cidscon 2017

CIDSCON 2017 7 Annual Conference of th

Clinical Infectious Diseases Society, India Supported by : Society of Critical Care Medicine, Nagpur Chapter

18th | 19th | 20th August, 2017 Venue : Le Méridien Nagpur, Maharashtra Theme : Advancing Science, Improving Care

Abstracts

www.cidscon.in

Oral Papers CIDSCON 2017

2

www.cidscon.in

Antimicrobial Stewardship Journey And It’s Impact At A Multispeciality Tertiary Health Care Facility

___________________________________________________________________________________________

Author Co-authors Institution

: Dr. Sukanya Rengaswamy : Murali Chakravarthy, Chakrapani, Ancy,Frency, Thejasvini, Priyadarshini, Arul Rose Suganya : Fortis Hospitals, Bannerghatta Road,Opp, Bangalore

INTRODUCTION: Antibiotic resistance has been a serious global concern over the years. The emergence of super bugs and consecutively, a drop in the availability of new antibiotics has triggered return of the pre-antibiotic era, where people would suffer or even die from untreatable bacterial infections. As a measure to curb and control antimicrobial resistance, the Antimicrobial stewardship program was initiated at Fortis Hospitals,Bannerghatta Road,Bengaluru,in 2013 OBJECTIVES: Objectives of this initiative were to optimize selection,dosing and duration of antimicrobials for therapy and prophylaxis METHODS AND MATERIALS: A Multidisciplinary team was formed in 2013, comprising of Infection control officer, Clinical Pharmacists, Quality champions, and AMS working group (Physicians, Intensivists, Consultants of different specialty) and the following initiatives were taken up. • Clinical awareness Drives for doctors on the importance of antibiotics and resistance, surgical prophylaxis, hospitals antibiogram and providing awareness on the current trends in antimicrobial therapy with their PK-PD studies. • Restricted Antimicrobial Policy: List of the restricted antimicrobials was circulated and implementation of the Justification Form for the use of restricted antibiotics was mandated.Irrational fixed drug combinations were also phased out from the formulary . • Surgical Prophylaxis: A well formulated protocol on the administration time,selection of the prophylactic agent, duration of prophylaxis post surgery and intraop re-dosing for the use of antibiotics for Surgical Prophylaxis was rolled out and monitored every quarterly in all the Surgical specialities.The data and analyses were then shared with surgeons. • Empiric therapy audits in MICU: Daily review of the empiric use of antibiotics particularly in the adult medical intensive care unit,based on the antibiotic policy of the hospital by the Clinical Pharmacists. • Preparation of antibiogram, Review of culture reports, Discussion on Antimicrobial management case wise with clinicians by The Clinical Microbiologist • Letters of communication and one to one talk by the Chairman of the AMS committee to the physicians in case of irrational prescription of antibiotics. • Regular AMS committee meetings (every quarterly) to discuss findings of the previous months and to address any issues. RESULTS: The outcomes of this initiative were measured through audits on Empiric therapy,Surgical prophylaxis and Resistance trends of Organisms and DRI(Drug Resistance Index) The key improvements over 2013-2016, were the decrease in the use of Carbapenems

CIDSCON 2017

3

www.cidscon.in

for >72hours(31% to 13%) and colistin use >72 hours(3.5% to 1%) . Escalations to higher antibiotics reduced from 37% to 5%. The 120 were excluded from the study.Patients who had DILI after at least 7 days of standard doses of ATT were labelled as “cases” and those without DILI were “controls”.Each case of DILI was compared with 3 controls selected randomly from the main cohort. Results: From a cohort of 460 TB/HIV co-infected patients,56 developed ATT induced DILI[12.17%].BTS guidelines were followed for ATT reintroduction and the culprit drugs were identified.Pyrazinamide was culprit in 26 cases[46.4%].isoniazid in 17 cases[30.3],rifampicin in11 cases[19.64] and ethambutol in 2 cases[3.5%].On bivariate logistic regression analysis,body mass index BMI32)

