Novel in-genome based analysis demonstrates the evolution of OmpK37, antimicrobial resistance gene from a potentially pathogenic pandrug resistant Klebsiella pneumoniae MS1 isolated from healthy broiler feces

Antimicrobial resistance transmission from farm animals to humans is a critical health concern and hence a detailed molecular surveillance is essential for tracking the spread and consequent evolution of antimicrobial resistance. In this study, a pan-drug resistant Klebsiella pneumoniae MS1 strain was isolated from a healthy broiler farm and studied. From the results of the study, MS1 was found to be is resistant to 18 tested antibiotics and has a high-risk to be pathogenic to humans with a probability of 0.80. The whole genome sequencing data of MS1 was used to predict the presence of antimicrobial resistance genes and pathogenicity. The genome analysis has revealed MS1 to have 34 AMR genes. Out of these, the AMR gene OmpK37 codes for an important protein involved in cell permeability and hence in antibiotic resistance. Further analysis was carried out by using an in-genome analysis method to understand the evolution of OmpK37 and the underlying reason for the emergence of resistance. From the detailed analysis, the current study could demonstrate for the first time the evolution of OmpK37 from OmpC. Though structurally OmpK37 was very similar to other porins present in MS1, it was found to have higher mutability as a distinguishing feature which makes it an important protein in monitoring the evolving resistances in microorganisms.

Prevalence of Antimicrobial Resistance Among the Hydrogen Sulfide Producing Bacteria Isolated on XLD Agar from the Poultry Fecal Samples

Poultry products remain as one of the most popular and extensively consumed foods in the world and the introduction of hydrogen sulfide (H2S) producing antibiotic resistant bacterial species into it is an emerging challenge. The current study has been designed to analyze the distribution of antibiotic resistance among the H2S producing bacteria isolated from the fecal samples of chickens from different poultry farms. Here, twenty bacterial isolates were selected based on their ability to produce H2S on XLD agar, and the16S rDNA sequencing was carried out for their molecular identification. The results showed the isolates as belong to Salmonella spp. and Citrobacter spp. and in the antibiotic susceptibility test (AST), three of the Salmonella strains were found to be resistant to antibiotics such as tetracycline, doxycycline, nalidixic acid, and amikacin. Also, fourteen Citrobacter strains showed resistance towards azithromycin, and furthermore, eleven of them were also resistant to streptomycin. Resistance towards tetracycline was observed among five of the Citrobacter strains, and seven were resistant to doxycycline. Further molecular screening by the PCR has showed three of the Salmonella strains along with eight Citrobacter isolates to have tetA gene along with four of the Citrobacter strains to have co-harbored blaTEM gene. The results on biofilm formation have also demonstrated three Salmonella strains along with nine Citrobacter strains to have the ability to form moderate biofilm. The study thus describes the occurrence of H2S producing multidrug-resistant bacteria in poultry feces, which might contribute towards the dissemination of antibiotic resistance genes to other microorganisms including human pathogens with likely risk to treat disease conditions.

Predicting Human Risk with Multidrug Resistant Enterobacter hormaechei MS2 having MCR 9 Gene Isolated from the Feces of Healthy Broiler Through Whole-Genome Sequence-Based Analysis

The zoonotic spread of antimicrobial resistance (AMR) and the associated infections are becoming a major threat to the human population worldwide. Strategies to identify the potential pathogen dissemination by seemingly healthy livestock are at a nascent stage and it is of significant importance to monitor environmental evolution of AMR. In this study, a multidrug resistant strain (MDR) of Enterobacter hormaechei MS2 isolated from the feces of healthy broiler chicken has been characterized by whole-genome sequencing-based method. Here, the isolate was primarily subjected to antimicrobial susceptibility testing followed genome sequencing and analysis. From the antimicrobial susceptibility testing result, the strain was found to be resistant to multiple classes of drugs including the colistin which is an important  last resort drug used to treat infectious diseases. The resistome prediction of genomic data further revealed the presence of 7 perfect and 26 strict hits including those for MCR-9 and FosA2. The pathogenicity prediction has also demonstrated the strain to have the potential to be a human pathogen with 0.72 probability. The phylogenetic analysis has also supported the zoonotic potential of the strain due to its clustering with isolates from both human and livestock-associated host groups. The results of the study suggest the need for a strong surveillance system to identify the opportunistic zoonotic pathogens to prevent a silent AMR menace mediated by them. Carriage of multi-drug resistant strains in the livestock gut microbiome is also a serious concern as it has high AMR transmissibility through contact and supply chain activities.

