Oro-Pharyngeal Candidiasis in Two Dengue Patients.

Dengue, a prevalent arboviral disease, has witnessed a resurgence in India, with outbreaks frequently reported. However, dengue-associated oral (oro-pharyngeal) candidiasis (DAOC) was never reported. We present two severe dengue cases with oral/oro-pharyngeal pseudomembranous candidiasis. Case 1 of a young man without any comorbidities or abuse or immunosuppression presented with fever, headache, altered sensorium, throat pain on recovery, and laboratory reports confirmed dengue with leukopenia, thrombocytopenia, and severe hepatic involvement with oro-pharyngeal candidiasis. Similarly, case 2 of a middle-aged man with a history of smoking and diabetes presented with fever, gum bleeding, and throat pain, later confirmed to be dengue NS1 positive with thrombocytopenia, and mild-moderate hepatic involvement along with oral-oro-pharyngeal candidiasis. Both cases showed improvement with conservative management and oral nystatin suspension. These cases prompt consideration of superadded candida infections in dengue patients, emphasizing the need for further study and clinical vigilance.

Predictors of Poor Outcome in Patients with COVID-19 associated Respiratory Failure: A Retrospective Observational Study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is majorly known to cause mild to moderate disease, but a small fraction of patients may develop respiratory failure due to diffuse lung injury, requiring management in the intensive care unit (ICU). This study attempts to identify factors that can predict unfavorable outcomes in moderate to severe COVID-19 patients. METHODS: Hospital records of 120 COVID-19 patients admitted to the ICU were retrospectively analyzed and data pertaining to demographic, clinical, and laboratory parameters were obtained. These data were then compared with outcome parameters like survival, duration of hospital stay, and various adverse events. RESULTS: Out of 120 patients, 70% were male, with a mean age of 54.44 years [standard deviation (SD) ± 14.24 years]. Presenting symptoms included breathlessness (100%), cough (94.17%), fever (82.5%), and sore throat (10.83%). Diabetes, hypertension, and chronic obstructive pulmonary disease (COPD) were the common comorbidities associated. Increased serum D-dimer, ferritin, interleukin-6 (IL-6) levels, and unvaccinated status were associated with higher mortality. Overall, 25.83% of patients survived, 24.41% of patients developed septic shock, and 10.6% of patients were discharged on oxygen. World Health Organization (WHO) clinical progression scale score ≥ 6 had 57 and 82% sensitivity and 83 and 77% specificity on days 7 and 14 after admission, respectively, for predicting mortality. A baseline National Early Warning Score 2 (NEWS 2) ≥ 9 had 48% sensitivity and 88% specificity for predicting mortality. CONCLUSION: Advanced age and associated comorbidities are linked to adverse outcomes in moderate to severe COVID-19. Persistently high D-dimer levels, despite standard treatment, may also contribute to increased mortality. WHO clinical progression scale and NEWS 2 have high specificity for predicting mortality.

The Role of Yoga in Hospitalized COVID-19 Patients: An Exploratory Randomized Controlled Trial.

Introduction The unpredictable course and sheer magnitude of coronavirus disease 2019 (COVID-19) have sparked a search for novel and repurposed pharmacological interventions. Non-pharmacological interventions may also play a role in the management of this multifaceted disease. This study aimed to evaluate the safety, feasibility, and effect of yoga in hospitalized patients with moderate COVID-19. Methods Twenty patients satisfying the inclusion criterion were randomized (1:1 ratio) into Intervention and Control groups. Patients in the intervention arm performed a one-hour yoga session that included pranayama and Gayatri mantra (GM) chant for up to 14 days. Sessions were fully supervised by a trained yoga trainer via an online platform. Patients in both groups received the normal treatment as per national guidelines. Outcome parameters were recorded on the 14th day/end of the hospital stay. Results Yoga is safe and feasible in hospitalized patients with COVID-19. The decline of high-sensitivity C-reactive protein (hs-CRP) levels was significantly greater in the Intervention Group. Quality of life (QOL), depression, anxiety, and fatigue severity scale (FSS) showed a decline in both groups with a significant decline observed in FSS scores of the Intervention Group. Median chest X-ray score values, duration of hospital stay, and reverse transcription-polymerase chain reaction (RT-PCR) conversion days were observed to be lower in the Intervention Group but were not significant (p>0.05). Conclusion The study found that incorporating pranayama and GM practices in hospitalized patients with moderate COVID-19 pneumonia was safe and feasible. It showed a notable reduction in hs-CRP levels and FSS scores in the Intervention Group, but the study was not powered to detect statistically significant results. Further research with larger sample sizes is needed for conclusive findings.

