Clinical Utility of Blood Culture Identification 2 Panel in Flagged Blood Culture Samples from the Intensive Care Unit of a Tertiary Care Hospital.

Background: The availability of rapid diagnostic platforms for positive blood cultures has accelerated the speed at which the clinical microbiology laboratory can identify the causative organism and facilitate early appropriate antimicrobial therapy. There is a paucity of data regarding the clinical utility of the blood culture identification 2 (BCID2) panel test and its correlation with phenotypic drug susceptibility testing (DST) in flagged blood culture bottles from intensive care units (ICUs) in countries such as India, which have high rates of multidrug-resistant gram-negative bacteria (MDR-GNB). Materials and methods: We conducted a retrospective observational study in a tertiary care ICU on 200 patients above 18 years of age in whom a BCID2 test was ordered when blood cultures flagged positive. Results: We found 99% concordance between BCID2 and cultures in the identification of bacteria and yeasts and 96.5% concordance between phenotypic and genotypic DST. Furthermore, BCID2 was available about 1.5 days earlier than conventional ID and DST and played a key role in tailoring antimicrobials in 82.5% of the patients. Polymyxin-based therapy was discontinued earlier after an empiric dose in 138 patients (69%) based on BCID2 reports. Conclusion: In critically ill patients with monomicrobial bacteremia, BCID2 rapidly identifies bacteria and antimicrobial resistance (AMR) genes and is significantly faster than conventional culture and sensitivity testing. Antibiotics were escalated in more than a third of patients and de-escalated in almost a fifth on the same day. We recommend that all ICUs routinely incorporate the test in their antibiotic decision-making process and in antimicrobial stewardship. How to cite this article: Vineeth VK, Nambi PS, Gopalakrishnan R, Sethuraman N, Ramanathan Y, Chandran C, et al. Clinical Utility of Blood Culture Identification 2 Panel in Flagged Blood Culture Samples from the Intensive Care Unit of a Tertiary Care Hospital. Indian J Crit Care Med 2024;28(5):461-466.

Xpert Carba-R Assay on Flagged Blood Culture Samples: Clinical Utility in Intensive Care Unit Patients with Bacteremia Caused by Enterobacteriaceae.

Introduction and background: Rapid molecular diagnostics to predict carbapenem resistance well before the availability of routine drug sensitivity testing (DST) can serve as an antimicrobial stewardship tool in the context of high rates of Carbapenem-resistant Enterobacteriaceae (CRE). Materials and methods: A retrospective observational study of patients more than 18 years of age on whom Xpert Carba-R (FDA approved for rectal swab specimen) was done on gram-negative bacteria (GNB) flagged blood culture samples, in an Indian intensive care unit between January 2015 and November 2018. We analyzed the performance of Xpert Carba-R in comparison with routine DST. Results: A total of 164 GNBs were isolated from 160 patients. Klebsiella pneumoniae and Escherichia coli were the predominant isolates. Carba-R was positive in 35.36% of samples and 45.34% were carbapenem-resistant (CR) on routine DST. The distribution of the CR gene was: Oxacillinase (OXA) (50%), NDM (32.7%) followed by OXA and NDM co-expression (15.51%). The sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, positive predictive value, and negative predictive value of Carba-R were 90.74, 93.15, 13.25, 0.10, 83.58 and 96.31% for Enterobacteriaceae. The median time to obtain the Carba-R report was 30 hours 34 minutes vs 74 hours and 20 minutes for routine DST. Based on the Carba-R report, 9.72% of patients had escalation and 27.08% had de-escalation of antibiotics. Conclusion: Xpert Carba-R serves as a rapid diagnostic tool for predicting carbapenem resistance in intensive care unit patients with bacteremia caused by Enterobacteriaceae. How to cite this article: Rajendran S, Gopalakrishnan R, Tarigopula A, Kumar DS, Nambi PS, Sethuraman N, et al. Xpert Carba-R Assay on Flagged Blood Culture Samples: Clinical Utility in Intensive Care Unit Patients with Bacteremia Caused by Enterobacteriaceae. Indian J Crit Care Med 2023;27(9):655-662.

