Citrobacter spp. Isolated from Pus Samples in a Tertiary Care Hospital and its Antibiogram in Sonepat, Haryana, India

Introduction: Citrobacter infection occurs in a hospital setting in patients with multiple comorbidities and it occasionally causes disease in general population. Neonates and immunocompromised are highly susceptible to Citrobacter infections which are mainly caused by Citrobacter freundii and Citrobacter koseri, the incidence of nosocomial infections caused by antibioticresistant Gram-negative pathogens is increasing. This study was done to know the development of drug resistance in emerging pathogen Citrobacter. Methods: The study was conducted in the department of microbiology in a tertiary care hospital for a period of 1 year. Bacterial identification was performed by routine conventional microbial culture and biochemical tests using standard recommended techniques. The antimicrobial susceptibility testing was performed by the Kirby–Bauer disk diffusion technique on Mueller‑Hinton agar, as per the Clinical and Laboratory Standards Institute guidelines. Results: In the present study, 1788 pus samples were processed for a period of 1 year, out of which in 808 pus samples, organisms were isolated. Staphylococcus aureus was isolated in 234 (28.96%) cases. Escherichia coli was isolated in 168 (20.79%) cases, Pseudomonas was isolated in 125 (15.47%) cases, and Proteus was isolated in 32 (3.96%) cases. Enterobacter spp. was isolated in 51 (6.31%) cases. Acinetobacter was isolated in 16 (1.98%) cases. Candida spp. was 17 (2.10%). Citrobacter spp. was isolated in 85 (10.52%) cases. In 85 cases of Citrobacter spp., 58 (68.23%) were C. freundii and 27 (31.76%) were C. koseri. In the present study, Citrobacter spp. was sensitive to amikacin in 36.47% of cases, gentamycin in 48.88% of cases, and levofloxacin in 29.41% of cases. Conclusion: Citrobacter species is an emerging pathogen developing drug resistance. Drug options are limited in the current scenario; hence, injudicious and inadequate use of antibiotics should be avoided.

Candida tropicalis: insight into the characteristics and outcome of adult patients admitted in medical and surgical intensive care units

Background: Non albicans species are emerging increasingly as significant ICU pathogens.  The increasing incidence of C. tropicalis infections is a significant problem because of its ability to develop rapid resistance to fluconazole.Methods: The study was designed to isolate, evaluate the risk factors and outcome of C. tropicalis infection from intensive care units. Identification was done by the biochemical methods. A total of 89 patients culture positive for C. tropicalis were selected for retrospective analysis over a period of one year. We collected various data about risk factors and outcome from the medical records.Results: A total of 89 patients culture positive for Candida tropicalis were analysed. Majority of these culture isolates were obtained from their blood (59.55%) followed by urine samples (31.46%). The indwelling devices (93.2%) remained a highest risk followed by prolonged administration of antibiotic therapy (92.1%) and admission in ICU for more than a week (88.8%). Overall mortality rate was 31.5%. Mortality was higher in patients with longer total length of stay in hospital (89.3%; p 1.000), indwelling devices (85.7%; p 0.5663) and in whom the antimicrobial therapy was administered for prolonged duration (82.1%; p 0.7581), although these factors remained statistically insignificant. 92.1% of isolates were sensitive to amphotericin B and showed 52.8%; 9.0% sensitivity to itraconazole and fluconazole respectively.Conclusions: C. tropicalis is now classified as the third or fourth NAC species being commonly isolated from clinical samples and associated with persistent systemic infections leading to a longer stay in the hospital. Several virulence factors seem to be responsible for high dissemination and mortality.

Application of serology and nested polymerase chain reaction for identifying Chlamydophila pneumoniae in community‑acquired lower respiratory tract infections in children.

Context: Chlamydophila pneumoniae is a common cause of community‑acquired respiratory infections, including pneumonia, bronchitis, and upper respiratory tract infections. Since it is difficult to detect C. pneumoniae in clinical practice, specific etiological diagnosis is established only in a minority of cases. Aims: To investigate the role of C. pneumoniae in community‑acquired lower respiratory tract infections (LRTIs) in children, with the use of serological tests and nested polymerase chain reaction (PCR) analysis. Settings and Design: One hundred children, age of 2 months to 12 years, hospitalized for community‑acquired LRTIs were investigated for C. pneumoniae etiology. Materials and Methods: We investigated 100 children hospitalized for community‑acquired LRTIs, using enzyme‑linked immunosorbent assay for detecting anti‑C. pneumoniae immunoglobulin M, and immunoglobulin G antibodies and nasopharyngeal aspirates for analysis of C. pneumoniae PCR. The demographic, clinical, and radiological findings for C. pneumoniae antibody positive and C. pneumoniae antibody negative cases were compared. Statistical Analysis Used: Data analysis was performed by Chi‑square test and Fisher’s exact tests using Epi Info (2002). Results: Clinical and radiological findings in both the groups were comparable. A relatively higher rate of C. pneumoniae infection in children was observed below 5 years of age. Serological evidence of C. pneumoniae infection was observed in 12 (12%) patients and nested PCR was positive in 5 (5%) children. Thirteen (13%) patients were diagnosed with C. pneumoniae infection by serology and/or nested PCR. Conclusions: Our study confirms that C. pneumoniae plays a significant role in community‑acquired LRTIs in children of all ages, even in children aged <5 years.

