Infection is a major cause of morbidity and mortality among patients admitted in intensive care units (ICUs). The application of the principles and the practice of Clinical Microbiology for ICU patients can significantly improve clinical outcome. The present article is aimed at summarising the strategic and operational characteristics of this unique field where medical microbiology attempts to venture into the domain of direct clinical care of critically ill patients. The close and strategic partnership between clinical microbiologists and intensive care specialists, which is essential for this model of patient care have been emphasized. The article includes discussions on a variety of common clinical-microbiological problems faced in the ICUs such as ventilator-associated pneumonia, blood stream infections, skin and soft tissue infection, UTI, infection control, besides antibiotic management.

The risk of healthcare-associated infections (HCAIs) in developing countries can exceed 25% compared to developed countries. Lack of awareness and institutional framework to deal with patient safety in general and HCAI in particular perpetuates the culture of acceptance of avoidable risks as inevitable. Most HCAIs are avoidable and can be prevented by relatively simple means. It is no longer acceptable to put patients at risk of avoidable infections. The World Health Organization (WHO)-led World Alliance for Patient Safety launched a worldwide campaign on patient safety focusing on simple means like hand hygiene to combat HCAIs. To drive necessary changes to deliver sustainable improvement in clinical care requires strategic approach and clinical leadership. This article reviews the scale of the problem, the WHO recommended interventions and improvement strategies in institutional setup in developing and transitional countries.

Background: Occupational exposure to blood/body fluids is associated with risk of infection with blood borne pathogens like human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV). Materials and Methods: We carefully document needle stick injuries (NSI) and implement post-exposure prophylaxis (PEP). We report a four-year continuing surveillance study where 342 healthcare workers (HCWs) sustained NSI. PEP was given to HCWs injured from seropositive sources. If the source was HbsAg positive, HCWs were given a hepatitis B immunization booster. If the HCW was antiHBs negative, both hepatitis B immunoglobulin (HBIG) and hepatitis B vaccine were administered. For HCWs who sustained injuries from HIV positive sources, antiretroviral therapy was started. Follow-up was done after three and six months of exposure. Recent interventions by the infection control committee at our hospital reduced NSI considerably during intravenous line administration and glucose monitoring. Results and Discussion: Of 342 injuries, 254 were from known sources and 88 from unknown sources. From known sources, 37 were seropositive; 13 for HIV, 15 for HCV, nine for HBV. Sixty six sharp injuries were sustained through garbage bags, 43 during IV line administration, 41 during injection administration, 35 during needle recapping, 32 during blood collection, 27 during blood glucose monitoring, 24 from OT instruments, 17 during needle disposal, 16 while using surgical blade, 7 during suturing and 34 from miscellaneous sources. Conclusion: No case of seroconversion has taken place, so far, as a result of needle stick injuries at our centre.

Purpose: In Kenya there is need for proper co-ordination of antiretroviral therapy (ART) and tuberculosis (TB) treatment as most (60%) of the TB patients are also human immunodeficiency virus (HIV) positive. This study aims to determine the difference in response to TB treatment among HIV-negative TB patients and HIV-positive TB patients receiving delayed highly active antiretroviral therapy (HAART) at Vihiga District Hospital. Materials and Methods: A total of 116 patients were diagnosed using direct smears from sputum prepared and stained using the Ziehl-Neelsen procedure. The patients were offered HIV testing and counselling, and then categorized into category A (PTB with HIV n=50) and category B (PTB without HIV co-infection n=66). They were put on the same TB chemotherapy of a short course comprising of: Two months of Rifampicin-R, Isoniazid-H, Pyrazinamide-Z and plain Ethambutal-E, followed by six months of Ethambutal and Isoniazid. The main outcome measured was the sputum conversion rate from positive sputum to negative sputum. One way analysis of variance (ANOVA) was used to test the null hypothesis. Results: Fifty patients (43%) were found to be HIV positive and were put on HAART. The other 66 patients (57%) were HIV negative. The sputum conversion rate for HIV positive TB patients after two months and five months was 88 and 94%, respectively. The sputum conversion rate for HIV negative TB patients at two months and after five months was 92 and 97%, respectively. However, there was no significant difference in the bacteriological outcome responses to TB chemotherapy between the two groups. Conclusion: The high sputum conversion rates in the two groups indicated good control and management of TB. Findings in this study indicated that delayed use of HAART during TB treatment leads to better outcome in TB treatment. The study recommends more concerted efforts to provide TB treatment to HIV positive TB patients in Kenya.

