Comparison of contamination of femoral heads and pre-processed bone chips during hip revision arthroplasty.

With bone impaction grafting, cancellous bone chips made from allograft femoral heads are impacted in a bone defect, which introduces an additional source of infection. The potential benefit of the use of pre-processed bone chips was investigated by comparing the bacterial contamination of bone chips prepared intraoperatively with the bacterial contamination of pre-processed bone chips at different stages in the surgical procedure. To investigate baseline contamination of the bone grafts, specimens were collected during 88 procedures before actual use or preparation of the bone chips: in 44 procedures intraoperatively prepared chips were used (Group A) and in the other 44 procedures pre-processed bone chips were used (Group B). In 64 of these procedures (32 using locally prepared bone chips and 32 using pre-processed bone chips) specimens were also collected later in the procedure to investigate contamination after use and preparation of the bone chips. In total, 8 procedures had one or more positive specimen(s) (12.5 %). Contamination rates were not significantly different between bone chips prepared at the operating theatre and pre-processed bone chips. In conclusion, there was no difference in bacterial contamination between bone chips prepared from whole femoral heads in the operating room and pre-processed bone chips, and therefore, both types of bone allografts are comparable with respect to risk of infection.

Isolation of non-tuberculous mycobacteria at three rural settings in Zambia; a pilot study.

To assess the role of non-tuberculous mycobacteria (NTM) as a cause of tuberculosis-like diseases in Zambia, 167 chronically ill patients, hospitalized in three rural hospitals in Katete, Sesheke and Chilonga, were examined by microscopy and liquid culture for the presence of NTM. The percentages of patients with a positive culture for Mycobacterium tuberculosis complex were similar in the three geographical locations (19-25%). In contrast, the percentage of NTM ranged from 78% in Katete and 65% in Sesheke to 21% in Chilonga. Furthermore, the distribution of NTM species was different at the three geographical sites. In seven patients, true NTM-associated disease was suspected: five with Mycobacterium lentiflavum and two with Mycobacterium intracellulare. Analysis of possible risk factors indicated that the OR for NTM culture-positive sputum was significantly higher for patients living in Katete and Sesheke. Female gender and chest X-ray appearances of tuberculosis were independently associated with NTM culture-positive sputum. NTM colonization and disease in hospitalized, chronically ill patients in rural Zambia appear to be common.

Device-independent, real-time identification of bacterial pathogens with a metal oxide-based olfactory sensor.

A novel olfactory method for bacterial species identification using an electronic nose device called the MonoNose was developed. Differential speciation of micro-organisms present in primary cultures of clinical samples could be performed by real-time identification of volatile organic compounds (VOCs) produced during microbial replication. Kinetic measurements show that the dynamic changes in headspace gas composition are orders of magnitude larger than the static differences at the end of fermentation. Eleven different, clinically relevant bacterial species were included in this study. For each of the species, two to eight different strains were used to take intra-species biodiversity into account. A total of 52 different strains were measured in an incubator at 37 degrees C. The results show that the diagnostic specificities varied from 100% for Clostridium difficile to 67% for Enterobacter cloacae with an overall average of 87%. Pathogen identification with a MonoNose can be achieved within 6-8 h of inoculation of the culture broths. The diagnostic specificity can be improved by broth modification to improve the VOC production of the pathogens involved.

Polymorphism in CC-chemokine ligand 2 associated with tuberculosis in Zambia.

Polymorphism in various genes that may influence susceptibility to tuberculosis (TB) was examined in 46 TB patients and 119 healthy tuberculin-positive controls in Zambia. The odds of having TB was 2.8-fold higher in carriers of the -2518 AG single-nucleotide polymorphism in the promoter region of the CC-chemokine ligand 2 than in those carrying the homozygous genotype AA (95%CI 1.3-5.5).

Rapid identification of mycobacteria by Raman spectroscopy.

