Infectious Diseases Journal of Pakistan

Content Pages - Oct - Dec Issue Vol. 34 No.4 (2025) - Infectious Diseases Journal of Pakistan (Quarterly)

Editor Office — 2025-12-30

Bleeding frequency among dengue patients with thrombocytopenia across various serotypes

Naila Ghouri — 2025-12-30

Background: Thrombocytopenia in dengue fever leads to bleeding of varying severity. Identifying predictors of bleeding can improve management, while the roles of demographic factors and dengue serotypes remain unclear. This study aimed to determine the frequency of various dengue serotypes and to compare the frequency of bleeding with thrombocytopenia in dengue fever with different serotypes of the dengue virus.

Materials and Methods: This prospective cross-sectional study was conducted at Sharif Medical City Hospital, Lahore, Pakistan, from January 2025 to July 2025 following approval from the ethical committee. A total of 53 patients aged 15 years or older, diagnosed with dengue fever and confirmed by Dengue virus RNA PCR, were enrolled. Thrombocytopenia was classified into very mild, mild, moderate, and severe categories. Bleeding manifestations were categorized into minor and major types. Data were collected through medical records, physical exams, and laboratory tests, and analyzed using IBM SPSS version 25.

Results: The median age of patients was 38 (28-51.5) years, with 41 (77.4%) males. DENV-4 was the most common serotype, followed by DENV-2, DENV-1, and DENV-3. Bleeding was observed in 17 (32.1%) of patients, with bleeding frequency significantly associated with thrombocytopenia severity (p < 0.001) and age (p = 0.037), but not with gender (p = 0.077) or serotype (p = 0.153).

Conclusion: Thrombocytopenia severity is a key determinant of bleeding frequency in dengue patients, with moderate and severe thrombocytopenia being strongly associated with higher bleeding risk.

Keywords: Bleeding, Demographics, Dengue fever, Dengue serotype, Thrombocytopenia

Extensively drug-resistant Salmonella typhi in febrile patients at a tertiary care hospital of South Punjab, Bahawalpur Pakistan

Muhammad Waseem Abbas — 2025-12-30

Background: Typhoid fever, caused by Salmonella enterica serovar typhi (S. typhi), persists as a significant public health challenge in low- and middle-income countries. This study aimed to assess the prevalence and antimicrobial resistance patterns of multidrug resistant (MDR), and extensively drug resistant (XDR) Salmonella typhi (S. typhi) among febrile patients.

Material and Methods: This cross-sectional study was carried out in the Department of Pathology, Bahawal Victoria Hospital, Bahawalpur, from January to October 2024. Febrile patients with suspected typhoid fever undergoing blood culture were included, while those with recent antibiotic use, alternative diagnoses, or incomplete records were excluded. Using consecutive sampling, 1,364 patients were enrolled. Demographic, clinical, exposure, water source, and vaccination data were recorded, and blood cultures with susceptibility testing were performed according to standard protocols.

Results: Of 1364 patients, 808 (59.2%) were male, and 556 (40.8%) female, while the median age was 15.0 (6.0-38.0) years. Recent travel to endemic areas was reported in 93 (6.8%), and household contact in 29 (2.1%) patients. Blood culture-confirmed S. typhi was found in 34 (2.5%) cases, peaking in August (29.4%). Among these 34-culture positive Salmonella typhi cases, 10 (29.4%) were non-MDR/non-XDR, 3 (8.8%) MDR, and remaining 21 (61.7%) were XDR, while none of the cases were sensitive to all the tested antibiotics. All isolates, including those classified as XDR, were sensitive to meropenem.

Conclusion: This study highlights an ongoing and evolving challenge posed by XDR S. typhi in febrile patients in South Punjab, Pakistan.

Keywords: Blood culture, Fever, Pakistan, Pathology, Salmonella typhi

Comparison of news and sirs score for early recognition of sepsis in medicine department

Gulzar Fatima — 2025-12-30

Background: By alerting doctors and nurses to patients who are deteriorating, an early warning score system enables them to promptly address adverse events. It is not clear as to which scoring system is better in patients with sepsis¹⁶. Therefore, the current study aimed to compare the predictive accuracy of NEWS and SIRS in terms of early diagnosis of sepsis.

