Fatima Khan

Rising prevalence of antimicrobial resistance in urinary tract infections during pregnancy: Necessity for exploring newer treatment options

Background: Urinary tract infections (UTI) are one of the most common medical complications of pregnancy. The emergence of drug resistance and particularly the Extended-spectrum beta-lactamase production by Escherichia coli and methicillin resistance in Staphylococci, limits the choice of antimicrobials. Materials and Methods: Patients in different stages of pregnancy with or without symptoms of urinary tract infection attending the antenatal clinic of obstetrics and gynaecology were screened for significant bacteriuria, by standard loop method on 5% sheep blood agar and teepol lactose agar. Isolates were identified by using standard biochemical tests and antimicrobial susceptibility testing was done using Kirby Bauer disc diffusion method. Results: A total of 4290 (51.2%) urine samples from pregnant females showed growth on culture. Prevalence of asymptomatic bacteriuria 3210 (74.8%) was higher than symptomatic UTI 1080 (25.2%). Escherichia coli was the most common pathogen accounting for 1800 (41.9%) of the urinary isolates. Among the gram-positive cocci, coagulase negative species of Staphylococci 270 (6.4%) were the most common pathogen. Significantly high resistance was shown by the gram negative bacilli as well as gram positive cocci to the β-lactam group of antimicrobials, flouroquinolones and aminoglycosides. Most alarming was the presence of ESBL in 846 (47%) isolates of Escherichia coli and 344 (36.9%) isolates of Klebsiella pneumoniae, along with the presence of methicillin resistance in 41% of Staphylococcus species and high-level aminoglycoside resistance in 45(30%) isolates of Enterococcus species. Glycopeptides and carbepenems were the only group of drugs to which all the strains of gram positive cocci and gram negative bacilli were uniformly sensitive, respectively. Conclusions: Regular screening should be done for the presence of symptomatic or asymptomatic bacteriuria in pregnancy and specific guidelines should be issued for testing antimicrobial susceptibility with safe drugs in pregnant women so that these can be used for the treatment. For empirical treatment cefoperazone-sulbactum can be recommended, which is a safe drug, covering both gram positive and gram negative organisms and with a good sensitivity.

Increasing antimicrobial resistance among uropathogens: Is fosfomycin the answer?

Introduction: Urinary tract infection (UTI) is one of the most common infectious diseases in clinical practice. The choice of antibiotics for the treatment of UTI is limited by the rising rates of antibiotic resistance. There is an urgent need to discover new effective treatment solutions. Fosfomycin may be an interesting alternative to the currently used treatments of UTIs. Materials and Methods: The study was conducted over 6 months period (January to June 2013) in Department of Microbiology, JNMCH, AMU, Aligarh. A total of 1840 urine samples were submitted. Culture and sensitivity was done as per standard microbiological procedures. Methicillin-resistant Staphylococcus aureus (MRSA), high-level aminoglycoside resistance (HLAR), extended spectrum beta-lactamases (ESBL), AmpC and metallo-beta-lactamases (MBL) production was detected. Results: Culture was positive in 504 (27.4%) cases. Gram-negative etiology was identified in 390 (73%) cases. ESBL production was detected in 154 (37.1%) while 82 (21.6%) were Amp C. No, MBL was detected. Among Gram-positive bacteria, 68 (51.5%) were MRSA, while 4 (13.3%) were vancomycin resistant enterococci (VRE). HLAR was seen in 53.3% of enterococci. Fosfomycin was effective in 100% of MRSA, VRE, ESBL, HLAR, and overall, susceptibility to fosfomycin in AmpC producers was extremely high (99%). Norfloxacin and cotrimoxazole were not proved effective as only three isolates were sensitive to norfloxacin, while all Gram-negative isolates were resistant to cotrimoxazole. Pseudomonas species showed 65% and 75% susceptibility to colistin and polymixin B, respectively. Conclusion: Fosfomycin has emerged as a promising option, especially in cases involving multi-drug-resistant pathogens in which previous antibiotics have failed to cure the infection.

