Elizabeth Mathai

Outbreak of Scrub Typhus in Southern India during the Cooler Months

Abstract: Orientia tsutsugamushi, the agent of scrub typhus, is a strict intracellular bacterium which is found in many parts of Asia including India. During the past few years, the number of patients with rickettsial infection and scrub typhus has increased, especially during the cooler months. We report in this study a recent outbreak of scrub typhus recorded during the cooler months (October 2001 to February 2002) in patients admitted to our hospital with acute febrile illness associated with diverse signs and symptoms. Overall, 28 patients were clinically and serologically confirmed to have scrub typhus. Fever for more than one week was the only common manifestation. Myalgias was the next most common feature (52%), and rash was observed in only 22% of the cases. Seventeen patients treated with doxycycline recovered in 1 to 3 days, as well as two patients who received chloramphenicol. In five patients who received ciprofloxacin, fever subsided only after five days. Finally three patients (10.7%) died, including one patient treated with doxycycline. These data indicate that scrub typhus is a reemerging infectious disease in India with a possibility of drug resistance. This reemergence emphasizes the need for further prospective studies to design effective control measures.

Integrons and multidrug resistance among Escherichia coli causing community‐acquired urinary tract infection in southern India

Antimicrobial resistance genes are often clustered in integrons, genetic elements capable of recombination. There is a paucity of data on the prevalence and role of integrons from community‐acquired infections in developing countries where resistance to co‐trimoxazole is high. We determined the prevalence of integrons among Escherichia coli causing community‐acquired urinary tract infection (UTI). Consecutive isolates of E. coli obtained from UTI of pregnant women at the Christian Medical College Hospital, Vellore, India, during 2002 were included. All isolates were tested for susceptibility to 16 antimicrobials using the disc diffusion method and for integrons of classes 1 and 2 by PCR. Of the 58 isolates tested, 28 (48.3%) were resistant to co‐trimoxazole and trimethoprim. All these isolates carried integrons. Three additional isolates were sulfonamide resistant but integron negative. Class 1 integrons were present in 21 (36.2%) isolates. Resistance to ampicillin (p=0.000), nalidixic acid (p=0.001), chloramphenicol (p=0.02), tetracycline (p=0.004) and gentamicin (p=0.02) was significantly more common in isolates with integrons. DNA sequencing of two isolates with integrons showed the presence of aadA, dfr1 and dfr7 genes. This study demonstrated that integrons are widely prevalent in India and that they might play a role in multidrug resistance in E. coli from community‐aquired UTI.

Case reports: scrub typhus during pregnancy in India.

Scrub typhus, caused by Orientia tsutsugamushi, is a rural zoonosis endemic in the Asian Pacific region. Doxycycline and chloramphenicol, the recommended drugs for treating this infection, may not be safe during pregnancy. We report on 5 patients with scrub typhus during pregnancy who were seen in India between October 2001 and February 2002. Four of the 5 women were treated initially with ciprofloxacin. Three women had stillbirths, 1 an abortion and 1 a low birthweight baby, which suggests that ciprofloxacin should not be used for treating pregnant women and that scrub typhus leads to severe adverse effects during pregnancy. Randomized controlled trials are urgently needed to ascertain the optimal drug choice, given that currently recommended drugs are contraindicated in pregnant women.

Antimicrobial resistance surveillance among commensal Escherichia coli in rural and urban areas in Southern India.

Objective  To assess antimicrobial resistance (AMR) in Tamil Nadu, India.

Antibiotic use and resistance: perceptions and ethical challenges among doctors, pharmacists and the public in Vellore, South India.

Inappropriate antibiotic use and resistance are major public health challenges. Interventional strategies require ascertaining the perceptions of major stakeholders and documenting the challenges to changing practice. Towards this aim, a qualitative study was conducted in Vellore, South India, using focus group discussions among doctors, pharmacists and public. There were eight groups with six to eight participants each. The themes explored were: understanding of infections, antibiotics and resistance; practices and pressure driving antibiotic use; and strategies for appropriate use. Data were transcribed, analysed, verified and a summary prepared with salient features and quotations. It was found that the public had minimal awareness of resistance, antibiotics and infections. They wanted symptomatic relief. Doctors reported prescribing antibiotics for perceived patient expectations and quick recovery. Business concerns contributed to antibiotics sales among pharmacists. Pharmaceutical industry incentives and healthcare provider competition were the main ethical challenges. Suggested interventional strategies by the participants included creating public awareness, better healthcare provider communication, improved diagnostic support, strict implementation of guidelines, continuing education, and strengthening of regulations. Perceived patient benefit, unrestricted autonomy and business-cum-industry pressures are promoting inappropriate use of antibiotics. Strategies improving responsible use will help preserve their effectiveness, and provide distributive justice and benefit for future generations.

