SARS-CoV-2 antigen detection in deceased bodies: implications for infection prevention

Background & objectives: High transmissibility of the SARS-CoV-2 has significant implications on healthcare workers’ safety, preservation, handling, transportation and disposal of the deceased bodies. The objective of this study was to detect SARS-CoV-2 antigen in nasopharyngeal samples and its implications in handling and care of COVID-19 deceased bodies. Methods: A study was conducted at a dedicated COVID-19 centre on deceased individuals from April to December 2020. Rapid antigen test (RAT) and reverse transcription (RT)-PCR was compared on all the SARS-CoV-2 positive cadavers recruited in the study. Results: A total of 115 deceased individuals were included in the study. Of these, 79 (68.7%) were male and 36 (31.3%) were female and majority were in the age group of 51-60 yr [31 (27%)]. SARS-CoV-2 antigen test was positive in 32 (27.8%) and negative in 83 (72.1%) individuals. The mean time interval between deaths to the sample collection was 13.2 h with interquartile range of eight to 20 h. Reverse transcription (RT)-PCR was used as the reference test and 24 (20.9%) cases were true positive; 93.6 per cent [95% confidence interval (CI) 88.8-98.4%] sensitivity, 45.2 per cent (95% CI 35.5-55%) specificity, 60.2 per cent (95% CI 50.6-69.8%) positive predictive value and 88.8 per cent (95% CI 82.7-95%) negative predictive value of antigen test was computed. Interpretation & conclusions: SARS-CoV-2 antigen test was positive beyond 19 h in COVID-19 deceased individuals. Antigen test was found to be highly sensitive in the deceased. Patients, suspected of having died due to COVID-19, can be screened by this method. As infectiousness of the virus in the deceased bodies cannot be directly concluded from either the antigen or RT-PCR test, yet possible transmission cannot be completely ruled out. Strict infection control measures need to be followed during the handling and clearance of COVID-19 cadavers.

Antibiotic susceptibilities, streptococcal pyrogenic exotoxin gene profiles among clinical isolates of group C or G Streptococcus dysgalactiae subsp. equisimilis & of group G S. anginosus group at a tertiary care centre.

Background & objectives: Group C and group G streptococci (together GCGS) are often regarded as commensal bacteria and their role in streptococcal disease burden is under-recognized. While reports of recovery of GCGS from normally sterile body sites are increasing, their resistance to macrolides, fluoroquinolone further warrants all invasive β haemolytic streptococci to be identified to the species level and accurately tested for antimicrobial susceptibility. This study was aimed to determine the prevalence, clinical profile, antimicrobial susceptibility and streptococcal pyrogenic exotoxin gene profile (speA, speB, speC, speF, smeZ, speI, speM, speG, speH and ssa) of GCGS obtained over a period of two years at a tertiary care centre from north India. Methods: The clinical samples were processed as per standard microbiological techniques. β-haemolytic streptococci (BHS) were characterized and grouped. Antimicrobial susceptibility of GCGS was performed using disk diffusion method. All GCGS were characterized for the presence of streptococcal pyrogenic exotoxins (spe) and spe genes were amplified by PCR method. Results: GCGS (23 GGS, 2GCS) comprised 16 per cent of β haemolytic streptococci (25/142 βHS, 16%) isolated over the study period. Of the 25 GCGS, 22 (88%) were recovered from pus, two (8%) from respiratory tract, whereas one isolate was recovered from blood of a fatal case of septicaemia. Of the total 23 GGS isolates, 18 (78%) were identified as Streptococcus dysgalactiae subsp equisimilis (SDSE, large-colony phenotype), five (21%) were Streptococcus anginosus group (SAG, small-colony phenotype). The two GCS were identified as SDSE. All GCGS isolates were susceptible to penicillin, vancomycin, and linezolid. Tetracycline resistance was noted in 50 per cent of SDSE isolates. The rates of macrolide and fluoroquinolone resistance in SDSE were low. Twelve of the 20 SDSE isolates were positive for one or more spe genes, with five of the SDSE isolates simultaneously carrying speA+ speB+ smeZ+ speF or speB+ smeZ+speF, speI+speM+speG+speH or, speI+spe M+speH or speA+ speB+ speC+ smeZ+ speF. One notable finding was the presence of spe B in four of the five isolates of the Streptococcus anginosus group. No isolate was positive for ssa. Interpretation & conclusions: Our study showed no association between GCGS isolates harbouring streptococcal pyrogenic exotoxins and disease severity. This might be attributed to the small sample size of spe-positive isolates.

Implementation of a short course of prophylactic antibiotic treatment for prevention of postoperative infections in clean orthopaedic surgeries.

