Early- vs Late-onset Ventilator-associated Pneumonia in Critically Ill Adults: Comparison of Risk Factors, Outcome, and Microbial Profile.

Background: Ventilator-associated pneumonia (VAP) is one of the most frequent hospital-acquired infections, which develops in mechanically ventilated patients after 48 hours of mechanical ventilation. The purpose of this study was to determine the incidence rate, various risk factors, microbiological profile, and outcome of early- vs late-onset ventilator-associated pneumonia (VAP) in medical intensive care unit (MICU). Materials and methods: This prospective study was conducted on 273 patients admitted to the MICU in JIPMER, Puducherry, from October 2018 to September 2019. Results: The incidence of VAP was 39.59 per 1000 ventilation days of MICU patients (93/273). Of these, 53 (56.9%) patients had early-onset VAP and 40 (43.1%) had late-onset VAP. Multiple logistic regression analysis showed that steroid therapy, supine head position, coma or impaired unconsciousness, tracheostomy, and re-intubation were found to be independent predictors of early- and late-onset VAP, respectively. Most cases of VAP were caused by Gram-negative bacteria (90.6%), with nonfermenters contributing to 61.8%. The most frequent pathogens causing early-onset VAP were Acinetobacter baumannii (28.9%) and Pseudomonas aeruginosa (20.6%), while in late-onset VAP, A. baumannii (32.9%) and Klebsiella pneumoniae (21.9%) were the most common. Maximum death rate was seen in patients infected with Escherichia coli (50%) and Stenotrophomonas maltophilia (38.5%). There was no significant association between the presence of VAP and mortality among the studied population. Conclusion: The incidence of VAP in our study was high. There were no significant differences in the prevalence of pathogens associated with early-onset or late-onset VAP. Our study shows that early-onset and late-onset VAP have different risk factors, highlighting the need for developing different preventive and therapeutic strategies. How to cite this article: Gunalan A, Sastry AS, Ramanathan V, Sistla S. Early- vs Late-onset Ventilator-associated Pneumonia in Critically Ill Adults: Comparison of Risk Factors, Outcome, and Microbial Profile. Indian J Crit Care Med 2023;27(6):411-415.

Prevotella oris: A lesser known etiological agent of pleural effusion.

Prevotella are gram negative, obligate anaerobes and includes pigmented and non-pigmented species. They are typically regarded as commensals, especially of the gastrointestinal tract and oral cavity, although opportunistic endogenous infections are known to be caused by a small number of strains. We report a case of a 51-year-old man with right-sided chest pain. Chest X-ray showed mild haziness in the right lung and he was diagnosed with right sided pleural effusion. Prevotella oris was isolated after pleural pus culture.

A Comparative Analysis of Microscopy, Coproantigen Serology, and Nested Multiplex PCR in the Laboratory Diagnosis of Entamoeba histolytica Infection.

Objectives Amoebiasis is caused by the most common intestinal protozoan parasite Entamoeba histolytica . This parasite causes amoebic colitis, which is manifested by diarrhea, followed by dysentery. The laboratory diagnosis of intestinal amoebiasis in most cases is by microscopic examination of stool samples. Other nonroutine methods include coproantigen enzyme-linked immunosorbent assay (ELISA) from stool samples, serum ELISA for antibodies, stool culture, isoenzyme analysis, and polymerase chain reaction (PCR). The present study aimed to comparatively analyze the different diagnostic modalities used for the detection of E. histolytica from the stool sample of patients with intestinal amoebiasis. Materials and Methods This study was undertaken with 631 patients, during a period of 3 years, from January 2017 to December 2019. Stool specimen obtained from each patient was subjected to direct microscopic wet mount examination, coproantigen ELISA, and nested multiplex PCR, respectively. Results Out of all the patients tested, 5.2% were positive for E. histolytica. Among the positive cases, stool microscopy was positive in 3.17%, coproantigen ELISA was positive in 29 (4.6%) cases, and PCR was positive in 30 (4.75%) cases. Statistical Analysis The prevalence of E. histolytica infection was summarized as percentages. The three diagnostic tests done were statistically analyzed, taking microscopy as the gold standard. The agreement between techniques (microscopy, coproantigen ELISA, and PCR) was analyzed with kappa statistics. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were summarized as percentage with 95% confidence interval. Conclusion In all suspected amoebiasis cases, a combination of stool microscopy, coproantigen testing with molecular detection of the parasite offers the best approach to diagnosis of this parasitic infection.

Potential impact of SARS COV-2 infection on the performance of serological assays used to diagnose arboviral diseases.

