Prevalence of non-cancer chronic morbidity in tobacco users among adults in Kolar district: community-based study

Background: Tobacco contains many chemicals which causes cancer and chronic morbidities as evidenced from number of studies. Information regarding the chronic morbidities resulting from tobacco use was lacking in Indian setting. This study was conducted with the objective to find the prevalence of chronic morbidities other than cancer and oral conditions in tobacco users among adults in Kolar district.Methods: This is a community based, cross sectional study conducted in Kolar district among selected sample size of 1534 from six taluks during December 2018 to March 2019. The structured questionnaire was used to collect information at different geographical and social meeting places to represent the sample. The questionnaire contained information about sociodemographic, tobacco use and self-declared morbidity conditions.Results: Study subjects were aged between 18 to 80 years and the mean age was 53.7±18.2 years. The prevalence of chronic morbidity was 14.4% in 1534 subjects and 24.2% in 521 tobacco users. Diabetes mellitus and cardiovascular diseases accounted for 80 percent of morbidities followed by respiratory and other systems. The odd ratio (OR) was 3.4 for tobacco users and chronic morbidities, OR for diabetes mellitus and cardiovascular diseases was 5-19 and 5-22 respectively.Conclusions: The prevalence of diabetes mellitus, cardiovascular diseases and other conditions are high among any form of tobacco use or consumption, illiterates, aged above 51 years and agriculture related workers compared to no tobacco users. There is a need of awareness about early detection of chronic morbidities to reduce the premature deaths and economic loss to the community.

Prevalence, outcome and risk factor associated with vancomycin-resistant Enterococcus faecalis and Enterococcus faecium at a Tertiary Care Hospital in Northern India.

Purpose: To determine the prevalence, genotype, risk factors and mortality in patients having vancomycin-resistant Enterococcus faecalis (VR E. faecalis) and Enterococcus faecium (VR E. faecium) infection or colonisation. Materials and Methods: A total of 1488 clinical isolates of E. faecalis and E. faecium were tested for vancomycin resistance by phenotypic (disk diffusion, E-test and broth micro-dilution test) and genotypic polymerase chain reaction methods. Records of all 1488 patients who had E. faecalis or E. faecium infection or colonisation were reviewed for the identification of host, hospital and medication related risk factors associated with VR E. faecalis and VR E. faecium. Results: Of 1488 isolates, 118 (7.9%) were vancomycin-resistant and their distributions were as follows: E. faecalis =72 (61%) and E. faecium =46 (39%). All 118 vancomycin-resistant isolates were vanA genotype (minimum inhibitory concentration [MIC] to vancomycin ≥64 μg/ml and MIC to teicoplanin ≥32 μg/ml) and none of the isolates was vanB genotype. Multivariate logistic regression analysis identified ventilator support and hospital stay for ≥48 h as independent risk factors associated with VR E. faecalis and VR E. faecium infection or colonisation. Hospital stay ≥48 h was the only independent risk factor for mortality in patients infected with vancomycin-resistant enterococci. Conclusions: Strategies to limit the nosocomial infection especially in patients on ventilator support can reduce VRE incidence and related mortality.

Intestinal microsporidiosis in renal transplant recipients: Prevalence, predictors of occurrence and genetic characterization.

Purpose: Intestinal microsporidiosis, which occurs in immunocompromised states such as acquired immunodeficiency syndrome, has rarely been studied in patients with renal transplantation (RT) on immunosuppressive therapy. Materials and Methods: Three hundred and twenty‑four consecutive RT recipients on immunosuppressive treatment and 170 healthy subjects were evaluated for intestinal microsporidiosis and other parasites by modified trichrome staining, wet mount using normal saline, iodine and polymerase chain reaction (PCR). Clinical, demographic and laboratory parameters associated with occurrence of intestinal microsporidiosis were studied using univariate and multivariate analysis. The species of microsporidia were studied using PCR‑restriction fragment length polymorphism (RFLP). Patients were treated with albendazole (400 mg twice daily for 2 weeks). Results: Of 324 RT recipients initially screened, 52 were excluded from final analysis due to incomplete data. Patients with RT [n = 272, age 42 ± 12.54 years, 222 (81.6%) male] more often had microsporidiosis than healthy subjects by modified trichrome stain and PCR [n = 170, age 33.8 ± 6.7 years, 123 (72.3%) male] [16/272 (5.8%) vs. 0/170 (0%), P < 0.001]. Patients with intestinal microsporidiosis were younger (33.9 ± 8.3 years vs. 42.3 ± 12.6 years; P = 0.009), had diarrhoea more often (13/16, 81% vs. 123/256, 48%; P = 0.02), which was longer in duration (60, 32.5-105 days vs. 12, 6.2-18 days; P < 0.001) and had associated giardiasis (2/16, 12.5% vs. 2/256, 0.8%; P = 0.018). Younger age, presence of diarrhoea and associated giardiasis were significant on multivariate analysis. Enterocytozoon bieneusi was detected in 15/16 (93%) patients with intestinal microsporidiosis. Conclusion: Intestinal microsporidiosis occurs frequently in patients with RT on immunosuppressive treatment, particularly among younger patients with longer diarrhoea duration and associated giardiasis. E. bieneusi is the major species identified among these patients.

