Staphylococcal scalded skin syndrome in neonate: Another face of CA-MRSA.

ABSTRACT: Staphylococcal scalded skin syndrome (SSSS), also known as Ritter's disease, in its severe form occurs predominantly in infants and children. It is caused by infection with group II (often phage group 71) Staphylococcus aureus. The foci of infection include nasopharynx, less commonly umbilicus, urinary tract, superficial abrasion, conjunctivae, and blood. Staphylococci are non-motile, non-spore-forming, catalase-positive, gram-positive cocci that appear predominantly as grape-like clusters. Although this organism is frequently a part of normal human microbial flora, it can cause significant opportunistic infections under certain conditions such as when extremes of age groups are involved, the presence of indwelling medical devices, and intravenous (iv) drug abuse. Staphylococcus aureus may cause a variety of infectious manifestations ranging from relatively benign skin infections to life-threatening systemic illnesses. SSSS caused by S. aureus strains produces exfoliative toxins which result in the development of blisters, erythema, and desquamation. Here, we present a case of an 11-day-old neonate who was diagnosed with SSSS. The causative agent responsible for this syndrome was identified as methicillin-resistant Staphylococcus aureus (MRSA). The molecular characterization of the gene Panton-Valentine leukocidin (PVL) was done by polymerase chain reaction (PCR) and was detected positive for PVL which is a distinctive virulence factor seen almost in all of the community-acquired MRSA strains. The patient was discharged after parenteral clindamycin therapy with almost complete resolution of symptoms.

Urinary Tract Infection in Pediatric Patients on Clean Intermittent Catheterization via a Mitrofanoff port with Reused Catheters - Any Association with Catheter Sterility?

OBJECTIVE: The objective of this study is to find out whether the reused catheters for clean intermittent catheterization (CIC) are colonized before insertion and its association with urinary tract infection (UTI). MATERIALS AND METHODS: This is a study conducted on 28 pediatric surgery patients who are on CIC via a Mitrofanoff port and who were reusing catheters, in a tertiary care private medical college hospital for 6-month period. Catheters to be used for the next catheterization were sent for culture along with urine culture. A questionnaire was utilized to assess CIC practice and UTI. RESULTS: Diseases of patients were: neurogenic bladder and exstrophy-epispadias and posterior urethral valve. Twenty-one of them had an augmented bladder. Hydronephrosis was present in ten and vesicoureteral reflux (VUR) in five. Their mean duration of CIC was 5.3 years. Of 28 catheter tip samples, 16 catheters were colonized with organism. Of the 28 urine culture samples, 17 cultures were positive and all were asymptomatic except one. Of the 16 positive catheter samples, only 9 had positive urine culture; four of them had grown different organisms and five of them had the same organism, and even in these five, single organism was seen only in three. Urine culture grew Gram-negative organism in 85%, but catheter grew Gram-positive organism in 46%. No difference was found in the variables between both groups such as hydronephrosis, VUR, and augmented bladder. CONCLUSION: Reused catheters were colonized in 57% of the study patients, but reused catheter may not be the cause of culture positivity or UTI in the study population.

Prevalence and the factors influencing soil-transmitted helminths among school age children (5-14 years age) in a rural area of Coimbatore district.

CONTEXT: Highest intensity of soil-transmitted helminthiasis (STH) is seen among school age children. AIMS: The aim of this study is to find out the prevalence and factors associated with soil-transmitted helminthic infection among school age children (5-14 years) in a rural area of Coimbatore district. SETTINGS AND DESIGN: The study was conducted in the field practice area of the Rural Health Training Centre (RHTC) Vedapatti, Coimbatore. RHTC caters to a total population of 23,841 distributed in 14 villages. After getting ethical clearance, five of the 14 villages of Vedapatti were selected by the cluster sampling method. Totally, 819 participated in the survey conducted between November 2015 and July 2016 in the field practice area. SUBJECTS AND METHODS: Structured questionnaire was used to collect the information. Consent from parents and assent from child were obtained. Totally, 610 gave one adequate stool sample. Early morning samples were collected and transported to the laboratory within four hours. Formal ether concentration method was performed, and examination was done. STATISTICAL ANALYSIS USED: Data analysis was performed with the SPSS version 19 software. The prevalence is expressed in percentage with 95% confidence interval (CI). Univariate and multivariate analyses were performed. Strength of association was expressed in terms of odds ratio (OR) and adjusted OR with 95% CI. P < 0.05 was considered as statistically significant. RESULTS: The prevalence of STH was 7.70% (95% CI: 5.58-9.82). Ascaris lumbricoides was highly prevalent 6.9% (4.89%-8.91%) followed by Hook worm 0.7% (0.04%-1.36%), and Trichuris trichura 0.2% (0.15%-0.55%). Mulitivariate logistic regression analysis showed that pucca houses offered protection against STH. CONCLUSIONS: The prevalence of STH in a rural area of Coimbatore is 7.7% (95% CI: 5.58-9.82), and is continuing as a public health problem.

