Performance of Xpert® MTB/RIF and Xpert® Ultra for the diagnosis of tuberculous meningitis in children.

OBJECTIVE: To assess Xpert® MTB/RIF (Xpert) and Xpert® MTB/RIF Ultra (Ultra) performance in diagnosing pediatric tuberculous meningitis (TBM).METHODS: We conducted a study among children with suspected meningoencephalitis in Pune, India. Clinical, radiological, laboratory, and treatment data were analyzed to classify disease as definite, probable, possible or no TBM, using microbiologic or composite reference standards. We tested cerebrospinal fluid (CSF) either using Xpert or Ultra and estimated test performance characteristics.RESULTS: Of 341 participants, 149 (43.7%) were tested using Ultra and 192 (56.3%) with Xpert. Ultra had higher sensitivity (50% vs. 18%), lower specificity (91% vs. 99%), poor positive predictive value (PPV) (13% vs. 75%), and higher negative predictive value (NPV) (99% vs. 93%) than Xpert using the composite reference standard, with similar results by the microbiologic reference standard. Of 10 participants with trace positivity on Ultra, none met clinical TBM definitions.CONCLUSION: This is the first study to report on diagnostic performance of Ultra in pediatric TBM, which showed higher sensitivity and NPV than Xpert. For children presenting with nonspecific clinical features, Ultra is a promising diagnostic test. Further studies are required to define its optimal clinical use, including interpretation of trace positive results.

Unhealthy alcohol use independently associated with unfavorable TB treatment outcomes among Indian men.

BACKGROUND: Approximately 10% of incident TB cases worldwide are attributable to alcohol. However, evidence associating alcohol with unfavorable TB treatment outcomes is weak.METHODS: We prospectively evaluated men (≥18 years) with pulmonary TB in India for up to 24 months to investigate the association between alcohol use and treatment outcomes. Unhealthy alcohol use was defined as a score of ≥4 on the Alcohol Use Disorders Identification Test-Concise (AUDIT-C) scale at entry. Unfavorable TB treatment outcomes included failure, recurrence, and all-cause mortality, analyzed as composite and independent endpoints.RESULTS: Among 751 men, we identified unhealthy alcohol use in 302 (40%). Median age was 39 years (IQR 28-50); 415 (55%) were underweight (defined as a body mass index [BMI] <18.5 kg/m²); and 198 (26%) experienced an unfavorable outcome. Unhealthy alcohol use was an independent risk factor for the composite unfavorable outcome (adjusted incidence rate ratio [aIRR] 1.47, 95% CI 1.05-2.06; P = 0.03) and death (aIRR 1.90, 95% CI 1.08-3.34; P = 0.03), specifically. We found significant interaction between AUDIT-C and BMI; underweight men with unhealthy alcohol use had increased risk of unfavorable outcomes (aIRR 2.22, 95% CI 1.44-3.44; P < 0.001) compared to men with BMI ≥18.5 kg/m² and AUDIT-C <4.CONCLUSION: Unhealthy alcohol use was independently associated with unfavorable TB treatment outcomes, highlighting the need for integrating effective alcohol interventions into TB care.

Measuring TB drug levels in the hair in adults and children to monitor drug exposure and outcomes.

INTRODUCTION: Testing for anti-TB drugs in small hair samples may serve as a non-invasive tool to measure cumulative drug exposure and/or adherence, as these determine treatment success. We aimed to assess how well hair assays of TB drugs predict TB treatment outcomes.METHODS: A small thatch of hair, ~30 strands, was cut from the occipital region in adults and children from a prospective TB cohort in India. Isoniazid (INH), acetyl-INH and pyrazinamide (PZA) were extracted from the hair samples and quantified using liquid-chromatography-tandem mass spectrometry. The relationship between drug concentrations in hair and time to unfavourable outcomes was assessed using Cox-proportional hazards regression models.RESULTS: A two-fold increase in hair acetyl-INH concentrations in the 264 participants in our cohort with hair assays for TB drugs indicated a lower hazard of unfavourable TB treatment outcomes (aHR 0.67, 95%CI 0.44-1.02) and TB treatment failure (aHR 0.65, 95%CI 0.42-1.01). Higher summed concentrations (a summed measure of INH and acetyl-INH) indicated a lower hazard of treatment failure (aHR 0.69, 95%CI 0.45-1.05)CONCLUSION: Hair levels of INH and its metabolite may predict TB treatment outcomes, indicating the potential utility of this measure to assess and optimise TB treatment outcomes.

