Randomized control trial on impact of clinical pharmacist led interventions on antibiotic stewardship program in children 0 to 18 years age in a tertiary care hospital in southern India.

A prospective randomized controlled interventional study was conducted at a quaternary care multispecialty hospital in South India with the primary objective of identifying opportunities to improve antibiotic prescribing patterns in neonates, children, and adolescents. The hospital has a robust clinical pharmacist program wherein antibiotic prescriptions were checked for appropriateness of antibiotic dose, route, formulation, duration of therapy, and IV to oral switch. These characteristics of antibiotic use were therefore similar in the 75 children in the control and 75 in the intervention group. The additional clinical pharmacist interventions analyzed in this study included checking if a provisional diagnosis had been made before initiating antibiotics, ensuring that appropriate cultures were sent before starting antibiotics, time taken to optimize antibiotic therapy in accordance to the culture sensitivity report and whether the indication for antibiotics use was as per Indian Acdemy of Pediatrics (IAP) Drug Formulary recommendations. The main outcomes were that all these parameters except the first (all children had a clinical diagnosis before initiating antibiotic/s) were better in the intervention group and there was a significant reduction in the total antibiotic days, an increase in antibiotic-free days, and an improvement in the appropriateness of duration of antibiotic therapy and frequency of the antibiotic dosing. However, since the incidence of severe sepsis was higher in the intervention group, broad-spectrum and restricted antibiotics were used, and thus treatment costs were higher in this group. The results indicate that despite already existing clinical pharmacist interventions, additional ones could further improve antibiotic prescription accuracy significantly; and re-emphasized the need to employ trained pediatric general and subspecialty clinical pharmacists in sufficient numbers to implement a successful pediatric antibiotic stewardship program in a hospital.

Comparison of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) as marker of adverse prognosis in patients with infective endocarditis.

Infective Endocarditis (IE) remains a life-threatening condition and early risk stratification helps us to predict mortality and the need for aggressive treatment. We compared NLR, PLR, and SII, on admission to predict in-hospital mortality. Consecutive IE patients, who met inclusion criteria were analysed. Receiver operating characteristic curve (ROC) analysis was conducted for NLR, PLR, and SII to predict in-hospital mortality. The median value of NLR was 19.6 (10.1-27) in patients with mortality, and 5.4 (3.2-8.5) in alive patients. The median value of PLR and SII were comparable in both groups. The area under the ROC curve of NLR showed a significant value of 0.83 (p = 0.001). A Kaplan Meier survival analysis for patients taking a cut-off value of NLR (9.8) was statistically significant (p < 0.001). In multivariate regression model, only NLR was statistically significant predictor of mortality. So NLR, which is a simple, readily available, and inexpensive parameter has a better association with in-hospital mortality in IE patients.

Microbiological Spectrum of Neutropenic Sepsis in Cancer Patients Admitted to a Tertiary Health Care Centre.

OBJECTIVE: To examine the microbiological profile, sensitivity of organisms, treatment and outcomes of in-patients suffering from febrile neutropenia in a tertiary healthcare centre. METHODS: Data was obtained from the Electronic Medical Health records in Aster Medcity, Cochin, IND. The study population included adult patients undergoing treatment for hematologic malignancies or solid tumors in the hospital between January 2021 and March 2023. Febrile neutropenia episodes were identified based on (1) absolute neutrophil count ≤1500 mm3, (2) at least a single recorded oral temperature of >38.0∘C (100.4∘F) sustained over a one-hour period. Febrile neutropenia consequences included ICU admission, length of ICU admission, and mortality. RESULTS: Total 115 cases of febrile neutropenia were identified in the time period from January 2021 to March 2023. Organisms were isolated from 43% of all the cultures taken. The most common organism isolated was Klebsiella pneumoniae (32.81%), followed by Escherichia coli (29.69%) and Pseudomonas aeruginosa (10.94%). Other organisms that were also isolated were Candida albicans (3.13%), Aeromonas hydrophilia, Acinetobacter baumannii, Burkholderia cepacia, Enterobacter cloacae, Enterococcus faecium, Staphylococcus epidermidis, Staphylococcus hemolyticus, Streptococcus spp, and one case of Ralstonia mannitolytica. Multi-drug resistance (MDR) was seen in 33% of isolates and extensive-drug resistance was seen in 19% of isolates. E. coli showed the highest prevalence of antibiotic resistance with 68% growing MDR isolates and 16% growing XDR isolates. ICU stay was required in 34% of patients with a median duration of stay of three days. A mortality rate of 16.52% was seen, with 17.11% in hematological malignancies and 15.38% in solid tumors. CONCLUSIONS: This study showed an increasing prevalence of Gram-negative bacterial infection in patients with febrile neutropenia. It also shows a high prevalence of antibiotic resistance in microbes in febrile neutropenia. Larger multi-hospital studies are required to better understand the microbiological profile of febrile neutropenia and identify the developing antimicrobial resistance trends.

