Bundle approach in emergency surgery for prevention of surgical site infections: a double-blinded randomized controlled trial

INTRODUCTION

Many studies have demonstrated significant antibiotic resistance by commonly isolated organisms. This is an eye-opener for the clinicians, who prescribe antibiotics day in and out. This situation shifts our attention towards the usage of antiseptic measures, which can at times play an important role in preventing and treating various infections.

METHOD

This is a double-blinded randomized controlled study that compares the bundle approach to the conventional approach for the prevention of surgical site infections in patients of peritonitis undergoing midline laparotomy in emergency. The bundle approach includes three measures, namely, painting of surgical site with chlorhexidine, dabbing the wound with povidone-iodine after the closure of the rectus sheath, and application of chlorhexidine-impregnated gauze piece over the skin wound.

RESULTS

The total sample size was 64 (32 in each arm). The rate of surgical site infection was significantly lower in the test arm (21.8%) as compared to the conventional arm (46.8%). The mean length of hospital stay was shorter by one day in the test arm, although, not significant. The isolates from the peritoneal fluid culture and wound culture were mostly gram-negative organisms. Most of the organisms exhibited resistance toward third generation cephalosporins, fluoroquinolones, and aminoglycosides.

CONCLUSION

Antibiotic resistance is a burning concern in today's world. Alternative methods of preventing infection in the form of using antiseptics should be sought. Although our study was limited to emergency cases, this bundle approach can be implemented in elective cases as well.

Edwardsiella tarda Causing Fishbone Injury Cellulitis Leading to Sepsis in a Case of Hematological Malignancy-A Rare Report and Review of Literature

Edwardsiella tarda ( E. tarda ), a gram-negative bacillus, a member of order Enterobacterales , is typically a fish pathogen frequently isolated from fresh and brackish water environments. It is very rarely implicated in human infections such as gastroenteritis (most common), cellulitis, gas gangrene, hepatobiliary infections, peritonitis, empyema, and meningitis. Bacteremia/sepsis caused by E. tarda can be fatal in humans, although very rare (<5%). To date, very few cases of E. tarda sepsis have been reported worldwide including India. We report a rare case of cellulitis caused by E. tarda following fishbone injury in a patient with underlying hematological malignancy leading to sepsis.

In Vitro Susceptibility of Burkholderia pseudomallei Isolates to Cefiderocol and Ceftazidime/Avibactam from Odisha, India

Introduction and Objectives  The availability of a limited arsenal of antibacterial agents effective against Burkholderia pseudomallei, the causative agent of melioidosis, together with sporadic reports of emergence of resistance necessitates an evaluation of in vitro activity of new antimicrobials against clinical B. pseudomallei isolates. Cefiderocol (CFDC), a novel siderophore cephalosporin, and ceftazidime-avibactam (CZA), a new β lactam combination agent, have shown promising results for the treatment of difficult-to-treat Gram-negative bacilli infections with limited treatment options. This study was conducted to determine the in vitro activity of CFDC and CZA against a contemporary collection of 60 B. pseudomallei clinical isolates. Materials and Methods  Minimum inhibitory concentrations (MIC) of CFDC and CZA were determined by broth microdilution and E-test, respectively. The performance of disk diffusion was also evaluated for CFDC. Results  All B. pseudomallei isolates were susceptible to CFDC and CZA with MIC range of 0.125 to 2 mg/L and 0.19 to 1 mg/L, respectively. Zone diameters for CFDC ranged from 31 to 40 mm. Conclusion  CFDC and CZA exhibited excellent in vitro activity against 60 B. pseudomallei isolates. Further pharmacokinetic-pharmacodynamics studies and clinical trials are needed to prove the clinical efficacy of CFDC and CZA in the treatment of melioidosis.

Microbiological Characterization and Clinical Facets of Elizabethkingia Bloodstream Infections in a Tertiary Care Hospital of Eastern India

Purpose

Elizabethkingia is an emerging non-fermenting Gram-negative bacillus (NFGNB) causing bloodstream infections (BSI) associated with high mortality. It demonstrates a unique antimicrobial profile in showing susceptibility to antimicrobials effective against Gram-positive bacteria. This study was undertaken to determine the overall frequency of Elizabethkingia BSI, associated risk factors, microbiological susceptibility, and clonal relationship of Elizabethkingia isolates using Enterobacterial Repetitive Intergenic Consensus Polymerase Chain Reaction (ERIC-PCR).

Patients and Methods

Elizabethkingia isolates obtained from the blood culture of admitted patients (August 2020-December 2021) were identified by the VITEK 2 system and subjected to an antimicrobial susceptibility test by standard procedures. Demographics, co-morbidities, risk factors for survival, and outcome were summarized and analyzed by Chi-square test, Kaplan-Meier curve, and Cox regression. Clonal relatedness between Elizabethkingia isolates was analyzed using ERIC‑PCR fingerprinting with the "PAST: Paleontological statistics software package".

Results

Of 13,747 blood samples received during the study period, 13.59% were culture positive, and 14.60% were NFGNBs. The frequency of Elizabethkingia spp. among all NFGNBs in BSI was 29.30%, and the overall prevalence in BSI was 4.21%. In patients with Elizabethkingia BSI, Foley's catheter was present in 81.25% of the cases. 100% susceptibility was observed to linezolid, followed by vancomycin (98.75%) and chloramphenicol (89.5%). The 30-day mortality rate in the patients of Elizabethkingia BSI was 26.25%. The Presence of COVID-19, pneumonia, diabetes mellitus (DM), mechanical ventilation (MV), and prior antibiotics were significantly different (p<0.05) between the survival and death groups. ERIC-PCR profile dendrogram of Elizabethkingia isolates showed ten major clusters indicating high genetic diversity.

Conclusion

Elizabethkingia was responsible for one-third of NFGNB BSI in a single-center study, with approximately 26% of 30-day all-cause mortality. Most isolates were susceptible to linezolid, vancomycin, and chloramphenicol. COVID-19 was the most significant risk factor associated with mortality. ERIC-PCR of Elizabethkingia isolates exhibited high genetic diversity.