Post-COVID multisystem inflammatory syndrome in adults: a study from a tertiary care hospital in south India.

Background & objectives: There are limited data from India on the post-COVID multisystem inflammatory syndrome in adults (MIS-A). The objective of the present study was to evaluate the clinical profile of patients with MIS-A admitted to a tertiary care centre in southern India. Methods: This single-centre retrospective study was conducted from November 2020 to July 2021, and included patients aged >18 yr admitted to the hospital as per the inclusion and exclusion criteria. Results: Nine patients (5 male, mean age 40±13 yr) met the criteria for MIS-A. Five patients had proven COVID-19 infection or contact history 36.8±11.8 days back. All patients were positive for SARS-CoV-2 IgG antibody, negative for COVID-19 PCR, and had negative blood, urine and sputum cultures. All patients had fever and gastrointestinal (GI) symptoms, and five patients had left ventricular dysfunction. All patients had neutrophilic leucocytosis at presentation and elevated biomarkers such as C-reactive protein serum procalcitonin, D-dimer and ferritin. The majority of the patients (7/9 i.e. 77.78%) were treated with intravenous hydrocortisone (50-100 mg q6h-q8h). Six patients recovered completely whereas three patients expired. Interpretation & conclusions: Fever and GI symptoms were the most common presentation of MIS-A. Elevated serum procalcitonin may not be useful in differentiating bacterial sepsis from MIS-A. Most patients responded to corticosteroids.

Fungal abscess after intra-orbital steroid injection: a case report.

A 28-year-old male presented with gradually progressive swelling of the right lower eyelid along with a prominence of the eye for 6 months. He had received oral steroids and intraorbital triamcinolone acetonide injection in the inferior quadrant for active thyroid eye disease. External examination revealed right eye proptosis and swelling along the inferior orbital region. Magnetic resonance imaging showed an ill-defined soft tissue lesion in the inferior extraconal space and a bulky right inferior rectus. Histopathology of the biopsied material revealed inflammation with septate fungal filaments, identified as Aspergillus flavus on culture. He responded well to oral voriconazole despite a recurrence during the course of treatment. Intraorbital steroids are given for idiopathic and thyroid-associated orbital inflammation. This is a report of a rare complication of fungal orbital abscess following intraorbital corticosteroid injection in an immunocompetent young patient.

Melioidosis-Commonly Missed, Yet Not Uncommon and Eminently Treatable.

How to cite this article: Gopalakrishnan R. Melioidosis-Commonly Missed, Yet Not Uncommon and Eminently Treatable. Indian J Crit Care Med 2021;25(3):258-259.

Clinical Profile of Non-neutropenic Patients with Invasive Candidiasis: A Retrospective Study in a Tertiary Care Center.

