Nocardia Infections: Ten Years Experience from a Tertiary Health Care Center in North India (2007-2016).

BACKGROUND: Nocardia species are important cause of infections in humans but are underreported due to missed diagnosis as well as misdiagnosis. Majority of the literature on these infections consists of case reports or series with few articles describing high number of cases. OBJECTIVE: To study the epidemiology of Nocardia infections in a tertiary care center. MATERIALS AND METHODS: This retrospective observational study was done in a tertiary care centre of North India over a period of 10 years (2007-2016). The detection of Nocardia spp. from clinical specimens was done by conventional methods viz. direct microscopy (Gram's stain, modified Ziehl -Neelsen stain [1%], KOH examination) and culture. RESULTS: A total of 25 cases of nocardiosis were diagnosed during the study period. The mean age of the patients was 50.9 years (range 30-72 years) with a male:female ratio of 3:2. The site of disease in these patients included pulmonary (n=18), cutaneous (n=4), perinephric abscess (n=1), ocular (n=1) and bone (n=1). Risk factors associated were underlying lung disease (n=11), smoking (n=7), diabetes (n=5) and steroid therapy (n=4) in pulmonary nocardiosis, iatrogenic (n=1) and leprosy (n=1) in cutaneous nocardiosis, diabetes in perinephric abscess and cataract surgery in ocular nocardiosis. Culture was positive in 12/25 (48%) patients for Nocardia spp. Direct microscopy was positive in 22 patients. We wish to highlight that meticulous observation of KOH wet mount examination helped in clinching the diagnosis of Nocardiosis in 3 cases which were earlier missed by other methods. CONCLUSION: Good communication with the clinician alongside a meticulous effort in the laboratory is essential for appropriate diagnosis and management of these cases.

Knee and the farm animals: An unusual presentation of Brucella melitensis masquerading as tuberculosis.

In many developed countries, brucellosis has been successfully eradicated. However, brucellosis, with its myriad presentations, continues to be a clinical and diagnostic challenge in primarily agrarian countries such as India. We present a case of a rare manifestation of brucellosis i.e., septic arthritis of the knee joint associated with a lytic lesion of the proximal tibia. The patient belonged to a Brucella endemic country, and clinical features were of chronic reactive knee arthritis with synovial hypertrophy and effusion. Advanced diagnostic methods played a pivotal role in excluding the diagnosis of tuberculosis, and thus unnecessary administration of antitubercular therapy and initiating focused narrowed anti-Brucella management, achieving the goal of antimicrobial stewardship also.

Laboratory diagnosis of Prosthetic Joint Infections: Current concepts and present status.

Prosthetic joint infection (PJI) is a challenging complication of total joint arthroplasty for both a microbiologist and an Arthroplasty surgeon with respect to diagnosis and management. The various investigations used for diagnosis of PJI based on different reference criteria have their own fallacies. Amongst the newer biomarkers evaluated to strengthen the diagnosis of PJI, Alpha defensins has been found to be a useful synovial fluid biomarker. In this review, we have discussed the various laboratory investigations, their benefits and shortcomings for the diagnosis of PJI. Other newer diagnostic methods like molecular methods and modified culture techniques to increase the performance characteristics for the diagnosis of PJI have also been presented.

Time to Detection of Yeast Isolates in Pediatric and Adult Patients with Fungemia and its Relevance to Clinical Profile and Outcome.

