Third generation cephalosporin-resistance in Klebsiella pneumoniae isolates: an emerging threat

Background: Newer generation cephalosporin-resistance among Klebsiella pneumoniae organisms has increased recently. Present study is undertaken to find incidence, antimicrobial susceptibility and prevalence of extended spectrum beta-lactamase (ESBL) in K. pneumoniae isolates in a tertiary care hospital.Methods: Prospective study was carried out between June to December 2011. Samples of pus, blood, urine, cerebro-spinal fluid, stool, peritoneal, pleural and synovial fluid were collected from indoor and outdoor patients for isolation and antimicrobial susceptibility pattern of K. pneumoniae in the department of microbiology, G.R. Medical College Gwalior, M.P. Ceftazidime resistant K. pneumoniae were subjected to Phenotypic Confirmatory Disc Diffusion Test (PCDDT) and Double Disc Synergy Test (DDST) for detection of ESBL.Results: Out of 2480 samples collected a total of 530 K. pneumoniae were isolated and subjected to antimicrobial susceptibility. Antibiotic sensitivity to imipenem, cefoperazone, amikacin and ofloxacin were 82, 74, 73 and 72% respectively whereas sensitivity to ceftizoxime, ceftriaxone cefotaxime, ceftazidime ranged between 47-50%. K. pneumoniae were found to be resistant to ampicillin, co-trimoxazole, doxycycline and gentamicin, by 91, 82, 54 and 50% respectively. Among third generation cephalosporins K. pneumoniae were least sensitive (47%) to ceftazidime. About 33 and 32% of the ceftazidime resistant strains were found to be ESBL positive by PCDDT and DDST respectively.Conclusions: This study has shown that prevalence of ESBL producing K. pneumoniae is the most important reason for increased resistance to third generation cephalosporins. There is need to carry out tests for detection of ESBL producing bacteria routinely

Lipid profile and its correlation with C-reactive protein in patients of acute myocardial infarction

Background: Acute myocardial infarction (AMI) is a significant cause of morbidity and mortality worldwide, which results from occlusion of coronary artery. Dyslipidemia is a major risk factor of AMI. C-reactive protein (CRP) is an acute phase protein, synthesized by hepatocytes in response to cytokines released into circulation by activated leukocytes and has been found to increase after AMI. The objective of the present study is to investigate lipid profile in AMI patients and correlate it with inflammatory marker i.e. CRP.Methods: The present study includes 150 AMI patients and 100 normal healthy individuals as controls. In all the cases and controls, serum lipid profile and inflammatory marker were measured by diagnostic kits supplied by ERBA.Results: The levels of lipid profile and inflammatory marker were significantly altered in the AMI cases compared to controls. We found significantly higher levels of total cholesterol, TG, LDL, VLDL, CRP and lower level of HDL in AMI compared to that of control subjects. We also found strong positive correlation of CRP with total cholesterol, triglyceride, LDL-C and VLDL-C and significant negative correlation with HDL-C in AMI patients.Conclusions: We found alterations in the lipid profile and inflammatory marker in AMI cases; hence, all the people should undergo regular check up including lipid profile evaluation and inflammatory marker such as CRP to decrease the incidence, morbidity and mortality from the disease

Prevalence and causes of blindness in patients coming to a tertiary eye care centre in western Uttar Pradesh

Background: Objective of the research was to study the prevalence of blindness in adult patients coming to a tertiary eye care centre in Western Uttar Pradesh and assess their causes. Methods: A cross-sectional study was conducted on adult patients coming to the outpatient department of a tertiary eye care centre over a period of 3 months and 375 patients were identified as having blindness. Complete ophthalmological examination was conducted to find out the cause for the same. Results: The prevalence of blindness was found out to be 4.096%. The major causes for blindness in adults were identified as cataract (33.06%), glaucoma (13.6%), ARMD (5.6%), diabetic retinopathy (5.06%), corneal scar/opacity/dystrophy (26.93%), amblyopia (3.2%) and trauma (2.13%). Conclusions: Knowledge of prevalence of blindness in a region is important in developing and implementing eye care services. Avoidable blindness needs to be identified and treated as soon as possible

Evaluation of Implementation of Intermittent Screening and Treatment for Control of Malaria in Pregnancy in Jharkhand, India.