A number of rapid identification methods have been developed to improve the accuracy for diagnosis of tuberculosis and to speed up the presumptive identification of Mycobacterium species. Most of these methods have been validated for a limited group of microorganisms only. Here, Raman spectroscopy was compared to 16S rRNA sequencing for the identification of Mycobacterium tuberculosis complex strains and the most frequently found strains of nontuberculous mycobacteria (NTM). A total of 63 strains, belonging to eight distinct species, were analyzed. The sensitivity of Raman spectroscopy for the identification of Mycobacterium species was 95.2%. All M. tuberculosis strains were correctly identified (7 of 7; 100%), as were 54 of 57 NTM strains (94%). The differentiation between M. tuberculosis and NTM was invariably correct for all strains. Moreover, the reproducibility of Raman spectroscopy was evaluated for killed mycobacteria (by heat and formalin) versus viable mycobacteria. The spectra of the heat-inactivated bacteria showed minimal differences compared to the spectra of viable mycobacteria. Therefore, the identification of mycobacteria appears possible without biosafety level 3 precautions. Raman spectroscopy provides a novel answer to the need for rapid species identification of cultured mycobacteria in a clinical diagnostic setting.

[A patient with fever following a visit to the tropics: tick-borne relapsing fever discovered in a thick blood smear preparation]. / Een patiënt met koorts na een bezoek aan de tropen: 'tick-borne relapsing fever' ontdekt in een dikkedruppelpreparaat.

A 26-year-old woman presented with a 2-day history of fever peaking to 39 degrees C and cold shivers that developed after a 2-weeks trip to Guatemala and Belize. Prior to the fever the patient had felt symptoms of a common cold and general malaise. Moreover, she complained of generalised myalgia and nausea. She had taken paludrine as a prophylactic against malaria. Borrelia spirochaetes, the pathogen of relapsing fever, were detected in a thick blood smear preparation. On the basis of the anamnesis, geography and specific exposure, the patient had a form of relapsing fever that is transmitted by ticks and not by lice: tick-borne relapsing fever. She was treated with doxycycline, 100 mg b.i.d. for 7 days. She could be discharged home in good condition after 2 days.

[Community-acquired pneumonia: pathogens and course in patients admitted to a general hospital]. / Buiten het ziekenhuis opgelopen pneumonie: verwekkers en beloop bij patiënten opgenomen in een algemeen ziekenhuis.

OBJECTIVE: To determine prognostic factors and the significance of (non-invasive) microbiological tests for the clinical course of patients admitted to one general hospital with community-acquired pneumonia (CAP). DESIGN: Prospective observational study. METHOD: Patients admitted to one location of a general hospital with symptoms of CAP during the period January 1998-December 1999 were included. Data from the anamnesis, physical examination and laboratory tests were recorded and samples were taken for diagnosis of the possible pathogens. Cultures were made of sputum and blood, serum and sputum were examined for infection with viral and atypical microorganisms, and the urine was screened for Streptococcus pneumoniae and Legionella antigens. RESULTS: Of the 157 patients studied, 28 (18%) died as a direct result of CAP. In a stepwise multivariate analysis, age > or = 65 years, increased serum-creatinine levels and hypercapnia were independent predictors of mortality. Streptococcus pneumoniae and Haemophilus influenzae were detected 53 and 19 times, respectively, and were the bacterial pathogens most frequently found. Among the nonbacterial pathogens, Mycoplasma pneumoniae was found 37 times and serologic tests for influenza A or B virus were positive in 34 cases. In 62 patients (39%), extensive microbiological tests revealed signs of a combined infection and in 20 patients (13%) no microorganism could be detected. An elevated serum-procalcitonin level was associated with bacterial infections. As a consequence of their retrospective nature, the results of the extensive serological tests did not contribute to reaching a diagnosis in daily clinical practice. In comparison with the literature, there was a markedly high number of subclinical or atypical infections with Legionella (8%) and Bordetella (18%) and a high incidence of viral and atypical microorganisms as the cause of CAP.

Microbiological screening of post-mortem bone donors - two case reports.

This study assesses the value of blood cultures in combination with swab culturing techniques in association with bone banking procedures. The results of blood and swab cultures of two postmortem bone donors were compared with procured grafts, cultured in their entirety. In one donor, who died of drowning, three of the 12 entire graft cultures were positive with the same microorganism of high pathogenicity as the blood culture, whilst the swab culture of only one graft was positive. In the second donor, who died from myocardial infarction, four entire cultures were positive with the same organism of high pathogenicity as the blood culture, whilst the swab cultures of three grafts were positive. In both donors identical organisms were cultured from the myocardium of the pulmonary or aortic heart valve. The results confirm the limited sensitivity of swab culturing techniques. Especially micro-organisms inside a graft, disseminated through the bloodstream, can remain unnoticed. Blood cultures seem to provide additional information on micro-organisms that have spread haematogenously pre-mortem and may even provide information on the source from which they have spread.

