Taking care of a diarrhea epidemic in an urban hospital in Bangladesh: Appraisal of putative causes, presentation, management, and deaths averted

Background In April 2018, a diarrhea epidemic broke out in Dhaka city and adjoining areas, which continued through May. The Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), a dedicated diarrheal disease hospital, had a large upsurge in patient visits during the epidemic. An enhanced understanding of the epidemiology of this epidemic may help health-related professionals better prepare for such events in the future. This study examined the microbial etiology and non-pathogen factors associated with diarrhea during the epidemic. The study also evaluated the patients’ presentation and clinical course and estimated the potential mortality averted by treating patients during the epidemic. Methodology/Principal findings Data from the patients who were treated at Dhaka Hospital during the diarrhea epidemic between April 2 and May 12, 2018 and were enrolled into the Diarrheal Disease Surveillance System (DDSS) at icddr,b were compared with the DDSS-enrolled patients treated during the seasonally-matched periods in the flanking years using logistic regression. icddr,b Dhaka Hospital treated 29,212 diarrheal patients during the 2018 epidemic period (and 25,950 patients per comparison period on average). Vibrio cholerae was the most common pathogen isolated (7,946 patients; 27%) and associated with diarrhea during the epidemic (adjusted odds ratio [AOR] 1.5, 95% CI: 1.1–2.0). The interaction of Vibrio cholerae with ETEC (AOR 2.7, 95% CI: 1.3–5.9) or Campylobacter (AOR 2.4, 95% CI: 1.1–5.1) was associated with further increased odds of diarrhea during the epidemic. In children under five years old, rotavirus was the most common pathogen (2,029 patients; 26%). Those who were adolescents (AOR 2.0, 95% CI: 1.3–3.1) and young adults (AOR 1.9, 95% CI: 1.4–2.5) compared to children younger than five years, resided within a 10 km radius of Dhaka Hospital (AOR 1.6, 95% CI: 1.1–2.2) compared to those living outside 20 km, borrowed money or relied on aid to pay for the transport to the hospital (AOR 1.6, 95% CI: 1.2–2.0), used tap water (AOR 1.8, 95% CI: 1.4–2.4) for drinking compared to tubewell water, and disposed of the solid waste directly outside the house (AOR 4.0, 95% CI: 2.7–5.9) were more likely to present with diarrhea during the epidemic. During the epidemic, patients were more likely to present with severe dehydration (odds ratio [OR] 1.6, 95% CI: 1.3–2.0) and require inpatient admission (OR 2.5, 95% CI: 1.9–3.3), intravenous rehydration (OR 1.7, 95% CI: 1.4–2.1), and antibiotics (OR 2.2, 95% CI: 1.8–2.7). The in-hospital case fatality rate was low (13 patients; 0.04%), and the hospital averted between 12,523 and 17,265 deaths during the epidemic. Conclusions/Significance Vibrio cholerae played the primary role in the 2018 diarrhea epidemic in Dhaka. Campylobacter, enterotoxigenic Escherichia coli, and rotavirus had a secondary role. Adolescents and adults, residents of the metropolitan area, and those who were relatively poor and lacked safe water, sanitation, and hygiene (WASH) practices comprised the most vulnerable groups. Despite the increased disease severity during the epidemic, the case fatality rate was less than 0.1%. icddr,b Dhaka Hospital saved as many as 17,265 lives during the epidemic.

Viral and Bacterial Causes of Labyrinthitis

Labyrinthitis is a known inflammation of the membranous structure of the inner ear. Affected patients usually present with nausea and vomiting, vertigo, hearing loss/impairment, and tinnitus. Many etiologies have been proposed to lead to the development of labyrinthitis, including bacterial, viral, systemic, and iatrogenic causes and the most commonly reported causes include viral and bacterial infections. Not many investigations have elaborated on the viral and bacterial etiologies, and the evidence seems to be scattered across the different studies. In the present study, we have reviewed the literature to discuss the current evidence regarding the viral and bacterial causes of labyrinthitis. Many viruses and bacteria were reported in the literature to cause the condition. However, the most common pathogen includes cytomegalovirus and maternal rubella infections, leading to congenital hearing loss. Other viruses as measles and mumps might also lead to developing post-natal labyrinthitis. Studies also indicates that COVID-19 can be a recent cause of the disease. However, evidence regarding this information, similar to the case with other viral and bacterial etiologies, still needs further validation and reporting before making solid conclusions. Accordingly, we encourage researchers to furtherly report about similar cases and conduct epidemiological investigations to better understand the etiology of the disease.

