Evaluating the dynamics of hospital COVID-19 contacts and subsequent conversion to SARS-CoV-2 infection: a multi-centre retrospective cohort study.

We investigated the dynamics of COVID-19 contacts subsequent conversion to SARS-CoV-2 infection in an inpatient setting across three National Health Service (NHS) Trusts. 9.2% (476/5,156) COVID-19 contacts met inclusion criteria, were typable and tested positive for COVID-19. There was no significant difference between Omicron and non-Omicron contacts overall conversion proportions. Omicron contacts converted faster than non-Omicron contacts (median 3 days vs 4 days, P=0.03), and had significantly greater proportions of early conversions at day 3, 5, and 7 timepoints.

Clinical features and management of individuals admitted to hospital with monkeypox and associated complications across the UK: a retrospective cohort study.

BACKGROUND: The scale of the 2022 global mpox (formerly known as monkeypox) outbreak has been unprecedented. In less than 6 months, non-endemic countries have reported more than 67 000 cases of a disease that had previously been rare outside of Africa. Mortality has been reported as rare but hospital admission has been relatively common. We aimed to describe the clinical and laboratory characteristics and outcomes of individuals admitted to hospital with mpox and associated complications, including tecovirimat recipients. METHODS: In this cohort study, we undertook retrospective review of electronic clinical records and pathology data for all individuals admitted between May 6, and Aug 3, 2022, to 16 hospitals from the Specialist and High Consequence Infectious Diseases Network for Monkeypox. The hospitals were located in ten cities in England and Northern Ireland. Inclusion criteria were clinical signs consistent with mpox and MPXV DNA detected from at least one clinical sample by PCR testing. Patients admitted solely for isolation purposes were excluded from the study. Key outcomes included admission indication, complications (including pain, secondary infection, and mortality) and use of antibiotic and anti-viral treatments. Routine biochemistry, haematology, microbiology, and virology data were also collected. Outcomes were assessed in all patients with available data. FINDINGS: 156 individuals were admitted to hospital with complicated mpox during the study period. 153 (98%) were male and three (2%) were female, with a median age of 35 years (IQR 30-44). Gender data were collected from electronic patient records, which encompassed full formal review of clincian notes. The prespecified options for data collection for gender were male, female, trans, non-binary, or unknown. 105 (71%) of 148 participants with available ethnicity data were of White ethnicity and 47 (30%) of 155 were living with HIV with a median CD4 count of 510 cells per mm3 (IQR 349-828). Rectal or perianal pain (including proctitis) was the most common indication for hospital admission (44 [28%] of 156). Severe pain was reported in 89 (57%) of 156, and secondary bacterial infection in 82 (58%) of 142 individuals with available data. Median admission duration was 5 days (IQR 2-9). Ten individuals required surgery and two cases of encephalitis were reported. 38 (24%) of the 156 individuals received tecovirimat with early cessation in four cases (two owing to hepatic transaminitis, one to rapid treatment response, and one to patient choice). No deaths occurred during the study period. INTERPRETATION: Although life-threatening mpox appears rare in hospitalised populations during the current outbreak, severe mpox and associated complications can occur in immunocompetent individuals. Analgesia and management of superimposed bacterial infection are priorities for patients admitted to hospital. FUNDING: None.

Analysis of an outbreak of nosocomial COVID-19 at a tertiary care centre in South India.

