Post on 03-Jun-2018
8/12/2019 86-Arshad Original Article
1/34
October - December 2010 Volume 19 Issue 04
ISSN 1027-0299
226
230
224
INFECTIOUS
DISEASES
JOURNALPublished by the Infectious Diseases Society of Pakistan
of Pakistan
IDJ
Infectious Diseases Journal of PakistanOfficial Organ of the Infectious Diseases Society of Pakistan
President Altaf AhmedConsultant Microbiology, The Indus Hospital
Karachi, Pakistan
Gen. Secretary Ejaz A. KhanDepartment of Pediatrics,Shifa International Hospital, Islamabd, Pakistan
Treasurer M. Asim BegPathology& Microbiology,Aga Khan University, Karachi, Pakistan
Editorial Office
Editor: Aamer Ikram
Naseem Salahuddin: Karachi
Naila B Ansari: Karachi
Shehla Baqi: Karachi
Nurul Iman: Peshawar
Ejaz Khan: Islamabad
Ayesha Khan: Islamabad
Overseas Advisers:
Murat Akova: Ankara,Turkey
Rayhan Hashmey: UAEDeborah Briggs: U Kansas, USA
Peter Chiodini: Royal College Trop Med/Hyg UK
Salman Siddiqui: USA
Adeel Butt: U of Pittsburgh, USA
Farida Jamal: KL, Malyasia
Business and CirculationNasir Hanook
Rights:No part of this issue or associated program may be reproduced, transmitted,transcribed, stored in a retrieval system or translated into language orcomputer language in any form or means, electronic, mechanical, magnetic,optical, chemical, manual or otherwise without the express permission ofthe editor/publisher and author(s) of IDJ.
Disclaimer:Statements and opinions expressed in the articals, news, letters to the editorsand any communications herein are those of the author(s), the editor and thepublisher disclaim any respons ibility or liabi lity for such mate rial. Neitherthe editor nor publisher guarantee, warrant, or endorse any product orservice advertised in their publication, nor do they guarantee any claimmade by the manufacturers of such product or service.
Frequency:Infectious DiseasesJournal (IDJ) is published quarterly.
Designed & Printed by:
Mediarc PublicationsE-259, Ground Floor, E- Market, Block 6, P.E.C.H.S,Karachi. Tel: 34555263, E-mail:guide@super.net.pk
Proprietor:
Infectious DiseasesSociety of PakistanA-53, Block-2, Gulshan-e-Iqbal,Karachi. Ph: 0333-3977011E-mail: idsp123@yahoo.com Price: Rs. 100/-
Ejaz Vohra: Karachi
Rumina Hasan: Karachi
Noaman Siddiqui: Abbottabad
Aamir J Khan: Karachi
D S Akram: Karachi
Editorial Board
234
243
246
250
Recognised and re gistered with the
Pakistan Medical & Dental CouncilNO.PF.11-F-96 (Infectious Diseases) 2560
College of Physicians & Surgeons, Pakistan
Higher Education Commission, Pakistan
Indexed- WHO EMRO
240
237
Oct-Dec 2010 . 223Volume 19 Issue 04
252
Courtesy: Department of Microbiology,
Armed Forces Institute of Pathology, Rawalpindi.
Colony color and morphology of four most commonlyisolated Candida species on CHROMagar plate.
GUEST EDITORIAL
ORIGINAL ARTICLES
General Practitioners Knowledge regarding Tuberculosis: A Survey
from Karachi
Fauzia Haji Mohammad, Tabinda Ashfaq, Qudsia Anjum,Yaseen Usman
Validation of BBL CHROMagar Candida Medium (BD Diagnostics)
in Isolating and Differentiating CandidaSpecies in Clinical Specimens
Ashraf Hussain, Aamer Ikram, Muhammad Roshan, Luqman Satti
Red Cell Distribution Width in the Diagnosis of Iron Deficiency
Anemia and Thalassemia Trait
Malik Muhammad Adil, Ayesha Junaid, Iffat Zaman, Zeshan Bin
Ishtiaque
Irrational use of Flagyl (Metronidazole) by Practitioners in
Outpatient Clinics
Tehmina Munir, Munir Lodhi
Treatment of Helicobacter pyloriInfection; A Controlled Randomized
Comparative Clinical Trial
Arshad Mehmood, Khan Usmanghani, Abdul Hannan, E. Mohiuddin,
Muhammad Akram, Muhammad Asif, Muhammad Riaz ur Rehman
Drug Susceptibility Pattern of Typhoidal Salmonellae to the
Conventional Anti-Typhoid Drugs; A Current Perspective
Anam Imtiaz , Saba Abbasi, Javaid Usman
CASE REPORT
Central Nervous System ring enhancing lesions in an
Immunocompromised Child with Status Epilepticus: A Case Report
and Literature Review
Amna Batool,Yawar Najam,
Ejaz Ahmed Khan,
Ismail A Khatri
Gelatinous Bone Marrow in AIDS
Salman Saleem, Mehreen Ali Khan, Ayesha Hafeez, Aamer Ikram,
Usman Rathore
NEWS & VIEWS
INSTRUCTIONS FOR AUTHORS 254
CONTENTS PAGE #
8/12/2019 86-Arshad Original Article
2/34
224 . Infectious Diseases Journal of Pakistan
GUEST EDITORIAL
Plagiarism in Todays World
Scientific progress has been provided an essential aid with the introduction of the internet. Literature search, correspondence andsubmission of research articles can all be performed at a fast speed. As in any other field, the use of new inventions can be misusedalso. This is seen as Plagiarism or intellectual theft, which is an integral component of scientific misconduct. According to theMerriam Webster Online Dictionary plagiarism is defined as, To steal and pass off (the ideas and words of another) as onesown, to use (anothers production) without crediting the source, committing literary theft, to present as new and original an ideaor product from an existing source. In other words plagiarism is an act of fraud. It has two components, stealing followed bylying1. Plagiarism has also been stated asone of the most serious crimes in academia2.
Authors resort to plagiarism for various reasons, the most important being to increase the number of publications in a short time.As demanded in Pakistan, doctors serving in the government teaching institutions require a fairly large number of research
publications in indexed journals for promotion. Being busy practitioners, these professionals at times resort to easy and unfairmeans for writing articles. Secondly, in this part of the world, most authors do not have a good command over English languageand copying verbatim from the net is simple and saves time and energy. At times the author is ignorant about the wrong doing,which is not an acceptable excuse. An important reason is lack of appropriate training. This is because the senior faculty, universitiesand governing bodies that are responsible for providing the correct guidance, lack expertise, time and funding resources to conductrequired training/workshops for the junior doctors.
Another reason commonly encountered is the desire to become eminent. Scientists want to have a large number of publicationsto their credit, so that they can be quoted all over the world. Low moral values are the most important factor, an honest individualwould never resort to unfair means. Ethical writing is a reflection of ethical practice3.
Whatever the reason, plagiarism is stealing of intellectual property and when detected has to be penalized. It not only bringsdisgrace to the author besides losing the published material, promotions may be stopped or even services terminated. Someinstitutions may impose a monitory penalty.
Ethics, trust and honesty are the basis of research and publication. Research is essential for the progress of science as the resultsobtained should be published for the benefit of others. The American College of Physicians in their Ethics Manual have statedthat, Dishonesty should not be tolerated - it should be investigated and punished, researchers should be careful, impartial, unbiasedand open to investigation and purpose of scientific research should not be self-promotion, personal publicity and financial gain4.
Ethics took shape with the Nuremberg Code formed in 1946, The Helsinki Declaration in 1964, and The Belmont Report of 19795.
All these have formed a base for important guidelines on Ethics in Research and have been adopted by the World Associationof Medical Editors (WAME)6, International Committee of Medical Journal Editors (ICMJE)7and Committee on Publication Ethics(COPE)8. These guidelines on ethics are followed by most scientific journals.
Despite the guidelines from international authorities which have been adopted by most journals and institutions, the act ofplagiarism is being detected and reported from all over the world. This dishonesty may start from school and continue to theprofessional colleges and university. A study on cheating from Croatia which included students in four medical universities,reported more than 99 percent to have admitted to at least one form of educational dishonesty and 78 percent reported to someform of cheating. The study concluded that Academic dishonesty of university students does not begin in higher education;students come in medical schools ready to cheat9.
Another questionnaire based study on Plagiarism by Shirazi et alincluded fourth year medical students and faculty members10.The results revealed that 19% and 22% of students and faculty knew about referencing material from other sources. Surprisingly,74% students and 69% faculty had observed that colleagues indulge in plagiarizing and were not reported. The study concludedthat there was a general lack of information regarding plagiarism among medical students and faculty members.
A third cross sectional questionnaire based study conducted by the editorial section of the Journal of Pakistan Medical Association(JPMA) included all authors who submitted their manuscripts for publication in 2010. This study was planned to score the levelof perception and practices regarding plagiarism. In this study of JPMA, only 22% of the participants could define plagiarismcorrectly. The level of perception and practices regarding plagiarism of authors submitting to JPMA was 30% above the 75th
Percentile. The study concluded that the authors submitting to JPMA had inadequate knowledge on plagiarism11.
Plagiarism has been reported earlier from Pakistan. In Pakistan, this problem is not uncommon and many such cases are broughtto the notice of editors of medical journals. Surprisingly, the people involved in this matter are usually from a higher academicechelon who had published a similar paper of their own in a local prestigious journal, which was earlier, published in an international
journal12. Preventive strategies regarding plagiarism have been advised by Hashim et al, Local literature has advocated usingreference managers to prevent plagiarism 13.
Detecting plagiarism is not difficult with the availability of the internet and numerous software. Hence, every journal should havea regular screening system. More than this, there is a dire need to root out plagiarism from our teaching institutions. For this,
awareness has to be created to consider plagiarism a fraudulent act and which can have drastic and damaging consequences if
8/12/2019 86-Arshad Original Article
3/34
detected. Faculty members have to acquaint themselves with the rules and teach their students. Workshops and hands-on trainingwould be an added advantage for the purpose. It is also essential for all institutions, journals and health policy makers to havedefinite guidelines on plagiarism which will promote ethical research and publication.
