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Context: Water is an important resource for hospitals. There are few studies about the quality, quantity and cost of water that is required for health care. Aims: To study the quality, quantity, cost and applications of water in a hospital. Settings and Design: Observational study. The study was done in a cancer hospital in eastern India. Methods and Material: Water generation and consumption patterns and costing were assessed after: Discussion with the engineers; analysis of documented records; observation of patient/visitor/staff behaviours; measurement of flow rates and metered readings; Individual water consumption surveys. Statistical Analysis Used: None. Results: The total filtered reverse osmosis (RO) water used by the hospital per day was 200,000 L. This equated to 1093 L/patient/day. The volume of filtered reversed osmosis water consumed showed that the total water usage for drinking was 1%, water usage for hand-washing was 18%, water usage for showering was 6%, kitchen water consumption was 2%, housekeeping activities usage was 4%, central sterile supply department usage was 4%, heating, ventilation, and air conditioning systems usage was 36%, hot water consumption was 5% and toilet flush usage was 24%. Cost was Rs. 1119/- for 10,000 liters of RO water and about Rs. 31/- for 10,000 liters of raw water. Conclusions: The economics of hospital water both in terms of consumption and cost is a valuable source of information for hospital planners, administrators and hospital engineers.

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Inconclusive SARS CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) reports for the detection of infection in symptomatic patients or during screening of asymptomatic contacts can cause clinical, diagnostic and infection control uncertainty. It has been noted that up to 5% of COVID RT-PCR reports may be inconclusive. The reasons for these inconclusive reports are varied and may be classified into virological causes, sample collection and sample quality-related issues and finally technical issues related primarily due to problems in RNA extraction. The objective of this article is to discuss these causes and suggest corrective measures.

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A 20-year-old female patient presented with complaints of redness, irritation, foreign body sensation, pain and excessive watering in the right eye since one month. On examination, conjunctiva was congested with pseudo membrane over the inferior fornix. Staphylococcus aureus was isolated from the conjunctival swab. Case was diagnosed as pseudomembranous conjunctivitis (PMC) caused by Staphylococcus aureus.

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Blood culture remains the most important microbiological investigation in the management of sepsis. The conventional definition of sepsis has been challenged recently and likely to increase number of patients screened for sepsis due to the change in the definition. Blood culture contamination still remains a challenge, especially in resource poor settings where educational facilities are limited. Clinical correlation of positive (as well as negative) blood culture is an important aspect of the investigation where a clinical microbiologist can significantly impact on the management of sepsis.

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Colistin is an important antibiotic against multidrug-resistant (MDR) Gram-negative bacteria (GNB), particularly Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii. Although it is an old antibiotic, Colistin has emerged as an important agent in the treatment of GNB infections, especially those caused by MDR pathogens in hospitalised patients. Limited therapeutic option against Carbapenem-resistant Gram-negative bacilli (E. coli, Klebsiella, Pseudomonas and Acinetobacter) is one of the major problems in clinical practice. The current review discusses the pharmacology, toxicity, drug resistance, importance of therapeutic drug level monitoring and cost of one of the most important antibiotics in the current practice.

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CONTEXT: In the wake of a growing burden of health care associated infections (HAIs), health-care workers (HCWs) are advised to revert to simple tools like hand hygiene (HH). AIMS: The aim of this study is to explore the existing knowledge, attitudes and practices with regard to HH, the total HH compliance and the various barriers to HH in our hospital so as to plan the strategies for bridging these gaps, thus improving patient care. SETTINGS AND DESIGN: A cross-sectional study was conducted among 300 HCWs of Jubilee Mission Medical College and Research Institute, Thrissur, belonging to six different categories, for a period of 2 months. MATERIALS AND METHODS: Knowledge, attitude and practices were evaluated using a validated WHO HH questionnaire, a self-structured attitude questionnaire and an observation checklist based on the concept of Five Moments of HH by WHO, respectively. Total compliance and the profile of missed opportunities were also assessed. STATISTICAL ANALYSIS USED: SPSS was used for data analysis. RESULTS: The knowledge on HH was good (190 out of 300, 63.3%), attitudes were poor with nursing staff having significantly better attitude than doctors (P < 0.05). In the observational study, physicians and nursing staff had better practice. Lack of time was the major barrier pointed out. The overall compliance was 46% among the HCWs of whom only 16% had proper HH practice. Rest of the 30% performed HH, but the technique was wrong. CONCLUSIONS: The study highlights the need for reinforcing the existing HH training programmes to address the gaps in knowledge, attitude and practice and thereby improving the level of HH compliance and enhancing patient safety.

