Association of multidrug resistance behavior of clinical Pseudomonas aeruginosa to pigment coloration.

Pseudomonas aeruginosa is an adaptable bacterial pathogen that infects a variety of organs, including the respiratory tract, vascular system, urinary tract, and central nervous system, causing significant morbidity and mortality. As the primary goal of this study, we wanted to determine how pigment color production differed between clinical strains of P. aeruginosa, and whether or not that variation was associated with multidrug resistance or the ability to form biofilms. We screened in total 30.1% of yellow, 39.8% green and 30.1% of no pigment-producing P. aeruginosa strains from a total of 143 various clinical isolates. Yellow pigment-producing strains presented significant resistance to antibiotics groups, including ß-lactam (91.5%), aminoglycosides (70.5%), and carbapenems (51.9%) compared to green and non-pigmented strains. Notably, 16.3% of yellow pigment-producing strains were resistant to colistin which is used as a last-resort treatment for multidrug-resistant bacteria, whereas only 2.3% of non-pigmented and 1.8% of green pigmented strains were resistant to colistin. Aside from that, yellow pigment-producing strains were frequent producers of enzymes belonging to the lactamase family, including ESBL (55.6%), MBL (55.6%), and AmpC (50%). Compared to the green groups (7.14%) and non-pigmented groups (28.5%), they had a higher frequency of efflux positive groups (64.2%). Notably, when compared to non-pigmented groups, green pigment-producing strains also displayed antibiotic susceptibility behavior similar to yellow pigment-producing strains. The majority of yellow pigment-producing strains outperformed the green and non-pigmented strains in terms of MIC levels when compared to the other two groups of strains. Despite the fact that previous studies have demonstrated a direct correlation between multidrug resistance behaviors and biofilm production, no such statistically significant association between pigment and biofilm formation was found in our investigation. Our research has demonstrated that the correlation of bacterial pigments on their susceptibility to antimicrobial agents. Yellow pigment-producing P. aeruginosa strains posed a significant problem due to the lack of alternative agents against such transformed strains, which may be associated with the development of multidrug resistance.

Retrospective Analysis of Urinary Tract Infection in the Pediatric Population at a Tertiary Care Centre.

BACKGROUND: Urinary tract infection (UTI) is among the most common infections occurring during childhood. It is caused by both gram-negative and gram-positive bacteria and Escherichia coli is the most common causative agent. METHODS: Data of all pediatric patients in the age group of 6 months to 18 years with urinary tract infection were taken for analysis. Urine samples were collected and cultured on the cystine lactose electrolyte-deficient medium. The presence of bacteria was identified using biochemicals, and the antimicrobial test was performed using the Kirby-Bauer test or the VITEK 2 compact system (bioMérieux, Inc., France). RESULTS: The prevalence of UTI was 23.5%. In total, 614 specimens tested positive with significant bacteriuria. The male-to-female ratio was 1:2.3. Approximately 54% patients presented with urinary symptoms alone. Culture positivity was significantly associated with pyuria (p < 0.0001). E. coli (334/614) was the most common isolate, followed by Enterococcus spp. (92/614). Colistin, polymyxin B, fosfomycin, nitrofurantoin, netilmicin, and amikacin were extremely good acting antimicrobials. Meanwhile, ampicillin, cefotaxime, ceftriaxone, and norfloxacin were highly resistant to gram-negative bacteria. Multidrug-resistant bacteria and extended-spectrum beta-lactamase-producing bacteria were found in 47% and 44.1% of cases, respectively. Vancomycin, linezolid, teicoplanin, and nitrofurantoin were highly effective against gram-positive bacteria. Furthermore, norfloxacin, trimethoprim/sulfamethoxazole, ciprofloxacin, and tetracycline were highly resistant to gram-positive bacteria. Of the 92, 42 Enterococcus spp. were resistant to high-dose gentamicin. CONCLUSION: Nitrofurantoin and amikacin can be used as empirical therapy for gram-negative and gram-positive bacteria. Because resistance to various commonly used antibiotics is found to be increasing, treatment must be guided by antibiotic susceptibility reports.

