Smart Nanofibrous Hydrogel Wound Dressings for Dynamic Infection Diagnosis and Control: Soft but Functionally Rigid

Chronic wounds, such as burns and diabetic foot ulcers, pose significant challenges to global healthcare systems due to prolonged hospitalization and increased costs attributed to susceptibility to bacterial infections. The conventional use of antibiotic-loaded and metal-impregnated dressings exacerbates concerns related to multidrug resistance and skin argyrosis. In response to these challenges, our research introduces a unique approach utilizing antibiotic-free smart hydrogel wound dressings with integrated infection eradication and diagnostic capabilities. Electrospinning stands out as a method capable of producing hydrogel nanofibrous materials possessing favorable characteristics for treating wounds and detecting infections under conditions utilizing sustainable materials. In this study, innovative dressings are fabricated through electrospinning polycaprolactone (PCL)/gelatin (GEL) hybrid hydrogel nanofibers, incorporating pDA as a cross-linker, εPL as a broad-spectrum antimicrobial agent, and anthocyanin as a pH-responsive probe. The developed dressings demonstrate exceptional antioxidant (>90% radical scavenging) and antimicrobial properties (95-100% killing). The inclusion of polyphenols/flavonoids and εPL leads to absolute bacterial eradication, and in vitro assessments using HaCaT cells indicate increased cell proliferation, decreased reactive oxygen species (ROS) production, and enhanced cell viability (100% Cell viability). The dressings display notable alterations in color that correspond to different wound conditions. Specifically, they exhibit a red/violet hue under healthy wound conditions (pH 4-6.5) and a green/blue color under unhealthy wound conditions (pH > 6.5). These distinctive color changes provide valuable insights into the versatile applications of the dressings in the care and management of wounds. Our findings suggest that these antibiotic-free smart hydrogel wound dressings hold promise as an effective and sustainable solution for chronic wounds, providing simultaneous infection control and diagnostic monitoring. This research contributes to advancing the field of wound care, offering a potential paradigm shift in the development of next-generation wound dressings.

9 MOG associated encephalitis presenting as idiopathic intracranial hypertension

A young Caucasian male (7y) with normal BMI was atypical for his provisional diagnosis of Idiopathic Intracranial Hypertension (IIH), that resolved following a Lumbar Puncture (LP). At 8y he presented with a 2-week history of headaches and vomiting that started some weeks after flu vaccination and an upper respiratory infection.Visual Acuity (VA) and colour vision were normal. Ocular motility was full. Fundoscopy and OCT showed recurrence of papilloedema, with enlarged blind spots on Kinetic perimetry.LP opening pressure was 30cm H2O and CSF white cells were elevated (23). Repeat brain and spine imaging showed new white matter signal changes in keeping with neuroinflammation, as well as enhancement of the left optic nerve extending to the chiasm and optic tract. VA, colour vision and pupillary reactions remained normal.Pattern VEP peak times were prolonged from the left eye compared to right eye to small check widths, consistent with relative macular-cortex pathway dysfunction. Hemifield PVEPs were slightly prolonged and reduced from the bitemporal fields indicating chiasmal dysfunction. Normal PERGs excluded PVEP delay associated with primary RGC disease.Further investigations showed oligoclonal band and serum-MOG antibody positivity.Management: Initial treatment with Acetazolamide 125mg bd for a week, following LP, was changed to IV methylprednisolone followed by oral prednisolone.Symptoms improved significantly following LP and steroid treatment. He will be followed in a Demyelination Clinic.MOG-associated disease has been reported with raised intracranial pressure and should be considered especially in children with atypical clinical phenotype for IIH.

Ternary nanocomposite-based smart sensor: Reduced graphene oxide/polydopamine/alanine nanocomposite for simultaneous electrochemical detection of Cd2+, Pb2+, Fe2+, and Cu2+ ions

