Knowledge and Awareness on Silver Diamine Fluoride among Paediatric Dentists and Post Graduates in India - A Survey

Silver diamine fluoride (SDF) is a topically applied liquid that has been used to treat tooth hypersensitivity and arrest cavitated carious lesions. Lesion arrest can be achieved by painting the cavitated lesion with the SDF liquid without removing any infected soft dentin. SDF can serve as an alternative, particularly for patients who cannot tolerate traditional dental treatment, and can reduce the need for dental care to be performed under general anesthesia, with its associated health risks. The aims of this study were to assess Indian pediatric dentist’s SDF educational experiences, knowledge, attitudes, and professional behavior and to explore the relationships among these constructs. A cross-sectional survey was conducted among 100 paediatric dentists and post graduates by asking them to take up a survey. All dentists from India. were invited to participate in the survey. An online multiple-choice and fill-in response questionnaire was created in Google Forms. Questions. The data obtained were compiled systematically and then statistically analyzed. Survey responses were received from 100 members. The data showed that 41% percent of respondents under 40 years of age in our study. Out of the 100 respondents were male (53%) than female (47%). The respondents ranged in age from 26 to 65 years; they had graduated from their BDS /MDS program. A lack of self-reported knowledge was most frequently reported concerning whether a restoration must be placed after SDF treatment even if SDF is being reapplied twice per year, whether SDF can be used on root caries lesions, and under which codes SDF treatment can be billed.

Perception of Radiation Protection among Dentist in South Chennai, Tamil Nadu

Aims and Objectives: This study aims to assess the attitude and awareness of radiation protection among dental surgeons in South Chennai.Materials and Methods: The study participants comprised 150 dental practitioners (general and specialty) in South Chennai. The information was collected from each participant through structured questionnaires regarding attitude and awareness toward radiation protection. Pearson’s correlation coefficient test was used to assess the validity and reliability of questionnaire, and any P≤ 0.05 was considered as statistically significant.Results: Of all the 150 dentists enrolled in the study, 69% of dental surgeons considered X-ray films as an image receptor. However, majority of the dentists (73%) failed to acquire informed consent of the patient before prescribing dental radiograph. While majority of dentists were unaware of position and distance rule (54%) and 46% were aware of the rule, it was also found that 59% of dental surgeons did not use film-holding device and only 41% used film-holding device. Majority of them (59%) were aware of the Atomic Energy Regulatory Board (AERB) certification and 41% were unaware of AERB, 15% of them hold the cone during exposure.Conclusion: The current study shows the utmost need for further implementation of radiation protection principle among dental surgeons in South Chennai. Majority of them did not practice radiation protection procedures. Emphasis on radiation safety is mandatory for continuing professional education and the development of radiographic selection criteria should be recommended.

Current strategy for local- to global-level molecular epidemiological characterisation of global antimicrobial resistance surveillance system pathogens

The prime goal of molecular epidemiology is to identify the origin and evolution of pathogens, which can potentially influence the public health worldwide. Traditional methods provide limited information which is not sufficient for outbreak investigation and studying transmission dynamics. The recent advancement of next-generation sequencing had a major impact on molecular epidemiological studies. Currently, whole-genome sequencing (WGS) has become the gold standard typing method, especially for clinically significant pathogens. Here, we aimed to describe the application of appropriate molecular typing methods for global antimicrobial resistance surveillance system pathogens based on the level of discrimination and epidemiological settings. This shows that sequence-based methods such as multi-locus sequence typing (MLST) are widely used due to cost-effectiveness and database accessibility. However, WGS is the only method of choice for studying Escherichia coli and Shigella spp. WGS is shown to have higher discrimination than other methods in typing Klebsiella pneumoniae, Acinetobacter baumannii and Salmonella spp. due to its changing accessory genome content. For Gram positives such as Streptococcus pneumoniae, WGS would be preferable to understand the evolution of the strains. Similarly, for Staphylococcus aureus, combination of MLST, staphylococcal protein A or SCCmec typing along with WGS could be the choice for epidemiological typing of hospital- and community-acquired strains. This review highlights that combinations of different typing methods should be used to get complete information since no one standalone method is sufficient to study the varying genome diversity.