Coinfection of Streptococcus agalactiae and Tuberculous Osteomyelitis of Tibia Mimicking Brodie's Abscess in an Immunocompetent Adult: A Case Report.

Introduction: Coinfection of tuberculous osteomyelitis with Streptococcus agalactiae has not been reported in an immunocompetent adult so far. The slow progress of tuberculous osteomyelitis, due to lack of significant elevations in the laboratory values and changes in the radiographic appearance, often leads to confusion with brodie's abscess. These two clinical conditions often lead to delay in diagnosis and progressive bone destruction. The aim of this report was to highlight recognizing the possibility of coinfections in tuberculous osteomyelitis and early treatment targeting both organisms simultaneously. Case Report: We report a case of a 24-year-old male patient from Kerala, India presented with pain and swelling over distal leg for 2 weeks along with mild fever for 1 month. Imaging showed a brodie's abscess over distal tibia. Pus culture isolated S. Agalactiae. Bone biopsy reported as necrotizing granulomatous lesion. Computed tomography thorax was suggestive of necrotic tuberculous mediastinal and hilar lymphadenopathy. Based on histopathology, microbiology, and radiological findings, coinfection of tuberculous osteomyelitis and bacterial infection was confirmed and antitubercular therapy was started, along with antibiotics for S. agalactiae. Conclusion: Tuberculous osteomyelitis mimicking brodie's abscess is very rare. It is important to consider coinfection in osteomyelitis and it is essential to do tuberculosis-polymerase chain reaction and histopathological examination, along with bacterial and fungal culture of pus in subacute osteomyelitis for the early diagnosis and treatment.

Use of Ceftazidime-Avibactam in the Treatment of Clinical Syndromes With Limited Treatment Options: A Retrospective Study.

Background With rising trends of multi-drug organism infections and the limited availability of new antimicrobials, management of such cases has become a hassle for the clinician. Ceftazidime-Avibactam (CEF-AVI) is evolving as an effective alternative to polymyxins in the management of Carbapenem-Resistant Organisms (CRO) infections. The Food and Drug Administration (FDA) has approved CEF-AVI in a restricted group of clinical syndromes where the drug could have potential use. Objective The goal of this study was to evaluate the clinical outcome in terms of 14-day all-cause mortality and clinical cure at seven days in patients on CEF-AVI. Methodology A retrospective study was conducted on patients who received CEF-AVI in a period of one year in our hospital. Patients were included in the study if they have received CEF-AVI for more than one day of therapy (DOT) and samples from relevant sites have been sent for culture and sensitivity. Variables and outcomes were collected from the hospital information system and medical records. Results A total of 78 patients were included, 52 (66.7%) were started empirically on CEF-AVI while 26 (33.3%) were on targeted therapy. Out of the 78 patients, 43 patients had positive cultures among which 32 patients had Carbapenem-Resistant Enterobacteriaceae (CRE)/Carbapenem-Resistant Pseudomonas aeruginosa (CRPA) infection. The most common clinical syndrome in which the drug was used was occult sepsis (27/78; 34.6%) followed by primary bacteremia (20/78; 25.6%) and neutropenic sepsis (11/78; 14.1%). The clinical efficacy which was primarily assessed in terms of clinical cure was met for 55 (70.5%) patients. The 14-day mortality for the studies group was found to be 18 (23%). Conclusion The analysis of results shows encouraging clinical cure rates and 14-day mortality rates in a subset of severe infections which has limited treatment options.

Mucormycosis of Neck a Rare Presentation.

Mucormycosis is a dreaded clinical entity caused by filamentous fungi of the order Mucorales mainly affecting immunocompromised individuals. Usually seen involving paranasal sinuses, orbit, lungs and gastrointestinal system, it is extremely rare in other areas. Herein we report a rare presentation of Mucormycosis affecting the ear and neck where early detection, timely intervention, multidisciplinary involvement and judicious use of local antibiotics apart from the mainstay treatment regimen like surgical debridement and intravenous Amphotericin B has saved the patient and given him a reasonably good quality of life devoid of morbidity.