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Introduction: Systemic autoimmune diseases include conditions where the immune system fails to recognize self antigens leading to production of "auto antibodies" and subsequent damage to several organs and tissue systems, e.g., Systemic lupus erythematosus, Scleroderma or Systemic sclerosis, Dermatomyosits, Polyarteritis nodosa and Mixed connective tissue disease. Detection of antinuclear antibodies (ANA) has been found to be the single most important criteria for the diagnosis of connective tissue disorders. Materials and Methods: The commonly used methods to detect ANA like ELISA and indirect immunofluorescence (IFA) were evaluated in this study. Results: ELISA showed a sensitivity, specificity, positive predictive value, negative predictive value, false positive rate and false negative rate of 93%, 54%, 60%, 92%, 45% and 7% respectively when compared to IFA. Conclusions: ELISA is non-specific and less useful as a diagnostic test whereas ANA IFA is a more accurate test and the gold standard.

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The clinical microbiology reporting (CMR) for culture and antimicrobial susceptibility test (C and AST) is the most important investigation reported from a microbiology laboratory. However, majority of Indian microbiology laboratories generate a basic level C and AST report comprising of identification of the organism isolated with a list of antimicrobials and their susceptibility results, without any additional comments or messages. This leads to improper communication between the laboratory physicians and clinical physicians. This may further lead to irrational use of antimicrobials, improper specimen collection practices, inappropriate filing of requisition forms and poor infection control practices, which are mainly due to either unawareness or negligence of clinicians. Therefore, it is essential that the laboratory microbiologists of India should uplift themselves to clinical microbiologists and foster their CMR to higher standards by incorporating specific comments, suggestions and advices in the C and AST report, as recommended by the regulatory agencies such as Clinical and Laboratory Standards Institute and European Committee on Antimicrobial Susceptibility Testing. The comments may be of several types which include report categories, in-progress reports, requisition form filling, specimen collection, footnotes in the AST table, infection control advices, antimicrobial agent-related suggestions, predicted susceptibility related and intrinsic resistance comments, etc. The use of comments will greatly help the clinicians to rationalise their antimicrobial practice, improvise practices of specimen collection, requisition form filling and finally instituting the appropriate infection control practices. These comments mentioned in this article are only author's recommendations; the end users may incorporate according their local practice and need.

