Aroma Oberoi

Scrub typhus in Punjab: an acute febrile illness with multisystem involvement

Scrub typhus is an important cause of acute febrile illness. This observational study describes the clinical features and complications of the patients diagnosed to have scrub typhus in Christian Medical College & Hospital, Ludhiana, Punjab, India. The diagnosis of scrub typhus was made by using Bioline SD Tsutsugamushi test kit which detects IgM, IgG or IgA antibodies to Orientia tsutsugamushi. Sixty-two patients of scrub typhus were seen during the study period of 1 year. The mean age of the study group was 39.9 years. All the patients presented with fever, and of these 31 (50%) had non-specific symptoms. All others had some complication, namely ARDS/ALI in 18 (29%), neurological involvement in 12 (19.4%), acute kidney injury (AKI) in 16 (25.8%), hypotension in eight (12.9%), thrombocytopenia in 23 (37.1%), hepatitis in 34 (54.8%) and MODS in 19 (30.7%). Eschar was present only in nine patients. Three patients expired due to multi-organ failure, hypotension and metabolic acidosis.

Scrub typhus-an emerging entity: A study from a tertiary care hospital in North India

Scrub typhus is a tropical febrile zoonotic disease caused by Orientia tsutsugamushi of the rickettsial family. These are obligate; intracellular Gram-negative coccobacilli transmitted by the bite of infected mites. It is usually under-diagnosed in India due to its varied and nonspecific clinical presentation, limited awareness, and low index of suspicion among clinicians and lack of diagnostic facilities. This study was planned to monitor the level of scrub typhus-specific antibodies among febrile patients in a tertiary care hospital over a period of 1 year for which a rapid qualitative immunochromatographic assay (Standard Diagnostics, Korea) was introduced for the detection of IgM, IgG and IgA antibodies to O. tsutsugamushi from the serum of suspected febrile patients. A total of 98 out of 772 fever patients (12.69%) tested positive for the presence of antibodies against O. tsutsugamushi. Persistent high-grade fever was the defining characteristic in all the cases with the presence of an eschar in only 10.2% (10/98) of cases. Three patients died during the study period while the rest responded to treatment with doxycycline.

Prevalence and antimicrobial susceptibility patterns of Shigella in stool samples in a tertiary healthcare hospital of Punjab

Background: Shigella is an important cause of invasive dysentery in children and others. The present study was done to study the prevalence, any seasonal variation, distribution among children and adults, and antimicrobial susceptibility pattern of Shigella isolates in stool. Materials and Methods: A retrospective study was conducted over a period of 1 year from June 2011 to June 2012 in the department of microbiology, in a tertiary care hospital in Punjab. Stool specimens from diarrhea/dysentery cases in different age-groups were processed. The specimens were processed by standard microbiological techniques. The suspected colonies of Shigella were identified by standard biochemical tests and serotyping was done by group specific antisera. The susceptibility of all the isolated Shigella species to different antibiotics were done by Kirby-Bauer′s disk diffusion technique as per the Clinical and Laboratory Standards Institute (CLSI) guidelines. Results: Shigella species were isolated from 30 (2.1%) of the total 1,402 stool samples received during the study period. Among these, Shigella flexneri was the predominant species accounting for 57% of isolates, followed by S. sonnei (36%) and S. boydii (7%). Over 70% of Shigella isolates were resistant to two or more drugs including ampicillin, trimethoprim-sulfamethoxazole, and norfloxacin; and 10% Shigella isolates were resistant to chloramphenicol and ceftriaxone during the study period. No resistance was observed to cefoperazone/sulbactam, piperacillin/tazobactam, and imipenem. Conclusions: The results of the study revealed the high prevalence of shigellosis with S. flexneri as the predominant species. The result also suggests that ampicillin, trimethoprim-sulfamethoxazole and norfloxacin should not be used empirically as the first line drugs in the treatment of shigellosis. Periodic analysis and reporting of antibiotic susceptibility is an important measure to check for antibiotic resistance and form appropriate treatment protocols.

