CIDSCON 2017

CIDSCON 2017
7 Annual Conference of
th
Clinical Infectious Diseases Society, India

Supported by : Society of Critical Care Medicine, Nagpur Chapter
18th | 19th | 20th August, 2017
Venue : Le Méridien Nagpur, Maharashtra
Theme : Advancing Science, Improving Care
Abstracts
www.cidscon.in
Oral
Papers
CIDSCON 2017 2 www.cidscon.in
Antimicrobial Stewardship Journey And It’s Impact At
A Multispeciality Tertiary Health Care Facility
___________________________________________________________________________________________
Author : Dr. Sukanya Rengaswamy
Co-authors : Murali Chakravarthy, Chakrapani, Ancy,Frency, Thejasvini,
Priyadarshini, Arul Rose Suganya
Institution : Fortis Hospitals, Bannerghatta Road,Opp, Bangalore
INTRODUCTION:
Antibiotic resistance has been a serious global concern over the years. The emergence
of super bugs and consecutively, a drop in the availability of new antibiotics has
triggered return of the pre-antibiotic era, where people would suffer or even die from
untreatable bacterial infections. As a measure to curb and control
antimicrobial resistance, the Antimicrobial stewardship program was initiated at Fortis
Hospitals,Bannerghatta Road,Bengaluru,in 2013
OBJECTIVES:
Objectives of this initiative were to optimize selection,dosing and duration of
antimicrobials for therapy and prophylaxis
METHODS AND MATERIALS:

A Multidisciplinary team was formed in 2013, comprising of Infection control
officer, Clinical Pharmacists, Quality champions, and AMS working group (Physicians,
Intensivists, Consultants of different specialty) and the following initiatives were taken
up.
• Clinical awareness Drives for doctors on the importance of antibiotics and resistance,
surgical prophylaxis, hospitals antibiogram and providing awareness on the current
trends in antimicrobial therapy with their PK-PD studies.
• Restricted Antimicrobial Policy: List of the restricted antimicrobials was
circulated and implementation of the Justification Form for the use of restricted
antibiotics was mandated.Irrational fixed drug combinations were also phased
out from the formulary .
• Surgical Prophylaxis: A well formulated protocol on the administration time,selection
of the prophylactic agent, duration of prophylaxis post surgery and intraop re-dosing
for the use of antibiotics for Surgical Prophylaxis was rolled out and monitored every
quarterly in all the Surgical specialities.The data and analyses were then shared with
surgeons.
• Empiric therapy audits in MICU: Daily review of the empiric use of antibiotics
particularly in the adult medical intensive care unit,based on the antibiotic policy of
the hospital by the Clinical Pharmacists.
• Preparation of antibiogram, Review of culture reports, Discussion on Antimicrobial
management case wise with clinicians by The Clinical Microbiologist
• Letters of communication and one to one talk by the Chairman of the AMS
committee to the physicians in case of irrational prescription of antibiotics.
• Regular AMS committee meetings (every quarterly) to discuss findings of the
previous months and to address any issues.
RESULTS:
The outcomes of this initiative were measured through audits on Empiric therapy,Surgical
prophylaxis and Resistance trends of Organisms and DRI(Drug Resistance Index)
The key improvements over 2013-2016, were the decrease in the use of Carbapenems

for >72hours(31% to 13%) and colistin use >72 hours(3.5% to 1%) . Escalations to higher
antibiotics reduced from 37% to 5%.
The <10days duration of stay in MICU decreased by 15% from 2013-2016.Total duration
of antibiotic use however,showed no major changes.
De-escalations after 72 hours showed marked improvement between 2013-2015(14% to

36%) and again a decline to 9% in 2016 due to several outbreaks of MDR gram negative
organisms.There was a decrease in the early initiation of empiric antibiotics(55% in 2013
to 25% in 2016).This highlights the judicious,policy based and appropriate use of Empiric
antibiotics after effective AMS programmes in MICU.
The surgical prophylaxis compliance from 2013-2016, showed marked improvement in

CABG, LSCS,Orthopaedics and Neurosurgical cases.
Major improvements were seen in the shorter duration of surgical prophylaxis(CABG

44%-95%,LSCS-78%-88%,Orthopaedics 68%-75% and Neurosurgery 37%-51%) and
change in the choice of the antimicrobials from 3rd generation cephalosporins and
combinations to a second generation Cefuroxime as a single choice.
There was gradual decrease in resistance to 3rd generation cephalosporins(43%-33%)

among the enterobacteriacea and decrease in carbapenem resistance among
Pseudomonas strains(25%-10%).
The Drug Resistance Index showed a drastic dip and decreasing trend. Overall DRI 0.5
to 0.4, gram negative DRI 0.53- 0.4 Klebsiella 0.64- 0.4 and Pseudomonas 0.29 to 0.1
over 2013-2015.
CONCLUSION:
Antimicrobial stewardship is a coordinated program that promotes the appropriate
use of antimicrobials improves patient outcomes, reduces microbial resistance and
decreases the spread of infections caused by multidrug-resistant organisms. Patients,
healthcare providers, hospital administrators and policy makers must work together
to employ effective strategies for improving appropriate antibiotic use – ultimately
improving medical care and saving lives.

Ventilator Associated Pneumonia - Incidence,
Microbiological Profile, And Measures Taken To reduce it
___________________________________________________________________________________________
Author : Dr. Patil Sunita
Co-authors : Dr. Sheik A R, Dr. Tilak T V, Dr. Moorchung N, Dr. Ravi P, Dr. Handa A
Department : Department of Pathology,
Institution : Command Hospital Air Force Bangalore.
Background:
Ventilator Associated Pneumonia (VAP) accounts for 9-27% of mechanically
ventilated patients, with five cases per 1000 ventilator days. India has wide range
in reporting of VAP data. Our objectives of this study were to measure the
incidence of VAP, the implicated pathogens, and efficacy of measures taken to
reduce the incidence of VAP.
Material and methods:

This is a prospective active surveillance study carried out in a medical- surgical ICU
at tertiary care setting in southern part of India over a period of three years. First phase
was assessment phase while second phase was intervention phase. In both phases
CDC criteria were followed for selection of VAP cases. All the cases were assessed
for etiological agent, its antibiotic sensitivity pattern and the clinical outcome. In
second phase of intervention, various measures like frequent subglottic suctioning,
proper weaning protocol and titrating sedation regimen applied to check their
efficacy on VAP rate.
Results:
VAP incidence rates in first phase were 12.14. Modifications in the VAP treatment
protocol like by emphasising the use of frequent subglottic aspiration/suctioning
technique, limiting duration of mechanical ventilation by proper weaning protocol
and titrating sedation regimen with the help of dedicated HICC nurse has helped in
reduction of incidence to 7.64 (sixty percent reduction in VAP).
The microbiological profiling of all tracheal aspirates and BAL samples revealed
predominance of Gram negative isolates in both phases. Klebsiella was the most
common isolate followed by Acinetobacter and Pseudomonas. No polymicrobial
growth noted in second phase.
Conclusion:
We strongly recommend implementation of appropriate and timely interventions to
reduce VAP rate. “Together everyone achieves more” is the best quote for every
Hospital infection control team to reduce VAP rate.

BK Virus Induced Haemorrhagic Cystitis in Haematopoietic
Stem Cell Transplant Setting – A 10 Year Retrospective
Case Control Study
___________________________________________________________________________________________
Author : Dr. Sharon Lionel

Co-authors : Dr. Anu Korula, Dr. Anup Devasia, Dr. Nisham PN, Dr. Uday.PK,
Dr. Kavitha ML, Dr. Aby Abraham, Dr. Alok Srivastava,
Dr. Vikram Mathews, Dr. Biju George
Department : Haematology
Institution : Christian Medical College, Vellore Tamilnadu, India.
Objective: BK virus infection causing Haemorrhagic cystitis (HC) is a well known

complication of Haematopoietic stem cell transplantation (HSCT) that is associated
with increased morbidity, mortality, longer hospital stays and increased hospital costs.
This analysis was done to ascertain etiological risk factors, incidence and outcomes of
BK virus induced HC following HSCT.
Methods:
In this retrospective case control study of patients undergoing HSCT in the department
of Haematology CMC Vellore between 2007 and 2016, we compared patients who
developed BK virus induced HC with those without BK virus infection [controls] matched
for age, diagnosis, conditioning regimen and donor source. Data was collected from
individual medical records and databases maintained in the departments of
Haematology and Virology
Results:
There were 1276 (120 haploidentical) transplants that were performed between 2007
to 2016. Two hundred and sixty two (20.5%) patients had HC and BK virus qualitative
virus PCR was tested for 189 patients, of which 105 were positive. Among the
cases, males were more affected and median age was 20 years. The most common
indication for transplant was Aplastic Anemia (31.4%), followed by acute myeloid (19.0%)
and lymphoblastic (15.2%) leukemia. In the patients with HC, Grade 3 HC was most
commonly (57.1%) seen and the median time to development of HC was 35 (range
0-858) days. Specific treatment with Cidofovir was given to only 5 patients, surgical
intervention in 2 patients and Foscarnet in 1 patient. Survival was significantly
lower in the cases (42.9% vs. 61%, p=0.013) Protective effect of non myeloablative
conditioning, residual disease at time of transplant, lower CD34 dose, presence of
acute GVHD and chronic GVHD, reactivation of CMV and presence of bacterial
Urinary tract infection(UTI) were significant factors on univariate analysis. Multivariate
logistic regression confirmed presence of acute GVHD, bacterial UTI and residual
disease at time of transplant as significant risk factors for BK viruria and disease.
Conclusion:
BK virus HC was seen in 8% of HSCT patients with mortality of 57.1%. Presence of acute
GVHD, bacterial UTI and residual disease at time of transplant emerged as significant
risk factors.

Poster
Papers
Profile of Urinary Tract Infections In Renal Transplant Patients
___________________________________________________________________________________________
Author : Dr Aadil Rafeeq
Co-authors : Dr. Ajaz Koul, Dr. Imtiyaz Wani
Institution : SKIMS, Soura, Srinagar, Kashmir
Background:
UTI is the most common infection in renal transplant recipients ranging from 6%-86%
and accounting for approximately 40-50% of all infectious complications.
Objective:
The aim of this study is to deduce the predisposing factors, clinical profile, common
organisms , antibiotic susceptibility profiles and outcome of urinary tract infections in
renal transplant recipients admitted in a tertiary-care centre.
Methods:
Urinary isolates from renal transplant patients attending SKIMS SRINAGAR were
identified by conventional methods. Antimicrobial susceptibility testing was performed
by Kirby Bauer's disc diffusion method.
Results:
This study involved 12 renal transplant patients which were followed over one year.
8 were males and 4 females with a mean age of 26.2 years. 8 patients were on
in-dwelling urinary catheter.Common presenting features were fever and dysuria.
All the cases were culture positive with the micro-organisms being klebsiella-pnemonia
(71.4 %), E.coli (14.2 %), Enterococcus (14.2%), Acinetobacter(14.2%), Pseudomonas
(14.2 %), Enterobacter (14.2%) and staph-aureus (28.5%). Antibiotic susceptibility
profiles showed high resistance to Ciproflox (25%), levofloxacin (12.5%),Cotrimox
(25%), imipenem (12.5%), Pip. Taz (12.5% ),vancomycin (12.5%). Sensitivity profiles
depicted higher sensitivities to Polymixin (50%) and Tigecycline (25%), especially during
the follow-up period but despite being on these high end sensitive antibiotics for weeks
and months, patients persisted with the infection.On follow-up, 5 out of 12 patients
had recurrent UTI with 2 relapses and 3 reinfections. 3 patients needed native kidney
nephrectomy for resolution of the infection.
Conclusion:
This study revealed that immunosuppression along with invasive urological interventions
predispose renal transplant patients to UTI.They have recurrent infections and antibiotic
spectrum tends to become more and more limited. Even after receiving the sensitive
antibiotics for months , repeatedly, most of them persist with the infection.

USE OF ANTIBIOTIC LOCK THERAPY
___________________________________________________________________________________________
Author : Dr. Aakash Doshi
Co-authors : Dr. Chirag Chhatwani, Dr. Ayesha Sunavala, Dr. Rajeev Soman,
Dr. Anjali Shetty, Dr. Camilla Rodrigues.
Institution : P. D Hinduja National Hospital and MRC Mahim, Mumbai.
Introduction:
The prevention and management of catheter-related bloodstream infections (CRBSI)
is a significant health care challenge. Antibiotic lock therapy (ALT) along with systemic
antibiotics appears to be an attractive option for catheter salvage in circumstances
where alternative vascular access is difficult.
* We have previously published an article in JAPI, Feb ' 16 showing ALT in 37 episodes of
bacteremia (CRBSI/symptomatic colonization) over a time period of 6 1/2 years. ( Feb
'08 to Sept '14). We are increasing our experience with this novel therapy with good
results.
Methods:
We report the use of antibiotic lock therapy in 22 patients who had 27 episodes of
bacteremia (CRBSI/symptomatic colonization) due to long-term catheters in our
hospital from Oct 2016 to May 2017. Patients received ALT if they had CRBSI or were
symptomatic with a colonized catheter. 14 days of systemic antibiotic therapy and a
lock was administered with dwell times of 24 hours.
Successful treatment was defined as any of the following: 1) Clinical cure with
disappearance of signs of sepsis 2) Microbiological cure with resolution of bacteremia
(confirmed by a negative blood culture which was obtained through the catheter 2-5
days after stopping therapy)
Results:
GN* GP GN+GP Fungal F+GN Total
No. of episodes 11 4 3 8 1 27
Success 11 3 3 4 1 22
Total success 81.48%
*GN- gram negative, GP- gram positive, GN+GP, F+GN- dual pathogen
Conclusion:
In patients with CRBSI due to Gram-negative pathogens, the use of ALT along with
systemic antibiotics had a 100% catheter salvage rate. Although, guidelines
discourage the use of ALT for Staph aureus+Candida CRBSI, we have used this in
extenuating circumstances with satisfactory result. However, more experience is
needed and such ALT strategies are needed to be further evaluated for the treatment
of CRBSIs.

Distribution of 16S RRNA Methylase Genes among
Clinical Isolates of Carbapenem Resistant Enterobacteriaceae
(CRE) from Cancer Patients.
___________________________________________________________________________________________
Author : Dr. Aarthi.M
Co-authors : Dr. PadmaKrishnan, Dr. Subramanian.S, Dr. Amirtharaj
Institution : Dr. ALM PG IBMS, University of Madras.
Objective:
To find the incidence of Pan-aminoglycoside resistance among CRE isolated from
cancer patients and to find distribution of 16s rRNA methylase genes among CRE.
Methods:
103 Enterobacterial isolates were collected from clinical specimens of cancer patients.
The isolates were speciated and carbapenem resistance was detected by antibiotic
sensitivity testing (AST), Modified Hodge Test, Double Disc Synergy Test and molecular
methods (NDM, IMP, VIM, KPC OXA- 48 like carbapenemases were detected by PCR).
Aminoglycoside resistance among carbapenem resistant isolates was detected by AST
and aminoglycoside resistant isolates were analysed for the presence of predominant
16S rRNA methylase genes viz., armA, rmt A, rmtB, rmtC by PCR (Wachino et.al,2006).
Results:
Among the 103 enterobacterial isolates, 38(36.89%) isolates were resistant to
carbapenem. Among 38 CRE isolates 26 isolates were E.coli and 12 isolates were
Klebsiella pneumoniae. 24/38(86.66%) CRE isolates were resistant to aminoglycosides
by AST. 4/24(16.66%) isolates were positive for armA gene. 8/24 (33.33%) isolates were
positive for rmtB gene. None of the isolates was positive for rmtA and rmtC. 2/4(50%)
armA positive isolates were also found to harbor both NDM and OXA-48 like
carbapenemase. All 16S rRNA methylase gene positive isolates were found to
coexist with either NDM or OXA-48 like carbapenemases. All the 16S rRNA methylase
gene positive isolates were negative for KPC, IMP, VIM carbapenemases.
Conclusion:
This study highlights the increased incidence of pan aminoglycoside resistance among
CRE isolates. rmtB gene is the predominant 16S rRNA methylase gene among CRE from
cancer patient in the present study and it is found to coexist with NDM.

Profile of UTI at a tertiary-care hospital
___________________________________________________________________________________________
Author : Dr Ajaz Koul
Co-authors : Dr Aadil Rafeeq, Dr Bashir Fomda
Institution : Skims, Srinagar, Kashmir.
Background:
UTI has become the most common hospital-acquired infection, accounting for as many
as 35% of nosocomial infections.150 million people suffer UTI per year worldwide.50- 80
% of women develop UTI once in their lifetime.5 % of GP visits are due to UTI and it recurs
in almost 30 % cases.
Objective:
The aim of this study is to deduce the predisposing factors, clinical profile,
common organisms , antibiotic susceptibility profiles and outcome of urinary tract
infections in in-patients of a tertiary-care centre.
Methods:
Urinary isolates from symptomatic UTI cases attending SKIMS SRINAGAR were identified
by conventional methods. Antimicrobial susceptibility testing was performed by Kirby
Bauer's disc diffusion method.
Results:
From an ongoing pilot study, around 100 cases were extracted and analysed.61
Females and 39 males, with mean age around 48.9 years. Around 73% cases were
Community-acquired and 27 % cases developed infection during hospital course.
Lower UTI was seen in 92 % cases and Upper UTI in only 8 %. 52% of patients were
on indwelling urinary catheter with an average duration more than 2 weeks. The
commonest presenting features of the infection were Dysuria (68%), fever (64%).
Common risk factors were catherization (52%), bed-ridden state (50%), diabetes (30%),
use of diapers (29%), pregnancy (16%), immunosuppression (14%), prostatomegaly
(14%). 62% cases were culture positive ( bacterial 46 and fungal 16 ) with common
micro-organisms being E.coli (52.1%), Enterococcus-faecalis (24%), klebsiella (13%),
pseudomonas (6.5%), Acinetobacter (4.3%), providencia (2.17%). 16% cases were
having fungal UTI with the organisms Candida albicans (56.25%), candida-parapsilosis
(25%), candida-krusei (12.5%) and candida- tropicalis (1.6%). High resistance seen with
ciproflox (25.8%), levoflox (35.5%), piperacillin-tazobactum (29%), ceftriaxone (27.4%),
cotrimoxazole (25.8%), imipenem (9.6%). 9.2% relapses were seen with predominance
among renal transplants.
Conclusion:
E.coli remains commonest cause of UTI. But we observed the decreasing percentage
of E.coli as compared to National and International statistics. Fungal UTIs are on rise.
Longer hospital stay increases morbidity and mortality in UTI. CA-UTI is a major morbidity
issue. Renal transplant UTI, new and a difficult entity were despite treatment with high
end sensitive antibiotics infection persisted.

Antibiotic susceptibility pattern of bacterial isolates from
blood culture.
___________________________________________________________________________________________
Author : Dr. Amarjit Singh Vij
Co-authors : Dr. Gomty Mahajan, Dr. Kailash Chand, Dr. Mandeep Singh Sethi,
Dr. Harman Singh
Institution : Punjab Institute of Medical Sciences, Jalandhar
Background:
Septicaemia plays an important role in morbidity and mortality, especially in
developing countries. Blood culture is an important investigation to isolate the
offending organism and know its antibiotic susceptibility.

Blood cultures collected over one year period (May, 2016 to April, 2017) from 253
suspected cases of sepsis were studied. The isolates were identified using standard
biochemical tests and antibiotic susceptibility pattern was analysed using modified
Kirby-Bauer disc diffusion method.
Results:
Out of 253 blood cultures, 42 (16.6%) were positive. Twenty two (57.2%) of the
culture isolates were Gram-negative bacilli and eighteen (42.8%) were Gram-positive
cocci. The Gram-positive organisms were Staph aureus (30.9%) and Enterococci (11.9%).
Out of Gram-negative bacilli, maximum were Klebsiella pneumoniae (21.4%). The most
sensitive drugs for Gram-positive isolates were vancomycin, teicoplanin and linezolid
and for Gram-negative were carbapenems, colistin, aminoglycosides, and tigecycline.
Conclusion:
This study highlights the need for the continuous screening and surveillance for
antibiotic susceptibility among the blood culture isolates.

IS IT TIME TO STOP C. DIFFICILE TOXIN TESTING BY ELISA ALONE?
___________________________________________________________________________________________
Author : Dr. Anand Shah
Co-authors : Dr. Karuna Tiwari, Dr. Rajeev Soman, Dr. Anjali Shetty,
Dr. Camilla Rodrigues.
Deptartment: Microbiology,
Institution : P.D. Hinduja National Hospital & MRC, Mumbai.
Clostridium difficile is a common cause of hospital-acquired diarrhoea, which is

usually associated with previous antibiotic use. Clostridium difficile should be
considered in diarrhoea cases with a history of antibiotic use within the last 8 weeks
or with a hospital stay of at least 3 days, regardless of the duration of antibiotic use.
Rapid changes in diagnostic approach with the introduction of polymerase chain
reaction to detect the gene for toxin production, which will soon revolutionize the
diagnostic approach to CDI.
Methodology:
A retrospective study from 1st Jan 2016 to 31st May 2017 was done comparing C.
difficile toxin assay by toxin A/B EIA to molecular tests for C.difficile (Xpert®C.difficile /
Filmarray® GI panel). Xpert®C.difficile assay is a qualitative in vitro diagnostic test which
detects sequence in the genes for Toxin B, binary toxin, tcdC detection 117 as well
as 027/NAP1/B1 strain. Filmarray® GI panel identifies C.difficile infection based on
detection of tcdA and/or tcdB genes.
Result & Discussion:

Total 66 stool samples were tested by both ELISA and molecular methods, 58 were
negative by both the methods, 8 were detected positive by molecular tests, out of
which 4 were positive by Xpert® and 4 by Filmarray® panel. All these 8 positive samples
were negative by ELISA.
According to ASM guidelines, testing for C.difficile should be limited to patients with >
3 non-formed stool specimens per 24 hr., unless ileus is suspected. We have not used
the gold standard method, “toxigenic culture” for confirmation of the above result.
Utilizing toxin A/B EIA is insensitive and no longer recommended as a standalone test.
Laboratories can use a NAAT as a standalone diagnostic test.
Conclusion:
Molecular tests are much more sensitive for the diagnosis of C.difficile infection in
comparison to ELISA based assays.

Prevalence of Adhesion and Biofilm Forming Genes among
Staphylococcus aureus Isolates from Skin and Soft Tissue
Infections in Chennai, South India.
___________________________________________________________________________________________
Author : Dr. Anbarasi. K
Co-authors : Esther Mary Selvam , Padma Krishnan
Department : Department of Microbiology
Institution : Dr.ALM PGIBMS, University of Madras,
Chennai & ESIC Hospital, K.K Nagar, Chennai.
OBJECTIVE :
To study the prevalence of adhesion(MSCRAMMs) and biofilm genes(icaAD,aap,atlE)
among Staphylococcus aureus isolates from skin and soft tissue infections in Chennai,
South India.
METHODS :
A total of 50 S.aureus isolates from various skin and soft tissue infections obtained from a
tertiary care unit in Chennai were included.Identification and confirmation was done by
standard biochemical methods followed by antibiotic susceptibility testing according
to CLSI guidelines.,2015. Methicillin resistance was screened using cefoxitin disc(30µg)
and confirmed by PCR for mecA gene(Nagarajan et al.,2013).Phenotypic detection of
biofilm formation was done by Congo red agar(CRA)(Freeman etal.,1989) and tissue
culture plate method(TCPM)(Christensen et al.,1985) followed by Genotypic detection
of biofilm genes (icaAD,aap,atlE) by Araujo etal.,2006 and Vandecasteele etal.,2003
and MSCRAMMs(eno,ebpS,cna,bbp,fnbpA,fnbpB,fib,clfA,clfB) by Tristan etal.,2003.
RESULTS :
Of the 50 isolates,21(42%) were found to be MRSA. Highest resistance was found
towards ciprofloxacin(88%) followed by cotrimoxazole(68%)and erythromycin
(64%) respectively. By CRA,12(24%) isolates produced black colonies after 24hours.
By TCPM,3(6%),1(2%)&36(72%) isolates showed strong,moderate and weak biofilm
production respectively. Overall,25(50%) isolates harboured biofilm genes(24aap,1atlE).
IcaAD was absent in all the isolates. Amongst the adhesion genes,clfB(92%)&eno(88%)
were predominant followed by ebpS(74%). Coexistence of eno,clfB and ebpS with
biofilm genes(aap or atlE) was found in 18 isolates(36%).
CONCLUSION :
The present study demonstrates high prevalence(50%) of biofilm-forming genes among
S. aureus isolates. The rate of coexistence between these genes with adhesive surface
genes were also high(36%) indicating their high pathogenic potential. Production of
polysaccharide intercellular adhesin by ica operon-encoded enzymes is currently the
best understood mechanism of biofilm formation in staphylococci. However, in our
study icaAD was absent in all the isolates,this interesting finding shows that even in the
absence of ica operon-encoded enzymes, S.aureus is still capable of forming biofilms
with the diverse array of cell surface adhesins used for binding to the host extracellular
matrix.

Fatal S. Sonnei encephalopathy – Ekiri Threat ?
___________________________________________________________________________________________
Author : Anitha P M
Co-authors : Kalpana George, Shabina M.B., Anju Vidyadharan, Beena Philomina J
Institution : Govt. Medical College, Kozhikode, Kerala
Background :
Diarrhea with Shigella spp. is common in developing countries. However deaths are
rare and is usually associated with complicated S. dysentriae type 1infection.We report
rare occurrence of deaths in children with S.sonnei infection, in North Kerala .
Objective :
To determine the aetiological agent of diarrhea followed by rapid development of
neurological complications and death in children.
Methods : A total of 6 cases were included in the study. Faeces, Blood and CSF were
cultured. The isolates identified by biochemical tests and confirmed by agglutination
with antisera.
The antibiotic susceptibility testing was done , as per the CLSI guidelines.PCR was done
at MCVR, Manipal . Post mortem findings were analysed. Isolates have been sent to
centre for genomic studies at Delhi, for genotyping.
Results:
Table 1. Case Analysis
Parameters Case1 Case2 Case3 Case4 Case 5 Case6

Age 8 yrs 4 yrs 8 yrs 41/2 31/2 8yrs
Fever and
+ + + + + +
diarrhea
Pus cells Pus cells Pus
Pus cells+ Pus Pus cell+
Stool M/e plenty .No plenty cells++No
No RBC cells+RBC+ RBC+
RBC RBC+ RBC
Stool
Neg S.sonnei S.sonnei Neg S.sonnei Neg
culture
S.sonnei
CSF culture Sterile Sterile Sterile Sterile Sterile
isolated
S to Azi R S to ceftri S to Azi R
Antibiotic
- to ceftri R to - to ceftri
sensitivity
A,CO,Cip A,CO,Cip A,CO,Cip
S.sonnei
PCR NT NT Negative NT Negative
detected
Post
Cerebral Cerebral
mortem ND ND ND ND
oedema+ oedema+
finding
Conclusion:
This report on fatal encephalopathy following S. sonnei infection emphasises the
need to be aware of this rare complication in India. It is important to recognise the
complication early and treat to minimise fatality.

Septic pulmonary emboli as a complication of peripheral
venous cannulation
___________________________________________________________________________________________
Author : Dr. Ankita Baidya
Co-authors : Dr. Vanishri Ganakumar, Dr. Ranveer S Jadon, Dr. Piyush Ranjan,
Dr. Smita Manchanda, Dr. Rita Sood
Institution : AIIMS, New Delhi.
Objective:
Septic embolism can have varied presentations and clinical considerations. The
major complication is due to vascular occlusion of the involved tissues or organs.
Infected central venous catheters are commonly associated with septic emboli but
peripheral vascular catheters are rarely implicated. We describe a rare case of septic
pulmonary emboli related to infected peripheral venous cannulation caused by an
unusual etiological agent.
Methods:
A gentleman of uttarakhand, India, presented with complaints of fever,
productive cough, sudden onset shortness of breath and cellulitis in both the upper
limbs with recen hospitalisation for dengue fever. On examination, patient was
febrile, tachypneic and in respiratory distress .On local examination, there were multiple
pus filled bullae in left hand and swelling and erythema involving right forearm that
had started at the site of cannulation. Chest examination showed active accessory
muscles of respiration, stony dull percussion at the base of right lung and decreased
breath sounds at right infrascapular, infraaxillary and mammary area. Chest X-ray
revealed bilateral multiple patchy heterogenous peripheral opacities and infiltrates
with right sided pleural effusion. Contast enhanced computed tomography (CECT)
chest showed feeding vessel sign confirming the diagnosis as septic emboli. Patient
was started empirically on ceftriaxone, vancomycin and clindamycin.
Laboratory findings showed marked leucocytosis (22000/mm3). The Pus culture

and sputum culture showed Klebsiella pneumoniae sensitive to cefoperazone -
sulbactum, piperacillin-tazobactum, meropenem and amikacin. The antibiotics
were modified to Cefoperazone-sulbactum. Despite giving appropriate antibiotics,
fever persisted, bronchoalveolar lavage (BAL) was done to confirm the etiology. BAL
galactomannan, geneXpert and fungal culture were negative. BAL culture showed
Klebsiella pneumoniae with same antimicrobial sensitivity profile. On day 6 of starting
cefoperazone-sulbactum, patient became afebrile. The skin lesions improved
significantly. He was administered 2 weeks of cefoperazone–sulbactum and discharged
on oral faropenem for 4 weeks. He was followed up regularly. Chest X-ray and skin
lesions showed complete resolution after 8 weeks.
Results & Discussion:

Till date only couple of cases of septic pulmonary emboli through peripheral
intravenous catheter have been reported in English literature. This case highlights that
a simple procedure of peripheral intravenous cannulation can lead to catastrophic
complication of septic pulmonary emboli and widespread cellulitis if not done with
proper care and precautions. Also the usual pathogens in such clinical settings are
gram positive bacteria, but with the history of recent hospitalization empirical therapy
should also cover drug resistant gram negative microorganisms. It also emphasise the
importance of appropriate healthcare practices to be taken care during all
procedures.

Chronic Aspergillosis presenting as Retroperitoneal
Mass in Immunocompetent Young Female!
___________________________________________________________________________________________
Author : Dr. Anuprita Daddi
Co-authors : Dr. S. Sawant, Dr. A. A .Dhir
Department : Department of Medicine
Institution : Tata Memorial Hospital ,Mumbai
Invasive aspergillosis is most frequently caused by Aspergillus fumigatus and

Aspergillus flavus.Mostly seen in immunocompromised patients , caused by inhalation
of aspergillus spores .We report a case of young, immunocompetent female patient
with disseminated invasive aspergillosis presenting as retroperitoneal mass. The patient
is on treatment with itraconazole therapy with symptomatic and metabolic response
to same.
History
32 year old married female having 2 children, in 2006 was diagnosed with abdominal
Tuberculosis treated with full course of AKT. In 2009 presented with low back pain,
CECT abdomen and pelvis suggestive of Left adrenal mass with diffuse enlargement
of right kidney with hydroureteronephrosis. She underwent bilateral DJ stent in march
2010. No treatment was offered for the adrenal mass as urinary metanephrines was
<15, plasma free metanephrines of 7.43 (Normal <90)}. She presented to Tata
Memorial hospital (TMH) for first time in 2013 with abdominal pain since 20 days.
CT scan showed mass in left suprarenal region of 10x7.5x12cms with small necrotic
focus within the mass with loss of planes with spleen, posterior intercostal muscles, left
kidney. Blood investigation done -Serum metanephrines 25.8, nor metanephrines 42.2,
ODS (overnight dexamethasone suppression test) cortisol,0.43, Basal ACTH 123 Basal
cortisol 10.65, DHEAS: 222. In Joint Clinic was planned for left radical nephrectomy,
splenectomy and distal pancreatectomy,after review of CT guided Bx of Left adrenal
mass .Histology showed granulomatous inflammation with Hyalinization, focal necrosis .
ZN( Ziehl–Neelsen) stain no acid fast bacilli. GMS (Grocott's methenamine silver) stain
shows fungal hyphae,Morphology suggestive of aspergillus. She was advised to see
Infectious Disease specialists but patient defaulted.
In DEC 2016 again presented to TMH with loss of appetite, low back ache and
weight loss, repeat CT scan was suggestive of increase in Retroperitoneal Mass
12.5x13.3cm retroperitoneal mass encasing aorta Infiltrates the kidney, Loss of plane
with spleen, stomach, pancreas, eroding ant margin of vertebra. Repeat HPR showed
Granulomatous inflammation rich in eosinophils. Septate fungal hyphae with acute
angle branching confirmed on fungal stains (GMS and PAS), consistent with
Aspergillus Sp. Patient was started on oral itraconazole. Follow up PET CT Scan
done after three month of oral antifungal therapy showed Complete metabolic
resolution of retroperitoneal mass with partial morphological regression (more visible
in splenic component) as compared to scan dated December 2016 .There was
significant improvement in appetite with weight gain .
Discussion:
Only few cases are reported of invasive aspergillosis in immunocompetent persons.
To our knowledge, this is the first case of invasive aspergillosis affecting the adrenal
glands in immunocompetent patient reported in India. Invasive aspegillosis still remains
a big clinical challenge and diagnosis relies largely on histopathological evidence of

mycelial growth in tissue. Treatment is most often prolonged or combined. The choice
of the anti-fungal was based on the normal immune status and non-severity of the
infection, which allows for oral treatment. Itraconazole is a reasonable drug for
patients who are immunocompetent, with non-life-threatening forms of aspergillosis.
In our patient there was no concomitant medication that would predict drug
interaction problems. It is also less expensive than the first line agent (voriconazole ) and
easily available for patient.

Sequence Analysis of NS5A-ISDR-PKR Binding Domain and
Response to Interferon Therapy in Indian Patients Infected
With HCV Genotype 3
___________________________________________________________________________________________
Author : Dr. Anzar Ashraf
Co-authors : Dr. Anita Chakravarti
Department : Department of Microbiology,
Institution : Maulana Azad Medical College, New Delhi-110002
Objective:
To find the genetic heterogeneity of ISDR-PKRBD region of HCV genotype 3 and
correlate it with therapeutic response.
Method:
Twenty seven patients of chronic hepatitis who attended OPD and wards, of Lok
Nayak Hospital, Delhi, India were included in the study. All patients were on
peg-IFN-α-2b and ribavirin therapy. The ISDR-PKRBD mutation analysis was done by
direct sequencing.
Results:
Twenty seven patients belonged to HCV genotype 3. Of them, 18 (18/27= 66.67%)
responded to therapy and 9 (9/27= 33.33%) did not respond to therapy. The total
no. of nucleotide changes in ISDR-PKRBD region was found to be significantly different
between responder and non-responder group in HCV 3 (p-value 0.0069) and viral load
was also determined in them. The analysis showed that the mean viral load was found
to be significantly different when compared between pre-therapy and post-therapy
group. The secondary structure of ISDR-PKRBD differed slightly when compared with
reference secondary structure of ISDR-PKRBD of HCV 3 but no clear structural
differences were observed between responder and non-responder group. Alpha-helix
positions were changed in ISDR-PKRBD region of HCV 3 patient sequence when
compared with the alpha-helix positions of reference sequence of HCV 3. Some
changes occur in the secondary structure of ISDR-PKRBD region when compared with
reference secondary structure of ISDR-PKRBD region of HCV 3, this may be due to the
mutation in amino acid of ISDR-PKRBD region of HCV.
Conclusion:
Number of mutations in ISDR-PKRBD region of HCV genome is significantly
associated with interferon therapy response. Mutations in ISDR-PKRBD cause changes
in secondary structures thereby affecting immunity against the virus and response
to therapy. Hence knowledge of mutations in ISDR-PKRBD and resulting secondary
structure changes are instrumental for predicting outcome of therapy, which is
indispensable in view of cost and side-effects of antiviral therapy.

Candida Auris Candidemia-an Emerging Threat in Critically
ill Patients
___________________________________________________________________________________________
Author : Dr. Aravind Reghukumar
Co-authors : Dr. Anil Sathyadas, Dr. Athul Gurudas, Dr. Kiran kumar V S, Dr. Samitha Nair
Institution : Government Medical College Thiruvananthapuram,Kerala.
Objective:
Candidemia is an important health care associated infection in critically ill
patients even without apparent immunodeficiency.Candida Auris has recently
been termed “Candida superbug” due to its resistance profile, especially its non
susceptibility to fluconazole and variable susceptibility to amphotericin and
echinocandins.In the ICU scenario,without optimal infection control.it will be difficult
to get rid of Candida Auris just like Acinetobacter species as it displays clonal inter and
intra-hospital transmission.This prospective study was done over a period of one year
to study the clinical profile,risk factors and outcomes of patients with candidemia in
critical care ICU.
Methods:
his prospective study was done in critical care ICU of medical college hospital
Thiruvananthapuram.Study period was from January 2016 to January 2017.Patients
with malignancy,HIV and those on chemotherapy were excluded from the study.
Patients with blood culture positive for candida [vitek 2 biomeriux]were included in
the study.Species level identification and Susceptibility was determined using VITEK
2 YST ID card.In case of candida haemulonii and famata,the isolate was subjected
to MALDI-TOF and in case of Candida Auris confirmed by MALDI-TOF,the isolates
were subjected to further molecular study at PGI Chandigarh for confirmation.Clinical
profiles ,risk factors and outcomes were studied.
Results:
Total 28 patients were included in this study.Average age in the study was 44 years
with 44% males.Average day in ICU at which candidemia was detected was 19.5.
But it was 13.4 for patients with necrotising pancreatitis.100% patients were on
broad spectrum antibiotics for more than 7 days.80.8% of patients had central
venous catheters in situ at time of detection of candidemia of which 50.6% showed
differential time to positivity more than two hours suggestive of CLABSI.75.9% of patients
were on mechanical ventilation,70% were in severe sepsis,20.5% had TPN and history
of gastrointestinal surgery was present in 35% cases.Average duration of broad
spectrum antibiotic use prior to development of candidemia was 17.5 days.
Central venous catheters were present for an average of 12.6 days prior to development
of candidemia.The most common species was Candida Tropicalis[28%],Auris[22%],
Haemulonni[17%].Albicans[17%],Parapsilosis[11%] and Glabrata[5%].Of the 6 patients
with Candida Auris,100% had resistance to fluconazole and Amphotericin B.16.6%
[1 patient] had capsofungin resistance.Overall mortality due to candidemia was 25%
and that due to candida Auris was 33.3%.
Conclusion:
Candida Auris is an emerging pathogen and understanding of this microbe
is evolving rapidly.Due to multi drug resistance exhibited,antifungal susceptibility
testing is very important.In this prospective study,22% of candida isolates were found
to be Candida Auris with 100% resistance to amphotericin B and fluconazole with 16.6%
resistance to capsofungin.

Anti Tuberculous Drug Induced Liver Injury among TB/HIV
co-infected patients: Nested Case Control Study
___________________________________________________________________________________________
Author : Dr. Aravind Reghukumar
Co-authors : Dr. Athul Gurudas, Dr. Kirankumar V S, Dr. Ranjani Ravi.
Institution : Government Medical College Thiruvananthapuram,Kerala, India.
Objective:
This study was conducted to determine the incidence and predictors of
anti-tuberculous drug induced liver injury[DILI] in TB/HIV co infected patients at
Medical college Thiruvananthapuram.
Methods:
Study design—a retrospective nested case control study of TB/HIV co-infected
patients was done to identify the incidence and predictors of ATT induced DILI.
Study was conducted in patients with TB/HIV co-infection between 2011 january
to 2017 january who attended infectious diseases clinic at medical college
thiruvananthapuram.Patients with cirrhosis, intravenous drug abuse,hepatitis B and
C,children below 12 years and those with baseline SGPT>120 were excluded from the
study.Patients who had DILI after at least 7 days of standard doses of ATT were labelled
as “cases” and those without DILI were “controls”.Each case of DILI was compared with
3 controls selected randomly from the main cohort.
Results:
From a cohort of 460 TB/HIV co-infected patients,56 developed ATT induced
DILI[12.17%].BTS guidelines were followed for ATT reintroduction and the
culprit drugs were identified.Pyrazinamide was culprit in 26 cases[46.4%].isoniazid in
17 cases[30.3],rifampicin in11 cases[19.64] and ethambutol in 2 cases[3.5%].On
bivariate logistic regression analysis,body mass index BMI<18.5kg/m2 [p<0.001.OR[95%
CI], female sex [p<0.005], hypoalbuminemia (albumin<2.5) [p<0.006], disseminated
pulmonary tuberculosis[p<0.00],CD4 count<50[p =0.018] and WHO stage 4 disease
[p<0.003] were significantly associated with ATT induced DILI.Predictor variables with
p-value <0.05 by bivariate analysis were analyzed by multivariate logistic regression
analysis and identified disseminated pulmonary tuberculosis[p=0.001],BMI<18.5[P=0.001
] and hypoalbuminemia[p=0.015] as independent predictors of ATT induced DILI.
Conclusion:
The incidence of ATT induced DILI in TB/HIV coinfected patients in this study
was 12.17%.The culprit drug was pyrazinamide[46.4%],INH[30.3%],rifampicin
[19.64%] and ethambutol[3.5%].Predictors of DILI were identified as disseminated
pulmonary tuberculosis,BMI<18.5 KG/M2 and hypoalbuminemia.These patients must be
closely followed up after initiation of ATT to identify DILI at the earliest.

Prevalence of urinary tract infection with special reference
to staphylococcus saprophyticus at a tertiary care
institute bommakal karimnagar.
___________________________________________________________________________________________
Author : Dr. Archana A R K
Co-authors : Dr. Sarwat fatima, Dr. Amar C. Sajjan, Dr. Archana B
Institution : Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar.
Objective:
S.saprophyticus was shown to be an important pathogen causing primarily acute
urinary tract infections in young healthy sexually active woman (Sheik &
Mehdinejad,2012).It is the second most frequent acute agent of community acquired
urinary tract infections after E. Coli (Ferreira et al.,2012). Current study under taken 1.
To know the prevalence of UTI in a tertiary care hospital, at Bommakal, Karimnagar
district, Telangana state. 2. To know the prevalence of S.saprophyticus as a causative
agent of UTI and its antimicrobial susceptibility pattern.
Materials and Methods:

A cross sectional observational study was carried out at CAIMS during the period
of six months. About 407 urine samples were screened for UTI by Semi quantitative
urine culture technique after collecting midstream clean catch urine samples from
symptomatic patients. Samples were cultured on Blood agar, Mac Conkey agar and
CLED agar (Cystine Lactose Electrolyte Deficient medium) medium. Positive cultures
were further processed for identification as per the standard procedures mentioned in
text book of practical Medical Microbiology by Mackie & McCartney.
Results:
In the present study prevalence of UTI was noted as (10.81%). The male to female
ratio was 2.4 i.e. 71.2% were males & 28.2% were females. Among the males
majority of the samples received were in the age group > 45 years (36.85% ) and in
females it was noted to be in the age group 18-45 years (17.4% ).More number of
males had symptomatic UIT i.e 63.3% than females 36.36%. Further it was seen that
UTI was more prevalent in males in the age group >45 years on the other hand
in females it was seen in 18-45 years and S.saprophyticus was isolated in females in
more number in this age group only. Of the various isolates, E.coli dominated by 59%,
K.pneumonia 18%, S.saprophyticus 13.36%,S.aures 4.5%,Pseudomonas & Proteus each
2.2%.S.saprophyticus was isolated from 1.2% of samples & it was more predominant
in females 1.2%.Antimicrobial susceptibility pattern in general showed, all the to be
susceptible to glycopeptides (Imipenam,Vancomycin,Linezolid) followed by
fluoroquinalones , aminoglycosides & Cephalosporins & least susceptible to Ampicillin.
The susceptibiltiy pattern for S. saprophyticus showed similar results.
Conclusion:
Staphylococcus saprophyticus is a predominant pathogen in sexually active
young women and susceptibility patten shows least susceptible to common anti
microbials used in the treatment like ampicilin .Hence it should be treated promptly
to avoid complications.

A Study on Cardiovascular Risk Factors among HIV
infected Patients Attending a Tertiary Care Hospital
___________________________________________________________________________________________
Author : Dr. Arnab Kumar Patra
Co-authors : Prof. Subhasish Kamal Guha, Dr. Soura Mukherjee
Institution : School of Tropical Medicine, Kolkata
Objective:
With more effective and widespread treatment of HIV infection cardiovascular disease
has emerged as an important cause of morbidity and mortality relative to decreasing
incidence of opportunistic infections. Our study aimed to observe the prevalence of
different cardiovascular risk factors in HIV infected patients and to estimate individual
cardiovascular risk by ACC/AHA pooled cohort hard CVD risk calculator.
Methods:
We conducted a cross-sectional, observational, descriptive study at school of
Tropical Medicine, Kolkata on 100 HIV infected adult (>18years) patients (divided
into two comparable groups; ART naive=50, ART experienced for >6months=50) who
neither had established CAD nor any past history of CVD to observe the prevalence
of different risk factors like age, sex, family history of CVD, hypertension, diabetes,
dyslipidemia, obesity, smoking or alcoholism, physical inactivity, chronic kidney
disease or microalbuminuria etc. After collecting basic demographic data patients
were examined for anthropometric data and blood and urine were collected for
necessary investigations like blood glucose, serum lipids, serum creatinine, urine
albumin etc. Statistical analysis was done using SPSS software, Chi-square test etc.
Result:
ART naive group had higher prevalence of low HDL, microalbuminuria and ART
experienced group had higher prevalence of obesity, diabetes, hypertension,
hypercholesterolemia, hypertriglyceridemia, high LDL and metabolic syndrome.
Pooled cohort risk score has moderate discrimination and good calibration in HIV
population and we observed minimally elevated risk in majority of people (as our
population consisted mainly of younger age group).
Conclusion:
HIV infection itself increases cardiovascular risk by promoting atherosclerosis.
Moreover ART causes increased incidence of hyperglycemia, hypertension,
dyslipidemia and lipodystrophy. Our study showed that Indian HIV population are
at increased cardiovascular risk and early and continuous use of ART with periodic
monitoring for modifiable risk factors, timely use of statins and restriction on smoking and
alcohol intake are needed to mitigate the risk.