Bioactive Metabolites of Serratia sp. NhPB1 Isolated from Pitcher of Nepenthes and its Application to Control Pythium aphanidermatum

Plant-associated bacteria have already been considered as the store house of bioactive compounds that confer the plant growth promotion and disease protection. Hence, the unique plant parts have already been expected to harbor diverse microbial communities with multi-beneficial properties. Based on this, the current study has been designed to identify the potential of Serratia sp. NhPB1 isolated from the pitcher of Nepenthes plant for its activity against the infamous pathogen Pythium aphanidermatum. The in vitro antifungal, plant growth promoting and enzymatic activities of the isolate indicated its promises for agricultural application. The isolate NhPB1 was also demonstrated to have positive effect on Solanum lycopersicum and Capsicum annuum, due to its plant beneficial metabolites. From the results of LC-MS/MS analysis, the isolate has also been revealed to have the ability to synthesize bioactive compounds including salicylic acid, cyclodipeptides, acyl homoserine lactone, indole-3-acetic acid, and serrawettin W1. These identified compounds and their known biological properties make the isolate characterized in the study to have significant promises as an eco-friendly solution for the improvement of agricultural productivity.

9-Tricosene Containing Blend of Volatiles Produced by Serratia sp. NhPB1 Isolated from the Pitcher Plant Provide Plant Protection Against Pythium aphanidermatum

Plant-associated bacteria exhibit diverse chemical means to protect plants from the pathogens. The present study has been conducted to evaluate the volatile-mediated antifungal activity of Serratia sp. NhPB1 isolated from the pitcher plant against the notorious pathogen Pythium aphanidermatum. The study has also evaluated the protective effect of NhPB1 on Solanum lycopersicum and Capsicum annuum leaves and fruits against P. aphanidermatum. From the results, NhPB1 was found to have remarkable activity against the tested pathogen. The isolate was also found to impart disease protection in selected plants as evidenced by the morphological changes. Here, the leaves and fruits of S. lycopersicum and C. annuum control which were treated with the uninoculated LB and distilled water were found to have the presence of P. aphanidermatum growth with lesions and decaying of tissues. However, the NhPB1-treated plants did not show any symptoms of fungal infection. This could further be confirmed by the microscopical examination of tissues by propidium iodide staining. Here, the normal architecture of leaf and fruit tissues could be observed in the NhPB1-treated group, but the tissue invasion by P. aphanidermatum was observed in the control group which further confirms the promises of selected bacteria for biocontrol applications.

Multifarious Plant Probiotic Features of Bacillus sp. W11 Isolated from Vermicast and Its Promises for Biocontrol Activity Against Phytopathogens

Organic agricultural practice using vermisources is considered as one of the common sustainable strategies in agriculture. Apart from their nutrient content, beneficial microbes associated with natural vermicast serve as an efficient bioinoculant for improving agricultural productivity. Hence, studies on the identification of suitable microbial inoculants with multi-trait plant beneficial properties from these hotspots are highly promising as an ecofriendly substitute against harmful chemical fertilizers. The current study has been designed to isolate bacterial strains with various plant probiotic and biocontrol properties against various fungal phytopathogens. Among the various bacteria obtained in the study, the isolate W11 was found to have remarkable inhibitory activity against a broad range of phytopathogens like Fusarium oxysporum, Pythium myriotylum, and Rhizoctonia solani, in addition to its multiple plant growth-promoting properties. The W11 was further identified as Bacillus sp. by 16S rDNA sequence-based analysis. The W11 treatment was also found to enhance the plant growth parameters of Vigna unguiculata. In addition, the priming of Bacillus sp. W11 on potato tuber has confirmed to protect it from Fusarium wilt caused by Fusarium oxysporum. This highlights the possible protective effect of W11 during the post-harvest storage of potatoes. Also, the metabolite analysis of W11 extract by LC-QTOF-MS/MS analysis has revealed the presence of lipopeptide surfactin derivatives with m/z of 1008, 1022, and 1036 (M + H)⁺. All the results obtained in the study thus indicate the remarkable agricultural promises of Bacillus sp. W11 isolated from vermicast. Even though vermicast has been studied for its beneficial agricultural applications, the isolation of plant beneficial bacteria from it and detailed characterization of its beneficial effects make the study important.

The injury patterns, management and outcomes of retroperitoneal haemorrhage caused by lumbar arterial bleeding at a Level-1 Trauma Centre: A 10-year retrospective review

PURPOSE

Haemorrhagic shock remains a leading preventable cause of death amongst trauma patients. Failure to identify retroperitoneal haemorrhage (RPH) can lead to irreversible haemorrhagic shock. The arteries of the middle retroperitoneal region (i.e., the 1st to 4th lumbar arteries) are complicit in haemorrhage into the retroperitoneal space. However, predictive injury patterns and subsequent management implications of haemorrhage secondary to bleeding of these arteries is lacking.

MATERIALS AND METHODS

We performed a retrospective cohort study of patients diagnosed with retroperitoneal haemorrhage who presented to our Level-1 Trauma Centre (2009-2019). We described the associated injuries, management and outcomes relating to haemorrhage of lumbar arteries (L1-4) from this cohort to assess risk and management priorities in non-cavitary haemorrhage compared to RPH due to other causes.

RESULTS

Haemorrhage of the lumbar arteries (LA) is associated with a higher proportion of lumbar transverse process (TP) fractures. Bleeding from branches of these vessels is associated with lower systolic blood pressure, increased incidence of massive transfusion, higher shock index, and a higher Injury Severity Score (ISS). A higher proportion of patients in the LA group underwent angioembolisation when compared to other causes of RPH.

