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  ~ Table of Contents - Current issue
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October-December 2017
Volume 35 | Issue 4
Page Nos. 443-625

Online since Thursday, February 1, 2018

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EDITORIAL  

Our microbial signatures p. 443
Prabha Desikan
DOI:10.4103/ijmm.IJMM_17_250  PMID:29405134
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REVIEW ARTICLES Top

An update on technical, interpretative and clinical relevance of antimicrobial synergy testing methodologies Highly accessed article p. 445
Shakti Laishram, Agila Kumari Pragasam, Yamuna Devi Bakthavatchalam, Balaji Veeraraghavan
DOI:10.4103/ijmm.IJMM_17_189  PMID:29405135
Testing for antimicrobial interactions has gained popularity in the last decade due to the increasing prevalence of drug-resistant organisms and limited options for the treatment of these infections. In vitro combination testing provides information, on which two or more antimicrobials can be combined for a good clinical outcome. Amongst the various in vitro methods of drug interactions, time-kill assay (TKA), checkerboard (CB) assay and E-test-based methods are most commonly used. Comparative performance of these methods reveals the TKA as the most promising method to detect synergistic combinations followed by CB assay and E-test. Various combinations of antimicrobials have been tested to demonstrate synergistic activity. Promising results were obtained for the combinations of meropenem plus colistin and rifampicin plus colistin against Acinetobacter baumannii, colistin plus carbapenem and carbapenem plus fluoroquinolones against Pseudomonas aeruginosa and colistin/polymyxin B plus rifampicin/meropenem against Klebsiella pneumoniae. Antagonism was detected in only few instances. The presence of synergy or antagonism with a combination seems to correlate with minimum inhibitory concentration of the agent and molecular mechanism involved in the resistance. Further studies need to be conducted to assess the utility of in vitro testing to predict clinical outcome and direct therapy for drug-resistant organisms.
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Stenotrophomonas maltophilia: From trivial to grievous p. 469
Lipika Singhal, Parvinder Kaur, Vikas Gautam
DOI:10.4103/ijmm.IJMM_16_430  PMID:29405136
Stenotrophomonas maltophilia, once regarded as an organism of low virulence, has evolved as a significant opportunistic pathogen causing severe human infections in both hospital and community settings, especially amongst highly debilitated patients. Globally, S. maltophilia ranks third amongst the four most common pathogenic non-fermenting Gram-negative bacilli (NFGNBs), others being Pseudomonas aeruginosa, Acinetobacter baumannii and Burkholderia cepacia complex (Bcc). The worth of accurate identification of S. maltophilia comes to the forefront as it needs to be differentiated from other NFGNBs such as Acinetobacter, P. aeruginosa and Bcc due to its inherently contrasting antibiotic susceptibility pattern. Consequently, its correct identification is essential as no single drug is amply effective against all NFGNBs, which hinders initiation of appropriate empirical treatment resulting in increased morbidity and mortality.
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ORIGINAL ARTICLES Top

Spectrum of infections in acute febrile illness in central India p. 480
Yogendra Pandurang Shelke, Vijayshri Suresh Deotale, Deepashri Laxmanrao Maraskolhe
DOI:10.4103/ijmm.IJMM_17_33  PMID:29405137
Introduction: Infectious agent when enters in the host results in febrile illness. This may lead to increase in morbidity or even mortality in undiagnosed/untreated cases. There are many aetiological agents which lead to acute febrile illness. Among these aetiological agents, important is bacterial or viral aetiology. Objective: The objective of this study is: (i) To know the aetiological agents responsible for acute undifferentiated febrile illness (AUFI) by serological test or by bacterial culture and (ii) To know the clinical profile of AUFI. Methodology: A total of 270 patients were enroled in the study with a history of AUFI admitted in medicine and paediatric department from January 2015 to November 2016 of tertiary care hospital of central India. Blood sample was collected for blood culture, clot culture and serological tests for immunochromatographic tests (ICTs) and ICT-positive results were confirmed by respective enzyme-linked immunosorbent assay (ELISA). All negative serum samples by immunochromatography were retested for disease-specific ELISA as scrub typhus, dengue and leptospirosis. Results: Out of 270 patients, 127 (47%) were of scrub typhus, 33 (12%) were malaria cases, 47 (17.40%) were dengue, 12 (4%) were enteric fever, 5 (2%) were leptospirosis, undiagnosed were 18 (6.66%) and other infections (viz viral, urinary tract infection, upper and lower respiratory tract infection and acute gastroenteritis) accounts for 28 (10.37%) cases. We have also noticed that there was co-infection of scrub typhus and dengue, leptospirosis and scrub typhus. Conclusion: It is important to know the cause and clinical profile of AUFIs for their proper management also it will help to prevent morbidity and mortality in AUFI cases.
