Prevalence and antibiogram of non-fermenting Gram-negative bacilli in blood stream infections: Study in a tertiary care centre, Western Uttar Pradesh, India.

Non-fermenting Gram-negative bacilli (NFGNB) are emerging as important cause of blood stream infections. We aimed to determine the prevalence and antibiotic susceptibility pattern of NFGNB isolated from blood of patients with sepsis. We found, in 176 patients, the most common to be Pseudomonas aeruginosa (74) and Acinetobacter baumanii complex (39) followed by Stenotrophomonas maltophilia (16), Sphingomonas paucimobilis (6), Burkholderia cepacia (5) and Ochrobactrum anthropic (1). Generally, organisms showed a good sensitivity towards colistin, carbapenems and fluoroquinolones, whereas cephalosporins were ineffective.

Addition of Questions on Parental Factors to the WHO (Integrated Management of Childhood Illnesses) IMCI-HIV Algorithm Improves the Utility of the Algorithm for Diagnosis of HIV Infection in Children.

The WHO Integrated Management of Childhood Illnesses-HIV (IMCI-HIV) algorithm and its regional adaptation have shown variable performance in clinically identifying HIV-infected children with lack of validation in low prevalence areas. Addition of certain 'parental factors' (proxy indicators of parental HIV) may improve its utility. In this study, children aged 2 months to 5 years were enrolled into Group A (n = 1000, 'suspected symptomatic HIV infected' children as per the IMNCI-HIV algorithm) and group B (n = 50, children newly diagnosed with HIV infection). Parental factors were asked and HIV infection was tested for in Group A. For Group B, retrospective data were collected regarding IMNCI-HIV algorithm signs and parental factors. Utility of individual and various combinations of IMNCI-HIV signs and parental factors to predict HIV status was evaluated. Results showed that incorporating parental factors to IMNCI-HIV algorithm improved its sensitivity and positive predictive value in identifying HIV-infected children while maintaining the same sensitivity.

Immune Response to Double Dose Hepatitis-B Vaccine using Four Dose Schedule in HIV Infected Children.

OBJECTIVE: To assess the immune response to hepatitis B vaccination in HIV infected children using 4 double dose schedule administered at 0-1-2-6 mo. METHODS: In a prospective observational study, 40 HIV infected children were vaccinated with hepatitis B virus (HBV) vaccine (20 mcg, 1 ml IM at anterolateral aspect of thigh of recombinant DNA vaccine) at 0-1-2-6 mo. Anti-HBsAb titre were assessed 4-8 wk after the last dose. Clinical severity was assessed according to WHO staging. Immune status of the patients was assessed using CD 4+ counts before the vaccination. RESULTS: Of the total 40 patients, 33 (28 boys, 5 girls) completed the study. Six patients were in pre-antiretroviral therapy (ART) care while 27 were receiving ART for a mean duration of 2.06 y. Ten patients belonged to WHO clinical stage 1, and 17, 2 and 4 patients to WHO clinical stage 2, 3 and 4 respectively. Median CD4+ cell count was 738/mm(3) and 28 patients had mild or no immunosuppression. Out of the total 33 patients who completed followup, only 2 patients (6 %) did not seroconvert (Anti HBsAb titre at end of study <10 IU/L), the rest (94 %) achieved different levels of Anti HBsAb titre at end of study. Twenty two (66 %) patients had anti HBsAb titre more than 1000 IU/L, 8 (24 %) had titre between 100 and 1000 IU/L and one (3 %) patient had level of 10-99.99 IU/L. CONCLUSIONS: In HIV-infected children who have no or mild immunosuppression, four dose, double dose schedule of HBV vaccine achieves very high seroconversion rates.

Evaluation of Immune Response to Measles Component of MMR Vaccine in Children with HIV Infection Receiving Antiretroviral Therapy.

BACKGROUND: Children with HIV (CLHIV) respond poorly to primary immunization with measles vaccine and those responding tend to lose protective titer of antibodies by 2-3 years old. Revaccinating CLHIV after immune reconstitution with antiretroviral therapy (ART) may result in good seroconversion, thereby conferring them protection from measles. The objective was to study prevalence of measles antibodies in CLHIV receiving ART before and after immunization with MMR vaccine. METHODS: CLHIV in the age 5-18 years receiving ART for >6 months and with CD 4 count >15% were included in this prospective study. Their serum was assayed for IgG measles antibodies by qualitative immune-enzymatic determination using enzyme linked immunosorbent assay. The subjects were then immunized with a single dose of MMR vaccine. A repeat venous sample was assayed for measles antibodies 8-12 weeks after immunization. RESULTS: Sixty-six subjects (46 males, 20 females, mean age 10.4 ± 2.8 years) were enrolled. The mean duration of ART was 3.4 ± 1.5 years and median CD4 count 716.5 µ/L (interquartile range: 563.3-950). At enrollment, 16 (24.2%) subjects tested positive, 8 (12.1%) equivocal and 42 (63.6%) negative for measles antibodies. After 8-12 weeks of immunization, 62 (93.3%) tested positive, 1 (1.5%) equivocal, and 3 (4.5%) negative. There was no difference among the seropositive and seronegative subjects postimmunization with respect to age, sex, duration of ART, nutritional status, CD4 count, or WHO clinical stage. No serious adverse reaction was observed to vaccination. CONCLUSIONS: MMR vaccine leads to an excellent seroconversion to measles component of vaccine in immune-reconstituted CLHIV.

