First study on detection of cryptic resistance to linezolid among clinical isolates of methicillin resistant Staphylococcus aureus from India.

PURPOSE: Linezolid is an oral antibiotic which is widely used for serious infections caused by Methicillin Resistant Staphylococcus aureus (MRSA). With emergence of vancomycin MIC creep among clinical strains of MRSA, it is essential to know the possible emergence of subclinical resistance against linezolid as well. With this background, we aimed to detect evident (phenotypic) and cryptic (hidden or genotypic) linezolid resistance among MRSA isolates. METHODS: 250 clinical isolates of MRSA were collected and their susceptibility patterns were determined. Every third MRSA isolate was subjected to PCR for domain V of the 23S rRNA for the mutation hotspot in the 746bp segment which harbors the classical mutation for linezolid resistance. Restriction Fragment Length Polymorphism was done to confirm presence of the G2576U mutation. RESULTS: Six isolates (2.4%) were phenotypically resistant to linezolid. Among these six LRSA isolates, 5 demonstrated the G2576U mutation by PCR - RFLP. Cryptic resistance to Linezolid was identified in two isolates among linezolid susceptible isolates. CONCLUSIONS: In the present study, hidden resistance to linezolid was observed in linezolid susceptible clinical isolates. Emergence of resistance against over-the-counter drugs like linezolid is major challenge. Identification of cryptic resistance among patients implies impending resistance to linezolid. Judicious use of antimicrobials, application of strict infection control practices and prescription audit needs to be made mandatory to preserve such drugs.

Development, optimization, standardization, and validation of a simple in-house agar gradient method to determine minimum inhibitory concentration of vancomycin for Staphylococcus aureus.

BACKGROUND: The Clinical and Laboratory Standards Institute recommends reporting minimum inhibitory concentration (MIC) values of vancomycin for Staphylococcus aureus. Commercial MIC strips are expensive, and the traditional broth microdilution method is cumbersome. With this background, we attempted to develop and standardize an in-house agar gradient method to determine MIC values of vancomycin for S. aureus. OBJECTIVES: To develop and validate an in-house vancomycin MIC strip, based on simple agar gradient method for S. aureus as per bioassay development guidelines. MATERIALS AND METHODS: Filter paper gradient strips were made in house and impregnated with varying concentrations of vancomycin to create an antibiotic gradient. During standardization, MICs of ninety clinical strains of S. aureus and ATCC 29213 were tested by the broth microdilution and commercial strip followed by the in-house strip. During the validation stage, MICs of ninety different clinical strains of S. aureus and ATCC 29213 were determined by the in-house strip followed by MIC detection by broth microdilution and commercial strips. A reading of more than ± 1log2 dilution compared with broth microdilution was considered as an outlier. RESULTS: During the initial stage, there were 7/90 outliers in the clinical strains, and no outliers were seen with the ATCC 29213 control strain. Corrective action included increasing precaution during the antibiotic impregnation on the strip. During validation stage, only 4/90 outliers were observed in the clinical strains. The commercial strips had 29/90 among clinical and 15/30 outliers in the control strain during the prevalidation phase. Despite maintaining cold chain during the validation phase, the outliers for commercial strip were 18/90 and 4/30 for clinical and control strains, respectively. CONCLUSION: Reporting vancomycin MIC for S. aureus may be attempted using the in-house method after validating it with a gold standard broth microdilution method and quality control as per protocol.

Diagnostic Potential of Circulating Biomarkers in Adenosine Deaminase Diagnosed Pleural Tuberculosis Cases.

