Utility of a real-time fluorescence imaging device in guiding antibiotic treatment in superficial skin infections.

The prescription of antibiotics empirically without confirmation of an infective etiology is on the rise. Administration of appropriate antibiotics can be guided by real-time fluorescence imaging using a point-of-care device. These composite images show the presence, type and the burden of infection. The time saved by this method over microbiological testing, especially in resource-poor settings, can lead to a paradigm shift in treatment by facilitating prompt and adequate antimicrobial therapy, surgical debridement as well as follow-up. Thumbnail sketches of a series of four cases highlighting different scenarios in which a fluorescent imaging device utilizing artificial intelligence and machine learning was found useful is presented in this report.

Coexistence of ß-Lactamases in Community-Acquired Infections in a Tertiary Care Hospital in India.

INTRODUCTION: The trends of ß-lactamases producing Enterobacteriaceae is ever increasing, and limited studies have reported investigating coexistence of ß lactamases in Enterobacteriaceae. A cross-sectional study after approval from the Institutional Ethical committee was conducted between June 2014 and May 2016 in community-acquired infections due to multidrug-resistant organisms in our tertiary care. Nonrepetitive clinical samples from the out-patient department (OPD) were processed for bacteriological culture and identification of Enterobacteriaceae. An antibiotic susceptibility test, screening, and phenotypic confirmation for ESBLs and carbapenemases and AmpC producers were performed to check for coexistence of these enzymes. RESULTS: Nonrepetitive clinical specimens processed for culture and identification in our hospital revealed 417 positive isolates in community acquired infections which were multidrug-resistant organisms, and on screening for ß-lactamases, 293 isolates were positive for one of the three beta lactamases, ESBL, AmpC, or carbapnemases. Coproduction of ESBL and MBL was seen in 5 isolates, 35 isolates showed coproduction of ESBL and AmpC enzymes, and AmpC and MBL coproduction was exhibited in only in 5 isolates. CONCLUSIONS: Coexistence of ESBLs, AmpC producers, and carbapenemases has been described. Continuous monitoring and surveillance and proper infection control and prevention practices will limit the further spread of these superbugs within the hospital and beyond.

Hepatitis B Immunisation in Health Care Workers.

BACKGROUND: Hepatitis B virus (HBV) infection is an important occupational risk in health care workers (HCW). In spite of HBV vaccine availability in Armed Forces, the high prevalence of HBV infection in HCW continues to be a problem. The study was undertaken to study the HBV vaccine-compliance among HCW. METHODS: A cross-sectional study was conducted at a tertiary care hospital. HCW were requested to fill up the pre set questionnaire to assess the HBV vaccination coverage. RESULT: Amongst 254 HCW, only 57.7% were vaccinated against HBV. The vaccine compliance was lowest among housekeeping professionals. The mean age at vaccination was high (30.5 years). Amongst the vaccine non-compliant subjects, 34.3% were above 30 years of age. 32.2% HCW completed primary vaccination after spending more than 10 years in the profession. Accessibility of HBV vaccine, knowledge and perception of HBV risk were important factors in vaccine non-compliance. CONCLUSION: Due to low and delayed HBV vaccine-compliance, HCW continue to be at the risk of occupational HBV. Health education highlighting occupational risk of HBV, accessibility of vaccine and mandatory vaccination of HCW is recommended to increase HBV vaccine compliance among HCW.

Prevalence of Human T Cell Leukaemia Virus amongst Blood Donors.

BACKGROUND: Human T cell leukaemia virus (HTLV) I/II are retroviruses implicated in transfusion transmitted infection. Present study was undertaken to assess seroprevalence of HTLV in voluntary blood donors along with pattern of blood utilisation. METHODS: A total of 258 healthy blood donors who were free from infectious markers in transfusion as per current transfusion guidelines were enrolled. They were screened for HTLV-I/II antibodies by commercially available enzyme immuno assay (EIA) and their blood utilisation data was analysed. RESULT: Five (1.9%) donors were found seropositive for HTLV-I/II of which 1.2 % were first time and 0.9% were repeat donors. Blood utilisation data revealed 20.9% and 38.8% units were utilised within 5 and 6-14 days of collection respectively. 45.9% recipients were transfused with single blood unit. 42.9% recipients were immunosuppressed due to underlying disease. CONCLUSION: The high prevalence of HTLV in blood donors, coupled with single unit transfusion, use of fresh blood, non availability of acellular blood products and immunosuppression in recipients can lead to significant transfusion transmitted HTLV infection. We suggest judicious use of blood products and screening of blood donors in prevention of transfusion transmitted HTLV-I/II.

Antibody to Hepatitis B Surface Antigen in Vaccinated Health Care Workers.

