Extent of knowledge and attitudes on plagiarism among undergraduate medical students in South India - a multicentre, cross-sectional study to determine the need for incorporating research ethics in medical undergraduate curriculum.

BACKGROUND: Undergraduate medical students in India participate in various research activities However, plagiarism is rampant, and we hypothesize that it is the lack of knowledge on how to avoid plagiarism. This study's objective was to measure the extent of knowledge and attitudes towards plagiarism among undergraduate medical students in India. METHODS: It was a multicentre, cross-sectional study conducted over a two-year period (January 2018 - December 2019). Undergraduate medical students were given a pre-tested semi-structured questionnaire which contained: (a) Demographic details; (b) A quiz developed by Indiana University, USA to assess knowledge; and (c) Attitudes towards Plagiarism (ATP) questionnaire. RESULTS: Eleven medical colleges (n = 4 government medical colleges [GMCs] and n = 7 private medical colleges [PMCs]) participated. A total of N = 4183 students consented. The mean (SD) knowledge score was 4.54 (1.78) out of 10. The factors (adjusted odds ratio [aOR]; 95% Confidence interval [CI]; p value) that emerged as significant predictors of poor knowledge score were early years of medical education (0.110; 0.063, 0.156; < 0.001) and being enrolled in a GMC (0.348; 0.233, 0.463; < 0.001).The overall mean (SD) scores of the three attitude components namely permissive, critical and submissive norms were 37.56 (5.25), 20.35 (4.20) and 31.20 (4.28) respectively, corresponding to the moderate category. CONCLUSION: The overall knowledge score was poor. A vast majority of study participants fell in the moderate category of attitude score. These findings warrant the need for incorporating formal training in the medical education curriculum.

Prevalence of oral human papillomavirus infection among Indian HIV-positive men who have sex with men: a cross-sectional study.

BACKGROUND: Oral human papillomavirus (HPV) infection has been causally linked to a subset of oropharyngeal cancers in Western populations, and both oropharyngeal cancer and oral HPV infection are increased among HIV-positive individuals. India has high incidences of oral and oropharyngeal cancers, and Indian HIV-positive men who have sex with men (MSM) may be at increased risk of developing oropharyngeal cancers. However, there is little information available on the prevalence of oral HPV in this population. METHODS: We tested 302 HIV-positive Indian MSM for oral HPV infection using L1 HPV DNA PCR with probes specific for 29 types and a mixture of 10 additional types. CD4+ level and plasma HIV viral load (VL) were measured. Participants completed an interviewer-administered questionnaire including a sexual history. RESULTS: The prevalence of oral HPV was 23.7% (95% CI: 19-29%) and 2.4% of participants had oncogenic HPV types. No participants had oral HPV type 16 (HPV-16) and the prevalence of other anogenital HPV types was low. Participants with higher CD4+ levels had reduced odds of having any oral HPV infection (OR: 3.1 [1.4-6.9]) in multivariable analyses. CONCLUSIONS: This is the first report of oral HPV among Indian HIV-positive MSM. Our results show a high prevalence of oral HPV infection consistent with studies from Western populations. However, oncogenic anogenital HPV types were relatively uncommon in our study population. It is unknown what the impact of this distribution of oral HPV will be on oropharyngeal cancers. HIV-positive MSM in India should be monitored closely for oral and oropharyngeal pre-cancer and cancer.

Genital Human Papillomavirus Infection in Indian HIV-Seropositive Men Who Have Sex With Men.

BACKGROUND: The incidence of penile cancer in Indian men is high. Little is known about genital human papillomavirus (HPV) infection in Indian HIV-seropositive men who have sex with men (MSM), a population that may be at particularly high risk for genital HPV infection and, potentially, penile cancer. In this study, we assessed the prevalence and risk factors for genital HPV infection in this population. DESIGN AND METHODS: Three hundred HIV-seropositive MSM were recruited from 2 clinical sites in India. They were tested for genital HPV infection using L1 HPV DNA polymerase chain reaction with probes specific for 29 types and a mixture of 10 additional types. Participants received an interviewer-administered questionnaire that included questions on demographics and behaviors. RESULTS: Human papillomavirus data were available from 299 participants. The prevalence of any HPV type in the penis and scrotum was 55% and 54%, respectively. Human papillomavirus type 35 was the most common oncogenic HPV type followed by HPV-16. In multivariate analysis, being the insertive partner with 100+ male partners increased the odds of any penile HPV infection compared with not being insertive with any partners (odds ratio, 2.5; 95% confidence interval, 1.3-5.1). Circumcision was protective against penile HPV infection (odds ratio, 0.39; 95% confidence interval, 0.19-0.76). CONCLUSIONS: The prevalence of penile and scrotal HPV infection was high among Indian HIV-seropositive MSM. The most common oncogenic HPV type in this population, HPV-35, is not included in any currently available HPV vaccines. Insertive anal sex with men and lack of circumcision were the primary risk factors for penile HPV infection in this population.

