Trends in antibiotic susceptibility of enteric fever isolates from South India, 2002-2013.

BACKGROUND: Enteric fever is endemic in India. Trends in antibiotic resistance in Salmonella enterica subspecies enterica serovars Typhi and Paratyphi A isolates over the past 12 years were studied. METHODS: A retrospective analysis of consecutive blood culture isolates of Salmonella Typhi and Salmonella Paratyphi A was performed from 2002 to 2013. Antibiotic susceptibility testing was carried out for ampicillin, chloramphenicol, cotrimoxazole, nalidixic acid (NA), ciprofloxacin and ceftriaxone by disc diffusion. The minimum inhibitory concentration of ciprofloxacin and azithromycin was determined using E-test strips. Mantel-Haenszel extended chi-square test was used for analysis of trends across years. RESULTS: Three thousand two hundred ninety-six Salmonella spp. were isolated; of which, 1905 were identified as Salmonella Typhi (58%) and 1393 as Salmonella Paratyphi A (42%). Multidrug resistance (chloramphenicol, ampicillin and cotrimoxazole) was relatively stable throughout the study period. NA resistance increased from 18% in 2007 to 100% in 2013 among Salmonella Paratyphi A isolates and from 67% to 82% among Salmonella Typhi isolates. Complete susceptibility to ceftriaxone and azithromycin was observed in this study. CONCLUSIONS: Knowledge of the local patterns of resistance would help in appropriate therapy for enteric fever. With increasing rates of fluoroquinolone resistance in our hospital setting, it is probably prudent to revert back to the first-line agents for treatment and save azithromycin and third-generation cephalosporins for difficult and non-responsive cases.

Molecular Characterization of Extended Spectrum ß-lactamase and Carbapenemase Producing Klebsiella pneumoniae from a Tertiary Care Hospital.

OBJECTIVE: The extended-spectrum beta-lactamase (ESBL) and carbapenemase producing gram-negative bacteria among the members of Enterobacteriaceae are of major health concern globally. The present study was carried out to determine proportion and genetic characterization of ESBL and carbapenemase producing Klebsiella pneumoniae strains isolated from intensive care units of a tertiary care hospital. MATERIALS AND METHODS: A total of 250 non-duplicate K. pneumoniae isolates were recovered from various clinical specimens from our intensive care units from May 2014 to May 2015. Antibiotic susceptibility testing was performed as recommended by Clinical and Laboratory Standard Institute. Phenotypic identification of ESBL and carbapenemase producing isolates were confirmed by the double-disk synergy test, modified Hodge test, imipenem and imipenem-EDTA combined test, respectively. Molecular characterization of ß-lactamase genes were performed by polymerase chain reaction. RESULTS: Out of 250 Klebsiella pneumonaie, 84% isolates were ESBL producers, 66% were carbapenem resistant based on their reduced susceptibility to imipenem, meropenem and ertapenem. Among these 165 carbapenem resistant isolates, 9.7% were positive for bla NDM-1 and these isolates were also found to be positive for one or more bla genes. Co-carriage of AmpC in ESBL and carbapenem resistant isolates were 7.8% and 3.6%, respectively and were negative for bla KPC genes. CONCLUSION: The study indicated the prevalence of ESBLs and bla NDM-1, with additional bla genes and AmpC among the K. pneumoniae isolates in our intensive care units. NDM-1 producing Enterobacteriaceae is a growing health care problem. Detection of the prevalence of antibacterial resistance pattern helps towards improved antibiotic policy and empirical antibiotic treatment. HOW TO CITE THIS ARTICLE: Beena HB, Shenoy SM, et al. Molecular Characterization of Extended Spectrum ß-lactamase and Carbapenemase Producing Klebsiella pneumoniae from a Tertiary Care Hospital. Indian J of Crit Care Med 2019;23(2):61-66.

Proinflammatory chemokines are major mediators of exuberant immune response associated with Influenza A (H1N1) pdm09 virus infection.

