A novel use of pneumococcal urinary antigen detection kits to identify Streptococcus pneumoniae cultures misidentified by the VITEK-2 system.

Streptococcus pneumoniae infections continue to be an important cause of morbidity and mortality in low-and middle-income countries. Differentiating S. pneumoniae from viridans group streptococci is essential to ensure appropriate antibiotic therapy. Conventional microbial identification tests can often misidentify the two groups. We used a common pneumococcal urinary antigen test to identify S. pneumoniae that were misidentified by the VITEK 2. The performance of the test was similar to the pneumococcal latex agglutination test.

Chronic fungal osteomyelitis of the tibia due to Acremonium curvulum: a rare case.

Fungal osteomyelitis is a rare disease which usually presents in an indolent manner. Opportunistic infections due to other non-aspergillus moulds are an emerging entity. We report a case of fungal osteomyelitis due to Acremonium spp in an immunocompetent adult which showed a chronic, indolent course but responded well to treatment with voriconazole. This case highlights the importance of diagnosing the causative agent in fungal osteomyelitis as species specific susceptibility can aid in the treatment of fungal osteomyelitis.

A prospective cross sectional study of detection of Clostridium difficile toxin in patients with antibiotic associated diarrhoea.

BACKGROUND AND OBJECTIVES: Clostridium difficile infections (CDI) include self-limiting antibiotic associated diarrhoea (AAD), antibiotic-associated colitis, and pseudomembranous colitis. The present study aimed at detecting C. difficile toxin in stool samples of patients with AAD and analyzing the antibiotic use and presence of other risk factors in these patients. MATERIALS AND METHODS: In this study, which was conducted on 660 samples, a 2- step strategy was used. In the first step, glutamate dehydrogenase (GDH) was detected in stool samples by enzyme-linked immunofluorescent assay (ELFA). In the second step, GDH positive samples were tested for C. difficile toxin A and B by ELFA. Nucleic acid amplification test (NAAT) was also performed on few samples that were found to be GDH positive and toxin negative or equivocal by ELFA. RESULTS: Of the 660 samples screened, toxin was detected in 8.8% (58/660) by ELFA and 9.7% (64/660) by NAAT. GDH was detected in 23.8% (157/660) and toxin in 36.9% (58/157) of the GDH positives. Most of the toxin positive patients were on one or more antibiotics prior to developing diarrhoea. The implicated antibiotics were meropenem, amikacin, colistin and cephalosporins. Diabetes, hypertension, use of proton pump inhibitors, previous hospitalization, malignancy and chemotherapy were found to be the risk factors in our study. CONCLUSION: Prevalence of GDH was 23.8% (157/660) by ELFA. Toxin prevalence was 9.7% (64/660). Detection rates of C. difficile associated diarrhoea (CDAD) increased with inclusion of NAAT testing by ELFA.

A Case Series and Review of Bacillus Cereus Endocarditis from India.

INTRODUCTION: Bacillus cereus is a gram positive bacilli found commonly in the soil and environment. It is a bacteria rarely associated with endocarditis. CASE HISTORY: Intravenous drug abuse, presence of valvular defects, pacemakers, immunodeficiency are some of the known risk factors for B.cereus endocarditis. We present here a case series of two patients with B.cereus endocarditis along with a review of the literature. CONCLUSION: This is the first report of B.cereus endocarditis from India to the best of our knowledge.

Multiple cortical brain abscesses due to Listeria monocytogenes in an immunocompetent patient.

Listeria monocytogenes is an intracellular organism which is well recognised for its ability to cause meningeal infections in neonates, immunosuppressed, debilitated and elderly individuals. 1 Other less common central nervous system (CNS) infections caused by Listeria spp. include rhomboencephalitis, cerebritis and abscesses in the brain, brain stem and spinal cord. The neuroradiological appearance of Listeria brain abscesses is similar to other types and may also mimic primary or metastatic brain tumours. 2 , 3 We report a case of Listeria brain abscesses in a patient who was being treated for atypical parkinsonism. A good clinical outcome was achieved after appropriate antimicrobial therapy.

Antibiotic Screening of Urine Culture for Internal Quality Audit at Amrita Hospital, Kochi.