Heavy metal ion (HMI) sensors are the most sought commercial devices for environmental monitoring and food analysis research due to serious health concerns associated with HMI overdosage. Herein, we developed an effective electrochemical sensor for simultaneous detection of four HMI (Cd²⁺, Pb²⁺, Fe²⁺, and Cu²⁺) using a ternary nanocomposite of reduced graphene oxide functionalized with polydopamine and alanine (ALA/pDA/rGO). Comprehensive spectroscopic and microscopic characterizations were performed to ensure the formation of the ternary nanocomposite. The developed nanocomposite on glassy carbon electrode (GCE) yields >2-fold higher current than GO/GCE electrode with excellent electrochemical stability and charge transfer rate. Using DPV, various chemical and electrochemical parameters, such as supporting electrolyte, buffer pH, metal deposition time, and potential, were optimized to achieve highly sensitive detection of targeted HMI. For Cd²⁺, Pb²⁺, Fe²⁺, and Cu²⁺ sensing devised sensor exhibited detection limits of 1.46, 2.86, 50.23, and 17.95 ppb and sensitivity of 0.0929, 0.0744, 0.0051, and 0.0394 μA/ppb, respectively, with <6% interference. The sensor worked similarly well for real water samples with HMI. This study demonstrates a novel strategy for concurrently detecting and quantifying multiple HMI in water and soil using a smart ternary nanocomposite-based electrochemical sensor, which can also detect HMI in food samples.

2D Materials-Based Aptamer Biosensors: Present Status and Way Forward

Current advances in constructing functional nanomaterials and elegantly designed nanostructures have opened up new possibilities for the fabrication of viable field biosensors. Two-dimensional materials (2DMs) have fascinated much attention due to their chemical, optical, physicochemical, and electronic properties. They are ultrathin nanomaterials with unique properties such as high surface-to-volume ratio, surface charge, shape, high anisotropy, and adjustable chemical functionality. 2DMs such as graphene-based 2D materials, Silicate clays, layered double hydroxides (LDHs), MXenes, transition metal dichalcogenides (TMDs), and transition metal oxides (TMOs) offer intensified physicochemical and biological functionality and have proven to be very promising candidates for biological applications and technologies. 2DMs have a multivalent structure that can easily bind to single-stranded DNA/RNA (aptamers) through covalent, non-covalent, hydrogen bond, and π-stacking interactions, whereas aptamers have a small size, excellent chemical stability, and low immunogenicity with high affinity and specificity. This review discussed the potential of various 2D material-based aptasensor for diagnostic applications, e.g., protein detection, environmental monitoring, pathogens detection, etc.

Impact of myoinositol with metformin and myoinositol alone in infertile PCOS women undergoing ovulation induction cycles - randomized controlled trial

PURPOSE

To evaluate the benefits of myoinositol plus metformin versus myoinositol alone in infertile polycystic ovarian syndrome (PCOS) women undergoing ovulation induction cycles.

MATERIALS AND METHODS

Total 116 infertile PCOS women were randomized: Group I (n = 57): metformin (1500 mg) plus myoinositol (4 g) per day; Group II (n=59): myoinositol 4 g per day. Subjects were advised to try for spontaneous conception. Those who did not conceive after three months were given three cycles of ovulation induction. Primary outcome was clinical pregnancy rate after 6 months. Secondary outcomes were improvement in metabolic and endocrine parameters, ongoing pregnancy, abortion and multiple pregnancy rate.

RESULTS

Baseline demographic, metabolic and hormonal parameters were comparable in two groups. After 3 months of therapy, both study groups had comparable improvement in metabolic and hormonal parameters. After 6 months, clinical pregnancy rate was 42.0% in Group I and 45.5% Group II respectively (RR 0.92(95% CI:0.60-1.43) (p > .05). Side-effects (mainly gastrointestinal) were significantly higher in Group I than group II.

CONCLUSIONS

Myoinositol (4 g) might be used alone as an insulin sensitizer to improve metabolic, hormonal and reproductive outcome in infertile PCOS women. Further studies with large numbers are warranted to confirm the role of myoinostiol as a sole insulin sensitizer.

3D-Printed Microfluidics and Potential Biomedical Applications

3D printing is a smart additive manufacturing technique that allows the engineering of biomedical devices that are usually difficult to design using conventional methodologies such as machining or molding. Nowadays, 3D-printed microfluidics has gained enormous attention due to their various advantages including fast production, cost-effectiveness, and accurate designing of a range of products even geometrically complex devices. In this review, we focused on the recent significant findings in the field of 3D-printed microfluidic devices for biomedical applications. 3D printers are used as fabrication tools for a broad variety of systems for a range of applications like diagnostic microfluidic chips to detect different analytes, for example, glucose, lactate, and glutamate and the biomarkers related to different clinically relevant diseases, for example, malaria, prostate cancer, and breast cancer. 3D printers can print various materials (inorganic and polymers) with varying density, strength, and chemical properties that provide users with a broad variety of strategic options. In this article, we have discussed potential 3D printing techniques for the fabrication of microfluidic devices that are suitable for biomedical applications. Emerging diagnostic technologies using 3D printing as a method for integrating living cells or biomaterials into 3D printing are also reviewed.