Role of Efflux Pumps in Reduced Susceptibility to Tigecycline among Clinical Isolates of Acinetobacter baumannii

Background

Acinetobacter baumannii (A. baumannii) is a very well-known emerging pathogen and has become a major burden on healthcare system especially in intensive care units (ICUs). Tigecycline is the last resort drug for treatment of multidrug-resistant A. baumannii infections. However, non-susceptibility to this drug is a rising problem. Resistance to tigecycline is mediated by Resistance-nodulation-cell division (RND) efflux pumps.

Objective

This study was done to detect efflux pump genes (adeABC) and regulator genes (adeS,adeR) responsible for tigecycline resistance among the clinical isolates of A. baumannii.

Materials and Methods

A total of 150 OXA-51 confirmed clinical isolates were subjected for tigecycline susceptibility test by broth microdilution (BMD) method. All isolates irrespective of their MIC were subjected to conventional PCR for detection of efflux genes (adeABC) and regulator genes (adeRS).

Results

Prevalence of tigecycline resistance was found to be 14 (9.33%) by the reference broth microdilution method (BMD). Overall prevalence of efflux genes was highest for adeB (69%) and lowest for adeR (29%). Combination of genes especially three, four or five were found more prevalent among resistant isolates with higher minimum inhibitory concentration (MIC).

Conclusion

Combination of efflux genes confer higher MIC and can be a major contributor for resistance to tigecycline.

Infection-Related Ventilator-Associated Complication and Possible Ventilator-Associated Pneumonia among Mechanically Ventilated Patients of Adult Medical and Surgical Intensive Care Units

Objective An observational study was conducted to evaluate (1) the incidence rates of infection-related ventilator-associated complication (IVAC) and possible ventilator-associated pneumonia (PVAP) among mechanically ventilated patients of adult medical and surgical intensive care units (ICUs) and (2) the pathogen distribution in patients with PVAP.

Materials and Methods The IVAC and PVAP rates of medical and surgical ICUs, between July 1, 2017, and June 30, 2021, per 1,000 mechanical ventilator (MV) days were calculated. The significance of difference in IVAC and PVAP rates between medical and surgical ICUs was calculated. The level of significance was set at less than 0.05.

Results MV utilization ratios of adult medical and surgical ICUs were 0.32 and 0.26, respectively (p < 0.001). About 8 and 7 episodes of IVAC and 14 and 6 episodes of PVAP were reported from adult medical and surgical ICUs, accounting for IVAC rates of 3.17 and 1.8 per 1,000 MV (p > 0.05) and PVAP rates of 2.46 and 1.59 per 1,000 MV days in medical and surgical ICUs, respectively (p > 0.05). Acinetobacter baumannii complex either singly or in combination was isolated in 11/20 PVAP cases.

Conclusion IVAC and PVAP were more in medical compared with surgical ICUs. The most common pathogen in patients with PVAP was A. baumannii complex. More studies are warranted to monitor the significance of ventilator-associated event on patient outcomes.

A Longer Quarantine Period May Be Needed for Effective Control of COVID-19 Transmission: Experience From Odisha, India

Background

The novel coronavirus disease (COVID-19) has become pandemic. For effective disease control, quarantine of the infected and exposed cases for an optimal period is critical. Currently, infected individuals are quarantined for 14 days. We tried to check if the quarantine period practiced is optimal in the Indian context.

Methods

This cross-sectional study was conducted in Odisha, India. We compiled and analyzed the information of 152 laboratory-confirmed SARS-CoV-2 positive cases. Descriptive analysis was conducted.

Results

Out of the 152 cases, 80% were males, 9.8% were symptomatic, 66.4% had travel history, and 53.9% had contact with COVID-19 cases. The incubation period ranged from 1-50 days with a median of 19.5 days (IQR: 17-27 days). The median periods were similar according to gender, history of contact, and presence of symptoms. Interestingly, 84.7% of the cases had an incubation period of more than 14 days. To cover 95% and 90% of the individuals, the quarantine period may have to be extended to 38 days and 35 days, respectively.

Conclusion

A longer observed incubation period (minimum 28 days) suggests the extension of the quarantine period for adults beyond the presently practiced 14 days. Considering the fast-spreading outbreak, an extended quarantine period for 28 days or active periodic follow-up could be more effective.

Molecular Detection of Carbapenemase Enzymes Directly from Positive Blood Cultures Using Xpert Carba-R

Objective  The performance of Xpert Carba-R assay for the direct identification of carbapenemases directly from positive blood culture vials was evaluated.

Materials and Methods  In total, 176 positively flagged blood culture vials, yielding carbapenem-resistant GNB (CR-GNB), were enrolled for the detection and differentiation of blaKPC, blaNDM, blaVIM, blaOXA-48, and blaIMP using Xpert Carba-R.

Results   Klebsiella pneumoniae (76/176, 43.1%), Acinetobacter baumannii complex (67/176, 38%), and Escherichia coli (29/176,16.4%) were the predominant isolates. Overall, NDM production was the commonest (61/176, 34.6%), followed by the co-production of NDM + OXA-48 and the absence of any CR gene (44/176, 25%), followed by OXA-48 (27/176, 15.3%). In CR K. pneumoniae , the co-production of NDM + OXA-48 was most frequent (34/76, 44.7%), whereas in the A. baumannii complex , no CR gene was detected in the majority of isolates (38/67, 56.7%). bla NDM was the commonest gene in E. coli (18/29, 62%) and A. baumannii complex (26/67, 38.8%).

Conclusion  Xpert Carba-R can identify the molecular mechanism of CR within hours after a blood culture turns positive and, thus, has the potential for optimization of antimicrobial therapy, choosing appropriate novel β-lactam combination agents, as well as infection control interventions.