Comparative Study Between the First and Second Wave of COVID-19 Deaths in India: A Single Center Study.

Introduction  The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is continuously evolving, and many mutant variants of the virus are circulating in the world. Recurrent waves of COVID-19 have caused enormous mortality all across the globe. Considering the novelty of the virus, it becomes crucial for healthcare experts and policymakers to understand the demographic and clinical attributes of inpatient deaths in the first and second waves of COVID-19. Methods This hospital record-based comparative study was conducted at a tertiary care hospital in Uttarakhand, India. The study included all COVID-19 RT PCR-positive patients admitted to the hospital during the first wave, from 1st April 2020 to 31st January 2021, and the second wave from 1st March 2021 to 30th June 2021. Comparisons were made with respect to demographic, clinical, laboratory parameters, and course of hospital stay. Results The study exhibited 11.34% more casualties in the second wave, with the number of deaths being 424 and 475 for the first and second waves, respectively. A male preponderance of mortality was evident in both waves with significant differences (p=0.004). There was no significant difference in age between the two waves (p=0.809). The significantly different comorbidities were hypertension (p=0.003) and coronary artery disease (p=0.014). The clinical manifestations demonstrating a significant difference were cough (p=0.000), sore throat (p=0.002), altered mental status (p=0.002), headache (p=0.025), loss of taste and smell (p=0.001), and tachypnea (p=0.000). The lab parameters with a significant difference across both waves were lymphopenia (p=0.000), elevated aspartate aminotransferase (p=0.004), leukocytosis (p=0.008), and thrombocytopenia (p=0.004). During the hospital course of the second wave, in terms of intensive care unit stay, the need for non-invasive ventilation and inotrope support was higher. The complications manifesting in the form of acute respiratory distress syndrome and sepsis were observed more in the second wave. A significant difference was discerned in the median duration of hospital stay in both waves (p=0.000). Conclusion Despite being of shorter duration, the second wave of COVID-19 culminated in more deaths. The study demonstrated that most of the baseline demographic and clinical characteristics attributed to mortality were more common during the second wave of COVID-19, including lab parameters, complications, and duration of hospital stays. The unpredictable nature of COVID-19 waves calls for instituting a well-planned surveillance mechanism in place to identify the surge in cases at the earliest possible time and prompt response, along with developing infrastructure and capacity to manage complications.

Predictors of Mortality Among Post-COVID-19 Discharged Patients in Northern India: A Case-Control Study.

Introduction The post-discharge all-cause mortality of COVID-19 disease is known, but predictors for the same have not been studied as much. The objective of this study was to develop an understanding of predictors of mortality to guide in prioritizing patient care and preventive approaches. Methods This current research is a single-center unmatched case-control study conducted at a tertiary care center in northern India, between April and September 2022. The data were extracted retrospectively from the hospital's electronic medical records of patients with the assistance of trained physicians using a standardized data extraction sheet. Results A total of 184 patients were enrolled and were segregated into two groups, cases and control, with 92 in each. The mean age of patients was 49.3 ± 17.53 years. The mortality group had a higher mean age (53.24 ± 18.53 yrs) as compared to the control group (45.37 ± 15.58 yrs, p=0.002). Bivariate analysis revealed a significant difference in the two groups with respect to O2 saturation at the time of admission (case - 91.12 ± 12.49 %, control - 95.46 ± 5.01 %, p=0.003); maximum O2 flow rate (L/min) (case - 11.01 ± 22.2, control - 6.41 ± 13.31, p=0.04); ICU need (p=0.005), cancer (p=0.001), O2 requirement at discharge (p=0.001) and acute kidney injury (AKI; p=0.007). On multiple regression analysis, cancer (adjusted odds ratio (aOR) - 2.469; 95% CI 1.183-5.150, p=0.016), ICU admission (aOR - 2.446; 95% CI 1.212-4.938, p=0.013), oxygen at discharge (aOR - 2.340; 95% CI 0.971-5.640, p=0.0586) and AKI (aOR - 5.6; 95% CI 2.351- 13.370, p=0.00) only found to be significant. Conclusion Among the patients released from the hospital post-COVID-19 treatment, the following aspects oxygen requirement (2.3 times), malignancy (2.4 times), ICU admission (2.4 times), and AKI (5.6 times) are risk factors of mortality. The presence of these variables would warrant a close follow-up for these patients in order to decrease post-COVID mortality.

