Comparison of preoperative prophylaxis with povidone-iodine (5%) and moxifloxacin (0.5%) versus povidone-iodine (5%) alone: a prospective study from India.

PURPOSE: To compare the effect of povidone-iodine (PI) 5% and moxifloxacin 0.5% solutions versus PI 5% solution alone on the conjunctival bacterial flora. METHODOLOGY: This is a comparative study in which the study population comprised adult patients scheduled for elective small incision cataract surgery. The eye to be operated (control eye) received topical moxifloxacin 0.5% drops 4 times, 1 day before surgery and 2 applications on the day of surgery. As placebo, the contralateral eye (study eye) received saline 0.90% drops as per the same schedule. Before surgery, on table, PI 5% was instilled in the conjunctival sac in both eyes. Conjunctival swabs were taken before initiation of therapy and 3 min after instillation of PI. RESULTS: Of the 96 pairs of eyes included in the study, conjunctival cultures before prophylaxis were similar between the two groups (p = 0.31), with 54 samples (56%) of the study group and 49 (51%) of the control group showing growth. With positive cultures reducing to 7 (14%) in the study group and 8 (16%) in the control group, both the prophylaxis methods appeared equally efficacious (p = 0.79). Both the groups showed a significant reduction in positive cultures following prophylaxis (p < 0.0001). CONCLUSIONS: PI 5% alone as preoperative prophylaxis was as effective as its combination therapy with moxifloxacin 0.5% in the reduction in conjunctival bacterial colonization.

Ochrobactrum intermedium septicemia.

Ochrobactrum species are emerging Gram-negative, non-fermenting bacteria with low virulence. Infection with the Ochrobactrum species is commonly nosocomial and has been reported in patients with indwelling medical devices and implants. Among the species of Ochrobactrum infecting humans, Ochrobactrum anthropic and Ochrobactrum intermedium are the commonest ones. We present a case of septicemia caused by Ochrobactrum intermedium in a 75-year-old patient with lower limb cellulitis. This report describes the epidemiology, clinical manifestations, laboratory diagnosis, antibiotic susceptibility pattern, and treatment of Ochrobactrum infections.

Differential expression of interferon inducible protein: Guanylate binding protein (GBP1 & GBP2) in severe dengue.

Dengue virus is reported to activate endothelial cells (EC), but the precise cause for severe dengue (SD) is not known. Guanylate binding proteins (GBPs) are IFN-inducible proteins secreted by ECs and are involved in the anti-oxidant and anti-viral response. The involvement of GBPs in the pathogenesis of dengue remains under explored. In the present study, we quantified the mRNA and protein levels of GBP1 and 2 during acute, defervescence and convalescent phase in SD-10, dengue without warning sign-15 and dengue with warning sign-25 compared to other febrile illnesses-10 and healthy controls-8 using RT-PCR and ELISA respectively. Lipid peroxidation in plasma samples were measured using the Kei Satoh method. Protein and DNA oxidation were determined by ELISA. The efficacy of the proteins in predicting disease severity was done by Support Vector Machine (SVM) model. A significant (P ≤ 0.01) decrease in the levels of mRNA and protein of both GBP1 and GBP2 was observed during defervescence in both SD and DWW cases. The levels were significantly (P ≤ 0.05) tapered off in SD cases from acute till critical phases compared to other study groups. DNA, protein and lipid oxidation markers showed an increasing trend in SD (P ≤ 0.01). Both GBP1 & 2 were found to be negatively associated plasma leakage and oxidative stress markers. EC's activated with SD serum showed a reduced expression of GBP 1 and 2. Nevertheless, the SVM model revealed that plasma levels of proteins along with clinical symptoms could predict the disease outcomes with higher precision. This is the first study reporting a downregulated expression of GBP1 & 2 and their association with oxidative stress and plasma leakage in dengue cases. This suggests the importance of GBPs in regulating disease manifestation. However, further investigations are required to ascertain its role as a biomarker or therapeutic target in dengue infection.

Antibiotic Susceptibility Pattern of Aerobic Bacterial Pathogen Isolated from Endotracheal Aspirate.