Incidence, characteristics and outcome of ICU-acquired candidemia in India.

PURPOSE: A systematic epidemiological study on intensive care unit (ICU)-acquired candidemia across India. METHOD: A prospective, nationwide, multicentric, observational study was conducted at 27 Indian ICUs. Consecutive patients who acquired candidemia after ICU admission were enrolled during April 2011 through September 2012. Clinical and laboratory variables of these patients were recorded. The present study is an analysis of data specific for adult patients. RESULTS: Among 1,400 ICU-acquired candidemia cases (overall incidence of 6.51 cases/1,000 ICU admission), 65.2 % were adult. Though the study confirmed the already known risk factors for candidemia, the acquisition occurred early after admission to ICU (median 8 days; interquartile range 4-15 days), even infecting patients with lower APACHE II score at admission (median 17.0; mean ± SD 17.2 ± 5.9; interquartile range 14-20). The important finding of the study was the vast spectrum of agents (31 Candida species) causing candidemia and a high rate of isolation of Candida tropicalis (41.6 %). Azole and multidrug resistance were seen in 11.8 and 1.9 % of isolates. Public sector hospitals reported a significantly higher presence of the relatively resistant C. auris (8.2 vs. 3.9 %; p = 0.008) and C. rugosa (5.6 vs. 1.5 %; p = 0.001). The 30-day crude and attributable mortality rates of candidemia patients were 44.7 and 19.6 %, respectively. Logistic regression analysis revealed significant independent predictors of mortality including admission to public sector hospital, APACHE II score at admission, underlying renal failure, central venous catheterization and steroid therapy. CONCLUSION: The study highlighted a high burden of candidemia in Indian ICUs, early onset after ICU admission, higher risk despite less severe physiology score at admission and a vast spectrum of agents causing the disease with predominance of C. tropicalis.

Incidence of multidrug resistance in Mycobacterium tuberculosis in a tertiary care hospital in South India--a prospective study.

Multidrug resistant tuberculosis (MDR-TB) is one worrisome element in this era of pandemic antibiotic resistance. This demands a need for diagnosis, and incidence of primary and acquired resistance to help in better management. Smear positive respiratory samples collected over a period of one year were processed for detection of M. tuberculosis, using biochemical methods and susceptibility to p-nitro benzoic acid. Finally, strains detected by the above method were subjected to susceptibility for 2 drugs--Isoniazid and Rifampicin by Absolute concentration method to detect multidrug resistant strains and mono-resistant strains. The study showed primary and acquired resistance for both drugs to be 1.25% and 19% respectively. The data was consistent with the prevalence values available from studies both in India and globally. Finally our study showed MDR-TB to be present more in default patients than new cases.

Fatal fulminant Salmonella infantis meningitis with septicemia.

We report a case of Salmonella meningitis due to Salmonella serotype infantis. The organism was isolated from the blood and CSF of a ten month old baby. The baby died due to fulminant meningitis with septicemia. This case has been reported for its rarity.

Mupirocin resistance in clinical isolates of staphylococci in a tertiary care centre in south India.

The present study was carried out to determine the rates of high-level and low-level mupirocin resistance in Staphylococcus spp. (MuH and MuL) in southern India. A prospective study was carried out on Staphylococcus spp. isolated for a period of three months in the microbiology laboratory of an 800-bedded tertiary care hospital. One hundred sixty-seven non-duplicate Staphylococcus spp. isolated from different specimens were tested for mupirocin susceptibility using 5 and 200 µg discs and by agar dilution. Rates of MuH were found to be two percent in methicillin-resistant Staphylococcus aureus (MRSA) and 28% in methicillin-resistant coagulase-negative Staphylococcus spp. (MRCoNS). MuL strains may be still treated with mupirocin, while MuH strains require other treatment options for eradication, making prior screening and differentiation important.