Headache in children with Sturge-Weber syndrome - Prevalence, associations and impact

BACKGROUND

Sturge-Weber syndrome (SWS) is a congenital neurovascular disorder characterised by capillary-venous malformations involving the skin, brain and eye. Patients experience headache, however little is known about its characteristics or associations. We aimed to estimate prevalence, associations and the impact of headache in children with SWS.

MATERIALS AND METHODS

Case notes of all patients in a national tertiary paediatric SWS clinic were retrospectively reviewed. Patients were categorised into those with or without a history of headache, with an analysis performed of clinical stigmata of their disease and headache symptomology, associations and treatment. A multivariable logistic regression analysis was undertaken to elicit independent predictors of headache.

RESULTS

37% of patients with SWS (n = 84) reported headaches that were variably associated with seizures, a preceding blow to the head and a minority had migraine features. In those reporting headaches, headaches interfered with daily activities of a quarter of the children and 39% experienced headaches frequently (more than 1/month). Headache was associated with glaucoma and aspirin administration while children with monoplegia and hemiplegia were less likely to have headache.

CONCLUSIONS

Headache is common in children with SWS, often without classical migraine features and affects daily activities. Awareness of headache and its associations in SWS may improve management of this complex population.

Hyperpigmentation as a cutaneous manifestation of fungal sepsis in neonates: Case series report

With improved and prolonged survival of very and extremely low birth weight infants, invasive fungal infection has emerged as an important concern in the neonatal intensive care units. Candidiasis is the third leading cause of late onset sepsis in these neonates and is associated with 20-30% mortality. Extreme prematurity, central venous catheters, prolonged antibiotic exposure, parenteral nutrition are important risk factors. Various forms of cutaneous manifestations of candidiasis have been described ranging from local diaper dermatitis and oral thrush to widespread erosive and ulcerative lesions with extensive crusting in invasive fungal dermatitis. We report a series of four cases with cutaneous hyperpigmentation as manifestation of systemic candidiasis.

Correction to: Spectrum of movement disorders and neurotransmitter abnormalities in paediatric POLG disease

Due to a typesetting error the wrong Table 2 was used. The correct Table 2 is shown here.

Spectrum of movement disorders and neurotransmitter abnormalities in paediatric POLG disease

OBJECTIVES

To describe the spectrum of movement disorders and cerebrospinal fluid (CSF) neurotransmitter profiles in paediatric patients with POLG disease.

METHODS

We identified children with genetically confirmed POLG disease, in whom CSF neurotransmitter analysis had been undertaken. Clinical data were collected retrospectively. CSF neurotransmitter levels were compared to both standardised age-related reference ranges and to non-POLG patients presenting with status epilepticus.

RESULTS

Forty-one patients with POLG disease were identified. Almost 50% of the patients had documented evidence of a movement disorder, including non-epileptic myoclonus, choreoathetosis and ataxia. CSF neurotransmitter analysis was undertaken in 15 cases and abnormalities were seen in the majority (87%) of cases tested. In many patients, distinctive patterns were evident, including raised neopterin, homovanillic acid and 5-hydroxyindoleacetic acid levels.

CONCLUSIONS

Children with POLG mutations can manifest with a wide spectrum of abnormal movements, which are often prominent features of the clinical syndrome. Underlying pathophysiology is probably multifactorial, and aberrant monoamine metabolism is likely to play a role.

Premonitory Symptoms of Migraine in Childhood and Adolescence

Purpose of Review

Premonitory symptoms in migraine; symptoms occurring before the onset of migraine pain or aura, are an increasingly recognised area of interest within headache research. It has been recently documented in the literature that these symptoms also occur in children and adolescents, with a comparable phenotype to adults. This review discusses the wide presentation of premonitory symptoms in migraine in children and adolescents, and the importance of understanding how these early symptoms are mediated in order to ensure that targeted abortive therapies are developed in the future. Recognition of these symptoms by parents, guardians, teachers and carers is of importance in ensuring early and effective attack treatment.

