ITPA polymorphisms do not predict additional risk beyond TPMT and NUDT15 for thiopurine-induced cytopenia in inflammatory bowel disease

INTRODUCTION AND AIM

Thiopurine-related leukopenia is associated with polymorphisms in the thiopurine methyltransferase (TPMT) and nucleoside diphosphate-linked moiety X type motif 15 (NUDT15) genes. However, those polymorphisms explain only a fraction of thiopurine-related leukopenia. Our aim was to study the role of an inosine triphosphate pyrophosphatase (ITPA) polymorphism in patients with inflammatory bowel disease (IBD) and thiopurine-related leukopenia that was unexplained by the TPMT and NUDT15 polymorphisms.

MATERIAL AND METHODS

We enrolled consecutive IBD patients on thiopurines (azathioprine or 6-mercaptopurine) from January 2019-March 2020, at a tertiary care center in North India. The presence of the ITPA (C.94C > A) polymorphism was evaluated in all patients, along with its association with thiopurine-related leukopenia.

RESULTS

Of the 33 patients (from a total of 119 patients) that developed leukopenia, 8 had the TPMT (n = 1) or NUDT15 (n = 7) polymorphism. Of the remaining 111 patients, their mean age was 36.36 ± 13.54 years and 57 (51.3%) were males. Twenty-five (21.01%) had unexplained leukopenia. The ITPA polymorphism was detected in 4 (16%) patients in the unexplained leukopenia group and 24 (27.9%) patients in the non-leukopenia group (p = 0.228). The odds ratio for predicting leukopenia with the ITPA polymorphism was 0.4921 (95% CI 0.1520-1.5830, p = 0.234).

CONCLUSION

The ITPA (C.94C > A) polymorphism was frequently detected in the study population but was not predictive for leukopenia in patients with IBD on thiopurine therapy.

Utility of multiplex real-time PCR for diagnosing paediatric acute respiratory tract infection in a tertiary care hospital

Background

Acute respiratory infections (ARIs) are responsible for considerable morbidity and mortality among children all over the world. Many of the etiologic agents of the infections especially viral go undiagnosed for lack of requisite facility and the cost factors. We have used a commercially available platform for diagnosis of ARIs in children receiving inpatient and outpatient services in a tertiary care centre.

Methods

The framework of the study was prospective and observational. In this study, clinical samples of children suffering from ARIs were subjected to real-time multiplex PCR targeting both viral and bacterial pathogens.

Results

Of 94 samples received at our centre (49 male and 45 female), the positivity for respiratory pathogens was detected in 50 (53.19%) samples. Clinical symptoms of patients and age distribution have been elaborated in text. A single pathogen (n = 29/50), two pathogens (15/50) and three pathogens (n = 6/50) were detected by multiplex RT-PCR. Of 77 isolates detected, maximum numbers were of human rhinovirus (HRV) (n = 14) (18.18%) Streptococcus pneumoniae (n = 14) (18.18%) followed by Staphylococcus aureus (n = 10) (12.98%).

Conclusion

The epidemiology of ARIs considering viral etiologies is poorly understood due to less number of studies especially in Indian subcontinent. The advent of latest advanced molecular methods has made it possible to identify common respiratory pathogens and has contributed to cover the gap in existing knowledge.

Covert Conditioning for Persistent Aggressive Behaviors: A Case Illustration

In psychotherapy practice and training, single case study design plays an indispensable role by effectively articulating the application of textbook knowledge, thereby bridging the gap between theory and practice. This article, on similar lines, illustrates one such successful example of the application of the classical behavioral technique of covert conditioning modified with a component of verbal challenging. A woman in her late-thirties reported with long-standing seemingly-resistant-to-treat symptoms of aggressive behavior of beating children. The client had a total of 10 daily sessions of 60-90 minutes each. By the end of one week, she reported not beating children in this period. She felt extremely relieved because it had happened for the first time in 10 years. The intensity of anger had decreased drastically, and she was not shouting any longer. She had to discontinue sessions abruptly due to unavoidable circumstances. Although she was suggested to follow up the intensive sessions again, she was not able to do it due to feasibility issues. The improvement was maintained on follow-up visits after two weeks, four weeks, and three months.

P256 A rare case of co-infection with Nigrospora oryzae with mucormycosis in an immunocompromised post-COVID patient

 

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM

Objective

A rare case of co-infection of Nigrospora oryzae with mucormycosis in an immunocompromised post-COVID patient.

