Epidemiology of candidemia in a tertiary care centre of north India: 5-year study

BACKGROUND

To determine the distribution of species of Candida and the risk factors associated with candidemia in Indian population for which we conducted a retrospective study for 5 years in a tertiary care centre of North India.

MATERIALS AND METHODS

Blood samples from 7,297 patients aged from 3 days to 85 years, suspected with candidemia, were collected and tested for Candida. The susceptibility patterns toward fluconazole for the year 2005 isolates were tested by micro-dilution assay as described in the CLSI (M27A-2 method).

RESULTS

Most of the episodes have been caused by species other than C. albicans. Non-albicans candidemia was 79%-80% in both female and male populations. The most frequent species isolated from 275 patients in 5 years (January 2001-December 2005) was C. tropicalis (35.3%), followed by C. albicans (21.5%), C. parapsilosis (20%), C. glabrata (17.5%), C. krusei (3.3%), C. haemulonii (1.5%), and C. guilliermondii (1%). C. parapsilosis was the predominant in the fifth year of the study (2004-2005). Dose-dependent susceptibility to fluconazole was observed in 5% (n = 3) of the strains. Antifungal resistance was found in 11.7% (n = 7), which includes only C. glabrata.

CONCLUSION

These results were comparable to those derived from other regions of India. C. tropicalis has been reported as the predominant species involved in the cases of candidemia. But in 2005 it has moved toward C. parapsilosis. No true antifungal resistance is reported. Further epidemiological surveillance is needed.

Biofilm formation by and antifungal susceptibility of Candida isolates from urine

Biofilm formation (BF) in the setting of candiduria has not been well studied. We determined BF and MIC to antifungals in Candida spp. isolates grown from urine samples of patients and performed a retrospective chart review to examine the correlation with risk factors. A total of 67 Candida spp. isolates were grown from urine samples from 55 patients. The species distribution was C. albicans (54%), C. glabrata (36%), and C. tropicalis (10%). BF varied greatly among individual Candida isolates but was stable in sequential isolates during chronic infection. BF also depended on the growth medium and especially in C. albicans was significantly enhanced in artificial urine (AU) compared to RPMI medium. In nine of the C. albicans strains BF was 4- to 10-fold higher in AU, whereas in three of the C. albicans strains and two of the C. glabrata strains higher BF was measured in RPMI medium than in AU. Determination of the MICs showed that planktonic cells of all strains were susceptible to amphotericin B (AMB) and caspofungin (CASPO) and that three of the C. glabrata strains and two of the C. albicans strains were resistant to fluconazole (FLU). In contrast, all biofilm-associated adherent cells were resistant to CASPO and FLU. The biofilms of 14 strains (28%) were sensitive to AMB (MIC(50) of <1 mug/ml). Correlation between degree of BF and MIC of AMB was not seen in RPMI grown biofilms but was present when grown in AU. A retrospective chart review demonstrated no correlation of known risk factors of candiduria with BF in AU or RPMI. We conclude that BF is a stable characteristic of Candida strains that varies greatly among clinical strains and is dependent on the growth medium. Resistance to AMB is associated with higher BF in AU, which may represent the more physiologic medium to test BF. Future studies should address whether in vitro BF can predict treatment failure in vivo.

Treatment of idiopathic hypereosinophilic syndrome with imatinib mesylate

Patients with idiopathic hypereosinophilic syndrome (HES) show persistent hypereosinophilia of unknown etiology that is associated with end-organ damage. Different treatments, including the use of corticosteroids and cytotoxics, have been investigated for HES with modest success. We report a young patient with HES who developed stroke and remained refractory to conventional therapy. Therapy with imatinib mesylate, a selective tyrosine kinase inhibitor that is highly effective in treating patients with BCR-ABL-positive chronic myeloid leukemia, was tried with the patient. The result was impressive, with hematologic remission achieved rapidly. Our finding concurs with recent reports that imatinib mesylate may be a promising agent in the treatment of some cases of HES.

Management of minor head injuries according to NICE guidelines and changes in the number of patients requiring computerised tomography imaging in a district general hospital: a retrospective study

The objective of this study was to investigate how many patients with minor head injury would have required computerised tomography (CT) imaging if they were to be managed according to the National Institute of Clinical Excellence (NICE) guidelines (June 2003) and the difference in workload for patients presenting out of hours at Calderdale Royal Hospital, Halifax. The study was a retrospective cohort analysis of patient's notes presenting with head injury at Calderdale Royal Hospital, Halifax. The data set comprised case notes of 844 patients with head injuries, 400 adults and 444 children attending the Accident and Emergency department from January to June 2003. The case notes were evaluated according to the NICE guidelines for the indications for CT imaging for the time that they presented to the Accident and Emergency department, and how many of them actually underwent CT imaging. The number of patients who required CT imaging and how many of them presented out of hours (between 17:00 and 21:00 hours on weekdays and at any time on weekends). Ten patients underwent CT imaging for minor head injuries from January to June 2003. Eighty-eight patients required CT imaging if they were to be managed according to the NICE guidelines. Sixty-three per cent of these patients presented out of hours when a radiologist was not available in the hospital. Adhering to the NICE guidelines would significantly increase the number of patients requiring CT imaging. A significant proportion of these patients would present out of hours.