In vitro activity of Tigecycline and comparators against
Gram negative and Gram positive pathogens from multiple
sites encountered in a tertiary care hospital in Mumbai:
TEST data 2015-2016
___________________________________________________________________________________
Author : Dr. Aruna Poojary
Co-authors : Dr. Anurag Kumar Bari, Dr. Seema Rohra, Dr. Shweta Kamat
Institution : Breach Candy Hospital Trust, Mumbai
Background:
The Tigecycline Evaluation and Surveillance Trial (TEST) is an ongoing (since 2004)
global study designed to monitor the in vitro activities of Tigecycline and a panel
of marketed antimicrobials against a range of clinically significant pathogens. The
present study reports on the activity of Tigecycline and comparators against
isolates collected from Breach Candy Hospital Trust (BCHT), Mumbai, India during
2015-2016 during the course of this surveillance study.
Material/methods:
Non-duplicate clinical gram-negative isolates (161) and gram positive isolates
(101) from BCHT, Mumbai, India were collected during 2015-2016 from multiple
anatomic sites, as per the protocol shared by International Health Management
Associates (IHMA) Inc, USA. Urinary isolates were restricted to <25%. Organisms
were identified by Vitek 2 Compact system. Susceptibility testing was performed
using broth micro dilution panels (Microscan) according to CLSI guidelines for all
antibiotics. For Tigecycline, the categorical interpretation of results was done using
US FDA breakpoints.
Results:
Tigecycline showed 100% susceptibility to S. aureus (MSSA), MRSA, Enterococcus
species & Enterobactericeae. For MRSA, Minocycline, Vancomycin and Linezolid
also showed 100% susceptibility. For Enterobactericeae, Meropenem, Minocycline,
Amikacin and BL/BLIs showed 69%, 68% and 57% susceptibility respectively.
Pseudomonas species had 48% susceptibility to Piperacillin-Tazobactam and
Ceftazidime followed by Amikacin 45% & Meropenem 41.9%. Acinetobacter
spp showed the worst susceptibilities with Minocycline 39%, followed by Amikacin
& Ceftazidime 26% and only 21 % susceptibility to Meropenem.
Conclusions:
Based on percent susceptibility, Tigecycline showed the best susceptibility, both
among gram positives and gram negative MDR pathogens. Tigecycline should
therefore be included in treatment regimens where mixed infections with gram
positive and gram negative bacteria are often suspected, especially at those sites
where Tigecycline concentrates well, like skin, soft tissues, and the gastrointestinal
tract.

Socio-demographic Profile of Patients attending the
Integrated Counselling and Testing Centre (ICTC) at
a Government Super-speciality hospital in Central India
___________________________________________________________________________________________
Author : Dr. Aseem Rangnekar
Co-authors : Dr. Prabha Desikan, Dr. Karuna Tiwari, Dr. Nikita Panwalkar,
Dr. Manoj Pateria, Dr. Virendra Singh Rajput
Department : Microbiology
Institution : Bhopal Memorial Hospital and Research Centre, Karond,
Raisen Bypass Bhopal.
Background:
HIV epidemic remains a matter of concern worldwide. Like most developing
countries, India too has borne the brunt. At present, around 2.1 million people live
with HIV and 68 thousand succumbed to AIDS-related illnesses in 2015-16 alone.
Counselling and testing is a cost-effective and simple way to reduce the
transmission. The Integrated Counseling and Testing Centre (ICTC) is the opening wedge
for diagnosis and support services, especially to the High risk groups.
Aim and objectives:

Analyze the socio-demographic profiles of the ICTC attendees and to evaluate the
changing trends of HIV sero-positivites over a period of 7 years.
Material and Methods:

This cross-sectional/ Prevalence study, carried out in the ICTC housed in a tertiary care
hospital at Bhopal, included socio-demographic details of all attendees over a period
of seven years (Jan 2009 till Jan 2016).
Results:
There were 24853 ICTC attendees from January 2009 to January 2016, of which,
183 (6.41%) attendees were tested seropositive. There were 15555 (62.5%) males,
9298 (37.5%) female attendees. Among 15555 males, 151 (0.97%) and of 9298 females,
32 (0.34%) were seropositive. Out of 151 seropositive men, 62 (41%) were between
19-30 years and 48 (31.7%) were between 31-40 years. Among the seropositive
females, 9 (28.1%) were between 19-30 years and 10 (31.2%) were in the 31-40 years
age group. We observed a rise in total number of ICTC attendees from Jan 2009 to
Jan 2016. The number of attendees increased to 4655 in 2013 out of which 27 (0.58%)
were seropositive, and by 2015 there were 4982 attendees with only 6 (0.12%)
seropositive.
Conclusion:
Such rising trends of attendees with a steady decline in the sero-positivity rates
are encouraging signs, reflecting the contribution of the ICTC in creating awareness
and reducing the transmission of HIV among the population served.

Granulomatous Aspergillus Sinusitis: A Less Understood Clinical
Entity
___________________________________________________________________________________________
Author : Dr. Ashish Bavishi
Co-authors : Mahesh Lakhe, Bharat Purandare, Rajeev Soman.
Institution : Bharati Hospital and Research Centre
Introduction:
Granulomatous Aspergillus Sinusitis, a rarer entity as compared to invasive fungal
sinusitis, is not suspected and understood by the general medical community. We
present a case highlighting the misconception regarding interpretation of the
histopathology, confusion with tuberculosis and pitfalls involving drug interactions
during its treatment.
Methods:
Case report and review of literature.
Results:
The patient presented with a history of multiple surgeries for nasal polyps along with
history of taking oral/nasal steroids on multiple occasions and Itraconazole for 6
weeks. The histopathology report was consistent with chronic granulomatous
inflammation with thin, septate, acute angle fungal hyphae on PAS staining,
consistent with Aspergillus. He had been prescribed anti tubercular drugs
including Rifampin, Itraconazole, acid suppressing drugs and Clarithromycin.
Upon referral, we stopped the anti tubercular medications, acid suppressing drugs and
Clarithromycin and changed his treatment to oral Voriconazole.
Conclusions:
We conclude that Granulomatous Aspergillus Sinusitis, being a lesser understood
clinical entity, needs to be suspected, diagnosed and treated appropriately.

Fatal Invasive Trichosporonosis in a Patient With Advanced
Retroviral Infection And Diffuse Large B Cell Lymphoma
___________________________________________________________________________________________
Author : Dr. Athul Gurudas
Co-authors : Dr Kirankumar Vs, Dr Saraswathy, Dr Aravind Reghukumar
Institution : Government Medical College, Thiruvananthapuram, Kerala
Case report
30 year old lady, diagnosed to have diffuse large B cell lymphoma [DLBCL]
centroblastic variant[CD 10,BCL-6 and CD 20 positive] and she was found to have
retroviral infection with CD4 count of 40/cumm.She was initiated on ART
[tenofovir+lamivudine+efavirenz] after ruling out other opputunistic infections. Her
HbsAg, anti HCV,VDRL were non reactive.Two weeks after initiation of ART, she
was started on CHOP 21 regimen [cyclophosphamide,doxorubicin,vincristine
and prednisolone].In view of increased risk of infection, Rituximab was not started
initially. She developed two episodes of febrile neutropenia in between cycles of
chemotherapy and was managed with intravenous antibiotics and GM-CSF. During
one episode of febrile neutropenia, patient had received prophylactic fluconazole for
14 days also. During both episodes of febrile neutropenia, klebsiella was isolated from
blood[ESBL],and was treated with intravenous ertapenem.
After completion of 4 cycles of chemotherapy, patient presented with fever,

cough, dyspnoea, oliguria and altered sensorium. As patient was in shock she was
resuscitated with crystalloids .As shock was refractory to crystalloids,noradrenaline
and vasopressin infusion were also started.She was mechanically ventilated in view of
hypoxaemia{Po2/FiO2=125} secondary to ARDS.After sending blood culture,she was
empirically started on Inj Meropenem 1 gm q8h,Inj Teicoplanin 400 mg and Inj
Fluconazole 800 mg iv stat followed by 400 mg iv od daily.Her Xray chest and
ABG were suggestive of ARDS.She was already on cotrimoxazole prophylaxis
and hence possibility of pneumocystis jiroveci pneumonia was not entertained.
Meningoencephalitis was ruled out by a CT brain and CSF study. At the time of
presentation, her absolute neutrophil count{ANC} was 50 only,Hb 8.2 gm%,
TC 500[P5L95],PLC-80000,ESR-70,UREA -80,S.Creatinine 2.5 mg%,Bil 1.6,SGOT 80, SGPT
90,ALP 245,T PROTEIN 5.5,ALBUMIN 2.5,GLOBULIN 3.0,INR 2.7,APTT 60,Peripheral smear
was suggestive of disseminated Intravascular coagulation. Diagnosis of septicemic
shock with ARDS,acute kidney injury and disseminated intravascular coagulation was
made.In view of refractory shock,Inj hydrocortisone 50 mg q6h was added and in view
of hepatocyte necrosis,fluconazole was substituted with anidulafungin 200 mg iv stat
followed by 100 mg iv od daily.GM CSF was added in view of persistent and prolonged
neutropenia.Patient was taken up for hemodialysis in view of oliguric acute kidney
injury[creatinine 5.5 mg% on day 3].On day 8 of admission patient died.

Filaments in Brain: Nocardia Farcinica Brain Abscess
___________________________________________________________________________________________
Author : Dr. Athul Gurudas
Co-authors : Dr. Aravind Reghukumar, Dr. Kiran Kumar VS, Dr. Vijay Narayanan,
Dr. Samitha Nair
Institution : Government Medical College, Thiruvananthapuram, Kerala
Introduction:
Nocardia farcinia is an emerging pathogen in immunocompromised patients
causing both localized and disseminated infections. Among different species of
nocardia, nocardia farcinica is characterized by its increased virulence and
resistance to multiple antibiotics especially third generation cephalosporins. We
are presenting a case of Nocardia Farcinica brain abscess, successfully treated by
a combination of ceftriaxone and amikacin. Patient couldn’t afford meropenem
and linezolid, Cotrimoxazole and tetracyclines were not considered in view of
pancytopenia.
Case Report: A 20 year old B Tech. student was diagnosed to have diffuse large
B-cell lymphoma [DLBCL-centroblastic variant CD 10,BCL-6 and CD-20 positive]
7 months back and was on RCHOP[Rituximab,cyclophosphamide,doxorubicin,
vincristine and prednisolone] from Regional Cancer Centre, Trivandrum.
He presented with history of low grade fever with cough of 2 months duration.
Chest Radiography and HRCT Thorax were suggestive of right upper lobe consolidation
with cavitation. Despite negative sputum AFB and GenXpert, he was empirically started
on CAT I ATT.He had no clinical or radiological improvement while on anti-tubercular
drugs.
One month later he presented with progressive headache, vomiting and recurrent
episodes right focal seizures with secondary generalization.MRI Brain showed multifocal
brain abscesses in frontal and bilateral parietal lobes. Axial T1-weighted image showed
multiple low signal intensity lesions. T2 weighting showed significant oedema around
the lesions. T1-weighted contrast-enhanced image showed multifocal, ring-enhancing
abscesses.

His laboratory investigations Hb 7.2gm%,TC 1200, P60 L40, Platelet 22,000, T Bil 1.0,
D.Bil 0.6,SGPT 70, SGOT 80, ALP 250, T Protein 6.8, Albumin 2.8,Globulin 4.0, S. Urea 15mg%,
S. Creatinine 0.8mg% HbsAg -neg, HIV- neg, anti HCV-neg, S.LDH-990
Differential diagnosis for lung and brain lesions entertained were: Lymphoma,
Mycobacterium tuberculosis, Atypical mycobacteria, .mucormycosis, aspergillus,
histoplasmosis, blastomycosis, coccididomycosis, nocardia, listeria and Toxoplasmosis.
Aspiration of brain abscess was done. Gram staining and culture was suggestive of
nocardia and species was identified as Nocardia Farcinica by MALDI-TOF..
In view of pancytopenia, he was started on Inj Ceftriaxone [2 gm.bd] and

Amikacin [1gm] for 1 month.
One month later, repeatimaging [MRI] revealed significant resolution of brain

abscess and lung lesion. As the hemogram had improved, he was started on
cotrimoxazole with aim to continue for 1 yr.
Discussion: This case is being presented as despite extensive literature search, we were
not able to find a case of nocardia farcinica brain abscess successfully treated with a
combination of ceftriaxone and Amikacin.

Comparison of Loop Mediated Isothermal Amplification (LAMP)
Assay with Conventional Methods for Diagnosis of Tubercular
Lymphadenitis
___________________________________________________________________________________________
Author : Dr. Baijayantimala Mishra
Co-authors : Dr. Vinaykumar Hallur, Dr. Bijayini Behera, Dr. C. Preetam,
Dr. Pritinanda Mishra, Dr. Jyotirmayee Turuk,
Dr. Prasanta Raghab Mohapatra
Institution : AIIMS, Bhubaneswar.
Objective:
Tubercular lymphadenitis (TBLA) is a major contributing component of all
extrapulmonary tuberculosis cases. Molecular methods for TBLA diagnosis like CBNAT
or PCR are costly and conventional methods like fine needle aspiration cytology,
histopathology lack sensitivity and specificity and culture which is considered as
gold standard require high turnaround time. Present study evaluated the Loop
mediated isothermal amplification (LAMP) assay for diagnosis of TBLA comparing
with conventional tests (Cytology, ZN smear, culture).

Fine needle aspirates were obtained from 40 patients with clinical suspicion of
tubercular lymphadenitis. Cytopathology, ZN staining and culture on LJ media
were done following standard protocol and LAMP assay was performed on extracted
DNA following manufacturer’s instruction.
Result:
Of the 40 samples tested, cytology showed epithelioid granuloma in 15 samples.
Positivity for mycobacteria was maximum by ZN staining (14/40) followed by culture
(6/40) and LAMP assay (5/40). Of the five LAMP positive samples, two were positive
by all the other three assays, of the remaining 3 one was positive by ZN staining and
cytology and remaining two were negative by all the three assays.
The sensitivity, specificity, PPV and NPV of LAMP assay was found to be 33.3%, 91.2 %, 40%
and 88.57% compared to 100%, 76.5%, 42.9% and 100% of ZN staining and 100%,73.5%,
40% and 100% of cytopathology.
Conclusion:
The low sensitivity of LAMP assay in the present study could be due to small sample
size, however addresses the need for comparison and validation of the commercially
available LAMP kits before used for patient diagnosis.

Post Neurosurgical Meningitis Caused by Corynebacterium
Striatum- A Case Report
___________________________________________________________________________________________
Author : Dr. Balavinoth Ramakrishnan
Co-authors : Dr. Abdul Ghafur, Dr. Vidya Devarajan, Dr. Vikash Agarwal,
Dr. Lakshmi Sree
Institution : Apollo Speciality Hospital, Anna Salai, Chennai, India
Corynebacterium striatum is a ubiquitous environmental pathogen which colonises

the skin and mucous membrane of normal hosts. Though historically considered to
be non pathogenic, in recent past there are many reports stating their pathogenic
role in wide range of human infections especially in immunocompromised hosts and
those with indwelling devices. Here we report a case of post neurosurgical meningitis
caused by this organism.
A 55 year old male with no co morbid conditions was admitted after a road
trauma. He was diagnosed to have fracture involving multiple facial bones.
Computerised tomography (CT) of Brain revealed fronto parietal contusion. Repair
of facial bone fracture was done. After two days, his sensorium worsened. Repeat
imaging showed large pneumocephalous with mass effect. Anterior cranial fossa
repair was done. In the next two days, he developed high grade fever and
cerebrospinal fluid (CSF) rhinorrhoea and became comatose. CT cisternography
revealed CSF leak in right nasal cavity. Lumbar puncture and CSF analysis was
done which showed polymorphonuclear meningitis (Table 1). He was empirically
treated with meropenem and vancomycin. CSF gram stain revealed numerous
gram positive bacilli and culture showed heavy growth of corynebacterium striatum
(Figure 1) identified by VITEK 2 auto analyzer ,Biomeriux ,France. The isolate was
susceptible to vancomycin. Meropenem was stopped and Vancomycin was
continued. Patient showed remarkable clinical improvement .Repeat CSF showed
improvement in parameters with negative culture. He was discharged home in a
neurologically stable condition. Vancomycin was continued for a total of 2 weeks
To our knowledge, this is the first case of meningitis caused by this pathogen
reported in India. The absence of immunosuppression and the occurrence of
meningitis in a non prosthetic device setting make our case peculiar. Given the
appropriate clinical setting, corynebacterium striatum should not be ignored as a
contaminant. Pathogenic potential of this diphtheroid needs to be kept in mind
and clinical judgment is essential in interpretation.
Parameters(Units) Before treatment After treatment

WBC(cells per microliter) 5600 200
Neutrophil (percentage) 85 55
Lymphocyte (percentage) 15 45
Protein (mg/dL) 134 56
Sugar(mg/dL) 63 66
Blood glucose (mg/dL) 150 100
Lactate (mmol/L) 50 18
Table 1.CSF parameters before and after a week of treatment

Figure 1.CSF culture growing Corynebacterium striatum

Utility of Filmarray Gastrointestinal Panel in Diarrhoea
– An Indian Perspective
___________________________________________________________________________________________
Author : Dr. Balavinoth Ramakrishnan
Co-authors : Dr. Ram Gopalakrishnan, Dr. Anil Tarigopula
Institution : Apollo Hospitals, Chennai, India.
Objective:
Polymerase chain reaction (PCR) based pathogen diagnostics of diarrhoeal stool
specimens are shown to be highly sensitive and rapid as opposed to conventional
methods of diagnosis. We analysed the performance of FilmArray Gastrointestinal (GI)
Panel, an FDA approved multiplex PCR test with 22 target pathogens, on stool
specimens in patients who presented with diarrhoeal illness.
Methods:
We analysed the results of FilmArray Gastrointestinal (GI) Panel on stool specimens
of patients who presented with diarrhoea to our hospital from March 2016-May 2017
and compared the results with conventional diagnostics (stool microscopy and culture)
whenever performed.
Results:
A total of 54 patients with a median age of 45 years were included of whom 37
were male (68.52%). Some form of immunocompromised state was present in 25
patients (46.30%). The panel detected at least 1 target in 37 out of 54 patients
(68.52%), with results available on same day as test order. Multiple targets were
detected in 16 out of 37 patients who tested positive (43.24%). Bacteria were
detected in 23 patients (62.16%). Enteroaggregative E. coli (EAEC) was detected in
12 patients (32.43%) and was the commonest pathogen detected. Viruses were
present in 9 specimens (24.32%) and Norovirus topped the list (55.56%). Parasites
were present in 7 patients and cryptosporidium was the commonest (71.43%).
Antimicrobials were optimised as per test results in all patients with bacterial and
parasitic diarrhoea. Empirical antibiotics were stopped in the majority (89%) of patients
with viral diarrhoea. All patients with panel positivity responded to treatment and there
were no mortality. Conventional diagnostic investigations were done in 26 patients of
the panel positive group (70.27%) and diagnosed the pathogen in only one patient.
Conventional investigations detected a pathogen in 3 of 17 patients (17.65%) who had
a negative panel: pathogens detected included Aeromonas and microsporidia which
are not included in the study panel.
Conclusion:
Multiplex PCR panels detect pathogens and co-infections which may be missed
by conventional diagnostics, especially in immune compromised hosts with diarrhea.
Even in immune competent hosts with severe diarrhea requiring hospitalization, rapid
turnaround time can facilitate treatment decisions, isolation policy and antimicrobial
stewardship.

Fatal Case of Salmonella enteritidis Food Poisoning.
___________________________________________________________________________________________
Author : Dr. Beena Philomina J
Co-authors : Dr. Anitha P.M., Dr. Shabina M.B., Dr. Anuja Mohan
Institution : Government Medical college, Kozhikode, Kerala.
Nontyphoidal salmonellae are a leading cause of bacterial diarrhea worldwide;

they are estimated to cause 94 million cases of gastroenteritis and 115,000 deaths
globally each year. There are no sufficient data on the prevalence of NTS serovars and
their antibiotic susceptibility pattern from India.
Here we report a case of a 4 year old healthy boy , who developed symptoms of
severe gastroenteritis , following consumption of jelly like pastry and succumbed
to death within 24 hours. His mother who had tasted the same food was hospitalised
with vomiting and diarrhoea .
Materials and methods:

Faeces, rectal swab, peritoneal aspirate, aspirate from small intestine, blood and CSF
of the boy obtained post mortem and mother’s stool was received in Microbiology
laboratory for culture.
Results:
Salmonella enteritidis was isolated from stool, rectal swab and small intestinal aspirate
of the boy and also from stool of mother. Identification was done based on
biochemical reactions and confirmed by agglutination with specific antiserum .
The organism was susceptible to Chloramphenicol, Ciprofloxacin, Cotrimoxazole,
Ceftriaxone Azithromycin and resistant to Ampicillin. The isolate was also confirmed
from Lady Hardinge Medical College, New Delhi.
Post mortem blood culture yielded mixed bacterial growth.
Autopsy:
suggestive of shock,without evidence of dehydration. Investigations of the food
samples collected did not give any findings.
Conclusion:
This is the first case of Salmonella enteritidis food poisoning causing death reported
from Kozhikode. Though non – typhoidal salmonellosis are relatively mild , some cases,
particularly infection in children can become severe and life-threatening. Mortality
rates of 0.5 to 1 percent have been reported in outbreaks of S. enteritidis, but these are
overestimates as milder cases tend to be unrecognized.

Healthcare- Associated Infections Caused By
Non Tubercular Mycobacteria
___________________________________________________________________________________
Author : Dr. Bharat Purandare
Co-authors : Dr. Sampada Patwardhan
Institution : Deenanath Mangeshkar Hospital
Introduction:
Non-tubercular Mycobacterial (NTM) infections present a peculiar problem as the
organisms are frequently resistant to standard anti-tubercular drugs. Diagnosis is
difficult unless the microbiologist is competent. Healthcare-associated NTM (HA-NTM)
infections are commonly associated operating scope use. We present a series of
21 cases with HA-NTM infections.
Methods:
Patients with a diagnosis of HA-NTM infection between June 2011 and May 2017
were included. All had history of operative procedures. The organisms were
cultured using Tuberculosis- Mycobacterium Growth Indicator Tube (TB MGIT-320)
method (Becton Dickinson) and drug susceptibility was determined using Kirby-Bauer
method. Drug treatment and follow up were recorded.
Results:
12/21 patients were females and median age was 31 years. 11 patients had
abdominal wall infections after laparoscopic surgeries or lower segment caesarian
section (LSCS). 6 had bone infections involving spine/shoulder/sternum following
operative procedures. Two had blood-stream infections following placement of
a tunneled catheter and 2 had post-angioplasty sepsis. Most patients presented
with fever, local pain and purulent discharge with sinus formation within 1-9 months
after the index procedure. Mycobacterium chelonae was leading pathogen
(13 cases) followed by fortuitum and abscessus species. Mycobacterium fortuitum
was generally susceptible and chelonae was frequently resistant to multiple agents.
Treatment for 4-11 months with multiple agents including parenteral amikacin was
required in most . 3 had spontaneous cure. Some developed hearing loss and
peripheral neuropathy during treatment. Outcome was generally favorable with 19
patients having cure, one patient had relapse and one died. Cause of death
was believed to be macrophage activation syndrome following extensive abdominal
wall infection.
Conclusion:
Healthcare-associated NTM infections are associated with surgical procedures
using and usually involve skin, soft tissues, bone and blood rather than lungs.
Culture and susceptibility data are important as organisms can frequently be multi-drug
resistant. Treatment usually extends into several months.

ABCCALC (Antibiotics Consumption Calculator) -
A New Possibility For Detecting Antimicrobial Resistance?
___________________________________________________________________________________________
Author : Dr. Bibekananda Panda
Co-authors : Dr. S.rai, Dr. N.P Singh, Dr. I.R. Kaur, Dr. B.K. Jain, Dr. R. Avasthi
Department : Microbiology, Surgery, Medicine
Institution : UCMS & GTB Hospital, Delhi.
Introduction:
Antibiotics are used to reduce the duration and severity of illnesses.
But the consequence of antibiotics overuse is development of resistance. Resistance
can be decreased by maintaining proper record of drug indentation, usage and
restricting antibiotic overuse. ABC calc is a tool to measure antibiotics consumption
in hospitals and wards. It was developed at National Center for Antimicrobials and
Infection Control, Staten’s Serum Institute, Denmark. It utilizes the Anatomical
Therapeutic Chemical Classification and Defined Daily Dose (ATC and DDD) system
to measure antibiotic consumption. This is calculated by using number of bed days
and the data about the antibiotics indented.
Objectives:
Quantification of various antibiotics indented and consumed in a surgical ward using
the ABCcalc software and correlation with resistance pattern.

The antibiotics data of a surgical ward was noted for a period of one year (April 2013 to
March 2014). The DDD per 100 bed days were calculated for drugs having ATC code.
Antibiotic sensitivity by Kirby Bauer disc diffusion method was performed for drugs
that were indented. Correlation between DDD per 100 bed days and percentage
resistance was calculated for the drugs Amikacin, Meropenem, Ceftazidime,
Streptomycin and Ciprofloxacin.
Results:
With increase in indents, percentage increase in resistance was not
observed for Amikacin, Meropenem, Ceftazidime and Streptomycin except for
Ciprofloxacin, as DDD per 100 bed days was increasing, percentage increase of
resistance was observed.
Conclusions:
An appropriate method of drug usage like ABCcalc must be used
to monitor antibiotics usage. Drug resistance trends should be recorded to take
appropriate timely action.

Single Center 17-year Experience on Different Drug Regimens
of Visceral Leishmaniasis (VL) on Development of PKDL –
Retrospective Observational Study
___________________________________________________________________________________________
Author : Dr. Bikram Das
Co-Authors : Dr. Mehebubar Rahman, Dr. Sukanta Debnath, Dr. Amartya Misra,
Dr. Rama Prosad Goswami.
Insttution : School of Tropical Medicine, Kolkata.
Objective:
With the advent of amphotericin B, lyophilized (AmB) or liposomal (L-AmB), number
of VL cases is declining dramatically whereas PKDL cases are rising steadily, serving
as reservoir of infection in the community. Prevention of PKDL is important for
Kala-Azar elimination program. This study is undertaken to find out the magnitude of
effect of different therapeutic regimens used for treatment of VL on development of
PKDL.
Method:
This retrospective observational study was conducted at the School of Tropical
Medicine (STM), Kolkata, India. Hospital records of patients admitted at the STM
from January 2000 to February 2017 with VL and/or PKDL were retrospectively analysed
with approval from the Clinical Research Ethics Committee of the STM.
Results:
709 VL (mean age 30.02 ± 15.88 years, 60% male) and 92 PKDL (mean age 29.31 ± 13.23
years, 80% male) cases were treated at STM over past 17 years. Complete treatment
history was available in 60 PKDL cases – 50 were previously treated for VL with sodium
stibogluconate (SSG) (83.33%), 6 with miltefosine (10%), 2 with AmB (3.33%) and 1 with
L-amB (1.66%). One PKDL patient had no past history of VL. Among 709 VL patients 100
were treated with SSG, 369 with AmB, 155 with L-AmB, 25 with miltefosine and 60 with
combination therapy (7.5-mg/kg single dose L-AmB + 14 day miltefosine). All VL patients
after initial cure were advised to report of any persistent skin lesion. Ten treated with
SSG (10%), 2 with miltefosine (8%), 2 with AmB (0.54%), 1 with L-AmB (0.64%), and none
with combination therapy (P<0.001) developed PKDL completing 5-year follow up.
Time-to-develop PKDL was significantly shorter with miltefosine (within 6 months)
followed by L-AmB and AmB (6 months to 1year) compared to SSG (>2 years).
Conclusion:
Combination therapy for VL might be effective in protection against development
of PKDL.

Diagnostic potential of circulating biomarkers in adenosine
deaminase diagnosed pleural tuberculosis cases
___________________________________________________________________________________________
Author : Dr. Bineeta Kashyap
Co-authors : Dr. Nisha Goyal, Dr. IR Kaur, Dr. NP Singh
Institution : University College of Medical Sciences and Guru Tegh Bahadur Hospital,
Delhi
Objectives: To assess diagnostic potential of six circulating biomarkers, including T-cell

function markers [interferon (IFN-), interleukin (IL-2) and IFN-/IL-2 ratio]; macrophage
activation marker [neopterin]; and oxidative stress markers [protein carbonyl and
malondialdehyde (MDA)] in pleural tuberculosis(PTB) cases diagnosed by chest
X-ray findings and adenosine deaminase (ADA) levels.
Materials and methods: 26 PTB cases diagnosed on the basis of suggestive chest
X-ray and raised serum ADA levels and 26 age & sex matched healthy controls
were included in the study. All pleural fluid specimens were subjected to ZN staining
and culture on LJ medium. Serum IFN-, IL-2, neopterin and protein carbonyl level
detection was done by commercially available ELISA kits and MDA levels were
determined by measuring the thiobarbituric acid reactive substances.
Results: Median serum levels of IFN-, IL-2, IFN-/IL-2 ratio, neopterin, protein
carbonyl and MDA were significantly different between cases and controls (p<0.05).
Levels of all biomarkers except IL-2 were significantly higher in cases with contact
history. Mean levels of ADA and ESR were 46.27 U/L and 46.62 mm/hr in PTB cases.
AUC for IFN-, IL-2, IFN-/IL-2 ratio, neopterin, protein carbonyl and MDA were
significantly discriminative for cases and controls. IFN-/IL-2 ratio was best
discriminatory biomarker with highest area under ROC curve. Though no correlation
was seen between ADA and any of the six biomarkers, ESR levels correlated significantly
with all biomarkers except IL-2 by spearman’s correlation coefficient.
Conclusion: Though all the circulating biomarkers under study could be useful in
the diagnosis of PTB, further studies are needed to validate these results.

Clinical Profile and Outcome of Critically Ill Patients
with Tuberculosis
___________________________________________________________________________________________
Author : Dr. Binila Chacko
Co-authors : Dr. Samuel Juppudi, Dr. Lovely Thomas, Dr. Alice Mathuram,
Gunasekaran Karthik, Dr. Sudha Jasmine, Dr. Ronald Carey,
Dr. Tina George, Dr. John Victor Peter
Department : Critical Care
Institution : Christian Medical College, Vellore
Objective:
India has the highest TB burden in the world. Despite curative therapy, mortality
with tuberculosis has been reported to be high with almost 2 million people dying
every year. The purpose of this study was twofold-to describe the clinical profile and
outcome of patients admitted to intensive care unit with tuberculosis and to assess if
the type of tuberculosis (pulmonary or extra-pulmonary) impacts outcomes.
Methods:
Retrospective study of electronic hospital intensive care data over 5 years 2012 to
2016. Demographics, clinical profile, microbiological data and outcome were
extracted into data forms. Patients were categorized as Pulmonary TB or
extrapulmonary TB, which included disseminated TB. Differences between pulmonary
and extra pulmonary TB were explored using t test or Fischer’s exact test as deemed
appropriate. Predictors of outcome were explored using bivariate logistic regression
analysis.
Results:
Of the 428 admissions coded as suspected tuberculosis, 220 records were
screened; 103 (61 male) were diagnosed as tuberculosis. The mean (SD) of the
whole cohort was 44.7 (17.4) years. The mean APACHE of 20.4(7) suggested a
moderate to severe illness severity. The main reasons for ICU admission were ventilatory
support (n=89), hemodynamic instability (n=40) or neurologic (n=25). Over two-thirds
(n=72) were diagnosed to have tuberculosis during their ICU admission. Overall
mortality was 48.5%. 35 patients were diagnosed as pulmonary TB and 68 had
either extrapulmonary or disseminated disease. Mortality was significantly (p=0.04)
higher with pulmonary (62.9%) than with extra pulmonary (41.2%). Although there was
no difference in ICU or hospital length of stay or nosocomial infections between the
two groups, pulmonary TB was associated with significantly lower ventilatory free days
(p=0.02). On multivariate logistic regression analysis incorporating APACHE, pulmonary
site of TB, inotropes and dialysis were independently associated with death.
Conclusion:
Patients with TB requiring ICU have a high mortality. Pulmonary site of involvement and
organ support (cardiac and renal) are associated with unfavorable outcomes.

Serum Procalcitonin Levels In Patients With Snake
Bite Induced Cellulitis
___________________________________________________________________________________________
Author : Dr. Chanaveerappa Bammigatti
Co-author : Dr. Preetham Reddy A, Dr. Nandeesha H, Dr. Swaminathan RP
Institution : Jawaharlal Institute of Postgraduate Medical Education and Research
(JIPMER)
Background:
Local cellultis is a major manifestation of snake envenomation. Whether it is due to
venom or infection from bacteria in the oral cavity of snakes is controversial.
Antibiotics are used routinely in snake bite cellulitis, with no proper evidence to support
it. Procalcitonin is a specific marker for bacterial infection. Measurement of
procalcitonin level might help in deciding if the cellulitis is due to bacterial infection
and may help in reducing unnecessary antibiotic usage.
Aim:
To assess serum procalcitonin levels in patients with cellulitis due to snake bite and
to study the dynamics of serum procalcitonin levels in these patients.
Methods:
Patients with definite history of snake bite and cellulitis crossing the joint line at
presentations between August 2014 and July 2016 were included. Patients who
had already received antibiotics or whose wounds were manipulated were excluded
from the study. Convenient sample size of 100 patients with snake bite cellulitis was
taken. Procalcitonin level was assessed at baseline for all patients; 2nd and 3rd samples
were taken after 12 and 24 hours of 1st sample for patients with progressive cellulitis.
Results:
A total of 327 patients were screened, and 100 were included in the study.
Cellulitis progressed in 48 cases. The median procalcitonin level at baseline (n=100)
was 0.282 (0.262-0.324) ng/ml. No statistically significant difference was found between
first and second procalcitonin values [0.281(0.267-0.302) ng/ml vs. 0.295 (0.270-0.351)
ng/ml, p=0.425] in patients with progressive cellulitis.
Conclusion:
Procalcitonin levels were much lower than the levels expected in cellulitis due to
bacterial infection. Routine use of antibiotics may not be required in snake bite cellulitis
as serum procalcitonin levels were not elevated significantly.

Factors Predicting Severity of Illness in Patients with
Dengue Fever: A Retrospective Study
___________________________________________________________________________________________
Author : Dr. Chandrashekar U K
Co-authors : Dr. Melissa SP, Dr. Sreedharan Nair, Dr. Girish Thunga,
Dr. Vijayanarayana Kunhikatta, Dr. Vasudeva Guddattu
Institution : Kasturba Medical College, Manipal- 576104
Objective:
Dengue fever is one of the important tropical disease of public health
significance caused by flavivirus. This study elucidates factors that could predict
the severity of illness.
Methods:
This retrospective study analyzed demographic, clinical, laboratory parameters and
treatment details of 550 patients with confirmed diagnosis of dengue.
Results:
An univariate analysis showed significant association of gender, backache, skin rash,
nausea and vomiting, abdominal distension, haemorrhage, breathlessness, oliguria,
hepatomegaly, splenomegaly, ascites, leukopenia, hypoproteinemia, and elevated
serum alanine transaminase (ALT) >63 IU/L with the severity of disease. On multivariate
analysis, haemorrhage, oliguria, ascites, ALT >63 IU/L and hypoproteinemia were identi-
fied as risk factors for the development of severe dengue.
Conclusion:
These factors may be used to predict the dengue infection severity and enable
clinicians to implement early appropriate intervention.

How does RIF resistance on Xpert MTB/RIF with very low
load correlate with TB MGIT DST?
___________________________________________________________________________________________
Author : Dr. Chirag Chhatwani
Co-authors : Dr. Aakash Doshi, Dr. Ayesha Sunavala, Dr. Rajeev Soman,
Dr. Anjali Shetty, Dr. Camilla Rodrigues
Institution : P.D.Hinduja Hospital
Objective:
To compare the RIF susceptibility data of Xpert MTB/RIF with very low load & Phenotypic
DST.
Methods:
13,600 Xpert MTB Rif samples of pulmonary and extra pulmonary TB were assessed
between January 2016 to march 2017 at P.D. Hinduja Hospital. 210 patients had very
low load with rifampicin resistance out of which 20 patients had phenotypic culture
with DST.
Results:
The details of 210 Xpert samples with MTB very low load and Rif resistance are described
in the following follow chart.
The most common Probes involved with Xpert “very low” load was Probe E (15),
other probes involved where Probe D(3) and A(2)
Conclusion:
Although the number of patients with rifampicin resistance very low load on gene
xpert is extremely small(20/210), 25% of these samples were discordant with MGIT
DST. These false RIF resistance results can result in inappropriate treatment with toxic
second line anti-tuberculosis drugs. Hence we conclude that for very low load
RIF-resistant results on Xpert, a gold standard culture based DST is preferred.

A Defined Approach- Key to Success in Managing
Dual Infection
___________________________________________________________________________________________
Author : Dr. Chirag Chhatwani,
Co-authors : Dr. Aakash Doshi, Dr. Ayesha Sunavala, Dr. Rajeev Soman,
Dr. Camila Rodrigues
Department : Internal Medicine and Infectious Disease
Institution : P.D Hinduja National Hospital MRC Mahim, Mumbai
Introduction:
• Pulmonary infections have been implicated as the most common cause of infection
related mortality in renal transplant recipients.
• Beside the knowledge of the microorganisms, an aggressive diagnostic approach

including the use of invasive tests is often essential to make an early diagnosis for
instituting timely and appropriate therapy.
Case Report:
• 57 year male diagnosed with CKD secondary to Obstructive uropathy,
underwent live related kidney transplant in 2015. In january 2017, developed cough
with expectoration and fever (admitted elsewhere). BAL culture had ESBL E.coli and
AFB positive but Gene Xpert MTB/RIF was negative. BAL Galatomanan was positive
(OD - 1.9), but got treatment only with multiple antibiotics on off for 2 months. In april
2017 sputum for AFB was still positive and LPA showed M.chelonae and BAL MGIT
culture showed RGM on mediocre regime of NTM.
• In may 2017, HRCT showed partial reduction in some cavitation with new left
parahilar cavitatory nodule while on NTM treatment, admitted to our
institution. Impression was NTM lung infection with probable IPA, hence was started
on voriconazole with proper RGM treatment with amikacin (creatinine clearance
based), azithromycin and linezolid.
JAN 2017 May 2017
Discussion:
• In this case, initially E.coli was considered as a cause of pneumonia(elsewhere).
• Later diagnosis of NTM was entertained was started on inappropriate treatment.

• Some of the lesion showed partial resolution, however a new cavitatory lesion in
left parahilar develop which could have been due to aspergillosis which had not
been treated.
Conclusion:
• Post KTR patient can have multiple simultaneous and sequential infection so
clinical, radiological and microbiological correlation is crucial to make correct
diagnosis and institute treatment.

“Microbiological profile of Urinary tract Infection
At A Tertiary Care Hospital In Kanpur”.
Author : Dr. Deepak Sameer
Co-authors : Dr. R.Sujatha
Department : Department Of Microbiology
Institution : Rama Medical College Hospital & Research Center, Kanpur
Background:
Urinary tract infection(UTI) is one of the most common bacterial infections in
humans and a major cause of morbidity. UTI has become difficult to treat because
of appearance of pathogens with increasing resistance to antimicrobial agents.
Objective:
We aimed to study the antibiotic resistance pattern of the urinary pathogens
isolated from patients is our tertiary care hospital.
Methods :
A prospective study was done during Dec 2016 – May2017at Rama medical
college hospital, Kanpur.The study included all the adult patients of OPD & IPD,
with symptoms of UTI, urine culture and sensitivity was carried out by standard
microbiological procedures.
Results:
Out of 450 urine samples significant bacteriuria was seen in 34.66%. Female
were 96(61.5% )and male were 60(38.4% ) the incidence of UTI was more in
patients in the age group of 20-40 years. E coli (42.3%) was the most common organism,
followed by Klebsiella sps(23.1%), Staphylococcus(15.3%), Proteus mirabilis(7.6%),Citro
bacter(3.8%), Enterococcus (3.8%), Candida albican(3.8%). E coli and Klebsiella were
resistant to Amikacin (75.7% & 83.3%) respectively. More than 90% of strains were
resistant to Ampicillin.GNB showed better sensitivity to Nitrofurantoin and
Imipenam. All the isolates were 100% sensitive to polymyxins.15.15% and 33.3%
of E.coli and Klebsiella sps were ESBL producers. 50% of the S.aureus were
methicillin resistant.
Conclusion:
In this study, female were mostly affected and the most common organism were
E.coli and Klebsiella sps, These isolates are sensitive to nitrofurantoin, imipenem
and polymyxins, and resistant to the most commonly used drugs like ampicillin,
amikacin used in UTI. Regular monitoring are required to establish reliable information
about resistance pattern of urinary pathogens for optimal empirical therapy of patients
with UTIs.
Key words:
Urinary tract infection, Antibiotic resistance, E.coli.

Prevalence of Hep.B in a tribal population in Kerala
___________________________________________________________________________________________
Author : Dr. Deepu Sasidharan
Co-authors : Dr Sheela Mathew
Department : Infectious Diseases
Institution : Govt. Medical College Hospital , Kozhikode, Kerala
Hepatitis B is one of the major diseases of mankind and is a serious global public
health problem Hepatitis B is a major health problem in India too. Based on the
prevalence of hepatitis B carrier state in the general population, countries are
classified as having high (8% or more), intermediate (2-7%), or low (less than 2%)
HBV endemicity. India is at the intermediate endemic level of hepatitis B, with
hepatitis B surface antigen (HBsAg) prevalence between 2% and 10% among the
populations studied. The prevalence does not vary significantly by region in the
country. The number of HBsAg carriers in India has been estimated to be over 40 million
(4 crore). We conducted a study to find out the prevalence of carrier state in a tribal
population of Kerala.

To estimate the magnitude of the disease in the community, representative
community-based sampling was done.A total no of 1118 people in a tribal village
in Palakad district of Kerala was screened for Hepatitis B carrier stage. The student
volunteers of NSS did the screening and data entry.Patient group included 417
males and 701 females.630 persons received usual childhood immunisation . The age
group varied from less than a year to 65 yrs. 849 persons were < 20 yrs. 33 persons were
detected to be positive for HBs Ag. This included 9 males and 24 females. Age group
ranged from 2yrs to 55 yrs. 18 persons <20 were positive. In 4 families different members
were found positive. The overall prevalence was3%.Those who were found negative
were given vaccine against Hep B.during the day of screening and advised to contact
the local PHC for continuing the vaccination schedule.
Discussion:
The overall prevalence was 3% in our study. So far there is non availability of data
from Kerala regarding the true prevalence in rural, urban or tribal populations
There are varying reports of overall rate of HBsAg positivity ranging between 2–4.7%.
A meta-analysis of the prevalence of HBV had estimated that the point-prevalence
of hepatitis B among nontribal and tribal populations was 3.07% (95% CI: 2.5–3.64)
and 11.85% (CI 10.76–12.93) respectively and the overall prevalence was 3.70%
(CI: 3.17–4.24) (corresponding to a chronic carrier rate of 2.96%).A high endemicity
of HBV infection has been reported in the tribal populations which has been
attributed to inbreeding, poor hygienic living conditions, close person-to-person
contact and certain socioculture practices which may facilitate transmission of HBV. .
In the tribal areas of Madhya Pradesh two studies reported prevalence rates of 15.7%(22)
and 4.4%(23).
References:
1. Thyagarajan SP, Jayaram S, Mohanavalli B. Prevalence of HBV in general
population in India. In: Sarin SK, Singal AK, (Eds). Hepatitis B in India: problems and
prevention. New Delhi: CBS;1996.pp.5-16.
2. Batham A, Gupta MA, Rastogi P, et al. Calculating prevalence of hepatitis B in India:
using population weights to look for publication bias in conventional meta-analysis.
Indian J Pediatr. 2009;76:1247-57.

