Blood Stream Infection Caused by Carbapenem-resistant Chryseobacterium indologenes Harboring blaNDM-1 Gene Isolated from a Tertiary Care Hospital in Tripura: An Emerging Threat

Objectives: Chryseobacterium indologenes has recently been identified as an inherently drug-resistant organism, responsible for a wide spectrum of infections, mainly device-associated infections in hospital settings. The presence of carbapenem resistance due to blaNDM-1 metallo-?-lactamase (MBL) gene further complicates the matter, leading to widespread dissemination of carbapenem resistance. This study aims to find out the presence of blaNDM-1 gene among C. indologenes strains causing bloodstream infections in a tertiary care hospital. Materials and methods: During 1 year of the study period, blood culture samples were collected from patients with features of bacteremia, and C. indologenes strains were isolated and identified as per protocol. Antibiotic sensitivity test was performed by using VITEK 2 Compact Automated AST machine (Biomerieux, France). Carbapenem-resistant strains were subjected to a combined disk diffusion test for detecting the presence of MBL enzyme. Strains positive for MBL production were subjected to a polymerase chain reaction (PCR) for detection of blaNDM-1 gene. Results: Out of 21 strains isolated during the study period, 12 strains (57.1%) were carbapenem-resistant. Among them, seven strains (58.3%) were MBL producers. After PCR, 3 strains (42.9%) were found to be harboring blaNDM-1 gene Discussion: As per our knowledge, this is the first report of blaNDM-1 gene harboring C. indologenes strain from Northeast India. This shows the emerging therapeutic dilemma due to the narrowing of treatment options against bloodstream infections due to C. indologenes strains. Strict antimicrobial stewardship has to be implemented to prevent the further compounding of the problem.

Comparison Of In-Hospital Mortality Of COVID-19 Patients Between Those Who Were Vaccinated And Who Were Not

Background:We compared the mortality rate of patients with moderate to severe COVID-19 who were vaccinated and who were not. Material And Methods:In this retrospective observational study, we collected data of patients who were admitted with moderate to severe COVID-19.The vaccination status and co morbidities of the patients were documented. The incidence and in-hospital mortality of COVID-19 patients was assessed.Univariate analysis was performed to determine the risk factors of in-hospital mortality.Result:Of 294 patients, 5.1% (n=15) received Covaxin™and 26.5% (n=78) received Covishield™;68.4%(n=201) patientswere unvaccinated.Of patientswho were vaccinated and contracted COVID-19, 24.8%(n=73) had taken the first dose and 6.8%(n=20) had taken the second dose of either vaccine.The in-hospital mortality rate was 13.6% (n=40). No significant association was found with the type of vaccine and the in-hospital mortality (p=0.23). Significant associations with in-hospital mortality were found with the interval before COVID-19 disease andvaccination (OR, 3.02; p=0.01); and the presence ofdiabetes mellitus (OR, 2.13; p=0.02), cardiovascular diseases (OR, 2.11; p<0.001), and malignancy (OR: 2.33; p=0.0325).Conclusion:The mortality rate of unvaccinated patients with moderate to severe COVID-19 was high. There was no significant difference in the effectiveness of Covaxin™ and Covishield™ in terms of the incidence of COVID-19 and in-hospital mortality. Diabetes mellitus, cardiovascular diseases, and malignancies had a significant association with in-hospital mortality in patients with moderate to severe COVID-19.

Establishing Antimicrobial Resistance Surveillance & Research Network in India: Journey so far

The Indian Council of Medical Research, in 2013, initiated the Antimicrobial Resistance Surveillance & Research Network (AMRSN) to enable compilation of data on six pathogenic groups on antimicrobial resistance from the country. The overarching aim of this network was to understand the extent and pattern of antimicrobial resistance (AMR) and use this evidence to guide strategies to control the spread of AMR. This article describes the conception and implementation of this AMR surveillance network for India. Also described are the challenges, limitations and benefits of this approach. Data from the Network have shown increasing resistance in Gram-negative bacteria in the hospitals that are part of this network. Combined resistance to third-generation cephalosporins and fluoroquinolones and increasing carbapenem resistance are worrisome, as it has an important bearing on the patients' outcome and thus needs to be addressed urgently. Data generated through this Network have been used to develop treatment guidelines, which will be supportive in harmonizing treatment practices across the tertiary level healthcare institutions in the country. While, the major benefit of having a surveillance system is the collection of real-time accurate data on AMR including the mechanisms of resistance, representativeness to community, sustaining the current effort and expanding the current activities to next levels of healthcare settings are the major challenges. The data emanating from the network besides providing evidence, expose several gaps and lacunae in the ecosystem and highlight opportunities for action by multiple stakeholders.