Granulicatella adiacens as an Unusual Cause of Empyema: A Case Report and Review of Literature

Granulicatella adiacens , a nutritionally variant Streptococcus (NVS), is part of the normal commensal flora of human mouth, genital, and intestinal tracts and rarely causes disease. It has been mostly reported from bacteremia and endocarditis cases, but rarely can cause vertebral osteomyelitis, pancreatic abscess, otitis media, and endovascular, central nervous system, ocular, oral, bone and joint, and genitourinary infections. Due to requirement of fastidious culture conditions and non-specific colony morphology, serious diagnostic difficulties may arise in cases of NVS infections. Here, we are reporting a rare fatal infection of G. adiacens presented with empyema complicated to sepsis and necrotizing fasciitis.

Clinicians should be aware of the pathogenic potential of Granulicatella adiacens (a normal commensal flora of human mouth, genital and intestinal tracts). Appropriate supplemented media and a reliable detection system should be used to identify these fastidious organisms. We present this rare case to bring awareness among clinicians regarding such a rare but potentially fatal infection.

Spectrum of Bacterial Pathogens in Critical COVID-19 Patients Admitted in Intensive Care Units of a Tertiary Care Hospital During the First and Second Wave of the Pandemic

OBJECTIVE

This study intends to compare the clinical characteristics and the prevalence and spectrum of bacterial pathogens in COVID-19 patients admitted to ICU during the first and second waves at a tertiary care, teaching and referral hospital of eastern India.

METHOD

This is a hospital-based retrospective study which analysed demographic details, clinical profile and bacterial culture results of severe and critically ill COVID-19 patients admitted in intensive care units (ICU) during April -Oct 2020 (1st wave) and April -July 2021 (2nd wave).

RESULT

The patients admitted during the 2nd wave were comparatively older and had multiple comorbidities compared to the 1st wave. (23.8%) (45/189) and 50% (173/346) of the COVID-19 patients admitted to ICU developed bacterial infection during the 1st and 2nd wave respectively. Overall, there was predominance of multidrug resistant Gram negative bacilli in both the waves. There was increased isolation of intrinsic colistin resistant microorganisms.

CONCLUSION

Multidrug resistant Gram negative bacterial infections, remain a dreaded complication in severe and critically ill hospitalised COVID-19 patients requiring ICU care and high usage of colistin spirals the emergence and spread of pathogens intrinsically resistant to colistin.

Ciprofloxacin-resistant Gram-negative isolates from a tertiary care hospital in Eastern India with novel gyrA and parC gene mutations

BACKGROUND

Expanded-spectrum quinolones (ciprofloxacin) are highly effective against gram-negative bacteria, but significant resistance to quinolones has been increasingly reported. We sought to evaluate the prevalence of gram-negative ciprofloxacin-resistant isolates (CRIs) from our hospital and their mechanism of action.

METHODS

Gram-negative CRIs were identified as per standard procedures and confirmed using the Ezy MICTM Strip (HiMedia). DNA from 67 CRIs was amplified for the quinolone resistance-determining region (QRDR) and plasmid-mediated quinolone resistance genes. Thirty isolates positive for QRDR DNA were sequenced by Sanger's method to detect mutation.

RESULTS

Of the isolates, 42.5% were found to be CRIs, the majority (74.42%) from inpatient departments, and E scherichia coli (64.19%) was the predominant isolate. Among the CRIs, 24.55% were ESBL producers and 35.29% were multidrug resistant. The polymerase chain reaction results showed the majority were amplified by QRDR target regions of gyrA (35.4%) while 4.61% were amplified for the plasmid-mediated fluoroquinolone resistance region of the qnrB gene. Further sequencing of QRDR-positive genes showed point mutations with amino acid changes at codons Ser83 and Asp87 in the gyrA gene and Ser80, Glu84, and Leu88 positions in the parC gene.

CONCLUSION

Ciprofloxacin resistance observed in our study was mostly due to point mutations. Hence, strategies for rational use of ciprofloxacin and adherence to the dose and duration of treatment could be helpful to prevent selection and spread of mutant CRIs/strains.

HLA Desensitization Based on Results of the Luminex Technique in Kidney Transplant - A Single-center Experience

Background:

There is little experience of human leucocyte antigen (HLA) desensitization in India based on the Luminex single-antigen bead (SAB) testing. We retrospectively analyzed our patients, who underwent HLA desensitization based on Luminex SAB results.

Method:

Between 2014 and 2018, patients with complement-dependent cytotoxicity cross-match (CDC-XM) negativity but flow cytometry crossmatch (FC-XM) positivity were further analyzed with Luminex SAB for donor-specific antibodies (DSAs). A total of 12 patients who had DSA mean fluorescent intensity (MFI) of >1000 and <10,000 were included in the study. Our protocol for desensitization consisted of plasmapheresis (PP) followed by low dose intravenous immunoglobulin (IV IG) 100 mg/kg and induction with antithymocyte globulin (ATG). Patients were taken for transplant when either MFI was <1000 and/or FC-XM was negative.

Results:

All 12 patients were first transplant and 10 had a history of some sensitizing event; pregnancy in 4, blood transfusions in 4, and both in 2 patients. FC-XM was positive for T-cell in 4, B-cell in 6, and both in 2 patients. On evaluation by Luminex SAB, 6 patients had MFI from 1000 to 2000, and 6 had MFI of >2000. All underwent desensitization successfully. Two patients had an increase in posttransplant DSA titers requiring posttransplant PP. The mean follow-up was 26.6 ± 13.9 months. On follow-up, only one patient developed acute T cell-mediated rejection 1 year after transplant, which responded to pulse steroids. There was no graft or patient loss until the last follow-up.

Conclusion:

This study shows that HLA desensitization is feasible and successful in the Indian setting if patients are properly selected.

