Infectious Diseases Journal of Pakistan

Clinical profile and azole resistance in clinical and environmental isolates of Aspergillus flavus complex from Pakistan

Adan Iftekhar — 2026-09-30

Objective: To determine the azole susceptibility profile of Aspergillus flavus (A. flavus) complex isolates from clinical and environmental sources in Pakistan, where data on azole resistance are limited.

Materials and Methods: A cross-sectional study was conducted at Aga Khan Hospital, Karachi, from January 2020 to December 2022. A total of 225 A. flavus complex isolates (151 clinical and 74 environmental) were included. Minimum inhibitory concentrations (MICs) for voriconazole, itraconazole, and posaconazole were determined using the broth microdilution method in accordance with Clinical and Laboratory Standards Institute (CLSI) guidelines. Epidemiological cut-off values (ECVs) were used to identify non–wild-type (NWT) isolates. Clinical data were available for 94 patients.

Results: Invasive aspergillosis was the most common clinical presentation (67/94; 71%), predominantly affecting patients with COVID-19 (35/67). Overall mortality was 32%. One clinical isolate exhibited MICs above the ECV for all three azoles, while two additional clinical isolates showed elevated MICs to posaconazole only. Among environmental isolates, two demonstrated MICs exceeding the ECV for posaconazole. Overall, NWT isolates were identified in 1.98% of clinical and 2.7% of environmental samples.

Conclusion: Azole resistance in A. flavus complex remains uncommon in Pakistan; the detection of NWT isolates in both clinical and environmental settings underscores the importance of ongoing surveillance and molecular studies to better characterize resistance mechanisms.

Keywords: Antifungal susceptibility testing, Aspergillosis, Aspergillus flavus, Azoles, Drug resistance, Fungal, Epidemiological cut-off values, Pakistan

Clinical spectrum of measles related diseases in children admitted in PICU of public-sector hospital of Pakistan

Urooj Faisal — 2026-09-30

Background: Measles is a highly contagious, grave viral disease that can cause severe complications and death. Despite the availability of a safe and cost-effective vaccine, measles remains a major health problem in many developing countries, including Pakistan.

Objectives: To evaluate the clinical spectrum of measles related diseases (MRD) including risk factors, complications and outcomes in children admitted with complicated measles in pediatric intensive care unit (PICU).

Materials and Methods: A descriptive retrospective analysis was done in patients with clinical diagnosis of measles under 12 years of age admitted in isolation room PICU of Sindh Institute of Child Health and Neonatology (SICHN) in Karachi from January 2023 to June 2023.

Results: Total 228 patients, 13.8% of total admissions were admitted with MRD in our PICU were included in study. Almost one third (39%) of patients were less than 9 months of age, malnourished (66%), 63% didn’t receive the first dose of vaccination and 85% didn’t receive the second dose. Case specific mortality was 10.08%. Pneumonia and Encephalitis were the most common complications and associated risk factors for mortality.

Conclusion: Measles elimination can be achieved through high vaccination coverage to decrease the spread of disease contacts.

Efficacy of prolonged versus standard infusion meropenem in critically Ill pediatric patients with sepsis: A randomized controlled trial

Nadia Iqbal — 2026-09-30

Background: This study compared meropenem administered for a longer duration with its standard duration in suspected and confirmed bacterial sepsis. This study aims assess the efficacy of prolonged infusion meropenem versus standard infusion in critically ill patients admitted to the pediatric ICU.

Material and Methods: This randomized controlled trial included 150 critically ill pediatric patients and was conducted in the Pediatric Intensive Care Unit of PNS Shifa Hospital, Karachi, from 01 January 2025 to 30 June 2025. The trial was registered at ClinicalTrials.gov (NCT07122596). Children (1 month to 16 years) with suspected or proven bacterial sepsis who required meropenem intravenously were selected. Independent samples t-test or Mann–Whitney U test was used to compare continuous variables, and chi-square or Fisher's exact test was used to compare categorical variables. The relative risks with 95% confidence intervals were used to express the effects of treatment.

