Antibiotic use and resistance: perceptions and ethical challenges among doctors, pharmacists and the public in Vellore, South India.

Inappropriate antibiotic use and resistance are major public health challenges. Interventional strategies require ascertaining the perceptions of major stakeholders and documenting the challenge to changing practice. Towards this aim, a qualitative study was conducted in Vellore, South India, using focus group discussions among doctors, pharmacists and public. There were eight groups with six to eight participants each. The themes explored were: understanding of infections, antibiotics and resistance; practices and pressure driving antibiotic use; and strategies for appropriate use. Data were transcribed, analysed, verified and a summary prepared with salient features and quotations.

Serological evidence for wide distribution of spotted fevers & typhus fever in Tamil Nadu.

BACKGROUND & OBJECTIVE: Although the re-emergence of spotted fevers and typhus was documented from southern India a few years ago, there was a paucity of community based data. Therefore a collaborative study was carried out in several districts of Tamil Nadu to understand the distribution of these infections. METHODS: Blood (3 ml) was collected from patients presenting to primary health centres (PHCs) with fever >10 days duration in 15 districts of Tamil Nadu during January 2004 to December 2005. Patients negative for malaria, were tested by Weil-Felix test. Clinical data were collected from patients visiting two hospitals. RESULTS: A total 306 samples were tested in 2004 and 115 (37.5%) had titres of >or=80 with OX K antigen, suggesting a diagnosis of scrub typhus. During 2005, 964 patients were tested and 89 (9.2%) were positive for scrub typhus. An additional 44 (4.6%) were positive for other rickettsial illnesses. In both years majority of scrub typhus occurred in individuals above 14 yr of age. Cases increased from August until the earlier part of next year. INTERPRETATION & CONCLUSION: This community based study from south India involving several districts in Tamil Nadu, showed that scrub typhus and rickettsial illnesses were widely distributed in the State. Measures to increase awareness and also to diagnose and treat this infection in the affected areas are essential.

Some virulence characteristics of uropathogenic Escherichia coli in different patient groups.

BACKGROUND & OBJECTIVE: Uropathogenic Escherichia coli have virulence properties, that are absent in non pathogenic E. coli. The distribution of these markers can vary according to patient populations. Hence, a study was undertaken to describe the presence of virulence factors like Pfimbriae, type 1 fimbriae and haemolysin in E.coli causing urinary infections in three groups of patients. Antibiogram was also recorded to determine differences, if any, between the groups. METHODS: E. coli isolated from three groups of subjects, in counts of >10(5) CFU/ml and in pure growth were tested for mannose resistant haemagglutination (MRHA) to indicate P fimbriae and mannose sensitive haemagglutination (MSHA) to indicate type 1 fimbriae. Haemolysin production and antimicrobial susceptibility patterns were also recorded. RESULTS: Significantly more isolates from antenatal and postnatal women possessed P fimbriae compared to groups with urologic abnormalities (P=0.05). Haemolysin production was also significantly higher (P<0.001) in this group. Greater proportions of isolates from pregnant women were susceptible to commonly used antimicrobials. However, resistance to third generation cephalosporins was present even in these isolates from community infections. INTERPRETATION & CONCLUSION: In patients with urological abnormality, E. coli with lower virulence can cause infections. Isolates from these patients exhibited greater drug resistance. In pregnant women and in community acquired infections, simple antimicrobial drugs like nitrofurantoin might still be useful. However, urgent and stringent policies for antimicrobial use and infection control in hospitals are required in India.

Scrub typhus.

Scrub typhus is being increasingly reported in adults in India.It should be considered a strong possibility in all undifferentiated fevers. Two children with this infection are being reported highlighting the wide variation in clinical presentation. Specific tests should be preferred over Weil Felix test wherever possible especially in areas reporting a high incidence of the infection.

Is C-reactive protein level useful in differentiating infected from uninfected neonates among those at risk of infection?

OBJECTIVE: To document effects of intrapartum risk factors for early onset sepsis (EOS) on CRP levels in neonates and to assess the suitability of this test in diagnosing EOS. DESIGN: Cohort study. SETTING: Labour and post natal wards in a tertiary level teaching hospital in India. SUBJECTS: 250 neonates at risk of developing infection. METHODS: CRP levels in cord blood and neonatal blood at 24 hrs were estimated using commercial kits. Babies were observed for signs of sepsis for at least 48 hours. RESULTS: Seven (2.8 Percent) neonates had elevated CRP levels in the cord blood. At 24 hours, 102 (40.8 Percent) babies had elevated levels. Elevated cord CRP levels was significantly associated with rupture of membranes for 24 hours (p =0.04), labour more than 12 hours (p = 0.002), and maternal fever (p = 0.01). At 24 hours, elevated CRP levels were associated with primiparity (p= 0.006), more than three vaginal examinations after membrane rupture (p=0.02), meconium staining of amniotic fluid (p =0.02) and amnioinfusion (p =0.02). Ten (4 Percent) babies developed EOS. The negative predictive value for elevated CRP levels at 24 h was 99 Percent. CONCLUSION: Several intrapartum risk factors for EOS can cause elevation in CRP levels. However, this test may be useful in excluding infection.

Indirect immunofluorescent antibody test for the rapid diagnosis of melioidosis.

Culture is the only reliable method available at present for the diagnosis of melioidosis. Though serological tests have been described, their value in routine diagnosis is controversial. All indirect immunofluorescent assay (IFA) was therefore evaluated to determine its use in the diagnosis of melioidosis. Whole cell antigen prepared from a laboratory isolate of Burkholderia pseudomallei was used to assay IgG and IgM antibodies. Fourteen of the 22 (63.6%) culture proven cases had IgM antibodies while only 10 (45.5%) had IgG antibodies. Negative predictive value of IgM assay was 92 per cent. Positive predictive value was 100 per cent if both IgM and IgG were considered together. The present study done on a limited number of samples suggests that IFA may be useful in routine diagnosis of melioidosis.

Typhidot test to detect IgG & IgM antibodies in typhoid fever.

BACKGROUND & OBJECTIVES: As typhoid fever is endemic in India, there is a continuing search for a simple test which can be carried out in small laboratories for an early and rapid diagnosis. We have evaluated the Typhidot test for this purpose. METHODS: The Typhidot test was carried out on coded sera according to the manufacturer's instructions. The test was performed on 30 Widal positive sera, 30 sera from blood culture positive patients, 60 Widal negative sera and 30 samples from patients whose blood culture grew Gram negative bacilli (GNB) other than Salmonella Typhi. RESULTS: Typhidot test was positive for both IgG and IgM in 39 samples, IgM alone in 24 and IgG alone in 2. Of the 30 culture positive samples, 27 were positive by Typhidot. The Typhidot test gave a sensitivity of 100 per cent and specificity of 80 per cent when bacteraemic patients were analysed. INTERPRETATION & CONCLUSION: The Typhidot is easy to perform, and requires no special equipment or training of staff for interpretation of results. It will be a useful complementary test to blood culture and the Widal test in the diagnosis of typhoid fever.

Evaluation of serological tests for the diagnosis of tuberculosis.

To evaluate the use of antibody detection kits in the diagnosis of pulmonary tuberculosis in an endemic area, serum samples from cases (sputum smear positive for AFB) and controls (healthy young adults) were collected and tested using five different kits. Sensitivity, specificity and predictive values were calculated using smear positivity as gold standard. Sensitivity of tests varied from 46% to 68% and the specificity from 68% to 100%. None of the kits evaluated can be used as a single screening test for tuberculosis. However kits with good specificity may be used in conjunction with conventional methods for diagnosis.