Recent Findings

A previous clinic-based questionnaire study in 103 children found a prevalence of premonitory symptoms in paediatric migraine of 67%, with a mean number of reported symptoms of two. A recent study found that in a clinic population of 100 children or adolescents with a migraine diagnosis who were preselected as having at least one premonitory symptom associated with their attacks, two or more premonitory symptoms were reported by 85% of patients. The most common symptoms were fatigue, mood change and neck stiffness.

Summary

Although the population prevalence of premonitory symptoms in migraine within the paediatric population, or their ability to predict accurately the onset of an impending headache cannot be deduced from the retrospective studies performed to date, premonitory symptoms occur in children as young as 18 months old. Understanding the biological basis of these, and their heterogeneous phenotype may help future targeted therapeutic research, helping the development of drugs that act before the onset of pain, limiting the morbidity associated with the migraine attack.

Characterising the premonitory stage of migraine in children: a clinic-based study of 100 patients in a specialist headache service

Background

The premonitory stage of migraine attacks, when symptomatology outside of pain can manifest hours to days before the onset of the headache, is well recognised. Such symptoms have been reported in adults in a number of studies, and have value in predicting an impending headache. These symptoms have not been extensively studied in children. We aimed to characterise which, if any, of these symptoms are reported in children seen within a Specialist Headache Service.

Methods

We reviewed clinic letters from the initial consultation of children and adolescents seen within the Specialist Headache Service at Great Ormond Street Hospital between 1999 and 2015 with migraine in whom we had prospectively assessed clinical phenotype data. We randomly selected 100 cases with at least one premonitory symptom recorded in the letter. For these patients, the age at headache onset, presence of family history of headache, headache diagnosis, presence of episodic syndromes which may be associated with headache, developmental milestones, gestation at birth, mode of delivery and presence of premonitory symptoms occurring before or during headache were recorded.

Results

Of the 100 patients selected, 65 % were female. The age range of the patients was 18 months to 15 years at the time of headache onset. The most common diagnosis was chronic migraine in 58 %, followed by episodic migraine (29 %), New Daily Persistent Headache with migrainous features (8 %) and hemiplegic migraine (5 %). A history of infantile colic was noted in 31 % and was the most common childhood episodic syndrome associated with migraine. The most common premonitory symptoms recorded were fatigue, mood change and neck stiffness. The commonest number of reported premonitory symptoms was two.

Conclusion

Premonitory symptoms associated with migraine are reported in children as young as 18 months, with an overall clinical phenotype comparable to adults. Better documentation of this stage will aid parents and clinicians to better understand the phenotype of attacks, better recognise migraine and thus initiate appropriate management. Larger studies with a broader base are warranted to understand the extent and implications of these symptoms for childhood and adolescent migraine.

Synthesis of Hydroxyapatite and ZnO Nanoparticles via Different Routes and its Comparative Analysis

Hydroxyapatite (HAp) was prepared from egg shells by various routes using hexane and acetic acid followed by heat treatment. HAp has a wide application in water treatment by removal of metal ions. XRD of the samples showed use of acetic acid followed by high temperature sintering leads to formation crystalline phases of HAp. Strong evidence of CaCO3 in calcite phase was obtained in other samples. Zinc oxide nanoparticles have also been synthesized by different methods such as sol-gel, co- precipitate and green synthesis. The effect of different synthesis methods were investigated using X-Ray Diffraction (XRD). The structural properties of nanoparticles including particle size were calculated from XRD data. The XRD reveals that the prepared ZnO samples were highly crystalline, having wurtzite crystal structure. The comparative analysis shows variations in particle size with different synthesis methods.

