Distinctive Mobile Genetic Elements Observed in the Clonal Expansion of Carbapenem-Resistant Klebsiella pneumoniae in India

Background: Klebsiella pneumoniae (Kp), a common multidrug-resistant pathogen, causes a wide spectrum of nosocomial infections with high rates of morbidity and mortality. The emergence of pan drug-resistant international high-risk clones such as ST258, ST14, ST15, ST147, and ST101 is a global concern. This study was performed to investigate the carbapenemases, the plasmid profile, and the clonal relationship among Indian K. pneumoniae. Materials and Methods: A total of 290 K. pneumoniae isolates from seven centers in India were characterized to determine sequence types (STs) and carbapenemases. A subset of isolates was subjected to whole genome sequencing and hybrid genome assembly to obtain the complete genome. Plasmids carrying carbapenemases were characterized to determine the dissemination of carbapenem-resistant (CR) K. pneumoniae. Results: From this study, 75 different STs were observed with ST231 being predominant. About 79% of the analyzed isolates were CR with 59% (n = 136) producing OXA48-like carbapenemases. While ST231 was the predominant clone among the OXA48-like producers; NDM producers and NDM+OXA48-like producers were mostly associated with ST14. Interestingly, 61% (n = 138) of the total CR K. pneumoniae were colistin resistant, belonging to 22 different STs. Plasmid profiling shows that bla_OXA48-like was exclusively carried by ColKP3, whereas bla_NDM was associated with IncFII-like plasmids. Conclusion: The highly mosaic genome of K. pneumoniae coupled with the diverse ecological niches in India makes it a hotspot for antimicrobial resistance, leading to increased morbidity and mortality. Extensive molecular surveillance of the clonal spread of K. pneumoniae could help in understanding AMR dynamics and thus rework therapeutic management.

Efficacy ratio: A tool to enhance optimal antimicrobial use for intra-abdominal infections

BACKGROUND

Antimicrobial resistance and inappropriate antibiotic regimen hamper a favorable outcome in intra-abdominal infections. Clinicians rely on the minimum inhibitory concentration (MIC) value to choose from the susceptible antimicrobials. However, the MIC values cannot be directly compared between the different antibiotics because their breakpoints are different. For that reason, efficacy ratio (ER), a ratio of susceptible MIC breakpoint and MIC of isolate, can be used to choose the most appropriate antimicrobial.

MATERIALS AND METHODS

A prospective, observational study conducted during 2015 and 2016 included 356 Escherichia coli and 158 Klebsiella spp. isolates obtained from the intra-abdominal specimens. MIC was determined by microbroth dilution method, and ER of each antibiotic was calculated for all the isolates.

RESULTS

For both E. coli and Klebsiella spp., ertapenem, amikacin, and piperacillin/tazobactam had the best activities among their respective antibiotic classes.

DISCUSSION

This is the first study calculating ER for deciding empiric treatment choices. ER also has a potential additional value in choosing the use of susceptible drugs as monotherapy or combination therapy. A shift in ERs over a period of time tracks rising MIC values and predicts antimicrobial resistance development.

CONCLUSION

Estimation of ER could be a meaningful addition for the interpretation of an antimicrobial susceptibility report, thus helping the physician to choose the best among susceptible antimicrobials for patient management.

Dosing strategy based on prevailing aminoglycoside minimum inhibitory concentration in India: Evidence and issues

Aminoglycosides are important agents used for treating drug-resistant infections. The current dosing regimen of aminoglycosides does not achieve sufficient serum level concentration for the infected bacterial pathogen interpreted as susceptible based on laboratory testing. Minimum inhibitory concentration was determined for nearly 2000 isolates of Enterobacteriaceae and Pseudomonas aeruginosa by broth microdilution method. Results were interpreted based on CLSI and EUCAST interpretative criteria and the inconsistencies in the susceptibility profile were noted. This study provides insights into the inconsistencies existing in the laboratory interpretation and the corresponding clinical success rates. This urges the need for revising clinical breakpoints for amikacin, to resolve under dosing leading to clinical failure.

Comparative in-vitro activity of ceftaroline against Staphylococcus aureus isolates from India

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Low level nitrogen laser therapy in pulmonary tuberculosis

BACKGROUND AND AIMS

WHO estimated 9 million new Tuberculosis cases and 1.5 million TB deaths in 2013. Globally 480000 Multi drug resistant tuberculosis cases were noted and majority of them were in India, China and Russian federation. Multi drug resistant tuberculosis cases are difficult to treat and have high mortality. Presently, it was aimed to assess prevalence of drug resistance in M. tuberculosis isolates in Central India, to check the in-vitro effect of N2 Laser on M. tuberculosis and to study the therapeutic effect of intra cavitary N2 laser on pulmonary Tuberculosis cases not responding to chemotherapy.