Acute undifferentiated fever in India: a multicentre study of aetiology and diagnostic accuracy.

BACKGROUND: The objectives of this study were to determine the proportion of malaria, bacteraemia, scrub typhus, leptospirosis, chikungunya and dengue among hospitalized patients with acute undifferentiated fever in India, and to describe the performance of standard diagnostic methods. METHODS: During April 2011-November 2012, 1564 patients aged ≥5 years with febrile illness for 2-14 days were consecutively included in an observational study at seven community hospitals in six states in India. Malaria microscopy, blood culture, Dengue rapid NS1 antigen and IgM Combo test, Leptospira IgM ELISA, Scrub typhus IgM ELISA and Chikungunya IgM ELISA were routinely performed at the hospitals. Second line testing, Dengue IgM capture ELISA (MAC-ELISA), Scrub typhus immunofluorescence (IFA), Leptospira Microscopic Agglutination Test (MAT), malaria PCR and malaria immunochromatographic rapid diagnostic test (RDT) Parahit Total™ were performed at the coordinating centre. Convalescence samples were not available. Case definitions were as follows: Leptospirosis: Positive ELISA and positive MAT. Scrub typhus: Positive ELISA and positive IFA. Dengue: Positive RDT and/or positive MAC-ELISA. Chikungunya: Positive ELISA. Bacteraemia: Growth in blood culture excluding those defined as contaminants. Malaria: Positive genus-specific PCR. RESULTS: Malaria was diagnosed in 17% (268/1564) and among these 54% had P. falciparum. Dengue was diagnosed in 16% (244/1564). Bacteraemia was found in 8% (124/1564), and among these Salmonella typhi or S. paratyphi constituted 35%. Scrub typhus was diagnosed in 10%, leptospirosis in 7% and chikungunya in 6%. Fulfilling more than one case definition was common, most frequent in chikungunya where 26% (25/98) also had positive dengue test. CONCLUSIONS: Malaria and dengue were the most common causes of fever in this study. A high overlap between case definitions probably reflects high prevalence of prior infections, cross reactivity and subclinical infections, rather than high prevalence of coinfections. Low accuracy of routine diagnostic tests should be taken into consideration when approaching the patient with acute undifferentiated fever in India.

Looking back to move forward: a twenty-year audit of herpes zoster in Asia-Pacific.

BACKGROUND: Herpes zoster (HZ) is a prevalent viral disease that inflicts substantial morbidity and associated healthcare and socioeconomic burdens. Current treatments are not fully effective, especially among the most vulnerable patients. Although widely recommended, vaccination against HZ is not routine; barriers in Asia-Pacific include long-standing neglect of adult immunisation and sparse local data. To address knowledge gaps, raise awareness, and disseminate best practice, we reviewed recent data and guidelines on HZ from the Asia-Pacific region. METHODS: We searched PubMed, Scopus, and World Health Organization databases for articles about HZ published from 1994 to 2014 by authors from Australia, China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, New Zealand, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. We selected articles about epidemiology, burden, complications, comorbidities, management, prevention, and recommendations/guidelines. Internet searches retrieved additional HZ immunisation guidelines. RESULTS: From 4007 retrieved articles, we screened-out 1501 duplicates and excluded 1264 extraneous articles, leaving 1242 unique articles. We found guidelines on adult immunisation from Australia, India, Indonesia, Malaysia, New Zealand, the Philippines, South Korea, and Thailand. HZ epidemiology in Asia-Pacific is similar to elsewhere; incidence rises with age and peaks at around 70 years - lifetime risk is approximately one-third. Average incidence of 3-10/1000 person-years is rising at around 5% per year. The principal risk factors are immunosenescence and immunosuppression. HZ almost always causes pain, and post-herpetic neuralgia is its most common complication. Half or more of hospitalised HZ patients have post-herpetic neuralgia, secondary infections, or inflammatory sequelae that are occasionally fatal. These disease burdens severely diminish patients' quality of life and incur heavy healthcare utilisation. CONCLUSIONS: Several countries have abundant data on HZ, but others, especially in South-East Asia, very few. However, Asia-Pacific countries generally lack data on HZ vaccine safety, efficacy and cost-effectiveness. Physicians treating HZ and its complications in Asia-Pacific face familiar challenges but, with a vast aged population, Asia bears a unique and growing burden of disease. Given the strong rationale for prevention, most adult immunisation guidelines include HZ vaccine, yet it remains underused. We urge all stakeholders to give higher priority to adult immunisation in general and HZ in particular.