Evaluation of HiCrome KPC Agar for the Screening of Carbapenem-Resistant Enterobacterales Colonization in the ICU Setting of a Tertiary Care Hospital

Background Spread of carbapenem-resistant Enterobacterales (CRE) is a significant concern in intensive care unit (ICU) settings. Approaches to routine screening for CRE colonization in all ICU patients vary depending on institutional epidemiology and resources. The present study was aimed to evaluate the performance of HiCrome Klebsiella pneumoniae carbapenemase (KPC) agar for the detection of CRE colonization in ICU settings taking the Centers for Disease Control and Prevention (CDC) recommended method as reference.

Methods Two-hundred and eighty rectal swabs (duplicate) from 140 patients were subjected to CRE detection in HiCrome KPC agar and MacConkey agar (CDC criteria).

Results Using CDC method, total 41 CRE isolates were recovered comprising of 29 Escherichia coli , 11 Klebsiella, and 1 Enterobacter spp. On the other hand, 49 isolates of CRE recovered from 140 rectal swabs using HiCrome KPC agar, out of which 33 were E. coli , 15 Klebsiella, and 1 Enterobacter sp.

Statistical Analysis Sensitivity, specificity, negative, and positive predictive values of CRE screening by HiCrome KPC agar were found to be 100% (91.4–100), 91.9% (84.8–95.8), 83.6% (70.9–91.4), and 100% (95.9–100), respectively, taking the CDC recommended method as reference.

Conclusion HiCrome KPC agar has high sensitivity in screening CRE colonization. Further studies are needed to establish its applicability for detecting the predominant circulating carbapenemases in the Indian setting.

Seroprevalence of SARS-CoV-2 antibodies among healthcare workers in a teaching hospital in Eastern India

Statement of the Problem:

Healthcare workers (HCW) are the most vulnerable group for contracting SARS-CoV-2. Assessment of seroprevalence of SARS-CoV-2 antibodies among HCW, thus can provide important data on pathogen exposure, infectivity, and adherence to personal protective equipment (PPE). The present study aimed at assessing SARS-CoV-2 seroprevalence among HCW and exploring associations with demographics, category of exposure to COVID-19 patients, preventive measures taken and relation with COVID-19 symptoms.

Method of Study:

HCWs with a minimum gap 2 weeks from last duty were eligible to participate in the study. The enrolled HCW were categorized into high-risk and low-risk category based on work in COVID-19 areas. HCWs SARS-CoV-2 specific IgG and IgM antibodies were detected using rapid immunochromatography test.

Results:

Out of 821 randomly selected HCWs, either IgM or IgG antibody was detected in 32 HCWs (32/821, 3.9%). Only IgM antibodies were detected in 14 (1.7%), only IgG was detected in 9 (1.0%), and both IgM and IgG antibodies were present in 9 HCWs. Seropositivity was significantly higher in high-risk category (5.7% vs. 2.2.%), HCWs who ever had COVID-19 related symptoms in last 3 months (5.6% vs. 2.8%), and those who had earlier tested positive for SARS-CoV-2 with real-time reverse transcriptase PCR (36.6% vs. 3.5%). Seroprevalence was highest (6.9%) among housekeeping and sanitation staff.

Conclusions:

Overall, low seroprevalence of SARS-CoV-2 antibodies in our HCWs is an indicator of effective infection control practice. HCW posted in dedicated COVID ward need more stringent implementation of infection prevention measures.

Detection of Colistin Resistance in Carbapenem Resistant Enterobacteriaceae by Reference Broth Microdilution and Comparative Evaluation of Three Other Methods

Objective Challenges in susceptibility testing of colistin along with increase in the prevalence of colistin-resistant carbapenemase-producing Enterobacteriaceae (CRE) pathogens needs addressal. Evaluation of user-friendly methods is necessary as an alternative to broth microdilution (BMD), the reference susceptibility testing method, for routine implementation in diagnostic clinical microbiology laboratories. Genotypic detection of the plasmid-mediated colistin resistance is also needed for infection control purposes.

Materials and Methods Colistin susceptibility of 200 nonduplicate clinical CRE isolates from December 2017 to June 2019 was determined by BMD, agar dilution (AD), E test, and rapid polymyxin NP test and interpreted as per the European Committee on Antimicrobial Susceptibility Testing. The results of AD, E test, and NP test were compared with that of BMD, considering minimal inhibitory concentration (MIC) ≤ 2 µg/mL as susceptible and > 2 µg/mL as resistant. Presence of any plasmid-mediated colistin resistance (mcr-1 and 2) was evaluated in 27 colistin-resistant CRE isolates by polymerase chain reaction.

Statistical Analysis Performance of different phenotypic methods was analyzed by comparing MIC results of AD and E test with that of reference BMD method. Agreement between BMD and the other two methods was expressed in terms of categorical agreement and essential agreement. Errors were expressed as very major error (VME: false-susceptible) and major error (ME: false-resistance) by AD/E test. VME and ME of 3% disagreement were considered unacceptable.

Results Colistin resistance was found in 27 (13.5%) isolates by BMD method. The VME rates of both AD (11%) and E test (37%) could not meet the Clinical and Laboratory Standards Institute recommendation (< 3% VME rate is acceptable) as alternative tests to the reference BMD. Colistin NP test showed sensitivity and specificity of 85% and 98%, respectively. The percentage discordant result in NP test was highest in Enterobacter spp. (17%). None of the 27 colistin resistant isolates showed presence of mcr-1 and mcr-2 genes.

Conclusion High VME rate in AD and E tests precludes their use as alternatives to BMD for colistin susceptibility testing. NP test with moderate sensitivity but excellent specificity can be a good alternative for testing colistin susceptibility in CRE isolates, except in Enterobacter spp. Absence of mcr-1 and mcr-2 gene necessitates the exploration of other mechanisms of colistin resistance.

In vitro activity of tigecycline against multidrug-resistant Enterobacteriaceae isolates from skin and soft tissue infections

Background

Tigecycline, a new agent against multidrug-resistant (MDR) bacteria, is especially licensed for use in complicated skin and soft tissue and intra-abdominal infections. We aimed to study the recent in vitro activity of tigecycline against MDR Enterobacteriaceae skin and soft tissue isolates.

