Clinical manifestation and outcomes of multi-drug resistant (MDR) Raoultella terrigena infection – A case series at Indus Health Network, Karachi, Pakistan

Background and objectives: There is paucity of literature available on Raoultella terrigena infection. Microbiological identification of Raoultella terrigena is difficult and isolates are frequently misidentified as Klebsiella species. This series of 3 cases with Raoultella terrigena septicemia provides a description of the pitfalls and challenges in the diagnosis and management of the highly resistant strains isolated and to the best of our knowledge, is the first report from Pakistan. Methods: The medical records of 3 cases of R. terrigena reported in the hospital over two months were reviewed retrospectively to record all relevant clinical information. Organism was identified by using Analytical profile index (API) 20 E with 90–95% successful identification and the sensitivity testing was performed by disc diffusion method. Results: This organism caused fulminant sepsis in case 2 resulting in mortality and complicated urinary tract infection in the third, while in case 1 it preceded the fatal candidemia. All three patients were females who had multiple co-morbid and had a history of protracted hospital stay and antibiotic usage elsewhere before being shifted to our hospital. The isolates were resistant to all beta lactams and were even colistin resistant in two patients, creating challenges and suboptimal response for effective antibiotic therapy. Conclusions: The purpose of this case series is to highlight the highly drug resistant profile of this organism and the fulminant infection it can cause, which if spreads in our hospitals due to breaches in infection control practices, can pose risk as a deadly and untreatable nosocomial infection. Keywords: Raoultella terrigena, Extensively drug resistant, Nosocomial infectio

Determinants of in-hospital mortality in COVID-19; a prospective cohort study from Pakistan.

A prospective cohort study was conducted at the Indus Hospital Karachi, Pakistan between March and June 2020 to estimate the in-hospital mortality among hospitalized COVID-19 patients and its determinants. A total of 170 adult patients were enrolled and all-cause mortality was found to be 39% (67/170). Most non-survivors were above 60 years of age (64%) while gender distribution was quite similar in both groups (males: 77% vs 78%). Most (80.6%) non-survivors came with peripheral oxygen saturation less than 93% while 95% of them had critical disease on arrival. Use of non-invasive ventilation in emergency room was higher among non-survivors (56.7%) versus survivors (26.2%). Median Interleukin-6 levels were higher among non-survivors (78.6: IQR = 33.8-49.0) compared to survivors (21.8: IQR = 12.6-36.3). Most patients in the non-survivor group (86.6%) required invasive ventilator support during hospital stay compared to 7.8% in the survivors. The median duration of ICU stay was longer for non-survivors (9: IQR = 6-12) compared to survivors (5: IQR = 3-7) days. Univariable binary logistic regression showed that age above 60 years, oxygen saturation below 93%, Neutrophil to lymphocyte ratio above 5, procalcitonin above 2ng/ml, unit increase in SOFA score and arterial lactate levels were associated with mortality. We also found that a unit decrease in Pao2/FiO2 ratio and serum albumin were associated with mortality in our patients. Multivariable regression showed that age above 60 years (aOR = 3.4: 95% CI = 1.6-6.9), peripheral oxygen saturation below 93% (aOR = 3.5:95% CI = 1.6-7.7) and serum pro-calcitonin above 2ng/ml (aOR = 4.8; 95% CI = 1.9-12.2) were associated with higher odds of mortality when adjusted by month of admission. Most common cause of death was multisystem organ failure in 35 (56.6%) non-survivors while 22 (35.5%) died due to respiratory failure. Larger prospective studies are needed to further strengthen these findings

The value of open-source clinical science in pandemic response: lessons from ISARIC

International audienc