INTRODUCTION: Lower respiratory tract infections (LRTIs) are among the most common infectious diseases of humans. This study focused on determining the recent trend of bacterial aetiology of LRTIs among the patients attending Tribhuvan University Teaching Hospital (TUTH) in Kathmandu. MATERIALS AND METHODS: This was a prospective study conducted over a period of six months in the bacteriology laboratory of TUTH. A total of 1120 specimens representing lower respiratory tract were received from patients with suspected LRTIs. The specimens were collected and processed according to standard methodology. RESULTS: Respiratory pathogens were recovered from 44.4% cases (n=497). Gram-negative bacteria were recovered in 84.1% (n=488). Bacteria were more commonly recovered from endotracheal secretion (41/61, 67.2%) than in sputum (454/1039, 43.7%) and bronchial washing (2/20, 10%). Ninety-one percent (n=454) growth was monomicrobial while the rest accounted for mixed growth. Among the organisms isolated, Haemophilus influenzae (112, 21%) was the most predominant pathogen followed by Klebsiella pneumoniae (102, 19.1%), Pseudomonads (91, 17.1%), Acinetobacter baumannii calcoaceticus complex (60, 10.9%), Streptococcus pneumoniae (46, 8.6%), Escherichia coli (37, 6.9%). CONCLUSIONS: H. influenzae and S. pneumoniae were the most common Gram-negative and Grampositive bacterial isolates recovered, respectively from LRTIs urging for monitoring and surveillance of these pathogens.

INTRODUCTION: Enteric fever caused by Salmonella enterica serovars Typhi and Paratyphi A is the common clinical diagnosis among febrile patients presenting to hospital in Nepal. The aim of this study was to evaluate the ciprofloxacin (CIP) and other antibiotics susceptibility patterns of Salmonella enterica serovars Typhi and Paratyphi A from blood samples of suspected enteric fever patients visiting KIST Medical College, Kathmandu. MATERIALS AND METHODS: Antibiotic susceptibility test was performed by Kirby Bauer disc diffusion method as per CLSI guidelines whereas MIC determination of ciprofloxacin was performed by agar dilution method. RESULTS: Altogether 64 presumptive Salmonella spp. were isolated from 840 blood samples of suspected enteric fever patients, of which 41 were S. Typhi and 23 were S. Paratyphi A. All Salmonella spp. isolates were sensitive to ceftriaxone and ofloxacin whereas 4 isolates were resistant to ciprofloxacin. One isolates each of S. Typhi and S. Paratyphi A were multidrug resistant. Fifty five isolates of Salmonella spp. were resistant to nalidixic acid (NA) with higher rate in S. Paratyphi A (91.3%) compared to S. Typhi (82.9%). MIC determination of ciprofloxacin revealed that majority of the isolates were resistant to ciprofloxacin and 2 isolates were resistant with MIC value of 4 µg/ml and 8 µg/ml. Importantly, we found simultaneous presence of NA resistance and decreased susceptibility to CIP suggesting that resistance to NA is a reliable indicator of decreased CIP susceptibility. CONCLUSIONS: Disc diffusion test failed to detect the reduced susceptibility of ciprofloxacin. Hence the MIC determination of ciprofloxacin against Salmonella spp. isolates would be important.