This study evaluated intermittent screening and treatment during pregnancy (ISTp) for malaria using rapid diagnostic tests (RDTs) at antenatal care (ANC) compared with passive case detection within the routine health system. The mixed-method evaluation included two cross-sectional household surveys (pre- and post-implementation of ISTp), in-depth interviews with health workers, and focus group discussions (FGDs) with pregnant women. Differences in proportions between surveys for a number of outcomes were tested; 553 and 534 current and recently pregnant women were surveyed (pre- and post-implementation, respectively). In-depth interviews were conducted with 29 health providers, and 13 FGDs were held with pregnant women. The proportion of pregnant women who received an RDT for malaria at ANC at least once during their pregnancy increased from pre- to post-implementation (19.2%; 95% CI: 14.9, 24.3 versus 42.5%; 95% CI: 36.6, 48.7; P < 0.0001), and the proportion of women who had more than one RDT also increased (16.5%; 95% CI: 13.1, 20.5 versus 27.7%; 95% CI: 23.0, 33.0; P = 0.0008). Post-implementation, however, only 8% of women who had completed their pregnancy received an RDT on three visits to ANC. Health workers were positive about ISTp mainly because of their perception that many pregnant women with malaria were asymptomatic. Health workers perceived pregnant women to have reservations about ISTp because of their dislike of frequent blood withdrawal, but pregnant women themselves were more positive. Intermittent screening and treatment during pregnancy was not sufficiently adopted by health workers to ensure the increased detection of malaria infections achievable with this strategy in this setting

Efficacy of two artemisinin-based combinations for the treatment of malaria in pregnancy in India: a randomized controlled trial.

BACKGROUND: In India, the recommended first-line treatment for malaria in the second and third trimester of pregnancy is artesunate + sulfadoxine-pyrimethamine (AS+SP). However, data on safety and efficacy of artemisinin-based combination therapy (ACT) in pregnancy is limited. This study assessed the safety and efficacy of AS+SP and artesunate + mefloquine (AS+MQ) for treatment of Plasmodium falciparum in pregnancy in India. METHODS: This open-label, randomized clinical trial was conducted from October 2010 to December 2013 at three sites in India (Ranchi and Jamshedpur in Jharkhand state, and Rourkela in Odisha state). Pregnant women in the second or third trimester who had P. falciparum mono-infection of any parasite density with or without fever were randomized to receive AS+SP or AS+MQ. Blood slides and filter paper samples for Polymerase Chain Reaction (PCR) were collected on days 0, 1, 2, 3, 14, 21, 28, 42 and 63 post treatment. Women were followed up at delivery and at day 42 postpartum. FINDINGS: Two hundred and forty-eight women of 7064 pregnant women (3.5%) who were screened at monthly antenatal clinics had a P. falciparum mono-infection and were randomized to receive AS+SP (125) or AS+MQ (123) and all of these women were included in the intention to treat (ITT) analysis. The primary endpoint of an adequate clinical and parasite response (ACPR) on day 63 was not available for 9 women who were counted as treatment failure in the ITT analysis. In the ITT population, the ACPR was 121/125 (96.8%; 95% Confidence interval (CI) 92.0-99.1%) in the AS+SP group and 117/123 (95.1%; 95% CI 89.7-98.2) in the AS+MQ group. Among the 239 women (121 from the AS+SP arm and 118 from the AS+MQ arm) who completed the day 63 follow up (per protocol analysis) the ACPR was 100% in the AS+SP group and 99.2% (117/118) in the AS+MQ group. There were five serious adverse events (SAE) among pregnant women (4 in the AS+SP group and 1 in the AS+MQ group) and 13 fetal/neonatal SAEs (7 in the AS+SP group and 6 in the AS+MQ) but none of them were related to the study drugs. A higher proportion of women in the AS+MQ arm reported vomiting within 7 days post-treatment than did women in the AS+SP arm (6.9 vs. 1.6%; p = 0.001). CONCLUSION: Both AS+SP and AS+MQ are safe and effective for treatment of uncomplicated falciparum malaria in pregnancy in India. Trial registration CTRI This study is registered with Clinical Trial Registry India (CTRI), number CTRI/2009/091/001055. Date of Registration 11 January 2010, http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=1185&EncHid=&userName=anvikar

Genetic variation in histidine rich proteins among Indian Plasmodium falciparum population: possible cause of variable sensitivity of malaria rapid diagnostic tests