Increasing resistance to fluoroquinolones in escherichia coli from urinary tract infections in the netherlands.

In continuous surveillance of routine samples from five Dutch laboratories, we studied resistance to the antibiotics most commonly prescribed for urinary tract infections (UTI) in The Netherlands, namely norfloxacin, amoxycillin, trimethoprim and nitrofurantoin, from 1989 to 1998 in >90000 Escherichia coli isolates. Resistance to norfloxacin increased from 1.3% in 1989 to 5.8% in 1998. Multiresistance, defined as resistance to norfloxacin and at least two of the other three antibiotics, increased from 0.5% in 1989 to 4. 0% in 1998. Multivariate analysis of the norfloxacin resistance demonstrated that this yearly increase (the odds ratio was 1.0 in 1989, 1.6 in 1992, 2.9 in 1995 and 6.1 in 1998) was independent of other determinants of resistance to norfloxacin, such as age, gender and origin of the isolate. Analysis of strata, classified by year, age and gender, demonstrated an association between prescription of fluoroquinolones (defined daily doses per case of UTI) and resistance to norfloxacin in E. coli (P < 0.001). There was no significant association with the prescription of nitrofuran derivatives (nitrofurantoin) and trimethoprim with or without sulphamethoxazole. The yearly increase of resistance to fluoroquinolones in E. coli from UTI may stem from increased prescription of fluoroquinolones for UTI. Resistance of E. coli to these agents is likely to increase further as fluoroquinolone use increases in future.

A comparative study of blood and bone marrow cultures in cadaveric bone donation.

The results of blood cultures taken from cadaveric bone donors were compared with bone marrow and also swab cultures of the procured grafts. In eight of the 95 donors evaluated, pathogenic micro-organisms were detected in the blood sample. In two, identical micro-organisms were cultured from the blood and bone marrow sample whilst the swab cultures were negative. Considering the low sensitivity of the swab culture, the organisms detected in the blood culture were likely to have spread haematogenously and considered to be present in the explanted grafts. Bacteriological screening of bone donors is extremely important since the transmission of micro-organisms via an allograft can lead to serious complications in the recipient. Positive blood cultures provide important information on the presence of pathogenic micro-organisms in grafts obtained from cadaveric bone donors and are therefore essential in deciding whether a graft is bacteriologically acceptable for transplantation.

Left ventricular loading modifications induced by pneumoperitoneum: a time course echocardiographic study.

UNLABELLED: The intraperitoneal insufflation of carbon dioxide during laparoscopic procedures is associated with an increase in mean arterial pressure and systemic vascular resistance. To evaluate the time course of the circulatory changes related to intraabdominal pressure variation, we used transesophageal echocardiography in 10 patients anesthetized for laparoscopic cholecystectomy. Left ventricular dimensions, fractional area shortening (FAS), and left ventricular afterload assessed by the left ventricular end-systolic wall stress (LVESWS) were measured from echocardiographic data before insufflation, during pneumoperitoneum, and during exsufflation. Three minutes after the onset of pneumoperitoneum, we observed a 25.7% +/- 10.5% (mean +/- SD) increase in mean arterial pressure, a 49.1% +/- 14.4% increase in LVESWS, and a 17.0% +/- 16.2% decrease in FAS. All measured variables returned to preinsufflation values after 30 min of pneumoperitoneum and thereafter were no longer significantly affected by postural changes (10 degrees head-up position) or pneumoperitoneum exsufflation. We conclude that the circulatory changes associated with pneumoperitoneum are transient and are probably mediated by factors other than intraabdominal pressure variations. IMPLICATIONS: Insufflation of gas into the abdominal cavity results in hemodynamic changes during laparoscopic procedures. We found that echocardiographic and blood pressure effects associated with gas insufflation were transient, indicating mediation by factors besides intraabdominal pressure.

Resistance of staphylococci in The Netherlands: surveillance by an electronic network during 1989-1995.

