Purpose : To assess the knowledge, attitudes and practices among the different health care workers (HCWs) on nosocomial infections. Methods : A total of 150 HCWs, doctors (n=50), nurses (n=50) and ward aides (n=50) were included. A questionnaire was administered to the HCWs to assess their knowledge, attitudes and practices on nosocomial infections. A scoring system was devised to grade those (KAP score). They were further subjected to a series of similar questionnaires at intervals of 6, 12 and 24 months after an education module. Subjects in each category of staff (n=10) were observed for compliance to hand washing practices in the ward in the post-education period. Statistical analysis was done using statistical software. Results : The study showed an increase in the number of subjects in each category scoring good and excellent in the post-education questionnaire; however this declined with the progress of time. It was observed that the compliance level to hand washing practices differed among the different HCWs. Total compliance was 63.3% and ward aides were most compliant 76.7% (adjusted Wald 95% CI= 58.80-88.48). Conclusions : Education has a positive impact on retention of knowledge, attitudes and practices in all the categories of staff. There is a need to develop a system of continuous education for all the categories of staff. In order to reduce the incidence of nosocomial infections, compliance with interventions are mandatory.

Infection with Brucella spp. continues to pose a human health risk globally despite strides in eradicating the disease from domestic animals. Brucellosis has been an emerging disease since the discovery of Brucella melitensis by Sir David Bruce in 1887. Although many countries have eradicated B. abortus from cattle, in some areas B. melitensis and B. suis have emerged as causes of this infection in cattle, leading to human infections. Currently B. melitensis remains the principal cause of human brucellosis worldwide including India. The recent isolation of distinct strains of Brucella from marine mammals as well as humans is an indicator of an emerging zoonotic disease. Brucellosis in endemic and non-endemic regions remains a diagnostic puzzle due to misleading non-specific manifestations and increasing unusual presentations. Fewer than 10% of human cases of brucellosis may be clinically recognized and treated or reported. Routine serological surveillance is not practiced even in Brucella - endemic countries and we suggest that this should be a part of laboratory testing coupled with a high index of clinical suspicion to improve the level of case detection. The screening of family members of index cases of acute brucellosis in an endemic area should be undertaken to pick up additional unrecognised cases. Rapid and reliable, sensitive and specific, easy to perform and automated detection systems for Brucella spp. are urgently needed to allow early diagnosis and adequate antibiotic therapy in time to decrease morbidity / mortality. The history of travel to endemic countries along with exposure to animals and exotic foods are usually critical to making the clinical diagnosis. Laboratory testing is indispensable for diagnosis. Therefore alertness of clinician and close collaboration with microbiologist are essential even in endemic areas to correctly diagnose and treat this protean human infection. Existing treatment options, largely based on experience gained > 30 years ago, are adequate but not optimal. In our experience, an initial combination therapy with a three drug-regimen followed by a two-drug regimen for at least six weeks and a combination of two drugs with a minimum of six weeks seems warranted to improve outcome in children and adult patients respectively with laboratory monitoring. A safe and effective vaccine in humans is not yet available. Prevention is dependent upon the control of the disease in animal hosts, effective heat treatment of dairy produce and hygienic precautions to prevent occupational exposure. This review compiles the experiences and diagnostic and treatment paradigms currently employed in fighting this disease.

Purpose : To evaluate the spectrum of activity of three β-lactamase inhibitors such as amoxicillin/ clavulanic acid, ticarcillin/ clavulanic acid and piperacillin/ tazobactam in comparison to cephalosporins against gram negative bacilli. Methods : Gram-negative bacilli isolated from the clinical specimens received in the laboratory were included in the study. Using the API system (bioMιrieux) during a one-year period, a total of 1,252 Enterobacteriaceae and 385 non-fermenters were evaluated. Results : The percentage resistance of the Enterobacteriaceae isolates was 82.92% to amoxicillin/ clavulanic acid, 58.22% to ticarcillin/clavulanic acid and 22.44% to piperacillin/tazobactam respectively. Pseudomonas aeruginosa showed resistance of 96% to ticarcillin/ clavulanic acid and 61% to piperacillin/ tazobactam and Acinetobacter baumannii showed 49% resistance to ticarcillin/ clavulanic acid and 77% resistance to piperacillin/ tazobactam respectively. The isolates exhibited high resistance to all the generations of cephalosporins and the other groups of antibiotics except carbapenems. Conclusions : Piperacillin/tazobactam was found to be the most active combination of the three against Enterobacteriaceae and Pseudomonas spp. and ticarcillin/clavulanic acid against Acinetobacter spp. and Stenotrophomonas maltophilia .

