Medicine

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Factors associated with urinary tract infections caused by extended spectrum β-lactamase producing organisms (ESBL-UTI) among hospitalized patients in a tertiary care hospital
(Sri Lanka Medical Association, 2016) Fernando, S.C.; Wickramasinghe, R.D.S.S.; Luke, W.A.N.V.; Gunathilake, M.P.M.L.; Sebastiampillai, B.S.; Miththinda, J.K.N.D.; Silva, F.H.D.S.; Premaratna, B.A.H.R.
INTRODUCTION AND OBJECTIVES: Management of infections caused by ESBL producers is a challenge and expensive. Known associations for ESBL-UTI include recent hospitalizations, recent treatment with cephalosporins, quinolones or penicillin, age over 60 years, male gender, diabetes mellitus, recent Klebsiella pneumoniae infection and obstructive uropathy. Associations for ESBL-UTI in Sri Lanka are not known. METHOD: In order to identify associations of urinary tract infections (UTIs) caused by ESBL producers (ESBL-UTI),a descriptive cross-sectional study was carried out in patients with culture positive ESBL-UTIs admitted to the Professorial Medical unit, Colombo North Teaching Hospital. Patients’ medical records and an interviewer administered questionnaire were used to obtain data. RESULTS: There were 61 patients, 30 (49.1%) males with a mean age of 64.1 years. Of them, 54 (88.5%) had diabetes mellitus,38 (62.2%) had hypertension and 10 (16.3%) had chronic liver disease (CLD). 21 (34.4%) had acute pyelonephritis, 19 (31.1%) had evidence of chronic kidney disease,8 (13%) had obstructive uropathy by ultrasonography. A history of constipation was given in 27 (44.2%), hospitalization during the past 3 months in 30 (49.2%), urinary catheterization in 20 (32.7%) and antibiotic treatment within the past 3 months in 39 (63.9%). CONCLUSION: Most associations for ESBL-UTI in Sri Lanka were similar to that had been previously described. However the observed higher incidence of CLD, hypertension and CKD needs further evaluation. The fact that 50.8% did not have a history of recent hospitalization and 36.1% did not have recent antibiotic therapy suggest high community prevalence of ESBL producing organisms.
Antibiotic sensitivity patterns among extended spectrum β-lactamase (ESBL) producing organisms causing urinary tract infections in Sri Lanka
(Sri Lanka Medical Association, 2016) Luke, W.A.N.V.; Fernando, S.C.; Wickremasinghe, R.D.S.S.; Sebastiampillai, B.S.; Gunathilake, M.P.M.L.; Miththinda, J.K.N.D.; Silva, F.H.D.S.; Premaratna, B.A.H.R.
INTRODUCTION AND OBJECTIVES: ESBLs are enzymes that confer resistance to all penicillins, cephalosporins, and aztreonam. ESBL producing organisms causing urinary tract infections (ESBL-UTI) are increasing in incidence and pose a major burden to health care requiring treatment with expensive antimicrobials and prolonged hospital stay. Documented antibiotic susceptibility of ESBL organisms include meropenem (95-100%) and aminoglycosides (45-60%). This study evaluated the antibiotic sensitivity patterns of ESBL-UTI in Sri Lanka. METHOD: Patients with ESBL-UTI admitted to Professorial Medical Unit, Colombo North Teaching Hospital (CNTH) from January – June 2015 were recruited to the study. Their Urine culture and ABST reports were evaluated after obtaining informed written consent. RESULTS: Of 61 culture positive ESBL-UTIs, E. coli accounted for 53 (86.8%), followed by Klebsiella in the 8 (13.1%). The ESBL organisms were mostly sensitive to carbapenems; 58 (95%) to Meropenem and 45 (73.7%) to Imipenem. The other sensitivity patterns were 37 (60.6%) to Amikacin, and 28 (45.9%) to Nitrofurantoin. Meropenem resistance was observed in 3 (4.9%) and were E.coli. These three patients had received multiple antibiotics including meropenem in the recent past for recurrent UTI. CONCLUSIONS: It is evident from the above data that Carbapenems remain as the first line therapy for the majority of ESBL-UTI in the local setting. However 4.9 % prevalence of meropenem resistance is alarming compared to 0.4% prevalence in Pakistan and 0.02% prevalence in Germany. Such high prevalence of meropenem resistance should draw attention of clinicians and needs to implement measures to prevent emergence and spread of carbapenum resistant ESBL organisms in the country.
