Genetic diversity of Plasmodium vivax clinical isolates from southern Pakistan using pvcsp and pvmsp1 genetic markers

Background: Plasmodium vivax is the prevalent malarial species accounting for 70% of malaria burden in Pakistan; however, there is no baseline data on the circulating genotypes. Studies have shown that polymorphic loci of gene encoding antigens pvcsp and pvmsp1 can be used reliably for conducting molecular epidemiological studies. Therefore, this study aimed to bridge the existing knowledge gap on population structure on P. vivax from Pakistan using these two polymorphic genes. Methods: During the period January 2008 to May 2009, a total of 250 blood samples were collected from patients tested slide positive for P. vivax, at the Aga Khan University Hospital, Karachi, or its collection units located in Baluchistan and Sindh Province. Nested PCR/RFLP was performed, using pvcsp and pvmsp1 markers to detect the extent of genetic diversity in clinical isolates of P. vivax from southern Pakistan. Results: A total of 227/250 (91%) isolates were included in the analysis while the remainder were excluded due to negative PCR outcome for P.vivax. Pvcsp analysis showed that both VK 210 (85.5%, 194/227) and VK 247 type (14.5%, 33/227) were found to be circulating in P. vivax isolates from southern Pakistan. A total of sixteen and eighty-seven genotypes of pvcsp and pvmsp-1 were detected respectively. Conculsion: This is the first report from southern Pakistan on characterization of P. vivax isolates confirming that extensively diverse pvcsp and pvmsp1 variants are present within this region. Results from this study provide valuable data on genetic diversity of P. vivax that will be helpful for further epidemiological studies

A comparison of fluoroquinolones versus other antibiotics for treating enteric fever: meta-analysis

Objectives To review evidence supporting use of fluoroquinolones as first line agents over other antibiotics for treating typhoid and paratyphoid fever (enteric fever)

Antimicrobial Resistance Among Neonatal Pathogens in Developing Countries

Introduction: Knowledge of antimicrobial resistance and trends in resistance patterns among major pathogens causing infections in young infants (up to 90 days of life) is an important component or developing community-based management strategies. Hospital-based data suggest alarming rates of resistance to ampicillin and gentamicin, the first-line antimicrobial agents recommended by WHO for treatment of serious infections in young infants. Methods: We searched the literature published since 1990 for studies front developing countries reporting resistance among serious community-acquired infections (including sepsis, pneumonia, and meningitis) in young infants. Results: Only 10 relevant reports were retrieved. Among the 3 major Pathogens studied (Escherichia coli, Staphyloccoccus aureus, and Klebsiella species), a high proportion of E. coli were ampicillin (72%) and cotrimoxazole (78%) resistant, 19% were resistant to third generation cephalosporins. Among Klebsiella species, almost all were resistant to ampicillin, 45% to cotrimoxazole, and 66% to third generation cephalosporins. Resistance to gentamicin was low among E. coli (13%), but much higher among Klebsiella species (60%). Methicillin resistance S. aureus (MRSA) was rare (1 of 33 isolates) but 46% were resistant to cotrimoxazole. Conclusions: Antimicrobial resistance data for infections in young infants, from community-based studies were extremely limited. Significant resistance, in particular 10 contrimoxazole among all pathogens, and to gentamicin and third generation cephalosporins among Klebsiella and emerging resistance in E. coli is cause for concern. Limited data pose a challenge in devising simple community-based management strategies. Further studies From different developing Country regions are needed to determine prevalence of resistant strains, as well as assess regional and time trends

Pathogens Associated With Sepsis in Newborns and Young Infants in Developing Countries

Introduction: Knowledge of pathogens causing infections in young infants (up to 90 days of life) is essential for devising community-based management strategies. Most etiological data from developing countries are hospital-based and may have little relevance to communities in which most babies are born at home. Methods: We searched the literature for studies from developing countries reporting etiology of community-acquired infections (sepsis, pneumonia, meningitis) published since 1980. Hospital-based studies reporting early onset sepsis, sepsis among babies admitted from, or born at home were included. Results: Of 63 studies, 13 focused on community-acquired infections, but limited data were available from home-born neonates. In the first week of life (3209 isolates), Klebsiella species (25%), Escherichia coli (15%), and Staphylococcus aureus (18%) were major pathogens. Group B streptococci (GBS) were relatively uncommon (7%), although regional differences existed. After the first week of life (835 isolates),. aureus (14%): GBS (12%), Streptococcus pnemoniae (12%). and nontyphoidal Salmonella species (13%) were most frequent. S. pneumoniae (27%) was most common in the postneonatal period (among 141 isolates). Gram-negatives predominated (77%) among home-delivered babies (among 170 isolates). Conclusions: Limited information is available on etiology of serious bacterial infections in community settings. Hospital-based studies suggest that most infections in the first week of life are due to Gram-negative pathogens, and many may be environmentally rather than maternally-acquired, owing to unhygienic delivery practices. Such practices may also explain the predominance of Gram-negative infections among home-born infants, although data from home settings are limited. These findings have implications for developing prevention and management strategies in communities and hospitals

