Retrograde Conduction in Left Bundle Branch Block: Insights From Left Bundle Branch Pacing.

BACKGROUND: Biventricular pacing is a well-established therapy for patients with heart failure (HF), left bundle branch block (LBBB) and left ventricular (LV) dysfunction. Left bundle branch pacing (LBBP) has emerged as an alternative to biventricular pacing. OBJECTIVES: The aim of this study was to assess the retrograde conduction properties of the left bundle branch in patients with nonischemic cardiomyopathy and LBBB during LBBP and its clinical implications. METHODS: Patients undergoing successful LBBP for nonischemic cardiomyopathy with LV ejection fraction (LVEF) ≤35% and LBBB were included. Continuous recording of His potential was performed using a quadripolar catheter. Unidirectional block was defined as retrograde His bundle activation during LBBP with stimulus to His potential (SH) duration less than or equal to antegrade HV interval and bidirectional block as VH dissociation or SH duration greater than HV interval. HF hospitalization, ventricular arrhythmias, and mortality were documented. RESULTS: A total of 165 patients were included. The mean follow-up duration was 21.8 ± 13.1 months. Bidirectional block (group I) was observed in 82% (n = 136), and these patients were noted to have advanced HF stage and prolonged baseline QRS duration. Unidirectional block (group II) with intact retrograde conduction was observed in 18% (n = 29) and was associated with narrow paced QRS duration and higher LVEF during follow-up. Super-response (LVEF ≥50%) was observed in 54.4% (n = 74) in group I compared with 73.3% (n = 22) in group II (P = 0.03). The OR for LVEF normalization was 4.1 (95% CI: 1.26-13.97; P = 0.02), with unidirectional block compared with bidirectional block in patients with LBBB and LV dysfunction. Adverse clinical outcomes as measured by a composite of HF hospitalization, ventricular arrhythmias, and mortality were significantly higher in group I compared with group II (12.5% vs 0%; P = 0.04). CONCLUSIONS: Bidirectional block in LBBB was characterized by advanced HF symptoms, while unidirectional block was associated with better clinical outcomes after cardiac resynchronization therapy by LBBP.

Ceftazidime-Avibactam resistance in clinical isolates of carbapenem-resistant Klebsiella pneumoniae: A phenotypic and genotypic analysis.

OBJECTIVE: To find the prevalence of Ceftazidime-Avibactam (CAZ-AVI) resistant Klebsiella pneumoniae in clinical isolates and to determine the genes responsible for Ceftazidime-Avibactam resistance using PCR. METHODS: A total of 89 carbapenem resistant Klebsiella pneumoniae from various clinical samples were included in the study. CAZ-AVI resistance was tested using E-test. CAZ-AVI resistant strains were subjected to conventional PCR for detection of carbapenamase genes blaNDM- 1, blaOXA-48, blaVIM, blaIMP, blaKPC. RESULTS: Of the 89 isolates screened for CAZ-AVI resistance, 45(50.5%) isolates were found to be resistant. 42 isolates were subjected to PCR for detection of ß lactamase genes.34 isolates were positive for blaNDM-1 and all 42 isolates were positive for blaOXA-48. Co-expression of NDM-1 and OXA-48 was seen in 34 isolates. Sensitivity of mCIM test to identify a carbapenamse compared to PCR was 61.9%. Sensitivity of eCIM test to identify NDM-1 was 80%. CONCLUSION: CAZ-AVI was effective in vitro in 49.4% of the isolates. Indicating that CAZ-AVI is a promising addition to antibiotics against CRE as well as a carbapenem sparing drug in ESBL producing organisms. ß-Lactamase-related mutations are the main mechanism leading to CAZ-AVI resistance.

Extra-intestinal salmonellosis in a tertiary care centre in South India.