Extended spectrum beta lactamase producing organisms causing urinary tract infections in Sri Lanka and their antibiotic susceptibility pattern -A hospital based cross sectional study
(BioMed Central, 2017) Fernando, , M.M.P.S.C.; Luke, W.A.N.V.; Miththinda, J.K.N.D.; Wickramasinghe, R.D.S.S.; Sebastiampillai, B.S.; Gunathilake, M.P.M.L.; Silva, F.H.; Premaratna, R.
BACKGROUND: Extended Spectrum Beta- Lactamase producing organisms causing urinary tract infections (ESBL-UTI) are increasing in incidence and pose a major burden to health care. While ESBL producing Klebsiella species seem to account for most nosocomial outbreaks, ESBL-producing E. coli have been isolated from both hospitalized and non-hospitalized patients. Although 95-100% ESBL organisms are still considered sensitive to meropenem, rapid emergence of carbapenem resistance has been documented in many countries. The objective of this study was to evaluate urinary tract infections caused by ESBL producers and the antibiotic susceptibility patterns in Sri Lanka. METHODS: Patients with confirmed ESBL-UTI admitted to Professorial Medical Unit, Colombo North Teaching Hospital from January - June 2015 were recruited to the study. Their urine culture and antibiotic susceptibility reports were evaluated after obtaining informed written consent. RESULTS: Of 61 culture positive ESBL-UTIs, E. coli caused 53 (86.8%), followed by Klebsiella in 8 (13.1%).30 (49.1%) had a history of hospitalization within the past three months and included 6/8(75%) of Klebsiella UTI and 24/53(45.2%) of E.coli UTI. Antibiotic susceptibility of ESBL organisms were; Meropenem 58 (95%), Imipenem 45 (73.7%), Amikacin 37 (60.6%) and Nitrofurantoin 28(45.9%). In 3(4.9%), E.coli were resistant to Meropenem. These three patients had received multiple antibiotics including meropenem in the recent past for recurrent UTI. CONCLUSIONS: We observed a higher percentage of E. coli over Klebsiella as ESBL producing organisms suggesting most ESBL-UTIs to be community acquired, Carbapenems seem to remain as the first line therapy for majority of ESBL-UTIs in the local setting. However 4.9% prevalence of meropenem resistance is alarming compared to other countries. Although prior antibiotic utilization and hospitalization may contribute to emergence of ESBL producing Klebsiella and E.coli in Sri Lanka, high prevalence of community acquired ESBL-E. coli needs further investigations to identify potential causes . Being a third world country with a free health care system, observed alarming rate of carbapenem resistance is likely to add a significant burden to health budget. We feel that treatment of infections in general needs a careful approach adhering to recommended antibiotic guidelines in order to prevent emergence of multi drug resistant organisms.
Predicting acute liver failure in dengue Infection
(American Gastroenterological Association(AGA) Institute, Published by Elsevier Inc., 2013) Ranawaka, C.; Niriella, M.A.; Kumarasena, R.S.; Miththinda, J.K.N.D.; de Silva, A.P.; Premaratna, R.; de Silva, H.J.
