Association of antibiotic duration and all-cause mortality in a prospective study of patients with ventilator-associated pneumonia in a tertiary-level critical care unit in Southern India.

OBJECTIVES: To estimate all-cause mortality in ventilator-associated pneumonia (VAP) and determine whether antibiotic duration beyond 8 days is associated with reduction in all-cause mortality in patients admitted with VAP in the intensive care unit. DESIGN: A prospective cohort study of patients diagnosed with VAP based on the National Healthcare Safety Network definition and clinical criteria. SETTING: Single tertiary care hospital in Southern India. PARTICIPANTS: 100 consecutive adult patients diagnosed with VAP were followed up for 28 days postdiagnosis or until discharge. OUTCOME MEASURES: The incidence of mortality at 28 days postdiagnosis was measured. Tests for association and predictors of mortality were determined using χ2 test and multivariate Cox regression analysis. Secondary outcomes included baseline clinical parameters such as age, underlying comorbidities as well as measuring total length of stay, number of ventilator-free days and antibiotic-free days. RESULTS: The overall case fatality rate due to VAP was 46%. There was no statistically significant difference in mortality rates between those receiving shorter antibiotic duration (5-8 days) and those on longer therapy. Among those who survived until day 9, the observed risk difference was 15.1% between both groups, with an HR of 1.057 (95% CI 0.26 to 4.28). In 70.4% of isolates, non-fermenting Gram-negative bacilli were identified, of which the most common pathogen isolated was Acinetobacter baumannii (62%). CONCLUSION: In this hospital-based cohort study, there is insufficient evidence to suggest that prolonging antibiotic duration beyond 8 days in patients with VAP improves survival.

Quantification of Organophosphorus Insecticide Removed by Gastric Lavage in Acutely Poisoned Patients: An Observational Study.

Introduction: The effectiveness of gastric lavage in organophosphorus (OP) poisoning has not been established. We assessed the ability of gastric lavage to remove OP insecticides as a preliminary stage in assessing effectiveness. Patients and methods: Organophosphorus poisoning patients presenting within 6 hours were included, irrespective of prior gastric lavage. A nasogastric tube was placed and gastric contents aspirated, followed by at least three cycles of gastric lavage with 200 mL of water. Samples from the initial aspirate and the first three lavage cycles were sent for identification and quantification of the OP compounds. Patients were monitored for complications of gastric lavage. Results: Around 42 patients underwent gastric lavage. Eight (19.0%) patients were excluded from the study because of a lack of analytical standards for ingested compounds. Insecticides were detectable in the lavage samples of 24 of 34 (70.6%) patients. Lipophilic OP compounds were detected in 23 of 24 patients, while no hydrophilic OP compounds could be detected in six patients with reported ingestion of hydrophilic compounds. For chlorpyrifos poisoning (n = 10), only 0.65 mg (SD 1.2) of the estimated ingested amount (n = 5) of 8,600 mg (SD 3,200) was recovered by gastric lavage. The mean proportion of the compound removed by initial gastric aspirate was 79.4% and subsequent three cycles removed 11.5, 6.6, and 2.7%. Conclusion: Lipophilic OP insecticides could be quantified in the stomach contents of OP poisoning patients with the first aspiration or lavage being most effective. The amount removed was very low; hence, routine use of gastric lavage for OP poisoning patients arriving within 6 hours is unlikely to be beneficial. How to cite this article: Mathansingh AJ, Jose A, Fleming JJ, Abhilash KPP, Chandiraseharan VK, Lenin A, et al. Quantification of Organophosphorus Insecticide Removed by Gastric Lavage in Acutely Poisoned Patients: An Observational Study. Indian J Crit Care Med 2023;27(6):397-402.

Role of Neutrophil Gelatinase-associated Lipocalin (NGAL) and Other Clinical Parameters as Predictors of Bacterial Sepsis in Patients Presenting to the Emergency Department with Fever.