Nutritional assessment in hospitalized elderly patients, its sociodemographic determinants and co-relation with activities of daily life.

Introduction: Present study was planned to identify various sociodemographic factors influencing nutritional status in elderly and impact of nutritional status on activities of daily living in them. Methods: Total of 177 patients were enrolled in a prospective observational study. Nutritional status was assessed at the time of discharge by using Mini Nutritional Assessment form (MNA). Kartz Activity of Daily Living was assessed at 3 months before admission, at the time of admission, at discharge and 3 months after discharge. After written informed consent and ethics clearance patients were enrolled in the study. Analysis was done using the SPSS version 23 and Chi Square test was used to find the association between different qualitative variables. Statistical significance was set at P < 0.05. Results: Mean age of the study participants was 68.64 ± 7.73 years. 40 patients (22.6%) were found to be malnourished. Higher age, living alone, high CCI score and low ADL at discharge were associated with malnutrition. Mean ADL score was 5.82 at - 3 months time point in well-nourished patients which decreased during admission and then increased to 4.94 at the 3 months after discharge. Mean ADL score was of 5.33 at -3 months time point which kept on decreasing during admission and at 3 months after discharge in malnourished group. All these changes were statistically significant (P < 0.001). Conclusion: Nutritional status is a modifiable risk factor in elderly so identifying and optimizing nutritional status of elderly will optimise their functional status and improve quality of life.

Complete heart block in COVID-19 without prior cardiac disease.

Cardiac involvement in COVID-19 is not rare but underdiagnosed. We report a 78-year-old man with COVID-19 and complete heart block, timely managed by teamwork involving internist, cardiologist, and intensivist. This case highlights the importance of involvement of the conducting system of the heart in COVID-19 that needs immediate life-saving intervention, especially in community.

The epidemiology and dynamics of COVID-19 disease transmission among healthcare workers of a tertiary healthcare setting in India.

Context: The novel coronavirus disease 2019 (COVID-19) that has emerged as a pandemic now has put health care workers (HCWs) at great risk as they are the warriors in frontlines screening and treating the infected patients. When a COVID-19-positive HCW is identified, its contacts need to be traced to check the spread of the infection among patients and other HCWs. Aims: This study was aimed to study epidemiology and risk factors associated with severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) infection among HCWs and to quantify the risk of infection among HCWs in a tertiary level health care setting. Settings and Design: This cross-sectional study enrolled all the HCWs who were exposed to a patient with COVID-19 in a tertiary level health care center, Rishikesh, Uttarakhand from 1st May to 30th July, 2020. Methods and Material: All the exposed HCWs were followed up for 14 days after the last exposure to a patient with confirmed COVID-19 infection. Epidemiological data were obtained using structured interviews. Statistical Analysis Used: The data were analyzed using SPSS 23.0. Frequencies and proportions were calculated for descriptive variables, and risk ratios were calculated for risk factors affecting the transmission of disease. Results: We observed that 1,141 HCWs of the tertiary level health care hospital were exposed to COVID-19 patients during the study period. A total of 22 HCWs were tested COVID-19 positive among these exposed HCWs. Univariate analysis revealed a high risk of exposure to be significantly associated with a higher secondary attack rate of SARS CoV-2. Conclusions: The study demonstrates the risk of COVID-19 transmission through asymptomatic carriers. Therefore, periodic testing of all health care workers is necessary to ensure early mitigation of the shortage of health care providers.

