A Day Saved is a Life Saved: Direct Antimicrobial Susceptibility Testing from Positively Flagged Blood Culture Bottles and their Concordance with the Routine Method.

BACKGROUND: Sepsis is a major health problem worldwide and is associated with high morbidity and mortality with every hour delay in initiation of therapy. A conventional method of blood culture and Antimicrobial Susceptibility Testing (AST) takes around 48-72 hours. Empirical antibiotics need to be administered until the sensitivity report is made available. It has been estimated that 20-50% of the empirical antibiotics are inappropriate, resulting in prolonged hospital stays, adverse effects, and emergence of drug resistance. Additionally, this also puts an extra financial burden on both the patients and healthcare settings. Performing direct Antimicrobial Sensitivity Testing (dAST) is an important tool to reduce turn-around time (TAT) by at least 18-24 hours, thus reducing morbidity and mortality among critically ill patients. METHODS: Direct AST (dAST) was performed from the positively flagged blood culture bottles received between December, 2021 to May, 2022 from Intensive Care Units (ICUs) on MuellerHinton Agar (MHA) using four drops of withdrawn blood. dAST was performed for six drugs: Ceftriaxone-30 µg (CTR), Piperacillin/Tazobactam-100/10 µg (PIT), Meropenem-10 µg (MRP), Ciprofloxacin-5 µg (CIP), Aztreonam-30 µg (AT), and Colistin (CL). The zone of inhibition was interpreted as per CLSI M100 ed32, 2022 guidelines. A parallel conventional method was also performed to examine for categorical agreement and disagreement. Identification was carried out using MALDI-TOF MS from the colonies that appeared on the dAST plate on the subsequent day. RESULTS: A total of 162 positively flagged blood culture bottles were included in the study. The majority of the Gram-negative organisms were from Enterobacterales (n=109), followed by Acinetobacter spp. (n=28) and Pseudomonas aeruginosa (n=25). Out of the 972 isolate-antimicrobial combinations, overall Categorical Agreement (CA) was seen in 936 (96.3%), whereas disagreement was observed in 36 with minor error (mE) in 21 (2.2%), major error (ME) in 7 (0.7%), and very major error (VME) in 8 (0.8%) when compared to the routine method. Categorical agreement (CA) of > 99% was seen in ceftriaxone (CTR) and ciprofloxacin (CIP). In comparison, the lowest CA was observed with meropenem (MRP) at 92%. Colistin dAST was performed using the E-strip method, and the result obtained was highly convincing, with an overall disagreement of only 1.2%. CONCLUSION: Rapid dAST from positively flagged blood culture bottles proved to significantly reduce the TAT from the time of sample collection to the first availability of antimicrobial susceptibility report with excellent categorical agreement of > 95% using the conventional disc diffusion method. Results obtained were within the acceptance criteria set by U. S. Food and Drug Administration (FDA) guidelines of > 90% categorical agreement for a new method. We were able to obtain excellent concordance for colistin using the E-strip method. Performing dAST not only saves a "day", but its proper implementation would save a "life".

Clinical Features, Radiological Findings, and Treatment Outcomes in Patients with Pulmonary Nocardiosis: A Retrospective Analysis.

Introduction Lack of specific clinical features makes the diagnosis of pulmonary nocardiosis difficult. A high index of suspicion is required for diagnosis especially in cohorts with pre-existing risk factors. This study aimed to study the clinical and radiological characteristics and outcomes in patients with pulmonary nocardiosis. Methods This was a retrospective observational study. Data of confirmed cases with pulmonary nocardiosis were collected from a digital patient management system. Results A total of eight cases of pulmonary nocardiosis were included. The mean age of patients was 50 ± 14.3 years with a female preponderance (62.5%). The most common co-morbidity was chronic lung disease (37.5%). The common clinical feature of pulmonary nocardiosis was cough with expectoration (50%) and the mean duration of symptoms was 18 days. The common radiological (CT thorax) findings were consolidation, bronchiectasis, mediastinal lymphadenopathy, and nodularity (50% each). One patient had an extension of pulmonary disease in the chest wall. Microbiological detection of Nocardia spp. was done in sputum samples (50%) and in bronchoalveolar lavage (BAL) samples (50%). Culture was positive in two BAL samples. Intravenous empirical antibiotics in combination with oral trimethoprim-sulfamethoxazole double standard (15 mg/kg trimethoprim) were started at the time of diagnosis. Ceftriaxone and amikacin were commonly used antimicrobials. Conclusion Nocardia spp. commonly causes disease in patients with pre-existing chronic disease. A high index of suspicion is required in patients with subacute to chronic respiratory symptoms, raised inflammatory markers, and the absence of common respiratory pathogens in evaluation.

Primary pelvic echinococcosis though uncommon but not rare.