Material and Methods: It was a cross-sectional study, conducted at the General Medicine Department, LUMHS, Hyderabad/Jamshoro, from Aug/2025 till Oct/2025. A total of 105 patients who fulfilled the selection criteria were included. SIRS and NEWS were applied as screening tools for early prediction of sepsis. Sepsis was confirmed based on the Sepsis-3 definition. Findings were noted down and were subjected to statistical analysis.

Results: The median (IQR) age of the patients was 41 (12) years. Sepsis was diagnosed by Sepsis-3 criteria in 58 (55.2%) patients. According to the NEWS, 53 (50.5%) had a high risk of sepsis and according to the SIRS score, 55 (52.4%) patients had a positive SIRS score for sepsis. The sensitivity, specificity, PPV, NPV and predictive accuracy of NEWS keeping Sepsis-3 as diagnostic was 81.2%, 87.1%, 88.7%, 78.7% and 83.8%, respectively, and for SIRS score, it was 75.9%, 76.5%, 79.9%, 72.1% and 76.2%.

Conclusion: For predicting sepsis, NEWS was associated with higher sensitivity, higher specificity and predictive accuracy as compared to SIRS.

Keywords: Critical care, NEWS, Sepsis, SIRS

COVID-associated pulmonary aspergillosis and azole resistance Aspergillus species; a laboratory-based study from Pakistan

Sadaf Zaka — 2025-12-30

Background: COVID-19-associated pulmonary aspergillosis (CAPA) has emerged as a significant complication in critically ill patients, leading to increased morbidity and mortality, particularly when diagnosis is delayed or antifungal resistance is present. A previous study from our centre reported a CAPA incidence of 21.7% with high associated mortality. This study aimed to evaluate azole resistance in Aspergillus species isolated from COVID-19 patients using a standardized screening approach.

Materials and Methods: This study included Aspergillus isolates recovered from respiratory specimens of COVID-19 patients admitted to Aga Khan University Hospital, Karachi, between July 2020 and January 2022. Azole resistance screening was performed using the CDC agar-based methodology with itraconazole, voriconazole, and posaconazole. Isolates that demonstrated growth in any azole-containing well were further tested for minimum inhibitory concentrations (MICs) using broth microdilution. Quality control strains included Candida parapsilosis ATCC 22019, Candida krusei ATCC 6258, and A. flavus ATCC 204304.

Results: A total of 174 Aspergillus isolates (A. flavus 85, A. niger 41, A. fumigatus 36, A. terreus 8, A. nidulans 3, A. versicolor 1) from 125 patients (40 CAPA; 85 colonization) were analysed. Growth was observed on voriconazole screening agar in 24 (13.7%) isolates. No growth was seen in the itraconazole or posaconazole wells. MIC testing of 18 voriconazole-screened isolates confirmed that all were azole-susceptible.

Conclusion: Although initial screening suggested possible azole resistance, none were confirmed resistant by MIC testing. These findings highlight the need for continued surveillance to monitor emerging resistance in Aspergillus species in Pakistan.

Keywords: Azole resistance, CAPA, COVID-19

Distribution of MDR and XDR typhoidal Salmonella and the association of neutrophil-to-lymphocyte ratio in enteric fever

Mehveen Iqbal — 2025-12-30

Background: The emergence of extensively drug-resistant Salmonella Typhi poses a global threat. The Neutrophil-to-Lymphocyte Ratio (NLR), an inflammatory marker, has shown prognostic value in various infections but its role in typhoidal Salmonellae is not well established. The objective of the study is to determine the antimicrobial resistance in typhoidal Salmonellae and to evaluate the role of NLR as a clinical biomarker in enteric fever

Material and Methods: Blood cultures from suspected patients of enteric fever were processed from August 2024 to August 2025. Antimicrobial susceptibility was performed by disc diffusion method. NLR was calculated from a complete blood count. ANOVA and Chi-square tests, were used to compare mean NLR across strain types

Results: A total of 450 samples were studied. Among which Typhoidal Salmonellae were isolated from 24.4% of samples. S. Typhi was the predominant serovar (86.3%). Among 90% of resistant isolates, 64.5% were XDR S. Typhi. The overall mean NLR was 2.04 ± 1.14. Statistical analysis revealed no significant difference in mean NLR values (p=0.559) or the distribution of High/Low NLR categories (p=0.87) across the different strain types (MDR, XDR, sensitive).

