Sanjay Biswas

The impact of the International Nosocomial Infection Control Consortium (INICC) multicenter, multidimensional hand hygiene approach in two cities of India

The fundamental tool for preventing and controlling healthcare-acquired infections is hand hygiene (HH). Nonetheless, adherence to HH guidelines is often low. Our goal was to assess the effect of the International Nosocomial Infection Control Consortium (INICC) Multidimensional Hand Hygiene Approach (IMHHA) in three intensive care units of three INICC member hospitals in two cities of India and to analyze the predictors of compliance with HH. From August 2004 to July 2011, we carried out an observational, prospective, interventional study to evaluate the implementation of the IMHHA, which included the following elements: (1) administrative support, (2) supplies availability, (3) education and training, (4) reminders in the workplace, (5) process surveillance and (6) performance feedback. The practices of health care workers were monitored during randomly selected 30-min periods. We observed 3612 opportunities for HH. Overall adherence to HH increased from 36.9% to 82% (95% CI 79.3-84.5; P=0.0001). Multivariate analysis indicated that certain variables were significantly associated with poor HH adherence: nurses vs. physicians (70.5% vs. 74%; 95% CI 0.62-0.96; P=0.018), ancillary staff vs. physicians (43.6% vs. 74.0%; 95% CI 0.48-0.72; P<0.001), ancillary staff vs. nurses (43.6% vs. 70.5%; 95% CI 0.51-0.75; P<0.001) and private vs. academic hospitals (74.2% vs. 66.3%; 95% CI 0.83-0.97; P<0.001). It is worth noticing that in India, the HH compliance of physicians is higher than in nurses. Adherence to HH was significantly increased by implementing the IMHHA. Programs targeted at improving HH are warranted to identify predictors of poor compliance.

Alarming prevalence of community-acquired multidrug-resistant organisms colonization in children with cancer and implications for therapy: A prospective study.

BACKGROUND Infection or colonization with multidrug-resistant organisms (MDRO) is associated with high mortality and morbidity. Knowledge of MDRO colonization may help in planning empirical antibiotic approach in neutropenic patients, which is known to improve patient outcomes. While routine cultures are positive and may help direct antibiotic therapy in only up to 15% neutropenic patients, surveillance cultures are positive in more than 90% of cancer patients. AIMS To assess the rate of MDRO carrier status at presentation and rate of conversion to MDRO during the treatment. MATERIALS AND METHODS Rectal swabs of all the outpatients presenting to pediatric oncology unit were sent within 7 days from date of registration from January 2014 to December 2014. Furthermore, stool cultures/rectal swabs of all patients who got directly admitted to the pediatric ward at presentation were sent within 24 h. Repeat rectal swabs were sent again for patients from this cohort when they got readmitted to the ward at least 15 days after last discharge or when clinically indicated. RESULTS Baseline surveillance rectal swabs were sent for 618 patients, which included 528 children with hematological malignancies and 90 children with solid tumors. Forty-five (7.3%) showed no growth. Of the remaining 573, 197 (34.4%) patients were colonized by two organisms and 30 (5.2%) by three organisms. Three hundred and thirty-four (58.4%) showed extended spectrum beta-lactamase (ESBL) Enterobacteriaceae, of which 165 (49.5%) were ESBL sensitive to beta-lactam with beta-lactamase inhibitors combinations and 169 (50.5%) were resistant to combinations. One hundred and sixteen (20.2%) were carbapenem-resistant Enterobacteriaceae (CRE) and 65 (11.4%) had vancomycin-resistant enterococci in baseline cultures. Only 63 (21%) patients were colonized by a sensitive organism in their baseline surveillance cultures. Morbidity (Intensive Care Unit stay) and mortality was higher in patients colonized by MDR organisms. There was a significant correlation between the place of residence and CRE colonization status with the highest rate (60%) of CRE colonization observed in children from East India. The repeat cultures showed the further conversion of sensitive isolates to MDRO in 80% of these children, of which 40% each converted from non-ESBL and non-CRE to ESBL and CRE, respectively. CONCLUSION This is the first study illustrating the alarming high prevalence of community-acquired MDRO colonization, especially CRE, which has grave implications for therapy for children with cancer potentially compromising delivery of aggressive chemotherapy and affecting outcomes. This incidence further increases during the course of treatment. Knowing the baseline colonization also guides us for the planning of chemotherapy as well as antibiotic approach and infection control strategies. Local antibiotics stewardship including education of the healthcare workers as well as national level interventions to prevent antibiotic misuse in the community is critical to minimize this problem.

