A prospective study of wound infection among post‑discharge patients at a level 1 trauma centre of India.

Background and Aim: To study the rate of wound infections in the post‑discharged patient population and to assess the usefulness of post‑discharge surveillance. Methods: A prospective surveillance of all the post‑discharged trauma patients was done during a period of 6 months. Discharge instructions were given to all the patients regarding identification of the signs and symptoms of wound infections. They were telephonically followed up after a week to enquire about the wound condition and followed up in the outpatient department (OPD). Microbiology culture samples of those showing any signs and symptoms of infections were sent and their antimicrobial therapy, any change in the treatment schedule and the length of their hospital stay were noted. Factors such as wound class, type of surgeries and readmissions were noted. Results: A total of 281 postdischarge patients were enrolled, of which 101 were completely followed up for wound infections. Males were predominant (89%). Of the 101 patients, 42 (41.6%) patients wound showed infection during the intense follow‑up in the OPD. However, 59 patients (59/101, 58.4%) showed wound swab culture positivity before discharge. These 42 patients developed signs and symptoms of infection post‑discharge; 23 (22.7%) of them had change of antibiotic therapy during the follow‑up period due to culture positivity. Acinetobacter sp., Staphylococcus aureus and Klebsiella pneumoniae were the predominant organisms isolated in the study. A total of 45 patients (44.5%) had to be readmitted due to wound site infections. Conclusions: Wound infections are common after discharge among trauma patients highlighting the importance of active surveillance and participation of patients.

Human immunodeficiency virus, hepatitis B virus and hepatitis C virus seroprevalence in critically ill emergency department patients at a Trauma Care Centre, India.

Introduction: Human Immunodeficiency Virus (HIV), Hepatitis B virus (HBV) and Hepatitis C virus (HCV) are the most common occupationally acquired infections amongst the healthcare workers (HCWs) with critically ill patients attending the emergency department being the most common source of occupationally acquired infections. Therefore, the present study was conducted at a 165 bedded level-1 trauma centre of India to ascertain the seroprevalence rate of HIV, HBV and HCV; and thus the risk associated with the occupational exposure in a busy emergency setting of the developing world. Methodology: A retrospective, 7 years study (2007-2013) was carried out at the JPNA Trauma Centre of the 2,500 bedded All India Institute of Medical Sciences, New Delhi. Records of all patients whose serum samples were sent to the laboratory for viral markers testing were obtained and those falling in the red area were included. Results: A total of 11,630 patients were received in the red area; and samples from 7,650 patients were sent for testing. Seropositivity of HIV, HBV and HCV in these samples was 0.28%, 3.4% and 0.9% respectively. The number of samples received was lesser than the total number of patients received in the red area. Conclusion: Adopting Standard Precautions (SP) can be used as an easy method to decrease the risk of occupationally acquired infections.

Profi le of fatal Streptococcal bacteraemia at a tertiary care Indian hospital.

Streptococcus pyogenes causes mild to acutely life-threatening diseases. Herein, we report our experience with fi ve cases of fatal bacteraemia due to various groups of Streptococci, three of them due to Group G Streptococcus and one case each due to Group A Streptococcus and Group F Streptococcus. The peculiarity of all these cases was the rapidity of deaths occurring in these patients despite all the strains being sensitive to Penicillin. Hence, timely intervention in all suspected cases is strongly advocated. All isolates of beta-haemolytic Streptococci should be identifi ed up till the species level and antimicrobial susceptibility be performed so that proper and early management can be done.

Device-associated infections at a level-1 trauma centre of a developing Nation: Impact of automated surveillance, training and feedbacks.