Autologous stem cell transplantation (ASCT) in AL amyloidosis: Feasibility outside national amyloidosis referral centers and proposal for simpler pre-transplant staging

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Background: Single center data from national amyloidosis referral centers suggest that high dose melphalan based ASCT is an effective upfront treatment strategy for AL amyloidosis. Absence of published randomized control trials, referral bias and center experience make generalizability of this data difficult since data from outside of major referrals centers is limited. Pre-transplant staging is complicated by the profusion of articles describing various adverse risk factors. Methods: Retrospective review of bone marrow transplant database at our institution was conducted. All patients with AL amyloidosis who underwent ASCT were included in the study. We stratified patients based on International Staging System (ISS) for multiple myeloma. Organ and hematological response were assessed using 2005 consensus guidelines. Results: 13 patients (6 males) underwent ASCT for AL amyloidosis with risk adapted high dose melphalan dosing (melphalan mg/m2 100 (n = 1), 150 (n = 8) and 200 (n = 4)). Median age of the patient population was 53 years (range 31–75 years). Organ involvement was as follows - single organ = 6, 2 organs = 4 and 3 organs = 3. 4 patients had cardiac amyloidosis. 100 day transplant related mortality (TRM) was 15.3%. Overall survival was 84 % (95 % CI 51–96%) @ 1 yr and 75% (95% CI 38–91%) @ 2 yrs. Median follow up was 18 months. No deaths were observed >17 months post-transplant. 45 % patients had organ response. Complete hematological response was observed in 45 % patients. Mean duration of peri-transplant hospital stay for ISS stage I, II and III were 20.5 days (n = 2), 23.3 days (n = 9) and 29 days (n = 1) respectively. Number of deaths observed in ISS stage I, II and III were 0 (0/2), 2 (2/9) and 1 (1/1) respectively. Conclusions: Autologous stem cell transplant (ASCT) for AL amyloidosis is a feasible, effective and safe procedure outside of major national referral centers. Pretransplant stratification of amyloidosis patients using ISS for multiple myeloma indicated a trend towards longer peri-transplant hospital stay and mortality with increasing ISS stage. This hypothesis needs to be tested in larger studies.

No significant financial relationships to disclose.

Phenotypic switching in Cryptococcus neoformans

Phenotypic switching has been described in serotype A and D strains of Cryptococcus neoformans. It occurs in vivo during chronic infection and is associated with differential gene expression and changes in virulence. The switch involves changes in the polysaccharide capsule and cell wall that affect the yeast's ability to resist phagocytosis. In addition, the phenotypic switch variants elicit qualitatively different inflammatory responses in the host. In animal models of chronic cryptococosis, the immune response of the host ultimately determines which of the switch variants are selected and maintained. The importance of phenotypic switching is further underscored by several findings that are relevant in the setting of human disease. These include the ability of the mucoid colony variant of RC-2 (RC-2 MC) but not the smooth variant (RC-2 SM) to promote increased intracerebral pressure in a rat model of cryptococcal meningitis. Furthermore, chemotherapeutic and immunological antifungal interventions can promote the selection of the RC-2 MC variant during chronic murine infection.

Phenotypic switching in a Cryptococcus neoformans variety gattii strain is associated with changes in virulence and promotes dissemination to the central nervous system

This is the first report of a Cryptococcus neoformans var. gattii strain (serotype B) that switches reversibly between its parent mucoid (NP1-MC) colony morphology and a smooth (NP1-SM) colony morphology. Similar to C. neoformans var. grubii and C. neoformans var. neoformans strains, the switch is associated with changes in the polysaccharide capsule and virulence in animal models. In murine infection models, NP1-MC is significantly more virulent than NP1-SM (P < 0.021). In contrast to the serotype A and D strains, the serotype B strain switches in vivo reversibly between both colony morphologies. The polysaccharide of NP1-MC exhibits a thicker capsule, and thus NP1-MC exhibits enhanced intracellular survival in macrophages. Consistent with this finding, switching to the mucoid variant is observed in pulmonary infection with NP1-SM. In contrast, the thin polysaccharide capsule of NP1-SM permits better crossing of the blood-brain barrier. In this regard, only smooth colonies were grown from brain homogenates of NP1-MC-infected mice. Our findings have important implications for the pathogenesis of cryptococcosis and suggest that phenotypic switching affects host-pathogen interactions in the local microenvironment. This altered interaction then selects for specific colony variants to arise in a pathogen population.