BACKGROUND: Class 1 integron element is innate to most of the multidrug resistant Acinetobacter baumannii and its spread is common among international clones worldwide. The aim of this study was to document the presence of blaVEB-1 harboring class 1 integron element and its gene cassettes in Thai A. baumannii in relation to A. baumannii European clone I, AYE strain. MATERIALS AND METHODS: Thirty seven carbapenem resistant A. baumannii isolates identified in routine microbiology laboratory of Siriraj Hospital, Bangkok were studied. The dot blot hybridization was performed to detect class 1 integron element integrase gene. PCR was used to amplify blaVEB-1, arr2, cmlA, blaOXA-10 resistance cassettes, and variable region of class 1 integron element. blaVEB-1 gene was localized by southern blot hybridization. RESULTS: The prevalence of class 1 integron element was 86.48% in the isolates studied. The blaVEB-1 was present in 7 isolates however the location of blaVEB-1 gene was different in different isolate. Four isolates (Ab03-168, Ab04-28, Ab08-20, and Ab08-22) harbored calss 1 integron element variable region sized 5.5 kb as described in strain AYE. However, blaVEB-1 was only amplified from Ab03-168. The cassette organization in this isolate was 5’CS-aadB-blaVEB-1-arr2-cmlA-blaOXA- 10-aadA1-3’CS. The class 1 integron element similar to the element identified in genomic resistance island, AbaRI of European clone I, AYE was identified in Thai A. baumannii. CONCLUSIONS: blaVEB-1 harboring class 1 integron element with minor cassette variation was identified in Thai A. baumanni isolate which might suggest the spread of this resistant cassette or the spread of the European clone I in Thailand. Monitoring of the global spread of multi-resistant A. baumannii is mandatory to control the spread of resistant genes and this multi-resistant pathogen.

INTRODUCTION: The role of blood cultures (BCs) in the management of community acquired pneumonia (CAP) has generated a lot of controversy among clinicians in recent times. The main objectives of this audit were to determine if BC results impact the choice of antibiotics, and hospital outcomes in CAP. MATERIALS AND METHODS: This was a retrospective study of adults with CAP treated in the ED of Goulbourn Valley Base Hospital, Shepparton in Australia from November 2010 to November 2011. RESULTS: Two hundred and twenty five patients were treated for CAP during the period in review with a mean age of 67.09±19.82 yrs and male:female of 1.5:1. 277 sets of BCs were performed and only 2.2% of the cases had true positive BCs .87% of the total cost of performing these BCs was spent on those with negative cultres.15.1% of the cases had their antibiotics changed during their hospitalization but the results of the BCs had no impact on the antibiotic change. Even though not statistically significant true positive BCs was associated with prolong length of hospital stay (7.6 ± 9.39 days vs 4.89 ± 3.24 days, p=0.44), and duration of IV antibiotic use (4.8±3.27 days vs 3.58±1.97 days, p=0.39). But the case fatality rate was much lower in those with positive BCs, (0 vs 5.7%,p> 120.4±12.46 bpm), neutrophilia (15.0± 8.16 /ul), and high CRP (326.4±146.32 ug/l) were predictors of true positive BCs. CONCLUSIONS: Routine BCs in the management of CAP is not cost-effective with large portion of the cost spent on cultures that returned negative result .Therefore it use show be limited to those likely to return positive cultures.

INTRODUCTION: Palpa is one of the rural districts of Nepal with high incidence of tuberculosis (TB) where Community Based Directly Observed Treatment Short Course (DOTS) strategy was being trailed to make TB services accessible at community level. In spite of this, it has high defaulter rate; every year more than 5% patients had defaulted from the treatment and death due to TB was around 6%. The study, therefore, aimed to assess the patients’ compliance to the treatment and its associated factors. MATERIALS AND METHODS: A quantitative crosssectional study was carried out using structured interview schedule. All registered TB patients (n=101) who were on treatment were enrolled in the study. RESULTS: TB patients of younger age group were found to be more compliant to the treatment (p=0.02). Side effect of the drugs was the major reason for the non compliance (36.00%). More than half of the TB patients had poor knowledge on TB and its treatment. Compliance was found to be significantly associated with knowledge (p=0.02) and perception (p=0.02) of the patients towards TB. Similarly, the study showed positive association between the compliance and service accessibility (distance: p=0.00), availability of treatment supervisor (p=0.01) and health education (p=0.02). CONCLUSIONS: Patients’ compliance with the TB treatment was found to be associated with their knowledge and perception on TB and its treatment. Health education and proper counseling was deemed necessary for the patients. Service accessibility along with communication skills training to the providers including community health volunteers can increase compliance rate.

