Antimicrobial Resistance Profile in ICU Patients Across India: A Multicenter, Retrospective, Observational Study

Background The pattern of antimicrobial resistance (AMR) changes with time and varies in countries and between hospitals within the same country. Physicians might thus benefit from information on regional resistance patterns of clinically significant bacterial isolates when deciding on the best empirical treatment. Numerous nosocomial infections are caused by multidrug-resistant (MDR) strains, notably methicillin-resistant Staphylococcus aureus (MRSA) strains, which are also linked to higher morbidity and death. Aim Evaluation of AMR profile in intensive care unit (ICU) patients of multiple tertiary care centers across India. Methods This was a multicenter, retrospective study based on electronic laboratory records of microbial isolates from clinical specimens from ICUs analyzed at microbiology laboratories of identified hospitals. Data of invasive sample records was collected from Microbiology labs of the identified hospitals within India and were aligned to WHO 5 Net standard reporting and as per Clinical & Laboratory Standards Institute (CLSI-2014) Guidelines for assessment. Data from 21556 samples were collected retrospectively from December 2021 to January 2010. Antibiotic susceptibility testing was done by using both the Kirby Baur disk diffusion method and the automated method (using the Vitek 2 compact system) as per CLSI (2014) guidelines. Results Of 21,556 enrolled patients, the majority (54.12%) were males and adults (62.07%). The median age was 58 years. Of 815 gram-positive bacteria reports, the commonest were S. aureus (552, 67.73%), Coagulase-negative Staphylococci (107, 13.13%), and Enterococcus spp. (105, 12.88%). For Coagulase-negative Staphylococci-positive samples, resistance was to penicillin (79, 73.83%), and erythromycin (73, 68.22%); and for S. aureus was to ciprofloxacin (361, 65.4%), and erythromycin (315,57.07%). Enterococcus spp. showed maximum resistance to erythromycin (73, 69.52%), followed by ampicillin, ciprofloxacin (68,64.76% each). Of 4,183 gram-negative bacteria reports, the commonest were Klebsiella pneumoniae (1,531, 36.6%), Escherichia coli (1,269, 30.34%), and Acinetobacter spp. (589, 14.08%), Pseudomonas aeruginosa (438, 14.08%), other Klebsiella spp. (174, 4.16%) and Enterobacter spp. (161, 3.85%). K. pneumoniae showed resistance to ciprofloxacin (1,001, 65.38%). E. coli showed resistance to ampicillin (918, 72.34%), and ciprofloxacin (798,62.88%); and Acinetobacter spp. to ceftazidime (525, 89.13%), and ciprofloxacin (507, 86.08%), while P. aeruginosa showed resistance to imipenem (234, 53.42%). Enterobacter spp. showed resistance to cefotaxime (129, 80.12%). MRSA samples showed resistance to phenoxymethylpenicillin (188, 35.54%) and benzylpenicillin (178, 33.46%). Conclusion Gram-negative bacteria were more common than gram-positive bacteria in causing antibiotic-resistant infections in ICU, with beta-lactams, fluoroquinolones, macrolides, and cephalosporins showing varied percentages of resistance. Fluoroquinolones, macrolides, and penicillin were noted to be highly resistant against gram-positive species. This indicates that evaluation based on MDR and antibiotic consumption patterns is imperative.

Infective Endocarditis Secondary to Mycoplasma pneumoniae

Mycoplasma pneumoniae (MP) is a gram-positive bacterium most commonly associated with community-acquired pneumonia in adults. It can also involve other systems of the body. Cardiovascular complications include pericarditis, myocarditis, congestive cardiac failure, and, rarely, infective endocarditis. We report a case of infective endocarditis secondary to MP infection in an adult. We treated our patient with doxycycline, which showed significant improvement.

Association between CMV and Invasive Fungal Infections After Autologous Stem Cell Transplant in Lymphoproliferative Malignancies: Opportunistic Partnership or Cause-Effect Relationship?