Methods

Consecutive isolates (56 Escherichia coli, 48 Klebsiella pneumoniae) were subjected to tigecycline susceptibility testing by Ezy MIC test and interpreted as per European Committee on Antimicrobial Susceptibility Testing.

Results

The minimum inhibitory concentrations (MICs) of tigecycline ranged from 0.016 to 48 μg/mL, with MIC₅₀ 0.19 μg/mL and MIC₉₀ 1.0 μg/mL respectively. Seven (6.7%) isolates were resistant to tigecycline, all K. pneumoniae.

Conclusion

Tigecycline remains a viable therapeutic option against MDR isolates, with excellent in vitro activity against E. coli and promising activity against K. pneumoniae. However, the limited availability of alternate therapeutic armamentarium necessitates its use with extreme judiciousness along with continuous monitoring for the emergence and spread of resistance.

•

Tigecycline has excellent in vitro activity against MDR E. coli.

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Tigecycline has comparatively lower activity against MDR K. pneumoniae.

•

Tigecycline remains a viable therapeutic option against MDR E. coli isolates.

•

Limited availability of alternate therapy necessitates cautious use of tigecycline.

Identification and Characterization of Burkholderia pseudomallei from Localized Pyogenic Infections in Eastern India: A Clinico-Microbiological Study

Melioidosis, caused by Burkholderia pseudomallei, is increasingly recognized in several regions of the globe. The present study was performed to identify and determine the frequency of B. pseudomallei infection in localized pyogenic lesions in eastern India and describe their clinico-microbiological profile. Pus samples were subjected to standard microbiological techniques for isolation and identification of various bacteria, including B. pseudomallei, which were confirmed by PCR. The clinical and demographic details of patients with melioidosis and antimicrobial susceptibility pattern of B. pseudomallei isolates were analyzed. Of 245 samples, 126 (51.4%) were culture positive, yielding 137 isolates. Staphylococcus aureus was the predominant pathogen accounting for 54 (39.4%) isolates, followed by B. pseudomallei accounting for 34 (24.8%) isolates. The mean age of the patients with melioidosis was 39.1 years, with males (24/34; 70.6%) being affected more than females (10/34; 29.4%). A majority of the patients were laborers (12/34; 35.3), followed by homemakers (8/34; 23.5%). Head and neck abscesses (35.3%) were the most common presentation followed by pyogenic lesions of the musculoskeletal system (32.3%) and deep organ abscesses (23.5%). Clinical resolution of infection was observed in 31 (91.2%) patients, relapse in two (5.9%) patients, and death in one (2.9%) patient, respectively. Susceptibility testing revealed all B. pseudomallei isolates to be completely susceptible to the following antimicrobials: ceftazidime, trimethoprim-sulfamethoxazole, imipenem, and doxycycline, with one (2.9%) resistant to amoxicillin-clavulanic acid. Burkholderia pseudomallei is an emerging etiological agent of localized pyogenic infections in eastern India, affecting a mainly adult male population. An increased vigilance along with appropriate diagnostic techniques helps in accurate diagnosis facilitating appropriate therapy.

Impact of modified CDC/NHSN surveillance definition on the incidence of CAUTI: a study from an Indian tertiary care hospital

Introduction

Catheter-associated urinary tract infections (CAUTIs) are one of the most common infections encountered in healthcare settings. Candida spp. were excluded as the causative agents of CAUTIs as per Centres for Disease Control and Prevention (CDC) and National Healthcare Safety Network (NHSN) definitions in 2015.

Aim

To determine the impact of the 2015 definition change on the CAUTI rate of patients admitted to medical and surgical intensive care units (ICUs) of a tertiary care and teaching hospital in India.

Method

CAUTI rates were compared in both the ICUs over a period of two years with inclusion and exclusion of Candida spp.

Results

Out of the total 116 CAUTI episodes during the study period, a mean of 9.08 CAUTIs per 1000 catheter days were observed in both the ICUs when Candida spp. were included, but the mean CAUTI rate was reduced to 4.78/1000 catheter days when Candida spp. were excluded.

Discussion/Conclusion

The mean CAUTI rate decreased by 46.03% solely by excluding Candida spp. This significant reduction in CAUTI rates may be applicable to institutions having high rates of candiduria in catheterised patients, but may not be applicable in centres where the incidence of candiduria is already low. Disregarding Candida as a causative agent of CAUTI did not impact rates of central line-associated bloodstream infections during the study period.

Harmonized One Health Trans-Species and Community Surveillance for Tackling Antibacterial Resistance in India: Protocol for a Mixed Methods Study

Background

India has the largest burden of drug‑resistant organisms compared with other countries around the world, including multiresistant and extremely drug‑resistant tuberculosis and resistant Gram‑negative and Gram‑positive bacteria. Antibiotic resistant bacteria are found in all living hosts and in the environment and move between hosts and ecosystems. An intricate interplay of infections, exposure to antibiotics, and disinfectants at individual and community levels among humans, animals, birds, and fishes triggers evolution and spread of resistance. The One Health framework proposes addressing antibiotic resistance as a complex multidisciplinary problem. However, the evidence base in the Indian context is limited.

Objective

This multisectoral, trans-species surveillance project aims to document the infection and resistance patterns of 7 resistant-priority bacteria and the risk factors for resistance following the One Health framework and geospatial epidemiology.

Methods

This hospital- and community-based surveillance adopts a cross-sectional design with mixed methodology (quantitative, qualitative, and spatial) data collection. This study is being conducted at 6 microbiology laboratories and communities in Khurda district, Odisha, India. The laboratory surveillance collects data on bacteria isolates from different hosts and their resistance patterns. The hosts for infection surveillance include humans, animals (livestock, food chain, and pet animals), birds (poultry), and freshwater fishes (not crustaceans). For eligible patients, animals, birds and fishes, detailed data from their households or farms on health care seeking (for animals, birds and fishes, the illness, and care seeking of the caretakers), antibiotic use, disinfection practices, and neighborhood exposure to infection risks will be collected. Antibiotic prescription and use patterns at hospitals and clinics, and therapeutic and nontherapeutic antibiotic and disinfectant use in farms will also be collected. Interviews with key informants from animal breeding, agriculture, and food processing will explore the perceptions, attitudes, and practices related to antibiotic use. The data analysis will follow quantitative (descriptive and analytical), qualitative, and geospatial epidemiology principles.