Results: Baseline characteristics were comparable between groups. The mean age was 7.7 ± 2.04 years in the prolonged infusion group and 7.6 ± 1.98 years in the standard infusion group. Day-7 clinical success was significantly higher with prolonged infusion (92.0% vs. 73.3%; RR 1.25, 95% CI 1.08–1.46; p=0.003), with greater microbiological eradication among culture-positive patients (91.4% vs. 75.4%; p=0.012). Prolonged infusion also reduced time to clinical improvement and PICU stay, while in-hospital mortality was lower but not statistically significant.

Conclusion: Prolonged infusion of meropenem improved clinical success and shortened PICU stay.

Keywords: Anti-bacterial agents, Critical illness, Infusions, Intravenous, Intensive care units, Meropenem, Pediatrics, Sepsis.

Direct identification of bacteria from positive blood culture bottles by VITEK-MS: evaluation of two lysis-centrifugation methods

Abdul Rehman — 2026-09-30

Background: Bloodstream infections cause significant global morbidity and mortality, and although MALDI-TOF MS accelerates pathogen identification, it still requires subculture. This study evaluated two in-house lysis-centrifugation methods (LCMs) using sodium dodecyl sulfate (SDS) and Triton X-100 for direct pathogen identification from positive blood culture bottles. To compare the diagnostic accuracy of SDS- and Triton X-100-based LCMs for direct bacterial identification from positive blood culture bottles using VITEK MS.

Material and Method: This study was conducted at the Chughtai Institute of Pathology, Lahore. Positive blood culture bottles were analyzed using the standard culture-based method and both LCM protocols in parallel. Blood cultures with polymicrobial growth, yeast on Gram stain, or no identification by the standard-of-care method were excluded. Concordance, diagnostic accuracy, and processing time were assessed.

Results: A total of 251 monobacterial positive blood cultures were analyzed. The SDS and Triton X-100 protocols correctly identified 62.5% and 59.8% of isolates, respectively (p = 0.52). Concordance was higher for Enterobacterales (66.7%) than for non-Enterobacterales (50.0% and 32.1%, respectively). Identification rates for Salmonella enterica were significantly lower than for other Enterobacterales (p < 0.001). Both methods required less than 15 minutes of hands-on time per sample and showed fair agreement (κ ≈ 0.31).

Conclusion: Both LCMs provided rapid, low-cost identification with comparable performance. Their utility was greater for Enterobacterales other than S. enterica, while low S. enterica identification rates limit their application for rapid enteric fever diagnosis.

Key words: Blood culture, MALDI-TOF, Sepsis, Bloodstream infection, Lysis centrifugation.

Prevalence of depression, anxiety, and stress among human immunodeficiency virus patients in Swabi District, Pakistan

Samiulhaq — 2026-09-30

Background: HIV infection causes psychological distress, with depression, anxiety, and stress as frequent comorbidities. However, data on their prevalence in rural Pakistan is limited. This study aimed to determine their prevalence and associated factors in Swabi District, Pakistan.

Methods: A cross-sectional study was conducted in the Infectious Diseases Department of MTI Bacha Khan Medical Complex, Swabi, Pakistan. A total of 323 patients who were on antiretroviral treatment and suffered from HIV were selected based on convenience sampling method. The Depression, Anxiety, and Stress Scale-21 (DASS-21) was applied for identifying the psychological distress of patients. SPSS version 21 was used for statistical analysis of data through descriptive statistics, chi-square, independent t-test and ANOVA.

Results: 56.7% of patients suffered from depression (n=183); the same percentage of them had anxiety (n=183); 52.3% were characterized by stress (n=169). Significantly high levels of mean DASS scores in females and transgender respondents were found in comparison to male patients in terms of all three scales (p<0.001). In bivariate analysis, it was determined that gender, marital status, education, occupation, place of residence, socioeconomic status, CD4 count, clinical stage, opportunistic infections, social support, stigma, and disclosure were significantly correlated with depression, anxiety, and stress (p<0.001).

Conclusion: Over half of the participants with HIV from this study have depression, anxiety or stress. The screening and intervention for mental health problems should be incorporated into the HIV service package.

Keywords: Anxiety, Depression, HIV, Pakistan, Stress.

