Molecular detection of antimalarial resistance in Plasmodium vivax isolates from a tertiary care setting in Puducherry

PURPOSE

The study was aimed at detecting the mutation patterns in the drug targets in Plasmodium vivax that confer resistance to the common antimalarial agents used in India.

METHODS

A total of 27 Plasmodium vivax isolates collected from whole blood samples over a three year period were subjected to PCR amplification followed by sequencing of the genes pvmdr1, pvdhfr, pvdhps and pvk12, which serve as the molecular targets to detect resistance to chloroquine, pyrimethamine, sulfadoxine and artemisinin respectively.

RESULTS

The study found T958 M F1076L double mutants of pvmdr1 in 52 %(14/27) isolates, S58R S117 N double mutants of pvdhfr in 67 % (18/27) isolates, A383G A553G double mutant pvdhps in 59 % (16/27) isolates and wild type of pvk12 gene in all the isolates.

CONCLUSIONS

There was a rise in the proportion of double mutants of pvmdr1 and pvdhfr over time. Those cases with double mutant pvmdr1 gene in their isolates were found to have a prolonged hospital stay compared to those without, indicating reduced clinical response to chloroquine.

Performance of microscopy compared to conventional PCR in identification of soil-transmitted helminth infections among antenatal women in a low-prevalence setting

PURPOSE

Traditional microscopy-based methods may provide inaccurate estimates of Soil transmitted helminth (STH) infections in mild intensity of infection. Therefore, we aimed to determine the prevalence of STH infections using molecular diagnostic methods and compare the diagnostic performance of microscopy with polymerase chain reaction (PCR) in stool samples collected from pregnant women in primary care settings in Puducherry, India.

METHODOLOGY

A singleplex PCR assay was developed to detect three species of STHs, namely Ascaris lumbricoides, Necator americanus, and Ancylostoma duodenale, by targeting the internal transcribed spacer regions (ITS1 and ITS2) of 5.8S rRNA. The PCR generated 420, 662, and 515 base pairs of DNA for the respective organisms. In addition to singleplex PCR, wet and concentration microscopy techniques were used. The results were expressed as percentages with 95% confidence intervals, and the diagnostic performance of microscopy was compared with PCR in terms of sensitivity, specificity, and positive, negative predictive values and kappa statistics.

RESULTS

Among the 650 pregnant women included, 48.8% were aged 25 years or less, 59% were primigravida, and half were from rural areas. The overall prevalence of any STH infection was higher in PCR compared to microscopy (8.9% vs. 7.2%). The prevalence of Ascaris lumbricoides was higher by microscopy (5.4% vs 2.6%), while the prevalence of Necator americanus was higher by PCR (6.3%) than by microscopy (1.8%). No species of Ancylostoma duodenale was detected. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of microscopy for detecting any STH infection was 22.4%, 94.3%, 27.7%, and 92.5%, respectively. The agreement between microscopy and PCR for the identification is as follows: for any STH infection, k ​= ​0.12, Ascaris k ​= ​0.16, and Necator k ​= ​0.20, respectively.

CONCLUSION

The prevalence of any STH infection identified by PCR was higher than microscopy, and the agreement between the two methods was poor.

Development of a new multiplex PCR to detect fecal coccidian parasite

BACKGROUND

Cryptosporidium spp., Cystoisospora belli and Cyclospora cayetanensis are common intestinal coccidian parasites causing gastroenteritis. The clinical presentation caused by each parasite is indistinguishable from each other. Uniplex polymerase chain reaction (PCR) for these three groups of intestinal coccidian parasites was developed by us in our laboratory. Thereafter, we planned to develop a single-run multiplex polymerase chain reaction (mPCR) assay to detect Cryptosporidium spp., C. belli and C. cayetanensis simultaneously from a stool sample and described it here as coccidian mPCR.

METHODS

New primers for C. belli and C. cayetanensis were designed and uniplex PCRs were standardized. The coccidian mPCR was standardized with known positive DNA control isolates. It was validated with 58 known positive and 58 known negative stool samples, which were previously identified by uniplex PCR.

RESULTS

The coccidian mPCR was standardized with earlier primers designed by us for Cryptosporidium spp. and C. cayetanensis, and a newly designed primer for the internal transcribed spacer-1 (ITS-1) gene for C. belli. The coccidian mPCR was 92.1% sensitive for Cryptosporidium spp., and 100% sensitive for C. belli and C. cayetanensis each, when tested on 116 known samples. It was 100% specific for all intestinal coccidian parasites. Two representative PCR products of the newly designed ITS-1 primer for C. belli were sequenced and submitted to the GenBank, which best match with the sequences of C. belli.

CONCLUSION

A highly sensitive, specific, cost-effective, indigenous, single-run coccidian mPCR has been developed, which can simultaneously detect Cryptosporidium spp., C. belli and C. cayetanensis.

Prevalence of malaria: A 7-year trend analysis from a tertiary care center, Puducherry

Background

Battle against malaria has been going on since time immemorial. Understanding the true burden of disease and the determinants of its transmission are important for implementing adequate control measures. This study intends to explore the local epidemiology and burden of malaria in Puducherry, a coastal Union territory located in the Southern part of India over a period of 7 years.

Methodology

A retrospective record-based study was conducted from 2015 to 2021, where details from all samples that tested positive for malaria by peripheral blood examination or rapid card test, from suspected cases were collected and analyzed.

Results

The overall prevalence of malaria over the 7 years was 1.7% (257/14,888). Majority of the patients were male (75.88%) and the major age group affected was from 21 to 40 years (56.03%). The disease was maximum seen during the monsoon season followed by the post-monsoon season. Vivax malaria predominated irrespective of the gender, seasonal change, and different age groups except in children <10 years was both falciparum and vivax malaria were seen in equivalence. The major species to cause infection among infants were Plasmodium falciparum (3/4).

Discussion and Conclusion

This study shows a declining trend of malaria transmission over the years. There is no change in the predominant species affected or seasonal trends over the years. The possibility of underestimation of cases due to various factors cannot be ignored.