CIDSCON 2017

89

www.cidscon.in

Splenic Abscess Caused by Salmonella typhi and Co-infection with Leptospira

___________________________________________________________________________________________

Author : Dr. Monalisa Sahu Co-authors : Dr. Arvind Kumar, Dr.Neeraj Nischal, Dr.Bharath BG Dr. Naveet Wig Department : Medicine Institution : All India Institute of Medical Sciences, New Delhi

Splenic abscesses caused by Salmonella typhi are a very rare complication of typhoid fever in this era of use of specific antibiotics. Co-infection with Leptospira in such a patient is even rarer. Splenic abscesses are potentially fatal complication of typhoid fever. In most of these patients, hemoglobinopathies or some other underlying immunocompromising state is usually present. We report a case of splenic abscess, caused by Salmonella typhi, and co-infection with Leptospira in a previously healthy young male. A 19 year old male was admitted to the emergency of our hospital with history of fever with chills and rigor, and jaundice for 15 days and pain abdomen in the left upper quadrant and left shoulder pain for 7 days. He had a history of splenic abscess, drained by pigtail catheter and managed conservatively 5 years back. The patient was apparently well during the intervening 5 years. At admission, his hematological profile was Hb 11, TLC 28,500, DLC: N91, L07, E01, B01 and E01. His total bilirubin was 10.7mg%. Widal test was positive in titre 1:320 For S.typhi O and H antigen. Ultrasonography showed a 12.8 cm sized spleen with upper and mid-pole splenic abscess with no adjacent splenic parenchyma. Xray chest moderate pleural effusion on the right side. An ultrasound guided aspiration of the splenic abscess was done. The aspirated material was positive for Salmonella typhi on culture. A blood culture and stool culture was done which were negative for Salmonella. Leptospira IgM antibody ELISA was positive in the patient, which could explain the high grade jaundice in the patient. He was managed with cefoperazone-sulbactam , ceftriaxone and linezolid, but splenectomy could not be avoided as there was high suspicion of splenic rupture into the pleural cavity. No predisposing factors were found in our case. No hemoglobinopathies were detected, the immunodeficiency workup was negative and the screening tests for HIV, HBsAg and Anti-HCV were negative. In the era of several new emerging infections, we should not miss the newer presentations of the older diseases.

CIDSCON 2017

90

www.cidscon.in

Unravelling the Polymicrobial Diversity of Foot Ulcer Infections via Next Generation Sequencing

___________________________________________________________________________________________

Author : Murali T S1 Co-Authors : Jnana A1, Satish N1, Varghese VK2, Ramya V1, Chakrabarty S2, and Satyamoorthy K2

Department of Biotechnology, School of Life Sciences, Manipal University, Manipal 576104, India 2 Department of Cell and Molecular Biology, School of Life Sciences, Manipal University, Manipal - 576104, India 1

Objectives: Non-healing foot ulcers are a common complication of diabetes exacerbated by microbial colonization. Current treatment employs an empirical approach that involves administration of antibiotics based on clinical presentation and microbiological testing. With increasing speed and decreasing cost of DNA sequencing technologies, we can now develop better alternatives to the classical treatment strategies. In the current study, we performed a rigorous analysis of the different grades of wound guided by the associated clinical data and information on antibiotic resistance using next generation sequencing approach. This can help build rapid, specific point of care devices that will aid in development of specific antibiotic regimens to prevent multidrug resistance and promote wound healing. Methods: Foot ulcer samples from 130 individuals were analysed using culture dependent and culture independent (16SrDNA metagenomics using Ion Torrent platform) methods. The major bacterial species were selected for a literature search to retrieve a list of the resistance genes in them in the last 5 years. Results: Majority of the wound isolates were aerobic Gram-negative bacteria (Phylum Proteobacteria). With sequencing, we obtained 49 million reads with an average of 391,188 reads per library. A total of 237 genera were classified and the dominant phyla were Proteobacteria and Firmicutes. 82 unique genes encoding resistance to 15 antibiotics were recorded and shortlisted for presumptive testing. Conclusion: Wound microbiomes show high degree of interindividual variability. Beta diversity analyses across all wound samples with grouping criteria of Wagner grade and disease status did not show clear clustering. Isolates obtained from culture-based approach were also found in NGS analysis in more than 70% of samples. Genes coding for antibiotic resistance shared >90% identity across different bacterial genera implying that global markers can be developed to capture antibiotic resistance from environmental samples.