Clinical Characteristics of 100 Patients With COVID-19-Associated Mucormycosis From a Tertiary Care Center in North India.

Background Fungal infection in patients with coronavirus disease 2019 (COVID-19) has emerged as a new challenge in healthcare facilities. This study aimed to describe the demographic and clinical characteristics of COVID-19-associated mucormycosis (CAM). Methodology This retrospective, single-center case series included patients who were hospitalized and diagnosed with COVID-19 and mucormycosis at the All India Institute of Medical Sciences, Rishikesh (North India) from April 15, 2021, onwards and last followed up on June 30, 2021. Demographic, clinical, laboratory, radiological, microbiological, pathological, and outcome data were then collected and analyzed. Results Of the 100 consecutive inpatients with CAM, 95 (95%) had diabetes mellitus. At the onset of illness, the most common manifestations were facial swelling (85%), eye swelling (83%), headache (68%), pain around the eyeball (67%), malaise (57%), and fever (50%). The most common organ involved on examination was the nose and paranasal sinus (96%), followed by the orbit (83%), palate (19%), and cranial nerves (7%). Pulmonary involvement was seldom observed (1%). Predominant pathological findings were the presence of aseptate hyphae (75%), necrosis (75%), angioinvasion (36%), and perineural invasion (2.6%). During the last follow-up, 13 patients died, with 11 (84.6%) having severe COVID-19 and two (15.3%) having moderate COVID-19. Conclusions Steroid use and diabetes mellitus are the significant risk factors of CAM. Patients with CAM usually present with face/eye swelling with radiological involvement of the nose and sinus and may die because of severe COVID-19.

Seroprevalence of Antibodies Against SARS-CoV-2 Among Health Care Workers at a Tertiary Care Hospital in Uttarakhand: A Retrospective Study.

Background The number of confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections is vastly underestimated. In this context, seroprevalence surveys are of utmost importance to assess the proportion of the population that has already developed antibodies against the virus and might potentially be protected against subsequent infection. Health care workers (HCWs) face a greater risk of developing SARS-CoV-2. Therefore, the present retrospective study was undertaken to estimate the prevalence of antibodies against SARS-CoV-2 among healthcare workers at a tertiary care institute in Uttarakhand, India. Material and methods Data were gathered from hospital records of 704 healthcare workers admitted to the coronavirus disease 2019 (COVID-19) unit and attended the COVID OPD of the tertiary care institute between July 15 to Aug 14, 2020. Result Out of the 704 recruited participants, 14 (1.99%) were seropositive for immunoglobulin G (IgG) antibodies against SARS-CoV-2. The cumulative prevalence of SARS-CoV-2 infection (presence of antibodies or past or current positive reverse transcription-polymerase chain reaction (RT-PCR)) was 4.40%. Conclusion The present study shows a low prevalence of SARS-CoV-2 IgG antibodies among health care workers. In addition, posting in COVID-19-positive areas was not associated with increased seropositivity. More studies are warranted to assess IgG/IgM antibodies against SARS-CoV-2 among those HCWs who are exposed to COVID-19 patients.

Primary Hypothyroidism Presenting as Cardiac Tamponade.

Hypothyroidism is commonly associated with pericardial effusion, but it can be rarely complicated by cardiac tamponade. We report a case series of two patients who presented with shortness of breath and distension of the abdomen, progressing to generalized edema. Each of them was found to have cardiac tamponade at presentation and eventually diagnosed with hypothyroidism. They were managed by urgent pericardiocentesis followed by intermittent drainage of the collected pericardial effusion along with thyroxine replacement to which they responded. The presence of cardiac tamponade with bradycardia should raise a suspicion of a hypothyroid etiology. Early diagnosis and treatment of hypothyroidism are essential to prevent such complications. How to cite this article: Panda PK, Pattar S, Singh BO, Cheema T. Primary Hypothyroidism Presenting as Cardiac Tamponade. Indian J Crit Care Med 2022;26(5):655-657.

Descriptive Epidemiology of COVID-19 Deaths during the First Wave of Pandemic in India: A Single-center Experience.