CONCLUSION

This study highlights the injury patterns, particularly TP fractures, in the prediction, early detection and management of haemorrhage from the lumbar arteries (L1-4). Compared to other causes of RPH, bleeding of the LA responds to early, aggressive haemorrhage control through angioembolisation. These injuries are likely best treated in Level-1 or Level-2 trauma facilities that are equipped with angioembolisation facilities or hybrid theatres to facilitate early identification and management of thoracolumbar bleeds.

Spectrophotometric Evaluation of Translucency of Various Commercially Available Zirconium Oxide Ceramic Systems: An In Vitro Study

AIM

To evaluate and compare the translucency of various commercially available zirconium oxide ceramic systems, i.e., Ceramill® Zolid Classic, Ceramill® Zi, and DD Bio ZX²71 by using a dual beam UV-visible spectrophotometer.

MATERIALS AND METHODS

The present study comprised of 21 disk-shaped samples of zirconia for every group, i.e., group I-Ceramill® Zolid Classic, group II-Ceramill Zi®, and group III-DD Bio ZX²71. Furthermore, each group was split into three subgroups and every subgroup had seven samples each one of 0.7, 0.8, and 0.9 mm thickness. The samples were prepared by computer-aided design/computer-aided manufacturing (CAD/CAM) system devised by Amann Girrbach AG in accord with the steps provided by the manufacturer. The entire sample was designed having 10 mm in diameter with 0.7, 0.8, and 0.9 mm thickness for every group. The UV-visible dual beam spectrophotometer equipped with D2 lamp and W lamp was used for the measurement of absorbance and transmittance in order to assess the translucency of the fabricated zirconia samples.

RESULTS

The mean value of transmittance % for Ceramill® Zi at 0.8 mm came out to be 0.849 ± 0.024, i.e., the least among all, whereas the mean value of Ceramill® Zolid Classic was 1.408 ± 0.033, being the highest for the same thickness. DD Bio ZX²71 had an intermediate value of 1.274 ± 0.012. The mean value of absorbance for Ceramill® Zi at 0.8 mm came out to be 2.086 ± 0.013, i.e., the maximum among all, whereas the mean value of Ceramill® Zolid Classic was, being the lowest for the same thickness. DD Bio ZX²71 had an intermediate value of 1.902 ± 0.004.

CONCLUSION

The present study data suggest that all the materials subjected to evaluation exhibited a substantial translucency. We attempted to study few of the desirable properties, these materials should possess when used for prosthetic rehabilitation with esthetic contentment a clinical setup. There has been an ambiguous distinction that Ceramill® Zi Zirconia supersedes the Ceramill® Zolid Classic and DD Bio ZX²71. Furthermore, 0.8 mm thickness substantiates to be the most ideal among 0.7, 0.8, and 0.9 mm.

CLINICAL SIGNIFICANCE

The desired outcome of the procedure becomes dependent solely on the clinician's judgment to opt for the material whose properties are most fitting as per the demands of the esthetics. While a clinician should always be ambitious, but a good clinician should also bear in mind that the success of any treatment procedure not only depends on the assortment of properties of these materials but also the host response and satisfaction evoked by these materials.

Rapid detection of mobile resistance genes tetA and tetB from metaplasmids isolated from healthy broiler feces

Containing antimicrobial resistance is the thought of the moment as it affects the human life from every aspect. Because, the inappropriate use of antibiotics in livestock animals for the growth promotion and prophylactic purpose has already generated significant challenges. The livestock farms which harbor and disseminate drug resistant microorganisms have already been identified as potential source of resistance genes acquired by the sensitive strains. Hence there is high demand for the affordable and effective surveillance method for the detection of antimicrobial resistance genes from livestock. In this study, direct detection of antibiotic resistance from metaplasmid DNA isolated from the poultry feces was conducted. For the initial standardization, plasmid DNA purified from the previously characterized Escherichia coli and Klebsiella pneumoniae were used. The tetA and tetB genes amplified from the purified plasmid DNA were further confirmed by agarose gel electrophoresis and sequencing. Further to this, metaplasmid DNA was purified from 29 different poultry fecal samples and these were further screened for the presence of resistance genes. Among the 29 metaplasmid samples, 8 were positive for tetA gene and 9 were positive for tetB gene. The results of the study indicate the potential of PCR based methods for the rapid screening of poultry samples for the antibiotic stewardship in the livestock sector.