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Correlation of in vitro sensitivity of chloroquine and other antimalarials with the partner drug resistance to Plasmodium falciparum malaria in selected sites of India p. 485
Supriya Sharma, Ram Suresh Bharti, Nitin Bhardwaj, Anupkumar R Anvikar, Neena Valecha, Neelima Mishra
DOI:10.4103/ijmm.IJMM_17_160  PMID:29405138
Background: Antimalarial drug resistance is a potential threat for control and elimination of malaria. To ascertain the status of antimalarial drug resistance at the study sites, correlation between in vitro drug sensitivity pattern and drug resistance molecular markers in Plasmodium falciparum malaria was undertaken. Materials and Methods: Polymorphisms in P. falciparum chloroquine resistance transporter (pfcrt) K76T and pfmdr1 N86Y were studied in relation to the in vitro susceptibility of P. falciparum in culture (n = 10) and field isolates (n = 40) to chloroquine (CQ), amodiaquine (AQ), quinine (QN), mefloquine (MQ) and artemisinin (ART). The prevalence of drug resistance molecular markers, pfdhfr (codon S108N, C59R, N51I, I164 L and A16V), pfdhps (codon S436F and A437G), pfATPase6 (codon D639G and E431K) and mutation in the propeller domain of pfK13 gene were also analysed. Chi-square test and parametric Pearson correlation test were performed using SPSS version 17. Results: In vitro assay showed 18% resistance to CQ, 8% to AQ and 4% to QN. However, no resistance was observed towards MQ and ART. The mutations in pfcrt and pfmdr1 were statistically not significantly associated with susceptibility responses for antimalarials; however, increased IC50values of drugs were reflected as mutant and/or mixed isolates for both gene polymorphisms. CQ was found as independent predictor for other antimalarials, i.e., AQ, QN and ART, with r2 score 0.241, 0.241 and 0.091, respectively. Mutation in the pfATPase6 gene at codon E431K was observed in only one sample from Tripura which also had increased IC50value of 6.28 nM. However, moderate numbers of mutations at codon S108N, C59R and I164 L for pfdhfr gene and S436F and A437G for pfdhps gene were also observed. None of the samples showed mutation in propeller domain of pfK13 gene. Conclusion: The correlation between IC50and molecular markers for antimalarial drug resistance is reported for the first time through this study. A positive correlation between in vitro drug resistance with molecular markers for antimalarial drug resistance could make in vitro assay a reliable tool to predict drug efficacy which is needed for detection of emerging resistance in the country.
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Microbiology, clinical spectrum and outcome of peritonitis in patients undergoing peritoneal dialysis in India: Results from a multicentric, observational study p. 491
Georgi Abraham, Amit Gupta, Kashi Nath Prasad, Anusha Rohit, Anil Kumar Bhalla, Vishwanath Billa, Rajasekhar Chakravati, Tonmoy Das, Thadakanathan Dhinakaran, Arup Ratan Dutta, Padmanabhan Giri, Gokulnath , Tarun Jeloka, Sampath Kumar, Ajay Marwaha, Radha Vijay Raghavan, Rajan Ravichandran, Roshan Rohit, Chandra Nath Sarkar, Naorem Sharat Kumar Singh
DOI:10.4103/ijmm.IJMM_17_392  PMID:29405139
Background: Peritoneal dialysis (PD)-related peritonitis is a major risk factor for drop out of patients on continuous ambulatory PD (CAPD) and automated PD (APD). Factors affecting PD-related peritonitis and centre-specific microbiological data are lacking in India. A multicentric prospective observational study was designed to overcome the gaps in the existing data regarding causative organism and outcome. Methodology: The present study was a prospective, uncontrolled, open-label; observational study conducted in 21 centres representing all the four geographical regions (North, South, East and West) of India between April 2010 and December 2011. Results: A total of 244 patients on chronic PD with peritonitis were enrolled in the study (CAPD and APD), who met the inclusion criteria, from 21 centres covering the different geographical areas of India. Amongst the 85 samples that were culture positive, 38 (44.7%) were in the monsoon season followed by 23 (27.1%) in the post-monsoon, 18 (21.2%) during winter and 11 (12.9%) during summer. Maximum culture positivity (72.7%) was observed with automated culture technique. Microorganisms could be isolated in only 85 cases (35.3%) while the remaining samples were culture negative (156/241, 64.7% of samples). Organisms isolated were Gram-negative in 47.8%, Gram-positive in 36.7%, fungal in 13.3% and Mycobacterium tuberculosis in 2.2%. Conclusion: This large multicentre study of peritonitis offers insights into the aetiology and outcomes of infectious complications of chronic PD in India that are germane to clinical decision-making.
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Pre-transplant cytomegalovirus immunoglobulin G antibody levels could prevent severe cytomegalovirus infections post-transplant in liver transplant recipients: Experience from a tertiary care liver centre p. 499
Ekta Gupta, Viniyendra Pamecha, Yogita Verma, Niteen Kumar, Archana Rastogi, Nadeem Hasnian, Ajeet Singh Bhadoria
DOI:10.4103/ijmm.IJMM_17_201  PMID:29405140
Background: Humoral immune responses in cytomegalovirus (CMV) are not studied well. Pre-transplant CMV immunoglobulin G (IgG) antibody levels (Pre-Tx IgG) could influence the occurrence of post-transplant CMV infections. Objective: Correlation between pre-Tx IgG and post-Tx risk of acquiring CMV infection was investigated. Materials and Methods: A total of 146 liver Tx recipients, not on CMV prophylaxis, were included. Pre-Tx IgG in donor (D) and recipient (R) were estimated and all the recipients were followed up for 1 year for CMV infections. Results: D+ R+ serostatus was seen in 142 (97.3%) and D− R+ in 4 (2.7%). A total of 113 (77.4%) recipients had pre-Tx IgG of ≥250 AU/ml. Overall, post-Tx CMV infections were seen in 54 (36.9%) recipients. In 32 (59.2%) patients, CMV infection was seen during the 1st month after TX. Incidences of post-Tx CMV infection in recipients with pre-Tx IgG <250 AU/mL and ≥250 AU/mL were 42.4% and 34.5%, respectively (P = 0.99). Median viral load was significantly higher in patients with pre-Tx IgG <250 AU/ml: 4log10 (R: 2.8–6.6 log 10) copies/ml than those with ≥250 AU/ml: 2.2 log10 (R: 1.6–3.8 log10) copies/ml, P = 0.04. There was no difference in the time of occurrence of CMV infection in both the groups. Concurrent occurrence of rejection and CMV infection was seen in significantly more patients 18/54 (32.7%) than in patients without CMV infection (12/99, 12%, P = 0.002). Conclusions: Higher pre-Tx CMV IgG levels might prevent severe CMV infections post-Tx. Recipients with low pre-Tx CMV titre might be benefitted by CMV prophylaxis or aggressive pre-emptive treatment.
