Detection of carbapenem resistance genes and cephalosporin, and quinolone resistance genes along with oqxAB gene in Escherichia coli in hospital wastewater: a matter of concern.

AIMS: This study was performed to detect the presence of Escherichia coli resistant to cephalosporins, carbapenems and quinolones in hospital wastewater. METHODS AND RESULTS: Wastewaters from a rural (H1) and an urban (H2) hospital were tested for E. coli resistant to cephalosporins, carbapenem and quinolones. Genes coding for chromosomal and plasmid-mediated resistance and phylogenetic grouping was detected by multiplex polymerase chain reaction (PCR) and for genetic relatedness by rep-PCR. Of 190 (H1 = 94; H2 = 96) E. coli examined, 44% were resistant to both cephalosporins and quinolones and 3% to imipenem. ESBLs were detected phenotypically in 96% of the isolates, the gene blaCTX-M coding for 87% and blaTEM for 63%. Quinolone resistance was due to mutations in gyrA and parC genes in 97% and plasmid-coded aac-(6')-Ib-cr in 89% of isolates. Only in one carbapenem-resistant E. coli, NDM-1 was detected. Nearly 67% of the isolates belonged to phylogenetic group B2. There was no genetic relatedness among the isolates. CONCLUSIONS: Hospital wastewater contains genetically diverse multidrug-resistant E. coli. SIGNIFICANCE AND IMPACT OF THE STUDY: This study stresses the need for efficient water treatment plants in healthcare settings as a public health measure to minimize spread of multidrug-resistant bacteria into the environment.

Carbapenem resistance among Escherichia coli and Klebsiella pneumoniae in a tertiary care hospital in south India.

Carbapenem resistance among clinical isolates of Enterobacteriaceae, especially Escherichia coli and Klebsiella pneumoniae, is largely conferred by metallo-ß-lactamase (MBL). Fifty-one non repetitive isolates of carbapenem-resistant (Meropenem and Imipenem) E. coli and K. pneumoniae were studied to determine the molecular mechanism for resistance. Presence of blaNDM and blaVIM was determined by polymerase chain reaction (PCR) and DNA sequencing. blaNDM was detected from majority of carbapenem-resistant K. pneumoniae (75%) and E. coli (66.6%). Timely detection and appropriate and aggressive infection control measures are required to control the spread of these bacteria in healthcare settings.

Qualitative study on perceptions of hand hygiene among hospital staff in a rural teaching hospital in India.

BACKGROUND: Hand hygiene is a simple but underutilized measure to control healthcare-associated infections. AIM: To explore staff perceptions of hand hygiene using focus group discussions (FGDs) in a teaching hospital in India. METHODS: Qualitative study. The FGD guide included questions on transmission of infections, hand hygiene practices and problems with implementation, and ways to improve adherence to hand hygiene recommendations. The FGDs were recorded, transcribed verbatim, translated into English (when conducted in Hindi) and analysed using content analysis. FINDINGS: Two themes emerged: 'inter-relationship of knowledge, beliefs, motivation, practices and needs' and 'roles and responsibilities for sustainable and efficient implementation of context-relevant approaches and interventions'. Staff were generally aware of the importance of hand hygiene for the prevention of healthcare-associated infections, but perceived practical problems with implementation. CONCLUSIONS: The staff suggested various interventions and appeared to be prepared to follow hand hygiene guidelines if the hospital provided the necessary facilities.

Antibiotic resistance profile & extended spectrum beta-lactamase (ESBL) production in Acinetobacter species.

