Abida Malik

Clinico-microbiological study and antimicrobial drug resistance profile of diabetic foot infections in North India

The study was carried out in diabetic patients with foot ulcer to determine the microbiological profile of infected ulcer, antibiotic resistance of the isolates and to find out the potential risk factors for infection with multidrug resistance and the outcome of these infections. A detailed clinical history and physical examination was carried out in each patient. Pus samples for bacterial culture were collected from 102 patients admitted with diabetic foot infections. All patients had ulcer with Texas grades 1-3. Seventeen patients (16.6%) had coexisting osteomyelitis. Aerobic gram negative bacilli were tested for extended spectrum β lactamase (ESBL) production by phenotypic and genotypic methods. Staphylococcus isolates were tested for susceptibility to oxacillin and cefoxitin by disk method. Potential risk factors for MDRO positive samples were explored. Gram negative aerobes were most frequently isolated (63.8%), followed by gram positive aerobes (36.1%) and anaerobes (31.4%). Forty five percent of patients were positive for MDROs. ESBL production and methicillin resistant was noted in 68.5% and 43.2% of bacterial isolates respectively. 34.5% gram negative strains were positive for bla(CTX-M) gene followed by bla(SHV) (23%) and bla(TEM) (7.4%). Among the anaerobic organism 17(31.4%) from 54 patients, most commonly isolated were Peptostreptococcus sp. (35.2%). MDRO positive status was associated with the presence of neuropathy (P<0.001), osteomyelitis (P<0.03), and ulcer size >4 cm(2) (P<0.01) [corrected] but not with patients characteristic, ulcer type and type of diabetes, or duration of hospital stay. Poor glycemic control in 68.6% patients, duration of infection>1 month (36.2%) and ulcer size >4 cm(2) (75.4%) were independently associated with risk of MDR organisms infection.

Multidrug‐resistant Pseudomonas aeruginosa strains harbouring R‐plasmids and AmpC β‐lactamases isolated from hospitalised burn patients in a tertiary care hospital of North India

The present study was designed to determine resistance rates and patterns in Pseudomonas aeruginosa isolates obtained from hospitalised burn patients in an Indian tertiary care hospital. To that end, we isolated plasmid(s) from the multidrug-resistant isolates, demonstrated the plasmid-mediated resistance by curing and transformation experiments, and screened all the isolates for the occurrence of AmpC beta-lactamases. Thirty isolates of P. aeruginosa were analysed for the presence of antibiotic resistance. Plasmid-curing experiments and AmpC beta-lactamase detection were performed on all the isolates and seven isolates showing the most common antibiotic resistance pattern were selected for plasmid isolation and transformation experiments. All 30 isolates were multidrug-resistant and the majority (83.3%) of isolates were resistant to seven or more antibiotics, out of 11 antibiotics tested including anti-pseudomonal and non-anti-pseudomonal antimicrobial drugs. The most striking feature was the presence of resistance to amikacin. A 48.5-kb plasmid was isolated from the isolates. Curing and transformation experiments showed that resistance to amikacin was plasmid-mediated. Phenotypic screening for the occurrence of AmpC beta-lactamases showed that 20% of isolates were AmpC producers whereas 10% of isolates were characterised as indeterminate for AmpC enzyme. In conclusion, a markedly high (56.7%) resistance to amikacin was noted in the present study. Amikacin resistance was determined to be plasmid-encoded and the presence of an AmpC beta-lactamase was inferred in 20% of isolates. This is among the first reports regarding the emergence of plasmid-mediated resistance to amikacin and the occurrence of AmpC beta-lactamases in P. aeruginosa strains from India.

Efficacy of tyndalized Lactobacillus acidophilus in acute diarrhea

Objective : A double-blind randomized controlled-trial was done to evaluate the efficacy of tyndalizedLactobacillus acidophilus in acute diarrhea.Methods : All children from 6 months to 12 years with acute diarrhea were included.Lactobacillus acidophilus/placebo was given to the children for 3 days with ORS and feeds. Intake-output was recorded 4 hourly. Of the 98 children, 48 receivedlactobacillus and 50 the placebo.Results : ORS consumed, frequency of stools, duration of diarrhea, time for rehydration, hospital stay, weight gain and IVF needed were comparable in the two study groups. There were 4 treatment failures in thelactobacillus group and none in the placebo group (OR 0.92,95%CI 0.84–0.99). In the rotaviral diarrhea and in those who had diarrhea of less then 60 hours the difference did not reach statistical significance.Conclusion : There is no significant benefit of tyndalizedLactobacillus acidophilus in acute diarrhea.

