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Hospital acquired infections are the most common non-cardiac complications after cardiac surgery. Organisms commonly found in this cohort of patients include Klebsiella spp, Escherichia coli, Pseudomonas spp, Staphylococcus aureus, Coagulase negative Staphylococcus and Enterococcus spp etc. We hereby present a case of post cardiac surgery patient presenting with Stenotrophomonas maltophilia bloodstream infection. Combination of ceftazidime-avibactam (CZA) and aztreonam(AT) was used as inactivity was exhibited to primary panel of drugs. Broth disc elution testing was done to exhibit synergy between CZA and AT. This case highlights the growing need for active interaction between the treating physician and the microbiologist., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Indian Association of Medical Microbiologists. Published by Elsevier B.V. All rights reserved.)

Background: Stenotrophomonas sepilia , identified in 2021, is part of the Stenotrophomonas maltophilia complex (Smc) and shares high genomic identity with S. maltophilia . Resistance to levofloxacin, the recommended fluoroquinolone for S. maltophilia , is being increasingly reported. Recent studies indicate that levonadifloxacin, a novel benzoquinolizine, may be more effective. This study evaluates the antimicrobial efficacy of levofloxacin and levonadifloxacin against clinical isolates of S. sepilia ., Objectives: To assess the antibacterial effectiveness of levofloxacin and levonadifloxacin against novel pathogen S. sepilia., Methods: A total of 116 S. maltophilia isolates, identified by MALDI-TOF MS, were collected from five centres across India. S. sepilia was confirmed by PCR using primers targeting a unique genomic sequence (NCBI accession number LXXZ00000000.1). Minimum inhibitory concentrations (MICs) of levonadifloxacin and levofloxacin were determined by using the microbroth-dilution method and Etest as per CLSI guidelines. The levofloxacin breakpoint was used to interpret MICs of levonadifloxacin., Results: Among a total of 116 circulating S. maltophilia isolates collected, 46 were identified as S. sepilia , representing a prevalence rate of (∼40%), thus highlighting its significance as an important pathogen within the Smc. Both levofloxacin and levonadifloxacin demonstrated a 98% inhibition rate against the 46 S. sepilia tested. Only one S. sepilia isolate resistant to levofloxacin showed intermediate susceptibility to levonadifloxacin, which consistently had lower MICs., Conclusions: Levofloxacin and levonadifloxacin show similar susceptibility rates against S. sepilia , with levonadifloxacin exhibiting lower MICs. Further studies are required to establish clinical utility of levonadifloxacin in managing these infections., (© The Author(s) 2024. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

The genus Ralstonia comprises of aerobic, gram-negative, oxidase positive, nonfermentative, largely environmental organisms. They are an emerging pathogen in the hospital setting and are increasingly associated with opportunistic infections and outbreaks. We hereby present a case series of six patients diagnosed with bacteraemia caused by Ralstonia spp. and a brief review of literature. These cases highlight that isolation of a nonfermenting gram-negative bacillus from blood culture of a patient admitted in critical care setting should not be ignored as mere contaminant. Clinicians and microbiologists need to work as a team to combat this novel bug.

