Atul Kothari

Emerging Technologies for Rapid Identification of Bloodstream Pathogens

Technologies for rapid microbial identification are poised to revolutionize clinical microbiology and enable informed decision making for patients with life-threatening bloodstream infections. Species identification of microorganisms in positive blood cultures can be performed in minutes using commercial fluorescence in situ hybridization tests or mass spectroscopy. Microorganisms in positive blood cultures can also be identified within 1-2.5 hours using automated polymerase chain reaction-based systems that can also detect selected antibiotic resistance markers, such as methicillin resistance. When combined with antibiotic stewardship programs, these approaches improve clinical outcomes and reduce healthcare expenditures. Tests for direct detection in whole blood samples are highly desirable because of their potential to identify bloodstream pathogens without waiting 1-2 days for blood cultures to become positive. However, results for pathogen detection in whole blood do not overlap with those of conventional blood culture techniques and we are still learning how best to use these approaches.

Costs associated with hospital-acquired bacteraemia in an Indian hospital: a case-control study.

Studies from around the world have shown that hospital-acquired infections increase the costs of medical care, morbidity and mortality. The aim of this study was to determine cost and attributable mortality associated with hospital-acquired bacteraemia in a tertiary care centre in India. This was a retrospective case-control, cost utility analysis set in the cardiothoracic unit of a 200-bedded tertiary care cardiac hospital. Cases included adult patients who underwent coronary artery bypass graft and/or valve replacement surgery who developed bacteraemia (indicated by positive blood cultures) during postoperative stay (N=24). Controls were age- and sex-matched adult patients who underwent similar procedures but who did not develop bacteraemia (N=48). Data were collected from patient medical records and other administrative databases for cost analysis. Prolongation of hospital stay, attributable mortality and extra costs associated with hospital-acquired bacteraemia were analysed. Statistical analysis was done using Fishers exact test and unpaired t-test. Patients with hospital-acquired bacteraemia experienced a significantly longer total hospital stay [mean: 22.9 days; 95% confidence interval (CI): 17.2-28.6; P<0.0001], significantly longer ICU stay (mean: 11.3 days; 95% CI: 9.0-13.6; P<0.0001), a significantly higher mortality (mean: 54%; P<0.0001) and cost significantly more (mean: US

Pacing lead endocarditis due to Aspergillus fumigatus.

14,818; 95% CI: 10,663-18,974; P<0.0001) than controls. We conclude that hospital-acquired bacteraemia significantly increases mortality and costs of hospitalisation in lower income developing countries. Our study demonstrates that costs associated with HAIs are similar between developing and developed countries. Better infection control planning and infrastructure may offset some of these costs.

Purple urine bag syndrome: a rare clinical entity in patients with long term indwelling catheters.

Invasive aspergillosis is an opportunistic infection with a high mortality rate that usually occurs in the immunocompromised host. Several cases of fungal infections have been reported after cardiac surgery. We present here a case of Aspergillus fumigatus tricuspid valve endocarditis associated with permanent pacemaker leads. Tricuspid valve vegetectomy was done and the pacing leads were also removed. Culture from the excised vegetation grew Aspergillus fumigatus. The patient was started on IV Amphotericin B for eight weeks. The patient was subsequently followed up in the out-patient clinic, and remains afebrile after one year, with no evidence of any vegetation.

Cytomegalovirus Infection in Neonates following Exchange Transfusion

An elderly gentleman, on urinary drainage catheter for 3 months developed a purple discoloration of the urinary bag with the urine inside remaining clear. He was found to have a urinary tract infection with a strain of E. coli manifesting as a rare clinical entity reported in literature as the “Purple urine bag syndrome”.