BACKGROUND & OBJECTIVES: Members of the genus Acinetobacter are an important cause of nosocomial infections and with widespread resistance to various antibiotics. Extended spectrum beta lactamase (ESBL) associated resistance among Acinetobacter species is now known. The aim of this study was to speciate clinical isolates of Acinetobacter, analyze their resistance patterns, identify the production ESBLs and compare the role of different cephalosporins in detecting ESBL production in the isolates. METHODS: One hundred and fifty clinical isolates of Acinetobacter were speciated by various phenotypic tests. Antibiotic susceptibility was determined by the standard disc diffusion method. ESBL production was detected by the double disk approximation test using clavulanate containing disk and four different cephalosporin disks. Results of the above test were confirmed using the NCCLS phenotypic confirmatory test for ESBLs on a limited number of isolates. RESULTS: Most of the isolates were of respiratory origin. A. calcoaceticus A. baumannii (Acb) complex was the predominant species isolated (75%). Most isolates were resistant to the antibiotics tested including the third generation cephalosporins. Most isolates were sensitive to carbapenems and cefoperazone-sulbactam. ESBL production was detected in 28 per cent of the isolates. In the double disc approximation test, cefepime and cefotaxime could detect most of the ESBLs in Acinetobacter isolates. INTERPRETATION & CONCLUSION: A high level of antibiotic resistance was found in Acinetobacter in our study. Acb complex was the predominant and the more resistant species. Relatively high levels (28%) of ESBL have been detected in Acinetobacter and may reflect the scenario in India. ESBL production in Acinetobacter should be promptly detected and reported as it helps in treating individual cases and also in controlling the spread of these resistant phenotypes to other individuals.

Blastomycosis in a South Indian patient after visiting an endemic area in USA.

We describe a case of blastomycosis in a diabetic patient from South India who had visited Milwaukee, Wisconsin, an endemic area for blastomycosis in the USA. After his return to Bangalore, India, the patient developed intermittent fever of moderate to high grade, cough, loss of weight and appetite, and abscesses in the left cubital fossa and thigh regions. Systemic examination at our hospital revealed that he had dullness to percussion over the chest region and decreased breath sounds. Direct examination of Gram-stained smears of the pus from an abscess showed many broad-based budding yeast cells and culture yielded a dimorphic fungus later identified as Blastomyces dermatitidis. Histologic examination of the curettage tissue slides stained with hematoxylin and eosin, periodic acid Schiff's reagent, and Gomori's methenamine silver stain procedures showed many broad-based budding cells characteristic of B. dermatitidis. The patient was successfully treated, initially with amphotericin B, followed by oral itraconazole for a period of 6 months. Blastomycosis cases in India are reviewed and the likely source of infection in this patient is discussed.

Intestinal parasitic infection and total serum IgG in asymptomatic adult males in an urban slum and efficacy of antiparasitic therapy.

Malnutrition is thought to potentiate the polyclonal stimulation of IgE by parasites. This diminishes immunity due to the decrease in specific anti-parasitic IgE. Prevalence of intestinal parasitic infections in chronically undernourished, asymptomatic adult males from a slum and efficacy of anti-parasitic therapy and its effect on total serum IgE were evaluated. Stool specimens from 51 subjects were examined. Anti-helminth and anti-protozoan therapy consisted of oral, single dose albendazole (400mg) and tinidazole (2g) respectively. Total serum IgE was measured. 23 (45.1%) subjects were positive. Albendazole and tinidazole cleared intestinal parasites but had no significant effect on total serum IgE levels.

Occurrence and characterisation of uropathogenic Escherichia coli in urinary tract infections.

PURPOSE: To study the occurrence of Uropathogenic Escherichia coli (UPEC) in cases with urinary tract infections. METHODS: A total of 220 cases from urinary tract infections and 50 stool samples from apparently healthy individuals were included. The colonies identified as Escherichia coli were screened for virulence factors namely haemolysin, Mannose Resistant and Mannose Sensitive Haemagglutination (MRHA, MSHA), Cell surface hydrophobicity and Serum resistance by recommended methods. RESULTS: Among 220 cases 91(41.36%) were haemolytic, 68(30.9%) showed MRHA, 58(26.36%) were cell surface hydrophobicity positive and 72(32.72%) were serum resistant. In 50 controls 3(6%) were haemolytic, 6(12%) showed MRHA, 9(18%) showed cell surface hydrophobicity and 12(24%) were serum resistant. The difference between cases and controls for haemolysis and MRHA were significant (p< 0.001 and p< 0.01 respectively). A total of 14 atypical Escherichia coli were isolated from urine and all showed the presence of one or the other virulence markers. Out of 18 mucoid Escherichia coli isolated 10 were serum resistant. Interestingly among the 15 Escherichia coli isolated from patients with pyelonephritis 8 were UPEC. CONCLUSIONS: Out of 220 urinary isolates, 151 could be labelled as UPEC.

