Antibiotic stewardship initiative in a Medicine unit of a tertiary care teaching hospital in India: A pilot study

Background & objectives: The models for implementation of antibiotic stewardship programme (ASP) in the acute care settings of developing countries are lacking. In most of the hospitals, patient turnover is high and a proper system for recording antibiotic-related information and tracking hospital-acquired infections is not in place. This pilot study was conducted in a tertiary care teaching hospital in north India to assess the feasibility of implementation of an ASP in a Medicine unit and to evaluate the effect of implementation as per the criteria applicable in this set up. Methods: A pre-post-quasi-experimental non-randomized study was conducted in two phases. In the first phase, current practices in the Medicine wards were observed. In the second phase, the ASP was implemented in a single Medicine unit, along with prospective audit and feedback, tracking of the process, as well as outcome measures. Patient risk stratification, blood culture on day one, day 3 bundle, dose optimization, de-escalation and intravenous to oral conversion of antibiotics were the key elements focused upon. Results: There was a significant improvement in the appropriateness of antibiotic prescription (66 vs. 86%, P<0.001) and reduction in the mean number of antibiotics used per person (4.41 vs. 3.86, P<0.05) along with decrease in the duration of hospital stay (17 vs. 14 days, P<0.05). There was a significant improvement in sending of blood cultures on day one during the stewardship phase (P<0.001). Interpretation & conclusions: The ASP approach used in our pilot study may be feasible and beneficial. However, it needs further confirmation in other settings and on a large scale.

A road less travelled: Clinical comparison of HIV seropositive and seronegative patients with cystoisosporiasis � An 11-year experience from a tertiary care centre in Northern India

Background: Cystoisospora is a well-known opportunistic enteric parasite among human immunodeficiency virus (HIV) seropositive patients but there is a paucity of data among HIV negative patients. This study investigated Cystosporiasis on both HIV positive and negative patients, with or without diarrhea, presenting to a tertiary care and super specialty center of northern India. Methodology: Oocysts of Cystoisospora were detected on light microscopy, by modified Kinyoun staining of stool specimens, over an 11-year study period. Results: Of the 10,233 stool specimens evaluated, Cystoisospora was detected in 64 patients, 37 (57.81%) of whom were HIV positive. Year-wise analysis showed an overall declining trend of cystoisosporiasis. Maximum cases were detected in May and June in HIV positive patients and February and September among HIV negative patients. Among HIV positive patients, the mean CD4 count was 152.04 � 81.12cells/?L, mean absolute eosinophil count (AEC) was 229.16 � 175.62 cells/?L and 12.5% patients had mild eosinophilia. Tuberculosis was the most common co-morbidity. Dual infections of Cystoisospora with Cryptosporidium and Giardia were also seen. Among HIV negative patients, eight had primary autoimmune disorders, seven were solid organ transplant recipients and the rest had chronic bowel diseases. The mean AEC was 485.47 � 414.88 cells/?L, with 14.81% patients showing mild and 11.11% showing marked eosinophilia. Dual infection with Giardia was seen. Recurrent cystoisosporiasis was noted, despite cotrimoxazole treatment in a single case. Conclusion: The epidemiology of cystoisosporiasis differs between HIV seropositive and seronegative patients in terms of year-wise and month-wise trends, co-infections and most importantly, AECs.

Intestinal cryptosporidiosis in renal transplant recipients: Prevalence, species detection and comparative evaluation of SSU rRNA and Cryptosporidium oocyst wall protein genes

Context: Cryptosporidiosis is intestinal opportunistic infection commonly occurring in immunocompromised patients including renal transplant (RT) recipients receiving continuous immunosuppressive therapy. Knowledge about species of Cryptosporidium-infecting RT recipients is necessary to know about mode of its transmission (anthroponotic or zoonotic). Various genes such as small subunit rRNA (SSU rRNA) and Cryptosporidium oocyst wall protein (COWP) genes may help in species identification though their sensitivity and specificity are highly variable. Subjects and Methods: A total of 993 and 575 stool samples were examined for Cryptosporidium by microscopy from 358 RT recipients and 200 healthy controls, respectively. Stool samples of RT recipients and healthy controls were subjected to polymerase chain reaction (PCR) followed by restriction fragment length polymorphism (RFLP) for species identification. Results: Cryptosporidium was more commonly detected amongst RT recipients than healthy controls (30/358, 8.4% vs. 0/200, respectively; P < 0.001). The infection was more common amongst patients with diarrhoea than those without (26/162, 16.1% vs. 4/145, 2.8%; P < 0.001). Cryptosporidium parvum was identified in 10/30 (33.3%) and Cryptosporidium hominis in 20/30 (66.7%) samples. SSU gene PCR-RFLP proved to be more sensitive (100%) than COWP (90%); however, specificity of both was same (100%). Conclusions: Cryptosporidiosis is common amongst RT recipients, particularly those with diarrhoea. C. hominis is the most common species in the studied population. SSU rRNA PCR was more sensitive molecular method for the differentiation of Cryptosporidium species.

