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Introduction: Carbapenem are recommended for the treatment of Ceftriaxone (CRO) resistant Enterobacterales, however, there are concerns of cost and resistance. Our aim is to compare the outcome of CRO resistant E-coli and Klebsiella bacteremia between Carbapenem and Beta-lactam/beta-lactamase inhibitors (BL/BLI).Methods A prospective cohort study conducted from October 2021 to June 2022. All adult patients with E coli or Klebsiella spp. bacteremia, CRO resistant and sensitive to both BL/BLI and Carbapenem were included. The patients were divided into BL/BLI and Carbapenem groups. Demographics, clinical features, comorbidities, laboratory parameters and intensive care unit stay were compared. Outcomes were bacteriological clearance, clinical success and all-cause mortality at day 14 of bacteremia.Results A total of 156 patients, 93(59.6%) in BL/BLI and 63(40%) in Carbapenem group were included. There was no difference in co-morbidities, risk factors and severity of disease. The 14 day all-cause mortality was 14.1%. No statistically significant difference was found between BL/BLI and Carbapenem group regarding bacteriological clearance (p = 0.27) and mortality (p = 0.95). The Carbapenem group had less clinical success rate (69.8% vs 82.8%, p = 0.057), however not statistically significant.Conclusion BL/BLIs were as effective as Carbapenem in microbiological clearance, clinical success and mortality in CRO resistant E-coli and Klebsiella bacteremia.

Background Diabetes mellitus (DM) is a chronic disease characterized by glucose dysregulation by insulin deficiency or resistance. DM is one of the risk factors and found to be associated with high mortality in patients with corona virus disease-19 (Covid-19). There are challenges in managing poorly controlled DM among Covid-19 patients. Our aim is to highlight the effect of Covid-19 and DM on each other by studying glycemic control and risk factors for mortality. Methods This study is a single center retrospective observational review from Pakistan. Covid-19 diagnosed patients admitted during the months of March 2020 to March 2021were included. The patients were divided into DM and non-DM. Demographics, clinical variables and outcome were collected and compared between these groups. Glycemic control during hospitalization (blood sugar level fasting and pre-meal twice a day) was noted. Fasting glucose level >120 mg/dl, and random >200 mg/dl were considered as poor glycemic control. Survivors and non- survivors among DM patients were compared. Results A total of 366 patients were included in this study, 113(30.87%) were DM and 253(69.12%) were non-DM. Mean age was comparable in two groups, however, patients in DM group were older (age >45 years, p=value 0.039). Significantly more patients with hypertension (p value< 0.001) and ischemic heart disease (p value< 0.001) developed Covid-19 in DM group. There was no difference in mortality among both groups (p=0.29). (Table 1) .In DM patients, the significant risk factors for mortality were age >60years, hypertension and renal disease. High fasting and pre-dinner blood glucose levels (mean) obtained at admission and day 5 were significantly associated with mortality. (Table2). Conclusion Diabetic patients with advanced age and concomitant other comorbid conditions is associated with increased risk of death. In diabetic patients, more attention should be focus on dynamic monitoring and strict glycemic control as severe COVID 19 infection and its treatment with steroids can have a negative impact on outcome. Disclosures All Authors: No reported disclosures.

Background Corona virus disease-19 (Covid-19) has significantly affected organ transplantation with concerns regarding severe infection and mortality. Data on Covid-19 in renal transplant recipients (RTRs) is scarce from Pakistan. The aim of this study is find out the factors effecting mortality among Covid-19 patients in renal transplant recipients from the largest transplant center of Pakistan. Methods All RTRs >18 years, with positive severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) polymerase chain reaction (PCR) and diagnosed as severe disease, between April to December 2020 were retrospectively reviewed. The severe disease was defined as O2 saturation < 94% at room air on admission. Survivors and non- survivors were compared. Demographics, immunosuppression, comorbid conditions, clinical features, laboratory investigations and graft function were noted. Results A total of 95 RTRs had severe disease. There was no difference in mortality between age, gender and co-morbid conditions among survivors and non-survivors. Both groups received similar immunosuppressive regimen. Intensive care unit (ICU) admission [16.5% vs 68.8% p< 0.001 OR 11.17 95% CI (3.3-37.6)] and high D-dimers >1.5µg/ml (p=0.052) at the time of admission were significantly associated with mortality. There was no association of graft function with mortality. Treatment with methyl-prednisolone was found to be significantly associated with survival [83% vs 43% P=0.02 OR 0.15 95% CI (0.05-0.49)]. (Table 1) WHO grading of the disease is shown in figure 1, there was a 100% mortality among patients on mechanical ventilator. Figure 1:WHO clinical grading of severe diseaseTable 2:Comparison between survivors and non-survivors among patients with severe disease Conclusion ICU admission and high D-dimers at the time of admission are the significant risk factors for mortality in patients with Covid-19 infection. There was no association of graft dysfunction with mortality. Steroids use has significantly improved survival in renal transplant recipients with severe Covid-19 infection. Disclosures All Authors: No reported disclosures.

