Post-COVID multisystem inflammatory syndrome in adults: a study from a tertiary care hospital in south India

Background & objectives: There are limited data from India on the post-COVID multisystem inflammatory syndrome in adults (MIS-A). The objective of the present study was to evaluate the clinical profile of patients with MIS-A admitted to a tertiary care centre in southern India. Methods: This single-centre retrospective study was conducted from November 2020 to July 2021, and included patients aged >18 yr admitted to the hospital as per the inclusion and exclusion criteria. Results: Nine patients (5 male, mean age 40±13 yr) met the criteria for MIS-A. Five patients had proven COVID-19 infection or contact history 36.8±11.8 days back. All patients were positive for SARS-CoV-2 IgG antibody, negative for COVID-19 PCR, and had negative blood, urine and sputum cultures. All patients had fever and gastrointestinal (GI) symptoms, and five patients had left ventricular dysfunction. All patients had neutrophilic leucocytosis at presentation and elevated biomarkers such as C-reactive protein serum procalcitonin, D-dimer and ferritin. The majority of the patients (7/9 i.e. 77.78%) were treated with intravenous hydrocortisone (50-100 mg q6h-q8h). Six patients recovered completely whereas three patients expired. Interpretation & conclusions: Fever and GI symptoms were the most common presentation of MIS-A. Elevated serum procalcitonin may not be useful in differentiating bacterial sepsis from MIS-A. Most patients responded to corticosteroids.

Policy document on antimicrobial stewardship practices in India

Antimicrobial resistance (AMR) in India has become a great threat because of high rate of infectious diseases. One of the key contributing factors is high antibiotic use due to poor prescription practices, self-medication, over-the-counter sale of drugs and lack of awareness. Antimicrobial stewardship programme (AMSP) have been proved to be successful in restraining sale and use of antibiotics to a large extent in many countries. An AMSP programme for a hospital is imperative for rational and evidence-based antimicrobial therapy. The ultimate aim is to improve patient outcomes, reduce emergence of bacterial resistance and ensure longevity of the existing antimicrobials. The primary goal of AMSP is to encourage cautious use of available antibiotics by training the healthcare workers and creating awareness. This article describes the strategies and recommendations for formulation of AMSP policy for India.

Newer ?-Lactam/?-Lactamase inhibitor for multidrug-resistant gram-negative infections: Challenges, implications and surveillance strategy for India

Antimicrobial resistance (AMR) is a major public health concern across the globe, and it is increasing at an alarming rate. Multiple classes of antimicrobials have been used for the treatment of infectious diseases. Rise in the AMR limits its use and hence the prerequisite for the newer agents to combat drug resistance. Among the infections caused by Gram-negative organisms, beta-lactams are one of the most commonly used agents. However, the presence of diverse beta-lactamases hinders its use for therapy. To overcome these enzymes, beta-lactamase inhibitors are being discovered. The aim of this document is to address the burden of AMR in India and interventions to fight against this battle. This document addresses and summarises the following: The current scenario of AMR in India (antimicrobial susceptibility, resistance mechanisms and molecular epidemiology of common pathogens); contentious issues in the use of beta-lactam/beta-lactamase inhibitor as an carbapenem sparing agent; role of newer beta-lactam/beta-lactamase inhibitor agents with its appropriateness to Indian scenario and; the Indian Council of Medical Research interventions to combat drug resistance in terms of surveillance and infection control as a national response to AMR. This document evidences the need for improved national surveillance system and country-specific newer agents to fight against the AMR.

Hyperinfection Syndrome Case report and review of Literature

After the introduction of the Antiretroviral Therapy (ART) very few case reports of Lymphocytic interstitial pneumonitis (LIP) with HIV are available till date, especially in adults. In children LIP is still considered as AIDS defining condition. LIP is a polyclonal proliferation of lymphocytes, which can be misdiagnosed as Pneumocystis carnii pneumonia (PCP) or Hypersensitivity pneumonitis (HP) if proper sampling is not done. The mainstay of treatment is ART. Here we are presenting a case of lymphocytic interstitial pneumonitis in a defaulter case of HIV-positive patient. The Video-Assisted Thoracoscopic lung biopsy was taken and diagnosis was made on the basis of histopathology examination. Hence, it is suggested to consider for LIP as a differential for cough and dyspnoea in all HIV positive cases, who are not on ART

Antimicrobial susceptibility of Salmonella enterica serovars in a tertiary care hospital in southern India.

