Nocardia brasiliensis primary pulmonary nocardiosis with subcutaneous involvement in an immunocompetent patient

This is a report of an unusual case of Nocardia brasiliensis causing primary pulmonary nocardiosis with disseminated subcutaneous lesions in an immunocompetent patient. This case highlights the importance of considering nocardiosis as a differential diagnosis in patients with pulmonary and cutaneous lesions and the need for vigorous management for complete cure.

Substance Use among Medical Students in Kathmandu Valley

Introduction: Substance use including tobacco and alcohol is the most important cause of preventable morbidity, disability, and premature mortality. The study aims to specify the prevalence and the pattern of use of different substance. Methods: A cross sectional study was performed amongst first year and final year students in four medical colleges in Kathmandu using self administered anonymous questionnaire.Data collectedfrom 446 students were analyzed. Results: Prevalence of substance use was found to be 60.3% among the medical students. Alcohol (57.6%) was the substance most prevalently used followed by tobacco (27.58%) and cannabis (12.8%). Mean age of first exposure was 17.94 (Confidence interval: 17.91-17.97). There was significant difference in the useof tobacco and cannabis amongst final year students than first year students. Male and female differed significantly in use of every substance except for benzodiazepine. Medical college, college and school were place of first exposure in 17.26%, 15.92% and 13.23% of the cases respectively. Family history was associated with substance use in medical students and was statistically significant (P<0.0001).Experimentation was the major reason for the use of most of the substances. Conclusions: Substance use is prevalent in male medical students of both first and final year. Hence steps should be initiated early in school, college and medical college to prevent substance use. Keywords: alcohol, medical students, substance use, tobacco.

Substance use among medical students in Kathmandu valley

INTRODUCTION

Substance use including tobacco and alcohol is the most important cause of preventable morbidity, disability, and premature mortality. The study aims to specify the prevalence and the pattern of use of different substance.

METHODS

A cross sectional study was performed amongst first year and final year students in four medical colleges in Kathmandu using self administered anonymous questionnaire.Data collectedfrom 446 students were analyzed.

RESULTS

Prevalence of substance use was found to be 60.3% among the medical students. Alcohol (57.6%) was the substance most prevalently used followed by tobacco (27.58%) and cannabis (12.8%). Mean age of first exposure was 17.94 (Confidence interval: 17.91-17.97). There was significant difference in the useof tobacco and cannabis amongst final year students than first year students. Male and female differed significantly in use of every substance except for benzodiazepine. Medical college, college and school were place of first exposure in 17.26%, 15.92% and 13.23% of the cases respectively. Family history was associated with substance use in medical students and was statistically significant (P<0.0001).Experimentation was the major reason for the use of most of the substances.

CONCLUSIONS

Substance use is prevalent in male medical students of both first and final year. Hence steps should be initiated early in school, college and medical college to prevent substance use.

Antimicrobial Resistant Streptococcus pneumoniae

Introduction: Pneumococcal infections are important cause of morbidity and mortality. Knowledge of antimicrobial susceptibility patterns plays important role in the selection of appropriate therapy.  Present study was undertaken to analyze the susceptibility patterns of pneumococcal isolates against  commonly used antimicrobials with special reference to determination of minimum inhibitory  concentration (MIC) of penicillin in a tertiary care hospital in eastern Nepal. Methods: Twenty-six strains of S. pneumoniae isolated from various clinical specimens submitted to microbiology laboratory were evaluated. All isolates were tested for antimicrobial susceptibility by  disk diffusion method. MIC of penicillin was tested by broth dilution method. Results: Of the total isolates 19 (73%) were from invasive infections. Seven isolates were resistant to cotrimoxazole. No resistance to penicillin was seen in disk diffusion testing. Less susceptibility to penicillin (MIC 0.1-1.0 mg/L) was observed in five (17%) isolates. High level resistance to penicillin was not detected. One isolate was multidrug resistant. Conclusions: S. pneumoniaeisolates with intermediate resistance to penicillin prevail in Tertiary Care Hospital in eastern Nepal, causing invasive and noninvasive infections. As intermediate resistance is not detected in routine susceptibility testing, determination of MIC is important. It helps not only in the effective management of life threatening infections but is also essential in continuous monitoring and early detection of resistance. In addition, further study on pneumococcal infections, its antimicrobial resistance profile and correlation with clinical and epidemiological features including serotypes and group prevalence is recommended in future. Keywords: antimicrobial susceptibility pattern, penicillin, Streptococcus pneumoniae.

