Cross-country transport and isolation and identification of Streptococcus pneumoniae by use of alternate sources of blood supplemented media among laboratories in India.

Background: The isolation of S. pneumoniae (Sp) depends on specimen integrity / transport, media and expertise. The non-availability of sheep blood agar poses a challenge in identification of colonial morphology and identification in India. Methods: Laboratories processed swabs containing either pure Sp or Sp in mixed cultures with a second (confounding) bacterium shipped across the country in cold conditions. Duplicate set of swabs was shipped back to the central laboratory to assess the impact of shipping on culture viability. The identical swab was cultured on sheep, human blood and one additional agar plate used in the laboratory. Results: 46/60(77%) of cultures containing only Sp were correctly identified. In specimens where Sp was present in mixed culture, the proportion of isolates in which Sp was correctly identified varied, with most variability attributed to the particular confounding organism rather than the media. There was no discernible impact of temperature-controlled (4-6°C) transport on the isolation of Sp from culture swabs. Conclusions: The study clearly elucidates the ability of laboratories for isolation of S. pneumoniae on human blood agar in resource limited settings. The results highlight the difficulties inherent in correctly identifying pathogens in mixed cultures in needs improvement using standardized tests across the study centers. The study also reaffirms the ability to transport biological specimens over long geographical distances without loss.

Tropical Fevers in Indian Intensive Care Units: A Prospective Multicenter Study.

BACKGROUND AND AIMS: Infections in tropics often present as undifferentiated fevers with organ failures. We conducted this nationwide study to identify the prevalence, profile, resource utilization, and outcome of tropical fevers in Indian Intensive Care Units (ICUs). MATERIALS AND METHODS: This was a multicenter prospective observational study done in 34 ICUs across India (July 2013-September 2014). Critically ill adults and children with nonlocalizing fever >48 h and onset < 14 days with any of the following: thrombocytopenia/rash, respiratory distress, renal failure, encephalopathy, jaundice, or multiorgan failure were enrolled consecutively. RESULTS: Of 456 cases enrolled, 173 were children <12 years. More than half of the participants (58.7%) presented in postmonsoon months (August-October). Thrombocytopenia/rash was the most common presentation (60%) followed by respiratory distress (46%), encephalopathy (28.5%), renal failure (23.5%), jaundice (20%), and multiorgan failure (19%). An etiology could be established in 365 (80.5%) cases. Dengue (n = 105.23%) was the most common followed by scrub typhus (n = 83.18%), encephalitis/meningitis (n = 44.9.6%), malaria (n = 37.8%), and bacterial sepsis (n = 32.7%). Nearly, half (35% invasive; 12% noninvasive) received mechanical ventilation, a quarter (23.4%) required vasoactive therapy in first 24 h and 9% received renal replacement therapy. Median (interquartile range) ICU and hospital length of stay were 4 (3-7) and 7 (5-11.3) days. At 28 days, 76.2% survived without disability, 4.4% had some disability, and 18.4% died. Mortality was higher (27% vs. 15%) in patients with undiagnosed etiology (P < 0.01). On multivariate analysis, multiorgan dysfunction syndrome at admission (odds ratio [95% confidence interval]-2.8 [1.8-6.6]), day 1 Sequential Organ Failure Assessment score (1.2 [1.0-1.3]), and the need for invasive ventilation (8.3 [3.4-20]) were the only independent predictors of unfavorable outcome. CONCLUSIONS: Dengue, scrub typhus, encephalitis, and malaria are the major tropical fevers in Indian ICUs. The data support a syndromic approach, point of care tests, and empiric antimicrobial therapy recommended by Indian Society of Critical Care Medicine in 2014.

Tropical fevers: Management guidelines.

