The impact of population mobility on dengue fever: an...

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________________________________________

1Department of Medicine, Faculty of Medicine, University of Jaffna, Sri Lanka 2 Civic Park Medical Centre, NSW 2145, Australia

Address for correspondence: Dr N Rajeshkannan, Civic Park Medical Centre, NSW 2145, Australia

Telephone: + 61410008811 Email: [email protected]

https://orcid.org/0000-0001-9045-3369

Received 5 June 2019 and revised version accepted 22 August 2019

This an open-access article distributed under the terms of the Creative Commons Attribution License, which permits

unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

SLJID • www. http://sljol.info/index.php/SLJID • Vol. 9, No. 2, October 2019

Perspective

The impact of population mobility on dengue fever: an experience from

northern Sri Lanka

T Kumanan1, V Sujanitha1, N Rajeshkannan2

Sri Lankan Journal of Infectious Diseases 2019 Vol.9 (2):98-102

DOI: http://dx.doi.org/10.4038/sljid.v9i2.8252

Abstract

Dengue infection continues to be a major public health issue and has been a challenge to health

authorities for years due to several reasons. It is well known that the virus, mosquito and human

factors play significant roles in the transmission of the infection. Traditionally, several

preventive measures that are targeted towards the mosquito are well implemented in several

countries, including Sri Lanka. Studies have shown that human mobility is a contributing factor

in dengue infection and the objective of this report is to give an account on the possibility of

human mobility as a major contributing factor for the outbreak of dengue infection in northern

Sri Lanka.

The gateway “A9” was reopened to the public in mid-2009, as the political unrest had come to

a halt by May 2009. Northern Sri Lanka was thereby reconnected with the south, which

increased population mobility both ways. An increase in the incidence rate of dengue fever

from 10.72 in 2008 to 539.65 in 2010, supported the hypothesis of the possible contribution of

human mobility in the dengue outbreak of 2010. Human mobility factors are often overlooked

when considering preventive aspects. Preventive measures targeting human movements may

enhance effectiveness of dengue control programs.

Key words: Dengue, Human mobility, Northern Sri Lanka, Prevention of dengue

Dengue has been identified as a national problem, causing a huge economic burden to the Sri

Lankan health sector in both primary and secondary care over the past two decades. The

epidemiology of dengue depends on three key aspects, the dengue virus (DENV) including the

four closely related virus serotypes (DEN-1, DEN-2, DEN-3, DEN-4 of Flavivirus genus), the

vector (Aedes aegypti) and the human host. Of these, the host factors are often overlooked

when considering preventive aspects. However, it is noted that the dengue virus could rapidly

spread into new human populations due to human mobility. Studies have shown the role of

movement of human population in the spread of dengue infection in several regions of the

world.1

https://orcid.org/0000-0001-9045-3369

http://dx.doi.org/

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According to the epidemiological reports of the Ministry of Health, Sri Lanka, the incidence

of dengue was minimal in the northern part of Sri Lanka until 2009 with a few sporadic cases

reported to the Epidemiology Unit, Ministry of Health as part of routine surveillance (Figure

1). However, as shown in Figure 1, a large outbreak was noted in 2010 followed by a gradual

increase in notifications with 4058 notifications being received from the Jaffna district in

2018.2,3

The land gateway to northern Sri Lanka, popularly known as the “A9” was a strategic point

during the three-decade old political unrest and was almost shut down for more than a decade

for public transport. The Northern Province (specifically the Jaffna Peninsula) of Sri Lanka

was not open to the rest of the island through the land route, though it was geographically

connected, owing to the political unrest which prevailed in the region. The A9 was reopened

to the public in mid-2009 since the political unrest has come to a halt by May 2009, but traffic

between the north and south was minimal initially. Population movement between the south

and the Jaffna peninsula increased exponentially in the months following the end of the civil

conflict in May 2009 and reached a peak in recent years.

The Jaffna peninsula experienced the highest incidence of dengue and its devastating

consequences in the latter part of 2009 and early 2010. From 2008 to 2010, there was a sudden

increase in Dengue Fever (DF)/Dengue Haemorrhagic Fever (DHF) in the Jaffna District. A

local study reported 58, 422, and 2648 cases of DF in 2008, 2009 and 2010 respectively.3 The

calculated incidence rate in 2008, 2009 and 2010 was 10.72, 68.98 and 539.65 respectively

(Incidence rate calculated per 100,000 by reported dengue cases in years 2008 (60), 2009 (386)

and 2010 (3020) divided by 2007 mid-year population). Movement of people in both directions

could have contributed significantly to the increase in number of DF/DHF cases following the

reopening of the “A9” highway. Even though some may argue that underreporting may explain

the low numbers reported prior to 2008, the increase of more than 2000 cases in 2010 cannot

be explained by underreporting and one important reason could be the increased human

mobility of the region.

Figure 1: Notification data of dengue cases 2003-2018 Source: Weekly Epidemiological Reports, Epidemiology Unit, Ministry of Health

100


Dengue is endemic in northern Sri Lanka since then, although seasonal variations exist. There

was clear evidence that the vector mosquito Aedes was present in the northern region for a long

time as shown by the epidemic of Chikungunya in the Northern Province in 2006/2007.4 It is

therefore most likely that the low incidence of DF/DHF prior to 2009 was due to the low level

of the DENV in Jaffna prior to this period. It is a well-known fact that the adult Aedes aegypti

can only fly short distances, on average 400 meters. This suggests that the introduction of the

dengue virus into the Jaffna peninsula, allowed rapid carriage of the dengue virus due to the

movement of the human population.5

A meta-analysis in India showed low co-circulation of multiple dengue virus serotypes as

possible contributors of outbreaks and endemic dengue.6 In 2017, Sri Lanka experienced an

outbreak of dengue infection which was extensively studied and the emergence of a new strain,

DEN-2, was identified as a possible contributing factor.7 However the study did not explore

human mobility as a factor for possible contribution to the outbreak which happened in the

Northern Province. Due to the absence of serological studies in the Northern Province,

comparison could not be made with serological studies in other part of the country such as the

Western Province.

A study reported from Vietnam found that a very narrow range of critical human population

densities between 3,000 to 7,000 people/km2 were prone to dengue outbreaks.8 Research done

in Taiwan and Puerto Rico showed that the spatial distribution of dengue incidence may be

positively related to the population density.9,10 Population density indicates how many people

live in a defined geographical area. Generally, population density is reported in square

kilometres/miles. The area of Jaffna district is 1,025 km² with a population density of

598.0/km² in 2018 with a change of +0.78%/year from 2012 to 201811,12. Epidemiologists are

well aware of the negative effect of a high population density on historical epidemics like

measles, influenza and dengue. An increase in the population of 24,263 from 2007 to 2012

and 29,118 from 2012 to 2018 (Table 1) can be correlated with the outbreaks in 2010 and 2017

respectively (peaks as shown in Figure 1).

Name Status Population

Census

1981-03-17

Population

Census

2001-07-17

Population

Special

Enumeration

2007

Population

Census

2012-03-20

Population

Estimate

2018-07-01

Jaffna District 738,788 490,621 559,619 583,882 613,000

Increase of 24,263 Increase of 29,118

Table1: Jaffna population over the decades

Source: Department of Census and Statistics, Sri Lanka (web).

Explanation: All 2018 estimates are provisional

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.

A study done recently in Pakistan pointed out that mobility estimates calculated based on

mobile phone application can be used to predict geographic spread and timing of emerging

locations.13 The researchers have combined transmission suitability maps with estimates of

seasonal dengue virus importation to generate fine-scale dynamic risk maps with direct

application to dengue containment and epidemic preparedness.10,14 This fact is further

emphasized by a study in Thailand which concluded that understanding of human movement

at the local level may be helpful for planning of dengue prevention activities.15

As discussed above, we postulate that human mobility contributed to the outbreak of DF/DHF

in 2010 and suggest that a country with endemic dengue should consider human mobility as an

important epidemiological aspect in the investigation of dengue outbreaks. It is therefore an

important consideration when drawing up prevention, surveillance, and preparedness strategies

to combat not only DF but all vector borne viral diseases. We conclude that rigorous studies

on the role of human movement by using different scales will significantly help in the

understanding of DENV transmission, which is critical to further improve the effectiveness of

prevention programs.

References

1. Stoddard ST, Forshey BM, Morrison AC, et al. House-to-house human movement drives dengue

virus transmission. Proc Natl Acad Sci U S A. 2013; 110(3):994-9.

doi: https://doi.org/10.1073/pnas.1213349110

2. Epidemiology Unit ,Ministry of Health, Weekly Epidemiological Reports, available at:

http://www.epid.gov.lk/web/index.php?option=com_content&view=article&id=148&Itemid=449

&lang=en accessed on 14.07.2019

3. Murugananthan K, Kandasamy M, Rajeshkannan N, et al. Demographic and clinical features of

suspected dengue and dengue haemorrhagic fever in the Northern Province of Sri Lanka, a region

afflicted by an internal conflict for more than 30 years—a retrospective analysis International

Journal of Infectious Diseases. 2014; 27,e32–e36 doi: https://doi.org/10.1016/j.ijid.2014.04.014

4. Surendran, S & Kannathasan, Kajatheepan, A, et.al. Chikungunya-type fever outbreak: some

aspects related to this new epidemic in Jaffna district, northern Sri Lanka. Tropical Medicine and

Health. 2007; 35:249-252. doi: https://doi.org/10.2149/tmh.35.249

5. WHO, Dengue control, The Mosquito , available at:

https://www.who.int/denguecontrol/mosquito/en/ accessed on 01/06/2019

6. Ganeshkumar P, Murhekar MV, Poornima V, et al. Dengue infection in India: A systematic

review and metanalysis. PLoS Negl Trop Dis 2018; 12(7):e0006618.

doi: https://doi.org/10.1371/journal.pntd.0006618

7. Ali S, Khan AW, Andrew WT, et.al. The unprecedented magnitude of the 2017 dengue outbreak in

Sri Lanka provides lessons for future mosquito-borne infection control and prevention Infection,

Disease & Health .2018; 23:114e120 doi: https://doi.org/10.1016/j.idh.2018.02.004

8. Schmidt W-P, Suzuki M, Dinh TV, et al. Population density, water supply, and the risk of dengue

fever in Vietnam: cohort study and spatial analysis. PLoS Med. 2011; 8(8):e1001082.

doi: https://doi.org/10.1371/journal.pmed.1001082

9. Ko, Y.C. Epidemiology of dengue fever in Taiwan. Kaohsiung J. Med. Sci. 1989; 5:1-11. 17.

PMID: 2659810

10. Morrison A.C, Getis A, Santiago M, et.al. Exploratory space-time analysis of reported dengue cases

during an outbreak in Florida, Puerto Rico, 1991–1992. Am. J. Trop. Med. Hyg. 1998; 58:287-298. PMID: 9546405

https://doi.org/10.1073/pnas.1213349110

http://www.epid.gov.lk/web/index.php?option=com_content&view=article&id=148&Itemid=449&lang=en

http://www.epid.gov.lk/web/index.php?option=com_content&view=article&id=148&Itemid=449&lang=en

https://doi.org/10.1016/j.ijid.2014.04.014

https://doi.org/10.2149/tmh.35.249

https://www.who.int/denguecontrol/mosquito/en/

https://doi.org/10.1371/journal.pntd.0006618

https://doi.org/10.1016/j.idh.2018.02.004

https://doi.org/10.1371/journal.pmed.1001082

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11. Department of Census and statistics, Basic Population information on Jaffna District, 2007.

Available at:

www.statistics.gov.lk/PopHouSat/Preliminary%20Reports%20Special%20Enumeration%202007/

Basic%20Population%20Information%20on%20Jaffna%20District%202007.pdf accessed on

14/07/2019

12. Jaffna (District, Sri Lanka) - Population Statistics - City Population available at:

https://www.citypopulation.de/php/srilanka-prov-admin.php?adm2id=41

Accessed on 14/07/2019

13. Wesolowski A, Qureshi T, Boni MF, et al. Impact of human mobility on the emergence of dengue

epidemics in Pakistan. Proc Natl Acad Sci U S A. 2015; 112(38):11887-92. doi: https://doi.org/10.1073/pnas.1504964112

14. Stoddard ST, Morrison AC, Vazquez-Prokopec GM, et.al. The role of human movement in the

transmission of vector-borne pathogens. PLoS Negl Trop Dis. 2009; 3(7):e481.


15. Houa, CYP. Kittayapongb J, Mumforda, LR, et.al. Dengue transmission through human movement

in regular and seasonal patterns on Koh Chang Island in Thailand, International Journal of

infectious disease, 2016; 53(S):95. doi: https://doi.org/10.1016/j.ijid.2016.11.239

http://www.statistics.gov.lk/PopHouSat/Preliminary%20Reports%20Special%20Enumeration%202007/Basic%20Population%20Information%20on%20Jaffna%20District%202007.pdf

http://www.statistics.gov.lk/PopHouSat/Preliminary%20Reports%20Special%20Enumeration%202007/Basic%20Population%20Information%20on%20Jaffna%20District%202007.pdf

https://www.citypopulation.de/php/srilanka-prov-admin.php?adm2id=41



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________________________________________

1General Sir John Kotelawala Defence University, Sri Lanka

Address for correspondence: Dr Nilanthi Senanayake, Department of Microbiology, Faculty of Medicine, University of

Colombo, Sri Lanka. Telephone: +94777598995 Email: [email protected]

https://orcid.org/ 0000 0002 6413 5559

Received 20 March 2019 and revised version accepted 5 July 2019

This an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Research article

The impact of a hand hygiene workshop on improving the knowledge of hand

hygiene of medical students

NP Senanayake1, V Navaratne1, A Balasuriya1



Abstract

Introduction and Objectives: Knowledge of hand hygiene is important for medical students. The aim

of this study was to compare the knowledge before and after a workshop on hand hygiene held for

medical students at the Faculty of Medicine, General Sir John Kotelawala Defence University, Sri Lanka.

Methods: A self-administered, pre-tested validated questionnaire, based on hand hygiene guidelines of

the World Health Organization (WHO), was distributed among the medical students before and after

conducting a workshop on hand hygiene.Results were assessed by comparing the current guidelines set

by the WHO with the knowledge of hand hygiene among the medical students.

Results: All 177 students participated in the study before conducting the workshop. There were 104

(58.8%) preclinical and 73 (41.2%) clinical students. Of the 104 preclinical students, the percentage who

knew the importance of “My five moments for hand hygiene” approach (hand hygiene before direct

contact with patients, after direct contact with patients, before clean/aseptic procedures, after contact with

blood/body fluid and after contact with patient’s surrounding) before conducting the workshop were

53.8%, 67.3%, 51.0%, 88.5% and 34.6% respectively. Of the 73 clinical students, the percentage who

knew the importance of the “My five moments for hand hygiene” approach before conducting the

workshop were 49.3%, 63.0%, 87.7%, 94.5% and 27.4% respectively. Of the 112 students who

participated in the workshop, there were 68 (60.7%) preclinical and 44 (39.3%) clinical students. Of the

68 preclinical students, 77.9%, 79.4%, 91.2%, 95.6% and 70.6% knew the importance of the “My five

moments for hand hygiene” approach post workshop. Post workshop, the percentage of the 44 clinical

students who knew the importance of “My five moments for hand hygiene” approach were 90.9%,

88.6%, 93.2%, 97.7% and 81.8% respectively.

Conclusions: The pre workshop knowledge of hand hygiene among the two categories of medical

students was not satisfactory. The knowledge on each component of “My five moments for hand

hygiene” concept improved to more than 70% after conducting the workshop.

Key words: Hand hygiene, Hospital acquired infections, Health care workers

mailto:[email protected]

https://orcid.org/

http://dx.doi.org/

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Introduction

Hospital-acquired infections (HAIs) are a major public health problem all over the world, particularly in

developing nations.1 Several studies have shown the role of healthcare workers’ (HCWs) hands in the

transmission of micro-organisms in healthcare institutions, resulting in the spread of hospital acquired

infections.2 Patients colonized with nosocomial pathogens contaminate their immediate surroundings

resulting in contamination of HCWs hands when handling the patients or their immediate surroundings

during routine care activities. It has been shown that these organisms are capable of surviving on HCWs’

hands for several minutes following contamination. Therefore, hand hygiene is vital in the prevention of

HAIs.

In institutions where hand hygiene practices are not carried out or are suboptimal, direct and indirect

transmission of nosocomial infections occur in patients.3 Therefore, hand hygiene is an important

healthcare issue and is the single most cost effective and practical measure to reduce the incidence of

HAIs.4,5 However, studies have shown that rates of compliance with hand hygiene practices are low in

most hospitals and overall compliance rates are below 50% and as a result, HAIs have become

increasingly common.6 Consequently, multi drug resistant pathogens such as methicillin resistant

Staphylococcus aureus (MRSA) have become increasingly reported during the past two decades,

especially in developing countries.7 Continuous efforts are being made to identify effective and

sustainable strategies to increase hand hygiene compliance. One such effort is the introduction of an

evidence-based concept of “My five moments for hand hygiene” by the World Health Organization

(WHO). The “My 5 Moments for Hand Hygiene” approach defines five key moments when health-care

workers should perform hand hygiene.

These five moments include the moment before touching a patient, before performing aseptic and clean

procedures, after being at risk of exposure to body fluids, after touching a patient, and after touching

patient surroundings. This concept has been used to improve hand hygiene among healthcare workers.8,9

A study from Saudi Arabia conducted in 2012 concluded that the knowledge of hand hygiene among

medical students was insufficient and that serious efforts are needed to improve the knowledge and

practices of hand hygiene among medical students.10 A study which was conducted at a Turkish medical

school in 2010 indicated that the knowledge and practices of hand hygiene among the medical students

was insufficient.11 Another study conducted at the Hannover Medical School, Germany in 2010 before

students entered the clinical phase showed that their knowledge on correct indications of hand hygiene

was lacking.12 Although the prevalence of health care associated infections is high in the Asian region,

there is a paucity of studies exploring this subject in this region.13-16 Hence, WHO’s concept of “My five

moments for hand hygiene” was made the basis of the present study to evaluate the knowledge of hand

hygiene among military medical students at the General Sir John Kotelawala Defence University, Sri

Lanka.

Health education, by conducting workshops on hand hygiene is one possible way to improve knowledge

and practices of hand hygiene among health care workers, including medical students. The objectives of

the present study therefore was to ascertain pre and post workshop knowledge of hand hygiene among

two categories of medical students (preclinical and clinical) in the Faculty of Medicine, General Sir John

Kotelawala Defence University (KDU), Sri Lanka and to determine whether participating in a workshop

on hand hygiene improved hand hygiene knowledge in each category.

105


Methods

This study was a descriptive cross-sectional study carried out at the Faculty of Medicine, General Sir

John Kotelawala Defence University (KDU) in September 2013. Ethical approval for the study was

obtained from the Ethical Review Committee, Faculty of Medicine, KDU.

A self-administered, pre-tested questionnaire based on the hand hygiene guidelines laid down by the

World Health Organization17 was used for data collection. The questionnaire was administered in English.

and distributed after a brief explanation. Students were given 15 minutes to answer the questionnaire. It

was explained to the students that participation is voluntary and that there will be no repercussions for

not participating in the study. The students were requested to hand over the completed questionnaire to

the Department of Para Clinical Sciences to ensure confidentiality. The questionare was given to all

medical students at KDU (n=177) before the workshop.