BACKGROUND: Rapid diagnostic tests (RDTs) have revolutionized the diagnosis of malaria. Among the various factors affecting RDTs sensitivity is genetic variation of the antigen used. The genetic variation in PfHRP2 and PfHRP3 proteins was studied among the Indian Plasmodium falciparum isolates. METHODS: One hundred and forty isolates of P. falciparum were collected from six geographical regions of India. Target genes encoding PfHRP2 and PfHRP3 antigens were sequenced to study genetic polymorphism. Minimum detection limit giving a positive rapid diagnostic test was also determined. RESULTS: Extensive variations were observed in amino acid repeat types of PfHRP2 and PfHRP3. PfHRP2 exhibited more polymorphism than PfHRP3. Significant relation was observed between type 2 and type 7 repeats and RDT detection rate as higher number of these repeats showed better sensitivity with RDTs. CONCLUSION: The results provide insights into the genetic diversity of Pfhrp2 and Pfhrp3 genes among Indian P. falciparum population and its relation to RDT sensitivity

Bacterial Etiologies and Antibiotic Sensitivities in Acute and Chronic Dacryocystitis: A Western U.P. Perspective

The current study aimed to assess and compare the bacteriological spectrum of acute and chronic dacryocystitis and the antibiotic susceptibility and resistance of the causative pathogens to commonly used antimicrobials. This was a prospective observational study. Cases of dacryocystitis were categorized as acute or chronic, based on clinical features. Specimens were obtained by sterile cotton swabs from the lower conjunctival fornix and from the puncta by applying pressure over the lacrimal sac area or by performing lacrimal syringing. Specimens were inoculated on appropriate culture media and incubated at 37ºC for 24-48 hours. Bacterial species were identified based on colony morphology and standard biochemical tests. Antibiotic Susceptibility Testing was assessed by Kirby Bauer disc diffusion technique using Mueller Hinton agar following Clinical and Laboratory Standards Institute guidelines. Out of 50 patients, 37 (74%) had chronic dacryocystitis and 13 (26%) had acute dacryocystitis. 35 bacterial species were recovered. Gram-positive organisms were the most isolated organisms i.e., 27 out of 35 (77.2%). In chronic dacryocystitis, the predominant bacterial species were Staphylococcus epidermidis (36%). In acute dacryocystitis, the predominant bacterial species were Staphylococcus aureus (40%). Against gram-positive organisms, Vancomycin and Linezolid were most effective (100%). Against gram-negative bacterial species, Amikacin was most effective (100%). High prevalence rate of antibiotic resistance was found, with 40% of the total bacterial species resistant to 5 or more antibiotics. The alarming rate of multi-drug resistance underscores the imperative need for tailored antibiotic strategies and continuous monitoring. Evidence based antibiotic therapy may also help to prevent failures of DCR, progression to chronicity and antibiotic resistance

Epidemiology of malaria and anemia in high and low malaria-endemic North-Eastern districts of India

Anemia and malaria are the two major public health problems that lead to substantial morbidity and mortality. Malaria infection destroys erythrocytes, resulting in low hemoglobin (Hb) levels known as anemia. Here we report the determinants of anemia in high and low malaria-endemic areas that would help understand which parasite densities, age, and gender-associated low Hb levels. Therefore, a cross-sectional mass survey (n = 8,233) was conducted to screen anemia and malaria in high and low malaria-endemic districts (HMED and LMED) of North-East India. Axillary body temperature was measured using a digital thermometer. The prevalence of anemia was found to be 55.3% (4,547/8,233), of which 45.1% had mild (2,049/4,547), 52.1% moderate (2,367/4,547) and 2.9% had severe anemia (131/4,547). Among anemic, 70.8% (3,219/4,547) resided in LMED and the rest in HMED. The median age of the anemic population was 12 years (IQR: 7–30). Overall, malaria positivity was 8.9% (734/8,233), of which HMED shared 79.6% (584/734) and LMED 20.4% (150/734) malaria burden. The village-wise malaria frequency was concordant to asymptomatic malaria (10–20%), which showed that apparently all of the malaria cases were asymptomatic in HMED. LMED population had significantly lower Hb than HMED [standardized beta (β) = −0.067, p &lt; 0.0001] and low-density Plasmodium infections had higher Hb levels than high-density infections (β = 0.113; p = 0.031). Women of reproductive age had higher odds for malaria (OR: 1.42; 95% CI: 1.00–2.05; p = 0.04). Females (β = −0.193; p &lt; 0.0001) and febrile individuals (β = −0.029; p = 0.008) have shown lower Hb levels, but malaria positivity did not show any effect on Hb. Young children and women of reproductive age are prone to anemia and malaria. Although there was no relation between malaria with the occurrence of anemia, we found low-density Plasmodium infections, female gender, and LMED were potential determinants of Hb

Effectiveness of intermittent screening and treatment for the control of malaria in pregnancy: a cluster randomised trial in India.