Fatema Jawad
Editor-in-chief
Journal of Pakistan Medical Association
Email:jpma_jpma@hotmail.com
References1. www.merriam-webster.com/dictionary/plagiarized. Cited 26 December
2010.2. Pechenik A. A short guide to writing about biology. 4th Edition. New York:
Addison Wesley Longman. 2001; p.10.3. Kolin F C. Successful writing at Work. 6th Edition. Houghton Mifflin.
2002.
4. American College of Physicians Ethics Manual. American College ofPhysicians.Ann Intern Med 2005; 101: 263-74.
5. Summary from the Nuremberg Code. Trials of War Criminals before theNuremberg Military Tribunals. Under Control Council Law 10, Volume 2,Nuremberg, October 1946 - April 1949. Washington DC, US GovernmentPrinting Office, 1949; pp. 181-2.
6. WAME http://www.wame.org/resources.7. www.icjme.org. Uniform Requirements for Manuscripts Submitted to
Biomedical Journals.8. Publishing and Editorial issues related to Publication in Biomedical Journals:
Overlapping Publications. www.rin.ac.uk/policy/committee-publicationethics-cope-guidel.
9. Taradi SK, Taradi M, Knezevic T, Dogas Z. Students come to medicalschools prepared to cheat: a multi-campus investigation.J Med Ethicsdoi10.1136/jma.2010.035410.
10. Shirazi B, Jafarey AM, Moazam F. Plagiarism and the medical fraternity:
A study of knowledge and attitudes.J Pak Med Assoc 2010; 60:269-73.11. Jawad F, Ejaz K, Riaz M K, Jafary A, Shirazi B. What is plagiarism and
how much authors know about it? Oral presentation at 5th RegionalConference on Medical Journals in the Eastern Mediterranean Region,Karachi-Pakistan, December 2-5, 2010 Abstract Book, page 71.
12. Gadit AA. Plagiarism: how serious is this problem in Pakistan?J PakMed Assoc2006; 56: 618.
13. Hashim MJ, Rahim MF, Alam AY. Training in reference managementsoftware - a part of new medical informatics workshops in Pakistan. J AyubMed Coll Abbottabad2007; 19: 70-1.
Oct-Dec 2010 . 225Volume 19 Issue 04
8/12/2019 86-Arshad Original Article
4/34
ORIGINAL ARTICLE
226 . Infectious Diseases Journal of Pakistan
Corresponding Author: Fauzia Haji Mohammad,
Department of Family Medicine, Ziauddin University,
Clifton, Karachi.
Email: fauziaakhtar@yahoo.com
Abstract
Objective
To assess the knowledge gaps regarding tuberculosis in general
practitioners of Karachi registered for attending the continuous
medical education programme.
Methods
This was a cross sectional survey targeting General Practitionersof Karachi attending the continuous medical education
programme organized by the College of Family Medicine,
through non-probability purposive sampling. For analysis, they
were arbitrarily divided into two groups on the basis of clinical
experience; group 1 with less than 5 years and group 2 with
more than 5 years of experience.
Results
A total of 120 general practitioners (GPs) attended the CME
programme, out of which 109 completed the questionnaire.
71 (65.13%) were males and 38 (34.86%) were females. Mean
age of general practitioners was 37.7 9.9 years and meanduration of their practice was 10.6 8.7 years. The overall
knowledge score was found to be slightly higher among general
practitioners in group 1. The most common symptom for
diagnosis of tuberculosis identified by 38% general practitioners
in group 1 was chronic cough, whereas 42% general practitioners
in group 2 recognized low grade fever with night sweats. Most
general practitioners in both groups, 59% versus 46% identified
sputum for acid fast bacillus (AFB) smear as investigation of
choice. Only 21% GPs in group 1 versus 37% in group 2 knew
about the correct duration of therapy for pulmonary tuberculosis,
and 12% group 1 versus 15% group 2 general practitioners
knew about the duration of treatment for extra pulmonary
tuberculosis. Drugs for initial phase were correctly identifiedby 55% general practitioners in group 1 and 54% in group 2.
The drugs for continuation phase were correctly identified by
10% general practitioners in group 1 and 20% from group 2.
Conclusion
The study identified gaps in knowledge regarding tuberculosis
among general practitioners from Karachi. Their active
engagement in educational activities could enhance their
knowledge and hence reduce the disease burden and development
of multi drug resistant tuberculosis.
Key Words
CME, General Physicians, Tuberculosis.
IntroductionTuberculosis (TB) is an important cause of morbidity and
mortality in the developing world. One third of the worlds
population, approximately two billion people are infected with
Mycobacterium tuberculosis1. In 2006, 1.7 million people died
from tuberculosis worldwide, majority from developing countries
with more than half of these deaths occurring in Asia. Pakistan,
being a third world country ranks eighth in prevalence of
tuberculosis2.
According to WHO estimated TB burden in 2004, its incidence
in Pakistan is 181/100,000 and prevalence is 329/100,000
people3
. Tuberculosis has been regarded primarily as a diseaseof poverty and overcrowding4. Factors contributing to persistent
prevalence of this devastating illness in the community include
inadequate knowledge of health care professionals, lack of
diagnostic tools in health care setup, non-availability of anti-
tuberculous drugs and poor patient compliance5. WHO declared
tuberculosis as a global emergency in 1993, thus national TB
guidelines were launched with a revision in 19986. Although
evidence based guideline is available, yet health care
professionals lack knowledge for appropriate management of
TB. A number of local studies have shown that private
practitioners are not compliant with the treatment guidelines7,10.
A study done on family physicians in Pakistan targeting
knowledge regarding Mantoux test, revealed an overall
inadequacy in knowledge; only 18.8% family physicians scored
>80% correct responses11.
An international study assessed knowledge of health care
professionals and community health workers. Although doctors
and nurses had better mean scores than non-professionals, yet
an overall knowledge gap existed12. A few other international
studies also revealed lower levels of knowledge regarding the
symptoms and diagnostic procedures for TB among doctors in
private practice and primary care physicians13,14. The literature
search in the area has suggested updating knowledge of general
practitioners (GPs) to improve the scenario for early detection
General Practitioners Knowledge regarding Tuberculosis: A Survey from Karachi
Fauzia Haji Mohammad*, Tabinda Ashfaq*, Qudsia Anjum**,Yaseen Usman*
*Department of Family Medicine, Ziauddin University, Karachi
**Al Ahli Hospital, Qatar
8/12/2019 86-Arshad Original Article
5/34
and treatment of TB. Therefore, this study was aimed to assess
the knowledge gaps regarding tuberculosis in general practitioners
of Karachi, who were registered for attending the continuous
medical education (CME) programme.
Material & Methods
This was a cross sectional survey targeting the GPs of Karachi
registered for attending the CME programme organized in
National Institute of Child Health during May-June 2010. This
CME programme was organized by the College of Family
Medicine for MRCGP (International) exam constituting a few
lectures on TB, in order to update GPs knowledge in the light
of recent guidelines. The data was collected on a pre-tested
self-administered questionnaire before attending the respiratory
module. The questionnaire was distributed simultaneously to
all of them after verbal informed consent. A total of 120 GPs
were surveyed using non-probability purposive sampling method.The sample size was calculated at 95% confidence level and
sampling error of 10%, assuming proportion of knowledge
among GPs to be 28%.
All the results were analyzed using SPSS version 11. A
knowledge score of TB was calculated from 18 MCQs (1 point
was given for each correct answer). Frequencies were calculated
for categorical variables (gender). Mean and standard deviations
were calculated for age and year of experience. GPs were
divided in two groups on the basis of years of experience for
the purposes of analysis, group 1 with less than 5 years and
group 2 with more than 5 years of clinical experience. Crosstabulation was done and chi-square test was applied to compare
the knowledge between two groups of GPs;p-value of 5 years
n %
0.44713 or more
8/12/2019 86-Arshad Original Article
6/34
228 . Infectious Diseases Journal of Pakistan
with findings in a study conducted in Oman18. This may lead
to delay in the diagnosis of disease with increasing spread of
disease as well as complications. The gold standard test for the
diagnosis of pulmonary TB is sputum smear for AFB; correctly
identified by almost half of GPs in both the groups. These
figures were almost similar to another study done in Karachi
(58.3 %)10. The overall reason for these results is that GPs
consider this test to be unreliable and inconvenient in outpatient
Most common symptom of tuberculosis
High grade fever with chills and rigors 6 9 5 12
Low grade fever with night sweats 25 37 17 42
Chronic cough (> 3 weeks) 26 38 9 22
Weight loss 6 9 5 12
Hemoptysis. 5 7 5 12
Investigation of choice to diagnose pulmonary tuberculosis
Complete blood count and ESR 7 10 5 12
Chest X-ray 6 9 6 15
Sputum for AFB smear 40 59 19 46
Tuberculin skin test 7 10 5 12
Blood for AFB smear 8 12 6 15
Three negative sputum samples can exclude the diagnosis
Yes 31 46 23 56
No 37 54 18 44
Duration of therapy for pulmonary tuberculosis
6 months 15 22 6 15
8 months 14 21 15 36
9 months 33 48 13 32
12 months 6 9 7 17
Duration of therapy for extra pulmonary tuberculosis
6 months 8 12 5 12
8 months 8 12 6 15
9 months 13 19 9 22
12 months 39 57 21 51
Duration of initial intensive phase and continuation phase
2 months + 7 months 17 25 9 22
2 months + 6 months 31 45 16 39
3 months + 6 months 14 21 7 17
3 months + 5 months 6 9 9 22
Drugs of initial intensive phase
HRE 19 28 6 15
HRZE 37 55 22 54
HRSE 5 7 7 17
HRZES 6 10 6 15
Drugs of continuation phase
HR 45 66 17 41
RE 7 10 11 27
RZ 9 14 5 12
HE 7 10 8 20
Table 2: Knowledge regarding diagnosis of tuberculosis
Knowledge of General Practitioners 5years p value
n=68 % n=41 %
0 .437
0 .763
0 .288
0 .095
0 .931
0 .293
0 .206
0 .035
H=isoniazid, R=rifampicin, Z=pyrazinamide, E=ethambutol, S=streptomycin
8/12/2019 86-Arshad Original Article
7/34
setting and also there is poor compliance of patients.
