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  ~ Table of Contents - Current issue
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October-December 2016
Volume 34 | Issue 4
Page Nos. 413-567

Online since Thursday, December 08, 2016

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EDITORIAL  

Strengthening surveillance key to addressing antimicrobial resistance Highly accessed article p. 413
K Walia, VC Ohri
DOI:10.4103/0255-0857.195378  
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REVIEW ARTICLES Top

Exploring the hidden potential of fosfomycin for the fight against severe Gram-negative infections p. 416
PV Saiprasad, K Krishnaprasad
DOI:10.4103/0255-0857.195379  
Gram-negative resistance is a serious global crisis putting the world on the cusp of 'pre-antibiotic era'. This serious crisis has been catalysed by the rapid increase in carbapenem-resistant Enterobacteriaceae (CRE). Spurge in colistin usage to combat CRE infections leads to the reports of (colistin and carbapenem resistant enterobacteriaceae) CCRE (resistance to colistin in isolates of CRE) infections further jeopardising our last defence. The antibacterial apocalypse imposed by global resistance crisis requires urgent alternative therapeutic options. Interest in the use of fosfomycin renewed recently for serious systemic infections caused by multidrug-resistant Enterobacteriaceae. This review aimed at analysing the recent evidence on intravenous fosfomycin to explore its hidden potential, especially when fosfomycin disodium is going to be available in India. Although a number of promising evidence are coming up for fosfomycin, there are still areas where more work is required to establish intravenous fosfomycin as the last resort antibacterial for severe Gram-negative infections.
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Understanding the viridians group streptococci: Are we there yet? p. 421
T Menon
DOI:10.4103/0255-0857.195371  
The viridans group streptococci are a heterogeneous group of organisms which exist as commensals in the oropharynx and the gut. They cause serious infections when they gain entry into sterile sites particularly in patients with predisposing conditions. Classification and species differentiation of these organisms has always been a challenge because of phenotypic differences between strains of the same species. Facklam's typing scheme based on six metabolic properties has been the most widely used and many commercial identification systems are based on it. Due to the ambiguity in species differentiation based on phenotypic tests, nucleic acid-based methods have been developed to improve the identification of these organisms. Results using genotypic methods such as 16S rRNA and sodA gene sequencing have been promising. Multilocus sequence analysis of seven house-keeping genes map, pfl, pyk, ppaC, rpoB, soda and tuf amplified by polymerase chain reaction was found to be an accurate alternative to other methods and could be useful in the characterisation of larger collections of isolates.
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ORIGINAL ARTICLES Top

Trend of human brucellosis over a decade at tertiary care centre in North Karnataka p. 427
DP Patil, GS Ajantha, C Shubhada, PA Jain, A Kalabhavi, PC Shetty, M Hosamani, S Appannanavar, RD Kulkarni
DOI:10.4103/0255-0857.195372  
Background: Brucellosis is an important zoonotic disease. India having a major agrarian population is expected to have a higher prevalence. However, due to lack of laboratory facility or awareness among clinicians, the disease is largely underreported. The aim of this study was to know the prevalence and trend of human brucellosis over a decade, in patients attending a teaching hospital in North Karnataka, and to understand their geographical distribution. Materials and Methods: The study was conducted from January 2006 to December 2015 at a tertiary care teaching hospital in North Karnataka. A total of 3610 serum samples were evaluated from suspected cases of brucellosis. All serum samples were initially screened by Rose Bengal plate test, and positive samples were further analysed by Serum agglutination test (SAT) using standard Brucella abortus antigen from Indian Veterinary Research Institute, Izatnagar, Uttar Pradesh, India. A titre above or equal to 1:80 IU/ml was considered as positive. Demographic data such as age, sex and native place of these patients were also analysed. Results: We observed that human brucellosis is present in North Karnataka. The overall seropositivity of brucellosis in suspected cases was 5.1%. The positive titres ranged from 1:80 to 163,840 IU/ml. The majority of the patients were from Gadag, Koppal and Haveri districts of North Karnataka. Conclusion: Our study confirms the presence of human brucellosis in the northern part of Karnataka. Further studies to understand the prevalence of animal brucellosis in these areas will help in implementing prevention measures.
