Manisha Biswal

Hydrogen peroxide vapour for decontaminating air-conditioning ducts and rooms of an emergency complex in northern India: time to move on

Overcrowding and patient overload in emergency services areas often mean that inadequate attention is paid to thorough cleaning, disinfection of rooms and air-conditioning ducts, which would require closing the area concerned. Over a period of time, this leads to accumulation of lint, fibre, dust and fungal growth. This study assessed the effectiveness of hydrogen peroxide fog to decontaminate the air-conditioning ducts as well as for room disinfection without having to close down the area. The Postgraduate Institute of Medical Education and Research emergency complex, Chandigarh, is distributed over three floors housing nine air-handling units (AHUs) and seven wards. The work was carried out over a period of seven days and involved cleaning of air-conditioning ducts and wards, cleaning and disinfection of fittings and furniture, vacuuming and fogging of AHU, ducts and room air. Fogging was done with 20% Ecoshield fog, a complex formulation of stabilised hydrogen peroxide 11% w/v with 0.015% w/v silver nitrate. Pre- and post-fogging samples were taken for microbiological culture, and air samples were also collected. Hydrogen peroxide fogging was highly effective for disinfection of room air, furniture and other articles. It decontaminated the air-conditioning ducts effectively, was rapid and cheaper than formalin, and no adverse effects were noted. There was minimum disturbance to the patients and the treated areas were ready to be populated again after 5-6h. Hydrogen peroxide has the advantage of being safer, less irritating, and has shorter cycle times compared with formalin fumigation which is more commonly practised in India.

Intensive care unit-acquired infections in a tertiary care hospital: An epidemiologic survey and influence on patient outcomes.

BACKGROUND AND OBJECTIVE Nosocomial infections are common in intensive care units (ICUs), but the pattern of infections and the distribution of microorganisms vary. We studied the ICU-acquired infections and their effect on patient outcomes in our ICU. METHODS Patients admitted to our ICU for >48 hours were studied prospectively over a year. Infections were diagnosed based on Centers for Disease Control and Prevention guidelines. Antibiotics were administered based on culture and sensitivity. Univariate and multivariate logistic regressions were carried out to determine the factors associated with infection. RESULTS One hundred ninety-eight patients were studied. The crude infection rate was 50% with ventilator-associated pneumonia (40%) and bloodstream infection (21%) being the most common. Acinetobacter calcoaceticus-baumannii complex, Pseudomonas aeruginosa, and Klebsiella pneumoniae were the most common microorganisms. More than 90% of patients received antibiotics, the most common being β lactam-β lactamase inhibitors, aminoglycosides, fluoroquinolones, and carbapenems. Thirty-five percent of staphylococci were methicillin-resistant, 50% of Enterococcus strains were vancomycin-resistant, and 68% of Acinetobacter calcoaceticus-baumannii complex, 47% of Pseudomonas strains, and 35% of Klebsiella strains were multidrug-resistant. A longer duration of ventilation was associated with infection. The overall ICU mortality rate was 24% and was similar in patients with or without infection. CONCLUSIONS The incidence of infection and the multidrug resistance in the ICU was high. Infection was associated with duration of ventilation but not mortality.

Outbreak of scrub typhus in North India: a re-emerging epidemic

Scrub typhus is re-emerging in India. We describe an outbreak of 45 cases from our tertiary care center in north India. This outbreak included city dwellers who had no history of travel to hilly areas. The classical feature of scrub typhus, the eschar, was also noted rarely in these patients. The changing epidemiology of scrub typhus should be kept in mind while attending patients with acute febrile illness.

Scrub Typhus in a Tertiary Care Hospital in North India

Scrub typhus, a zoonotic disease caused by the bacterium Orientia tsutsugamushi, has become endemic in many parts of India. We studied the clinical profile of this infection in 228 patients that reported to this tertiary care center from July 2013 to December 2014. The median age of patients was 35 years (interquartile range = 24.5-48.5 years), and 111 were males and 117 females. A high-grade fever occurred in 85%, breathlessness in 42%, jaundice in 32%, abdominal pain in 28%, renal failure in 11%, diarrhea in 10%, rashes in 9%, and seizures in 7%. Common laboratory abnormalities at presentation were a deranged hepatic function in 61%, anemia in 54%, leukopenia in 15%, and thrombocytopenia in 90% of our patients. Acute kidney injury (32%), acute respiratory distress syndrome (ARDS) (25%), and disseminated intravascular coagulation (DIC) (16%) were the commonest complications. A hepatorenal syndrome was seen in 38% and multiple organ dysfunction syndrome (MODS) in 20% patients. The overall case fatality rate was 13.6%. In univariate analysis, ARDS requiring mechanical ventilation, acute kidney injury requiring hemodialysis, hypotension requiring inotropic support, central nervous system dysfunction at presentation, and MODS were inversely associated with survival. Survival was significantly higher in patients that presented with a duration of fever < 10 days compared with those that presented ≥ 12 days (P < 0.05) after onset. In conclusion, scrub typhus has become a leading infectious disease in north India and an important cause of infectious fever. An increasing awareness of this disease coupled with prompt management will go a long way in reducing both morbidity and mortality from this disease.

Adherence to hand hygiene in high-risk units of a tertiary care hospital in India

To improve the compliance to hand hygiene in our health care workers, 3 hand hygiene awareness weeks have been conducted over the past one-and-a-half years in our hospital. This observational audit conducted from October 2011 to March 2012 was planned to assess the impact of the above awareness drives. Although overall compliance increased significantly in 7 intensive care units from 23.1% to 41.2% (P < .0001), several deficiencies were noticed both in technique used as well as during specific opportunities of hand hygiene.

