Correction: Tear Samples for Protein Extraction: Comparative Analysis of Schirmer's Test Strip and Microcapillary Tube Methods.

[This corrects the article DOI: 10.7759/cureus.50972.].

A multicentre study to determine the in vitro efficacy of flomoxef against extended-spectrum beta-lactamase producing Escherichia coli in Malaysia.

Background: The high burden of extended-spectrum beta-lactamase-producing (ESBL)-producing Enterobacterales worldwide, especially in the densely populated South East Asia poses a significant threat to the global transmission of antibiotic resistance. Molecular surveillance of ESBL-producing pathogens in this region is vital for understanding the local epidemiology, informing treatment choices, and addressing the regional and global implications of antibiotic resistance. Methods: Therefore, an inventory surveillance of the ESBL-Escherichia coli (ESBL-EC) isolates responsible for infections in Malaysian hospitals was conducted. Additionally, the in vitro efficacy of flomoxef and other established antibiotics against ESBL-EC was evaluated. Results: A total of 127 non-repetitive ESBL-EC strains isolated from clinical samples were collected during a multicentre study performed in five representative Malaysian hospitals. Of all the isolates, 33.9% were isolated from surgical site infections and 85.8% were hospital-acquired infections. High rates of resistance to cefotaxime (100%), cefepime (100%), aztreonam (100%) and trimethoprim-sulfamethoxazole (100%) were observed based on the broth microdilution test. Carbapenems remained the most effective antibiotics against the ESBL-EC, followed by flomoxef. Antibiotic resistance genes were identified by PCR. The blaCTX-M-1 was the most prevalent ESBL gene, with 28 isolates (22%) harbouring blaCTX-M-1 only, 27 isolates (21.3%) co-harbouring blaCTX-M-1 and blaTEM, and ten isolates (7.9%) co-harbouring blaCTX-M-1, blaTEM and blaSHV. A generalised linear model showed significant antibacterial activity of imipenem against different types of infection. Besides carbapenems, this study also demonstrated a satisfactory antibacterial activity of flomoxef (81.9%) on ESBL-EC, regardless of the types of ESBL genes.

Knowledge, Attitude and Practice of Hand Hygiene among Healthcare Workers Caring for Children with Leukaemia in the Paediatric Oncology Ward of King Saud Medical City, Saudi Arabia.

Background: Hands are the most common vehicle of pathogen transmission in a healthcare setting. Therefore, hand hygiene is the leading method of reducing healthcare-associated infections. This study aimed to determine the knowledge, attitude and practice (KAP) of hand hygiene and predictors for poor hand hygiene practice among healthcare workers who care for children with leukaemia in the paediatric oncology ward of King Saud Medical City (KSMC) in Saudi Arabia. Methods: One hundred and ninety medical doctors and nurses, who were registered with the Saudi Commission for Health Specialities, were selected to participate in this cross-sectional study using a simple sampling technique. Their KAP of hand hygiene was assessed using a self-structured questionnaire and the collected data was analysed using IBM® SPSS® version 26.0. Results: Of the 190 healthcare workers, 74.7% were nurses and 25.3% were medical doctors. Among the participants, 53.7% (102) had good knowledge of hand hygiene, 51.6% (98) had positive attitudes towards hand hygiene and 55.8% (106) practised satisfactory hand hygiene. Bachelor education level (adjusted OR = 2.736; 95% CI = 1.101, 6.799; P = 0.030), postgraduate education level (adjusted OR = 6.256; 95% CI = 2.171, 18.028; P = 0.001), poor knowledge (adjusted OR =2.575; 95% CI = 1.263, 5.246; P = 0.009) and negative attitude (adjusted OR = 4.702; 95% CI = 1.263, 5.246; P < 0.001) were the significant predictor variables of unsatisfactory hand hygiene practice among healthcare workers. Conclusion: The performance of hand hygiene among healthcare workers is still far less than optimal, particularly in settings like oncology units. Effective programmes are needed to increase their awareness of hand hygiene KAP, while strict guidelines are needed to reduce nosocomial infections.

Tear Samples for Protein Extraction: Comparative Analysis of Schirmer's Test Strip and Microcapillary Tube Methods.