Epidemiology of blood stream infections in pediatric patients at a Tertiary Care Cancer Centre

BACKGROUND Blood stream infections (BSI) are among the most common causes of preventable deaths in children with cancer in a developing country. Knowledge of its etiology as well as antibiotic sensitivity is essential not only for planning antimicrobial policy, but also the larger infection prevention and control measures. AIMS To describe the etiology and sensitivity of BSI in the pediatric oncology unit at a tertiary cancer center. MATERIALS AND METHODS All the samples representative of BSI sent from pediatric oncology unit during the period of January to December, 2013 were included in the study, and analyzed for microbiological spectrum with their antibiotic sensitivity. RESULTS A total of 4198 samples were representative of BSI. The overall cultures positivity rate was 6.97% with higher positivity rate (10.28%) from central lines. Of the positive cultures, 208 (70.9%) were Gram-negative bacilli (GNB), 71 (24.2%) were Gram-positive organisms, and 14 (4.7%) were Candida species. Lactose fermenting Enterobacteriaceae i.e., Escherichia coli (28.4%), Klebsiella pneumoniae (22.1%), and Enterobacter (4.8%) accounted for 55.3% of all GNB. Pseudomonas accounted for 53 (25.5%) and Acinetobacter 19 (9.1%) of GNB. Among Gram-positive isolates, staphylococci were the most frequent (47.8%), followed by Streptococcus pneumoniae 17 (23.9%), beta-hemolytic streptococci 11 (15.5%), and enterococci 9 (12.68%). Of GNB, 45.7% were pan-sensitive, 24% extended spectrum beta-lactamase (ESBL) producers, 27% were resistant to carbapenems, and 3.4% resistant to colistin. Pseudomonas was most sensitive, and Klebsiella was least sensitive of GNB. Of the staphylococcal isolates, 41.67% were methicillin-resistant Staphylococcus aureus (MRSA) and 10% of Coagulase Negative Stapylococci (CONS) were methicillin. CONCLUSION A high degree of ESBL producers and carbapenem-resistant Enterobacteriaceae is concerning; with emerging resistance to colistin, raising the fear of a return to the preantibiotic era. An urgent intervention including creating awareness and establishment of robust infection control and antibiotic stewardship program is the most important need of the hour.

Scalp flora in Indian patients undergoing craniotomy for brain tumors - Implications for pre-surgical site preparation and surgical site infection

Causation of surgical site infection (SSI) following craniotomy is multifactorial. Most preventive strategies (including site preparation and antibiotic prophylaxis) revolve around reducing preoperative contamination of the local site. There is little evidence, however, linking site contamination with postoperative infections. This is important given the preference for performing non-shaved cranial surgery. We undertook a prospective study to document the scalp flora in neurosurgical patients in an Indian setting and to assess possible association with SSI. A prospective study recruited 45 patients undergoing non-shaved clean craniotomies for various brain tumors. Standard perioperative procedures and antibiotic policy were employed. Prior to and immediately following the pre-surgical scrubbing, we collected swabs and evaluated their growth qualitatively. SSI was documented adhering to CDC guidelines. The association of swab-positivity with various parameters (including SSI) was evaluated. Pre-scrub positivity was seen in 18 of 44 patients, three of them developed subsequent SSI. Most were known skin contaminants. Five patients had swab positivity after scrubbing, though none of these developed any SSI. Four of these five had pre-scrub positivity. In three the same organisms persisted (two being Staphylococcus aureus) , and one had different growth post-scrub, whereas one patient developed new growth (contaminant mycelial fungus) in the post-scrub swab. We did not find any association between swab positivity and SSI. Swab positivity was also not related to hair-length or hygiene. Scalp flora in Indian patients is similar to that described. Pre-surgical preparation does not always eliminate this contamination (especially staphylococcus). However, this does not necessarily translate into increased SSI. Moreover, the results also provide objective evidence to support the performance of non-shaved cranial surgery without an undue risk of SSI.

Bacteriological profile and antibiotic susceptibility patterns of clinical isolates in a tertiary care cancer center.

