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Okeke N, Snell LB, Rathish B, Hussein A, Newsholme W, Mack D, Breathnach A, Otter JA. Evaluating the dynamics of hospital COVID-19 contacts and subsequent conversion to SARS-CoV-2 infection: a multi-centre retrospective cohort study. Infect Prev Pract 2024; 6:100325. [PMID: 38590514 PMCID: PMC10999996 DOI: 10.1016/j.infpip.2023.100325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/12/2023] [Indexed: 04/10/2024] Open
Abstract
We investigated the dynamics of COVID-19 contacts subsequent conversion to SARS-CoV-2 infection in an inpatient setting across three National Health Service (NHS) Trusts. 9.2% (476/5,156) COVID-19 contacts met inclusion criteria, were typable and tested positive for COVID-19. There was no significant difference between Omicron and non-Omicron contacts overall conversion proportions. Omicron contacts converted faster than non-Omicron contacts (median 3 days vs 4 days, P=0.03), and had significantly greater proportions of early conversions at day 3, 5, and 7 timepoints.
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Affiliation(s)
- Nneoma Okeke
- Directorate of Infection, Guy's and St. Thomas NHS Foundation Trust, St. Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH, UK
| | - Luke B. Snell
- Directorate of Infection, Guy's and St. Thomas NHS Foundation Trust, St. Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH, UK
| | - Balram Rathish
- Directorate of Infection, Guy's and St. Thomas NHS Foundation Trust, St. Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH, UK
| | - Amal Hussein
- Directorate of Infection, Guy's and St. Thomas NHS Foundation Trust, St. Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH, UK
| | - William Newsholme
- Directorate of Infection, Guy's and St. Thomas NHS Foundation Trust, St. Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH, UK
| | - Damien Mack
- Department of Microbiology, Royal Free Hospital, Royal Free London NHS Foundation Trust, Pond Street NW3 2QG, UK
| | - Aodhan Breathnach
- Department of Infection, St George's University Hospitals NHS Foundation Trust, Tooting, London SW17 0QT, UK
| | - Jonathan A. Otter
- Directorate of Infection, Guy's and St. Thomas NHS Foundation Trust, St. Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH, UK
- National Institute for Healthcare Research Health Protection Research Unit (NIHR HPRU) in HCAI and AMR, Imperial College London & Public Health England, Hammersmith Hospital, Du Cane Road, W12 0HS, UK
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Fink DL, Callaby H, Luintel A, Beynon W, Bond H, Lim EY, Gkrania-Klotsas E, Heskin J, Bracchi M, Rathish B, Milligan I, O'Hara G, Rimmer S, Peters JR, Payne L, Mody N, Hodgson B, Lewthwaite P, Lester R, Woolley SD, Sturdy A, Whittington A, Johnson L, Jacobs N, Quartey J, Ai Payne B, Crowe S, Elliott IA, Harrison T, Cole J, Beard K, Cusack TP, Jones I, Banerjee R, Rampling T, Dunning J. Clinical features and management of individuals admitted to hospital with monkeypox and associated complications across the UK: a retrospective cohort study. Lancet Infect Dis 2023; 23:589-597. [PMID: 36566771 DOI: 10.1016/s1473-3099(22)00806-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 11/24/2022] [Accepted: 11/25/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The scale of the 2022 global mpox (formerly known as monkeypox) outbreak has been unprecedented. In less than 6 months, non-endemic countries have reported more than 67 000 cases of a disease that had previously been rare outside of Africa. Mortality has been reported as rare but hospital admission has been relatively common. We aimed to describe the clinical and laboratory characteristics and outcomes of individuals admitted to hospital with mpox and associated complications, including tecovirimat recipients. METHODS In this cohort study, we undertook retrospective review of electronic clinical records and pathology data for all individuals admitted between May 6, and Aug 3, 2022, to 16 hospitals from the Specialist and High Consequence Infectious Diseases Network for Monkeypox. The hospitals were located in ten cities in England and Northern Ireland. Inclusion criteria were clinical signs consistent with mpox and MPXV DNA detected from at least one clinical sample by PCR testing. Patients admitted solely for isolation purposes were excluded from the study. Key outcomes included admission indication, complications (including pain, secondary infection, and mortality) and use of antibiotic and anti-viral treatments. Routine biochemistry, haematology, microbiology, and virology data were also collected. Outcomes were assessed in all patients with available data. FINDINGS 156 individuals were admitted to hospital with complicated mpox during the study period. 153 (98%) were male and three (2%) were female, with a median age of 35 years (IQR 30-44). Gender data were collected from electronic patient records, which encompassed full formal review of clincian notes. The prespecified options for data collection for gender were male, female, trans, non-binary, or unknown. 105 (71%) of 148 participants with available ethnicity data were of White ethnicity and 47 (30%) of 155 were living with HIV with a median CD4 count of 510 cells per mm3 (IQR 349-828). Rectal or perianal pain (including proctitis) was the most common indication for hospital admission (44 [28%] of 156). Severe pain was reported in 89 (57%) of 156, and secondary bacterial infection in 82 (58%) of 142 individuals with available data. Median admission duration was 5 days (IQR 2-9). Ten individuals required surgery and two cases of encephalitis were reported. 38 (24%) of the 156 individuals received tecovirimat with early cessation in four cases (two owing to hepatic transaminitis, one to rapid treatment response, and one to patient choice). No deaths occurred during the study period. INTERPRETATION Although life-threatening mpox appears rare in hospitalised populations during the current outbreak, severe mpox and associated complications can occur in immunocompetent individuals. Analgesia and management of superimposed bacterial infection are priorities for patients admitted to hospital. FUNDING None.
