Role of tigecycline in the treatment of urinary tract infections: a systematic review of published case reports.

Introduction: The emergence of multi-drug resistance has forced clinicians to occasionally use drugs that are not approved to treat urinary tract infections (UTIs). This systematic review aimed to evaluate the utility of tigecycline in patients with UTIs. Methodology: A systematic review of case studies was used to retrieve articles between 1.1.1999 to 1.1.2021 from two databases, PubMed and Embase. The title-abstract screening was done for 198 articles, out of which 69 articles were included for full-text screening. A total of 18 articles with 27 cases were included for final analysis. Results: Of the 27 cases, there were 13 cases with complicated UTI and five had catheter-associated UTI. The most common organisms were Klebsiella pneumoniae (n=11), Acinetobacter baumannii (n=9), and Escherichia coli (n=6). Tigecycline was used as monotherapy in 19 patients and as a combination therapy in 8 patients. The median duration of tigecycline was 13 (10-15) days. A favourable clinical or microbiological response at varying intervals was seen in 24/27 (88.9%). Within three months of a favourable response, recurrence of symptoms was seen in four patients. Conclusion: In a small analysis of published case reports, tigecycline appeared to be a relatively effective treatment in patients with UTIs, caused by multidrug-resistant organisms. Where tigecycline is the only susceptible drug, it can be used for treatment. Further research, such as randomized controlled trials, is needed to fully assess the drug's efficacy in this context.

Clinical Study of Use of Remdesivir and Tocilizumab in Severely Ill COVID-19 Patients.

Introduction: Remdesivir and Tocilizumab are two experimental drugs used in severely ill COVID-19 patients. Various clinical trials studying these drugs are giving conflicting results. Our aim is to study these two drugs and share the experience in our setting. Methods: Our Study is a retrospective analysis of Clinico-laboratory details and outcome of three groups of patients who were given either (i) Remdesivir or (ii) Tocilizumab or (iii)both Remdesivir and Tocilizumab . We compared the outcome of these patients with other patients who did not receive either of these drugs, when it was not available or not introduced as experimental drugs earlier in treatment guidelines. Results: Out of a total of 521 patients, in the above three groups who received either or both Remdesivir or Tocilizumab, 334 survived. Out of 214 patients who did not receive any of the two drugs only 74 survived. The outcome was better individually for all the three groups of patients receiving either or both of the drugs as compared to neither of the drugs.(p <0.01) Conclusion: Remdesivir and Tocilizumab were useful drugs in treatment of severely ill covid -19 patients as compared with the patients who did not receive any of the above drugs.

Nontuberculous mycobacteria: A report of eighteen cases from a tertiary care center in India.

CONTEXT: Nontuberculous mycobacteria (NTM) are ubiquitous mycobacteria present in environment and generally affect patients with either structural lung disease or immunosuppression and commonly involve lungs, lymph node, or skin. MATERIALS AND METHODS: Between July 2016 and February 2019, 18 cases of NTM were diagnosed and their relevant clinical, diagnostic, and treatment details were recorded after taking informed consent. RESULTS: We report 18 cases of NTM involving lungs (n = 11), skin and soft tissue (n = 3), joint (n = 2), genitourinary (n = 1), and central nervous system (n = 1). History of immunosuppression was present in two patients, whereas history of some form of intervention was seen in six patients. Mycobacterium fortuitum group (n = 5) was the most commonly isolated organism, followed by Mycobacterium avium complex (n = 4), Mycobacterium abscessus (n = 3), Mycobacterium kansasii (n = 2), and Mycobacterium chelonae (n = 1). In two patients, M. chelonae and M. abscessus were isolated in succession. Of these 18 patients, clinical response was present in 15 of the patients. Diagnosis and treatment of NTM in resource limited settings is extremely challenging. CONCLUSION: Most of the patients with NTM are misdiagnosed and are treated as tuberculosis in India, sometimes with a multidrug resistance regimen, which results in significant morbidity and mortality. We present these cases to shed some light on the epidemiology of NTM in this part of India.

Preliminary Observations and Experiences of Physiotherapy Practice in Acute Care Setup of COVID 19: A Retrospective Observational Study.