Assessment of Plasmodium falciparum histidine rich protein 2 and /3 (pfhrp 2&/ pfhrp 3) gene deletion or mutation in Plasmodium falciparum positive blood samples in a tertiary care centre in South India

Rapid diagnostic card tests (RDTs) enable timely and appropriate diagnosis of malaria especially in remote areas. Plasmodium falciparum histidine rich protein 2 (PFHRP2) is the most targeted antigen for the detection of Plasmodium falciparum infections by rapid diagnostic card test. Genetic mutations and gene deletions are important emerging factors for false-negative RDTs, which may delay the provision of life-saving treatment for the patients. Hence, we would like to evaluate for the existence of pfhrp2/3 gene deleted P. falciparum parasites in our health care setting. This study was conducted for a period of 2 years in a tertiary care centre in South India. Blood samples that are microscopically confirmed as P. falciparum but negative by RDT were assessed for the presence of pfhrp2, pfhrp3, and their flanking genes using conventional PCR. Follow up of the clinical outcomes were also done for these patients. Of the 63 positive samples collected (50 /63) 79.4% were P.vivax and (13/63) 20.6% were P.falciparum by PCR. Among the 13 P. falciparum positive samples, 4 samples (4/13), (95% CI -10.36% to 61.11%) were found to be RDT negative but microscopically positive.Pfhrp2,pfhrp3 and their flanking genes were amplified for these 4 samples. All 4 samples were found to be negative for both pfhrp2-2 & pfhrp2-3 exon regions and also varying patterns of flanking gene deletions were also noted.This study provides molecular evidence for the existence of pfhrp2 & pfhrp3 deleted P. falciparum parasites in a tertiary care centre in South India warranting periodic evaluation of pfhrp2 based RDT use. Only pfhrp2/3 RDT based decision on diagnosis of P.falciparum malaria should always be reconsidered especially in remote areas.

Molecular characterization of Giardia intestinalis assemblages in children among the rural and urban population of Pondicherry, India

Introduction:

Giardiasis is one of the greatest public parasitic infections causing diarrheal and also known to be associated with high morbidity and mortality, among the children's particularly in developing countries with less cleanliness practices. Thus, studying genomic variety of Giardia intestinalis aids to improve our perspective related to the variability in the genome of the parasite.

Materials and Methods:

In this cross-sectional study, 1006 stool samples were collected from the rural (n = 500) and urban settings (n = 506) from the children (<15 years) with and without symptoms and were screened for the presence of G. intestinalis by polymerase chain reaction (PCR) targeting triosephosphate isomerase gene. Further, all PCR-positive amplicons were subjected to restriction fragment length polymorphism using RsaI restriction enzyme.

Results:

Of the total 1006 stool samples, 500 samples from rural screened by PCR 108 (21%) were found to be positive for assemblage A, 116 (23.2%) belong to assemblage B, and 5 (1%) were mixed assemblages (A + B). Whereas in urban, of the 506 samples screened by PCR, 92 (18.1%) were found to be positive for assemblage A, 93 (18.3%) assemblage B, and 10 (1.9%) were mixed assemblages (A + B). No significant difference was found between the G. intestinalis assemblages with clinical details of symptomatic and asymptomatic in children.

Conclusions:

This signifies the first study inspection in our location to shed lights and delivers some preliminary data on assemblages and subassemblages. The results suggest that anthroponotic transmission could be a foremost transmission path for giardiasis among the study population.

Prevalence of intestinal parasitic infection and its associated factors among children in Puducherry, South India: a community-based study

There is paucity of studies at community level on prevalence of intestinal parasitic infection among under 18 years age group. This cross-sectional community-based research aimed to determine the prevalence of intestinal worm infections and its associated risk factors among 1 to 18 years age group in Puducherry, India. Sociodemographic, behavioral and other associated factors were collected using a structured questionnaire. One stool sample was collected from each participant and examined using direct (saline/iodine wet mount) and concentration (floatation/sedimentation) microscopic techniques. Log binomial regression analysis was used to find the factors independently associated with intestinal parasitic infection. Of 187 participants who provided the stool sample, 25 (13.4%) had at least one of the parasitic infections and among them 12 (6.4%) had Soil Transmitted Helminth infection (STH) and 13 (6.9%) had intestinal protozoan parasites. Parasitic infection is marginally higher among 1 to 7 years age group (14.4%) compared to 8 to 18 years age group (12.1%). After adjusting for confounding, urban residence (APR = 3.3, 95% CI 1.4-8.0) and open-air defecation (APR = 3.3, 95% CI 1.4-7.5) were significantly associated with intestinal parasitic infections. One out of eight children had any of the parasitic infection and nearly 50% of parasitic infections were caused by STH. Those children residing in urban areas and practice of open-air defecation had higher prevalence of parasitic infection.

Tuberculosis-Learning the Impact of Nutrition (TB LION): protocol for an interventional study to decrease TB risk in household contacts

BACKGROUND

Comorbidities such as undernutrition and parasitic infections are widespread in India and other tuberculosis (TB)-endemic countries. This study examines how these conditions as well as food supplementation and parasite treatment might alter immune responses to Mycobacterium tuberculosis (Mtb) infection and risk of progression to TB disease.

METHODS

This is a 5-year prospective clinical trial at Jawaharlal Institute of Post Graduate Medical Education and Research in Puducherry, Tamil Nadu, India. We aim to enroll 760 household contacts (HHC) of adults with active TB in order to identify 120 who are followed prospectively for 2 years: Thirty QuantiFERON-TB Gold Plus (QFT-Plus) positive HHCs ≥ 18 years of age in four proposed groups: (1) undernourished (body mass index [BMI] < 18.5 kg/m2); (2) participants with a BMI ≥ 18.5 kg/m2 who have a parasitic infection (3) undernourished participants with a parasitic infection and (4) controls-participants with BMI ≥ 18.5 kg/m2 and without parasitic infection. We assess immune response at baseline and after food supplementation (for participants with BMI < 18.5 kg/m2) and parasite treatment (for participants with parasites). Detailed nutritional assessments, anthropometry, and parasite testing through polymerase chain reaction (PCR) and microscopy are performed. In addition, at serial time points, these samples will be further analyzed using flow cytometry and whole blood transcriptomics to elucidate the immune mechanisms involved in disease progression.

