Anil K. Saxena

Sudden irreversible sensory-neural hearing loss in a patient with diabetes receiving amikacin as an antibiotic-heparin lock.

Gram‐negative septicemia due to central venous catheter‐related infection is a leading cause of mortality and morbidity among patients who undergo hemodialysis. Antibiotic‐heparin locks are valuable for preserving access sites and lowering the cost and inconvenience associated with central venous catheter replacement and surgical interventions. The optimal duration of use of an antibiotic‐heparin lock is unknown. Prolonged use of an amikacin‐heparin lock may lead to severe irreversible sensory‐neural hearing loss. Patients at risk for this complication should be monitored for its emergence to facilitate early detection. A 43‐year‐old man with diabetic end‐stage renal disease received hemodialysis through a permanent catheter. After 16 weeks of using an amikacin‐heparin lock, he suddenly developed sensory‐neural hearing loss of 40 dB, which affected high frequencies. His condition progressed relentlessly within 1 week despite immediate discontinuation of the amikacin‐heparin lock. The patient developed severe irreversible hearing loss below 80 dB for both high and low frequencies.

THE IMPACT OF NASAL CARRIAGE OF METHICILLIN-RESISTANT AND METHICILLIN-SUSCEPTIBLE STAPHYLOCOCCUS AUREUS (MRSA & MSSA) ON VASCULAR ACCESS-RELATED SEPTICEMIA AMONG PATIENTS WITH TYPE-II DIABETES ON DIALYSIS

Background: Fairly higher nasal carriage rates among type-II diabetics place them at a greater risk of endogenous Staphylococcus aureus linked vascular access-related septicemia (VRS) that is also dependent on the type of vascular access used for hemodialysis (HD). The prevalence of nasal carriage of methicillin susceptible and methicillin-resistant S. aureus (MSSA and MRSA) and its impact on VRS was determined in order to identify most vulnerable group and plan potential prophylactic strategies, accordingly. Methods: Five standardized nasal swab cultures were performed in 208 patients enrolled for long-term HD through July 1996 to July 1999. Persistent nasal carriage was defined by two or more positive cultures for MSSA or MRSA. Peripheral blood cultures were collected on clinical suspicion of septicemia. Results: The prevalence of type-II diabetes of 28.0% with 72.4% of nasal carriage rate and three folds higher S. aureus related VRS (RR-3.19, p<0.0001) than diabetic non-carriers on HD, was observed. Type-II diabetics also had higher MSSA and MRSA nasal carriage rates (53.4% and 19.0%) than non-diabetic nasal carriers (18.6 and 6.0%) yet, carried a comparable (RR-4.0 vs. 4.5) risk of VRS between MSSA and MRSA nasal carriers. Among diabetic type-II S. aureus nasal carriers, central venous catheters (CVCs) carried 35 and 38 times higher collective risk of developing MSSA and MRSA nasal carriage-related VRS respectively than Arterio-venous fistula (AVF). The AVF recorded the lowest risk of developing MSSA and MRSA nasal carriage-related VRS (0.013 and 0.010 episodes/patient-year) in both diabetic type-II MSSA and MRSA nasal carrier groups. Conclusions: Diabetic type-II S. aureus nasal carriers on HD through CVCs make an extremely high-risk group for MSSA and MRSA nasal carriage-related VRS. The incidence of S. aureus nasal carriage-related VRS could reasonably be reduced through a challenging obligation of optimizing AVF prevalence in this high-risk group, while limiting the use of CVCs, at the same time.

Nosocomial transmission of syphilis during haemodialysis in a developing country

Patients with end-stage renal disease (n =187) secondary to diverse aetiologies who underwent haemodialysis (HD) between November 1996 and November 2000 were routinely screened for syphilis using the rapid plasma reagin (RPR) test and confirmed by means of a microhemagglutination assay for Treponema pallidum. All the confirmed syphilis patients were asymptomatic and were diagnosed serologically. A true seroprevalence of 6.9% (13/187) and a biological false seropositivity of 4.2% (8/187) for syphilis were recorded. Most (11/13) of the true seropositive patients were aged between 51 and 80 y. Whilst 10/13 patients were true syphilis seropositive at the time of first HD, 3/13 patients became true seropositive an average of 12 months (range 10-14 months) after HD. Penicillin treatment was given to all 13 patients simultaneously only after the appearance of 3 new true syphilis seropositive cases. Complete seroreversion was observed in 4/10 patients in the pre-HD true syphilis seropositive group of presumptive transmitters who became RPR-negative, whereas the 3 new true seropositive cases showed a serial 4-fold decline in RPR titres 12 months after penicillin therapy, suggestive of an active disease with adequate therapeutic response. These results clearly indicate that latent syphilis is prevalent in long-term elderly HD patients. The true seroconversion of 3 new patients who had undergone HD for an average of 12 months is indicative of nosocomial transmission and the silently active nature of the disease, which necessitates regular monitoring of syphilis serology among HD patients.