Thereafter, a one-day workshop on hand hygiene which consisted of lectures on hand hygiene

(introduction to hand hygiene, indications for hand washing, surgical implications of hand hygiene and

technique of hand hygiene) and practical demonstrations of hand washing was conducted for a total of

112 students. The same questionnaire was distributed 2 weeks after the workshop among all the students

who attended the workshop.

Results were assessed by comparing the current guidelines set by the World Health Organization (WHO)

with the knowledge of hand hygiene among these medical students.2 The following questions were

analysed. Hand hygiene is the single most important event in the prevention of hospital acquired

infections, indications for My Five Moments for Hand Hygiene (hands should be washed before having

direct contact with patients, after having direct contact with the patients, before clean/ aseptic procedures,

after contact with body fluid/ excretion/ blood/ mucus membranes/ non-intact skin/ wound dressings,

after contact with any object in patient’s immediate surroundings), hands should be washed when moving

from a contaminated body site to a clean body site in the same patient, duration of hand washing and the

need for further education in hand hygiene. The percentages were calculated and compared using the z

test for proportions. A p value of less than 0.05 was statistically significant.

Results

All 177 students to whom the questionnaires were distributed participated in the pre-test before the

workshop on hand hygiene. Of the students, 132 (74.6%) were males. There were 104 (58.8%) preclinical

students and 73 (41.2%) clinical students. Less than one-third of preclinical (28.8%) and clinical (34.2%)

students knew that hand washing is the single most important event in the prevention of hospital acquired

infections before conducting the workshop but there was no statistically significant difference between

the two student groups (χ2=0.58, p=0.445).

The numbers (and percentages) of the preclinical students and clinical students who knew the importance

of each component of hand hygiene before the workshop on hand hygiene is shown in Table 1.

106


Before conducting the workshop, the knowledge of hand hygiene when moving from a contaminated

body site to a clean body site in the same patient was significantly better among preclinical students

(p=0.01) and the knowledge of hand hygiene before clean/ aseptic procedures was significantly better

among clinical students (p<0.001). Although significantly more clinical students knew the correct

duration of hand washing (p=0.007), the actual number of students in both groups who recognized the

need to wash hands for the required duration of 40-60 seconds was very low (22 of 102 preclinical and

29 of 78 clinical students). A large proportion of students in both groups (pre-clinical-71.2% and clinical-

76.7%) said they needed further education on hand hygiene.

A workshop on hand hygiene was conducted for 112 medical students (response rate 63.3%) which

included 68 (60.7%) preclinical students and 44 (39.3%) clinical students (response rates of 65.4% and

60.3% respectively). Sixty (88.2%) of the preclinical students and 41 (93.2%) of the clinical students

knew that hand washing is the single most important event in the prevention of hospital acquired

infections after participating in the workshop (p=0.390).

The numbers and percentages of the preclinical students, pre and post workshop differences in the

knowledge of hand hygiene are shown in Table 2.

Component of hand hygiene

Preclinical

students

n=104

Clinical

students

n=73

p value

Hands should be washed No % No %

a before having direct contact with patients 56 53.8 36 49.3 0.55

b after having direct contact with the patients 70 67.3 46 63.0 0.55

c before clean/ aseptic procedures 53 50.9 64 87.7 <0.001

d

after contact with body fluid/ excretion/ blood/ mucus membranes/ non-intact skin/ wound dressings

92 88.4 69 94.5 0.17

e after contact with any object in patient’s immediate surrounding

36 34.6 20 27.39 0.31

f

When moving from a contaminated body site to a Clean body site in the same patient

52 50.0 23 31.50 0.01

g for the correct duration 22 21.2 29 39.7 0.007

Table 1: The pre-workshop knowledge of preclinical and clinical students (n=177)

107


All the components of hand hygiene improved among the preclinical students after conducting the

workshop with statistically significant improvements in all components except b and d. Percentage

improvement ranged from 7.2% to as high as 53.9%.

The numbers and percentages of the clinical students, pre and post workshop differences in the

knowledge of hand hygiene are shown in Table 3.

Component of hand hygiene Pre workshop

n=104 Post workshop

n=68

p

value Hands should be washed Number % Number %

a. before having direct contact with patients 56 53.8 53 77.9 0.001

b. after having direct contact with the patients 70 67.3 54 79.4 0.08

c. before clean/ aseptic procedures 53 50.9 62 91.2 <0.001

d. after contact with body fluid/ excretion/ blood/ mucus

membranes/ non-intact skin/ wound dressings 92 88.4 65 95.6 0.11

e. after contact with any object in patient’s immediate surrounding 36 34.6 48 70.6 <0.001

f. when moving from a contaminated body site to a clean body site

in the same patient 52 50.0 49 72.1 <0.001

g. knew the correct duration of hand washing 22 21.1 51 75.0 <0.001

Table 2: Pre and post workshop difference in knowledge of hand hygiene of pre-clinical students

Component of hand hygiene Pre workshop n=73

Post workshop n=44

p value

Hands should be washed Number % Number %

a. hands should be washed before having direct contact with

patients 36 49.5 40 90.9 <0.001

b. after having direct contact with the patients 46 63.0 39 88.6 0.003

c. before clean/ aseptic procedures 64 87.7 41 93.2 0.34

d. after contact with body fluid/ excretion/ blood/ mucus

membranes/ non intact skin/ wound dressings 69 94.5 43 97.7 0.41

e. after contact with any object in patient’s immediate

surrounding 20 27.4 36 81.8 <0.001

f. If moving from a contaminated body site to a clean body site

in the same patient 23 31.5 37 84.1 <0.001

g. knew the correct duration of hand washing 29 39.7 38 86.4 <0.001

Table 3: Pre and post workshop differences in knowledge of hand hygiene of clinical students

108


All the components of hand hygiene improved among the clinical students after conducting the workshop

with statistically significant improvement in components a, b, e, f and g. Percentage improvement ranged

from 3.2% to as high as 54.4%.

Discussion

Hospital acquired infection is an important global health problem, and hand hygiene is an effective

method of infection control.4 Recent studies have found low awareness of hand hygiene among medical

students and certified HCWs.18-22 The present study was aimed to assess the knowledge of hand hygiene

among preclinical and clinical students at the Faculty of Medicine, KDU before and after conducting a

workshop on hand hygiene.

Although hand hygiene is a simple procedure, the knowledge of hand hygiene among these medical

students did not meet the current guidelines set by WHO before conducting the workshop.2 It was evident

that development of hand hygiene promotion programs would be necessary to improve the hand hygiene

of our medical students. There was a significant difference in the pre-workshop knowledge of preclinical

and clinical students on hand washing before clean/ aseptic procedures and the duration of hand washing.

This difference could be due to the limited clinical experience of pre-clinical students. Interestingly,

clinical students had a significantly poorer knowledge than preclinical students on hand washing when

moving from a contaminated to a clean body site in the same patient. One possible reason for this could

be the lack of role models in the clinical setting.

The workshop on hand hygiene was focused on educating the medical students on preventing HAIs by

increasing their awareness and knowledge of hand hygiene compliance. Specifically, the workshop

addressed the need to improve education of medical students concerning hand hygiene. This approach

used a combination of lectures and practical demonstrations to provide additional instructions on how to

prevent HAIs by means of hand hygiene, especially against highly resistant organisms such as

methicillin-resistant Staphylococcus aureus.

Statistically significant (p<0.05) improvements were seen in the preclinical students in all components

tested except the need to wash hands after contact with body fluid / bodily excretions / blood / mucus

membranes / non-intact skin / wound dressings (components b and d in Table 2). This could be due to

these students having a high awareness of this component even before the workshop as shown in Table

2. Although significant improvements were seen, the actual percentage of pre-clinical students who were

able to correctly identify the need to wash hands was less than 80% in components a, b, e, f and g

suggesting that some students may have difficulty in comprehending the importance of these facets of

hand hygiene at this stage of their medical career. In contrast, over 80% knowledge was seen in all

components in the clinical group with significant improvement seen in components a, b, e, f and g. Non-

significance in components c and d was probably due to the high level of knowledge prior to the

workshop as shown in Table 3.

A study conducted at the University of Miami Miller School of Medicine, Department of Anesthesiology,

Miami, Florida, USA in 2010 concluded that there was a statistically significant improvement of

knowledge of hand hygiene among health care workers (nurses, medical students and physicians in

ascending order) after conducting an awareness program on hand hygiene.23 Another study conducted at

the National University Hospital (NUH), Singapore, during the period 2009 to 2012, showed that there

was a statistically significant improvement of hand hygiene among nursing students after health

109


education by conducting an experimental learning assignment on hand hygiene.24 These two studies were

based on awareness programs and learning assignments. In the present study, a one-day workshop was

conducted which was more expeditious. The knowledge of hand hygiene among medical students before

and after conducting a workshop on hand hygiene has not been previously compared.

One limitation of the study was that the post-workshop knowledge was assessed immediately after

conducting the workshop on hand hygiene. Assessing the knowledge after a period of time would have

given an understanding on how much of knowledge is retained. In addition, only the knowledge of hand

hygiene was assessed. An observational assessment would have given a better assessment of the depth

of understanding and its translation to actual clinical practice.

Recent global increases in health care associated infection rates suggest that there is a critical need for

improved periodic education and training of HCWs concerning hand hygiene. By conducting a workshop

on hand hygiene, we were able to achieve an improvement in knowledge of hand hygiene among these

medical students.

Conclusions

A statistically significant improvement of knowledge about hand hygiene among medical students

(preclinical and clinical) was observed after conducting a workshop on hand hygiene, which consisted

of lectures on hand hygiene and practical demonstrations of hand washing. The importance of educating

medical students on hand hygiene and infection prevention and control is highlighted by this study.

Conflicts of Interests: The authors have no conflict of interest

References

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situation in Spanish hospitals. Journal of Hospital Infection 2009; 72(1):50–56.

doi: 10.1016/j.jhin.2009.01.013.

2. WHO: WHO guidelines for hand hygiene in health care. Geneva: World Health Organization, 2009.

3. Pittet D, Allegranzi B, Sax H, et al. WHO Global patient safety challenge, World Alliance for patient

safety. Evidence-based model for hand transmission during patient care and the role of improved practices.

Lancet Infectious Diseases 2006; 6(10): 641-652. doi:10.1016/s1473-3099(06)70600-4

4. Mathur P, Hand hygiene: back to the basics of infection control, Indian Journal of Medical Research

2011; 134 (5):611–620. doi: 10.4103/0971-5916.90985.

5. Kelcikova S, Skodova Z, Straka S. Effectiveness of hand hygiene education in a basic nursing school

curriculum, Public Health Nursing 2012; 29 (2):152–159. doi: 10.1111/j.1525-1446.2011.00985.x.

6. Cummings LK, Anderson DJ, Kaye KS. Hand hygiene noncompliance and the cost of hospital-acquired

Methicillin Resistant Staphylococcus aureus infection. Infection Control and Hospital Epidemiology

2010; 31(4):357-364. doi: 10.1086/651096.

7. Borges LFDA, Rocha LA, Nunes MJ, et al. Low compliance to hand washing program and high

nosocomial infection in Brazil Hospital. Inter disciplinary Perspectives on Infectious Diseases 2012;

Article ID 579681 doi: 10.1155/2012/579681.

8. Sax H, Allegranzi B, Uçkay I, et al. My five moments for hand hygiene: a user-centred design approach

to understand, train, monitor and report hand hygiene. Journal of Hospital Infection 2007; 67 (1):9–21.

doi:10.1016/j.jhin.2007.06.004

9. Chou DT, Achan P, Ramachandran M. The World Health Organization ‘5 moments of hand hygiene’: the

scientific foundation. Journal of Bone Joint Surgery 2012; 94(4):441–445. doi:10.1302/0301-

620X.94B4.27772.

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110


10. Al Kadi A, Salati SA. Hand hygiene practices among medical students. Inter disciplinary Perspectives on

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________________________________________

1Department of Parasitology, Faculty of Medicine, University of Peradeniya, Sri Lanka

Address for correspondence: Dr S Wickramasinghe, Department of Parasitology, Faculty of Medicine, University

of Peradeniya Telephone: +94770074544 Email: [email protected]

https://orcid.org/0000-0003-2046-1093

Received 13 June 2019 and revised version accepted 6 September 2019

This an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted

use, distribution, and reproduction in any medium, provided the original author and source are credited.


Research article

Prevalence of canine tick-borne haemoparasites in three Divisional

Secretariat Divisions (Rambewa, Tirappane, and Galenbidunuwewa) in the

Anuradhapura district, Sri Lanka

D Weerathunga1, AAmarasinghe1, D Iddawela1,

S Wickramasinghe1



Abstract

Introduction and Objectives: Ticks act as the vector for transmission of many parasitic

pathogens. Several tick-borne haemoparasite infections are widespread among canines in tropical

countries. However, information is scarce regarding canine tick-borne infections in Sri Lanka. The

present study was therefore carried out to identify the canine tick-borne haemoparasite species and

thereby assess their prevalence in three Divisional Secretariat divisions in the Anuradhapura

district.

Materials and methods: Blood samples were collected from dogs in three Divisional Secretariat

(DS) divisions namely, Rambewa, Tirappane, and Galenbindunuwewa in the Anuradhapura

district, Sri Lanka. From each blood sample, two thin smears were prepared and stained with

Giemsa. Stained slides were subsequently examined with a light microscope to detect

haemoparasites.

Results: Out of 319 blood samples, 139 were positive for haemoparasites. Of the positives,

51.61% were from Rambewa, 40.47% were from Galenbindunuwewa and 38.88% were from

Tirappane. Three haemoprotozoan species, Hepatozoon canis, Babesia gibsoni, Babesia canis and

one bacterial species, Ehrlichia canis were morphologically identified in the present study.

Conclusions: Comparatively, the prevalence of ehrlichiosis (20.06%) and babesiosis (16.29%)

were high in three DS divisions compared to the prevalence of H. canis infection (1.56%). The

prevalence of the haemoprotozoan infections was significantly different among thee DS divisions


http://dx.doi.org/

112


(P<0.01). Co-infections among dogs suggest that the same vector may be involved in transmitting

different infections.

Keywords: Haemoprotozoa, Hepatozoon canis, Babesia gibsoni, Babesia canis, Ehrlichia canis

Introduction

Canine tick-borne diseases are a major health problem among dogs in tropical and subtropical

countries. Ticks have the capability to successfully transmit disease agents such as viruses, bacteria

andprotozoa.1 Babesiosis, ehrlichiosis and hepatozoonosis are some common tick-borne parasitic

infections in dogs.2,3 These infections can occur in dogs due to the transmission of haemoparasites

by several tick species or by the same species.4 For example, the main vector of B. canisvogeli, H.

canis, and E. canis is the brown dog tick (Rhipicephalus sanguineus).5

Babesiosis is caused by intraerythrocytic piroplasms of the genus Babesia. It is a common disease

among domestic and wild canines.6 Ehrlichia is an alphaproteobacterium belonging to the family

Ehrlichiaceae. E. canis and E. ewingii cause tropical canine pancytopenia and canine granulocytic

ehrlichiosis respectively.7 E. canis causes severe clinical signs in dogs compared to the other

species. E. chaffeensis causes infections in both humans and dogs.9 Canine hepatozoonosis is a

systemic disease caused by the protozoan H. canis (Apicomplexa, Hepatozoidae). It is

transmitted by the dog tick R. sanguineus. H. canis is found in Africa, Southern Europe, Asia,

Australia and America.7 Ticks acquire the pathogen by feeding on an infected host. Transstadial

transmission from the nymph to the adult stage can occur.

Previous studies have determined the prevalence of canine haemoparasites in Sri Lanka. H. canis

was first identified in 1961 in Sri Lanka.9 In 2017, cases of acute hepatozoonosis, characterized by

neurological symptoms, ataxia or paresis, emaciation and anaemia was detected.10 An early study

has determined the prevalence of canine ehrlichiosis in Sri Lanka based on conventional

examination of stained blood smears.11 A study carried out to determine the prevalence of canine

vector-borne diseases in the Western Province identified the prevalence of both single and mixed

infections among dogs.12 However, there is a relative paucity of studies on the prevalence of canine

tick-borne infections in Sri Lanka. In the present study, our objectives were to identify the canine

tick-borne haemoparasite species and assess their prevalence in three Divisional Secretariat

divisions in the Anuradhapura district.

Materials and Methods

Study area

This study was conducted in three Divisional Secretariat (DS) divisions: Rambewa, Tirappane,

and Galenbindunuwewa in the Anuradhapura district, Sri Lanka (Figure 1).

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Sample collection

The sample size was calculated using the Creative Research Systems survey software

(http://www.surveysystem.com/sscalc.htm). The calculated sample size was 375 (dog population

was about 14,698 and the confidence interval was 95%). Blood samples were collected from April

2014 to July 2014 at the prophylactic anti-rabies vaccination and sterilization centers. Blood

samples (1-2 ml) were collected into ethylenediaminetetraacetic acid (EDTA) tubes. Samples were

stored at 4 °C and dispatched to the Department of Parasitology, Faculty of Medicine, University

of Peradeniya, Sri Lanka to carry out the laboratory investigations.

Figure 1: Map of Anuradhapura District Divisional Secretariat (DS)

Divisions. The three sampling sites; Rambewa, Galenbindunuwewa and Tirappane DS

divisions are highlighted.

http://www.surveysystem.com/index.htm

114


Microscopic examination

From each blood sample, 2-3 thin smears were prepared and stained with Giemsa according to the

method described in a previous study.13 Smears were examined with a light microscope (Carl

Zeiss™ PrimoStar™, Germany) under oil immersion (×1000) to identify the haemoparasites. H.

canis was identified by observing the gamonts with an ellipsoidal, brick-like shape inside the

cytoplasm of the neutrophils.14 In the erythrocytes, B. canis was identified by the morphology of

merozoites described in a previous study.15 Detection of B. gibsoni in the infected erythrocytes

was carried out according to the morphological features described by Lempereur et al.(2014).16 E.

canis was identified by the round shape and purple colour morulae in the cytoplasm of

lymphocytes.17

Statistical analysis

Chi square test was conducted in R18 to identify whether the prevalence of the haemoprotozoan

infections was significantly different among the three DS divisions.

Results

Sample collection

All the dogs included in this study were females with an average age of 3 years and were

asymptomatic. A total of 319 blood samples were collected from Rambewa (124), Tirappane (108)

and Galenbindunuwewa (87) DS divisions. Of those, 312 were obtained from stray dogs and 7

were from pet dogs.

Microscopic examination

Four haemoparasites namely E. canis, H. canis, B. canis and B. gibsoni were identified by

microscopic examination (Figure 2).

Prevalence in the three DS divisions

The prevalence of infection differed significantly between the divisions. (χ2=18.47, df=6, P<0.01).

In Rambewa DS division, the number of mixed infections was high (Table 1). There were no H.

canis single infections. In Galenbindunuwewa, H. canis with B. gibsoni, B. gibsoni with E. canis

were the only mixed infections detected. In Tirappane the only mixed infection detected was B.

gibsoni with E. canis. However, no B. canis infections were identified in Tirappane DS division.