Unlike allogeneic transplant, autologous stem cell transplantation (ASCT) represents a procedure with a low-risk of cytomegalovirus (CMV) symptomatic reactivation-infection/end-organ disease (CMV complications) and invasive fungal disease (IFD). However, novel drugs for the treatment of lymphoproliferative malignancies could cause an increase of such opportunistic infections, even after ASCT. To the best of our knowledge, there are no published data demonstrating an association between CMV and IFD in the autologous setting, while this association has been widely reported in allogeneic transplantation. We have reviewed our series of 347 ASCT in myeloma and lymphoma patients performed over a period of 14 years with the aim of investigating the descriptive and analytical epidemiology of bacterial, CMV and IFD complications, focusing on the association between CMV and IFD. Patients with myeloma have significantly fewer bacterial infections and IFD than patients with lymphoma, but a similar rate of CMV complications. Descriptive epidemiological data are consistent with the literature, indicating an overall incidence of 36%, 3.5% and 15.5% for bacterial infections, IFD and CMV complications, with a case mortality rate of 4%, 16.7% and 3.7%, respectively. A strong correlation between CMV and IFD exists, with 8 cases of IFD out of a total of 12 presenting a CMV complication. At multivariate analysis, a diagnosis of lymphoma, ≥3 previous treatment lines and age ≥60 years were found to be independent risk factors for IFD. Duration of neutropenia (ANC < 500/mm³) ≥7 days represents an independent risk factor for CMV complications, where neutropenia most likely represents a crude surrogate biomarker indicating a deeper and longer state of overall immunosuppression. From our data we conclude that (1) myeloma patients are at lower risk of bacterial infections and IFD as compared with lymphoma patients but are at equal risk of CMV complications, most likely as a consequence of a selective impact of bortezomib on Herpes Viruses infection control; (2) a significant association exists between CMV and IFD, although a possible cause-effect relationship remains to be determined; (3) IFD is a rare complication after ASCT but burdened by a mortality rate of about 17%, with peak rates in older lymphoma patients who underwent more intensive therapeutic regimens.

High frequency equipment promotes antibacterial effects dependent on intensity and exposure time

Background

The indiscriminate use of antibiotics has caused bacteria to develop mechanisms of resistance to antibacterial agents, limiting treatment options. Therefore, there is a great need for alternative methods to control infections, especially those related to skin. One of the alternative methods is the high frequency equipment (HFE), which is used on skin conditions as an analgesic, an anti-inflammatory, and mainly to accelerate cicatricial processes and have a bactericidal effect through the formation of ozone. This research investigated the antibacterial effect of HFE on standard cultures of bacteria.

Materials and methods

Dilutions (10⁴ colony forming unit mL⁻¹) were performed for Enterobacter aerogenes and Staphylococcus aureus with 24-hour growth bacteria. Then, 1 μL of each dilution was pipetted into suitable medium and the HFE flashing technique was used at intensities of 6, 8 and 10 mA for 30, 60, 90, 120 and 180 seconds. The control group received no treatment. Plates were incubated at 37°C for 24 hours and then read.

Results

The spark at intensity of 6 mA had no bactericidal effect on the E. aerogenes; however, a significant bacterial growth reduction occurred at intensity of 8 mA after 120 and 180 seconds, and at 10 mA, reduction in bacterial growth could already be verified at 30 seconds and total bacterial growth inhibition occurred in 180 seconds. For S. aureus, there was a strong bacterial growth inhibition at all intensities used; however, at 6 mA, absence of bacterium growth after 120 and 180 seconds was observed. By increasing the flashing intensity to 8 and 10 mA, it was observed that the bacterium growth was inhibited after only 30 seconds of irradiation.

Conclusion

The HFE has time-dependent antibacterial effects against E. aerogenes and S. aureus bacteria that have several resistance mechanisms.