BACKGROUND: The rapid outbreak of coronavirus disease 2019 (COVID-19), a public health emergency of grave concern, warranted hospital admissions with almost 90,000 cases in June 2020 in city of Mumbai. 3-10% of the patients with moderate to severe involvement required intensive care unit (ICU) admission with respiratory support. Patients admitted in ICU with an acute COVID event present with respiratory dysfunction and are more likely to have critical illness myopathy and neuropathy (CIMN). Physiotherapy services being integral part of non-pharmacological management of any ICU was implemented for patients with COVID 19; a novel viral disease. OBJECTIVE: This retrospective study was undertaken to explore the physiotherapy practices that could be implemented in patients admitted with COVID 19 in the ICU and its effect on mobility and oxygen requirement as an outcome. METHODOLOGY: Following ethical permission of institute, the data was extracted from electronic data record sheet in which daily parameters for physiotherapy intervention were recorded. Data from a single ICU and step down unit (SDU) from 5th June to 5th July 2020 was analysed. Records of patients diagnosed with COVID 19 and admitted in ICU or SDU were studied. Those in the age group of 18 to 90 years, of either gender were included. Demographic characteristics, disease severity, oxygen requirement, mobility status, physiotherapy intervention were studied. RESULTS: 278 record sheets (110 ICU and 168 SDU) were retrospectively analysed for demographics. 44.55% of patients improved with side lying position, 37.27% with prone position and 10.91% with quarter prone position. 4.55% of patient maintained oxygenation in propped up sitting. 2.73% could not be positioned. Chest physiotherapy techniques applied were deep breathing, ACBT, paced breathing and diaphragmatic breathing. Deep intercostal pressure on NIV along with vibrations was given to 12.72% of patients in the ICU. Group therapy sessions were conducted in SDU where 50.59% patients participated. ICU mobility score showed significant improvement on Wilcoxon Signed Ranks test status on day 7 in the ICU (z=-5.99, p=0.00) and SDU (z= 7.676, p=0.00) compared to day 1. Descriptive analysis showed a definitive reduction in oxygen support requirement. CONCLUSION: Most common form of physiotherapy interventions in patients with Covid 19 were therapeutic positioning, early mobilization and breathing exercises. Physiotherapy intervention appears promising in facilitating early patient ambulation and discharge. This study shows that it is safe and feasible to provide early physiotherapy treatment techniques in patients with COVID-19 using appropriate measures of infection prevention and cross contamination.

Impact of trainee-driven Antimicrobial Stewardship Program in a high burden resource-limited setting.

Antimicrobial Stewardship Program (ASP) is one of the most critical interventions required to halt the growing global antimicrobial resistance. The study aimed to evaluate the effect of trainee driven ASP implementation with limited available resources on outcome variables. An ASP team comprising of infectious diseases trainees and consultants was constituted to conduct stewardship activities in the Department of Medicine, All India Institute of Medical Sciences, a tertiary care apex institute in north India. Prospective audit and feedback were conducted by the team, and the following outcome variables were recorded and analyzed: the practice of sending cultures, appropriateness of prescribed empiric antibiotics, gross antimicrobial consumption and mortality. ASP intervention led to an increase in blood culture positivity rates by two folds (p<0.001). The trend of empiric prescription choices gradually shifted over time towards the use of more effective antibiotics according to the local antibiogram. Redundant usage of antibiotics substantially reduced over time. There was no impact of the antimicrobial stewardship program on the all-cause mortality rate. ASP had a significant effect on the practice of sending cultures and appropriateness of antibiotic usage. In resource-limited settings, trainee-driven antimicrobial stewardship program can succeed in inculcating rational practices among fellow residents and practicing physicians.

The 2019 Novel Coronavirus Outbreak - A Global Threat.

The 2019 Novel Corona virus infection (COVID 19) is an ongoing public health emergency of international significance. There are significant knowledge gaps in the epidemiology, transmission dynamics, investigation tools and management. In this article, we review the available evidence about this disease. Every decade has witnessed the evolution of a new coronavirus epidemic since the last three decades. The varying transmission patterns, namely, nosocomial transmission and spread through mildly symptomatic cases is an area of concern. There is a spectrum of clinical features from mild to severe life threatening disease with major complications like severe pneumonia, ARDS, acute cardiac injury and septic shock. Presence of bilateral ground glass opacity and consolidation on imaging in appropriate clinical background should raise a suspicion about COVID 19. Poor prognostic factors include Multilobular infiltration on chest imaging, Lymphopenia, Bacterial co-infection, Smoking history, Chronic medical conditions like Hypertension and age >60 years (MuLBSTA score). Diagnosis is confirmed with PCR based testing of appropriate respiratory samples. Management is primarily supportive, with newer antivirals (lopinavir ritonavir and Remdesivir) under investigation. Role of steroids is still inconclusive. Standard infection control and prevention techniques should be followed. Vigilant screening of suspected cases and their contacts is important. Isolation of symptomatic cases and home quarantine of asymptomatic contacts is recommended. To conclude, controlling this highly transmissible disease requires international co-ordination.

