The Effect of Double Carbapenem Regimen in the Management of Carbapenem-Resistant Klebsiella pneumoniae Infections: A Report of Five Cases.

The treatment of infections caused by carbapenem-resistant organisms is challenging. Carbapenems in combination with vaborbactam and relebactam are recommended to treat infections caused by extensively drug-resistant organisms including carbapenemase-producing isolates, while ceftazidime-avibactam plus aztreonam, or cefiderocol is recommended for infections caused by New Delhi metallo beta-lactamase (NDM)-producing Enterobacteriaceae. As, in India, except for ceftazidime-avibactam and aztreonam, the other drugs are not approved for marketing, in this case report, the role of a double carbapenem regimen (ertapenem plus meropenem) in the treatment of carbapenem-resistant Klebsiella pneumoniae infections has been presented. In one case, the in vitro effect of the double carbapenem regimen on pan drug-resistant (PDR) K. pneumoniae isolates from a blood culture specimen of a critically ill patient using a time-kill study is presented. In this case, only a double carbapenem regimen with 2 MIC (minimum inhibitory concentration) meropenem + 2 MIC ertapenem demonstrated bactericidal activity by inhibition of bacterial growth of PDR K. pneumoniae isolate, at four and eight hours, which was sustained till 24 hours. However, while 2 MIC meropenem + 2 MIC colistin inhibited bacterial growth at four hours and eight hours, bacterial regrowth occurred by 24 hours. In addition, four cases of critically ill patients with infections caused by carbapenem-resistant Enterobacteriaceae are presented in whom a double carbapenem regimen was recommended for treatment. Of these four cases, a complete clinical cure was observed in three cases, and a microbiological cure in the fourth case. As the double carbapenem regimen demonstrated effect in an in vitro time-kill study in the first case and on clinical outcomes in three out of the latter four cases, it appears to be a life-saving, salvage therapy in infections caused by carbapenem-resistant K. pneumoniae in India.

Assessment of core capacities for antimicrobial stewardship practices in indian hospitals: Report from a multicentric initiative of global health security agenda.

Introduction: Antimicrobial-resistant HAI (Healthcare associated infection) are a global challenge due to their impact on patient outcome. Implementation of antimicrobial stewardship programmes (AMSP) is needed at institutional and national levels. Assessment of core capacities for AMSP is an important starting point to initiate nationwide AMSP. We conducted an assessment of the core capacities for AMSP in a network of Indian hospitals, which are part of the Global Health Security Agenda-funded work on capacity building for AMR-HAIs. Subjects and Methods: The Centers for Disease Control and Prevention's core assessment checklist was modified as per inputs received from the Indian network. The assessment tool was filled by twenty hospitals as a self-administered questionnaire. The results were entered into a database. The cumulative score for each question was generated as average percentage. The scores generated by the database were then used for analysis. Results and Conclusion: The hospitals included a mix of public and private sector hospitals. The network average of positive responses for leadership support was 45%, for accountability; the score was 53% and for key support for AMSP, 58%. Policies to support optimal antibiotic use were present in 59% of respondents, policies for procurement were present in 79% and broad interventions to improve antibiotic use were scored as 33%. A score of 52% was generated for prescription-specific interventions to improve antibiotic use. Written policies for antibiotic use for hospitalised patients and outpatients were present on an average in 72% and 48% conditions, respectively. Presence of process measures and outcome measures was scored at 40% and 49%, respectively, and feedback and education got a score of 53% and 40%, respectively. Thus, Indian hospitals can start with low-hanging fruits such as developing prescription policies, restricting the usage of high antibiotics, enforcing education and ultimately providing the much-needed leadership support.

Extraintestinal infections caused by nontyphoidal Salmonella from a tertiary care center in India.