Microbiological profile of septic arthritis in adults: Lessons learnt and treatment strategies

Objective: The aim of this study is to characterise the clinical and microbiological profile of adult patients treated at our orthopaedic unit with septic arthritic between 2006 and 2017. Materials and Methods: A total of 70 patients who were admitted with a diagnosis of septic arthritis between 2006 and 2017 were included in the study. The patients' clinical and epidemiological characteristics were surveyed; microbiological profile and the complications relating to the patients' treatment were identified. Results: Septic arthritis was more common among males (83%). About 75% of the patients presented with a history of fever. The knee was the most commonly affected joint (71%), followed by the hip. While C-reactive protein was found to be consistently >75, total blood white blood cell (WBC) counts were found not to be reflective of the presence of infection with a mean WBC count of only 13,561/cu.mm, and Gram stain examination had a poor sensitivity of 47%. Among the co-morbidities, the most prevalent association was with diabetes mellitus. The infectious agent most frequently isolated was Staphylococcus aureus(42.85%). The antibiotic sensitivity pattern has evolved since the early years, with resistant strains becoming increasingly prevalent. Unusually, high incidence of streptococci was noted (30%), contrary to the published literature. One-third of the patients had multi-resistant organisms. Septic arthritis left 70% of the patients with a significant residual disability at 6 months follow-up and had 4.25% mortality. Conclusion: Changing sensitivity patterns of microbes in septic arthritis point to a need for reconsidering empirical antibiotic therapy. Joint damage following infection can lead to significant disability.

Extended spectrum β‑lactamase producing Shigella flexneri serotype‑2 causing bacteremia in a patient with uncontrolled diabetes mellitus.

We report a case of Shigella flexneri serotype‑2 causing bacteremia in an elderly gentleman with uncontrolled diabetes mellitus, who had no other apparent risk factors. Antibiotic susceptibility testing revealed that the organism was a multidrug resistant extended spectrum beta‑lactamase producing strain, which was confirmed by molecular characterization. This rare case alerts both the clinician and microbiologist to a previously unaddressed risk factor of Shigella spp. causing bacteremia, as well as emerging resistant strains that are on the rise in immunocompromised patients.

Epidemiological characterisation of Streptococcus pneumoniae from India using multilocus sequence typing.

Objective: The aim of this study was to utilize the multilocus sequence typing (MLST) technique to characterise Streptococcus pneumoniae among clinical isolates in India. MLST was used to determine clonality, to establish genetic relatedness, to check for correlation between serotypes and sequence types (STs) and its relevance associated with antibiotic resistance. Methods: Forty consecutive invasive S. pneumoniae isolates in children <5 years were characterised. Preliminary identification of serotype and antibiotic susceptible profile was followed with MLST technique to identify the STs of the isolates. STs were then analysed for clonality using an eBURST algorithm and genetic relatedness using Sequence Type Analysis and Recombinational Tests version 2 software. Results: The most common ST was ST63. Among the forty isolates, we identified nine novel STs, six of which had known alleles but in new combinations, three of which had new alleles in their sequence profile. The new STs assigned were 8501–8509. One clonal complex was found among the 40 strains characterised. The most common serotypes in this study were serotype 19F, 14 and 5. Non-susceptibility to penicillin and erythromycin was observed in 2.5% and 30% of the isolates, respectively. Conclusion: This study shows a significant number of novel STs among the 40 isolates characterised (9/40, 22.5%), however, internationally recognised strains were also circulating in India, indicating, there could be greater geographical variation in pneumococcal STs in India. Molecular epidemiology data is essential to understand the population dynamics of S. pneumoniae in India before the introduction of pneumococcal vaccines in NIP in India.

Changing paradigm of Cryptococcal meningitis: An eight-year experience from a tertiary hospital in South India.

Background: Cryptococcal meningitis (CM) is a common opportunistic fungal infection causing sub-acute meningitis with the potential for complications and signifi cant mortality. We conducted this study to describe the difference in presentation and outcome between HIV-infected and HIV-uninfected patients. Materials and Methods: Patients admitted to a tertiary care centre between 2005 and 2013 with confi rmed CM were included in the analysis. Details of the clinical presentation, laboratory fi ndings, treatment details, risk factors for infection and outcome were documented and analysed. Results: During the study period, 102 (87.2%) cases of CM occurred among HIV infected individuals, whereas 15 (12.8%) occurred among HIV-uninfected patients. HIV-infected patients with CM were younger compared with HIV-uninfected patients (38.2 ± 8.5 years vs. 45 ± 11.5 years; P = 0.07). The median duration of symptoms prior to presentation was shorter in the HIV-infected group (20 ± 32 vs. 30 ± 42; P = 0.03). There was no difference between the cerebrospinal fl uid (CSF) lymphocyte counts, CSF protein counts, and CSF sugar levels in both the groups. The diagnostic yield of Cryptococcus was similar with CSF India ink smear (89% vs. 87%), CSF fungal culture (95% vs. 87%), and blood culture (100% vs. 75%) in both the groups. Case fatality rate in the HIV-infected group was 30.6%, whereas there were no deaths in the HIV-uninfected group. Conclusion: HIV-infected patients with CM have a worse outcome compared to HIV-uninfected patients. The overall trend over 3 decades shows increasingly successful rates of treatment and hence early diagnosis and treatment are of paramount importance.

