Co-existence of blaIMP, blaNDM-1, and blaSHV, genes of Pseudomonas aeruginosa isolated from Quetta: Antimicrobial resistance and clinical significance

Objective

Molecular detection and co-presence of carbapenem-resistant genes in the isolates of Pseudomonas aeruginosa are less commonly reported from Quetta. In the present study, we determined to highlight the antibiotic sensitivity profile and genetic mechanism of carbapenem resistance.

Methods

The cross-sectional study was conducted from May to September 2018 at the Hi-tech laboratory, Centre for Advance Studies in Vaccinology and Biotechnology, University of Baluchistan, Quetta. Biochemical and molecular methods were ascertained for the recognition of the isolates and minimum inhibitory concentration was performed using E-test and broth microdilution methods. The molecular basis of carbapenemase activity was determined by identifying carbapenemase genes in the isolates.

Results

Of the (n=23) P. aeruginosa isolated from pus aspirates obtained from surgical/burn units, we have detected blaIMP (n=7/8) 87.5%, blaNDM-1 (n=5/8) 62.5%, and blaSHV (n=4/8) 50%. The co-existence of multiple antibiotic-resistant genes, blaIMP, blaNDM-1 and blaSHV was found in (n=2/8) 25% isolates. These isolates displayed resistance against a range of antimicrobials from β-lactams, tetracyclines, cephalosporins, quinolones, monobactams, aminoglycosides, sulphonamides, phosphoric acid, macrolides, and polypeptide groups, suggesting extensive-drug resistance.

Conclusion

The emergence of MBL and ESBL producers is an alarming threat in the region. It is of great importance to determine the resistance mechanism of bacterial bugs. The lack of new antimicrobials particularly against gram-negative bacteria is quite alarming worldwide.

Anti-bacterial activity of essential oils against multidrug-resistant foodborne pathogens isolated from raw milk

The presence of pathogenic bacteria in food is considered as a primary cause of food-borne illness and food quality deterioration worldwide. The present study aimed to determine the effectiveness of five essential oils (EOs) against multidrug-resistant foodborne pathogens. In the current study Gram-negative bacteria (Escherichia, Enterobacter, Citrobacter, Proteus, Pseudomonas, and Klebsiella) and the Gram-positive bacteria Staphylococcus were isolated from raw milk and biochemically characterized. The anti-bacterial effect of different antibiotics and EOs (thyme, oregano, lemongrass, mint, and rosemary) was determined using the standard disc diffusion method. The antibiogram study revealed that Gram-negative bacteria were highly resistant to penicillin while Staphylococcus was resistant to streptomycin, amoxicillin, and lincomycin. Moderate resistance was observed to doxycycline, amikacin, enrofloxacin, kanamycin and cefixime. Isolates were found less resistant to gentamycin, chloramphenicol, and ciprofloxacin. EOs showed a broad range of antimicrobial activity against all bacteria except P. aeruginosa. Of these, thyme was more effective against most of the multi-drug resistant bacterial strains and formed the largest zone of inhibition (26 mm) against Escherichia followed by oregano oil (18 mm) against Staphylococcus (p<0.05). Klebsiella spp and Citrobacter spp showed resistance to mint and lemongrass oil respectively. The EOs such as lemongrass, mint and rosemary were less active against all the bacteria. The findings of the recent study suggest the use of EOs as natural antibacterial agents for food preservation.

Dissemination of NDM-1 in pseudomonas aeruginosa and klebsiella pneumoniae isolated from pus samples in tertiary care hospitals of Quetta, Pakistan

OBJECTIVE

To highlight the prevalence and epidemiology of New Delhi metallo-ß-lactamase-1. producers in pus samples.

METHODS

The cross-sectional study was conducted from April to August 2018 at the Biotechnology Laboratory, Balochistan University of Information Technology Engineering and Management Sciences, Quetta, Hi-tech Laboratory, Centre for Advance Studies in Vaccinology and Biotechnology, University of Balochistan, Quetta and Microbiology Laboratory, Bolan Medical Complex Hospital, Quetta, Pakistan. Biochemical and molecular approaches were used for the identification of the isolates and Modified Hodge Test for the phenotypic detection of class-A carbapenemase activity. Minimum Inhibitory Concentration was performed using E-test and broth microdilution method. Molecular basis of carbapenemase activity was ascertained by the recognition of blaNDM-1 gene in the isolates.

RESULTS

Of the 300 pus samples taken from surgical/burn units, 6(2%) blaNDM-1 harbouring isolates were found; 3(50%) each being Klebsiella pneumoniae and Pseudomonas aeruginosa. Klebsiella. pneumoniae isolates were extensively drug-resistant. The Pseudomonas aeruginosa isolates displayed resistance against 21 antibiotics of tetracyclines, quinolones, b-lactams, aminoglycosides, monobactams, sulphonamides, macrolides, cephalosporins, phosphonic acid and polypeptide groups, suggesting pan-drug resistance.