INTRODUCTION: Urine antimicrobial activity is a seldom analysed laboratory test which greatly impacts the quantification of urine specimens. Presence of antimicrobial activity in the urine reduces the bacterial load in these specimens. Hence, the chances of erroneously reporting insignificant bacteriuria can be reduced on analysis of the antimicrobial activity in urine. AIM: The aim of the study was to measure the antimicrobial activity of urine samples obtained from patients in a tertiary care hospital. MATERIALS AND METHODS: A total of 100 urine specimens were collected from the study group. Tests like wet mount, Gram staining and culture were performed. Antimicrobial susceptibility testing was done on the bacteria isolated from each specimen. The urine specimens were reported as significant bacteriuria (>105 Colony Forming Unit (CFU)/ml) and insignificant bacteriuria (<105 CFU/ml - clean catch midstream urine; <102 CFU/ml - catheterized urine sample) according to the CFU/ml. Staphylococcus aureus ATCC® 25923™ and Escherichia coli ATCC® 25922™ were used to identify the presence of antimicrobial activity in the urine sample by Urine Anti-Bacterial substance Assay (UABA). McNemar test was used for statistical analysis using Statistical Package for the Social Sciences (SPSS) version 21.0. RESULTS: On analysis of the antimicrobial activity of urine sample with the prior antibiotic history of the patients, 17 were true positives and 43 were true negatives. Twenty six of samples with UABA positivity were culture negative and 28 samples with UABA positivity were culture positive. Sensitivity and specificity of the test was 85% and 53.8% respectively. Accuracy of the test was 60%. The p-value of UABA was <0.001. Enterobacteriaceae was the most common bacterial family isolated from the urine specimens. A total of 85% patients responded to treatment. CONCLUSION: Presence of antimicrobial activity in urine has a great impact on the interpretation of urine culture reports. Identification of urine antimicrobial activity helps in evaluating the quantification of bacterial growth reported in urine culture. It facilitates speedy recovery of patients by early administration of antibiotics.

Simple low cost differentiation of Candida auris from Candida haemulonii complex using CHROMagar Candida medium supplemented with Pal's medium / Diferenciación sencilla y de bajo coste de Candida auris del complejo Candida haemulonii con el empleo del medio CHROMagar Candida enriquecido con medio de Pal

Background. Candida auris is unique due to its multidrug resistance and misidentification as Candida haemulonii by commercial systems. Its correct identification is important to avoid inappropriate treatments. Aims. To develop a cheap method for differentiating C. auris from isolates identified as C. haemulonii by VITEK2. Methods. Fifteen C. auris isolates, six isolates each of C. haemulonii and Candida duobushaemulonii, and one isolate of Candida haemulonii var. vulnera were tested using CHROMagar Candida medium supplemented with Pal's agar for better differentiation. Results. On CHROMagar Candida medium supplemented with Pal's agar all C. auris strains showed confluent growth of white to cream colored smooth colonies at 37°C and 42°C after 24 and 48h incubation and did not produce pseudohyphae. The isolates of the C. haemulonii complex, on the contrary, showed poor growth of smooth, light-pink colonies at 24h while at 48h the growth was semiconfluent with the production of pseudohyphae. C. haemulonii complex failed to grow at 42°C. Conclusions. We report a rapid and cheap method using CHROMagar Candida medium supplemented with Pal's agar for differentiating C. auris from isolates identified as C. haemulonii by VITEK2 (AU)

Antecedentes. Candida auris es una especie única debido a su resistencia a múltiples fármacos y a la identificación errónea por sistemas comerciales como Candida haemulonii. Su correcta identificación es importante para evitar un tratamiento inadecuado. Objetivos. Desarrollar un método de bajo coste para diferenciar C. auris de aislamientos identificados como C. haemulonii por el método VITEK®2. Métodos. Quince aislamientos de C. auris, seis de C. haemulonii, seis aislamientos de Candida duobushaemulonii y un aislamiento de Candida haemulonii var. vulnera se sembraron en medio CHROMagar Candida enriquecido con medio de Pal para una mejor diferenciación. Resultados. En el medio CHROMagar Candida enriquecido con medio de Pal, todos los aislamientos de C. auris presentaron un crecimiento confluente con colonias lisas de color blanco a blanco amarillento a 37 y 42°C tras 24 y 48 h de incubación; no hubo producción de seudohifas. Los aislamientos del complejo C. haemulonii, en cambio, mostraron un crecimiento menor. Las colonias eran lisas y de un color rosa claro a las 24 h; a las 48 h el crecimiento fue semiconfluente y se observó producción de seudohifas. No hubo crecimiento de ninguno de los aislamientos a 42°C. Conclusiones. El medio CHROMagar Candida enriquecido con medio de Pal es rápido y de bajo coste, y resulta efectivo para identificar C. auris entre cepas previamente identificadas como C. haemulonii por el método VITEK®2 (AU)