A hospital based study of hepatitis E by serology.

Hepatitis E virus is recently recognised as an important cause of non-A, non-B hepatitis. A total of 569 serum samples were screened for HEV between April 1997 and March 2000, by a commercially available HEV IgM capture ELISA. The diagnosis was invariably acute viral hepatitis for differential diagnosis of jaundice. The percentage of seropositivity was found to be 18.8% in confirmed Hepatitis E cases.

Human ocular dirofilariasis in Kerala Southern India.

A twenty-six year old female presented to the Ophthalmology OPD with swelling of the upper eyelid. On excision, two long, thin, dead worms were removed. Microscopic and HPE showed the worms to belong to the Dirofilaria species.

Detection of virulent Shigella and enteroinvasive Escherichia coli by induction of the 43 kDa invasion plasmid antigen, ipaC.

The invasion plasmid antigen, ipaC (43 kDa) of Shigella spp. and enteroinvasive Escherichia coli (EIEC) could be induced in vitro by growing them in the presence of Congo red. An enzyme-linked immunosorbent assay (ELISA) using antibodies to the 43 kDa protein of Shigella has been developed for specific detection of virulent Shigella spp and EIEC. The test is independent of initial isolation of individual colonies. As few as 10(2) CFU/ml of virulent Shigella present in mixed cultures could be detected and concurrently their susceptibility to antibiotics could be analysed after an initial growth of 8-16 h in Congo red-containing medium. The test may prove useful in the diagnosis and treatment of bacillary dysentery caused either by Shigella or EIEC through their rapid identification and proper antimicrobial therapy.

Improved microscopical diagnosis of pulmonary tuberculosis in developing countries.

The diagnosis of pulmonary tuberculosis (TB) relies on the bacteriological examination of sputum. However, microscopy of smears made directly from sputum has a low sensitivity and there is an urgent need for improved methods. We have compared microscopy of smears made directly from sputum with microscopy after liquefaction of sputum with household bleach (NaOCl) and concentration of bacteria by centrifugation. In 3 studies performed in Ethiopia and India, the use of the NaOCl method increased the number of samples positive for acid-fast bacilli by more than 100%. The technique is appropriate for developing countries and its application would increase the efficiency of TB control programmes. As a potent disinfectant, NaOCl also has the advantage of lowering the risk of laboratory infection.

Short-course treatment of typhoid fever with ciprofloxacin in south India.

This study assessed the performance of short-course ciprofloxacin for the treatment of 34 adult patients with culture-positive typhoid fever. Patients received ciprofloxacin, 750 mg orally twice daily for 7 d. Measurement of response was based upon time from initial treatment to fever lysis, to afebrile state, and to symptom resolution. Ciprofloxacin-treated patients defervesced in a mean of 3.21 d (+/- 0.56), with stabilization of temperature in 4.0 +/- 0.73 d. After 90 d follow-up, no relapse or carrier was identified. Side effects during therapy were minimal.

Age-specific sero-prevalence of amoebiasis and giardiasis in southern Indian infants and children.

The age-specific sero-prevalence of amoebiasis and giardiasis was estimated in 91 pediatric diarrhoea and in 70 non-diarrhoeal cases from Southern India. Anti-amoeba/giardia IgG assays on 20 children with inflammatory bowel disease from the UK yielded base-line levels in a non-endemic symptomatic population. IgG, IgM, and IgA levels were estimated to E. histolytica and G. lamblia using an ELISA. Concomittant faecal examinations were done for the Indian children. There was a significant correlation between acquisition of sero-positivity and age. A rise in the IgG response to both organisms was evident between 38 and 47 and 13-24 months, respectively, in diarrhoeal and non-diarrhoeal cases. An appreciable IgM response occurred predominantly in diarrhoea cases and at a younger age (less than 24 months). IgA responses were low. Anti-protozoal IgG levels in the UK children were negligible. There was no relationship between faecal excretion and sero-positivity. The study shows an age-related antibody response to E. histolytica and G. lamblia.