Assessment of the Xpert assay among adult pulmonary tuberculosis suspects with and without diabetes mellitus.

SETTING: Pune and Pimpri-Chinchwad Municipal Corporation area, Maharashtra State, India.OBJECTIVE: To assess the sensitivity and specificity of the Xpert® MTB/RIF assay among adults with suspected pulmonary tuberculosis (PTB) and with or without diabetes (DM).DESIGN: As part of a prospective cohort study, we screened 2359 adults presumed to have PTB with no history of TB. All individuals underwent testing for two sputum smears, culture, Xpert, glycated haemoglobin and fasting blood sugar. We calculated sensitivity and specificity of Xpert by comparing it with TB sputum culture result as a gold standard.RESULTS: Among screened individuals, 483 (20%) were diagnosed with DM and 1153 (49%) with pre-DM; 723 (31%) had no DM. Overall sensitivity of Xpert was 96% (95%CI 95-97) and specificity was 91% (95%CI 89-93). Xpert sensitivity was significantly higher among DM group (98%) than in the 'No DM' (95%; P < 0.01) and pre-DM (96%; P < 0.05) groups. Among sputum smear-negative individuals, Xpert sensitivity was higher in the DM group than in the No DM (92% vs. 82%; P = 0.054) and pre-DM group (92% vs. 82%; P = 0.037).CONCLUSION: High sensitivity and specificity of Xpert underscores the need for its rapid scale up for the early detection of TB in settings with a high dual burden of TB and DM.

Trends in HbA1c levels and implications for diabetes screening in tuberculosis cases undergoing treatment in India.

SETTING: The optimal timing of screening for diabetes mellitus (DM) among tuberculosis (TB) cases is unclear due to the possibility of stress hyperglycemia. DESIGN: We evaluated adult (18 years) pulmonary TB cases at treatment initiation as well as at 3 months, 6 months and 12 months. DM was identified by self-report (known DM) or glycated hemoglobin (HbA1c)  6.5% (new DM). Trends in HbA1c levels during treatment were assessed using non-parametric tests. RESULTS: Of the 392 participants enrolled, 75 (19%) had DM, 30 (40%) of whom had new DM. Of the 45 participants with known DM, respectively 37 (82%) and 40 (89%) received medication to lower glucose levels at treatment initiation and completion; one participant with new DM initiated glucose-lowering medication during follow-up. The median HbA1c level in participants with known, new and no DM was respectively 10.1% (interquartile range [IQR] 8.3-11.6), 8.5% (IQR 6.7-11.5) and 5.6% (IQR 5.3-5.9) at treatment initiation, and 8.7% (IQR 6.8-11.3), 7.1% (IQR 5.8-9.5) and 5.3% (IQR 5.1-5.6) at treatment completion (P < 0.001). Overall, 5 (12%) with known and 13 (43%) with new DM at treatment initiation had reverted to HbA1c < 6.5% by treatment completion (P = 0.003); the majority of reversions occurred during the first 3 months, with no significant reversions beyond 6 months. CONCLUSION: HbA1c levels declined with anti-tuberculosis treatment. Repeat HbA1c testing at treatment completion could reduce the risk of misdiagnosis of DM.

Novel interferon-gamma assays for diagnosing tuberculosis in young children in India.

