Cluster outbreak of Pseudomonas stutzeri acute endophthalmitis following phacoemulsification: A report of 14 cases from North India

Purpose: To report clinical features, antibiotic susceptibility profile, management, and outcomes of a cluster outbreak of post?cataract surgery Pseudomonas stutzeri endophthalmitis. Methods: This was a hospital?based case series in which 14 patients with acute postoperative endophthalmitis who underwent cataract surgery on the same day were included. Based on severity of presentation, they either underwent pars plana vitrectomy (PPV) with intraocular antibiotics (IOAB) or vitreous tap with IOAB. Vitreous aspirates and environmental surveillance samples were inoculated on culture media and further processed by MALDI?TOF MS for identification and Vitek3 for susceptibility profile. Results: There were 8 females and 6 males with a mean age of 62.14 ± 8.08 years. Presenting signs included corneal folds (100%), hypopyon (57.1%) and fibrin (50%). Ten patients with mild presentation underwent vitreous tap with IOAB. Four patients with severe presentation underwent PPV with IOAB. Pseudomonas stutzeri was isolated from the vitreous samples and was pan?sensitive. Six eyes required multiple interventions. Favorable outcome was obtained in 12 eyes, one eye developed phthisis, and one patient was lost to follow?up. Conclusion: We report the first ever cluster outbreak of Pseudomonas stutzeri endophthalmitis following phacoemulsification with IOL implantation in a single surgeon setting. Majority of the patients had a mild presentation and responded well to targeted anti?microbial treatment.

Chronic brucellosis with hepatic brucelloma and AA amyloidosis in a patient with autosomal dominant polycystic kidney disease

We describe an autopsy case of a 45-year-old male diagnosed with autosomal dominant polycystic kidney disease who presented with complaints of altered sensorium. The autopsy revealed multiple tumor-like masses in the liver, which on histological examination depicted multiple large suppurative granulomas with the presence of variable acid-fast coccobacilli (consistent with Brucella spp.). Interestingly, extensive amyloid deposition in multiple organs was noted. To the best of our knowledge, this is the first case of chronic brucellosis causing tumor-like abscesses in the liver accompanied by secondary systemic amyloidosis in a patient with underlying autosomal dominant polycystic kidney disease.

Bacillus cereus causing intratumoral brain abscess.

We report a case of intratumoral brain abscess due to Bacillus cereus in an adult male patient, which was managed successfully with excision of lesion and piperacillin‑tazobactam for the duration of 5 weeks. To the best of our knowledge, this is a first case report of B. cereus infection leading to intratumoral brain abscess in a patient with a history of steroid administration by the intravenous route.

Ribosomal RNA‑based panbacterial polymerase chain reaction for rapid diagnosis of septicaemia in Intensive Care Unit patients.

Early diagnosis and treatment of sepsis by appropriate antibiotics is of utmost importance. Therefore, we evaluated 16S rRNA panbacterial polymerase chain reaction (PCR) for rapid diagnosis of sepsis in 49 adult patients in Intensive Care Units (ICUs) and compared it with an automated blood culture. 8 ml of 10 ml blood collected was inoculated into BACTEC® aerobic bottle and the remaining 2 ml was used for DNA extraction and PCR. 109 of 115 (93%) episodes of suspected sepsis showed concordant results between automated culture and PCR. Six episodes were positive by PCR only. Panbacterial PCR reduces turnaround time with rapid differentiation between systemic inflammatory response syndrome and sepsis.

Naso-pharyngeal Carriage of Organisms in Children Aged 3-59 months Diagnosed with Severe Community-acquired Pneumonia.

Objective: To study the naso-pharyngeal carriage of organisms in children diagnosed with severe pneumonia. Methods: Nasopharyngeal aspirate and swabs for microbiological analyses were collected from 377 children aged 3-59 months with severe pneumonia. Results: 28.6% of the samples were positive for S. pneumoniae, 9.6% were positive for H. influenzae, and 8.5% were positive for both the organisms. Respiratory syncytial virus was detected in 27% of samples. The rate of isolation of S. pneumonia and H. influenzae was significantly more in the age group of 12-59 months. Conclusions: In children with severe pneumonia, most common organisms isolated/detected from naso-pharyngeal aspirates were S.pneumoniae and Respiratory Syncytial Virus.

Has Vector-Rodent Relationship Changed in Plague? Experiences of Plague Affected Hilly Terrains of Himachal Pradesh, India.