Evaluation of biomarkers: Galactomannan and 1,3-beta-D-glucan assay for the diagnosis of invasive fungal infections in immunocompromised patients from a tertiary care centre

Purpose: Due to limitations of traditional microbiological techniques, standardised fungal biomarker tests such as Galactomannan Index (GMI) and 1,3-beta-D-glucan (BDG) are being preferred for diagnosis of invasive fungal infections (IFIs). These tests have been extensively used in developed countries but seldom in developing countries. The present study was performed to evaluate these tests for the diagnosis of IFIs in immunocompromised patients at an Indian tertiary care centre. Materials and Methods: A retrospective hospital-based study was done in immunocompromised patients with clinical suspicion of IFI. The demographic, clinical, radiological and mycological details of the patients were recorded. The patients were categorised into proven, probable and no IFI (as per European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria). The sensitivity and specificity of BDG Fungitell and Platelia Aspergillus antigen assays was estimated. Results: A total of 70 consecutive patients were included, of which 41 had IFI (10 proven and 31 probable) while 29 had no IFI. A significant association was found between IFI and the presence of a central venous line (P = 0.035) and history of intake of T-cell immunosuppressants (P = 0.001). Median BDG values (pg/ml) in patients with proven IFI, probable IFI and no IFI were 300 (range: 70�0), 165 (range: 53�0) and 45 (range: 31�0), respectively. The receiver operating characteristic (ROC) curve analysis for BDG revealed an area under the curve of 0.995, sensitivity: 97.4% and specificity: 96.6% for IFI diagnosis. The ROC curve analysis of GMI revealed an AUC of 0.75 and 90% patients with invasive aspergillosis (IA) had positive GMI. Conclusion: BDG has good sensitivity and specificity for distinguishing IFI from no IFIs and GMI may be used for diagnosing IA.

Histoplasmosis in non-endemic North-Western part of India

Purpose of Study: The western and North-Western parts of India are usually considered non-endemic for histoplasmosis. On the contrary, we observe histoplasmosis cases with relatively higher frequency from this region although the awareness and laboratory facility to diagnose the disease are not adequate. Hence, we planned the present retrospective study to compile the cases and to analyse different clinical parameters. Materials and Methods: Medical records of the patients diagnosed with histoplasmosis during January 2012–August 2017 at two infectious disease clinics of Ahmedabad were included in this study. Results: During the study, 12 cases of histoplasmosis were diagnosed. The median age of the patients was 53 years; all males except one. The diagnosis of histoplasmosis was confirmed on histopathology for 11 cases, and one patient was diagnosed as probable histoplasmosis. The patients were either from Gujarat or Rajasthan without any travel history to endemic zone of histoplasmosis, except one patient. The majority (67%) of the patients had no apparent immunosuppression. Adrenal enlargement, oral ulcers and lymphadenopathy were common presentations in four patients each. We lost two patients in follow-up, and rest 10 patients responded to either to amphotericin B deoxycholate and/or itraconazole therapy. Conclusion: This study highlights that Gujarat and Rajasthan are an endemic region for histoplasmosis, and a systematic study is required to understand epidemiology of the disease. Histoplasmosis should be a differential diagnosis in a patient presenting with adrenal enlargement, lymphadenopathy, oral ulcers and fever of unknown origin in this region.