Purpose: Microsporidial infections have been recognized as an increasingly important infection in immuncompromised patients, particularly those infected with HIV/AIDS. This study was designed to study immune responses associated with experimental Encephalitozoon intestinalis infection in immunocompetent rats. Materials and Methods: Thirty-four Rats in 3 groups, A (Control), B (Intraperitoneal) and C (Oral) were given injections of 0.5 ml of 2 x 10 ⁶ of purified spores of Encephalitotozoon intestinalis spores and were observed for serum specific IgG for 21 days using both direct and indirect ELISA. Results: In indirect ELISA, specific lgG were detected on days 7, 14 and 21 for the group B rats and on day 21 for group C and in direct ELISA method, specific lgG were detected in-group B rats on days 7 and 21, for group C rats on day 21 only, while in the control rats, specific lgG were not detected. There was no significant difference between the direct and indirect methods (df=1, X ² , P>0.05). E. intestinalis was observed in stool samples of rats in 1/12 (08.33%) on days 14 and 21 in group B, and in 4/10 (33.33%), 3/10 (25.00%) and 2/10 (16.67%) on days 7, 14 and 21 respectively in group C. In group A, which is the control rats, no microsporidia were observed on days 0, 7, 14 and 21. Conclusions: There were no changes in the T-lymphocyte counts of rats prior to and after inoculation with spores. Extensive lesions were observed along the intestinal walls especially on the middle and lower sections of group C rats only.

Purpose : To evaluate the frequency of ocular cysticercosis and to demonstrate the changing trends in localisation of ocular cysticercosis along with a brief review of literature. Methods : A retrospective analysis of histology proven ocular cysticercosis cases seen over a period of 20 years (1981 through 2000) was done. The pathology record forms were reviewed for demographics, clinical features with specific reference to the location of cysts in four subgroups: subconjunctival; intraocular orbit and eyelid. The distribution of cases in four five-year periods namely group A: 1981-1985, group B: 1986-1990, group C: 1991-1995 and group D: 1996-2000 and the changing trends in the location of cysts was evaluated. Results : One hundred eighteen cysts from 118 patients aged 4-72 (mean 17.1) years were submitted to the pathology service of S D Eye Hospital, Hyderabad. Male to female ratio was 1: 1.2. Total number of cases in groups A, B, C and D were 33, 41, 16 and 25 respectively. Location of cysts was subconjunctival - 74 (62.7%); intraocular-31 (26.3%); orbital-8 (7%) and lid-5 (4%). In last 20 years, significant decrease ( P =0.0001) was noted in subconjunctival cases (85% vs. 28%) with a significant rise ( P =0.0001) in intraocular cysticercosis (6% vs. 60%). Conclusions : Frequency of surgically excised ocular cysticercosis remained constant over last two decades with an increasing manifestation of intravitreal cysticercosis in the recent years. This could imply either improved diagnostic modalities, available expertise in vitreo-retinal surgery or ineffective medical treatment for intraocular parasitic infection. The relative decrease in extraocular cysticercosis is probably due to the increased preference and success with medical management.

Purpose : Blood cultures form a critical part of evaluation of patients with suspected sepsis. The present study was undertaken to study the risk factors, duration of incubation for obtaining positive cultures, and the clinical impact of the culture report. Methods : A total of 220 samples from 107 pediatric patients presenting with suspected bacteraemia were processed aerobically. Results : Cultures were positive in 18.7% of the samples. Most of the positive cultures were obtained after 24 hours of incubation of the broth and no isolates were obtained beyond day 4 of incubation. Therapy was modified in 54.23% of the patients after receipt of culture report. Conclusions : Incubation beyond four days (unless with specific indication like enteric fever) may be unnecessary for issuing a negative culture report. Repeated isolation of doubtful pathogens confirms true bacteraemia. Early culture report increases therapeutic compliance.

