Clinical Utility of Blood Culture Identification 2 Panel in Flagged Blood Culture Samples from the Intensive Care Unit of a Tertiary Care Hospital.

Background: The availability of rapid diagnostic platforms for positive blood cultures has accelerated the speed at which the clinical microbiology laboratory can identify the causative organism and facilitate early appropriate antimicrobial therapy. There is a paucity of data regarding the clinical utility of the blood culture identification 2 (BCID2) panel test and its correlation with phenotypic drug susceptibility testing (DST) in flagged blood culture bottles from intensive care units (ICUs) in countries such as India, which have high rates of multidrug-resistant gram-negative bacteria (MDR-GNB). Materials and methods: We conducted a retrospective observational study in a tertiary care ICU on 200 patients above 18 years of age in whom a BCID2 test was ordered when blood cultures flagged positive. Results: We found 99% concordance between BCID2 and cultures in the identification of bacteria and yeasts and 96.5% concordance between phenotypic and genotypic DST. Furthermore, BCID2 was available about 1.5 days earlier than conventional ID and DST and played a key role in tailoring antimicrobials in 82.5% of the patients. Polymyxin-based therapy was discontinued earlier after an empiric dose in 138 patients (69%) based on BCID2 reports. Conclusion: In critically ill patients with monomicrobial bacteremia, BCID2 rapidly identifies bacteria and antimicrobial resistance (AMR) genes and is significantly faster than conventional culture and sensitivity testing. Antibiotics were escalated in more than a third of patients and de-escalated in almost a fifth on the same day. We recommend that all ICUs routinely incorporate the test in their antibiotic decision-making process and in antimicrobial stewardship. How to cite this article: Vineeth VK, Nambi PS, Gopalakrishnan R, Sethuraman N, Ramanathan Y, Chandran C, et al. Clinical Utility of Blood Culture Identification 2 Panel in Flagged Blood Culture Samples from the Intensive Care Unit of a Tertiary Care Hospital. Indian J Crit Care Med 2024;28(5):461-466.

Improving Antimicrobial Resistance Awareness Among Medical Students in India: The Sensitization of Medical Students on Antimicrobial Resistance (SOS-AMR) Study.

OBJECTIVES: To evaluate the impact of an online educational intervention on improving knowledge of antimicrobial resistance (AMR) and stewardship among final-year medical students in Chennai, India. METHODS: This was a prospective 'before-after' study conducted across 5 medical colleges in Chennai, India. Participants who were final-year (fourth year) undergraduate medical students were administered a pretest to evaluate baseline knowledge. Students were then provided access to online educational material comprising 20 short lectures. Lectures were delivered by content experts and covered a range of topics which included basics of microbiology, fundamental concepts in AMR and stewardship, diagnosis and management of common infections, basics of antimicrobial pharmacokinetics and pharmacodynamics, and vaccination. Students were required to take a posttest at the end of these modules. Primary outcome was improvement in test scores from pretest baseline which was analyzed using a t test. A 30% improvement in the mean scores from baseline was predefined as a measure of success. RESULTS: A total of 599 students participated from 5 medical colleges among whom 339 (56.6%) were female participants; 542 (90.4%) students completed the posttest. Mean pretest score was 11.6 (maximum possible score of 25) (SD: 4.3) and the mean posttest score was 14.0 (SD: 4.6). Comparing pre and posttest scores, there was an improvement of 2.4 marks (20%) from the baseline (95% confidence interval: 1.9, 2.9) (P < .001). Improvement in scores was similar for male and female participants. CONCLUSIONS: In this before-after study evaluating the impact of an educational intervention on AMR among final-year medical students, there was an improvement in knowledge; however, the extent of improvement did not meet the predefined metric of success.

A Pilot Feasibility Randomized Controlled Trial of Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit: The Lessening Organ Dysfunction with Vitamin C-India (LOVIT-India) Trial.

Background: The burden of sepsis is high in India and is associated with substantial morbidity and mortality. Vitamin C, an endogenous antioxidant, may improve patient outcomes. Methods: This was a parallel-group pilot feasibility randomized controlled trial conducted at 2 intensive care units in India. Adult patients (≥18 years) with proven or suspected infection as the main diagnosis and needing a continuous intravenous vasopressor infusion were randomized to intravenous vitamin C (50 mg/kg every 6 hours for a maximum of 16 doses) or matching placebo. Primary outcomes were related to protocol adherence and feasibility (enrollment per month). The key secondary outcome was the composite of mortality or persistent organ dysfunction (POD) at day 28 after randomization. Results: 60 patients were screened, 51 were eligible, 32 were randomized, and 30 were included in the analysis (randomized/eligible ratio: 0.63). The overall rate of enrollment was 1.5 patients per month. The median (IQR) age was 63.5 (51.0, 70.0) and 70.0% of the patients were male. In both arms, all patients received ≥90% of scheduled doses of the study drug. No patient received open-label vitamin C and there were no deviations from the glucose monitoring protocol. The composite outcome of mortality or POD at day 28 occurred in 56.3% (9/16) in the vitamin C arm as compared to 42.9% (6/14) in the placebo arm [RR: 1.31 (95% CI: 0.62, 2.76), p = 0.47]. Conclusion: In this pilot feasibility randomized controlled trial of vitamin C for adult patients with sepsis, protocol adherence was excellent and feasibility endpoints were met. Trial registration: CTRI/2020/03/024371. How to cite this article: Vijayaraghavan BKT, Venkataraman R, Ramanathan Y, Margabandhu S, Jayakumar D, Ramachandran P, et al. A Pilot Feasibility Randomized Controlled Trial of Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit: The Lessening Organ Dysfunction with Vitamin C-India (LOVIT-India) Trial. Indian J Crit Care Med 2023;27(12):910-916.

