Clinical spectrum, phenotypic and molecular characterization, and antifungal susceptibility of an emerging human pathogen, Acrophialophora, from India.

Acrophialophora is implicated in superficial and invasive infections, especially in immunosuppressed individuals. The present study was undertaken to provide clinical, microbiological, phylogenetic, and antifungal susceptibility testing (AFST) profile of Acrophialophora isolated from India. All the isolates identified as Acrophialophora species at National Culture Collection for Pathogenic Fungi, Chandigarh, India were revived. Phenotypic and molecular characterization was performed, followed by temperature studies, scanning electron microscopy (SEM) and AFST. We also performed systematic review of all the cases of Acrophialophora species reported till date. A total of nine isolates identified as Acrophialophora species were identified by molecular method as A. fusispora (n = 8) and A. levis (n = 1), from brain abscess (n = 4), respiratory tract (n = 3) and corneal scraping (n = 2). All patients but two had predisposing factors/co-morbidities. Acrophialophora was identified as mere colonizer in one. Temperature studies and SEM divulged variation between both species. Sequencing of the ITS ribosomal DNA and beta-tubulin loci could distinguish species, while the LSU ribosomal DNA locus could not. AFST showed lowest MICs for triazoles and highest for echinocandins. Systematic literature review revealed 16 cases (11 studies), with ocular infections, pulmonary and central nervous system infections, and A. fusispora was common species. All the patients except three responded well. High MICs were noted for fluconazole, micafungin and caspofungin. This is the first study delineating clinical, phenotypic, and genotypic characteristics of Acrophialophora species from India. The study highlights microscopic differences between both species and emphasizes the role of molecular methods in precise identification. Triazoles appear to be the most effective antifungals for managing patients.

We describe clinical, phenotypic, and genotypic characteristics of Acrophialophora species. This species causes mild infection to fatal infection in immunosuppressed individuals. Triazoles are effective in treating such infections.

Artificial Intelligence: Exploring utility in detection and typing of fungus with futuristic application in fungal cytology.

Artificial Intelligence (AI) is an emerging, transforming and revolutionary technology that has captured attention worldwide. It is translating research into precision oncology treatments. AI can analyse large or big data sets requiring high-speed specialized computing solutions. The data are big in terms of volume and multimodal with the amalgamation of images, text and structure. Machine learning has identified antifungal drug targets, and taxonomic and phylogenetic classification of fungi based on sequence analysis is now available. Real-time identification tools and user-friendly mobile applications for identifying fungi have been discovered. Akin to histopathology, AI can be applied to fungal cytology. AI has been fruitful in cytopathology of the thyroid gland, breast, urine and uterine cervical lesions. AI has a huge scope in fungal cytology and would certainly bear fruit with its accuracy, reproducibility and capacity for handling big data. The purpose of this systematic review was to highlight the AI's utility in detecting fungus and its typing with a special focus on future application in fungal cytology. We also touch upon the basics of AI in brief.

Acute disseminated encephalomyelitis due to a zoonotic co-infection.

Acute disseminated encephalomyelitis (ADEM) is a post-infectious, autoimmune, demyelinating neurological illness, usually attributed to infection with viruses. We describe a case of ADEM occurring in a child with Leptospira-Brucella co-infection. The 12-year-old girl developed a biphasic febrile illness with encephalopathy. On evaluation, she was found to have serological evidence of Brucella and Leptospira infections. Persistence of neurological symptoms after initiating treatment for the co-infection led us to do a magnetic resonance imaging scan of the brain which showed typical findings suggestive of ADEM. Patient responded appropriately to treatment of ADEM with glucocorticoids. The high prevalence of these zoonotic infections in developing countries, and the risk that these may lead to ADEM highlights the importance of detailed evaluation of such cases for proper treatment and better outcomes.

ADEM is a serious neurological disease which occurs as an uncommon complication of certain infections that lead to formation of antibodies which attack the cells of the nervous system. It usually occurs after viral infections, but we came across a 12-year-old girl with ADEM who tested positive for simultaneous infection with two different micro-organisms, both not viruses. These microbes, called Leptospira and Brucella, are common in developing countries and usually lead to infection in individuals in close contact with animals, or with consumption of infected, unpasteurized animal products. Neurological symptoms are uncommon in both infections. However, our case highlights that both infections can occur together and lead to serious neurological illness which needs proper evaluation and a different kind of treatment so that patient has better recovery.

Spectrum of Multiorgan Dysfunction in Scrub Typhus Infection.

