Has Data Quality of an Antimicrobial Resistance Surveillance System in a Province of Nepal Improved between 2019 and 2022?

An operational research study was conducted in 2019 to assess the quality of data submitted by antimicrobial resistance (AMR) surveillance sites in the Bagmati Province of Nepal to the National Public Health Laboratory for Global Antimicrobial Resistance and Use Surveillance System (GLASS). Measures were implemented to enhance the quality of AMR surveillance by strengthening capacity, improving infrastructure, implementing data sharing guidelines, and supervision. The current study examined reports submitted by surveillance sites in the same province in 2022 to assess whether the data quality had improved since 2019. The availability of infrastructure at the sites was assessed. Of the nine surveillance sites in the province, seven submitted reports in 2022 versus five in 2019. Completeness in reporting improved significantly from 19% in 2019 to 100% in 2022 (p < 0.001). Timely reports were received from two sites in 2019 and only one site in 2022. Specimen-pathogen consistency in accordance with the GLASS guidelines for urine, feces, and genital swab specimens improved, with ≥90% consistency at all sites. Overall, the pathogen-antibacterial consistency improved significantly for each GLASS priority pathogen. The study highlights the importance of dedicated infrastructure and institutional arrangements for AMR surveillance. Similar assessments covering all provinces of the country can provide a more complete country-wide picture.

Detection of Beta-Lactamases (ESBL and MBL) Producing Gram-Negative Pathogens in National Public Health Laboratory of Nepal.

Background: Bacterial resistance to antibiotics has increased in recent years. Resistance to ß-lactams in Gram-negative bacteria has been reported to be associated with extended spectrum beta-lactamases and metallo-beta-lactamases. This study was aimed at determining the distribution and antibiotic susceptibility patterns of Gram-negative pathogens producing extended spectrum beta lactamases and metallo-beta lactamases. Method and Methodology. This cross-sectional study was conducted at the National Public Health Laboratory during a period of six months. All clinical specimens were obtained and processed for the identification of Gram-negative pathogens by culture, morphological, and biochemical tests. Antibiotic susceptibility testing of the isolates was performed by the Kirby Bauer disc diffusion and the isolates were tested for ESBL and MBL by the combined disk method. Results: Out of 4266 clinical specimens, 197 (4.6%) were found to be Gram-negative bacterial isolates. 47 (23.9%) isolates were ESBL producers. The most predominant organisms were Escherichia coli (53%), Klebsiella pneumonia (23%), and Pseudomonas spp. (13%). 16 (8.2%) were positive for MBL producers, and 6(3.1%) were both ESBL and MBL producers. The MBL activity was seen in E. coli (38%), followed by Pseudomonas spp. (31%), and K. pneumoniae (19%). The ESBL producers showed a higher degree of sensitivity towards imipenem and amikacin, followed by piperacillin tazobactam. MBL producers showed sensitivity towards amikacin only. Conclusion: The prevalence of ESBL and MBL producing Gram-negative bacteria was found to be high in bacterial infections in Nepal. Routine laboratory testing for ESBL and MBL is needed in order to optimize antibiotic management and reduce the risk of spread of infections caused by ESBL and MBL producers.

Quality Assessment of an Antimicrobial Resistance Surveillance System in a Province of Nepal.

Antimicrobial resistance (AMR) is a global problem, and Nepal is no exception. Countries are expected to report annually to the World Health Organization on their AMR surveillance progress through a Global Antimicrobial Resistance Surveillance System, in which Nepal enrolled in 2017. We assessed the quality of AMR surveillance data during 2019-2020 at nine surveillance sites in Province 3 of Nepal for completeness, consistency, and timeliness and examined barriers for non-reporting sites. Here, we present the results of this cross-sectional descriptive study of secondary AMR data from five reporting sites and barriers identified through a structured questionnaire completed by representatives at the five reporting and four non-reporting sites. Among the 1584 records from the reporting sites assessed for consistency and completeness, 77-92% were consistent and 88-100% were complete, with inter-site variation. Data from two sites were received by the 15th day of the following month, whereas receipt was delayed by a mean of 175 days at three other sites. All four non-reporting sites lacked dedicated data personnel, and two lacked computers. The AMR surveillance data collection process needs improvement in completeness, consistency, and timeliness. Non-reporting sites need support to meet the specific requirements for data compilation and sharing.

Rifampicin-resistant Mycobacterium tuberculosis by GeneXpert MTB/RIF and Associated Factors Among Presumptive Pulmonary Tuberculosis Patients in Nepal.

BACKGROUND: Mycobacterium tuberculosis(MTB) remains a major public health problem worldwide, and emergence of drug-resistant TB has become a significant obstacle to effective TB control. However, the rate of MTB and rifampicin resistant-MTB (RR-MTB) in the Nepalese setting has not been studied extensively. Therefore, the present study aims to assess the rate of MTB and RR-MTB and further determine the factors associated with it. METHODS: A retrospective cross-sectional study, among national representative data of 990 consecutive presumptive TB resister of patients subjected to the GeneXpert test that presented to the tuberculosis referral hospital, was conducted over a one year period from February 2018 to January 2019. Significance for the difference for categorical data was performed by Chi-square test and factors associated with MTB and RR-MTB were assessed using binary logistic regression yielding OR with 95%CI. RESULTS: Of total 990 presumptive tuberculosis analyzed cases, median ages of the patients were 39±19.09 years and two-thirds of the patients were male 653 (66.0%). The estimated prevalence of MTB in presumptive TB patients was 13.8% (95%CI: 11.88%-16.16%), and risk for MTB was significantly associated with previously treated patients: OR: 10.4 (P<0.001). The estimated prevalence of RR-MTB in MTB confirmed patients was 10.2% (4.97%-15.1%). Our study confirmed no association of RR-TB with age, sex, ethnicity, geographical diversity and previous history of treatment failure (P>0.05). CONCLUSION: The overall prevalence of MTB and RR-MTB was high in Nepalese study population,  and that being previously treated with anti-TB drug remained significant predictors for MTB; proactive measures are urgently needed to address the challenge of prompt diagnosis, early management and improved monitoring of treatment to limit the emergence drug-resistant MTB strains in the community.

