OP0143 CANCER IN GIANT-CELL ARTERITIS PATIENTS: A LARGE NATIONWIDE STUDY

Background:

The association between giant-cell arteritis (GCA) and malignancy is controversial.

Objectives:

To asses malignancy rates and risk in GCA patients in a large-scale population-based study.

Methods:

We utilized the medical database of Clalit-Health-Services for this retrospective cohort study. Follow-up was from January 1,2002 and continued until death or end of follow-up on September 1,2018. Incident GCA patients were compared with age-and-sex-matched controls. Hazard-ratios for subtypes of malignancies were obtained by the Cox proportional-hazard model, adjusted for socio-demographic variables and cancer risk factors.

Results:

The study population included 7,213 GCA patients and 32,987 age- and sex-matched controls who were not diagnosed with the disease. The mean age of GCA diagnosis was 72.3±9.9 years (median 73.1 years) and 69.1% were women. At Kaplan–Meier survival analysis, assessing cumulative cancer-free survival in GCA patients and controls, GCA patients had worse curve than controls (chi-squared = 49.84; degrees of freedom = 1; p < 0.0001; Figure 1). At the cox-survival analysis adjusted for age, sex, SES and cancer risk factors GCA patients showed increased risk for overall cancer (HR 1.29 [95%CI 1.20-1.39]), kidney cancer (HR 1.60 [95%CI 1.15-2.23]), sarcoma (HR 2.14 [95%CI 1.41-3.24]), acute-leukemia (HR 1.81 [95%CI 1.06-3.07]), chronic-leukemia (HR 1.82 [95%CI 1.19-2.77]), Hodgkin’s lymphoma (HR 2.42 [95%CI 1.12-5.20]), non-Hodgkin’s lymphoma (HR 1.66 [95%CI 1.21-2.29]) and multiple myeloma (HR 2.40 [95%CI 1.63-3.53) (Table 1). The time (mean [months] ± SD) to the diagnosis of any malignancy was significantly shorter in GCA patients (48.6 ± 41.3) compared to controls (58.1 ± 43.6; p<0.001).

Table 1.

Cox survival analysis assessing crude and adjusted hazard for cancer in GCA patients compare to controls

Type of malignancyAdjusted HRHR95% CIAny malignancy1.291.20, 1.39Oropharyngeal cancer0.960.69, 1.35Thyroid cancer1.200.66, 2.16Breast cancer0.930.75, 1.14Lung cancer1.260.99, 1.59Esophagus cancer1.860.93, 3.75Stomach Cancer0.610.37, 0.98Colorectal Cancer1.120.93, 1.36Liver and bile ducts cancer1.060.69, 1.62Kidney cancer1.601.15, 2.23Bladder cancer1.150.88, 1.50Uterus cancer0.850.55, 1.30Cervical cancer of the uterus0.450.37, 1.46Ovary Cancer0.960.58, 1.59Prostate Cancer1.070.80, 1.43Sarcoma2.141.41, 3.24Melanoma1.110.80, 1.55Acute Leukemia1.811.06, 3.07Chronic Leukemia1.821.19, 2.77Myelodysplastic syndrome1.840.94, 3.60Hodgkin’s Lymphoma2.421.12, 5.20Non-Hodgkin’s Lymphoma1.661.21, 2.29Multiple Myeloma2.401.63, 3.53Figure 1.

Kaplan-Meier cancer-free survival curve

Conclusion:

GCA patients are at increased risk for sarcoma, kidney cancer, hematological malignancies and overall malignancies compared to age-and-sex matched controls from the general population.

References:

[1]Watad A, McGonagle D, Bragazzi NL, Tiosano S, Comaneshter D, Shoenfeld Y, et al. Autoantibody status in systemic sclerosis patients defines both cancer risk and survival with ANA negativity in cases with concomitant cancer having a worse survival. Oncoimmunology 2019;8:e1588084.

[2]Ben-Shabat N, Tiosano S, Shovman O, Comaneshter D, Shoenfeld Y, Cohen AD, et al. Mortality among patients with giant-cell arteritis: A large-scale population-based cohort study. J Rheumatol 2019;

Disclosure of Interests:

None declared

Comparison of conventional, immunological and molecular techniques for the diagnosis of symptomatic congenital human cytomegalovirus infection in neonates and infants

PURPOSE

Human cytomegalovirus (HCMV) is the commonest pathogen causing congenital infection globally. The diagnosis of congenital infection is based either on viral isolation (in cell culture) or demonstration of HCMV DNA from the urine. Saliva is also being used as an alternative sample to urine for the same. The objective of this study was to compare the following assays-polymerase chain reaction (PCR) from urine, saliva and blood, serology (anti-HCMV IgM) and antigen detection (HCMV pp65 antigenaemia) for the diagnosis of congenital HCMV infection.

