Clinical Utility of Blood Culture Identification 2 Panel in Flagged Blood Culture Samples from the Intensive Care Unit of a Tertiary Care Hospital.

Background: The availability of rapid diagnostic platforms for positive blood cultures has accelerated the speed at which the clinical microbiology laboratory can identify the causative organism and facilitate early appropriate antimicrobial therapy. There is a paucity of data regarding the clinical utility of the blood culture identification 2 (BCID2) panel test and its correlation with phenotypic drug susceptibility testing (DST) in flagged blood culture bottles from intensive care units (ICUs) in countries such as India, which have high rates of multidrug-resistant gram-negative bacteria (MDR-GNB). Materials and methods: We conducted a retrospective observational study in a tertiary care ICU on 200 patients above 18 years of age in whom a BCID2 test was ordered when blood cultures flagged positive. Results: We found 99% concordance between BCID2 and cultures in the identification of bacteria and yeasts and 96.5% concordance between phenotypic and genotypic DST. Furthermore, BCID2 was available about 1.5 days earlier than conventional ID and DST and played a key role in tailoring antimicrobials in 82.5% of the patients. Polymyxin-based therapy was discontinued earlier after an empiric dose in 138 patients (69%) based on BCID2 reports. Conclusion: In critically ill patients with monomicrobial bacteremia, BCID2 rapidly identifies bacteria and antimicrobial resistance (AMR) genes and is significantly faster than conventional culture and sensitivity testing. Antibiotics were escalated in more than a third of patients and de-escalated in almost a fifth on the same day. We recommend that all ICUs routinely incorporate the test in their antibiotic decision-making process and in antimicrobial stewardship. How to cite this article: Vineeth VK, Nambi PS, Gopalakrishnan R, Sethuraman N, Ramanathan Y, Chandran C, et al. Clinical Utility of Blood Culture Identification 2 Panel in Flagged Blood Culture Samples from the Intensive Care Unit of a Tertiary Care Hospital. Indian J Crit Care Med 2024;28(5):461-466.

Can urinary histoplasma antigen test improve the diagnosis of histoplasmosis in a tuberculosis endemic region?

BACKGROUND: Many patients with histoplasmosis are treated with anti-tubercular therapy (ATT) in tuberculosis endemic regions as diagnosis of histoplasmosis requires invasive sampling. We sought to study the utility of urinary Histoplasma antigen detection test. METHODS: Case records of patients with a diagnosis of histoplasmosis prior to (Period A) and after (Period B) introduction of urinary Histoplasma antigen detection test were analysed in this single centre retrospective study. RESULTS: Thirty-seven patients (18 in Period A, and 19 patients in Period B) were studied. There was nearly a threefold increase in diagnoses (from 0.39 cases to 1.18 cases per month) after the introduction of antigen test. Nine patients (24.3%) were immunocompromised (6 had HIV infection and 3 were on steroids), and 28 (75.6%) were immunocompetent. Empirical ATT had been given to 10 patients prior to histoplasmosis diagnosis. Invasive tissue sampling was required in only two patients in Period B to confirm the diagnosis. Immunocompromised patients were younger, were more likely to have skin and mucosal findings, anaemia and leucopenia as compared to immune-competent patients. CONCLUSION: This study emphasises that histoplasmosis cases may be missed and patients may receive ATT unnecessarily. Histoplasma antigen increased the diagnostic yield by almost threefold in our study.

ICU care through NGS - Based identification of infectious agents: A comparative study.

