The treatment of infections caused by carbapenem-resistant organisms is challenging. Carbapenems in combination with vaborbactam and relebactam are recommended to treat infections caused by extensively drug-resistant organisms including carbapenemase-producing isolates, while ceftazidime-avibactam plus aztreonam, or cefiderocol is recommended for infections caused by New Delhi metallo beta-lactamase (NDM)-producing Enterobacteriaceae. As, in India, except for ceftazidime-avibactam and aztreonam, the other drugs are not approved for marketing, in this case report, the role of a double carbapenem regimen (ertapenem plus meropenem) in the treatment of carbapenem-resistant Klebsiella pneumoniae infections has been presented. In one case, the in vitro effect of the double carbapenem regimen on pan drug-resistant (PDR) K. pneumoniae isolates from a blood culture specimen of a critically ill patient using a time-kill study is presented. In this case, only a double carbapenem regimen with 2 MIC (minimum inhibitory concentration) meropenem + 2 MIC ertapenem demonstrated bactericidal activity by inhibition of bacterial growth of PDR K. pneumoniae isolate, at four and eight hours, which was sustained till 24 hours. However, while 2 MIC meropenem + 2 MIC colistin inhibited bacterial growth at four hours and eight hours, bacterial regrowth occurred by 24 hours. In addition, four cases of critically ill patients with infections caused by carbapenem-resistant Enterobacteriaceae are presented in whom a double carbapenem regimen was recommended for treatment. Of these four cases, a complete clinical cure was observed in three cases, and a microbiological cure in the fourth case. As the double carbapenem regimen demonstrated effect in an in vitro time-kill study in the first case and on clinical outcomes in three out of the latter four cases, it appears to be a life-saving, salvage therapy in infections caused by carbapenem-resistant K. pneumoniae in India.

Introduction: Blood cultures play an important role in the early diagnosis of sepsis and its management. Early detection of pathogens in Blood Stream Infections (BSI) and their Antimicrobial Susceptibility Testing (AST) pattern, plays a vital role in the diagnosis of sepsis and is important for guidance of appropriate therapy. Aim: To evaluate the accuracy of shortly incubated blood cultures in comparison with standard method for an early Identification (ID) and AST. Materials and Methods: This was a prospective observational study undertaken from July 2015-June 2016 at Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India. The blood cultures were loaded in the BacT/Alert system. A total of 92 patients with two sets of blood cultures that flagged positive within 24 hours of collection were included in the study. Grams stain and subcultures of the broths were done. The culture plates were examined after four hours and then at hourly intervals for the presence of growth. Once the growth was sufficient it was processed immediately for ID and AST by Vitek 2C. Incubation of the plates was continued for the rest of the 24 hours at 37oC and was processed again. The mean time for detection were compared between short and standard cultures. Results: Gram negative pathogens were the predominant organisms isolated in 82/92 (89%) followed by Gram positive in 10/92 (10%). The short and standard cultures had comparable results with respect to ID of the isolates. But, the AST results were comparable only in 88/92 (95.6%) patients. Of the remaining four patients, the AST showed Very Major Error (VME) in 3 (3.3%) patients and Major Error (ME) in 1 (1.08%) patient. Conclusion: Short incubation of cultures enabled earliest ID and AST of the isolates from blood cultures than standard incubation

Purpose: To report a retrospective series of three cases of infectious panophthalmitis post-dengue fever with ex vivo confirmation of dengue virus ribonucleic acid (RNA) in the tissues of the eye. Methods: Four eyes of three patients, who were diagnosed with panophthalmitis following dengue fever and who underwent evisceration, were included. All demographic and clinical data were recorded. The eviscerated samples were subjected to direct microscopy, culture for bacteria, fungi, and parasites, and molecular virology (dengue virus [DENV] NS1-specific reverse transcription loop-mediated isothermal amplification (RT-LAMP) assay). Results: The time from the development of dengue fever to the occurrence of ocular symptoms was 4.33 ± 1.15 (median 5) days. DENV NS1 RNA, suggestive of the presence of the dengue virus, was confirmed in all evisceration specimens (uveal tissue, cornea). All the patients recovered completely from dengue fever and on follow-up had healthy eviscerated sockets. Conclusion: Demonstration of the DENV RNA in the eviscerated specimens of panophthalmitis following dengue fever implicates the DENV in the pathophysiology of the ocular infection.

