Deepak Juyal

Microbiology of chronic suppurative otitis media in a tertiary care setup of uttarakhand state, India.

Background: Chronic suppurative otitis media (CSOM) is a notorious infection and a major health problem in developing countries causing serious local damage and threatening complications. Early and effective treatment based on the knowledge of causative micro-organisms and their antimicrobial sensitivity ensures prompt clinical recovery and possible complications can thus be avoided. Aims: The aim of this study was to isolate the organisms associated with CSOM and to detect the antibiogram of the aerobic isolates. Materials and Methods: A total of 204 patients clinically diagnosed of CSOM were enrolled in the study and the samples were obtained from each patient using sterile cotton swabs and cultured for microbial flora. Drug susceptibility testing for aerobic isolates was conducted using Kirby-Bauer disc diffusion method. Results: The most common causative organisms isolated were Staphylococcus aureus (48.69%) and Pseudomonas aeruginosa (19.89%) amongst the 191 aerobic isolates. Anaerobes accounted for 29.41% of the isolates while 12.25% were fungi. Antimicrobial profile of aerobic isolates revealed maximum sensitivity to amikacin (95.5%), ceftriaxone (83.4%) and gentamicin (82.7%). Conclusion: Knowing the etiological agents of CSOM and their antimicrobial susceptibility is of essential importance for an efficient treatment, prevention of both complications and development of antibiotic resistance and finally, the reduction of the treatment costs.

Emergence of non-albicans Candida species in neonatal candidemia.

Background: Candida species are one of the most common causes of blood stream infections among neonates and account for 9-13% of such infections. Although Candida albicans remains the most common fungal isolate from neonatal candidemia, longitudinal studies have detected a shift towards non-albicans Candida (NAC) species. Aim: To examine the prevalence and epidemiology of candidemia among infants admitted to our hospital. Materials and Methods: Blood samples were collected from 548 neonates and only those which yielded pure growth of Candida spp. were included in the study. The isolates were identified as per standard mycological techniques and antifungal susceptibility (AFS) was done by disc diffusion method. Results: Of the total 132 neonates included in the study, NAC species were responsible for 80.30% cases with C. parapsilosis (25.0%) and C. tropicalis (21.97%) as the most predominant species; whereas 19.70% of cases were caused by C. albicans. AFS results revealed that 65.91, 73.49, and 96.21% isolates were sensitive to fluconazole (FLK), itraconazole (ITR), and amphotericin B (AMB), respectively. Conclusion: Candidemia in neonates is an ominous prognostic sign and is an important entity in our hospital. Strict infection control strategies, appropriate preventive and therapeutic measures such as prophylactic antifungal use and a restrictive policy of antibiotic use should be implemented.

The prevalence of inducible clindamycin resistance among staphylococci in a tertiary care hospital - a study from the garhwal hills of uttarakhand, India.

OBJECTIVE This study was undertaken to assess the frequency of the phenotypic expression of the inducible resistance to clindamycin which was due to the expression of the erm genes in various clinical isolates of the Staphylococcus species. MATERIALS AND METHODS This was a cross sectional study conducted in the Dept. of Microbiology and Immunology, Veer Chandra Singh Garhwali Govt. Medical Sciences and Research Institute, Srikot, Uttarakhand, from July 2010 to December 2011. A total of 373 consecutive, non duplicate strains of Staphylococci isolated from various clinical samples like pus, wound swab, blood, urine and other body fluids, were tested. The isolates which had a discordant resistance pattern (clindamycin-sensitive and erythromycin-resistant) by Kirby Bauer Disk Diffusion method were selected and subjected to the D-test for inducible clindamycin resistance, as per the Clinical and Laboratory Standards Institutes (CLSI) guidelines. RESULTS Among the 373 clinical isolates of Staphylococci which were studied, 134 isolates showed a discordant resistance pattern. Among these discordant strains, 45 (33.6%) isolates were D-test positive, which had inducible clindamycin resistance and belonged to the inducible macrolide lincosamide streptogramin- B phenotype (MLSBi). 89 (66.4%) isolates were D-test negative and they belonged to the macrolide streptogramin phenotype (MS). Among the MLSBi phenotypes, 6 (13.3%) isolates were methicillin-resistant Staphylococcus aureus (MRSA), 13 (28.9%) were Methicillin-sensitive S.aureus (MSSA) and 26 (57.8%) were coagulase negative staphylococci (CONS). CONCLUSION The D-test is a simple, effective and an important method for the phenotypic detection of inducible clindamycin resistance and it should be used routinely, as it will help in guiding the empirical therapy. The possible clinical failures can thus be avoided.