Nested polymerase chain reaction on blood clots for gene encoding 56 kDa antigen and serology for the diagnosis of scrub typhus

PURPOSE Scrub typhus is a zoonotic illness endemic in the Asia-Pacific region. Early diagnosis and appropriate management contribute significantly to preventing adverse outcomes including mortality. Serology is widely used for diagnosing scrub typhus. Recent reports suggest that polymerase chain reaction (PCR) could be a rapid and reliable alternative. This study assessed the utility of these tests for scrub typhus diagnosis. MATERIALS AND METHODS Nested PCR to detect the 56 kDa antigen gene of O. tsutsugamushi was performed on blood clots from 87 individuals with clinically suspected scrub typhus. Weil-Felix test and scrub typhus IgM ELISA were performed on serum samples from the same patients. As a gold standard reference test was not available, latent class analysis (LCA) was used to assess the performance of the three tests. RESULTS The LCA analysis showed the sensitivity of Weil-Felix test, IgM ELISA and PCR to be 59%, 100% and 58% respectively. The specificity of ELISA was only 73%, whereas those of the Weil-Felix test and PCR were 94% and 100% respectively. CONCLUSION Nested PCR using blood clots while specific, lacked sensitivity as compared to IgM ELISA. In resource-poor settings Weil-Felix test still remains valuable despite its moderate sensitivity.

Low prevalence of chlamydial endocervical infection in antenatal south Indian women.

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Antimicrobial activity of amniotic fluid in South Indian women

Samples of amniotic fluid obtained from 48 South Indian women in the third trimester of pregnancy were studied for antimicrobial activity. The growth of Staphylococcus albus, Candida albicans and Clostridium perfringens was inhibited by nearly all samples studied while the growth of Staphylococcus aureus, Escherichia coli and Bacteroides fragilis was inhibited by 50%, 42% and 18% of samples respectively. The growth of Streptococcus faecalis was not inhibited. Using radial immunodiffusion, IgG was measurable in all 10 samples studied (mean 23 mg/dl), whereas IgA was measurable in only three of these samples (mean 1.32 mg/dl). However, while specific IgA against C. albicans was detected by indirect immunofluorescence in 93% of samples, specific IgG against C. albicans was detected in only 26% of samples (P<0.001). Amniotic fluid obtained from parous women had greater inhibitory activity against E. coli (P<0.05) than did the amniotic fluid obtained from nulliparae.

THE GRIESS TEST : AN INEXPENSIVE SCREENING TEST FOR ASYMPTOMATIC BACTERIURIA IN PREGNANCY

EDITORIAL COMMENT: We accepted this paper for publication, even though the test it describes is not new (A), to remind practitioners that this is a method for screening women for asymptomatic bacteriuria in pregnancy without the expense of culturing a mid‐stream specimen of urine. The Griess test will be more familiar to most readers as the detection of urinary nitrates, which is possible using commercially available dipsticks without the necessity for the preparation of the Griess reagent. These dipsticks often also incorporate a test for leucocyte esterase activity. Whilst the individual specificities of the urinary nitrites and leucocyte esterase activity are probably too low to be used as sole screening tests for asymptomatic bacteriuria in pregnancy, the combination of the tests (either test abnormal) has a sensitivity of 92% and a specificity of 95% when compared with formal urine culture (B). The dipstick test is approximately 1/100th the cost of urine culture, so those practitioners who do not perform a urine culture at the booking visit because of cost may wish to consider testing urine for the presence of nitrites and leucocyte esterase activity, and reserving urine culture for those positive for one of the screening tests. Treatment of asymptomatic bacteriuria in pregnancy is associated with a clear and significant decrease in the risk of preterm delivery (C).