Blood Stream Infection by Escherchia hermannii in a Neonate.

Escherichia hermannii is a Gram negative bacillus, facultative anaerobe and member of the family Enterobacteriaceae. It was earlier classified as Enteric Group 11 by the Enteric Section of Centers for Disease Control (CDC) and was reported in the clinical laboratory as a yellow pigmented E. coli strain. On the basis of its unique genomic features, this organism was labelled as a distinct species in 1982. A successfully treated case of a blood stream infection by E. hermannii in a neonate is being described.

Chloramphenicol - A Potent Armament Against Multi-Drug Resistant (MDR) Gram Negative Bacilli?

INTRODUCTION: Multidrug-resistant gram-negative bacteria cause infections which are hard to treat and cause high morbidity and mortality. Due to limited therapeutic options there is a renewed interest upon older antimicrobials which had fallen into disuse as a result of toxic side effects. One such antibiotic is chloramphenicol which was sidelined due to reports linking its use with the development of aplastic anaemia. AIM: A study was conducted to evaluate the susceptibility of chloramphenicol in light of the emerging problem of multi-drug resistant gram negative bacteria (MDR GNB). MATERIALS AND METHODS: A total of 483 MDR GNB of the 650 consecutive Gram Negative Bacteria isolated from various clinical samples of patients admitted at a tertiary care hospital in Jaipur between January-June 2014 were screened for chloramphenicol susceptibility by the disc diffusion method as per CLSI guidelines. RESULTS: The MDR GNB isolates were obtained from 217 (45%) urine, 163 (34%) from respiratory samples, 52(11%) from pus, 42 (9%) from blood and 9 (2%) from body fluids. A 68% of the MDR GNB isolates were found to be sensitive to chloramphenicol. CONCLUSION: Clinicians should always check for the local susceptibility of Gram-negative bacteria to chloramphenicol. This antibiotic has a potential to play a role in the therapeutic management of infections due to MDR GNB pathogens.

Epidemiological study of prevalence, determinants, and outcomes of infections in medical ICU at a tertiary care hospital in India.

OBJECTIVES: To determine the prevalence of infections, risk factors, and outcomes in a medical intensive care unit (ICU), we performed a hospital-based study. MATERIALS AND METHODS: Consecutive patients were enrolled and details of risk factors and bacteriological data were obtained. Outcomes were death/transfer to palliative care or recovery. Statistical analyses were performed. RESULTS: Four hundred and eighty-seven patients were admitted during the study period (age 55.6 ± 19 yr, men 68%). Diseases responsible were respiratory (37%), gastrointestinal/liver (22%), neurological (20%), renal (8%), and trauma (6%) related. Majority of admissions were direct (45%) or transfers from other hospitals (41%). Most important comorbidities were hypertension (41%), diabetes (31%), and chronic obstructive pulmonary disease (15%). Median APACHE-2 score was 13.0 (IQR 1-25). Antibiotics were administered in 98%. Bacteriological cultures were positive in 28% (n = 623). Respiratory infections were the most common (45.5%) followed by blood (23.3%) and urinary (16.1%). Gram-negative bacteria were common-Acinetobacter baumannii (20.9%), Klebsiella pneumoniae (19.7%), Escherichia coli (18.3%), and Pseudomonas aeruginosa (14.0%). There a high prevalence of resistance to common antibiotics. Patients with positive cultures were older, transferees (46 vs 37%, P = 0.07), with respiratory disease (48 vs. 33%, P = 0.003), with more than two comorbidities (33 vs 21%, P = 0.009), and higher APACHE-2 score (17.7 ± 8 vs. 13.3 ± 8, P = 0.07). Three hundred and fifty-two (72.3%) recovered, 68 (13.9%) died, and 67 (13.8%) were transferred to palliative care. Survival was associated with younger age, lower APACHE-2 score, negative cultures, and shorter duration in ICU (P < 0.05). Mortality was greater in patients with Acinetobacter (OR 2.36, 1.17-4.73), Klebsiella (OR 2.81, 1.33-5.92), Pseudomonas (OR 8.03, 2.83-22.76), or Enterobacter (OR 6.73, 1.29-35.12) infection. CONCLUSIONS: There is high prevalence of infections in patients in a medical ICU in India. Gram-negative bacteria are the most prevalent and resistance to antibiotics is high. Risk factors are age, hospital transfers, APACHE-2 score, and multiple comorbidities.

Breast Abscess by Salmonella Paratyphi A: Case Report and Literature Review.

