Incidence of ventilator associated pneumonia and drug-resistant bacterial preponderance: a fact to ponder

Background: Management of ventilator-associated pneumonia (VAP) in critically ill patients is a challenge to intensivists. This study aimed at identifying microbial factors and infection control practices that influenced incidence of VAP in a tertiary care hospital.Methods: Incidence of VAP among patients admitted to the intensive care units (ICU) from January to December 2016 was estimated. A one year period of study was divided into 3 segments of January to April, May to August, and September to December. Isolation rates of Gram Negative Bacteria (GNB) from respiratory samples and their extensively drug resistance (XDR) pattern were also analyzed.Results: A total of 14 patients had developed VAP. Incidence of VAP in the 1st, 2nd and 3rd segments of the year was 25.3, 15.2 and 4.1/1000 ventilator days respectively. Acinetobacter baumannii was the causative agent in all patients (100%). Among all GNB isolated the rate of Acinetobacter baumannii was 83%, 64%, 59% during the 3 segments of the year. XDR strains were 76%, 62% and 55%. Interventional factors like improvement in infection control practices which included hand hygiene, cohorting of MDR/XDR infected patients and environmental surveillance was noted.Conclusions: The VAP incidence declined in the later part of the year than the earlier (25.3 Vs 4.1/1000 ventilator days), with a notable decrease in the isolation of Acinetobacter baumannii (p value-0.005) and XDR organisms (p value-0.01). Directly proportionate association of VAP incidence with microbial factors were noted. Infection control measures to curtail MDR organisms should be an important component in the management of patients on ventilators

High frequency of multiresistant respiratory tract pathogens at community level in South India

ObjectiveTo describe the patterns of antibiotic susceptibility of outpatient strains of Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis in the district of Pondicherry in South India.MethodsThe antibiotic susceptibilities of 94 S. pneumoniae, 97 H. influenzae and 104 M. catarrhalis strains, collected from outpatients with respiratory tract infections, were determined by disk diffusion and Etest.ResultsResistance or reduced susceptibility to trimethoprim–sulfamethoxazole was found in 67% of S. pneumoniae, 53% of H. influenzae and 24% of M. catarrhalis strains. Thirty-seven per cent of S. pneumoniae and 39% of H. influenzae strains were resistant or showed reduced susceptibility to tetracycline. Reduced susceptibility to penicillin was found in 6% of S. pneumoniae strains. Overall, 10% of S. pneumoniae and 38% of H. influenzae strains showed reduced susceptibility to ≥3 antibiotics. Comparisons between the antibiotic susceptibility patterns of the Indian strains and a corresponding collection of strains from Sweden indicate that the susceptibility of the native susceptible population is independent of geographic origin.ConclusionsThe findings indicate high consumption of tetracycline and trimethoprim–sulfamethoxazole in the area, which emphasizes the need for surveillance of the pattern of antibiotic susceptibility among respiratory tract pathogens at community level in developing countries and for the implementation of local guidelines for rational use of antibiotics

Lid abscess: An unusual presentation of melioidosis

Melioidosis caused by Burkholderia pseudomallei (B. pseudomallei), is an emerging infection in India. Clinical manifestation of melioidosis is variable ranging from localized benign infection to fulminant septicemia. Ocular presentation of melioidosis is rare. However, cases of endophthalmitis, keratitis and orbital infections have been reported. We report the isolation of B. pseudomallei in a 40 year old male, presenting with fever and lid abscess. The patient was treated with meropenem during the acute phase and switched to trimethoprim/sulfamethoxazole for eradication phase

Escherichia coli in hospitalised patients

Background Extended spectrum betalactamase (ESBL)-producing organisms are a major cause of hospital-acquired infections. ESBL-producing Escherichia coli (E. coli) have been recovered from the hospital environment. These drug-resistant organisms have also been found to be present in humans as commensals. The present investigation intended to isolate ESBL-producing E. coli from the gut of already infected patients; to date, only a few studies have shown evidence of the gut microflora as a major source of infection. Aims This study aimed to detect the presence of ESBL genes in E.coli that are isolated from the gut of patients who have already been infected with the same organism. Methods A total of 70 nonrepetitive faecal samples were collected from in-patients of our hospital. These in-patients were clinically diagnosed and were culture-positive for ESBL-producing E. coli either from blood, urine, or pus. Standard microbiological methods were used to detect ESBL from clinical and gut isolates. Genes coding for major betalactamase enzymes such as blaCTX-M, blaTEM, and blaSHV were investigated by polymerase chain reaction (PCR). Results ESBL-producing E. coli was isolated from 15 (21 per cent) faecal samples of the 70 samples that were cultured. PCR revealed that out of these 15 isolates, the blaCTX-M gene was found in 13 (86.6 per cent) isolates, the blaTEM was present in 11 (73.3 per cent) isolates, and blaSHV only in eight (53.3 per cent) isolates. All 15 clinical and gut isolates had similar phenotypic characters and eight of the 15 patients had similar pattern of genes (blaTEM, blaCTX-M, and blaSHV) in their clinical and gut isolates. Conclusion Strains with multiple betalactamase genes that colonise the gut of hospitalised patients are a potential threat and it may be a potential source of infection