Purpose: Device-associated infections constitute the majority of health care-associated infections (HAIs) in ICUs. Trauma patients are predisposed to acquire such infections due to various trauma-related factors. The prevalence of HAIs is underreported from developing nations due to a lack of systematic surveillance. This study reports the impact of an intensive surveillance on the rates and outcome of device-associated infections in trauma patients from a developing country and compares the rates with a previous pilot observation. Materials and Methods: The study was conducted at a level-1 trauma centre of India. Surveillance for ventilator-associated pneumonia (VAP), central line-associated blood stream infections (CLA-BSIs) and catheter-associated urinary tract infections (CA-UTIs) was done based on centre for disease control-National Healthcare Safety Network (CDC-NHSN) defi nitions. The impact of an intensive surveillance, education and awareness drive on the rates of infections over the study period, and compliance to preventive bundles and hand hygiene was assessed. Results: A total of 15,462 ventilator days, 12,207 central line days and 17,740 urinary catheter days were recorded in the study population. The overall rates of VAP, CLA-BSI and CA-UTI were respectively 17, 7.2 and 15.5/1000 device days. There was a signifi cant correlation between device days and the propensity to develop infections. Infections were the cause of death in 36.6% of fatal trauma cases. A signifi cantly higher rate of VAP, CLA-BSI and CA-UTIs was noted in fatal cases. The compliance to ventilator bundle, central line bundle, bladder bundle and hand hygiene were 74.5%, 86%, 79.3% and 64.6%, respectively. A high rate of multi-drug-resistance was observed in all pathogens. A gross reduction in the rates of all infections was observed over time during the study due to implementation of a stringent surveillance system, feedbacks and education. The compliance to hand hygiene and preventive bundles also increased over time. Conclusion: The automated surveillance was easy and useful for data entry and analysis. Surveillance had a signifi cant impact on reduction of HAIs and mortality in trauma patients.

Distribution of different yeasts isolates among trauma patients and comparison of accuracy in identification of yeasts by automated method versus conventional methods for better use in low resource countries.

Introduction: As most trauma patients require long‑term hospital stay and long‑term antibiotic therapy, the risk of fungal infections in such patients is steadily increasing. Early diagnosis and rapid treatment is life saving in such critically ill trauma patients. Aims: To see the distribution of various species of Candida among trauma patients and compare the accuracy, rapid identification and cost effectiveness between VITEK 2, CHROMagar and conventional methods. Settings and design: Retrospective laboratory‑based surveillance study performed over a period of 52 months (January 2009 to April 2013) at a level I trauma centre in New Delhi, India. Materials and Methods: All microbiological samples positive for Candida were processed for microbial identification using standard methods. Identification of Candida was done using chromogenic medium and by automated VITEK 2 Compact system and later confirmed using the conventional method. Time to identification in both was noted and accuracy compared with conventional method. Statistical analysis: Performed using the SPSS software for Windows (SPSS Inc. Chicago, IL, version 15.0). P values calculated using χ2 test for categorical variables. A P < 0.05 was considered significant. Results: Out of 445 yeasts isolates, Candida tropicalis (217, 49%) was the species that was maximally isolated. VITEK 2 was able to correctly identify 354 (79.5%) isolates but could not identify 48 (10.7%) isolates and wrongly identified or showed low discrimination in 43 (9.6%) isolates but CHROM agar correctly identified 381 (85.6%) isolates with 64 (14.4%) misidentification. Highest rate of misidentification was seen in C. tropicalis and C. glabrata (13, 27.1% each) by VITEK 2 and among C. albicans (9, 14%) by CHROMagar. Conclusions: Though CHROMagar gives identification at a lower cost compared with VITEK 2 and are more accurate, which is useful in low resource countries, its main drawback is the long duration taken for complete identification.

Diagnosis of ventilator-associated pneumonia: Comparison between ante-mortem and post-mortem cultures in trauma patients.

Purpose: To evaluate the diagnostic utility of ante‑mortem tracheal aspirates for diagnosis of ventilator‑associated pneumonia (VAP). Trauma victims represent an otherwise healthy population, who are on multiple invasive life‑support devices, which predispose them to severe infections like VAP. The diagnosis of VAP is challenging, due to the difficulty in obtaining a representative sample from lungs. We studied the diagnostic utility of tracheal aspirates by comparing its results with the post‑mortem lung cultures. Materials and Methods: A total of 106 fatal trauma patients were included in the study. Lung samples and cardiac blood were taken for culture at the time of autopsy. The results of ante‑mortem and post‑mortem cultures were compared. Results: Septicemia was the cause of death in 51 (48%) of the fatal cases and VAP was identified in 36 (34%) cases. A total of 96 (90.5%) cases had pathogens isolated from lung samples. In 62 (58%) cases, the same organism was isolated from ante‑mortem and post‑mortem respiratory samples. Conclusions: Culture results of a properly collected tracheal aspirate should be taken into consideration along with Centre for Disease Control and Prevention (CDC’s) diagnostic criteria to maximise the diagnosis of VAP.