Methods

A 41-year-old male diabetic patient, with sub-optimal glycemic control, contracted COVID-19 infection and was managed with high-dose steroids. A month after recovery from COVID-19 infection, he developed severe headache with sudden onset right-sided facial swelling. A contrast-enhanced magnetic resonance imaging was done which was suggestive of infective/inflammatory rhinosinusitis with intracranial extension with a possibility of fungal etiology. Functional endoscopic sinus surgery was performed and tissue was sent for microbiological processing. On KOH mount, broad pauciseptate fungal hyphae were seen. Fungal growth was obtained on SDA at 25°C and 37°C within 4 days of inoculation. It was confirmed as Rhizopus arrhizus both phenotypically as well as by MALDI-TOF. Patient was put on antifungal therapy in form of Inj liposomal Amphotericin B 500 mg/d. However, patient had persistent headache, vomiting, and low-grade fever post-procedure. A repeat CE-MRI was performed which was suggestive of necrotic brain tumor/abscess and was planned for frontal lobe abscess drainage. Pus was inoculated on routine mycological media. On KOH mount, broad pauciseptate hyphae along with narrow septate hyphae were seen. Fungal growth was obtained on SDA at 25°C within 5 days of inoculation, which on LPCB were identified as Nigrospora spp. The identity of the isolate was confirmed by Next generation sequencing as Nigrospora oryzae. Post-2 weeks of treatment and strict glycemic control, patient started improving. The headache and swelling subsided. He was further started on oral hypoglycemic agents and discharged and was asked to follow up after a month.

Results

COVID-19 epidemic that emerged by the end of 2019 has been associated with a huge number of deaths globally. Acute invasive fungal rhino-sinusitis is a potentially fatal infection in immune-compromised patients post COVID-19. Various studies reveal that invasive fungal infections have been the leading cause of death in 25%-73.7% of patients. Among these invasive fungal infections, Mucor spp. were detected in 77.8% patient, Aspergillus fumigatus in 30.6% while 8.3% showed mixed infection with both the fungi. Along with the established pathogenicity of Mucorales in causing invasive fungal infection, other fungal co-infections are also being observed. These invasive fungal infections in an immune-compromised host carry a high mortality and morbidity rate (18%-80%). Therefore, early diagnosis, followed by aggressive medical care, surgical debridement, and control of underlying diseases is of utmost importance.

Conclusion

Acute invasive fungal rhinosinusitis saw a spurt in incidence during the widespread COVID-19 pandemic.

Diagnosis of invasive fungal infection is based on the clinical setting and characteristic presentation, supported by radiological and microbiological evidence. Prompt diagnosis and treatment are the need of the hour.

P377 Study of the prevalence of candidemia and its antifungal susceptibility pattern in a tertiary care hospital

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PM

 

Objectives

Study of the prevalence of candidemia and its resistance pattern in a tertiary care hospital.

Methods

Results

Conclusion

Candida spp. are a part of the normal flora of healthy hosts but are also found to be a major cause of invasive fungal infections which is now found to be one of the leading causes of mortality in hospitalized patients. The emergence of unusual and relatively unknown Candida species as nosocomial pathogens with increasing treatment failure, emphasizes the need to isolate and identify all species and to start early definitive treatment according to the susceptibility pattern reported to decrease mortality and morbidity rates.

Catheter-related blood stream infections: prevalence, risk factors and antimicrobial resistance pattern

Background

Intravascular devices have significant potential for producing iatrogenic diseases resulting in catheter-related blood stream infections (CRBSIs). A study was undertaken to find the prevalence of CRBSI among patients in acute wards and to analyze the associated risk factors, causative pathogens with their antibiotic susceptibility (ABST) patterns.

Methods

Randomly ten days per month were chosen, for a period of two years. All the acute wards patients who were on indwelling blood catheters were identified. Those fulfilling the CRBSI criteria were further worked up for confirmation of diagnosis by differential time to positivity. The catheter tip was cultured by Maki's semiquantitative method. ABST of the isolates obtained was performed by Kirby-Bauer disk diffusion method.

Results

The prevalence of CRBSI was found to be 39.25% with the most common organism isolate being Serratia marcescens (23.81%). The immunocompromised status of the patients and catheterisation time were significant risk factors. Methicillin resistance was found to be 33.33% in coagulase-negative staphylococci. The resistance to vancomycin among the Entercoccus faecium isolates was found to be 33.33%. Among the gram negatives, resistance to aminoglycosides, fluoroquinolones and third-generation cephalosporins was high.

Conclusion

The study highlights the importance of regular surveillance programs, an efficient infection control program, strict adherence to antiseptic measures and use of a rational antibiotic policy for the early diagnosis and better management of CRBSI.

Prevalence of non tuberculous mycobacterial infection in surgical site infections and their antibiotic susceptibility profile

Background

Surgical site infections (SSIs) are one of the leading causes of hospital-acquired infections contributing to about 20% of all cases, thereby causing an increase in morbidity and financial burden. Causative organisms associated with SSIs have not changed greatly over the last 10-15 years; however, the proportions of different types of causative organisms have changed with an increase in case reports of rare organisms such as non-tuberculous mycobacteria (NTM).

Methods

Samples received from patients with SSI were simultaneously cultured for the isolation of NTM along with routine bacteriological examination. On isolation of NTM, identification was carried out by biochemical tests, and further antibiotic susceptibility profile was determined by using RAPMYCO kit.