Potential Synergistic Antibiotic Combinations against Fluoroquinolone-Resistant Pseudomonas aeruginosa.

The rise in multiple-drug-resistant (MDR) phenotypes in Gram-negative pathogens is a major public health crisis. Pseudomonas aeruginosa is one of the leading causes of nosocomial infections in clinics. Treatment options for P. aeruginosa have become increasingly difficult due tdo its remarkable capacity to resist multiple antibiotics. The presence of intrinsic resistance factors and the ability to quickly adapt to antibiotic monotherapy warrant us to look for alternative strategies like combinatorial antibiotic therapy. Here, we report the frequency of P. aeruginosa multidrug-resistant and extensively drug-resistance (XDR) phenotypes in a super-specialty tertiary care hospital in north India. Approximately 60 percent of all isolated P. aeruginosa strains displayed the MDR phenotype. We found highest antibiotic resistance frequency in the emergency department (EMR), as 20 percent of isolates were resistant to 15 antipseudomonal antibiotics. Presence of plasmids with quinolone-resistance determinants were major drivers for resistance against fluoroquinolone. Additionally, we explored the possible combinatorial therapeutic options with four antipseudomonal antibiotics-colistin, ciprofloxacin, tobramycin, and meropenem. We uncovered an association between different antibiotic interactions. Our data show that the combination of colistin and ciprofloxacin could be an effective combinatorial regimen to treat infections caused by MDR and XDR P. aeruginosa.

Upshaw-Schulman Syndrome with a Novel Deletion in Exon 17 of ADAMTS 13 Gene.

Upshaw-Schulman syndrome is a rare congenital form of thrombotic thrombocytopenic purpura (TTP) characterized by single or recurrent episodes of thrombocytopenia, microangiopathic hemolyticanemia (MAHA), and widespread microvascular thrombosis, leading to the ischemic damage of multiple organs (mainly kidney, heart and brain). A 6-mo-old female infant, second born of a third-degree consanguineous marriage, with a history of severe neonatal jaundice with thrombocytopenia secondary to hemolysis requiring exchange transfusion on day 2 of life, presented with high-grade fever without focus of 2-d duration. Initial workup revealed microangiopathic hemolyticanemia with thrombocytopenia. In view of microangiopathic hemolyticanemia with thrombocytopenia against a background of severe neonatal jaundice, a diagnosis of congenital TTP was considered and was managed with FFP transfusion. The diagnosis was confirmed with her exome sequencing showing autosomal recessive homozygous frameshift deletion c.2063delG (p.Trp688fs) at Exon 17 (NM_139025) of ADAMTS 13 gene.

Clinical spectrum and risk factors for hospital-acquired septicemia in a tertiary care centre of North-East India.

INTRODUCTION: Although several studies have shown an increasing prevalence of sepsis due to multidrug-resistant organisms, specific data on hospital-acquired septicemia is lacking. MATERIALS AND METHODS: An observational prospective study was carried out for a duration of 1 year in which patients developing hospital-acquired septicemia were included and their disease spectrum and associated risk factors were analyzed. RESULTS: Among a total of 350 patients, 145 came out to be culture positive. Genitourinary infections were the most common infections encountered in this study, whereas the presence of invasive device came out to be the most prevalent risk factor. CONCLUSION: Septicemia is still a rising problem; hence, we should manage it carefully. Coagulase-negative Staphylococci can no longer be considered as contaminants and it should be treated as pathogens.

Pyogenic liver abscess: Clinical features and microbiological profiles in tertiary care center.