Klebsiella pneumoniae (Kp) has gained prominence in the last two decades due to its global spread as a multidrug-resistant (MDR) pathogen. Further, carbapenem-resistant Kp are emerging at an alarming rate. The objective of this study was (1) to evaluate the prevalence of β -lactamases, especially carbapenemases, in Kp isolates from India, and (2) determine the most prevalent sequence type (ST) and plasmids, and their association with β -lactamases. Clinical samples of K. pneumoniae ( n = 65) were collected from various pathology labs, and drug susceptibility and minimum inhibitory concentrations (MIC) were detected. Whole genome sequencing (WGS) was performed for n = 22 resistant isolates, including multidrug-resistant (MDR) ( n = 4), extensively drug-resistant (XDR) ( n = 15), and pandrug-resistant (PDR) ( n = 3) categories, and genomic analysis was performed using various bioinformatics tools. Additional Indian MDRKp genomes ( n = 187) were retrieved using the Pathosystems Resource Integration Center (PATRIC) database. Detection of β -lactamase genes, location (on chromosome or plasmid), plasmid replicons, and ST of genomes was carried out using CARD, mlplasmids, PlasmidFinder, and PubMLST, respectively. All data were analyzed and summarized using the iTOL tool. ST231 was highest, followed by ST147, ST2096, and ST14, among Indian isolates. bla ampH was detected as the most prevalent gene, followed by bla CTX-M-15 and bla TEM-1 . Among carbapenemase genes, bla OXA-232 was prevalent and associated with ST231, ST2096, and ST14, which was followed by bla NDM-5 , which was observed to be prevalent in ST147, ST395, and ST437. ST231 genomes were most commonly found to carry Col440I and ColKP3 plasmids. ST16 carried mainly ColKP3, and Col(BS512) was abundantly present in ST147 genomes. One Kp isolate with a novel MLST profile was identified, which carried bla CTX-M-15 , bla OXA-1 , and bla TEM-1 . ST16 and ST14 are mostly dual-producers of carbapenem and ESBL genes and could be emerging high-risk clones in India.

Background: The genus Providencia , earlier considered a rare pathogen, is now increasingly recognized as a notorious opportunistic pathogen capable of causing serious nosocomial infections, mainly urinary tract infections (UTIs). Treating these infections is an onerous task given the resistance seen in clinical strains to many currently available antimicrobials. The objective of the present study is to provide an overall view into the prevalence of Providencia spp. causing UTIs, their antibiotic susceptibility pattern, and respective clinical outcomes., Materials and Methods: This is a retrospective observational study carried out in a tertiary care teaching referral hospital located in Jaipur, India from March 2021 to May 2021. All Providencia spp. strains isolated from urine samples were included in the study. Data were entered in Microsoft Office Excel worksheet. Results are presented in numbers and percentages., Results: Out of 1,261 urine samples processed in the laboratory during the study period, 426 were culture positive and the majority were gram-negative isolates and included Escherichia coli (46.0%) and Klebsiella spp. (28.0%). Providencia spp. was the fourth most common gram-negative pathogen (6.0%). The median age of patients was 65 years. The male:female ratio was 3:2 and maximum patients belonged to the 30-60-year age-group. Diabetes was the commonest associated comorbidity. All patients had an indwelling urinary catheter. Three (20.0%) patients succumbed to infections., Conclusion: Providencia is an opportunistic pathogen that cannot be neglected due to escalating antibiotic resistance. Effective infection control and antibiotic stewardship policies are required to prevent the development of further antibiotic resistance., How to Cite This Article: Rajni E, Jain A, Garg VK, Sharma R, Vohra R, Jain SS. Providencia Causing Urinary Tract Infections: Are We Reaching a Dead End? Indian J Crit Care Med 2022;26(4):446-451., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2022; Jaypee Brothers Medical Publishers (P) Ltd.)

Objective: To identify different Candida spp along with antifungal susceptibility pattern and risk factors associated with candidemia., Design Setting and Patients: This retrospective observational study was conducted in a tertiary-care academic hospital in Jaipur, Western India, for 3 years (July 2017-June 2020)., Methods: Blood cultures were performed according to standard microbiological methods, and only 1 isolate per patient was included in the study. Isolates of Candida spp were identified using a VITEK-2 automated system and matrix-assisted laser desorption ionization-time of flight mass spectrometry. Antifungal susceptibility tests were performed using the broth microdilution assay according to the Clinical and Laboratory Standards Institute guidelines., Results: Of 3,443 blood cultures received from suspected sepsis cases, candidemia was identified in 95 (2.8%). In addition to Candida tropicalis (n = 36; 38%) and Candida parapsilosis (n = 17; 18%), 10 isolates of Candida auris comprised the fourth most common cause of candidemia. Presence of central venous catheter and diabetes were statistically significant risk factors for development of candidemia by NAC. Resistance to fluconazole was 36%, resistance to voriconazole was 20%, resistance to 5-flucytosine was 4%, and resistance to amphotericin-B was 7%. C. auris isolates were more resistant than other NAC spp. We detected no resistance among the echinocandins., Conclusions: The emergence of highly resistant isolates like C. auris emphasizes the need for constant monitoring of candidemia cases for species identification and routine antifungal susceptibility so that appropriate measures can be taken to reduce the related morbidity and mortality., (© The Author(s) 2022.)