BACKGROUND: Ventilator-associated pneumonia (VAP) is one of the major hospital-acquired infections and the emergence of bacterial resistance is common among patients in the intensive care units (ICUs). The aim of the study is to identify the common bacterial pathogen isolated from an endotracheal (ET) aspirate and its antibiotic susceptibility pattern. MATERIALS AND METHODS: A prospective analytical study was carried out in a tertiary care hospital for a period of 1 year. All ET aspirate sample sent to the microbiology laboratory was processed and identified by standard biochemical tests and antibiotic sensitivity was by disk diffusion method as per Clinical and Laboratory Standards Institute (CLSI) guidelines. RESULTS: Of the total 217 samples studied, 85 (39.17.1%) were culture sterile and 132 (60.82%) showed culture positive. Among 132 isolates, the predominant organism was Acinetobacter baumannii (36.36%) followed by Klebsiella pneumoniae (24.24%) and Pseudomonas aeruginosa (20.45%). We have reported a higher percentage of resistance among the isolated gram-negative bacilli to carbapenems, aminoglycosides, and third-generation cephalosporins, with increased sensitivity to piperacillin-tazobactam and cefoperazone-sulbactam. CONCLUSION: In our study, A. baumannii was the predominantly isolated gram-negative bacilli followed by K. pneumoniae and P. aeruginosa. One of the rising concerns to hospital-acquired respiratory pathogens is the surge of multidrug resistance patterns. Hence, strict adherence to antibiotic policy and appropriate use according to the guidelines will save the use of drugs in the future in life-threatening conditions.

In-vitro anti-Mycobacterium tuberculosis effect of essential oil of Ocimum sanctum L. (Tulsi/Basil) leaves.

BACKGROUND/OBJECTIVES: Mycobacterium tuberculosis, the causative agent of tuberculosis has developed resistance to most of the available antimicrobials. Consequently, it is difficult to cure all the patients with tuberculosis and in future, the incidence of tuberculosis by drug resistant M. tuberculosis is likely to increase, worldwide. Therefore detection and development of new antimicrobials against M. tuberculosis is needed urgently. METHODS: Essential oil from the leaves of Ocimum sanctum L (Tulsi/Basil) was obtained by hydro distillation. The anti-mycobacterial effect of essential oil was evaluated against H37Rv and nine clinical isolates of M. tuberculosis in the BD BACTEC MGIT instrument using different volumes of essential oil. RESULTS: The essential oil inhibited the growth of H37Rv and all the nine clinical isolates of M. tuberculosis. The minimal inhibitory concentration of H37Rv was 3 µl (2.931 µg) and those of the clinical isolates of M. tuberculosis ranged from 1.5 µl (1.4655 µg) to 6 µl (5.862 µg). CONCLUSION: The Essential oil from the leaves of O. sanctum L.(Tulsi/Basil) has anti-M. tuberculosis effect in the in-vitro BD BACTEC MGIT method.

COVID-19 Pandemic-Frontline Experiences and Lessons Learned From a Tertiary Care Teaching Hospital at a Suburban Location of Southeastern India.

The key challenges to any health care setup during emergency situations, such as that of the COVID-19 pandemic would be to rapidly address hospital preparedness and response tailored to the local population, societal influences, political factors within the existing infrastructure, and workforce. Second, to adopt and moderate policies, standard operating procedures (SOPs) and guidelines issued by national and international agencies, such as WHO, CDC, and the Indian Council for Medical Research (ICMR) were tailor-made to the local conditions of the hospital and community. In this publication, we have discussed the challenges and experiences in preparation and responses to the ongoing COVID-19 pandemic at a tertiary teaching hospital situated at a suburban locale in a small union territory. Puducherry is located in the South Eastern Coromandel Coast of India. The core processes, such as hospital preparedness, adoption, and amendments to SOPs based on dynamic changes in guidelines released by the central and local government, training given to health care workers, setting up the in-house diagnostic facility, surge capacity, management of supplies during the lockdown, infection prevention, and control and patient care are discussed. We have also reinforced our experiences in translating COVID-related opportunities for research and innovation in the form of awards and research proposals for the faculty and students of our institute. The lessons learned in terms of strength and limitations on the ground level of public health during this process is worth sharing as it would provide guidance in preparing the health care setups for pre- and post-pandemic.