The Neglected Medical Emergency- Rabies
___________________________________________________________________________________________
Author : Dr. Dhanashri Atre Singh
Co-authors : Dr. Supriya Dutta, Dr. Ravindra Ghawat, Dr. Harshad Purandare
Institution : Jupiter Hospital.
Objective:
To report the rarity of paralytic rabies occurring despite post-exposure prophylaxis
confirmed by antemortem brain biopsy.
Case:
58-year-old man was admitted with sudden onset weakness of right arm since 8 hours.
He had fever and vomiting for 2 days. Significant history elicited unprovoked bite (Grade
3) by his pet dog on right forearm a month back, after which four doses of vaccine were
administered immediately. Clinical examination revealed a febrile and apprehensive
patient, GCS 15/15. His pulse was 110/min, BP 100/70 mm Hg. He was tachypnoeic.
Neurological examination revealed atonic areflexic paralysis of right upper limb with
neck flexor weakness. Power in other limbs was 4/5. No aerophobia or hydrophobia was
seen. A provisional diagnosis of paralytic rabies versus vaccine induced GBS was made.
MRI was performed (Fig). CSF did not reveal cytoalbumin dissociation. Rabies PCR
on CSF, saliva and corneal smears was negative. Patient was empirically treated
with acyclovir, antibiotics, methylprednisolone, IVIG and IV fluids. Within hours patient
became quadruparetic with worsening of GCS and impending respiratory failure.
He needed mechanical ventilation. Autonomic dysfunction ensued. MRI on Day
5 showed worsening of the brainstem lesions. For definitive diagnosis a brain biopsy
was performed with consent on day 7, samples were sent for fluorescent antibody
testing.
Results:
Histopathology confirmed classical intracytoplasmic NEGRI body lesions, perivascular
infiltrates, and Babes nodules (Fig). FTA Ab was positive.
Conclusion:
Paralytic rabies is uncommon (10-20%) and needs high clinical index of suspicion.
Animal bites have to be considered as medical emergency, post-exposure
prophylaxis with human rabies immunoglobulin could have been a life-saving in this
case.
Fig: (Left) MRI brain on admission revealed bilateral symmetrical T2/FLAIR

hyperintensities in the basal ganglia, periaqueductal grey matter and central grey
matter of the spinal cord. (Right) Histopathology of R hippocampus

Prognostic Significance Of Rising Trends Of Urea And
Creatinine In Patients Of Acute Hepatitis E
___________________________________________________________________________________________
Author : Dr. Dhawade Pallavi Prakash
Co-authors : Dr. R.L. Khare, Dr. Archana Toppo, Dr. Shashank Gupta
Department : Medicine
Institution : Pt. JNM Medical College Raipur
HEV is responsible for major outbreak of acute hepatitis in various developing

countries with mortality reaching upto 1% during outbreak. Mortality reaches upto
10-30% in pregnant patients. HEV is responsible for decompensation in patients of
pre-existing chronic liver disease.
Objective:
To assess relationship between rising trend of urea and creatinine and mortality in
admitted patients of Hepatitis E .
Methods:
Study was conducted in Dept. of Medicine, Pt. JNM Medical College Raipur and
Dr. B.R.A.M. hospital in 70 patients of hepatitis E. Their Clinical profiles were noted. Serial
laboratory parameters for LFT, coagulation profile, creatinine and urea were done on
day 1, 3 and 5 of admission .Patients were investigated for viral markers anti HAV IgM
antibody, HBsAg, HCV IgM antibody and HEV IgM antibody by ELISA assay method.
Final outcome was noted in the form of discharge and death.
Result:
Males had higher incidence of HEV infection as compared to females. Overall
mortality observed was 10%. 4% patients were having chronic liver disease. Mean
values of urea on day 1, 3 and 5 of admissions in 63 patients who got discharged
were 27.52±15, 23.5±10, 22.01±8 respectively. Seven patients who died had mean value
of urea on day 1, 3 and 5 of admissions were 44.71± 24 (p=0.011), 58.14 ±35 (p<0.0001),
57.71 ± 46 (p<0.0001) respectively. Mean value of creatinine on day 1, 3 and 5 of
admissions were 1.11 ±0.4, 1.09 ±0.3, 1.02 ±0.25 respectively in discharged patients and
1.57 ±1.47, 1.94±1.77 (p=0.001), 2.28± 2.07(p<0.0001) respectively in patients who died.
Conclusion:
Rising values of urea and creatinine on serial measurements were significantly
associated with mortality in patients with acute hepatitis E.

A Rare Case of Isolated Intramedullary Nocardial Abscess in an
Imunocompetent Child
___________________________________________________________________________________________
Author : Dr. Dudhat Vaibhav Laxmikant
Co-authors : Dr Maithili Kavathekar, Dr Deepa Divekar, Dr Sonal Patil,
Dr Prashant Khandgave
Institution : Sahyadri Speciality Hospitals Pune.
Introduction:
Nocardiosis is rare but potentially life threatening condition caused by several
species of Nocardia, Nocardia asteroids most frequently causing human infections.
N. farcinica could be fatal because of aggressiveness, tendency to disseminate and
resistance to antibiotics, causing infections in immunocompromised patients involving
commonly respiratory tract. Here in we describe unique case of isolated intramedullary
nocardial abscess in an 8 yr old immunocompetent child.
Case report: A 8 year old girl presented to our hospital with neck stiffness and
pain, aggravated by neck movements, a history of productive cough and fever
and imbalance while walking. MRI spine showed heterogeneously enhancing lesion
within cervical cord from C2 to C5 vertebral bodies which was isointense on T1 and
hyperintense on T2. Thick intramedullary capsule and yellow puslike material was
observed and drained. The histopathology was suggestive of acute necrotizing
inflammation. Gram stain showed Gram positive branched filaments which were acid
fast on modified ZN stain s/o Nocardia. Culture confirmed growth of Nocardia spp.
MALDI-TOF identified the species as N. farcinica. Patient was treated with intravenous
imipenem and amikacin and oral Cotrimoxazole sensitivity report. Patient improved
and was discharged with 1 month course of IV antibiotic advice.
Discussion: Nocardia infection is a rare disorder affecting commonly lungs and skin,
CNS being rare. It is an infection mainly of immunocompromised. Clinical and
radiological presentation is chronic and nonspecific and microbiological diagnosis
is often difficult. It is commonly mistaken as tuberculosis, bacterial pneumonia and
malignancies. Treatment includes sulphonamides, Cotrimoxazole with surgical
drainage with alternatives like Amikacin, Imipenem, Minocycline, Linezolid and
cephalosporins.
Conclusion: Difficulty and slowness of growth, along with lack of serologic tests for
nocardiosis necessitates its inclusion in differential diagnosis

“Search for Multiple Opportunistic Infection in HIV“
___________________________________________________________________________________________
Author : Dr. Farhan Fazal
Co-authors : Dr. Devashish Desai Dr. Ashutosh Biswas, Dr. Manish Soneja,
Dr. Upendar Baitha, Dr. Pankaj Jorwal
Institution : All India Institute of Medical Sciences (AIIMS), New Delhi, India
Authors : Farhan Fazal;Devashish Desai; Ashutosh Biswas; Manish Soneja;
Upendar Baitha, Pankaj Jorwal
Affiliation : Department of Medicine ,All India Institute of Medical Sciences (AIIMS),
New Delhi, India
Introduction:
HIV TB co infection is more common with CD4 <50 cells/ µl .Disseminated TB in HIV
infected patient is around 28% in India. Cryptococcol infection is a common
opportunistic infection which presents as insidious meningoencephalitis but
dissemination of the infection is not as common as tuberculosis.
Case report:
A 43-yr-old male recently diagnosed with HIV with a CD4 count 8cells/µl
presented with low grade fever, easy fatigability and weight loss since 3 months.
On examination Patient had pallor, lymphadenopathy in left cervical and left
axilla with splenomegaly. Kernigs sign was positive. Fundus examination revealed
multifocal choroiditis, suggestive of tuberculosis, No signs of papilloedema(fig 1) .
On further evaluation he had pancytopenia, serum albumin of 2.4g/dl,

S.creatinine 1.5mg/dl, urea 80mg/dl, normal serum electrolytes and liver function
test. With a suspicion of TB meningitis a CT brain(normal) followed by lumbar puncture
was done which showed clear CSF, cell count 40/µl, 60% lymphocyte, 40 % neutrophil
,protein 62mg/dl, sugar 34mg/dl (blood sugar 104mg/dl), ADA 4IU/L, Gene Xpert for
TB was negative , bacterial culture and India ink were negative , CSF cryptococcol
antigen was positive with 1:16 titre and culture was positive for Cryptococcus
neoformans .Bone marrow evaluation and lymph node biopsy were carried out which
were negative for acid fast bacilli and Gene Xpert but showed culture positive for
Cryptococcus neoformans .PET CT showed hypermetabolism in bilateral cervical ,
axillary ,mediastinal ,inguinal lymph nodes along with adrenals, kidney and spleen.
Serum and urine cryptococcol antigen were positive .Patient was treated with
liposomal amphotericin and fluconazole as per standard protocol and discharged
after 3 weeks.
Conclusion:
HIV with low CD4 count is known to be associated with multiple opportunistic
infections and tuberculosis is usually suspected. The patient had findings suggestive
of Tuberculosis but on further evaluation patient had disseminated cryptococcal
infection. This report showed that disseminated cryptococcol infection is not
uncomman and can masquerade as tuberculosis.
figure 1

Outcome of Tuberculosis in Chronic Kidney Disease
___________________________________________________________________________________________
Author : Dr. Fibi Ninan K
Co-authors : Dr. Ajoy Oommen John, Dr. Ajay Kumar Mishra, Dr. O. C. Abraham
Department : General Medicine
Institution : Christian Medical College,Vellore
Objectives:
To study the outcomes among patients with chronic kidney disease(CKD) and
tuberculosis and to assess the factors associated with adverse outcome.
Methods:
We conducted a retrospective cohort study in a tertiary care hospital in South
India.The discharge summaries of all patients admitted in medical wards from April
2005–December 2015 were screened for the diagnosis of ‘tuberculosis and CKD’.
Patients included were adults with tuberculosis(defined in accordance to 2016
RNTCP guidelines as microbiologically confirmed or clinically diagnosed)
and CKD(KDIGO-2012 criteria) who followed up until the end of intensive phase(IP).
Primary outcome was death while on anti-tuberculous therapy(ATT).Patients who
completed ATT with clinical, radiological or microbiological cure were
classified as ‘cured’.Those who did not follow up after IP were classified as ‘lost to
follow up’(LFP).’Cured’ and ‘LFP’ were analyzed together as ‘censored’.
Results:
248 patients had diagnosis of tuberculosis and CKD.64 patients fulfilled our inclusion
criteria with age ranging from 18-73 years.45(70.3%) were males.Majority(n=44,68.8%)
had extra-pulmonary tuberculosis and 56.8%(n=25) had disseminated disease.
44 patients(68.7%) had GFR>30ml/min/1.73m2 and 12%(n=8) were on chronic

renal replacement therapy.Outcome analysis revealed that 24 patients(37.5%) died,
30 patients(46.9%) were cured and 10(15.6%) were LFP.

Factors affecting the outcome were:
Variable Unadjusted Adjusted

Odds Confidence
Death Censored P value P value
Ratio interval
Creatinine(mg/dL)
(median,IQR) 2.6(1.7-3.6) 1.6(1.2-2.6) 0.005 1.7 0.01 1.1-2.8
GFR(kg/min/1.73m2 ) 11(55%) 9(45%)
<30
13(29.5%) 31(27.5%) 0.05 2.9 0.05 0.9-8.6
>30
Pulmonary TB 9(37.5%) 15(62.5%) 0.93
Extra-pulmonary TB 18(40.9%) 26(59.1%) 0.40
Disseminated TB 12(40.9%) 13(59.1%) 0.27
Charlson comorbidity
index(median,IQR) 5.5(3.2-7) 4.0(2.0-4.0) 0.261
Conclusion:
The mortality rate in our cohort of adult patients with CKD and tuberculosis was
high.The factors affecting mortality were related to the severity of the CKD rather than
the extent of the tuberculosis.

Hemophagocytic Lymphohistiocytosis Associated with
Plasmodium vivax infection – Unusual Manifestation
___________________________________________________________________________________________
Author : Dr. Gangula Rahul Sai
Co-authors : Dr. Biji Bob Thomas, Dr. B A Shastry
Institution : Kasturba Medical College, Manipal
Hemophagocytic Lymphohistiocytosis (HLH) is a life threatening inflammatory

process, involving multiple systems, due to excessive and prolonged activation of
antigen presenting cells. It is characterized by fever, splenomegaly, bicytopenia,
hepatitis and hemophagocytosis in bone marrow biopsy or aspiration or liver
biopsy specimens. It can occur as a primary syndrome or as secondary to triggers like
autoimmune diseases, infections-viral, bacterial, parasitic. Here we report an unusual
case of HLH associated with Plasmodium vivax infection. Patient was a 57 year old
male farmer who presented with fever, chills and myalgias. Physical examination
had revealed splenomegaly. According to Proposed Diagnostic Criteria of 2009,
diagnosis of HLH was confirmed with presence of splenomegaly, bicytopenia and
hemophagocytosis in bone marrow aspiration specimen. He was treated with
intravenous artesunate, antibiotics (neutropenic sepsis- 4th generation
cephalosporins) and oral primaquine following which had improved symptomatically
without any further complications. No relapse of malaria found on follow-up till date.
This implies that active search and early recognition of this fatal condition in endemic
areas could improve the mortality.

An unusual presentation of Melioidosis with
epididymo-orchitis – A Case Report
___________________________________________________________________________________________
Author : Dr Gautam Raj Panjabi
Co-authors : Dr Shipra Rai ; Dr Kavitha Saravu ;
Institution : Kasturba Medical College, Manipal, India
Melioidosis is an anthropozoonosis caused by Burkholderia pseudomallei which is

endemic in Southeast Asia. Its clinical presentation is varied, with acute, subacute,
or chronic forms. Burkholderia pseudomallei causes a wide spectrum of disease,
ranging from asymptomatic infection to abscesses, pneumonia, and disseminated
disease. Although the most frequent form is acute pulmonary infection, the most
severe form of the disease is acute septicemic infection, with a mortality rate, ranging
from 40% with treatment to 90% without treatment. Different organs may be involved,
such as the lungs, liver, spleen, skin, brain, bones, lymph nodes, eyes, and adrenal
glands. Genitourinary forms are uncommon. We report a case of melioidosis presenting
as epididymo-orchitis.
A 55 year old male businessman from Uttara Karnataka, India a known diabetic
and hypertensive on treatment presented with high grade fever with chills since
ten days and pain in the genital region since four days. On examination patient was
febrile, other vitals were stable. There was no rash or eschar. General and systemic
examination were unremarkable. Genital examination revealed red, tender
scrotum. Labs showed high total counts with bands (22%), elevated creatinine (1.9mg/dl).
Blood for culture grew Burkholderia pseudomallei , serum procalcitonin was
positive. Ultrasound of the scrotum showed epididymo-orchitis. Patient was treated with
intravenous Meropenem and oral Doxycycline for 2 weeks (intensive phase) followed
by eradication phase of oral Trimethoprim-Sulfamethoxazole for 16 weeks. Following
the intensive phase patient responded and improved clinically. His serum creatinine
and counts returned to normal and patient was asymptomatic at follow up.
Learning points :
1. Physicians should consider the possibility of melioidosis especially when patients
from an endemic area for melioidosis or patients with uncontrolled diabetes are
referred.
2. Melioidosis can present with epididymo-orchitis which is uncommon.

Targeted infection control surveillance stemmed to
“Low incidence of surgical site infections” - in total
Hip and Knee arthroplasty, Hyderabad 2013 to 2016
___________________________________________________________________________________________
Author : Dr. Guda Vaishnavi
Co-authors : Dinaker M2, Ramesh R Allam3 , Ganesh Oruganti4
Department : Infection Control Nurse
Institution : GYD DIAGNOSTICS AND CLINICS
Guda Vaishnavi 1, Dinaker M2, Ramesh R Allam3 , Ganesh Oruganti4
1. Infection Control Nurse, GYD Diagnostics and Clinics, Hyderabad, Telangana
2. Director, Internal Medicine & Life Style Disorders, Sunshine Hospitals, Hyderabad,
Telangana.
3. Consultant Epidemiologist, GYD Diagnostics and Clinics, Hyderabad, Telangana.
4. Lab Consultant & Microbiologist, Sunshine Hospitals, Hyderabad, Telangana.
Affiliation: GYD Diagnostics and Reference Laboratories
Introduction
Deep surgical site infection (SSI) following total knee or hip arthroplasty is a devastating
Complication that occurs in approximately 2% of surgical procedures and account for
some 20% of health care-associated infections. Despite improvements in prevention,
SSIs remain a significant clinical problem as they are associated with substantial
mortality and morbidity .Prevention of SSIs emphasis the importance of good
patient preparation, aseptic practice, and attention to surgical technique;
antimicrobial prophylaxis is also indicated in specific circumstances.
Methods
SSIs are defined as infections occurring up to up to one year after surgery.
Targeted surveillance was instituted among cohort of patients with primary Hip
and Knee arthroplasty between January 2013 to September 2016. Follow-up was done
during the physiotherapy appointment and surgical site review visits by the infection
control professionals. Infection control team instituted policies and capacity building
of known risk factors like admitting patients only on day of surgery, pre-operative
chlorhidine bath, hair clipping, timing of antibiotic prophylaxis, peri-op gycaemic
control, use of HEPA filters and reducing Operation theatre traffic. . We calculated
the incidence density, trend of SSI and post-operative follow-up rates.
Results
Among 9479 patients with Hip and Knee arthroplasty over four years 7881 were
successfully followed up to one year. 49 cases of SSI were identified of 7881 followed-up
(0.5 %). Over the three years the SSI rates decreased from 0.6% to 0.3% and the lost to
follow up rates decreased from 28% to 8%. Cases of SSI had co-existing co-morbidities
hypertension, diabetes.
Conclusion:
Targeted surveillance with adherence to infection control practices will reduce
incidence of SSI rates. Stringent documentation and follow-up of patients post-surgery
will be ensure that the SSIs are monitored and attended to.

Serum Procalcitonin as a marker in Diagnosis of Septicemia in
Neonatal intensive care unit at a Tertiary Care Hospital
___________________________________________________________________________________________
Author : Dr Haniya Jafar
Co-authors : Dr Jyotsna Agarwal, Dr. R K Kalyan, Dr. Sheetal Verma,
Dr. Mala Kumar, Dr. Shalini Tripathi
Institution : King George Medical University, Lucknow
Introduction:
Early and accurate diagnosis of neonatal sepsis remains challenging due to non
specific signs and variable turnaround time of different diagnostic modalities.
Procalcitonin shows promising value in improving diagnosis to decrease indiscriminate
use of antibiotics. This study was done to assess role of procalcitonin as a diagnostic
marker in neonatal septicemia and provide cut off values by correlating it with blood
culture positivity in our setup.
Objective:
Role of Procalcitonin along with blood culture in diagnosis of neonatal sepsis

Blood samples of 275 neonates (>35 weeks of gestation) admitted to NICU, KGMU, with
suspicion of neonatal sepsis were collected for bacteriological cultures and sensitivities
and for serum Procalcitonin level detection.
Results:
Out of 275 blood samples received, 32% (n=90) showed positive blood culture
result. Raised procalcitonin level (>0.5ng/ml) was found in 59.3% (n=163). 65 blood
samples showed both blood culture positivity and raised procalcitonin level. Out
of 112 samples which did not have raised procalcitonin level, 87 samples (77%)
showed negative blood culture result. The diagnostic efficacy of Procalcitonin with
blood culture were as follows: sensitivity, specificity, Positive predictive value, Negative
predictive value and accuracy were 72.2%, 47%, 39.9%, 77.7% and 53.3% respectively.
Conclusion:
Results conclude that though Procalcitonin alone had low specificity in association
with blood culture, a high Negative predictive value makes it useful in ruling out
neonatal sepsis. Combining Procalcitonin with other parameters will increase its
diagnostic efficacy.

Should Pulmonary Aspergillosis be taken seriously???
___________________________________________________________________________________________
Author : Dr. Haritha Madigubba
Co-author : Dr. Kiran Chawla
Department : Microbiology,
Institution : Kasturba Medical College, Manipal.
Objective:
1. Assessment of clinical and microbiological profile of all the culture positive cases of
pulmonary aspergillosis detected from January 2016-2017, at a tertiary care hospital in
Southern India
Methods:
An observational and retrospective study of 15 culture confirmed cases of
pulmonary aspergillosis was carried out among patients admitted to tertiary
health care center in Southern India during January 2016- 2017, with special reference
to clinical presentations, epidemiology, predisposing factors, underlying comorbidities
and treatment. Invasive Aspergillosis (IA) was defined as growth of Aspergillus from
pulmonary specimens along with Galactomanan antigen test positive. Further based
on the clinical and laboratory findings cases were classified as proven, probable and
possible Invasive Aspergillosis (IA) following EORTC/MSG consensus group.
Results:
Out of the 15 culture confirmed cases predominant were males (11/15; 73.3%),
the mean age of the study population was 58.3 ± 14.2. Based on the following
findings, among 15 patients, 33.3% were. Proven Bronchopulmonary Aspergillosis cases
and 66.6% were Probable cases. The main predisposing factors identified in our study
was steroid induced (66.6%), COPD (60%), DM (33.3%). Cough with expectoration was
the most common symptom (100%) followed by dyspnea(73.3%). Chest radiography
revealed consolidation/opacity in 86.6% of the patients, followed by cavitatory lesions
and nodules in 33.3% each. Microbiologically, microscopy showed positivity for the
presence of gram positive, acutely branched, fungal hyphae, suggestive of Aspergillus,
in all the cases. Aspergillus fumigatus was the predominant species that was isolated in
46.6% (7/22) cases. Galactomannan antigen was positive for 33.3%. Voriconazole was
the antifungal therapy initiated in 33.3% (5/15) patients and clinical improvement was
observed among these patients. However the remaining 10/15 (66.6%) were not started
on anti-fungals and were discharged against medical advice.
Conclusion:
Invasive aspergillosis is a severe disease and can be found in immunocompromised
and critically ill patients. Treatment of all clinically suspected pulmonary aspergillosis
cases is a requisite to avoid further complications.

Filmarray, an Automated Nested Multiplex PCR System for
Multi-pathogen Detection in Suspected Septecimia Cases
___________________________________________________________________________________________
Author : Dr. Jemima Kingsley
Co-authors : Dr. TP Nisheeth, Dr. Subash Chezian, Dr. Kishore Kumar, Dr. CN Srinivas
Institution : MIOT Hospitals, Chennai
Objective:
To demonstrate the automated identification of the pathogens from their
corresponding target amplicon(s) by analysis of DNA melting curve of the amplicon
in the suspected septicaemia patient.
Methods:
In this study, Flimarray analysis was used to examine 67 cases of suspected septicaemia.
It includes 47 from Haemato-oncology unit, 16 from ICU’s, and 4 from general wards.
Blood specimens were collected and loaded into the automatic BacT/Alert machine
using specific bottles. Then filmarray was carried out after minimum of 4 to 6 hrs of
incubation.
Results:
The number of positives identified by Microarray(6.55%) was significantly higher than
the number of positives identified by the culture(3.27%).
Discussion:
In the last decade advances in diagnostic testing have led to changes in clinical
laboratory evaluation that have translated into improved clinical care. The filmarray
system addresses these concerns in that it has the capability for high-order multiplex
testing, yet is simple to use and requires minimal hands on time.
Especially in haemato-oncology, fever or hypotension / tachycardia during

chemotherapy induced neutropenia may be the only indication of a severe
underlying infection, because signs and symptoms of inflammation typically are
attenuated as the blood counts are very low. In non-neutropenic patients the
seriousness of infection and time to get a systemic sepsis is relatively more. In
haemato-oncology as there no neutrophils to provide innate immunity, the time to
develop a septicaemia is very limited. In today’s situation the bugs become
refractory as they are not sensitive to the first line empirical antibiotics. Flimarray
technique provides rapid results within 2hrs time.
Conclusion:
To conclude the advent of diagnostic platforms with the capability of medium
level multiplexing opens up the potential for development of a set at multi
pathogen panels that are focused on a specific disease indication rather than a
specific organism.

“Prevalence of HIV-2 and dual infection among
HIV infected individuals in a tertiary care teaching hospital,
Mangalore: The present scenario.”
___________________________________________________________________________________________
Author : Dr. Jutang Babat Ain Tiewsoh
Co-Authors : Dr. Rekha Boloor, Dr. Beena Antony
Institution : Fr. Muller Medical College Kankanady, Mangalore-575002, Karnataka
Introduction:
Human immunodeficiency virus belonging to the Genus Lentiviruses is made up of
two main types HIV-1 and HIV-2 which are the causative agents of Acquired immune
deficiency syndrome. It is a well known fact that HIV-1 infection is predominantly found
but HIV-2 infection has also been detected occasionally now and then.
Objective:
To investigate the prevalence of HIV-2 and dual infection in HIV positive patients in
a tertiary care centre, Mangalore.
Materials & Methods:

A prospective cross sectional study was carried out in a tertiary care teaching
hospital for a period of two years from August 2013 to July 2015, after obtaining
approval from the Institutional Ethics Committee. Patients attending clinics and
admitted in the hospital confirmed as HIV positive as per NACO guidelines willing
to participate in the study were included in the study.
Result & Discussion:

In our study out of a total of 214 patients, 2.8% (n=6) were HIV-2 and 1.4% (n=3)
were dual infected. Males were more commonly affected than females in a ratio
of 8:1. All these 9 cases were above 35 years of age where 7 showed improvement
on discharged while 2 left against medical advice and outcome is unknown in these
cases.
Conclusion:
Hence, clinicians should keep in mind that incidence of HIV-2 infection does occur,
so as to provide appropriate treatment and prevent mother to child transmission.
So also retro-positive cases are to be referred to ICTC and to the nearest ART centre
for care, support and treatment.

“Sero-prevalence of HBV/HCV among HIV infected patients
in a tertiary care teaching hospital in Mangalore, South India.”
___________________________________________________________________________________________
Author : Dr. Jutang Babat Ain Tiewsoh
Co-Authors : Dr. Rekha Boloor, Dr. Beena Antony
Institution : Fr. Muller Medical College Kankanady, Mangalore-575002, Karnataka
Background:
Human immunodeficiency virus (HIV) pandemic according to World Health
Organisation (WHO) estimates 36.7 million people were living with HIV by 2015 end
while chronic infection of Hepatitis B virus (HBV) and Hepatitis C virus (HCV) occurs
in 240 and 130-150 million people worldwide . Since the general modes of transmission
are similar to HIV, co-infection of HIV with HBV/HCV is commonly found, being variable
worldwide.
Aims and objectives:1

)To investigate the sero-prevalence of HBV/HCV in HIV positive patients.
2) To analyse the demographic pattern and laboratory parameters.
Settings and Design:

Descriptive cross-sectional study.
Methods and Material:

The serum samples from confirmed HIV-positive patients were screened and confirmed
for HBV and HCV following standard operative procedures. The demographic pattern
and laboratory parameters were also obtained.
Statistical analysis used:

SPSS version 23-0
Results:
The sero-prevalence of HBV and HCV in 137 HIV patients was found to be 6.6%
and 0.7%. Males (n=7) were more commonly infected than females (n=3) with the
age group of 31-40 years being the most common and majority were married (n=9).
In HBV-HIV co-infected, the mean values of S. Globulin, S. total bilirubin, Conjugated
bilirubin, Aspartate amino-transferase (AST), Alanine amino-transferase (ALT) and
alkaline Phosphatase are increased but in the only case of HCV-HIV co-infected
only haemoglobin (Hb) and platelet count were decreased. Majority (n=8) improved
on discharge.
Conclusions:
The sero-prevalence of HBV in HIV patients was high with laboratory test showing
a significant correlation between HBV-HIV co-infection and S.globulin and ALT.
Hence, awareness and understanding these diseases and providing screening test
in suspected individuals is the need of the hour which will improve the mortality
rates related to them.

Acinetobacter baumannii Outbreak in Adult Medical Intensive
Care Unit of a Tertiary Care Hospital
___________________________________________________________________________________________
Author : Dr. Jyoti Gokhale
Co-authors : Lt. Gen. (Dr) L. P. Sadhotra
Institution : Laboratory Medicine, Seven Hills Hospital, Mumbai.
Multidrug-resistant Acinetobacter baumannii is decidedly among the most difficult

antimicrobial-resistant gram-negative bacilli to control and treat. A. baumannii survives
for prolonged periods under a wide range of environmental conditions, and is known
to cause outbreaks of health care–associated infections. Antimicrobial resistance
greatly limits the therapeutic options for patients who are infected with this
organism, especially if isolates are resistant to the carbapenem class of antimicrobial
agents. Greater emphasis on the prevention of health care–associated transmission
of multidrug-resistant Acinetobacter infection is essential.
We experienced an outbreak in Adult Intensive Care Unit, in May 2017, with 5 cases
of Acinetobacter baumannii being isolated from samples of the 5 patients. All the
isolates were multi drug resistant, with resistance to carbapenems, and sensitive to
Colistin & Tigecycline only.
Objective:
1. To cohort the cases and verify and investigate the outbreak and take adequate
infection control measures to control the spread.
2. To trace the source of infection and mode of transmission, and identify the patients
at risk
3. To implement preventive measures to prevent recurrence.
Method:
Outbreak Management Team was formed, with Microbiologist leading the same.
Samples from environment, disinfectants, water and hands of health care workers were
processed to identify the possible source of infection. Control measures were taken
such as cohorting cases, contact isolation, and strict standard precautions, especially
hand hygiene, and environmental cleaning etc. The outbreak was investigated using
Epidemic curve, and tracing of source to various environmental sources.
Preventive measures were implemented to prevent the recurrence of outbreak.
Result:
We isolated A. baumannii from telephone receivers, one patient bed, one stethoscope,
suction machine, and hands of 2 staff nurses.
Conclusion:
We conclude that a rapid and thorough investigation of the environment during an
outbreak of A. baumannii is essential to tracing the source of the infection, and that
the hands of healthcare workers and certain environment surfaces may be a source of
such outbreaks.

Needle Stick Injury – Our Experience
___________________________________________________________________________________________
Author : Dr. J.Jayalakshmi

Co-authors : Dr. Marina Thomas, Dr. B. Appalaraju, Dr. Vimal Kumar Govindan
Institution : PSG Institute of Medical Sciences & Research , Coimbatore – 641004
Background:
Needle stick injuries (NSIs) are one of the commonest occupational hazards that
a health care worker (HCW) is exposed to in a hospital. About 40–75% of these injuries
are not reported. It’s important to assess the risk and educate all categories of health
care workers (HCWs) and also provide a safe working environment.
Objective:
To review the setting and reasons for sharp injury events among HCWs and also the
effectiveness of educational interventions.
Methodology:
This observational retrospective study was conducted at a tertiary care teaching
hospital following Institutional ethical committee’s approval. We analyzed the data
of all the HCWs who voluntarily reported injury by needle stick during the last 8 years
(2009-2016). Information regarding the type of injury, severity of the injury, work area of
occurrence ,activity that lead , source of injury , use of personal protective equipment
at the time , type of work the HCW does, hepatitis B vaccination status of the HCW and
the immediate post exposure measures .
Results:
About 257 NSIs were documented during the study period, with the highest
occurrence during 2014 ( 49) and least during 2016 (30) following a structured
educational intervention conducted during 2015 . NSI occurred more frequently at
the Emergency Medicine Department followed by OT and ICU. Doctors (39.2%)
encountered more injuries followed closely by Nurses (96) and others .Most (39.6%)
events occurred while handling biomedical waste.
Conclusion:
It’s important to identify breach in standard practices and conduct focused strategic
interventions and also bring accountability among HCWs to further reduce NSI .

Pharyngitis By Corynebacterium Pseudodiphtheriticum –
A Diagnostic Challenge In Diphtheria Endemic Area
___________________________________________________________________________________________
Author : Dr. Kalpana George
Co-authors : Dr. Sohanlal T, Dr. Geetha Raveendran
Institution : Government Medical College, Manjeri
Objective:
Corynebacterium pseudodiphtheriticum is a common commensal of upper respiratory
tract and rarely can be pathogenic. Here we present a case pf pharyngitis caused by
macrolide resistant strain of C.pseudodipheriticum.
Methods:
A nine-year-old fully immunized boy presented with fever, throat pain and
dysphagia. On examination the child was febrile, not toxic. Examination of throat
showed a white patch on right tonsils. Throat swab was collected and sent for
microbiological examination.
Results:
Gram’s smear showed pus cells with plenty of gram positive bacilli. On blood agar,
white opaque nonlytic colonies were seen. On Potassium Tellurite agar greyish black
colonies appeared. Gram’s stain of colonies showed cuneiform shaped Gram
positive bacteria. Granules were demonstrated in methylene blue preparation.
Patient was initiated on Erythromycin empirically as the area is endemic to
diphtheria. On antibiotic sensitivity testing the isolate was found to be sensitive to
Penicillin, Ampicillin, Vancomycin and Linezolid and resistant to Erythromycin,
Azithromycin and Clindamycin. Antibiotic was changed to Linezolid accordingly.
The isolate was identified as C.pseudodiphtheriticum by VITEK (bioMerieux). Presence
tox gene was ruled out by Polymerase chain reaction. The patient was well in five days.
Conclusion:
The patient was from a diphtheria endemic area. Currently an active outbreak is
going on in the area. Hence a presumptive diagnosis of diphtheria was made
and treatment was initiated. It is possible that signs and symptoms in our patient
was due to C.pseudodiphtheriticum. The patch may be due to an inflammatory
reaction. The isolate was resistant to macrolides. In places where diphtheria is endemic
the possibility of C.pseudodiphtheriticum causing illness similar to diphtheria poses a
diagnostic challenge.

Rare presentations of Burkholderia pseudomallei in
diabetic hosts
___________________________________________________________________________________________
Author : Dr. Kalpesh Sukhwani
Co-authors : Dr. P Senthur Nambi, Dr. SureshKumar Dr. Durairajan, Dr. Nitin Bansal,
Dr. Ram Gopalakrishnan
Institution : Apollo Hospitals, Chennai.
Introduction:
Most of the studies from India report visceral abscess or pneumonia as common
presentation of melioidosis [1, 2]. We hereby report three diabetics who had
melioidosis presenting as infective endocarditis, intraocular and parotid abscess.
Case 1:
This 60 year male from West Bengal, diabetic, presented with fever, cough and
significant weight loss for three weeks. Clinical examination was unremarkable and
investigations showed cavitatory pneumonia, multifocal liver and splenic abscess
(Fig 1) along with mediastinal and abdominal lymphadenopathy on CT. In view of
disseminated infection with liver and splenic abscesses possibility of infective
endocarditis was considered. Trans-esophageal echocardiogram showed vegetation
on mitral valve (Fig 2). Blood cultures grew B .pseudomallei (Fig 3). Intensive phase
(ceftazidime and cotrimoxazole) was given for 6 weeks and then cotrimoxazole was
continued for 6 months.
patient belongs to assam, he presented with fever, preauricular tender swelling,

headache and healing ulcer over dorsal aspect of right foot of 2 weeks following
water exposure while bathing in pond. MRI neck[image1] and brain with
contrast showed left parapharyngeal and parotid abscess with polymophoneuclear
Leucocytosis in blood and lymphocytic pleocytosis with high protein, normal sugar
and no bacterial growth on csf culture. Blood cultures and tissue cultured from parotid
gland deep lobe during surgical debridement grew B.pseudomallei. A final
diagnosis of B pseudomallei suppurative parotitis with parapharengeal abscess
was made. He steadily improved on ceftazidime and cotrimoxazole (intensive therapy)
along with therapeutic drainage of the abscess. He is currently continued on
cotrimoxazole as a part of eradication phase on scheduled for OP follow u patient
belongs to assam, he presented with fever, preauricular tender swelling,headache
and healing ulcer over dorsal aspect of right foot of 2 weeks following water
exposure while bathing in pond. MRI neck[image1] and brain with contrast showed
left parapharyngeal and parotid abscess with polymophoneuclear Leucocytosis
in blood and lymphocytic pleocytosis with high protein, normal sugar and no
bacterial growth on csf culture. Blood cultures and tissue cultured from parotid
gland deep lobe during surgical debridement grew B.pseudomallei. A final
cotrimoxazole as a part of eradication phase on scheduled for OP follow u
patient belongs to assam, he presented with fever, preauricular tender swelling,
headache and healing ulcer over dorsal aspect of right foot of 2 weeks following
water exposure while bathing in pond. MRI neck[image1] and brain with con-

trast showed left parapharyngeal and parotid abscess with polymophoneuclear
Leucocytosis in blood and lymphocytic pleocytosis with high protein, normal
sugar and no bacterial growth on csf culture. Blood cultures and tissue cultured from
parotid gland deep lobe during surgical debridement grew B.pseudomallei. A final
cotrimoxazole as a part of eradication phase on scheduled for OP follow u
Case 2:
This 46 male from Assam, diabetic, presented with fever, preauricular tender
swelling, headache and healing ulcer over dorsal aspect of right foot of 2 weeks
following water exposure while bathing in pond. MRI [Fig4] revealed left
parapharyngeal and parotid abscess. CSF showed lymphocytic pleocytosis with
high protein and normal sugar but did not grow organisms. Blood and pus culture
from deep lobe of parotid gland grew B. pseudomallei. He steadily improved on
ceftazidime and cotrimoxazole (intensive therapy – 4 weeks) along with therapeutic
drainage of the abscess followed by a maintenance therapy with cotimoxazole for
3 months
Case 3:
This 40 year old farmer from West Bengal presented with fever of 2 weeks and
right eye swelling of 1 week. He was newly detected to have diabetes during
evaluation of this illness. Clinical exam showed periorbital swelling with chemosis and
restricted eye movements in all directions and normally reacting pupils bilaterally (Fig 5).
MRI orbit revealed retro-orbital and peri-orbital micro-abscesses with cellulitis (Fig 6) and
blood culture grew B. pseudomallei. He was initiated on ceftazidime and cotrimoxazole
and then reffered to government hospital for debridement but was lost to follow up.
Discussion:
Although the exact prevalence in India is not known, melioidosis is being
increasingly recognised and reported in recent times [2-4]. Diabetes mellitus,
alcoholism, chronic lung disease and chronic renal disease are well recognised risk
factors [1]. The increasing prevalence of diabetes in the Indian population may be
contributing to the emergence of the disease.
The clinical spectrum of melioidosis is extremely diverse ranging from acute fulminant
septicaemia to chronic indolent infection [3,4]. It can also present with subcutaneous
abscesses and visceral abscesses involving the liver, spleen, prostate and lymph nodes
[6].
Cardiac involvement is rare. Pericarditis is the most common cardiac manifestation.

Heart valve involvement have very rarely been reported [7, 8]. Duration and prognosis
of B.pseudomallei endocarditis treatment is unknown. Our patient did not have any
known valvular disease and virulence of B pseudomallei to infect native healthy valve
is unknown. We treated our patient with 6 weeks of ceftazidime and cotrimoxazole
followed by 6 months of cotrimoxazole and he responded well to therapy.
Although B. Pseudomallei accounts of 40% cases of suppurative parotitis in Thailand,

this presentation is rarely seen in India [9]. Complications include abscess formation,

spontaneous rupture into the auditory canal, facial nerve palsy, septicemia and
osteomyelitis [10-11]. The overall prognosis for localized infection is good. Our
patient underwent thorough debridement of deep lobe of parotid gland with 4 weeks
of intensive phase therapy followed by maintenance with oral cotrimoxazole for
3 months.
Ocular melioidosis is rarely described in the literature and early diagnosis and
treatment of endophthalmitis caused by B. pseudomallei may prevent evisceration
of the eyes [12,13]. Intravitreal ceftazidime at an appropriate dosage may be
necessary for cases of B. pseudomallei endophthalmitis along with vitreal aspiration.
Our patient had retroorbital abscesses with periorbital cellulitis without endopthalmitis
and we gave him only IV therapy but unfortunately he was referred to other centre and
was lost to follow up. B pseudomallei should be considered in the etiologies for orbital
cellulitis syndrome, parotid abscess and rarely infective endocarditis especially in
patients from endemic areas with appropriate risk factors.
We conclude that melioidosis is an important consideration in diabetics who present

with focal pyogenic infections.
References:
Cheng AC, Currie BJ. Melioidosis: epidemiology,pathophysiology, and management.
ClinMicrobiol Rev2005;18:383-416
Clinical spectrum of melioidosis at a tertiary care hospital in South India

Malladi, S.V.S. et al. International Journal of Infectious Diseases , Volume 45 , 47
Melioidosis :
An Emerging Infection in India R Gopalakrishnan1 , D Sureshkumar2 , MA Thirunarayan
3, V Ramasubramanian1. Journal of the association of physicians of india • september
2013 • VOL. 61.
Anuradha K, Meena AK, Lakshmi V. Isolation of Burkholderia pseudomallei: an

emerging pathogen in India. Indian J Med Microbiol 1997;15:1-2
5.Saravu K, Vishwanath S, Kumar RS, et al Melioidosis a case series from south

India. Trans R Soc Trop MedHyg 2008;102:18-20.
Mansoor CA, Jemshad A, Meliodosis with endocarditis and massive cerebral infarct.
Ital J Med, doi:10.4081/ itjm.2015.589.
Piyasiri, L.B. et al., (2016). Endocarditis in melioidosis. Ceylon Medical Journal. 61(4),
pp.192–193
Stoesser N, Pocock J, Moore CE, et al. Pediatric suppurative parotitis in Cambodia

between 2007 and 2011. Pediatr Infect Dis J. 2012;31:865-868.
Lumbiganon P, Viengnondha S. Clinical manifestations of melioidosis in children.

Pediatr Infect Dis J 1995; 14: 136-140. 8. How SH, Liam CK. Melioidosis: A potentially life
threatening infection. Med J Malaysia 2006; 61: 386-394.
Dance DA, Davis TM, Wattanagoon Y, Chaowagul W, Saiphan P, Looareesuwan S,

et al. Acute suppurative parotitis caused by Pseudomonas pseudomallei in children. J

Infect Dis 1989; 159: 654-66
Yang, I. H., J. J. Lee, J. W. Liu, and M. C. Teng. 2006. Melioidosis with endophthalmitis.
Arch. Ophthalmol. 124:1501-1502.
Siripanthong, S., S. Teerapantuwat, W. Prugsanusak, Y. Suputtamongkol,

P. Viriyasithavat, W. Chaowagul, D. A. Dance, and N. J. White. 1991. Corneal
ulcer caused by Pseudomonas pseudomallei: report of three cases. Rev. Infect.
Dis. 13:335-337.
Figure 1:
Vegetation on Anterior leaflet of mitral valve (Left); Distinct ‘crinkled’ colonial
morphology of B. pseudomallei.

Clinical Profile of Clostridium Difficile Associated Diarrhea:
A study from Tertiary Care Centre of South India
___________________________________________________________________________________________
Author : Dr. Kalpesh Sukhwani
Co-authors : Dr. Anil Gopula, Dr. Nitin Bansal, Dr. Ram Gopalakrishnan
Institution : APOLLO HOSPITALS
Background:
Though Clostridium difficile infection (CDI) is a common cause of diarrhea in
hospitalized patients worldwide and is associated with significant morbidity and
mortality, it is uncommonly reported from Indian hospitals and the clinical profile of
Indian patients with CDI is not well studied.
Methods:
This was a retrospective study done in a 550 bedded tertiary care centre in South
India over a period of 1 year. Case records of all patients for whom stool samples
were sent for either C. difficile toxin assay or GeneXpert C. difficile were analysed.
Coloured immunoassay (CerTech) was used for detecting Glutamate dehydrogenase
(GDH) and Toxin A and B and nucleic acid amplification assay (Xpert, Cepheid) were
used. Choice of the test was left to clinician discretion.
Results:
A total of 98 samples were sent over the study period, out of which 13 (13.2%) were
positive for CDI (12 had positive toxin assay, 1 had positive GeneXpert).
Pseudomembrane colitis was seen in 3 of these positive cases. Positive cases were
taken as study group (n =13) and negative cases were taken as control group (n = 85).
There was no significant difference in age, gender, frequency and duration of diarrhea,
use of proton pump inhibitors, smoking, alcohol, recent surgery, co-morbid conditions,
presence of shock, total leucocyte count and creatinine in between the two study
groups. Presence of fever (OR = 10.8), tenesmus (OR = 7), hematochezia (OR = 6.7),
cramps (OR = 5.4), use of immunosuppressive agents (OR = 4) and duration of
antibiotics (5.61±2.10 vs 3.90±3.13 days) was significantly higher in study group. Out
of the 13 CDI positive cases, 2 were mild, 7 were moderate and 4 were severe.
Vancomycin was used in treatment of 7 cases, and metronidazole was used in 6 cases.
The mean duration of treatment was 8.46±1.80 days. All the patients improved and
none showed any complications.
Conclusion:
Although the prevalence of CDI is low in India compared to the west, it still
contributes to significant morbidity in hospitalized patients as it is responsible for
more than 1 in 8 cases of diarrhea in hospitalized patients. Fever, cramps, tenesmus,
hematochezia, use of immunosuppressants and antibiotic therapy of more than 5 days
suggest a diagnosis of CDI, and should trigger testing and treatment. Outcomes are
good with appropriate therapy.