BACKGROUND: Pyogenic liver abscess (PLA) is the end result of a number of pathologic processes that cause a suppurative infection of the liver parenchyma. MATERIALS AND METHODS: Sixty-five patients of age more than 18 years and radiologically confirmed cases of liver abscess were included in this study. Pus and blood samples were collected. Pus was processed for microscopy of trophozoite of Entamoeba histolytica and aerobic and anaerobic bacterial culture. Blood was processed for antibody ELISA for Entamoeba histolytica and aerobic bacterial culture. Identification of aerobic and anaerobic isolates was done by Vitek2 and antibiotic sensitivity test for aerobic bacterial isolates was done by Vitek2. RESULT: Out of sixty five, twenty five were confirmed as PLA. All patients were male with mean age 37.9 years. Fever and upper abdominal pain were the most common symptoms. Right lobe comprised 80% of the abscess. Pus sample was more sensitive than blood sample for diagnosis. There were a total of 33 isolates in our study. Klebsiella pneumoniae (6/33) was the most common aerobic isolate and Clostridium spp. (7/33) was the anaerobic isolate. All gram-negative bacteria were showing good sensitivity for 3rd and 4th generation cephalosporins, fluoroquinolones, amikacin, gentamicin, piperacillin-tazobactam, imipenem and meropenem. Abscess >5 cm was treated with percutaneous drainage while abscess <5 cm was treated with antibiotics only. CONCLUSION: Diagnosis should be made with the combination of clinical suspicion, radiology, and microbiology. Empirical therapy should include anaerobic coverage too. Only antibiotic therapy can be given under consideration of size of abscess, persistence of fever after giving antibiotics, and any suspected complications.

Death from rabies: The reason being poor compliance to vaccination or it's failure.

Rabies is endemic in India and responsible for 20,000 human deaths every year. It is 100% preventable when the vaccine is taken along with proper wound care and rabies immunoglobulin administration though update continues regarding the requirement of the number of vaccine doses, the need for immunoglobulin, and if required their types. We study four cases of rabies having street dogs' bite category grade 3. Everyone took vaccines at least three doses but none of them took rabies immunoglobulin. They developed symptoms of rabies with a gap of 15-28 days after the bites and admitted to a tertiary care center. One patient was left against medical advice and three patients were treated according to the modified Milwaukee protocol. But, none of them could be saved. So, it may be proposed that the reason of deaths may be due to lack of administration of rabies immunoglobulin (passive vaccination) or failure of vaccines. Hence, the government may focus on the administration of complete and quality post-exposure prophylaxis in all cases of animal bites. Although Milwaukee protocol saves few lives, it may be further improved or other treatment modalities may be developed for rabies treatment.

Child survivor of rabies in India: a case report.

A 4-year-old boy was admitted with an acute onset fever for 4 days and drowsiness for 3 days, followed by progressive flaccid weakness of both lower limbs and encephalopathy soon after admission. He had sustained a WHO Class III stray dog bite 2 weeks previously and had received three doses of post-exposure rabies vaccination with purified vero cell vaccine but not rabies immunoglobulin. He was diagnosed with rabies based on the presence of rabies virus neutralising antibody in CSF (Day 1 1:128 and Day 26 1:2048) and typical findings on neuro-imaging. Rabies viral RNA was not detected in CSF, in saliva or on nuchal skin. The child survived with supportive treatment alone but he has extensive neurological sequelae. This report demonstrates the detailed clinico-investigative profile of a child who survived rabies following inadequate post-exposure prophylaxis and adds to the sparse knowledge of this usually fatal condition. ABBREVIATIONS: ADEM, acute disseminated encephalomyelitis; CBNAAT, cartridge-based nucleic acid amplification test; CSF, cerebrospinal fluid; EEG, electroencephalogram; GCS, Glasgow coma scale; EVM, eye opening, best verbal response, best motor response; IM, intramuscular; IVIg, intravenous immunoglobulin; MRC, Medical Research Council; MRI/FLAIR, magnetic resonance imaging/fluid attenuation inversion recovery; PCR, polymerase chain reaction; RFFIT, rapid fluorescent focus inhibition test; RIg, rabies immunoglobulin; RNA, ribonucleic acid; WBC, white blood cells; WHO, World Health Organization.

