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A middle-aged recently diagnosed uncontrolled diabetic from Mumbai, India presented with fever and headache for 8 weeks. Two weeks prior to his symptoms, he travelled to Lonavala during the monsoons and gave history of indoor swimming in a chlorinated pool. Investigations showed isolated neurological involvement with multiple brain abscesses. Abscess cultures grew a non-lactose fermenter. Automated systems failed to identify it. After assessment of his background history and detailed microbiological analysis of the organism, specific investigations were requested which confirmed the suspected diagnosis of melioidosis. We report an unusual presentation of ceftazidime-resistant Burkholderia pseumodmallei as isolated neuromelioidosis with brain abscesses.

Incidence of carbapenem-resistant Gram-negative infections has risen alarmingly all across the globe, both in developed and developing countries alike. The purpose of this study was to assess whether challenges of life-threatening infections with very high resistance pattern can be successfully addressed by a modified approach.This is a retrospective study of 26 patients with osteoarticular and soft tissue infections with carbapenem-resistant Gram-negative bacilli treated between 2001 and 2017 with at least two year follow-up after stopping antibiotics. All were treated by a multispecialty team approach with primary aim of "source control at the earliest and avoiding recurrence at all cost". The protocol involved opting for early compromises especially in at "risk individuals", such as resorting to early amputations, especially if salvage meant multiple bony and soft tissue reconstructive procedures, explanation of prosthesis than staged revision, avoiding internal fixations, opting for shortest possible time in external fixators with reshaping and telescoping bone ends to get bony stability and increase surface area even if it meant compromising length.There were five amputations, two excision arthroplasty of hip, many minor but acceptable malunions and shortening. However, lives of 24/26 patients could be salvaged, much better than most of the published data. The two patients who died had peri-prosthetic joint infection after total hip arthroplasty and presented very late in sepsis and died within days of explantation. Infection remission could be achieved in remaining patients.These "risk to life" cases can be successfully treated by lowering the aims and expectations from "excellent function to salvage of life and infection remission". Therein lies the "success" in these complex high-risk cases.

Introduction:Lower limb amputations secondary to diabetic foot infection/osteomyelitis (OM) are the most common cause for non-traumatic amputations of the lower extremity. Hind/midfoot amputations are commonly done for metatarsal (MT) OM. They are, however, associated with higher complication and revision rates and often lead to below knee amputation. In comparison, distal/forefoot toe disarticulation/ray amputation (R amp) have lesser revision rates/complications and give better functional outcome. Here, we report a case of 2nd R amp with an uncommon complication. Case Report:A 42-year-old male with uncontrolled diabetes and bilateral diabetic neuropathy presented with discharging sinus over plantar aspect of the left foot since 1 week. There was no evidence of underlying OM on MRI. Wound healed with soft-tissue debridement and empirical antibiotics (culture negative) for 2 weeks. Re-debridement was done for a wound gape 6 weeks later. Infection resolved with targeted antibiotics (oral ciprofloxacin and doxycycline) for Enterobacter cloacae given for 1 month. Six months later, he developed pain and swelling in the left foot following prolonged barefoot walking and possible injury with a stone. There was local redness, swelling, and a plantar sinus. MRI revealed septic arthritis of the left 2nd metatarsophalangeal (MTP) joint, OM of the 2nd MT head, and an encapsulated soft-tissue abscess. Aggressive debridement with 2nd R amp and careful separation of encapsulated abscess was done leaving behind base of 2nd MT to maintain stability of the Lisfranc joint. Wound healed primarily. Targeted antibiotics for Methicillin Susceptible Staphylococcus aureus were given for 6 weeks. Good diabetic control and avoiding bare foot walking were advised and he is infection free, fully functional, and asymptomatic at 36 months. However, he was noted to have developed valgus deformity of the midfoot secondary to Charcot osteoarthropathy of the Lisfranc joints at 36 months follow-up, involving 1st, 3rd, and 4th TMT joints. The other foot did not show any evidence of Charcot arthropathy. Conclusion:Recurrent wound infections with subsequent OM are a common feature of diabetic foot. R amps have better functional outcomes with preserved foot stability, shorter length of hospitalization, and associated costs as compared to hind/midfoot amputations. They may, however, develop Charcot osteoarthropathy due to the void between adjoining MTs resulting in altered forces across the Lisfranc joints. Surgeons must beware of this complication, especially following R amps and monitor these patients with serial clinical and radiographic examination.