Mucormycosis in the Immunocompetent – A Case Series
___________________________________________________________________________________________
Author : Dr. Kanishka Davda
Co-authors : Dr. Pratik Savaj, Dr. Rajeev Soman, Dr. Ayesha Sunavala,
Dr. Anjali Shetty, Dr. Camilla Rodrigues
Institution : P.D. Hinduja National Hospital and Medical Research Centre,
Mumbai, Maharashtra
Objectives:
Mucormycosis is a rare angio-invasive fungal infection, which is usually associated
with specific risk factors such as diabetes mellitus (especially diabetic ketoacidosis),
prolonged neutropenia, hematologic malignancies, trauma etc. However, a small
number of patients are also immunocompetent with no classical risk factors. We
decided to assess the epidemiology, clinical features, management and outcome
of these patients.
Methods:
A retrospective analysis was done of 5 patients with mucormycosis, who had no
apparent risk factors for it. The findings were -
Patients Epidemiologi- Route of Syndrome Management Outcome

cal factors inoculation
Patient 1, Chest wall Unknown Chest wall Debridement, Amb- Died
23/M Hematoma abscess + d, Posaconazole,
following renal mucor- caspo- fungin, de-
strenuous mycosis with ferasirox
exercise subsequent
dissemination
Patient 2, None of note Inhalation ROCM Debridement with Cured
37/M enucleution,
Amb-d,
Posaconazole,
Anidulafungin
Patient 3, None of note Per- Post- ap- Debridement, Cured
38/M cutaneous pendectomy Amb-d, deferasirox
abdominal
wall
Patient 4, 3/F None of note Unknown Isolated renal B/L nephrectomy, Cured
Amb-d, deferasirox
Patient 5, None of note Unknown GI mucor Amb-d, Posacon- Cured
52/M azole
Results:
Although mucormycosis has traditionally been associated with specific risk factors,
it should also be considered in the differential diagnosis of immunocompetent patients
with a compatible clinical syndrome. A variety of clinical syndromes were seen, which
makes diagnosis especially challenging in the immunocompetent host. We have used
deferasirox in some of these patients, with a satisfactory outcome. Although the sample
size is small, outcome has been reasonably good in this series, perhaps due to the
immunocompetent nature of the host.

When the ‘Xpert’ can misguide us
___________________________________________________________________________________________
Author : Dr. Kanishka Davda,
Co-authors : Dr. Pratik Savaj, Dr. Rajeev Soman, Dr. Ayesha Sunavala, Dr. Anjali Shetty,
Dr. Camilla Rodrigues
Department: Department of Internal Medicine and Infectious Diseases
Institute : P.D. Hinduja National Hospital and Medical Research Centre,
Mumbai, Maharashtra
Introduction:
The Xpert MTB/Rif is increasingly being used for the rapid diagnosis of TB and for
the simultaneous detection of Rifampicin resistance. Here, we describe a case with
discordance between the Xpert result and the phenotypic DST.
Case – A 28/F presented with fever, weight loss and night sweats for 1 year. She
also had backache (sacro-iliac region) with right leg tingling and numbness for
5 months following a minor fall on her back. MRI revealed enhancing intraosseus
abscesses and marrow edema in sacrum and right iliac bone, enhancing pre-sacral
abscesses and an enhancing abscess in right gluteus maximus muscle – s/o ?
tuberculous etiology. The abscess was drained. Pus showed – Xpert MTB-Detected,
Load-low, Rif resistance-detected. Samples were also sent for TB MGIT culture. Based
on the Xpert, she was started on 2nd line ATT. 1 month later, TB MGIT culture returned
positive and phenotypic DST showed pansusceptible TB. Hence, treatment was
changed to 1st line ATT. Rifampicin and Isoniazid levels were asked for which were
in the sub-therapeutic range. Hence, doses were increased to R – 900 mg/d, and
INH – 450 mg/d, and levofloxacin was started as an additional drug. A week later,
therapeutic levels were acheived and levofloxacin was discontinued. She is currently
doing well on 1st line ATT.
Xpert Phenotypic DST Explanation Solution

R S 1. Silent mutation 1. Pre-test probability of
2. Mutation conferring low MDR-Tb should be kept
level resistance in mind while interpret-
3. When Load – V low, there ing results.
can be instability of the 2. DST can help
probe to amplicon binding, 3. Sequencing study–
resulting in a false +ve Rif – R can pinpoint actual
result mutations.
Conclusion:
This case illustrates the importance of doing phenotypic DST which is currently the gold
standard, and also highlights an issue with the GeneXpert assay and proposes a
solution.

Outbreak Control of Multi Drug Resistant Acinetobacter
baumannii in ICU Settings.
___________________________________________________________________________________________
Author : Dr. Karan Ostwal
Co-authors : Dr. Nikalje. A
Institution : MIT Superspeciality Hospital
Objective:
Ventilator associated pneumonia (VAP) is a type of nosocomial pneu¬monia that
occurs more than 48–72 hours after endotrache¬al intubation and receiving
mechanical ventilation in ICU.1 A. baumannii is an opportunistic pathogen, frequently
involved in infection outbreaks, especially in the ICU. It is a common cause of sepsis,
pneumonia, and urinary tract infection following hospitalization of seriously
ill patients.1MDR/carbapenem-resistant A. baumannii is associated with treatment
challenges, emphasizing the importance of preventing and controlling the
dissemination of this strain outbreaks due to MDR/carbapenem-resistant A.
baumanii have been reported, mainly in ICUs, and treatment of these strains has
been considered a global problem.2
Methodology:
A total of 122 Endotracheal aspirates were collected during the period of
January-2016 to December -2016.Endotracheal aspirates were subjected to
liquification and homogenization by vortexing for 1 min with glass beads followed
by centrifuging at 3000 revolutions/min for 10 min. Inoculated on Blood & MacConkey
Agar and incubated aerobically at 37oC. Identification & Antibiotic susceptibility
testing was performed on Vitek-2 compact 30.
Result:
In this cross-sectional retrospective study we found decrease in the prevalence of
Acinetobacter baumannii after strict reinforcement of various infection control
protocols designed inhouse The prevalence of Acinetobacter baumanii was found
to be decreased from 40% (Jan-June -2016) to 11% (July-Dec-2016).
Conclusion:
Early case recognition, meticulous cohorting, reinforcement of strict housekeeping
protocols and active culture surveillance during an outbreak are the key components
in controlling the outbreaks.
Reference:
1. Gupta A, Agrawal A, Mehrotra S, Singh A, Malik S, Khanna A. Incidence, risk
stratification, antibiogram of pathogens isolated and clinical outcome of ventilator
associated pneumonia. Indian J Crit Care Med. 2011;15:96-101
2. Romanelli. R , Adriana. L, Clemente. W , Lima.S, Rezende.E ,Coutinho. R, Moreira.R,
et. al . Outbreak of Resistant Acinetobacter baumannii – Measures and Proposal
for Prevention and Control. The Brazilian Journal of Infectious Diseases 2009;13(5):
341-347

A Case Report of Polymicrobial endophthalmitis in tertiary care
hospital in Varanasi
___________________________________________________________________________________________
Author : Dr Ketan Priyadarshi
Co-authors : Dr M.K.Gupta, Prof Ragini Tilak , Dr A.Chandra
Institution : Institute of Medical Sciences, Banaras Hindu University, Varanasi,
Uttar Pradesh, India , Consultant ophthalmologist2
Introduction:
Endophthalmitis is a vision-threatening ocular complications, mostly following
intraocular surgeries (postoperative) and open-globe injuries (posttraumatic).
Gram-positive cocci were most common isolate including Staphylococcus
epidermidis, Staphylococcus aureus, Streptococcus pyogenes and Streptococcus
pneumoniae, followed by Gram-negative bacteria, anerobes and fungus (Candida
albicans and Aspergillus species).
Objectives:
To case report Polymicrobial endophthalmitis caused by Streptococcus pyogenes and
Staphylococcus aureus.
Methods:
7years female presented late with history of blunt trauma in right eye, with corneal tear
with iris prolapsed, undergone cornal tear repair with intra-vitreal antibiotics. Vitreous
humor was aspirated and sent for bacteriological and mycological screening.
Vitreous was cultured onto BHI blood agar, SDA and SDA with chloramphenicol
and incubated at 37oC and 28oC respectively. Also, Grams stain and 10% KOH mount
was prepared. Colonies on blood agar identified using grams stain, catalase test,
coagulase test, furazolidone (100µg), bacitracin (0.04U) and cotrimoxazole (25 µg) disc
sensitivity screening, CAMP test. AST was performed using CLSI guidelines
Results:
On grams stain of Vitreous, numerous pus cells (20- 30 /lpf) was seen with no
visualized micro-organism. KOH mount revealed no yeast cells or fungal elements.
Two types of colonies seen on blood agar. One identified as Staphylococcus
aureus was beta haemolytic, GPC in clusters, catalase positive, slide and tube
coagulase positive, furazolidone sensitive, and bacitracin resistant. Other colony
identified as Streptococcus pyogenes was beta-haemolytic, GPC in short chains,
catalase negative, bacitracin sensitive, cotrimoxazole resistant, CAMP negative.
Staphylococcus aureus was methicillin susceptible and to cotrimoxazole, vancomycin,
linezolid, netilimicin and gentamicin and resistant to erythromycin, clindamycin,
ciprofloxacin and moxifloxacin. Streptococcus pyogenes was susceptible to β-lactams
Conclusions:
The present case is of traumatic polymicrobial endophthalmitis. This indicates that
every such case should be promptly screened for infective etiology and AST performed
at the earliest to improve deteriorating visual prognosis.

Fungal Brain Abscess: 38 Year Study from Tertiary
Neuro-Care Center.
___________________________________________________________________________________________
Author : Dr. Kruthika P
Co-authors : Dr Nagarathana S, Dr Veenakumari , Dr Dwarakanath ,
Dr Rose Dawn Bharath, Dr Binu Kumar
Department : Department of Neuro- microbiology,
Institution : NIMHANS, Bangalore
Introduction: - Fungal brain abscess is a universal health problem with grave

outcome. Brain abscess forms approximately 8% of intracranial insult in developing
countries and 1-2 % in western countries. Majority of the times diagnosis of fungal brain
abscess is unexpected and done only after postmortem.
Objectives:
The following study was undertaken to study the spectrum of fungal isolates
causing brain abscess, demographic data of the affected patients and their
clinical presentation with advances over years in diagnostic and management
modalities.

A Retrospective study was conducted on culture proven fungal brain abscess
cases in the department of Neuro-microbiology, NIMHANS, Bangalore for 38 years
from the January 1979 to April 2017. Demographic data, clinical details and diagnosis
with management modalities were collected from the hospital medical record section.
Results:
35 culture proven fungal brain abscess were recovered from total of 2916 brain
abscess for 38 years duration, with the incidence rate of 1.2% per year. Fungal brain
abscess was seen in all age group of life. Male: Female ratio was 4:1. Neurotropic
Cladophialaphora bantiana was the predominant isolate 14(40%) with cryptic origin in
majority of cases, followed by local contiguous spread by Aspergillus spp in 11(31.4%)
cases and Rhizopus spp in 3(8.5%) cases with diabetes mellitus. Head ache, limb
weakness and fever were the most common presentation. 95 % of cases were treated
with Amphotericin. Craniotomy with Excision/ Decompression/ Aspiration (50%) was the
predominant surgical management. Outcome was fatal in 60%.
Conclusion:
Neurotropic Cladophialaphora bantiana remains to be the most notorious cause
for fungal brain abscess over 38 years with fatal outcome till date. High index of
suspicion with early diagnosis and appropriate intervention alone can result in
reduction of mortality and morbidity.

A Case of Katayama Fever (Acute Schistosomiasis)
___________________________________________________________________________________________
Author : Dr. Kuldeep Kumar Ashta
Co-author : Dr. Ravi Kumar
Institution : Military Hospital Kirkee pune
Introduction:
Acute schistosomiasis is an uncommon and rare complication of Schistosoma
hematobium infection.
Case Report:
25 year old army doctor on UN Mission in Sudan presented with history of high
grade fever with chills and rigors, dysuria, intermittent hematuria, dragging severe
right sided abdominal pain since 2 days. He gave history of similar symptoms since past
2 months.
On examination he had high fever, tacypnea, tachycardia and tender hepatomegaly

with tenderness over the right flank and epigastrium. He was managed with broad
spectrum antibiotics and anti-malarials. He had polymorphoneuclear leucocytosis,
deranged renal functions with hematuria, bacteuria and pyuria. His centrifuged
urinary sediments microscopically showed helminth eggs. He was put on tab
praziquental thereafter his clinical and laboratory parameters got normalized in 1 week
and he recovered fully.
Discussion:
Acute schistosomiasis mimics UTI and other febrile illnesses but requires high degree
of suspicion, specific diagnosis and management to avoid grave complications
especially in travelers to sub Saharan africa.
References:
1. Ross Allen GP, Bartley B Paul, Sleigh C Adrian, Olds Richard D, Li Yuesheng et al,
Schistosomiasis. New England Journal of Medicine 2002; 346:1212-1220.
2. Chitsulo L, Engels D, Montresor A, Savioli L. The global status of schistosomiasis and
its control. Acta Trop 2000; 77:41-51.
3. Adel AF Mahmoud, Harrisons Principles of Internal Medicine, 16 Edition, Mc Graw
Hill, 2005: 1266.
4. Agrawal MC, Rao VG, Vohra, S Bhondeley, Ukey MJ, et al, Is active schistosomiasis
present in India, Current Science 2007; 92: 889.
5. Doherty JF, Moody AH, Wright SG. Katayama fever: an acute manifestation of
schistosomiasis. BMJ 1996; 313:1071-1072.
6. Thomas H, Gonnert R. The efficacy of praziquantel against cestodes in animals.
Z Parasitenkd 1977; 52:117-127.

Evaluation of Procalcitonin & C- Reactive Protein as Diagnostic
Markers of Bacterial Infection with Clinical Correlation at
a Tertiary Cancer Care Hospital
___________________________________________________________________________________________
Author : Dr. Kumar Vivek
Co-authors : Dr. Vinod N. K, Dr. Jyothi, ICN, Dr. Chandini Roy, Dr. Srinath B.S.
Institution : Sri Shankara Cancer Hospital & Research Centre.
Introduction:
In India, one of the biggest challenges in the health care today is increasing number
of patients affected with cancer, and infection is most important lethal aspect. Earlier
detection and treatment play important role in this. Presentation of sepsis is atypical
compare to non-malignant patients, so we need the specific fast detection method
with good sensitivity & specificity. Many biomarkers are there in which procalcitonin
(PCT) & C-reactive protein (CRP) are most commonly used one. In resource limited
setting it is difficult to do both methods so we need specific, who give the answer in
cancerous patients.
Objectives:
Comparative study of procalcitonin and CRP in SIRS, sepsis & severe sepsis/septic shock
condition with their clinical correlation in malignant patients
Methodology:
Retrospective data collected from June 2016 to April 2017. All PCT & CRP tests were
correlated with clinical data. Multiple approach used for justifying the case as SIRS,
sepsis & severe sepsis/septic shock and followed till final patients outcome to
standardised the above categorisation.
Results:
Total 233 patients were studied
Microbiology culture Microbiology culture

positive negative
Total patients 115 118
Patients with SIRS - 27
Patients with sepsis 78 61
Patients with severe sepsis/septic shock 43 34
PCT performed 114 123
PCT correlate with clinical condition 72 88
CRP performed 102 114
CRP correlate with clinical condition 74 90
PCT & CRP performed together 60 75
Inter-correlated PCT & CRP value 36 44
irrespective of clinical conditions
correlation
No. of sepsis incidence when PCT 98 71
performed

Correlation of PCT value with sepsis 57 42
incidence
No. of sepsis incidence when CRP 84 64
performed
Correlation of CRP value with sepsis 63 51
incidence
No. of septic shock incidence when 52 46
PCT performed
Correlation of PCT value with septic 26 29
shock incidence
No. of septic shock incidence when 55 41
CRP performed
Correlation of CRP value with septic 42 33
shock incidence
SIRS Condition Clinically correlated Clinically non-correlated

PCT 21 1
CRP 12 5
PCT & CRP 8 4
Conclusion:
Our results showed CRP as a valuable marker of bacterial infections especially in
malignancy. Incidence of SIRS are small in my study, so final conclusion of good
sensitivity and specificity of procalcitonin in SIRS need further evaluation. More
prospective and large scale studies are warranted to confirm these findings.

How Effective is Infection-Control in the Orthopedic Units?
___________________________________________________________________________________________
Author : Dr. Latha T
Co-authors : Dr. Anil K Bhat, Dr. Manjunatha M Hande Dr. Chiranjay Mukhyopadhyay,
Dr. Anice George, Dr. Baby S Nayak, Dr. Elsa Sanatombi Devi
Institution : Manipal University
Objective:
The objective of the study was to assess the infection-control measures followed in the
orthopedic units of a tertiary care hospital, South India.
Methodology:
In this cross-sectional descriptive survey, the infection-control measures followed in the
orthopedic units of a tertiary care, teaching, super-specialty hospital of South India was
observed through participatory method. A total 200 observation was made among
doctors, nurses, technicians and physiotherapists using observational checklist. Ethical
permission was obtained.
Result:
The observation revealed that hand-wash after performing the procedure (69.4%)
was double than before the procedure (33.9%). More than 90% the HCPs have
washed their hands, but, many of them did not follow all the steps of hand-wash.
Majority of the subjects were using gloves (78.3%) and discarding it properly (76.7%).
Personal factors; wearing clean cloth (97.8%), personal hygiene including hair and
body cleanliness (98.9%), clean and trimmed fingernails (88.8%) were found to be
good. HCPs followed proper infection-control measures during the procedure (wound
care – 92.9%, dressing change – 97.7% and other procedures – 74.6%). Personal
protective clothing were available and accessible. The infection-control policy
and protocol was accessible to all the HCPs. Though screening of HCP while hiring is
not a routine procedure, they are screened when required. Specimen collection
procedure, waste management and teaching of infection-control measures were
well maintained.
Conclusion:
The HCPs of orthopedic unit were following adequate infection-control measures
except for hand-wash. Hand-wash is considered as one of the very important
intervention in preventing infection. Therefore, different intervention such as education,
surveillance, CC TV observation, frequent feedback or reinforcement can be
implemented to improve the compliance of hand-wash.

Risk Factors For Development Of Carbapenem Resistant
Enterobacterobacteriaceae
___________________________________________________________________________________________
Author : Dr. Lavu Rohit Reddy
Co-authors : Dr.Muralidhar Varma
Institution : Kasturba hospital Manipal
Aim:
To find out the risk factors for development of carbapenem resistance among
enterobacteriaceae
Material & methods:

This study is prospective observational Case Control study in patients more than
18 years admitted at Kasturba Hospital, Manipal from June 2015 to august 2016.
Patients with blood cultures isolating CRE are cases and those with carbapenem-
sensitive Enterobacteriaceae (CSE) were defined as controls. The case to control
ratio was taken as 1:2 after gender and age matching .Statistical analysis done using
SPSS15.0.
Results:
In 30 patients with CRE, the isolates were E. coli (50.0%) K. pneumoniae (46.7%), and
Enterobacter cloacae complex (3.3 %).Among the 60 controls , isolates were Klebsiella
pneumoniae (38.3%), E. coli (53.3%) and Enterobacter cloacae (3.3%). Logistic
regression analysis showed prior hospitalization (OR: 0.610; 95% CI: 0.169 -2.683)
antibiotics exposure (OR: 0.138; 95% CI: 0.029-0.652),invasive devices- urinary catheter
(OR: 0.560; 95% CI: 0.137-2.290), central venous lines (OR: 0.135; 95% CI: 0.048-0.378),
presence of endotracheal tube (OR: 0 .058; 95% CI: 0. .009-0. 376) were not found to
have significant association with CRE compared to CSE group .Other factors not found
to be significant are T 2 DM, Cirrhosis, CKD, RVD, and prior major surgery. But the
mortality rates were higher in CRE compared to CSE groups.
Conclusion:
CRE infections were associated with higher mortality rates and poorer clinical
response rates: Except for prior ICU stay, none of the risk factor studied were associated
with more chance of CRE acquisition than CSE. Hence the ICU patients need to be
monitored for CRE acquisition.
Risk factors analysed CR(%) N=30 CS(%) N=60 P value

Diabetes mellitus 9(30%) 29(48.3%) 0.07
Hepatic disease 8(26.7) 13(21.7) 0.606
Renal disease 5(16.7) 9(15) 0.531
HIV 2(6.7) 1(1.7) 0.257
Presence of central lines 16(53.3) 8(13.3) <0.01
Urinary catheter 25(83.3) 21(35) <0.01
Mechanical Ventilation 15(50) 2(3.3) <0.01
Previous ICU stay 20(66.7) 6(10) <0.05

Previous hospitalization 18(60) 19(31.7) <0.01
Organism isolated

Two Unusual Ocular Parasites
___________________________________________________________________________________________
Author : Dr. Madhavi Deshmukh
Co-authors : Dr. Shailendra Mundhada
Institution : Dhruv Labs
Case 1:
Seventeen year old male patient presented with cellulitis and mass in the eye.
This he noticed about 3 months back. It was about 1 cm in size and was situated
at the limbus. All pre-operative routine investigations were normal. Surgical
exploration revealed a sub-conjunctival cystic mass about 1 cm in diameter. It was near
the lateral rectus muscle. This was excised. Gross pathological examination revealed
a thin walled cystic mass. There was hard nodule in the center. Microscopy revealed
a wall of cysticercosis. Scolex was also seen. Surrounding tissue revealed numerous
acute and chronic inflammatory cells. The case was confirmed by CDC, Atlanta, and
was also included it in their departmental presentation as an interesting case.
Taenia solium or pork tapeworm is causative parasite for Cysticercosis cellulosae.

Humans are the intermediate host in the life cycle of Taenia solium. The parasite
may be encysted in various body tissues, central nervous system and subcutaneous
tissue. It may also produce severe inflammatory reaction. Ocular cysticercosis is a rare
condition. It may be extraocular (in the sub-conjunctival or orbital tissues) or intraocular
(in the vitreous, sub-re¬tinal space or anterior chamber).
Case 2:
Sixty year old lady presented in ophthalmic OPD with the complaints of itching
over fore head and right eye since 5 days. She was prescribed steroid eye drops
and anti allergic tablets. The itching aggravated with eye drops along with watering
and foreign body sensation. On revisit the ophthalmologist noticed a worm in the right
upper sub-conjunctival space. The worm was carefully removed in-toto and sent to
laboratory for identification. The worm was thin, cylindrical, 7-8 cm long, white in colour.
After microscopic and gross examination of the worm, it was identified as Dirofilaria spp.
CDC (Atlanta) confirmed the diagnosis of Dirofilaria. The patient was treated with anti
allergic medication and was relieved of symptoms without recurrence.

Colistin Resistance in Gram Negative Bacilli in Blood Cultures
___________________________________________________________________________________________
Author : Dr. Madhura R Bharati
Co-authors : Dr. Baijayanti Mishra
Institution:
St. John’s Medical College & Hospital Bangalore 560034
Objectives:
This study was done to map the Colistin resistance pattern in multi-drug resistant
Gram negative bacilli (GNB) isolated from blood cultures, the patient profile and their
treatment outcomes in a tertiary health care centre.
Methods:
A retrospective study was done at St. John’s Medical College & Hospital,
Bangalore from December 2016 to May 2017. We have looked at the profile of the
GNB that were isolated from automated blood cultures in patients suspected to have
bloodstream infection (BSI). The identification of the isolate and the antibiogram were
studied, to look at the nature and number of Colistin resistant isolates which was then
correlated with the patient profile and the treatment outcome.
Results:
A total of 51 multidrug resistant GNB isolates were obtained in the study period. Of
those, 6 (11.6%) patients who were admitted in the Intensive Care Unit grew isolates
that were resistant to both Meropenem and Colistin. Out of 6, 4 were identified to be
Klebsiella pneumoniae subspecies pneumoniae; other 2 were identified as Providencia
stuartii and Burkholderia cepacia. The patients were started on empirical antibiotics
which included Meropenem and Colistin before culture and susceptibility pattern
reports could be obtained; but succumbed to their illness due to overwhelming sepsis.
Conclusions:
Colistin is often used as a last resort antibiotic for managing severe infections with
Gram negative bacilli. However, there is an alarming increase in Colistin resistance
being reported, especially from South-east Asia and the Indian subcontinent. This
may have a severe impact on the outcome of critically ill patients and may warrant
a revaluation of antimicrobial practices and the rationale for empirical therapy.
Keywords:
Colistin resistance, MDR GNB, Blood culture, Septicaemia

Sero-prevalence and genotype distribution of
Hepatitis B infection
___________________________________________________________________________________________
Author : Dr. Madhuri Kulkarni
Co-Author : Dr Deepak Kumar
Institution : JSS Medical College, Mysore
Objective:
To determine the seroprevalence, risk factors and genotype distribution of Hepatitis B
infection in patients attending JSS Hospital during study period
Method:
HBs Ag was detected by chemi-luminisence immunoassay(Abott) in all serum
samples submitted to the Microbiology Laboratory for a period of one year ( Jan – Dec
2016). These included samples from suspected cases of Hepatitis, pre-operative and
antenatal subjects. Risk factors were elucidated by detailed clinical history. HbeAg,
Ati HBs IgM and IgG were detected by ELISA in all HBsAg positive samples. ALT/AST
and serum bilirubin were estimated. HBsAg positive samples were subjected to DNA
extraction and initial PCR for S gene detection (Purefast viral nucleic and minispin prep
kit, HELINI.)130 S gene positive samples were subjected to Real time PCR (HELINI) to
determine the genotypes.
Results:
Of the 4648 serum samples tested 284 were positive for HBsAg (6.1%) 96 patients
were asymptomatic( 33.8% ) 60 had acute viral hepatitis (21.1%) and 32 cases(11.6%)
had clinical picture subservient with chronic hepatitis. Blood transfusion, dialysis
followed by exposure to surgical procedure were the major risk factors.
The most predominant genotype was C (66/130) followed by genotype G (29/130)

Genotype D was associated with 22 cases H with 7 and A with 3 samples. One each of
Genotype G and F were also detected.
30 Patients of Genotype C were diagnosed as acute viral hepatitis while the rest
were asymptomatic. 3 patients with genotype A had very high levels of ALT and HBeAg
was Positive.20 cases of Genotype G were asymptomatic and the rest were acute viral
hepatitis. Of 22 cases of Genotype D 10 were asymptomatic 10 had acute hepatitis
and 2 were of chronic hepatitis.
Conclusion:
Intermediate sero-positivity prevails for Hepatitis B infection with Genotypes C, G and
D being detected in most of the cases. Few cases of Genotype A had severe
hepatitis. Blood transfusion and surgical exposure were the predominant risk factors,
while a significant number of patients had asymptomatic infection.

A case report of NTM skull bone osteomyelitis.
___________________________________________________________________________________________
Author : Dr. Maheshkumar M Lakhe
Co-author : Dr. Rajeev N Soman, Dr. Bharat D Purandare, Dr. Avinas KM
Institution : Infectious Diseases and Infection Control Pune, India
52yr old female MS, had hypertension related intracranial hemorrhage. She
underwent de-compressive craniotomy at a multispecialty hospital in the city. A part
of skull bone removed and was preserved in the hospital refrigerator. After three
months, she underwent surgery and the bony flap was replaced. She did well for
next 5-6 weeks, later she started having headache and boggy swelling over the
scalp at the operated region. She took a short course of antibiotics Cefuroxime
and Itraconazole orally for 10 days. The swelling and headache persisted. She got
hospitalized and underwent a MRI brain which was s/o old changes of craniotomy
and ICH, no meningeal enhancement and nonspecific edema under the scalp.
The CSF showed total cell count of 112(L86%), normal Protein and glucose, CSF Gr and
ZN stain Neg, India Ink-Neg, Culture negative. Patient has been re-operated and the
scalp was excised and yellow cheesy semisolid material came out . The skull bone flap
came out easily and had a “moth eaten’ appearance as described by the surgeon.
The bone piece was sent for cultures and histopathology. The histopath examination
showed nonspecific inflammation. The Gram stain and ZN stain were negative. The
MycoFlytic culture of the bone grew Mycobacterium fortuitum at the end of one
week. Patient underwent thorough debridement of the wound, she has been treated
with Inj Amikacin I/M with Tab Linezolid 600mg 1 OD and Tab Moxifloxacin 400mg 1
OD for 1 month, later Tab Linezolid and Tab Moxifloxacin were continued for 4 months.
Patient did well and underwent mesh cranioplasty after 4 months of therapy.

Invasive candidiasis: Beware of the opportunist!!
___________________________________________________________________________________________
Author : Dr. Manali Agarwal
Co-authors : Dr. Vandana K E, Dr. Muralidhar Varma, Dr. Chiranjay Mukhopadhyay
Institution : Kasturba Medical College, Manipal
Objective:
Candidemia is the most frequently encountered invasive fungal infection (IFI) in
hospitalized patients, ranking fourth as a cause of nosocomial bloodstream
infection. Present study was carried out to determine the most common Candida
species causing bloodstream infection among patients admitted to a tertiary care
hospital and to study the common antifungal susceptibility patterns among different
Candida species isolated from patients suffering from candidemia.
Method:
A retrospective study was conducted at a tertiary care hospital in South India, in
which 94 bloodstream isolates were included from August 2015 to February 2017.
The most common Candida species were determined and their susceptibility patterns
were studied.
Results:
Most common Candida species identified was C. tropicalis (38/94; 40.4%) followed
by C. albicans (18/94; 19.14%). Median time to positivity was 31.33 (18.80 – 44.60)
hours. Time to positivity more than 24 hours was most commonly seen in C. albicans
(18/94) followed by C. parapsilosis (15/94) and less than 24 hours was most commonly
seen with C. tropicalis (33/94).
8 isolates were found resistant to flucytosine, out of which 7 were C. tropicalis . C.
haemulonii had intermediate susceptibility to amphotericin B.
Conclusion:
The current study witnessed an increase in non albicans Candida species, which
is alarming due to increased resistance reported worldwide from the non albicans
group, hence it emphasizes the need for speciation and antifungal susceptibility of
yeast isolates from blood stream infections.

Role of Multiplex Molecular Technique in the Early
Management of Acute Bacterial and Viral Meningoencephalitis
Cases in a Tertiary Care Hospital
___________________________________________________________________________________________
Author : Dr. Manasvee Dewan
Co-authors : Dr. Navin Kumar, Dr. Sharmila Sengupta
Institution : Medanta-The Medicity
Objective:
To determine the effectiveness of Multiplex Polymerase Chain Reaction (PCR) in
optimising antimicrobial treatment in patients diagnosed with acute bacterial/viral
meningoenceohalitis.

This is a prospective, single centre, observational study for a year (Feb2016-Jan2017).
Adult patients admitted with provisional diagnosis of acute meningitis were included
in the study. The cerebrospinal fluid (CSF) samples were sent for multiplex PCR, aerobic
culture, staining and biochemical analysis. Multiplex PCR panel includes S.pneumoniae,
H.influenza, Listeria monocytogenes, N.meningitidis, Enterovirus, Herpes simplex virus-1,
Herpes Simplex Virus-2, Varicella zoster, Parechovirus. The identification and sensitivity
was done using VITEK 2 (bioMe’rieux) and Multiplex PCR. The patients were followed up
for outcome and stay in the hospital.
Result:
A total of 102 patients were included in the study. The results of multiplex PCR for all
patients were reported on the same day of sample collection, aerobic culture
results were available 48 hours to 72 hours after inoculation. 10 patients out of 102 were
positive for viral causes and they were switched to antiviral treatment from empirical
therapy on the same day of admission. Likewise, antiviral drugs were withheld in 7
multiplex PCR positive cases of bacterial meningitis. These patients with PCR positive
meningoencephalitis had shorter hospital stay than the patients with negative results
(4 days vs. 8.5 days)
Conclusion:
Acute meningitis is a medical emergency; immediate treatment and early diagnosis
leads to favourable outcome. Though multiplex PCR is an expensive technique than
culture but in long-term it proves to be more cost-effective in terms of patient care for:
• Early diagnosis
• Institution of specific treatment and reducing days of empirical therapy
• Reduces length of hospital stay.

Clinical Pattern of Cryptococcal meningitis from patients at
a tertiary care super speciality institute in Northern India.
___________________________________________________________________________________________
Author : Dr. Manodeep Sen
Co-authors : Dr. Pushpa Yadav, Dr. Anupam Das, Dr. A.K.Singh ,
Dr. Pradeep Kumar maurya, Dr. H.S. Malhotra, Dr. K.P. Malhotra,
Dr. Gaurav Raj Agarwal
Institution : Dr. Ram Manohar Lohia Institute of Medical Sciences
Introduction:
Cryptococal meningitis is a life- threatening, opportunistic fungal infection of worldwide
distribution, including India, especially in the HIV positive population.
Objective:
To determine the clinical pattern and the antifungal susceptibility of Cryptococcal
meningitis patients admitted at Dr. Ram Manohar Lohia Institute of Medical Sciences &
associated hospitals and King George’s Medical University, Lucknow.
Method:
CSF from all cases of Cryptococcal meningitis were tested for positive India ink,
Cryptococcal Antigen Latex Agglutination test, followed by fungal culture and Urease
Biochemical test. For Pathological examination, CSF cell count, Biochemical Analysis
and corresponding blood sugar level were recorded.
These isolates were further subjected to an automated yeast identification and

susceptibility system- VITEK TM (Biomerieux, India) and observe antifungal sensitivity
pattern based on Clinical and Laboratory Standards Institute (CLSI) guidelines.
Result:
In two years of study, there were 14 cases of Cryptococcal meningitis including 5
cases with HIV co-infection. The most common in all fourteen patients complaint was
fever and headache. All 14 isolates were identified as Cryptococcus neoformans; out
of which 13 were sensitive to Amphotericin B and Fluconazole, while in remaining one
isolate- both antifungal agents were found to have intermediate susceptibility.
Conclusion:
In present study, headache and fever were the commonest manifestation. Antifungal
testing is more helpful to document the emergence of resistance.

Institutional Outbreak of Varicella in a Child Welfare Institute in
Chandigarh, North INDIA.
___________________________________________________________________________________________
Author : Dr. Mini P Singh
Co-authors : Dr. Tripti Rungta, Dr. Archit Kumar, Dr. Kapil Goyal, Dr. Bhavneet Bharti,
Dr. RK Ratho
Department : Virology and Social Pediatrics
Institution : Post Graduate Institute of Medical Education and Research
Objective:
Varicella is a highly contagious disease that presents with fever and exanthematous
rash. The disease can spread rapidly in closed communities as varicella has a
secondary attack rate of more than 85%. The conventional diagnosis relies on the
detection of specific IgM antibodies which develop only after 5 days of infection.
Hence, this method may not be suitable for early diagnosis which is required for early
initiation of control measures. The present study aimed to investigate a VZV outbreak
which occurred in a child welfare institution in Chandigarh in the month of June, 2016.
Also the suitability of alternative samples to blood for diagnosis was assessed.
Method:
An active surveillance of the affected area identified 15 clinically suspected cases.
The blood samples from these children were tested for VZV IgM antibodies by
commercial ELISA kit. The vesicular swab, urine and saliva samples from the patients
with active lesions were tested for VZV DNA by conventional PCR and Real Time PCR.
Result:
The outbreak affected male children in the age group of 8-13 years. VZV IgM
antibodies could be detected only in 3 (20%) children who had fever duration of more
than 5 days. The PCR in vesicular swab, saliva and urine had positivity of 100% (14/14),
69.2% (9/13) and 66.6% (10/15) respectively. The positivity by real time PCR was 100%
(14/14) in swab, 84% (11/13) in saliva and 80% (12/15) in urine. The mean viral load in
vesicular swab samples was 177539.7copies/µl, in saliva samples was 4751.4copies/µl
and in urine samples was 3036.6copies/µl. All these patients had an illness of less than 5
days.
Conclusion:
Real Time PCR using alternative samples was found to be more sensitive than serology
and conventional PCR and it can be used for early diagnosis of an outbreak.

ICU Acquired Multi-Drug Resistant Bacteremia Due to
Burkholderia, Chryseobacterium and Sphingobacterium
___________________________________________________________________________________________
Author : Dr. Mohan Gurjar
Co-authors : Dr. Sai Saran, Dr. Syed Nabeel Muzaffar, Dr. Arvind Kumar Baronia
Department : Department of Critical Care Medicine
Institution : Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS),
Lucknow (UP), India
Objective:
To review clinical characteristics and antimicrobial susceptibility for rare Gram-negative
bacteremia, acquired in critically ill patients.
Method:
Medical records of ICU patients, having rare Gram-negative bacteremia, were
reviewed (July 2016 – April 2017).
Result: Case 1:
25-y-m, no co-morbidities, with diagnosis of dengue fever and pneumonia, admitted
to our ICU, after five days of illness due to septic shock and ARDS. Antibiotics given:
meropenem and teicoplanin. Tracheal aspirates: MRSA + and blood cultures:
Burkholderia cepacia. Trimethoprim-sulphmethaxozole was added on 5th day of ICU
stay. Fever, shock and ARDS improved over next 48 hours and he was discharged later
on.
Case 2:
79-y-m, h/o uncontrolled diabetes (HbA1c 8.2) and hypertension, admitted to ICU
with diagnosis of severe community acquired pneumonia, septic shock and acute
kidney injury (10th day of illness). Antibiotics given: meropenem and azithromycin.
Later (5thday of ICU) developed VAP (Klebsiella pneumoniae), treated with polymyxin
and carbapenam. Had persistent shock; blood culture: Chrysobacterium indologenes.
Trimethoprim-sulmethaxozole added, clinical condition improved (2nd week of ICU
stay). In due course (3rd week ICU), condition rapidly worsened due to MDR Klebsiella
bacteremia and succumbed to his illness.
Case 3:
45-y-m, h/o uncontrolled diabetes (HbA1c: 9), with diagnosis of right leg cellulitis,
septic shock, encephalopathy, status post-cardiac arrest. Antibiotics given:
clindamycin and amoxicillin/ clavulanate. During further course, Klebsiella bacteremia,
treated with polymyxin and carbapenam. On 20th day of ICU stay, blood cultures:
Sphingobacterium multivorum. Levofloxacin was added, with clinical improvement.
He was discharged in minimally conscious state with tracheostomy tube after 1 month
of ICU stay.
Conclusion:
Burkholderia, Chrysobacterium and Sphingobacterium spp. are aerobic,
gram-negative catalase positive, non-lactose fermenting bacilli usually reported as
opportunistic pathogens, mainly in immunocomprised and sometimes in
immunocompetent critically ill patients. All three bacteria are intrinsically resistant to

carbapenams. Identification and appropriate anti-microbial therapy is cornerstone for
treating these rare bacteria.
Table 1: Anti-microbial susceptibility for rare Gram-negative bacteria
Bacteria Sensitive (MIC) Resistant (MIC)

Case 1 Burkholderia Levofloxacin (2) Amikacin (>32)
cepacia Trimethoprim- Aztreonam (>16)
sulfamethoxazole (0.5) Ceftazidime (>16)
Cefoperazone–sulbactam
(>8)
Meropenem (>8)
Case 2 Chrysobacterium Tetracycline (8) Amikacin (>32)
indologenes Ciprofloxacin (1) Ceftazidime (>16)
Trimethoprim- Gentamicin (>8)
suphamethaxozole (0.5) Imipenam,Meropenam (>8)
Cefoperazone-sulbactum
(>16/8)
Case 3 Sphingobacterim Piperacillin-tazobactam Imipenem (>8)
multivorum (4/4) Levofloxacin (<0.5) Meropenam (>8)
Ceftazidime (>16)
Aztreonam (>16)
Amikacin (>32)

Splenic Abscess Caused by Salmonella typhi and
Co-infection with Leptospira
___________________________________________________________________________________________
Author : Dr. Monalisa Sahu
Co-authors : Dr. Arvind Kumar, Dr.Neeraj Nischal, Dr.Bharath BG Dr. Naveet Wig
Department : Medicine
Institution : All India Institute of Medical Sciences, New Delhi
Splenic abscesses caused by Salmonella typhi are a very rare complication of

typhoid fever in this era of use of specific antibiotics. Co-infection with Leptospira in
such a patient is even rarer. Splenic abscesses are potentially fatal complication
of typhoid fever. In most of these patients, hemoglobinopathies or some other
underlying immunocompromising state is usually present. We report a case of splenic
abscess, caused by Salmonella typhi, and co-infection with Leptospira in a previously
healthy young male.
A 19 year old male was admitted to the emergency of our hospital with history of
fever with chills and rigor, and jaundice for 15 days and pain abdomen in the left
upper quadrant and left shoulder pain for 7 days. He had a history of splenic abscess,
drained by pigtail catheter and managed conservatively 5 years back. The patient was
apparently well during the intervening 5 years.
At admission, his hematological profile was Hb 11, TLC 28,500, DLC: N91, L07, E01, B01
and E01. His total bilirubin was 10.7mg%. Widal test was positive in titre 1:320 For
S.typhi O and H antigen.
Ultrasonography showed a 12.8 cm sized spleen with upper and mid-pole splenic
abscess with no adjacent splenic parenchyma. Xray chest moderate pleural effusion
on the right side. An ultrasound guided aspiration of the splenic abscess was done. The
aspirated material was positive for Salmonella typhi on culture.
A blood culture and stool culture was done which were negative for Salmonella.
Leptospira IgM antibody ELISA was positive in the patient, which could explain the
high grade jaundice in the patient.
He was managed with cefoperazone-sulbactam , ceftriaxone and linezolid, but

splenectomy could not be avoided as there was high suspicion of splenic rupture
into the pleural cavity.
No predisposing factors were found in our case. No hemoglobinopathies were

detected, the immunodeficiency workup was negative and the screening tests for HIV,
HBsAg and Anti-HCV were negative.
In the era of several new emerging infections, we should not miss the newer
presentations of the older diseases.

Unravelling the Polymicrobial Diversity of Foot Ulcer Infections
via Next Generation Sequencing
___________________________________________________________________________________________
Author : Murali T S1
Co-Authors : Jnana A1, Satish N1, Varghese VK2, Ramya V1, Chakrabarty S2,
and Satyamoorthy K2
1
Department of Biotechnology, School of Life Sciences, Manipal University, Manipal -
576104, India
2
Department of Cell and Molecular Biology, School of Life Sciences, Manipal University,
Manipal - 576104, India
Objectives:
Non-healing foot ulcers are a common complication of diabetes exacerbated by
microbial colonization. Current treatment employs an empirical approach that involves
administration of antibiotics based on clinical presentation and microbiological testing.
With increasing speed and decreasing cost of DNA sequencing technologies, we can
now develop better alternatives to the classical treatment strategies. In the current
study, we performed a rigorous analysis of the different grades of wound guided by the
associated clinical data and information on antibiotic resistance using next generation
sequencing approach. This can help build rapid, specific point of care devices that will
aid in development of specific antibiotic regimens to prevent multidrug resistance and
promote wound healing.
Methods:
Foot ulcer samples from 130 individuals were analysed using culture dependent
and culture independent (16SrDNA metagenomics using Ion Torrent platform)
methods. The major bacterial species were selected for a literature search to retrieve
a list of the resistance genes in them in the last 5 years.
Results:
Majority of the wound isolates were aerobic Gram-negative bacteria (Phylum
Proteobacteria). With sequencing, we obtained 49 million reads with an average
of 391,188 reads per library. A total of 237 genera were classified and the dominant
phyla were Proteobacteria and Firmicutes. 82 unique genes encoding resistance to 15
antibiotics were recorded and shortlisted for presumptive testing.
Conclusion:
Wound microbiomes show high degree of interindividual variability. Beta diversity
analyses across all wound samples with grouping criteria of Wagner grade and
disease status did not show clear clustering. Isolates obtained from culture-based
approach were also found in NGS analysis in more than 70% of samples. Genes
coding for antibiotic resistance shared >90% identity across different bacterial
genera implying that global markers can be developed to capture antibiotic resistance
from environmental samples.

HYPERCALCEMIA – Rare Aderverse Effect of TENOFOVIR ??
___________________________________________________________________________________________
Author : Dr. Navneet Kumar Agrawal
Co-authors : Dr. Rudra Prasad Sahu, Dr. Sandesh M Raykar, Dr. Saswata Saha,
Siddharth Jain, Dr. Aman Chaudhary, Dr. Chandan Kumar,
Prof.Jaya Chakravarty, Prof.Shyam Sundar.
Institution : Institute of Medical Science, Banaras Hindu University.
Objectives:
To make attention on rare adverse event (Hypercalcemia) of Tenofovir, most frequently
used antiretroviral drug, not reported till now.
Methods and Observations:

We have six patients, developed renal dysfunction with hypercalcemia after starting
Tenofovir based ART.
Case 1- 32/F, on ATT for pulmonary kochs for 20 days presented with fever, headache
and decreased responsiveness (E1V1M2) for 10 days.
Case 2- 45/M, presented with fever, dry cough and breathlessness for 10 days.
Case 3- 50/M, presented with fever ,cough for 2 months, diarrhea for 3 days and
altered sensorium (E4V3M4) for last 1 day.
Case 4- 28/M, presented with pain abdomen and vomiting for 5 days with mild
tachycardia, tachypnea and GCS of E1V1M4.
Case 5- 40/M, icteric, on ATT for pulmonary kochs for 15 days presented with Pain
abdomen, nausea & vomiting, yellowish discoloration of eye and urine, for last 5 days.
Case 6- 27/M, presented with of acute onset sensory motor LMN type quadriparesis
(ATM) .
Case Tenofovir Presentation TLC S.cr/ Na/K S.Ca/ iCa TP/Alb SGOT/PT TB/DB
urea Po4
1 6/6/16 24/6/16 9000 2.4/109 135/4 - 1.6 6/1.1 132/54 5.9/2.5
2 4/1/16 24/2/16 14100 7.8/220 135/5.4 11/6.9 1.72 9.5/3.1 224/214 .4/.1
3 13/7/15 8/4/16 12210 5.5/167 153/7 12.1/9.7 _ 7.2/2.5 61/67 .7/.2
4 27/12/16 4/1/17 10700 9.1/233 139/6.5 11.3 1.42 6.1/2.7 83/35 5.2/3.2
5 20/12/16 16/1/17 10700 2.4/95 129/5.3 11/5.4 1.45 6.8/1.8 56/26 6.6/5
6 2/12/16 14/3/17 5510 2.6/108 136/4.6 12.4/4.6 - - 24/27 .2/.1
Results:
All Patients showed improvement in hypercalcemia and renal dysfunction after
stopping Tenofovir and other conservative management.One patient required
hemodialysis. Two patients died , one was due to aspiration pneumonitis and other
due to multi-organ failure. One patient discontinue the treatment and rest improved.
Conclusion:
Tenofovir induced hypercalcemia is an unrecognized adverse event requiring
close monitoring and further studies to confirm causality and to evaluate
pathophysiology .