Tropical fevers were defined as infections that are prevalent in, or are unique to tropical and subtropical regions. Some of these occur throughout the year and some especially in rainy and post-rainy season. Concerned about high prevalence and morbidity and mortality caused by these infections, and overlapping clinical presentations, difficulties in arriving at specific diagnoses and need for early empiric treatment, Indian Society of Critical Care Medicine (ISCCM) constituted an expert committee to develop a consensus statement and guidelines for management of these diseases in the emergency and critical care. The committee decided to focus on most common infections on the basis of available epidemiologic data from India and overall experience of the group. These included dengue hemorrhagic fever, rickettsial infections/scrub typhus, malaria (usually falciparum), typhoid, and leptospira bacterial sepsis and common viral infections like influenza. The committee recommends a 'syndromic approach' to diagnosis and treatment of critical tropical infections and has identified five major clinical syndromes: undifferentiated fever, fever with rash / thrombocytopenia, fever with acute respiratory distress syndrome (ARDS), fever with encephalopathy and fever with multi organ dysfunction syndrome. Evidence based algorithms are presented to guide critical care specialists to choose reliable rapid diagnostic modalities and early empiric therapy based on clinical syndromes.

Pantoea agglomerans infection behaving like a tumor after plant thorn injury: an unusual presentation.

Pantoea agglomerans infections in humans are uncommon. Most common infections reported are septic arthritis or synovitis. We report the case of a 25-year-old, healthy male, who presented with indurated swelling over the posterolateral aspect of his right thigh, associated with pain for one month. Magnetic resonance imaging (MRI) revealed muscle edema with cystic areas in the posterior-most part of the vastus lateralis of the right thigh. The condition was clinically diagnosed as a right-sided benign tumor of the vastus lateralis muscle. However, Pantoea agglomerans was isolated on a culture of the excised muscle tissue. On the basis of the awareness of the common association of Pantoea with penetrating trauma by vegetation, the patient was asked to recollect any prior such injury. He then gave a history of a fall in the field and a plant thorn prick in the thigh four years back, when he was an agricultural worker. We emphasize the importance of Pantoea agglomerans infection of the soft tissues that can have an atypical presentation as a non-suppurative, indurated, muscle cyst in our case. Thorn injuries are usually ignored as trivial incidents, however, Pantoea infections should always be borne in mind when encountering soft tissue lesions, as antibiotic treatment is required for complete resolution of the lesion.

Direct inoculation on Phoenix panels for identification and antimicrobial susceptibility from positive BACTEC cultures: first study from India.

PURPOSE: This was a prospective study planned in a super-specialty hospital in Delhi to reduce turnaround times of identification-susceptibility results of positive blood cultures. MATERIALS AND METHODS: One hundred consecutive single morphology non-duplicate cultures were inoculated on Becton Dickinson Phoenix™ panels by growth recovered directly from liquid BACTEC™ media and after pure growth on solid media. RESULTS: Complete concordance was observed in 72.4% of gram-negative and 45.8% of gram-positive isolates. For gram-negative isolates, categorical agreement (CA) was >83% and essential agreement (EA) was >96% among all antibiotics tested, very major errors (VME) were 0.13%, major errors (ME) 0.54%, and minor errors (MiE) were 3.01%. For gram-positive isolates, VME was 0.73%, 1.10% MiE and no ME. It was observed that average time from receipt of specimen to release of reports was 30:34 h and 32 h for gram-negative and gram-positive isolates if reports of "Direct" panels were to be released. CONCLUSIONS: By direct panel inoculation, a decrease of at least 18-20 h in turnaround time was observed compared with the standard method. This helps early change to effective antibiotic therapy and also reduces the expenditure incurred for a patient's hospital stay by average Rs 20,000 ($443) per day.

Rhodotorula fungemia: two cases and a brief review.

Rhodotorula is emerging as an important cause of nosocomial and opportunistic infections. We present two cases of Rhodotorula mucilaginosa fungemia diagnosed over a period of 3 months at our hospital. The first case was of a pre-term neonate in the neonatal ICU who presented with respiratory failure and sepsis. The second involved an adult female who had been injured in a road traffic accident requiring an operation for a hematoma and was later shifted to the medical ICU. For a new hospital like ours, finding two cases of Rhodotorula fungemia within a span of 3 months prompted us to describe them in this report. These cases emphasize the emerging importance of Rhodotorula mucilaginosa as a pathogen and the importance of identification and MIC testing for all fungal isolates recovered from the blood stream.