Purpose: To evaluate the reliability of the gyrB PCR-RFLP technique in differentiating clinical Mycobacterium tuberculosis complex isolates. Materials and Methods: A primer pair MTUB-f and MTUB-r for M. tuberculosis complex (MTBC) was used to differentiate 79 mycobacterial isolates by specific amplification of the 1,020-bp fragment of the gyrB gene (gyrB-PCR1). The MTBC isolates were further differentiated using a set of specific primers MTUB-756-Gf and MTUB-1450-Cr that allowed selective amplification of the gyrB fragment specific for M. tuberculosis (gyrB-PCR2). The DNA polymorphisms in the 1,020-bp gyrB fragment for 7 M. tuberculosis strains confirmed by PCR as well as 2 reference strains; M. tuberculosis H37Rv and M. bovis BCG were analyzed with the restriction enzyme Rsa1. Results: Seventy-seven (97.5%) isolates were positive for gyrB-PCR1 and thus identified as members of M. tuberculosis complex (MTBC) and two (2.6%) isolates were negative and identified as Mycobacteria other than tuberculosis (MOTT). All the M. tuberculosis isolates showed the typical M. tuberculosis specific Rsa1 RFLP patterns (100, 360, 560-bp) while 360 and 480-bp fragments were generated from M. bovis BCG. Conclusion: The gyrB PCR-RFLP using the endonuclease Rsa1 can be used to differentiate M. tuberculosis from M. bovis in clinical isolates.

Aim: To evaluate E-test as a tool for rapid determination of drug susceptibility against the conventional LJ method focusing on reliability, expense, ease of standardization and performance of the technique in low resource settings. Materials and Methods: A total of 74 clinical isolates (2004-2005) of Mycobacterium tuberculosis were tested using E-test for susceptibility to streptomycin (STM), isoniazid (INH), rifampicin (RIF) and ethambutol (EMB) by E-strip and LJ (LJPM) proportion methods. Results: The LJPM method, the gold standard, detected resistance against STM in 16.2%, INH in 40.5%, RIF in 18.9% and EMB in 27% cases. In comparison, the resistance values showed by E-test was 66.67% for STM, 57.14% for INH 71.43% for RIF and 80% for EMB. The susceptible correlation was 90.32% for STM, 73.91% for INH, 93.33% for RIF and 59.26% for EMB. E-test correctly identified only eight of the 12 (66.6%) MDR isolates and wrongly identified four isolates which were not MDR. The overall agreement between the two methods was only 48.6%. Resistant isolates showed false positive resistance observed while using E-strip towards all the drugs. Conclusion: E-strips are not quite feasible as a replacement for LJ-proportion method on a large scale due to high risk of cross contamination, laboratory infection, expense associated with it and high false positive resistance observed to all first line drugs. However, the good correlation observed for RIF between the two methods indicates that E-test could contribute to the role in rapid screening of MDR TB isolates as rifampicin mutations are invariably observed in MDR TB isolates.