Knowledge regarding treatment of pulmonary and extra
pulmonary TB was also found to be deficient in both groups,
which is consistent with another study done among Pakistani
GPs7. Our finding of almost 50% GPs giving treatment for more
than recommended duration is similar to a study from Jamnagar
India 19. This would result in increased side effects, poor
compliance and increased treatment cost. The response for
correct drugs for intensive and continuation phase of primary
pulmonary TB was less than similar kind of study from Karachi(73.3 %)10. Similarly drugs of initiation and continuation phase
were correctly identified by limited number of GPs. The reason
is lack of knowledge and familiarization with TB guidelines by
GPs. Current situation is expected to result in increased number
of multi-drug resistant TB cases.
Conclusion
The study identified gaps in knowledge regarding TB among
GPs from Karachi. Their active engagement in educational
activities could enhance their knowledge and hence reduce the
disease burden and development of multi-drug resistant
tuberculosis.
Refrences1. Tuberculosis fact sheet [Online] 2008 [cited 2008 December
30]. Available from:
URL h t tp : / /www.who . in t /med iacen t re / fac t shee t s / f s104 /
en/index.html.
2. WHO Report 2008: Global tuberculosis control-surveillance, planning
and financing Geneva: WHO; (WHO/HTM/TB/2008.393).
3. WHO Report 2006.Global tuberculosis control, surveillance,
planning and financing. Geneva: WHO; (WHO/HTM/TB/2006.392).
4. S h a bb i r I , M i r z a N , I q ba l R , K h a n S U , Aw a n SR .
Clinicoepidemiological profile of one hundred AFB smear
posi tive cases of pulmonary tuberculosis . Pak J Ches t Med
2005; 11:29-33.
5. Masroor M, Ahmed I, Qamar R, Imran K, Aurangzeb,Tanveer, Khan MH.
Prevalence and pattern of resistance to anti-tuberculosis drugs in our
community.Pak J Chest Med 2007;13(1):21-30.
6. Tubercu losi s : A Globa l Emergency. [on l ine] 1999[c i t ed
2010 June 11] Available from: URL http://www.nfid.org/
factsheets/tb.shtml.
7. Ahmed M, Fatmi Z, Ahmed J, Ara N. Knowledge, attitude
and practice of private practitioners regarding TB-DOTS in a rural district
of Sindh, Pakistan.J Ayub Med Coll2009; 21:28-31.
8. Hussain A, Mirza Z, Qureshi FA, Hafeez A. Adherence of private
practitioners with the National Tuberculosis Treatment Guidelines in
Pakistan: a survey report.JPMA2005; 55:17-9.
9. Shehzadi R, Irfan M, Zohra T, Khan JA, Hussain SF. Knowledge regarding
management of tuberculosis among general practitioners in northern areas
of Pakistan.JPMA 2005; 55:174-6.
10. Khan J, Malik A, Hussain H, Ali NK, Akbani F, Hussain SJ, Kazi GN,
Hussain SF. Tuberculosis diagnosis and treatment practices of private
physicians in Karachi , Pakistan. East Med Health J2003; 9:769-75.
11. Ali NS, Jamal K, Khuwaja AK. Family physicians understanding about
Mantoux test: A survey from a high endemic country.Asia Pac Fam Med
2010; 9:8. Published online 2010 May 31; DOI: 10.1186/1447-056X-9-8.
12. Keifer EM, Shao T, Carrasquillo O, Nabeta P, Seas C. Knowledge and
attitudes of tuberculosis management in San Juan de Lurigancho district
of Lima, Peru.J Inf Dev Countries2009; 3:783-8.
13. Dato MI, Imaz MS. Tuberculosis control and the private sector in a low
incidence setting in Argentina. Rev Salud Publica (Boqota) 2009;
11:370-82.
14. Savicevic AJ. Gaps in tuberculosis knowledge among primary health care
physician in Croatia: epidemiological study. Coll Antropol2009; 33:481-6.
15. Mushtaq MU, Majrooh MA, Ahmad W, Rizwan M, Luqman MQ, Aslam
MJ, Siddiqui AM, Akram J, Shad MA. Knowledge, attitudes and practices
regarding tuberculosis in two districts of Punjab, Pakistan.Int J Tubers
Lung Dis2010; 14:303-10.16. Khan JA, Irfan M, Zaki A, Beg M, Hussain SF, Rizvi N. Knowledge,
attitude and misconceptions regarding tuberculosis in Pakistani patients.
JPMA2006; 56:211-4.
17. Khan SJ, Anjum Q, Khan NU, Nabi FG. Awareness about common diseases
in selected female college students of Karachi. JPMA2005; 55:195-8.
18. Al-Maniari AA, Al-Rawas OA, Al-Ajmi F, De Costa A, Eriksson B, Diwan
VK. Tuberculosis suspicion and knowledge among private and public
general practitioners: Questionnaire based study in Oman.BMC Public
Health2008; 8:177-183.
19. S. Yadav, A. Patel, S. V. Unadkat, V. V. Bhanushali. Evaluation of
management of TB patients by General Practitioners of Jamnagar City.
Ind J Com Med2006; 31:259-60.
Side effect of Isoniazid
1. Vision impairment 6 9 5 12 0.529
2. Orange colored body fluids 23 34 9 22
3. Peripheral neuropathy 28 41 16 39
4. Ototoxicity 6 9 5 12
5. Gout 5 7 6 15
Side effect of Rifampicin
1. Vision impairment 9 13 6 15 0.697
2. Orange colored body fluids 39 58 18 44
3. Peripheral neuropathy 7 10 5 12
4. Ototoxicity 7 10 7 175. Gout 6 9 5 12
Side effect of Ethambutol
1. Vision impairment 40 59 18 44 0.521
2. Orange colored body fluids 9 13 6 15
3. Peripheral neuropathy 8 12 5 12
4. Ototoxicity 6 9 7 17
5. Gout 5 7 5 12
Side effect of Pyrazinamide
1. Vision impairment 7 10 6 15 0.742
2. Orange colored body fluids 6 9 5 12
3. Peripheral neuropathy 11 16 6 15
4. Ototoxicity 5 7 5 12
5. Gout 39 58 19 46
Knowledge of 5years p-value
General Practitioners n=68 % n=41 %
Table 3: Knowledge regarding side effects of antituberculous
Oct-Dec 2010 . 229Volume 19 Issue 04
8/12/2019 86-Arshad Original Article
8/34
Validation of BBL CHROMagar Candida Medium (BD Diagnostics) in Isolating and Differentiating
CandidaSpecies in Clinical Specimens
Corresponding Author: Ashraf Hussain,
Pathology Department, Combined Military Hospital,
Chhor.
Email: hussainashraf78@yahoo.com
Abstract
Objective
To determine the diagnostic efficacy of BBL CHROMagar
Candida (BD Diagnostics) in isolating and differentiating various
Candidaspecies using API 20 C AUX (BioMerieux) as gold
standard.
Methods
One hundred and six isolates of yeasts isolated from various
clinical specimens were studied from March 2007 through
September 2007. All suspected Candida colonies were
presumptively identified on Gram staining and tested up to
species level by simultaneous inoculation on CHROMagar
Candida medium and API 20 C AUX test strips followed by
recommended incubation.
Results
Out of the total, 52.8% were identified as C. albicans. High
sensitivities (98.2%-100%) and specificities (95%-96.8%) were
shown by CHROMagar Candida medium for most commonlyisolated Candida species of C. albicans, C. krusei, C. tropicalis
and C. glabrata.
Conclusion
CHROMagar Candida medium was easy to use, cost effective
and reliable agar medium for isolation and differentiation of
most frequently occurring yeast species in the clinical specimens
and is recommended for use in peripheral labs.
Key words
API 20C AUX Medium,Candida Infections, CHROMagar
Candida medium, non-albicans Candida species.
Introduction
The incidence of fungal infections is rising with increasing
number of immunocompromised patients, widespread use of
broad spectrum antibiotics and invasive procedures1. Candida
species are important cause of local and blood stream infections
causing significant mortality and morbidity especially in critically
ill patients, immunocompromized population and infants. Overall
incidence has risen five fold during this decade and is currently
between fourth and sixth most common nosocomial blood
isolate in America and Europe2,3. A tilt towards non-albicans
Candidahas been reported especially in hematological and
transplant patients4. Moreover fungemia/colonization ratio of
non-albicans Candidahas also been found to be more than that
of Candida albicans5. Identification of different Candidaspecies
has important therapeutic implication as C. glabratais less
sensitive to ketoconazole and fluconazole than other species
and C. krusei displays innate resistance to fluconazole6.
Presumptive identification of C. albicansis usually done through
testing for germ-tube formation7. However, C. tropicalis, C.
parapsilosisand Cryptococcus gastricum also have resembling
structures8. Therefore it should not be used as a sole criterion
for identification of C. albicans. Reference identification
procedures using biochemical and morphological studies and
conventional methods of yeast identification mainly consisting
of assimilation / fermentation characteristics are difficult andrequire expertise7. Packaged kit and automated systems are
expensive and limited by the size of their database10 .
Chromogenic agar media like BBL CHROMagar Candida are
easy to use and interpret due to formation of distinct color and
morphologies resulting from cleavage of chromogenic substrates
by species specific enzymes10. The rationale of the study is to
evaluate the diagnostic efficacy of CHROMagar Candida for
identification and differentiation of various yeast species in
clinical samples as it is now direly needed to precisely identify
the pathogen not only at the reference laboratories but also at
the peripheral diagnostic facilities.