BACKGROUND: The COVID-19 pandemic caused by SARS-CoV-2 was first described in December 2019, in China. In addition, there has also been an increase in arboviral infections in recent years. As both infections have similar symptoms, misdiagnosis may occur if both outbreaks occur at the same time. OBJECTIVE: Our objective was to assess the potential impact of SARS-CoV-2 infection on diagnostic assays used for arboviral diseases. MATERIALS AND METHODS: We conducted this study by testing samples obtained during the precovid phase (before November 2019) and during the covid period (after February 2020). Samples were further grouped as those with acute febrile illness (AFI) and those without. All samples were tested for anti SARS-CoV-2 Ab, Chikungunya and Dengue specific IgM antibodies to evaluate potential serological cross-reactions between COVID-19 and Arbovirus specific antibodies. RESULTS: One sample from the 62 cases of AFI during the pre-covid phase showed seropositivity for SARS-CoV-2 antibodies. Also, in asymptomatic individuals, arboviral seropositivity was significantly higher in the COVID period samples (22%) compared to pre-COVID samples (3%). CONCLUSION: Due to similar clinical symptoms and cross reactions in both infections, relying solely on serological testing for arboviral diagnosis may be less sensitive; other clinical and laboratory parameters may be required.

Clinical profile and outcomes of multisystem inflammatory syndrome in children (MIS-C): Hospital-based prospective observational study from a tertiary care hospital in South India.

AIM: To study the clinical profile and outcomes in children with multisystem inflammatory syndrome in children (MIS-C). METHODS: Children aged 1 month to 15 years presenting with MIS-C (May 2020 to November 2021) were enrolled. Clinical, laboratory, echocardiography parameters and outcomes were analysed. RESULTS: Eighty-one children (median age 60 months (24-100)) were enrolled. Median duration of fever was 5 days (3-7). Twenty-nine (35.8%) had shock (severe MIS-C) including 23 (28.3%) requiring inotropes (median duration = 25 h (7.5-33)). Ten required mechanical ventilation, 12 had acute kidney injury and 1 child died. Left ventricular (LV) dysfunction was seen in 38 (46.9%), 16 (19.7%) had coronary artery abnormalities (CAA) and 13 (20%) had macrophage activation syndrome. Sixty-one (75.3%) were SARS CoV-2 positive (10 by RT-PCR and 51 by serology). Sixty-eight (83.9%) received immunomodulators. Younger age was significantly associated with CAA (P value = 0.05). Older age, LV dysfunction, SARS CoV-2 positivity, low platelet count and elevated serum ferritin were significantly associated with severe MIS-C (univariate analysis). Younger age was an independent predictor of CAA (P = 0.05); older age (P = 0.043) and low platelet count (P = 0.032) were independent predictors of severe MIS-C (multivariate logistic regression analysis). CONCLUSION: Our patients had diverse clinical manifestations with a good outcome. Younger age was significantly associated with CAA. Older age, LV dysfunction, low platelet count and elevated serum ferritin were significantly associated with severe MIS-C. Younger age is an independent predictor of CAA. Older age and low platelet count are independent predictors of severe MIS-C.

Epstein-Barr Virus: An Infrequent Pathogen of Acute Undifferentiated Febrile Illness From a Tertiary Care Hospital in Southern India.

CONTEXT: Acute undifferentiated febrile illness (AUFI) is characterized by a sudden onset of raised body temperature and is a common cause of hospital admission though not recognized as a disease state by the World Health Organization. Epstein-Barr virus (EBV) is reported to account for a significant occurrence of AUFI cases. AIM: To know the role of EBV infection as a cause of acute undifferentiated febrile illness (AUFI). SETTINGS AND DESIGN: We have used the combination of EBV serological assays to establish the role of the Epstein-Barr virus as the cause of acute undifferentiated febrile illness. METHODS AND MATERIAL: A total of 721 suspected cases of acute undifferentiated febrile illness which were tested negative for other common causes of acute febrile illness were selected for the study. Serum samples collected from these cases were tested for the presence of the EBV viral capsid antigen (VCA) IgM antibody. All positive serum samples were tested for the presence of EBV Epstein-Barr nuclear antigen (EBNA) IgG. STATISTICAL ANALYSIS USED:  Statistical analysis was performed with the help of Microsoft Excel software (Microsoft Corporation, Redmond, USA).  Results: Out of 721 suspected AUFI cases tested for EBV VCA IgM antibodies, 117 samples were positive and 604 were negative. All these 117 samples were tested for EBV EBNA IgG antibodies in which 88 were positive and 29 were negative. In our study, we found that around 4% (positive for VCA IgM and negative for EBNA IgG) of AUFI cases can be attributed to primary acute EBV infection. CONCLUSIONS: EBV infection should be considered particularly in AUFI cases of less than five years of age even in those who do not meet the typical presentation of fever, lymphadenopathy and sore throat. Our study should help to raise awareness regarding the possibility of EBV infection particularly in AUFI cases. A high index of suspicion and timely diagnosis will definitely help clinicians to avoid a battery of investigations and misuse of antibiotics in cases of AUFI.

