High multidrug resistance in urinary tract infections in a tertiary hospital, Kathmandu, Nepal

SETTING:

Tribhuvan University Teaching Tertiary Care Hospital, Kathmandu, Nepal, May–October 2019.

OBJECTIVE:

1) To describe the bacteriological profile, 2) to identify the antimicrobial resistance (AMR) pattern, and 3) to find the demographic characteristics associated with the presence of bacterial growth and multidrug resistance (MDR) in adult urine samples undergoing culture and drug susceptibility testing.

DESIGN:

This was a hospital-based, cross-sectional study using routine laboratory records.

RESULTS:

Among 11,776 urine samples, 16% (1,865/11,776) were culture-positive, predominantly caused by Escherichia coli (1,159/1,865; 62%). We found a high prevalence of resistance to at least one antibiotic (1,573/1,865; 84%) and MDR (1,000/1,865; 54%). Resistance to commonly used antibiotics for urinary tract infections (UTIs) such as ceftazidime, levofloxacin, cefepime and ampicillin was high. Patients aged ⩾60 years (adjusted prevalence ratio [aPR] 1.6, 95% CI 1.4–1.7) were more likely to have culture positivity. Patients with age ⩾45 years (45–59 years: aPR 1.5, 95% CI 1.3–1.7; ⩾60 years: aPR 1.4, 95% CI 1.2–1.6), male sex (aPR 1.3, 95% CI 1.2–1.5) and from inpatient settings (aPR 1.4, 95% CI 1.2–1.7) had significantly higher prevalence of MDR.

CONCLUSION:

Urine samples from a tertiary hospital showed high prevalence of E. coli and MDR to routinely used antibiotics, especially among inpatients. Regular surveillance and application of updated antibiograms are crucial to monitor the AMR situation in Nepal.

High drug resistance among Gram-negative bacteria in sputum samples from an intensive care unit in Nepal

SETTING

Tribhuvan University Teaching Hospital, Kathmandu, Nepal.

OBJECTIVES

1) To report the number and proportion of Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas (PABS) species among intensive care unit (ICU) patients with sputum culture; and 2) to assess antimicrobial resistance patterns, demographic and clinical characteristics associated with resistance to at least one antibiotic and ICU discharge outcomes among those patients with PABS species admitted to hospital between 14 April 2018 and 13 April 2019.

DESIGN

This was a hospital-based, cross-sectional study using secondary data.

RESULTS

Of 166 who underwent sputum culture, 104 (63%) had bacterial growth, of which, 67 (64%) showed PABS species. Of the positive cultures, Pseudomonas, Acinetobacter, Burkholderia and Stenotrophomonas were present in respectively 32 (30.7%), 31 (29.8%), 1 (1%) and 3 (2.8%). Pseudomonas showed a high level of resistance to levofloxacin (61%), cefepime (50%) and amikacin (50%). Acinetobacter was largely resistant to cefepime (95%), imipenem (92%) and levofloxacin (86%). Of the 67 with PABS infection, 32 (48%) died.

CONCLUSION

The study showed a high prevalence of Pseudomonas and Acinetobacter and the emergence of Stenotrophomonas in sputum culture samples of ICU patients. This highlights the need for monitoring PABS and associated resistance patterns to reduce mortality in ICU patients.

Antimicrobial resistance in neonates with suspected sepsis

SETTING

Nobel Medical College and Teaching Hospital, Biratnagar, Nepal.

OBJECTIVE

To determine the pattern of antimicrobial resistance and hospital exit outcomes in neonates with suspected sepsis in a tertiary neonatal intensive care unit (NICU).

DESIGN

This hospital-based cohort study was conducted to follow patients from January to December 2019. All identified cases of suspected sepsis were enlisted from hospital records.

RESULTS

Sepsis was suspected in 177 (88%) of the 200 cases admitted in the NICU; 52 (29%) were culture-positive. Pseudomonas was the predominant organism isolated (n = 40; 78%), followed by coagulase negative staphylococcus (n = 12, 23%). Nine (17%) of the 52 isolates were resistant to the Access and Watch group of antibiotics, including some resistance to Reserve group drugs such as imipenem and linezolid. Most treated cases (n = 170, 96%) improved, although 7 (4%) left against medical advice.

