Analysis and Conclusion:

The analysis shows a clear picture of the dominance of Klebsiella followed by Acinetobacter in this part of the country. The sensitivity of these pathogens is very scary to see. Pseudomonas, VRE, and MRSA are also in the line, so need to be careful. Judicious use of antibiotics, and combination therapy de-escalation in a timely manner is the need of the hour. Segregation of patients with difficult-to-treat situations can be lifesaving. Currently, Phage therapy, polymeric biomaterials, nanoparticles, and plant-derived products are being in trials but till then we need to be vigilant.

References:

1. Parmanik A, Das S, Kar B, Bose A, Dwivedi GR, Pandey MM. Current Treatment Strategies Against Multidrug-Resistant Bacteria: A Review. Curr Microbiol. 2022 Nov 3;79(12):388. doi: 10.1007/s00284-022-03061-7. PMID: 36329256; PMCID: PMC9633024.
2. Pal N, Sharma P, Kumawat M, Singh S, Verma V, Tiwari RR, Sarma DK, Nagpal R, Kumar M. Phage therapy: an alternative treatment modality for MDR bacterial infections. Infect Dis (Lond). 2024 Jul 17:1-33. doi: 10.1080/23744235.2024.2379492. Epub ahead of print. PMID: 39017931.

Author:

1. Dr. Apurba Kumar Borah, Consultant, Critical Care Medicine
2. Dr. Vicky Lahkar, Consultant Microbiologist

The post Hospital Antibiogram of a Tertiary Care Centre in North East India : appeared first on CCEM Journal.

Antimicrobial resistance is one of the major global threats is already a well-established fact humanity and even WHO (World Health Organization) express that the mortality of infection due to Methicillin Resistance Staphylococcus Aureus (MRSA) may be as high as 64% more than infection due to infection by Methicillin Sensitive Staphylococcus Aureus (MSSA)1. Even the infection atypical bacteria are also on the rise so the concern of resistance is also rising2,3.

A benzoquinolizine subclass of fluoroquinolone Levonadifloxacin (intravenous) and alalevonadifloxacin (oral prodrug) were licensed for clinical use in India in 2019. This broad-spectrum antibiotic with active moiety, levonadifloxacin, has high potency against methicillin-resistant Staphylococcus. aureus, multi-drug resistant pneumococci, and anaerobes which is good news to the medical fraternity of the world4.

Aims and Objectives:

In this study, we tried to analyze in vitro efficacy of Levonadifloxacin in respiratory, urinary, and bloodstream infections from both community and nosocomial sources.

 Materials and Methods:

We collected 250 consecutive gram-positive bacterial isolates from both community and hospital-acquired infections, including Staphylococcus Aureus, and Enterococcus strains, sourced from respiratory tract, urine, and blood samples at the Microbiology department. These isolates underwent antimicrobial susceptibility testing using the Kirby-Bauer disc diffusion method on Mueller-Hinton agar (Hi-Media), with interpretation based on the latest CLSI guidelines.

Results:

All the isolates were sensitive to Levonadifloxacin which were Staphylococcus including MRSA, MSSA, and Coagulase negative Staphylococcus Species (CONS). All Enterococcus isolates were sensitive to Levonadifloxacin except Vancomycin Resistant Enterococcus (VRE) which were all resistant to Levonadifloxacin ( total no 16).

Conclusion:

In our in vitro analysis we found that Levonadifloxacin is a good drug to be used in MSSA, MRSA, and CONS where needed to be treated. VRE seems to be not a good target. However further studies are needed.