CONCLUSIONS

This study will help determine whether undernutrition and parasite infection are associated with gene signatures that predict risk of TB and whether providing nutritional supplementation and/or treating parasitic infections improves immune response towards this infection. This study transcends individual level care and presents the opportunity to benefit the population at large by analyzing factors that affect disease progression potentially reducing the overall burden of people who progress to TB disease. Trial registration ClinicalTrials.gov; NCT03598842; Registered on July 26, 2018; https://clinicaltrials.gov/ct2/show/NCT03598842.

'I was scared I will end up in another abortion': a mixed-methods study assessing the impact of COVID-19 pandemic and lockdown on the antenatal care of pregnant women in Puducherry, South India

BACKGROUND

As a mitigation measure for COVID-19 pandemic, lockdown was implemented in India for a period of 2 months (24 March-31 May 2020). Disruption in antenatal care (ANC) provisions during lockdown is expected due to diversion of public health facilities on pandemic.

OBJECTIVE

To assess the proportion of pregnant women who had not completed the ideal number of antenatal visits, availability of iron-folic acid (IFA) supplements and challenges in availing health services during the period of lockdown.

METHODS

A concurrent mixed-methods study was conducted among pregnant women in Puducherry, India. Information on obstetric characteristics and details regarding antenatal visits were collected through telephonic interviews. In-depth interviews were conducted to understand the perceived challenges in availing health services during the lockdown period.

RESULTS

Out of 150 pregnant women, 62 [41.3%; 95% confidence interval (CI) 33.6-49.3] did not complete the ideal number of visits and 61 (40.7%, 95% CI 32.7-49.0) developed health problems. Out of 44 women who received medical care for health problems, 11 (25%) used teleconsultation. Of all the women, 13 (8.7%, 95% CI 4.9-14.0) had not taken the IFA supplements as prescribed by the health provider. Economic hardship, restricted mobility, lack of information about the health system changes and psychological stress due to the fear of COVID were the challenges in accessing care.

CONCLUSIONS

Two out of five pregnant women did not complete the ideal number of visits and developed health problems during the lockdown period.

A Comparative Analysis of Microscopy, Coproantigen Serology, and Nested Multiplex PCR in the Laboratory Diagnosis of Entamoeba histolytica Infection

Objectives  Amoebiasis is caused by the most common intestinal protozoan parasite Entamoeba histolytica . This parasite causes amoebic colitis, which is manifested by diarrhea, followed by dysentery. The laboratory diagnosis of intestinal amoebiasis in most cases is by microscopic examination of stool samples. Other nonroutine methods include coproantigen enzyme-linked immunosorbent assay (ELISA) from stool samples, serum ELISA for antibodies, stool culture, isoenzyme analysis, and polymerase chain reaction (PCR). The present study aimed to comparatively analyze the different diagnostic modalities used for the detection of E. histolytica from the stool sample of patients with intestinal amoebiasis.

Materials and Methods  This study was undertaken with 631 patients, during a period of 3 years, from January 2017 to December 2019. Stool specimen obtained from each patient was subjected to direct microscopic wet mount examination, coproantigen ELISA, and nested multiplex PCR, respectively.

Results  Out of all the patients tested, 5.2% were positive for E. histolytica. Among the positive cases, stool microscopy was positive in 3.17%, coproantigen ELISA was positive in 29 (4.6%) cases, and PCR was positive in 30 (4.75%) cases.

Statistical Analysis  The prevalence of E. histolytica infection was summarized as percentages. The three diagnostic tests done were statistically analyzed, taking microscopy as the gold standard. The agreement between techniques (microscopy, coproantigen ELISA, and PCR) was analyzed with kappa statistics. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were summarized as percentage with 95% confidence interval.

Conclusion  In all suspected amoebiasis cases, a combination of stool microscopy, coproantigen testing with molecular detection of the parasite offers the best approach to diagnosis of this parasitic infection.

Pulmonary cryptosporidiosis in a case of adenocarcinoma of stomach: A rare case report

Cryptosporidium species are commonly known to cause chronic intractable diarrhea in patients suffering from human immunodeficiency virus (HIV)-acquired immunodeficiency syndrome, however extra-intestinal presentations have been rarely reported. Hereby, we report a rare case of isolated pulmonary cryptosporidiosis in a 75-year-old HIV-negative patient with metastatic carcinoma of the stomach who was managed conservatively with hemostatic radiotherapy for palliative care. The patient had presented with cough with expectoration for 2 months. Sputum microscopic examination was suggestive of pulmonary cryptosporidiosis. There was no evidence of intestinal cryptosporidiosis. Therapy for pulmonary cryptosporidiosis was started with tablet nitazoxanide. The patient succumbed to the disease few days later following discharge. Although rare, patients with disseminated gastrointestinal malignancy can potentially have isolated pulmonary cryptosporidiosis.

Cryptosporidium and waterborne outbreaks - A mini review

Cryptosporidium spp. is one of the prime agents of infectious diarrhea. Cryptosporidium spp. has been gaining awareness as a pathogen of public health importance in India and other developing countries. Owing to the nature of multiple transmission routes such as person-to-person, animal-to-person, waterborne and foodborne, the epidemiology of cryptosporidiosis in humans is not well known. A deeper understanding of the pathogenesis may lead to better diagnosis and better treatment of the condition. Asymptomatic human and animal transmission illustrates that the spread of infection through the environment is a more plausible explanation, waterborne transmission in particular. The disease burden is underestimated and its global impact is yet to be quantified due to the lack of country-specific estimates. Assessment of the disease itself has been crucial since the morphological indistinguishability, differences in distribution and transmission, and variations in the genotypes.