Purpose : This study was carried out to analyze the epidemiology of gonorrhea based on antimicrobial susceptibility testing, auxotyping and serotyping in New Delhi, India. Methods : Sixty gonococcal isolates from males with urethritis, females with endocervicitis and their sexual contacts were studied. The isolates were subjected to antimicrobial susceptibility testing, auxotyping and serotyping for epidemiological characterization. Results : We observed nine antibiotic resistance patterns. Ninety-eight percent of isolates were resistant to ciprofloxacin, while 20% isolates were penicillinase producing N. gonorrhoeae (PPNG) and 18.3% isolates were tetracycline resistant N. gonorrhoeae (TRNG). Eight auxotypes were observed, of which the NR (non-requiring), proline requiring and arginine requiring were most common auxotypes. On the basis of serotyping alone, the gonococcal isolates could be differentiated into three serogroups and 18 serovars. Serogroup WI represented 46.7% and WII/III represented 51.7% of isolates and one strain was WI and WII/WIII serogroup combination. When results of auxotyping and serotyping were combined (A/S) 29 A/S classes could be identified. The most prevalent A/S classes were NR/Aost, NR/Arost, Pro/Aost and Pro/Boprt. Conclusions : Although A/S typing had the highest discriminatory index, isolates recovered from index case and their sexual contacts were found to be identical by all typing methods.

Purpose : To describe the changes in antibiotic susceptibility patterns of common intensive care unit pathogens with time from the medical intensive care unit of a tertiary care hospital. Methods : A prospective observational study was conducted in the medical intensive care unit (MICU) of a 2100 bed tertiary care hospital in South India. All data regarding patient characteristics, disease characteristics, infective agents, identified along with their antibiotic sensitivity patterns and patient outcomes were prospectively recorded in MICU data base. Various bacterial pathogen antibiotic sensitivity patterns from August 2004 to May 2005 were prospectively documented. During this period 491 patients were admitted to the MICU. Data were analyzed using excel spreadsheets. Results : Ceftazidime resistance reduced in Klebsiella spp. while cefotaxime resistance increased. In E. coli however, ceftazidime and cefotaxime resistance increased. Klebsiella resistance to cefotaxime and ceftazidime ranged from 25-50% and 14-91%, while E. coli resistance to these antibiotics ranged from 50-70% and 50 to 80% respectively. In Pseudomonas and the non-fermenting gram-negative bacteria (NFGNB) ceftazidime resistance decreased. Third generation cephalosporin resistance seemed to be reducing in the NFGNB, however, carbapenem resistance appeared to be increasing, possibly due to their increasing use. Conclusions : This study demonstrates the trend in antibiotic susceptibility pattern (AST) of common gram negative infections seen in intensive care units. It demonstrates the changes seen especially after a change in the protocol antibiotic. Changes in the AST patterns of Klebsiella, E. coli, Pseudomonas and non-fermenting gram negative bacteria were seen. The data on the changing antibiotic susceptibility trends we believe is an important pillar in our efforts at infection control especially in intensive care settings.

Purpose : To evaluate the role of the radiometric BACTEC 460TB system and the conventional Lowenstein-Jensen (LJ) medium for isolation of M. tuberculosis from cerebrospinal fluid (CSF) samples of tuberculous meningitis (TBM) patients. Methods : CSF specimens (n=2325) from suspected TBM patients were processed for isolation of mycobacteria by inoculating BACTEC 12B medium and the LJ medium. The isolation of mycobacteria in both media was confirmed by microscopy and biochemical identification. Drug sensitivity testing for the anti-TB drugs was carried out by BACTEC radiometric method. Results : Among the total 2325 CSF specimens processed by both methods, M. tuberculosis was isolated from 256 specimens. The isolation rates were 93% and 39% for the BACTEC system and LJ medium respectively. Both the media supported growth in 32% of the culture-positive specimens. BACTEC system alone yielded growth in 61% and LJ alone in 7%, of the culture-positive specimens. Among 205 isolates tested for drug susceptibility 81% were sensitive to all the drugs tested and 19% were resistant. Conclusions : The BACTEC 460TB system provides a highly sensitive and rapid tool for the isolation and drug susceptibility testing of M. tuberculosis , from CSF of TBM patients. Use of a solid medium in conjunction with the BACTEC 12B medium is essential for optimal recovery for M. tuberculosis from CSF specimens.