Background: Bacterial sepsis is associated with significant morbidity and mortality. However, to date, there is no single test that predicts sepsis with reproducible results. We proposed that using a combination of clinical and laboratory parameters and a novel biomarker, plasma neutrophil gelatinase-associated lipocalin (NGAL) may aid in early diagnosis. Method: A prospective cohort study was conducted at a tertiary care center in South India (June 2017 to April 2018) on patients with acute febrile episodes fulfilling the Systemic Inflammatory Response Syndrome (SIRS) criteria. Plasma NGAL and standard clinical and laboratory parameters were collected at the admission. Bacterial sepsis was diagnosed based on blood culture positivity or clinical diagnosis. Clinically relevant plasma NGAL cut-off values were identified using the receive operating characteristic (ROC) curve. Clinically relevant clinical parameters along with plasma NGAL's risk ratios estimated from the multivariable Poisson regression model were rounded and used as weights to create a new scoring tool. Results: Of 100 patients enrolled, 37 had bacterial sepsis. The optimal plasma NGAL cut-off value to predict sepsis was 570 ng/mL [area under the curve (AUC): 0.69]. The NGAL sepsis screening tool consists of the following clinical parameter: diabetes mellitus, the presence of rigors, quick sequential organ failure assessment (qSOFA) >2, a clear focus of infection, and the plasma NGAL >570 ng/mL. A score of <3 ruled out bacterial sepsis and a score >7 were highly suggestive of bacterial sepsis with an interval likelihood ratio (LR) of 7.77. Conclusion: The NGAL sepsis screening tool with a score >7 can be used in the emergency department (ED) to identify bacterial sepsis. How to cite this article: Paul A, Newbigging NS, Lenin A, Gowri M, Varghese JS, Nell AJ, et al. Role of Neutrophil Gelatinase-associated Lipocalin (NGAL) and Other Clinical Parameters as Predictors of Bacterial Sepsis in Patients Presenting to the Emergency Department with Fever. Indian J Crit Care Med 2023;27(3):176-182.

A systematic review of artificial intelligence-based COVID-19 modeling on multimodal genetic information.

This study systematically reviews the Artificial Intelligence (AI) methods developed to resolve the critical process of COVID-19 gene data analysis, including diagnosis, prognosis, biomarker discovery, drug responsiveness, and vaccine efficacy. This systematic review follows the guidelines of Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA). We searched PubMed, Embase, Web of Science, and Scopus databases to identify the relevant articles from January 2020 to June 2022. It includes the published studies of AI-based COVID-19 gene modeling extracted through relevant keyword searches in academic databases. This study included 48 articles discussing AI-based genetic studies for several objectives. Ten articles confer about the COVID-19 gene modeling with computational tools, and five articles evaluated ML-based diagnosis with observed accuracy of 97% on SARS-CoV-2 classification. Gene-based prognosis study reviewed three articles and found host biomarkers detecting COVID-19 progression with 90% accuracy. Twelve manuscripts reviewed the prediction models with various genome analysis studies, nine articles examined the gene-based in silico drug discovery, and another nine investigated the AI-based vaccine development models. This study compiled the novel coronavirus gene biomarkers and targeted drugs identified through ML approaches from published clinical studies. This review provided sufficient evidence to delineate the potential of AI in analyzing complex gene information for COVID-19 modeling on multiple aspects like diagnosis, drug discovery, and disease dynamics. AI models entrenched a substantial positive impact by enhancing the efficiency of the healthcare system during the COVID-19 pandemic.

Retrospective study of comparison of clinical severity and outcome of hospitalised COVID-19 patients during the first and second waves of the pandemic in India.

