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   Table of Contents - Current issue
Coverpage
January-June 2019
Volume 21 | Issue 1
Page Nos. 1-53

Online since Monday, August 12, 2019

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ACADEMY NEWS  

Academy news p. 1
Manjusree Shanmugham
DOI:10.4103/jacm.jacm_12_19  
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EDITORIAL ON SPECIAL ARTICLE Top

Antimicrobial stewardship programme p. 2
Chand Wattal
DOI:10.4103/jacm.jacm_16_19  
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SPECIAL ARTICLE Top

Antimicrobial stewardship programme – from policies to practices: A survey of antimicrobial stewardship programme practices from 25 centres in India Highly accessed article p. 4
Sanjay Bhattacharya, Vinitha Mary Joy, Gaurav Goel, Swapna R Nath, Shabina Santosh, Kalpana George, Ranganathan Iyer, Kavita Raja, A Uma, Aarti Gupta, Anitha Madhavan, Arindam Chakraborty, Barsha Sen, Beena Philomina, Dhruv K Mamtora, KP Dinoop, J Lancy, Mahua Dasgupta, Mannu R Jain, Mohd Tajuddin, Neethu Kishor, Prithi Nair, K Rejitha, Rekha N Nair, Sarada Devi, TS Shailaja, A Shilpa, Shoba Kurian, KV Suseela, SG Sagila, Syed Mustaq Ahmed, Yogesh Kumar Gupta
DOI:10.4103/jacm.jacm_17_19  
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ORIGINAL ARTICLES Top

