Rheumatic heart disease: progress and challenges in India.

Rheumatic heart disease, a neglected disease, continues to be a burden in India and other developing countries. It is a result of an autoimmune sequalae in response to group A beta hemolytic streptococcus (GAS) infection of the pharynx. Acute rheumatic fever (RF), a multisystem inflammatory disease, is followed by rheumatic heart disease (RHD) and has manifestations of joints, skin and central nervous system involvement. A review of epidemiological studies indicates unchanged GAS pharyngitis and carrier rates in India. The apparent decline in RHD rates in India as indicated by the epidemiological studies has to be taken with caution as methodological differences exist among studies. Use of echocardiography increases case detection rates of RHD in population surveys. However, the significance of echo based diagnosis of carditis needs further evaluation to establish the significance. Research in this area through prospective follow up studies will have to be undertaken by the developing countries as the interest of developed countries in the disease has waned due the declined burden in their populations. Prevention of RHD is possible through treatment of GAS pharyngitis (primary prophylaxis) and continued antibiotic treatment for number of years in patients with history of RF to prevent recurrences (secondary prophylaxis). The cost effectiveness and practicality of secondary prophylaxis is well documented. The challenge to any secondary prophylaxis program for prevention of RF in India will be the availability of benzathine penicillin G and dissipation of fears of allergic reactions to penicillin among practitioners, general public and policy makers. The authors review here the progress and challenges in epidemiology, diagnosis and primary and secondary prevention of RF and RHD.

Association between neuropsychiatric morbidity and streptococcal infections in children.

We conducted a case control study to study the association between neuropsychiatric morbidity and group A streptococcal infections in children. Twenty two cases of neuropsychiatric morbidity were compared with 64 controls. Fourteen (63.6%) of the 22 cases were positive for ASO and/or ADNB while 21 of the 64 controls (32.8%) were positive for either or both antibodies (OR = 3.428; CI: 1.15-10.18; P=0.026). We conclude that there is a statistically significant association between neuropsychiatric morbidity and streptococcal infection in children.

Needle stick injuries in a tertiary care hospital.

BACKGROUND: Accidental needle stick injuries (NSIs) are an occupational hazard for healthcare workers (HCWs). A recent increase in NSIs in a tertiary care hospital lead to a 1-year review of the pattern of injuries, with a view to determine risk factors for injury and potential interventions for prevention. METHODS: We reviewed 1-year (July 2006-June 2007) of ongoing surveillance of NSIs. RESULTS: The 296 HCWs reporting NSIs were 84 (28.4%) nurses, 27 (9.1%) nursing interns, 45 (21.6%) cleaning staff, 64 (21.6%) doctors, 47 (15.9%) medical interns and 24 (8.1%) technicians. Among the staff who had NSIs, 147 (49.7%) had a work experience of less than 1 year (n = 230, 77.7%). In 73 (24.6%) of the NSIs, the patient source was unknown. Recapping of needles caused 25 (8.5%) and other improper disposal of the sharps resulted in 55 (18.6%) of the NSIs. Immediate post-exposure prophylaxis for HCWs who reported injuries was provided. Subsequent 6-month follow-up for human immunodeficiency virus showed zero seroconversion. CONCLUSION: Improved education, prevention and reporting strategies and emphasis on appropriate disposal are needed to increase occupational safety for HCWs.

Role of quantitative endotracheal aspirate and cultures as a surveillance and diagnostic tool for ventilator associated pneumonia: a pilot study.