CONCLUSION

Most of the pathogens were resistant to WHO Access and Watch antibiotics and occasional resistance was observed to Reserve group drugs. Most sepsis was caused by Gram-negative bacilli. Improving turnaround times for antibiotic sensitivity testing using point-of-care testing, and a greater yield of culture-positive results are needed to enhance the management of neonatal sepsis.

Management of Organophosphorus Poisoning

Organophosphorus (OP) compounds are widely used for agriculture, domestic pest-control and chemical warfare. Pesticide self-poisoning accounts for one-sixth to one-eighth of the world's suicides and a third of suicide deaths in rural Asia each year. OP pesticides inhibit cholinesterase enzymes leading to overstimulation of cholinergic receptors. Clinical features depend on the types of receptors stimulated at various sites of the body. The diagnosis of OP poisoning is made on the basis of history of poisoning, smell of pesticides, the characteristic clinical signs and reduced cholinesterase activity. Measurement of plasma cholinesterase is useful for diagnosis of OP poisoning although it may not directly correlate with severity of the poisoning. Atropine remains the main stay of treatment of OP poisoning with clear evidence of benefit if administered effectively. Atropine therapy should be monitored to maintain systolic blood pressure > 80 mmHg, pulse > 80 beats/min and clear chest on auscultation. Oximes reactivate cholinesterase enzymes and help to overcome even the nicotinic effects of OP poisoning. However, evidence for its effectiveness after self-poisoning is weak. Although several newer adjuvant therapies are tried to achieve better outcome, their potential benefits are not yet established.

Role of sonography done by clinicians/surgery residents in the diagnosis and management of clinically palpable breast lumps

Introduction and Objective: The aim of the study is to correlate the sonographic findings of breast ultrasound done by clinicians/surgery residents with radiologists and also to correlate the sonographic findings of breast ultrasound with cytopathological or histopathological findings.Materials and Methods: A prospective observational study conducted at KMCTH from March 2014 to March 2015. All consecutive patients presenting with clinically palpable breast lumps were included in the study. A sample size of 30 patients was taken. All patients with clinically palpable solid breast lumps were subjected to ultrasound by a clinician/surgical resident. Ethical clearance was taken from the institutional review board and informed consent was taken from the individual patients.Results: We found that the sonography done by clinicians/surgery residents had 100% sensitivity, 84.6% specificity and PPV of 50%. There was significant correlation between the findings of the surgery residents and radiologists and the cytopathology/histopathology as well.Conclusion: Breast Sonography performed by clinicians/surgery residents is comparable to radiologists in the diagnosis of clinically palpable breast lumps. It has good correlation with cytopathological and histopathological findings.

Anterior abdominal wall dermatofibrosarcoma protuberans: a case report

Dermatofibrosarcoma protuberans is a rare low-grade fibrohistiocytic tumor ,common in age group of 20 to 50 years. Histologically, it is diagnosed on the basis of a spindle-cell tumor arranged in small bundles in a characteristic cartwheel pattern. Though local recurrence rate is high, the treatment of choice is surgical resection with negative margins. We describe a case of a 34-year-old lady with dermatofibrosarcoma protuberans.

Role of C-reactive Protein in Acute Appendicitis

Background Acute appendicitis is the common surgical emergency. This study analyzed the value of C-reactive protein as the diagnostic marker of acute appendicitis. Objective To assess the level of C-reactive protein in acute appendicitis and to relate the quantitative measurement with degree of inflammation of appendix. Method A cross sectional study was done with consecutive patients diagnosed with acute appendicitis that underwent appendectomy over six months period. Peroperative findings and histopathology report were compared and analyzed with the level of C-reactive protein. Result A total of 54 patients were enrolled in this study. 94.40% were proved as acute appendicitis in histopathology. The level of C-reactive protein was significantly raised among highly inflamed appendix. C-reactive protein showed 84.31% sensitivity, 66.66% specificity, 97.72% positive predictive value and 20% negative predictive value in diagnosing acute appendicitis. Conclusion With degree of inflammation of appendix, value of C-reactive protein was raised. Quantitative assessment can predict severity of inflammation. Raised level of C-reactive protein is an aid for diagnosing acute appendicitis.

