Rare yeasts causing fungemia in immunocompromised and haematology patients: Case series from Delhi.

Systemic fungal infection related to fluconazole‑resistant yeasts are emerging in immunocompromised patients. In this case‑series, we report eight cases of fungemia caused by Trichosporon spp. (2), Stephanoascus ceferrii (1), Kodamaea ohmeri (1), Pichia kutrawersi (2), Candida rugosa (1) and Candida lusitianae (1) in immunocompromised patients. All the yeasts except (Trichosporon asahii) were sequenced. As these rare species are inherently resistant to antifungal agents and they may lead to the development of nosocomial outbreaks, therefore, accurate identification followed by antifungal susceptibility testing is crucial for proper treatment and management.

Clinico‑demographical profile of keratomycosis in Delhi, North India.

This study was undertaken to evaluate the clinico‑demographical profile of keratomycosis. (January 2004 to January 2012). The corneal scrapings were processed by direct microscopic methods and standard culture techniques. Of 209 cases of keratitis studied, culture yielded growth in 80 cases (38.3%). Out of these 80 cases of growth, fungi were isolated in 77.5% and bacteria in 22.5%. The spectrum of keratomycosis was Aspergillus flavus (22.5%), Fusarium solani (16.1%), A. fumigatus (11.3%), Candida albicans (6.4%), etc., Routine surveillance of fungal keratitis is necessary to know the existing and emerging pattern of pathogens and to prevent use of un‑warranted anti‑microbial therapy.

Clinical and microbiological characteristics of Rhodotorula mucilaginosa infections in a tertiary-Care facility.

Background: Rhodotorula spp. are an emergent opportunistic pathogen, particularly in immunocompromised individuals. Materials and Methods: The aim of the study was to review reported cases of Rhodotorula infection over a period of 9 years to determine epidemiology, risk factors, treatment and outcome. Results: The Rhodotorula spp. were isolated from cerebrospinal fluid (9) and blood (5). The most common pre-disposing factors were prolonged hospital stay (>1 month) and prolonged usage of broad-spectrum antibiotics (>1 month). All the isolates were identified as R. mucilaginosa by conventional methods. Amphotericin B demonstrated lowest minimum inhibitory concentration (MIC) as compared with other anti-fungal agents (fluconazole, itraconazole and voriconazole). Conclusions: The recognition of unusual yeasts as an agent of life-threatening infection and their intrinsic resistance increases the burden on the mycology laboratory for complete species identification and to determine minimum inhibitory concentration.

The use of E-test for the drug susceptibility testing of Mycobacterium tuberculosis - A solution or an illusion.

Aim: To evaluate E-test as a tool for rapid determination of drug susceptibility against the conventional LJ method focusing on reliability, expense, ease of standardization and performance of the technique in low resource settings. Materials and Methods: A total of 74 clinical isolates (2004-2005) of Mycobacterium tuberculosis were tested using E-test for susceptibility to streptomycin (STM), isoniazid (INH), rifampicin (RIF) and ethambutol (EMB) by E-strip and LJ (LJPM) proportion methods. Results: The LJPM method, the gold standard, detected resistance against STM in 16.2%, INH in 40.5%, RIF in 18.9% and EMB in 27% cases. In comparison, the resistance values showed by E-test was 66.67% for STM, 57.14% for INH 71.43% for RIF and 80% for EMB. The susceptible correlation was 90.32% for STM, 73.91% for INH, 93.33% for RIF and 59.26% for EMB. E-test correctly identified only eight of the 12 (66.6%) MDR isolates and wrongly identified four isolates which were not MDR. The overall agreement between the two methods was only 48.6%. Resistant isolates showed false positive resistance observed while using E-strip towards all the drugs. Conclusion: E-strips are not quite feasible as a replacement for LJ-proportion method on a large scale due to high risk of cross contamination, laboratory infection, expense associated with it and high false positive resistance observed to all first line drugs. However, the good correlation observed for RIF between the two methods indicates that E-test could contribute to the role in rapid screening of MDR TB isolates as rifampicin mutations are invariably observed in MDR TB isolates.

Role of enteric fever in ileal perforations: an overstated problem in tropics?