BACKGROUND: Health care workers (HCWs) in Armed Forces are immunised against Hepatitis B virus (HBV), however they are not subjected to anti-HBs (antibody to Hepatitis B surface antigen) assessment after primary vaccination. The present study was undertaken to determine the protection offered by HBV vaccine in HCW. METHODS: Cross-sectional study was carried out at tertiary care hospital. A total 146 HBV vaccine compliant HCW were evaluated for quantitative anti-HBs by enzyme immune assay. RESULT: 129 (88.4%) subjects had protective levels of anti-HBs. Higher age at vaccination was an important risk factor in low vaccine response. Decline in anti-HBs with time was evident. Anti-HBs levels were more than 10mIU/ml in subjects even after 11 years of primary vaccination. There was no difference in protection in booster and non booster groups. CONCLUSION: Age is the most important factor in HBV vaccine response. Booster dose of HBV vaccine is not necessary in healthy HCW for atleast ten years after primary vaccination. The study recommends early primary vaccination of HCW and 'initial' anti-HBs assay for confirmation of vaccine response.

Immunochromatographic Methods in Malaria Diagnosis.

BACKGROUND: Malaria remains a major cause of morbidity and mortality in India. This study was carried out to evaluate the use of parasite lactate dehydrogenase (pLDH) test in diagnosis of malaria. METHODS: Blood slides of 400 patients who presented with fever including 104 patients with clinical features suggestive of malaria were studied. The results were compared with microscopy and another immunochromatography test (ICT) based on detection of histidine rich protein-2 antigen [Pfhrp-2] secreted by Plasmodium falciparum. RESULT: In this study the sensitivity and specificity for detection of Plasmodium vivax was 100% while for Plasmodium falciparum the values were 96% and 100% respectively. CONCLUSION: ICT is useful for diagnosis of malaria caused by Plasmodium falciparum in field but microscopy of a well-prepared blood smear must not be omitted in a laboratory setting.

Helicobacter pylori in Dyspepsia - Antibiotic Sensitivity and Virulence Patterns.

BACKGROUND: Helicobacter pylori is implicated in acute superficial gastritis, chronic atrophic gastritis, gastric carcinoma and MALT associated lymphoma. Though colonization can occur in normal individuals, treatment is given if the organism is associated with virulence factors like vacuolating toxin and cytopathic toxin as coded by vacA and cagA genes respectively. No causal relationship between non-ulcer dyspepsia (NUD) and H pylori has been established. This study was carried out to delineate colonizers from pathogens so that appropriate treatment can be planned. METHOD: 100 patients were recruited, 62 with NUD and 38 age and sex matched controls. 4 gastric biopsies and a serum samples were taken from each patient. The biopsies were examined for H pylori by culture, histopathology, rapid urease test, PCR and serum for IgG, IgM and IgA. RESULTS: Culture showed 22.6% positivity and urease 19% among the test group. Histopathology showed 53.2% superficial gastritis and 30.6% chronic gastritis among the test group (P<0.001), PCR for H pylori was positive in 48.3% and vacA and cagA were 29% and 22.6% respectively (P=0.001) among the tests. IgG, IgM and IgA were 41.9%, 46.8% and 43.5% respectively. CONCLUSION: The culture and rapid urease tests were highly specific with high positive predictive value but if negative, infection cannot be ruled out. Similarly IgA and IgM positivity has high positive predictive value for on-going infection where as IgG may be positive in old healed infections also. PCR assay in biopsy specimens is a valuable technique for detection of H pylori with high specificity and sensitivity. The presence of vacA and cagA genes can differentiate innocuous bystanders and potentially invasive organisms.

Outbreak of Multi-drug Resistant Salmonella Typhi Enteric Fever in Mumbai Garrison.

BACKGROUND: There was an epidemic of enteric fever in Mumbai garrison during Nov-Dec 2000 with more than 150 cases admitted to a tertiary care service hospital. METHODS: All the cases presented with fever and some had splenomegaly, bradycardia, abdominal pain and diarrhoea. The epidemic was investigated by the station health organization (SHO) and the case and bacteriological study was carried out in pathology laboratory of the service hospital. The serological study was carried out at Armed Forces Medical College (AFMC), Pune and the Phage typing was carried out at Lady Harding Medical College, New Delhi. RESULTS: Blood cultures were positive in 92(63%) for Salmonella typhi and Widal test was positive in 83(55%). All strains were resistant to four primary drugs i.e. ampicillin, chloramphenicol, co-trimoxazole and tetracycline. All but two were treated successfully with ceftriaxone. The Salmonella typhi belonged to phage group E1 and biotype I. CONCLUSION: Extensive epidemiological investigation of cases and water sources of cantonment area pointed to a common source of the epidemic i.e. the well near 'Gurudwara'.