The role of next generation sequencing in infection prevention in human parainfluenza virus 3 infections in immunocompromised patients

ObjectivesThis study was undertaken to ascertain the acquisition of cytomegalovirus infection following exchange transfusion and factors affecting such transmission in newborn infants at a tertiary care hospital in India.MethodsNeonates undergoing double volume exchange transfusion (for any indication) with whole blood in the Neonatal Intensive Care Unit were enrolled over a 8 month period. Serum samples from the infant were collected for CMV serology before exchange transfusion, and at 6 and 12 weeks following the exchange. CMV serology was also conducted on samples obtained from the respective maternal and donor blood.ResultsOf 47 neonates who received exchange transfusion during the study period; only 26 (55.3%) neonates were finally followed up till 12 weeks of age. Only 3 (11.5%) children demonstrated CMV seroconversion during follow-up; all were low birth weight and small for gestational age. None of them demonstrated any clinical, hematological, biochemical, or radiological signs suggestive of perinatal CMV infection either at birth or during the course of follow-up.ConclusionExchange transfusion in neonates can result in perinatal transmission of CMV infection in low birth weight neonates. Such transmission does not result in any immediate manifestations. Data are not sufficient to warrant routine CMV screening of donor blood for exchange transfusion in our setting.

Gastrointestinal histoplasmosis in a patient after autologous stem cell transplant for multiple myeloma

BACKGROUND Respiratory viral infections are a significant problem in patients with hematologic malignancies. We report a cluster of HPIV 3 infections in our myeloma patients, and describe the utility of next generation sequencing (NGS) to identify transmission linkages which can assist in infection prevention. OBJECTIVES To evaluate the utility of NGS to track respiratory viral infection outbreaks and delineate between community acquired and nosocomial infections in our cancer units. STUDY DESIGN Retrospective chart review conducted at a single site. All patients diagnosed with multiple myeloma who developed symptoms suggestive of upper respiratory tract infection (URTI) or lower respiratory tract infection (LRTI) along with a respiratory viral panel (RVP) test positive for HPIV 3 between April 1, 2016, to June 30, 2016, were included. Sequencing was performed on the Illumina MiSeq™. To gain understanding regarding community strains of HPIV 3 during the same season, we also performed NGS on HPIV3 strains isolated from pediatric cases. RESULTS We saw a cluster of 13 cases of HPIV3 infections in the myeloma unit. Using standard epidemiologic criteria, 3 cases were considered community acquired, 7 cases developed infection during treatment in the cancer infusion center, while an additional 3 developed infections during hospital stay. Seven patients required hospitalization for a median duration of 20days. NGS enabled sensitive discrimination of the relatedness of the isolates obtained during the outbreak and provided evidence for source of transmission. Two hospital onset infections could be tracked to an index case; the genome sequences of HPIV 3 strains from these 3 patients only differed by a single nucleotide. CONCLUSIONS NGS offers a significantly higher discriminatory value as an epidemiologic tool, and can be used to gather real-time information and identification of transmission linkages to assist in infection prevention in immunocompromised patients.

Typhoidal focal suppurative lymphatic abscess

A 59‐year‐old patient with multiple myeloma on maintenance chemotherapy presented with fever, weight loss, and night sweats. An F‐18 fluorodeoxyglucose (FDG) positron emission tomography (PET) computed tomography (CT) showed intra‐abdominal lymphadenopathy with a mesenteric mass that led to further workup and diagnosis of histoplamosis. The patient was treated with amphotericin B and subsequently switched to itraconazole. This exemplifies the usefulness of FDG PET CT in diagnosis of infectious complications.

Skin lesion in a patient with acute myeloid leukemia

Abstract We describe a submandibular suppurative lymphatic abscess caused by Salmonella typhi in an 8-year-old child. The diagnosis was confirmed by repeated isolation of S. typhi from the abscess. A literature search found no previous report of a similar nature and this therefore seems to be the first case report of focal suppurative typhoidal lymphatic abscess. The child responded to cephalexin and surgical drainage.

Lasiodiplodia species fungal osteomyelitis in a multiple myeloma patient.

We present the case of a 51‐year‐old man with acute myeloid leukemia who developed fevers with a skin lesion following the first cycle of induction chemotherapy. Skin biopsy showed evidence of invasive fungal infection. Cultures remained negative, but polymerase chain reaction on tissue detected Rhizopus oryzae complex. The patient was started on liposomal amphotericin B and underwent surgical debridement. He was switched to posaconazole, with plans for allogeneic hematopoetic stem cell transplant in the future.