Introduction: This increased risk of bacterial infections in the cancer patient is further compounded by the rising trends of antibiotic resistance in commonly implicated organisms. In the Indian setting this is particularly true in case of Gram negative bacilli such as Escherichia coli, Klebsiella pneumoniae and Acinetobacter spp. Increasing resistance among Gram positive organisms is also a matter of concern. The aim of this study was to document the common organisms isolated from bacterial infections in cancer patients and describe their antibiotic susceptibilities. Methods: We conducted a 6 month study of all isolates from blood, urine, skin/soft tissue and respiratory samples of patients received from medical and surgical oncology units in our hospital. All samples were processed as per standard microbiology laboratory operating procedures. Isolates were identified to species level and susceptibility tests were performed as per Clinical Laboratory Standards Institute (CLSI) guidelines -2012. Results: A total of 285 specimens from medical oncology (114) and surgical oncology services (171) were cultured. Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus and Acinetobacter spp. were most commonly encountered. More than half of the Acinetobacter strains were resistant to carbapenems. Resistance in Klebsiella pneumoniae to cephalosporins, fluoroquinolones and carbapenems was >50%. Of the Staphylococcus aureus isolates 41.67% were methicillin resistant. Conclusion: There is, in general, a high level of antibiotic resistance among gram negative bacilli, particularly E. coli, Klebsiella pneumoniae and Acinetobacter spp. Resistance among Gram positives is not as acute, although the MRSA incidence is increasing.

Prevalence and patterns of cytomegalovirus DNAemia in adult patients with acute lymphoblastic leukemia on chemotherapy.

Th e use of immunosuppressive agents such as high-dose steroids and anti-metabolites for prolonged periods can predispose patients with acute lymphoblastic leukemia (ALL) to develop cytomegalovirus (CMV) reactivation and disease, more so in countries with a background of high CMV seropositivity ( 90%) such as India [1]. Th ere are abundant data on the pattern and time course of CMV reactivation or primary infection in allogeneic stem cell transplant recipients, and well-defi ned strategies have been developed for prophylaxis, screening and pre-emptive treatment [2]. However, there is a remarkable paucity of data regarding CMV reactivation in ALL. Reactivation can lead to prolonged cytopenias, fever and other manifestations, which are often misdiagnosed and treated empirically with antimicrobials. Delays in diagnosis and therapy can compromise the dose intensity of chemotherapy, a key to achieving cure in ALL. Th ese facts underlie the importance of understanding the pattern, time of occurrence and clinical manifestations of CMV reactivation in ALL. To address this, we analyzed adult patients with ALL ( 14 years) who were treated with multi-agent chemotherapy (MCP-841) between July 2009 and July 2011 at Tata Memorial Hospital, India to understand the clinical features and pattern of CMV reactivation. CMV DNA was estimated in blood with real time quantitative polymerase chain reaction (PCR) (Roche; CMV DNA Quant Kit) in patients with clinical suspicion of CMV reactivation. Th is included the presence of persistent fever alone (fever of unknown origin), hepatomegaly and/or splenomegaly (relapse of ALL being ruled out), cytopenias (absolute neutrophil count less than 1000/mm 3 , platelet count less than 100 000/mm 3 , hemoglobin less than 8 g/dL) unexplained by the previous chemotherapy, respiratory symptoms (cough, coryza, infi ltrates on chest radiography), gastrointestinal symptoms (abdominal pain, anorexia, loose stools), unexplained liver dysfunction, signifi cant weight loss and skin rashes. Th e lowest detection limit with this method was 392 copies/mL. CMV serology was not done at baseline prior to ALL therapy given the high prevalence of CMV seropositivity in our population. We did not carry out active surveillance for CMV reactivation. Th ese patients were not given any antibacterial, antifungal or antiviral prophylaxis except co-trimoxazole. Patients with neutropenic and non-neutropenic fever were investigated with blood (bacterial/fungal), sputum and urine culture, computed tomography (CT) of the thorax, ultrasound scan of the abdomen and pelvis, bronchoscopy with culture of bronchoalveolar lavage in cases with pneumonia (if there was no response to antibacterial and antifungal therapy), and were included if no cause was found or if there was no response to therapy. Patients with deranged liver function tests were included if they had normal imaging, negative serology for hepatitis viruses and no history of hepatotoxic drug usage. None of the patients was subjected to biopsy to prove CMV disease due to low platelets and coagulopathy. Patients with raised CMV DNA copy numbers and clinical features suggestive of CMV infection (after excluding all other causes) were treated with ganciclovir. CMV DNA copy numbers were monitored until they became negative. Isolation of CMV DNA in whole blood along with clinical or laboratory features consistent with CMV infection, response to ganciclovir based therapy and temporal association of response to declining CMV DNA copy numbers was labeled as CMV reactivation. Case records were analyzed for demographics, chemotherapy details and the type of therapy prior to CMV reactivation, clinical features, laboratory parameters, viral load, antiviral therapy and response.