Enhancing Wheat Disease Diagnosis in a Greenhouse Using Image Deep Features and Parallel Feature Fusion

Since the assessment of wheat diseases (e.g., leaf rust and tan spot) via visual observation is subjective and inefficient, this study focused on developing an automatic, objective, and efficient diagnosis approach. For each plant, color, and color-infrared (CIR) images were collected in a paired mode. An automatic approach based on the image processing technique was developed to crop the paired images to have the same region, after which a developed semiautomatic webtool was used to expedite the dataset creation. The webtool generated the dataset from either image and automatically built the corresponding dataset from the other image. Each image was manually categorized into one of the three groups: control (disease-free), disease light, and disease severity. After the image segmentation, handcrafted features (HFs) were extracted from each format of images, and disease diagnosis results demonstrated that the parallel feature fusion had higher accuracy over features from either type of image. Performance of deep features (DFs) extracted through different deep learning (DL) models (e.g., AlexNet, VGG16, ResNet101, GoogLeNet, and Xception) on wheat disease detection was compared, and those extracted by ResNet101 resulted in the highest accuracy, perhaps because deep layers extracted finer features. In addition, parallel deep feature fusion generated a higher accuracy over DFs from a single-source image. DFs outperformed HFs in wheat disease detection, and the DFs coupled with parallel feature fusion resulted in diagnosis accuracies of 75, 84, and 71% for leaf rust, tan spot, and leaf rust + tan spot, respectively. The methodology developed directly for greenhouse applications, to be used by plant pathologists, breeders, and other users, can be extended to field applications with future tests on field data and model fine-tuning.

Characteristics of the leachate produced during nutrient recycling of food and poultry slaughter wastes by fly larvae

Biowaste management is a pertinent problem and nutrient recycling utilizing fly larvae is an emerging solution. The leachate produced during biowaste management has potential implications for the environment but studies on this issue are scanty. This study was conducted to assess the characteristics of leachate produced during the bioconversion of food (BW-I) and poultry slaughter waste (BW-II) by natural fly larval activity. The results showed that total volumes of 2.2 L and 1.1 L leachate were produced for BW-I and II respectively. The highest pH in BW-I leachate was 7.43 ± 0.01 and the lowest pH in BW-II was 3.30 ± 0.12. The highest levels of BOD in BW-I and II were 36733.33 ± 430.63 mg/l and 2800.000 ± 999.50 mg/l. The highest level of COD in BW-I was 52575.000 ± 1076.86mg/l while in BW-II it was 4316.67 ± 790.45 mg/l. The high BOD and COD values of the leachate indicated that they needed to be pretreated before being released into the environment.

Protective effect of (+)-catechin against lipopolysaccharide-induced inflammatory response in RAW 264.7 cells through downregulation of NF-κB and p38 MAPK

Catechin, a flavonol belonging to the flavonoid group of polyphenols is present in many plant foods. The present study was done to evaluate the effect of catechin on various inflammatory mediators using lipopolysaccharide (LPS)-stimulated RAW 264.7 macrophages. The effect of catechin on total cyclooxygenase (COX) activity, 5-lipoxygenase (5-LOX), myeloperoxidase, nitrite and inducible nitric oxide synthase (iNOS) level, secretion of tumor necrosis factor-α (TNF-α) and interleukin-10 (IL-10) were assessed in LPS-stimulated RAW 264.7 cells. The expression of COX-2, iNOS, TNF-α, nuclear factor-ĸB (NF-κB) and p38 mitogen-activated protein kinase (MAPK) genes were also investigated. The effect was further analyzed using human PBMCs by assessing the level of TNF-α and IL-10. The study demonstrated that the inflammatory mediators such as COX, 5-LOX, nitrite, iNOS, and TNF-α were significantly inhibited by catechin in a concentration-dependent manner whereas IL-10 production was up-regulated in RAW 264.7 cells. Moreover, catechin down-regulated the mRNA level expression of COX-2, iNOS, TNF-α, NF-κB and p38 MAPK. The current study ratifies the beneficial effect of catechin as a dietary component in plant foods to provide protection against inflammatory diseases.

AB0360 A DECADE OF SUSPECTED GIANT CELL ARTERITIS: CLINICAL FEATURES OF A HIGHLY HETEROGENEOUS DISEASE

Background:

Giant cell arteritis is the most common chronic systemic vasculitis in older adults. Permanent visual loss is the most concerning complication can occur in up to 20% of patients (1). Diagnosis is based on a combination of clinical findings, laboratory evidence of inflammatory markers, and temporal artery biopsy (TAB) confirming histologic evidence of inflammation. There are no definitive markers of the disease when TAB is negative.

Objectives:

The objective of this study was to illustrate the clinical features of subjects suspected with GCA evaluated at the Dallas Veterans Affairs Medical Center (VAMC) and identify those features that would differentiate between TAB positive GCA, TAB negative GCA and non-GCA patients.

Methods:

This retrospective study searched the Dallas VAMC database for subjects between January of 2010 until December 2019 with ICD-9 and ICD-10 entry code for GCA. Based on the 1990 ACR clinical classification criteria for GCA, suspected patients were classified as TAB positive GCA, TAB negative GCA and non-GCA. Subjects with incomplete data needed for classification were excluded. Group comparisons were performed with Fisher’s exact test for categorical variables and the Mann-Whitney test for continuous variables.