Background: The present study was conducted with objectives to elucidate the existence of sylvatic cycle of plague and to document the changing pattern of relationship between rodents and fleas. Methods: Collection of samples was done from 15 sites (25 locations) from plague affected areas of Shimla district of Himachal Pradesh, India during 5 visits between June 2011 to July 2012, which were thereafter entomologically investigated in a BSL-3 laboratory Results: 57 fleas (3 species) from 243 rodents (3 species) were collected in domestic (n=16), peridomestic (n=3) and wild (n=6) locations. Rattus rattus (n=197) and Nosopsyllus fascitus (n=43) was most frequently trapped rodent and flea species respectively. Rattus rattus (domestic rodent species) was also trapped from wild areas and Nosopsyllus fascitus (domestic flea species) was also isolated from Rattus norvegicus (wild rodent species). One rare rodent species Cornilurus albipes was also found. Most common rodent-flea association was Rattus norvegicus-Nosopsyllus fascitus. The recovery of rodents and flea was higher in months of June and December respectively. Conclusions: The study concluded that sylvatic cycle persisted in study area and rodent and flea mixing was widely prevalent between domestic and wild area. This demands regular and intensive surveillance in plague prone hilly areas of Himachal Pradesh.

Intestinal Colonization Among Very Low Birth Weight Infants in First Week of Life.

Objective: To study intestinal colonization patterns in very low birth weight infants in the first week of life in a neonatal intensive care unit. Methods: Meconium/stool specimens were obtained on days 1, 3, 5 and 7 from 38 very lowbirth- weight infants in a level III neonatal intensive care unit. Results: On day 1, 45% had sterile guts, and by day 3, all infants were colonized. E. coli, K. pneumoniae and Enterococcus fecalis were predominant organisms. Lactobacilli was found in one isolate and Bifidobacteria was not detected during the study period. There was an association between formula feeding and E. coli colonization. Conclusions: Very low birth weight infants admitted in neonatal intensive care units have abnormal intestinal colonization patterns.

Methicillin resistant Staphylococcus aureus (MRSA) in India Prevalence & susceptibility pattern.

Background & objectives: Methicillin resistant Staphylococcus aureus (MRSA) is endemic in India and is a dangerous pathogen for hospital acquired infections. This study was conducted in 15 Indian tertiary care centres during a two year period from January 2008 to December 2009 to determine the prevalence of MRSA and susceptibility pattern of S. aureus isolates in India. Methods: All S. aureus isolates obtained during the study period in the participating centres were included in the study. Each centre compiled their data in a predefined template which included data of the antimicrobial susceptibility pattern, location of the patient and specimen type. The data in the submitted templates were collated and analysed. Results: A total of 26310 isolates were included in the study. The overall prevalence of methicillin resistance during the study period was 41 per cent. Isolation rates for MRSA from outpatients, ward inpatients and ICU were 28, 42 and 43 per cent, respectively in 2008 and 27, 49 and 47 per cent, respectively in 2009. The majority of S. aureus isolates was obtained from patients with skin and soft tissue infections followed by those suffering from blood stream infections and respiratory infections. Susceptibility to ciprofloxacin was low in both MSSA (53%) and MRSA (21%). MSSA isolates showed a higher susceptibility to gentamicin, co-trimoxazole, erythromycin and clindamycin as compared to MRSA isolates. No isolate was found resistant to vancomycin or linezolid. Interpretation & conclusions: The study showed a high level of MRSA in our country. There is a need to study epidemiology of such infections. Robust antimicrobial stewardship and strengthened infection control measures are required to prevent spread and reduce emergence of resistance.

Effect of Lactobacillus acidophilus & epidermal growth factor on experimentally induced Clostridium difficile infection.

Background & objectives: Clostridium difficile-associated disease (CDAD) remains an important nosocomial ailment. Antimicrobial therapy used for CDAD gives inconsistent results. This experimental study was planned to investigate the beneficial effects of Lactobacillus acidophilus and epidermal growth factor (EGF) for CDAD management. Methods: Among 10 groups of BALB/c mice (6 in each), group 1 served as controls receiving no inoculum. Animals in groups 2-10 received C. difficile, those in groups 3, 6 and 9 received L. acidophilus and those in groups 4, 7 and 10 received EGF after C. difficile inoculation. Animals in groups 5-7 were pre-treated with ampicillin and those in groups 8-10 with lansoprazole prior to C. difficile. The animals were killed and investigated for colonisation by C. difficile and toxin production, myeloperoxidase (MPO) activity and histopathology. Results: Colonisation by C. difficile was found to be significantly different (P<0.001) in the various groups. C. difficile toxin titres and MPO activity were significantly lower in animals given L. acidophilus and EGF after ampicillin (groups 6 and 7) and lansoprazole (groups 9 and 10). The severity of acute inflammation was also significantly less (P<0.05) in caecal and colonic segments of animals in groups 6 and 7 compared to those in group 5. Although the severity of acute inflammation was less in the caecal and colonic segment of animals in groups 9 and 10, the reduction was not significant compared to group 8. Interpretation & conclusions: Our findings showed that the administration of L. acidophilus and EGF reduced the severity of C. difficile infection in the experimental animals.