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Affiliation(s)
- Douglas L Fink
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London, UK; Division of Infection and Immunity, University College London, London, UK.
| | - Helen Callaby
- Rare and Imported Pathogens Laboratory, UK Health Security Agency, Porton Down, Wiltshire, UK
| | - Akish Luintel
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London, UK
| | - William Beynon
- Department of Infectious Diseases, Belfast Health and Social Care Trust, Belfast, UK
| | - Helena Bond
- Department of Infectious Diseases, Belfast Health and Social Care Trust, Belfast, UK
| | - Eleanor Y Lim
- Department of Infectious Diseases, Cambridge University Hospitals, Cambridge, UK
| | | | - Jospeh Heskin
- Department of HIV/GUM, Chelsea and Westminster Hospital, London, UK
| | | | - Balram Rathish
- Department of Infectious Diseases, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Iain Milligan
- Department of Infectious Diseases, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Geraldine O'Hara
- Department of Infectious Diseases, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Stephanie Rimmer
- Department of Infectious Diseases, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Joanna R Peters
- Department of Infectious Diseases, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Lara Payne
- Department of Sexual Health and HIV, King's College Hospital NHS Foundation Trust, London, UK
| | - Nisha Mody
- Department of Sexual Health and HIV, King's College Hospital NHS Foundation Trust, London, UK
| | - Bethany Hodgson
- Department of Infectious Diseases, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Penny Lewthwaite
- Department of Infectious Diseases, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rebecca Lester
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Stephen D Woolley
- Tropical and Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Ann Sturdy
- Department of Infectious Diseases, London North West University Healthcare NHS Trust, UK
| | - Ashley Whittington
- Department of Infectious Diseases, London North West University Healthcare NHS Trust, UK
| | - Leann Johnson
- Department of Infectious Diseases, North Manchester General Hospital, Manchester, UK
| | - Nathan Jacobs
- Department of Infectious Diseases, North Manchester General Hospital, Manchester, UK
| | - John Quartey
- Department of Infection and Tropical Medicine, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK
| | - Brendan Ai Payne
- Department of Infection and Tropical Medicine, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK
| | - Stewart Crowe
- Department of Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ivo Am Elliott
- Department of Infectious Diseases, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Thomas Harrison
- Department of Infectious Diseases, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Joby Cole
- Department of Infectious Diseases, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Katie Beard
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Tomas-Paul Cusack
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Imogen Jones
- Infection Care Group, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Rishi Banerjee
- Infection Care Group, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Tommy Rampling
- Rare and Imported Pathogens Laboratory, UK Health Security Agency, Porton Down, Wiltshire, UK; Hospital for Tropical Diseases, Division of Infection, University College London Hospitals NHS Foundation Trust, London UK
| | - Jake Dunning
- Department of Infectious Diseases, Royal Free London NHS Foundation Trust, London, UK; Division of Infection and Immunity, University College London, London, UK; Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Rathish B, Wilson A, Warrier A, Prakash S, Babu R, Joy S, Bhattacharjee S. Analysis of an outbreak of nosocomial COVID-19 at a tertiary care centre in South India. J R Coll Physicians Edinb 2021; 51:332-337. [PMID: 34882129 DOI: 10.4997/jrcpe.2021.404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Nosocomial outbreaks of COVID-19 have been reported sporadically since the beginning of the COVID-19 pandemic. We sought to study the transmission dynamics in a nosocomial COVID-19 outbreak in our centre. METHODS This was a retrospective cohort study in a 500 bedded tertiary care hospital in South India. Inpatients who were suspected to have likely or definite hospital-acquired COVID-19 and hospital staff members who were found to be COVID-19 positive during the same time frame were studied and the likely transmission dynamics described. RESULTS During the study period, 173 patients were diagnosed to have COVID-19, out of which, 15 (8.6%) patients who fulfilled the criteria for likely or definitely hospital-acquired COVID-19 infection were identified from six different wards. During the same period, 121 hospital staff members were diagnosed with COVID-19. Out of these, 18 (14.9%) hospital staff members were identified who could have been the potential source of infection for these 15 patients based on the overlap of location of the staff and the patients, and their infectivity windows. Direct contact and fomite transmission were likely the predominant driver of transmission in our study as there was use of universal face masks and face shields. CONCLUSION Despite the admission of a large number of COVID-19 patients and a relatively large proportion of hospital staff members who tested positive for the disease, the proportion of nosocomial COVID-19 in our centre remained low. A policy of universal gloving, coupled with the already existing practice of universal N95 masking and face shield use, could potentially bring down the rate of nosocomial COVID-19 even further.