Conclusion: This study highlights the concerning distribution of drug-resistant Salmonella Typhi. Although the neutrophil-to-lymphocyte ratio does not correlate directly with antimicrobial resistance patterns, it may serves as a strong, readily available prognostic indicator of disease severity. We recommend the routine calculation of NLR to facilitate early identification and timely clinical management of the patient

Keywords: Antimicrobial resistance, Extensively drug-resistant, Multidrug resistance, Salmonella typhi, Neutrophil-to-lymphocyte ratio, Typhoid fever

Diagnostic accuracy of GeneXpert vs. fluorescence microscopy on pulmonary tuberculosis: High-burden country

Ramlla Hatif — 2025-12-30

Background: Pulmonary tuberculosis (PTB) is a significant public health challenge in developing countries, and it is one of the leading causes of infection-related morbidity and mortality. Early and accurate diagnosis is crucial for controlling its transmission and improving patient outcomes.

Material and Methods: This cross-sectional study was carried out at the microbiology laboratory of Indus Hospital and Health Network, Karachi, from February 1, 2023, to July 31, 2023. A consecutive (non-probability) sampling technique was employed. We performed Xpert MTB/RIF, fluorescence microscopy, and mycobacterial cultures on all pulmonary samples. The sensitivity, specificity, predictive values, and diagnostic accuracy of Xpert MTB/RIF and fluorescence microscopy were calculated and compared with culture as the gold standard.

Results: A total of 386 sputum samples were included in the study. More samples tested positive with Xpert MTB/RIF (n = 77, 20%) than fluorescence microscopy (n = 52, 13%). Xpert MTB/RIF demonstrated higher sensitivity (95%) than fluorescence microscopy (64%), while both methods showed comparable specificity (100%) and positive predictive values (100%). The negative predictive value of Xpert MTB/RIF (99%) exceeded that of fluorescence microscopy (91%). Likewise, the diagnostic accuracy of Xpert MTB/RIF (99%) was higher than fluorescence microscopy (97%).

Conclusion: The Xpert MTB/RIF demonstrated better diagnostic efficacy, highlighting its importance for prompt and accurate diagnosis of PTB. However, the accessibility and utility of fluorescence microscopy in low-resource settings cannot be overlooked.

Keywords: Microscopy, Fluorescence; Mycobacterium tuberculosis / microbiology, Nucleic acid amplification techniques, Predictive value of tests, Tuberculosis, Pulmonary, Sensitivity and specificity

A comparison of reduced and standard incubation time for antimicrobial susceptibility testing by the disk diffusion method

Nida Safdar — 2025-12-30

Background: Antimicrobial resistance is a major worldwide health problem, and early availability of antibiotic susceptibility testing results has become vital for the planning of treatment. Despite being commonly utilized, the disk diffusion method requires an 18 to 24 hours incubation, resulting in delays in clinical decision-making.

Material and Methods: This prospective study was performed in the Microbiology Department at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, between October 2024 and March 2025. One hundred clinical isolates were tested against selected antibiotics using CLSI disk diffusion breakpoints. The zones of inhibition were measured at 6 hours, 10 hours, and 18–20 hours. Categorical agreement (CA) and error rates were calculated later.

Results: In total, 600 drug–organism combinations were analyzed. CA improved from 83.8% at 6 hours to 92.2% at 10 hours. Error rates declined markedly between 6 hours and 10 hours (mE: 7.0% → 3.2%; ME: 5.7% → 2.2%; VME: 3.8% → 1.1%). There was a consistent CA of >90% for meropenem, nitrofurantoin, vancomycin, and linezolid at early incubation periods; however, ciprofloxacin for Acinetobacter and Enterococcus species displayed a low accuracy initially, which improved at 10 hours.

Conclusion: An early measurement of zone of inhibition at 10 hours of incubation in disk diffusion testing has demonstrated notably reliable results for several therapeutically important drug-organism pairs. Particularly in resource-poor settings, AST reporting using shorter incubation times may enable timely initiation of targeted treatment and improvement in antimicrobial stewardship.