Increasing Trend of Vancomycin-resistant Enterococci Bacteremia in a Tertiary Care Hospital of South India: A Three-year Prospective Study.

Introduction: Vancomycin-resistant enterococci (VRE) are emerging as an important multidrug-resistant pathogen causing nosocomial infections, predominantly bacteremia and urinary tract infections. VRE bacteremia has caused a significant increase in the duration of the hospital stay and mortality and had caused high public health threat due to limited treatment options. Materials and methods: Between October 2017 and September 2020, all consecutive patients with culture-proven bloodstream infection with Enterococcus species, isolated for the first time, were included in the study. A total of 427 Enterococcus species were identified, and antimicrobial susceptibility tests were performed and interpreted using Clinical and Laboratory Standard Institute guidelines. Results: Of the total 427 Enterococcus species isolated, 63 (45.6%) were VRE. Among them, 51/63 (81%) were Enterococcus faecium (E. faecium) and 5/63 (8%) were Enterococcus faecalis. There was an increased trend of VRE rate in the bloodstream infections of 6.12% (2018), 13.2% (2019), and 19.2% (2020). The majority of the VRE patients [43/63 (68%)] were admitted to the intensive care units (ICUs). Vancomycin A (VanA) is the most common phenotype isolated from 51/63(81%) patients. Conclusion: This increasing trend of VRE bacteremia is a red alert to the clinicians and the infection control practitioners, so that strict antibiotic policies and proper adherence to the infection control practices can be initiated to reduce the VRE rate. How to cite this article: Sivaradjy M, Gunalan A, Priyadarshi K, Madigubba H, Rajshekar D, Sastry AS. Increasing Trend of Vancomycin-resistant Enterococci Bacteremia in a Tertiary Care Hospital of South India: A Three-year Prospective Study. Indian J Crit Care Med 2021;25(8):881-885.

Intestinal parasitic infections and its trends: a 5-year findings from a tertiary care centre, Puducherry, South India.

Intestinal parasitic infection (IPI) constitute a global health burden causing clinical morbidity in 450 million people. Many of these are women of reproductive age and children in developing countries. Mass deworming programmes with improvement in lifestyle are likely to reduce the intensity and prevalence of infection over the years. Hence, we aimed to assess the prevalence of intestinal parasitic infections among patients in a tertiary healthcare setting and to examine its time trends. A descriptive cross-sectional study was done using routinely collected data in a tertiary care hospital in South India. Details of examination of stool samples for the presence of intestinal helminth and protozoan ova/cysts, over the period of 5 years (2014-2019) were extracted from laboratory register and hospital information system. The presence of intestinal parasitic infection was determined by stool microscopy (direct wet mount and concentration techniques). Of the total 3267 stool samples, 303 (9.3%) had at least one parasite; 3.9% (93/3267) with helminths and 2.5% (81/3267) Entamoeba and multi-parasitism was seen in 0.14%. Stool samples from more than 18 years age had high positivity rate than others. Majority of the helminth infections were caused by Ascaris (57%) followed by hookworm (42%). Initially IPI which was 10.9% in 2014 declined to 10% in 2016 and attained a peak of 12.4% in 2017 then decreased to 6.7% in 2018. Nearly one out of ten patients had a parasitic infection. Prevalence surveys in the community followed by strengthening the deworming procedures will reduce the burden of IPIs.

Effect of combined colistin and meropenem against meropenem resistant Acinetobacter baumannii and Pseudomonas aeruginosa by checkerboard method: A cross sectional analytical study.

BACKGROUND: Meropenem-resistant Acinetobacter baumannii and Pseudomonas aeruginosa are the two most common nosocomial pathogens causing ventilator-associated pneumonia. To combat this resistance, different combinations of antibiotics have been evaluated for their efficacy in laboratories as well as in clinical situations. AIM: The aim of the study was to investigate the effect of combined colistin and meropenem against meropenem-resistant isolates of A. baumannii and P. aeruginosa by checkerboard method. MATERIALS AND METHODS: Fifty meropenem-resistant isolates of A. baumannii (n = 25) and P. aeruginosa (n = 25) from endotracheal aspirates were studied. The MIC of colistin and meropenem was found using the microbroth dilution method. The fractional inhibitory concentration was calculated for the combination of antibiotics by checkerboard assay and the antibiotic interactions were assessed. Fisher's exact test was carried out for statistical comparison of categorical variables. RESULTS: A synergistic effect between colistin and meropenem was observed in 18/25 (72%) and 6/25 (24%) isolates of Acinetobacter baumannnii and P. Aeruginosa, respectively, with fractional inhibitory concentration indices of ≤0.5. None of the tested isolates exhibited antagonism. CONCLUSION: Our results showed that combinations of colistin and meropenem are associated with improvement in minimum inhibitory concentration and may be a promising strategy in treating meropenem-resistant A. baumannii respiratory tract infections.