Epidemiological and mycological characteristics of candidemia in patients with hematological malignancies attending a tertiary-care center in India

BACKGROUND AND OBJECTIVES We undertook the present study to ascertain the contributing risk factors and explore the epidemiological and mycological characteristics of opportunistic candidemia among patients with hematological malignancies. DESIGN AND SETTINGS Observational cross-sectional study in a tertiary care center. PATIENTS AND METHODS Consecutive patients with hematological malignancies reporting to the collaborating medical and pediatric units with a febrile episode were recruited and screened for candidemia by blood culture. Recovered Candida isolates were speciated and antifungal susceptibility testing was performed as per Clinical and Laboratory Standards Institute guideline (CLSI) guidelines M44-A. Further analysis was done for potential risk factors and compared between culture positive and negative patients. RESULTS Of 150 patients recruited, the majority (n=27) were between 51 and 60 years and the male to female ratio was 1.63:1. Fifteen patients (10%) were culture positive. The culture positivity was significantly higher in acute lymphocytic leukemia (ALL) than in non-ALL patients (p=0.03). There was significant association of candidaemia with leucopenia, chemotherapeutic drugs, corticosteroids and presence of indwelling devices. Duration of disease (p=0.032) and duration of hospitalization (p=0.003) were significantly prolonged in culture positive patients. C. tropicalis was the commonest isolate (46.67%), with non- Candida albicans outnumbering C. albicans in all categories of hematological malignancies (2.75:1). All isolates of C. albicans were uniformly sensitive to all the azoles, but only 50% were sensitive to amphotericin B and none to nystatin and flucytosine. CONCLUSIONS This observational study identifies ALL and chronic lymphocytic leukemia (CLL) as the forms of hematological malignancy predominantly associated with candidemia; specifies risk factors and chemotherapeutic agents predisposing patients towards its occurrence; reports a preponderance of C. tropicalis among the causative agents and finds voriconazole to be the most effective antifungal agent against the recovered isolates. This information could assist in tailoring prophylactic and therapeutic antifungal practices for this infection, according to local epidemiological and mycological characteristics.

PREVALENCE AND DETECTION OF GENOTYPE OF HEPATITIS C VIRUS IN CHRONIC RENAL DISEASE PATIENTS UNDERGOING HAEMODIALYSIS IN TERTIARY CARE HOSPITAL IN PUNJAB

BACKGROUND Hepatitis C Virus (HCV) infection is the commonest blood borne infection among haemodialysis patients. Despite reduction of Hepatitis C prevalence after recognition of the virus and testing of blood products, haemodialysis patients still comprise a high risk group. Hepatitis C Virus is detected on the basis of serology, liver function profile and molecular methods. Genotyping is an important tool in epidemiological study, pathogenesis and reaction to antiviral therapy. MATERIALS AND METHODS The haemodialysed patients with appropriate symptoms were tested for Hepatitis C Virus (HCV) infection, between July 1, 2015 and February 18, 2016. Blood was aseptically collected and processed for detection of Anti-HCV antibody by ELISA in Department of Microbiology, CMC and H, Ludhiana. Quantitative detection of HCV-RNA was done by Real Time Polymerase Chain Reaction (RTPCR) and if this was positive genotyping was done. RESULTS A total of 52 Chronic Renal Disease patients (39 male and 13 female patients) who underwent haemodialysis were tested for HCV RNA, out of which 10 (19.23%) came as positive. In 3 patients Genotyping has result of 2 patients with genotype 1 (66.67%) and 1 patient with genotype 4 (33.33%). Patients with Chronic Renal Disease with HCV infection had received more number of dialysis sessions (biweekly) as compared to those without HCV infection. Currently, Hepatitis C virus is most frequently found in patients with Chronic Renal Disease patients undergoing haemodialysis. The diagnosis of HCV is confirmed by detection of HCV-RNA by Polymerase Chain Reaction. CONCLUSION In the present study, it was seen that duration and frequency of dialysis is significantly longer among HCV positive patients as compared to HCV negative patients. Attention should be given to strict adherence to infection control measures in dialysis setting.