BACKGROUND: With the looming threat of recurrent waves of coronavirus disease-2019 (COVID-19) in the presence of mutated strains, it is of paramount importance to understand the demographic and clinical attributes of COVID-19 related mortalities in each pandemic wave. This could help policy makers, public health experts, and clinicians to better plan preventive and management strategies to curb COVID-19 related mortality. MATERIALS AND METHODS: This was a hospital record-based, retrospective cross-sectional descriptive study, at a tertiary care hospital in Rishikesh, India. The study included all deceased patients between March 2020 and January 2021 (first wave) who had tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by reverse transcription polymerase chain reaction (RT-PCR) and were hospitalized. The study was done to describe demography, clinical presentation, laboratory parameters, treatment given, and associated complications of all COVID-19 deaths. RESULT: Out of 424 mortalities, 298 (70.38%) were males and 126 (29.62%) were females. Mean age of patients was 55.85 ± 16.24 years, out of which 19.5% were less than 45 years old, 33.6% were 45-60 years old, and 41.8% were more than 60 years old. Comorbidity in the form of type II diabetes mellitus was present in 41.4% [95% CI (41.4-51.1)], hypertension in 39.8% [95% CI (35.1-44.6)], and coronary artery disease (CAD) in 15.2% [95% CI (11.8-18.8)]. At the time of presentation, shortness of breath was present in 73.6% [95% CI (69.1-77.7)], fever in 64.92% [95% CI (60.1-69.4)], and cough in 46.1%, [95% CI (41.1-50.8)]. Deranged laboratory parameters were lymphopenia in 90.2% [95% CI (86.8-92.7)], transaminitis in 59.7% [95% CI (54.8-64.3)], and hypercreatinemia in 37.7% [95% CI (33.1-42.5)]. Complications manifested were acute respiratory distress syndrome (ARDS) in 78.3% [95% CI (74-82.1)] and shock in 54.7% [95% CI (49.8-59.5)]. Median time duration between onset of symptom and hospital admission was 5 days (interquartile range (IQR) = 3-5 days) and median length of hospital stay was 9 days (IQR = 4-14 days). CONCLUSION: During the first pandemic wave, COVID-19 related mortality was 2.37 times higher among males, 2.14 times in the age group >60 than <45 years. The most common associated comorbidities (>40%) were type II diabetes mellitus and hypertension. The most common associated symptoms (>60%) were shortness of breath and fever. Lymphopenia was seen in >90% cases while liver involvement in 60% and kidney in 38% cases. Median hospital stay was doubled the prehospital illness. HOW TO CITE THIS ARTICLE: Tendulkar P, Pandey P, Panda PK, Bhadoria AS, Kulshreshtha P. Descriptive Epidemiology of COVID-19 Deaths during the First Wave of Pandemic in India: A Single-center Experience. Indian J Crit Care Med 2022;26(1):71-75.

The symptomatology of fever: A step towards qualitative definition of fever.

Background: The old definitions of fever are based on cross-sectional surveys of the population without analyzing the associated symptomatology as fever is a sign, not symptom. Therefore, a longitudinal follow-up study is the need of hour to analyze associated symptoms with fever. Methods: In a longitudinal study over one year, 196 participants recorded three temperature readings daily, one after waking up, one between 12 and 3 PM, one before sleeping, and filled the symptomatology questionnaire in a thermometry diary. Results: Per protocol analysis was done for febrile participants (n = 144). Fatigue (50.3%), warmth (47.3%), headache/head heaviness (47.0%), feeling malaise/general weakness (46.7%), loss of appetite (46.5%), muscle cramps/muscle aches (45.6%), chills/shivering (44.6%), increased sweating (43.0%), nausea (42.5%), irritability (38.9%), increased breathing rate (37.1%), and restlessness/anxiety/palpitations (36.5%) were the symptoms maximally seen during the febrile phase. A higher number of associated symptoms are associated with higher temperature readings. Dehydration suggested the numerically highest temperature values (100.86 ± 1.70°F) but seen in few febrile patients. Conclusions: Incorporation of symptom analysis in febrile patients is the need of the hour. Fatigue and warmth are found to be the most prevalent symptoms during febrile phase. Associated symptoms can help in predicting the intensity of fever also.

