Multidrug-resistant Vibrio cholerae O1 in Belgaum, south India.

An outbreak of acute diarrhoea occurred in the Belgundi area (population 3896) of Belgaum Taluka (population 815 581) in Karnataka, South India, in June 2010. An estimated 16.22 % of people were affected and 0.16 % deaths were reported. Vibrio cholerae O1 El Tor was isolated from 18 of the 147 stool samples cultured. Seven out of eight drinking water samples collected from different sources were found to be grossly contaminated with faecal coliforms. All isolates were multidrug resistant, with some showing resistance to quinolones, gentamicin and cephalosporins in addition to co-trimoxazole and tetracycline, the drugs that were being used by the state health authorities for empirical treatment. Two serotypes and at least eight genotypes of V. cholerae were observed among the isolates. Cholera was confirmed as one, if not the only, cause of the outbreak, which, to our belief, is the first report of cholera from this region. It might have occurred due to a 'flare up' in the number of endemic strains triggered by shortage of portable water, onset of monsoon rains and breakdown of sanitation systems, rather than being a de novo outbreak arising out of new exogenous infectious sources. A change in the empirical treatment, coupled with chlorination, improvement in sanitation measures and extensive Information Education Communication activities, resulted in decline of the outbreak and prevention of further deaths.

Increasing burden of hospital acquired infections: resistance to cephalosporin antibiotics among klebsiella and Escherichia coli.

The drug susceptibility pattern of klebsiella species and Escherichia coli to cephalosporins was examined in the year 2004 and 2005. A total of 180 klebsiella and 220 E coli in 2004 and 95 klebsiella and 210. E coli in the year 2005, isolated from various clinical specimens were studied. Resistance rates among the klebsiella species, ranged from 50.00%-86.36% and 42.10%-84.21% in 2004 and 2005 respectively. Resistance rates among E coli ranged from 46.66%-90.8% and 50.0%-86.66% in 2004 and 2005 respectively. In the year 2005 resistance to cefixime and cefpodoxime significantly increased. Resistance marginally increased to cephalexin, cefuroxime and ceftazidime. Resistance to cefotaxime was considerably low (42.10%) in 2005 compared to 62.96% in 2004. The study highlights the importance of exercising caution in the choice of empirical therapy. It also points towards the need for regular monitoring of resistance pattern in the hospital and temporary withholding of the antibiotic with high resistance so as to prevent the spread of multidrug resistant strains in the hospital and the community.

Comparison of disc diffusion methods for the detection of extended-spectrum Beta lactamase-producing enterobacteriaceae.

BACKGROUND: Resistance to broad-spectrum ß lactams, mediated by extended-spectrum ß lactamases (ESBLs), is an increasing problem world wide. This resistance poses problems for in vitro testing and reporting. Increased prevalence of ESBLs among Enterobacteriaceae creates a great need for laboratory testing methods that will accurately identify their presence. MATERIALS AND METHODS: During the study, the Enterobacteriaceae isolated were tested for the presence of ESBL by the National Committee for Clinical Laboratory Standards (NCCLS) screening test, Jarlier double disc synergy (approximation) test (DDST) and NCCLS phenotypic confirmatory test (PCT), and compared their efficiency in detection. RESULTS: A total of 313 Enterobacteriaceae were isolated and tested for the presence of ESBL. NCCLS PCT identified 200 (63.89%) as ESBL producers and DDST identified 176 (56.23%), with a P-value of <0.001. Among the screening agents, ceftazidime had a better sensitivity (89.49%) and specificity (95.74%). CONCLUSIONS: Close monitoring of the susceptibility pattern of isolates and careful spacing with specific discs can identify many ESBL producers. Ceftazidime has a better sensitivity and specificity as a screening agent. A combination of different tests can be useful for accurate identification.

Detection and antifungal susceptibility testing of oral Candida dubliniensis from human immunodeficiency virus-infected patients.

CONTEXT: Candida dubliniensis, an opportunistic yeast that has been implicated in oropharyngeal candidiasis (OPC) in patients infected with Human Immunodeficiency Virus (HIV) may be under-reported due to its similarity with Candida albicans. Resistance to Fluconazole is often seen in C. dubliniensis isolates from clinical specimens. AIMS: To know the prevalence of C. dubliniensis in OPC in patients infected with HIV and their antifungal susceptibility pattern. SETTINGS AND DESIGN: One hundred and thirty-two HIV seropositive individuals and 50 healthy controls were included in the study. MATERIALS AND METHODS: Two oral swabs were collected from the site of the lesion from 132 HIV-infected patients. Oral rinse was obtained from 50 healthy controls. Samples were inoculated on Sabouraud's dextrose agar (SDA) medium and on HiCrome Candida Differential Agar (CHROM agar) medium. Isolates were speciated by standard tests. Dark green-colored, germ tube positive isolates, which failed to grow at 420C and negative for xylose assimilation were identified as C. dubliniensis. Antifungal susceptibility test was performed by Macro broth dilution technique (National Committee for Clinical Laboratory Standards guidelines). RESULTS AND CONCLUSIONS: From 132 patients, 22 (16.3%) C. dubliniensis were isolated; samples from healthy controls did not reveal their presence. Antifungal susceptibility test showed higher resistance among C. dubliniensis isolates to azoles compared to C. albicans. Five (22.7%) isolates of C. dubliniensis were resistant to Fluconazole followed by four (18.2%) to Ketoconazole. This study emphasizes the importance of identification and antifungal susceptibility testing of C. dubliniensis in HIV-infected patients.