Clostridium difficile associated pseudomembranous colitis: An under-recognized threat - Scenario from a Tertiary Care Hospital

This is regarding one article by Vaishnavi et al. “clinical and demographic profile of patients reporting for Clostridium difficile infection (CDI) in a Tertiary Care Hospital”.[1] We had a similar experience in a Tertiary Care Hospital for the time period of 10.5 years starting from January 2005 to May 2015, where we received 716 faecal samples for diagnosing CDI by the qualitative detection of C. difficile toxin (CDT) A and B using RIDASCREEN CDT A/B (C0801) kit with a sensitivity of 89.7%, specificity of 96.8%, positive predictive value of 81.3% and negative predictive value of 98.4%. The results obtained by us were different from the above-mentioned study. In our study, CDT A/B was detected in 7.40% (n = 53) faecal samples. Among CDT-positive patients, 67.92% were males and 32.08% were females. In age-wise distribution, infant (0–2 years), paediatric group (>2–18 years), adult group (>18–60 years) and geriatric group (>60 years); prevalence of CDT positivity was 1.89%, 5.66%, 35.85% and 56.60%, respectively. Prevalence of CDT in patients with clinical condition was similar to the above mentioned study: gastrointestinal diseases (28.30%), renal diseases (26.42%), surgical conditions (18.87%), hepatic disorders (13.21%), cancers (9.43%) and blood diseases (3.77%). The majority of these patients were on antibiotics such as cephalosporins, aminoglycosides, fluoroquinolones, glycopeptides, carbapenems and chloramphenicol. Some patients also received antifungal therapy (26.42%) and steroids (28.80%). We also looked in patients with CDT positivity for the presence of various predisposing risk factors; percentage prevalence of patients with co-morbidities such as diabetes mellitus type 2, chronic kidney disease, hypertension was 64.07%, age >50 years in 57.50%, compromised immunity in 31.15%, frequent hospitalisation in 58.85%, intake of >3 antibiotics in 95.66% and administration of proton pump inhibitors in 98.85%. The difference in the prevalence of CDT positivity between the two studies mentioned seems to be due to the huge difference in sample size. The prevalence of CDT positivity reported by other authors in the past varied from 11% to 22%.[2-5]

Species distribution and antifungal susceptibility of candidemia at a multispecialty center in North India

Introduction: Fungi have emerged as major opportunistic pathogens. Candida species account for nearly 96% of all opportunistic mycoses and is an important cause of bloodstream infections. There has been a progressive shift from the predominance of Candida albicans to nonalbicans Candida species as the major cause of candidemia all over the world. Resistance to antifungal drugs is more in nonalbicans Candida species. Hence, speciation and antifungal susceptibility testing is the need of the hour. Materials and Methods: This retrospective study was conducted in a multispecialty center in North India from January 1, 2014 to March 31, 2015. The blood culture samples that were positive for Candida species were processed further. Species identification was done by standard microbiological techniques. Antifungal drug susceptibility was done by disk diffusion method (Clinical and Laboratory Standards Institute M44-A2). Results: A total of 10893 samples were processed, 1440 (13.2%) blood cultures were positive. Candida species was isolated from 105 (7.3%) samples, of which 15 (14.3%) were C. albicans and 90 (85.7%) were nonalbicans Candida. Nonalbicans Candida included Candida tropicalis (50.5%), Candida glabrata (19.0%), Candida parapsilosis (14.3%) and one isolate each of Candida guillermondi and Candida krusei. Majority of the Candida spp. isolates were resistant to clotrimazole (55.5%) fluconazole (42%) and itraconazole (69%) and and ketoconazole (38%). All isolates were uniformly sensitive to amphotericin B. Conclusion: There is predominance of nonalbicans Candida species in hospital setting. A high index of suspicion, early diagnosis, and a prompt and appropriate therapy remains the cornerstone of treatment.