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Incidence of ventilator-associated pneumonia and impact of multidrug-resistant infections on patient's outcome: Experience at an Apex Trauma Centre in North India p. 504
Surbhi Khurana, Purva Mathur, Subodh Kumar, Kapil Dev Soni, Richa Aggrawal, Priyam Batra, Nidhi Bhardwaj
DOI:10.4103/ijmm.IJMM_16_186  PMID:29405141
Introduction: Ventilator-associated pneumonia (VAP) remains one of the most common nosocomial infections in the Intensive Care Unit. In the face of extremely high rates of antimicrobial resistance, it is essential to gauge the clinical significance of isolation of multidrug-resistant (MDR) pathogens from clinical samples. This study details the trend of VAP and the clinical significance of isolation of MDR pathogens from respiratory samples at an Indian tertiary care hospital. Methods: The study was conducted over a 5-year period. VAP was diagnosed on the basis of centres for disease control and prevention criteria. The trend in the rates was compared with preventive measures. Phenotypic and genotypic resistance to beta-lactamases was determined using standard methods. The correlation of isolation of a multi-resistant pathogen with the clinical outcome, length of stay and cost of antimicrobial was ascertained. A clone of Acinetobacter baumannii identified through multilocus sequence typing was used to answer the question of whether resistant bugs always have a fatal outcome. Results: The total ventilator days (VDs) for these patients amounted to 36,278. A total of 433 episodes of VAP occurred during the study, amounting to an overall VAP rate of 11.9/1000 VDs. There was a decline in the rates of VAP over the 5-year period, due to intensive surveillance and preventive activities. A. baumannii (54%) was the most common pathogen, followed by Pseudomonas aeruginosa (21%). A high rate of MDR was seen, with the presence of extended-spectrum beta-lactamases, AmpC and carbapenemase genes. The presence of MDR was not always associated with a fatal outcome. Conclusions: Isolation of MDR pathogens from bronchoalveolar lavage does not always adversely affect the outcome of patients. It requires an interdisciplinary team of clinical microbiologists, physicians and hospital infection control nurses, to collectively manage these patients.
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Distribution of different genes responsible for invasive characteristics, detection of point mutations in capsular gene wchA and biofilm production among the invasive and non-invasive isolates of Streptococcus pneumoniae p. 511
James John, Kripa Shanker Kasudhan, Reba Kanungo, Savitri Sharma, Vaishali Dohe, K Prashanth
DOI:10.4103/ijmm.IJMM_17_183  PMID:29405142
Background: Streptococcus pneumoniae continues to cause morbidity and mortality across the globe, with developing countries bearing the brunt of the disease. It is mainly responsible for meningitis, pneumonia and septicaemia primarily in children, elderly and immunocompromised persons. Colonisation and persistence in the human nasopharynx occur during early childhood, and it appears to be prerequisite for invasive pneumococcal disease (IPD). Factors that help in persistent colonisation and subsequent invasion are ill understood. Several virulence factors have been incriminated for nasopharyngeal carriage (NC) as well as for the manifestation of the pathogenesis of IPD. Materials and Methods: This study attempts to characterise the S. pneumoniae isolates through analysing the distribution of different virulence markers such as lytA, ply, pbpA, eno, psaA, amiA, ciaR and wchA among the isolates obtained from disease and NC. A total of 37 isolates which include 14 invasive and 23 non-invasive isolates were investigated by polymerase chain reaction to detect the genes. Eight representative isolates were investigated for mutations in wchA by DNA sequencing that may responsible for capsular variation. Results: Ply, pbpA, amiA and eno were observed in a greater percentage of invasive isolates than non-invasive isolates though these differences are not statistically significant. Other two genes ciaH and psaA did not show any significant difference between two groups of isolates. Biofilm production was significantly higher in than non-invasive isolates when compared to invasive isolates. Sequence analysis of wchA revealed three significant point mutations or single-nucleotide polymorphisms (SNPs) among the isolates of one particular cluster (cluster III). These SNPs are responsible for a non-synonymous mutation in wchA bringing in an amino acid change in WchA protein, which is a part of the capsule of S. pneumoniae. Notably, all the three isolates present in cluster III had these SNPs and all of them were isolated from ocular infections. Conclusion: The results of our study implies a possible capsular variations among the isolates and this may have an impact on capsular typing.
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Hypertonic xylose agar medium: A novel medium for differentiation of Candida dubliniensis from Candida albicans p. 518
Abiroo Jan, Gulnaz Bashir, Bashir Ahmad Fomda, Dekyong Angmo Urgain Khangsar, Munazah Manzoor, Amrish Kohli, Sulmaz Reshi, Mohd Suhail, Saba Choudhary, Akeela Fatima
DOI:10.4103/ijmm.IJMM_17_216  PMID:29405143
Background: Candida dubliniensis is a pathogenic Candida species which shares many phenotypic features with Candida albicans. These similarities have caused significant problems in the identification of C. dubliniensis in an average clinical mycology laboratory. Several phenotypic-based tests have been developed to distinguish C. albicans from C. dubliniensis but none has been demonstrated being sufficient alone for accurate differentiation of the two species. Aim: To facilitate the differentiation of these species, we evaluated the utility of a novel medium 'Hypertonic Xylose Agar Medium' (HXAM). Materials and Methods: A total of 200 Candida spp. were tested in this study which included 186 stock strains of C. albicans and 14 strains of C. dubliniensis. Identification of all these strains was confirmed by polymerase chain reaction-restriction fragment length polymorphism using Bln I (Avr II) enzyme. All isolates were inoculated on HXAM, incubated at 28°C and examined for visible growth every day up to 7 days. Results: On this medium at 28°C, all 186 C. albicans isolates showed visible growth at 48 h of incubation whereas none of the 14 C. dubliniensis isolates did so even on extending the incubation period up to 7 days. Conclusion: Hence, we propose HXAM as a sole phenotypic method for identifying C. dubliniensis from germ-tube-positive isolates or from stock collections of known C. albicans.
