Prabhav Aggarwal

Increasing antimicrobial resistance of campylobacter jejuni isolated from paediatric diarrhea cases in a tertiary care hospital of new delhi, India.

INTRODUCTION The resistance to the clinically important antimicrobial agents, particularly the fluoroquinolones and the macrolides, is increasing among the Campylobacter isolates. Only limited data is available regarding the changing antimicrobial resistance pattern in the Indian scenario. METHODOLOGY Three hundred fifty cases (ages ≤12years) of acute diarrhoea, who were admitted to a tertiary-care hospital, were investigated for Campylobacter spp. The antimicrobial susceptibilities of all the C. jejuni isolates were assessed by the disk diffusion method according to the CLSI guidelines. RESULTS A total of 36 isolates of C. jejuni were tested for their antimicrobial susceptibilities. A high degree of resistance to the fluoroquinolones (100% to Nalidixic acid and 86.66% to Ciprofloxacin) was detected in the Campylobacter isolates. The frequency of resistance against Tetracycline was 33.33% and that against Erythromycin was 22.2%. Fifteen (41.66%) isolates were multiresistant, being resistant to 3 or more antimicrobial agents. CONCLUSIONS An increased resistance to the quinolones and the macrolides and multidrug resistance warrant a reconsideration of their use as the drugs of choice in patients with severe gastroenteritis when Campylobacter is the presumed cause.

Clinical and Microbiological Profile of HIV/AIDS Cases with Diarrhea in North India

Intestinal infections are a significant cause of morbidity and mortality in people living with HIV/AIDS (PLWHA) especially in developing countries. The present study was conducted to assess the clinical and microbiological spectrum in HIV/AIDS cases with diarrhea and to correlate the occurrence of such pathogens with stool characters, HIV seropositivity status, and CD4 counts. Stools from 154 HIV seropositive subjects and 50 HIV negative controls were examined by direct microscopy, fecal cultures, and serological tests (Clostridium difficile Toxin A, Cryptosporidium antigen, and Entamoeba histolytica antigen ELISA). CD4 T cell enumeration was done using FACS count (Becton Dickinson). The study showed a male preponderance (112 males and 42 females). Weakness, abdominal pain, and anorexia were the most common symptoms. Coccidian parasites were the most common cause of diarrhea in HIV seropositive cases. C. parvum was seen in 60.42% while Isospora belli in 9.03%. Amongst the bacterial pathogens C. difficile was detected in 18.06%, diarrheagenic Escherichia coli in 11.11%, and Shigella spp. in 2.78%. Pathogen isolation rates were more in HIV seropositive cases and subjects with low CD4 T lymphocyte counts. Regular monitoring of CD4 T lymphocyte counts and screening for enteric pathogens will help improve the quality of life for PLWHA.

Sexually transmitted infections and HIV in self reporting men who have sex with men: A two-year study from India

Homosexuality is not legally and socially accepted in India. Thus, this area of research has largely been ignored by Indian authors, resulting in dearth of knowledge, particularly with respect to sexually transmitted infections (STIs) in this high-risk group. Over a period of two years (2013-2014), 738 males sought care at skin and venereal diseases clinics, 52 (7.05%, 95% CI=5.4-9.14%) of who identified themselves as MSM and were enrolled in the study. Diagnosis was made on the basis of clinical presentation and laboratory testing, wherever indicated. Thirty six percent of MSM had only homosexual preferences, while 64% were bisexual. The most common sexually transmitted infection was genital warts (23.08%, 95% CI=13.58-36.28%). Fourteen patients (26.92%, 95% CI=16.67-40.35%) were VDRL and TPHA positive (two, five and four with primary syphilis, secondary syphilis and latent syphilis, respectively). These were followed by genital herpes (11.54%, 95% CI=5.03-23.34%), genital molluscum contagiosum (9.62% 95% CI=3.75-21.04%), and gonorrhea (5.77%, 95% CI=1.38-16.25%). Of those tested, 23.08% (95% CI=13.58-36.28%) of patients were reactive for HIV serology. Thus, MSM is a high-risk group with high prevalence of HIV and other STIs in this group, mandating greater focus, education and counseling.