Evaluation of anti‐bacterial activity of silver nanoparticles synthesised by coprophilous fungus PM0651419

The study explored biological synthesis of metallic silver nanoparticles (AgNPs) from the less explored non‐pathogenic coprophilous fungus, sterile mycelium, PM0651419 and evaluates the antimicrobial efficacy of biosynthesised AgNPs when impregnated in wound fabrics and in combination with six antimicrobial agents. AgNPs alone proved to be potent antibacterial agents and in combination they enhanced the antibacterial activity and spectrum of antibacterials used in the study against a microbiologically diverse battery of Gram positive, Gram negative and multidrug‐resistant bacteria. AgNPs impregnated on the wound dressings established their antibacterial activity by significantly reducing the bacterial load of pathogenic bacteria like Staphylococcus aureus and Bacillus subtilis e stablishing potential as effective antimicrobial wound dressings for treatment of polymicrobial wound infections. This study presents the first report on the potential of biosynthesis of AgNPs from the under explored class of coprophilous fungi. Their promise to be used in wound dressings and as potent antibacterials alone and in combination is evaluated

Mechanisms of peptide sex pheromone regulation of conjugation in Enterococcus faecalis

In many gram positive bacteria, horizontal transfer and virulence are regulated by peptide-mediated cell-cell signaling. The heptapeptide cCF10 (C) activates conjugative transfer of the Enterococcus faecalis plasmid pCF10, whereas the iCF10 (I) peptide inhibits transfer. Both peptides bind to the same domain of the master transcription regulator PrgX, a repressor of transcription of the prgQ operon encoding conjugation genes. We show that repression of prgQ by PrgX tetramers requires formation of a pCF10 DNA loop where each of two PrgX DNA-binding sites is occupied by a dimer. I binding to PrgX enhances prgQ repression, while C binding has the opposite effect. Previous models suggested that differential effects of these two peptides on the PrgX oligomerization state accounted for their distinct functions. Our new results demonstrate that both peptides have similar, high-binding affinity for PrgX, and that both peptides actually promote formation of PrgX tetramers with higher DNA-binding affinity than Apo-PrgX. We propose that differences in repression ability of PrgX/peptide complexes result from subtle differences in the structures of DNA-bound PrgX/peptide complexes. Changes in the induction state of a donor cell likely results from replacement of one type of DNA-bound peptide/PrgX tetramer with the other.

Antimicrobial Peptides: Mechanisms of Action and Resistance

More than 40 antimicrobial peptides and proteins (AMPs) are expressed in the oral cavity. These AMPs have been organized into 6 functional groups, 1 of which, cationic AMPs, has received extensive attention in recent years for their promise as potential antibiotics. The goal of this review is to describe recent advances in our understanding of the diverse mechanisms of action of cationic AMPs and the bacterial resistance against these peptides. The recently developed peptide GL13K is used as an example to illustrate many of the discussed concepts. Cationic AMPs typically exhibit an amphipathic conformation, which allows increased interaction with negatively charged bacterial membranes. Peptides undergo changes in conformation and aggregation state in the presence of membranes; conversely, lipid conformation and packing can adapt to the presence of peptides. As a consequence, a single peptide can act through several mechanisms depending on the peptide's structure, the peptide:lipid ratio, and the properties of the lipid membrane. Accumulating evidence shows that in addition to acting at the cell membrane, AMPs may act on the cell wall, inhibit protein folding or enzyme activity, or act intracellularly. Therefore, once a peptide has reached the cell wall, cell membrane, or its internal target, the difference in mechanism of action on gram-negative and gram-positive bacteria may be less pronounced than formerly assumed. While AMPs should not cause widespread resistance due to their preferential attack on the cell membrane, in cases where specific protein targets are involved, the possibility exists for genetic mutations and bacterial resistance. Indeed, the potential clinical use of AMPs has raised the concern that resistance to therapeutic AMPs could be associated with resistance to endogenous host-defense peptides. Current evidence suggests that this is a rare event that can be overcome by subtle structural modifications of an AMP.

Role of Glycosyltransferases Modifying Type B Flagellin of Emerging Hypervirulent Clostridium difficile Lineages and Their Impact on Motility and Biofilm Formation