Functional protein C and anti-cardiolipin antibody in children with portal vein thrombosis.

BACKGROUND: Portal vein thrombosis (PVT) is a common cause of portal hypertension in children from developing countries. Deficiencies of proteins C and S and elevated anticardiolipin antibody (aCL) levels have been shown to predispose to venous thrombosis. We studied these factors in children with idiopathic PVT. METHODS: 19 children with PVT (mean [SD] age 5.7 [2.1] y; 15 boys) were studied; all had had variceal bleeding, and had PVT on ultrasonography. Functional protein C activity was measured using a clotting assay; if it was normal, a clotting assay for functional protein S activity was performed. IgG aCL levels were measured in all sera using an in-house standardized solid-phase ELISA. RESULTS: Protein C functional activity ranged from 4% to 109%. Eight children had activity below 70%, the lower cut-off of the normal range. Protein S assay, done in 10 of the 11 children with normal protein C activity levels, was normal (above the cut-off level of 65% of the normal range). IgG aCL levels were abnormally elevated (>mean + 2SD of 16 healthy control children) in nine children; of these, three had associated protein C deficiency. Thus, of the 19 children with idiopathic PVT, 14 had abnormality in one or more tests. CONCLUSION: A majority of children with PVT of unknown etiology have functional protein C deficiency or abnormally elevated levels of aCL antibodies.

IMMUNOCHROMATOGRAPHIC TEST: A NEW DIMENSION IN DIAGNOSIS OF PLASMODIUM FALCIPARUM MALARIA.

75 patients with clinical features suggestive of malaria were studied to evaluate the efficacy of immunochromatographic test (ICT), which detects histidine rich protein-2 antigen secreted by Plasmodium falciparum (Pfhrp-2), as against direct microscopy. There were 40 cases of P falciparum malaria, 14 cases of P vivax malaria and 21 cases of non-malarial fevers. Direct microscopy could detect 27(67.5%) P falciparum cases but failed to detect 13 cases (32.5%) whereas ICT could detect 35(87.5%) P falciparum cases out of 40 but failed to detect 5(12.5%) cases. All the P vivax cases and non-malarial fever cases were negative for ICT. The sensitivity and specificity of ICT is 87.5% and 100% respectively where as the positive predictive value and the negative predictive value of the test is 100% and 87.5% respectively. It is concluded that ICT test is a good adjunct to blood smear studies in fever cases with neurological and multiorgan dysfunction and in antenatal ladies.

Thio- and oxoflavopiridols, cyclin-dependent kinase 1-selective inhibitors: synthesis and biological effects.

Flavopiridol analogues, thio- and oxoflavopiridols which contain a sulfur (16) or oxygen (18) atom linker between a chromone ring and the hydrophobic side chain, are selective cyclin-dependent kinase 1 (CDK1) inhibitors with an IC(50) of 110 and 130 nM. These analogues were prepared from key intermediate 7 by substituting the ethyl sulfoxide. Enantio pure intermediate piperidone 10 was obtained from the racemic piperidone 8 via a very efficient "dynamic kinetic resolution" in 76% yield. Hydrophobic side chains such as chlorophenyl or tert-butyl produced potent CDK1 inhibitory activity, while hydrophilic side chains such as pyrimidine or aniline caused a severe reduction in CDK inhibitory activity. These analogues are competitive inhibitors with respect to ATP, and therefore activity was dependent upon the CDK subunit without being affected by the cyclin subunit or protein substrate. Thio- and oxoflavopiridols 16 and 18 are not only selective within the CDK family but also discriminated between unrelated serine/threonine and tyrosine protein kinases. CDK1 selective thio- and oxoflavopiridol analogues inhibit the colony-forming ability of multiple human tumor cell lines and possess a unique antiproliferative profile in comparison to flavopiridol.

HIV PATHOGENESIS-EMERGING CONCEPTS.

CD4 receptor molecules on 'T' lymphocytes and macrophages have already been identified as the route of entry for HIV. However CCR5 and CXCR4 are identified only recently as the second receptors for HIV on macrophages and 'T' lymphocytes respectively. Presence of homozygous CCR5 Δ 32, a defective CCR5 gene leads to resistance to HIV infection in the risk groups. While heterozygous CCRS Δ 32 leads to delay in the progress of HIV infection to AIDS.

ANTIBIOTIC RESISTANCE PATTERN OF ISOLATES FROM WOUND AND SOFT TISSUE INFECTIONS.