Fungal infections with non-Aspergillus species are increasingly reported even among immunocompetent individuals. We report a case of bilateral injection abscesses by Scedosporium apiospermum in an immunocompetent patient. This rare fungus was isolated and identified by culture from the surgical tissue and was confirmed by Vitek MS and sequencing of the internal transcribed spaces region of rDNA. The patient is being treated with Voriconazole for the past 3 months with no recurrence of the abscesses.

Introduction: Urosepsis is a serious, life-threatening consequence of a complicated Urinary Tract Infection (UTI). It is caused by bacterial infection of the urinary tract or prostate that spreads into the bloodstream. Since urosepsis is associated with a very high mortality rate (20-40%), an early diagnosis and identification of the causative bacteria is important so as to facilitate a prompt treatment with appropriate antibiotics. Nearly 50% cases of urosepsis are caused by the Gram Negative Bacterial (GNB) pathogen, Escherichia coli(E. coli). Aim: To determine the bacteriological profile, antimicrobial susceptibility pattern, phenotypic resistance of the organisms associated with urosepsis and to correlate the levels of proinflammatory markers with the clinical outcome of the patient associated with urosepsis. Materials and Methods: This was a prospective observational study including all patients with simultaneously positive urine and blood cultures, with identical bacterial isolate(s). The details of clinical presentation, antibiotic therapy and other relevant information such as C-Reactive Protein (CRP) and Procalcitonin (PCT) values were recorded and analysed using Microsoft office excel 2013. Results:E. coli was the commonest isolate (43/53, 81.1%). Of the total 43 E. coli isolates, 4/43 (9.3%) were Extended Spectrum Beta Lactamase (ESBL) producers and 23/43 (53.49%) were Carbapenemase producers. Significant rise of the proinflammatory markers (PCT>10 ng/mL) and (CRP>100 mg/l) were associated with high mortality (49%). Out of the 53 patients, 43.4% (23/53) patients had more than one risk factor associated with severe sepsis and poor prognosis. conclusion: Early recognition of symptoms followed by accurate diagnosis and early goal directed therapy is essential to decrease morbidity and mortality from urosepsis.

Carbapenemases play important roles in conferring resistance to beta-lactam antibiotics, including the carbapenems. Detection of carbapenemase activity helps to understand the possible mechanism(s) of carbapenem resistance. Identification of carbapenemases is currently being done by various phenotypic methods and molecular methods. However, innovative biochemical and spectrophotometric methods are desirable as they will be easy to perform, affordable, and rapid. A novel chromogenic method called Carba NP test was introduced recently to screen for carbapenemases in clinical isolates of gram-negative pathogens. We adopted this assay (1) to detect the total carbapenemase activity, (2) to discriminate Class A, B, and D carbapenemases with inhibitors, (3) to compare with carbapenemase genotype, and (4) for direct differential diagnosis of carbapenemases in uncultured clinical sample such as tracheal aspirate. The study included 132 purulent tracheal aspirates. All samples were processed and screened by a protocol optimized in our laboratory, which showed good sensitivity and correlation with genotyping and conventional phenotyping. Our protocol not only offers the fastest way to identify the pathogen but also its carbapenemase profile, directly from uncultured clinical samples in less than 4 hr. Our protocol is currently being validated on other types of clinical specimens in our laboratory.