Pleural tuberculosis accounts for nearly 20% of Extra pulmonary tuberculosis. Adenosine deaminase, commonly used biomarker for the diagnosis, is non specific and there is paucity of literature on its correlation with conventional or newer methods for the diagnosis of extra pulmonary forms of TB. The aim of the study was to assess diagnostic potential of T cell function markers [interferon (IFN-γ), interleukin (IL-2) and IFN-γ/IL-2 ratio]; macrophage activation marker [neopterin]; and oxidative stress markers [protein carbonyl and malondialdehyde (MDA)] in pleural tuberculosis. 26 pleural TB cases diagnosed on the basis of suggestive chest X-ray and raised serum ADA levels and healthy controls were included in the study. Pleural fluid specimens were subjected to Zeihl Neelsen staining and culture on Lowenstein Jensen medium. Serum IFN-γ, IL-2, neopterin and protein carbonyl levels detection were done by ELISA and MDA levels were determined by measuring the thiobarbituric acid reactive substances. Median serum levels of IFN-γ, IL-2, IFN-γ/IL-2 ratio, neopterin, protein carbonyl and MDA were significantly different between cases and controls. Levels of all biomarkers except IL-2 were significantly higher in cases with contact history. Mean levels of ADA and ESR were 46.27 U/L and 46.62 mm/hr in PTB cases. AUC for IFN-γ, IL-2, IFN-γ/IL-2 ratio, neopterin, protein carbonyl and MDA were significantly discriminative for cases and controls. IFN-γ/IL-2 ratio was best discriminatory biomarker with highest area under ROC curve. Though no correlation was seen between ADA and any of the six biomarkers, ESR levels correlated significantly with all biomarkers except IL-2 by spearman's correlation coefficient. Though all the circulating biomarkers under study provide useful supportive evidence for the diagnosis of PTB, further studies involving diverse control groups particularly non-PTB effusion are needed to validate these results.

Anti-HBs Titers Following Pentavalent Immunization (DTwP-HBV-Hib) in Term Normal Weight vs Low Birthweight Infants.

OBJECTIVE: To compare anti-HBs titers between term low birth weight (1800-2499 g) infants and normal birthweight infants, 6 weeks after last dose of primary immunization with pentavalent vaccine, and to study adverse events following immunization (AEFI) with pentavalent vaccine. DESIGN: Cohort study. SETTING: Tertiary-care hospital predominantly catering to urban poor population of East Delhi. PARTICIPANTS: 265 low birthweight (1800-2499 g) and 265 normal birthweight (2500-4000 g) infants. Monovalent Hepatitis B vaccine was administered within 24 hours of birth followed by three primary doses of pentavalent vaccine at 6, 10 and 14 weeks. Anti-HBs titers were estimated after 6 weeks of third dose of pentavalent vaccine. Adverse events following immunization (AEFI) month were observed for a month after each dose of pentavalent vaccine. MAIN OUTCOME MEASURES: Anti HBs antibody titers after 6 weeks of primary immunization, and AEFI. RESULTS: 443 (83.5%) infants (225 low birthweight and 218 normal birthweight infants) completed the follow-up. Seroprotection against hepatitis B virus was achieved in both groups after pentavalent vaccine administration. Anti HBs GMTs in low birthweight infants (194.8 mIU/mL) and normal birthweight infants (204.2 mIU/mL) were comparable (P = 0.17). No serious adverse events were observed in either group. CONCLUSIONS: Three primary doses of pentavalent vaccine administered along with zero dose of Hepatitis B vaccine at birth provide good seroprotection. The vaccine appears to be safe in both low birth weight and normal birthweight infants born at term.

Comparative Diagnostic Utility of Neopterin and IFN-γ/IL-2 in Extrapulmonary Tuberculosis.

Resurgence of TB has emphasized the need for newer methods of diagnosis. Extrapulmonary tuberculosis (EPTB), being paucibacillary, is a diagnostic dilemma. The aim of the present study was to correlate IFN-γ/IL-2 with neopterin in diagnosis of EPTB. Extrapulmonary specimens from 69 clinically diagnosed cases were stained by Ziehl-Neelsen and cultured on Lowenstein-Jensen medium for Mycobacterium tuberculosis. ELISA was used to assess serum IFN-γ, IL-2 and neopterin levels. Median serum levels of IFN-γ/IL-2 and neopterin were 3.22 and 21.6 nmol/L in clinically diagnosed EPTB cases and 0.52 and 4.20 nmol/L in healthy controls respectively (p < 0.001). Both IFN-γ/IL-2 and neopterin were significantly higher in culture positive (14.64 and 49.8 nmol/L) than culture negative cases (3.01 and 17.5 nmol/L) respectively (p < 0.05). IFN-γ/IL-2 was significantly higher in AFB smear positive cases (8.63) than smear negative cases (3.04) (p = 0.003), whereas no significant difference in neopterin levels was seen (p = 0.307). A positive correlation between IFN-γ/IL-2 and neopterin was seen in EPTB cases (spearman's rho = 0.453, p < 0.001), whereas in healthy controls no such correlation existed (spearman's rho = 0.018, p = 0.884). An urgent need for research in the field of biomarkers exists to utilize them as point of care test in the diagnosis of EPTB.

