Long-term outbreak of Klebsiella pneumoniae& third generation cephalosporin use in a neonatal intensive care unit in north India.

BACKGROUND & OBJECTIVES: The indiscriminate use of third generation cephalosporin has contributed to the emergence and widespread dissemination of extended spectrum ß lactamases (ESBL) genes in Klebsiella pneumoniae. This study was undertaken to elaborate the genetic behaviour of ESBL - producing K. pneumoniae isolates in the neonatal intensive care unit (NICU) of a tertiary care hospital in north India causing successive outbreaks in context with empirical third generation cephalosporin use. METHODS: Isolates of K. pneumoniae (43 from blood, 3 from pus and endotracheal tube, 4 from environment) causing successive outbreaks in the NICU of a tertiary care university hospital were studied for two years. Antimicrobial susceptibility testing was done by disc diffusion and minimum inhibitory concentration (MIC) determination by agar dilution methods. ESBL production was determined by phenotypic and genotypic methods. Clonal relatedness among the isolates was studied by enterobacterial repetitive intergenic consensus polymerase chain reaction (ERIC-PCR). Genetic environment of these isolates was assessed by the presence of integrons and gene cassettes. Transformation experiments were done, and plasmids of these isolates were characterized by stability testing and incompatibility testing. Subsequently, a change in the ongoing antibiotic policy was adopted, and corresponding changes in the behaviour of these isolates studied. RESULTS: During the period from August 2011 to January 2013, 46 isolates of monoclonal ESBL K. pneumoniae were obtained from different neonates and four similar environmental isolates were studied. Multidrug-resistant ESBL isolates harboured both blaCTXM-15 and bla SHV-5. The dfr and aac-6 ' resistant genes were found in gene cassettes. A 50 kb plasmid belonging to IncFIIA group was detected in all the isolates which was transferable and stable. The emergence and regression of the outbreaks coincided with antibiotic usage in the NICU, with widespread empirical use of cefotaxime being responsible for their persistence in the environment. INTERPRETATION & CONCLUSIONS: The study indicates that empirical use of third generation cephalosporins may promote the emergence, persistence, and dissemination of resistant isolates in the hospital environment. Periodic review of antibiotic policy is necessary for rationalized use of antibiotics.

Sociodemographic profile of patients attending the integrated counseling and testing center at a government super-specialty hospital in Central India.

CONTEXT: The HIV epidemic continues to be a matter of concern worldwide. Integrated counseling and testing center (ICTC) is an opening wedge for HIV diagnosis and support services, especially to the high-risk groups. Counseling and testing is a cost-effective and simple way of reducing HIV transmission. AIMS: The aim of the study was to analyze the sociodemographic profiles of the ICTC attendees to evaluate the changing trends of HIV seropositivities over a period of 7 years. SETTINGS AND DESIGN: This was a retrospective study done in the ICTC housed in a tertiary care hospital at Bhopal. MATERIALS AND METHODS: All attendees in the period of 7 years were included. STATISTICAL ANALYSIS USED: percentages and proportions were calculated. RESULTS: There were 24,853 ICTC attendees from January 2009 to January 2016, of which 183 (6.41%) attendees were tested seropositive. There were 15,555 (62.5%) males and 9298 (37.5%) female attendees. Among 15,555 males, 151 (0.97%) were seropositive, and of 9298 females, 32 (0.34%) were seropositive. Of 151 seropositive males, 62 (41%) were in the age group of 19-30 years and 48 (31.7%) were in the age group of 31-40 years. Among the seropositive females, 9 (28.1%) were in the age group of 19-30 years and 10 (31.2%) were in the age group of 31-40 years. We observed a rise in total number of ICTC attendees from January 2009 to January 2016. The number of attendees increased to 4655 in 2013, of which 27 (0.58%) were seropositive, and by 2015, there were 4982 attendees with only 6 (0.12%) seropositives. CONCLUSION: Such rising trends of attendees and a steady decline in the seropositivity rates are encouraging signs, reflecting the contribution of the ICTC in creating awareness, and reducing the transmission of HIV among the population served.

Public health relevance of non-tuberculous mycobacteria among AFB positive sputa.

BACKGROUND: Sputum smear microscopy for acid fast bacilli (AFB) is used by most public health programmes to detect tuberculosis. While most AFB in countries endemic for tuberculosis are Mycobacterium tuberculosis (MTB), some may also be non-tuberculous mycobacteria (NTM). The inability to differentiate NTM from MTB by sputum smear microscopy may lead to erroneous diagnoses of tuberculosis, leading in turn to inappropriate therapy. METHODS: This was a retrospective study of consecutive sputum samples received from November 2013 to March 2015 in the Department of Microbiology, Bhopal Memorial Hospital & Research Centre, Bhopal, India. Samples underwent smear microscopy, line probe assay (LPA) for MTB complex, culture, biochemical tests and LPA for NTM. RESULTS: Of 4095 sputum samples, 2886 were AFB smear positive (70.5%). Of these, MTB complex was detected in 2611 (90.5%) samples by LPA. Of the remaining 275 samples, 47 grew AFB on culture. Nine strains belonged to the MTB complex. The remaining 38 (1.3%) were NTM, and could be speciated in 26 strains; 14 (53.8 %) were M. abscessus; 10 (38.4%) M. intracellulare, one (3.8%) M. kansasii and one (3.8%) M. fortuitum. The remaining 12 NTM could not be speciated. CONCLUSION: NTM were present in at least 1.3% of all smear positive samples. It is important for public health programs to recognize the avoidable burden on logistics, infrastructure and finances caused by this. Detection and quantification of this burden would help design an appropriate strategy for optimal tuberculosis control.

Acute Monoarthritis of the Wrist Joint: Tuberculosis or Not?

Background Extrapulmonary tuberculosis (EPTB) is known to have many and varied presentations. However, isolated involvement of bone with tubercular infection is uncommon. The clinical features of such infections are known to mimic chronic pyogenic osteomyelitis, Brodie abscess, or tumors, but not acute monoarthritis. Case Description We describe here an unusual case of tuberculous osteomyelitis that mimicked features of acute monoarthritis of the wrist joint. Literature Review Extraspinal tuberculous osteomyelitis is rare and comprises only about 2 to 3% of all cases of osteoarticular tuberculosis, with the hip and knee joints being the most commonly involved. An extensive literature review did not show any published report of tuberculous osteomyelitis presenting as acute monoarthritis of the wrist joint. Clinical Relevance This case underlines the importance of making EPTB an important differential diagnosis even in cases with clinical features that are completely inconsistent with tubercular infections.