Incidence, Etiology and Risk Factors Associated with Neonatal Healthcare-Associated Conjunctivitis: A Prospective Study from a Tertiary Care Hospital in India.

INTRODUCTION: Healthcare-associated conjunctivitis (HAC) can lead to serious sequelae including blindness. We conducted a one-year prospective study to determine the epidemiology of neonatal HAC at a tertiary-care hospital in India. METHODS: From the neonates fulfilling a set of predefined inclusion criteria, cases of HAC were diagnosed based on CDC guidelines. Conjunctival swabs, obtained from neonates with suggestive clinical signs, were processed using standard protocols. Twenty-eight potential risk factors were analyzed. RESULTS: We detected 24 cases of HAC among 591 enrolled neonates, with Escherichia coli being the most frequently isolated microorganism. On multivariate analysis, intubation at birth (p = 0.046) and orogastric feeding (p = 0.029) had a statistically significant association with neonatal HAC. Average hospitalization increased from 9.6 to 20.8 days for neonates diagnosed with HAC. CONCLUSION: A standardized case-definition and physician awareness of potential serious sequelae would help improve detection rates and timely institution of therapy. Hand hygiene could help control the menace of neonatal HAC.

Risk Factor Analysis in Clinical Isolates of ESBL and MBL (Including NDM-1) Producing Escherichia coli and Klebsiella Species in a Tertiary Care Hospital.

BACKGROUND: Extended-spectrum ß-lactamase (ESBL) and metallo-ß-lactamase (MBL) producing Gram negative organisms are emerging as a worldwide public health concern. AIM: To elucidate risk factors for infection with ESBL and MBL (also NDM-1) producing E. coli and Klebsiella spp. MATERIALS AND METHODS: A prospective observational study was conducted from November 2010 to March 2012. ESBL production was detected using ESBL E-test, MBL by MBL E-test and NDM-1 by polymerase chain reaction (PCR). Risk factors analysed includes age, sex, clinical specimen, type of infection, duration of hospital stay prior to collection of sample, admitting ward, antimicrobial susceptibility, previous antibiotics used, co-morbid illnesses like diabetes mellitus, immunodeficiency, low birth weight, respiratory/neurological/cardiac/haematological/liver diseases, malignancy, urinary or central venous catheter, ventilatory support, surgical procedures and dialysis. STATISTICAL ANALYSIS: z-test or Fisher's exact test. RESULTS: E. coli - ESBL producing isolates E. coli revealed female preponderance, equal incidence of hospital and community acquired infections, mostly from surgical wards, isolated from urine, age group among females >20-30 years and among males >28 days-1 year. They showed high resistance to cephalosporins, monobactam, penicillin but low resistance to carbapenems and aminoglycosides. Co-morbid conditions observed were surgery, urinary catheterisation, haematological disease, ventilatory support, diabetes mellitus and neurological disease. MBL producing strains were mainly from females, surgical wards, (including both NDM-1 isolates), hospital acquired infections, isolated from body fluids (NDM-1 positive), female genital tract specimen and urine (one NDM-1 positive). NDM-1 positive isolates belonged to age groups >5-10 year and >0-28 days and underwent surgery and urinary catheterisation. Klebsiella spp.- ESBL producing isolates showed female preponderance, hospital acquired infections, from surgical wards, high resistance levels to cephalosporins, fluoroquinolones, monobactam, but low levels to carbapenems, among males isolated from pus in age group >0-28 days and >28 days -1 year and among females from urine in >20-30 years, no significant difference when correlated with risk factors. MBL (NDM-1) producing isolates were mainly from females with age range 0 days to 70 years, mainly admitted to ICU/postoperative wards with urinary catheter in-situ, ventilatory support, surgery, diabetes mellitus, haematological and neurological disease. CONCLUSION: Risk factors for infections due to ESBL and MBL producing Gram Negative Bacteria (GNB) should be clearly identified to reduce their spread and to optimise antibiotic use.