Concordance between the National Healthcare Safety Network (NHSN) Surveillance Criteria and Clinical Pulmonary Infection Score (CPIS) Criteria for Diagnosis of Ventilator-associated Pneumonia (VAP).

Background: Ventilator-associated pneumonia (VAP) is one of the most common hospital-acquired infections among mechanically ventilated patients and the incidence rates are widely used as an index of quality of care given in an ICU. Since there is no gold standard method available to diagnose VAP, the incidence rate varies based on different criteria used for calculation. Therefore, we conducted a study to determine the concordance between the National Healthcare Safety Network (NHSN) surveillance criteria and clinical pulmonary infection score (CPIS) criteria for the diagnosis of VAP. Materials and methods: This was a prospective study that evaluated patients in the medical intensive care units (MICUs) of a tertiary care hospital, India, who were intubated for >48 hours between October 2018 and September 2019. All the patients (n = 273) were followed up daily and assessed using both CPIS and NHSN surveillance criteria for diagnosing VAP. Results: Of these 273 patients, 93 patients (34.1%) had VAP according to CPIS criteria as compared with 33 patients (12.1%) using the NHSN criteria. The corresponding rates of VAP were 39.59 vs 11.53 cases per 1,000 ventilator days, respectively. The agreement of the two sets of criteria was fairly good (kappa statistics, 0.42) Conclusion: The NHSN surveillance criteria have a lower sensitivity in detecting VAP cases and have to be modified to achieve better results. How to cite this article: Gunalan A, Sistla S, Sastry AS, Venkateswaran R. Concordance between the National Healthcare Safety Network (NHSN) Surveillance Criteria and Clinical Pulmonary Infection Score (CPIS) Criteria for Diagnosis of Ventilator-associated Pneumonia (VAP). Indian J Crit Care Med 2021;25(3):296-298.

In-vitro synergistic activity of colistin and meropenem against clinical isolates of carbapenem resistant E.coli and Klebsiella pneumoniae by checkerboard method.

CONTEXT: The emergence of drug resistant pathogens pose major threat to hospitalized patients as well as to the community associated with increased mortality and morbidity. The treatment of carbapenem resistant enterobacteriaceae, one of the top WHO priority pathogen remains a global issue. Combination therapy with different classes of antibiotics have been tried with the aim to reduce toxicity, to increase the efficacy of the drugs and to reduce resistance. The in-vitro synergy methods have to be carried out to determine whether the combination of those antibiotics are synergistic, antagonistic or additive. AIMS: We have performed in-vitro synergy testing by checkerboard method for colistin -meropenem combination to determine whether the combination of the two antibiotics were synergistic or antagonistic. METHODS AND MATERIAL: All the consecutive twenty five blood isolates of Escherichia coli and twenty five blood isolates of Klebsiella pneumoniae which were showing resistance to carbapenems by either disc diffusion or vitek 2 were collected over a period of 6 months and checkerboard method was performed. STATISTICAL ANALYSIS USED: The reduction of MIC of colisin on combination with meropenem compared to MIC of colistin alone is analyzed by McNemar's chisquare test with the help of software Stata version 14 and p value < 0.05 is considered as significant. RESULTS: 56% of K. pneumoniae showed synergy and 44% showed additive/indifference results. For E. coli 40% showed synergy and 60% showed additive/indifference. None of the isolates of E. coli and K. pneumoniae showed antagonism. There was more than two fold reduction in MIC of colistin (significant) on combining withmeropenem. CONCLUSIONS: The study results support the combination therapy to treat infections by multi-drug-resistant Klebsiela pneumoniae and Escherichia coli by in-vitro checkerboard testing method which inturn will be helpful for clinicians for judicious use of antimicrobials.

Pathogenic potential of Parabacteroides distasonis revealed in a splenic abscess case: a truth unfolded.

Splenic abscess is a rare entity, however if unrecognised or left untreated, it is invariably fatal. We herein report a case of splenic abscess in a 40-year-old man presenting with fever, left-sided abdominal pain, altered sensorium and vomiting. On clinical examination, hepatosplenomegaly was noted and the ultrasound of the abdomen showed multiple hypoechoic regions in the upper pole of spleen, and the diagnosis of splenic abscess was made. The patient received antimicrobial therapy and underwent an open splenectomy with full recovery. Pus aspirated from the splenic abscess grew an unusual organism named Parabacteroides distasonis In the literature, there are only a few recorded cases of P. distasonis causing splenic abscess. Through this case report, we would like to emphasise the pathogenic role of P. distasonis in causing clinical disease, as this organism is typically known to constitute a part of the normal flora.