Clostridium difficile is the principal cause of nosocomial infectious diarrhea worldwide. The pathogen modifies its flagellin with either a type A or type B O-linked glycosylation system, which has a contributory role in pathogenesis. We study the functional role of glycosyltransferases modifying type B flagellin in the 023 and 027 hypervirulent C. difficile lineages by mutagenesis of five putative glycosyltransferases and biosynthetic genes. We reveal their roles in the biosynthesis of the flagellin glycan chain and demonstrate that flagellar post-translational modification affects motility and adhesion-related bacterial properties of these strains. We show that the glycosyltransferases 1 and 2 (GT1 and GT2) are responsible for the sequential addition of a GlcNAc and two rhamnoses, respectively, and that GT3 is associated with the incorporation of a novel sulfonated peptidyl-amido sugar moiety whose structure is reported in our accompanying paper (Bouché, L., Panico, M., Hitchen, P., Binet, D., Sastre, F., Faulds-Pain, A., Valiente, E., Vinogradov, E., Aubry, A., Fulton, K., Twine, S., Logan, S. M., Wren, B. W., Dell, A., and Morris, H. R. (2016) J. Biol. Chem. 291, 25439–25449). GT2 is also responsible for methylation of the rhamnoses. Whereas type B modification is not required for flagellar assembly, some mutations that result in truncation or abolition of the glycan reduce bacterial motility and promote autoaggregation and biofilm formation. The complete lack of flagellin modification also significantly reduces adhesion of C. difficile to Caco-2 intestinal epithelial cells but does not affect activation of human TLR5. Our study advances our understanding of the genes involved in flagellar glycosylation and their biological roles in emerging hypervirulent C. difficile strains.

Biofabrication of broad range antibacterial and antibiofilm silver nanoparticles

Silver nanoparticles (AgNPs) were biosynthesized via a green route using ten different plants extracts (GNP1- Caryota urens, GNP2-Pongamia glabra, GNP3- Hamelia patens, GNP4-Thevetia peruviana, GNP5-Calendula officinalis, GNP6-Tectona grandis, GNP7-Ficus petiolaris, GNP8- Ficus busking, GNP9- Juniper communis, GNP10-Bauhinia purpurea). AgNPs were tested against drug resistant microbes and their biofilms. These nanoparticles (NPs) were characterised using UV-vis spectroscopy, transmission electron microscope, Fourier transform infrared spectroscopy, X-ray diffraction and Image J software. Most of the AgNPs were distributed over a range of 1 of 60 nm size. The results indicated that AgNPs were antibacterial in nature without differentiating between resistant or susceptible strains. Moreover, the effect was more prominent on Gram negative bacteria then Gram positive bacteria and fungus. AgNPs inhibited various classes of microbes with different concentration. It was also evident from the results that the origin or nature of extract did not affect the activity of the NPs. Protein and carbohydrate leakage assays confirmed that the cells lysis is one of the main mechanisms for the killing of microbes by green AgNPs. This study suggests that the action of AgNPs on microbial cells resulted into cell lysis and DNA damage. Excellent microbial biofilm inhibition was also seen by these green AgNPs. AgNPs have proved their candidature as a potential antibacterial and antibiofilm agent against MDR microbes.

Microbicidal activity of TiO2 nanoparticles synthesised by sol-gel method

In this study, the authors investigated antimicrobial activity of TiO2 nanoparticles (NPs) synthesised by sol-gel method. As synthesised TiO2 NPs were characterised by X-ray diffraction, scanning electron microscopy and ultraviolet-visible absorption spectroscopy. The antimicrobial activity of calcined TiO2 nanoparticle samples was examined in day light on Gram positive bacteria (Staphylococcus aureus, Streptococcus pneumonia and Bacillus subtilis), Gram negative bacteria (Proteus vulgaris, Pseudomonas aeruginosa and Escherichia coli) and fungal test pathogen Candida albicans. The synthesised TiO2 NPs were found to be effective in visible light against Streptococcus pneumonia, Staphylococcus aureus, Proteus vulgaris, Pseudomonas aeruginosa and Candida albicans.

Laboratory-based evaluation of MDR strains of Pseudomonas in patients with acute burn injuries

Localization of burn was variable: head and face in 76 patients (29%), trunk in 58 (49%), upper limb in 37 (52%), lower limbs in 44 (41%), hands in 16 (15%), perinea area in 26 (5.5%) and whole body except perinea area in 10 (9%) patients. Inhalation syndrome was present in 56 (44%) patients. Ninety patients (82%) had indwelling venous catheters, 83 (75.5%) patients' arterial catheter and 86 (78%) patients' urinary catheters. By multivariate analysis: age ≤4 years, Garcés 4, colistin use in documented multiresistant infections, and mechanical ventilation were independent variables related with mortality and graft requirement was a protective factor for mortality. Despite advances in care, gram negative bacterial infections and infection with Pseudomonas aeruginosa remain the most common cause of bacteria related mortality early in the hospital course. Viral infections are also associated with mortality and numbers have remained stable when compared to data from prior years.