Revisiting the Utility of Histopathological Examination of Biopsy: A Necessity in Microbiology.

INTRODUCTION: Culture is the gold standard, while potassium hydroxide mount is simplest technique used for diagnosis of fungal pathogens. Histopathological examination is the only definitive means to identify certain uncultivable fungi. AIM: To analyse role of histopathological examination and potassium hydroxide (KOH) mount for diagnosing fungal infections by correlating them with culture. MATERIALS AND METHODS: In this nine year retrospective study, all biopsy specimens submitted for microbiological examination were included. Histopathological examination of biopsies of cases with positive microbiological findings on either KOH mount or culture was carried out. Any discrepancy between histopathology interpretation and microbiology KOH or culture results, taking culture as the gold standard, were noted. STATISTICAL ANALYSIS: Open Epi software was used for statistical analysis. Comparisons between groups were made by using the chi-square test. A p-value < 0.05 was considered statistically significant. Cohen's Kappa coefficient (κ) was calculated as a measure of agreement between different variables. RESULTS: Concurrent pathology specimen could be obtained in 70 samples positive for fungal elements in either KOH or culture. Thirty-two cases were positive for fungi in culture, of which 16 were correctly identified by histopathological examination. Histopathological examination was strongly associated with culture result. KOH mount was in good agreement with positive culture result for yeast. Eleven culture negative but KOH and histopathology positive cases included seven samples with hyphae suggestive of zygomycosis, and two cases of rhinosporidiosis. Allergic mucin was strongly associated with Aspergillus species. KOH mount and detection of allergic mucin on histopathological examination were found to be excellent complementary tools for diagnosing Aspergillus species. Necrosis was highly specific for fungal growth in culture and had good positive predictive value. CONCLUSION: We advocate using histopathology, culture and KOH examination in an integral manner to avoid potential lapses in patient management.

Clinical and serological characteristics of nail psoriasis in Indian patients: A cross-sectional study.

BACKGROUND: Nail involvement in psoriasis is common with a lifetime incidence of 80-90%. It may reflect severity of cutaneous involvement and predict joint disease. Yet it remains, poorly studied and evaluated especially in Indian psoriatic patients. AIM: The present study was undertaken to evaluate clinical and serological profile of nail involvement in psoriasis and to assess quality of life impairment associated with nail involvement in Indian patients. METHODS: Consecutive patients with nail psoriasis were assessed for severity of cutaneous disease (psoriasis area severity index score) and nail disease (nail psoriasis severity index score). The impairment in quality of life attributable to nail disease was scored with nail psoriasis quality of life 10 score. All patients were also assessed for joint disease and tested for inflammatory and serological markers as erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor and anti-cyclic citrullinated peptide antibodies. RESULTS: In our cohort of 38 patients with nail psoriasis, 9 had concomitant psoriatic arthritis. The mean psoriasis area severity index was 14.4 ± 9.6 (range = 0.4-34). The most commonly recorded psoriatic nail changes were pitting (97.4%), onycholysis (94.7%) and subungual hyperkeratosis (89.5%). The mean nail psoriasis severity index score was 83.2 ± 40.1 (range = 5-156) and mean nail psoriasis quality of life 10 was 1.1 ± 0.4. Erythrocyte sedimentation rate and C-reactive protein were raised in 22/38 (57.9%) and 15/38 (39.5%) patients, respectively; rheumatoid factor was positive in 5/38 (13.2%) and anti-cyclic citrullinated peptide antibody was raised in 4/38 (10.5%) patients. LIMITATIONS: Small sample size and lack of a control group. CONCLUSIONS: In Indian patients with nail psoriasis, severity of nail involvement was found to be poorly correlated with the extent of cutaneous disease. In addition the impact of nail disease on patient's quality of life was found to be minimal. This suggests the need for a quality of life questionnaire suited to the Indian population. Serological markers were raised overall in the study patients and more so in the patients with concomitant arthritis.