Root cause analysis in the NHS: time for change?

Root cause analyses were intended to search for system vulnerabilities rather than individual errors, using a human factors engineering approach. In practice, root cause analyses done in the NHS may generally fail to identify components where there are organisational failures, as there may be an inherent desire to protect institutional reputation. A human factors approach to root cause analysis looks at system vulnerabilities, considering the entirety of the environment in which an individual works and taking into account factors such as the physical environment and individual mental characteristics. Other human factors include group dynamics, task complexity and concurrent tasks. It is time that the growing evidence of the potential shortcomings of root cause analysis, especially as frequently applied within the NHS, is heeded. At present, rather than assisting learning it may be an impediment to patient safety. The authors propose that root cause analyses should be performed by a group of people who are not managing the service. External organisations such as the General Medical Council, Nursing and Midwifery Council, Care Quality Commission and Practitioner Performance Assessment are heavily reliant on this tool when concerns are raised. If the flaws in root cause analysis can be eliminated, drawing on the available evidence, cases such as those of Dr Hadiza Bawa-Garba and Mr David Sellu might be avoided.

Molecular Characterization of New Delhi Metallo-ß-Lactamases-Producing Bacteria in the Gastrointestinal Tract of Intensive Care Unit Patients.

BACKGROUND: The emergence of carbapenem-resistance in the gut flora of patients in the intensive care unit (ICU) poses a significant risk for infection with these types of pathogens. MATERIALS AND METHODS: New Delhi metallo-ß-lactamase 1 (NDM-1) in the gut flora of ICU patients was detected in cultures of a single rectal swab from each patient admitted to the ICU for a minimum period of 48 hrs. Samples were processed in the microbiology laboratory using blood agar and MacConkey agar. Identification of pathogens, carbapenem resistance, and metallo-ß-lactamase production was made using standard laboratory procedures. Bacterial isolates were also used for the determination of the NDM-1 gene by molecular methods. RESULTS: One hundred twenty-two patients with different clinical presentations were recruited in the study. Two hundred nine bacteria were isolated, with Escherichia coli being the most common isolate. A total of 54/122 (44.3%) patients harbored carbapenem-resistant organisms (CRO), 36/122 (29.5%) carried metallo-ß-lactamase-producing organisms (MBLO), and 30/122 (24.6%) carried bacteria with the NDM-1 gene. Patients who harbored CRO and MBLO had longer mean duration of stay in the ICU and hospital than those not harboring CRO and MBLO. All the metallo-ß-lactamases were simultaneously resistant to other groups of antibiotics also. Use of invasive devices, three or more classes of antibiotics, hospitalization during the previous six months, comorbidities, and hospital stay for ≥48 hours before ICU admission had a significant association with colonization with CRO. CONCLUSION: Patients admitted in ICU or with serious diseases should be screened for gastrointestinal carriage of carbapenem-resistant organisms. Irrational use of antibiotics must be stopped to prevent the emergence and spread of such organisms.

Long-term follow-up of platelet-rich plasma injections for refractory lateral epicondylitis.

BACKGROUND: Lateral epicondylitis (LE)1 affects between 1 and 3% of the population. Recently, platelet-rich plasma (PRP)2 has gained popularity. AIM: Assess the long-term outcomes of PRP for patients with refractory LE. METHODS: We assessed 31 patients who had failed conservative management using the Oxford Elbow Score (OES).3. RESULTS: Mean follow-up: 5.2 years (range 4.2-6.1 years).87.1% exhibited minimum clinically important difference (MCID)4 in pain scores between pre-op and long-term. 90.3% displayed MCID in function and psycho-social domains.Two patients had a repeat injection and six underwent open release. DISCUSSION: PRP is successful in treating refractory LE in most patients and avoiding surgery.

