Experience of Indian association of medical microbiology external quality assurance scheme centre, New Delhi: Challenges and quality assessment of clinical microbiology laboratories

Introduction: EQAS program at New Delhi under IAMM was started in January 2014 across North and North east regions of India with 217 participants, which grew up to 540 by 2018. Materials and Methods: In 2014, 4 analytes per year were sent for 3 exercises, i.e. smear culture and serology. 2018 onwards PT analytes were increased from 4 to 12 and comparative performance of techniques analysed. Results: Out of the 22 smears sent for gram staining, ZN staining, Kinyoun staining and Albert staining, completely correct results ranged between 29.55% - 79.9%, 94.3% - 99.2%, 35.5% & 93.8%, respectively. Correct results for culture isolate identification & susceptibility testing and serology exercises varied between 70 & 92.4% and 73.1 & 98.59%, respectively. In the year 2018, 470 responses were received for bacterial culture identification & antibiotic susceptibility testing out of which manual and automated systems were used by 54% & 46% and 52.5% & 47.5% participants, respectively. Techniques used in BBV assays for HBsAg, HCV & HIV found all methods like ELISA, ELFA, CLIA and Card Test performing similarly. The major challenges in running the EQA program included requirement of large amount of specimens for PT item preparation, stability in hot and humid conditions and timely delivery of PT challenges in remote parts of the country. Conclusion: A large number of the participating laboratories (77%) had an overall score of >80% for all exercises, demonstrating acceptable baseline performance of EQAS registered laboratories. However, continued EQAS participation could further improve the quality of results.

Utility of GenoType MTBDRplus assay in rapid diagnosis of multidrug resistant tuberculosis at a tertiary care centre in India.

Purpose: Molecular methods which allow rapid detection of tuberculosis as well as drug resistance directly from clinical samples have become the most popular diagnostic methodology with the emergence of multidrug resistant tuberculosis. The aim of the present study was to evaluate the performance of a line probe assay, GenoType MTBDRplus for the rapid detection of Mycobacterium tuberculosis and mutations causing rifampicin and INH resistance directly in smear positive pulmonary specimens and also in M. tuberculosis isolates grown from various clinical specimens. Materials and Methods: The MTBDRplus assay was done directly on 37 smear positive pulmonary specimens and also on 69 M. tuberculosis isolates obtained by rapid automated culture using Bact/Alert 3D. The results were compared with phenotypic drug susceptibility testing (1% proportion method) using Bact/Alert 3D. Results: The sensitivity and specificity for detection of resistance to rifampicin was 100% and 97.3%, and to INH was 91.9% and 98.4%, respectively, in comparison with the phenotypic drug susceptibility testing. Conclusion : MTBDRplus assay had good sensitivity and specificity with turn around time of less than 48 hours. It may be a useful tool for rapid detection of multidrug resistant tuberculosis at a tertiary care centre.

Alpha-adrenergic receptor blocking effect of Cleistanthus collinus (Roxb.) Benth. and Hook f. leaf extract on guinea pig isolated smooth muscle preparations.

Aqueous extract of C. collinus leaves inhibited norepinephrine induced contraction in guinea pig vas deferens and aortic strip in a dose-dependent manner. Inhibition of acetylcholine induced contraction in ileum was dose independent. C. collinus extract per se had no effect on isolated guinea pig vas deferens and aortic strip, but inhibited norepinephrine induced contraction in a dose-dependent manner probably by its antagonist action on α-adrenergic receptor. It had inconsistent effect on guinea pig ileum in vitro preparation.

Role of melatonin against oxidative tissue damage induced by Cleistanthus collinus in rat brain.

Background & objectives: The leaves of Cleistanthus collinus, an extremely poisonous plant are consumed for suicidal purposes in various parts of India. The mortality rate is high and there is no antidote. In this study, we attempted to delineate oxidative stress as a possible mechanism of action of C. collinus toxicity in rats and the role of melatonin against injury to brain and heart caused by C. collinus. Methods: Adult Wistar rats (130 -200 g, n = 6 per group) of either sex were used. C. collinus at 8 mg/kg body weight (LD50) was administered orally followed by melatonin 15 mg/kg body weight ip or cysteine 500 mg/kg body weight ip (standard) after 2 h. Malondialdehyde (MDA), reduced glutathione (GSH), glutathione peroxidase and catalase levels in brain, heart and blood were estimated and histopathological examinations (brain and heart) were done. For the survival study, rats were treated with increasing doses of melatonin (5, 10 and 15 mg/kg body weight ip) following a lethal dose of C. collinus (10.5 g/kg body weight orally). Results: The results showed a significant (P<0.05) increase in blood and brain MDA levels and decrease in tissue GSH in the LD50 group. This was accompanied by marked gliosis, spongiform necrosis and lymphocytic inflammatory infiltrates in brain and marked congestion, inflammation and muscle necrosis in heart. Melatonin significantly (P<0.05) reduced lipid peroxidation and reversed the histopathological changes induced by C. collinus in the brain but not in the heart. Interpretation & conclusion: Our results suggest that oxidative mechanisms play an important role in C. collinus induced tissue damage and melatonin, by balancing oxidant-antioxidant status ameliorates oxidative organ injury in brain due to C. collinus toxicity.