Results

The study was funded in May 2019 and approved by Institute Ethics Committees in March 2019. The data collection started in September 2019 and shall continue till March 2021. As of June 2020, data for 56 humans, 30 animals and birds, and fishes from 10 ponds have been collected. Data analysis is yet to be done.

Conclusions

This study will inform about the bacterial infection and resistance epidemiology among different hosts, the risk factors for infection, and resistance transmission. In addition, it will identify the potential triggers and levers for further exploration and action.

International Registered Report Identifier (IRRID)

DERR1-10.2196/23241

Soil transmitted helminth infections among school going age children of slums from Bhubaneswar, Odisha

OBJECTIVE

The objective is to determine prevalence and risk factors for soil-transmitted helminth (STH) infection among school-going age children from slums of Bhubaneswar.

DESIGN

Cross-sectional observational study.

SETTING

Microbiology laboratory of a tertiary care hospital, Bhubaneswar, during May 1-October 30, 2015 (6 months) including 360 children of 3-15 years from two populated slums of Bhubaneswar, assuming STH prevalence - 50%, confidence interval 95% and 10% relative precision. Purposively sampling by house to house visit was adopted to collect stool samples along with risk factors through questionnaires from each child after written informed consent of parents/guardians.

MATERIALS AND METHODS

Direct saline mount and egg counting by Kato-Katz (KK) method for STH-positive samples was done.

RESULTS

STH prevalence was 13.3%, more in males (68.8%), and significantly high (62.5%. P < 0.05) in school-going children between 6 and 12 years of age. Predominant STH was Ancylostoma duodenale (56.2%), 15% of parents were illiterate, 80% of houses had toilets, 70% were washing hand with soap and using footwear. STH infection was much less (12.5%) in those practicing handwashing with soap. Fifty percent of children had STH infection even after receiving deworming within the past 6 months. More egg counts - 216 eggs/gram of feces were found in 29 cases by KK method. Entamoeba histolytica (56.5%) was predominant among non-STH infections.

CONCLUSION

STH prevalence of Bhubaneswar slums was minimum (13.3%), school-going children of 6-12 years were more affected and handwashing habit with soap was the key factor to prevent STH infection. The proportion of participants having toilet facility and using footwear regularly had no role in STH prevention.

COVID 19 and diabetes: An endocrinologist's perspective

The clinical manifestation of COVID-19 is diverse, oscillating from mild flu-like symptoms to more severe outcome, such as acute respiratory distress syndrome, multiple organ failure, and death. Advanced age and comorbidities, such as diabetes mellitus, high blood pressure, and history of cerebrovascular accidents are reported to have worse outcome. Chronic inflammation by cytokine storm and direct insult to pancreatic by COVID-19 might be postulated mechanisms of inducing or deteriorating diabetes. Individualized patient-centric treatment and optimal blood sugar control should be made based on disease severity, presence of comorbid condition, and complications related to diabetes, age, and other risk factors. Recent clinical trials have shown some hope to anti-interleukin antibody as a potential therapeutic option against COVID-19 especially in people with severe illness.

Melioidosis in Odisha: A clinico-microbiological and epidemiological description of culture-confirmed cases over a 2-year period

Melioidosis is an emerging infectious disease in India mostly reported from South-western coastal Karnataka and North-eastern Tamil Nadu. We speculate the existence of another major hidden focus in Odisha, one of the eastern coastal states. The clinico-epidemiological features of 47 culture-confirmed melioidosis at a tertiary care teaching hospital over a period of 2 years are reported. Septicaemia was the most common clinical presentation. Diabetes mellitus (DM) was present in 72.3% of our cases. The geo-climatic conditions of Odisha and other coastal states of India and the rise in the incidence of DM demand a nationwide surveillance of melioidosis and creation of melioidosis registry.

Deciphering polymyxin B minimum inhibitory concentration from colistin minimum inhibitory concentration and vice versa: An analysis on 156 carbapenem-resistant Enterobacteriaceae isolates

The susceptibility determination to polymyxins (colistin and polymyxin B) remains a challenge for clinical microbiology laboratories. We evaluated the minimum inhibitory concentration (MIC) of both antimicrobials by the broth microdilution method in a selected subset of 156 carbapenem-resistant Enterobacteriaceae (CRE) isolates. Good concordance between polymyxin B and colistin MIC values was obtained, and there was 98% categorical agreement in CRE isolates. Future large-scale multicentre study is needed to draw conclusion if the MIC of colistin can be used to extrapolate the MIC of polymyxin B and vice versa.

Maxillary Fungal Osteomyelitis: A Review of Literature and Report of a Rare Case

Fungal osteomyelitis is a life-threatening and seldom seen opportunistic infection. It is commonly an affectation of the nose and paranasal sinuses within the orofacial region. It is an aggressive infection that needs to be addressed promptly to prevent fatal consequences. Here, we present a case of a 62-year-old female who presented with complaints of pain and pus discharge from the extraction socket of the left maxillary 23, 24, 25, 26 teeth. She had a history of uncontrolled diabetes mellitus. On further investigation, using diagnostic and Interventional aids, a final diagnosis of maxillary fungal osteomyelitis was made. The infective fungal agents were a mixture of Mucorales and Aspergillus species. A review of all literatures on the subject in the past 13 years using different search engines showed that craniofacial fungal infections with primary maxillary involvement are a rare phenomenon. The primary aim of reporting this case, therefore, is to highlight its rarity, presentation, management and most importantly the outcome of management.

