture cleanser solution. CONCLUSION: The color stability of denture base acrylic resin was influenced by the type of denture cleansers used.

Inducible clindamycin resistance in Staphylococcus species.

OBJECTIVE: To determine the frequency of inducible clindamycin resistance in clinical isolates of Staphylococcus species by phenotypic D-test. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Ziauddin University Hospital, Karachi, from July to December 2011. METHODOLOGY: Consecutive clinical isolates of Staphylococcus species were collected and identified by conventional microbiological techniques. Antimicrobial susceptibility testing and inducible clindamycin resistance was carried out by performing D-test using CLSI criteria. Methicillin resistance was detected by using Cefoxitin disk as a surrogate marker. Statistical analysis was performed by SPSS version-17. RESULTS: A total of 667 clinical isolates of Staphylococcus species were obtained during the study period. In these isolates, 177 (26.5%) were Staphylococcus aureus, and 490 (73.5%) were coagulase negative Staphylococci. The total frequency of inducible clindamycin resistance among isolates of Staphylococcus species was 120/667 (18%). Frequency of inducible clindamycin resistance among coagulase negative Staphylococci group and Staphylococcus aureus group were 18.57% and 16.38% respectively. Median age of patients in D-test positive group was 19.5 (1 - 54) years. CONCLUSION: The frequency of inducible clindamycin resistance among Staphylococcus species may differ in different hospital setup. Clinical microbiology laboratories should implement testing simple and effective D-test on all Staphylococcus species. D-test positive isolates should be reported clindamycin resistant to decrease treatment failure.

Fatal primary meningoencephalitis caused by Naegleria fowleri.

Naegleria fowleri is a free living parasite which habitats in fresh water reservoirs. It causes a fatal nervous system infection known as primary amoebic meningoencephalitis by invading through cribriform plate of nose and gaining entry into brain. We report a case of primary amoebic meningoencephalitis caused by Naegleria fowleri in Karachi, Pakistan, in a 42 years old male poultry farm worker having no history of swimming. Clinical course was fulminant and death occurred within one week of hospital admission. Naegleria fowleri was detected by wet mount technique in the sample of cerebrospinal fluid collected by lumbar puncture of patient. This is a serious problem and requires immediate steps to prevent general population to get affected by this lethal neurological infection.

Diagnostic cut-off levels of plasma brain natriuretic peptide to distinguish left ventricular failure in emergency setting.

OBJECTIVE: To determine the diagnostic cut-off values of brain natriuretic (BNP) peptide to establish left ventricular failure in patients presenting with dyspnoea in emergency department. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Ziauddin University Hospital, Karachi, from July to December 2011. METHODOLOGY: BNP estimation was done on Axysm analyzer with kit provided by Abbott diagnostics, while the Doppler echocardiography was done on Toshiba istyle (UICW-660A) using 2.5 MHz and 5.0 MHz probes. Log transformation was done to normalize the original BNP values. A receiver operating curve was plotted to determine the diagnostic cut-off value of BNP which can be used to distinguish CHF from other causes of dyspnoea. Statistical analysis was performed by SPSS version 17. RESULTS: A total of 92 patients presenting with dyspnoea in the emergency department were studied. There were 38/92 (41.3%) males and 54/92 (58.7%) females, and the average age of the study population was 64 ± 14.1 years. These patients had BNP levels and Doppler echocardiography done. The average BNP was found to be 1117.78 ± 1445.74 pg/ml. In log transformation, the average was found to be 2.72 ± 0.58. BNP value of 531 pg/ml was found to be the cut off to distinguish between cardiogenic and non-cardiogenic causes of dyspnoea. CONCLUSION: BNP value of 531 pg/ml can distinguish CHF from other conditions as a cause of dyspnoea in emergency.

Bacteremia due to Aeromonas hydrophila in acute lymphoblastic leukemia.

