Assessment of in vitro colistin susceptibility of carbapenem-resistant clinical Gram-negative bacterial isolates using four commercially available systems & Whole-genome sequencing: A diagnostic accuracy study.

AIM: To analyze the diagnostic utility of commercially available platforms and Whole-genome sequencing (WGS) for accurate determination of colistin susceptibility test results. MATERIAL & METHODS: An exploratory diagnostic accuracy study was conducted in which sixty carbapenem-resistant Gram-negative bacteria were subjected to identification and AST using MALDI-TOF MS & MicroScan walkaway 96 Plus. Additional AST was performed using the BD Phoenix system and Mikrolatest colistin kit. The test isolates were subjected to Vitek-2 and WGS at CRL, Bengaluru. RESULTS: There was no statistically significant agreement between the colistin susceptibility results obtained by WGS, with those of commercial phenotypic platforms. The MicroScan 96 Plus had the highest sensitivity (31 %) & NPV (77 %), and the BD Phoenix system had the highest specificity (97 %) and PPV (50 %), respectively, for determining colistin resistance. CONCLUSION: The utility of WGS as a tool in AMR surveillance and validation of phenotypic AST methods should be explored further.

Percutaneous Cholecystostomy to Manage a Hot Gallbladder: A Single Center Experience.

Objective A percutaneous cholecystostomy (PC) is a suitable option for treating acutely inflamed gallbladders. Its use has been postulated before for treating acute cholecystitis (AC), especially in elderly populations. The primary aim of our study is to analyze and present the positive results of PC as a bridge to laparoscopic cholecystectomy. Methods All patients who underwent PC at our hospital, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, London, GBR, from October 2020 were reviewed using a retrospective approach. Results Our study comprises 123 patients, with 72 females (58.5%) and 51 males (41.4%). In our study, many patients had significant comorbidities, and some of them were categorized as high-risk due to their frailty and medical conditions. The majority of the patients were in American Society of Anaesthesiologists' (ASA) groups II and III (45, 61), respectively. Though hospital stays can depend on variable factors, in our experience, the mean hospital length of stay was 12.7 days. In our study, 119 patients (96.8%) had the procedure through the interventional radiological approach, while only four patients had it through the laparoscopic approach. The transhepatic route for drainage was more commonly practiced at our center and was used in 108 patients. At the time of writing this article, 54 patients have already had a laparoscopic cholecystectomy (LC) done as an interval procedure after surpassing the acute attack of cholecystitis, while 42 patients are still awaiting their surgical procedure. Conclusion Our results show that PC is a viable option, especially in cases of AC that are not responding to conservative treatments. Our study has shown low complications and conversion rates after PC. We believe PC is a safe and effective tool for managing severe and refractory cases of AC.

Technical Tips Following 850 Consecutive One Anastomosis Gastric Bypass (OAGB) Patients.

Background: The surgical procedure One Anastomosis Gastric Bypass (OAGB) has become widely used worldwide. Since its inception, many modifications have been introduced to improve results. Objectives: The primary aim of this study was to share the modifications that we have introduced to our OAGB technique after reflecting on the problems and complications we have faced during the evolution of this procedure in our unit. Method: A total of 850 patients who underwent OAGB under the same surgical team at two different hospitals in the United Kingdom were displayed according to demography and comorbidities. All complications were reviewed and analysed to instigate the changes in our technique. Results: There were 756 (89%) primary and 94 (11%) revisional procedures. There were 596 females (70.11%) and 254 males (29.89%) in our study group. The body mass index range was 32-84 and the mean was 45. The pre-operative weight range was 89-274 kg and the mean was 126.4 kg. Conclusions: With experience and reflecting on our complications we have modified our surgical approach, and these alterations have helped us to adopt OAGB as the mainstream bariatric procedure. We want to share our experience with the bariatric community for the benefit of patient care.

Role of Matrix-Assisted Laser Desorption Ionization-Time-of-Flight Mass Spectrometry for Species Identification of Acinetobacter Strains.