Brain Studded with Innumerable Larger Stones: Starry Sky at Night Appearance: Multiple Calcified Giant Tuberculoma with 15 Years of Follow-up

Tuberculosis is rapidly reemerging as a major health problem due to rising incidence of HIV cases across the globe. Central nervous system involvement is rare, but rarely multiple intracerebral granulomas can occur or occasional solitary tuberculoma also develops. The authors report a unique case of 24-year-old woman suffering from pulmonary tuberculosis developed headache and vomiting. Cranial CT scan revealed multiple widespread deposit of intracranial granuloma of sizeable lesion mimicking starry sky at night appearance. Excision of one tuberculoma was done for confirmation of definitive diagnosis, and histopathology was suggestive of tuberculoma. The patient also underwent VP shunt surgery. At last follow-up at 15 years following surgery, she was doing well.

Emerging enteric fever due to switching biotype of Salmonella (paratyphi A) in Eastern Odisha

BACKGROUND

Typhoid fever is classically caused by Salmonella enterica serotype typhi.Recently the frequency of isolation of S. paratyphi A (SPA) has been increased in comparison to S. typhi in Indian scenario.

AIM

To observe the rate of isolation and antimicrobial susceptibility pattern of SPA from suspected enteric fever cases attending tertiary care centres of Eastern Orissa.

SETTINGS AND DESIGN

Retrospective study Materials and Methods: 1488 blood samples were collected during different duration of fever and cultured in BACTEC blood culture system and bottles showing signal for growth were subcultured and identified as Salmonella spp. by standard procedure and mini API (Biomeriux) and antimicrobial susceptibility by disc diffusion method.

STATISTICAL ANALYSIS

Chi square test.

RESULTS

167 Salmonella spp. were isolated including 83.8% Salmonella paratyphi A and 16.6% S. typhi. Among them 102 were males and 65 were females with mean age of 22.7 yrs. S. paratyphi A was the predominant spp. each year but during 2008 - 2011, there was a dramatic rise (significant P value- 0.034). Multidrug resistance was noticed in 10.2% of the isolates. 98% of S. paratyphi A were resistant to nalidixic acid and 41% to ciprofloxacin, but the MIC of ciprofloxacin was raised between 1-2 μgm/dl showing the relation between nalidixic acid resistance and raised MIC of ciprofloxacin.

CONCLUSION

Nalidixic acid should be tested along with ciprofloxacin disc while testing for susceptibility and MIC of ciprofloxacin is mandatory before advocating therapy to prevent treatment failure.

Evaluation of Genotypic and Phenotypic Methods for Detection of Methicillin Resistant Staphylococcus aureus in a Tertiary Care Hospital of Eastern Odisha

INTRODUCTION

Methicillin resistant Staphylococcus aureus has emerged as an important pathogen in nosocomial and community acquired infections. Accurate and rapid identification of MRSA in clinical specimens is essential for timely decision of effective antimicrobial chemotherapy.

AIM

The present study was conducted to compare efficacy of four conventional phenotypic methods, with mec- A based polymerase chain reaction (PCR) for MRSA identification.

MATERIALS AND METHODS

Methicillin resistance was determined in 200 S.aureus isolates by oxacillin disc diffusion, cefoxitin disc diffusion, Oxacillin Resistance Screening Agar and E-test. The results were compared with mec-A based PCR.

RESULTS

Among 200 S.aureus isolates 62 (31%) were positive for mec-A gene by PCR. Cefoxitin disc diffusion, Oxacillin Resistance Screening Agar and E-test showed 100% specificity. Oxacillin disc diffusion had lowest sensitivity (82.5%) and specificity (98.5%) among all. The conventional methods take more time than PCR for diagnosing MRSA. Linezolid, Vancomycin & Dalfopristin were the highly sensitive drugs against MRSA isolates.

CONCLUSION

Cefoxitin disc diffusion, is rapid, simple and cheaper, hence can be used routinely as an alternative to PCR for detection of MRSA in resource constraint laboratories.

Role of Reconstructive Surgery (RCS) in Improving the Quality of Life of Leprosy Afflicted Persons

Since time immemorial, stigma has been associated with leprosy mainly due to deformity and disability which in turn affects the physical, psychological, social and economical well being of some of the leprosy afflicted persons (LAPs). To prevent and correct deformities Government of India has focused on early diagnosis and appropriate treatment. In addition government has been providing services of Reconstructive Surgery (RCS). RCS corrects the deformity and is expected to help in reducing the stigma in society and reintegrate the affected persons in to society so that they become economically self reliant and carry out their normal livelihood activities without any prejudice. As the stigma has cultural background, this study has.been carried out with to assess the existing stigma level in pre RCS in society in parts of Odisha and compare with that of post RCS. The study was conducted in Sonepur district of Odisha. The sample size is the entire universe of all the 60 patients who had undergone the RCS process, during these the recent years. The methods adopted for data collection were the tools like questionnaire schedules, interview, observation, FGD and in depth case studies. Almost 86% of these Leprosy afflicted persons (LAPs) were very satisfied due to improvement in acceptance by their family, friend, relatives and society after surgery because of the correction of deformity by RCS as it enabled them to get back into normal life. The economical status improved in 8/60 (13%) after RCS, some becoming capable of earning more than Rs. 10,000/- per month after RCS. To conclude, in this settings of Sonepur (Odisha). RCS appeared to help the LAPs in improving their social acceptance thereby reducing stigma and also improving their economic status thus empowering them to lead their life as a normal human beings. There is need to enlarge and expand these studies to other parts of state/region so that the link with beliefs, type of disabilities and also type of surgery could be better understood and the knowledge generated could be applied to get optimum results.

Biofilm as a virulence marker in Candida species in Nosocomial blood stream infection and its correlation with antifungal resistance

Nosocomial blood stream infections (BSI) due to fungi especially Candida is increasing steadily. A two year prospective study was conducted in the S.C.B. Medical College with an aim to evaluate the species distribution, antifungal susceptibility and biofilm formation of Candida spp. isolated from nosocomial BSIs. 34 Candida spp. were isolated from 359 blood cultures. Antifungal susceptibility was performed by microbroth dilution technique and both visual and spectrophotometric method were used for biofilm detection. C. tropicalis was the common spp. isolated followed by C. parapsilosis and others. Most (92%) of the isolates were susceptible to Amphoterecin-B and highest resistance was observed against Flucytosine (37%) and Fluconazole(35%). Biofilm production and antifungal resistance was observed more in nonalbicans Candida spp.