Antimicrobial stewardship programme (AMSP) practices in India.

A survey was conducted to ascertain practice of antimicrobial stewardship programme (AMSP) in India for 2013. A total of 20 health care institutions (HCI) responded to a detailed questionnaire. All the institutions contacted were tertiary care HCI, of which 12 were funded by government (GHCI) and 8 were corporate/private HCI (PHCI). Further, all catered to both rural and urban populations and were spread across the country. Written documents were available with 40 per cent for AMSP, 75 per cent for hospital infection control (HIC) and HIC guidelines and 65 per cent for antimicrobial agents (AMA) prescription guidelines. Records were maintained for health care associated infections (HCAI) by 60 per cent HCI. Antimicrobial resistance (AMR) data were being analysed by 80 per cent HCI. AMA usage data were analysed by only 25 per cent HCI and AMA prescription audit and feedback by 30 per cent. PHCI performed better than GHCI across all fields of AMSP. The main contributory factor was possibly the much higher level of accreditation of PHCI hospitals and their diagnostic laboratories. The absence of infectious diseases physicians and clinical pharmacists is worrying and demands careful attention.

Targets for intervention to improve virological outcomes for patients receiving free antiretroviral therapy in Tamil Nadu, India.

Operational research to identify factors predicting poor clinical outcomes is critical to maximize patient care and prolong first-line regimens for those receiving free antiretroviral therapy (ART) in India. We sought to identify social or clinical factors amenable to intervention that predict virological outcomes after 12 months of ART. We examined a retrospective cohort of consecutive adults initiating free nonnucleoside reverse transcriptase inhibitor-based regimens. Individuals remaining in care 12 months post-ART initiation were tested for HIV viral load and surveyed to identify barriers and facilitators to adherence, and to determine clinic travel times and associated costs. Uni- and multivariate logistic regression identified factors predicting HIV viral load >200 copies/mL after 12 months of ART. Of 230 adults initiating ART, 10% of patients died, 8% transferred out, 5% were lost to follow-up, and 174/230 (76%) completed 12 months of ART, the questionnaire, and viral load testing. HIV viral load was <200 copies/mL in 140/174 (80%) patients. In multivariate models, being busy with work or caring for others (OR 2.9, p < 0.01), having clinic transport times ≥ 3 hours (OR 3.0, p = 0.02), and alcohol use (OR 4.8, p = 0.03) predicted viral load >200 copies/mL after 12 months of ART. Clinical outcomes following ART are related to programmatic factors such as prolonged travel time and individual factors such as being busy with family or using alcohol. Simple interventions that alter these factors should be evaluated to improve clinical outcomes for populations receiving free ART in similar settings.

Pharmacy and self-report adherence measures to predict virological outcomes for patients on free antiretroviral therapy in Tamil Nadu, India.

Over 480,000 individuals receive free antiretroviral therapy (ART) in India yet data associating ART adherence with HIV viral load for populations exclusively receiving free ART are not available. Additionally estimates of adherence using pharmacy data on ART pick-up are not available for any population in India. After 12-months ART we found self-reported estimates of adherence were not associated with HIV viral load. Individuals with <100% adherence using pharmacy data predicted HIV viral load, and estimates combining pharmacy data and self-report were also predictive. Pharmacy adherence measures proved a feasible method to estimate adherence in India and appear more predictive of virological outcomes than self-report. Predictive adherence measures identified in this study warrant further investigation in populations receiving free ART in India to allow for identification of individuals at risk of virological failure and in need of adherence support.