Background and Objectives: Extra-intestinal salmonellosis is associated with higher case fatality and is underestimated in the developing countries like India. Here we present a case series of bacteriologically proven extra-intestinal salmonellosis managed at our institute over the past two years. Materials and Methods: Retrospective analysis of bacteriologically proven extra-intestinal salmonellosis over two years between January 2020 to December 2021 was carried out. Medical records were reviewed for site of infection, evidence of any underlying or predisposing illnesses and antimicrobial susceptibility report. Results: Eight patients were diagnosed with extra-intestinal salmonellosis. Male to female ratio was 3:1. Mean age was 44 years. Four were typhoidal and four were nontyphoidal Salmonellae. The extra-intestinal sites involved were purulent aspirates from scrotum, caecum, perianal region, intraperitoneal collection, synovium, and urine. Predisposing factors include chronic myeloid leukemia, HIV and gastric malignancy. All deep seated abscess required surgical intervention. All typhoidal Salmonella (n=4) were sensitive to cotrimoxazole, ampicillin, ceftriaxone. Among nontyphoidal Salmonella, one was resistant to cotrimoxazole; two were resistant to ampicillin, ceftriaxone and three resistant to ciprofloxacin. Conclusion: The diagnosis of extra-intestinal salmonellosis requires a high degree of clinical suspicion and should be included in the differential diagnosis in patients with deep-seated abscesses.

Cerebral phaeohyphomycosis due to Cladophialophora bantiana: case report and systematic review of cases.

PURPOSE: Cladophialophora bantiana is a wonted melanized fungus causing brain abscess. In past many cases were reported from Asia, particularly from India. Of late, there is a rise in cases in places besides Asia and hence a review of the cases is warranted. METHODS: We present a case of fatal cerebral phaeohyphomycosis caused by C. bantiana and conduct a systematic review of culture confirmed brain abscess due to C. bantiana reported between 2015 and 2022. RESULTS: Of the 39 cases found, majority (68%) were immunocompromised. The various clinical presentations were headache (53%), hemiparesis (34%), visual disturbance (25%), altered sensorium (18%), aphasia/dysarthria (12%) and seizures (9%). Isolated lesion was observed in 18 (60%) patients. In the sequence of occurrence, the lesions were in frontal (30%), temporal (27%) and parietal (20%) region. There were five cases with coinfections such as concurrent detection of Nocardia pneumonia in two cases, toxoplasma DNA in brain abscess, coexisting pulmonary Cryptococcus neoformans infection and coexisting Candida in a case of brain abscess in one case each. Surgical intervention was performed in 84% cases. Antifungal therapy included voriconazole (80%), liposomal amphotericin B (76%), 5-fluorocytosine (30%), posaconazole (10%), and amphotericin B deoxycholate (6%). The overall mortality was 50% with lower mortality (42%) in regions outside Asia compared to Asia (63.6%) though not statistically significant. CONCLUSIONS: C. bantiana brain abscess is an emerging infection worldwide. Next generation sequencing is an upcoming promising diagnostic test. Early complete excision of the lesion with effective antifungals may improve the outcome.

Left bundle branch pacing lead for sensing ventricular arrhythmias in implantable cardioverter-defibrillator: A pilot study (LBBP-ICD study).