Assessing the need for training: general practitioners knowledge, attitude and practice concerning dengue and malaria in Karachi, Pakistan

Changing environmental conditions have increased the transmission period for both dengue and malaria. Annual incidence of malaria in 2006 alone was 247 million cases leading to nearly 881 000 deaths; whereas another 50 to 100 million dengue infections, associated with an overall mortality of 2.5%, are expected each year. In Pakistan, like many developing nations with endemic malaria, an empirical clinical diagnosis is usually made, due to a lack of resources and availability of diagnostic facilities. Since both diseases are endemic in the same population and presenting symptoms are similar a thorough knowledge of both diseases is essential for improving diagnosis on clinical grounds. Thus our study aims were to evaluate knowledge, attitudes and practices of family medicine practitioners with regard to dengue and malaria and thereby assess the need for further training. Ninety consenting general practitioners (GPs) in different towns of Karachi, Pakistan were administered an extensive questionnaire of 50 questions regarding their knowledge, attitudes and practices on management of dengue and malaria. The authors concluded that despite possessing basic knowledge of the disease, the majority of GPs in the area needed training regarding both diseases and their management. Key targets identified for training programs included clinical diagnosis and management of endemic vector borne diseases

Management of Newborn Infections in Primary Care Settings A Review of the Evidence and Implications for Policy?

Background: Long-term, sustainable programs to address high incidence and death rates from neonatal infections are required for improving child survival. There is an urgent need to define the role of community-based management for neonates with serious bacterial infections-both at home and at first-level facilities. Methods: We reviewed available evidence for community-based antibiotic management strategies for serious neonatal infections. Results: Nine distinct studies contributing data for community-based management of neonatal pneumonia and sepsis were identified. In a pooled analysis of 5 controlled trials of community-based management of neonatal pneumonia (4 using cotrimoxazole, 1 ampicillin, or penicillin), all-cause neonatal mortality showed 27% [95% confidence interval (CI): 18%-35%] reduction and pneumonia-specific mortality, 42% (95% CI: 22%-0 57%). Substantial reductions in neonatal mortality have been demonstrated in a nonrandomized controlled study in rural India (62% reduction, P \u3c 0.001) and in a cluster randomized trial in rural Bangladesh (34% reduction, 95% CI: 7%-53%). Reduced case fatalities (0%-3%) with community-based management of neonatal sepsis were observed in 2 small uncontrolled studies from India and Guatemala and a recent randomized trial from Pakistan. Conclusions: Although methodological limitations preclude estimating the precise contribution of antibiotics toward neonatal mortality reduction in community settings in low income Countries, available data suggest substantial benefit of case management approaches using antibiotics for neonatal sepsis in such settings

Physician and Nurse Practitioner Attitudes on Generic Prescribing of Oral Contraceptive Pills and Antidepressants

ImportanceAs prescription drug costs rise, it is important to understand attitudes among primary care physicians and nurse practitioners (NPs) towards generic drugs.ObjectiveWe aimed to examine the generic skepticism index (GSI) among primary care clinicians, and their willingness to discuss and prescribe generic antidepressants (ADs) and generic oral contraceptives (OCPs).DesignWe used a factorial vignette design survey to test 4 factors: message source, message, brand preference, and drug class. Participants were randomized to different combinations of factors.SettingThis was a cross-sectional study.ParticipantsPhysicians registered with the American College of Physicians (ACP) and NPs registered with the American Association of Nurse Practitioners (AANP) participated in the study.Main measuresThe primary outcomes were generic skepticism as measured using the generic skepticism index (GSI), and clinician willingness to discuss and prescribe generics.ResultsSurveys were completed by 56% of physicians (n = 369/661) and 60% of NPs (n = 493/819). Compared with physicians, NPs were younger (p < 0.001), predominantly female (p < 0.001), and differed in the race (p < 0.001). According to the GSI, 16% (n = 138/862) were identified as generic skeptics (18.5% of NPs and 12.7% of physicians, p = 0.023). Generic skeptics had lower odds of willingness to discuss switching (OR 0.22, 95% CI (0.14-0.35), p < 0.001) or prescribe (OR 0.18, 95% CI (0.11-0.28), p < 0.001) generic OCPs. Participants had lower odds of willingness to prescribe generic drugs to patients with brand preference compared with brand-neutral patients (OR 0.64, 95% CI 0.50-0.82, p < 0.001).Conclusions and relevanceGeneric skepticism was associated with lower willingness to discuss or prescribe generic drugs. Clinicians reported lower willingness to discuss switching or prescribe generics for OCPs than for ADs. Patient brand preference hindered generic prescribing. Message source and message type were not significantly associated with outcomes