BACKGROUND: There are limited data regarding the incidence of pneumothorax in COVID-19 patients as well as the impact of the same on patient outcomes. METHODS: A retrospective review of the medical records at three large tertiary care hospitals in Mumbai was performed to identify patients hospitalised with COVID-19 from March 2020 to October 2020. The presence of pneumothorax and/or pneumomediastinum was noted when chest radiographs or CT scans were performed. Demographic and clinical characteristics of patients who developed air leak were recorded. RESULTS: 4,906 patients with COVID-19 were admitted, with 1,324 (27%) having severe COVID-19 disease. The overall incidence of pneumothorax and/or pneumomediastinum in patients with severe disease was 3.2% (42/1,324). Eighteen patients had pneumothorax, 16 had pneumomediastinum and 8 patients had both. Fourteen patients (33.3%) developed this complication breathing spontaneously, 28 patients (66.6%) developed it during mechanical ventilation. Overall mortality in this cohort was 74%, compared with 17% in the COVID-19 patients without pneumothorax (p

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.

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Objectives Fungal spores are ubiquitously present in the environment. Appropriate temperature and humidity can lead to fungal growth. It is of concern in a hospital environment. Diabetic and immunosuppressed persons are more vulnerable to such infections. The fairly humid and slightly warm climate of Mumbai is ideal for fungal growth. According to an article released in March 2021, the total fungal count in Mumbai was 16.2 CFUs. Here is a brief gist of how fungal spores were controlled within a tertiary hospital in Mumbai, India which is located near sea by simple but effective methods. Methods Air sampling of the Operation Theatre (OT), Central Sterile Supply Department (CSSD), Bone marrow transplant (BMT) areas is done on weekly basis in the hospital and for areas such as ICU (Intensive Care Unit), Oncology (ONCO) Ward, Cardiac Catheterization (Cath) lab and Digital subtraction angiography (DSA) lab monthly air sampling is done to check for bacterial and fungal load. Two types of air samplers are used: Heico air sampler from HiMedia and Dyanamicro air sampler. OT, BMT, CSSD have HEPA (high efficiency particulate air) filters installed for filtration of air. The other areas like ICU, ONCO ward, Cath lab, and DSA lab do not have HEPA filters. Results In the last 4 years there were two instances where fungal growth was observed once in BMT and once in ICU. In ICU Aspergillus niger growth was observed and in BMT there was a growth of multiple Aspergillus spp. It took nearly 3-4 months for the eradication of the fungus in BMT and 2 months to clear the fungus from ICU. Due to strict engineering control, we were able to restrict the spread within hospital. In BMT unit the growth was observed during rainy season when because of heavy rain there was seepage in one wall of the unit and also there was a leakage of sink in the ante-room area. When these repairs were done the fungal growth was not observed afterward. In ICU thorough cleaning of the Air Handling Unit (AHU) filter leads to resolution of the issue. Both these episodes were uneventful as no patient had any infection due to these. Factors that helped in controlling the fungal spores spread are: Conclusion Even though the hospital is situated near sea and the outside air has high humidity and high microbial load, effective engineering measures and close monitoring of the areas can help in controlling the spread of fungus within the hospital. Routine periodic checks of the air for fungal spores can also help prevent nosocomial infections.