The diabetic foot infections: Biofilms and antimicrobial resistance

AIMnTo study the difference in antimicrobial resistance profile among biofilm producing and non-producing microorganisms isolated from diabetic foot ulcer in a tertiary care hospital in North India.nnnMETHODOLOGYnWe performed a prospective study on 162 DFU in patients treated in a multidisciplinary based diabetes and endocrinology center of JNMCH, AMU, Aligarh, India during the period of December 2008-March 2011. Detailed history and physical examination was carried out for every subject. Patients profile, grade of DFU, co-morbidities and complications, laboratory data and final outcome were collected. Standard methods of sample collection and identification of microorganism were adopted. Risk factors for biofilm producing infections were determined by univariate analysis with 95% of CI. P value <0.05 were considered as significant.nnnRESULTSnThe overall biofilm producing infection rate among DFU was 67.9%. On univariate analysis, significant risk factors for biofilm producing infection were male sex [P=0.015, OR 2.35, RR 1.71], duration of diabetes [P<0.006, OR 4.0, RR 2.7], duration of ulcer >1 month [P<0.02, OR 2.26, RR 1.72], size of ulcer >4 cm(2) [P<0.05, OR 2.03, RR 1.54], Grade II ulcer [P<0.06, OR 1.87, RR 1.63], necrotic ulcer [P<0.002, OR 5.79, RR 3.59], previous antibiotic use [P<0.007, OR 4.24, RR 2.74], subcutaneous infection [P<0.06, OR 1.87, RR 1.63], HbA1c >7% [P<0.04, OR 3.19, RR1.87] and polymicrobial infection [P<0.001, OR 6.64, RR 3.21] were significant risk factors.nnnCONCLUSIONSnTreating the DFU by shifting from the planktonic model of microbiology to the biofilm model was recommended. With this new scientific approaches along with coordination of clinical and laboratory efforts, education, and research, it is possible to imagine overcoming much of biofilm disease.

Incidence, risk factors for amputation among patients with diabetic foot ulcer in a North Indian tertiary care hospital

OBJECTIVEnAim of this study was to evaluate the incidence and risk factors for amputation among patients with diabetic foot ulcer (DFU).nnnRESEARCH DESIGN AND METHODSnWe performed a prospective study of 162 DFU in patients treated in a multidisciplinary based diabetes and endocrinology centre of Jawaharlal Nehru Medical College of Aligarh Muslim University, Aligarh, India during the period of December 2008-March 2011. Detailed history and physical examination was carried out for every subject. Risk factors for amputation were determined by univariate analysis with 95% of CI.nnnRESULTSnThe overall amputation rate was 28.4%. On univariate analysis, male sex [OR 2.8, RR 1.28], hypertension [OR 2.83, RR 1.31], neuropathy [OR 3.01, RR 1.35], nephropathy [OR 2.24, RR 1.26], LDL-C (>100mg/dl) [OR 2.53, RR 1.28], total cholesterol (>150mg/dl) [OR 3.74, RR 1.52],HDLC(<40mg/dl) [OR 1.19, RR 1.18], triglycerides (>200mg/dl) [OR 5.44, RR1.76], previous antibiotic use [OR 9.12, RR 1.92], osteomyelitis [OR 6.97, RR 2.43] and biofilm infection [OR 4.52, RR 1.41] were significant risk factors.nnnCONCLUSIONnThe risk factors for amputation were presence of PVD, leukocytosis, neuropathy, nephropathy, hypertension, dyslipidemia, over use of antibiotics, osteomyelitis, biofilm production and higher grade of ulcer.

25-Hydroxyvitamin D [25(OH)D] levels and diabetic foot ulcer: Is there any relationship?