Changing characteristics of Vibrio cholerae: emergence of multidrug resistance and non-O1, non-O139 serogroups.

The serogroups and antimicrobial susceptibility patterns of V. cholerae isolated in Hubli, India during the years 2000 to 2004 were monitored. A total of 256 V. cholerae isolates were obtained during the study period, of which 129 (50.4%) belonged to serogroup O1 while the O139 and non-O1, non-O139 serogroups constituted 61 (23.8%) and 66 (25.8%) isolates, respectively. V. cholerae O1 Ogawa was the predominant isolate during the first 2 years of the study. However, this was replaced by V. cholerae non-O1, non-O139 serogroups in the following years. The V. cholerae, which was susceptible to most enteric antimicrobials in 2000, was found to be multidrug resistant in subsequent years, with the development of fluroquinolone resistance since 2002. Surveillance of the epidemiological and microbiological characteristics of V. cholerae provides useful information for managing cholera cases. The V. cholerae non-O1, non-O139 serogroups coupled with multiple antimicrobial resistance may form a group of emerging diarrheal pathogens in the tropics.

Significance of isolation and drug susceptibility testing of non-Candida albicans species causing oropharyngeal candidiasis in HIV patients.

Oropharyngeal candidiasis (OPC) continues to be a common opportunistic infection in patients infected with Human Immunodeficiency Virus (HIV) and is predictive of increasing immunosuppression. Though Candida albicans remains the predominant isolate, a rise in the frequency of isolation of non-albicans Candida (NAC) species is being observed. The levels of virulence and the sensitivities to available antifungal drugs vary among these species. Of 340 HIV seropositive patients in this study, 132 (38.8%) had oral lesions suggestive of candidiasis. Samples were collected from the lesion using sterile cotton swabs. Isolation and speciation were done by standard techniques. Antifungal drug susceptibility testing was done by macro broth dilution. The total number of Candida isolates was 135, of which, 45 (33.3%) were NAC species and 90 were C.albicans (66.6%). Of the NAC species, C. dubliniensis was the predominant pathogen (22,48.9%). Antifungal susceptibility testing showed that 14 (31.1%) of the NAC species and 11 (12.2%) of C. albicans were resistant to fluconazole (MIC > 8 microg/ml). A very high MIC of > 32 microg/ml was noted among the NAC species resistant to fluconazole.

Listeria monocytogenes meningitis: an uncommon opportunistic infection in HIV/AIDS.

OBJECTIVE: To report an interesting case of meningitis caused by Listeria monocytogenes meningitis in an HIV seropositive individual. MATERIALS & METHODS: A previously healthy 45 years old HIV seropositive man, presented with atypical clinical features of meningitis. Blood and Cerebrospinal fluid (CSF) were obtained for biochemical and microbiological investigations. RESULTS: CSF analysis showed pleocytosis with lymphocytic predominance. Gram stain of CSF was negative; however culture yielded growth of gram positive bacilli with tumbling motility. Based on relevant biochemical tests the isolate was identified as Listeria monocytogenes. Patient was treated with i.v. ampicillin and recovered completely. CONCLUSION: Listeriosis is relatively rare in HIV/AIDS among the immunodeficient populations. Atypical clinical and laboratory findings make the diagnosis difficult and these infections may go undiagnosed. Since it is easily treated with readily available antibiotics, it is important to diagnose them at the earliest and thereby prevent treatment failure.

Extended spectrum beta lactamase producing Klebsiella pneumoniae in neonatal intensive care unit.

OBJECTIVE: As infections due to Extended Spectrun beta Lactamase (ESbetaL) producing Klebsiella pneumoniae were increasing in the NICU at Karnataka Institute of Medical Sciences Hospital, Hubli, India, the present study was carried out to identify any environmental sources and the mode of transmission. METHODS: Environmental samples from various sites were collected monthly for a period of six months. RESULTS: ESbetaL producing K. pneumoniae were isolated from all the sites except room air at least on one occasion. ESbetaL producing K. pneumoniae was always isolated from one of the incubators, medicine trolley and sink; while at least one of the health care workers carried it in the hands four out of six times tested. ESbeta L producing K. pneumoniae with similar antibiogram were also isolated from the clinical samples obtained from the neonates. CONCLUSION: Widespread use of third generation cephalosporins as a pre-emptive antibiotic for suspected cases of septicaemia may have contributed to emergence of ESbetaL producing K. pneumoniae in addition to other risk factors. ESbetaL producing K. pneumoniae have extensively colonised the environment of the NICU. Transmission of these pathogens to the neonates has probably occurred through the healthcare workers. Efforts to improve hand hygiene among the healthcare workers and mothers are urgently needed.

Methicillin resistant Staphylococcus aureus infections-implications in hospital infection control.