Routine Measurement of Serum Amylase in Acute Abdomen

BACKGROUND

Acute abdominal pain is a common condition presenting to both the emergency department (ED) and surgical admission unit. Increase in serum amylase levels are found in much gastrointestinal pathology. Serum amylase level is consistently high in acute pancreatitis though high values are not pathognomonic of pancreatitis .The aim of this study to assess the level of serum amylase in various diseases presenting with acute abdominal pain and to evaluate the role of routine measurement of serum amylase in the screening of patient with acute abdominal pain for the diagnosis of acute pancreatitis in a prospective series.

METHODS

A prospective observational study was performed from 15th May 2014 - 15th Nov 2014 (6 months) at Department of Surgery of Kathmandu medical College Teaching Hospital; Kathmandu. All consecutive patients presented at emergency department and required admissions in surgical ward were included. A multivariate analysis was performed to assess the level of serum amylase in various diseases presenting with acute abdominal pain including acute pancreatitis.

RESULTS

Overall, 318 patients were included during a period of 6 months among them 48 patients were excluded. 34 cases (12.6 %) were diagnosed of acute pancreatitis. three cases (1.1%) of non pancreatic pathology with raised serum amylase level (> 1000 U\L).

CONCLUSIONS

Routine assessment of serum amylase is helpful in excluding differential diagnosis of patient presenting with acute abdomen and this study identified serum amylase as a good screening tool if done in cases with clinical suspicion.

Correlation of serum free prostate-specific antigen level with histological findings in patients with prostatic disease

BACKGROUND

Prostate Specific Antigen (PSA) has been widely used in the diagnosis and management of patients with prostate cancer. It may be elevated in other prostatic diseases and surgical procedures. PSA exists in two forms, a major bound form (cPSA) and a free form (fPSA).

OBJECTIVES

The objective of the study was to determine the relationship between serum fPSA levels and histologic findings in biopsy specimens of men with prostatic disease.

MATERIAL AND METHODS

This study includes 91 patients planned for transurethral resection of prostate (TURP). Blood samples were collected before TURP and tested for fPSA. Histology of the tissue samples collected after TURP were studied and the relationship with fPSA analysed using SPSS 11.5.

RESULTS

The median values for benign, premalignant and malignant lesions were 1.8 ng/ml, 4.5 ng/ml and 13.20 ng/ml respectively (p<0.001). Most cases of benign prostatic hyperplasia(BPH) without inflammation had fPSA levels <2 ng/ ml, while most with active inflammation had levels >5 ng/ml. Low grade prostatic intraepithelial neoplasia (LGPIN) saw levels <5 ng/ml while high grade intraepithelial neoplasia (HGPIN) and prostate cancer (PCa) had levels > 5 ng/mL (p<0.05). For detection of high grade lesions (HGPIN and PCa), the sensitivity and specificity of fPSA level > 5 ng/ml was found to be 88.8% and 90.2% respectively.

CONCLUSIONS

Serum fPSA is elevated marginally in patients with BPH without inflammation. Active inflammation and high grade lesions are associated with fPSA level more than 5 ng/ml.

Accuracy of ultrasonography in evaluation of level and cause of biliary obstruction: a prospective study

AIM

To find out the accuracy of ultrasound in evaluation of level and cause of biliary obstruction.

MATERIALS AND METHODS

Forty-five patients (26 to 86 years of age) with suspected biliary obstruction underwent Ultrasonography followed by Direct Cholangiograms (Percutaneous Transhepatic Cholangiography / Endoscopic Retrograde Cholangiography). The levels of biliary obstructions were grouped as hilar, suprapancreatic and intrapancreatic. Similarly the causes were grouped as malignant and benign. Diagnosis was confirmed either at surgery or histopathologically (USG-guided FNAC or ERC-biopsy).

RESULTS

Ultrasonography accurately identified the level of obstruction in 89 %( hilar), 91% (suprapancreatic) and 87% ( intrapancreatic) cases. Malignancy was found in 33 patients and remaining 12 had benign diseases. USG accurately identified malignant and benign causes in 91% and 84% cases respectively. Findings were found to be statistically significant (p-value =< 0.05 at 95%confidence interval).

CONCLUSION

This study showed that USG has high accuracy in identifying the level and cause of biliary obstruction. Considering cost, availability and patient friendly nature, Ultrasound should be the first imaging modality of choice in evaluation of biliary obstruction.