Five-year trend of bacterial isolates and their antibiotic resistance from automated BACTEC blood culture system from a rural medical college hospital in North Kerala, India: 2012–2016 p. 10
Syed Mustaq Ahmed, Ramakrishna Pai Jakribettu, Sumita Rajeevan, Ann George, Muhsina A K Mariyam, S Vidya Rao
DOI:10.4103/jacm.jacm_26_18  
INTRODUCTION: Blood stream infections (BSI) accounts for the most serious infection encountered in hospital. It has high rate of morbidity and mortality with high cost of treatment including high end antibiotics. Therefore, early detection, identification of the pathogens with their antibiogram is very important. With the advent of increasing antibiotic resistance, a close monitoring of change in the antibiotic resistance pattern is essential. Thus, the present study was undertaken to study the bacteriological profile with antibiogram of the aerobic pathogens isolated from the automated blood (BACTEC) culture system from 2012-2016. MATERIALS AND METHODS: It was a retrospective study conducted at Clinical Microbiology Department, MES Medical College Hospital, Perinthalmanna. All the positive BACTEC blood culture samples from January 2012 to December 2016, of patients above 18 years of age, were included in the study. RESULTS: During the study period of 5 years, out of 11,966 BACTEC samples, 932 ( 7.78%) were positive. The gram positive bacteria constituted for 539 (57.83%) compared to 393 (42.16%) Gram negative isolates. Staphylococcus aureus ( 41.41%) was the most common isolate among Gram positive and Escherichia coli (16.41%) among the gram negative isolate. During the study period 2012-2016, there was steady rise in the Methicillin Resistant Staphylococcus aureus (MRSA) from 0.86%, 1.07%, 2.25%, 3.76%, 6.12%. Among the Gram negative isolates, the resistance for 3rd Cephalosporins, Fluoroquinolones, β lactum- β lactum inhibitors, Carbapenems have also increased. CONCLUSION: In the present study, we have observed the rise in multidrug resistant isolates especially MRSA, Escherichia coli, Acinetobacter species. This helped us to update the empirical antibacterial regime for the patient with suspected sepsis.
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Appropriateness of antimicrobial therapy for culture-proven blood stream infections p. 16
Monica Selvan, R Deepashree, Prasanna Bhat, R Akshatha, Sunil Jayakar, Apurba Sankar Sastry
DOI:10.4103/jacm.jacm_29_18  
INTRODUCTION: Blood stream infections (BSIs) are responsible for significant morbidity and mortality. Numerous studies have pointed to the importance of early and prompt institution of empirical antimicrobial therapy in reducing morbidity and mortality in BSI. The antibiotic spectrum must be narrowed as soon as possible, considering the clinical condition of the patient, the pathogens identified in cultures and the sensitivity profile obtained from the antibiogram. When no evidence of bacterial infection is present, antibiotic therapy must be suspended. However, it is often observed that the clinician does not adhere to the guideline and continues with the same empirical treatment. MATERIALS AND METHODS: The study was conducted at Department of Microbiology, in a tertiary care hospital from April 2017 to September 2017. Two hundred patients with microbiologically documented BSIs were included in the study. They were followed up to find the appropriateness of change in empirical treatment carried out according to culture sensitivity report, and antimicrobial consumption was also calculated. RESULTS: We observed that there was an increased use of antipseudomonal penicillins plus beta-lactamase inhibitors, amikacin and carbapenems which was due to higher prevalence of multidrug-resistant Gram-negative bacilli among blood culture isolated. We also found that in most of the patients, the empirical treatment was inappropriately modified at day four after availability of culture reports, i.e., inappropriately escalated or de-escalated or continued while there was no indication to do so. CONCLUSION: Treatment inappropriate group was associated with higher treatment failure as compared to treatment appropriate group. Studies of the other factors associated with inappropriate treatment such as changes in resistance patterns, antimicrobial-related adverse effect and of the long-term clinical outcomes are warranted.
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‘Clinicomycological correlation and antifungal susceptibility pattern of Aspergillus species’ – A retrospective and prospective study in a tertiary care centre in South India p. 24
Bhavna T Jishnu, Ananya Thupakki Sriparna, K Vichitra, Anupma Jyoti Kindo
DOI:10.4103/jacm.jacm_30_18  
CONTEXT: Aspergillus is present ubiquitously in the environment in the form of spores. Infection due to Aspergilli is uncommon in immunocompetent individuals, unless they possess any abnormalities or have undergone any treatment with corticosteroids in which pulmonary aspergillosis is the most common. In immunocompromised individuals, the infection by this fungus is in a higher extent of risk. AIM: A retrospective study was done and correlated with the antifungal susceptibility pattern of Aspergillus species. MATERIALS AND METHODS: A total of 72 isolates of Aspergillus were collected and confirmed by conventional methods except Aspergillus tetrazonus was identified by DNA sequencing. Antifungal susceptibility testing (AFST) was performed by conventional broth microdilution according to the Clinical Laboratory Standards Institute M38-A2 2008 to all the isolates. RESULTS: In our study, Aspergillus flavus was found to be the predominant followed by Aspergillus niger being the second most to be identified. AFST was performed for all the isolates, where they exhibited minimum inhibitory concentration (MIC) values within the range of 0.0078–2 μg/ml except Aspergillus terreus (4 μg/ml), which exhibited intrinsic resistance to Amphotericin B. CONCLUSION: Aspergillus infection can be treated easily, unless they become invasive. Therefore, antifungal therapy should be started early by determining the MIC values for the isolates, especially for the systemic infections and prevent from mortality.
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Ten-year retrospective study on ventriculoperitoneal shunt infections from a university teaching hospital, South India p. 29
Sushma Krishna, Kavitha R Dinesh, Tintu Abraham, Dilip Panikar, Sanjeev Singh, Shamsul Karim
DOI:10.4103/jacm.jacm_8_19  
BACKGROUND: Ventriculoperitoneal shunt insertions are one of the important neurosurgical procedures done to enhance the neurological functions and improve the survival of patients with hydrocephalus. However, shunt infections are associated with an increased risk of morbidity and the mortality of 30%–40%. The study objective was to evaluate the clinical features, aetiology, resistance pattern and outcome of patients with cerebrospinal fluid (CSF) shunt infections over a 10-year period (2001–2010) amongst the microbiologically-proven cases. METHODOLOGY: Retrospective chart review was carried out to evaluate the age, sex and aetiology of hydrocephalus, biochemical parameters, clinical features and outcome of the culture-positive cases. RESULTS: Out of the 184 post-procedure and initial (<24 months) CSF samples received, 28 of them were culture positive with a growth of 36 isolates. The shunt infection rate (unadjusted) was found to be 15.21%. Seventeen were male and 11 were female. Thirteen were children below the age of 1 year, 3 between 7 and 30 years and 12 were above 50 years. Congenital hydrocephalus and Post-meningitis were the commonly noted presentations (n = 9, 32.1%) patients. Fever (64.3%) and vomiting (46.4%) were the most common clinical symptoms. CSF pleocytosis (n = 13), low glucose (n = 5) and elevated proteins (n = 18) were seen, respectively, of the 18 records available. A total of 19 patients recovered from the episode and five documented deaths were noted. Three of the isolates persisted over 10 days with repeat isolations. The most common causative microorganism was Coagulase Negative Staphylococcus (CONS) n = 13 (36.5%) (in vitro resistance to methicillin was 36.3% and to gentamicin was 45.4%). CONCLUSION: CONS continues to be a challenge to neurosurgeons in the treatment of shunt infections. Adequate prophylactic antibiotics based on the local susceptibility pattern should be administered besides strengthening the infection control protocols of the hospital. Surveillance of healthcare-associated infections may well extend to shunt infections at the locations where insertions are carried out.
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CASE REPORTS Top