Expression dynamics of vascular endothelial markers: endoglin and syndecan-1 in predicting dengue disease outcome.

Plasma leakage is a hallmark process in dengue viral (DENV) infection that occurs due to the loss of vascular integrity in endothelial cells. Endoglin (ENG) and Syndecan-1 (SDC-1) are released by activated endothelial cells; however, the complete dynamics of its expression at the gene and protein levels during the course of DENV infection remains unknown. In the present study, we quantified the mRNA and soluble protein levels of ENG and SDC-1 in dengue cases during febrile, defervescence, and convalescence stages in Dengue without Warning Sign (DWOW-15), Dengue with Warning Sign (DWW-22), and Severe Dengue cases (SD-10) compared to nondengue Other Febrile Illness (OFI-10) and healthy control (HC-8). Respective protein and mRNA levels along with clinical characters were further analyzed for their efficacy in predicting disease outcomes using Support Vector Machine (SVM). We observed a steady and significant (P ≤ 0.01) increase in the levels of protein and mRNA of both the ENG and SDC-1 towards defervescence which is considered a critical phase in both severe and non-severe dengue cases. Importantly during the critical phase, the levels were significantly higher (P ≤ 0.001) in SD cases compared to DWW, DWOW, and OFI controls. However, at the time of admission (febrile), no such significant changes were observed within dengue, OFI, and healthy controls. SVM analysis revealed that the serum levels of ENG and SDC-1 along with other clinical symptoms could predict the disease severity with 100% accuracy. Based on the results we have proposed a mechanism on how ENG and SDC-1 could be involved in vascular dysfunction rather than just being a biomarker.

Prevalence of Clostridium difficile infection among the patients attending a tertiary care teaching hospital.

BACKGROUND: Clostridium difficile, a most important nosocomial enteric pathogen, is recognized globally as responsible for antibiotic-associated diarrhea and colitis. It is associated with considerable morbidity and mortality due to widespread use of antibiotics. AIMS: The study was done to determine the prevalence of C. difficile infection (CDI) among the patients attending a tertiary care teaching hospital in Puducherry. SETTINGS AND DESIGN: We performed a prospective cohort study in Mahatma Gandhi Medical College and Research Institute. MATERIALS AND METHODS: Around 150 patients were evaluated along with the patient details. C. difficile toxin detection was done as per the standard algorithm using the C. Diff Quik Chek Complete® assay (TECHLAB, Blacksburg, VA, USA). STATISTICAL ANALYSIS USED: Analysis was done using statistics software (SPSS 16.0, SPSS Inc., Chicago, IL, USA). RESULTS: The prevalence of CDI was found to be 4%. More toxin-positive cases were between 50 and 60 years of age, and there was no difference in gender. Intensive Care Unit showed more toxin-positive cases; however, there was no significant association between the occurrence of CDI and the primary diagnosis of the patients. CONCLUSIONS: The prevalence of CDI in our hospital was found to be 4%, which was relatively lower compared to other Indian studies. However, awareness of the risk factors may assist in identifying patients at higher risk for CDI, guide implementation of appropriate preventive measures, and modulate potential intervention measure during management.

Urinary tract infection due to Chryseobacterium gleum, an uncommon pathogen.

Chryseobacterium species are gaining importance as an emerging opportunistic nosocomial pathogen. Limited availability of clinical data necessitates reporting of such isolates. We report a case of nosocomial urinary tract infection by metallo-ß-lactamase-producing Chryseobacterium gleum in an elderly diabetic male with chronic renal disease. Identification and antibiotic sensitivity test performed by conventional methods were confirmed by Matrix-assisted Laser Desorption Ionization Time-of-Flight and VITEK-2 systems, respectively. The patient responded well to intravenous ciprofloxacin therapy.