Emergence of coryneform bacteria as pathogens in nosocomial surgical site infections in a tertiary care hospital of North India

PURPOSE A prospective study was conducted to assess the role of coryneform bacteria in surgical site infections among obstetric and gynecological patients undergoing surgery. MATERIALS AND METHODS The surgery was graded according to the degree of contamination, and surgical site infections (SSIs) were classified as superficial or deep. Pus samples were collected from SSIs according to rigorous aseptic precautions, and the quality of specimens was assessed by Q-score. A detailed clinical and treatment history was elicited from all patients. The samples were processed using standard protocols. Coryneform bacteria were considered significant pathogens only if they fulfilled rigorous clinical and microbiological criteria. Antibiotic susceptibility testing was performed using the Kirby-Bauer method according to the CLSI guidelines. RESULTS In total, 127 patients developed SSIs among 882 postoperative patients. Of these, 89 (70.1%) were culture positive: 40 (44.9%) were Gram-positive cocci, 27 (30.3%) were coryneform, and 22 (24.7%) were Gram-negative bacilli. All coryneform-infected patients had fever and post-operative wound dehiscence leading to a prolonged hospital stay. The most commonly isolated organism was Staphylococcus aureus (33.7%), followed by Corynebacterium amycolatum (11.2%), Escherichia coli (8.9%), Citrobacter spp. (7.8%) and coagulase-negative Staphylococci (6.7%). In our study, 45.5% were ESBL producers, 18.2% were Amp C producers, and 40% were MRSA. All the coryneform bacteria were multidrug resistant, and 51.8% of isolates were sensitive to only gatifloxacin and vancomycin. Symptomatic improvement was observed in all coryneform-infected patients after the administration of appropriate therapy. CONCLUSION Coryneform bacteria appear to be emerging as significant nosocomial surgical site pathogens. The high level of multidrug resistance observed in coryneform bacteria in our study is cause for alarm.

Toxoplasma gondii in women with bad obstetric history and infertility: a five-year study

Abstract Objective To evaluate the role of Toxoplasma gondii in women with bad obstetric (BOH) history and in women with primary and secondary infertility. Methods This study was conducted in the Department of Microbiology, Jawaharlal Nehru Medical College and Hospital for a period of 5 years from January 2004 to December 2009. Quantitative determination of IgM antibodies to Toxoplasma gondii infection was done by IgM capture ELISA in patients with history of BOH or infertility. Results Out of a total of 441 subjects included in the study, 417 (94.6%) had a BOH and 24 (5.4%) subjects had infertility. Toxoplasma was found to be more common in females with two or more abortions 52 (76.5%). Similarly in patients with infertility due to Toxoplasma , secondary infertility (66.7%) was more common than primary infertility. About 40.3% patients with BOH and 20% patients with infertility had healthy live issues after treatment with spiramycin. Conclusions Toxoplasmosis is thus, an easily treatable cause of abortions and infertility. All antenatal females and females with infertility should be screened for toxoplasmosis.

Synergy of drug combinations in treating multidrug-resistant Pseudomonas aeruginosa.