Intestinal parasitic infections and its trends: a 5-year findings from a tertiary care centre, Puducherry, South India

Intestinal parasitic infection (IPI) constitute a global health burden causing clinical morbidity in 450 million people. Many of these are women of reproductive age and children in developing countries. Mass deworming programmes with improvement in lifestyle are likely to reduce the intensity and prevalence of infection over the years. Hence, we aimed to assess the prevalence of intestinal parasitic infections among patients in a tertiary healthcare setting and to examine its time trends. A descriptive cross-sectional study was done using routinely collected data in a tertiary care hospital in South India. Details of examination of stool samples for the presence of intestinal helminth and protozoan ova/cysts, over the period of 5 years (2014-2019) were extracted from laboratory register and hospital information system. The presence of intestinal parasitic infection was determined by stool microscopy (direct wet mount and concentration techniques). Of the total 3267 stool samples, 303 (9.3%) had at least one parasite; 3.9% (93/3267) with helminths and 2.5% (81/3267) Entamoeba and multi-parasitism was seen in 0.14%. Stool samples from more than 18 years age had high positivity rate than others. Majority of the helminth infections were caused by Ascaris (57%) followed by hookworm (42%). Initially IPI which was 10.9% in 2014 declined to 10% in 2016 and attained a peak of 12.4% in 2017 then decreased to 6.7% in 2018. Nearly one out of ten patients had a parasitic infection. Prevalence surveys in the community followed by strengthening the deworming procedures will reduce the burden of IPIs.

A comparative study assessing the effect of haematological and biochemical parameters on the pathogenesis of malaria

Malaria is one of the most common parasitic disease affecting mankind since millennia. The most pronounced changes related to malaria involve the blood and the blood forming system, the spleen and the liver. The abnormal haematological and biochemical parameters observed in malaria cases adversely affect the prognosis of the disease. The aim of this study was to assess the severity of malaria by observing the significant abnormalities in haematological and biochemical parameters in the malaria infected cases as compared to the healthy controls. The study population comprised of 138 individuals, of which 69 were malaria cases and 69 were apparently healthy controls. All the 138 individuals were subjected to haematological and biochemical workup, following which statistical analysis was done to observe any association of altered haematological and biochemical parameters with severity of malaria, as compared to the healthy controls. Among the 138 study population, 69 patients were malaria cases whereas the other 69 were healthy controls. Haematological investigations revealed, that the haemoglobin levels, total RBC counts and haematocrit were significantly altered in the malaria cases as compared to the healthy controls. Also the leucogram profile showed significant leucopenia and neutropenia in the malaria patients as compared to the controls. Thrombocytopenia was also seen to be more pronounced in the malaria infected. The liver enzymes and serum bilirubin levels were raised in the malaria cases more than the controls. Altered haematological and biochemical parameters are indicators of disease progression to severity. Early detection and management of these parameters, will prevent the development of complications in malaria.

Genetic diversity of Indian Plasmodium vivax isolates based on the analysis of PvMSP3β polymorphic marker

Background

Malaria is one of the major communicable diseases in India and worldwide. PvMSP3β is a highly polymorphic gene due to its large insertions and deletions in the central alanine-rich region, which, in turn, makes it a valuable marker for population genetic analysis. Very few studies are available from India about the genetic diversity of Plasmodium vivax based on PvMSP3β gene, and hence, this study was designed to understand the molecular diversity of the P. vivax malaria parasite. The accumulating epidemiological data provide insights into the circulating genetic variants of P. vivax in India, and ultimately benefits the vaccine development.

Materials and Methods

A total of 268 samples confirmed to be positive by microscopy, rapid diagnostic test, and quantitative buffy coat test were collected from four different regions of India (Puducherry, Mangaluru, Jodhpur, and Cuttack) in the present study. Polymerase chain reaction (PCR)-based diagnosis was carried out to confirm the P. vivax monoinfection, and only the mono-infected samples were subjected to PvMSP3β gene amplification and further restriction fragment length polymorphism (RFLP) to determine suballeles.

Results

Based on the size of the amplified fragment, the PvMSP3β gene was apportioned into two major types, namely Type A genotype (1.6-2 Kb) was predominantly present in 148 isolates and Type B (1-1.5 Kb) was observed in 110 isolates. The percentage of mixed infections by PCR was 3.73%. All the PCR products were subjected to RFLP to categorize into suballeles and we detected 39 suballeles (A1-A39) in Type A, and 23 suballeles (B1-B23) in Type B genotype. A high degree of diversity was observed among the isolates collected from Mangaluru region when compared to isolates collected from other regions.

Conclusion

The present study showed a high degree of genetic diversity of PvMSP3β gene among the isolates collected from various parts of India. High polymorphism in PvMSP3β gene makes it a promising marker for epidemiological and vaccine development studies.

Prevalence of intestinal parasites among rural and urban population in Puducherry, South India - A community-based study

Introduction:

Developing country, like India intestinal parasitic infections are still remaining as the most important health problem in public of concern. The infection remains the most leading cause of morbidity and mortality especially among the childrens. It is presumed that the prevalence is high in developing countries probably due to poor sanitary conditions and improper personal hygiene practice.

Aim:

The main aim of this study was carried to find out the prevalence of intestinal parasitic infection among rural and urban population of Puducherry, India.

Materials and Methods:

This is a cross-sectional descriptive study carried out between the period September 2016 to December 2018. Random sampling was adopted to collect stool samples from urban and rural population in Puducherry. A door to door survey was done. Stool samples were collected from rural setting (n = 500) and urban setting (n = 506) and transport to the parasitology section, Dept. of Microbiology, JIPMER were subjected to routine stool investigations. The results were recorded, and data were presented in the form of frequency and distribution. Data entry was done in MS Excel and analysis was carried out in SPSS software version 22.