Currently, available phenotyping and commercial methods report A. baumannii only as Acinetobacter calcoaceticus-baumannii complex (ACB) and do not identify individual members of the complex.This is a single blind study aimed to evaluate certain commonly used species-specific genetic markers namely, Intergenic Transcribed Spacer region in 16S rRNA of A. baumannii (Ab-ITS) and gyrB, for identification of ACB members.These molecular targets were first validated on clinical isolates (n = 200) and subsequently on uncultured tracheal aspirates (n = 172).Among the clinical isolates, 183/200 (91.5%) were positive for Ab-ITS.The clinical isolates 17 (17/200) which are failed to amplify in Ab-ITS PCR were subsequently diagnosed by gyrB PCR as A. calcoaceticus (n = 2), A. pitti (n = 6) and A. nosocomialis (n = 9) but not A. baumannii.Among the tracheal aspirates, 62 samples were reported as sterile in Advanced Expert System of VITEK-2, among the remaining 110 samples, 68.1% (75/110) samples contained Ab-ITS target.Twenty-five of the sterile samples (25/62) were found to contain Ab-ITS target sequence.Since, our sample processing method enabled identification of all the species of ACB complex by PCR even in uncultured tracheal aspirates, adaptation of our protocol would enable same day (6 -8 h) reporting and help the clinician make evidence based therapeutic decision quickly.

Purpose. Rapid and accurate detection of carbapenem resistance is a critical requirement for the selection of appropriate therapy and initiation of infection control measures. Although several tests are available, their use is limited by one or more factors. Phenotypic tests are lengthy, have variable sensitivity and specificity and do not generally identify the carbapenemase. Molecular assays overcome many of these issues but cost can be a barrier to adoption, particularly in low-resource settings. To address the need for affordable, molecular tools, we have assessed the performance characteristics of loop-mediated isothermal amplification (LAMP)-based assays for the major carbapenemase genes, blaNDM, blaKPC, blaOXA-48, blaOXA-23 blaVIM and blaIMP.Methodology. The assays were validated using 1849 Gram-negative Indian clinical isolates obtained from seven hospitals and diagnostic centres.Results. The assays had diagnostic sensitivities of 98.14 %, 98.92 %, 100 %, 98.48 %, and diagnostic specificities of 98.94 %, 99.61 %, 97.42 %, 99.38 % for blaNDM, blaOXA-48, blaOXA-23 and blaVIM, respectively. Due to a low number of isolates positive for blaKPC and blaIMP, the performance characteristics of assays for these two genes could not be suitably evaluated.Conclusion. The performance characteristics suggest suitability for diagnostic and surveillance purposes.

Apophysomyces elegans species complex is an important cause of cutaneous mucormycosis in India. However, majority of those cases are reported as case reports only. We desired to analyze our patients with Apophysomyces infection reported over 25 years (1992-2017) to understand the epidemiology, management, and outcome of the disease. During the study period 24 cases were reported, and the majority (95.8%) of them presented with necrotizing fasciitis following accidental/surgical/iatrogenic trauma. One patient presented with continuous ambulatory peritoneal dialysis (CAPD) related peritonitis. Healthcare related Apophysomyces infection was noted in 29.2% patients. In addition to trauma, comorbidities were noted in 37.5% patients (type 2diabetes mellitus-6, chronic alcoholism-2, and chronic kidney disease-1). Of the 24 isolates, 11 isolates starting from year 2014 were identified as Apophysomyces variabilis by molecular methods. Majority (95.8%) of the patients were managed surgically with or without amphotericin B deoxycholate therapy, while one patient was treated with amphotericin B deoxycholate alone. Among 24 patients, seven (29.1%) recovered, six (25%) patients could not afford antifungal management and left the hospital against medical advice, and 11 (45.9%) patients died.The present case series highlights that necrotizing fasciitis caused by A. variabilis is prevalent in India, and the disease may be healthcare related. Although diagnosis is not difficult, awareness among surgeons is still limited about the infection, leading to a delay in sending samples to the mycology laboratory. Apophysomyces infection must be considered in the differential diagnosis in apatient with progressive necrosis of a wound who is not responding to antibacterial therapy.