MATERIALS AND METHODS

Drug sensitivity testing was carried out on 567 isolates of M. tuberculosis by proportion method. To check the effect of N2 laser on M. tuberculosis, suspension spread on LJ plate and part of the plate exposed to N2 laser for 10 min and plate incubated for 4 weeks to see the effect. For exposure to lung cavity a needle was introduced into the lung through which fiber was passed to the cavity for N2 laser irradiation for 10 min.

RESULTS

Only 12.8% isolates of M. tuberculosis were sensitive to all anti-Tubercular drugs and 21.5% were found to be resistant to Rifampicin qualifying definition of Multi drug resistant tuberculosis. Bactericidal effect for N2 laser was seen in-vitro on exposure to N2 laser. Clinical improvement occurred in 90% of the 96 patients; 60% of the patients showed improvement on their X-rays and 75% turned out to be Acid fast bacilli smear negative in 4 to 15 days.

CONCLUSIONS

Intra-cavitory N2 laser therapy was found to have remarkable success as an adjunct to chemotherapy.

A simple and economical in-house phage technique for the rapid detection of rifampin, isoniazid, ethambutol, streptomycin, and ciprofloxacin drug resistance in Mycobacterium tuberculosis, directly on decontaminated sputum samples

OBJECTIVES

The early detection of drug resistance would be a boon for TB control programs. The aim of the present study was to set up a rapid phage assay for the testing of drug susceptibility of Mycobacterium tuberculosis to rifampin, isoniazid, ethambutol, streptomycin, and ciprofloxacin, directly on decontaminated sputum samples.

METHODS

Mueller-Hinton broth was used instead of 7H9 broth to make the method more economical. Vancomycin and polymyxin B were added to the concentrated sputum samples to reduce the bacterial contamination. The phage assay on decontaminated sputum samples was compared with the proportion method using M. tuberculosis isolates from the same sputum samples.

RESULTS

Phage assay results were available within 48h for rifampin and streptomycin and within 72h for all the other drugs. In contrast the proportion method required 4-6 weeks from the primary cultures. The sensitivity of the phage assay was in the range of 93% to 100% and specificity in the range of 96% to 100% for all the drugs tested. The interpretation of results was possible for 334 of the 370 (90.3%) acid-fast bacillus (AFB) smear-positive sputum samples by the phage assay.

CONCLUSIONS

The phage assay for the detection of drug resistance on direct decontaminated sputum samples is economical, easy to perform, and rapid.

Incidence of ESBL producers amongst Gram-negative bacilli isolated from intra-abdominal infections across India (based on SMART study, 2007 data)

OBJECTIVES

This study was conducted in 9 centers spread over India from January 1 to December 31, 2007 to monitor in vitro susceptibility of Gram-negative bacilli to Group I carbapenem, ertapenem and other antimicrobials in intra-abdominal infections and to identify early changes in susceptibility pattern of community or hospital acquired organisms, with a focus on ESBL producers.

MATERIAL AND METHODS

Gram-negative bacilli isolated from intra-abdominal samples of patients with documented intra-abdominal infections were processed for identification by conventional/ automated methods and antimicrobial susceptibility by Micro-Scan (Siemens) MIC panel against 12 antimicrobials (3rd and 4th generation cephalosporins, Groups I and II carbapenems, amikacin, levofloxacin, amoxicillin-clavulanic acid and piperacillin-tazobactam).

RESULTS

A total of 588 isolates were identified, of which 351 (60%) were E. coli and 114 (19%) were Klebsiella spp. 79% of E. coli and 70% of Klebsiella spp. were ESBL producers in general. 110 of E. coli and 35 of Klebsiella isolates were from community-acquired intra-abdominal infections. 80% of E. coli and 63% of Klebsiella isolates from community-acquired infections were ESBL producers, against 79% of E. coli and 73% of Klebsiella isolates from hospital-acquired infections. Amongst the ESBL-positive isolates of E. coli, 94% were susceptible in vitro to ertapenem, 96% to imipenem and 76% to piperacillin-tazobactam. For ESBL-positive isolates of Klebsiella spp., the corresponding figures were 80%, 94% and 59% respectively.

CONCLUSION

The study showed a high incidence of ESBL-producers amongst Enterobacteriaceae isolates from intra-abdominal infections in both community-acquired and hospital-acquired settings across India. Ertapenem was comparable with imipenem against ESBL-positive E. coli isolates, while imipenem was more effective than ertapenem against ESBL-positive Klebsiella isolates.