Soil warming alters microbial substrate use in alpine soils

Will warming lead to an increased use of older soil organic carbon (SOC) by microbial communities, thereby inducing C losses from C-rich alpine soils? We studied soil microbial community composition, activity, and substrate use after 3 and 4 years of soil warming (+4 °C, 2007-2010) at the alpine treeline in Switzerland. The warming experiment was nested in a free air CO2 enrichment experiment using depleted (13)CO2 (δ(13)C = -30‰, 2001-2009). We traced this depleted (13)C label in phospholipid fatty acids (PLFA) of the organic layer (0-5 cm soil depth) and in C mineralized from root-free soils to distinguish substrate ages used by soil microorganisms: fixed before 2001 ('old'), from 2001 to 2009 ('new') or in 2010 ('recent'). Warming induced a sustained stimulation of soil respiration (+38%) without decline in mineralizable SOC. PLFA concentrations did not reveal changes in microbial community composition due to soil warming, but soil microbial metabolic activity was stimulated (+66%). Warming decreased the amount of new and recent C in the fungal biomarker 18:2ω6,9 and the amount of new C mineralized from root-free soils, implying a shift in microbial substrate use toward a greater use of old SOC. This shift in substrate use could indicate an imbalance between C inputs and outputs, which could eventually decrease SOC storage in this alpine ecosystem.

Current pattern of antibiotic resistance of clinical isolates among conjunctival swabs

Objectives: To identify the etiological agent in bacterial conjunctivitis and to determine the antibiogram of bacterial isolates.

Methodology: This observational study was conducted at Dr. Essa’s Laboratory over a period of 12 months ending in March 2012. Two hundred samples taken from conjunctiva of patients with conjunctivitis were cultured on routine medium and the antibiograms of bacterial isolates were determined by Kirby- Bauer disc diffusion method.

Results: The analysis of the culture showed that 41% were cultured positive with gram positive bacteria Staphylococcus aureus 52.5% and Staphylococcus epidermidis 30.1% and Micrococci 8.3%. However, 9.1% were gram negatives with Klebsiella pneumoniae 5.14% and Pseudomonas aeruginosa 2.6% and 1.36% were others (Acinetobacter, Haemophilus , E.coli and Moraxella) keeping in view the increasing use of contact lens and unclean fingers. The overall antibiograms of bacterial isolates indicate aminoglycosides (gentamicin, tobramicin) and the newer quinolones as apparent drug of choice for empirical therapy, followed by chloramphenicol, since drug fussy gram-negatives such as Pseudomonas, Acinetobacter and E.coli were among the conjunctival isolates. Resistance profile of gram positive isolates shows cefixime 91.4%, doxycycline 57.9%, cotrimoxazole 29.3%, ampicillin 22.9%, ciprofloxacin 13.4%, cephradine 8.3%, cefuroxime 7.1%, fosfomycin 4.7%, ceftriaxone 3.6%, co-amoxiclav 3.6%, cefotaxime 3.5%, vancomycin 2.6%.

Conclusion: Resistance to all conventionally used antibiotics is increasing, therefore identification of etiological agent and antibiogram is important to treat conjunctivitis and to avoid complications.

Antibiotic sensitivity profile of bacterial pathogens in postoperative wound infections at a tertiary care hospital in Gujarat, India

Objective:

To find out the most common bacterial pathogens responsible for post-operative wound infection and their antibiotic sensitivity profile.

Materials and Methods:

This prospective, observational study was carried out in patients of postoperative wound infection. Samples from wound discharge were collected using a sterile swab and studied for identification of isolates by Gram stains and culture growth followed by in vitro antibiotic susceptibility testing performed by disc diffusion method on Mueller Hinton agar.

