Assessment of core capacities for antimicrobial stewardship practices in indian hospitals: Report from a multicentric initiative of global health security agenda

Introduction: Antimicrobial-resistant HAI (Healthcare associated infection) are a global challenge due to their impact on patient outcome. Implementation of antimicrobial stewardship programmes (AMSP) is needed at institutional and national levels. Assessment of core capacities for AMSP is an important starting point to initiate nationwide AMSP. We conducted an assessment of the core capacities for AMSP in a network of Indian hospitals, which are part of the Global Health Security Agenda-funded work on capacity building for AMR-HAIs. Subjects and Methods: The Centers for Disease Control and Prevention's core assessment checklist was modified as per inputs received from the Indian network. The assessment tool was filled by twenty hospitals as a self-administered questionnaire. The results were entered into a database. The cumulative score for each question was generated as average percentage. The scores generated by the database were then used for analysis. Results and Conclusion: The hospitals included a mix of public and private sector hospitals. The network average of positive responses for leadership support was 45%, for accountability; the score was 53% and for key support for AMSP, 58%. Policies to support optimal antibiotic use were present in 59% of respondents, policies for procurement were present in 79% and broad interventions to improve antibiotic use were scored as 33%. A score of 52% was generated for prescription-specific interventions to improve antibiotic use. Written policies for antibiotic use for hospitalised patients and outpatients were present on an average in 72% and 48% conditions, respectively. Presence of process measures and outcome measures was scored at 40% and 49%, respectively, and feedback and education got a score of 53% and 40%, respectively. Thus, Indian hospitals can start with low-hanging fruits such as developing prescription policies, restricting the usage of high antibiotics, enforcing education and ultimately providing the much-needed leadership support.

Biofilm production and its correlation with antibiogram among clinical isolates of uropathogenic Escherichia coli

Background: Urinary tract infection (UTI) is one of the commonest health problem encountered in clinical practice. The biofilms play major role in decreasing the susceptibility to the antimicrobial agents. The present study aimed at isolation and identification of Escherichia coli from cases of urinary tract infection, and to find out production of biofilms by these isolates and to correlate it with antimicrobial resistance.Methods: This study was a cross sectional study. Urine specimen from patients suspected of UTIs were collected and processed by standard operative procedure, antibiotic susceptibility test was done by Kirby Bauer disc diffusion method. Biofilm production in isolates was done by Tissue culture plate (TCP) method, Christensen’s test tube (CTT) method, and Congo red agar (CRA) method.Results: Out of the total of 250 isolates 191 (76%) showed biofilm positive by TCP method, 180 (72%) showed biofilm positive by CTT method, 161 (64%) showed biofilm positive by CRA method. 90% of total extended spectrum beta lactamase (ESBL) producing Escherichia coli were biofilm producers. There is more resistance for each and every antibiotic among biofilm producers in comparision to biofilm non producers.Conclusions: The microbial biofilms may pose a public health problem, as the microorganisms in the biofilms are difficult to be treated with antimicrobial agents.

Phenotypic modulation in Mycobacterium tuberculosis infected neutrophil during tuberculosis.

Background & objectives: Polymorphonuclear leucocytes (PMN) or neutrophils infiltrate to the inflammatory sites and phagocytose mycobacteria thereby inhibiting the bacillary spread initially until the accumulated macrophages get activated. The present study was carried out to highlight the interaction of neutrophils with the two clinical isolates (S7 and S10) of Mycobacterium tuberculosis and the subsequent morphological changes. Methods: Dextran purified neutrophils from normal and TB patients infected with M. tuberculosis isolates were cultured for 3 and 18 h time points. At the end of termination, the cell surface expression of CD16, CD69, CXCR2 and induction of apoptosis were analyzed using flow cytometry. Cytokines and chemokines were estimated in supernatants by ELISA. Results: All infected PMN showed decrease in CD16 at both time points in normals while at 18 h in TB group. Interestingly, CD69 expression was significantly high at early time point in TB-PMN compared to normals. The high expression of CXCR2 was sustained in infected TB-PMN at both the time points. S7 and S10 infected neutrophils showed high phagocytic indices compared to H37Rv in both the groups. A significant increase in apoptosis was observed at both the time points in infected TB-PMN but only at 18 h in normals. Increased pro-inflammatory cytokine (TNF-α) and chemokine (IL-8) response was observed in infected neutrophils at 3 h in both the groups. Interpretation & conclusions: This study demonstrates the varying degree of modulation of neutrophil functions in both the groups. TB-PMN was more competent in amplifying the innate immune response and conferring protection at the early phase of infection. However, the response was not strain specific in either of these groups.