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Background: The diagnosis of chronic hepatitis B (CHB) infection has progressed from serological to molecular diagnostic methods. The newer sensitive technique of quantitation of hepatitis B virus (HBV) DNA by real-time polymerase chain reaction (RT-PCR) has helped in understanding the clinical stages of CHB, deciding on treatment and monitoring treatment response. Aim: This study aimed to determine the HBV DNA load by quantitative RT-PCR in the various clinical stages of CHB. Materials and Methods: Blood samples of CHB patients from the Gastroenterology Department received from June 2014 to December 2014 in the Microbiology Department were subjected to quantitative PCR analysis for HBV DNA. However, to facilitate analysis, only those patients' samples where hepatitis B e antigen (HBeAg) and alanine aminotransferase (ALT) status were known were selected for the study. Statistical analysis was done using SPSS (PASW statistics 18) for windows software. Chi-square test was used to analyse the differences in DNA level between the study groups. Results: A total of 71 CHB patients were included in the study. Of these, 29 (40.8%) were inactive carriers (HBeAg-negative ALT normal) and 42 (59.2%) were chronic active hepatitis B patients (ALT elevated with HBeAg-positive and HBeAg-negative cases). HBeAg was positive in 26 (36.6%) and negative in 45 (63.3%) patients. Among the 45 HBeAg-negative patients, 16 (22.5%) had CHB. Of the 71 CHB patients, 61 (85.9%) had detectable viral load. Serum HBV DNA load of 16 patients who were HBeAg-negative was significantly lower (median 5.5 × 10⁵) than that of 26 patients who were HBeAg-positive (median 2.4 × 10⁸) and higher than the 29 inactive carriers (median 1.6 × 10³). Based on HBV load, 14 CHB patients who were HBeAg-positive and seven who were HBeAg-negative were started on antiviral therapy. Conclusion: Quantitation of HBV DNA based on HBeAg and ALT status helps to determine the stages of CHB. It could play an important role in assessing the status of those patients who are HBeAg-negative and inactive carriers with respect to viral load, as the former require treatment. The major role of HBV DNA determination is to evaluate patients with CHB (HBeAg-positive or HBeAg-negative) and to decide on antiviral therapy.

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Genus Malassezia consists of 14 species of yeast like fungi that commonly causes superficial mycoses. It is a topic of intense interest but its fastidious nature restricts its research. Speciation gives us better treatment strategies especially with global concern over high Minimum Inhibitory Concentrations (MICs) to anti-fungal agents and emerging resistance. Aim of the study was to speciate Malassezia using phenotypic methods and to analyse the risk factors and its clinical correlation. The study was conducted at our university teaching hospital in south India over a one year period after approval by the Institutional Ethics Committee. A total of 105 patients, who had skin lesions resembling diseases caused by Malassezia, were included. The skin scrapings were subjected to 10% KOH wet mount. Culture was put up on Sabouraud's dextrose agar (SDA), with and without olive oil overlay (SDA-O) and modified Dixon's agar. Gram's stain, catalase test, aesculin hydrolysis, Tween assimilation, temperature tolerance and Tween 40-based precipitate production were done to characterise Malassezia species. The most common age was 20-40 years, with a slight female predominance (58.1%). Among the study group (n = 105), 87 had the prototype disease - pityriasis versicolour (PV). Out of 105 patients, 62.9% were fresh cases and 37.1% came with recurrences. The most common site to be affected by PV was the back, followed by chest. M. globosa was the most common species in both the hypopigmented and hyper pigmented groups. In three patients, two species were isolated from the same lesion. A sequential use of these simple tests helps greatly in a financially constrained set up for speciation of Malassezia in the laboratory.

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Background: The pathogenic bacterium on the hands of healthcare workers (HCWs) is considered as the main route of spread of nosocomial infections. The study was aimed to determine the bacterial contamination of hands of HCWs during routine patient care in a large teaching hospital. Material and Methods: This study includes a total of 200 consecutive, non-repetitive participants. Doctors, medical students, nurses and attendants from the Department of Anaesthesia and Department of Medicine of the hospital were included, who were actively providing health care. The informed consent was taken from all the participants of the study. The hand impressions of the participants were taken on 5% blood agar and processed as per guidelines. After taking the hand impressions, hand cleaning of each participant was done by standard preparation of 70% isopropyl alcohol-based hand rub. The hand impressions from the participants were again taken on 5% blood agar plates. Results: Out of 200 samples collected from HCWs, 95 (47.5%) samples showed growth of microorganisms. Most commonly isolated microorganism was Staphylococcus aureus present in 70% of nurses, 60% of students and 40% of attendants. Prevalence of Acinetobacter spp. was also found to be high among nurses (20%), followed by attendants, sweepers (16%) and doctors (4%). Conclusions: Hands of hospital staff are colonised with pathogenic bacteria, especially Gram-positive such as S. aureus. Hand hygiene is an effective method of reducing the bacterial flora on the hands of the HCWs.