Simple low cost differentiation of Candida auris from Candida haemulonii complex using CHROMagar Candida medium supplemented with Pal's medium.

BACKGROUND: Candida auris is unique due to its multidrug resistance and misidentification as Candida haemulonii by commercial systems. Its correct identification is important to avoid inappropriate treatments. AIMS: To develop a cheap method for differentiating C. auris from isolates identified as C. haemulonii by VITEK2. METHODS: Fifteen C. auris isolates, six isolates each of C. haemulonii and Candida duobushaemulonii, and one isolate of Candida haemulonii var. vulnera were tested using CHROMagar Candida medium supplemented with Pal's agar for better differentiation. RESULTS: On CHROMagar Candida medium supplemented with Pal's agar all C. auris strains showed confluent growth of white to cream colored smooth colonies at 37°C and 42°C after 24 and 48h incubation and did not produce pseudohyphae. The isolates of the C. haemulonii complex, on the contrary, showed poor growth of smooth, light-pink colonies at 24h while at 48h the growth was semiconfluent with the production of pseudohyphae. C. haemulonii complex failed to grow at 42°C. CONCLUSIONS: We report a rapid and cheap method using CHROMagar Candida medium supplemented with Pal's agar for differentiating C. auris from isolates identified as C. haemulonii by VITEK2.

Antimicrobial susceptibility profile, treatment outcome and serotype distribution of clinical isolates of Salmonella enterica subspecies enterica: a 2-year study from Kerala, South India.

BACKGROUND/PURPOSE: Typhoid and paratyphoid fever continue to be important causes of illness and death in parts of Asia, being associated with poor sanitation and consumption of unsafe food and water. Antimicrobial resistance has emerged to traditional first-line drugs, namely, the fluoroquinolones, as well as to third-generation cephalosporins, posing challenges to treatment. Azithromycin has proven to be an effective alternative for treatment of uncomplicated typhoid fever. The purpose of this study was to determine the antimicrobial susceptibility, clinical outcome and serotype distribution pattern of clinical isolates belonging to Salmonella enterica subspecies enterica. METHODOLOGY: All clinical isolates of S. enterica obtained from blood, sterile body fluids, as well as stool and urine samples at Amrita Institute of Medical Sciences and Research Centre, Kerala, India, between August 2011 and July 2013 were included in the study and processed based on standard microbiology protocols. RESULTS: A total of 118 isolates of Salmonella were obtained during the study period. Out of these, 79 were of S. Typhi (66.95%), followed by isolates of S. Paratyphi A (22; 18.64%) and S. Typhimurium 12 (10.17%). Five isolates could not be identified further. There was 100% susceptibility to ceftriaxone in all S. enterica subspecies. Ciprofloxacin susceptibility was 32.91% for S. Typhi and 40.90% for S. Paratyphi A as determined by the disk diffusion method. The susceptibility profile of S. Typhi isolates to different antimicrobials was as follows: chloramphenicol (94.93%), ampicillin (77.21%), cotrimoxazole (75.94%) and azithromycin (78.48%). For S. Typhi, the minimum inhibitory concentration (MIC) of ciprofloxacin required to inhibit the growth of 50% of organisms was 0.5 µg/mL (intermediate) and MIC required to inhibit the growth of 90% of organisms was 1 µg/mL (resistant). S. Typhimurium was 100% susceptible to cotrimoxazole, ampicillin, ceftriaxone, chloramphenicol, ofloxacin and azithromycin. Susceptibility to ciprofloxacin was 66.66%. Patients from whom S. Typhimurium was isolated had comorbidities with documented risk. Of the 118 patients, 3 expired. Two had typhoid fever and were in sepsis at admission. One had S. Typhimurium and was suffering from multiple myeloma. CONCLUSION: S. Typhi was the predominant isolate. All isolates were susceptible to ceftriaxone. Chloramphenicol susceptibility was >90%. No multidrug-resistant Salmonella strains were isolated. Susceptibility to ciprofloxacin for S. Typhi was 33%. Recovery rate was 97%.