Keywords: Antibiotic susceptibility testing, Disk diffusion, Reduced incubation

Electrolyte balance in dengue viral infection: Exploring the “hidden reef”

Aisha Ayyub — 2025-12-30

Background: Dengue fever is a common acute febrile illness worldwide, caused by the dengue virus and transmitted mainly by the female Aedes aegypti mosquito. This study aims to determine the Association between serum electrolyte abnormalities and disease severity in dengue virus infection.

Material and Methods: This comparative cross-sectional study was conducted at the Pathology Department, Combined Military Hospital Malir, Karachi, from July to December 2022. It included 519 hospitalized patients with confirmed dengue infection; patients with other febrile illnesses were excluded. Cases were classified as severe or non-severe dengue fever. Hyponatremia and hypokalemia were defined as serum sodium <135 mEq/L and potassium <3.5 mEq/L, respectively. Data were analyzed using SPSS v25, with p ≤ 0.05 considered significant.

Results: Of 519 dengue patients, 28.3% (n = 147) had severe dengue fever. Hyponatremia was common (46.8%) and significantly more frequent in severe cases (56.5%; p < 0.001), while hypokalemia occurred in 19.3% and was also associated with severity (p < 0.001). Median serum sodium was significantly lower in severe disease (129 vs. 137 mEq/L; p < 0.001), whereas potassium showed no significant difference (p = 0.077). Severe dengue was significantly associated with male sex and older age (p < 0.001).

Conclusion: Hyponatremia, mostly mild, was the most common electrolyte disturbance and showed a strong association with dengue severity. Potassium abnormalities were common but did not differ significantly across severity groups. Age and gender were also significantly associated with disease severity.

Keywords: Dengue viral infection, Electrolyte balance, Exploring, Hidden reef

Antimicrobial Stewardship in Pakistan: Challenges and solutions

Nosheen Nasir — 2025-12-30

Antimicrobial resistance (AMR) is a major public health threat globally, and it presents as an accelerating crisis for Pakistan. As multi-drug-resistant infections rise across both community and healthcare settings, antimicrobial stewardship (AMS) has become a national imperative. Yet, despite increasing awareness, Pakistan continues to face significant structural, behavioural, and regulatory barriers that hinder effective implementation of stewardship programmes. Addressing these challenges will require coordinated action across public health, clinical medicine, and policy domains.¹

Unregulated access to antibiotics is one of the most persistent challenges. Over-the-counter sales, self-medication, and the use of broad-spectrum agents for minor ailments remain commonplace, which drives misuse and gives rise to resistance. Owing to this excessive antibiotic use, Pakistan ranks 3^rd amongst low-middle-income countries (LMICs) in antimicrobial consumption.² Furthermore, in many public and private hospitals, microbiology laboratories are under-resourced, lacking timely culture facilities and standardized susceptibility testing. Clinicians often prescribe empirically even when diagnostic guidance may be available either due to long turnaround times, lack of trust in laboratory capacity or perceived cost. There is under-reporting of resistance patterns from LMICs and although Pakistan participates in the World Health Organization Global Antimicrobial Resistance Surveillance System (GLASS), data collection remains fragmented. As a result, clinicians lack accessible, updated antibiograms to inform therapy, leading to inappropriate empiric use of broad-spectrum antibiotics. There are large gaps in antimicrobial stewardship programs and inconsistencies in implementation. While a few tertiary hospitals, particularly in major cities, have begun implementing AMS activities, these programs are not uniformly established or supported. Many facilities lack infectious disease specialists, trained pharmacists, or structured stewardship committees. High patient expectations, pressure to receive “quick fixes”, limited consultation times, and cost constraints all contribute to inappropriate prescribing. In rural areas, traditional healers and unlicensed practitioners frequently provide antibiotics without adequate training. Household studies show leftover antibiotic use and inappropriate storage as additional contributors. Another important and overlooked aspect of stewardship is the non-therapeutic antibiotic use in poultry and livestock which contributes substantially to resistance. Regulatory oversight is limited, and farmers often rely on antibiotics as growth promoters.³

