Mallika Sengupta

Scrub typhus continues to be a threat in pregnancy

Scrub typhus, a zoonosis, caused byOrientia tsutsugamushi is a widely prevalent disease in the Asia–Pacific region. It is transmitted by the bite of the larval trombiculid mite. The clinical features are similar in pregnant and nonpregnant women and include high fever with chills, myalgia, and headache. The eschar is a 5 to 20-mm necrotic lesion on the skin at the site of the vector bite. It is present in 60% of scrub typhus patients and, if present, is pathognomonic for the disease [1]. Scrub typhus can lead to various complications such as pneumonia, acute respiratory distress syndrome, myocarditis, liver failure, acute renal failure, encephalitis, and shock. Opinion varies on the effects of scrub typhus in pregnancy. The aim of the present study was to evaluate the effect and outcome of scrub typhus infection in pregnancy. The medical records of 46 pregnant women with scrub typhus treated at the Christian Medical College, Vellore, India, between January 1, 2011, and December 31, 2012, were reviewed. Patients who had fever at least one day before deliverywere included. Data for four patients were not available and these patients were excluded. The retrospective nature of the study rendered it exempt from informed consent and IRB approval. The patients’ serum was tested for IgM antibodies to Orientia tsutsugamushi using the Scrub Typhus Detect IgM ELISA System (Inbios International Inc, Seattle, WA, USA). The test was performed according to the manufacturer’s instructions and a positive result was identified as an optical density of greater than or equal to 0.5. All 42 pregnant patients included in the study were IgM ELISA positive for scrub typhus. A total of 28 (67%) patients delivered live healthy fetuses, while 14 (33%) patients had pregnancy loss. Of the 6 (14%) patients in the first trimester, 4 (67%) had a spontaneous abortion. Among 16 (38%) patients in the second trimester, 6 (38%) experienced pregnancy loss. Of the 20 (48%) patients in the third trimester, 4 (20%) had an intrauterine death. There was one maternal death due to the infection. In the general population the standard rates of pregnancy loss across all trimesters, in the first trimester, and in the early and late second trimester are 10%−20% [2], 12%–24% [3], and 1%−5% and 0.3% [2], respectively. In the third trimester the background occurrence of stillbirth is 1%−3% [4]. During the study period, there were an average of 1128 pregnant patients per month, with a live birth rate of 97.2% and a pregnancy loss rate of 2.8%. Therefore, pregnancy loss in patients infected with scrub typhus is significantly higher in this setting (33% vs 2.8%; P b 0.001). The hospital is a tertiary care and referral center and the mode of delivery was similar in both groups: 30.5% lower section cesarean delivery rate in the general population compared with 32.7% in patients with scrub typhus. Regarding the associated risk factors, two patients were hepatitis B surface-antigen positive: onehad a live birth and onehad a spontaneous abortion. Three patients had hepatitis E infection: one had a live fetus and two had fetal loss. All patients were younger than 35 years (range, 20−33 years; mean 24.3 years). None of the patients had any associated medical risk factors such as diabetes or hypertension. We could not find any relation between parity and fetal loss. None of the patients had a background of recurrent pregnancy loss or poor obstetric history. All of the patients had fever greater than or equal to 38.3 °C and 15 (36%) patients had an eschar. Among the 14 patients with pregnancy loss, 8 (57%) had an eschar. IgM ELISA is a reliable test for sero-diagnosis of scrub typhus. The optical density value of IgM ELISA for these patients was between 0.656 and 3.336, with a mean of 2.624. Only two of the 42 patients had an optical density value of less than or equal to 1.5. In our experience, optical density of greater than or equal to 1.5 has a very high specificity for scrub typhus. In conclusion, scrub typhus infection in pregnancy carries a high risk of fetal loss. The risk is highest in the first trimester and decreases with advancing gestational age. However, this correlation needs further evaluation in large prospective studies.