Purpose : The purpose of the present study was to determine the degree of expression of virulence factors such as adherence, cell surface hydrophobicity (CSH) and production of proteinase by different morphological forms of Candida albicans causing oral candidiasis in human immunodeficiency virus (HIV)-infected individuals. Methods : C. albicans 3153A and two strains isolated from oral thrush in HIV infected individuals were induced to undergo phenotypic switching by exposure to UV light and the degree of expression of virulence factors by the different morphological forms was studied. Results : Three different morphological forms of C. albicans were obtained namely, star (S), wrinkled (W) and ring (R) types from the original smooth (O) variety. It was found that proteinase production was greatest with the W type followed by the R type and O type. The S type produced the least proteinase. Expression of cell surface hydrophobicity and adherence was greatest in the O type followed by the R and then the W type and finally the S type. Conclusions : The differential expression of virulence factors occurs with different phenotypic forms of C. albicans and this may provide a particular morphological type with a distinct advantage over other types in causing candidiasis.

Clinico-microbiological analysis of a series of 25 patients with culture proven melioidosis was done. All patients came from the coastal regions of Kerala and Karnataka and presented between June 2005 to July 2006. They were analysed with respect to clinical presentation, occupation, epidemiology and microbiological features. No single presenting clinical feature was found to be typical of melioidosis. The disease was found to mimic a variety of conditions, including tuberculosis and malignancy. Burkholderia pseudomallei was isolated from blood, sputum, pus, urine, synovial, peritoneal and pericardial fluids. Diabetes mellitus was the most common predisposing factor and 80% of the cases presented during the Southwest monsoon (June to September). It is probable that melioidosis is highly prevalent in western coastal India and yet, greatly underestimated. Better awareness, both among clinicians and microbiologists, coupled with improved diagnostic methods to allow early diagnosis and hence early treatment, will significantly reduce the morbidity and mortality associated with this disease.

Hepatitis C virus (HCV) is the major causative agent of non-A and non-B viral hepatitis. Factors associated with disease progression following HCV infection include the viral genotype, the patient's alcohol consumption, and viral load. In this study, the COBAS AMPLICOR HCV MONITOR test, a commercially available quantitative assay for HCV RNA, was used for HCV genotyping analysis. Amplification products obtained from 100 HCV-positive cases were subjected to real-time polymerase chain reaction (PCR) typing using a single pair of fluorescence resonance energy transfer (FRET) probes and melting-curve analysis. Of 100 samples tested, two inhibited the PCR, two samples yielded discrepancies between our results and the reference laboratory results, and the remaining samples provided correct typing. The present report suggests that HCV genotypes can be determined rapidly with FRET probes directly from COBAS AMPLICOR MONITOR test PCR products.

This study examined circulating filarial antigen by monoclonal antibody Og4C3-enzyme-linked immunosorbent assay (ELISA) from 114 men with hydrocele, living in an endemic area. Nocturnal blood and hydrocele fluid were collected and examined for microfilaria. ELISA was performed on serum and hydrocele fluid for detection of antigen. Amongst 114 cases, 5(4.4%) showed microfilaria in blood but none in fluid. ELISA was positive in 13(11.40%) serum and 5 (4.4%) fluid samples. All five fluid antigen positive cases were positive for antibodies and showed microfilaria in blood. These findings emphasize the use of circulating filarial antigen detection and alternative usage of hydrocele fluid for diagnosis of filariasis.