Safety and immunogenicity of Bio Pox™, a live varicella vaccine (Oka strain) in Indian children: A comparative multicentric, randomized phase II/III clinical trial.

Varicella or chickenpox is a highly contagious disease with a high secondary attack rate. Almost 30% of Indian adolescents lack protective antibodies against varicella, emphasizing the need of routine varicella immunization. The Oka VZV is a well-established, safe and efficacious vaccine strain that is highly immunogenic and produces lifelong protective immunity. The present multicentric, open label, randomized, controlled Phase II/III study, compared the Bio Pox™ (indigenous investigational vaccine) with a licensed vaccine, Varivax™ [a][a] Please note that this article refers to the product named VARIVAX as manufactured by Changchun Keygen Biological Products Ltd., China and marketed in India by VHB Life Sciences Limited, Mumbai, and not the product VARIVAX® owned by Merck Sharp & Dohme Corp., Rahway, New Jersey, USA. Merck Sharp & Dohme Corp. have asked us to make clear that the product manufactured by Changchun Keygen Biological Products Ltd. is unrelated to and is not sponsored, endorsed or otherwise authorised by Merck Sharp & Dohme Corp. , for its safety and immunogenicity profile in 252 healthy subjects in the age group of 1-12 y (cohort I: 6-12 years, II:1-6 years) in 3 tertiary medical institutions. Antibodies were measured by VZV Glycoprotein Enzyme Linked Immunoassay (IgG ELISA) kit. Seroconversion percentage in children having pre-vaccination anti VZV IgG titer <10 mIU/mL (< 5 gp ELISA units/mL) were 80% for Bio Pox™ and 77% for Varivax™ (p = 0.692). The seroconversion rate in the group receiving Bio Pox™ was non-inferior to the group that received Varivax™. There were mild local reactions for both the vaccines; none of the patient had fever or required hospitalization or medication. The Bio Pox™ was found to be safe and immunogenic in children against VZV infection.

Convergence of Minds: For Better Patient Outcome in Intensive Care Unit Infections.

BACKGROUND: There is emergence of resistance to the last-line antibiotics such as carbapenems in Intensive Care Units (ICUs), leaving little effective therapeutic options. Since there are no more newer antibiotics in the armamentarium in the near future, it has become imperative that we harness the interdisciplinary knowledge for the best clinical outcome of the patient. AIMS: The aim of the conference was to utilize the synergies between the clinical microbiologists and critical care specialists for better patient care and clinical outcome. MATERIALS AND METHODS: A combined continuing medical education program (CME) under the aegis of the Indian Association of Medical Microbiologists - Delhi Chapter and the Indian Society of Critical Care Medicine, Delhi and national capital region was organized to share their expertise on the various topics covering epidemiology, diagnosis, management, and prevention of hospital-acquired infections in ICUs. RESULTS: It was agreed that synergy between the clinical microbiologists and critical care medicine is required in understanding the scope of laboratory tests, investigative pathway testing, hospital epidemiology, and optimum use of antibiotics. A consensus on the use of rapid diagnostics such as point-of-care tests, matrix-assisted laser desorption ionization-time of flight mass spectrometry, and molecular tests for the early diagnosis of infectious disease was made. It was agreed that stewardship activities along with hospital infection control practices should be further strengthened for better utilization of the antibiotics. Through this CME, we identified the barriers and actionables for appropriate antimicrobial usage in Indian ICUs. CONCLUSIONS: A close coordination between clinical microbiology and critical care medicine opens up avenues to improve antimicrobial prescription practices.

Changing trends in antimicrobial susceptibility pattern of bacterial isolates in a burn unit.