References:

1. Bhagwat SS, Nandanwar M, Kansagara A, Patel A, Takalkar S, Chavan R, Periasamy H, Yeole R, Deshpande PK, Bhavsar S, Bhatia A, Ahdal J, Jain R, Patel M. Levonadifloxacin, a Novel Broad-Spectrum Anti-MRSA Benzoquinolizine Quinolone Agent: Review of Current Evidence. Drug Des Devel Ther. 2019 Dec 24;13:4351-4365. doi: 10.2147/DDDT.S229882. PMID: 31920285; PMCID: PMC6935279.
2. Yu Y, Fei A. Atypical pathogen infection in community-acquired pneumonia. Biosci Trends. 2016 Feb;10(1):7-13. doi: 10.5582/bst.2016.01021. PMID: 26961211.
3. Huong Ple T, Hien PT, Lan NT, Binh TQ, Tuan DM, Anh DD. First report on prevalence and risk factors of severe atypical pneumonia in Vietnamese children aged 1-15 years. BMC Public Health. 2014 Dec 18;14:1304. doi: 10.1186/1471-2458-14-1304. PMID: 25524126; PMCID: PMC4300840.
4. https://www.sciencedirect.com/science/article/abs/pii/S025508572200247X

Author:

1. Dr. Vicky Lahkar, Consultant Microbiologist
2. Dr. Apurba Kumar Borah

The post In Vitro Sensitivity of Levonadifloxacin in Staphylococcus Aureus, Coagulase negative Staphylococcus species and Enterococcus species in a tertiary care Centre in North east India: appeared first on CCEM Journal.

Commonly encountered bugs causing UTI  in clinical practice, typically are bacterial pathogens such as Escherichia coli. We present a case of a 45-year-old female who presented with burning micturition, subsequently diagnosed with a UTI caused by an uncommon urinary pathogen, Staphylococcus sciuri . This case underscores the importance of considering unusual pathogens in the differential diagnosis of UTIs.

Introduction:

Urinary tract infections (UTIs) are primarily caused by Gram-negative bacteria like Escherichia coli. However, infections due to Gram-positive organisms such as Staphylococcus species are less common in the urinary tract. Here, we report a case of burning micturition caused by Staphylococcus sciuri, which is so uncommon,  highlighting the diagnostic challenges and management considerations associated with this uncommon pathogen.

Staphylococcus sciuri, is a Gram-positive, oxidase-positive, coagulase-negative member of the bacterial genus Mammaliicoccus consisting of clustered cocci. It was previously known as Mammaliicoccus sciuri (1) .

Materials and Methods:

We collected thirty consecutive positive Gram-negative bacterial isolates from both community and hospital-acquired infections, including Carbapenemase-producing strains, sourced from respiratory tract, urine, and blood samples at the Microbiology department. These isolates underwent antimicrobial susceptibility testing using the Kirby-Bauer disc diffusion method on Mueller-Hinton agar (Hi-Media), with interpretation based on the latest CLSI guidelines.

Case Presentation:

 A 76-year-old female presented to the outpatient clinic with complaints of low back ache, burning sensation during urination for the past 2/3 days. She had no h/o fever, chills, or flank pain.  There was no h/o T2 DM or recent antibiotic use. On examination, vital signs were within normal limits. A urine culture was performed, which unexpectedly grew  MDR Staphylococcus sciuri (>100,000 CFU/ mL).

Investigations:

Treatment and Management: 

The patient was started empirically on inj Ciprofloxacin daily till  pending urine culture results. Upon confirmation of Staphylococcus sciuri, the antibiotic regimen was adjusted to inj Linezolid based on susceptibility testing. The patient reported symptomatic improvement within 48 hours of initiating targeted antibiotic therapy.

Discussion:

Staphylococcus sciuri is a coagulase-negative Staphylococcus species that is increasingly recognized as an opportunistic pathogen, particularly in immunocompromised individuals  or those with underlying conditions such as diabetes mellitus. While uncommon, it can cause UTIs, especially in the elderly population or those with structural abnormalities of the urinary tract. Treatment  typically  involves targeted antibiotic therapy based on susceptibility testing.