Introduction: Invasive candidiasis (IC) is a major cause of morbidity and mortality in critically ill patients in the intensive care unit (ICU). In this study, we aim to analyze the clinical profile, species distribution, and susceptibility pattern of patients with IC. Methods: Case records of non-neutropenic patients ≥18 years of age with IC between January 2016 and June 2019 at a tertiary care referral hospital were analyzed. IC was defined as either candidemia or isolation of Candida species from a sterile site (such as CSF; ascitic, pleural, or pericardial fluid; or pus or tissue from an intraoperative sample) in a patient with clinical signs and symptoms of infection. Results: A total of 114 patients were analyzed, out of which 105 (92.1%) patients had bloodstream infection (BSI) due to Candida and 9 (7.9%) had IC identified from a sterile site. Central line-associated blood stream infection (27 patients, 23.6%) and a gastrointestinal source (30 patients, 26.3%) were the most common presumed sources for candidemia. The commonest species was Candida tropicalis 42 (36.8%), followed by Candida glabrata 20 (17.5%). Serum beta-D-glucan (BDG) was done only in 32 patients of the 114 (35.3%); among those who were tested, 5 (15.6%) had a BDG value of less than 80 pg/mL despite having Candida BSI. Fluconazole sensitivity was 69.5% overall. At 14 days after diagnosis of IC, 49.1% had recovered, with the remainder having an unfavorable outcome (32.4% had died and 18.4% had left against medical advice). Clinical significance: IC is a major concern in Indian ICUs, with a satisfactory outcome in only half of our patients. Serum BDG is a valuable test to diagnose blood culture-negative IC, but more studies are needed to determine its role in the exclusion of IC, as we had a small minority of patients with negative tests despite proven IC. Conclusion: We recommend sending two sets of blood cultures and serum BDG assay for all suspected patients. Initiating empiric antifungal therapy with an echinocandin is advisable, in view of increasing azole resistance and the emergence of Candida auris, with de-escalation to fluconazole for sensitive isolates after clinical stability and blood culture clearance. How to cite this article: Sridharan S, Gopalakrishnan R, Nambi PS, Kumar S, Sethuraman N, Ramasubramanian V. Indian J Crit Care Med 2021;25(3):267-272.

Talaromyces marneffei Outside Endemic Areas in India: an Emerging Infection with Atypical Clinical Presentations and Review of Published Reports from India.

Talaromycosis is a disseminated disease caused by Talaromyces (Penicillium) marneffei, mainly seen in acquired immunodeficiency syndrome (AIDS) patients. Its distribution is restricted to southeast Asian countries; a small pocket of endemicity exists in the northeast Indian state of Manipur. Here, we present a series of five cases presenting to our tertiary care hospital, originating from non-endemic states neighboring Manipur. In addition to the geographical distinction, a variety of unique features were noted in our cases, including human immunodeficiency virus (HIV)-negative hosts, the absence of typical skin lesions, presentation as pneumonia and generalized lymphadenopathy. Our series highlights the importance of distinguishing this disease from histoplasmosis and tuberculosis, both endemic in India.

Can urinary histoplasma antigen test improve the diagnosis of histoplasmosis in a tuberculosis endemic region?

BACKGROUND: Many patients with histoplasmosis are treated with anti-tubercular therapy (ATT) in tuberculosis endemic regions as diagnosis of histoplasmosis requires invasive sampling. We sought to study the utility of urinary Histoplasma antigen detection test. METHODS: Case records of patients with a diagnosis of histoplasmosis prior to (Period A) and after (Period B) introduction of urinary Histoplasma antigen detection test were analysed in this single centre retrospective study. RESULTS: Thirty-seven patients (18 in Period A, and 19 patients in Period B) were studied. There was nearly a threefold increase in diagnoses (from 0.39 cases to 1.18 cases per month) after the introduction of antigen test. Nine patients (24.3%) were immunocompromised (6 had HIV infection and 3 were on steroids), and 28 (75.6%) were immunocompetent. Empirical ATT had been given to 10 patients prior to histoplasmosis diagnosis. Invasive tissue sampling was required in only two patients in Period B to confirm the diagnosis. Immunocompromised patients were younger, were more likely to have skin and mucosal findings, anaemia and leucopenia as compared to immune-competent patients. CONCLUSION: This study emphasises that histoplasmosis cases may be missed and patients may receive ATT unnecessarily. Histoplasma antigen increased the diagnostic yield by almost threefold in our study.

Profile of Infective Endocarditis: At a Tertiary Care Referral Centre.