Background & objectives: Perioperative antimicrobial prophylaxis constitutes the bulk of antimicrobial consumption in any hospital. This study was conducted at a level 1 Trauma Centre of a tertiary care hospital of India to assess the efficacy of a short (24 h) course of perioperative antibiotic prophylactic regimen in preventing surgical site infections (SSI) in open reduction and internal fixation (ORIF) of closed fractures of limbs and to assess if the same can be implemented as a general policy. Methods: Patients of either sex, aged 18 yr or more, who were scheduled for ORIF and were willing and able to give informed consent, were included in the study. Patients were randomly allocated into two groups. Group 1 (n=100) received 3 doses of 1 g i.v. cefuroxime perioperatively spaced 12 h apart and group 2 (n=97) received the conventional existing regimen [5 days of i.v. antibiotics (cefuroxime 1 g twice daily along with amikacin 15 mg/kg in 2 divided doses), followed by oral cefuroxime, 500 mg twice daily till suture removal]. Results: Of the 197 patients, four patients developed a surgical site infection (three with methicillin resistant Staphylococcus aureus and one Acinetobacter baumanii). Of these, two patients were in group 1 and the remaining two in group 2. These patients were treated with i.v. antibiotics based on the culture and antimicrobial sensitivity reports. The cost of the short course treatment was ` 150 per patient as compared to ` 1,900 per patient for conventional regimen. Interpretation & conclusions: There was no significant difference in rates of SSI among the two groups in our study. Cost evaluation revealed that shorter course was less expensive than conventional long course regimen. Implementation of a short course perioperative regimen will go a long way in reducing antimicrobial resistance, cost and adverse reactions to antimicrobials.

Hand hygiene: Back to the basics of infection control.

Health care associated infections are drawing increasing attention from patients, insurers, governments and regulatory bodies. This is not only because of the magnitude of the problem in terms of the associated morbidity, mortality and cost of treatment, but also due to the growing recognition that most of these are preventable. The medical community is witnessing in tandem unprecedented advancements in the understanding of pathophysiology of infectious diseases and the global spread of multi-drug resistant infections in health care set-ups. These factors, compounded by the paucity of availability of new antimicrobials have necessitated a re-look into the role of basic practices of infection prevention in modern day health care. There is now undisputed evidence that strict adherence to hand hygiene reduces the risk of cross-transmission of infections. With “Clean Care is Safer Care” as a prime agenda of the global initiative of WHO on patient safety programmes, it is time for developing countries to formulate the much-needed policies for implementation of basic infection prevention practices in health care set-ups. This review focuses on one of the simplest, low cost but least accepted from infection prevention: hand hygiene.

Salmonella enterica enteritidis arthritis following trauma in a child with thalassemia major.

Osteoarticular infections caused by Non-typhi Salmonella are exceptionally encountered. We report a case of a bacteriologically documented knee joint infection due to Salmonella enterica serotype enteritidis, following trauma in a child with thalassemia major. Emergency arthrotomy combined with antimicrobial therapy was helpful in eradication of infection. Physicians should be aware of this rare manifestation of Non-typhi Salmonella infections in thalassemic patients.

Tigecycline susceptibility report from an Indian tertiary care hospital.

Background & objectives: Treatment of serious life threatening infections due to multi-drug resistant pathogens presents a difficult challenge due to the limited therapeutic options. Therefore, we studied the in vitro susceptibility of tigecycline, a new glycylcycline with promising broad spectrum of activity against Gram positive and Gram negative bacteria at a tertiary care hospital in north India. Methods: A total of 75 multi-drug resistant isolates of methicillin resistant Staphylococcus aureus (21), vancomycin resistant enterococci (14), vancomycin resistant Streptococcus spp. (3), extended spectrum β lactamase producing Gram negative bacteria (11) and multi-resistant Acinetobacter spp. (26) were tested for tigecycline susceptibility by the E- test and disc diffusion methods. An additional 83 multi-resistant Gram negative clinical isolates were screened by disc diffusion method alone. Results: All the isolates of MRSA, VRE, vancomycin resistant Streptococcus spp. and ESBL producing enteric bacteria were sensitive to tigecycline by the E-test and disc diffusion methods. However, only 42 per cent of Acinetobacter spp. were found to be sensitive to tigecycline by the E-test method. Interpretation & conclusions: In conclusion, tigecycline was found to be highly effective against Gram- positive bacteria and Gram-negative members of Enterobacteriaceae, but a high prevalence of resistance in members of Acinetobacter spp. is worrisome.

Chronic diarrhea and malabsorption caused by Leishmania donovani.

Chronic diarrhea and malabsorption are uncommon in immunocompetent patients with visceral leishmaniasis. We report two immunocompetent patients with visceral leishmaniasis where the predominant presentation was chronic diarrhea. One of them had clinically overt malabsorption and duodenal mucosa was loaded with Leishmania donovani bodies. The other patient had diffuse colonic aphthous and discrete ulcerations and Leishmania donovani bodies were seen in the crush smears of the colonic mucosa. With amphotericin B, there was reversal of malabsorption and healing of colonic ulcers.

