High prevalence of fluoroquinolone resistance amongst commensal flora of antibiotic naïve neonates: a study from India.

BACKGROUND: The emergence of resistance amongst commensal flora is a serious threat to the community. However, there is paucity of data regarding antibiotic resistance in commensals in the absence of antibiotic pressure. METHODS: Altogether, 100 vaginally delivered antibiotic naïve exclusively breastfed neonates were selected. Stool samples collected on day (D)1, D21 and D60 of birth were cultured. Enterobacteriaceae isolates were screened for nalidixic acid (NA) and ciprofloxacin susceptibility as per CLSI guidelines. In 28 randomly selected neonates, isolates (n=92) resistant to NA and ciprofloxacin were characterized for the presence of plasmid-mediated quinolone resistance (PMQR) genes (qnrA, qnrB and qnrS, qepAand aac(6')-Ib-cr) and mutations in the quinolone resistance determining region (QRDR) of gyrA and parC genes by specific primers and confirmed by sequencing. RESULTS: A total of 343 Enterobacteriaceae were isolated from 100 neonates. On D1, 58 % of neonates were colonized with at least one Enterobacteriaceae predominantly E. coli. Overall resistance to NA was 60 % but ciprofloxacin resistance increased significantly from 15 % (14/96) on D1 to 38 % (50/132) on D60 (P-value <0.001). The predominant mechanism of fluoroquinolone resistance was mutation in gyrA (n=49) with or without PMQR. PMQR carrying isolates increased more than fivefold from D1 to D60. CONCLUSION: A high level of fluoroquinolone resistance in gut flora of antibiotic naïve and exclusively breastfed neonates suggests a rampant rise of resistance in the community. The source of resistance genes on D1 is probably maternal flora acquired at birth. High load of PMQR genes in commensal flora are a potential source of spread to pathogenic organisms.

Hemozoin Pigment: An Important Tool for Low Parasitemic Malarial Diagnosis.

Low parasitemic condition in malaria remains a diagnostic challenge; as the available diagnostic methods failed to detect. Currently, hemozoin (Hz) pigment is gaining attention in the diagnosis of malaria. The major drawback is ease of detection of Hz in routine practice. A pilot study was conducted to evaluate the role of Hz pigment and to compare the performance of quantitative buffy coat assay (QBC) and PCR in such conditions. Clinically suspected cases of malaria were examined by both Giemsa stain and immunochromatographic test (ICT). Samples positive by ICT and negative by Giemsa stain were further examined by nested PCR targeting 18S rRNA and QBC for the presence of malaria parasites and pigments. Thirty blood samples fulfilled the inclusion criteria out of which 23 were Plasmodium vivax (Pv), 4 Plasmodium falciparum (Pf), and 3 mixed (Pv and Pf) by immunochromatographic test. Twenty-one out of 30 (70%) were positive by nested PCR in comparison to 25/30 (83%) by QBC. Samples containing both malaria parasites and Hz pigment by QBC completely showed concordance with the PCR result. However, 61% of total samples containing only Hz pigment were observed positive by PCR. Hz pigment remains an important tool for malaria diagnosis. Identification of leukocytes containing pigments by QBC not only indicates recent malarial infections but also puts light on severity of the disease. QBC assay is a rapid, highly sensitive, and cost-effective method to detect malaria parasites and Hz pigment especially in low parasitemic conditions.

Intestinal Parasitosis in Relation to Anti-Retroviral Therapy, CD4(+) T-cell Count and Diarrhea in HIV Patients.

Intestinal parasitic infections are one of the major causes of diarrhea in human immunodeficiency virus (HIV) seropositive individuals. Antiretroviral therapy has markedly reduced the incidence of many opportunistic infections, but parasite-related diarrhea still remains frequent and often underestimated especially in developing countries. The present hospital-based study was conducted to determine the spectrum of intestinal parasitosis in adult HIV/AIDS (acquired immunodeficiency syndrome) patients with or without diarrhea with the levels of CD4(+) T-cell counts. A total of 400 individuals were enrolled and were screened for intestinal parasitosis. Of these study population, 200 were HIV seropositives, and the remaining 200 were HIV uninfected individuals with or without diarrhea. Intestinal parasites were identified by using microscopy as well as PCR assay. A total of 130 (32.5%) out of 400 patients were positive for any kinds of intestinal parasites. The cumulative number of parasite positive patients was 152 due to multiple infections. A significant association of Cryptosporidium (P<0.001) was detected among individuals with CD4(+) T-cell counts less than 200 cells/µl.