A comparative study of bacterial and parasitic intestinal infections in India.

BACKGROUND Infectious diarrhea causes a major health problem in developing countries with significant morbidity and mortality. Very often, rehydration therapy alone does not suffice, mandating the use of antimicrobial agents. However, rapidly decreasing antimicrobial susceptibility is complicating the matters. MATERIALS AND METHODS The study aimed to determine the prevalent bacterial and parasitic agents of diarrhea in India. A cross-sectional study was done at Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi, during 2012-14. Stool samples were received from patients of all age groups and processed for bacteriological and parasitological identification by microscopy, bacterial culture, biochemical identification, serotyping and antimicrobial susceptibility tests. The study also aimed to identify the recent papers (after year 2000) reporting aetiology of infectious diarrhea in India involving the general population as a whole and compare them with present findings. RESULTS Out of 6527 samples, 581 (8.90%) were positive for bacterial pathogens. A total of 280 samples (of 3823 under-five year children) were positive for diarrheagenic Escherichia coli. Other organisms like Vibrio cholera were found in 159 (2.44%) cases, Shigella spp. in 126 (1.93%), Salmonella Typhi in 7 (0.11%), Salmonella Typhimurium in 6 (0.10%), Aeromonas hydrophila in 3 (0.05%) cases. Levels of resistance to nalidixic acid, amoxicillin and ciprofloxacin were alarmingly high. Third generation cephalosporins were seen to be moderately active except against E. coli. Parasites were identified in 312 (4.78%) cases. Giardia intestinalis, Ascaris lumbricoides and Entamoeba histolytica were identified in 2.27%, 1.15% and 0.64% cases respectively. CONCLUSION Analysis of recent nationwide studies revealed V. cholerae was the most common bacterial/parasitic agent of diarrhea across all populations, being followed by diarrheagenic E. coli and Giardia intestinalis. Periodic laboratory monitoring of antimicrobial susceptibility pattern is essential, as is formulation of effective antibiotic use policy.

Seroprevalence of Toxoplasma among HIV infected and HIV non-infected individuals in North India

Abstract Objective To determine the seroprevalence of Toxoplasma infection in the HIV infected and HIV non-infected individuals in our region, including antenatal women. Methods Five mL of blood sample was collected from a total of 1 181 individuals aged 12 years and above. These included 661 (55.9%) from HIV positive patients and 520 (44.1%) from HIV negative individuals. A total of 238 samples out of the 520 HIV negative patients were collected from the antenatal women. Demographic profile of the subjects was recorded. Immunoglobulin G ELISA was performed for all the samples, while only the samples received from antenatal women were tested by immunoglobulin M capture ELISA. Results Seroprevalence among HIV infected and non-infected was found to be 21.3% (95% confidence interval = 18.4%−24.6%) and 14.2% (95% confidence interval = 11.5%−17.5%), respectively. The difference was statistically significant ( P = 0.003). No significant gender differences were found. Seroprevalence increased from 9.1% to 30% with increasing age in the HIV infected patients. Only 2 (0.84%) samples of antenatal women were positive for immunoglobulin M capture ELSIA, while one sample was equivocally reactive. Conclusions Seroprevalence of latent toxoplasmosis in our region is moderately high, particularly in the HIV infected patients, exposing them to the risk of reactivation. This suggests that serologic testing of all HIV infected patients is essential to initiate Toxoplasma prophylaxis. Similarly, screening for active Toxoplasma gondii infection during antenatal care and preventive education is essential to prevent and minimize congenital toxoplasmosis.

Enteric Pathogens, Immune Status and Therapeutic Response in Diarrhea in HIV/AIDS Adult Subjects from North India