Introduction Acinetobacter species has become a leading cause of nosocomial infections in recent years. Objectives The aim of the study was to establish the usefulness of matrix-assisted laser desorption ionization-time-of-flight (MALDI-TOF) mass spectrometry (MS) for the identification of Acinetobacter species with respect to conventional biochemical methods and MicroScan WalkAway 96 Plus system and to compare the antibiotic susceptibility test results Kirby-Bauer disk diffusion method with MicroScan WalkAway 96 Plus automated identification and antimicrobial susceptibility testing system. Materials and Methods The study sample comprised 100 clinical isolates of Acinetobacter species. They were all identified using MALDI-TOF MS and compared with other two identification systems. Statistical Analysis Comparison of categorical variables by Fisher's exact test or Pearson's chi-square test was done. All statistical tools were two tailed, and a significant level p < 0.05 was used. All statistical tests were performed using SPSS v22.0 (Armonk IBM Corp., New York, United States). Cohen's kappa coefficients were also calculated and used as applicable. Results MALDI-TOF MS revealed 92 A. baumannii , 2 Acinetobacter nosocomialis , 3 Acinetobacter lwoffii , and 1 each was identified as Acinetobacter junii , Acinetobacter johnsonii , and Acinetobacter tandoii . There was moderate agreement between identification by MicroScan WalkAway and MALDI-TOF, and substantial agreement between conventional biochemical tests and MALDI-TOF. We found that there was a 100% categorical agreement with respect to susceptibility of aminoglycosides (amikacin, gentamicin, tobramycin) and cephalosporins (ceftazidime, cefepime, cefotaxime) between disk diffusion method and MicroScan WalkAway 96 Plus system. Total of 16 errors were observed. Conclusion Although MALDI-TOF MS could be useful to identify A. baumannii but not other species in the genus, it is a rapid, reliable method and can be routinely used in clinical laboratories.

Diverticulosis and Diverticulitis: Epidemiology, Pathophysiology, and Current Treatment Trends.

Diverticular disease is a common surgical condition, especially in the Western world. Its existence is well known in Asian countries as well; however, its impact on Asian health care is not the same as that in Western countries. Diverticular disease has a variable presentation, and its implications can be challenging to manage both for the patient and the medical professionals. Diet and lifestyle are commonly associated with its etiology. In Western countries, much attention is given to diverticular disease, and with the acceptance of colonoscopy as a surveillance investigation, a greater number of people are diagnosed with diverticular disease at an early stage and overall. In acute presentations, a CT scan of the abdomen remains the investigation of choice. The most common presentation of diverticular disease is pain in the abdomen or a change in bowel habits. In most cases, diverticular disease is treated with medical intervention; however, in cases associated with severe complications or advanced stages, surgical modality remains the primary treatment.

An insight into whole genome sequencing data of methicillin-resistant Staphylococcus aureus circulating in a teaching hospital in North India.

PURPOSE: To provide an insight into the Whole-genome sequencing (WGS) data of MRSA strains circulating in a teaching hospital in north India. METHODS: An exploratory study was conducted in which fifty non-repetitive MRSA isolates obtained from pus samples of inpatients from July 2018 to February 2019 were subjected to preliminary identification (ID) and antibiotic susceptibility testing (AST) at our centre. These isolates were later sent to Central Research Laboratory, India for further testing using the VITEK-2 compact system followed by WGS. Only eighteen isolates were eventually considered for final analysis and the rest (n â€‹= â€‹32) were excluded due to various technical reasons. RESULTS: The WGS confirmed MRSA isolates predominantly belonged to CC22 (56.25%) and CC30 (31.25%). The CC22 MRSA strains carried SCCmec types IVa (77.8%) & IVc (22.2%) and belonged to spa types t005 (44.4%), t4584 (22.2%), t11808 (11.1%), t1328 (11.1%) and t309 (11.1%), respectively. The MRSA isolates of CC30 carried SCCmec types IVa (60%), IVg (20%) & V (20%) and belonged to spa types t021 (80%) & t2575 (20%), respectively. One MRSA isolate carried a novel SCCmec type V. The luk-PV and tsst-1 genes were present in 93.75% and 33.33% of MRSA isolates, respectively. The concordance between the phenotypic and genotypic AST results was 100% for Beta-lactams, Fluoroquinolones, Tetracyclines & Lipoglycopeptides, respectively. CONCLUSIONS: Through this study, we intend to embark upon a relatively newer avenue of clinical-genomic surveillance of nosocomial bacterial isolates like MRSA, which would help us improve the existing infection control and antibiotic stewardship practices in our hospital.

Bovine Fibroblast-Derived Extracellular Matrix Promotes the Growth and Preserves the Stemness of Bovine Stromal Cells during In Vitro Expansion.