Antimicrobial resistant Streptococcus pneumoniae

INTRODUCTION

Pneumococcal infections are important cause of morbidity and mortality. Knowledge of antimicrobial susceptibility patterns plays important role in the selection of appropriate therapy. Present study was undertaken to analyze the susceptibility patterns of pneumococcal isolates against commonly used antimicrobials with special reference to determination of minimum inhibitory concentration (MIC) of penicillin in a tertiary care hospital in eastern Nepal.

METHODS

Twenty-six strains of S. pneumoniae isolated from various clinical specimens submitted to microbiology laboratory were evaluated. All isolates were tested for antimicrobial susceptibility by disk diffusion method. MIC of penicillin was tested by broth dilution method.

RESULTS

Of the total isolates 19 (73%) were from invasive infections. Seven isolates were resistant to cotrimoxazole. No resistance to penicillin was seen in disk diffusion testing. Less susceptibility to penicillin (MIC 0.1-1.0 mg/L) was observed in five (17%) isolates. High level resistance to penicillin was not detected. One isolate was multidrug resistant.

CONCLUSIONS

S. pneumoniae isolates with intermediate resistance to penicillin prevail in Tertiary Care Hospital in eastern Nepal, causing invasive and noninvasive infections. As intermediate resistance is not detected in routine susceptibility testing, determination of MIC is important. It helps not only in the effective management of life threatening infections but is also essential in continuous monitoring and early detection of resistance. In addition, further study on pneumococcal infections, its antimicrobial resistance profile and correlation with clinical and epidemiological features including serotypes and group prevalence is recommended in future.

Peritonitis in Continuous Ambulatory Peritoneal Dialysis

INTRODUCTION: Access to hemodialysis is limited in Nepal due to geographical terrain and hemodialysis centers being mostly limited to major city. Therefore, continuous ambulatory peritoneal dialysis is likely to be a better option in Nepal. In 1998, CAPD was initiated in Nepal without success. High rate of peritonitis was cited for failure. Hot tropical climate and poor sense of hygiene among patients was thought to be responsible for the high rate of peritonitis. A new CPD program was started in 2002 in our institute. We reviewed the incidence of peritonitis and factors predisposing. METHODS: All chronic renal failure patients on CAPD since 2002 to 2007 were included in the study. They were followed up for complications and treatment outcome. Patients complicated with peritonitis (N=19) and patients without peritonitis (N=31) were compared. RESULTS: A total of 50 patients were enrolled and mean duration of dialysis was 12 month per patients (Total patients month=600). Twenty six episodes of peritonitis in 19 patients were recorded during this period. Fourteen episode of peritonitis were culture positive. Culture sterile peritonitis was recorded in 12 episodes. Low serum albumin was predisposing factors for peritonitis and peritonitis rate was higher in end stage disease related due to diabetes mellitus. CONCLUSION: Peritonitis rate was comparable in our new program. Thus peritonitis is not a limiting factor for growth of CAPD in Nepal. Hypoalbuminemic and diabetic patients are prone for CAPD related peritonitis.  KEYWORDS: continuous ambulatory peritoneal dialysis, Peritonitis, Peritonitis rate.