Evaluation and comparison of tests to detect methicillin resistant S. aureus.

BACKGROUND AND OBJECTIVES: Phenotypic methods for detection of methicillin resistant Staphylococcus aureus (MRSA) have been compared with the gold standard which, as of now, is by the detection of mecA gene and femA gene by polymerase chain reaction (PCR). Discrepancies in detection have an adverse effect on patient management, thereby highlighting the importance of accuracy in detection. Our study aims to evaluate the efficacy of cefoxitin disk diffusion test to detect MRSA and compare it with other phenotypic and molecular methods. METHODOLOGY: The study was conducted from June 2006 to December 2007 and included 610 Staphylococcus aureus (S. aureus) isolates obtained from clinical samples. All isolates were tested for MRSA using oxacillin screen agar plates with 6 microg/ml of oxacillin, cefoxitin disk diffusion using 30 microg disk and MIC of oxacillin. Selected isolates (55) were tested for presence of mecA gene and Fem A gene by PCR. RESULTS: Out of 610 isolates, MRSA was identified in 34.09% by cefoxitin disk diffusion, 34.9% by oxacillin screen agar, 34.4% by MIC and 37.3% by oxacillin disk diffusion. When selected isolates were tested with molecular methods, the cefoxitin disk diffusion and PCR tests were comparable. DISCUSSION: Prevalence of MRSA (34.09%) is quite high as in other studies. The oxacillin disk diffusion test which was used routinely earlier is showing low specificity (56%). Among all phenotypic methods, cefoxitin disk diffusion and PCR alone have similar sensitivity and specificity. CONCLUSION: Results of cefoxitin disk diffusion test are in concordance with the PCR for mecA gene. Thus, the test can be an alternative to PCR for detection of MRSA in resource constraint settings.

Prevalence of community acquired MRSA in a tertiary care facility.

Traditionally, methicillin resistant Staphylococcus aureus (MRSA) is considered as a nosocomial pathogen, but an increasing prevalence of community acquired MRSA is being reported worldwide including India, which implies a strategic change in the antibiotic of choice for treatment of community acquired Staphylococcal infections, which till now is cloxacillin. This study is aimed at identifying the prevalence and susceptibility characteristics of community acquired MRSA in our hospital. The study group consisted of 208 consecutive MRSA identified on the basis of their resistance to cefoxitin disk (30 microg) by the disc diffusion method and mecA gene detection by polymerase chain reaction (PCR). Isolates were categorized as community acquired MRSA based on criteria for inclusion and their antibiotic susceptibility was compared with that of the hospital acquired MRSA isolates. Among the 208 MRSA analyzed, 18% (n = 37) were community acquired and were from infections such as cellulitis and superficial injuries. The isolates were significantly more sensitive to ciprofloxacin than the hospital acquired MRSA isolates. The prevalence of community acquired MRSA in this study (18%) is comparable to its prevalence in other studies across India. Susceptibility to antibiotics other than glycopeptides was an important characteristic of community acquired MRSA. In the absence of other reliable phenotypic test for its identification, susceptibility to ciprofloxacin is suggested as an alternative. A prudent clinician should be aware that, cloxacillin, the drug of choice for skin infections such as carbuncle and cellulitis, will not be effective in these cases and that community acquired MRSA has a range of antibiotics to choose from, other than the glycopeptides, when compared with that of hospital acquired MRSA.

"Inducible clindamycin resistance in Staphylococcus aureus isolated from clinical samples".

Increasing frequency of methicillin resistant Staphylococcus aureus (MRSA) infections and changing patterns in antimicrobial resistance have led to renewed interest in the use of macrolide-lincosamide-streptogramin (MLS) antibiotics to treat such infections. Inducible macrolides, lincosamides, type B streptogramins (MLS(Bi)) resistance has to be identified to avoid clinical failure of clindamycin therapy. Hence we wanted to study the incidence of inducible clindamycin resistance in MRSA and methicillin susceptible Staphylococcus aureus (MSSA). Staphylococcus aureus was isolated in 1049 patients over a period of two years from various clinical materials. All the isolates were tested for inducible clindamycin resistance by disc diffusion induction test (D-zone test). A total of 726 MSSA and 323 MRSA were tested for the inducible clindamycin resistance (MLS(Bi)) by D-zone test. Inducible resistance to clindamycin (MLS(Bi)) where D test was positive was observed in 42.1% of MRSA and 3.4% of MSSA. Inducible resistance to clindamycin (MLS(Bi)) was found to be higher in MRSA than MSSA isolates. Clindamycin is one of the important alternative antibiotics to treat MRSA infections in resource poor countries. To avoid treatment failure with clindamycin, prior D testing is necessary.

