Pushpa Aggarwal

Ciprofloxacin-Resistant Neisseria meningitidis, Delhi, India

Decreased susceptibility of Neisseria meningitidis isolates to ciprofloxacin emerged from an outbreak in Delhi, India. Results of antimicrobial susceptibility testing of the meningococcal isolates to ciprofloxacin and further sequencing of DNA gyrase A quinolone-resistance–determining region confirmed the emergence of ciprofloxacin resistance in the outbreak.

Current perspectives of enteric fever: a hospital-based study from India

Abstract The last two decades have seen a change in the pattern of enteric fever with the emergence of multidrug-resistant strains (MDRS), particularly strains resistant to nalidixic acid. Aim: The aim of the study was to undertake a retrospective analysis of blood culture-confirmed cases of enteric fever diagnosed at Safdarjang Hospital, New Delhi, India from January 2001 to December 2003. Methods: The epidemiological details, clinical features, treatment outcome and antimicrobial resistance patterns were studied. Results: Of 377 blood culture-positive cases, 80.6% were Salmonella typhi and 19.4% Salmonella paratyphi A; 21.7% were children aged under 5 years and 6.1% were under 2 years. A significant decline in MDRS was observed, from 21.9% in 2001 to 12.4% in 2003 (p=0.04). There was a significant increase in nalidixic acid-resistant Salmonella (NARS) from 56.9% in 2001 to 88.9% in 2003 (p=0.0001). Complete resistance to ciprofloxacin (MIC>4 μg/ml) was detected in only two isolates, both Salmonella paratyphi A. Minimal inhibitory concentrations (MICs) of ciprofloxacin for NARS were increased (0.125–0.5 μg/ml) but were within National Committee for Clinical Laboratory Standards susceptibility ranges. NARS had a significantly longer fever defervescence time (7.7 vs 4.7 days, p<0.001) and hospital stay (12.1 vs 8.2 days, p<0.001), and higher rates of complications (55.5% vs 24.0%, p=0.014) and mortality than nalidixic acid-sensitive Salmonella (NASS). The rate of isolation of MDRS was higher in NARS than NASS (18.8% vs 7.3%, p=0.013). Conclusion: The high rate of occurrence of enteric fever in children <5 years and also of infections caused by Salmonella paratyphi A in India calls for critical re-assessment of vaccination strategy. Nalidixic acid resistance and rising MICs of fluoroquinolones in Salmonella spp pose a new global threat requiring debate on the optimum treatment of enteric fever.

Epidemiologic and clinicomycologic profile of onychomycosis from north India

Background  Onychomycosis is an important public health problem because of the increase in immunosuppressive states. Large‐scale studies in India are scarce, and so the baseline incidence of onychomycosis is not firmly established.

Microflora of bile aspirates in patients with acute cholecystitis With or without cholelithiasis: a tropical experience

The current study determined the spectrum of biliary microflora with special emphasis on enteric fever organisms in patients with acute cholangitis with and without cholelithiasis or other biliary diseases. The patients were divided into three groups: Group A consisted of patients with acute cholecystitis with cholelithiasis; Group B consisted of patients with acute cholecystitis with gastrointestinal ailments requiring biliary drainage and group C consisted of patients with gallbladder carcinoma. Gallbladder, bile and gallstones were subjected to complete microbiological and histopathological examination. Antimicrobial susceptibility of the isolates was performed as per CLSI guidelines. Bacteria were recovered from 17 samples (32%) in Group A, 17 (51.4%) in Group B and 1 (1.6%) in Group C. The most common organisms isolated were Escherichia coli (11, 29.7%), Klebsiella pneumoniae (10, 27%), Citrobacter freundii (3, 8.1%), Salmonella enterica serovar Typhi (3, 8.1%), etc. The majority of Enterobacteriaceae isolates were susceptible to piperacillin-tazobactam and meropenem. As regards Salmonella spp., S. Typhi was isolated from 2 (3.8%) patients in Group A and 1 (16%) in Group C. Antimicrobial susceptibility of potential causative organisms, the severity of the cholecystitis, and the local susceptibility pattern must be taken into consideration when prescribing drugs. A protocol regarding the management of such cases should be formulated based on observations of similar studies.

Epidemiological and clinico-mycological profile of fungal wound infection from largest burn centre in Asia.

The current study was conducted to know the incidence, predisposing factors, spectrum, clinical profile and antifungal susceptibility (AFS) of fungal wound infection (FWI) in burn patients. Of a total of 71 patients, 20 (28.2%) emerged with the diagnosis of FWI. Fungal pathogens in this study were Candida tropicalis (14%), Candida parapsilosis (5.6%), Aspergillus niger (2.8%) and one each of Candida albicans (1.4%), Candida glabrata (1.4%), Syncephalestrum (1.4%) and Fusarium solani (1.4%). All patients with mould infections expired before the mycological culture results could be conveyed to clinicians. Of the yeasts isolated in the study, one each of C. tropicalis and C. albicans showed cross‐resistance to azoles. All the moulds were susceptible to amphotericin B. This study depicted that fungal invasion is associated with a high mortality, burn size 30–60% and high incidence of inhalational injury. Fungal invasion was detected on an average of 14 days after injury. Association of use of four classes of drugs – aminoglycosides, imipenem, vancomycin and third generation cephalosporins and use of total parenteral nutrition was observed. Expedient laboratory diagnosis of FWI and appropriate systemic antifungal therapy guided by AFS may improve outcome for severely injured burn victims.