Frequency of functional outcome and predictors of mortality in patients with tuberculous meningitis at tertiary care hospital Karachi

Hafiza Neelam Zulfiqar Lakhani — 2026-09-30

Background: Tuberculous meningitis is a severe form of extrapulmonary tuberculosis associated with significant neurological disability and mortality. To determine the frequency of functional outcome and predictors of mortality in patients presenting with tuberculous meningitis at Tertiary Care Hospital, Karachi.

Material and Methods: This descriptive, longitudinal study was carried out in the Department of Neurology, Jinnah Postgraduate Medical Centre (JPMC), Karachi from February 2026 to July 2026. All patients with tuberculous meningitis were recruited using a non-probability consecutive sampling method. Functional outcomes were evaluated after admission at 90 days with the modified Rankin Scale [mRS] of which good functional outcome was considered as mRS ≤2 and poor functional outcome as mRS 3–6. British Medical Research Council (BMRC) staging system was used. A p-value ≤0.05 was considered statistically significant.

Results: Among 147 patients with tuberculous meningitis, the median age was 41.0 years (IQR: 31.0–55.0), and 89 (60.5%) were male. Mortality was significantly higher among patients with BMRC Stage III disease than among those with Stage I/II disease (60.9% vs. 22.8%, p<0.001). On multivariable logistic regression analysis, mechanical ventilation (adjusted odds ratio [AOR]=6.92, 95% CI: 2.41–19.84, p<0.001), BMRC Stage III disease (AOR=4.58, 95% CI: 2.01–10.42, p<0.001), hydrocephalus (AOR=3.37, 95% CI: 1.42–7.98, p=0.006), and serum sodium ≤125 mmol/L (AOR=2.76, 95% CI: 1.12–6.79, p=0.027) were independently associated with increased odds of mortality.

Conclusions: Despite treatment, tuberculous meningitis was found to be associated with significant mortality and functional disability.

Keywords: Tuberculous meningitis, Functional outcome, Modified Rankin Scale, Prognostic factors.

Evaluation of a ceftazidime-avibactam and aztreonam disc diffusion synergy test using the broth disc elution method as the reference standard

Faiza Zaheer — 2026-09-30

Background: Ceftazidime-avibactam (CZA) combined with aztreonam (ATM) restores activity against metallo- -lactamase-producing Enterobacterales. Broth disc elution (BDE) is recommended for testing this combination but is often impractical in resource-limited settings. This study determined the diagnostic accuracy of a CZA–ATM disc diffusion synergy test using BDE as the reference standard.

Material and Methods: This prospective cross-sectional study was conducted at the Armed Forces Institute of Pathology, Rawalpindi, from November 17, 2025, to May 17, 2026. A total of 140 non-duplicate carbapenem-resistant Enterobacterales isolates non-susceptible to CZA and ATM were tested in parallel by disc diffusion synergy and BDE using independent, blinded readers. Sensitivity, specificity, predictive values, accuracy, and Cohen's with 95% confidence intervals (CIs) were calculated.

Results: BDE detected synergy in 80 of 140 isolates (57.1%). Disc diffusion yielded 55 true positives, 60 true negatives, 25 false negatives, and no false positives. This demonstrated a sensitivity of 68.8% (95% CI 57.9–77.9), specificity of 100% (95% CI 94.0–100), positive predictive value of 100% (95% CI 93.5–100), negative predictive value of 70.6% (95% CI 60.2–79.2), accuracy of 82.1% (95% CI 75.0–87.6), and Cohen's of 0.65 (95% CI 0.54–0.77).

Conclusion: The disc diffusion synergy test showed 100% specificity but moderate sensitivity for in-vitro CZA–ATM synergy. A positive result reliably identifies synergy, whereas approximately one-third of synergistic isolates were missed.

Keywords: Antimicrobial susceptibility testing, Aztreonam, Broth disc elution, Carbapenem-resistant Enterobacterales, Ceftazidime-avibactam, Disc diffusion, Metallo- -lactamase.