Mucor menace in an immunocompetent young male after dental manipulation.

Fungal rhino-orbital sinusitis due to mucormycetes is a rapidly progressive condition with high mortality, rarely seen in immunocompetent individuals. A 26-year-old immunocompetent male presented with rhino-orbital mucormycosis after a history of dental manipulation. The patient was successfully managed with a combination of surgery, amphotericin B, and posaconazole. Here, we highlight the delay in diagnosis and challenges faced in the management.

An Unusual Sequelae of Uncomplicated Vivax Malaria.

Albeit malaria is a common health problem in many parts of the world, the entity of post-malaria neurological syndrome (PMNS) is not well recognized. This is a rare entity of neurological and psychiatric manifestations described in patients with falciparum malaria which usually develops within 2 months of recovery from the illness. It has been reported in 1.2/1000 falciparum malaria cases, more commonly in those with severe disease. We report case of a 62-yrs-old male presenting with recurrent generalized seizures following adequately treated vivax malaria. Relevant investigations were done to rule out other differentials. The patient recovered completely reiterating the self-limiting course of PMNS. Occurrence of PMNS following uncomplicated vivax malaria is peculiar in this report.

Is there a need for shifting patients on long term nevirapine based regimens to efavirenz based regimens: a cross-sectional study?

Non-nucleoside reverse transcriptase inhibitors (NNRTIs) are the backbone of effective anti-retroviral therapy in the developing world. Efavirenz is the current NNRTI of choice due to reports of higher incidence of serious adverse events with nevirapine. Majority of patients with Human immunodeficiency virus (HIV) infection in India are still on nevirapine based therapy. The aim of the study was to evaluate the need of shifting these patients to efavirenz based therapy. A cross-sectional study was conducted on adult patients, who were on NNRTI based regimen for more than one year with good adherence. The patients were divided into efavirenz or nevirapine groups based on the treatments they were receiving at the time of study. The different arms were compared based on their clinical and laboratory profile, adverse events and immunological response. A total of 244 patients were recruited. A total of 125 patients were receiving nevirapine based regimen while 119 patients were receiving efavirenz based regimen. There was no significant difference in the frequency of hematological and biochemical derangements between the two groups. There was no difference in the median highest CD4 count achieved during therapy between the two groups. Clinically observed side effects were more common in the efavirenz group. These results suggest that there isn't enough evidence to shift patients tolerating long term nevirapine based therapy to efavirenz based therapy.

A Curious Case of Afebrile Dengue.

A 50-year-old male presented to us with features of diabetic ketoacidosis which was managed with adequate hydration and insulin therapy. His routine laboratory investigation revealed transaminitis, acute kidney injury and pancytopenia. Further evaluation for hematological and biochemical derangements uncovered positive dengue test (NS1 antigen and polymerase chain reaction assay). Patient distinctively reported no history of fever and remained afebrile during the course of illness. We report this case to highlight the possibility of afebrile dengue in endemic areas.

Isolated Renal Mucormycosis.

Mucormycosis in humans has been described as early as 1885 in literature. Isolated renal mucormycosis is rare as it has been mainly described in developing countries like India and China. It is rarer still to find this entity in immunocompetent young males without any risk factors. Specific guidelines on the treatment is not yet known but combined surgical and medical therapy is considered the best modality for its management. We describe a young male who presented with bilateral hydroureteronephrosis. He was initially treated as a case renal tuberculosis which is relatively more common in TB endemic country like ours. However when he did not respond to the anti-tuberculosis drug (ATT), a biopsy revealed mucormycosis. He was treated with nephrectomy and liposomal amphotericin B and oral posaconazole. On follow up of 2 years he is healthy and leading his normal life.

Tuberculosis and Guillain-Barre syndrome: A chance association?

An 18-year-old boy presented with acute-onset quadriparesis that had developed 4 weeks prior. He had an intermittent fever and significant weight loss during this period. After extensive investigations, the patient was diagnosed with an acute motor and sensory axonal neuropathy (AMSAN) variant of Guillain-Barre syndrome (GBS) and disseminated tuberculosis with mediastinal lymphadenopathy, pericarditis, and pleural effusion. Plasmapheresis was performed and first-line anti-tubercular therapy was administered. At the follow-up at 6 months, the patient was asymptomatic, he had no residual weakness and could walk without support, and tuberculosis had completely resolved on X-rays. Many infectious agents have been known to trigger GBS, but only a few cases of GBS and tuberculosis have been reported. This association needs to be evaluated further.