A possible alternative to the error prone modified Hodge test to correctly identify the carbapenemase producing Gram-negative bacteria.

Context: The modified Hodge test (MHT) is widely used as a screening test for the detection of carbapenemases in Gram‑negative bacteria. This test has several pitfalls in terms of validity and interpretation. Also the test has a very low sensitivity in detecting the New Delhi metallo‑β‑lactamase (NDM). Considering the degree of dissemination of the NDM and the growing pandemic of carbapenem resistance, a more accurate alternative test is needed at the earliest. Aims: The study intends to compare the performance of the MHT with the commercially available Neo‑Sensitabs ‑ Carbapenemases/ Metallo‑β‑Lactamase (MBL) Confirmative Identification pack to find out whether the latter could be an efficient alternative to the former. Settings and Design: A total of 105 isolates of Klebsiella pneumoniae resistant to imipenem and meropenem, collected prospectively over a period of 2 years were included in the study. Subjects and Methods: The study isolates were tested with the MHT, the Neo‑Sensitabs ‑ Carbapenemases/MBL Confirmative Identification pack and polymerase chain reaction (PCR) for detecting the blaNDM‑1 gene. Results: Among the 105 isolates, the MHT identified 100 isolates as carbapenemase producers. In the five isolates negative for the MHT, four were found to produce MBLs by the Neo‑Sensitabs. The Neo‑Sensitabs did not have any false negatives when compared against the PCR. Conclusions: The MHT can give false negative results, which lead to failure in detecting the carbapenemase producers. Also considering the other pitfalls of the MHT, the Neo‑Sensitabs ‑ Carbapenemases/MBL Confirmative Identification pack could be a more efficient alternative for detection of carbapenemase production in Gram‑negative bacteria.

Revised ciprofloxacin breakpoints for Salmonella Typhi: Its implications in India.

The rise of multidrug resistant strains of Salmonella Typhi in the last decade of the previous century led to the use of fl uoroquinolones as the drug of choice. However, over the past few years fl uoroquinolone resistance has been increasingly reported. In accordance with the revised Clinical and Laboratory Standards Institute (CLSI) breakpoints, only 3% of the isolates were susceptible to ciprofl oxacin in comparison to 95% as per the earlier guidelines when 488 isolates collected between 2010 and 2012 were re-interpreted. Interestingly, re-emergence of strains susceptible to chloramphenicol, ampicillin and cotrimoxazole is being seen. Amidst the changing susceptibility profi le, azithromycin remains a promising alternative.

Polymyxins: Antimicrobial susceptibility concerns and therapeutic options.

The increasing prevalence of multidrug-resistant nosocomial pathogens such as Acinetobacter baumannii, Pseudomonas aeruginosa and Klebsiella pneumoniae poses a great challenge to the treating physicians. The paucity of newer effective antimicrobials has led to renewed interest in the polymyxin group of drugs, as a last resort for treatment of gram-negative bacterial infections. There is a dearth of information on the pharmacological properties of colistin, leading to difficulties in selecting the right dose, dosing interval, and route of administration for treatment, especially in critically-ill patients. The increasing use of colistin over the last few years necessitates the need for accurate and reliable in vitro susceptibility testing methods. Development of heteroresistant strains as a result of colistin monotherapy is also a growing concern. There is a compelling need from the clinicians to provide options for probable and possible colistin combination therapy for multidrug-resistant bacterial infections in the ICU setting. Newer combination drug synergy determination tests are being developed and reported. There are no standardized recommendations from antimicrobial susceptibility testing reference agencies for the testing and interpretation of these drug combinations. Comparison and analysis of these reported methodologies may help to understand and assist the microbiologist to choose the best method that produces accurate results at the earliest. This will help clinicians to select the appropriate combination therapy. In this era of multidrug resistance it is important for the microbiology laboratory to be prepared, by default, to provide timely synergistic susceptibility results in addition to routine susceptibility, if warranted. Not as a favour or at request, but as a responsibility.

Prevalence of inducible clindamycin resistance in gram positive organisms in a tertiary care centre.