BACKGROUND: Dengue infections (DI) can range from being asymptomatic to severe illness. Unusual manifestations such as encephalitis, myocarditis, and acute liver failure (ALF) have been recognized. ALF is uncommon, but has a poor prognosis. The aim of this study was to identify predictors of ALF in DI. METHODS: Serologically confirmed patients with DI who were admitted to hospital from January 2009 to March 2010 were included. Patients consisted of direct admissions as well as referrals, some with deranged liver functions. Data was obtained from patient records. Clinical details and serum biochemistry was evaluated for up to five days from onset of illness. ALF in DI was defined as evidence of coagulation abnormality [International normalised ratio (INR) ≥ 1.5], and any degree of mental alteration (encephalopathy) in a patient without pre-existing cirrhosis. RESULTS: Out of 240 patients [57.7% male, 42.3% female; mean age 35.6 years (SD 15.4 years)], 164 had dengue with warning signs, 27 had dengue without warning signs and 49 had severe dengue. 15/49 severe dengue patients had profound shock. Abdominal pain, persistent nausea and vomiting (PNV), bleeding, hepatomegaly and ascites were present in 125, 92, 39, 129 and 28 cases respectively. Elevated aspartate aminotransferase (AST), serum bilirubin (SB), alkaline phosphatase (ALP) and gamma glutamyl transpeptide (GGT) were observed in 208, 20, 18 and 60 patients respectively. Of the 240 patients 41 had AST .1000 IU/ml (this included 4/ 15 with profound shock). 16/41 patients with AST .1000 IU/ml, including 4 with profound shock, developed ALF while none with AST ,1000 IU/ml developed ALF. In patients with AST .1000 IU/ml, presence of 2 or 3 of elevated SB, elevated ALP or PNV predicted the development of ALF with 93.8% sensitivity, 98.7% specificity, 83.3% positive predictive value and 99% negative predictive value (Fisher's exact test). CONCLUSIONS: Dengue patients with AST,1000 IU/ml are not at risk of developing ALF. Patients with AST .1000 (regardless of presence or absence of profound shock), with 2 or 3 of elevated SB, elevated ALP or PNV seem to be at risk of developing ALF. These findings need to be validated in a larger cohort of patients.
Association between road accidents and low-grade hepatic encephalopathy among Sri Lankan drivers with cirrhosis: a prospective case control study
(Biomed Central, 2016) Subasinghe, S.K.C.E.; Nandimuni, Y.; Ranasinghe, S.; Niriella, M.A.; Miththinda, J.K.N.D.; Dassanayake, A.S.; de Silva, A.P.; de Silva, H.J.
BACKGROUND: Low-grade hepatic encephalopathy (LGHE) comprises minimal hepatic encephalopathy (MHE) and grade 1 hepatic encephalopathy. LGHE has no or minimal recognizable symptoms but has mild cognitive and psychomotor deficits. Studies in Western countries have demonstrated increased road accidents (RA) among patients with MHE. Our objective was to investigate the association between Sri Lankan LGHE phenotype and RA. STUDY DESIGN AND METHODS: A prospective, case–control study was conducted in the University Medical Unit, North Colombo Teaching Hospital, Ragama Sri Lanka. Patients with cirrhosis of any aetiology, without OHE, who had been driving during previous 1 month were included. A similar number of age matched, healthy control drivers were also enrolled. Both groups were subjected to five pencil-paper based psychometric tests used to detect LGHE in cirrhotics. Self-reported RA during the previous 1 month were recorded: categorized as ‘major’ when resulted in hospitalization of the involved, ‘minor’ when there were injuries, but not serious enough for hospitalization of the involved and ‘other’ when limited to damages to vehicle or environment without injuries. RESULTS: Among 55 drivers with cirrhosis and LGHE [males, median age 53 years (range 30–60)], 7 (12.7 %) reported RA compared to 6 (10.9 %) among 55 controls [males; median age 51 years (range 30–60)]. There were no ‘major’ accidents in either group. 2/55 (3.6 %) cases and 2/55 (3.6 %) controls reported ‘minor’ accidents. CONCLUSION: There was no increased frequency of RA among Sri Lankan drivers with LGHE compared to healthy controls. This is with the limitation of the study based only on self reported RA.
Antibiotic sensitivity patterns of Extended-Spectrum β-Lactamase urinary tract infections in Sri Lanka
(Faculty of Medicine, University of Kelaniya, Sri Lanka, 2016) Sebastiampillai, B.S.; Premaratna, B.A.H.R.; Luke, W.A.N.V.; Wickramasinghe, R.D.S.S.; Gunathilake, M.P.M.L.; Miththinda, J.K.N.D.