CIDSCON 2017

91

www.cidscon.in

HYPERCALCEMIA – Rare Aderverse Effect of TENOFOVIR ??

___________________________________________________________________________________________

Author Co-authors Institution

: Dr. Navneet Kumar Agrawal : Dr. Rudra Prasad Sahu, Dr. Sandesh M Raykar, Dr. Saswata Saha, Siddharth Jain, Dr. Aman Chaudhary, Dr. Chandan Kumar, Prof.Jaya Chakravarty, Prof.Shyam Sundar. : Institute of Medical Science, Banaras Hindu University.

Objectives: To make attention on rare adverse event (Hypercalcemia) of Tenofovir, most frequently used antiretroviral drug, not reported till now. Methods and Observations: We have six patients, developed renal dysfunction with hypercalcemia after starting Tenofovir based ART. Case 1- 32/F, on ATT for pulmonary kochs for 20 days presented with fever, headache and decreased responsiveness (E1V1M2) for 10 days. Case 2- 45/M, presented with fever, dry cough and breathlessness for 10 days. Case 3- 50/M, presented with fever ,cough for 2 months, diarrhea for 3 days and altered sensorium (E4V3M4) for last 1 day. Case 4- 28/M, presented with pain abdomen and vomiting for 5 days with mild tachycardia, tachypnea and GCS of E1V1M4. Case 5- 40/M, icteric, on ATT for pulmonary kochs for 15 days presented with Pain abdomen, nausea & vomiting, yellowish discoloration of eye and urine, for last 5 days. Case 6- 27/M, presented with of acute onset sensory motor LMN type quadriparesis (ATM) . Case Tenofovir

Presentation TLC

S.cr/ urea

Na/K

S.Ca/ Po4

iCa

TP/Alb

SGOT/PT TB/DB

1

6/6/16

24/6/16

9000

2.4/109

135/4

-

1.6

6/1.1

132/54

5.9/2.5

2

4/1/16

24/2/16

14100

7.8/220

135/5.4

11/6.9

1.72

9.5/3.1

224/214

.4/.1

3

13/7/15

8/4/16

12210

5.5/167

153/7

12.1/9.7

_

7.2/2.5

61/67

.7/.2

4

27/12/16

4/1/17

10700

9.1/233

139/6.5

11.3

1.42

6.1/2.7

83/35

5.2/3.2

5

20/12/16

16/1/17

10700

2.4/95

129/5.3

11/5.4

1.45

6.8/1.8

56/26

6.6/5

6

2/12/16

14/3/17

5510

2.6/108

136/4.6

12.4/4.6

-

-

24/27

.2/.1

Results: All Patients showed improvement in hypercalcemia and renal dysfunction after stopping Tenofovir and other conservative management.One patient required hemodialysis. Two patients died , one was due to aspiration pneumonitis and other due to multi-organ failure. One patient discontinue the treatment and rest improved. Conclusion: Tenofovir induced hypercalcemia is an unrecognized adverse event requiring close monitoring and further studies to confirm causality and to evaluate pathophysiology .

CIDSCON 2017

92

www.cidscon.in

Etiological Diagnosis of Microbial Keratitis in Lucknow, U.P

___________________________________________________________________________________________

Author Co-authors Institution

: Dr Nazia Khan : Dr. Gopa Banerjee, Dr. Prashant Gupta, Dr. Poonam Kishore, Dr. Arun Sharma. : King George’s Medical University, Lucknow (U.P.)

