Case Report of Pediatric Osteomyelitis: A Double Whammy of Unusual Etiology and Antibiotic Susceptibility

Introduction

Osteomyelitis is one of the infrequent presentations of Salmonella infection. Most of the case reports are among adult patients. It is very rare in children, and is most often associated with hemoglobinopathies or other predisposing clinical conditions.

Case Report

In this article, we present a case of osteomyelitis caused by Salmonella enterica serovar Kentucky, in a previously healthy 8-year-old child. Further, this isolate had an unusual susceptibility pattern; it showed resistance to the third-generation cephalosporins, akin to ESBL production among Enterobacterales.

Conclusion

Osteomyelitis caused by Salmonella does not have any specific clinical or radiological features, both in adult and pediatric age groups. A high index of suspicion, using appropriate testing methodologies and awareness about emerging drug resistance helps in accurate clinical management.

Two Case Reports of Ochrobactrum anthropi Bacteremia: An Overlooked Pathogen

Ochrobactrum anthropi, due to its robust survival abilities, has been known to cause nosocomial and opportunistic infections, posing both diagnostic and therapeutic challenges. Low virulence, indolent clinical presentation, and lack of awareness on their clinical significance attribute to the underreporting of the same. We report two cases of bacteremia in oncology patients presented to us in a short span of 6 months, which indicates that such infections might be quite common in immunocompromised hosts. Both our strains were susceptible to carbapenems, trimethoprim/sulfamethoxazole, and minocycline, and recovered with monotherapy. More vigilant and accurate diagnostic techniques need to be followed not to miss such pathogens. Early identification and administration of appropriate antibiotics have been associated with a good outcome.

Cross-country transport and isolation and identification of Streptococcus pneumoniae by use of alternate sources of blood supplemented media among laboratories in India

Background

The isolation of S. pneumoniae (Sp) depends on specimen integrity / transport, media and expertise. The non-availability of sheep blood agar poses a challenge in identification of colonial morphology and identification in India.

Methods

Laboratories processed swabs containing either pure Sp or Sp in mixed cultures with a second (confounding) bacterium shipped across the country in cold conditions. Duplicate set of swabs was shipped back to the central laboratory to assess the impact of shipping on culture viability. The identical swab was cultured on sheep, human blood and one additional agar plate used in the laboratory.

Results

46/60(77%) of cultures containing only Sp were correctly identified. In specimens where Sp was present in mixed culture, the proportion of isolates in which Sp was correctly identified varied, with most variability attributed to the particular confounding organism rather than the media. There was no discernible impact of temperature-controlled (4-6°C) transport on the isolation of Sp from culture swabs.

Conclusions

The study clearly elucidates the ability of laboratories for isolation of S. pneumoniae on human blood agar in resource limited settings. The results highlight the difficulties inherent in correctly identifying pathogens in mixed cultures in needs improvement using standardized tests across the study centers. The study also reaffirms the ability to transport biological specimens over long geographical distances without loss.

Molecular Characterization of Extended Spectrum β-lactamase and Carbapenemase Producing Klebsiella pneumoniae from a Tertiary Care Hospital

Objective

The extended-spectrum beta-lactamase (ESBL) and carbapenemase producing gram-negative bacteria among the members of Enterobacteriaceae are of major health concern globally. The present study was carried out to determine proportion and genetic characterization of ESBL and carbapenemase producing Klebsiella pneumoniae strains isolated from intensive care units of a tertiary care hospital.

Materials and methods

A total of 250 non-duplicate K. pneumoniae isolates were recovered from various clinical specimens from our intensive care units from May 2014 to May 2015. Antibiotic susceptibility testing was performed as recommended by Clinical and Laboratory Standard Institute. Phenotypic identification of ESBL and carbapenemase producing isolates were confirmed by the double-disk synergy test, modified Hodge test, imipenem and imipenem-EDTA combined test, respectively. Molecular characterization of β-lactamase genes were performed by polymerase chain reaction.

Results

Out of 250 Klebsiella pneumonaie, 84% isolates were ESBL producers, 66% were carbapenem resistant based on their reduced susceptibility to imipenem, meropenem and ertapenem. Among these 165 carbapenem resistant isolates, 9.7% were positive for bla_NDM-1 and these isolates were also found to be positive for one or more bla genes. Co-carriage of AmpC in ESBL and carbapenem resistant isolates were 7.8% and 3.6%, respectively and were negative for bla_KPC genes.

Conclusion

The study indicated the prevalence of ESBLs and bla_NDM-1, with additional bla genes and AmpC among the K. pneumoniae isolates in our intensive care units. NDM-1 producing Enterobacteriaceae is a growing health care problem. Detection of the prevalence of antibacterial resistance pattern helps towards improved antibiotic policy and empirical antibiotic treatment.