Evaluation of whole blood IFNgamma test using PPD and recombinant antigen challenge for diagnosis of pulmonary and extra-pulmonary tuberculosis

Quantiferon TB gold (QFT-G) with recombinant antigen cocktail is well evaluated for diagnosis of pulmonary tuberculosis (PTB). However, diagnosis of extra-pulmonary tuberculosis (EPTB) is more difficult due to limitations of conventional techniques. This study compares recombinant antigens based QFT-G and low cost PPD based interferon test for the diagnosis of PTB and EPTB. IFNgamma release, with recombinant antigens and PPD, was assayed by ELISA from 140 cases of EPTB, 100 cases of PTB along with acid fast bacillus (AFB) detection, AFB culture on LJ and MGIT BACTEC. Sensitivity and specificity for QFT-G recombinant antigens was 84.29% and 96%, while for PPD based interferon was 70% and 84% for EPTB group. The sensitivity was far superior to AFB smear and culture for both the antigens. Nine samples were identified as non-tubercular mycobacteria (NTM) in the EPTB group and all were negative for QFT-G, but six of them were positive for PPD based test. Results of the study show that QFT-G using recombinant antigen is sensitive and specific for both PTB and EPTB diagnosis. The PPD based test is economic and offers comparable performance for PTB and EPTB diagnosis and also useful for diagnosis of NTM.

Chikungunya infection in neonates

We describe two neonates in whom chikungunya infection was confirmed by RNA PCR. Important clinical features include apnea, fever, erythematous maculo-papular rash and generalized hyperpigmentation.

Chronic knee monoarthritis caused by Mycobacterium chelonae

Extrapulmonary tuberculosis occurs in 20% of all patients with tuberculosis and tubercular arthritis occurs in 10% of those with extrapulmonary tuberculosis. Arthritis caused by Mycobacterium tuberculosis is not uncommon in India. However, arthritis caused by Mycobacterium chelonae has not been reported to the best of our knowledge. We report a patient with arthritis caused by Mycobacterium chelonae in whom the diagnosis was confirmed by smear and culture of acid-fast bacilli. Polymerase chain reaction of the synovial fluid using IS6110 was negative.

Role of cancer antigen-125 from pleural & ascitic fluid samples in non malignant conditions

BACKGROUND & OBJECTIVE

CA-125, an ovarian tumor marker is known to increase in non malignant conditions such as tubercular and non tubercular pleuritis and ascites. We undertook this study to evaluate non-specific rise in CA-125 levels in conditions associated with pleural effusion and ascites and also to understand the mechanism of its secretion.

METHODS

CA-125 levels in 38 pleural and 46 ascitic fluid samples from non malignant cases and 10 blood samples from pulmonary tuberculosis cases were estimated by ELISA. The ascitic fluid samples were collected from cases of bacterial peritonitis, tuberculosis, hepatitis, cirrhosis of other aetiology and pleural fluid samples were from cases of tubercular, pyogenic, cardiomegaly and other conditions.

RESULTS

Both ascitic and pleural fluid samples (transudative and exudative) showed elevated CA- 125 levels. The CA-125 levels were significantly higher in ascitic fluid samples than in pleural fluid samples.

INTERPRETATION & CONCLUSION

Our findings showed that elevated levels of CA-125 in pleural and ascitic fluid could be because of varied aetiologies which need to be ruled out before considering malignancy. Peritoneum has a greater capacity to secrete CA-125 than the pleural epithelium and the secretion occurs following inflammation or mechanical distress. Pulmonary tuberculosis as a closed lesion without involvement of pleural epithelium does not evoke high CA-125 release.

In vitro Susceptibility to Meropenem and Other Antimicrobial Agents among Gram-Negative Bacilli Isolated from Hospitalized Patients in Central India

BACKGROUND

Growing multiple drug resistance among gram-negative bacilli among hospitalized patients is a serious therapeutic problem, and the aim of the study was to assess the situation in our hospital.

METHODS

Antimicrobial susceptibility testing with the disk method was carried out on 1,533 isolates of gram-negative bacilli from urine, pus, body fluid and blood from hospitalized patients.

RESULTS

Seventeen percent of isolates were susceptible only to meropenem and either to piperacillin + tazobactam, to cefoperazone + sulbactam or to both. Eleven percent of isolates were susceptible only to meropenem and 6% were resistant to all antimicrobial agents including meropenem.

CONCLUSION

Growing multiple drug resistance among gram-negative bacilli in hospital practice demands a rigid antibiotic policy and strict infection control measures.

Elisa kit evaluation for IGG and IGM antibodies to A-60 tubercular protein antigen

AIMS

The purpose of this study is to evaluate the A-60 antigen-based enzyme-linked immuno sorbent assay (ELISA) test for its sensitivity, specificity, and other related statistical parameters.

SETTINGS AND DESIGN

Sera from 114 healthy volunteers, 105 bacteriologically confirmed cases of pulmonary tuberculosis (PTB), 59 sera from family contacts of PTB, and 40 sera from cases of lung infections other than tuberculosis collected from September to December 2003 were used for the kit evaluation.

METHODS AND MATERIALS

Enzyme-linked immuno sorbent assay test using tuberculosis A-60 antigen-based kit manufactured by Anda Biologicals, France was used for the evaluation.

STATISTICAL ANALYSIS

Differences in the optical density (OD) values for immunoglobulins G (IgG), and immunoglobulins M (IgM) antibodies in various groups were studied using t-test.