Introduction: Microbial keratitis is a potentially sight threatening inflammation that can be caused by bacteria, virus, fungus or parasite. Incidence of corneal ulcers vary from country to country and from region to region within a country. Untreated infections may lead to endophthalmitis, blindness and even perforation. Thus prompt identification and appropriate management is required to save the eye. Objective: To identify the causative agents of microbial keratitis in a tertiary care centre , Lucknow. Methods: The study was performed between August 2016 to April 2017. 120 corneal scrapings were done under strict aseptic precautions using Bard parker blade. Gram Stain, KOH mount and culture on Blood Agar (BA) and Sabouraud’s Dextrose Agar (SDA) were done. BA plate and SDA plate were incubated for 48 hours and 4 weeks respectively and any relevant growth was subsequently processed. Results: Out of 120 corneal scrapes, 42 were culture positive (29 fungus and 13 bacterial). Aspergillus spp and Coagulase Negative Staphylococcus spp were the commonest fungal and bacterial isolates respectively. Conclusion: 1. Fungal isolates were more common than bacterial isolates in our setup. 2. Knowledge of local disease trend is more important to start the empirical treatment. 3. Rapid progression of disease and virulent nature of causative organisms demand early identification and immediate treatment to prevent blindness.

CIDSCON 2017

93

www.cidscon.in

Ferritin in Dengue: A Stranger in a Trial (Boon or Goon?)

___________________________________________________________________________________________

Author Co-authors Institution

: Dr. Nazneen Nahar Begam : Dr. Sukanta Debnath, Dr. Bikram Das, Dr. Mehebubar Rahman, Dr. Rama Prosad Goswami : School of Tropical Medicine, Kolkata

Objective: Considering recent change in clinical manifestations of dengue and large number of patients at risk of infection and complications in India, we tried to identify the factors, ferritin in particular, in dengue virus infection. Methods: Single centre observational study conducted at School of Tropical Medicine, Kolkata, India from July to October 2016 prospectively. All admitted patients with proven dengue (ELISA for NS1 and/or IgM for dengue virus - reactive) were included and clinico-epidemiological, haematological and biochemical profiles were analysed. Serum ferritin was estimated in 65 dengue and 78 non-dengue short fever cases. Results: 110 patients with dengue (mean age 26 ± 14 years, duration of fever 5.5 ± 2.2 days) were admitted with Hb 12.2 ± 2.21 gm/dL; TLC 5339 ± 2618 and platelet 116963 ±76302 (/μL); PCV 37.3 ±7.1; AST 229.8 ± 360.6 and ALT 127.1 ± 169 IU/L. High serum ferritin was observed in 69.2% (>500 μg/L) and 55.4% (>1000 μg/L). Following complications were observed: pleural effusion 31.8%, ascites 20%, hepatomegaly 41.8%, ALT>100 in 32.7%, AST>100 in 50.9%,bleeding manifestation 20.9%, platelet count 16mg/L, amphotericin B 2mg/L, 5-Flucytosine 0.06mg/L, fluconazole 8mg/L and voriconazole 0.25mg/L. However, her repeat culture showed clearance of S. capitata after 96 hours of amphotericin B but she continued to deteriorate and succumbed to her illness with refractory pulmonary hemorrhage as her immediate cause of death. Case 2: This 60 year old lady with multiple myeloma, presented with progressive disease in form of bilateral pleural effusion and vertebral lesions. She reveived bortezomib, dexamethasone and cyclophosphamide based chemotherapy. In course of this illness she developed candidemia (C. glabarata) for which she was started on caspofungin. After 5 days of treatment of candidemia, she had fever with hypotension and worsening pleural effusion (required intercostal tube drainage). Blood cultures sent during this episode showed S. capitata with similar antifungal MICs as in Case 1. She was started on liposomal amphotericin B but she continued to remain sick and later succumbed to her illness.

