Clonal dissemination of vanA positive Enterococcus species in tertiary care hospitals in Karachi, Pakistan

OBJECTIVE: To perform molecular typing of vancomycin resistant Enterococcus spp. (VRE) strains endemic in various hospitals of Karachi, to characterize the mechanism of glycopeptide resistance and assess the genetic relatedness, for understanding its transmission locally. METHOD: This was a cross sectional study conducted in the clinical and research laboratory of Aga Khan University Hospital (AKUH), Karachi, Pakistan from October 2007 to September 2008. Non-duplicate 86 (65 AKUH and 21 non-AKUH) VRE strains were included. Molecular typing of nosocomial isolates of VRE was carried out by using Pulsed field gel electrophoresis (PFGE) and identification of vanA and vanB genes were performed by conventional Polymerase Chain Reaction (PCR). RESULTS: Analysis of PFGE data by Tenover scheme showed single major pulsotype A with its subtypes A1, A2 and A3 present among different tertiary hospitals in Karachi. The dice coefficient of similarity among AKUH, non-AKUH and total 86 (AKUH and non-AKUH) had a value of 90%, 88% and 89% reflecting their clonal relatedness. In all 60/65 (92%) and 19/21 (90%) AKUH and non-AKUH isolates had vanA gene respectively. None had vanB gene. CONCLUSION: Molecular typing suggested that VRE isolates had same clonal origin indicating nosocomial transmission. Institution of strict infection control measures with active surveillance should be taken to avoid its further spread

Antimicrobial Susceptibility Testing of Neisseria Gonorrhoeae Isolates in Pakistan by Etest Compared to Calibrated Dichotomous Sensitivity and Clinical Laboratory Standards Institute Disc Diffusion Techniques.

Background Accurate detection of Neisseria gonorrhoeae antimicrobial resistance is essential for appropriate management and prevention of spread of infection in the community. In this study Calibrated Dichotomous Sensitivity (CDS) and Clinical Laboratory Standards Institute (CLSI) disc diffusion methods were compared with minimum inhibitory concentration (MIC) by Etest in Neisseria gonorrhoeae isolates from Karachi, Pakistan. CDS and CLSI disc diffusion techniques, and Etest for ceftriaxone, penicillin G, spectinomycin and ciprofloxacin against 100 isolates from years 2012–2014 were performed. Due to lack of CLSI breakpoints for azithromycin, it was interpreted using cut-offs from British Society of Antimicrobial Chemotherapy (BSAC). Due to lack of low concentration tetracycline discs, tetracycline was tested with CLSI disc diffusion and Etest only. Comparisons were based on the identified susceptibility, intermediate susceptibility and resistance (SIR) categories using the different methods. Complete percent agreement was percentage agreement achieved when test and reference method had identical SIR-category. Essential percent agreement was percentage agreement when minor discrepancies were disregarded. Results There was 100 % and 99 % overall essential agreement and 50 % versus 23 % overall complete agreement by CDS and CLSI methods, respectively, with MICs for all tested antibiotics. Using either method, there was 100 % complete agreement for ceftriaxone and spectinomycin. There was 90 % versus 86 % complete agreement for ciprofloxacin, and 60 % and 75 % for penicillin using CDS and CLSI method, respectively. Essential agreement of 99 % and complete agreement of 62 % was found for tetracycline with CLSI method. There was 100 % essential and complete agreement by CDS, BSAC and Etest for azithromycin. Conclusion No major errors with regard to identified SIR-categories were found for penicillin, ciprofloxacin, ceftriaxone and spectinomycin using CLSI and CDS methods. All isolates were susceptible to ceftriaxone and spectinomycin, and 99 % to azithromycin. In low-resource settings, both the CLSI and CDS disc diffusion techniques might be used for susceptibility testing of gonococcal isolates. However, these methods require considerable standardization and quality controls for adequate levels of reproducibility and correct interpretation to reflect appropriately the MIC values of the different antimicrobials. New, emerging, or rare resistance should be confirmed by MIC determination. Keywords Antimicrobial surveillance Neisseria gonorrhoeae CDS CLSI Disc diffusion Etes

Increasing Trend of Resistance to Penicillin, Tetracycline, and Fluoroquinolone Resistance in Neisseria gonorrhoeae from Pakistan (1992–2009)