INTRODUCTION: Bovine tuberculosis (bTB) is an important public health concern worldwide. This study was conducted to determine the status of bTB in animals raised by tuberculosis patients in Western Chitwan, Nepal. MATERIALS AND METHODS: This cross-sectional study was conducted from August, 2011 to January, 2012. A total of 100 bovines (cattle and buffalo) raised in 60 farms of tuberculosis patients were tested with single intradermal tuberculin test considering various animal factors. Well designed questionnaire survey was taken with 70 tuberculosis patients of same 60 families focusing knowledge, awareness and various practices related to bovine tuberculosis. RESULTS: Overall 15% bovines were positive for tuberculosis (13.6% cattle and 15.4% buffaloes).

INTRODUCTION: Epistaxis is a common clinical manifestation in endemic areas of Visceral Leishmaniasis (VL). This study aims to see the prevalence of epistaxis in VL in Eastern Nepal. MATERIALS AND METHODS: This study was a prospective cross sectional hospital based study. Diagnosis was made by Rk-39 from peripheral smear and Leishmania donovani (LD) bodies from bone marrow. Before starting anti–kalaazar treatment, nasal examination findings were noted. RESULTS: Ninenteen out of 80 diagnosed case of VL patients had epistaxis (23.8%) with age group between 7-66 years. One patient had developed severe epistaxis and hemotoma and died. CONCLUSION: Epistaxis is a common ent finding in endemic area of VL, however this needs to be confirm with larger cohorts.

INTRODUCTION: Japanese encephalitis (JE) is a disease of rural agricultural areas in the Terai regions of Nepal. The aim of the study was to compare particle agglutination assay (PA) with IgM capture ELISA. MATERIALS AND METHODS: The descriptive crosssectional study was conducted from August 2006 to September 2008. A total of 552 serum samples were collected from patients clinically diagnosed as acute encephalitis syndrome (AES) or viral fever in Tribhuvan University Teaching Hospital (TUTH) in Kathmandu, Lumbini Zonal Hospital (LZH) in Rupandehi and Bheri Zonal Hospital (BZH) in Banke districts. The samples were tested for Japanese encephalitis virus (JEV) specific IgM by two serological methods, IgM capture ELISA and PA. RESULTS: Among 552 samples, 258 samples were positive by PA and 205 were positive by IgM capture ELISA. The overall seroprevalence was 46.7% and 37.1% by the PA and IgM ELISA respectively. Two hundred fifty eight samples (47.7%) were positive for anti-JE IgM by PA assay and 200 samples (77.5%) of the 258 PA IgM positive samples were also IgM positive for anti-JE IgM by IgM-capture ELISA. Thus, PA assay had a sensitivity of 97.5% and specificity of 83.3% in comparison with IgM-capture ELISA. A positive predictive value of 0.77 and negative predictive value of 0.98 was observed with PA in comparison with IgM-capture ELISA. CONCULSIONS: The result from PA was highly compatible with IgM capture ELISA. Both sensitivity and specificity of PA was acceptable in comparison with IgM-capture ELISA.

INTRODUCTION: Very few reports exist regarding the causes of ocular morbidity in Western Nepal. The study is performed to identify the causes of ocular morbidity in a clinic at Waling in Western Nepal. MATERIALS AND METHODS: A retrospective study was done by reviewing the case records of all patients attending the eye clinic at Waling from August 2010 to August 2011. RESULTS: The study included 915 patients, 617 were females (67.5%), and 298 were males (32.5%). Refractive error was the most common ocular morbidity accounting 26.8% followed by conjunctivitis 20.6%, cataract 11.8%, pterygium 6%, chalazion/stye 4%, ectropion/entropion 3.9%, keratitis 3.8%, dry eyes 2.8%, and corneal opacities 2.3%. CONCLUSIONS: The study gives a picture and patterns of ocular disease in Western Nepal which will be helpful in planning and management of ocular health programmes in Nepal.