Prospective analysis of risk factors associated with group B streptococcal colonisation in neonates born at a tertiary care centre in India.

BACKGROUND: Bacterial colonisation of neonates and the birth canal by group B streptococci (GBS) plays a significant role in the development of neonatal infections. OBJECTIVES: To determine the rate of GBS colonisation in neonates in the first 48 hours of life and to identify the risk factors associated with GBS colonisation. METHODS: To estimate GBS colonisation, a prospective cross-sectional analysis of 1050 neonates delivered at a tertiary care hospital in India was undertaken. Swabs were taken from the neonates' skin and/or mucus membranes of the external ear canal, anterior nares, umbilicus, throat and ano-rectal sites between 24 and 48 hours of age. Data regarding the various risk factors were collected on a predesigned performa. RESULTS: 338 (32·2%) of 1050 neonates had bacterial colonisation. Escherichia coli (25·9%), was the bacteria most commonly isolated, followed by Staphylococcus aureus (16·3%) and coagulase-negative Staphylococci (CONS) (12·6%). The overall rate of GBS colonisation was 3·23%. Preterm birth, respiratory distress at birth, prolonged rupture of membranes (≧18 hrs), intrapartum antibiotics, underlying medical illness in the mother, prolonged labour, maternal fever and other obstetric complications were identified as significant risk factors associated with neonatal GBS colonisation (P<0·05). CONCLUSION: Multi-centre and community-based studies in India are recommended to identify the true colonisation rates for GBS, and it is necessary to perform cultures from multiple body sites of neonates in order to obtain an accurate bacteriological evaluation.

Fever of unknown origin attributable to haematocolpos infected with Salmonella enterica Serotypetyphi resistant to nalidixic acid: a case report.

The prevalence of nalidixic acid-resistant Salmonella Typhi (NARST) infection is increasing worldwide. We are reporting an unusual case of infected haematocolpos presenting as urinary obstruction in a patient with fever of unknown origin (FUO). This case report highlights the importance of quinolone-resistant typhoid fever in the differential diagnosis of any acute febrile illness in countries, like India, where Salmonella infection is endemic.

Youngest survivor of naegleria meningitis.

Primary amebic meningoencephalitis (PAME) is a rare condition, usually caused by free living motile amebae. These are universally fatal infections with very few survivors reported till now. The authors report a 25-d-old boy, the youngest survivor of Naegleria meningitis. The child was admitted with a diagnosis of partially treated meningitis. Cerebro-spinal fluid wet mount examination revealed free living motile amebae resembling Naegleria, which was further confirmed by culture. He was treated with amphoterecin B, rifampicin and fluconazole for 4 wk and ventriculoperitoneal shunt for obstructive hydrocephalous. At 8 mo follow up, child has survived with neurological sequlae.

Practical disk diffusion method for detection of inducible clindamycin resistance in Staphylococcus aureus at a tertiary care hospital: implications for clinical therapy.

The increase in incidence of variety of infections due to Staphylococcus aureus and especially methicillin resistant Staphylococcus aureus has highlighted on the need for better agents to treat such infections. Also the resistance to antimicrobial agents among staphylococci is an increasing problem. The macrolide-lincosamide-streptogramin B (MLS(B)) groups of antibiotics are commonly used in the treatment of staphylococcal infections with clindamycin being the preferred agent. This study demonstrates a simple phenotypic method (D-test) for detecting inducible clindamycin resistance in erythromycin resistant strains of staphylococcus aureus & coagulase negative Staphylococcus. A total of 181 erythromycin resistant staphylococcal isolates were obtained from various clinical specimens. Among the Staphylococcus aureus isolates, 38 (25.4%) were methicillin resistant Staphylococcus aureus (MRSA) and 112 (74.6%) were methicillin sensitive staphylococcus aureus (MSSA). Constitutive resistance was seen in 56 (37.3%) of isolates. Of these 18 (47.4%) were MRSA and 38 (33.9%) were MSSA. Inducible resistance was seen in 25 (16.6%) isolates, in which 11(28.9%) were methicillin resistant Staphylococcus aureus & 14 (12.6%) were methicillin sensitive staphylococcus aureus. It is likely that the true percentage of clindamycin resistance is being underestimated, since testing for inducible resistance is not being routinely performed. So the test should be done routinely in all the labs to avoid therapeutic failures.

Conjunctivitis in the newborn- a comparative study.