Cultivated meat is a fast-growing research field and an industry with great potential to overcome the limitations of traditional meat production. Cultivated meat utilizes cell culture and tissue engineering technologies to culture a vast number of cells in vitro and grow/assemble them into structures mimicking the muscle tissues of livestock animals. Stem cells with self-renewal and lineage-specific differentiation abilities have been considered one of the key cell sources for cultivated meats. However, the extensive in vitro culturing/expansion of stem cells results in a reduction in their abilities to proliferate and differentiate. Extracellular matrix (ECM) has been used as a culturing substrate to support cell expansion for cell-based therapies in regenerative medicine due to its resemblance to the native microenvironment of cells. In this study, the effect of the ECM on the expansion of bovine umbilical cord stromal cells (BUSC) in vitro was evaluated and characterized. BUSCs with multi-lineage differentiation potentials were isolated from bovine placental tissue. Decellularized ECM prepared from a confluent monolayer of bovine fibroblasts (BF) is free of cellular components but contains major ECM proteins such as fibronectin and type I collagen and ECM-associated growth factors. Expansion of BUSC on ECM for three passages (around three weeks) resulted in about 500-fold amplification, while cells were amplified less than 10-fold when cultured on standard tissue culture plates (TCP). Moreover, the presence of ECM reduced the requirement for serum in the culture medium. Importantly, the cells amplified on ECM retained their differentiation abilities better than cells cultured on TCP. The results of our study support the notion that monolayer cell-derived ECM may be a strategy to expand bovine cells in vitro effectively and efficiently.

Clinico-Microbiological Profile and Clinical Predictor of Urinary Tract Infection in Children: A Single-Center Study From Himalayan Foothills.

BACKGROUND:  Urinary tract infection (UTI) in children is one of the commonest bacterial infections seen in the pediatric population. Clinical presentation ranges from fever with or without focus and isolation of microbiological agents streamline the treatment. Moreover, local/regional microbial profiles are helpful in antibiotic selection, we conducted a study to assess the prevalence of urine culture positivity in a suspected case of UTI. In addition, antibiotic susceptibility patterns and ultrasonography (USG) finding in culture-positive patients were also studied. METHODS AND MATERIALS: It is a prospective observational study comprising symptomatic children aged one month to 18 years presenting to the outpatient department (OPD), inpatient department (IPD), and the emergency department of Pediatrics with UTI during the period of September 2019 to September 2020. The recorded variables were demographic, clinical presentation, anthropometry, physical examination, blood biochemistry, and outcome. Urine samples were collected and processed as per standard protocols. USG was done for all culture-positive children. Data were presented as frequency, mean (SD) and parametric and non-parametric data were analyzed by Wilcoxon-Mann-Whitney U Test, Chi-Squared Test, or Fisher's Exact Test.  Results: Of the total 354 children, 202 (57.1%) were male and the prevalence of UTI was 64 (18.1%). E. coli (70.3%) was the commonest isolated organism followed by Klebsiella spp (15.6%) and Pseudomonas spp (7%) respectively. The mean (SD) age (months) of presentation of symptoms was significantly lower in culture-positive children as compared to [ 83.49 (58.96) vs 110.10 (58.60); p=0.001] culture-negative children. Fever (96.6%) followed by dysuria (20.1%) were the most common symptoms presented for UTI however dysuria (p=0.003), pus cells (p<0.0001), and RBCs (p=0.002) were significantly present in culture positive children. This study shows increased resistance to third generation of cephalosporins. This study revealed significant differences among various groups (organism growth in positive culture) and the Antibiotic susceptibility test (AST) with a p-value of <0.001.  Conclusion: The prevalence of culture-positive UTI was similar to the reported literature and the presence of fever, dysuria, pus cells, and RBC in urine were commonly observed in the lower age group. Amikacin can be used in suspected UTIs with cephalosporin as empirical antibiotics in the Himalayan Foothills region.

Post-COVID pulmonary fungal infections: An unanticipated predicament or a ticking time bomb? Clinico-microbiological profile of cases encountered during the second wave of COVID-19 pandemic at a teaching hospital in the Himalayas with a brief literature review.