Evaluation of a rapid immunochromatographic test for diagnosis of kala-azar & post kala-azar dermal leishmaniasis at a tertiary care centre of north India.

BACKGROUND & OBJECTIVE: Definitive diagnosis of kala-azar requires demonstration of parasites by diagnostic protocols based on invasive organ aspirations. We evaluated in the present study the diagnostic utility of an immunochromatographic test (ICT) for detection of anti- rK-39 antibodies for the non-invasive diagnosis of kala-azar and post kala-azar dermal leishmaniasis (PKDL) at a tertiary care centre of north India. METHODS: The study was conducted in the Department of Microbiology, All India Institute of Medical Sciences, New Delhi, from July 2003 to October 2004. Of the 120 samples tested, 57 were found to be positive by ICT; of which, 51 were diagnosed as kala-azar and 6 as PKDL. The controls included individuals from endemic (50) and non endemic (19) areas with malignancies, haemolytic disorders, chronic liver diseases, hypersplenism, portal hypertension, metabolic disorders and sarcoidosis. In addition, 47 sera from confirmed cases of tuberculosis, malaria, typhoid, filariasis, leptospirosis, histoplasmosis, toxoplasmosis, invasive aspergillosis, amoebic liver abscess, AIDS, leprosy, cryptococcosis, strongyloidiasis, cyclosporosis, patients having collagen vascular diseases and hypergammaglobulinaemia were also tested to check the specificity of the test. RESULTS: Of the 51 cases with kala-azar 43 were males, children accounted for 25 per cent of these cases. All had fever of duration ranging from <1 month to 1.5 yr (median 4.5 months). All PKDL patients (n=6, 4 males) gave a history of having suffered from kala-azar in the past, and their slit skin test smears were microscopically positive for Leishman-Donovan (LD) bodies. The strip test was positive in all the cases of kala-azar and PKDL (estimated sensitivity 100%), all control sera were negative by the ICT (specificity 100%). INTERPRETATION & CONCLUSION: The rK-39 ICT is a highly sensitive and specific test, and may be suitable for a rapid, cost-effective and reliable field diagnosis of kala-azar and PKDL.

Comparison of trypsin treatment method and standard laboratory technique for diagnosis of dermatomycosis.

Dermatomycosis is prevalent worldwide. Discrepancy between microscopic examination and culture findings can create problems in the diagnosis of this common infection. In this study, samples from 60 patients were processed after trypsin treatment and examined by neutral red staining to distinguish viable and non-viable fungal elements. The trypsin treatment method was compared with standard laboratory techniques. A higher number of direct-microscopy-positive, culture-negative samples were obtained without trypsin treatment. Trypsin treatment increased the isolation of fungi from clinical samples, and neutral red staining was able to distinguish viable fungal elements.

Streptococcus pyogenes meningitis.

Group A Streptococcus (GAS) is a rare cause of meningitis. Although it has a high mortality, the condition is easily treatable if diagnosed early since the bacteria retains its sensitivity to many antimicrobials. The authors report here two cases of GAS meningitis along with a review of world literature.

Spectrum of beta-haemolytic streptococcal soft tissue infections at a tertiary care hospital of north india.

BACKGROUND & OBJECTIVES: An increase in the incidence of invasive beta haemolytic streptococcal infections has been observed in many Western countries. However, the role of beta-haemolytic streptococci in soft tissue infections is not well documented in developing countries. A retrospective study was carried out to review the spectrum of soft tissue infections caused by beta-haemolytic streptococci (betaHS) in a tertiary care hospital of north India. METHODS: The laboratory records of all patients with betaHS isolated from soft tissues between January 1996 and December 2000 were reviewed. Detailed clinical, laboratory and demographic data were recorded for all patients. RESULTS: A total of 39288 samples from soft tissue infections were received in the bacteriology laboratory for bacterial culture during the study period. betaHS were recovered from 205 samples. Of these, 56 per cent isolates were obtained from patients of suspected osteomyelitis. A seasonal pattern was observed with maximum isolation occuring in the winter months. Group A was the commonest isolate (75%), followed by group B Streptococcus (11%). Group C and G betaHS together accounted for about 3 per cent of all the isolates. All the isolates were sensitive to penicillin. INTERPRETATION & CONCLUSION: Soft tissue infections due to betaHS are common in our country. Group A streptococci were encountered most frequently with these infections though other groups of betaHS also contributed substantially. Since these infections are life threatening, there is a need to develop preventive, diagnostic and therapeutic strategies against betaHS.