Regional variations in antimicrobial susceptibility of community-acquired uropathogenic Escherichia coli in India: Findings of a multicentric study highlighting the importance of local antibiograms.

Objectives: Evidence-based prescribing is essential to optimize patient outcomes in cystitis. This requires knowledge of local antibiotic resistance rates. Diagnostic and Antimicrobial Stewardship (DASH) to Protect Antibiotics (https://dashuti.com/) is a multicentric mentorship program guiding centers in preparing, analyzing and disseminating local antibiograms to promote antimicrobial stewardship in community urinary tract infection. Here, we mapped the susceptibility profile of Escherichia coli from 22 Indian centers. Methods: These centers spanned 10 Indian states and three union territories. Antibiograms for urinary E. coli from the outpatient departments were collated. Standardization was achieved by regional online training; anomalies were resolved via consultation with study experts. Data were collated and analyzed. Results: Nationally, fosfomycin, with 94% susceptibility (inter-center range 83-97%), and nitrofurantoin, with 85% susceptibility (61-97%), retained the widest activity. The susceptibility rates were lower for co-trimoxazole (49%), fluoroquinolones (31%), and oral cephalosporins (26%). The rates for third- and fourth-generation cephalosporins were 46% and 52%, respectively, with 54% (33-58%) extended-spectrum ß-lactamase prevalence. Piperacillin-tazobactam (81%), amikacin (88%), and meropenem (88%) retained better activity; however, one center in Delhi recorded only 42% meropenem susceptibility. Susceptibility rates were mostly higher in South, West, and Northeast India; centers in the heavily populated Gangetic plains, across north and northwest India, had greater resistance. These findings highlight the importance of local antibiograms in guiding appropriate antimicrobial choices. Conclusions: Fosfomycin and nitrofurantoin are the preferred oral empirical choices for uncomplicated E. coli cystitis in India, although elevated resistance in some areas is concerning. Empiric use of fluoroquinolones and third-generation cephalosporins is discouraged, whereas piperacillin/tazobactam and aminoglycosides remain carbapenem-sparing parenteral agents.

Subcutaneous entomophthoramycosis in a child presenting as panniculitis: a case report from Bihar, India.

A 5-year-boy from Bihar, India was admitted to a tertiary care hospital with painful swelling over both lower limbs and buttocks, which had been increasing progressively for the past 1 year. The condition was initially undiagnosed and was later misdiagnosed as non-infective panniculitis, delaying treatment. Subsequently, the patient was diagnosed with subcutaneous entomophthoramycosis caused by Basidiobolus spp. A preliminary diagnosis was made by considering the history, clinical features, radiological findings and histopathological examination of the biopsied tissue. The confirmatory diagnosis was made using conventional techniques on aspirated pus, which included KOH wet mount and fungal culture on Sabouraud dextrose agar tubes incubated at 28°C and 37°C, respectively. Lactophenol cotton blue mount and slide culture were performed for identification of the fungal isolate. The patient responded well to oral itraconazole and oral potassium iodide. Delayed diagnosis and extensive involvement in a rare case of subcutaneous entomophthoramycosis causing panniculitis emphasizes the importance of correct diagnosis and appropriate, effective treatment.

Fungal Keratitis Due to Fusarium lichenicola: A Case Report and Global Review of Fusarium lichenicola Keratitis.

Fusarium species are among the most commonly isolated causes of fungal keratitis. Most species of the genus Fusarium belong to Fusarium solani species complex (FSSC). Fusarium lichenicola, a member of the FSSC complex, is a well-established plant and human pathogen. However, reports of fungal keratitis due to Fusarium lichenicola have not been frequently reported. To the best of our knowledge, only twelve cases of Fusarium lichenicola keratitis have been reported in the past fifty years. Clinical cases of Fusarium lichenicola may have most likely been misidentified because of the lack of clinical and microbiological suspicion, as well as inadequate diagnostic facilities in many tropical countries where the burden of the disease may be the highest. We report a case of fungal keratitis caused by Fusarium lichenicola and present a global review of the literature of all cases of fungal keratitis caused by this potentially blinding fungus.

Melioidosis in Bihar, India: unearthing the first of many?

Melioidosis, a disease with protean clinical manifestations, is prevalent in many parts of India, with established endemic hotspots on the southern coast of the country. However, it is still underdiagnosed in many resource-poor regions of the country. We report what is, to the best of our knowledge, the first case of melioidosis diagnosed and treated in Bihar, an economically underdeveloped state in East India. The patient, a 52-year-old diabetic male, presented to the outpatient department with a fever of insidious onset along with pain and restriction of movement in the right shoulder joint and right knee joint, and swelling and tenderness of bilateral ankle joints. Radiological features were suggestive of multiple joint and organ abscesses. A diagnosis of disseminated septicaemic melioidosis was confirmed microbiologically. The patient improved clinically following aggressive treatment with meropenem and cotrimoxazole. The case highlights the need for increased clinical suspicion of melioidosis and adequate diagnostic facilities, as well as the need for early institution of appropriate empirical antibiotics in suspected cases of melioidosis in this region of the world.

