Search

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM Background COVID-19 has opened a pandora's box of opportunistic infections and immune alteration. We hereby present a series of patients with recurrent fungal urinary tract infections triggered by an episode of COVID-19. Description Case 1: A 66-year-old male, diabetic, known chronic kidney disease, had moderate COVID-19 in September 2020 needing remdesivir and steroids; 2 months later, he was treated for a fungal UTI elsewhere. In May 2021, he presented with right-sided pyelonephritis, hydroureter, and pyonephrosis. DJ stenting was done and cultures grew C. tropicalis. Record of anti-fungal susceptibility from the fluconazole resistance and was hence treated with 21 days of micafungin with significant improvement. Despite 3 weeks of directed anti-fungal treatment, he had recurrent episodes of candiduria with azotemia. Cystoscopy and selective sampling yielded C. tropicalis from the right pelvi-calyceal system, but as he was unwilling for nephrostomy and local antibiotic instillation he was started on anidulafungin and long-term 5-flucytosine suppression. Case 2: A 61-year-old male, diabetic, with uncontrolled sugars, had severe COVID-19 in September 2020 needing oxygen, remdesivir, and steroids; 1 month later, presented with right-sided flank pain and four episodes of painless passage of fleshy tissue per urethra in the last 1 year (Fig. 2). He had multiple episodes of bacterial UTIs which were treated, with complete resolution. The fleshy mass showed septate fungal elements and culture grew Aspergillus flavus sensitive to voriconazole, itraconazole, and posaconazole. He received multiple prolonged courses of voriconazole and caspofungin prior to presenting to us. CT revealed right-sided pyelonephritis with dilated pelvi-calyceal system. The patient was started on 2 weeks of micafungin followed by a prolonged course of voriconazole and 5-flucytosine with close clinical and therapeutic drug monitoring. Case 3: A 68-year-old female, diabetic, had moderate COVID-19 in April 2021, and was given remdesivir and steroids. She was admitted 1 month later with UTI (Pyelonephritis with early forming renal abscess) with urine culture growing CR Klebsiella p. (OXA-48) and C. glabrata for which she was given ceftazidime-A, vibactam, and voriconazole and underwent bilateral DJ stenting followed by stent removal after 1 month along with switching to micafungin in view of repeated candiduria on treatment. She has developed multiple UTIs in the subsequent months with C. auris being isolated twice and bacterial UTIs, treated with antibiotics and micafungin. Subsequent CT revealed retroperitoneal fibrosis encasing the ureters causing obstruction, a biopsy was inconclusive but was empirically started on methotrexate for IgG4 disease. Discussion The proposed immune alteration mechanism of COVID-19 of decreased phagocytic function, uncontrolled sugars, and steroid-related neutrophil dysfunction predisposes to several opportunistic infections including fungal infections. It is intriguing that these patients with refractory funguria never underwent any instrumentation The challenges associated with the management of these cases included deranged renal functions precluding the use of intravenous contrast for imaging and several anti-fungal drugs; inadequate urinary penetration of antifungals especially with deranged renal functions and hesitancy with local instillation of antibiotics, and the need for repeated surgical intervention including insertion of stents in an infected urinary tract.

Aim The aim of this review article is not only to analyze the clinical burden of methicillin-resistant Staphylococcus aureus (MRSA) in intensive care unit (ICU) setting of India, along with the patterns of prevalence and its prevention measures, but also to focus on the new anti-MRSA research molecules which are in late stage of clinical development. Background Methicillin resistance is reported to be present in 13-47% of Staphylococcus aureus infections in India. Therapeutic options to combat MRSA are becoming less, because of emerging resistance to multiple classes of antibiotics. Intensive care units are the harbinger of multidrug-resistant organisms including MRSA and are responsible for its spread within the hospital. The emergence of MRSA in ICUs is associated with poor clinical outcomes, high morbidity, mortality, and escalating treatment costs. There is an urgency to bolster the antibiotic pipeline targeting MRSA. The research efforts for antibiotic development need to match with the pace of emergence of resistance, and new antibiotics are needed to control the impending threat of untreatable MRSA infections. Review results Fortunately, several potential antibiotic agents are in the pipeline and the future of MRSA management appears reassuring. Clinical significance The authors believe that this knowledge may help form the basis for strategic allocation of current healthcare resources and the future needs. How to cite this article Mehta Y, Hegde A, Pande R, Zirpe KG, Gupta V, Ahdal J, et al. Methicillin-resistant Staphylococcus aureus in Intensive Care Unit Setting of India: A Review of Clinical Burden, Patterns of Prevalence, Preventive Measures, and Future Strategies. Indian J Crit Care Med 2020;24(1):55-62.