Gram positive organisms are one of the leading pathogens causing skin and soft tissue infections. For these infections, clindamycin is a useful alternate drug in penicillin-allergic patients. This study was conducted to investigate the prevalence of erythromycin-induced clindamycin resistance in gram positive organisms in the southern part of the country. A total of 522 consecutive clinical isolates from blood, CSF, sputum, throat, pus, and urine were collected between November 2006 and April 2007 and tested for erythromycin resistance and inducible clindamycin resistance. There was a relatively higher incidence of inducible clindamycin resistance among the MRSA isolates. We conclude, therefore, that clindamycin is not a suitable alternative antibiotic for use in staphylococcal skin and soft tissue infections.

Prevalence of gestational diabetes mellitus in South India (Tamil Nadu)--a community based study.

AIM: Women diagnosed to have Gestational Diabetes Mellitus (GDM) are at increased risk of developing diabetes in future. Thus, diagnosis of GDM is an important public health issue. In a random survey 16.2% of pregnant women were found to have GDM in the Chennai urban population. Hence we undertook a planned community based study to ascertain the prevalence of GDM. MATERIALS AND METHODS: We conducted a prospective screening for GDM in the urban, semi urban and rural areas. All pregnant women irrespective of gestational weeks underwent a 75 g glucose challenge test in the fasting state. Diagnosis of GDM was made if the 2 hr plasma glucose was > or = 140 mg/dl (WHO criteria). RESULTS: A total of 4151, 3960 and 3945 pregnant women were screened in urban, semi urban and rural areas, respectively. GDM was detected in 739 (17.8%) women in urban, 548 (13.8%) in semi urban and 392 (9.9%) in rural areas. Out of 1679 GDM women, 1204 (72%) were detected in first visit and the remaining 28% in subsequent visits. A significant increase (P < 0.0001) in the prevalence of GDM was observed with family history of diabetes, increased maternal age and BMI. A trend for increased prevalence of GDM was observed in women with less physical activity, however, not statistically significant. CONCLUSION: In this community based study, the prevalence of GDM varied in the urban, semi urban and rural areas. Age > or = 25 years, BMI > or = 25 and family history of diabetes were found to be risk factors for GDM.

Estimation of faecal carriage of Clostridium difficile in patients with ulcerative colitis using real time polymerase chain reaction.

BACKGROUND & OBJECTIVE: Ulcerative colitis (UC) is a disease of unknown aetiology in which exacerbations are sometimes linked to intestinal colonization by toxin-producing Clostridium difficile. We undertook this study to detect and quantitatively assess C. difficile in the stool of patients with UC using real time polymerase chain reaction (RT-PCR), and to compare it with healthy individuals. METHODS: A total of 37 consecutive patients with UC (26 male, mean age 41.3 yr) and 36 healthy adult volunteers (20 male, mean age 36.4), none of whom had received antibiotics within two months prior to faecal collection, were included in the study. Faecal DNA was extracted, quantitative PCR (qPCR) carried out using primers to amplify species-specific segments of 16S rDNA of C. difficile, and expressed as relative fold difference against amplification of highly conserved (universal) segments. Toxins A and B were assayed by ELISA. RESULTS: Quantitative PCR detected C. difficile sensitively, and spiking with increasing numbers of the organism resulted in linear increase in amplification (R(2)=0.974). C. difficile was detected by qPCR in faeces of 20 of 36 healthy volunteers and 34 of 37 patients with UC. Relatively greater amplification of C. difficile (fold difference) was noted in UC compared to controls (P<0.0001). There was no significant difference in C. difficile amplification between patients with proctitis, left sided colitis and pancolitis, or between active and quiescent colitis. Toxin was detected in the faeces of 8 of 37 patients with UC compared to 2 of 36 healthy volunteers. INTERPRETATION & CONCLUSION: Findings of this study showed overgrowth of C. difficile in the stool of Indian patients with UC. However, its relevance to disease pathogenesis and severity in a tropical country like India needs to be investigated further.

