Submammary Approach for Harvesting Pectoralis Major Myocutaneous Flap in Females with Oral Cavity Cancers: Report of Technique and Our Experience.

Background: Oral squamous cell carcinoma is one of the most common types of cancers affecting both male and female population worldwide. Currently gold standard for reconstruction of oral cavity defects is free flap reconstruction. However, in developing countries due to large case load, infrastructural and resource constraints, Pectoralis major myocutaneous flap is still widely being used. Harvesting PMMC flap in females is challenging due to thick fat and breast tissue affecting its reliability and also increased donor site morbidity. This article aims at highlighting our experience with harvesting PMMC flap in female patients by submammary approach and its outcomes. Methods: A total of 23 female patients who underwent wide local excision of oral cavity cancers and reconstruction with PMMC flap were included. Data was analysed as mean, median, mode, percentages and statistical averages. Results: Majority of patients belonged to 40-60 years of age group (60.86%). Buccal mucosa was the most common site of primary lesion in 16 patients (69.56%). Out of the 23 patients who underwent PMMC flap reconstruction, recipient site complications were seen in 4 patients including total flap loss in 2 patients (8.69%), minor complications, e.g. infection in 2 patients (8.69%). Donor site morbidity in the form of axillary seroma was seen in only 1 patient (4.34%). Conclusion: In our experience, PMMC flap is still a viable option for reconstruction especially in resource constraint settings. Submammary approach to PMMC flap harvest is a safe technique as it is associated with minimum recipient site complications whilst preserving donor site anatomy and thereby reducing donor site morbidities to minimum.

Evolving Trends of Button Battery Ingestion in Indian Children at a Tertiary Care Hospital.

INTRODUCTION: Foreign body ingestion is a common problem encountered in the pediatric age group. Impaction of lithium batteries of greater than 20-mm diameter in the esophagus is associated with severe complications. This study aimed at analyzing the evolving trends of button battery ingestion in pediatric age groups at our tertiary care center in terms of clinical presentation, intraoperative findings, and the correlation of various clinical variables. METHODS: A retrospective observational study was done. All children younger than 18 years with impaction of a button battery of size greater than 20 mm in the esophagus between January 2015 and December 2018 were included in the study. All children underwent removal of the battery using direct laryngoscopy/rigid esophagoscopy under general anesthesia. RESULTS: There were 100 children included in the study with a mean age of 29.92 months having 93 children (93%) younger than 6 years. The mean duration of impaction was 34.7 hours. Increased duration of impaction was associated with an increased risk of complications and an increased difficulty in removal. There was a significant correlation between the site of impaction and the age of the patient. Complications were seen in 10% of cases with severe complications in 6 cases. No fatalities were reported in this study. CONCLUSIONS: Button batteries impacted in the esophagus can lead to severe complications including death. There has been an increasing trend in the ingestion of button batteries over the last 4 years. A prompt diagnosis and emergent removal of the battery are crucial to minimize the rate of complications. Symptoms of stridor and dysphagia must be given more attention, and these children are prioritized because they are more prone to have complications. Furthermore, primary prevention and caregiver education should be emphasized, and the need for a legislation to change the policies for securing the batteries in their products must be endorsed.

Evaluation of role of interferon gamma release assays in the diagnosis of latent tuberculosis in human immunodeficiency virus-infected patients.