Frequency of bacterial isolates and pattern of antimicrobial resistance in patients with hematological malignancies: A snapshot from tertiary cancer center.

BACKGROUND Infections are the most important cause of mortality in patients with high-risk febrile neutropenia. Emergence of multi-drug resistant organisms (MDROs) has become a major challenge for hemato-oncologists. Knowledge of the prevalent organisms and their antimicrobial sensitivity can help deciding the empirical therapy at individual centers and allows timely measures to reduce the risk of antimicrobial resistance. AIMS To evaluate the frequency of bacterial isolates from all the samples and the pattern of bacterial bloodstream infections and incidence of MDROs. SETTINGS AND DESIGN This is a retrospective analysis from a tertiary care cancer center. MATERIALS AND METHODS From January to June 2014 information on all the samples received in Department of Microbiology was collected retrospectively. The data from samples collected from patients with hematological cancers were analyzed for types of bacterial isolates and antimicrobial sensitivity. RESULTS A total of 739 isolates were identified with 67.9% of isolates being Gram-negative. The predominant Gram-negative organisms were Escherichia coli, Psuedomonas spp. and Klebsiella spp. Among the bacterial bloodstream infections, 66% were Gram-negative isolates. MDROs constituted 22% of all isolates in blood cultures. Incidence of resistant Gram-positive organisms was low in the present dataset (methicillin resistant Staphylococcus aureus and vancomycin-resistant enterococci-1.3%). CONCLUSIONS The analysis reconfirms the Gram-negative organisms as the predominant pathogens in bacteremia seen in patients with hematological cancers. The high frequency of multi-drug resistance in the dataset calls for the need of emergency measures to curtail further development and propagation of resistant organisms.

Fulminant post-craniotomy wound infection and meningitis with pneumocephalus caused by Acinetobacter baumannii: An unusual presentation

Sir, Acinetobacter baumannii (AB) is being increasingly recognized as an important cause of multi-drug-resistant nosocomial infections.[1] In neurosurgical literature it has been associated with secondary intracranial infections (post-traumatic/post-surgical meningitis and abscess formation).[2,3,4,5] Recently, AB has been implicated in necrotizing soft-tissue infections.[6,7,8] A similar type of fulminant wound infection after craniotomy has not been described. We report an unusual case where we had a combination of such wound infection with meningitis and pneumocephalus. A 45-year-old male presented with a one-month history of progressively increasing left-sided focal motor seizures and features of raised intracranial pressure. He had undergone surgery and radiotherapy for a right frontotemporal astrocytoma (Grade 2) three years back. The magnetic resonance imaging (MRI) brain revealed a right frontal enhancing mass [Figure 1]. He reported high-grade intermittent fever with chills since a week and at the time of admission had anemia, thrombocytopenia and pre-renal azotemia. The peripheral smear was positive for schizonts and merozoites of Plasmodium vivax. After appropriate antimalarial and supportive medical management he was operated eight days after his admission. On the sixth postoperative day he developed craniotomy flap swelling which in an hours time had markedly progressed to involve the entire scalp. He also became confused and incoherent. A computed tomography (CT) scan revealed significant scalp edema with air pockets in the subcutaneous and subgaleal regions [Figures ​[Figures22 and ​and3].3]. There were postoperative changes in the operated site and diffuse pneumocephalus which had not been present in the immediate postoperative scan obtained a few days earlier [Figure 2]. Suspecting a fulminant necrotizing wound infection with associated meningitis, broad-spectrum antibiotics were started empirically and emergency re-exploration of the wound was performed. At surgery there was soft-tissue edema with crepitus. No tissue necrosis or pus was encountered. The dura appeared intact. A thorough wound wash was given after collecting a swab. The swab grew Acinetobacter baumannii sensitive to colistin, netilmicin, tigecycline and ceftazidime, as well as methicillin-resistant Staphylococcus aureus and Escherichia coli. With appropriate antibiotics (colistin, vancomycin and imepenem) he improved neurologically over a period of two weeks and was discharged for further adjuvant therapy. Figure 1 Preoperative magnetic resonance imaging (T1, T2 and post-contrast T1 images) showing a right frontal recurrent tumor Figure 2 Immediate postoperative computed tomography scan showing only minimal air in the resection cavity Figure 3 Subsequent computed tomography scan showing significant soft tissue and intracranial pneumocephalus AB has been reported to cause necrotizing soft-tissue infections,[7] especially with war-related injuries.[8] The wound infection in our case mimicked a necrotizing soft-tissue infection which has not been earlier described in a postoperative setting. Pneumocephalus was also a very unusual occurrence. Though pneumocephalus can occur in the postoperative setting, an earlier scan (immediate postoperative scan a few days earlier) in the same patient did not show any pneumocephalus. Besides, there was no dural leak noted at resurgery (which could also have accounted for the pneumocephalus). Moreover, presence of air in the soft tissue as well as intracranial compartments supports our contention that it was a case of necrotizing wound infection with meningitis producing pneumocephalus caused by AB. Spontaneous pneumocephalus due to meningitis has been reported with gas-forming as well as non gas-forming organisms.[9,10] Though AB is not gas-forming, it still causes necrotizing soft-tissue infections, and hence can even cause pneumocephalus by similar pathogenic mechanisms. Following successful treatment of the infection and improvement in clinical features, this pneumocephalus also resolved, reinforcing the association of the infection by AB and the spectrum of clinico-radiological findings.