RESULTS

On the basis of the findings the threshold value was setup as 400 U for IgG and mean OD for sera from healthy volunteers +2SD as the threshold for IgM. The sensitivity was 80% and specificity 95.8% for the IgG antibody test. The efficiency and predictive values were also high. The sensitivity for IgM was low (28.5%) but the specificity was high (95.7%). None of the 40 nontubercular lung infection cases were positive for the IgG and IgM antibody test for A-60, whereas five and three cases of 59 family contacts of PTB were positive for IgG and IgM antibody test. The test reproducibility was good for both IgG and IgM.

CONCLUSION

IgG antibody test using A-60 antigen has good sensitivity and specificity, whereas IgM antibody test had high specificity but low sensitivity. Multicentric trials suggested evaluation of the diagnostic utility of the test for the extra-PTB.

Biomedical waste in laboratory medicine: audit and management

Pathology, microbiology, blood bank and other diagnostic laboratories generate sizable amount of biomedical waste (BMW). The audit of the BMW is required for planning proper strategies. The audit in our laboratory revealed 8 kgs anatomical waste, 600 kgs microbiology waste, 220 kgs waste sharps, 15 kgs soiled waste, 111 kgs solid waste, 480 litres liquid waste along with 33,000 litres per month liquid waste generated from labware washing and laboratory cleaning and 162 litres of chemical waste per month. Section wise details are described in the text. Needle sharps are collected in puncture proof containers and the needles autoclaved before sending to needle pit. The glass forms the major sharp category and is disinfected with hypochlorite before washing/recycling. All microbiology waste along with containers/plates/tubes are autoclaved before recycling/disposal. The problem of formalin fixed anatomical waste as histology specimens is pointed out. The formalin containing tissues cannot be sent for incineration for the fear of toxic gas release and the guidelines by the Biomedical waste rule makers need to be amended for the issue. The discarded/infected blood units in blood bank need to be autoclaved before disposal since chemical treatments are difficult or inefficient. The liquid waste management needs more attention and effluent treatment facility needs to be viewed seriously for hospital in general. The segregation of waste at source is the key step and reduction, reuse and recycling should be considered in proper perspectives.

Elisa kit evaluation for IGG and IGM antibodies to A-60 tubercular protein antigen

AIMS

The purpose of this study is to evaluate the A-60 antigen-based enzyme-linked immuno sorbent assay (ELISA) test for its sensitivity, specificity, and other related statistical parameters.

SETTINGS AND DESIGN

Sera from 114 healthy volunteers, 105 bacteriologically confirmed cases of pulmonary tuberculosis (PTB), 59 sera from family contacts of PTB, and 40 sera from cases of lung infections other than tuberculosis collected from September to December 2003 were used for the kit evaluation.

METHODS AND MATERIALS

Enzyme-linked immuno sorbent assay test using tuberculosis A-60 antigen-based kit manufactured by Anda Biologicals, France was used for the evaluation.

STATISTICAL ANALYSIS

Differences in the optical density (OD) values for immunoglobulins G (IgG), and immunoglobulins M (IgM) antibodies in various groups were studied using t-test.

RESULTS

On the basis of the findings the threshold value was setup as 400 U for IgG and mean OD for sera from healthy volunteers +2SD as the threshold for IgM. The sensitivity was 80% and specificity 95.8% for the IgG antibody test. The efficiency and predictive values were also high. The sensitivity for IgM was low (28.5%) but the specificity was high (95.7%). None of the 40 nontubercular lung infection cases were positive for the IgG and IgM antibody test for A-60, whereas five and three cases of 59 family contacts of PTB were positive for IgG and IgM antibody test. The test reproducibility was good for both IgG and IgM.

CONCLUSION

IgG antibody test using A-60 antigen has good sensitivity and specificity, whereas IgM antibody test had high specificity but low sensitivity. Multicentric trials suggested evaluation of the diagnostic utility of the test for the extra-PTB.

Modified blood supplemented Lowenstein Jensen medium improves recovery of mycobacteria from sputum samples

Lowenstein Jensen medium containing 3% human blood in CPDA anticoagulant was compared with plain LJ medium for mycobacterial growth using 565 sputum samples. Mycobacterial growth appeared on both the media in case of 148 samples. However, growth was faster by one week and colony size larger over blood supplemented LJ in 53 of the 145 culture positives. Additional 12 samples which showed no growth on plain LJ could grow only on LJ supplemented with blood. While 3 samples revealed scanty growth on plain LJ alone. The experience suggests that two LJ slants; one plain and the other supplemented with blood be in inoculated routinely to increase speed of growth and recovery of mycobacteria from clinical samples.