Objective: To assess the views of health service providers towards coronavirus disease 2019 vaccination with Cansino, Sinovac and Sinopharm vaccines. Method: The analytical cross-sectional study was conducted at the Sindh Institute of Urology and Transplantation, Karachi, in May and June 2021, and comprised doctors, nurses, technical staff, and medical social officers. Data was collected using a questionnaire, in Urdu and English languages, assessing determinants of hesitancy. Data was analysed using SPSS 19. Results: Of the 331 subjects, 156(47%) were males and 175(53%) were females. Overall, 183(55%) subjects were aged 60 years. Among the responders, 274(83%) were vaccinated, 49(15%) wanted to delay, and 8(2.4%) were outright refusers. Among the hesitant, 43(80%) were women, and 56(98%) were aged

Introduction Whipple's disease (WD) is a rare multi-systemic disorder caused by actinomycetes, Tropheryma Whipplei (T. Whipplei). It presents with weight loss, arthralgia and diarrhea and may involve the heart, lung or central nervous system. The use of immunosuppressive medications or underlying immunodeficiency states are associated risk factors. Six cases in transplant recipients have so far been reported worldwide. We describe our experience of Whipple's disease in renal transplant recipients. Methods All renal transplant recipients who presented with diarrhea and were diagnosed with Whipple's disease on duodenal biopsy from 2016 till 2019 were included. Their data regarding duration since transplantation, immunosuppressive therapy, symptoms, treatment response and outcome was analyzed. Results Seven cases were diagnosed as Whipple's disease based on duodenal biopsy, with histological findings of Periodic acid Schiff positive granules in macrophages. All were male. The most common symptoms were chronic diarrhea and weight loss. Average time since transplantation was 4.8 years. All patients were on azathioprine and everolimus. Clinical relapse or adverse effects was seen in 5 of 7 patients treated with doxycycline and hydroxychloroquine which was discontinued. Trimethoprim/sulphamethoxazole for one year, with initial intravenous ceftriaxone in 2 patients, resulted in complete remission in all patients at a follow-up period averaging 1.5 years. Conclusion Whipple's diseases in renal transplant recipients most commonly presents as an intestinal disorder. Treatment of one year with Trimethoprim/sulphamethoxazole has good response with complete remission at 1.5 years of follow up. This article is protected by copyright. All rights reserved.

A 43-year-old male patient developed varicella virus (chickenpox) 4 months after receiving a liver transplant. Within 5 days of complete recovery, he presented with widespread cutaneous vesicular eruptions involving the face, back, abdomen, and upper extremities. Tzanck smear showed ground glass inclusions in the nuclei of multinucleated giant cells, suggestive of viral pathology. The patient was subsequently diagnosed with Kaposi varicelliform eruption, a rare dermatologic emergency. He was treated with high-dose intravenous acyclovir and fully recovered.