Serum antibody response in children with Giardia lamblia infection and identification of an immunodominant 57-kilodalton antigen.

Giardia lamblia antigens which react with sera from children with G. lamblia infection were investigated by sodium-dodecyl polyacrylamide gel electrophoresis and immunoblotting. Serum IgG, IgM and IgA response to the antigens were immunochemically characterized. Serum antibodies from all giardiasis patients, but none of the controls, was found to react with a 57-kilodalton antigen. The 57 kDa antigen elicited IgG and IgA but not IgM antibodies. The protein nature of the 57 kDa antigen was demonstrated by loss of antibody recognition after trypsin treatment of G. lamblia trophozoites. Subcellular fractionation of G. lamblia trophozoites followed by SDS-PAGE and immunoblotting showed that the 57 kDa antigen was probably not a component of the cytoskeleton.

Epidemiological study of an outbreak of Serratia marcescens in a haemodialysis unit.

Twenty-three isolates of Serratia marcescens were isolated over a 10-month period from the blood and arteriovenous shunt sites of patients undergoing haemodialysis in an artificial kidney unit. Surveillance measures performed on the equipment, sterile materials, environment and personnel of this unit yielded Serratia from the air conditioner and one of the dialysis units. The isolates from the patients and dialyser unit were pigmented and had an identical biochemical profile, antibiograms, phage typing pattern and O serotype. The isolate from the air conditioner, though of the same biotype, had a different phage and serotype. It was concluded that the dialyser was the 'common source' and that the organism was persisting in the machine in spite of recommended sterilization procedures being implemented.

Non-specific reactions in enzyme linked immunosorbent assays for serum antibody to entamoeba histolytica and Giardia lamblia in non-endemic areas.

Serum samples from 20 Indian children with diarrhoea were compared with those from 20 children resident in the United Kingdom who had been diagnosed as having ulcerative colitis, or Crohn's disease, or indeterminate colitis using enzyme linked immunosorbent assays specific for Entamoeba histolytica and Giardia lamblia. More than 50% of the United Kingdom patients had high IgG responses in ELISAs for E histolytica and G lamblia. A confirmatory ELISA showed that the British sera reacted specifically to bovine serum proteins rather than to protozoal antigens. Prior incubation of sera with 5% bovine serum prohibited this reaction. Bovine serum is an integral part of the crude soluble antigen used in most ELISAs for E histolytica and G lamblia and needs to be replaced with purified antigen preparations. The British sera also reacted to other commonly used blocking agents such as bovine serum albumin, casein, and normal sheep serum. These reactions were attributed to uptake of dietary antigens or an enhanced immunological response to these antigens in patients with inflammatory bowel disease.

Cerebrospinal fluid C-reactive protein measurement--a bedside test in the rapid diagnosis of bacterial meningitis.

C-reactive protein (C-RP) determinations were performed by the Latex agglutination method on the cerebrospinal fluid (CSF) samples of 212 patients with clinical features suggestive of meningitis. Patients were grouped as follows Group I: bacterial meningitis and partially treated bacterial meningitis (n = 22). Group II: viral encephalitis (n = 11). Group III: tuberculous meningitis (n = 18). Group IV: (i) febrile convulsions (n = 87); (ii) epileptic seizures (n = 70); (iii) intracranial haemorrhage (n = 4). C-RP was a better indicator of bacterial meningitis (sensitivity 91 per cent) than the Gram's stain (sensitivity 46 per cent). C-RP was positive in 91 per cent of patients in Group I, none in Groups II and III and 0.6 per cent in Group IV. C-RP determination in CSF proved to be a useful indicator of bacterial meningitis and served to distinguish it from viral encephalitis, tuberculous meningitis, febrile convulsions and other central nervous system disorders.