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  ~ Table of Contents - Current issue
January-March 2018
Volume 36 | Issue 1
Page Nos. 1-148

Online since Wednesday, May 2, 2018

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Sexually transmitted infections: Need for extragenital screening Highly accessed article p. 1
Jyoti Rawre, Sonu Agrawal, Benu Dhawan
DOI:10.4103/ijmm.IJMM_18_46  PMID:29735819
Extragenital infections can occur concurrently with simultaneous urogenital infections. Extragenital sites are believed to serve as hidden reservoirs and play a critical role in their transmission. The etiological relationship of the most widespread Sexually transmitted diseases (STD) pathogen to reproductive tract has long been established, but the distribution to extragenital sites appears to be infrequent and its correlation with the sexual practice still requires to be investigated. Optimal-screening strategies for extragenital infections are largely unknown. However, there is a lack of data on clinical outcomes and optimal treatment regimens for rectal and pharyngeal extragenital infections. Further studies are needed in settings other than reproductive health and STD clinics, especially in primary care clinics and resource-limited settings.
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Fusarium: The versatile pathogen Highly accessed article p. 8
Ananya Tupaki-Sreepurna, Anupma Jyoti Kindo
DOI:10.4103/ijmm.IJMM_16_24  PMID:29735820
Fusarium is an emerging human opportunistic pathogen of growing importance, especially among immunosuppressed haematology patients due to an increased incidence of disseminated infections over the past two decades. This trend is expected only to continue due to the advances in medical and surgical technologies that will prolong the lives of the severely ill, making these patients susceptible to rare opportunistic infections. Production of mycotoxins, enzymes such as proteases, angio-invasive property and an intrinsically resistant nature, makes this genus very difficult to treat. Fusarium is frequently isolated from the cornea and less commonly from nail, skin, blood, tissue, Continuous Ambulatory Peritoneal Dialysis (CAPD) fluid, urine and pleural fluid. Conventional microscopy establishes the genus, but accurate speciation requires multilocus sequence typing with housekeeping genes such as internal transcribed spacer, translation elongation factor-1α and RPB1 and 2 (largest and second largest subunits of RNA polymerase), for which expansive internet databases exist. Identifying pathogenic species is of epidemiological significance, and the treatment includes immune reconstitution by granulocyte–colony-stimulating factor, granulocyte macrophage–colony-stimulating factor and a combination of the most active species – specific antifungals, typically liposomal amphotericin-B and voriconazole. However, patient outcome is difficult to predict even with in vitro susceptibility with these drugs. Therefore, prevention methods and antifungal prophylaxis have to be taken seriously for these vulnerable patients by vigilant healthcare workers. The current available literature on PubMed and Google Scholar using search terms 'Fusarium', 'opportunistic invasive fungi' and 'invasive fusariosis' was summarised for this review.
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Changing panorama for surveillance of device-associated healthcare infections: Challenges faced in implementation of current guidelines p. 18
Renu Gupta, Sangeeta Sharma, Parwez , Sonal Saxena
DOI:10.4103/ijmm.IJMM_18_50  PMID:29735821
Healthcare-associated infections (HAI) are preventable in up to 30% of patients with evidence-based infection prevention and control (IPC) activities. IPC activities require effective surveillance to generate data for the HAI rates, defining priority areas, identifying processes amenable for improvement and institute interventions to improve patient's safety. However, uniform, accurate and standardised surveillance methodology using objective definitions can only generate meaningful data for effective execution of IPC activities. The highly exhaustive, complex and ever-evolving infection surveillance methodology pose a challenge for effective data capture, analysis and interpretation by ground level personnel. The present review addresses the gaps in knowledge and day-to-day challenges in surveillance faced by infection control team for effective implementation of IPC activities.
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Molecular characterisation of Staphylococcus aureus using spa typing as a diagnostic tool in Haryana, India p. 26
Gurjeet Singh, Shobha Broor, Priti Agarwal
DOI:10.4103/ijmm.IJMM_17_330  PMID:29735822
Background: Staphylococcus aureus is one of the top six most common etiologic agents of nosocomial, community and livestock acquired bacterial infections. These infections although initially were described as a major problem in hospitals have now also become a serious threat in community not only in India but also worldwide. Its prevalence varies depending on the health-care setting, country or a particular region. Thus to better understand the epidemiology of methicillin-resistant S. aureus (MRSA) in a particular geographical location, it is important to study the variations in the population using molecular tools. Methods: This prospective study was carried out in the Department of Microbiology of Shree Guru Gobind Singh Tricentenary (SGT) Medical College. Staphylococcal protein A (spa) typing was done on 250 S. aureus isolates obtained from various clinical specimens including pus, wound swabs, urine, catheters, blood and cerebrosspinal fluid from both indoor and outdoor patients of SGT Hospital, Budhera, Gurgaon. Results: The selected region of the spa gene of all 250 isolates which includes 87 MRSA and 163 methicillin-susceptible S. aureus were amplified. The spa gene was detected in 248 out of 250 isolates (99.2%), whereas in 2 isolates (0.8%), it remained undetected and referred as non-typable isolates. The 248 S. aureus isolates were typed into 39 spa types, which clustered into six different spa clonal clusters and eight singletons. Conclusion: High diversity observed within S. aureus isolates indicated that many different strains circulate in the study region or in the hospital. The results would contribute in the understanding of epidemiology related to S. aureus spread and prevention.