INTRODUCTION: Tuberculosis (TB) is the most common opportunistic infection in human immunodeficiency virus (HIV)-infected individuals. The risk of eventually developing active TB from latent TB infection (LTBI) is about 10% per year in HIV-positive patients in contrast to 10% lifetime risk in HIV-negative patients. Until recently, the tuberculin skin test (TST) was the only tool available for diagnosing LTBI. Interferon-gamma release assays (IGRAs) were recently developed and address many of the limitations of TST test, especially in immunocompromised state. AIMS AND OBJECTIVES: (1) To determine the prevalence of latent, active pulmonary, and multidrug-resistant (MDR)-TB among HIV-positive patients in and around Aligarh region; (2) sensitivity and specificity of TST and IGRAs for diagnosis of LTBI in HIV positive patients; and (3) to assess drug resistance and mutational patterns of the clinical isolates of MDR-TB in HIV-TB co-infection. MATERIALS AND METHODS: A cross-sectional study was done on all the patients attended the ICTC centre, JNMC, AMU Aligarh, seropositive for HIV, i.e. 469 (sample size) for the study period of 2 years from October 2015 to October 2017. All 469 HIV-positive patients were screened for latent and active pulmonary TB. Diagnosis of TB (active and latent) was made using clinical, radiological, and microbiological tests. TST and IGRA testing along with CD4 cell counts were also determined. Line probe assay was also done to assess drug resistance and mutational patterns of MDR-TB in HIV patients. RESULTS: In our study, prevalence of HIV infection was 5.04%. Sixty-seven (14.28%) patients were as active TB (HIV-TB co-infection), out of which only one patient (1.49%) was confirmed as MDR-TB, 117 (24.94%) were diagnosed as LTBI. It was also evaluated that IGRA has more sensitivity (75%) and specificity (76%) than TST with sensitivity of 71.7% and specificity 66%. CONCLUSION: As there is no gold standard test for latent TB, longitudinal follow-up is needed to interpret discordant test results. There is a need to interpret negative QFT results with caution and to test for latent TB at higher CD4 counts, if possible. Interferon gamma assays can become better tool for diagnosis of especially for latent TB. However, more research study required for establish their relevance, especially in immunocompromised states.

Molecular characterization and phylogenetic analysis of human pathogenic Leptospira species circulating in a tertiary care hospital of Western Uttar Pradesh in India.

Leptospirosis is identified as an important reemerging zoonotic disease distributed worldwide, caused by Leptospira. This study was carried out to explore the genetic characterization and its phylogenetic analysis of circulating Leptospira species, among the Aligarh region of western Uttar Pradesh in India, utilizing secY gene-based nucleotide sequence. A total of 190 human samples were included in the study. Positive samples were identified by ELISA, MAT and PCR. MAT was carried out utilizing local circulating Leptospira serovars. Four positive samples including two MAT positive samples were subjected to DNA sequencing for further confirmation and phylogenetic tree was constructed. Out of the total of 190 samples, 24 patients were found positive by ELISA and 29 by PCR. Two samples were found reactive in MAT with L. interrogans serovars like hebdomadis and copenhageni. Phylogenetic analysis of four isolates based on partial secY gene nucleotide sequences revealed that species obtained from the Aligarh region clustered with the several published pathogenic Leptospira interrogans, while some of our isolates nucleotide sequences also clustered with the published sequence of intermediate and saprophytic Leptospira serovars like Leptospira inadai and Leptospira meyeri. This pilot study will help us to decipher the present scenario of circulating serovars of leptospira as well as to identify the nucleotide changes in secY gene, in this region.

Profile of drug-resistant-conferring mutations among new and previously treated pulmonary tuberculosis cases from Aligarh region of Northern India.

Background: The prevalence of multidrug-resistant-tuberculosis (MDR-TB) among new and previously treated cases is increasing worldwide as well as in India. Rapid detection of MDR-TB allows the establishment of an effective treatment regimen; minimizes the risk of further resistance, and limits the spread of drug-resistant strains. Early diagnosis of MDR-TB is the need of the hour in high-TB burden countries like India, and GenotypeMTBDRplus is quite sensitive and specific in determining the molecular resistance in drugs such as rifampicin and isoniazid. Methods: The present study was done for molecular detection of rifampicin and isoniazid resistance and resistance patterns among MDR-TB suspects and comparison of resistance patterns among new and previously treated cases by GenoType® MTBDRplus Line Probe Assay. A total of 1268 sputum samples of MDR-TB suspects were subjected to fluorescent microscopy. Fluorescent microscopy positive samples were subjected to GenoType® MTBDRplus (HAIN Lifescience) assay. Results: MDR-TB was detected 11.02%, 20.03% in new and previously treated cases. Among MDR-TB patients S531 L was the most common mutation detected in rpoB gene; 71.43% in new, and 72.17% in previously treated cases. S315T1 was the most common mutation noted in katG gene; 100% in new and 81.74% in previously treated. While in hA gene, it was C15T (7.8%) among previously treated cases. Conclusion: MDR-TB has high prevalence in the western part of Uttar Pradesh, India. Previously treated cases have even more high rate of MDR-TB than new TB cases. The most dominant gene mutations associated with resistance to INH and RIF were observed in codon 315 of the katG gene and codon 531 of the rpoB gene. While comparing the mutation patterns by Genotype MTBDRplus assay, previously treated cases showed more diversity of mutations and had greater number of unknown mutations.