Bacteriology and Antibiotic Susceptibility Pattern of Peitonsillar Abscess

INTRODUCTION: Peritonsillar abscess is a common complication of acute tonsillitis. Its management consists of aspiration or surgical drainage followed by appropriate antibiotics. Appropriate antibiotic treatment depends on the common organisms associated with infection and their antibioticsensitivity pattern in local scenario. METHODS: Pus samples aspirated from diagnosed cases of peritonsillar abscess and submitted for culture and sensitivity in last two years were included in this study. Identification of different microorganisms was made on the basis of the microscopic findings, observation of their colony morphology and standard biochemical reactions. Susceptibility pattern to commonly used antibiotics were determined by Clinical Laboratory Standards Institute (CLSI) guidelines. RESULTS: Altogether 24 pus samples were included in the study. Positive culture was obtained from 18 samples. Among them one organism was isolated from 13 samples whereas from five samples multiple organisms were isolated. From six samples no organisms could be cultured. Altogether Streptococcus pyogenes was isolated from 12 samples and Staphylococcus aureus from five samples. Other isolated organisms included Haemophlilus influenzae, Pseudomonas aeruginosa, Escherichia coli and Enterococcus species. Penicillin was effective for Streptococcus pyogenes whereas Staphylococcus aureus was resistant to it. Cloxacillin was found to be effective for Staphylococcus aureus. Ciprofloxacin and Ceftazidime were found to be effective for both organisms. CONCLUSIONS: Streptococcus pyogenes and Staphylococcus aureus were more commonly associated with peritonsillar abscess. Streptococcus pyogenes were sensitive to penicillin but all Staphylococcus aureus were resistant to it. This fact should be considered in clinical practice for management of peritonsillar abscess. KEYWORDS: Bacteriology, Peritonsillar abscess, Susceptibility pattern.

Peritonitis in Continuous ambulatory peritoneal dialysis

INTRODUCTION

Access to hemodialysis is limited in Nepal due to geographical terrain and hemodialysis centers being mostly limited to major city. Therefore, continuous ambulatory peritoneal dialysis is likely to be a better option in Nepal. In 1998, CAPD was initiated in Nepal without success. High rate of peritonitis was cited for failure. Hot tropical climate and poor sense of hygiene among patients was thought to be responsible for the high rate of peritonitis. A new CPD program was started in 2002 in our institute. We reviewed the incidence of peritonitis and factors predisposing.

METHODS

All chronic renal failure patients on CAPD since 2002 to 2007 were included in the study. They were followed up for complications and treatment outcome. Patients complicated with peritonitis (N=19) and patients without peritonitis (N=31) were compared.

RESULTS

A total of 50 patients were enrolled and mean duration of dialysis was 12 month per patients (Total patients month=600). Twenty six episodes of peritonitis in 19 patients were recorded during this period. Fourteen episode of peritonitis were culture positive. Culture sterile peritonitis was recorded in 12 episodes. Low serum albumin was predisposing factors for peritonitis and peritonitis rate was higher in end stage disease related due to diabetes mellitus.

CONCLUSION

Peritonitis rate was comparable in our new program. Thus peritonitis is not a limiting factor for growth of CAPD in Nepal. Hypoalbuminemic and diabetic patients are prone for CAPD related peritonitis.

Bacteriology and antibiotic susceptibility pattern of peritonsillar abscess

INTRODUCTION

Peritonsillar abscess is a common complication of acute tonsillitis. Its management consists of aspiration or surgical drainage followed by appropriate antibiotics. Appropriate antibiotic treatment depends on the common organisms associated with infection and their antibiotic sensitivity pattern in local scenario.

METHODS

Pus samples aspirated from diagnosed cases of peritonsillar abscess and submitted for culture and sensitivity in last two years were included in this study. Identification of different microorganisms was made on the basis of the microscopic findings, observation of their colony morphology and standard biochemical reactions. Susceptibility pattern to commonly used antibiotics were determined by Clinical Laboratory Standards Institute (CLSI) guidelines.

RESULTS

Altogether 24 pus samples were included in the study. Positive culture was obtained from 18 samples. Among them one organism was isolated from 13 samples whereas from five samples multiple organisms were isolated. From six samples no organisms could be cultured. Altogether Streptococcus pyogenes was isolated from 12 samples and Staphylococcus aureus from five samples. Other isolated organisms included Haemophlilus influenzae, Pseudomonas aeruginosa, Escherichia coli and Enterococcus species. Penicillin was effective for Streptococcus pyogenes whereas Staphylococcus aureus was resistant to it. Cloxacillin was found to be effective for Staphylococcus aureus. Ciprofloxacin and Ceftazidime were found to be effective for both organisms.

CONCLUSIONS

Streptococcus pyogenes and Staphylococcus aureus were more commonly associated with peritonsillar abscess. Streptococcus pyogenes were sensitive to penicillin but all Staphylococcus aureus were resistant to it. This fact should be considered in clinical practice for management of peritonsillar abscess.