BACKGROUND: Left bundle branch pacing (LBBP) has been suggested as an alternative modality for biventricular pacing in cardiac resynchronization therapy (CRT)-eligible patients. As it provides stable R-wave sensing, LBBP has been recently used to provide sensing of ventricular arrhythmia in patients receiving implantable cardioverter-defibrillator (ICD) with CRT. OBJECTIVE: The aim of this study was to analyze the long-term safety and efficacy of the LBBP lead for appropriate detection of ventricular arrhythmia and delivery of antitachycardia pacing (ATP) in patients requiring defibrillator therapy with CRT. METHODS: CRT-eligible patients who underwent successful LBBP-optimized ICD and LBBP-optimized CRT with defibrillator were enrolled. The LBBP lead was connected to the right ventricular-P/S port after capping the IS-1 connector plug of the DF-1-ICD lead. LBBP-optimized ICD or LBBP-optimized CRT with defibrillator was decided on the basis of correction of conduction system disease. Documented arrhythmic episodes and therapy delivered were analyzed. RESULTS: Thirty patients were enrolled. The mean age was 59.7 ± 10.5 years. LBBP resulted in an increase in left ventricular ejection fraction from 29.9% ± 4.6% to 43.9% ± 11.2% (P < .0001). During a mean follow-up of 22.9 ± 12.5 months, 254 ventricular arrhythmic events were documented. Appropriate events (n = 225 [89%]) included nonsustained ventricular tachycardia (VT) (n = 212 episodes [94%]), VT (n = 8 [3.5%]), and ventricular fibrillation (n = 5 [2.5%]). ATP efficacy in terminating VT was 75%. Eleven percent of episodes (n = 29) were inappropriately detected because of T-wave oversensing. Inappropriate therapy (ATP) was delivered for 14 episodes (5.5%). Three patients (10%) had worsening of tricuspid regurgitation. CONCLUSION: Sensing from the LBBP lead for arrhythmia detection is safe as ∼90% of the episodes were detected appropriately. Future studies with a dedicated LBBP-defibrillator lead along with algorithms to avoid oversensing can help in combining defibrillation with conduction system pacing.

Right sided approach for left bundle branch pacing using lumen-less lead: Technical considerations and follow-up outcome.

INTRODUCTION: Left bundle branch pacing has gained significant momentum in the last few years. The procedure involves deploying the lead deep inside the interventricular septum through left subclavian vein. We aimed at analyzing the feasibility, efficacy and long-term outcome of left bundle branch pacing (LBBP) using lumen-less lead through the right subclavian vein. METHODS: This was a retrospective-institutional, single center observational study done in consecutive patients who underwent LBBP using 3830 selectsecuretm lead. Left subclavian venous access was the primary strategy for lead implantation. Patients requiring right sided approach due to venous obstruction or persistent left superior-vena-cava (PLSVC) for LBBP were included in the study. RESULTS: Right sided approach was successful in 16 out of 19 (84%) attempted patients. C315-His catheter was used in all patients without modifying its curvature. PLSVC (n = 7), left venous obstruction (n = 7), right sided device upgradation (n = 1) and left pocket infection (n = 1) were the reasons for right sided approach. Mean follow-up duration was 17 ± 12 months. LBBP resulted in reduction in QRS duration from 137.3 ± 37.8 ms to 122.3 ± 9.5 ms (p -.13) and increase in LV ejection fraction from 46.2 ± 16.3% to 54.4 ± 11.6% (p -.11). The mean fluoroscopy duration and radiation dose were significantly high in right sided approach (n = 16) as compared to left sided approach (n = 293). In patients requiring cardiac-resynchronization therapy (CRT), right sided LBBP resulted in reduction in QRS duration from 171.8 ± 18.5 to 125.5 ± 11.9 ms (p -.0001) and increase in LVEF from 29.1 ± 3.8 to 45.1 ± 11.9% (p -.005). CONCLUSION: Right sided LBBP is feasible, safe and effective in patients requiring pacing for symptomatic bradyarrhythmia and CRT. Further development in dedicated tools for right-sided approach would help in reducing the fluoroscopy-duration and radiation-dose.

Predictors of procedural failure of left bundle branch pacing in scarred left ventricle.