The baseline widal titre among the healthy individuals of the hilly areas in the garhwal region of uttarakhand, India.

INTRODUCTION Typhoid fever is endemic in all parts of India and the Widal test is widely used for its diagnosis. In the endemic areas, the healthy people may contain antibodies which are capable of reacting upto a variable titre in the Widal test, due to a past exposure, TAB vaccination and cross reacting antigens. Therefore it varies widely from place to place and is referred to as the baseline titre of that area. The aim of this study was to determine the average baseline titre of the apparently healthy population in the Garhwal region of Uttarakhand, India. MATERIAL AND METHODS Blood samples were collected from healthy volunteers over the period from February 2011 to January 2012 and they were analyzed for the presence of the Salmonella antibodies by carrying out the Widal tube agglutination test. RESULTS Among the 2164 serum specimens which were tested, 922 (42.6%) sera were found to be positive for the Widal test and 1242 were negative. The most frequently recorded titre of the reactive sera was 1:40 for the anti-O antibodies and it was 1:80 for the anti-H antibodies and this was the baseline titre for this region. CONCLUSION Based on the above results of our study, it has been recommended that the cut-off titre of 1:80 for the anti-O antibodies and of 1:160 for the anti-H antibodies may be considered as diagnostic for enteric fever in the Garhwal region of Uttarakhand, India.

Bacteriological Profile of Surgical Site Infections and Their Antibiogram: A Study From Resource Constrained Rural Setting of Uttarakhand State, India.

INTRODUCTION Surgical site infections (SSI) constitute a major public health problem worldwide and are the second most frequently reported nosocomial infections. They are responsible for increasing the treatment cost, length of hospital stay and significant morbidity and mortality. AIM To determine the incidence of SSIs and the prevalence of aerobic bacterial pathogens involved with their antibiogram. MATERIALS AND METHODS Samples were collected using sterile cotton swabs from 137 patients clinically diagnosed of having SSIs and were processed as per standard microbiological techniques. Antimicrobial susceptibility testing was done using modified Kirby-Bauer disc diffusion method. This cross sectional study was conducted for a period of six months (January 2013 to June 2013) in the Department of Microbiology at a rural tertiary care hospital of Uttarakhand state, India. RESULTS Out of 768 patients, 137 (17.8%) were found to have SSIs and samples were collected from them. Out of total 137 samples, 132 (96.4%) yielded bacterial growth and 139 bacterial isolates were obtained. Staphylococcus aureus (50.4%) was the commonest organism followed by Escherichia coli (23.02%), Pseudomonas aeruginosa (7.9%) and Citrobacter species (7.9%). Antimicrobial profile of gram positive isolates revealed maximum sensitivity to vancomycin, teicoplanin and linezolid, whereas among gram negative isolates meropenem, piperacillin-tazobactam, and amikacin were found to be most sensitive. CONCLUSION The rate of SSI observed in this study was comparable to other similar studies, however we observed a higher degree of antimicrobial resistance. Adherence to strict infection control measures, maintenance of proper hand hygiene and optimal preoperative, intraoperative and postoperative patient care will surely reduce the incidence of SSIs.

Significance of fungal flora in chronic suppurative otitis media

Introduction: Chronic suppurative otitis media (CSOM) is defined as infection of the middle ear that lasts for >3 months and is accompanied by tympanic membrane perforation. The incidence is higher in developing countries, especially among the low socioeconomic strata of the society. Many authors have focused their attention on the bacterial flora of CSOM, but very little is known about the mycological aspects of these, the importance of which has been increasing in the recent years. Objective: The present study was aimed to speculate the etiological fungal flora responsible for the cases of CSOM among patients who attended the Ear, Nose, and Throat Department of our hospital a tertiary care center in Uttarakhand. Materials and Methods: The total of 107 patients (both males and females) who were clinically diagnosed with CSOM and were on any antibiotics (oral, topical or systemic) for >14 days and still persisted with symptoms were included in this study. Results: Among the 107 cases of CSOM studied, fungi were isolated in 83 (77.57%). Majority of the patients were in second and third decades of life (62.62%). Of the 83 fungal culture positive cases, the predominantly isolated fungi were Aspergillus species (47%), Candida species (41%), and Penicillium species (9.6%). Among the Aspergillus, the predominant species were Aspergillus flavus (17 isolates) and Aspergillus niger (12 isolates). Candida albicans (19 isolates) and Candida tropicalis (9 isolates) were the commonly isolated species of Candida. Conclusion: A definite search for fungal etiology is desirable in all cases of CSOM. Prolonged use of topical antibiotics or antibiotics-steroids ear drops may cause suppression of bacterial flora and the subsequent emergence of fungal flora. This probably increases the incidence of fungal superinfection. Otologists should suspect mycotic otitis media in patients with continuous otorrhea and who do not respond to the antibacterial treatment.