PURPOSE: To determine the role of enteric fever in ileal perforations. METHODS: A prospective cohort of 47 patients of ileal perforation was subjected to clinical examination and investigations for APACHE II scoring. Blood, ulcer edge biopsy, mesenteric lymph node and peritoneal aspirate were subjected to culture to determine the predominant aerobic bacterial isolate and its antibiogram. RESULTS: Seven patients (14.9%) required intensive care and seven (14.9%) developed septicaemia. Mortality was 17%. Highest isolation rate was seen in ulcer edge (70.2%) followed by lymph node (66%) culture. The bacterial spectrum was Escherichia coli (23.4%), Enterococcus faecalis (21.3%), Salmonella enterica serovar Typhi (6.3%), Salmonella enterica serovar Paratyphi A (4.2%), etc. CONCLUSIONS: Enteric fever organisms are not the predominant causative agents of ileal perforations. Culture of ulcer edge biopsy, lymph node is crucial for aetiological diagnosis. The use of APACHE II triaging and prescription of antimicrobials based on the local pattern of susceptibility profile of the aetiological agent is recommended.

Clinical and mycological profile of cryptococcosis in a tertiary care hospital.

This study examined the extent of cryptococcosis in clinically diagnosed cases of meningitis in HIV-1 seropositive and apparently immunocompetent patients. One hundred and forty-six samples, obtained from 126 chronic meningitis patients comprised of cerebrospinal fluid (CSF), blood, sputum and urine. The samples were processed by standard microbiological procedures. Cryptococcal isolates were identified by microscopy, cultural characteristics, melanin production on niger seed agar and hydrolysis of urea. The isolates were further speciated on cannavanine glycine bromothymol blue (CGB) media. Cryptococcal antigen detection of CSF samples was performed by latex agglutination test (LAT). Minimum inhibitory concentration (MIC) of amphotericin B for the isolates was also tested. Cryptococcosis was diagnosed in 13 patients (eight HIV-1 seropositive and five apparently immunocompetent). Cryptococcus neoformans var. neoformans was the predominant isolate. Cryptococcal antigen was detected in all, whereas microscopy could detect yeast cells in nine patients. The isolates were sensitive to amphotericin B. CD4 cell counts ranged from 8 to 96/cu mm. The study concludes that all CSF samples with clinical diagnosis of subacute and chronic meningitis should be subjected to tests for detection of Cryptococcus in clinical laboratory irrespective of the immune status.

Eumycetoma pedis due to Exophiala jeanselmei.

A case of eumycetoma of foot in an 8-year old male child was clinically diagnosed as chronic osteomyelitis and was microbiologically confirmed as eumycetoma. The case is being reported for its uncommon clinical presentation and etiological agent, Exophiala jeanselmei. The patient recovered completely after treatment with ketoconazole.

Characterization and changing minimum inhibitory concentration (MIC) of Acinetobacter species from a tertiary care setup.

128 isolates of Acinetobacter species from admitted and outdoor patients were subjected to biotyping and resistotyping. Resistance phenotype analysis included nine antibiotics and two betalactam inhibitor combination drugs. In 100 strains of Acinetobacter spp. ciprofloxacin, amikacin, cefotaxime and cefepime minimum inhibitory concentration (MIC) was done by agar dilution using NCCLS 2002 criteria. In forty-nine isolates MIC level was determined by E-strip also. Extended spectrum beta lactamase (ESBL) production was detected by double disc synergy technique. Inducible beta lactamases (IBL's) were detected by disc approximation method. The relationship between biotypes and resistance phenotype was analyzed. Majority of isolates (93.75%) were from admitted patients. The biotyping revealed Acinetobacter calcoaceticus-Acinetobacter baumannii complex (87.2%) to be the predominant species and they were isolated from tracheal aspirates of patients with ventilator associated pneumonia. By Kirby Bauer disc diffusion antimicrobial sensitivity testing Acinetobacter spp. were most sensitive to the combination of drug cefoperazone-sulbactam (95.6%) followed by meropenem (94.6%), piperacillin-tazobactam (92.6%). On screening incidence of Imipenem Nonsensitive Acinetobacter spp. (INSA) was (5.4%). Acinetobacter spp. were typable by six resistance phenotypes and six biotypes. Most common (66.6%) resistant phenotype of A. calcoaceticus-A. baumannii complex was susceptible to cefoperazone-sulbactam and or meropenem and or piperacillin-tazobactam. ESBL production was seen in 6% and IBL (Inducible Beta Lactamase) production was seen in 7% of Acinetobacter spp. The MIC90 for ciprofloxacin was =256 microg/ml, cefotaxime 512 microg/ml, cefepime 512 microg/ml, and amikacin 32 microg/ml. Multidrug resistance was seen in more than 90% of A. calcoaceticus-A. baumannii complex and 20% of Acinetobacter lwoffii. Acinetobacter spp. has other emerging novel mechanism of resistance that requires continuous research. Simpler, reproducible and reliable methods of biotyping and their subsequent correlation with resistotyping are more cost effective than molecular methods, which are available only in reference laboratories.