Emerging and re-emerging bacterial diseases in India.

There has been a remarkable progress in the prevention,control and even eradication of infectious diseases with improved hygiene and development of antimicrobials and vaccines. However,infectious diseases still remain a leading cause of global disease burden with high morbidity and mortality especially in the developing world. Furthermore, there have been threats of new diseases during the past three decades due to the evolution and adaptation of microbes and the re-emergence of old diseases due to the development of antimicrobial resistance and the capacity to spread to new geographic areas. The impact of the emerging and re-emerging diseases in India has been tremendous at socioeconomic and public health levels. Their control requires continuing surveillance,research and training,better diagnostic facilities and improved public health system. Emerging and reemerging zoonotic diseases, foodborne and waterborne diseases and diseases caused by multiresistant organisms constitute the major threats in India. This review of bacterial emerging and re-emerging diseases should be of critical importance to microbiologists,clinicians,public health personnel and policy makers in India.

Significance of atypical pathogens among community-acquired pneumonia adult patients admitted to hospital in Kuwait.

OBJECTIVES: The aim of this study is to determine the microbial etiology and severity of community-acquired pneumonia (CAP) in Kuwait. SUBJECTS AND METHODS: The severity of consecutive adult CAP cases admitted to 3 hospitals over a 1-year period was classified according to the Pneumonia Outcome Research Team (PORT) severity index. The microbial etiology was determined using standard methods for bacteria and serological tests for atypical and viral pathogens. RESULTS: The study population was 124 of the 135 admissions; 63 female, 61 male; mean age 41.3+/-18 years. The severity class distribution was: class I 31%, class II 37%, class III 17%, class IV 13%, and class V 2%. Etiological agents were identified from 44 patients (35%), with one pathogen in 31 (25%), two in 9 (7%), and three or more in 4 (3%). The most common pathogens identified were: Mycoplasma pneumoniae in 14 patients (11%), Legionella pneumophila in 10 (8%), Chlamydia pneumoniae in 8 (6%), influenza B virus in 8 (6%), influenza A virus in 5 (4%), Haemophilus influenzae in 4 (3%), Streptococcus pneumoniae in 3 (2%), Staphylococcus aureus in 3 (2%), gram-negative enterobacteria in 5 (4%), Moraxellacatarrhalis in 2 (2%), and viruses in 4 (3%). The yields from laboratory tests were 48% for paired serology, 20% from adequate sputum sample, and 3% from blood culture. CONCLUSION: Our study shows that a large percentage of mild CAP cases are admitted to hospitals in Kuwait. Atypical pathogens have a significant role in the etiology of CAP. There is overtreatment of CAP with a combination treatment consisting mainly of third-generation chephalosporins and macrolides.

Pathogenesis of infective endocarditis.

The present knowledge of epidemiology, microbiology and pathogenesis of infective endocarditis in both native valve and prosthetic valve endocarditis is described. An attempt has been made to discuss early events in its pathogenesis. This understanding may help in the prevention and management strategies.

Antimicrobial susceptibility, phage typing and plasmid profile of Salmonella enterica serotype paratyphi A strains isolated in Kuwait.

OBJECTIVE: To determine the antimicrobial susceptibility, phage type and plasmid profile pattern of Salmonella enterica serotype paratyphi A strains isolated in Kuwait. MATERIAL AND METHODS: From January 1995 to December 1999, 106 strains of S. enterica serotype paratyphi A isolated from an equal number of cases of enteric fever, attending the Infectious Disease and Mubarak Al-Kabeer Hospitals in Kuwait were investigated. The isolates were tested for antimicrobial susceptibility to 8 commonly used antimicrobial agents. Their phage type and plasmid profile patterns were determined using an international set of phages and Qiagen plasmid mini kit, respectively. RESULTS: All of the isolates were susceptible to ciprofloxacin, cefuroxime, ceftazidime, piperacillin and co-trimoxazole. One hundred isolates were susceptible to ampicillin, 99 to chloramphenicol and 98 to tetracycline. None of the isolates was multidrug resistant. Sixty-six percent of the isolates were phage type I, 27.4% phage type II and 6.6% were untypable. All phage type I and untypable strains had 3 plasmids of 2.2, 5 and 20 kb, whereas phage type II strains had only 1 plasmid of 20 kb. CONCLUSION: The findings indicate that while all of the isolates of the S. enterica serotype paratyphi A were susceptible to 4 of the drugs tested, some were resistant to ampicillin, chloramphenicol or tetracycline, thereby indicating the need for continued surveillance and monitoring of antimicrobial susceptibility of these isolates.

