Pan Drug-Resistant Salmonella Serovar Typhi Septicaemia In A Child: A Case Report.

Typhoid fever, caused by Salmonella enterica serovar Typhi, is a common cause of febrile illness, especially in lower middle-income countries. The only known reservoirs of this infection are humans, and it is prevalent in areas with limited availability of clean drinking water and sanitary conditions. Lately, extensively drug-resistant Salmonella ser. Typhi (XDR S. Typhi) has emerged as one of Pakistan's most challenging public health concerns. Here, we report a case of relapsed typhoid fever in a child, in whom the isolate was found to be resistant to meropenem and azithromycin.

Awareness of Hepatitis 'B' Among People of Khyber Pakhtunkhwa Province of Pakistan.

Hepatitis B virus is causing serious health concerns in countries like Pakistan. In Khyber Pakhtunkhwa province, 0.6 milion people were estimated to be infected with this virus in 2008. The authors aimed to assess knowledge regarding vaccination, testing and routes of transmission of hepatitis B virus among people of Khyber Pakhtunkhwa, as such knowledge among masses will help limit the infection. People belonging to 12 different districts of Khyber Pakhtunkhwa province were interviewed over a period of 5 months from October 2013 to February 2014. Apre-tested questionnaire was used and in-person survey of randomly selected 1,938 people was carried out throughout the province. Ninety-nine percent people said they knew about hepatitis B virus and 42% said they had got tested for it too. Out of them, 63.2% knew that a vaccine is available for hepatitis B virus. The proportion of respondents, who said hepatitis B virus can spread by sharing razors, toothbrush, syringes or sexual contact, was 97.94%, 95%, 99.3% and 77%, respectively. Only 28.7% knew, it can also spread vertically from mother to child during childbirth. People were quite aware of the routes of transmission of this disease, but they lacked knowledge regarding vaccination and prevention of this menace. Settings should be set up where routine preventive care and immunization services are provided.

In Vitro Effect of New Antibiotics Against Clinical Isolates of Salmonella Typhi.

OBJECTIVE: To determine the in vitrodisk diffusion and MIC patterns of the therapeutic alternatives for Salmonella Typhi. STUDY DESIGN: Across-sectional study. PLACE AND DURATION OF STUDY: Armed Forces Institute of Pathology, Rawalpindi, from June 2011 to May 2013. METHODOLOGY: Clinical samples were collected from suspected cases of Salmonella infections. Culture was obtained on standard media. Suspected Salmonella colonies were tested by API 20E and confirmed by serology. The isolates were tested for resistance to various antibiotics by Kirby-Bauer disc diffusion method. MIC was done on MDR and ciprofloxacin intermediate or resistant cases by E-strips for selected antibiotics. RESULTS: One hundred and twenty-eight isolates of Salmonella Typhi were recovered from 2230 specimens. Resistance by disk diffusion technique was 72% for ampicillin, 41.2% for cotrimoxazole, 38% for chloramphenicol, 8% for ciprofloxacin, 4.7% for cefpodoxime, 3.5% each for ertapenem aztreonam and moxifloxacin 2.4% for ceftriaxone and 2.3% for doripenem. No resistance was noted for imipenem, cefepime and gatifloxacin. Imipenem MIC90was 0.38 and MIC50 was 0.25. For cefpirome, MIC90was 0.64 and MIC50 was 0.09. For aztreonam, MIC90 was 0.12 and MIC50 was 0.09. For cefpodoxime MIC90 was 0.75 and MIC50 was 0.38. For azithromycin, these values were 16.0 and 7.0; and for tigecycline they were 0.25 and 0.09. CONCLUSION: Imipenem, azithromycin, tigecycline, aztreonam, cefpodoxime and cefpirome are potential therapeutic agents for resistant Salmonella Typhi infection.

Non-dermatophyte moulds as pathogens of onychomycosis.

OBJECTIVE: To determine the role and pattern of non-dermatophyte moulds as causative agents of onychomycosis. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Department of Microbiology, Armed Forces Institute of Pathology (AFIP), Rawalpindi, from November 2009 to July 2010. METHODOLOGY: Nail clippings and nail scrapings were obtained from abnormal looking nails with treatment and detection failure for onychomycosis. Microscopic (40% potassium hydroxide mounts) examination and culture on Sabouraud's dextrose agar (SDA), SDA containing chloramphenicol, and SDA containing actidione and chloramphenicol were used for species identification. RESULTS: Non-dermatophyte moulds were isolated from 32 out of the total 47 culture positive cases (68%). Alternaria alternata was the commonest species (46%). Dermatophytes were isolated from only 7 patients (15%) belonging to genus Trichophyton. Yeasts were isolated in 8 (17%). There was no fungal growth in 53% of cases. CONCLUSION: The non-dermatophytes should be considered important in evaluating the culture negative cases for dermatophytes as well as those cases ending up in treatment failure after empirical treatment for dermatophyte infections.