Leptin response in patients with tuberculous pleuritis.

BACKGROUND & OBJECTIVES: Tuberculous pleuritis is used as a model to understand the protective immune response in tuberculosis. It is predominated by Th1 response at the site of infection, where a possible role for the leptin, a known enhancer of Th1 response, could be speculated. Hence, we investigated leptin levels in pleural effusions in patients with both tuberculous (TP) and non-tuberculous (NTP) pleural effusion. METHODS: Leptin and cytokine levels were assessed in serum and pleural fluid of TP and NTP patients (N = 20 each) by ELISA. Multivariate regression analysis were performed to find the possible determinants of leptin taking leptin as the dependent and body mass index (BMI), gender, source of leptin [i.e., serum or pleural fluid (PF)], age and disease status as independent variables. RESULTS: PF leptin levels were significantly higher than serum leptin levels in both the groups however the PF leptin levels were significantly lower in TP subjects compared to NTP. The results showed that the leptin was found to be dependent on BMI but not on the other parameters. However, regression analysis based on the source of leptin showed males to be a better predictor of leptin. No correlation was observed between leptin and measured immune parameters. INTERPRETATION & CONCLUSION: Our findings demonstrated that the decreased leptin levels were associated with reduction in BMI but not with the disease status in tuberculous pleuritis.

Expression of co-stimulatory molecules B7.1 & B7.2 on macrophages infected with various strains of Mycobacterium tuberculosis & its influence on T-cell apoptosis.

BACKGROUND & OBJECTIVE: Activation of T cells is mediated through two critical signals provided by activated macrophages. The first signal is triggered when T cell receptor (TCR) binds to the major histocompatibility antigen (MHC/Ag) complex. The second signal is the interaction of co-stimulatory molecules with their respective ligands on T cells for their activation and proliferation. We undertook this study to observe the modulation in B7.1 (CD80) and B7.2 (CD86) co-stimulatory molecules on Mycobacterium tuberculosis infected monocyte derived macrophages (MDM) and their role in T helper (Th1) cell apoptosis. METHODS: M. tuberculosis clinical strains (S7 and S10) and laboratory strains (H37Ra and H37Rv) were used to infect the MDMs. The modulation of apoptosis was assessed by treating T cells with anti-CD3 and anti-CD28 antibodies. The infected MDMs were co-cultured with autologous PPD pulsed T cells to ascertain the role of co-stimulatory molecules during infection. RESULTS: In infected MDMs, all strains on day 1 but only S7 on day 2 showed significant decrease (P<0.05) in B7.1 expression compared to uninfected. The expression levels of B7.2 were also low on day 1 in S7, S10 and H37Ra infected MDMs. The anit-CD3 induced apoptosis in PPD pulsed Tcells showed further reduction with anti-CD28 antibodies. However, the modulation observed in B7.1 expression in infected MDMs was not reflected in T cell apoptosis in co-culture experiments. INTERPRETATION & CONCLUSION: Our results confirmed the role of B7.1 in rescuing the activated Tcells from undergoing apoptosis. During infection when the expression of B7.1 is downregulated, other co-stimulatory molecules may take over its crucial role to confer protective immune response against M. tuberculosis.