How to cite this article: Hegde A. Measurement of Interleukin-6 Levels in COVID: Illuminative or Illogical? Indian J Crit Care Med 2022;26(1):9–10.

Most cases of severe malaria are caused by Plasmodium falciparum. Severe malaria is characterized by severe organ dysfunction. Both peripheral smear examination and rapid diagnostic test have a role in the diagnosis. Parenteral artesunate is clearly the drug of choice for the management of severe malaria. Parenteral artesunate should always be followed up with ACT. Most of the complications of severe malaria require supportive care only. The role of exchange transfusions in the management of severe malaria is questionable in the postartesunate era. Malaria in pregnancy can be quite severe and artesunate is now the drug of choice for all three trimesters. Vivax malaria is being increasingly recognized as a cause of severe malaria. The cause for this increased virulence is still not clear. Management of severe vivax malaria is similar to that of severe falciparum malaria. How to cite this article: Hegde A. Malaria in the Intensive Care Unit. Indian J Crit Care Med 2021;25(Suppl 2):S127–S129.

Background: The increasing burden of carbapenem-resistant Enterobacteriaceae (CRE) carriage and infection in different patient settings in India has created an acute need for guidance for c...

How to cite this article: Hegde A. Antibiotic Stewardship: Easy to Preach, Difficult to Practice. Indian J Crit Care Med 2021;25(6):608–609.

How to cite this article: Kulkarni AP, Hegde A, Ramakrishnan N. Acute Kidney Injury in the Critically Ill: Herein Lies the Problem! Indian J Crit Care Med 2020;24(Suppl 3):S83.

How to cite this article: Kulkarni AP, Sengar M, Chinnaswamy G, Hegde A, Rodrigues C, Soman R, Khilnani GC, Ramasubban S, Desai M, Pandit R, Khasne R, Shetty A, Gilada T, Bhosale S, Kothekar A, Dixit S, Zirpe K, Mehta Y, Pulinilkunnathil JG, Bhagat V, Khan MS, Narkhede AM, Baliga N, Ammapalli S, Bamne S, Turkar S, Bhat KV, Choudhary J, Kumar R, Divatia JV. Indian Journal of Critical Care Medicine 2019;23(Suppl 1): S64-S96.

How to cite this article: Kulkarni AP, Samavedam S, Hegde A. Success is the Sum of Small Efforts! Indian J Crit Care Med 2019;23(Suppl 3):S171.

How to cite this article: Hegde A. Approach to an Anemic Critically Ill Patient. Indian J Crit Care Med 2019;23(Suppl 3):S178–S180.