Point prevalence surveys of healthcare-associated infections and use of indwelling devices and antimicrobials over three years in a tertiary care hospital in India

Few hospitals in India perform regular surveillance for healthcare-associated infections (HAIs) and use of indwelling devices and antimicrobials. The aim of this study was to conduct two one-day point prevalence surveys of HAIs and use of indwelling devices and antimicrobials in a large 1800-bed tertiary care hospital in India. The overall prevalence of HAIs was 7%, and surgical site infections were the most common (33%). Indwelling devices were present in 497 (27%) patients, and 915 (50%) patients were receiving antimicrobials. This study helped to generate robust baseline data on the prevalence of HAIs and use of indwelling devices and antimicrobials in the study hospital.

Hepatitis E Virus Induced Acute Liver Failure with Scrub Typhus Coinfection in a Pregnant Woman

Coinfections contribute significantly to diagnostic challenges of acute febrile illnesses, especially in endemic areas. The confusion caused by overlapping clinical features impedes timely management. Herein, we report an unusual, previously unreported case of a pregnant woman suffering from a coinfection of scrub typhus and hepatitis E virus. A 25-year-old, 31-week pregnant woman presented with jaundice for 5 days and altered sensorium for 2 days. She had features of both viral acute liver failure (ALF) and tropical infections mimicking ALF, including hyperbilirubinemia, coagulopathy, anemia, thrombocytopenia, intravascular hemolysis, and hepatosplenomegaly. Etiological workup revealed rare coinfection of hepatitis E and scrub typhus. Despite all supportive measures, the patient succumbed to her illness (i.e., absent brainstem reflexes and intracranial bleed secondary to coagulopathy) and had poor fetal outcome, which resulted in stillbirth. ALF in a pregnant woman is a medical and obstetric emergency. It can result from varied etiologies that though differ in their incidence, mode of occurrence, and pregnancy outcome, can clinically masquerade as each other, causing diagnostic dilemma. This unusual case report highlights the significance of keeping all such possibilities in mind while managing a pregnant woman with ALF, especially in a country like India where maternal and perinatal mortality rates, the core indicators of national health, are still among the highest in the world.

Syphilis serology in human immunodeficiency virus patients: a need to redefine the VDRL test cut-off for biological false-positives.

The interpretation of non-treponemal and treponemal specific serological tests in a population where syphilis and human immunodeficiency virus (HIV) are endemic may not be straightforward (Augenbraun et al., 1994). The VDRL test for syphilis screening may, under certain circumstances, yield positive results in patients not infected with Treponema pallidum (biological false-positive reaction). In contrast, treponemal antibody tests such as the T. pallidum particle agglutination (TPPA) test have a high specificity, but in HIV-infected patients false-negative reactions have been reported (Erbelding et al., 1997; Gwanzura et al., 1999). A retrospective study was carried out to test the adequacy of VDRL as a screening test for the diagnosis of syphilis in HIV patients and to estimate the prevalence of HIV–syphilis coinfection in the North Indian population.

Working awareness of healthcare workers regarding sterilisation, disinfection, and transmission of bloodborne infections and device-related infections at a tertiary care referral centre in north India.

MacConkey agar and were incubated again for 24–48 h. The bacteria were then identified through standard microbiological techniques. The sterile gloves exhibited no growth. The open box glove results are shown in Table I. Nine out of ten open box gloves sampled were contaminated with bacteria, none of which were of high virulence. The keyboard and mouse cultures were positive for: Pseudomonas luteola, Bacillus sp., Ewingella americana, viridans Streptococcus, coagulase-negative Staphylococcus, Stenotrophomonas maltophilia. Open box gloves in labour and delivery rooms are unlikely to be fomites. This study did not identify any major or virulent pathogens, only common environmental bacteria. Althoughmore glove samples over a greater period of timemay have demonstrated a knownpathogen, that finding would not have been due to gloves per se, but an indication of poor compliance to hand hygiene. The rates of crosscontamination are unlikely to change no matter the hospital type or acuity level, as longashandwashing isparamount. A literature search failed to identify any cases of chorioamnionitis, endomyometritis, or early neonatal infectionwith any of the bacterial species identified in the open box gloves. These are ubiquitous environmental bacteria, only associated with illness in cases of immunosuppression or indwelling foreign bodies. Interestingly, neither of the positive control keyboard and mouse cultures grew major pathogens. Most intrauterine infection is the result of ascendingbacteria from the vagina rather than infection from extraneous sources. Common vaginal flora that are found in the absence of infection include everything from Bacteroides spp. to Escherichia coli.5 The bacteria found on the open box gloves are certainly less virulent than the bacteria commonly found in the vagina. Chlorhexidine solution vaginal cleansing during labour does not reduce infection.6 Furthermore, use of sterile technique, including gowns, gloves, and liberal use of iodine solution, during vaginal examinations and insertion of intrauterine monitors does not decrease intra-amniotic infection.7 Another consideration is fiscal and environmental cost. The difference in price between an open box glove and a single packaged sterile glove is 100-fold. Using open box gloves for the first vaginal examination in all women who delivered in 2008 would have saved more than £21,000 (

Evaluation of commercial boric acid containing vials for urine culture: Low risk of contamination and cost effectiveness considerations

35,000). The open box glove also has less waste with one cardboard box per 100 gloves and thus a smaller environmental impact when compared to a sterile packaged glove, which has two outer shells. A limitation of this study is that aerobic culture techniques were used.8 Polymerase chain reaction techniques might have demonstrated bacteria that traditional culture cannot, such as mycoplasma or ureaplasma. We also used open box gloves from a variety of rooms without documenting how long each box had been opened to show ‘typical use’ bacterial loads. As glove sampling occurredwithout the staff having beenwarned, and the rooms from which the gloves were sampled were in active use, it is highly probable that our results reflect typical use.