A case of suspicious breast mass due to Salmonella enterica serotype Paratyphi A in a non-lactating, diabetic female is being described. The infection was successfully treated with a combination of surgical drainage and antibiotic treatment. This case highlights the fact that a focal Salmonella infection involving the breast should be considered as a rare differential diagnosis for breast malignancy and submission of specimens for microbiological analysis may be helpful in establishment of an accurate diagnosis and management.

Identification and differentiation of carbapenemases in Klebsiella pneumoniae: a phenotypic test evaluation study from jaipur, India.

BACKGROUND: Carbapenem resistance is one of the major threats faced in antimicrobial treatment of infections caused by gram negative organisms. In recent years, carbapenem resistance has emerged in Klebsiella pneumoniae isolates due to acquisition of carbapenemases which belong to Ambler class A KPC type enzymes or to Ambler class B metallo-ß-lactamases (MBL). Routine lab detection of carbapenemase producing K. pneumoniae isolates is crucial, both for a therapeutic management and an efficient infection control. MATERIALS AND METHODS: A study was conducted on 60 carbapenem resistant Klebsiella pneumoniae strains which were isolated from various clinical samples over a period of one year (September 2010-August 2011), at a tertiary care hospital in Jaipur. Phenotypic confirmatory test was done by using discs of Meropenem alone and those with phenyl boronic acid (PBA) or Ethylenediaminetetraacetic acid (EDTA) or both, for detection of carbapenemase production and differentiation of KPC and MBL enzymes. RESULTS: Of the 60 carbapenem resistant Klebsiella pneumoniae isolates, 53 (88.33%) were found to be MBL producers, 4(6.66%) were found to be MBL and KPC co-producers and the rest of the 3(5%) isolates were negative for both MBL and KPC production, as was seen by combined disc testing. CONCLUSION: The combined disc test is a simple test which can be used for differentiation of carbapenemases and it can be easily incorporated in routine microbiology lab testing.

Fatal Necrotizing Soft Tissue Infection by Aeromonas hydrophila.

Aeromonas infections in healthy individuals are self limiting, but those in patients with immuno-compromised conditions are frequently associated with significant morbidity and mortality. The current case report describes a fatal case of necrotizing soft tissue infection by Aeromonas hydrophila in an immuno-competent patient.

Septicaemic melioidosis: case report from a non-endemic area.

Melioidosis is a clinically diverse disease caused by the facultative intracellular Gram-negative bacterium, Burkholderia pseudomallei. In recent times melioidosis has been increasingly reported in India especially from the southern and coastal states. We report a fatal case of septicaemic melioidosis from the state of Rajasthan with a view to increase awareness about the existence of this disease in an area yet unrecognized.

Occupationally related outbreak of chickenpox in hospital staff: a learning experience.

Varicella (chicken pox) is a highly contagious disease which is caused by Varicella Zoster Virus (VZV), a ubiquitous human α herpes virus. Nosocomial varicella in hospital employees can be costly to the hospital and disruptive to patient care. This case report describes an occupationally related outbreak of chickenpox in hospital staff and the lessons which were learnt by the hospital during this experience.

A hospital based serosurveillance study of dengue infection in jaipur (rajasthan) , India.

BACKGROUND: Dengue has been known to be endemic in India for over two centuries. There is a need to assess the magnitude of dengue virus establishment in the state of Rajasthan. A surveillance study was conducted to analyze dengue seropositivity among patients with clinical suspicion of dengue fever like illness, who presented to or were admitted at a tertiary care private hospital at Jaipur. METHODS: Serum samples from 2169 suspected dengue cases (1356 males and 813 females) were received in the Serology lab over the four year study period (2008-2011). The samples were subjected to a rapid immuno-chromatography assay with differential detection of IgM and IgG antibodies. A primary dengue infection was defined by a positive IgM band and a negative IgG band, whereas a secondary infection was defined by a positive Ig G band with or without an IgM band. RESULT: Among the 2169 patients who were screened; 18.99% (412) were dengue specific IgM positive cases. 64. 49% (1399) cases were negative for dengue specific antibodies, 5.67% (123) were primary dengue cases, and 23.51% (510) were total secondary dengue cases. During the study period, the Dengue IgM seropositivity was highest in the year 2009 and was lowest in the year 2011. Most of the cases occurred in the post-monsoon season, with a peak in the month of October, each year. CONCLUSION: A detailed and continuous epidemiological surveillance is required, for monitoring the incrusion and spread of dengue viruses. This will help in undertaking and implementing effective control and management strategies.

Meningitis due to Stenotrophomonas maltophilia after a Neurosurgical Procedure.