Drug Resistance and Molecular Epidemiology of Carbapenem Resistant Gram-negative Bacilli Isolates.

OBJECTIVES: Detection and comparison of metallo-ß-lactamase (MBL) production in clinical isolates by phenotypic and genotypic measures. The objective of this study is to evaluate clinical characteristics and risk factors in patients infected with MBLs. MATERIALS AND METHODS: Study was conducted by the Department of Microbiology, Jawaharlal Nehru Medical College from February 2014 to December 2015. Bacterial culture, identification, and antibiotic susceptibility were carried out according to standard guidelines. MBL production was detected both phenotypically (Modified Hodge test [MHT], imipenem-ethylene diamine tetraacetic acid double disk potentiation test [IMP-EDTA DDPT], IMP-EDTA combined disk synergy test [IMP-EDTA CDST]), and genotypically (blaNDM-1, blaVIM and blaIMP). RESULTS: Among 116 carbapenem-resistant Gram-negative Bacilli (CRGNB), Citrobacter species 28 (24.1%) was the most common pathogen. Phenotypically, MHT, IMP-EDTA DDPT, and IMP-EDTA CDST detected MBL production in 105 (90.5%), 96 (81%), and 87 (75%) CRGNB, respectively. BlaNDM-1 genes were detected in 6 6 (56.8%) isolates, however, very few blaVIM (16, 15.2%) and blaIMP (1, 1.2%) were identified. Considering polymerase chain reaction (PCR) as the gold standard, it was observed that IMP-EDTA CDST was most specific (78.3%) while MHT was most sensitive (97.4%). Results of blaNDM-1 gene by PCR were further confirmed by sequencing (Triyat genomics, Nagpur). All the 11 representative strains were confirmed to be NDM-1 gene. Major risk factors in patients infected with MBLs were in-dwelling devices (68%), prolonged hospital stay (72%) and prior antibiotic treatment (86%). However, on tracing their outcome, it was interesting to note that mortality was relatively low 5 (4.3%). CONCLUSION: The present study shows a rising trend of blaNDM-1 in CRGNB, an ominous sign heralding the post antibiotic era. It is essential to assess the prevalence of various MBLs so that infection control measures can be reinforced. We recommend three phenotypic tests in tandem for the detection of MBL. While phenotypic tests are easy and cost-effective to perform, quick, effective molecular diagnostic techniques can tailor treatment guidelines to optimize patient's management.

Alarming resistance of Neisseria gonorrhoeae in a tertiary care hospital of North India.

Background: This study attempted to elucidate the spectrum of sexually transmitted infections in a tertiary care centre in North India and to assess the antimicrobial resistance in Neisseria gonorrhoeae. Materials and Methods: Antimicrobial resistance pattern of N. gonorrhoeae was determined by the standard techniques. Genotypic detection of gyrA, parC and blaTEM genes was also carried out. The results of gyrA gene by polymerase chain reaction were confirmed by DNA sequencing. Results: N. gonorrhoea was identified in 10 (4.98%) patients, and antimicrobial sensitivity was performed in seven patients. All the seven patients tested were quinolone-resistant N. gonorrhoeae (QRNG), 5/7 were penicillinase-producing N. gonorrhoeae, 1/7 was chromosomally mediated penicillin-resistant N. gonorrhoeae and 3/7 were tetracycline-resistant N. gonorrhoeae. Minimal inhibitory concentration (MIC) by E-test was performed in five strains, and we observed that MIC90 for ciprofloxacin was ≥4 µg/ml, for penicillin was ≥6 µg/ml and for tetracycline was 12 µg/ml, which clearly brackets them as resistant isolates. The presence of TEM gene was confirmed genotypically in six out of seven cases. In all seven cases, gyrA and parC were observed, thus confirming their QRNG status. Conclusion: Alarming increase in the resistance to commonly used antimicrobials for gonorrhoea in our study, especially of fluoroquinolones, is a clarion call for the urgent need for prudence in prescribing them. Observing the rampant resistance exhibited by N. gonorrhoeae, it is clear that the day is not far when it will acquire a superbug status and become intractable to treatment by the available antibiotics.