Fever in the tropics: aetiology and case-fatality - a prospective observational study in a tertiary care hospital in South India.

BACKGROUND: The objective of this study was to describe aetiology and case fatality of fever among inpatients in a tertiary care hospital in South India. METHODS: This was an observational, prospective study conducted in a tertiary care hospital in Vellore, Tamil Nadu, India. Between July 2nd 2007 and August 2nd in 2007, adult patients admitted to the hospital with temperature ≥ 38.0°C were included consecutively and followed during the hospitalisation period. Demographic and clinical data were collected and analysed for each patient. Associations were sought between death and various clinical and demographic variables. RESULTS: One hundred patients were included, 61 male and 39 female. Mean age was 37.5 (range: 16 to 84) years. Mean fever duration was 5.4 (range: 0.1 to 42.9) weeks.The following infectious aetiologies were recorded: tuberculosis (19%), lower respiratory infection (11%) including three with sepsis, urinary tract infection (10%) including three with E. coli sepsis, Plasmodium falciparum malaria (5%) including three patients with mixed P. vivax infection, scrub typhus (5%), typhoid fever (4%), cryptococcal meningitis (4%) including three HIV positive patients, endocarditis (3%) including two patients with Staphylococcus aureus sepsis, spleen abscess (2%), amoebic liver abscess (2%), sepsis undefined focus (1%), HIV infection (1%), hepatitis B (1%), rubella (1%), peritonitis (1%) and cholecystitis (1%).Non-infectious causes of fever were diagnosed in 15%, including systemic lupus erythematosus in four and malignancy in six patients. Cause of fever remained unknown in 13%.Case fatality during hospitalisation was 7% (7/100). Six of those who died were male. Five fatalities had bacterial sepsis, one spleen abscess and malignancy, and one had lymphomalignant disorder.Diabetes and increasing age were significant risk factors for fatal outcome in unadjusted analyses, but only increasing age was a risk factor for death in adjusted analysis. CONCLUSIONS: A high number of tuberculosis and bacterial infections and a high case fatality rate from sepsis were found in this cohort, underlining the importance of microbiological diagnostics and targeted antimicrobial treatment in the management of fever. P. falciparum was identified in all malaria cases, and this rapidly fatal infection should be considered in patients with acute undifferentiated fever in India.

In vitro activity of cefiderocol against comparators (ceftazidime-avibactam, ceftazidime-avibactam/ aztreonam combination, and colistin) against clinical isolates of meropenem-resistant Klebsiella pneumoniae from India.

Cefiderocol (FDC), a novel siderophore drug, is active against Gram-negative bacteria producing carbapenemases, including metallo-beta-lactamases. The objective of this study is to compare the in vitro activity of FDC with ceftazidime-avibactam (CZA), CZA/aztreonam (AT) combination, and colistin (CST), in clinical isolates of meropenem-resistant (MER-R) Klebsiella pneumoniae. From the 2,052 clinical specimens submitted for culture testing, 245 K. pneumoniae isolates were recovered within a 6-month period in 2021. One hundred three non-duplicate, non-outbreak, MER-R (minimum inhibitory concentration, MIC >4 µg/mL) strains were included in the study. Identification and susceptibility were performed using VITEK-2 (bioMérieux). Meropenem-susceptible isolates (n = 10) served as controls. For FDC, broth microdilution (BMD) was performed after in-house standardization. Disk diffusion (Liofilchem, Italy) and broth microdilution (ComASP, STC, Liofilchem, Italy) were used for susceptibility testing of CZA and CST, respectively. Synergy testing for CZA and AT was performed using disk approximation method. CLSI breakpoints were used for the interpretation of the results. For FDC, MIC50 and MIC90 were 2 and 8 µg/mL, respectively. A total of 80% of isolates were susceptible to FDC, 26.2% of isolates were susceptible to CZA, synergy testing with CZA/AT was positive for 74 (72%) of the isolates, and 89.3% were intermediate to CST. Nine (8.7%) were susceptible only to FDC. FDC is active in vitro against MER-R K. pneumoniae >CZA/AT > CZA > CST, as observed in this study, applying CLSI criteria. Clinico-microbiological studies should be performed to assess the clinical efficacy of this novel drug in this region with a high prevalence of carbapenem resistance among Gram-negative organisms. IMPORTANCE Management of infections with multi-drug resistant Klebsiella pneumoniae is a major challenge in hospital settings, with few treatment options. In this study, the authors aim to assess the in vitro susceptibility of these clinical isolates to cefiderocol, a novel siderophore. Comparators are colistin, ceftazidime-avibactam, and ceftazidime-avibactam/aztreonam synergy, which are currently available options for treatment in this region. Baseline-resistance rates against cefiderocol are higher than those in the previously published studies, with MIC50 and MIC90 at 2 and 8 µg/mL, respectively.