Cross sectional study on nutritional status among elderly people in the rural community of Pondicherry.

Introduction: Food intake is diminished among old age people due to ill health, disability, co-morbid condition. Hence the quality of life of elderly affects nutrition & protein deficiency contributes to high percentage of DALY. Objectives: To know the calorie deficiency and nutritional status among elderly people Material and methods: This was a cross sectional and community based study done on 300 elderly people among 17079 in rural village of Puducherry during march and April 2015. Data were collected by two methods (questionnaire,basic anthropometry measurement) at their residence. Data was analysed for calorie deficiency and body mass index. Results: There were equal number of men and women. Sixty percent of the subjects were aged between 60-70 years and 7% were aged more than 80 years. Caloric deficit was more in males than females and 35% of them were either overweight or obese according to body mass index. Conclusion: There were no serious micro nutrient deficiency individuals but more than 35% are already obese/ overweight and 50% are suffering from age related problems. The rehabilitation service of old age group is strongly recommended in order to give quality of life.

Study on perception of food items as hot or cold in the rural area of Pondicherry.

Introduction: It has been observed in our society that the theory of hot and cold is believed in and practiced by almost all section of the society. It is necessaary to know the prevalence of such belief in the community from time to time. Objectives: To know the prevalence of perception of hot or cold food items and their impact on t health status of the community. Material and methods: It was a cross sectional study done between the time period of March and April 2015 among 317 families and their members at t their doorsteps. Pretested questionnaire was filled with the information given by the subjects after their verbal consent. Descriptive questions regarding the family’s perception of hot and cold foods were asked in the categories of cereals, pulses, oils, vegetables, dairy products, non-vegiterian, fruits, beverage, spice and water. Results: Sixty six percent of the families told Brinjal, 84% told chicken and 34.6% told curd are hot foods and produces Gastrointestinal tract (74%) and Genitourinary tract (73%) illnesses. Similarly 15.6% of the families told carrot, 26.33% told grapes, 20% told fish and 58.6% told buttermilk are cold foods leading to development of respiratory tract illnesses. Only one percent of the families did not have any idea about hot or cold food items. Conclusion: The prevalence of misconception of hot or cold foods exist among families and misunderstanding about the nutritive value of food items which are likely to cause deficiency in vitamins, minerals in their family diet.

Utilization of health facilities at primary health centre by rural community of Pondicherry.

Background: The utilization of services at Primary Health Centre (PHC) by the community differs from place to place and changes over the time based on the availability of quality of services. It is also necessary to evaluate the utilization trend of primary health centre services by the community. Objective: to know the pattern of utilization by rural community on availability, utilization and perception of facilities at primary health center. Material and methods: A cross sectional, descriptive, community based study was done during September to November 2014 in selected sample from PHC area by interviewing 300 families on various aspects at their doorstep. The date collected from each family on the aspects such as awareness, availability, utilization and perception of facilities at primary health center. Results: More than 80% were aware about the PHC, its location and more than 75% on availability of free medicines and laboratory investigations. Many preferred to visit PHC for their ailments and waiting time for treatment was less than 30 minutes and 70% of families visited the PHC at least once since last 3 months for some kind of health problems. The common ailments were respiratory problems, fever episodes and accidental injuries. Nearly 50% were aware about the contents in the display of posters on various health education topics. Conclusion: Periodic assessment of pattern of utilization of PHC is important to improve the service utilization by the community through their involvement.

Incidence of blaNDM-1 gene in Escherichia coli isolates at a tertiary care referral hospital in Northeast India.