BACKGROUND: Infection with Salmonella has become an increasing problem worldwide. Recently, nontyphoid Salmonella (NTS) has become a global concern causing threat to the health of human. It causes gastrointestinal infection which may be self-limiting, but invasive infections may be fatal, requiring appropriate therapy. This study was done to analyze the spectrum of NTS infections causing extraintestinal infections and its susceptibility pattern from a tertiary care center in India. MATERIALS AND METHODS: The medical records of 27 patients whose cultures were positive for NTS between the years 2013-2016 were included in this retrospective study. The relevant demographic, clinical, and laboratory data were analyzed. RESULTS: Among the 27 patients, predominant patients were in the age group of 20-30 years. The male to female ratio is 1.7:1. Salmonella typhimurium was the predominant NTS isolated among 15/27 (55.5%), followed by Salmonella enteritidis 4/27 (14.8%). 18/27 (66.6%) of NTS were isolated from blood. Nalidixic acid was sensitive in 2/15 of S. typhimurium, 2/4 of S. enteritidis and 1/3 of Salmonella weltevreden, while others are nalidixic acid-resistant implying resistance to quinolones. They were sensitive to other antibiotics reported. CONCLUSION: This study highlights the spectrum of NTS causing extraintestinal infections which is an emerging infection occurring mostly in immunosuppressed individuals. There should be a high degree of clinical suspicion which would help in the early diagnosis and management of patients.

Bacteriological profile of intra-abdominal infections in a tertiary care hospital.

BACKGROUND AND OBJECTIVES: Intra-abdominal infections (IAIs) include a wide spectrum of pathological conditions, ranging from uncomplicated appendicitis to fecal peritonitis .The resulting infections should be diagnosed early and treated based on the organism isolated and its susceptibility. In this study the bacteriological profile and antimicrobial resistance pattern of intra-abdominal infections was analyzed. MATERIALS AND METHODS: A retrospective analysis of samples received from 119 cases of intra-abdominal infections in our Institute from January 2015 to December 2017 was analyzed. Patients with primary peritonitis from cirrhosis or ascites were not included in the study. The specimens were primarily processed, as per standard methods. Identification and antimicrobial susceptibility testing was done by the Vitek-2 system. Anaerobic culture was performed on 5% sheep blood agar plates and incubated in GEN bag anaerobic pouches. RESULTS: In our study perforative peritonitis 43/119 (36.1%) was predominant IAI followed by acute pancreatitis 14/119 (11.7%) and pancreatic necrosis 12/119 (10%). Microbial growth was observed in 66.3% (79/119) of the cases and combined infections were observed in14/119 (11.7%) of the cases. Escherichia coli was the predominant organism isolated in 58/119 (40.8%), out of which 41/58 (70.6%) were ESBL producers and 16/58 (27.5%) were multi drug resistant isolates. Klebsiella pneumoniae was isolated from 11/119 (9.2%) cases out of which 8/11 (72.7%) were ESBL and 3/11 (27.2%) were multidrug resistant isolates. Post-operative complications was observed in 12/119 (10%) patients with mortality in 15/119 (12.6%) patients. CONCLUSION: Early diagnosis and appropriate management of the infections will help to prevent the morbidity and mortality associated with these infections.

Aerobic bacteriological profile and antimicrobial susceptibility pattern of pus isolates from tertiary care hospital in India.

INTRODUCTION: Pyogenic infections are an important cause of sepsis. These infections are difficult to treat because of the pathogens with increasing antibiotic resistance. It is important to know the pathogens causing the infections and its antibiotic susceptibility for proper management of the patients. METHODOLOGY: A retrospective analysis of 1428 culture positive pus and tissue samples received in the department of microbiology from various departments in the hospital between January 2012 to 2017 was performed. Data regarding the pathogen isolated and its antimicrobial susceptibility were collected and analyzed. The specimens were primarily processed, as per standard methods. Identification and susceptibility testing was done using the Vitek-2C system. RESULTS: Among the samples males outnumbered females (M: F-2.5:1) and the median age was 47 years. The total number of patients were 1428 with total number of isolates being 1525 as in our study monomicrobial infections were seen in 93.2% (1331/1428) patients whereas combined infections with growth of two pathogens in 6.8% (97/1428). Gram-negative bacilli were isolated in 68.3% (1042/1525). Among the Gram-negative bacilli Escherichia coli was the major pathogen isolated (38.6%, 403/1042). Gram positive organisms were isolated in 31.6% (483/1525) of cases and Staphylococcus aureus was the predominant organism isolated (91.7%, 443/483). Rare pathogens like Burkholderia pseudomallei in 3 patients and Nocardia in one patient were also isolated. CONCLUSION: This study emphasizes to understand the common organisms isolated from wound infections and it helps in empirical treatment of patients based on antibiotic susceptibility patterns.