Overall prevalence of the haemoparasites

When considering the percentage overall prevalence in the three DS divisions, of the positive

samples, the highest prevalence (51.61%) was from Rambewa and the lowest (38.88%) from

Tirappane (Table 1). Among haemoparasites, Rambewa DS division had a significantly high

number of E. canis infections. The highest number of B. gibsoni infections was found in the

Tirappane DS division. H. canis was present in all three DS divisions. B. canis presented in

Rambewa and Galenbindunuwewa DS divisions but was not present in the Tirappane DS division

(Table 1).

115


The prevalence of each species was determined by examining all the positive samples. H. canis

was present in 1.56% of samples as a single infection. Another 1.56% had mixed infections of H.

canis with both E. canis and B. gibsoni. In 15.04% of the samples, B. gibsoni was detected as a

single infection. B. gibsoni showed mixed infections in 5.05% of samples either with E. canis, B.

canis or H. canis. In 1.25% of samples B. canis was observed as a single infection. Another 1.25%

had mixed infections of B. canis and E. canis. In 20.05% of samples, E. canis was detected as a

single infection. Furthermore, 4.38%had E. canis mixed infections with one or more of the other

three species.

Figure 2: Haemoparasite species identified in the

canine blood samples.

a: Morulae (arrow) of E. canis in the lymphocytes.

b: Gamont of H. canis in the neutrophil (G-Gamont and N-Nucleus of

the neutrophil).

c: Pear shaped B. canis merozoite (arrow) in the red blood cell.

d: Signet ring shaped B. gibsoni merozoite (arrow) in the red blood cell (Scale bar in each figure represents 20 µm).

116


Discussion

In this study, the prevalence and distribution of canine vector-borne infections in three DS

divisions in the Anuradhapura district were investigated. There were 43.88% dogs positive for

haemoparasites indicating infections caused by this group of parasites are common among dogs in

the localities examined. Single infections were found in 37.93% of dogs. This is higher than a

previous report on dogs in the Western Province (29.15%).11 Mixed infections were detected in

5.95% of dogs examined which agrees with the previous study done by Kumara et al. in 2013.12

Mixed infections with only two pathogens were observed in 5.6% dogs. Similar results have been

documented in the Western Province of Sri Lanka.11

This study reports a high prevalence of E. canis infections (20.06%) compared to the previously

reported prevalence of 14% in dogs in the Western Province.12 The prevalence of B. canis (1.25%)

and B. gibsoni (15.04%) reported in this study were also higher than previously reported in the

Western Province.11 The prevalence of H. canis (1.56%) was lower than in the Western Province

(8.57%).12

A study conducted in Nigeria has shown a high rate of mixed infection (37%) that was caused by

the same haemoparasite species identified in this sutdy.19 E. canis infection can predispose dogs

to opportunistic pathogens, such as B. canis and H. canis.5 Having multiple tick-transmitted

infections in dogs is associated with severe and fatal conditions.5 The Brown dog tick (R.

sanguineus) is the main vector transmitting the pathogens found in mixed infections.20 The

prevalence of this tick species is common among domestic animals in the dry zone.21 It can

therefore be suggested that any control measures taken to eradicate this tick species can reduce

more than one type of haemoparasitic infection found in dogs. All the haemoparasite infections

identified are known to be asymptomatic.22-25 However, in some dog breeds, B. gibsoni infection

can be symptomatic.26

Table 1: Prevalence of single and mixed infections of canine haemoparasites in three Divisional

Secretarial divisions in the Anuradhapura district

n: number of samples collected in each DS division

Type of infection Rambewa n=124

Galenbindunuwewa n= 87

Tirappane n=108

Overall prevalence n=319

Single infections B. canis 2 (1.61%) 2 (2.29%) 0 (0.00%) 4 (1.25%) B. gibsoni 13 (10.48%) 11 (12.64%) 24 (22.22%) 48 (15.04%) E. canis 35 (28.22%) 16 (18.39%) 13 (12.03%) 64 (20.06%) H. canis 0(0.00%) 2 (2.29%) 3 (2.77%) 5 (1.56%) Mixed infections

H. canis+ E. canis 1 (0.80%) 0(0.00%) 0 (0.00%) 1 (0.31%)

H. canis+ B. gibsoni 1 (0.80%) 2(2.24%) 0 (0.00%) 3 (0.94%)

H. canis+ E. canis +

B. gibsoni

1 (0.80%) 0(0.00%) 0 (0.00%) 1 (0.31%)

B. canis+ B. gibsoni 1 (0.80%) 0(0.00%) 0 (0.00%) 1 (0.31%)

B. gibsoni+ E. canis 7 (5.64%) 1(1.14%) 1 (0.92%) 9 (2.82%)

B. canis+ E. canis 3 (2.41%) 0(0.00%) 0 (0.00%) 3 (0.94%)

Total prevalence 64 (51.61%) 34 (39.08%) 41 (38.88%) 139 (43.57%)

117


Differences in the distribution of vector-borne diseases are largely determined by the geographical

distribution and local density of their arthropod vectors. Furthermore, environmental changes have

a direct impact on the geographical distribution of arthropods, size of their population and their

ability to act as a vector to transmit diseases.27,28 Future studies are required to examine the

putative tick vectors and their population characteristics. Results obtained during this study would

be useful for the accurate design of such investigations. We would suggest implementation of

coordinated control and prevention programs of canine tick-borne diseases with the help of

veterinary and public authorities. Prophylactic measures, including the use of acaricides and

insecticides can be used to control the vectors.29 These control measures are necessary to prevent

any possible zoonotic transmission.

Limitations of the study

Blood samples were collected only at the prophylactic anti-rabies vaccination and sterilization

centers. However, the expected numbers of dogs were not brought to these centers. As a result, the

number of samples collected are less than the calculated sample size. Any background information

about these dogs was not considered. Haemoparasite species were identified using morphological

characteristics. Species identities should be further confirmed using molecular techniques.

Conclusions

This study was carried out on tick-borne canine haemoparasitic infections in three DS divisions in

Anuradhapura district, Sri Lanka. Comparatively, the prevalence of ehrlichiosis and babesiosis

was high in the three DS divisions. The prevalence of H. canis was low. Co-infections among dogs

suggest that the same vector may be involved in transmitting different infections.

Acknowledgments: Authors would like to acknowledge the Veterinary Surgeons of Animal

Health Organization for the support extended to collect samples. Special thanks to the technical

staff of the Department of Parasitology, Faculty of Medicine, University of Peradeniya for their

assistance during the laboratory work.

Funding: This research did not receive any specific grant from funding agencies.

Conflict of interests: The authors declare that they have no conflicts of interests.

Ethical statement: This study was approved by the Institutional Animal Ethics Committee of the

Postgraduate Institute of Science (PGIS), University of Peradeniya, Sri Lanka.

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________________________________________

1 Faculty of Medicine, University of Colombo, Sri Lanka 2 Department of Parasitology, Faculty of Medicine, University of Colombo, Sri Lanka 3 Department of Surgery, Faculty of Medicine, University of Colombo, Sri Lanka

Address for correspondence: Prof Y Siriwardana, Department of Parasitology, Faculty of Medicine, University of

Colombo, Telephone: +94112695300 Ext:182 Mobile: +940772988910 Email: [email protected]

https://orcid.org/ 0000-0003-3283-0140

Received 20 July 2019 and revised version accepted 21 October 2019



Research article

Literature review and a preliminary study on leishmaniasis to inform

community awareness campaigns in Sri Lanka

KSS Chandrasiri1, S Chandrasinghe1, C Chathuranga1,

DR Fernando2, I De Zoysa3, HVYD Siriwardana2



Abstract

Background: Accurate knowledge about transmission and potential risk factors of leishmaniasis

among residents in endemic areas is imperative. This paper presents a review of the existing

literature on leishmaniasis risk factors in Sri Lanka and a preliminary study of the disease related

awareness, attitudes and practices in an endemic area.

Methods: Publications on epidemiology of leishmaniasis in Sri Lanka were reviewed. Data were

collected using an interviewer administered questionnaire from 120 inhabitants in Dickwella

Divisional Secretariat in the District of Matara by a multistage cluster sampling method.

Results: Around 20 publications were reviewed, and potential risk factors identified. In the field

survey, 21.7% (n=26/120) were aware of the name “leishmaniasis”. Disease vector was identified

by 68.1% (n=64/94) through the shown picture and description. Acne form was known as a type

of early leishmanial skin lesion by 81.1% (n=73/90). Potential risk factors such as cracks of house

walls (55.8%, n=67/120), damp areas in houses (60.0%, n=72/120), animal burrows (45%,

n=54/120) and livestock pens (12.5%, n=15/120) were abundant in this area. Western medical

treatment was preferred by 78.9% (n=71/90) as the treatment option. Around 58.9% (n=53/90) of

respondents felt that disease prevention is a combined responsibility of community and the

government.

Conclusions: Even though, potential environmental risk factors were abundant, this study found

poor awareness regarding the salient aspects of leishmaniasis among the participants. They

possessed positive attitudes towards curability of the disease, obtaining proper treatment and

disease control.

http://dx.doi.org/

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Keywords: Cutaneous Leishmaniasis, Knowledge, Attitudes and Practices, Sandfly

Introduction

Leishmaniasis is a neglected tropical disease caused by a sandfly-borne protozoan parasite of the

genus Leishmania. This infection presents in three major clinical forms: cutaneous leishmaniasis

(CL), the commonest form resulting in skin lesions, muco-cutaneous leishmaniasis (MCL) which

affects mucosal tissues and visceral leishmaniasis (VL), the most serious form which invades

internal organs.1 As per the global estimates from the World Health Organization (WHO), there

are 700,000 to 1,000,000 new cases of leishmaniasis and 26,000 to 65,000 deaths due to

leishmaniasis occurring annually.1

The increase in the incidence of leishmaniasis is mainly attributed to domestic factors, peri-

domestic factors, environmental conditions and human behavior. Many studies have found that

characteristics of the domicile such as houses with cracked, mud or thatched plastered house walls,

as well as dirt or damp earthen floors can enhance vector abundance.2 Rearing animals like cattle,

dogs, goats, pigs, hens and presence of rodents were identified as risk factors which enhance

aggregation of sandflies.3 Practices such as dumping animal dung near houses and sleeping outside

the house near animal shelters, under trees and in farm fields at night were also associated with

acquiring leishmaniasis.3 Leishmaniasis tends to affect the poorest people and marginalized

societies. Migration into villages can also increase cases of leishmaniasis.4 In addition, natural

disasters like earthquakes can create breeding places for sand flies.5 Other environmental factors

including elevation, forest coverage, proximity to woodland, new agricultural projects and

irrigation lead to increase in the sand fly population.6

Sri Lanka is a recently established focus of leishmaniasis caused by a genetically modified variant

of Leishmania donovani.7 The main clinical form remains as CL in this focus.8,9 Sri Lanka has two

main foci for transmission of leishmaniasis in the north and south.9 In 2008, leishmaniasis was

made a notifiable disease in Sri Lanka.10 Establishment of more dangerous forms (VL, MCL)11,

the presence of locally acquired mucosal leishmaniasis12 and a humoral response associated with

CL13 have been reported recently. Furthermore, an array of problems are presented with the

standard treatment, sodium stibogluconate.14 The potential vector Phlebotomus argentipes is

widely prevalent in the country.15 Due to these potential threats, implementation of prevention and

control strategies are vital. Understanding attitudes, practices and the nature of existing risk factors

related to the disease in the affected community would be useful in formulating such programmes.

The aim of this preliminary study was to review the existing literature on risk factors for

leishmaniasis in Sri Lanka, to study their prevalence and assess disease related community

awareness, attitudes and practices.

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Materials and Methods

Review of existing literature

Data bases including PUBMED and Google Scholar were searched with keywords

“leishmaniasis”, “risk factors”, together with “Sri Lanka”. Risk factors and other relevant

information found during the literature survey were considered in favour of either outdoor or peri-

domestic transmission in the relevant study areas.

Field Survey

Study setting: Sri Lanka consists of 25 districts. Each district has several Divisional Secretariat

(DS) divisions which consist of smaller subunits called Grama Niladhari divisions (GNDs).

Dickwella DS in the Matara district of southern Sri Lanka is “a notable hotspot for CL” as it has

shown a concentration of CL cases.16 This descriptive cross sectional study was conducted in the

Dickwella DS division which consists of 48 GNDs.

Sampling method: The study population consisted of inhabitants within 16 to 60 years of age and

living in the Dickwella DS division for at least one year. This was to include those who have

acquired infection from the same locality. A random three stage cluster sampling method was used

to recruit 120 of households. In the first stage, four GNDs were randomly selected, following

which one road was randomly selected from each chosen GND. At the third stage, 30 households

were recruited from both sides of each selected road starting from the junction of the main road

and the selected road. Only one occupant was interviewed from each house to overcome the effect

of clustering and family association.

Data collection tool: An interviewer administered pretested questionnaire was used for data

collection. Interviews were conducted in the preferred language of the participant (either Sinhala

or Tamil). The questionnaire consisted of questions to collect information on demographic

characteristics, knowledge of clinical manifestations and treatment options, attitudes and existing

practices on prevention and treatment of CL and the presence of identified risk factors in the

environment.

Data analysis: Data were analyzed using the Statistical Package for Social Sciences (SPSS)

software, version 22. Associations were tested using Chi-Square test. The selected significant level

was 5%.

Results

Review of existing literature on leishmaniasis risk factors in Sri Lanka

Risk factors associated with cutaneous leishmaniasis in Sri Lanka have been studied on a few

occasions. Earlier publications speculated the presence of a local transmission cycle.17 Both

outdoor and peri-domestic transmission were subsequently described as reasons for the increase

in newly identified cases.8 The first formal study from northern Sri Lanka on leishmaniasis,

indicated outdoor occupational behaviour, close proximity to jungles, lack of awareness and

123


inadequate use of preventive measures as associated risk factors.18 The second study, also

conducted in northern Sri Lanka identified male gender, spending a mean of >5 hours/day in

outdoor work, and an age range of between 20 and 40 years as the most important risk factors.8

A study conducted using 938 subjects in the Hambantota district indicated possible peri-domestic

transmission.8 This study found an association of a twofold higher risk of acquiring leishmaniasis

between the ages of 11and 40 years, five or more members in a household and the presence of

cracks and crevices in the walls of the house. Household’s ownership of animals, the presence of

animal shelters in the home compound, the frequency of visits to animal sheds and the type of roof

were not found to have any significant effect on the risk of CL.8 Another study with a sample size

of 2260 done in the Matara district16 showed a higher number of affected females (60.5%, p< 0.05)

than males. They identified un-plastered brick walled houses (p<0.05) and excessive time (>4

hours/day) spent outdoors (P<0.05) as significant factors for CL. Occupation, common water

source as the mode of water supply and presence of animal shelters in their gardens within 200 m

were not associated with the risk of acquiring the disease in this study.16

In a cross sectional study done with 834 participants in Thalawa MOH, Anuradhapura district 19,

distance to paddy fields from the residencies of CL patients was significant (p=0.01) whereas

distances to forest, marsh, scrub jungles, and water bodies were not. Contradictory findings were

presented in another study conducted using 57 patients attending the Anuradhapura Teaching

Hospital20, in which existence of scrub jungles around the residence or occupational places

(p=0.003), presence of sandflies (p=0.021) and working outside for more than 6 hours per day

(p=0.001) were significant. Rearing animals, CL lesions in family members or neighbors and

living in rural or urban areas were not reported as significant risk factors in this study.20 A seasonal

trend of leishmaniasis was found in a study which evaluated the data available from 2009 to 2016

and a peak was shown in the period between July to September in the north-central region and in

October to December in the southern region.21

Field survey

The response rate was 100% (n=120). The majority of the sample consisted of females 69.2% (n

=83), of whom 58.3% were housewives (n=70/83). All participants were between 35 to 60 years

(mean age 45.42years). The mean monthly income was LKR 33,900.94. Most of the participants

were educated up to GCE Ordinary Level (OL) or more (85%, n=102). The mean duration of

residence in the Dickwella area was 32.98 years.

Knowledge on CL: Leishmaniasis was known to 90 (75%) participants who knew it either as

leishmaniasis (n=26/120, 21.7%) or after seeing the picture of the vector and the description given

by the interviewers (n=64/94, 68.1 %). Knowledge of CL was thereafter assessed only from the

90 participants who had knowledge of the disease. Acne or pimple was mentioned as a symptom

of CL by 81.1% (n=73/90). Possibility of ulceration was known by 56.7% (n= 51/90) and 12.2%

(n=11/90) knew that the lesions are slow healing while 8.9% (n=8/90) knew that they enlarge in

size. Knowledge regarding the mode of transmission of the disease was inquired only from

participants who knew the disease by its name (n=26/120), of whom 23 knew the disease was

communicable, 12 knew that it was transmitted via sandflies and 7 identified the sand fly in the

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shown images as “fruit fly”. The frequency distribution of knowledge on breeding sites, resting

places and biting times of the sand flies is given in Table 1.

Only 42.2% (n=38/90) had some awareness of currently available and accepted treatment options.

Cryotherapy treatment was known by 27 (71.1%) and intra-lesional drug administration by 17

(44.7%). Sources of the knowledge about the disease included other villagers (66.7%), healthcare

workers (4.44%), family members (15.56%), relatives (3.33%) and no specific source (10%).

Attitudes of participants: The majority of participants (78.9%, n=71/90) considered

leishmaniasis to be an important disease that affected their daily routine. Many participants (64.4%

n=58/90) identified it as a disease on which a large expenditure needs to be incurred for treatment.

Belief that the disease is completely curable was held by 72.2%. If a family member was infected,

western medical treatment was the option of most participants (78.9%), with home care using

traditional methods by 6.7% and no treatment option would be sought by 14.5%. Motivating fact

is that, 58.9% thought both the community and health authorities should be held responsible in the

prevention and control of leishmaniasis.

Practices of participants: The most adopted protective measure was ordinary bed nets (88.3%,

n=106/120), while 47.5% (n=57/120) wore adequately covered clothes, 33.3% (n=40/120) used

insecticide repellants and 40% (48/120) used mosquito coils.

Potential risk factors: The frequency distribution of potential risk factors is given in Table 2.

Statistically significant association was found (p=0.006) between the monthly income and the

number of preventive measures used. Associations between education level and the prevalent

household risk factors (p=0.552), preventive measures and gender (p=0.29) and prevalent

household risk factors and monthly income (p = 0.720) were not statistically significant.

Discussion

Since the detection of the first autochthonous case of CL in 1992, the incidence of CL has been

continuing to rise along with several cases of VL and one case of MCL. This emphasizes the

necessity of public awareness and control programmes on leishmaniasis. The current study was

aimed to review potential risk factors and investigating their presence and to assess awareness,

attitudes and practices related to leishmaniasis of permanent residents of the Dickwella DS division

in Matara. The study sample consisted mostly of middle aged women (69.2%), the majority of

whom were housewives. In contrast, a previous study8 identified male gender as a risk factor.

