Antimicrobial resistance in food-borne pathogens at the human-animal interface: Results from a large surveillance study in India.

Background: The burden of foodborne diseases and antimicrobial resistance carried by key foodborne pathogens in India is unknown due to a lack of an integrated surveillance system at the human-animal interface. Methods: We present data from the WHO-AGISAR (Advisory Group on Integrated Surveillance of Antimicrobial Resistance), India project. Concurrent human and animal sampling was done across a large area across north India. Community-acquired diarrhea cases (n = 1968) of all age groups were included. Cross-sectional sampling of stool/ intestinal contents (n = 487) and meat samples (n = 419) from food-producing animals was done at farms, retail shops, and slaughterhouses. Pathogens were cultured and identified, and antimicrobial susceptibility was performed. Results: Over 80% of diarrhoeal samples were obtained from moderate to severe diarrhea patients, which yielded EAEC (5%), ETEC (4.84%), EPEC (4.32%), and Campylobacter spp. (2%). A high carriage of EPEC (32.11%) and Campylobacter spp. (24.72%) was noted in food animals, but the prevalence of ETEC (2%) and EAEC (1%) was low. Atypical EPEC (aEPEC, 84.52%, p ≤0.0001) were predominant and caused milder diarrhea. All EPEC from animal/poultry were aEPEC. Overall, a very high level of resistance was observed, and the MDR rate ranged from 29.2% in Campylobacter spp., 53.6% in EPEC, and 59.8% in ETEC. Resistance to piperacillin-tazobactam, cefepime, ceftriaxone, and co-trimoxazole was significantly higher in human strains. In contrast, resistance to ciprofloxacin, aminoglycosides, and tetracycline was higher in animal strains, reflecting the corresponding usage in human and animal sectors. ESBL production was commoner in animal isolates than in humans, indicating high use of third-generation cephalosporins in the animal sector. C. hyointestinalis is an emerging zoonotic pathogen, first time reported from India. Conclusion: In one of the most extensive studies from India, a high burden of key foodborne pathogens with MDR and ESBL phenotypes was found in livestock, poultry, and retail meat.

Spontaneous Emergence of Azithromycin Resistance in Independent Lineages of Salmonella Typhi in Northern India.

BACKGROUND: The emergence and spread of antimicrobial resistance (AMR) pose a major threat to the effective treatment and control of typhoid fever. The ongoing outbreak of extensively drug-resistant Salmonella Typhi (S. Typhi) in Pakistan has left azithromycin as the only remaining broadly efficacious oral antimicrobial for typhoid in South Asia. Ominously, azithromycin-resistant S. Typhi organisms have been subsequently reported in Bangladesh, Pakistan, and Nepal. METHODS: Here, we aimed to understand the molecular basis of AMR in 66 S. Typhi organisms isolated in a cross-sectional study performed in a suburb of Chandigarh in Northern India using whole-genome sequencing and phylogenetic analysis. RESULTS: We identified 7 S. Typhi organisms with the R717Q mutation in the acrB gene that was recently found to confer resistance to azithromycin in Bangladesh. Six out of the seven azithromycin-resistant S. Typhi isolates also exhibited triple mutations in gyrA (S83F and D87N) and parC (S80I) genes and were resistant to ciprofloxacin. These contemporary ciprofloxacin/azithromycin-resistant isolates were phylogenetically distinct from each other and from those reported from Bangladesh, Pakistan, and Nepal. CONCLUSIONS: The independent emergence of azithromycin-resistant typhoid in Northern India reflects an emerging broader problem across South Asia and illustrates the urgent need for the introduction of typhoid conjugate vaccines in the region.

Comparative analysis of virulence determinants, phylogroups, and antibiotic susceptibility patterns of typical versus atypical Enteroaggregative E. coli in India.