Association of interleukin‑28B rs12979860 and rs8099917 polymorphisms with sustained viral response in hepatitis C virus genotype 1 and 3 infected patients from the Indian subcontinent.

Background: Polymorphisms of the IL28B gene (rs12979860 and rs8099917) have been shown to impact treatment responses in hepatitis C virus (HCV) infected patients. The association of these polymorphisms with sustained viral response (SVR) has been studied in HCV genotype 3 infected patients in India, but not in genotype 1. Objectives: This study aimed to determine the association of IL28B gene polymorphisms and other host and viral factors with treatment response in patients with HCV genotype 1 and 3 infection. Materials and Methods: DNA from 42 HCV‑infected patients on antiviral therapy was analysed for the IL28B polymorphisms using polymerase chain reaction‑restriction fragment length polymorphism (PCR‑RFLP). Bidirectional sequencing was performed on a subset of samples for verification of PCR‑RFLP results. Information on age, weight, height, diabetic status, pre‑treatment viral load and alanine aminotransferase (ALT) levels was obtained from clinical records. The IL28B genotypes and the other factors were analysed for their association with SVR. Results: The frequency distribution of rs12979860 CC/CT/TT genotypes was found to be 66.7%, 26.2% and 7.1%, respectively. For rs8099917 genotype, the TT/GT/GG distribution was 73.8%, 21.4% and 4.8%, respectively. SVR was seen in 61.9% of cases (55.6% in genotype 1 and 62.5% in genotype 3). CC genotype at rs12979860 and TT genotype at rs8099917 were significantly higher in responders (P = 0.013 and 0.042, respectively). Lower baseline ALT and rapid viral response were also found to be associated with SVR. On logistic regression analysis, CC genotype at rs12979860 emerged as the most powerful predictor of treatment response. Conclusion: IL28B polymorphisms are strong predictors of SVR in patients from the Indian subcontinent infected with HCV genotype 3 and genotype 1.

Identification of opportunistic enteric parasites among immunocompetent patients with diarrhoea from Northern India and genetic characterisation of Cryptosporidium and Microsporidia.

Purpose: Enteric parasitic infestation is a major public health problem in developing countries. Parasites such as Cryptosporidium spp., Cyclospora spp., Cystoisospora spp. and Microsporidia may cause severe diarrhoea among immunocompromised patients. There is scanty data on their frequency among immunocompetent patients. Accordingly, we studied the frequency of enteric opportunistic parasites among immunocompetent patients with diarrhoea from northern India; we also performed genetic characterisation of Cryptosporidia and Microsporidia among them. Patients and Methods: Stool samples from 80 immunocompetent patients with diarrhoea, and 110 healthy controls were examined. Parasites were detected by direct microscopy, modified acid-fast (Kinyoun’s) and modified trichrome stain. Polymerase chain reaction – restriction fragment length polymorphism was used for genetic characterisation of selected species such as Cryptosporidia and Microsporidia. Results: Enteric parasites were detected in 16/80 (20%) patients (mean age 28.8 ± 20 years, 45, 56% males) and in 2/110 (1.8%) healthy controls (P = 0.00007). Parasites detected were Cryptosporidium spp. (8/16, 50.0%), Cystoisospora spp. (4/16, 25%), Microsporidia (1/16, 6.25%), Cyclospora spp. (1/16, 6.25%) and Giardia spp. (1/16, 6.25%). One patient had mixed infection with Cystoisospora spp. and Giardia spp. The species of Cryptosporidia and Microsporidia detected were Cryptosporidium hominis and Enterocytozoon bieneusi, respectively. Parasites were more often detected in younger patients (≤20 years of age) than in older. Most of the parasite infected patients presented with chronic diarrhoea. Conclusion: Opportunistic enteric parasitic infestation was more common among immunocompetent patients with diarrhoea than healthy subjects. Special staining as well as molecular methods are essential for appropriate diagnosis of these parasites.