BACKGROUND: Infective endocarditis (IE) remains a serious challenge with a persistently high morbidity and mortality despite the availability of improved diagnostic and treatment amenities in the developing world. Data on the clinical and microbiological profile of IE in India is still limited. The emergence of modern risk factors such as hospitalization and device insertion has changed the epidemiology of the disease in the western world, whereas in India and other parts of the developing world the situation is more complex because of the concomitant burden of rheumatic heart disease and congenital heart defects. We therefore attempted to describe the changing epidemiology of the disease in a cohort of patients with definite IE admitted to a tertiary care centre. METHODS: 145 cases were identified as IE during the period January 2010-December 2015 (6 years) of which 120 'definite' cases of IE according to the modifies Dukes' criteria were analysed. RESULTS: The mean age of patients was 53 years ± 15 years (age range 18 to 79 years) with a male preponderance of 72%. Native valve disease was seen in 103 cases and 17 cases had prosthetic valve infections. IE was classified as community acquired in 87 (72.5%) cases and healthcare associated in 33(27.5%) events. Predisposing factors contributing to healthcare associated events included hemodialysis in 8.3%, recent surgical intervention which included urological instrumentation with urosepsis and gastrointestinal procedures in 5.8% events. Postpartum IE was seen in 1.7% cases. There was evidence of remote abscess, prior bacteraemia or septic foci in the preceding 3 months of presentation with IE in 8.3% of patients and 3.3% patients underwent prior dental procedure. Prior structural heart disease was present in 47.5% of cases of which Rheumatic heart disease (RHD) was seen in 15%. A previous episode of infective endocarditis was observed in significantly more patients with PVE (29.4%) than with NVE (1.9%). Blood cultures were negative in 50 (41.7%) of cases of whom 60% had received antibiotics prior to admission. Nine of 17 patients with PVE (52.9%) were culture negative. In the 70(58.3% of all patients) patients with positive blood cultures, Streptococcus sp were the commonest bacteria isolated in 15.8%, of which Viridans group Streptococci (VGS) was seen in majority of the cases (13.3%) followed by Staphylococcus sp (14.2%) with methicillin resistant staphylococcus was seen in 3.3% and Enterococcus sp in 13.3%. Gram negative bacteraemia were seen in 8.3%. In addition, ESBL E coli constituted 4% of our culture positive cases, perhaps representing a complication of this common community acquired bacteraemia and increasing resistance in E coli. Tissue / valve cultures in patients who underwent surgery was positive in four cases, 3 of whom where blood culture negative The mortality rate was higher among PVE (33%) compared to 10% in NVE. The most common cause of death in IE was usually congestive cardiac failure. CONCLUSIONS: Thought Rheumatic heart disease continues to be the most common predisposing factor, degenerative heart diseases and healthcare associated IE are also gradually increasing. Use of antibiotics prior to sending blood cultures remains a significant cause of culture negativity. Viridans streptococci continue to be the commonest pathogen and though ESBL E coli constituted a significant minority it could expound the changing epidemiology and risk factors for Gramnegative endocarditis especially non-HACEK group necessitating an updated review of this subject.

Experience with ß-D-Glucan Assay in the Management of Critically ill Patients with High Risk of Invasive Candidiasis: An Observational Study.

BACKGROUND: The (1,3)-ß-D-glucan assay (BDG) is recommended for the early diagnosis of invasive candidiasis (IC). METHODS: Records of 154 critically ill adults with suspected IC, on whom BDG was done, were analyzed. Patients were divided into three groups: Group A (confirmed IC), Group B (alternative diagnosis or cause of severe sepsis), and Group C (high candidal score and positive BDG [>80 pg/mL] but without a confirmed diagnosis of IC). RESULTS: Mean BDG levels were significantly higher in Group A (n = 32) as compared to Group B (n = 60) and Group C (n = 62) (448.75 ± 88.30 vs. 144.46 ± 82.49 vs. 292.90 ± 137.0 pg/mL; P < 0.001). Discontinuation of empiric antifungal therapy based on a value <80 resulted in cost savings of 14,000 INR per day per patient. CONCLUSION: A BDG value of <80 pg/ml facilitates early discontinuation of empirical antifungal therapy, with considerable cost savings.

Seven cases of Saccharomyces fungaemia related to use of probiotics.