Emergence and spread of drug resistant Neisseria gonorrhoeae is global concern. We evaluated trends of antimicrobial resistance in Neisseria gonorrhoeae over years 1992–2009 in Pakistan. Resistance rates were compared between years (2007–2009) and (1992–2006). Antimicrobial susceptibility testing was performed and interpreted according to Clinical Laboratory Standards Institute (CLSI) criteria using the disk diffusion methodology against penicillin, ceftriaxone, tetracycline and ofloxacin. Additional antibiotics tested in 100 strains isolated during 2007–2009, included cefotaxime, cefoxitin, cefuroxime, cefipime, ceftazidime, ceftizoxime, cefixime, cefpodoxime, spectinomycin and azithromycin. Neisseria gonorrhoeae ATCC 49226 was used as control. Chi-square for trend analysis was conducted to assess resistance trend over the study period. During study period significant increase in combined resistance to penicillin, tetracycline and ofloxacin was observed (P value <0.01). Resistance rates during the two study period also increased significantly (P value <0.01). Ceftriaxone resistance was not observed. None of the isolates were found to be resistant or with intermediate sensitivity to additional antibiotics. Our findings suggest that penicillin, ciprofloxacin, tetracycline should not be used in the empirical treatment of gonorrhea in Pakistan. Ceftriaxone and cefixime should be the first line therapy; however periodic MICs should be determined to identify emergence of strains with reduced susceptibility

Increase in isolation of extended spectrum beta lactamase producing multidrug resistant non typhoidal Salmonellae in Pakistan.

Background:Increasing resistance to quinolones and ceftriaxone in non typhoidal Salmonellae is a global concern. Resistance to quinolone and 3rd generation cephalosporin amongst non typhoidal Salmonellae (NTS) from Pakistan has been reported in this study. Methods: Retrospective analysis of laboratory data was conducted (1990-2006). NTS were isolated and identified from clinical samples using standard microbiological techniques. Antimicrobial susceptibility testing was performed by Kirby Bauer. Extended spectrum beta lactamase production (ESBL) was detected using combined disc method. Ciprofloxacin sensitivity was detected by nalidixic acid screening method. Minimum inhibitory concentration (MIC) of ciprofloxacin was determined by agar dilution method. Statistical analysis was performed using SPSS version 13. Results: Analysis of 1967 NTS isolates showed a significant increase in ciprofloxacin resistance from 23% in 2002 to 50.5% in 2006, with increased mean MIC values from 0.6 to 1.3 ug/mL. Ceftriaxone resistant NTS also increased and ESBL production was seen in 98.7% isolates. These isolates exhibited high resistance against amoxicillin clavulanic acid (57%), gentamicin (69%), amikacin (44%) and piperacillin tazobactam (30%). No resistance to carbapenem was seen. Ceftriaxone resistance was significantly higher in childrenyear, in invasive isolates and in Salmonella Typhimurium. Conclusion: Increase in quinolone and ceftriaxone NTS is a serious threat to public health requiring continuous surveillance and use of appropriate screening tests for laboratory detection

Increased isolation of ESBL producing Klebsiella pneumoniae with emergence of carbapenem resistant isolates in Pakistan: report from a tertiary care hospital

OBJECTIVE: To report trends of extended spectrum beta lactamase (ESBL), multidrug resistant (MDR) ESBL and emergence of carbapenem resistant ESBL producing isolates of K. pneumoniae from Pakistan. METHODS: Retrospective analysis of laboratory data was conducted (2002-2007). K. pneumoniae were isolated and identified from clinical samples using standard microbiological techniques. Antimicrobial susceptibility testing was performed by Kirby Bauer. ESBL was detected using combined disc method. Statistical analysis was performed using SPSS version 13. RESULTS: 15914 K. pneumoniae isolates (2002-2007) were analyzed. Significant increase in ESBL and MDR ESBL producing K. pneumoniae (p = or \u3c 0.0001) was observed. We found significant association of ESBL positive K. pneumoniae with age less than 10 years, males and blood isolates (p = 0.001). 0.4% (n=23) of ESBL positive isolates were carbapenem resistant. CONCLUSIONS: Increase in ESBL and carbapenem resistant K. pneumoniae is a serious threat to public health requiring continuous surveillance and use of appropriate screening tests for laboratory detection

A review of coronaviruses associated with Kawasaki Disease: Possible implications for pathogenesis of the Multisystem Inflammatory Syndrome associated with COVID-19