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Molecular characterisation of antimicrobial resistance in Pseudomonas aeruginosa and Acinetobacter baumannii during 2014 and 2015 collected across India p. 433
AK Pragasam, S Vijayakumar, YD Bakthavatchalam, A Kapil, BK Das, P Ray, V Gautam, S Sistla, SC Parija, K Walia, VC Ohri, S Anandan, B Veeraraghavan
DOI:10.4103/0255-0857.195376  
Background: Surveillance of antimicrobial resistance (AMR) is of great importance. Pseudomonas aeruginosa and Acinetobacter baumannii are important pathogens and emergence of resistance in these have increased the morbidity and mortality rates. This surveillance study was initiated by the Government of India - Indian Council of Medical Research. The aim of this study is to determine the antimicrobial susceptibility profile and to characterise the enzyme mediated antimicrobial resistance such as extended spectrum beta-lactamases (ESBLs) and carbapenemases among multidrug-resistant (MDR) P. aeruginosa and A. baumannii. Materials and Methods: A multi-centric study was conducted from January 2014 to December 2015 with a total number of 240 MDR P. aeruginosa and 312 MDR A. baumannii isolated from blood, cerebrospinal fluid, respiratory, pus, urine and intra-abdominal infections. Kirby–Bauer disc diffusion was done to determine the antimicrobial susceptibility profile. Further, MDR isolates were characterised by multiplex polymerase chain reaction to determine the resistance genes for ESBLs and carbapenemases. Results: Among the ESBLs, blaVEB (23%), blaTEM (5%) and blaSHV (0.4%) in P. aeruginosa and blaPER (54%), blaTEM (16%) and blaSHV (1%) in A. baumannii were the most prevalent. Likewise, blaVIM (37%), blaNDM (14%), blaGES (8%) and blaIMP (2%) in P. aeruginosa and blaOXA-23like (98%), blaOXA-58like (2%), blaNDM (22%) and blaVIM (3%) in A. baumannii were found to be the most prevalent carbapenemases. blaOXA-51like gene, intrinsic to A. baumannii was present in all the isolates tested. Conclusion: The data shown highlight the wide difference in the molecular mechanisms of AMR profile between P. aeruginosa and A. baumannii. In P. aeruginosa, plasmid-mediated mechanisms are much lesser than the chromosomal mediated mechanisms. In A. baumannii, class D oxacillinases are more common than other mechanisms. Continuous surveillance to monitor the trends in AMR among MDR pathogens is important for implementation of infection control and to guide appropriate empirical antimicrobial therapy.
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Drug susceptibility of rapid and slow growing non-tuberculous mycobacteria isolated from symptomatics for pulmonary tuberculosis, Central India p. 442
B Goswami, P Narang, PS Mishra, R Narang, U Narang, DK Mendiratta
DOI:10.4103/0255-0857.195375  
Background: Non-tuberculous mycobacteria (NTM) are emerging as important pathogens. Their treatment also differs from that of Mycobacterium tuberculosis. In India, any datum on them is scarce as species identification and drug susceptibility are not performed in most laboratories. Susceptibility also differs from one geographic area to another, and in our country, there are no data even to guide the clinicians to start treatment empirically.Methodology: The present study endeavours to generate drug susceptibility data on NTM isolated from sputum samples collected and stored from 6445 symptomatics for pulmonary tuberculosis during a prevalence survey and from specimens received from the hospital. Isolates were not necessarily associated with the disease. Species were identified and antibiotic susceptibility was performed using micro-broth dilution technique as per the standard Clinical and Laboratory Standards Institute guidelines. Results: A total of 65 NTM with 11 species were identified, of which 27 belonged to Mycobacterium fortuitum complex, 14 Mycobacterium gordonae, 9 Mycobacterium avium, 7 Mycobacterium flavescens, 4 Mycobacterium scrofulaceum and one each of others. Sensitivity to amikacin for M. fortuitum was 95.22% (20 out of 21), followed by ciprofloxacin (76.19%) and clarithromycin (71.42%). All the 9 M. avium isolates, 11 of M. gordonae (78.57%), 5 of M. flavescens and 2 of M. scrofulaceum were sensitive to clarithromycin. All NTM were resistant to first-line antitubercular drugs except 8, which were sensitive to streptomycin. Conclusions: Drug sensitivity of NTM varies from species to species. While amikacin was the best for rapidly growing mycobacteria, clarithromycin was the most active drug against M. avium and other slow growers.
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Distribution of virulence determinants among antimicrobial-resistant and antimicrobial-susceptible Escherichia coli implicated in urinary tract infections p. 448
SAM Stephenson, PD Brown
DOI:10.4103/0255-0857.195354  
Introduction: Uropathogenic Escherichia coli (UPEC) rely on the correlation of virulence expression with antimicrobial resistance to persist and cause severe urinary tract infections (UTIs). Objectives: We assessed the virulence pattern and prevalence among UPEC strains susceptible and resistant to multiple antimicrobial classes. Methods: A total of 174 non-duplicate UPEC strains from patients with clinically significant UTIs were analysed for susceptibility to aminoglycoside, antifolate, cephalosporin, nitrofuran and quinolone antibiotics for the production of extended-spectrum β-lactamases and for the presence of six virulence determinants encoding adhesins (afimbrial, Type 1 fimbriae, P and S-fimbriae) and toxins (cytotoxic necrotising factor and haemolysin). Results: Relatively high resistance rates to nalidixic acid, ciprofloxacin, cephalothin and trimethoprim-sulfamethoxazole (82%, 78%, 62% and 59%, respectively) were observed. Fourteen distinct patterns were identified for the virulence determinants such as afaBC, cnfI, fimH, hylA, papEF and sfaDE. The toxin gene, cnfI (75.3%), was the second most prevalent marker to the adhesin, fimH (97.1%). The significant association of sfaDE/hylA (P < 0.01) among antimicrobial resistant and susceptible strains was also observed notwithstanding an overall greater occurrence of virulence factors among the latter. Conclusions: This study provides a snapshot of UPEC complexity in Jamaica and highlights the significant clonal heterogeneity among strains. Such outcomes emphasise the need for evidence-based strategies in the effective management and control of UTIs.
