Candiduria-Study of Virulence Factors and Its Antifungal Susceptibility Pattern in Tertiary Care Hospital.

Background The increased incidence of candiduria in hospitalized patients is due to the use of indwelling devices, long-term antibiotics, parenteral nutrition, and immunocompromised status of the patient. In this study, an attempt was made to speciate, characterize, and determine the antifungal susceptibility pattern of Candida isolated from urinary tract infections (UTIs). Materials and Methods A total of 70 Candida isolates were obtained from urine samples. The isolated Candida species were studied for the production of virulence factors like phospholipase, protease activities, hemolysin, and biofilm production. Antifungal susceptibility testing of the isolated yeasts was done using Mueller-Hinton agar supplemented with 0.5 mg/mL methylene blue by E-test method for amphotericin B, fluconazole, caspofungin, and voriconazole. Results Out of 70 isolates, Candida tropicalis was the most frequently isolated species (65.7%), followed by Candida albicans (14.3%), Candida glabrata (7.1%), Candida krusei (5.7%), Candida parapsilosis (4.3%), and Candida dubliniensis (2.9%). A total of 37.1% were biofilm producers, 62.9% showed proteinase activity, 38.6% were phospholipase positive, and 58.6% isolates showed hemolytic activity. Antifungal susceptibility profile of Candida species showed 38.6, 25.7, 15.7, and 12.9% resistance to amphotericin B, fluconazole, caspofungin, and voriconazole, respectively. Conclusion A rising trend in isolation of non-albicans Candida from urinary isolates was noticed, which was statistically significant when comparing catheterized and noncatheterized urinary isolates from our study. However, there was no statistically significant difference when different virulence factor expressions were compared among Candida spp. isolated from catheterized and noncatheterized urinary samples. Due to this rise in non-albicans Candida species causing UTI that are intrinsically resistant to certain antifungal agents like azoles and increasing incidence of antifungal resistance, it is essential to monitor the antifungal susceptibility profile of Candida species causing candiduria.

Prevalence of Clostridium difficile infection among the patients attending a tertiary care teaching hospital.

BACKGROUND: Clostridium difficile, a most important nosocomial enteric pathogen, is recognized globally as responsible for antibiotic-associated diarrhea and colitis. It is associated with considerable morbidity and mortality due to widespread use of antibiotics. AIMS: The study was done to determine the prevalence of C. difficile infection (CDI) among the patients attending a tertiary care teaching hospital in Puducherry. SETTINGS AND DESIGN: We performed a prospective cohort study in Mahatma Gandhi Medical College and Research Institute. MATERIALS AND METHODS: Around 150 patients were evaluated along with the patient details. C. difficile toxin detection was done as per the standard algorithm using the C. Diff Quik Chek Complete® assay (TECHLAB, Blacksburg, VA, USA). STATISTICAL ANALYSIS USED: Analysis was done using statistics software (SPSS 16.0, SPSS Inc., Chicago, IL, USA). RESULTS: The prevalence of CDI was found to be 4%. More toxin-positive cases were between 50 and 60 years of age, and there was no difference in gender. Intensive Care Unit showed more toxin-positive cases; however, there was no significant association between the occurrence of CDI and the primary diagnosis of the patients. CONCLUSIONS: The prevalence of CDI in our hospital was found to be 4%, which was relatively lower compared to other Indian studies. However, awareness of the risk factors may assist in identifying patients at higher risk for CDI, guide implementation of appropriate preventive measures, and modulate potential intervention measure during management.

Neonatal sepsis caused by Shewanella algae: A case report.

Sepsis remains a leading cause of mortality among neonates, especially in developing countries. Most cases of neonatal sepsis are attributed to Escherichia coli and other members of the Enterobacteriaceae family. Shewanella algae (S. algae) is a gram-negative saprophytic bacillus, commonly associated with the marine environment, which has been isolated from humans. Early onset neonatal sepsis caused by S. algae is uncommon. We report a case of S. algae blood stream infection in a newborn with early onset neonatal sepsis.

A study of antibiogram of Salmonella enterica serovar Typhi isolates from Pondicherry, India.

