Analysis of an outbreak of nosocomial COVID-19 at a tertiary care centre in South India.

BACKGROUND: Nosocomial outbreaks of COVID-19 have been reported sporadically since the beginning of the COVID-19 pandemic. We sought to study the transmission dynamics in a nosocomial COVID-19 outbreak in our centre. METHODS: This was a retrospective cohort study in a 500 bedded tertiary care hospital in South India. Inpatients who were suspected to have likely or definite hospital-acquired COVID-19 and hospital staff members who were found to be COVID-19 positive during the same time frame were studied and the likely transmission dynamics described. RESULTS: During the study period, 173 patients were diagnosed to have COVID-19, out of which, 15 (8.6%) patients who fulfilled the criteria for likely or definitely hospital-acquired COVID-19 infection were identified from six different wards. During the same period, 121 hospital staff members were diagnosed with COVID-19. Out of these, 18 (14.9%) hospital staff members were identified who could have been the potential source of infection for these 15 patients based on the overlap of location of the staff and the patients, and their infectivity windows. Direct contact and fomite transmission were likely the predominant driver of transmission in our study as there was use of universal face masks and face shields. CONCLUSION: Despite the admission of a large number of COVID-19 patients and a relatively large proportion of hospital staff members who tested positive for the disease, the proportion of nosocomial COVID-19 in our centre remained low. A policy of universal gloving, coupled with the already existing practice of universal N95 masking and face shield use, could potentially bring down the rate of nosocomial COVID-19 even further.

Clinical Outcomes in Carbapenem-Resistant Enterobacteriaceae Infections Treated With Ceftazidime-Avibactam: A Single-Center Observational Study.

Introduction Among the several newer beta lactam+beta lactase inhibitors (BL/BLI), ceftazidime-avibactam is the only drug showing activity against OXA-48-like producers. Hence, it is being increasingly used in India to treat infections caused by carbapenem-resistant Enterobacteriaceae (CRE), especially as a colistin-sparing agent. We have used ceftazidime-avibactam in patients suspected and confirmed to have CRE infections in our center, and present a retrospective analysis of our experience. Methods We conducted a single-center, retrospective study involving all patients who were treated with ceftazidime-avibactam for suspected and proven CRE infections during a one-year period at our 500-bedded hospital. Our primary objective for this study was taken as all-cause mortality. The secondary objectives were to determine the clinical cure, defined as the end of the treatment regimen with a resolution of primary infection and resistance to ceftazidime-avibactam in patients who underwent the Epsilometer test (E-test). Results  A total of 103 patients who received ceftazidime-avibactam were identified. The all-cause mortality was 27% while a clinical cure was achieved in 73%. Fifty-two patients received empirical therapy and 51 patients received ceftazidime-avibactam for confirmed CRE infection. Forty-eight patients had an E-test done, out of which 79% of patients had CREs sensitive to ceftazidime-avibactam, and 21% of patients had ceftazidime-avibactam resistant CREs. A higher Sequential Organ Failure Assessment (SOFA) score, Charlson comorbidity index (CCI) score, intensive care unit (ICU) admission, inotrope requirement, and lower days of therapy (DOT) with ceftazidime-avibactam were found to be associated with increased mortality. Conclusion Colistin has been considered to be the last-line agent in CRE infections, but there are concerns about its adverse effects and the emergence of resistance. Given our relatively low mortality of 27% in CRE infections treated with ceftazidime-avibactam, coupled with the high susceptibility of the tested isolates, there may be a role for the empirical use of this drug in infections caused by CRE, especially in a setting where colistin may not be ideal.

Nocardia araoensis Causing Brain Abscess.

Nocardial brain abscess is a rare central nervous system infection with high morbidity and mortality. Most of the human infections, i.e., about 90%, are due to Nocardia asteroides group comprising N. asteroides complex, Nocardia farcinica, and Nocardia nova. Other species rarely cause human infections. Here, we report a case of left parieto-occipital abscess caused by a rare species, Nocardia araoensis, its diagnosis, treatment options, and review of literature. A 73-year-old male, known case of diabetes mellitus, on prolonged oral corticosteroid for autoimmune hemolytic anemia presented with a 1-month history of memory deficit and gait imbalance. On examination, he had a right inferior quadrantanopia and hemiparesis. Magnetic resonance imaging showed a multiloculated ring-enhancing lesion in the left parieto-occipital region. Navigation-assisted biopsy was done. The organism isolated was N. araoensis. He was treated successfully with prolonged course of antibiotics which resulted in complete clinical and radiological resolution. N. araoensis is a rare cause of brain abscess and needs to be suspected in immunocompromised individuals. Early diagnosis and prolonged treatment can result in complete clinical and radiological resolution.

How to Save Half a Million Dollars: An Antimicrobial Stewardship Program in a Tertiary Care Center.