A unique case of fever with skin lesions.

The incidence of Nocardiosis was c.1-2 per 100,000 population worldwide in the early 2000s. Co-infection with Nocardia and MOTT (mycobacterium other than tuberculosis) is even more uncommon and has been described only in the setting of pulmonary manifestations in an immunocompromised (HIV) patient. However, over the last two decades, the incidence of Nocardiosis has increased to about 7-8 per 100,000 population, with pulmonary manifestations being the most common. With this background, we present the case of a middle-aged immunosuppressed man (post renal transplant with rejection), who presented with fever with extensive skin lesions and features suggestive of sepsis, without pulmonary involvement.

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.

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.

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.

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.

A road-map for addressing antimicrobial resistance in low- and middle-income countries: lessons learnt from the public private participation and co-designed antimicrobial stewardship programme in the State of Kerala, India.

BACKGROUND: The global concern over antimicrobial resistance (AMR) is gathering pace. Low- and middle-income countries (LMICs) are at the epicentre of this growing public health threat and governmental and healthcare organizations are at different stages of implementing action plans to tackle AMR. The South Indian state of Kerala was one of the first in India to implement strategies and prioritize activities to address this public health threat. STRATEGIES: Through a committed and collaborative effort from all healthcare related disciplines and its professional societies from both public and private sector, the Kerala Public Private Partnership (PPP) has been able to deliver a state-wide strategy to tackle AMR A multilevel strategic leadership model and a multilevel implementation approach that included developing state-wide antibiotic clinical guidelines, a revision of post-graduate and undergraduate medical curriculum, and a training program covering all general practitioners within the state the PPP proved to be a successful model for ensuring state-wide implementation of an AMR action plan. Collaborative work of multi-professional groups ensured co-design and development of disease based clinical treatment guidelines and state-wide infection prevention policy. Knowledge exchange though international and national platforms in the form of workshops for sharing of best practices is critical to success. Capacity building at both public and private institutions included addressing practical and local solutions to the barriers e.g. good antibiotic prescription practices from primary to tertiary care facility and infection prevention at all levels. CONCLUSION: Through 7 years of stakeholder engagement, lobbying with government, and driving change through co-development and implementation, the PPP successfully delivered an antimicrobial stewardship plan across the state. The roadmap for the implementation of the Kerala PPP strategic AMR plan can provide learning for other states and countries aiming to implement action plans for AMR.

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.

Six-year study on peripheral venous catheter-associated BSI rates in 262 ICUs in eight countries of South-East Asia: International Nosocomial Infection Control Consortium findings.

BACKGROUND: Short-term peripheral venous catheter-associated bloodstream infection rates have not been systematically studied in Asian countries, and data on peripheral venous catheter-associated bloodstream infections incidence by number of short-term peripheral venous catheter days are not available. METHODS: Prospective, surveillance study on peripheral venous catheter-associated bloodstream infections conducted from 1 September 2013 to 31 May 2019 in 262 intensive care units, members of the International Nosocomial Infection Control Consortium, from 78 hospitals in 32 cities of 8 countries in the South-East Asia Region: China, India, Malaysia, Mongolia, Nepal, Philippines, Thailand, and Vietnam. For this research, we applied definition and criteria of the CDC NHSN, methodology of the INICC, and software named INICC Surveillance Online System. RESULTS: We followed 83,295 intensive care unit patients for 369,371 bed-days and 376,492 peripheral venous catheter-days. We identified 999 peripheral venous catheter-associated bloodstream infections, amounting to a rate of 2.65/1000 peripheral venous catheter-days. Mortality in patients with peripheral venous catheter but without peripheral venous catheter-associated bloodstream infections was 4.53% and 12.21% in patients with peripheral venous catheter-associated bloodstream infections. The mean length of stay in patients with peripheral venous catheter but without peripheral venous catheter-associated bloodstream infections was 4.40 days and 7.11 days in patients with peripheral venous catheter and peripheral venous catheter-associated bloodstream infections. The microorganism profile showed 67.1% were Gram-negative bacteria: Escherichia coli (22.9%), Klebsiella spp (10.7%), Pseudomonas aeruginosa (5.3%), Enterobacter spp. (4.5%), and others (23.7%). The predominant Gram-positive bacteria were Staphylococcus aureus (11.4%). CONCLUSIONS: Infection prevention programs must be implemented to reduce the incidence of peripheral venous catheter-associated bloodstream infections.

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.