OBJECTIVES: To compare the clinical severity and outcome of hospitalised patients during the two waves of the COVID-19 pandemic in India. SETTING: A tertiary care referral hospital in South India. PARTICIPANTS: Symptomatic SARS CoV-2 reverse transcriptase PCR positive patients presenting to the emergency department during the two waves were recruited. The first wave spanned between April and December 2020 and the second wave between April and May 2021. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome of interest was mortality. Secondary outcomes included illness severity at presentation, need for oxygen therapy, non-invasive ventilation (NIV) and hospital or intensive care unit admission. RESULTS: The mean (SD) age of the 4971 hospitalised patients in the first wave was similar to the 2293 patients in the second wave (52.5±15.4 vs 52.1±15.1 years, p=0.37). When compared with the first wave, during the second wave, a higher proportion of patients presented with critical illness (11% vs 1.1%, p<0.001) and needed supplemental oxygen therapy (n=2092: 42.1% vs n=1459: 63.6%; p<0.001), NIV (n=643; 12.9% vs n=709; 30.9%; p<0.001) or inotropes/vasoactive drugs (n=108; 2.2% vs n=77: 3.4%; p=0.004). Mortality was higher during the second wave (19.2% vs 9.3%; p<0.001). On multivariable regression analysis, age >60 years (risk ratio, RR 2.80; 95% CI 2.12 to 3.70), D-dimer >1000 ng/mL (RR 1.34; 95% CI 1.15 to 1.55), treatment with supplemental oxygen (RR 14.6; 95% CI 8.98 to 23.6) and presentation during the second wave (RR 1.40; 95% CI 1.21 to 1.62) were independently associated with mortality. CONCLUSION: The second wave of the COVID-19 pandemic in India appeared to be associated with more severe presentation and higher mortality when compared with the first wave. Increasing age, elevated D-dimer levels and treatment with supplemental oxygen were independent predictors of mortality.

Clinical presentation of type 1 and type 2 pyrethroid poisoning in humans.

BACKGROUND: It is unclear if the clinical presentation of poisoning with type 1 and type 2 pyrethroid compounds is different. This study was undertaken to detail the clinical profile and outcome of patients presenting with pyrethroid poisoning and to quantify serum pyrethroid levels. PATIENTS AND METHODS: In this prospective study, patients were categorised as poisoning with type 1 pyrethroids or type 2 pyrethroids. Blood samples were sent for compound identification and quantification. Clinical features and outcomes were compared between the two groups. Factors associated with moderate and severe toxicity were explored using univariate logistic regression analysis and presented as odds ratio (OR) and 95% confidence intervals (CI). RESULTS: Type 1 pyrethroids were implicated in 16 patients and type 2 in 43 patients. The incidence of nausea and vomiting (81.2% vs. 81.3%) and tremor (37.5% vs. 32.6%) were similar in type 1 and type 2 poisoning; paraesthesia (6.2% vs. 32.6%, p = 0.04), hypersalivation (0% vs. 20.9%, p = 0.04), seizures (0% vs. 7%, p = 0.29) and depressed sensorium (0% vs. 18.6%, p = 0.03.) were observed more frequently in type 2 pyrethroid poisoning. Pyrethroids were detected in the serum samples of 24 patients; quantification was possible in 22 patients in whom serum levels ranged from 1.1 to 453 µg/ml. The compounds were undetectable in 35 patients. Two patients (lambda-cyhalothrin poisoning and cypermethrin poisoning) required intubation for low sensorium and respiratory distress. The median (interquartile range) duration of hospitalization was 12 (12-24) hours. All patients survived. Factors associated with moderate and severe toxicity included ingestion of a type 2 pyrethroid, lambda-cyhalothrin (OR 7.81, 95%CI 1.55-39.37, p = 0.01) and volume ingested (OR 1.01, 95%CI 1.00-1.02, p = 0.02). CONCLUSION: Patients with pyrethroid poisoning present predominantly with mild to moderate symptoms. Paraesthesia and hypersalivation are more frequent in type 2 poisoning. A favourable outcome can be expected.

Plasma Von Willebrand Factor Levels Predict Survival in COVID-19 Patients Across the Entire Spectrum of Disease Severity.