Probiotics are increasingly used in critically ill patients without enough safety data. The aim of the present study was to determine the association of probiotics with Saccharomyces cerevisiae fungaemia. Seven patients with S. cerevisiae fungaemia were reported at two hospitals in India between July 2014 and September 2015. Detailed clinical history of patients was recorded. Besides the seven patient isolates, three probiotics sachets used in those patients and five unrelated clinical isolates were used for association study by Fluorescent amplified fragment length polymorphism (FAFLP). Antifungal susceptibility testing was performed by broth microdilution technique of CLSI (M27-A3) and interpreted according to CLSI (M27S4). Two patients were premature neonates and five were adults. They were admitted in intensive care unit and were on probiotics containing S. boulardii (except one adult patient). FAFLP analysis showed 96.4-99.7% similarity between blood and corresponding probiotic isolates. Of the three AFLP types (group I, II, II) identified, all the probiotic isolates clustered in group I (major cluster) including majority of the blood isolates. The isolates were susceptible to all antifungal agents tested. Five patients, who could be evaluated, responded promptly to echinocandins or voriconazole. As the prescription of probiotic containing S. boulardii in critically ill patient's leads to the fungaemia, we recommend avoiding this probiotic in those patients.

Listeria in Adults - Truly Rare or Rarely Diagnosed in India?

Listeria monocytogenes is a facultative anaerobic intracellular Gram positive rod causing infection in pregnant women, extremes of age and immune-compromised hosts. In clinical specimens, the organisms may be gram-variable: laboratory misidentification of L. monocytogenes isolates as diphtheroids, streptococci, or enterococci is not uncommon and the isolation of a diphtheroid from blood or CSF should always alert the clinician to the possibility that the organism may be L. monocytogenes. The disease has rarely been reported in India in non-pregnant adults. We herein report four cases of L. monocytogenes infection in immune-compromised adults.

A Study of 24 Patients with Colistin-Resistant Gram-negative Isolates in a Tertiary Care Hospital in South India.

BACKGROUND: As the use of colistin to treat carbapenem-resistant Gram-negative infections increases, colistin resistance is being increasingly reported in Indian hospitals. MATERIALS AND METHODS: Retrospective chart review of clinical data from patients with colistin-resistant isolates (minimum inhibitory concentration >2 mcg/ml). Clinical profile, outcome, and antibiotics that were used for treatment were analyzed. RESULTS: Twenty-four colistin-resistant isolates were reported over 18 months (January 2014-June 2015). A history of previous hospitalization within 3 months was present in all the patients. An invasive device was used in 22 (91.67%) patients. Urine was the most common source of the isolate, followed by blood and respiratory samples. Klebsiella pneumoniae constituted 87.5% of all isolates. Sixteen (66.6%) were considered to have true infection, whereas eight (33.3%) were considered to represent colonization. Susceptibility of these isolates to other drugs tested was tigecycline in 75%, chloramphenicol 62.5%, amikacin 29.17%, co-trimoxazole 12.5%, and fosfomycin (sensitive in all 4 isolates tested). Antibiotics that were used for treatment were combinations among the following antimicrobials-tigecycline, chloramphenicol, fosfomycin, amikacin, ciprofloxacin, co-trimoxazole, and sulbactam. Among eight patients who were considered to have colonization, there were no deaths. Bacteremic patients had a significantly higher risk of death compared to all nonbacteremic patients (P = 0.014). CONCLUSIONS: Colistin resistance among Gram-negative bacteria, especially K. pneumoniae, is emerging in Indian hospitals. At least one-third of isolates represented colonization only rather than true infection and did not require treatment. Among patients with true infection, only 25% had a satisfactory outcome and survived to discharge. Fosfomycin, tigecycline, and chloramphenicol may be options for combination therapy.

Antiretroviral Therapy for HIV Infection: Time to Switch to Once-Daily Regimens?