Generally, most outdoor environmental workers such as farmers and soldiers are males, and this

was thought to be a reason for male preponderance in acquiring leishmaniasis. However, it is

possible that in the current study, occupational categories and gender could have been influenced

by the timing of data collection as it was done during the working day. It was noted in the present

study that the majority of participants had an educational level of GCE OLs or above which is a

favourable sign for awareness activities.

125


Characteristic** $ Number

agreed

%

*Breeding sites / Resting places

Cracks / crevices in:

• Moist ground 37 41.1

• Walls of houses 15 16.7

• Tree hollows 3 3.3

• Rocks 3 3.3

• Un-plastered brick walls 10 11.1

Vegetation 34 37.8

Dampened areas in house 20 22.2

Livestock pens 10 11.1

Decaying organic matter (leaf litter,

cow dung etc.)

10 11.1

Sand 8 8.8

Loose soil 6 6.7

Fruits 4 4.4

Animal burrows 3 3.3

Don’t know 25 27.8

Biting times

Morning (6am – 12noon) 7 7.8

Afternoon (12 noon to 3pm) 14 15.6

Evening (3pm – 6pm) 10 11.1

Night (6pm onwards) 3 3.3

Morning and Evening 20 22.2

Anytime 6 6.7

Don’t know 30 33.3

$-Total respondents (n=90) were considered for percentages of

each category in each question.

** Multiple answers were accepted in both parts.

* Percentages didn’t add up to 100% as participants gave more

than one response for breeding sites.

Table 1: Knowledge of vector behaviour

Characteristic *$ Numbe

r

%

1. Household risk factors

Rearing Animals

Dogs 23 19.2

Cattle 3 2.5

Household clustering

(Family members/No. of bedrooms)

<2 106 88.3

= or >2 14 11.7

2. Breeding/resting places present

(inside or within10 m distance

from household) Cracks / Crevices of:

House walls 67 55.8

Moist ground 59 49.2

Rocks 14 11.7

Tree hollows 12 10.0

Others:

Damp areas in houses 72 60.0

Un-plastered brick walls 55 45.8

Animal burrows 54 45.0

Loose soil 47 39.2

Livestock pens 15 12.5

3. Risky behaviors of human host

Time spent outdoors (hours)

<5 102 85.0

= or >5 18 15.0

Period of the day spent outdoors

Morning (Before 12noon) 87 72.5

Evening (After 12 noon) 19 15.8

Both 14 11.7

Number of preventive methods used

0 4 3.3

= or <3 63 52.5

>3 53 44.2

Sleeping outside/ on the ground

Sleep outside 8 6.7

Sleep on the ground 14 11.7

* Multiple answers accepted.

$ Total respondents (n=120) was considered for

percentages each category in each question

Table 2: Presence of potential risk

factors for cutaneous leishmaniasis in the

study area

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Inadequate knowledge in most aspects of leishmaniasis was identified in the current study. From

the entire sample, only 21.7% knew the disease by its name ‘leishmaniasis’. Nearly one fourth

(n=30/120) were not aware of the vector borne nature of this disease, despite being inhabitants of

a region endemic for leishmaniasis. The current findings are similar to that of the study conducted

by Surendran et al in Delft Island in northern Sri Lanka15 where none of the respondents were

aware of a disease named ‘leishmaniasis’. Of the 90 participants who knew about the disease, the

majority (81.1%) identified the acne form of lesions as a symptom of CL, 42.2% were aware of

the availability of treatment options in government hospitals and 30% knew that leishmaniasis is

preventable. A study in Anuradhapura also showed that, nearly half the community did not know

of the availability of treatment for leishmaniasis.19

Knowledge of initial symptoms is valuable in early case detection as a high parasite load at the

early stage gives a higher probability of detecting parasites in contrast to patients with chronic

lesions who have a lower parasite load. Early diagnosis will thereby reduce the delay in seeking

treatment. The attitudes of the participants towards treatment seeking was generally positive. Early

treatment minimizes the long course of illness, reduces the risk of recurrence, visceralization and

transmission.

Fellow villagers were the source of information for 66.6% of participants who knew about

leishmaniasis. This indicates that leishmaniasis has been a topic of discussion among the villagers

providing a receptive background for awareness programmes. Interestingly, inputs received from

primary healthcare workers was found to be quite low. Most participants (58.9%) felt that the

community needs to play a role in preventing and controlling leishmaniasis in addition to health

authorities. This also indicates that people will be receptive towards awareness campaigns. With

regard to practices, a considerable proportion of participants used protective methods such as

mosquito nets, repellants and use of proper clothing. Provision of impregnated nets will be a

worthwhile disease controlling step in endemic areas.

Multiple potential sandfly breeding and resting conditions were found in the peridomestic

environments of the study site. Information gathered from the literature review also was in favour

of peridomestic transmission in the study area. Isolation of sandflies from different environmental

conditions, identification of their behaviours and large scale case control studies are required to

confirm this.

This is the first study on the awareness, attitudes and presence of environmental factors in

leishmaniasis among the general public conducted in southern Sri Lanka. Some gaps and needs

with regard to community perceptions, behaviour and existence of potential risk factors were

identified. Limitations in available time and resources of this undergraduate study hindered

collection of data from a larger sample. Study findings may not be fully generalized due to

presence of micro differences in population perceptions, behaviour and environmental factors in

the context of other affected areas within the island. Information found on awareness, practices

and attitudes on cutaneous leishmaniasis in this community can be combined with findings of

regional and country wide risk factor studies to formulate community awareness campaigns in

more meaningful manner.

127


Conclusion

The majority of the study population had inadequate knowledge on most aspects of cutaneous

leishmaniasis, despite living in an endemic area. Participants were shown to have practices that

are likely to increase the chances of disease acquisition. The majority had a positive attitude

towards seeking proper treatment and adopting vector control strategies. These findings highlight

the importance of conducting awareness campaigns for endemic communities.

Acknowledgements: Faculty of Medicine, Colombo, Ministry of health care and Nutrition, Office

of the Regional Director of health Services (RDHS) and the staff of the Dickwella Medical Officer

of Health (MOH) office are acknowledged.

Conflicts of interest: None

Ethical Considerations: Ethical approval for the study was obtained from the Ethics Review

Committee (ERC) of the Faculty of Medicine, University of Colombo. Informed consent was taken

from all participants prior to the study.

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________________________________________

1Ph.D Scholar, Gujarat University; Department of Microbiology, The Gujarat Cancer & Research Institute,

Asarwa, Ahmedabad, Gujarat, India 2Department of Microbiology, B. J. Medical College, Asarwa, Ahmedabad, Gujarat, India

Address for correspondence: Dr Foram Patel, Department of Microbiology, The Gujarat Cancer & Research

Institute, Asarwa, Ahmedabad, Gujarat, India Telephone: +9898070240 Email: [email protected]

https://orcid.org/0000-0002-6692-2724

Received 8August 2019 and revised version accepted 20 October 2019



Research article

Prevalence of nosocomial infections by multidrug resistant organisms in

patients admitted to the critical care area of the Regional Cancer Center,

Gujarat, India

FM Patel1, MM Vegad2



Abstract

Introduction: Nosocomial infection is a main cause of mortality and morbidity among patients

admitted in different critical areas [post-operative, Intensive Care Units (ICU), and for bone

marrow transplantation (BMT)] in a hospital. Availability of a clinical microbiology service for

patients admitted to critical areas can significantly improve clinical outcome.

Methods: During the study period (January 2014 to March 2014) 330 patients from different

oncology departments were admitted to critical areas of the hospital. Conventional and molecular

methods were used to determine resistance mechanisms [methicillin resistance (MRSA), extended

spectrum β-lactamase (ESBL), carbapenemases and Amp C) of clinically significant isolates.

Results: Of 330 patients admitted to critical care areas during the study period, 84 (25.4%) were

identified as having acquired infection during their stay in the critical areas. Of these 84 patients

16 had dual infections. The mean age of patients was 44.5 yrs. The most common infection in the

ICU was wound infection (49%) followed by respiratory infection (19%). The most common

isolated organisms from wound infection were Escherichia coli (42.8%) followed by

Pseudomonas aeruginosa (14.2%). The majority of bacterial isolates were multidrug resistant

(MDR). Using both conventional and molecular methods of 88 isolated Gram negative bacilli

(GNB), 45.9% were found to be ESBL producers, 16 % Amp C producers and 4.5%

carbapenemase producers. The prevalence of MRSA was 30.7% (4/13) by a conventional method

and 23% (3/13) using a molecular method.

Conclusion: From this study, we concluded that cancer patients admitted to critical areas are at a

greater risk of acquiring nosocomial infection. However, the increasing prevalence of MDR-

GNBs, especially those resistant to cephalosporins and carbapenems, could contribute to both


https://orcid.org/

http://dx.doi.org/

130


increased morbidity and mortality due to non-response to routinely used first line antibiotics and

resultant recourse to colistin.

Keywords: MDR, Critical care area, Cancer patients

Introduction

Nosocomial infection is a main cause of mortality and morbidity among patients admitted to the

different critical areas (post-operative, ICU, and BMT) in hospital. Knowledge with regard to

clinical microbiology of patients admitted in these critical areas can significantly improve clinical

outcome.1

The critical care support offered in hospitals is classified as general ICU, post-operative ICU,

cardiothoracic ICU, neuro-ICU, neonatal/paediatric ICU and bone marrow transplant unit.

Infection is a major problem in patients with cancer. Recent advances in technology, such as bone

marrow and hematopoietic stem cell transplantation and the use of chemotherapeutic regimens

have added to the number of patients who are able to survive malignancy but with seriously

impaired host defense mechanisms that compromise their ability to resist or contain infections.2

Common infections in critical care unit patients3 include ventilator associated pneumonia, skin and

soft tissue infection, blood stream infections (BSIs) including catheter related and urinary tract

infection.

Burden of Infection in critical areas:

Infection rate in indoor patients range from 5% to 17%.4 In critical areas, where frequent use of

invasive procedures and multiple therapies expose patients to an increased risk, prevalence rates

are even higher.5 Patients in critical areas account for about 25% of all hospital infections. The

prevalence of infections acquired in critical care areas is significantly higher in developing

countries than in developed countries, varying between 4.4% and 88.9%.6 A recently published

World Health Organization (WHO) review showed that “in low- and middle-income countries, the

frequency of ICU-acquired infection is at least 2–3 times higher than in high-income countries;

device-associated infection densities are up to 13 times higher than in the USA”.7 Critically ill

patients with severe sepsis in intensive care units (ICUs) require lengthy and expensive

management, with an associated high mortality, with rates ranging from 30% to 50%.7 Graft versus

host disease (GVHD) occurs in 20% to 70% of bone marrow transplant(BMT) recipients receiving

grafts from different donor sources and are associated with bacteremia.8

This study includes discussions on a variety of common clinical-microbiological problems faced

in the critical areas and detection of their etiological agents and resistance patterns by conventional

and molecular methods.

131


Materials and methods

This prospective study was carried out from January to March 2014 at the Department of

Microbiology, Gujarat Cancer & Research Institute (GCRI), which is a tertiary care cancer

hospital.

All patients who were admitted to the critical care areas with different complaints and presentations

and who developed clinical features of infection were included in this study.

Different types of clinical samples were collected from these patients depending on the system

involved. All samples were transferred to the microbiology laboratory according to standard

microbiology protocols.

In the laboratory, all samples were processed according to standard guidelines for isolation of the

causative microorganism(s). All isolates were identified on an automated bacterial identification

and sensitivity system (Vitek 2 compact, Biomerieux) using Gram negative and Gram positive

identification cards. Antibiotic sensitivity testing (AST) was performed using different AST cards

on the same system and the minimum inhibitory concentration (MIC) of antibiotics for each isolate

recorded.

Presence of MRSA, ESBL, carbapenemases and Amp C in all isolates was investigated using

conventional and molecular methods (Table 1).

132


Results

During the study period

330 patients from different

oncology departments

(medical, surgical,

gynecology, neurology,

pediatric, and emergency)

were admitted to critical

areas. Of these patients, 84

(25.4%) developed clinical

signs and symptoms of

infection during their stay

in the critical areas. Of

these 84 patients, 16 had

mixed infections (two or

more pathogens being

isolated).

Fig.1 shows the age distribution of the 84 patients. Mean age of these patients was 44.5 yrs. Fig.

2 shows the unit source of patients in the study. Fig. 3 shows the sites of infections.

Fig. 4 demonstrates the bacterial isolates from the study patients.

40%

23%

19%

11%7%

Fig.2: Patients unit wise data (n=84)

Surgery (38)

Medicine (19)

Gynecology (16)

Pediatric (9)

Neurology (6)

49%

19%

16%

10%6%

Fig. 3: Pattern of different types of infections in critical care areas

Wound infection (49)

Respiratory infection (19)

Blood stream infection (16)

Urinary tract infection (10)

Gastrointestinal infection (6)

0

5

10

15

20

25

30

35

40

45

01--10 01--11 21-30 31-40 41-50 51-60 61-70 71-80 Total

Ye

ars

Fig. 1: Demographic data of patients. (n=84)

Male

Female

133


Fig. 4: Infection caused by different pathogens (n=100)

Fig. 5: Comparison of molecular and conventional testing of resistance

mechanisms in Gram negative and Gram positive organisms (n=100)

134


Organism ESBL + Amp C +

Carbapenemase

ESBL +

Amp C

Amp C +

Carbapenemase

ESBL +

Carbapenemase

Escherichia

coli

1

Pus swab 7

Pus swabs-6

Peripheral blood-1

1

Pus swab

2

Pus swabs-2

Klebsiella

pneumoniae

- 2

ET secretion-1

pus swab-1

- 1

Urine

Pseudomonas

aeruginosa

- 2

Peripheral blood- 2

- -

Burkholderia

cepacia

- - - 1

Peripheral blood-1

Total 1 11 1 4

Table 2: Multi resistance mechanisms in isolated organisms (n=17)

65%

22%

10% 3%

Fig. 6: ESBL patterns among different GNBs (n=40)

Escherichia coli (26)

Klebsiella spp. (9)

Pseudomonas (4)

Burkholderia (1)

57%

15%

14%

14%

Fig. 7: Amp C pattern among different GNBs (n=14)


Klebsiella spp. (2)

Pseudomonas aerugonisa (3)

Acinetobacter (2)

50%

25%

25%

Fig. 8: Carbapenemases patterns among different GNBs (n=4)


Klebsiella spp. (1)

Burkholderia (1)

135


E. coli

n=37

Klebsiella

n=16

P. aeruginosa

n=16

Acinetobacter

n=12

Enterobacter

n=4

Burkholderia

n=2

(as per CLSI)

Antibiotics n (%)

β-lactam

Ampicillin 20 (54) 11(68) NT NT 2 (50) 1 (50)

Amoxicillin/

Clavulanic Acid

14 (37) 10 (62) NT NT 2 (50) 1 (50)

Piperacillin/

Tazobactum

12 (32) 9 (56) 4 (25) 2(12) 2 (50) 1 (50)

Cefuroxime 22 (59) 11(68) NT NT 1(25) 1 (50)

Ceftriaxone 22 (59) 11(68) NT NT 1(25) 1 (50)

Cefoperazone/

Sulbactam

(manufacturer’s

defined criteria -

Biomerieux)

10 (27) 9 (56) 5 (31) 3 (25) 2 (50) 1 (50)

Cefepime 27 (72) 11(68) 5 (31) 6 (50) 2 (50) 1 (50)

Aminoglycosides

Amikacin 4 (10) 9 (56) 4 (25) 3 (25) 2 (50) 1 (50)

Gentamicin 14 (37) 8 (50) 3 (18) 7 (58) 2 (50) 1 (50)

Quinolones

Ciprofloxacin 24 (64) 12 (75) 4 (25) 7 (58) 1(25) 0

Levofloxacin 2 (5) 3(18) 5 (31) 6 (50) 2 (50) 2 (100)

Carbapenems

Imipenem 5 (13) 9 (56) 4 (25) 6 (50) 2 (50) 1 (50)

Meropenem 5 (13) 9 (56) 3 (18) 2(12) 2 (50) 1 (50)

Ertapenem 3 (8) 7 (43) NT NT 1(25) NT

Others

Aztreonam NT NT NT 4 (33) 1(25) NT

Minocycline NT NT 8 (50) 2(12) NT NT

Tigecycline 0 4 (25) NT NT 1(25) NT

Table 3: Prevalence of antibiotic resistance in Gram negative bacilli (n=87)

136


0

5

10

15

20

25

30

35

Surgery Medicine Gynecology Pediatric Neurology

34

19

16

9

6

19

13

11

65

45

10

1

11

1

43

0

Fig. 9: Outcome of patients with infections (n=84)

Total

Recovered

Expired

Discharged against medical

advice

Table 4: Prevalence of antibiotic resistance in Gram

positive cocci (n=13)

S. aureus

(n=6)

CONS

(n=7)

Antibiotics n (%)

β lactam

Penicillin 6 (100) 7 (100)

Aminoglycosides

Gentamicin 3 (50) 2 (28)

Quinolones

Ciprofloxacin 3 (50) 4 (57)

Levofloxacin 2 (33) 3 (42)

Others

Tigecycline 2 (33) 0

Co-trimoxazole 3 (50) 5 (71)

Clindamycin 3 (50) 1(14)

Erythromycin 3 (50) 3 (42)

Linezolid 1(16) 0

Tetracycline 2 (33) 1(14)

Vancomycin 0 0

Teicoplanin 2 (33) 0

137


Discussion

Cancer patients having treatment in all the critical areas like the ICU and BMT unit are at a higher

risk of nosocomial infections due to different causes such as disruption of barriers to infection by

endotracheal intubation and tracheostomy, urinary bladder catheterization and central venous

catheterization, and also by immuno-suppression and bone marrow transplantation.

The percentage of nosocomial infection in our study was 25.4%. In a study done by Shaikh JM1et

al, the frequency of nosocomial infection in general patients in the ICU was 29.13%.9 A similar

study by Moolchandani et al from southern India showed an infection rate of 22.2% in the ICUs.10

In another recent study from eastern India by Sugata et al, the nosocomial infection rate in the ICU

settings was 11.98%.11 The higher rate of infection in the current study compared to the study of

Dasgupta S et al was attributed to the fact that patients in the current study were

immunocompromised.

Amongst 84 patients admitted into critical areas, the largest group of patients were from the surgery

department (40.4%) followed by the medicine department (22.6%).

Common infections observed in ICUs are wound infection, respiratory infection including VAP,

bloodstream, urinary tract and gastrointestinal infections. The most common infections in ICUs in

the current study were wound infection (49%) followed by respiratory infection (19%). In a study

by Shaikh JM1 et al, the commonest infection in the ICU was urinary tract infection (39.2%)

followed by respiratory (30%) and wound (22.7%) infections.9 A higher incidence of wound

infection in our study was possibly because we had more surgical patients from both the

gynecology and surgery departments as compared to the latter study.

Wound infections were the most common nosocomial infection as the highest number of

admissions to critical care areas were surgical patients (49%). The most commonly isolated

organisms from wound infection were E. coli (42.8%) followed by P. aeruginosa (14.2%).

