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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

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Treasurer M. Asim BegPathology& Microbiology,Aga Khan University, Karachi, Pakistan

Editorial Office

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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 #


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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


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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:[email protected]

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.



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ORIGINAL ARTICLE


Corresponding Author: Fauzia Haji Mohammad,

Department of Family Medicine, Ziauddin University,

Clifton, Karachi.

Email: [email protected]

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


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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


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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



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


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




4. Ototoxicity 7 10 7 175. Gout 6 9 5 12

Side effect of Ethambutol





5. Gout 5 7 5 12

Side effect of Pyrazinamide





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



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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.


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


Ashraf Hussain, Aamer Ikram, Muhammad Roshan, Luqman Satti

Department of Microbiology, Armed Forces Institute of Pathology, Rawalpindi


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



10/34


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


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.



12/34

Corresponding Author: Malik Muhammad Adil,

Department of Medicine,

Shifa International Hospital, Islamabad.


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


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


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)


14/34


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.


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.


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.



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


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


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

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among children- oral rehydration, maintaining nutritional therapy. MMWR

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2004; 350(1): 38-47.

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and Practice of infectious diseases. New York: Churchill Livingstone, 2000;

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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.

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practitioners and pediatricians for childhood diarrhoea in Karachi, Pakistan.

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developing world. Child Health Research Project Special Report 2002;

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16. Metronidazole (Flagyl) facts, e-MedExpert.com 31 Mar 2008.



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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.


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


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



20/34


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

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among adults in the United States.J Infect Dis 2000; 181 (4): 135963.

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Pract Res Clin Gastroenterol2007;21 (2): 20514.

8. Mgraud F.H. pyloriantibiotic resistance: prevalence, importance, and

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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.


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: [email protected]

Abstract

Introduction

Typhoid fever is an important public health issue in developingcountries like Pakistan du

Documents

86-Arshad Original Article