BACKGROUND: Data is scarce regarding virologic and immunologic outcomes and the side-effect profile of antiretroviral therapy in the private health sector in India. METHODS: We retrospectively reviewed the case records of 250 HIV infected individuals being followed up at a private sector hospital, with emphasis on the nature of antiretroviral regimens prescribed, virologic and immunologic response to therapy and the side-effect profile of medications. RESULTS: Once daily co-formulated tenofovir-emtricitabine-efavirenz was the most commonly used antiretroviral regimen (58% of patients). Virologic suppression (HIV RNA quantitative RT-PCR < 200 copies/ml) was achieved in 79% of patients at 6 months, 81% patients at 1 year and 87% at 5 years. The mean CD4 count at treatment initiation was 191 cells/ µl, and increased to 359 cells/µl after 1 year and to 521 cells /µl after 5 years. Stavudine was stopped in 16.7% due to side-effects, abacavir associated hypersensitivity reactions developed in 13%, zidovudine associated anemia developed in 5.2% and tenofovir was discontinued due to nephrotoxicity in 1.4%. Serum LDL, fasting blood glucose and serum creatinine did not significantly change over time in our patient population. CONCLUSIONS: In a private sector setting, ART with co-formulated single tablet TDF/FTC/EFV resulted in excellent virologic suppression and immune reconstitution and had few adverse effects over a follow up period of almost 5 years. Nephrotoxicity was not a major concern and it may not be necessary to monitor blood glucose and lipid profiles on this regimen. Based upon our results and WHO guidelines, we recommend that the public sector ART program adopt annual virologic monitoring and switch to single pill once daily relatively non-toxic formulations as first-line regimens.

Carbapenem resistant Gram-negative bacteremia in an Indian intensive care unit: A review of the clinical profile and treatment outcome of 50 patients.

BACKGROUND: Growing antimicrobial resistance and limited therapeutic options to treat carbapenem-resistant bacteremia prompted us to evaluate the clinical outcomes associated with healthcare-associated bacteremia. METHODS: This was a retrospective observational study of carbapenem-resistant Gram-negative bacteremia performed at a tertiary care facility in Chennai, India between May 2011 and May 2012. RESULTS: In our study, patients had mean 11.76 days of intensive care unit (ICU) care and mean time to onset of bacteremia was 6.4 days after admission. The commonest organism was Klebsiella pneumoniae (44%). Patients with combination treatment had lower mortality (44.8%) compared with colistin monotherapy (66.6%); (P = 0.35). CONCLUSION: Carbapenem resistant bacteremia is a late onset infection in patients with antibiotic exposure in the ICU and carries a 30 days mortality of 60%; K. pneumoniae is the most common organism at our center. Two drug combinations appear to carry a lower mortality compared with monotherapy.

An elderly male with septic arthritis and bacteremia.

Rhodococcus hoagii is a gram positive actinomycete found in horses and cattle. Humans can be infected by ingestion or inhalation through contaminated food or soil. The organism usually infects immunosuppressed hosts with pneumonia being the common presentation. We present a case of an 89 years old, apparently immunocompetent host presenting with fever, encephalopathy and arthritis who grew Rhodococcus hoagii in blood and synovial fluid, The patient responded well to a combination of vancomycin, azithromycin and imipenem-cilastatin. Our case demonstrates that extra-pulmonary manifestations such as septic arthritis and bacteremia can be seen in immune competent hosts.

Epidemiology and outcomes of infections during extracorporeal membrane oxygenation in adult patients with COVID-19 ARDS- A single center study.