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Antimicrobial susceptibility profiles of gram-negative bacteria causing infections collected across India during 2014–2016: Study for monitoring antimicrobial resistance trend report p. 32
Balaji Veeraraghavan, Mark Ranjan Jesudason, John Antony Jude Prakasah, Shalini Anandan, Rani Diana Sahni, Agila Kumari Pragasam, Yamuna Devi Bakthavatchalam, Rajesh Joseph Selvakumar, TN Dhole, Camilla Rodrigues, Indranil Roy, Sangeetha Joshi, Bhaskar Narayan Chaudhuri, DS Chitnis
DOI:10.4103/ijmm.IJMM_17_415  PMID:29735823
Background: The emergence of antibiotic resistance among bacterial pathogens in the hospital and community has increased the concern to the health-care providers due to the limited treatment options. Surveillance of antimicrobial resistance (AMR) in frequently isolated bacterial pathogens causing severe infections is of great importance. The data generated will be useful for the clinicians to decide empiric therapy on the local epidemiological resistance profile of the antimicrobial agents. This study aims to monitor the distribution of bacterial pathogen and their susceptibility pattern to the commonly used antimicrobial agents. Materials and Methods: This study includes Gram-negative bacilli collected from intra-abdominal, urinary tract and respiratory tract infections during 2014–2016. Isolates were collected from seven hospitals across India. All the study isolates were characterised up to species level, and minimum inhibitory concentration was determined for a wide range of antimicrobials included in the study panel. The test results were interpreted as per standard Clinical Laboratory Standards Institute guidelines. Results: A total of 2731 isolates of gram-negative bacteria were tested during study period. The most frequently isolated pathogens were 44% of Escherichia coli (n = 1205) followed by 25% of Klebsiella pneumoniae (n = 676) and 11% of Pseudomonas aeruginosa (n = 308). Among the antimicrobials tested, carbapenems were the most active, followed by amikacin and piperacillin/tazobactam. The rate of extended-spectrum beta-lactamase (ESBL)-positive isolates were ranged from 66%–77% in E. coli to 61%–72% in K. pneumoniae, respectively. Overall, colistin retains its activity in > 90% of the isolates tested and appear promising. Conclusion: Increasing rates of ESBL producers have been noted, which is alarming. Further, carbapenem resistance was also gradually increasing, which needs much attention. Overall, this study data show that carbapenems, amikacin and colistin continue to be the best agents available to treat drug-resistant infections. Thus continuous monitoring of susceptibility profile of the clinically important Gram-negative pathogens is of great importance to guide effective antimicrobial therapy.
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Molecular characterisation and phylogenetic analysis of dengue outbreak in Pasighat, Arunachal Pradesh, Northeast India p. 37
Biswajyoti Borkakoty, Mandakini Das, Kishore Sarma, Aniruddha Jakharia, Palash Kumar Das, Chandrakanta Bhattacharya, Basumoti Apum, Dipankar Biswas
DOI:10.4103/ijmm.IJMM_17_30  PMID:29735824
Background and Objectives: Dengue is one of the most prevalent arboviral diseases in the world with 390 million dengue infections per year. In this study, we report the molecular characterisation of dengue outbreak in Pasighat, Arunachal Pradesh, Northeast India during 2015. Subjects and Methods: A total of 613 dengue-suspected cases were screened for dengue virus by dengue NS1 Ag and anti-dengue IgM antibody depending on the duration of sample collection and onset of symptom. Further, molecular characterisation was done by amplifying the C-PrM region by real-time polymerase chain reaction followed by phylogenetic analysis. Results: Molecular characterisation revealed that the dengue outbreak was predominantly due to dengue virus serotype-1 (DENV-1) (90.9%) while DENV-2 was detected in 7.5% of samples. Co-infection of DENV-1 and DENV-2 was detected in one case. Phylogenetic analysis of the DENV-1 strains with the prototype revealed that the DENV-1 strains were grouped within genotype III. Similarly, DENV-2 strains were clustered within genotype IV. The study revealed a change in the predominant serotype in recent years with DENV-3 in 2012 to DENV-1, 2, 3 and 4 in 2014 to DENV-1 in 2015 in the study region. A unique L24M mutation was observed in the DENV-1 strains of Arunachal Pradesh which was absent in all the circulating strains in India except one strain from the state of Kerala in South India. Marked variation within the DENV-2 strains was observed at A102V and I163V in one strain similar to earlier circulating isolates in India. Conclusions: The present study reveals a shift in the serotype dominance in the study region. As serotype shifts and secondary infection with a heterologous DENV serotype are frequently associated with disease severity, there is an urgent need for sustained monitoring of the circulating serotypes and enhanced surveillance operations, especially in the monsoon and post-monsoon periods to prevent large-scale, severe dengue outbreaks in this region.
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High-level aminoglycoside resistance in Acinetobacter baumannii recovered from Intensive Care Unit patients in Northeastern India p. 43
Supriya Upadhyay, Annie Bakorlin Khyriem, Prithwis Bhattacharya, Amitabha Bhattacharjee, Santa Ram Joshi
DOI:10.4103/ijmm.IJMM_17_225  PMID:29735825
Background: Acinetobacter baumannii has emerged as an important nosocomial pathogen, its ability to acquire resistance to carbapenems and aminoglycosides, has complicated their treatment regimen. The present study investigates the prevalence and diversity of aminoglycoside-modifying enzymes and 16S methyltransferases in A. baumannii isolates recovered from patients admitted in Intensive Care Unit (ICU) of a tertiary referral hospital in Northeastern India. Materials and Methods: We investigated the high-level aminoglycoside-resistance (HLAR) (gentamicin and amikacin minimum inhibitory concentration ≥ 512 μg/ml) among 164 multidrug-resistant A. baumannii obtained from ICU. Genes encoding aminoglycoside-modifying enzymes, 16S methyltransferase and coexisting beta-lactamases were amplified. Horizontal transferability, plasmid stability and elimination assays were performed. Clonality and sequence types were evaluated by repetitive extragenic palindromic-polymerase chain reaction and multilocus sequence typing (MLST) respectively. Results: A total of 130 (79.2%) isolates were found to exhibit HLAR, with acquired aminoglycoside-resistance genes in 109 (83.8%) isolates along with coexisting extended-spectrum beta-lactamases and metallo-beta-lactamases. Genes aph (3') I, aph (3') VIa and armA were predominant and horizontally transferable. Plasmids were eliminated with single sodium dodecyl sulphate treatment. Seventeen haplotypes were found responsible for the infection. MLST revealed circulation of ST583 and ST188 in ICU. Conclusions: This study reveals the presence of aminoglycoside-resistance genes in combination with blaCTXM and blaNDM, which are highly stable and not frequently reported from this geographical region. Further, the study could predict limited treatment option and need for formulating infection control strategy.