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Affiliation(s)
- Balram Rathish
- Department of Infectious Diseases, Aster Medcity, Kochi, India
| | - Arun Wilson
- Department of Infectious Diseases, Aster Medcity, Kochi, India,
| | - Anup Warrier
- Department of Infectious Diseases, Aster Medcity, Kochi, India
| | - Shilpa Prakash
- Department of Clinical Pharmacy, Aster Medcity, Kochi, India
| | - Rachana Babu
- Department of Clinical Microbiology, Aster Medcity, Kochi, India
| | - Sonya Joy
- Department of Clinical Microbiology, Aster Medcity, Kochi, India
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4
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Rathish B, Wilson A, Warrier A, Babu R, Ahammadunny R, Joy S. Nocardia farcinica ventriculitis and meningitis in an immunocompromised man with Crohn's disease. Infect Dis Now 2021; 51:572-574. [PMID: 34486525 DOI: 10.1016/j.idnow.2020.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/06/2020] [Accepted: 11/18/2020] [Indexed: 11/26/2022]
Affiliation(s)
- B Rathish
- Dept of Infectious Diseases, Aster Medcity, Kochi, India
| | - A Wilson
- Dept of Infectious Diseases, Aster Medcity, Kochi, India.
| | - A Warrier
- Dept of Infectious Diseases, Aster Medcity, Kochi, India
| | - R Babu
- Dept of Clinical Microbiology, Aster Medcity, Kochi, India
| | - R Ahammadunny
- Dept of Internal Medicine, Aster Medcity, Kochi, India
| | - S Joy
- Dept of Clinical Microbiology, Aster Medcity, Kochi, India
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5
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Maramattom BV, Rathish B, Meleth HA. Miller Fisher Syndrome and Boomerang Sign: A Rare Presentation of Typhoid Fever. Cureus 2021; 13:e15386. [PMID: 34249538 PMCID: PMC8253474 DOI: 10.7759/cureus.15386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2021] [Indexed: 11/21/2022] Open
Abstract
Miller Fischer syndrome (MFS) is a variant of Guillain-Barré syndrome which is characterized by a triad of ataxia, ophthalmoplegia, and areflexia. It is uncommonly associated with systemic illnesses. We present the case of a young boy who came back after a trip to New Delhi in India, who developed MFS. MRI showed a callosal splenial hyperintensity which is called the boomerang sign. The evaluation revealed typhoid fever. This is probably the first such report of MFS associated with this infection.
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Pillay R, Rathish B, Pillay VV, Mukthar F. Awareness of the Standard of Care for Snakebite Management Among Physicians in Kerala: A Cross-sectional Study. Am J Trop Med Hyg 2021; 105:528-531. [PMID: 34153000 DOI: 10.4269/ajtmh.21-0114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/12/2021] [Indexed: 11/07/2022] Open
Abstract
Snakebite remains a largely neglected yet important cause of morbidity as well as mortality in Kerala. This study aimed to assess the knowledge about the standard of care for snakebite management among physicians in Kerala. This was a cross-sectional study using a questionnaire-based survey among 110 physicians from Kerala. The overall knowledge levels were assessed using a questionnaire with answers being scored as 0 for wrong answers and as 1 for correct answers. The total knowledge scores for all respondents were calculated, with a maximum possible score of 14 and a minimum possible score of 0. Comparisons were made between subsets of respondents. The questionnaire was administered to 110 physicians who fulfilled the predetermined criteria. The overall mean knowledge score during the study was 10.7 (standard deviation ± 2.9). However, there were certain pitfalls associated with the management of snakebite. In particular, questions about tourniquet use, bringing a dead snake to the physician, and the anti-snake venom test dose had high proportions of incorrect answers. Significantly higher knowledge levels were also observed in certain subgroups. There seems to be varying knowledge gaps associated with various aspects of snakebite management for certain subsets of respondents who are likely to benefit from specific training.