Elucidating the Structural Composition of an Fe-N-C Catalyst by Nuclear- and Electron-Resonance Techniques.

Fe-N-C catalysts are very promising materials for fuel cells and metal-air batteries. This work gives fundamental insights into the structural composition of an Fe-N-C catalyst and highlights the importance of an in-depth characterization. By nuclear- and electron-resonance techniques, we are able to show that even after mild pyrolysis and acid leaching, the catalyst contains considerable fractions of α-iron and, surprisingly, iron oxide. Our work makes it questionable to what extent FeN4 sites can be present in Fe-N-C catalysts prepared by pyrolysis at 900 °C and above. The simulation of the iron partial density of phonon states enables the identification of three FeN4 species in our catalyst, one of them comprising a sixfold coordination with end-on bonded oxygen as one of the axial ligands.

Heterotopic ossification following anterior shoulder dislocation.

Heterotopic ossification (HO) is the abnormal growth of extraskeletal bone. Joint involvement may result in chronic stiffness and pain causing considerable functional impairment and the inability to perform the activities of daily living. HO affecting the shoulder joint is rare and little is known about its clinical course or treatment. Here, we describe the first reported case of glenohumeral HO following anterior dislocation. This occurred in a 70-year-old man following a fall onto outstretched hand. Due to persistent stiffness and pain at 8 months from initial injury, he underwent plain radiographs and MRI scans that confirmed rotator cuff tear and HO. He was managed conservatively with physiotherapy and non-steroidal anti-inflammatory drugs. At 1-year follow-up, the patient maintains a good functional outcome.

Patient-directed reminders to improve preventive care in general practice for patients with type 2 diabetes: A proof of concept.

BACKGROUND AND OBJECTIVES: Preventive care in general practice is fundamental to managing the Australian diabetes epidemic. Recommended preventive care is nonetheless underperformed. The aim of this pilot study was to demonstrate proof of concept that pre-consultation patient-directed reminders could improve preventive care in general practice. METHOD: Over two weeks, four general practices used a special software tool to generate reminder sheets listing recommended checks for a subset of patients with type 2 diabetes mellitus (T2DM). The sheets were given to patients before their consultations. The number of checks performed was compared for patients who did and did not receive reminders. General practitioners (GPs) were interviewed about the reminders and chronic disease management. RESULTS: Patients who received reminders had more recommended checks performed than those who did not receive reminders. GPs found the reminders useful but suggested that broader system changes are required. DISCUSSION: Pre-consultation patient-directed reminders could potentially be an effective tool to increase preventive care for patients with T2DM in general practice.

Fragility fractures in the upper limb: proximal and distal humerus.

The incidence of fragility fractures of the humerus is increasing worldwide. Although clinicians are aware of fractures of hips and wrists, fractures of the shoulder and elbow do not receive much attention. A considerable proportion of the elderly population (estimated at 10-24%) is dependent on walking aids. A well-functioning and pain-free shoulder and elbow is essential for use of these aids. The impact of loss of mobility in the elderly is well known, hence the overall impact of these fractures on the individual can be considerable. This article increases the awareness of these fractures among non-orthopaedic colleagues and provides a brief outline of their management. In the elderly population using walking aids, the shoulder and elbow are effectively weight-bearing joints. Fractures of the shoulder or elbow in the elderly require extra attention to maintain their mobility during this period by physiotherapy to the lower limbs and chest. In patients who mobilize using a frame, the use of a stick on the opposite side of the injury may have to be considered while recovery is in progress.

A comparative study of bacterial and parasitic intestinal infections in India.