An outbreak of neonatal Candidemia due to non-albicans Candida species in a resource constrained setting of Uttarakhand State, India

This case report describes the outbreak of candidemia caused by non-albicans Candida (NAC) species, which within a short period of 11 days, affected six neonates housed in the same room of neonatal intensive care unit of a rural tertiary care center in Uttarakhand state, India. The NAC species isolated showed complete resistance to azole compounds tested. All the neonates were having central venous catheters at the time of diagnosis, received total parenteral nutrition and were on broad spectrum antibiotics. Though two neonates survived the infection, but four of them had an unfortunate outcome and they died despite of aggressive therapy with amphotericin B. It was concluded that candidemia was associated with previously described risk factors and that poor infection control practices were likely responsible for outbreak.

Meningitis Due to Cryptococcus gattii in an Immunocompetent Patient.

The incidence of cryptococcal infection is high in developing countries such as India. Cryptococcus gattii, formerly known as Cryptococcus neoformans var gattii, is an encapsulated yeast that causes disease in both immunocompetent and immunosupressed individuals. The organism enters via respiratory tract and causes a spectrum of illness ranging from asymptomatic infection to severe illness, including pneumonia and disseminated infection involving multiple sites, including the central nervous system, eyes and skin. Cryptococcal meningitis is generally considered as rare in immunocompetent patients; therefore, specific treatment is not implemented until the organism is identified or a cryptococcal antigen is detected. We describe the case of a 30-years-old man without prior medical history who presented with meningitis and was treated successfully. This case illustrates the importance of considering infectious causes such as C.gattii in the differential diagnosis of meningitis, regardless of the patients immune status.

Intestinal parasitic infection-intensity, prevalence and associated risk factors, a study in the general population from the Uttarakhand hills

Background: Intestinal parasitic infection is an important public health problem in developing countries. Low socioeconomic conditions, lack of access to potable drinking water, poor personal hygiene and environmental sanitation are the factors associated with intestinal parasitic infection. Aim: The aim of this study was to estimate the prevalence of intestinal parasitic infections and identify the associated risk factors. Materials and Methods: Study was performed on 327 stool specimens of all age groups from August 2012 to May 2013. Specimen collected and examined with direct wet mount, formal ether sedimentation and salt flotation methods. Results: Out of the total 327 participants prevalence of intestinal infections was 11.62%. Among the Protozoa, Giardia lamblia (3.06%) was the most common, followed by Entamoeba histolytica (0.92%). Hookworm (2.75%) and Hymenolepis nana (2.14%) were the most common helminthes found. Parasitosis was seen more in female (17.07%) than male (8.33%) and highest between 51 and 60 years (22.22%) age group with risk factors like open defecation (22.69%), untreated river water (17.91%) and among people living in rural areas (15.17%). Conclusion: There is a need to create awareness about safe drinking water, personal hygiene and environmental sanitation and to take urgent remedial steps to prevent and control intestinal parasitic infections.

Fonsecaea pedrosoi: a rare etiology in fungal keratitis.

Fungal corneal ulcer is common in India due to tropical climate and a large agrarian population that is at risk. Fonsecaea pedrosoi is the most common agent of chromoblastomycosis, a chronic localized fungal infection of the skin and subcutaneous tissues mainly involving lower extremities. We report a rare case of corneal chromoblastomycosis caused by F.pedrosoi, which was successfully treated with topical Amphotericin B followed by a long course of oral antifungal therapy. To the best of our knowledge, this is the first case of mycotic keratitis caused by F.pedrosoi, from the foothills of Himalayas.