Ecology of blood stream infection and antibiotic resistance in intensive care unit at a tertiary care hospital in North India

OBJECTIVE: To analyse the prevalent microorganisms and their antimicrobial resistance among intensive care unit patients in a tertiary care centre in New Delhi. METHODS: A retrospective study of all consecutive blood cultures from various intensive care unit patients in the hospital during four years (January 2008 to December 2011). Antibiotic consumption data in the intensive care units were also analysed during the same period. RESULTS: Out of the total 22,491 blood cultures processed, 2846 samples were positive and 3771 microorganisms were isolated. The blood culture positivity was estimated as 12.7% of which 67.5% were monomicrobial and 32.5% polymicrobial infections. Gram negative bacilli, Gram positive cocci, and fungi were isolated in 49%, 33%, and 18% cases, respectively. Coagulase negative staphylococcus was the commonest single isolate followed by Candida spp. A drastic shift in the distribution of Candida spp. towards nonalbicans along with high resistance to azole group of antifungals suggest echinocandins for the empiric therapy of candidemia. High penicillin resistance in Gram positive isolates suggest vancomycin, linezolid and tigecycline as the options for empiric therapy, whereas tigecycline and colistin are the only options remaining for highly resistant Gram negative isolates. Aminoglycosides were observed to have better sensitivity and reduced usage when compared with cephalosporins and ß-lactam + ß-lactam inhibitor combinations. CONCLUSIONS: High frequencies of multidrug resistant organisms were observed in intensive care units which is a warning as to use the only few effective antimicrobials wisely to reduce selective pressure on sensitive strains. .

Non-albicans Candida species in blood stream infections in a tertiary care hospital at New Delhi, India.

Background & objectives: During recent decades, there has been a change in the epidemiology of Candida infections, characterized by a progressive shift from a predominance of Candida albicans to non-albicans Candida species. This study was undertaken to analyze the change in the epidemiology of candidaemia and antifungal use at tertiary care hospital in New Delhi, India, over a period of 10 years. Methods: A retrospective review of candidaemia between 1999 and 2008 and antifungal use from 2000 to 2008 was performed at Sir Ganga Ram Hosptial, New Delhi. Initially (1999-2005), isolates were differentiated as C. albicans and non- albicans Candida species. Between 2006-2008, these were identified to the species level and antifungal susceptibility was performed. Results: The occurrence of candidaemia and total antifungal use increased significantly. Candidaemia due to non-albicans species increased and this was correlated with an increasing use of fluconazole. There was emergence and increased isolation of a novel species C. haemulonii with decreased susceptibility to both amphotericin B and azoles. Overall, sensitivities of 89.6, 90.9, 88.6, 68.8 and 54.3 per cent to amphotericin B, 5 flucytosine, voriconazole, fluconazole and itraconazole, respectively were observed. Cross-resistance or reduced susceptibility to both fluconazole (MIC >16 μg/ml) and voriconazole was observed in 11.3 per cent isolates. Interpretation & conclusions: The study demonstrates a shift to non-albicans Candida species causing fungaemia and the emergence of amphotericin B and azole resistant novel species, C. haemulonii. Decreased susceptibility to fluconazole, as well as the threat of emergence of cross-resistance to voriconazole in the background of high azole consumption may limit the use of these agents as a presumptive therapy for Candida blood stream infections (BSI).

Role of Imatinib in Achieving Euglycemic State in Patient with GIST.

Gastrointestinal stromal tumor (GIST) are rare tumors arising from Interstitial Cells of Cajal and require immunohistochemical marker c-kit (CD 117) for diagnosis. Imatinib Mesylate is an orally administered drug which competitively inhibits tyrosine kinase associated with the KIT protein. We present a rare case report highlighting role of Imatinib Mesylate in achieving euglycemic state in patient with GIST. Imatinib Mesylate is an effective form of treatment for patients with KIT (CD 117) positive unresectable and/ or metastatic malignant GIST. Proper patient selection and adequate treatment may help in achieving euglycemic state in patient with GIST.

A ten year analysis of multi-drug resistant blood stream infections caused by Escherichia coli & Klebsiella pneumoniae in a tertiary care hospital.

Background & objectives: Extensive use of antibiotics has added to the escalation of antibiotic resistance. This study was undertaken to evaluate the association, if any between antibiotic use and resistance in a hospital setting, and also detect the predominant mechanism of antibiotic resistance in Escherichia coli and Klebsiella pneumoniae over a period of 10 years. Methods: In a retrospective study of 10 years, a total of 77,618 blood culture samples from 2000 to 2009 from indoor patients were screened and those yielding E. coli and K. pneumoniae were included in the study. Antibiotic susceptibility records as well as the percentage of ESBL producers were noted. A total of 423 isolates of 2009 were also screened for AmpC and carbapenemase production. Antibiotic consumption data of 10 years were analysed. Results: ESBL producing E. coli increased from 40 per cent in 2002 to 61 per cent in 2009, similarly there was a significant (P<0.05) rise in resistance to cefotaxime (75 to 97%), piperacillin-tazobactum (55- 84%) and carbapenem (2.4-52%) in K. pneumoniae. A significant (P<0.05) association was observed between resistance and consumption of carbapenem and piperacillin and tazobactum consumption in K. pneumonia. Interpretation & conclusions: Our study demonstrated a rise in consumption and resistance to broad spectrum antimicrobial agents and also established an association between consumption and resistance to these antibiotics. Over a period of 10 years, the emergence of pan-resistance in K. pneumoniae could be due to the production of carbapenemases whereas ESBL production was the common mechanism of resistance in E. coli. This study warrants a directed effort towards continued surveillance and antibiotic stewardship to minimize selection pressure and spread.

Clinicopathological profile of an unusual case of chondroid syringoma: a case report.

Chondroid syringoma or mixed tumor of the skin is an uncommon tumor that typically presents as small, solitary, slow growing, firm, subcutaneous or intracutaneous nodule. It presents commonly in the head and neck region. This is a case report of 45-year-old female who presented with multiple masses in the flank, chest wall, arm, -thigh and neck measuring 10, 6, 3.5, 2 and 1 cm in maximum dimension. FNAC and excision biopsy revealed benign chondroid syringoma. This is a rare case of chondroid syringoma exhibiting large size, multiplicity and unusual locations in flank, chest wall and thigh.

Evaluation of invasive and non-invasive diagnostic modalities for Helicobacter pylori infection in children.

Invasive and non invasive tests for Helicobacter pylori performed on 31 children were evaluated as diagnostic modalities. Investigations included upper gastrointestinal endoscopy and endoscopic grasp biopsy (EGB) from antrum and corpus (for rapid urease test, impression smear, histology and culture), antral brushings, serum ELISA for IgG antibodies, rapid blood test, and IgG antibodies in unstimulated saliva. Our results suggested that amongst the invasive methods brush cytology was more sensitive than histology and impression smear. Best interpretation of urease test was possible at 4 hours incubation. Culture of EGB sample constitutes the most specific way to establish the diagnosis of infection but is not easy. Hence, non-invasive modalities like serum ELISA, rapid blood test and salivary ELISA can be used in children for the detection of H pylori infection.