Laparoscopic Evaluation of Chronic Pelvic Pain.

The present study was undertaken to find out the role of laparoscopy in evaluation of chronic pelvic pain and to correlate laparoscopic findings with preoperative pelvic findings. Fifty-two women with pelvic pain of more than 6 months duration were included. They were examined clinically and then subjected to Transabdominal sonography and laparoscopy. Of 52 patient's enrolled for study, 51.92% of patients were in the age group of 21-30 years with equal number of cases from rural and urban areas. Abnormal menstrural cycle patterns were seen in 32.70% of patients with menorrhagia contributing 23.07%. 44.24% patients had abnormal pelvic findings on preoperative pelvic examination. Ultrasonography could detect abnormality in 32.70% of patients as compared to Laparoscopy which had abnormal findings in 75%. Most common pelvic pathology was PID in 26.92% followed by adhesions in 12.07% cases which could not be detected clinically and on sonography. Laparoscopy is a more sensitive and superior method for evaluation of chronic pelvic pain as compared to ultrasonography. Laparoscopy can establish a definitive diagnosis, modify and provide treatment without resorting to exploratory laparotomy .

Detection of IgM and IgG antibodies to Chlamydophila pneumoniae in pediatric community-acquired lower respiratory tract infections.

Context: Chlamydophila pneumoniae (C. pneumoniae) is an emerging infectious agent with a spectrum of clinical manifestations including lower and upper respiratory tract infections. Aims: To investigate the role of C. pneumoniae in community-acquired lower respiratory tract infections (LRTIs) in children using serological tests. Settings and Design: Two hundred children, age 2 months to 12 years, hospitalized for community-acquired LRTIs were investigated for C. pneumoniae etiology. Materials and Methods: We investigated 200 children hospitalized for community-acquired LRTIs, using ELISA for detecting anti-C. pneumoniae IgM and IgG antibodies. The demographic, clinical and radiological findings for C. pneumoniae antibody positive and C. pneumoniae antibody negative cases were compared. Statistical Analysis Used: Data analysis was performed by Chi-square test and Fisher's exact tests using Epi Info (2002). Results: Clinical and radiological findings in both the groups were comparable. Serological evidence of C. pneumoniae infection was observed in 12 (6%) patients; specific IgM antibodies were detected in 11 (91.67%; specific IgG antibodies in 1 (8.33%) patients, while 4-fold rise in C. pneumoniae IgG antibody titers were noted in none of the patients. Conclusions: C. pneumoniae has a role in community-acquired LRTIs, even in children aged < 5 years. Serological detection using ELISA would enable pediatricians in better management of C. pneumoniae infections.

Evaluation of rapid techniques for the detection of mycobacteria in sputum with scanty bacilli or clinically evident, smear negative cases of pulmonary and extra-pulmonary tuberculosis

The objective of the current study was to compare two rapid methods, the BBL Mycobacteria Growth Indicator Tube (MGIT TM) and Biotec FASTPlaque TB TM (FPTB) assays, with the conventional Löwenstein-Jensen (LJ) media assay to diagnose mycobacterial infections from paucibacillary clinical specimens. For evaluation of the clinical utility of the BBL MGIT TM and FPTB assays, respiratory tract specimens (n = 208), with scanty bacilli or clinically evident, smear negative cases and non-respiratory tract specimens (n = 119) were analyzed and the performance of each assay was compared with LJ media. MGIT and FPTB demonstrated a greater sensitivity (95.92 percent and 87.68 percent), specificity (94.59 percent and 98.78 percent), positive predictive value (94.91 percent and 99.16 percent) and negative predictive value (96.56 percent and 90.92 percent), respectively, compared to LJ culture for both respiratory tract and non-respiratory tract specimens. However, the FPTB assay was unable to detect nontuberculous mycobacteria and few Mycobacterium tuberculosis complex cases from paucibacillary clinical specimens. It is likely that the analytical sensitivity of FPTB is moderately low and may not be useful for the direct detection of tuberculosis in paucibacillary specimens. The current study concluded that MGIT was a dependable, highly efficient system for recovery of M. tuberculosis complexes and nontuberculous mycobacteria from both respiratory and non-respiratory tract specimens in combination with LJ media.