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM Objective Candida spp is the fourth leading cause of catheter-related blood stream infection (CRBSI). The standard treatment is prompt removal of the device (central venous catheter, CVC, or port or hemodialysis catheter) along with administration of systemic antifungal therapy. However, in patients with a lack of alternative intravenous access and in some critically ill patients, this standard of care is challenging. Our success with antibiotic lock solution in MDR GNB CRBSI, prompted us to consider similar therapy in Candida spp CRBSI. Methods Catheter salvage using antifungal lock therapy was tried in a total of 15 cases in two centers. In 10 cases echinocandin (9 anidulafungin, 1 micafungin) and in 5 cases amphotericin b deoxycholate (AmB-d) were used to obtain an antifungal concentration of ∼ 1000 mcg/ml in the lock solutions. All these formulations had additional NAC, heparin, and normal saline. Systemic antifungal therapy was also administered concurrently. Success was defined as clearance of candidemia at 48 h and 14 days and/or till the use of the device was needed. Some of these patients had prior/co-infections with bacterial pathogens and they were managed with appropriate systemic antibiotics with antibiotic lock therapy. Results In 11/15 episodes of CRBSI due to Candida species, catheter salvage was achieved. One case could not be assessed at 14 days as a port was removed in view of megaprosthesis in situ. In two cases this therapy failed and one patient lost to follow-up. See Figures 1 and 2 for details of all cases. Conclusions Antifungal lock therapy using echinocandins and AmB-d appears to be a promising therapy in patients where catheter removal is difficult. However, this success neither means that this can become standard practice, nor should it make clinicians and hospital staff complacent about infection control practices.

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM Two cases of Rhinocladiella mackenziei have been noted in our institute, the first case in 2015 (post-renal transplant) and the second case in 2021 (post-COVID infection). Both the patients had received immunosuppressants for varying duration. Both the cases presented to the hospital with neurological deficit secondary to brain abscess. On initial assessment, the melanized fungus was noted which was later identified as Rhinocladiella on culture and further confirmed with molecular methods. Both the cases were treated with injection of L AmB, voriconazole and 5FC for a prolonged duration and later discharged when the condition improved. The renal transplant patient was advised lifelong voriconazole since he would continue to be on immunosuppressants. To our knowledge, the second patient diagnosed post-COVID could be the first case report of invasive dematiaceous fungal infection in an apparently immunocompetent individual. Both cases also highlight the challenges in management such as designing an appropriate regimen, deciding the optimum duration of antifungal therapy, and managing the toxicities associated with long-term antifungal use. R. mackenziei is a frequently fatal melanized neurotropic fungus known to carry almost 100% mortality despite the combination of antifungal agents and surgery. Central nervous system infections due to R. mackenziei have been exclusively reported from the Middle East, except for cases recently reported from India.

A young Indian man presented elsewhere with a short history of haematuria and cough. Investigations revealed renal and pulmonary lesions. Histopathology of these lesions was reported as mucormycosis. He consulted us two months after onset of symptoms, asymptomatic and clinically well, having received no treatment. In view of clinico-histopathological discordance, a review of the biopsy slides was advised but the patient refused further work-up at that time. One week later, however, he was admitted with left hemiparesis. Brain imaging showed an abscess. He underwent surgical excision of the brain abscess and nephrectomy. Review of previous slides showed septate fungal filaments with granulomatous inflammation. Intraoperative cultures grew Aspergillus flavus. He received voriconazole for one year and is well at his two-year follow-up. His immunological work-up was negative for immunodeficiency. This case illustrates that granulomatous aspergillosis may be an indolent infection in apparently normal individuals and reiterates the importance of interpreting diagnostic reports in conjunction with clinical features.