Prevalence of scrub typhus in pyrexia of unknown origin and assessment of interleukin-8, tumor necrosis factor-alpha, and interferon-gamma levels in scrub typhus-positive patients.

BACKGROUND: Scrub typhus is lesser known cause of fever of unknown origin in India. Even if there have been reports documenting the prevalence of scrub typhus in different parts of India, it is still an unknown entity, and clinicians usually do not consider it as differential diagnosis. The present study was performed to document the prevalence of scrub typhus among febrile patients in western part of Uttar Pradesh and to assess the clinical profile of infected patients on the one hand and knowledge, attitude, and practices among clinicians on the other. MATERIALS AND METHODS: A total of 357 adult patients with fever of more than 5-day duration were recruited. All patients underwent complete physical examination, and detailed clinical history was elicited as per predesigned pro forma. After primary screening to rule out malaria, enteric fever, and leptospirosis infection, secondary screening for scrub typhus was done by rapid screen test and IgM ELISA. RESULTS: Scrub typhus infection was positive in 91 (25.5%) cases. The most common symptoms among the patients were fever (100%), pain in abdomen (79.1%), pedal edema 56 (61.5%), rash 44 (48.3%), headache 44 (48.3%), vomiting 42 (46.1%), constipation 33 (36.2%), cough 28 (30.7%), and lymphadenopathy 20 (21.9%). The median values of interleukin-8, interferon-gamma, and tumor necrosis factor-alpha in healthy controls were 15.54 pg/ml, 7.77 pg/ml, and 54.1 pg/ml, respectively, while the median values of these cytokines in scrub typhus-positive patients were 21.04 pg/ml, 8.74 pg/ml, and 73.8 pg/ml, respectively. CONCLUSION: Our results highlight that scrub typhus infection is an important cause of pyrexia of unknown origin, and active surveillance is necessary to assess the exact magnitude and distribution of the disease.

Alarming emergence, molecular characterization, and outcome of blaNDM-1 in patients infected with multidrug-resistant Gram-negative bacilli in a tertiary care hospital.

INTRODUCTION: This study was conducted to assess the prevalence of metallo-beta-lactamases (MBLs) in general and blaNDM-1 in particular. It also aimed at evaluating clinical characteristics and outcome in patients infected with MBLs. MATERIALS AND METHODS: A total of 116 carbapenem-resistant Gram-negative bacilli (CRGNB) were evaluated in the study. These CRGNB were tested for MBL production both phenotypically for MBLs and genotypically for blaNDM-1 gene by polymerase chain reaction (PCR). Representative stains of NDM-1 isolates were further sequenced by Triyat Scientific Co., (Nagpur, India). RESULTS: Among 116 CRGNB Citrobacter species 28 (24.13%) was the most common pathogen. Phenotypically, MHT, imipenem-EDTA (IPM-EDTA) double-disk synergy test and IPM-EDTA combined disk synergy test (CDST) detected MBL production in 105 (90.51%), 96 (81.03%), and 87 (75%) CRGNB, respectively. However, blaNDM-1 genes were detected in 66 (56.89%) isolates. The prevalence of blaNDM-1 gene was highest among Escherichia coli 26 (100%). Considering PCR as gold standard, it was observed that IMP-EDTA CDST was most specific (78.38%) while MHT was most sensitive (97.47%). Results of blaNDM-1 gene by PCR were further confirmed by sequencing (Triyat genomics, Nagpur). All the 11 representative strains were confirmed to be an NDM-1 gene. The presence of MBLs in our group of patients (non-Intensive Care Unit patients) is a cause for concern. However, on tracing their outcome, it was interesting to note that while the duration of stay lengthened in a large number of patients 112 (96.5%), mortality was relatively low 5 (4.31%). CONCLUSION: The results of this study provide insight into the prevalence of MBLs, including blaNDM-1, in a tertiary care hospital. Antibiotic stewardship implemented in all seriousness may to a great extent stave off the impending pan-drug resistance. The surprising outcome of our patients suggests either that the bacteria trade off virulence for drug resistance or the relatively robust immune response of non ICU patients fights back.