Results

SSI occurred in 3.95% of the 7675 surgeries performed during the study period of which 10.9% were caused owing to NTM. Only rapidly growing NTM were isolated of which, Mycobacterium fortuitum was the most common (51.51%) and had least resistance to drugs. Other isolates were Mycobacterium abscessus and Mycobacterium chelonae having high degree of antimicrobial resistance.

Conclusion

NTM are an important cause of SSI having delayed presentation, are difficult to diagnose and often not treated correctly. Identification and susceptibility testing is important as different species respond differently to antimicrobial agents.

Change in Attitude among Nursing Undergraduate Students Following One-Month Exposure in a Mental Healthcare Setting

BACKGROUND

Attitude of treating professionals plays an important role in the treatment of mental illnesses. Nursing professionals are an important part of the mental health care team. As a part of their nursing coursework, nursing students are posted in a mental health setting. It is important to assess the impact of such postings on their attitudes.

MATERIALS AND METHODS

A total of 235 undergraduate nursing students posted in a mental healthcare setting for one month participated in the study. Their attitude towards mental illness and psychiatry was assessed before and after the posting, using Personal data sheet, Attitude Scale of Mental Illness (ASMI), and Attitude towards Psychiatry Scale (ATP).

RESULTS

At pre-assessment, the nursing students had a negative attitude on all dimensions of ASMI except benevolence, and positive attitude on all the six domains of ATP. At post-assessment, attitude improved significantly on pessimistic prediction dimension of ASMI, and they were able to maintain their positive attitude on ATP.

CONCLUSIONS

One-month posting had a weak positive impact on attitude towards mental illness and no detrimental impact on attitude towards psychiatry. There is a need for better efforts to increase the impact of training on attitude towards mental illness.

Point prevalence & risk factor assessment for hospital-acquired infections in a tertiary care hospital in Pune, India

Background & objectives:

Hospital-acquired infections (HAIs) are a major challenge to patient safety and have serious public health implications by changing the quality of life of patients and sometimes causing disability or even death. The true burden of HAI remains unknown, particularly in developing countries. The objective of this study was to estimate point prevalence of HAI and study the associated risk factors in a tertiary care hospital in Pune, India.

Methods:

A series of four cross-sectional point prevalence surveys were carried out between March and August 2014. Data of each patient admitted were collected using a structured data entry form. Centers for Disease Control and Prevention guidelines were used to identify and diagnose patients with HAI.

Results:

Overall prevalence of HAI was 3.76 per cent. Surgical Intensive Care Unit (ICU) (25%), medical ICU (20%), burns ward (20%) and paediatric ward (12.17%) were identified to have significant association with HAI. Prolonged hospital stay [odds ratio (OR=2.81), mechanical ventilation (OR=18.57), use of urinary catheter (OR=7.89) and exposure to central air-conditioning (OR=8.59) had higher odds of acquiring HAI (P<0.05).

Interpretation & conclusions:

HAI prevalence showed a progressive reduction over successive rounds of survey. Conscious effort needs to be taken by all concerned to reduce the duration of hospital stay. Use of medical devices should be minimized and used judiciously. Healthcare infection control should be a priority of every healthcare provider. Such surveys should be done in different healthcare settings to plan a response to reducing HAI.

Modeling of live-birth rates and cost-effectiveness of oocyte cryopreservation for cancer patients prior to high- and low-risk gonadotoxic chemotherapy

STUDY QUESTION

What is the live-birth rate (LBR) and cost-effectiveness of fertility preservation with oocyte cryopreservation (FP-OC) compared to expectant management in cancer patients age 25-40 based on estimated gonadotoxicity of treatments 5 years after cancer diagnosis?

SUMMARY ANSWER

Oocyte cryopreservation prior to cancer treatment is more costly, yet more effective (producing more live births), than not undergoing oocyte cryopreservation but it is most beneficial for patients undergoing high-risk chemotherapy (HRC).

WHAT IS KNOWN ALREADY

The decision to undergo FP prior to treatment is multifactorial and can be costly and delay treatment. Not all treatments carry the same gonadotoxicity and patients may choose to undergo FP-OC based on the probability of premature ovarian insufficiency, predicted outcomes and cost. A comprehensive model that incorporates age at diagnosis and toxicity of treatment to help guide patients in the decision to undergo FP-OC does not yet exist.

STUDY DESIGN, SIZE DURATION

This study used a Decision Analysis Model to estimate effectiveness and cost of FP for cancer patients.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Age-based estimates of LBR and cost per live birth were calculated for ages 25-40 years based on gonadotoxicity of treatment. A decision analysis model was constructed using Treeage Pro 2015 with case base probabilities derived from national registries, practice guidelines and medical records from a national network of infertility practices (IntegraMed).