Despite formidable obstacles, there are several solutions that can strengthen antimicrobial stewardship (AMS) in Pakistan through focused, actionable interventions. First, enforcing prescription-only antibiotic policies with tighter pharmacy regulation, routine inspections, and public awareness campaigns to curb over-the-counter misuse. Second, augmenting microbiology laboratory networks by investing in infrastructure, subsidizing culture testing, standardizing protocols, and linking smaller hospitals to regional hubs will enable more data-driven therapeutic decisions. Third, establishing robust stewardship programmes in all secondary and tertiary hospitals by forming multidisciplinary committees, conducting prospective audits and feedback, restricting high-risk antibiotics, and promoting guideline-based prescribing is essential. Fourth, creating national and regional antibiograms via a centralized digital surveillance system that integrates public and private labs will equip clinicians with local resistance patterns and inform national guidelines. Fifth, regulating antibiotic use in agriculture by phasing out growth-promoting antibiotics, enhancing livestock biosecurity, and routinely inspecting veterinary pharmacies addresses a key driver of resistance. Sixth, implementing education and behaviour-change strategies for healthcare professionals through ongoing training and for the community via schools, media and religious institutions. These can shift prescribing and consumption norms. Finally, leveraging telemedicine and digital health tools such as decision-support systems, remote infectious disease consultation, and prescription alerts can standardize care and extend stewardship into underserved regions. Combined, these targeted solutions present a realistic and comprehensive framework for sustainable AMS in Pakistan.

Pakistan stands at a critical juncture in its battle against AMR. The challenges are substantial but they are not insurmountable. By implementing antimicrobial stewardship programmes, supported by regulation, education, diagnostics, and surveillance, Pakistan can shift the trajectory toward safer and more effective antimicrobial use and be able to combat the threat of resistance.

Combatting human metapneumovirus: Prevention and preparedness strategies

Rida Inam — 2025-12-30

Dear Editor,

We are writing this letter to expound upon the outbreak of Human Metapneumovirus (HMPV). Member of the Paramyxoviridae family, HMPV was initially identified in the Netherlands in 2001 after being recovered from a child with symptoms resembling those of an infection with human Respiratory Syncytial Virus (RSV). Since then, 4– 16% of acute respiratory infection patients have been found to have HMPV.¹As it is a respiratory infection, infectious airborne droplets are the means of transmission.¹ This widespread pathogen causes upper and lower respiratory tract infections especially in immunocompromised hosts, children, and older individuals. From minor upper to serious lower respiratory tract infections (such as croup, pneumonia, and bronchiolitis), symptoms can vary in young children. Clinical signs of reinfection in adults usually include colds and flu-like symptoms. Immunocompromised individuals are more susceptible to the disease, which can occasionally be fatal.² Numerous methods, such as culture, nucleic acid amplification tests (NAAT), antigen detection, and serologic testing, can be used to diagnose HMPV infection, NAAT being the most sensitive to detect viral RNA.³ Supportive interventions are the pillars of treatment. For fever, antipyretic drugs such ibuprofen and acetaminophen are administered. Intravenous fluid hydration is recommended if the patient seems dehydrated and is unable to manage oral hydration. Furthermore, individuals with HMPV may need additional oxygen support, such as a high flow nasal cannula or, in extreme situations that result in acute respiratory failure, mechanical ventilation. This is particularly true for patients who already have a respiratory or cardiac condition or who are immunocompromised. As it has a good prognosis so the majority of people do fully recover.⁴The use of monoclonal antibodies that target the HMPV fusion protein in high-risk infants—such as those born preterm or with chronic conditions—is being investigated. These antibodies may lessen the severity of disease and avoid hospitalization, much like RSV prevention. HMPV outbreaks have been documented in studies.

The average HMPV positive rate in a national investigation that included 188,104 clinical samples was 4.7%. Regional rates, however, differed greatly; Chongqing reported the highest rate at 15.88%, while rates were less than 3% in Beijing, Shanghai, Jiangxi, and Hainan.³About 5–7% of all pediatric pneumonia admissions are linked to the human HMPV. Year-round HMPV was found, with February and August seeing the highest levels. There was a substantial correlation between the HMPV infection and sore throat.⁵ The NIH official concluded that while Pakistan is capable of identifying and readiness is essential. Need of hour is to raise awareness and educate people to adopt proper hygiene measures like washing hands, wearing mask, covering mouth while sneezing and coughing to stop its spread because the world is not ready to face another pandemic.