Fosfomycin susceptibility among multidrug-resistant, extended-spectrum beta-lactamase-producing, carbapenem-resistant uropathogens

Introduction: Urinary tract infection (UTI) is one of the most common infectious diseases. With the emergence of multidrug resistance (MDR), therapeutic options for treatment of UTIs are becoming limited. Fosfomycin has emerged as a novel oral therapeutic option with bactericidal activity against the MDR uropathogens. We evaluated the susceptibility pattern of uropathogens to this antibiotic. Methods: A prospective study was conducted for 6 months in a tertiary care hospital in Eastern India to evaluate whether the common uropathogens were susceptible to fosfomycin. Identification of organisms causing significant bacteriuria was done by conventional biochemical and VITEK 2 Compact System™. Antimicrobial susceptibility testing was performed against these pathogens by Kirby-Bauer disc diffusion method. Minimum inhibitory concentrations were measured for certain drugs by E-strips and VITEK 2 Compact System. Results: A total of 2229 urine samples were referred for culture during the study period, which yielded 356 significant bacterial isolates. Among these isolates, 64.78% were extended-spectrum beta-lactamases producers, 15.97% were carbapenem-resistant Enterobacteriaceae, and 42.7% isolates were found to be MDR Enterobacteriaceae (MDRE). However, 95.18% of the total isolates and 95.93% of MDRE were found to be susceptible to fosfomycin. Conclusion: The common uropathogens, including MDR isolates, show high in vitro susceptibility to fosfomycin, which therefore has the potential to emerge as a promising alternative oral agent for outpatient therapy of UTIs.

Cystic echinococcosis: A neglected disease at usual and unusual locations

Echinococcus granulosus causes a zoonotic infection called cystic echinococcosis (CE) or more commonly known as hydatid disease. Although the two most common locations of hydatid cyst are liver and lung, it may also appear in other parts of the body. Clinical presentation of the hydatid disease depends on the site and size of the lesion. A retrospective study was done in Medical College and Hospital, Kolkata, from January 2012 to June 2014, to find the site of involvement, distribution, clinical features, history of contact, mode of presentation, laboratory diagnosis, and treatment modalities of the cases of hydatid cyst. The cases were identified by radiological and laboratory methods, the data were entered in Excel spreadsheet, and analysis was done. Among the 21 cases of hydatid cyst included in the study, solitary hepatic involvement was seen in 11 (52.38%), pulmonary involvement in 4 (19%), and 6 (28.71%) were in unusual locations such as liver cyst extending as retroperitoneal, omental cyst, choledochal cyst, splenic cyst, and in hepatorenal pouch. History of contact with dog was seen in 15 (71.43%). All the patients were treated with surgery and albendazole and were discharged in healthy condition. CE may be present in usual and unusual locations with a lot of variations in the clinical features. Hence, proper radiological and laboratory diagnosis is required for accurate diagnosis and appropriate management of these cases.

Early Onset Neonatal Septicaemia Caused by Pantoea agglomerans

Pantoea agglomerans is an opportunistic pathogen causing infection in the immunocompromised patients. It is a plant pathogen and a rare human pathogen causing neonatal sepsis, joint infection, urinary tract infection and bloodstream infections. Neonatal Gram negative septicaemia may have an unusual presentation of subtle generalised neonatal seizures without any other cardinal features of sepsis. An appropriate diagnosis is therefore the key to proper management. P. agglomerans being an unusual cause of neonatal sepsis should be diagnosed early with proper antibiogram for clinical cure. Here, we report a case of neonatal sepsis caused by P. agglomerans in a tertiary care hospital in Eastern India.

Scrub Typhus Seroprevalence in Healthy Indian Population.

Scrub typhus, a zoonosis caused by Orientia tsutsugamushi, is an important cause of acute febrile illness in India. This preliminary study determines the seroprevalence of scrub typhus in healthy Indian adults by measuring IgM and IgG antibodies to scrub typhus by ELISA in 100 healthy blood donors. Our study demonstrates a 15% seroprevalence of scrub typhus in adults. Further studies are needed to confirm these findings especially in children.

Outstanding Prevalence of Methicillin Resistant Staphylococcus aureus in Neonatal Omphalitis

