Educating healthcare workers to optimal hand hygiene practices: addressing the need.

The education of healthcare workers is essential to improve practices and is an integral part of hand hygiene promotional strategies. According to the evidence reviewed here, healthcare worker education has a positive impact on improving hand hygiene and reducing healthcare-associated infection. Detailed practical guidance on steps for the organization of education programmes in healthcare facilities and teaching-learning strategies are provided using the World Health Organization (WHO) Guidelines for Hand Hygiene in Health Care as the basis for recommendations. Several key elements for a successful educational programme are also identified. A particular emphasis is placed on concepts included in the tools developed by WHO for education, monitoring and performance feedback.

Clinicopathologic profile of normocomplementemic and hypocomplementemic urticarial vasculitis: a study from South India.

BACKGROUND: This study aims to study the clinical and histopathological characteristics of hypocomplementemic and normocomplementemic urticarial vasculitis (HUVS and NUV) among dermatology clinic attendees in a tertiary care hospital in South India. PATIENTS AND METHODS: A prospective study was conducted in the dermatology department from February 2003 to May 2004. Seventy-five patients met the inclusion criteria for UV. Sixty-eight patients in whom complement levels were available were classified into either NUV or HUVS groups. Clinical features, laboratory parameters and histological features were compared, and the significance of differences was established using Pearson's Chi-squared test. RESULTS: There was a female preponderance among patients with HUVS. Wheals > 24 h were seen in 90% of patients, and in 54.4% of patients, the wheals were partially blanching or non-blanching. Angioedema was more prevalent in patients with NUV than HUVS (44.4% vs. 21.4%). Systemic involvement was seen in 64.3% of patients with HUVS and 44.4% of patients with NUV. Fever, ANA positivity and systemic lupus erythematosus (SLE) were significantly associated with HUVS. In most cases of UV, a provoking factor could not be identified. Neutrophilic small vessel vasculitis was seen in 42.9% of patients with HUVS and 16.6% patients with NUV. Direct immunofluorescence test showing immunoreactants at the dermo-epidermal junction were present in 60% of patients with HUVS and 33.3% patients with NUV. CONCLUSION: The clinical features of Indian patients with UV were similar to those reported from the West. Fever, ANA positivity and SLE were significantly associated with HUVS.

The effect of bile acids on the growth and adherence of Helicobacter pylori.

Bile reflux gastritis occurs in the absence of Helicobacter pylori (H. pylori). The aim of this study was to see if the bile acids cheno or ursodeoxycholic acid affected the growth or adherence of H. pylori in vitro. Twenty-seven strains growth were inhibited by 0.1% chenodeoxycholic acid whereas only 11 out of the 27 were inhibited by 0.1% ursodeoxycholic acid. Growth was totally inhibited by a combination of 0.05% chenodeoxycholic acid +0.05% ursodeoxycholic acid. Chenodeoxycholic acid was a more effective inhibitor of adherence in that the number inhibited and percentage inhibition were greater than with ursodeoxycholic acid. Bile salts might be useful in the treatment of H. pylori infection.

Outbreak of scrub typhus in southern India during the cooler months.

Orientia tsutsugamushi, the agent of scrub typhus, is a strict intracellular bacterium which is found in many parts of Asia including India. During the past few years, the number of patients with rickettsial infection and scrub typhus has increased, especially during the cooler months. We report in this study a recent outbreak of scrub typhus recorded during the cooler months (October 2001 to February 2002) in patients admitted to our hospital with acute febrile illness associated with diverse signs and symptoms. Overall, 28 patients were clinically and serologically confirmed to have scrub typhus. Fever for more than one week was the only common manifestation. Myalgias was the next most common feature (52%), and rash was observed in only 22% of the cases. Seventeen patients treated with doxycycline recovered in 1 to 3 days, as well as two patients who received chloramphenicol. In five patients who received ciprofloxacin, fever subsided only after five days. Finally three patients (10.7%) died, including one patient treated with doxycycline. These data indicate that scrub typhus is a reemerging infectious disease in India with a possibility of drug resistance. This reemergence emphasizes the need for further prospective studies to design effective control measures.

Tuberculosis among healthcare workers in a tertiary-care hospital in South India.

It is possible that tuberculosis is transmitted from patients to healthcare workers (HCWs). However, there are few data on this from developing countries. The object of this study was to document the incidence of tuberculosis among HCWs in the Christian Medical College (CMC), Vellore, India during a 10-year period (January 1992-December 2001). Data were collected from records maintained in the staff and students health services of CMC. A total of 125 cases were diagnosed during the period of study. The overall incidence of sputum positive cases was similar to that observed in the general population, during most years. However, it appears that focal outbreaks occur with transmission between HCWs. The chance of developing extra-pulmonary tuberculosis was higher in HCWs compared with the general population.

Typing of Acinetobacter baumannii isolated from hospital-acquired respiratory infections in a tertiary care centre in southern India.