CONCLUSIONS

The resistance pattern of the bacterial isolates poses a significant clinical threat in the region.

Lower mortality rate in health workers and their families infected with COVID-19 associated pneumonia in Quetta, Baluchistan

Objectives:

A bunch of pneumonia cases in Wuhan, China, was caused by a novel beta-corona virus, (COVID-19) in December 2019 from where it spread rapidly across the globe. The aim of the study was to find out relevant reasons and offered suggestions to reduce the risk of infection and check clinical outcomes of the infected healthcare workers.

Methods:

This study was conducted in COVID-19 Real Time Polymerase Chain Reaction (RT-PCR) laboratory, Bolan Medical Complex Hospital Quetta, Baluchistan from May to June 2020. Eight hundred (n=800) health workers and their families were included in this study. Data were obtained with standardized data collection forms shared by the WHO. Nasopharyngeal samples were collected following the WHO protocols. RNA was extracted and amplified using real time reverse transcriptase polymerase chain reaction (RT-PCR). Serum ferritin level, C-reactive protein, D-dimer and radiological results of the RT-PCR confirmed individuals were also recorded and analyzed.

Results:

Among (n=800) health workers and their families 457 (57.1%) were COVID-19 PCR negative, 332 (41.5%) positive and 11 (1.4%) individuals were PCR positive but asymptomatic carriers, 234 (29.5%) were male and 103 (12.9%) were female. Mortality rate in our study was very low, only three patients (0.87%) died of this COVID-19 pneumonia.

Conclusion:

Our results showed increased rate of positive cases with fortunately lower mortality rate, although this novel pneumonia was associated with acute respiratory distress syndrome ARDS and intensive care unit (ICU) admission. Timely decisions, risk awareness knowledge and supply of necessary equipments are inevitable for the control of such epidemics.

Evaluation of serum procalcitonin level as a biomarker for disease severity in COVID-19 patients

The pandemic of coronavirus disease 2019 (COVID-19) has infected millions of individuals around the globe. Forecasting the COVID-19 severity is essential, and various biomarkers could be used to evaluate it. The current study was therefore aimed to evaluate the serum pro-calcitonin (PCT) level as a biomarker for bacterial co-infection and disease severity in COVID-19 patients. A total of 430 COVID-19 positive individuals were examined, in which 332 (77.2%) were male individuals while 98 (22.8%) were female individuals. Among the examined samples, 281 were classified as moderate (PCT value 0.07 ± 0.06 ng/mL), 95 were severe (PCT value 0.5 ± 0.4 ng/mL), and 54 were classified as critical (PCT value > 1 ng/mL) individuals. The increase in the total serum level of PCT was observed with the severity of the disease (p < 0.05). The statistical analysis represented no association of PCT value with gender (p 0.9650) while revealed a significant association (p < 0.001) with the age and PCT value in COVID-19 patients. It can be concluded that the serial PCT measurement could determine the prognosis of the disease and the presence of bacterial co-infection in COVID-19 patients. Further exploration of the topic is needed to evaluate the effect of different therapies on the PCT level and to prescribe specific treatment options for coinfection.

Unrecognized HIV infection in asymptomatic volunteer blood donors at district Peshawar, Khyber Pakhtunkhwa, Pakistan

Acquired immunodeficiency syndrome (AIDS) is a global epidemic that impacts the lives of many individuals each year. Human immunodeficiency virus (HIV) is a retrovirus that infects human CD4⁺ T helper cells and macrophages thereby causing severe immune disease. The current study aimed to examine the prevalence of HIV among the blood donors of Khyber Pakhtunkhwa at Peshawar. In this study, a total of 8634 volunteers who donated blood were carefully screened for HIV using ELISA and RT-PCR techniques. Among the volunteers (n = 8634), 63 were positive by both ELISA and RT-PCR; which shows a prevalence of 0.73%. Both diagnostic techniques exhibited similar results. All the positive individuals were informed immediately and advised to start treatment to control the progression of the infection. It was concluded that HIV is on the rise in Peshawar, and routine screening and preventive measures are immediately required to address the urgent situation of HIV infection.

Culture and PCR based detection of bacteria causing urinary tract infection in urine specimen

Objectives:

Urinary tract infections are the second most common bacterial infections occurring at all ages and both sexes. The increasing rate of antibiotic resistance is a global concern. The use of routinely used antibiotics is resulting in treatment failure. The objective of this study was to diagnose the urinary tract infections by routine culture sensitivity test and by molecular methods.