Purpose: Increasing reports on New Delhi metallo-β-lactamase-1 (NDM-1) producing Escherichia coli constitute a serious threat to global health since it is found to be highly resistant to most of the currently available antibiotics including carbapenems. This study has been performed to find out the incidence blaNDM-1 in E. coli isolates recovered from the various clinical samples at a tertiary care referral hospital in Northeast India. Materials and Methods: A total of 270 non-duplicated E. coli isolates were recovered from the various clinical samples at a tertiary care referral hospital in Northeast India. All isolates with reduced susceptibility to meropenem or ertapenem (diameter of zones of inhibition, ≤21 mm) were further phenotypically confirmed for carbapenemase production by modified Hodge test. All screened isolates were also subjected to the polymerase chain reaction detection of blaNDM-1 gene and additional bla genes coding for transmission electron microscopy, SHV, CTX-M, and AmpC. Results: Out of 270 E. coli isolates, 14 were screened for carbapenemase production on the basis of their reduced susceptibility to meropenem or ertapenem. All screened isolates were found to be positive for blaNDM-1 . Each of the blaNDM-1 possessing isolate was also positive for two or more additional bla genes, such as blaTEM , blaCTX-M and blaAmpC . Phylogenetic analysis showed very less variation in blaNDM-1 gene with respect to blaNDM-1 possessing E. coli isolates from other parts of India and abroad. Conclusions: Our findings highlight the incidence of blaNDM-1 in E. coli isolates with a reduced susceptibility to meropenem or ertapenem.

A new approach of real time polymerase chain reaction in detection of vancomycin-resistant enterococci and its comparison with other methods.

Background: Vancomycin-resistant enterococci (VRE) are third leading cause of nosocomial infection. Therefore, an effective, accurate and early detection of VRE along with their minimum inhibitory concentrations (MICs) is required to initiate appropriate therapy and thus better patient outcome. Objective: To detect VRE by real time quantitative polymerase chain reaction (Q-PCR) and to compare the results with chrom ID (C-ID) VRE and PCR. Further the study also determined the fold change of vanA gene by Q-PCR in different groups of VRE isolates classified on the basis of glycopeptides MIC range. Subjects and Methods: A total of 145 (80 VRE and 65 vancomycin-susceptible enterococci) clinical isolates were included in the study. After the screening of VRE isolates MICs were determined by E-test and agar dilution method. Further VRE was confirmed by vanA and vanB specific PCR and Q-PCR. Results: The sensitivity and specificity of C-ID VRE was 100% and 95.38%. However, sensitivity and specificity of conventional and Q-PCR were found to be 100%. Conventional and Q-PCR confirmed that our all isolates were vanA type. Mean R value was significantly higher ( P < 0.001) in group I (MIC > 1024 μg/ml) when compared to group II (MIC 512-1024 μg/ml) and group III (MIC < 512 μg/ml) isolates. The mean R was also significantly higher in group II when compared to group III isolates ( P = 0.038). Conclusion: Q-PCR is a rapid technique to detect vanA in enterococci along with their MIC range, thus it might be helpful to decide the treatment modalities of infections caused by VRE.

Rationale of azithromycin prescribing practices for enteric fever in India.

Purpose: The present study was performed to assess the current susceptibility pattern of blood isolates of Salmonella spp from a super specialty hospital in North India against nalidixic acid, ciprofloxacin and azithromycin and compare the in vitro and in vivo response against azithromycin. Materials and Methods: We evaluated the minimum inhibitory concentration's (MIC's) of 107 blood isolates of Salmonella spp against nalidixic acid, azithromycin and ciprofloxacin and correlated in vitro and in vivo response of azithromycin from the treatment and discharge summaries from the Hospital Information System (HIS) software. Results: Among the 107 isolates evaluated, 94 (87.8%) were nalidixic acid-resistant (NAR) Salmonella and 36 were resistant to azithromycin by MIC testing. The MIC 90 value for azithromycin was 24 μg/mL. Among the 57 treatment histories evaluated using the HIS software, 19 (33%) patients had documented clinical non-response to azithromycin which required change of therapy. Conclusions: The present study observed a higher MIC 90 values for azithromycin compared to Salmonella isolates from Western studies. There was also a documented clinical non-response against azithromycin. The in vitro and in vivo findings in this study suggest a guarded use of azithromycin for cases of enteric fever in India. The study also augments the reversal of resistance pattern in favour of chloramphenicol, ampicillin and trimethoprim - sulfamethoxazole.

