In vitro ciprofloxacin resistance patterns of gram-positive bacteria isolated from clinical specimens in a teaching hospital in Saudi Arabia

BACKGROUND

Over the last few decades the ever-increasing level of bacterial resistance to antimicrobials has been a cause of worldwide concern. Fluoroquinolones, particularly ciprofloxacin has been used indiscriminately for both gram-positive and gram-negative bacterial infections. The increased use of ciprofloxacin has led to a progressive loss of bacterial susceptibility to this antibiotic. Therefore it is necessary to have update knowledge of resistance pattern of bacteria to this antibiotic so that alternate appropriate antibiotics can be used for ciprofloxacin-resistant bacterial infections.

OBJECTIVE

To evaluate the trends of ciprofloxacin resistance pattern in commonly isolated gram-positive bacteria over time in a Saudi Arabian teaching hospital.

METHODS

A retrospective analysis was carried out for ciprofloxacin susceptibility patterns of 5534 isolates of gram-positive bacteria isolated from clinical specimens submitted to microbiology laboratories at King Fahd Hospital of the University (KFHU), Al-Khobar, Saudi Arabia during the period from January 2002 to August 2005.

RESULTS

Increase in ciprofloxacin resistance rates with some fluctuations, among these isolates, were observed. For Staphylococcus aureus, it varied from 4.62, 1.83, 7.01 and 3.98%, methicillin resistant Staphylococcus aureus (MRSA) 97.92, 97.75, 87.01 and 88.26%, Streptococcus pyogenes 5.35, 4.47, 14.44 and 3.53% during the years 2002, 2003, 2004 and 2005 respectively. Cirprofloxacin resistance during the years 2002, 2004 and 2005 for other isolates was as follows: Streptococcus pneumoniae, 30.23, 23.02 and 26.47%; enterococcus group D, 43.05, 20.68 and 57.03% and non-enterococcus group D, 62.96, 76.92 and 87.50% respectively.

CONCLUSION

Ciprofloxacin resistance in gram-positive bacterial clinical isolates particularly Staphylococcus aureus, methicillin resistant Staphylococcus aureus (MRSA) enterococcus group D, and non-enterococcus group D, has greatly increased and ciprofloxacin no more remains the drug of choice for these infections.

Ischaemic posterior circulation stroke in State of Qatar

BACKGROUND

Ischaemic stroke features may show regional differences. Posterior circulation stroke (PCS) is of special interest, as symptomatology, course and outcome are usually different and complex. No significant studies or registries have reported on the characteristics and outcomes of PCS in our region.

METHODS

We prospectively collected data of 116 patients with PCS admitted from 2005 through 2008 in the only stroke admitting hospital in Qatar. Demographics, risk factors, clinical signs/symptoms, pattern of presentation, aetiology, imaging features, complications and outcome at discharge and follow-up were recorded.

RESULTS

Mean age was 53 years with 25% aged < or = 45, 85% were males. Demographically 47% were Arabs and 51% of South-Asian origin. Mean duration from onset to presentation was 29 h. Major risk factors were obesity (66%) and hypertension (61%). Minimal or fluctuating symptoms were present in 64%, while 9% had maximal deficit at onset. Thirty nine per cent had lesions in proximal territory and 23% in multiple territories. Around 41% had no occlusion, 16% had vertebro-basilar, 16% vertebral, 8% basilar occlusion. Etiologically 53% patients had large artery disease, 16% small vessel disease, and 17% cardioembolism. Seventy per cent of patients were discharged home, while 10% expired. Modified Rankin score (mRS) at discharge was < or = 2 in 53% and > or = 4 in 13% patients. At 30-day follow-up, 68% had mRS of < or = 2. Ninety-day survival status showed 89% alive with mRS < or = 2 in 73%.

CONCLUSION

The aetiology and lesion topography of PCS in this heterogeneous population differs from the pattern observed in other populations.