The incidence of tuberculosis (TB) is many fold higher in transplant recipients than in the general population with the highest risk in first year post-transplant. The purpose of this review is to describe the epidemiology, clinical characteristics, management, and outcomes of TB in organ transplant recipients from TB endemic regions and highlight the challenges faced in their management. TB can be increasingly difficult to diagnose and manage in transplant recipients. Clinical manifestations are often atypical leading to delay in diagnosis and available diagnostic modalities are limited in their ability to accurately detect TB. Moreover, the treatment of TB is particularly difficult owing to drug–drug interactions with post-transplant medications. Hence, the focus of recent research has been identification and treatment of latent TB infection pre-transplant. The prevalence of TB in transplant recipients is reportedly 12% in TB endemic countries compared to 5% in developed countries. The risk is greatest among transplant recipients with residence in a country with high TB burden. The clinical presentation can vary from the classic symptoms to unusual extrapulmonary manifestations, particularly involvement of genitourinary tract in renal transplant recipients. The first-line treatment is similar to that for immunocompetent patients but requires greater vigilance in monitoring of side effects, particularly hepatotoxicity. Longer treatment duration may be needed in those in whom a first-line regimen could not be used or those with drug-resistant TB. All transplant recipients should be screened for latent TB infection (LTBI) and given prophylaxis if found to have evidence of LTBI.

Introduction Renal transplant recipients are at high risk of tuberculosis (TB). We started Isoniazid (INH) prophylaxis of 1 year duration in all renal transplant recipients from April 2009. Our aim was to assess the incidence of TB on INH prophylaxis and its tolerability. Methods This was a retrospective observational study. The files of renal transplant recipients from April 2009 to December 2011 were reviewed till June 2015. We noted the incidence of TB, INH tolerability and development of resistance. We compared the incidence of TB with the historical controls who never received the prophylaxis. Results A total of 910 patients were reviewed and followed for 4.8 years. INH prophylaxis was completed by 825 (91%) patients. A total of 46 patients (5%) developed active TB as compared to 15% in the historical controls. The median time of TB diagnosis from transplantation was 2.8 years. In the first-year post transplant, out of total TB cases, 52% occurred in the historical controls whereas 13% occurred in study cohort. Around 67% had TB > 2 years after transplant. Overall 1.43% had hepatotoxicity. There was a significant reduction in TB among those who completed prophylaxis to those who did not (p Conclusion INH prophylaxis was well tolerated. The incidence of TB decreased in the first 2 years. However there was a surge in TB cases 1 year after stopping INH therapy. We should consider prolonging the duration of INH prophylaxis in high TB burden countries in renal transplant recipients. This article is protected by copyright. All rights reserved.

Multidrug-resistant tuberculosis (MDR-TB) is caused by mycobacterium tuberculosis that is resistant to isoniazid (INH) and Rifampin (Rif). The use of immunosuppressive drugs in solid organ transplant (SOT) recipients can increase the risk of TB. Management of MDR-TB is quite challenging in general population with poor compliance due to lengthy treatment duration and drug toxicities. New drugs as well as shorter regimen have been used to increase the likely hood of adherence. The experience of treating MDR-TB in transplant recipients is limited. New drugs like bedaquiline, linezolid, clofazimine and delamanid have rarely been used in transplant recipients. To the best of our knowledge, only 14 cases of MDR TB in transplant population have been reported in the literature and no case from Pakistan, a high TB burden country. We are reporting our experience of treating 4 renal transplant recipients. We used new drug regimen and found many side effects. Treatment outcome was successful with complete cure in 3 of our patients, however one died of severe drug toxicity. The most worrisome drug interaction was between azathioprine and linezolid, with life threatening thrombocytopenia. There was no graft dysfunction noted at the end of the therapy. The management of MDR-TB in transplant recipients is challenging, excellent coordination between transplant team and Infectious Diseases Physician for close monitoring and follow-up is needed.

This paper examines the relationship between sustainability targets and their impacts on corporate environmental innovation. Using data over the period 2009-2018 on 202 companies from BRICS countries, covering firm-level governance, social responsibility and sustainability this paper examines firm-level sustainability targets, and incentives encourage managers to engage in more environmentally friendly activities. Using panel data probit regression, and after controlling for country-level governance and institutional factors, the study finds that embedding environmental targets in corporate strategy does encourage corporate managers to design and develop eco-friendly products and services, and such firm-level commitments at the top motivates managers to promote, market, and label environmentally friendly products. The findings call for greater emphasis on aligning executive compensation with sustainability targets rather than focusing too much on short-term accounting and market-based measures of firm performance.