AIMSnIn recent years, there has been an effort to understand possible roles of 25(OH)D, including its role in the immune system particularly on T cell medicated immunity, pancreatic insulin secretion and insulin action. 25(OH)D stimulates the cell differentiation and reduces cell proliferation, which is essential for cell growth and wound healing. However, data on the association between low level of plasma 25(OH)D and diabetic foot syndrome are scarce.nnnMATERIALS AND METHODSnCirculating plasma levels of 25(OH)D were measured in diabetic patients with ulcer (n=162) and without ulcer (n=162) in a prospective cohort hospital based study.nnnRESULTSnOf these patients, 85.1% had type 2 diabetes. Subjects with diabetic foot ulcer showed lower median plasma level of 25(OH)D [6.3(4.2-11.1) vs 28.0(21.4-37.0)] ng/ml after adjusting the age and BMI. Regardless of the low levels of 25(OH)D in cases and controls, it was associated with neuropathy, sex (female), duration of ulcer healing, and smoking status and independent of confounding factors, including BMI (kg/m²), A1c (%), hypertension, nephropathy, foot ulcer, retinopathy, CAD, PAD, HDL-C (mg/dl) and LDL-C (mg/dl). The factors which predict the risk of developing ulcer independent of 25(OH)D status were A1c (>6.9%) [OR 4.37; RR 1.77], HDL-C (<40mg/dl) [OR 1.16; RR 1.07], LDL-C (>100mg/dl) [OR 1.07; RR 1.03], triglycerides (>200mg/dl) [OR 1.40; RR 1.19], neuropathy [OR 6.88; RR 3.12], retinopathy [OR 3.34; RR 1.91], hypertension [OR 1.64; RR 1.28], nephropathy [OR 3.12; RR 1.87] and smoking [OR 4.53; RR 2.99] using odds and risk ratios.nnnCONCLUSIONnIt is not clear whether the suppression of delayed wound healing seen during 25(OH)D deficiency is due to the secondary effect or is a direct action of vitamin D on certain components of the immune system. Long-term randomized trials are needed to see the impact of vitamin D supplementation on the outcome of diabetic foot patients.

Study of plasmid-mediated extended-spectrum β-lactamase-producing strains of enterobacteriaceae, isolated from diabetic foot infections in a North Indian tertiary-care hospital.

AIMnThis study evaluated the incidence and factors responsible for plasmid-mediated extended-spectrum β-lactamase (ESBL) infection among patients with diabetic foot ulcer (DFU).nnnSUBJECTS AND METHODSnA prospective study was conducted on 162 DFU inpatients treated in a multidisciplinary-based diabetes and endocrinology center at Jawaharlal Nehru Medical College of Aligarh Muslim University, Aligarh, India, during the period of December 2008-March 2011. Detailed history and patients profile, grade of DFU, co-morbidities and complications, laboratory data, and final outcome were collected. Standard methods were used for culture identification, sensitivity testing, and ESBL detection. Polymerase chain reaction for bla genes was performed, and the risk factors for bla gene positivity were determined by univariate analysis with 95% confidence interval.nnnRESULTSnIn total, 127 (78.3%) Enterobacteriaceae members were isolated. The most common isolate was Escherichia coli (71; 55.9%), followed by Klebsiella sp. (33; 25.9%) and Proteus sp. (13; 10.2%). By phenotypic methods, 67.8% were ESBL producers. In the molecular detection of ESBLs, 81.9% were found to be positive for the bla gene, of which bla(CTX-M) showed 81.8% positivity, followed by bla(TEM) (50%) and bla(SHV) (46.9%). In a univariate analysis, bla gene-positive status was associated with low-density lipoprotein-cholesterol (>100u2009mg/dL) (P<0.004, odds ratio 13.4, relative risk 8.65) and triglycerides (>200u2009mg/dL) (P<0.003, odds ratio 6.5, relative risk 4.11).nnnCONCLUSIONnESBL constitutes a major threat to currently available β-lactam therapy, leading to complications in DFUs. Aminoglycosides, cephalosporin, and β-lactam inhibitor drugs would probably be more appropriate empirical agents after establishing the patients history of previous antibiotic use. The detection of ESBL should be done on a routine basis.

Cathepsin-D, adiponectin, TNF-α, IL-6 and hsCRP plasma levels in subjects with diabetic foot and possible correlation with clinical variables: a multicentric study.