Maintaining standards in surgical training

In order to assess the efficacy of inspection and accreditation by the Specialist Advisory Committee for higher surgical training in orthopaedic surgery and trauma, seven training regions with 109 hospitals and 433 Specialist Registrars were studied over a period of two years.

There were initial deficiencies in a mean of 14.8% of required standards (10.3% to 19.2%). This improved following completion of the inspection, with a mean residual deficiency in 8.9% (6.5% to 12.7%.) Overall, 84% of standards were checked, 68% of the units improved and training was withdrawn in 4%.

Most units (97%) were deficient on initial assessment. Moderately good rectification was achieved but the process of follow-up and collection of data require improvement. There is an imbalance between the setting of standards and their implementation. Any major revision of the process of accreditation by the new Post-graduate Medical Education and Training Board should recognise the importance of assessment of training by direct inspection on site, of the relationship between service and training, and the advantage of defining mandatory and developmental standards.

Molecular epidemiology of clinical Cryptococcus neoformans strains from India

Little is known about the molecular epidemiology of the human pathogenic fungus Cryptococcus neoformans in India, a country now in the midst of an epidemic of AIDS-related cryptococcosis. We studied 57 clinical isolates from several regions in India, of which 51 were C. neoformans var. grubii, 1 was C. neoformans var. neoformans, and 5 were C. neoformans var. gattii. This strain set included 18 additional sequential isolates from 14 patients. Strains were characterized phenotypically by measuring the polysaccharide capsule and by determining the MICs of standard antifungals. Molecular typing was performed by a PCR-based method using the minisatellite-specific core sequence (M13), by electrophoretic karyotyping, by restriction fragment length polymorphisms with the C. neoformans transposon 1 (TCN-1), and by URA5 DNA sequence analysis. Overall, Indian isolates were less heterogeneous than isolates from other regions and included a subset that clustered into one group based on URA5 DNA sequence analysis. In summary, our results demonstrate (i) differences in genetic diversity of C. neoformans isolates from India compared to isolates from other regions in the world; (ii) that DNA typing with the TCN-1 probe can adequately distinguish C. neoformans var. grubii strains; (iii) that TCN-1 sequences are absent in many C. neoformans var. gattii strains, supporting previous studies indicating that these strains have a limited geographical dispersal; and (iv) that human cryptococcal infection can be associated with microevolution of the infecting strain and by simultaneous coinfection with two distinct C. neoformans strains.

Impact of post-methanation distillery effluent irrigation on groundwater quality

Molasses-based distilleries generate large quantities of effluent, which is used for irrigation in many countries including India. The effluent is rich in organic and inorganic ions, which may leach down and pollute the groundwater. An on-farm experiment was conducted to assess the impact of long-term irrigation with post-methanation distillery effluent (PMDE) on nitrate, sulphate, chloride, sodium, potassium, and magnesium contents in the groundwater of two sites in northwest India. Electrical conductivity (EC), pH, total dissolved solids (TDS), sodium adsorption ratio (SAR) and colour were also determined to assess the chemical load in the groundwater. Nitrate content in the groundwater samples ranged from 16.95 mg L(-1) in the unamended fields to 59.81 mg L(-1) in the PMDE-amended fields during the 2-year study (2001-2002). Concentrations of TDS in water samples from tubewell of the amended field was higher by 40.4% over the tubewell water of the unamended field. Colour of the water samples of the amended fields was also darker than that of the unamended fields. The study indicated that the organic and inorganic ions added through the effluent could pose a serious threat to the groundwater quality if applied without proper monitoring.

Cutaneous metastasis from glioblastoma

A rare case of glioblastoma with isolated cutaneous metastasis adjacent to the scar site is described. Its pathogenesis and clinical significance are discussed.

Transdermal Delivery of An Analgesic Agent Using Elastic Liposomes: Preparation, Characterization and Performance Evaluation

The aim of the present study was to prepare and characterize novel vesicular carrier elastic liposomes, of most commonly used non-steroidal anti-inflammatory agent diclofenac for its sustained and targeted delivery. Elastic liposomes of diclofenac were prepared and characterized in vitro and in vivo. The effect of different formulation variables like type of surfactant, concentration of surfactant and dose of drug on transdermal flux, amount of drug deposited into the skin, muscle and plasma concentration was investigated. The biological activity of optimized formulation was evaluated using carrageenan induced rat paw edema model and results were compared with commercial hydrogel formulation. The elastic liposomal formulations achieved muscle drug concentration between 2.2+/-0.14 to 5.3+/-0.22 microg/g at 12 hr. The same dose of commercial hydrogel formulation produced drug levels between 0.41+/-0.07 to 1.1+/-0.09 microg/g in the muscle. Plasma concentration study showed regiospecificity of elastic liposomal formulation. The results of in vivo study revealed that incorporation of diclofenac in elastic liposomes increased its biological activity two fold as compared to commercial hydrogel formulation. The results of the present study demonstrated greater effectiveness of dermaly applied diclofenac elastic liposomal formulation in comparison to conventional delivery system. The optimized elastic liposomal formulation offers a promising means for the non-invasive treatment of local pain and inflammation by topical application.