INTRODUCTION: Emerging antimicrobial resistance in nosocomial bacterial isolates, limits the available treatment options for burn wound infections, among them multi-drug resistant Gram negative bacteria and methicillin-resistant Staphylococcus aureus (MRSA) are major contributors to the increase in morbidity and mortality rates. MATERIAL AND METHODS: A retrospective cross-sectional study was done in the Department of Microbiology, University College of Medical Sciences & Guru Teg Bahadur Hospital, Delhi. A total of 818 wound samples from patients admitted in the burn wards and Intensive Care Units (ICUs) examined between 2010-2014 (5 years period). Pseudomonas aeruginosa was found as the most common isolate (37%) followed by Klebsiella pneumoniae (15%) and Acinetobacter baumanii (12%) among Gram negative organisms while S. aureus (12%) remained the major isolates among Gram positive organisms. A significant decrease in incidence of Gram positive organisms was observed in comparison with previous study. However, resistance to ceftazidime and aminoglycosides were increased significantly in Gram negative organisms. Multi-drug resistant P. aeruginosa (MDR PA) accounted for 15.2%, multi-drug resistant A. baumanii (MDR AB) was prevalent in 13.8% and MRSA in 77.4% of burn wound infections. DISCUSSION AND CONCLUSION: Emerging bacterial drug resistance has both clinical and financial implications for the therapy of infected burn patients. Spectrum of bacterial drug resistance in an institution is important for epidemiological as well as clinical purposes. Rising frequency of MDR strains in burn patients is alarming for clinicians as it downgrades the treatment efficacy.

Neopterin and oxidative stress markers in the diagnosis of extrapulmonary tuberculosis.

BACKGROUND: Extrapulmonary tuberculosis (EPTB) often presents with nonspecific signs and symptoms. Further the paucibacillary nature of extrapulmonary specimens and irregular distribution of bacilli lower the sensitivity of conventional diagnostic methods making EPTB, a diagnostic dilemma. OBJECTIVE: To study neopterin, protein carbonyl and malondialdehyde (MDA) in EPTB. METHODS: Sixty nine clinically confirmed cases with an equal number of age and sex matched healthy controls were enrolled. Ziehl-Neelsen staining for acid fast bacilli and culture on Lowenstein-Jensen medium were performed on all the extrapulmonary specimens. Serum neopterin and protein carbonyl levels were estimated using commercial ELISA kits. Malondialdehyde was determined by measuring thiobarbituric acid reactive substances. RESULTS: Serum neopterin, protein carbonyl and MDA levels were significantly discriminative for cases of EPTB from healthy controls (p < 0.05). Levels of all the three biomarkers under study significantly differed between culture as well as smear positive and negative cases. A positive correlation between neopterin and protein carbonyl was seen among the cases. CONCLUSIONS: So far few studies have integrated combination of validated host biomarkers for active disease in EPTB. Our study suggests the potential diagnostic role of neopterin, protein carbonyl and MDA in EPTB.

Front loading sputum microscopy - an alternative approach for diagnosis of pulmonary tuberculosis.

INTRODUCTION: Until newer, rapid, economical tools are introduced for diagnosis of Pulmonary Tuberculosis in resource limited settings, optimization of sputum smear examination for increasing case detection remains of utmost priority. The aim of the study was to detect presumptive TB patients using Front Loading sputum microscopy and compare it with Standard method. METHODS: Three sputum specimens (Spot 1- on spot at the time of first visit, Spot 2- one hour after Spot 1 and early morning-next day early morning sample) from 552 TB suspect cases were collected. Zeihl Neelsen staining (spot 1, spot 2 and early morning respectively) and microscopy by Front Loading (spot 1, spot 2) and Standard method (spot 1, early morning) of sputum microscopy were done. RESULTS: Culture on LJ media being the gold standard, the sensitivity and specificity of the Front Loading and the Standard method of sputum microscopy were 68.65%, 94.43% and 70.14%, 93.6% respectively. The difference between two methods was not statistically significant. 91.1% patients gave preference for same day sampling process. CONCLUSION: The sensitivity and specificity of sputum microscopy using an early morning sample followed by another sputum one hour later from the same day appears not to be inferior to using two early morning samples on subsequent days. The Front Loading sputum microscopy can be implemented in DOTS clinic on the day of first visit of patients to health care center to increase compliance of patients with diagnostic procedure and decrease drop-outs.

Laparoscopy in the diagnosis of tuberculosis in chronic pelvic pain.