Background: Sepsis claims 1 in 5 lives annually as per global statistics. Sepsis incidence in recent studies represents at least 35 % of all ICU admissions and has a high mortality rate, especially in the presence of co-existing morbidities. The challenge has been to accurately diagnose the causative organism, considering factors such as possible polymicrobial infections, commensals and environmental contaminants. Legacy techniques such as culture, automated culture systems or even newer species-specific PCR or film array these challenges difficult to overcome. The Bactfast® and Fungifast® assays along with the integrated workflow is based on next generation sequencing and have the ability to demarcate infecting pathogen from contamination and commensal. The unique ability to pinpoint the exact pathogen, considering the commensal and contamination in a variety of samples, with an extremely high sensitivity could lead it to be a tool of diagnostic choice for non-resolving ICU sepsis due to its comprehensive coverage and speed. The aim of this study was to evaluate the use of Bactfast® and Fungifast® as a last mile diagnostic tool in a ICU setting. Method: This study was carried out considering access to four intensive care units (ICU). Legacy testing, mostly done on culture, was conducted at the various integrated microbiology facilities of the hospitals where the ICUs were located, in Chennai, India. NABL accredited laboratory Micro Genomics (India) Pvt Ltd, was established as the central processing facility for next generation sequencing to run the Bactfast® and Fungifast® assay. Co-relation of results for 490 samples was done retrospectively by a multi-disciplinary team of consultants which comprised of microbiologists, and infectious disease physicians. Result: The diagnostic workflow established with the Bactfast® assay provided a sensitivity of 94.1 % and specificity of 86.6 %. Identification of pathogens in Bactfast® was better when compared to the data published in 2017, as reflected by positive co-relation with clinical confirmation. Although the Fungifast® specificity was high, at 99.4 %, only 12 samples were positive on fungal culture out of 490 samples. Therefore, it was concluded a further study for fungi based on multiple technologies with more true positive samples is required to evaluate the test. Conclusion: Bactfast® can identify pathogens in a sample without any bias. Its introduction as diagnostic modality in life threatening ICU sepsis could reduce mortality and morbidity. Although the initial results of Fungifast® are encouraging a further research is required for more information on test sensitivity.

Improving Antimicrobial Resistance Awareness Among Medical Students in India: The Sensitization of Medical Students on Antimicrobial Resistance (SOS-AMR) Study.

OBJECTIVES: To evaluate the impact of an online educational intervention on improving knowledge of antimicrobial resistance (AMR) and stewardship among final-year medical students in Chennai, India. METHODS: This was a prospective 'before-after' study conducted across 5 medical colleges in Chennai, India. Participants who were final-year (fourth year) undergraduate medical students were administered a pretest to evaluate baseline knowledge. Students were then provided access to online educational material comprising 20 short lectures. Lectures were delivered by content experts and covered a range of topics which included basics of microbiology, fundamental concepts in AMR and stewardship, diagnosis and management of common infections, basics of antimicrobial pharmacokinetics and pharmacodynamics, and vaccination. Students were required to take a posttest at the end of these modules. Primary outcome was improvement in test scores from pretest baseline which was analyzed using a t test. A 30% improvement in the mean scores from baseline was predefined as a measure of success. RESULTS: A total of 599 students participated from 5 medical colleges among whom 339 (56.6%) were female participants; 542 (90.4%) students completed the posttest. Mean pretest score was 11.6 (maximum possible score of 25) (SD: 4.3) and the mean posttest score was 14.0 (SD: 4.6). Comparing pre and posttest scores, there was an improvement of 2.4 marks (20%) from the baseline (95% confidence interval: 1.9, 2.9) (P < .001). Improvement in scores was similar for male and female participants. CONCLUSIONS: In this before-after study evaluating the impact of an educational intervention on AMR among final-year medical students, there was an improvement in knowledge; however, the extent of improvement did not meet the predefined metric of success.

Expert panel opinion on adult pneumococcal vaccination in the post-COVID era (NAP- EXPO Recommendations-2024).