INTRODUCTION: Presence of scar at the implantation-site is considered as a major factor in determining the success of left bundle branch pacing (LBBP). We aimed at analyzing the predictors of procedural failure in patients with scarred-left ventricle (LV) as demonstrated by cardiac-magnetic resonance-imaging (CMR). METHODS: This was a retrospective, observational single-center-study that included consecutive cardiomyopathy patients with LV-scar as demonstrated by late-gadolinium-enhancement (LGE) in CMR requiring LBBP. Procedural-failure was defined as the inability to penetrate the septum to reach the LV subendocardium RESULTS: A total of 25 cardiomyopathy patients demonstrated LGE in CMR and were included in the study. LBBP was successful in 16 patients (group-I; 64% acute-procedural-success). In the remaining 9 patients (group-II) lead could not be penetrated and hence biventricular-pacing was done. LBBP resulted in reduction in QRS-duration and improvement in LV ejection fraction in group-I patients during a mean follow-up of 11.2 ± 3.7 months. Computed-tomography-angiography after LBBP showed the successful lead deployment site (LBBP-Zone) as the overlapping areas of inferior aspect of antero-septum and superior aspect of infero-septum (segment 2/3; AHA-model) in short-axis view(figure-1C). CMR showed LGE in significantly more number of LV-segments and high scar-burden in group-II as compared to group-I (figure-1). A total scar score value of >1.0 predicted failure with 100%-sensitivity and 75%-specificity. CMR revealed transmural-scar in the LBBP-Zone in all patients in group-II (n = 9; 100%). Transmural scar in LBBP-Zone by CMR had 100%-sensitivity and 100%-specificity for predicting the procedural-failure. CONCLUSION: CMR helps in predicting the procedural failure of LBBP in patients with scarred LV. Presence of transmural-LGE in the LBBP-Zone predicts failure with high sensitivity and specificity.

Elizabethkingia meningoseptica Infections: A Case Series from a Tertiary Hospital in South Tamil Nadu.

Elizabethkingia meningoseptica is an opportunistic pathogen increasingly reported as hospital-acquired infection. Here, we report a series of cases of eight patients with invasive E. meningoseptica infections over a period of 27 months in a tertiary teaching hospital from South India. Age range was 45 days to 84 years, median 66 years, with male preponderance. Associated risk factors included recent hospitalization with surgeries, diabetes mellitus, renal failure, mechanically ventilated, and central line. All isolates were susceptible to minocycline. Combination therapy with ciprofloxacin and piperacillin tazobactam was most common. Six recovered and two patients were lost to follow-up. How to cite this article: Ganesan V, Sundaramurthy R. Elizabethkingia meningoseptica Infections: A Case Series from a Tertiary Hospital in South Tamil Nadu. Indian J Crit Care Med 2022;26(8):958-960.

Risk Factors and Clinical Outcomes of Stenotrophomonas maltophilia Infections: Scenario in a Tertiary Care Center from South India.

Stenotrophomonas maltophilia, a gram-negative non-fermenter has evolved from a colonizer to a significant pathogen over the last decade. It resides in various ecological niches both inside and outside the hospital settings. Infections due to S. maltophilia can be life-threatening, especially in immunocompromised patients. S. maltophilia is intrinsically resistant to most of the antibiotics, which limits treatment options. There are several risk factors involved. The present study was done to assess the risk factors and clinical outcomes associated with S. maltophilia blood stream infections and non-blood stream infections. How to cite this article: Varshini MK, Ganesan V, Sundaramurthy R, Rajendran T. Risk Factors and Clinical Outcomes of Stenotrophomonas maltophilia Infections: Scenario in a Tertiary Care Center from South India. Indian J Crit Care Med 2022;26(8):935-937.

Hand Hygiene Auditing: Is It a Roadway to Improve Adherence to Hand Hygiene Among Hospital Personnel?

Background Over the years, there has been an increase in hospital-acquired infections (HAIs) among patients in India. One of the main reasons is a lack of compliance with infection control guidelines, such as hand hygiene. So the present study was conducted to determine the compliance of hand hygiene among healthcare workers in a private tertiary care teaching hospital in South India. Materials and methods The prospective observational study was carried out between April 2017 and March 2020. Nineteen areas were directly observed for hand hygiene (HH) compliance. At each location, HH audit was conducted for one hour per day for five days per month. HH complete adherence rate (HHCAR) and HH partial adherence rate (HHPAR) were analyzed. Results Nine hundred and twenty observation periods were completed during the entire study period. Overall, hand hygiene complete adherence rate was 29.9% (11,981/39,998); partial adherence rate was 45.3% (18,131/39,998) and the non-adherence rate was 24.7% (9886/39,998). A better adherence rate was seen among nurses (44.7%), followed by other staff (33.7%) and doctors (33.04%). Moment-specific adherence rates show almost equal adherence rates of 50.7%, 50.75%, and 50.1%, respectively, for moments 2, 3, and 4, and comparatively low for moments 1 and 5 (48.4% and 47.6%, respectively). Conclusion Despite adequate hand hygiene facilities, compliance remains low. Hand hygiene is a bundle care approach that needs to consider factors including healthcare staff, clinical, institutional, environmental, and behavioral changes. Multimodal interventions and multidisciplinary commitment are mandatory for sustained compliance.