Detection of occult hepatitis B and window period infection among blood donors by individual donation nucleic acid testing in a tertiary care center in South India.

With the introduction of highly sensitive hepatitis B surface antigen immunoassay, transfusion associated HBV infection have reduced drastically but they still tend to occur due to blood donors with occult hepatitis B infection (OBI) and window period (WP) infection. Sera from, 24338 healthy voluntary blood donors were screened for HBsAg, HIV and HCV antibody using Vitros Enhanced Chemiluminescent Immunoassay. The median age of the donor population was 30 (range 18-54) with male preponderance (98%). All serologically negative samples were screened by nucleic acid testing (NAT) for viral DNA and RNA. NAT-positive samples were subjected to discriminatory NAT for HBV, HCV, and HIV and all samples positive for HBV DNA were tested for anti-HBc, anti-HBs, HBeAg. Viral load was determined using artus HBV RG PCR Kit. Of the 24,338 donors screened, 99.81% (24292/24338) were HBsAg negative of which NAT was positive for HBV DNA in 0.0205% (5/24292) donors. Four NAT positive donors had viral load of <200 IU/ml making them true cases of OBI. One NAT positive donor was negative for all antibodies making it a case of WP infection. Among OBI donors, 75% (3/4) were immune and all were negative for HBeAg. Precise HBV viral load could not be determined in all (5/5) NAT positive donors due to viral loads below the detection limit of the artus HBV RG PCR Kit. The overall incidence of OBI and WP infections was found to be low at 1 in 6503 and 1 in 24214 donations, respectively. More studies are needed to determine the actual burden of WP infections in Indian blood donors.

Chromoblastomycosis due to Fonsecaea pedrosoi: an old wine in a rare bottle.

Chromoblastomycosis is a chronic subcutaneous mycosis commonly caused by Fonsecaea, Phialophora, and Cladophialophora spp. Out of these, Fonsecaea pedrosoi is the most common etiological agent, implicated in 70%-90% of the cases reported worldwide. The histopathological diagnosis of chromoblastomycosis is based on visualization of medlar or sclerotic bodies in the tissue. These sclerotic bodies divide by planar division. Rarely, budding is seen in these sclerotic bodies. As this entity can be confused with phaeohyphomycosis, it is important to be aware of such a presentation also. We report two cases of chromoblastomycosis that showed budding sclerotic bodies.

Percutaneous endoscopic gastrostomy (PEG) site infections: a clinical and microbiological study from university teaching hospital, India.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is used to provide enteral access in patients who are unable to swallow. Infection of the stoma is an important complication and there is little data from India on this problem, which can be used to inform infection prevention and prophylactic strategies. AIM: The objective was to assess the prevalence and the role of contributory factors in PEG site infections. METHODS: A total of 173 patients underwent PEG insertion from January 2011 to May 2012. Clinical and microbiological data were collected for culture-positive cases. Insertion was performed using a standard sterile pull-through technique. Infections were defined as two of: peristomal erythema, induration, and purulent discharge. RESULTS: A total of 54 PEG infections occurred in 43 patients (28.85%). Seventy-seven organisms were isolated. Pseudomonas aeruginosa was the most common (n=29) followed by coliforms (n=21) and meticillin resistant Staphylococcus aureus (MRSA) (n=6). Thirty-one (72%) received amoxicillin-clavulanic acid as prophylaxis and 12 (28%) were receiving concomitant antibiotics for their underlying conditions. The occurrence of PEG site infections was statistically independent of the administered prophylactic antibiotics (p=0.3). CONCLUSIONS: This study has demonstrated the importance of PEG sites as a cause of healthcare associated infections. Educating patients on wound care practices would play a significant role in prevention of PEG site infections.