Bacterial population changes in hospital effluent treatment plant in central India

Hospital effluent with its high content of multidrug resistant (MDR) enterobacteria and the presence of enteric pathogens could pose a grave problem for the community. It was planned at our tertiary care hospital in central India to study the population changes at various steps of effluent treatment plant (ETP) like collection, aeration, clarification, liquid sludge, dried sludge, high-pressure filter and treated wastewater. The study included viable bacterial counts, coliform counts, staphylococcal, enterococcal, Pseudomonas and multiple drug resistant (MDR) gram negative bacterial counts in the different stages of ETP. In order to study the distribution of bacteria as free floating in liquid and adherent to suspended particles, enumeration of the bacteria in the filterate and the sediment was also carried out. The effluent input showed 55% of the 8.6 x 10(6)/ml bacteria as coliforms and E. coli which was a typical of fecal flora. The prevalence of MDR coliforms was 0.26%. The substantial reduction (> 3log) was seen for the effluent coming from the clarifier. The bulk of the bacteria in the hospital effluent remains firmly adhered to solid particles; aeration and clarification removes bulk of the bacteria by physical processes like flocculation. The treated liquid effluent still contains sizeable loads of MDR bacteria and inactivation by procedure such as chlorination is required. The bacteria get concentrated in sludge and a greater concentration of chlorine is required for decontamination.

Current status of drug resistance among gram-negative bacilli isolated from admitted cases in a tertiary care centre

AIMS

To study the prevalence of drug resistance among gram-negative bacilli and susceptibility to the Cefoperazone + Sulbactam and Piperacillin + Tazobactam combination among the hospital isolates resistant to all other antimicrobial agents.

METHODS

A total of 367 gram-negative bacilli isolated from various pathological samples were tested for susceptibility to antimicrobial agent by the disc diffusion technique and 300 isolates of gram-negative bacilli which were resistant to all the other antibiotics were checked for sensitivity to piperacillin + tazobactam and cefoperazone + sulbactam combination.

RESULTS

Resistance to ampicillin and amoxicillin + clavulanic acid ranged from (72.1-83.8%) which was highest. Resistance to cotrimoxazole, gentamicin, netilmycin, quinolones and all the generation of cephalsporins was often above 50%. piperacillin + tazobactam combination had the lowest incidence of resistance (14 to 20.5%).

CONCLUSION

Drug resistance for most of the antimicrobial agents was greater than 50% including the various generations of cephalosporins. Inefficiency of amoxicillin + clavulanic acid (resistance among 72-79.5% isolates) suggests the presence of extended spectrum beta-lactamases among the isolates. Addition of sulbactam to cefoperazone showed increased activity (resistance 27 to 34%) but piperacillin + tazobactam was the most effective combination in vitro.

Hypochlorite (1%) is inefficient in decontaminating blood containing hypodermic needles

Infectious biomedical waste and sharps have a potential hazard of transmission of pathogens. Among sharps, used needles form a major share and disinfection by 1 % hypochlorite is recommended in biomedical waste management rules of India. The aim of the present study was to evaluate the efficacy of hypochlorite for the decontamination of needles. Needles (16 g) filled with suspensions of standard strains and clinical isolates of gram positive and gram negative bacteria in plain normal saline and in human blood containing anticoagulant, were exposed to 1% hypochlorite and the surviving bacteria were subjected to viable counts. The observations indicated that 85 - 90 % of the needles filled with bacterial suspensions in saline are disinfected to a level of > 5 log bacterial reduction (standard disinfection) on exposure to hypochlorite but only 15 to 30% needles contaminated with the challenge bacteria suspended in blood showed > 5 log reduction in viable counts. Thus, hypochlorite treatment is inadequate for disinfecting needles contaminated with pathogenic bacteria in presence of blood and should not be recommended as an option for disinfection of the needles.

Prevalence of fungal meningitis among HIV positive & negative subjects in Indore (MP state)

The aim of the study was to find out the prevalence of fungal meningitis among AIDS cases and to assess the prognosis of fungal meningitis among HIV positive & negative subjects. The study comprised of 15 & 10 cases of fungal meningitis among HIV positive & negative subjects respectively during the study period 1992-2001. India ink preparation and Gram's staining procedures were carried out on the centrifuged CSF deposits. The CSF deposits were also used for bacterial and fungal culture. In the present study the prevalence of fungal meningitis was noted among 15 (3.1%) of 483 AIDS cases. Twelve of them had cryptococcal meningitis while 3 were infected with Candida albicans. Four AIDS cases presented fungal meningitis as a primary opportunistic infection and HIV status was confirmed in 4 of them after the diagnosis of fungal meningitis. 13 of the 15 cases were in the age group 26-40 yrs while one was 55 yrs old and the other 16 month old child; these two cases had blood transfusion transmitted and vertically transmitted mode of HIV transmission respectively. Further, only two of 15 cases were females and both acquired HIV infection through blood transfusion. Overall prognosis of fungal meningitis was poor among HIV positives and 7 of the 15 cases died in hospital within 2-3 weeks after diagnosis of cryptococcal meningitis. Among HIV negative subjects, ten cases of fungal meningitis (3 with Candida albicans and 7 with Cryptococcous neoformans) were noted at our end and nine of them had immunocompromised status (3 cases of renal transplant on immunosuppressives, 3 cases neonates/infant and 2 diabetic subjects. The fungal meningitis is one of the important causes of morbidity & mortality among immunocompromised among HIV positive subjects.