In India, the case fatality ratio of the pandemic A (H1N1) pdm09 influenza was relatively higher when compared to seasonal Influenza A infection. Hypercytokinemia or "cytokine storm" has been previously implicated in the pathogenesis of other influenza viruses. The present study was undertaken to compare the cytokine profiles of A (H1N1) pdm09 influenza and seasonal H3 infection in Indian population and to correlate the findings with disease severity. Plasma levels of 18 cytokines/chemokines were measured by flow-cytometry using a bead based assay in patients infected with A (H1N1) pdm09 virus (n = 96) and Influenza A seasonal H3 virus (n = 30) categorised into mild, moderate, and severe groups along with healthy controls (n = 36). There was an overall trend indicating an exuberant cytokine/chemokine response in A (H1N1) pdm09 as compared to seasonal H3 influenza, which was more evident in severe cases, suggesting a role for these cytokines/chemokines in the pathogenesis of A(H1N1) pdm09. Increased levels of CXCL-8/IL-8, IL-10, IL-6, and IL-17A were seen in both A(H1N1) pdm09 influenza and seasonal H3 cases when compared to healthy controls. However, dysregulated production of proinflammatory chemokines was seen more pronounced in A (H1N1) pdm09 influenza cases as compared to seasonal H3 cases. This study has brought forth the potential role of chemokines as prognostic indicators of disease severity and outcome. Further research on modulating the host immune response to limit severity of the disease could help in the treatment and management of influenza.

Spontaneous bacterial peritonitis caused by S. paratyphi A.

Spontaneous (primary) bacterial peritonitis (SBP) due to S. paratyphi A is relatively uncommon. Clinical manifestations of SBP vary widely from severe to slight or absent, necessitating laboratory investigation of ascitic fluid. The disease is confirmed by number of neutrophils > 250/mm3 associated with or without bacterial growth in ascitic fluid culture from diagnostic abdominal paracentesis. Here, we present a case of S. paratyphi A SBP occurring in a patient with chronic liver disease and portal hypertension.The patient was treated with intravenous cefotaxime with good clinical response.

Salmonella typhimurium meningitis in infancy.

We report a case of meningitis due to Salmonella typhimurium in a four-month-old female infant. The child was brought to the pediatric emergency department with complaints of fever, cold, and generalized convulsion. On examination, the child was febrile and was having seizures. The anterior fontanelle was not bulging. Lumbar puncture was done and Salmonella typhimurium was isolated from cerebrospinal fluid. Initially the infant improved clinically with appropriate management, but had a fatal outcome due to nosocomial pneumonia.

Two Case Reports of Ochrobactrum anthropi Bacteremia: An Overlooked Pathogen.

Ochrobactrum anthropi , due to its robust survival abilities, has been known to cause nosocomial and opportunistic infections, posing both diagnostic and therapeutic challenges. Low virulence, indolent clinical presentation, and lack of awareness on their clinical significance attribute to the underreporting of the same. We report two cases of bacteremia in oncology patients presented to us in a short span of 6 months, which indicates that such infections might be quite common in immunocompromised hosts. Both our strains were susceptible to carbapenems, trimethoprim/sulfamethoxazole, and minocycline, and recovered with monotherapy. More vigilant and accurate diagnostic techniques need to be followed not to miss such pathogens. Early identification and administration of appropriate antibiotics have been associated with a good outcome.

Case Report of Pediatric Osteomyelitis: A Double Whammy of Unusual Etiology and Antibiotic Susceptibility.

Introduction: Osteomyelitis is one of the infrequent presentations of Salmonella infection. Most of the case reports are among adult patients. It is very rare in children, and is most often associated with hemoglobinopathies or other predisposing clinical conditions. Case Report: In this article, we present a case of osteomyelitis caused by Salmonella enterica serovar Kentucky, in a previously healthy 8-year-old child. Further, this isolate had an unusual susceptibility pattern; it showed resistance to the third-generation cephalosporins, akin to ESBL production among Enterobacterales. Conclusion: Osteomyelitis caused by Salmonella does not have any specific clinical or radiological features, both in adult and pediatric age groups. A high index of suspicion, using appropriate testing methodologies and awareness about emerging drug resistance helps in accurate clinical management.