BACKGROUND: Enteric fever caused by Salmonella enterica serovar Typhi (S. Typhi) is an important public health problem in developing countries like India.1 The emergence of resistance to fluoroquinolones has reduced the therapeutic options available. Currently, the uniform laboratory interpretation of ciprofloxacin and azithromycin susceptibility remains unclear. AIMS: To study the antibiogram of S. Typhi isolates with special emphasis on in-vitro activity of ciprofloxacin and azithromycin. METHOD: We evaluated the antimicrobial susceptibility pattern of 16 S. Typhi isolates from January 2012 to June 2013. We also determined by Epsilometer-test (E-test) method, the minimum inhibitory concentration (MIC) of ciprofloxacin and azithromycin against these isolates and compared them with their corresponding disc diffusion sizes. RESULTS: Fifteen (93.75 per cent) isolates were sensitive to chloramphenicol, 14 (87.5 per cent) were sensitive to cotrimoxazole. All isolates were resistant to nalidixic acid. MICs for ciprofloxacin ranged from 6µg/ml to 15µg/ml and corresponding zone diameters ranged from 15mm to 26mm. MIC and zone diameters for ciprofloxacin had significant negative correlation. MICs for azithromycin ranged from 3µg/ml to 24µg/ml, corresponding zone diameters ranged from 13mm to 19mm. However, MIC and zone diameters for azithromycin had no significant negative correlation. CONCLUSION: The widespread emergence of resistance to fluoroquinolones and reappearance of sensitivity to firstline drugs has reinforced the need for antibiotic recycling. There is a need to have uniform laboratory testing guidelines for testing susceptibility to ciprofloxacin and azithromycin for S. Typhi isolates.

Antibiotic screening of urine culture as a tool for interal quality audit.

BACKGROUND: Microbiologic culture of urine is an important component in the diagnosis of urinary tract infections (UTI). However, confounding factors like the patient's current history of antibiotic usage can affect the interpretation of urine culture results. AIMS: This study was undertaken to find out the occurrence of unreported antibiotic consumption prior to urine culture and its clinical consequences. METHOD: In this descriptive study conducted from February to August 2013, we tested consecutive urine specimens for the presence of antibiotics with a modified urine antibacterial substance assay (UABA) and compared the results obtained with the accuracy of antibiotic data entry on the accompanying request forms. In addition, the consequences of culturing urine specimens with incomplete antibiotic history received in the laboratory were investigated. RESULTS: Out of 2,040 urine specimens, 721 (35.34 per cent) were UABA positive. Comparison of antibiotic screening of urine with antibiotic data entry from request forms showed 1,299 (63.68 per cent) true-negative, 38 (1.86 per cent) true- positive, 20 (0.98 per cent) false-negative, and 683 (33.48 per cent) false-positive results. The sensitivity and specificity of this test were 65.52 per cent and 65.54 per cent, respectively. The positive and negative predictive values were 5.27 per cent and 98.48 per cent, respectively. The UABA had a positive diagnostic likelihood ratio of 1.901. CONCLUSION: This internal audit demonstrates how the accurate history of current antibiotic usage in the request forms impacts the interpretation of urine culture results.

Dengue co-infection in a blood stream infection caused by Stenotrophomonas maltophilia: A case report.

Stenotrophomonas maltophilia (S. maltophilia) is an emerging opportunistic bacterial pathogen with resistance to several commonly used antibiotics. Owing to its multidrug resistance (MDR), management of S. maltophilia blood stream infection (BSI) is challenging and requires the selection of appropriate antibiotic therapy. The presence of thrombocytopenia and shock are independent risk factors associated with increased mortality in patients with S. maltophilia BSI. We describe an unusual case of S. maltophilia BSI in a middle-age female complicated by dengue fever. We highlight the importance of early recognition of both dengue and S. maltophilia infection in management of such cases.

Bacteriophage types of methicillin-resistant Staphylococcus aureus in a tertiary care hospital.