Aerococcus viridans Bacteremia: A Rare Case Report from India.

Aerococci are fastidious, gram-positive Streptococcus-like organisms widely distributed in the hospital environment. Aerococcus viridans is primarily an opportunistic pathogen. Very few cases of A. viridans bacteremia have been reported so far probably because of its misidentification as streptococci. Here we report an interesting case of A. viridans bacteremia. How to cite this article: Varshini K, Ganesan V, Charles J. Aerococcus viridans Bacteremia: A Rare Case Report from India. Indian J Crit Care Med 2022;26(1):127-128.

Left bundle branch pacing-optimized implantable cardioverter-defibrillator (LOT-ICD) for cardiac resynchronization therapy: A pilot study.

Left bundle branch pacing (LBBP) involves direct capture of left bundle fibers by placing the lead deep inside the interventricular septum. Several studies have shown the feasibility and efficacy of LBBP as an alternative modality for cardiac resynchronization therapy (CRT). This paper describes approach for providing cost effective CRT with defibrillator (CRT-D) by LBBP and dual chamber implantable cardioverter defibrillator (ICD) which we label as LBBP optimized ICD (LOT-ICD). LBBP was performed using C315 sheath and 3830 Selectsecure lead in all patients by premature ventricular complex guided approach. In patients with complete correction of conduction system disease, IS-1 connector plug of the IS-1/DF-1 lead was capped and 3830 lead connected to the dual chamber ICD pulse-generator at RV-P/S port. LOT-ICD provided stable R-wave sensing for arrhythmia monitoring and resulted in cost-effective resynchronization therapy at reduced fluoroscopy duration and radiation dose.

Device-Associated Hospital-Acquired Infections: Does Active Surveillance With Bundle Care Offer a Pathway to Minimize Them?

Background and objective The prevalence of hospital-acquired infections (HAIs) is underreported in developing nations due to a lack of systematic active surveillance. This study reports the burden of device-associated HAIs (DA-HAIs) based on two years of active surveillance with in situ bundle care in closed intensive care units (ICUs) of a tertiary care hospital. Materials and methods A prospective surveillance study was carried out in 140-bedded ICUs (2,100-bed hospital) of a tertiary care private medical college hospital. Daily active surveillance for catheter-associated urinary tract infection (CAUTI), ventilator-associated event (VAE), and central line-associated bloodstream infection (CLABSI) was done by trained infection control nurses (ICNs) along with quality champion nurses with HAI surveillance forms with bundle care auditing, which was attached to the case sheets of all patients on devices. The surveillance definitions of DA-HAIs were adapted from the Centers for Disease Control and Prevention (CDC)'s National Healthcare Safety Network (CDC-NHSN) 2017 surveillance criteria. Data were analyzed at the end of every month to generate the cumulative device-associated infection (DAI) rates and device utilization ratio (DUR). These data were compared with NHSN and International Nosocomial Infection Control Consortium (INICC) - India HAI rates and communicated to corresponding ICUs and also presented at the hospital infection control committee (HICC) meeting. Results The surveillance data were reported over 71,877 patient days during the study period. The DUR of urinary catheters, ventilator, and central line were 0.53, 0.16, and 0.22, respectively. CAUTI, VAE, and CLABSI rates were 0.97, 10.5, and 0.43 per 1,000 device days, respectively. Among 166 DA-HAIs reported, 182 pathogens were identified. Klebsiella pneumoniae was the most common organism isolated, accounting for 37.4% of all DA-HAI cases, followed by Acinetobacter baumanii (30.8%). Most of the Gram-negative organisms were carbapenem-resistant (153/175; 87.4%). Vancomycin resistance rate in Enterococcus was 28.5% (2/7). Conclusion DUR and CAUTI, VAE, CLABSI rates were less/on par with the benchmarks of INICC and CDC-NHSN in almost all ICUs of our tertiary care unit. Gram-negative pathogen with 87.4% carbapenem resistance worsened the scenario. Proper active surveillance with bundle care and training by ICNs made a significant difference in all DA-HAI rates, especially VAE, which decreased to 10.5 from 23.6 per 1,000 ventilator days. Sustained active surveillance of HAI and bundle care auditing by a trained infection prevention team with a stringent antibiotic policy are the need of the hour to combat DAIs.