Hand hygiene: An educational intervention targeting grass root level.

BACKGROUND: Hands are the most common vehicle for the transmission of pathogens within the healthcare environment. Hand hygiene is the leading measure for reducing healthcare-associated infections (HCAIs) and preventing the spread of antimicrobial resistance. OBJECTIVE: An interventional study was carried out to evaluate the knowledge, attitude and practices of hand hygiene among third semester medical students. MATERIALS AND METHODS: A total of 152 medical students were evaluated using a pretest self-structured questionnaire to assess the knowledge, attitude and practices regarding hand hygiene. The students were trained by faculty of microbiology vigorously with the help of a lecture and demonstration on hand hygiene followed by hands-on training. The same group of students were then distributed the post-training questionnaire. The pre-training and post training data was analyzed and compared. RESULT: There was a significant improvement in knowledge, attitude and practice towards hand hygiene among students after intervention, as seen on comparison of results of post-test questionnaire from its pre-test counter-part because the doubts in the mind of the students got cleared in the education sessions. CONCLUSION: Targeting medical students and teaching them the good standard practices was fruitful as they were young, easy to mold and enthusiastic and above all they are the future doctors. Such educational intervention regarding hand hygiene will be carried out for each batch of medical students in future.

Linezolid and Vancomycin Resistant Enterococci: A Therapeutic Problem.

INTRODUCTION: Enterococci are recognized as opportunistic pathogens, as well as commensals in both humans and animals. They are an important cause of nosocomial infections, difficult to treat, as the organism have intrinsic and acquired resistance to many antibiotics. AIM: To isolate and identify clinically relevant Enterococcus up to species level from all the clinical samples processed in the microbiology laboratory and also to study their resistance pattern. MATERIALS AND METHODS: A prospective study was carried out for a period of one year from May 2014 to April 2015 at the Department of Microbiology, Subharti Medical College, Meerut, Uttar Pradesh, India. A total of 200 isolates of Enterococcus species from 15342 clinical samples obtained from IPD/OPD patients irrespective of age, having suspicion of bacterial infection were processed in the microbiology laboratory. Identification was done with standard biochemical methods. Antibiotic susceptibility testing was done on Muller Hilton agar plate by Kirby Bauer disc diffusion method. High-Level Gentamycin Resistance (HLGR) and High-Level Streptomycin Resistance (HLSR) were further confirmed by Agar dilution method and Broth microdilution method. Vancomycin and linezolid resistance was further confirmed by Agar dilution method and MIC was calculated by using VITEK 2, Biomerieux. All methodology was followed as per Clinical and Laboratory Standards Institute (CLSI) M100-S 24, 2014 guidelines. RESULTS: E. faecalis (n=169, 84.5%) was the predominant species isolated, followed by E. faecium (n=27, 13.5%) and E. casseliflavus (n=4, 2%). A total of 25 (12.5%) isolates were HLGR, 13 (6.5%) isolates were HLSR and 62 (31%) isolates were HLGR+HLSR. Vancomycin resistance was found in 14 (7%) isolates of which 11 (78.5%) were Van A and 3 (21.4%) were Van B, detected phenotypically as per relative MIC of vancomycin and teicoplanin. Linezolid resistance was seen in 4 (2%) of isolates which were vancomycin as well as high-level gentamycin and high-level streptomycin resistant. CONCLUSION: Isolation of Enterococcus species resistant to most of the higher antibiotics like vancomycin and linezolid, with high prevalence of High-Level Aminoglycoside Resistance (HLAR), from hospitalized patients is a major concern as such isolates have limited or no therapeutic option.

Small Vessel Vasculitis, an Uncommon Presentation of Systemic Lupus Erythematosus.

We report a nineteen year old female with gangrene of toes as the only clinical feature of systemic lupus erythematosus. She was treated successfully with pulse cyclophosphamide and steroid.

Methicillin Resistant Staphylococcus aureus: Inconsistencies in Vancomycin Susceptibility Testing Methods, Limitations and Advantages of each Method.