Prevalence of S315T mutation within the katG gene in isoniazid-resistant clinical Mycobacterium tuberculosis isolates from Dubai and Beirut.

OBJECTIVE: To determine the prevalence of S315T mutation within the katG gene that confers clinically significant resistance to isoniazid in isoniazid-resistant Mycobacterium tuberculosis isolates recovered from tuberculosis patients in Dubai and Beirut. METHOD: A total of 28 and 17 isoniazid-resistant and seven and six susceptible clinical M. tuberculosis isolates from Dubai and Beirut, respectively, were tested. The presence of S315T mutation in the katG gene was detected by amplification of the DNA region around codon 315 by polymerase chain reaction followed by restriction digestion with Msp I to generate restriction fragment length polymorphism. The genotyping of the isolates carrying S315T mutation was carried out by touchdown double-repetitive-element PCR (DRE-PCR). RESULTS: The mutation S315T was detected in 18 (64%) of 28 isoniazid-resistant isolates from Dubai and in six (35%) of 17 resistant strains from Beirut. None of the susceptible strains contained this mutation. The genotyping studies showed that the majority of the isolates carrying the S315T mutation exhibited unique DNA banding patterns. CONCLUSION: The data show a varying prevalence of S315T mutation within the katG gene in M. tuberculosis strains isolated from the two geographical locations, Dubai and Beirut.

Antibiotic resistance of enterococci isolated at a teaching hospital in Kuwait.

Enterococci isolated in a teaching hospital were studied for their resistance to different antibiotics. Minimum inhibitory concentrations to high-level aminoglycosides and glycopeptide antibiotics were determined by agar dilution and E-test methods respectively. Genes encoding aminoglycoside-modifying enzymes were detected by the polymerase chain reaction (PCR). 195 enterococci were isolated from urines (54.3%), wounds (16.4%), blood (10.2%), and miscellaneous sources (18.9%). They consisted of E. faecalis (88.7%), E. faecium (9.2%), E. casseliflavus (1.5%) and E. bovis (0.5%). None of the enterococci produced penicillinase but 3.5% of them were resistant to ampicillin. They were also resistant to high-level gentamicin (15.9%), kanamycin (22.0%), streptomycin (21.0%), tetracycline (65.1%), erythromycin (62.6%), ciprofloxacin (36.1%), chloramphenicol (26.1%), vancomycin (3.0%) and teicoplanin (2.0%). Most of the high-level aminoglycoside-resistant isolates contained genes coding the bifunctional aminoglycoside modifying enzymes AAC(6')-APH(2"), APH(3') and ANT(6') but not the ANT(4') enzyme. The results demonstrated a low prevalence of vancomycin resistance among Enterococci in this hospital.

Xanthomonas maltophilia infection in chronic peritoneal dialysis patients.

Xanthomonas maltophilia infection has only been occasionally reported in patients receiving chronic peritoneal dialysis. We describe four cases of Xanthomonas maltophilia infection associated with chronic peritoneal dialysis. Two patients presented with peritonitis and two with exit site infection. All patients were diabetics, who immediately prior to the study had not received antibiotic therapy. Failure to respond to multiple antibiotic therapy resulted in catheter removal in both patients with peritonitis. In those patients with only exit site infections, dialysis could be continued following antibiotic therapy and catheter replacement in one. Catheter loss in our patients was directly attributed to peritonitis with Xanthomonas maltophilia infection.

