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   2017| January-June  | Volume 19 | Issue 1  
    Online since June 15, 2017

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Role of line probe assay in detection of extra-pulmonary tuberculosis/multidrug-resistant tuberculosis: The experience from Kerala state, India
Praveen Sanker, Anjana Satheesan, Anusree P Ambika, Ravikrishnan Balakrishnan, Hisham Moosan, Sunil Kumar Mrithunjayan
January-June 2017, 19(1):12-18
Background: There are limited data on use of line probe assay (LPA) for detection of TB and Rifampicin resistance among extra-pulmonary tuberculosis (EPTB) patients under specific TB control programme settings. Our aim was to compare the positivity of LPA with Lowenstein–Jensen (LJ) and Bactec MGIT and to test its utility in faster testing and in patients on treatment. Methodology: The data of all 387 EPTB samples processed in two years by the state-level accredited laboratory in 2013–2014 were selected for the study. The laboratory used standard N-acetyl-L-cysteine – sodium hydroxide processing method for all samples except for cerebrospinal fluid and urine samples before conducting Ziehl-Neelsen smear microscopy, LPA and culture on both LJ and MGIT. Those samples with a negative LPA result if culture positive was subjected to a second LPA as per laboratory protocol. Doubtful Rifampicin resistant (RR) results were cleared by phenotypic testing by MGIT. Anti-TB treatment (ATT) duration was correlated with positivity of these tests later. Results and Discussion: LPA done on 321 processed samples out of 387 EPTB samples identified eight RR cases among 136 positive results within two to four days. Performing LPA on culture positive isolates identified an additional seven RR cases, thus reducing turn-around-time by two to eight weeks for the susceptibility results. It also demonstrated far better positivity in smear negative (15.2%) and in smear positive samples (74.3%) compared to culture methods as the test demonstrated clearly, better positivity among patients on ATT for more than two months. Conclusion: LPA in association with culture is an excellent combination with very good results in rapid identification of EPTB along with detection of Rifampicin resistance. LPA gives far superior positivity compared to MGIT and solid cultures among patients under ATT.
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Neonatal sepsis: Aetiological agents and risk factors
Arya Ravindran Vasantha, Saritha Narayanan Kutty, Ramani Bai Joseph Theodore
January-June 2017, 19(1):36-41
Introduction: India accounts for 30% of neonatal deaths globally. Bacterial sepsis is a major cause of morbidity and mortality in newborns. Prompt detection of microorganisms and early institution of therapy are of paramount importance. Materials and Methods: The study was conducted in the Department of Microbiology over a period of one year. Two samples of blood were collected under aseptic precautions, 1 ml each was added to conventional blood culture bottle with biphasic media and paediatric BacT/ALERT bottle. Microorganisms were identified by Gram staining, standard biochemical tests and appropriate antibiograms. The common microorganisms responsible for early- and late-onset neonatal sepsis were identified, and the resistant strains were studied in detail. The main clinical presentations and maternal and neonatal risk factors associated with neonatal sepsis were identified and statistically correlated. Results: Of the 233 newborns, 44 (18.9%) were culture positive, with higher incidence of sepsis in low birthweight male babies. Of the 44 isolates, 31 (70.5%) were Gram-negative organisms, with Klebsiella pneumoniae subspecies pneumoniae (45.5%) being the most common isolate. The prevalence of extended-spectrum beta-lactamase production in this study was 54.8%. Screening for AmpC production showed that 25.8% of the isolates were positive. The maternal risk factor of premature rupture of membrane of more than 18 h was seen in the case of 74 babies (31.8%), and 138 (59.2%) babies had prematurity as neonatal risk factor leading to sepsis. Conclusion: As the aetiological agents in neonatal sepsis vary in different circumstances and antimicrobial resistance due to different mechanisms is prevalent, antibiotic usage should be based on culture and sensitivity results.