Clinical and Laboratory Factors in Predicting Mortality Among COVID-19 RT-PCR Positive Patients: A Retrospective Observational Study From a Tertiary Care Center.

BACKGROUND: In coronavirus disease 2019 (COVID-19) patients, risk stratification based on clinical presentation, co-morbid illness, and combined laboratory parameters is essential to provide an adequate, timely intervention based on an individual's conditions to prevent mortality among cases. METHODS: A retrospective observational study was carried out from June to October 2020, including all reverse transcription-polymerase chain reaction (RT-PCR) positive COVID-19 non-survivors and control group survivors randomly selected after age and sex matching. Clinical and demographic information was collected from the medical records. Categorical variables were expressed by frequency and percentage. To explore the risk factors associated with mortality, univariable and multivariable logistic regression models were used. RESULTS AND DISCUSSIONS: All non-survivors (n = 100) and 100 survivors (out of 1,018) were analyzed. Male gender (67.4%) was the independent risk factor for COVID-19 infection. Advanced age group, diabetes, cardiovascular, neurological, and hypertensive co-morbidities were statistically associated with mortality. Cardiac arrest and acute kidney injury (AKI) were the most common complications. Mortality is significantly associated with lymphopenia and raised lactate dehydrogenase (LDH), as shown by higher odds. In addition, raised neutrophils, monocytes, aspartate aminotransferase (AST), serum creatinine, interleukin 6 (IL-6), and C-reactive protein (CRP) are also significantly associated with mortality. The most common causes of death were respiratory failure (84%) and acute respiratory distress syndrome (77%). Of the non-survivors, 92% received corticosteroids, 63% were on high-flow nasal cannula oxygen therapy, 29% were mechanically ventilated, and 29% received tocilizumab. CONCLUSION: Serial monitoring of neutrophils, lymphocytes, D-dimer, procalcitonin, AST, LDH, CRP, IL-6, serum creatinine, and albumin might provide a reliable and convenient method for classifying and predicting the severity and outcomes of patients with COVID-19.

Melioidosis in a Tertiary Care Center from South India: A 5-year Experience.

The present study was done with the objective to know the clinical presentation, microbiological features, and treatment outcome of melioidosis patients in our hospital, which is an emerging infection in India, and to know the differences in clinical course and outcome between bacteremic and nonbacteremic patients. This retrospective observational study was carried out over a period of 5 years from January 2015 to December 2019. Thirty-five cases of culture-confirmed melioidosis were identified with age range between 5 and 74 years. A large number of patients (n = 31) presented with uncontrolled diabetes mellitus. Six patients died of septic shock, and the outcome of eight patients was unknown as they were discharged against medical advice. There were no relapses observed. Melioidosis growing as a neglected tropical disease in India warrants awareness among all clinicians across the country. How to cite this article: Ganesan V, Murugan M, Sundaramurthy R, Soundaram GVG. Melioidosis in a Tertiary Care Center from South India: A 5-year Experience. Indian J Crit Care Med 2021;25(3):327-330.