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The bioinformatics analyses reveal novel antigen epitopes in major outer membrane protein of Chlamydia trachomatis p. 522
Tao ZHang, Huijun Li, Xi Lan, CHuntao ZHang, ZHangsheng Yang, Wenyan Cao, Ning Fen, Yumei Liu, Yi Yan, Amanguli· Yasheng, Xiumin Ma
DOI:10.4103/ijmm.IJMM_17_251  PMID:29405144
Purpose: The aim of this study was to predict the T-cell and B-cell epitopes in major outer membrane protein (MOMP) of Chlamydia trachomatis (CT) by using online software and also to analyse the secondary structure of MOMP through bioinformatics tools. Materials and Methods: The predictions of secondary structure of MOMP protein were carried out using SOPMA software, and the prediction of B-cell epitopes in MOMP protein was carried out using IEDB and LEPS software, while the T-cell epitopes were predicted by the software of IEBD and SYFPEITHI. The predictions from the software were combined with MOMP protein characteristics, including surface features, hydrophilicity, flexibility, accessibility and plasticity, to analyse the common epitope areas' response by T-cells and B-cells. Results: In the secondary structure of CT MOMP, the alpha-helices accounted for 41.62% of total amino acid, while the beta sheets and random coil accounted for 19.80% and 32.49%, respectively. Predictions combined with MOMP protein surface features, hydrophilicity, flexibility, accessibility and plasticity were further characterised, and three high-score B-cell epitope areas were found as located in 24–31, 307–311 and 318–327 amino acids of MOMP protein, respectively; in the meanwhile, three high-score T-cell epitope areas were found in 234–236, 323–329 and 338–343 amino acids of MOMP using major histocompatibility complex (MHC) class I HLA-A 0201 restrictive T-cell epitope analyser. Conclusion: We established the methods by using the biological information network technologies for looking the T-cell antigen epitopes and B-cell antigen epitopes in MOMP of CT, and three novel T-cell epitopes as well as three novel B-cell epitopes were identified in the current study. It provides important information for further studying the antigenicity of CT MOMP protein and also provides useful information for developing highly efficient subunit vaccines for CT.
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Aetiological study of viruses causing acute encephalitis syndrome in North West India p. 529
Jitendra Kumar Tiwari, Bharti Malhotra, Aradhana Chauhan, Hemant Malhotra, Pratibha Sharma, Farah Deeba, Khushbu Trivedi, Anjenya M Swamy
DOI:10.4103/ijmm.IJMM_17_180  PMID:29405145
Context: Acute encephalitis syndrome (AES) is a serious public health problem, caused mainly by viruses. However, the profile of viruses causing AES in Rajasthan is not well characterised. Aims: The present study was undertaken to identify the viruses causing AES and develop diagnostic algorithm so as to help in improved diagnosis, treatment, prevention and control. Settings and Design: The present study is a hospital-based descriptive, observational study. Samples were processed at Grade-1 DHR/ICMR Viral Research and Diagnostic Laboratory at SMS, Jaipur. Subjects and Methods: Cerebrospinal fluid (CSF) samples were processed for IgM antibody detection by enzyme-linked immunosorbent assay (ELISA) for mumps virus (MPV), measles virus (MV), Rubella virus (RV), Japanese encephalitis virus (JEV), West Nile virus (WNV) and Dengue virus using commercial kits. Nucleic acid was extracted from CSF using automated extraction system. Real-time polymerase chain reaction was done using specific primers and probes for Herpes simplex virus (HSV), Varicella-zoster virus (VZV), Epstein-Barr virus (EBV), cytomegalovirus (CMV) and enterovirus (EV). Statistical Analysis Used: Statistical analysis was done using ANOVA. Results: Among 3088 patients, 702 (22.7%) patients were positive for one or more viruses. HSV (261;8.45%) was the most common followed by EBV (173;5.6%), VZV (97;3.1%), CMV (68;2.2%), EV (32;1.03%), MPV (27;0.9%), DV (28;0.9%), MV (19;0.6%) and RV (6;0.2%). Conclusions: AES occurred sporadically in Rajasthan, samples should be tested first for herpes group of viruses followed by EV or/and for arboviruses depending on season or measles, mumps and RVs in children.
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Identification of medically important Candida species by polymerase chain reaction-restriction fragment length polymorphism analysis of the rDNA ITS1 and ITS2 regions p. 535
Suphi Bayraktar, Nizami Duran, Gülay Gülbol Duran, Naciye Eryilmaz, Hayat Aslan, Cansu Önlen, Burçin Özer
DOI:10.4103/ijmm.IJMM_17_102  PMID:29405146
Aim: We aimed to identify the distribution of species in candidal strains isolated from clinical samples and restriction fragment length polymorphism (RFLP) method based on Msp I and Bln I restrictive enzyme cuts of polymerase chain reaction (PCR) products after the amplification of ITS1 and ITS2 regions of rDNA genotypically. Materials and Methods: One hundred and fifty candidal strains isolated from various clinical samples were studies/ included. Phenotypic species assessment was performed using automated VITEK-2 system and kit used with the biochemical tests. Common genomic region amplification peculiar to candidal strains was carried out using ITS1 and ITS2 primer pairs. After the amplification, PCR products were cut with Msp I and Bln I restriction enzymes for species identification. Results: The majority of Candida isolates were isolated from urine (78.6%) while other isolates were composed of strains isolated from swab, wound, blood and other samples by 11.3%, 3.3%, 2% and 4.7%, respectively. The result of RFLP analysis carried out with Msp I and Bln I restriction enzymes showed that candidal strains were Candida albicans by 45.3%, Candida glabrata by 19.3%, Candida tropicalis by 14.6%, Candida parapsilosis by 5.3%, Candida krusei by 5.3%, Candida lusitaniae by 0.6% and other candidal strains by 9.3%. Conclusion: When the ability to identify Candida to species level of phenotypic and PCR-RFLP methods was assessed, a great difference was found between these two methods. It may be argued that Msp I and Bln I restriction enzyme fragments can be used in the identification of medically important Candida species. Further studies are needed to develop this kind of restriction profile to be used in the identification of candidal strains.