Procalcitonin as a predictor of prognosis in patients with bacteremia admitted to the intensive care unit

Sidra Noor — 2026-09-30

Background: The study aimed to determine the association between procalcitonin levels and clinical outcomes in patients with bacteremia admitted to the intensive care unit and to compare procalcitonin levels between community-acquired and hospital-acquired bacteremia.

Material and Methods: A prospective observational longitudinal study was conducted from 1^st September 2025 to 28^th February 2026 in the adult intensive care units of Mem on Medical Institute Hospital, Karachi. Using consecutive sampling, a total of 199 adult patients with proven bacteremia were enrolled. The Roche Cobas e411 ECLIA platform was used to measure procalcitonin levels at admission, day 5, and day 10. Hospital mortality was the primary outcome. Data were analyzed using SPSS version 26.

Results: Among 199 ICU patients with bacteremia, the median age was 53.5 years, and 59.3% were male; sepsis was the most common diagnosis (31.2%). Median procalcitonin (PCT) levels declined from 8.90 ng/mL at baseline to 5.70 and 3.60 ng/mL on days 5 and 10, respectively. PCT levels were significantly higher in hospital-acquired than community-acquired bacteremia at all three time points (p≤0.009). Baseline PCT was highest among non-survivors (14.80 ng/mL), compared with survivors (6.40 ng/mL) and patients leaving against medical advice (9.60 ng/mL). Mortality increased significantly with rising PCT levels, from 7.5% for PCT 10 ng/mL (p<0.001).

Conclusion: Higher baseline procalcitonin levels were significantly associated with mortality among ICU patients with bacteremia. Procalcitonin levels were also significantly higher in patients with hospital-acquired bacteremia compared with those with community-acquired bacteremia.

Keywords: Bacteremia, Hospital-acquired bacteremia, Intensive care unit, Mortality, Procalcitonin, Prognosis.

Frequency of hyperchloremia and mortality in patients presenting with sepsis at tertiary care hospital, Karachi

Arika Ishtiaq — 2026-09-30

Background: Hyperchloremia is frequently encountered in critically ill patients with sepsis and may reflect disease severity, altered renal handling, or exposure to chloride-rich intravenous fluids. This study was designed to assess the prevalence and in-hospital mortality for hyperchloremia in patients with sepsis.

Material and Methods: This cross-sectional study included 165 adults aged 30 to 80 years admitted with sepsis to the Department of Medicine, Aga Khan University Hospital, Karachi. Chloride was tested within 12 hours of admission and hyperchloremia was defined as >107 milliequivalents per liter (mEq/L). Demographic characteristics, comorbidities, intensive care unit admission and in-hospital mortality were documented. Chi-square test or Fisher's exact test was used to assess associations with a p-value ≤0.05 regarded as statistically significant.

Results: Hyperchloremia was present in 66 (40.0%) of 165 patients and 33 (20.0%) patients died during hospital stay. Patients with sepsis duration >24 hours had significantly higher incidence of hyperchloremia compared to those with ≤24 hours duration of sepsis (73.1% vs. 33.8%, p<0.001). Important associations were also noted with diabetes mellitus (p=0.001), hypertension (p=0.002), dyslipidemia (p=0.006) and anaemia (p<0.001). Among the patients who had hyperchloremia, 16 (24.2%) died compared with 17 (17.2%) patients who did not have hyperchloremia; this was not statistically significant (p=0.266).

Conclusions: Hyperchloremia was prevalent in patients with sepsis and was linked to longer sepsis duration and specific co-morbidities. While there was a higher number of deaths in the hyperchloremic group, hyperchloremia was not significantly related to in-hospital death.

Keywords: Chlorides, Critical care, Fluid therapy, Hospital mortality, Sepsis.

Contents Pages

Editor Office — 2026-10-05

Disconnection between guidelines, policy and implementation of Infection prevention and control in Pakistan

Shoba Luxmi — 2026-10-05

A few months ago, I was engaged by a private university teaching hospital to help pass a Sindh Healthcare Commission (SHCC) licensing audit. I was hired for one week as a consultant; an IPC nurse was brought on for four days — long enough to be present during the inspection, to demonstrate that "processes existed." The hospital's actual interest was not in improving care. It was in the certificate that would let it keep operating for the next two years.