An electronic surveillance network for monitoring antibiotic resistance in The Netherlands has been in operation since 1989. Seven public health laboratories participate and the system covers about 25% of all bacteriological determinations in The Netherlands. This paper reports the results of staphylococci isolated in the period 1989-1995. About 0.3% of the Staphylococcus aureus isolates in the study period were resistant to methicillin. This low percentage may be due to the restrictive use of antibiotics and to strict isolation measures aimed at eradicating methicillin-resistant S. aureus. Low frequencies of resistance among methicillin-resistant S. aureus were found for vancomycin (0%), chloramphenicol (11%), cotrimoxazole (11%), mupirocin (3% low-level resistance) and fusidic acid (7%). Twenty-one percent of the coagulase-negative staphylococci were resistant to methicillin. Low frequencies of resistance among these methicillin-resistant coagulase-negative staphylococci were those to vancomycin (0.4%), nitrofurantoin (2%), doxycycline (20%) and amikacin (20%). Coagulase-negative staphylococci from cerebrospinal fluid, blood and skin were less often resistant to quinolones than isolates from respiratory tract, faeces and urine. A significant increase in resistance of coagulase-negative staphylococci to methicillin, erythromycin, gentamicin and ciprofloxacin was observed in the investigated period but the resistance to doxycycline and co-trimoxazole decreased in the last few years. To confirm the determination of methicillin resistance and coagulase production, a PCR method was developed which detects both the mecA and the coagulase gene. The results of the PCR method correlated well with the methicillin MIC as determined by an agar-dilution method.

Contamination of bone allografts: analysis of incidence and predisposing factors.

We analysed the bacterial contamination of 1999 bone allografts retrieved from 200 cadaver donors under sterile operating conditions. The effect of various factors on the relative risk of contamination was estimated using a multiple logistic regression model. Organisms of low pathogenicity were cultured from 50% of the grafts and of high pathogenicity from 3%. The risk of contamination with low pathogenic organisms (mainly skin commensals) increased by a factor of 1.6 for each member added to the procurement team. The risk of contamination with high pathogenic organisms (mainly contaminants from the gastrointestinal tract) was 3.4 times higher in donors with a traumatic cause of death and 5.2 times higher in those with a positive blood culture. Preceding organ procurement did not significantly influence the risk of contamination. Rinsing the graft with an antibiotic solution was not an effective decontamination method. The major source of contamination is exogenous and is strongly influenced by the procurement team. Contamination from endogenous sources can be controlled by donor selection. We discuss methods that can be used to decrease contamination and the rate of discarding of bone allografts.

Hemorrhagic fevers: few clues after 25 years.

There is a high prevalence of Ebola antibodies found in the Kenya population, related to geographical area and season, although the clinical disease was never found and the virus was not isolated. A field study was carried out in 7 hospitals in western Kenya, 1986 -1987 (including surveillance studies in suspect areas), to intensify collection and transport of samples, testing facilities, patient observation with record keeping and follow-up. This study involved 1109 admitted patients with fever and/or bleeding, 155 contacts of haemorrahagic fever antibody (Hfab) patients, and 916 people in suspect areas. Respectively 160,44 and 80 persons were found Hfab positive mainly to Ebola, using an indirect immunofluorescent assay. From 676 viral cultures no virus was isolated. A relationship between antibody titres and ecological factors, social habitat, age, sex or season was not found. The non-specificity of IF testing was demonstrated by: 1) the disagreement between the results of two reference laboratories; 2) the unpredictability of the titre conversation course; and 3) by proving a significant cross-reactivity with Borrelia burgdorferii antibodies, Plasmodium falcparum antibodies and Salmonella typhi antibodies. Renewed testing in 1995 of 90 positive sera (with low titres) showed 19 sera to be positive by Elisa (2 in Zaire, 1 in Sudan, 9 in Reston and 7 in Cote d'Ivoire) from which 4 were confirmed by IFI 2 in Reston and 2 in Cote d'Ivoire. These findings are more proof that non-human virulent strains of Filoviridae, especially Ebola virus, are around in Kenya.

Antibiotic resistance mechanisms in Salmonella species causing bacteraemia in Malawi and Kenya.

In two studies on the causative agents of bacteraemia in Malawi and Kenya, 33 Salmonella strains were isolated. Fourteen strains of Salmonella typhimurium and Salmonella enteritidis were found to exhibit resistance to amoxicillin, amoxicillin/clavulanic acid and cotrimoxazole as well as decreased susceptibility to a range of aminoglycosides. The resistant strains were studied to establish their resistance mechanisms. Beta-lactamase co-focusing with TEM-1 was present in 12 strains. In two strains, both S. typhimurium from Kenya, an OXA-1 beta-lactamase was detected. The aminoglycoside-modifying enzyme ANT(2") was found in 10 strains. The presence of the encoding genes was confirmed by PCR. For comparison, susceptibility records of 73 Salmonella strains isolated during the past 14 years in our hospital were studied retrospectively. Only one of these strains was resistant to amoxicillin. This resistance was acquired during therapy.