MAIN RESULTS AND THE ROLE OF CHANCE

Compared to no FP-OC, FP-OC improved LBRs for women of all ages undergoing either low-risk chemotherapy (LRC) or HRC; however, it was most cost effective for women undergoing LRC at older ages or HRC at younger ages. Although FP-OC results in higher LBRs, it was always more costly. Using donor oocyte IVF can be a successful alternative to autologous FP-OC.

LIMITATIONS REASONS FOR CAUTION

Decision tree results reflect probabilities of certain events and are compiled from multiple reputable sources but are not directly derived from a recruited cohort of patients. Outcomes are based on United States estimates and should be interpreted in the broader context of individual patient diagnoses, treatment care plans and country of origin.

WIDER IMPLICATIONS OF THE FINDINGS

The development of this analytic model will help guide practitioners in their counseling of women from age 25 to 40 years, who are considering FP-OC at the time of cancer diagnosis. It provides a realistic pathway from diagnosis to LB and accounts for the majority of costs and outcome possibilities.

STUDY FUNDING/COMPETING INTEREST(s)

This study was partially funded by a grant from National Institute of Health (NIH)/National Institute of Child Health and Human Development (NICHD) (R01 HD67683) to A.Z.S. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Prevalence and molecular characterization of methicillin resistance among Coagulase-negative Staphylococci at a tertiary care center

BACKGROUND

Methicillin-resistant Coagulase-negative Staphylococci (MR-CoNS) have emerged as an important cause of nosocomial infections especially in patients with prosthetic devices and implants. This study was conducted with an aim to determine the prevalence of methicillin resistance among CoNS isolates at a tertiary care center by both phenotypic and genotypic methods.

METHODS

This cross sectional study was carried out from September 2011 to February 2014 in which 150 non-repetitive clinical isolates of CoNS were identified at the species level by conventional phenotypic methods. Cefoxitin disk (30 μg) diffusion testing was used to determine methicillin resistance and confirmed by detection of mecA gene by polymerase chain reaction (PCR).

RESULTS

Out of 150 CoNS isolates, 51 were methicillin resistant by cefoxitin disk diffusion method. Out of these 51 isolates, mecA gene was detected only in 45 isolates. Moreover, mecA gene was also detected in 4 isolates, which were cefoxitin sensitive. Thus, the prevalence of methicillin resistance among CoNS was found to be 32.7% by PCR.

CONCLUSION

The prevalence of methicillin resistance among Coagulase-negative Staphylococci (CoNS) was 32.7% by PCR detection of mecA gene. The sensitivity and specificity of cefoxitin disk diffusion method against mecA gene detection by PCR were found to be more than 90%. It can be concluded from this study that cefoxitin disk diffusion test can be used as a useful screening method to detect methicillin resistance among CoNS isolates. However, detection of mecA gene by PCR remains a more accurate method of detecting methicillin resistance among CoNS.

Phenotypic detection and molecular characterization of beta-lactamase genes among Citrobacter species in a tertiary care hospital

Objective:

To examine the distribution, emergence, and spread of genes encoding beta-lactamase resistance in Citrobacter species isolated from hospitalized patients in a tertiary care hospital.

Methods:

A prospective study was conducted in a 1000-bed tertiary care center in Pune, India from October 2010 to October 2013. A total of 221 Citrobacter spp. isolates were recovered from clinical specimens from different patients (one isolate per patient) admitted to the surgical ward, medical ward and medical and surgical Intensive Care Units. Polymerase chain reaction (PCR) assays and sequencing were used to determine the presence of beta-lactamase encoding genes. Conjugation experiments were performed to determine their transferability. Isolate relatedness were determined by repetitive element based-PCR, enterobacterial repetitive intergenic consensus-PCR and randomly amplified polymorphic DNA.

Results:

Among 221 tested isolates of Citrobacter spp. recovered from various clinical specimens, 179 (80.9%) isolates showed minimum inhibitory concentration (MIC) >4 μg/ml against meropenem and imipenem. One hundred and forty-five isolates with increased MICs value against carbapenems were further processed for molecular characterization of beta-lactamase genes. Susceptibility profiling of the isolates indicated that 100% retained susceptibility to colistin. Conjugation experiments indicated that bla_NDM-1 was transferable via a plasmid.

Conclusion:

The ease of NDM-1 plasmid transmissibility may help their dissemination among the Citrobacter species as well as to others in Enterobacteriaceae. Early detection, antimicrobial stewardship and adequate infection control measures will help in limiting the spread of these organisms.

Multidrug resistant NDM-1 metallo-beta-lactamase producing Klebsiella pneumoniae sepsis outbreak in a neonatal intensive care unit in a tertiary care center at central India

OBJECTIVE

The objective of the following study is to detect genes encoding carbapenem resistance in Klebsiella pneumoniae sepsis outbreak in a neonatal intensive care unit (NICU).