Endogenous endophthalmitis caused by Aspergillus flavus in an immunocompetent individual – A rare case with review of literature p. 34
Suneetha Viswanathaiah, Manohar Babu, M Manjunatha
DOI:10.4103/jacm.jacm_8_18  
There are very few reports of Aspergillus flavus causing endogenous Aspergillus endophthalmitis (EAE) in immunocompetent individuals although it is well recognized in the immunocompromised. Treatment can be with intravitreal, intravenous and oral antifungal agents. We present a case of EAE in a 23-year-old female with no predisposing risk factors. A detailed systemic evaluation failed to reveal any systemic focus or predisposing factor for fungal infection. The patient had received an intravenous dextrose infusion two days before this episode while being treated at a rural hospital for fever. She presented with a sudden loss of vision and was subsequently managed with intravitreal voriconazole therapy. This case adds to the limited literature on the prevalence of endogenous endophthalmitis in immunocompetent patients and supports the use of voriconazole in such cases.
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Fungal prosthetic valve endocarditis by amphotericin-resistant Candida parapsilosis: A case report from South Kerala p. 38
KM Rafeeda, M Geethanjali, BL Umapathy, Mary Mathew
DOI:10.4103/jacm.jacm_1_19  
Fungal prosthetic valve endocarditis is a rare but serious complication of valve replacement surgery. We describe a case report of prosthetic valve endocarditis caused by Candida parapsilosis resistant to Amphotericin B, and the patient was completely recovered due to prompt redo surgery and with Caspofungin and Fluconazole therapy.
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Phaeoacremonium parasiticum hand infection in renal transplant patient p. 40
Sheeja T M Rajan, Sindhu Bhaskaran, Mamta George, Sapna Helen George
DOI:10.4103/jacm.jacm_24_18  
Phaeohyphomycosis is a group of rare opportunistic infections caused by dematiaceous fungi. Their significance in the newly emerging and rare fungal infections of solid organ transplant recipients is being increasingly recognised. We present a case of fungal infection of both hands in a post-renal transplant patient on immunosuppressive drugs, by Phaeoacremonium parasiticum. Diagnostic confirmation by fungal cultures, histopathologic examination with special stains and confirmation by polymerase chain reaction technique was done. Remission was achieved by a combination of surgical debulking followed by systemic azoles, intralesional amphotericin B and saturated solution of potassium iodide. Significance of such infections in transplant tourism is implicated since the fungus is frequently found in tropical and subtropical regions.
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Gram's stain report of bone marrow aspirate that proved to be a lifesaver in a case of fever of unknown origin p. 44
Sumana Mahadevaaiah Neelambike, Sowmya Govindanahalli Shivappa, Chetak Kadbasal Basavaraj
DOI:10.4103/jacm.jacm_32_18  
Gram's stain is an invaluable, simple and inexpensive staining technique which gives a clue to the aetiological bacterial agent, thus helping in choosing the appropriate antibiotic. The significance of Gram's stain in bone marrow aspirate has not been described in previous literature. This is the case report of a child who presented with fever of unknown origin, where all high-end investigations proved inconclusive, but Gram's stain of bone marrow showed both extra-cellular and intra-cellular gram-positive cocci in clusters morphologically resembling Staphylococcus. This report helped the paediatricians choose the right antibiotic that proved to be a lifesaver of the child.
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Mixed opportunistic infection with Mucor, Aspergillus and Candida in oculo-rhino-cerebral mycosis: An uncommon case p. 47
Deepa Pandey, Meenakshi Agarwal, Seema Chadha, Divya Aggarwal
DOI:10.4103/jacm.jacm_2_19  
Mucormycosis is a life-threatening invasive fungal infection usually occurring in immunocompromised patients or in patients with uncontrolled diabetes mellitus. It carries a high mortality rate. Aspergillosis which is caused by Aspergillus species may cause an invasive disease in immunosuppressed patients. A 63-year-old female patient with type 2 diabetes mellitus presented with sudden onset painless diminution of vision in the right eye and restriction of orbital movements. Oculo-rhino-cerebral mucormycosis was diagnosed on contrast-enhanced computed tomography scan. Histopathology and fungal culture showed mixed infection with Mucor, Aspergillus and Candida. Liposomal Amphotericin B was started and surgical debridement was done.
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SHORT COMMUNICATION Top