Results:

One-hundred and sixty-nine subjects had ICD-9/10 entry code for GCA. Ophthalmology was the specialty who did the initial evaluation in 46% of the suspected cases. Seventy-one patients were excluded due to incomplete data. Of the remaining 98 patients, 42 (42.9%) were diagnosed with GCA out of which 10 patients had a positive TAB. Seventy-six percent of patients diagnosed with GCA had negative temporal artery biopsies. In 56 (57.1%) patients GCA was ruled out (Figure 1). New-onset headache was the predominant symptom suggestive of GCA affecting 88.9% TAB positive and 100% of TAB negative cases compared to 56.6% of non-GCA patients (p< 0.001), followed by scalp tenderness in 33.3%, 58.1% and 10.9%, respectively (p< 0.001), jaw claudication in 57.1%, 34.5% and 14.9% (p=0.021), and elevated sedimentation rate in 33%, 65.6% and 33% (p=0.013) (Table 1). Polymyalgia rheumatica was present in 28.6% and 21.7% of patients diagnosed with GCA compared to zero percent in non-GCA cases (p=0.017). More than 30% of patients with GCA had normal acute phase reactants in this cohort.

Table 1.

Comparison of demographics and clinical features of patients with suspected GCA

GCA TAB Positive (n=10)GCA - TAB Negative (n=32)non-GCA (n=56)n%n%n%pAge (mean/sd)71.3 (7.8)67.3 (8.1)67.3 (8.9)0.367Male99030/3293.851/5691.10.885Clinical findingsNew onset headache8/988.932/3210030/5356.6<0.001Visual symptoms9/109022/3268.842/5477.80.351Jaw claudication4/757.110/2934.57/4714.90.021PMR2/728.65/2321.70/3000.017Scalp tenderness2/633.318/3158.15/4610.9<0.001Fever0/505/2321.72/355.70.117ESR > 501/333.321/3265.618/5433.30.013CRP > 101/333.35/3016.76/5411.10.473Anemia (hemoglobin < 12 g/ dl)2/728.615/3246.921/5240.40.642Thrombocytosis (platelets >400)2/728.63/329.44/517.80.228

Conclusion:

There is clinical heterogeneity within the patients diagnosed with GCA regardless of TAB. A high index of clinical suspicion needs to be the cornerstone of diagnosis. There is need for new classification criteria to include patients with negative TAB.

References:

[1]Soriano A, et al. Nat Rev Rheumatol. 2017 Aug;13(8):476-484.

Disclosure of Interests:

Adela Castro: None declared, Jiby Mathew: None declared, Ola Azzouqah: None declared, Jesus Diaz: None declared, Andreas Reimold Consultant of: Lilly, Grant/research support from: Abbvie

Pfizer

Gilead, Kyawt Shwin: None declared

Evaluation of Anti-quorum Sensing Potential of Saraca asoca (Family Caesalpiniaceae) against Chromobacterium violaceum and Pseudomonas aeruginosa PA01

Aim: The present study was performed to evaluate the anti-quorum sensing (QS) potential of traditional medicinal herb Saracaasoca (family Caesalpiniaceae) stem bark extract against Chromobacterium violaceum and Pseudomonas aeruginosa PA01. Study Design: First, the test sample (bark extract) was screened for anti-QS activity. Then systematic in-vitro and biochemical tests were performed to evaluate the effect of the test sample on the QS mediated virulence factors. Place and Duration of Study: All the experimental works were performed in Lab 311, pharmacology division, CSIR-NBRI Lucknow from June 2019 to October 2019. Methodology: The samples of Saraca asoca stem bark were washed, dried and extracted using 70% methanol. The minimum inhibitory concentration (MIC) of the prepared Sarca asoca bark extract was determined using the Alamar blue assay, and the anti-QS activity was screened using standard agar overlay method against CV 12472 at subinhibitory concentrations 100, 200 and 300 µg (< MIC value). SAE effect on biofilms formation was assessed by growing biofilms on glass slides in a static culture of PA01. Anti-virulence effect of SAE on the production of QS-regulated virulence factors such as Pyocyanin, proteases, elastases, rhamnolipid and alginate in Pseudomonas aeruginosa was determined using the supernatant of a 24 hours old broth culture of PA01 supplemented with SAE. Using the agar plate technique, the swimming and swarming motility assays were conducted on 0.3% and 0.5% agar plates respectively. One-way ANOVA was used to analyze the data, presented as mean ± SD (standard deviation) of three independent experiments. Results: Preliminary screening results showed significant QS inhibition against CV 12472 in an agar overlay disk diffusion assay in a concentration-dependent manner. Data from the biofilm assay showed loose, distorted, irregular PA01 biofilm formation at 200 µg (48%) and 300 µg (65%). SAE caused a significant drop in virulence factor production, with maximum reduction in pyocyanin (58%), proteases (67%), elastases (52%), rhamnolipid (53%), and alginate (44%) observed at 300 µg concentration. At SAE sub-lethal concentrations (200 and 300 µg), both the swimming and swarming motility of PA01 were significantly inhibited. Conclusions: The present study demonstrates the broad-spectrum anti-QS potential of SAE, reported for the first time, suggesting that SAE could be considered as an alternative herbal source to develop antimicrobial agents which can be either solitary or synergistically with conventional antimicrobial drugs.