Stenotrophomonas maltophilia is an aerobic, glucose non- fermentative, gram negative bacillus, which is being increasingly recognized as a cause of serious infections such as bacteraemia, urinary tract infections, respiratory tract infections, skin and soft tissue infections, endocarditis, meningitis and ocular infections in hospitalized patients. The treatment of invasive S. maltophilia infections is difficult, as this pathogen shows high levels of intrinsic or acquired resistance to different antibiotics, thus reducing the options which are available for treatment. Meningitiscaused by S. maltophilia is rarely encountered and so its experience is also limited. We are describing here a case of a six months old, male child who developed meningitis caused by Stenotrophomonas maltophilia, after he underwent a neurosurgical procedure.

The Prevalence of Intestinal Parasitic Infestation and the Related Profile of the CD4 (+) Counts in HIV/AIDS People with Diarrhoea in Jaipur City.

INTRODUCTION: Gastrointestinal Tract (GIT) infections are among the most frequent infections in HIV/AIDS patients. The intestinal opportunistic parasitic infections in HIV-infected subjects present most commonly as diarrhoea. A study was conducted to determine the prevalence of enteric parasitic infections in HIV infected patients with diarrhoea, with different levels of immunity. METHODS: This study was carried out at the HIV Lab of the Microbiology Department of a tertiary care teaching hospital in Jaipur, Rajasthan, between June-October 2009 among consecutively enrolled 75 HIV infected patients who presented with diarrhoea. Stool samples were collected and examined for enteric parasites by using microscopy and special staining methods. The CD4 (+) cell counts were estimated by using the FACS count system. RESULTS: Intestinal parasitic pathogens were detected in 38.66% patients, Cryptosporidium species was the most common enteric opportunistic parasite which accounted for 37.93 % of the total parasites, followed by Isospora belli 31.03 %. In the HIV infected patients with CD4 (+) counts of < 200 cells/µl, parasites were identified in 56.25 % patients and in HIV patients with CD4 (+) counts between 200-499 cells /µl, parasites could be identified in 27.5 % of the patients . No parasite was detected in the patients with CD4 (+) counts of >500 cells/ µl. CONCLUSION: Parasitic infections were detected in 38.66% HIV infected patients with diarrhoea and a low CD4 (+) count was significantly associated with opportunistic infections. Identification of the aetiological agent of diarrhoea in an HIV patient is very important, as it can help in the institution of the appropriate therapy and the reduction of the morbidity and the mortality in these patients.

Comparative Evaluation of the in-vitro Activity of Six ß-lactam/ß-lactamase Inhibitor Combinations against Gram Negative Bacilli.

BACKGROUND: The extensive use of the ß-lactam antibiotics in hospitals and in the community has created major resistance problems which has led to increased morbidity, mortality and healthcare costs. The use of the ß-lactamase inhibitors in combination with the ß-lactam antibiotics is currently the most successful strategy used for circumventing the resistance mechanisms. OBJECTIVE: To evaluate the in-vitro activity of six commercially available ß-lactam/ß-lactamase inhibitor combinations against Gram Negative Bacilli (GNB). MATERIALS AND METHODS: A total of 384 non duplicate, consecutive, gram negative bacilli (278 Enterobacteriaceae and 106 non fermenters) isolated from various clinical samples were subjected to antimicrobial sensitivity testing by the Kirby-Bauer method. The following ß-lactam/ß-lactamase inhibitor combinations were tested: amoxycillin-clavulanic acid, ampicillin-sulbactam, cefoperazonesulbactam, piperacillin-tazobactam, cefepime-tazobactam and ticarcillin-clavulanic acid. RESULTS: Against the Enterobacteriacae, the sensitivity of Cefepime- tazobactam was 90. 64%, followed by Cefoperazone-sulbactam (84.89%) and Piperacillin - tazobactam (53.95 %). The sensitivity of the non fermenters was the highest for Cefepime- tazobactam (49.04%) and was least for Ampicillin-sulbactam and Amoxycillinclavulanic acid (4.71% each). Cefepime-tazobactam was sensitive for all the extended spectrum ß-lactamase (ESBL) isolates. CONCLUSION: Among the six ß-lactam/ß-lactamase inhibitor combinations tested, Cefepime-tazobactam exhibited the best in-vitro activity against the gram negative bacilli isolated at our centre.

Infective Endocarditis by Aggregatibacter paraphrophilus: Case Report and Literature Review.

Aggregatibacter paraphrophilus (former name, Haemophilus paraphrophilus) is a normal inhabitant of the naso- and oropharynx and has been rarely reported as a cause of human infections. A case of infective endocarditis by this organism is being reported and literature of endocarditis cases caused by Aggregatibacter paraphrophilus is being reviewed.

