Objective: To gain better insight into the extent of secondary bacterial and fungal infections in hospitalized patients in India, and to assess how these alter the course of coronavirus disease 2019 (COVID-19) so that control measures can be suggested. Methods: In this retrospective, multicentre study, the data of all patients who tested positive for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) on reverse transcriptase polymerase chain reaction (RT-PCR), admitted to hospital between March 2020 and July 2021, were accessed from the electronic health records of a network of 10 hospitals across five states in North India. Results: Of 19,852 patients testing positive for SARS-CoV-2 on RT-PCR and admitted to the study hospitals during the study period, 1940 (9.8%) patients developed secondary infections (SIs). Patients with SIs were, on average, 8 years older than patients without SIs (median age 62.6 vs 54.3 years; P <0.001). The risk of SIs was significantly (P <0.001) associated with age, severity of disease at admission, diabetes, admission to the intensive care unit (ICU), and ventilator use. The most common site of infection was urine (41.7%), followed by blood (30.8%) and sputum/bronchoalveolar lavage/endotracheal fluid (24.8%); the least common was pus/wound discharge (2.6%). Gram-negative bacilli (GNB) were the most common organisms (63.2%), followed by Gram-positive cocci (GPC) (19.6%) and fungi (17.3%). Most patients with SIs were on multiple antimicrobials. The most commonly used antibiotics against GNB were beta-lactam/beta-lactamase inhibitors (76.9%), carbapenems (57.7%), cephalosporins (53.9%), and antibiotics against carbapenem-resistant Enterobacteriaceae (47.1%). Empirical use of antibiotics against GPC was seen in 58.9% of patients with SIs, and empirical use of antifungals was observed in 56.9% of patients with SIs. The average length of hospital stay for patients with SIs was almost twice as long as that of patients without SIs (median 13 vs 7 days). Overall mortality among patients with SIs (40.3%) was more than eight times higher than that among patients without SIs (4.6%). Only 1.2% of patients with SIs with mild COVID-19 at admission died, compared with 17.5% of those with moderate COVID-19 at admission and 58.5% of those with severe COVID-19 at admission (P <0.001). The mortality rate was highest in patients with bloodstream infections (49.8%), followed by those with hospital-acquired pneumonia (47.9%), urinary tract infections (29.4%), and skin and soft tissue infections (29.4%). The mortality rate in patients with diabetes with SIs was 45.2%, compared with 34.3% in those without diabetes (P < 0.001). Conclusions: SIs complicate the course of patients hospitalized with COVID-19. These patients tend to have a much longer hospital stay, a higher requirement for oxygen and ICU care, and a significantly higher mortality rate compared with those without SIs. The groups most vulnerable to SIs are patients with more severe COVID-19, elderly patients and patients with diabetes. Judicious empirical use of combination antimicrobials in these groups of vulnerable patients can save lives. It is desirable to have region- or country-specific guidelines for appropriate use of antibiotics and antifungals to prevent their overuse.

Gastro – intestinal duplications are usually detected in children before 2 years of age due symptoms/complications associated with the condition or during surgery in the child for some unrelated condition. In adults colonic duplication is of rare occurrence and often diagnosed during surgery. However, it may be diagnosed pre operatively due to symptoms of obstruction, volvulus or rarely due to perforation. We present an adult having tubular duplication of ascending colon, that presented with perforation. The duplication had a blind end and did not have distal communication. In addition, it had its own blood supply. The management of the case is discussed. Aetiogenesis of the anomaly is enumerated and literature reviewed. For ascending colon duplication similar meaning word accessory ascending colon has also been used in the manuscript.

Sub hepatic caecum and appendix is an uncommon condition. It occurs due to incomplete rotation of foetal foregut and mal descent of caecum. This condition may be mistaken for acute cholecystitis, liver abscess, duodenal perforation or right renal calculus. Diagnosis may be delayed when acute appendicitis develops complications - appendicular rupture, perforation or localized abscess. The condition may be missed on ultra sound and CT abdomen may be inconclusive. Thus, surgeon should have a high index of suspicion in such undiagnosed right upper abdominal pain. In such cases an early diagnostic laparoscopy is suggested to avoid further complications. The present case is being reported due to difficulty in diagnosis of the condition, need for timely surgical intervention to avoid life threatening complications.

Gall bladder duplication is a rare congenital anomaly. True duplication is still rarer. Pre-operative detection helps in avoiding complications or missing the gall bladder during surgery. Ultrasonography (USG) and magnetic resonance cholangiography are investigation of choice. Laparoscopic cholecystectomy is the preferred modality for management of double gall bladder. We present a case diagnosed as cholelithiasis on USG. While doing laparoscopic surgery 2 gall bladders were found. She had a normal gall bladder that was lying in the supraduodenal area. It had cystic duct that joined the common bile duct. There was an accessory gall bladder attached to the anterior free margin of the liver. This gallbladder was occluded with a big solitary calculus occupying the whole of gall bladder cavity and had a small feeding vessel; whereas its duct had fibrosed.