BACKGROUND: Extended-spectrum β-lactamase (ESBL) producing organisms causing urinary tract infections (UTI) are increasing in incidence and poses a major burden to health care requiring treatment with expensive antimicrobials and prolonged hospital stay. The prevalence of ESBL producing organisms particularly in the Asian region remains unknown. OBJECTIVES: To identify common ESBL producing organisms and to evaluate the antibiotic sensitivity patterns of ESBL UTIs in Sri Lanka. METHODS: Patients admitted with ESBL-UTI to Professorial Medical Unit, Colombo North Teaching Hospital, Ragama over a period of 6 months from January 2015 were recruited. Their Urine culture and ABST reports were analysed after obtaining informed written consent. RESULTS: Of the 52 patients who consented to be on the study, 30 (57.7%) were males. Mean age was 64.11 (SD=12.59) years. E. coli was the commonest organisms (84.6%; n=44), causing the ESBL-UTI followed by Klebsiella (15.4%; n=8). Fifty (96.2%) patients were sensitive to meropenem, 38 (73.1%) to imipenem, 30 (57.7%) to amikacin and 24 (46.2%) to nitrofurantoin. Meropenem resistance was found in 2 (3.8%) cases which were due to infection with E. coli.These two patients had received multiple antibiotics including meropenem in the recent past for recurrent UTI. CONCLUSIONS: While E. coli and Klebsiella are the commonest ESBL producing organisms causing UTI, carbapenems remain as the first line therapy. However 3.8% prevalence of meropenem resistance among the study population should draw attention of clinicians and needs implementation of measures to prevent emergence of carbapenum resistant ESBL organisms.
Predicting acute liver failure in dengue infection
(Sri Lanka Medical Association, 2016) Kumarasena, R.S.; Niriella, M.A.; Ranawaka, C.K.; Miththinda, J.K.N.D.; de Silva, A.P.; Dassanayake, A.S.; de Silva, H.J.
In a retrospective study involving 240 patients with dengue infection, we attempted to identify early predictors of acute liver failure (ALF). Sixteen out of 41 patients with serum AST more than 1000 IU/ml developed ALF compared to none with serum AST less than 1000 IU/ml. Among patients with serum AST more than 1000 IU/ml, presence of two of the three following phenomena, within the first 5 days of illness: elevated serum bilirubin, elevated alkaline phosphatise or persistent nausea and vomiting, predicted development of ALF (93.8% sensitivity, 98.7% specificity, 83.3% positive predictive and 99% negative predictive value). The presence of elevated serum bilirubin, alkaline phosphatase and persistent nausea and vomiting in patients with very high serum AST during the early phase of dengue infection should alert the physician of impending ALF.
A study to determine quantitative predictors for development of third space fluid accumulation in adult patients with dengue
(Sri Lanka Medical Association, 2012) Premaratna, R.; Ragupathy, A.; Miththinda, J.K.N.D.; de Silva, H.J.
INTRODUCTION: Prediction of severe illness remains the most important measure in preventing mortality associated with dengue. Increased vascular permeability leading to reduced intravascular volume is the hallmark of dengue shock syndrome. Third space fluid accumulation (TSFA) reflects severe vascular permeability and therefore, it is important to quantitatively identify parameters which predict the occurrence of TSFA in dengue. METHODS:102 patients with confirmed dengue were prospectively followed up for clinical, haematological, biochemical parameters and for evidence of TSFA by serial utrasonography. These parameters were tested against development of TSFA using Receiver Operating Characteristic [ROC] curves to identify quantitative predictors of development of TSFA. RESULTS: 102 patients (52 males) with mean age 28.3 years (SD 11.8), TSFA was detected in 34/95 [36%) after admission; 21/95 developed ascites at mean 5.7 days of illness (SD 1.3) and 33/95 had pleural effusion at 5.4 days (SD 1.5). Onset of TSFA could be identified using percentage rises of highest PCV (p= 0.002) where 6.5% rise of PCV predicted TSFA(sensitivity 61%, specificity 62%)], highest Hb (p=0.017) where rise of 6.1% in Hb predicted TSFA (sensitivity 55%, specificity 64%), lowest recorded platelet count (p<0.000) where platelet count of 48500/mm3 or less predicted TSFA (sensitivity of 83%, specificity 51) post-admission fluid input-output balance per day (p 0.002) where positive balance more than 777cc/day predicted TSFA (sensitivity 65%, specificity 64%). CONCLUSIONS: Rise of PCV and Hb, platelet count, WBC count and daily fluid balance appear to be useful quantitative predictors of TSFA in dengue.