Sema3A chemorepellant regulates the timing and patterning of dental nerves during development of incisor tooth germ.

Semaphorin 3A (Sema3A) axon repellant serves multiple developmental functions. Sema3A mRNAs are expressed in epithelial and mesenchymal components of the developing incisor in a dynamic manner. Here, we investigate the functions of Sema3A during development of incisors using Sema3A-deficient mice. We analyze histomorphogenesis and innervation of mandibular incisors using immunohistochemistry as well as computed tomography and thick tissue confocal imaging. Whereas no apparent disturbances in histomorphogenesis or hard tissue formation of Sema3A (-/-) incisors were observed, nerve fibers were prematurely seen in the presumptive dental mesenchyme of the bud stage Sema3A (-/-) tooth germ. Later, nerves were ectopically present in the Sema3A (-/-) dental papilla mesenchyme during the cap and bell stages, whereas in the Sema3A (+/+) mice the first nerve fibers were seen in the pulp after the onset of dental hard tissue formation. However, no apparent topographic differences in innervation pattern or nerve fasciculation were seen inside the pulp between postnatal and adult Sema3A (+/+) or Sema3A (-/-) incisors. In contrast, an abnormally large number of nerves and arborizations were observed in the Sema3A (-/-) developing dental follicle target field and periodontium and, unlike in the wild-type mice, nerve fibers were abundant in the labial periodontium. Of note, the observed defects appeared to be mostly corrected in the adult incisors. The expressions of Ngf and Gdnf neurotrophins and their receptors were not altered in the Sema3A (-/-) postnatal incisor or trigeminal ganglion, respectively. Thus, Sema3A is an essential, locally produced chemorepellant, which by creating mesenchymal exclusion areas, regulates the timing and patterning of the dental nerves during the development of incisor tooth germ.

Semaphorin 3A controls timing and patterning of the dental pulp innervation.

Timing and patterning of dental pulp innervation are strictly spatio-temporally regulated but it is still not known how they are controlled at molecular level. We analyzed postnatal innervation of the dental pulp in the mandibular first molar of mice deficient for Semaphorin 3A (Sema3A) axon repellant molecule. Immunohistochemical localization of nerve fibers on serial sections covering the whole tooth germs using anti-peripherin antibody revealed that nerve fibers were prematurely present within the preodontoblast layer next to the inner enamel epithelium already at PN0 in Sema3A(-/-) mice. In contrast, in the wild-type (Sema3A(+/+)) mice nerve fibers were seen in the pulp only after enamel formation at PN3. The nerves in Sema3A(-/-) pulp were notably defasciculated and thinner compared to that of Sema3A(+/+) mice. A premature formation of an abnormal, enlarged nerve plexus with a high number of arborizations was apparent in the pulp-dentin border target area in Sema3A(-/-) already at PN2 whereas in the wild-type mice the first sign of plexus formation was seen at PN7. The expression of mRNAs for Ngf, Gdnf and Ncam neuroregulatory molecules in mandibular molar as well as receptors for neurotrophic factors and class 3 semaphorins including Sema3A (TrkA, p75, TrkB, TrkC, Ret, Npn1, Npn2, PlxA4) in trigeminal ganglia were not altered in the Sema3A(-/-) mice. Collectively, this data show that Sema3A serves an essential role in molar tooth pulp innervation controlling the timing of nerve fiber penetration into the pulp, their patterning and the formation of nerve plexus at pulp-dentin border area, and provide further support for the hypothesis that tooth innervation is regulated by the coordinated activity of locally expressed neuroregulatory molecules exerting positive and negative influences on growing dental nerve fibers.

Developmentally regulated expression of Sema3A chemorepellant in the developing mouse incisor.

OBJECTIVE: Semaphorin 3A (Sema3A) is an essential chemorepellant controlling peripheral axon pathfinding and patterning, but also serves non-neuronal cellular functions. Incisors of rodent are distinctive from molars as they erupt continuously, have only one root and enamel is present only on the labial side. The aim of this study is to address putative regulatory roles of Sema3A chemorepellant in the development of incisor innervation and formation. MATERIALS AND METHODS: This study analyzed expression of Sema3A mRNAs during embryonic and early post-natal stages of mouse mandibular incisor using sectional radioactive in situ hybridization. RESULTS: Although Sema3A mRNAs were observed in condensed dental mesenchyme during the early bud stage, they were absent in dental papilla or pulp at later stages. Sema3A mRNAs were observed in the dental epithelium including the cervical loops and a prominent expression was also seen in alveolar bone. Interestingly, transcripts were absent from the mesenchymal dental follicle target area (future periodontal ligament) throughout the studied stages. CONCLUSION: The expression patterns of Sema3A indicate that it may control the timing and patterning of the incisor innervation. In particular, Sema3A appears to regulate innervation of the periodontal ligament, while nerve penetration into the incisor dental pulp appears not to be dependent on Sema3A. Moreover, Sema3A may regulate the functions of cervical loops and the development of alveolar bone. Future study with Sema3A deficient mice will help to elucidate the putative neuronal and non-neuronal functions of Sema3A in incisor tooth development.