Readiness for antimicrobial resistance (AMR) surveillance in Pakistan; a model for laboratory strengthening

Background: Limited capacity of laboratories for antimicrobial susceptibility testing (AST) presents a critical diagnostic bottleneck in resource limited countries. This paper aims to identify such gaps and to explore whether laboratory networks could contribute towards improving AST in low resource settings. Methods: A self-assessment tool to assess antimicrobial susceptibility testing capacity was administered as a pre-workshop activity to participants from 30 microbiology laboratories in 3 cities in Pakistan. Data from public and private laboratories was analyzed and capacity of each scored in percentage terms. Laboratories from Karachi were invited to join a support network. A cohort of five laboratories that consented were provided additional training and updates sessions over a period of 15 months. Impact of training activities in these laboratories was evaluated using a point scoring (0-11) tool. Results: Results of self-assessment component identified a number of areas that required strengthening (scores of ≤60%). These included; readiness for AMR surveillance; 38 and 46%, quality assurance; 49 and 55%, and detection of specific organisms; 56 and 60% for public and private laboratories respectively. No significant difference was detected in AST capacity between public and private laboratories [ANOVA; p \u3e 0.05]. Scoring tool used to assess impact of training within the longitudinal cohort showed an increase from a baseline of 1-5.5 (August 2015) to improved post training scores of 7-11 (October 2016) for the 5 laboratories included. Moreover, statistical analysis using paired t-Test Analysis, assuming unequal variance, indicated that the increase in scored noted represents a statistically significant improvement in the components evaluated [p \u3c 0.05]. Conclusion: Strengthening of laboratory capacity for AMR surveillance is important. Our data shows that close mentoring and support can help enhance capacity for antimicrobial sensitivity testing in resource limited settings. Our study further presents a model wherein laboratory networks can be successfully established and used towards improving diagnostic capacity in such setting

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Effect of Intravenous Immunoglobulin in Reducing Bilirubin Levels in Hemolytic Disease of Newborn

Background: To assess the efficacy of intravenous immunoglobulins in reducing the duration of phototherapy and the need for exchange transfusion in neonates with Rh and/or ABO incompatibility. Methods: In this descriptive study 60 patients diagnosed with hemolytic disease of newborn were grouped into group A and B. All neonates were treated with standard protocol for phototherapy and exchange transfusion. Group A patients received intravenous immunoglobulins in a dose of 0.5gm/kg of body weight and phototherapy.Group B received only phototherapy. Exchange transfusion was given to the patients of both groups if the bilirubin reached 20mg/dl or more, or rose by 0.5 mg/dl per hour. Results:Mean pre and post treatment bilirubin levels were 14.87+ 4.45, 15.37+4.85 and 14.05+ 2.48, 14.35+1.97 mg/dl in group A and B respectively. Improvement in bilirubin level was significant in group A 82.75% vs 48.38 % (CI: 95%, P-value 0.005). Similarly phototherapy duration was reduced in the same group 86.2% vs 16.1% (p-0.000). Exchange transfusion and hospital stay were also reduced in group A 3.4% vs 48.4%, 35.49 % vs 86.20% (95% CI, P=0.000) respectively. Conclusion: Addition of intravenous immunoglobulins for treatment of hemolytic disease of newborn significantly reduces bilirubin levels, duration of phototherapy, need for exchange transfusion and hospital stay

Efficacy of Vitamin C in Reducing Duration of Severe Pneumonia in Children

Background : To determine the efficacy of vitamin C in reducing duration of severe pneumonia in childrenMethods: In this descriptive study children suffering from pneumonia , under age 5 were enrolled.. In vitamin C group (n=111), patient received 200mg of vitamin C once daily and in other group 111 children received placebo drops which matched exactly in color and taste. Clinical progress of both groups was taken thrice daily in terms of oxygen saturation, respiratory rate and chest in drawing.Results: Among 222 children, majority (61.71%) were male and 85(38.28%) were female. Majority (58.55%) were infants, 29.72% were between 1-3 years and 11.71% were between 4-5 years(15.14+7.76 months). Oxygen saturation was improved in < 01 day (p=0.003) and respiratory rate was improved in < 04 days (p=0.03) in vitamin C group. No statistically significant difference was found in chest in drawing.Conclusion: Vitamin C is effective in reducing duration of severe pneumonia in children less than five years of age

Additional file 3: of Readiness for antimicrobial resistance (AMR) surveillance in Pakistan; a model for laboratory strengthening

Questionnaire to evaluate impact of knowledge based intervention on laboratory performance during study period. Presents questionnaire used for evaluating impact of knowledge based intervention on laboratory performance during the study period. (DOCX 12 kb

Additional file 2: of Readiness for antimicrobial resistance (AMR) surveillance in Pakistan; a model for laboratory strengthening

Scoring method used including percentage scores for each question in a given category. Total scores and percentage scores for each category of laboratory capacity for both public and private sector are also presented. Presents the scores including total percentage of public and private sector in each category as well as the individual scores in the different components that constituted a particular category. (DOCX 25 kb

Effect of Antiplatelet Therapy on Survival and Organ Support–Free Days in Critically Ill Patients With COVID-19

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