Triad of palpitation, angina, and murmur in a non-cardiac patient.

The triad of palpitation, angina, and murmur is a classical feature of cardiac pathology. However, their presence sometimes uncovers a thyroid etiology. Identification well in time decreases out-of-pocket expenditures on illness and suffering. We report a case of a 40-year-old woman who presented with fever with chills, vomiting, palpitations, and shortness of breath for the past month. Also, she described chest pain as typical of angina. Multiple diagnoses were made elsewhere, but none of the treatments resulted in the resolution of symptoms. ST changes were suggestive of ischemic pathology, cardiac MRI done showed up hypertrophied myocardium. After a negative blood culture for infective endocarditis and serology sought for fever work-up, suspicious cardiac examination with a murmur, and an abnormal thyroid profile with a thyroid scan, led to a diagnosis of Graves' disease. This case defines the triad in a noncardiac patient and emphasizes what a thyroid disease does to the heart.

Comparative Evaluation of Nasopharyngeal and Oropharyngeal Swab Based Rapid SARS-CoV-2 Antigen Detection and Real-Time RT-PCR for Diagnosis of COVID-19 in Tertiary Care Hospital.

PURPOSE: To assess and compare the diagnostic accuracy of the GenBody COVID-19 Antigen kit (GenBody Inc., Cheonan, South Korea) available in the market with the gold standard reverse transcription-polymerase chain reaction (RT-PCR) assay to detect severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). METHODS: Nasopharyngeal and oropharyngeal swabs were collected from suspected coronavirus disease 2019 (COVID-19) patients and tested by RT-PCR and GenBody Rapid antigen kit. Performance characteristic of the antigen kit was calculated. RESULTS: We tested nasopharyngeal swabs and oropharyngeal swabs (n=240). Amongst the 102 positive RT-PCR samples, the rapid antigen test detected 36 as positive, showing an overall sensitivity of 35.3%. All the samples detected positive with the antigen rapid test were also detected positive by RT-PCR. CONCLUSION: The performance of the rapid antigen kit was good with respect to high viral load samples, whereas those with lower levels were missed. Unfortunately, the overall low sensitivity of the antigen kit does not allow using it alone as the frontline testing kit for COVID-19 diagnosis.

Primary to tertiary COVID-19 transmission in a hospital - A cluster outbreak analysis.

The recent pandemic of SARS COV-2, a novel coronavirus requires research into understanding of its transmission dynamics and clinical presentations to help in understanding the spread of the disease, how to prevent it not only locally but also for national policy formulations. In this study, we described the transmission dynamics and clinical presentations of a cluster outbreak of SARS COV-2 in a tertiary level hospital. We also calculated the secondary attack rate for the primary, secondary, and tertiary transmissions. We conclude that symptomatic COVID-19 are primary and secondary contacts rather than tertiary contacts, hence, former to be quarantined. However, tertiary transmission is causing more COVID-19 compared to other transmissions in a hospital outbreak without further transmissibility. And overall secondary attack rate is very low in a hospital outbreak.

Dichlorvos Poisoning: A Mystery Case of Distributive Shock Unraveling with Atropine.

Hypotension can be explained by the cardiotoxic effects of an organophosphate poison, but a distributive shock is a rare event. This is a case report of a young north Indian man who presented to the emergency room in a comatose state and distributive shock. He was initially managed with intravenous crystalloids but required inotropic therapy to maintain the desired mean arterial pressure and organ perfusion and also required mechanical ventilation. He improved during the hospital stay only after 4 days when cocktail treatment of atropine was started considering the possibility of organophosphorus toxin exposure and had tapered off the inotropes and mechanical ventilation. Dichlorvos ingestion was confirmed later on after recovery from the coma. At 4-week follow-up, he developed delayed neuropathy. This case is a torchlight toward organophosphorus poisoning presenting as a distributive shock. Atropine may be used as a cocktail treatment in distributive shock where the diagnosis is uncertain. How to cite this article: Suresh S, Panda PK. Dichlorvos Poisoning: A Mystery Case of Distributive Shock Unraveling with Atropine. Indian J Crit Care Med 2021;25(3):337-339.