Echinococcosis is caused by larva of Echinococcus granulosus. Liver being most commonly involved, other organs/body parts such as bone involvement is not so uncommon, especially in cattle-raising countries such as India. Primary osseous echinococcosis remains undiagnosed until complications have developed. We report a case of complicated pelvic echinococcosis presented with left gluteal mass, acetabulum and femoral head destruction, and reduced hip mobility. Pre- and postoperative chemotherapy with albendazole and en bloc surgical removal of the cyst were advocated as the preferred option of treatment. Primary osseous echinococcosis must be kept in mind when encountering a case of chronic bony mass not responding to antitubercular therapy, and hydatid serology should be performed along with other imaging and histopathological examinations to support or confirm the diagnosis to prevent long-term complications.

West Nile Viral Meningoencephalitis in an Immunocompetent Female: A Case Report from Western Rajasthan, India.

BACKGROUND: West Nile virus (WNV) is a positive-sense single-stranded RNA virus of the family Flaviviridae and genus Flavivirus. The virus is transmitted primarily by the bite of Culex species mosquito and is of global concern. The infection is associated with a wide spectrum of signs and symptoms and is more fatal in the elderly, infants, and immunocompromised individuals. CASE PRESENTATION: We report a case of WNV meningoencephalitis in an immunocompetent female who presented with features of acute meningitis with a 5-days history. After the radiological suspicion of viral meningoencephalitis, viral serology was performed and was reactive for IgM antibody against WNV, delaying the diagnosis for at least 5 days. CONCLUSION: The purpose of this case report is to prime the treating physicians on the usefulness of viral serology in such a scenario. Viral serology is a simple and relatively rapid technique to diagnose or rule out the suspected viral cause of meningoencephalitis and minimize the time gap between diagnosis and start of supporting treatment wherever appropriate antivirals are not available for clinical use.

Antifungal profile of vulvovaginal candidiasis in sexually active females from a tertiary care hospital of Western Rajasthan.

INTRODUCTION: Vulvovaginal candidiasis (VVC) is the commonest form of sexually transmitted infection especially in sexually active females. Various species of Candida i.e., Candida albicans and non-albicans Candida are associated with VVC. More than 75% of women experiences vulvovaginal candidiasis at least once in their lifetime and 10% of it can lead to recurrent VVC. So, this study was planned to evaluate the clinico-mycological profile and antifungal profile of VVC in sexually active female attending tertiary care hospital. MATERIALS AND METHODS: The present two months study was conducted in sexually active females attending Obstetrics -gynecology OPD with VVC in tertiary care hospital. Two high vaginal swabs were taken and fungal culture was done on SDA agar by standard methods. Identification and antifungal susceptibility testing of candidial isolates were done by standard mycological methods. RESULTS: Most of the patients belonged to younger age group between 18 and 29 years (55%). Lower abdominal pain was the most common symptom after vaginal discharge followed by burning sensation and pruritis. Candida glabrata (15) with 58% of all the isolates was the most common Candida species associated with VVC in this study, followed by Candida albicans (5, 19%). Highest antifungal resistance was observed to itraconazole (81%) followed by amphotericin B (35%) and fluconazole (31%). 81% resistance to itraconazole among Candida glabrata and Candida albicans. Voriconazole was maximum susceptible to all Candida species. CONCLUSION: This study highlights the incidence of VVC among sexually active females of reproductive age group as its recurrence may result into obstetric complications and even infertility and also enlightens the common Candida species and their antifungal profile, which would help the treating clinicians to formulate local antifungal treatment policy for VVC.

Case Series and Mini-Review on Elizabethkingia meningoseptica, A high Alert Organism Causing Meningitis in Premature Neonates from A Tertiary Care Hospital of Western Rajasthan.

BACKGROUND: Elizabethkingia meningoseptica is a ubiquitous organism rarely associated with human diseases, but its association especially among hospitalized premature neonates and immunocompromised individuals are not so common. CASE: We report two cases of neonatal bacteraemia and meningitis among low birth weight premature neonates admitted in neonatal intensive care units (NICU) by E. meningoseptica, a high alert organism associated with such conditions. CONCLUSIONS: E. meningoseptica, a high alert organism associated with meningitis among premature underweight neonates. High degree of resistant to most of the broad-spectrum antibiotics makes its management a challenging task. A good communication between the clinician and the microbiologist becomes very important for the proper management of the patients.

Pulmonary Nocardiosis with Aspergillosis in a patient with COPD: A rare co-infection.

Pulmonary Nocardiosis and invasive Aspergillosis are well documented in immunocompromised patients. The coexistence of both infections is a diagnostic rarity, especially in patients with underlying structural lung diseases. We describe this rare association in a 46-year-old female with a history of pulmonary tuberculosis and COPD. The diagnosis of pulmonary Nocardiosis is challenging due to non-specific clinical features, inherent ability to mimic malignancy, tuberculosis and difficulty in the cultivation of the organism. The treating physicians should aware of the rare occurrence of such co-infections in order to prevent misdiagnosis and prompt treatment.

Simultaneous detection of IgM antibodies against dengue and chikungunya: Coinfection or cross-reactivity?

