Purva Mathur

Epidemiology of candidaemia in critically ill trauma patients: experiences of a level I trauma centre in North India

There is a need to understand the epidemiology and risk factors associated with candidaemia in critically ill trauma patients. The rise in incidence of non-albicans candidaemia and the emergence of antifungal resistance have made such a study necessary. A prospective laboratory-based surveillance study was performed over a period of 21 months (April 2008-December 2009) at a level I trauma centre in New Delhi, India. All blood culture samples positive for Candida were processed for microbial identification by standard methods. Identification was carried out by conventional methods, using chromogenic medium (CHROMagar Candida) and by the automated Vitek 2 system. These isolates were characterized for their susceptibility to amphotericin B, fluconazole, flucytosine and voriconazole. Eighty-nine episodes of candidaemia occurred in 89 patients during the study period. The incidence was 0.71 episodes per 1000 patient days. A total of 136 Candida isolates were obtained, with non-albicans Candida species accounting for over 80 %. Candida rugosa, a rarely isolated pathogen, accounted for 25 (18.4 %) of the isolates, and 5.9 % of the isolates were resistant to fluconazole. None of the isolates showed resistance against amphotericin B, flucytosine or voriconazole. The present study revealed that non-albicans Candida species caused most of the cases of candidaemia in the trauma patients. The isolation of C. rugosa from a large number of cases highlights the ability of this rarely reported pathogen to cause bloodstream infections. The presence of azole resistance among many of the Candida isolates is a matter of concern.

Staphylococcal blood stream infections: Epidemiology, resistance pattern and outcome at a level 1 Indian trauma care center

Purpose: Blood stream infection (BSI)/bacteremia is a potentially life threatening infection and are associated with a high crude mortality. Coagulase negative Staphylococcus (CONS) and Staphylococcus aureus are the most commonly isolated gram positive bacteria from blood culture samples. While S. aureus is a known pathogen causing BSIs, CONS are considered to be common contaminants of blood culture. Of late many studies have challenged this traditional viewpoint. The aim of this study was to determine the epidemiology and significance of Staphylococcus aureus and CONS bacteremia, their resistance patterns and associated mortality in critically ill trauma patients admitted to a level 1 trauma center. Materials and Methods: The study was conducted from January 2009 to June 2011. All patients from whose blood samples yielded a S. aureus or CONS on culture were included in this study. A detailed history was obtained and follow-up of the patients was done. The isolates of Staphylococci were identified to species level. Antibiotic susceptibility was performed by the disc diffusion method and VITEK-2 system. Results: During this 30 month period, total of 10,509 blood samples were received from 2,938 patients. A total of 1,961 samples taken from 905 patients were positive for one or more pathogens. S. aureus/CONS were isolated from 469 samples from 374 patients. Crude mortality amongst the patients having Staphylococcal BSI was 25% (94/374). Conclusion: Staphylococcal blood stream infections are a leading cause of morbidity and mortality.

A cost effectiveness based safety and efficacy study of resterilized intra-parenchymal catheter based intracranial pressure monitoring in developing world

Background: The management of traumatic brain injury (TBI) aims to maintain the normal cerebral perfusion in spite of the mass lesions that may occur (haematoma, contusion, and oedema). The monitoring of the intracranial pressure (ICP) is a step in that direction. The intra-parenchymal catheters have the lowest incidence of infection compared to intra-ventricular/subdural catheters with reliable and accurate pressure recordings. The major disadvantage of the intra-parenchymal catheters is the cost, especially in developing nations. Hypothesis: Resterilized intra-parenchymal strain gauge catheters can be used safely for ICP monitoring without any added risk of meningitis. The reusage of catheters can bring down the costs. Resterilized catheters/equipment have been approved for usage in cardiac usage, but such study on ICP catheters has not been carried out so far in any part of the world. Methodology: A total of 100 consecutive cases of severe TBI receiving ICP monitoring at a level 1 trauma center of a developing nation were prospectively studied (34 cases had fresh catheters, and 66 had resterilized [using ethylene oxide] catheters). Observations: The use of reused resterilized catheters was not associated with increased incidence of meningitis or fever (the surrogate marker for infection in this study). Also, there was concordance between the pressure recording of reused catheters and operative finding/subsequent computed tomography scans. These catheters after sterilization could be reused 2–4 times and reliably recorded the ICP (insignificant drift) with no increase in the incidence of meningitis. Conclusions: Usage of resterilized intra-parenchymal ICP catheters is feasible, safe, efficacious, and cost effective and brings down the cost of monitoring significantly.