BACKGROUND: Characterization of reticulo-endothelial activation in COVID-19 may guide treatment. OBJECTIVES: To assess reticulo-endothelial activation and its correlation with disease severity and death in patients across the entire spectrum of COVID-19 severity. METHODS: Consecutive hospitalized COVID-19 patients were studied, with similar number of patients in each disease severity category. Baseline serum ferritin, sCD163 (macrophage activation markers) and plasma von Willebrand factor (VWF) antigen (endothelial activation marker) levels were studied. Clinical parameters and plasma D-dimer levels were also studied. The study parameters were correlated with COVID-19 severity and survival. RESULTS: The 143 patients (104 males [80%], age 54 [42 - 65] years, median [inter-quartile range]) presented 4 (3-7) days after symptom onset. Thirty-four patients had mild disease, 36 had moderate disease, 36 had severe disease and 37 had critical disease at baseline. With increasing COVID-19 severity, ferritin, sCD163, VWF and D-dimer levels significantly increased at baseline, however, 139 patients had normal sCD163 levels. Of the reticulo-endothelial markers, VWF level independently correlated with COVID-19 severity and with survival. VWF level > 332.6 units/dl correlated with COVID-19 severity (odds ratio [OR]: 2.77 [95% confidence interval (C.I): 1.1 - 6.99], p value: 0.031) and in-hospital death (OR [95% CI]: 29.28 [5.2 - 165], p value < 0.001). CONCLUSIONS: Reticulo-endothelial activation markers increased incrementally with worsening COVID-19 severity. Baseline endothelial activation marker (VWF), and not macrophage activation markers, independently correlated with COVID-19 severity and death.

Predicting antitubercular drug-induced liver injury and its outcome and introducing a novel scoring system.

Background: Tuberculosis (TB) is a major global health problem, mainly in developing countries. Despite the availability of highly effective first-line antitubercular (ATT) drugs, ATT drug-induced liver injury (ATT DILI) leads to treatment interruption and consequently loss of therapeutic efficacy. Methods: In this prospective cohort study from India, all consecutive patients who met inclusion criteria and started on ATT were included. The incidence, risk factors, and outcome of ATT DILI were determined. A clinical prediction score for ATT DILI was derived. Results: A total of 393 patients were included. The incidence of ATT DILI was 9.7% (95% confidence interval 7%-13.2%). HIV infection, daily regimen, disseminated disease, and chronic liver disease were identified as significant risk factors (P < 0.05) for developing DILI. A prediction score derived from the risk factors showed that a score of >5 could predict DILI with a sensitivity of 74% and a specificity of 67%. All-cause mortality in DILI was 4.7%. Conclusion: The incidence of ATT DILI was 9.7% in our cohort with higher incidence among the patients on daily regimen. The study suggests that the combination of risk factors of extensive TB disease, HIV infection, chronic liver disease, and under nutrition increases the vulnerability to DILI, particularly with daily treatment regimen, emphasizing the role of acquired risk factors in the development of DILI.

Clinical spectrum, aetiology and predictors of acute febrile encephalopathy at a tertiary hospital in south India - A prospective observational study.

Acute febrile encephalopathy is a common syndrome in the tropics with high mortality encountered by emergency physicians. In order to study the aetiology of acute febrile encephalopathy and its mortality and functional outcome over one year, data on all patients >18 years of age with short duration of fever (<14 days) and altered mental status were collected and followed up until one month after discharge. Non-infectious aetiology, found in 29%, portends a poor outcome.

Micturition syncope: a rare presentation of bladder paraganglioma.

A 68-year-old woman presented with episodes of headache, palpitations, sweating and poorly controlled hypertension for the past 6 years. These symptoms were, at times, associated with micturition, and there were few episodes of micturition syncope as well. She had elevated 24-hour urinary normetanephrine and was found to have a paraganglioma arising from the urinary bladder infiltrating the sigmoid colon. She underwent laparotomy with excision of the bladder paraganglioma, following which her symptoms subsided. Paragangliomas are extra-adrenal catecholamine-producing tumours. Bladder paragangliomas need to be considered when evaluating hypertensive patients with headache, palpitations or syncope related to micturition.

Rodenticide Poisoning: Critical Appraisal of Patients at a Tertiary Care Center.