MATERIALS AND METHODS

Urine and blood samples were collected from 31 infants (median age: 13 weeks) with suspected HCMV infection. For 18 infants, additional saliva samples were collected and all the above assays were compared.

RESULTS

PCR for HCMV DNA from urine and anti-HCMV IgM were performed for all 31 infants. Of these, 22 (70.9%) were positive for both assays. In 18 (of the 22) infants positive by both assays, PCR for HCMV DNA from saliva was positive in all 18 (100%), PCR from blood in 7/18 (38.8%) and HCMV pp65 antigenaemia only in 1/18 (5.5%) of the infants.

CONCLUSION

Detection of HCMV DNA in urine combined with anti-HCMV IgM are suitable assays to diagnose HCMV infection in infants. Both PCR from the blood and HCMV pp65 antigenaemia lack sensitivity in infants. Salivary PCR combines convenience with high sensitivity and can substitute PCR from urine, especially in the outpatient and field settings. To the best of our knowledge, this is the first study from India to evaluate salivary PCR for the diagnosis of congenital HCMV infection.

Pneumocystis jirovecii dihydropteroate synthase (DHPS) genotypes in non-HIV-immunocompromised patients: a tertiary care reference health centre study

Studies on Pneumocystis jirovecii dihydropteroate synthase (DHPS) genotypes among non-HIV immunocompromised patients from developing countries are rare. In the present prospective investigation, 24 (11.8%) cases were found to be positive for Pneumocystis jirovecii out of 203 non-HIV patients with a clinical suspicion of Pneumocystis pneumonia (PCP). Dihydropteroate synthase (DHPS) genotype 1 (Thr55+Pro57) was noted in 95.8% P. jirovecii isolates in the present study in contrast to only 4.1% of patients with DHPS genotype 4 (Thr55Ala + Pro57Ser).

Quality assurance of annual HIV sentinel surveillance 2006: experience of regional institute, central zone

National AIDS Control Organisation (NACO) identified five regional institutes (RIs) to monitor and supervise the 2006 round of annual HIV sentinel surveillance. The task mandated was quality control of both epidemiological data collection and HIV testing. The team at RI consisted of epidemiologist and microbiologist. We describe here the process of quality control and the quality of surveillance in the states of Uttar Pradesh, Uttarakhand, Bihar, Jharkand, and Delhi. The supervisors visited almost 90% of the sentinel sites. Performance of vast majority of the sentinel sites (92%) was satisfactory. The testing laboratories were found to be adhering to standard operating procedures. Concordance rate of test results between testing laboratory and the designated reference laboratory was high. Overall, the quality of sentinel surveillance was good. The lacunae found during the visit have been enumerated along with the recommendations for future surveillance round.

Dengue fever with papilledema: a case of dengue-3 virus infection in central nervous system

BACKGROUND AND OBJECTIVES

Neurological manifestations of dengue fever are rarely reported during acute illness and clinical presentation commonly observed is of acute encephalitis or one of the post-infectious immune mediated manifestations. We describe a case of dengue fever having mild encephalopathy and papilledema at presentation.

CASE REPORT

Twenty-year-old female presented with fever, headache and vomiting. On examination she did not have classical signs of dengue fever and was found to have bilateral papilledema on fundus examination. Detailed work-up did not reveal any other cause of papilledema. Diagnosis of dengue fever was established by blood IgM antibody test on day 7 of illness. Retrospective analysis of CSF (drawn on day 5 of illness) by RT-PCR assay showed a characteristic band of dengue-3 virus. Papilledema was transient and subsided following symptomatic treatment. The patient recovered from acute illness and follow-up was unremarkable.

CONCLUSION

Especially in dengue endemic areas, in the patients having acute febrile illness with subtle signs and symptoms suggestive of CNS involvement, dengue virus infection should also be ruled out early in the clinical course.