BACKGROUND: Women often suffer silently with reproductive tract infections (RTIs) and sexually active young women are particularly susceptible to sexually transmitted Infections (STIs). The study aimed to know the prevalence of reproductive tract infections among married women attending Gynecological Outpatients Department of Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal. MATERIALS AND METHODS: A hospital based crosssectional design was used to investigate RTIs among women attending outpatients department of Gynae and Obstetrics, TUTH from July to November, 2006. A total of 208 samples from 104 women were examined microscopically and culture using standard microbial technique to investigate etiological agents of RTIs. Study samples were selected and examined on the basis of either having discharge or complaints of lower abdominal pain. RESULTS: A total of 208 samples collected from 104 patients were examined and 26% samples were positive for different causative agents of RTIs. Thirty percent of women reported having symptoms related to RTIs and was common in young married women. Nineteen percent had STIs. Thirteen percent had trichomonasis and 7% had gonorrhoea identified in Gram stained smears and cultures. Many women had endogenous RTIs. Bacterial vaginosis was diagnosed in 15% and vaginal candidiasis in 25% of women. CONCLUSIONS: Young married women have a high prevalence of RTIs. Education and outreach programs are needed to reduce embarrassment and lack of knowledge related to RTIs. The low socio?economic status of women appears to have influence on high rate of infections.

INTRODUCTION: Shigellosis still remains a public health problem in developing countries because of poverty, poor sanitation, personal hygiene and poor water supply. Antimicrobial therapy for shigellosis reduces the duration and severity of the disease and can also prevent potentially lethal complications. However, over the past few decades Shigella spp. has become resistant to most of the widely used antimicrobials. This study assessed the patterns of antimicrobial susceptibility and mutations in marA and marR genes of Shigella isolates and its association. MATERIALS AND METHODS: Fifty three isolates of Shigella spp. were tested to evaluate the antimicrobial susceptibility by disc diffusion method (Kirby-Bauer) according to the Clinical Laboratory Standard Institute (CLSI) for the following antimicrobials: ciprofloxacin, norfloxacin, ampicillin, tetracycline, chloramphenicol, trimethoprim, gentamicin and streptomycin and mutation on marAR genes by using polymerase chain reaction–Single strand conformation polymorphism analysis. RESULTS: Study revealed that there was significant association in between resistant to ciprofloxacin, norfloxacin and gentamicin with mutation in marA gene