IMPORTANCE: Rodenticide poisoning is a common occurrence in India. Of the different classes of rodenticides available, yellow phosphorus is considered highly toxic. There are scarce epidemiological data regarding the ingestion of yellow phosphorus in the subcontinent. OBJECTIVES: This study aimed to identify the clinical profile of rodenticide-poisoned patients and delineate mortality predictors. DESIGN: Prospective observational study. SETTING AND PARTICIPANTS: Study was conducted at the Department of Internal Medicine, Government Villupuram Medical College and Hospital. All adult inpatients with a history of rodenticide poison exposure were eligible participants. A total of 99 patients completed the study protocol. MAIN OUTCOME: Survival with or without morbidity and death. RESULTS: In all, 90.91% of patients consumed the paste formulation of rodenticide [yellow phosphorus (67.2%) and yellow phosphorus + zinc phosphide (24%)].The time to resuscitation showed significance to mortality. Survival rate among patients instituted gastric decontamination within 2 hours of exposure (97.87%) was significantly higher than those who were not (84.62%) (p = 0.033). The clinical picture revealed conspicuous absence of signs and symptoms during the first 24 hours. In all, 72.73% (n = 72) manifested with toxidrome after a lag period of 24-36 hours (range 18-72 hours). The dominant clinical manifestations included abdominal pain (52.53%), jaundice (22.21%), coagulopathy (15.15%), encephalopathy (10.10%), shock (10.10%), acute kidney injury (AKI; 7.08%), and multi-organ failure (17.17%). Laboratory data showed elevated aspartate transaminase (AST; 48.47%), alanine aminotransferase (ALT; 49.50%), bilirubin levels (22.21%), metabolic acidosis (10.12%), serum creatinine (7.08%), prothrombin time prolongation (PT/INR; 15.15%), and activated partial thromboplastin time (aPTT) (3.30%). The mortality was 9.1% (n = 9) of which 77.78% (n = 7) died of fulminant hepatic failure. The mean time for death was 4.22 days since exposure (range 2-8 days). CONCLUSION: Rodenticide poisoning in Southern India is dominated by yellow phosphorus. In this study, we identified delayed resuscitation, jaundice, hepatic encephalopathy, elevation of AST and ALT to >1000 IU/L, metabolic acidosis, and refractory shock as reliable predictors of bad outcome in this patient population. The common mode of death was fulminant hepatic failure. RELEVANCE: Rodenticide poisoning ranks second in mortality hierarchy at our institute, and systematic analysis of this patient population is an urgent need. HOW TO CITE THIS ARTICLE: Gopalakrishnan S, Kandasamy S, Iyyadurai R. Rodenticide Poisoning: Critical Appraisal of Patients at a Tertiary Care Center. Indian J Crit Care Med 2020;24(5):295-298.

Amlodipine-Induced Gingival Hyperplasia in a Young Male with Stage 5 Chronic Kidney Disease.

Gingival hyperplasia is a rare finding in clinical practice. Nevertheless, when it occurs, it is a finding of great value as it can lead to definite clinical diagnosis. The present case is a 19-year-old male who was referred for further management of stage 5 chronic kidney disease. On evaluation, he was found to have gingival hyperplasia. He was evaluated for reversible causes of kidney disease, and since none were found, renal replacement therapy was advised. He had been taking amlodipine for blood pressure control. As this was presumed to be the cause of gingival hyperplasia, it was stopped and replaced by a combination of beta-blocker and prazosin. At six-month follow-up, he had complete resolution of gingival hyperplasia. Amlodipine as a cause of gingival hyperplasia is a rare occurrence. However, it is crucial to keep in mind such a possible side effect of this commonly prescribed antihypertensive drug.

Cytomegalovirus ventriculoencephalitis presenting with hydrocephalus in a patient with advanced HIV infection.