Predictors of duration and degree of third space fluid accumulation in adult patients with dengue
(Sri Lanka Medical Association, 2012) Premaratna, R.; Ragupathy, A.; Miththinda, J.K.N.D.; de Silva, H.J.
INTRODUCTION: Fluid leakage is the hallmark of dengue shock syndrome. It is important to identify clinical and biochemical parameters which predict duration and degree of fluid leakage in dengue. METHODS: 102 patients with confirmed dengue were prospectively followed up for clinical, haematological and biochemical parameters, and they were correlated with ultrasonographic evidence of third space fluid accumulation (TSFA). RESULTS: Of the 102 patients (52 males; mean age 28.3 years(SD=11.8), TSFA was detected in 34/95(36%) after hospital admission; 33/95 had pleural effusions which included all except one of 21/95 who had ascites. 72.7% pleural effusions lasted 3 or more days and 52.4% ascites lasted less than 3 days. Duration of pleural effusion showed a significant positive correlation with maximum percentage rises of PCV (r=0.526,p=0.001) and Hb(r=0.525, p=0.001) and negatively correlated with WBC count (r=-0.361, p=0.020) and platelet count (r=-0.585, p=0.000). There was no correlation with any of the other parameters. The mean lowest WBC count of 3005/mm3that was recorded for patients who developed bilateral pleural effusions (n=21) was significantly less (p=0.042) than the mean lowest WBC count of 4091/mm3 that was detected for unilateral effusions(n=12). Duration of ascites was significantly positively correlated with highest AST(r=0.598, p=0.002) and highest ALT(n=0.721, p=.001. CONCLUSIONS: Maximum percentage rise of Hb and PCV, lower WBC and platelet counts seem to be associated TSFA. Among these, lower WBC counts appear to be more predictive of the degree of fluid leakage. Higher ALT and AST levels seem to be useful in predicting the duration of ascites.
Profile of gastric varices among Sri Lankan cirrhotics
(Sri Lanka Medical Association, 2012) Ranawaka, C.K.; Mettananda, K.C.D.; de Alwis, W.H.S.; Miththinda, J.K.N.D.; Mriella, M.A.; de Silva, A.P.; de Silva, H.J.
INTRODUCTION: Gastric varices (GV) can result in life threatening bleeding. There have been no studies on the characteristics of GV among Sri Lankan cirrhotics. Aims: To perform a descriptive analysis of GV among a Sri Lankan cirrhotic population METHODS: Medical records of all upper gastrointestinal endoscopies performed on cirrhotics at presentation, in the University Endoscopy Unit, Colombo North Teaching Hospital, Ragama, from 2006 to 2011 were screened. Demographics, indication and findings of endoscopy were analysed. RESULTS: 628/641(98%] of the cirrhotic population screened had a complete data set for analysis. 70/628(11%) patients had GV[ma!e-61(87%), female-9(13%); mean age 55(SD = +/- 10.7, range 23-81 years]]. 48/70(69%] had oesophageal varices (Gastro Oesophageal Varices (GOVl-18/48(38%), GOV2- 30/48(62%] in addition to GV and 22/70(31%] had Isolated GV (JGV1 -10(45%], IGV2 -12(55%]]. 38/70(54%] had portal hypertensive gastropathy and 3/70(4%] had gastric antral vascular ectasia in addition to GV. 51/70 (73%] were detected on initial screening of cirrhotics, while 19/70(27%][6/22(27%] with IGV] were detected at presentation with upper gastrointestinal bleed (UGIB]. 288/628(46%] had oesophageal varices (EV). 240/288(83%] had only EV without GV. 163/240(68%) were detected on initial screening of cirrhotics, while 77/240(32%) were detected at presentation with UGIB. There was no statistical significance between proportion of patients detected to have isolated EV or IGV at presentation with UGIB (p=0.64; ?2=0.2) CONCLUSIONS: The profile of GV among our patients is comparable to what is previously described elsewhere. Findings suggest in cirrhotic patients presenting with UGIB searching for presence of GV, by retroflexion at endoscopy, is as important as identifying EV.

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