Respiratory tract infections were the second commonest nosocomial infection in patients in the

critical care setting. The frequency of respiratory tract infection in ICUs reported in different

studies were 29% (Moolchandani et al10) and 27% (by Dasgupta et al11). In the current study, 19%

of the patients in critical care areas acquired respiratory infection. The predominant pathogens

causing respiratory infections were P. aeruginosa (21%), A. baumannii (21%) followed by K.

pneumonia (15.7%). Similar findings were noted by Shaikh JM1 et al who found P. aeruginosa as

the predominant organism causing respiratory tract infection.9

Blood stream infection was also a common infection observed in critically ill patients. Frequency

of blood stream infection in our study was 16%. The common pathogens isolated from these

patients were S. aureus (25%) followed by K. pneumoniae (18.7%) and E. coli (18.7%). Blood

stream infections in the study by Shaikh et al was 22.7% with S. aureus being the predominant

pathogen.9

138


In our study, urinary tract infection was found in 10 patients and was mainly caused by E. coli

(50%) followed by P. aeruginosa and Klebsiella. Gastrointestinal infection caused by E. coli in

six patients was also observed in the current study.

Prevalence of antibiotic resistance in nosocomial infection

Antibiotic sensitivity testing showed that the majority of bacterial isolates were resistant to

multiple antibiotics (MDR). More than 50% of E. coli was resistant to all β-lactams. Quinolones,

carbapenems, amikacin and levofloxacin showed relatively good sensitivity against E. coli.

Approximately 60% of Klebsiella showed resistance to β-lactams and β-lactam inhibitors,

quinolones and to aminoglycosides. Klebsiella showed better sensitivity against levofloxacin and

tigecycline. P. aeruginosa showed less resistance to commonly used antibiotics as compared to E.

coli and Klebsiella. Acinetobacter showed resistance of around 50% to gentamicin, quinolones

and imipenem. A. baumannii showed good response to piperacillin/tazobactam, meropenem and

to minocycline.

Resistance to antibiotics in Gram positive bacteria was less as compared to Gram negative

pathogens. Tigecycline, linezolid, tetracycline and teicoplanin were active against the isolated

Gram positive cocci. No strain was resistant to vancomycin.

A study by Moolchandani et al10observed that Gram negative bacilli isolated in their study were

multidrug resistant (MDR) and were resistant to cephalosporins, carbapenems, aminoglycosides,

tetracycline and fluoroquinolones.

Antibiotic resistance mechanism in isolated pathogens

Amongst 88 isolated Gram negative pathogens, 45.9% were ESBL producers, 16% were Amp C

producers and 4.5% were carbapenemase producers when tested by both conventional and

molecular methods. The prevalence of MRSA showed a discrepancy between the conventional

method (4/13:30.7%) and the molecular method (3/13:23%). No vancomycin resistant strains were

isolated in the current study. Similar results were noted in an ICU based study by Chiranjay et al.4

Multi drug resistance mechanisms were observed in 17 strains in the current study. Similar findings

were observed in a study by Moolchandani et al.10

Of the ESBL producers, E. coli from pus swabs (17/40) was the commonest followed by Klebsiella

spp. (3/40). Of the 40 ESBL positive strains, Amp C expression was observed in 14 strains, of

which the commonest strains were E. coli from pus swabs (7/14). Similarly, 2 of the 4

carbapenemase producing strains were E. coli isolated from pus swabs.

Of the 84 patients, 11 discharged themselves from surgical units. The highest mortality was

observed in the medicine department (5/84) followed by 4 patients from the surgery department.

This could be due to MDR E. coli which was more prevalent in these units. In the study by Shaikh

JM1 et al, the highest mortality was observed in surgical (11/97) and medicine (3/97) departments.9

139


Conclusion

From this study, we conclude that cancer patients admitted to critical areas are at a greater risk of

acquiring nosocomial infection. Infection is not always the single contributory factor for mortality

and morbidity for patients in critical areas. However, the increasing prevalence of MDR-GNBs,

especially those resistant to cephalosporins and carbapenems, could contribute to both increased

morbidity and mortality due to non-response to routinely used first line antibiotics and recourse to

colistin.

We recommend that education and awareness among healthcare workers and professionals as well

as adherence to standard guidelines for prevention of nosocomial infection should be used to

reduce frequency of nosocomial infection in critical care areas. A multidimensional approach

including Care Bundle, education, surveillance, performance feedback of infection control

practices should be implemented to reduce hospital acquired infections. Of all the strategies, hand

hygiene remains the corner stone in healthcare associated infection prevention.

Ethics: Approval of the Institutional Review Board and Ethics committee was taken for the

study.

References

1. Bhattacharya S, Mondal A. Clinical microbiology in the intensive care unit: Strategic and operational

characteristics. Indian J Med Microbiol. 2010;28(1):5. doi:10.4103/0255-0857.58720

2. Patel Foram M, Lunagariya Rahul C, Varun GPN. Infections in Patients with Cancer - GCRI (Gujarat

Cancer and Research Institute) Experience. Gujarat Cancer Society Research Journal 2013;15(2):22-

28.No doi

3. Weinstein RA. Nosocomial infection update. Emerg Infect Dis. 1998;4(3):416-420.

doi: 10.3201/eid0403.980320

4. Mukhopadhyay C. Infection control in intensive care units. Indian Journal of Respiratory care 2018;

7(1):14-21. doi: 10.4103/ijrc.ijrc_9_17

5. Toufen Junior C, Hovnanian ALD, Franca SA, Carvalho CRR. Prevalence rates of infection in

intensive care units of a tertiary teaching hospital. Rev Hosp Clin Fac Med Sao Paulo.

2005;58(5):254-259. doi:10.1590/s0041-87812003000500004 6. Ulu-Kilic A, Ahmed S, Alp E, Doğanay M. Challenge of intensive care unit-acquired infections and

Acinetobacter baumannii in developing countries. OA Crit Care. 2013;1(1):1-5. doi:10.13172/2052-

9309-1-1-382

7. Iwuafor AA, Ogunsola FT, Oladele RO, et al. Incidence, clinical outcome and risk factors of intensive

care unit infections in the lagos university teaching hospital (LUTH), Lagos, Nigeria. PLoS One.

2016;11(10):1-15. doi:10.1371/journal.pone.0165242

8. Bock AM, Cao Q, Ferrieri P, et al. Bacteremia in blood or marrow transplantation patients : Clinical

risk factors for infection and emerging antibiotic resistance. Biol Blood Marrow Transplant.

2013;19(1):102-108. doi:10.1016/j.bbmt.2012.08.016

9. Shaikh JM1, Devrajani BR, Shah SZ, et al. Frequency, pattern and etiology of nosocomial infection in

intensive care unit : an experience at a tertiary care hospital J Ayub Med Coll Abbottabad.

2008;20(4):37-40. PMID: 19999200

140


10. Moolchandani K, Sastry AS, Deepashree R, et al. Antimicrobial resistance surveillance among

intensive care units of a tertiary care hospital in South India. J Clin Diagnostic Res. 2017;11(2):DC01-

DC07. doi:10.7860/JCDR/2017/23717.9247

11. Dasgupta S, Das S, Chawan NS, Hazra A. Nosocomial infections in the intensive care unit: Incidence,

risk factors, outcome and associated pathogens in a public tertiary teaching hospital of Eastern India.

Indian J Crit Care Med. 2015; 19(1):14-20. doi:10.4103/0972-5229.148633

141

________________________________________

1University Medical Unit, Teaching Hospital Jaffna, Sri Lanka

Address for correspondence: Dr R Arujun, Teaching Hospital, Jaffna, Sri Lanka Telephone: +94 771546924

Email: [email protected] https://orcid.org/0000-0001-8502-9934

Received 9 May 2019 and revised version accepted 14 August 2019



Short Report

The iron and testosterone levels in amoebic liver abscess patients - a

preliminary study from northern Sri Lanka

R Arujun,1 T Kumanan,1 V Sujanitha1



Abstract

Amoebic liver abscesses (ALA) are observed among adult males who consume locally

brewed alcohol in the tropics. The contributory role of alcohol-induced hepatic iron stores

and the male hormone testosterone were said to be playing a pivotal role in the pathogenesis

of ALA. This descriptive preliminary study was intended to see a possible relationship of

serum iron profile and testosterone level among toddy (a local palm wine) drinkers who

presented with ALA to the Teaching Hospital Jaffna. Results have shown very high serum

ferritin levels (902.58ng/ml) in these patients with ALA. However, the serum iron levels

(43.05µg/dl) and the transferrin saturation levels (22.01%) were observed to be normal or

below normal and Total Iron Binding Capacity (TIBC) level was unexpectedly low

(193.3µg/dl) for the corresponding low serum iron levels. Furthermore, the serum

testosterone level (2.44ng/ml) was also low or low normal when compared with the reference

range in the study population. As this preliminary study contrasts with previously postulated

theories, further study is recommended to arrive at a concrete conclusion.

Introduction

Amoebic liver abscess (ALA) has been a common public health problem over many

centuries. The magnitude of the problem is enormous, particularly in the tropics. Studies

from the Indian subcontinent in the recent past clearly demonstrate its persistent nature and

its detrimental impact on the health-care cost of low middle-income countries of this region.

A recent study from India found that active bleeding from the colon is unexpectedly high in

these ALA patients leading to very high morbidity and mortality.1,2

Epidemiological studies have shown that ALA is common in adult males who are habitual

drinkers of the indigenously brewed alcohol beverage toddy, which is a palm wine obtained

from the palmyra tree (Borassus flabellifer).3 Owing to the scarcity of evidence to say that

the contamination of these beverages with amoebae is minimal, several mechanisms have

been put forward from time to time to explain the pathogenesis of ALA in this vulnerable

group.4


http://dx.doi.org/

142


Amoebiasis and ALA pose serious public health issues in the Northern Province of Sri

Lanka.5 Entamoeba histolytica was recently confirmed as a common cause of these clinically

diagnosed liver abscesses in northern Sri Lanka.6

Several factors have been postulated to play a role in the development of ALA in adult males

who consume locally brewed beverages. The contributory role of alcohol-induced hepatic

iron stores and the male hormone testosterone have been suggested as playing an important

role in the pathogenesis of ALA.7 Although human studies are lacking, testosterone level

determines susceptibility to ALA in mouse models.8 The present study describes the

testosterone level and serum iron profile of these ALA patients.

Methods

This study was conducted at the Teaching Hospital, Jaffna, which is the only tertiary care

center in the Northern Province of Sri Lanka. Twenty patients who were treated in the

medical wards for ALA within a period of 3 months in 2018 were randomly recruited.

Amoebic liver abscess was confirmed in these patients ultrasonically. Blood samples were

obtained from all the patients on discharge after clinical resolution of symptoms with

metronidazole alone. Informed written consent was obtained from the study participants and

ethical approval for the study was obtained from the Directorate of the Teaching Hospital,

Jaffna. A control group was not included for this non-interventional study.

Basic demographic details were taken from the patients who were confirmed with liver

abscess. From each patient 2ml of blood was taken for the analysis of testosterone levels and

a full iron profile, including serum ferritin, total iron, transferrin saturation, total iron binding

capacity, unfractionated iron binding capacity. Enhanced chemiluminescence immune assay

was used to measure these parameters.

Results

All 20 patients were male toddy drinkers treated only with metronidazole. The distribution of

the iron profile with different age groups is given in Table 1, while Figure 1 shows the

testosterone level in the different age groups. Figure 2 shows the level of transferrin

saturation in these age groups.

The results showed very high serum ferritin levels. Among the participants, 16 out of 20

patients have serum ferritin more the 500ng/ml with a mean value of 902.58ng/ml. Mean

value of serum iron levels and the transferrin saturation levels were 43.05µg/dl (33 -193) and

22.01% (15 -35) respectively which was within the range of normal population. Mean value

Age groups

(in years)

Number

of

patients

Ferritin mean

value

(ng/ml)

Iron

mean value

(µg/dl)

TIBC

Mean value

(µg/dl)

Haemoglobin

levels

(g/dl)

25 – 39 7 850.54 36.7 169.3 12.74

40 – 54 5 975.46 64 224 12.04

55 – 69 5 1106.38 32.2 143.6 10.94

70 – 84 3 562.86 41 163.3 10.23

Table 1: Iron studies in patients with ALA

143


of TIBC was 193.3µg/dl (228 -428) which is also unexpectedly low for the corresponding

serum iron levels. The mean value of serum testosterone level was 2.44ng/ml (2.7 – 10.7)

which is low for the reference range in this study population.

Fig.1: Serum testosterone levels with different age groups in patients with ALA

Discussion

Iron and testosterone have been implicated in previous studies by several investigators in the

pathogenesis of hepatic amoebiasis.7 This simple observational preliminary study was

designed to describe these two factors in patients with ALA.

0

1

2

3

4

25 - 39 40 - 54 55 - 69 70 - 84

Analysis of testosterone levels with age

Testosterone

levels (ng/ml)

Age

Age (years)

Fig. 2: Percentage transferrin saturation with age in patients with ALA

Transferrin

saturation (%)

0

5

10

15

20

25

30

35

25 - 39 40 - 54 55 - 69 70 - 84

144


The results have shown very high serum ferritin levels in 80 percent of patients with ALA.

The mean value of serum ferritin was 902.58ng/ml. Studies done in the past too have shown

that the serum ferritin was high among patients with ALA.9 The postulated explanations are

that ferritin being an acute phase reactant is expected to be elevated in infection with

Entamoeba histolytica and different pathogenic processes are discussed as possible reasons

for elevated serum ferritin level in inflammation.9 It is reasonable to assume that though the

blood samples were taken on discharge, it may take time for the acute phase protein levels to

normalize. A follow up measurement of ferritin in these patients would be more informative

of their actual iron status.

Serum iron levels (43.05µg/dl) and the transferrin saturation levels (22.01%) of the study

population were observed to be within the reference range. The TIBC level was 193.3µg/dl

which is also unexpectedly low for the corresponding serum iron levels which range from

36.7µg/dl to 64µg/dl. The presence of anaemia in these patients can partly explain these

findings.

Anaemia is common in ALA, both due to the chronic infection leading to anemia of chronic

disease and due to the commonly prevailing iron deficiency in developing countries.

Anaemia promptly responding to amoebicidal drugs favors anaemia of chronic disease rather

than iron deficiency.10 A detailed study including blood picture, bone marrow iron store

levels will accurately determine the iron status of these patients.

Serum testosterone levels (2.44ng/ml) are low for the reference range in this study

population. This finding contradicts with a laboratory-based study that found testosterone

increased the susceptibility of mice to Entamoeba histolytica liver abscess by reducing the

interferon-gamma secretion by natural killer cells but human studies are lacking.11 A further,

well designed prospective cohort study would be favorable to explore this observation. It has

been suggested, based on animal models (hamster), that the male hormone testosterone could

be a host factor that favors the development of ALA.4 The positive role of testosterone could

be one of the explanations that middle-aged men were mostly affected, with ALA reaching a

peak by the age of 40 years. With increasing age (after 50 years) the incidence declines with

the reduction of testosterone levels. In fact, a rise in serum testosterone level noted in the

elderly age group cannot be extrapolated as the number of patients in the elderly age group is

comparatively low.

Conclusion

This study shows a complex iron profile and difference in the testosterone levels compared to

the postulated theories in the past. A small number of samples and coexisting anemia may

have influenced the results which are not in par with the previously postulated explanations.

A further well designed prospective cohort study with a larger number of samples and more

precise statistical analysis of the clinical profile, evaluation of anaemia and other

confounding causes that could influence the iron studies would be recommended to study the

correlation of these two widely attributed risk factors for developing invasive ALA.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

145


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doi: http://doi.org/org/10.1155/2018/6901751

https://www.ncbi.nlm.nih.gov/pubmed/?term=Chadee%20K%5BAuthor%5D&cauthor=true&cauthor_uid=6385727

https://www.ncbi.nlm.nih.gov/pubmed/?term=Meerovitch%20E%5BAuthor%5D&cauthor=true&cauthor_uid=6385727


https://www.ncbi.nlm.nih.gov/pubmed/?term=Kannathasan%20S%5BAuthor%5D&cauthor=true&cauthor_uid=28061872

https://www.ncbi.nlm.nih.gov/pubmed/?term=Murugananthan%20A%5BAuthor%5D&cauthor=true&cauthor_uid=28061872

https://www.ncbi.nlm.nih.gov/pubmed/?term=Kumanan%20T%5BAuthor%5D&cauthor=true&cauthor_uid=28061872


https://www.ncbi.nlm.nih.gov/pubmed/?term=Makkar%20RP%5BAuthor%5D&cauthor=true&cauthor_uid=12924485

https://www.ncbi.nlm.nih.gov/pubmed/?term=Sachdev%20GK%5BAuthor%5D&cauthor=true&cauthor_uid=12924485

https://www.ncbi.nlm.nih.gov/pubmed/?term=Malhotra%20V%5BAuthor%5D&cauthor=true&cauthor_uid=12924485

https://www.ncbi.nlm.nih.gov/pubmed/12924485

https://www.ncbi.nlm.nih.gov/pubmed/?term=Lotter%20H%5BAuthor%5D&cauthor=true&cauthor_uid=23424637

https://www.ncbi.nlm.nih.gov/pubmed/?term=Helk%20E%5BAuthor%5D&cauthor=true&cauthor_uid=23424637

https://www.ncbi.nlm.nih.gov/pubmed/?term=Bernin%20H%5BAuthor%5D&cauthor=true&cauthor_uid=23424637

https://www.ncbi.nlm.nih.gov/pubmed/23424637

https://doi.org/10.4269/ajtmh.1964.13.790

146

________________________________________

1 Department of Tropical Medicine, School of Tropical Medicine, C R Avenue Road, Kolkatta-700073, West

Bengal, India

Address for correspondence: Dr Saurabh Pandey, Department of Tropical Medicine, School of Tropical

Medicine, C R Avenue Road, Kolkatta-700073, West Bengal, India. Telephone: +9073321386

Email: [email protected] https://orcid.org/0000-0001-5600-6346

Received 20 August 2019 and revised version accepted 3 October 2019



Case Series

Non-tuberculous mycobacterium affecting adults in Eastern India:

Case series from a resource limited tertiary care setting

S Pandey1, S Ghosh1, P Halder1, D Pal1, D Modak1, SK Guha1


DOI: http://dx.doi.org/ 10.4038/sljid.v9i2.8263

Abstract

Non-tuberculous mycobacteria (NTM) are among the less commonly reported causes of

infection which are being increasingly reported owing to better diagnostic tools and physician

awareness. We report a series of six patients presenting to the Department of Tropical

Medicine, School of Tropical Medicine, West Bengal, India over a one year period (2017-

2018) who were diagnosed with NTM infection by culture of pus samples or bone marrow

aspirates. Identification of NTM was carried out by initial Ziehl Neelsen staining followed by

culture and DNA sequencing of isolates for species identification. Of the six patients, two

were HIV positive.

Mycobacterium avian complex (MAC) and M. Senegalese were isolated from one patient

each and M. abscessus from the remaining 4 patients. All patients were treated using the

standard guidelines for periods of 6 to 12 months. Clinical response was noted after 1 to 2

months of therapy with complete response around 3 to 6 months. No relapse was noted

during a 9 month follow up.

DNA sequencing provided a significant advantage for diagnosis and enabled appropriate

treatment with a good outcome on these six patients.