A 38-year-old lady with advanced human immunodeficiency virus (HIV) infection presented to the emergency department with headache, vomiting and fluctuating alertness for 3 weeks. On examination, she had tachycardia, bilateral papilledema, restriction of upward gaze, gaze-evoked nystagmus and signs of meningeal irritation. Magnetic resonance imaging of the brain showed hydrocephalus and periventricular high T2-signal regions with restriction on diffusion-weighted imaging. Polymerase chain reaction done on the cerebrospinal fluid obtained after the insertion of an external ventricular drain was positive for cytomegalovirus (CMV). She was treated with intravenous ganciclovir followed by oral valganciclovir with which she made a dramatic recovery. CMV ventriculoencephalitis can present with hydrocephalus in HIV-infected individuals. A high index of suspicion must be maintained to diagnose this disease and start appropriate therapy on time.

Predictors of Major Bleeding and Mortality in Dengue Infection: A Retrospective Observational Study in a Tertiary Care Centre in South India.

We conducted a retrospective observational study to describe the clinical profile and outcomes of patients admitted with a diagnosis of dengue fever in a tertiary hospital in South India. A total of 159 patients admitted from April 2014 to October 2018 were included in the study. Vomiting (70.4%), myalgia (60.4%), headache (42.1%), abdominal pain (38.4%), bleeding (38%), and rash (37.1%) were the most common symptoms at presentation. The mean duration of hospital stay was 4.9 days (SD ± 2.4), and the median cost was INR 19,708 ($285) (IQR INR 12,968-32,056 ($188-$305)). Major bleeding was associated with elevated SGOT and SGPT, severe dengue, and secondary dengue. Mortality was associated with elderly age; elevated total leukocyte count, serum bilirubin, serum creatinine, SGOT, and SGPT; and high SOFA score. In view of these observations, we recommend stratifying patients according to the WHO classification of dengue and avoiding the use of thrombocytopenia as a single marker of the severity of the illness.

Fatal colchicine intoxication by ingestion of Gloriosa superba tubers.

Gloriosa superba is an ornamental herb, wildly found in the tropics especially in the southern parts of India and Sri Lanka. All parts of the plants are toxic, especially the tuberous rhizomes in view of their high content of colchicines and its derivatives. We report a case of fatal ingestion of the tubers of G. superba, with an intention of deliberate self harm, leading to systemic coagulopathy and progressive multiple organ dysfunctions. The patient was managed with intralipid rescue therapy, plasmapheresis, haemodialysis and intensive care. The ease of availability makes plant poisons, a common method of deliberate self-harm in South India. This report reiterates the need for clinician's awareness of common toxidromes associated with plant poisons.

A case report of cardiac amyloidosis presenting with chronic pericardial effusion and conduction block.

BACKGROUND: Amyloidosis is caused by the deposition of abnormal proteins in the extracellular space of various organs. The clinical features of amyloidosis depend on the type of amyloid protein and the organ system involved. CASE SUMMARY: A 51-year-old woman developed complete heart block which warranted a permanent pacemaker insertion. She was referred for evaluation of chronic pericardial effusion. The patient had stable vital signs and muffled heart sounds on examination of the cardiovascular system. Her chest X-ray film showed a permanent pacemaker in situ, and echocardiogram showed a chronic pericardial effusion without features of tamponade. On further evaluation, she was found to have an M band on serum electrophoresis, elevated free light chain ratio and amyloid deposits in bone marrow biopsy. Technetium pyrophosphate (Tc-PYP) scintigraphy was consistent with cardiac amyloidosis. DISCUSSION: Cardiac amyloidosis can have diverse clinical presentations. Chronic pericardial effusion and conduction block can be a rare presentation of cardiac amyloidosis and needs to be considered while evaluating the same. Cardiac magnetic resonance imaging and Tc-PYP imaging can be used in establishing the diagnosis of cardiac amyloidosis, if endomyocardial biopsy is not feasible.

Cutaneous botryomycosis of the foot: A case report and review of literature.

