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.

Chronic diarrhea and parasitic infections: Diagnostic challenges.

BACKGROUND: Diarrhea is among the top ten global causes of death. Chronic diarrhea may have destructive impact on physical and mental health of patients and is also associated with high risk of mortality in children. Parasitic intestinal infections remain an important cause of chronic diarrhea especially in the developing part of the world. OBJECTIVE: To study the parasitic causes of chronic diarrhea and highlight the challenges faced in the diagnosis of chronic diarrhea caused due to parasitic infections. CONTENT: Due to non-specific symptoms, insensitive available diagnostic techniques, asymptomatic carriage and transmission, recurrent infections in endemic areas, pose a challenge for diagnosis of the parasitic infections and thus delay the treatment. Conventional techniques like microscopy, though cheaper are not very sensitive. Advanced techniques like molecular methods are more sensitive but expensive and are not readily available in resource limited settings. Newer cost-effective diagnostic techniques with higher sensitivity and specificity are required to detect the infectious agent and for appropriate management.

Evaluation of hand hygiene compliance over the years, in an intensive care unit of a north Delhi hospital preparing for accreditation: A 3-year study.

INTRODUCTION: World Health Organization (WHO) initiated a global movement to achieve universal health coverage (UHC). Hand hygiene (HH) is critical for achieving UHC as it is a practical and evidence-based approach with a gaugeable impact on the quality of care and patient safety in healthcare. MATERIAL AND METHODS: A cross-sectional observational study was conducted in an intensive care unit of a government hospital spanning a period of 3 years. WHO single-observer direct observation technique was used and HH compliance was noted. The results were compared over the years since the hospital was preparing to undergo a National Accreditation Board for Hospitals and Healthcare (NABH) assessment. RESULTS: The overall compliance significantly increased over the years (P < 0.0001). HH compliance for hand rub (HR) and hand wash (HW) was compared among doctors, nurses, and ICU technicians, respectively. HR compliance remained more or less the same over the years (P = 0.4738) while HW compliance significantly improved (P < 0.0001). CONCLUSIONS: This is one of the first studies from our country evaluating HH compliance over the years in a healthcare setup undergoing accreditation. During the course of the study, we observed a significant increase in HH compliance. This can be attributed to the unflinching support of our hospital's administration and relentless efforts of our infection control team. This is our first step initiative towards improving HH and thus preventing healthcare-associated infections (HCAIs) in our setup.

Isolation of Salmonella typhi from high vaginal swab in a case of septic abortion.

Salmonella Typhi can be a significant cause of morbidity and mortality in pregnant females with adverse outcomes. Risk of infections increases manifold during pregnancy due to hormonal changes and immunological phenomena. S. Typhi has the ability to cross placenta (vertical transmission) resulting in miscarriage, stillbirth or premature labour. We report a case of a pregnant female who was admitted to emergency department with fever, missed abortion and hypovolaemic shock. Subsequently, S. Typhi was isolated from her high vaginal swab and blood cultures. Follow-up cultures were negative for S. Typhi, and the patient was discharged after 10 days. The possibility of salmonellosis should be considered if a pregnant woman residing in an endemic area presents with high-grade fever. Furthermore, it should be promptly treated to prevent foetal loss.

Staphylococcal bullous impetigo in a neonate.

An otherwise healthy, full-term neonate presented at day 15 of life to the pediatric emergency with generalized papulo-pustular rash for 2 d. This was finally diagnosed as bullous impetigo caused by Staphylococcus aureus (S. aureus). The skin lesions decreased significantly after starting antibiotic therapy and drainage of blister fluid. There was no recurrence of the lesions on follow-up. This case of generalized pustular eruption due to S. aureus in a neonate is reported, as it poses a diagnostic dilemma and can have serious consequences if left untreated.

Staphylococcus aureus phage types and their correlation to antibiotic resistance.