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Comparison of antimicrobial susceptibility testing practices in 20 clinical microbiology laboratories in India
Kavita Raja, Sanjay Bhattacharya, J Beena Philomina, Savitha Nagaraj, KL Devi Sarada, KA Sathiavathy, Seema Oommen, AV Sangeetha, J Sudarsana, Reena John, Renu Mathew, Ajitha Pillai, Kiran Gopal, Syed Mustaq Ahmed, Shoba Kurian, TL Deepasankari, Anitha Madhavan, Pravin K Nair, Lathi Nair, P P Mohammed Hisham, K Sheena
January-June 2017, 19(1):5-11
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Present scenario of microbiological pattern in chronic suppurative otitis media and its management guidelines
Karan Sharma, Loveena Oberoi, Vrinda Narula
January-June 2017, 19(1):47-53
AIMS: Chronic suppurative otitis media (CSOM) is a common infectious chronic ear disease in India resulting in serious complications, especially hearing impairment. Irrational use of antibiotics for its management has led to the emergence of multidrug-resistant bacterial strains. Considering this, this study was conducted to know the pattern of causative organisms associated with CSOM and their antimicrobial sensitivity. Materials and Methods: Ear discharge from 200 clinically diagnosed cases of CSOM was collected by suction using sterile techniques in a sterilised test tube on wash bottle principle consisting of a glass tube made air tight with the help of a cork with an inlet and outlet facility. All samples were processed in the department of microbiology for the identification of bacterial and fungal isolates and their antimicrobial sensitivity testing. Results: Among the 200 samples of ear discharge, 127 were from ear having tubotympanic (mucosal or safe) type of CSOM while 73 were from ear with attico-antral (squamosal or unsafe) CSOM. Among aerobic isolates, Pseudomonas aeruginosa (35%) was most common followed by Staphylococcus aureus. Other aerobes isolated were Klebsiella spp., coagulase-negative Staphylococcus, Proteus spp. and Escherichia coli. Fungus was isolated in tubotympanic (9.45%) CSOM only. Among anaerobic isolates, Peptostreptococcus (1%) was most common. Conclusion: Monomicrobial isolates, especially P. aeruginosa and Staphylococcus species, were found to be most common in our study. Therefore, evaluation of microbiological pattern and their antibiotic sensitivity pattern in local area becomes helpful in prescribing empirical antibiotics for successful treatment of CSOM.
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Hepatitis B vaccination - immune response and persistence of protection in susceptible population
Nasha Kollathodi, Anitha Puduvail Moorkoth, Kalpana George, Mini Palathingal Narayanan, Shabina Methele Pangat Balakrishnan, Sarada Devi Karunakaran LelithaBai
January-June 2017, 19(1):42-46
Background: Hepatitis B vaccine confers long-term protection, and anti-HBs titre is a marker for protective immune response. The evaluation of immune status following vaccination is important in susceptible individuals as up to 10% immunised individuals tend to be non-responders who continue to be at risk of acquiring hepatitis B. AIM: The aim of the study was to determine the immune response and persistence of protective antibody levels after basic course of hepatitis B vaccination in susceptible individuals and to determine the factors affecting it. Materials and Methods: A cross-sectional study on 400 susceptible participants who were tested for anti-HBs by quantitative ELISA at a tertiary care centre in North Kerala for a period of 1 year. The study population included healthcare workers and medical students divided into Category I: those vaccinated with 0-1-6 schedule within the past six months and Category II: beyond six months but within 10 years. Individuals who have taken booster doses were excluded from the study. Results: 97.75% showed adequate anti-HBs levels (≥10 mIU/ml) after basic course of immunisation. Category I showed 99% response and Category II showed 96.5%. On giving one additional booster, the remaining 2.25% also responded. No non-responders were detected. 80.4% participants in the 10–20 age group showed anti-HBs >1000 mIU/ml, whereas only 25% participants in the 51–60 age group showed such high response. 97.9% males and 97.7% females had adequate response. Diabetic patients (66.7% vs. 98%) and smokers (66.7% vs. 98.2%) had a lower response (P < 0.001). Conclusion: Protective immune response was achieved in all participants after an additional dose in indicated individuals. There is a decline in antibody levels with time, but a good immunological memory persists up to 10 years after vaccination. Vaccine response is adversely affected by advancing age, smoking and diabetes.
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Soaps and infection control: From chemistry to microbiology
Gaurav Goel, Sanjay Bhattacharya, Mammen Chandy
January-June 2017, 19(1):66-69
Context: Soap and water cleaning of hands and body surfaces is one of the primary aspects of infection prevention and control. A systematic study of commonly used soaps is lacking. AIMS: To investigate: (a) whether the so-called medicated soaps have a composition which is significantly different from ordinary soaps, (b) whether the ingredients responsible for enhanced antimicrobial activity posed any health risk and (c) whether the medicated soaps offered any specific advantages over non-medicated soaps. Settings and Design: Study was done with soaps available in Indian market, used predominantly in community settings but also in hospitals. Materials and Methods: Chemical composition was checked from package labels. No chemical or microbiological tests were done to verify actual composition against stated composition. Maximum retail prices as mentioned on the pack label were noted. Statistical Analysis Used: None. Results: Soaps contain a multiplicity of ingredients. Exact composition is unknown as none of the soaps studied mentioned percentages. A number of antimicrobial agents were identified in soaps, which included salts of ethylenediaminetetraacetic acid, sodium chloride, triclocarban, triclosan, cresol compounds and certain quaternary ammonium compounds. No clear advantage was noted of the so-called ‘medicated soap’ over ‘non-medicated soaps’ in terms of ingredients or their actions. Certain medicated soaps may contain ingredients which may have a deleterious effect on microbial flora (generation of resistance) or human health (enzyme inhibition). Conclusion: While purchasing soaps either for domestic use or for hospital infection control, we need to pay due attention to its composition.