Molecular analysis of high-level ciprofloxacin resistance in Salmonella enterica serovar Typhi and S. Paratyphi A: need to expand the QRDR region?

Fourteen strains of S. Typhi (n=13) and S. Paratyphi A (n=1) resistant to ciprofloxacin were compared with 30 ciprofloxacin decreased-susceptibility strains on the basis of qnr plasmid analysis, and nucleotide substitutions at gyrA, gyrB, parC and parE. In ciprofloxacin-resistant strains, five S. Typhi and a single S. Paratyphi A showed triple mutations in gyrA (Ser83-->Phe, Asp87-->Asn, Glu133-->Gly) and a novel mutation outside the quinolone resistance determining region (QRDR) (Met52-->Leu). Novel mutations were also discovered in an isolate (minimum inhibitory concentration 8 microg/ml) in gyrA gene Asp76-->Asn and outside the QRDR Leu44-->Ile. Out of 30 isolates with reduced susceptibility, single mutation was found in 12 strains only. Genes encoding qnr plasmid (qnr A, qnr B, AAC1-F) were not detected in ciprofloxacin-resistant or decreased-susceptibility strains. Antimicrobial surveillance coupled with molecular analysis of fluoroquinolone resistance is warranted for reconfirming novel and established molecular patterns of resistance, which is quintessential for reappraisal of enteric fever therapeutics.

Current scenario of cryptococcosis and antifungal susceptibility pattern in India: a cause for reappraisal

This study analysed the spectrum, antifungal susceptibility pattern, clinical course and molecular epidemiology of cryptococcosis. Four hundred and thirty‐nine samples obtained from 378 meningitis patients were processed by standard procedures. Minimum inhibitory concentration (MIC) of fluconazole and amphotericin B for the isolates was tested by broth micro dilution and by E‐strip method. Molecular analysis by random amplified polymorphic DNA‐PCR of eight isolates was performed using M13 primer. Cryptococcosis was diagnosed in 35 patients [HIV‐1 seropositive (19) and apparently immunocompetent (16)]. Cryptococcus neoformans var. neoformans (serotype A and D) was the predominant isolate on phenotypic identification. Three C. neoformans var. gattii were isolated from HIV‐1 seropositive (2) and apparently immunocompetent (1) patients. MIC 90 for amphotericin B and fluconazole were 1 and 8 μg ml−1 respectively. On RAPD‐PCR, less diversity was seen among Indian isolates. AIDS remains the single most important risk factor for cryptococcosis. Rising MIC of the available induction and maintenance drugs is of grave concern. The DNA typing technique showed less diversity among Indian strains. Routine surveillance and application of molecular typing methods are crucial to know the baseline and existing pattern of cryptococcosis.

Clinical and mycological profile of cryptococcosis in a tertiary care hospital

This study examined the extent of cryptococcosis in clinically diagnosed cases of meningitis in HIV-1 seropositive and apparently immunocompetent patients. One hundred and forty-six samples, obtained from 126 chronic meningitis patients comprised of cerebrospinal fluid (CSF), blood, sputum and urine. The samples were processed by standard microbiological procedures. Cryptococcal isolates were identified by microscopy, cultural characteristics, melanin production on niger seed agar and hydrolysis of urea. The isolates were further speciated on cannavanine glycine bromothymol blue (CGB) media. Cryptococcal antigen detection of CSF samples was performed by latex agglutination test (LAT). Minimum inhibitory concentration (MIC) of amphotericin B for the isolates was also tested. Cryptococcosis was diagnosed in 13 patients (eight HIV-1 seropositive and five apparently immunocompetent). Cryptococcus neoformans var. neoformans was the predominant isolate. Cryptococcal antigen was detected in all, whereas microscopy could detect yeast cells in nine patients. The isolates were sensitive to amphotericin B. CD4 cell counts ranged from 8 to 96/cu mm. The study concludes that all CSF samples with clinical diagnosis of subacute and chronic meningitis should be subjected to tests for detection of Cryptococcus in clinical laboratory irrespective of the immune status.

Eumycetoma pedis due to Exophiala jeanselmei

A case of eumycetoma of foot in an 8-year old male child was clinically diagnosed as chronic osteomyelitis and was microbiologically confirmed as eumycetoma. The case is being reported for its uncommon clinical presentation and etiological agent, Exophiala jeanselmei. The patient recovered completely after treatment with ketoconazole.

Rhinosporidiosis in Delhi, North India: Case Series from a Non-endemic Area and Mini-review

We report three cases of rhinosporidiosis from migrant population of Delhi. Three male patients had sino-nasopharyngeal, nasopharyngeal and nasal rhinosporidiosis, respectively. One patient gave a history of bathing in stagnant water. The diagnosis was made by clinical presentation and microscopic observation of characteristic sporangia of Rhinosporidium seebri in mycological and histopathological investigations. All the patients were successfully treated with complete surgical excision of lesions and cauterization of base. There were no recurrences.