Purpose: To detect the presence of autolysin and pneumolysin genes among Streptococcus pneumoniae strains isolated from different disease entities among Indian patients. The study also attempted to determine antimicrobial susceptibility of the isolates. Materials and Methods: A total of 24 S. pneumoniae isolates were checked for the presence of lytA gene coding for autolysin and ply gene coding for pneumolysin using polymerase chain reaction (PCR). All the isolates were subjected to susceptibility testing by disc diffusion method for 10 different therapeutically relevant antibiotics. Minimum inhibition concentration (MIC) was determined using broth dilution method for ampicillin, penicillin and ciprofloxacin. Results: Eleven isolates from ocular infections and 13 isolates from different invasive diseases showed susceptibility to most of the antibiotics tested except chloramphenicol and ciprofloxacin. Fifty percentage of the isolates showed resistance to chloramphenicol and ciprofloxacin. A moderate level of resistance of 18% was noted for cefepime and ceftriaxone. Only 6% of resistance was observed for amoxicillin and ceftazidime. MIC levels ranged from 0.015 to 1 μg/mL for ampicillin and only one isolate had an MIC of 1 μg/mL. The MIC levels for penicillin ranged from 0.062 to 4 μg/mL, wherein nine isolates showed high levels of MICs ranging from 2 to 4 μg/mL. Six isolates had a very high resistance levels for ciprofloxacin with MIC ranging from 32-128 μg/mL. The presence of lytA was observed in 23 out of 24 isolates tested whereas only 17 isolates were positive for pneumolysin. Four ocular isolates and one isolate from ear infection were negative for pneumolysin. Conclusion: Emerging resistance observed for cefepime and ceftriaxone might be due their increased and frequent usage nowadays. Presence of pneumolysin appears to be more critical for pathogenesis of invasive infections than the ocular infections. However, presence of lytA gene in all the isolates signifies that irrespective of site of isolation, kind of infection caused, autolysin is an obligate necessity for this organism.

Background: Helicobacter pylori (Hp) is a bacterium recognised as a main causative agent for the development of chronic active gastritis, peptic ulcer disease, gastric adenocarcinoma and primary gastric lymphoma. Objective: Determination of the levels of IFN-γ (pro-inflammatory) and IL-4 (anti inflammatory) cytokine expression as indicators of Th1 and Th2 immune responses in gastric cancer (GC) and non gastric cancer (Non GC) dyspeptic patients by gene specific RT-PCR. Materials and Methods: Biopsy specimens were collected from three groups of gastric cancer (GC=18), non ulcer dyspepsia (NUD = 38) and peptic ulcer patients (PUD=20). Total RNA was extracted and complementary DNA was synthesised. PCR amplification was performed for HPRT, IFN-γ and IL-4 cytokines and the intensity of each band was measured by densitometry and normalized against HPRT expression as a house keeping gene. Results: Comparison of the results from different groups of patients indicated that IFN-γ gene expression was similar in nonGC dyspeptic patients (NUD and PUD groups; 3.38 ± 0.57,3.43 ± 0.41, respectively) whereas, in GC patients, it was significantly higher than others (5.52 ± 0.59; P < 0.0001). On the other hand, IL-4 gene expression showed no significant difference between NUD and GC patients (2.81 ± 0.43,2.3 ± 0.12 respectively), whereas the expression rate of this cytokine was significantly higher in PUD patients (3.7 ± 0.1; P 0.05). Our data indicate an association between Th1 and Th2 immune responses and the development of gastric cancer and peptic ulcer disease respectively.

Chlamydia trachomatis is considered a major aetiological agent of conjunctivitis in newborns. The objective of the present study was to determine the aetiology of neonatal conjunctivitis and clinico-epidemiological correlates of chlamydial ophthalmia neonatorum. Fifty-eight newborns with signs and symptoms of conjunctivitis were studied. Conjunctival specimens were subjected to Gram staining, routine bacteriological culture, culture for Neisseria gonorrhoeae and direct fluorescent antibody (DFA) staining for diagnosis of C. trachomatis infection. C. trachomatis was detected in 18 (31%) neonates. Findings suggest that since C. trachomatis is the most common cause of neonatal conjunctivitis, routine screening and treatment of genital C. trachomatis infection in pregnant women and early diagnosis and treatment of neonatal Chlamydial conjunctivitis may be considered for its prevention and control.

