Narayan Prasad Parajuli

Elevated Cardiovascular Risks among Postmenopausal Women: A Community Based Case Control Study from Nepal

Cardiovascular disease (CVD) is one of the leading causes of death worldwide which is more prevalent in women after menopause. Hormonal changes associated with menopause are accountable for dyslipidemic pattern that causes CVD and associated complications. Therefore, the present study was commenced to compare the lipid profile in pre- and postmenopausal women. A descriptive cross-sectional study was conducted at Manmohan Memorial Institute of Health Sciences (MMIHS) from February 2016 to July 2016. A total of 260 fasting samples were collected from healthy women, 130 from premenopausal and 130 from postmenopausal women, and analyzed for Total Cholesterol (TC), Triacylglycerol (TAG), High Density Lipoprotein Cholesterol (HDL-C), and Low Density Lipoprotein Cholesterol (LDL-C) as per the guideline provided by the reagent manufacturer (Human, Germany). All the parameters were analyzed by Stat Fax 3300 semi auto analyzer. TC, TAG, HDL-C, and LDL-C were highly significantly increased in postmenopausal women when compared to premenopausal women. LDL/HDL ratio was significantly elevated in postmenopausal women than in premenopausal women. BMI was significantly positively correlated with TC and TAG in both pre- and postmenopausal population and it was positively correlated with HDL-C in premenopausal population while negatively correlated in postmenopausal population. Since more of the atherogenic lipid parameters are increased in postmenopausal women, they appear to be more prone to have CVD and associated complications in near future. Hence, it is mandatory to monitor and manage dyslipidemic pattern in every woman experiencing menopause.

Bacteremia caused by a rare pathogen – Chromobacterium violaceum : a case report from Nepal

Chromobacterium violaceum is a gram negative saprophytic bacterium, prevalent in tropical and subtropical climates. Infections caused by C. violaceum are very uncommon, yet it can cause severe systemic infections with higher mortality when entered into the bloodstream through open wound. A case of symptomatic bacteremia in a woman caused by C. violaceum was identified recently at a tertiary care teaching hospital in Nepal. Timely diagnosis by microbiological methods and rapid administration of antimicrobials led to a successful treatment of this life-threatening infection in this case. From this experience, we suggest to include this bacterium in the differential diagnosis of sepsis, especially when abraded skin is exposed to soil or stagnant water in tropical areas. The precise antimicrobial selection and timely administration should be considered when this infection is suspected.

Emerging Perils of Extended Spectrum β-Lactamase Producing Enterobacteriaceae Clinical Isolates in a Teaching Hospital of Nepal

Introduction. Infections due to extended spectrum β-lactamase producing Enterobacteriaceae are on the rise. They pose serious public health problems due to their resistance to large number of antibiotics. However, little is known about the genotypes of ESBL from Nepal. Therefore, the study presents results of phenotypic and molecular characterization of ESBL producing Escherichia coli and Klebsiella spp. isolated from various clinical specimens in a tertiary care teaching hospital of Nepal. Methods. A total of 172 Enterobacteriaceae clinical isolates recovered from various clinical specimens were analyzed for their antibiotic susceptibility test. Detection of ESBLs was carried out using combination disk test and multiplex PCR for their genotypes (CTX-M, SHV, and TEM). Results. Out of 172 clinical isolates, 70 (40.6%) of them were found ESBL producers. The major source of ESBL producers was urinary tract samples and the highest ESBL production was observed in Escherichia coli (46.5%). Among ESBL genotypes, CTX-M (91.4%) was most predominant, followed by TEM (65.7%) and SHV (11.4%) in both of the isolates. Conclusions. High level of drug resistance and ESBL production was observed among the clinical isolates. There is a need for longitudinal and nationwide surveillance for drug resistance in clinical isolates and antimicrobial stewardship is necessary to guide the appropriate and judicious antibiotic use.

Enteric Fever Caused by Salmonella enterica Serovars with Reduced Susceptibility of Fluoroquinolones at a Community Based Teaching Hospital of Nepal

Enteric fever continues to be an important public health problem especially in developing countries of the tropical region including Nepal. In this study, we aimed to investigate the incidence of enteric fever associated with Salmonella enterica and determine its antimicrobial susceptibilities to therapeutic antimicrobials in a community based teaching hospital of Nepal. A total of 2,304 blood samples from suspected enteric fever patients attending Manmohan Memorial Teaching Hospital were processed with standard microbiological methods for the isolation and identification of bacterial pathogens. The Salmonella enterica clinical strains were subjected to antimicrobial susceptibility testing by Kirby–Bauer disk diffusion method, and the results were interpreted according to the criteria suggested by the Clinical and Laboratory Standards Institute (CLSI). A total of 245 (10.6%) cases of enteric fever associated with Salmonella enterica were confirmed by blood culture. Out of them, 162 (66.1%) were caused by Salmonella Typhi and 83 (33.9%) by Salmonella Paratyphi. On Kirby–Bauer disk diffusion antimicrobial susceptibility testing, Salmonella isolates were highly susceptible to cefixime (100%), ceftriaxone (100%), ampicillin (97.9%), cotrimoxazole (94.6%), azithromycin (96.7%), tetracycline (95.5%), and chloramphenicol (97.5%), respectively. Two hundred twenty-six (92.2%) of Salmonella isolates were nalidixic acid resistant with reduced susceptibility to ciprofloxacin (36.7%) and ofloxacin (54.8%), respectively. Although the rate of MDR Salmonella strains was very low (<5%), their reduced susceptibility to fluoroquinolones has restricted their routine empirical use. Third generation cephalosporins are the safest choice for empirical use but ampicillin, cotrimoxazole, azithromycin, and chloramphenicol can be effective alternatives.