Self-reported reproductive tract infection/ sexually transmitted infection and health care seeking behavior among the women living in a slum of Kolkata

Background: Sexually Transmitted Infection (STI) is a public health problem of significance in most parts of the world. It adversely affects reproductive health in both sexes but its impact on women‟s reproductive health is far devastating. Objectives: The study was conducted to know the prevalence of self-reported STI among the currently married women living in the slum area of Kolkata, the factors related with it and also to study their care seeking behavior following the infection. Materials and methods: This community based descriptive study was conducted by interviewing currently married women residing in a slum of Kolkata. Symptoms of STI and healthcare seeking behavior following the infection were enquired. Symptoms were grouped into complexes and presumptive diagnosis was made. Results: The prevalence of symptoms suggestive of STIs in the study population was found to be 47.8%.The most common symptoms reported by the sufferers were low backache (29.6%), burning micturition (25.2 %), and genital itching (23.5%). All symptoms were more common in the women living in the joint family, having one or more history of abortion. Symptoms of urinary tract infection was more in the age group of >30 years and those with >10 years of marriage. Whereas, vaginitis was more common in <30 years (p= 0.01). Only 49.0% of the sufferers consulted a health facility for Chakrabarti S, Chakrabarti A. Self-reported reproductive tract infection/ sexually transmitted infection and health care seeking behavior among the women living in a slum of Kolkata. IAIM, 2017; 4(4): 46-52. Page 47 treatment and most of them (62.9%) availed health service from the urban health training centre of the area. Conclusion: The present study found high prevalence of self-perceived reproductive morbidity among women in the slum setting. In the study there was no scope of laboratory investigation and was based on recall of the event in preceding three months

High fungal spore burden with predominance of Aspergillus in hospital air of a tertiary care hospital in Chandigarh.

The prevalence of fungal spores in the hospital air is essential to understand the hospital‑acquired fungal infections. Air conditioners (ACs) used in hospitals may either reduce spores in air or be colonised by fungi and aid in its dissemination. The present study was conducted to assess the fungal spore burden in AC and non‑AC areas. We found a high fungal spore count in air irrespective of whether the area was AC or non‑AC. The most predominant species isolated were Aspergillus flavus and Aspergillus fumigatus. Such high concentrations of pathogenic fungi in air may predispose individuals to develop disease.

Regorafenib: A novel tyrosine kinase inhibitor: A brief review of its therapeutic potential in the treatment of metastatic colorectal carcinoma and advanced gastrointestinal stromal tumors.

Regorafenib is a novel oral multitargeted tyrosine kinase inhibitor having both antitumor and anti‑angiogenic activities. Regorafenib was recently approved by US Food and Drug Administration in February 25, 2013 in the treatment for patients with advanced gastrointestinal stromal tumor and for the treatment of patients with metastatic colorectal carcinoma after disease progression or intolerance to imatinib mesylate and sunitinib therapy. Oral regorafenib demonstrates a high level of efficacy with acceptable tolerability with the 160 mg daily for 3 weeks followed by 1 week off schedule; a continuous schedule could be of interest. Hypertension, mucositis, hand foot skin reaction, diarrhea and asthenia are the most common side‑effects. Regardless of these encouraging results, studies investigating, adjuvant and neoadjuvant settings are awaited, as well as trials using regorafenib in combination with chemotherapy or other targeted therapies. Clinical trials investigating regorafenib in other tumor types are ongoing.

A rare case of onychomycosis caused by Emericella quadrilineata (Aspergillus tetrazonus).

Onychomycosis is a common chronic nail disorder where dermatophytes are the predominant pathogens. However, non‑dermatophytic moulds like Aspergillus can also be implicated as the causative agents. Herein, we report a rare case of onychomycosis due to Emericella quadrilineata (Aspergillus tetrazonus) in an apparently immunocompetent host.

Ethical issues in microbiology.

Ethical issues facing microbiologists could be considered in two parts. The first relates to the way the ethical issues during their laboratory work. The second pertains to ethical issues on the data/reports they generate for the patients or in research. In both segments, there is pressure to perform, which is exerted by both, the community, as well as peers. It has therefore become increasingly necessary to recognize the facts that unethical actions might be a frequent reality. Since some of these activities generate serious ethical concerns, both in practice and research, it is necessary for microbiologists to be aware and equipped to meet these issues in a prepared and measured way.. In an attempt to highlight this requirement, this article outlines the important ethical issues and guidelines relevant to the field of Microbiology.

Effect of Ayurvedic mercury preparation Makaradhwaja on geriatric canine–A preliminary study.