OBJECTIVES: We planned this study to determine the clinical spectrum and compare incidence of multiorgan dysfunction in children hospitalized with scrub typhus with other etiologies of tropical fever. DESIGN: Prospective cohort study. SETTING: Pediatric emergency and PICU services of a university teaching hospital situated in the sub-Himalayan region. PATIENT: Children aged 2 months to 14 years with acute undifferentiated fever of more than 5 days. INTERVENTIONS: Detailed fever workup was performed in all children. We compared scrub typhus IgM positive children (cases) with remaining febrile children who were negative for scrub IgM assay (controls) for mortality and morbidity. MAIN RESULTS: We enrolled 224 febrile children; 76 children (34%) were positive for scrub typhus IgM ELISA. Scrub typhus group had a significantly higher incidence of multiorgan dysfunction [OR 3.5 (95% CI 2.0-6.3); p < 0.001] as compared to non-scrub typhus group requiring supportive care. The incidence of altered sensorium [OR 8.8 (95% CI 3.1-24.9)], seizures [OR 3.0 (95% CI 1.1-8.3)], acute respiratory distress syndrome [OR 17.1 (95% CI 2.1-140.1)], acute renal failure (5% vs. 0%), meningitis [OR 6.2 (95% CI 1.2-31.6)], thrombocytopenia [OR 2.8 (95% CI 1.5-5.1)], transaminitis [OR 2.7 (95% CI 1.6-4.8)], requirement of oxygen [OR 17.8 (95% CI 4.0-80.3)], positive pressure support [OR 3.7 (95% CI 1.2-10.5)] and shock requiring inotropes [OR 3.0 (95% CI 1.3-6.7)] was significantly higher in scrub typhus group as compared to the non-scrub typhus group (Table 1). CONCLUSIONS: Pediatric scrub typhus who were hospitalized had severe systemic manifestations when compared to other causes of fever.

Phaeohyphomycosis Caused by Rhytidhysteron rufulum and Review of Literature.

Phaeohyphomycosis is caused by a heterogeneous group of mycelial dematiaceous (phaeoid) fungi, which produce melanin pigment. This condition is often confused with chromoblastomycosis. Rhytidhysteron is a dematiaceous fungus, which has been recently found to be causing human infections. Till date only three cases of infection with Rhytidhysteron rufulum have been reported in the literature. All three cases have been from North India. Hereby, we present another two cases where Rhytidhysteron was isolated. Both the patients belonged to Chandigarh (India) and presented with subcutaneous lesions. The isolates were confirmed by ITS sequencing. Both the patients were immunocompetent and gave no history of trauma or any other predisposing factor. Phaeohyphomycosis are often missed due to lack of knowledge regarding the fungi causing the infections and there is need for clinical, pathological and microbiological correlation for effective diagnosis and treatment in these cases.

Fusarium sacchari, a cause of mycotic keratitis among sugarcane farmers - a series of four cases from North India.

The two most common filamentous fungi causing mycotic keratitis are Aspergillus and Fusarium spp. Around 70 Fusarium spp. are involved in causing human infections. In this study, four cases of keratitis in sugarcane farmers in India are being reported, caused by the sugar cane pathogen Fusarium sacchari, a species of the Fusarium fujikuroi species complex. Fusarial keratitis was established by potassium hydroxide/Calcofluor white wet mounts and fungal culture of corneal scrapings on conventional media. Final identification was done by genetic sequencing at CBS-KNAW, Utrecht, The Netherlands. The antifungal susceptibility testing was done using broth microdilution method as per CLSI document M38-A2. Four cases of F. sacchari keratitis were identified. Three of them had trauma with sugarcane leaves, whereas one sugarcane farmer reported trauma by vegetative matter. The morphological similarities among various Fusarium species warrant use of molecular methods for identification of cryptic species. A wide distribution of sugarcane farming could be the possible explanation for emergence of F. sacchari keratitis in India.

Mycological Profile and Antifungal Susceptibility of Fungal Isolates from Clinically Suspected Cases of Fungal Rhinosinusitis in a Tertiary Care Hospital in North India.