Antimicrobial Susceptibility Patterns of Salmonella enterica Serotype Typhi in Eastern Nepal

The aim of the present study was to evaluate antimicrobial susceptibility patterns with special reference to multidrug resistance, susceptibility to ciprofloxacin, and bacteriophage typing of Salmonella enterica serotype Typhi isolated from blood sent for culture in a tertiary-care teaching hospital in eastern Nepal during January 2000\u2013December 2004. In total, 132 strains of S. enterica Typhi, isolated from 2,568 blood culture samples collected from cases of suspected enteric fever, were tested for susceptibility to commonly-used antimicrobials by the disc-diffusion method. There were 35 multidrug-resistant strains. None of the isolates were resistant to ciprofloxacin.Of 52 isolates tested for minimum inhibitory concentration (MIC) of ciprofloxacin, 36 (69.23%) showed reduced susceptibility (MIC 650.25 mg/L). Of 112 strains tested for nalidixicacid susceptibility,86(76%) were resistant. Strains with reduced susceptibility to ciprofloxacin and resistance to nalidixic acid could be correlated. The commonest phage type was E1. Nalidixic acid susceptibility could be a useful screening test for the detection of decreased susceptibility of S. Typhi to ciprofloxacin, a drug which is commonly used even for minor ailments in this area

Hemophagocytic lymphohistiocytosis: an unusual complication in Orientia tsutsugamushi disease (scrub typhus).

Background: Hemophagocytic lymphohistiocytosis (HLH) is an uncommon, potentially fatal, hyperinflammatory syndrome that may rarely complicate the clinical course of Orientia tsutsugamushi disease (scrub typhus). Methods: We describe here the clinicopathological features, laboratory parameters, management, and outcome data of three adult patients (1 female, 2 males) with scrub typhus associated HLH from a tertiary center with a brief and concise review of international literature. Results: All three patients satisfied the HLH-2004 diagnostic criteria; one had multi organ dysfunction with “sky high” ferritin level; and all had a dramatic recovery following doxycyclin therapy. Literature review from January 1990 to March 2014 revealed that scrub typhus associated HLH were reported in 21 patients, mostly from the scrub endemic countries of the world. These included 11 females and 10 males with mean age of 35 years (range; 8 months to 81 years). Fifteen of 17 patients (where data was available) had a favorable outcome following early serological diagnosis and initiation of definitive antibiotic therapy with (N=6) or without (N=9) immunosuppressive/immunomodulator therapy. Mutation analysis for primary HLH was performed in one patient only, and HLH-2004 protocol was used in two patients. Conclusion: We suggest that HLH should be considered in severe cases of scrub typhus especially if associated with cytopenia (s), liver dysfunction, and coagulation abnormalities.  Further studies are required to understand whether an immunosuppressive and/or immunomodulator therapy could be beneficial in those patients who remain unresponsive to definitive antibiotic therapy

Polyarthritis and massive small bowel bleed: An unusual combination in Scrub typhus

Scrub typhus is an acute febrile illness caused by the intracellular parasite Orientia tsutsugamushi. Although most cases present with mild symptoms and signs and recover spontaneously, some cases can be severe with multi-organ dysfunction and a protracted course, which may be fatal if left untreated. Apart from fever and constitutional symptoms, atypical presentations allow this disease to mimic several common conditions. We report a case of scrub typhus in an 18-year-old male who presented with severe polyarthritis involving all large joints and a massive lower gastrointestinal bleed from ulcers in the terminal ileum, secondary to vasculitis in the small bowel. This combination of pathologies has not previously been reported in cases of scrub typhus. The patient improved following surgical intervention and specific anti-rickettsial therapy with azithromycin