Material and methods
This study was conducted at Department of Microbiology,
Armed Forces Institute of Pathology, Rawalpindi, from March
2007 through September 2007. One hundred and six yeast
isolates yielded from various clinical specimens including blood,
high vaginal swabs, urine, sputum, stool and tissues sent for
culture and sensitivity to the department of microbiology were
included in the study irrespective of age and gender of patients.
Upon isolation of a yeast colony, 0.5 MacFarland suspension
was prepared in normal saline and 100 uL of the suspension
was dispensed on CHROMagar (BD Diagnostics) plate and
spread with wire loop. The plates were incubated at 370C for
48 hrs. Identification of Candida species was made according
ORIGINAL ARTICLE
230 . Infectious Diseases Journal of Pakistan
Ashraf Hussain, Aamer Ikram, Muhammad Roshan, Luqman Satti
Department of Microbiology, Armed Forces Institute of Pathology, Rawalpindi
8/12/2019 86-Arshad Original Article
9/34
Only four out of these ten yeast species could be identified on
CHROMagar Candida medium (Table 2). Distinctive colony
morphology is depicted in figure 2.
Table 1: Frequency of various yeast species identified on
API 20C AUX (n = 106)
S. No. Yeast Identified Number of Isolates %
1. Candida albicans 56 52.8
2. Cryptococcus laurentii 2 1.9
3. Candida krusei 19 17.9
4. Candida humicola 4 3.8
5. Candida tropicalis 11 10.4
6. Candida glabrata 7 6.6
7. Candida parapsilosis 3 2.8
8. Rhodotorula rubra 1 0.9
9. Trichosporon cutaneum 2 1.9
10. Trichosporon capitatum 1 0.9
Total 106 100
to the color and morphology of the yeast colonies. Distinct
green colored were labeled as Candida albicans, metallic blue
color as Candida tropicalis and pinkish colonies with spreading
margins and velvety texture were presumptively identified asCandida krusei(Fig 1).
Figure 1: Colony color and morphology of four most
commonly isolated Candida species on CHROMagar plate.
Clockwise: Pink velvety: C. krusei, green: C. albicans,
purple: C. glabrata, blue: C. tropicalis
All the yeast isolates were simultaneously inoculated on API 20C
AUX (BioMerieux, France) test strips in accordance with the
manufacturers instructions. Interpretation was done after 48 and
72 hours of incubation. This method was considered as goldstandard in the study and results of CHROMagar Candida medium
were compared. Sensitivity, specificity, positive predictive value
(PPV) and negative predictive value (NPV) were calculated.
Results
A total of 106 specimens yielding growth of various yeasts
were studied. The mean age for these patients was 42 years
(range 1 - 80 years) with greatest number around 30 years of
age. 67% (n = 71) specimens were from female patients. The
most frequent specimen which yielded Candida spp was urine
closely followed by high vaginal swab, 45.3% and 40.6%
respectively. Sputum yielded growth of yeast species in 7.5%of the specimens. Other specimens containing yeasts with a
lesser frequency included pus and pus swab, blood, throat swab,
stool, catheter tip and tissue.
Ten different yeast species could be identified using API 20 C
AUX medium (Table 1). Candida albicanswas found to be the
most common yeast present in the clinical specimen (52.8%).
This was followed by Candida krusei(17.9%), Candida tropicalis
(10.4%) and Candida glabrata(6.6%). Other less frequently
isolated yeasts included Candida parapsilosis, Candida humicola,
Cryptococcus laurentii, Trichosporon cutaneum, Trichosporon
capitatumandRhodotorula rubra.
Table 2: Various yeast species identified using CHROMagar
Candida (n = 106)
S. No Yeast Identified Frequency Percent
1. Candida albicans 57 53.8
2. Candida krusei 23 21.7
3. Candida tropicalis 14 13.2
4. Candida glabrata 12 11.3
Total 106 100
Figure 2: Close view of distinct colony colors and morphology
of Candidaspecies on CHROMagar Candida
Oct-Dec 2010 . 231Volume 19 Issue 04
8/12/2019 86-Arshad Original Article
10/34
232 . Infectious Diseases Journal of Pakistan
The sensitivities, specificities negative and positive predictive
values of the four Candida species identified on CHROMagar
Candida medium are shown in table 3:
tropicalis.
Although CHROMagar candida was able to support growth of
all 106 yeast isolates, it placed them in one of the four speciesof Candida: C. albicans, C. krusei, C. tropicalis or C. glabrata.
Generally 10% to 14% of the specimens are found to be
containing mixed Candidaspecies, however in our study; we
were unable to detect any mixed infections. The reason probably
lies in the method of study as the yeast was first isolated on
non-differential media like SDA, blood agar and CLED agar
etc, and then isolated colonies were tested for species
identification on these systems. This might have led to failure
to put to test the apparently similar looking yeast colonies of
different species. Although detection of mixed Candidainfection
is also considered to be an advantage with the use of
CHROMagar Candida medium, this aspect could not be directly
determined during the study. However keeping in view the test
results obtained for major Candidaspecies, it can be said with
confidence that mixed infections with Candida albicans, C.
tropicalisand C. kruseican easily be detected while using this
medium for isolation of yeast.
It can be appreciated from the results that although C. albicans
still remains the major yeast to be isolated from the clinical
specimen, non-albicans Candidaspecies now make a very
substantial component of the total number.Presuming all the
isolates as C. albicans without identifying the actual species
can lead to error thus affecting management. In a critical patient,
an undesirable outcome due to such an error of presumption iscompletely unacceptable. Similarly, chronic cases may remain
unresponsive to the subsequently used antifungals and their
misery may prolong.
In this study, the sensitivity and specificity of CHROMagar
Candida medium was found to be very high for Candida
albicans, C. krusei, C. tropicalisand C. glabrata. This is in
accordance with other studies conducted to check these
parameters for these species by CHROMagar Candida medium13.
Pfaller MA et al, by adhering to the manufecturers guidelines
and published criteria of Odds and Bernaerts14, were able to
identify correctly 100% of the tested isolates of C. albicans, C.tropicalisand C. kruseiand 90% of the isolates of C. glabrata
up to the species level14. These four species constituted around
87% of the total isolates in that study; however, despite high
sensitivity and specificity obtained for C. glabrata, the PPV
for this particular species was only 58.3%. This is due to the
fact that some of the relatively infrequently isolated species
like C. parapsilosisdid give a light purple shade in cream
colored colonies, the criteria set for identification of C. glabrata
on CHROMagar. The manufacturer doesnt claim the
identification of this particular species on this medium, but
studies are available in which C. glabratawas successfully
identified on this agar medium by its light purplish colony14
.
Table 3: Sensitivities, Specificities, Negative and Positive
predictive values for Candida specieson CHROMagar
Candida Medium
Yeast Species Sensitivity Specificity PPV NPV
% % % %
Candida albicans 98.2 96 96.5 97.9
Candida krusei 100 95.4 82.6 100
Candida tropicalis 100 96.8 78.5 100
Candida glabrata 100 94.9 58.3 100
Discussion
With ever increasing number of immunocompromised patients
in various medical facilities, isolation of various yeast species
is expected to rise. Candida species is the most common yeast
causing mortality and morbidity in such patients. Injudicious
empirical use of fluconazole without correctly identifying the
involved species has resulted not only in treatment failure but
also in the development of fluconazole resistant Candida
glabrataand Candida krusei sttrains6.
While PCR is extremely helpful in definite identification of
infection with various microbes, these nucleic acid amplification
techniques for Candida are still in the investigatory stage and
not available for routine clinical use 11. The classical Wickerhan
and Burton method utilizes identification through assessment
of assimilation by determining the ability of given yeast isolate
to grow in a set of defined minimal liquid media supplemented
with different carbohydrates11,12. Though precise, it is laborious
and time consuming and therefore not preferable for routine
use. Auxanographic technique replaced this for use in clinical
laboratory. This is more simple and rapid method and several
of its modifications are commercially available such as API
20C, API ID 32C, Vitek, MINITEK etc. These generally are
the most frequently employed techniques for the purpose of
identification of the yeasts to the species level. However, mostof the peripheral laboratories dont have access even to these
biochemical identification techniques in developing countries
like ours. The main reason is high cost in addition to technical
expertise required for performing and interpretation of these
tests. Alternative methods are required in routine clinical
laboratories which must be cheap and sufficiently reliable.
Sabourauds dextrose agar is an excellent medium for primary
isolation of yeasts, but it fails to differentiate various species
in clinical specimen5. CHROMagar Candida medium by BD
Diagnostics is a medium claimed to have high sensitivity and
specificity for detection of three of the most commonly isolated
yeast species: Candida albicans, Candida kruseiand Candida
8/12/2019 86-Arshad Original Article
11/34
In this study, all the isolates of C. glabratawere successfully
identified as such, but several other isolates like C. parapsilosis
were falsely identified as C. glabrata. Interpretation of results
when dealing with C. glabrataon CHROMagar has beenunreliable in several other studies14, 15. Beighton D et alconcluded
that colonies identified as C. glabrata varied in color from
purple to pale pink that could lead to some degree of confusion
with colonies subsequently identified as C. parapsilosisas
evident in this study as well15. Although, the PPV in this study
for C. glabratawas rather low, the NPV (100%) still highlights
its value for this species. This shows that although some of the
infrequently isolated Candida species were identified as C.
glabrata in this study, none of the C. glabratapresent in the
specimens were missed. This has a practical significance, since
C. glabratamay be involved in several chronic infections like UTI11.
Conclusion
CHROMagar Candida medium has been found to be easy to
use, cost effective and reliable agar medium for isolation and
differentiation of most frequently occurring yeast species from
the clinical specimen and its usage is recommended for peripheral
laboratories.
References1. Moran GP, Sullivan DJ, Coleman DC. Emergence of non-candida albicans
species as pathogens. In: Calderone RA Candida and Candidiasis.
Washington DC.Am Soc Microbiol2003; 37-53.