Non-responding surgical site infections and disseminated infection in HIV patients not

responding to anti-tuberculous and antifungal therapy should be considered for diagnosis of

NTM.

Keywords: Nontuberculous mycobacterium (NTM), M. abscessus, M. Senegalese, HIV,

Surgical site infection

http://dx.doi.org/

147


Introduction

NTM is an emerging infectious disease in India and across the world1-10 which is attributed

to better diagnostic tools, especially DNA sequencing.7 NTM infection mimics tuberculosis,

therefore necessitating culture and molecular methods for species identification. Pulmonary

or surgical site infections are the usual sites of NTM infections among immune-competent

patients but are more likely to be systemic in the immune-compromised hosts such as those

who are infected with the Human Immunodeficiency Virus (HIV).11 Surgical procedures, pre-

existing lung disease and immunosuppression predispose to infections by NTM as they are

ubiquitously distributed in nature and thereby the main source of human infection.8 NTM

infections have a protracted course and require prolonged treatment and appropriate surgical

debridement.

Case reports

Six patients were diagnosed as having NTM infection in 2017 in our centre which is a major

referral centre for tropical infectious diseases in Eastern India.

A detailed history including drug treatment, clinical examination and general investigation

was documented in all patients referred to our centre. All the clinical specimens received

were subjected to smear microscopy using Ziehl–Neelsen (ZN) staining, fungal stain and

Gram stain. All samples were then inoculated into BacT/ALERT 3D system containing

modified Middlebrook 7H9 media along with fungal culture and bacterial culture media. All

cultures which had growth in the mycobacterial culture were subjected to ZN staining and

molecular testing by DNA sequencing of 16 S rRNA gene regions.

Patients who were identified with an NTM infection were offered treatment according to

ATS-IDSA guidelines12,13 for NTM infection. These patients were followed up for a

minimum period of 9 months. Response to treatment and relapse were recorded. No follow

up culture was done due to financial constraints.

Case 1

A 38 year old female had persistent discharge (Fig.1)

for a period of one and half months from the surgical

site of her open cholecystectomy (CCT). She already

had 1 month monotherapy with clarithromycin and

then she was diagnosed with NTM. There was no

visible discharge at the 3 month follow up visit and

treatment was continued for 12 months.

Case 2

A 42 year old female developed a small abscess 3 days

following an intramuscular injection 1 month

previously and had received 12 days of clarithromycin at her visit to us. She responded to

treatment which was continued for 6 months (Fig. 2).

Case 3

A 44 year old man had persistent pus with sinus formation at the incision site (Fig. 3)

following a laparotomy 2 months previously. He had already received 45 days of

Fig 1: Open cholecystectomy scar

showing pus pockets along incision

line on day 1

148


clarithromycin and a few days of levofloxacin at his visit. He responded to treatment which

was continued for 6 months.

Case 4

A 53 year old lady presented with multiple pus discharging

sinuses for one year post laparoscopic cholecystectomy

(Fig. 4). She had received 6 months of suboptimal dose

therapy of clarithromycin and a few days of levofloxacin

and amikacin before visiting us. She responded to treatment

which was continued for 12 months.

Case 5

A 48 year old HIV positive man presented with pyrexia of

2 months duration associated with an evening rise of

temperature, weight loss and associated lower respiratory

tract infection. He had multiple retro-peritoneal lymph

nodes and was started on anti-tubercular treatment without

any response even after 4 weeks. A bone marrow sample

was cultured for mycobacteria and fungi from which M. avium complex (MAC) was isolated.

He became afebrile 2 weeks after initiation of treatment with significant relief after 2 months.

No relapse had occurred on follow up at 12 months.

Case 6

A 16 year old boy newly diagnosed with HIV disease presented with fever for 2 months.

There were associated night sweats and evening rise of temperature. He was anaemic

(haemoglobin:8.2/g/dl) and had multiple retroperitoneal lymph nodes and mild splenomegaly.

He had received 2 months of empiric anti-tuberculous drugs (ATD) without any significant

improvement. He refused bone marrow testing or lymph node FNAC initially. He was treated

with amphotericin B deoxycholate 1 mg/kg/day for 2 weeks without any improvement.

Culture of bone marrow was taken after 3 weeks of admission which grew M abscessus. He

was treated and began to show response after 2 weeks and significantly improved after 1

month of therapy. No relapse occurred within 9 months.

Fig. 2: Mild pus at the intramuscular

injection site with sinus

Fig. 3: Laparotomy scar showing

pus pocket on 1st visit

Fig. 4: 1st day visit - 2 spots of fluid

discharge from laparoscopy port

site

149


Clinical characteristics along with treatment offered is shown in Table I.

Discussion

NTM is a chronic granulomatous infection similar in presentation to tuberculosis but with

less morbidity. Since they do not respond completely to standard ATD, culture and DNA

sequencing are required for definite diagnosis.7 There is an increase in use of histopathology,

advance culture technique and DNA sequencing for species level diagnosis which has led to

increased reporting of NTM infections.3 The estimated incidence of NTM from different

geographical locations in India is 3.4% to 24.7%.1-10 The defined risk populations expected to

harbour NTM are immune-compromised patients including patients with HIV infection and

diabetes mellitus, pre-existing lung cavitation, old age, recent surgery or penetrating injury.7-8

The disease spectrum of NTM is divided into chronic pulmonary infections, superficial

lymphadenitis, skin and skeletal infections, and disseminated disease.8 Among HIV infected

patients, clinical presentation is nonspecific and mimics tuberculosis.7

The predominant species in India as cited by Indian studies are the rapid growers M.

abscessus and M. fortuitum. Other commonly reported species are M. intracellulare, M.

chelonae, MAC, M. kansasii, M. gordonae, and M. scrofulaceum.1-5 S Khatter et al reported a

predominance of MAC, M. abscessus and M. fortuitum in their study of an HIV infected

population.11 In our series M. abscessus was the commonest species, agreeing with previous

INDICES CASE 1 CASE 2 CASE 3 CASE 4 CASE 5 CASE 6

Predisposition Laparoscopic

surgery

Intramuscular

injection

Laparotomy

incision

Laparoscopic

surgery

HIV HIV

Complaint

duration

(months)

1.5 1 2.5 12 3 2

Presentation Persistent

discharge at

surgical site

Pus formation

at injection

site

Pus formation at

surgical site

Persistent

discharge -

surgical site

Pyrexia of

unknown origin

Pyrexia of

unknown origin

Clarithromycin

duration (days)

30 12 45 180 No No

Initial

antibiotics

received

Amoxicillin,

Ciprofloxacin

None Amikacin,

Levofloxacin

Amikacin,

Amoxicillin

Piperacillin/

Tazobactum,

Piperacillin,

Vancomycin

ATD history No No No Yes Yes Yes

Sample Pus Pus Pus Pus BM aspirate FNAC lymph

node

Species M. abscessus M.

senegalenese

M. abscessus M. abscessus MAC M. abscessus

Treatment given CL 500mg BD,

C-DS OD

L 750mg OD

CL 500mg

BD

E 800 mg OD

L 750mg OD

CL 500mg BD

C-DS OD

L 750mg OD

CL 500mg BD

A 1gm OD

C-DS OD

L 750mg OD

CL 500mg BD

R 600 mg OD

E 800 mg OD

CL 500mg

E 800 mg OD

A 1gm OD

Complete

response

(months)

2 1 3 4 1.5 1

Associated

comorbidity

none HTN. T2DM none T2DM HIV, COPD HIV

CL- Clarithromycin; L- Levofloxacin; A- Amikacin; C-DS- Cotrimoxazole-double strength; E- Ethambutol OD- Once daily; R- Rifampcin HTN- Hypertension; COPD- Chronic obstructive Pulmonary Disease ; T2DM- Type 2 Diabetes Mellitus; BD- Twice daily

Table 1: Characteristics and profile of patients infected with NTM

150


Indian data. M senegalese was an uncommon finding and did not corroborate with other

studies.

NTM only responds to rifampicin and ethambutol of the standard ATDs. Second line agents,

especially aminoglycosides, macrolides, quinolones, and other drugs - doxycycline,

sulphonamides and carbapenems - are included in the IDSA recommendations for treatment

of NTM infections. M abscessus is treated with drugs along with surgical resection and MAC

lymphadenopathy is treated with excision and drugs in non-responding cases. The ATS-IDSA

guidelines suggest a duration of treatment for 1 year for treatment of NTM infections except

for disseminated and lymph node infections caused by MAC.12,13

The cumulative outcome of NTM infections has been considered as good with appropriate

therapy and surgical intervention whenever required.2 A study from Southern India on

surgical site infection with NTM in 24 patients showed a favourable outcome in 22 cases

after appropriate antibiotics and debridement.10 Similarly our patients with post-surgical

infection had a good outcome without relapse at around 1 year. Another study by M K

Gundayada et al. on surgical site infection had a good outcome with complete cure in all

patients.8 One possible reason for these post-operative surgical site infections in the Indian

setting could be the use of 2.5% gluteraldehyde for disinfection and use of boiled water for

cleansing of instruments.10

NTM in AIDS can present as localized or disseminated disease. McCarthy et al showed a

prevalence of 2% among HIV patients group with 34% as pulmonary and 5% as disseminated

diseases.14 It sometimes present as the Immune Reconstitution Inflammatory Syndrome

(IRIS) after initiation of antiretroviral therapy (ART).15

All our patients responded well to treatment and there were no adverse drug reaction during

follow up. In this background this case series becomes important as it provides follow up

response to therapy and appropriate use of DNA sequencing of isolates in all culture positive

cases.

Conclusion

NTM are emerging infections especially in the Indian context. Skin or soft tissue infections

not responding to antibiotics and antitubercular therapy must be cultured and DNA

sequencing should be offered for specific diagnosis. Similarly, NTM should be suspected in

HIV infected persons with disseminated infection not responding to antituberculous and

fungal therapy. A prolonged course of macrolide based combination therapy generally has a

good response and outcome is excellent.

Ethical consent: Informed consent was taken from the patient as proof of their permission to

participate in the reporting.

Conflict of interest: There was no conflict of interest

References

1. Jain S, Sankar MM, Sharma N et al. High prevalence of non-tuberculous mycobacterial disease

among non-HIV infected individuals in a TB endemic country--experience from a tertiary centre

in Delhi, India. Pathog Glob Health. 2014; 108(2):118-22.

151


doi: https://doi.org/10.1179/2047773214y.0000000133

2. Desikan P, Tiwari K, Panwalkar N, et al. Public health relevance of non-tuberculous

mycobacteria among AFB positive sputa. GERMS. 2017; 7(1):10-18.

doi: https://doi.org/10.18683/germs.2017.1103

3. A. K. Maurya, V. L. Nag, S. Kant, et al, “Prevalence of nontuberculous mycobacteria among

extrapulmonary tuberculosis cases in tertiary care centers in northern India. BioMed Research

International. 2015, 2015; Article ID 465403. doi: https://doi.org/10.1155/2015/465403

4. Tapti S, Parijat D, Tirthankar S. Epidemiology and drug resistance of non-tuberculous

mycobacteria in India: a mini review. Biostat Biometrics Open Acc J. 2017; 1(4):555568

doi: https://doi.org/10.19080/bboaj.2017.01.555568

5. Gopinath K, Singh S. Non-tuberculous mycobacteria in TB-endemic countries: Are we neglecting

the danger? PLoS Negl Trop Dis 2010; 4(4): e615.


6. Shah A K, Gambhir R. P. S., Hazra N et al. Non- tuberculous mycobacteria in surgical wounds- a

rising cause of concern? Indian J Surg 2010; 72:206–210 doi: https://doi.org/10.1007/s12262-

010-0057-9

7. Umrao J, Singh D, Zia A, et al. Prevalence and species spectrum of both pulmonary and

extrapulmonary nontuberculous mycobacteria isolates at a tertiary care center. Int J

Mycobacteriol. 2016; 5(3):288-293. doi: https://doi.org/10.1016/j.ijmyco.2016.06.008

8. Gundavda MK, Patil HG, Agashe VM, et al. Nontuberculous mycobacterial infection of the

musculoskeletal system in immunocompetent hosts. Indian J Orthop 2017; 51:205-12.

doi: 10.4103/0019-5413.201718

9. Karak K, Bhattacharyya S, Majumdar S, et al. Pulmonary infection caused by Mycobacteria other

than M. tuberculosis in and around Calcutta. Indian J Pathol Microbiol. 1996; 39(2):131-4.

PubMed PMID: 9401242.

10. Krishnappa R, Samrasam I. Atypical mycobacterial infection in post laparoscopy surgical

wounds: our observations and review of literature Int Surg J. 2017;4(9):2943-2946

doi: https://doi.org/10.18203/2349-2902.isj20173875

11. Khatter S, Singh UB, Arora J, et al. Mycobacterial infections in human immuno-deficiency virus

seropositive patients: role of non-tuberculous mycobacteria. Indian J Tuberc. 2008; 55(1):28-33.

PMID: 18361308

12. Griffith DE., Aksamit T., Brown-Elliott B.A., et al An official ATS/IDSA statement: diagnosis,

treatment, and prevention of nontuberculous mycobacterial diseases, Am. J. Respir. Crit. Care

Med. 2007; 175:367–416. doi: https://doi.org/10.1164/rccm.200604-571st

13. Stevens DL, Bisno AL, Chambers HF et al Infectious Diseases Society of America. Practice

guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by

the Infectious Diseases Society of America. Clin Infect Dis. 2015; 59(2):e10-52.

doi: https://doi.org/10.1093/cid/civ113

14. McCarthy KD, Cain KP, Winthrop KL, et al. Nontuberculous mycobacterial disease in patients

with HIV in Southeast Asia. Am J Respir Crit Care Med. 2012; 185(9):981-8.

doi: https://doi.org/10.1164/rccm.201107-1327oc

15. Shah A, Stani A, Adalja M, et al. Immune reconstitution disease or mycobacteria other than

tuberculosis or both: A dilemma in a patient of AIDS. Indian J Sex Transm Dis AIDS. 2012; 33

(1):44-6. doi: https://doi.org/10.4103/0253-7184.93824

https://doi.org/10.1179/2047773214y.0000000133

152

________________________________________

1 Department of Mycology, Medical Research Institute, Colombo 8, Sri Lanka 2 Oromaxillary Facial Unit, Teaching Hospital, Kegalle, Sri Lanka 3 Department of Oral Pathology, Faculty of Dental Sciences, University of Peradeniya, Sri Lanka

Address for correspondence: Dr. Naamal Jayawardena, Department of Mycology, Medical Research Institute,

Colombo 8, Sri Lanka. Telephone: +94773074599 Email: [email protected]

https://orcid.org/0000-0003-1928-8086

Received 9 April 2019 and revised version accepted 20 July 2019

This an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted

use, distribution, and reproduction in any medium, provided the original author and source are credited.


Case Report

Histoplasmosis in Sri Lanka - a masquerader in a strange land:

A Case Report

MN Jayawardena1, K. Siriwardane2, P. Jayasooriya3, S Sigera1,

PI Jayasekera1



Abstract

We present a patient with an oral mucosal ulcer who was diagnosed with disseminated

histoplasmosis. This fungal infection is endemic in the United States, and thus may be not

considered in the differential diagnosis of oral ulcers in Sri Lanka. Furthermore, it may mimic

many common diseases found in Sri Lanka. It is therefore important to be aware of this entity,

since it is potentially curable if diagnosed and treated early.

Key Words: Histoplasmosis, Sri Lanka, Histoplasma capsulatum

Introduction

Histoplasma capsulatum is a soil inhabiting fungus, which causes infections most often in the

immunocompromised host. Most cases are reported in the Midwest and Southeast United States,

but Sri Lanka is by no means free of this disease. This fungus is acquired by inhalation and

classically forms caseating and non-caseating granulomas. It is important to consider this entity,

as it mimics many common diseases, and is potentially curable if diagnosed and treated early.

Here, we report a case of probable disseminated histoplasmosis, diagnosed in early 2017.

Case history

A 66-year-old retired labourer presented to the Oromaxillary Facial Unit of Teaching Hospital

Kegalle, complaining of an oral ulcer of six-months duration (Figure 1). He was a diabetic, well-

http://dx.doi.org/

153


controlled on oral-hypoglycemics, a smoker and betel chewer. During this period, he also

complained of low-grade fever, dysphagia and weight loss. There was a pus discharging mucosal

ulcer in the mid palatal region extending to the palatal aspect of the left anterior maxilla. Systemic

examination was normal and there was no cervical

lymphadenopathy. Full blood counts and liver

function tests were normal. Moderately elevated

renal functions and an elevated sedimentation rate

(55mm 1st hour) were detected.

Samples following incisional biopsy of the alveolar

ridge were dispatched for histology, suspecting oral

squamous cell carcinoma. The histology, however,

showed presence of yeast forms, which, following

fungal staining, was suggestive of histoplasmosis

(Figure 2). Fungal studies confirmed the presence of

Histoplasma capsulatum, with yeast forms seen in the direct smear (Figure 3) and thermal

dimorphism demonstrated on culture. The patient was started on oral itraconazole 200mg twice

daily, with monitoring of liver enzymes. He showed good response, with the oral ulcer regressing

over time.

His retroviral screening was negative. As the chest X

ray, ultrasound scan and non-contrast CT chest revealed

multiple minute opacities in bilateral lung fields, the

patient was referred to a chest physician, even though

the patient didn’t complain of any respiratory

symptoms. Bronchoscopy was performed and brushing

and washing samples were sent for fungal studies. The direct smear revealed yeast forms, but

cultures were sterile.

After completion of 6 weeks of itraconazole therapy, the patient’s oral ulcers resolved with no

significant drug-related adverse effects. However, the patient passed away from unrelated causes

a few months later. The timeline of the patient’s course is shown in Figure 4.

Figure 1: Oral ulcer in upper palate

at initial presentation

Figure 2: Histoplasma yeast forms at

microscopy x20 stained with Grocott

methanamine

Figure 3: Microscopy x40 of

culture stained with Lactophenol

cotton blue showing Histoplasma

capsulatum tuberculate

macroconidia

154


Discussion

Histoplasmosis has been documented worldwide1, while Sri Lanka first reported it in 1975.2 It has

previously been found that 4% of healthy adults and 6.3% of those with chronic lung disease in

Sri Lanka test positive for the histoplasma skin test.3 So far, five indigenous cases of

histoplasmosis have been reported in Sri Lanka.2-7 Four of these patients presented with oral ulcers

and the other presented with features of disseminated histoplasmosis with hepatosplenomegaly,

fever and generalized lymphadenopathy. One was treated for non-Hodgkin’s lymphoma and had

previously been employed in Saudi Arabia3, while another was an elderly local.5 The third was a

young, previously well female of European origin.6 The fourth was a 53-year-old farmer from

Batticaloa, who had an accidental injury to the same area in the oral cavity two years prior caused

‘by the stick used to drive the buffaloes while ploughing the fields’.2 The fifth was a 59 year old

farmer from Akuressa, a poorly-controlled diabetic, betel chewer and illicit liquor consumer.7

Clinically, histoplasmosis may manifest as pulmonary or disseminated forms. The disseminated

form manifests itself when haematogenous spread occurs through parasitized macrophages. Foci

of viable organisms can remain in various organs, and get reactivated many years later, as they are

not completely killed by the immune system.8

Certain patient groups are vulnerable to develop acute dissemination of the organism during

periods of low cell mediated immunity. These include patients with haematological malignancies,

transplant recipients, those on corticosteroids and tumour necrosis factor antagonists, HIV, infants

and the elderly. These patients suffer from a slowly progressive and usually fatal form of the

disease, unless effectively treated.8 It has been found that those over 55 years of age are at risk for

disseminated infection.9 In our patient, the only risk factor of note was his age, as he was not

suffering from any of the above conditions and HIV screening was negative.