In an attempt to define the epidemiology of Acinetobacter baumannii infection, 27 isolates, obtained from hospital-acquired respiratory infections, were typed using random amplified polymorphic DNA (RAPD) profile and antimicrobial susceptibility patterns. Ten different patterns were obtained with ERIC2 primer: 14 isolates had a similar profile representing a single strain. Within RAPD types, isolates could be further classified based on their antibiogram; however, strains of different types had similar antibiograms. This study showed that many different genetic types of A. baumannii are prevalent in our hospital. While antibiograms alone are not sufficiently discriminatory, RAPD typing helps in identifying outbreaks and in assessing infection control procedures within a hospital.

Case reports: scrub typhus during pregnancy in India.

Scrub typhus, caused by Orientia tsutsugamushi, is a rural zoonosis endemic in the Asian Pacific region. Doxycycline and chloramphenicol, the recommended drugs for treating this infection, may not be safe during pregnancy. We report on 5 patients with scrub typhus during pregnancy who were seen in India between October 2001 and February 2002. Four of the 5 women were treated initially with ciprofloxacin. Three women had stillbirths, 1 an abortion and 1 a low birthweight baby, which suggests that ciprofloxacin should not be used for treating pregnant women and that scrub typhus leads to severe adverse effects during pregnancy. Randomized controlled trials are urgently needed to ascertain the optimal drug choice, given that currently recommended drugs are contraindicated in pregnant women.

Candida antibodies in amniotic fluid.

Amniotic fluid samples were tested for specific immunoglobulins against Candida albicans by indirect immunofluorescence. Nineteen of the 23 samples tested contained specific IgA while specific IgG antibodies were detected in only seven samples (P less than 0.01). None of the samples contained specific anticandidal IgM (P less than 0.001). These 23 samples and a further 30 amniotic fluid samples were tested for Candida mannan antigen by latex agglutination. Mannan was not detected in any of the samples tested. It is concluded that anticandidal IgA in amniotic fluid is naturally occurring.

Coagglutination test in the diagnosis of typhoid fever.

Staphylococcal coagglutination (CoA) test for the detection of Salmonella typhi O (factor 9) antigen was evaluated as a diagnostic test in typhoid fever. Supernatants from 106 blood cultures with Gram negative bacilli were subjected to CoA test. The sensitivity of the CoA test for the detection of S. typhi O antigen was 88 per cent and the specificity 97 per cent.

Determination of high level resistance to aminoglycosides among enterococci.

Two hundred and ten strains of enterococci showing resistance to gentamicin (10 micrograms/disc) were tested for high level resistance by detecting the minimum inhibitory concentration and by using high content disc diffusion test. Only 67 per cent of these had high level resistance to gentamicin. High level kanamycin resistance in the group was 84 per cent, while high level streptomycin resistance was 61 per cent. Only 85 of the 140 strains with high level gentamicin resistance had similar streptomycin resistance. Results using locally made high content discs, correlated 100 per cent with MIC results. High level resistance to enterococci should be reported on a routine basis, especially when isolated from patients with serious infections.

Identification of gram positive cocci isolated from urine.

A total of 195 strains of Gram positive cocci isolated from urine, in pure culture and in counts of > 10(3) colony forming units/ml, during January-September 1992, were speciated using schema recently described by Facklam and Washington, and Kloos and Lambe. Seventy three (85%) of the 86 enterococci were identified as Enterococcus faecalis while 11 (13%) were E. faecium. Eighteen (29%) of the 62 staphylococcal isolates were Staphylococcus aureus; 20 (45%) of the 44 coagulase negative staphylococci were speciated as Staph. haemolyticus. Of the 47 strains of beta haemolytic streptococci isolated, 45 (96%) were group B; one was group G and the other group F. Our results show the diverse species of Gram positive cocci associated with bacteriuria and the need to speciate them in a diagnostic laboratory. In the context of a larger number of tests required for the speciation of Gram positive cocci, we recommend a simplified scheme which we found feasible on a routine basis.

Evaluation of different solid media used for cultivation of Helicobacter (Campylobacter) pylori.

The ability of nine blood containing media to support the growth of H. pylori was compared. Eighteen strains of H. pylori isolated from antral biopsies were cultivated in two dilutions, for colony counts on the media to be tested. Columbia base chocolate agar without additives was found to be the best medium for growth of H. pylori. However, all other fresh blood containing media also supported the growth of this organism satisfactorily.

Ceftazidime resistance among Klebsiella pneumoniae in south India.

Fifteen strains of K. pneumoniae resistant to ceftazidime were tested for extended spectrum beta lactamase (ESBL) production by double disc diffusion synergy test using ceftazidime and augmentin, and by testing for reduction in minimum inhibitory concentration of ceftazidime in combination with clavulanic acid. All strains were found to produce ESBL. We document the presence of ESBL producing strains in south India. There is a possibility of the spread of this resistance to other bacteria because the resistance could be transferred to recipient Escherichia coli from two strains.

Detection of Bacteroides infection by counter immunoelectrophoresis test.