Makaradhwaja, an alchemical Ayurvedic mercury preparation is used as stimulant and vitalizer. Towards veterinary practices, the acceptability, tolerability and toxicity studies were undertaken in geriatric pet dogs aged more than 10 years irrespective of breed and sex for future use. Makaradhwaja (2.5 mg/kg) was used with honey once daily for 30 days. Before and after treatment, blood was collected for hematological studies as well as liver, kidney function and anti-oxidant activity. In control group, honey itself showed no appreciable change whereas, Makaradhwaja lowered neutrophil and total leucocyte count. Serum cholesterol, urea, glucose, alanine amino transferase, aspartate amino transferase, sodium, phosphorus and calcium were decreased. Haemoglobin and serum creatinine were significantly increased. There was appreciable physical, behavioral and body weight change including quality of life. The dose was used in replication of human dose (125 mg/50kg). Anti-oxidant study showed significant increase of lipid per oxidation in experimental group while the values of ABTS radical cation decolorisation assay although decreased but did not show any significant changes. Decrease of serum urea and increase of serum creatinine could not be explained on single dose response. Different dose study could only explain the optimum dose to be required in canine practices.

Anti-seizure efficacy of nimodipine in pentylenetetrazole and kainic acid combined seizure models in mice.

The present study aimed at establishing two models of experimental seizures by combination treatment with subconvulsive doses of PTZ and kainic acid in adult male mice and evaluating the modulatory role of cerebroselective dihydropyridine calcium channel blocker, nimodipine. The CD50 +/- SEM value for PTZ was found to be 20.00 +/- 0.92 mg/kg, ip in kainic acid (administered at per se subconvulsive dose of 1.00 mg/kg, ip) pretreated mice while CD50 +/- SEM value for kainic acid was found to be 0.30 +/- 0.08 mg/kg, ip in PTZ (administered at per se subconvulsive dose of 30.00 mg/kg, ip) pretreated mice. Nimodipine (5.00 mg/kg, ip) significantly protected the mice from seizure in both of the combination in vivo seizure models. The results suggested synergistic interaction between PTZ and kainic acid at subconvulsive dose combination while the protective efficacy of nimodipine suggested the role of calcium ion as an important mediator for the genesis of seizures.

Polymerase chain reaction for early diagnosis of post-operative fungal endophthalmitis.

BACKGROUND AND OBJECTIVES: Fungal endophthalmitis is a devastating form of ocular infection and postoperative endophthalmitis following cataract surgery is the commonest form of such infection. Early diagnosis is very important for effective management of these patients. As conventional techniques take longer time and lacks sensitivity, polymerase chain reaction (PCR) for detection of fungal DNA was evaluated for early diagnosis of postoperative fungal endophthalmitis. METHODS: Fifty consecutive patients with postoperative endophthalmitis (excluding proven bacterial endophthalmitis) and 25 individuals undergoing pars plana vitrectomy (PPV) of non infectious aetiologies (control group) were included in the study. Aqueous/vitreous fluids, collected from these patients, were evaluated by conventional methods including direct microscopy and culture, and by PCR for detection of fungal DNA using panfungal primers (ITS1 and ITS4) for diagnosis of fungal aetiology. RESULTS: None of the controls were positive for fungal aetiology by microscopy, culture or PCR. Four patients were positive for fungal endophthalmitis by conventional method of diagnosis. PCR based method detected fungal DNA in three of these patients and in three additional patients who were negative on microscopy and culture. All six patients, who were positive for PCR, showed clinical improvement after full course of antifungal therapy. INTERPRETATION AND CONCLUSION: Compared to the conventional technique, PCR for detection of fungal DNA was found to be a rapid and more sensitive method in the early diagnosis of postoperative fungal endophthalmitis.

Microbiology of systemic fungal infections.

The increased incidence of systemic fungal infections in the past two decades has been overwhelming. Earlier, it was pathogenic dimorphic fungi, which were known to cause systemic infections. However, starting from the 1960s, opportunistic fungi started causing more number of infections, especially in the immunocompromised host. More recently, newer and less common fungal agents are being increasingly associated with infection in immunosuppressed hosts. Amongst dimorphic fungi, infections due to Histoplasma capsulatum and Penicillium marneffei are increasingly reported in patients with AIDS in India. H. capsulatum is found country wide, but P marneffei remains restricted to Manipur state. Although both varieties of C. neoformans, C. neoformans var. neoformans (serotypes A & D), and C. neoformans var. gattii (serotypes B & C) are reported in India, most of the cases reported are of serotype A. Increased incidence of cryptococcosis is reported from all centers with the emergence of AIDS. Systemic infection due to species under Candida, Aspergillus and zygomycetes is widely prevalent in nosocomial setting, and outbreaks due to unusual fungi are reported occasionally from tertiary care centers. This global change in systemic fungal infections has emphasized the need to develop good diagnostic mycology laboratories in this country and to recognize this increasingly large group of potential fungal pathogens.