A prospective observational study was conducted for 18 months to analyze the mycological profile of clinically suspected cases of fungal rhinosinusitis requiring endoscopic sinus surgery and test antifungal susceptibility of the isolates according to Clinical and Laboratory Standards Institute guidelines. Per-operative biopsies (n = 126) from 106 patients were processed by standard mycological procedures. Out of 126 samples, 59 (46.83 %) had fungal elements on KOH mount examination. Fungal growth was obtained in 76 (60.32 %) samples, of which single fungal organism was isolated in 68 samples and more than one fungal species in eight samples. The most common isolates belonged to the genus Aspergillus (n = 53, A. flavus being most common) followed by mucormycetes (9), Candida species (7), Penicillium species (5), Alternaria species (5), Fusarium species (1), Curvularia species (1) and black yeast (1). Two hyaline septate fungal isolates could not be identified. Aspergillus species were susceptible to amphotericin B (n = 46), itraconazole (n = 48), voriconazole (n = 52), posaconazole (n = 53), caspofungin (n = 51), anidulafungin (n = 53) and micafungin (n = 53). All mucormycetes isolates (n = 9) were susceptible to amphotericin B, posaconazole and itraconazole. Filamentous non-Aspergillus, non-mucormycetes isolates (n = 15) were susceptible to amphotericin B (n = 12), itraconazole (n = 13), voriconazole (n = 15), posaconazole (n = 15) and echinocandins (n = 15). Amongst the 07 Candida species, 05 isolates of Candida tropicalis were susceptible to amphotericin B, posaconazole, echinocandins and 5-flucytosine; one isolate of Candida albicans had the same susceptibility but was resistant to 5-flucytosine also, and one strain of Candida species was susceptible to all the nine antifungal drugs.

Changing Epidemiology of Mucoralean Fungi: Chronic Cutaneous Infection Caused by Mucor irregularis.

INTRODUCTION: The fungi pertaining to order Mucorales usually cause an acute form of clinical disease called mucormycosis. A primary chronic presentation in an immunocompetent patient is a rare form of mucormycosis. Mucor irregularis is known for causing chronic cutaneous infections geographically confined to Asia, mainly in China. We describe a case of primary chronic cutaneous mucormycosis caused by M. irregularis from a new geographical niche in India, highlighting changing aspects of its epidemiology. CASE PRESENTATION: The patient was a farmer with a history of skin lesions over the lower limb for the past 6 years. The biopsy taken from the lesions showed pauci-septate hyphae with right-angle branching on KOH wet mount as well as special fungal stains. On fungal culture, greyish-white cottony mycelial growth of Mucormycetes was obtained. The strain was finally identified as M. irregularis on macro- and microscopic features on 2 % MEA and DNA sequencing. The antifungal susceptibility was done using EUCAST broth microdilution method and was found to be susceptible to commonly used antifungal agents. The patient was started on oral itraconazole and saturated solution of potassium iodide (SSKI). While undergoing treatment for 2 months, he was lost to follow-up, however, after a year when he recently visited the hospital; the disease got completely healed with no new crops of skin lesions. CONCLUSION: Mucoralean fungi should also be suspected in cases with chronic presentation, in immunocompetent host, as there is emergence of such fungi in new endemic areas, particularly located in Asia. The role of other antifungal agents apart from amphotericin B for the treatment of chronic mucormycosis needs to be explored.

From Spores to Solutions: A Comprehensive Narrative Review on Mucormycosis.

Mucormycosis is an infrequent but fatal illness that mainly affects patients with uncontrolled diabetes mellitus, diabetic ketoacidosis, solid and hematologic neoplasms, organ transplantation, chronic steroid intake, prolonged neutropenia, iron overload states, neonatal prematurity, severe malnutrition, and HIV. Many cases were reported across the world recently following the COVID-19 pandemic. Recent research has led to a better understanding of the pathogenesis of the disease, and global guidelines are now available for managing this serious infection. Herein, we comprehensively review the etiological agents, pathogenesis, clinical presentations, diagnosis, and management of mucormycosis.

Antifungal Susceptibility Profile of Clinical and Environmental Isolates of Aspergillus Species From a Tertiary Care Center in North India.

INTRODUCTION: Aspergillus species are ubiquitously found in the environment worldwide and are important causative agents for infection. Drug resistance among Aspergillus species is emerging, hence the present study was undertaken to look for antifungal susceptibility profiles of clinical and environmental isolates of Aspergillus species. MATERIALS AND METHODS: During the period from January 2018 to June 2019, a total of 102 Aspergillus isolates (40 clinical, 40 hospital, and 22 community environment) were tested for antifungal susceptibility testing for determination of minimum inhibitory concentration (MIC)/minimum effective concentration (MEC) as per Clinical and Laboratory Standards Institute (CLSI) M38-A3 method for itraconazole, voriconazole, amphotericin B, and caspofungin. RESULTS: Out of these 102 Aspergillus isolates, A. flavus was the most common species present. Aspergillus species were found to have low MIC values to azoles such as itraconazole and voriconazole except for one clinical isolate, which showed a MIC value of 2 µg/ml to voriconazole. Two isolates were non-wild-type for amphotericin B, but all isolates were wild-type for caspofungin. CONCLUSION: Antifungal susceptibility testing among clinical Aspergillus isolates and environmental surveillance studies in view of emerging drug resistance should be undertaken at a larger scale.