SETTING: The tuberculin skin test (TST) and interferon-gamma release assays (IGRAs) are used as supportive evidence to diagnose active tuberculosis (TB). Novel IGRAs could improve diagnosis, but data are lacking in young children. DESIGN: Children (age 5 years) with suspected TB were prospectively screened at a tertiary hospital in Pune, India; the children underwent TST, and standard (early secretory antigenic target 6 and culture filtrate protein 10) and enhanced (five additional novel antigens) enzyme-linked immunospot (ELISpot) assays. RESULTS: Of 313 children (median age 30 months) enrolled, 92% had received bacille Calmette-Guérin vaccination, 53% were malnourished and 9% were coinfected with the human immunodeficiency virus (HIV); 48 (15%) had TB, 128 (41%) did not, and TB could not be ruled out in 137 (44%). The sensitivity of enhanced (45%) and standard (42%) ELISpot assays for diagnosing TB was better than that of TST (20%) (P  0.03); however, enhanced ELISpot was not more sensitive than the standard ELISpot assay (P = 0.50). The specificity of enhanced ELISpot, standard ELISpot and TST was respectively 82% (95%CI 74-89), 88% (95%CI 81-94) and 98% (95%CI 93-100). Rv3879c and Rv3615c, previously reported to be promising antigens, failed to improve the diagnostic performance of the ELISpot assay. CONCLUSION: The TST and the standard and novel ELISpot assays performed poorly in diagnosing active TB among young children in India.

Prevalence of dysglycemia and clinical presentation of pulmonary tuberculosis in Western India.

SETTING: Pune, India. OBJECTIVES: To estimate the prevalence and risk factors of pre-diabetes mellitus (DM) and DM, and its associations with the clinical presentation of tuberculosis (TB). DESIGN: Screening for DM was conducted among adults (age  18 years) with confirmed TB between December 2013 and January 2017. We used multinomial regression to evaluate the risk factors for pre-DM (glycated hemoglobin [HbA1c]  5.7-6.5% or fasting glucose 100-125 mg/dl) and DM (HbA1c  6.5% or fasting glucose  126 mg/dl or random blood glucose > 200 mg/dl or self-reported DM history/treatment) and the association of dysglycemia with the severity of TB disease. RESULTS: Among 1793 participants screened, 890 (50%) had microbiologically confirmed TB. Of these, 33% had pre-DM and 18% had DM; 41% were newly diagnosed. The median HbA1c level among newly diagnosed DM was 7.0% vs. 10.3% among known DM (P < 0.001). DM (adjusted OR [aOR] 4.94, 95%CI 2.33-10.48) and each per cent increase in HbA1c (aOR 1.42, 95%CI 1.01-2.01) was associated with >1+ smear grade or 9 days to TB detection. CONCLUSION: Over half of newly diagnosed TB patients had DM or pre-DM. DM and increasing dysglycemia was associated with higher bacterial burden at TB diagnosis, potentially indicating a higher risk of TB transmission to close contacts.

Isoniazid hair concentrations in children with tuberculosis: a proof of concept study.

Assessing treatment adherence and quantifying exposure to anti-tuberculosis drugs among children is challenging. We undertook a 'proof of concept' study to assess the drug concentrations of isoniazid (INH) in hair as a therapeutic drug monitoring tool. Children aged <12 years initiated on a thrice-weekly treatment regimen including INH (10 mg/kg) for newly diagnosed tuberculosis were enrolled. INH concentrations in hair were measured using liquid chromatography-tandem mass spectrometry at 1, 2, 4 and 6 months after initiating anti-tuberculosis treatment. We found that INH hair concentrations in all children on thrice-weekly INH were detectable and displayed variability across a dynamic range.

High prevalence of class 1 integrons in clinical isolates of methicillin-resistant Staphylococcus aureus from India.

INTRODUCTION: Class1 integrons are one of the prevalent mechanisms of antibiotic resistance gene transfer in Gram-negative organisms, but their prevalence and role in the spread of antibiotic resistance genes in methicillin-resistant Staphylococcus aureus (MRSA) is unexplored. The purpose of this study was to investigate the prevalence of class 1 integrons in clinical isolates of MRSA. MATERIALS AND METHODS: Total 143 MRSA isolates obtained from two different cities in India (Pune and Mumbai) were characterized by biochemical tests, and the antibiotic sensitivity was performed using the Clinical and Laboratory Standards Institute (CLSI) guidelines. The presence of class 1 integrons, sul1/qacE0Δ1 region of class 1 integron and mecA gene among these isolates was determined by polymerase chain reaction (PCR). RESULTS: All 143 isolates were mecA positive and coagulase-positive. Overall, 71% of the MRSA isolates carried class 1 integrons; 58% (45/77) of the isolates obtained from Mumbai and 85% (56/66) of the isolates from Pune carried class 1 integrons. In all, 39% of these isolates carried sul1/qacEΔ1 region, thus confirming the association of class 1 integrons with antibiotic resistance genes. Along with ß-lactam antibiotics the MRSA isolates were resistant to several other antibiotics, with resistance to erythromycin, ciprofloxacin and trimethoprim-sulfamethoxazole being observed in 75%, 66% and 60% of the isolates, respectively. CONCLUSION: To the best of our knowledge, this is the first report of class 1 integrons in MRSA isolates from India. The study provides insights into the prevalence of a novel mechanism adapted by MRSA for the propagation of antibiotic resistance genes.