Results:

Among the rural and urban population, 500 stool samples from the rural population showed nearly 40.4% intestinal parasites Giardia intestinalis (21.2%), Blastocystis spp (8.8%), Entamoeba spp (6.6%), hookworm (2.8%), Ascaris lumbricoides (1%), Hymenolepis nana (0%) and 506 stool samples from urban population showed 20.3% of intestinal parasites (Giardia intestinalis (10.4%), Blastocystis spp (3.7%), Entamoeba spp (3.3%), hookworm (1.7%), Hymenolepis nana (0.9%), Ascaris lumbricoides (0%). There was a noticeable male predominance pattern (31.4%) compared to female showing 29.1% positivity. The increase in the prevalence of intestinal parasites among rural population than the urban population was statistically significant.

Conclusion:

The stool samples collected from rural population showed high prevalence of intestinal parasite infestation when compared to urban population, hence necessary interventions like health education, awareness creation and medical intervention should be undertaken particularly among the rural population. In our study population, age group between 1-10 years are predominantly infected with these parasites.

Detection of Blastocystis in clinical stool specimens using three different methods and morphological examination in Jones' medium

Background:

Blastocystis was identified almost a century ago, yet its biology and pathogenicity status in humans is obscure. Studies on Blastocystis in India are scanty and are mostly microscopy based. This study compared three detection modalities to determine their efficiency in the identification of Blastocystis in human feces.

Materials and Methods:

A total of 279 stool samples were screened using microscopy, culture (Jones' medium), and polymerase chain reaction (PCR)-based methods. Among the three, PCR is considered the gold standard test for detection of Blastocystis, as it helps to authenticate the sensitivity, specificity, and kappa agreement obtained by the other two tests. The morphological features of Blastocystis were recorded at 24, 48, and 72 h. After positive morphological identification, ten samples were cultured on Löwenstein–Jensen (LJ) medium and Locke's egg slant medium.

Results:

The sensitivity and specificity determined on the basis of microscopy were 36.2% and 99.4%, respectively. On the other hand, Jones' medium showed 67.6% sensitivity and 100% specificity. Further, we documented various morphological and reproductive features of Blastocystis using various staining techniques on cultures positive in Jones' medium. In addition, we also found that LJ medium was not equally efficacious as Jones' medium in assisting the growth of Blastocystis.

Conclusions:

Although molecular diagnosis is a necessary tool for understanding the true epidemiology of Blastocystis, in laboratories devoid of molecular detection facilities, stool microscopy in conjunction with stool culture on Jones' medium could serve as the best alternative tool for the detection of Blastocystis.

Multiple parasitic and viral infections in a patient living with HIV/AIDS on antiretroviral therapy

Patients with human immunodeficiency virus (HIV) infection are more prone for gastrointestinal infections causing diarrhoea, particularly with parasites. Parasitic infections have been regularly reported in such patients. A female patient confirmed positive for HIV 1 on antiretroviral therapy came with complaints of chronic diarrhoea for the past 7 months. Her initial CD4 count was 89 cells/μl of blood, and antibodies to cytomegalovirus and herpes simplex virus 1 and 2 virus were found to be positive in the patient's serum, but there was no HIV-associated retinopathy. Her stool examination showed decorticated fertilised eggs of Ascaris lumbricoides, cysts of Blastocystis sp. and Entamoeba species in the unconcentrated sample and oocysts of Cystoisospora species, egg of Schistosoma haematobium and eggs of Trichuris trichiura in the concentrated. The patient responded well to cotrimoxazole and albendazole, and repeat samples were negative for all these parasites.

A prospective study of wound infection among post-discharge patients at a level 1 trauma centre of India

BACKGROUND AND AIM

To study the rate of wound infections in the post-discharged patient population and to assess the usefulness of post-discharge surveillance.

METHODS

A prospective surveillance of all the post-discharged trauma patients was done during a period of 6 months. Discharge instructions were given to all the patients regarding identification of the signs and symptoms of wound infections. They were telephonically followed up after a week to enquire about the wound condition and followed up in the outpatient department (OPD). Microbiology culture samples of those showing any signs and symptoms of infections were sent and their antimicrobial therapy, any change in the treatment schedule and the length of their hospital stay were noted. Factors such as wound class, type of surgeries and readmissions were noted.

RESULTS

A total of 281 postdischarge patients were enrolled, of which 101 were completely followed up for wound infections. Males were predominant (89%). Of the 101 patients, 42 (41.6%) patients wound showed infection during the intense follow-up in the OPD. However, 59 patients (59/101, 58.4%) showed wound swab culture positivity before discharge. These 42 patients developed signs and symptoms of infection post-discharge; 23 (22.7%) of them had change of antibiotic therapy during the follow-up period due to culture positivity. Acinetobacter sp., Staphylococcus aureus and Klebsiella pneumoniae were the predominant organisms isolated in the study. A total of 45 patients (44.5%) had to be readmitted due to wound site infections.

CONCLUSIONS

Wound infections are common after discharge among trauma patients highlighting the importance of active surveillance and participation of patients.

A case report of an uncommon parasitic infection of human balantidiasis

Balantidium coli, a large, ciliated pathogen, is known to cause balantidiasis in humans. We report a case of B. coli infection in a 37-year-old male with tuberculosis and presenting with fever, anorexia, mild abdominal pain, and episodes of loose stools for 1 week.

Association of Mycoplasma genitalium with infertility in North Indian women

OBJECTIVES

Data regarding the association of Mycoplasma genitalium with infertility is scarce. This study was planned to look for the presence and association of M. genitalium in women with infertility.

MATERIALS AND METHODS

A prospective observational study was conducted on 100 cases of infertile women. The control group included 100 healthy fertile women. Samples of first void urine (FVU), endocervical swabs (ECS), and endometrial biopsies were subjected to polymerase chain reaction targeting MgPa gene to look for the presence of M. genitalium DNA. All endometrial biopsy samples were subjected to histopathological examination. A detailed clinical history of patients was taken, and all relevant investigations were recorded.