Enteroaggregative Escherichia coli (EAEC) is an evolving enteric pathogen that causes acute and chronic diarrhea in developed and industrialized nations in children. EAEC epidemiology and the importance of atypical EAEC (aEAEC) isolation in childhood diarrhea are not well documented in the Indian setting. A comparative analysis was undertaken to evaluate virulence, phylogeny, and antibiotic sensitivity among typical tEAEC versus aEAEC. A total of 171 EAEC isolates were extracted from a broad surveillance sample of diarrheal (N = 1210) and healthy children (N = 550) across North India. Polymerase chain reaction (PCR) for the aggR gene (master regulator gene) was conducted to differentiate tEAEC and aEAEC. For 21 virulence genes, we used multiplex PCR to classify possible virulence factors among these strains. Phylogenetic classes were identified by a multiplex PCR for chuA, yjaA, and a cryptic DNA fragment, TspE4C2. Antibiotic susceptibility was conducted by the disc diffusion method as per CLSI guidelines. EAEC was associated with moderate to severe diarrhea in children. The prevalence of EAEC infection (11.4%) was higher than any other DEC group (p = 0.002). tEAEC occurrence in the diarrheal group was higher than in the control group (p = 0.0001). tEAEC strain harbored more virulence genes than aEAEC. astA, aap, and aggR genes were most frequently found in the EAEC from the diarrheal population. Within tEAEC, this gene combination was present in more than 50% of strains. Also, 75.8% of EAEC strains were multidrug-resistant (MDR). Phylogroup D (43.9%) and B1 (39.4%) were most prevalent in the diarrheal and control group, respectively. Genetic analysis revealed EAEC variability; the comparison of tEAEC and aEAEC allowed us to better understand the EAEC virulence repertoire. Further microbiological and epidemiological research is required to examine the pathogenicity of not only typical but also atypical EAEC.

Epidemiological investigation of an outbreak of Acute Viral Hepatitis A and E in a semi-urban locality in Chandigarh, North Indian Union Territory, 2016-17.

CONTEXT: During ongoing passive surveillance in Burail, Chandigarh an unexpected rise in number of acute viral hepatitis (AVH) was reported during December 2016. AIMS: An outbreak of AVH was investigated in an urbanized village, Burail, in Chandigarh, India with an objective of describing its epidemiological features. SETTINGS AND DESIGN: A house-to-house survey was conducted in Burail (population 51,958). SUBJECTS AND METHODS: WHO's standard case definition for AVH was used to identify cases. Suspected cases were tested for hepatitis A virus (HAV) and E virus (HEV) using enzyme-linked immunosorbent assay. Drinking water samples were tested for fecal contamination. Control measures were implemented to contain the outbreak. STATISTICAL ANALYSIS USED: Descriptive analysis was done as per time, person, and place. RESULTS: Out of 141 confirmed cases of AVH, 85.1% were positive for HEV, 12.8% for HAV, and 2.1% for both HAV and HEV. The attack rate was 27.1 per 10,000 in a population. Males were affected more than females (P < 0.05). One of the areas reported a leakage in drinking water pipeline and had highest attack rate (36.8/10000 population). Drinking water samples were found negative for contamination. Around 27% of confirmed cases reported history of taking food from local vendors in Burail 2-6 weeks prior to the onset of symptoms. CONCLUSION: This study described the epidemiological features of dual hepatitis outbreak due to HAV and HEV from Chandigarh, Union Territory, north India.

Mycological Profile and Antifungal Susceptibility of Fungal Isolates from Clinically Suspected Cases of Fungal Rhinosinusitis in a Tertiary Care Hospital in North India.