INTRODUCTION: Tear sampling is an attractive option for collecting biological samples in ophthalmology clinics, as it offers a non-invasive alternative to other invasive techniques. However, there are many tear sampling methods still in consideration. This study explores the suitability of Schirmer's test strip and microcapillary tube as reliable and satisfactory methods for tear sampling. METHODS: Tear samples were collected from eight healthy volunteers using the standard Schirmer's test strip method with or without anesthesia and microcapillary tubes. The total tear protein concentrations were analyzed via spectrophotometry and bicinchoninic acid (BCA) protein assay. The protein profile was determined by sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE). The optimal wetting length of Schirmer's strip and suitable buffer solutions were compared. Discomfort levels reported by participants and the ease of execution for ophthalmologists were also evaluated. RESULTS: Tear samples exhibited typical protein profiles as shown by SDS-PAGE. The mean total protein obtained from an optimum wetting length of 20 mm using Schirmer's strip without anesthesia in phosphate-buffered saline (PBS) yielded substantial quantities of protein as measured by nanophotometer (220.20 ± 67.43 µg) and the BCA protein assay (210.34 ± 59.46 µg). This method collected a significantly higher quantity of protein compared to the microcapillary tube method (p=0.004) which was much more difficult to standardize. The clinician found it harder to utilize microcapillary tubes, while participants experienced higher insecurity and less discomfort with the microcapillary tube method. PBS used during the tear protein extraction process eluted higher tear protein concentration than ammonium bicarbonate, although the difference was not statistically significant. Using anaesthesia did not ease the sampling procedure substantially and protein quantity was maintained. CONCLUSION: Good quality and quantity of protein from tear samples were extracted with the optimized procedure. Schirmer's strip test in the absence of local anesthesia provided a standard, convenient, and non-invasive method for tear collection.

A systematic review of the epidemiology of Hepatitis E virus infection in South - Eastern Asia.

Hepatitis E virus (HEV) infection is an emerging zoonotic viral disease, with an increasingly international public health challenge. Despite the concerns that the global disease burden may be underestimated. Therefore, evaluation of the disease epidemiology in South - eastern Asia through a systematic review will assist in unraveling the burden of the disease in the subregion. A priori protocol was prepared for the systematic review and followed by a literature search involving five electronic databases. Identified publications were screened for high quality studies and the elimination of bias and relevant data extracted. A total of 4157 citations were captured, and only 35 were included in the review. A wide range of HEV seroprevalence was recorded from 2% (urban blood donors in Malaysia) to 77.7% (lowland communities in Lao PDR). Sporadic HEV infection and epidemics were also detected in the subregion. Indicating hyperendemicity of the disease in South - eastern Asia.

Significant Clinical Presentation of Leptospirosis in Relation to Sociodemographic and Risk Factors in a Tertiary Hospital, Malaysia.

Introduction: Incidence of leptospirosis has increased within the past few years in many countries. Its clinical presentations were generally nonspecific, making it difficult to assist in the diagnosis. Besides the determination of the common clinical features, the sociodemographic background is essential to identify high-risk populations to assist in prevention. Methods: Data for this study were obtained from electronic medical records among patients clinically diagnosed with leptospirosis at a tertiary hospital in Malaysia from the years 2011 to 2015 and were recorded using standard pro forma. Associations between clinical features and sociodemographics were performed using bivariate analysis and logistic regression. Results: Data were collected from 283 patients. Their mean age was 30.71 years old. Out of 283 patients, 206 (72.8%) were male. Involvement in outdoor events and water activities was the highest risk factor of acquiring leptospirosis in 64 (22.7%) patients followed by 59 (20.8%) patients who were staying in crowded housing areas with poor sanitation. Although fever was the main clinical presentation in 274 (96.8%) patients with leptospirosis, gastrointestinal (GIT) symptoms were the second most frequent in 159 (56.2%) patients followed by pulmonary symptoms, myalgia, headache, and jaundice. From the total number of 283 patients, only 21 (92.6%) presented with severe leptospirosis. GIT symptoms were a significant predictor for leptospirosis severity, while the age group was the significant sociodemographic factor toward GIT presentation in leptospirosis. The relationship between GIT symptoms and crowded housing areas with poor sanitation was also significant. Multivariable logistic regression showed that crowded housing areas with poor sanitation (odds ratio [OR] = 3.570, p < 0.001) and age between 20 and 40 years old (OR = 2.056, p = 0.014) were more likely to have GIT symptoms. Conclusions: Information regarding the clinical features of leptospirosis to the public is necessary, while targeted prevention by educational outreach among 20-40 year olds especially those participating in outdoor water activities are crucial to decrease the incidence and complications of leptospirosis.