Drug resistance among tubercle bacilli from pulmonary tuberculosis cases in central India

An estimate of drug resistance is extremely important in the epidemiology and control of tuberculosis. Data on drug resistance among mycobacterial isolates from sputum samples analysed at Microbiology dept. of Choithram Hospital and Research Centre, Indore, M.P. is presented here. Drug sensitivity testing was carried out on 1426 Mycobacterial isolates by the method of proportion using critical concentration in Lowenstein Jensen medium. Resistance for Isoniazid, streptomycin, and pyrazinamide was found to be high (54.2%, 41.5% and 50% respectively) and was followed by resistance to rifampin (25%) and ethambutol (22%). Resistance for kanamycin, p-aminosalicylic acid, thiacetazone and ciprofloxacin was much lower (18%, 13%, 6.5% and 3.6% respectively). Only 12% of the isolates were sensitive to all the anti-TB drugs while resistance to two, three, and four or more drugs was in the range of 20-25%. Pattern wise, simultaneous resistance to INF and Rifampin with or without resistance to other drugs was observed in 8.1% while resistance for Isoniazid + pyrazinamide and Isoniazid + streptomycin was 11.9 and 11.5% respectively. Resistance for Isoniazid + ethambutol was the lowest (5.1%). Growing multiple drug resistance among tubercle bacilli warrant urgent attention in tuberculosis control programme.

Viral hepatitis during pregnancy

OBJECTIVE

A great degree of controversy prevails over the existing reports on the severity and outcome of acute viral hepatitis (AVH) during pregnancy. The present study describes the outcome of AVH associated with pregnancy. A correlation was also assessed for gestation period, viral etiology and outcome of AVH.

METHOD

The serum samples of 273 females with viral hepatitis (age group 18--23 years) were included in the study. Among them, 127 females were pregnant and 146 were non-pregnant cases (as a control group). The sera were screened for seromarkers of the hepatitis A virus (HAV) through to the hepatitis E virus (HEV) by the latest available generation ELISA kits. Among the 127 pregnant females, 83 were AVH cases, while 44 were fulminant hepatic failure (FHF) cases. Among the 146 non-pregnant females, 129 were AVH and 17 were FHF cases.

RESULT

Among the AVH pregnant females, 73 (57.5%) had HEV infection. Fifty-eight percent of the HEV infected pregnant females were associated with FHF. Among non-pregnant females HEV was documented in 67 (46%) cases. HBV infection was observed in 19% and 18% of the pregnant and non-pregnant females, respectively. Twenty percent of the pregnant and 33% of the non-pregnant females remained non-reactive for seromarkers of HAV-HEV. The mortality rate was highest (56%) among HEV infected FHF cases during third trimester of pregnancy. The chi(2) test was applied to check the statistical significance for the differences over the prevalence in various groups.

CONCLUSION

In the present study, HEV was found to be the chief etiological agent, associated with higher morbidity and mortality. However, the incidence of HEV in pregnant females was not significantly different from non-pregnant females. The prevalence of HAV, HCV and HDV were very low in the study. An increased incidence of FHF was noted among HEV infected pregnant females, while infection with an agent other than A-E was commonly associated with FHF among non-pregnant females.

Smears from rat liver suspension as modified substrate for antinuclear antibody test

Immunofluorescence still remains a standard method for documenting antinuclear antibodies (ANA). Cryostat cut sections of rodent liver or Hep2 cell nuclei have been used as substrate in the test but are often difficult to arrange in laboratories in developing countries. Hence, a modification was developed using smears from rat liver suspensions. The smears were compared with the cryostat cut sections over 338 sera samples of suspected cases of collagen diseases, rheumatoid arthritis, thyroid disorders, hepatitis B, enteric fever, tuberculosis and normal subjects. The sera from suspected collagen diseases cases were also compared with ANA test using Hep2 cells. The modified smear technique was well comparable and the clarity of the immunofluorescence was even better than for cryostat cut sections. Using the modified smear technique 272 sera out of 2,851 sera gave positive test for ANA. The homogenous, speckled and peripheral patterns were seen for 203, 66 and 3 samples respectively. To conclude: The smears prepared from homogenised rat liver suspension and fixed like bacterial smears offer a very convenient and reliable tissue substrate for ANA test.