Short Course Versus 7-Day Course of Intravenous Antibiotics for Probable Neonatal Septicemia: A Pilot, Open-label, Randomized Controlled Trial.

Objective: To compare a short course of antibiotics (48 to 96 hours) and a standard course of antibiotics (7 days) for probable neonatal sepsis. Design: Randomized, controlled, open-labeled trial with blocking and stratification according to birth weight. Setting: Tertiary care, referral, teaching hospital in Northern India. Participants: Neonates >30 wks gestation and >1000 g at birth, with probable sepsis (clinical signs of sepsis, raised C-reactive protein) were enrolled. Babies with major malformations, severe birth asphyxia, meningitis, bone or joint or deep-seated infection, those who were already on antibiotics, and those undergoing surgery were excluded. Neonates, who had clinically remitted on antibiotic therapy – by the time a sterile blood culture report was received – were randomized. Intervention: In the intervention arm, antibiotics were stopped after the 48-hour culture was reported sterile. In the control arm, antibiotics were continued to a total of 7 days. Main outcome measure: “Treatment failure” defined as reappearance of signs suggestive of sepsis within 15 days of stopping antibiotics, supported by laboratory evidence and adjudicated by a blinded expert committee. Results: 52 neonates were randomized to receive a short course or 7-day course (n=26 each). Baseline variables were balanced in the 2 groups. There was no significant difference in the treatment failures between the 2 groups (3 babies in the 7-day group vs none in short course group, P=0.23). Conclusion: No difference in the treatment failure rates could be identified between short course and 7-day groups among neonates >30 weeks and >1000 grams with probable sepsis.

Detection of TEM & SHV genes in Escherichia coli & Klebsiella pneumoniae isolates in a tertiary care hospital from India.

Background & objectives: Extended spectrum beta lactamases (ESBLs) have been observed in virtually all the species of family Enterobacteriaceae. The enzymes are predominantly plasmid mediated and are derived from broad-spectrum beta lactamase TEM-1, TEM-2 or SHV-1 by a limited number of mutations. This study was undertaken to characterize ESBL producers among Escherichia coli and Klebsiella pneumoniae by PCR-RFLP, which were initially screened by phenotypic method. Methods: A total of 100 isolates of each species (E. coli and K. pneumoniae) were screened for ESBL production. PCR analysis for b-lactamase genes of the family TEM and SHV was also carried out. PCR products of TEM and SHV genes were subjected to digest with three different restriction enzymes. The digested products were run on 1.5 per cent agarose gel, stained and examined for DNA bands. Results: PCR carried out on plasmid DNA alone detected 30 per cent ESBL positive isolates using TEM primer and 38 per cent using SHV primer, whereas PCR for both plasmid and chromosomal DNA showed 56 per cent positivity for TEM and 60 per cent positivity for SHV. Interpretation & conclusion: RFLP yielded homogeneous band pattern, suggesting that there may be a point source or a common evolutionary origin for all the ESBL isolates.

Plasmid profile of ESBL producing Gram-negative bacteria and correlation with susceptibility to β-lactam drugs.

Background: Members of family Enterobacteriaceae can acquire resistance to extended spectrum beta lactams by a number of mechanisms; most important being the plasmid encoded extended spectrum beta lactamase (ESBL) and AmpC beta lactamase. This study has been designed to look for the presence of plasmids and their correlation with drug resistance. Methods: ESBL production was studied in different gram-negative bacteria and susceptibility testing of ESBL positive isolates was done for various beta lactams, cephalosporins and other commonly used drugs against them. Plasmid DNA isolation of all the ESBL positive strains was done by alkalilysis method. Finally the presence of plasmid was correlated with susceptibility to beta lactam drugs. Results: E. coli, K. pneumoniae, Enterobacter aerogenes and A. anitratus harbored multiple plasmids. One plasmid (M.W greater than 21,226 bp) was unanimously present in all the isolates. Conclusion: There is a strong correlation between the number of plasmids harbored by an isolate and resistance to various drugs tested.