Role of Hospital Housekeeping and Materials Management Including Disinfection and Waste Management

Pathogens are shed on hospital surfaces and aerosolized continuously in all patient care areas. Hospital surfaces thus constitute a major reservoir of potentially pathogenic and resistant organisms. Proper and regular cleaning of housekeeping (non-critical) surfaces reduces this reservoir and also provides an aesthetically pleasing environment. Cleaning of health-care facilities is performed for medical and sociocultural reasons. Maintaining an environment with a low microbial burden is required to avoid complications during the care and recovery of patients. Moreover, a healthy, safe, and aesthetically pleasing environment in a health-care facility with clean surfaces is comforting to patients, their families, and visitors by giving an impression of good quality care without additional health hazards. Clean surroundings are also soothing for the health-care workers. The cleaning procedures should be such that they reduce aerosolization and the bio-burden of pathogens from hospital surfaces. The cleaning products should be safe, environment-friendly, and effective to reduce the pathogenic contamination of hospital surfaces. Thus, health-care settings require intensive and frequent cleaning with a wide range of products.

Single versus double blade technique for skin incision and deep dissection in surgery for closed fracture: a prospective randomised control study

Purpose. To compare blade cultures in surgery for closed fracture using a single or double blade technique to determine whether the current practice of double blade technique is justified. Methods. 155 men and 29 women aged 20 to 60 (mean, 35) years who underwent surgery for closed fracture with healthy skin at the incision site were included. Patients were block randomised to the single (n=92) or double (n=92) blade technique. Blades were sent for bacteriological analysis. Outcome measures were early surgical site infection (SSI) within 30 days and cultures from the blades. Results. The 2 groups were comparable in baseline characteristics. In the single blade group, 6 surgical blades and 2 control blades showed positive cultures; 4 patients developed SSI, but only one had a positive culture from the surgical blade (with different organism isolated from the wound culture). In the double blade group, 6 skin blades, 7 deep blades, and 0 control blade showed positive culture; only 2 patients had the same bacteria grown from both skin and deep blade. Five patients developed SSI, but only one patient had a positive culture from the deep blade (with different organism isolated from the wound culture). The difference in incidence of culture-positive blade or SSI between the 2 groups was not significant. The relative risk of SSI in the single blade group was 0.8. Positive blade culture was not associated with SSI in the single or double blade group. Conclusion. The practice of changing blade following skin incision has no effect on reducing early SSI in surgery for closed fracture in healthy patients with healthy skin.

Diversity and antifungal resistance patterns of prevalent opportunistic pathogenic yeasts colonizing the oral cavities of asymptomatic human immunodeficiency virus-infected individuals, and their relation to CD4 + counts

Background: Yeasts are important opportunistic pathogens, in individuals infected with human immunodeficiency virus (HIV). Yeast species inhabiting the oral mucosa of HIV-infected persons can act as source of oral lesions, especially as the individual progresses towards immunocompromised state. Present study was conducted to evaluate the diversity of yeasts in oral cavities of asymptomatic HIV-infected persons and their association with CD4 + cell counts. Materials and Methods: 100 HIV seropositive subjects and 100 healthy controls were screened for oral yeast carriage using standard procedures. Results: Of the 100 HIV-seropositive persons screened, 48 were colonized by different yeasts, either alone or in association with another species. Candida albicans was the most common species (56.90%) while non C. albicans Candida (NCAC) accounted for 39.65%. Among NCAC, Candida tropicalis and Candida krusei were most common. One isolate each of rare opportunistic pathogenic yeasts, Geotrichum candidum and Saccharomyces cereviseae, was recovered. The control group had an oral candidal carriage rate of 23%; C. albicans was the predominant species, followed by Candida glabrata, C. tropicalis and Candida parapsilosis. Antifungal susceptibility testing revealed no resistance in C. albicans, to the commonly used antifungal agents, whereas resistance or dose dependent susceptibility to fluconazole was observed in some of the NCAC species. Conclusion: Oral carriage of opportunistic pathogenic yeasts was greater in HIV-seropositive persons heading towards immunocompromised state, as evidenced by their CD4 + cell count. The predominant yeast isolated in this study (C. albicans), was found to be susceptible to commonly used antifungals.