Anti-MRSA activity of aldehyde Schiff base N-aryl thiosemicarbazones.

Eight different newly synthesised aldehyde Schiff base N-aryl thiosemicarbazones, differing in R, R' groups, are tested on 25 clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA) and a standard strain. Antibacterial activity was carried out by a well-diffusion method in concentrations of 15-500 microg/well. Compounds 1, 2, 3, 4 and 6 showed good inhibition of MRSA. Increasing concentration of the test compounds enlarged the inhibition zone. Determination of minimum inhibitory concentration (MIC) was carried out using a dilution susceptibility test in concentrations of 4-512 microg/mL of the medium. The lowest MIC value (16 microg/mL) was produced by compound 4.

Assessment of pheromone response in biofilm forming clinical isolates of high level gentamicin resistant Enterococcus faecalis.

Twenty five clinical isolates of high level gentamicin resistant Enterococcus faecalis were tested for their biofilm formation and pheromone responsiveness. The biofilm assay was carried out using microtiter plate method. Two isolates out of the 25 (8%) were high biofilm formers and 19 (76%) and four (16%) isolates were moderate and weak biofilm formers respectively. All the isolates responded to pheromones of E. faecalis FA2-2 strain. On addition of pheromone producing E. faecalis FA2-2 strain to these isolates, seven of 19 (37%) moderate biofilm formers developed into high biofilm formers. Similarly one of the 4 (25%) weak biofilm formers developed into high level biofilm former. Twelve (48%) of the 25 isolates were transconjugated by cross streak method using gentamicin as selective marker. This proves that the genetic factor for gentamicin resistance is present in the pheromone responsive plasmid. Among these twelve transaconjugants, seven isolates and one isolate were high biofilm formers on addition of E. faecalis FA2-2 and prior to its addition respectively. Out of the total 25 isolates, eight transconjugants for gentamicin resistance could turn to high biofilm formers on addition of the pheromone producing strain. All the isolates were resistant to more than two antibiotics tested. All the isolates were sensitive to vancomycin. The results indicate the significance of this nosocomial pathogen in biofilm formation and the role of pheromone responding clinical isolates of E. faecalis in spread of multidrug resistance genes.

Evaluation of an enzyme-linked immunoassay for the detection of Cryptosporidium antigen in fecal specimens of HIV/AIDS patients.

Cryptosporidium parvum, a protozoan parasite, causes severe diarrhea in immunodeficient hosts like HIV/AIDS patients, leading to significant morbidity and mortality. Diagnosis of the Cryptosporidium oocyst in the stool of these patients by conventional microscopy is labor intensive and time consuming. Therefore, we planned to evaluate the usefulness of a stool ELISA test in detecting Cryptosporidial antigen. About 89 stool specimens obtained from HIV-seropositive patients with diarrhea were subjected to an ELISA test and modified acid-fast staining (gold standard), on both direct and formol ether-concentrated specimens. The prevalence of Cryptosporidial diarrhea was found to be 12.4% (11/89). Other enteric pathogens detected were Isospora belli (3), Giardial cyst (3), Entamoeba coli cyst (2), and Entamoeba histolytica cyst (1). Dual infection with Cryptosporidium and Isospora belli was seen in two patients. Concentration technique improved identification by microscopy. The sensitivity and specificity for stool ELISA were found to be 90.9% and 98.7% respectively. The results of stool ELISA indicate that this simple, rapid, reliable, and standardized immunoassay test is sensitive and specific for routine diagnosis and may be useful for large-scale epidemiological studies of Cryptosporidiosis.

Oerskovia turbata and Myroides species: rare isolates from a case of acalculus cholecystitis.

Here we report a case of acalculus cholecystitis, which presented with features of obstructive jaundice of one-week duration. The patient underwent cholecystectomy and bile grew a mixed culture of Oerskovia turbata and Myroides spp. Being a rare isolate, characteristic features of the former are described in this report. The patient recovered without any complication.