Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
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Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help ones reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journalsNo manuscriptsNo authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2009 | Month : October | Volume : 3 | Issue : 5 | Page : 1754 - 1759

The Changing Scenario Of The Salmonella Serotype And Its Drug Resistance Pattern

ARORA D *, SEETHA K S **, KUMAR R ***

*(Asst. Prof.), ***(Lecturer)Department of Microbiology,Adesh Medical college and Hospital.Bhatinda, Punjab, India-151001,**(Additional Prof.), Dept of Microbiology,Kasturba Medical college, Manipal(KR)

Correspondence Address :
Dr. Deepak Arora (Asst. Prof.)Department of
Microbiology,Adesh Medical college and Hospital.Bhatinda, Punjab,India-151001.
E-mail: drdeepakarora@yahoo.co.in,Tel: +91-9781566786,Fax: +91-0164 2742902

Abstract

Enteric fever continues to be a global health problem because of its high morbidity and mortality and presently, due to the increased incidence of multi drug resistant salmonella. So, the present study was planned to evaluate the change in frequency of the isolated salmonella serotype and to know its drug resistance pattern.

Keywords

enteric fever, multi- drug resistant salmonella

Introduction
Enteric fever continues to be a global health problem and it is endemic in developing countries including India. Enteric fever occurs in all parts of world where the water supplies and sanitation are sub-standard. Enteric fever includes typhoid fever caused by S. typhi and paratyphoid fever caused by S. paratyphi A, B and C. As enteric fever causes high morbidity and mortality, it is of great threat to the public and also to the clinician. There is evidence of the emergence of multi- drug resistant salmonella strains, which has been seen in many patients. .Salmonella typhi has rapidly developed resistance to commonly used drugs like ampicillin, chloramphenicol and cotrimoxazole, which were formerly the mainstay of treatment. To some extent, this problem was resolved with the advent of fluoroquinolones like ciprofloxacin. However, of late, the efficacy of this antibiotic too has been questioned, mainly due to increasing reports of increasing defervescence time and poor patient response. This indicates that the organism has begun to develop resistance to fluoroquinolones and is corroborated by a steady increase in the minimum inhibitory concentration (MIC) of ciprofloxacin. So, the present study was undertaken to know the frequency of isolation of salmonella serotypes and their antibiotic susceptibility in KMC, Manipal, Karnataka, a tertiary hospital.

Material and Methods

Blood and bone marrow samples were collected from suspected cases of enteric fever who were admitted to KMCH. Their blood culture was done by standard microbiological methods. Antibiotic testing was done by the Kirby-Bauer Method (Table/Fig 1). The tests were interpreted by comparing their results with the Kirby-Bauer table and the control strain used was Escherchia coli (ATCC 25922). 50 strains of salmonella were used to check for the minimum inhibitory concentrations (MICs) of ciprofloxacin and ceftriaxone by the agar dilution method. The E test was carried out using 3 strains for ciprofloxacin with dilutions ranging from 0.125µg/ml to 512 µg/ml (doubling dilutions), which has been shown in, (Table/Fig 2 ,3,4,5) refer to (Table/Fig 2)

Results

309 strains of salmonella serotypes were isolated over a period of 6yrs and 9 months i.e. from Jan. 2002-Oct.2008. Out of 309 cases, 240 were caused by S. typhi and 69 were caused by S. paratyphi A. Enteric fever caused by S. typhi was prominent in 2002 – 2003 and then, from 2004 onwards, S. paratyphi A was the most common causative agent, (13.46% in 2004 to 54.16% in 2007) as shown (Table/Fig 6) ref to [Table/Fig 3]. In our study, the isolation rate of S.typhi was almost the same in all the years from 2003-2006. In 2007, the incidence of S. typhi increased to a great extent, whereas the incidence of S. paratyphi ‘A’ increased drastically i.e. (9.3% in 2002 to 54.16% in 2007).The antimicrobial sensitivity pattern of commonly used antibiotics are as shown in (Table/Fig 7) refer to [Table/Fig 4] , (Table/Fig 8) refer to [Table/Fig 5],(Table/Fig 9) refer to [Table/Fig 6], (Table/Fig 10) refer to [Table/Fig 7] . The reports of the antibiotic sensitivity of S.typhi are variable from time to time. The antimicrobial sensitivity pattern is as shown in the table against Ampicillin (AMP), cotrimaxozole (COT) Chloramphenicol (Chl), Ciprofloxacin (CF), ceftriaxone (CEF) and resistance was seen in AMP, ChL, COT more, from 2003-2005. Then, from 2006 onwards, the resistance decreased. S. typhi showed 3-5% resistance to ciprofloxacin from 2003-2008 and later on, there was a decrease in its resistance.