BACKGROUND: Phage typing had been utilised extensively to characterise methicillin-resistant Staphylococcus aureus (MRSA) outbreak strains in the past. It is an invaluable tool even today to monitor emergence and dissemination of MRSA strains. AIMS: The aim of this study was to determine the prevalent phage types of MRSA in south India and the association between phage types, antibiotic resistance pattern and risk factors. METHOD: A total of 48 non-duplicate MRSA strains recovered from various clinical samples during January to December, 2010 were tested against a panel of anti-staphylococcal antibiotics. Phage typing was carried out at the National Staphylococcal Phage Typing Centre, New Delhi. Out of 48, 32 hospitalised patients were followed up for risk factors and response to empirical and post sensitivity antibiotic therapy. The risk factors were compared with a control group of 30 patients with methicillin sensitive Staphylococcus aureus (MSSA) infection. RESULTS: Amongst the five prevalent phage types, 42E was most common (52%), followed by a non-typable variant (22.9%), 42E/47/54/75 (16.6%), 42E/47 (6.2%) and 47 (2%). Phage type 42E was the predominant strain in all wards and OPDs except in the ICU where 42E/47/54/75 was most common. Although not statistically significant, strain 42E/47/54/75 (n=8) showed higher resistance to all drugs, except ciprofloxacin and amikacin, and were mostly D-test positive (87.5%) compared to the 42E strain (32%). Duration of hospital stay, intravenous catheterisation and breach in skin were the most significant risk factors for MRSA infection. CONCLUSION: We found MRSA strain diversity in hospital wards with differences in their antibiotic susceptibility pattern. The findings may impact infection control and antibiotic policy significantly.

Changing Trends in Resistance Pattern of Methicillin Resistant Staphylococcus aureus.

BACKGROUND: Methicillin resistance in Staphylococcus aureus is associated with multidrug resistance, an aggressive course, increased mortality and morbidity in both community and health care facilities. Monitoring of newly emerging and prevalent Methicillin Resistant Staphylococcus aureus (MRSA) strains for their resistance patterns to conventional as well as novel drugs, are essential for infection control. AIMS: To study the changing trends in resistance patterns of MRSA at our hospital. SETTINGS AND DESIGN: This cross sectional study was carried out in a 750 bed tertiary care hospital in south India. MATERIAL AND METHODS: One hundred and two clinical isolates of MRSA which were obtained in 2004-2011 were identified by using oxacillin, cefoxitin disc diffusion test and oxacillin screening agar test. Antibiotic susceptibility test was done for commonly used non beta lactam anti-Staphylococcal drugs, as well as for anti-MRSA drugs like vancomycin, linezolid, mupirocin and rifampicin. Minimum inhibitory concentration (MIC) of vancomycin was determined by using Vancomycin HiComb strip (Himedia, Mumbai, India). Statistical Analysis which was done: Chi-square test and proportions were used to compare the two groups. RESULTS: MRSA isolates showed high resistance to co-trimoxazole (82.3%), ciprofloxacin (76.4%), gentamicin (64.7%) and tetracycline (49%) as compared to other drugs. High prevalence of ciprofloxacin resistance was detected, particularly among outpatients. Multi resistant MRSA with a ≥ 3 non-beta lactam agent resistance was 79%. All MRSA isolates were sensitive to vancomycin, linezolid, mupirocin and rifampicin. MRSA had displayed increase in resistance to most antibiotics except tetracycline in recent years. CONCLUSIONS: Taking into consideration the prevalence of multidrug resistance in MRSA, resistance patterns should be evaluated periodically and antibiotic therapy should be guided by susceptibility testing.

Detection of metallo-beta-lactamase producing Pseudomonas aeruginosa in intensive care units.

BACKGROUND: Metallo-beta-lactamase (MBL) producing Pseudomonas aeruginosa has emerged as a threat to hospital infection control, due to its multi-drug resistance, especially in intensive care units (ICUs). AIMS: This study was carried out to detect MBL producing P. aeruginosa isolates from medical and surgical ICUs, to compare and evaluate different phenotypic methods currently in use and to determine antibiograms. METHOD: A prospective study was undertaken to detect MBLs in P. aeruginosa isolates obtained from various clinical samples. A total of 49 strains were recovered from patients admitted in inpatient wards and ICUs, and screened for imipenem resistance by Kirby Bauer disk diffusion method. Detection of MBLs was further done by imipenem-EDTA disk synergy test and combined disk test. RESULTS: Out of 49 isolates, 11 isolates (22.4 per cent) were imipenem resistant. All 11 imipenem resistant P. aeruginosa strains, when further tested, were positive for MBL production by combined disk test, but, only eight showed positive results by imipenem-EDTA disk synergy test. CONCLUSION: MBL production was the main resistance mechanism in the 11 carbapenem resistant P. aeruginosa isolates collected, with multidrug resistance associating significantly with MBL production in P. aeruginosa from our institution.

Multi-drug resistant Acinetobacter species from various clinical samples in a tertiary care hospital from South India.