RESULTS

M. genitalium was found in 16% of women with infertility from either of the samples that is, FVU and/or ECS and/or endometrium biopsy, and none from controls. ECS and biopsy could detect the highest number of cases (27%). Asymptomatic cases predominated in the study and M. genitalium positivity (73.3%) was seen more in primary infertility. Tubal occlusion and disordered proliferative endometrium were demonstrated in 33% and 26.66% of M. genitalium positive cases respectively.

CONCLUSIONS

The study shows an association of M. genitalium infection and infertility and suggests routine screening of this pathogen in patients with infertility.

Effectiveness of Intensive Interactive Classes and Hands on Practice to Increase Awareness about Sharps Injuries and Splashes among Health Care Workers

BACKGROUND

Occupational exposure to sharps and splashes pose a major hazard among health care workers (HCWs); so knowledge and awareness regarding sharps/splashes by blood and potentially infectious body fluids (BBF) is a must. Hence, the study was done to assess the extent of knowledge of the staff and using awareness classes and hands on practice as a model to increase awareness as well as prevention.

MATERIALS AND METHODS

This prospective interventional cohort study, using before - after trial, was conducted in a Level I trauma care centre. All cadres of HCWs were enrolled randomly into 5 different groups of 15 each. This study was conducted in 2 phases - interactive classes and hands on practice (Phase I) and questionnaire assessment and work area observation (phase II). This was repeated twice and the final outcome was analysed. A systematic level of grading was used to assess the improvement.

RESULTS

It was observed that Group 1 (doctors) and group 2 (nurses) had the maximum knowledge about such exposures and its prevention compared to the other groups (groups 3, 4 and 5) during the initial assessment (Phase I). The remaining groups showed a major improvement after the 2(nd) assessment, though their knowledge was poor in the beginning. Groups 1and 2 showed 32% and remaining groups showed a 25% improvement in voluntary reporting after the second assessment (Phase II).

CONCLUSION

Awareness classes and hands on practice are indeed useful in generating knowledge about sharps/ splashes. Certain incentives given at right time can improve it further.

Distribution of different yeasts isolates among trauma patients and comparison of accuracy in identification of yeasts by automated method versus conventional methods for better use in low resource countries

INTRODUCTION

As most trauma patients require long-term hospital stay and long-term antibiotic therapy, the risk of fungal infections in such patients is steadily increasing. Early diagnosis and rapid treatment is life saving in such critically ill trauma patients.

AIMS

To see the distribution of various species of Candida among trauma patients and compare the accuracy, rapid identification and cost effectiveness between VITEK 2, CHROMagar and conventional methods.

SETTINGS AND DESIGN

Retrospective laboratory-based surveillance study performed over a period of 52 months (January 2009 to April 2013) at a level I trauma centre in New Delhi, India.

MATERIALS AND METHODS

All microbiological samples positive for Candida were processed for microbial identification using standard methods. Identification of Candida was done using chromogenic medium and by automated VITEK 2 Compact system and later confirmed using the conventional method. Time to identification in both was noted and accuracy compared with conventional method.

STATISTICAL ANALYSIS

Performed using the SPSS software for Windows (SPSS Inc. Chicago, IL, version 15.0). P values calculated using χ2 test for categorical variables. A P<0.05 was considered significant.

RESULTS

Out of 445 yeasts isolates, Candida tropicalis (217, 49%) was the species that was maximally isolated. VITEK 2 was able to correctly identify 354 (79.5%) isolates but could not identify 48 (10.7%) isolates and wrongly identified or showed low discrimination in 43 (9.6%) isolates but CHROM agar correctly identified 381 (85.6%) isolates with 64 (14.4%) misidentification. Highest rate of misidentification was seen in C. tropicalis and C. glabrata (13, 27.1% each) by VITEK 2 and among C. albicans (9, 14%) by CHROMagar.

CONCLUSIONS

Though CHROMagar gives identification at a lower cost compared with VITEK 2 and are more accurate, which is useful in low resource countries, its main drawback is the long duration taken for complete identification.

Magnitude of enterococcal bacteremia in trauma patients admitted for intensive trauma care: a tertiary care experience from South asian country

Background:

Bloodstream infection (BSI) and bacteremias due to Enterococcus spp. are increasing worldwide with the current need to understand its causes among hospitalized trauma patients. Hence, the study was conducted.

Methodology:

A 3-year retrospective laboratory cum clinical based study was performed at a level I trauma center in India. Patients with health care associated enterococcal bacteremia were identified using the hospital database, their episodes of BSI/bacteremia calculated and their clinical records and treatment were noted.

Results:

A total of 104 nonrepetitive Enterococcus spp. was isolated of which Enterococcus faecium was the most common (52%). High-level resistance to gentamicin high-level aminoglycoside resistance was seen in all the Enterococcus spp. causing bacteremia, whereas a low resistance to vancomycin and teichoplanin was observed. Overall mortality was more in patients infected with vancomycin-resistant Enterococcus (5/11, 46%) compared to those with vancomycin sensitive Enterococcus (9/93, 10%); though no significant association of mortality with Enterococcus spp. bacteremia (P > 0.05) was seen. The rate of bacteremia due to Enterococcus spp. was 25.4 episodes/1,000 admissions (104/4,094) during the study period.

Conclusion:

Enterococcal bacteremia is much prevalent in trauma care facilities. Here, a microbiologist can act as a sentinel and help in preventing such infections.

Association of Mycoplasma genitalium with infertility in North Indian women

OBJECTIVES

Data regarding the association of Mycoplasma genitalium with infertility is scarce. This study was planned to look for the presence and association of M. genitalium in women with infertility.

MATERIALS AND METHODS

A prospective observational study was conducted on 100 cases of infertile women. The control group included 100 healthy fertile women. Samples of first void urine (FVU), endocervical swabs (ECS), and endometrial biopsies were subjected to polymerase chain reaction targeting MgPa gene to look for the presence of M. genitalium DNA. All endometrial biopsy samples were subjected to histopathological examination. A detailed clinical history of patients was taken, and all relevant investigations were recorded.

