Regional variations in antimicrobial susceptibility of community-acquired uropathogenic Escherichia coli in India: Findings of a multicentric study highlighting the importance of local antibiograms.

Objectives: Evidence-based prescribing is essential to optimize patient outcomes in cystitis. This requires knowledge of local antibiotic resistance rates. Diagnostic and Antimicrobial Stewardship (DASH) to Protect Antibiotics (https://dashuti.com/) is a multicentric mentorship program guiding centers in preparing, analyzing and disseminating local antibiograms to promote antimicrobial stewardship in community urinary tract infection. Here, we mapped the susceptibility profile of Escherichia coli from 22 Indian centers. Methods: These centers spanned 10 Indian states and three union territories. Antibiograms for urinary E. coli from the outpatient departments were collated. Standardization was achieved by regional online training; anomalies were resolved via consultation with study experts. Data were collated and analyzed. Results: Nationally, fosfomycin, with 94% susceptibility (inter-center range 83-97%), and nitrofurantoin, with 85% susceptibility (61-97%), retained the widest activity. The susceptibility rates were lower for co-trimoxazole (49%), fluoroquinolones (31%), and oral cephalosporins (26%). The rates for third- and fourth-generation cephalosporins were 46% and 52%, respectively, with 54% (33-58%) extended-spectrum ß-lactamase prevalence. Piperacillin-tazobactam (81%), amikacin (88%), and meropenem (88%) retained better activity; however, one center in Delhi recorded only 42% meropenem susceptibility. Susceptibility rates were mostly higher in South, West, and Northeast India; centers in the heavily populated Gangetic plains, across north and northwest India, had greater resistance. These findings highlight the importance of local antibiograms in guiding appropriate antimicrobial choices. Conclusions: Fosfomycin and nitrofurantoin are the preferred oral empirical choices for uncomplicated E. coli cystitis in India, although elevated resistance in some areas is concerning. Empiric use of fluoroquinolones and third-generation cephalosporins is discouraged, whereas piperacillin/tazobactam and aminoglycosides remain carbapenem-sparing parenteral agents.

Recurrent sternal wound infection caused by Gordonia bronchialis after open heart surgery.

Gordonia bronchialis is an aerobic gram-positive bacilli and also weakly acid fast. It requires a long incubation time and extensive biochemical reactions for identification. Therefore, use of broad-range polymerase chain reaction (PCR) for amplification of genes such as 16S rRNA or hsp65 followed by sequencing or advanced techniques like MALDI-TOF MS is needed for identification. Here, we present a case of persistent sternal wound infection following open heart surgery, caused by G. bronchialis in a 58 years old male, identified using MALDI-TOF MS-based system. The patient improved with oral Cefpodoxime 200 mg BD for four weeks.

Genotype Distribution and Antibiotic Susceptibility Pattern of Clinical Isolates of Group B Streptococcus in a Tertiary Care Hospital in Puducherry, South India.

Background: Streptococcus agalactiae apart from being a colonizer in the genital region is also associated with several other invasive infections in all age groups. With the varied distribution of serotypes across different regions of the world, universal vaccination is also unattainable. However, in India, the knowledge of group B Streptococcus (GBS) genotype distribution is deficient. Thus, this study was initiated to add data on this aspect. Methodology. A cross-sectional study was conducted using isolates of group B Streptococcus from all clinical specimens. Along with that, the clinical specimen type and the antibiotic resistance profile of the isolates were correlated with the genotypes recognized through a multiplex PCR assay. Results: Among the 86 isolates subjected to multiplex PCR for genotype identification, five genotypes were identified with genotype Ib as the predominant one (34.9%), followed by III (20.9%), II (16.3%), Ia (12.7%), and V (11.6%). Conclusion: The results demonstrated a correlation of types Ib and III with vaginal colonization and type II with urine specimens in the current study. This preliminary study exhibited the distribution of common genotypes and their antibiotic resistance profiles in various GBS isolates. However, multiple studies across the country with larger sample sizes are needed to validate these findings.

In Vitro Activity of Two Cefepime-Based Novel Combinations, Cefepime/Taniborbactam and Cefepime/Zidebactam, against Carbapenemase-Expressing Enterobacterales Collected in India.

