Chlamydia trachomatis in women with pelvic inflammatory disease (PID): report from a tertiary center in eastern Nepal.

Chlamydia trachomatis is an important agent of pelvic inflammatory disease (PID) globally. Laboratory diagnosis, which is vital for early and appropriate treatment, remains a challenge in resource-limited settings. Our study was undertaken to detect C. trachomatis in women with clinical features of PID. Three endocervical swabs, each obtained from 100 women clinically diagnosed with PID, were subjected to C. trachomatis antigen detection, microscopy and bacteriological culture. Logistic regression was used to assess the risk factors associated with PID. C. trachomatis antigen was present in 6%. The use of hormonal contraception, previous history of PID and a smoking habit were found to have statistically significant association in those who tested positive. Adjunctive use of rapid Chlamydia antigen test with a routinely practiced syndromic approach is beneficial for timely and appropriate antimicrobial therapy in women with PID.

Outcome of Endoscopic Variceal Band Ligation.

INTRODUCTION: Bleeding from esophageal varices in cirrhosis is an emergent condition with high mortality. One of the preferred modality of treating esophageal varices is EVL. We aimed to find out the outcome of EVL in controlling acute esophageal variceal bleeding, prophylactic banding to prevent future bleeding and the number of sessions required for complete eradication of varices. METHODS: This descriptive observational study was carried out in Gastroenterology and Hepatology unit of Bir Hospital, NAMS from June 2016 to May 2017. Consecutive cases who presented in emergency room with acute variceal bleeding due to liver cirrhosis and cases of liver cirrhosis with large varices and red color signs on endoscopic examination were enrolled. They underwent EVL and subsequent re-endoscope at one month interval till the eradication of varices was achieved. RESULTS: Among 83 patients, 15 (18.1%) were of Child Pugh class A, 29 (34.9%) B and 39 (47%) were of C. In 20 (24.1%) cases varices could be eradicated in one session of EVL while 57 (68.7%) required two sessions and in 6 (7.2%) cases it took three sessions. Total average EVL session required for obliteration of esophageal varices was 1.84±0.53. There was only one (1.2%) of early re-bleeding post EVL. CONCLUSIONS: EVL is an effective modality of treatment in controlling acute esophageal variceal bleeding, in preventing future variceal bleeding as well as in eradicating esophageal varices with very few complications.

Acute Upper Gastrointestinal Bleeding in a Tertiary Care Centre of Nepal.

INTRODUCTION: AUGIB is characterized by hematemesis or melena or both. Peptic ulcers and variceal bleed account for majority of cases. Use of proton pump inhibitors in current era is associated with a gradual reduction in burden of peptic ulcer disease. We conducted this study to look into the cause of AUGIB in our community. METHODS: We studied 100 patients in one year period who presented to us with hematemesis or melena. The study was conducted in department of Gastroenterology, Bir hospital, Kathmandu. We identified the culprit lesions by upper gastrointestinal endoscopy. RESULTS: The average age of patients with AUGIB was 51.6 years with 59 (59%) males. Duodenal ulcers are most common 29 (29%), followed by varices 23 (23%) and gastric ulcers 14 (14%). More than one lesion was identified in 38 (38%) patients. Patients with variceal bleed were more likely to present with hematemesis alone as compared to those with ulcer bleed (P=0.005). Variceal bleed patients presented earlier to the hospital (P=0.005), had lower MAP at presentation (P=0.0002), had lower hemoglobin level (P=0.0001) and higher serum creatinine level at presentation (P=0.001). Patients with variceal bleed were more likely to have consumed alcohol 20 (86.9%) and patients with ulcer bleed were more likely to be smokers 29 (67.4%) or consume tobacco 14 (32.5%) (P=0.006). CONCLUSIONS: Ulcer related bleeding is still the most common cause of AUGIB. Many patients with AUGIB have more than one lesions identified during upper gastrointestinal endoscopy.

Colorectal Cancer in Different Age Groups in a Tertiary Hospital in Nepal.

INTRODUCTION: Some studies have suggested that colorectal cancer at a younger age had distinct biological characteristics: different clinical presentations, more advanced stage at time of diagnosis and poorly differentiated carcinoma. The aim of the study is to analyze clinical and histopathological differences between younger (≤40 years of age) and older (>40 years of age) colorectal cancer patients. METHODS: A cross-sectional analysis was conducted amongst the colorectal cancer patients who visited Bir Hospital between July 2015 and April 2017. All colonoscopically diagnosed and histopathologically proven cases of colon cancer were included. Chi-square test and independent t - test was performed to analyze the difference between clinical presentations and histopathological findings among two groups of patients and P value of <0.05 was considered as significant. RESULTS: Thirty younger patients and thirty older patients were enrolled without any differences in gender proportion. There were no statistical differences between clinical presentation and histological grade and type in younger and older patients. The younger patients had more complaints of altered bowel habit (P <0.001) while older patients mostly presented with per rectal bleeding (P< 0.008). CONCLUSIONS: In this study, colorectal cancer at younger ages showed similar characteristics to those of older patients except altered bowel habit was more common in younger patients while per rectal bleeding was more common in older patients. Although colorectal cancer incidence increases with age, younger patients with altered bowel habits, weight loss, anemia and anorexia should also be given due medical attention and undergo evaluation promptly.