Study of biofilm in bacteria from water pipelines

CONTEXT

A biofilm is a layer of microorganisms contained in a matrix (slime layer), which forms on surfaces in contact with water. Their presence in drinking water pipe networks can be responsible for a wide range of water quality and operational problems.

AIM

To identify the bacterial isolates, obtained from water pipelines of kitchens, to evaluate the water quality & to study the biofilm producing capacity of the bacterial isolates from various sources.

SETTINGS AND DESIGN

A prospective study using water samples from aqua guard & pipelines to kitchens of S.C.B Medical College hostels.

MATERIALS AND METHODS

Standard biochemical procedures for bacterial identification, multiple tube culture & MPN count to evaluate water quality & tissue culture plate (TCP) method for biofilm detection was followed.

STATISTICAL ANALYSIS

STATA software version 9.2 from STATA Corporation, College station road, 90 Houston, Texas was used for statistical analysis.

RESULTS

One hundred eighty seven isolates were obtained from 45 water samples cultured. The isolates were Acinetobacter spp. (44), Pseudomonas spp.(41), Klebsiella spp.(36) & others . Biofilm was detected in (37) 19.78 % of the isolates (95% CI 30.08% -43.92%) including Acinetobacter spp.-10, Klebsiella spp. - 9, Pseudomonas spp. - 9, & others, majority (34) of which were from kitchen pipelines.

CONCLUSION

Water from pipeline sources was unsatisfactory for consumption as the MPN counts were > 10. Most of the biofilm producers were gram negative bacilli & Pseudomonas & Acinetobacter spp. were strong (4+) biofilm producers.

NS1 Antigen Capture ELISA an Effective Method for Diagnosis of Early Dengue Infection - Report of an Outbreak at Angul District, Odisha, India

BACKGROUND

An outbreak of dengue infection occurred in Angul district of Odisha in the month of August & September, 2011. The study was undertaken to detect NS1 antigen positivity among the study population, to compare IgM capture ELISA with NS1 antigen detection for diagnosis of dengue and to identify the predominant genotype of Dengue virus responsible for the outbreak.

MATERIALS AND METHODS

Total 1020 serum samples were collected from clinically suspected cases of dengue from the outbreak. All were subjected for NS1 antigen detection, 92 were selected based on their clinical severity of illness (fever, rash, bleeding manifestation, arthralgia) for further study of IgM ELISA and platelet count and 148 NS1 positive samples were selected from different Blocks of Anugul district for RT-PCR at NIV, Pune, India.

RESULTS

Five hundred and thirteen (50.2%) samples were positive for NS1 antigen (highly significant p-value <0.0001, C.I - 95%) with 88% positivity during 1-5 days. The NS1 Ag positivity was peaked to 86.9% on days 3 to 5 (Sensitivity & NPV - 100% each) & declined to 6.2% during 6-10 days with a low sensitivity of 7.14% but 100% specificity & PPV. However, the IgM antibody positivity was 81.2% on days 6 to 10 and 87.5% after 10 days (Sensitivity- 100%, Specificity-13.33%,PPV-7.14% & NPV - 100%). RT-PCR resulted 32.4% positivity (6- DEN1, 39 - DEN 2 & 3- DEN 3) among which 20% were in IgM +ve & 68% in IgM -ve cases.

CONCLUSION

Therefore, early diagnosis of dengue could be mainly by NS1 antigen detection whereas Ig M ELISA is a better tool during the later stage of infection &RT-PCR is more effective in IgM -ve cases.The predominant genotype responsible for the outbreak was found to be DEN-2.

Coexistence of cutaneous tuberculosis (scrofuloderma) and hanseniasis-a rare presentation

Cutaneous tuberculosis, pulmonary tuberculosis and hanseniasis are all caused by different spp. of Mycobacterium, an intracellular pathogen whose development depends on impaired cell mediated immunity. Scrofuloderma is the most common variant of cutaneous tuberculosis, which is characterized by a direct extension of the skin which overlies the infected lymph gland, bone or joint, that breaks down to form an undermined ulcer. We are reporting a rare association of Scrofuloderma (cutaneous tuberculosis) with Hanseniasis (leprosy) in an adult male whose immune status was controversial.

Electrospun Fe2O3-Al2O3 nanocomposite fibers as efficient adsorbent for removal of heavy metal ions from aqueous solution

In this study, Iron oxide-alumina mixed nanocomposite fiber was prepared by electrospinning method and its performance was evaluated as a heavy metal ion adsorbent. Here boehmite nanoparticle was synthesized by sol-gel method and was impregnated in PVP-iron acetylacetonate solution in a ratio of 1:1:2. These boehmite impregnated polymer solution was electrospun to form nanocomposite polymer fiber. The electrospun nanofiber was sintered at 1000°C for converting it to pure oxide form for further application as adsorbent. Iron oxide-alumina mixed nanocomposite fiber was characterized by UV-vis-DRS, IR, SEM-EDX, TEM, BET and TGA-DTA analytical techniques. Batch adsorption experiments were carried out to study the sorption behavior of Cu(2+), Pb(2+), Ni(2+) and Hg(2+) ions as a function of initial concentration, contact time and pH. The removal percentage was in the order of Cu(2+)<Pb(2+)<Ni(2+)<Hg(2+). The maximum sorption capacities by applying the Langmuir equation were found to be 4.98 mg/g for Cu(2+), 32.36 mg/g for Ni(2+), 23.75 mg/g for Pb(2+) and 63.69 mg/g for Hg(2+) ions. The regeneration studies of mixed nanocomposite adsorbents were also reported here.