Pulmonary embolism in an ESRD patient following minimal venotomy and milking for salvage of dysfunctional autogenous arteriovenous fistula.

Pulmonary embolism can be a complication following an attempted salvage of a dysfuctional arteriovenous fistula (AVF). We report a case of bilateral pulmonary embolism in a patient with underlying pericardial effusion who, following minimal venotomy and milking of the AVF, developed sudden and significant respiratory distress, and later improved.

Carbapenemase among Clinical Bacterial Isolates in Nepal.

Gram-negative isolates producing carbapenemase enzymes is a great public health problem in developing countries and their control is challenging task due to the involvement of multiple factors including the practice of self-medication, use of antibiotics on animal farms, poor hospital hygiene, etc. During this study, we searched various databases for relevant publication on carbapenemase-producing isolates in Nepal. Various classes of carbapenemases had been reported in Nepal. Most frequent was the New Delhi Metallo beta lactamase with many variants where NDM-1 was most prevalent. Similarly, Oxacillinase and Klebsiella pneumoniae carbapenemase producers were also prevalent in Nepal. While other carbapenemases like VIM, IPM, and DIM also detected. The isolates producing carbapenemases were extremely drug-resistant as they also co-produced various other carbapenemases, beta-lactamases, 16S rRNA methylase. Most isolates were resistant to many members of carbapenem, cephalosporin, quinolone, penicillin, aminoglycoside group of antibiotics. Such isolates had very few treatment options as only last line drugs like colistin, fosfomycin, and tigecycline was effective against most of these isolates. Carbapenemase production by almost all major human pathogens including E. coli, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter. Citrobacter, Proteus, Providencia is a matter of concern because some of these enzymes are located on plasmids and pose rapid dissemination among various gram-negative pathogens. Timely surveillance for carbapenemase producers throughout the nation, their proper treatment, and proper hospital hygiene to prevent nosocomial infections by carbapenemase producers, controlled use of carbapenems, educating health care workers, students and the general public about the adverse effects of antimicrobial resistance is imminent.

Prevalence of Colistin-resistant Gram-negative Isolates Carrying the mcr-1 Gene among Patients Visiting a Tertiary Care Center.

INTRODUCTION: Gram-negative isolates harboring mobilized colistin resistance (mcr-1) gene are a great threat to human health. They have been reported worldwide among various bacterial isolates. This work aimed to study the prevalence of colistin resistance among Gram-negative bacteria and the incidence of mcr-1 gene among these isolates. METHODS: A descriptive cross-sectional study was done at a tertiary care center from June 2016 to February 2017. An ethical approval was taken from review board of the Nepal Health Research Council (Reg. no: 274/2016). Convenience sampling was used. The data was collected and analyzed using Microsoft Excel 2010 and Statistical Package for Social Sciences (SPSS) Version 16 . Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. RESULTS: Among 485 gram-negative isolates, only 13 (2.68%) (1.26-6.62 at 95% Confidence Interval) isolates were colistin-resistant and mcr-1 was present in two isolates. Predominant colistin-resistant isolates were E. coli 6 (4.1%), Enterobacter spp 2 (2.81%), and Acinetobacter spp 2 (2.81%). A high level of colistin-resistance was noted in 4 (30.7%) isolates as indicated by the very high value of colistin MIC (>256 µg/ml). ICU was the major site of isolation of colistin-resistant and mcr-1 positive pathogens. The majority of colistin-resistant isolates were highly drug-resistant and were sensitive only to polymyxin B. Antibiotics like imipenem, amikacin, gentamicin, aztreonam, ciprofloxacin, and piperacillin-tazobactam were effective for few of these isolates. CONCLUSIONS: Though the prevalence of mcr-1 gene was low among colistin-resistant gram-negative isolates, the resistant pattern was quite alarming as these isolates were highly drug-resistant.