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Background and Objectives: Liver abscess is a potentially life-threatening condition with a majority of cases being amoebic in tropical countries. In India, poor sanitary conditions and low socioeconomic status contribute to the endemicity of amoebiasis. As treatment modalities are different for amoebic and pyogenic liver abscesses (ALA and PLA, respectively), it is necessary to differentiate them. Facilities for amoebic culture are not available and microscopy is nondiscriminatory, hence serological tests are greatly relied upon for the identification. No studies have been done so far in our region on patients admitted with liver abscess. The aims of this study were to find the aetiology of liver abscess in admitted patients and to know the proportion of amoebic liver abscess using serological techniques. Materials and Methods: The study was done for 6 months and the sample size was 50. The ultrasonography (USG)-guided aspirates were subjected to microscopy and aerobic and anaerobic cultures on appropriate media. Serum samples of all patients were examined for Entamoeba histolytica immunoglobulin G (IgG) antibodies by enzyme-linked immunosorbent assay (ELISA) along with 35 control samples. Results: Of the 50 patients, 34 were diagnosed as amoebic by (ELISA) (68%), 11 as pyogenic (22%) and five as indeterminate (10%). Alcohol was found to have a higher association with ALA than with PLA. Of the 34 amoebic liver abscesses, only four (8.8%) showed motile trophozoites. The mortality rate was only 2.2%. Conclusion: Rapid diagnosis with serology and prompt treatment can result in reduced hospital stay in cases of ALA.

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Histoplasmosis is commonly found in US and central America; recently cases were diagnosed from Kerala also. The causative organism Histoplasma capsulatum is found abundant in soil mixed with bird or bat guano. Infection occurs by the inhalation of small oval conidia which can enter the terminal bronchioles and then the alveolar spaces. They multiply inside the macrophages and the cellular immune system of the host decides the outcome. Usually it is a self limiting pulmonary infection, but it can vary from mild pneumonitis to severe acute respiratory distress syndrome. If primary manifestation progresses, disseminated histoplasmosis involving liver, spleen, bone marrow, adrenal gland and mucocutaneous membranes result. Skin test antigen is used in epidemiological studies to find the true extent of infection. Rapid diagnosis is possible with histoplasma antigen detection but serology is useful only in certain cases. Histopathology aids the diagnosis a lot. But the fungal culture remains the gold standard for the confirmation. Histoplasmosis is successfully treated with azoles if it is a mild infection and if severe liposomal Amphotericin B is used initially and then switched over to Itraconazole to be continued for several months.

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Low-temperature sterilisation basically depends on four types of sterilisation systems, i.e. gamma irradiation, Ethylene oxide sterilisation, Hydrogen peroxide (H₂O₂) and steam Formaldehyde sterilisation. The article has been described on the basis of these low-temperature sterilisation systems with their infrastructural ease, regulatory requirements, cycle time, sterilisation efficacy, safety features and cost. In our experience, the H₂O₂-based sterilisation system is superior over the other methods due to its easy installation and cycle time that helps to perform more procedure in a day and reduces infection by providing terminal sterilisation (ready-to-use) processes. Besides due to the short cycle time of the H₂O₂ steriliser, it requires fewer inventories and saves cost to the management in the long run.

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A case of left subclavian artery aneurysm with thrombus from which Moraxella group was recovered on culture is described. Patient had presented with life threatening hemoptysis, which on computed tomography (CT) scan evaluation of the chest, revealed a fistulous communication between aneurysm from the origin of left subclavian artery and segmental left upper lobe bronchus. Biochemically on the Vitek system and by growth characteristics organism present was identified as Moraxella osloensis. It was highly sensitive to all antibiotics tested. Cocci with exactly the same morphology could be seen in the Gram stain of a sputum sample from the patient. Postoperative antibiotics eradicated the bacteria and so no growth occurred on culture of the sputum. To our knowledge, this is the first ever time Moraxella species has been isolated from an arterial thrombus, particularly so from a person with normal heart valves.