Mortality profile of patients with traumatic spinal injuries at a level I trauma care centre in India.

Background & objectives: There is no national spinal trauma registry available in India at present and the research on epidemiology of these injuries is also very limited. The purpose of this study was to describe the mortality profile of patients with spinal injuries brought to a level I trauma centre in India, and to understand the predictive factors which identify patients at an increased risk of spinal trauma mortality. Methods: Retrospective data were collected from computerized patients records and autopsy reports maintained in the department of Forensic Medicine. All the cases with spinal injuries whether in isolation or as a part of polytrauma were reviewed. A total of 341 such cases were identified between January 2008 to December 2011. The demographic data, type of trauma, duration of survival, body areas involved, level of spinal injury and associated injuries if any, were recorded. Results: There were 288 (84.45%) males and 53 (15.55%) females. Most victims (73%) were between 25 and 64 yr of age, followed by young adults between 16 and 24 yr (19.35%). Male: female ratio was 5.4:1. Fifty five per cent cases had spinal injuries in isolation. Injury to the cervical spine occurred in 259 (75.95%) patients, thoracic spine in 56 (16.42%) and thoraco-lumbar spine in 26 (7.62%) patients. The commonest cause of injury was high energy falls (44.28%), followed by road traffic accidents (41.93%). The majority of deaths (51.6%) occurred in the phase IV (secondary to tertiary complications of trauma, i.e. >1 wk). Forty patients died in phase I (brought dead or surviving <3 h), 55 in phase II (>3 to 24 h) and 70 in phase III (> 24 h to 7 days). Interpretation & conclusions: Our data suggest that there is an urgent need to take steps to prevent major injuries, strengthen the pre-hospital care, transportation network, treatment in specialized trauma care units and to improve injury surveillance and the quality of data collected which can guide prevention efforts to avoid loss of young active lives

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.

Mortality due to septicemia at a level 1 Indian trauma care centre: An epidemiological analysis.

Trauma contributes to a signifi cant proportion of mortality and morbidity in the economically productive age group of 15-45 years. Infections are the second most important cause of death in trauma patients after head injury. Despite advances in trauma care, deaths due to septicemia are increasing. An epidemiological study of septicemia-related deaths were conducted at a level 1 Trauma Centre from January 2011 to December 2011. A total of 201 patients died due to suspected septicemia. The average age of the deceased trauma victims was 35.9 years and the median length of stay in hospital before death was 27 days. In our study, a high proportion of patients had grown pathogens in signifi cant counts from respiratory specimens (36%) and blood (23%) during ante-mortem period, which may have contributed to their fatal outcome. Infections are one of the most common and fatal complications following trauma and complicate the recovery of a signifi cant number of injured patients.

Elizabethkingia meningoseptica : An emerging pathogen causing meningitis in a hospitalized adult trauma patient.

A 23-year-old male patient who was a follow-up case of neurosurgery presented to our emergency department with a history of high-grade fever and clinical features of meningitis for 1 week. The cerebrospinal fluid (CSF) was sent to our laboratory for culture. The culture demonstrated growth of 1-2 mm in diameter light yellow coloured colonies of Gram-negative bacilli on chocolate and blood agar. There was no growth on MacConkey agar. The bacterium was multidrug resistant. Based upon the growth characteristics, bio-chemical reactions, drug susceptibility pattern and identification by Vitek 2 system the isolate was identified as Elizabethkingia meningoseptica. Patient was treated with injection piperacillin-tazobactam, injection vancomycin and cotrimoxazole tablets for 21 days along with intrathecal injection of tigecycline and finally, patient improved clinically and the CSF cultures became sterile. The presence in hospital environment along with multidrug resistance makes E. meningoseptica a successful emerging nosocomial pathogen.

A case of dual infection in a paediatric trauma victim of primary cutaneous aspergillosis caused by Aspergillus flavus and Aspergillus terreus.