BACKGROUND: Vancomycin may be ineffective against an increasing proportion of methicillin resistant Staphylococcus aureus (MRSA) with minimum inhibitory concentrations (MICs) well within the susceptible range. On the other hand it is common knowledge that determination of vancomycin MICs is method dependent. Therefore, given the apparent variability in vancomycin MIC results obtained with the different methods, the use of the vancomycin MIC to predict the outcome of serious S. aureus infections needs to take into account the method used and the results of studies using that particular method. AIM: Comparative study was carried out to evaluate the MICs obtained by BMD method, E-test, and Vitek 2 method and to detect inconsistencies in these vancomycin for 66 MRSA isolates obtained from various samples of patients attending the OPDs & IPDs within a period of one year. MATERIALS AND METHODS: A comparative study was carried out to evaluate the MICs obtained by BMD method, E-test, and Vitek 2 method to detect vancomycin susceptibility in 66 clinical isolates of MRSA obtained from various samples of patients attending the OPDs & IPDs within a period of one year. The study was conducted in Department of Microbiology, Subharti Medical College, Meerut from January to December 2012. RESULTS: On determination of MICs for vancomycin for the MRSA isolates, all were identified as VSSA by BMD, E-Test & Vitek 2 methods. However, the vancomycin MIC values obtained by E-test correlated better with BMD method (correlation factor= 0.6727) than Vitek 2 (correlation factor=0.5316), indicating E-Test to be a better method for determination of vancomycin MICs as compared to Vitek 2. CONCLUSION: MRSA isolates with higher vancomycin MICs, even within the susceptibility range, are being observed more frequently which result in treatment failures with vancomycin. Because of the discrepancy that exists in vancomycin MIC results from different methods, the prediction of outcome of serious S.aureus infections should take into account the method used & results of studies using that particular method.

Ibuprofen-mediated reversal of fluconazole resistance in clinical isolates of Candida.

INTRODUCTION: In view of the increasing prevalence of invasive Candidiasis in today's health-care scenario and the emergence of fluconazole resistance among clinical isolates of Candida, we sought to determine if Ibuprofen could elicit a reversal of fluconazole resistance and thereby offer a potential therapeutic breakthrough in fluconazole-resistant Candidiasis. MATERIALS AND METHODS: We selected 69 clinical isolates of Candida, which demonstrated an MIC of >32 µg/ml for fluconazole, and subjected them to broth microdilution in presence and absence of Ibuprofen. RESULTS: Forty two of the 69 isolates (60.9%) demonstrated reversal of Fluconazole resistance with concomitant use of Ibuprofen. This was characterized by significant species-wise variation (p=0.00008), with all the C. albicans isolates and none of the C. glabrata isolates demonstrating such reversal. Only 22.2% and 37.7% of C. krusei and C. tropicalis isolates respectively showed Ibuprofen-mediated reversal of Fluconazole resistance. CONCLUSION: Since Ibuprofen is a known efflux pump inhibitor, our findings hint at the possible mechanism of Fluconazole resistance in most of our Candida isolates and suggest a potential therapeutic alternative that could be useful in the majority of Fluconazole-resistant clinical isolates of Candida.

Profile of infective microorganisms causing ventilator-associated pneumonia: A clinical study from resource limited intensive care unit.

BACKGROUND: Ventilator-associated pneumonia (VAP) is the most common cause of hospital acquired infection and death among patients admitted in ICU. Microorganisms responsible for VAP vary from place to place. Gram-negative bacteria (GNB) have emerged as a major group of pathogen causing VAP and over the years carbapenem group of antibiotics has emerged as one of the important antibiotics used in the critically ill patients. There have been reports of increased occurrence of infection by carbapenem-resistant bacteria in health care settings in recent times. AIM: The aim of the study was to assess the incidence of VAP, their microbiological profile with reference to carbapenemase producing GNB in the intensive care unit of a tertiary care hospital, their relation to initial emperical antibiotic therapy, sensitivity patterns, and outcome. MATERIALS AND METHODS: This prospective study was carried out over the period of 1 year (July 2010-June 2011) on 100 randomly selected patients above the age of 18 years admitted in the emergency/ICU and requiring intubation and mechanical ventilation for more than 72 hours. The diagnosis of VAP was established on the basis of clinical and radiological parameters as per Centre of Disease Centres (CDC) guidelines. A baseline sample was obtained after initial endotracheal intubation. Thereafter, the culture sent on the first day of occurrence of clinical sign of VAP. Culture was done on blood agar and MacConkey agar. All imipenem-resistant strains were further confirmed by Modified Hodge test and combined disc for confirmation of respective carbapenemase. RESULTS: Incidence of VAP was found to be 51%. GNB mainly Citrobacter 28 (52.83%) and Klebsiella pneumoniae 7 (13.21%), were the most commonly isolated pathogens. The prevalence of carbapenemase-producing GNB was alarmingly high 24/50 (48%). The entire carbapenemase producers showed high degree of cross resistance to antibiotics with some sensitivity to Polymyxin B (94 %) and Tigecycline (96%). CONCLUSION: High incidence of VAP and the potential carbapenemase-producing GNB are real threat in our ICU. The emergence of microorganisms known for its inherent resistance among most of the common first-line antibiotics calls for a alarm in all upcoming tertiary care hospitals.