Hemorrhagic Fevers : Few Clues after 25 Years

There is a high prevalence of Ebola antibodies found in the Kenya population; related to geographical area and season; although the clinical disease was never found and the virus was not isolated. A field study was carried out in 7 hospitals in western Kenya; 1986 -1987 (including surveillance studies in suspect areas); to intensify collection and transport of samples; testing facilities; patient observation with record keeping and follow-up. This study involved 1109 admitted patients with fever and/or bleeding; 155 contacts of haemorrahagic fever antibody (Hfab) patients; and 916 people in suspect areas. Respectively 160;44 and 80 persons were found Hfab positive mainly to Ebola; using an indirect immunofluorescent assay. From 676 viral cultures no virus was isolated. A relationship between antibody titres and ecological factors; social habitat; age; sex or season was not found. The non-specificity of IF testing was demonstrated by: 1) the disagreement between the results of two reference laboratories; 2) the unpredictability of the titre conversation course; and 3) by proving a significant cross-reactivity with Borrelia burgdorferii antibodies; Plasmodium falcparum antibodies and Salmonella typhi antibodies. Renewed testing in 1995 of 90 positive sera (with low titres) showed 19 sera to be positive by Elisa (2 in Zaire; 1 in Sudan; 9 in Reston and 7 in Cote d'Ivoire) from which 4 were confirmed by IFI 2 in Reston and 2 in Cote d'Ivoire. These findings are more proof that non-human virulent strains of Filoviridae; especially Ebola virus; are around in Kenya

Analysis of hospital records in four African countries, 1975-1990, with emphasis on infectious diseases.

Detailed standardized annual reports are analysed for 17 rural hospitals in four African countries, with admission figures of 1.2 million patients (excluding deliveries) and more than 67,000 deaths over a period of 16 years. The countries involved are Zambia, Tanzania, Kenya and Ghana. Figures on admission, causes of death and clinical case fatality rates are presented per country and per 4-year calendar period for the most important infectious diseases. The number of admissions increased substantially in 3 of the 4 countries (50-77%) between 1976 and 1990, but admission rates (per 1,000 population per year) by much less (6-25%), indicating that a large part of the increase in the volume of services was due to population growth. The number of infectious disease admissions in Ghana, however, decreased by 12% and even more in terms of admission rates (by 42%). About 75% of all admissions in children below 15 years of age were due to infections and infection related diseases; for adults this figure was 31%. Malaria is the single most important infectious disease both in terms of admissions and as a cause of death; it has increased substantially in three of the four countries. Bacterial infections, in particular pneumonia, gastroenteritis, meningitis and tuberculosis, are also important diseases in terms of admissions and deaths. On the whole they have remained at more or less the same level in 1975-1990 in terms of both admissions and deaths. Immunizable diseases and measles, once important as causes of admissions and deaths, have declined in all countries. Case fatality rates vary substantially by type of disease. They are very high for tetanus (36.7-68.8%) and meningitis (14.7-43%), and low for malaria (0.6-4.6%). However, they vary considerably in the four countries included in the study and are usually lower in children than in adults. A need for detailed studies with good "standardized" hospital records is emphasized. Representative data are needed from all hospitals in a given catchment area, with defined diagnoses for diseases and details regarding age and sex. This kind of information is highly desirable for planning and operation of curative and preventive medical care in developing countries.