Vitamin D deficiency and risk of postpartum tuberculosis among HIV-infected breastfeeding mothers in India.

Some studies have associated low vitamin D levels with the risk of tuberculosis (TB), but its association in human immunodeficiency virus (HIV) infected mothers in a TB-endemic region has not been well studied. We conducted a nested 1:2 case-control study among HIV-infected mothers in western India to evaluate the association between maternal vitamin D levels and the risk of postpartum TB. Vitamin D insufficiency, moderate deficiency and severe deficiency were observed in a high proportion of HIV-infected mothers, but were not associated with the risk of postpartum TB.

Modifiable risk factors associated with tuberculosis disease in children in Pune, India.

SETTING: India accounts for the largest burden of tuberculosis (TB) worldwide, with 26% of the world's cases. OBJECTIVE: To assess the association between novel modifiable risk factors and TB in Indian children. DESIGN: Cases were children aged ≤ 5 years with confirmed/probable TB based on World Health Organization definitions (definition 1). Controls were healthy children aged ≤ 5 years. Logistic regression was performed to estimate the adjusted odds ratio (aOR) of being a TB case given exposure, including indoor air pollution (IAP; exposure to tobacco smoke and/or biomass fuels) and vitamin D deficiency. Cases were re-analyzed according to a new consensus research definition of pediatric TB (definition 2). RESULTS: Sixty cases and 118 controls were enrolled. Both groups had high levels of vitamin D deficiency (55% vs. 50%, P = 0.53). In multivariable analysis, TB was associated with household TB exposure (aOR 25.41, 95%CI 7.03-91.81), household food insecurity (aOR 11.55, 95%CI 3.33-40.15) and IAP exposure (aOR 2.67, 95%CI 1.02-6.97), but not vitamin D deficiency (aOR 1.00, 95%CI 0.38-2.66). Use of definition 2 reduced the number of cases to 25. In multivariate analysis, TB exposure, household food insecurity and IAP remained associated with TB. CONCLUSIONS: Household TB exposure, exposure to IAP and household food insecurity were independently associated with pediatric TB.

Ochrobactrum anthropi: an unusual pathogen: are we missing them?

With increasing incidence of immunocompromised patients, many unusual organisms are emerging as pathogens in these patients. Ochrobactrum anthropi is an emerging opportunistic pathogen in immunocompromised patients. Here, we report two cases of neonates who presented with septicemia due to O. anthropi. Both were preterm and low birth weight babies admitted in the Neonatal Intensive Care Unit of our Hospital. One baby manifested with respiratory distress and eventually died. The second baby responded well to treatment and was discharged. The clinical presentation of infections along with microbiological characteristics and clinical significance of the organism are described.

Comparison of efficacy of three commercially available antibiotic discs.

A study was undertaken to evaluate the efficacy of commercially available antimicrobial discs manufactured by Oxoid, UK, HiMedia Laboratories, Mumbai and Span Diagnostics, Surat. The discs were evaluated for their performance on the basis of percentage of coefficient of variation (%CV) which is a measure of reproducibility, mean zone diameters which is a measure of accuracy and range of zone diameter using both standard ATCC strains and clinical isolates. The data showed variation for all three manufacturers and therefore routine and regular quality control of discs as well as meticulous following of good laboratory practices is strongly advocated in clinical laboratories.

Disseminated histoplamosis.

A case of disseminated histoplasmosis in a 45-year-old male patient with acquired immunodeficiency syndrome (AIDS) from Pune is reported. The patient presented with high-grade fever and pain in hypochondrium. Clinical signs were pallor and hepatosplenomegaly. Bone marrow and splenic aspirate revealed numerous intracellular oval shaped yeast forms. Histoplasma capsulatum was isolated from the bone marrow and splenic aspirate. H. capsulatum infection is an opportunistic infection usually reported from patient with AIDS in areas endemic for H. capsulatum. The present case highlights the fact that histoplasmosis could be an emerging opportunistic infection in India.