Review on mechanisms of dairy summer infertility and implications for hormonal intervention

In dairy cows and buffaloes, summer heat stress (HS) reduces milk yield and delays return to pregnancy leading to financial loss. Clues for effective interventions against summer infertility (SI) lie in understanding the underlying mechanisms. This article reviews current knowledge on the mechanisms of bovine SI and their implication for hormonal management. Under HS dairy animals encounter anestrous, silent cycles and repeat breeding which extend their open period. These effects are attributed mainly to HS induced disturbances in luteinizing hormone (LH) secretion, follicular dominance and estrogen secretion, ovulation and oocyte competence, luteal development and progesterone secretion, utero-placental function and embryo-fetal development. Hormonal timed artificial insemination protocols and LH support around estrous improved summer pregnancy rates by avoiding need for estrus detection, assisting follicular development and ovulation, enhancing quality oocytes and stimulating luteal function. Progesterone supplementation to enhance embryonic development did not produce significant improvement in summer pregnancy rates. There is need for evaluating integrated approaches combining hormones, metabolic modifier and cyto-protective agents.

A Clinically Severe Variant of β-Mannosidosis, Presenting with Neonatal Onset Epilepsy with Subsequent Evolution of Hydrocephalus

β-Mannosidosis results from a functional deficiency of the lysosomal enzyme, β-mannosidase. While being a well recognised, naturally occurring disease in both goats and cattle, it is an extremely rare disorder in humans with the first cases only being recorded in 1986. Until now the severity of the human disease has not mirrored that of its bovine or caprine counterparts, whose presentation is typically in the neonatal period with both altered skull morphology and seizures. Human β-mannosidosis has previously appeared to be a more indolent disease, with its only consistent phenotypic feature being developmental delay of varying severity. We report a patient, homozygous for a private mutation, who presented in the immediate perinatal period with seizures and who subsequently developed communicating hydrocephalus at 2 years of age.These are two new phenotypic features for β-mannosidosis. The first being the neonatal onset of the seizures, for while seizures have been seen in 3 out of the previous 20 documented cases, they have never before manifested prior to 6 months of age. However, as in the previous documented cases, the seizures were difficult to control and were associated with severe developmental delay.The second unique feature about this case was the development of communicating hydrocephalus. We discuss the possible mechanisms of its development.In summary, β-mannosidosis must thus now be considered in the differential diagnosis of neonatal onset seizures, and the potential for the development of hydrocephalus should be monitored during subsequent clinical follow-up.

Alteration in sample preparation to increase the yield of multiplex Polymerase Chain Reaction assay for diagnosis of genital ulcer disease

PURPOSE

Genital Ulcer Disease (GUD) is common sexually transmitted infection (STI). Multiple studies have shown that GUDs are strongly associated with the transmission and the acquisition of HIV infection. An accurate diagnosis of common etiology of GUD namely Herpes, syphilis and Chancroid is possible using Multiplex PCR (M-PCR). However, frequent presence of Polymerase Chain Reaction inhibitors in the ulcer swab specimen limits the performance of the assay. In order to overcome this problem, alternative specimen preparation method was used.

MATERIALS AND METHODS

To determine the common etiology, GUD specimens obtained under an STI operations research study were tested with M-PCR after the samples were prepared using Roche Amplicor specimen preparation kit. PCR inhibiting samples were identified from that, which showed negative results. These samples were subjected to phenol-chloroform extraction and ethanol precipitation before the conduct of M-PCR on them.

RESULTS

Of the 237 GUD specimens tested, in 145 etiologies could be detected, whereas 92 samples were found negative. Further spiking with one of the target DNA, 128 of the negative samples were found to contain the inhibitors. These 126 samples were then subjected to phenol chloroform extraction and ethanol precipitation followed by M-PCR. Using this method for sample preparation, etiology could be determined in 46 (23%) additional samples. This success rate of altered sample preparation method has been lower than that has reported.

CONCLUSION

The results indicate that sample preparation using phenol chloroform extraction and ethanol precipitation, prior to M-PCR helps to eliminate the inhibitors and increase the yield of the assay. However, being a laborious procedure, it may be used for samples giving negative results after the screening by Roche Amplicor specimen preparation kit.

Spontaneous rapid resolution of acute basal ganglia changes in an untreated infant with propionic acidemia: a clue to pathogenesis?

Basal ganglia lesions are a well reported feature of acute decompensation in propionic acidemia; however, their underlying causation still needs to be fully elucidated. We report an 8-month-old infant whose lesions had almost completely resolved radiologically within 3 weeks of initial presentation without specific metabolic management and in light of this, we discuss the current thinking on their pathogenesis.