INTRODUCTION Omphalitis is the infection of the umbilical cord stump, which can lead to septicaemia and significant neonatal morbidity and mortality. Very little data is available on the aetiology of neonatal omphalitis in India. AIM To identify the causative agents of omphalitis in neonates and determine the antimicrobial susceptibility patterns of the isolates. MATERIALS AND METHODS A prospective study was conducted at ESI-PGIMSR and ESIC Medical College, Joka, a tertiary care teaching hospital in Eastern India for a period of four months (from 1st January 2016 to 30th April 2016). Neonates were screened for omphalitis on the basis of presence of pus and redness for inclusion. Clinical examination, Gram stain and culture of umbilical discharge, identification of organisms by biochemical tests and VITEK 2 Compact (bioMereiux Inc., France) was done. Antimicrobial susceptibility by Kirby Bauer disc diffusion method and E-strip agar diffusion method (for vancomycin and teicoplanin) were performed and interpreted according to the Clinical and Laboratory Standards Institute (CLSI) guidelines version 2015. RESULTS A total of 623 neonates were screened, among whom 21 (3.37%) were positive for our screening criteria for omphalitis. Cultures from the exudates of those cases yielded growth of Staphylococcus aureus in 19 (90.47%) samples, all of which were found to be methicillin resistant Staphylococcus aureus (MRSA). Resistance to erythromycin was seen among 36.82% isolates and inducible clindamycin resistance was seen among 31.57% isolates of Staphylococcus aureus. CONCLUSION MRSA can be the most common cause of omphalitis. However, this finding needs to be evaluated in larger prospective studies.

In vitro activity of levofloxacin against lower respiratory tract pathogens.

Background: Considerable morbidity and mortality are associated with lower respiratory tract infections (LRTIs) that put a considerable strain on the health budget. Selection of appropriate antibiotics as empirical therapy maximizes positive patient outcomes, and that depends on regular surveillance of infective agents and their antibiograms, which vary according to the geographical areas. Aim: The aim was to study the drug susceptibility pattern of the isolated pathogens of the respiratory tract infections. Settings and Design: Retrospective study for a period of 1-year 3 months from January 2013 to March 2014 at a Tertiary Care Hospital. Materials and Methods: Eleven hundred and eighty-four sputum samples from both outdoor and indoor patients with symptoms of LRTI were processed, and antibiotic sensitivity test was done to commonly used antibiotics. Descriptive statistics was used to analyze the data. Results: Among 502 quality sputum samples, 312 (62.15%) samples showed growth of pathogenic bacteria. The most common pathogens were Klebsiella spp. (38.14%), Moraxella spp. (16.02%), Streptococcus pneumoniae (14.10%), Pseudomonas spp. (9.93%), S. aureus (9.29%). It was found that the overall susceptibility pattern was <50% for amoxicillin, amoxicillin-clavulanic acid, cefuroxime, cotrimoxazole and erythromycin whereas for cefotaxime, cefixime, and cefoperazone-sulbactum it was 60.08%, 51.59%, 69.04%, respectively. The susceptibility to ciprofloxacin, ofloxacin, and levofloxacin were 66.67%, 70.19% and 83.33%, respectively. Conclusion: Klebsiella spp. was the most common LRTI pathogen. There was limited activity of amoxicillin, amoxicillin-clavulanic acid, cefuroxime, cotrimoxazole and erythromycin for the treatment of LRTI whereas levofloxacin, (being an oral drug with good compliance) had good activity against respiratory pathogens and could be used for empiric treatment in LRTI.

The bug with the metallic gun - in the corridors of a peripheral medical college and hospital, India

Context: Pseudomonas aeruginosa is an obsessive invader in the hospitals worldwide. It has powerful antibiotic resistance mechanisms, one of such being metallo beta lactamase, which is taking away from our hands our last resort, carbapenem group of antibiotics, to fight them. Not only they possess this metallic gun, they are exceptionally good gun dealers also, as the genes producing this metallo beta lactamase resides on plasmids and hence, are easily and efficiently transferrable among other bacteria, Thus it becomes a present day concern to detect the presence of MBL positive Pseudomonas aeruginosa in every hospital to have a powerful and effective antibiotic regimen in the future also. Aims: To determine the presence and extent of MBL positive Pseudomonas aeruginosa in a Midnapore Medical College, West Midnapore district, West Bengal, India. Materials and Methods: A total of 630 samples were processed, out of which 112 isolates of Pseudomonas aeruginosa were found. Among these, 20, were found to be imipenem resistant and these were subjected to EDTA impregnated imipenem disc potentiation test. Discussion: Out of 112 P. aeruginosa , 8 isolates (7%) turned out to be MBL producers. Also, a high susceptibility pattern was found for aminoglycosides. Conclusion: Although we found a low prevalence of MBL producing P. aeruginosa , still it is worrisome. Constant vigilance and careful selection of antibiotics are necessary.