Change in distribution & antifungal susceptibility of Candida species isolated from candidaemia cases in a tertiary care centre during 1996-2000.

BACKGROUND & OBJECTIVES: As a marked increase in the number of patients with candidaemia was reported in the first half (1991-1995) of the last decade at the Postgraduate Institute of Medical Education & Research, Chandigarh, India, the present study was aimed at determining further change if any, in the incidence and distribution of Candida species and their antifungal resistance pattern during the second half (1996-2000) of the same decade. METHODS: The patients with candidaemia were studied to determine the frequency of candidaemia and Candida species isolated during 1996-2000. One hundred Candida strains other than Pichia anomala (C. pelliculosa) were randomly selected from those isolates to evaluate antifungal susceptibility pattern against amphotericin B, 5-fluorocytosine, ketoconazole, fluconazole and itraconazole. The results were compared with our previous study. RESULTS: An increase in the number of patients with candidaemia was observed during 1996 (538) and 1997 (421) compared to 1998-2000 due to P. anomala outbreak. With the control of the outbreak, a substantial decrease in the incidence of candidaemia was observed from 1998 (251 in 1998, 122 in 1999 and 165 in 2000). A higher isolation of non-C. albicans Candida species (89.8%) was observed, with C. tropicalis being the most common (541, 36.1%) agent. No major change in the isolation rate of other non-C. albicans Candida species (C. guilliermondii, C. krusei, C. glabrata and C. parapsilosis) was observed. An emergence of resistance to amphotericin B in 15.4 per cent C. albicans, 8.1 per cent C. tropicalis and 33.3 per cent C. krusei strains was observed. An increase in resistance to ketoconazole (from 0% to 13%) and 5-fluorocytosine (from 1% to 8%) and a decrease to fluconazole (from 13% to 6%) were observed. Resistance to itraconazole was observed in 17 per cent of Candida strains by broth macro-dilution method. INTERPRETATION & CONCLUSION: A change in the isolation of Candida species was observed i.e. in the incidence and isolation of non-C. albicans Candida species. Emergence of resistance to amphotericin B and increase of resistance to most other antifungals are cause for concern.

Mannan antigen detection in the diagnosis of patients with invasive candidiasis.

BACKGROUND & OBJECTIVES: With the increase in the incidence of invasive candidiasis (IC) in recent years, there is a need to improve the sensitivity of diagnosis. A conventional technique like blood culture is positive in nearly 50 per cent of cases. To improve the diagnostic efficiency in invasive candidiasis mannan antigen detection holds promise. Hence mannan antigen detection was evaluated in patients with suspected invasive candidiasis in the Paediatric Intensive Care Unit (PICU). METHODS: A prospective study, involving 186 consecutive patients admitted to the PICU of the Advanced Paediatric Center at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh between March 1999 and November 1999 were followed up for possible invasive candidiasis. Sixty five children clinically suspected to have sepsis and at risk for developing IC and or who stayed in the hospital more than 5 days were further evaluated for the diagnosis of IC by collecting two blood culture samples 48 h apart and by mannan antigen and anti-mannan antibody detection. Both antigen and antibody were detected by in-house standardized techniques: antibody by whole cell agglutination (WCA) and antigen by sandwich enzyme linked immunosorbent assay (ELISA). RESULTS: Twenty of 65 patients (30.7%) were positive by blood culture. Mannan antigen was positive in all 20 patients and significant anti-mannan antibody titre (> or = 128) was present in 12 (60%) patients. Mannan antigen was detected in 15 more patients, who were negative for isolation of Candida from blood. Twelve of these patients had febrile episode not responding to antibacterial therapy but responding to fluconazole/itraconazole therapy indicating that the patients possibly had IC. Mannan concentration was also found to be significantly higher in the patients with Candida isolated from blood. INTERPRETATION & CONCLUSION: Thus, the present study confirms the earlier claim that mannan antigen detection possibly improves the diagnostic efficiency of IC.