Impact of a “Direct Approach” to Live Kidney Donation in the British Indo-Asian Community

Although a general imbalance exists between the demand for renal transplants and the supply of suitable organs, the shortfall is particularly severe for patients from the Indo-Asian (I-A) community. It seems unlikely that this will be remedied by any increase in cadaveric donation. Our aim was to increase the rate of live donor transplantation (LDT) in the I-A population through a direct approach to patients and their families, in a culturally acceptable environment by an Asian transplant coordinator. Whereas an increase in LDT was seen in the I-A population over the period of review, 1997 to 2003, 15 compared with none prior to 1997, significant attrition was seen within the program, with only 10% of the original cohort coming to donation. There are multiple reasons for this including medical, social and psychological.

VON RECKLINGHAUSEN'S DISEASE

Von Recklinghausen's disease (VRD) is a rare genetic autosomal dominant disorder that affects the ectodermaltissues (nerve and skin). The cardinal features of this disorder are spots of increase pigmentation (cafe-au-lait spot, CAL), peripheral nerve tumours (neurofibromatosis) and iris hamartoma (Lisch nodule). Clinicaldiagnosis of VRD is based on the criteria given by National Institute of Health (NIH) because the mutationanalysis is laborious. Here, we are reporting a case of a family with VRD.Key Words: VonRecklinghausen's disease (VRD), Cafe-au-lait (CAL) spot, Lisch nodule,Neurofibromatosis (NF)

Third generation cephalosporins versus conventional antibiotics for treating acute bacterial meningitis

BACKGROUND

Antibiotic therapy for suspected acute bacterial meningitis (ABM) needs to be started immediately, even before the results of cerebrospinal fluid culture and antibiotic sensitivity are available. It is not clear whether the available evidence supports the choice of third generation cephalosporins over the conventional antibiotic combination of ampicillin and chloramphenicol. Immediate institution of effective treatment through intravenous route may reduce death and disability in survivors.

OBJECTIVES

The objective of this review is to determine the effectiveness and safety of the third generation cephalosporins and conventional treatment with penicillin/ampicillin-chloramphenicol in patients with community-acquired acute bacterial meningitis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2003) which contains the Cochrane Acute Respiratory Infections Group trials register, MEDLINE (January 1966 to November 2003), and EMBASE (January 1990 to November 2003). We also searched the reference list of review articles and textbook chapters and contacted experts for any unpublished trials.

SELECTION CRITERIA

Randomised controlled trials comparing ceftriaxone or cefotaxime with conventional antibiotics as empirical therapy of acute bacterial meningitis.

DATA COLLECTION AND ANALYSIS

Two independent reviewers applied the study selection criteria, assessed methodological quality and extracted data.

MAIN RESULTS

Eighteen trials included 993 patients in the analysis. The kappa (chance-corrected agreement) between the observers in study selection and data extraction was substantial. There was no heterogeneity of results among the studies in any outcome except diarrhoea. There was no statistically significant difference between the groups in the risk of death (risk difference -1%; 95% confidence interval (CI) -4% to +3%), risk of deafness (risk difference -4%; 95% CI -9% to +1%), risk of treatment failure (risk difference -2%; 95% CI -5% to +2%). However, there were significantly decreased risk of culture positivity of CSF after 10-48 hours (risk difference -6%; 95% CI -11% to 0%) and statistically significant increased in the risk of diarrhoea between the groups (risk difference +8%; 95% CI +3% to +13%) with the third generation cephalosporins. The risk of neutropenia and skin rash were not significantly different between the two groups. However, all the studies have been conducted in the eighties except two, which have been conducted in 1993 and 1996.

REVIEWERS' CONCLUSIONS

Although the review shows no clinically important difference between ceftriaxone or cefotaxime and conventional antibiotics, the studies are done decades ago and may not apply to current routine practice. However, in situations where ceftriaxone or cefotaxime are not available or affordable, ampicillin-chloramphenicol combination may be used as an alternative. The antimicrobial resistance pattern against various antibiotics needs to be closely monitored in developing as well as developed countries. The factors determining overuse of antibiotics in developing countries and educational interventions to limit such practice are priority area for research in developing countries.