Susceptibility pattern of extended spectrum ß-lactamase producing isolates in various clinical specimens.

OBJECTIVE: To determine the susceptibility pattern of extended spectrum ß-lactamase (ESBL) producing Gram negative isolates from various clinical specimens. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Microbiology Department, Armed Forces Institue of Pathology, Rawalpindi, from January 2008 to January 2009. METHODOLOGY: A total of 308 ESBL producing isolates from various clinical specimens sent to AFIP for culture and sensitivity were identified using standard microbiological techniques and tested for antimicrobial susceptibility. At the same time screening for ESBL production was also done. ESBL production was confirmed by combination disc synergy method. The susceptibility pattern of isolates was then recorded in frequency percentages. RESULTS: Out of the 308 ESBL producing isolates more than 99% were susceptible to carbapenems, 84% to tazobactam/ piperacillin, 81% to sulbactam/cefoperazone, 12% to fluoroquinolones, 13% to cotrimoxazole, 59% to amikacin and 18% to gentamicin. Among the urinary isolates 49% were susceptible to Nitrofurontoin and only 5% to Pipemidic acid. CONCLUSION: Antibiotic choices in case of ESBL producing isolates are limited and at present only carbapenems can be regarded as treatment of choice. As empirical agents, beta-lactam/beta lactamase inhibitor combinations should be used cautiously for serious infections. Fluoroquinolones showed very poor efficacy. Amikacin can be used alternatively in such cases. Nitrofurantoin is still a good oral agent for treating UTI.

Ambu bag as a source of Acinetobacter baumannii outbreak in an intensive care unit.

This case report describes an outbreak of multidrug resistant Acinetobacter baumannii in the intensive care unit of a tertiary care hospital. Three patients were infected on the same day from an Ambu bag which was used on all the patients. The outbreak was immediately identified and the source was traced within one week. Appropriate measures were taken and a continuous surveillance was carried out resulting in reporting of no such case from the intensive care unit in the last 6 months.

Vancomycin resistant enterococcal sepsis in an acute myeloid leukemic patient.

Neutropenic fever is an important cause of morbidity and mortality during therapy of acute myeloid leukemia. Patients with acute myeloid leukemia are at increased risk of acquiring vancomycin resistant enterococcal infection and its treatment remains problematic. Vancomycin therapy for more than 7 days is usually associated with inducible vancomycin-resistant enterococcal infections. We report a case of vancomycin resistant enterococcal sepsis in a patient of acute myeloid leukemia.

Frequency and antimicrobial susceptibility pattern of methicillin resistant Staphylococcus aureus.

OBJECTIVE: To determine the frequency of methicillin resistant Staphylococcus aureus and its antimicrobial susceptibility pattern in patients reporting to Combined Military Hospital (CMH), Pano Aqil. STUDY DESIGN: A non-interventional, cross-sectional study. PLACE AND DURATION OF STUDY: Pathology Laboratory, Combined Military Hospital (CMH), Pano Aqil, from December 2005 to January 2008. METHODOLOGY: Strains of Staphylococcus aureus were isolated from a variety of clinical specimens. Standard methodology, using modified Kirby-Bauer disk diffusion method, was adopted for antibiotic sensitivity test. The MIC of oxacillin and vancomycin was performed by E-strips, for MRSA isolates and isolates revealing vancomycin resistance on disk diffusion. RESULTS: A total of 195 hospital and 42 community acquired isolates were tested. Forty-seven (19.8%) non-duplicate strains were found to be methicillin resistant Staphylococcus aureus (MRSA); methicillin resistance did not differ among hospital strains (n=42) as compared to community ones (n=5, p=0.1555). No isolates from the community and hospital acquired showed resistance to vancomycin. Community and hospital acquired isolates revealed higher resistance against penicillin and doxycycline than against ciprofloxacin, erythromycin, gentamicin and chloramphenicol. However, resistance against these antibiotics did not differ significantly among community and hospital acquired isolates. CONCLUSION: Increase in prevalence of MRSA is impending in future, appealing preventive measures to be adopted. However, Staphylococcus aureus resistant to vancomycin was not observed.

Secondary syphilis presenting as vertigo.

Syphilis is a chronic, systemic and sexually transmitted infectious disease affecting most of the organs in the body. A young African man presented with vertigo, unsteadiness of gait and a skin rash suggestive of secondary syphilis. Diagnosis was confirmed on serology and was treated with two shots of long-acting penicillin, following which his symptoms settled.