The present study was done to detect the antibiotic resistance in S. pneumoniae . One hundred twenty S. pneumoniae isolates from clinical specimens and 50 from nasopharyngeal sites were subjected to antimicrobial susceptibility testing by Kirby Bauer disk diffusion method and minimum inhibitory concentration (MIC) determination for penicillin and cefotaxime non-susceptible isolates. A total of 22 isolates (18.3%) from clinical sites and eight (16%) from nasopharyngeal sites showed decreased susceptibility to penicillin by oxacillin disk diffusion test. MICs of 26 of these resistant strains ranged from 0.12-1 µg/mL (intermediate resistance) by broth dilution and E test. Only four isolates, two from sputum and two from nasopharyngeal swabs, showed MIC of 2 µg/mL (complete resistance). However, MIC of two cefotaxime resistant isolates (by disk diffusion) was in the susceptible range (0.5 µg/mL). Highest antimicrobial resistance was seen to cotrimoxazole (55.2%) and tetracycline (61.2%). Antimicrobial resistance to cotrimoxazole and tetracycline was much more in clinical isolates than colonizing isolates. Multi-drug resistant phenotype was detected in 76.9% (20 of 26) of isolates that were intermediately sensitive to penicillin and 50% (2 of 4) of penicillin resistant isolates (co-resistant to tetracycline and cotrimoxazole). Routine screening for antibiotic susceptibility is recommended for clinical isolates of pneumococci. Strains with reduced susceptibility to penicillin should be subjected to MIC determination to detect relative resistance or true resistance as such strains are associated with increased virulence.The choice of antibiotics should be guided by the prevalence of local resistance patterns of pneumococci.

Resistance to aciclovir (ACV) among Herpes simplex virus (HSV) isolates is increasingly being reported in the literature particularly in immunocompromised patients. However, there is only limited data available from India despite widespread use of ACV in our hospital. A cross-sectional study was hence conducted to determine the aciclovir (ACV) susceptibility of HSV 1 and 2 isolates using a dye uptake (DU) assay. This study showed a 3.0% prevalence of ACV resistance among HSV-1 strains (2/66, median IC ₅₀ 0.098 µg/mL) while in HSV-2 strains, it was 7.8% (5/64, median IC ₅₀ 0.195 µg/mL). The IC ₅₀ for the HSV-1 and HSV-2 strains resistant to ACV was greater than or equal to 6.25 µg/mL.

In vitro isolation of rabies virus using mouse neuroblastoma cells (MNA) was evaluated. The sensitivity and reliability of in vitro procedure was performed in comparison with mouse inoculation test (MIT), the in vivo method of virus isolation, direct fluorescent antibody test (FAT) and Sellers staining. Of the 33 animal brain samples tested, 24 (72.72%) were positive by MIT. Sensitivity of Sellers stain, FAT and rapid tissue culture infection test (RTCIT) was found to be 54.16, 100 and 91.6% respectively. Concordance of Sellers stain, FAT, RTCIT with MIT was found to be 66.6, 100 and 93.93% respectively. Two samples which were positive by FAT and MIT showed gross contamination in cell lines, which is one of the drawbacks of RTCIT. However, rabies virus could be isolated in MNA cells from two of the eight human cerebrospinal fluid (CSF) samples from clinico-epidemiologically suspected cases of rabies. Both MIT and FAT showed negative results in the two CSF samples. RTCIT appears to be a fast and reliable alternative to MIT and holds promise in antemortem diagnosis of rabies, which is otherwise, a challenging task for a reference laboratory.

There is only scanty data on the effects of specific antibody, with or without complement, on Candida albicans or Candida krusei in cell-free systems in vitro , although previously published work has shown that specific antibody mediates anti- Candida immunity in vivo by inhibition of adherence to host cells or surfaces and by the promotion of phagocytosis and intra-phagocytic killing. The MTT (3-[4, 5-dimethyl-2-thiazolyl] -2, 5-diphenyl -2H- tetrazolium bromide)-reduction method as a test of the viability of fungi was used to investigate the effect of complement, normal serum and immune serum on these two species of Candida that are of increasing importance as opportunistic pathogens. We report that normal rabbit serum or strain-specific, polyclonal anti- Candida rabbit antibody, with or without guinea pig complement, did not cause the reduction of total cell-mass or of the viability of either C. albicans or C. krusei, in vitro as determined by the MTT-reduction test. Complement alone without specific antibody, also, had no such effect on these two Candida species.