Studies on blood factors responsible for rise in ESR

Rise in ESR following inflammation processes is well known. However, the exact factors in blood responsible for the rise remain largely unknown. The present experimental work on mixing of plasma from pulmonary tuberculosis cases with RBCs from healthy volunteers indicates that ESR rising properties reside in plasma and not in RBCs. Levels of C-reactive proteins (CRP) are also known to rise following inflammation and hence CRP could contribute to rise in ESR. However, absorption of C-reactive protein from the plasma does not reduce the ESR and suggests that C-reactive proteins are not directly involved in raising ESR. Further experimental work was carried out to see whether cytokines released by mononuclear cells are responsible. However, cell culture supernatants added to whole blood samples did not cause rise in ESR. The ESR rising substances in plasma were non-dialysable and thus were of larger molecular weight.

Acridine orange stained blood wet mounts for fluorescent detection of malaria

The age old Romanowsky stained thick blood smear examination for malarial parasites may fail to reveal the low parasitaemia. The commercial 'QBC' like acridine orange stained capillary tube preparation has a limitation of precise species identification and the detection of extra-erythrocytic parasites. Hence, the present study was aimed to improve malarial parasite detection by using acridine orange to stain large blood drops in the form of wet coverglass mounts. The acridine orange stained blood wet mounts over 2420 suspected malaria cases from Indore city were examined under fluorescent microscope and the results compared with the Leishman's stained thick blood smears in a blind study. The positivity of malarial parasites reported by the modified acridine orange staining was 248 against 109 by Leishman's stained thick blood smears. The modified acridine orange stained method is simple, instant and more efficient, requires less scanning time and skill, allows scanning of larger blood volume (75 ul) at lower magnification and the morphological details at higher magnification helps to make the precise species identification.

Prevalence of anti-delta antibodies in central India

A total of 238 sera samples from cases of hepatitis, renal failure, thalassaemia, healthy health care workers (HCWs) & asymptomatic HBsAG carriers coming from central India from July 1992 to June 1998, were screened for anti-delta antibodies. Among 238 subjects, 206 were reactive for hepatitis B surface antigen (HBsAg) while 32 were HBsAg non-reactive. The prevalence of anti-delta antibodies was low (1.9%) among 54 patients of acute viral hepatitis (AVH) while it was higher (5.7%) among 52 patients of chronic liver disease (CLD). The anti-delta antibodies positivity among 34 patients with hepatic failure was around 15% and all of them were FHF patients. Among multitransfused subjects such as chronic renal failure (CRF) the prevalence of anti-delta antibodies was low (2.3%). None of the apparently healthy HBsAg reactive HCWs and asymptomatic HBV carriers were reactive for anti-delta antibodies. Similarly anti-delta antibodies could not be detected in HBsAg negative viral hepatitis patients. There is a wide variation in the prevalence of anti-delta antibodies in different parts of India. However, overall prevalence of anti-delta antibodies appears to be lower in the Indian population in comparision to western countries.

Emerging bacterial drug resistance in hospital practice

The growing multiple drug resistance among bacteria in hospital practice is posing a serious threat to the successful antimicrobial therapy. Our data on the bacterial drug resistance at a tertiary care centre during 1995-1996 has been alarming with an incidence of 73 to 99% resistance to the common antibiotics like ampicillin, chloramphenicol, cotrimoxazole and first generation cephalosporins among the gram negative isolates. The resistance to gentamicin and ciprofloxacin ranged from 53 to 79%. Resistance to amikacin, netilmicin and the third generation cephalosporins ranged from 30 to 73%. The frightening observation was the emergence of resistant isolates which were sensitive only to two drugs, sensitive only to one drug and resistant to all the available antibiotics (2.64, 17.6 and 11.5% respectively) during 1994 to 1996. Resistance among the gram positive bacteria was much less but the increase in methicillin resistant Staphylococci (52-65%) was a serious matter. The data were an eye opener and the infection control measures could bring marginal improvement in the situation in 1996. It is vehemently appealed that the national antibiotic policies be formed and be stringently implemented before we are thrown back to the pre-antibiotic era.

Haemagglutination system for the simultaneous detection of LPS and anti LPS antibodies of S.typhi

In view of the limitations of Widal test for the diagnosis of typhoid, haemagglutination test using sensitized sheep red blood cells was designed at our laboratory. The test gave only 1.8% positivity at 1:40 dilution among 500 normal persons. Eighteen of the 30 culture proven cases gave the HA test positive while the positivity was 62.5% among suspected cases of typhoid. Thus, the anti LPS haemagglutination test showed a sensitivity of 60% and specificity of 98.2%. The positive predictive value and negative predictive value were 66.66% and 96.7% respectively. The haemagglutination inhibition test was also developed for the detection of LPS antigen of S. typhi in the serum samples of typhoid cases and could detect 1.5625 micrograms/ mL of S. typhi LPS antigen but failed to detect LPS in the sera of bacteriologically proven cases of typhoid. However, it could detect the growth of simulated blood cultures of S. typhi within one hour of inoculation and did not give any cross reactions with other bacterial cultures. The data suggest that the haemagglutination test could be a good adjunct for Widal test and the haemagglutination inhibition test could help the early detection of S. typhi in culture.