2. Pfaller MA, Diekema DJ, Jones RN, Sader HS, Fluit AC, Hollis RJ.
International surveillance of blood stream infections due to candida species:
frequency of occurrence and in vitro susceptibilities to fluconazole,ravuconazole, and voriconazole of isolates collected from 1997 through
1999 in the SENTRY Antimicrobial Surveillance Program.J Clin Microbiol
2001; 39:3254-9.
3. Marchetti O, Bille J, Fluckiger U, Eggimann P, Ruef C. Epidemiology of
candidemia in Swiss tertiary care hospitals: secular trends 1991-2000.
Clin Infect Dis2004; 38: 311-20.
4. Schelenz S, Gransden WR. Candidemia in London teaching Hospital:
analysis of 128 cases over a 7 year period. Mycoses2003; 46:390-6.
5. Roilides E, Farmaki E, Evdoridou J, Francesconi A, Kasai M, Filioti J.
Candida tropicalis in a neonatal intensive care unit: Epidemiologic andmolecular analysis of out break of infection with an uncommon neonatal
pathogen.J Clin Microbiol2003; 41:735-41.
6. Bouchara JP, Declerck P, Cimon B. Planchenault C, De Gentile L, Chabasse
D. Routine use of CHROMagar candida medium for presumptive
identification of candida yeast species and detection of mixed fungal
populations. Clin Microbiol Infect1996; 2:202-8.
7. Freydiere AM, Guinet R, Bioron P: Yeast identification in the clinical
microbiology laboratory: Phenotypical methods.Med Mycol2001, 39:9-33.
8. Pfaller MA, Messer SA, Hollis RJ, Jones RN, Doem GV, Brandt ME.
Trends in species distribution and susceptibility to flunconazole among
blood stream isolates of candida species in the United States. Diagn
Microbiol Infect Dis1999; 33:217-22.
9. Koehler AP, Chu KC, Houang ETS, Cheng AF. Simple, reliable and cost
effective yeast identification scheme for the clinical laboratory. J Clin
Microbiol 1999; 37: 422-6.
10. Bauters TG, Nelis HJ. Comparison of chromogenic and fluorogenic
membrane filtration methods for detection of four Candida species.J Clin
Microbiol2002; 40: 1838-9.
11. Hazen KC, Howel SA. Candida, Cryptococcus, and other yeasts of medical
importance. In: Murray PR, Baron EJ, Landry ML, Jorgensen JH, Pfaller
MA, editors. Manual of Clinical Microbiology. Washington, D.C: ASM
Press; 2007.
12. Reiss E, Morrisson CJ. Non culture methods for diagnosis of disseminated
candidiasis. Clin MicrobiolRev 1993; 6:311-23.
13. Pfaller MA, Houston A, Coffman S. Application of CHROMagar Candida
for rapid screening of clinical specimens for Candida albicans, Candida
tropicalis, Candida krusei, and Candida (Turolopsis) glabrata.J Clin
Microbiol1996; 34: 58-61.
14. Odds FC, Bernaerts R. CHROMagar Candida, a new differential isolationmedium for presumptive identification of clinically important Candida
species.J Clin Microbiol1994; 32:1923-9.
15. Beighton D, Ludford R, Clark DT, Brailsford SR, Pankhurst CL. Use of
CHROMagar Candida medium for isolation of yeasts from dental samples.
J Clin Microbiol 1995; 33: 3025-7.
Oct-Dec 2010 . 233Volume 19 Issue 04
8/12/2019 86-Arshad Original Article
12/34
Corresponding Author: Malik Muhammad Adil,
Department of Medicine,
Shifa International Hospital, Islamabad.
Email: malikmuhammad.adil@gmail.com
Abstract
Objective
To evaluate diagnostic importance of Red Cell Distribution
Width (RDW) in differentiating iron deficiency anemia from
Thalassemia trait.
Patients and methods
A total of 100 cases aged 5 months to 50 years of either sexwith diagnosed iron deficiency anemia or thalassemia trait were
compared with respect to their RDW value.
Results
RDW value in iron deficiency anemia was between 36.2% to
55.2% (Mean 44.1%). The range of RDW in Thalassemia trait
was 14.7% to 24.9% (Mean 19.8%).
Conclusions
The very high range of RDW in iron deficiency anemia as
compared to slight elevation of the value in thalassemia trait in
our study suggests that RDW value obtained from simpleComplete Blood Counts (CBC) can help in differentiating the
two pathologies.
Key words
Iron deficiency anemia, RDW, Thalassemia trait
Introduction
Iron deficiency anemia is one of the most common nutritional
disorders in the world1. In Pakistan after iron deficiency anemia,
beta thalassemia trait is the second most common cause of
hypochromic microcytic anemia2. However, in population where
thalassemia is also prevalent, it is important to distinguish
between these two common causes of microcytic anemia. For
the diagnosis of iron deficiency anemia and thalassemia trait,
estimation of serum iron, TIBC and level of HbA2are required3.
Red blood cell size variation (anisocytosis), along with
poikilocytosis, has been recognized as morphologic hallmarks
of some anemias. Traditionally, microscopists subjectively
assess anisocytosis as either slight, moderate, or marked. This
subjective assessment has limitations, and therefore more
objective quantitative measurements are desirable. It has been
suggested that Red Cell Distribution Width (RDW) could fulfill
this role4. RDW which is an objective measure of the degree of
anisocytosis, has been proposed to be useful in early classification
of anemias because it becomes abnormal earlier in nutritional
deficiency anemia than any of the other red cell parameters,
especially in case of iron deficiency anemia 5,6. Bessman andcolleagues have indicated that the use of RDW, made available
by new automated blood cell analyzers, has improved the
distinction between iron deficiency anemia and thalassemia
trait5. However, the reliability of using RDW as a sole method
for diagnosis of anemia is uncertain7.
The purpose of this study was to determine whether we could
reproduce the accuracy of classification in our population using
RDW in patients with iron deficiency anemia and thalassemia
trait keeping in view the financial constraints in a developing
country. If this were so, the time and expense of evaluating iron
deficiency anemia and thalassemia trait might be reduced.
Material and methods
A total of 100 patients (50 with iron deficiency anemia and 50
with thalassemia trait), aged 5 months to 50 years, who reported
to Shifa International Hospital, Islamabad, for iron studies and
hemoglobin electrophoresis were included in the study. The
study was carried out from June 2004 to December 2004.
Patients with iron deficiency anemia
5 ml venous blood was collected from each of the subject using
aseptic technique. In order to avoid the problem of diurnal
variation in iron level, all blood samples were collected between
10 am to 12 noon. The blood was distributed as follows:
(a) 3 ml of blood was added to K2EDTA at a final
concentration of 2.5mg/ml for blood complete examination
(b) 1.8 ml was added to plain tube and centrifuged at 1500
rpm for 5 minutes to obtain serum. This serum was
analyzed for serum iron and TIBC.
Blood complete examination was carried out using SYSMEX-
KX hematology analyzer. Low, normal & high controls prepared
commercially were tested before each batch of samples. Quality
control was assured by running normal specimen after every
19 test samples. Serum iron & TIBC were analyzed using
ROCHE DIAGNOSTICS reagents on automated clinical
ORIGINAL ARTICLE
234 . Infectious Diseases Journal of Pakistan
Red Cell Distribution Width in the Diagnosis of Iron Deficiency Anemia and Thalassemia Trait
Malik Muhammad Adil, Ayesha Junaid, Iffat Zaman, Zeshan Bin Ishtiaque
Pathology Department, Shifa International Hospital, Islamabad
8/12/2019 86-Arshad Original Article
13/34
with other studies.
Distribution of iron deficiency anemia by RDW is shown in
figure 1, 44% of cases had RDW in range of 40.1-45%. Figure 2shows distribution of Thalassemia trait by RDW, 86% of cases
have RDW in range of 14-20%.
chemistry analyzer HITACHI-911. Commercial controls were
run before every batch of samples in order to standardize the
sample results. The quantitative determination of both serum
iron and TIBC were based upon direct photometric method.The following criteria were used:
Anemia was defined as hemoglobin concentration of less than
11.5 gm/dl(WHO criteria).
Mean Corpuscular Volume (MCV)
8/12/2019 86-Arshad Original Article
14/34
236 . Infectious Diseases Journal of Pakistan
Discussion
The availability of automated blood cell analyzers that provides
index of RDW has new approaches to patients with anemia.
While the emergency physician is primarily responsible for thedetection of patients with anemia, the inclusion of the RDW in
the complete blood count has made diagnosing certain anemias
easier, especially microcytic8. The measure of elevated RDW
was used by Bessman to classify microcytic anemias into two
categories5. Anemia with normal RDW (microcytic homogenous)
included heterozygous thalassemia and chronic disease, and
those with elevated RDW (microcytic heterogeneous) included
iron deficiency, S beta thalassemia, hemoglobin H, and RBC
fragmentation. In Bessman study, 96% of thalassemia trait cases
were with normal RDW (mean RDW 3.71.6%), while 97%
of iron deficiency anemia cases were with elevated RDW (mean
RDW 16.31.8%). Thus Bessman et alwere able to classify
96% of anemias due to thalassemia minor and 97% due to irondeficiency using RDW 5while Flynn et al7results categorized
only 55% of thalassemia cases as microcytic homogeneous
(normal RDW). In our study RDW was elevated in both cases
(iron deficiency anemia and thalassemia trait) but there was
great difference between their means i.e. 44.14.1% for iron
deficiency and 181.8% for thalassemia trait. In iron deficiency
cases the RDW elevated more than double the normal while in
thalassemia trait, increase was in fractions, so in general our
study did show that it was very unusual for a patient with iron
deficiency to have normal RDW. It appears that iron and
hemoglobin studies are still required to confirm the diagnoses
of iron deficiency and thalassemia in our population.
However, cost and time may be saved by following a sequence
of investigation in evaluating microcytic RBCs. The CBC with
differential and RDW provides the first and most important test
with significant cost savings in our population where affordability
is main problem in diagnosing these two common conditions.