BACKGROUND: Conjunctivitis of the newborn is defined as hyperemia and eye discharge in the neonates and is a common infection occurring in the neonates in the first month of life. In the United States, the incidence of neonatal conjunctivitis ranges from 1-2%, in India, the prevalence is 0.5-33% and varies in the world from 0.9-21% depending on the socioeconomic status. AIM: To study the organisms causing conjunctivitis of the newborn and to correlate the etiology with the mode of delivery. DESIGN: Single center, prospective, observational study. MATERIALS AND METHODS: A total of 300 mothers and their newborns, born over a period of one year, were included in the study. Of these 200 newborns were delivered through vaginal route (Group A) and 100 (Group B) delivered by lower segment caesarean section (LSCS). At the time of labour, high vaginal swabs were taken from the mothers. Two conjunctival swabs each from both eyes of the newborn were collected at birth and transported to Microbiology department in a candle jar immediately. RESULTS: Eight babies in Group A, developed conjunctivitis at birth. None of the babies in Group B developed conjunctivitis, this difference was statistically highly significant (P<0.000). The organisms found in the conjunctiva of the newborns in Group A were Coagulase negative Staphylococcus, α hemolytic Streptococcus, Escherichia coli and Pseudomonas spps. However, the commonest organism leading to conjunctivitis in the newborn in this study was Coagulase negative Staphylococcus. It was observed that the mothers of 5 out of 8 babies (60%) developing conjunctivitis gave history of midwife interference and premature rupture of membranes so the presence of risk factors contribute to the occurrence of conjunctivitis in the newborn. CONCLUSIONS: It is inferred that the mode of delivery and the presence of risk factors is responsible for conjunctivitis in the newborn.

Is screening of TORCH worthwhile in women with bad obstetric history: an observation from eastern Nepal.

This pilot case-control study at a tertiary-care hospital over a four-month period was aimed at evaluating the possible usefulness of screening of TORCH (Toxoplasma gondii, rubella virus, cytomegalovirus, and Herpes simplex virus) in females with bad obstetric history. The study included 12 women with bad obstetric history and a similar number of matched controls with previous normal pregnancies. A serological evaluation of TORCH infections was carried out by detecting IgG and IgM antibodies against these infections by ELISA test-kit. Statistical analysis was not done to compare the results relating to the two groups due to a small number of cases and controls included in the study. Ten (83.3%) of the 12 cases with bad obstetric history and two (16.7%) of the 12 healthy controls were serologically positive at least for one of the TORCH agents. The seropositivity rate in women with bad obstetric history was quite high compared to that in the normal healthy controls. The results suggest that a previous history of pregnancy wastage and the serological evaluation of TORCH infections during current pregnancy must be considered while managing cases with bad obstetric history.

Bacterial colonization of rings and cell phones carried by health-care providers: are these mobile bacterial zoos in the hospital?

Our objective was to assess the presence of pathogenic organisms on the rings (worn on fingers) and cell phones carried by health-care workers (HCWs) and the public. Forty-two percent of mobile phones carried by HCWs and 18% carried by the general public were found to carry one or more organisms; 82% of the rings worn by HCWs and 36% of those worn by the general public were found to be positive for the presence of at least one type of microbe.

Serological immunity to diphtheria and tetanus in healthy adults in Delhi, India.

Widespread childhood immunization with DPT (diphtheria, pertussis and tetanus) has largely eradicated diphtheria and tetanus from many countries. The reduction in the circulation of toxigenic strains has resulted in less natural boosting of adult immunity. As a result, the adult population in countries with high childhood immunization coverage have become susceptible to the disease. The duration of immunity after primary immunization to diphtheria and tetanus is limited and a reduction in immunity is common in adults. With this perspective, the present study was carried out on a random serum sample of 255 healthy individuals aged 20-50 years. The serum samples were tested for immunoglobulin G levels against diphtheria and tetanus by enzyme immuno assays. Fifty-three per cent of adults were unprotected; 22 % were seen to have only a basic protection against diphtheria; 25% were protected against both diseases; and 47% were susceptible to tetanus. The susceptibility was seen to increase with age. To avoid epidemics in the future, immunity must be improved. It is important to treat even the most trivial wound with care and tetanus toxoid immunization. Also, it is necessary to monitor the community for immunity to diphtheria using standard techniques in order to undertake epidemiological surveillances of, and prevention from, these dreadful diseases.

Cladosporium bantianum meningitis in a neonate.

Cladosporium bantianum meningitis has been reported mostly in adult farmers between 20 and 30 years of age. We report a 6-day-old male neonate who was admitted with fever, focal seizures and not accepting feeds. Initial investigations suggested a diagnosis of pyogenic meningitis but antibiotic therapy for 14 days did not result in any significant clinical improvement. Repeat CSF examination after 14 days suggested a diagnosis of C. bantianum meningitis which was supported by presence of multiple abscesses in the cerebral cortex on CT scan of the head and confirmed by CSF culture. Clinical response to antifungal therapy remained unsatisfactory.