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Banana peel culture as an indigenous medium for easy identification of late-sporulation human fungal pathogens p. 457
AJ Kindo, A Tupaki-Sreepurna, M Yuvaraj
DOI:10.4103/0255-0857.195369  
Aim: Fungi are increasing in incidence as human pathogens and newer and rarer species are continuously being encountered. Identifying these species from growth on regular culture media may be challenging due to the absence of typical features. An indigenous and cheap medium, similar to the natural substrate of these fungi, was standardised in our laboratory as an aid to species identification in a conventional laboratory setting. Materials and Methods: Ripe banana peel pieces, sterilised in an autoclave at 121°C temperature and 15 lbs pressure for 15 min promoted good growth of hyphae and pycnidia or acervuli in coelomycetes, flabelliform and medusoid fruiting bodies of basidiomycetes and fruit bodies such as cleistothecium in ascomycetes. The growth from the primary isolation medium was taken and inoculated onto the pieces of double-autoclaved ripe banana peel pieces in a sterile glass Petri dish with some moisture (sprinkles of sterile distilled water). A few sterile coverslips were placed randomly inside the Petri dish for the growing fungus to stick on to it. The plates were kept at room temperature and left undisturbed for 15–20 days. At a time, one coverslip was taken out and placed on a slide with lactophenol cotton blue and focused under the microscope to look for fruit bodies. Results: Lasiodiplodia theobromae, Macrophomina phaseolina, Nigrospora sphaerica, Chaetomium murorum, Nattrassia mangiferae and Schizophyllum commune were identified by characteristic features from growth on banana peel culture. Conclusions: Banana peel culture is a cheap and effective medium resembling the natural substrate of fungi and is useful for promoting characteristic reproductive structures that aid identification.
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Genomic profile of antibiotic resistant, classical ctxB positive Vibrio cholerae O1 biotype El Tor isolated in 2003 and 2005 from Puri, India: A retrospective study p. 462
T Bhotra, MM Das, BB Pal, DV Singh
DOI:10.4103/0255-0857.195356  
Objectives: To examine eight strains of Vibrio cholerae O1 isolated in 2003 and 2005 from Puri, India, for antibiotic susceptibility, presence of virulence and regulatory genes, cholera toxin (CT) production, CTX arrangement and genomic profiles. Materials and Methods: Bacterial strains were tested for antibiotic susceptibility using disc diffusion assay. Polymerase chain reaction determined the presence of antibiotic resistance, virulence and regulatory genes. To determine the type of cholera toxin subunit B (ctxB), nucleotide sequencing was performed. Southern hybridisation determined the number and arrangement of CTXΦ. Ribotyping and pulsed-field gel electrophoresis (PFGE) were used to determine the genomic profile of isolates. Results: All the eight strains, except one strain, showed resistant to nalidixic acid, sulphamethoxazole, streptomycin and trimethoprim and possessed the sullI, strB, dfrA1 and int SXT genes. All the strains carried the toxin-co-regulated pilus pathogenicity island, the CTX genetic element, the repeat in toxin and produced CT. Restriction fragment length polymorphism (RFLP) analysis showed that V. cholerae O1 possess a single copy of the CTX element flanked by tandemly arranged RS element. Nucleotide sequencing of the ctxB gene showed the presence of classical ctxB. RFLP analysis of conserved rRNA gene showed two ribotype patterns. PFGE analysis also showed at least three PFGE patterns, irrespective of year of isolations, indicating the genomic relatedness among them. Conclusion: Overall, these data suggest that classical ctxB-positive V. cholerae O1 El Tor strains that appeared in 2003 continue to cause infection in 2005 in Puri, India, and belong to identical ribotype(s) and/or pulsotype(s). There is need to continuous monitor the emergence of variant of El Tor because it will improve our understanding of the evolution of new clones of variant of V. cholerae.
