The CREATE-ECLA Randomized Controlled TrialThe CREATE-ECLA Trial Group Investigators* See also pp 427 and 489.

No abstract

Thyroid function test should be included in clinical evaluation of RA patients.

Efflux-pump system and biofilm formation are two important mechanisms Pseudomonas aeruginosa deploys to escape the effects of antibiotics. The current study was undertaken from September 2019 to March 2020 at a tertiary-care hospital in Kathmandu in order to ascertain the burden of P. aeruginosa in clinical specimens, examine their biofilm-forming ability and determine their antibiotic susceptibility pattern along with the possession of two efflux-pump genes-mexA and mexB. Altogether 2820 clinical specimens were collected aseptically from the patients attending the hospital and processed according to standard microbiological procedures. Identification of P. aeruginosa was done by Gram stain microscopy and an array of biochemical tests. All the P. aeruginosa isolates were subjected to in vitro antibiotic susceptibility testing and their biofilm-forming ability was also examined. Presence of mexA and mexB efflux-pump genes was analyzed by Polymerase Chain Reaction (PCR) using specific primers. Out of 603 culture positive isolates, 31 (5.14%) were found to be P. aeruginosa, of which 55% were multi-drug resistant (MDR). Out of 13 commonly used antibiotics tested by Kirby-Bauer disc diffusion method, greatest resistance was shown against piperacillin-tazobactam 15 (48.4%) and ceftazidime 15 (48.4%), and least against meropenem 6 (19.4%) and ofloxacin 5 (16.2%). Of all 17 MDR isolates subjected to biofilm detection, strong biofilm formation was exhibited by 11 (65%) and 14 (82%) isolates with microtiter plate method and tube method respectively. Out of 17 isolates tested, 12 (70.6%) isolates possessed mexA and mexB genes indicating the presence of active efflux-pump system. Higher number of the isolates recovered from sputum 7 (58.3%) and pus 5 (41.7%) possessed mexA/mexB genes while the genes were not detected at all in the isolates recovered from the urine (p<0.05). This study assessed no significant association between biofilm production and multi-drug resistance (p>0.05). Adoption of stern measures by the concerned authorities to curb the incidence of multi-drug resistant and biofilm-forming isolates is recommended to prevent their dissemination in the hospital settings.

(1) Background: Scrub typhus (ST) is endemic to Nepal. It is often underdiagnosed and misdiagnosed due to non-specific clinical presentation coupled with limited microbiological facilities, leading to adverse clinical outcomes. This study aimed to assess the seroprevalence of scrub typhus in febrile patients attending Sukraraj Tropical and Infectious Disease Hospital (STIDH), Nepal, from August 2018 to April 2019. (2) Materials and Method: Blood/serum samples and clinical and demographic data of adult febrile patients (≥19 years) who attended or were referred to the hospital were collected after obtaining written informed consent from the participants excluding immunocompromised individuals. Collected blood/serum samples were subjected to hematological, biochemical, and serological tests. A serological test for scrub typhus was performed using the ImmuneMed scrub typhus rapid diagnostic test kit. Data generated were analyzed using SPSS software version 24.0. (3) Results: Amongst the 2070 febrile patients, 462 (22.3%) were seropositive to at least one etiological agent of febrile illnesses (scrub typhus: 253 cases, dengue: 101 cases, leptospirosis: 9, brucellosis: 52, malaria: 9 and kala-azar: 20 cases). Scrub typhus accounted for 12.2% (n = 253) of total febrile illnesses followed by dengue (4.9%, n = 101). Mixed seropositivity of scrub typhus with dengue, brucellosis, and typhoid was found in 12 (0.6%), 9 (0.4%), and 5 (0.2%) cases, respectively. Among 253 scrub typhus patients, 53.4% were female. Among the 154 patients, the most common symptoms were fever (100%), headache (79.2%), sweating (70.1%), breathing difficulty (51.3%), redness of the eye (43.5%), and pathognomonic eschar was observed in 9.1% patients. Fifty percent of scrub typhus patients had low platelet count and >30% of patients had an elevated level of liver enzymes (such as serum glutamic oxaloacetic transaminase (SGPT) and serum glutamic pyruvic transaminase (SGOT). (4) Conclusion: Scrub typhus is a considerable cause of febrile illness in Nepal. Females apparently have a higher chance of acquiring scrub typhus. ST presents nonspecific clinical presentation. The diagnostic dilemma of typhus patients can be minimized by the early monitoring of ST-associated symptoms. The country’s health system needs to be strengthened for early outbreak detection, and immediate response actions against scrub typhus to control the future outbreak of ST.