A prospective observational study was conducted for 18 months to analyze the mycological profile of clinically suspected cases of fungal rhinosinusitis requiring endoscopic sinus surgery and test antifungal susceptibility of the isolates according to Clinical and Laboratory Standards Institute guidelines. Per-operative biopsies (n = 126) from 106 patients were processed by standard mycological procedures. Out of 126 samples, 59 (46.83 %) had fungal elements on KOH mount examination. Fungal growth was obtained in 76 (60.32 %) samples, of which single fungal organism was isolated in 68 samples and more than one fungal species in eight samples. The most common isolates belonged to the genus Aspergillus (n = 53, A. flavus being most common) followed by mucormycetes (9), Candida species (7), Penicillium species (5), Alternaria species (5), Fusarium species (1), Curvularia species (1) and black yeast (1). Two hyaline septate fungal isolates could not be identified. Aspergillus species were susceptible to amphotericin B (n = 46), itraconazole (n = 48), voriconazole (n = 52), posaconazole (n = 53), caspofungin (n = 51), anidulafungin (n = 53) and micafungin (n = 53). All mucormycetes isolates (n = 9) were susceptible to amphotericin B, posaconazole and itraconazole. Filamentous non-Aspergillus, non-mucormycetes isolates (n = 15) were susceptible to amphotericin B (n = 12), itraconazole (n = 13), voriconazole (n = 15), posaconazole (n = 15) and echinocandins (n = 15). Amongst the 07 Candida species, 05 isolates of Candida tropicalis were susceptible to amphotericin B, posaconazole, echinocandins and 5-flucytosine; one isolate of Candida albicans had the same susceptibility but was resistant to 5-flucytosine also, and one strain of Candida species was susceptible to all the nine antifungal drugs.

Linezolid resistant Staphylococcus haemolyticus: first case report from India.

Linezolid is being increasingly used in the treatment of infections with gram-positive organisms especially methicillin resistant Staphylococcal isolates. Though resistance to this antimicrobial is emerging but it is extremely rare. Here we document first case of linezolid resistant Staphylococcus haemolyticus (S.haemolyticus) from India. This organism was isolated from pus oozing from a postsurgical site in 61 year old male hailing from an adjoining state of Haryana.

Secondary peritonitis caused by Streptomyces viridis.

Streptomyces organisms are soil inhabitants rarely causing nonmycetomic infections. We describe a case of secondary peritonitis caused by Streptomyces viridis in a chronic alcoholic patient who presented with fever, abdominal distension, and pain in the abdomen. The most likely source of infection was by inoculation through multiple paracenteses, done for treatment of ascites, before the patient came to our health care center. This is the second case report of Streptomyces peritonitis and the first case caused by Streptomyces viridis, which is usually found in the soil in our geographic region.

Streptococcus bovis causing perforating corneal ulcer.

PURPOSE: The purpose of this study was to report the first case of Streptococcus bovis causing a perforating corneal ulcer in a healthy adult. METHODS: Observational case report. RESULTS: A healthy 77-year-old man presented with rapidly progressing corneal ulcer, resulting in perforation within 4 days. Preoperative and operative cultures isolated the same organism, S. bovis, susceptible only to vancomycin and ceftriaxone. The patient underwent a successful corneal transplantation, with histopathology revealing full-thickness necrosis and scattered bacteria. CONCLUSIONS: Although a rare pathogen in ocular infections, we report a case of devastating corneal infection caused by S. bovis and highlight consideration of this pathogen in rapidly progressing corneal ulcers.

Foreign versus domestic education of physicians for the United States: a case study of physicians of South Asian ethnicity in California.

Physician supply in the U.S. is again on the national health policy agenda. A central issue in this debate is the availability of physicians willing to work in underserved and disadvantaged communities-an issue closely linked to the number of minority and international medical graduate (IMG) physicians working in the U.S. In California, South Asian IMGs, but not South Asian U.S. medical graduates, are more likely to work in underserved communities. Incorporation of strong policy levers aimed at an equitable geographic distribution of physicians will be critical as the U.S. moves toward greater self-sufficiency of physician supply. More specifically, the authors note the continuing central importance to addressing the needs of medically underserved populations of training physicians from under-represented minority groups (African Americans, American Indians, and Hispanic Americans) in U.S. medical schools.