[Crossed pattern of sensory loss with left thoracic level in a right dorsolateral medullary infarction]

INTRODUCTION

Medullary infarctions as consequence of vertebro-basilar strokes are frequent findings in clinical practice. Medulla oblongata, the lowest segment of the brainstem, is a dense anatomic structure with different conglomerate of nuclei, ascending and descending pathways within a very small area and tiny insults can present with expressive clinical manifestations. Sensory dysfunction is often a noteworthy element in lateral medullary infarctions and its distribution depends of the site and shape of the lesion within the medulla oblongata. From etiological point of view the most frequent cause of lateral medullary infarctions is atherosclerosis although vertebral dissection has to be carefully ruled out.

CASE REPORT

A 65 year-old man with a left pain and temperature sensory level up to T4 in a right lateral medullary infarctions due to ipsilateral PICA territory infarction. Crossed pattern of sensory loss with a sensory level is a quite unusual presentation of lateral medullary infarctions and expresses the involvement of the most external aspect of the spinothalamic tract.

Inequity in maternal health-care services: evidence from home-based skilled-birth-attendant programmes in Bangladesh

OBJECTIVE

To explore use-inequity in maternal health-care services in home-based skilled-birth-attendant (SBA) programme areas in Bangladesh.

METHODS

Data from a community survey, conducted from February to May 2006, were analysed to examine inequities in use of SBAs, caesarean sections for deliveries and postnatal care services according to key socioeconomic factors.

FINDINGS

Of 2164 deliveries, 35% had an SBA, 22.8% were in health facilities and 10.8% were by caesarean section. Rates of uptake of antenatal and postnatal care were 93% and 28%, respectively. There were substantial use-inequities in maternal health by asset quintiles, distance, and area of residence, and education of both the woman and her husband. However, not all inequities were the same. After adjusting for other determinants, the differences in the use of maternal health-care services for poor and rich people remained substantial [adjusted odds ratio (OR) 2.51 (95% confidence interval, CI: 1.68-3.76) for skilled attendance; OR 2.58 (95% CI: 1.28-5.19) for use of caesarean sections and OR 1.53 (95% CI: 1.05-2.25) for use of postnatal care services]. Complications during pregnancy influenced use of SBAs, caesarean-section delivery and postnatal care services. The number of antenatal care visits was a significant predictor for use of SBAs and postnatal care, but not for caesarean sections.

CONCLUSION

Use of maternity care services was higher in the study areas than national averages, but a tremendous use-inequity persists. Interventions to overcome financial barriers are recommended to address inequity in maternal health. A greater focus is needed on the implementation and evaluation of maternal-health interventions for poor people.

The use of D-Dimer assay by enzyme immunoassay and latex agglutination techniques in the diagnosis of deep vein thrombosis

The blood of 107 patients undergoing venography for suspected deep vein thrombosis (DVT) was tested for D-Dimers using enzyme immunoassay (EIA) and two latex agglutination techniques. D-Dimer levels by EIA were raised in 88% of patients with proven DVT. However, levels detected with the two agglutination tests were much less sensitive, being raised in only 43% patients with DVT. A more sensitive rapid screening test is needed to provide a useful non-invasive test for the exclusion of DVT.

The clinical relevance of plasma viscosity in Hodgkin's disease

The erythrocyte sedimentation rate has previously been identified as an important prognostic factor in Hodgkin's disease. The plasma viscosity has replaced the ESR measurement in many laboratories, but doubts exist about its clinical relevance. In this study plasma viscosity at presentation/diagnosis was studied in 107 patients with Hodgkin's disease. A multivariate analysis of factors influencing prognosis and relapse-free survival identified plasma viscosity and number of disease sites as being highly significant. The risk of relapse increases initially with a rise in plasma viscosity, but after a value of about 2.0 mPa.s no further increase in risk is observed. When all of the prognostic factors are made available to the proportional hazards model, treatment modality and plasma viscosity are selected as the best set for predicting time to first relapse. This study demonstrates that measurement of plasma viscosity at presentation is an important prognostic factor in Hodgkin's disease, in terms of predicting outcome or risk of relapse.