BACKGROUND: Infectious diarrhea causes a major health problem in developing countries with significant morbidity and mortality. Very often, rehydration therapy alone does not suffice, mandating the use of antimicrobial agents. However, rapidly decreasing antimicrobial susceptibility is complicating the matters. MATERIALS AND METHODS: The study aimed to determine the prevalent bacterial and parasitic agents of diarrhea in India. A cross-sectional study was done at Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi, during 2012-14. Stool samples were received from patients of all age groups and processed for bacteriological and parasitological identification by microscopy, bacterial culture, biochemical identification, serotyping and antimicrobial susceptibility tests. The study also aimed to identify the recent papers (after year 2000) reporting aetiology of infectious diarrhea in India involving the general population as a whole and compare them with present findings. RESULTS: Out of 6527 samples, 581 (8.90%) were positive for bacterial pathogens. A total of 280 samples (of 3823 under-five year children) were positive for diarrheagenic Escherichia coli. Other organisms like Vibrio cholera were found in 159 (2.44%) cases, Shigella spp. in 126 (1.93%), Salmonella Typhi in 7 (0.11%), Salmonella Typhimurium in 6 (0.10%), Aeromonas hydrophila in 3 (0.05%) cases. Levels of resistance to nalidixic acid, amoxicillin and ciprofloxacin were alarmingly high. Third generation cephalosporins were seen to be moderately active except against E. coli. Parasites were identified in 312 (4.78%) cases. Giardia intestinalis, Ascaris lumbricoides and Entamoeba histolytica were identified in 2.27%, 1.15% and 0.64% cases respectively. CONCLUSION: Analysis of recent nationwide studies revealed V. cholerae was the most common bacterial/parasitic agent of diarrhea across all populations, being followed by diarrheagenic E. coli and Giardia intestinalis. Periodic laboratory monitoring of antimicrobial susceptibility pattern is essential, as is formulation of effective antibiotic use policy.

The effect of platelet-rich plasma injection on lateral epicondylitis following failed conservative management.

OBJECTIVE: We assessed the effect PRP injection on pain and function in patients with lateral epicondylitis where conservative management had failed. METHODS: We prospectively reviewed 34 patients. The mean follow-up was 26 weeks (range 6-114 weeks). We used the Oxford Elbow Score (OES) and progression to surgery to assess outcomes. RESULTS: 88.2% improved their OES. 8.8% reported symptom progression. One patient had no change. No patients suffered adverse reactions. Two patients underwent an open release procedure. One had the injection repeated. CONCLUSION: An injection of PRP improves pain and function in patients suffering from LE where conservative management has failed.

Awareness in patients with COPD about the disease and pulmonary rehabilitation: A survey.

BACKGROUND AND OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death worldwide. It overloads the healthcare system and increase healthcare expenditure. As a patient's awareness enables him/her to acquire better self-management skills, it helps to reduce the severity and frequency of exacerbations, prevents hospitalizations, and improves health-related quality of life. The current study aims to assess the awareness amongst COPD patients about the disease itself and pulmonary rehabilitation. MATERIALS AND METHODS: A cross-sectional survey was carried out in order to evaluate awareness through "a COPD awareness questionnaire". This was developed and validated for its content. A total of 21 questions were included in this questionnaire. These questions were divided into two domains that included pulmonary disease (1-12) and pulmonary rehabilitation (13-21). RESULTS: Three hundred patients were recruited of which 282 were included in the study. The subject group consisted of 177 males and 105 females. The mean age of the subjects was 63.54 ± 10.656. Awareness in the "disease domain" was 47.84% and "pulmonary rehabilitation domain" was 25.14%. Awareness about the causes of COPD was 34.8%, of common symptoms was 83.0%, and of activities of daily living that could increase breathlessness was found to be 73.8%. The need to consult a physiotherapist was reported by only 26.2%. 81.2% of the subjects believed that breathing exercise could cause breathlessness; whereas, only 19.5% were aware of secretion removal techniques. CONCLUSION: The findings of the study suggest an imminent need to educate the public about the disease and the scope of pulmonary rehabilitation and its role in the management of COPD. The education of patients in this regard needs to be incorporated into standard health care practice in order to improve their self-management skills and their quality of life.