"Nurse-The Archer" Fighting Against the Hidden Enemy.

Background and aim: The coronavirus disease-2019 (COVID-19) pandemic is a global threat spreading like a wildfire and taking the world by its storm. It has challenged the healthcare delivery systems and disrupted them in a way no one ever imagined before. We at Apollo Hospitals, Chennai, Tamil Nadu, India received many patients in the COVID critical care unit (CCU) and found a gradual lack of bundle care compliance resulting in an upsurge of central line-associated bloodstream infection (CLABSI) amid the patients. Materials and methods: A qualitative research approach and quasi-experimental research design were selected to assess the knowledge of the 150 frontline COVID CCU nurses regarding the CLABSI bundle and its prevention strategies. Results: This study revealed that 57% [mean (M) = 12.6; standard deviation (SD) = 2.37] of nurses had inadequate knowledge of the CLABSI bundle and its prevention strategies, in the pretest and scored 80% (M = 6.7; SD = 2.28) in the post-test, with "t" = 22.06 at p < 0.00001 after the hands-on training. The percentage of compliance to CLABSI bundle care increased to 83% and thereafter in an increasing trend. This was clearly evident through the reduction in the preventable CLABSI rate among critically ill COVID-19 patients. Conclusion: Nurses are on the frontline in preventing and controlling healthcare-associated infections (HAIs). Fighting with all the visible and invisible challenges, our research focused on hands-on training for frontline warriors to adhere to the CLABSI bundle care which drove us to the reduction in preventable CLABSI rate in our hospital through improved CLABSI bundle compliance. How to cite this article: Premkumar S, Ramanathan Y, Varghese JJ, Morris B, Nambi PS, Ramakrishnan N, et al. "Nurse-The Archer" Fighting Against the Hidden Enemy. Indian J Crit Care Med 2023;27(4):246-253.

Not so uncommon, yet neglected 'Severe Streptococcus pyogenes infections at a tertiary care center in south India.

Streptococcus pyogenes (SP) causes uncomplicated infections of throat & skin to severe life-threatening invasive diseases and poststreptococcal sequelae. Despite being common, it hasn't been studied much in recent times. Data of 93 adult patients >18 years, culture proven (SP) infections from 2016 to 2019 was studied in south India. Irrespective of comorbidities, SSTI were most common followed by surgical site infections& bacteremia. Isolates were susceptible to penicillin, cephalosporins but 23% were resistant to clindamycin. Timely surgical interventions and appropriate antibiotics reduced morbidity& limb salvage by 9 times. Larger studies, worldwide, to see the current trend of SP need to be conducted.

Disseminated Protothecosis Caused by Prototheca zopfii in a Liver Transplant Recipient.

Prototheca is a genus of achlorophyllic algae present ubiquitously in the environment. Human infections are rare affecting immunocompromised individuals. We report a case of fatal algaemia caused by Prototheca zopfii in a patient who underwent liver transplant. Tissue diagnosis is mandatory for diagnosing rare entities in seriously ill, immunocompromised individuals.

Carbapenem-resistant enterobacteriaceae screening: A core infection control measure for critical care unit in India?

BACKGROUND: Infection/colonization due to carbapenem-resistant enterobacteriaceae (CRE) are emerging as an important challenge, particularly in high risk patients due to widespread use of Carbapenems. Therefore, preventing both CRE infections and their transmission has become an important infection control objective. AIMS AND OBJECTIVE: Determine the proportion of asymptomatic carriers of CRE among patients admitted to our critical care unit (CCU) from the community and other health care facilities. Enumerate risk factors and guide implementation of infection control interventions. METHODS: This prospective surveillance study was done in a 24 bed CCU of a tertiary care hospital, at Chennai, India between August2017 through December 2017. Patients were screened based on a composed questionnaire framed from Centers for Diseases Control and Prevention CRE tool-kit. Two rectal swabs were collected from each patient. They were processed in microbiology laboratory. RESULTS: A total of 102 patients were included. CRE colonization were identified in 8 (7.8%) of the total samples. Among 8 CRE colonized patients 3 (37.5%) patients developed systemic infection. Patients who were exposed to high end antibiotic and past history of surgery had significant association with CRE colonization of (P = 0.0029) and (P = 0.0167) respectively. CONCLUSION: Overall CRE colonization rates among our CCU patients were found to be low. Risk factors associated with CRE colonization were high end antibiotic exposure and surgery in past 90 days. Hence rectal screening should be a risk factor-based active surveillance. Association of systemic infection among CRE colonizers was more significant. This study led us to modify our infection control practices in CCU.