In recent times, discovery efforts for novel antibiotics have mostly targeted carbapenemase-producing Gram-negative organisms. Two different combination approaches are pertinent: ß-lactam-ß-lactamase inhibitor (BL/BLI) or ß-lactam-ß-lactam enhancer (BL/BLE). Cefepime combined with a BLI, taniborbactam, or with a BLE, zidebactam, has been shown to be promising. In this study, we determined the in vitro activity of both these agents along with comparators against multicentric carbapenemase-producing Enterobacterales (CPE). Nonduplicate CPE isolates of Escherichia coli (n = 270) and Klebsiella pneumoniae (n = 300), collected from nine different tertiary-care hospitals across India during 2019 to 2021, were included in the study. Carbapenemases in these isolates were detected by PCR. E. coli isolates were also screened for the presence of the 4-amino-acid insert in penicillin binding protein 3 (PBP3). MICs were determined by reference broth microdilution. Higher MICs of cefepime/taniborbactam (>8 mg/L) were linked to NDM, both in K. pneumoniae and in E. coli. In particular, such higher MICs were observed in 88 to 90% of E. coli isolates producing NDM and OXA-48-like or NDM alone. On the other hand, OXA-48-like-producing E. coli or K. pneumoniae isolates were nearly 100% susceptible to cefepime/taniborbactam. Regardless of the carbapenemase types and the pathogens, cefepime/zidebactam showed potent activity (>99% inhibited at ≤8 mg/L). It seems that the 4-amino-acid insert in PBP3 (present universally in the study E. coli isolates) along with NDM adversely impact the activity of cefepime/taniborbactam. Thus, the limitations of the BL/BLI approach in tackling the complex interplay of enzymatic and nonenzymatic resistance mechanisms were better revealed in whole-cell studies where the activity observed was a net effect of ß-lactamase inhibition, cellular uptake, and target affinity of the combination. IMPORTANCE The study revealed the differential ability of cefepime/taniborbactam and cefepime/zidebactam in tackling carbapenemase-producing Indian clinical isolates that also harbored additional mechanisms of resistance. NDM-expressing E. coli with 4-amino-acid insert in PBP3 are predominately resistant to cefepime/taniborbactam, while the ß-lactam enhancer mechanism-based cefepime/zidebactam showed consistent activity against single- or dual-carbapenemase-producing isolates including E. coli with PBP3 inserts.

A study of community-associated methicillin-resistant Staphylococcus aureus in patients with pyoderma.

BACKGROUND: Health care-associated methicillin-resistant Staphylococcus aureus(HA-MRSA) are resistant to multiple antibiotics, therefore infections caused by them are difficult to treat resulting in high morbidity and mortality. While most of the research activities and public health initiatives are focused on HA-MRSA, the newly emerging pathogen, community-associated methicillin-resistant Staphylococcus aureus(CA-MRSA) is gaining in significance in respect to patient morbidity. There is a significant paucity of data regarding CA-MRSA in the developing parts of the world. AIM: To study the proportions of HA-MRSA and CA-MRSA infections among patients with culture-proven S. aureus infection and to find out how many of these patients showed presence of MRSA in nasal cultures of healthy contacts. MATERIALS AND METHODS: Clinical details of 227 patients were recorded in the study, such as the duration and recurrence of the infection, history of antibiotic intake, and the presence of other medical illnesses. A pus swab was taken from each lesion and sent for culture and sensitivity. If the culture grew S. aureus, they were screened for methicillin resistance. A swab from the anterior nares of the healthy contact of each patient, whenever available, was collected and it was screened for MRSA. RESULTS: Furunculosis was most common among the primary pyodermas (53/134; 39. 5%). Out of 239 pus culture samples obtained from 227 patients, 192 (84.58%) grew S. aureus; of these 150 (78.12%) were methicillin-sensitive S. aureus (MSSA), whereas 42 (21.98%) were MRSA. Out of the 42 MRSA isolated, 33 turned out to be CA-MRSA (78%) and 9 (22%) were HA-MRSA. Nasal swabs of healthy contacts of 34 MRSA patients were cultured. Out of them, two grew MRSA in the culture. CONCLUSION: The isolation rate of S. aureus was high in our study. Furthermore, our study, although hospital based, clearly indicated the substantial magnitude of the CA-MRSA problem in the local population.

Predebridement wound culture in open fractures does not predict postoperative wound infection: A pilot study.