A 31-year Indian homemaker, known to have Systemic Lupus Erythematosus (SLE) and lupus nephritis, was admitted previously in another medical care unit with fever, hemoptysis, arthralgia, and joint swelling. She had been treated with antibiotics and corticosteroids for probable diffuse alveolar hemorrhage (DAH) with clinical and radiological resolution. She was readmitted one month later for similar complaints. Her autoimmune workup revealed evidence of active lupus. Her chest imaging showed the presence of well-circumscribed macronodular lesions with halo sign, but Bronchoalveolar Lavage (BAL) cultures and serum galactomannan were negative. BAL tested positive for hemosiderin-laden macrophages. She was treated with corticosteroids, plasmapheresis, and empiric antibiotics with partial clinical response. One week later, her fever recurred, and she developed new-onset myositis. Bactec blood cultures grew Burkholderia pseudomallei. She received treatment for 3 months with good clinical and radiological resolution. In hindsight, a CT-guided biopsy of the lung lesion may have provided an earlier diagnosis of melioidosis.

We present a case of a 59-year-old man, who on being evaluated for abdominal pain and headache, was found to have a pancreatic head mass and inflammatory hypophysitis. Xpert MTB/Rif of the pancreatic mass biopsy showed the presence of tuberculosis (TB) with a very low load, and rifampicin resistance was detected with absence of probes A and B. Pyrosequencing (a novel genotypic test for TB) of the Xpert MTB/Rif isolate detected a single, rare, high-confidence mutation (S512T) in the rpoB region (rifampicin resistance determining region in the MTB genome). The TB mycobacteria growth indicator tube (TBMGIT) phenotypic drug susceptibility test (DST), however, showed rifampicin susceptibility. Incidentally, he was unable to tolerate rifampicin and responded well to a non-rifampicin-based regimen. We discuss a possible hypothesis of the Xpert-DST discordance in accordance with a recent literature review on phenotypic DST methods. We also discuss the utility of pyrosequencing in clinical practice for the diagnosis of TB and its resistance patterns.

We evaluated the performance of pyrosequencing, a genotypic test which detects TB and XDR-defining mutations within 6 h, directly on CSF samples for diagnosing TB meningitis(TBM).This retrospective, diagnostic accuracy study was conducted in Hinduja hospital, Mumbai from May-2017 to May-2019. 107 consecutive patients with physician-suspected TBM for whom CSF pyrosequencing was requested were screened. Seven patients with incomplete data were excluded. Diagnostic accuracy of pyrosequencing was compared with Xpert MTB/Rif and TBMGIT (TB Mycobacterial Growth Indicator Tube) culture against the uniform case definition of definite or probable TBM. Susceptibility concordance rate of pyrosequencing with TBMGIT culture and Xpert MTB/Rif was determined.The study cohort comprised of 100 patients[Definite(n = 33), Probable(n = 20), Possible(n = 30), Alternative(n = 17)] with 50% males[median age(years):38(Range:2-87)]. Against the uniform case definition, pyrosequencing had 98·11%(95%CI 89·93-99·95; n = 52/53) sensitivity and 97·79%(86·31-99·67; n = 44/45) negative predictive value(NPV) compared with 43.39%(29·83-57·72; n = 23/53,p 0.0001) sensitivity and 61.04%(55·31-66·48; n = 47/77) NPV for Xpert MTB/Rif and 45·28%(31·56-59·55; n = 24/53,p 0.0001) sensitivity and 61·84%(55·92-67·43; n = 47/76) NPV for TBMGIT culture. Susceptibility concordance rate of pyrosequencing with phenotypic Drug Susceptibility Testing was 91.3%(n = 21/23) and with Xpert MTB/Rif was 95·45%(n = 21/22).CSF pyrosequencing is significantly more sensitive than Xpert MTB/Rif and TBMGIT culture for diagnosing TBM. Additionally, it facilitates early therapeutic decision-making by providing information on XDR-defining mutations.

Environmental conditions, resource limitations, and unavailability of certain antifungal (AF) agents are important challenges in management of invasive fungal infections in Asian countries. Lack of awareness and inadequate expertise also produces various pitfalls in management. There is an unmet need of addressing all these concerns, as also of generating and locally validating novel low cost management strategies. Intensive educational activities and AF stewardship need to be emphasized to prevent Asia from becoming an AF resistance hotspot in future.