Evaluation of genotype MTBDRplus line probe assay in detection of rifampicin and isoniazid resistance in comparison to solid culture drug susceptibility testing in a tertiary care centre of western Uttar Pradesh.

BACKGROUND: Isoniazid (INH) and rifampicin (Rif) are the key first-line antituberculosis drugs, and resistance to these drugs i.e., multi-drug-resistant tuberculosis (MDR-TB), is likely to result in treatment failure and poor clinical outcomes. India has the highest burden of TB and MDR-TB in the world, disproportionately high even for India's population. The GenoType® MTBDRplus molecular method allows rapid detection of Rif and INH resistance. AIM: The present study was done to compare the performance of line probe assay test (GenoType® MTBDRplus) with solid culture method for an early diagnosis of MDR-TB. METHODS: Totally 1503 sputum samples of MDR-TB suspects were subjected to fluorescent microscopy. Decontamination was done by N-acetyl-L-cysteine and sodium hydroxide method. Fluorescent microscopy-positive samples were subjected to GenoType® MTBDRplus (HAIN Lifescience) assay. Sixty-two random samples were compared with phenotypic drug susceptibility testing (DST) (1% proportion method) using solid culture method by Lowenstein-Jensen media. RESULTS: The sensitivity, specificity, positive predictive value and negative predictive value for detection of resistance to Rif were 94.74%, 95.35%, 90% and 97.62% and to INH were 92.00%, 91.89%, 88.46% and 94.44%, respectively, in comparison with the phenotypic DST. CONCLUSION: GenoType® MTBDRplus has good sensitivity and specificity in detecting MDR-TB cases with a significantly lesser turnaround time as compared to conventional DST method and simultaneous detection of Rif and INH resistance. This technique saves several weeks of time required for culture and DST.

Synergy of drug combinations in treating multidrug-resistant Pseudomonas aeruginosa.

BACKGROUND: With the emergence of metallo-betalactamases (MBL) in Pseudomonas aeruginosa (P. aeruginosa), the value of carbapenem, the drug of last resort, is being severely compromised. Curtailing the use of carbapenems becomes paramount if resistance is to be reined in. AIMS: To study the role of synergy between combinations of drugs as an alternative treatment choice for P. aeruginosa. Synergy was studied between combinations of levofloxacin with piperacillin-tazobactam and levofloxacin with cefoperazone-sulbactam by time-kill and chequerboard techniques. METHODS: P. aeruginosa were tested for antibiotic susceptibility by the disc diffusion assay (260 isolates) and E-test (60 isolates). Synergy testing by chequerboard and time-kill assays was performed with combinations of piperacillin-tazobactam with levofloxacin (11 isolates) and cefoperazone-sulbactam with levofloxacin (10 isolates). RESULTS: Nearly all isolates were susceptible to piperacillin-tazobactam (96.1 per cent), followed by piperacillin (78.5 per cent). Seventy-one isolates (27.3 per cent) were found to be multidrug resistant and 19.6 per cent were ESBL producers. MIC50 of amikacin was 32µg/ml and MIC90 was 64µg/ml. MIC50 and MIC90 of cefoperazone-sulbactam was 32µg/ml and 64µg/ml, and for levofloxacin it was 10µg/ml and 240µg/ml, respectively. Piperacillin-tazobactam had MIC50 and MIC90 of 5µg/ml and 10µg/ml, respectively. Synergy was noted in 72.7 per cent isolates for levofloxacin and piperacillin-tazobactam combination, the remaining 27.3 per cent isolates showed addition by both chequerboard and time-kill assay. For levofloxacin and cefoperazone-sulbactam, only 30 per cent isolates had synergy, 40 per cent showed addition, 20 per cent indifference, and 10 per cent were antagonistic by the chequerboard method. CONCLUSION: The combination of levofloxacin and piperacillin-tazobactam is a good choice for treatment of such strains.

Increasing antimicrobial resistance among uropathogens: Is fosfomycin the answer?