MATERIALS AND METHODS

Antibiotic sensitivity test was performed by standard Kirby Bauer disc diffusion technique and minimum inhibitory concentrations of antibiotics was determined by VITEK-2. Polymerase chain reaction (PCR) assays and sequencing was used to determine the presence of beta-lactamase encoding genes. Conjugation experiments were performed to determine the transferability of beta-lactamase. Isolate relatedness were determined by repetitive-element PCR (REP), enterobacterial repetitive intergenic consensus (ERIC) PCR and random amplified polymorphic deoxyribonucleic acid (RAPD).

RESULTS

All the isolates were completely resistant to the second and third generation cephalosporins tested as well as carbapenems. Susceptibility profiling of the isolates indicated that 100% retained susceptibility to tigecycline and colistin. Conjugation experiments indicated that blaNDM-1 was transferable and likely through a plasmid-mediated event. All the isolates showed the presence of blaNDM-1 with co association of blaCTX-M-15. REP-PCR, ERIC-PCR and RAPD revealed a single clonal type circulating in NICU environment.

CONCLUSION

Co-production of NDM-1 with CTX-M-15 in K. pneumoniae isolates was detected for the first time in our NICU. Transmission of plasmid carrying these resistant genes to other members of Enterobacteriaceae will increase the incidence of multidrug resistance. Early detection of these genes will help in prevention and adequate infection control by limiting the spread of these organisms.

Emergence of multidrug resistant enterococci at a tertiary care centre

BACKGROUND

Enterococci have assumed great clinical importance because of their increasing resistance to various antimicrobial agents. Thus, knowledge about the antibiogram of these multidrug resistant isolates is of utmost importance in formulating an effective antibiotic policy to treat these infections and reducing the morbidity and mortality. Aim of this study was to assess the antimicrobial resistance pattern of enterococci and determine the prevalence of multidrug resistance among them.

METHODS

This cross sectional study was carried out from August 2011 to February 2014, in which 200 non-repetitive clinical isolates of enterococci were included. Antimicrobial susceptibility testing was done by disc diffusion method. Minimum inhibitory concentration (MIC) of gentamicin, streptomycin, vancomycin, teicoplanin and linezolid was determined by E-test method.

RESULTS

The prevalence of multidrug resistance among enterococcal isolates was found to be 63%. Varying levels of resistance was seen to various antibiotics. Most of the isolates were resistant to penicillin (95%), ampicillin (95%) and cotrimoxazole (90%). High level aminoglycoside resistance (HLAR) and glycopeptide resistance was seen in 39% and 14% isolates respectively. Only 4 isolates (2%) were found to be resistant to linezolid.

CONCLUSION

The prevalence of multidrug resistance among enterococci was found to be 63%, the resistance being more common in Enterococcus faecium as compared to Enterococcus faecalis. The study highlights the emergence and increased prevalence of multidrug resistant enterococci which pose a serious therapeutic challenge.

A case of septicemia due to Chyresobacterium indologenes producing blaNDM-1

A multidrug resistant Chyresobacterium indologenes was isolated from blood in a case of septicemia. The organism was resistant to carbapenems and was positive for blaNDM-1; transferable through plasmid.

Emergence of Escherichia coli, Co-Producing NDM-1 and OXA-48 Carbapenemases, in Urinary Isolates, at a Tertiary Care Centre at Central India

OBJECTIVE

To detect genes encoding carbapenem resistance in urinary isolates of Escherichia coli recovered from hospitalized patients in tertiary care centre in Pune, India.

METHODS

From Jan 2012 to Dec 2012, a total of 300 consecutive non-duplicate (one isolate per patient) clinical isolates of Escherichia coli were recovered from urine cultures of hospitalized patients including hospital acquired infection cases admitted to the medical and surgical intensive care units. Polymerase chain reaction (PCR) assays and sequencing was used to determine the presence of beta-lactamase encoding genes. Conjugation experiments were performed to determine the transferability of beta-lactamase.

RESULTS

All the isolates were completely resistant to the second and third generation cephalosporins tested as well as carbapenems. All the isolates showed 100% susceptibility to tigecycline and colistin in vitro. Conjugation experiments demonstrated that blaNDM-1 was transferable via plasmid. All the isolates showed presence of blaNDM-1 and co-association of blaOXA-48 was 25/45(55%) of the isolates. Repetitive element based PCR (REP PCR), Enterobacterial Repetitive Intergenic Consensus (ERIC PCR) and Randomly Amplified Polymorphic DNA (RAPD) revealed a diversity of six clonal types among E.coli isolates.

CONCLUSION

Co-production of NDM-1with OXA-48 in urinary isolates of E. coli was detected for the first time in India. Transmission of plasmid carrying these resistant genes to other members of Enterobacteriaceae will increase incidence of multidrug resistance. Early detection of these genes will help in prevention and adequate infection control by limiting the spread of these organisms.