White light generation by carbonyl based indole derivatives due to proton transfer: an efficient fluorescence sensor.

The motivation of the present work is to understand the optical, chemical, and electrical aspects of the proton transfer mechanism of indole (I) and some carbonyl based indole derivatives: indole-3-carboxaldehyde (I3C) and indole-7-carboxaldehyde (I7C) for both powder form and their liquid solution. Structural information for indole derivatives (isolated molecule and in solution) is obtained with density functional theory (DFT) and time dependent DFT (TD-DFT) methods. Calculated transition energies are used to generate UV-vis, FTIR, Raman, and NMR spectra which are later verified with the experimental spectra. The occurrence of different conformers [cis (N(c)), trans (N(t)), and zwitterion (Z*)] have been interpreted by Mulliken charge, natural bond orbital (NBO) analysis, and polarization versus electric field (P-E loop) studies. (1)H and (13)C NMR and molecular vibrational frequencies of the fundamental modes established the stability of Nc due to the presence of intramolecular hydrogen bonding (IHB) in the ground state (S0). Computed/experimental UV-vis absorption/emission studies reveal the creation of new species: zwitterion (Z*) and anion (A*) in the excited state (S1) due to excited state intramolecular and intermolecular proton transfer (ESI(ra)PT and ESI(er)PT). Increased electrical conductivity (σ(ac)) with temperature and increased ferroelectric polarization at higher field verifies proton conduction in I7C.

Trends in the antibiotic resistance patterns of enteric Fever isolates - a three year report from a tertiary care centre.

BACKGROUND: The incidence of multidrug resistant enteric fever is increasing alarmingly. This study was planned to determine the rate of isolation of Salmonella spp. and to compare the isolates for their epidemiological parameters and antimicrobial susceptibility patterns at our center. METHODS: The study was conducted over a span of three years with a total of 8142, 8134, and 8114 blood culture samples processed for the years 2008, 2009, and 2010 respectively. The minimum inhibitory concentration (MIC) for ciprofloxacin and chloramphenicol was determined using an agar dilution method. The MIC for ciprofloxacin was also confirmed by Epsilon-test (E -test) strips. RESULTS: Of the total 302 Salmonella spp. isolated, 257 were Salmonella enterica serotype Typhi (85.1%) and 45 (14.9%) were S. enterica serotype Paratyphi A. The majority of the isolates recovered were from the pediatric age group (54.6%) and males (60.6%). Complete susceptibility was observed to chloramphenicol, cefotaxime, ceftriaxone, and azithromycin over the last two years (2009 and 2010), with an increase in resistance to nalidixic acid (100%) and ciprofloxacin (13.6%). CONCLUSION: In our study, we found augmentation of resistance to nalidixic acid and fluoroquinolones and complete sensitivity to ceftriaxone along with reemergence of chloramphenicol sensitivity for Salmonella isolates. This report emphasises the necessity of continuous surveillance of antibiograms of enteric fever isolates in an area.

Acrophialophora fusispora as an Agent of Mycotic Keratitis: A Case Report and Review of Literature.

BACKGROUND: Acrophialophora species is an infrequent human opportunistic pathogen. It is widely distributed in temperate as well as tropical regions. Here, we present a rare case of fungal keratitis caused by A. fusispora. CASE PRESENTATION: A 26-year male driver presented with pain, watering, redness, whitish discoloration, and blurring of vision in the left eye for the last 3-4 days. Upon examination, he had a dry-looking corneal ulcer with infiltration and satellite lesions. Corneal scrapings were positive for septate fungal hyphae by Gram staining and KOH mount. After five days, the growth observed was presumptively identified as genus Acrophialophora and finally identified as Acrophialophora fusispora by genetic sequencing. The patient failed to respond medically and was planned for therapeutic keratoplasty. DISCUSSION: To date, four cases of ocular involvement due to Acrophialophora have been described. Amongst which one case was associated with an immunocompromised state. Three of the cases were resolved medically, while one required therapeutic keratoplasty, indicating possible strong pathogenicity to the eye. CONCLUSION: As Acrophialophora seems to have a predilection for eye infections, an early diagnosis with timely appropriate treatment is the best way to restore the normal vision of a patient.