Role of CSF serology in follow-up of subacute Sclerosing Panencephalitis patients on treatment

Subacute sclerosing panencephalitis (SSPE) is a progressive inflammatory disease of the central nervous system with poor prognosis and high mortality. No effective treatment has a proven role; oral isoprinosine and intrathecal administration of alpha-interferon may prolong survival. We report an unusual case of adult onset SSPE patient on treatment with significant clinical improvement, even in the absence of conversion to seronegativity in either CSF or serum, on follow-up serological examination.

Expression and humoral immune response to hepatitis C virus using a plasmid DNA construct

PURPOSE

The objective of this study was to clone a c-DNA fragment of hepatitis C virus in a eukaryotic expression vector and to measure the efficacy of humoral immune responses in mice inoculated with this recombinant plasmid. This study was an attempt to lay a foundation for HCV nucleic acid vaccine development in the future.

METHODS

A c-DNA fragment of BK146, a clone of HCV type 1b, was sub-cloned into an eukaryotic expression vector pMT3. HepG2 and COS cells were transfected with this construct, named pMT3-BK146. The expression of HCV mRNA and proteins was studied by reverse transcribed polymerase chain reaction, radio Immunoprecipitation (RIPA) and immunofluorescence (IFA). The DNA of this construct was injected into the footpad of BALB/c mice and antibody response was tested by enzyme immunoassay and indirect immunofluorescence.

RESULTS

COS and HepG2 cells transiently transfected with the recombinant plasmid pMT3-BK146 showed the expression of HCV proteins by RT-PCR, RIPA and immunofluorescence. This DNA clone when injected into Balb/c mice was able to generate specific antibody response to hepatitis C virus by ELISA and IFA.

CONCLUSIONS

A c-DNA fragment of HCV cloned in an eukaryotic expression vector was able to express core protein. This DNA clone was also able to elicit antibody response in mice. This can be an initial step towards the development of a potential DNA vaccine for hepatitis C virus infection.

Predominace of a novel Mycobacterium tuberculosis genotype in the Delhi region of India

Using IS 6110 -restriction fragment length polymorphism (RFLP) and spoligotyping, genetic variations of 83 Mycobacterium tuberculosis strains isolated from tuberculosis patients from two wards in a hospital in Delhi and a rural chest clinic near Delhi were analysed. The vast majority of the isolates (75%) were closely related and this novel genogroup was designated the 'Delhi type'. Both drug-sensitive and drug-resistant strains were found among strains of this genogroup. A minority of the strains harboured a single IS 6110 copy and only one strain belonged to the Beijing genotype, a genotype that is predominant in other parts of Asia. A comparison of the RFLP and spoligotype with existing data suggests that the predominance of Delhi genogroup is geographically limited to the Indian subcontinent and perhaps to specific regions in India. Despite the high prevalence of the M. tuberculosis strains of the Delhi type, the strains could easily be discriminated due to polymorphisms in the IS 6110 patterns. Future studies may disclose the genetic characteristics of strains belonging to the Delhi genotype, analogous to the recently observed virulence among the Beijing genogroup.

Foodborne outbreak caused by a Norwalk-like virus in India

An outbreak of acute gastroenteritis occurred in the nurses' hostel of a civil hospital in Delhi, after a farewell party involving 130 nurses and some of the housekeeping staff. All affected persons had eaten salad sandwiches at the party. Stool samples were collected from six of these patients on the second day of infection. All six samples, when tested for the presence of common bacteria, parasites, and rotavirus, were found to be negative. The clinical features of this outbreak matched the criteria set for outbreaks caused by Norwalk-like viruses (NLVs). Reverse transcription-polymerase chain reaction (RT-PCR) was carried out on these six samples, using primers from the RNA-dependent RNA polymerase (RdRp) gene of NLVs. Immunoelectron microscopy was carried out on two of the samples, using convalescent phase serum. All six samples were positive for genogroup (GG) II NLVs by RT-nested PCR. Aggregates of 32-nm viral particles were visualized by immunoelectron microscopy in one of the two samples. Sequencing of the RdRp gene was done on amplicons from three samples; phylogenetic analysis placed the isolates NDV/1999 in a Toronto virus cluster of GG II NLVs. This is the first report of a food-borne outbreak attributable to NLVs from India.

Polymerase chain reaction in clinically suspected genitourinary tuberculosis: comparison with intravenous urography, bladder biopsy, and urine acid fast bacilli culture

OBJECTIVES

To evaluate the role of urinary polymerase chain reaction (PCR) in the detection of Mycobacterium tuberculosis (MTb) in patients with a clinical suspicion of genitourinary tuberculosis (GUTB) and to compare its sensitivity with intravenous urography (IVU), bladder biopsy, and urine culture for acid fast bacilli (AFB).