Results:

Out of 183 organisms, 126 (68.85%) isolated organisms were gram negative. Staphylococcus aureus, 48 (26.23%), was the predominant organism. S. aureus was sensitive to rifampicin (89.58%), levofloxacin (60.42%), and vancomycin (54.17%). Pseudomonas aeruginosa was sensitive to ciprofloxacin (83.78%), gatifloxacin (51.35%), and meropenem (51.35%). Escherichia coli was sensitive to levofloxacin (72.41%) and ciprofloxacin (62.07%). Klebsiella pneumoniae was sensitive to ciprofloxacin (63.16%), levofloxacin (63.16%), gatifloxacin (63.16%), and linezolid (56.52%). Proteus mirabilis was sensitive to ciprofloxacin (75%) and linezolid (62.50). Proteus vulgaris was sensitive to ampicillin+sulbactam (57.14%) followed by levofloxacin (50%).

Conclusions:

There is an alarming increase of infections caused by antibiotic-resistant bacteria, particularly in the emergence of VRSA/VISA, meropenem, and third generation cephalosporin resistant Pseudomonas aeruginosa. Linezolid showing sensitivity against Gram negative bacteria.

Practical considerations for conducting ecotoxicity test methods with manufactured nanomaterials: what have we learnt so far?

This review paper reports the consensus of a technical workshop hosted by the European network, NanoImpactNet (NIN). The workshop aimed to review the collective experience of working at the bench with manufactured nanomaterials (MNMs), and to recommend modifications to existing experimental methods and OECD protocols. Current procedures for cleaning glassware are appropriate for most MNMs, although interference with electrodes may occur. Maintaining exposure is more difficult with MNMs compared to conventional chemicals. A metal salt control is recommended for experiments with metallic MNMs that may release free metal ions. Dispersing agents should be avoided, but if they must be used, then natural or synthetic dispersing agents are possible, and dispersion controls essential. Time constraints and technology gaps indicate that full characterisation of test media during ecotoxicity tests is currently not practical. Details of electron microscopy, dark-field microscopy, a range of spectroscopic methods (EDX, XRD, XANES, EXAFS), light scattering techniques (DLS, SLS) and chromatography are discussed. The development of user-friendly software to predict particle behaviour in test media according to DLVO theory is in progress, and simple optical methods are available to estimate the settling behaviour of suspensions during experiments. However, for soil matrices such simple approaches may not be applicable. Alternatively, a Critical Body Residue approach may be taken in which body concentrations in organisms are related to effects, and toxicity thresholds derived. For microbial assays, the cell wall is a formidable barrier to MNMs and end points that rely on the test substance penetrating the cell may be insensitive. Instead assays based on the cell envelope should be developed for MNMs. In algal growth tests, the abiotic factors that promote particle aggregation in the media (e.g. ionic strength) are also important in providing nutrients, and manipulation of the media to control the dispersion may also inhibit growth. Controls to quantify shading effects, and precise details of lighting regimes, shaking or mixing should be reported in algal tests. Photosynthesis may be more sensitive than traditional growth end points for algae and plants. Tests with invertebrates should consider non-chemical toxicity from particle adherence to the organisms. The use of semi-static exposure methods with fish can reduce the logistical issues of waste water disposal and facilitate aspects of animal husbandry relevant to MMNs. There are concerns that the existing bioaccumulation tests are conceptually flawed for MNMs and that new test(s) are required. In vitro testing strategies, as exemplified by genotoxicity assays, can be modified for MNMs, but the risk of false negatives in some assays is highlighted. In conclusion, most protocols will require some modifications and recommendations are made to aid the researcher at the bench.

Endodontic microbiology

Root canal therapy has been practiced ever since 1928 and the success rate has tremendously increased over the years owing to various advancements in the field. One main reason is the complete understanding of the microbiology involved in the endodontic pathology. This has helped us to modify the conventional treatment plans and effectively combat the microorganisms. Now, studies are aiming to explore the characteristics of the "most" resistant organism and the methods to eliminate them. This article gives an insight of the microbiology involved in endodontic pathology and discusses its role in our treatment procedure. Information from original reviews listed in PubMed, published from 1995 to 2010, has been mainly included in this review.