Comparison of mean platelet volume in patients with diabetes mellitus, impaired fasting glucose and non-diabetic subjects

INTRODUCTION

Large platelets are more thrombogenic and thus put the patient at a higher risk status. Mean platelet volume (MPV) is a determinant of platelet functionality and increased MPV is associated with increased risk for myocardial infarction, stroke and transient ischaemic attacks. The objective of this study is to compare the MPV in patients with diabetes mellitus (DM), impaired fasting glucose (IFG), and non-diabetic controls.

METHODS

This cross-sectional study was conducted at Dow University of Health Sciences, Karachi, Pakistan between the period of September 2006 and May 2007. Sample size of 204 in each group was calculated using power (1-beta) of 90 percent and level of significance (alpha) at five percent. Confirmed patients with DM, IFG and non-diabetic controls were selected and allocated to respective groups. A total of 612 patients were selected and allocated to three groups of 204 patients each, referred to as DM group, IFG group and non-DM group. Fasting blood glucose, platelet counts and MPV were done.

RESULTS

Mean MPV in the DM group was 9.34 fl, in the IFG Group 8.98 fl, and in the non-DM group 8.63 fl. Comparison of MPV values for the three groups showed statistically significant intergroup and intragroup differences, with a p-value of 0.00.

CONCLUSION

MPV was significantly increased in the IFG group, as compared to the non-DM group, and it increased further when compared to the DM and IFG groups.

Aerobic vaginal pathogens and their sensitivity pattern

BACKGROUND

The vaginal flora is a complicated environment, containing dozens of microbiological species in variable quantities and relative proportions. The frequent cause of vaginal discharge is an infection or colonization with different microorganisms. Some pathologic conditions causing vaginitis are well defined yet, 7-72% of women with vaginitis may remain undiagnosed and such forms of abnormal vaginal flora neither considered as normal, nor can be called bacterial vaginosis have been termed as 'intermediate flora' and its management probably differ from that of bacterial vaginosis. It is of crucial importance in pregnant females at risk of preterm delivery. The present study has been conducted especially to elucidate this type of aerobic vaginal isolates and their culture and sensitivity towards currently used antibiotics. This study was conducted at the Microbiology Department of Fauji Foundation Hospital, Rawalpindi over a period of two years (April 2004-March 2006).

METHODS

One thousand, nine hundred and twenty three high vaginal swabs, both from indoor and outdoor patients were collected, cultured and their susceptibility to various antibiotics was determined.

RESULTS

Significant growth was obtained in 731 samples. The highest frequency of infection (39.5%) was observed at 31-40 years followed by 41-50 years (35.8%). About 76% were from outdoor and 24% were from indoor patients. Staphylococcus aureus was the most prevalent vaginal pathogen at 11-60 yrs & with highest prevalence at 31-40 years followed by 41-50 years. It was a predominant pathogen in both indoor (35%) as well as outdoor (41.6%) patients, followed by enteric gram-negative bacilli and other gram-positive cocci. There were very few antibiotics among the conventionally available aminoglycosides, third generation cephalosporins, penicillin, quinolones, sulfonamides and tetracyclines possessing good sensitivity (> 80%) against any one the common aerobic vaginal pathogens. The effective chemotherapeutics agents belong to the groups of carbapenems and beta-lactams beta-lactamase inhibitor combinations.

CONCLUSIONS

The high prevalence of gynaecological infections demands that the patients with gynaecological symptoms be investigated thoroughly. Culture must invariably be done. Currently the antibiotics showing good sensitivity are very expensive. So there is a need for an effective antimicrobial policy. Effective drug should be reserved for the treatment of serious life threatening situations only.