Revised ciprofloxacin breakpoints for Salmonella Typhi: Its implications in India.

The rise of multidrug resistant strains of Salmonella Typhi in the last decade of the previous century led to the use of fl uoroquinolones as the drug of choice. However, over the past few years fl uoroquinolone resistance has been increasingly reported. In accordance with the revised Clinical and Laboratory Standards Institute (CLSI) breakpoints, only 3% of the isolates were susceptible to ciprofl oxacin in comparison to 95% as per the earlier guidelines when 488 isolates collected between 2010 and 2012 were re-interpreted. Interestingly, re-emergence of strains susceptible to chloramphenicol, ampicillin and cotrimoxazole is being seen. Amidst the changing susceptibility profi le, azithromycin remains a promising alternative.

Relapsing linear acantholytic dermatosis in a four-year-old boy.

Linear acantholytic dermatoses are a spectrum of cutaneous disorders that form a subset of linear dermatoses with distinct clinical features and histopathologically show acantholysis. The lesions may be zosteriform or follow the lines of Blaschko. This report describes a four-year-old boy who, on a follow up of two years, exhibited a relapsing acantholytic dermatosis along the lines of Blaschko. Histopathology of a representative lesion revealed epidermal acantholysis with multiple acantholytic keratinocytes with in the prickle cell layer and an absence of corp ronds and grains, consistent with features of Hailey-Hailey disease. This, to our knowledge, is the third case of relapsing linear acantholytic dermatosis reported.

Prescribing pattern of antiedema therapy in stroke by neurologists and general physicians.

BACKGROUND: In acute stroke, a number of drugs are used to reduce the raised intracranial pressure (ICP) although their scientific basis has not been established or shown in randomized controlled trials. AIMS: In this communication, we report the pattern of use of antiedema therapy in acute stroke by general physicians (GPs) and neurophysicians (NPs) in India. MATERIAL AND METHODS: A questionnaire was developed regarding the use of various antiedema measures in stroke and responses were collected either through post or when the responders were attending a national conference. The use of antiedema therapy by NPs and GPs was analyzed employing the Chi-square test. RESULTS: We could collect responses from 102 physicians, of whom 48 were NPs and 54 GPs. More than two-thirds of the physicians managed more than three strokes per week and all used antiedema therapy at some time or the other. Thirteen used it in all the patients and the remaining used it in patients with large and moderate strokes or in patients with herniation. Twelve used only one drug, while the remaining physicians used various combinations in different doses and frequency. The prescribing pattern was significantly different between GPs and NPs with respect to the frequency of the antiedema drugs used, type of stroke where these were used, combination of drugs, timing and dose of mannitol. CONCLUSION: This study highlights that antiedema therapy in acute stroke is practiced without any uniformity.

Tuberculous meningitis with pulmonary miliary tuberculosis: a clinicoradiological study.

BACKGROUND AND AIMS: This study aims at evaluating the clinical and radiological outcome of tuberculous meningitis (TBM) patients with pulmonary miliary tuberculosis. MATERIAL AND METHODS: Diagnosis of TBM was based on clinical, CT scan or MRI and CSF criteria, and that of miliary tuberculosis on chest radiograph. Detailed clinical evaluation was done in all. Severity of meningitis was graded into Grades I, II and III. Complete hemogram, serum chemistry and Montaux tests were performed. The recovery was defined on the basis of 6 months Barthel index score as poor, partial or complete. RESULTS: 20 out of 165 patients with TBM had pulmonary miliary tuberculosis. Their mean age was 30 years; there was one child and 13 patients were females. The mean duration of symptoms was 6.3 months. Montoux test was negative in 9 patients. Six patients were in stage I, 3 in stage II, and 11 in stage III meningitis. Hemoglobin was below 12 gm% in 13 and liver dysfunction and hypocalcaemia was present in 8 and 18 patients respectively. CT scan was abnormal in 16 patients and revealed hydrocephalus (10), granuloma (7), exudates (3) and infarction (1). MRI was abnormal in 7 out of 8 patients and 3 of these patients had normal CT scan. MRI revealed multiple granuloma in 7 patients and exudates in 2. At 6 months, 2 patients died, 10 had complete, 2 had partial and 4 had poor recovery. CONCLUSION: TBM with pulmonary miliary tuberculosis was commoner amongst females who were anemic and hypocalcaemic. MRI revealed multiple granuloma and the majority of the patients improved.