Thrombocytopenia as an adverse effect of levetiracetam therapy in a child

Levetiracetam is one of the newer anti-epileptic medications, which is now widely used in the treatment of childhood epilepsy. Thrombocytopenia is not a well-known adverse effect of this medication. There have only been two adult case reports describing this feature as an adverse effect of levetiracetam. We describe this feature in a child. A six and half-year-old boy developed symptomatic epilepsy secondary to cerebral venous sinus thrombosis. He was treated with levetiracetam. He made a good recovery from his primary illness, but five weeks after he started taking levetiracetam, he presented with thrombocytopenia requiring platelet transfusion. Extensive investigations for known causes of thrombocytopenia were negative. Withdrawal of levetiracetam led to the resolution of thrombocytopenia. Levetiracetam-induced thrombocytopenia is a rare, but significant adverse effect.

Production of bioactive metabolites by Nocardia levis MK-VL_113

AIMS

To isolate and identify the bioactive compounds produced by Nocardia levis MK-VL_113.

METHODS AND RESULTS

Cultural characteristics of Noc. levis isolated from laterite soils of Guntur region were recorded on International Streptomyces Project media. Morphological studies of the strain through scanning electron microscopy revealed the clear pattern of its hyphal fragmentation into rod-shaped bacilli. Chemical examination of the secondary metabolites of the strain grown on sucrose-tryptone broth led to the isolation of three fractions active against Bacillus cereus. Further analysis of second fraction resulted in the isolation of two active subfractions. Two different phthalate esters, namely, bis-(2-ethylhexyl) phthalate and bis-(5-ethylheptyl) phthalate, were purified from the first active subfraction, and the structural elucidation of these compounds was confirmed on the basis of FT-IR, mass and NMR spectroscopy. The partially purified second subfraction subjected to Gas Chromatography-Mass spectroscopy contained nine components: decanedioic acid; 2,6-piperdione monooxime; 1-eicosanol; beta-1-arabinopyranoside, methyl; cyclopentaneundecanoic acid; hexadecanoic acid; silane, trichloro eicosyl; 1-hexacosanol; and 1,2-dodecanediol. The antimicrobial activity of the bioactive compounds produced by Noc. levis was expressed in terms of minimum inhibitory concentration.

CONCLUSIONS

The present study clearly revealed that the metabolites of Noc. levis act as bioactive compounds against gram-positive and gram-negative bacteria, yeast and filamentous fungi. It also supports the idea that there are a number of rare actinomycetes remained to be explored for new bioactive compounds.

SIGNIFICANCE AND IMPACT OF THE STUDY

Metabolites of Noc. levis exhibited antibacterial and antifungal activities. This is the first report of bis-(5-ethylheptyl) phthalate as well as the nine partially purified compounds from actinomycetes. In addition, this is also the first report of bis-(2-ethylhexyl) phthalate from the genus Nocardia.

Multiple Sclerosis in Keralite siblings after migration to the Middle East: a report of familial Multiple Sclerosis from India

OBJECTIVE

To report Multiple Sclerosis (MS) in two migrant Indian siblings in the Middle East.

BACKGROUND

MS was thought to be rare in the Indian subcontinent, but, of late, with ready availability of Magnetic Resonance Imaging (MRI) scan, evoked potential studies and immunoglobulin estimation in this part of the developing world, there have been several reports of definite cases of MS from India. However familial MS remains hitherto unreported from the Indian subcontinent.

REPORT

A 39-year-old South Indian Hindu female presented with an episode of hemiparesis which remitted with treatment. Three months later she had a relapse in an acute disseminated form, with residual deficits in gait, vision and mental faculties. MRI revealed discrete and confluent plaques in the centrum semiovale. Four years later, her brother was diagnosed to have central demyelinating disease with discrete and confluent plaques in the cervical cord and corona radiata when he presented at age 39 with neck pain and episodic tonic spasms in the lower limbs. Leucodystrophies were ruled out through appropriate biochemical tests. Cases satisfied diagnostic criteria for MS and were confirmed by follow up. HLA associations were studied. Starting a decade after migration from the South Indian state of Kerala to the Middle East, the disease had slow secondary progression in the female but a stable benign course, so far, in the male sibling.

CONCLUSIONS/RELEVANCE

This is the first case report of familial MS from the Indian subcontinent. Onset of MS in South Indian siblings after several years of stay in the Middle East may support aetiological postulations of gene-environment interactions.