Etiological Diagnosis of Microbial Keratitis in Lucknow, U.P
___________________________________________________________________________________________
Author : Dr Nazia Khan
Co-authors : Dr. Gopa Banerjee, Dr. Prashant Gupta, Dr. Poonam Kishore,
Dr. Arun Sharma.
Institution : King George’s Medical University, Lucknow (U.P.)
Introduction:
Microbial keratitis is a potentially sight threatening inflammation that can be
caused by bacteria, virus, fungus or parasite. Incidence of corneal ulcers vary
from country to country and from region to region within a country. Untreated
infections may lead to endophthalmitis, blindness and even perforation. Thus prompt
identification and appropriate management is required to save the eye.
Objective:
To identify the causative agents of microbial keratitis in a tertiary care centre , Lucknow.
Methods:
The study was performed between August 2016 to April 2017. 120 corneal scrapings
were done under strict aseptic precautions using Bard parker blade. Gram Stain, KOH
mount and culture on Blood Agar (BA) and Sabouraud’s Dextrose Agar (SDA) were
done. BA plate and SDA plate were incubated for 48 hours and 4 weeks respectively
and any relevant growth was subsequently processed.
Results:
Out of 120 corneal scrapes, 42 were culture positive (29 fungus and 13 bacterial).
Aspergillus spp and Coagulase Negative Staphylococcus spp were the commonest
fungal and bacterial isolates respectively.
Conclusion:
1. Fungal isolates were more common than bacterial isolates in our setup.
2. Knowledge of local disease trend is more important to start the empirical treatment.
3. Rapid progression of disease and virulent nature of causative organisms demand
early identification and immediate treatment to prevent blindness.

Ferritin in Dengue: A Stranger in a Trial (Boon or Goon?)
___________________________________________________________________________________________
Author : Dr. Nazneen Nahar Begam
Co-authors : Dr. Sukanta Debnath, Dr. Bikram Das, Dr. Mehebubar Rahman,
Dr. Rama Prosad Goswami
Objective:
Considering recent change in clinical manifestations of dengue and large number of
patients at risk of infection and complications in India, we tried to identify the factors,
ferritin in particular, in dengue virus infection.
Methods:
Single centre observational study conducted at School of Tropical Medicine,
Kolkata, India from July to October 2016 prospectively. All admitted patients with
proven dengue (ELISA for NS1 and/or IgM for dengue virus - reactive) were included
and clinico-epidemiological, haematological and biochemical profiles were analysed.
Serum ferritin was estimated in 65 dengue and 78 non-dengue short fever cases.
Results:
110 patients with dengue (mean age 26 ± 14 years, duration of fever 5.5 ± 2.2 days)
were admitted with Hb 12.2 ± 2.21 gm/dL; TLC 5339 ± 2618 and platelet 116963 ±76302
(/μL); PCV 37.3 ±7.1; AST 229.8 ± 360.6 and ALT 127.1 ± 169 IU/L. High serum ferritin was
observed in 69.2% (>500 μg/L) and 55.4% (>1000 μg/L).
Following complications were observed: pleural effusion 31.8%, ascites 20%,

hepatomegaly 41.8%, ALT>100 in 32.7%, AST>100 in 50.9%,bleeding manifestation 20.9%,
platelet count <50,000 in 50%, persistent hypotension needing volume expansion 20.9%
and need for critical care unit (CCU) admission in 16.4%. Patients with dengue fever
had significantly higher serum ferritin compared to other fevers (2602 ± 3269 vs193 ± 189,
respectively, p<0.001). In ROC analysis best cut off of ferritin distinguishing dengue from
non-dengue cases was 674 (sensitivity 67.7%, specificity 100%, AUC 0.9 (0.85 – 0.96)).
Ferritin > 1000 was associated with the following dengue-related complications:
pleural effusion (OR: 4.9, 95% CI: 1.7 – 14.6, p=0.004), ascites (OR: 7.7, 95% CI: 1.9 – 30.3,
p=0.003), platelet count <50,000 (OR: 2.8, 95% CI: 1.03 – 7.8, p=0.04) and transaminitis
(OR: 5.6, 95% CI: 1.9 – 16.5, p=0.002).
Conclusion:
Serum ferritin level may be used as both diagnostic and prognostic marker in dengue
infection.

Reverse Antibiotics: Treating antibacterial Resistance –
A Challenge
___________________________________________________________________________________________
Author : Dr. Neeraj Kumar
Co-author : Dr. Marc Benson
Institution : Medical University of the Americas, Nevis, St Kitts & Nevis, WI.
Objective:
Antibiotic resistance, designated at crisis levels in 2016 by United Nations, has
become an escalating problem to global public health and a grave challenge for
health care industries. There is a compelling need to develop novel strategies that aim
to make traditional antibacterial treatments efficacious. One such novel approach is
the development of reverse antibiotics, which act to restore the sensitivities of multidrug
resistant bacteria to traditional antibiotics.
Methods:
A comprehensive literature search was conducted in the PubMed database using
the search terms: reverse antibiotics, drug resistance, nybomycin, Mycobacterium
tuberculosis. The analysis was based on many relevant primary sources.
Results:
Our search revealed three major mechanisms of potential reverse antibiotic
therapies, all in the beginning stages of design: 1) the inhibition of the antibiotic
resistance protein, 2) activation of a redundant wild type antibiotic-activation
pathway, and 3) phage-mediated genetic engineering. Under the first category, the
Staphylococcus aureus fluoroquinolone-resistance mutant gene, gyrA, was
preferentially inhibited by the reverse antibiotic nybomycin and resulted in a
strong bactericidal activity against fluoroquinolone-resistant S. aureus strains.
Interestingly, exposure to nybomycin promoted genetic revertants back to wild type
gyrA, enabling the use of traditional antibiotic therapy to eliminate bacterial survival.
The second mechanism includes the Small Molecule Aborting Resistance molecule,
SMARt-420, which activates a redundant bioactivation pathway of the ethionamide
antibiotic, enabling the bioactive ethionamide to act on the bacteria. The third
mechanism is the phage-mediated delivery of dominant sensitive genes directly to
the pathogen. By reverting the rpsL and gyrA genes to wild type states using this
technology, streptomycin and nalidixic acid sensitivity was conferred to a drug
resistant M. tuberculosis strain.
Conclusion:
Though these experiments are far from clinical trials, they embody promising
strategies and a step toward solving the major threat of drug-resistant pathogens.
If proven to be successful, reverse antibiotics would make it possible to treat a wide
array of bacterial infections.

Early Detection of CRE colonization: how does it impact
antimicrobial treatment?
___________________________________________________________________________________________
Author : Dr. Neetu Biyani
Co-authors : Dr. Rupashree Patkar, Dr. Shashikala shivaprakash
Institution : Sir H. N. Reliance foundation Hospital
Objective:
Multi drug resistant organisms pose difficulties in management of individual patients
and are responsible for outbreaks. This study is conducted to prevent such outbreaks
by screening and surveillance of high risk patients and also by enforcing strict isolation
and transmission precautions.
Method:
Patients from outside hospitals, H/o prior Carbapenem use in last 6 months, H/o broad
spectrum antibiotic use and hospitalization in last 6 months were screened for CRE
colonization. Rectal swab received on admission. Rectal swabs processed according
to CDC guideline for CRE screening in Microbiology Laboratory.
Results:
Total 152 samples received for CRE (Carbapenem Resistant enterobacteriacae)
screening from 1st April 2016 to 31st march 2017. 27.63 % (n=42) were positive for CRE
colonization. Out of 42, 50 % (n= 21) patients developed infections from different
bacteria. Organism name and their meropenem sensitivity is listed below:
Sr No Organism isolated No of organism No of No of organism Meropenem

isolated Organism Meropenem resistance (%)
Meropenem Resistant
sensitive
1 Klebsiella pneumonae 11 2 9 81
2 E.coli 4 2 2 50
3 Acinetobacter baumannii 2 - 2 100
4 Pseudomonas aeruginosa 6 - 6 100
All organisms were colistin sensitive except one Klebsiella pneumoniae and one
Acinetobacter baumannii. These 2 colistin resistant organisms were sensitive to
Tetracyclin, minocycline and tigecyclin.
Conclusion:
If patient with CRE colonization develop infection, there is a high chances of
Carbapenem resistance. Only available options for Carbapenem resistant
organism are amikacin, colistin, minocycline and tigecyclin. In current situation, there
is high requirement of definitive decolonization protocol for colonized patient. A good
infection control practices and antibiotic stewardship program in hospital can help very
much in decreasing CRE colonization rate.

Role of Real time PCR in diagnosis of Hepatitis E in Lucknow
___________________________________________________________________________________________
Author : Dr. Nidhi Bhatnagar
Co-authors : Dr. Amita Jain, Dr. Vimala Venkatesh, Dr. D. Himanshu
Institution : King George's Medical University, Lucknow
Introduction :
Hepatitis E is a significant public health problem causing large outbreaks of acute
hepatitis. It can be diagnosed by demonstration of anti HEV IgM antibodies in the serum
by ELISA or by detection of viral genomic RNA in the serum or feces by PCR.
Objective :
To study the diagnostic value of Real time PCR in detection of Hepatitis E at a tertiary
care centre in Lucknow.
Method:
Serum samples were collected from patients suspected of acute viral hepatitis
attending OPD and wards of medicine department of King George Medical
university, Lucknow from april 2016 to april 2017 and ELISAs were performed for anti
HEV IgM, anti HAV IgM, HBsAg and anti HCV antibodies. 177 samples which were anti
HEV IgM positive and 31 samples which were negative for all hepatotropic viruses (and
of unknown etiology) were further tested for HEV RNA by real time PCR.
Results :
• Out of 177 anti HEV IgM positive samples, 57 were positive and 120 were negative
for HEV RNA in real time PCR.
• Out of 31 samples which were negative for all hepatotropic viruses, 3 were
positive and 28 were negative for HEV RNA.
Conclusion:
Real time PCR can be used as an effective tool for the diagnosis of acute viral
hepatitis of unknown etiology with negative serological markers for all hepatotropic
viruses.

“Antimicrobial Susceptibility Surveillance of Intensive Care
Associated Infections at Kanpur (UP)”
___________________________________________________________________________________________
Author : Dr. Nidhi Pal
Co-authors : Dr. R. Sujatha
Institution : Rama Medical College Hospital And Reserach Center, Kanpur (UP)
Objectives:
Health care associated infections are considered as complications of patient care
in the hospital, especially in ICU. This study was planned to rule out the microbiology
and sensitivity pattern of health care associated infections.

This multicenter prospective study was conducted from October 2015 to February
2017. Total 200 cases were observed for health care associated infection along
with clinical and microbiological correlation. Antimicrobial susceptibility testing
was performed by Kirby-Bauer disk diffusion methods. Enzymatic resistance
mechanisms were confirmed by according to CLSI guideline 2016.
Results:
Of 200 cases, total 315 samples were collected. Total 121 strains
(colonizer/pathogen) were isolated. There were 19.5% cases suffered from VAP
and most frequent isolates were Acinetobacter baumannii (33.3%), followed by
K.pneumoniae (23.1%), P.aeruginosa (20.5%), K.oxytoca(7.7%), E.coli (5.1%) etc.
Rate of CA-UTI were 18.5% due to E.coli (44%), followed by Candida species (24%),
Citrobacter species (8%), K.pneumoniae, K.oxytoca, A.baumannii, P.aeruginosa,
and Enterococcus species (4% for each). Nine cases (9 out of 52, 17.3%) were
affected from blood stream infection and A.baumannii was most common
isolate(55.6%) followed by P.auroginosa, K.pneumonia, K.oxytoca, C.tropicalis
(11.1% for each). Five cases of SSIs were observed with pathogenic strain E.coli (60%)
followed by A.baumannii, P.aeruginosa (20% each). All the isolated strains were
multidrug resistant (MDR). More than 75% of strains were extreme drug
resistant(XDR). 67.8% (82 out of 121) were ESBLs producers and 79.3% were MBLs
producers. blaIMP-1, blaVIM-2, and blaNDM-1 gene were found to be the cause
of carbapenem resistance in A.baumannii.
Conclusion:
This study showed that health care associated infections are prevalent in Kanpur.
These infections can be controlled with the appropriate measures and antibiotic policy
taken by the hospital personnel, by proper hand washing and awareness of infection
control measures.

A Novel Case Of Hiv/Aids Cholangiopathy Secondary
to Infection With Toxoplasma Gondii And Isospora Belli
___________________________________________________________________________________________
Author : Dr. Nikhil Kenny Thomas
Co-authors : Dr. Basavaprabhu Achappa
Institution : KMC Mangalore
Objectives:
To report a case of HIV cholangiopathy secondary to coinfection with Toxoplasma
gondii and Isospora belli.
Methods:
A 57-year-old gentleman presented to the medical unit since one month with
right upper quadrant abdominal pain, anorexia, weight loss, diarrhoea and
vomiting. He is a case of HIV on ART. On examination, tenderness is present in the
right upper quadrant and his oral mucosa showed oral candidiasis. Blood tests
showed normochromic anaemia with leucopoenia and LFT. USG abdomen showed
a dilated common bile duct and intrahepatic biliary radicles. ERCP showed a
stenosed sphincter of Oddi and stricture of the distal CBD. A sphinterotomy and stricture
dilatation performed, brushing done were sent for culture and a biliary stent left in-situ.
Results:
Brushing done showed Toxoplasma gondii and Isospora . These organisms were
previously reported to cause granulomatous hepatitis and acalculous cholecystitis
respectively. However, were not previously associated with HIV cholangiopathy. To
our knowledge, this is the first reported case of HIV cholangiopathy secondary to
coinfection with Toxoplasma gondii and Isospora belli.
Conclusion:
Biliary disorders in HIV patients can arise from three broad pathological
mechanisms: Non-HIV associated (e.g. stone, benign stricture, neoplasm, ascarasis),
Acalculous cholecystitis and HIV cholangiopathy. Typically, HIV cholangiopathy arises
following Cryptosporidium parvum or CMV infection, (80% of cases).

Leading Bacterial Pathogens causing Infective Keratitis and
their Antimicrobial Susceptibility in a Tertiary Care Eye Centre
from North India
___________________________________________________________________________________________
Author : Dr. Nishat Hussain Ahmed
Co-authors : Dr. Gita Satpathy, Dr. Jeewan S. Dr. Titiyal, Dr. Radhika Tandon,
Dr. Namrata Sharma.
Institution : All India Institute of Medical Sciences, New Delhi
Objective:
Bacterial keratitis is a potentially sight-threatening ocular emergency due to the
often rapid progression with threat of corneal perforation and visual loss. Pending
the reports of bacterial culture and antimicrobial susceptibility, empirical
antimicrobials are started, the preference of which can be made evidence based
with understanding of recent local epidemiological pattern of pathogens and
their susceptibility profile. In the present study, bacterial pathogens causing infective
keratitis and their antimicrobial susceptibility profiles were retrospectively studied.
Methods:
Records of corneal scraping samples from clinically suspected cases of bacterial
keratitis from July 2015 to December 2016 in a tertiary care eye centre were
retrospectively analyzed. In the study duration of 18 months, a total of 3046
corneal scraping specimens were processed by standard bacteriological procedures.
Demographic and clinical details of the patients, pathogenic bacteria isolated and
their antimicrobial susceptibility were noted and analyzed.
Results:
Bacterial pathogens were identified in 841 (27.6%) out of 3046 specimens. The
most common isolates were coagulase negative Staphylococci (532, 63.3% of
841), followed by Pseudomonas (130, 15.5%), Gram negative bacilli of family
Enterobacteriaceae (72, 8.6%) Staphylococcus aureus (69, 8.2%), and
Streptococcus species (17, 2%). More than 50% of Staphylococcus and 66% of
Pseudomonas isolates were resistant to moxifloxacin, which is the most commonly
prescribed empirical antibiotic in bacterial keratitis. In addition, 66% and 22% of
Pseudomonas isolates were resistant to ceftazidime and polymixin-B. On the
other hand, most of the bacterial isolates were susceptible to now less
prescribed gentamycin and tobramycin.
Conclusion:
The study has thrown light on the current trend of the bacterial pathogens
causing infective keratitis. Staphylococci and Pseudomonas were found to be the most
common pathogens. Increased resistance was seen against some of the commonly
prescribed empirical antibiotics. Such evidence is useful for restructuring the empirical
prescription practices from time to time.

Experience with Beta-D-Glucan for Diagnosis of Pneumocystis
jirovecii Pneumonia: Pilot Study from India
___________________________________________________________________________________________
Author : Dr. Nitin Bansal
Co-author : Dr. Nandini Sethuraman, Dr. Ram Gopalakrishnan
Indtitution : Apollo Hospitals Chennai.
Background:
Establishing a diagnosis of Pneumocystis jirovecii pneumonia (PCP) requires
identification of this pathogen in respiratory tract samples requiring
bronchoscopy which may not be available or possible in every patient with clinical
suspicion of PCP. Beta-D-Glucan (BDG) has emerged as an attractive non-invasive
marker for diagnosis of PCP but has not been studied in India.
Methods:
This was a retrospective observational study done in a tertiary centre in south India
over a period of 6 months. Patients who had compatible clinical and radiological
picture and who responded to specific PCP therapy were included for analysis.
Choice of respiratory tract sample for identification of the fungal pathogen was left
to clinician's discretion. Patients having evidence of other invasive fungal infections
were excluded from the study. FDA approved Fungitell assay was used to measure BDG
levels (pg/mL).
Results:
Total 7 patients (3 HIV, 2 post renal transplant, 1 Lymphoma and 1 SLE) fulfilled the
clinical and radiological criteria for probable PCP, while only in 1 out of 7 had evidence
of PCP in BAL fluid [Table 1]. Mean BDG was 472.0 ± 51.12 pg/mL, which was much
higher than the manufacturer suggested cut off of 80pg/mL. Factors which can cause
false elevation of BDG (eg: beta-lactam antibiotics, immunoglobulin or albumin
infusion, surgical mesh) were not present in any of these patients. Oral thrush was
seen in only 2 patients. Conclusion: BDG with appropriate cut-off can be used as
a non- invasive diagnostic test for PCP in patients with compatible clinical and
radiological picture.
S Clinical Details HRCT Viral Load/ Immuno Serum PCP Serum Response
No chest CD4 count in suppression LDH (U/L) stain* β-D- to PCP
finding HIV positive from Spu- Glucan** therapy
patient tum or (pg/mL)
BAL fluid
1 37y/M Diffuse NA Tacrolimus 325 Cysts of 523 Improved
Fever, dys- ground 4mg, PCP seen
pnea, dry glass MMF (BAL fluid)
cough for 3 opacity 1000mg,
weeks in both Predniso-
Spo2 on R/A – lungs lone 10mg
88% (Post Renal
Transplant)
2 58y/M Diffuse 69000copies/ NA 415 Nega- 455 Improved

Dyspnea fever ground mL; 52cells/ tive on
for 4 weeks glass µL sputum
Spo2 on RA – opacity sample
78% in both
lungs

3 17y/F Diffuse NA Methotrex- 600 Nega- 523 Improved
Fever,cough ground ate mer- tive on
&dyspnea for glass captopurine sputum
1 week opacity (T Cell Lym- sample
Spo2 on RA- in both phoma)
90% lungs
4 65y/M Diffuse 200000cop- NA 412 Nega- 402 Improved

Fever, cough ground ies/mL; tive on
and dyspnea glass 102cells/µL sputum
for 14 days opacity sample
in both
lungs
5 43y/M Diffuse 160000cop- NA 515 Nega- 455 Improved
Dyspnea fever ground ies/mL; tive on
for 3 weeks glass 52cells/µL sputum
Spo2 on RA – opacity sample
87% in both
lungs
6 30y/M Diffuse NA Tacrolimus 425 Nega- 423 Improved
Fever, dys- ground 4mg, tive on
pnea, dry glass MMF 1g, sputum
cough for 5 opacity Predniso- sample
days in both lone 10mg
Spo2 on R/A – lungs (Post Renal
88% Transplant)
7 21y/M Diffuse NA Predniso- 510 Negative 523 Improved

Fever,cough ground lone 50mg on ET se-
&dyspnea for glass (SLE) cretions
1 week opacity
Spo2 on RA- in both
90% lungs
*Direct Immunofluorescence
**Values greater than the upper limit of detection of undiluted samples of 523pg/ml
were taken as 523 for statistical analyses.

Breakthrough Saprochaete capitata Infections among Patients
with Hematological Malignancies
___________________________________________________________________________________________
Author : Dr. Nitin Bansal
Co-authors : Dr. Abdul Ghafur K, Dr. Vidya Devarajan, Dr. Balavinodh R, Dr. Pratik Patil
Institution : Apollo Speciality Hospital, Chennai
Introduction:
Saprochaete capitata (formerly known as Geotrichum capitatum and
Blastoschizomyces capitatus) is a fungus found in soil, water, air, plants and dairy
products [1]. It is a rare opportunistic pathogen causing serious infections in patients
with hematological maligancies [2]. Till now only single case report exist from India in
a renal transplant recipient [3]. We hereby, report two cases of invasive Saprochaete
capitata infection in onco-haematological settings.
Case 1:
This 29 year old female was diagnosed as having Acute Myeloid Leukemia
(AML- M2) during her last trimester of pregnancy. Immediately after delivery, she
was given cytarabine and daunorubicin based induction chemotherapy, after
which she developed neutropenic sepsis with carbapenem resistant Klebsiella
pneumonia bacteremia for which she received colistin and fosfomycin therapy.
She also received micafungin as mold prophylaxis. Despite these measures, she
continued to remain in septic shock, although repeat blood cultures showed
clearance of bacteremia after 72 hrs of antibiotics. Her CT showed dilated bowel
loops with features of bowel perforation for which she underwent explorative
laparatomy and end ileostomy was done. She showed some features of improvement
in septic parameters. She again deteriorated after 3 days requiring inotrope support
and she was started on liposomal amphotericin B as her blood culture showed
yeast which was later identified as S. capitata with MIC of caspofungin > 16mg/L,
amphotericin B 2mg/L, 5-Flucytosine 0.06mg/L, fluconazole 8mg/L and voriconazole
0.25mg/L. However, her repeat culture showed clearance of S. capitata after 96 hours
of amphotericin B but she continued to deteriorate and succumbed to her illness with
refractory pulmonary hemorrhage as her immediate cause of death.
Case 2:
This 60 year old lady with multiple myeloma, presented with progressive disease in
form of bilateral pleural effusion and vertebral lesions. She reveived bortezomib,
dexamethasone and cyclophosphamide based chemotherapy. In course of this illness
she developed candidemia (C. glabarata) for which she was started on caspofungin.
After 5 days of treatment of candidemia, she had fever with hypotension and
worsening pleural effusion (required intercostal tube drainage). Blood cultures sent
during this episode showed S. capitata with similar antifungal MICs as in Case 1.
She was started on liposomal amphotericin B but she continued to remain sick and
later succumbed to her illness.

Discussion:
S. capitata is an emerging cause of invasive and disseminated infections, especially in
immune compromised haematological patients, although it has also being reported
from solid organ transplant recipients [4]. Risk factors for invasive S. Capitata infections
are prolonged neutropenia, aggressive chemotherapy, the use of broad spectrum
antibiotics and the alteration of local defenses by breakdown of skin and mucosa [5].
The most common underlying hematological malignancy is acute myeloid leukemia
[1]. The 30 day mortality reported in earlier case series was in the range of 60% to 100%,
however in a recently published 6 year survelliance study of 47 patients mortality rate
of 39% was reported [1,2,6]. In the largest published case series so far of 104 cases,
median age was 56 years, 56% were males, and half of them had acute myeloid
leukemia, 22% had acute lymphoid leukemia, and 22% had other malignancies
with mortality rate of 60% [7]. The clinical features of invasive infection with S.
Capitata frequently resemble those of invasive candidiasis. Ulu-Kilic A et al.
reported that median duration of neutropenia was 21.5 days in patients with S.
capitata fungaemia, whereas in patients with candidemia it was 8 days. Previous
use of caspofungin was significantly more common in patients with S. capitata
highlighting that breakthrough on echinocandin is a important feature of this
organism [6]. In vitro susceptibilities determined by the clinical laboratory
standards institute (CLSI) methods indicate that S. capitata is highly susceptible to
amphotericin B, itraconazole and voriconazole. Most of the studies suggest that
echinocandins have limited activity against S. capitata. Although Franchi et al.
reported successful treatment of S. capitata pneumonia in a leukemia patient
with voriconazole and caspofungin in-vitro correlation with treatment outcomes
with echinocandins is not established [8]. Due lack of evidence and rare nature of this
organism, optimal antifungal therapy is not clear.
Both of our cases were on echinocandins when S. capitata breakthrough

happened. Neutropenia was present in 1st case with AML, where as 2nd case of
myeloma was on aggresive chemotherapy at the time of breakthrough infections.
Our in-vitro susceptibilites showed high caspofungin MIC which is in conjunction with
cases reported worldwide. Overall mortality rate is very high in S. capitata infections
likely due to lack of awareness, sick nature of the patients in which it happens and
unclear therapeutic measures.
Conclusion:
Our cases show that S. capitata infections should be kept in mind especially in
patients with hematological malignancies on echinocandin prophylaxis or therapy.
Referrences
1. Girmenia C, Pagano L, Martino B, et al . Invasive infections caused by
Trichosporon species and Geotrichum capitatum in patients with hematological
malignancies: a retrospective multicenter study from Italy and review of the
literature. J Clin Microbiol 2005; 43 : 1818 – 1828.
2. Schuermans C, van Bergen M, Coorevits L, Verhaegen J, Lagrou K, Surmont

I,Jeurissen A. Breakthrough Saprochaete capitata infections in patients receiving
echinocandins: case report and review of the literature. Med Mycol. 2011
May;49(4):414-8.
3. Mandarapu S, Krishna V, Raju S B, Pamidimukkala U, Nimmagadda S. Saprochaete
capitata fungal infection in renal transplant recipient. Indian J Nephrol 2016;
26:464-6.
4. Savioni V, Catavitello C, Balbinot A, et al . Multidrug-resistant Geotrichum
capitatum from a haematology ward. Mycoses 2010.
5. Ersoz G, Otag F, Erturan Z, et al . An outbreak of Dipodascus capitatus infection
in the ICU: three case reports and review of the literature. Jpn J Infect Dis 2004; 57 :
24 8– 252.
6. Ulu-Kilic A, Atalay MA, Metan G, Cevahir F, Koç N, Eser B, Çetin M, Kaynar L, Alp E.
Saprochaete capitata as an emerging fungus among patients with haematological
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7. Mazzocato S, Marchionni E, Fothergill AW, Sutton DA, Staffolani S, Gesuita R, et al.
Epidemiology and outcome of systemic infections due to Saprochaete capitata:
Case report and review of the literature. Infection 2015;43:211-5.
8. Fianchi L, Montini L, Caira M, et al . Combined voriconazole plus caspofungin
therapy for the treatment of probable Geotrichum pneumonia in a leukemia
patient. Infection 2008; 36 :65 – 67.

Bug wars: the story of a long standing fight between bones
and bugs.
___________________________________________________________________________________________
Author : Dr. Nitin Gupta
Co-authors : Dr. Nitin Gupta, Dr. Sayantan Banerjee, Dr. Timitrov, Dr. Rohini Sharma,
Dr. Shambo Guha Roy, Dr. Trupti M Shende, Dr. Mohammed Tahir Ansari,
Dr. Gagandeep Singh, Dr. Neeraj Nischal, Dr. Naveet Wig,
Dr. Manish Soneja
Institution : All India Institute of Medical Sciences New Delhi.
A 26-year-old male patient presented with features suggestive of osteomyelitis

involving the entire left femur, hip joint and knee joint. Culture from the debrided
tissue grew Acinetobacter spp. and he was treated with sensitivity based antibiotics
but symptoms did not resolve. The synovial biopsy showed multinucleated giant
cells and acid fast bacilli on Ziehl Neelsen stain. Cartridge based nucleic acid
amplification test (GeneXpert) was negative. The Mycobacteria growth indicator
tube culture was found to be positive for Mycobacterium abscessus. The patient
was started on imipenem, amikacin and macrolide based therapy. There was
partial response initially but the patient worsened again. A girdle stone arthroplasty
with cemented nail (with tobramycin) insertion after debridement of the infected tissue
was done. KOH from the debridement sample was found to be positive for aseptate
hyphae suggestive of mucormycosis. He was treated with liposomal amphotericin B.
He was evaluated for immunodeficiency in view of multiple atypical infections and was
found to have low CD4 count. The patient was discharged on amikacin, azithromycin,
trimethoprim-sulfamethoxazole and posaconazole. Follow up showed considerable
resolution both clinically and radiologically. To our knowledge, this is the first reported
case of osteomyelitis with co-infection of Acinetobacter spp., M.abscessus and
mucormycetes. We report this case to highlight the possibility of multiple rare infections
in patients with immunodeficiency. Also, atypical complicated bone infections, such as
Mycobacterium abscessus and Mucormycetes might require combined medical and
surgical treatment.
Figure 1: Serial FDG PET scan showing evidence of osteomyelitis in June 2016(1A), partial
resolution in October, 2016 (1B) and near complete resolution in April 2017 (1C)

Morbidity and Mortality in Dengue fever patients treated with
Doxycycline.
___________________________________________________________________________________________
Author : Dr. Noopur Kedare
Co-authors : Dr. S Bhaskar, Dr. S. Prasad
Institution : St. Philomena’s Hospital, Bangalore.
Introduction:
dengue fever is a mosquito borne disease prevalent in India(1). Doxycycline is a
tetracycline derivative inhibits dengue viral plaque formation by disrupting the
conformational changes in the viral envelope.
Aims and Objective:

To study the effect of doxycycline on the morbidity and mortality of dengue fever
in hospitalized patients.

• Study area & population- patients hospitalized with positive IgM or NS1 dengue
test
• Sample size= N=60 [doxycycline treated patients (n1=30) and symptomatically
treated patients (n2=30).]
• statistical tool- Unpaired “t” test
• Parameters - temperature, BP, PCV & platelet count, on Day 0 and Day 5 of
treatment, duration of hospital stay & overall morbidity.
Result:
Mean parameters were compared in both study groups; group 1(using doxycycline)
& group 2(symptomatic treatment), on Day 0 & 5, and findings were -
Mean temperature in group 1 was 98.6& 98 degree F, t value 3.69(p<0.05) & in group 2
98.9 & 100 degree F, t value 1.78(p>0.05)
Mean BP in group 1 was 110/70 &120/80 mmHg with t value 4.01(p<0.05) & in group 2
90/50 & 110/70 with t value 2.60 (p<0.05)
Mean PCV for group 1 was 49 & 38 with t value 2.85 (p<0.05) & in group 2 47 & 44 with t
value 2.45(p<0.05)
Mean platelet count in group 1 was 63,000 & 1,10,000 with t value 2.91(p<0.05) & in
group 2 was 98,000 &94,000 with t values 1.12(p<0.05)
Average hospital stay in group 1was 5 days & in group 2 was 8 days
Mortality was zero in both study groups.
Conclusion:
The analysis was significant, in group1, in all parameters(p<0.05), while in group 2,
analysis was out of significance in 2 parameters P(>0.05). Hence, doxycycline is more
effective in treatment of dengue fever.

Trends of seroprevalence of Toxoplasma gondii in North India
from 2004-2013: a retrospective analysis
___________________________________________________________________________________________
Author : Dr. Parakriti Gupta
Co-authors : Dr. Abhishek Mewara, Dr. Sumeeta Khurana
Institution : Postgraduate Institute of Medical Education and Research,
Chandigarh, India
Objectives:
Toxoplasmosis is a ubiquitous infection affecting ~30% of the world’s population
with varying seroprevalence between countries. A retrospective analysis of 10 years
of the seroprevalence of toxoplasmosis in different groups of patients presenting to
a tertiary care hospital in North India was done.
Methods:
Serum samples received in the Department of Medical Parasitology for
anti-toxoplasma IgG and IgM serology from 2004-2013 were analyzed
retrospectively with respect to different patient categories, viz. pediatric age group,
pregnant females and those with bad obstetric history, HIV positive, hematological
malignancies, ocular diseases etc. The serological testing was done using in-house
ELISA.
Results:
Of the 7432 samples submitted to the laboratory from 2004-2013, a total of 1719 (23.13%)
were seropositive for toxoplasma antibodies, with 11.73% only positive for IgM, 6.49%
only positive for IgG, and 4.93% positive for both. A total of 46.34% pregnant females
were seropositive, while females presenting with abortion/bad obstetric history/infertility
were 48.4% seropositive. In HIV positive patients, 21.90% were seropositive, in suspected
toxoplasmosis in children, 8% were seropositive, while in adults presenting with ocular
symptoms, 45.16% were seropositive. In HIV patients, males were more affected than
females (138 vs. 75), and the majority of patients were < 20 yrs, followed by 20-35 yrs. The
seroprevalence ranged from 9.5% to 30.78% in 10 yrs.
Conclusion:
A high seroprevalence of 23.13% was observed in our study population, and was
especially high in females and in HIV positive patients. A constant monitoring of the
seroprevalence trends in essential to implement intervention measures pertaining
to personal hygiene and environmental factors for control and management of the
disease.

Rendevous with Dengue Fever
___________________________________________________________________________________________
Author : Dr. Parul Kodan
Co-author : Dr. Archith Boloor
Institution : Kasturba Medical College,Mangalore
Objective:
This study the clinical profile of dengue fever with particular focus on atypical
manifestations in a coastal city of South India.
Methods:
Prospective and retrospective observational study of 500 IgM or NS1 confirmed dengue
cases admitted to KMC group of hospitals. Demographic,clinical and laboratory details
of all confirmed dengue cases was recorded. Final outcome was assesed as death or
discharge.
Data Analysis:
Data was collected on a pre-designed proforma in MS Excel. Categorical and
continuous variables were analyzed using Chi-Square test and independent
t-test respectively.A logistic regression model was performed to determine the factors
independently associated with mortality in dengue fever.
Result:
In our study most common presenting complaints included fever (99.6 %),
bleeding manifestations (15.8%), arthralgia (11.8%), gastrointestinal symptoms (64%)
and respiratory symptoms (19.2%). Thrombocytopenia, defined as a platelet count
< 100,000 µL was present in 99.8% of patients. Mean ± SD platelet count at
presentation was 22000 ± 2000 µL. Platelet count at admission was not correlated with
mortality. Atypical manifestations included Dengue Acalculous Cholecystitis(22%),
Myocarditis(1.8%) and ARDS(1%) , Hemorrhagic Encephalitis(0.4%) and
Haemophagocytic Lymphohistiocytosis (0.4%).
Conclusion:
There is an alarming rise in number of dengue cases in recent years . Clinicians
should be aware that dengue is not equivalent to platelet count disorder.Dengue
can have varied presentations and atypical manifestations should be promptly
diagnosed and managed.

TREND OF SEROPREVALENCE OF SYPHILIS IN A TERTIARY CARE
CENTRE
___________________________________________________________________________________________
Author : Dr. Pradnya Premanand Naik
Co-authors : Dr. Pinto M J W
Institution : GOA MEDICAL COLLEGE
Background and Objectives:

Syphilis is a sexually transmitted disease (STD), caused by Treponema pallidum
subsp. pallidum. In this study done in a Tertiary Care Centre, seroprevalence and rising
or falling trend of syphilis in different groups among patients was analyzed .

A retrospective study was carried over a period of 3 alternate years from 1st May 2012
to 30th April 2013, 1st May 2014 to 30th April 2015 and 1st May 2016 to 30th April 2017.
Seroprevalence of syphilis in different patient groups was analyzed by Venereal Disease
Research Laboratory (VDRL) and Treponema Pallidum Hemagglutination Assay (TPHA).
A Rising or falling trend of syphilis seroprevalence was also analyzed.
Results:
Among the 17941 serum samples tested, 504 (2.80%) were found reactive by VDRL
test. A total of 1244 were tested by both quantitative VDRL test & TPHA assay. A
falling trend of seroprevalence was observed from 1.04% in May 2012-April 2013 to 0.58%
in May16-April17, although not statistically significant. A falling trend was observed in
STD clinic attendees from 7.9% in May 2012-April 2013 to 6.12% in May 2016-April 2017.
A seroprevalence of 61.72% was observed in males compared to 38.27% in females.
Conclusion:
A decreasing trend of syphilis was observed over a study period, though not
statistically significant among antenatal women, STD clinic attendees & HIV -
seropositive individuals. These findings could be interpreted as indicators of
sustained efforts for case detection, treatment and improved programme for
prevention & management of STD’s.

A Study to Compare Curb-65 Vs Pneumonia Severity Index
Score for Prognosis in Adult Patients with Community
Acquired Pneumonia
___________________________________________________________________________________________
Author : Dr Pranav Kumar Choudhary
Co-author : Dr R Shankarprasad
Department : Internal Medicine
Institution : St Philomena's Hospital , Bangalore.
Background and objectives:

Community acquired pneumonia (CAP) is one of the most common infectious
diseases associated with significant morbidity and mortality is one of the leading
cause of death from infectious diseases in the developing countries. Prompt,
accurate diagnosis and assessment of severity of illness which corresponds to
decisions regarding the intensity of management is the first and single most important
decision in the overall management of CAP. This study aims to compare the CURB-65
and PSI score in the outcome of community acquired pneumonia in an Indian setting
to help in predicting the prognosis and to classify patients that would need intensive
care treatment.
Methodology:
In this single centre prospective observational study which was conducted in the
Department of Internal medicine at St Philomena's hospital, Bangalore Karnataka.
The data which includes clinical history, examination findings and CURB-65 and
PSI scores were collected from 205 subjects admitted with CAP during the study
period from september 2014 to september 2016 and they were analysed in order
to know the prognostic significance of CURB-65 and PSI scores.
Results:
In this study it was found that high risk classes as per both PSI and CURB-65 scores
were strongly associated with increased duration of hospital stay, ICU care, need
for mechanical ventilation and mortality. PSI class ≥ IV was more sensitive the
prognosis in terms of increased duration of hospital stay, need for ICU care,
ventilator support requirement and mortality compared to CURB-65 score ≥ 3 which
was found to be more specific for the aforementioned parameters.
Conclusion and interpretation:

CURB 65 is the preferred method to predict overall prognosis in terms of duration
of hospital stay, ICU admission, need for ventilator support and mortality in patients
with community acquired pneumonia as apart from having better specificity and
comparable sensitivity with PSI, CURB-65 is easier to implement.

Prognostic Significance of Serum Procalcitonin Level in
Critically ill Patients with Ventilator Associated Pneumonia
in Liver Diseases
___________________________________________________________________________________________
Author : Dr. Prathiba Kale
Co-authors : Dr. Vikas Khillan, Dr. L G Mitra, Dr. S K Sarin,
Department : 1)Department of Microbiology,
2)Department of Critical Care Medicine,
3)Department of Hepatology
Institution : Institute of Liver and Bilairy Sciences, New Delhi.
Objectives:
Procalcitonin (PCT) is a marker of severe sepsis caused by bacteria and generally
grades well with the degree of sepsis. The prognostic role of serum procalcitonin
level in critically ill patients with ventilator-associated pneumonia (VAP) is undetermined.
The aim of our study was to investigate the relationship between serum procalcitonin
level in critically ill patients with ventilator-associated pneumonia with associated liver
disease.
Methods:
Data of 100 critically ill patients with liver diseases was prospectively analysed.
(50 – no VAP, 50- with VAP). The Demographics, comorbidities, and serial serum
procalcitonin level of these patients were compared. The final outcome considered
were mortality within one month after diagnosis or discharge of the patient with stable
parameters. Statistical analyses were performed to assess the prognostic role of serum
procalcitonin level in these patients.
Results:
Serum procalcitonin level was not associated with age, gender, or other comorbidities.
The median PCT level was higher in the VAP Group (1.19 vs. 0.8ng/ml) and 30-day
mortality (3.3 vs.1.4 ng/ml) groups. No association was found between PCT
concentration and the adequacy of antibiotic therapy or the aetiology of VAP.
Patients with higher PCT at admission had higher mortality.
Conclusion:
Serum procalcitonin is raised in patients with VAP, irrespective of the aetiology of
VAP or the underlying liver disease. Higher procalcitonin values are associated
with higher mortality and poor outcome in critically ill patients. However, application
of serum procalcitonin alone seems to be limited in predicting outcomes.

Awareness on Factors Contributing to Antimicrobial Resistance
Crisis from a Developing Country Perspective
___________________________________________________________________________________________
Author : Dr. Pratik Y.Patil
Co-authors : Dr. Pr Vidyalakshmi, Dr. Abdul Ghafur,
Institution : Apollo Cancer Institute, Chennai
Background:
Antimicrobial Resistance (AMR) is a global challenge and poses a substantial
economic and health burden. Physicians, nurses and clinical pharmacists are key
stake holders in tackling the in-hospital and to some extent, the community aspect
of the challenge. Proper understanding of all the components of AMR is required
to tackle this issue in a holistic way. This study was conducted to evaluate the
perception and awareness of health care workers (Doctors, Nurses and Clinical
Pharmacists), on various components contributing to antimicrobial resistance crisis.

A questionnaire compromising thirteen open ended questions were distributed
amongst the health care workers (Doctors, nurses and clinical pharmacists) in a tertiary
care centre in South India. Likert scale was used for the assessment.
Results:
A total of 135 health care workers attempted the survey. More than two-third of
the participants were aware of the role of over the counter sale (OTC) of antibiotics
without prescription, improper in-hospital antibiotic use, poor infection control practices
and inadequate vaccine coverage as contributing factors to the AMR crisis. One third
of the participants were unaware of the role of poor sanitation, lack of political will and
inappropriate use of antibiotics in veterinary practice as contributing factors.
Conclusion:
Though there is good awareness on the role of in-hospital and OTC antibiotic use
and inadequate infection control contributing the AMR scenario, there is inadequate
awareness on the importance of sanitation and the need of political will to tackle the
crisis.
In addition to the ongoing efforts, we should augment the awareness activities

among health care professionals, on all components contributing to AMR crisis; so that
the challenge can be successfully tackled.

EARLY EXPERIENCE WITH FOSFOMYCIN
___________________________________________________________________________________________
Author : Dr. Pratik Savaj
Co-authors : Kanishka Davda, Rajeev Soman, Ayesha Sunavala, Anjali Shetty,
Camilla Rodrigues
Department : Department of Internal Medicine and Infectious Diseases
Mumbai, Maharashtra
OBJECTIVE:
Antimicrobial resistance in gram negative organisms (GNB’s) is a global problem.
There is a great interest in fosfomycin due to its PK/PD properties. The IV preparation
has been recently introduced as rescue therapy for MDR organisms. However, clinical
experience data are lacking in our country.
METHODS:
We retrospectively studied patients referred for ID opinion with proven or
suspected sepsis & had received IV fosfomycin between January & May 2017.
Clinical & microbiological outcome, adverse reactions were recorded. Of 14 patients,
3 patients were excluded (2 with leukemia, 1 with fosfomycin resistance).11 patients
were thus included in the study.
RESULTS:
Among the 11 patients, 7 were given directed whereas 4 received empirical
treatment. The most frequent isolated organism was Klebsiella pneumoniae
(4 patients). 10 patients received combination therapy & 1 patient received
monotherapy. 5 patients were clinically cured, while another 5 worsened on treatment
due to adverse drug reactions or secondary infections (one developed Acinetobacter
pneumonia, the other developed CR E.Coli UTI with fosfomycin resistance).
Microbiological cure was seen in 3 patients. 1 patient had persistently positive
culture while on treatment. 8 patients developed adverse drug reactions. The
most common adverse drug reaction was diarrhea which occurred in 7 patients.
Among them, 1 had diarrhea due to C. difficile. Other adverse reactions observed
were hypernatremia (in 4) and hypokalemia (in 6). 3 patients developed serious side
effects (2 developed non-cardiogenic pulmonary edema and 1 developed torsades
de pointes with QT prolongation.
CONCLUSION:
Fosfomycin appears to be a useful addition to the depleted armamentarium as
salvage therapy for infections with CR/CCR GNB’s. However there is a need to
demonstrate susceptibility of the causative organisms. While adverse events have
not been considered significant in most reviews, they were significant in our limited
experience & needed careful management.