Hospital acquired infection is inversely related to utilization of isopropyl alcohol and tissue paper pulls--a prospective observational study.

INTRODUCTION: Healthcare associated infections not only cause morbidity and mortality, but also drain the resources in the hospitals across the globe. It has been shown repeatedly that practicing hand hygiene is a deterrent to hospital acquired infection. It is essential for the infection control committee and the hospital administrators to have a fair idea of the prevailing hand hygiene practice in the healthcare facility. This is commonly obtained direct observation, self-reporting by healthcare workers and indirect calculation based on hand hygiene disinfectant product usage. AIMS: This study was planned to assess the indirect surrogates of hand hygiene among healthcare workers in an Indian hospital. METHODS: We presumed that the tools used to perform hand hygiene, the alcoholic hand rub and the tissue paper towel may throw light on the prevailing hand hygiene practice. An analysis of the quantity of alcohol hand rub and the number of tissue paper towel usage against the incidence of hospital acquired infection was made. OBSERVATION: The mean incidence of HAI during the period of study was 8.5 +/- 6.7 (range 2 to 27) per month. There was a decrease in the HAI rates with increasing of alcoholic hand rub and tissue paper towels. It was predicted using the regression graphs that if the quantity of alcoholic hand rub usage increased to 2620 Ltrs/ month, the HAI would be '0'. Similarly if 427,0000 tissue paper towel pulls were used, the HAI would be '0'. CONCLUSION: Studying the incidence consumption of the quantity of tissue paper rolls and isopropyl alcohol may be used as a surrogate of hand hygiene practice among healthcare workers.

Cross-country transport and isolation and identification of Streptococcus pneumoniae by use of alternate sources of blood supplemented media among laboratories in India.

Background: The isolation of S. pneumoniae (Sp) depends on specimen integrity / transport, media and expertise. The non-availability of sheep blood agar poses a challenge in identification of colonial morphology and identification in India. Methods: Laboratories processed swabs containing either pure Sp or Sp in mixed cultures with a second (confounding) bacterium shipped across the country in cold conditions. Duplicate set of swabs was shipped back to the central laboratory to assess the impact of shipping on culture viability. The identical swab was cultured on sheep, human blood and one additional agar plate used in the laboratory. Results: 46/60(77%) of cultures containing only Sp were correctly identified. In specimens where Sp was present in mixed culture, the proportion of isolates in which Sp was correctly identified varied, with most variability attributed to the particular confounding organism rather than the media. There was no discernible impact of temperature-controlled (4-6°C) transport on the isolation of Sp from culture swabs. Conclusions: The study clearly elucidates the ability of laboratories for isolation of S. pneumoniae on human blood agar in resource limited settings. The results highlight the difficulties inherent in correctly identifying pathogens in mixed cultures in needs improvement using standardized tests across the study centers. The study also reaffirms the ability to transport biological specimens over long geographical distances without loss.

Cytoplasmic-anti-neutrophil cytoplasmic antibodies targeting myeloperoxidase in Wegener's granulomatosis: a rare phenomenon.

Wegener's granulomatosis (WG) patients can rarely have antineutrophil cytoplasmic antibodies (ANCAs) directed against myeloperoxidase (MPO), producing a cytoplasmic pattern on indirect immunofluorescence (IIF). This has important implications in the diagnosis and pathophysiology of the disease. We present to you a report of three cases of WG, demonstrating a cytoplasmic-ANCA pattern on indirect IIF, but directed against MPO. It is necessary to diagnose a patient taking into account both the autoimmune test results and the clinical features.