Introduction: This study attempts to generate preliminary data regarding post-COVID pulmonary fungal infections, namely, COVID-19-associated pulmonary aspergillosis (CAPA), COVID-19-associated pulmonary mucormycosis (CAPM), and mixed infections from the Himalayas and compares the micro-radio-clinical profile and outcomes of the affected patients. Materials and Methods: A retrospective data analysis was conducted, where clinical profiles, microbiological and radiological reports, and outcomes of n = 16 patients of post-COVID pulmonary infections were compared. Results: Of n = 16 patients, n = 7 had CAPA (n = 5 Aspergillus fumigatus, n = 1 Aspergillus flavus, and n = 1 Aspergillus niger), n = 5 CAPM (Rhizopus arrhizus), and n = 4 with mixed infections (n = 3 infected with Aspergillus fumigatus and Rhizopus spp. and n = 1 with Aspergillus flavus and Rhizopus arrhizus). Thick-walled cavitary lesions, air-fluid levels, and multiple centrilobular nodules were some of the common radiological findings reported among these patients. Conclusion: The immuno-compromised state following COVID-19 infection and treatment might be responsible for the progression of regular exposure to the dense Himalayan vegetation into an invasive pulmonary fungal infection. Suspecting post-COVID pulmonary fungal infection is necessary for primary care physicians to ensure timely referral to higher centers. Mixed pulmonary fungal infections (coinfection with Aspergillus spp. and Rhizopus spp.) are also emerging as important sequelae of COVID-19.

Measurement of malignant spiculated mass lesions on mammogram: Do we include the length of the spicules?

AIM: The aim of this study is to determine if the core size or size with spicules has a better correlation with the final histologic size of spiculated mass lesions. METHODS: A retrospective study of 48-month duration from January 2014 to December 2017 of biopsy-proven invasive ductal carcinoma presenting as spiculated mass lesions on mammogram was conducted. RESULTS: There were 195 patients in the study. The mean of the core size was 16.6 mm; when spicules were included the mean size was 27.4mm and final histologic size 21.1 mm. Using unpaired Student 't' test difference in the means was statistically significant (p<0.0001). Pearson number (R) core size versus final histologic size was 0.535 (P < 0.001) and for size with spicules versus final histologic size was 0.495 (P < 0.001). CONCLUSION: Our study demonstrated that the core size has a stronger positive correlation to final histologic size and should be used preoperatively in decision-making about surgery.

Epidemiology of paediatric pyogenic musculoskeletal infections in a developing country.

Background: Epidemiological data regarding paediatric pyogenic musculoskeletal infections from developing countries of Asia and Africa are sparse and further complicated by the presence of factors like malnutrition, delay in initiating treatment and belief in alternative forms of treatment and under vaccination. The aim of this study is to retrospectively analyse the cases of paediatric pyogenic musculoskeletal infections in a tertiary care centre in India. Methods: It is a retrospective study including patients below 18 years of age who had been diagnosed with any pyogenic musculoskeletal infection. Demographic, clinical, laboratory, and radiological details were collected. Results: A total of 216 children, with a mean age of 12.8 ± 4.9 years (10 days-18 years), were included in the study. The causative organism could be isolated in 98 cases (45.3%). Escherichia coli and methicillin-sensitive Staphylococcus aureus were the most common pathogens isolated in infants and children, respectively. Imipenem and linezolid were the commonest sensitive antibiotics for children up to 10 years and above 10 years, respectively. Linezolid was the antibiotic of choice in culture-negative cases. The majority (78.3%, n = 169) of children underwent a surgical procedure during the stay at the hospital. A higher relapse rate (61%) was noted in culture-negative patients. Conclusion: Improved methods of pathogen detection should be explored to improve the rate of positive cultures. Additional prospective studies with longer patient follow-up and the creation of care protocols are necessary to improve therapeutic decision-making and the prognosis for children with suspected musculoskeletal infection.

Comparative Evaluation of Colistin Broth Disk Elution Method With Two Commercially Available Systems for Colistin Susceptibility Testing Against Carbapenem-Resistant Klebsiella pneumoniae: A Single-Center Exploratory Study.

PURPOSE: The purpose is to explore the diagnostic utility of colistin broth disk elution (CBDE) as a simple and reliable method of colistin susceptibility testing. MATERIALS AND METHODS: An exploratory study was undertaken in a tertiary care teaching hospital in Uttarakhand, from September 2021 to March 2022, after obtaining approval from the Institute Ethics Committee. Twenty-five non-repetitive carbapenem-resistant Klebsiella pneumoniae clinical isolates were included in the study. Matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS) and BD Phoenix M50 system were used to perform species-level identification and antibiotic susceptibility testing (AST), respectively, as per the manufacturer's instructions. AST results (including those of colistin) were interpreted as per the CLSI guidelines 2022. The test isolates were further subjected to additional in vitro colistin susceptibility testing using a commercially available Mikrolatest colistin susceptibility testing kit and CBDE, respectively. RESULTS: The in vitro colistin resistance rates varied from 8% by BD Phoenix system to 20% by Mikrolatest kit and 32% by CBDE, respectively. For colistin susceptibility, a higher CA was observed between the BD Phoenix system and CBDE (64.71%) than between the Mikrolatest kit and CBDE (31.60%). Overall, a statistically significant fair agreement was observed between the BD Phoenix system and CBDE (Kappa: 0.312; 95% CI: 0.036 to 0.660) and Mikrolatest MIC colistin kit and CBDE (Kappa: 0.286; 95% CI: 0.111 to 0.683), respectively. CONCLUSIONS: In vitro colistin testing remains a significant challenge globally. Although the present study results are inconclusive due to the small sample size, we should conduct multi-centric studies globally, taking a considerable sample size representing different Gram-negative bacilli to generate conclusive evidence on the utility of CBDE as a reliable method of colistin susceptibility testing.