Clinical features and risk factors for death in acute undifferentiated fever: A prospective observational study in rural community hospitals in six states of India.

BACKGROUND: Acute undifferentiated fever (AUF) ranges from self-limiting illness to life-threatening infections, such as sepsis, malaria, dengue, leptospirosis and rickettsioses. Similar clinical presentation challenges the clinical management. This study describes risk factors for death in patients hospitalized with AUF in India. METHODS: Patients aged ≥5 y admitted with fever for 2-14 d without localizing signs were included in a prospective observational study at seven hospitals in India during 2011-2012. Predictors identified by univariate analysis were analyzed by multivariate logistic regression for survival analysis. RESULTS: Mortality was 2.4% (37/1521) and 46.9% (15/32) died within 2 d. History of heart disease (p=0.013), steroid use (p=0.011), altered consciousness (p<0.0001), bleeding (p<0.0001), oliguria (p=0.020) and breathlessness (p=0.015) were predictors of death, as were reduced Glasgow coma score (p=0.005), low urinary output (p=0.004), abnormal breathing (p=0.006), abdominal tenderness (p=0.023), leucocytosis (p<0.0001) and thrombocytopenia (p=0.001) at admission. Etiology was identified in 48.6% (18/37) of fatal cases. CONCLUSIONS: Bleeding, cerebral dysfunction, respiratory failure and oliguria at admission, suggestive of severe organ failure secondary to systemic infection, were predictors of death. Almost half of the patients who died, died shortly after admission, which, together with organ failure, suggests that delay in hospitalization and, consequently, delayed treatment, contribute to death from AUF.

Phenotypic & molecular characterization of AmpC ß-lactamases among Escherichia coli, Klebsiella spp. & Enterobacter spp. from five Indian Medical Centers.

BACKGROUND & OBJECTIVES: AmpC ß-lactamases which are often plasmid mediated hydrolyze all ß-lactam antibiotics except cefepime and carbapenems. We evaluated the presence of AmpC ß-lactamases among Enterobacteriaceae strains recovered prospectively from patients at five Indian tertiary care centres. METHODS: The study included 909 consecutive Gram-negative isolates recovered from clinically significant specimens during June 2007 - May 2008 as part of an ICMR-ESBL study. Among the study isolates, 312 were found to be cefoxitin resistant by disc diffusion test (DDT). Minimum inhibitory concentration (MIC) determination by E test was done against amikacin, levofloxacin, impinem, meropenem, ertapenem, tigecycline and piperacillin-tazobactam. Combined DDT using phenyl boronic acid as inhibitor with cefoxitin was used for phenotypic confirmation of AmpC phenotype. The common Amp C genotypes ACC, FOX, MOX, DHA, CIT and EBC were detected by multiplex PCR. RESULTS: Plasmid mediated Amp C phenotype was confirmed in 114 of the 312 (36.5%) cefoxitin resistant isolates with 255 (81.7%) showing multidrug resistance. Susceptibility to tigecycline was highest (99%) followed by imipenem, meropenem (97%), ertapenem (89%), amikacin (85%), and piperacillin-tazobactam (74.6%). Levofloxacin resistance was 82 per cent. ESBL co carriage was observed among 92 per cent of Amp C producers. Among 114 Amp C producers, 48 could be assigned a genotype, this included CIT- FOX (n = 25), EBC (n = 10), FOX (n = 4), CIT (n = 3), EBC-ACC (n = 2) and one each of DHA, EBC-DHA, FOX -DHA and FOX-EBC-DHA. INTERPRETATION & CONCLUSIONS: Overall, AmpC phenotypes were found in 12.5 per cent isolates, multidrug resistance and ESBL co-carriage among them was high suggesting plasmid mediated spread. The study results have implications in rational antimicrobial therapy and continued surveillance of mechanisms of resistance among nosocomial pathogens.