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Molecular analysis of Rv0679c and Rv0180c genes of Mycobacterium tuberculosis from clinical isolates of pulmonary tuberculosis p. 471
L Rupa, A Srikantam, SS Lakshmana Rao, U Devi, KSR Sivasai
DOI:10.4103/0255-0857.195357  
Context: Two novel proteins/genes Rv0679c and Rv0180c of Mycobacterium tuberculosis (MTB) H37Rv were classified as a hypothetical membrane and transmembrane proteins which might have a role in the invasion. Molecular analysis of these genes in human clinical isolates of pulmonary tuberculosis (PTB) patients was not well characterised. Aims: To assess the molecular diversity of Rv0679c and Rv0180c genes of MTB from clinical isolates of PTB patients. Settings and Design: DNA from 97 clinical isolates was extracted and subjected to amplification using selective primers by polymerase chain reaction (PCR). The PCR product obtained was sequenced commercially. Patients and Methods: Clinical isolates obtained from tuberculosis patients were investigated for polymorphisms in the Rv0679c and Rv0180c genes by PCR and DNA sequencing. Genomic DNA isolated by cetyltrimethylammonium bromide method was used for amplification of genes. Results: Rv0679c gene was highly conserved in 61 out of 65 clinical isolates assessed for sequence homology with wild-type H37Rv gene and was identical using ClustalW. Fifty-five out of 78 (70.5%) clinical isolates assessed for Rv0180c were positive for single nucleotide polymorphism (SNP) at 258th position where the nucleotide G was replaced with T (G to T). In clinical isolates of untreated cases, the frequency was 54.5% for SNP at 258th position which is low compared to cases undergoing treatment where the frequency was 73.1%. Conclusions: Molecular analysis of Rv0180c in clinical isolates of PTB assessed in this study was the first report, where an SNP at 258th position G to T was identified within the gene. Rv0679c gene was highly conserved (94%), within Indian clinical isolates as compared to reports from other nations.
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Molecular characterisation of Panton–Valentine leucocidin-producing methicillin-resistant Staphylococcus aureus clones isolated from the main hospitals in Taif, KSA p. 476
EM Eed, MM Ghonaim, YM Hussein, SS Al-Shehri, AS Khalifa
DOI:10.4103/0255-0857.195364  
Introduction: Panton–Valentine leucocidin (PVL) is a bicomponent pore-forming cytolytic toxin encoded by the lukF-PV and lukS-PV genes. Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) may carry the pvl genes which may be related to increased disease severity. This study aimed to characterise the PVL-producing MRSA recovered from different Taif Hospitals, Saudi Arabia. Methods: The study included 45 hospital-acquired-MRSA (HA-MRSA) and 26 CA-MRSA strains which were identified from 445 S. aureus strains isolated from different clinical samples. MRSA strains were identified by standard oxacillin salt agar screening procedure and by the detection of the mecA gene by the polymerase chain reaction (PCR). Detection of the S. aureus-specific femA, mecA and pvl genes was performed by multiplex PCR. PCR-restriction fragment length polymorphism (PCR-RFLP) analysis was done for coagulase (coa) gene. Results: The staphylococcal cassette chromosome mec types of the 45 HA-MRSA strains were Type I (n = 24), Type II (n = 7) and Type III (n = 14) whereas the 26 CA-MRSA strains were Type IV (n = 14), Type V (n = 11) and one isolate was non-typeable. All the HA-MRSA and six CA-MRSA strains were PVL-negative PCR-RFLP analysis of coa gene showed that PVL-positive MRSA (n = 20) isolates showed six different patterns, and five patterns were shared by PVL-positive methicillin-susceptible S. aureus (MSSA). The eighth pattern was the most frequent in both MRSA and MSSA. Conclusion: PVL is more frequent among CA-MRSA than MSSA. All the HA-MRSA and 25% of CA-MRSA strains were negative for PVL. The pvl gene was related to the severity of infection but not related to coa gene RFLP pattern.
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Flooding adds pathogenic Escherichia coli strains to the water sources in southern Khyber Pakhtunkhwa, Pakistan p. 483
MS Shah, M Eppinger, S Ahmed, AA Shah, A Hameed, F Hasan
DOI:10.4103/0255-0857.195350  
Purpose: Seasonal rains in Pakistan result in heavy floods across the country, whereby faecal contaminants will be added to the water bodies and cause numerous food-borne outbreaks. The present study was aimed to determine the prevalence of diarrheagenic Escherichia coli (DEC) strains in the water sources. Materials and Methods: Two hundred water samples collected during (2011–2012) were processed for the isolation of E. coli (EC) strains. EC strains were further analysed for antibiotic susceptibility patterns, and pathogroups-specific virulence factors stx1, stx2, stx2c, eae, tir, hlyA, bfpA, estA and eltA were detected using multiplex polymerase chain reaction. Results: Thirty-three percent of the water samples were contaminated with EC pathotypes. Fifty percent (33/66) of the DEC pathotypes were identified as enterotoxigenic EC (ETEC). Seventy-two percent (13/18) of the enteropathogenic EC (EPEC) strains were identified as typical EPEC and 28% (5/18) as atypical EPEC. Eleven percent (7/66) of the Shiga toxin EC (STEC) isolates carried a combination of stx1 and stx2 genes. Summer was found as a peak season with 47% (31/66) for EC pathogroups' activities. Eighty-nine percent of the strains showed resistance against tetracycline. Conclusion: ETEC and EPEC are the primary causes of water contamination in southern regions of Khyber Pakhtunkhwa province, Pakistan. Firm adherence to the prescribed drugs can decrease trends in antibiotic resistance.