40 Improving Urinary Catheter Documentation and Care in Geriatric Wards

Introduction

NICE guidelines state that urinary catheter insertion, changes and care should be documented. Duration of catheterization is directly linked to the risk of developing a catheter-associated UTI. Furthermore, Public Health England has announced a national aim to reduce the incidence of Gram-negative bacteraemia by 50% by March 2021, and targeting catheters is one of the first steps.

Local problem

These issues are relevant to the elderly population at Princess Royal University Hospital, where documentation surrounding catheters was found to be inadequate. Despite there being an Electronic Patient Record (EPR) order for catheter insertion and monitoring available, this was not being used. Our primary aim was for all patients to have this order. We also hoped to reduce the weekly rate of catheter days (catheter days per 100 bed days), and improve documentation in clinical notes.

Methods

We focused on two medical wards and sampled all patients admitted over a period of 4 months who had a catheter at the time of data collection. We identified catheterized patients and whether they had an EPR catheter order on a daily basis. Additional parameters such as indication, insertion date, inserter, and documentation standards were extracted from EPR on a weekly basis. Patients were kept “live” and contributing to catheter day calculations until they were no longer on the ward or if the catheter was removed.

Interventions

We implemented changes over 2 PDSA cycles. Interventions included the addition of catheter columns to boards and education sessions for doctors and nurses (cycle 1), as well as catheter posters, alert cards, and circulation of emails with guidance to doctors and nursing staff (cycle 2).

Results

A total of 87 patients were analysed during the project. There was an increase in EPR orders being used, with the 100% target being reached on the final data collection point, and with data showing a significant shift above baseline. Furthermore, there was a decrease in the weekly rate of catheter days, but changes were difficult to sustain. We also saw a general improvement in documentation standards.

Conclusion

By improving documentation and reducing unnecessary catheterization, we hope to have reduced the overall risk of infection whilst improving patient comfort and experience. Lessons may be transferrable to other trusts.

Penile fracture associated with complete urethra and bilateral corpora cavernosa transection

Penile fracture is a rare urological emergency caused by blunt trauma to the erect penis. It occurs due to the forcible bending of the turgid erect penis against resistance leading to tunica albuginea tear. The rupture of tunica albuginea surrounding the corpora cavernosa leads to hematoma formation and classical 'aubergine' deformity. Timely intervention is essential to improve sexual function. Urethral injury may occur concomitantly in case of severe trauma. Blood at the meatus, inability to void and haematuria are distinctive features. We describe a case of 36-year-old man who presented to the emergency department with penile fracture during sexual intercourse associated with blood at the meatus and voiding difficulty. On surgical exploration, complete bilateral corpora cavernosa tear and penile urethral transection was noted. The patient was successfully managed with timely repair. This case highlights the need for suspicion of an associated urethral injury in patients of penile fracture with blood at the meatus.

Healthy broilers disseminate antibiotic resistance in response to tetracycline input in feed concentrates

Wide varieties of antibiotics are used in poultry farms to improve the growth and also to control the infection in broiler chicken. To identify the seriousness of the same in the poultry sector, current study has been designed to analyze the presence of tetracycline in poultry feed and also the tetracycline resistance among the bacteria released through the excreta of poultry. In the study, 27 bacteria belonging to the Escherichiacoli and Klebsiellapneumoniae. were isolated from the faecal samples collected from five different farms. Antibiotic susceptibility analysis showed 77% of E. coli and 100% of the K. pneumoniae. to be resistant to tetracycline. Further, molecular screening for tetA and tetB genes showed 85.18% of isolates to have tetA and 22.22% with tetB. The presence of tetracycline in collected feed samples was also analysed quantitatively by Liquid chromatography-mass spectrometry (LC-MS). Here, three out of five feed samples were found to be positive for tetracycline. The study showed a direct correlation between the antibiotic supplemented feed and the emergence of antimicrobial resistance among the intestinal microflora. The results of the study indicate the need for strict control over antibiotic use in animal feed to limit the rapid evolution and spread of antimicrobial resistance.

Genome sequencing and annotation of multi-virulent Aeromonas veronii XhG1.2 isolated from diseased Xiphophorus hellerii

The present study was intended to elucidate the genomic basis of antibiotic resistance and hyper-virulence of the fish pathogen Aeromonas veronii XhG1.2 characterized in our previous work. The identity of XhG1.2 was confirmed through 16S rDNA sequence analysis and whole genome sequence analysis. The top-hit species distribution analysis of XhG1.2 sequence data revealed major hits against the Aeromonas veronii. The identification of virulence genes using the VFDB showed the genome of XhG1.2 to have the genes coding for the virulence factors viz. aerolysin, RtxA, T2SS, T3SS and T6SS. The presence of antibiotic resistance predicted through the CARD database analysis showed it to have the CephA3, OXA-12, adeF and pulvomycin resistance genes. By the phylogenetic and comparative genomic analysis, A. veronii species were found to have genes for toxin production. This also confirmed the pathogenicity and drug resistance of A. veronii XhG1.2 and also its potential to cause disease in diverse ornamental fishes.