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Profiling of Aggregatibacter actinomycetemcomitans Serotypes B and C and the genotypes in periodontal health and disease p. 543
Swati Setty, Tanvee Wadikar, SS Suprith, Kishore Bhat, Srinath Thakur
DOI:10.4103/ijmm.IJMM_17_115  PMID:29405147
Background: A. actinomycetemcomitans is prevalent in periodontitis but is found in some periodontally healthy individuals as well. Certain serotypes of the organism have shown to determine severity of the disease. The distribution of serotype and genotype is affected by geographic and ethnic variation. Therefore, the present study was aimed to detect serotypes b & c of A. actinomycetemcomitans and the genotypes and find its correlation with periodontal status. Materials and Methods: A total of 75 subjects (25 aggressive periodontitis, 25 chronic periodontitis and 25 periodontally healthy) in age range of 14-55 yrs were included. Subgingival plaque samples were collected and checked for the presence of A. actinomycetemcomitans. Following isolation of the organism, detection of the serotype b or c was done by multiplex PCR. Genotyping of A. actinomycetemcomitans was done by arbitrarily primed PCR(polymerase chain reaction). Results: Out of 75 plaque samples, 35(46.66%) tested positive for A. actinomycetemcomitans. Serotype c was detected in 19/35 (54.28%), whereas serotype b alone was not detected in any of the samples. Two samples were positive for both the serotypes (b and c) (5.71%) and 14 (40%) were untypeable. 14 different arbitrarily primed PCR genotypes were obtained among 35 A. actinomycetemcomitans isolates. Conclusion: Serotype c was predominant in periodontally diseased as well as periodontally healthy individuals. An association could be present between genotype – serotype and genotype – periodontal status.
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Fasciolopsiasis in children: Clinical, sociodemographic profile and outcome Highly accessed article p. 551
Kumar Saurabh, Shilpi Ranjan
DOI:10.4103/ijmm.IJMM_17_7  PMID:29405148
Purpose: To describe the clinical and sociodemographic profile of fasciolopsiasis in children. Materials and Methods: A chart review of 56 children presenting with the passage of adult Fasciolopsis buski per stool from February 2015 to January 2016 was done for their clinical profile and risk factors for acquiring fasciolopsiasis in the Paediatric Unit of a medical college of Northern India. Results: The mean age of presentation was 8.2 years (2–14 years age group). Persistent diarrhoea (85.71%) was the most common presentation, whereas anaemia (71.42%) was the most common sign. Protein-energy malnutrition (PEM) and tuberculosis were well-associated comorbid conditions in this study. Polyparasitism was an important finding, Hymenolepis nana being the most common associated parasite. Patients were treated either with praziquantel or nitazoxanide. Conclusion: All patients recovered well except one who died due to severe PEM and disseminated tuberculosis and two cases presented with relapse. Most of the cases of polyparasitism were associated with tuberculosis.
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Fecal carriage of carbapenem-resistant Enterobacteriaceae and risk factor analysis in hospitalised patients: A single centre study from India p. 555
Balvinder Mohan, Amber Prasad, Harsimran Kaur, Vinaykumar Hallur, Neha Gautam, Neelam Taneja
DOI:10.4103/ijmm.IJMM_17_144  PMID:29405149
Purpose: Carbapenem-resistant Enterobacteriaceae (CRE) have emerged and disseminated widely causing a variety of infections. In India, the carriage of CRE in hospitalised patients has not been well-studied. Therefore, we conducted the present study to observe gut carriage rate of CRE in patients admitted to our tertiary care hospital. Methods: A total of 232 faecal swabs collected from consecutive stool samples from admitted patients were inoculated on ChromID extended spectrum β-lactamase plates and members of Enterobacteriaceae family were subjected to antibiotic susceptibility as per the Clinical Laboratory Standards Institute guidelines. Polymerase chain reaction for blaVIM, blaKPC, blaIMPand blaNDM-1 genes was performed. CRE was identified if the isolates showed resistance to either imipenem or meropenem or showed the presence of resistant genes. Risk factors of patients with or without CRE colonisation were also analysed. Results: A total of 232 faecal swabs yielded 252 Enterobacteriaceae isolates, of which 49 isolates from 42 patients showed the presence of CRE (occurrence 42/232; 18.1%); 27 isolates from 22 patients carried blaNDM-1, whereas 20 isolates from 17 patients possessed blaVIMgene. No isolate was positive for blaKPCand blaIMPgenes. The CRE was common in both intensive care units (38.4%) and wards (46%) which may reflect the excessive use of broad-spectrum antibiotics in both these settings. The CRE was also found to have a significantly higher antimicrobial resistance as compared to non-CRE isolates. The logistic regression analysis of significance showed the presence of any indwelling device (P = 0.049) and nasogastric tube (P = 0.043) as independent risk factors for acquiring gut colonisation. Conclusions: The study is the first from India to show high CRE carriage in patients admitted to a tertiary care centre and emphasises the need of strict antimicrobial stewardship implementation in hospitals to prevent dissemination of multidrug-resistant CRE.