RESULTS

M. genitalium was found in 16% of women with infertility from either of the samples that is, FVU and/or ECS and/or endometrium biopsy, and none from controls. ECS and biopsy could detect the highest number of cases (27%). Asymptomatic cases predominated in the study and M. genitalium positivity (73.3%) was seen more in primary infertility. Tubal occlusion and disordered proliferative endometrium were demonstrated in 33% and 26.66% of M. genitalium positive cases respectively.

CONCLUSIONS

The study shows an association of M. genitalium infection and infertility and suggests routine screening of this pathogen in patients with infertility.

Soft Tissue and Wound Infections Due to Enterococcus spp. Among Hospitalized Trauma Patients in a Developing Country

Soft tissue and wound infections due to Enterococcus spp. are increasing worldwide with current need to understand the epidemiology of the Enterococcal infections of wounds. Hence, we have looked into the distribution of Enterococcus spp. responsible for causing wound and soft tissue infections among trauma patients, its antibiotic resistance pattern and how it affects the length of hospital stay and mortality. A laboratory cum clinical-based study was performed over a period of 3 years at a level I trauma center in New Delhi, India. Patients with Enterococcal wound and soft tissue infections were identified using the hospital data base, their incidence of soft tissue/wound infections calculated, drug resistance pattern and their possible risk factors as well as outcomes analyzed. A total of 86 non-repetitive Enterococcus spp. was isolated of which E. faecium were maximally isolated 48 (56%). High level of resistance was seen to gentamicin HLAR in all the species of Enterococcus causing infections whereas a low level resistance to vancomycin and teicoplanin was observed among the isolates. Longer hospital stay, repeated surgical procedure, prior antibiotic therapy and ICU stay were observed to associate with increased morbidity (P < 0.05) and hence, more chances of infections with VRE among the trauma patients. The overall rate of wound and soft tissue infections with Enterococcus sp. was 8.6 per 1,000 admissions during the study period. Enterococcal wound infection is much prevalent in trauma care facilities especially in the ICUs. Here, a microbiologist can act as a sentinel, help in empirical therapeutic decisions and also in preventing such infections.

Antimicrobial Resistance in Pseudomonas sp. Causing Infections in Trauma Patients: A 6 Year Experience from a South Asian Country

Drug resistance to Pseudomonas sp. has spread to such a level irrespective of the type of patients, that its pattern of distribution and antibiotic resistance needs to be studied in detail, especially in trauma patients and hence the study. A 6 year study was carried out among trauma patients to see the trend and type of resistance prevalent in the apex hospital for trauma care in India among nonduplicate isolates where multidrug-resistance (MDR), cross-resistance and pan-drug resistance in Pseudomonas sp. were analyzed. Of the total 2,269 isolates obtained, the species, which was maximally isolated was Pseudomonas aeruginosa (2,224, 98%). The highest level of resistance was seen in tetracycline (2,166, 95.5%, P < 0.001) and chloramphenicol (2,160, 95.2%, P < 0.001) and least in meropenem (1,739, 76.7%, P < 0.003). Of the total, 1,692 (74.6%) isolates were MDR in which P. aeruginosa (75%) were maximum. MDR Pseudomonas is slowing increasing since the beginning of the study period. Of 1,797 imipenem-resistant P. aeruginosa isolated during the study period, 1,763 (98%) showed resistance to ciprofloxacin or levofloxacin, suggesting that cross-resistance may have developed for imipenem due to prior use of fluoroquinolones. Antibiotic resistance in Pseudomonas sp. is fast becoming a problem in trauma patients, especially in those who requires prolong hospital stay, which calls for proper antimicrobial stewardship.

Epidemiology and outcomes of Stenotrophomonas maltophilia and Burkholderia cepacia infections among trauma patients of India: a five year experience

BACKGROUND

Infections by uncommon non-fermenting Gram negative bacteria are on the rise, but little is known about the risk factors and drug resistance in trauma patients in India. This study explored the infections caused by Stenotrophomonas maltophilia and/or Burkholderia cepacia in trauma patients over a period of 5 years.

MATERIAL AND METHODS

Patients admitted for trauma care with S. maltophilia and/or B. cepacia isolated from clinical specimens were enrolled. Characteristics regarding the strain isolation, drug sensitivity pattern, multidrug resistance (MDR), patient, outcomes, and differentiation of true infection from colonisation were observed.

RESULTS

Of the total 233 isolates, 102 were S. maltophilia and 131 were B. cepacia; 4.3% were responsible for polymicrobial infections with other bacteria. There were more B. cepacia MDR isolates than S. maltophilia. Maximum resistance was found to tetracycline (86.7%) and tobramycin (86.7%) in B. cepacia and to co-trimoxazole (68.7%) in S. maltophilia. Of these, 21 (16.03%) had a fatal outcome and the remaining 111 (84.7%) were discharged healthy. The in-hospital mortality rate associated with B. cepacia was much (16%) higher than S. maltophilia (13%) at this centre.

CONCLUSION

The analysis of epidemiology and outcome of these infections will help to inform their management and treatment.

Resistance pattern of mupirocin in methicillin-resistant Staphylococcus aureus in trauma patients and comparison between disc diffusion and E-test for better detection of resistance in low resource countries

Introduction:

Mupirocin is an effective antibiotic for elimination of methicillin-resistant Staphylococcus aureus (MRSA) from nasal colonization and has been used to control outbreaks. Current reports show an increasing trend of resistance to this antibiotic.

Objective:

This study was conducted to analyze the resistance pattern of MRSA to mupirocin among the patients admitted following trauma to an apex trauma care center of India and to compare the efficacy between two methods of antimicrobial sensitivity testing.

Materials and Methods:

A total of 150 isolates of MRSA from various clinical samples of trauma patients over a period of 2 years were included in this study. These strains were confirmed for MRSA using VITEK^® 2 Compact and the Clinical Laboratory Standard Institute disc diffusion methods. The mupirocin susceptibility of the strains was tested by using E-test and 5 μg mupirocin disc in parallel each time, and the results were compared.