Aims To obtain information on organizational aspects, case mix and practices in Indian Intensive Care Units (ICUs). Patients and methods An observational, 4-day point prevalence study was performed between 2010 and 2011 in 4209 patients from 124 ICUs. ICU and patient characteristics, and interventions were recorded for 24 h of the study day, and outcomes till 30 days after the study day. Data were analyzed for 4038 adult patients from 120 ICUs. Results On the study day, mean age, Acute Physiology and Chronic Health Evaluation (APACHE II) and sequential organ failure assessment (SOFA) scores were 54.1 ± 17.1 years, 17.4 ± 9.2 and 3.8 ± 3.6, respectively. About 46.4% patients had ≥1 organ failure. Nearly, 37% and 22.2% patients received mechanical ventilation (MV) and vasopressors or inotropes, respectively. Nearly, 12.2% patients developed an infection in the ICU. About 28.3% patients had severe sepsis or septic shock (SvSpSS) during their ICU stay. About 60.7% patients without infection received antibiotics. There were 546 deaths and 183 terminal discharges (TDs) from ICU (including left against medical advice or discharged on request), with ICU mortality 729/4038 (18.1%). In 1627 patients admitted within 24 h of the study day, the standardized mortality ratio was 0.67. The APACHE II and SOFA scores, public hospital ICUs, medical ICUs, inadequately equipped ICUs, medical admission, self-paying patient, presence of SvSpSS, acute respiratory failure or cancer, need for a fluid bolus, and MV were independent predictors of mortality. Conclusions The high proportion of TDs and the association of public hospitals, self-paying patients, and inadequately equipped hospitals with mortality has important implications for critical care in India.

Invasive fungal infections in critically ill patients are associated with increased morbidity and mortality. Candida species are among the most common causes of nosocomial bloodstream infections and of invasive infections in intensive care units (ICUs). The high mortality mandates early identification of invasive candidiasis which is vital to initiate appropriate and timely treatment and improve outcomes. Delaying the initiation of treatment could result in an increase in mortality which can be avoided by usage of more rapid diagnostic techniques. There are multiple diagnostic tests including culture and non-culture tests like 1,3-β-D-glucan and newer techniques like MALDI-TOF which are available to diagnose candidemia but each with their drawbacks. Additionally, there are various guidelines like IDSA and ESCMID on treatment which aim to minimize death, late complications from deep-seated candidiasis and rise of drug- resistant Candida strains. Through this consensus statement prepared by a panel of experts, all of whom are senior intensivists, infectious disease specialists and microbiologists, we aim to address the major aspects of management of invasive candidiasis in the Indian population as per the authors opinions, backed by published evidence and supported by the latest clinical guidelines.

Rapid identification of infection has a major impact on the clinical course, management, and outcome of critically ill intensive care unit (ICU) patients. We compared the results of PCR and procalcitonin with blood culture for ICU patients suspected of having septicemia. Ninety patients (60 patients meeting the criteria for sepsis and 30 patients not meeting the criteria for sepsis) were evaluated. Compared with blood culture as the gold standard, the sensitivity, specificity, and positive and negative predictive values for PCR were 100%, 43.33%, 46.87%, and 100%, respectively, and for procalcitonin were 100%, 61.66%, 56.6%, and 100%, respectively. The average times required to produce a final result were as follows: PCR, 10 h; blood culture, 33 h; procalcitonin, 45 min. Both PCR and procalcitonin may be useful as rapid tests for detecting septicemia but compared with blood cultures lacked specificity.

Objective: The presence of exogenous DNA in commercially available polymerase chain reaction (PCR) reagent preparations is a serious problem when amplifying conserved regions of bacteria. The preferred and currently in-use method of decontamination using 8-methoxypsoralen (8-MOP) and UVA requires re-standardization of decontamination with increasing concentrations of 8-MOP and UVA irradiation timings, if the DNA load of reagents is high due to lot-to-lot differences. The objective of this study was to develop a decontamination method, which would (i) work at the minimum reported concentration of 8-MOP and UVA irridation timings; and (ii) take care of inter-batch DNA-load variability of reagents. Materials and methods: The improved method described here was formulated after studying the exact molecular mechanism of action of 8-MOP with DNA. The successful working of the method was experimentally proven and validated with 6–7 new batches of PCR reagents. The sensitivity of eubacterial PCR, after using the new method of decontamination, to be used clinically was checked with both the spiked specimens and the actual clinical specimens. Results and discussion: The new method was found to work at the same starting parameters of 8-MOP and UVA in such situations. The increased efficiency of this method was found to be due to the synergistic effect of both the selective treatment of Taq DNA polymerase and the split-irradiation approach.