The cost of keeping a hospital clean: Insights from a cancer hospital in East India p. 50
Jonathan Lister, Saswati Rakshit, Srabanti Bose, Kingshuk Dhar, Maitrayee Sarkar De, Sanjay Bhattacharya, Venkata Raman Ramanan, Aseem Yogishwar Mahajan, Mammen Chandy
DOI:10.4103/jacm.jacm_10_18  
CONTEXT: Assessment of cleaning cost of hospitals is important for hospital administrators, infection control experts and housekeeping managers. Such data are lacking in the medical literature. AIMS: The aim of this study was to determine the cleaning cost of a tertiary care not-for-profit private cancer hospital. SETTINGS: This study was conducted in Tata Medical Center, Kolkata, India, which has 183 inpatient beds. DESIGN: This was a retrospective observational study. MATERIALS AND METHODS: Cleaning cost assessment was done from financial records over one financial year (April 2015–March 2016). The methodology involved taking into account the cost of various types of wastes (general, biomedical and microbiological), human resource cost (housekeeping staff salary), laundry cost, costs of cleaning equipment, cost of consumables (personal protective equipment, soap solutions, disinfectants, cleaning mops etc.) and the cost of water consumption. STATISTICAL ANALYSIS: No special statistical tests were used. RESULTS: The cost of keeping the hospital clean was INR Rs. 49,206,015 ($745,546 USD/€668,854). This comprised 4% of the total operational expenditure of the hospital. The maximum proportion of cost for cleaning hospitals was due to housekeeping staff salaries (66%), followed by cost of laundry (17%) and cost of cleaning consumables (13%). The trend analysis of the multidrug-resistant organism (MDRO)-related bacteraemia rate during the study period (calendar year of 2015 and 2016) showed a slight reduction of Methicillin- resistant Staphylococcus aureus, Vancomycin- resistant Enterococci and extended-spectrum beta-lactamase and AmpC beta-lactamase bacteraemia rates. CONCLUSION: Keeping hospital clean is resource intensive. This is an essential strategy to keep MDRO infection rates under control.
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