BACKGROUND: Dengue and chikungunya sharing same mosquito vector are two most important arboviruses circulating in northern India including Delhi and are responsible for frequent outbreaks. Antigen and antibodies detection ELISA kits are the major tool to diagnose these viral illnesses, and are sometimes associated with cross-reactivity, giving a false picture of coinfection, although simultaneous harboring of both the viruses is not uncommon. Various studies have reported coinfection up to 25% from the same region. PROCEDURE: This study was conducted in the Department of Microbiology, Maulana Azad Medical College, New Delhi, during the month of September 2016 which included 200 blood samples from clinically suspected cases attending Medicine OPD of associated Lok Nayak Hospital, New Delhi. Diagnosis of dengue and chikungunya was made using NS-1 antigen and IgM MAC ELISA for dengue and IgM MAC ELISA for chikungunya as per manufacturer's instructions. RESULTS: Out of 200 suspected cases, 34 (17%) were positive for dengue serology, 77 (38.5%) were positive for chikungunya serology, and 29.9% of positive chikungunya cases were simultaneously affected with dengue. This higher percentage of coinfection might be because of cross-reactivity of the ELISA kits. DISCUSSION: India being a hyperendemic region for dengue and chikungunya, frequent outbreaks are quite common. Circulation of both the virus and huge susceptible population are the major causes for frequent outbreaks. Restricting our attention to diagnose one of them is not sufficient, and coinfection further complicates the illness. CONCLUSION: Simultaneous diagnosis of dengue and chikungunya is need of time to diagnose dual infection and prevent complications by starting supportive treatment well in time. Molecular technique if ever possible should be employed whenever the coinfection number is higher than expected to rule out cross-reactivity.

Association of interleukin-2, -4 and -10 with dengue severity.

BACKGROUND: Dengue is an arboviral disease caused by four distinct serotypes of dengue virus. The pathogenesis of dengue is not very clearly understood. Various pro- and anti-inflammatory cytokines are involved in the immune pathogenesis of dengue. Interleukin (IL)-2/IL-2 receptor interaction is supposed to play a protective role, while IL-4 acts as pro-inflammatory whereas IL-10 acts as anti-inflammatory cytokines. So far, not much information is available regarding the established role of these cytokines with dengue infection and severity. AIMS: our study aimed to show the association of IL-2, -4, and -10 with severity of dengue infection. SETTINGS AND DESIGN: This was a cross-sectional study. MATERIALS AND METHODS: The study was conducted in the year 2015; 150 blood samples from suspected dengue cases were confirmed for dengue and then with an equal number of healthy control samples were tested for cytokines levels (IL-2, -4, and -10) by ELISA. Severity of the dengue infection was determined on the basis of clinical manifestations based on the WHO criteria. STATISTICAL ANALYSIS: for statistical analysis, SPSS version 21 (IBM, New York, United States) was used. RESULTS: Out of 150 samples, 56 samples came to be dengue positive. Thirty-eight (67.85%) cases were classified as nonsevere dengue and 18 (32.15%) were severe dengue. The serum levels of IL-4 and -10 were significantly raised in severe dengue cases as compared to nonsevere dengue cases. No significant association was observed between serum IL-2 levels and the severity of dengue. CONCLUSION: IL-4 and -10 levels can be used as marker of severe dengue and help in early preparedness to start the treatment in the line of severe dengue.

Dengue: Lessons of an Outbreak.

INTRODUCTION: Since 1967 there have been many outbreaks of dengue in Delhi. In the year 2015 Delhi has suffered it's one of the worst dengue outbreaks, with more than 15000 dengue confirmed cases and the highest number of deaths (60) in recent years. AIM: To determine the status of Dengue cases as compared to previous six years, the ratio of primary and secondary dengue cases and to review the effectiveness of the one test strategy (either NS1 antigen or IgM antibody) for the confirmation of Dengue. MATERIALS AND METHODS: A cross-sectional study was performed in the year 2015. A total of 7177 serum samples were tested for the confirmation of suspected cases of dengue at our institute. We performed dengue NS1 antigen and dengue IgM antibody ELISA tests for the confirmation of dengue cases in acute and convalescent fever cases respectively. Hundred random samples negative for NS1 antigen were tested for IgM antibody and 100 random samples negative for IgM antibody were tested for NS1 antigen. For determination of ratio of primary and secondary dengue cases, IgG Avidity ELISA was performed on random 76 dengue positive samples. RESULTS: Out of 7177 samples tested, 2358 were positive either by NS1 antigen or for IgM antibody from January to December. Percentage positivity rates for IgM antibody detection and NS1 antigen detection tests were 24.8% (626) and 37.1% (1732) respectively. Out of 100 NS1 negative samples 8 were positive for IgM antibody and out of 100 IgM negative samples 6 were positive for NS1 antigen. Among the 76 samples tested for dengue IgG Avidity ELISA 52 (68.4%) were found to be of secondary dengue. CONCLUSION: Number of dengue cases is constantly rising in Delhi since 2011 and 2014. IgM antibody detection and NS1 antigen detection both the tests should be performed for each patient. Due to the increased prevalence of past infection of dengue, percentage of secondary dengue cases is also increasing in Delhi.