Antibiotic resistance pattern of community acquired uropathogens at a tertiary care hospital in jaipur, rajasthan.

BACKGROUND: Urinary tract infections (UTIs) are amongst the most common infections described in outpatients setting. OBJECTIVES: A study was conducted to evaluate the uropathogenic bacterial flora and its antimicrobial susceptibility profile among patients presenting to the out-patient clinics of a tertiary care hospital at Jaipur, Rajasthan. MATERIALS AND METHODS: 2012 consecutive urine specimens from symptomatic UTI cases attending to the outpatient clinics were processed in the Microbiology lab. Bacterial isolates obtained were identified using biochemical reactions. Antimicrobial susceptibility testing was performed by the Kirby-Bauer disc diffusion method. Extended spectrum beta lactamase (ESBL) production was determined by the double disk approximation test and the Clinical and Laboratory Standards Institute (formerly NCCLS) confirmatory method. RESULTS: Pathogens were isolated from 346 (17.16%) of the 2012 patients who submitted a urine sample. Escherichia coli was the most frequently isolated community acquired uropathogen accounting for 61.84% of the total isolates. ESBL production was observed in 23.83% of E. coli strains and 8.69% of Klebsiella strains. With the exception of Nitrofurantoin, resistance to agents commonly used as empiric oral treatments for UTI was quite high. CONCLUSION: The study revealed E. coli as the predominant bacterial pathogen for the community acquired UTIs in Jaipur, Rajasthan. An increasing trend in the production ESBLs among UTI pathogens in the community was noted. Nitrofurantoin should be used as empirical therapy for primary, uncomplicated UTIs.

Seroprevalence of hepatitis B surface antigen, antibodies to the hepatitis C virus, and human immunodeficiency virus in a hospital-based population in jaipur, rajasthan.

BACKGROUND: Hepatitis B, hepatitis C, and HIV infections are a serious global and public health problem. To assess the magnitude and dynamics of disease transmission and for its prevention and control, the study of its seroprevalence is important. A private hospital catering to the needs of a large population represents an important center for serological surveys. Available data, at Rajasthan state level, on the seroprevalence of these bloodborne pathogens is also very limited. OBJECTIVE: A study was undertaken to estimate the seroprevalence of hepatitis B surface antigen (HBsAg) and antibodies to hepatitis C (anti-HCV Ab) and human immunodeficiency virus (anti-HIV Ab) in both the sexes and different age groups in a hospital-based population in Jaipur, Rajasthan. MATERIALS AND METHODS: Serum samples collected over a period of 14 months from patients attending OPDs and admitted to various IPDs of Fortis Escorts Hospital, Jaipur, were subjected within the hospital-based lab for the detection of HBsAg and anti-HCV Ab and anti-HIV Ab using rapid card tests. This was followed by further confirmation of all reactive samples by a microparticle enzyme immunoassay (Abbott AxSYM) at Super Religare Laboratories (formerly SRL Ranbaxy) Reference Lab, Mumbai. RESULTS: The seroprevalence of HBsAg was found to be 0.87%, of anti-HCV Ab as 0.28%, and of anti-HIV Ab as 0.35%. CONCLUSION: The study throws light on the magnitude of viral transmission in the community in the state of Rajasthan and provides a reference for future studies.

Prevalence of extended spectrum beta lactamase and AmpC beta lactamase producers among Escherichia coli isolates in a tertiary care hospital in Jaipur.

Resistance to broad spectrum beta lactams, mediated by extended spectrum beta lactamase (ESbetaL) and AmpC betaL enzymes is an increasing problem worldwide. Presence of these in clinical infections can result in treatment failure if one of the second or third generation cephalosporins is used. Therefore, it is recommended that any ESbetaL-producing organism according to the National Committee for Clinical Laboratory Standards (NCCLS) criteria can be reported as resistant to all extended spectrum beta lactam antibiotics regardless of the susceptibility test results. In this study, a total of 250 Escherichia coli (E. coli) isolates were subjected to Double disc test and AmpC disc test for the detection of ESbetaL- and AmpC betaL-producing strains, respectively. Prevalence of ESbetaL- and AmpC betaL-producing strains among E. coli isolates, over a 3-month-period in the hospital-based population of Jaipur, was 64.80% (162/250). AmpC betaL producers were 24.00% (60/250) and co-existence of ESbetaL and AmpC betaL was detected in 8.00% (20/250) of the isolates.