Risk factors for mortality in a south Indian population on generic antiretroviral therapy.

BACKGROUND: Antiretroviral treatment (ART) programs from low-income countries utilizing standardized ART regimens, simplified approaches to clinical decision making and basic lab monitoring have reported high mortality rates. We determined the risk factors for mortality among HIV-infected adults following the initiation of ART from a single center in south India. METHODS: ART-naive HIV-infected south Indian adults attending the Infectious Diseases clinic in a 2000-bed academic medical center in south India who were initiated on ART (generic, fixed-dose combinations) as per the national guidelines were followed up. Cases (32 patients who died) were compared with age and sex matched controls. RESULTS: Eight-hundred and twenty-two patients were started on ART from January 1, 2000 to December 31, 2008. The cumulative mortality was 6.8% (56/822). Among the cases mean age was 44 years, 18% were women and mean CD4 counts was 107 cells/microl. Among the controls mean age was 41 years, 18% were women and mean CD4 counts were 113 cells/microl. Stavudine based ART was predominant 62.5% in the cases vs 37.5% in the controls, followed by zidovudine based therapy in 31.2% of cases and 43.7% in the controls. Tenofovir based therapy was used in 6.2% of cases vs 18.7% in the controls. The commonest causes of death were drug toxicity 19%, advanced Acquired Immunodeficiency Syndrome (AIDS) in 37%, Immune Reconstitution Inflammatory Syndrome (IRIS) in 16%, non AIDS related deaths in 22% and malignancies 6%. In a univariate analysis, absolute lymphocyte count <1200 cells/cmm (p=0.03), development of immune reconstitution inflammatory syndrome (IRIS) (p=0.000) and mean CD4 cell count increase <75 cells/microl after 1 year of ART (p=0.001) were significantly associated with mortality. CONCLUSIONS: The mortality among our patients was comparable to that reported from other low-income countries. Earlier initiation of ART may reduce the high mortality rates observed.

Antibiotic Susceptibility Testing (AST) Practices in India: Need for a National AST Forum.

Background Accurate interpretation of antibiotic susceptibility testing (AST) is one of the most crucial functions of the microbiology laboratory. However, its performance depends on a number of critical factors. We conducted a status survey to understand the existing practices in Indian laboratories that have a potential to influence performance of AST. Method We developed a 22-point online survey questionnaire on information about respondent's specifications, use of AST consumables, existing quality control protocols, and matters of contention in AST practices, and sent it by Google forms to 362 clinical microbiologists (holding MD or DNB certification). Participation was voluntary. Results were analyzed using descriptive statistics. Results Among 362, a total of 103 returned the questionnaire. The first 100 responses that were complete (all 22 questions answered) were analyzed. Respondents were from medical colleges (61%), private hospitals (26%), and stand-alone laboratories (13%). Analysis revealed that the Clinical & Laboratory Standards Institute (CLSI) guidelines were followed by all. Overall, 54% used disc diffusion as the primary method for performing AST. For the internal quality control testing of media and AST, 24% and 16% had adequate testing components and frequency, respectively. For performing AST of colistin, broth microdilution was used by 19%. Also, 86% participated in external quality control programs, and 54% respondents were dissatisfied or unsure about the development of competencies in AST methodology during their postgraduate training. Conclusion This survey reveals that potential gaps exist in the performance parameters and internal quality control of AST. There is an urgent need for harmonization in AST performance and postgraduate training in clinical microbiology in India.

Impact of an Antimicrobial Stewardship Intervention on Usage of Antibiotics in Coronavirus Disease-2019 at a Tertiary Care Teaching Hospital in India.

Background: There was evidence that antibiotic usage increased in hospitalized COVID-19 patients during the early days of the pandemic. Objective: We assessed the impact of stewardship interventions on antibiotic usage in these patients. Methods: We designed a quasi-experimental study using an interrupted time series. Patients were stratified according to the severity category of the illness - mild and moderate-to-severe (O2 saturation ≥94% and <93% respectively). Baseline antibiotic usage data was collected in the pre-intervention phase. Intervention was given in the form of focus group discussion (FGD) and followed up with feedback-audit during the post-intervention phase. Primary outcome was the change in days of therapy (DOT) per 1000 patient-days. Results: 361 adult patients were recruited in both phases during July to December, 2020. In the post-intervention phase, DOT per 1000 patient-days reduced from 589 to 523 (P=0.013) and from 843 to 585 (P <0.0001) in mild and moderate-to-severe categories, respectively. De-escalations at 48 hours increased significantly from 21% to 41% (P=0.0079) and from 31% to 62% (P=0.0006), respectively. No difference in mortality was observed. Conclusion: We found high usage of empirical antibiotics in adult patients hospitalized with COVID-19. FGD and feedback audits can successfully reduce antibiotic overuse in these patients.