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Cytomegalovirus reactivation and disease amongst patients with allogeneic haematopoietic stem cell transplantation in Eastern India: Epidemiology, outcome and healthcare cost p. 49
Meet Kumar, Mita Roychowdhury, Jeevan Kumar, Anusha Harishankar, Subir Sinha, Saurabh Jayant Bhave, Anupam Chakrapani, Vivek Radhakrishnan, Reena Nair, Sanjay Bhattacharya, Mammen Chandy
DOI:10.4103/ijmm.IJMM_17_269  PMID:29735826
Purpose: Data from developing countries about incidence, prognosis and healthcare cost of cytomegalovirus (CMV) reactivation amongst patients with allogeneic hematopoietic stem cell transplantation (AHSCT) remain scarce. The purpose of the study was to describe the epidemiology, outcome and cost implications of CMV reactivation and CMV disease amongst patients with AHSCT in cancer hospital in Eastern India. Materials and Methods: The study design was a retrospective audit of clinical records. Results: Ninety-nine per cent of patients and 94% of the donors were found to be CMV seropositive. CMV reactivation rate was 43.8% amongst patients with AHSCT (n = 130 patients). CMV reactivation occurred 118 days after AHSCT (median; range: 28–943 days). Patients with any grade of graft-versus-host disease (GVHD) had higher CMV reactivation rate than patients without GVHD. Patients with CMV reactivation had more frequent GVHD than patients without CMV reactivation. Use of steroids was associated with CMV reactivation. We found no differences in overall survival of patients with or without CMV reactivation. The cost of in-house CMV-polymerase chain reaction at our centre was USD $57 (Rs. 3650), cost for intravenous ganciclovir was USD $26 (Rs. 1665) per infusion and oral valganciclovir USD $8 (Rs. 512)/900 mg tablet. The median duration of anti-CMV therapy was 14 days (interquartile range: 14–28 days) and the average cost per patient per month directed towards CMV management ranged between USD $800 and USD $1,300 (Rs. 51,238–Rs. 83,264). Three patients (2.3%) in this series had CMV disease, all of whom died. Conclusion: In an increasingly globalised world, where medical tourism is common, data from developing countries regarding cost and outcome of CMV infections in AHSCT patients are of relevance.
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Molecular characterisation for clonality and transmission dynamics of an outbreak of Klebsiella pneumoniae amongst neonates in a tertiary care centre in South India p. 54
Chaitra Shankar, Manish Kumar, Ashtawarthani Baskaran, Miracle Magdelene Paul, Nithya Ponmudi, Sridhar Santhanam, Joy Sarojini Michael, Balaji Veeraraghavan
DOI:10.4103/ijmm.IJMM_17_426  PMID:29735827
Purpose: Sepsis is a significant cause of morbidity and mortality amongst neonates. Klebsiella pneumoniae is a common cause of nosocomial outbreaks causing bacteraemia and having potential of acquiring plasmids enhancing antimicrobial resistance. In the present study, we investigate K. pneumoniae outbreak causing bacteraemia amongst neonates over a span of 2 months. Isolates were characterised for antimicrobial resistance, virulence, molecular typing for clonality and plasmid typing for transmission dynamics, and patient outcome was investigated. Methods: Thirteen isolates of K. pneumoniae were obtained during October–November 2016. Antimicrobial susceptibility testing was performed, and multiplex polymerase chain reaction (PCR) for β-lactamases and PCR for ompK35 and ompK36 were performed. To study hypervirulence, string test and PCR for rmpA and rmpA2 were performed. Multilocus sequence typing and Inc plasmid typing were carried out to study transmission dynamics. Results: Amongst 13 isolates, all isolates harboured blaSHVand blaTEM; 12 isolates carried blaCTX-M-1. ompK35 was present in all, but ompK36 was absent in 12 isolates. Ten isolates belonged to ST48, 6 amongst which contained IncFII (K) plasmid. One isolate each belonged to ST29, ST111 and ST2647 (novel clone). None of the isolates was hypervirulent. Conclusion: Extended-spectrum β-lactamase K. pneumoniae is commonly seen in Indian hospitals and main mechanisms being production of SHV, TEM and CTX-M enzymes as seen in the present study. Outer membrane porins contribute significantly to antimicrobial resistance. Emergence of new clones such as ST2647 implies continuous evolution of the organism and also potential for rapid genetic recombination leading to multidrug resistance. Outbreaks amongst neonates lead to fatal outcome, and stringent hospital infection control is necessary.