Candidemia is one of the significant causes of mortality amongst critically ill patients in Intensive Care Units (ICUs). This study aimed to assess the incidence, risk factors and antifungal susceptibility pattern in candidemia cases admitted in ICU in a tertiary care hospital in Jaipur, Rajasthan from June 2021 to November 2021. Candida species isolated from blood culture of clinically suspected patients of sepsis were defined as candidemia cases. Blood culture and antifungal susceptibility testing were performed as per standard laboratory protocol. Analyses of risk factors was done between candidemia cases and matched controls in a ratio of 1 : 3. Forty-six candidemic cases and 150 matched controls were included in the study. C. tropicalis was the most prevalent species (22/46; 48%) followed by C. auris (8/46; 17%) and C. albicans (7/46; 15%). Candida species showed good sensitivity to echinocandins (97%) followed by amphotericin B (87%) and voriconazole (80%). In multivariate analysis, longer stay in ICU, presence of an indwelling device, use of immunosuppressive drugs and positive SARS-CoV-2 infection were associated with increased risk of candidemia. The constant evaluation of risk factors is required as prediction of risks associated with candidemia may help to guide targeted preventive measures with reduced morbidity and mortality.

Candida auris is identified as an emerging pathogen worldwide. It is multidrug resistant and causes invasive healthcare-associated infections. Our retrospective study was conducted to determine the prevalence and epidemiology of C. auris infections in a tertiary care hospital in Jaipur., 24 clinical C. auris strains were included, most being from urine. The majority patients needed intensive care and had at least one underlying co-morbid condition. A history of broad-spectrum antibiotic or antifungal usage was present in 85%. Fluconazole, voriconazole, amphotericin B and 5-fluorocytosine resistance was seen in 96, 42, 33 and 8% isolates respectively. No echinocandin resistance was noted.

Background: The ongoing pandemic of coronavirus disease 2019 (COVID-19) has overwhelmed healthcare facilities and raises an important novel concern of nosocomial transmission of Candida species in the intensive care units (ICUs)., Methods: We evaluated the incidence and risk factors for development of candidemia in 2384 COVID-19 patients admitted during August 2020-January 2021 in ICUs of 2 hospitals (Delhi and Jaipur) in India. A 1:2 case-control matching was used to identify COVID-19 patients who did not develop candidemia as controls., Results: A total of 33 patients developed candidemia and accounted for an overall incidence of 1.4% over a median ICU stay of 24 days. A 2-fold increase in the incidence of candidemia in COVID-19 versus non-COVID-19 patients was observed with an incidence rate of 14 and 15/1000 admissions in 2 ICUs. Candida auris was the predominant species (42%) followed by Candida tropicalis. Multivariable regression analysis revealed the use of tocilizumab, duration of ICU stay (24 vs 14 days), and raised ferritin level as an independent predictor for the development of candidemia. Azole resistance was observed in C auris and C tropicalis harboring mutations in the azole target ERG11 gene. Multilocus sequence typing (MLST) identified identical genotypes of C tropicalis in COVID-19 patients, raising concern for nosocomial transmission of resistant strains., Conclusions: Secondary bacterial infections have been a concern with the use of tocilizumab. In this cohort of critically ill COVID-19 patients, tocilizumab was associated with the development of candidemia. Surveillance of antifungal resistance is warranted to prevent transmission of multidrug-resistant strains of nosocomial yeasts in COVID-19 hospitalized patients., (© The Author(s) 2021. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: World is in grip of coronavirus disease-2019 (COVID-19) pandemic right now. Majority of studies center around its epidemiological and clinical characteristics. Information regarding secondary bacterial infections is limited. This retrospective observational study was done to determine the prevalence and characteristics of bloodstream infections in COVID-19 patients admitted in a tertiary care center in Jaipur., Materials and Methods: All blood cultures received from COVID-19 positive patients admitted in designated COVID care ICUs and wards were included in the study. A predesigned pretested questionnaire was used to collect relevant data. Blood cultures were done using BD BACTEC™ FX40, and identification and antimicrobial susceptibility testing of isolates were done by VITEK® 2 COMPACT., Results: One thousand five hundred seventy-eight (1578) COVID-19 positive patients were admitted in center during 5-month study period from whom 158 blood cultures were received. Out of these, 15 (9.4%) were positive. Median age of patients with positive blood culture was 54 years and included 10 males and 5 females. Ten (67%) patients needed intensive care in ICU. Significant correlation of blood culture positivity was found with parameters like ICU admission, presence of an indwelling device, underlying comorbidity, raised biochemical markers, and adverse clinical outcome., Conclusions: Incidence of bloodstream infections is low for COVID-19 patients. Antibiotic prophylaxis needs to be used with caution, and prompt discontinuation should be done based on clinical judgment., How to Cite This Article: Rajni E, Garg VK, Bacchani D, Sharma R, Vohra R, Mamoria V, et al. Prevalence of Bloodstream Infections and their Etiology in COVID-19 Patients Admitted in a Tertiary Care Hospital in Jaipur. Indian J Crit Care Med 2021;25(4):369-373., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2021; Jaypee Brothers Medical Publishers (P) Ltd.)