Background & objectives: Salmonella enterica serovars Typhi and Paratyphi are predominantly known to cause enteric fever. Multidrug resistance in S. Tphi and S. Paratyphi has emerged as a cause of concern. This study was done to evaluate status in antimicrobial susceptibility patterns of Salmonella enterica serovar Typhi (S. Typhi) and S. Paratyphi obtained from blood culture in a tertiary care hospital in south India. Methods: Blood isolates of Salmonella species over a two year period between May 2009 and June 2011 were studied. A total of 322 isolates of Salmonella species were tested for antimicrobial susceptibility by Kirby-Bauer disc diffusion method. The MIC of ciprofloxacin was obtained by E-test, and azithromycin MIC was confirmed by agar dilution method for a limited number of isolates. Results: Of the total of 322 isolates studied, 186 (57.8%) were S. Typhi, 134 (41.6%) were S. Paratyphi A, and two were S. Paratyphi B. Of these, 44(13.66%) were resistant to ciprofloxacin (MIC <0.50 μg/ml) and 296 (91.9%) were nalidixic acid resistant. Of these 296 nalidixic acid resistant isolates, 278 (94%) were susceptible to ciprofloxacin by MIC criteria (<0.5 μg/ml). Of the 262 isolates tested for azithromycin sensitivity, only 120 (46%) were susceptible, whereas 81 (31%) were resistant and 55 (21%) showed intermediate susceptibility. Of the isolates, 322 (90%) were susceptible to ampicillin and (95%) were susceptible to co-trimoxazole. However, all the isolates were susceptible to chloramphenicol and ceftriaxone. Interpretation & conclusions: Nalidixic acid resistance screening is not a reliable surrogate indicator of ciprofloxacin resistance. Ciprofloxacin MIC should to be routinely done. Azithromycin resistance appears to be emerging. However, isolates showed a high degree of susceptibility to ampicillin, co-trimoxazole and chloramphenicol. Thus, antibiotics like ampicillin and co-trimoxazole may once again be useful for the management of enteric fever in southern India.

"The Chennai declaration" Recommendations of "A roadmap- to tackle the challenge of antimicrobial resistance" - A join meeting of medical societies of India.

"A Roadmap to Tackle the Challenge of Antimicrobial Resistance - A Joint meeting of Medical Societies in India" was organized as a pre-conference symposium of the 2 nd annual conference of the Clinical Infectious Disease Society (CIDSCON 2012) at Chennai on 24 th August. This was the first ever meeting of medical societies in India on issue of tackling resistance, with a plan to formulate a road map to tackle the global challenge of antimicrobial resistance from the Indian perspective. We had representatives from most medical societies in India, eminent policy makers from both central and state governments, representatives of World Health Organization, National Accreditation Board of Hospitals, Medical Council of India, Drug Controller General of India, and Indian Council of Medical Research along with well-known dignitaries in the Indian medical field. The meeting was attended by a large gathering of health care professionals. The meeting consisted of plenary and interactive discussion sessions designed to seek experience and views from a large range of health care professionals and included six international experts who shared action plans in their respective regions. The intention was to gain a broad consensus and range of opinions to guide formation of the road map. The ethos of the meeting was very much not to look back but rather to look forward and make joint efforts to tackle the menace of antibiotic resistance. The Chennai Declaration will be submitted to all stake holders.

Colonization of probiotic bacteria and its impact on ornamental fish Puntius conchonius.