High level ciprofloxacin resistance in Salmonella enterica isolated from blood.

PURPOSE: Over the last few years, resistance to ciprofloxacin in Salmonella enterica has become a global concern. The present study was undertaken to find out the susceptibility pattern of Salmonella enterica isolates in our hospital. METHODS: Blood cultures were done using BacT/ALERT 3D system. The antimicrobial susceptibility testing was carried out by the Kirby-Bauer disc diffusion method using CLSI breakpoints. Minimum inhibitory concentration was determined for ciprofloxacin-resistant strains using E-test and Vitek-1 automated system. RESULTS: A total of 25,953 samples of blood culture yielded 431 Salmonella enterica serotype Typhi and 198 serotype Paratyphi A isolates. Twenty-two isolates of serotype Typhi were resistant to ciprofloxacin, while two isolates of Typhi and two Paratyphi A were intermediately susceptible to ciprofloxacin. Ciprofloxacin resistance is 5.6% (24 isolates) among Salmonella enterica serotype Typhi. Ampicillin, chloramphenicol and co-trimoxazole resistance in Salmonella enterica serotype Typhi appears to have decreased to 14.9% (64/431) in comparison to the 27% (55/205) during 2003. All isolates were sensitive to ceftriaxone. CONCLUSIONS: Ciprofloxacin can no longer be considered as the drug of choice in treating Salmonella infections. While first-line antimicrobials may still have a role to play in the treatment of enteric fever, ceftriaxone remains the sole defence against ciprofloxacin-resistant Salmonella infections.

Vertical transmission of Salmonella paratyphi A.

Neonatal enteric fever is a rare but life-threatening illness. Patients may present with varying severity, Salmonella enterica serotype Typhi causing more severe illness than Salmonella enterica serotype Paratyphi A. Salmonella enterica serotype Paratyphi A is considered to cause milder infection with fewer complications. We report a rare case of vertical transmission of Salmonella enterica serotype Paratyphi A with severe complications and high mortality. Even though there are case reports of vertical transmission of Salmonella enterica serotype Typhi, to our knowledge, this is the first case report of vertical transmission of Salmonella enterica serotype ParatyphiA. The role of blood culture in accurate diagnosis and treatment is also discussed.

Treatment of anal fissures using a combination of minoxidil and lignocaine: a randomized, double-blind trial.

AIM : Anal fissures are associated with hypertonia of the internal anal sphincter and pain. We evaluated the efficacy of local application of a combination of minoxidil and lignocaine in healing anal fissures. METHODS: In this prospective, randomized, double-blind study, 90 patients with anal fissure were recruited. Patients received local applications of ointments containing 5% lignocaine (n=28), 0.5% minoxidil (n=36), or both (n=26). Healing of anal fissure at 6 weeks was used as the primary end-point. RESULTS: Rates of complete healing of fissure were similar in the three groups (lignocaine alone 8/27, minoxidil alone 10/34, combination 7/22; p=ns). Mean (SD) time taken for complete healing with combination treatment [1.9 (0.6) weeks] was significantly shorter than that with minoxidil alone (3.1 [1.7] weeks; p=0.001) or with lignocaine alone (3.3 [0.8] weeks; p=0.002). Rates of pain relief were similar in the three groups. Stoppage of bleeding occurred more often with combination treatment than with lignocaine alone. No patient had systemic or local side effects. CONCLUSION: Combination treatment with minoxidil and lignocaine helps in faster healing of anal fissures and provides better symptomatic relief than either drug alone.

A clinical and laboratory profile of Cleistanthus collinus poisoning.