Aeromonas hydrophila (A. hydrophila) is a low virulent organism but may cause devastating fatal infections in immunocompromised host especially in liver cirrhosis. It is rarely reported to cause septicemia in a patient with Acute Lymphoblastic Leukemia (ALL). The mortality rate of septicemia due to A. hydrophila is 29% to 73%. We report a case of 59-year-old female patient who was a known case of ALL, presented with the complaints of fever, lethargy and generalized weakness for one month. After taking blood samples for investigations, empirical antimicrobial therapy was started. She did not improve after 48 hours of therapy. Meanwhile blood culture revealed pure growth of A. hydrophila. After sensitivity report was available, ciprofloxacin was started. Patient became afebrile after 48 hours of treatment with ciprofloxacin. It is very vital to correctly identified and treat bacteremia due to A. hydrophila especially in the underlying leukemic patient.

Pleural empyema due to Salmonella typhi.

Salmonella serotypes most often produce gastroenteritis, enteric fever, bacteremia, vascular infection and chronic carrier state. Localized infection may occur at any site after Salmonella bacteremia. Pulmonary involvement due to Salmonella infection is rare. Empyema occurs usually in elderly patients or in patients with underlying diseases such as diabetes mellitus, malignancy, or pulmonary disease. We report the case of an 83-year-old male diabetic patient who presented with fever, productive cough, and difficulty in swallowing. The chest radiographs revealed soft shadowing mild atelactasis and pulmonary abscess on left side. CT-guided aspiration of pus was done. Salmonella enterica serotype typhi was isolated from pus sample. Pleural empyema or abscess usually requires surgical drainage in addition to antimicrobial therapy. After complete course of antimicrobial therapy, the patient improved.

Activity of beta-lactam beta-lactamase inhibitor combinations against extended spectrum Beta-lactamase producing Enterobacteriaceae in urinary isolates.

OBJECTIVE: To determine the susceptibility pattern of beta-lactam beta-lactamase inhibitor combinations against extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae in urinary isolates. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Ziauddin University Hospital, Karachi, from February to October 2008. METHODOLOGY: A total of 190 consecutive non-duplicate isolates of ESBL producing Enterobacteriaceae from urine samples of in-patients were included in the study. Urinary samples from out-patients, repeat samples and non-ESBL producing isolates were excluded. Detection of ESBL was carried out by double disk diffusion technique. Antimicrobial susceptibility testing was performed using modified Kirby Bauer's disk diffusion method according to CLSI guidelines. Statistical analysis was performed by SPSS version 10. RESULTS: Of the 190 ESBL isolates tested, 88 cases (46.31%) were sensitive and 6 cases (3.15%) were resistant to all three combinations, the rest 96 cases (50.52%) were resistant to at least one of the combinations. Susceptibility pattern of cefoperazone/sulbactam, piperacillin/tazobactam, and amoxicillin/clavulanic acid was 95.26, 92.10, and 44.31 percent respectively. CONCLUSION: Cefoperazone/sulbactam exhibited the best activity against ESBL producing Enterobacteriaceae followed by piperacillin/tazobactam. Hospital antibiotic policies should be reviewed periodically to reduce the usage of extended spectrum cephalosporins and replace them with beta-lactam beta-lactamase inhibitor combinations agent for treating urinary tract infections.

Frequency of extended spectrum beta lactamase producing enterobacteriaceae among urinary pathogen isolates.

OBJECTIVE: To determine the frequency of extended-spectrum beta lactamase (ESBL) producing Enterobacteriaceae in urinary isolates. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Ziauddin University Hospital, Karachi, from February to October 2008. METHODOLOGY: All members of Enterobacteriaceae isolated from urinary samples of in-patients were included and identified using standard biochemical tests. Urinary samples from out-patients were excluded. Detection of ESBL was carried out by double disk diffusion technique. Statistical analysis was performed by SPSS version 10. RESULTS: A total of 289 isolates of Enterobacteriaceae were identified during the study period. Of those 190/289 (65.7%) of the isolates were found to be ESBL producing. ESBL positivity within individual organism group was highest in Klebsiella species 84.16%, followed by Escherichia coli 68.55%, Enterobacter species 36.84%, and Proteus mirabilis 28.55%. Mean age of patients with ESBL producing organisms was 58.69 ± 18.97 years. ESBL production was almost similar in all age groups. CONCLUSION: A high frequency of ESBL producing organisms especially Klebsiella species and Escherichia coli amongst the hospital obtained urinary isolates was documented particularly in the older age group. The data points towards an urgent need for regular screening and surveillance for ESBL producing organisms in this region.