Purpose: The objective of the study was to perform antimicrobial susceptibility testing of rapidly growing mycobacteria (RGM) isolated from various clinically suspected cases of extrapulmonary tuberculosis, from January 2007 to April 2008, at a tertiary care centre in Mumbai. Materials and Methods: The specimens were processed for microscopy and culture using the standard procedures. Minimum inhibitory concentrations (MIC) were determined by broth microdilution, using Sensititre CA MHBT. Susceptibility testing was also carried out on Mueller Hinton agar by the Kirby Bauer disc diffusion method. Results: Of the 1062 specimens received for mycobacterial cultures, 104 (9.79%) grew mycobacteria. Of the mycobacterial isolates, six (5.76%) were rapid growers. M. abscessus and M. chelonae appeared to be resistant organisms, with M. chelonae showing intermediate resistance to amikacin and minocycline. However, all the six isolates showed sensitivity to vancomycin and gentamicin by the disc diffusion test. Also all three isolates of M. abscessus were sensitive to piperacillin and erythromycin. Further studies are required to test their sensitivity to these four antimicrobials by using the microbroth dilution test, before they can be prescribed to patients. Conclusions: We wish to emphasize that reporting of rapidly growing mycobacteria from clinical settings, along with their sensitivity patterns, is an absolute need of the hour.

This retrospective study incorporates a six years, six months (January 2000-June 2006) laboratory data comprising 258 isolates of Salmonella. Cultures were identified by standard methods. Salmonella enterica serotype Typhi (S.Typhi) was the more frequent serotype isolated i.e., 61.62% with the remaining 38.37% being Salmonella enterica serotype Paratyphi A (S. Paratyphi A). There was emergence of S. Paratyphi A as the predominant serotype in 2003-2004 with resurgence of serotype Typhi thereon. A total of 66.27% isolates were resistant to one or more antibiotics. MDR S. Typhi was 10.69% and while 13.13% were MDR S. Paratyphi A. There was decrease in resistance to ampicillin, cotrimoxazole in 2004 and nalidixic acid beyond 2005 and increase in resistance to cefuroxime. We also documented a decrease in resistance to ciprofloxacin after 2005.

This study aims to determine the genotypes of hepatitis C virus (HCV) among blood donors at Ahvaz Blood Transfusion Centre. Blood samples were taken from 2376 blood donors - 1795 (75.54%) male and 581(24.45%) female - who referred to Ahvaz Blood Transfusion Centre during 2007-2008. Detection of anti-HCV antibody for all the donors was carried out by ELISA and the confirmatory RIBA tests. HCV RT-PCR followed by RFLP test was carried out for anti-HCV positive samples. Out of 2376 blood donors, only 55 (2.3%) male donors showed to be positive for HCV antibody by ELISA and RIBA tests out of which 45(1.8%) donors were positive for RT-PCR test. Female donors were negative for HCV antibody. The result of HCV genotyping by RFLP test showed 24 (53.3%) for 1a, 17 (37.7%) for 3a (a) and 4 (8.8%) for 3a (b) genotypes respectively. In conclusion, high prevalence of 53.3% HCV 1a genotype was observed among blood donors in Ahvaz city.

Abstract Identification of Mycobacterium leprae, which causes leprosy, is done by Ziehl Neelsen Carbol Fuchsin (ZNCF) stained slit skin smear microscopy that aids in the diagnosis and quantification of approximate bacterial load carried by the patient. We attempted M. leprae DNA extraction from 46 stained slit skin smear negative slides, using Proteinase K and SDS lysis, followed by ethanol precipitation. M. leprae specific primers (16SrRNA) were used for PCR-based amplification of DNA. We could detect M. leprae DNA in 15 (32.6%) samples. The method can be useful in the diagnosis of apparently slit skin smear negative leprosy cases.

Intracranial infections, especially subdural empyema, due to salmonella are rare. Subdural empyema caused by Salmonella paratyphi A has been documented only once earlier in the literature. Hence, we report a case of subdural empyema and osteomyelitis of cranial vault due to S. paratyphi A. A 42- year-old male presented with headache and purulent discharge from right parietal burr hole wound site. Patient gave a history of head injury two years ago. He underwent burr hole evacuation of chronic subdural haematoma, excision of outer membrane and right parietal craniectomy. The cultures grew S. paratyphi A. Recovery was uneventful following surgical intervention and antibiotic therapy.