Efficacy of Prophylactic use of Ciprofloxacin and Metronidazole in Mild and Moderately Severe Acute Pancreatitis.

INTRODUCTION: There are new concepts and developments in the diagnosis and management of acute pancreatitis. Current evidence suggests that there is no role of prophylactic antibiotics use in acute pancreatitis. However, it is still a common practice to administer prophylactic antibiotics in a country like Nepal. So, we have conducted a study in mild and moderately severe acute pancreatitis to study the efficacy of prophylactic antibiotics. METHODS: A case control study was conducted among 76 patients comparing efficacy of prophylactic antibiotics versus no antibiotics in patients with mild and moderately severe acute pancreatitis. RESULTS: The two most common etiology of acute pancreatitis in AG and NAG were alcohol 21 (55.2%) vs. 24 (63.1%) and biliary 10 (26.3%) vs. 4 (10.5%) respectively. Pancreatic necrosis was seen in five (13.1 %) in AG and four (10.5%) in NAG. Four (10.5%) developed extra pancreatic complications in AG and five (13.1%) in NAG. There was one (2.6%) death in AG and no death in NAG. Abdominal pain improvement seen in AG vs. NAG was 3.2 days vs. 2.4 days (P=0.002). The hospital stay was 7.7±2.23 days in AG and 7.5±1.85 days in NAG (P=0.65). CONCLUSIONS: The routine use of prophylactic antibiotics for mild and moderately severe acute pancreatitis is not associated with improvement in meaningful clinical outcomes.

Tobacco and alcohol: the relation to pulmonary tuberculosis in household contacts.

Tuberculosis is transmitted commonly by droplet nuclei and facilitated by weak immune system. Lowered immunity may be associated with cigarette smoking, tobacco chewing and alcohol consumption. The co-relationship between these all factors to TB should be explored. This study aims to detect the hidden household contacts (HC) cases early and to examine the relative contribution of tobacco and alcohol use to the risk of TB. Across-sectional study was in Dharan among HCs. From June 2009 to May 2010, 184 index cases with sputum smear positive for AFB and their 802 HCs were included. Three sputum specimens were collected from each HCs and examined microscopically for AFB detection. AFB were detected in sputum of 13 (1.6%) HCs. The association between habits (alcohol user and smoking) and TB was found except with chewing tobacco user (P > 0.05). The risk of contact TB was 4 and 8 times greater in smoker (OR = 3.94 95% CI = 1.26-12.26, P < 0.05) and alcoholic (OR = 8.23 95% CI = 2.71-24.98, P < 0.05) HCs respectively. This study has revealed smoking and alcohols as the risk factors for tuberculosis. Effective campaign to discourage use of alcohol and tobacco, and awareness programme about the mode of transmission of TB are needed in community.

In vitro activity of cefoperazone-sulbactam combination against gram negative bacilli.

Cefoperazone is a â-lactam antimicrobial and Sulbactam is an irreversible â-lactamase inhibitor. The objective of this study was to know the susceptibility pattern of gram negative bacilli (GNB) towards cefoperazone-sulbactum. All GNB isolated from different clinical samples during the period of May, 2010 to Aug, 2010 were tested for susceptibility to cefoperazone-sulbactum, meropenem, ceftazidime, cefotaxime, ceftriaxone, chloromphenicol, cotrimoxazole, ampicillin, amikacin, nalidixic acid, ciprofloxacin, carbenicillin and piperacillin using standard Kirby-Bauer disc diffusion antimicrobial susceptibility testing method. The susceptibilities were recorded according to CLSI guidelines. A total of 406 GNB were isolated (urine: 66.7%, pus: 19.2%, and blood: 7.9%). Escherichia coli (54.4%) was most frequently isolated organisms followed by Acinetobacter species (17.7%), Klebsiella pneumoniae (9.1%) and Pseudomonas species (6.1%). Overall, 11.8% of isolates showed resistance to cefoperazone-sulbactam. Frequencies of isolates showing resistance to meropenem and amikacin were 14.7% and 26.25% respectively. Only 3.9% of Escherichia coli isolates showed resistance to cefoperazone-sulbactam. For other organisms, their lowest frequency ranging from 0-20%, exhibited resistance to meropenem. In Pseudomonas spp, in-vitro activity of amikacin was also better as only 11.1% isolates showed resistance to it. This study demonstrated the in-vitro synergistic effect of cefoperazonerazone-sulbactam and meropenem having good activity against GNB compared to the activity of other commonly tested antimicrobials. Cefoperazone-sulbactam can be recommended for the clinical practice against GNB exhibiting resistant to other antimicrobials as it is cheaper alternative to meropenem. Our results also focused on the continuous surveillance of the trends and features of resistance of common antimicrobials.