Primary Cutaneous Mucormycosis: A Necrotising Soft Tissue Infection with Poor Prognosis.

BACKGROUND: Cutaneous mucormycosis is an unusual fungal infection that continues to occur. It needs aggressive surgical debridement and timely administration of antifungals due to its high fatality rate. High clinical suspicion on the part of a surgeon is required to prevent the same. CASE PRESENTATION: We present two cases of cutaneous mucormycosis in which the patients succumbed to death, highlighting the seriousness of the condition. One patient had a lower leg ulcer and was diabetic, and the other patient had a gluteal abscess following an intramuscular injection. Tissue samples grew Rhizopus arrhizus and Apophysomyces sp., respectively. Both patients were treated with amphotericin B, and extensive debridement was performed. DISCUSSION: Cutaneous mucormycosis can be reported in immunocompetent people, and there is a need for early recognition of the entity as a differential diagnosis of any nonhealing necrotic ulcer. CONCLUSION: Proper training and education of technical and clinical staff should be done at peripheral primary and secondary care centres so as not to miss out on cases of mucormycosis and for better prognosis in a cutaneous variety of mucormycosis in surgical patients.

Open-labeled Randomized Controlled Trial on Efficacy of Azithromycin Versus Doxycycline in Pediatric Scrub Typhus.

BACKGROUND: Doxycycline (DX) is the first-line therapeutic agent for scrub typhus. Macrolides, especially azithromycin (AZ), have been found to be equally efficacious as DX for treating scrub typhus in adults. We conducted this study to compare the efficacy of AZ versus DX in pediatric scrub typhus. STUDY DESIGN: Open-label randomized controlled trial. METHODS: Children 1-14 years of age suffering from acute febrile illness of ≥5 days and with a positive scrub IgM serology were randomized to receive either DX (2.2 mg/kg/dose twice daily in <40 kg; 100 mg BD in >40 kg for 7 days) or AZ (10 mg/kg/day for 5 days). The primary outcome was defervescence within 7 days of DX or 5 days of AZ. RESULTS: We had 75 children randomized and analyzed using an intention-to-treat approach and 60 children analyzed via per-protocol analysis. The proportion of children achieving defervescence was comparable in 2 groups [per-protocol analysis: 90.9% in the DX group vs. 96.3% in the AZ group, RR: 0.94 (95% CI: 0.83-1.08)]. On Kaplan-Meier curves, AZ showed a significantly higher probability of defervescence at any time point during treatment as compared with DX (log-rank test P value 0.035). CONCLUSION: AZ and DX had comparable rates of defervescence among children with scrub typhus. Trial registration No.: CTRI/2020/01/022991.

Phaeohyphomycosis: A study from tertiary health care center in North India.

Objectives: Phaeohyphomycosis refers to infections caused by phaeoid/dematiaceous or darkly pigmented fungi. This study was undertaken to further increase our knowledge about the incidence of phaeohyphomycosis and its causative agents. Materials and Methods: The present study was conducted over a period of one and a half years (January 2018-June 2019) on specimens received from patients with varied clinical manifestations ranging from superficial infections, subcutaneous cysts, pneumonia, brain abscess to a disseminated infection. These specimens were processed in the Department of Microbiology for potassium hydroxide (KOH) examination and culture and in Pathology for cytology/histopathological examination (HPE). All specimens positive on direct examination for dark grey, brown or black fungi were included in the study. Results: A total of 20 specimens were confirmed as phaeohyphomycosis. Most of the patients belonged to the age group of 41 to 50 years. Male: Female ratio was 2.3:1. Trauma was the most common risk factor. Spectra of the isolated fungal pathogens comprised of Bipolaris species, Exophiala species, Curvularia geniculata, Phialemonium species, Daldinia eschscholtzii, Hypoxylon anthochroum, Phaeoacremonium species, Leptosphaerulina australis, Medicopsis romeroi, Lasiodiplodia theobromae, Eutypella species, Chaetomium globosum, Alternaria species, Cladophialophora bantiana and 2 unidentified dematiaceous fungi. Recovery from phaeohyphomycosis was seen in 12 patients, 7 were lost to follow up and one patient succumbed to the illness. Conclusion: Infections caused by phaeoid fungi can no longer be viewed as rare. In fact, phaeohyphomycosis can have myriad of presentations spanning from mild cutaneous infections to fatal brain disease. Therefore, a high index of clinical suspicion is needed to diagnose such infections. The primary treatment modality remains surgical removal of the lesion in cutaneous or subcutaneous infections however disseminated disease with a guarded prognosis requires aggressive management.