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Generation and characterisation of monoclonal antibodies specific to avian influenza H7N9 haemagglutinin protein p. 489
A Malik, VVA Mallajosyula, NN Mishra, AP Arukha, R Varadarajan, SK Gupta
DOI:10.4103/0255-0857.195366  
Introduction: Emerging virulent strains of influenza virus pose a serious public health threat with potential pandemic consequences. A novel avian influenza virus, H7N9, breached the species barrier from infected domestic poultry to humans in 2013 in China. Since then, it has caused numerous infections in humans with a close contact to poultry. Materials and Methods: In this study, we describe the preliminary characterisation of five murine monoclonal antibodies (MAbs) developed against recombinant haemagglutinin (rHA) protein of avian H7N9 A/Anhui/1/2013 virus by their Western blot and enzyme-linked immunosorbent assay (ELISA) reactivity and binding affinity. Results: Of the five MAbs, four were highly specific to H7N9 HA and did not show any cross-reactivity in ELISA with rHA protein from pandemic as well as seasonal H1N1, H2N2, H3N2, H5N1 and influenza virus B (B/Brisbane/60/2008). However, one of the MAbs, MA-24, in addition to HA protein of H7N9 also reacted strongly with HA protein of H3N2 and weakly with HA of pandemic and seasonal H1N1 and H2N2. All the five MAbs also reacted with H7N9 rHA in Western blot. The MAbs bound H7N9 rHA with an equilibrium dissociation constant (KD) ranging between 0.14 and 25.20 nM, indicating their high affinity to HA. Conclusions: These antibodies may be useful in developing diagnostic tools for the detection of influenza H7N9 virus infections.
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Does the presence of Klebsiella pneumoniae carbapenemase and New Delhi metallo-β-lactamase-1 genes in pathogens lead to fatal outcome? p. 495
P Mathur, S Sagar, S Kumar, V Sharma, D Gupta, S Lalwani, R Rani, A Muruganantham
DOI:10.4103/0255-0857.195367  
Introduction: Infections due to multidrug-resistant (MDR) pathogens are a medical challenge. There is considerable apprehension among clinicians regarding pathogens reported as carrying New Delhi metallo-β-lactamase-1 (NDM) and Klebsiella pneumoniae carbapenemase (KPC) genes from their patients. In the face of extremely high rates of antimicrobial resistance, it is essential to gauge the clinical significance of isolation of pathogens carrying these genes from clinical samples. This study compares the outcome of patients infected with pathogens carrying NDM/KPC genes versus those without these genes. Methods: The study was conducted over a 1-year period at a Level-1 trauma centre. Hospital-acquired infections were diagnosed on the basis of CDC's criteria. The correlation of isolation of a multi-resistant pathogen carrying KPC or NDM genes with the clinical outcome was ascertained. Results: A total of 276 consecutive patients admitted to the Intensive Care Units/wards of the JPNA Trauma Centre were included in this study. Of the 371 isolates recovered from these patients, 116 were from patients who had a fatal outcome. The difference in prevalence of blaNDMand blaKPCwas not significant in any genera of Gram-negative pathogens isolated from patients who survived versus those who had a fatal outcome. Conclusion: Isolation of MDR pathogens carrying NDM/KPC genes from clinical samples is not always a harbinger of a fatal outcome. Efforts should be made to prevent cross-transmission of these pathogens.
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Coagulase-negative staphylococci causing blood stream infection at an Indian tertiary care hospital: Prevalence, antimicrobial resistance and molecular characterisation p. 500
S Singh, B Dhawan, A Kapil, SK Kabra, A Suri, V Sreenivas, BK Das
DOI:10.4103/0255-0857.195374  
Introduction: Recent years have seen a rise of coagulase-negative staphylococci (CoNS) from common contaminants to agents of nosocomial blood stream infections (BSI's). Molecular typing and establishing a correlation with antibiotic resistance is essential particularly in countries like India where genotyping studies for drug-resistant CoNS are sparse. Methods: A prospective study was done over 18 months, wherein 42,693 blood samples were received, and 59 patients with BSI due to CoNS were evaluated. The isolates recovered were identified by a biochemical test panel and matrix-assisted laser desorption ionization – time of flight mass spectrometry followed by antimicrobial susceptibility testing by Kirby–Baur disc diffusion method and E-test strips. Staphylococcal chromosomal cassette mec (SCCmec) element was characterised by multiplex polymerase chain reaction for all methicillin-resistant (MR) isolates. Results: The majority of CoNS isolated were constituted by Staphylococcus haemolyticus (47.5%) followed by Staphylococcus epidermidis (33.9%), Staphylococcus hominis (11.86%), Staphylococcus cohnii (5.08%) and Staphylococcus warneri (1.69%). Among all isolates 57.6% were MR with statistically significant higher resistance versus methicillin sensitive-CoNS. This difference was significant for erythromycin (76% vs. 44%, P = 0.011), rifampicin (50% vs. 12%,P= 0.002) and amikacin (26.5% vs. 4%, P = 0.023), ciprofloxacin (64.7% vs. 20%, P = 0.001) and cotrimoxazole (55.9% vs. 20%, P = 0.006). SCCmec type I was predominant (61.8%, P = 0.028) and exhibited multidrug resistance (76.2%). Coexistence of SCCmec type I and III was seen in 8.82% MR isolates. Conclusion: CoNS exhibit high antimicrobial resistance thereby limiting treatment options. The presence of new variants of SCCmec type in hospital-acquired CoNS may predict the antibiotic resistance pattern. This is the first evaluation of the molecular epidemiology of CoNS causing BSI from India and can serve as a guide in the formulation of hospital infection control and treatment guidelines.