HIV/AIDS is still a formidable challenge for human race both in terms of development and mortality. Researchers and scientists have been trying hard to find diagnostic tools for its early detection so as to reduce morbidity and mortality from it. So far they have been successful but are still striving to find more accurate and rapid HIV detection test and considering cost effectiveness of the tests. It is of much public health significance to detect HIV infection in acute stage because this stage is highly infectiousness and appears to account for a disproportionate amount of HIV transmission. The latest advances in HIV testing, including third-generation enzyme immunoassays (EIAs) that detect anti-HIV IgM and IgG antibodies, fourth-generation combination EIAs that detect both anti-HIV antibodies and HIV p24 antigen, and nucleic acid–based testing for HIV RNA, have obviously decreased the time interval between infection and detection of infection. The availability and wide use of these latest technologies have motivated review of recommended HIV testing algorithms. A persons’ knowledge of their HIV sero-status contributes to reducing transmission risk behaviors. Thus, widespread testing, facilitated by the latest technology, permits more people to identify their sero-status and is the first step in any successful effort to control the incidence of HIV infection. Available rapid diagnostic tests using samples of oral fluid, whole blood, plasma, or serum are lateral flow devices able to detect anti-HIV IgG and IgM but not HIV antigen. The sensitivities and specificities of available lateral flow devices range from 99.3% to 100% and 99.7% to 99.9%, respectively, with narrow 95% confidence intervals, per the product information of these rapid diagnostics. Newer diagnostic techniques permit earlier detection of HIV infection during acute infection than does Western blot testing. After infection, symptoms may appear within 2 weeks. HIV p24 levels (measurable with fourth-generation EIAs) typically peak after the onset of symptoms, at about 2.5 weeks to 3 weeks after infection; plasma HIV RNA levels (measurable by nucleic acid amplification tests (NAATs) begin to increase at about 1.5 weeks to 2 weeks, peaking at around 3 weeks to 6 weeks after infection. With the subsequent occurrence of antibody response, third-generation EIAs can detect antibody as early as 3 weeks to 4 weeks after infection, and second-generation tests can return positive results at around 4.5 weeks to 5 weeks after infection. By comparison, Western blot testing first begins to show positive results at around 5 weeks. Direct comparison of some of the newer techniques with Western blot testing has shown that positive results are obtained days to weeks before the Western blot test yields positive or even indeterminate results. Indeterminate Western blot test results are frequently associated with detection of anti-p24 antibody in the setting of both false-positive and negative screening EIAs. Indeed, anti-p24 antibody is the most commonly detected antibody in the setting of false positive EIAs and indeterminate-result Western blots.1 The fact that rapid HIV testing techniques do not include a p24 assay may allow such tests to avoid a proportion of false-positive results. The potential value of rapid testing in this respect is illustrated by findings in a study in which women in labor for whom no HIV test results were available were screened.2 Among 7680 women screened, 54 (0.7%) new HIV infections were identified. Oral rapid testing yielded 6 false-positive results and no false-negative results. EIA testing yielded 15 false-positive results, of which 7 were positive for p24 only and 8 were negative on Western blot testing. Overall, specificities for the oral rapid test and the EIA were 99.9% and 99.0%, respectively, and positive predictive values were 90% and 76%, respectively. Such findings indicate that p24-excluding rapid tests may be less prone to false-positive results in the labor and delivery setting, potentially avoiding unnecessary exposure of mothers and infants to antiretroviral drugs. REFERENCES 1. Midthun K, Garrison L, Clements ML, Farzadegan H, Fernie B, Quinn T. Frequency of indeterminate Western blot tests in healthy adults at low risk for human immunodeficiency virus infection. The NIAID AIDS Vaccine Clinical Trials Network. J Infect Dis 1990;162:1379-1382. 2. Bulterys M, Jamieson DJ, O'Sullivan MJ, et al. Rapid HIV-1 testing during labor: a multicenter study. J Am Med Assoc 2004;292:219-223.