We report here the emergence of a new focus of cutaneous leishmaniasis (CL) due to Leishmania tropica (L. tropica) in the Ajmer city of Rajasthan, India, a previously non-endemic area. Between January-February 2006, 13 new indigenously acquired cases of CL were diagnosed among the patients attending the Skin and STD department, JLN Hospital, Ajmer. The diagnosis was based on clinical presentation, demonstration of amastigotes (LT bodies) in Giemsa stained smear of the lesion and response to intralesional / local anti-leishmanial drug therapy. In addition, culture of the promastigote forms of L. tropica from the lesion was successfully attempted in four of the smear negatives cases. By retrospective analysis, 23 new indigenous cases of CL have been diagnosed in the same setting during the period January 2004 - December 2005, based on clinical and therapeutic response alone. There was no clear-cut history of sandfly bite and travel outside the district or state to endemic area in any of the cases. However, all of them came from a common residential area (famous dargah of Ajmer) and the peak incidence was seen in January, four months after the famous Urs fair of Ajmer, the location was urban and the lesions were characteristic of L. tropica. Therefore, the disease is suspected to be anthroponotic. These features are suggestive of a common mode of transmission, source and/or vector signalling introduction of this infection into a non-endemic area.

Ocular involvement with Gnathostoma spinigerum occurs years after the initial infection that is acquired by ingestion of poorly cooked, pickled seafood or water contaminated with third stage larvae. Here we report a case of gnathostomiasis of the left eye of a 32-year-old lady hailing from Meghalaya, India. Her vision had deteriorated to hand movement. Slit lamp examination revealed a live, actively motile worm in the anterior chamber, which was extracted by supra temporal limbal incision and visual acuity was restored.

A case of nocardiosis in a post-renal transplant patient is being reported for the first time from Eastern India. The patient had multiple abscesses on the right thigh and chest. Direct examination of the aspirated pus by Gram stain and modified Ziehl Neelsen stain revealed gram-positive beaded, partially acid-fast, branching filaments. Culture of the pus yielded Nocardia asteroides . The patient responded to surgical drainage and sulphamethoxazole therapy.

Increase in cryptococcal infection has been noticed after acquired immunodeficiency syndrome pandemic. Cryptococcus neoformans can be isolated from blood in the process of dissemination to brain. We report a case of cryptococcal fungaemia in a patient whose cerebrospinal fluid was negative for Cryptococcus neoformans . Retrospective analysis revealed human immunodeficiency virus seropositivity of the patient. He was treated with amphotericin B and fluconazole. Antiretroviral therapy was started, however, the patient succumbed to the infection.

A case of cellulitis of the left lateral side of the face caused by the zygomycete Apophysomyces elegans in a healthy male following a road traffic accident is reported. The contaminated soil was the source of fungus. Broad aseptate fungal hyphae were seen in the necrosed tissues. Extensive tissue debridement and treatment with amphotericin B were not successful in controlling the rapid invasion of the tissues by the fungus. Patient developed angioinvasion, severe cellulitis and finally succumbed to the infection three weeks after admission.

Nodular granulomatous perifolliculitis is a well-recognized infection of the dermal and subcutaneous tissue caused by dermatophytes, which normally do not invade beyond the epidermis. We report here one such case that occurred in an immunosuppressed individual. The patient was a 35-year-old farmer who presented with small pruritic eruption that had initially appeared on the lower leg and then had gradually spread to hair-bearing areas of the body, finally producing nodular and pustular inflammatory lesions with exacerbations and remissions. Fungal examination by direct potassium hydroxide mount and culture revealed Trichophyton rubrum. Granulomatous changes were seen on histopathological examination. The patient completely responded to systemic antifungal therapy.

A case of zygomycosis presenting with non-healing multiple discharging sinuses in a diabetic patient is reported here. The debrided tissue on histopathological examination revealed dense infiltration with aseptate fungal hyphae. Potassium hydroxide mount showed hyaline aseptate hyphae suggestive of zygomycosis. On culture, Absidia corymbifera was isolated. The patient responded to surgical debridement and therapy with amphotericin B followed by itraconazole.

We report a case of nocardiosis in an immunosuppressed elderly patient who presented with prolonged pyrexia. Nocardia asteroides was isolated from the thyroid, with CT scan evidence of dissemination to the brain, abdomen and lungs. The patient succumbed to illness despite aggressive therapy. Autopsy could not be performed. To the best of our knowledge, this is the first reported case from India, on Nocardia asteroides affecting the thyroid tissue.

Here we report a case of acalculus cholecystitis, which presented with features of obstructive jaundice of one-week duration. The patient underwent cholecystectomy and bile grew a mixed culture of Oerskovia turbata and Myroides spp. Being a rare isolate, characteristic features of the former are described in this report. The patient recovered without any complication.