Ram Gopalakrishnan

Seven cases of Saccharomyces fungaemia related to use of probiotics

Probiotics are increasingly used in critically ill patients without enough safety data. The aim of the present study was to determine the association of probiotics with Saccharomyces cerevisiae fungaemia. Seven patients with S. cerevisiae fungaemia were reported at two hospitals in India between July 2014 and September 2015. Detailed clinical history of patients was recorded. Besides the seven patient isolates, three probiotics sachets used in those patients and five unrelated clinical isolates were used for association study by Fluorescent amplified fragment length polymorphism (FAFLP). Antifungal susceptibility testing was performed by broth microdilution technique of CLSI (M27‐A3) and interpreted according to CLSI (M27S4). Two patients were premature neonates and five were adults. They were admitted in intensive care unit and were on probiotics containing S. boulardii (except one adult patient). FAFLP analysis showed 96.4‐99.7% similarity between blood and corresponding probiotic isolates. Of the three AFLP types (group I, II, II) identified, all the probiotic isolates clustered in group I (major cluster) including majority of the blood isolates. The isolates were susceptible to all antifungal agents tested. Five patients, who could be evaluated, responded promptly to echinocandins or voriconazole. As the prescription of probiotic containing S. boulardii in critically ill patients leads to the fungaemia, we recommend avoiding this probiotic in those patients.

Carbapenem resistant Gram-negative bacteremia in an Indian intensive care unit: A review of the clinical profile and treatment outcome of 50 patients.

Background: Growing antimicrobial resistance and limited therapeutic options to treat carbapenem-resistant bacteremia prompted us to evaluate the clinical outcomes associated with healthcare-associated bacteremia. Methods: This was a retrospective observational study of carbapenem-resistant Gram-negative bacteremia performed at a tertiary care facility in Chennai, India between May 2011 and May 2012. Results: In our study, patients had mean 11.76 days of intensive care unit (ICU) care and mean time to onset of bacteremia was 6.4 days after admission. The commonest organism was Klebsiella pneumoniae (44%). Patients with combination treatment had lower mortality (44.8%) compared with colistin monotherapy (66.6%); (P = 0.35). Conclusion: Carbapenem resistant bacteremia is a late onset infection in patients with antibiotic exposure in the ICU and carries a 30 days mortality of 60%; K. pneumoniae is the most common organism at our center. Two drug combinations appear to carry a lower mortality compared with monotherapy.

Pulmonary cryptococcosis: An unusual presentation

Cryptococcal infection of the lung is usually asymptomatic in immunocompetent hosts. Symptomatic cryptococcal lung infection presenting as an endobronchial mass lesion in an immunocompetent host is rare. We report our experience with an immunocompetent young patient presenting with an endobronchial mass lesion caused by cryptococcal infection. This male patient presented with left sided collapse, consolidation on computed tomography scanning, and was found to have a polypoid lesion in the left main bronchus. The diagnosis was confirmed by bronchial biopsy and the patient responded well to parenteral antifungal therapy. The case report is followed by a review of pulmonary cryptococcosis including clinical features, diagnosis, and treatment.

A study of 24 patients with colistin-resistant Gram-negative isolates in a tertiary care hospital in South India

Background: As the use of colistin to treat carbapenem-resistant Gram-negative infections increases, colistin resistance is being increasingly reported in Indian hospitals. Materials and Methods: Retrospective chart review of clinical data from patients with colistin-resistant isolates (minimum inhibitory concentration >2 mcg/ml). Clinical profile, outcome, and antibiotics that were used for treatment were analyzed. Results: Twenty-four colistin-resistant isolates were reported over 18 months (January 2014-June 2015). A history of previous hospitalization within 3 months was present in all the patients. An invasive device was used in 22 (91.67%) patients. Urine was the most common source of the isolate, followed by blood and respiratory samples. Klebsiella pneumoniae constituted 87.5% of all isolates. Sixteen (66.6%) were considered to have true infection, whereas eight (33.3%) were considered to represent colonization. Susceptibility of these isolates to other drugs tested was tigecycline in 75%, chloramphenicol 62.5%, amikacin 29.17%, co-trimoxazole 12.5%, and fosfomycin (sensitive in all 4 isolates tested). Antibiotics that were used for treatment were combinations among the following antimicrobials-tigecycline, chloramphenicol, fosfomycin, amikacin, ciprofloxacin, co-trimoxazole, and sulbactam. Among eight patients who were considered to have colonization, there were no deaths. Bacteremic patients had a significantly higher risk of death compared to all nonbacteremic patients (P = 0.014). Conclusions: Colistin resistance among Gram-negative bacteria, especially K. pneumoniae, is emerging in Indian hospitals. At least one-third of isolates represented colonization only rather than true infection and did not require treatment. Among patients with true infection, only 25% had a satisfactory outcome and survived to discharge. Fosfomycin, tigecycline, and chloramphenicol may be options for combination therapy.