Mucor by inhalation and Klebsiella by irrigation
___________________________________________________________________________________________
Author : Dr. Pratik Savaj
Co-authors : Kanishka Davda, Rajeev Soman, Ayesha Sunavala, Anjali Shetty,
Camilla Rodrigues
Department : Department of Internal Medicine and Infectious Diseases
Mumbai, Maharashtra
Introduction :
We present a case of rhino-orbito-cerebral mucormycosis (ROCM) in an
immunocompetent adult with a nosocomial bacterial infection with several difficulties
encountered in the management.
Case:
47 year male presented elsewhere with sub-acute onset of headache, left
ophthalmoplegia and vision loss. MRI-left orbital cellulitis with orbital apex syndrome
and temporal lobe abscess, elsewhere. Finally came to our institute after receiving
AmB–d and subsequent acute kidney injury. For suspected ROCM aggressive surgical
debridement with 1.Lid sparing left eye exenteration, 2. Bilateral FESS clearance
3. Temporal craniotomy with evacuation of the abscess was done. Calcoflour staining
showed broad aseptate fungal filaments, and culture grew Rhizopus arrhizus. L-AMB,
posaconazole, anidulafungin and deferasirox were started. Since the orbital clearance
could not be done adequatelt Irrigation of the orbital cavity with AmB-d solution
was carried out by the ophthalmologist for 2 weeks in the ward. Few days later
patient developed swelling and erythema over craniotomy site followed by fever.
Re-imaging- collection overlying craniotomy site in communication with left orbital
cavity. Re-exploration and debridement was done and the pus grew CR-Klebsiella
pneumoniae (colistin MIC =2 and was fosfomycin resistant). Despite 15 days of Colistin
patient continued spiking fever. Re-imaging showed partial resolution of the abscess.
In a view of radiological resolution and no alternate cause of fever, drug fever due to
posaconazole & neurotoxicity due to colistin was considered as a possibility. Colistin and
posaconazole were withdrawn and the patient became afebrile and was discharged.
Treatment Difficulties Management

L-AMB ↑ creatinine, ↓K, ↓Mg Need Fluids and electrolyte supplementation
to give Colistin along with After 4 weeks of treatment, AmB was
AmB considered less important than Colistin
& was withdrawn
Posaconazole Needed to be given dose ↑ to 200 mg 6 times a day and PPI
through NG tube Sub - avoided
therapeutic levels ? Drug
fever
Deferasirox Pancytopenia Stopped
Polymyxin – B Neuromuscular weakness Change to Colistin
Colistin ↑creatinine? Drug fever Stopped
Neurotoxicity
Discussion:
While the management of mucormycosis by itself is complex, management of
associated problems like nosocomial infections, drug interactions & adverse drug
reactions add further difficulties which need careful weighing of therapeutic options &
clinical judgement.

Genexpert MTB/RIF Assay in Early Diagnosis of Patients with
Suspected Pulmonary Tuberculosis
___________________________________________________________________________________________
Author : Dr. Pratyush Sharan Singhal
Co-author : Dr. Devnath Jha
Institution : Batra Hospital & Medical Research centre
Objective:
To compare the sensitivity & specificity of Genexpert MTB/RIF assay with the smear
microscopy and culture for mycobacteria in sputum specimens of patients with
suspected pulmonary tuberculosis.To assess the role of Genexpert MTB/RIF assay as
an early diagnostic marker for pulmonary tuberculosis.

A total of 75 patients with suspected Pulmonary Tuberculosis who could
expectorate sputum were subjected to Smear Microscopy, Culture & Genexpert
Assay during October 2014 to March 2016. The Sensitivity, Specificity and PPV &
NPV were calculated for Genexpert assay and smear microscopy keeping Culture of
Mycobacterium tuberculosis as gold standard.
Results:
Out of 75 patients, 31 were confirmed as cases of pulmonary tuberculosis by
sputum culture (considered as the gold standard) of which smear microscopy
detected only 21 patients giving it a sensitivity of 67.7% (95%CI=48.5-82.6) and a
specificity of 100% (95%CI=89.9-100.9). However, Genexpert MTB/RIF assay detected
29 patients out of 31 culture positive patients giving it a sensitivity of 93.5% (95%CI=77.1-
98.8) & specificity of 100% (95%CI=89.9-100.0). The NPV was 95.7% (95%CI=83.9-99.2)
and PPV was 100%(85.4-100.0).
Conclusion:
Genexpert MTB/RIF assay is an effective tool for the diagnosis of pulmonary
tuberculosis with high sensitivity and specificity and can replace sputum microscopy
as an early diagnostic marker for pulmonary tuberculosis. Also, the additional ability
to detect Rifampicin resistance is a major advantage especially in areas with high
prevalence of Drug resistant TB and this should be evaluated in further studies.

An Insight Into Pediatric Candidemia
___________________________________________________________________________________________
Author : Dr. Prerna Khurana
Co-authors : Dr. Karnika Saigal, Dr. Arnab Ghosh, Dr. Mamta Jajoo, Dr. Diganta Saikia,
Dr. Anup Mohta
Institution : Chacha Nehru Bal Chikitsalaya, Delhi
Background:
Candida species is the most common cause of invasive fungal infections in
pediatric population and is a cause of high mortality and morbidity with a mortality rate
ranging from 10%-47%.
Objectives:
To evaluate the clinical spectrum of bloodstream infections caused by Candida
species in a tertiary care pediatric centre in North India, and to evaluate the
susceptibility pattern of Candida species causing infections.
Methodology:
Children under 12 years of age with candidemia over a period of one year from
January to December 2016 were included in the study. The risk factors were assessed
along with the susceptibility pattern of the Candida species causing infections.
Results:
Over a period of 1 year, 63 patients had bloodstream infection due to Candida
species. Out of these, 39 (61.9%) patients required ICU and 24 (38.1%) were admitted
in the inpatient department.
35 (55.6%) of the patients were <28 days old. 22 (34.9%) of the patients were
preterm. 16 ( 25.4%) of the patients were low birth weight while 5 (7.9%) of the
patients had extremely low birth weight. Out of the 63 patients, 57 (90.5%) were hospital
deliveries. 37 (58.7%) of the patients had prior exposure to hospital environment and
38 (60.3%) of the patients were exposed to broad spectrum antibiotics for more than
7 days before the isolation of Candida species. The risk factors present were: history
of surgery (31.7%); NEC (9.5%); presence of central line (11.1%) and ventilator
requirements (55.6%). Maximum infection (28.6%) occurred from May-July. 17 (27%)
of these infections were HAIs.
Microbiologically, the most common species isolated was C.tropicalis (30.1%)

followed by C.albicans (23.8%) and C.pelliculosa (20.6%). Most (90.4%) of our isolates
were susceptible to fluconazole except 2 isolates of C.albicans and 1 isolate of C.krusei.
3 isolates (2 of C.pelliculosa and 1 of C.albicans) were intermediate to fluconazole.
Conclusion:
This study highlights the high incidence of candidemia in neonates, risk factors for
Candida infection and the emergence of infections due to Non-Albicans
Candida even without prior fluconazole exposure. More effective infection control and
strict treatment protocols could be beneficial to patients with known risk factors and
Candida colonization

A Study on the role of Genexpert MTB/RIF Assay in
Early Diagnosis of Extra Pulmonary Tuberculosis
___________________________________________________________________________________________
Author : Dr. Prerna Sharma
Co-authors : Dr. Meghana Kabra
Institution : Batra Hospital & Medical research centre (BHMRC)
Objective:
To study the sensitivity and specificity of Genexpert MTB/RIF assay in patients with
extrapulmonary Tuberculosis in a tertiary care setting in India.To correlate Genexpert
MTB/RIF results with smear microscopy and culture.
Methods:
This was a prospective observational comparative study done from January 2015
to June 2016 on 92 suspected extrapulmonary tuberculosis patients with 34 pus ,37
body fluids(pleural, ascitic, pericardial),11 cerebrospinal fluid and 3 urine samples.
Each sample was subjected to smear microscopy, culture for Mycobacterium
Tuberculosis and Genexpert MTB/RIF assay.Results were calculated in terms of
sensitivity, specificity, PPV, and NPV & also stratified on the basis of sample type.
Results:
Of the 92 samples, 25 were confirmed as cases of Extrapulmonary tuberculosis by
culture (the gold standard), of which smear microscopy detected 9 & Genexpert
MTB/RIF assay detected 22 giving a sensitivity of 36% and since Genexpert detected 1
additional culture negative case showing a sensitivity of 88% and specificity of 98.5%
with PPV and NPV both being 95.7%. Genexpert also detected an additional 14 cases
otherwise missed by smear microscopy. Sample wise, Genexpert showed a sensitivity of
95%, 50% and 100% in pus, body fluids and tissue biopsies respectively.
Conclusion:
Genexpert appears to be a good tool for the early diagnosis of extrapulmonary
tuberculosis especially in pus, body fluid and tissue samples and can be of great
significance in smear negative cases. It can easily replace smear microscopy for
diagnosis with an added benefit of rifampicin resistance detection. However, high cost
may be a hinderance, for which a cost benefit analysis must be carried out.

Bacteriological Profile and Antimicrobial Susceptibility of
Blood Culture Isolates from AIIMS, Raipur
___________________________________________________________________________________________
Author : Dr. Priyadarshini Patro
Co-authors : A. Bhargava, P.Das, U.N.Gaikwad,S.N Negi, D.Dash
Department : Department of Microbiology,
Institution:
All India Institute of Medical Science, Raipur, Chhattisgarh
Introduction:
Blood stream infections (BSI) constitute a significant public health problem with
increasing morbidity and mortality in hospitalized patients. Bacteraemia ranges
from self‑limiting infections to life‑threatening septicemia that requires rapid and
aggressive antimicrobial treatment. Rapid and reliable detection of bacterial
pathogens and rational use of antimicrobials are required for proper management.
Again with the emergence of Multi-drug resistant organisms, there is increased risk of
death in these patients.
Aims & Objective:

The present retrospective study was undertaken to know the profile of organisms
causing bacteraemia with their antibiogram from clinically suspected cases of
bacteraemia.

Blood cultures reports submitted during the period of two years from 2014 – 2016
were analysed. 1377 blood culture samples were processed and the bacterial isolates
from positive cultures were identified by standard protocols and antimicrobial sensitivity
patterns were determined by CLSI guidelines.
Results:
Positive blood cultures were obtained in 13.87% (191/1377). Of 191 positive cultures,
bacterial isolates were obtained in 173/191 (90.57%) and 18/191(9.43%) were Candida
spp. Of 173 bacterial isolates, Gram-positive bacteria accounted for 55(31.79%) cases
and Gram negative bacteria were 118 (68.21%) with predominance of Salmonella spp.
(37.29%) followed by E. coli (11.01%), Acinetobacter spp. (9.32%) and others ( 9.32%).
CONS was the most common isolate (32.72%) followed by S. aureus (29.09%) among the
gram positive bacteria.
All Salmonella isolates were third-generation cephalosporin sensitive. Multiple drug

resistance (resistant to ampicillin, chloramphenicol and co-trimoxazole) was found in
19.35% of Salmonella isolates. Ciprofloxacin and nalidixic acid susceptibility was 31.81
% and 4.54 % respectively.
Among other Enterobactericae 52.17% were multi‑drug resistant . Imipenem (81.82%)
and amikacin (80%) showed the highest activity among Enterobacteriaceae.
Gram‑negative isolates showed 100% sensitivity toward colistin. About 25% of S. aureus
were Methicillin‑resistant. All Gram-positive isolates showed (100%) sensitivity to
Vancomycin and Linezolid.

Conclusion:
The present study highlights the bacteriological etiology of sepsis along with their
sensitivity towards commonly used antimicrobials. The Majority of bacterial isolates
were multidrug resistant.Thus providing useful guide to clinicians in initiating
empiric therapy and will also help in formulation of antibiotic policy in effective
management of such cases.

Predicting Severity of Dengue Based on Few Clinical and
Laboratory Indicators: A Retrospective Analysis
___________________________________________________________________________________________
Author : Dr. Purwa Doke
Co-authors : Dr. Bharat Purandare, Dr. Mahesh Lakhe, Dr. Rajeev Soman
Institution : Bharati Vidyapeeth Medical College and Research Centre, Pune
Dengue is the commonest arthropod borne viral illness in adults. Its diverse
spectrum poses difficulty in estimation of morbidity and mortality. In India, in last three
years from 2013 to 2015 about 75,000 – 1,00,000 cases and 193 – 220 deaths have
been officially reported. It is difficult to ascertain the vulnerability of patients to adverse
outcome. There is a paucity of information about ‘outcome predicting conditions’.
Objective:
Our study was carried out to measure association between the laboratory
investigations and clinical findings with outcome/course particularly with regard to
admission in ICU among the indoor dengue patients. Need of admission to ICU
was considered as proxy of severity of dengue.
Methods:
This is a retrospective study of patients from 1st July to 31st December 2015. Data
of 370 adult dengue patients was retrieved from a tertiary hospital in Pune,
Maharashtra. Data included demographical variables, method of diagnosis, co-morbid
conditions, duration of ward/ICU stay, laboratory investigations and clinical outcome.
A simple scoring system was designed having age, bleeding tendency, platelet count,
co-morbid condition and SGPT levels. Each variable was given maximum 2 points
Results:
Out of the total 370 cases 64.60% were males. Mean age was 30.68 years (SD = 11.49).
Maximum number of cases (60%) occurred in the month of October and November
2015. As expected, platelet count showed association with bleeding tendency. Almost
half the patients having diabetes and hypertension needed ICU admission. Among
patients with score of 5, ICU was needed in 1% only. However if the score was 9-10, the
need for ICU admission was 100%.
Conclusion:
Higher the score, greater is the chance of needing admission to ICU. Our scoring
system is easy to calculate and may be used to take immediate actions and which
may help to reduce case fatality rate.

Repeated Outbreaks of Paratyphoid Fever– An Ongoing Threat
in North Kerala
___________________________________________________________________________________________
Author : Dr. Pushpa Kizhakkekarammel
Co-authors : Dr. Ajithkumar V T, Dr. Rekha Rachel Philip, Dr. Geetha Raveendran.
Department : Departments of Microbiology
Institution : Government Medical College Manjeri
Introduction:
Two major episodes of Salmonella paratyphi A outbreaks had occurred in
different localities of a same Muncipality panchayath following wedding feasts- the
first episode in April 2016 and the second one in January 2017. Patients presented with
fever and abdominal discomfort, 10-14 days after the suspected exposure.
Objective:
To identify the magnitude and source of two different food borne outbreaks of
Salmonella paratyphi A.
Methods:
A team from the local tertiary care centre which included personnel from
Departments of Microbiology, Community Medicine and Paediatrics had visited
the places, conducted medical camps and field visits. Blood samples were
collected from symptomatic patients for culture and serological tests. Stool samples
were subjected to culture. Drinking water sources and food samples were collected for
microbiological analysis.
Results:
Blood cultures yielded Salmonella paratyphi A in 5 out of 34 patients during the
first episode and 7 out of 59 patients in the second episode. The isolates were
sensitive to Ampicillin, Ceftriaxone, Ciprofloxacin and Chloramphenicol. Significant
levels of Salmonella paratyphi A antibody were demonstrated in 53% (18/34) and 27%
(18/59) of patients during first and second episodes respectively. Stool cultures and
environment samples were negative for Salmonella species.
Conclusion:
All identified patients were treated with Ceftriaxone or Ciprofloxacin for 2 weeks
and no relapse was noted. Intensive health awareness programs were conducted
all over the panchayath, along with chlorination of drinking water sources and health
education. Salmonella paratyphi A infection, which was once thought to be rare
compared to Salmonella typhi enteric fever, is being reported more frequently
associated with outbreaks.

Serum Cytokine Levels of Active MTB Patients and
Healthy Subjects
___________________________________________________________________________________________
Author : Dr. R.Gopinath
Co-author : Dr. Elanchezhiyan Manickan
Institution : Dr. ALM. Post Graduate Institute of Basic Medical Sciences,
University of Madras
Introduction:
Tuberculosis remains a major challenge to public health worldwide. It is estimated
that one out of every three humans is infected with its etiologic agent, Mycobacterium
tuberculosis (MTB).Cytokines play a major role in immunity against MTB infection
and regulate the immune responses at a cellular level. The goal of this study was to
determine the levels of IFN-γ, TNF-α, IP-10 (Th1 cytokines), IL-10, IL-6 (Th2 cytokines)
among TB patients and control subjects.
Objective:
To evaluate the cytokine levels in the serum of tuberculosis patients and controls
individuals.
Methods:
Serum of 81 TB patients (40 treatment naïve and 41 under therapy) and 32 controls
were subjected for various Th-1 cytokines and Th-2 cytokines by ELISA.
Results:
Serum of TB patients had elevated levels of Th-1 cytokines than the controls. In contrast
there was no such difference in Th-2 cytokines. Elevated Th-1 cytokines declined upon
anti TB treatment. There was no difference between genders or age groups.
Conclusion:
From this study we report that during MTB infection the levels of Th-1 cytokines namely
IFN-γ, TNF-α, IP-10 (Th1 cytokines) increased and it declined after treatment.

“Prevalence of Aerobic vaginitis in woman presenting with
preterm labour at a Tertiary care centre in Lucknow”.
___________________________________________________________________________________________
Author : Dr Radha Chaudhary
Co-authors : Dr Prashant Gupta, Dr Gopa Banerjee, Dr Jyotsna Agarwal ,
Dr Smriti Agrawal
Department : Microbiology, Obstetrics and Gynaecology,
Institution : King George’s Medical University, Lucknow.
Introduction:
Aerobic vaginitis (AV) is defined as a displacement of the healthy vaginal
lactobacillary flora, predominantly by aerobic microflora mainly composed of
enteric commensals or pathogens such as Enterobacteriace , Enterococcus faecalis,
Group B streptococcus (GBS), and Staphylococcus aureus, accompanied by signs
of inflammation. Aerobic vaginitis should not be confused with Bacterial vaginosis
(BV), which is associated with Overgrowth of anaerobic bacteria (Gardnerella
vaginalis, Mobiluncus sp., Bacteroides sp., Peptostreptococcus sp., etc.), with Offensive
discharge without any vaginal inflammation.
Objectives:
The study was conducted to assess the prevalence of aerobic vaginitis in women
presenting with preterm labour at a tertiary care centre in lucknow.
Material & Methods:

Vaginal swabs of 113 pregnant ladies with preterm labour presenting to the
gynecology department were taken. Wet mount preparation ,Gram staining and
culture on Blood agar and MacConkey agar was done. Culture plates were
examined after 24 hr. Significant growth of suspected organism causing aerobic
vaginitis was subsequently processed.
Result:
Out of 113 samples received,10 were culture positive, of which 3 were CONS, 2 were
Staphylococcus aureus, 2 were Escherichia coli, 1 was Enterococcus faecalis, 2 were
Acinetobacter spp,
Conclusion:
Aerobic vaginitis is an under-recognised disease which may lead to miscarriage ,
chorioamnionitis , preterm birth , Preterm -premature rupture of membrane in
pregnant ladies. Thus early identification and appropriate treatment (however data is
lacking for the same), may help in preventing such grave complication in pregnancy.
Hence this study was undertaken to know the prevalence of Aerobic Vaginitis in our
setup.

Etiology of multiple cholangiitic abscesses in the background of
malignancy and differentiation from hepatic metastases -
a Case series
___________________________________________________________________________________________
Author : Dr. Rahul D. Arora
Department : Medical Hepatology
Institution : Institute of Liver and Biliary Sciences, New Delhi -110070
Introduction:
Clinical and radiological characterisation of multiple abcesses in the setting of
underlying hepatic malignancy poses a unique diagnostic challenge.
Case details:
Case one- A 43 year old female type 2 DM, case of metastatic adenocarcinoma
of the gall bladder with malignant biliary stricture, significant bilateral IHBR dilatation
on ERCP suggestive of a Type iiia Hilar stricture which was managed with PTBD with
stenting underwent bilateral PTBD. She was restarted on reduced dosage of adjuvant
chemotherapy, following which she developed multiple cholangiitic abcesses.
Case two- A 65 year old female a known case of adenocarcinoma of the Gall
bladder neck with involvement of the primary confluence (Bismuth Corlette type ii) with
infiltration of the liver, duodenum and hepatic flexure of the colon who had undergone
ERCP with stenting. MRCP done subsequently was suggestive of cholangiitis and
cholangiolar abscesses in the segment vii and viii which grew E. coli on culture.
S.No Name of antibiotic Dosage Duration (days)

Case One
1. Inj Tigecycline 100 mg stat followed by 25 mg bd 15+15+30
2. Inj Meropenem 1 gm iv stat ,bd 15+30
3. Inj Netilmycin 200 mg iv od !5+15+30
4. Inj Metronidazole 500 mg iv bd
Case Two
1. Inj Tigecycline 100 mg iv stat followed by 50 mg iv bd 3
2. Inj Amikacin 750 mg iv od 7
3. Inj Metronidazole 500 mg iv tds 6
4. Inj Ceftriaxone 2 gm iv bd 4
Conclusion:
MRCP and Chemotherapy in adenocarcinoma of the gall bladder may also be
associated with the development of multiple cholangiolar abscesses which need to
be differentiated from metastases. A composite scale involving Radiological
characterization on MRI , correlation with Leucocyte count, CRP and Procalcitonin
levels needs to be developed to decide upon further management of these patients.
Key words:
Adenocarcinoma Gall bladder Cholangiolar abscesses

Sero-Epidemiology of Hepatitis A and Hepatitis E:
How Common Is Co-Infection?
___________________________________________________________________________________________
Author : Dr Rahul Garg
Co-authors : Dr Mridula M, Dr Barnini Banerjee, Dr Vandana K E, Dr Manjunatha Hande,
Dr Kiran Chawla.
Department : Microbiology, Medicine
Institution : Kasturba Medical College, Manipal, Manipal University
Objective:
1. To study the sero-positivity of Hepatitis A (HAV) and Hepatitis E (HEV) in clinically
suspected cases of viral hepatitis.
2. To understand the clinical and microbiological profile of cases which tested
positive for both HAV and HEV.

Retrospective study, from January to December 2016 was conducted at KMC
Manipal. All consecutive samples which were tested for IgM antibodies against
HAV and HEV were included. Positive results were noted to calculate the Sero -
positivity. Seasonal variation was also determined. The samples which were positive
for both were further evaluated for clinical details. Statistical data analysis was
performed using SPSS (version 15).
Results:
A total of 1520 patients suspected of acute viral hepatitis during the study period.
Out of that Sero-positivity for HAV and HEV was 10.47 % (86/821) and 11.16 % (78/699)
respectively. Males were commonly affected in both the groups and a majority of
patients tested positive were of the age group 21-40 (39.33%). A seasonal
preponderance was seen from September to December. HAV-HEV coinfection
was observed in 0.92% (14/1520) of cases. All of these cases showed an impaired liver
function test with a median value of total bilirubin, AST, ALT, and ALP being 5.5, 772.5,
307.5 and 193 respectively.
Out of all the HAV and HEV positive cases, individuals with co-existence of
alcoholic liver disease; hepatitis B and C were seen in 10 and12 patients respectively.
No mortality was reported among the study population.
Conclusion:
Both HAV and HEV are endemic, with differing rates of infections in children and
adults. Although both the infections are self-limiting, in the presence of other co-morbid
conditions they can be serious. Co-infection in rare cases may lead to acute hepatic
failure and worsen the prognosis. Timely diagnosis by serology may help in the early
management and prevention of complications.

Inducible Clindamycin Resistance in Staphylococcus aureus-
A Matter of Concern for Microbiologists and Clinicians
___________________________________________________________________________________________
Author : Dr. Raminder Sandhu
Co-authors : Dr. Pallavi Sayal , Diksha Budhani, Dr. Gaurav Sharma
Institution : BPS Govt. Medical College for Women, Khanpur Kalan, Sonepat.
Objective:
Antimicrobial resistance in Staphylococcus aureus has become an ever
increasing problem among hospitalized patients, persons in long term care
facilities and outpatient settings. Clindamycin has long been an option for treating
both MSSA and MRSA infections. Multi drug resistant strains of MRSA are rapidly evolving,
including more serious glycopeptide-non susceptible strains. Reporting Staph aureus as
susceptible to Clindamycin without further checking for inducible resistance may result
in inappropriate therapy, treatment failure or relapse.
Methods:
Three hundred and seventeen isolates of Staph aureus were recovered from
various clinical specimens. Standard identification protocols were employed and
antibiotic susceptibility testing was interpreted according to CLSI guidelines. Cefoxitin
disc diffusion method was used for detection of MRSA. Isolates showing zone size of ≤21
mm were reported as methicillin resistant. Inducible Clindamycin resistance (iMLSb) was
determined by Double disk approximation test (D-test) according to CLSI guidelines on
erythromycin resistant isolates.
Results:
A total of 317 Staph aureus isolates obtained from consecutive clinical specimens
were included, consisting of 155 (48.9%) from inpatients and 162 (51.1%) from
outpatients. A total of 145 (45.74%) were detected to be MRSA and remaining
172 (54.26%) as MSSA. Out of 317 isolates, 160 (50.47%) exhibited resistance to
Erythromycin. These isolates were subjected further to D-test. Constitutive resistance
(MLSb) was demonstrated in 68 (42.5%), inducible Clindamycin (iMLSb) resistance
in 37 (23.13%) and non inducible (MS phenotype) in 55 (34.38%) isolates. Another
distinct induction phenotype D+ was observed in 6 (16.22%) isolates. The percentages
of inducible resistance were higher among MRSA (20%) as compared to MSSA (4.65%).
Linezolid and Vancomycin remained most efficacious with resistance rates as low as
2.84% and 4.73% respectively.
Conclusion:
Clinical microbiology laboratories should consider performing routine testing and
reporting for inducible Clindamycin resistance in staphylococcal isolates as close
follow up and monitoring for failure or relapse is needed, if Clindamycin is used to treat
infections with iMLSb producing isolates.

Trend of Swine Flu (H1N1): A Study from South India.
___________________________________________________________________________________________
Author : Dr Ranjeeta Adhikary
Co-authors : Dr Sangeeta Joshi, Dr Bhavana MV
Institution : Manipal Hospital, Bangalore
Department : Laboratory Medicine (Microbiology)
Objectives:
India has first reported outbreak of H1N1 virus in 2009 during flu pandemic. The
outbreak became widespread in 2015 and 2017. The objective of this study was to
determine theseasonal trend of H1N1 cases reported from our quaternary care center
in South India.
Methods:
This is a retrospective laboratory based study analyzing the month wise distribution
of H1N1 cases from January 2012 to April 2017.The study included only those who
patients who belonged to category B and C (according to national guidelines) and
were tested for H1N1 by real-time PCR.
Results:
A total of 8746 samples examined during this 5 years 4 months period, 1979 cases
were confirmed positive for H1N1 with positivity ratio of 22.63%. A total of 142 cases were
reported in 2012, 37 in 2013, 66 in 2014, 927 in 2015, 32 in 2016 and 775 till April 2017. Out
of them, 966 (48.81%) were males and 1013 (51.18%) were females (M:F=1:1.05). Most of
the patients (580) were in the age group of 0-18 years which was 29.3% of total positive
cases. 27.33% of all suspected and 42.55% of all positive for H1N1 were seen during the
month of February.
Conclusion:
With the above observation of H1N1 trend, it is likely that incidence is higher in young
and more during winter months. Therefore, vaccination of this vulnerable age group
having no risk factors should form the target of future studies and control measures of
wide spread prevention of swine flu.

A Syndromic Approach for the Diagnosis of Infections
in Immunosuppressed Patients
___________________________________________________________________________________________
Author : Dr Ravindran K
Co-authors : Shakeera Banu M, Helen Hencida, Thangavelu, CP, Mani M &
Brahmadathan KN
Institution : Division of Molecular Diagnostics, Microbiological Laboratory Research &
Services Pvt Ltd, Coimbatore, Tamil Nadu.
Objective:
Infection with undiagnosed etiology is an important cause of morbidity and
mortality in immunosuppressed patients. Conventional methods such as microscopy
and culture are time consuming and lack good sensitivity; hence alternate methods
are necessary to diagnose them. Here we report our experience with a commercial
multiplex - panel PCR test kit for the identification of agents causing infection in
immunosuppressed patients.
Method:
One thousand four hundred and fifty four respiratory specimens and 95 blood
samples from as many patients collected during Dec 2014 - Dec 2016 were used for
this study. Nucleic acid was extracted using a Qiagen kit and subjected to
multiplex PCR in a real-time format using two commercial kits (Fast-track Diagnostics,
Luxemburg) including a respiratory panel and a BCE panel (BKV, CMV, EBV). Testing
was done in a real-time format and was performed according to manufacturer’s
instructions.
Results:
Nine hundred and forty two (64.8%) of the 1454 respiratory samples and 26 (27.4%)
of the 95 blood samples were positive by the test. Of these, 323 (22.2%) were identified
as single pathogen, 26(1.8%) as dual pathogens and 7 (0.48%) as triple pathogens.
RSV (32.1%) was the most prevalent followed by influenza virus A (4.57%). Bordetella sp.
(4.7%), Streptococcus pneumoniae (5.9%) and Klebsiella pneumoniae (5.8%) were the
only bacteria identified. CMV (46.1%), EBV (38.5%) and BK virus (15.4%) were identified
in blood samples. Taking 30th ct cycle as a cut-off point, pathogenic significance of
seven of 10 dual and one of 2 triple pathogens could be evaluated.
Conclusion:
Multiplex-panel PCR can be conveniently used in the syndromic approach for the
diagnosis of infection in immunocompromised patients. Interpretation based on ct
cycle cut-off is useful in assessing the significance of multiple agents.

Osteomyelitis (OM) in a Tertiary Care Hospital of South India:
Microbiologist’s viewpoint in order to develop antibiotic
management strategy
___________________________________________________________________________________________
Author : Dr. Rohit Gupta
Co-authors : Dr. Sudipta Patra, Dr. Tushar Shaw, Dr. Barnini Banerjee,
Dr. Padmaja Shenoy, Dr. Kiran Chawla, Dr. Anil K Bhat,
Dr. Chiranjay Mukhopadhyay
Department : Microbiology and Orthopedics
Institution : Kasturba Medical College and Hospital, Manipal
Objective:
The study is aimed to determine the clinical and microbiological profile of OM and
the underlying risk factors, and to analyze the antibiotic sensitivity pattern in order
to formulate antibiotic policy.

The study was done prospectively from November 2016 to April 2017 in the tertiary
care hospital of south Karnataka. Patients with clinically suspected OM were studied
further for radiographic, histopathological, and microbiological profile. Bacterial
isolates were identified by MALDI-TOF (Matrix Assisted Laser Desorption Ionization Time
of Flight) and antimicrobial susceptibility testing were performed by VITEK 2 system
(bioMerieux, Inc., Durham, NC) respectively. Xpert® MTB/RIF (Cepheid, GeneXpert) ¬
performed for Mycobacterium tuberculosis.
Results:
We report the clinical and microbiological characteristics of 35 cases of OM. Out
of which 30 (85.7%) were male and mean age was 46.37+_17.44. Tibia was the
commonly involved bone. Twenty four patients had chronic OM (68.6%), out of
which Mycobacteria tuberculosis was isolated in 7(20%) cases with 1(14.3%) MDR
strain. Among non-tubercular etiology, Staphylococcus aureus 14(35%) was the
commonest with 64.3% (9/14) being MRSA. Most predisposing factor was diabetes
mellitus (14; 40%) followed by road traffic accident (10; 28.6%). Most of the patients
(26; 74.3%) patients were had surgery. However, gentamicin (20; 57.1%) was the
most commonly used antibiotic. The antibiotic policy is formulated according to the
sensitivity pattern of the bacterial isolates and is followed subsequently.
Discussion:
OM is one of the most common conditions in the orthopedic outdoor and emergency,
which needs admission and long-term treatment in many occasions. Infections in OM
leading to unfavorable outcomes, are always challenging to manage, unless antibiotic
policy is followed strictly and microbiologists play an active role in management.

Prevalence of Dermatophytoses in a Tertiary Care Hospital at
Gulbarga, North Karnataka
___________________________________________________________________________________________
Author : Dr.Roopa.C
Co-authors : Dr.Guruprasad.K.Y,
Institution : Khaja Bandanawaz Institute of Medical Sciences, Gulbarga
Introduction and Objectives:

Dermatophytosis is superficial fungal infection caused by dermatophytes, a group
of fungi that are capable of growing by invading keratin of skin, hair, and nails and
include three genera Trichophyton, Microsporum, and Epidermophyton. Invasion of
keratin is aided by keratinases found exclusively in dermatophytes1. Overcrowding,
poor hygiene, low standards of living and high humidity contribute to the increased
prevalence of dermatophytic infections2. Gulbarga is known for its hot and humid
conditions making its population at risk for many fungal infections. This study was
undertaken to know the prevalence of dermatophytoses in a tertiary care hospital
at Gulbarga and to identify the most common dermatophyte causing tinea infection.

This is a three months study where a total of 65 samples from patients who came
to Dermatology OPD of our hospital and were clinically suspected to have
dermatophytoses were collected. Skin scrapings, hair samples and nail clippings
were collected in sterilized Whartman paper and direct examination for fungal
elements was done by using 10% KOH for skin and hair samples and 20% KOH for
nail samples. Samples were cultured on Sabouraud’s dextrose agar (SDA) with
gentamicin and cycloheximide (SDA with actidione). Cultures were examined twice
weekly for the appearance of growth. Identification of fungal growth was done
by macroscopic examination of colony morphology, pigment production and
microscopic examination by lactophenol cotton blue preparation. Urease test
was performed to differentiate Trichophyton species2,3.
Results:
In this study, out of 65 clinically suspected cases, 47(72.3%) samples were positive in
direct examination and 30 (46.15%) cases were culture positive. Most number of cases
was observed between age groups of 31–40 years and in males. Dermatophyte species
isolated were Trichophyton rubrum 19(63.33%), Trichophyton mentagrophytes 6(20%),
Trichophyton tonsurans 2(6.66%), Trichophyton schoenleinii 1(3.33%), Epidermophyton
floccosum 1(3.33%) and Microsporum gypseum 1(3.33%).
Conclusion:
Most common dermatophyte causing infection was Trichophyton and most
common species causing infection in patients coming to our hospital was Trichophyton
rubrum.
References:
1. Tainwala R, Sharma YK. Pathogenesis of dermatophytoses. Indian J Dermatol 2011;
56:259-61.
2. Poluri LV, Indugula JP, Kondapaneni SL. Clinicomycological study of
dermatophytosis in South India. J Lab Physicians 2015;7:84-9.
3. Shenoy MM, Teerthanath S, Karnaker VK, Girisha BS, Krishna Prasad M S,
Pinto J. Comparison of potassium hydroxide mount and mycological culture with
histopathologic examination using periodic acid-Schiff staining of the nail clippings
in the diagnosis of onychomycosis. Indian J Dermatol Venereol Leprol 2008;74:226-
29.

“Microbiological Profile Of Chronic Sinusitis With Special
Reference To Fungal Rhinosinusitis : A Study In Central India.’’
___________________________________________________________________________________________
Author : Dr. Ruchita O. Attal
Co-author : Dr. Vijayshri Deotale
Institution : Mahatma Gandhi Institute of Mrdical Sciences, Sewagram
Objectives:
1. To determine the aerobic, anaerobic & fungal etiological agents of Chronic
Rhinosinusitis.
2. To study the clinical presentation of the Chronic Rhinosinusitis.
3. To correlate the microbiological findings with the clinical diagnosis of Chronic
Rhinosinusitis.
Methods:
A cross-sectional study was conducted in the Department of Microbiology, MGIMS,
Sevagram during the period of June- July 2016 after due approval from the Institutional
Ethical Committee. Fifty-two suspected patients were included in the study. Data was
collected in a brief predetermined format. Samples like nasal lavages, sinus secretions,
and tissue specimens were processed and examined by aerobic, anaerobic and
mycological culture using recommended techniques. Gram stain, KOH mount & Slide
culture were done to observe the microscopic morphology.
Results:
During the period of study, out of 52 patients with chronic sinusitis entered, average
duration of symptoms was 20 months. The age of the patients was in between 0-60
years.. There were 27 males and 25 females in our study. The most common symptom
was nasal discharge in (71.11%) and history of allergy was present in 66% of patients
who underwent surgery. On microbiological analysis of the biopsy/swab from infected
sinuses, 36.53% were showing no growth aerobically; 59.61% were showing growth
of aerobic organism and 3.84% were fungi. No anaerobic growth was found.
Staphylococcus aureus(54.8%) was found to be the most common etiological agent.
The fungus so isolated were Aspergillus flavus and Candida albicans each.
Conclusion:
Our finding suggests that if empiric antimicrobial therapy is used to treat chronic
sinusitis, a detailed examination along with correlation with culture results is
necessary. This study also emphasizes the need for adoption of anaerobic and
mycological culture along with aerobic culture as the diagnostic procedure for
Chronic rhinosinusitis in health care centres to determine the specific causative agent
and guide proper medical care.

A Prospective Study of Abnormalities of Vision at Diagnosis
And On Treatment In CNS Tuberculosis
___________________________________________________________________________________________
Author : Dr. Ruju Gala
Co-authors : Dr. Priyank Dumade, Dr. Uma Sundar
Institution : LTMMC&H, Sion
Background:
Visual dysfunction in CNS TB is multifactorial.
Aims:
To assess prevalence of vision abnormalities in patients with CNS TB, correlate them
with Imaging findings and assess response to treatment.
Methods:
Prospective observational study over 18 months in 70 patients
• IC: All patients ≥12 years of age with clinical, imaging and CSF data consistent with
CNS TB.
• Ec: Any patient with significant prior visual dysfunction
Complete clinical and ophthalmological examination was done at baseline. Clinical

review was repeated at 2,4,6 weeks and at 3 months , repeat imaging was done at 3
months.
Stats- SPSS Package version 20
Results :
Mean age was 25.6years, M: F 1:2.68, HIV + 14.28%.
1. Among 70 patients of CNS TB,(35 TBM, 29 tuberculoma, 6 having both), there
were 62 vision abnormalities seen in 52 patients, 87% (54/62) at diagnosis, while
13% (8/62) occurred on treatment and review over 3 months.
2. These included papilledema: 43% (26/62), ophthalmoplegias 40% (25/62), optic
atrophy 7% (4/62),optic neuritis 5% (3/62), ethambutol toxicity 1% (1/62), One-and-
half syndrome 1% (1/62), choroid tubercle 1%(1/62), and cortical blindness 1% (1/62).
3. Papilledema showed a significant correlation with raised CSF proteins (p value
0.0001), imaging features of hydrocephalus (p value 0.0007) and cerebral edema
(p value 0.0177).
4. Ophthalmoplegias showed a significant correlation with basal exudates on imaging
(p value 0.0201).
5. During the 3 month follow-up period, 40%(25/62) vision abnormalities improved.
6. Improvement was seen maximally in ophthalmoplegias viz.72% (18/25), followed by
papilledema 20% (5/25), optic neuritis 4% (1/25) and choroid tubercle 4% (1/25).
7. Optic atrophy, ethambutol toxicity and cortical blindness showed no improvement.
Conclusions: 52/70 patients showed visual abnormalities totalling to 62, over a 3 month
course in CNS TB, Papilledema and Ophthalmoplegias being most common.

Meningitis: Changing Trends
___________________________________________________________________________________________
Author : Dr. Sairam B
Co-authors : Dr. Atul gogia, Dr. Atul Kakar
Institution : Sir Ganga Ram Hospital
Objective:
To study clinical profile of patients with meningitis in our hospital
Method:
We conducted a 3 month - retrospective study in the department of medicine of our
hospital, on the patients diagnosed to have meningitis. Patients with laboratory proven
meningitis, on CSF analysis, were included in the study. Demography, clinical features,
risk factors, duration of hospital stay and course of hospitalisation were noted down.
Results:
On retrospectively analysing the inpatient records, there were 6 patients of meningitis
in the past 3 months, admitted and treated under department of medicine. Out of the
6 patients, 2 were tubercular meningitis (33%), 2 were VZV meningitis (33%), 1 was HSV
meningitis (16.5%) and 1 was cryptococcal meningitis (16.5%). RT-PCR on CSF was the
method used for the diagnosis of all 6 cases. Duration of hospitalisation was between
18 to 30 days. Almost all patients had rough hospital course.
Diagnosis Age/Sex Immunity Hospitalisation

Case 1 TBM 28/F Competent 1 month
Case 2 TBM 23/F Competent 18 days
Case 3 VZV 54/F Competent 21 days
Case 4 VZV 71/F Competent 22 days
Case 5 HSV 56/M Competent 25 days
Case 6 Cryptococcus 27/M Compromised 25 days
Conclusion:
Varicella zoster meningitis is not that rare a cause of meningitis, as it was believed to
be, in the past. These cases provided us compelling evidence to consider varicella
as one of the leading causes of viral meningoencephalitis. RT-PCR is the quickest
and the most sensitive test for picking up the causative organism. Intensive parenteral
therapy, prolonged hospitalisation and continuous monitoring plays an essential part
of the management. PLHA patient should be investigated with an open mind, for
all possibilities of infections.

Prospective Study Estimating Healthcare Associated Infections in
a Tertiary Cancer Care Hospital in South India
___________________________________________________________________________________________
Author : Dr. Santosh B Shirol
Co-Authors : Dr. Kumar Vivek, Dr. Jyothi, Dr. Chandini Roy, Srinath B.S.
Institution : Sri Shankara Cancer Hospital & Research Centre, Bengaluru
Background & Objectives:

Healthcare associated infections (HAIs) are responsible for morbidity and
mortality among immunocompromised and critically ill patients. We undertook this
study to estimate the burden of HAIs in the cancer patients in a tertiary care hospital in
south India.
Methods:
This prospective, observational study, based on active surveillance for a period of
16 months was undertaken in a 200 bedded tertiary cancer hospital. All patients
were followed prospectively for the development of HAIs and defined as per standard
criteria.
Results:
During 16 months period total 46875 in-patients days were calculated. Incidence
of all HAIs were 80.917/1000 patients. Among all HAIs, phlebitis has highest incidence
of 20.85%. Except phlebitis the HAIs incidence drop down to 4.48 /1000 patients.
Incidence rate of catheter associated blood stream infections (CA-BSI), catheter
associated urinary tract infections (CA-UTI) and ventilator associated injuries (VIC)
were 4.04, 2.22 & 1.78/1000 patient-days, respectively. Surgical site infections, needle
stick injuries and bed sores were 2.18, 0.13 & 2.51/100 patients, respectively.
Interpretation & Conclusions:

The incidence of HAIs in the cancer patients in the study was high, of which
phlebitis was the commonest one, which is mainly due to malnutrition and very
fragile veins of chemotherapy receiving patients.

Non responsive intestinal strongyloidiasis - indicator of
HTLV-1 infection
___________________________________________________________________________________________
Author : Dr. Sarada Devi K.L.
Co-authors : Dr. Anitha P.M., Dr. Sameera P. , Dr. Vishnu K. and Dr. Beena Philomina J.
Department : Dept of Microbiology
Institution : Govt. Medical College, Kozhikode, Kerala
Background :
Though Strongyloidiasis is particularly important in immunocompromised patients due
to auto infection and dissemination , persistant intestinal strongyloidiasis also needs to
be further evaluated.
Objective :
To evaluate the cause of persistent intestinal strongyloidiasis , in spite of appropriate
management in an apparently immunocompetant individual.,

A 52 year male diagnosed of intestinal strongyloidiasis , and referred with
persistent symptoms of vomiting, loose stool, weight loss ,epigastric pain& occasional
fever in spite treatment with Ivermectin , was evaluated.Routine blood tests ,screening
for immunosuppressive aetiology and serological assay for HTLV1 and GE endoscopy
were done.
Result:
On evaluation, The GE endoscopy showed evidence of duodenitis and diffuse
gastritis. Aspirate from duodenum showed presence of Rhabditiform larvae of
Strongyloides stercoralis and Biopsy from D2 also showed evidence of presence of
strongyloides larvae in HPR.The blood routine tests were as follows :Hb- 14.8mg%,
ESR-6mm in 1st hour.TC- 21000 /cmm(P42,L86,M49).Ascitic fluid had raised LDH- 430
(0-248).Serology for HIV,HCV, HBsAg- Negative. Sputum wet film was negative for
Strongyloides and stool microscopy showed No ova/cyst/ parasite.
Peripheral smear- showed presence of Absolute lymphocytosis ,suggestive of

Leukemia/lymphoma. Bone marrow aspirate also indicated - Leukemia/lymphoma.
Flow cytometry- immunophenotyping of lymphoid cells - strong CD3, CD5&CD25
positivity- consistent with Adult T cell leukemia/ lymphoma. Serological test for HTLV1-
Positive .
Patient was referred to Regional cancer centre for further evaluation and
management.
Conclusion:
Hyper infection strongyloidiasis with disseminated disease is common in patient on
steroid therapy, chemotherapy and post-transplant patients etc. However hyper
infection syndrome, therapeutic failure in an apparently healthy patient with
non-disseminated strongyloidiasis may be an indicator of HTLV1 infection and has to
be worked up for the same.