Rhizobium radiobacter is a gram negative bacillus that is infrequently recognized in clinical specimens but is emerging as an opportunistic human pathogen. Infections due to Rhizobium radiobacter are strongly related to the presence of foreign plastic material and effective treatment often requires removal of the device. We report a case of R. radiobacter bloodstream infection associated with a central venous catheter which was easily controlled by antimicrobial treatment and did not require removal of intravascular device. To the best of our knowledge, this is the first case report from India implicating R. radiobacter as a cause of human infection.

Acute pancreatitis occasionally presents as pancreatic abscess with complications like pleural effusion and ascites. There are several pre-disposing factors, the most common being cholelithiaisis, alcohol abuse, infective causes, trauma, and metabolic causes such as diabetic ketoacidosis, while some cases are idiopathic. Here, we report a rare case of acute necrotizing pancreatitis in a 40-year-old male who presented with pain in the abdomen, ascites and left basal pleural effusion. A computerized tomography (CT) scan showed findings suggestive of pancreatic necrosis, with abscess formation and free-fluid surrounding area. The aspirated pus sample was processed for Gram staining and culture, which yielded growth of Prevotella species in an anaerobic culture. Exploratory laparotomy was performed and intra-abdominal collection drained. Necrosectomy of the distal tail and body of the pancreas was performed. The patient was started on antibiotics and along with supportive treatment, responded well.

We report a case of Acanthamoeba keratitis with Curvularia co-infection. Acanthamoeba and fungal co-infection have been uncommonly reported in literature, worldwide. A classical history with a strong clinical suspicion and experienced laboratory personnel with systematic examination of corneal scrapings for bacterial, viral, parasitic and fungal causes are imperative for accurate diagnosis. Early diagnosis of Acanthamoeba keratitis or fungal infection followed by aggressive and appropriate treatment with effective agents is critical for the retention of good vision. Acanthamoeba keratitis is difficult to diagnose and, despite improvement in treatment options, may culminate in prolonged morbidity and significant loss of visual acuity. This case emphasizes the important role played by clinical microbiologists in making prompt diagnosis which can ultimately reduce visual morbidity.

Invasive aspergillosis is an opportunistic infection with a high mortality rate that usually occurs in the immunocompromised host. Several cases of fungal infections have been reported after cardiac surgery. We present here a case of Aspergillus fumigatus tricuspid valve endocarditis associated with permanent pacemaker leads. Tricuspid valve vegetectomy was done and the pacing leads were also removed. Culture from the excised vegetation grew Aspergillus fumigatus. The patient was started on IV Amphotericin B for eight weeks. The patient was subsequently followed up in the out-patient clinic, and remains afebrile after one year, with no evidence of any vegetation.

Filariasis, a mosquito-borne disease, is wide spread in India. While laboratory diagnosis has been conventionally done by demonstrating microfilaria in peripheral blood smears, occasionally they are reported in various body fluids including pericardial fluid. We report the case of 33-year-old man with severe dyspnoea and chest pain, referred from a private nursing home with a provisional diagnosis of unresolving pericarditis. Pericardial tap revealed massive pericardial effusion with actively motile microfilariae. No microfilariae (Mf) were seen in the peripheral blood. Haemorrhagic effusion resolved completely with DEC. Though relatively uncommon, tropical diseases must always be considered in the etiological diagnosis of pericardial effusion.

Human dirofilariasis is a zoonotic infection most commonly caused by Dirofilaria repens. It has not been widely recognized in India. There is probably a focus of human infection with D. repens in Kerala. We report the first case of dirofilariasis, from the Eastern-part of India, to the best of our knowledge. Among the documented cases of human dirofilariasis caused by D. repens, recorded in India, most of them had ocular infections and few had subcutaneous involvement of the face. This is the first case report of human dirofilariasis from India involving the lower part of human body.