BACKGROUND: There is confusion in the current literature regarding the value of obtaining predebridement wound cultures in the management of open fractures with several studies reporting contrasting results. We undertook a pilot study to determine the initial bacterial flora of open fractures in our environment and determine the correlation between subsequent wound infection if any, and the initial bacterial flora. MATERIALS AND METHODS: Initial/predebridement wound swabs were obtained for 32 patients with open fractures. Patients underwent a debridement of the open wound and preliminary stabilization of fracture in the operating room within 24 h. Postdebridement wound cultures were obtained at 48 h and repeated subsequently, if indicated, during the follow-up period. The antibiotic therapy was modified based on the culture reports. RESULTS: Initial wound swab culture showed bacterial contamination in 18 patients (56%); 14 patients (44%) developed an infection in the immediate postoperative period or during follow-up. Age, gender, co-morbid medical condition, delay in presentation, and grade of open fracture were not found to be predictors of postoperative infection. No patient had an infection with the same organism, which was present in the initial culture. CONCLUSION: The findings of this study suggest that the initial flora are not the infecting organisms in the open fracture wounds, and predebridement wound cultures have no value in predicting postdebridement wound infection.

Simultaneous gut colonisation and infection by ESBL-producing Escherichia coli in hospitalised patients.

BACKGROUND: Extended spectrum betalactamase (ESBL)-producing organisms are a major cause of hospital-acquired infections. ESBL-producing Escherichia coli (E. coli) have been recovered from the hospital environment. These drug-resistant organisms have also been found to be present in humans as commensals. The present investigation intended to isolate ESBL-producing E. coli from the gut of already infected patients; to date, only a few studies have shown evidence of the gut microflora as a major source of infection. AIMS: This study aimed to detect the presence of ESBL genes in E.coli that are isolated from the gut of patients who have already been infected with the same organism. METHODS: A total of 70 non-repetitive faecal samples were collected from in-patients of our hospital. These in-patients were clinically diagnosed and were culture-positive for ESBL-producing E. coli either from blood, urine, or pus. Standard microbiological methods were used to detect ESBL from clinical and gut isolates. Genes coding for major betalactamase enzymes such as bla CTX-M , bla TEM, and bla SHV were investigated by polymerase chain reaction (PCR). RESULTS: ESBL-producing E. coli was isolated from 15 (21 per cent) faecal samples of the 70 samples that were cultured. PCR revealed that out of these 15 isolates, the bla CTX-M gene was found in 13 (86.6 per cent) isolates, the bla TEM was present in 11 (73.3 per cent) isolates, and bla SHV only in eight (53.3 per cent) isolates. All 15 clinical and gut isolates had similar phenotypic characters and eight of the 15 patients had similar pattern of genes (bla TEM, bla CTX-M, and bla SHV) in their clinical and gut isolates. CONCLUSION: Strains with multiple betalactamase genes that colonise the gut of hospitalised patients are a potential threat and it may be a potential source of infection.

Changing Trend in the Antibiotic Resistance Pattern of Pseudomonas Aeruginosa Isolated from Wound Swabs of Out-Patients and in-Patients of a Tertiary Care Hospital.

CONTEXT: Pseudomonas aeruginosa is the most common gram negative bacteria associated with nosocomial infections. Active surveillance of trends in antibiotic resistance of P. aeruginosa is necessary for the selection of appropriate antimicrobial agent for empirical therapy. AIM: To assess the rates of antibiotic resistance and multidrug resistance among P. aeruginosa isolates and to observe the trend in its resistance pattern over a period of 5 years. MATERIALS AND METHODS: Pseudomonas aeruginosa isolated from wound swabs during January to June 2007 and January to June 2012 were included in the study. Isolates were identified by conventional tests and antibiotic susceptibility was determined by disc diffusion method according to CLSI guidelines. RESULTS: A total of 307 Pseudomonas aeruginosa isolates were included in the study. Among these isolates, 165 were isolated during Jan-June 2007 and 142 were isolated during Jan-June 2012. Among in-patients, there was a significant reduction in resistance rates of the isolates to ciprofloxacin (49% to 33%), ceftazidime (50% to 33%), meropenem (35% to 19%) and imipenem (28% to 14%) in 2012. Similarly, the rate of MDR Pseudomonas aeruginosa among the in-patients decreased from 37.9% in 2007 to 23.7% in 2012 (p value 0.0241). There was no significant difference in the resistance rates of the isolates from out-patients during the two study periods. CONCLUSION: There was a significant decreasing trend in the resistance rates of the isolates to ciprofloxacin, ceftazidime, meropenem and imipenem. Reduction in the use of ciprofloxacin could be probable reason for the decreased resistance among P. aeruginosa isolates, which needs to be further investigated.