Epstein-Barr virus DNA load and its association with Helicobacter pylori infection in gastroduodenal diseases

Helicobacter pylori and Epstein-Barr virus (EBV) infections are common worldwide. Although H. pylori infection is a major factor in gastroduodenal diseases, its role in association with EBV infection is unknown. Objective: To study the association of H. pylori infection and EBV DNA load in patients with gastroduodenal diseases. Methods: Biopsy samples were collected from 200 adult patients [non-ulcer dyspepsia (NUD) 100, peptic ulcer disease (PUD) 50, gastric carcinoma (GC) 50] undergoing upper gastrointestinal endoscopy. H. pylori infection was diagnosed by rapid urease test, culture, histopathology, PCR and Q-PCR. EBV DNA was detected by non-polymorphic Epstein-Barr nuclear antigen-1 (EBNA-1) gene based Q-PCR. Results: In patients with GC and PUD, EBV DNA was detected more often than NUD (GC versus NUD = 90 percent versus 37 percent, p < 0.001; PUD versus NUD = 70 percent versus 37 percent, p < 0.001). The dual prevalence of H. pylori infection and EBV DNA was significantly higher in patients with GC and PUD than in those with NUD. Median copy number of EBV DNA was considerably higher in GC and PUD than NUD (p < 0.01). The copy number of EBV DNA was significantly higher in H. pylori infected patients (p = 0.015). The number of ureA gene copies was also found to be significantly higher in PUD and NUD with presence of EBV DNA. However, in GC no significant difference was seen between EBV positive and negative status. Conclusion: There was a trend for higher EBV DNA load in H. pylori positive individuals suggesting a probable role of H. pylori in modulating the conversion of EBV to its lytic phase.

Virulence attributes of Helicobacter pylori isolates & their association with gastroduodenal disease.

Background & objectives Certain genotype(s) of Helicobacter pylori strains may play important role in the development of gastric cancer (GC) and peptic ulcer disease (PUD). This study was undertaken to investigate the association of cagA, cagA3/ region subtypes, babA2 and vacA genotypes of H. pylori with GC, PUD and non-ulcer dyspepsia (NUD) as there are no such studies from India. Methods A total of 348 consecutive adult patients (NUD 241, PUD 45, GC 62) undergoing upper gastrointestinal endoscopy between September 2002 and May 2007 in a tertiary referral centre at Lucknow, north India, were enrolled. H. pylori infection was diagnosed by rapid urease test, culture, histopathology and PCR. Genotyping for cagA, cagA3/ subtypes, babA2 and vacA was performed by PCR using sequence specific primers. Results H. pylori infection was higher in patients with PUD than with GC (80 vs. 56.5%, P < 0.01) and NUD (80 vs. 55.2%, P= 0.002). cagA positive H. pylori isolates were detected in 80 per cent in GC, 83.3 per cent in PUD and 76.7 per cent in NUD with no significant difference among them. Only A subtype of cagA3/ was detected and its distribution in GC, PUD and NUD was 68.8, 69.4 and 52.6 per cent respectively. Presence of babA2 genotype was 31.4 per cent and it had significant association with PUD when compared with NUD (52.8 vs. 26.3%, P<0.003). On univariate regression analysis, s1a allele was associated with GC (P<0.050) and s1a/m2 vacA genotype with both GC (P=0.014) and PUD (P=0.016). Interpretation & conclusions H. pylori infection was strongly associated with PUD with a very high proportion of patients with GC have s1a allele and s1a/m2 vacA genotype. Both s1a/m2 vacA genotype and babA2 are associated with PUD. The study shows that different virulence attributes of H. pylori are involved in different gastroduodenal disorders.

Nosocomial cross-transmission of Pseudomonas aeruginosa between patients in a tertiary intensive care unit.

Background: Nosocomial infection caused by Pseudomonas aeruginosa (P. aeruginosa) is very common, despite the application of various preventive measures in intensive care units (ICUs) leading to increased morbidity, mortality, prolonged hospital stay, and increased treatment cost. Aim: The aim of the present study is to identify the source of P. aeruginosa infection in patients admitted to tertiary ICU. Materials and Methods: From 200 patients selected randomly, appropriate clinical specimens from different sites were collected and processed for the isolation and identification of the nosocomial pathogens. Surveillance samples from environmental sites and hands of nursing staff were also cultured. Results: P. aeruginosa was found to be the most common pathogen associated with nosocomial infections accounting for 23.3% of all bacterial isolates from different infection sites in the ICU. Serotyping of the clinical isolates and surveillance sample isolates from nurses' hands showed serotype E as the most common serotype. Other serotypes of P. aeruginosa were isolated from environmental cultures such as sinks, floors, walls, tap water, etc. Conclusion: Study revealed a high prevalence of P. aeruginosa infections in the ICU attributed to cross transmission from patient to patient via hands of the nursing staff. Strict enforcement of infection control protocols is essential to minimize the disease burden.

