Banani Poddar

Epidemiology of bacterial colonization at intensive care unit admission with emphasis on extended-spectrum β-lactamase- and metallo-β-lactamase-producing Gram-negative bacteria - an Indian experience

An important risk factor for nosocomial infection in an intensive care unit (ICU) is prior colonization. This study was undertaken to determine the spectrum of bacterial colonization and predisposing risk factors in patients being admitted to an ICU in India, with special emphasis on extended-spectrum beta-lactamase (ESBL)- and metallo-beta-lactamase (MBL)-producing Gram-negative bacteria. Nasal, oral and rectal swab samples were collected and processed for isolation of ESBL-producing Gram-negative bacteria and MBL-producing Pseudomonas aeruginosa and Acinetobacter species. Bacterial colonization (of one or more sites) on admission was detected in 51 out of 96 patients included in the study. Non-fermenters, i.e. P. aeruginosa and Acinetobacter baumannii, were the most common colonizers, present in 37 patients, with simultaneous colonization in 12 patients. A total of 16 patients were colonized with MBL-producing members of the family Enterobacteriaceae, out of which 11 isolates (from 5 patients) were also carrying ESBL-encoding genes. As for MBLs, most of our patients have shown colonization with ESBL-producing bacteria. On admission, 47 of 51 patients (92 %) have been colonized by ESBL-producing members of the family Enterobacteriaceae, at one or more of the three anatomical sites. The most common MBL subtype was bla(IMP) (51.56 %), whereas bla(CTX) was the most common gene (84.9 %) identified among ESBL producers. Risk factors for colonization on admission to the ICU were hospitalization for more than 48 h, use of >or=3 groups of antibiotics, co-morbidities and mechanical ventilation for more than 48 h prior to ICU admission. There is an increasing incidence of MBLs and ESBLs in the Indian population. The identified risk factors can be used as a guide for empiric antibiotic therapy targeted to these resistant bacteria.

Prospective comparison of new Japanese Association for Acute Medicine (JAAM) DIC and International Society of Thrombosis and Hemostasis (ISTH) DIC score in critically ill septic patients

INTRODUCTIONnWe prospectively compared the new Japanese Association for Acute Medicine (JAAM) score with the International Society of Thrombosis and Hemostasis (ISTH) score for diagnosis of disseminated intravascular coagulation (DIC) in septic patients admitted in a general critical care intensive care unit.nnnMATERIAL AND METHODnSeptic patients with platelet count of <150 × 10(9)/L were included. Both DIC scores were estimated from day 1 to day 4 along with APACHE II and SOFA scores.nnnRESULTSnOut of the 148 blood samples drawn from 42 patients (28 male & 14 female) the JAAM and ISTH DIC scores had an overall significant agreement (k=0.246, p<0.001) in 83 samples. JAAM score had higher diagnostic rates on all four days. Significant (p ≤ 0.001) day wise variation existed in JAAM and ISTH DIC scores. Correlation between JAAM DIC and ISTH DIC scores on day 1 (r=0.631) & day 4 (r=0.609) was significant (p<0.001). Pneumonia was the predominant cause of sepsis. Twenty seven (64.3%) patients died during their stay in ICU. Amongst DIC patients both severity scores (SOFA/APACHE II) and DIC scores (JAAM/ISTH) did not discriminate between survivors and non-survivors. Health care associated infection (p=0.040), high lactate levels (p=0.020) on day 1 and high procalcitonin levels (p=0.036) were found to have significant discriminating ability between survivors and non-survivors. Significantly shorter length of stay was observed amongst non-survivors (p=0.002).nnnCONCLUSIONSnIn sepsis the JAAM DIC score identified most of the patients diagnosed by the overt ISTH criteria, but failed to discriminate between survivors and non-survivors amongst DIC patients.

Outcome of mechanical ventilation in patients of Guillain-Barre syndrome: An audit from a tertiary care centre

Background: About a third of patients with Guillain-Barre Syndrome (GBS) presents with acute respiratory failure requiring invasive mechanical ventilation. We studied the outcome of patients with GBS. Material and Methods: A retrospective data extraction was done on clinical records of 103 patients with diagnosis of GBS admitted in intensive care unit (ICU) over a period of 7 years. All patients requiring ICU admission and mechanical ventilation for more than 48 h were included in the study. Demographic profile, clinical characteristics, treatment given, duration of mechanical ventilation, ICU acquired infections, incidence of pressure sores, and length of ICU stay was noted. Results: Eighty six patients fulfilled the inclusion criteria. The mean age of patients was 32.4 (± 18.12) years. Mean duration of ICU stay was 28.9 (± 26.99) days. Majority (82%) of our patients were male. The most common co-morbidities were diabetes mellitus and hypertension. Axonal neuropathy was the most common (76%) lesion. Autonomic dysfunction was present in 35% of patients. Fifty two percent of patients received immunoglobulin therapy while 64% of required mechanical ventilation for more than 14 days. Tracheostomy was performed in 85% of patients. Ventilator associated pneumonia (VAP) was seen in 33% of patients, blood stream infection in 11% and urinary tract infection in 7%. Forty percent of patients developed bed sore grade 1-2. Seven (8.3%) patients died perhaps due to complications including VAP and sepsis. Conclusions: GBS has a good outcome despite prolonged mechanical ventilation and ICU stay.