BACKGROUND With the emergence of metallo-betalactamases (MBL) in Pseudomonas aeruginosa (P. aeruginosa), the value of carbapenem, the drug of last resort, is being severely compromised. Curtailing the use of carbapenems becomes paramount if resistance is to be reined in. AIMS To study the role of synergy between combinations of drugs as an alternative treatment choice for P. aeruginosa. Synergy was studied between combinations of levofloxacin with piperacillin-tazobactam and levofloxacin with cefoperazone-sulbactam by time-kill and chequerboard techniques. METHODS P. aeruginosa were tested for antibiotic susceptibility by the disc diffusion assay (260 isolates) and E-test (60 isolates). Synergy testing by chequerboard and time-kill assays was performed with combinations of piperacillin-tazobactam with levofloxacin (11 isolates) and cefoperazone-sulbactam with levofloxacin (10 isolates). RESULTS Nearly all isolates were susceptible to piperacillin-tazobactam (96.1 per cent), followed by piperacillin (78.5 per cent). Seventy-one isolates (27.3 per cent) were found to be multidrug resistant and 19.6 per cent were ESBL producers. MIC50 of amikacin was 32μg/ml and MIC90 was 64μg/ml. MIC50 and MIC90 of cefoperazone-sulbactam was 32μg/ml and 64μg/ml, and for levofloxacin it was 10μg/ml and 240μg/ml, respectively. Piperacillin-tazobactam had MIC50 and MIC90 of 5μg/ml and 10μg/ml, respectively. Synergy was noted in 72.7 per cent isolates for levofloxacin and piperacillin-tazobactam combination, the remaining 27.3 per cent isolates showed addition by both chequerboard and time-kill assay. For levofloxacin and cefoperazone-sulbactam, only 30 per cent isolates had synergy, 40 per cent showed addition, 20 per cent indifference, and 10 per cent were antagonistic by the chequerboard method. CONCLUSION The combination of levofloxacin and piperacillin-tazobactam is a good choice for treatment of such strains.

Assessment of combination therapy by time kill curve analysis and chequerboard assay for treatment of multi-drug resistant Pseudomonas aeruginosa isolates

Multidrug resistant Pseudomonas aeruginosa is a major nosocomial pathogen, and effective therapy presents a great clinical challenge. Combination therapy, employing pre-existing antibiotics, is an attractive approach for the treatment of such infections which may also curtail drug resistance. This study was undertaken with the objectives to assess the synergy of five different antimicrobial combinations (piperacillin-tazobactum with levofloxacin, cefoperazone-sulbactum with levofloxacin, piperacillin-tazobactum with amikacin, cefoperazone-sulbactum with amikacin and amikacin with levofloxacin for the treatment of Pseudomonas aeruginosa isolates with varied susceptibility profile by time kill curve assay and the chequerboard technique. In our study concordance between these two methods was noted in 71.7% isolates tested. Le-Pt combination demonstrated maximum synergy (72.7%), followed by Ak-Le (66.7%) and Ak-Cfs (60%) combination. Le-Cfs and Ak-Pt however, showed synergy in significantly lower number of isolates. However, at sub-MIC concentrations Ak-Pt combination was found to be most effective. Synergy between different drugs should be routinely monitored for exploring more feasible treatment options and to prevent the emergence of multi-drug resistant strains. Piperacillin-tazobactum emerged as a versatile drug whose potential should be explored with other drugs for combination treatment of P. aeruginosa isolates.

Prevalence of genotype D in chronic liver disease patients with occult HBV infection in northern region of India

BACKGROUND Etiology of nearly 30% cases of chronic viral hepatitis remains undetected. Occult HBV infection (OBI) has emerged as an important clinical entity in this scenario. Apart from prevalence and clinical outcome of OBI patients genotype was determined in northern region of India. MATERIALS AND METHODS A total of 847 patients with chronic liver disease (CLD) were screened for common viral etiologies and others serological markers of HBV. Amplification of surface, precore and polymerase genes of HBV was performed in patients negative for other etiologies. Genotyping and sequencing of the precore region was performed for OBI cases. RESULTS Twenty-nine (7.61%) cases of OBI were identifiedof which 9 had chronic liver disease (CHD), 11 liver cirrhosis (LC) and 9 hepatocellular carcinoma (HCC). Majority of OBI cases were detected by amplification of surface gene 26 (89.6%), followed by pre-core gene 12 (41.3%). Their liver functions tests were significantly deranged in comparison to overt HBV cases. IgG anti HBc was present in 8 (27.6%) OBI cases. Mutation was observed in 8 (32%) in pre-core region at nt. 1896 of overt HBV cases. Genotype D was the predominant genotype. IN CONCLUSION OBI in our study was characterized by predominance of genotype D and more severe clinical and biochemical profile in comparison to overt HBV. IgG anti HBc positivity could be utilized as a marker of OBI. We recommend use of sensitive nested PCR for diagnosis of OBI, amplifying at least surface and precore gene.