BACKGROUND: Nosocomial outbreaks of COVID-19 have been reported sporadically since the beginning of the COVID-19 pandemic. We sought to study the transmission dynamics in a nosocomial COVID-19 outbreak in our centre. METHODS: This was a retrospective cohort study in a 500 bedded tertiary care hospital in South India. Inpatients who were suspected to have likely or definite hospital-acquired COVID-19 and hospital staff members who were found to be COVID-19 positive during the same time frame were studied and the likely transmission dynamics described. RESULTS: During the study period, 173 patients were diagnosed to have COVID-19, out of which, 15 (8.6%) patients who fulfilled the criteria for likely or definitely hospital-acquired COVID-19 infection were identified from six different wards. During the same period, 121 hospital staff members were diagnosed with COVID-19. Out of these, 18 (14.9%) hospital staff members were identified who could have been the potential source of infection for these 15 patients based on the overlap of location of the staff and the patients, and their infectivity windows. Direct contact and fomite transmission were likely the predominant driver of transmission in our study as there was use of universal face masks and face shields. CONCLUSION: Despite the admission of a large number of COVID-19 patients and a relatively large proportion of hospital staff members who tested positive for the disease, the proportion of nosocomial COVID-19 in our centre remained low. A policy of universal gloving, coupled with the already existing practice of universal N95 masking and face shield use, could potentially bring down the rate of nosocomial COVID-19 even further.

Miller Fisher Syndrome and Boomerang Sign: A Rare Presentation of Typhoid Fever.

Miller Fischer syndrome (MFS) is a variant of Guillain-Barré syndrome which is characterized by a triad of ataxia, ophthalmoplegia, and areflexia. It is uncommonly associated with systemic illnesses. We present the case of a young boy who came back after a trip to New Delhi in India, who developed MFS. MRI showed a callosal splenial hyperintensity which is called the boomerang sign. The evaluation revealed typhoid fever. This is probably the first such report of MFS associated with this infection.

Awareness of the Standard of Care for Snakebite Management Among Physicians in Kerala: A Cross-sectional Study.

Snakebite remains a largely neglected yet important cause of morbidity as well as mortality in Kerala. This study aimed to assess the knowledge about the standard of care for snakebite management among physicians in Kerala. This was a cross-sectional study using a questionnaire-based survey among 110 physicians from Kerala. The overall knowledge levels were assessed using a questionnaire with answers being scored as 0 for wrong answers and as 1 for correct answers. The total knowledge scores for all respondents were calculated, with a maximum possible score of 14 and a minimum possible score of 0. Comparisons were made between subsets of respondents. The questionnaire was administered to 110 physicians who fulfilled the predetermined criteria. The overall mean knowledge score during the study was 10.7 (standard deviation ± 2.9). However, there were certain pitfalls associated with the management of snakebite. In particular, questions about tourniquet use, bringing a dead snake to the physician, and the anti-snake venom test dose had high proportions of incorrect answers. Significantly higher knowledge levels were also observed in certain subgroups. There seems to be varying knowledge gaps associated with various aspects of snakebite management for certain subsets of respondents who are likely to benefit from specific training.

Pneumococcal Bacteremia and Cryptococcal Meningitis Dual Infection in a Patient With Multiple Myeloma.

Infections remain one of the major complications in patients with multiple myeloma, having a significant impact on morbidity and mortality. The increased risk of infection in these patients are a result of various factors contributing to the impairment of immune system caused by the disease and the chemotherapy regimens given during the treatment phases. Here we report a rare case of pneumococcal bacteraemia and cryptococcal meningitis dual infection in a patient with underlying multiple myeloma who had a favourable clinical outcome. This case also serves to highlight the importance of adult vaccinations especially in patients with underlying comorbidities.

A comparison of COVID-19 secondary attack rate in household and close contacts compared to current risk stratification guidelines of the Kerala government.

COVID-19 has been found to be highly infectious with a high secondary attack rate with a R0 of 3.3. However, the secondary attack rate based on risk stratification is sparsely reported, if ever. We studied the contact tracing data for two index cases of COVID-19 with some overlap of contacts. We found that 60% of high-risk contacts and 0% of low-risk contacts of symptomatic COVID-19 patients contracted the infection, in keeping with the Kerala government contact risk stratification guidelines.

Pubic symphysis tuberculosis: A diagnostic dilemma.

Symphysis pubis tuberculosis (TB) is extremely rare in the reported literature. The diagnosis of pelvic TB is confounded by close differentials such as osteomyelitis as well as the low yield of TB bacilli in microbiological sampling in the initial stages of the disease. Pelvic TB should be suspected early on in areas with high TB burden, and prompt treatment with antitubercular treatment may help prevent disability associated with the disease. Here, we present a 49-year-old diabetic man with pubic symphysis TB which was diagnosed on the basis of clinical and radiological aspects, with near-total resolution following 9 months of anti-tubercular treatment.