The counterimmunoelectrophoresis (CIE) test using sonicated antigens of Bacteroides fragilis NCTC 2553 and a B. asaccharolyticus strain, standardised in the laboratory yielded a negative result in the 50 normal sera tested, while it was positive in 24 of 34 (71%) patients with infection due to black pigmented bacteroides and in 10 of 15 (67%) with B. fragilis infection. The microagglutination test (MAT) done in parallel showed a positivity of only 44 and 40 per cent respectively. The CIE test done with B. asaccharolyticus antigen was negative in 87 per cent of patients with infection due to B. fragilis whereas MAT showed cross reactivity to a greater extent.

An outbreak of post-streptococcal reactive arthritis.

We describe an outbreak of an illness with fever, mono-, pauci- or polyarticular arthritis, and high antideoxyribonuclease B (ADNB) titres in 11 patients. Two patients had concomitant non-purulent conjunctivitis and one had endogenous endophthalmitis. There was no clinical or echocardiographic (6 patients) evidence of carditis. Blood culture grew Group A beta haemolytic streptococci in one patient. A simultaneous synovial fluid culture in this patient and similar cultures in four more patients yielded no microorganism. Most patients recovered completely, but one developed rheumatoid factor negative spondyloarthropathy. Monoarticular arthritis in several patients, the absence of carditis, and the presence of high ADNB titres without high anti-streptolysin O titres indicate that this was not acute rheumatic fever but post-streptococcal reactive arthritis (PSRA).

Changing patterns of group B streptococcal serotypes associated with human infections.

One hundred strains of group B streptococci (GBS) isolated from diverse clinical specimens of patients seen in our hospital were subjected to serotyping by an indigenously prepared coagglutination system. Serotype NT/c was the most predominant (24%), followed by Ia (23%), II/c (12%) and Ib (11%). Type Ia was the most predominant in all specimens except genital samples where NT/c was the most predominant. Comparison of the distribution of serotypes identified during 1975-78 with that of the present study showed a great increase in the prevalence of types NT/c, II/c and Ia and a dramatic decline of types III, Ia/c and Ib. Despite the inclusion of reagents for newer serotypes, IV and V two strains were nontypable indicating the prevalence of hitherto unidentified GBS serotypes in our community.

Prevalence of genital mycoplasma & ureaplasma infections in pregnancy & their effect on pregnancy outcome.

A cohort of 200 women with singleton pregnancies attending the antenatal clinic, were studied to determine the prevalence of genital mycoplasma and ureaplasma infections in pregnant women and the effect of infection on pregnancy outcome. Vaginal and endocervical swabs were taken at 26-30 wk and again at 36-38 wk of pregnancy and cultured for mycoplasma and ureaplasma. Forty (20%, 95% CI 14.5-25.6%) women were found to be infected with arginine metabolising mycoplasmas and 79 (39.5%, 95% CI 32.7-46.3%) with ureaplasma at either site or either time. The mean +/- SD birth weight of infants born to women infected with mycoplasma alone was 2879 +/- 471 g while that of infants born to women infected with ureaplasma alone was 2964 +/- 412 g. Mean +/- SD birthweight of infants born to women infected with both organisms was 2969 +/- 389 g while that of infants born to uninfected women was 2919 +/- 432 g. These differences were not statistically significant. The median gestation at delivery was 39 wk in the cohort; the differences among the groups were minor and statistically not significant. Thus, although genital mycoplasma/ureaplasma infections were frequent, no association was observed between infection and pregnancy outcome.

Evaluation of an ELISA for the diagnosis of brucellosis.

Brucela serology using ELISA and standard agglutination test was performed on 23 patients with prolonged fever where the test was requested, on 26 randomly chosen patients with prolonged fever where it was not requested and on 17 controls. ELISA was positive in 39.1, 26.9 and 0 per cent respectively in these groups. Brucellosis may often be unsuspected because of its varied clinical manifestations and may be a more important cause of fever than previously considered. Our data reaffirm that ELISA is superior to the standard agglutination test for the diagnosis of brucellosis.

Development of vaccines against falciparum malaria.

Falciparum malaria is a leading cause of death in many countries. Drug resistance has emerged as a major cause for concern, increasing the pathogenic potential of the parasite. So far vaccines have been an elusive option. We discuss here some of the antigens and vaccines that show promise and on which studies are in progress.

Audit of management of pregnant women with positive VDRL tests.

BACKGROUND: Syphilis is a preventable cause of foetal loss and congenital disease. Although the VDRL test is an integral part of routine antenatal care in India, little is known about the disease burden in pregnancy in India. Therefore, we carried out a study to determine the prevalence of VDRL positivity and syphilis among pregnant women in Vellore and to audit the management and outcome of VDRL-positive pregnancies. METHODS: A retrospective review of case records. RESULTS: Only 0.98% of pregnant women were positive by the VDRL test. However, foetal loss occurred in 16 (32%) of the 50 seropositive women; 15 of these did not receive antenatal care. Seventeen of the 34 seropositive multiparous women had had previous foetal losses. Only 16 women had received penicillin. CONCLUSION: Although the seroprevalence of syphilis in pregnancy is low, it is an unrecognized cause of foetal loss in Vellore. An audit of the testing and management of VDRL positivity in pregnancy provides valuable information on the quality of antenatal care in an area.