Distribution of carbapenem resistant Acinetobacter baumannii with blaADC-30 and induction of ADC-30 in response to beta-lactam antibiotics.

A wide range of intrinsic Acinetobacter-derived cephalosporinases (ADC) along with other carbapenemases has now been detected in Acinetobacter baumannii leaving clinicians with few treatment options. The present study reports the spread of ADC-30 co-producing KPC-2 along with other ß-lactamases among carbapenem resistant A. baumannii strains obtained from ICU patients in two Indian hospitals. Primer extension analysis revealed higher transcript level of the ADC gene when induced with cefoxitin at 8 µg/ml (170 fold), ceftriaxone at 8 µg/ml (136 fold), ceftazidime at 4 µg/ml (65 fold), cefepime at 8 µg/ml (77 fold) and aztreonam at 8 µg/ml (21 fold) when compared with the basal level without antibiotic pressure. Slight increase in expression of blaADC-30 when induced with imipenem and meropenem at 0.25 µg/ml (3 and 6 fold) was observed and may help in conferring resistance to carbapenem. MLST analysis revealed the circulation of A. baumannii sequence types ST188, ST386, ST583 and ST390 in these hospitals.

Cerebral malaria caused by Plasmodium vivax in adult subjects.

Cerebral malaria is a diffuse encephalopathy associated with seizures and status epilepticus which can occur in up to one-third of patients with severe malaria, particularly that caused by Plasmodium falciparum. In this article, we report three cases of Plasmodium vivax malaria (all adult male patients) complicated by seizures and symptoms of diffuse meningoencephalitis. Two patients had predominantly meningeal signs, while in the third patient the features were purely of encephalitis All cases were treated with artesunate. Usually, cerebral malaria is caused by P. falciparum, and rarely, cerebral malaria is a presenting complication or occurs during the course of P. vivax infection.

Successful management of massive intraoperative pulmonary fat embolism with percutaneous cardiopulmonary support.

We report a patient who sustained catastrophic pulmonary fat embolism, during open reduction, internal fixation (ORIF) of fracture femur. In our opinion, the use of percutaneous cardiopulmonary support with (PCPS), saved the patient from certain death.

Cerebrovascular manifestations and alteration of coagulation profile in scorpion sting: a case series.

Cerebrovascular manifestations are uncommon presentations of scorpion sting in the Indian subcontinent. A prospective study was carried out on 42 patients with scorpion sting in the intensive care unit (ICU) of the Institute of Medical Sciences, Banaras Hindu University, Varanasi-05, INDIA, during the period of May 2005 to October 2007. In all the patients detailed history, physical examination with a specific neurological examination and routine biochemical testing and fundus examination were done. Computerized tomography and magnetic resonance imaging were done in cases with neurological deficit. All these patients also underwent a complete hematological, rheumatologic and cardiovascular work-up for stroke. Cerebrovascular involvement was noted in three patients (7.15%). Hemorrhagic stroke was noted in two patients (4.77%) and thrombotic stroke was noted in one patient (2.39%). The mean time of presentation of neurological symptoms was 3 days. Contrary to world literature, there have been no reports of cranial nerve palsies or neuromuscular involvement in our series.

High-level aminoglycoside resistance in Acinetobacter baumannii recovered from Intensive Care Unit patients in Northeastern India.

BACKGROUND: Acinetobacter baumannii has emerged as an important nosocomial pathogen, its ability to acquire resistance to carbapenems and aminoglycosides, has complicated their treatment regimen. The present study investigates the prevalence and diversity of aminoglycoside-modifying enzymes and 16S methyltransferases in A. baumannii isolates recovered from patients admitted in Intensive Care Unit (ICU) of a tertiary referral hospital in Northeastern India. MATERIALS AND METHODS: We investigated the high-level aminoglycoside-resistance (HLAR) (gentamicin and amikacin minimum inhibitory concentration ≥ 512 µg/ml) among 164 multidrug-resistant A. baumannii obtained from ICU. Genes encoding aminoglycoside-modifying enzymes, 16S methyltransferase and coexisting beta-lactamases were amplified. Horizontal transferability, plasmid stability and elimination assays were performed. Clonality and sequence types were evaluated by repetitive extragenic palindromic-polymerase chain reaction and multilocus sequence typing (MLST) respectively. RESULTS: A total of 130 (79.2%) isolates were found to exhibit HLAR, with acquired aminoglycoside-resistance genes in 109 (83.8%) isolates along with coexisting extended-spectrum beta-lactamases and metallo-beta-lactamases. Genes aph (3') I, aph (3') VIa and armA were predominant and horizontally transferable. Plasmids were eliminated with single sodium dodecyl sulphate treatment. Seventeen haplotypes were found responsible for the infection. MLST revealed circulation of ST583 and ST188 in ICU. CONCLUSIONS: This study reveals the presence of aminoglycoside-resistance genes in combination with blaCTXM and blaNDM, which are highly stable and not frequently reported from this geographical region. Further, the study could predict limited treatment option and need for formulating infection control strategy.

Changes of splanchnic perfusion after applying positive end expiratory pressure in patients with acute respiratory distress syndrome.

BACKGROUND: Positive end-expiratory pressure (PEEP) improves oxygenation and can prevent ventilator- induced lung injury in patients with acute respiratory distress syndrome (ARDS). Nevertheless, PEEP can also induce detrimental effects by its influence on the cardiovascular system. The purpose of this study was to assess the effects of PEEP on gastric mucosal perfusion while applying a protective ventilatory strategy in patients with ARDS. MATERIALS AND METHODS: Thirty-two patients were included in the study. A pressure-volume curve was traced and ideal PEEP, defined as lower inflection point + 2cmH(2)O, was determined. Gastric tonometry was measured continuously (Tonocap). After baseline measurements, 10, 15 and 20cmH(2)O PEEP and ideal PEEP were applied for 30 min each. By the end of each period, hemodynamics, CO(2) gap (gastric minus arterial partial pressures), and ventilatory measurements were taken. RESULTS: PEEP had no effect on CO(2) gap (median [range], baseline: 18 [2-30] mmHg; PEEP 10: 18 [0-40] mmHg; PEEP 15: 17 [0-39] mmHg; PEEP 20: 16 [4-39] mmHg; ideal PEEP: 19 [9-39] mmHg; P = 0.19). Cardiac index also remained unchanged (baseline: 4.7 [2.6-6.2] l min(-1) m(-2) ; PEEP 10: 4.4 [2.5-7] l min(-1) m(-2) ; PEEP 15: 4.4 [2.2-6.8] l min(-1) m(-2) ; PEEP 20: 4.8 [2.4-6.3] l min(-1) m(-2) ; ideal PEEP: 4.9 [2.4-6.3] l min(-1) m(-2) ; P = 0.09). CONCLUSION: PEEP of 10-20 cmH(2)O does not affect splanchnic perfusion and is hemodynamically well tolerated in most patients with ARDS, including those receiving inotropic supports.