Elevated levels of IL-8 in fatal leptospirosis.

Leptospirosis causes a wide range of clinical outcomes, including organ failure and death. Early treatment significantly increases the chances of cure. Interleukin-8 (IL-8) is a chemoattractant cytokine for neutrophil and is associated with multiple organ failure. Research has indicated IL-8 to be raised in severe and fatal cases of leptospirosis, but its suitability as a prognostic biomarker has yet to be confirmed. This study aimed to evaluate the significance of IL-8 with the clinical outcomes of leptospirosis patients. Plasma IL-8 was measured in fifty-two samples from hospitalized patients and nineteen healthy controls. The comparisons were made between mild, severe-survived and fatal groups identified by clinical or laboratory findings. IL-8 was significantly higher in fatal (p = 0.01) compared to mild cases. IL-8 was also significantly higher in fatal (p = 0.02) when compared to survived cases of leptospirosis. IL-8 levels in the plasma of fatal leptospirosis cases were significantly elevated compared to survived cases and may serve as a potential prognostic biomarker in determining the possible outcome of leptospirosis patients.

Hypocalcemia, hypochloremia, and eosinopenia as clinical predictors of leptospirosis: A retrospective study.

BACKGROUND: Underestimation of leptospirosis cases is happening in many countries. The most common factor of underreporting is misdiagnosis. Considering the limitations of direct detection of pathogen and serological diagnosis for leptospirosis, clinical features and blood tests though non-specific are usually referred in making presumptive diagnosis to decide disease management. METHODS: In this single-centre retrospective study, comparative analysis on clinical presentations and laboratory findings was performed between confirmed leptospirosis versus non-leptospirosis cases. RESULTS: In multivariate logistic regression evidenced by a Hosmer-Lemeshow significance value of 0.979 and Nagelkerke R square of 0.426, the predictors of a leptospirosis case are hypocalcemia (calcium <2.10mmol/L), hypochloremia (chloride <98mmol/L), and eosinopenia (absolute eosinophil count <0.040×109/L). The proposed diagnostic scoring model has a discriminatory power with area under the curve (AUC) 0.761 (p<0.001). A score value of 6 reflected a sensitivity of 0.762, specificity of 0.655, a positive predictive value of 0.38, negative predictive value of 0.91, a positive likelihood ratios of 2.21, and a negative likelihood ratios of 0.36. CONCLUSION: With further validation in clinical settings, implementation of this diagnostic scoring model is helpful to manage presumed leptospirosis especially in the absence of leptospirosis confirmatory tests.

Raised levels of Il-6, Il-17a, and Il-22 in fatal leptospirosis.

Clinical manifestations of leptospirosis range from mild, common cold-like illness, to a life-threatening condition. The host immune response has been hypothesized to play a major role in leptospirosis outcome. Increased levels of inflammatory mediators, such as cytokines, may promote tissue damage that lead to increased disease severity. The question is whether cytokines levels may predict the outcome of leptospirosis and guide patient management. This study aimed to assess the association between Th1-, Th2-, and Th17-related cytokines with the clinical outcome of patients with leptospirosis. Different cytokine levels were measured in fifty-two plasma samples of hospitalized patients diagnosed with leptospirosis in Malaysia (January 2016-December 2017). Patients were divided into two separate categories: survived (n = 40) and fatal outcome (n = 12). Nineteen plasma samples from healthy individuals were obtained as controls. Cytokine quantification was performed using Simple Plex™ assays from ProteinSimple (San Jose, CA, USA). Measurements were done in triplicate and statistical analysis was performed using GraphPad software and SPSS v20. IL-6 (p = 0.033), IL-17A (p = 0.022), and IL-22 (p = 0.046) were significantly elevated in fatal cases. IL-17A concentration (OR 1.115; 95% CI 1.010-1.231) appeared to be an independent predictor of fatality of leptospirosis. Significantly higher levels of TNF-α (p ≤ 0.0001), IL-6 (p ≤ 0.0001), IL-10 (p ≤ 0.0001), IL-12 (p ≤ 0.0001), IL17A (p ≤ 0.0001), and IL-18 (p ≤ 0.0001) were observed among leptospirosis patients in comparison with healthy controls. Our study shows that certain cytokine levels may serve as possible prognostic biomarkers in leptospirosis patients.