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Affiliation(s)
- Roshni Pillay
- Posion Control Centre, Amrita Institute of Medical Sciences and Research, Kochi, India
| | - Balram Rathish
- Department of Infectious Diseases, Aster Medcity, Kochi, India
| | - V V Pillay
- Posion Control Centre, Amrita Institute of Medical Sciences and Research, Kochi, India
| | - Faiz Mukthar
- Department of Internal Medicine, Taluk Headquarters Hospital, Malappuram, India
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7
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Raheem A, Rathish B, Charles D, Wilson A, Warrier A. Pneumococcal Bacteremia and Cryptococcal Meningitis Dual Infection in a Patient With Multiple Myeloma. Cureus 2021; 13:e15089. [PMID: 34155458 PMCID: PMC8210704 DOI: 10.7759/cureus.15089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Infections remain one of the major complications in patients with multiple myeloma, having a significant impact on morbidity and mortality. The increased risk of infection in these patients are a result of various factors contributing to the impairment of immune system caused by the disease and the chemotherapy regimens given during the treatment phases. Here we report a rare case of pneumococcal bacteraemia and cryptococcal meningitis dual infection in a patient with underlying multiple myeloma who had a favourable clinical outcome. This case also serves to highlight the importance of adult vaccinations especially in patients with underlying comorbidities.
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Affiliation(s)
| | | | | | - Arun Wilson
- Infectious Diseases, Aster Medcity, Kochi, IND
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8
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Rathish B, Wilson A, Joy S. A comparison of COVID-19 secondary attack rate in household and close contacts compared to current risk stratification guidelines of the Kerala government. Trop Doct 2021; 51:461-463. [PMID: 33765905 DOI: 10.1177/00494755211002012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
COVID-19 has been found to be highly infectious with a high secondary attack rate with a R0 of 3.3. However, the secondary attack rate based on risk stratification is sparsely reported, if ever. We studied the contact tracing data for two index cases of COVID-19 with some overlap of contacts. We found that 60% of high-risk contacts and 0% of low-risk contacts of symptomatic COVID-19 patients contracted the infection, in keeping with the Kerala government contact risk stratification guidelines.
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Affiliation(s)
- Balram Rathish
- Clinical Fellow, Department of Infectious Diseases, Aster Medcity, Kochi, India
| | - Arun Wilson
- Specialist, Department of Infectious Diseases, Aster Medcity, Kochi, India
| | - Sonya Joy
- Consultant, Department of Infection Control and Clinical Microbiology, Aster Medcity, Kochi, India
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Ahammadunny R, Rathish B, Wilson A, Warrier A. Pubic symphysis tuberculosis: A diagnostic dilemma. Int J Mycobacteriol 2021; 10:98-100. [PMID: 33707381 DOI: 10.4103/ijmy.ijmy_16_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Symphysis pubis tuberculosis (TB) is extremely rare in the reported literature. The diagnosis of pelvic TB is confounded by close differentials such as osteomyelitis as well as the low yield of TB bacilli in microbiological sampling in the initial stages of the disease. Pelvic TB should be suspected early on in areas with high TB burden, and prompt treatment with antitubercular treatment may help prevent disability associated with the disease. Here, we present a 49-year-old diabetic man with pubic symphysis TB which was diagnosed on the basis of clinical and radiological aspects, with near-total resolution following 9 months of anti-tubercular treatment.