Third generation cephalosporin use in a tertiary hospital in Port of Spain, Trinidad: need for an antibiotic policy

Background

Tertiary care hospitals are a potential source for development and spread of bacterial resistance being in the loop to receive outpatients and referrals from community nursing homes and hospitals. The liberal use of third-generation cephalosporins (3GCs) in these hospitals has been associated with the emergence of extended-spectrum beta- lactamases (ESBLs) presenting concerns for bacterial resistance in therapeutics. We studied the 3GC utilization in a tertiary care teaching hospital, in warded patients (medical, surgical, gynaecology, orthopedic) prescribed these drugs.

Methods

Clinical data of patients (≥ 13 years) admitted to the General Hospital, Port of Spain (POSGH) from January to June 2000, and who had received 3GCs based on the Pharmacy records were studied. The Sanford Antibiotic Guide 2000, was used to determine appropriateness of therapy. The agency which procures drugs for the Ministry of Health supplied the cost of drugs.

Results

The prevalence rate of use of 3GCs was 9.5 per 1000 admissions and was higher in surgical and gynecological admissions (21/1000) compared with medical and orthopedic (8 /1000) services (p < 0.05). Ceftriaxone was the most frequently used 3GC. Sixty-nine (36%) patients without clinical evidence of infection received 3Gcs and prescribing was based on therapeutic recommendations in 4% of patients. At least 62% of all prescriptions were inappropriate with significant associations for patients from gynaecology (p < 0.003), empirical prescribing (p < 0.48), patients with undetermined infection sites (p < 0.007), and for single drug use compared with multiple antibiotics (p < 0.001). Treatment was twice as costly when prescribing was inappropriate

Conclusions

There is extensive inappropriate 3GC utilization in tertiary care in Trinidad. We recommend hospital laboratories undertake continuous surveillance of antibiotic resistance patterns so that appropriate changes in prescribing guidelines can be developed and implemented. Though guidelines for rational antibiotic use were developed they have not been re-visited or encouraged, suggesting urgent antibiotic review of the hospital formulary and instituting an infection control team. Monitoring antibiotic use with microbiology laboratory support can promote rational drug utilization, cut costs, halt inappropriate 3GC prescribing, and delay the emergence of resistant organisms. An ongoing antibiotic peer audit is suggested.

Extended-spectrum beta-lactamase producing enterobacteriaceae in a tertiary care hospital in Trinidad and Tobago

Extended-spectrum beta-lactamase (ESBL) mediated resistance to third generation cephalosporins, amongst the family Enterobacteriaceae, is emerging worldwide. This is the Caribbean's first survey on ESBL production, and was conducted during two six-month periods in 1998 and 2001, in a tertiary health institution in Trinidad and Tobago. Consecutive ampicillin resistant isolates of the family Enterobacteriaceae from in-patients were screened for resistance to third generation cephalosporins, and for ESBL production. The proportion of isolates found to be ESBL producers was similar in both samples (40 of 560 and 23 of 361). Overall, ESBL production was more frequent in enterobacter, citrobacter and proteus (and related organisms) than in Klebsiella and Escherichia (11.2% and 4.6%, respectively, p < 0.001). In the 1998 sample, this proportion (9.8% versus 5.8%) was significant (p < 0.05), but the difference was more marked in the 2001 sample (13.6% versus 2.9%, p < 0.001). Continued distribution of these resistant bacterial strains is of concern. In the Caribbean region, more laboratory surveillance and increased infection control vigilance are recommended, with focus on specific genera in the family.

Determinants of gonorrhoea infection among STD clinic attenders in Trinidad--II: sexual behavioural factors

Sexual behavioural factors associated with gonococcal infection among 991 STD clinic attenders in Trinidad, West Indies (WI) were determined by univariate and stepwise multiple logistic regression analysis. Casual sex (odds ratios [OR] 1.6) was the only predictor of gonorrhoea. Among males, significant associations were identified by univariate analysis between concurrent partnerships, > or =one sexual partner(s) in the past 6 months, and drug use prior to engaging in casual and/or oral sex. No significant associations were identified between gonorrhoea and sexual behaviour factors among females. This study is the first to describe sexual behaviours associated with gonococcal infection in Trinidad and to evaluate risk behaviours by gender.