Candida colonization in urine samples of ICU patients: determination of etiology, antifungal susceptibility testing and evaluation of associated risk factors.

The presence of Candida in urine presents a therapeutic challenge for the physician as it is often asymptomatic, and management guidelines have not been clearly laid down on this issue. The presence of Candida in urine may represent contamination of clinical sample, actual colonization of the lower urinary tract or may be a true indicator of invasive infection of lower and/or upper urinary tract. In a clinical setting like the ICU, multiple risk factors for Candida colonization may be present in the same patient, thereby increasing the chances of candiduria, manifold. In the present study on 80 patients in ICU, high rate of Candida colonization (57.5%) was found in urine samples of ICU patients with C. tropicalis (57.3%) being the predominant species. We also isolated 8 strains of Trichosporon species, all of these presented as a mixed infection along with Candida species. Among the various risk factors studied, urinary catheterization and previous antibiotic therapy were identified as statistically significant (P value <0.05). The minimum inhibitory concentration of the isolates was determined for amphotericin B, fluconazole and itraconazole by E-test. Most of the isolates were susceptible to amphotericin B. The C. parapsilosis strains did not show any drug resistance; however, resistance to fluconazole was observed 18.6, 27.27, 50 and 25% in C. tropicalis, C. albicans, C. glabrata and Trichosporon species, respectively.

COVID-19 and Plethora of Fungal Infections.

Purpose of Review: Severe-acute respiratory coronavirus 2 (SARS-CoV-2) causing corona virus disease 2019 (COVID-19) has been the single most important pathogen driving health care delivery system for the last one and half years. Now, as the time is passing, many issues related to co-infections/secondary infections/superinfections in COVID-19 patients are emerging. The literature is getting enriched everyday by addition of reports from all over the world for the same. The purpose of this review is to decipher the plethora of fungal infections in COVID-19. Recent Findings: COVID-19 infection along with it brought many risk factors namely lung injury, immunosuppression, need for oxygen therapy, monoclonal antibodies, steroid therapy, etc. which are known predisposing factors for fungal infections. Rather the extent and severity of fungal pathogens has been so much that it has led to new terminologies like CAC (COVID-19-associated Candida), CAPA (COVID-19-associated pulmonary aspergillosis) and CAM (COVID-19-associated mucormycosis). There is increase in invasiveness of Candida, prevalence of aspergillosis in COVID-19 damaged lung and outbreak of mucormycosis in COVID-19 patients resulting in "double trouble," keeping laboratory personnel, clinicians, and intensivists on their toes in managing these patients. Summary: Awareness and understanding regarding these possible complications is necessary to decrease the morbidity and mortality among patients. The COVID-19 and fungal coinfections may bring more insight into ways of pathogenesis of fungal infections, need for better antifungal agents, quick diagnostic modalities, and better management policies in the near future.

Bacterial Colonization of Home Nebulizers Used by Children With Recurrent Wheeze.

OBJECTIVE: To look for bacterial colonization of parts of home nebulizers used for children with recurrent wheeze and asthma. METHODS: Children aged 1 mo-12 y, using home nebulizers for recurrent cough and wheeze were enrolled from May to October, 2019. Caregivers were administered a structured questionnaire by a single researcher, during their hospital visit, to elicit information on their nebulizer cleaning practices. Samples were taken from nebulizer medicine chamber and tubing for bacterial culture and sensitivity. RESULT: Bacterial growth was observed in 17 culture samples obtained from medicine chamber and/or tubing of nebulizers used by 12 (20.3%) out of the 59 enrolled children. The bacteria isolated were Klebsiella pneumoniae, Pseudomonas aeruginosa and Staphylococcus aureus (Methicillin resistant S. aureus and Coagulase negative staphylococci) and these were resistant to many of the commonly used antimicrobials. Almost 20% parents had never cleaned the nebulizers. Diluent re-use was significantly associated with bacterial colonization of nebulizer parts [AOR (95% CI) 20.6 (2.26-188.5); P=0.007]. CONCLUSION: Home nebulizers, if not cleaned properly as per set protocols, may get colonized with potentially harmful bacteria. There is a need to increase awareness about their proper use amongst parents of children with recurrent wheeze.