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Corynebacterium xerosis is a part of the normal flora of the skin, nasopharynx, conjunctiva and vagina. There are three cases of C. xerosis isolated from various clinical specimens. All the patients were immunocompromised. The clinical condition improved after treatment with Ampicillin and Cephalexin.

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A case of a 3-month-old child with conjunctivitis subsequent to nasolacrimal duct (NLD) obstruction is reported. Serratia marcescens (S. marcescens) was cultured from the discharge from the left eye; the child was treated and cured effectively with appropriate antibiotics.

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Melioidosis is a disease of public health importance in South East Asia and northern Australia, caused by a Gram negative soil-dwelling bacterium, Burkholderia pseudomallei. Sporadic cases are reported from other parts of the world, including India, while detailed information is unavailable. The disease is mainly seen in the population who are in prolonged contact with soil and are diabetic. There is a close association of the disease with rainfall. The primary manifestation is pneumonia with or without septicaemia, but other organs like bone and joints, liver, spleen, lymph nodes may also be affected. Despite improvements in antibiotic therapy, melioidosis is still associated with a significant mortality attributable to severe sepsis and its complications. The accurate and practical diagnostic set up is still unavailable in many parts of India, which leads to under- or mis-diagnosis, and fatality. The disease needs more attention from the microbiologists, clinicians and researchers from India, since studies related to the pathogenesis and virulence factors, preventive measures, vaccine prospects, and better management may reduce the burden of the disease.

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Background: There are limited data on use of line probe assay (LPA) for detection of TB and Rifampicin resistance among extra-pulmonary tuberculosis (EPTB) patients under specific TB control programme settings. Our aim was to compare the positivity of LPA with Lowenstein–Jensen (LJ) and Bactec MGIT and to test its utility in faster testing and in patients on treatment. Methodology: The data of all 387 EPTB samples processed in two years by the state-level accredited laboratory in 2013–2014 were selected for the study. The laboratory used standard N-acetyl-L-cysteine – sodium hydroxide processing method for all samples except for cerebrospinal fluid and urine samples before conducting Ziehl-Neelsen smear microscopy, LPA and culture on both LJ and MGIT. Those samples with a negative LPA result if culture positive was subjected to a second LPA as per laboratory protocol. Doubtful Rifampicin resistant (RR) results were cleared by phenotypic testing by MGIT. Anti-TB treatment (ATT) duration was correlated with positivity of these tests later. Results and Discussion: LPA done on 321 processed samples out of 387 EPTB samples identified eight RR cases among 136 positive results within two to four days. Performing LPA on culture positive isolates identified an additional seven RR cases, thus reducing turn-around-time by two to eight weeks for the susceptibility results. It also demonstrated far better positivity in smear negative (15.2%) and in smear positive samples (74.3%) compared to culture methods as the test demonstrated clearly, better positivity among patients on ATT for more than two months. Conclusion: LPA in association with culture is an excellent combination with very good results in rapid identification of EPTB along with detection of Rifampicin resistance. LPA gives far superior positivity compared to MGIT and solid cultures among patients under ATT.

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Continuous quality monitoring in sterilisation processes is paramount importance for supplying sterile materials to the patients. The sterilisation monitoring is required because early prediction of steriliser malfunctioning is impossible, and malfunction gets detected only when it runs. Internationally there are three types of sterilisation monitoring system such as physical, chemical and biological monitoring. The physical monitoring system is dependent on time, temperature and pressure. The chemical and biological monitoring systems are also dependent on the same physical parameters but in addition require the presence of condensing steam for sterility assurance. The main aim of this article is to elaborate differences between the 'conventional biological indicator' and the 'rapid biological indicator' with their benefits and disadvantages for biologically proven sterility assurances. However, it is not possible to determine whether biological material in the indicator is alive or dead, visually. The article explains that the detection of living spores can be technically challenging, and each and every step should be monitored carefully because spores are highly resistant to harsh environmental conditions. The results show that proper incubation time in an appropriate growth medium and optimal temperature is the only way to detect the living microorganisms in a biological indicator for proper sterility assurance.