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Affiliation(s)
| | - Balram Rathish
- Department of Infectious Diseases, Aster Medcity, Kochi, Kerala, India
| | - Arun Wilson
- Department of Infectious Diseases, Aster Medcity, Kochi, Kerala, India
| | - Anup Warrier
- Department of Infectious Diseases, Aster Medcity, Kochi, Kerala, India
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Rathish B, Mohammed SM, Ullal K, Hassan S, Wilson A. Tropical Aquatic Skin and Soft Tissue Infections: A Series of Three Cases. Cureus 2021; 13:e13170. [PMID: 33692929 PMCID: PMC7938669 DOI: 10.7759/cureus.13170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Bacterial infections following aquatic exposure occur frequently and most commonly present as skin and soft tissue infections (SSTI). Aquatic SSTI bacterial infections are usually caused by a limited number of organisms. Here we present three cases from the same geographical region, caused by three different organisms in patients who had exposure to an aquatic environment: Mycobacterium marinum, Shewanella algae, and Vibrio vulnificus. We wish to highlight that aquatic bacterial infections can cause varying degrees of morbidity and even mortality. Each of these three cases represents an aquatic, tropical SSTI with a delayed diagnosis, most likely as a result of the lack of widespread awareness about these organisms.
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Affiliation(s)
| | | | | | | | - Arun Wilson
- Infectious Diseases, Aster Medcity, Kochi, IND
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Rathish B, Wilson A, Warrier A, Prakash S, Babu R, Joy S. Clinical Outcomes in Carbapenem-Resistant Enterobacteriaceae Infections Treated With Ceftazidime-Avibactam: A Single-Center Observational Study. Cureus 2021; 13:e13081. [PMID: 33680621 PMCID: PMC7931974 DOI: 10.7759/cureus.13081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2021] [Indexed: 12/28/2022] Open
Abstract
Introduction Among the several newer beta lactam+beta lactase inhibitors (BL/BLI), ceftazidime-avibactam is the only drug showing activity against OXA-48-like producers. Hence, it is being increasingly used in India to treat infections caused by carbapenem-resistant Enterobacteriaceae (CRE), especially as a colistin-sparing agent. We have used ceftazidime-avibactam in patients suspected and confirmed to have CRE infections in our center, and present a retrospective analysis of our experience. Methods We conducted a single-center, retrospective study involving all patients who were treated with ceftazidime-avibactam for suspected and proven CRE infections during a one-year period at our 500-bedded hospital. Our primary objective for this study was taken as all-cause mortality. The secondary objectives were to determine the clinical cure, defined as the end of the treatment regimen with a resolution of primary infection and resistance to ceftazidime-avibactam in patients who underwent the Epsilometer test (E-test). Results A total of 103 patients who received ceftazidime-avibactam were identified. The all-cause mortality was 27% while a clinical cure was achieved in 73%. Fifty-two patients received empirical therapy and 51 patients received ceftazidime-avibactam for confirmed CRE infection. Forty-eight patients had an E-test done, out of which 79% of patients had CREs sensitive to ceftazidime-avibactam, and 21% of patients had ceftazidime-avibactam resistant CREs. A higher Sequential Organ Failure Assessment (SOFA) score, Charlson comorbidity index (CCI) score, intensive care unit (ICU) admission, inotrope requirement, and lower days of therapy (DOT) with ceftazidime-avibactam were found to be associated with increased mortality. Conclusion Colistin has been considered to be the last-line agent in CRE infections, but there are concerns about its adverse effects and the emergence of resistance. Given our relatively low mortality of 27% in CRE infections treated with ceftazidime-avibactam, coupled with the high susceptibility of the tested isolates, there may be a role for the empirical use of this drug in infections caused by CRE, especially in a setting where colistin may not be ideal.
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Affiliation(s)
| | - Arun Wilson
- Infectious Diseases, Aster Medcity, Kochi, IND
| | | | | | - Rachana Babu
- Clinical Microbiology, Aster Medcity, Kochi, IND
| | - Sonya Joy
- Clinical Microbiology, Aster Medcity, Kochi, IND
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Pillay R, Rathish B, Wilson A, Warrier A, Philips GM. A quality improvement project on adherence to antibiotic policy in acute admissions from a tertiary care hospital in south India. Clin Med (Lond) 2021; 21:e88-e91. [PMID: 33479083 DOI: 10.7861/clinmed.2020-0253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The indiscriminate use of antibiotics in clinical practice may be an independent risk factor for the development of antimicrobial resistance. To combat this, our hospital implemented a hospital antibiotic policy which outlines the appropriate antibiotic to be used in an acute admission, based on a continuously updated local antibiogram. However, we felt that compliance with the policy was poor and hence carried out a quality improvement project (QIP) to assess and increase compliance. We show that a simple QIP model combined with the use of a mobile application can serve to improve compliance even in a low-resource setting with minimum infrastructure. This model could be easily extrapolated into similar settings.