BACKGROUND: A significant part of nosocomial infections are caused by methicillin resistant Staphylococcus aureus (MRSA). Nosocomial MRSA are known to be multidrug resistant and thus difficult to treat. METHODS: A 2 year study was conducted between January 2001 and December 2002 at Karnataka Institute of Medical Sciences Hospital, Hubli to assess the prevalence of MRSA and its antibiotic susceptibility pattern in various wards. RESULTS: S. aureus was isolated from 714 patients, 283 (37.53%) of which exhibited methicillin resistance. Although these MRSA were multidrug resistant in all the wards, the problem was more severe in NICU and orthopedic wards. CONCLUSION: The results highlight the need for effective implementation of infection control measures in the hospital. There is a need for the judicious use of antimicrobial agents in the hospital and outside as their indiscriminate use can exert pressure in selecting out MRSA and other multidrug resistant organisms.

Fluoroquinolone-resistant Vibrio cholerae isolated during a cholera outbreak in India.

During the cholera epidemic of 2002 in and around Hubli, south India, Vibrio cholerae strains resistant to fluoroquinolones were isolated. Among the isolates of V. cholerae non-O1, non-O139 serogroups, 55.9% and 47.1% were resistant to norfloxacin and ciprofloxacin, respectively. However, only 12.5% of the O1 serogroup strains were resistant to both norfloxacin and ciprofloxacin. Though the O139 serogroup strains were susceptible to these antibiotics, they exhibited multidrug resistance. Emergence of fluoroquinolone-resistant V. cholerae that also exhibited multidrug resistance is of great significance in the epidemiology and control of cholera.

Neonatal sepsis caused by Salmonella enterica serovar Weltevreden.

Salmonella enterica serovar Weltevreden is an uncommon cause of gastroenteritis occurring worldwide. For the first time, we report 2 cases of neonatal sepsis caused by S. Weltevreden from Hubli, India. In the first case, the neonate had features of septicemia and S. Weltevreden was isolated from a blood culture. The other neonate had omplalitis and clinical features of septicemia. S. enterica serovar Weltevreden was isolated from the umbilical swab culture of this neonate. Even though extensive investigations were conducted, the source of infection could not be identified. Both neonates recovered completely after appropriate antibiotic and supportive therapy.

Community-acquired methicillin-resistant Staphylococcus aureus infections in a south Indian city.

There are increasing numbers of reports of community-acquired Staphylococcus aureus being resistant to methicillin. The present study was undertaken as no such reports are available for the developing nations. In a prospective study, between June to December 2001, at the Karnataka Institute of Medical Sciences, Hubli, Karnataka, India, methicillin-resistant S. aureus (MRSA) isolates were tested for clindamycin-susceptibility, a surrogate marker for community-acquired strains. Patients with clindamycin-susceptible isolates were interviewed to determine if they had acquired them in the community and also to identify any risk factors. Of the 116 patients with S. aureus infection, 18.1% had infection with methicillin-resistant strains. Clindamycin-susceptible MRSA accounted for 61.9% of cases. Among these, 46.1% patients were confirmed to have acquired the MRSA from the community, based on inclusion criteria. The community-acquired MRSA were susceptible to multiple antibiotics, as compared to nosocomial isolates. Except for one patient with diabetes mellitus, no other patient had any known risk factor for acquiring MRSA. As significant numbers of MRSA infections are being acquired from the community, treatment options for S. aureus infections may need to be reviewed. Effective infection control programs for the community should be considered to prevent the spread of these infections.

Intestinal helminthic infestation in children.

In this study of fecal samples from 1000 children below 6 years of age, 680 (68.0%) detected to have intestinal helminthic infection. The incidence of intestinal helminthiasis in urban group of children was 56.8% (284 out of 500 tested) while in rural group of children was 79.2% (396 out of 500 tested). Both in rural and urban population Ascaris lumbricoides was the single predominant species, whereas a combination of A. lumbricoides and Trichuris trichiura was common multiple infection. All cultures of fecal samples positive for hook worm ova revealed the prevalent species as Necator americanus in this area.

Incidence of Vibrio cholerae serogroup O139 infection with low virulence in Hubli, Karnataka (India).

384 stool samples from patients with acute gastroenteritis were processed by standard culture techniques and antibiogram of V. cholerae was performed. Stool samples from 93 (24.22%) patients yielded V. cholerae, 58 (62.37%) of which were V. cholerae, El Tor O1 Ogawa, 31 (33.33%) V. cholerae O139 and 4 (4.30%) V. cholerae non O1 non O139. Of the culture proven cholera cases watery diarrhoea was observed in 79 (84.95%), vomiting in 57(61.29%), muscle cramps in 21 (22.58%) and sweating in 18 (19.35%). Majority of these patients presented with moderate dehydration 57 (61.29%). Mild dehydration was found in 19 (20.43%) and severe dehydration in 17 (18.28%). While majority of patients with O139 infection had mild to moderate dehydration 25 (80.65%), severe dehydration was more common with O1 infection 11 (64.71%). This study reflects the importance of monitoring the V. cholerae by serogrouping, antibiogram typing, which keep on varying constantly.