INTRODUCTION: Pneumococcal diseases pose a significant public health concern in India, with substantial morbidity and mortality, with the elderly and those with coexisting medical conditions being most at risk. Pneumococcus was also seen to be one of the main reasons for co-infection, pneumonia and complications in COVID. Current guidelines recommend vaccination for specific adult populations, but there is a lack of uniformity and guidance on risk stratification, prioritisation and optimal timing. METHODS: Nation Against Pneumococcal Infections - Expert Panel Opinion (NAP-EXPO) is a panel convened to review and update recommendations for adult pneumococcal vaccination in India. The panel of 23 experts from various medical specialties engaged in discussions and evidence-based reviews, discussed appropriate age for vaccination, risk stratification for COPD and asthma patients, vaccination strategies for post-COVID patients, smokers and diabetics, as well as methods to improve vaccine awareness and uptake. OUTCOME: The NAP-EXPO recommends the following for adults: All healthy individuals 60 years of age and above should receive the pneumococcal vaccine; all COPD patients, regardless of severity, high-risk asthma patients, post-COVID cases with lung fibrosis or significant lung damage, should be vaccinated with the pneumococcal vaccine; all current smokers and passive smokers should be educated and offered the pneumococcal vaccine, regardless of their age or health condition; all diabetic individuals should receive the pneumococcal vaccine, irrespective of their diabetes control. Strategies to improve vaccine awareness and uptake should involve general practitioners (GPs), primary health physicians (PHPs) and physicians treating patients at high risk of pneumococcal disease. Advocacy campaigns should involve media, including social media platforms. CONCLUSION: These recommendations aim to enhance pneumococcal vaccination coverage among high-risk populations in India in order to ensure a reduction in the burden of pneumococcal diseases, in the post-COVID era. There is a need to create more evidence and data to support the recommendations that the vaccine will be useful to a wider range of populations, as suggested in our consensus.

Addressing Unmet Needs in Vaccination for Older Adults in the Asia Pacific: Insights from the COVID-19 Pandemic.

The impact of vaccinating the older population against vaccine-preventable diseases in terms of health, social and economic benefits has been increasingly recognised. However, there is a gap in the utilisation of vaccines worldwide. The population is ageing at an unprecedented pace in the Asia-Pacific (APAC) region, with the number of persons older than 65 years set to double by 2050 to around 1.3 billion. More than 18% of the population in Japan, Hong Kong, and China is over the age of 65 years. This highlights the importance of prioritising resources to address societal obligations toward the needs of the ageing generation. This review provides an overview of the challenges to adult vaccination in APAC, drivers to increase vaccination coverage, vaccination insights gained through the COVID-19 pandemic, and potential measures to increase the uptake of adult vaccines in the region.

Micafungin versus liposomal amphotericin B for candidaemia and invasive candidosis: a phase III randomised double-blind trial.

BACKGROUND: Invasive candidosis is increasingly prevalent in seriously ill patients. Our aim was to compare micafungin with liposomal amphotericin B for the treatment of adult patients with candidaemia or invasive candidosis. METHODS: We did a double-blind, randomised, multinational non-inferiority study to compare micafungin (100 mg/day) with liposomal amphotericin B (3 mg/kg per day) as first-line treatment of candidaemia and invasive candidosis. The primary endpoint was treatment success, defined as both a clinical and a mycological response at the end of treatment. Primary analyses were done on a per-protocol basis. This trial is registered with ClinicalTrials.gov, number NCT00106288. FINDINGS: 264 individuals were randomly assigned to treatment with micafungin; 267 were randomly assigned to receive liposomal amphotericin B. 202 individuals in the micafungin group and 190 in the liposomal amphotericin B group were included in the per-protocol analyses. Treatment success was observed for 181 (89.6%) patients treated with micafungin and 170 (89.5%) patients treated with liposomal amphotericin B. The difference in proportions, after stratification by neutropenic status at baseline, was 0.7% (95% CI -5.3 to 6.7). Efficacy was independent of the Candida spp and primary site of infection, as well as neutropenic status, APACHE II score, and whether a catheter was removed or replaced during the study. There were fewer treatment-related adverse events--including those that were serious or led to treatment discontinuation--with micafungin than there were with liposomal amphotericin B. INTERPRETATION: Micafungin was as effective as--and caused fewer adverse events than--liposomal amphotericin B as first-line treatment of candidaemia and invasive candidosis.