Background and Objective: Cutaneous Leishmaniasis (CL) is a dermal manifestation caused by various species of Leishmania. This is the most common Leishmanial syndrome seen worldwide and is emerging as and threatens to become an uncontrollable disease. The present study was planned to understand the current epidemiology of CL in the conventionally endemic area of Bikaner, Rajasthan. Species characterization was also done., Material and Methods: The diagnostic modalities used in the study were microscopy, histopathologic examination, antigen testing and confirmation and species characterization by PCR. Field evaluation of the new antigen detection kit approved by FDA in 2016 CL Detect™ IC-RDT was done and its results compared with other available diagnostic tests., Results: A total of 14 cases with 25 skin lesions presented to the Skin OPD during the six month study period (January to June 2018). Out of these, 5 were males and 9 were females, average age being 32 yrs. Students and housewives of poor socio economic group were the most frequently affected groups. Lesions were found on the exposed areas of the body, mainly on the upper limbs and facial region. Majority of them were ulcerated plaques. Out of 14 cases under study, antigen test confirmed 7 positives; thereby yielding a positive rate of 50% against 71.4% for microscopy, 72.7% for PCR and a mere 38.5% for histopathology. Species characterization revealed Leishmania tropica as the causative organism., Interpretation and Conclusion: The study indicates that the number of cases have declined substantially over the past decade in Bikaner. Despite being the oldest technique used, microscopy still is a good option for diagnosis. Combined with PCR, diagnostic accuracy and hence utility is increased multifold. In its current form, IC-RDT may not be very useful., Competing Interests: There are no conflicts of interest., (Copyright: © 2019 Tropical Parasitology.)

Presence of Bush class C enzymes in uropathogenic strains of Klebsiella pneumoniae & E. coli resistant to extended spectrum cephalosporins is an emerging threat to clinical therapeutics. These resistant strains result in considerable treatment failure and cannot be detected by routine antibiotic sensitivity screening methods. An effort was therefore made to study AmpC beta lactamase production in E. coli and Klebsiella pneumoniae strains causing UTI. A total of 126 E. coli and 49 K. pneumnoniae strains isolated from urine samples were selected for study out of which AmpC beta lactamase production was seen in 23% E. coli (29 isolates) and 18% K. pneumoniae (49 isolates). The susceptibility of AmpC beta lactamase producers to Imipenem, Nitrofurantoin and Amikacin was found to be 100%, 92% and 80% respectively. Thereby the present study emphasizes the importance of monitoring and control of usage of extended spectrum cephalosporins.