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13
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Varkey Maramattom B, Rathish B. Case Report: Ascending Myelo-Encephalitis after a Penetrating Injury to the Foot: An Atypical Case of Neuromelioidosis. Am J Trop Med Hyg 2021; 104:1260-1264. [PMID: 33432905 DOI: 10.4269/ajtmh.20-0609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 11/25/2020] [Indexed: 11/07/2022] Open
Abstract
Organisms penetrate the central nervous system (CNS) via three routes. The commonest is the hematogenous route, and other routes include contiguous or penetrating injury or rarely via retrograde axoplasmic route. Although the axoplasmic highway is often used by viruses, only a few bacteria are known to penetrate the CNS via this route. We present a 57-year-old man who developed a penetrating injury while working in a field. Over the next 4 months, he developed pain at the site of the poorly healing wound, which ascended up the right leg and presented as a conus-cauda syndrome. Magnetic resonance imaging (MRI) showed an enhancing intradural intramedullary enhancing lesion in the conus on the right side with cord edema from D11 to L1 level. Extensive evaluation was negative, and he continued to progress to holocord myelitis and developed bilateral corticospinal tract lesions ("tractopathy") in the brain stem and internal capsule. He died after developing a right-sided cerebritis with mass effect. Tissue biopsy from the brain at the time of decompressive craniectomy grew Burkholderia pseudomallei and confirmed a diagnosis of neuromelioidosis (NM). We reviewed the literature for NM, its variable presentations, and the concept of an "infectious tractopathy" and imaging findings which could generate suspicion of this entity.
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Affiliation(s)
| | - Balram Rathish
- Department of Internal Medicine, Aster Medcity, Kochi, India
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Hassan S, Rathish B, Mukthar F. An Unusual Case of Hyperpigmented Maculopapular Rash with Unmasking of Lepromatous Leprosy after Steroid Cessation. Am J Trop Med Hyg 2021; 103:1353. [PMID: 33269681 PMCID: PMC7543856 DOI: 10.4269/ajtmh.20-0510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Shafeeqa Hassan
- Leprology and Venereology, Department of Dermatology, Lourdes Hospital, Ernakulam, India
| | - Balram Rathish
- Department of Internal Medicine, Aster Medcity, Kochi, India
| | - Faiz Mukthar
- Department of Internal Medicine, Aster Medcity, Kochi, India
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15
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Ahammadunny R, Rathish B, Abraham M, Wilson A, Warrier A. A Case of Levamisole Induced Multifocal Inflammatory Leukoencephalopathy and Secondary Nocardia Veterana Brain Abscess. Ann Indian Acad Neurol 2021; 24:814-816. [PMID: 35002165 PMCID: PMC8680905 DOI: 10.4103/aian.aian_575_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 06/21/2020] [Accepted: 06/30/2020] [Indexed: 11/15/2022] Open
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16
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Pillay R, Chemban FM, Pillay VV, Rathish B. Little Known Dangers of an Exotic Poisonous Fruit: Lessons From Two Cases of Konjac Ingestion. Cureus 2020; 12:e11972. [PMID: 33425544 PMCID: PMC7790319 DOI: 10.7759/cureus.11972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Amorphophallus konjac, often abbreviated to Konjac, is a perennial plant that is not uncommon in parts of Asia where it is cultivated as a food source. However, consumption of the raw plant has been known to be toxic to animals. We report the first human cases of Konjac poisoning in two children after accidental ingestion of its seeds.
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17
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Azeez F, George A, Rathish B, Philips G, Joseph C, Joy S. Aeromonas Hydrophila Causing Endogenous Endophthalmitis: A Rare Manifestation. J R Coll Physicians Edinb 2020; 50:420-421. [DOI: 10.4997/jrcpe.2020.417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Fareeda Azeez
- Dept of Internal Medicine, Aster Medcity, Kochi, India
| | - Arun George
- Dept of Internal Medicine, Aster Medcity, Kochi, India
| | | | | | - Ciju Joseph
- Dept of Ophthalmology, Aster Medcity, Kochi, India
| | - Sonya Joy
- Dept of Clinical Microbiology, Aster Medcity, Kochi, India
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18
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Cyril G, Rathish B, Wilson A, Warrier A, Viswam V. A Case of Diphtheria and Infectious Mononucleosis Co-Infection in a Partially Vaccinated Boy. Cureus 2020; 12:e11227. [PMID: 33269155 PMCID: PMC7704157 DOI: 10.7759/cureus.11227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We report the case of an eight-year-old partially immunized boy who presented with presumed bacterial tonsillitis. He was initially prescribed amoxicillin-clavulanic acid which resulted in the development of an erythematous maculopapular over the face which spread to the trunk and extremities including palms and soles and resolved over the next three days. He was diagnosed to have diphtheria and infectious mononucleosis (IMN) co-infection. He made an uneventful recovery and an extensive review of the literature showed that the incidence of diphtheria and IMN co-infection is a relatively rare clinical entity. We wish to highlight the possibility of such co-infections which often mimic one another.