Botryomycosis is a chronic bacterial infection that manifests clinically as tumours or plaques that are often ulcerated and have discharging sinuses draining small white-coloured granules. Therefore, they closely mimic mycetoma or other fungal infections. It is most commonly caused by Staphylococcus aureus. It can present as cutaneous or visceral disease. The cutaneous form can invade deep tissue leading to extensive destruction and disfigurement. A 31-year-old female presented with progressive swelling of her right foot over a period of 8 years. She had a disfigured right foot with multiple sinuses discharging pus. X-ray and magnetic resonance imaging of the foot showed invasion and destruction of the deep layers of the foot including the bone. Deep biopsy from the foot showed an abscess cavity with Gram-positive cocci within and bacterial culture grew S. aureus establishing the diagnosis of botryomycosis. Botryomycosis is a rare presentation of a common pathogen and needs to be considered while evaluating a chronic invasive subcutaneous infection.

Risk Factors for Acquiring Scrub Typhus among the Adults.

BACKGROUND: Behavioral and geographical factors may play a role in the acquisition of scrub typhus infection. In this prospective case-control study, we studied the factors associated with infection. PATIENTS AND METHODS: Consecutive adult patients admitted with scrub typhus infection over 10 months were recruited. For every case, a geographical control from the same area and a gender-matched clinical control admitted with acute febrile illness were enrolled. The risk factors, which included sanitation, environment, activity, and protective measures, were compared between cases and controls using univariable and multivariable conditional logistic regression analysis and expressed as odds ratio (OR) with 95% confidence interval (CI). RESULTS: The study cohort (n = 225; 132 female) aged 44 ± 17 years comprised of 75 cases and 150 controls from mid to low socioeconomic background. When compared with clinical controls, on univariable conditional regression analysis, cases were more likely to be involved in farming or gardening and less likely to have a toilet within the house. On multivariate regression analysis, only involvement in farming or gardening was associated with infection (OR: 4.2, 95% CI: 1.5-11.5). When compared with geographical controls, on univariable conditional regression analysis, cases were less likely to change undergarments or clothes before sleeping (OR: 3.5, 95% CI: 1.3-9.5) and more likely to have rodents in their house (OR: 2.5, 95% CI: 1-6.4) and rest on grass/mud without a mat (OR: 2.4, 95% CI: 1.1-5.3). On multivariate regression analysis, not changing undergarments or clothes tended to be associated with infection (OR: 2.7, 95% CI: 0.98-7.3). CONCLUSION: Certain behavioral factors predisposed our cohort to develop scrub typhus infection. Lifestyle changes may reduce the burden of scrub typhus in South India.

Clinical spectrum, susceptibility profile, treatment and outcome of culture-confirmed brucellosis from South India.

Brucellosis, a common zoonosis, is under reported in India despite its endemicity and increased exposure to livestock among the population. This study was conducted to determine the clinical manifestations, antibiotic susceptibility pattern, treatment and outcome of culture confirmed brucellosis. Adult patients with culture confirmed brucellosis who presented to a large teaching hospital in South India between 2009 and 2015 were included. A diagnosis of brucellosis was confirmed on automated culture. Clinical profile, laboratory parameters, drug susceptibility, treatment and outcome were documented by reviewing the medical records. The cohort comprised of 22 patients with mean ± SD age of 42 ± 13 years. Twenty one (95.5%) was male. Thirteen (59%) patients were from rural area and risk of acquisition of brucellosis including occupational exposure or consumption of unpasteurized milk was evident in 16 (72.7%) patients. The mean duration of symptoms before presentation was 54.5 ± 52 days. The commonest clinical presentation was prolonged fever without a definite focus in 18 patients (82%), whereas 2 (9%) patients had osteoarticular involvement and one patient (4.5%) each had genital involvement and endocarditis. Eighteen patients (82%) with uncomplicated brucellosis were treated with aminoglycoside and doxycycline for 6 weeks. There was no relapse or mortality at 18 ± 9 months of follow up. Brucellosis in this cohort had acute or subacute presentation with prolonged fever and bacteremia. High index of clinical suspicion based on significant epidemiological history along with automated blood culture improves the efficiency of diagnosis. Cure with lack of relapse among these cases suggests a combination therapy with doxycycline and aminoglycoside is highly effective for the treatment.