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Histoplasmosis in non-endemic North-Western part of India p. 61
Atul K Patel, Ketan K Patel, Harsh Toshniwal, Swati Gohel, Arunaloke Chakrabarti
DOI:10.4103/ijmm.IJMM_18_12  PMID:29735828
Purpose of Study: The western and North-Western parts of India are usually considered non-endemic for histoplasmosis. On the contrary, we observe histoplasmosis cases with relatively higher frequency from this region although the awareness and laboratory facility to diagnose the disease are not adequate. Hence, we planned the present retrospective study to compile the cases and to analyse different clinical parameters. Materials and Methods: Medical records of the patients diagnosed with histoplasmosis during January 2012–August 2017 at two infectious disease clinics of Ahmedabad were included in this study. Results: During the study, 12 cases of histoplasmosis were diagnosed. The median age of the patients was 53 years; all males except one. The diagnosis of histoplasmosis was confirmed on histopathology for 11 cases, and one patient was diagnosed as probable histoplasmosis. The patients were either from Gujarat or Rajasthan without any travel history to endemic zone of histoplasmosis, except one patient. The majority (67%) of the patients had no apparent immunosuppression. Adrenal enlargement, oral ulcers and lymphadenopathy were common presentations in four patients each. We lost two patients in follow-up, and rest 10 patients responded to either to amphotericin B deoxycholate and/or itraconazole therapy. Conclusion: This study highlights that Gujarat and Rajasthan are an endemic region for histoplasmosis, and a systematic study is required to understand epidemiology of the disease. Histoplasmosis should be a differential diagnosis in a patient presenting with adrenal enlargement, lymphadenopathy, oral ulcers and fever of unknown origin in this region.
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Nonspecific amplification of human DNA by Streptococcus pneumoniae LytA primer p. 65
Helen Hencida Thangamony, Ravindran Kumar, Chinnappan Palaniappan Thangavelu, Mani Mariappa, Berlin Grace Viswanathan Mariammal, Kootallur Narayanan Brahmadathan
DOI:10.4103/ijmm.IJMM_17_342  PMID:29735829
Background: Determination of various analytical parameters is essential for the validation of primers used for in-house nucleic acid amplification tests. While standardising a high-resolution melt analysis (HRMA) for detection of Streptococcus pneumoniae in acute pyogenic meningitis, we encountered non-specific amplification of certain base pair sequences of human DNA by Centers for Disease Control & Prevention, USA recommended S. pneumoniae LytA primer. Materials and Methods: HRMA was standardised using DNA extracted from an ATCC strain of S. pneumoniae using SP LytA F373 primer and Type-it HRMTM polymerase chain reaction kit in Rotor-Gene Q Thermal Cycler according to the manufacturer's instructions. Specificity of the primers was determined in dry and wet laboratory experiments against diverse related and unrelated microbial pathogens by HRMA and on DNA extracted from unspiked clinical samples negative for SP DNA. Sensitivity was determined by calculating lower limit of detection threshold in experiments with spiked samples. The amplicon from spiked experiments was sequenced and analysed through Gene Bank. Results: Our dry/wet laboratory experiments showed two separate curves and different Tm values indicating certain non-specific amplification by the primer. Basic Local Alignment Search Tool (BLAST) analysis of the amplicon obtained in the spiked experiment showed sequences of human chromosome 20 associated with Homo sapiens protein tyrosine phosphatase, receptor type T gene. The problem was resolved by stopping the reaction at 30th Ct cycle and observing the Tm values. Conclusion: Since HRMA is done without a specific probe, one should be aware of non-specific amplifications while using primers for HRMA of human clinical samples.
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Changing trends of culture-positive typhoid fever and antimicrobial susceptibility in a tertiary care North Indian Hospital over the last decade p. 70
Priyanka Sharma, Sushila Dahiya, Neelam Manral, Bhavana Kumari, Sambuddha Kumar, Sangeeta Pandey, Seema Sood, Bimal Kumar Das, Arti Kapil
DOI:10.4103/ijmm.IJMM_17_412  PMID:29735830
Purpose: The present study was undertaken to analyse the trend in prevalence of culture-positive typhoid fever during the last decade and to determine antimicrobial susceptibility profile of Salmonella Typhi and Salmonella Paratyphi A isolated from patients of enteric fever presenting to our hospital. Methods: All the culture-positive enteric fever cases during 2005–2016 presenting to our Hospital were included in the study. Antimicrobial susceptibility was done against chloramphenicol, amoxicillin, co-trimoxazole, ciprofloxacin, ofloxacin, levofloxacin, pefloxacin, ceftriaxone and azithromycin as per corresponding CLSI guidelines for each year. We also analysed the proportion of culture positivity during 1993–2016 in light of the antibiotic consumption data from published literature. Results: A total of 1066 strains-S. Typhi (772) and S. Paratyphi A (294) were isolated from the blood cultures during the study. A maximum number of cases were found in July–September. Antimicrobial susceptibility for chloramphenicol, amoxicillin and co-trimoxazole was found to be 87.9%, 75.5%, 87.3% for S. Typhi and 94.2%, 90.1% and 94.2% for S. Paratyphi A, respectively. Ciprofloxacin, ofloxacin and levofloxacin susceptibility were 71.3%, 70.8% and 70.9% for S. Typhi and 58.1%, 57.4% and 57.1% for S. Paratyphi A, respectively. Azithromycin susceptibility was 98.9% in S. Typhi. Although susceptibility to ceftriaxone and cefixime was 100% in our isolates, there is a continuous increase in ceftriaxone minimum inhibitory concentration (MIC)50and MIC90values over the time. The proportion of blood culture-positive cases during 1993–2016 ranged from a minimum of 0.0006 in 2014 to a maximum of 0.0087 in 1999. Conclusion: We found that the most common etiological agent of enteric fever is S. Typhi causing the majority of cases from July to October in our region. MIC to ceftriaxone in typhoidal salmonellae is creeping towards resistance and more data are needed to understand the azithromycin susceptibility.
