Coagulase‑negative staphylococci causing blood stream infection at an Indian tertiary care hospital: Prevalence, antimicrobial resistance and molecular characterisation.

Introduction: Recent years have seen a rise of coagulase‑negative staphylococci (CoNS) from common contaminants to agents of nosocomial blood stream infections (BSI’s). Molecular typing and establishing a correlation with antibiotic resistance is essential particularly in countries like India where genotyping studies for drug‑resistant CoNS are sparse. Methods: A prospective study was done over 18 months, wherein 42,693 blood samples were received, and 59 patients with BSI due to CoNS were evaluated. The isolates recovered were identified by a biochemical test panel and matrix‑assisted laser desorption ionization – time of flight mass spectrometry followed by antimicrobial susceptibility testing by Kirby–Baur disc diffusion method and E‑test strips. Staphylococcal chromosomal cassette mec (SCCmec) element was characterised by multiplex polymerase chain reaction for all methicillin‑resistant (MR) isolates. Results: The majority of CoNS isolated were constituted by Staphylococcus haemolyticus (47.5%) followed by Staphylococcus epidermidis (33.9%), Staphylococcus hominis (11.86%), Staphylococcus cohnii (5.08%) and Staphylococcus warneri (1.69%). Among all isolates 57.6% were MR with statistically significant higher resistance versus methicillin sensitive‑CoNS. This difference was significant for erythromycin (76% vs. 44%, P = 0.011), rifampicin (50% vs. 12%, P = 0.002) and amikacin (26.5% vs. 4%, P = 0.023), ciprofloxacin (64.7% vs. 20%, P = 0.001) and cotrimoxazole (55.9% vs. 20%, P = 0.006). SCCmec type I was predominant (61.8%, P = 0.028) and exhibited multidrug resistance (76.2%). Coexistence of SCCmec type I and III was seen in 8.82% MR isolates. Conclusion: CoNS exhibit high antimicrobial resistance thereby limiting treatment options. The presence of new variants of SCCmec type in hospital‑acquired CoNS may predict the antibiotic resistance pattern. This is the first evaluation of the molecular epidemiology of CoNS causing BSI from India and can serve as a guide in the formulation of hospital infection control and treatment guidelines.

Neuronavigation in a developing country: A pilot study of efficacy and limitations in intracranial surgery.

CONTEXT: Neuronavigation provides a patient-specific, three-dimensional (3-D) anatomy for preoperative planning and intraoperative navigation. However, the initial and maintenance costs are quite prohibitive, especially in the Indian scenario. AIMS: To study the efficacy and limitations of neuronavigation, especially in the Indian scenario. SETTINGS AND DESIGN: A prospective nonrandomized study. MATERIALS AND METHODS: A total of 121 patients underwent intracranial surgery from 2002-2006, in which neuronavigation was used. In this, the initial part, we studied the efficacy and limitations of neuronavigation in the initial 37 patients. The efficacy of the image guidance was graded according to a point's scale in which points were awarded ranging from 0 to 3. Cranial image guided score (IGS) was calculated by the summation of grading during designing the flap/burr hole, delineation of the intraoperative anatomy, navigation and access to the lesion and resection / biopsy of the lesion or completion of the procedure. The scoring ranged from 0-12 and the utility of IGS in cranial neurosurgical procedures was calculated based on the total points for each surgery. RESULTS AND CONCLUSION: Cranial image guidance was useful in a variety of operative steps. Intraoperative approach and navigation was relatively easier with an increase in perception of safety. Limitations of IGS include learning curve, cost and the phenomenon of brain shift. Drawbacks of the study included that this was a subjective rather than a truly objective study and the relatively lesser number of patients. We hope to conduct a larger study with randomization but the question of ethical approval would be a primary concern.

Spontaneous subdural empyema in falciparum malaria: a case study.

CLINICAL HISTORY: Malaria is one of the most common diseases in the tropical countries. Cerebral malaria is usually a diffuse symmetric encephalopathy with focal signs being unusual. METHODS : We present a three-year old girl lapsing into unconsciousness following a seizure while undergoing treatment for malaria. Imaging revealed a large heterogenous density, left hemispheric acute subdural haematoma with brain herniation. Investigations revealed anaemia, thrombocytopenia and positive peripheral blood smear for falciparum malaria. RESULTS: Treatment involved surgical evacuation of the clot and the associated subdural empyema, intravenous quinine and antibiotics. CONCLUSION: This is the second case report of spontaneous subdural empyema in complicated falciparum malaria and highlights a rare but surgically manageable complication.

Brain abscess--an unusual complication of ventriculo-peritoneal shunt.

The authors report a case of a 10-year-old boy, who was operated for a craniopharyngioma with hydrocephalus. He succumbed to delayed development of brain abscess and its consequence, secondary to incompletely treated shunt tract infection. This unfortunate complication developed, despite the fact that conventional steps (removal of VP shunt and intravenous antibiotics) recommended for the treatment of VP shunt infection were adopted. The pathogenesis, management and review of literature of this extremely rare clinical entity is presented.

Giant vertebrobasilar junction aneurysms: unusual cases.