Skin and soft tissue infections (SSTIs) with Nontuberculous Mycobacteria (NTMs) are increasingly encountered in recent times. We describe a case of a chronic non-healing ulcer on the foot of a young immunocompetent lady caused by Mycobacterium simiae. The diagnostic approach and successful management of the case have been reviewed. This is probably the first case report SSTI due to M. simiae from India.

INTRODUCTION:Pyogenic infections are an important cause of sepsis. These infections are difficult to treat because of the pathogens with increasing antibiotic resistance. It is important to know the pathogens causing the infections and its antibiotic susceptibility for proper management of the patients.METHODOLOGY:A retrospective analysis of 1428 culture positive pus and tissue samples received in the department of microbiology from various departments in the hospital between January 2012 to 2017 was performed. Data regarding the pathogen isolated and its antimicrobial susceptibility were collected and analyzed. The specimens were primarily processed, as per standard methods. Identification and susceptibility testing was done using the Vitek-2C system.RESULTS:Among the samples males outnumbered females (M: F-2.5:1) and the median age was 47 years. The total number of patients were 1428 with total number of isolates being 1525 as in our study monomicrobial infections were seen in 93.2% (1331/1428) patients whereas combined infections with growth of two pathogens in 6.8% (97/1428). Gram-negative bacilli were isolated in 68.3% (1042/1525). Among the Gram-negative bacilli Escherichia coli was the major pathogen isolated (38.6%, 403/1042). Gram positive organisms were isolated in 31.6% (483/1525) of cases and Staphylococcus aureus was the predominant organism isolated (91.7%, 443/483). Rare pathogens like Burkholderia pseudomallei in 3 patients and Nocardia in one patient were also isolated.CONCLUSION:This study emphasizes to understand the common organisms isolated from wound infections and it helps in empirical treatment of patients based on antibiotic susceptibility patterns.

INTRODUCTION: Chronic osteomyelitis (COM) is a common infection, especially in developing countries. An adequate bone biopsy specimen processed with appropriate microbiology culture methods for isolation and identification of the causative organisms is considered as the gold standard for the diagnosis of osteomyelitis. MATERIALS AND METHODS: The present study is a retrospective microbiology analysis of the specimen from 219 clinically diagnosed cases of COM between January 2013 and April 2016. RESULTS: The overall culture positivity was 111/219 (50. 6%), colonization was seen in 22/219 (10.5%), while the rest 86/219 (39.3%) were culture-negative specimen; culture positivity was highest from tissue specimen (71/113, 62.8%). Among the swabs, 40/106 (37.7%) were culture positive. About 28/40 (70%) culture-positive swabs showed significant growth of Gram-positive organisms. Colonization with skin flora such as diphtheroids and Coagulase-negative Staphylococci was seen in 22/106 (20.7%) of the swabs. Sterile cultures (44/106, 41.6%) were high among the swab specimen. Gram-positives were most common (75/111, 67.56%). Staphylococcus aureus was the predominant organism isolated in 70/111 (63%) cases. Gram-negative bacilli showed a high level of antibiotic resistance. CONCLUSION: As per our data, the culture yield from wound swabs was low or contaminated with normal skin flora, as compared to the biopsy or tissue specimen. Hence, an appropriate sampling of the infected bone using recommended protocols is highly essential for improving microbiological yield and the outcome of COM.