BACKGROUND: To estimate the prevalence of genital tuberculosis in women with idiopathic chronic pelvic pain on laparoscopy, correlate laparoscopic findings with microbiological and histological diagnosis of tuberculosis and assess the response to anti tubercular treatment (ATT) in these cases. METHOD: In a prospective cohort study, fifty women with idiopathic chronic pelvic pain were enrolled. Diagnostic laparoscopy was done in all women and fluid from pouch of Douglas and/or saline washings were sent for acid fast bacilli (AFB) smear, conventional and rapid culture and DNA polymerase chain reaction (PCR) analysis for diagnosis of genital TB. The results of these tests were analyzed and agreement with laparoscopy was assessed using Kappa statistics. Pain scores using visual analogue scale were compared before and after treatment. RESULTS: Pelvic pathology was present in 44 (88%) women of idiopathic chronic pelvic pain, with a 34% prevalence rate of genital tuberculosis. Pelvic inflammation was associated with positive peritoneal fluid PCR (n=4) and AFB culture (n=3). Acid fast bacilli PCR had substantial agreement (kappa statistics=0.716) with visual findings at laparoscopy. There was a significant reduction in pain scores after treatment. CONCLUSION: Genital tuberculosis contributes to one-third cases of chronic pelvic pain. Pelvic inflammation is an early feature of genital TB and peritoneal fluid PCR has the best co-relation with laparoscopic findings of genital tuberculosis.

Vitamin D Supplementation for Treatment and Prevention of Pneumonia in Under-five Children: A Randomized Double-blind Placebo Controlled Trial.

OBJECTIVE: To evaluate the efficacy of single oral mega-dose of Vitamin D3 for treatment and prevention of pneumonia in under-five children. DESIGN: Randomized, double blind, placebo-controlled trial. SETTING: Tertiary-care hospital. PARTICIPANTS: 324 children (of 980 assessed) between 6 mo-5 y age (median (IQR): 12 (7,19.8) mo) with WHO-defined severe pneumonia. Of these, 126 (39%) were vitamin D deficient (serum 25(OH)D <12 ng/mL). INTERVENTION: 100,000 IU of oral cholecalciferol (n= 162) or placebo (n= 162) in single dose, administered at enrolment. Outcome variables: Primary: Time to resolution of severe pneumonia and proportion of children having recurrence of pneumonia in next 6 months; Secondary: Change in serum levels of 25(OH)D; immunoglobulins IgA, IgG, IgM, and cathelicidin 2 weeks following supplementation; and time taken for overall resolution of illness. OUTCOME VARIABLES: Primary: Time to resolution of severe pneumonia and proportion of children having recurrence of pneumonia in next 6 months; Secondary: Change in serum levels of 25(OH)D; immunoglobulins IgA, IgG, IgM, and cathelicidin 2 weeks following supplementation; and time taken for overall resolution of illness. RESULTS: Median (95% CI) time for resolution of severe pneumonia was 30 (29, 31) h in the vitamin D group as compared to 31 (29,33) h in the placebo group [adjusted hazard ratio (95% CI): 1.39 (1.11, 1.76); P = 0.005]. The risk of recurrence of pneumonia in next 6 months was comparable in the two groups [placebo: 36/158 (22.8%); vitamin D: 39/156 (25%); RR (95% CI): 1.13 (0.67,1.90); P 0.69]. Proportion of vitamin D deficient children declined from 38% to 4% in the supplementation group, and from 41% to 33% in the placebo group, two weeks after supplementation. There was no significant effect of vitamin D supplementation on serum levels of cathelicidin, IgA and IgG. The time taken for complete recovery from pneumonia, duration of hospitalization, and fever clearance time were comparable for the two groups. No adverse event was noted related to the intervention. CONCLUSION: There is no robust evidence of a definite biological benefit, either for therapy or prevention, to suggest a routine megadose supplement of vitamin D3 for under-five children with severe pneumonia.

Significance of Anti-cyclic Citrullinated Peptide Autoantibodies in Immune-mediated Inflammatory Skin Disorders with and without Arthritis.