How to cite this article

Beena HB, Shenoy SM, et al. Molecular Characterization of Extended Spectrum β-lactamase and Carbapenemase Producing Klebsiella pneumoniae from a Tertiary Care Hospital. Indian J of Crit Care Med 2019;23(2):61-66.

Cytoplasmic-anti-neutrophil cytoplasmic antibodies targeting myeloperoxidase in Wegener's granulomatosis: a rare phenomenon

Wegener's granulomatosis (WG) patients can rarely have antineutrophil cytoplasmic antibodies (ANCAs) directed against myeloperoxidase (MPO), producing a cytoplasmic pattern on indirect immunofluorescence (IIF). This has important implications in the diagnosis and pathophysiology of the disease. We present to you a report of three cases of WG, demonstrating a cytoplasmic-ANCA pattern on indirect IIF, but directed against MPO. It is necessary to diagnose a patient taking into account both the autoimmune test results and the clinical features.

Salmonella typhimurium meningitis in infancy

We report a case of meningitis due to Salmonella typhimurium in a four-month-old female infant. The child was brought to the pediatric emergency department with complaints of fever, cold, and generalized convulsion. On examination, the child was febrile and was having seizures. The anterior fontanelle was not bulging. Lumbar puncture was done and Salmonella typhimurium was isolated from cerebrospinal fluid. Initially the infant improved clinically with appropriate management, but had a fatal outcome due to nosocomial pneumonia.

Spontaneous bacterial peritonitis caused by S. paratyphi A

Spontaneous (primary) bacterial peritonitis (SBP) due to S. paratyphi A is relatively uncommon. Clinical manifestations of SBP vary widely from severe to slight or absent, necessitating laboratory investigation of ascitic fluid. The disease is confirmed by number of neutrophils > 250/mm3 associated with or without bacterial growth in ascitic fluid culture from diagnostic abdominal paracentesis. Here, we present a case of S. paratyphi A SBP occurring in a patient with chronic liver disease and portal hypertension.The patient was treated with intravenous cefotaxime with good clinical response.

Syphilis infection among female sex workers in Nagaland, Northeast India: analysing their vulnerability to the infection

This paper describes the sex work characteristics and factors associated with syphilis among female sex workers (FSWs) in Dimapur district of high HIV prevalence Indian state, Nagaland. The study recruited 426 FSWs in 2006 using respondent-driven sampling. The prevalence of syphilis was 21.1% and HIV prevalence was 11.7%. Approximately half were under 25 years of age. Clients were solicited mainly in public places (32.7%), while hotels/lodges/rented rooms were the most common places of entertainment (57.2%). Condom use during the last sex was 36.5% with occasional and 27% with regular clients. Being married, being widowed/divorced/separated, being illiterate or having a history of drug use increased the likelihood of syphilis infection. Entertaining clients in bars/booze joints decreased the probability of syphilis. FSWs who moved between soliciting in public places or bars/booze joints and then entertaining in hotels/lodges/rented rooms had a higher vulnerability to syphilis. In summary, we found that the vulnerability to syphilis among mostly young FSWs in Dimapur varied according to their sex work characteristics, marital and educational status and drug use habits. They may be more vulnerable to HIV and sexually transmitted infections (HIV/STIs) due to the low rate of condom use. The findings have direct implications for HIV/STI prevention programmes in Northeast India.

Assessment of the scale, coverage and outcomes of the Avahan HIV prevention program for female sex workers in Tamil Nadu, India: is there evidence of an effect?

BACKGROUND

Avahan, the India AIDS Initiative, a large-scale HIV prevention program, using peer-mediated approaches and STI services, was implemented for high-risk groups for HIV in six states in India. This paper describes the assessment of the program among female sex workers (FSWs) in the southern state of Tamil Nadu.

METHODS

An analytical framework based on the Avahan impact evaluation design was used. Routine program monitoring data, two rounds of cross-sectional biological and behavioural surveys among FSWs in 2006 (Round 1) and 2009 (Round 2) and quality assessments of clinical services for sexually transmitted infections (STIs) were used to assess trends in coverage, condom use and prevalence of STIs, HIV and their association with program exposure. Logistic regression analysis was used to examine trends in intermediate outcomes and their associations with intervention exposure.

