Archana Thakur

Candiduria in catheterized intensive care unit patients: Emerging microbiological trends

OBJECTIVES Urinary tract infection (UTI) as a result of Candida spp. is becoming increasingly common in hospitalized setting. Clinicians face dilemma in differentiating colonization from true infection and whether to treat candiduria or not. The objective of the present study was to look into the significance of candiduria in catheterized patients admitted in the ICUs and perform microbiological characterization of yeasts to guide treatment protocols. MATERIALS AND METHODS One hundred consecutive isolates of Candida spp. from the urine sample of 70 catheterized patients admitted in the ICU were collected and stocked for further characterization. A proforma was maintained containing demographic and clinical details. Blood cultures were obtained from all these 70 patients and processed. Species identification of yeasts was done on VITEK. RESULTS Candiduria was more common at extremes of age. The mean duration of catheter days was 11.1 ± 6 days. Other associated risk factors such as diabetes mellitus and antibiotic usage were seen in 38% and 100% of our study group. Concomitant candidemia was seen in 4.3% of cases. Non-albicans Candida spp. (71.4%) emerged as the predominant pathogen causing nosocomial UTI. CONCLUSION The present study reiterates the presence of candiduria in catheterized patients, especially in the presence of diabetes and antibiotic usage. Non-albicans Candida spp. are replacing Candida albicans as the predominant pathogen for nosocomial UTI. Hence, we believe that surveillance for nosocomial candiduria should be carried out in hospitalized patients.

Brain Abscess Due to Xylohypha bantiana

A case of brain abscess due to Xylohypha bantiana without any obvious predisposing factors and with the uncommon clinical feature of seizures is presented.A case of brain abscess due to Xylohypha bantiana without any obvious predisposing factors and with the uncommon clinical feature of seizures is presented.

Infection control practices among doctors and nurses in a tertiary care hospital

Background: Basic infection control measures in any healthcare setup can reduce the rates of healthcare-associated infections. A study to assess the knowledge and practice of 400 healthcare personnel regarding hospital infection control practices was performed. Materials and Methods: A structured questionnaire was distributed to the study group and collected the same day. Knowledge and practices of 329 nurses and 71 doctors regarding hand hygiene, SPs, hospital environmental cleaning and needle stick injury were collected and analyzed. Results: The study group had suboptimal knowledge regarding the SPs (55.3%) and risks associated with NSI (31.8%). The implementation of SPs was biased towards the HIV positive status of the patient. Only 57% of the doctors and nurses followed the maximal barrier precautions before a CVC insertion. Discussion: The lack of knowledge and practices regarding basic infection control protocols should be improved by way of educational intervention, in the form of formal training of the doctors and nurses and reinforcement of the same.

Knowledge and attitude of doctors and nurses regarding indication for catheterization and prevention of catheter-associated urinary tract infection in a tertiary care hospital

Background and Aims: Catheter-associated urinary tract infection (CAUTI) is one of the most common health care acquired infection encountered in clinical practice. The present study was planned to assess the knowledge and attitude of health care providers regarding the indications for catheterization and methods of preventing CAUTI. Methods: A prospective questionnaire-based survey was done from March 2011 to August 2011. A structured questionnaire comprising of 41 items related to demographic details of the respondents, their knowledge regarding indications for catheterization and methods of preventing CAUTI was given to 54 doctors and 105 nurses. The response was evaluated for statistical correlation using a computer software. Results: The mean years of experience of the respondents in the health care setup was 6.8 years. Only 57% of the respondents could identify all the measures for prevention of CAUTI. The knowledge regarding the indication for catheterization though suboptimal was significantly better amongst the doctors as compared to nurses. Conclusion: The knowledge regarding indication and preventive measures was suboptimal in our study group. There is a tremendous scope of improvement in catheterization practices in our hospital and education induced intervention would be the most appropriate effort toward reducing the incidence of CAUTI.