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Comparison of different methods of RNA preparation from peripheral blood for nucleic acid amplification assay p. 77
Dong Eun Lee, Hanna Lee, Seon Duk Lee, Hyung Soo Han, Jae Young Choe, Sora Yun, Hong-Jun Park, Jungbae Park, Jong Kun Kim
DOI:10.4103/ijmm.IJMM_18_104  PMID:29735831
Background: Nucleic acid amplification assays (NAAs), such as polymerase chain reaction or loop-mediated isothermal amplification (LAMP), are used for disease diagnosis. Current nucleic acid isolation kits require several hours for completion of protocol including the complicated handling steps. Objective: In this study, a simple and cost-effective nucleic acid preparation method was developed, and its performance was compared with those of commercial kits. Materials and Methods: RNA was prepared using our method and three commercial RNA isolation kits. The RNA quantity and quality were evaluated using the NanoDrop spectrophotometer and Agilent 2100 bioanalyser. Reverse transcription LAMP (RT-LAMP) reactions were performed to determine the usability of the RNA preparation methods. Results: The concentrations of RNA extracted from blood samples by four different methods were sufficient for use in NAAs. The RNA integrity number was >7.0 when RNA was isolated using other RNA isolation kits but lower when prepared using our method. The RT-LAMP reaction was successfully performed when RNA was prepared using any of the methods. Conclusions: These results demonstrate that despite the lower purity and integrity of RNA, our RNA preparation protocol is simple and rapid and shows reasonable performance in RT-LAMP.
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Identification of multiple strains of Porphyromonas gingivalis using heteroduplex polymerase chain reaction in varying severity of chronic periodontitis p. 81
Mihir Raghavendra Kulkarni, Kishore G Bhat, Betsy Sara Thomas, G Subraya Bhat, Raghavendra Dhirendra Kulkarni
DOI:10.4103/ijmm.IJMM_17_434  PMID:29735832
Aim: Research has demonstrated that there are multiple strains of Porphyromonas gingivalis with varying potency to cause periodontal disease. The current study aims at using heteroduplex polymerase chain reaction (PCR) to detect the strain diversity of P. gingivalis in periodontitis lesions of varying severity in a sample of the Indian population. Materials and Methods: Subgingival plaque samples were collected from 60 individuals with varying severity of chronic periodontitis and 30 individuals with a clinically healthy periodontium. The samples were subjected to PCR analysis to identify P. gingivalis, followed by heteroduplex analysis to identify the strain diversity in a given sample. Bacterial culture was carried out as a comparative standard. Results: Of the 56 samples that were positive for P. gingivalis by PCR, 54 samples yielded eight different heteroduplex patterns. Analysis of these patterns indicated that two strains of P. gingivalis were present in 41 individuals (45.6%) and three strains were present in 13 individuals (14.4%). Detection of P. gingivalis by PCR was significantly more in the periodontitis group as compared to the healthy group. Conclusions: Species-specific PCR and heteroduplex analysis provide a simple and accurate method to analyse the strain diversity of P. gingivalis. P. gingivalis was detected in both healthy periodontal sites as well as sites with periodontitis. The presence of two or three P. gingivalis strains was seen in 60% of the samples.
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Echinocandins: Their role in the management of Candida biofilms p. 87
Subramanian Swaminathan, Shweta Kamat, Nalini Adele Pinto
DOI:10.4103/ijmm.IJMM_17_400  PMID:29735833
The importance of antifungal agents and their clinical implications has received little attention in comparison to antibiotics, particularly in the health-care setting. However, apart from bacterial infections rising in hospitals, the incidences of fungal infections are growing with the development of resistance to conventional antifungal agents. Newer antifungal agents such as echinocandins (ECs) have been extensively studied over the past decade and are recognised as a superior treatment compared with prior antifungals as a first line of therapy in tertiary institutions. Caspofungin (CAS), micafungin (MICA) and anidulafungin (ANID) are the three most widely used EC antifungal agents. The treatment of biofilm-associated fungal infections affecting patients in tertiary health-care facilities has been identified as a challenge, particularly in Indian Intensive Care Unit (ICU) settings. With the rising number of critically ill patients requiring invasive devices such as central venous catheters for treatment, especially in ICUs, these devices serve as a potential source of nosocomial infections. Candida spp. colonisation is a major precursor of these infections and further complicates and prolongs treatment procedures, adding to increasing costs both for hospitals and the patient. Analysing studies involving the use of these agents can help in making critical decisions for antifungal therapy in the event of a fungal infection in the ICU. In addition, the development of resistance to antifungal agents is a crucial factor for assessing the appropriate antifungals that can be used for treatment. This review provides an overview of ANID in biofilms, along with CAS and MICA, in terms of clinical efficacy, resistance development and potency, primarily against Candida spp.
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Utility of GeneXpert in the diagnosis, reliance on urine microscopy and clinical characteristics of genitourinary tuberculosis at a tertiary care hospital p. 93
Ajaz Nabi Koul, Basharat A Kassana, Aadil Rafeeq Rather
DOI:10.4103/ijmm.IJMM_18_114  PMID:29735834
Background: One-third of the world's population is infected with tuberculosis (TB) with new infection occurring every second. In humans, TB is primarily caused by Mycobacterium tuberculosis(MTB). Genitourinary TB (GUTB) is still a major health problem in many developing countries including India and had been declared by the World Health Organisation as 'public health emergency' in 1993. Materials and Methods: This is a prospective study conducted at a tertiary care hospital involving 46 patients who presented with clinical feature suggestive of GUTB – urine specimens of these 46 patients were analysed for acid–fast bacilli (AFB), AFB culture, GeneXpert, and other relevant investigations were done to reach the diagnosis. Majority of patients were female (65.25%). This is especially relevant to rural and low socioeconomic areas in developing countries where women's health is worse than men's (in terms of nutrition); women's risk of disease may be increased. Most of our patients were above 30 years of age and exhibited nonspecific symptoms such as dysuria, haematuria and frequency. All patients were put on antitubercular drugs and followed as per the guidelines. Conclusion: The sample size in the present study is small to arrive at a brisk inference, but it may safely be postulated that yield of detection for GeneXpert may be improved using multiple sampling, especially the early morning ones. It is also pertinent to mention here that GeneXpert may not be able to pick up mutant genomes.