TaqMan Array card testing of participant-collected stool smears to determine the pathogen-specific epidemiology of travelers’ diarrhea

Background: We assessed the compliance with self-collection of stool smears on Whatman® FTA® Elute Card (FTA Card) and detection of travelers’ diarrhea (TD) associated pathogens using a quantitative PCR assay (customized TaqMan® array card [TAC]), in a prospective, observational cohort of travelers. Methods: Enrolled travelers documented symptoms on a travel diary and collected an FTA Card during a diarrheal episode, or at the end of travel if they remained asymptomatic. TAC testing was performed on FTA Cards from TD cases and 1:1 matched asymptomatic controls and 1:1 matched loose stool cases that did not meet TD criteria. Odds ratios (OR) were used to determine the association between detected pathogens and TD. Results: 484 of 2456 (19.7%) travelers completed an illness diary and met TD criteria, and 257 (53.1%) collected an FTA Card during the TD episode. FTA Cards were stored for a median of 2 years at room temperature (IQR: 1-4 years) before extraction and testing. The overall TAC detection rate in TD cases was 58.8% (95%CI: 52.5-64.8). Enterotoxigenic E. coli was the most common pathogen in TD cases (26.8%) and 3.5% of samples were positive for norovirus. The odds of detecting TD-associated pathogens in 231 matched cases and asymptomatic controls was 5.4 (95% CI: 3.6-8.1) and 2.0 (95% CI:1.1-3.7) in 121 matched TD and loose stool cases (p < 0.05). Enteroaggregative E coli was the most common pathogen detected in asymptomatic controls and loose stool cases. Detection of diarrheagenic E coli, Shigella/enteroinvasive E coli (EIEC), and Campylobacter spp. was significantly associated with TD. Conclusions: FTA Cards are a useful adjunct to traditional stool collection methods for evaluating the pathogen-specific epidemiology of TD in austere environments. Qualitative detection of pathogens was associated with TD. Measures to improve compliance and quality of FTA Card collection with decreased storage duration may further optimize detection.

Factors Affecting the Necessity of Tracheostomy in Patients with Deep Neck Infection

Deep neck infection (DNI) is a serious disease that can lead to airway obstruction, and some patients require a tracheostomy to protect the airway instead of intubation. However, no previous study has explored risk factors associated with the need for a tracheostomy in patients with DNI. This article investigates the risk factors for the need for tracheostomy in patients with DNI. Between September 2016 and February 2020, 403 subjects with DNI were enrolled. Clinical findings and critical deep neck spaces associated with a need for tracheostomy in patients with DNI were assessed. In univariate and multivariate analysis, older age (≥65 years old) (OR = 2.450, 95% CI: 1.163–5.161, p = 0.018), multiple spaces involved (≥3 spaces) (OR = 4.490, 95% CI: 2.153–9.360, p = 0.001), and the presence of mediastinitis (OR = 14.800, 95% CI: 5.097–42.972, p < 0.001) were independent risk factors associated with tracheostomy in patients with DNI. Among the 44 patients with DNI that required tracheostomy, ≥50% of patients had involvement of the parapharyngeal or retropharyngeal space (72.72% and 50.00%, respectively). Streptococcus constellatus (25.00%) was the most common pathogen in patients with DNI who required tracheostomy. In conclusion, requiring a tracheostomy was associated with a severe clinical presentation of DNI. Older age (≥65 years old), multiple spaces (≥3 spaces), and presence of mediastinitis were significant risk factors associated with tracheostomy in patients with DNI. The parapharyngeal and retropharyngeal spaces were the most commonly involved, and Streptococcus constellatus was the most common pathogen in the patients with DNI that required tracheostomy.

Common Pathogen and their Drug Sensitivity Pattern in Urinary Tract Infection at Chandka Medical College Hospital Larkana