Detection of glycopeptide resistance genes in enterococci by multiplex PCR

BACKGROUND

Vancomycin Resistant Enterococci (VRE) are a major cause of nosocomial infections. There are various phenotypic and genotypic methods of detection of glycopeptide resistance in enterococci. This study utilizes multiplex PCR for reliable detection of various glycopeptides resistance genes in VRE.

METHOD

This study was conducted to detect and to assess the prevalence of vancomycin resistance among enterococci isolates. From October 2011 to June 2013, a total of 96 non-repetitive isolates of enterococci from various clinical samples were analyzed. VRE were identified by Kirby Bauer disc diffusion method with Clinical and Laboratory Standards Institute (CLSI) guidelines. Minimum inhibitory concentration (MIC) of all isolates for vancomycin and teicoplanin was determined by E-test. Multiplex PCR was carried out for all enterococci isolates using six sets of primers.

RESULTS

Out of 96 isolates, 14 (14.6%) were found to be resistant to vancomycin by vancomycin E-test method (MIC ≥32 μg/ml). Out of these 14 isolates, 13 were also resistant to teicoplanin (MIC ≥16 μg/ml). VanA gene was detected in all the 14 isolates by Multiplex PCR. One of the PCR amplicons was sent for sequencing and the sequence received was submitted in the GenBank (GenBank accession no. KF181100).

CONCLUSION

Prevalence of VRE in this study was 14.6%. Multiplex PCR is a robust, sensitive and specific technique, which can be used for rapid detection of various glycopeptide resistance genes. Rapid identification of patients infected or colonized with VRE is essential for implementation of appropriate control measures to prevent their spread.

Molecular Characterization of Carbapenem Resistant Isolates of Acinetobacter baumannii in An Intensive Care Unit of A Tertiary Care Centre at Central India

OBJECTIVE

To detect genes encoding carbapenem resistance in Acinetobacter baumannii in an intensive care unit.

METHODS

A. baumannii isolates were recovered from various clinical specimens of hospitalized patients admitted to the Medical and Surgical intensive care units of a tertiary care centre in Pune. Bacterial identification was performed by routine conventional microbial culture and biochemical tests using standard recommended techniques. Antibiotic sensitivity test was performed by standard Kirby Bauer disc diffusion technique. PCR amplification and automated sequencing was carried out.

RESULTS

A total of 155 /368 (42.11%) isolates A. baumannii were found to have reduced susceptibility to imipenem (diameter of zones of inhibition ≤13mm) by disc diffusion method. Among these 155 isolates tested 130 (83.87%) isolates showed MIC values for imipenem and meropenem ranging from16-64 mg/L as per CLSI breakpoints. Among these 155 isolates, Carbapenemase production was confirmed by Modified Hodge test for 93 (60%) isolates. Out of 155 isolates, DDST was positive for 89 (57.41%), CDST was positive for 73(47.09%) and MBL (IP/IPI) E-test was positive for 105 (67.74%). blaOXA-51 gene was detected in 47/105 (44.76%), blaOXA-23 gene in 55/105 (52.38%) and blaOXA-58 like gene in 15/105 (14.28%).

CONCLUSION

MBL production along with co- production of OXA enzymes are considered to be the important reason for resistance to imipenem in Acinetobacter in our health care settings. Hence, early detection of these drug resistant genes by molecular methods is essential in limiting the spread of infection due to these organisms.

Emergence of VIM-2 metallo-beta-lactamase producing Ralstonia pickettii clinical isolate in India

A multidrug-resistant clinical isolate of Ralstonia pickettii from a woman was analysed. Modified Hodge test was positive for carbapenemase production. Conjugation experiment revealed the presence of conjugative plasmid of >140 Kb size typed as IncN type. This is the first report of emergence blaVIM-2 in R. pickettii in India.

In vitro vancomycin susceptibility amongst methicillin resistant Staphylococcus aureus

BACKGROUND

Vancomycin is drug of choice for treatment of Methicillin Resistant Staphylococcus aureus (MRSA) infections. S. aureus with reduced vancomycin susceptibility (SA-RVS) is on rise. Current guidelines of detection of SA-RVS are based on MIC (Minimum Inhibitory Concentration) by broth or agar dilution methods. Vancomycin MIC by E test (Epsilometer Test) is an alternative. A study was undertaken to know the prevalence of SA-RVS and compare vancomycin MIC by agar dilution and E test.

METHODS

A prospective study was undertaken at tertiary care hospital; 232 clinical MRSA isolates were included. Vancomycin MIC was undertaken by agar dilution method and E test.

RESULTS

All isolates were sensitive to Linezolid. Two MRSA isolates had vancomycin MIC ≥4 μg/ml; vancomycin MIC50 and MIC90 of MRSA isolates was 0.5 and 0.2 μg/ml respectively by agar dilution method. There was agreement over 93.5% isolates in vancomycin susceptibility by agar dilution and E test. E test had sensitivity and positive predictive value of 1.0 (CI - 0.34-1.0) and 0.5 (CI - 0.17-0.83) respectively compare to agar dilution method.