Systemic Inflammatory Response Syndrome in Home Delivered Neonates: A Prospective Observational Study.

Objective To determine the severity of systemic inflammatory response syndrome (SIRS) at admission, bacteriological profile, antibiotic sensitivity of pathogens and factors associated with fatality in home delivered neonates with sepsis. Methods This was a prospective observational study conducted in the referral neonatal unit of a teaching hospital admitting extramural neonates. The subjects comprised of 80 home delivered neonates presenting with systemic inflammatory response syndrome at admission. Skin temperature, oxygen saturation, capillary refill time and blood sugar were recorded in all the neonates at admission. For Blood culture, blood collected by venipuncture was placed in a tryptic soy broth culture bottle. Serum TNF-α was measured by ELISA kit. Results Early onset sepsis was seen in 27.5%. The commonest clinical feature in the study population was decreased oral acceptance (53.8%). The mean distance traveled to reach the hospital was 19±3 km. At admission, acute physiological derangement in the form of abnormal skin temperature, oxygen saturation, perfusion and blood sugar was present in 53 neonates and 44% had more than one parameter deranged. Only 11% cases had early sepsis while the SIRS was well established in the rest. Klebsiella pneumoniae was the predominant bacteria isolated in 14 cases. Resistance of Klebsiella isolates to Ampicillin was 90% and to Gentamicin 57%. The fatality was higher in presence of advanced stages of SIRS at admission. Conclusion SIRS was well established in 89% cases at admission. Klebsiella resistant to antibiotics was the predominant etiological organism. Fatality was higher in culture positive sepsis and in those associated with meningitis and pneumonia.

Serum tumor necrosis factor α and C-reactive protein in pediatric patients with sepsis and its correlation with microbiologic findings.

Objective: To study the association of tumor necrosis factor-a (TNF-a) and C - reactive protein (CRP) with microbiologically documented cases of sepsis versus clinically documented cases of sepsis. Materials and Methods: Seventy nine pediatric patients with sepsis were studied. Relevant specimens were processed for bacterial or fungal etiology. TNF-a was detected by enzyme immunoassay and CRP was detected by latex agglutination. Thirty healthy cases were included in the study to establish baseline TNF-α levels. Results: Forty two (53.2%) patients had a microbiologically documented sepsis. Among Gram negative bacilli Escherichia coli was the most common isolate followed by Klebsiella spp. Staphyloccus aureus and Streptococcus pneumoniae predominated among the Gram positive cocci. Patients with a positive culture had significantly higher TNF-α levels than patients with a negative culture (70pg/ml vs. 33 pg/ml P < 0.01). Further, pure gram negative infection correlated with significantly higher TNF-α levels than pure (P < 0.01) gram positive infection. The CRP values did not highlight these differences significantly. Conclusions: TNF-α level was significantly raised in patients with sepsis. TNF-a levels were raised significantly in culture positive cases in general and in Gram negative infections in particular. Serum TNF-α was a more sensitive marker for different categories of sepsis compared to CRP and microbiology culture.

Comparison of PCR, culture & serological tests for the diagnosis of Mycoplasma pneumoniae in community-acquired lower respiratory tract infections in children.

BACKGROUND & OBJECTIVE: Mycoplasma pneumoniae is known to be a major cause of lower respiratory tract infections in children. A specific diagnosis is important to institute the appropriate treatment. Information on diagnostic methods used for M. pneumoniae in Indian paediatric population is scarce. The study was thus conducted to compare polymerase chain reaction (PCR), culture and serology for the diagnosis of M. pneumoniae in community-acquired lower respiratory tract infections in children. METHODS: Seventy five children aged 6 months to 12 yr with signs of community-acquired lower respiratory tract infections were selected for the study. Culture of nasopharyngeal aspirates was done. The serum samples were analyzed for the detection of IgM and IgG antibodies to M. pneumoniae. A 543 base pairs (bp) region of P1 gene of M. pneumoniae was selected for amplification in PCR assay applied to nasopharyngeal aspirates. RESULTS: M. pneumoniae was isolated in culture from 4 (5.33%) children. Serological evidence of M. pneumoniae infection was observed in 16(21.3%) children. All culture positive patients were also positive by serology. Overall, PCR for M. pneumoniae was positive in 13 (17.3%) patients. All four culture positive patients were also positive by PCR. In 11 out of 13 (84.62%) PCR positive patients, serological evidence was there. Culture and/or serology and/or PCR positive results diagnosed M. pneumoniae infection in 18 (24%) of 75 patients. INTERPRETATION & CONCLUSION: A combination of culture, serology and PCR may provide diagnostic information on the aetiology of M. pneumoniae community-acquired lower respiratory tract infections in paediatric population.