A Low Prevalence of Inducible Macrolide, Lincosamide, and Streptogramin B Resistance Phenotype among Methicillin-Susceptible Staphylococcus aureus Isolated from Malaysian Patients and Healthy Individuals.

BACKGROUND: Antibiotic resistance among Staphylococcus aureus is of great concern worldwide. This resistance is further complicated by the ability of S. aureus to confer cross-resistance to other antibiotics due to the presence of resistance genes, such as erythromycin resistance methylase (erm) genes, which render the bacterium resistant to macrolide-lincosamide-streptogramin B (MLSB) antibiotics. Resistance to these antibiotics can lead to therapeutic failure, resulting in significant morbidity and mortality in patients with S. aureus infections. OBJECTIVES: This study was performed to examine the distribution of MLSB-resistant strains of methicillin-susceptible S. aureus (MSSA), which were obtained from hospitalized patients and normal healthy individuals (carriers) using phenotypic methods, such as the double-disk diffusion (D-test) and the genotypic method by polymerase chain reaction (PCR). METHODS: A total of 183 nonduplicative MSSA isolates obtained from hospitalized patients (133) and carriers (50) in our previous studies were randomly selected for the D-test. The guidelines of the Clinical and Laboratory Standards Institute (CLSI) were used for the interpretation of the results of this test. The detection of ermA, ermB, ermC and msrA genes by PCR was performed for isolates that had positive D-test results and that were resistant to erythromycin. RESULTS: Of the 183 MSSA isolates, 97.2% and 98.4% were highly susceptible to erythromycin and clindamycin, respectively. MSLB resistance was detected in four isolates (2.2%). Of the 133 MSSA isolated from hospitalized patients, only 3.0% (4/133) and 2.3% (3/133) exhibited resistance to erythromycin and clindamycin, respectively. With regard to the MLSB resistance phenotypes, only 1.6% and 0.6% exhibited inducible MLSB (iMLSB) and MS phenotypes, respectively. The ermC gene was detected in all three iMLSB phenotypes, and the msrA gene was detected in the MS phenotype. Surprisingly, all MSSA isolates (100%) from carriers exhibited extremely high susceptibility to both antibiotics. CONCLUSIONS: The prevalence rates of iMLSB MSSA isolates vary according to geographical locations and the local antibiotic policy. The low prevalence rate of iMLSB MSSA isolates could probably be related to the judicious use of antibiotics for treating S. aureus infections in our studied population. Nonetheless, continuous antibiotic surveillance is still necessary to control any emergence of resistance isolates so that targeted therapy and effective control can be implemented accordingly.

Genotypic characterization of Streptococcus pneumoniae serotype 19F in Malaysia.

Streptococcus pneumoniae is an epidemiologically important bacterial pathogen. Recently, we reported the antibiotic susceptibility patterns of a limited collection of pneumococcal isolates in Malaysia with a high prevalence of erythromycin resistant strains. In the present study, 55 of the pneumococcal isolates of serotype 19F were further analysed by pulsed field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). The generated genotypic patterns were then correlated with the antibiograms previously reported. Forty-seven different PFGE profiles (PTs) were obtained, showing that the isolates were genetically diverse. MLST identified 16 sequence types (STs) with ST-236 being predominant (58.2%), followed by ST-81 (10.3%). Among the ST-236 isolates, 22 were erythromycin resistant S. pneumoniae (ERSP) and 15 were trimethoprim/sulfamethoxazole (TMP/SMX) resistant, while among ST-81, four isolates were ERSP and two were TMP/SMX resistant. The high prevalence of erythromycin resistant serotype 19F isolates of ST-236 in this study has also been reported in other North and South East Asian countries.