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Seroprevalence, risk factors and genotype distribution for Hepatitis C infection: A study from rural hospital in Maharashtra p. 563
Satish Ramchandrra Patil, Kailash D Datkhile, MV Ghorpade, Supriya Satish Patil, Satish V Kakade
DOI:10.4103/ijmm.IJMM_16_96  PMID:29405150
Background and Objectives: Hepatitis C is global health problem affecting a significant portion of the world's population. Available data in Western Maharashtra on seroprevalence, risk factors and genotype distribution are very limited. Objectives: The present study was carried out to estimate the seroprevalence, factors influencing transmission and distribution of genotype of hepatitis C virus (HCV) in a hospital-based population. Materials and Methods: This was a cross-sectional, hospital-based study. A total of 25193 serum samples were tested for HCV and HBV infection. All samples from HCV antibody-positive patients were subjected for HCV RNA detection and genotype. Chi-square, unpaired t-test, logistic regression analysis was used for statistical analysis. Results: The seroprevalence for anti-HCV-Ab was 0.46%. Backward multivariate logistic regression analysis revealed increasing age; alcoholic, blood transfusion and dialysis were significant risk factors. Of 116 patients with HCV, 8 (6.89%) patients had HCV-HBV co-infection. The most common genotype (61.90%) was 3 followed by Genotype 1 (38.09%). Conclusions: In the present study, significant risk factors were a history of blood transfusion, habit of alcohol, dialysis. The prevention of HCV infection can be achieved by screening of blood and blood products and creating awareness about risk factors. Since the efficacy of current and new therapies differ by genotype, genotype study is essential.
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Evaluation of genotype MTBDRplus line probe assay in detection of rifampicin and isoniazid resistance in comparison to solid culture drug susceptibility testing in a tertiary care centre of western Uttar Pradesh p. 568
Shariq Ahmed, Indu Shukla, Nazish Fatima, Sumit K Varshney, Mohammad Shameem
DOI:10.4103/ijmm.IJMM_17_321  PMID:29405151
Background: Isoniazid (INH) and rifampicin (Rif) are the key first-line antituberculosis drugs, and resistance to these drugs i.e., multi-drug-resistant tuberculosis (MDR-TB), is likely to result in treatment failure and poor clinical outcomes. India has the highest burden of TB and MDR-TB in the world, disproportionately high even for India's population. The GenoType® MTBDRplus molecular method allows rapid detection of Rif and INH resistance. Aim: The present study was done to compare the performance of line probe assay test (GenoType® MTBDRplus) with solid culture method for an early diagnosis of MDR-TB. Methods: Totally 1503 sputum samples of MDR-TB suspects were subjected to fluorescent microscopy. Decontamination was done by N-acetyl-L-cysteine and sodium hydroxide method. Fluorescent microscopy-positive samples were subjected to GenoType® MTBDRplus (HAIN Lifescience) assay. Sixty-two random samples were compared with phenotypic drug susceptibility testing (DST) (1% proportion method) using solid culture method by Lowenstein–Jensen media. Results: The sensitivity, specificity, positive predictive value and negative predictive value for detection of resistance to Rif were 94.74%, 95.35%, 90% and 97.62% and to INH were 92.00%, 91.89%, 88.46% and 94.44%, respectively, in comparison with the phenotypic DST. Conclusion: GenoType® MTBDRplus has good sensitivity and specificity in detecting MDR-TB cases with a significantly lesser turnaround time as compared to conventional DST method and simultaneous detection of Rif and INH resistance. This technique saves several weeks of time required for culture and DST.
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Genetic diversity and allelic variation in south Indian isolates of Group A streptococci causing invasive disease p. 575
Reena Rajkumari, John Melbin Jose, Kootallur Narayanan Brahmadathan
DOI:10.4103/ijmm.IJMM_17_298  PMID:29405152
Background: Reported literature on invasive group A streptococcal isolates in India is very scanty. This study was undertaken to determine the molecular heterogeneity of such isolates as seen in a tertiary care center. Materials and Methods: Thirty two blood culture isolates and 18 from other sterile body fluids were characterized by emm gene sequencing and multilocus sequence typing. Results: Forty two emm types were identified including 25 from 32 blood isolates and 17 from 18 other body fluid isolates. Types 110, 74, 63, 85, 102, 105, 124 and st854.1 were common to both groups and accounted for 40% of the isolates. Two types namely, stKNB6 and stKNB9 were newly identified types. MLST identified forty eight sequence types (MLST - ST) of which 31 were from 32 blood isolates and 17 from 18 body fluid isolates; thirty three of them were hitherto unrecognized at the time of identification. Two blood isolates of emm 85 had the same MLST - ST 484 while three blood isolates of emm 110 had three different STs namely, ST 493, 494 and 497. Two types, ST 493 and ST497 had single locus variation while ST 497 had a double locus variation. Conclusions: Our study shows that subtle allelic variations in the house keeping genes results in the development of new strains in a given emm type and contribute significantly to the existing high diversity of strains circulating in the community.
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Effect of Interleukin-28B polymorphism on Interleukin-28 expression and immunological recovery amongst HIV-1-infected individuals following antiretroviral therapy p. 580
BV Srinidhi, G John Fletcher, Jaiprasath Sachidanantham, Priscilla Rupali, Veena Vadhini Ramalingam, JP Demosthenes, OC Abraham, Susanne A Pulimood, Grace Rebekah, Rajesh Kannangai
DOI:10.4103/ijmm.IJMM_17_299  PMID:29405153
Purpose: Type III interferon is well known to have diverse antiviral and immunomodulatory activities. Studies describing the association of interleukin (IL)-28 polymorphisms in treatment-experienced HIV participants are limited. This study was aimed to determine the association of IL-28B gene polymorphisms with immunological recovery in HIV patients on 6–9 months of antiretroviral therapy (ART). Methods: Eighty treatment-naive HIV patients were recruited, of which 48 patients were followed up after 6–9 months of ART. Whole blood samples were collected before and after 6–9 months of ART. CD4, CD8 and CD3 counts were enumerated flow cytometry. IL-28B polymorphisms (rs12979860 and rs8099917) were profiled by polymerase chain reaction (PCR)-restriction fragment length polymorphism. The IL-28 mRNA and plasma HIV-1 viral load were estimated using real-time PCR and plasma IL-28 level by ELISA. Results: The CD4, CD4/CD3%, IL-28 mRNA and reversal of CD4/CD8 ratio were significantly increased following 6–9 months of ART (P < 0.01). The rs12979860 CC genotype and rs12979860:rs8099917 (CC: TT) haplotype showed significant association with higher CD4+ T-cell count amongst treatment-naive HIV-infected individuals (P < 0.05). In addition, there was a significant association of rs12979860 CC genotype with increase in CD4/CD3% following 6–9 months of ART. IL-28 mRNA showed correlation with the HIV-1 viral load, and there was a significant increase in the IL-28 mRNA expression following 6–9 months of ART. Conclusion: Our preliminary findings suggest that IL-28 polymorphisms could influence both immunological recovery and therapeutic response in HIV infection. Hence, functional studies are warranted to understand the mechanistic basis of IL-28-mediated host genetic influence on HIV therapeutic response.