Shigellosis Caused by CTX-M Type ESBL Producing Shigella flexneri in Two Siblings of Rural Nepal: First Case Report from the Country

Shigellosis is an acute infectious disease characterized as severe bloody diarrhea (dysentery) and is accountable for a significant burden of morbidity and mortality especially in children under the age of 5 years. Antimicrobial therapy is required in the cases of severe dysentery associated with Shigella. However, emergence of multidrug resistant (MDR) strains of Shigella spp. over the last two decades has restricted the use of common therapeutic antimicrobials. In MDR strains, the third-generation cephalosporins have been used for the treatment, but, unfortunately, emerging reports of enzyme mediated β-lactam resistance among Shigella isolates from various parts of the world have greatly compromised the therapy of pediatric dysentery. In Nepal, drug resistant strains of Shigella spp. have been reported, but MDR and extended spectrum β-lactamase (ESBL) producing strains were previously unknown. Here, we report two Shigella flexneri isolates harboring ESBL genotype-CTX-M associated with acute dysentery in two siblings which were presented and treated in a tertiary care teaching hospital of Kathmandu, Nepal.

Evaluating the Trends of Bloodstream Infections among Pediatric and Adult Patients at a Teaching Hospital of Kathmandu, Nepal: Role of Drug Resistant Pathogens

Bloodstream infections (BSIs) are among the significant causes of morbidity and mortality for patients of all age groups. However, very little is known about the trends of bacterial bloodstream infections and antimicrobial susceptibilities among pediatric and adult population from Nepal. In this study, we have investigated the different etiological agents responsible for bloodstream infections among pediatric and adult patients and the role of drug resistant organisms in these infections at a tertiary care teaching hospital of Kathmandu, Nepal. A total of 3,088 blood culture specimens obtained from pediatric and adult patients suspected to have bloodstream infections were processed by standard microbiological methods. Significant bacterial pathogens were identified by morphological, biochemical, and serological methods as suggested by American Society for Microbiology. In vitro antimicrobial susceptibility testing was performed by Kirby-Bauer disk diffusion method and interpreted according to the guidelines of Clinical and Laboratory Standards Institute. Overall, incidence of bloodstream infections among the suspected patients was 7.48%. Pediatric patients (n = 90, 9.37%) were the significant subgroup of patients affected with bloodstream infections compared to adults (p < 0.05, CI-95%). Gram positive (n = 49, 54.4%) bacteria in pediatric and gram negative bacteria (n = 141, 78.7%) in adult patients were the most common isolates for BSI. Staphylococcus aureus (n = 41, 45.6%) in pediatric patients and Salmonella enterica (n = 40, 28.3%) in adult patients were the leading pathogens. Trends of antimicrobial resistance among isolated bacterial strains were significantly high in adults compared to pediatric patients. Methicillin resistant Staphylococcus aureus (MRSA) (31.4%), extended spectrum beta-lactamase (ESBL) (12.5%), and metallo-beta-lactamase (MBL) (3.9%) producing gram negatives were major resistant strains. Our study shows higher rates of bloodstream infections in pediatric patients compared to adult patients. Alarming rates of antimicrobial resistance among blood culture isolates is a serious issue. Prompt and accurate diagnosis and rational antimicrobial therapy are extremely needed.

Renaissance of Conventional First-Line Antibiotics in Salmonella enterica Clinical Isolates: Assessment of MICs for Therapeutic Antimicrobials in Enteric Fever Cases from Nepal

Enteric fever caused by Salmonella enterica is a life-threatening systemic illness of gastrointestinal tract especially in tropical countries. Antimicrobial therapy is generally indicated but resistance towards commonly used antibiotics has limited their therapeutic usefulness. Therefore, we aimed to determine the antimicrobial susceptibility pattern by minimum inhibitory concentration method of common therapeutic regimens against Salmonella enterica from enteric fever clinical cases. Salmonella enterica clinical isolates recovered from the patients with suspected enteric fever whose blood samples were submitted to microbiology laboratory of Manmohan Memorial Community Hospital, Kathmandu, from March 2016 to August 2016, were studied. These isolates were subjected to antimicrobial susceptibility testing against common therapeutic antimicrobials by Kirby-Bauer disk diffusion method. The minimum inhibitory concentration of ciprofloxacin, azithromycin, chloramphenicol, and cefixime was determined by Agar dilution method based on the latest CLSI protocol. A total of 88 isolates of Salmonella enterica were recovered from blood samples of enteric fever cases. Out of them, 74 (84.09%) were Salmonella Typhi and 14 (15.91%) were Salmonella Paratyphi A. On Kirby-Bauer disk diffusion antimicrobial susceptibility testing, entire isolates were susceptible to cotrimoxazole, cefixime, ceftriaxone, azithromycin, and chloramphenicol. Sixty-four (72.7%) Salmonella enterica isolates were nalidixic acid resistant and nonsusceptible to ciprofloxacin and levofloxacin. On MIC determination, four Salmonella isolates were ciprofloxacin resistant with MIC 1 µg/ml and two isolates were ciprofloxacin intermediate with MIC 0.5 µg/ml. The MIC range of azithromycin was from 0.125 µg/ml to 2.0 µg/ml, whereas that for chloramphenicol was 2.0 µg/ml–8.0 µg/ml and for cefixime was 0.0075–0.5 µg/ml, respectively. Despite global surge of antimicrobial resistance among Salmonella enterica clinical isolates, the level of drug resistance in our study was not so high. However, higher level of NARST strains limits therapeutic use of fluoroquinolones and necessitates the routine monitoring of such resistance determinants in order to effectively and rationally manage enteric fever cases.