INTRODUCTION: Urinary tract infection (UTI) is one of the most common infectious diseases in clinical practice. The choice of antibiotics for the treatment of UTI is limited by the rising rates of antibiotic resistance. There is an urgent need to discover new effective treatment solutions. Fosfomycin may be an interesting alternative to the currently used treatments of UTIs. MATERIALS AND METHODS: The study was conducted over 6 months period (January to June 2013) in Department of Microbiology, JNMCH, AMU, Aligarh. A total of 1840 urine samples were submitted. Culture and sensitivity was done as per standard microbiological procedures. Methicillin-resistant Staphylococcus aureus (MRSA), high-level aminoglycoside resistance (HLAR), extended spectrum beta-lactamases (ESBL), AmpC and metallo-beta-lactamases (MBL) production was detected. RESULTS: Culture was positive in 504 (27.4%) cases. Gram-negative etiology was identified in 390 (73%) cases. ESBL production was detected in 154 (37.1%) while 82 (21.6%) were Amp C. No, MBL was detected. Among Gram-positive bacteria, 68 (51.5%) were MRSA, while 4 (13.3%) were vancomycin resistant enterococci (VRE). HLAR was seen in 53.3% of enterococci. Fosfomycin was effective in 100% of MRSA, VRE, ESBL, HLAR, and overall, susceptibility to fosfomycin in AmpC producers was extremely high (99%). Norfloxacin and cotrimoxazole were not proved effective as only three isolates were sensitive to norfloxacin, while all Gram-negative isolates were resistant to cotrimoxazole. Pseudomonas species showed 65% and 75% susceptibility to colistin and polymixin B, respectively. CONCLUSION: Fosfomycin has emerged as a promising option, especially in cases involving multi-drug-resistant pathogens in which previous antibiotics have failed to cure the infection.

Prevalence of genotype D in chronic liver disease patients with occult HBV infection in northern region of India.

BACKGROUND: Etiology of nearly 30% cases of chronic viral hepatitis remains undetected. Occult HBV infection (OBI) has emerged as an important clinical entity in this scenario. Apart from prevalence and clinical outcome of OBI patients genotype was determined in northern region of India. MATERIALS AND METHODS: A total of 847 patients with chronic liver disease (CLD) were screened for common viral etiologies and others serological markers of HBV. Amplification of surface, precore and polymerase genes of HBV was performed in patients negative for other etiologies. Genotyping and sequencing of the precore region was performed for OBI cases. RESULTS: Twenty-nine (7.61%) cases of OBI were identifiedof which 9 had chronic liver disease (CHD), 11 liver cirrhosis (LC) and 9 hepatocellular carcinoma (HCC). Majority of OBI cases were detected by amplification of surface gene 26 (89.6%), followed by pre-core gene 12 (41.3%). Their liver functions tests were significantly deranged in comparison to overt HBV cases. IgG anti HBc was present in 8 (27.6%) OBI cases. Mutation was observed in 8 (32%) in pre-core region at nt. 1896 of overt HBV cases. Genotype D was the predominant genotype. IN CONCLUSION: OBI in our study was characterized by predominance of genotype D and more severe clinical and biochemical profile in comparison to overt HBV. IgG anti HBc positivity could be utilized as a marker of OBI. We recommend use of sensitive nested PCR for diagnosis of OBI, amplifying at least surface and precore gene.

Evaluation of the virulence markers in the clinical isolates of citrobacter species: the first report from India.