Clinical profile of respiratory viral infections: A study from tertiary care centre of South India

Abstract Background The recent influenza pandemic caused by the 2009 California H1N1strain increased awareness of the importance of influenza among hospitalized patients but there are few reports on other influenza strains and other non influenza respiratory viral infections in hospitalised patients. Aim To study epidemiological, clinical profile and outcome in patients hospitalised with respiratory viral infections. Materials and methods A prospective, observational study was conducted in a tertiary care hospital in Chennai, Tamil Nadu from September 2015 to July 2016. Respiratory samples from patients hospitalised with suspected acute viral respiratory infections were sent for molecular PCR based technique. Results Total 40 patients were studied. The most common respiratory virus was rhino virus in 9(22.5%) patients followed by influenza H3/H3N2 in 7(17.5%), H1N1 in 6(15%) and RSV in 4 (10%). After the diagnosis of the viral infection, antibiotics were completely stopped in 10(30.3%) patients and de-escalated to a narrower spectrum agent in another 10 (30.3%) patients. No patient whose antibiotics were de-escalated died, whereas there were 5 deaths in patients in whom de-escalation was not done. Conclusion Diagnosis with PCR facilitates early use of antiviral agents, droplet isolation, prevention of cross-transmission of viruses and antibiotic stewardship practice.

Scrub Typhus Causing Unilateral Optic Neuritis.

To the Editor: Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi. Reports of scrub typhus in children are being increasingly reported in India [1]. We report a case of scrub typhus complicated by unilateral optic neuritis. An 8-y-old girl from Tripura presented with fever, headache and pain over the right eye, associated with blurring of vision rapidly progressing to complete loss of vision. Examination revealed right eye optic disc blurring with papillitis and positive relative afferent pupillary defect consistent with optic neuritis. An eschar was present over left forearm (Fig. 1). WBC count was 17,900/cmm with 63 % neutrophils; Alanine transaminase (ALT) 60 IU/ml. Other blood investigations including Anti-nuclear antibody (ANA), Double-stranded deoxyribonucleic acid (dsDNA), ferritin, Angiotensin converting enzyme (ACE) level, Lactate dehydrogenase (LDH), Thyroid stimulating hormone (TSH) and vitamin B12 levels were normal. Magnetic resonance imaging (MRI) brain and orbit (without contrast) was normal. Cerebrospinal fluid (CSF) analysis: WBC-60 cells with 70 % lymphocytes; CSF glucose-54 mg/dl; protein27 mg/dl; negative bacterial, fungal, Acid fast bacillus (AFB) and India ink stains. CSF Xpert Mycobacterium tuberculosis (MTB), cryptococcal antigen, herpes simplex Polymerase chain reaction (PCR) and oligoclonal bands were negative. Blood and CSF cultures were negative. Scrub typhus DetectTM IgM Enzyme-linked immunosorbent assay (ELISA) antibody (InBios International Inc.) in blood was positive. She was started on oral doxycycline and intravenous methylprednisone pulse therapy for 5 d. Her vision gradually improved, fever subsided and there were no residual visual defects at follow up after 1 mo. Optic neuritis in children is less common, usually bilateral and most often immune-mediated secondary to viral infection, post-immunization and demyelination [2, 3]. In our case, the clinical picture, characteristic eschar, positive scrub typhus serology and an excellent response to doxycycline support a postscrub typhus etiology as the cause of optic neuritis. Scrub typhus can involve either the central (aseptic meningitis) or peripheral nervous system [4]. Neuroocular complications described include meningoencephalitis [3], bilateral sixth and seventh cranial nerve palsies, myoclonus [4], opsoclonus [5], polyneuropathy [5], bilateral optic neuritis [2], retinal vein occlusion and hemorrhage. Isolated unilateral optic neuritis without any other neurological manifestations following scrub typhus is not reported in literature. The postulated mechanism may be a post* Laxman G. Jessani laxmanj27@gmail.com

Scrub Typhus in Hospitalized Children: A Missed Entity?