Non-COVID area of a tertiary care hospital: A major source of nosocomial COVID-19 transmission.

COVID-19 pandemic has spread to all corners of the world where infection control measures are being implemented. There is now a resurgence of the disease in health care facilities with documented in-hospital transmission and cases becoming positive in areas designated to cater for COVID-19 negative patients. We encountered such an event at our institution where fourteen patients (including health care workers) in the non-COVID zone were found to be COVID-19 positive. This highlights the loopholes in the system and the need for better and systematic infection control measures in hospitals that deal with infectious diseases with high infectivity. Findings also suggests the failure of government's criteria for suspected COVID-19 cases, and therefore needs a rethinking.

Compliance of WHO Guideline on Dengue Management among Indian Patients: An Interventional Quality Improvement Study.

INTRODUCTION: Dengue fever management is guided by WHO guideline, the recent one being 2009; however, compliance to the guideline is difficult to assess and in India there is no data on it. The present study, a longitudinal pre-post interventional quality improvement study, was done to determine the compliance to the guideline on dengue patients before and after resident physicians' training during two peak seasons and their impact on survival. METHODS: This study was conducted in a tertiary health care centre in North India over 18 months. Data of hospitalized patients who admitted with dengue fever diagnosis in a peak season was collected in the form of quality indicators as described by the WHO-2009 guideline on dengue. Resident physicians were then given appropriate training about the guideline during the off season. Data of new dengue patients in next peak season after resident training was collected and compared with the baseline by standard statistical tests. RESULTS: The post-intervention compliances of all components increased (total mean score by giving one point to each of the quality indicators reached 7.9 from 6.4). The compliance to individual indicator also increased: the admission criteria (baseline, 44% to post-intervention, 52%, p = 0.37), classification criteria (91.7% to 96%, p = 0.33), correct staging/triage (42.9% to 86%, p <0.001), vitals monitoring (85.7% to 92%, p = 0.28), correct usage of bolus fluids (34.3% to 69.5%, p <0.001), crystalloid as choice of fluid (100% in both groups), proper fluid titration (26.2% to 56%, p <0.001), hematocrit monitoring (95.2% to 98%, p = 0.42), platelet transfusion when indicated (65.5% to 58%, p = 0.39), antibiotic use when required (61.5% to 80%, p = 0.03), and discharge criteria (100% in both groups). The mortality decreased from 7.1% (baseline) to zero (post-intervention). The median duration of hospital stay also reduced by 1 day. CONCLUSION: The study affirms that the compliance to WHO guideline on dengue management in India can be further improved by regular physician training on the guideline. Simultaneously, this educational intervention not only improves patient outcomes but also direct proper resource utilization especially platelet transfusion and antibiotic use. Furthermore, every hospital/institute should have an internal quality improvement program like this to improve the management of dengue patients. Future studies are needed to understand various barriers to 100% implementation of the guideline.

Cocktail treatment of antibiotic, steroid, and analgesic in a tubercular case; the urgency to set up antimicrobial stewardship practices in the community.

Tuberculosis is a well-known entity in India with many implemented policies to ensure the cost-effective early management. Missed, delayed, and complicated presentations do occur, requiring expensive tertiary level of health care. Among many contributing factors, lack of antibiotic stewardship is at the top. We report a case of 65-year-old man who presented with on and off fever for six months, receiving cocktail treatments of antibiotics, analgesics, and steroids from a local dispensary. Our initial investigations revealed microcytic anemia with high erythrocyte sedimentation rate, leukocytosis, and bilateral pleural effusion on chest X-ray. Contrast enhanced computer tomography of chest and abdomen suggested disseminated tuberculosis including bilateral empyema. Frank pus was drained on thoracocentesis, which was negative for Gram stain, Ziehl-Neelsen stain, and bacterial culture, but positive CB-NAAT for tubercular bacilli with no resistance to rifampicin. Mantoux test and stool occult blood were positive. This case highlights an unusual presentation of tuberculosis and the ongoing lacunae in the society with importance to the primary care providers in the effective management of tuberculosis focusing on antimicrobial stewardship.