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Methicillin-resistant Staphylococcus aureus intracranial abscess: An analytical series and review on molecular, surgical and medical aspects p. 97
Veena Kumari Haradara Bahubali, Priya Vijayan, Vasundhra Bhandari, Nagarathna Siddaiah, Dwarakanath Srinivas
DOI:10.4103/ijmm.IJMM_17_41  PMID:29735835
Purpose: Intracranial abscess caused by methicillin-resistant Staphylococcus aureus (MRSA) is rare and unexplored. The aim of the present study is to examine the prevalence, clinical and molecular characteristics, treatment options and outcome of MRSA intracranial abscess over a period of 6 years. Patientsand Methods: A total of 21 patients were included in this retrospective study. The demographic and clinical details of all the patients were collected. Molecular typing including staphylococcal cassette chromosome mec typing, spa typing and polymerase chain reaction of Panton–Valentine leucocidin toxin (PVL) gene for the latter 6 isolates was performed. Results: The paediatric population was the most affected group (33.3%). The primary route of infection was post-operative/trauma in 7 (33.3%) cases. All the patients were treated surgically either by aspiration or excision. Fifteen (71%) patients received anti-MRSA treatment with vancomycin or linezolid, where linezolid-treated patients showed better prognosis. Of the 11 patients who were on follow-up, unfavourable outcome was observed in 3 (27.3%) cases and 8 (72.7%) cases improved. The molecular typing of six isolates revealed four community-associated (CA) MRSA, one each of livestock-associated (LA) and healthcare-associated MRSA with PVL gene noted in all. Conclusion: We propose that timely diagnosis, surgical intervention and appropriate anti-MRSA treatment would contribute to better outcome. The occurrence of CA-MRSA and LA-MRSA infection in the central nervous system signifies the threat from the community and livestock reservoir, thus drawing attention towards surveillance and tracking to understand the epidemiology and implement infection control measures.
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Association of glycerol kinase gene with class 3 integrons: A novel cassette array within Escherichia coli p. 104
Rajkumari Elizabeth, Debadatta Dhar Chanda, Atanu Chakravarty, Deepjyoti Paul, Shiela Chetri, Deepshikha Bhowmik, Jayalaxmi Wangkheimayum, Amitabha Bhattacharjee
DOI:10.4103/ijmm.IJMM_17_188  PMID:29735836
Background: Integrons are genetic elements which are known for their role in capturing and spreading of antibiotic resistance determinants among Gram-negative bacilli. So far, there is no study regarding Class 3 integron and their genetic organisation in India. Objective: This study investigates the occurrence of Class 3 integron and their gene cassette array among Escherichia coli. Materials and Methods: In this study, a total of 200 E. coli isolates were collected from indoor and outdoor patients from Silchar Medical College and Hospital during September 2015 to February 2016. Detection of the integrase genes and gene cassettes within the Class 3 integron was performed by polymerase chain reaction which was further analysed by sequencing. Results: Twenty-seven isolates were found to harbour Class 3 integron. Sequencing of the gene cassettes and whole Class 3 integron revealed the presence of nine different types of cassettes array, out of which the arrangement with glycerol kinase gene cassette was found to be the most prevalent. Arrangement with blaCTX-Mgene cassette was also detected in few isolates. Conclusion: This study provides epidemiological profiling of Class 3 integrons in this geographical area. The data generated in this study are helpful in infection control programme, anti-infective research and search for epidemiological markers.
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Diagnostic performance of serological tests to detect antibodies against acute scrub typhus infection in central India p. 108
Kiran Pote, Rahul Narang, Pradeep Deshmukh
DOI:10.4103/ijmm.IJMM_17_405  PMID:29735837
Background: Differentiating scrub typhus from other acute febrile illness is difficult due to non specificity of clinical symptoms and relative absence of eschar in Indian population. The diagnosis thus relies mainly on laboratory tests. Antibody based serological tests are mainstay of scrub typhus diagnosis. Here, we evaluated the diagnostic performance of IgM ELISA, IgM IFA and ICT to detect antibodies against O. tsutsugamushi in acute serum of febrile patients. Methodology: The serum samples from 600 randomly selected patients suffering from acute undifferentiated fever were tested by all the three tests mentioned above. We used latent class analysis to generate unbiased results as all the tests for scrub typhus diagnosis are imperfect and none of them can be considered as reference standard. Results: We found that IgM ELISA with cutoff titer 0.5 OD has high diagnostic accuracy (sensitivity 99.9% and specificity 99.15) than IgM IFA (sensitivity 96.8% and specificity 99.7%) for scrub typhus diagnosis. ICT used in our study had very high specificity 100% but low sensitivity (38%) which would limit its use for acute serum samples. ICT being a screening or point of care test, has to be more sensitive while some compromise with specificity is affordable. Hence, optimal cutoff for ICT should be evaluated under different settings. Conclusion: IgM ELISA being simple and affordable could be an alternative diagnostic test to IgM IFA which is subjective and costly.