Changing profile of prostatic abscess

PURPOSE: To compare the clinical presentation of prostatic abscess and treatment outcome in two different time frames with regards to etiologies, co-morbid factors and the impact of multidrug resistant organism. MATERIALS AND METHODS: We retrospectively assessed the charts of 48 patients with the diagnosis of prostatic abscess from 1991 to 2005. The period was divided arbitrarily into two different time frames; phase I (1991-1997) and phase II (1998-2005). Factors analyzed included presenting features, predisposing factors, imaging, bacteriological and antibiotic susceptibility profile, treatment and its outcome. RESULTS: The mean patient age in phase I (n = 18) and phase II (n = 30) were 59.22 ± 11.02 yrs and 49.14 ± 15.67 respectively (p = 0.013). Diabetes mellitus was most common predisposing factor in both phases. Eleven patients in phase II had no co-morbid factor, of which nine were in the younger age group (22 - 44 years). Of these eleven patients, five presented with pyrexia of unknown origin and had no lower urinary tract symptoms LUTS Two patients with HIV had tuberculous prostatic abscess along with cryptococcal abscess in one in phase II. Two patients had melioidotic prostatic abscess in phase II. The organisms cultured were predominantly susceptible to first line antibiotics in phase I whereas second or third line in phase II. CONCLUSION: The incidence of prostatic abscess is increasing in younger patients without co-morbid factors. The bacteriological profile remained generally unchanged, but recently multi drug resistant organisms have emerged. A worrying trend of HIV infection with tuberculous prostatic abscess and other rare organism is also emerging.

Scope for prevention of diabetes--'focus intrauterine milieu interieur'.

The prevalence of diabetes is increasing globally and India is no exception. The lifestyle modification and drug intervention are likely to delay or postpone the development of overt diabetes in persons diagnosed to have impaired glucose tolerance. This is a post primary prevention strategy. The primary prevention is more important as this effort is likely to reverse or halt the epidemic of disease. Women with Gestational Diabetes Mellitus (GDM) are an ideal group for the primary prevention of diabetes as they are at increased risk of future diabetes, predominantly type 2 diabetes, as are their children. Pima Indians have the highest prevalence of diabetes. This is attributed to the children exposed in utero to maternal diabetes. Hence as a policy to identify GDM and its consequences on the infant, a 75 gm Oral Glucose Tolerance Test has been recommended to all Pima Indian women during the 3rd trimester of pregnancy. Ethnically Asian Indian women also have high prevalence of diabetes and the relative risk of developing Gestational Diabetes Mellitus in them is 11.3 times compared to White women. This necessitates universal screening for gestational diabetes during pregnancy in India. Probably the undiagnosed gestational diabetes that has been occurring in the past has resulted in the increased prevalence of diabetes in India. The timely action taken now in screening all pregnant women for glucose intolerance, achieving euglycemia in them and ensuring adequate nutrition may prevent in all possibility, India becoming the diabetes capital of the world.

An "epidemic" of post cataract surgery endophthalmitis by a new organism.

We report a case series of endophthalmitis by an organism hitherto not reported in the eye. Nineteen of 63 cataract patients operated in a high-volume setup were urgently referred to us with acute onset of decreased vision one to two days following cataract surgery. All patients had clinical evidence of acute endophthalmitis with severe anterior chamber exudative reaction. Vitreous tap was done in three representative patients and repeated intravitreal injections were given as per established protocol. The vitreous sample from all three patients grew Enterobacter amnigenus Biogroup II, a gram-negative bacillus which, to the best of our knowledge, has never been reported in the eye. With prompt and accurate microbiological support, it was possible to salvage 17 of these eyes without performing vitrectomy. Six eyes regained 6/200 or better vision.

Glycemic level at the first visit and prediction of GDM.

OBJECTIVE: To evaluate the glycemic level at the first visit that is likely to predict gestational diabetes mellitus (GDM). METHODS: Consecutive pregnant women underwent a 75g oral glucose tolerance Test (OGTT) recommended by WHO and diagnosed GDM if 2hr post plasma glucose (PG) value > or = 140 mg/dl. Women with normal OGTT results at the first visit were screened again with an OGTT at the subsequent visits. RESULTS: A total of 4151 pregnant women from different trimesters underwent OGTT. Of them 739 women (17.8%) had GDM. Among the GDM women, 528 (71.4%) were detected at the first visit. On screening during subsequent visits, GDM was diagnosed in the remaining 211(28.6%) women who had normal OGTT in the first visit. We performed the analysis taking the glycemic level in the first visit of 211 pregnant women who manifested GDM in the subsequent visit. During normal pregnancy, 2hr PG level is < 120 mg/dl. Taking this value into consideration among the 211 women who turned to have GDM in the subsequent visits 119 women (56.4%) had 2hrPG > or = 120 mg/dl and the remaining 92(43.6%) had 2hrPG < 120 mg/dl. CONCLUSION: Pregnant women irrespective of 2 hr PG > or = or < 120 mg/dl at initial visit progressed to GDM in the subsequent visit. No glycemic level in the early weeks of pregnancy predicts GDM and at the same time at no statistically significant glycemic cut-off level could we say that a woman will not develop GDM. Hence rescreening in the subsequent trimester or visits is essential.