Methods:

This study was conducted in Microbiology laboratory, Bolan Medical Complex Hospital, Quetta, from July 1^st to 31^st March 2019. Isolates were identified biochemically by API20E & API20NE. Antibiogram was performed using disc diffusion Kirby Bauer technique. The 16S rDNA gene approach was used for molecular identification of bacterial isolates. The presence of the bla_NDM-1 gene was identified by polymerase chain reaction (PCR).

Results:

We isolated 146 bacterial isolates namely Escherichia coli (n=99) 67.80%, Klebsiellapneumoniae (n=33) 22.60%, Pseudomonas aeruginosa (n=11) 7.53% and Proteus mirabilis (n=3) 2.05% from 2032 urine samples. The resistance pattern was dominated by Multi Drug Resistance (MDR). Remarkably, four isolates of Escherichia coli (n=3) and Klebsiellapneumoniae (n=1) were displaying resistance against a range of antibiotics used in the study, including carbapenems but sensitive to tigecycline and polymyxins only, suggesting extensive drug resistance having bla NDM-1 gene.

Conclusion:

This is the first report on direct molecular detection of bacterial pathogens from urinary tract infected patients in Balochistan. The presence of bla_NDM-1 in different bacterial species and their extensive drug resistance pattern poses a significant clinical threat. Molecular detection of bacteria and resistant gene may reduce the diagnostic time of patients.

Prevalence of extensive drug resistance in bacterial isolates harboring blaNDM-1 in Quetta Pakistan

Objective:

Extensive drug resistant Gram-negative bacilli, harboring New Delhi metallo-β-lactamase-1 (bla_NDM-1) having the ability to hydrolyze β-lactams, have become a vital global clinical threat. The present study was, therefore, designed to investigate the prevalence and epidemiology of NDM-1 producers in Quetta, Pakistan.

Methods:

This study was carried out in Microbiology Laboratory, Bolan Medical Complex Hospital Quetta, Biotechnology laboratory, BUITEMS Quetta and Hi-tech laboratory, CASVAB, University of Balochistan, Quetta, from March to June 2018, during the hot season. Biochemical and molecular approaches were applied for the identification of bacterial isolates. Minimum Inhibitory Concentrations (MICs) were determined using E-test method. Carbapenemase activity was ascertained by Modified Hodge Test (MHT) and the presence of bla_NDM-1 gene was recognized by Polymerase Chain Reaction (PCR).

Results:

We isolated five bla_NDM-1 harboring isolates of three different species namely Morganella morganii (n=2) Enterobacter cloacae (n=2) and Citrobacter freundii (n=1), from 300 pus samples. These isolates were found extensive drug resistant (XDR). Strikingly, two isolates of M. morganii were displaying resistance against 23 antibiotics of sulphonamides, aminoglycosides, polypeptide, monobactams, tetracyclines, quinolones, macrolides, cephalosporins, phosphonic acid and β-lactams groups, suggesting Pan Drug Resistance (PDR).

Conclusion:

This is the first report on emergence of PDR strain of M. morganii producing NDM-1 in the province of Balochistan, Pakistan. The presence of bla_NDM-1 in different bacterial species and their extensive rather pan drug resistance pattern poses a momentous clinical threat.

Treatment of corticosteroid refractory optic neuritis in multiple sclerosis patients with intravenous immunoglobulin

BACKGROUND

Patients with severe visual loss because of optic neuritis refractory to high dose corticosteroids have limited therapeutic options. The use of intravenous immunoglobulin (IVIG) has been advocated in the past, but data are scarce. In this study, we use a protocol different from those used in other studies, with different timing and dosage.

METHODS

Consecutive patients with corticosteroid-refractive optic neuropathy were treated with IVIG and compared with control patients who received only corticosteroids in an open-label, non-randomized, controlled prospective study.

RESULTS

Twenty-three patients received treatment with IVIG and 24 matched patients who did not receive treatment with IVIG were followed as controls. All patients had visual acuity 20/400 or worse in the affected eye. There was significant improvement in the IVIG group with 18/23 (78%) subjects reaching near normal vision (20/30 or better), compared with the control group with only 3/24 (12.5%) responding similarly.

CONCLUSIONS

The use of IVIG, following corticosteroids, may be useful using the protocol described herein, with sustained pulsed dosing. A larger controlled trial is indicated to confirm these results.