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Molecular epidemiology of circulating human adenovirus types in acute conjunctivitis cases in Chandigarh, North India p. 113
Mini P Singh, Jagat Ram, Archit Kumar, Tripti Rungta, Amit Gupta, Jasmine Khurana, Radha Kanta Ratho
DOI:10.4103/ijmm.IJMM_17_258  PMID:29735838
Human adenovirus (HAdV) is a major cause of viral conjunctivitis. The various serotypes implicated in the causation are 3, 4, 8, 19 and 37. The present study aimed to know the circulating types of HAdV causing acute conjunctivitis in North India. A total of 23 conjunctival swabs were collected from patients with clinically suspected acute viral conjunctivitis during 2014–2015. The HAdV was implicated in the etiology in 65.2% of cases. The sequencing of representative samples using hexon gene suggests the presence of serotype 8 and 4. The serotype eight sequences showed 99%–100% similarity with other Indian strains. The phylogenetic analysis showed that the current circulating serotypes, responsible for conjunctivitis, belonged to epidemic keratoconjunctivitis strains.
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Survey of probiotic preparations and labeling practices in Indian market p. 116
Vikas Chandrashekhar Ghattargi, Swapnil H Kalam, Sumeet S Pandit, Shrikant P Pawar, Yogesh S Shouche
DOI:10.4103/ijmm.IJMM_18_63  PMID:29735839
A cross-sectional survey was conducted across 320 chemists shop in Pune city for their availability and labeling practices. The questionnaire revealed the data about the most sold probiotic preparations, their mode of sale, and their available forms such as tablet, capsule, and sachet. Top ten probiotic preparations were evaluated for labeling practice as per the existing regulations of the Indian Council of Medical Research-Department of Biotechnology, Indian guidelines. Majority of probiotic preparations were listing the best before date, viability, probiotic organisms, net quantity, and batch number, but none of them mentioned the health claims.
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In vitro analysis of the minimal inhibitory concentration values of different generations of anti-methicillin-resistant Staphylococcus aureus antibiotics p. 119
Aneta Guzek, Zbigniew Rybicki, Dariusz Tomaszewski
DOI:10.4103/ijmm.IJMM_17_136  PMID:29735840
Methicillin-resistant Staphylococcus aureus (MRSA) resistance to antimicrobials may result in the increased risk of treatment failure. The objective of the study was to analyse in vitro MRSA susceptibility to vancomycin, linezolid, daptomycin, tigecycline, ceftaroline, dalbavancin, clindamycin, ciprofloxacin and trimethoprim/sulfamethoxazole. All MRSA strains isolated from hospitalised patients were analysed according to the current microbiological recommendations. Finally, a total of 124 MRSA strains were analysed; all were susceptible to tested antibiotics. Dalbavancin had the lowest minimum inhibitory concentration (MIC), and vancomycin the highest MIC value. There were 28/124 strains of MRSA susceptible for clindamycin, 36/124 for ciprofloxacin and 121/124 for trimethoprim/sulfamethoxazole. Dalbavancin was the most effective antimicrobial in our study.
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Foetomaternal outcomes of hepatitis E infection outbreak in North India p. 121
Neha Gautam, Shriya Ganju, Sunite A Ganju, Sohini Walia, Anil Kanga Kumar
DOI:10.4103/ijmm.IJMM_16_422  PMID:29735841
Hepatitis E infection (HEV) in pregnant females, especially in the third trimester is associated with poor foetomaternal outcomes. However, the mechanisms of severe liver injury remain obscure. In a recent HEV outbreak in North India, six pregnant females were detected to be positive for HEV infection with concomitant hepatitis A infection in three pregnant females. None of the pregnant females were positive for hepatitis B or hepatitis C infection. The mortality was 50% in pregnant females. In an outbreak, besides, testing for hepatitis markers and understanding the pathogenesis of HEV infection in pregnancy, improving basic hygienic standards is of utmost importance.
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Role of insertion sequence element is256 as a virulence marker and its association with biofilm formation among methicillin-resistant Staphylococcus epidermidis from hospital and community settings in Chennai, South India p. 124
Saravanan Murugesan, Stalin Mani, Indhumathy Kuppusamy, Padma Krishnan
DOI:10.4103/ijmm.IJMM_17_276  PMID:29735842
The objective of this study was to detect the association of biofilm formation with IS256 among clinical and carrier isolates of methicillin-resistant Staphylococcus epidermidis (MRSE). A total of 71 MRSE isolates were included in this study. Phenotypic detection of biofilm formation was done by Congo red agar method. Detection of genes associated with biofilm formation (icaAD, aap and atlE) and insertion sequence IS256 was done by polymerase chain reaction. Of the 71 MRSE isolates,19/40 (47.5%) clinical isolates from hospital settings and 11/31 (35.5%) carrier isolates from community settings respectively were found to be positive for all the three genes tested, namely, icaAD+, aap+ and atlE+ genes. Nearly 80% of clinical isolates were found to harbour IS256, whereas only 13% of community isolates harboured IS256.
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In silico and In vitro activity of ceftolozane/tazobactam against pseudomonas aeruginosa collected across Indian hospitals p. 127
Agila Kumari Pragsam, D Thirumal Kumar, C George Priya Doss, Ramya Iyadurai, Sowmya Satyendra, Camilla Rodrigues, Sangeeta Joshi, Indranil Roy, Bhaskar Narayan Chaudhuri, DS Chitnis, Dhole Tapan, Balaji Veeraraghavan
DOI:10.4103/ijmm.IJMM_17_349  PMID:29735843
Ceftolozane/tazobactam is a novel antimicrobial agent with activity against Pseudomonas aeruginosa and other common Gram-negative pathogens. In this study, we determined the antimicrobial susceptibility for a total of 149 clinical isolates of P. aeruginosa for the most commonly used antimicrobials including the new agent ceftolozane/tazobactam (C/T). Broth microdilution was performed to determine the minimum inhibitory concentration against various antimicrobials including C/T. Among the β-lactam/β-lactamase inhibitor, overall susceptibility was 67%, 55% and 51% for C/T, Piperacillin/Tazobactam (P/T) and Cefoperazone/Sulbactam, respectively. The variations in the susceptibility rates were noted among the three different β-lactam/β-lactamase inhibitors. Interestingly, 33% susceptibility was noted for C/T against isolates that were resistant to P/T, indicating the higher activity of C/T. This finding suggests about 33% of the P/T-resistant isolates can still be treated effectively with C/T. C/T could be a better alternative for the treatment of ESBL-producing organism, and thereby usage of higher antimicrobials can be minimised.