BACKGROUND: Citrobacter, a gram negative bacillus, is emerging as one of the major pathogens in hospital settings, with a potential to cause serious infections. Virulence markers are the factors which enhance the survival ability of the micro-organisms. Among the gram negative bacilli, these have been extensively studied in Escherichia coli. To the best of our knowledge as per internet search, we report that this study has been done for the first time in India on Citrobacter. AIMS: An investigation was done to determine the ability of Citrobacter in producing virulence markers like the ability to survive the serum bactericidal activity, the resistance to the intracellular killing in the Polymorphonuclear Leucocytes (PMNLs) and the Cell Surface Hydrophobicity (CSH). SETTINGS AND DESIGN: This prospective study was conducted in the Department of Microbiology of a tertiary care hospital in Aligarh, India, for a period of one year and six months. MATERIAL AND METHODS: A total of 105 clinical isolates and 20 control isolates from healthy subjects were identified as having Citrobacter spp. by using standard biochemical tests and they were studied for the presence of virulence markers like the ability to survive the serum bactericidal activity, the resistance to the intracellular killing in the Polymorphonuclear Leucocytes (PMNLs) and the cell surface hydrophobicity. The statistical analysis which was used: The standard deviations and the p-values were calculated for comparison. RESULTS: Out of the 105 clinical isolates of Citrobacter which were studied, 86.6% isolates were resistant to 100% serum after 180 minutes of incubation and intracellular killing in PMNL was demonstrated in 17% strains. The Salt Aggregation Test (SAT) for the cell surface hydrophobicity was positive in 17.1% strains at different concentrations of ammonium sulphate. The presence of more than one virulence marker was present in 71.4% of the clinical isolates while in the control isolates. CONCLUSIONS: The presence of the virulence markers in Citrobacter demonstrated its pathogenic potential. Its invasiveness and ability to disseminate can be studied by identifying these markers.

Emergence of coryneform bacteria as pathogens in nosocomial surgical site infections in a tertiary care hospital of North India.

PURPOSE: A prospective study was conducted to assess the role of coryneform bacteria in surgical site infections among obstetric and gynecological patients undergoing surgery. MATERIALS AND METHODS: The surgery was graded according to the degree of contamination, and surgical site infections (SSIs) were classified as superficial or deep. Pus samples were collected from SSIs according to rigorous aseptic precautions, and the quality of specimens was assessed by Q-score. A detailed clinical and treatment history was elicited from all patients. The samples were processed using standard protocols. Coryneform bacteria were considered significant pathogens only if they fulfilled rigorous clinical and microbiological criteria. Antibiotic susceptibility testing was performed using the Kirby-Bauer method according to the CLSI guidelines. RESULTS: In total, 127 patients developed SSIs among 882 postoperative patients. Of these, 89 (70.1%) were culture positive: 40 (44.9%) were Gram-positive cocci, 27 (30.3%) were coryneform, and 22 (24.7%) were Gram-negative bacilli. All coryneform-infected patients had fever and post-operative wound dehiscence leading to a prolonged hospital stay. The most commonly isolated organism was Staphylococcus aureus (33.7%), followed by Corynebacterium amycolatum (11.2%), Escherichia coli (8.9%), Citrobacter spp. (7.8%) and coagulase-negative Staphylococci (6.7%). In our study, 45.5% were ESBL producers, 18.2% were Amp C producers, and 40% were MRSA. All the coryneform bacteria were multidrug resistant, and 51.8% of isolates were sensitive to only gatifloxacin and vancomycin. Symptomatic improvement was observed in all coryneform-infected patients after the administration of appropriate therapy. CONCLUSION: Coryneform bacteria appear to be emerging as significant nosocomial surgical site pathogens. The high level of multidrug resistance observed in coryneform bacteria in our study is cause for alarm.

Cervicofacial actinomycosis mimicking sebaceous cyst.

Actinomycosis is a rare, torpid, suppurative and chronic granulomatous infection caused by a Gram-positive organism that was initially thought to be a fungus. These organisms normally live as commensals in the human oral cavity, respiratory and digestive tracts, but become invasive when they gain access to the subcutaneous tissue through a musosal lesion, the triggering events being dental caries, dental manipulation and maxillofacial trauma. It is often misdiagnosed as it can mimic numerous infectious and non-infectious diseases. We describe an interesting case of cervical actinomycosis that was misdiagnosed as sebaceous cyst and precisely identified after histopathological examination of the tissue.

Prevalence and assessment of role of SEN virus in acute and chronic hepatitis in India.