Use of rK39 for diagnosis of post kala-azar dermal leishmaniasis in Nepal

A recently developed nitrocellulose-based dipstick test, rK39, has been widely used for the diagnosis of kala-azar. In this study, we evaluated its use for the diagnosis of post kala-azar dermal leishmaniasis (PKDL). We also investigated the time taken by patients to develop PKDL after apparent cure of kala-azar (visceral leishmaniasis, VL) and the time taken by patients to come to the hospital after the appearance of symptoms of PKDL. A majority of patients developed the disease within three years after the apparent cure of kala-azar (KA). A majority of patients sought treatment within five years after the onset of PKDL. The amastigotes of Leishmania donovani bodies (LDBs) were demonstrated in 70, 20, and 20% of slit-skin smears (SSS) prepared, respectively, from nodular, papular, and macular forms. The presence of highest density (6+) LDBs in the SSS of 20% of nodular PKDL patients indicated that they may have acted as reservoir in the community. Other reservoirs are not known in Nepal. Only 8% cases were detected by aldehyde test. Although this test is obsolete it is still used in rural parts of Nepal. The dipstick (rK39) was 96% sensitive and 100% specific to diagnose PKDL. Its positive predictive value, negative predictive value, and diagnostic efficacy were 100, 91, and 97% respectively. Due to the advantage of cost compared with the direct agglutination test (DAT), and being easy to use and store in field conditions, rK39 is a good tool to diagnose PKDL in rural situations. All the PKDL patients were cured of the disease after treatment by SAG.

Fungal maxillary sinusitis: a prospective study in a tertiary care hospital of eastern Nepal

INTRODUCTION

The incidence of mycotic infections and the diversity of pathogenic fungi have increased dramatically in recent years. Fungal sinusitis should be considered in all the patients with chronic maxillary sinusitis (CMS), especially in association with certain clinical features that serve as clue to the diagnosis. Aspergillus is the most common fungal pathogen in maxillary sinus.

METHODOLOGY

A total of 100 patients those who fulfilled the diagnostic criteria (Lanza and Kennedy, 1992) for chronic rhinosinusitis were eligible for this open level and randomized prospective study. Only those above 14 years of age were included.

RESULTS

Fungal maxillary sinusitis was seen in 14% of all cases of chronic maxillary sinusitis in eastern part of Nepal. We identified Acremonium and Candida species as commonest fungi involved in fungal maxillary sinusitis (FMS). To the best of our knowledge this is the first such study conducted in eastern Nepal.

Spontaneous bacterial peritonitis (SBP) in cirrhotic ascites: a prospective study in a tertiary care hospital, Nepal

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is one of the potentially lethal complications of cirrhosis and is defined as infected ascites in the absence of any recognizable secondary cause of infection. Objective was to study the occurrence of SBP, clinical and laboratory characteristics and the response to antibiotics.

METHODS

We had prospectively evaluated 81 cirrhotic patients with ascites during one-year period. All SBP patients were treated with cefotaxime, 2gm IV, every 12h for 5days.

RESULTS

Of these 81 patients, 24.67% of patients (n=20) had SBP and its variants (classical SBP n= 4, CNNA n=13 and bacterascites n=3). There were thirteen males and 7 females in the study.85% of the cases had Child;s class C cirrhosis. UGI bleeding and abdominal pain were the most common presenting symptoms of SBP. Culture positives were 35% (n=7). The most frequent organisms were Escherichia coli (n=3) and Streptococcus pneumoniae (n=2). 94% of the patients responded to therapy after 48 hours of treatment. Total resolution after 5 days of therapy was 73% and in-hospital mortality was 15% (n=3).

CONCLUSION

SBP, if diagnosed early can be treated with very good success rate up to 73%. Appropriate treatment of SBP with cefotaxime can help in reducing mortality and morbidity in patients with chronic liver disease.

Brain abscess due to Scedosporium apiospermum in a non immunocompromised child

Scedosporium apiospermum is a filamentous fungi that commonly causes cutaneous infection. In certain circumstances, S. apiospermum can also cause invasive disease, which can involve the central nervous system (CNS). When the CNS becomes involved, treatment is difficult, therapeutic options are limited and the prognosis is poor. Early identification and treatment can decrease the mortality rate. Here we present a case of brain abscess with chronic suppurative otitis media, caused by S. apiospermum. This is the first such case report from Nepal. We could identify the organism only post mortem. We could not save the patient, probably due to delay in diagnosis.