Intestinal infection causing diarrheal disease is a dominant contributor to high morbidity and mortality in developing countries. This intervention study aimed to assess the response of specific anti-microbial and anti-retroviral therapy (ART) on enteropathogens identified in HIV/AIDS adult subjects from northern India. Seventy five ART naive (group 1) and seventy five ART adherent (group 2) HIV/AIDS adult subjects with diarrhea were enrolled. Stool samples from all subjects were examined for enteropathogens by wet mount, staining methods, culture and ELISA. Subjects with enteropathogens were started on specific therapy as per National AIDS Control Organisation, Government of Indias guidelines. Follow-up stool samples were examined after 2-4 weeks of completion of therapy for persistence/clearing of enteropathogens. CD4+ T lymphocyte count was done for all subjects. At enrollment, group 1 had 26.13% bacterial, 57.66% parasitic & 16.22% fungal pathogens while group 2 had 11.9%, 69.05% & 19.05% pathogens, respectively. Parasitic diarrhea was more common than bacterial diarrhea. The coccidian parasites (Cryptosporidium spp. & Isospora belli) were the common parasites identified. Clearance of enteric pathogens was significant after specific anti-microbial therapy (p = 0.0001). Persistence of enteropathogens was seen primarily for coccidian parasites. Clearance of enteropathogens after specific therapy and the diagnostic yield of stool specimens were influenced by the CD4+ counts. Immune competence coupled with specific anti-microbial therapy displays the best response against enteric pathogens.

Correlation between venereal diseases research laboratory titers and CD4 T-lymphocyte count determined by flow cytometry in HIV-infected adults: A 5-year study

Introduction: Venereal Diseases Research Laboratory (VDRL) is one of the key tests for the diagnosis of syphilis; however in HIV-positive individuals, it has been reported to give inappropriate results at times. Thus, this study was conducted to determine if the VDRL test titers vary with the severity of immunosuppression as determined by CD4 cell count. Materials and Methods: A total of 2630 samples from HIV-positive adults were tested by qualitative and quantitative VDRL test and if reactive, by Treponema pallidum hemagglutination (TPHA) test. CD4 cell counts were determined at the same time by flow cytometry (BD FACSCount™ system). Correlation between CD4 T-lymphocyte cell count and VDRL titers was sought for. Results: Nearly 6.7% (176/2631) of individuals were VDRL reactive, males more than females (7.6% vs. 5.1%, P = 0.014). Four of the VDRL-reactive patients were found negative by TPHA test and were excluded from further study. VDRL titers ranged from weakly reactive to being reactive at 1:128 (median = 1:2). The CD4 cell count ranged from 23 cells/μl to 883 cells/μl (median = 276 cells/μl, mean = 323.9 ± 200.9). Pearsons coefficient of correlation (R) between CD4 cell count and VDRL titers was calculated to be 0.0559; coefficient of determination (R2) was 0.0031. Conclusions: Although the correlation coefficient shows a positive correlation, the association was very weak. Therefore, CD4 cell count cannot be expected to influence VDRL titers in HIV-positive adults significantly.

Utility of Laboratory Diagnosis for Confirmation of the Syndromic Case Management in Married Indian Women with Vaginal Discharge

OBJECTIVE WHO and NACO recommend treatment of STIs/RTIs on the basis syndromic case management (SCM), even without laboratory confirmation, which may lead to over-treatment. Thus, this study was conducted to evaluate the utility of laboratory diagnosis for confirmation of patients with vaginal discharge diagnosed on the basis of SCM. METHODOLOGY 234 married women in reproductive age group, diagnosed as having vaginal discharge syndrome were included. Normal saline wet-mount slide preparations were made for detection of motile trichomonads. Gram stained smear were prepared and scored as per classification developed by Nugent. The presence of pseudohyphae and/or budding yeast cells was considered diagnostic of candidal infection. VDRL, TPHA and HIV testing were also done as per protocol. RESULTS The median age of the study population was 34 years. Most common cause was bacterial vaginosis (positive= 21.4%, 95% CI= 16.6-27.1%; intermediate score= 17.5%, 95% CI= 13.2-22.9%), followed by candidiasis (13.7%, 95% CI= 98-18.7%) and trichomoniasis (0.4%, 95% CI= 0-2.6%). No etiological diagnosis for vaginal discharge could be established in approximately half of the women. Only two women were HIV positive; one was reactive by VDRL and TPHA tests. CONCLUSION Our study highlights the possible lacunae in SCM. Large number of patients may be over-treated if only syndromic management is followed, with financial, medical and social implications. Thus we recommend, the treatment maybe initiated on the basis of SCM, but it is essential that laboratory diagnosis is sought for and the treatment modified accordingly.