Disseminated histoplasmosis in an apparently immunocompetent individual from north India: a case report and review.

Mucocutaneous histoplasmosis is frequently reported in patients with acquired immune deficiency syndrome (AIDS), but it is rare in immunocompetent hosts. Disseminated histoplasmosis involving skin and larynx in a 50-year-old immunocompetent male is described from a non-endemic area in India. The infection appeared to be imported from Thailand. The patient responded very well to intravenous amphotericin B followed by itraconazole. A review of all cases of histoplasmosis occurring in immunocompetent patients from India is reported. Most cases are reported from the Gangetic plains. Adrenals are the most common organ involved in immunocompetent patients, but adrenal insufficiency is not common. Skin lesions and oral ulcers are seen in more than one-third of patients. Predisposing factors like exposure to birds, farming, mining, diabetes were observed in few patients.

Knowledge, attitude, and practices of Bio-medical Waste Management rules, 2016; Bio-medical Waste Management (amendment) rules, 2018; and Solid Waste Rules, 2016, among health-care workers in a tertiary care setup.

INTRODUCTION: Biomedical waste poses physical, chemical, radiological, and microbiological risks to the public and health-care workers (HCWs) for current and future generations. AIM: The aim was to gauge the depth of understanding amongst HCWs on biomedical waste management (BMWM). MATERIALS AND METHODS: A predesigned questionnaire on knowledge, attitude, and practices on BMWM Rules, 2016 (Principle), and 2018 (Amendment), Solid Waste Rules, 2016, and health hazards in HCW was distributed to all participants. RESULTS: Only 68% of the participants knew that the most important step in waste management is waste segregation. Eighty-two percent of the HCWs working in this setup knew of the different color-coded bins used for segregation. However, awareness was lacking with respect to health hazards associated with improperly segregated and disposed off biomedical waste as only 49% answered the questions on the hazards of waste correctly. Laboratory waste handling was found to be the least understood area of the newer guidelines. CONCLUSIONS: Training aspects of health-care waste management should be strengthened so that the current, existing, and future regulations are practiced diligently and uniformly. Periodic evaluation and assessment should become routine to enforce adherence to waste management.

Epidemiology and Antifungal Susceptibility of Infections Caused by Trichosporon Species: An Emerging Non-Candida and Non-Cryptococcus Yeast Worldwide.

Introduction: Over the past four decades, there has been an increase in the number of fatal opportunistic invasive trichosporonosis cases especially in immunocompromised hosts. Objective: The objective of the study is to evaluate the epidemiological, clinical details and antifungal susceptibility pattern of the patients with Trichosporon infections. Materials and Methods: Twenty-four clinical isolates of Trichosporon species isolated from blood, samples, pleural fluid and nail were included in this study, over a period of 12 years (2005-2016) in a tertiary hospital in North India. The isolates were characterised phenotypically and few representative isolates were sequenced also. The minimum inhibitory concentration (MIC) was determined as per Clinical and Laboratory Standards Institute, 2012. Results: Trichosporon spp. from blood culture (57.78%), nail (37.5%) and pleural fluid (4.17%). On phenotypic tests, 79.16% of the isolates were Trichosporon asahii, followed by Trichosporon dermatis (8.33%), Trichosporon japonicum (4.17%), Trichosporon ovoides (4.17%) and Trichosporon mucoides (4.17%). The MIC range of Trichosporon species from invasive infections were fluconazole (0.06-256 µg/ml), amphotericin B (0.125-16 µg/ml), voriconazole (0.0616-8 µg/ml), posaconazole (0.0616-32 µg/ml) and caspofungin (8-32 µg/ml). The isolates from superficial infection were resistant to fluconazole (0.06-256 µg/ml) and itraconazole (0.125-32 µg/ml), all were susceptible to ketoconazole and while only two were resistant to voriconazole (0.25-4 µg/ml). Conclusion: T. asahii was the most common isolate. Disseminated trichosporonosis is being increasingly reported worldwide including India and represents a challenge for both diagnosis and species identification. Prognosis is limited, and antifungal regimens containing triazoles appear to be the best therapeutic approach. In addition, accurate identification, removal of central venous lines and voriconazole-based treatment along with control of underlying conditions were associated with favourable outcomes.

Current scenario of cryptococcosis and antifungal susceptibility pattern in India: a cause for reappraisal.

This study analysed the spectrum, antifungal susceptibility pattern, clinical course and molecular epidemiology of cryptococcosis. Four hundred and thirty-nine samples obtained from 378 meningitis patients were processed by standard procedures. Minimum inhibitory concentration (MIC) of fluconazole and amphotericin B for the isolates was tested by broth micro dilution and by E-strip method. Molecular analysis by random amplified polymorphic DNA-PCR of eight isolates was performed using M13 primer. Cryptococcosis was diagnosed in 35 patients [HIV-1 seropositive (19) and apparently immunocompetent (16)]. Cryptococcus neoformans var. neoformans (serotype A and D) was the predominant isolate on phenotypic identification. Three C. neoformans var. gattii were isolated from HIV-1 seropositive (2) and apparently immunocompetent (1) patients. MIC 90 for amphotericin B and fluconazole were 1 and 8 mug ml(-1) respectively. On RAPD-PCR, less diversity was seen among Indian isolates. AIDS remains the single most important risk factor for cryptococcosis. Rising MIC of the available induction and maintenance drugs is of grave concern. The DNA typing technique showed less diversity among Indian strains. Routine surveillance and application of molecular typing methods are crucial to know the baseline and existing pattern of cryptococcosis.