Sero surveillance of leptospirosis among sewer workers in Pune.

Leptospirosis is an important occupational disease affecting people coming in contact with animals and their discharges. The occurrence of infection in ones workplaces is linked to the environment to which the worker is exposed and the adaptability of the organism in that working environment. Rodents usually abound in underground sewers and are carriers of leptospira. The urine of rodents and other animals present in that area is likely to contaminate these sewers. Leptospira are excreted in the urine of infected animals. Thus sewer workers are at a potential risk of leptospirosis. The prevalence of leptospirosis in these workers could thus indirectly predict the presence of the disease in animals in a particular geographical niche. Total seventy-eight sewer workers from 5 different municipal wards in Pune were examined to find out the evidence of past infection with leptospira using microagglutination test (MAT). The prevalence rate was found to be 16.6%. The serovars to which antibodies were detected include autumnalis (38.4%), pyrogenes (23.0%), canicola (15.3%) and pomona (15.3%). Evidence of leptospiral infection was found to be maximum in sewer workers in the areas of the city that were infested with rodents and stray animals.

Common infecting leptospiral serovars in and around Pune, Maharashtra.

Leptospirosis is a disease with protean manifestations. The present study was conducted in Pune to examine the possibility of leptospiral infection among a group of patients with fever of undetermined origin and to identify the common infecting serovars. Serological evidence of leptospirosis was found in 22 of the 118 (18.6%) patients with the help of microagglutination test (MAT) using a battery of 9 antigens. The serovars responsible for infection included autumnalis in eight cases, copenhageni in six, pomona in three, grippotyphosa in two and australis, batavia and canicola in one case each. Thus, there appears to be a focus of leptospirosis in and around Pune with autumnalis and copenhagni as the common infecting serovars.

Evaluation of clinical criteria for the diagnosis of leptospirosis.

OBJECTIVES: Leptospirosis has a wide range of clinical presentation and therefore, clinical suspicion of the infection is often difficult. The objective of this study is to find out the usefulness of the clinical and epidemiological criteria in the diagnosis of leptospirosis and its comparison with microagglutination test (MAT). METHODS: A total of 118 patients with undiagnosed fever of more than seven days duration were included in the study. Their clinical presentation was scored on the basis of a clinical criteria. Sera of the patients were tested for antibodies against leptospira with the help of microagglutination test using a battery of antigens. The usefulness of the criteria was evaluated and compared with microagglutination test. RESULTS: A total of 44 out of 118 (37.28%) patients could be provisionally diagnosed as cases of leptospirosis on the basis of the clinical criteria. Eighteen of these 44 (40.9%) patients had serological evidence of leptospirosis. The criteria had a sensitivity of 81.81%, specificity of 72.91%, a positive predictive value of 40.9% and a negative predictive value of 94.59% when compared with microagglutination test. CONCLUSIONS: The criteria had a moderate sensitivity and specificity. Considering the non-specific signs and symptoms of this infection, the positive predictive value is significantly high. The criteria has a high negative predictive value and this would help the clinicians exclude the diagnosis of leptospirosis with precision.

Contaminated antiseptics--an unnecessary hospital hazard.

A total of 284 antiseptic solutions were studied to check for their sterility. The overall antiseptic contamination rate was 15.14%. 14.85% of freshly prepared antiseptics were contaminated. Here, the problem could be attributed to inadequate precautions while preparing the antiseptics. 15.3% of the in-use antiseptics were contaminated. This could be due to improper handling. Non-fermenters (45.45%), Pseudomonas aeruginosa (30.30%) and Klebsiella spp. (22.72%) were the commonest organisms recovered from the antiseptics. In 44.44% of patients, the isolates obtained from the catheterised urine in the same wards matched with the isolates from antiseptics of that ward. Antiseptic solutions have to be regularly monitored. If they are found to be contaminated, they should be discarded immediately and replaced by fresh sterile antiseptics otherwise instead of preventing infection, antiseptics will become a source of hospital-acquired infection.