BACKGROUND: Anti-cyclic citrullinated peptides (CCPs) are autoantibodies directed against citrullinated peptides. Rheumatoid factor (RF), an antibody against the Fc portion of IgG, is known to form immune complexes and contribute to the etiopathogenesis of various skin disorders. C-reactive protein (CRP), an acute-phase protein, increases following secretion of interleukin-6 from macrophages and T cells. Anti-CCP, RF, and CRP are well-established immune-markers, their diagnostic potential in immune-mediated skin disorders remains less widely studied. AIMS AND OBJECTIVES: To determine the correlation between anti-CCP, RF, and CRP in immune-mediated inflammatory skin diseases. MATERIALS AND METHODS: About 61 clinically diagnosed cases of various immune-mediated skin diseases (psoriasis [n = 38], connective tissue diseases such as systemic lupus erythematosus and systemic sclerosis [n = 14], and immunobullous disorders including pemphigus vulgaris and pemphigus foliaceus [n = 9]) were included in the study. These patients were subclassified on the basis of presence or absence of arthritis. Arthritis was present in nine cases of psoriasis and seven connective tissue disorder patients. Detection of serum anti-CCP was done using enzyme-linked immunosorbent assay, whereas CRP and RF levels were detected using latex agglutination technique. RESULTS: Of the 61 specimens, 14.75% had elevated serum anti-CCP levels. RF and CRP levels were elevated in 18.03% and 39.34% specimens, respectively. RF was elevated in 13.16% of inflammatory and 42.88% of connective tissue disorders, whereas anti-CCP was raised in 10.53% of inflammatory and 35.71% of connective tissue disorders. CRP positivity was highest in connective tissue disorders (50%), followed by 39.47% in inflammatory and 22.22% in immunobullous conditions. In none of the immunobullous patients, anti-CCP or RF levels were found to be elevated. Association of the presence of arthritis with elevated anti-CCP was found to be statistically significant. CONCLUSIONS: Although anti-CCP, RF, and CRP levels are valuable markers of chronic immune-mediated skin disorders, elaborate studies enrolling a larger number of patients are required to validate these diagnostic markers.

Anti-cysticercus antibody detection in saliva as a potential diagnostic tool for neurocysticercosis.

OBJECTIVES: This study was planned to determine the usefulness of anti-cysticercus IgG antibody detection in saliva for neurocysticercosis (NCC) diagnosis, along with serum C-reactive protein (CRP) level to serve as a surrogate marker. MATERIALS AND METHODS: In this prospective study of 14 months duration, blood and saliva samples were collected from 40 patients suspected to be suffering from NCC and were subjected to anti-cysticercus IgG antibody detection by ELISA. Serum CRP levels were estimated as acute-phase reactant by high sensitivity CRP ELISA. RESULTS: Anti-cysticercus IgG was detected in serum and saliva of 34 and 30 patients, respectively. Cases positive for salivary antibody were positive for serum antibody and their serum CRP level was higher than normal. Cases negative for salivary antibody had low serum CRP levels. Anti-cysticercus IgG detection in saliva was 88.24% sensitive, 100% specific, and had a positive predictive value of 100% and negative predictive value of 60%. Positive salivary anti-cysticercus IgG and high serum CRP level showed a significant association. Difference between CRP levels of patients positive for anti-cysticercus antibody in both serum and saliva, and patients positive for antibody in serum but not saliva was highly significant. CONCLUSIONS: Saliva, being painless and noninvasive, can be used as alternative to serum for NCC diagnosis.

Effect of oral cranberry extract (standardized proanthocyanidin-A) in patients with recurrent UTI by pathogenic E. coli: a randomized placebo-controlled clinical research study.