BACKGROUND: Acinetobacter species are gram-negative coccobacilli belonging to the group of Non-Fermenting Gram-Negative Bacilli, which are ubiquitous in nature. They cause outbreaks in intensive care units and healthcare settings, and are becoming increasingly drug resistant. AIMS: To determine the prevalence of multi-drug resistant Acinetobacter species from various clinical samples. METHOD: Clinical samples were processed as per standard microbiological techniques. Antibiotic susceptibility testing was carried out on all the Acinetobacter isolates by Kirby- Bauer disc diffusion method as per CLSI guidelines. RESULTS: A total of 122 Acinetobacter spp. were isolated. 110 (90.16 per cent) were from inpatients, and 12 (9.83 per cent) were from outpatients. Out of 122 isolates, 44 (36.06 per cent) were from the ICU. The majority of the isolates, 47 (38.52 per cent), were from pus samples followed by 25 (20.49 per cent) from endotracheal tube aspirate. Out of 122 isolates, 87 (71.31 per cent) were multi-drug resistant of which 15 (12.29 per cent) were resistant to all drugs tested. CONCLUSION: Acinetobacter infections associated with multi-drug resistant and pan-resistant strains have emerged as important nosocomial pathogens in our setting.

Detection of extended spectrum beta lactamases, ampc beta lactamases and metallobetalactamases in clinical isolates of ceftazidime resistant Pseudomonas Aeruginosa

We studied the prevalence of ceftazidime resistance in Pseudomonas aeruginosa and the rates of extended-spectrum β-lactamase (ESBL), AmpC β-lactamase (AmpC) and metallo-β-lactamase (MBL) production among the ceftazidime resistant Pseudomonas aeruginosa. A very high rate of MBL production was observed, which suggested it to be an important contributing factor for ceftazidime resistance among Pseudomonas aeruginosa.

Anterior abdominal wall abscess caused by Streptococcus pneumoniae in a patient with self-inflicted stab injury: An unusual presentation.

Streptococcus pneumoniae is a major cause of community-acquired pneumonia, otitis media, paranasal sinusitis, bacteremia and meningitis, as well as osteomyelitis and occasionally peritonitis. We report the case of a 25-year-old female who had stabbed herself with a kitchen knife above the umbilicus 10 days prior to admission. Subsequently, she developed an anterior abdominal wall abscess caused by S. pneumoniae. This case is unusual as the focus was distant from the respiratory tract, the usual primary site of infection caused by this organism. Furthermore, the case assumes significance because it occurred in the absence of any typical risk factors for S. pneumoniae.

Detection of extended spectrum beta lactamases, ampc beta lactamases and metallobetalactamases in clinical isolates of ceftazidime resistant Pseudomonas Aeruginosa.

We studied the prevalence of ceftazidime resistance in Pseudomonas aeruginosa and the rates of extended-spectrum ß-lactamase (ESBL), AmpC ß-lactamase (AmpC) and metallo-ß-lactamase (MBL) production among the ceftazidime resistant Pseudomonas aeruginosa. A very high rate of MBL production was observed, which suggested it to be an important contributing factor for ceftazidime resistance among Pseudomonas aeruginosa.

Total lymphocyte count as a tool for timing opportunistic infection prophylaxis in resource-limited settings: a study from India.

INTRODUCTION: In resource-limited settings, due to the high cost of CD4 cell count testing, physicians must decide about opportunistic infection (OI) prophylaxis without a laboratory evaluation of HIV stage and level of immune suppression. This study aimed to evaluate the correlation of total lymphocyte count (TLC), an inexpensive laboratory parameter, to CD4 count, and to determine a range of TLC cut-offs for the initiation of OI prophylaxis that is appropriate for resource-limited settings. METHODOLOGY: Spearman correlation between CD4 count and TLC was assessed in patients attending the Anti-Retroviral Therapy (ART) centre at Mysore, India. Positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity of various TLC cut-offs were computed for CD4 counts < 200 cells/mm3. Correlation and statistical indices were computed for all patients and for HIV patients with active tuberculosis. RESULTS: Good correlation was noted between the 106 paired TLC and CD4 counts (r = 0.3497).TLC < 1200cells/mm3 had 88.14% sensitivity and 34.78% specificity for CD4 count < 200 cells/mm3. In those patients with active tuberculosis, TLC < 2000cells/mm3 had 95.24% sensitivity and 100% specificity for CD4 count < 200cells/ mm3. CONCLUSIONS: TLC could serve as a low-cost tool for determining when to initiate prophylaxis in resource-constrained settings.