BACKGROUND: Accurate diagnosis and appropriate treatment of ventilator associated pneumonia (VAP) is crucial for good outcomes. Endotracheal suctioning is performed in ventilated patients as part of routine care and for tracheal toileting. AIM: We evaluated if quantitative endotracheal aspirate (ETA) was a suitable alternative to bronchoalveolar lavage (BAL) for suspected VAP. In addition we assessed if surveillance ETA guided antibiotic selection for subsequent VAP. SETTING AND DESIGN: Prospective study in the surgical intensive care unit (ICU) of a tertiary hospital in India. MATERIALS AND METHODS: Two hundred consecutive patients with mean (standard deviation) APACHE II score of 12.3+/-5 and requiring mechanical ventilation beyond 48 hours underwent surveillance ETA cultures. A second ETA and BAL were performed if the patient developed features of VAP. The threshold for microbiological diagnosis of VAP was taken as 10 5 colony forming units/ml (cfu/ml) for ETA and 10 4 cfu/ml for BAL. STATISTICAL ANALYSIS: The sensitivity and specificity of surveillance and concurrent ETA aspirate cultures were compared with BAL cultures. RESULTS: VAP was suspected clinically and corroborated radiologically in 27/177 patients (15.3%). Although microbiological support for VAP was obtained by ETA in 19 patients, bronchoscopy was possible only in 13 patients, 8 of whom had isolates at significant threshold. Of the 16 organisms isolated from BAL, 11 were of significant threshold with 9/11 (82%) BAL isolates having a similar antibiogram to a concurrent ETA. Only one BAL isolate (9%), at significant threshold, was not isolated on a concurrent ETA. On the other hand just 6/11 BAL isolates (55%) had an identical antibiogram to surveillance ETA. BAL had 3 additional isolates (27%) at significant threshold not isolated on surveillance ETA. CONCLUSIONS: Concurrent quantitative ETA could substitute BAL cultures for VAP. Surveillance ETA at 48 hours of ventilation does not appear to assist with antibiotic selection for a subsequent VAP.

Prevalence of inducible clindamycin resistance in gram positive organisms in a tertiary care centre.

Gram positive organisms are one of the leading pathogens causing skin and soft tissue infections. For these infections, clindamycin is a useful alternate drug in penicillin-allergic patients. This study was conducted to investigate the prevalence of erythromycin-induced clindamycin resistance in gram positive organisms in the southern part of the country. A total of 522 consecutive clinical isolates from blood, CSF, sputum, throat, pus, and urine were collected between November 2006 and April 2007 and tested for erythromycin resistance and inducible clindamycin resistance. There was a relatively higher incidence of inducible clindamycin resistance among the MRSA isolates. We conclude, therefore, that clindamycin is not a suitable alternative antibiotic for use in staphylococcal skin and soft tissue infections.

Pyopericardium due to group D streptococcus.

Beta-hemolytic Enterococcus faecalis was isolated from the pericardial fluid obtained from a patient with pyopericardium. The patient was immunocompetent and had mild pleural effusion. He was treated with parenteral co-amoxiclav and amikacin, had underwent pericardiectomy with repeated pericardial aspiration, and recovered completely. To our knowledge, this is the first report of pyopericardium due to E. faecalis .

One year trends in the gram-negative bacterial antibiotic susceptibility patterns in a medical intensive care unit in South India.

PURPOSE: To describe the changes in antibiotic susceptibility patterns of common intensive care unit pathogens with time from the medical intensive care unit of a tertiary care hospital. METHODS: A prospective observational study was conducted in the medical intensive care unit (MICU) of a 2100 bed tertiary care hospital in South India. All data regarding patient characteristics, disease characteristics, infective agents, identified along with their antibiotic sensitivity patterns and patient outcomes were prospectively recorded in MICU data base. Various bacterial pathogen antibiotic sensitivity patterns from August 2004 to May 2005 were prospectively documented. During this period 491 patients were admitted to the MICU. Data were analyzed using excel spreadsheets. RESULTS: Ceftazidime resistance reduced in Klebsiella spp. while cefotaxime resistance increased. In E. coli however, ceftazidime and cefotaxime resistance increased. Klebsiella resistance to cefotaxime and ceftazidime ranged from 25-50% and 14-91%, while E. coli resistance to these antibiotics ranged from 50-70% and 50 to 80% respectively. In Pseudomonas and the non-fermenting gram-negative bacteria (NFGNB) ceftazidime resistance decreased. Third generation cephalosporin resistance seemed to be reducing in the NFGNB, however, carbapenem resistance appeared to be increasing, possibly due to their increasing use. CONCLUSIONS: This study demonstrates the trend in antibiotic susceptibility pattern (AST) of common gram negative infections seen in intensive care units. It demonstrates the changes seen especially after a change in the protocol antibiotic. Changes in the AST patterns of Klebsiella, E. coli, Pseudomonas and non-fermenting gram negative bacteria were seen. The data on the changing antibiotic susceptibility trends we believe is an important pillar in our efforts at infection control especially in intensive care settings.

Microbiological diagnosis of streptococcal pharyngitis: lacunae and their implications.