Pneumococcal carriage at age 2 months is associated with growth deficits at age 6 months among infants in South India.

Nasopharyngeal colonization is the first step in the pathway to Streptococcus pneumoniae (Spn) infection, a leading cause of childhood morbidity and mortality. We investigated the effect of Spn colonization at ages 2 and 4 mo on growth at age 6 mo among 389 infants living in rural South India by using data from an Spn carriage study nested within a randomized, double-blind, placebo-controlled community trial designed to evaluate the impact of newborn vitamin A supplementation on Spn carriage in the first 6 mo of life. Primary outcomes were weight, length, and anthropometric indices of nutritional status. Growth data at age 6 mo were available for 84% (389 of 464) of infants in the Spn carriage study. Carriage at age 2 mo was associated with increased odds of stunting [OR: 3.07 (95% CI: 1.29, 7.36) P = 0.012] and lower weight [ß: -266 g (95% CI: -527, -5) P = 0.045], length [ß: -1.31 cm (95% CI: -2.32, -0.31) P = 0.010], and length-for-age Z scores [ß: -0.59; (95% CI: -1.05, -0.13) P = 0.012] at age 6 mo. Spn carriage at age 4 mo did not affect growth. Carriage of invasive serotypes at age 2 mo was associated with decreases in mean weight [ß: -289 g; (95% CI: -491, -106) P = 0.002] and length [ß:-0.38 cm (95% CI: -1.49, -0.01) P = 0.047] at age 6 mo. Newborn vitamin A supplementation did not modify the association between Spn carriage and growth. Results suggest that pneumococcal carriage at age 2 mo is an independent risk factor for poor growth in young infants. Future studies need to clarify the role of Spn carriage on growth retardation in low-income countries.

Patient satisfaction regarding eye care services at tertiary hospital of central India.

PURPOSE: To evaluate patients' satisfaction regarding eye care services and suggest policy changes accordingly. STUDY DESIGN: Descriptive study. MATERIALS AND METHODS: This study was conducted between September 2005 and June 2006. Patients attending the eye clinic of Sadguru Netra Chikitsalaya, Chitrakoot, Madhya Pradesh, India, and admitted as in-patients in this hospital were our study population. Randomly selected patients were interviewed by trained staff. Close-ended questionnaire was used to conduct these structured interviews. Their responses were grouped into one of five categories and evaluated to determine satisfaction for different components of eye care services. RESULTS: Three hundred and twenty persons were interviewed. The satisfaction was of excellent grade among 77 (48.1%) patients attending clinic and 156 (97.5%) patients who were admitted in the hospital. The participants expressed dissatisfaction for the long waiting period in clinics, poor cleanliness, and insufficient toilet facilities. Those admitted in the hospital felt that food facilities were less than the expected quality. Child-friendly facilities received high satisfaction scores. CONCLUSION: Although eye care services both in clinics and in the wards were satisfactory according to the end-users, there are scopes for improvement. Patient satisfaction surveys should be encouraged in hospitals for better accountability and also for strengthening the quality of eye care services.

Follicular dendritic cell tumor of mesentery--a case report.

Follicular dendritic cell sarcoma also known as dendritic reticulum cell tumor is uncommon. It can arise in lymph nodes and extra nodal sites namely tonsils and intra abdominal locations. The tumor morphologically mimicks soft tissue sarcomas and hence requires immunohistochemical study for correct diagnosis. It pursues an indolent protracted course with recurrence and still be compatible with long survival. We report a case of follicular dendritic cell tumor of mesentery.

Impact of supplementing newborn infants with vitamin A on early infant mortality: community based randomised trial in southern India.

OBJECTIVE: To assess the impact of supplementing newborn infants with vitamin A on mortality at age 6 months. DESIGN: Community based, randomised, double blind, placebo controlled trial. SETTING: Two rural districts of Tamil Nadu, southern India. PARTICIPANTS: 11 619 newborn infants allocated 24 000 IU oral vitamin A or placebo on days 1 and 2 after delivery. MAIN OUTCOME MEASURE: Primary outcome measure was mortality at age 6 months. RESULTS: Infants in the vitamin A group had a 22% reduction in total mortality (95% confidence interval 4% to 37%) compared with those in the placebo group. Vitamin A had an impact on mortality between two weeks and three months after treatment, with no additional impact after three months. CONCLUSION: Supplementing newborn infants with vitamin A can significantly reduce early infant mortality.