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Affiliation(s)
| | | | - Arun Wilson
- Infectious Diseases, Aster Medcity, Kochi, IND
| | | | - Vineeth Viswam
- Otolaryngology - Head and Neck Surgery, Aster Medcity, Kochi, IND
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19
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Abstract
Without a vaccine or proven therapeutic options in COVID-19, the World Health Organization (WHO) recommends a combination of measures: rapid diagnosis and immediate isolation of cases; rigorous contact tracing; and precautionary self-isolation of close contacts to curb the spread of COVID-19. During a Nipah outbreak in Kerala, India in 2019, it was confined to a single case. The authors were involved in the in-hospital contact tracing. With a single patient producing a contact list of 98 in a healthcare setting, the implications in a community setting during a pandemic of the scale of COVID-19 are huge but it proves that early and rigorous tracing with quarantining is an effective strategy to limit clusters. We believe that if the public is encouraged to maintain their own contact list on a daily basis, it would help in significantly reducing the time and effort invested into contact tracing in the event of a person contracting COVID-19.
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Affiliation(s)
- Arun Wilson
- Specialist, Department of Infectious Diseases, Aster Medcity, Kochi, India
| | - Anup Warrier
- Lead Consultant, Department of Infectious Diseases, Aster Medcity, Kochi, India
| | - Balram Rathish
- Postgraduate Registrar, Department of Internal Medicine, Aster Medcity, Kochi, India
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20
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Abstract
The leading causes of death in the world are cardiovascular disease (CVD) and stroke according to the World Health Organization, as is also the case in India. There is also a high prevalence of major conventional risk factors in India, where 18.3%, 9.0% and 14.1% of adults are diagnosed with hypertension, diabetes and smoking, respectively. The aim of the present study was to look at the risk of CVD among doctors in our country using a validated tool developed by the National Health Service (NHS) in the UK, the QRISK3 calculator.
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Affiliation(s)
- Roshni Pillay
- PG Registrar CMT, Department of Internal Medicine, Aster Medcity, Kochi, India
| | - Balram Rathish
- PG Registrar CMT, Department of Internal Medicine, Aster Medcity, Kochi, India
| | - Geetha M Philips
- Lead consultant, Department of Internal Medicine, Aster Medcity, Kochi, India
| | - R Anil Kumar
- Lead Consultant, Department of Cardiology, Aster Medcity, Kochi, India
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21
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Gopinath P, Rathish B. Tracheostomal myiasis: A rare clinical entity. Indian J Med Res 2020; 152:S59. [PMID: 35345121 PMCID: PMC8257152 DOI: 10.4103/ijmr.ijmr_1909_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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22
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Rathish B, Wilson A, Warrier A, Pillay R, Thomas J. Aspergillus fumigatus meningitis in an immunocompetent young woman. INDIAN J PATHOL MICR 2020; 63:488-490. [DOI: 10.4103/ijpm.ijpm_252_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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23
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Rathish B, Wilson A, Pillay R, Warrier A, Philips G. A Bundled Approach to Pulmonary Tuberculosis Testing: Experience from a Tertiary Care Centre in South India. Cureus 2019; 11:e6042. [PMID: 31824808 PMCID: PMC6886623 DOI: 10.7759/cureus.6042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The diagnosis of pulmonary tuberculosis (PTB) is based on a stepwise approach consisting of sputum microscopy and molecular testing (GeneXpert), with the use of Mycobacterium culture in select cases. We analysed a bundled approach of PTB testing, consisting of all three of these tests during the patient's first visit, for all patients fitting into the clinical criteria of PTB. We retrospectively analysed the medical records of all patients who underwent the TB diagnosis bundle during a period of 29 months. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of sputum microscopy and GeneXpert were compared against the gold standard of Mycobacterium culture. The incremental yield of diagnosing PTB by addition of Mycobacterium culture in the diagnostic bundle during the initial testing was also calculated. The bundled approach conferred an advantage in terms of faster clinical decision and increased diagnosis rates, by virtue of the speed of smear microscopy and GeneXpert, combined with the higher sensitivity of culture. The bundle also had the additional benefit of detecting non-tuberculous Mycobacterium (NTM) by the culture method. Hence we feel that the bundled approach ensures fewer number of hospital visits and reduces the potential delays in a clinical decision making.