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Background: The aim of this study was to determine the prevalence of Group A streptococcus (GAS) pharyngitis and its carriage among schoolchildren in the age group 5-15 years in Barabanki district, Uttar Pradesh, India. The study also aimed to determine the minimum inhibitory concentration (MIC) of Penicillin G, antimicrobial susceptibility pattern and inducible Clindamycin resistance in GAS. Materials and Methods: Three hundred schoolchildren from six different schools were included in the study. Identification of group A streptococcus was done on the basis of Bacitracin sensitivity test, pyrrolidonyl peptidase (PYRase) test and Lancefield grouping by latex agglutination test. Antibiotic susceptibility test and D-zone test were done in GAS isolates. Results: Out of the 300 schoolchildren, GAS was found in three (4.7%) out of 63 symptomatic children and two (0.8%) out of 237 asymptomatic children. The overall prevalence of GAS pharyngitis and of GAS carriage was 1% and 0.67%, respectively. The isolation of GAS was significantly higher in symptomatic cases when compared to asymptomatic cases (P value = 0.0308). All the strains were sensitive to Penicillin, Ampicillin, Quinupristin-Dalfopristin, Vancomycin and Linezolid. Conclusion: A low prevalence of GAS pharyngitis and GAS carriage was observed in the study, probably due to the cross-sectional nature of the study. All five GAS isolates were sensitive to Penicillin.

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Pseudomonas aeruginosa (Ps. aeruginosa) is a classic opportunistic pathogen with innate resistance to many antibiotics and disinfectants. The aim of this study was to find the prevalence and the resistance pattern, phenotypic, and genotypic characterization of Ps. aeruginosa from different source of infection. The present study was carried out with a total of 1000 clinical samples including 500 pus samples and 500 urine samples, which were received from patients admitted in the various departments of Rajah Muthiah Medical College and Hospital, Annamalai University, Chidambaram. Of the 500 pus and 500 urine samples screened, the percentage positivity of Ps. aeruginosa was 12.8% (64) and 4% (20), respectively. Pseudomonas aeruginosa from different samples showed different sensitivity patterns to different antibiotics. In case of isolates from pus, all (100%) were sensitive to Imipenem, while resistance was maximum to Cefotaxime (93.75%). When Pseudomonas aeruginosa isolated from urine was tested for the same antibiotics, sensitivity was maximum (90%) to Tobramycin, while resistance was maximum (80%) to Cefotaxime and Aztreonam. ESBL positive Ps. aeruginosa isolated from pus and urine was 50% and 40%, respectively. The genotype characterization of 25 of these strains showed 6 with CTX-M and 12 with SHV genes.

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Aim: This study was conducted to find out the bacterial aetiological agents of burn wound infections with antimicrobial testing of the bacterial isolates. Materials and Methods: This is a descriptive study of 203 patients with burn wound infections at Government Medical College, Thiruvananthapuram during the period January 2010 to April 2011. The specimens were cultured using aerobic microbiological techniques. Antimicrobial susceptibility testing to different agents was carried out using the disc diffusion method. Results: Cultures from burn wound revealed Pseudomonas aeruginosa as the most common organism followed by Staphylococcus aureus, Escherichia coli, Acinetobacter baumannii and Klebsiella pneumoniae. There was a high rate of multidrug-resistant organisms. However, all the staphylococci were susceptible to Vancomycin and the gram negatives were susceptible to Carbapenems. Conclusion: Collection of appropriate specimens for culture before starting of antibiotics helps in better management, along with isolation precautions. However close follow-up and repeat specimens are necessary for appropriate change in antibiotics. For empiric treatment Vancomycin and Imipenem appear to be a good combination in this hospital.

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Nocardia is known to cause myriad of infections like pulmonary, cutaneous or disseminated in immunocompromised persons. We report a rare case of Nocardia asteroides complex causing chronic suppurative otitis media (CSOM) in a patient with idiopathic thrombocytopenic purpura (ITP), and then leading to cortical venous thrombosis. The patient was treated successfully and discharged till follow-up.

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