References:

1. Kloos, W. E.; Schliefer, K. H.; Smith R. F. (1 January 1976). “Characterization of Staphylococcus sciuri sp.nov. and its Subspecies”. International Journal of Systematic Bacteriology. 26 (1): 22–37. doi:10.1099/00207713-26-1-22
2. Madhaiyan, M.; Wirth, J. S.; Saravanan V. S. (14 October 2020). “Phylogenomic analyses of the Staphylococcaceae family suggest the reclassification of five species within the genus Staphylococcus as heterotypic synonyms, the promotion of five subspecies to novel species, the taxonomic reassignment of five Staphylococcus species to Mammaliicoccus gen. nov., and the formal assignment of Nosocomiicoccus to the family Staphylococcaceae

Author:

1. Dr Babu Hussain, IDCCM fellow , Narayana Superspeciality Guwahati, INDIA

The post A Case Report of Urosepsis Due to Rare Bugs i.e. Staphylococcus sciuri appeared first on CCEM Journal.

In view of worsen global antibiotic resistance which is causing serious health concerns, aminoglycosides are seen as promising due to their broad antimicrobial spectrum, bactericidal property which is rapid and synergistic nature with other drugs in life threatening infections. The mechanism of action is same like other aminoglycosides to inhibit protein synthesis by binding to 30s and 50s ribosomal subunits of susceptible bacterias.

Isepamicin is a semisynthetic aminoglycoside derived from actinomycetes micromonospora with superior action against those strains that produce type I 6′-acetyltransferase. Just like other aminoglycosides like amikacin it also has nephrotoxicity, vestibular toxicity, and ototoxicity, but is lower than its other counterparts. The spectrum of coverage is Enterobacteriaceae and staphylococci but anaerobes, Neisseriae, and streptococci are interestingly resistant. Isepamicin is safe and effective in acute pyelonephritis even in children and can be considered in high aminoglycoside resistance situations ¹ .

Aims and Objectives:

In this study we tried to compare in vitro efficacy of isepamicin, amikacin and gentamicin in gram negative bacteria causing respiratory, urinary and bloodstream infections from both community and nosocomial source.

 Materials and Methods:

We collected thirty consecutive positive Gram-negative bacterial isolates from both community and hospital-acquired infections, including Carbapenemase-producing strains, sourced from respiratory tract, urine, and blood samples at the Microbiology department. These isolates underwent antimicrobial susceptibility testing using the Kirby-Bauer disc diffusion method on Mueller-Hinton agar (Hi-Media), with interpretation based on the latest CLSI guidelines.

 Results and Discussion:

In all isolates those are producing carbapenemases , isepamicin and amikacin showed resistance rate of 100% , but interestingly gentamicin is 22.22% susceptible. The exact mechanism of resistance is unknown because of unavailability of further testing methods in our institution.

For non carbapenemases isolates , isepamicin is showing 66.67% sensitivity as compared to sensitivity of amikacin which is 66.67% and gentamicin which is  41.66% sensitive.

The cohort of gram negative organisms are comprises of klebsiella pneumonia, acinetobacter baumanni, pseudomonas aeruginosa, proteus mirabilis and escherichia coli with mostly klebsiella pneumonia.

In belgian Isepamicin Multicenter Study Group which was published in 2001, they found 91% sensitivity of isepamicin in 1087 gram negative bacilli isolates from icu of 11 different hospitals  in comparison to amikacin which was 89% susceptible and gentamicin which was 88% susceptible ² . In a study done in houston , USA it was found that isepamicin is as stable as amikacin as it is not inactivated by the presence of beta lactam compounds and beta lactamase inhibitors. It was also found that heparin presence did not influence isepamicin iactivation ³ .

Conclusion:

In the current scenario of increasing antimicrobial resistance all over the world causing significant mortality and morbidity, the drug discovered in 1978 has lots of potentials in difficult to treat nosocomial as well as community acquired infections owing to its quick bactericidal property and lesser side effects in its own aminoglycoside community.