Ventilator-associated pneumonia caused by carbapenem-resistant Enterobacteriaceae carrying multiple metallo-beta-lactamase genes.

Context: Ventilator-associated pneumonia (VAP) is a leading nosocomial infection in the intensive care unit (ICU). Members of Enterobacteriaceae are the most common causative agents and carbapenems are the most commonly used antibiotics. Metallo-beta-lactamase (MBL) production leading to treatment failure may go unnoticed by routine disc diffusion susceptibility testing. Moreover, there is not much information on association of MBL-producing Enterobacteriaceae with ICU-acquired VAP. Therefore, a study was undertaken to find out the association of MBL-producing Enterobacteriaceae with VAP. Settings: This study was conducted in a large tertiary care hospital of North India with an eight-bed critical care unit. Materials and Methods: The respiratory samples (bronchoalveolar lavage, protected brush catheter specimens and endotracheal or transtracheal aspirates) obtained from VAP patients (during January 2005-December 2006) were processed, isolated bacteria identified and their antibiotic susceptibilities tested as per standard protocols. The isolates of Enterobacteriaceae resistant to carbapenem were subjected to phenotypic and genotypic tests for the detection of MBLs. Results: Twelve of 64 isolates of Enterobacteriaceae were detected as MBL producers, bla IMP being the most prevalent gene. Additionally, in three strains, simultaneous coexistence of multiple MBL genes was detected. Conclusion: The coexistence of multiple MBL genes in Enterobacteriaceae is an alarming situation. As MBL genes are associated with integrons that can be embedded in transposons, which in turn can be accommodated on plasmids thereby resulting in a highly mobile genetic apparatus, the further spread of these genes in different pathogens is likely to occur.

Extended spectrum β--lactamases in Escherichia coli & Klebsiella pneumoniae & associated risk factors.

Background & objectives: Extended spectrum β-lactamases (ESBLs) have emerged as a major threat worldwide with limited treatment options. The genotypes of ESBL producing strains largely remain unknown in India; hence the present study was aimed to determine the occurrence of ESBLs in Escherichia coli and Klebsiella pneumoniae, their molecular types and associated risk factors in a tertiary care hospital. Methods: Total 200 consecutive clinical isolates of E. coli (n=143) and K. pneumoniae (n=57) collected between February and July 2006 at Sanjay Gandhi Postgraduate Institute of Medical Sciences, a tertiary care hospital in north India, were examined phenotypically for ESBL production. ESBL strains were further typed for the blaTEM/SHV/CTX-M genes by PCR using specifi c primers. The blaCTX-M cluster was identifi ed by restriction analysis and genotype by sequencing of PCR product. Resistance to other antimicrobial agents was also studied. Various risk factors associated with ESBL infections were analyzed by logistic regressions. Results: ESBLs were found in 63.6 per cent E. coli and 66.7 per cent K. pneumoniae isolates. Majority of the typeable isolates harboured two or more ESBL genes (57.3%). Overall blaCTX-M was the commonest genotype (85.4%) followed by blaTEM (54.9%) and blaSHV (32.9%) either alone or in combination. All CTX-M enzymes in E. coli and 87.5 per cent in K. pneumoniae belonged to the CTX-M-1 cluster. Sequencing was done for randomly selected 20 blaCTX-M PCR products and all were identifi ed as CTXM- 3. Resistance of ESBL isolates to other antibiotics was amikacin 14.7 per cent, gentamicin 66.7 per cent, trimethoprim/sulphamethoxazole 79.1 per cent and ciprofl oxacin 93.8 per cent. Prior antibiotic exposure, use of intravenous device and urinary catheter, renal insuffi ciency and ICU admission were associated with ESBL infection on univariate analysis. On multivariate, antibiotic exposure (P=0.001) and use of urinary catheter (P<0.001) were identififi ed as risk for ESBL infection. Interpretation & conclusions: Our study showed high ESBL occurrence with CTX-M as the emerging type in our hospital and CTX-M-3 being reported for the fi rst time in India. High co-resistance to other non-β-lactam antibiotics is a major challenge for management of ESBL infections.

Cell cycle arrest & apoptosis of epithelial cell line by cytolethal distending toxin positive Campylobacter jejuni.