Laboratory diagnosis in ulcerative keratitis

AIMS

To identify the common bacterial and fungal isolates from corneal ulcers and to determine the antimicrobial susceptibility patterns of bacterial isolates to commonly used antibiotics at B.P. Koirala Institute of Health Sciences (BPKIHS), eastern Nepal. Culture and direct microscopic correlation and reliability were also compared.

METHODS

All patients with suspected corneal ulceration presenting to the Ophthalmology Department of BPKIHS from 1st August 1998 to 31st July 2001 were evaluated. Corneal scraping was performed and processed for direct microscopy and culture for bacterial and fungal isolates. Bacterial isolates were subjected to antimicrobial susceptibility testing.

RESULTS

Of 447 specimens examined direct microscopy was positive in 216 (48%) specimens. Culture positivity could be correlated with direct microscopy in 179 (83%) of specimens. Growth of etiologic agents was found in 303 (67.8%) samples. Of these 145 (47.8%) had pure fungal growth, 103 (34%) had pure bacterial growth and 55 (18.2%) had mixed fungal and bacterial infection. The commonest fungal pathogen was Aspergillus spp.in 78 (38.4%) followed by Fusarium spp. in 45 (22%). Aureobasidium sp. was isolated in 25 (12.3%) samples. Staphylococcus aureus (93, 56.7%) dominated the scene as the commonest bacterial agent. Streptococcus pneumoniae (33, 20%) was second in the list. Most of the bacterial isolates were sensitive to commonly used antibiotics.

CONCLUSION

This study emphasizes the importance and need of the continued surveillance of the agents and their antimicrobial susceptibility for the prevention and management of corneal ulcers and their complications.

MANAGEMENT OF SNAKEBITE – CURRENT CONCEPT

Abstract

Infective endocarditis: report of a prospective study in an Indian hospital

Forty-six patients who fulfilled the Duke's clinical diagnostic criteria for infective endocarditis (IE) were evaluated. Thirty-five (76%) patients were below 40 years of age with rheumatic heart disease being the most common underlying heart lesion affecting 26 (56%). An obvious predisposing cardiac lesion could not be ascertained in 22%. Blood culture positivity was 44% with streptococcus heading the list. The incidence of the staphylococcal (25%) and gram negative bacillary endocarditis (15%) were found to be increasing. Streptococci were susceptible to penicillin with minimum bactericidal concentration: minimum inhibitory concentration within acceptable limits. However, the appearance of methicillin resistant staphylococcus aureus and high level gentamicin resistant enterococcus as aetiological agents of infective endocarditis were found to add to the complexity of the problem. With the emergence of drug-resistant organisms as causative agents of IE, whenever medical therapy is the primary method of treatment of this condition, the selection of antibiotics should depend upon extensive in vitro testing and in vivo monitoring of clinical efficacy.

Sexual habits and clinico-etiological profile of sexually transmitted diseases in Nepal

A total of 100 patients giving histories suggestive of sexually transmitted disease (STDs) and attending the dermatology OPD at BPKIHS (B.P. Koirala Institute of Health Sciences) in Nepal over a period of one year from 1st July 1999 to 30th June 2000 were included in this study. Out of 10,400 new dermatology cases, a total of 100 cases (0.96%) of STDs were seen. Of these 73 were males, and the majority (53%) were in the age group of 21-30 years. Most of the patients were from Sunsari district (54%). The most common profession (21%) was businessman followed by housewife (19%). The most common age for first sexual contact was 16 to 19 years (45%). Eleven percent had their first sexual contact at the age of 15 or below 15 years. Premarital sexual exposure was recorded in 17% of the unmarried males. There were only 3 homosexuals and 1 bisexual patient. Multiple contacts were recorded in 55% of the patients. The most common source of contact was a commercial sex worker in 34.15%. Condoms were always used by only 7%. The various types of sexually trasmitted diseases (STDs) were syphilis (31%) followed by condylomata acuminata (16%), herpes genitalis (15%), gonorrhoea (9%), and mixed infections (12%). Despite their varied sexual behavior, none of the patients were HIV positive; however, it is always advisable to screen all STD patients for HIV antibody.

Vancomycin-resistant Staphylococcus aureus in Nepal: an impending crisis?

DOI: http://dx.doi.org/10.3126/nepjoph.v4i1.5878 NEPJOPH 2012; 4(1): 197-198