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Invasive yeast infections in the intensive care unit of a tertiary care centre in South India
Sivaranjini B Alagiri, Rajyoganandh S Vijayaraman, Vijayakumar Ramaraj, Anupma Jyoti Kindo
January-June 2017, 19(1):19-26
Introduction: The incidence of invasive mycoses has increased enormously due to the rising population of critically ill patients. Emergence of rare yeasts with variable sensitivity patterns has underlined the need to monitor laboratory data for the emergence of resistance. AIMS: To determine the prevalence and susceptibility patterns of invasive mycoses and analyse the causative risk factors in the Intensive Care Unit (ICU) of a tertiary care centre in South India. Materials and Methods: This is a retrospective, observational study performed on invasive Candida species isolated from patients admitted to the ICU. All the blood and cerebrospinal fluid (CSF) samples from ICU patients, over a period of one year, were included in the study. Preliminary identification of the isolates was done by VITEK. Genotypic identification of each isolate was done using colony polymerase chain reaction-restriction fragment length polymorphism and gene sequencing. Susceptibility pattern was ascertained by broth microdilution method according to the Clinical and Laboratory Standards Institute guidelines in document M27-A3. Relevant clinical details of the patients were collected from the records for the analysis of risk factors and outcome. Results: The present study was done on 4629 blood and 341 CSF specimens, which were sent to the central clinical microbiology laboratory for diagnosis, between November 2013 and October 2014. A total of 49 Candida strains were isolated during the study period, with a prevalence of candidaemia in our ICU to be 1.05%. Candida tropicalis 19 (35.8%) was found to be the predominant species, followed by Candida albicans, Candida parapsilosis, Candida auris, Candida glabrata, Candida duobushaemulonii and Candida krusei. All the Candida species were found to be sensitive to Anidulafungin and Micafungin. Candida isolates were sensitive to Fluconazole - 39 (80.4%), Voriconazole - 49 (100%), Amphotericin B - 27 (54.7%) and Caspofungin - 48 (96.3%). Risk factor analysis revealed intravenous catheterisation as the major predisposing factor, followed by prior therapy with broad-spectrum antibiotics, mechanical ventilation, urinary catheterisation, diabetes mellitus and steroid therapy. Four isolates of Cryptococcus neoformans were also isolated from the blood samples. Three (0.8%) cases of fungal meningitis were diagnosed from 341 CSF samples, with C. tropicalis, C. neoformans and Cryptococcus gattii as causatives. Conclusion: It is of paramount importance to promptly identify and precisely determine the susceptibility of these agents, to combat this medical battle.
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The spectrum of Bacillus cereus infections in patients with haematological malignancy
Swapna R Nath, Sagila S Gangadharan, P Kusumakumary, Geetha Narayanan
January-June 2017, 19(1):27-31
Background: Bacillus cereus is a rare but important cause of serious infections in patients with haematological malignancies. Since these infections are rapidly fatal, increased awareness, early recognition and appropriate antibiotic therapy will lead to favourable outcome. AIMS: The aim of this study is to describe the clinical spectrum and laboratory diagnosis of B. cereus infections in patients with haematological malignancies. Study Setting and Design: This is a retrospective observational study on the data from a tertiary care cancer hospital. Methodology: Patients with haematological malignancy having clinical and microbiological evidence of B. cereus infections during 2013–2015 were included in the study. Clinical records were reviewed to assess the type of underlying haematological malignancies, the spectrum of infections caused by B. cereus, risk factors, antibiotic therapy and outcome. Microbiological methods used for isolation and identification of B. cereus as well as their antibiotic susceptibility profile were also reviewed. Results: Seven patients had B. cereus infection during the study period. Four patients (57.1%) had sepsis, two patients (28.6%) had skin infections with cellulitis and one patient (14.3%) had meningitis. All patients with bloodstream infections had severe neutropenia. One patient died of the infection, while others survived with appropriate antibiotic treatment. Conclusion: B. cereus, a common agent producing acute diarrhoeal disease, can cause sepsis, invasive infections and cutaneous infections in patients with neutropenia and cancer. In patients with sepsis associated with gastrointestinal symptoms or in those with a preliminary report of Gram-positive bacilli in blood cultures, empirical antibiotic therapy should include a drug effective against B. cereus.