Estimates of Sepsis Prevalence and Outcomes in Adult Patients in the ICU in India: A Cross-sectional Study.

BACKGROUND: Sepsis is a global health problem. Limited data exist on the prevalence of sepsis using current definitions in ICUs in India. RESEARCH QUESTION: In adult patients admitted to ICUs in India, what is the prevalence of sepsis using the previous (Second International Consensus Definitions for Sepsis and Septic Shock [Sepsis-2]) and current (Third International Consensus Definitions for Sepsis and Septic Shock [Sepsis-3]) definitions? STUDY DESIGN AND METHODS: Prospective, observational, multicentre, 1-day, cross-sectional study. The primary outcome was the sepsis prevalence using both the Sepsis-2 and Sepsis-3 definitions and their concordance (using Cohen's κ coefficient). Additional outcomes included reporting on current microbiological characteristics, antimicrobial use, multidrug-resistant infections, and 30-day discharge and mortality status in patients with sepsis. RESULTS: A total of 35 ICUs (85.7% private, 14.3% public) participated, enrolling 680 patients (median age, 60 years [interquartile range, 24 years]; 62.1% men). The most common primary diagnosis was renal disease, and common comorbidities were diabetes (44.0%) and chronic renal failure (11.6%). The sepsis prevalence on the study day was 382 of 677 patients (56.4%). Prevalence by Sepsis-3 and Sepsis-2 definitions was 33.2% and 46.2%, respectively, with minimal concordance (κ = 0.32). In patients with sepsis, the most common microorganisms were bacterial (77.9%) followed by fungal (14.1%) infections. Approximately 45% of infections were caused by multidrug-resistant organisms. Mortality at 30 days after the study day (27.6% vs 5.3%; P < .01) and rates of discharge against medical advice (12.8% vs 4.9%; P < .01) were significantly higher in the sepsis cohort compared with the cohort without sepsis, respectively. INTERPRETATION: This multicenter point prevalence study in Indian ICUs showed a high burden of sepsis using both Sepsis-2 and Sepsis-3 criteria, with associated high rates of antimicrobial resistance and mortality. These findings have implications for public health and future research.

Early dissemination of NDM-1- and OXA-181-producing Enterobacteriaceae in Indian hospitals: report from the SENTRY Antimicrobial Surveillance Program, 2006-2007.

Among 39 carbapenem-resistant Enterobacteriaceae (2.7% overall; Escherichia coli, Enterobacter cloacae, and Klebsiella pneumoniae strains) isolated in 2006 and 2007 in India, 15 strains carried bla(NDM-1) and 10 harbored a gene encoding a variant of the carbapenemase OXA-48, named bla(OXA-181). One E. cloacae strain harbored bla(VIM-6), and one K. pneumoniae strain carrying bla(OXA-181) also possessed bla(VIM-5). Multiple pulsed-field gel electrophoresis patterns and clonal dissemination within and among sites were observed. Isolates producing NDM-1 were disseminated in Indian health care facilities as early as 2006.

Risk Factors for Stroke in Rural Population of Telangana State of India, an Unmatched Case Control Study.

Context Stroke tops the list of causes for acquired disability among adults and is the second leading cause of death worldwide. Evidence from developed countries indicate significant decline in stroke incidence and mortality, attributable to prevention of risk factors in general population. There is limited evidence on risk factors for stroke in rural India. Aims This study aims to ascertain the risk factors for stroke in rural Telangana and provide a guide to health care providers in adopting treatment and prevention strategies. Settings and Design The study was conducted in the Moinabad mandal of Ranga Reddy District, Telangana state of India. This is a population based unmatched case-control study. Methods and Materials All the houses of Moinabad were approached by a door-to-door survey to identify cases. A total of 288 persons were enrolled in the study which included 144 cases and 144 controls. Statistical Analysis To derive age and gender adjusted odds ratios of various risk factors, binary logistic regression analysis was performed. Results The estimated crude prevalence of stroke in Moinabad mandal is 257 per lakh population. Modifiable risk factors identified were, total cholesterol, systolic blood pressure, alcohol consumption, smoking, diastolic blood pressure, low high-density lipoprotein cholesterol, and central obesity as measured by waist circumference. Nonmodifiable risk factors identified were male gender and higher age group. Conclusion The high prevalence of stroke in rural Telangana makes it an important public health challenge for the state. The identified risk factors need to be addressed at population level.