Can Dengue Be A Cause Of Acute Viral Hepatitis- A Few Cases
___________________________________________________________________________________________
Author : Dr. Saswata Saha
Co-authors : Dr. Aman Chaudhury, Dr. Sandesh M Raykar, Dr. Siddharth Jain,
Dr. Navneet Kumar Agrawal, Dr. Chandan Kumar, Prof. M.Rai
Institution : Institute of Medical Sciences, BHU
Objective:
Dengue is world’s most important arboviral disease. Mild hepatic dysfunction is
common in Dengue. Its presentation as acute viral hepatitis is unusual with few cases
reported.
Methods:
We had 5 patients of Dengue (NS1Ag +ve) with severe transaminitis (>1000)
admitted between June’16- October’16. All patients had stable vitals and no
hemorrhagic manifestations. Acute viral serology (Hep. A, B, C & E) including ANA
and previous drug history were negative. Details of the patients are given below-
Case-1:
54 years female with fever, headache and bodyache for 3 days and altered
sensorium for 1 day (GCS- E3V4M5). Case-2: 53 years female with fever, headache
and bodyache for 5 days and jaundice for 2 days. Case-3: 46 years male with fever,
generalized weakness, jaundice and decreased appetite for 3 days. Case-4: 36 years
male with fever and decreased appetite for 5 days. Case-5: 28 years male with fever,
headache, bodyache and nausea & vomiting for 4 days.
Comorbidity Hct TLC (DLC) Platelets SGOT/ TB/DB TP/Alb ALP PT/
SGPT INR
Case-1 T2DM 38.2 8700 15000 5330/ 1.9/1.4 6.6/3 425 18/
(N50L38M11) 1250 1.51
Case-2 Bronchial 46.4 5500 44000 4730/ 2.8/0.6 7.4/3.3 532 17.5/
Asthma (N47L40M12) 1210 1.46
Case-3 T2DM 40.6 12800 35000 7240/ 3.4/2.9 5.2/2.7 147 12.7/1
(N71L12M16) 2480
Case-4 NIL 40.1 9200 32000 2465/ 1.2/0.5 6.4/3.3 118 16.2/
(N63L34M02) 1578 1.27
Case-5 NIL 50.7 7060 20000 3690/ 2.2/0.5 5.1/3.2 70 15.5/
(N72L19E7) 1600 1.23
Results:
All patients were managed conservatively and symptomatically with fluids, antipyretics
and bed rest. 1 patient presented with encephalopathy and expired. Rest 4 patients
improved following management and follow up was uneventful.
Conclusion:
Hepatocytes and Kupffer cells are prime targets for DENV as in case reports. Severe
hepatic dysfunction is rare. Management is primarily supportive. Care must be taken
regarding the diagnosis and use of hepatotoxic drugs.

A prospective study of HIV and visceral leishmaniasis
co-infection with special reference to treatment regimen and
peripheral blood buffy coat as a reliable diagnostic tool
___________________________________________________________________________________________
Author : Dr. Saurabh Pandey
Co-authors : Dr. Arnab Patra, Dr. Prantiki Halder, Dr. Mausam Mondal,
Dr. Soumen Nath Halder, Dr. Dipankar Pal, Dr. Madhuchanda Monadal,
Dr. Dolan Champa Modak, Dr. Subhashish Kamal Guha
Department : Department of Tropical Medicine
Introduction:
HIV-VL co-infection is as an important cause of frequent relapse of VL.. This complex
interaction has to be dealt with aggressive treatment.
Methods and materials:

Study done at department of Tropical Medicine, School of Tropical Medicine over
2 years and 30 newly diagnosed VL patients were screened for HIV. 7 were reactive
for HIV-1. 5 were followed up for 1 year. Treatment schedule was either divided or
consecutive 10 doses of injection Liposomal Amphotericin B. Outcome studied in
terms of clinical improvement, relapse, and CD4 rise. No secondary prophylaxis was
administered.
Results:
All patients were from endemic zone and 4 as males. Mean CD4 count was 213.18.
3 were newly diagnosed HIV and were ART naïve. 1 patient had atypical symptom
as absence of fever. 2 patients had hepatomegaly and previous VL. 4 were Buffy
coat positive. 1 patient had coexisting. 1 patient had creatinine > 1.5 mg/dl at end
of treatment. No death, permanent renal damage and relapse were observed.
Conclusion:
HIV-VL co-infection requires longer treatment with consecutive 10 days regimen as
good as intermittent one. It has better compliance as well as equal safety. Peripheral
blood buffy coat for LD bodies’ demonstration is an alternate reliable method and
splenic puncture should be avoided in all such patients. No relapse over 1 year was
observed.
Patient 1 Patient 2 Patient Patient 4 Patient 5

Duration of HIV illness 4 years New New New New
Spleen size- ad/6/12 m 10/ N/P 13/3/ N/P 3/ N/P 5/ 2/ N/P 2/ NP
CD4 count- admission 182 261 137 101 388
6/12 months 282/ 397 281/ 360 200/ 258 150/270 231/ 278
Treatment regimen (mg/kg)/ 4/ divided 10/ 4/ divided 10/ 4/ divided
divided/consecutive consecutive consecutive
S creatinine during /end of 1.1/ 1.0 1.2/1.1 1.2/ 1.0 1.1/ 1.6 1.0/1.3
treatment
Buffy coat positive negative positive positive positive positive
Splenic aspirate for LDB and positive positive positive positive positive
rK39 test

Sustained Virological Response following DAA Therapy in
a Chronic Hepatitis C patient -Detection by Real Time
Quantitative PCR
___________________________________________________________________________________________
Author : Dr. Shabina M.B
Co-authors : Dr. Beena Philomina J, Dr. John Britto
Institution : Govt Medical College Kozhikode,Kerala.
Hepatitis C virus (HCV) is a genetically complex, RNA virus with six recognized
genotypes. Its treatment has evolved from interferon to oral, directly acting
antiviral (DAA). Here we report a case of chronic Hepatitis C an initial non responder
to Interferon therapy who achieved sustained virological response after 6 months of
DAA treatment .
Objective:
To detect sustained virological response (SVR) in a chronic Hepatitis C patient with
genotype 1 C after 6 months of DAA(Sofosbuvir and Daclatasvir) therapy by Real Time
Quantitative PCR.
Methods:
Patient ‘s blood samples during Interferon therapy and after 3, 6 months of
DAA treatment were processed.. RNA was extracted from serum using Qiagen
RNA extraction kit and amplified using Amplisure HCV Quantitative PCR kit in BIORAD
thermocycler.
Result:
The patient’s initial load was 1.7x105 copies/ml ..He was started on Inj Pegylated
interferon 135 µg once wkly and Ribavirin 200mg twice daily .After 6 months of
therapy his load was 2.4x106 copies /ml. He was considered a non responder. For
2 yrs he was on regular follow up without treatment .With the introduction of newer
DAA he was started on Sofosbuvir 400mg od and Daclatasvir 60 mg od for 6 months in
view of his high viral load 6.5x106 copies/ml .HCV RNA was not detected after 3 and 6
months of DAA therapy thereby attaining SVR 24 .
Conclusion:
SVR is defined as aviremia 24 weeks after completion of antiviral therapy .It is the best
indicator of successful therapy determined using quantitative PCR . Our patient
achieved SVR after 6 months of treatment as shown by undetectable RNA .

Evaluation of Wound Healing Activity of Hydro-alcoholic Extract
of Syzygium Cumini Seeds in Wistar Rats.
___________________________________________________________________________________________
Author : Dr. Shadma Quazi
Co-author : Dr. Sushil Kumar Varma
Department : Pharmacology
Institution : MGIMS, Sevagram
Objective:
To provide a scientific evaluation for the wound healing potential of hydro-alcoholic
extract of Syzygium cumini seeds in Wistar rats.

Albino Wistar rats of either sex were used for the study. Excision, incision wounds
were inflicted upon four groups of six rats each. Group I was assigned as control
(ointment base). Group II was treated with HESC (hydroalcoholic extact of
Syzygium cumini seeds) 5% ointment. Group III was treated with HESC 10% ointment.
Group IV was treated with standard (soframycin) ointment. The parameters observed
were percentage of wound contraction, epithelialization period, tensile strength.
The data was recorded and analyzed, by using ANOVA.
Result:
It was noted that the effect produced by the hydro-alcoholic extract of HESC
ointment showed significant (P < 0.01) healing in all wound models when
compared with the control group. All parameters such as wound contraction,
epithelialization period, tensile strength showed significant (P < 0.01) changes
when compared with the control.
Conclusion:
The hydro-alcoholic extract of HESC ointment effectively stimulates wound contraction;
increases tensile strength of excision, incision wounds.
Keywords:
Syzygium cumini, excision injury, incision injury, wound healing, soframycin.

A Study of Gastroenteritis Outbreak Caused by
Aeromonas verionii.
___________________________________________________________________________________________
Author : Dr. Shah Pooja Gautam
Co-author : Dr. Ingole Kishor Vishwasrao
Institution : Shri Bhausaheb Hire Government Medical College, Dhule.
Work was carried out at Dr. VM GMC, Solapur
Objective:
Aeromonas belongs to family Aeromonadaceae. Aeromonas veronii causes
diarrhoea and gastroenteritis. It is Gram negative motile bacilli.The objective of the
study is to find out the cause of outbreak and to trace the source of infection.
Methods:
The present study was carried out in Microbiology department of Dr. VM GMC,
Solapur. We are reporting an outbreak due to A.verionii in which seven patients
with gastroenteritis were admitted to paediatric ward. All the Patients went for
fishing three days back to Sena river which lies at the border of Maharashtra &
Karnataka. Patients suffered from severe acute gastroenteritis. Stool samples were
collected from all the patients microscopy revealed highly motile microorganisms
and organism was identified as Aeromonas verionii. The source of infection was
traced water sampling was done from the Sena river and A.verionii was isolated from
water sampling. The isolates were sent for molecular typing & virulent gene detection.
Results:
The Antibiotic Susceptibility pattern was identical of all the strains isolated from
stool as well as water. The patients were treated with norfloxacin and were discharged
after three days. The strains were confirmed as Aeromonas veronii biovar veronii by 16S
rDNA PCR. The gene sequencing of the strain was done and the the pathogenic genes
were found out to be-dam,eno and gidA.
Conclusion:
Tracing of source must be done in cases of outbreak. Proper investigation, prompt
diagnosis and early implementation of treatment is required to prevent mortality
and morbidity.

Role of Genexpert Mtb/Rif Assay in Rapid Detection of
Spine Tuberculosis.
___________________________________________________________________________________________
Author : Dr. Shaik Jani Basha
Co-authors : Dr. Falguni Parikh
Institution : Kokilaben Dhirubhai Ambani Hospital and Medical Research Instituition
The purpose of this study was to compare the Genexpert MTB/RIF assay with
conventional methods in rapid diagnosis of spine tuberculosis and in identification
of multidrug resistant tuberculosis (MDR-TB).
Methods:
This was a prospective observational study conducted in a quaternary health care
institute, Mumbai, India from September 2014 to March 2016. A total of 79 patients
were enrolled in the study. They all underwent MRI. Image guided/surgical biopsy
or pus aspiration was done to establish the diagnosis when possible. Material
obtained was sent for Ziehl – Neilsen Stain, Real Time PCR (CBNAAT, Genexpert,
Cepheid), Mycobacterium Tuberculosis (MTB) culture (automated liquid culture, Bac T
Biomerieux) and histopathology.
Results:
Total of 79 patients diagnosed with spinal TB based on clinical and MRI findings.
There were 37 males and 42 females of age group ranging between 12 – 88 years
(median – 50.5 years). Image guided biopsy/aspiration was done in 27 patients,
Surgical operative biopsy was done in 35 patients. Biopsy material was available in
62 patients for Microbiologic tests. Of these Genexpert was done in 49 patients and
Mycobacterial culture was done in 56 patients. In culture positive patients, Genexpert
assay was detected in all AFB smear positive cases 100% (15/15) and in 62.5% (10/16)
AFB smear negative cases. The positivity rates of AFB smear, Genexpert MTB/RIF
assay and MTB culture in our study were 30.6% (15/49), 61.2%(30/49) and 63.3%(31/49)
respectively. There were 11 patients who were found to have MDR–TB of which 7 were
male and 4 female. Eight were detected by Genexpert assay and later confirmed on
MTB culture and sensitivity.
Conclusion:
Genexpert test allows prompt diagnosis of TB and modification of treatment
regimen if needed as rifampicin resistance is a surrogate marker of MDR TB. Tissue
diagnosis, Genexpert, Mycobacterial culture should form part of diagnostic workup
of spine TB.

Emergence of Colistin Resistance among Pseudomonas
aeruginosa in Urinary Tract Infections from Super Specialty
Hospital of North Delhi
___________________________________________________________________________________________
Author : Dr. Shakti Jain
Department : Microbiology Department
Institute : Max Super Speciality Hospital, Shalimar Bagh, New Delhi, India
Objective:
As the use of colistin is increasing due to the increasing prevalence of multi
drug resistant gram negative bacteria (GNB). Increasing prevalence of
carbapenem resistant GNB is a serious clinical and public health challenge
because the treatment options are limited to colistin, Tigecycline etc. Colistin
resistance is being increasingly reported in Indian hospitals. Bacteria resistant to
all available antibiotics (Pan Drug Resistance) is also increasing and left no
treatment option. Resistance to colistin is a major threat that limits therapeutic
choices for treating carbapenem-resistant Pseudomonas aeruginosa infections.
We hereby report the prevalence of colistin resistant Pseudomonas aeruginosa
from urinary tract infection.
Methods:
This study was performed from January 2016 to December 2016 in Max Super
Speciality Hospital, Shalimar Bagh, New Delhi, India. A total of 201 out of 2273 positive
urinary isolates of Pseudomonas aeruginosa were included in this study. Identification
and sensitivity was conducted by Vitek 2 compact automated system. Susceptibility of
colistin was interpreted according to the Clinical Laboratory Standards Institute (CLSI
2016) guidelines.
Results & Conclusions:

Colistin resistant was 18% and carbapenem resistant was 60% out of 201 isolates of
Pseudomonas aeruginosa from urinary samples. Resistance of colistin against
Pseudomonas aeruginosa is increasing which is alarming and it is the right time to use
colistin judiciously. Isolation of Pseudomonas aeruginosa may be colonization and
should be differentiate from true infection before starting treatment.

Rare Incidental Finding of double Malignancy with underlying
cause being Chronic Syphilis.
___________________________________________________________________________________________
Author : Dr. Shantanu Roy
Co-authors : Dr. S.N.Pore, Dr. A.R.Joshi, Dr.R.S.Bindu
Institution : Government Medical College, Aurangabad.
Introduction:
The problem of the influence of syphilis upon the neoplastic process in general has
not been solved. Some investigators, on one hand, have ascribed to syphilis an
etiological role. Others deny any relationship between the two diseases. The consensus
of opinion, however, is that an interrelation exists between the two. In addition to a
causative role,syphilis affects clinical course of tumour through the personal equation
involved or through some alteration in the pathology of the disease.
Materials and method:

Haematoxylin and eosin stained histopathological slides. Case history: We, present
a case of 30 years old female, who presented in the OPD with complaints of
white curdy discharge coating labia minora with vegetative growth,slightly tender.
She had a swelling over labia majora with varicosities over upper thigh bilaterally.
History of vaginal prolapse was also present. Patient has been taking treatment for
CondylomaLata but not responding to it.On examination, significant findings were
two matted lymph nodes in left inguinal region, non tender, of size 4x3 cm.
Investigations:
Ultra rapid test for syphilis was positive. Histopathological examination was done
of two biopsy specimen received as;
a) Vulval biopsy specimen: On gross, tissue piece of size 1x0.5 cm, externally
whitish in color, firm in consistency. Microscopically, features are suggestive
of Moderately differentiated Adenocarcinoma.
b) Vaginal growth specimen: On gross, tissue piece of size 1x1 cm, whitish in
color, friable. Microscopically, features are suggestive of Squamous cell
Carcinoma Grade II.
Discussion:
To a lesser degree, the opinion is held among pathologists and clinicians that cancer
is more highly malignant in the syphilitic patient. Leaving syphilis untreated during the
treatment of cancer, may worsen the prognosis.
Key words:
Syphilis, Adenocarcinoma, Squamous cell Carcinoma.

Epidemiology of Diphtheria In Kerala – A Year After Onset
___________________________________________________________________________________________
Author : Dr Sheela Mathew
Institution : Govt. Medical College Hospital Kozhikode, Kerala
Kerala is still experiencing the diphtheria epidemic which started in June 2016.
Despite wide vaccination coverage the disease is spreading and affects more
districts of Kerala. It involves both rural and urban areas and involves more
females. Very few household contacts are involved, but disease seems involving mainly
house bound females. In this study the epidemiological trends are reviewed.
MONTH WISE ADMISSION IN CURRENT EPIDEMIC
JUNE 4
JULY 102
AUGEST 64
SEPTEMBER 20 Total No 279
OCTOBER 15 Females 155
NOVEMBER 5 Males 124
DECEMBER 12
JANUARY 12
FEBRUARY 12
MARCH 5
APRIL 11
MAY 12
District wise distribution

Kozhikode 145 Palakad 6
Kannur 10 Wayanad 15
Malappuram 97 Others 6
<20 102
20-29 81
30-39 60
40-49 20
50- 59 7
>60 6
MAXIMUM AGE 65
IMMUNISATION STATUS
Fully immunised 115
Partially immunised 19
Unknown 74
Unimmunised 71

Duration of illness varied from 1 day to 10 days. Sore throat alone was the
presenting symptom in 12 patients. Majority (259) had fever, & sore throat. Dysphagia
was complained by 24 patients. Other symptoms included myalgia (5), headache (9),
palpitation & breathlessness (2) and cough and epistaxis(2).
Membrane was present in 270 patients. Those who were not having membrane
were admitted because of culture positivity. One patient was admitted later with
cardiac failure. Membrane was bilateral in 174 patients.46 had Left tonsillar
membrane and 44 had Right tonsillar membrane. Membrane was seen on
posterior pharyngeal wall alone in 6 patients.3 patients showed membrane
extension to palate. Membrane was seen on the epiglottis in 1 patient. None of the
patients showed nasal membrane. Bilateral lymph node enlargement was seen in 127
patients.46 patients with membrane did not have lymph node enlargement.
156 patients were given antitoxin. Among them 13 patients didn’t tolerate antitoxin.
27 patients could not tolerate crystalline penicillin. They were given erythromycin.
3 patients were given higher dose penicillin as they reined febrile and toxic after 48 hrs.
ECG abnormalities were observed during first week itself ; 179 patients had some
form of ECG changes.4 patients were readmitted because of complications, which
included peripheral neuropathy, palatal palsy, cardiac failure and unilateral upper
limb edema.
3 patients expired during the hospitalized period.
The epidemic is continuing and all the patients are under follow up also.

Diffuse alveolar hemorrhage & anterior spinal artery thrombosis
in Leptospirosis
___________________________________________________________________________________________
Author : Dr Sheela Mathew
Co-authors : Dr. Deepu Sasidharan
Institution : Govt. Medical College Hospital Kozhikode, Kerala
Diffuse alveolar hemorrhage is one of most serious pulmonary complication of

leptospirosis. Leptospira initiates an autoinflammatory response and results in
deposition of Ig G , Ig A , C 3 in lung tissue. High dose steroids are considered to be
effective adjuvant in the treatment.CNS manifestations of leptospirosis can be
Asceptic meningitis, Meningoencephalitis ,Demyelination Polyneuritis & Vasculitis -
can present as stroke. Here we present a case of Leptospirosis with Diffuse alveolar
hemorrhage, anterior spinal artery occlusion, & internal jugular vein thrombosis in same
patient.
22 year old male, presented with h/o Fever, Myalgia , Headache &Yellowish
discolouration of urine. On the day of presentation he had dyspnea. O/E He had
Tachypnea, Conjunctival congestion, &Calf muscle tenderness. Pulse rate -123 / mt,
Blood pressure – 110/ 80 mm Respiratory rate – 36 / mt SPO2 76%; Chest – bilateral fine
basal crepitations ;CVS – S 3 present; Abdomen – hepatomegaly.
TC – 17400 RFT -38 / 1.6

DC – P 82% SE -124/ 4
HB -12.7 TB/DB – 2.2/ 1.2
MCV-83 TP / ALB- 5.7/ 2.8
HCT – 37 SGPT- 78
PLT -81000 ALP – 108
ESR - 90 INR – 1.86
URE – ALB – TRACE APTT – 50
pus cells- 15-20 IGM LEPTOSPIRA –POSITIVE
RBC- 3-4 / hpf
Patient was started on antibiotics and supportive measures. His fever & dyspnoea
decreased.Later he developed cough , chest discomfort with blood streaking of sputum
.Xray showed bilateral interstitial shadows suggesting diffuse alveolar heamorrhage.

Started on methyl prednisolone pulse for 3 days.On day 3 of steroid developed
acute onset numbness below the chest involving both lower limbs and urinary
retention followed by weakness of both lower limbs. O/E Hypotonia ;sluggish reflexes
of both lower limbs with grade 2 power ;Plantar bilateral extensor; Pain and
temperature sensations decreased below the xiphisternum ; position and vibration
sense preserved & examination was consistent with anterior spinal artery occlusion
MRI was confirmatory and showed evidence of internal jugular vein thrombosis
additionally. The markers of coagulaton were negative and patient survived.

Trends in antibiotic susceptibility pattern of lysine-positive
non-fermenters over ten years (2007-2016)
___________________________________________________________________________________________
Author : Dr. Shveta Sethi
Co-authors : Dr. Sunil kumar, Dr. Pallab Ray, Dr. Vikas Gautam
Department : Medical Microbiology
Institution : Post Graduate Institute of Medical Education and Research,
Chandigarh, India
Objectives:
Amongst the four most common nonfermenters that include Burkholderia
cepacia complex and Stenotrophomonas maltophilia, to analyse antibiotic (Ab)
susceptibility pattern of these two lysine positive nonfermenters over the last 10 years
(2007-2016).
Methods:
Retrospective data of Antibiotic sensitivity pattern of B. cepacia complex and
S. maltophilia for minocycline, levofloxacin, co-trimoxazole, ceftazidime and
meropenem have been analysed and compared with the previous studies. The
identification was done by conventional methods (upto 2013) and later by MALDI-TOF.
Their Antibiotic susceptibility was conducted by Kirby‑Bauer disc diffusion method
according to CLSI (Clinical & Laboratory Standards Institute) guidelines. Some of
the isolates which were identified as Burkholderia cenocepacia (by MLST) were
subjected to MIC testing.
Results:
In 2016, for S. maltophilia, minocycline showed sensitivity of 96%, levofloxacin 94%,
co-trimoxazole 87%. Compared to the previous years sensitivity to levofloxacin (80-94%)
has shown increasing trend while there is decrease in susceptibility of co-trimoxazole
(90-87%) and minocycline (100-96%).
In 2016, among B. cepacia complex, (99% Burkholderia cenocepacia),

minocycline showed sensitivity of 74%, co-trimoxazole 89%, ceftazidime 65%,
meropenem 43% sensitivity. The sensitivity to co-trimoxazole (80-89%) has increased
over the years. The sensitivity to minocycline (100-74%), meropenem (60-43%),
ceftazidime (83-65%) had shown progressive decline compared to last years. Results
of MIC will be discussed in full paper.
Conclusion:
There is a decline in Ab susceptibiblities for both nonfermenters. For S. maltophilia
minocycline and in B. cenocepacia co-trimoxazole are the better choices among
all antibiotics. S. maltophilia showed better sensitivity pattern compared to
B. cenocepacia. Based on the previous studies, and present study levofloxacin can
be considered as a good alternative for S. maltophilia. Formation of a standard
Antibiotic policy further emphasizes the importance of correct identification as well
as Antibiotic sensitivity analysis of such MDR bugs in routine settings.

Antimicrobial Resistance Pattern of Klebsiella Species from
Different Clinical Sample at a Tertiary Care Centre at Kanpur
___________________________________________________________________________________________
Author : Dr. Shweta Bajpai
Co-author : Dr. R.Sujatha
Institution : Rama Medical College Hospital & Research Center, Kanpur
Background:
Klebsiella Species has become one of the more common causes of community as
well as hospital acquired infections. This study was conducted to determine the
isolation rate of Klebsiella, their antibiogram in a tertiary care centre at Kanpur.

A total number of 50 Klebsiella species were isolated from different clinical
samples during March 2017 to May 2017 and identified by standard microbiological
methods. Antibiogram were determining by standard protocol according to CSLI
guideline. carbapenamase and ESBL production were determine by CDDT.
Result:
Of 50 Klebsiella Species 27 were K.pneumoniae and rest 23 were K.oxytoca. The
most prevalent infection caused by K.pneumoniae were respiratory tract
infection (48.14%,13 out of 27) followed by urinary tract infection (33.33%,9 out of 27),
bacterimia (11.11%, 3 out of 27) and pyogenic infection(7.4%, 2 out of 27). K.oxytoca
caused urinary tract infection (56.52%, 13 out of 23) followed by respiratory tract
infection(34.78%, 8 out of 23) and wound infections(8.6%, 2 out of 25). A male Females
ratio was 1:1.2 and above 60 years of age was more affected. K. pneumonia was
found to be 100% sensitive to polymyxin and tegicyclines. 82% Klebsiella exhibited
resistant to carbapenems 66.66% K.pneumoniae and 69.56% k.oxytoca were ESBL
producers. Among Klebsiella isolates76%, 80%, and 90% were resistant to amikacin,
ciprofloxacin and cefixime respectively.
Conclusion:
The data of this study revealed the resistance to commonly used antibiotics.
Because of the high risk for developing resistance during treatment, all severe infections
should be carefully watched during therapy.
Keywords:
Antimicrobial Resistance, Klebsiella Species, ESBL

To study new focus of Visceral Leishmaniasis in recent
times based on the patient profile admitted in Sir Sunderlal
Hospital,BHU.
___________________________________________________________________________________________
Authors : Dr. Siddharth Jain,
Co-authors : Dr Navneet Agrawal, Dr Aman Chaudhary, Prof Jaya Chakravarty,
Prof Shyam Sundar.
Institute : Institiute of Medical Sciences, BHU
Introduction & Background:

Leishmaniasis is a parasitic disease caused by hemoflagellate parasite, a
unicellular eukaryotic protozoa of the genus Leishmania.It is caused by around
20 species of leishmania transmitted by phlebotomise sand flies.
Leishmaniasis manifests in three forms : visceral leishmaniasis (VL), cutaneous

leishmaniasis (CL) and mucocutaneous leishmaniasis (MCL).VL is the most severe form
and is commonly reported form while exact distribution of other two forms is not clear.
Epidemiology :
The annual incidence of Kala Azar (KA) is between 201,500-378,500 of which more
than 90% occurs in six countries :Bangladesh, Brazil , Ethiopia , India, Nepal, Sudan.
India alone accounts for 50% of global burden of leishmaniasis.
Kala Azar is at present endemic in 54 districts in the country of which 33 districts of

Bihar , 4 of Jharkhand, 11 of West Bengal and 6 districts of UP.There has been decrease
in cases from 38% to 33 % between 2011 to 2014 with few unreported cases.We studied
the current scenario of the disease distribution in districts in Bihar and UP.

As discussed above Leishmaniasis is endemic in certain districts in Bihar and UP
with majority of them being treated in our centre.The commonly reported districts in
Uttar Pradesh include 6 districts : Balia,Deoria,Gazipur,Gorakhpur,Kushinagar,
Gonda and 10 major districts in Bihar : Muzaffarpur,Madhepura,Purnia,Sahara,
Samastipur,Saran,Sitamarhi,Vaishali,Arabia and east champaran.
We mapped the districts from where cases of leishmaniasis are admitted in our
centre in last 2 years between 2015-2017 and compared with the old scenario reported
from our centre and found sporadic cases in new districts from where cases haven't
been reported earlier suggesting shifting of infection to new regions in addition to older
ones.
Results and conclusion:

Based on our study of disease distribution we found development of sporadic
cases from non-endemic regions surrounding endemic regions in both UP and
Bihar including 2 sporadic cases from Madhya Pradesh suggesting shifting of or
spread of infection and need to further potentiate programmes in these regions to
fulfill the goal of disease elimination.

A RARE CASE OF BCG-OSIS
___________________________________________________________________________________________
Author : Dr. Silpita Katragadda
Co-authors : Dr. Suneeta Narreddy, Dr. Ravi Kiran Barigala, Dr. Sanjay Sinha,
Dr. Amina Sheik
Institution : Apollo Hospitals, Hyderabad 
Introduction:
Intravesical administration of Bacillus Calmette-Guerin (BCG), a live attenuated
strain of Mycobacterium bovis, has become a mainstay of adjunctive therapy for
superficial urothelial bladder cancer. Generally it is well tolerated, but sometimes
local or systemic BCG infection can occur. Here we present a rare case of
disseminated BCG infection.
Case Description:
69 year old male with carcinoma bladder post trans-urethral bladder resection
and currently on intravesical BCG presented with fever and dysuria for 7 days.
Transient self limiting dysuria and frequency of micturition occurred after each
intravesical instillation of BCG. Urine grew ESBL Escherichia coli and he was
appropriately treated. Fever reappeared after completing the course of antibiotics.
Urine and blood cultures were sterile. PET CT of the whole body was negative for
hypermetabolic activity. Bone marrow biopsy showed multiple non-caseating
granulomas at inter-trabecular spaces. He also developed hyperbilirubinemia. He was
started on a three drug anti-tuberculous treatment (ATT) regimen (rifampin, isoniazid,
ethambutol). He improved symptomatically, LFTs normalized and is doing well on follow
up.
Discussion:
Although serious complications following intravesical BCG are rare, systemic
infections and sepsis can occur. This risk may be increased if BCG is instilled too early
following surgery or after traumatic catheterization. Acid fast bacilli staining,
histological demonstration of granulomatous inflammation, mycobacterial culture,
PCR based assays are diagnostic. Mycobacterium bovis is susceptible to most of
the anti-tubercular drugs except pyrazinamide and cycloserine. Localised cystitis
can be treated with a short course of fluoroquinolone or isoniazid. Systemic infections
need combination ATT for 3-6 months with corticosteroids for hypersensitivity related
symptoms.There are no obvious predictors of risk for serious BCG infection and no
proven methods of prophylaxis. Hence,clinicians need a high index of suspicion
to promptly treat patients with unexplained symptoms following BCG therapy even
if PET CT says otherwise.

Comparison of Direct Examination and Culture in Various
Mycological Infections
___________________________________________________________________________________________
Author : Dr. Sneha Kukanur F
Co-authors : Dr. Naveen G
Institution : Karwar Institute of Medical Sciences, Karwar
Objective:
To evaluate the ability of KOH preparation and fungal culture to detect the fungus in
the given sample.

The study was conducted for a period of three months in a rural tertiary care
hospital. All samples suspected for mycological infections received at our clinical
laboratory were subjected to KOH (10%) preparation. Under 40x, the specimen was
observed for hyphae, arthroconidia, yeasts etc. within 3 hours of preparation.
Further the specimen was inoculated onto Sabouraud dextrose agar with
chloramphenicol and cycloheximide using sterile technique. The inoculated media
were incubated at 250 C and room humidity. Cultures were read at weeks 1, 2 and 3.
Culture was reported negative after 4 weeks of incubation. For cultures with growth,
a lactophenol-cotton blue preparation was made. Fungi were identified on
macroscopic (i.e., color, texture, rate of growth, pigment production) and microscopic
(i.e., microconidia, macroconidia, hyphal elements) morphology.
Results:
Out of 63 suspected samples sent from various Outpatient departments,
35 samples were KOH positive and 21 samples were culture positive. Two cases were
culture positive but KOH smear negative. Various cases from Outpatient departments
included rhinocerebral mucormycosis(1), lung mycosis(1), Tinea pedis(2), Tinea
capitis(3), Vulvovaginal candidiasis(9) and keratomycosis(5). The fungi isolated
were Rhizopus oryzae, Aspergillus fumigatus, Trichophyton rubrum, Epidermophyton
floccosum, Microsporum spp., Fusarium spp., Candida albicans, Candida glabrata
and other non albicans Candida spp. Sensitivity and specificity of KOH preparation
were 90.4% and 66.6% respectively. Sensitivity and specificity of fungal culture were
60% and 100% respectively.
Conclusion:
KOH smear and culture are complimentary diagnostic modalities. KOH is a
good screening test whereas culture is the specific test and considered as gold
standard.

Antimicrobial Utilization Pattern in Cases of Neonatal Sepsis
in NICU of Tertiary Care Hospital in Rural area : A Cross Sectional
Study ”.
___________________________________________________________________________________________
Author : Dr. Sonali Kirde
Co-authors : Dr. Bhalchandra Awari, Dr. Sushil kumar Varma
Institution : Pharmacolgy Deptt,MGIMS,Sewagram Wardha.
Objectives:
To explore and describe the current pattern of antimicrobials prescribing practices
and utilization in neonates with sepsis.

A cross sectional study conducted in the patients with Neonatal Sepsis admitted
to NICU of paediatric department of a tertiary care teaching hospital. Approval of
the institutional ethics committee was sought before commencing the study.
Inclusion Criteria :
1. Confirmed or suspected cases of neonatal sepsis.
2. Age group from 0-28 days.
3. Either sex
4. Duration of stay for minimum 3 days
Exclusion Criteria :
1. Neonates expired within 24 hrs.
2. Neonates referred to higher centre for surgical management.
3. Neonates having gross congenital anomalies.
4. Age more than 28 days.
Results:
• The commonest organism isolated was Staphylococcus aureus followed by
Klebsiella pneumonae and least organism isolated was Citrobacter freundii.
• Majority of neonates are prescribed 2 or 3 antibiotics and only one neonate
received 6 antibiotics in their whole course of NICU stay.
• Most frequently used antibiotic was Amikacin followed by Ampicillin and
Gentamicin and least preferred was Ciprofloxacin.
• Vancomycin, Linezolid were the most sensitive antibiotics for gram positive
organisms causing neonatal sepsis.
• Meropenem, Cefttazidime, amikacin were the most sensitive antibiotics for
gram negative organisms causing neonatal sepsis.
Conclusion:
Present study gives an overall pattern of antimicrobial utilization pattern in patients
of neonatal sepsis in NICU of a tertiary care hospital where antimicrobial combinations
are seen to be the mainstay of treatment of neonatal sepsis as empirical regimens and
also as the second line regimens in proven sepsis cases with respect to clinical decision.

Unknown Bite presenting as Acute Kidney injury ,
Lymphadenopathy and Bone Marrow Infection
___________________________________________________________________________________________
Author : Dr. Srikanth Yadav
Co-author : Dr Basava Prabhu
Institution : Kmc Mangalore
Introduction:
Unknown bite infection is very common with an estimated cases of around
10 million per year in India which can be life threatening. We are presenting an
intresting case of unknown bite infection where patient developed cellulitis ,sepsis,
AKI, and lymphadenopathy.
Case Report:
55 year old male came with complains of Unknown bite over left lower limb and
was conservatively managed before and discharged. After a week he came
with complaints of fever, breathlessness and left lower limb swelling. On examination
vitals were stable, lymphadenopathy was present .HB-13.9 Wbc-14,800 Plt-52000
Urea-105 Creat-7.2 diagnosed to have cellulitis, AKI, sepsis. Inspite of antibiotic
treatment patient had persistent fever spikes and on further evaluation wound
swab and bone marrow culture has grown MRSA. Patient was started on Vancomycin,
Rifampicin, Linezolid in view of severe sepsis and AKI. His renal parameters improved
gradually and was discharged after 40 days of hospital stay.
Conclusion:
From this case we can conclude that every unknown bite should not be managed
conservatively. An extensive evaluation has to be done apart from the routine
investigations as in this case, which has surprisingly grown MRSA in the bone marrow.

Acute Pancreatitis Due To 2009 Pandemic Influenza A Virus
(pH1N1)
___________________________________________________________________________________________
Author : Dr Srinivasa Reddy
Co-authors : Dr Deepak Madi, Dr John Ramapuram
Institution : Kasturba Medical College ,Mangalore
Introduction:
H1N1 influenza usually causes self-limiting flu-like illness. It can also cause pneumonia
and ARDS.Encephalitis,Guillain-Barre syndrome and myocarditis are unusual
complications of H1N1. Acute pancreatitis is a rare complication of H1N1 influenza
infection. Here we are reporting a case of acute pancreatitis due to H1N1 from South
India
Case report:
62-year old gentleman presented to medicine department with 1week history
of low grade fever, cough and breathlessness. He was recently detected to have
diabetes mellitus.On examination he was febrile and his respiratory rate was 24/min.
His saturation was 82% with 4 litres oxygen. Respiratory system examination showed
bilateral crepitations . ABG showed type 1 respiratory failure . His random blood
sugar was – 650mg/dl. Throat swab came positive for H1N1 influenza . Chest Xray
revealed bilateral pneumonia.Blood culture showed no growth. Oseltamivir 150 mg BD
was initiated .After 2days of admission, patient complained of severe upper abdominal
pain radiating to back. On evaluation serum amylase was 134mg/dl and serum lipase
was 252mg/dl .Serum lipase increased to 679mg/dl on fourth day of hospital admission.
CECT abdomen revealed acute oedematous grade 2 pancreatitis.He was treated with
broad spectrum antibiotics. The patient was discharged after 15days of hospital stay.
Serum lipase was normal on follow up visit after 1 week.
Conclusion:
H1N1 cases are increasing in India. Diagnosis of acute pancreatitis should be
considered in H1N1 patients who complain of abdominal pain.Physicians must be
aware of this entity as timely diagnosis decreases morbidity and mortality .

Cervicofacial Melioidosis: A Case-Series From An Emerging
Foci Of Probable Endemicity
___________________________________________________________________________________________
Author : Dr. Srujana Mohanty
Co-authors : Dr. Saurav Sarkar, Dr. Sagarika Dhal, Dr. Jyotirmayee Turuk,
Dr. Snigdharani Choudhury, Dr. Baijayantimala Mishra
Department : Microbiology and Otorhinolaryngology.
Institution : AIIMS Bhubaneswar, Odisha
Objective:
Melioidosis, caused by Burkholderia pseudomallei, is increasingly being recognized
in several regions of the globe. Especially prevalent in rural India, diabetes and
alcoholism are the commonest risk factors. Both sepsis with bacteremia and localized
disease involving joints or focal abscesses are common presentations. The largest
clustersof cases from India has been reported from Western Coastal region of South
India. We present seven cases of cervicofacial melioidosis from a tertiary care institute
of Eastern India, highlighting the existence of a probable, as yet undiscovered, hidden
endemic focus in the Eastern Coastal region of India.
Methods:
The demographic profile, risk factors and treatment outcome of patients presenting to
our hospital with culture-proven B. pseudomallei abscesses in the cervicofacial region
are discussed.
Results:
Of the seven patients, six were female and one was male with age range 5 to
49 years. Six patients had cervical abscess, while one had parotid abscess. Four
presented with left-sided and three with right-sided abscesses. Two patients had
diabetes. All seven B. pseudomallei isolates were susceptible to trimethoprim -
sulfamethoxazole and meropenem, while one isolate was resistant to ceftazidime
and three to amoxicillin- clavulanate. All the patients were managed with incision
and drainage alongwith administration of parenteral ceftazidime or meropenem
for a minimum duration of two-weeks with advice of oral trimethoprim -
sulfamethoxazole therapy for 6-months. All had a favourable outcome at 3-months
follow-up.
Conclusion:
Cervicofacial melioidosis is an emerging entity in the Eastern region of India,
affecting mostly females. An increased awareness has likely contributed to the
increasing number of cases being diagnosed, unravelling the existence of a
probable endemic focus. Melioidotic abscesses in the cervicofacial region may
likely be confused with cold abscesses caused by Mycobacterium tuberculosis in
a tuberculosis endemic country like India. Hence, the need to correctly identify
and distinguish between the two disease entities cannot be overemphasized because
of the widely divergent treatment modalities of the two conditions.

Observations from a follow up study on elderly persons with HIV
in a tertiary centre of Eastern India
___________________________________________________________________________________________
Author : Dr. Subhayan Bhattacharya
Co-authors : Dr. B Bhattacharjee, Dr. S Mallik, A Naskar, Dr. MK Ghosh & B Saha
Background:
With increasing awareness, the mean age of diagnosis of HIV is rising. Associated
comorbidities accelerate the disease. They also have less support from care givers.
Consequently they carry a high range of mortality, poor control and adherence.
Present study aims to observe the presentation, opportunistic infections, co-morbidities

and outcome of treatment in elderly HIV patients.
Methods:
Data of patients aged more than 50 years admitted in the hospital and subsequently
registered for antiretroviral therapy from 1st January 2013 to 31st December, 2015 were
recorded. They were followed up till 31st December 2016. Data is analyzed using SPSS
with approval from the Ethical Committee.
Results:
91 patients (68 males) with mean age Male 57.25±6.32 and Female 56.47±5.98
years were studied. High risk sexual behavior was admitted by 61 males and 4 females.
Median CD4 count at the time of presentation in females[255 (IQR=71-325)] is
significantly higher than males[98 (IQR=41-195)] (p<.001).Extrapulmonary tuberculosis
was the commonest opportunistic infection (19.1% males, 30.4% females) followed
by cryptococcal meningitis (14.7%).Of 55 males started on ART, 3 were lost to follow
up, 13 died. Of 39 alive, drug regimen changed in7 for failure and 9 for toxicity. Of 17
females started on ART, 4 were lost to follow up, 4 died. Regimen modified in 2 for failure
and 3 for toxicity. Total 22 males and 6 females of study population died. Among the
48living patients on ART, (39 male and 9 female) 45 (37 male and 8 female) showed
improvement of CD4 count during follow up.
Conclusion:
74.7% were male. Mean age was 57.054±6.21 years. Extrapulmonary tuberculosis
was commonest opportunistic infection. Median CD4 at presentation was significantly
higher in females.
Total 22 males and 6 females of study population died.
Among 48 patients alive on ART, 45 (93.75%) showed CD4 count improvement during
follow up.

MIC creep in Glycopepetides - A Myth or Reality?
___________________________________________________________________________________________
Author : Dr. Sudarsana J
Co-authors : Dr. Anjuna Mohan
Institution : Baby Memorial Hospital, Kozhikode, Kerala
Objectives:
The role of Vancomycin in the treatment of MRSA has been questioned and
debated due to an increase in the distribution of higher Vancomycin MIC values
but within the susceptibility range proposed by the Clinical Laboratory Standards
Institute (CLSI), so called “MIC creep”.These MRSA isolates have raised serious
concern because patients infected by these strains are less responsive to Vancomycin.
E test is considered to be one of the standard measurement methods for determining
the MIC of S. aureus with reduced susceptibility to Vancomycin and Teicoplanin.
This study was proposed to evaluate the MIC trends of Glycopeptides against MRSA
isolates in a tertiary care hospital using micro broth dilution method (BD Phoenix 100)
and E test.
Methods:
This prospective study was conducted at the Microbiology department of Baby
Memorial Hospital, Kozhikode during the period of 3 months from 18th December 2016
to 17th March 2017. Fifty MRSA isolates were collected and their susceptibility test
for Vancomycin and Teicoplanin were done by E test and BD Phoenix 100( Micro
broth dilution method)
Clinical samples collected from both in patients and out patients of Baby Memorial
Hospital were processed for culture in the Microbiology laboratory. All Staph
aureus isolates were identified using standard microbiological methods. Only one
MRSA isolate per patient was included in this study. Methicillin susceptibility testing
was performed using the Cefoxitin disc diffusion method in accordance with the criteria
of CLSI. Vancomycin and Teicoplanin MIC determination was performed using the E
test method, according to the manufacturer’s guidelines.
Results:
• Of the 50 MRSA isolates 47(94%) were susceptible to Vancomycin </=2µg/ml by
E Test.
• 26 (52%) isolates had MIC of 3µg/ml by E Test to Vancomycin showing MIC creep.
• 3(6%) MRSA isolates had Vancomycin MIC 4µg/ml which are categorized as VISA.
• All the 50 MRSA isolates were susceptible to Teicoplanin </=8µg/ml by E Test.
• 4 (8%) isolates had MIC 8µg/ml. Though technically they are susceptible to
Teicoplanin, there is a MIC creep within the breakpoint.
• The 17 MRSA isolates, tested both by BD Phoenix and E Test had Vancomycin and
Teicoplanin MIC </=1µg/ml by BD Phoenix method.
• When these isolates were tested by E Test there exists a larger discrepancy in the MIC
values of Vancomycin and Teicoplanin.
• The BD Phoenix 100 method has been associated with underestimation of
Vancomycin MIC when compared to E Test.
Conclusion:
In conclusion, a decrease in Vancomycin susceptibility in MRSA isolates was detected
by the E Test. A matter of concern is that a discrepancy exists in the Vancomycin and
Teicoplanin MIC obtained between E Test and the BD Phoenix 100. E Test should be
the method to estimate Vancomycin MIC in critical high inoculum infections to avoid
treatment failure.