BACKGROUND AND AIM: SEN virus (SENV), is a recently discovered single-stranded DNA virus of Annelloviridae family and is believed may play a role in non A-E hepatitis. We conducted this study to identify the prevalence and clinical association of SENV with acute and chronic hepatitis. METHODS: 135 liver disease patients were studied. Extent of liver damage was assessed using the Model for End Stage Liver Disease (MELD) score. A-E viruses and HIV were detected by enzyme immunoassay. Nested PCR was performed for detection of SENV and its genotypes D and H. RESULTS: 34 cases (25.18%) were positive for SEN virus DNA, a statistically significant finding (p < 0.01) of which 22 (64%) had acute viral hepatitis, 4 (11.76%) had chronic viral hepatitis, 3 (8.82%) fulminant hepatic failure and 5 (14.70%) cirrhosis. Mean AST was 47.85 IU/L, ALT 51.2 IU/L and INR 1.73, mean MELD score was 18.38 (11 to 24). 17.64% had severely deranged MELD score. SENV-D genotype was detected in 13 (38%) and SENV-H in 19 (58%) cases. SENV-H occurred in both acute (53%) and chronic hepatitis (47%). SENV-D was strongly associated with acute hepatitis (85%). Cirrhotic and FHF cases were SENV-H positive. 12 (44.11%) were co-infected with HBV, 5 (14.7%) with TTV, 4(11.76%) with HEV, 2 (5.88%) with HCV and 5 (14.4%) with HIV. CONCLUSION: Significant prevalence of SENV in hepatitis patients was observed. On the basis of clinical findings and abnormal liver function tests, we conclude that SENV appears to be not only hepatotropic but also capable of liver damage. Higher prevalence of SENV-H in cirrhotics may point to its possible role in the development of cirrhosis.

Emergence of hepatitis B virus genotype f in aligarh region of north India.

Introduction. HBV genotypes and subtypes are useful clinical and epidemiological markers. In this study prevalent HBV genotypes were assessed in relation to serological profile and clinical status. Material & Methods. 107 cases of HBV were genotyped. Detailed clinical history was elicited from them. HBsAg, HBeAg, anti-HBs, anti-HBe, and anti-HBc-IgM were assessed. HBV genotyping was performed using Kirschberg's type specific primers (TSP-PCR), heminested PCR, and Naito's monoplex PCR. Nucleotide sequencing was performed. Results. A total of 97 (91%) were genotyped following the methods of Kirschberg et al./Naito et al. Genotype D was by far the most prevalent genotype 91 (85.04%) in this region. A surprising finding was the detection of genotype F in 5 (4.67%) of our patients. Genotype A strangely was observed only in one case. In 85.7% genotype D was associated with moderate to severe liver disease, 43.9% HBeAg, and 18.7% anti-HBc-IgM positivity. Majority of genotype F (80%) was seen in mild to moderate liver disease. It was strongly associated with HBeAg 60% and 20% anti-HBc-IgM positivity. Conclusion. Emergence of genotype F in India merits further study regarding its clinical implications and treatment modalities. Knowledge about HBV genotypes can direct a clinician towards more informed management of HBV patients.

Assessment of combination therapy by time kill curve analysis and chequerboard assay for treatment of multi-drug resistant Pseudomonas aeruginosa isolates.

Multidrug resistant Pseudomonas aeruginosa is a major nosocomial pathogen, and effective therapy presents a great clinical challenge. Combination therapy, employing pre-existing antibiotics, is an attractive approach for the treatment of such infections which may also curtail drug resistance. This study was undertaken with the objectives to assess the synergy of five different antimicrobial combinations (piperacillin-tazobactum with levofloxacin, cefoperazone-sulbactum with levofloxacin, piperacillin-tazobactum with amikacin, cefoperazone-sulbactum with amikacin and amikacin with levofloxacin for the treatment of Pseudomonas aeruginosa isolates with varied susceptibility profile by time kill curve assay and the chequerboard technique. In our study concordance between these two methods was noted in 71.7% isolates tested. Le-Pt combination demonstrated maximum synergy (72.7%), followed by Ak-Le (66.7%) and Ak-Cfs (60%) combination. Le-Cfs and Ak-Pt however, showed synergy in significantly lower number of isolates. However, at sub-MIC concentrations Ak-Pt combination was found to be most effective. Synergy between different drugs should be routinely monitored for exploring more feasible treatment options and to prevent the emergence of multi-drug resistant strains. Piperacillin-tazobactum emerged as a versatile drug whose potential should be explored with other drugs for combination treatment of P. aeruginosa isolates.