AB0596 PREDICTORS, LONG TERM CLINICAL AND TREATMENT OUTCOMES IN SOUTH ASIAN PATIENTS WITH IDIOPATHIC INFLAMMATORY MYOSITIS: A SINGLE CENTER STUDY

Background:

Idiopathic inflammatory myositis (IIM) are a heterogeneous group of immune-mediated disorders with varied presentations and multiple organ involvement. Data on long term outcome among South Asian patients with IIM is sparse.

Objectives:

To study the long term clinical outcome, treatment responses and factors predicting outcome among adult patients with IIM

Methods:

Patients diagnosed as ‘Idiopathic Inflammatory Myositis’ under the department of Clinical Immunology and Rheumatology at CMC, Vellore, India were screened retrospectively. Patients aged 18 years and above, satisfying Bohan and Peter criteria, having follow up of one year or more with atleast two outpatient or inpatient visits between January 2010 and April 2019 were included in this study. Those patients with connective tissue disease associated myositis were not included. Details on muscle weakness, extramuscular involvement, muscle enzymes and treatment administered were recorded at baseline, 3, 6, 12, 18, 24 months and yearly thereafter. After assessing their cumulative response, categorization of patients into complete and partial responders was done. Complete responders were defined as patients with persistent muscle power of more than 4/5 and/or MMT 8 more than 76/80, complete resolution of skin, articular and lung involvement (if any) as well as muscle enzymes less than twice the upper limit of normal without any documented flares during the entire follow up period. Patients not satisfying the said criterias were grouped as Partial responders. Disease free survival duration was also analyzed.

Results:

Out of 310 patients of IIM identified, 187 (60.3%) patients satisfied the inclusion criteria. Women were 2.2 times more than men and mean age at symptom onset was 35.7±12.6 years. Dermatomyositis was the predominant myositis subtype seen. All patients were put on steroids with the mean dose being 45.9 ± 18.6 mg/day. At baseline, the key immunosuppressants used were methotrexate in 44.9% and mycophenolate in 37.6% patients. The median follow up duration was 48 (25-80) months. An associated malignancy was diagnosed in 3.2% after a median duration of 24.5 months. Five patients expired after a median duration of 80 months from diagnosis. Normal muscle power was attained in 76.1% patients and 88.6% were vocational by the last follow up visit. Steroids were discontinued in 56.7% patients after a median duration of 24 months (p=0.0002). Discontinuation of the immunosuppressant was feasible in 10.2% patients after a median duration of 44 months. Assessment of the cumulative responses revealed a relapsing and remitting course in 45.9%. Outcome predictors in univariate analysis were Jo-1 status, presence of arthritis, interstitial lung disease and pericardial effusion at baseline. On multivariate analysis, absence of pericardial effusion (p=0.011) and interstitial lung disease (p=0.067) at baseline were found to be predictors of complete response. Disease free survival probability estimated at 5 years and 10 years was 91.6% and 72.4% respectively. Estimating the probability gender wise, males achieved disease free status earlier than females.

Conclusion:

A favorable clinical and functional outcome was seen in a significant proportion of these patients with IIM on long term follow up. Pericardial effusion and ILD were identified as predictors of poor clinical outcome.

References:

[1]Taborda AL, Azevedo P, Isenberg DA. Retrospective analysis of the outcome of patients with idiopathic inflammatory myopathy: a long-term follow-up study. Clin Exp Rheumatol. 2014 Apr; 32(2):188–93.

Acknowledgments:

Nil

Disclosure of Interests:

None declared

THU0523 CLINICAL UTILITY OF TESTING CONVENTIONAL AND NON-CONVENTIONAL ANTI-PHOSPHOLIPID ANTIBODIES IN SUSPECTED OBSTETRIC ANTI-PHOSPHOLIPID SYNDROME

Background:

Anti-phospholipid syndrome (APS) is an important cause for recurrent pregnancy losses (RPL). Conventional APS antibodies (aPLs) like lupus anti-coagulant (LA), anti-cardiolipin(ACL) and anti-beta 2 glycoprotein I (anti-β2 GP I) are not present in significant number of obstetric APS(OAPS) patients, leading to a state described as “ sero-negative” OAPS (SNOAPS). Recent literature shows non-conventional aPLs like Anti phosphatidylserine-prothrombin complex (Anti-PSPT) and Anti-Annexin V (Anti-Ann V) can be positive in up to 50% of SNOAPS patients

Objectives:

Testing the performance of conventional and non-conventional aPLs in suspected OAPS patients (obstetric events as defined in the Sydney classification criteria for APS)

Methods:

We performed a retrospective chart review of 101 patients who underwent combined testing for non-conventional aPLs for suspected OAPS from May 2016 to November 2019 at our department. Patients were categorized into OAPS cases (n=50, median age 31 years) and controls (n=51, median age 30 years) based on their fulfillment of clinical definition of OAPS events defined by Sydney criteria. Conventional aPLs were tested by methods adapted in Sydney criteria and Anti PSPT /Anti Ann V were tested by commercial ELISA. The sample size(n=101) has 95% confidence interval with a margin of error of 10% for the objective of the study.