Background & objectives: Campylobacter jejuni is the leading cause of gastroenteritis worldwide; cytolethal distending toxin (CDT) being an important virulence determinant. As its role in pathogenesis remains unclear, this study aims to investigate cell cycle arrest and apoptosis by CDT (+ve) and CDT (-ve) C. jejuni isolates on HeLa cells. Methods: Culture supernatants and lysates from 10 C. jejuni isolates [CDT (+ve) and CDT (-ve), five each] were incubated with HeLa cells. CDT activity on HeLa cells was confirmed by cell distension, cell cycle arrest by flowcytometry, and apoptosis by DNA fragmentation and flowcytometry. Results: Culture supernatant and lysate of only CDT (+ve) C. jejuni isolates produced cell distension. For CDT (+ve) and CDT (-ve) isolates, the cells at G2/M phase after 24, 48 and 72 h were 25.8 ± 3.79 per cent and 11.2 ± 0.58 per cent, 72.9 ± 2.44 and 14.3 ± 1.88 per cent, 93.5 ± 0.54 per cnet and 18.0 ± 1.80 per cent respectively (P<0.001). All CDT (+ve) isolates induced DNA fragmentation. Apoptosis induced by CDT (+ve) C. jejuni was significantly greater than CDT (-ve) (26.3 ± 3.49 % vs. 10.4 ± 1.01% at 24 h, 43.9 ± 2.40% vs. 17.6 ± 0.88% at 48 h, 68.4 ± 1.61% vs. 28.4 ± 1.62% at 72 h); (P<0.001). Interpretation & conclusion: The present study shows that CDT (+ve) C. jejuni contributes to the pathogenesis through epithelial cell G2/M phase arrest and apoptosis.

Aeromonas caviae septicemia in immunocompetent gastrointestinal carriers

Aeromonas caviae strains have been isolated from blood and stool cultures of three immunocompetent patients, residents of Northern India, who presented with community acquired septicemia without any recent history of diarrhea. Cell culture infectivity test performed on Hep-2 cells have shown substantial degree of invasiveness in the isolated strains. This case unleashes a possibility of asymptomatic gastrointestinal carriage of such strains of A. caviae in a very large population of India, as several areas of India have very high rates of Aeromonas induced acute diarrhea/gastroenteritis (up to 13 percent). It needs to be appraised further in India as well as other countries having high rates of Aeromonas induced acute diarrhea/gastroenteritis.

Bacterial isolates from mechanically ventilated patients with nosocomial pneumonia within intensive care unit of a tertiary care center.

Nosocomial pneumonia is a common complication in mechanically ventilated patients. A study was carried out to determine the incidence, common bacterial etiologic agents and their antimicrobial susceptibility, and outcome of such pneumonia in an Intensive Care Unit (ICU) of a tertiary care center. In Surgical ICU (SICU) 176 patients required mechanical ventilation for more than 72 hours. A total of 39 (22.1%) of these patients developed nosocomial bacterial pneumonia as determined by microbiological assays. Endotracheal aspirate cultures detected a single bacterial isolate in 22 (56.4%) patients while two and three organisms were isolated from 10 (25.6%) and 7 (17.9%) patients respectively. Fifty three (84.1%) of a total of 63 isolates were Gram negative bacilli. The most frequently encountered pathogens were Pseudomonas aeruginosa, Klebsiella pneumoniae and Acinetobacter species among the Gram negative bacilli and Staphylococcus aureus among the Gram positives. Resistance of bacterial isolates varied from 24 to 90% against commonly used antibiotics. Amikacin had the best profile, with 14% to 55% resistance against various isolates. Twenty three (59%) of 39 patients with pneumonia expired in the ICU. P. aeruginosa (25.6%) and K. pneunmoniae (17.9%) were the predominant isolates in these patients. Nosocomial pneumonia with high mortality is a frequent occurrence in mechanically ventilated patients in our ICU setting. Gram negative organisms with high levels of antimicrobial resistance are the most common isolates. Regular surveillance and monitoring of changes in antibiotic susceptibility of bacterial pathogens and appropriate therapeutic measures are likely to reduce the mortality in these patients.

Nocardiosis in patients of chronic idiopathic thrombocytopenic purpura on steroids.

We present two cases of chronic idiopathic thrombocytopenic purpura (ITP) on prolonged steroid therapy who developed subcutaneous and brain abscesses due to Nocardia asteroides. The special diagnostic and therapeutic challenges encountered in the patients because of severe thrombocytopenia are being highlighted.