References:

1. https://www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceutical-science/isepamicin.
2. Belgian Isepamicin Multicenter Study Group. Comparative in vitro activity of isepamicin and other antibiotics against gram-negative bacilli from intensive care units (ICU) in Belgium. Acta Clin Belg. 2001 Sep-Oct;56(5):307-15. doi: 10.1179/acb.2001.045. PMID: 11774843.
3. Walterspiel JN, Feldman S, Van R, Ravis WR. Comparative inactivation of isepamicin, amikacin, and gentamicin by nine beta-lactams and two beta-lactamase inhibitors, cilastatin and heparin. Antimicrob Agents Chemother. 1991 Sep;35(9):1875-8. doi: 10.1128/AAC.35.9.1875. PMID: 1952861; PMCID: PMC245284.

Author:

1. Dr. Apurba Kumar Borah, Narayana Superspeciality Hospital, Guwahati, India.
2. Dr. Vicky Lahkar, Narayana Superspeciality Hospital, Guwahati, India

The post In Vitro Sensitivity of Isepamicin in comparison to Amikacin and Gentamicin appeared first on CCEM Journal.

Abstract:

Pulmonary embolism (PE) is a serious medical condition characterized by the obstruction of pulmonary arteries by emboli, commonly originating from deep vein thrombosis (DVT). We report a case of PE in a 46-year-old male patient with a recent history of tendoachilis tear ( left lower limb)  22 days ago and prolonged bed rest since then. The patient presented with sudden onset breathlessness from 5-6 hours . Clinical evaluation and imaging studies confirmed the diagnosis of PE. This case underscores the importance of recognizing the increased risk of thromboembolic events in patients immobilized due to musculoskeletal injuries and highlights the need for vigilant monitoring and prophylactic measures to prevent potentially life-threatening complications like PE.

INTRODUCTION

Herein, we present the case of a 46-year-old male patient who, following a tendoachilis tear necessitating prolonged bed rest, presented with sudden-onset breathlessness and was subsequently diagnosed with PE upon undergoing CT cardio angiography. This case underscores the importance of recognizing the heightened thromboembolic risk associated with immobilization due to musculoskeletal injuries and highlights the critical role of prompt diagnosis and intervention in mitigating the potentially life-threatening consequences of PE.

CASE PRESENTATION:

Patient Information:

• Age: 46 years
• Gender: Male
• Chief Complaint: Sudden onset of breathlessness from 5/6 hours
• DOA – 2/04/2024

History of Present Illness: The patient, a 46-year-old male, presented to the emergency department o f Narayana Superspeciality Hospital Amingaon, Guwahati, Assam with a chief complaint of sudden onset breathlessness. He reported a recent history of tendoachilis tear in his left foot 22 days ago , which had rendered him bedridden for the past 22 days. During this period of immobility, he had not experienced any significant respiratory symptoms until the sudden onset of breathlessness prompted his visit to the hospital.
Clinical Examination: On examination, the patient appeared distressed and was in respiratory distress. Vital signs revealed tachypnea and tachycardia. Oxygen saturation was decreased (84% in room air), and he required supplemental oxygen to maintain adequate saturation. Cardiovascular examination revealed a dilated right atrium (RA) and right ventricle (RV) , with evidence of RV dysfunction. No murmurs were appreciated. Examination of the lower limbs revealed no signs of swelling and mild pain in left LL. Patient was admitted in ICU for further management.

INVESTIGATIONS::

1. MRI of Left Ankle with Leg (Plain):
   Findings: Thickened Achilles tendon in its lower half with a partial thickness interstitial tear extending for a length of 10 cm up to the insertion site.
2. 2D Echocardiography (2D ECHO):
   Findings: Dilated RA and RV, no regional wall motion abnormalities (RWMA), RV dysfunction, left ventricular ejection fraction (LVEF) 50-55%.
3. Doppler Study of Left Lower Limb:
   Findings: Thrombus in the popliteal vein extending into the femoral vein.
4. CT Angiography:
   Findings: Acute pulmonary embolism (PE) with evidence of right ventricular strain (clot load of 50-60%).