The present study was conducted to assess the establishment and effect of probiotic bacteria such as Bacillus coagulans, Bacillus mesentericus, and Bifidobacterium infantis in the gut of freshwater ornamental fish Puntius conchonius. Postlarvae of 60 days old Puntius conchonius divided in four experimental groups each with three replicates. T1, T2 and T3 groups were fed with Bacillus coagulans, Bacillus mesentericus and Bifidobacterium infantis enriched copepod Thermocyclops decipiens respectively. T0 was the control group (without probiotic treated T.decipiens). The experiment was conducted for 45 days. The initial gut analysis of fish showed significant level of pathogenic bacteria in the gut of fish (p<0.05). Total plate count of initial gut analysis of fish larvae were enumerated as 1.2 x 104 CFU ml-1. The bacteriological study indicated that final gut microflora of post-larvae have decreased level of pathogens. Total plate count of T1, T2, T3 and T0 were reported to be as 1.08x104, 1.06x104, 1.27x104 and 2.1x105 CFU ml -1, respectively. Three experimental groups (T1, T2 and T3) were significantly different from control group (T0) (p<0.05). At the end of the experiment, establishment of probiotics were examined. One week after probiotics administration, gut analysis of fish larvae showed, poor spore formation of Bacillus coagulans (2.3x10³ CFU ml -1), when compared to B. mesentericus (3.2±0.03x10³ CFU ml -1) and Bifidobacterium infantis (3.1x10³ CFU ml -1). The results from the study suggest that the probiotic bacteria significantly established in gut of P. conchonius and significant effects on the pathogenic gut inhabitants of the fish.

Increase in minimum inhibitory concentration to quinolones and ceftriaxone in salmonellae causing enteric fever.

Multidrug resistance among Salmonella typhi is well known. Reports of treatment failure in enteric fever with Ciprofloxacin made us undertake this study to determine the antibiotic susceptibility pattern of S. typhi and S. paratyphi A isolated from typhoid bacteremia cases, by disc diffusion and MIC by broth dilution method. A total of 50 strains were tested, 48 of Salmonella typhi and 2 of S. paratyphi A. The disc diffusion method was done using ampicillin, chloramphenicol, cotrimoxazole, tetracycline, ciprofloxacin, ofloxacin, cefuroxime and ceftriaxone as antibiotics. The MIC was performed using ciproloxacin, ofloxacin and ceftriaxone based on standard procedure. ACCOT resistance as determined by disc diffusion method was seen in 68% of isolates. All the strains remained susceptible to flouroquinolones cephalosporins and aminoglycosides. The MIC of ciprofloxacin, ofloxacin and ceftriaxone were in the recommended range of susceptibility as given by NCCLS, 14 (28%) strains had MIC of ciprofloxacin greater than 0.5 ug/ml with 4 strains having an MIC of 1.56 ug/ml; 25 (50%) strains had MIC of ofloxacin greater than 0.5 ug/ml and 20 (40%) strains had MIC of ceftriaxone greater than 0.5 ug/ml. The high levels of MIC of ciprofloxacin may account for treatment failure cases. The rising levels of MIC of ofloxacin and ceftriaxone in S. typhi and S. paratyphi is also of concern. We document here the emergence of high levels of MIC not only to ciprofloxacin, but also ofloxacin and ceftriaxone in S. typhi and S. paratyphi A. We recommend that MIC levels of ofloxacin and ceftriaxone should be monitored along with ciprofloxacin in treatment failure cases of enteric fever.

Normal variations in spirometry in health following placebo inhalation.

Normal i.e., chance variations in spirometry were evaluated in 80 healthy Indian adults by the measurement of base-line spirometric indices (FVC, FEV1 and FEF25-75%) and the per cent changes following placebo administration of aerosolized saline. There was a mean per cent change of 0.7, 0.4 and 0.3 per cent over the base-line values in FVC, FEV1 and FEF25-75% respectively following placebo inhalation. The cut off responses for 95 per cent confidence limits were 11.2 per cent for FVC and 12.7 per cent for FEV1 following placebo inhalation. Since the test sample represents a healthy Indian population, a per cent change greater than 12.7 per cent in FEV1 is more than that observed in 95 per cent of healthy Indians. It is suggested that for both delta FEV1 per cent and delta FVC per cent, the lower limit should be fixed at more than 15 per cent to define 'abnormality' in clinical practice.