METHODS

The study was carried out between September 1997 and December 1998 in 42 patients with a clinical suspicion of GUTB. Their clinical features, organ involvement, and investigation results were studied. The diagnostic yield of urinary PCR for MTb and its sensitivity in comparison with routine urine AFB culture, bladder biopsy, and IVU were assessed.

RESULTS

There were 25 male and 17 female patients, with a mean age of 31.04 years. Patients suspected of having GUTB most often presented with irritative voiding symptoms. Two patients had abnormal renal parameters. Of the 42 patients clinically suspected of having GUTB, radiologic abnormalities suggestive of GUTB were found in 37 (88.09%); MTb was isolated in the urine AFB culture in 13 (30.95%); bladder biopsy was positive in 11 (45.83%); and urinary PCR for MTb was positive in 34 cases (80.95%). Of 35 cases of proven GUTB, IVU was suggestive of the diagnosis in 32 (91.42%) and MTb was isolated in the urine AFB culture in 13 cases (37.14%). Bladder biopsy was positive in 11 (45. 83%) of 24 patients in whom biopsy was taken, and urinary PCR for MTb was positive in 33 (94.29%).

CONCLUSIONS

A high index of suspicion is necessary for a diagnosis of GUTB. In clinically suspected cases, IVU may be suggestive of GUTB, but it is not specific. In the present study, IVU was suggestive in 88.09% of patients. MTb was isolated in the urine AFB culture in only 37.14% of patients, and bladder biopsy was positive in 45.83%. Urinary PCR for MTb was the most sensitive indicator and was positive in 94.29% of patients. It is evident from this series that PCR provides a much faster diagnosis of urinary MTb. It is a rapid, sensitive, and specific diagnostic method and avoids a delay in starting treatment.

Levels of CD4 and CD8 among the inhabitants of Manipur, India

Data on mean reference CD4 and CD8% is in general lacking in India. Manipur in the North-East India has high prevalence of HIV infection among the injecting drug users. This study was carried out to establish mean reference CD4 and CD8 cell count in normal and HIV infected individuals in our population, for use in interpretation of these prognostic markers in HIV infected persons. Whole blood sample was collected in EDTA from 14 normal and 23 HIV infected individuals. Fluorescence staining was carried out with FITC conjugated anti-CD4 and CD8 antibodies (Becton Dickinson) directly on whole blood, followed by single step lysis using commercial lysing solution (Optilyse C, Immunotec). The samples were analyzed by two-colour flow cytometry on Coulter Elite cytometer. It was observed that the mean CD4 and CD8 positive cells in normal healthy individuals were 36% (absolute 848/cumm) and 21% (absolute 427/cumm) respectively. The mean CD4% was significantly decreased in HIV infected individuals with a mean value of 13.4% (absolute 246/cumm), while the mean CD8% was significantly increased to 39.2% (absolute 660/cumm) in HIV infected individuals. A lower CD4+ cell count was also observed as compared to the western population among the normal healthy individuals. The mean CD4 and CD8 positive cells in normal healthy adult population were found to be 36% and 21% respectively, and 13.4% and 39.2% in HIV infected individuals respectively. These values should be considered when interpreting CD4 and CD8 counts in HIV infected individuals in this part of the country.

Rapid detection of respiratory viruses by centrifugation enhanced cultures from children with acute lower respiratory tract infections

BACKGROUND

Acute respiratory tract infection (ARI) is the major cause of morbidity and mortality in young children in developing countries. Information on viral aetiology in ARI in India is very limited.

OBJECTIVE

The aim of the study was to define the role of viruses in acute lower respiratory tract infections (ALRTI) in children in India using centrifugation enhanced cultures followed by indirect immunofluorescence (IIF).

STUDY DESIGN

Nasopharyngeal aspirates (NPAs) were collected from children from September 1995 to April 1997, attending paediatric clinic of All India Institute of Medical Sciences (AIIMS) with symptoms of ALRTI. Virus isolation was done by centrifugation enhanced cultures using HEp-2, LLC-MK2 and MDCK cells. The viruses were identified at 24-48 h post inoculation by IIF staining using monoclonal antibodies to respiratory syncytial virus (RSV), parainfluenza virus (PIV), influenza virus and adenovirus.