Tropical Aquatic Skin and Soft Tissue Infections: A Series of Three Cases.

Bacterial infections following aquatic exposure occur frequently and most commonly present as skin and soft tissue infections (SSTI). Aquatic SSTI bacterial infections are usually caused by a limited number of organisms. Here we present three cases from the same geographical region, caused by three different organisms in patients who had exposure to an aquatic environment: Mycobacterium marinum, Shewanella algae, and Vibrio vulnificus. We wish to highlight that aquatic bacterial infections can cause varying degrees of morbidity and even mortality. Each of these three cases represents an aquatic, tropical SSTI with a delayed diagnosis, most likely as a result of the lack of widespread awareness about these organisms.

Clinical Outcomes in Carbapenem-Resistant Enterobacteriaceae Infections Treated With Ceftazidime-Avibactam: A Single-Center Observational Study.

Introduction Among the several newer beta lactam+beta lactase inhibitors (BL/BLI), ceftazidime-avibactam is the only drug showing activity against OXA-48-like producers. Hence, it is being increasingly used in India to treat infections caused by carbapenem-resistant Enterobacteriaceae (CRE), especially as a colistin-sparing agent. We have used ceftazidime-avibactam in patients suspected and confirmed to have CRE infections in our center, and present a retrospective analysis of our experience. Methods We conducted a single-center, retrospective study involving all patients who were treated with ceftazidime-avibactam for suspected and proven CRE infections during a one-year period at our 500-bedded hospital. Our primary objective for this study was taken as all-cause mortality. The secondary objectives were to determine the clinical cure, defined as the end of the treatment regimen with a resolution of primary infection and resistance to ceftazidime-avibactam in patients who underwent the Epsilometer test (E-test). Results  A total of 103 patients who received ceftazidime-avibactam were identified. The all-cause mortality was 27% while a clinical cure was achieved in 73%. Fifty-two patients received empirical therapy and 51 patients received ceftazidime-avibactam for confirmed CRE infection. Forty-eight patients had an E-test done, out of which 79% of patients had CREs sensitive to ceftazidime-avibactam, and 21% of patients had ceftazidime-avibactam resistant CREs. A higher Sequential Organ Failure Assessment (SOFA) score, Charlson comorbidity index (CCI) score, intensive care unit (ICU) admission, inotrope requirement, and lower days of therapy (DOT) with ceftazidime-avibactam were found to be associated with increased mortality. Conclusion Colistin has been considered to be the last-line agent in CRE infections, but there are concerns about its adverse effects and the emergence of resistance. Given our relatively low mortality of 27% in CRE infections treated with ceftazidime-avibactam, coupled with the high susceptibility of the tested isolates, there may be a role for the empirical use of this drug in infections caused by CRE, especially in a setting where colistin may not be ideal.

Case Report: Ascending Myelo-Encephalitis after a Penetrating Injury to the Foot: An Atypical Case of Neuromelioidosis.

Organisms penetrate the central nervous system (CNS) via three routes. The commonest is the hematogenous route, and other routes include contiguous or penetrating injury or rarely via retrograde axoplasmic route. Although the axoplasmic highway is often used by viruses, only a few bacteria are known to penetrate the CNS via this route. We present a 57-year-old man who developed a penetrating injury while working in a field. Over the next 4 months, he developed pain at the site of the poorly healing wound, which ascended up the right leg and presented as a conus-cauda syndrome. Magnetic resonance imaging (MRI) showed an enhancing intradural intramedullary enhancing lesion in the conus on the right side with cord edema from D11 to L1 level. Extensive evaluation was negative, and he continued to progress to holocord myelitis and developed bilateral corticospinal tract lesions ("tractopathy") in the brain stem and internal capsule. He died after developing a right-sided cerebritis with mass effect. Tissue biopsy from the brain at the time of decompressive craniectomy grew Burkholderia pseudomallei and confirmed a diagnosis of neuromelioidosis (NM). We reviewed the literature for NM, its variable presentations, and the concept of an "infectious tractopathy" and imaging findings which could generate suspicion of this entity.