IntroductionRenal transplant recipients are at high risk of tuberculosis (TB). We have started Isoniazid (INH) prophylaxis of 1 year duration in all renal transplant recipients from April 2009. Our aim is to assess the incidence of TB on INH prophylaxis and its tolerability.MethodsThis was a retrospective observational study. The files of renal transplant recipients from April 2009 to December 2011 were reviewed till June 2015. We noted the incidence of TB, INH tolerability and development of resistance. We compared the incidence of TB with the historical controls who never received the prophylaxis.ResultsA total of 910 patients were reviewed and followed for 4.8 years. INH prophylaxis was completed by 825 (91%) patients. A total of 46 patients (5%) developed active TB as compared to 15% in the historical controls. The median time of TB diagnosis from transplantation was 2.8 years. In the first-year post transplant, out of total TB cases, 52% occurred in the historical controls whereas 13% occurred in study cohort. Around 67% had TB > 2 years after transplant. Overall 1.43% had hepatotoxicity. There was a significant reduction in TB among those who completed prophylaxis to those who did not (p=0.02). Out of 14 cultures one isolate was INH resistant (7%).ConclusionINH prophylaxis is well tolerated. The incidence of TB has decreased during the first 2 years. However there was a surge in TB cases 1 year after stopping INH therapy. We should consider prolonging the duration of INH prophylaxis in high TB burden countries in renal transplant recipients.

Environmental innovation is regarded as an essential tool to achieve the Paris Climate Conference agreement and Net Zero by 2050. Despite the extensive studies on the determinants of environmental innovation in developed countries, little attention has been paid to developing countries despite their dominance of emissions and different institutional characteristics. This paper fills the gap in the literature by investigating the determinants of environmental innovation in developing countries. In addition, the paper examines the role of national culture, an informal institutional factor, as a potential determinant of environmental innovation. Using 10,764 firm-year observations for a sample of 15 developing countries from 2015 to 2019, we find that environmental innovation is mainly driven by the demand-pull factor, rather than the technology-push factor, in developing countries. In addition, certain national cultural dimensions such as masculinity and long-term orientation enhance environmental innovation, while other dimensions such as power distance, individualism, uncertainty avoidance, and indulgence reduce it. The paper makes a theoretical contribution by extending the Porter Hypothesis towards institutional theory to include informal institutional factors (i.e. national culture) as a determinant of environmental innovation. The finding also suggests a rethink of policy in developing countries to focus more on demand-pull factors to promote environmental innovation.

Background: Polymyxins (colistin) have emerged for the treatment of carbapenem resistant (CR) gram-negative infections. There is a paucity of data on treatment outcomes and adverse effects of high-dose colistin treatment in Pakistan. The aim of this study was to determine the efficacy and toxicity of colistin in CR bacteremia, including patients with renal failure and on hemodialysis, and to determine patient outcomes. Methods: This prospective cohort study was performed from May to December 2017 at Sindh Institute of Urology and Transplantation, Karachi, Pakistan. Patients aged >18 years with documented gram-negative bacteremia were included. Data were compared between those who received colistin and those who did not, including risk factors for CR bacteremia, bacterial clearance, adverse effects, and all-cause mortality up to 14 days of follow-up. Results: The study included 137 patients, 73 (53.3%) in the colistin group and 64 (46.7%) in the non-colistin group. Patients in the colistin group were 1.47 times more likely to have died by day 14 of follow-up as compared to those in the non-colistin group (19.2% vs 7.8%; relative risk 1.47, p= 0.05). Patients in both groups achieved more than 80% bacteriological clearance. The colistin group patients were less likely to have received appropriate empirical antibiotics as compared to the non-colistin group patients (4.1% vs 62.5%; relative risk 0.09, p< 0.001). Factors significantly associated with mortality were inappropriate empirical antibiotics and acute renal failure. Of the 73 patients in the colistin group, 27 (37.0%) developed reversible neurological adverse effects. Patients with renal insufficiency, not on hemodialysis, were evaluated for colistin nephrotoxicity. Creatinine decreased from 8.08 mg/dl at baseline to 4.85 mg/dl on day 7 in the colistin group, and from 6.5 mg/dl to 3.9 mg/dl in the non-colistin group. Patients with normal renal function had no significant rise in serum creatinine. Conclusions: Colistin is efficacious in clearing bacteremia even in patients with impaired renal function. The adverse effects were found to be minimal and reversible. We recommend the use of colistin in combination with carbapenems for CR gram-negative bacteria in renal failure. Most importantly, however, this study highlights the role of empirical colistin treatment in patients with risk factors for CR bacteremia.