High rates of regimen change due to drug toxicity among a cohort of South Indian adults with HIV infection initiated on generic, first-line antiretroviral treatment.

OBJECTIVES: To determine the rates, reasons and predictors of treatment change of the initial antiretroviral treatment (ART) regimen in HIV-infected south Indian adults. METHODS: In this prospective cohort study, ART-naive adults initiated on generic, fixed dose combination ART as per the National AIDS Control Organization guidelines were followed up at an academic medical center. Treatment change was defined as any event which necessitated a change in or discontinuation of the initial ART regimen. RESULTS: Two hundred and thirty persons with HIV infection (males 74.8% and median age 37 years) were followed up for median duration of 48 weeks. The majority (98.7%) had acquired HIV infection through the heterosexual route. Most (70.4%) had advanced IV infection (WHO clinical stage 3 or 4) and 78% had CD4+ T-lymphocyte counts below 200 cells/microL. The initial ART regimens used were: Lamivudine (3TC) with Stavudine (d4T) (in 76%) or Azidothymidine (AZT) and Nevirapine (NVP) (in 86%) or Efavirenz (EFV). The cumulative incidence of treatment change was 39.6% (91 patients). Drug toxicity (WHO grade 3 or 4) was the reason for treatment change among 62 (27%) (incidence rate 35.9/100 person-years). The most common toxicities were attributable to the thymidine analogue nucleoside reverse transcriptase inhibitors (NRTIs), d4T and AZT [lactic acidosis (8.7%), anemia (7%) and peripheral neuropathy (5.2%)]. The other toxicities were rash (3.9%) and hepatitis (1.3%) due to NVP. The mortality (4.6/100 person-years) and disease progression rates (4.1/100 person-years) were low. CONCLUSIONS: The ART regimens used in this study were effective in decreasing disease progression and death. However, they were associated with high rates of drug toxicities, particularly those attributable to thymidine analogue NRTI. As efforts are made to improve access to ART, treatment regimens chosen should not only be potent, but also safe.

Prospective 1-year follow-up study of all cured, new sputum smear positive tuberculosis patients under the Revised National Tuberculosis Control Program in Hyderabad, Telangana State, India.

BACKGROUND: Tuberculosis (TB) is one of the leading causes of mortality in India. The Revised National Tuberculosis Control Program (RNTCP) is a robust public health system to deal with TB in India. Unless the treated patient comes back to the system with signs and symptoms of TB due to relapse or re-infection, there is no mechanism of follow-up or any method to know the relapse rate in the population. We attempted to follow the patients declared as "Cured" as per the RNTCP guidelines for 1-2 years to identify the health status of the index cases and their household contacts in posttreatment phase. MATERIALS AND METHODS: In this prospective cohort study, 187 index cases, who were declared "Cured" in six randomly selected TB units of Hyderabad district, were followed up for 1-2 years through home visits by trained staff with structured data collection forms. Data were analyzed using SPSS v20.0. RESULTS: The mean age of the index cases was 33.64 (±16.10) years, and there were 75 females and 112 males. The study sample was homogenous for gender, age, smear grade, religion, marital status, smoking status, alcohol consumption, and human immunodeficiency virus status, etc., At 1-year posttreatment follow-up of 187 index cases, 143 (76.47%) were healthy and working without any symptoms of TB. Symptoms of TB were present in 26 (13.90%) cases, and seven index cases (4.06%) were re-diagnosed with TB. The 2-year posttreatment survival was 92%. CONCLUSION: Long-term follow-up of cured, new smear-positive TB cases reinforce the effectiveness of anti-TB treatment under the RNTCP as assessed by improved health outcomes in more than two-thirds of cases and posttreatment survival of 92% of index cases. We recommend continuing such follow-up for all TB cases treated under the RNTCP for effective end-TB strategy.