PIP: Two Dutch researchers analyzed detailed standardized annual reports from 17 mission hospitals in Ghana, Kenya, Tanzania, and Zambia to determine what can be learned from hospital records on the volume of medical services provided as well as on the incidence and seriousness of major diseases and their patterns of change during 1975-90. These hospitals had more than 1.2 million patients (excluding deliveries, neonates, and premature births) and 67,534 deaths. The number of hospital admissions increased considerably (50-77%) in all countries except Ghana. Yet admission rates (per 1000 population/year) rose at a much lower rate (6-25%) in the three countries, suggesting that population growth accounted for a large part of the increase. During 1975-90, in Ghana, the admission rates decreased by 42% and the number of infectious disease admissions fell by 12%. More than 50% of all admissions were for infectious diseases in Kenya and Tanzania compared to 33% for Zambia and 35% for Ghana. Children aged under 15 years were more likely to be admitted for an infection or infection-related disease than adults (75% vs. 31%). The most common infectious disease responsible for admissions and a cause of death was malaria, probably due to a slowly rising resistance in the malaria parasite, resistance to insecticides in the mosquito, and the decreased immunity of the population due to uncontrolled use of antimalarials. In three countries (except Zambia for admissions and Ghana for causes of death), malaria has risen considerably (p 0.001). The case fatality rate for meningitis had also increased significantly during 1975-90 (p 0.001). Other significant causes of admissions and deaths included pneumonia, gastroenteritis, and tuberculosis. In all four countries, immunizable diseases and measles have declined greatly (p 0.001). Case fatality rates (CFRs) were highest for tetanus (36.7-68.8%) and meningitis (14.7-43%) and lowest for malaria (0.6-4.6%). CFRs for malaria, gastroenteritis, and pneumonia were much higher in adults than in children. These type of data are needed for planning and the operation of curative and preventive care.

Bacteraemia in patients presenting with fever.

In three studies, in Ghana and Kenya, blood from 639 patients admitted with fever was cultured. Standard treatments were antimalarials (54-100%) and antibiotics (39-90%). According to the criteria in use, however, only 10-31% had malaria alone; of those who received antibiotics, 66% were diagnosed with malaria, gastrointestinal infections, post-operative recuperations, circulatory problems, central nervous system disorders or FUO, and did not need antibiotics at the first encounter. For those with wounds and abscesses (8%), generalised antibiotic treatment can also be questioned. Bacteraemia was found in 71 (11.3%) patients; in the HIV patients, however, 5 (23%) of 22 had bacteraemia. This is a minimum incidence, since culture techniques were not optimal for the isolation of fastidious microorganisms. The most prevalent organisms isolated were Salmonella, Klebsiella/Enterobacter and S. aureus. Resistance (intrinsic and extrinsic) in the Gram- bacteria was high: 31-100% were resistant to amoxycillin, 0-80% to cotrimoxazole, 15-95% to chloramphenicol and 9-15% to gentamicin. The need for cultures and sensitivity tests for patients with prolonged or undiagnosed fever is stressed. Specific treatment should be given only when infections, whether malarial or bacterial, have been positively diagnosed.

Native-valve endocarditis due to CDC coryneform group ANF-3: report of a case and review of corynebacterial endocarditis.

Endocarditis due to a bacterium of CDC coryneform group ANF-3 developed in the native aortic valve of a patient without predisposing factors other than valvular calcification. A review of the literature indicates that corynebacteria are an increasingly important cause of endocarditis. Problems in identification and treatment remain. Techniques for the culture and quick identification of these organisms and effective regimens for treatment of the infections they cause are needed.

Analysis of infectious diseases in rural tropical areas.

A study of 256 annual reports from 17 rural tropical hospitals in 4 African countries over a period of 16 years showed an absolute increase in the number of patients admitted with infectious diseases. Admissions were highest for malaria, followed by pneumonia and gastroenteritis. Admissions for immunisable diseases are decreasing in all countries. Fever remains the most important indicator of infectious diseases. Analysis of fever patients in rural tropical hospitals relies on knowledge of the epidemiology of diseases, plus expertise in physical examination. In this study, a detailed analysis of 900 fever patients indicated that 4% showed no infection, 21% of infections could be diagnosed by physical examination, 35% were diagnosed with the help of additional laboratory tests and 40% of patients were diagnosed as FUO (fever of unknown origin). 17% of FUO patients had a short, self limiting fever, but the remaining 23% were severely ill, suggesting bacterial sepsis, as was indicated by earlier studies. Undiagnosed fevers with resulting over-treatment and high resistance are costly and dangerous. These effects stress the need for better and more laboratory facilities, including possibilities for bacterial cultures. At present, patients are generally over-treated with antimalarials and antibiotics, since further diagnostic facilities are not available. Resistance is high for antimalatials ( Malaria) and for Amoxycillin, Cotrimoxazole and Gentamicin (Gram-bacteria from urine and blood).