CONCLUSIONS

MRSA isolates continues to be susceptible to vancomycin and Linezolid. E test was found equally suitable in initial screening for vancomycin susceptibility. Due to geographic variation in prevalence, there is need of ongoing surveillance of SA-RVC.

Emergence of NDM - 1 in the Clinical Isolates of Pseudomonas aeruginosa in India

OBJECTIVE

The present study was undertaken to detect the prevalence of the blaNDM-1 metallo beta lactamases (MBLs) in the isolates of Pseudomonas aeruginosa, which were recovered from various clinical samples from hospitalized patients in a tertiary care centre in Pune, India.

METHODS

A total of 200 isolates of P. aeruginosa which were obtained from various clinical samples were subjected to antibiotic susceptibility testing by the disc-diffusion method and their MICs were determined by the Vitek - 2 Automated Antimicrobial Identification and Susceptibility Testing System against imipenem, meropenem, ticarcillin, amikacin, gentamicin, tobramycin, ciprofloxacin, levofloxacin, moxifloxacin, tigecycline, trimethoprim/sulfamethoxazole, ampicillin/sulbactam, piperacillin/tazobactam, cefoperazone/sulbactam, cefepime, tetracycline, ceftazidime, ceftriaxone and colistin. Their MICs were also determined by the Etest method against imipenem, meropenem, piperacillin, tobramycin, ceftazidime, tigecycline and colistin. The presence of blaNDM-1 was detected by PCR and it was confirmed by sequencing the gene which was present in the isolates which exhibited carbapenem resistance. The experimental transferability of the plasmids which carried blaNDM-1 was determined by using E. coli J53 as the recipient.

RESULT

In the present study, four isolates of P. aeruginosa, which carried the blaNDM-1 gene, were resistant to imipenem and meropenem. These blaNDM-1 carrying isolates remained susceptible to colistin. The plasmid carrying blaNDM-1 was successfully transferred from the four isolates to E. coli J53 recipients.

CONCLUSIONS

We are reporting the emergence of the P. aeruginosa carrying NDM-1gene, which exhibited resistance to imipenem and meropenem, for the first time from India.

Emergence of VIM-6 metallo-beta-lactamase-producing Alcaligenes faecalis clinical isolates in a hospital in India

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Allogeneic haematopoietic stem cell transplantation: the Army hospital experience

BACKGROUND

We analysed the results of allogeneic haematopoietic stem cell transplantation (HSCT) in various genetic disorders, bone marrow failures and haematological malignancies done from 2002 to 2010 at the Army Hospital, Research and Referral, Delhi.

METHODS

A total of 119 matched-related allogeneic- HSCTs (allo-HSCTs) were done in 114 patients (men 76, women 38) aged between 2 and 60 years. Peripheral blood stem cells (n=75) and bone marrow (n=43) were used as the source of stem cells.

RESULTS

The overall survival was 62.3% (71/114) at a median follow-up of 34 months. Graft versus host disease (GVHD) was seen in 42 (36.8%) patients; grade III/IV acute GVHD in 17 (15%) and chronic GVHD in 24 (21%) patients. There were 4 (3.5%) graft rejections and one nonengraftment. The overall mortality was 37.7% (n=43) and the main causes of death were GVHD (32%), infections (26%), relapse (23%) and regimen-related toxicity (11%).

CONCLUSION

Our results are comparable to published data in most disease conditions. With improvements in GVHD prophylaxis and better supportive care, we need to further reduce our mortality and morbidity.

Reverse transcription loop-mediated isothermal amplification (RT-LAMP) for diagnosis of dengue

BACKGROUND

Dengue is an emerging public health problem causing serious morbidity and mortality in tropical developing countries. Early, sensitive and specific diagnosis is paramount for clinical decision making. Currently available diagnostic tests are limited in scope and utility. This study highlights applicability of RT-LAMP in dengue diagnosis.

METHODS

100 dengue confirmed cases, 100 dengue negative cases and 79 healthy negative controls from dengue epidemic between Sep 2009 to Jul 2011 were included. Dengue cases were profiled using WHO guidelines 2006, haematological and biochemical parameters evaluated and diagnosed using NS1 antigen, IgM and IgG enzyme immunoassay, RT-PCR and RT-LAMP. Positive cases were serotyped, genotyped and various tests were compared.

RESULTS

Mean haematocrit, PT, PTT, platelet count, activated lymphocytes, serum fibrinogen, transaminases, bilirubin, lactate dehydrogenase, protein and sodium were significantly elevated in DHF/DSS as compared to DF. NS1 antigen, RT-PCR and RT-LAMP were sensitive during 1-3 days while μ-capture IgM EIA was specific after 5-7 days of initial infection. DEN-1 genotype III was predominant.