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Lichtheimia ramosa isolated from a young patient from an infected wound after a road traffic accident
Venkataraman Neelaveni, Ananya Tupaki-Sreepurna, Vijayakishore Thanneru, Anupma Jyoti Kindo
January-June 2017, 19(1):59-61
A 38 year-old male, a known case of diabetes mellitus on treatment, sustained an injury to his left foot in a Road Traffic Accident (RTA) and developed a polymicrobial wound infection. The causative organisms were found to be Pseudomonas aeruginosa along with a Zygomycete which could not be speciated by conventional microscopy but was identified as Lichtheimia ramosa by Polymerase Chain Reaction (PCR) and Internal Transcribed Spacer (ITS)sequencing. The infection was treated successfully by debridement and daily dressing with antiseptic solution. The patient recovered due to early diagnosis and did not require systemic antifungals.
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Nasal conidiobolomycosis: Report of a rare case
Rejitha Kurukkanari, Geetha Raveendran, Pushpa Kizhakkekarammal, Sheena Krishnan
January-June 2017, 19(1):54-56
Entomophthoromycosis is a rare fungal infection caused by fungi belonging to the genera, Conidiobolus and Basidiobolus coming under the order Entomophthorales. We report a case of Conidiobolomycosis in an adult male patient who presented with a mass in the left nostril. Fungal culture yielded Conidiobolus coronatus, and the patient was treated with Itraconazole for six months. The patient responded very well.
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Role of IgG Chlamydia antibody in predicting tubal factor infertility
Dolly Johnrose, Geetha Raveendran, Sheila Balakrishnan, Anitha Malathy
January-June 2017, 19(1):32-35
Background and Objectives: Infertility is not a health problem, but a serious psychological trauma that affects the social status of women in the society. Treatment of infertility imposes a heavy economic burden on the family. Infertility can be due to a single or combination of causes and identification of the cause is essential for the proper management. Chlamydia trachomatis is one of the most common causes of tubal factor infertility. No recent study has been done in Kerala to assess the burden of C. trachomatis in genitourinary infections. The aim of the study was to assess the role of C. trachomatis IgG antibody in patients with tubal factor infertility among women with primary or secondary infertility attending the fertility clinic in a tertiary care hospital in Kerala. Materials and Methods: The study was done for one year and the sample size included 95 cases and 63 age-matched controls. Tubal disease was diagnosed by laparoscopy or hysterosalpingography. Serum samples of all the patients and controls were tested for C. trachomatis IgG antibodies by enzyme-linked immunosorbent assay. Results: Of the 95 patients with tubal pathology, 14 (14.7%) had antibodies to C. trachomatis. Of the 63 patients with normal tubes, 12 (19%) had antibodies. However, of the 26 patients who were positive for Chlamydia antibodies, 14 (53.8%) had tubal disease. Conclusions: The prevalence of Chlamydia IgG in our study among women attending fertility clinic for the treatment of primary or secondary infertility is 26/158 (16.5%). Fifty-one (81%) patients had normal tubes.
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Aspergillus quadrilineatus infection in an elderly debilitated patient
N Chadiesh, Bhavna T Jishnu, Ananya Tupaki-Sreepurna, R Ramanan, Vijayakishore Thanneru, Anupma Jyoti Kindo
January-June 2017, 19(1):62-65
We report a case of Aspergillus quadrilineatus isolated from post-tracheostomy bronchial wash sample of an 85-year-old hypertensive male admitted in the Intensive Care Unit with subarachnoid haemorrhage and low Glasgow Coma Scale score. Although the patient had a history of nasal infection and was symptomatic at the time of admission, the radiological findings were non-specific and included pulmonary infiltrates. This could be the first probable case of invasive infection by A. quadrilineatus reported from India. The patient was treated successfully with Itraconazole and was discharged after recovery from his illness.
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Academy news
Chithra Valsan
January-June 2017, 19(1):1-1
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Fonsecaea pedrosoi causing leg abscess
Sheena Krishnan, Rejitha Kurukkanari, Pushpa Kizhakkekarammel, Geetha Raveendran
January-June 2017, 19(1):57-58
Chromoblastomycosis is a localised fungal infection of cutaneous and subcutaneous tissue caused by dematiaceous fungi. Etiological agents are black moulds found growing as saprophytes of woods. Here, we report a case of Fonsecaea pedrosoi causing leg abscess in the 41-year-old male patient.
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Editorial on antibiotic susceptibility testing
Kavita Raja
January-June 2017, 19(1):2-4
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