Yokenella regensburgei infection in India mimicking enteric fever.

Yokenella regensburgei is an opportunistic human pathogen of the Enterobacteriaceae family rarely reported to cause human infections. Here, we present a case report of Y. regensburgei bacteraemia from India clinically resembling enteric fever in an apparently immunocompetent paediatric patient.

Comparison of an automated system with conventional identification and antimicrobial susceptibility testing.

The present study was designed to compare a fully automated identification/antibiotic susceptibility testing (AST) system BD Phoenix (BD) for its efficacy in rapid and accurate identification and AST with conventional manual methods and to determine if the errors reported in AST, such as the (very major errors) VME (false susceptibility), (major errors) ME (false resistance), and (minor errors) MiE (intermediate category interpretation) were within the range certified by FDA. Identification and antimicrobial susceptibility test results of eighty-five clinical isolates including both gram-positive and negative were compared on Phoenix considering the results obtained from conventional manual methods of identification and disc diffusion testing of antibiotics as standards for comparison. Phoenix performed favorably well. There was 100% concordance in identification for gram-negative isolates and 94.83% for gram-positive isolates. In seven cases, Phoenix proved better than conventional identification. For antibiotic results, categorical agreement was 98.02% for gram-positive and 95.7% for gram-negative isolates. VME was 0.33%, ME 0.66%, MiE 0.99% for gram-positive isolates and 1.23% VME, 1.23% ME, and 1.85% MiE for gram-negative isolates. Therefore, this automated system can be used as a tool to facilitate early identification and susceptibility pattern of aerobic bacteria in routine microbiology laboratories.

Aureobasidium pullulans keratitis.

BACKGROUND: Corneal ulcer caused by Aureobasidium pullulans is considered to be a rare entity. So far very few reports have appeared in the world literature and the authors' hospital is the first to report from Nepal. Although A. pullulans is regarded as a contaminant, it should be considered as a pathogen if isolated from corneal ulcer specimen with clinical signs of infection and with growth of the organism on two or more culture media or growth in one medium with consistent direct microscopy findings or growth of the same organism on repeated corneal scrapings. In the present study, a series of proven cases of A. pullulans corneal ulcers at a tertiary eye care centre of Eastern Nepal is reported. METHODS: A retrospective analysis of stored data of microbiological and clinical cases of corneal ulcer was carried out. All consecutive patients (447 patients) with presumed microbial keratitis from 1 August 1998 to 31 July 2001 were evaluated with regards to clinical details, microbiological examination and management. RESULTS: Of 200 fungal organisms isolated from the cultures, 25 were identified as A. pullulans. These ulcers showed negligible improvement to topical natamycin and required either topical fluconazole or topical itraconazole in all along with systemic intravenous fluconazole in eight patients. Of 25 eyes, 22 responded well to antifungal therapy and 2 required therapeutic penetrating keratoplasty. One patient was lost to follow up for 3 months and revealed phthisis bulbi on subsequent examination. CONCLUSIONS: Aureobasidium pullulans corneal infection should be considered as a cause of keratomycosis.

Chromoblastomycosis: report of two cases from Nepal.

Chromoblastomycosis is a chronic fungal infection of the skin and subcutaneous tissue caused by dematiaceous fungi. The first case, a 67-year-old male farmer, presented with itchy hyperkeratotic, scaly plaques with scarring and black dots on the lateral aspects of his left arm and dorsum of his left hand of 28 years duration. The case was clinically diagnosed as chromoblastomycosis. The second case, a 75-year-old farmer, presented with erythematous, crusted, scaly plaques on the dorsum of the left foot of 30 years duration. Initially, a clinical diagnosis of lupus vulgaris was made, but treatment with anti tuberculosis therapy showed no improvement. On the basis of histopathological examinations of skin biopsies and isolation of fungus on culture, both cases were diagnosed as chromoblastomycosis. To the best of our knowledge, these two cases are the first case reports of chromoblastomycosis from Nepal and are presented for their academic interest.