Ventilator-associated pneumonia.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a type of nosocomial pneumonia that occurs in patients who receive mechanical ventilation (MV). According to the International Nosocomial Infection Control Consortium (INICC), the overall rate of VAP is 13.6 per 1,000 ventilator days. The incidence varies according to the patient group and hospital setting. The incidence of VAP ranges from 13-51 per 1,000 ventilation days. Early diagnosis of VAP with appropriate antibiotic therapy can reduce the emergence of resistant organisms. METHOD: The aim of this review was to provide an overview of the incidence, risk factors, aetiology, pathogenesis, treatment, and prevention of VAP. A literature search for VAP was done through the PUBMED/MEDLINE database. This review outlines VAP's risk factors, diagnostic methods, associated organisms, and treatment modalities. CONCLUSION: VAP is a common nosocomial infection associated with ventilated patients. The mortality associated with VAP is high. The organisms associated with VAP and their resistance pattern varies depending on the patient group and hospital setting. The diagnostic methods available for VAP are not universal; however, a proper infection control policy with appropriate antibiotic usage can reduce the mortality rate among ventilated patients.

Role of Appropriate Therapy in Combating Mortality among the Ventilated Patients.

CONTEXT: Ventilator associated pneumonia (VAP) is a nosocomial infection prevalent among the intensive care unit (ICU) patients despite proper infection control practices. The diagnosis of VAP still remains controversial and hence the mortality rate is higher among this group of patients. AIM: The aim of our study was to identify the antibiotic pattern and the appropriateness of treatment followed in the ICU in relation with the clinical pulmonary infection score (CPIS) as a tool to diagnose VAP. This was compared with patients who had an inappropriate treatment in comparison to the CPIS and the clinical outcome. RESULTS: Out of the 18 VAP patients, 12 (66.7%) received appropriate therapy based on the antibiotic susceptibility pattern of the causative organism, while 1 (5.5%) received partially inappropriate therapy and 5 (27.8%) received totally inappropriate therapy. Nine of the 18 (50%) VAP patients died, while only 5 of the 58 (8.6%) patients without VAP died. 72.2% patients with VAP received appropriate treatment based on the sensitivity of the isolates. The mortality rate in VAP patients receiving inappropriate therapy was 80%, while in those receiving appropriate therapy the mortality rate was 38.5%. The mortality rate among VAP patients with blood culture positivity was 100%, while it was 43.75% among those with negative blood culture. CONCLUSION: The mortality rate among the patients receiving inappropriate therapy is high compared to other group of patients. Hence, a proper evaluation and administration of appropriate antibiotics can curb mortality among the ventilated patients.

Bacteriophage types of methicillin-resistant Staphylococcus aureus in a tertiary care hospital.

BACKGROUND: Phage typing had been utilised extensively to characterise methicillin-resistant Staphylococcus aureus (MRSA) outbreak strains in the past. It is an invaluable tool even today to monitor emergence and dissemination of MRSA strains. AIMS: The aim of this study was to determine the prevalent phage types of MRSA in south India and the association between phage types, antibiotic resistance pattern and risk factors. METHOD: A total of 48 non-duplicate MRSA strains recovered from various clinical samples during January to December, 2010 were tested against a panel of anti-staphylococcal antibiotics. Phage typing was carried out at the National Staphylococcal Phage Typing Centre, New Delhi. Out of 48, 32 hospitalised patients were followed up for risk factors and response to empirical and post sensitivity antibiotic therapy. The risk factors were compared with a control group of 30 patients with methicillin sensitive Staphylococcus aureus (MSSA) infection. RESULTS: Amongst the five prevalent phage types, 42E was most common (52%), followed by a non-typable variant (22.9%), 42E/47/54/75 (16.6%), 42E/47 (6.2%) and 47 (2%). Phage type 42E was the predominant strain in all wards and OPDs except in the ICU where 42E/47/54/75 was most common. Although not statistically significant, strain 42E/47/54/75 (n=8) showed higher resistance to all drugs, except ciprofloxacin and amikacin, and were mostly D-test positive (87.5%) compared to the 42E strain (32%). Duration of hospital stay, intravenous catheterisation and breach in skin were the most significant risk factors for MRSA infection. CONCLUSION: We found MRSA strain diversity in hospital wards with differences in their antibiotic susceptibility pattern. The findings may impact infection control and antibiotic policy significantly.