The Mystery of Mucormycosis in COVID-19: A Multifactorial Menace or an Enigmatic Delta Variant Associated Phenomenon? An Exploratory Study from a Tertiary Care Centre in North India with a Brief Literature Review.

Background: There was a global surge in cases of mucormycosis in COVID-19 patients during the second wave of the pandemic in 2021, reported especially from India. Various predisposing factors such as diabetes mellitus, rampant use of corticosteroids, and COVID-19 per se may be responsible for this spike. Some public health experts have postulated that the epidemiological link between the Delta variant of SARS-CoV-2 and mucormycosis should be explored. Material and Methods: A retrospective exploratory study was conducted, in which data of 15 laboratory-confirmed cases of COVID-19 with mucormycosis and/or aspergillosis co-infections were collected after obtaining approval from the institute's ethics committee. These patients were admitted to the Mucor wards of our hospital. The positive COVID-19 status of these patients was confirmed by reverse transcriptase-polymerase chain reaction (RT-PCR). The residual SARS-CoV-2 RNA containing elutes of these patients were stored at -80°C in deep freezers and subjected to whole-genome sequencing in June 2021 at the National Centre for Disease Control (NCDC), New Delhi, India as part of the Indian SARS-CoV-2 Genomic Consortia (INSACOG) program. Concomitant fungal infections in these patients were diagnosed by KOH wet mount and fungal culture as per standard guidelines. Descriptive statistics in the form of percentages and median were used to report the findings. Results: Periorbital swelling and ocular pain (14/15; 93.33%), followed by facial swelling (11/15; 73.33%) and nasal obstruction (9/15; 60%), were the most common clinical features observed in these patients. Rhizopus arrhizus was the most common causative fungal agent (12/15; 80%). The majority of the patients (9/13; 69.23%) were infected with the Delta variant of SARS-CoV-2. Conclusion: COVID-associated mucormycosis seems to be multifactorial in origin. Although there may be a possible association between mucormycosis and the Delta variant, more studies should be conducted to explore this seemingly reasonable proposition.

Comparative Evaluation of Two Automated ID/AST Systems and Mikrolatest Kit in Assessing the In Vitro Colistin Susceptibility of Carbapenem-Resistant Enterobacteriaceae Isolates: A Single-Center Exploratory Study from North India.

Aims: To generate preliminary data about comparative evaluation of two automated ID/AST systems and Mikrolatest kit in determining in vitro colistin susceptibility of carbapenem-resistant Enterobacteriaceae spp. Materials and methods: Twenty-three carbapenem-resistant Escherichia coli and Klebsiella pneumoniae and two carbapenem-sensitive multidrug-resistant E. coli isolates obtained from various clinical samples of inpatients were included in the study. Species-level identification and antibiotic susceptibility testing (AST) of test isolates was performed using BD phoenix and MicroScan WalkAway 96 Plus automated systems. Identity was reconfirmed by matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS). Additional colistin susceptibility testing was performed using Mikrolatest MIC colistin susceptibility testing kit (reference method). Results: Results showed that 16% isolates (27.3% [3/11] K. pneumoniae and 7.1% [1/14] E. coli) exhibited in vitro colistin resistance by the reference method. While the categorical agreement between BD Phoenix M50 ID/AST system and reference test w. r. t in vitro colistin susceptibility results was 100% and 92.9% for K. pneumoniae & E. coli, respectively, it was much lower between MicroScan WalkAway 96 plus ID/AST system and the latter. Almost perfect agreement (96%; kappa: 0.834) was observed between BD Phoenix M50 system and reference method. Conclusions: The results of this study are preliminary and cannot be generalized. Multicentric studies with large sample sizes should be conducted throughout the country to gain a deeper understanding of the subject under consideration.