BACKGROUND: The control of malaria in pregnancy (MiP) in India relies on testing women who present with symptoms or signs suggestive of malaria. We hypothesised that intermittent screening and treatment for malaria at each antenatal care visit (ISTp) would improve on this approach and reduce the adverse effects of MiP. METHODS: A cluster randomised controlled trial comparing ISTp versus passive case detection (PCD) was conducted in Jharkhand state. Pregnant women of all parities with a gestational age of 18-28 weeks were enrolled. Women in the ISTp group were screened with a rapid diagnostic test (RDT) for malaria at each antenatal clinic visit and those in the PCD group were screened only if they had symptoms or signs suggestive of malaria. All RDT positive women were treated with artesunate/sulfadoxine-pyrimethamine. The primary endpoint was placental malaria, determined by placental histology, and the key secondary endpoints were birth weight, gestational age, vital status of the newborn baby and maternal anaemia. RESULTS: Between April 2012 and September 2015, 6868 women were enrolled; 3300 in 46 ISTp clusters and 3568 in 41 PCD clusters. In the ISTp arm, 4.9% of women were tested malaria positive and 0.6% in the PCD arm. There was no difference in the prevalence of placental malaria in the ISTp (87/1454, 6.0%) and PCD (65/1560, 4.2%) groups (6.0% vs 4.2%; OR 1.34, 95% CI 0.78 to 2.29, p=0.29) or in any of the secondary endpoints. CONCLUSION: ISTp detected more infections than PCD, but monthly ISTp with the current generation of RDT is unlikely to reduce placental malaria or impact on pregnancy outcomes. ISTp trials with more sensitive point-of-care diagnostic tests are needed

Prescription practices and availability of artemisinin monotherapy in India: where do we stand?

<p>Abstract</p> <p>Background</p> <p>The World Health Organization has urged all member states to deploy artemisinin-based combination therapy and progressively withdraw oral artemisinin monotherapies from the market due to their high recrudescence rates and to reduce the risk of drug resistance. Prescription practices by physicians and the availability of oral artemisinin monotherapies with pharmacists directly affect the pattern of their use. Thus, treatment practices for malaria, with special reference to artemisinin monotherapy prescription, in selected states of India were evaluated.</p> <p>Methods</p> <p>Structured, tested questionnaires were used to conduct convenience surveys of physicians and pharmacists in eleven purposively selected districts across six states in 2008. In addition, exit interviews of patients with a diagnosis of uncomplicated malaria or a prescription for an anti-malarial drug were also performed. Logistic regression was used to determine patient clinical care, and institutional factors associated with artemisinin monotherapy prescription.</p> <p>Results</p> <p>Five hundred and eleven physicians from 196 health facilities, 530 pharmacists, and 1, 832 patients were interviewed. Artemisinin monotherapy was available in 72.6% of pharmacies and was prescribed by physicians for uncomplicated malaria in all study states. Exit interviews among patients confirmed the high rate of use of artemisinin monotherapy with 14.8% receiving such a prescription. Case management, i.e. method of diagnosis and overall treatment, varied by state and public or private sector. Treatment in the private sector (OR 8.0, 95%CI: 3.8, 17) was the strongest predictor of artemisinin monotherapy prescription when accounting for other factors. Use of the combination therapy recommended by the national drug policy, artesunate + sulphadoxine-pyrimethamine, was minimal (4.9%), with the exception of one state.</p> <p>Conclusions</p> <p>Artemisinin monotherapy use was widespread across India in 2008. The accessible sale of oral artemisinin monotherapy in retail market and an inadequate supply of recommended drugs in the public sector health facilities promoted its prescription. This study resulted in notifications to all state drug controllers in India to withdraw the oral artemisinin formulations from the market. In 2010, artesunate + sulphadoxine-pyrimethamine became the universal first-line treatment for confirmed <it>Plasmodium falciparum </it>malaria and was deployed at full scale.</p