RESULTS

Of 200 NPA samples, 89 (44.5%) were positive for one or more viral pathogens. RSV was detected in 34 (17%) of all ALRTI cases followed by influenza viruses in 29 (14.5%), PIVs in 23 (11.5%) and adenoviruses in three (1.5%). In 79 children with bronchiolitis, RSV was most frequently isolated (25%) pathogen, while in bronchopneumonia cases (101) the most common viral pathogen was influenza virus (17%). In eight cases (4%) of ALRTI dual infections were detected. In 100 NPA specimens IIF staining on direct cell smears was carried out and viruses were detected in only 17%. RSV and influenza virus infection peaked from September to December, where as PIV infections were more frequent from January to April.

CONCLUSION

Respiratory viruses accounted for 44.5% of cases of ALRTI in India and the results of viral aetiology could be given in 24-48 h using centrifugation enhanced cultures. RSV was the most common viral agent associated with ALRTI in children under 5 years of age with greater association with bronchiolitis.

Dengue virus infection during post-epidemic period in Delhi, India

Dengue fever (DF) and dengue hemorrhagic fever (DHF) are major public health problems in India. During the period following an epidemic, a study was carried out using virological and serological tests for confirmation of suspected cases of dengue virus infection in fever cases presenting to the All India Institute of Medical Sciences. Serum samples of suspected DF/DHF cases were processed from January to December 1997. In 37 samples from patients with fever of less than 5-day duration, received on ice, virus isolation was attempted in C6/36 clone of Aedes albopictus cell line, followed by indirect fluorescent antibody staining with monoclonal antibodies to dengue viruses 1 to 4. One hundred and forty-three serum samples from patients with more than 5 days fever were tested for dengue specific IgM antibody by either MAC-ELISA or a rapid immunochromatographic assay. Dengue virus type 1 was demonstrated by culture in 8 (21.6%) of 37 serum samples and IgM antibody could be detected in 42 (29.4%) of the 143 serum samples by the serological methods. The peak of dengue virus infection was seen from September to November 1997.

The first major outbreak of dengue hemorrhagic fever in Delhi, India

India An outbreak of dengue hemorrhagic fever/dengue shock syndrome (DHS/DSS) occurred in 1996 in India in and near Delhi. The cause was confirmed as dengue virus type 2, by virus cultivation and indirect immunofluorescence with type-specific monoclonal antibodies. This is the largest such outbreak reported from India, indicating a serious resurgence of dengue virus infection.

Acute hemorrhagic conjunctivitis due to enterovirus 70 in India

An outbreak of acute hemorrhagic conjunctivitis occurred in Delhi, India, during August and September 1996. The etiologic agent was confirmed as enterovirus type 70 by a modified centrifugation-enhanced culture method followed by immunofluorescence and neutralization tests. After nearly a decade, this virus is reemerging as a cause of acute hemorrhagic conjunctivitis in India.

Myocardial dysfunction in children with dengue haemorrhagic fever

BACKGROUND

Dengue fever/dengue haemorrhagic fever/dengue shock syndrome is a serious health problem in tropical countries. Intravascular fluid depletion due to capillary leak is presumed to be the cause of hypotension in dengue haemorrhagic fever. The treatment guidelines of the World Health Organization lay stress primarily on monitoring and fluid replacement therapy. During the 1996 epidemic in New Delhi, we observed problems in fluid management of such children and prospectively looked for myocardial dysfunction as an additional factor for hypotension.

METHODS

Fifty-four children (< 12 years old) admitted to the All India Institute of Medical Sciences, New Delhi after 15 October 1996 with various grades of the disease, who were fit to be shifted to the echocardiography laboratory, were examined clinically and subjected to a detailed M-mode, 2-dimensional and colour doppler echocardiography. Ejection fractions (Teichholz/Modified Simpson's) and shortening fractions were calculated.

RESULTS

Ejection fraction by modified Simpson's rule was reduced (< 50%) in 9/54 (16.7%) children; 2 of these had significant reductions (< 35%). These 9 children belonged to all stages of clinical severity. Three of these 9 children who had a repeat echocardiogram within 2 months of the illness had improved ejection fractions.

CONCLUSION

The role of myocardial dysfunction remains to be defined as there was no correlation with clinical severity. Myocardial functions need to be assessed in patients with this disease, especially those who have persistent hypotension in spite of adequate hydration.