Time trends of seroepidemiology of hepatitis C virus and hepatitis B virus coinfection in human immunodeficiency virus-infected patients in a Super Specialty Hospital in New Delhi, India: 2012–2014

Background: Hepatitis viruses and human immunodeficiency virus (HIV) coinfection is a major cause of liver diseases worldwide. High prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) in Asia makes it important to understand HBV and HCV coinfection with HIV in this part of the globe. This study was done with the aim of assessing the time trends of seroepidemiology of HBV and HCV coinfection in HIV patients over the last 3 years. Materials and Methods: Year wise retrospective analysis of data between January 2012 and December 2014 was done. Results: The prevalence of HIV infection among 0–20 years and >60 years age group decreased over the last 3 years (2012–2014), 8.4%, 6.4%, and 3.1% and 3.6%, 3.8%, and 1.5%, respectively. While increasing prevalence was seen among 21–40 years age group, 57.8%, 60.2%, and 67.1%, respectively in 2012, 2013, and 2014. There was no significant relationship between age/gender and HBV/HCV seropositivity among HIV-positive patients. The risk of acquiring HBV infection was more in HIV-positive patients who were >60 years of age (odds ratio = 3.3182; 95% confidence interval: 0.3669–30.005). The prevalence of HCV seropositivity is less in HIV-positive patients as only one case was anti-HCV antibody positive in last 3 years who was a male patient in the age group 21–40 years. A declining trend was observed for HIV positive cases over 2012–2014 while no significant trend change is seen in HBV/HCV seropositivity among HIV patients from 2012 to 2104. Conclusion: It is recommended to screen HIV patients routinely for concurrent HBV/HCV infection as hepatotropic viruses with HIV increase the risk of liver mortalities.

Cryptococcal granulomas in an immunocompromised HIV-negative patient

Disseminated cryptococcosis usually occurs in immunocompromised individuals with defective cell-mediated immunity, most commonly seen with HIV infection. We present a case of disseminated cryptococcosis in an HIV-negative male patient who presented with headache, fever, altered sensorium of short duration and multiple cutaneous lesions. An emergency CT scan of the head showed multiple intracranial and intraventricular granulomas. Routine laboratory investigations were within the normal range. A CSF examination revealed capsulated yeasts on India ink and a culture yielded cryptococcus neoformans. A cryptococcal antigen test by latex agglutination kit was positive. A biopsy revealed multiple capsulated yeasts cells in the cutaneous lesions, which were consistent with cryptococcus neoformans. The patient was successfully treated with Amphotericin B and Fluconazole with regression of cranial and cutaneous lesions.

Candida albicans meningitis with ventriculitis in a four-year-old child

There are also isolated reports of infratentorial hemorrhage following supratentorial surgery and vice-versa.[4-6] The pathophysiology of this entity is poorly understood though various hypotheses have been put forward. Initially it was thought that transient hypertensive peaks during recovery from anesthesia was the causative factor. But recent studies have refuted this theory as only very few patients had documented high blood pressure readings perioperatively, thus suggesting probably surgery itself may be a contributing factor in inducing coagulation abnormalities. It has also been hypothesized that the tissue thromboplastin released from the injured brain tissue in severe TBI leads to a local consumptive coagulopathy. The loss of substantial cerebrospinal fluid (CSF) volume during surgery appears to play a central role in the pathophysiological development of remote site hemorrhage.[1] Suction of the CSF may cause intracranial hypotension. Further reduction of intracranial pressure leads to an increased transluminal venous pressure with subsequent rupture of vessels.[1] Substantial loss of CSF leads to sagging of the cerebellum away from the tentorium and thus stretching of the cerebellar veins with an increase in the transmural pressure or it may be due to jugular vein compression by the transverse process of atlas in extended neck position. [6] Cerebellar “sag” as a result of CSF hypovolemia, causing transient occlusion of superior bridging veins within the posterior fossa and consequent hemorrhagic venous infarction, has been proposed to be the most likely pathophysiological cause of remote cerebellar hemorrhage. The loss of CSF volume within the cisterns and ventricles is likely to draw interstitial fluid into the cerebellar compartment leading to increased venous pressure and venous hemorrhage.