PURPOSE: To evaluate the effect of cranberry extract (PAC-A ~ proanthocyanidin-A) on the in vitro bacterial properties of uropathogenic (E. coli) and its efficacy/tolerability in patients with subclinical or uncomplicated recurrent UTI (r-UTI). MATERIALS AND METHODS: After obtaining clearance from the ethics committee and administering a written informed consent, 72 patients with r-UTI were enrolled as per protocol (November 2011 to March 2013) in this prospective study, to randomly receive (PAC-A: group I, 36) or (placebo: group II, 36), for 12 weeks. Any change/reduction in the incidence of r-UTI at 12 weeks was construed to be the primary endpoint of this study. RESULTS: After 12 weeks, bacterial adhesion scoring decreased (0.28)/(2.14) in group I/II (p < 0.001); 32/36 (88.8 %) and 2/36 (5.5 %) in groups I and II, respectively, turned MRHA negative (p < 0.001); biofilm (p < 0.01) and bacterial growth (p < 0.001) decreased in group I; microscopic pyuria score was 0.36/2.0 in group I/II (p < 0.001); r-UTI decreased to 33.33 versus 88.89 % in group I/II (p < 0.001); mean subjective dysuria score was 0.19 versus 1.47 in group I/II (p < 0.001), while mean urine pH was 5.88 versus 6.30 in group I/II (p < 0.001). No in vitro antibacterial activity of cranberry could be demonstrated, and no adverse events were noted. CONCLUSIONS: The overall efficacy and tolerability of standardized cranberry extract containing (PAC-A) as a food supplement were superior to placebo in terms of reduced bacterial adhesion; bacterial MRHA negativity; urine pH reduction; and in preventing r-UTI (dysuria, bacteriuria and pyuria). Larger randomized controlled trials are needed to elucidate the precise role, exact dose and optimal duration of PAC-A therapy in patients at risk of r-UTI.

Application of a stool antigen test to evaluate the burden of Helicobacter pylori infection in dyspepsia patients.

Helicobacter pylori (HP) is causally associated with peptic ulcer disease and gastric carcinoma. Determination of the prevalence of HP infection in dyspepsia patients' in particular geographical area is imperative for the appropriate management of dyspepsia. HP antigen detection in stool is a noninvasive diagnostic test of HP infection. This prospective study was conducted to find out the prevalence of HP infection based on stool antigen testing in dyspeptic patients who had also undergone upper gastrointestinal (GI) endoscopy. This study highlights the high prevalence of HP infection in dyspeptic Indian patients, particularly males, and emphasizes the growing importance of the bacterium causing infection among children. We also found HP stool antigen testing to be superior to upper GI endoscopy for detecting HP infection. Hence, we recommend initial testing for HP stool antigen in dyspeptic patients before initiating treatment and before carrying out any invasive procedure such as endoscopy.

Efficacy and safety of vi-tetanus toxoid conjugated typhoid vaccine (PedaTyph™) in Indian children: School based cluster randomized study.

Vi polysaccharide typhoid vaccines cannot be used in children <2 years owing to poor immunogenic and T cell independent properties. Conjugate vaccine prepared by binding Vi to tetanus toxoids (Vi-TT) induces protective levels even in children <2 years. We evaluated efficacy and safety following vaccination with a Vi-TT vaccine in children 6 months to 12 years of age. Overall, 1765 subjects were recruited from two registered municipal urban slums of southern Kolkata. Most of the children of the slum dwellers attended the schools in the locality which was selected with permission from the school authority. Schools were randomly divided into vaccinated (Test group) and unvaccinated group (Control group). Children and their siblings of test group received 2-doses of PedaTyph™ vaccine at 6 weeks interval. Control group received vaccines as per national guidelines. Adverse events (AEs) were examined after 30 minutes, 1 month and clinical events were observed till 12 months post-vaccination. Incidence of culture positive typhoid fever in the control group was 1.27% vis-a-vis none in vaccine group during 12 months. In subgroup evaluated for immunogenicity, an antibody titer value of 1.8 EU/ml (95% CI: 1.5 EU/ml, 2.2 EU/ml), 32 EU/ml (95% CI: 27.0 EU/ml, 39.0 EU/ml) and 14 EU/ml (95% CI: 12.0 EU/ml, 17.0 EU/ml) at baseline, 6 weeks and 12 months, respectively was observed. Sero-conversion among the sub-group was 100% after 6 weeks of post-vaccination and 83% after 12 months considering 4-fold rise from baseline. The efficacy of vaccine was 100 % (95% CI: 97.6%, 100%) in the first year of follow-up with minimal AEs post vaccination. Vi conjugate typhoid vaccine conferred 100% protection against typhoid fever in 1765 children 6 months to 12 years of age with high immunogenicity in a subgroup from the vaccine arm.