Diagnosis: Based on the clinical presentation and investigative findings, the patient was diagnosed with:

• Pulmonary embolism secondary to deep vein thrombosis (DVT) in the left lower limb.
• Tendoachilis tear with associated findings of thickening and partial thickness interstitial tear on MRI.

MANAGEMENT:

The patient was immediately started on therapeutic anticoagulation with intravenous heparin (UFH) to prevent further propagation of the thrombus and to stabilize the pulmonary embolism. Oxygen therapy was continued to maintain adequate oxygenation. Close monitoring of vital signs, oxygen saturation, and cardiac function was initiated.

FOLLOW-UP AND PROGNOSIS:

The patient was admitted to the intensive care unit for close monitoring and management of his condition. The prognosis would depend on the response to anticoagulation therapy, resolution of the pulmonary embolism, and prevention of further thromboembolic events. Long-term management would involve anticoagulation therapy, rehabilitation for the tendoachilis tear, and monitoring for potential complications such as recurrent PE or post-thrombotic syndrome.

DISCUSSION:

Pulmonary embolism is a potentially life-threatening condition that requires prompt diagnosis and management to prevent adverse outcomes. While PE is commonly associated with older individuals and comorbidities such as malignancy, obesity, and immobility, it can also occur in young, otherwise healthy individuals, as demonstrated in this case.

The diagnosis of PE in young patients can be challenging due to the nonspecific nature of symptoms and the low pretest probability. However, a high index of suspicion is warranted, particularly in individuals with acute onset dyspnea and chest pain, as delay in diagnosis and treatment can lead to significant morbidity and mortality.

In this case, the diagnosis of PE was confirmed by CTPA, which is considered the gold standard imaging modality for the evaluation of PE. Treatment involves anticoagulation to prevent further thrombus propagation and embolization. Close monitoring for complications such as bleeding is essential, particularly in young patients who may be at lower risk for bleeding complications compared to older individuals.

CONCLUSION:

This case highlights the importance of considering pulmonary embolism in patients with a history of immobilization due to musculoskeletal injuries, even in the absence of typical risk factors. Prompt diagnosis and management are essential to prevent adverse outcomes associated with pulmonary embolism and deep vein thrombosis. Collaboration between specialties such as cardiology, radiology, and vascular medicine is crucial for the comprehensive management of such complex cases.

Authors:

Dr. Babu Hussain, Narayana Superspeciality Hospital Guwahati, Assam

References:

1. Caroff SN, Mann SC, Keck PE Jr, Francis A. Clonidine-induced encephalopathy in a patient with schizoaffective disorder. J Clin Psychopharmacol. 1994 Feb;14(1):68-9. doi: 10.1097/00004714-199402000-00011. PMID: 8150734.
2. Kilpatrick CJ, Smith JA. Clonidine poisoning in the adult. Br Med J (Clin Res Ed). 1983 Jan 15;286(6360):156-7. doi: 10.1136/bmj.286.6360.156. PMID: 6401087; PMCID: PMC1546763.
3. Gold MS, Pottash AC, Sweeney DR, Davies RK. Clonidine overdose: report of six cases and review of the literature. Am J Psychiatry. 1979 Dec;136(12):1567-71. doi: 10.1176/ajp.136.12.1567. PMID: 498962.
4. Katzung BG, Trevor AJ, Masters SB. Basic and Clinical Pharmacology. 14th ed. New York: McGraw Hill Education; 2017.
5. Various internet sources

The post Acute Plumonary Embolism: Case Report appeared first on CCEM Journal.

Clonidine, a centrally acting alpha-2 adrenergic agonist, is commonly used in the management of hypertension and withdrawal symptoms. However, its use in patients with renal impairment, requires careful consideration due to the potential for drug accumulation and adverse neurological effects. We present a case of clonidine-induced encephalopathy in a patient undergoing peritoneal dialysis, highlighting the challenges in managing hypertension in this population and the importance of cautious medication management.