Drug-resistant Gram-negative bacilli in urinary tract infection: A need for strict antibiotic prescription policy

Introduction: The etiology of urinary tract infections (UTIs) and the antibiotic resistance of uropathogens have been changing over the past years. This retrospective study was conducted to survey the resistance pattern of Gram-negative uropathogens to first-line agents for UTIs; this would be helpful for the clinicians to facilitate the empiric treatment and management of patients with UTI and maybe useful for the formulation of guidelines of antibiotic policies. Materials and Methods: Isolated uropathogens were tested against ampicillin-sulbactam, amikacin, ceftriaxone, cefotaxime, cefoperazone, gentamicin, norfloxacin, ofloxacin, piperacillin-tazobactam, and imipenem. Result: A total of 2,146 urine samples were cultured, of which 448 samples were positive for Gram-negative bacilli. The most common Gram-negative isolate was Esherichia coli (52%) followed by Klebsiella pneumoniae (17.6%) and Pseudomonas aeruginosa (12.9%). E. coli was found to be most resistant to ampicillin-sulbactam (90.1%), followed by norfloxacin (76.3%), and most sensitive to imipenem. P. aeruginosa was least resistant to amikacin (27.5%). Overall resistance to imipenem is less than 20% among the Gram-negative uropathogens except Acinetobacter spp. and P. aeruginosa. Conclusion: Ofloxacin and amikacin are recommended as the drugs of choice for the empirical treatment of UTI, whereas specific treatment should be based on the etiological agent isolated in the urine culture. There is a strict need for developing specific guidelines for antibiotic prescriptions for UTI in India.

Prevalence of Carbapenemases and Metallo-β-lactamases in Clinical Isolates of Enterobacter Cloacae.

The emergence of metallo-β-lactamases (MBL’s) in Gram-negative bacilli is increasingly posing a therapeutic threat since the enzymes usually possess a broad hydrolysis profile including carbapenems and extended-spectrum β-lactams [1]. Enterobacter species are among the most common causes of gram-negative health-care associated infections [2]. Resistance to β-lactam antibiotics often complicates the treatment of Enterobacter infections resulting in higher mortality, longer hospitalizations, and higher medical costs [3,4]. The study was undertaken to ascertain the occurrence of carbapenem resistance in E. cloacae. Carbapenem resistance in E. cloacae is unique and various factors such as porin alterations combined with hyperproduction of chromosomal cephalosporinase [5], and production of class A carbapenem- hydrolyzing non metallo-β-lactamases [6] have been described. ESBLs are more difficult to detect in Enterobacter spp. because of AmpC chromosomal enzymes, which are induced by clavulanate, and can then hydrolyse the indicator cephalosporin, thereby masking any synergy arising from inhibition of ESBLs by clavulanate [7]. A total of 68 Enterobacter strains isolated from various clinical samples (blood, ET, drain fluids, pus, others) during a study period of seven months (Feb 2011 to Aug 2011) were included in the study. Species identification was done by the Vitek 2 system. Additional antimicrobial susceptibility testing was done by the Kirby-Bauer disk-diffusion method as per guidelines. The phenotypic methods used for enzyme detection were Disk Combination Test for ESBL’s (Ceftazidime 30μg and Ceftazidime + Clavulanic Acid 30μg + 10μg), Modified Hodge Test for Carbapenemase [8] and Combined Disk Test with EDTA for Metallo-β-lactamases [8]. Sixty eight Enterobacter species were isolated. Out of 68 strains of Enterobacter spp., 40(58.8%) strains of E.cloacae were isolated followed by 25 (36.7%) strains of E.aerogenes. Three strains of E.dissolvens were also isolated [Table/Fig-1]. [Table/Fig-1]: Bar diagram showing number of carbapenem resistant strains of E.cloacae and E.aerogenes Carbapenem resistance was detected in 30 (75%) isolates of E.cloacae and 5 (20%) isolates of E.aerogenes. Majority (40%) of the resistant isolates were from endotracheal secretion. Majority of the patients had undergone surgery under specialties of Gastroenterology or Neurology. The mean time from admission to isolation of carbapenem resistant E. cloacae was 14±5 d. Of the 30 strains of carbapenem resistant E.cloacae, 24 (80%) were seen to produce carbapenemase. Production of metallo-β-lactamases was detected in 20 (83.3%) of the 24 carbapenemase producing strains. The rest 4 carbapenemase producing strains were seen to be negative for metallo-β-lactamases suggesting the presence of KPC like carbapenemase. Also, presence of ESBL’s was seen in only 11 (36.6%) strains. Mortality was higher in patients with Carbapenem resistance (33% vs 26%). MIC of Carbapenem resistant strains ranged from 4-16μg/ml and that in sensitive strains from 0.25-2μg/ml. Maximum sensitivity was seen towards Tigecycline (90.6%), followed by Levofloxacin (54.5%) [Table/Fig-2]. The strains were uniformly resistant to beta-lactams. [Table/Fig-2]: Bar diagram showing percentage of Enterobacter strains sensitive to various antibiotics Repeated nosocomial outbreaks of infections can be attributed to the ability of E.cloacae to spread among patients [9]. In E.cloacae, reduced outer membrane permeability is associated with reduced susceptibilities to β-lactams and some non-β-lactam antibiotics and [5,10] in conjunction with derepression of intrinsic AmpC cephalosporinases [5]. In this study, we have studied the prevalence of carbapenem resistant Enterobacter in our hospital and also the emergence of metallo-β-lactamase producing strains of E.cloacae. The resistant strains showed 0% sensitivity to β-lactam drugs and maximum sensitivity to Tigecycline(90%). This correlates with the in vitro activity of tigecycline against MBL-producing organisms as documented by some other authors [11]. 33% of the patients with carbapenem resistant strains met with a fatal outcome as compared to 26% in patients with carbapenem sensitive strains. Similar effects on patient outcomes were observed in imipenem-resistant isolates of Enterobacteriaceae in some other studies (Marchaim et al.,) [2,12]. The carbapenems are the last resort for the treatment of resistant Enterobacteriaceae. Thus, recent reports on carbapenem -resistant Enterobacteriaceae are a matter of great concern. Emergence of carbapenem resistant Enterobacter cloacae is on the rise with the production of carbapenemase being the predominant cause of carbapenem resistance. With limited therapeutic options, the antibiogram should be the guide for the implementation of antibiotic therapy. Prevention of MDR related infections will aid in the reduction of overall morbidity. Timely detection and compliance to infection control measures is the key to prevention of spread. According to the current recommendations, Cefepime is considered to be the preferred substrate for the detection of ESBL in Enterobacter spp. Due to supply constraints we were unable to comply. DNA finger printing for epidemiological study and further molecular studies need to be done for confirmation.