Etiological agents of corneal ulcer: five years prospective study in eastern Nepal.

To identify the most common isolates from the corneal ulcers with antimicrobial pattern of bacterial isolates. All patients with suspected corneal ulceration presenting to BP Koirala Institute of Health Sciences from Jan 2004 - Dec 2008 were evaluated. Corneal scraping was performed and processed for direct microscopy, bacteriological and fungal culture. Bacterial isolates were subjected to antimicrobial susceptibility testing. Of 351 specimens examined, growth of etiological agents were obtained in 278 (79.20%). Of these, 113 (40.65%) had pure fungal growth, 108 (38.85%) had pure bacterial growth and 57 (20.50%) had mixed fungal and bacterial infection. The commonest fungal pathogen was Aspergillus spp 50 (33.33%) followed by Fusarium spp 19 (12.66%). Staphylococcal aureus 57 (44.53%) was isolated as commonest bacterial agent. Coagulase Negative Staphylococci 20 (15.6%) was second in the list. Pseudomonas spp 12 (9.40%) was the most common gram negative bacilli isolated. Most of the bacterial isolates were sensitive to commonly used antibiotics. Corneal Ulcer is a common problem in eastern Nepal. Knowledge of both fungal and bacterial agents associated with this condition is of value for the prevention and management of corneal ulcers and their complications.

Prevalence of tuberculosis in household contacts of sputum smears positive cases and associated demographic risk factors.

Pulmonary tuberculosis (PTB) is transmitted by aerosolized droplets nuclei. Home is the vulnerable place for transmission of this disease to its contacts. Risk factors associated with this contact transmission may differ according to locality. This study aims to determine the prevalence of household contact (HC) PTB and examine the risk factors contributing to it. A cross-sectional study was conducted to determine the prevalence of HC TB among HCs aged > 5 years in Dharan. During the study period (June 2009 - May 2010), 184 index cases with sputum smear positive for AFB and their 802 HCs were included. Three sputum specimens were collected from each HCs and examined microscopically for AFB detection. The prevalence of HC TB was found to be 1.6%. The result was statistically associated (P < 0.05) with illiterate HCs (OR= 5.77, 95%CI =1.52-21.81), close proximity with ICs (OR=3.07, 95%CI = 1.02-9.25), primary relatives to ICs (OR= 4.85, 95%CI = 1.07-22.05) and slum dweller (OR = 4.56, 95%CI = 1.25-16.71). Similarly, AFB positivity was associated (P<0.05) with household crowding (OR = 7.46, 95%CI = 2.36-23.49), room size < or = 10 x 10 feet (OR=4.05, 95%CI = 1.23-13.25), firewood user while cooking (OR = 5.96, 95%CI = 1.92-18.45). The prevalence of HCs tuberculosis is found to be 1.6%. Poverty, illiteracy, overcrowding, close proximity, close relation with ICs, firewood while cooking, slum dweller, are major factors highlighted by this study as risk factors of contact TB. Our results recommend a much better contact tracing and treatment program.

Antimicrobial resistant Streptococcus pneumoniae.

INTRODUCTION: Pneumococcal infections are important cause of morbidity and mortality. Knowledge of antimicrobial susceptibility patterns plays important role in the selection of appropriate therapy. Present study was undertaken to analyze the susceptibility patterns of pneumococcal isolates against commonly used antimicrobials with special reference to determination of minimum inhibitory concentration (MIC) of penicillin in a tertiary care hospital in eastern Nepal. METHODS: Twenty-six strains of S. pneumoniae isolated from various clinical specimens submitted to microbiology laboratory were evaluated. All isolates were tested for antimicrobial susceptibility by disk diffusion method. MIC of penicillin was tested by broth dilution method. RESULTS: Of the total isolates 19 (73%) were from invasive infections. Seven isolates were resistant to cotrimoxazole. No resistance to penicillin was seen in disk diffusion testing. Less susceptibility to penicillin (MIC 0.1-1.0 mg/L) was observed in five (17%) isolates. High level resistance to penicillin was not detected. One isolate was multidrug resistant. CONCLUSIONS: S. pneumoniae isolates with intermediate resistance to penicillin prevail in Tertiary Care Hospital in eastern Nepal, causing invasive and noninvasive infections. As intermediate resistance is not detected in routine susceptibility testing, determination of MIC is important. It helps not only in the effective management of life threatening infections but is also essential in continuous monitoring and early detection of resistance. In addition, further study on pneumococcal infections, its antimicrobial resistance profile and correlation with clinical and epidemiological features including serotypes and group prevalence is recommended in future.