Catheter associated urinary tract infections (CAUTI) are supposedly a very common cause of nosocomial infection in the Intensive Care Unit (ICU).[1] Pyuria and bacteruria are, however, inevitable in every patient who has a Foley's Catheter in place for a few days. It is, therefore, difficult to separate catheter associated bacteruria from true CAUTI.[2] In our country, ventilator associated pneumonia and central line associated blood stream infections (CLABSI) remain the main bug bears in the ICU. Many of the episodes of CAUTI occur after the patient has been transferred out of the ICU after removal of the catheter (especially if the catheter has been removed prematurely and the patient needs re catheterization). Even so, the incidence of true CAUTI is probably over estimated. In this Issue Jain et al.[3] have studied the knowledge and attitude of doctors and nurses towards prevention of CAUTI in a Tertiary Care Hospital. Irrespective of the true incidence of CAUTI, this is an important study. The focus of this study was CAUTI, but the findings of this study are a reflection of the knowledge and attitudes of Health Care Workers (HCW) toward prevention of any nosocomial infection. If a similar study were done about hospital acquired pneumonia or about CLABSI, it is unlikely that the results would be any less depressing. It is interesting to note that the HCW were reasonably good at identifying effective methods of preventing urinary tract infections. They however were very poor at identifying the noneffective methods (metal cleaning, bladder wash, prophylactic antibiotics, etc.). Many useless, expensive and potentially harmful practices are unfortunately therefore still being followed in many ICUs in our country. This is also probably the reason why many other useless practices such as fumigation, removal of foot wear, restriction of visitors, etc., continue to be popular. This study was conducted in a tertiary care hospital, one shudders to think of the results of a similar survey in smaller hospitals. It is a small mercy that HCW in the ICU performed slightly better than the others. This is probably because intensive care is the only speciality, which gives some importance to infection prevention. It is also heartening to note that most of those surveyed recognized that infection prevention should be a priority. They also recognized the importance of education. Preventive medicine has never got the importance it deserves in the medical and nursing curriculum. It is the “Cinderella,” the neglected step sister. This needs to change. Preventive medicine needs a godmother, “Cinderella” needs to be transformed. Infection prevention should be part of the curriculum at both under graduate and postgraduate level (irrespective of specialty). There should be at least one question related to infection control in the qualifying examinations. While seeking renewal of registration, it must become mandatory for a physician to have attended at least one continuing medical education on infection prevention each year. Hospitals must dedicate a minimum of 1-day each year to re-educating and re training their staff in infection prevention. Unfortunately, increased knowledge does not always translate into better practice. In a study performed in a premier teaching hospital in India, doctors scored better than nurses in knowledge of infection prevention practices, but performed much worse when it came to practice of these measures.[4] In a study from South India, after an education program, in spite of an increase in knowledge scores, doctors were the least compliant of the HCW in infection control practices. Several studies have shown that doctors are the worst offenders when it comes to hand washing.[5] Why do doctors have such a poor attitude towards infection control? A major share of the blame must go to the senior doctors. The average age of the respondents in this study was quite low, the results would probably have been more dismal if more senior personnel had been surveyed. Junior doctors and even other HCW tend to copy the behavior and attitudes of the Senior doctors. Unfortunately until recently Senior doctors have been very poor role models at least as far as infection prevention is concerned. Fortunately, intensive care is a relatively young specialty with relatively younger more enlightened leaders. It is their responsibility to lead by example.[6] In these days of “Bad Bugs, No Drugs,” infection prevention is all we have.

We have recently treated three patients with malaria who developed post malaria immune mediated hemolysis. These cases, seen with in a span of three month period (September 09 to November 09) form the basis of this report. Out of three patients, two were treated with steroids and both responded favorably.

Bisphosphonates are routinely used in the prevention and treatment of osteoporosis. Osteonecrosis of the jaw is known to be an important but rare complication of bisphosphonate usage. We present our experience with two patients of osteonecrosis of the jaw due to bisphosphonate usage.

How to cite this article: Hegde A. Diuretics in Acute Kidney Injury. Indian J Crit Care Med 2020;24(Suppl 3):S98–S99.