Case Presentation:

A 55-year-old female with end-stage renal disease , undergoing peritoneal dialysis for the past few years, presented with a history of seizure. On admission, she was unconscious and required mechanical ventilation. Initial laboratory investigations showed raised serum creatinine and bun. CT brain showed age related atrophic changes. Hemodialysis was done for the patient after discussion with nephrologist. Patient showed signs of neurological improvement after HD but did not regain full consciousness. She was started on multiple antihypertensives but her blood pressure was uncontrolled. As such clonidine 0.1 mg tds was started after two days of admission.

On 4^th day of admission patient’s consciousness was found to be further decreased. At this stage her blood pressure was under control. Further evaluation ruled out other causes of encephalopathy such as metabolic disturbances or structural brain lesions. MRI brain revealed no significant abnormality. EEG was done but showed no epileptic activity. Given the temporal association with clonidine initiation and absence of other identifiable causes, clonidine-induced encephalopathy was suspected.

Management and Outcome:

Clonidine was promptly discontinued upon suspicion of drug-induced encephalopathy. Supportive measures were initiated. Over the next two days, the patient gradually regained consciousness, with improvement in neurological status noted on serial examinations. She was extubated from mechanical ventilator on the 7th day from admission.

Discussion:

 Clonidine is known to cross the blood-brain barrier and exert its effects on central alpha-2 adrenergic receptors, leading to central nervous system depression. It is predominantly cleared by renal excretion, and its pharmacokinetics can be significantly altered in patients with renal impairment, leading to drug accumulation and toxicity. The central nervous system manifestations of clonidine toxicity include sedation, confusion, and rarely, encephalopathy. Patients with impaired renal function, are particularly vulnerable to these effects.

In this case, the patient’s pre-existing renal impairment likely contributed to clonidine accumulation, precipitating encephalopathy. The prompt recognition of drug-induced toxicity and discontinuation of clonidine were crucial in achieving clinical improvement.

Conclusion:

Clonidine-induced encephalopathy should be considered in patients with chronic kidney disease, who present with unexplained neurological symptoms. Clinicians should exercise caution when prescribing clonidine in this population, considering dose adjustments and close monitoring for adverse effects. Timely recognition and management are essential to mitigate potential complications associated with drug-induced encephalopathy. This case underscores the importance of individualized medication management and heightened vigilance for adverse drug reactions in patients with chronic kidney disease.

Authors:

Dr. Manash Ranjan Chaudhury
Junior Consultant, Critical Care medicine
Narayana Superspeciality Hospital, Guwahati, India

References:

1. Caroff SN, Mann SC, Keck PE Jr, Francis A. Clonidine-induced encephalopathy in a patient with schizoaffective disorder. J Clin Psychopharmacol. 1994 Feb;14(1):68-9. doi: 10.1097/00004714-199402000-00011. PMID: 8150734.
2. Kilpatrick CJ, Smith JA. Clonidine poisoning in the adult. Br Med J (Clin Res Ed). 1983 Jan 15;286(6360):156-7. doi: 10.1136/bmj.286.6360.156. PMID: 6401087; PMCID: PMC1546763.
3. Gold MS, Pottash AC, Sweeney DR, Davies RK. Clonidine overdose: report of six cases and review of the literature. Am J Psychiatry. 1979 Dec;136(12):1567-71. doi: 10.1176/ajp.136.12.1567. PMID: 498962.
4. Katzung BG, Trevor AJ, Masters SB. Basic and Clinical Pharmacology. 14th ed. New York: McGraw Hill Education; 2017.
5. Various internet sources

The post Clonidine-induced Encephalopathy in a Patient with Chronic Kidney Disease : A Case Report appeared first on CCEM Journal.