Diagnosis of pulmonary tuberculosis by polymerase chain reaction for MPB64 gene: an evaluation in a blind study

Polymerase chain reaction (PCR) has been found to be a sensitive and rapid method to confirm a clinical diagnosis of tuberculosis. We evaluated PCR for M. tuberculosis complex specific MPB64 gene for the diagnosis of pulmonary tuberculosis, in a double blind study. One hundred and eighty-two clinical samples (sputum, bronchioalveolar lavage and pleural fluid) from patients with a clinical diagnosis of pulmonary tuberculosis and 72 samples from patients with non-tubercular pulmonary lesions and normal healthy individuals were included. The samples were coded and clinical details were concealed from the laboratory, where conventional diagnostic methods and PCR were carried out independent of each other. On decoding and analysing the data, PCR was positive in 59% of single sputum samples from clinically diagnosed pulmonary tuberculosis, while M. tuberculosis could be grown in 18% of the samples. PCR could identify M. tuberculosis in 81.8% of the culture positive sputum samples. PCR was also positive in 71.4% of bronchioalveolar lavage (BAL) fluid and 60.7% pleural fluid samples from clinically suspected cases, which were mostly culture negative. On comparison with response to treatment, PCR was positive in 79.5% of patients who improved on anti-tuberculosis treatment, with a positive predictive value of 92%. PCR for MPB64 gene provides a useful alternative for the diagnosis of pulmonary tuberculosis from sputum and paucibacillary samples like BAL and pleural fluid in which conventional methods show low sensitivity, especially in areas from which strains show a low copy number of other PCR targets like the IS 6110 insertion sequence.

Evaluation of polymerase chain reaction for rapid diagnosis of clinically suspected tuberculous meningitis

SETTING

Since conventional bacteriological methods rarely detect Mycobacterium tuberculosis in cerebrospinal fluid (CSF) and are of limited use in the diagnosis of tuberculous meningitis (TBM), clinical features suggestive of TBM supported by indirect evidence such as CSF examination and computerized tomography (CT) of the head have been used for the early diagnosis of TBM.

OBJECTIVE

We evaluated the efficacy of polymerase chain reaction (PCR) in the diagnosis of TBM.

METHODS

Coded CSF samples from 40 patients with TBM and from 49 patients with other neurological disorders were processed. In the absence of a reliable sensitive and specific test for M. tuberculosis in CSF, we used a set of established clinical criteria as the gold standard. Accordingly, the patients were divided into definite, highly probable, probable and possible TBM. The samples were decoded only after completion of the laboratory tests.

RESULTS

PCR was positive in 2/4, 19/20, 13/16 patients with highly probable, probable and possible TBM respectively. None of the samples were positive by conventional bacteriological methods. However, 3/49 CSF samples from non-TBM patients were also found positive by PCR. PCR detected M. tuberculosis genomic DNA in the CSF of 85% of clinically suspected TBM cases and 6.1% of non-tuberculous controls.

CONCLUSION

PCR, along with the suggested clinical criteria, offers a rapid and fairly accurate diagnosis of TBM.

Classification of rotavirus into G and P types with specimens from children with acute diarrhea in New Delhi, India

Sixty rotavirus-positive stool specimens from children with diarrhea were classified into G and P genotypes. G typing was done by PCR and then by hybridization with G type-specific (G1 to G4) oligonucleotide probes, whereas nested PCR was performed for P typing. Thirty-nine samples could be classified into both G and P types, of which P8G1 and P4G2 (33% each) genotypes were predominant. The P6 genotype was detected in four children with diarrhea.

Multidrug resistant Salmonella typhi in Delhi

In 1990, we isolated 158 strains of Salmonella typhi from blood cultures of patients suffering from typhoid fever. Seventy nine (50%) of these isolates were found to be simultaneously resistant to chloramphenicol, ampicillin and cotrimoxazole. These strains were also resistant to streptomycin and tetracycline, but sensitive to gentamicin, amikacin and cephalexin. The minimum inhibitory concentrations of chloramphenicol and trimethoprim for a representative number of these strains were found to be greater than 1024 micrograms/ml and greater than 128 micrograms/ml respectively. Majority of the multidrug resistant (MDR) strains tested against cefotaxime (23/23), ciprofloxacin (38/38) and amoxycillin plus clavulanic acid (23/24) were sensitive to these drugs.