Salmonella Typhimurium pneumonia in a patient with multiple myeloma.

Pneumonia due to non-typhoidal Salmonella is a rarely reported entity. A fatal case of Salmonella pneumonia is reported here where Salmonella Typhimurium was isolated from the endotracheal aspirate and blood culture.

Nocardia farcinica brain abscess: epidemiology, pathophysiology, and literature review.

BACKGROUND: Infections caused by Nocardia farcinica are potentially lethal because of the organism's tendency to disseminate and resist antibiotics. Central nervous system involvement has been documented in 30% of infections caused N. farcinica. METHODS: Case report and review of the literature. RESULTS: A case of primary brain abscess caused by N. farcinica, identified by 16SrRNA sequencing, is presented, and 39 cases reported previously in the literature are reviewed. Our patient underwent a neuronavigation-guided right frontal craniotomy and was treated with trimethoprim/sulfamethoxazole and amoxicillin-clavulanic acid for 12 mo. He showed marginal improvement in his prior left hemiparesis at the last review 14 months later. CONCLUSION: Cases of N. farcinica infections are being reported increasingly because of recent changes in taxonomy and diagnostic methodology. This change in epidemiology has implications for therapy because of the organism's pathogenicity and natural resistance to multiple antimicrobial agents, including third-generation cephalosporins. Any delay in starting appropriate antibiotic therapy can have adverse consequences.

Autochthonous blastomycosis of the adrenal: first case report from Asia.

Systemic endemic mycoses, such as blastomycosis, are rare in Asia and have been reported as health risks among travelers who visit or reside in an endemic area. Adrenal involvement is rarely seen in blastomycosis and has never been reported from Asia. We report the first case of blastomycosis with bilateral involvement of the adrenals in a diabetic patient residing in the state of Arunachal Pradesh, India.

Detection of oxacillin-susceptible mecA-positive Staphylococcus aureus isolates by use of chromogenic medium MRSA ID.

Reports of oxacillin-susceptible mecA-positive Staphylococcus aureus strains are on the rise. Because of their susceptibility to oxacillin and cefoxitin, it is very difficult to detect them by using routine phenotypic methods. We describe two such isolates that were detected by chromogenic medium and confirmed by characterization of the mecA gene element.

Revised Ciprofloxacin Breakpoints for Salmonella: Is it Time to Write an Obituary?

OBJECTIVES: To determine the minimum inhibitory concentration of ciprofloxacin among 50 blood stream isolates of Salmonella enterica. MATERIAL AND METHODS: A total of 50 consecutive isolates of Salmonella enterica were tested for susceptibility to antimicrobials using the Kirby Bauer disk diffusion method. Minimum inhibitory concentrations were determined using Hi-Comb strips. All results were interpreted according to the CLSI guidelines. RESULTS: Of the 50 isolates 70%were Salmonella Typhi, 4% Salmonella paratyphi A, 2% Salmonella paratyphi B and the remaining 10% were identified only as Salmonella species. Using the CLSI 2011 breakpoints for disc diffusion, 86% (43/50) were resistant to nalidixic acid(NA), 22% (11/50) to ciprofloxacin, 12% to azithromycin, 6% to cotrimoxazole, 4% to ampicillin and 1% to chloramphenicol. The MIC50 and MIC90 of ciprofloxacin for S.Typhi were 0.181 µg/mL and 5.06 µg/mL respectively. While the same for S. paratyphi A was 0.212µg/mL and 0.228µg/mL respectively. None of the isolates were multi drug resistant and all were susceptible to ceftriaxone. Using the CLSI 2012 revised ciprofloxacin breakpoints for disc diffusion (>31mm) & MIC (<0.06 µg/mL), 90% (45/50) of these isolates were found to be resistant. CONCLUSION: MIC's of ciprofloxacin should be reported for all salmonella isolates and should be used to guide treatment. Blindly following western guidelines for a disease which is highly endemic in the subcontinent will spell the death knell of a cheap and effective drug in our armamentarium. Therefore it will be too premature to declare that "the concept of using ciprofloxacin in typhoid fever is dead!"