Patient satisfaction survey of microbiological tests done in G.B. Pant Hospital

PURPOSE Measuring patient satisfaction plays an increasingly important role in the growing push toward healthcare provider accountability. This study seeks to evaluate G.B. Pant Hospital (a North Indian tertiary care centre) patient satisfaction with clinical laboratory services. DESIGN/METHODOLOGY/APPROACH A total of 100 out- and in-patients were randomly selected and interviewed about microbiological services using a standard format, a method which can be easily used to compare patient satisfaction with laboratory services elsewhere. FINDINGS Patients represented all age groups: females and males were balanced. Few were from poor socio-economic backgrounds. Patients do not have problems getting tests done, but the laboratorys inconvenient location caused dissatisfaction. Patients do not have problems communicating with staff, but medical terms are not understood by patients. Hospital cleanliness needs improving, especially toilets, which causes the most patient dissatisfaction. Hospital staff were deemed highly competent and judged to give excellent technical help to patients. The questionnaires financial subscale shows 100 per cent satisfaction because all tests in the microbiology department are free. The overall satisfaction with services stood at 83 per cent. Satisfaction scores for G.B. Pant Hospital appear to be satisfactory. RESEARCH LIMITATIONS/IMPLICATIONS This study does not compare patient satisfaction in two or more hospitals and findings may not be generalisable. PRACTICAL IMPLICATIONS Patient satisfaction surveys are the best way to identify deficiencies and improve hospital services. Repeating studies at six monthly intervals is a useful managerial intervention aimed at delivering and maintaining quality healthcare. ORIGINALITY/VALUE This laboratory satisfaction survey is the first of its kind for government hospitals in India. The survey revealed a positive feedback and helped to identify the areas of concern along with estimating the patient satisfaction scores. This is the best way to identify the areas of deficiencies and improving the services provided by the hospital. The authors feel that repeating such studies at a regular interval of six months would be a useful guide for the managerial interventions.