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Affiliation(s)
| | - Arun Wilson
- Infectious Diseases, Aster Medcity, Kochi, IND
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24
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Prakash S, Wilson A, Warrier AR, Babu R, Joy S, Rathish B. 2019. Multicentric Antimicrobial Point Prevalence Survey in Four Tertiary Care Hospitals in Southern India. Open Forum Infect Dis 2019. [PMCID: PMC6808783 DOI: 10.1093/ofid/ofz360.1699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Antibiotic consumption data are scarce in the subcontinent. Defined Daily Doses (Doses) and Days of Therapy (DOT)-based metrics both have inherent disadvantages limiting their application in resource-limited settings primarily in terms of resource hours.. Point Prevalence Study (PPS) offers an offer an initial feasible step for describing antimicrobial use and identifying targets to reduce inappropriate use. Aim of the present study was to use PPS to identify quantitative and qualitative aspects of antimicrobial consumption. Methods A cross-sectional hospital-based PPS was conducted in 4 tertiary care hospitals—Aster Medcity (Kochi, Kerala), Aster MIMS (Calicut, Kerala), Aster Ramesh (Guntur, Andhra Pradesh), and Aster CMI (Bengaluru, Karnataka)—based on a standardized format derived from the GLOBAL-PPS initiative and WHO resources. Results The total number of patients surveyed was 944.42.7% patients had a standing antibiotic order, out of which 19.80%patients were receiving reserve antimicrobials (WHO classification). 76.23% of prescriptions were used empirically, 16.08% were used as prophylaxis meanwhile 7.67% had a culture-based indication. The overall DOT (per 1000 patient-days) for all antimicrobials in the 4 centers were 86.54, 64.19, 93.71 and 85.93 respectively with a cumulative mean DOT of 82.59. Reserve antimicrobials DOT were 26.28, 14.83, 28.08 and 19.61, respectively, with a mean of 22.2. The most common class of antimicrobial prescribed was β lactam -β lactamase inhibitors (BL/BLI) 27.3% while Carbapenems (8.16%) was the most common amongst reserve antimicrobials. Out of all the prescriptions only 7.67% had indications documented. Documented errors of dosing were seen in 8 patients. Adherence to monitoring for ADE was done in 92.57%. Conclusion The study reveals antibiotic use in almost 40% of patients under survey with a DOT of 82.59 per 1000 patient-days. Improving empirical use of antimicrobials, BL/BLI focused intervention and improved documentation has been identified as potential areas for intervention based on this study.The study also highlights the scope of PPS as an effective tool in resource-limited setting to define and refine antimicrobial use and contribute toward antimicrobial stewardship as well as other activities aimed reducing antimicrobial resistance across a range of settings. ![]()
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Disclosures All authors: No reported disclosures.
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Abstract
We started a quality improvement project (QIP) with the aim of implementing an antimicrobial stewardship program (AMSP) to optimize antimicrobial use. We implemented this QIP in our tertiary care center with baseline data from July 1, 2017, to December 31, 2017 (pre-AMSP period), and the project period between January 1, 2018, and June 30, 2018. It covered every inpatient with a positive microbiological culture and patients who were initiated on a pre-selected list of 16 restricted antimicrobials. Numerous plan-do-study-act (PDSA) cycles were conducted alongside daily AMSP rounds, consisting of prospective audit and feedback to all stakeholders. The outcome measures used were antibiotic consumption and costs, Clostridium difficile infection (CDI) rates, the average length of stay (LOS), and adverse drug reaction (ADR) reporting rates. We demonstrated a considerable reduction in the consumption of the selected antibiotics, as well as a direct translation to cost-saving. The AMSP directly contributed to collective savings of around half a million US dollars in hospital bills for patients. We also demonstrated reduced average LOS, CDI rates, and increased reporting of ADRs to antibiotics. The reduction in average LOS was also directly beneficial to patients with reduced time spent in the hospital. The reduction in CDI rates proves that there is a reduction in the development of AMR, and in the short term, fewer incidences of healthcare-associated infections. This, in addition to better surveillance of ADRs to antimicrobials, improved patient safety and quality of care.
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Affiliation(s)
| | - Arun Wilson
- Infectious Diseases, Aster Medcity, Kochi, IND
| | | | - Rachana Babu
- Clinical Microbiology, Aster Medcity, Kochi, IND
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