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BRIEF COMMUNICATIONS Top

Synergism between fluconazole and methylene blue-photodynamic therapy against fluconazole-resistant Candida strains p. 506
JP Lyon, CR Carvalho, RR Rezende, CJ Lima, FV Santos, LM Moreira
DOI:10.4103/0255-0857.195351  
Photodynamic therapy (PDT) has been proved to be effective against fungi and it may be employed as a coadjutant to conventional antifungal agents, leading to a more effective microbial control minimising side effects. This work evaluates the combined effect of PDT and fluconazole against resistant Candida albicans, Candida glabrata and Candida krusei. The yeasts were submitted to methylene blue-PDT (MB-PDT) in sub-inhibitory concentrations. In the present work, MB-PDT combined with fluconazole was more efficient in the inhibition of the C. albicans and C. glabrata than each treatment alone, being possible to infer that the treatments are synergic.
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In vitro sensitivity pattern of chloroquine and artemisinin in Plasmodium falciparum p. 509
Supriya Sharma, Kamlesh Kaitholia, Neelima Mishra, Bina Srivastava, CR Pillai, Neena Valecha, Anupkumar R Anvikar
DOI:10.4103/0255-0857.195365  
Artemisinin (ART) and its derivatives form the mainstay of antimalarial therapy. Emergence of resistance to them poses a potential threat to future malaria control and elimination on a global level. It is important to know the mechanism of action of drug and development of drug resistance. We put forwards probable correlation between the mode of action of chloroquine (CQ) and ART. Modified trophozoite maturation inhibition assay, WHO Mark III assay and molecular marker study for CQ resistance at K76T codon in Plasmodium falciparum CQ-resistant transporter gene were carried out on cultured P. falciparum. On comparing trophozoite and schizont growth for both CQ-sensitive (MRC-2) and CQ-resistant (RKL-9) culture isolates, it was observed that the clearance of trophozoites and schizonts was similar with both drugs. The experiment supports that CQ interferes with heme detoxification pathway in food vacuoles of parasite, and this may be correlated as one of the plausible mechanisms of ART.
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Can minocycline be a carbapenem sparing antibiotic? Current evidence p. 513
B Veeraraghavan, C Shankar, S Vijayakumar
DOI:10.4103/0255-0857.195380  
With the increasing incidence of multidrug-resistant organisms, there is a need for newer antibiotics. However, due to the lack of new antimicrobial agents, it is necessary to re-evaluate the older agents like minocycline which is a second-line antimicrobial agent. In this study, minocycline susceptibility testing was performed for 693 Escherichia coli, 316 Klebsiella spp. and 89 Acinetobacter spp. Among extended spectrum beta-lactamase producing E. coli and Klebsiella spp. percentage susceptibility to minocycline were 76 and 85, respectively. Among the carbapenem resistant E. coli, Klebsiella spp. and Acinetobacter spp. minocycline susceptibility were 52%, 55% and 42%, respectively. Based on the susceptibility profile, minocycline can be considered for treatment of infections by multidrug-resistant organisms.
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Pulmonary Mycobacterium kansasii disease in immunocompetent host: Treatment outcomes with short-course chemotherapy p. 516
C Padmapriyadarsini, D Nair, NS Gomathi, B Velayudham
DOI:10.4103/0255-0857.195370  
Mycobacterium kansasii, most virulent of all atypical mycobacteria, causes pulmonary disease identical to the disease caused by Mycobacterium tuberculosis. Early identification of the species and prompt initiation of treatment for M. kansasii is necessary to prevent morbidity and mortality due to this disease. This case series highlights the similarity in the clinical presentation of both M. tuberculosis and M. kansasii and response to direct observation of short-course chemotherapy with rifampicin, in the management of pulmonary M. kansasii disease. Larger studies are required to evaluate the long-term effect of short-course chemotherapy, especially use of moxifloxacin, in the management of pulmonary M. kansasii disease.
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Six-year susceptibility trends and effect of revised Clinical Laboratory Standards Institute breakpoints on ciprofloxacin susceptibility reporting in typhoidal Salmonellae in a tertiary care paediatric hospital in Northern India p. 520
R Saksena, C Nayyar, V Manchanda
DOI:10.4103/0255-0857.195362  
The antimicrobial trends over 6 years were studied, and the effect of revised Clinical Laboratory Standards Institute (CLSI) breakpoints (2012) for ciprofloxacin susceptibility reporting in typhoidal Salmonellae was determined. A total of 874 (95.4%) isolates were nalidixic acid-resistant (NAR). Using the CLSI 2011 guidelines (M100-S21), 585 (66.9%) isolates were ciprofloxacin susceptible. The susceptibility reduced to 11 (1.25%) isolates when interpreted using 2012 guidelines (M100-S22). Among the forty nalidixic acid susceptible (NAS) Salmonellae, susceptibility to ciprofloxacin decreased from 37 isolates (M100-S21) to 12 isolates (M100-S22). The 25 cases which appeared resistant with newer guidelines had a minimum inhibitory concentration (MIC) range between 0.125 and 0.5 μg/ml. MIC50 for the third generation cephalosporins varied between 0.125 and 0.5 μg/ml over 6 years whereas MIC90 varied with a broader range of 0.19–1 μg/ml. The gap between NAR and ciprofloxacin-resistant strains identified using 2011 guidelines has been reduced; however, it remains to be seen whether additional NAS, ciprofloxacin-resistant isolates are truly resistant to ciprofloxacin by other mechanisms of resistance.