Since the discovery of penicillin by Sr. Alexender Fleming in 1928, it had been instrumental in treating critically ill patients and increasing life expectancy. However the emergence of penicillin resistance in 1940s has threatened all the gains offered by it. Newer pharmaceutical companies emerged and newer antimicrobial agents were discovered and commercialized for the treatment of infections but most of them are already ineffective to treat infections due to growing antimicrobial resistance. This emergence of multi-drug (MDR), pan-drug (PDR) and extensively-drug resistant (XDR) pathogens is a global problem, the seriousness of which is evident by the fact that WHO adopted the World Health Day theme 2011 as “Combating antimicrobial resistance”. The growing resistance has posed serious effects for the health care systems in addition to the economic burden to the patients and families. Almost one third of world’s population is infected with tuberculosis and it’s a public health problem. Emergence of TB among HIV infected has worsened the scenario of both the diseases. Malaria is another disease of the poor complicating the situation. In addition to these infectious diseases of public health importance numerous bacterial, viral, protozoal and fungal agents are infecting patients in the hospitals and the community. Usually the first line antimicrobial agents cure the patients, but the treatment has to be switched to second line when they emerge as drug resistant. This second line drugs (reserve drugs) are more expensive and more toxic and are also becoming ineffective. The methicillin resistant and vancomycin resistant Staphylocccus aureus, MDR and PDR Acinetobacter baumannii, Pseudomonas aeruginosa, Citrobacter spp., Stenotrophomonas malotphila etc., metallo-betalactamase producing E. coli and Klebsiella pneumoniae, antiretroviral resistant HIV-1, MDR and XDR strains of M. tuberculosis have already emerged in the globe.1,2,3,4 Growing antimicrobial resistance has numerous effects like, prolonged hospital stay, treatment failure, spread of resistant pathogens to other patients, secondary complications and economic, social and mental problems to the patients as well as for their families. The achieved success in controlling TB will be ruined by increasing MDR and XDR strain and is a threat to the TB control programmes. Similarly, emergence of Artesunate resistance in malaria parasite will pose challenge in malaria control.5 The emergence of resistance is due to inappropriate and indiscriminate use of over the counter antimicrobial agents, irrational use, inadequate infection control practices, poor compliance, over prescription of antimicrobial agents for incentives and ineffective pharmacovigillance systems. Moreover, the emergence of resistance is intimately associated with poverty compelling patients to abort treatment against medical advice. Antimicrobial agents are also becoming popular in agriculture, veterinary and fishery. This wide use of antimicrobials has created selective pressure for human and environmental microorganisms to evolve themselves as resistant. The antimicrobial resistant microorganisms and their resistant genes are growing as an environmental pollutant in the globe. The universal success on containing antimicrobial resistance is possible through combined efforts on advocacy of rational use of antimicrobial agents, development of effective policy to address the rational use of antimicrobials and its implementation, strengthening antimicrobial surveillance network, rational use of antimicrobials in veterinary, fishery and agriculture, standardization of treatment guidelines and most importantly global commitment, adequate resources allocation and research work in this arena to generate evidence to formulate/guide the policy to address antimicrobial resistance. REFERENCES 1. Kumarasamy KK, Toleman MA, Walsh TR, et al. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study. Lancet Infect Dis 2012;10:597–602. 2. David L. Paterson. Resistance in Gram-negative bacteria: Enterobacteriaceae. Am J Infect Control 2006;34:S20-28 3. Louis B. Rice. Antimicrobial resistance in Gram-positive bacteria. Am J Med 2006;119:S11–S19 4. Pawlowski A, Jansson M, Sköld M, Rottenberg ME, Källenius G (2012) Tuberculosis and HIV Co-Infection. PLoS Pathog 8(2): e1002464. doi:10.1371/journal.ppat.1002464 5. Delacollette C, Bustos MD, Thimasarn K, Ortega L, Christophel EM, Ringwald P. Antimalarial and artemisinin resistance in the Greater Mekong subregion. Regional Health Forum 2011;15:131-133.

INTRODUCTION: Dengue fever (DF) is an emerging mosquito borne viral disease and important public health problem in low land Terai region which is also moving towards hilly region Nepal. This study was designed to determine the sero-prevalence of dengue virus infection in patients visiting hospitals of Nepal. MATERIALS AND METHODS: This study was conducted during period (June-November) of 2010 in Nepalese patients with fever visiting hospitals of Birganj, Damouli, Biratanagar, Dhading Besi and Chitwan. The sero-prevalence of dengue virus specific IgM was determined by enzyme linked immunosorbent assay (ELISA). Serum samples were collected from 289 patients visiting hospitals with history of fever and clinically suspected dengue fever. RESULTS: The anti-dengue IgM positivity was found to be 8.99%. The positive dengue cases were higher in male (10.8%) as compared to female (7.1%) though it was not statistically significant (P>0.05). Among different age groups, the highest positive cases (12.3%) were from age group below 15 years followed by above 50 years 8.3%. Out of 5 hospitals, the highest positive cases were in Tanahu hospital, Damouli (23.8%) followed by Bharatpur hospital and Chitwan (22.2%). Age and gender were found to be independent predictors. The highest numbers of dengue positive cases were in occupation group business (13.3%) followed by agriculture (12.7%). CONCLUSIONS: Prevalence of dengue virus infection is increasing and proper control measure should be provided. IgM capture ELISA was used for laboratory analysis and remains as a reliable and inexpensive method for the diagnosis of dengue. Hence, the IgM capture ELISA has become the most accepted technique for the diagnosis of dengue in developing countries like Nepal.