Characterization of rpoB mutations in rifampin-resistant Mycobacterium tuberculosis isolates from the Middle East.

The nature and frequency of mutations in the rpoB gene of rifampin-resistant clinical Mycobacterium tuberculosis isolates vary considerably according to geographical locations. There is no information on the prevalence of specific mutations in clinical M. tuberculosis strains isolated from patients in Middle-Eastern countries. In this study, 13 rifampin-resistant and 6 susceptible clinical M. tuberculosis isolates were tested for identification and characterization of mutations in the rpoB gene by INNO-LiPA Rif. TB kit and DNA sequencing of the PCR amplified target DNA. The kit identified all six susceptible strains as rifampin-sensitive and the DNA sequence of the amplified rpoB gene in the target region matched perfectly with the wild-type sequence. The kit identified 12 resistant isolates as rifampin-resistant with specific detection of mutations in 8 isolates while one of the rifampin-resistant strain was identified as rifampin-susceptible. DNA sequencing confirmed these results and, in addition, led to the specific detection of mutations in 4 rifampin-resistant isolates in which specific base changes within the target region could not be determined by the INNO-LiPA Rif. TB kit. The majority (8 of 13) of resistant isolates involved base changes at codon 531 of the rpoB gene. Mutations at codon position 531 within the rpoB gene have also been reported in majority of rifampin-resistant strains from Greece and St. Petersburg, Russia but not from other geographical locations.

Antimicrobial susceptibility profile of soil isolates of Nocardia asteroides from Kuwait.

OBJECTIVES: To find the antimicrobial susceptibility profile of 42 soil isolates of Nocardia asteroides against 14 antimicrobial agents representing beta-lactams, aminoglycosides, ciprofloxacin, minocycline, erythromycin and third generation cephalosporins. METHODS: The antimicrobial susceptibility was determined by the disk diffusion method using Mueller-Hinton agar medium. A homogeneous suspension giving an inoculum of 106-108 CFU/mL was used to streak the plates. The zone of inhibition was read after 36-48 h of incubation at 37 degrees C. RESULTS: All the soil isolates of N. asteroides were susceptible to amikacin, imipenem and tobramycin. Susceptibility to cephalosporins was quite variable; 86% of the isolates were susceptible to cefotaxime, 57% to ceftriaxone and 40% to cefamandole. Fifty-seven per cent of the isolates showed intermediate susceptibility to cefamandole, 33% to ceftriaxone and 5% to cefotaxime. Ninety-three per cent of the isolates were resistant to sulfamethoxazole alone or in combination with trimethoprim. CONCLUSIONS: The study reports a wide variation in the antimicrobial susceptibility profile of soil isolates of N. asteroides originating from a single geographical area. Of interest is the finding that over 90% of N. asteroides isolates were resistant to sulfamethoxazole without any previous exposure to this drug. This may have serious therapeutic implications as sulphonamides or the combination of trimethoprim-sulfamethoxazole is the therapy of choice for nocardiosis. Demonstration of resistance to beta-lactam antibiotics may be attributed to the presence of beta-lactamases which was detectable in > 90% of the soil strains of N. asteroides. The study underscores the importance of antimicrobial susceptibility testing for clinical isolates of Nocardia since individual strains show considerable differences in their susceptibility patterns necessitating therapeutic adjustments.

Molecular diagnosis of antimicrobial resistance.

Advances in molecular technology have helped in better understanding of mechanisms and diagnosis of diseases in many medical fields. Several molecular techniques are available for determining the genotypic drug-resistance and monitoring epidemic spread of a particular antimicrobial resistance gene in a hospital or patient population. The molecular (genotypic) testing has several advantages over conventional (phenotypic) testing in being faster and unambiguous, more accurate, able to detect masked resistance and can serve as a "gold" or "reference" test for detecting antibiotic resistance genes. This article addresses these molecular tests with their application and limitations and provide examples of their use especially in Mycobacterium tuberculosis and methicillin resistant Staphylococcus aureus.