Aetiological agents of ventilator-associated pneumonia and its resistance pattern - a threat for treatment.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a common type of nosocomial pneumonia encountered in intensive care units. There are several aetiological agents which make treatment challenging. Improper antibiotic treatment of ventilated patients may lead to the emergence of multidrug resistant (MDR) pathogens. METHOD: A prospective study was performed over a period of 20 months. Our study had two arms: the first, 'Incidence and risk factors of VAP in a tertiary care hospital' was the subject of an earlier publication; we therefore present the second investigative arm in this work. The aetiological agents of patients on mechanical ventilation (MV) were identified by standard bacteriological method. The susceptibility pattern was evaluated by Kirby-Bauer disc diffusion method. Extended spectrum beta lactamase (ESBL) testing was performed by combination disc method, and metallo-beta lactamase (MBL) testing was performed by EDTA disk synergy test (EDS). RESULTS: Late-onset VAP was associated with Pseudomonas aeruginosa, Klebsiella pneumoniae and Escherichia coli, while early-onset VAP was commonly caused by members of Enterobacteriaceae, Candida albicans and Staphylococcus aureus. 72.2 per cent of VAP patients had monomicrobial and 27.8 per cent had polymicrobial infection. Out of the 24 isolates obtained from patients with VAP, seven (29.2 per cent) were MDR pathogens. ESBL and MBL production was detected in 40 per cent and 20 per cent of Klebsiella pneumoniae isolated in our study. Around 50 per cent of isolates associated with late-onset VAP were MDR, while 22.2 per cent isolates obtained from patients with earlyonset VAP were MDR. CONCLUSION: VAP is a nosocomial pneumonia that is common among ventilated patients. The aetiological agents vary from common organisms to MDR pathogens that are difficult to treat. A proper knowledge of MDR pathogens and early isolation followed by prevention of prolonged antibiotic therapy can reduce the mortality of late onset VAP.

Prevalence of Candida co-infection in patients with pulmonary tuberculosis.

BACKGROUND: Candida species are emerging as a potentially pathogenic fungus in patients with broncho-pulmonary diseases. The synergistic growth promoting association of Candida and Mycobacterium tuberculosis has raised increased concern for studying the various Candida spp . and its significance in pulmonary tuberculosis patients during current years. AIMS: This study was undertaken with the objective of discovering the prevalence of co-infection caused by different Candida species in patients with pulmonary tuberculosis. METHOD: A total of 75 patients with pulmonary tuberculosis diagnosed by sputum Ziehl-Neelsen staining were included in the study. Candida co-infection was confirmed using the Kahanpaa et al. criteria. Candida species were identified using gram stain morphology, germ tube formation, morphology on cornmeal agar with Tween-80, sugar fermentation tests and HiCrome Candida Agar. RESULTS: Candida co-infection was observed in 30 (40%) of patients with pulmonary tuberculosis. Candida albicans was the most common isolate observed in 50% of the patients with co-infection, followed by C. tropicalis (20%) and C. glabrata (20%). Candida co-infection was found in 62.5% of female patients, while it was observed in only 29.4% of the male patients (P value 0.0133). Mean ± SD age of the patients with C. glabrata infection was 65.83 ± 3.19, while the mean ± SD age of the patients with other Candida infections was 43.25 ± 20.44 (P value 0.0138). CONCLUSION: Many patients with pulmonary tuberculosis have co-infection with Candida spp. The prevalence of non-albicans Candida species is increasing and may be associated with inadequate response to anti-tubercular drugs. C. glabrata infection has a strong association with old age.

Incidence and risk factors of ventilator associated pneumonia in a tertiary care hospital.