Screening of invasive fungal infections by a real-time panfungal (pan-ACF) polymerase chain reaction assay in patients with haematological malignancy.

BACKGROUND: Invasive fungal infection (IFI) is a fatal infection in haematology patients. There is an urgent need for reliable screening methods facilitating timely diagnosis and treatment. A real-time panfungal polymerase chain reaction (PCR) assay based on TaqMan technology targeting 18S ribosomal RNA gene was used to screen whole blood specimen obtained from series of Haematology malignancy patients for IFIs. MATERIALS AND METHODS: The panfungal (Pan-ACF) assay was employed to investigate specimen from 133 patients in duplicate with suspected IFI. In addition twenty healthy subjects and twenty patients with bacterial infections were taken as control. The patients with suspected IFI were also diagnosed by conventional methods including direct microscopy, culture techniques and antigen detection (galactomannan antigen ELISA and latex agglutination for cryptococcal antigen). The results of molecular testing were evaluated in relation to the criteria proposed by the European Organization for Research and Treatment of Cancer and patients were classified as having proven and probable IFD. RESULTS: Of 133 patients, 89 had proven, 18 had probable and 26 had possible IFI. One hundred four samples were reverse transcription-PCR positive. Of 89 proven cases, 84 were panfungal PCR positive. These 84 cases included 82 cases which revealed growth on fungal blood culture and two cases were negative on fungal blood culture. Of the 82 cases which revealed growth on culture: 74 grew Candida in culture, 3 grew Fusarium solani, 5 grew Aspergillus species on blood culture. The later five were also galactomannan antigen positive. The five specimen which were negative on panfungal PCR, two grew Trichosporon asahii, one grew Candida rugosa and two grew as Cryptococcus neoformans var. neoformans. Of the 18 probable cases, 18 were panfungal PCR positive. These were also galactomannan antigen positive. The sensitivity and specificity of panfungal PCR in proven cases were 94.3% and 95.2%, respectively. The positive and negative predictive values proven cases were 97.6% and 88.9%, respectively. CONCLUSIONS: The panfungal (Pan-ACF) real-time PCR assay can detect common fungal genera and it may be used as an adjunct to conventional methods for screening of IFI.

Resistance to erythromycin and rising penicillin MIC in Streptococcus pyogenes in India.

There has been worldwide resurgence in the incidence of Streptococcus pyogenes infection and its sequelae. S. pyogenes remains uniformly susceptible to penicillin, and it is speculated that its minimum inhibitory concentration (MIC) has not changed during the past 70 years. The purpose of the present study was to determine the occurrence and pattern of resistance to penicillin and erythromycin amongst clinical isolates of S. pyogenes. A total of 34 clinical strains of S. pyogenes were identified by standard procedures. Antimicrobial susceptibility was analyzed by the Kirby-Bauer method of disk diffusion, and the E-test method was used to determine the MIC to penicillin and erythromycin. All the strains were sensitive to penicillin, clindamycin and vancomycin on disk diffusion. Ten (29.4%) strains were resistant to erythromycin. The pattern of macrolide resistance observed was M type. By the E-test method, 7 (20.6%) strains were penicillin nonsusceptible and 6 (17.6%) were erythromycin resistant. We concluded that surveillance of its susceptibility pattern is crucial to monitoring the development of antibiotic resistance in S. pyogenes.

Emergence of non-albicans Candida species and antifungal resistance in a tertiary care hospital.

The spectrum of candidiasis has changed with the emergence of non-albicans Candida spp. and acquired antifungal resistance, especially in immunocompromised hosts. This changing scenario has necessitated routine antifungal susceptibility testing. In the present work, 102 Candida spp. isolates gathered during 2003 - 2004 were characterized by standard procedures, and antifungal susceptibility testing to amphotericin B, fluconazole and itraconazole was performed by broth macrodilution (BMD)-minimum inhibitory concentration (MIC) and disk diffusion (DD) methods. Among all isolates, 77.4% were from an ICU and 10.8% were obtained from a nursery. The majority of the isolates were C. tropicalis (48%), followed by C. parapsilosis (27.4%) and C. albicans (22.5%). Overall 6.9, 4.9 and 3.9% of all isolates were resistant to amphotericin B, fluconazole and itraconazole, respectively. Out of the 5 (4.9%) isolates resistant to fluconazole, 4 (3.9%) were from patients with AIDS on fluconazole prophylaxis. A discrepancy was observed between the results of susceptibility testing by DD and those by BMD-MIC: 15 (14.7%) isolates were reported to be resistant by DD despite having low MICs. Based on these results, it was concluded that initial antifungal screening of clinical isolates by the DD method followed by confirmation of resistant strains by the broth dilution method is desirable to optimize patient management.

Quinolone and cephalosporin resistance in enteric Fever.

Enteric fever is a major public health problem in developing countries. Ciprofloxacin resistance has now become a norm in the Indian subcontinent. Novel molecular substitutions may become frequent in future owing to selective pressures exerted by the irrational use of ciprofloxacin in human and veterinary therapeutics, in a population endemic with nalidixic acid-resistant strains. The therapeutics of ciprofloxacin-resistant enteric fever narrows down to third- and fourth-generation cephalosporins, azithromycin, tigecycline and penems. The first-line antimicrobials ampicillin, chloramphenicol and co-trimoxazole need to be rolled back. Antimicrobial surveillance coupled with molecular analysis of fluoroquinolone resistance is warranted for reconfirming novel and established molecular patterns for therapeutic reappraisal and for novel-drug targets. This review explores the antimicrobial resistance and its molecular mechanisms, as well as novel drugs in the therapy of enteric fever.