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Observation of a new pattern of mutations in gyrA and parC within Escherichia coli exhibiting fluroquinolone resistance p. 131
Nivedita Dasgupta, Deepjyoti Paul, Debadatta Dhar Chanda, Shiela Chetri, Atanu Chakravarty, Amitabha Bhattacharjee
DOI:10.4103/ijmm.IJMM_17_181  PMID:29735844
Therapeutic options with quinolones are severely compromised in infections caused by members of Enterobacteriaceae family. Mutations in chromosomal region are one of the major reasons for bacterial resistance towards this group of antibiotic. The aim of the study is to detect the mutations in gyr A and par C responsible for quinolone resistance among clinical isolates of Escherichia coli. A total of 96 quinolone-resistant clinical isolates of E. coli were collected from a tertiary care hospital of North-east India during March 2015 to August 2015. All the quinolone-resistant E. coli strains were investigated for mutations in the topoisomerases genes gyrA and parC by amplifying and sequencing the quinolone resistance determining regions. Among the 96 E. coli isolates, 83.3% were resistant to nalidixic acid and 80.2%, 66.6%, 23.9% and 50% to ciprofloxacin, norfloxacin, levofloxacin and ofloxacin, respectively. Several alterations were detected in gyrA and parC genes. Three new patterns of amino acid substitution are reported in E. coli isolates. The findings of this study warrant a review in quinolone-based therapy in this region of the world to stop or slow down the irrational use this drug.
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A first-line antiretroviral therapy-resistant HIV patient with rhinoentomophthoromycosis p. 136
Rachita Dhurat, Rajendra J Kothavade, Anand Kumar
DOI:10.4103/ijmm.IJMM_16_330  PMID:29735845
The Conidiobolus coronatus-related rhinoentomophthoromycosis in immunocompetent and immunocompromised (HIV negative) individuals has been treated successfully with antifungal drugs. However, C. coronatus infections in first-line antiretroviral therapy (ART)-resistant (HIV infected) individuals particularly with rhinoentomophthoromycosis have not been reported previously. Here, we describe a case of itraconazole non-responding rhinoentomophthoromycosis in an HIV-infected patient with first-line antiretroviral (ART) drug resistance which was successfully managed through systematic diagnostic and therapeutic approaches in dermatologic setting. A 32-year-old HIV-1-infected man presented with painless swelling, nasal redness and respiratory difficulty. The patient was receiving first-line ART and had a history of traumatic injury before the onset of nasopharyngeal manifestations. The patient's previous history included oral candidiasis and pulmonary tuberculosis.
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Fungal keratitis caused by Laetisaria arvalis p. 140
Lakshey Dudeja, Lakshmipriya Jeganathan, N Venkatesh Prajna, Lalitha Prajna
DOI:10.4103/ijmm.IJMM_15_532  PMID:29735846
A 53-year-old female presented with keratitis (right eye) after fall of insect 10 days back. The ulcer worsened in spite of aggressive treatment with topical natamycin (5%) and amphotericin-B (0.15%) eye drops and finally perforated. Iris tissue sealed the perforation site, and ulcer healed with formation of adherent leucoma. This case represents first reported case of keratitis caused by Laetisaria arvalis and stresses on aggressive course of keratitis caused by this fungus. Importance of DNA sequencing in identification of unidentified fungal species is also highlighted.
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Acute hepatitis due to Epstein–Barr virus with cross-reacting antibodies to cytomegalovirus p. 143
Asli Karadeniz, Zuhal Yesilbag, Fatih Öner Kaya, Feride Sinem Akgün
DOI:10.4103/ijmm.IJMM_17_378  PMID:29735847
Epstein–Barr virus (EBV) is the cause of systemic infection known as infectious mononucleosis with classic presentation of fever, oropharyngitis and lymphadenitis. EBV rarely causes acute hepatitis. In this report, we present a 19-year-old patient presented with nausea, fatigue and jaundice. Her physical examination and laboratory tests revealed the diagnosis as acute hepatitis due to EBV with cross-reacting antibodies to cytomegalovirus.
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Septicemic listeriosis: An emerging food-borne illness in India? p. 145
Angel T Miraclin, Susmitha K Perumalla, John Davis Prasad, Thambu David Sudarsanam
DOI:10.4103/ijmm.IJMM_16_337  PMID:29735848
Listeriosis is a food borne illness of significant public health concern, caused by consumption of food contaminated by gram negative bacilli, Listeria monocytogenes. Clinical listeriosis is relatively rare and it has varying spectrum of presentation, ranging from severe sepsis in immune-compromised individuals, febrile gastroenteritis and meningo-encephalitis in infants and adults. This disease is under reported in developing nations due to the lack of awareness and inadequate laboratory facilities to promptly isolate and identify the organism. We report a case of sporadic food-borne listeriosis, in an otherwise healthy individual presenting with meningo-encephalitis. Prompt identification and appropriate antibiotic therapy led to a favorable outcome.
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Client partner notification and management: A rational approach to reduce new HIV infections p. 147
Sunite A Ganju, Anil K Kanga
DOI:10.4103/ijmm.IJMM_15_214  PMID:29735849
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Carrier study and treatment of close contacts: A must for diphtheria eradication p. 148
Usha Udgaonkar
DOI:10.4103/ijmm.IJMM_17_346  PMID:29735850
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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