BACKGROUND: Ventilator associated pneumonia (VAP) is a type of nosocomial pneumonia associated with increased morbidity and mortality. Knowledge about the incidence and risk factors is necessary to implement preventive measures to reduce mortality in these patients. METHOD: A prospective study was conducted at a tertiary care teaching hospital for a period of 20 months from November 2009 to July 2011. Patients who were on mechanical ventilation (MV) for more than 48 hours were monitored at frequent intervals for development of VAP using clinical and microbiological criteria until discharge or death. RESULTS: Of the 76 patients, 18 (23.7%) developed VAP during their ICU stay. The incidence of VAP was 53.25 per 1,000 ventilator days. About 94% of VAP cases occurred within the first week of MV. Early-onset and late-onset VAP was observed in 72.2% and 27.8%, respectively. Univariate analysis showed chronic lung failure, H2 blockers usage, and supine head position were significant risk factors for VAP. Logistic regression revealed supine head position as an independent risk factor for VAP. CONCLUSION: VAP occurred in a sizeable number of patients on MV. Chronic lung failure, H2 blockers usage, and supine head position were the risk factors associated with VAP. Awareness about these risk factors can be used to inform simple and effective preventive measures.

Detection of extended spectrum beta lactamases, ampc beta lactamases and metallobetalactamases in clinical isolates of ceftazidime resistant Pseudomonas Aeruginosa

We studied the prevalence of ceftazidime resistance in Pseudomonas aeruginosa and the rates of extended-spectrum β-lactamase (ESBL), AmpC β-lactamase (AmpC) and metallo-β-lactamase (MBL) production among the ceftazidime resistant Pseudomonas aeruginosa. A very high rate of MBL production was observed, which suggested it to be an important contributing factor for ceftazidime resistance among Pseudomonas aeruginosa.

Anterior abdominal wall abscess caused by Streptococcus pneumoniae in a patient with self-inflicted stab injury: An unusual presentation.

Streptococcus pneumoniae is a major cause of community-acquired pneumonia, otitis media, paranasal sinusitis, bacteremia and meningitis, as well as osteomyelitis and occasionally peritonitis. We report the case of a 25-year-old female who had stabbed herself with a kitchen knife above the umbilicus 10 days prior to admission. Subsequently, she developed an anterior abdominal wall abscess caused by S. pneumoniae. This case is unusual as the focus was distant from the respiratory tract, the usual primary site of infection caused by this organism. Furthermore, the case assumes significance because it occurred in the absence of any typical risk factors for S. pneumoniae.

Detection of extended spectrum beta lactamases, ampc beta lactamases and metallobetalactamases in clinical isolates of ceftazidime resistant Pseudomonas Aeruginosa.

We studied the prevalence of ceftazidime resistance in Pseudomonas aeruginosa and the rates of extended-spectrum ß-lactamase (ESBL), AmpC ß-lactamase (AmpC) and metallo-ß-lactamase (MBL) production among the ceftazidime resistant Pseudomonas aeruginosa. A very high rate of MBL production was observed, which suggested it to be an important contributing factor for ceftazidime resistance among Pseudomonas aeruginosa.

Invasive pulmonary aspergillosis caused by Aspergillus versicolor in a patient on mechanical ventilation.

Aspergillus spp. often colonise the respiratory tract of critically ill patients in intensive care units and subsequently cause invasive disease. The risk of developing invasive disease is more in immunocompromised patients. Here we report a case of fatal invasive pulmonary aspergillosis caused by Aspergillus versicolor in a post-operative patient on mechanical ventilation, who did not respond to intravenous itraconazole. We then discuss the challenges involved in the accurate diagnosis of this condition and appropriate management.

Multifocal keloids associated with Mycobacterium fortuitum following intralesional steroid therapy.

We report a case of subcutaneous abscess formation with Mycobacterium fortuitum following intralesional steroid injection into multifocal keloids. A high index of suspicion of atypical mycobacteria infection is needed in patients with a history of skin and soft tissue infections, in particular late-onset infections, which are negative for routine bacterial cultures and without a clinical response to antibiotics used for acute pyogenic infections.