Assessment Of Serological Assays For Solving the Dilemma
Between Acute Hepatitis (AHB) And Chronic Hepatitis B with
Acute Exacerbation (CHB-AE).
___________________________________________________________________________________________
Author : Dr. Sujata Lall
Co-authors : Dr. Pragya Ranjan, Dr. Guresh kumar, Dr. Ekta Gupta
Institution : Institute Of Liver and Biliary Sciences,New Delhi
Objective:
To differentiate AHB and CHB-AE with simple and effective serological tools which
present as major diagnostic dilemma clinically at the time of initial presentation.
Methodology:
A retrospective study was done from May 2016 to May 2017 on 172 (male=131,
female =41) patients with serological confirmation of acute hepatitis B infection (HBsAg
and HBcIgM positive) .Patients were grouped as; AHB (n=89) and CHB-AE (n= 83) based
on the clinical history and loss of hepatitis B surface antigen within 6 months.ALT levels
five times the upper limit of normal and more than twice the baseline value was taken
as inclusion criteria in both groups. Patients with co-infection with any other hepatitis
virus: HCV, HEV and HAV were excluded. Chemilluminiscent microparticle
immunoassay Architect i1000sr was done to quantify IgM Core antibody ,hepatitis
Be antigen( HBeAg) ,hepatitis B surface antigen quant(HBsAg Quant). Real time PCR
using Cobas Taq Man Assay was done for measuring HBV viral load. Various markers
were analyzed in both the groups.
Results:
On multivariate regression the two groups were comparable with respect to
features like prodrome, onset of jaundice (within 4 weeks), serum Bilirubin levels mg/
dl (AHB-median17,7.05-22.85 CHB-AE median 15.4,4.3-26.47)and albumin(AHB median
3.207,CHB median 2.9,2.4-3.7).HBV markers like HBeAg (p value 0.644), HBsAg Quant,
(p value 0.498)HBV DNA levels(p value 0.937) were also comparable. Only IgM
anti –HBc levels were different in both the groups, AH(S/Co ratio: 29.15±8.47) and
CH-AE(S/Co ratio 11.48±11.12) ,p value<0.01.A value of 17.5 HBcIgM could diagnose
AHB from CHB-AE easily(sensitivity 97%,specificity 84% and area under ROC curve .95).
Conclusion:
IgM anti Hbc can act as significant independent predictor of Acute Hepatitis B and can
differentiate between AHB and CHB-AE.

Purpura Fulminans in Adults - Aetiology and Outcomes
___________________________________________________________________________________________
Author : Dr. Sumayya Abdul Kalam
Co-authors : Dr. Ronald Albert Benton Carey, Dr. O C Abraham,
Dr. John Antony Jude Prakash
Institution : Christian Medical College,Vellore
Introduction:
Purpura fulminans is a rare syndrome of intravascular thrombosis and infarction of
the skin which is characterized by development of non blanching haemorrhagic
purpura often accompanied by Disseminated intravascular coagulation.
Objective:
To analyse the clinical characteristics, risk factors, aetiology and outcomes of adult
patients (> 18 years)diagnosed with purpura fulminans.
Methods:
We did a retrospective chart review of patients diagnosed with purpura fulminans over
a 12 year period (2005 –2017) in the department of General Medicine.
Results:
There were a total of ten patients diagnosed to have purpura fulminans between 2005
and 2017. Six patients (60%) were males. Nine (90%) cases were from Tamil Nadu and
one(10%) from Andhra Pradesh. Majority of the patients had an acute undifferentiated
febrile illness (70%) while others had acute meningoencephalitis (30%) Four patients
had Type 2 Diabetes Mellitus and one had HIV infection. All patients had fever and
skin lesions at presentation. Distribution of skin lesions were in bilateral limbs in 9(90%)
patients. Multiorgan dysfunction and DIC was seen in six patients (60%). Blood cultures
grew Neisseria meningitidis,Staphylococcus aureus and Aeromonas in 1 patient each.
Four patients had serology confirmed rickettsial infection of which two were found to
have positive Weil Felix reaction and two 2 tested positive serology for Spotted fever.
One patient had Dengue haemorrhagic fever. Peripheral gangrene occurred in 3(30%)
patients.
Five (50%) patients required ICU care and death occurred in 4(40%) patients. Of the
four patients who were discharged alive, two had rickettsial infection. Two patients left
against medical advice.
Conclusions:
Purpura fulminans is a rare entity but has a high mortality. .Rickettsial infections were
common and had better outcomes when compared to bacterial infections. Empiric
therapy for patients with purpura fulminans should include treatment for bacterial as
well as rickettsial infections.

Prevalence of mupirocin resistance in Staphylococci isolated
from skin and soft tissue infection
___________________________________________________________________________________________
Author : Dr. Tanya Mohindroo
Co-authors : Dr. Kalpana Date, Dr. Umesh Hassani
Institution : NKP Salve Institute of Medical Sciences
Introduction:
Mupirocin (pseudomonic acid A) is a topical antimicrobial agent with excellent
antistaphylococcal activity. It is used to treat superficial skin infections and
control spread of MRSA, which is now endemic in India. The increased pressure of MRSA
infections among patients and its carriage in health care staff has led to indiscriminate
use of mupirocin which has resulted in emergence of its resistance. Mupirocin
susceptibility is categorized into: low level mupirocin resistance with MIC of ≤ 4 µg/ml,
and high level mupirocin resistance with MIC ≥ 200 µg/ml.
Aim:
The present study is aimed to determine prevalence of mupirocin resistance and
the rates of high and low level mupirocin resistance of Staphylococcus aureus
and Coagulase negative Staphylococcus (CONS) species isolated from skin and soft
tissue infections.

Clinical isolates of Staphylococcus aures and CONS, isolated from skin and soft
tissue infections of patients were included in the study and identified as Staphylococcus
aureus and CONS by standard laboratory techniques. The antibiotic susceptibility
testing was done by CLSI guidelines. Low and High level mupirocin resistance
was screened by using 5µgm and 200µgm discs respectively.
Results:
Total of 68 samples was collected out of which 16(23.5%) showed both low and
high level mupirocin resistance and 3(0.04%) showed only low level mupirocin
resistance. Staphylococcus aureus isolated were 37(54%), 19% of which showed
both low and high level resistance to mupirocin. CONS isolated were 31(45%) , 22%
of which showed both low and high level mupirocin resistance and 0.9% showed only
low level mupirocin resistance.
Conclusion:
Mupirocin resistance in Staphylococcus species is increasing and thus is a cause
for concern. It can be limited by regular surveillance and effective control in the
prophylactic use of mupirocin.

Acute encephalitis syndrome in children: Evaluating the utility
of a laboratory algorithm
___________________________________________________________________________________________
Author : Dr. Tina Damodar
Co-authors : Reeta Mani, Anita Desai, Basavara G.V, Mahantesh S, V. Ravi
Department : Department of Neurovirology & Pediatrics
Institution : Indira Gandhi Institute of Child Health (IGICH), Bangalore 560029
Objective:
Acute encephalitis syndrome (AES) is a major public health problem in India.
A number of agents are known to be causative agents of this syndrome. In order
to facilitate rapid identification of the causative agent of AES, NIMHANS has
developed an algorithmic approach for public health purposes. However, the
utility of this algorithm for routine diagnosis of AES cases admitted to a hospital has
not been evaluated. Hence, this study was undertaken to determine the applicability
of a surveillance algorithm in a diagnostic set-up.

Serum and CSF samples of 20 suspected AES cases (as per WHO definition) admitted
in a month’s duration to Indira Gandhi Institute of Child Health, Bangalore, were
subjected to serological and molecular studies using the AES surveillance algorithm.
All serum samples were tested initially for Japanese encephalitis virus (JEV) IgM. All
JEV-IgM negative serum samples were tested for IgM Dengue, Chikungunya, West
Nile viruses and Orientia tsutsugamushi (Scrub typhus). All CSF samples were
initially tested by Real time PCR (RT-PCR) for detection of S. pneumoniae, H. influenzae
and N. meningitidis DNA followed by RT PCR for Herpes Simplex virus-1 DNA and
Enterovirus RNA. Clinical details and epidemiological risk factors were collected
using a standardized clinical proforma. In addition, other routine laboratory
investigations including CSF analysis, routine blood investigations were noted.
Results:
Amongst, the 20 children studied the age group ranged from 0-13 years and
included equal number of males and females. The majority of children were from
urban areas (65%).Fever was present in all cases and was the presenting symptom
in 11/20 cases (55%). Seizure and altered sensorium were present in 17/20(85%) and
15/20(75%) cases respectively. Other clinical findings observed were chills in 6/20 (30%),
headache in 6/20 (30%) and abnormal behavior in 3/20(15%) cases. Involvement of
Gastro-intestinal system was observed in 6/20(30%) and Respiratory system was involved
in 7/20(35%) cases. Neurological sequelae in the form of hemiparesis and speaking
difficulty were seen in 3 patients. Laboratory testing using the algorithm enabled
etiological identification in 7/20(35%) of AES cases. Amongst the cases positive, 3/7
cases (15%) were diagnosed as JE, 2/7 (10%) as Chikungunya, and one each as
Dengue (5%) and S.pneumoniae meningitis (5%).
Conclusion:
These results suggest that the AES laboratory testing algorithm developed for
public health purposes can be adopted for diagnostic purposes as well. However,
a detailed evaluation using a large number of samples is required to ascertain its
large scale application at a national level.

Bacteriology and Antibiogram of pathogen from wound
infection at a tertiary care hospital, Kanpur
___________________________________________________________________________________________
Author : Dr. Twinkle
Co-authors : Dr. R.Sujatha
Institution : Rama Medical College Hospital and Research Center Kanpur (India)
Objective:
Wound infection results in sepsis, limb loss, long hospital stays, and higher cost and are
responsible for significant human mortality and morbidity worldwide.The aim of this
study was to investigate the profile of pathogen cultured from wound infection and
determine the antimicrobial susceptibility pattern.

A retrospective analysis of bacterial pathogen and their AST was done on wound swab
samples that have been cultured at Microbiology lab from June 2016-June 2017. AST
was done using disc diffusion technique as per standard of Kirby-Bauer method.
Result:
Out of the 400 wound samples analysed, 240 (60%) were culture positive,
Staphylococcus aureus was the most common organism (37.9%) and 2.5% were
methicillin resistant strains, followed by CoNS(28.7%), Klebsiellaspp (15%),E.coli (10.4%),
Pseudomonas (8.3%). Majority of isolates S.aureus and CoNSwere highly resistant to
most of the commonly prescribed antimicrobial drugs but showed better sensitivity
for vancomycin, linezolid.Gram negative bacilli were highly resistant for penicillin and
cepahlosporins but show better sensitivity forimipenem, piperacillin–tazobactum. All
the isolates were 100% sensitive for colistin and polymixin-B.
Conclusion:
The most frequently isolated bacteria were S.aureus and sensitive to vancomycin
and linezolid .For empiricaltreatment periodic surveillance of aetiology and drug
susceptibility both in the community and hospital settings is recommended.

Inclusion of clinical case discussions in undergraduate
microbiology curriculum: an infant step towards grooming
the medical graduates for ID training
___________________________________________________________________________________________
Author : Dr. Ujjwala Gaikwad
Co-authors : Dr. Debobrata Dash, Dr. Padma Das, Dr. Anudita Bhargava,
Dr. Sanjay Singh Negi, Dr. Sarika Kombade, Dr. Zoyev Khan,
Dr. Pragya Agarwala, Dr. Priyadarshini Patro.
Institution : All India Institute of Medical Sciences, Raipur
Objective:
To imbibe the practice of adopting syndromic approach to common infectious
diseases at an undergraduate level.
Methods:
A problem based learning module based upon common clinical case scenarios
was prepared targeting the students of second MBBS. The students were subjected
to the module in the second term of their tenure in Microbiology. The module consisted
of a group activity in which the students were divided in a group of ten and each
group was given a clinical case scenario featuring one among the most the common
infectious disorders encountered in the clinical practice. The case was approached
by the students by their own taking the help of the literature and previous teaching
sessions. The activity was conducted in two sessions. In the first session, part-I of the
case was given and the discussion was focused only upon understanding the key
terms in the scenario, searching the literature and arriving at the differential
diagnosis. While in the second session, part – II of the case was given which consisted
of additional information in the form of laboratory investigations. The discussion was
focused on correlating the clinical scenario and arriving at the final diagnosis and
presentation of cases in front of the teachers. Each group was evaluated for overall
problem solving approach, quality of presentation, group co-ordination, and ability to
respond to the question answer session as well as peer rating within the group by the
students. Student’s feedback about the activity was recorded on 5-point Likert scale.
Results:
The activity was well perceived by the students as reflected from the feedback.
The score ranged between 4 and 5 i.e. Agree(A) and Strongly Agree (SA) for
maximum items like recognizing the importance of microbiology in clinical
practice (Scores: SA-76.9%, A- 21%), creating the interest, enthusiasm, encouragement
for self learning (Scores: SA- 69.4%, A- 26.4%), enhancing the knowledge and skills
required for diagnosis of common infectious disorders (Scores: SA- 69.4%, A- 29.3%),
developing critical thinking (Scores: SA-65.3%, A- 24.2%).
Conclusion:
Incorporation of modules based upon clinical approach to microbiology in
undergraduate curriculum can prove useful in creating an interest for
understanding microbiology. It can further strengthen the attitude of practicing
and managing common infectious diseases with enhanced competency at the
graduate level.

Study of Ventilator-associated pneumonia in a tertiary care
hospital in India: incidence and risk factors
___________________________________________________________________________________________
Author : Umesh Hassani
Institution : NKP Salve Institute of Medical Sciences& Research Center, Nagpur
Background:
Mechanical ventilation is an essential, life-saving therapy for patients with critical
illness and respiratory failure. Despite major advances in techniques in caring for
patients whose respiratory tracts are instrumented and the routine use of efficient
disinfection procedures for the respiratory equipment, nosocomial bacterial
pneumonia continues to complicate the course.
Objective:
The aim of the study is to know the incidence, risk factors, spectrum of organisms
and sensitivity patterns, and the outcome in patients with Ventilator-associated
pneumonia (VAP) in a tertiary care hospital setting.

This prospective observational study was carried out over a period of 2 years. VAP
was diagnosed using the clinical pulmonary infection score. Endotracheal aspirate
(ETA)/BAL samples of suspected cases of VAP were collected from patients admitted in
medicine ICU and processed as per standard protocols.
Results:
During the study period Four hundred & thirty nine patients were on Mechanical
ventilation for more than 2 days. Eighty three patients developed VAP & were
included in the study. The incidence of early-onset VAP (within 96 h) was found to
be 18.07% while the late-onset type (>96 h) was 80.72%.The incidence of VAP in
our study was 48.06/1000 ventilator days. The risk factor significantly associated
with VAP in our study was found to be duration of ventilator support, reintubation,
advanced age and altered consciousness. Neurological disorders followed by
respiratory failure were the commonest underlying conditions associated with VAP.
In our study 18.07% cultures were polymicrobial. The most common organism isolated
in our institution was Klebsiella (47.7%) followed by Pseudomonas (20.45%). High level
of antibiotic resistance with 87.5% ESBL positivity was seen. The overall mortality
associated with VAP was observed to be 49.35%.
Conclusions:
The incidence of VAP was 48.06/1000 ventilator days. Study showed that the
incidence of VAP is directly proportional to the duration of mechanical ventilation.
The most common pathogens causing VAP were Klebsiella spp. and Pseudomonas
aeruginosa and were associated with a high fatality rate.

Case report of Rhinosporidiosis in nasal tissue specimen at
a tertiary care hospital in Varanasi
___________________________________________________________________________________________
Author : Dr. Uneza Husain
Co-author : Prof Ragini Tilak
Institution : Department of Microbiology,
Institution : Institute of Medical Sciences, Banaras Hindu University, Varanasi,
Uttar Pradesh, India
Rhinosporidiosis isa chronic granulomatous fungal infection with mucocutaneous

involvement..The causative organism is named as Rhinosporidium seeberi because
it reproduced by endosporulation in the host tissue, giving rise to sporangia and
spores. Nasopharynx and palpebral conjunctiva account for 85% of the sites.
Other mucosal sites affected are oropharynx, larynx, rectum and external genitalia.
Disseminated rhinosporidiosis is usually associated with mucosal lesions.
Objectives:
To report cases of R. seeberi in Varanasi.
Material methods:
A case presented in ent opd with history of slow growing swelling in the nose along
with unilateral nasal obstruction and nasal discharge. On examination the swelling
was friable, polypoidal with a strawberry appearance. Nasal tissue specimen was
cultured on blood agar and sabouraud’s dextrose agar at 30oC, along with
direct smear 10% KOH mount . Fungal stains such as methenamine silver and
Periodic acid-Schiff were used for identification .PCR was performed directly from
nasal tissue and amplification products were detected by electrophoresis on 2%
agarose gels stained with ethidium bromide and visualized with UV transilluminator.
Results:
On 10% KOH mount, fungal elements in form of spherical large sporangia
containing numerous sporangiospores were seen .Culture results were negative
as expected in suspected organism. R. seeberi is visualized positively with GMS
stain showing sporangia.Thick wall of trophocytes stained pink with PAS stain, and
were surrounded by inflammatory cells.It was successfully detected by PCR (molecular
approach to diagnosis).
Conclusions:
The present case is of Rhinosporidiosis. This indicates that fungal etiology can be
suspected in cases presenting with nasal polyp. Local surgical excision is mainstay
of treatment,though dapsone is also found to be effective.

Molecular Test For Rapid Bacterial Identification From
Blood Cultures: Ready For Prime Time In India?
___________________________________________________________________________________________
Author : Dr. V R Yamunadevi
Co-authors : Dr. Vidya, Anil, Dr. RamGopalakrishnan
Institution : Apollo Hospitals, Chennai
Objective:
To evaluate the usefulness of The Film Array blood culture identification (FA-BCID)
in comparison to conventional techniques in early identification & antimicrobial
initiation
Method:
Patients admitted in ICU whose blood culture bottles flagged in laboratory using
the BACTEC-FX system was processed by FA-BCID & conventional method. It is a
multiplex-PCR based molecular platform which includes 19 bacteria, five yeasts,
and mecA, vanA/vanB, & KPC gene.
Results:
A total of 36 positive blood culture bottles were analyzed by both FA-BCID &
conventional method from patients admitted in intensive care unit. 77.8%
organisms were accurately identified by FA-BCID. Total organisms identified by FA-BCID
were 41.7% Gram negative bacteria, 33.3% Gram positive bacteria and 2.8% both.
FA-BCID identified 71.5% of organisms to species level and 22.5% to genus level. mec
A gene was accurately identified in 16.7%. None of the isolates had KPC gene or
VAN A/B. Resistant gene were not picked up by FA-BCID in 25% of organisms
among which were CRE 19.4%, 2.8% carbapenem resistant Non lactose fermenting
organism .Turnaround time of FA-BCID was 60minutes & 48hrs for conventional
method. 38.9% of patient’s antibiotic was de-escalated and 8.3% was escalated
based on FA-BCID within 3hrs.
Conclusion:
FA-BCID can dramatically improve sensitivity, specificity & turnaround times in the
diagnosis of blood stream infections. Physicians can rapidly optimize antibiotic
prescription, especially for gram positive organisms. The major limitation of this
assay is its failure to detect certain non-lactose fermenting organisms and locally
prevalent resistance genes for gram negative bacteria. The rapid diagnostic test
& it’s implementation strategy needs to be individualized or modified for each
country based on local prevalence of resistance mechanisms, antibiotic usage
patterns & antimicrobial stewardship activities.

Scrub typhus presenting as acute gastroenteritis with
respiratory distress
___________________________________________________________________________________________
Author : Dr. Vasanthi Dodda
Co-authors : Dr Deepak Madi
Institution : Kasturba Medical College, Mangalore
Introduction:
Scrub typhus is an emerging infection in India which usually presents as an acute
febrile illness with or without rash .Varying manifestations of Scrub typhus is seen in
clinical practice. We are describing a case of scrub typhus presenting with
gastroenteritis and respiratory distress from South India. Timely detection of eschar
gave a clue to the diagnosis in our case. Another unique feature in our case is that
PCR from eschar material was positive.
Case Report:
A 53 year old female presented to the medicine department with complaints of
diarrhea of four days duration. History of low grade fever was present. On examination
she was febrile. Her Blood Pressure was 90/60mmhg , pulse 98/min. she was initially
treated with Ceftriaxone for acute gastroenteritis. During hospital stay she also
developed respiratory distress . Clinical examination revealed eschar on the right
forearm. The IgM M-IFA and scrub typhus IgM ELISA was positive. Nested polymerase
chain reaction (PCR) for 56-kDa type-specific antigen from the eschar was positive.
She was treated with Doxycycline . Patient improved and was discharged after 10
days of hospital stay and she was fine on follow up.
Conclusion:
Clinical diagnosis of scrub typhus is difficult as it can mimic other tropical febrile
illnesses. Scrub typhus should be considered in the differential diagnosis of fever
with gastroenteritis in tropical countries. Thorough clinical examination should be
done to detect the eschar. Early institution of appropriate therapy based on the
detection of eschar will reduce mortality and morbidity.

A NOVEL ANTIHERPES SIMPLEX VIRUS (HSV) PROPERTIES OF
CRUDE EXTRACT AND NANOPARTICLES DERIVED FROM
PONGAMIA PINNATA LINN., AN INDIAN MEDICINAL PLANT
___________________________________________________________________________________________
Author : Dr. Vasanthi. K
Co-authors : Dr. Sathya Narayanan, Dr. Govindaraju, Dr. M.Elanchezhiyan
Institution : University of Madras-Taramani campus Taramani,
Chennai-600113.2Nanoscience Division, Centre for Ocean Research
Sathyabama University, Rajiv Gandhi Road, Chennai-600119
Introduction:
Nanotechnology is a recently emerging active area of research and
nanoparticles (Np’s) derived from plant sources possess alluring properties of which
the most attractive property is biodegradability. Pongamiapinnata, Linn (P. pinnata)
has been reported to have several bioactivities and crude extracts of it showed
attractive anti HSV activity. However anti HSV properties nanoparticles derived from
P. pinnata has not been fully evaluated so far.
Objective:
1. To evaluate the anti-HSV propertyof silver and gold Np’s of different parts of
P. pinnata.
2. To Study the Cyto-toxicity of silver and gold Np’s of different parts of P. pinnata
Methods:
Different parts of P.pinnata (Leaf, seed, bark, and flower) were collected, surface
sterilized and made into powder, lyophilised, silver and gold Np’s was synthesised
and were stored at 4ºC until use. Different concentration of the Silver or Gold Np’s
were added on to Vero cells in 96 well plates that were infected with either HSV-1
or HSV-2 two hour ago. Cultures were incubated for 3-5 days at 37ºC and inhibitory
activity of the extract was calculated using CPE reduction assay. Cultures were
followed every day microscopically for development of any cytotoxicity or
abnormality.
Result:
Nanoparticles of P. pinnata seed followed by leaf have strong viricidal activity
against both HSV-1 and 2 than the crude extracts. The complete CPE reduction of
HSV-1 and HSV-2 was occurred at 1mg/ml and 20mg/ml with crude extract. Such
inhibition was noticed with NP’s at a minimal concentration for HSV-1 (2µg/ml,
5µg/ml-Gold and Silver Np’s respectively) and HSV-2 (15 µg/ml, 20µg/ml- Gold and
Silver Np’s respectively) indicating the superior anti HSV potency of Np’s. None of the
extracts showed any cytotoxicity at the concentrations tested.
Conclusion:
Our study has clearly showed that more crude extract was required for neutralization
of HSV-1 and 2 wereas less concentration of NP was able to bring about viral
neutralization.

Fungemia Due to a rare Plant Fungus Ustilago Prior to Cardiac
Transplant –Treated and Transplanted!
___________________________________________________________________________________________
Author : Dr. Vidya Devarajan
Co-authors : Dr. Suresh Rao, Dr. K R Balakrishnan, Dr. Veena, Dr. Jagdish, Dr. Jai Kishen
Department : Cardiac Critical Care
Institution : Fortis Malar Chennai
Introduction:
Patients awaiting cardiac transplant can present with challenging to treat blood
stream infections .There is a paucity of literature on the role that Ustilago spp. (a plant
fungus) which may play a role in human diseases. There are very few invasive diseases
in humans and hence there is limited data on therapeutic recommendation .
We hereby report a case fungemia due to genus Ustilago successfully treated

with echinocandin and subsequently transplanted .
Case details
A 40 year old doctor,diagnosed to have post partum cardiomyopathy was
presented with history of fever of 5 days duration ,abdominal discomfort and a few
episodes of loose stools.
On clinical examination she was febrile haemodyanamically stable.Systemic

examination was non contributory.Preliminary lab data showed normal total counts.
LFT and renal parameters were normal.Possibilities considered were community
acquired syndromes like Typhoid or viral illnesses
Work up for Dengue ,malaria was negative. She was empirically started on
ceftriaxone and azithromycin pending blood cultures. But she continued to have
low grade fever .Her Blood cultures grew yeast.At this point the patient did not
have a high candida risk score .But as she had a prosthesis(Automated Implantable
Cardioverter Defibrillator ) a repeat culture was sent she was started on an
echinocandin pending identification and sensitivities of the yeast. Repeat blood
culture prior to echinocandin also grew yeast.
Now the fungemia was evaluated .ECHO and CT showed no vegetations in the
ICD leads.USG abdomen was normal.Fundus examination was also normal.
The Vitek and MALDITOFF could not identify the yeast.
Hence a Pan fungal DNA PCR was done and the yeast was identified as Ustilago.
She had clearance of the fungemia and underwent cardiac transplant subsequently
and recovered well.She received caspofungin for a duration of four weeks.
The AICD was removed at the time of transplant and the leads were negative for the
fungi
Conclusion:
While traditionally thought of as only a plant pathogen, therecontinues to be
emerging data that this agent can play a role in human disease..This case highlights
the importance of considering environmental fungi as pathogens in clinical practice.
This warrants a continued research into antifungal options for these organisms.

Ventilator Associated Pneumonia From A Tertiary Care Hospital
Of Central India
___________________________________________________________________________________________
Author : Dr. Vijayshri Deotale
Co-author : Dr. Saryauti Reang
Institution : Mahatma Gandhi institute of Medical science (MGIMS) Sevagram
Wardha, State - Maharashtra India
Introduction:
The critically ill patient is at particular risk of developing intensive care unit
acquired infection, with the lungs being especially vulnerable. Nosocomial
bacterial pneumonia occurring after two days of mechanical ventilation is referred
to as ventilator associated pneumonia, and is the most common nosocomial
infection seen in the intensive care unit.
Objective:
• To collect Endotracheal aspirate (EA) and mini broncheoalveolar lavage (mini BAL)
from patients on ventilator ≥48hours
• Culture and isolate the organism
• Quantitify the number of organism in each specimen
• Comparison of IL-8 and CPIS score

A total of 62 Endotracheal aspirate(EA) samples were collected between
12.03.2016 to 13.11.2016 and 45 mini broncheoalveolar lavage (mini BAL) samples
were collected from 22.05.2016 to 13.11.2016. EA and mini BAL were serially diluted
in sterile normal saline. 0.01 ml of dilution was inoculated on routine media. After
incubation at 37ºC in a 5% CO2 incubator for 24 hours, a colony counting was
done and expressed as colony forming units per ml (CFU/ml). The micro organisms at
a concentration more than 105 CFU/ml and 104 CFU/ml for EA and mini BAL
respectively were considered as VAP pathogens. IL-8 ELISA was performed on 42 serum
samples using Human IL-8 ELISA Kit from thermo scientific.According to kit insert, the
mean level of human IL-8 in 11 normal serum samples was 8.6pg/mL ranging from 1.2
to 16.7pg/mL.
Results:
Organisms isolated in single from Endotracheal aspirates were Acinetobacter
baumannii(45.16%), Escherichia coli(16.12%), Pseudomonas aeruginosa (11.29%),
Klebsiella pneumonia (9.67%), Coagulase positive Staphylococcus(8.06%),
Acinetobacter lwoffi(3.22%), .Associated organism isolated from Endotracheal
aspirates were Acinetobacter baumannii(27.77%), Klebsiella pneumoniae (22.22%),
Pseudomonas aeruginosa (22.22%) and Coagulase positive Staphylococcus(22.22%),
Escherichia coli(5.55%).
Organisms isolated from mini BAL were Acinetobacter baumannii(44.44%),

Pseudomonas aeruginosa (13.33%) , Escherichia coli(11.11%), Coagulase positive
Staphylococcus(11.11%) , and Klebsiella pneumoniae (6.66%).Associated
organisms isolated from mini BAL were Pseudomonas aeruginosa (37.5%) Acinetobacter
baumannii(25%), Klebsiella pneumoniae (12.5%), Escherichia coli(12.5%) and

Coagulase positive Staphylococcus(12.5%)
IL-8 ELISA was found to be within normal range in 5 patients whose CPIS score were
<6 and 1 patient with CPIS score 6 and above 16.7 pg/dl in 32 patients with CPIS≥6 and
4 patients with CPIS <6
Conclusion:
In our study, Acinetobacter baumannii was the predominant organism in VAP
patients.IL-8 ELISA of 32 of the 42 serum samples of patients with CPIS≥6 showed
increased level of IL-8.

Predictors Of The Etiology Of “Tropical Jaundice” In Adults
Presenting To Emergency In A Tertiary Care Hospital In North
India.
___________________________________________________________________________________________
Author : Dr. Vikas Suri
Co-authors : Dr. A. Bhalla, Dr. Singh Mandeep S , Dr. Duseja A,M. Biswal, Dr. R. Ratho,
Dr. M. P Singh, Dr. Gaurav Prakash, Dr. Alka Khadwal, P. Dr. Malhotra,
Dr. Savita Kumari, Dr. Sanjay Jain, Dr. Subhash Varma
Institution : PGIMER CHANDIGARH
Introduction:
Fever with jaundice or tropical jaundice is common presenting feature of the
patients visiting for emergency medical care. The knowledge of region specific
prevalence of the various causes and their disease characteristics is needed to
improve the management of such patients.
Patient & Methods:

106 adult patients (more than or equal to 14 years of age) with a diagnosis of
“Tropical Jaundice Fever(body temperature > 1010F) of 14 days or less in duration
without any localized source of infection on initial clinical evaluation but causing
jaundice (hyperbilirubinemia ≥ 1.5 mg/dl or elevation of aspartate aminotransferase
or alanine aminotransferase more than three times upper limit of the reference range)
were enrolled. All these patients with fever and jaundice were evaluated on the
basis of a standard proforma and were evaluated for malaria(peripheral smears/rapid
diagnostic kits), scrub typhus( PCR /IgM ELISA),leptospirosis(IgM ELISA), enteric fever by
blood cultures and dengue by dengue (NS1 antigen test and IgM ELISA),Hepatitis (IgM
ELISA of EBV/HSV, IgM ELISA of HAV/HEV and HBsAg with IgM HBc ELISA if HBsAg positive)
Results:
63 (59.5%) were males and 43 (40.5%) were females. The mean duration of fever
before presentation was 7.75 ± 3.58 days. 7 patients (6.6%) died. 92 patients (86.8%)
improved with treatment and were discharged while 7 patients (6.6%) left treatment
against medical advice. The various etiologies included scrub typhus24 (22.6%),
Hepatitis E 14 (13.2%),malaria 9 (8.5%),dengue fever, enteric fever, hepatitis A and
leptospirosis in 4 (3.8%), 2 (1.9%), 2 (1.9%) patients and 1 (0.9%) patient respectively.
Probable sepsis accounted for 31 patients. Conjunctival suffusion (OR=22.17), severe
anemia (OR=5.5), respiratory crepitations (OR=5.27), thrombocytopenia (OR=1.14),
hepatomegaly (OR=1.04), normal INR (OR=0.29) and altered mentation (OR=0.25) were
significant predictors of a diagnosis of scrub typhus in patients with fever and jaundice.
Severe anemia(Hb<8), Hypoalbuminemia,severe thrombocytopenia (Platelet
count <50,000)and a near normal INR at admission were predictors of a malarial vs
a viral etiology of Tropical jaundice. Co-infections were observed in 13 (12.4%)
patients. Co-infection with scrub typhus and malaria was seen in 4 patients (vivax-3
and falciparum-1) and viral hepatitis A & E was observed in 3 patients.
Discussion:
Scrub infection has emerged as common etiology of tropical jaundice in recent
times. Simple tests like a baseline platelet count and coagulogram(INR/PTTK) can help
in early diagnosis and thus treatment.

Clinical and epidemiological study of mucormycosis caused
by Rhizopus homothallicus
___________________________________________________________________________________________
Author : Dr. Vinitha Mary Joy
Co-authors : Dr. Harsimran Kaur,Dr. Hariprasad, Dr. M.R. Shivaprakash, Dr. Anup Ghoshe,
Dr. Arunaloke Chakrabarti
Institution : PGIMER
Mucormycosis is a devastating invasive fungal infection, with high mortality rate despite
active management. Rhizopus homothallicus is one of the rare mucorales reported
mainly from India. First two cases of mucormycosis due to this agent were reported
earlier by us.
In the present study, we describe the clinical characters of patients with R

homothallicus mucormycosis, along with mycological characters and antifungal
susceptibility profile of the isolates. Antifungal susceptibility testing (AFST) on the
isolates was performed using broth dilution technique according to CLSI (M38 –A2).
The data of patients with R homothallicus mucormycosis reported from our institute
during 2012 – 2017 were collected and analysed. All cultures were identified by
sequencing of ITS region of rDNA.
Of 219 cases of mucormycosis from this period, majority (90%) was caused by
Rhizopus arrhizus. R. homothallicus was isolated in 2.7% cases (n=6).
Five patients were diabetic, with two of them in state of diabetic ketoacidosis. One
patient was on corticosteroids for nephrotic syndrome.
Four patients presented with rhino-orbital mucormycosis (ROM), remaining two had
pulmonary mucormycosis (PM). R homothallicus could be isolated from five cases
and sixth was identified by direct sequencing from lung biopsy sample Production
of abundant zygospores and its features helped in its identification from culture.
Five isolates showed good in vitro susceptibility against amphotericin B, itraconazole,

terbinafine and posavuconazole.
All ROM patients underwent surgical debridement, along with conventional

amphotericin B (cumulative range 850-2050mg). Both PM cases received
Amphotericin deoxycholate; however one case, with severe CKD on dialysis and
corticosteroids, succumbed to the disease due to delay in diagnosis.
R homothallicus is an emerging pathogen in India. The species has good in vitro

susceptibility against common antifungals used for management of mucormycosis.
Early diagnosis and treatment is essential in improving its prognosis.

Infections in Cancer Patients: Bacteriological Spectrum and
Resistance Patterns of Common Clinical Isolates
___________________________________________________________________________________________
Author : Dr. Vivek G Bhat
Co-authors : Dr. Rohini Kelkar, Dr. Sanjay Biswas
Institution : ACTREC, Tata Memorial centre
Introduction:
Cancer patients are at increased risk of bacterial infections. This may due to the
disease process itself, the effect of chemotherapeutic drugs or invasive procedures
such as catheterization. A wide variety of bacteria including some emerging
pathogens are increasingly being reported from these patients. The incidence of
multidrug resistant organisms particularly in the Gram negative group is also increasing,
with higher resistance rates seen to cephalosporins, β-lactam/β-lactam inhibitor
combinations and the carbapenems. This study documents the bacteriological
spectrum of infections and their resistance patterns in cancer patients.
Methods:
This study includes all bacterial isolates recovered from infections cancer patients
over a period of 18 months. Samples included Blood cultures, Pus/wound swabs,
urine, tissue biopsies, body fluids, catheter tips and respiratory specimen such as sputum
and bronchoalveolar lavage (BAL). All samples were processed in the microbiology
laboratory as per standard laboratory protocols. Organisms were identified to species
level and antimicrobial susceptibility testing was performed manually by the disc
diffusion technique or in the Vitek-2 (Biomereux, France) instrument. Interpretations
were as per Clinical laboratory Standards Institute (CLSI) guidelines.
Results:
A total of 1150 bacterial isolates were cultured from 884 test samples during the
study period. Of these 227 were Gram positive and 923 were Gram negative
organisms. Staphylococcus aureus (99 isolates) was the commonest Gram positive
isolate followed by Enterococcus (79) and Gr A Streptococcus (30).
Among the Gram negatives, E. coli (304), Pseudomonas aeruginosa (201) and
Klebsiella pneumoniae (190) were the most common. Of the Staphylococcus
aureus isolates 27.2% were methicillin resistant. Only 5.06% enterococci were
vancomycin resistant. High rates of resistance to cefotaxime and ciprofloxacin
were seen amongst E. coli (84.8% & 83.55%) and Klebsiella pneumoniae (71 & 62.1%)
respectively. Resistance to carbapenems (meropenem) was high at 70% in
Acinetobacter spp.; however all isolates were sensitive to colistin. Among the
aminoglycosides, amikacin retained good efficacy against Escherichia coli (82.9%)
and Pseudomonas aeruginosa (78.1%). Occasional isolates of emerging pathogens
such as Chryseobacterium indologens, Roseomonas and Achromobacter xyloxidans
were also recovered.
Conclusion:
The common infections in cancer patients include respiratory, wound, tract
infections and sepsis. The commonest isolates include Staphylococcus aureus,
Enterococci, Escherichia coli, Klebsiella pneumoniae & Pseudomonas aeruginosa.
There is a high level of resistance to the commonly used antibiotics among Gram
negative organisms.

A Rare Case of Hemophagocytic Lymphohistiocytosis
secondary to Hepatitis A Infection
___________________________________________________________________________________________
Author : Dr. Vivek K Koushik
Co-authors : Pavan MR, Chakrapani M
Institution : Kasturba Medical College Mangalore
Dr. Vivek K Koushik (Postgraduate General Medicine KMC Mangalore), Dr. Chakrapani
M(Associate Dean and Professor, General Medicine KMC Mangalore), Dr. Pavan M R
(Associate Professor, General Medicine KMC Mangalore)
Objectives:
Haemophagocytic Lymphohistiocytosis (HLH) secondary to infectious diseases is
now gaining importance. HLH secondary to dengue fever, malaria, scrub typhus
and leptospirosis are known. Here we discuss a case of Hepatitis A infection
transforming into secondary HLH.
Clinical Features:
A 32 year old male presented with symptoms of viral hepatitis. Serology for Heptitis
A was positive. Over a period of 12 days in the hospital the patient perisited to
have high grade fevers, symptoms of vomiting and pain abdomen and developed
bicytopenia (low platelets and WBCs). Blood culture, WIDAL, smear for malarial
parasite, IgM dengue were all negative. HIV serology was negative. Chest Xray was
normal. In view of unsettling fever ANA was sent – which was negative. On the 13th
day of persistent fever, serum ferretin and triglyceride levels were sent to look for
features of HLH. Both serum ferritin (6023) and Triglyceride (338)were high. H score
calculated was 205 which shows about 92% probability of HLH in this patient.
Results:
As the initial clinical, biochemical and serological evidence point towards Viral
Hepatitis A, a diagnosis of HLH secondary to HAV was considered. Patient responded
to conservative treatment and spontaneously improved after 16 days. He was
discharged in an afebrile state.
Conclusion:
Any fever of known/ unknown etiology with deviation from natural history or
presence of atypical features must prompt the evaluation in terms of HLH especially
in developing countries like India were the trend is shifting from infections to immune
disorders. Identification of HLH early would help reduce mortality as timely intervention
with steroids or immunosuppressant can be tried.

Rhadomyolysis Due To Chikungunya – A Rare Manifestation!
___________________________________________________________________________________________
Author : Dr. Wasim Yunus Khot
Co-authors : Dr. Sanjeev Sinha, Dr. Lalit Dar, Dr. Manish Soneja, Dr. Neeraj Nischal,
Dr. Aashish Chaudhary
Institution : All India institute of Medical Sciences, New Delhi
Introduction:
Chikungunya is an acute viral illness usually characterized by fever with prominent
joint involvement. Only four cases of Chikungunya leading to rhabdomyolysis
have been reported in the literature, none from India. We report one such case.
Case summary:
25 year old male presented with high grade fever with chills, myalgias and
arthralgias involving small and large joints. It was accompanied by generalized
nonpruritic erythematous rash. On fifth day of illness, he had decreased urine
output with passage of cola colored urine. He then became anuric and had
dyspnea at rest for which he was admitted. On general examination he had
normal blood pressure, mild tachycardia and facial puffiness. His thigh and calf
muscles were tender. He had fine bilateral end inspiratory basal crepitations and
mild splenomegaly on systemic examination. Investigations showed Creatinine of
5.7 mg/dL, S.Urea 65 mg/dl, SGOT 1623 U/L and SGPT 236 U/L. Urine protein 3+,
blood 3+, plenty of RBCs and 5-6 WBCs. Urine myoglobin was positive. His CPK
was >160000 U/L while CK MB was 50 U/L. USG abdomen demonstrated increased
renal cortical echogenicity with maintained cortico-medullary differentiation. His
workup for acute febrile illness namely malaria, dengue, leptospirosis, enteric
fever, scrub typhus, blood and urine cultures were negative. His autoimmune
profile (RF, Anti CCP, ANA) was negative. Chikungunya IgM as well as PCR in blood
were positive, thus a diagnosis of Chikungunya fever with rhabdomyolysis with AKI was
made. He required multiple sessions of hemodialysis due to anuria and fluid overload.
Eventually renal parameters recovered and he was discharged with a creatinine of 1.2
mg/dL .On follow up the patient is currently asymptomatic with normal creatinine.
Conclusion:
Rhabdomyolysis with oliguric acute kidney injury is a rare presentation of Chikungunya
infection. A high degree of suspicion for such cases is needed during an outbreak of
Chikungunya.

Rate of Rifampicin-resistant Mycobacterium tuberculosis by the
Xpert MTB/RIF Assay at a Tertiary Care Centre in Northern India
___________________________________________________________________________________________
Author : Dr. Richa Misra

Co-authors : Dr. Alok Nath, Dr. D K Singh, Dr. T N Dhole
Institution : Sanjay Gandhi Postgraduate Institute of Medical Sciences
Background:
Effective use of accurate and rapid molecular techniques is urgently needed to
decrease the transmission of drug resistant (DR) tuberculosis (TB).The WHO Global
TB Report-2016, estimated 4, 80,000 new cases of multidrug-resistant TB (MDR-TB) and
an additional 1,00, 000 people with rifampicin-resistant TB (RR-TB). An estimated 9.7%
cases of MDR TB are extensively drug resistant (XDR).
Objective:
To evaluate the diagnostic performance of the Xpert MTB/RIF Assay taking LJ medium
culture as the reference standard and to calculate the rate of rifampicin resistance at
our centre.
Methods:
All samples received for Xpert MTB/RIF Assay were simultaneously put up for
culture also. Direct smears were prepared from the specimens using Ziehl-Neelsen
staining. Specimens were decontaminated with the standard N-acetyl-L-cysteine
(NALC)-NaOH method. This was followed by inoculation on Lowenstein-Jensen agar.
The Xpert MTB/RIF test was performed as per the manufacturer’s instruction (Cepheid,
Sunnyvale, CA).The duration of the study is 20th March to 25th May 2017.
Results:
A total of 332 specimens from suspected DR-TB patients were received at the TB
laboratory for Xpert MTB/RIF Assay and concomitant culture during the study period.
Out of these 226 specimens were pulmonary (sputum, tracheal aspirate, BAL) while 106
were extra-pulmonary like ascitic fluid, lymph node aspirate, CSF and CAPD fluid. MTBC
was detected in 123 (37%) samples and 27 (21.9%) were rifampicin resistant. All samples
detected by the Xpert MTB/RIF Assay were culture positive.Three samples, 1sputum and
2 BAL fluids that were smear negative as well as negative by the Xpert MTB/RIF Assay
were culture positive for MTBC.
Conclusion:
We conclude that the MTB/RIF test is a simple method, and routine staff with
minimal training can use the system. The test appears to be as sensitive as culture with
smear-positive specimens but less sensitive with smear-negative specimens.

CIDSCON 2017 - Abstracts

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CIDSCON 2017 - Abstracts

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Clinical Infectious Diseases Society, India

18th | 19th | 20th August, 2017

Venue : Le Méridien Nagpur, Maharashtra

Theme : Advancing Science, Improving Care

METHODS AND MATERIALS:

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De-escalations after 72 hours showed marked improvement between 2013-2015(14% to

The surgical prophylaxis compliance from 2013-2016, showed marked improvement in

Major improvements were seen in the shorter duration of surgical prophylaxis(CABG

There was gradual decrease in resistance to 3rd generation cephalosporins(43%-33%)

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Material and methods:

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Author : Dr. Sharon Lionel

Objective: BK virus infection causing Haemorrhagic cystitis (HC) is a well known

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Material and methods:

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Clostridium difficile is a common cause of hospital-acquired diarrhoea, which is

Result & Discussion:

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Parameters Case1 Case2 Case3 Case4 Case 5 Case6

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Laboratory findings showed marked leucocytosis (22000/mm3). The Pus culture

Results & Discussion:

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Invasive aspergillosis is most frequently caused by Aspergillus fumigatus and

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Materials and Methods:

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Aim and objectives:

Material and Methods:

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After completion of 4 cycles of chemotherapy, patient presented with fever,

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In view of pancytopenia, he was started on Inj Ceftriaxone [2 gm.bd] and

One month later, repeatimaging [MRI] revealed significant resolution of brain

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Material and methods:

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Corynebacterium striatum is a ubiquitous environmental pathogen which colonises

Parameters(Units) Before treatment After treatment

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Nontyphoidal salmonellae are a leading cause of bacterial diarrhea worldwide;

Materials and methods:

Post mortem blood culture yielded mixed bacterial growth.

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