Clinical course after change of immunomodulating therapy in relapsing-remitting multiple sclerosis

We examined the clinical course after switching disease-modifying therapy (DMT) in patients with relapsing-remitting multiple sclerosis (RRMS). Eighty-five consecutive RRMS patients who received weekly interferon beta-1a (IFN beta-1a) 6 MU i.m. for at least 18 months were enrolled. Baseline annualized relapse rate (ARR) for the 2 years prior to initiating therapy with IFN beta-1a was obtained from charts. All 85 patients received treatment with IFN beta-1a at 6 MU i.m. weekly for 18-24 months (mean 19.7 months). Treatment with IFN beta-1a reduced the mean ARR from 1.41 to 1.23 (P=0.005). All 85 patients were then switched to glatiramer acetate (GA) 20 mg s.c. daily and prospectively followed up for 36-42 months (mean 37.5 months). Patients were switched because of persistent clinical disease activity (n=62) or persistently unacceptable toxicity (n=23) as determined by the treating neurologist. Treatment with GA reduced the mean ARR from 1.23 to 0.53 (P=0.0001). Subgroup analysis showed that in patients who were switched because of lack of efficacy (n=62), the mean ARR was reduced from 1.32 on IFN beta-1a to 0.52 on GA (P=0.0001). In contrast, in patients who switched because of persistent toxicity (n=23), the mean ARR was reduced from 0.61 on IFN beta-1a to 0.47 on GA (P, non-significant). Our observations suggest that clinical observations such as relapse rate and tolerability may be used as criteria for switching DMT in clinical practice. More definitive consensus criteria incorporating magnetic resonance imaging and clinical observations for defining optimal response and tolerability need to be developed for the routine clinical management of RRMS patients receiving DMT.

Nutritional treatment for acquired immunodeficiency virus-associated wasting using beta-hydroxy beta-methylbutyrate, glutamine, and arginine: a randomized, double-blind, placebo-controlled study

BACKGROUND

The current study was designed to examine whether a combination of three nutrients, consisting of beta-hydroxy-beta-methylbutyrate (HMB), a metabolite of leucine, L-glutamine (Gln) and L-arginine (Arg), each of which has been previously shown to slow muscle proteolysis, could synergistically alter the course of muscle wasting in patients with established acquired immunodeficiency syndrome (AIDS).

METHODS

Sixty-eight human immunodeficiency virus (HIV)-infected patients with a documented weight loss of at least 5% in the previous 3 months were recruited from the HIV clinic at Nassau County Medical Center. The subjects were randomly assigned in a double-blind fashion to receive either placebo containing maltodextrin or the nutrient mixture (HMB/Arg/Gln) containing 3 g HMB, 14 g L-glutamine, and 14 g L-arginine given in two divided doses daily for 8 weeks. Body weights (BW) were recorded weekly and lean body mass (LBM) and fat mass (FM) were measured by air displacement plethysmography and by a single computerized tomography (CT) slice through the thigh at 0, 4, and 8 weeks.

RESULTS

Forty-three subjects completed the 8-week protocol, (placebo, n = 21; HMB/Arg/Gln, n = 22). At 8 weeks, the subjects consuming the HMB/Arg/Gln mixture gained 3.0 +/- 0.5 kg of BW while those supplemented with the placebo gained 0.37 +/- 0.84 kg (p = .009). The BW gain in the HMB/Arg/Gln-treated subjects was predominantly LBM (2.55 +/- 0.75 kg) compared with the placebo-supplemented subjects who lost lean mass (-0.70 +/- 0.69 kg, p = .003). No significant change in FM gain was observed (0.43 +/- 0.83 kg for the group receiving HMB/Arg/Gln and 1.07 +/- 0.64 kg for the group receiving the placebo, p > .20). Similar percentage changes in muscle mass and fat mass were observed with CT scans. Immune status was also improved as evident by an increase in CD3 and CD8 cells and a decrease in the HIV viral load with HMB/Arg/Gln supplementation.

CONCLUSIONS

The data indicate that the HMB/Arg/Gln mixture can markedly alter the course of lean tissue loss in patients with AIDS-associated wasting.

Hemodilution in complicated high velocity vascular injuries of limbs

Normovolemic hemodilution with 3,5% polygeline was carried out in fourteen ASA (American Society of Anesthesiologists) Class-I patients, who had developed false aneurysms or arteriovenous fistulas following high velocity injury on limbs. At the end of surgical procedure volume of mean blood drained was 1400.00 +/- 194.46 ml, mean surgical blood loss was 1665.71 (+/- 33.9) ml and fluid balance was 557.14 (+/- 176.40) ml. Arteriovenous oxygen content difference (C(a-v) O2), central venous pressure (CVP), heart rate and mean arterial pressure (MAP) did not show any significant variation from pre-hemorrhage value. Hematocrit (Hct%) and hemoglobin (Hb gm%) showed a highly significant fall following hemodilution and retransfusion. However on the day of discharge Hct% (37.5(+/- 3.88) and Hb gm% (12.84 (+/- 0.82) had increased from post hemodilution value of 28.96 (+/- 1.98) and 10.04 (+/- 0.87) respectively. 71% patients did not need any homologous blood transfusion. Prothrombin time index (PTI%) showed 7.5% fall at the conclusion of blood retransfusion and 3.94% fall on the day of discharge. Technique is safe, avoids use of homologous blood and is thus recommended during surgical correction of complicated high velocity vascular injury of limbs.