CONCLUSION

Deranged haematocrit and liver function tests are indicators of the severity of the disease. RT-LAMP is rapid, cost effective, highly sensitive and specific qualitative and quantitative technique which can detect dengue infection in both early and intermediary stages when NS1 antigen titres are not in the detectable range and the IgM antibody titres have just started to rise. Its superiority over existing techniques, amenability for automation and promising utility in low resource healthcare setups and field conditions raise it as the new gold standard for dengue diagnosis.

Therapeutic challenges of ESBLS and AmpC beta-lactamase producers in a tertiary care center

BACKGROUND

Resistance to broad-spectrum beta lactams mediated by extended spectrum beta lactamases (ESBLs) and AmpC beta lactamases (AmpC βLs) enzymes is an increasing problem worldwide. Determination of their prevalence is essential to formulate an effective antibiotic policy and hospital infection control measures. Present study was undertaken to determine the prevalence of ESBL and AmpC βL producers in ICU of a tertiary care center.

METHODS

A total of 262 clinical isolates comprising of Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis that were recovered from various clinical specimens over a one year period, were studied. Antibiogram profile was determined to conventionally used antibiotics, along with recommended tests for detection of ESBL and AmpC βL production.

RESULTS

40.07% (105/262) were found to be ESBL producers, 14.8% (39/262) were AmpC bL producers. The coexistence of ESBL and AmpC βL producers was detected in 9.9% (26/262) of the isolates.

CONCLUSION

Screening of multidrug resistant bacteria especially belonging to the Enterobacteriaceae poses considerable therapeutic challenges in critical care patients because of the production of ESBL and AmpC βL. Strategies to keep a check on the emergence of such drug resistant microbes by hospital environmental surveillance and laboratory monitoring should form an important aspect of Hospital Infection control policy guidelines.

Tuberculosis of breast: unusual manifestation of tuberculosis

Tuberculosis affects almost every organ of the body, and the breast is no exception. However, tuberculosis of the breast is rare, and the varied presentation requires a high index of suspicion, especially in middle-aged women for whom a clinical diagnosis of malignancy is likely to be made. We report two cases of primary tuberculosis of breast with different manifestations. One case presented as tuberculous mastitis and the other presented with a lump masquerading as breast carcinoma. The diagnosis in both cases was based on demonstration of acid-fast bacilli on histopathological examination. Resolution was complete with antitubercular therapy, and major surgical intervention was not necessary.

Ecological niche of Cryptococcus neoformans var. grubii and Cryptococcus gattii in decaying wood of trunk hollows of living trees in Jabalpur City of Central India

Cryptococcus neoformans var. grubii and C. gattii were repeatedly isolated from decaying wood of trunk hollows in living trees growing in Jabalpur City in Central India. The isolation of C. gattii has been reported from decayed wood inside trunk hollow of Tamarindus indica (15.6%), Mangifera indica (2.2%), Pithecolobium dulce (12.5%), Syzygium cumini (14%), and one from bark of S. cumini. C. n. var. grubii was isolated from decaying wood debris of T. indica (4.4%), M. indica (13.3%), Terminalia arjuna (25%), S. cumini (2%), Cassia fistula (4.5%), and two from bark of S. cumini. The two species [corrected] never co-occurred in the same hollow. C. gattii [corrected] isolates belonged to serotype B. [corrected] The data strongly supported the colonization of the pathogen in decaying wood hollow of all six-tree species. Evidence of this was found by repeated isolation up to 820 days. P. dulce is being reported for the first time as natural habitat of C. gattii and T. arjuna and C. fistula as natural habitat for C. n. var. grubii. M. indica is being reported for the second time as the natural habitat of both species [corrected] (C. n. var. grubii and C. gattii). The population density of these pathogens from decaying wood debris of various tree species ranged between 0.5 x 10(3) cells/g and 6 x 10(5) cells/g. The seasonal variation has been seen in isolation of these pathogens. [corrected] Our result further reinforce the recently emerging evidence that the natural habitat of C. n. var. grubii and C. gattii is more generalized.

A five year review of clinical profile in HSP

To study the clinical profile of Henoch Schönlein Purpura [HSP] in children. A retrospective case series of 30 consecutive children with a diagnosis of HSP, with special focus on clinical manifestations. Two cases with unusual features are described in detail. Data of 19 boys and 11 girls with a mean age of 10.55 years was reviewed. Overall skin was involved in 100%, joints in 86.7%, GIT in 80% and renal system in 30% Two-thirds had palpable purpura at presentation. The mean duration of appearance of skin lesions after preceding joint and gastrointestinal symptoms was 8.6 days and 6.6 days respectively. Abdominal pain was the most common gastrointestinal symptom. Knee and ankle involvement occurred in more than 3/4th of the patients with arthritis. Vesciculobullous lesions were seen in two patients while one patient had rheumatic fever. Most children with HSP will have classical manifestation of the disease but diagnostic confusion can occur in those with atypical or absent cutaneous features at the onset.