We started a quality improvement project (QIP) with the aim of implementing an antimicrobial stewardship program (AMSP) to optimize antimicrobial use. We implemented this QIP in our tertiary care center with baseline data from July 1, 2017, to December 31, 2017 (pre-AMSP period), and the project period between January 1, 2018, and June 30, 2018. It covered every inpatient with a positive microbiological culture and patients who were initiated on a pre-selected list of 16 restricted antimicrobials. Numerous plan-do-study-act (PDSA) cycles were conducted alongside daily AMSP rounds, consisting of prospective audit and feedback to all stakeholders. The outcome measures used were antibiotic consumption and costs, Clostridium difficile infection (CDI) rates, the average length of stay (LOS), and adverse drug reaction (ADR) reporting rates. We demonstrated a considerable reduction in the consumption of the selected antibiotics, as well as a direct translation to cost-saving. The AMSP directly contributed to collective savings of around half a million US dollars in hospital bills for patients. We also demonstrated reduced average LOS, CDI rates, and increased reporting of ADRs to antibiotics. The reduction in average LOS was also directly beneficial to patients with reduced time spent in the hospital. The reduction in CDI rates proves that there is a reduction in the development of AMR, and in the short term, fewer incidences of healthcare-associated infections. This, in addition to better surveillance of ADRs to antimicrobials, improved patient safety and quality of care.

Faecal carriage rate of extended-spectrum ß-lactamase-producing Enterobacteriaceae in hospitalised patients and healthy asymptomatic individuals coming for health check-up.

The prevalence of extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-PE) in hospitalised and community patients is of significant public health concern. The aim of this study was to estimate the faecal carriage rate of ESBL-PE in hospitalised patients and healthy asymptomatic individuals coming for health check-up. Non-repetitive, consecutive stool samples from 480 adults (260 healthy individuals and 220 hospitalised patients) aged ≥18 years from November 2011 to July 2013 were screened using MacConkey agar supplemented with ceftazidime. All screen-positive isolates were identified to species level and were tested for ESBL production. Representative ESBL-PE isolates were subjected to susceptibility testing and multiplex ESBL PCR. The faecal carriage rate of ESBL-PE was found to be 62.7% among hospitalised patients and 33.8% among healthy asymptomatic individuals. The most common ESBL-PE was Escherichia coli (70.3% and 78.4% in hospitalised patients and healthy individuals, respectively), followed by Klebsiella pneumoniae (26.8% and 17.0%). ESBL-PE showed the highest sensitivity to carbapenems (85% and 100%, respectively), followed by amikacin (67.2% and 98%), cefoperazone/sulbactam (27.8% and 88.2%) and piperacillin/tazobactam (18% and 74.5%). Ciprofloxacin exhibited a high level of resistance among both groups. Molecular analysis for ESBL genes showed a predominance of the CTX-M gene. In conclusion, the faecal carriage rate of ESBL-PE among hospitalised patients was almost double that of healthy individuals. Carriage of carbapenem-resistant isolates is emerging among hospitalised patients. The spread of these organisms in the community merits radical measures to improve sanitation and implement antibiotic stewardship.

Trichosporon asahii infection presenting as chronic meningo-ventriculitis and intra ventricular fungal ball: a case report and literature review.

Central nervous system trichosporonosis is a rare clinical entity and so far only six cases including three each of brain abscess and meningitis has been on record. We report a rare case of chronic meningo-ventriculitis and intraventricular fungal ball due to Trichosporon asahii in an 18-year-old immunocompetent male from Burundi, east Africa. Neuroendoscopy showed multiple nodules and a fungal ball within the ventricle, which on culture grew T. asahii. He was initially empirically treated with liposomal amphotericin B. However, the antifungal susceptibility testing of T. asahii isolate revealed high minimum inhibitory concentration for amphotericin B (2 µg ml⁻¹), flucytosine (16 µg ml⁻¹) and caspofungin (2 µg ml⁻¹) but exhibited potent activity for voriconazole, posaconazole, itraconazole and fluconazole. The patient rapidly succumbed to cardiac arrest before antifungal therapy could be changed. Although disseminated trichosporonosis has been increasingly reported the diagnosis represents a challenge especially in rare clinical settings such as intraventricular fungal ball in the present case, which has not been described previously.

Invasive mycosis due to species of Blastobotrys in immunocompromised patients with reduced susceptibility to antifungals.

Cases of invasive mycosis due to Blastobotrys serpentis and B. proliferans identified by sequencing in a preterm patient and a rhabdomyosarcoma patient, respectively, are reported. Both species revealed elevated fluconazole and echinocandin MICs by the CLSI broth microdilution method. Additionally, B. serpentis exhibited high amphotericin B MICs, thus posing serious therapeutic challenges.

Autochthonous blastomycosis of the adrenal: first case report from Asia.

Systemic endemic mycoses, such as blastomycosis, are rare in Asia and have been reported as health risks among travelers who visit or reside in an endemic area. Adrenal involvement is rarely seen in blastomycosis and has never been reported from Asia. We report the first case of blastomycosis with bilateral involvement of the adrenals in a diabetic patient residing in the state of Arunachal Pradesh, India.