Facial nerve involvement in critical illness polyneuropathy.

Although ICU-acquired neuromuscular weakness is a well-known problem, critical illness neuropathy is an under-diagnosed entity in critically ill patients. Facial musculature is typically not involved in critical illness neuropathy. This report highlights an unusual presentation of critical illness polyneuropathy in a patient with involvement of facial musculature.

Epidemiology of central line-associated bloodstream infections at a tertiary care centre in northern India

1. Shakil S, Khan AU. Detection of CTX-M-15-producing and carbapenem-resistant Acinetobacter baumannii strains from urine from an Indian hospital. J Chemother 2010;22:324e327. 2. Seki LM, Pereira PS, Conceição MS, et al. Molecular epidemiology of CTX-M producing Enterobacteriaceae isolated from bloodstream infections in Rio de Janeiro, Brazil: emergence of CTX-M-15. Braz J Infect Dis 2013;17:640e646. 3. Potron A, Munoz-Price LS, Nordmann P, Cleary T, Poirel L. Genetic features of CTX-M-15-producing Acinetobacter baumannii from Haiti. Antimicrob Agents Chemother 2011;55:5946e5948. 4. Silbert S, Pfaller MA, Hollis RJ, Barth AL, Sader HS. Evaluation of three molecular typing techniques for nonfermentative Gramnegative bacilli. Infect Control Hosp Epidemiol 2004;25: 847e851. 5. Monstein HJ, Ostholm-Balkhed A, Nilsson MV, Nilsson M, Dornbusch K, Nilsson LE. Multiplex PCR amplification assay for the detection of blaSHV, blaTEM and blaCTX-M genes in Enterobacteriaceae. APMIS 2007;115:1400e1408. 6. Woodford N, Ellington MJ, Coelho JM, et al. Multiplex PCR for genes encoding prevalent OXA carbapenemases in Acinetobacter spp. Int J Antimicrob Agents 2006;27:351e353. 7. Poirel L, Walsh TR, Cuvillier V, Nordmann P. Multiplex PCR for detection of acquired carbapenemase genes. Diagn Microbiol Infect Dis 2011;70:119e123. 8. Shahcheraghi F, Nikbin VS, Feizabadi MM. Prevalence of ESBL genes among multidrug-resistant isolates of Pseudomonas aeruginosa isolated from patients in Tehran. Microb Drug Resist 2009;15:37e39. 9. Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing; twentieth informational supplement. CLSI M100-S25. Wayne, PA: Clinical and Laboratory Standards Institute; 2015.

Incidence, risk factors and associated mortality of central line-associated bloodstream infections at an intensive care unit in northern India

ObjectivenTo evaluate the incidence, risk factors and associated mortality of central line-associated bloodstream infection (CLABSI) in an adult intensive care unit (ICU) in India.nnnDesignnThis prospective observational study was conducted over a period of 16 months at a tertiary care referral medical center.nnnSettingnWe conducted this study over a period of 16 months at a tertiary care referral medical center.nnnParticipantsnAll patients with a central venous catheter (CVC) for >48 h admitted to the ICU were enrolled.nnnIntervention and main outcome measuresnPatient characteristics included were underlying disease, sequential organ failure assessment (SOFA), acute physiology and chronic health evaluation (APACHE II) scores and outcome. Statistical analysis of risk factors for their association with mortality was also done.nnnResultsnThere were 3235 inpatient-days and 2698 catheter-days. About 46 cases of CLABSI were diagnosed during the study period. The overall rate of CLABSI was 17.04 per 1000 catheter-days and 14.21 per 1000 inpatient-days. The median duration of hospitalization was 23.5 days while the median number of days that a CVC was in place was 17.5. The median APACHE II and SOFA scores were 17 and 10, respectively. Klebsiella pneumoniae was the most common organism (n = 22/55, 40%). Immunosuppressed state and duration of central line more than 10 days were significant factors for developing CLABSI. SOFA and APACHE II scores showed a tendency towards significance for mortality.nnnConclusionsnOur results underscore the need for strict institutional infection control measures. Regular training module for doctors and nurses for catheter insertion and maintenance with a checklist on nurses chart for site inspection and alerts in all shifts are some measures planned at our center.