Neurobehavioural study of subchronic administration of oxydemeton-methyl (insecticide and acaricide) in rats.

Oxydemeton-methyl, an organophosphate insecticide and acaricide produced decrease in the exploratory behaviour and prolongation of barbitone sodium induced hypnosis in rats after intermittent aerosol spray inhalational exposure, for 1/2 hour daily for 7 consecutive days, compared to the saline control group. Further, ED50 +/- SEM value for haloperidol induced catalepsy, CD50 +/- SEM value for pentylenetetrazole induced seizure and CI50 +/- SEM value for electroshock (i.e. the dose of haloperidol, PTZ and intensity of electroshock producing catalepsy or positive seizure response in 50% of rats) were significantly decreased after 7 days exposure to oxydemeton-methyl compared to that of saline control group. The study has established the central nervous system depressant effect, extrapyramidal effect and proconvulsant potential of oxydemeton-methyl which is widely used by the agricultural workers in the form of field spray.

In vitro susceptibility pattern of Sporothrix schenckii strains isolated from three centers in India.

BACKGROUND & OBJECTIVES: With the availability of more number of antifungal agents in recent years, drugs other than saturated solution of potassium iodide (SSKI) are being increasingly used to treat sporotrichosis. It was therefore considered pertinent to evaluate in vitro antifungal susceptibility pattern of Sporothrix schenckii strains isolated at three centers in India against five commonly used antifungal agents. METHODS: Agar dilution method was used to evaluate 50 clinical isolates (25 from north, 17 from east and 8 from south India) both in its yeast and mycelial forms against amphotericin-B, 5-fluorocytosine, ketoconazole, fluconazole and itraconazole. RESULTS: No resistance was observed in the yeast form of S. schenckii against amphotericin B and azoles. However, 54 per cent strains in the yeast form were resistant to 5-fluorocytosine. None of the strains was susceptible to amphotericin B and ketoconazole, 56 and 10 per cent strains in the mycelial form were susceptible to itraconazole and fluconazole respectively. No significant difference was observed in the antifungal susceptibility pattern among the strains isolated from these three regions in India. INTERPRETATION & CONCLUSION: Clinical isolates of S. schenckii from three regions of India had a more or less uniform antifungal susceptibility pattern. Itraconazole had the best in vitro susceptibility results against the clinical isolates of S. schenckii and has the potential to replace SSKI.

Sporotrichosis in Manipur: report of two cases.

Two cases of lymphocutaneous sporotrichosis are reported from Imphal. Sporothrix schenekii was isolated from pus from the lesion and identity was confirmed by mycelial to yeast conversion at 37 degrees C and mice pathogenicity test. One patient gave history of injury with bone of fermented fish (Ngari). Both the patients were treated successfully with oral administration of potassium iodide. These two cases are the first authentic cases of sporotrichosis from Manipur.

Structural perturbation of proteins in low denaturant concentrations.

The presence of very low concentrations of the widely used chemical denaturants, guanidinium chloride and urea, induce changes in the tertiary structure of proteins. We have presented results on such changes in four structurally unrelated proteins to show that such structural perturbations are common irrespective of their origin. Data representative of such structural changes are shown for the monomeric globular proteins such as horseradish peroxidase (HRP) from a plant, human serum albumin (HSA) and prothrombin from ovine blood serum, and for the membrane-associated, worm-like elongated protein, spectrin, from ovine erythrocytes. Structural alterations in these proteins were reflected in quenching studies of tryptophan fluorescence using the widely used quencher acrylamide. Stern-Volmer quenching constants measured in presence of the denaturants, even at concentrations below 100 mM, were higher than those measured in absence of the denaturants. Both steady-state and time-resolved fluorescence emission properties of tryptophan and of the extrinsic probe PRODAN were used for monitoring conformational changes in the proteins in presence of different low concentrations of the denaturants. These results are consistent with earlier studies from our laboratory indicating structural perturbations in proteins at the tertiary level, keeping their native-like secondary structure and their biological activity more or less intact.