BACKGROUND Broilers are vulnerable to various types of microorganisms, including Salmonella, Escherichia coli and Staphylococcus aureus, resulting in multiple infections. Broad-spectrum antibacterial drugs such as florfenicol (FF) are widely used in the treatment of such infections. Suspected residues of these drugs in body tissues of treated birds can be passed to humans through meat consumption and thus lead to serious ill effects on human health. The present study was designed to estimate the presence of FF residues in broiler meat and liver samples. RESULTS The mean residual concentrations of FF in broiler meat and liver samples were 311.42 ± 186.56 and 2585.44 ± 1759.71 µg kg−1 respectively, which are higher than their respective maximum residual limits (MRLs). The results showed that 126 and 24 samples were FF-positive and FF-negative respectively. Of the positive samples, 84 and 42 samples were above and below the MRL respectively. CONCLUSION The results indicate the presence of FF residues in broiler meat and liver samples. Usage of this contaminated meat causes resistance in consumers and poses a public health threat. Thus there is a need to educate farmers about the ill effects of residual drugs on human health and their withdrawal times in poultry. © 2015 Society of Chemical Industry

Human Immunodeficiency Virus associated neurocognitive dysfunction can present as a case of movement disorder in a patient with prolonged antiretroviral therapy. Diagnosis was made after ruling out space occupying lesions, nutritional deficiencies and infectious causes through brain imaging and cerebrospinal fluid analysis. With multidisciplinary care and change of antiretroviral therapy to drugs with higher cerebrospinal fluid penetration, symptoms of the patient improved over a span of six months. Delayed neurological damage due to Human Immunodeficiency Virus can present with isolated cerebellar symptoms.

Furunculosis in renal transplant recipients may be associated with increased morbidity. With the aim to study the presentation, morbidity, and risk factors for furunculosis, this observational study was conducted at the Sindh Institute of Urology and Transplantation, between January to December 2014. All patients with furuncles or abscesses were included. The clinical presentation and risk factors were recorded. A morbidity scale of 0 and 1 was made on the basis of hospital stay for ≥7 days, bacteraemia, large abscesses and repeated furunculosis. Out of 38 patients, 29 (76%) had large abscesses and 9 (24%) had furuncles, with gluteal region being the most common site. Twelve (32%) had severe disease; 29 (76%) had morbidity scale of ≥1. High dose immunosuppression was significantly associated with severe disease while repeated furunculosis had significantly more risk factors. Furunculosis is a severe disease with high morbidity in renal transplant recipients and more studies are needed on skin colonisation and preventive strategies.

A. Nasim, S. Baqi, S.F. Akhtar. Pseudomonas aeruginosa endocarditis in renal transplant recipients. Transpl Infect Dis 2012: 14: 180–183. All rights reserved Abstract: Infective endocarditis (IE) is a serious and life-threatening disease. Transplant recipients are at increased risk of acquiring serious infections. The most common organisms causing IE in solid organ transplant recipients are reported to be gram positive. IE due to Gram-negative organism has rarely been reported. We report 2 cases of renal transplant recipients who met the Duke's criteria for IE due to Pseudomonas aeruginosa.

Broilers are vulnerable to various types of microorganisms, including Salmonella, Escherichia coli and Staphylococcus aureus, resulting in multiple infections. Broad-spectrum antibacterial drugs such as florfenicol (FF) are widely used in the treatment of such infections. Suspected residues of these drugs in body tissues of treated birds can be passed to humans through meat consumption and thus lead to serious ill effects on human health. The present study was designed to estimate the presence of FF residues in broiler meat and liver samples.The mean residual concentrations of FF in broiler meat and liver samples were 311.42 ± 186.56 and 2585.44 ± 1759.71 µg kg(-1) respectively, which are higher than their respective maximum residual limits (MRLs). The results showed that 126 and 24 samples were FF-positive and FF-negative respectively. Of the positive samples, 84 and 42 samples were above and below the MRL respectively.The results indicate the presence of FF residues in broiler meat and liver samples. Usage of this contaminated meat causes resistance in consumers and poses a public health threat. Thus there is a need to educate farmers about the ill effects of residual drugs on human health and their withdrawal times in poultry. © 2015 Society of Chemical Industry.