BACKGROUND: There is a scarcity of data regarding nosocomial infections in patients with COVID-19 treated with ECMO. This observational study from India aims to describe the epidemiology and microbiology of infections in patients with COVID-19 associated ECMO. METHODS: This is an ambi-directional observational study of COVID-19 ECMO patients admitted from April 2021 to June 2022 in a tertiary care hospital. The total number of sepsis episodes for each patient was recorded and were categorized as bloodstream infections (BSI), pneumonias, skin and soft tissue infections (SSTI), invasive candidiasis (IC), catheter associated urinary tract infection (CAUTI), intra-abdominal infections (IAI), and Clostridioides difficile infections. Details regarding each infection including the microbiological profile and outcomes were recorded. RESULTS: 29 patients who received ECMO for COVID-19 pneumonia during the study period were identified. Of the 29 patients, there were a total of 185 septic episodes. The incidence of septic episodes was 72.4 per 1000 ECMO days. Of the 185 sepsis events, 82 (44.3%) were BSI, 72 (39%) were pneumonia, 19 (10.3%) were SSTI, 7 (3.8%) were CAUTI and 5 (2.7%) were IAIs. Of these 29 patients, 16 (55.2%) patients were discharged and 13 (44.8%) died. CONCLUSIONS: The most common infections in our patients were bloodstream infections followed by pneumonia. High rates of gram negative infections, including those caused by carbapenem resistant bacteria, reflect the Indian critical care unit epidemiology in general. Despite these high infection rates with antimicrobial resistant set of micro-organisms, we had a successful outcome in 55.2% of patients.

Antimicrobial susceptibility of Salmonella enterica serovars in a tertiary care hospital in southern India.

BACKGROUND & OBJECTIVES: Salmonella enterica serovars Typhi and Paratyphi are predominantly known to cause enteric fever. Multidrug resistance in S. Tphi and S. Paratyphi has emerged as a cause of concern. This study was done to evaluate status in antimicrobial susceptibility patterns of Salmonella enterica serovar Typhi (S. Typhi) and S. Paratyphi obtained from blood culture in a tertiary care hospital in south India. METHODS: Blood isolates of Salmonella species over a two year period between May 2009 and June 2011 were studied. A total of 322 isolates of Salmonella species were tested for antimicrobial susceptibility by Kirby-Bauer disc diffusion method. The MIC of ciprofloxacin was obtained by E-test, and azithromycin MIC was confirmed by agar dilution method for a limited number of isolates. RESULTS: Of the total of 322 isolates studied, 186 (57.8%) were S. Typhi, 134 (41.6%) were S. Paratyphi A, and two were S. Paratyphi B. Of these, 44(13.66%) were resistant to ciprofloxacin (MIC <0.50 µg/ml) and 296 (91.9%) were nalidixic acid resistant. Of these 296 nalidixic acid resistant isolates, 278 (94%) were susceptible to ciprofloxacin by MIC criteria (<0.5 µg/ml). Of the 262 isolates tested for azithromycin sensitivity, only 120 (46%) were susceptible, whereas 81 (31%) were resistant and 55 (21%) showed intermediate susceptibility. Of the isolates, 322 (90%) were susceptible to ampicillin and (95%) were susceptible to co-trimoxazole. However, all the isolates were susceptible to chloramphenicol and ceftriaxone. INTERPRETATION & CONCLUSIONS: Nalidixic acid resistance screening is not a reliable surrogate indicator of ciprofloxacin resistance. Ciprofloxacin MIC should to be routinely done. Azithromycin resistance appears to be emerging. However, isolates showed a high degree of susceptibility to ampicillin, co-trimoxazole and chloramphenicol. Thus, antibiotics like ampicillin and co-trimoxazole may once again be useful for the management of enteric fever in southern India.

Not so uncommon, yet neglected 'Severe Streptococcus pyogenes infections at a tertiary care center in south India.

Streptococcus pyogenes (SP) causes uncomplicated infections of throat & skin to severe life-threatening invasive diseases and poststreptococcal sequelae. Despite being common, it hasn't been studied much in recent times. Data of 93 adult patients >18 years, culture proven (SP) infections from 2016 to 2019 was studied in south India. Irrespective of comorbidities, SSTI were most common followed by surgical site infections& bacteremia. Isolates were susceptible to penicillin, cephalosporins but 23% were resistant to clindamycin. Timely surgical interventions and appropriate antibiotics reduced morbidity& limb salvage by 9 times. Larger studies, worldwide, to see the current trend of SP need to be conducted.