Results:

36 cases (72%) were ‘sero-positive’ & 14 cases (28%) were truly ‘sero-negative’ for conventional aPLs. 5 (35.7%) of the SNOAPS patients were positive for Ant-PSPT and/or Anti AnnV antibodies. Performance of the various aPLs in suspected OAPS is displayed in Table 1 & Figure 1.

Table 1

showing the performance of the various conventional and non-conventional APLs in suspected obstetric APS cases

AntibodySensitivitySpecificityLikelihood Ratio(+)Likelihood Ratio (-)Positive Predictive ValueNegative Predictive ValueAccuracyYouden’s IndexLA50%94.1 %8.50.589.3%65.7%72.3%44.1%ACL32%98%16.30.794.1%59.5 %65.3%30 %anti β2 GP I IgM38.4%91.4 %4.50.783.3%57.1 %63.5%29.8%anti β2 GP I IgG24%96.1 %6.10.885.7%56.3%60.4%20.1%Anti PSPT28%96.1 %7.10.787.5%57.6 %62.4%24.1%Anti AnnV28%98 %14.30.793.3%58.1%63.4%26%Conventional APLs72%88.2%6.10.385.7%76.3 %79.8%60.2%Non-conventional APLS38%94.1%6.40.786.4%60.7 %66.3%32.1%All APLs82%86.3%6.000.2085.4%83 %84.2%68.3%Figure 1

showing the comparative diagnostic performance of Conventional aPL testing vs Combined testing along with non-conventional aPLs in suspected obstetric APS scenario

Conclusion:

In a delicate situation like RPL, performance of non-conventional aPLs on their own, though not as sensitive as conventional aPLs, still demonstrate better specificity. Non-conventional APLs can newly identify 1/3rd of SNOAPS as APS. The real value of testing Anti PSPT & Anti Ann V in RPL, is combined testing with conventional aPLs wherein they improve the sensitivity and accuracy of diagnosis of OAPS by 10% & 4.4 % respectively, with only 1.9% drop in specificity. Non-conventional aPLs should be tested in SNOAPS.

Disclosure of Interests:

None declared

A checklist for trauma quality improvement meetings: A process improvement study

BACKGROUND

Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM.

METHODS

This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop.

RESULTS

There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7; 95% CI:1.4-9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001) and agreed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001).

CONCLUSION

This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients.

Administration of tranexamic acid for victims of severe trauma within pre-hospital care ambulance services (PHCAS) in Malaysia

INTRODUCTION

Trauma is a Global threat and the 5th highest cause of all-cause mortality in Malaysia caused predominantly due to road traffic accidents. Majority of trauma victims are young adults aged between 21-40 years old. In Malaysia, 24 out of 100,000 population die annually due to trauma, rating us amongst the highest in South East Asia. These alarming figures justify aggressive preventive and mitigation strategies. The aim of this paper is to promote the implementation of evidence-based interventions that will reduce the rate of preventable death because of trauma. Tranexamic acid is one of the few interventions in the early management of severe trauma with level-one evidence. Tranexamic acid has been proven to reduce all causes of mortality and mortality due to bleeding. Evidence proves that it is most effective when administered early, particularly within the 1st hour of trauma. This proposed guideline is formulated based upon quality evidence from multicentre studies, clinical practices in other countries and consideration of the local demographic factors with the intent of enabling an easy and simple pathway to administer tranexamic acid early in the care of the severely injured.

CONCLUSION

The guideline highlights select pre-hospital criteria's and the methods for drug administration. The authors recognise that some variants may be present amongst certain institutions necessitating minor adaptations, nevertheless the core principles of advocating tranexamic acid early in the course of pre-hospital trauma should be adhered to.

Distribution of antibiotic resistance and virulence factors among the bacteria isolated from diseased Etroplus suratensis

Considering the emerging concern with the antimicrobial resistance (AMR) evolution, the study has been designed to identify the antibiotic resistance and virulence properties of culturable bacteria isolated from the diseased fish Etroplus suratensis. This has resulted in the purification of 18 morphologically distinct bacterial isolates which were identified by both biochemical and molecular methods. Antibiotic resistance analysis showed the resistance of these isolates to multiple antibiotics and remarkable evolution of AMR. Further screening for virulence factors confirmed five isolates to be positive for haemolytic activity, eight with caseinase, four with DNase, one with gelatinase and three with biofilm-forming properties. In addition to these, the isolates were subjected to PCR-based screening to detect the presence of genes coding for aerolysin and haemolysin. Results showed the presence aerolysin gene in the isolates ESS3.2, ESS3.8, ESI3.3 and ESS3.6, while haemolysin gene was observed to be present in ESG3.1 and ESI3.2. The observed results hence indicate the need for frequent monitoring of these properties among bacterial isolates from diverse environment especially those associated with edible fish.