Two-hundred and eighty bacterial isolates from wound and soft tissue infections were studied for species identification and antibiotic resistance pattern. Amongst them 122 isolates were from community acquired infection and 158 were from nosocomial infections. The common community acquired pathogens were Staphylococcus aureus (67.8%) and Streptococcus pyogenes (10.7%), whereas Staphylococcus aureus (60.1%) and E. Coli (8.9%) were common in nosocomial infection. Only two anaerobes (Cl perfringens) were isolated. Penicillin resistance was found to be 87% and 92% for Staphylococccus aureus in community acquired and noscomial infections respectively. 85% of Proteus isolates were resistant to ampicillin. There was relatively lower level of resistance by all isolates to cefotaxime. Gentamicin showed higher rate of resistance than netilmicin and amikacin. Resistance of E. coli isolates to fluoroquinolones being 79% for norfloxacin, 81% for ciprofloxacin and 60% for ofloxacin. The study showed a higher resistance of methicillin resistant Staphylococcus aureus (MRSA) to other antibiotics. Amikacin and ofloxacin were the best recommended drugs for empirical therapy for all organisms, the susceptibility rate being 80.7% and 80.4%.

Cardioselective antiischemic ATP-sensitive potassium channel (K(ATP)) openers. 6. Effect of modifications at C6 of benzopyranyl cyanoguanidines.

The effect on potency and selectivity of modifications at the C6 position of the cardioprotective K(ATP) opener BMS-180448 (2) is described. Structure-activity studies show that a variety of electron-withdrawing groups (ketone, sulfone, sulfonamide, etc.) are tolerated for cardioprotective activity as measured by EC(25) values for an increase in time to the onset of contracture in globally ischemic rat hearts. Changes made to the sulfonamido substituent indicate that compounds derived from secondary lipophilic amines are preferred for good cardioprotective potency and selectivity. The diisobutyl analogue 27 (EC(25) = 0.04 microM) is the most potent compound of this series. The cardiac selectivity of 27 results from a combination of reduced vasorelaxant potency and enhanced cardioprotective potency relative to the potent vasodilating K(ATP) openers (e.g., cromakalim). The diisobutylsulfonamide analogue 27 is over 4 orders of magnitude more cardiac selective than cromakalim (1). These results support the hypothesis that the cardioprotective and vasorelaxant properties of K(ATP) openers follow distinct structure-activity relationships. The mechanism of action of 27 appears to involve opening of the cardiac K(ATP) as its cardioprotective effects are abolished by the K(ATP) blocker glyburide.

CHANGES IN URINARY ISOLATES AND THEIR ANTIBIOTIC RESISTANCE PATTERN.

A total of 338 urinary isolates were studied at AFMC, Pune during 1998 for species identification and antibiotic resistance. Out of 145 community isolates E coli were 67% followed by Staph aureus (11%). The hospital isolates of E coli and Proteus spp showed higher resistance to ampicillin (81% and 89% respectively) than to cefotaxime (23% and 22% respectively). K pneumoniae showed relatively higher resistance to cefotaxime i.e. 54% for community strains and 75% for hospital strains. Proteus spp showed higher resistance to fluoroquinolones i.e. 78% for norfloxacin and 82% for ofloxacin as compared to other coliforms and Pseudomonas aeruginosa. Among aminoglycosides bacterial resistance to amikacin is less than to commonly used netilmicin and gentamicin. Hospital isolates of K pneumoniae are 100% resistant to sulphamethoxazole and to trimethoprim. Susceptibility testing is emphasized as a must both for hospital and community isolates, but when empirical treatment is contemplated for community isolates nitrofurantoin, nalidixic acid, amikacin, cefotaxime, gentamicin and piperacillin are recommended as first line choices and for hospital isolates amikacin, cefotaxime and netilmicin are recommended until susceptibility report is available.

UREAPLASMAS UREALYTICUM AND HUMAN INFERTILITY: EFFECT ON SPERMATOZOA MORPHOLOGY.

Seminal fluids of 197 males with complaints of involuntary infertility were examined for spermatozoal counts, morphological changes in the spermatozoa and cultured for ureaplasmas and mycoplasmas. In 12, no spermatozoa were present, 29 had a count of less than one million and 156 had more than one million spermatozoa per mL of the seminal fluid. Various morphological changes were detected in the spermatozoa in some cases. U urealyticum and M hominis were grown in 43.15% and 16.75% in comparison to control figures of 15.9% and 11.4% respectively. There was no correlation between growth of ureaplasmas and the spermatozoal count. Among the morphological changes, presence of coiled tails, presence of a fuzzy coat around the tail and microcolonies were highly specific for culture positivity (98.2, 98.2 and 97.35% respectively) but of low sensitivity (55.2%, 14.1% and 8.2% respectively).