Post-streptococcal sequelae, especially acute rheumatic fever/rheumatic heart disease continue to occur in significant proportions in many parts of the world. Despite several attempts with various intervention strategies, little success has been achieved in the control of acute rheumatic fever/rheumatic heart disease in India. The success of the control programmes depends upon timely primary prophylaxis with benzathine penicillin for which a microbiological confirmation of group A streptococcal pharyngitis is essential. Isolation of beta hemolytic streptococci from throat cultures and their identification as GAS in the laboratory, clinches the microbiological diagnosis while demonstration of a 'significant rise' in antibody titers such as Anti-streptolysin O and Anti-deoxyribonuclease B differentiates it from a group A streptococcal carrier state or pharyngitis of a viral etiology. Despite the easiness with which these can be achieved, many laboratories in India are not equipped to do so. Enhancing bacteriological and serological facilities in laboratories across the country will drastically improve the clinician's ability to diagnose bona fide GAS pharyngitis and help to institute penicillin prophylaxis at the appropriate time. This will go a long way in enhancing the compliance to penicillin prophylaxis which is the cornerstone of any RF/RHD control program.

Evaluation of simplified DNA extraction methods for emm typing of group A streptococci.

Simplified methods of DNA extraction for amplification and sequencing for emm typing of group A streptococci (GAS) can save valuable time and cost in resource crunch situations. To evaluate this, we compared two methods of DNA extraction directly from colonies with the standard CDC cell lysate method for emm typing of 50 GAS strains isolated from children with pharyngitis and impetigo. For this, GAS colonies were transferred into two sets of PCR tubes. One set was preheated at 94 degrees C for two minutes in the thermal cycler and cooled while the other set was frozen overnight at -20 degrees C and then thawed before adding the PCR mix. For the cell lysate method, cells were treated with mutanolysin and hyaluronidase before heating at 100 degrees C for 10 minutes and cooling immediately as recommended in the CDC method. All 50 strains could be typed by sequencing the hyper variable region of the emm gene after amplification. The quality of sequences and the emm types identified were also identical. Our study shows that the two simplified DNA extraction methods directly from colonies can conveniently be used for typing a large number of GAS strains easily in relatively short time.

Outcome of bacterial culture from mastoid granulations: is it relevant in chronic ear disease?

OBJECTIVE: To detect the presence of bacteria in mastoid granulations and compare its prevalence in both types of chronic suppurative otitis media (CSOM). To find out if stage of disease activity, age, duration of disease, and aditus patency relate to obtaining positive cultures. STUDY DESIGN AND SETTING: A prospective, parallel group study done at a tertiary care referral centre. Mastoid granulations from 79 patients with CSOM undergoing mastoidectomy were processed for anaerobic and aerobic bacteria. RESULTS: Aerobes were isolated from 57.55 per cent of the tubotympanic and 74.4 per cent of atticoantral disease (p=0.18). Anaerobic cultures were positive in one case from each group. Monomicrobial growth was detected in 37.5 per cent of tubotympanic and 48.5 per cent of atticoantral disease. Polymicrobial growth occurred in 20 per cent and 25.6 per cent in the tubotympanic and atticoantral groups, respectively. The predominant aerobic isolate was coagulase negative Staphylococcus, followed by Pseudomonas aeruginosa, Staphylococcus aureus, non-fermenting Gram-negative bacteria, Enterobacter and Enterococcus, Proteus species, Citrobacter, non-pathogenic Neisseria, aerobic spore formers were grown only in atticoantral disease. A single isolate of Aspergillus was grown. Correlating the state of disease activity of the ears with positive mastoid granulation cultures, six out of the eight inactive ears were culture positive along with seven out of the nine active and 10 out of the 23 quiescent ears. Positive mastoid granulation cultures were obtained in 60 per cent of those with blocked aditus and 42.9 per cent with patent aditus. CONCLUSION AND SIGNIFICANCE: In this study, we found that mastoid granulations are not sterile but harbour polymicrobial pathogens. Positive cultures were obtained irrespective of stage of disease activity, age, duration of disease and aditus patency. The pattern of organisms cultured from safe and unsafe CSOM and also from ears in active, quiescent and inactive stages, were similar. These findings suggest that these organisms may be responsible for mastoid granulations. We also noted that positive cultures had no statistical correlation with aditus patency and duration of disease. We suggest further studies to evaluate the significance of asymptomatic mastoid granulations harbouring organisms and whether opening the mastoid antrum and achieving aditus patency, irrespective of the stage of disease activity, will help improve the long-term surgical outcome and also prevent recurrence of ear discharge.