A quality improvement project on adherence to antibiotic policy in acute admissions from a tertiary care hospital in south India.

The indiscriminate use of antibiotics in clinical practice may be an independent risk factor for the development of antimicrobial resistance. To combat this, our hospital implemented a hospital antibiotic policy which outlines the appropriate antibiotic to be used in an acute admission, based on a continuously updated local antibiogram. However, we felt that compliance with the policy was poor and hence carried out a quality improvement project (QIP) to assess and increase compliance. We show that a simple QIP model combined with the use of a mobile application can serve to improve compliance even in a low-resource setting with minimum infrastructure. This model could be easily extrapolated into similar settings.

A Case of Diphtheria and Infectious Mononucleosis Co-Infection in a Partially Vaccinated Boy.

We report the case of an eight-year-old partially immunized boy who presented with presumed bacterial tonsillitis. He was initially prescribed amoxicillin-clavulanic acid which resulted in the development of an erythematous maculopapular over the face which spread to the trunk and extremities including palms and soles and resolved over the next three days. He was diagnosed to have diphtheria and infectious mononucleosis (IMN) co-infection. He made an uneventful recovery and an extensive review of the literature showed that the incidence of diphtheria and IMN co-infection is a relatively rare clinical entity. We wish to highlight the possibility of such co-infections which often mimic one another.

Aspergillus fumigatus meningitis in an immunocompetent young woman.

Aspergillus meningitis is a rare clinical entity that is much more frequently observed among immunocompetent patients. Here we present the case of a 28 year old immunocompetent lady with Aspergillus fumigatus meningitis possibly following spinal anaesthesia for her caesarean section. The diagnosis of Aspergillus meningitis is very difficult and challenging. Even after diagnosis, clinical outcomes remain poor with treatment. We wish to highlight the need for high index of suspicion for Fungal meningitis in patients presenting with meningism after Neurosurgeries and procedures involving invasion into the CSF compartment.

Contact tracing: a lesson from the Nipah virus in the time of COVID-19.

Without a vaccine or proven therapeutic options in COVID-19, the World Health Organization (WHO) recommends a combination of measures: rapid diagnosis and immediate isolation of cases; rigorous contact tracing; and precautionary self-isolation of close contacts to curb the spread of COVID-19. During a Nipah outbreak in Kerala, India in 2019, it was confined to a single case. The authors were involved in the in-hospital contact tracing. With a single patient producing a contact list of 98 in a healthcare setting, the implications in a community setting during a pandemic of the scale of COVID-19 are huge but it proves that early and rigorous tracing with quarantining is an effective strategy to limit clusters. We believe that if the public is encouraged to maintain their own contact list on a daily basis, it would help in significantly reducing the time and effort invested into contact tracing in the event of a person contracting COVID-19.

Cardiovascular and stroke disease risk among doctors: a cross-sectional study.

The leading causes of death in the world are cardiovascular disease (CVD) and stroke according to the World Health Organization, as is also the case in India. There is also a high prevalence of major conventional risk factors in India, where 18.3%, 9.0% and 14.1% of adults are diagnosed with hypertension, diabetes and smoking, respectively. The aim of the present study was to look at the risk of CVD among doctors in our country using a validated tool developed by the National Health Service (NHS) in the UK, the QRISK3 calculator.

Little Known Dangers of an Exotic Poisonous Fruit: Lessons From Two Cases of Konjac Ingestion.

Amorphophallus konjac, often abbreviated to Konjac, is a perennial plant that is not uncommon in parts of Asia where it is cultivated as a food source. However, consumption of the raw plant has been known to be toxic to animals. We report the first human cases of Konjac poisoning in two children after accidental ingestion of its seeds.