Aspergillus spp. are widely distributed throughout the environment. They are opportunistic pathogens causing infection at various sites in the body such as lungs, sinuses, eyes, skin, central nervous system etc., Primary cutaneous aspergillosis is an uncommon disease entity. Primary infections usually occur at sites having disruption of the skin and usually occur in burn patients, trauma and surgical patients. A 4-year-old girl who was run over by a truck and suffered extensive de-gloving injury to bilateral lower limbs developed greenish discharge and scaly lesions around the wound margins after 50 days of hospital stay. The skin biopsy demonstrated the presence of thin septate hyphae branching at acute angles and culture demonstrated growth of Aspergillus flavus and Aspergillus terreus. The child was started on voriconazole therapy for 3 weeks and the lesion healed satisfactorily. Subsequent skin biopsy culture was negative for fungi. Prompt diagnosis and management of such cases can salvage the limbs in severe trauma cases.

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.

The first successful simultaneous pancreas-kidney transplant in India.

Insulin-dependent diabetes mellitus is associated with renal failure, diabetic retinopathy, neuropathy and vasculopathy. We report the first successful simultaneous pancreas-kidney transplant in India in a young diabetic with renal failure. The dual transplant has cured his diabetes and renal failure and has had a beneficial effect on his neuropathy, retinopathy and quality of life. Obstacles to dual transplant in India include a lack of suitable recipients and a cadaver donor programme that is still in its infancy.

Intercostodiaphragmatic hernia secondary to a bull gore injury: a delayed detection.

We report a case of a 45-year-old male presenting with asymptomatic right lower chest mass following a forgotten penetrating trauma. This case highlights a rare; delayed complication of lower chest penetrating injuries by the bull gore, involving the diaphragm. Intercostodiaphragmatic hernia should be kept as a differential diagnosis of slowly growing lower chest wall asymptomatic masses with forgotten injuries in the past.

Coexisting carcinoma and tuberculosis of stomach.

We report a rare association of carcinoma and tuberculosis of the stomach. It is difficult to explain the simultaneous occurrence or a causal relationship of the two diseases.

Risk factors for wound infection following elective cholecystectomy.

A study of risk factors for wound infection among patients undergoing elective cholecystectomy was undertaken. Over a 2-Year period 177 patients who underwent elective cholecystectomy for symptomatic gall stone disease were randomized into groups, one receiving antibiotics (96 patients) and the other not receiving antibiotics (81 patients). Gall bladder bile and wound swab were cultured to detect bacterial growth. Duration of preoperative hospital stay, type of skin incision and operating time were noted for each patient. Postoperatively wound infection developed in 22/177 (12%) patients. The infection rate was lower in the antibiotic group 3/96 (3%) as compared to the non-antibiotic group 19/81 (23.5%). Wound sepsis occurred in 11/37 (23%) of patients with bactibilia as compared to 11/140 (7.8%) patients with sterile bile. Stepwise logistic regression analysis showed that bactibilia and use of prophylactic antibiotics were the most significant predictors of wound infection in low risk patients undergoing elective cholecystectomy.

Omental rhabdomyosarcoma presenting with pyrexia.

A 45-year-old man was admitted with pyrexia and intermittently palpable lump in the left lumbar region. Laparotomy revealed a primary omental tumor which on histological examination showed alveolar rhabdomyosarcoma of the omentum. Following surgery the fever subsided. Presentation of omental rhabdomyosarcoma with fever has not been reported earlier.

Mini-lap cholecystectomy--an attractive alternative to conventional cholecystectomy.

A prospective study was conducted to determine the safety and efficacy of cholecystectomy through a 5 cm transverse abdominal incision. 181 consecutive patients who underwent elective cholecystectomy for symptomatic gall stone disease in a single surgical unit at the All India Institute of Medical Sciences, New Delhi between December 1990 to February 1992, were prospectively randomized into 5 cm transverse and midline incision groups. Operative time, blood loss, post-operative stay and complications were compared in the two groups. Ninety seven patients were included in the transverse incision group and 84 patients in the midline group. Cholecystectomy could be safely performed through a 5 cm transverse incision in 84 patients (86.8%) without increase in operative complications, morbidity or mortality. In another 84 patients cholecystectomy was performed through a midline incision. The average operating time and blood loss were comparable in both groups. The average post-operative stay in 5 cm transverse incision group was 2.6 days (range 1-4 days) and in the midline group was 4.0 days (range 3-5 days). There were 7 post-operative complications (all wound infections) in the 5 cm transverse group and 12 post-operative complications (10 wound infections and 2 pneumonitis) in the midline group. However, the difference in wound infection rate was not statistically significant (p > 0.1). In Conclusion, Cholecystectomy can be safely performed through a 5 cm transverse incision.