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BRIEF COMMUNICATIONS Top

Dosing strategy based on prevailing aminoglycoside minimum inhibitory concentration in India: Evidence and issues p. 585
Balaji Veeraraghavan, Agila Kumari Pragasam, Abi Manesh, Priscilla Rupali, Ramya Iyadurai, Camilla Rodrigues, Sangeeta Joshi, Indranil Roy, Bhaskar Narayan Chaudhuri, DS Chitnis, Dhole Tapan
DOI:10.4103/ijmm.IJMM_17_386  PMID:29405154
Aminoglycosides are important agents used for treating drug-resistant infections. The current dosing regimen of aminoglycosides does not achieve sufficient serum level concentration for the infected bacterial pathogen interpreted as susceptible based on laboratory testing. Minimum inhibitory concentration was determined for nearly 2000 isolates of Enterobacteriaceae and Pseudomonas aeruginosa by broth microdilution method. Results were interpreted based on CLSI and EUCAST interpretative criteria and the inconsistencies in the susceptibility profile were noted. This study provides insights into the inconsistencies existing in the laboratory interpretation and the corresponding clinical success rates. This urges the need for revising clinical breakpoints for amikacin, to resolve under dosing leading to clinical failure.
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Clinically relevant yeast species identified by sequencing the internal transcribed spacer region of r-RNA gene and Vitek 2 compact (YST card) commercial identification system: Experience in a Tertiary Care Hospital in Assam, Northeast India p. 588
Reema Nath, Reeta Bora, Biswajyoti Borkakoty, Lahari Saikia, Pratap Parida
DOI:10.4103/ijmm.IJMM_17_100  PMID:29405155
In this retrospective study from 2012 to 2015, 333 clinical isolates of yeasts were identified using Vitek 2 Compact System YST ID card (Biomerieux, France) and internal transcribed spacer (ITS) sequencing. Eighteen species were identified by ITS sequencing. Candida albicans was the most common species (46.5%), followed by Candida tropicalis (27%). The total species supported by Vitek System was 11 (61.11%). The sensitivity of the system in identifying these 11 species was 66.66%–100%; specificity 98.37%–100%; positive predictive value 70%–100%, negative predictive value 96.05%–100%, and diagnostic accuracy 96.99%–100%. Diagnostic accuracy of ITS1 and ITS2 sequences individually was 98.49% and 100% using NCBI Genbank database.
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Melioidosis: Reinfection going incognito as relapse p. 593
Isra Halim, Tushar Shaw, Chaitanya Tellapragada, KE Vandana, Chiranjay Mukhopadhyay
DOI:10.4103/ijmm.IJMM_17_140  PMID:29405156
Melioidosis has recently gained importance as an emerging disease in India. Recurrent melioidosis has been reported from different parts of the world and can be due to relapse or reinfection. Distinction between relapse and reinfection is important for epidemiology, investigation and management. Here, we present the data regarding rate of recurrence and utility of multilocus sequence typing (MLST) in differentiating relapse form reinfection amongst melioidosis patients from a tertiary care hospital in South India. Amongst the 31 patients who survived and underwent follow-up, 4 (13%) presented with recurrence. Three cases (75%) were identified as reinfection and one (25%) as relapse based on MLST. Re-exposure to environmental Burkholderia pseudomallei amongst patients with melioidosis in endemic areas is likely. In such a scenario, more often than not, recurrence of melioidosis can be attributed to reinfection.
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An improvised medium for axenic cultivation of Acanthamoeba spp. p. 597
Kirti Megha, Amit Gupta, Rakesh Sehgal, Sumeeta Khurana
DOI:10.4103/ijmm.IJMM_17_151  PMID:29405157
Acanthamoebae can be easily grown in bacterised cultures, but their growth in axenic media is tedious and many times unsuccessful. We thus experimented with some additives in the conventional axenic medium for growth of various isolates of Acanthamoeba. Addition of Torula yeast RNA was found to significantly enhance the growth of Acanthamoebae in the axenic culture medium.
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Molecular identification and detection of virulent factors in Helicobacter pylori from gastric biopsy samples of patients attended at Assam Medical College and Hospital, Dibrugarh, Assam, India p. 600
Anisha Sarma, Lahari Saikia, Ratna Kanta Bhuyan, Ezaz Hussain
DOI:10.4103/ijmm.IJMM_17_232  PMID:29405158
The present study aimed to detect the major virulence determinants of Helicobacter pylori, the gastric bacteria by polymerase chain reaction from genomic DNA of 314 gastric biopsies from dyspeptic patients in 2015-2016 through upper gastrointestinal endoscopy. In 153 cases out of 314, the high prevalence of oipA gene followed by cagA-vacA s1 m1 combined genotypes was found in mostly gastritis/duodenitis patients followed by the peptic ulcer and normal patients. Therefore, the clinical significance of the virulence markers of H. pylori associated with the severe forms of gastroduodenal diseases is still a matter of controversy since the endoscopically normal patients were found to harbour the virulent genes.