Among the cases caused by S. typhi, 187(77.%) were males and 53(22.08%) were females and among the 69 cases of S. paratyphi ‘A’ which were isolated, 61(88.40%) and 8(11%) were females in our study as shown (Table/Fig 12), [Table/Fig 9].

Fever was observed throughout the year the peak incidence was seen in Jan, Feb, April, July and Nov.

A comparison of the blood culture and the widal test reports was also done, as shown in (Table/Fig 13) refer to [Table/Fig 10]. In our study, 60-83% of S. typhi cases were both blood culture and widal test positive, 15.83% were blood culture positive and widal negative and in 23.33% cases, widal was not done due to lack of blood samples. Among the S. paratyphi ’A’ cases which were isolated, 40.57% were blood culture and widal positive, 37.68% were blood culture positive and widal negative and in 21.73% cases, widal was not done due to lack of blood samples.

Discussion

Enteric fever (EF) is one of the most common causes of pyrexia of unknown origin (PUO) in most parts of the world and it continues to be a major health problem despite the use of antibiotics and the development of newer antibacterial drugs. EF occurs in all parts of the world where water supplies and sanitation are sub- standard. In otherwords, EF continues to be global health problem.

Numerous outbreaks due to MDR salmonella have been reported from different parts of world and even from India (2), (3), (4). EF is mainly caused by the S.enterica typhiserotype and paratyphi A’has been reported less frequently. But the incidence of paratyphi ‘A’ is increasing since 2004 and this is similar to the reports from the study byS.S Thankhiwale (17) The isolation rate of S.typhi has decreased to a greater extent whereas the incidence of S.paratyphi ‘A’ has drastically increased. The reason may be due to the usage of the typhi -oral vaccine which is effective only against S. typhi. The reports of the antibiotic sensitivity pattern of S. typhi are variable in our study.S. typhi was more resistant to ampicillin, chloramphenicol and cotrimaxozole. From2002-2005, many chloramphenicol resistant strains of S. typhi were reported simultaneously from Mexico and Kerala (1),(5) In 1997, 100% resistance to chloramphenicol was reported from Hubli (9) and in 1999, more than 95% resistance to chloramphenicol was reported from Hyderabad (10). Resistance to 3 conventionally used antibiotics, mainly Chlor, AMP and COP was seen is our study and these results correlate with that of other studies (2), (6), [13.] From 2006 onwards, in our study, the resistance of S. typhi was found to decrease and this was also comparable to the findings of other studies(17). The reason attributable to this, may be the non- usage of the drug form a long time.

S. typhi showed 3-5% resistance to ciprofloxacin in 2003-2008 in our study and this is similar to the findings of a study done at Nagpur.(17) Out of 25 isolates of S. typhi, 3 showed an MIC of 0.125 µg/ml for CF, 20 showed an MIC of 0.5 µg/ml and 2 showed an MIC of 2 µg/ml. The developing resistance is due to the overuse of CF in the treatment of EF. Incomplete treatment may also be a factor which contributes to resistance. This provides a strong case for CF, reconsidering the use of the first line of antibiotics for Rx viz, AMP, Chlor and COT and this has been reported by others also (9),(10),(11),(18). All the 309 isolates were sensitive to ceftriaxone as found in our study. This underlines the importance of this drug for treating cases with multidrug, EF and CF resistance.. Emphasis has to be laid on the sparing use of the drug. It should be used only if the 1st and 2nd line antibiotics failed to evoke a satisfactory response, or it the isolate is resistant to CF.