Extended spectrum beta-lactamases in enteric gram-negative bacilli: related to age and gender

BACKGROUND

Extended Spectrum beta-Lactamases (ESBLs)-producing strains of Enterobacteriaceae have emerged as a major problem in hospitalized as well as community based patients. Infections due to ESBLs-producers range from uncomplicated urinary tract infection to life threatening sepsis. The objective of this study was to find out the prevalence of ESBLs-producing Gram- negative bacilli among clinical isolates.

METHODS

This descriptive study was conducted at the Microbiology department of Fauji Foundation Hospital, Rawalpindi over a period of two years (March 2004-April 2006). Six hundred and nine isolates of Enteric Gram-negative rods from various samples were tested for ESBLs-production by double disc synergy test. In 176 ESBLs-producing isolates, source of samples in term of indoor/outdoor was analyzed. In 165 ESBLs-producing isolates, patients' gender and age was analysed from 3 months to 70 years.

RESULTS

The ESBLs-producing isolates were more commonly isolated from indoor patients (88.1%) as compared to outdoor patients (11.9%). Escherichia coli was found to be most prevalent organism in indoor patients while Klebsiella pneumoniae, was the most prevalent organism in outdoor patients. ESBLs were most commonly isolated from female patients (64.3%) suffering from urinary tract infections ((41.5%), as compared to male patients (35.7%) in which the organisms were most commonly isolated from pus samples (54.2 %). ESBLs-producing Enteric Gram-Negative rods were most frequent at later part of life where they were most common (27.9%) at 61-70 years, followed by 41-50 years of age group (20.0%). Another peak (13.3%) was also seen at younger age group (11-20 years). The least prevalence (5.5%) was seen in two age groups (0-10 and 31-40 yrs). In case of female patients, ESBLs-producing EGNR were most frequently (29.2%) isolated from middle age group (41-50 years) followed by later age groups (51-60 and 61-70 years, (15.1% and 25.5%).

CONCLUSIONS

Considering the high prevalence of ESBLs in Enteric Gram-negative rods, it is suggested that all such isolates should be tested for the production of ESBLs in the routine microbiology laboratory.

Olmsted syndrome

Olmsted syndrome is a rare disorder characterized by symmetrical sharply marginated mutilating keratoderma of palms & soles & hyperkeratotic plaques around the body orifices, onychodystrophy, ainhum & amputation of digital phalanges, flextion deformities of the fingers, localized alopecia, leukokeratosis of the tongue, shortness of stature & laxity of large joints. Inheritance is autosomal dominant, although sporadic cases have been reported. Here we describe two cases of this rare disorder with thickened hyperkeratotic lesion over palm & soles & along with amputation of 3rd , 4th & 5th toes in one case. In one of our case (case no. 2) the immediate younger brother has got the same disease. Both of them were treated with tab. Neotegason 25 mg orally daily for 3 months & there was significant improvement after treatment.

Serum hormonal, electrolytes and trace element profiles in the rutting and non-rutting one-humped male camel (Camelus dromedarius)

The camel is known to be a seasonal breeder and, in the male camel, the breeding activity maximizes during the rutting period (winter and spring seasons). During the non-rutting period (summer and autumn), however, the breeding activity almost ceases completely. Serum steroid hormonal, electrolytes and trace element profiles were studied in 16 adult male camels aged 5-9 years, slaughtered during the rutting (n=8) and non-rutting periods (n=8). Moreover, testicular and epididymal tissue contents of electrolytes and trace elements were also studied during these two periods. Serum levels of testosterone, progesterone and T(4):T(3) ratio were higher in the rutting animals when compared to the non-rutting ones, while the reverse was true for serum T(3), T(4) and corticosterone levels (p<0.01). Among minerals, serum levels of sodium, calcium, copper and zinc were higher, while those of potassium were lower, in the rutting than non-rutting camels. In the testicular tissue, the levels of sodium, calcium, copper and iron were higher in the rutting group, while magnesium was higher in non-rutting one. In the epididymis, the tissue levels of chloride, iron and zinc were higher in the rutting than non-rutting period. These results demonstrate a clear evidence of the distribution of steroid hormones, electrolytes and trace elements forming and maintaining a certain level at two different physiological states in camels.