Mucous membrane ulceration in the gingival and buccal mucosa or tongue may prompt the

clinician to consider oral squamous cell carcinoma, as in our patient. Other sites involved in

disseminated histoplasmosis may include lips, pharynx and larynx, well as skin ulcers and nodules.

Figure 4: Timeline of the patient’s course

155


Almost any system can be affected. In any patient with mucocutaneous lesions due to

histoplasmosis, disseminated infection should always be considered, as isolated oral lesions are

very infrequent.8 We therefore presumed this patient was suffering from disseminated

histoplasmosis, due to the presence of the oral lesions and asymptomatic granulomas in the chest.

Chronic pulmonary histoplasmosis may present similarly to pulmonary tuberculosis. Most patients

have pre-existing lung pathology such as chronic obstructive pulmonary disease.8

Histology and fungal cultures of biopsy samples are the gold standard for the diagnosis of

histoplasmosis. In addition, antigen testing and serology are sensitive, have a shorter turn-around-

time, and can be easily interpreted by the clinician.10 H. capsulatum antigen detection in serum

and urine is useful, specially to monitor treatment response.8 Although molecular methods are

available, none are FDA approved for routine clinical use as yet.10

Conclusion

Due to its uncommon nature, histoplasmosis is possibly under-reported in Sri Lanka. A high index

of suspicion is needed, as the identification of this organism requires specialized laboratory tests

and prolonged incubation.

Conflicts of interest: Authors declare that there are no conflicts of interest.

References

1. Histoplasma capsulatum (Histoplasmosis) George S. Deepe, Jr. In : Mandell, Douglas & Benett's

Principles and practice of infectious diseases. Eigth edition 2015. Volume 1. 2949-2962. Elsevier

2. Jayaweera FRB, Attapatu M, Fonseka I, et al. Histoplasmosis of the buccal cavity. Ceylon Med

J; 1975; 20(1):45-47 No doi

3. Karunanayake L. Samaraweera I.P., de Silva K., et al. Isolation of Histoplasma capsulatum from an

immunocompromised patient. Bulletin of the Annual Academic Sessions of the Kandy Society of

Medicine (KSM). 2009; 31:188-189 No doi

4. Randhawa HS, Gugnani HC,. Occurrence of histoplasmosis in the Indian sub-continent: An overview

and update. J Med Res Prac; 2018; 7(3):71–83 doi: https://doi.org/10.20936/jmrp/07/03/02

5. Sigera LSM., Gunawardane SR, Malkanthi MA, et al. Histoplasma capsulatum caused a localized

tongue ulcer in a non-HIV patient - a case from nonendemic country. Ear, Nose & Throat Journal

2019; Epub; 1–3. doi: 10.1177/0145561319844246.

6. Harten P, Euler HH, Wolf E, et al. Disseminated histoplasmosis in a non-immunocompromised host.

Clin Investig. 1994; 72(11):878–882. doi: http://dx.doi.org/10.1007/BF00190745

7. Vidanagama D, Dias DK, Wijayaratne WMDGB, et al. Histoplasmosis of the oral cavity. Bull Sri Lanka

College Microbiol. 2010; 8:27. No doi

8. Kauffman CA. Histoplasmosis: A clinical and laboratory update. Clin Microbiol Rev. 2007; 20(1):115–

132. doi: http://dx.doi.org/10.1128/CMR.00027-06

9. Wheat LJ, Slama TG, Norton JA, et al. Risk factors for disseminated or fatal histoplasmosis. Analysis

of a large urban outbreak. Ann Intern Med. 1982; 96(2):159-63. doi: http://dx.doi.org/10.7326/0003-

4819-96-2-159

10. Azar MM, Hage CA. Laboratory diagnostics for histoplasmosis. J Clin Microbiol 2017; 55:1612–1620.

doi: https://doi.org/10.1128/JCM .02430-16.

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156

________________________________________

1Colombo South Teaching Hospital, Kalubowila, Sri Lanka.

Address for correspondence: Dr. Selladurai Pirasath, Colombo South Teaching Hospital,

Kalubowila, Sri Lanka. Telephone: +94775122995 Email: [email protected]

https://orcid.org/0000-0002-4274-4919

Received 9 July 2019 and revised version accepted 2 October 2019

This an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are

credited.


Case Report

Cholestatic hepatitis with ciprofloxacin therapy:

A Case Report

ARM Misthaq1, S Pirasath1,

ND Jayaweerabandara1, AGH Sugathapala1



Abstract

Ciprofloxacin has generally been well-tolerated and is the commonly prescribed

fluoroquinolone antibiotic for treatment of urinary tract and gastrointestinal

infection. The adverse effects on the liver usually range from asymptomatic

elevation of liver enzymes to fulminant hepatitis. However, acute fulminant

hepatitis and cholestatic hepatitis are reported rarely in literature. Here, we report a

case of ciprofloxacin induced cholestatic hepatitis in a 52 year old woman

following intravenous ciprofloxacin for acute gastroenteritis.

Keywords: Ciprofloxacin, Cholestasis, Hepatitis, Toxicity

Introduction

Ciprofloxacin is a commonly prescribed fluoroquinolone antibiotic that has broad

antimicrobial coverage and high oral bioavailability. It is commonly used in the

treatment of urinary tract and gastro-intestinal infections due to its activity against

both Gram-positive and Gram-negative bacteria.1 It has associated severe adverse

effects including tendon rupture, Stevens-Johnson syndrome, interstitial nephritis,

and liver injury. Liver injury is usually limited to an asymptomatic elevation in liver

enzymes.2 However, a broad spectrum of drug-induced liver diseases ranging from

an asymptomatic elevation in liver enzymes and hepatitis to fulminant hepatic

failure have been reported.2 Acute fulminant hepatitis and cholestatic hepatitis are

reported rarely in the literature.3 Ciprofloxacin at times causes acute liver injury

http://dx.doi.org/

157


within a period of two days to two weeks following initiation of treatment. Having

a high index of suspicion is important for clinicians to recognize and discontinue

any medication suspected of producing such reactions. Here, we report a case of

cholestasis in a patient treated with ciprofloxacin for acute gastroenteritis. To the

best of our knowledge there is no previous report of ciprofloxacin-induced

cholestatic hepatitis in Sri Lanka.

Case report

A 52 year old hypertensive woman presented with acute onset of fever and severe

watery diarrhea of three days duration. She had not passed urine for 24 hours. She

had no other systemic symptoms and no history of substance abuse, herbal

medication or drug overdose prior to admission and had no family history of liver

cell disease.

On examination, she was severely dehydrated with a pulse rate of 120/min and low

volume. Her blood pressure was 70/40mmHg. The rest of the systemic examination

was normal. Her complete blood count showed marked leukocytosis (18,000/mm3)

with predominant neutrophils (90%). Her inflammatory markers were high

(ESR:80mm/1st hour, CRP:490 mg/dL) suggestive of bacterial gastroenteritis. Her

serum creatinine was 610 μmol/L (normal value:79-118 μmol/L) and blood urea

was 60mg/dL (normal value:8-25 mg/dL). Her serum electrolytes (serum

sodium:135mmol/dL, serum potassium:4.5mmol/dL) and liver function tests

(serum aspartate aminotransferase (AST):25 U/L, serum alanine aminotransferase

(ALT):35 units/L, total bilirubin:17 μmol/L, and alkaline phosphatase (ALP):49

units/L) were normal. Her blood, urine and stool cultures were negative.

The patient was initially managed with boluses of normal saline, oral rehydration

salt and antiemetic and was stabilized with initial treatment. Subsequently she was

treated with renal dose of intravenous ciprofloxacin 200mg twice daily following

12 hours of admission due to leucocytosis with high inflammatory markers. She

clinically improved with settling of fever and reduction of inflammatory markers.

However, she was found to have jaundice on the fifth day of admission without any

evidence of obstructive jaundice. She was deeply icteric. Her laboratory

investigations showed a total bilirubin of 147 μmol/L, direct bilirubin of 87 μmol/L,

AST and ALT of 254 U/L and 566 units/L respectively and ALP of 149 units/L.

Other metabolic and hematological parameters were normal on work up.

A complete work up of investigations to exclude other possible causes of acute viral

hepatitis (Hepatitis A antibody, Hepatitis B surface antigen, Hepatitis C antibody,

Hepatitis E antibody), urine toxicology screening and autoimmune markers

(antinuclear antibody) were negative. Her radiological imaging was negative.

The liver injury secondary to use of ciprofloxacin was made because her symptoms

started on the 5th day of ciprofloxacin therapy. Therefore, ciprofloxacin was

stopped. The patient was treated with supportive therapy with hydration and anti-

emetics as needed. Subsequently the patient's symptoms resolved over the next five

158


days with improvement of her liver enzyme levels. Her liver function tests

normalized gradually with cessation of ciprofloxacin and completely recovered

with normal limits within two weeks time (total bilirubin:15 μmol/L, AST:34 U/L,

ALT:26 units/L, and ALP:59 units/L). Timeline of the clinical course is given

below.

The onset of symptoms following ciprofloxacin use coupled with the pattern of

cholestatic picture of liver pathology and the normalization of liver function tests

following withdrawal of ciprofloxacin therapy all pointed towards the diagnosis of

ciprofloxacin induced acute hepatitis.

Discussion

Ciprofloxacin related liver injury ranges from asymptomatic elevation of liver

enzymes to fulminant hepatitis.2 Ciprofloxacin is absorbed well in the

gastrointestinal tract and metabolized in the liver and then excreted by the kidneys.

It causes 1-3% self-limited transient elevation of liver enzymes. Jaundice with

hepatomegaly may be noted on clinical examination. Cholestatic hepatitis is rarely

reported in the literature.3 The pathogenesis related to liver injury is unknown.

However, an idiosyncratic reaction resulting in hepatocellular necrosis has been

described.3 The type of liver injury could be differentiated from the pattern of

Day 1

Fever with

watery diarrhoea

for 3 days

Day 4

Clinical recovery

with subsiding fever

and inflammatory

markers

Day 8

Ciprofloxacin induced

cholestatic hepatitis

Other possible

aetiologies excluded

Ciprofloxacin withdrawn

Day 2

Acute bacterial

gastroenteritis with

acute kidney injury

Ciprofloxacin started

Day 6

Jaundice on day 5

Abnormal liver

function tests

Cholestatic hepatitis

2 weeks

Complete

recovery

Liver function

returned to

baseline levels

Timeline for progression of disease

159


elevation of liver enzymes. The elevation of ALP more than two times or ALT/ALP

ratio less than 2 indicates cholestatic hepatitis.4

The cholestatic hepatitis associated with markedly elevated liver enzymes was

described in our patient. There are no specific tests to establish the diagnosis of

drug induced hepatitis which is usually a diagnosis of exclusion. The onset of

symptoms following ciprofloxacin therapy should alert the clinician and needs

prompt discontinuation of the drug and suggest further evaluation. Ciprofloxacin

induced hepatitis is usually nonfatal and self-limiting following discontinuation.

One fatal case has been reported in the literature.5 A high clinical suspicion of a

drug reaction is important to discontinue the drug immediately and prevent further

adverse reactions. Prerenal acute kidney injury due to gastroenteritis had no impact

on the hepatic outcome because the initial liver function tests were normal.

Our patient developed ciprofloxacin induced liver injury on the 5th day of initiation

of drug therapy. The patient’s liver biochemical profile returned to normal in 2

weeks following the stopping of ciprofloxacin. A complete negative work up for

the possible causes of acute viral hepatitis, urine toxicology screening, autoimmune

markers and radiological imaging favored the diagnosis of ciprofloxacin induced

hepatitis in our patient.

This case provides evidence that ciprofloxacin can cause liver injury at therapeutic

doses. Ciprofloxacin can cause severe hepatitis and physicians should be aware of

this possible drug reaction.

Conflicts of interest: There are no conflicts of interest.

Ethics: Informed written consent was obtained from the patient for publication of

this case report.

References 1. Bertino JJ, Fish D. The safety profile of the fluoroquinolones. Clin Ther 2000; 22: 798-

817. http://dx.doi.org/10.3390/antibiotics6040026.

2. Chalasani N, Fontana RJ, Bonkovsky HL, et al. Drug Induced Liver Injury Network

(DILIN): Causes, clinical features, and outcomes from a prospective study of drug-

induced liver injury in the United States. Gastroenterol 2008; 135: 1924–1934.

https://doi.org/10.1053/j.gastro.2008.09.011

3. Cholongitas E, Georgousaki C, Spyrou S, Dasenaki M. Ciprofloxacin-induced acute

cholestatic hepatitis. Ann Hepatol 2009; 8: 400–401.

http://annalsofhepatology.com/revista/numeros/2009/HP94-20-Ciprofloxacin.pdf

4. Andrade RJ. Spanish group for the study of drug-induced liver disease: Drug-induced

liver injury: an analysis of 461 incidences submitted to the Spanish registry over a 10-

year period. Gastroenterol 2005; 129:512-21.

https://doi:10.1053/j.gastro.2005.05.006

5. Unger C, Al-Jashaami LS. Ciprofloxacin exposure leading to fatal hepatotoxicity: An

unusual correlation. Am J Case Rep 2016:17: 676–681.

https://dx.doi.org/10.12659%2FAJCR.899080.

160

________________________________________

1Department of Medicine, Kapit Hospital, Ministry of Health, 96800 Kapit, Sarawak, Malaysia

Address for correspondence: Dr Chee Yik Chang, Department of Medicine, Kapit Hospital, Ministry of

Health, 96800 Kapit, Sarawak, Malaysia. Telephone: +60182856630 Email: [email protected]

https://orcid.org/0000-0002-3104-8168

Received 22 July 2019 and revised version accepted 10 September 2019



Case Report

Melioidosis presenting with periorbital cellulitis and eyelid abscess in

Sarawak, Malaysian Borneo - A Case Report

Chee Yik Chang1


DOI: http://dx.doi.org/ 10.4038/sljid.v9i2.8259

Abstract

Melioidosis is an infectious disease caused by the Gram-negative bacillus

Burkholderia pseudomallei and presents with a broad spectrum of clinical

manifestations and organ involvement. Ocular manifestation in melioidosis is rare. We

present a case of periorbital cellulitis and eyelid abscess caused by B. pseudomallei in

a diabetic patient successfully treated with antibiotic and surgical drainage.

Keywords: Melioidosis, Burkholderia pseudomallei, Periorbital cellulitis, Eyelid abscess

Introduction

Melioidosis is caused by Burkholderia pseudomallei, a Gram negative bacillus found

in soil and water. It is an endemic disease in northern Australia and Southeast Asian

countries, especially Thailand and Malaysia. Despite the availability of effective

antimicrobial therapy in the treatment of melioidosis, the mortality rate remains high.1

Melioidosis is difficult to diagnose because of its diverse clinical presentation and can

affect almost any organ. The manifestations of melioidosis are highly variable,

ranging from pneumonia, septic arthritis, liver or splenic abscesses, pericardium and

parapharyngeal space abscesses, skin abscesses, pan ophthalmitis to fatal

septicaemia.2 Ocular involvement in melioidosis is rare and the prevalence was

estimated at 0.49-1.02%.3 A 23-year retrospective review of 16 cases of ocular

involvement in melioidosis in Thailand revealed orbital cellulitis as the most common

manifestation (7 cases) followed by endophthalmitis (4 cases), preseptal cellulitis (2

cases), pan ophthalmitis (2 cases), and pan uveitis (1 case).3 Melioidosis can also

present with lid abscess in isolation without orbital cellulitis.4

Case Presentation

A 58-year-old male farmer presented in May 2018 to Kapit Hospital, Sarawak with

fever and right eye swelling of 1 week duration. His past medical history included

bacteraemic melioidosis which was diagnosed in 2016. At that time, he received

http://dx.doi.org/

161


intravenous ceftazidime as intensive phase therapy, followed by eradication therapy

with oral trimethoprim-sulfamethoxazole. He was also diagnosed with type 2 diabetes

mellitus during that hospitalization and started on oral anti-diabetic medications.

However, he had defaulted on his medications for 1 year.

Upon arrival to the hospital, his general condition was stable and the vital signs were

normal. The random blood sugar was 31.2 mmol/L. There was periorbital swelling of

the right eye with swelling and erythema of the upper and lower eyelids. The

conjunctiva appeared normal. The visual acuity of the right eye was 6/15 while vision

of the left eye was reduced to finger counting. The remainder of systemic examination

was unremarkable.

Haematological analysis showed a haemoglobin of 15.6 g/dL, white blood cell count of

7.4 x 103/μL and platelet count of 162 x 103/μL. His renal and liver function tests were

within normal limits. The chest radiograph and abdominal ultrasonography did not

reveal any abnormality. Our initial working diagnosis was right periorbital cellulitis.

He was started on intravenous ampicillin-sulbactam 1.5 gram 8-hourly. However,

persistent fever was observed over the next 3 days. At this point, melioidosis was

suspected in view of multiple risk factors including diabetes mellitus, occupational

exposure and previous history of melioidosis. The antibiotic regime was escalated to

intravenous ceftazidime 2 gram 8-hourly to treat for melioidosis.

He was also referred to the ophthalmologist for an opinion. Computed tomography

(CT) of the orbit showed right periorbital cellulitis (Fig. 1).

Detailed ophthalmic

examination showed mild

non-proliferative diabetic

retinopathy in both eyes and

increased cup-to-disc ratio

of the left eye. As a result,

floater only vitrectomy of

the left eye was done by the

ophthalmology team.

On day 8 of hospitalization,

he developed an abscess

over the right upper eyelid.

Incision and drainage of the

abscess was performed in

which copious amounts of

pus was drained and sent for

microbiological analysis.

The cultures of blood and

pus from the eyelid abscess

yielded B. pseudomallei,

grown on modified Ashdown selective culture medium. The organism was susceptible

to ceftazidime, amoxicillin-clavulanic acid and trimethoprim-sulfamethoxazole. The

identification of B. pseudomallei was confirmed by a positive PCR assay specific for

the detection of B. pseudomallei.

a

b

Fig. 1 Axial CT scan of orbit

(a) right periorbital swelling with soft tissue thickening

(b) increased attenuation of fat planes of right periorbital area

while bilateral globes, extraocular muscles and optic nerve are

preserved.

162


He completed a 2-week course of intravenous ceftazidime. The fever completely

settled on day 10 of hospitalization and the right eye swelling progressively reduced.

His blood glucose control was good while on insulin therapy. He completed

eradication therapy consisting of trimethoprim-sulfamethoxazole and doxycycline for

20 weeks. During a follow-up review at the medical clinic, he was well and showed

no signs of disease recurrence. The right eye swelling had totally resolved, and visual

acuity returned to baseline levels.