CIDSCON 2017

103

www.cidscon.in

Discussion: S. capitata is an emerging cause of invasive and disseminated infections, especially in immune compromised haematological patients, although it has also being reported from solid organ transplant recipients [4]. Risk factors for invasive S. Capitata infections are prolonged neutropenia, aggressive chemotherapy, the use of broad spectrum antibiotics and the alteration of local defenses by breakdown of skin and mucosa [5]. The most common underlying hematological malignancy is acute myeloid leukemia [1]. The 30 day mortality reported in earlier case series was in the range of 60% to 100%, however in a recently published 6 year survelliance study of 47 patients mortality rate of 39% was reported [1,2,6]. In the largest published case series so far of 104 cases, median age was 56 years, 56% were males, and half of them had acute myeloid leukemia, 22% had acute lymphoid leukemia, and 22% had other malignancies with mortality rate of 60% [7]. The clinical features of invasive infection with S. Capitata frequently resemble those of invasive candidiasis. Ulu-Kilic A et al. reported that median duration of neutropenia was 21.5 days in patients with S. capitata fungaemia, whereas in patients with candidemia it was 8 days. Previous use of caspofungin was significantly more common in patients with S. capitata highlighting that breakthrough on echinocandin is a important feature of this organism [6]. In vitro susceptibilities determined by the clinical laboratory standards institute (CLSI) methods indicate that S. capitata is highly susceptible to amphotericin B, itraconazole and voriconazole. Most of the studies suggest that echinocandins have limited activity against S. capitata. Although Franchi et al. reported successful treatment of S. capitata pneumonia in a leukemia patient with voriconazole and caspofungin in-vitro correlation with treatment outcomes with echinocandins is not established [8]. Due lack of evidence and rare nature of this organism, optimal antifungal therapy is not clear. Both of our cases were on echinocandins when S. capitata breakthrough happened. Neutropenia was present in 1st case with AML, where as 2nd case of myeloma was on aggresive chemotherapy at the time of breakthrough infections. Our in-vitro susceptibilites showed high caspofungin MIC which is in conjunction with cases reported worldwide. Overall mortality rate is very high in S. capitata infections likely due to lack of awareness, sick nature of the patients in which it happens and unclear therapeutic measures. Conclusion: Our cases show that S. capitata infections should be kept in mind especially in patients with hematological malignancies on echinocandin prophylaxis or therapy. Referrences 1. Girmenia C, Pagano L, Martino B, et al . Invasive infections caused by Trichosporon species and Geotrichum capitatum in patients with hematological malignancies: a retrospective multicenter study from Italy and review of the literature. J Clin Microbiol 2005; 43 : 1818 – 1828. 2. Schuermans C, van Bergen M, Coorevits L, Verhaegen J, Lagrou K, Surmont

CIDSCON 2017

104

www.cidscon.in

3.

4. 5.

6.

7.

8.

I,Jeurissen A. Breakthrough Saprochaete capitata infections in patients receiving echinocandins: case report and review of the literature. Med Mycol. 2011 May;49(4):414-8. Mandarapu S, Krishna V, Raju S B, Pamidimukkala U, Nimmagadda S. Saprochaete capitata fungal infection in renal transplant recipient. Indian J Nephrol 2016; 26:464-6. Savioni V, Catavitello C, Balbinot A, et al . Multidrug-resistant Geotrichum capitatum from a haematology ward. Mycoses 2010. Ersoz G, Otag F, Erturan Z, et al . An outbreak of Dipodascus capitatus infection in the ICU: three case reports and review of the literature. Jpn J Infect Dis 2004; 57 : 24 8– 252. Ulu-Kilic A, Atalay MA, Metan G, Cevahir F, Koç N, Eser B, Çetin M, Kaynar L, Alp E. Saprochaete capitata as an emerging fungus among patients with haematological malignencies. Mycoses. 2015 Aug;58(8):491-7 Mazzocato S, Marchionni E, Fothergill AW, Sutton DA, Staffolani S, Gesuita R, et al. Epidemiology and outcome of systemic infections due to Saprochaete capitata: Case report and review of the literature. Infection 2015;43:211-5. Fianchi L, Montini L, Caira M, et al . Combined voriconazole plus caspofungin therapy for the treatment of probable Geotrichum pneumonia in a leukemia patient. Infection 2008; 36 :65 – 67.