Diabetic foot, characterized by a pronounced inflammatory reaction, decreased collagen content and biosynthesis and accelerated degradation are crucial in wound healing. Cathepsin D, an aspartic endopeptidases implicated in cell growth, apoptosis, and its inhibitor has been reported to reverse the inhibition of collagen biosynthesis in wounded rat skin with diabetes. To date, the increased proteolytic activity of Cathepsin D in diabetic foot has not been evaluated and the pathogenic significance of the inflammation has received little attention. Of the patients [with ulcer (n=211) and without ulcer (n=208)], 89.73% had type 2 diabetes. Subjects with diabetic foot ulcer showed higher median plasma level of Cathepsin D [556.3 (312.6-587.3) RFC/ml vs 306.3 (92.6-337.3) RFC/ml], TNF-α [96.6 (79.9-121.5) ng/ml vs 8.4 (7.1-9.20) ng/ml], IL-6 [32.2 (8.52-48.4) ng/ml vs 4.9 (4.5-5.6) ng/ml], hsCRP [12.6 (11.2-14.1) mg/ml vs 3.90 (3.50-4.60) mg/ml] and lower median plasma levels of adiponectin [8.50 (7.10-9.5) ng/ml vs 13.3 (12.1-14.2) ng/ml]. A positive correlation was found between grades of ulcer, BMI, A1c and retinopathy for Cathepsin D, for adiponectin, between grades of ulcer, BMI, retinopathy, nephropathy & smoking, for IL-6, between grades of ulcer, BMI, nephropathy, CAD & smoking, for hsCRP, grades of ulcer, BMI, LDL-C, nephropathy & smoking, while total cholesterol, nephropathy, PAD, smoking and neuropathy for TNF-α.

Comparison of the activities of amphotericin B, itraconazole, and voriconazole against clinical and environmental isolates of Aspergillus species

BACKGROUNDnInvasive fungal infections are a significant cause of morbidity and mortality in immunocompromised populations.nnnAIMSnTo evaluate the susceptibility pattern of our isolates against amphotericin B, itraconazole, and voriconazole and to compare the antifungal activities of these agents with each other against the Aspergillus species tested.nnnSETTINGS AND DESIGNnA prospective study was designed to include clinical and environmental isolates of Aspergillus species.nnnMATERIALS AND METHODSn420 sputum samples, 70 bronchoalveolar lavage fluids, 160 oral washings, and 47 environmental samples were collected. Direct microscopy by potassium hydroxide and lactophenol cotton blue mounts followed by culture on Sabourad`s dextrose agar (SDA) was done. Susceptibility testing was performed by the broth microdilution technique as per Clinical Laboratory Standards Institute standards (M-38A). Additionally, all the isolates were also tested by the colorimetric microdilution technique using Alamar Blue dye.nnnSTATISTICAL ANALYSISnIt was done by the Chi-square test and Z-test using SPSS statistical software version 12.0.nnnRESULTS AND CONCLUSIONnTwenty-seven isolates (47.3%) were recovered from patients with chronic bronchial asthma followed by fibrocavitary pulmonary tuberculosis in 9 (15.7%), allergic bronchopulmonary aspergillosis (ABPA) in 6 cases (10.5%), bronchiectasis in 3 (5.2%), bronchogenic carcinoma in 5 (8.7%) and those receiving radiotherapy for head and neck cancer 7 (12.2%). Thirteen environmental isolates were also included in the study. The most common isolate was A. fumigatus 28 (40%), followed by A. niger 22 (31%), A. flavus 13 (19%), and A. terreus 7(10%). All isolates were susceptible to amphotericin B, itraconazole, and voriconazole. Among the three agents tested, voriconazole exhibited lowest MICs (≤1 μg/ml) against all Aspergillus species.

Occupational exposure to Aspergillus and aflatoxins among food-grain workers in India

Abstract Background: Aflatoxins are a metabolite of Aspergillus molds and are widespread in the natural environment. Workers who handle food grains are at increased risk of exposure to aflatoxins and subsequently certain respiratory conditions. In India, more than half of the employed population is engaged in some type of agricultural work, yet little known about the respiratory problems as a result of exposure to aflatoxins among workers who handle food grains in India. Objectives: The aim of this study was to determine the risk of occupational exposure to aflatoxins in food-grain workers compared to workers who are not occupationally exposed to food grains. Methods: Bronchoalveolar lavage (BAL) and serum samples from 46 food-grain workers and 44 non-food-grain workers were analyzed for the presence of aflatoxins. Microscopy and culture of BAL samples were performed to detect Aspergillus species. Results: Aflatoxins were detected in 32·6% of the food-grain workers and 9·1% of non food grain workers (P<0·01). A significant difference was also found in BAL culture for Aspergillus (P<0·01) between the two groups. About 47·8% of the food-grain workers and 11·4% of non-food-grain workers had chronic respiratory symptoms. Conclusion: Occupational exposure to aflatoxins in food-grain workers was found to be associated with the increased presence of respiratory symptoms.