Incidence of carbapenem resistant nonfermenting gram negative bacilli from patients with respiratory infections in the intensive care units.

Resistance to carbapenems is commonly seen in nonfermenting gram negative bacilli (NFGNB). We document herein the prevalence of carbapenem resistance in NFGNB isolated from patients with respiratory tract infections in the intensive care units (ICUs). A total of 460 NFGNB were isolated from 606 endotracheal aspirate specimens during January through December 2003, of which 56 (12.2%) were found to be resistant to imipenem and meropenem. Of these, 24 (42.8%) were Pseudomonas aeruginosa , 8 (14.2%) were Acinetobacter spp. and 24 (42.8%) were other NFGNB. Stringent protocols such as antibiotic policies and resistance surveillance programs are mandatory to curb these bacteria in ICU settings

Increasing erythromycin resistance among group A streptococci causing tonsillitis in a tertiary care hospital in southern India.

Group A streptococci (GAS) (n = 1313) isolated from patients with clinical symptoms of pharyngitis or tonsillitis attending a tertiary care hospital in southern India during 1986-2002 were tested for susceptibility to penicillin and erythromycin. The overall erythromycin resistance rate was 2.7% (n = 36). During 1986-1993, erythromycin resistance was observed in only one (2%) isolate in 1987, but reappeared in 1994 (2.7%), increased to 5.8% in 1999, and reached a maximum frequency of 13.8% in 2002. All isolates were susceptible to penicillin. The data indicate the need for continued surveillance of susceptibility patterns among GAS isolates in order to monitor the development of antibiotic resistance.

Antimicrobial susceptibility patterns of clinical isolates of Staphylococcus aureus in Nepal.

Isolates of Staphylococcus aureus (n = 117) from patients attending a tertiary care centre in western Nepal were tested for susceptibility to penicillin, oxacillin, gentamicin, erythromycin and ciprofloxacin. Eighteen (15.4%) were methicillin-resistant. Susceptibility among methicillin-resistant isolates varied from 0% (penicillin) to 16.6% (erythromycin and gentamicin), but varied among methicillin-susceptible isolates from 39.4% (penicillin) to 97.0% (ciprofloxacin). Fourteen (77.8%) of the methicillin-resistant isolates were resistant to all agents tested. Implementation of an appropriate antibiotic policy would reduce the risk of further development of antimicrobial resistance.

Dynamics of anti-M antibody response in a mouse model following intranasal infection with group A Streptococcus M-18.

Dynamics of anti-M antibody response following intranasal infection with group A Streptococcus (GAS) M-18 were investigated in a Swiss albino mouse model. Mice arranged in three groups were inoculated intranasally with 2.0x10(7) c.f.u. ml-1 of GAS M-18 on 1, 2 alternate and 3 alternate days. Plasma collected from the retro-orbital plexus was tested for antibodies by an in-house indirect ELISA. The antibody titres of the plasma samples varied from 1 : 8 to 1 : 1024 in the 1 day dose, from 1 : 4 to 1 : 256 in the 2 day dose and from 1 : 4 to 1 : 128 in the 3 day dose. Peak titres were seen on day 42 or 56 and in all cases the titres had declined by day 84. Swiss albino mouse can thus serve as a useful animal model to study different aspects of type-specific anti-M immune responses against GAS disease when designing candidate streptococcal vaccines.

Detecting mycobacteraemia for diagnosing tuberculosis.