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Improved detection of Shigella using Escherichia coli medium enrichment: Polymerase chain reaction from stool samples p. 526
PK Gupta, SB Appannanavar, B Mohan, N Taneja
DOI:10.4103/0255-0857.195355  
Laboratory diagnosis of shigellosis using conventional culture technique is limited by lower sensitivity and higher turnaround time. Here, we have evaluated the role of polymerase chain reaction from stool samples after enrichment in Escherichia coli medium for detection of Shigellae. The technique not only increased the sensitivity but also decreased the turnaround time.
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High fungal spore burden with predominance of Aspergillus in hospital air of a tertiary care hospital in Chandigarh p. 529
SM Rudramurthy, G Singh, V Hallur, S Verma, A Chakrabarti
DOI:10.4103/0255-0857.195359  
The prevalence of fungal spores in the hospital air is essential to understand the hospital-acquired fungal infections. Air conditioners (ACs) used in hospitals may either reduce spores in air or be colonised by fungi and aid in its dissemination. The present study was conducted to assess the fungal spore burden in AC and non-AC areas. We found a high fungal spore count in air irrespective of whether the area was AC or non-AC. The most predominant species isolated were Aspergillus flavus and Aspergillus fumigatus. Such high concentrations of pathogenic fungi in air may predispose individuals to develop disease.
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A high yield DNA extraction method for medically important Candida species: A comparison of manual versus QIAcube-based automated system p. 533
P Das, P Pandey, A Harishankar, M Chandy, S Bhattacharya
DOI:10.4103/0255-0857.195360  
The prognosis of infected individuals with candidemia depends on rapid and precise diagnosis which enables optimising treatment. Three fungal DNA extraction protocols have been compared in this study for medically important Candida species. The quality and quantity of the DNA extracted by physical, chemical and automated protocols was compared using NanoDrop ND-2000 spectrophotometer. It was found that the yield and purity (260/230) ratio of extracted DNA was significantly high in the physical treatment-based protocol as compared to chemical based or automated protocol. Extracted DNA-based real time-polymerase chain reaction showed an analytical sensitivity of 103 cfu/mL. The result of this study suggests physical treatment is the most successful extraction technique compared to other two protocols.
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Internalisation of hepatitis C virus core protein by human conjunctival fibroblasts p. 536
AR Rajalakshmy, J Malathi, HN Madhavan, S Bhaskar, GK Iyer
DOI:10.4103/0255-0857.195358  
Recent studies indicate that hepatitis C virus (HCV) proteins can mediate innate immune response and inflammation in conjunctival fibroblasts which contributes to the pathology of dry eye condition associated with chronic HCV infection. The present study investigates the phagocytic potential of human conjunctival fibroblasts (HCFj) for HCV core protein. HCFj cells were incubated with HCV core antigen for different periods of time, and fluorescent micrographs were taken to observe protein internalisation. HCFj cells were capable of internalising HCV core antigen within 1 h; this gives an insight into another molecular mechanism which may contribute towards HCV-associated conjunctival inflammation.
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Application of real-time quantitative polymerase chain reaction assay to detect Legionella pneumophila in patients of community-acquired pneumonia in a tertiary care hospital p. 539
A Angrup, R Chaudhry, S Sharma, A Valavane, K Passi, K Padmaja, S Javed, AB Dey, B Dhawan, SK Kabra
DOI:10.4103/0255-0857.195353  
Legionella pneumophila is one of the important pathogen responsible for community –acquired pneumonia attributing for 1-5% of cases. Since early and accurate therapy reduces mortality, rapid and reliable diagnostic methods are needed. A total of 134 samples of blood, urine and respiratory tract fluids were collected. Blood was tested for IgG, IgM and IgA antibodies using commercially available kits. A total of 8 (6%) samples were found to be positive for L. pneumophila by quantitative reverse transcription polymerase chain reaction (qRT-PCR), compared to conventional PCR where 6 (4.4%) samples were positive. Serology was positive in a total of 32 (23%) cases though only 3 (2.2%) of the PCR-positive cases were positive by serology as well. These results suggest that real-time PCR can detect Legionella infection early in the course of the disease before serological response develops.