Acute methotrexate toxicity presenting as multiorgan failure and acute pneumonitis: A rare case report

Acute methotrexate toxicity rarely presents as medical emergency in form of multiorgan failure. Acute pneumonitis following low-dose methotrexate is rarely reported in literature. It is important to recognize this, as the drug must be discontinued immediately and rescue measures in form of folinic acid and hydration instituted promptly.

Blood glucose variability and outcomes in critically ill children

Objectives: To find the incidence of hyperglycemia (blood glucose [BG] ≥150 mg/dl), hypoglycemia (BG ≤60 mg/dl), and variability (presence of hypoglycemia and hyperglycemia) in critically ill children in the 1st week of Intensive Care Unit (ICU) stay and their association with mortality, length of ICU stay, and organ dysfunction. Materials and Methods: The design was a retrospective observational cohort study. Consecutive children ≤18 years of age admitted from March 2003 to April 2012 in a combined adult and pediatric closed ICU. Relevant data were collected from chart review and hospital database. Results: Out of 258 patients included, isolated hyperglycemia was seen in 139 (53.9%) and was unrelated to mortality and morbidity. Isolated variability in BG was noted in 76 (29.5%) patients and hypoglycemia was seen in 9 (3.5%) patients. BG variability was independently associated with multiorgan dysfunction syndrome on multivariate analysis (adjusted odds ratio [OR]: 7.1; 95% confidence interval [CI]: 1.6–31.1). Those with BG variability had longer ICU stay (11 days vs. 4 days, on log-rank test, P = 0.001). Insulin use was associated with the occurrence of variability (adjusted OR: 3.6; 95% CI: 1.8–7.0). Conclusion: Glucose disorders were frequently observed in critically ill children. BG variability was associated with multiorgan dysfunction and increased ICU stay.

The effects of atorvastatin on inflammatory responses and mortality in septic shock: A single-center, randomized controlled trial

Aim of the Study: Pleiotropic effect of statins can modulate inflammation in septic shock. We tested the hypothesis whether statins can reduce mortality in septic shock. Patients and Methods: We conducted a randomized double-blinded trial with treatment (40 mg dose of atorvastatin for 7 days) and control (placebo) arm in adult septic shock patients admitted to the Intensive Care Unit. Primary (28-day mortality) and secondary (vasopressor-, ventilation-, and renal replacement therapy-free days) outcomes, with lipid profile and adverse effects, were documented. Inflammatory biomarkers (interleukin [IL]-1, IL-6, tumor-necrosis-factor [TNF]-α, interferon [IFN], and C-reactive protein [CRP]), were also measured before (day 1 [D1]) and after start of trial drug (D4 and D7). Results: Seventy-three septic shock patients with 36 and 37 included in the atorvastatin and placebo group, respectively. Both groups were equally matched. Twenty-eight-day mortality, event-free days, lipid profile, and adverse effects were also not significantly different between groups. Reduced levels of IL-1, IL-6, TNF-α, IFN, and CRP were observed in the atorvastatin group. Also observed were significant day-wise changes in inflammatory biomarkers. Conclusions: Atorvastatin-induced changes in inflammatory biomarkers did not confer mortality benefit in septic shock (ClinicalTrials.govNCT02681653).

Right heart in septic shock: prospective observational study

BackgroundThe right heart often receives less attention during echocardiography. The situation is no different in septic shock. We prospectively investigated the echocardiographic indices of the right heart in septic shock adult patients.MethodsSeptic shock ICU patients within 24xa0h of admission were subjected to transthoracic echocardiography (TTE) as per the 2005 guidelines from the American Society of Echocardiography.ResultsEighty-eight septic shock patients (M:Fu2009=u200952:36) underwent TTE. Thirty-six patients survived. Significant differences in demographic and biochemical (laboratory and metabolic) parameters, severity scores, life-support therapies (vasopressors, ventilation), and length of ICU stay were observed between survivors and non-survivors. Right heart abnormalities of chamber dimension and systolic and diastolic function existed in 79, 25, and 86xa0% of patients, respectively. Right ventricle subcostal wall thickness (91xa0%), pulse Doppler myocardial performance index (73xa0%), and E/E′ (63xa0%) were the predominant abnormalities in chamber dimension, systolic function, and diastolic function of the right heart, respectively. However, the presence of these abnormalities did not signify poor survival in our study.ConclusionsRight heart dimensional and functional abnormalities exist in high proportions in septic shock. However, their predictability of poor outcomes remains questionable.