Head and neck squamous cell carcinoma (HNSCC) 5 year study at BSMMU

Head and Neck Squamous Cell Carcinoma (HNSCC) are generally similar in their clinical features, epidemiology and etiology although their natural and clinical history and treatment differ. Despite lot of improvement in diagnostic and management technique, there is little improvement in survival rate over the last few decades. This study was carried-out in a multidisciplinary tertiary level hospital (BSMMU), with a country-wide catchment area to see the burden of HNSCC existing in our country and their clinical pattern. The overall incidence rate of HNSCC in this study was (0.15%) i.e. 150 person in 1,00,000 population. Male incidence (0.19%) was higher than female (0.12%). This study revealed that carcinoma of the larynx (25.22%) and pyriform fossae (20.57%) were the main culprit, whereas buccal carcinoma was the main component (37.70%) in the female series. Highest incidence was found in the 6th decade in both sexes. As the treatment of HNSCC may be time consuming, requires multidisciplinary approach, demands lot of clinical, social and financial consideration, therefore, the best treatment can be offered through a combined board consisting of Surgical, Radiation, Medical oncologists, Histopathologist and Speech therapist as required.

Surgical delay in the management of dog bite injuries in children, does it increase the risk of infection?

Dog bites are contaminated wounds and convention dictates that any surgical treatment should be performed at the earliest opportunity. This practice, however, may be in direct conflict with NCEPOD guidelines to reduce night time operating. We audited our treatment of dog bite injuries in children over a 5-year period (1998-2002) to determine whether delaying surgery to conform to operating guidelines increased the incidence of infection. A retrospective case note study identified 118 patients admitted to Sheffield Children's Hospital with dog bite injuries. Details of their injury, treatment and outcome were recorded. There were 70 males and 48 females and an average age of 6.6 years (range 1-15 years). The most common type of injury was a single laceration (32%) and the most frequent site of injury was the face (59%). The majority of wounds (68%) were cleaned and dressed before theatre and 89% were closed directly after minimal debridement. All patients received prophylactic antibiotics. Of the 114 patients that required surgery, 57 (50%) were operated on within 12 h of their injury and 57 (50%) after 12 h. There were three cases of infection in the early group (<12 h) and none in the delayed group (>12 h). We suggest that delaying the surgical treatment of dog bites in children to avoid operating at night does not increase the infection rate.

Antidermatophyte activity of ether extract of Nigella sativa and its active principle, thymoquinone

The antifungal activity of ether extract of Nigella sativa seed and its active principle thymoquinone was tested against eight species of dermatophytes: four species of Trichophyton rubrum and one each of Trichophyton interdigitale, Trichophyton mentagrophytes, Epidermophyton floccosum and Microsporum canis. Agar diffusion method with serial dilutions of ether extract of Nigella sativa, thymoquinone and griseofulvin was employed. The incubation was carried out at 30 degrees C for 14 days. The diameter of fungal colonies and the percentage inhibition of the fungal growth at each dilution were determined, taking those of the controls as 100%. The minimum inhibitory concentration (MIC) was considered as the minimum concentration of the drug, which inhibited 80-100% of the fungal growth. The MICs of the ether extract of Nigella sativa and thymoquinone were between 10 and 40 and 0.125 and 0.25 mg/ml, respectively, while those of griseofulvin ranged from 0.00095 to 0.0155 mg/ml. These results denote the potentiality of Nigella sativa as a source for antidermatophyte drugs and support its use in folk medicine for the treatment of fungal skin infections.