BACKGROUND: Infection with Salmonella has become an increasing problem worldwide. Recently, nontyphoid Salmonella (NTS) has become a global concern causing threat to the health of human. It causes gastrointestinal infection which may be self-limiting, but invasive infections may be fatal, requiring appropriate therapy. This study was done to analyze the spectrum of NTS infections causing extraintestinal infections and its susceptibility pattern from a tertiary care center in India. MATERIALS AND METHODS: The medical records of 27 patients whose cultures were positive for NTS between the years 2013-2016 were included in this retrospective study. The relevant demographic, clinical, and laboratory data were analyzed. RESULTS: Among the 27 patients, predominant patients were in the age group of 20-30 years. The male to female ratio is 1.7:1. Salmonella typhimurium was the predominant NTS isolated among 15/27 (55.5%), followed by Salmonella enteritidis 4/27 (14.8%). 18/27 (66.6%) of NTS were isolated from blood. Nalidixic acid was sensitive in 2/15 of S. typhimurium, 2/4 of S. enteritidis and 1/3 of Salmonella weltevreden, while others are nalidixic acid-resistant implying resistance to quinolones. They were sensitive to other antibiotics reported. CONCLUSION: This study highlights the spectrum of NTS causing extraintestinal infections which is an emerging infection occurring mostly in immunosuppressed individuals. There should be a high degree of clinical suspicion which would help in the early diagnosis and management of patients.

Background and Objectives: Intra-abdominal infections (IAIs) include a wide spectrum of pathological conditions, ranging from uncomplicated appendicitis to fecal peritonitis .The resulting infections should be diagnosed early and treated based on the organism isolated and its susceptibility. In this study the bacteriological profile and antimicrobial resistance pattern of intra-abdominal infections was analyzed. Materials and Methods: A retrospective analysis of samples received from 119 cases of intra-abdominal infections in our Institute from January 2015 to December 2017 was analyzed. Patients with primary peritonitis from cirrhosis or ascites were not included in the study. The specimens were primarily processed, as per standard methods. Identification and antimicrobial susceptibility testing was done by the Vitek-2 system. Anaerobic culture was performed on 5% sheep blood agar plates and incubated in GEN bag anaerobic pouches. Results: In our study perforative peritonitis 43/119 (36.1%) was predominant IAI followed by acute pancreatitis 14/119 (11.7%) and pancreatic necrosis 12/119 (10%). Microbial growth was observed in 66.3% (79/119) of the cases and combined infections were observed in14/119 (11.7%) of the cases. Escherichia coli was the predominant organism isolated in 58/119 (40.8%), out of which 41/58 (70.6%) were ESBL producers and 16 /58 (27.5%) were multi drug resistant isolates. Klebsiella pneumoniae was isolated from 11/119 (9.2%) cases out of which 8/11 (72.7%) were ESBL and 3/11 (27.2%) were multidrug resistant isolates. Post-operative complications was observed in 12/119 (10%) patients with mortality in 15/119 (12.6%) patients. Conclusion: Early diagnosis and appropriate management of the infections will help to prevent the morbidity and mortality associated with these infections.

Background and Objectives: Infective endocarditis (IE) is a microbial infection of the endothelial surface of the cardiacvalves. Rapid diagnosis, effective treatment and prompt recognition of complications are essential, in order to improve the outcome. We retrospectively reviewed and determined the clinical characteristics, microbiological profile and management strategies of IE cases, changing microbial spectrum of pathogens and outcome in Native Valve Endocarditis (NVE) and Prosthetic Valve Endocarditis (PVE) cases. Materials and Methods: We retrospectively reviewed the medical records of 191 patients, clinically diagnosed with IE, based on modified Dukes criteria, from January 2011 to December 2016. Blood cultures received from all these patients were processed, using BacT/Alert system (bioMerieux, Marcy l'Etoile, France). Results: Sixty eight (68/191) cases were positive for bacterial pathogens. Twenty four (24/191) cases had PVE and 167/191 had NVE. Nineteen cases (19/24, 79.1%) were PVE positive and forty nine (49/167, 29.3%) were NVE positive. Culture negative endocarditis cases were 123/191 (64.39%). The most common pathogen isolated from NVE cases, in our study was Streptococcus mitis, followed by methicillin-resistant coagulase negative staphylococcus (MRCONS) in PVE. The NVE were treated intravenously with a combination of a β-lactam or glycopeptide with an aminoglycoside, for prolonged period of 4-6 weeks, with a successful outcome. The PVE cases were treated with the appropriate antibiotics as per the antibiotic susceptibility report. Conclusion: The high morbidity and mortality rates are associated with IE and hence accurate identification of aetiological agents and appropriate antimicrobial therapy is required.