In one study, the result was interesting in a way that they
suggested slight increase in RDW in patients with iron deficiency
and moderately elevated RDW in thalassemia trait4. Results of
another study from India are in accordance with our study which showed
elevated RDW in all cases of iron deficiency anemia
9
.
Conclusion
We suggest that RDW may be useful in initial differentiation
between iron deficient and thalassemia trait patients. In iron
deficiency anemia patients, RDW is likely to be moderately to
markedly elevated, and thalassemia trait patients show slightly
elevated RDW. The cost and time may be saved by following
a sequence of steps in evaluating microcytic RBC.
References1. DeMaeyer EM, Dallman P, Gurney JM, Hallberg L, Sood SK, Srikantia
SG. Preventing and controlling iron deficiency anemia through primary
health care: a guide for health administrators and programme managers1989:5-58 WHO Geneva, Switzerland.
2. Akhtar F, Malik HS, Anwar M. Prevalence of beta thalassemia trait in
patients with hypochromic microcytic anemia. Pak J Pathol 2002;
13(2): 11-3.
3. Weatherall DJ, Clegg JB.Thalassemia syndromes. Oxford 1972; p.113.
4. Roberts GT, El Badawi SB.Red blood cell distribution width index in
some hematologic diseases. Am J Clin Pathol 1985; 83(2):222-6.
5. Bessman JD, Gilmer PR Jr, Gardner FH. Improved classification of
anemias by MCV and RDW. Am J Clin Pathol 1983; 80(3):322-6.
6. Das Gupta A, Hegde C, Mistri R. Red cell distribution width as a measure
of severity of iron deficiency in iron deficiency anemia.Indian J Med Res
1994; 100:177-83.
7. Flynn MM, Reppun TS, Bhagavan NV. Limitations of red blood cell
distribution width (RDW) in evaluation of microcytosis.Am J Clin Pathol
1986; 85(4): 445-9.8. Evans TC, Jehle D. The red blood cell distribution width.J Emerg Med
1991; 9(1):71-4.
9. Viswanath D, Hegde R, Murthy V, Nagashree S, Shah R. Red cell
distribution width in the diagnosis of iron deficiency anemia. Indian J
Pediatr 2001;68(12):1117-9.
10. Laso FJ, Mateos F, Ramos R, Herrero F, Perez-Arellano JL, Gonzalez
Buitrago JM. Amplitude of the distribution of erythrocyte size in the
differential diagnosis of microcytic anemia.Med Clin (Barc)1990; 94(1):1-4.
8/12/2019 86-Arshad Original Article
15/34
Irrational Use of Flagyl (Metronidazole) by Practitioners in Outpatient Clinics
ORIGINAL ARTICLE
Corresponding Author: Tehmina Munir,
Department of Pathology, Combined Military Hospital ,
Multan.
Email: tehmunir_doc@yahoo.com
Abstract
Objective
To determine the frequency of prescription of flagyl by general
practitioners in outpatient clinics in order to limit its use for
treatment of acute diarrhoea and other GIT symptoms.
Study DesignA descriptive study.
Place and Duration of Study
Combined Military Hospital, Multan between 1stJanuary and
31stMay 2010.
Methodology
Total number of patients who were given flagyl during study
period was retrieved from the computerized record of the
patients. Clinical diagnosis was not available in most of the
cases, so to determine the number of patients with diarrhoea,
patients who were advised oral rehydration salts in addition to
oral flagyl was determined. A questionnaire about the preference
of the physicians for various antibiotics for the treatment of
acute diarrhoea was developed and distributed among the doctors
working in the outdoor clinics.
Results
Over a period of 5 months, 4068 patients were prescribed flagyl
for their ailment. The age range of the patients was between 9
months to 65 years. Male to female ratio was 3:1. Out of 4068
patients, 1074(26%) were given flagyl along with oral rehydration
salts indicating that the antimicrobial was being prescribed for
acute diarrhoea. Sixteen doctors working in outdoor/ emergency
departments responded to the questionnaire; 14 (87.5%) preferredflagyl, whereas 8 (50%) prescribed oral flagyl for acute as well
as chronic gastroenteritis. Out of 14 doctors who said that they
prescribed flagyl for acute diarrhoea, 12(75.1%) were highly
qualified medical practitioners and only 2 (12.5%) of them were
without any postgraduate qualification.
Conclusion
Our study showed that flagyl was being grossly misused in the
hospital and being given for the treatment of acute diarrhoea.
Appropriate measures need to be taken and importance of better
prescribing habits should be highlighted during clinical meetings
and discussions.
Key WordsDiarrhoea, Metronidazole.
Introduction
Worldwide acute diarrhoea constitutes a major cause of morbidity
and mortality, especially in the developing countries1. Most
cases of acute diarrhoea are caused by enteric infections. Food
and water-borne outbreaks constitute a major portion of
diarrhoeas reported in outpatient setup. Significant morbidity
and mortality in the developing world is attributable to diarrhoeal
diseases2.
Childhood diarrhoea is a major cause of morbidity and mortality
and causes 3.3 million deaths worldwide. Rotavirus has been
reported to be the most common cause of severe childhood
diarrhoea in developing as well as developed world3. Other
organisms isolated in the stools of patients with diarrhoea are
Es ch er ich ia co li, Ae romo na s spp , Sal mo nel la spp ,
Campylobacter spp, Entamoeba histolytica, Giardia lamblia,
Cryptosporidium etc.Among parasites E. histolyticacauses
bloody diarrhoea, giardiasis results in chronic diarrhoea and
Cryptosporidium causes diarrhoea in immunocompromised
individuals4. Most cases of acute diarrhoea are self-limiting or
viral and last less than a day. Treatment of diarrhoea primarily
consists of rehydration. Bismuth subsalicylate may reduce
enterotoxin action and if there is no significant febrile orinflammatory process, low doses of anti-motility agents may
offer some relief with minimal risk5,6,7.Appropriate antibiotics
may be given for infectious bacterial diarrhoeas8. Most of the
doctors performing their duties in our outpatient departments
are general duty medical officers who have a tendency to over
prescribe medicines and antibiotics.
In our setup, metronidazole is being prescribed to patients of
any age and sex irrespective of type or cause of diarrhoea. A
study was carried out at CMH Multan, 500-bedded hospital, to
know about the prescribing habits of the physicians particularly
for patients of diarrhoea in the outdoor clinics in order to limit
Tehmina Munir*, Munir Lodhi**
* Department of Pathology, ** Paediatric Department, Combined Military Hospital, Multan.
Oct-Dec 2010 . 237Volume 19 Issue 04
8/12/2019 86-Arshad Original Article
16/34
the use of the antimicrobial for the treatment of acute diarrhoea
and other gastrointestinal symptoms.
Material & MethodsTotal number of patients in the hospital, given flagyl
(metronidazole) from 1st January to 31stMay 2010, was
determined from computerized record of the hospital. As most
of the doctors do not write the diagnosis on the prescription
forms, an indirect attempt was made through number of patients
given ORS along with flagyl.
A questionnaire about the preference of the physicians for
various antibiotics for the treatment of acute diarrhoea was
developed and distributed among the doctors working in the
outdoor clinics. Fresh fecal specimens were collected in clean
container and examined under the microscope to detect Giardia
lamblia, Entamoeba histolytica and eggs and ova of otherintestinal parasites. An attempt was made to collect the dysenteric
and watery specimens and pass them on to laboratory within
15 minutes of collection. Direct and eosin slides were prepared
and examined under microscope (10x and 40x).
E. histolyticawas identified by presence of trophozoites having
single nucleus, containing ingested red cells and showing active
directional amoeboid movement. Giardia lambliawas identified
by the presence of small pear shaped flagellate with a rapid
tumbling and spinning motility in fresh diarrhoeal specimens
particularly in mucus. Giardia lambliacysts were looked for
in formed specimens.
Results
During five months, 4068 patients were prescribed flagyl. Mean
age was 33 years; range 9 months to 65 years. Male to female
ratio was 3:1; 3099 (76%) males and 969 (24%) females. All
the outdoor patients were prescribed oral flagyl. Table I shows
patients of var ious age groups who were given flagyl.
Out of 4068 patients, 1074 (26.4%) were given flagyl along
with oral rehydration salts, indicating that the antimicrobial was
being prescribed for acute diarrhoea.
Sixteen doctors who were working in outdoor/emergency
departments responded to the questionnaire. The preferred
antibiotic for acute diarrhoea by 14 doctors was flagyl, whereas
8 prescribed flagyl for acute as well as chronic diarrhoea. Out
of 14 doctors prescribing oral flagyl for acute diarrhea, 12 (75%)
were highly qualified medical practitioners and only 2 (12.5%)were general duty doctors.
During 5 months, 801 stool examinations were performed.
Vegetative form of Giardia intestinaliswas detected in 17
patients whereas that of E. histolytica was not detected.
Discussion
The study observed that flagyl was being misused in the hospital,
unnecessarily prescribed for 1074 patients of acute diarrhoea.
However the extent of the problem may be much bigger as mild
cases of diarrhoea and patients with other GIT symptoms might
have been treated with flagyl. Our results also showed that most
of our qualified practitioners also prefer giving flagyl for acutediarrhoea.
Keeping in view the climatic and the sanitary conditions,
prevalent diarrhoeal diseases constitute a major proportion of
our outpatient workload. A large number of patients were being
treated with flagyl reserved for GIT infections like amoebiasis,
giardiasis, trichomoniasis, anaerobic infections and Clostridium
difficileassociated diarrhoea 9. Metronidazole has also been
used with other drugs for eradicatingH. pyloriin patients with
duodenal ulcer10. Inappropriate use of antimicrobials with
specific reference to flagyl has also been seen in other hospitals
of the country as well. In one of the hospitals in Karachi, 39%of general practitioners and 32% of pediatricians prescribed
anti-amoebics to more than 30% diarrhoeal patients11. The
frequent irrational use of flagyl has been reported in other
developing countries like Bangladesh where in one study 17%
of the patients were treated with metronidazole in outdoor clinics
irrespective of the diagnosis12.