Timeline of clinical progression

Time Events Actions/treatments

Day 1 Admission for fever and right eye

swelling for 1 week; treated as right

periorbital cellulitis

IV ampicillin-sulbactam 1.5 gram

8-hourly

Day 3 Persistent fever and suspected

melioidosis

IV ceftazidime 2 gram 8-hourly

Day 4 CT orbit showed right periorbital

cellulitis

Co-managed by ophthalmology

team

Day 5 Blood culture grew B. pseudomallei

Day 8 Appearance of right eyelid abscess

Incision and drainage (pus culture

grew B. pseudomallei)

Day 10 Resolution of fever and reducing right

eye swelling

Antibiotic continued

Day 14 Completed IV ceftazidime for 14 days Discharged home well with

trimethoprim-sulfamethoxazole

and doxycycline

Discussion

Melioidosis can present with a wide spectrum of clinical presentations. Pneumonia was

the principal presentation of melioidosis in approximately half of the cases. Less

common presentations include genitourinary infection, skin infection, bacteraemia

without evident focus, septic arthritis or osteomyelitis and neurological melioidosis.5

Ocular manifestation in melioidosis is rare. There have been several case reports

previously on corneal ulcers, orbital cellulitis and endophthalmitis caused by B.

Pseudomallei. 6-8 Melioidosis presenting with periorbital cellulitis and eyelid abscess

has not been reported previously.

Periorbital cellulitis, also known as preseptal cellulitis is an infection of the eyelid and

superficial periorbital soft tissues without the involvement of the globe and orbit.9

Patients with periorbital cellulitis generally do not require surgical intervention except

in cases of eyelid abscess where drainage of abscess is recommended in addition to

antibiotic treatment.9 Culture of the material is important to confirm the diagnosis and

as a guide to appropriate antibiotic therapy.10

There are 3 modes of acquisition of B. pseudomallei which could result in melioidosis

infection, namely inhalation, ingestion, and inoculation.2 The patient described in this

case was a farmer who had constant exposure to soil or water in which this organism

is found. We postulated that the most probable mode of acquisition was through direct

inoculation into the affected eye causing primary ocular melioidosis and later, blood

163


stream infection. This is consistent with the observation that most cases of ocular

melioidosis are associated with B. pseudomallei bacteraemia, as reported by

Yaisawang et al.3

Early diagnosis and prompt treatment are crucial for a favourable outcome. Periorbital

cellulitis, if not treated promptly, can extend posteriorly into the orbit causing orbital

cellulitis, subperiosteal abscess or orbital abscess. These would potentially lead to

significant visual and central nervous system complications.9 In this case, our patient

achieved resolution of periorbital cellulitis and eyelid abscess without any long term

ophthalmic complication following early diagnosis of melioidosis, effective antibiotic

therapy and surgical drainage.

Conclusion

Diagnosis of melioidosis should be considered in patients who present with periorbital

cellulitis or eyelid abscess in areas where melioidosis is endemic. Surgical drainage of

the abscess is an important part of management besides standard antibiotic treatment.

Acknowledgements

I would like to thank the Director General of Health Malaysia for his permission to

publish this article. The author thanks the Director of Kapit Hospital, Dr Hii King

Ching for her guidance and support, Dr Tan Li Mun, Ophthalmologist at Sibu Hospital

for her expert opinion, and all staff of Kapit and Sibu Hospitals involved in the care of

this patient.

Conflict of interest: The author declares that there are no conflicts of interest

regarding the publication of this paper.

Consent for publication: Written informed consent for publication of the clinical

details and clinical images was obtained from the patient.

References

1. Wiersinga WJ, van der Poll T, White NJ, et al. Melioidosis: insights into the

pathogenicity of Burkholderia pseudomallei. Nat Rev Microbiol 2006; 4(4):272–82.

doi:https://doi.org/038/nrmicro1385

2. Cheng AC, Currie BJ. Melioidosis: epidemiology, pathophysiology, and management.

Clin Microbiol Rev 2005; 18(2):383–416.

doi: https://doi.org/10.1128/CMR.18.2.383-416.2005

3. Yaisawang S, Asawaphureekorn S, Chetchotisakd P, et al. Ocular involvement in

melioidosis: a 23-year retrospective review. J Ophthalmic Inflamm Infect 2018; 8(1):5.

doi: http://doi.org/10.1186/s12348-018-0147-6

4. Wadwekar B, Suresh Ninan R, Bhat S, et al. Lid abscess: An unusual presentation of

melioidosis. AMJ 2018; 11(6):322–5.

doi:https://doi.org/10.21767/AMJ.2017.2809

5. Currie BJ, Ward L, Cheng AC. The epidemiology and clinical spectrum of melioidosis:

540 cases from the 20 year Darwin prospective study. PLoS Negl Trop Dis 2010;

4(11):e900. doi: https://doi.org/10.1371/journal.pntd.0000900

6. Siripanthong S, Teerapantuwat S, Prugsanusak W, et al. Corneal Ulcer caused by

Pseudomonas pseudomallei: Report of Three Cases. Clin Infect Dis 1991; 13(2):335–7.

doi: https://doi.org/10.1093/clinids/13.2.335


https://doi.org/10.1186/s12348-018-0147-6

https://doi.org/10.1093/clinids/13.2.335

164


7. Wong PK, Ng PH. Melioidosis presenting with orbital cellulitis. Singapore Med J 1996;

37(2):220–1. URL: https://www.ncbi.nlm.nih.gov/pubmed/8942270

8. Chen KJ, Sun MH, Hou CH, et al. Burkholderia pseudomallei Endophthalmitis. J Clin

Microbiol 2007; 45(12):4073-4. doi: https://doi.org/10.1128/JCM.01467-07

9. Lee S, Yen MT. Management of preseptal and orbital cellulitis. Saudi J Ophthalmol

2011; 25(1):21–9. doi: https://doi.org/10.1016/J.SJOPT.2010.10.004

10. Inglis TJJ, Rolim DB, Rodriguez JLN. Clinical guideline for diagnosis and management

of melioidosis. Rev Inst Med Trop Sao Paulo 2006; 48(1):1–4. doi: https://doi.org/ 10.1590/S0036-46652006000100001

https://doi.org/10.1590/S0036-46652006000100001

https://doi.org/10.1590/S0036-46652006000100001

165

________________________________________

1Sri Jayewardenepura General Hospital, Sri Lanka 2 Asiri Medical Hospital:181, Kirula road, Narahenpita, Colombo 5

Address for correspondence: Dr. M. Alles, Sri Jayewardenepura General Hospital, Sri Lanka.

Telephone: +94774307125 Email: [email protected] https://orcid.org/0000-0003-3718-2146

Received 2 June 2019 and revised version accepted 19 October 2019



Case Report

Group B streptococcal infective endocarditis in a young non-pregnant female

with rheumatic heart disease - A Case Report

M Alles1, K Jayatilleke1, S Chandrasiri2, S Pathirage2, KVC Janaka1,

J Herath1, N Amarasena1, D Wariyapola1



Abstract

Group B Streptococcus (GBS) is a rare cause of infective endocarditis in adults associated with a

high mortality rate due to the frequent occurrence of local and systemic complications. Here we

report a case of infective endocarditis (IE) in a young non-pregnant female with a history of

rheumatic heart disease (RHD) who presented with a short history of fever, shortness of breath

and constitutional symptoms. GBS was isolated from a single blood culture along with

echocardiographic findings of a cardiac vegetation and ophthalmologic findings of a Roth spot.

Based on the Modified Duke Criteria, a definitive diagnosis of infective endocarditis was made.

She was treated with a prolonged course of intravenous (IV) ceftriaxone, with gentamicin being

added to the regimen, following which she made a complete recovery.

Keywords: Group B Streptococcus, Infective endocarditis, Roth spot, Bacteraemia, Rheumatic

heart disease

Introduction

GBS is a known colonizer of the female genital tract1, with a potential to cause severe infection

in newborns and pregnant women.2 However, cases of invasive GBS infection among elderly

adults are increasingly being reported.3 Endocarditis occurs in a proportion of them resulting in a

high mortality rate4 due to frequent complications.5

Case report

A 32 year old female presented with a one day history of fever with chills, cough, headache and

vomiting. Shortly after admission to hospital, she developed shortness of breath and visual

blurring in her right eye. She had a history of RHD causing mitral stenosis, which was diagnosed


http://dx.doi.org/

166


during the 3rd trimester of pregnancy. However, antibiotic prophylaxis was not given. Delivery

was via elective caesarian section (with no history of prolonged rupture of membranes or

prolonged labor) 7 months prior to this presentation, without any unfavorable outcomes for the

mother or baby. She was not screened for GBS vaginal colonization during her pregnancy. The

rest of her past medical and surgical history was unremarkable.

On examination she was ill looking and febrile, with a blood pressure of 120/80 mmHg and a

pulse rate of 92 beats per minute. Investigations showed an elevated white blood cell (WBC)

count (13.6x109/L) with 92.8% neutrophils and C reactive protein level (CRP) of 204 mg/L. A

single blood culture yielded Gram positive cocci in chains resembling streptococci after 8 hours

of incubation. The organism was identified as Lancefield Group B streptococci (Streptococcus

agalactiae) and its antibiotic sensitivity pattern was assessed via BD Phoenix (Becton, Dickinson

and Company, USA). Its minimum inhibitory concentration (MIC) for penicillin was <= 0.03125

μg/ml.

The patient was initially managed as a left lower lobar and right bronchopneumonia (with

suggestive X ray features) and treated with piperacillin/tazobactam, levofloxacin and

vancomycin. A provisional diagnosis of IE was made after obtaining the blood culture report and

the patient was further investigated as described below.

Following an unremarkable bedside transthoracic echocardiogram (TTE), a repeat TTE done two

days later by the same cardiologist at the Cardiology Department showed a vegetation measuring

2-3 mm nested in the anterior aspect of the anterior mitral valve leaflet. No complications of

endocarditis such as valve perforation or abscesses were noted. Ophthalmological examination

revealed a Roth spot in the macular region of her right eye (which caused visual blurring) (Fig.

1). A CT scan of the brain revealed no abnormalities.

According to the Modified Duke Criteria6, a definitive

diagnosis of IE was made on day 5 of illness based on

the presence of one major criterion (cardiac vegetation)

and four minor criteria (predisposition due to mitral

stenosis, fever > 380C, immunological phenomenon of a

Roth spot and a single positive blood culture). As per

the current guidelines6, on the same day the patient was

started on IV ceftriaxone 2g daily, to be continued for 4

weeks, with IV gentamicin 3mg/kg/day as a daily dose

during the first 2 weeks.

A repeat blood culture taken 6 days after the initial

positive culture and following 4 days of treatment with

ceftriaxone was negative. A repeat TTE done 2 weeks

after commencing treatment showed an improvement of

the previously noted vegetation. The patient was

Fig.1: Roth spot in the macular region

of the right eye

167


discharged in order to complete the final two weeks of IV antimicrobial therapy as an outpatient.

On discharge her WBC count was 5.9x109/L and CRP was 13mg/ml. However, 5 days after

discharge she was readmitted, complaining of fever. A blood culture done during that admission

was negative and a repeat TTE found the previously noted oscillating mass on the anterior mitral

valve leaflet to be minimal (1.5mm) with no valve distortion or complications. WBC count was

normal (7.8x109/L) and CRP was 8mg/ml. The patient was offered a transoesophageal

echocardiogram (TOE) for which she refused consent. Taking these into consideration, the

treatment duration of IV ceftriaxone was extended by a further 2 weeks. Renal functions were

monitored regularly, and hearing assessments were done during treatment with gentamicin, with

no adverse effects being noted. She was subsequently placed on antibiotic prophylaxis for RHD.

At the time of writing she was asymptomatic for 3 months.

Timeline of the illness is given below.

Time Description of events

Day 1 • Acute onset fever, cough, headache and vomiting

Day 2 • Admission to hospital; developed shortness of breath and visual blurring of right

eye

• WBC= 13.6x109/L, CRP=204 mg/dL, chest X ray: bilateral pneumonia

• Started on IV piperacillin/tazobactam and oral levofloxacin

Day 3 • Blood culture: Gram positive cocci in chains

• Started on IV vancomycin

• Bedside 2D echocardiogram: rheumatic heart disease, no features of endocarditis

• USS abdomen: no abnormalities detected

Day 4 • CRP=213 mg/dL

• Continued with IV vancomycin

• Omitted other antibiotics

Day 5 • Repeat 2D echocardiogram at Cardiology Department: Endocarditis diagnosed

• Blood culture: Group B Streptococcus, sensitive to penicillin G

• Omitted IV vancomycin

• Started on IV ceftriaxone and IV gentamicin

• Ophthalmological examination: ??Roth spot in right macula (too ill for OCT)

Day 7 • CT brain: no abnormalities detected

• BD Phoenix ID: Group B Streptococcus, penicillin MIC <= 0.03125 μg/mL

Day 8 • Patient afebrile, clinical improvement noted

• Roth spot in macular region of right eye confirmed

• Blood culture repeated: No growth

Day 19 • 2D echo: improvement of previously noted vegetation

• WBC= 5.9x109/L, CRP=13 mg/dL

• Patient discharged to complete two weeks of OPAT

Day 24 • Readmitted with on and off fever

• WBC=7.8x109/L, CRP=8 mg/dL

Day 28 • Afebrile, clinically well

• 2D echo: Previously noted vegetation now minimal

• Planned to complete a total of 6 weeks of IV ceftriaxone prior to discharge

Day 90 • Asymptomatic, clinically well

168


Discussion:

GBS is a colonizer of the genital tract in up to 40% of women worldwide.1 A Sri Lankan study

found that GBS colonization reached up to 30% among pregnant mothers7, giving it the potential

to cause severe infection in newborns and pregnant women due to ascending spread along the

reproductive tract.2 However, recently it has also been increasingly involved in causing invasive

infection among elderly adults.3 Risk factors for invasive GBS infection include diabetes

mellitus, malignancy, neurologic disorders, hepatic disease, and skin disease.3 However, in this

patient, no such risk factors were present apart from RHD which predisposes to IE with any

causative organism. Investigations (i.e. urine culture, abdominal ultrasound scan, etc) failed to

reveal the source of bacteraemia in this patient.

IE accounts for 2-18% of invasive GBS infections.2 It progresses rapidly, culminating in a

mortality rate reaching 47%.4 This could be attributed to frequent local and systemic

complications including heart failure, valvular destruction and systemic embolization.5 The rate

of embolization could reach 50% in these patients4, partly due to the large size and increased

friability of vegetations which are common in GBS endocarditis.1 While a CT scan of the brain

was done in our patient to exclude embolization as a cause for visual blurring, no such imaging

(apart from a chest X ray) was performed to exclude it as a cause for her respiratory symptoms.

The presence of visual blurring itself makes this case significant since patients with endocarditis

presenting with early onset visual symptoms has only rarely been documented.8

Administration of a beta-lactam antibiotic (penicillin or ceftriaxone) for 4 to 6 weeks with

gentamicin being added in the first 2 weeks is recommended for treatment of IE. Vancomycin is

recommended for those with beta-lactam allergy.6 Patients with RHD should also receive

antibiotic prophylaxis.9

Conclusion

This case showcases GBS as a cause of IE occurring in a predisposed young adult with no risk

factors for invasive GBS infection and with no identifiable source of bacteraemia. Early

diagnosis was facilitated by the isolation of GBS from a blood culture. Management should

consist of a prolonged course of a beta-lactam, combined with gentamicin, as opposed to short

term antibiotic therapy.

Acknowledgement:

We thank the patient and the family for consenting to publication of the case details.

Conflict of interest: None declared.

References

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https://doi.org/10.1016/j.ajem.2016.03.013

Sri Lankan Journal of Infectious Diseases 2019; Vol. 9(2):169 DOI : http://dx.doi.org/10.4038/sljid.v9i2.8271

Abeygunasekera Nalaka Gamage Chandika Magana-Arachchi Dhammika Siriwardana Yamuna

Abeywardena Madhumanee Goonesekera Chula Malavige Gathsaurie Sriyani Ekanayake

Agampodi Suneth Gunasekara Chalukya Manamperi Nuwani Sumathipala Gayan

Amarasinghe Ananda Gunasekara Samanmalee Manathunge Ariyaratne Sunil-Chandra Narapity

Athukorala Dushyanthie Gunasena Sunethra Mendis Kamini Surendran Noble

Gunawardena Sharmini Mubarak Nasmiya Sumudu Suranadee

Banneheke Hasini Guruparan Lakshy Muthugala Rohitha

Murugananthan Kalamathy Tambyah Paul Anantharajah

Chandrasekharan Naduviladath Hapuarachchi Chathurika Thennegedara Asanka

Chandrasiri Shirani Happugoda Menaka Nagahawatte Ajit Thevanesam Vasanthi

Chatterjee Mitali Nanayakkara Kanthi Tillekeratne Gayani

Chinniah Terrence Rohan Iddawela devika Natkunam Ketheesan Tshokey Tshokey

Cooray Karven Illapperuma Suchetha Navaratnasingam Janakan

Corea Enoka Inglis Tim J J Niriella Madunil Vidanagama Dhammika

Noordeen Faseeha

Dance David Janakan Navaratnasingam Wadanamby Rohini

Danthanarayana Nayomi Janage Nadeeka Panagoda Gehan Warnasekera Janith

de Silva Aruna Jayasekera Primali Parahitiyawa Nipuna Weerasekera Manjula

De Silva Dharshan Jayatilleke Kushlani Pathirage Sujatha Weerasinghe Laksiri

de SIlva Nelun Perera Jennifer Wickramasinghe Susiji

de Silva Nilanthi Kanakaratne Nalaka Perera Nelun Wijayaratne W. M. D. Gaya

de Silva Rajiva Kannathasan Selvam Piyasiri Bhagya Wijekoon Nirmala

de Zoysa Ishan Karawita Don Piyasiri Dammalage Lasanthi Wijesooriya Lakmini

Dissananayaka Anuruddhika Karunaratne Kumudu Wijesundera Sulochana

Dissanayake Nilanthi Karunaratne Nedra Rajakaruna Rupika Subashini Wimalaratne Omala

Karunaratne Parakrama Ranasinghe Shalindra

Ekanayake Sriyani Karunanayake Panduka Ratnatunga Champa Yapa Lakmini

Elumogi Ngozi Karunaweera Nadira Richards Judith

Emmanuel Xavier Koralage Hasitha

Kothalawala Mahen Samarakoon Sujatha

Fernando Deepika Kottahachchi Jananie Samaranayake Nilakshi

Fernando Dinesh Kudagammana Wasana Sathiadas Gitanjali

Fernando LakKumar Senanayake Chaminda

Fernando Neluka Liyanapathirana Veranja Senanayake Channa

The Sri Lankan Journal of Infectious Diseases would like to thank all our reviewers who have willingly offered their time, energy and expertise to evaluate and provide

constructive and helpful reviews of manuscripts received by the Journal. Without your unstinting cooperation, it would have been very difficult to publish the Journal since its

inception in 2011. We look forward to your continuing support of the Journal.

SLJID Reviewers 2011– 2019

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