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Infections in live donor liver transplant recipients: A study of timeline, aetiology and antimicrobial resistance of bacterial and fungal infections from the developing world p. 604
Vikas Khillan, Pratibha Kale, Viniyendra Pamecha, Neha Rathor, Shiv Kumar Sarin
DOI:10.4103/ijmm.IJMM_17_295  PMID:29405159
Infections are the leading cause of morbidity and mortality in liver transplant (LT) recipients. We studied timeline, spectrum of infection, system involved, and antimicrobial resistance in 64 patients undergoing live donor LT with 6-month follow-up. Of 64 patients, 38 (59.5%) patients had 103 infectious episodes, 10 patients had single infectious episode and 28 patients had two or more infectious episodes. 96 (93.2%) were bacterial and Candida infections were in 7 (6.8%). Early phase had 30 (29.1%) episodes; intermediate phase 25 (24.2%) and late phase 48 (46.6%). Mortality was 11/64 (17.1%). Knowledge of timeline, aetiological agent and antimicrobial resistance is useful to guide empirical therapy and infection prevention.
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Demographic profile of healthy children with nasopharyngeal colonisation of Streptococcus pneumoniae: A research paper p. 607
Radhika Raman, Janani Sankar, Sulochana Putlibai, Vaidehi Raghavan
DOI:10.4103/ijmm.IJMM_15_347  PMID:29405160
Background: Pneumonia is a preventable cause of mortality in children. Streptococcus pneumoniae colonising the nasopharynx of healthy children can cause invasive diseases and the serotype distribution of colonisation isolates should be an indicator of invasive disease, antibiotic resistance profiles, and potential vaccine coverage. Identifying factors influencing nasopharyngeal colonisation, the serotypes and antimicrobial resistance pattern can improve rational preventive strategies. Objectives: Identify risk factors associated with nasopharyngeal colonisation of S.pneumoniae in healthy children between 6 months to 5 years of age. Determine the serotype and antibiotic sensitivity of S. pneumoniae isolated from nasopharynx of healthy children. Methods: This prospective observational included 500 healthy children, 6months to 5 years of age. Demographic features of the study population, the serotypes and antimicrobial sensitivity pattern of S.Pneumoniae isolated from cultures of nasopharyngeal swabs were subjected to statistical analysis. Results: S. pneumoniae was isolated in 9% of 450 children. Increased nasopharyngeal carriage rate was associated with overcrowding 48.8% and poor ventilation 35.5%. 6B (n=16) was the most common serotype isolated. 69% were serogroups known to cause invasive disease All S. pneumoniae isolates were susceptible to vancomycin and linezolid. Antimicrobial susceptibility of PCV 7 serotypes were greater than non PCV 7 serotypes for almost all antimicrobials tested. Penicillin resistance was 11 % and MDR 51%
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Increased recognition of Chryseobacterium species as an emerging cause of nosocomial urinary tract infection following introduction of matrix-assisted laser desorption/ionisation-time of flight for bacterial identification p. 610
Harsimran Kaur, Balvinder Mohan, Vinaykumar Hallur, Atul Raj, Madhunarayana Basude, Ravimohan S Mavuduru, Neelam Taneja
DOI:10.4103/ijmm.IJMM_15_413  PMID:29405161
Chryseobacterium species are rarely reported as aetiological agents of nosocomial urinary tract infection. Here, we evaluated the clinical significance of 19 isolates of Chryseobacterium species (15 Chryseobacterium indologenes and 4 Chryseobacterium gleum; identified by matrix-assisted laser desorption/ionisation-time of flight [MALDI-TOF]) obtained from urine or percutaneous nephrostomy drainage of 16 patients with urological complaints. The strains possessed drug resistance to multiple antibiotics. 14 isolates showed the presence of carbapenemases. Both MALDI-TOF and repetitive sequence-based-polymerase chain reaction grouped them into three clusters (Kappa 1.000). They may colonise the urinary tract acting as a reservoir for dissemination of drug resistance within hospital environment.
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Diagnosis and treatment of diffusible Penicillium marneffei in human immunodeficiency virus-negative patients: A challenge for the physician p. 617
Xiao-Hua Chi, Yao-Ming Xue, Quan-Shi Wang, Gui-Ping Li, Hong-Sheng Zhou, Yong-Shuai Qi
DOI:10.4103/ijmm.IJMM_15_418  PMID:29405162
Penicillium marneffei infection in human immunodeficiency virus (HIV)-negative patients is addressed far less often. In this article, a small cohort of HIV-negative patients who disseminated P. marneffei infection was included. Sites of infection were found from blood culture, as subcutaneous nodules, or from lymph node biopsy. Fever, rash, swollen lymph nodes, anaemia and weight loss were common characteristics in most infected patients. The signs and symptoms are diverse and create challenges for accurate diagnosis. This paper will assist our understanding of this disease and contribute to an appropriate regime of therapy, thus improving the health of P. marneffei-positive patients.
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CASE REPORT Top

Cladophialophora bantiana brain abscess: A report of two cases treated with voriconazole p. 620
Ram Gopalakrishnan, Nandini Sethuraman, R Madhumitha, Kalpesh Sukhwani, Nitin Bansal, Indira Poojary, Arunaloke Chakrabarti
DOI:10.4103/ijmm.IJMM_17_72  PMID:29405163
Cerebral phaeohyphomycosis is an infection caused by a number of dematiaceous fungi, characterised by the presence of melanised hyphae in the invaded tissue. Cladophialophora bantiana is the most common species affecting the humans, which has a predilection for causing the central nervous system infections resulting in high mortality. We hereby report a success story of two cases of brain abscess caused by C. bantiana who were treated with surgical source reduction and voriconazole therapy.
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CORRESPONDENCE Top

Implementation challenges in bio-medical waste management rules, 2016 Highly accessed article p. 623
Malini R Capoor, Kumar Tapash Bhowmik
DOI:10.4103/ijmm.IJMM_17_416  PMID:29405164
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© 2004 - Indian Journal of Medical Microbiology
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