A Dutch researcher studied popularity of drugs particularly
metronidazole in treating diarrhoea in Philipines13. She attributed
this popularity to high frequency of amoebiasis in that country,
poor diagnostic methods, unreliable laboratories and aggressive
pharmaceutical marketing. Our hospital however had an efficient
clinical laboratory and the diagnosis of Giardiasis is rather
simple requiring minimal cost and time. Lack of laboratory
facilities or the inability of patients to afford microbiological
tests were said to be main reason for prescribing antimicrobials
in diarrhoeal cases in Pakistan. However, extremely short
communication time between doctor and patient was also a
major reason for omitting required laboratory tests 14 .
Inadequate knowledge might be an important determinant for
unrestricted and irrational use of metronidazole. Whereas
knowledge may be necessary for good practice, improving
knowledge may not improve prescribing practices15. In our
study even qualified practitioners prescribed flagyl for cases of
238 . Infectious Diseases Journal of Pakistan
Table 1: Age distribution of Patients
Below then 10 years 77
10 to 29 1363
30 to 49 2120
50 to 69 447
Above then 70 61
Age Group No. of Patients
8/12/2019 86-Arshad Original Article
17/34
acute diarrhoea. Studies are needed to look in more depth at the
reasons for this discordance and the extent to which better
knowledge may lead to improvement in prescribing practice for
acute diarrhoea.
Metronidazole is a potential carcinogen and mutagen in rodents.
Acute toxicity causes gastrointestinal tract symptoms whereas
chronic toxicity causes neurological damage16. We should be
extremely cautious while prescribing metronidazole in cases
where its usage is not warranted.
Conclusion
This comparatively smaller scale study showed that metronidazole
is being grossly misused in our hospital. This finding may only
be the tip of the iceberg; a larger scale multicentre study may
provide the exact extent of inappropriate prescription by the
general as well as qualified practitioners. Continued medicaleducation is needed to limit its usage in indicated cases only.
References1. King CK, Glass R, Bresee JS, Duggan C. Managing Acute Gastroenteritis
among Children. Recommendations and Reports- National Center for
Infectious Diseases- Nov 21, 2003/52(RR6); 1-16.
2. Sazawal S, Black RE, Bhan MK. Zinc supplementation reduces the incidence
of persistent diarrhoea and dysentery among low socioeconomic children
in India. J Nutr1996;126:443-50.
3. Shah M, Yousaf Zai M, Lakhani NB, Chotani RA, Naushad G. Prevalence
and correlates of diarrhoea. Ind J Ped iat r 2003; 70(3): 207-11.
4. Lawrence S, Friedman Kurt J. Diarrhea and constipation- Isselbacher and
Brunwald.eds. In: Harrisons Principles and Practice of Internal Medicine.
Vol 1.13th Ed. McGraw Hill 1994. New York, 213-21.
5. Chaudhury SAR. Prescribing a rational drug.Bangla J Physiol Pharmacol
1991;7:1.
6. Palmar DL, Koster FT, Islam AFMR. A comparison of sucrose and glucose
in oral electrolyte therapy of cholera and other severe diarrhoeas.N EngJ Med1997; 297:1107.
7. King Ck, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis
among children- oral rehydration, maintaining nutritional therapy. MMWR
Resource Rep 2003; 52:1-16.
8. Thielman NM, Guerrant RL. Acute infectious diarrhoea.N Eng J Med
2004; 350(1): 38-47.
9. Finegold SM. Metronidazole. In: Mandell, Douglas and Bennetts Principles
and Practice of infectious diseases. New York: Churchill Livingstone, 2000;
361- 5.
10. Carpintero P, Blanco M, Pajares JM. Ranitidine versus colloidal bismuth
subcitrate in combination with amoxicillin and Metronidazole for eradicating
Helicobacter pyloriin patients with duodenal ulcer. Clin Infect Dis1997;
25:1032-7.
11. Murakami K, Okimoto T, Kodama M, Sato R, Wtanabe K, Fujitoka T.
Evaluation of three different proton pump inhibitors with amoxicillin andmetronidazole in the treatment of Helicobacter pyloriinfection. J Clin
Gastroentrol2008; 42(2): 139-42.
12. Nizami SQ, Khan IA, Bhutta ZA. Drug Prescribing Practices of general
practitioners and pediatricians for childhood diarrhoea in Karachi, Pakistan.
Soc Sci Med1996; 42(8): 1133-9.
13. Gyon AB, Barman A, Ahmed JU, Ahmed AU, Alam MS. A baseline survey
on use of drugs at the primary health care level in Bangladesh.Bull WHO
1994; 72(2): 265-71.
14. Van Staa A. Myth and Metronidazole in Manila. The popularity of drugs
among prescribers and dispensers in the treatment of diarrhoea. Master thesis
in Medicine and cultural Anthropology, University of Amsterdam, 1993.
15. Radyowwijati A, Hilbrand H. Determinants of Antimicrobial use in the
developing world. Child Health Research Project Special Report 2002;
4(1): 1-35.
16. Metronidazole (Flagyl) facts, e-MedExpert.com 31 Mar 2008.
Oct-Dec 2010 . 239Volume 19 Issue 04
8/12/2019 86-Arshad Original Article
18/34
240 . Infectious Diseases Journal of Pakistan
Treatment of Helicobacter pyloriInfection; A Controlled Randomized Comparative Clinical Trial
ORIGINAL ARTICLE
Abstract
Background
Helicobacter pylori induces chronic inflammation of the
underlying gastric mucosa and is strongly linked to the
development of duodenal and gastric carcinoma.
Methods
A study was conducted to evaluate the efficacy of Pylorex, a
herbal formulation, for treatment of H. pylori infection as
compared to triple allopathic therapy (Omeprazole, Amoxicillin,
Metronidazole). The therapeutic evaluations of these medicines
were conducted on 97 clinically and immunologically diagnosed
cases ofH. pyloriinfection.
Results
H. pylori was eradicated in 16 (32.6%) out of 49 patients by
the use of triple allopathic therapy (Control drugs), and in 9(18.7%) out of 48 patients by the use of Pylorex (Test drug).
Conclusion
Pylorex possesses a therapeutic value for the treatment ofH.
pyloriassociated symptoms but the eradication rate is superior
in triple allopathic therapy.
Introduction
Helicobacter pylori, gram-negative bacterium, is found on the
luminal surface of the gastric epithelium. It contains a
hydrogenase which produces energy by oxidizing molecular
(H2) that is produced by intestinal bacteria. It produces catalase,
urease and oxidase. It is capable of forming biofilms and can
convert from spiral to a possibly coccoid form. The coccoid
form can adhere to gastric epithelial cells in vitro1- 4. Half of
the world's population is infected by this bacterium. Actual
infection rates vary; people in under developed countries have
much higher infection rates than the developed countries where
estimated rates are around 25% 5-6. Infections are usually acquired
in early childhood. In developed nations it is currently uncommon
to find infected children. The percentage of infected people
increases with age; about 50% infected over the age of 60 yearsas compared to around 10% between 18 and 30 years.7-8
Coded herbal formulation Pylorex contains Curcuma longa,
Mallotus philippinensis and Glycyrrhiza glabra.These medicinal
herbs used in this study were selected on the basis of their
traditional use in Greek system of medicine, especially for
treatment ofH. pyloriinfection9.
This study was conducted to evaluate the efficacy of Pylorex
for treatment of H. pylori infection as compared to triple
allopathic therapy (Omeprazol, Amoxicillin, Metronidazole)
among the population living in Gadap Town.
Materials and methods
The therapeutic evaluations of these medicines were conducted
on clinically and immunologically diagnosed cases ofH. pylori
infection at Shifa-ul-Mulk Memorial Hospital, for Eastern
Medicine, Hamdard University Karachi, from June 2007 to July
2009. All selected patients (n=97) were thoroughly examined.
Participants who were willing to undergo treatment and to attend
all the follow up visits during the clinical trial were selected.
The therapeutic evaluation of the drug was made on the basic
improvement in the subjective signs and symptoms, clinical
observations and laboratory investigations at periodic intervals
during the course of treatment. Patients were randomly assigned
to receive triple allopathic therapy (Omeprazole 20 mg twice
daily 15 minutes before meal, Amoxicillin 500 mg twice daily
and Metronidazole 500 mg twice daily after meal; and 500 mg
Pylorex twice daily. The duration of treatment was 15 days with
a window for follow up visit of 15-30 days for periodic
assessment.
Primary analysis was based on antigen test that uses enzyme
immunoassay to detect the presence of H. pylori antigen in
stool specimens. The samples were tested at Aga Khan
Laboratories Karachi. Weekly record of sign and symptoms
Corresponding Author: Muhammad Akram,
Department of Basic Medical Sciences,
Faculty of Eastern Medicine, Hamdard University,
Madinat-al-Hikmah, Muhammad Bin Qasim Avenue,
Karachi, Pakistan.
Email: makram0451@hotmail.com
Arshad Mehmood*, Khan Usmanghani*, Abdul Hannan*, E. Mohiuddin*, Muhammad Akram*,Muhammad Asif**, Muhammad Riaz ur Rehman**
*Department of Clinical Sciences, Faculty of Eastern Medicine, Hamdard University Karachi, Pakistan
**College of Conventional Medicine, Faculty of Eastern Medicine, The Islamia University Bahawalpur
8/12/2019 86-Arshad Original Article
19/34
was maintained for analyzing the improvement in H. pylori
associated symptoms. Disappearance of abdominal pain, heart
burning, and regurgitation, fullness of stomach, nausea, vomiting,
melena and hematemesis were especially noted.
The subjects were randomly divided into two groups; the test
and the control groups (Table 1). The data was adjusted based
on the number of cases in the light of demographic factor using
statistical methods like multinomial logistic regression. P-value
less than 0.05 was considered as statistically significant.