Results:

Clear zones of inhibition were observed in both tests. Though, good correlation was observed between the disc diffusion and E-tests in >98%, E-test showed a tendency to show lower minimum inhibitory concentration (MIC) in the remaining. These finding did not affect the final interpretation or outcomes. Of the total 150 strains, 138 (92%) showed sensitivity with the zone size in the range of 30-45 mm by 5 μg disc; rest (8%) showed sensitivity with the zone in the range of 18-30 mm by 5 μg disc, but 143 (95%) showed MIC ≤ 0.094 μg/ml and 8 (5%) gave MIC ≤ 0.75 μg/ml but ≥0.094 μg/ml by E-test. However, when both tests were compared, 5 (3.3%) showed zone size between 14 and 25 mm with ≤0.75 but >0.25 μg/ml MIC; 7 (5%) falling between 25 and 30 mm zone with MIC of ≤0.25 but >0.094 μg/ml and 138 (92%) showed zone >30 mm with MIC ≤0.094 but >0.064 μg/ml.

Conclusions:

All the MRSA isolates in our study were sensitive to mupirocin which is an encouraging finding. Though good screening for sensitivity can be done with 5 μg mupirocin disc, E-test provides a much clear and accurate results in clinical set-up. Hence, disc test can be used in resource poor countries and supplemented with E-test when needed.

A prospective look at the burden of sharps injuries and splashes among trauma health care workers in developing countries: true picture or tip of iceberg

OBJECTIVES

Health care workers (HCWs) face constant risk of exposure to cuts and splashes as occupational hazard. Hence, a prospective observational study was conducted to observe the exposure of HCWs to various sharp injuries and splashes during health care and to work up a baseline injury rate among HCWs for future comparison in trauma care set ups.

METHODS

A 2 year and 5 month study was conducted among the voluntarily reported exposed HCWs of the APEX trauma centre. Such reported cases were actively followed for 6 months after testing for viral markers and counselled. The outcomes of such exposed HCWs and rate of seroconversion was noted. To form a future reference point, the injury rate in trauma care HCWs based on certain defined parameters along with the rate of under reporting were also analysed in this study.

RESULTS

In our study, doctors were found to have the highest exposure (129, 36.2%), followed by nurses (52, 14.6%) and hospital waste disposal staff (27, 7.6%). Of the source patients, a high number of them were HBV positive (11, 3.1%), followed by HIV positive patients (8, 2.2%). No seroconversion was seen in any of the exposed HCWs. Injuries by sharps (303, 85.1%) outnumber those due to splashes (53, 14.9%) which were much higher in those working in pressing situations. Underreporting was common, being maximally prevalent in hospital waste disposal staff (182, 51.1%).

CONCLUSIONS

High rates of exposure to sharp injuries and splashes among HCWs call for proper safety protocols. Proper methods to prevent it, encouraging voluntary reporting and an active surveillance team are the need of the hour.

Outcomes of surgical site infections in orthopedic trauma surgeries in a tertiary care centre in India

BACKGROUND

Surgical site infections (SSIs) still cause significant morbidity and mortality despite advances in trauma care. We have studied in this paper the rate of SSIs, their outcomes in patients undergoing interventions for trauma and SSI trends in developing countries.

MATERIALS AND METHODS

A 16-month study (May, 2011- August, 2012) was carried out. Patients undergoing interventions for orthopedic trauma were followed and assessed for SSIs and their outcomes and antimicrobial sensitivity patterns of the micro-organisms isolated were noted and correlated.

RESULTS

A total of 40 (4.4%) confirmed cases of SSIs were identified among 852 patients of orthopedic trauma. Based on the new CDC criteria, after ruling out cellulitis, only 24 (2.6%) were found to have SSIs. A total of 12.5% of the SSIs were detected during follow-up. Acinetobacter baumannii was the predominant organism as also Staphylococcus aureus. Outcomes observed included changes in antibiotic regime, revision surgery, readmission to hospital and deaths.

CONCLUSION

SSI is prevalent in orthopaedic trauma patients and an active surveillance program will help in early management and prevention.

Procalcitonin as a predictor of sepsis and outcome in severe trauma patients: a prospective study

INTRODUCTION

Despite the advances in medical sciences, the morbidity and mortality due to sepsis in severe trauma patients remains high; hence the need for early and accurate diagnosis. Very few prospective studies are available in a country like India, which tried to analyze the prediction of sepsis using serum procalcitonin (PCT) in such a large scale among trauma patients. This study explores the role of the biomarker PCT in early diagnosis of sepsis and prediction of outcomes in severe trauma cases.

MATERIALS AND METHODS

We studied the patient population prospectively in two different groups. One with acute trauma but no clinical evidence of sepsis and the second group with clinical evidence of sepsis and are followed. Bronchoalveolar lavage, tracheal aspirates, pus, urine, body fluids from sterile body sites, etc., were collected including blood for culture and serum for PCT assays. Such assays were done on samples collected on days 1 and 4 and then compared. Additionally, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels were also tested. Antimicrobial sensitivity tests were carried out for all the isolates from the clinical samples and correlated with the clinically suspected cases of sepsis. Outcomes of the patients were noted.

RESULTS

Patients with high initial PCT levels (>2 ng/ml) in severe trauma cases had poor outcomes and risk of developing complications. Its correlation with severe outcomes was better marked as compared with CRP and ESR levels. The difference in PCT levels between days 1 and 4 in group two patients was statistically significant (P = 0.006) but were not statistically significant for CRP (P = 0.646) and ESR (P = 0.935). The study also shows that PCT levels fall in response to appropriate antimicrobial treatment.

CONCLUSION

PCT is a useful biomarker for early and accurate prediction of sepsis in severe trauma patients. If used in adjunct to clinical findings, it proves to be a good biomarker for early diagnosis, treatment and for monitoring response to therapy in confirmed cases of sepsis. It will prove to be a good supportive indicator of sepsis in early stages for the trauma patients in a low resource country like India.