The antibiotic sensitivity pattern is highly variable in S. paratyphi ‘A’. It was found that resistance to AMP was 100% in 2002 which decreased in 2005 and suddenly increased to 66.66% in 2006 (17), followed by a decrease to 24% in 2007 and an increase to 50% in 2008 and this is comparable to the findings from the study by Tankhiwal et al (17). In literature, Chloramphenicol.sensitivity was found to range from 19.7- 100% (12),(13),(14),(15) and it was the same case in our study. The sensitivity was 100% in 2007 and in 2008. There was a decrease in resistance (15-25%) to COT. The concerned isolates were 100% sensitive to CF from 2002 to 2006. It showed intermediate sensitivity from 2007 to 2008 (MIC 2 µg/ml) CF is the drug of choice for EF in India. In a recent study from New Delhi, 32% of isolated S. paratyphi ‘A’ were found to have a decreased sensitivity to CF and the results of our study are comparable to this study (19). All isolated strains were sensitive to ceftriaxone in our study and this was similar to the findings of others (17).

With the emergence of MDR S. typhi, quinolone, particularly fluoroquinolones, have been widely used and recommended as alternative drugs for typhoid fever where the first- line drug is no longer in use. Fluoroquinolones which are available since 1980, have good in vitro susceptibility and in vivo efficacy against salmonella species, including S. typhi. Nalidixic acid, the prototype and the first member of the quinolone group, is now seldom used. Resistance to Nalidixic acid as a screening test for detecting reduced susceptibility to the quinolone group of drugs merits considerationbecause there are strains with a decreased susceptibility to ciproflaoxacin but which are susceptible to nalidixic acid. The current NCCLS recommendations to check for Nalidixic acid resistance is easy to implement, but may have a reduced specificity. So resistance can be detected by Standard disc diffusion and MIC can detect fluorquinolone resistance (22), (23).

Out of the 240 cases caused by S .typhi , 191(9.58%) were adults and 49 (20.41%) were children. Out of the 69 cases caused by S. paratyphi ‘A’, 63(91.30) were adults and 6(8.69%) were children (20). The % incidence in the middle aged group may be due to their working conditions where they are forced to eat outside their homes. School going children were affected due to their eating habits ie: eating on the road side 77.9% of the patients were males and 22.08% were females. More cases reported are males than females probably as a result for increase of exposure to infection due to their eating habits outside the house (21) But the carrier rate is more in females.

EF due observed through out the years. The peak incidence was in Jan, Feb, April, July, Nov ., This coincides with the hot climate and the rainy season. Increase in flies in the mango season (April) and in the hot season, the consumption of ice-creams in which the typhoid bacilli survive for over a month, contributed to it. It is more in moist winter conditions because of the survival of the bacteria (16) in soil irrigated with sewage. .

A comparison of the blood culture and the Widal test in our study showed that blood culture is a more sensitive method for the diagnosis of EF than the Widal test. We isolated salmonella spp. only after 72-96 hours of incubation. Culture positivity was also less. This was due to following reasons viz. KMCH is a tertiary Hospital. The patient might have taken antibiotics before coming to this hospital.

In many suspected cases, the blood culture as well as the Widal test was negative ie: the patient may not be suffering from enteric fever. In some cases, the blood culture was positive but the Widal test was negative. This occurs when the blood for the Widal test is drawn at a very early stage of the disease, if it is within a week.

Conclusion

309 strains of salmonella serotypes were isolated over a period of 6yrs and 9 months i.e. from Jan. 2002- Oct. 2008. Antibiotic sensitivity testing was done by the Kirby-Bauer Method and the present study indicates that the first line of antibiotics still have a role to play in the treatment of enteric fever. As there is a trend for the development of Ciprofloxacin (CF) resistance,,it is concluded that the indiscriminate use of the drug should be strongly discouraged and that it should be used in an event of non responsiveness to the three conventional drugs. Also, the treatment must not be completely dependent on the Widal test. Blood culture, along with the Widal test and clinical history, must be taken into consideration for treatment.

References

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Chopra, Basu and Bhattacharya. Present phage types and antibiotic susceptibility of salmonella. Ind J Path Microb 1992; 35(4): 345-50.
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Nadgir S, Krishna BVS, Halesh LH, Tallur S S. Mutidrug resistant salmonella typhi in Hubli. Ind J Med Microbiol 1998; 16(4) : 185.
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Hemalatha R, Vijaylakshmi P, Gyneshwari Rao MVR, amani A. Multidrug resistant salmonella typhi in Hyderabad. Ind J Med Microbiol 1999; 17(1) : 39-41
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