Giant vertebrobasilar (VB) junction aneurysms are uncommon aneurysms, especially those associated with multiple aneurysms of the posterior circulation. We report two cases, one with a small and a giant aneurysm of the VB junction which were surgically clipped; and the other with a small left anterior inferior cerebellar artery (AICA) aneurysm which resolved spontaneously. The patient, however, developed a de-novo giant VB junction aneurysm, which was detected on a follow-up angiogram. This aneurysm was treated by surgical clipping. The clinical features, angiographic considerations and surgical treatment of such rare conditions are discussed and the relevant literature reviewed.

Subarachnoid hemorrhage and intracereebral hematoma following lumboperitoneal shunt for pseudotumor cerebri: a rare complication.

Placement of lumboperitoneal (LP) shunt as a surgical treatment for benign intracranial hypertension (BIH) is generally a safe procedure, with complications like mechanical failure, overdrainage and infections. Subarachnoid hemorrhage and intracerebral hematoma were seen after lumboperitoneal shunt in a patient having BIH. These complications were the cause of the patient's deterioration. After removal of the hematoma and performing a decompressive procedure, patient's neurological condition improved. The clinical features, investigations and clinical course are described and the literature reviewed.

Microneural anastomosis with fibrin glue: an experimental study.

An experimental study was designed to compare the histological analysis of nerve anastomosis with 10-0 microsurgical sutures and fibrin adhesive. Wistar albino rats' sciatic nerves were transected and repaired either with fibrin adhesive-Beriplast P (M/s Centeon-Cadila Health Care) or with 10-0 monofilament microsutures. Histological assessment was performed at 10, 20, 30, 60 and 90 days after surgery. Functional recovery of the sciatic nerves started at two months and was near normal by three months. Separation of the stumps did not occur in any of the glued nerves. Histological evaluation showed no appreciable difference in the outcome of nerve regeneration after microsurgical repair using sutures or fibrin tissue adhesive. However, inflammation and granuloma formation were appreciated at the suture site, which presented a focal hindrance to myelin and axonal regeneration. Fibrin glueing is attractive for clinical purposes, since it is simpler and less time consuming than suturing.

Acinetobacter infection in neurosurgical intensive care patients.

BACKGROUND: This study was performed to analyse the incidence of Acinetobacter infections in neurosurgical patients in the postoperative period. METHODS: Two thousand three hundred and twenty postoperative cranial neurosurgical intensive care unit (ICU) patients were studied from March 1995 to August 1996; 419 patients had a variety of infections and 42 patients had multiple infections. Acinetobacter was isolated in 103 patients (24.6% of total patients infected and 4.4% of total patients analysed). Statistical analyses were performed to identify the risk factors, antibiotic sensitivity and outcome of therapy of Acinetobacter infection. RESULTS: Acinetobacter infection was not significantly related to the length of hospital stay prior to surgery but was related significantly to the length of stay in the ICU after surgery. Acinetobacter was isolated from sputum/tracheal secretions in 47/103 (45.6%), followed by cerebrospinal fluid [24/103 (23.3%)], urine [15/103 (14.56%)] and blood [15/103 (11.65%)]. Acinetobacter infection was present in 54 (3.21%) of 1680 patients who had undergone routine/elective surgery and in 49 (7.66%) of 640 patients following emergency surgery. Elective/supportive ventilation for > 5 days, external ventricular cerebrospinal fluid drainage for > 5 days, intracranial pressure monitoring and prolonged indwelling Foley's urinary catheter during the perioperative period were independent risk factors (p < 0.005). Acinetobacter isolated from sputum/tracheal secretions were mostly sensitive to amikacin, cefotaxime and ceftriaxone; while those grown from the cerebrospinal fluid were more often sensitive to ciprofloxacin, amikacin and netilmycin. Twenty-four patients succumbed to Acinetobacter infection; in 11 of these patients the organism was resistant to all antibiotics. CONCLUSION: Acinetobacter is an important nosocomial infection in neurosurgical intensive care patients.

Etiology of isolated mitral regurgitation: a clinico-echocardiographic study.

One hundred and ninety two consecutive patients with isolated mitral regurgitation (MR) with an audible murmur were studied for determination of etiology. There were 95 males & 97 females (mean age 24.5 +/- 10.8 years; range 13 to 58 years) with 102 patients in NYHA classes I and II, 81 in class III and 9 in NYHA class IV. The etiological grouping was: rheumatic 74 (38.5%), probable rheumatic 28 (15%), mitral valve prolapse 26 (13.5%), dilated cardiomyopathy 15 (8%), infective endocarditis 12 (6%), isochaemic heart disease 10 (5%), miscellaneous group (including rupture chordae tendinae, aortoarteritis etc) 9 (4.5%) and patients with indeterminate etiology 18 (9.5%). Etiology could be determined in 174 out of 192 cases. The clinical methods combined with echocardiography were helpful in 79 cases while echocardiography alone could diagnose etiology in 89 cases. Clinical features alone gave the diagnosis in 6 patients. The findings of gross morphology of the surgically removed mitral valves in 30 patients of this study were similar to their pre-operative etiologic diagnosis based on clinical and echocardiographic features. These findings may be of value in planning treatment and prophylactic strategies in cases of isolated MR.