100 years of Widal test & its reappraisal in an endemic area

A reappraisal of the Widal test was made for its diagnostic utility in typhoid fever in an endemic area of Central India. The significant basal antibody level in the normal population based on 1200 voluntary/relative blood donors at the cut-off titre of 80 or above was observed in 13.83 and 8.0 per cent for 'O' and 'H' antigens of Salmonella typhi respectively. A retrospective study (1991-1995) over 138 bacteriologically proven cases of typhoid showed a positivity of 64.49 and 78.26 per cent respectively for 'O' and 'H' antibodies at the titre of 80 or above and 44.2 and 63.04 per cent at the titre of 160 and above. The retrospective data also showed a greater positivity (46.41%) in 1991 which decreased to 25 per cent in 1995 and appeared to follow the incidence of multi drug resistant S. typhi over the period. The detection of 'H' antibodies is no less important than the 'O' antibodies in the present study. Our data bring out the diagnostic limitations of Widal test done on single samples collected in the early phase of illness (4-10 days) from patients suspected to have typhoid in an endemic area of Central India.

Aetiology and prognostic factors in hepatic failure in central India

The present study was undertaken to establish the aetiology and prognostic factors of liver failure in central India. Of the 122 cases of hepatic failure 95 (78%), 19 (15.5%) and 8 (6.5%) were labelled as fulminant hepatic failure (FHF), chronic hepatic failure (CHF) and subacute hepatic failure (SAHF) respectively. Hepatitis E virus (HEV) and hepatitis B virus (HBV) were aetiological agents amongst 41% (n = 39) and 37% (n = 35) patients with FHF respectively. Mixed infection among such cases even though observed was infrequent and 15% (n = 14) of FHF did not have any serological markers. They were presumed to be due to non A-E viral infection. Thirty-one (33%) of the FHF patients were pregnant and 29 (94%) of them were due to HEV. Amongst patients with SAHF and CHF, HBV and HCV were important aetiological agents. The static prognostic risk factors noted in the present study are age above 40 years, presence of identifiable viral aetiology (A to E), alcoholic status in males and pregnancy particularly in the third trimester or postpartum state. Among the dynamic factors, bilirubin level above 20 mg/dl and prothrombin time over 20 seconds appeared to be the risk factors.

Antibiogram study over bacterial isolates from cases of bacteraemias

During January, 1994 to December, 1994, 703 of the 1778 blood specimen were positive for blood culture and 59.9% of the isolates were of staphylococci. Thirty two percent of the staphylococci were methicillin resistant. Netilmycin showed the lowest in vitro resistance among Gram positive cocci & Klebsiella species. Netilmycin, amikacin, ciprafloxacin and the third generation cephalosporins in general showed greater in vitro sensitivity among gram negative bacilli. The netilmycin had the lowest incidence of drug resistance based on the pooled data over the blood culture.

Prevalence of anti-HCV antibodies in central India

The study group screened for anti-HCV comprised 789 subjects of hepatitis, renal failure, thalassaemia and healthy voluntary blood donors coming from Central India during July 1992 to November 1995. The prevalence of HCV was low (4.85%) among 103 patients of acute viral hepatitis (AVH) while it was higher (25.64%) among 117 patients of chronic liver disease (CLD) with the highest rate of 31.57 percent in 57 patients of cirrhosis. The anti-HCV positivity among 101 patients with hepatic failure was around 10 percent. High risk groups such as chronic renal failure (CRF) patients mainly on haemodialysis and thalassaemics receiving multiple blood transfusions showed the prevalence of anti-HCV in 41.9 and 25.45 percent respectively. Only 1.78 percent of the 280 voluntary blood donors showed positivity for anti-HCV. Comparison of the data on HCV in the present study with data from other parts of India showed a wide variation in the different centers. The higher prevalence of HCV among CRF patients and thalassaemics indicates the need for screening of the blood units for anti-HCV before transfusion to these high risk patients.

Immunogenicity of low dose hepatitis B vaccine by the intradermal route & persistence of anti-HBs after three years

Plasma derived hepatitis B vaccine given intradermally (0.2 ml; 4 micrograms HBsAg) at 0, 1, 6 months to 200 health care workers, produced seroconversion in 97.5 per cent. Antibody levels to hepatitis B surface antigen (anti-HBs) crossed 1000 mIU/ml in 62 per cent while 26.5 per cent had levels of 100 to 1000 mIU/ml. Anti-HBs levels persisted in the same range in 41.7 per cent but dropped by a log in 58.3 per cent subjects at the end of 3 yr. Protective antibodies above 10 mIU/ml were documented in 93.3 per cent vaccinees after 3 yr. The 0.2 ml vaccine by intradermal (id) route was also found to give a good booster effect in another group of 27 persons who had received full dose vaccine 5 yr earlier. Thus, 0.2 ml vaccine by id route was safe, gave high seroconversion and persistent antibody levels over 3 yr and could offer effective protection at an economic cost.