CIDSCON 2017

105

www.cidscon.in

Bug wars: the story of a long standing fight between bones and bugs.

___________________________________________________________________________________________

Author Co-authors Institution

: Dr. Nitin Gupta : Dr. Nitin Gupta, Dr. Sayantan Banerjee, Dr. Timitrov, Dr. Rohini Sharma, Dr. Shambo Guha Roy, Dr. Trupti M Shende, Dr. Mohammed Tahir Ansari, Dr. Gagandeep Singh, Dr. Neeraj Nischal, Dr. Naveet Wig, Dr. Manish Soneja : All India Institute of Medical Sciences New Delhi.

A 26-year-old male patient presented with features suggestive of osteomyelitis involving the entire left femur, hip joint and knee joint. Culture from the debrided tissue grew Acinetobacter spp. and he was treated with sensitivity based antibiotics but symptoms did not resolve. The synovial biopsy showed multinucleated giant cells and acid fast bacilli on Ziehl Neelsen stain. Cartridge based nucleic acid amplification test (GeneXpert) was negative. The Mycobacteria growth indicator tube culture was found to be positive for Mycobacterium abscessus. The patient was started on imipenem, amikacin and macrolide based therapy. There was partial response initially but the patient worsened again. A girdle stone arthroplasty with cemented nail (with tobramycin) insertion after debridement of the infected tissue was done. KOH from the debridement sample was found to be positive for aseptate hyphae suggestive of mucormycosis. He was treated with liposomal amphotericin B. He was evaluated for immunodeficiency in view of multiple atypical infections and was found to have low CD4 count. The patient was discharged on amikacin, azithromycin, trimethoprim-sulfamethoxazole and posaconazole. Follow up showed considerable resolution both clinically and radiologically. To our knowledge, this is the first reported case of osteomyelitis with co-infection of Acinetobacter spp., M.abscessus and mucormycetes. We report this case to highlight the possibility of multiple rare infections in patients with immunodeficiency. Also, atypical complicated bone infections, such as Mycobacterium abscessus and Mucormycetes might require combined medical and surgical treatment.

Figure 1: Serial FDG PET scan showing evidence of osteomyelitis in June 2016(1A), partial resolution in October, 2016 (1B) and near complete resolution in April 2017 (1C)

CIDSCON 2017

106

www.cidscon.in

Morbidity and Mortality in Dengue fever patients treated with Doxycycline.

___________________________________________________________________________________________

Author : Dr. Noopur Kedare Co-authors : Dr. S Bhaskar, Dr. S. Prasad Institution : St. Philomena’s Hospital, Bangalore.

Introduction: dengue fever is a mosquito borne disease prevalent in India(1). Doxycycline is a tetracycline derivative inhibits dengue viral plaque formation by disrupting the conformational changes in the viral envelope. Aims and Objective: To study the effect of doxycycline on the morbidity and mortality of dengue fever in hospitalized patients. Materials and methods: • Study area & population- patients hospitalized with positive IgM or NS1 dengue test • Sample size= N=60 [doxycycline treated patients (n1=30) and symptomatically treated patients (n2=30).] • statistical tool- Unpaired “t” test • Parameters - temperature, BP, PCV & platelet count, on Day 0 and Day 5 of treatment, duration of hospital stay & overall morbidity. Result: Mean parameters were compared in both study groups; group 1(using doxycycline) & group 2(symptomatic treatment), on Day 0 & 5, and findings were Mean temperature in group 1 was 98.6& 98 degree F, t value 3.69(p0.05) Mean BP in group 1 was 110/70 &120/80 mmHg with t value 4.01(p