NDM-1 in the Indian environment: hitherto the problem is not disquieting

Section of Antimicrobial Agents & Drug Resistance Research and Molecular Biology, Department of Medical Microbiology, Jawaharlal Nehru Medical College & Hospital, Aligarh Muslim University, Aligarh-202002, Uttar Pradesh, India Department of Community Medicine, Jawaharlal Nehru Medical College & Hospital, Aligarh Muslim University, Aligarh-202002, Uttar Pradesh, India

Emergence of coryneforms in osteomyelitis and orthopaedic surgical site infections.

BACKGROUND Coryneform species other than Corynebacterium diphtheriae are coming up as important pathogens with the potential to cause serious and life-threatening infections not only in immunocompromised but in immunocompetent individuals as well. The exact infectious potential of these bacteria and their rational antimicrobial treatment is a challenging but essential task. METHOD The study was conducted in the Department of Microbiology and the Department of Orthopaedics, JNMCH, AMU, Aligarh between August 2007 and May 2009. Pus samples were collected from patients of osteomyelitis and other bone infections including orthopaedic surgical site infections. The Corynebacterium species isolated in the study was identified using standard microbiological techniques and antimicrobial sensitivity testing was done by Kirby bauer disc diffusion method. RESULTS A total of 312 Corynebacterium species were isolated. The majority of the coryneforms were isolated from the immunocompetent patients 270 (86.54%). C. jeikium was the most common coryneform isolated. Nearly half of the patients 153 (49.04%) had acute infection caused by Corynebacterium species after orthopaedic surgery, a quarter 66 (21.15%) had chronic infection and 72 (23.08%) patients had device-related infection. Coryneforms exhibited maximum resistance to aminoglycosides (58.65%) and P-lactams (penicillin group- 57.55%. C.jeikium was found to be the most resistant amongst all the Corynebacterium species. CONCLUSION The study highlights the fact that the coryneforms are no longer just opportunistic pathogens but they are also becoming important pathogens among immunocompetent individuals as well. The emergence of drug resistance amongst these isolates is of most concern. More studies should be done on identification and on antimicrobial susceptibility of these organisms for the proper treatment of patients with such infections.

Citrobacter as a uropathogen, its prevalence and antibiotics susceptibility pattern

Introduction: Urinary tract infection (UTI) continues to be the most common infection diagnosed in outpatients as well as in hospitalized patients. Citrobacter spp. is an emerging urinary pathogen. The present study assessed the prevalence and antibiotic sensitivity pattern of Citrobacter spp. in patients admitted to or attending outpatient departments with Complain of UTI in a tertiary care hospital. Materials and Methods: A total of 36,250 urine samples were included in the study. UTI was confirmed in 7099 samples. Of these 246 (3.46%) had UTI due to Citrobacter spp. Identification was by conventional biochemical methods. Antimicrobial susceptibility testing was performed using Kirby-Bauer disc diffusion method as recommended by Clinical and Laboratory Standards Institute M2-A9. Multidrug-resistant (MDR) was defined as resistance to more than two groups of drugs. Extended spectrum beta-lactamase (ESBL), AmpC, and metallo beta-lactamase (MBL) were detected by phenotypic methods. Results: Females predominated in the study 193 (78.4%) with 53 (21.5%) males. Most of the isolates were in the age group 21-30 and 31-40. 49 (19.9%) patients were inpatients, and 197 (80.08%) were outpatients. Aminoglycosides had a better spectrum of antimicrobial sensitivity (70.2%) with 85.2% isolates sensitive to amikacin. Fluoroquinolones had a poor activity against Citrobacter (46% sensitive). Ureidopenicillins had poor efficacy (15.4%). Out of the 246 strains, 129 (52.4%) were MDR, 61 (24.7%) of which were ESBL producers and 65 (26.4%) were AmpC producers. Most of the ESBL producing strains were isolated from inpatients. No MBL were identified in this study. Conclusion: Citrobacter though not uncommon isolate is posing a problem due to its MDR character. Infection control practices should be observed strictly, and any type of unnecessary instrumentation should be avoided.