The diagnostic performance of AO stain was evaluated for the detection of bacteria and or fungi from positive blood cultures. The sensitivity of Gram stain (GS) was 98.26% while Acridine Orange (AO) stain proved to be more sensitive (100%) with a Positive and Negative Predictive Value of 100% each. The specificity of both the stains was 100%. Overall agreement between the two stains was 98.23% (688/700). The organisms that were missed by GS and positive by AO were Candida species (Sutton, 2006) and Gram negative bacilli (GNB) (Sutton, 2006). Sensitivity of GS was 82.35% and AO was 100% among mixed cultures. Immediate reporting of the results of AO stain would have a significant impact on clinical management of patients with serious blood stream infections.

Renal transplantation is an effective and commonly performed procedure for end-stage renal disease. Urinary tract infections are a major cause of morbidity and mortality in renal transplant patients. As data on postrenal transplant urinary tract infections from the Indian subcontinent are limited, the present study was conducted to estimate the burden of urinary tract infections in this vulnerable group of patients. This was a prospective study on patients undergoing renal transplantation in 2014 at our tertiary hospital in South India with a follow-up of 2 years to evaluate the risk factors for urinary tract infections. The prevalence of urinary tract infections was 41.9% with a male preponderance of 76.9%. Mean age of the 31 patients was 32.4 ± 10.2 years (range: 16–55 years). Gram-negative bacilli were the most common isolates with Escherichia coli being the predominant pathogen (53.3%). All the infections occurred within 1 year of transplantation with delayed graft function (P < 0.001; confidence interval [CI]: 29.0–96.3) and prolonged hospital stay (P = 0.0281; CI: 42.1–99.6) being the significant risk factors for acquiring urinary tract infections. Carbapenemase production was noted in 33.3% of isolates and all the Gram-negative organisms isolated in the 1st month of transplantation were carbapenem-resistant (CR) E. coli. The high rate of carbapenem-resistant organisms in the early posttransplant period is a point of concern, especially with cadaver transplants. Infection control practices and catheter care need to be strictly monitored to minimize the risk for UTI in the immediate posttransplant period.

Background: Dengue fever is a rapidly spreading mosquito-borne viral disease in the world. Methods: We prospectively studied adult patients with dengue fever (n=148) at our tertiary care teaching hospital from November 2010 to September 2012. Their clinical presentation, laboratory manifestation and outcome are reported. Results: Eighty eight (59.1%) patients had severe forms of dengue fever. The various complaints noted by patients included vomitings, headache, body aches, low backache, retro-orbital pain, rash, loose motions, pain abdomen and jaundice. Melena was the most common bleeding manifestation. Thrombocytopenia was present in 91.9% of patients. Elevation of hepatic transaminases was found in 80.9% of patients. Hypoalbuminemia (serum albumin <3. 5 g/dL) was present in 62 (42.9%) patients. Albuminuria was seen in 39 (26.4%) patients. Abdominal ultrasonography showed ascites in 28.6%, hepatomegaly in 26.1%, splenomegaly in 28.4%, and acalculous cholecystitis in 20.5%. Chest radiograph showed pleural effusion in 31(21%) patients. Electrocardiogram revealed bradycardia in 30 (20.3%) patients. Packed red cell transfusion was given to 14 (9.5%) patients and platelet rich plasma (PRP) and single donor platelets (SDP) were given to 36 (24.3%) patients with severe dengue fever. Of the 148 patients, nine (6.1%) died. Conclusions: Fever, vomiting were the most common symptoms, melena was the most common bleeding manifestation in patients presenting with dengue fever.