Results
The intent-to-treat population consisted of 97 patients enrolled;
48 were treated with coded herbal formulation Pylorex and 49
with triple allopathic therapy. The mean age of patients prescribed
Pylorex was 27 years and 26.1 years for males and females
respectively. The mean age of patient prescribed triple allopathictreatment was 26.3 and 28.5 years for males and females
respectively.
According to the analysisH. pylori was eradicated in 16 patients
(32.6%) out of 49 patients by the use of triple allopathic therapy
(Control drug), and in 9 patients (18.7%) out of 48 patients by
the use of Pylorex (Table 2). All differences that were equal to
or more than the set cut-off values were considered clinically
significant. Results of stool antigens before and after both the
treatments are shown in table 1 and 2. The evaluation of H.
pylorieradication was significantly high in the control group
as compared with test group. But there was a significantdifference inH. pylori associated symptoms as observed between
two treated groups at the end of therapy (fig 1).
Discussion
Hundreds of plants worldwide are used in traditional medicine
as treatment for bacterial infections. Some of these have also
been subjected to in vitroscreening but the efficacy of such
herbalmedicines has seldom been rigorously tested in controlled
clinical trials. Conventional drugs usually provide effective
antibiotic therapy for bacterial infections but there is anincreasing
problem of antibiotic resistance and a continuingneed for new
solutions. Although natural products are not necessarilysafer
than synthetic antibiotics, some patients prefer to useherbal
medicines. Thus healthcare professionals should be awareof
the available evidence for herbal antibiotics.
It has been previously reported that Curcuma longa, Mallotus
philippinensis and Glycyrrhiza glabrahave anti-H. pylorieffects
commonly used for the treatment of this infection10-12. In a recent
study, anti-H. pylori activity of 50 commonly used Unani
(traditional) medicinal plants from Pakistan, extensively utilized
for the cure of gastrointestinal disorders, were explored as
natural source compounds againstH. pylori13.
Curcumin is the substance that gives the spice turmeric its
yellow color. Dozens of studies have shown that it is chemo-
preventative, and recently it has been shown to have a strong
antibacterial effect againstH. pylori. Studies have indicatedthat curcumin could be considered as a valuable support in the
treatment of infections14-15.
In a recent study, researchers found that licorice extract produced
a potent effect against clarithromycin-resistantH. pylori strains.
The authors concluded that licorice extract could form the basis
for alternativeH. pyloritherapeutic agent. Licorice extracts are
also effective againstH. pyloristrains resistant to both amoxicillin
and clarithromycin10.
Mallotus philippinensis(Kameela) also has activity against
H. Pyloriespecially against clarithromycin and metronidazole
Table 1: Baseline stool antigen in patients
Baseline
Treatment group
Control(Triple allopathic
therapy)
Total(n)
48 49 97
Test (Pylorex)
Positivestool
antigen
Figure 1: Improvement response in symptoms after treatment
HeartB
urn
Abdo
min
alPa
in
Nausea/vom
iting
Regu
rgita
tion
Fulln
esso
fstomach
Table 2: Stool antigen after treatment
Aftertreatment
Treatment group
Control(Triple allopathic
therapy)
Total(n)
-tive 09 (18.7%) 16 (32.6%) 25
+tive 39 (81.3%) 33 (67.4%) 72
Total 48 49 97
Test(Pylorex)
Stoolantigen
p-value
0.359
Oct-Dec 2010 . 241Volume 19 Issue 04
8/12/2019 86-Arshad Original Article
20/34
242 . Infectious Diseases Journal of Pakistan
resistant strains which could be utilized for the development of
antimicrobials against H. py lori related disorders11 .
So taking advantage, the coded herbal formulation Pylorex,
contains the three ingredients Curcuma longa, Mallotusphilippinensis and Glycyrrhiza glabra for the treatment of
H. pyloriinfection.
Triple allopathic therapy is commonly used for the treatment
of H. pylori infection but it exerts side effects. In order to
overcome this problem, there is a need to find new medicinal
agents, which have good efficacy and less adverse effects. The
control drugs exhibited side effects like gastrointestinal
intolerance nausea and vomiting, whereas Pylorex was well
tolerated by the treated patients. More detailed studies are
needed to evaluate such herbal medicines.
ConclusionThe eradication rate ofH. pyloriis superior in triple allopathic
therapy as compared to Pylorex, however Pylorex possesses a
therapeutic value for the treatment of associated symptoms.
References1. Brown LM .Helicobacter pylori: epidemiology and routes of transmission.
Epidemiol Rev2000;22 (2): 28397.
2. Olson JW, Maier RJ. Molecular hydrogen as an energy source for
He li co ba ct er py lo ri . Science 2002;298 (5599): 178890.
3. Stark RM, Gerwig GJ, Pitman RS (1999). Biofilm formation by
Hel icobacter pyl ori . Let t Appl Mic robi ol 1999;28 (2): 1216.
4. Chan WY, Hui PK, Leung KM, Chow J, Kwok F, Ng CS. Coccoid forms
ofHelicobacter pyloriin the human stomach.Am J Clin Pathol1994;102
(4): 5037.
5. Pounder RE, Ng D. The prevalence ofHelicobacter pyloriinfection in
different countries. Aliment Pharmacol Ther 1995;9(2): 339.
6. Everhart JE, Kruszon-Moran D, Perez-Perez GI, Tralka TS, McQuillanG. Seroprevalence and ethnic differences inHelicobacter pyloriinfection
among adults in the United States.J Infect Dis 2000; 181 (4): 135963.
7. Malaty HM. Epidemiology of Helicobacter pylori infection. Best
Pract Res Clin Gastroenterol2007;21 (2): 20514.
8. Mgraud F.H. pyloriantibiotic resistance: prevalence, importance, and
advances in testing. Gut2004;53 (9): 137484.
9. Said HM (1969). Hamdard Pharmacopoeia of Eastern Medicine. Hamdard
Foundation Karachi;12: 406.
10. Krausse R, Bielenberg J, Blaschek W, Ullmann U.In vitroanti-Helicobacter
pyloriactivity of extractum liquiritiae, glycyrrhizin and its metabolites.
J Antimicrob Chemother2004;54(1):243-6.
11. Syed Faisal Haider Zaidi, Ikuko Yoshida, Farhana Butt, Muhammed
Aasim Yusuf, Khan Usmanghani, Makoto Kadowaki and Toshiro Sugiyama.
Potent Bactericidal Constituents from Mallotus philippinensis againstClarithromycin and Metronidazole resistant strains of Japanese and
Pakistani Hel icobacter pylori . Biol Pharm Bull 2009; 32:631-6.
12. Warren JR, Marshall BJ. Unidentified curved bacilli on gastric epithelium
in active chronic gastritis.Lancet 1983;1:1273-5.
13. Vaezi MF, Falk GW, Peek RM. CagA-positive strains ofHelicobacter
pylori may protect against Barretts esophagus. Am J Gastroenterol
2000;95:220611.
14. Mahady GB, Pendland SL, Yun G, Lu ZZ. Turmeric (Curcuma
longa) and curcumin inhibit the growth ofHelicobacter pylori, a group
1 carcinogen.Anticancer Res 2002.; 22(6):4179-81.
15. Nostro A, Cellini L, Di Bartolomeo S, Di Campli E, Grande R, Cannatelli
MA, Marzio L, Alonzo V. Antibacterial effect of plant extracts against
Helicobacter pylori.Phytother Res2005;3:198-202.
H1N1 INFLUENZA ALERT
In recent weeks several young women, mostly peripartum, and a young male have been admitted to three Karachi
hospitals with acute lung injury (ARDS) and suspected or confirmed H1N1 influenza pneumonia. They all required
ventilatory support.
IDSP strongly recommends influenza vaccination, especially in pregnant women, and vigilance for lower respiratoryinvolvement in all patients with influenza-like illness.
Early diagnosis and treatment with oseltamivir or zanamivir is known to improve outcome.
8/12/2019 86-Arshad Original Article
21/34
Introduction
Typhoid is one of the major health problems of the developingworld where it is responsible for serious morbidity1. Moreover,
the widespread acquisition of plasmid mediated resistance
against the conventional anti-typhoid drugs has added to the
problem2.
The resistance to chloramphenicol emerged in 1970s and the
multidrug resistant strains came to notice in the late 1980s and
early 1990s 3. In Pakistan, the first multi-drug resistant S. typhi
was isolated in 1987 and by the end of 1990s isolation rates
reached epidemic proportions leaving fluoroquinolones and the
3rd generation cephalosporins as the only treatment options 4, 5.
Injudicious use of these drugs has lead to the emergence ofresistance against quinolones as well 6-9.
In recent years, there have been increasing reports of reversal
towards sensitivity to the conventional anti-typhoid drugs from
various parts of the world10,11. Such observations prompted us
to conduct a study at our institute to determine the trend of
susceptibility of typhoidal Salmonellae against the conventional
drugs and help local therapeutic recommendations.
Methods
This study was carried out on typhoidal Salmonellaeisolated
from blood during January 2006 to December 2009 at the
Department of Microbiology of Army Medical College, NationalUniversity of Sciences and Technology (NUST), Rawalpindi.
The blood culture samples were received from the wards of
Military Hospital (MH), Rawalpindi; 1100-bedded tertiary care
hospital. Five mL of venous blood was collected aseptically
using a disposable syringe and added to 50mL of sterile Brain
Heart Infusion broth (BHI) (Merck) from adults and 3mL blood
in 30mL BHI from children. The top of the culture bottle was
cleaned with iodine immediately before the addition of blood.
The subcultures were done on MacConkeys agar (Oxoid,
Basingstoke, UK) at 24 hr, 48 hr, and 5th and 7 thdays. Cultures
showing no growth till seven days were considered as negative.
Corresponding Author: Anam Imtiaz,
Army Medical College, National University of Sciences and
Technology (NUST),
Rawalpindi, Pakistan.
E-mail: anam_ib@hotmail.com
Abstract
Introduction
Typhoid fever is an important public health issue in developingcountries like Pakistan du