Conventional versus molecular methods for diagnosis of tuberculosis in a tertiary care center: A study from Punjab

Background: A fast and accurate diagnosis is necessary to control and eliminate tuberculosis (TB). There have been various studies evaluating the efficacy of polymerase chain reaction (PCR) testing in clinical practice. Most of these studies have found PCR as a useful tool to diagnose TB and more so for the extra-pulmonary cases. Aims and Objectives: The aim of the study was to evaluate the results of TB by real-time PCR versus the conventional methods of diagnosis in a tertiary care center in Punjab. Materials and Methods: This study was done in a tertiary care center of Punjab to look for the results of clinical samples tested for TB using PCR, Ziehl–Neelsen staining and culture on Lowenstein–Jensen medium. 16S rRNA gene was used for Mycobacterium tuberculosis detection in PCR. This study included all samples tested for TB from July 2015 to October 2015. Results: A total of 214 samples were tested for TB using smear microscopy, culture and PCR (including 194 [90.6%] extra-pulmonary and 20 [9.3%] pulmonary samples). These included 76 cerebrospinal fluid, 30 pleural fluid, 42 tissues, 17 ascitic fluid, 13 urine, 15 bronchoalveolar lavage (BAL), 16 pus, and 5 sputum samples. Smear microscopy was positive in a total of 4 samples out of 214 (1.8%), which included 2 sputum, 1 tissue, and 1 ascitic fluid samples, while culture was positive for 6 samples (2.8%) which included 2 sputum, 1 pus, 1 BAL, 1 tissue, and 1 ascitic fluid sample. The TB PCR results were positive in a total of 71 (33.1%) samples out of 214. In addition, three samples also tested positive for Mycobacteria other than TB. Conclusion: PCR is a very rapid and accurate diagnostic tool for early detection of TB in particularly for extrapulmonary TB.

Prevalence of carbapenemase-producing organisms in a tertiary care hospital in Ludhiana

Aim: This study was done to determine the minimum inhibitory concentration (MIC) of imipenem for multidrug-resistant (MDR) clinical isolates and identify carbapenemase-producing organisms among these MDR isolates. Materials and Methods: The antibiotic susceptibility of clinical isolates was determined by Kirby–Bauer disc diffusion method. MDR isolates showing resistance or reduced susceptibility to carbapenems were further tested for MIC with imipenem and carbapenemase production by Modified Hodge test (MHT). Results: A total of 65 MDR isolates were tested, of which 46 (70.77%), 15 (23%), and 4 (6.15%) had MIC in resistant, sensitive, and intermediate range, respectively. MHT was positive for 37 (57%) isolates. The most common carbapenemase producers in order of frequency were Acinetobacter baumannii, Klebsiella pneumoniae, Enterobacter aerogenes, Escherichia coli, Pseudomonas spp. Conclusion: Phenotypic tests such as MHT are simple, cost-effective, and easy to perform and hence can be used in any microbiology laboratory to detect carbapenemase production and applied clinically to guide the antimicrobial therapy, especially in severe and life-threatening infections.

Prevalence of inducible clindamycin resistance among Staphylococcal isolates in a tertiary care hospital in North India

produce a reservoir pool of the pathogen. Increasing age and underlying co-morbidities increase the risk of acquiring CDI. Among the underlying co-morbidities identified in the present analysis, gastrointestinal diseases were the commonest, followed by surgical conditions, renal diseases and cancers, and CDT positivity was found in 17-21% of them. Antibiotics like nitroimidazole, penicillin, fluoroquinolones, glycopeptides, carbapenems and drugs like proton pump inhibitors, immunosuppressives and chemotherapeutics were found to be associated with CDT positivity in the present study. Thus, it is important to identify patients who are at high risk for severe CDI early in the course of their infection thereby decreasing the responsibility of the clinicians and improving the patient condition.