RESULTS

The Avahan program in Tamil Nadu was scaled up and achieved monthly reported coverage of 79% within four years of implementation. The cross-sectional survey data showed an increasing proportion of FSWs being reached by Avahan, 54% in Round 1 and 86% in Round 2 [AOR=4.7;p=0.001]. Quality assessments of STI clinical services showed consistent improvement in quality scores (3.0 in 2005 to 4.5 in 2008). Condom distribution by the program rose to cover all estimated commercial sex acts. Reported consistent condom use increased between Round 1 and Round 2 with occasional (72% to 93%; AOR=5.5; p=0.001) and regular clients (68% to 89%; AOR=4.3; p=0.001) while reactive syphilis serology declined significantly (9.7% to 2.2% AOR=0.2; p=0.001). HIV prevalence remained stable at 6.1% between rounds. There was a strong association between Avahan exposure and consistent condom use with commercial clients; however no association was seen with declines in STIs.

CONCLUSIONS

The Avahan program in Tamil Nadu achieved high coverage of FSWs, resulting in outcomes of improved condom use, declining syphilis and stabilizing HIV prevalence. These expected outcomes following the program logic model and declining HIV prevalence among general population groups suggest potential impact of high risk group interventions on HIV epidemic in Tamil Nadu.

Species distribution and anti-fungal susceptibility of Candidaemia at a multi super-specialty center in Southern India

Candidaemia is one of the leading causes of nosocomial bloodstream infections. There is a rise in the incidence of non-albicans candidaemia and emergence of anti-fungal resistance. We performed a retrospective laboratory-based study over a period of 2 years (January 2009 to December 2010) at our quaternary care multi super-specialty hospital in Southern India. There had been 68 Candida isolates detected from the bloodstream of 55 patients during the study period. Overall, 74% of cases were due to non-albicans Candida. C. tropicalis was most commonly isolated (39.7%), followed by C. albicans (26.4%). All Candida isolates remain susceptible to voriconazole, whereas highest degree of resistance was observed for fluconazole.

Hospital acquired infection is inversely related to utilization of isopropyl alcohol and tissue paper pulls--a prospective observational study

INTRODUCTION

Healthcare associated infections not only cause morbidity and mortality, but also drain the resources in the hospitals across the globe. It has been shown repeatedly that practicing hand hygiene is a deterrent to hospital acquired infection. It is essential for the infection control committee and the hospital administrators to have a fair idea of the prevailing hand hygiene practice in the healthcare facility. This is commonly obtained direct observation, self-reporting by healthcare workers and indirect calculation based on hand hygiene disinfectant product usage.

AIMS

This study was planned to assess the indirect surrogates of hand hygiene among healthcare workers in an Indian hospital.

METHODS

We presumed that the tools used to perform hand hygiene, the alcoholic hand rub and the tissue paper towel may throw light on the prevailing hand hygiene practice. An analysis of the quantity of alcohol hand rub and the number of tissue paper towel usage against the incidence of hospital acquired infection was made.

OBSERVATION

The mean incidence of HAI during the period of study was 8.5 +/- 6.7 (range 2 to 27) per month. There was a decrease in the HAI rates with increasing of alcoholic hand rub and tissue paper towels. It was predicted using the regression graphs that if the quantity of alcoholic hand rub usage increased to 2620 Ltrs/ month, the HAI would be '0'. Similarly if 427,0000 tissue paper towel pulls were used, the HAI would be '0'.

CONCLUSION

Studying the incidence consumption of the quantity of tissue paper rolls and isopropyl alcohol may be used as a surrogate of hand hygiene practice among healthcare workers.

Assessment of intervention outcome in the absence of baseline data: 'reconstruction' of condom use time trends using retrospective analysis of survey data

Background

Avahan, the India AIDS Initiative, is a large-scale targeted intervention. Data on condom use prior to Avahan are unavailable. The authors used a novel method of analysing cross-sectional survey data to ‘reconstruct’ condom use rates in presurvey years, and to assess the relationship between Avahan and time trends in condom use among female sex workers (FSWs).

Methods

Among FSWs reporting consistent condom use (CCU) with clients in surveys from 21 districts in southern India (n=7358), data on length of time using condoms, and length of time selling sex, were converted into number of FSWs using condoms (numerator) and selling sex (denominator) by year, to give yearly rates of CCU from 2001 to year of survey. Linear regression with generalised estimating equations was used to assess time trends and to compare the rate of increase in condom use before and after Avahan initiation in 2003.

Results

In all 21 districts, the rate of increase in CCU from 2001 to time of the surveys was highly significant. Overall CCU increased from 27% (22%) with occasional (regular) clients in 2001, to 76% (68%) in 2006, respectively. The yearly rate of increase in CCU was significantly greater after (slope 2003–2006: 12.7% (12.0%) per year for occasional (regular) clients) than prior to Avahan (slope 2001–2003: 5.1% (5.3%) per year for occasional (regular) clients) implementation (p<0.0001).

Conclusions

The findings indicate a positive relationship between implementation of the Avahan programme and rates of CCU increase among FSW. This method of analysis may be useful in other contexts where preintervention data are lacking.