CONTEXT: Time to detection (TTD) given by continuous monitoring automated blood culture systems (CMABS) have been found to be a predictor of clinical outcome, drug resistance and type of microorganism in cases of bacteremia but the studies evaluating TTD with respect to fungemia are scarce especially from India. AIMS: To evaluate TTD for yeast isolates in fungal bloodstream infections with respect to the type of yeast isolates, risk factors and outcome and to study yeast susceptibility and distribution of yeast isolates with respect to patient population. MATERIALS AND METHODS: All blood culture specimens were processed in CMABS. The TTD for yeast isolates were recorded. The identification of yeast and susceptibility testing was done by automated methods. A correlation of TTD was done with respect to prior/concurrent yeast isolates, use of antifungal, risk factors and clinical outcome. RESULTS: Out of 80 yeast isolates, the maximum was C. parapsilosis (26.25%) followed by C. albicans (16.25%) and C. tropicalis (13.75%). A statistically significant difference in the occurrence of yeasts with early TTD (TTD < = 48 hours) and late TTD (TTD > 48 hours) was found. TTD of C. glabrata was significantly longer (p = 0.002) while TTD of C. tropicalis was significantly shorter (p = 0.013). There was an observable favorable outcome in shorter TTD (< = 48 hours). C. albicans and C. tropicalis depicted 100% susceptibility for Azoles, Amphotericin B and Echinocandins. CONCLUSION: TTD may be used as both diagnostic and prognostic adjunct in fungal bloodstream infections. This study is a step towards this novel approach. We also emphasize on the importance of speciation of yeast isolates and susceptibility testing. HOW TO CITE THIS ARTICLE: Butta H, Sardana R, Mendiratta L, Sibal A, Gupta V, Chawla R, Jafri AA. Time to Detection of Yeast Isolates in Pediatric and Adult Patients with Fungemia and its Relevance to Clinical Profile and Outcome. Indian Journal of Critical Care Medicine, January 2019;23(1):27-30.

Evaluation of bacterial inactivation in random donor platelets and single-donor apheresis platelets by the INTERCEPT blood system.

BACKGROUND: Blood transfusion of contaminated components is a potential source of sepsis by a wide range of known and unknown pathogens. Collection mechanism and storage conditions of platelets make them vulnerable for bacterial contamination. Several interventions aim to reduce the transfusion of contaminated platelet units; however, data suggest that contaminated platelet transfusion remains very common. AIM: A pathogen inactivation system, "INTERCEPT", to inactivate bacteria in deliberately contaminated platelet units was implemented and evaluated. MATERIALS AND METHODS: Five single-donor platelets (SDP) and five random donor platelets (RDP) were prepared after prior consent of donors. Both SDP and RDP units were deliberately contaminated by stable stock ATCC Staphylococcus aureus and Escherichia coli, respectively, with a known concentration of stock culture. Control samples were taken from the infected units and bacterial concentrations were quantified. The units were treated for pathogen inactivation with the INTERCEPT (Cerus Corporation, Concord, CA) Blood system for platelets (Amotosalen/UVA), as per the manufacturer's instructions for use. Post illumination, test samples were analyzed for any bacterial growth. RESULTS: Post-illumination test samples did not result in any bacterial growth. A complete reduction of >6 log10 S. aureus in SDP units and >6 log10 Escherichia coli in RDP units was achieved. CONCLUSION: The INTERCEPT system has been shown to be very effective in our study for bacterial inactivation. Implementation of INTERCEPT may be used as a mitigation against any potential bacterial contamination in platelet components.

Nocardia Farcinica Brain Abscess in an Immunocompetent Old Patient: A Case Report and Review of Literature.

By definition, a brain abscess is an intraparenchymal collection of pus. Nocardia shows to have a special tropism for the neural tissue. Solitary abscess represents the most common manifestation in the central nervous system, accounting for 1%-2% of all cerebral abscesses. In this report, we present a case of primary multiple brain abscesses due to Nocardia farcinica in an immune competent patient. Early diagnosis and surgical intervention is significant for the patient.

Bifidobacterium: An Emerging Clinically Significant Metronidazole-resistant Anaerobe of Mixed Pyogenic Infections.

Bifidobacterium sp. are anaerobic, Gram-positive, short, irregular rods with rudimentary branching. These organisms are reported to be associated with health benefits and their significance as a pathogen is not much reported. We are reporting two cases of mixed pyogenic infections due to Bifidobacterium sp. In the first patient, the infection mimicked tubercular bone infection. The second patient was a case of hydronephrosis with double J (DJ) stent blockage. In both cases, Bifidobacterium sp. was isolated in combination with Escherichia coli from the evacuated pus samples. The factors which contributed significantly for detecting Bifidobacterium sp. were gram stain examination, use of rapid and automatic anaerobic cultivation system (Anoxomat, MART Microbiology B.V., The Netherlands), and quick identification by MALDI-TOF (Matrix-Assisted Laser Desorption-Time-of-Flight) Mass Spectrometry (Biomerieux, France). Both strains were found to be resistant to metronidazole and both patients showed a good clinical response to treatment with beta-lactam antibiotics. So, we highlight the importance of seeking Bifidobacterium species in all clinical pyogenic samples.