Evaluation of phenotypic tests for the detection of AmpC beta-lactamase in clinical isolates of Escherichia coli.

BACKGROUND: AmpC beta lactamases are cephalosporinases that confer resistance to a wide range of beta lactam drugs thereby causing serious therapeautic problem. As there are no CLSI guidelines for detection of AmpC mediated resistance in Gram negative clinical isolates and it may pose a problem due to misleading results, especially so in phenotypic tests. Although cefoxitin resistance is used as a screening test, it does not reliably indicate AmpC production. MATERIALS AND METHODS: We planned a study to determine the occurrence of AmpC beta lactamase in hospital and community, clinical isolates of Escherichia coli and simultaneously evaluate different phenotypic methods for detection of AmpC beta lactamases. RESULTS: It was observed that 82.76% isolates were ESBL positive and 59% were cefoxitin screen positive. Using phenotypic confirmatory tests the occurrence of Amp C beta lactamases was found to be 40% and 39% by inhibitor based method using boronic acid (IBM) and modified three dimensional test (M3D) respectively. CONCLUSION: Both the test showed concordant result. Co-production was observed in 84.62% isolates Screening of ESBL and Amp C can be done in routine clinical microbiology laboratory using aztreonam and IBM respectively as it is a simple, rapid and technically less demanding procedure which can be used in all clinical laboratories.

The Beta Lactam Antibiotics as an Empirical Therapy in a Developing Country: An Update on Their Current Status and Recommendations to Counter the Resistance against Them.

In a developing country like India, where the patients have to bear the cost of their healthcare, the microbiological culture and the sensitivity testing of each and every infection is not feasible. Moreover, there are lacunae in the data storage, management and the sharing of knowledge with respect to the microorganisms which are prevalent in the local geographical area and with respect to the antibiotics which are effective against them. Thus, an empirical therapy for treating infections is imperative in such a setting. The beta lactam antibiotics have been widely used for the empirical treatment of infections since the the discovery of penicillin. Many generations of beta lactams have been launched with, the claims of a higher sensitivity and less resistance, but their sensitivity has drastically decreased over time. Thus, the preference for beta lactams, especially the cephalosporins, as an empirical therapy, among the prescribers was justified initially, but the current sensitivity patterns do not support their empirical use in hospital and community acquired infections. There is a need for increasing the awareness and the attitudinal change among the prescribers, screening of the antibiotic prescriptions, the strict implementation of antibiotic policies in hospital settings, restricting the hospital supplies and avoiding the prescriptions of beta lactams, a regular census of the local sensitivity patterns to formulate and update the antibiotic policies, upgradation of the laboratory facilities for a better and faster detection of the isolates, proper collection, analyses and sharing of the data and the encouragement of the research and development of newer antibiotics with novel mechanisms of action.

Profile of hepatitis B virus, hepatitis C virus, hepatitis d virus and human immunodeficiency virus infections in hemodialysis patients of a tertiary care hospital in uttarakhand.

BACKGROUND AND AIM: Viral hepatitis and human immunodeficiency virus (HIV) infection are important causes of morbidity and mortality in hemodialysis (HD) patients. The present study was performed to assess the prevalence of hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV) and HIV infections in hemodialysis patients of a tertiary care hospital in Uttarakhand. METHODS: All patients undergoing maintenance HD at our center were screened for hepatitis B surface antigen (HBsAg), antibody to HCV (anti-HCV), antibody to HDV (anti-HDV) and HIV antibody by ELISA. Detailed history regarding age, sex, duration of dialysis, blood transfusions, number of dialysis centers, dialyzer reuse and laboratory data was recorded. RESULTS: A total of 118 patients (79 males and 39 females) were followed for 18 months with screening for the presence of HBV, HCV and HIV infections. At baseline, 12 (10.2%) patients were positive for HBsAg, 19 (16.1%) for anti-HCV and 2 (1.7%) for HIV antibody. Over 18 months, one additional patient became HBsAg positive and an additional 17 became anti-HCV-positive to give a total of 36 HCV-positive patients. Dual HBV and HCV infection was seen in 5 (4.2%) and anti-HDV antibodies were found in 1 (0.9%) patient. History of blood transfusions, duration of HD, dialyzer reuse and dialysis at multiple centers were found to be important risk factors for anti-HCV positivity. CONCLUSIONS: Implementation and adherence to universal work precautions by dialysis staff is imperative to prevent transmission of these infections.

Ocular thelaziasis in Assam: a report of two cases.

Small, white, thread-like, motile worms were recovered from the conjunctival sac of a 13-year-old girl and a 50-year-old woman from Dibrugarh district, Assam, India. They were identified as thelazia species. These two cases have been reported due to their rarity in India and elsewhere.