AIMS: 1. To study the clinical features in patients with Cleistanthus collinus poisoning, 2.To study in them the effect of Cleistanthus collinus poisoning on the various organ systems and metabolic parameters using standard laboratory investigations. METHODS: All patients admitted to the hospital between September 1998 and April 2000 were studied. Statistical analysis of the results was done using chi-square test, Fisher's exact test and Student's 't' test. RESULTS: Forty six cases were studied, 15 (32%) of whom died. Eighty percent of the patients were in the second to third decade. The female:male ratio was 3:2. Ingestion of the poison as a decoction prepared from the leaves and ingestion of a large number of leaves otherwise were associated with a poor outcome. While survivors remained relatively asymptomatic, fatally poisoned patients presented with significant clinical signs and symptoms, however, laboratory abnormalities such as hypokalaemia, hyponatremia, an elevated AST/LDH/CPK/CPK-MB, nonspecific ST-T changes and QTc prolongation on ECG, metabolic acidosis and hypoxia with widened alveolar-arterial oxygen difference (A-aDO2) were seen in both groups. CONCLUSION: It is a poisoning seen in the young with significant mortality. Cause of death appears to be mainly due to its cardiac and respiratory effects. Metabolic disturbances especially hypokalaemia was a prominent feature. Most deaths occurred on the 3rd day and all within a week. No specific antidote is available.

Recruitment of subjects for clinical trials after informed consent: does gender and educational status make a difference?

CONTEXT: Researchers and investigators have argued that getting fully informed written consent may not be possible in the developing countries where illiteracy is widespread. AIMS: To determine the percentage of patients who agree to participate in a trial after receiving either complete or partial information regarding a trial and to find out whether there were gender or educational status-related differences. To assess reasons for consenting or refusing and their depth of understanding of informed consent. SETTINGS AND DESIGN: A simulated clinical trial in two tertiary health care facilities on in-patients. METHODS AND MATERIAL: An informed consent form for a mock clinical trial of a drug was prepared. The detailed / partial procedure was explained to a purposive sample of selected in-patients and their consent was asked for. Patients were asked to free list the reasons for giving or withholding consent. Their depth of understanding was assessed using a questionnaire. Chi-square test was used for statistical analyses. RESULTS: The percentages of those consenting after full disclosure 29/102 (30%) and after partial disclosure 15/50 (30%) were the same. There was a significant (p=0.043) gender difference with a lesser percentage of females (30%) consenting to participation in a trial. Educational status did not alter this percentage. Most patients withheld consent because they did not want to give blood or take a new drug. Understanding of informed consent was poor in those who consented. CONCLUSIONS: The fact that only one-third of subjects are likely to give consent to participate in a trial needs to be considered while planning clinical trials with a large sample size. Gender but not educational status influences the number of subjects consenting for a study. Poor understanding of the elements of informed consent in patients necessitates evolving better methods of implementing consent procedures in India.

Objective structured practical examination in pharmacology for medical laboratory technicians.

The objective structured practical examination (OSPE) is a useful evaluation method for testing psychomotor skills. Students for the degree in medical laboratory technology require to learn certain skills which will make them useful in any research or teaching laboratory in experimental pharmacology. We outline an OSPE which can be used for evaluating students in experimental pharmacology.

A computer program for calculation of sample size.

Sample size must be determined while planning a study to ensure that valid conclusions can be drawn when the study is over. different formulae for calculating the required size of the sample are used for different study designs and situations. A computer program is described here to ease the complexity of calculation of sample size for studies designed to use students 't' test.

Ascorbic acid delays the development of tolerance to amphetamine induced anorexia but does not affect the reverse tolerance which develops to the locomotor activity.

Ascorbic acid (1 g/kg) accentuated anorectic and locomotor effects of amphetamine (5 mg/kg) and delayed development of tolerance to anorectic effect. On the contrary, it did not alter the pattern of reverse tolerance to increased locomotor activity. The results suggest that modulation of dopamine receptor sensitivity by ascorbic acid may be the reason for the delay in development of tolerance to amphetamine induced anorexia.

Short term anti-tubercular drug therapy and hepatic microsomal enzyme activity. Antipyrine metabolism as an index.

The effect of short course chemotherapy on the drug metabolising capacity of the liver was studied in 7 newly diagnosed pulmonary tuberculosis patients, using antipyrine as a model drug. Antipyrine elimination half-life and plasma clearance rate were not significantly altered by 3 weeks of therapy. It is concluded that short course chemotherapy does not affect antipyrine metabolising enzyme activity.

Ampicillin pharmacokinetics in Indian geriatric subjects.

Ampicillin elimination was studied in geriatric and younger subjects, 10 in each group. The geriatric subjects had higher serum concentration and elimination half-life of the drug. The plasma clearance and urinary excretion of the drug were significantly reduced in them when compared to younger subjects. Urinary excretion of the drug had significant correlation with creatinine clearance of the subjects.