Correlation of HPV DNA result with cervical cancer in a tertiary care cancer centre

T long natural history of HPV diseases (e.g., CIN) provides an opportunity for potentially effective non-surgical management of these conditions before they become frank cancer. Traditional surgical treatment modalities have potential complications like bleeding, cervical stenosis, adverse pregnancy outcomes, infections, pain and most concerning, a high overall recurrence rate. Up to one in five women treated with local destructive surgical techniques will recur within two years thus potentially requiring another traumatic locally destructive therapy. Since surgical treatments are not ideal, there has long been interest in less invasive modalities for management of HPV diseases including vulvar and cervical dysplasias. We will attempt to briefly discuss these non-invasive management options that could be considered alternatives to local destructive surgical techniques in certain situations. Specific topics covered will include condom use, smoking, nutrients, retinoids, indoles, interferons, antimetabolites, immune therapies and more.

Comparison of isolates and antibiotic sensitivity pattern in pediatric and adult cancer patients; is it different?

BACKGROUND Infection is a common cause of mortality and morbidity in cancer patients. Organisms are becoming resistant to antibiotics; age appears to be one of the factors responsible. We analyzed common organisms and their antibiotic sensitivity pattern in the correlation with age. METHODS This is a single institutional, retrospective analysis of all culture positive adult and pediatric cancer patients from January 2007 to December 2007. For statistical analysis, Chi-square test for trend was used and P values were obtained. Of 1251 isolates, 262 were from children <12 years of age and 989 were from adolescents and adults (>12 years of age). Gram-negative organisms were predominant (64.95) while Gram-positive constituted 35.09% of isolates. RESULTS The most common source in all age groups was peripheral-blood, accounting to 47.8% of all samples. The most common organisms in adults were Pseudomonas aeruginosa (15.3%) while in children it was coagulase negative Staphylococcus aureus (19.8%). Antibiotic sensitivity was different in both groups. In pediatric group higher sensitivity was seen for Cefoparazone-sulbactum, Cefipime, Amikacin, and Tobramycin. No resistance was found for Linezolid. CONCLUSIONS The isolates in both children and adults were predominantly Gram-negative though children had proportionately higher Gram-positive organisms. High-dose cytarabine use, cotrimoxazole prophylaxis, and frequent use of central lines in children especially in hematological malignancies could explain this observation. Children harbor less antibiotic resistance than adults; Uncontrolled, cumulative exposure to antibiotics in our community with increasing age, age-related immune factors and variable bacterial flora in different wards might explain the higher antibiotic resistance in adults. Thus age is an important factor to be considered while deciding empirical antibiotic therapy.