BackgroundScrub typhus, caused by Orientia tsutsugamushi (formerly classified as Rickettsia tsutsugamushi), is an acute infectious disease of variable severity that is transmitted to humans by an arthropod vector of the Trombiculidae family. It affects people of all ages including children. It may be missed in this population unless clinically suspected. Materials and MethodsWe reviewed medical records of children admitted with scrub typhus between January 2010 and June 2012 in a tertiary care pediatric referral hospital. Scrub typhus was confirmed by a positive Detect TM immunoglobulin M enzyme-linked immunosorbent assay (In Bios International, Inc). This enzyme-linked immunosorbent assay detects immunoglobulin M antibodies in the human serum to O. tsutsugamushi–derived recombinant antigen (1–10). ResultsTwelve cases were analyzed during this period. The mean age was 8.25 years, with 7 male and 5 female patients. Fever was present in all 12 patients, followed by abdominal pain/vomiting in 7 (58.3%), headache in 4 (33.3%), rash in 3 (25%), and cough in 3 (25%). The mean duration of symptoms before presentation was 9 days. An eschar was present in 4 (33.3%). Thrombocytopenia was noted in 11 (90%). Splenomegaly on examination was present in 10 (83.3%). Five were treated with azithromycin; 4, with doxycycline; and 3, with both. Three of the 12 required intensive care unit stay. ConclusionsScrub typhus in children should be considered in all hospitalized children, especially if there is a recent rural or outdoor exposure, an eschar, splenomegaly, or thrombocytopenia. Unlike adults, renal dysfunction and central nervous system involvement seem to be uncommon. All children recovered after treatment with azithromycin, doxycycline, or the combination.

Clinical efficacy and safety of cefepime–tazobactam in hospitalized patients in South India

To the Editor,Due to a threatening increase of carbapenem resistance, there is an urgent need of a general decrease in carbapenem use and to find alternatives. In a recent French report in the pres...

Experience with β-D-Glucan assay in the management of critically ill patients with high risk of invasive candidiasis: An observational study

Background: The (1,3)-β-D-glucan assay (BDG) is recommended for the early diagnosis of invasive candidiasis (IC). Methods: Records of 154 critically ill adults with suspected IC, on whom BDG was done, were analyzed. Patients were divided into three groups: Group A (confirmed IC), Group B (alternative diagnosis or cause of severe sepsis), and Group C (high candidal score and positive BDG [>80 pg/mL] but without a confirmed diagnosis of IC). Results: Mean BDG levels were significantly higher in Group A (n = 32) as compared to Group B (n = 60) and Group C (n = 62) (448.75 ± 88.30 vs. 144.46 ± 82.49 vs. 292.90 ± 137.0 pg/mL; P < 0.001). Discontinuation of empiric antifungal therapy based on a value <80 resulted in cost savings of 14,000 INR per day per patient. Conclusion: A BDG value of <80 pg/ml facilitates early discontinuation of empirical antifungal therapy, with considerable cost savings.

Experience with β-D-Glucan Assay for Diagnosis of Invasive Candidiasis in ICU Patients: Pilot Study from India

Abstract Background β-d-Glucan assay (BDG) has been recently introduced in India and is recommended for the early diagnosis of invasive candidiasis (IC), but there are a number of factors (eg β-lactam antibiotics, immunoglobulin and albumin infusions, bacteremia and surgical mesh) which may falsely elevate BDG levels. Methods This was a retrospective, observational study done in the 23 bedded multi-disciplinary ICU of a tertiary care hospital in South India. Case records of adult (> 18 years) non-neutropenic patients having severe sepsis or shock with ≥ 1 risk factor for IC were analyzed. As a standard practice, BDG assay was sent and effective antifungals were started on the day of suspicion of IC. All neutropenic, immunocompromised patients, those already on antifungal and those who were diagnosed with other invasive fungal infections were excluded from the study. FDA approved Fungitell assay was used to measure serum BDG levels (pg/mL). Results Patients were divided into 3 groups. Group A (n = 16) comprised of patients in whom diagnosis of IC was confirmed (blood culture or another sterile site grew candida). Group B (n = 30) comprised of patients in whom alternative diagnosis of severe sepsis or septic shock was found or they did not improve after administration of antifungals. Group C (n = 31) comprised of those patients in whom neither diagnosis of IC was confirmed nor an alternative explanation was found but they improved clinically on giving antifungal therapy. Mean BDG levels was significantly higher in Group A as compared with Group B and Group C (448.75 ± 88.30 vs 144.46 ± 82.49 vs 292.90 ± 137.0 pg/mL; P < 0.001). The mean value of the BDG was higher than the accepted cutoff of 80 pg/mL in all three groups (Figure 1). The use of agents which cause false elevation of BDG was significantly higher in Group B as compared with Group A (P = 0.02). Conclusion A BDG assay cutoff of 80 pg/mL leads to a higher number of false positive results in ICU patients, where false positive factors are unavoidable. The results of this study suggest that a higher cutoff of at least 144 pg/mL will be more specific for IC, although this may need further validation with larger trials.Figure 1: Mean BDG values in various groups Disclosures All authors: No reported disclosures.