Multisystem Inflammatory Syndrome in Children (MIS-C), representing a new entity in the spectrum of manifestations of COVID-19, bears symptomatic resemblance with Kawasaki Disease (KD). This review explores the possible associations between KD and the human coronaviruses and discusses the pathophysiological similarities between KD and MIS-C and proposes implications for the pathogenesis of MIS-C in COVID-19. Since 2005, when a case-control study demonstrated the association of a strain of human coronavirus with KD, several studies have provided evidence regarding the association of different strains of the human coronaviruses with KD. Thus, the emergence of the KD-like disease MIS-C in COVID-19 may not be an unprecedented phenomenon. KD and MIS-C share a range of similarities in pathophysiology and possibly even genetics. Both share features of a cytokine storm, leading to a systemic inflammatory response and oxidative stress that may cause vasculitis and precipitate multi-organ failure. Moreover, antibody-dependent enhancement, a phenomenon demonstrated in previous coronaviruses, and the possible superantigenic behavior of SARS-CoV-2, possibly may also contribute toward the pathogenesis of MIS-C. Lastly, there is some evidence of complement-mediated microvascular injury in COVID-19, as well as of endotheliitis. Genetics may also represent a possible link between MIS-C and KD, with variations in FcγRII and IL-6 genes potentially increasing susceptibility to both conditions. Early detection and treatment are essential for the management of MIS-C in COVID-19. By highlighting the potential pathophysiological mechanisms that contribute to MIS-C, our review holds important implications for diagnostics, management, and further research of this rare manifestation of COVID-19

The many guises of primary hyperparathyroidism… an unchanged scenario

Abstract OBJECTIVE: To study the causes, characteristics and outcome of treatment of patients with primary hyperparathyroidism. METHODS: This retrospective cohort analysis was conducted at the Jinnah Postgraduate Medical Centre, Karachi, and comprised data of patients with primary hyperparathyroidism between 2004 and 2014. .SPSS 17 was used for data analysis. RESULTS: Of the 25 patients,1(4%)was male and 24(96%) were female. The overall mean age was 41.72±15.9 years, with a mean duration of symptoms of 4.1±3.3 years. The mean pre-operative parathyroid hormone level was 879.48±793.51 pg/ml. Skeletal manifestations were reported in 17(68%) patients, whereas 4(16%) patients had renal stone disease. Besides, 2(8.0%) patients presented with severe abdominal pain, 1(4%) had asymptomatic hypercalcaemia and 1(4%) patient presented with headache and was diagnosed as parathyroid adenoma in the context of multiple endocrine neoplasia type 2A. All patients underwent parathyroidectomy. A solitary adenoma was reported in 23(92%) patients, carcinoma in 1(4%) and an adenoma with hyperplasia of other glands in 1(4%) patient. CONCLUSIONS: A high index of suspicion is required for early diagnosis of primary hyperparathyroidism

Clinical isolates of salmonella enterica serovar agona producing NDM-1 metallo-beta-lactamase: first report from Pakistan

We report two cases of infantile diarrhea due to multidrug-resistant, NDM-1 metallo-beta-lactamase-producing Salmonella enterica serovar Agona from Pakistan. This study alerts toward possible risk of NDM-1 transmission to enteric fever pathogens and encourages microbiologists to consider active screening of carbapenem resistance in nontyphoidal Salmonella isolates

Emergence of quinolone-resistant Neisseria gonorrhoeae in Pakistan

Quinolone-resistant Neisseria gonorrhoeae (QRNG) have not been reported from Pakistan to date. This is the first report of the presence of QRNG in Pakistan. The study was performed at a tertiary care hospital laboratory in Karachi, Pakistan. Antimicrobial susceptibility data on all N. gonorrhoeae isolated between 1992 and 2002 were retrieved and analysed. Minimum inhibitory concentrations (MICs) of QRNG isolated in year 2002 were performed, and clinical information was collected. QRNG was first noted in 1999 and its proportion increased to 42% in 2002. MICs of the 12 isolates tested in 2002 showed a high level of resistance to ofloxacin with MIC of more than 4 microg/mL. Clinical information from patients with QRNG showed treatment failure. Emergence of QRNG in developing countries is alarming as there is no proper surveillance of increase in resistance. We strongly urge the need of detection and documentation of the resistant gonococcal isolates, as in vitro resistance is associated with clinical failure

Delayed diagnosis in Vitamin D – dependent rickets type II results in severe skeletal deformities

Vitamin D-dependent Rickets Type II (VDDR-II) is a rare autosomal recessive disorder caused by a vitamin D receptor gene mutation, leading to end-organ resistance to 1,25-dihydroxyvitamin D 1,25(OH)2D. We aimed to investigate two cases of VDDR-II. Case 1 was of a 14-year old male, presenting with bone pains, bowing of legs, multiple bone deformities, and fractures since childhood. On examination, Chvostek's and Trousseau's signs were positive, and there was no alopecia. Case 2 was a 15-year old male who presented with pain in both legs since childhood and difficulty in walking lately. Upon investigation, it was found that bowing of legs, and Chvostek's and Trousseau's signs were positive. Both cases had severe hypocalcaemia, normal/low phosphate levels, and high alkaline phosphatase (ALP). ---Continu