A. Nasim, S. Anis, S. Baqi, S.F. Akhtar, N. Baig-Ansari. Clinicalpresentation and outcome of dengue viral infection in live-relatedrenal transplant recipients in Karachi, Pakistan.Transpl Infect Dis 2013. All rights reservedAbstract: Introduction. In Pakistan, dengue viral infection hasbecome hyper-endemic. Renal transplantation is also expanding. Weaimed to study dengue in renal transplant recipients (RTR).Methods. We conducted a study of RTR reported to be anti-dengueimmunoglobulin-M antibody positive from January 2009 toDecember 2010 at our institution in Karachi and follow their clinicalcourse and outcome.Results. Median age was 28 years; 75 (73.7%) were males. Clinicalpresentation included fever in 82 (80.4%), gastrointestinal symptomsin 35 (34.3%), hemorrhagic complications in 9 (8.8%), andthrombocytopenia in 97 (95%), which was of >15 days duration in24%. Fever was seen less frequently in patients on high-dose(>7.5 mg) steroids as compared with low-dose (≤7.5 mg) steroids.Forty-four patients (43%) had primary and 58 (56.8%) had secondarydengue infection. Dengue fever (DF) occurred in 90 (88%), anddengue hemorrhagic fever/dengue shock syndrome (DHF/DSS)occurred in 12 (11.7%). DHF/DSS was seen in 3 (6.8%) of those withprimary and in 9 (15.5%) of those with secondary infection(P < 0.22). In secondary infection, patients on cyclosporine-containing regimen had less severe disease, with DHF/DSS in 22%as opposed to DF in 59% (P < 0.04). Of 102 RTR, 68 (66.7%) had graftdysfunction, 5 of whom died. Of the remaining 63, in 54 patients(85.7%) creatinine returned to baseline by an average of 12.6 days.Of 102 patients, 95 (93%) recovered and 7 (6.9%) died, 6 of whom hadbacteremia with sepsis and 1 had respiratory failure. None died dueto dengue infection alone.Conclusion. In conclusion, in RTR without life-threatening co-morbidities, the clinical course of dengue infection is mild, withgood recovery and preserved renal function.A. Nasim

Chronic necrotizing pulmonary aspergillosis is a chronic semi invasive pulmonary disease. It is an uncommon disease and has never been reported in transplant recipients. We report a case of chronic necrotizing pulmonary aspergillosis in a renal transplant recipient.

Dengue Fever (DF) with acute acalculous cholecystitis is a rare and atypical presentation. We report a case of dengue fever presenting as acute acalculous cholecystitis. The patient presented with abdominal pain, vomiting and fever. Her platelet counts were low and Dengue antibody test was positive. Ultrasound showed acute acalculous cholecystitis. The patient was successfully managed conservatively.

The poverty level in Pakistan has been increasing and despite decades after independence it is still a very critical socioeconomic issue. This study examines the effects of macroeconomic variables (GDP, inflation, unemployment, and tax revenues) on the poverty rate in Pakistan since 1974 to 2014. Moreover, this study also investigated the impact of a different regime i.e. democracy and military regime with reference to macroeconomic variables and poverty rate. The descriptive statistical analysis was carried out by using graphs and inferential statistical analysis was performed using Pearsons correlation and multiple regression analysis. The results showed that the real GDP and tax revenues have significant negative effects on the poverty rate. The inflation also showed a significant positive effect on the poverty rate, which implied that an increase in inflation hurts the poor more and leads to increased poverty. The unemployment rate showed insignificant positive impact on the poverty rate. On the aspect of influence of different regimes i.e. democracy and military rule, the results showed democracy has a negative impact on the poverty rate, implying that the democratic regimes are more favourable for poverty reduction in Pakistan.