CONTEXT: Staphylococcus aureus is one of the most devastating human pathogen. The organism has a differential ability to spread and cause outbreak of infections. Characterization of these strains is important to control the spread of infection in the hospitals as well as in the community. AIM: To identify the currently existing phage groups of Staphylococcus aureus, their prevalence and resistance to antibiotics. MATERIALS AND METHODS: Study was undertaken on 252 Staphylococcus aureus strains isolated from clinical samples. Strains were phage typed and their resistance to antibiotics was determined following standard microbiological procedures. STATISTICAL ANALYSIS: Chi square test was used to compare the antibiotic susceptibility between methicillin resistant Staph. aureus (MRSA) and methicillin sensitive S. aureus (MSSA) strains. RESULTS: Prevalence of MRSA and MSSA strains was found to be 29.36% and 70.65% respectively. Of these 17.56% of MRSA and 40.44% of MSSA strains were community acquired. All the MSSA strains belonging to phage type 81 from the community were sensitive to all the antibiotics tested including clindamycin and were resistant to penicillin. Forty five percent strains of phage group III and 39% of non-typable MRSA strains from the hospital were resistant to multiple antibiotics. CONCLUSION: The study revealed that predominant phage group amongst MRSA strains was phage group III and amongst MSSA from the community was phage group NA (phage type 81). MSSA strains isolated from the community differed significantly from hospital strains in their phage type and antibiotic susceptibility. A good correlation was observed between community acquired strains of phage type 81 and sensitivity to gentamycin and clindamycin.

A prospective double-blinded comparative analysis of framycetin and silver sulphadiazine as topical agents for burns: a pilot study.

Burn wound sepsis remains the leading cause of mortality if conservative methods of wound management are employed. Topical agents are still the mainstay of such wound management in the developing world. Non availability of agents like Mafenide or silver ion dressings in the developing world due to corporate strategies or cost concerns necessitates a search for alternatives to silver sulphadiazine, which is the gold standard. We report the use of framycetin 1% cream (Soframycin) in 20 patients of major burns (ranging from 15% to 40% TBSA), and in a double blinded study quantitatively comparing the bacterial load on day 4 and day 7 with a group of similar patients in whom silver sulphadiazine was used. The age group of the 40 patients was 10-50 years and they were without any co-morbid condition. All bacterial isolates from the 40 patients were also tested for framycetin sensitivity. Serial kidney function tests were done on all patients, and patients in the framycetin group underwent an audiometric testing at a mean time of 28 days. All results were statistically analyzed. It was noted that there was no statistically significant difference in the colony counts on days 4 and 7 between the two groups. As a corollary, it was also evident that there was no statistically significant difference in the rise in colony counts from day 4 to day 7 in the two groups. Sixty-four percent of all bacterial isolates were sensitive to framycetin, although, this could not be compared with sensitivity to silver sulphadiazine. It was not possible to do assays for framycetin levels in blood but no patient developed nephrotoxicity or ototoxicity with its use. According to our pilot study results framycetin appears to be an alternative to silver suphadiazine as a topical agent for major burns. Framycetin application is also painless and it leads to no discoloration of the wound.

Chronic wuchereriasis presenting as a vaginoperineal fistula: report of a case with aspiration cytologic diagnosis.

BACKGROUND: Filariasis is often an occult disease with myriad presentations. Cytology has an established role in diagnosing clinically unsuspected cases. CASE: A 20-year-old female presented with recurring perineal ulcers, vaginal discharge and inguinal lymphadenopathy. Radiology revealed a vaginoperineal fistula. Fine needle aspiration (FNA) of the ulcer bed and smears prepared from the ulcer discharge showed an adult, gravid, female filarial worm and unsheathed larvae. Similar microfilariae were also seen in FNA smears from inguinal lymph nodes. The atypical clinical presentation and unusual parasite morphology posed initial difficulties in characterization of the microfilarial species. CONCLUSION: This case report highlights the morphologic clues to the dif ferential diagnosis offilarial species on cytologic specimens. Chronic wuchereriasis presenting as a vaginoperineal fistula has not been reported previously.

Etiology of endemic viral hepatitis in urban North India.

This study was carried out to determine the presence of markers of hepatitis viruses in patients with acute liver disease. Coinfection of HAV, HBV, HCV, and HEV was studied. Sera from 306 patients with a clinical diagnosis of acute liver disease were tested for the presence of anti-HAV antibody, HBsAg, anti-HBc antibody, anti-HBs antibody, anti-HCV antibody and IgM anti-HEV antibody by ELISA. Liver function tests were correlated with the presence of infection. Of the 306 cases, 7 (2.3%) had IgM anti-HAV, 9 (2.9%) had IgM anti-HBc, 37 (12.1%) had HBsAg, 84 (27.4%) had anti-HBs, 10 (3.3%) were HCV infected and 63 (20.6%) had IgM anti-HEV. There was no significant difference in the clinical and liver function profiles of infected and uninfected patients. Similarly, no difference was observed in cases coinfected with more than one virus compared with those infected with a single pathogen. HEV had the highest prevalence amongst our cases. There was no difference in the clinical profiles of patients with non-A, non-B, non-C, non-E hepatitis by antibody assays and testing for viremia could be helpful in making the correct diagnosis.