The profile of Infective endocarditis (IE) has been evolving continuously. Like other infectious Diseases (ID) syndromes, IE has not escaped from antibiotic resistance issues. The aim of this study was to determine the implications for diagnosis and treatment by studying the clinical profile and outcome of patients admitted with IE in a tertiary care centre in Mumbai during the period from 2007-2015.53 patients having definite or possible IE as per Modified Duke's Criteria (MDC), that were referred to the ID division, were included in this study.44 (83%) patients had definite IE and 9 (17%) patients had possible IE. 77.4% of the patients were above 40 years of age. 3 patients presented as euthermic IE. Vegetations were not seen on transthoracic echocardiography (TTE) in 3 patients and were seen only on transesophageal echocardiography (TEE). 15 patients had prosthetic valve IE. 7 patients had rheumatic heart disease. 3 patients had bicuspid aortic valve and 4 had ventricular septal defect (VSD). The rest had no apparent underlying heart disease (45.3%). 41 patients (77.3%) had culture-positive IE and 12 patients (22.6%) had culture-negative IE. Streptococcus spp. was found in 14 (26.4%) patients, Enterococcus spp. in 9 patients (17%). Other organisms isolated were methicillin-sensitive S. aureus (3), Methicillin Resistant S. aureus (1), Eikenella corrodens (1), B. cepacia (2), Salmonella Typhi (1), P. aeruginosa (1), M. abscessus (2) and other rapidly growing mycobacteria (RGM) (5), Candida parapsilosis (1), Candida pelliculosa (1) and Aspergillus fumigatus (1). Notably there was only one case of MRSA. Among the Streptococcus spp., Penicillin MIC testing was done in 11 cases of the 14 cases of Strep spp. 3 of them showed intermediate resistance and 2 were resistant. Among enterococcal IE, 3 had high level aminoglycoside resistance (HLAR) and 2 had β-lactamase producing enterococci with HLAR and 1 had Vancomycin resistance. These were successfully treated with combinations of Ampicillin with Ceftriaxone, Ampicillin-Sulbactam with Imipenem and Daptomycin respectively. The only case of MRSA prosthetic valve endocarditis was successfully treated with Vancomycin and Rifampicin in addition to surgery. Surgery for IE was performed in 26 out of 53 (49%) patients. Early valve surgery (within 15 days of hospital admission) was performed in 6 of these 26 patients. .There is a change in the spectrum and antimicrobial susceptibility of organisms causing IE. We encountered several difficulties with the use of the MDC as 43.5% patients had no predisposing factors for IE and blood cultures were negative in 22.6% cases. In our study, PVE was the most common predisposing condition for IE. VGS followed by enterococci were found to be the commonest cause for IE in our setting. Both organisms show variable drug resist patterns. MRSA was isolated in 1 patient only. Thus vancomycin may not be required as empiric treatment in our setting. This is important from the perspective of antimicrobial stewardship Good infection control practices are essential to prevent nosocomial IE due to pathogens such as non-tuberculous mycobacteria (NTM). Important changes in the disease characteristic, treatment, and outcome are noted. Surgery, whenever indicated, helps in improving outcome in these patients thus reiterating the need for a team approach for optimal management of this complex, challenging condition..

We report five patients with infective endocarditis (IE) due to rapidly growing mycobacteria (RGM) which we postulate are related to the reuse of percutaneous transluminal angioplasty balloon catheters prior to the intravascular stent placement. The index procedure was performed at various institutes in different parts of the country. We call attention to diagnostic and therapeutic difficulties and the uniformly dismal outcome of RGM IE as well as the potential hazards of re-use of single-use devices.

Fungi have long been implicated as important pathogens in selected patients with acute or chronic sinusitis. Inhalation of fungal spores is considered to be the primary means by which these organisms gain access to the sinonasal tract. Fungal sinusitis is an important clinical entity. However, changing terminology and emerging theories of pathogenesis make it an area of confusion and controversy. An analysis of tissue invasion and host immunological response is an important step in the evaluation of the patient.