BACKGROUND & OBJECTIVES: In human immunodeficiency virus (HIV) infected persons with pulmonary tuberculosis (TB), sputum may not always show acid fast bacilli (AFB). Moreover, in most cases of suspected extrapulmonary TB (irrespective of HIV status) mycobacteria-containing material is not readily available for investigation. This study evaluated whether blood culture for Mycobacterium tuberculosis bacteraemia (mycobacteraemia) help in diagnosing TB in such cases. METHODS: A total of 93 consecutive subjects with a clinical diagnosis of tuberculosis with or without laboratory confirmation, 42 with and 38 without coexisting HIV infection, and 13 patients with HIV infection without clinical evidence of TB were enrolled. Mycobacterial blood cultures were done using lysis centrifugation technique followed by subculturing onto the modified Lowenstein-Jenson medium (LJ-1) and Selective Kirchner's medium followed by subculturing onto the modified Lowenstein-Jenson medium (LJ-2, LJ-3). RESULTS: Of the 15 (16.2%) subjects with evidence of mycobacteremia in 4 (26.7%) blood was the first/ only source of diagnosing TB. Among 80 patients with clinical diagnosis of TB whether supported by laboratory tests or not, 14 (17.5%) had mycobacteraemia. Among the 21 HIV infected patients with laboratory proven TB, 9 (43%) had mycobacteraemia. INTERPRETATION & CONCLUSION: Blood culture appears to be a useful additional test to diagnose TB in persons with HIV infection. In patients without HIV infection, but with clinical picture compatible with TB, blood culture for mycobacteraemia may occasionally help in the diagnosis. We recommend the use of the lysis centrifugation technique followed by direct smear of the sediment along with inoculation of the sediment into both modified Lowenstein-Jenson medium and the Selective Kirchner's medium with subsequent subculturing onto the modified Lowenstein-Jenson medium for mycobacterial blood culture for detecting mycobacteraemia.

Extensive deep neck space abscess due to B-haemolytic group G streptococci-a case report.

Beta haemolytic phenotype of group G streptococci was isolated from the pus obtained from a patient with extensive deep neck space abscess. Patient was immunocompetent and made complete recovery after surgical drainage and administration of amoxycillin with clavulanic acid, amikacin and metronidazole. To our knowledge, this is the first report of deep neck space abscess due to group G streptococci.

Investigation of antimicrobial use pattern in the intensive treatment unit of a teaching hospital in western Nepal.

BACKGROUND: Inappropriate use of antimicrobials is of special importance in the intensive treatment unit because of the large number of drugs prescribed, the chance for drug errors, and the likelihood of development of drug resistance. METHODS: A total of 297 records of patients admitted to the intensive treatment unit of the Manipal teaching hospital, a tertiary care hospital in Pokhara, western Nepal, were studied to determine the prescribing frequency and rationality of use of antimicrobials. Patient outcome, duration of stay in the intensive treatment unit, and the age and sex distribution of the patients were also studied. RESULTS: Mean+/-SD drugs per patient was 3.4+/-1.8. About half (50.2%) of the patients received an antimicrobial; 84.6% of the antimicrobials were used without obtaining bacteriologic evidence of infection. The commonest organisms isolated on culture were Pseudomonas aeruginosa, Klebsiella pneumoniae, Streptococcus pneumoniae, and Staphylococcus aureus. A total of 28.9% of the antimicrobials were prescribed for lower respiratory tract infections on the basis of the putative site of infection; 61.9% of the antimicrobials were prescribed by the parenteral route and mainly the older generation of antimicrobials were used. In 39 of the 149 patients prescribed an antimicrobial, the use was irrational. CONCLUSIONS: Prescriber education to improve prescribing patterns and regular auditing of antimicrobial prescriptions to prevent their inappropriate use and unnecessary cost to the patients are required. The high percentage of inappropriate use of antimicrobials raises concerns about the development and spread of drug resistance, which must be addressed.

Evaluation of serological tests for the diagnosis of tuberculosis.

To evaluate the use of antibody detection kits in the diagnosis of pulmonary tuberculosis in an endemic area, serum samples from cases (sputum smear positive for AFB) and controls (healthy young adults) were collected and tested using five different kits. Sensitivity, specificity and predictive values were calculated using smear positivity as gold standard. Sensitivity of tests varied from 46% to 68% and the specificity from 68% to 100%. None of the kits evaluated can be used as a single screening test for tuberculosis. However kits with good specificity may be used in conjunction with conventional methods for diagnosis.

Typing of Acinetobacter baumannii isolated from hospital-acquired respiratory infections in a tertiary care centre in southern India.

In an attempt to define the epidemiology of Acinetobacter baumannii infection, 27 isolates, obtained from hospital-acquired respiratory infections, were typed using random amplified polymorphic DNA (RAPD) profile and antimicrobial susceptibility patterns. Ten different patterns were obtained with ERIC2 primer: 14 isolates had a similar profile representing a single strain. Within RAPD types, isolates could be further classified based on their antibiogram; however, strains of different types had similar antibiograms. This study showed that many different genetic types of A. baumannii are prevalent in our hospital. While antibiograms alone are not sufficiently discriminatory, RAPD typing helps in identifying outbreaks and in assessing infection control procedures within a hospital.