Objective: To study the pattern of existing common pathogen of Urinary Tract Infection and their drug sensitivity pattern. Methods: It was a cross sectional study held in Medical Unit-I, CMC Teaching Hospital, Shaheed Mohtarma Benazir Bhutto Medical University(SMBBMU), Larkana with collaboration of Pathology Laboratory CMC Larkana, Aga Khan University Hospital Lab, Rahila Research Lab and Chughtai Lab. All the participants meeting inclusion criteria were enrolled. The reports of Urine culture were collected from above mentioned laboratories which include bio data, causative organism, their count and drug sensitivity pattern. The results were copied on proforma by researcher himself. SPSS version 25 was applied for data analysis. Results: Total 302 participants were registered in the study. Out of them 75.8% of them were female and 24.2% were male. Mean age of the patients was 40 ± 9 years. E-coli was found in 52.3%, Enterococcus in 13.2% and Klebsiella pneumonia in 9.6% cases. Meropenem was found sensitive in 92.4%, while cefoperazone sulbactam, Amikacin and Fosfomycin were found to be sensitive in 86.6%, 85%, 76.2% respectively. Ampicillin and Vancomycin was used in 50 cases for Enterococci. Ampicillin was found sensitive in 70% of cases where as vancomycin was found sensitive in 100% of cases with no vancomycin resistant Enterococci. For Enterobacteria Moxifloxacin was found resistant in 84.4% of cases, Ampicillin in 83.5%, Nalidix acid in 78% cases. While Ceftazidime and Amoxiclav was found resistant in 71.1% and 54.1% respectively. Conclusion: E-coli, Enterococcus and klabsella were the most pathogens found in this study. The drug sensitivity pattern showed that Meropenem, Cefoperazone Sulbactam, Amikacin, Fosfomycin and Vancomycin were found commonly sensitive while Moxifloxacin, Ampicillin, Ceftazidime and Amoxiclav was found resistant. Keywords: Urinary Tract Infection, Culture and Sensitivity, Meropenem, Vancomycin, Cefoperazone Sulbactam CMC @ SMBBMU, Larkana.

Pyogenic liver abscess in non-liver cancer patients and liver cancer patients treated with TACE: etiological characteristics, treatment, and outcome analysis

Background: The purpose of this study was to evaluate the clinical, laboratory and microbiological features, clinical outcomes, and prognosis of pyogenic liver abscess (PLA) in non-liver cancer (Non-LC) patients and liver cancer patients treated with transarterial chemoembolization (TACE, LC-TACE).Methods: Clinical data of 48 consecutive PLA patients from January 2016 to December 2020 were retrospectively analyzed. The mortality was compared between the two groups of PLA patients, and risk factors for mortality were evaluated.Results: A total of 48 PLA patients meeting the inclusion criteria were included in this study from January 2016 to December 2020, including 31 males and 17 females. Among them, there were 32 patients in the Non-LC group and 16 patients in the LC-TACE group. Fever and chills were the most common symptoms in both groups, followed by abdominal pain. Shock occurred in 2 patient in the Non-LC group and 3 patients in the LC-TACE group. The positive rate of pus culture in the Non-LC group was 87.5%, among which the most common pathogen was Klebsiella pneumoniae (50%, 14/28), and the positive rate of pus culture in the LC-TACE group was 81.3%, among which the most common pathogen was Escherichia coli (30.8%, 4/13). In the Non-LC group, 28 patients improved after treatment, 1 patient did not improve, and 3 patients died during hospitalization, with a mortality rate of 9.4%. In the LC-TACE group, 9 cases improved after treatment, 3 cases did not improve, and 4 cases died during hospitalization, with a mortality rate of 25%. Multivariate analysis revealed no independent prognostic factor associated with mortality. The cure time of the Non-LC group was 37.4±23.1 days (6-90 days), while that of the LC-TACE group was 91.5±49.7 days (19-180 days), with a statistically significant difference between the two groups (P < 0.001).Conclusions: PLA of the Non-LC group and the LC-TACE group were different in terms of pathogenic bacteria and cure time, etc. For PLA after TACE, a more aggressive and comprehensive treatment should be considered.

Horizontal and vertical transmission of transgenerational memories via the Cer1 transposon

Animals face both external and internal dangers: pathogens threaten from the environment, and unstable genomic elements threaten from within. Previously, we discovered that C. elegans protects itself from pathogens by “reading” bacterial small RNAs and using this information to both induce avoidance and transmit memories for several generations. Here we found that these memories can be transferred to naïve animals via Cer1 retrotransposon-encoded capsids. Cer1 functions at the step of transmission of information from the germline to neurons, and is required for C. elegans’ learned avoidance ability and for mothers to pass this information on to progeny. The presence of the Cer1 retrotransposon in wild C. elegans strains correlates with the ability to learn and inherit small RNA-induced pathogen avoidance. Together, these results suggest that C. elegans has co-opted a potentially dangerous retrotransposon to instead protect itself and its progeny from a common pathogen through its inter-tissue signaling ability, hijacking this genomic element for its own adaptive immunity benefit.