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CASE REPORTS Top

Aeromonas hydrophila meningitis and fulminant sepsis in preterm newborn: A case report and review of literature p. 544
A Kali, R Kalaivani, PMV Charles, KS Seetha
DOI:10.4103/0255-0857.195383  
Neonatal meningitis is a lethal infection occurring in the 1st month of life. The risk of developing permanent neurological sequels is high among the neonates who survive. Bacterial pathogens are commonly associated with this condition. Aeromonas is a Gram-negative bacteria of aquatic habitat. Although isolation of Aeromonas species from neonates with blood stream infection is infrequently reported, neonatal meningitis caused by Aeromonas is exceedingly rare. We present a case of fulminant sepsis and meningitis caused by Aeromonas hydrophila in a preterm newborn male. The bacteria was isolated in culture from blood and cerebrospinal fluid. In spite of targeted antibiotics and supportive therapy, the baby failed to respond and died on the 12th day of life.
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Infections related to Granulicatella adiacens: Report of two cases and review of literature p. 547
S Macin, AÇ İnkaya, Ö Tuncer, S Ünal, Y Akyön
DOI:10.4103/0255-0857.195377  
Infections due to nutritionally variant streptococci are diagnosed rarely due to difficulties encountered during identification and isolation. Mortality rate in these infections is high therefore appropriate supplemented media and reliable detection systems should be implemented to isolate these fastidious organisms. Here, we describe two cases of Granulicatella adiacens infections. All microbiologic identifications were made with MALDI-TOF Vitek MS (BioMerieux, France), and the results confirmed by 16S ribotyping.
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Successful treatment of primary cerebral mucormycosis: Role of microbiologist p. 550
KK Benachinmardi, P Rajalakshmi, HB Veenakumari, RD Bharath, V Vikas, A Mahadevan, S Nagarathna
DOI:10.4103/0255-0857.195373  
Fungal brain abscess is rare with a rapidly progressive disease with fulminant course and invariably fatal outcome, unless diagnosed early and treated rapidly. We report a 56-year-old woman diagnosed to have fungal abscess who recovered completely following amphotericin B treatment. She presented with weakness of the right hand, deviation of mouth to left and aphasia for 2 days. Computed tomography of the brain revealed a left frontal capsuloganglionic hypodense lesion. Stereotactic biopsy was performed, and microbiological confirmation of non-septate fungal hyphae from pus from aspirate within 2 h helped initiate timely and appropriate treatment leading to cure. Histopathology and culture later confirmed mucormycosis.
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Severe unresolving Plasmodium falciparum malaria following artemisinin combination therapy: Emergence of drug resistance in Saudi Arabia Highly accessed article p. 553
IA Al-Zaydani, A Al-Hakami, A Kumar, SA Abdalla, M Otaif, RMA Thiqa, H Ahmed, K Alnahili
DOI:10.4103/0255-0857.195352  
A 5-year-old female child presented with fever of 1-week duration after visiting a malaria endemic zone without antimalarial prophylaxis. The patient presented with respiratory distress, decreased level of consciousness and high-grade fever. An elevated parasitaemia reaching 800,000/μl was observed. Antimalarial therapy was initiated with artesunate being administered intravenous (IV) along with IV clindamycin. Contrary to the expectations, there was no resolution of fever. Following a week of unresolved fever, the drug therapy was revised and altered to IV quinine dihydrochloride and IV clindamycin. Emergence of non-responsiveness to artesunate in Saudi Arabia is an alarming sign and requires revision of management protocols.
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CORRESPONDENCE Top

In vitro susceptibility of carbapenem-resistant Enterobacteriaceae to colistin: A hope at present p. 558
S Mohanty, R Gaind
DOI:10.4103/0255-0857.195381  
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Gonococcal opa gene as a diagnostic target for nucleic acid amplification tests in Indian Population p. 560
R Verma, N Mahajan, S Sood
DOI:10.4103/0255-0857.195361  
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Stamp's modified Ziehl–Neelsen staining for Brucella: Beware of the first impressions p. 561
K Tilak, VK Eshwara, C Tellapragada, C Mukhopadhyay
DOI:10.4103/0255-0857.195363  
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Medical Council of India circular on research publications: Flaring up the fire Highly accessed article p. 563
D Juyal, V Thawani, S Thaledi, B Dhawan
DOI:10.4103/0255-0857.195368  
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Polymyxin Nordmann/Poirel test for rapid detection of polymyxin resistance in Enterobacteriaceae: Indian experience p. 564
Yamuna Devi Bakthavatchalam, Balaji Veeraraghavan, Purva Mathur, Swathi Purighalla, Vijay Samuel Richard
DOI:10.4103/0255-0857.195382  
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ERRATUM Top

Erratum: Endemic Indian clones of Klebsiella pneumoniae harbouring New Delhi metallo beta lactamase 1 on a hybrid plasmid replicon type: A case of changing New Delhi metallo beta lactamase plasmid landscapes in India? p. 567

DOI:10.4103/0255-0857.195384  
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2004 - Indian Journal of Medical Microbiology
Published by Wolters Kluwer - Medknow

Online since April 2001, new site since 1st August '04