Screening of Gestational Diabetes Mellitus with Glucose Challenge Test in High Risk Group

The present study of screening for gestational diabetes mellitus was carried out in 480 high risk women attending Suvidha Mother & Child Nursing Home. The patients underwent glucose challenge test with 50 gm glucose (GCT ) using glucometer, between 18-20 weeks and if negative the test was again done after 28 weeks. All the 120 patients with abnormal GCT were subjected to 3 hours 100gm oral glucose tolerance test (OGTT ) and 49 patients were found to have abnormal GTT. 3.05% of women were found to have gestational diabetes . Sensitivity of glucose challenge test in detection of gestational diabetes in high risk group was 40.5% The incidence of PIH in patients with abnormal GCT was 22.5%.Since screnning of high risk group was done with the help of glucometer it required no extra laboratory facilities, long waiting period or trained manpower. It has no side effects and guarantees good compliance of patient. GCT hence is a reliable method to detect gestational diabetes mellitus in high risk group.

Changing face of septicaemia and increasing drug resistance in blood isolates.

In a retrospective study conducted between January, 2000 and December 2000, 7157 adults and children were studied. Amongst these, 1071 patients had positive blood cultures. Of these, 575 (53.6%) cases were community acquired septicaemia and 486 (46.4%) cases had developed septicaemia of nosocomial origin. Gram negative aerobes accounted for 708 (66.1%) isolates. Amongst them, Klebsiella pneumoniae predominated (23%), followed by Escherichia coli (14%). Acinetobacter spp. emerged as the next common pathogen (9%), followed by Salmonella typhi (5.4%). Staphylococcus aureus (9%) and coagulase negative staphylococci (9%) were the most common gram positive isolates followed by Enterococcus faecalis (4.7%). Antibiotic susceptibility of all these isolates was performed by the modified Stokes' method. Both Klebsiella pneumoniae and Escherichia coli showed alarmingly high resistance to all groups of antibiotics with 70-80% resistance to amoxicillin and cephalexin. Minimum resistance was observed against cefotaxime (23%) and ciprofloxacin (12%). Majority of Enterococcus faecalis were multidrug resistant. Streptococcus pneumoniae exhibited 26% resistance to penicillin. Thus, the study clearly highlights the rising level of drug resistance amongst the bacterial isolates from blood and hence the need to update and formulate newer drug policies.

Serum resistance of Escherichia coli strains causing urinary tract infection and diarrhoea in relation to alpha haemolysin production and O type.

A total of 46 alpha-hemolytic and 40 non-hemolytic clinical isolates of Escherichia coli were collected from pediatric patients with urinary tract infection and diarrhoea. Of 39 (84.7%) alpha-hemolytic strains and 27 (67.5%) non-hemolytic strains were resistant to 10% serum and there was no significant difference between urinary and stool isolates. On the contrary when 100% serum was used, 22 (47.8%) of the alpha-hemolytic and 7 (17.5%) of the non-hemolytic strains were resistant (p<0.01). and significantly greater resistance was found in urinary tract infection than from the stool samples (47% versus 24%, p<0.01). Serum resistance was higher in serogroups O6, O18 and O75. Production of alpha-hemolysin was more frequent in serogrops O2, O6, O8, O18 and O75. Thus, the resistance to human serum can determine clinical significance of Escherichia coli from different sources and alpha-hemolysin contributes to the virulence of Escherichia coli in initiation and perpetuation of clinical infection.

Outbreak of Acinetobacter spp septicemia in a neonatal ICU.

An outbreak of Acinetobacter spp infection in the neonatal unit at Lok Nayak Hospital, New Delhi, India, is described. During a 6-month period, 68 strains of Acinetobacter baumannii were isolated from the blood and CSF of 47 neonates admitted to the intensive care unit. Diagnosis of clinically significant bacteremia was made in 36 patients. On environmental/personnel sampling, Acinetobacter spp isolates with similar antibiogram were recovered from intravenous catheter and washbasin. Control of the outbreak was possible only after strict infection control practices in the unit. It was concluded that any clinical multidrug resistant A. baumannii isolate can be a potential nosocomial outbreak strain.

Killing of Escherichia coli strains from clinical specimens in human serum and polymorphonuclear leucocytes.

Hundred Escherichia coli strains were collected from extra-intestinal and intestinal disease for the present study. Of the strains isolated 49 (49%) were serum sensitive and 47 (47%) serum resistant. The remaining 4 (4%) strains showed intermediate sensitivity to the pooled normal human serum (PNHS). Strains isolated from faeces were significantly more sensitive than strains of extra-intestinal origin (P<0.01). Response of Escherichia coli strains to killing by polymorphonuclear leucocytes was seen in 50 isolates (50%). Faecal strains showed significantly more intracellular killing as compared to extra-intestinal strains (P<0.01). Thus, clinical significance of Escherichia coli strains from different sources can be determined by the resistance to the bactericidal effect of human serum and killing in polymorphonuclear leucocytes.