I had, in fact, written IPC policies for this hospital before — properly referenced against National Institutes of Health (Pakistan) and WHO guidelines. I found them again on that visit: bound, shelved, and covered in a fine layer of dust in the ward office. No one had opened them. No one, as far as I could establish, had ever read them — not the policy document, not the underlying national guideline, not the WHO source material it was built on.

When I went for rounds on the wards, another story unfolded. Sharps bins overflowing past their fill line. No functioning hand hygiene station, sanitizer bottles empty. No waste segregation system of any kind — sharps, infectious, and general waste handled identically. Bed railings caked with dirt. Toilets that had clearly not been cleaned that day, or the day before. Bed linens stained and soiled. Curtains between beds, by the nursing staff's own admission, had not been laundered or replaced in years. No isolation facility for a patient with a transmissible infection; no personal protective equipment stock available. A microbiology laboratory so rudimentary it had no functioning reporting pathway. No infectious diseases service, and an IPC committee, an antimicrobial stewardship committee, and a healthcare waste management committee that existed only on paper. This is not an isolated story. This is the situation of IPC in many of our private, public, and academic hospitals.^1,2

There is no shortage of technical direction. WHO and NIH guidelines have detailed the requirements of a functioning IPC program.^3,4 Provincial healthcare commissions have built IPC standards into licensing requirements, and functioning AMR, IPC, and waste management committees are now a checklist item for accreditation. Training follows the same pattern. SHCC, WHO, JHPIEGO, NIH, MMIDSP, the CDC, and others repeatedly gather the same clinicians in hotel conference rooms for content that is genuinely sound, then send everyone home with a certificate and no follow-up. No one tracks whether ward practice changes afterward; no resources accompany the learning, and the next workshop is already being scheduled.^5,6,7

I do not think I can write this editorial honestly without turning the question on myself and on colleagues who do similar work. When a hospital's only focus is on "getting through the audit," what is our responsibility? I took the engagement; I wrote what I believed were genuinely useful policies; I cannot say with confidence that the facility is safer today than before I arrived, only that it is licensed.

The responsibility to close the gap between trainings, guidelines, and implementation lies with the regulatory and licensing bodies, and more so with government. This is not because independent agencies such as WHO and JHPIEGO are failing — they are doing a great job — but because sustainability is ultimately a state responsibility, not a donor or NGO one. SHCC and the equivalent provincial commissions should stop treating licensing as a single scheduled visit and instead build sustainability into the license itself: random, unannounced inspections through the license period, and a named facility-level IPC focal person from whom periodic reports are formally demanded, rather than a committee that meets to generate minutes. The National Institutes of Health should run a national surveillance program for healthcare-associated infections, with the resulting data made public hospital by hospital, so that performance carries a reputation as well as a regulatory consequence.

The guidelines were never the missing piece, and neither, in the end, the policies nor are more training the missing piece: we have run a great many good sessions in conference rooms. The gap between what we know and what we do will not close through another document; another workshop, or another consultant brought in for a week to make a healthcare facility look compliant. It will close only when government allocates a substantially larger share of the national budget to healthcare, and to IPC and infection control infrastructure. Pakistan's public health expenditure has, for years, hovered at roughly 1% of GDP — among the lowest allocations in South Asia, and a fraction of what a health system carrying this burden of preventable, IPC-related infection requires. The government must allocate considerably more.

A case series of suspected dengue-like illness in Pakistan

Haleema Sadia — 2026-09-30

Dengue is an arbovirus endemic to Pakistan, with frequent outbreaks reported nationwide. We report a case series of 11 patients who presented during an outbreak of dengue-like illness in Karachi between November and December 2021. Although initial dengue testing was negative in most patients, further molecular testing identified Zika virus in two patients, including one patient with dengue and Zika virus co-infection. Neither patient had a recent travel history; however, absence of travel history alone does not establish local transmission. This case series highlights the diagnostic challenge of distinguishing Zika virus and dengue virus infection in patients presenting with dengue-like illness and supports consideration of broader molecular testing during unexplained arboviral outbreaks.

Keywords: Arboviruses, Coinfection, Dengue, Outbreaks, Zika virus.