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Background and Objectives: Candidaemia is a potentially life-threatening emergency in the intensive care units (ICUs). Surveillance using common protocols in a large network of hospitals would give meaningful estimates of the burden of candidaemia and central line associated candidaemia in low resource settings. We undertook this study to understand the burden and epidemiology of candidaemia in multiple ICUs of India, leveraging the previously established healthcare-associated infections (HAI) surveillance network. Our aim was also to assess the impact that the pandemic of COVID-19 had on the rates and associated mortality of candidaemia., Methods: This study included adult patients from 67 Indian ICUs in the AIIMS-HAI surveillance network that conducted BSI surveillance in COVID-19 and non-COVID-19 ICUs during and before the COVID-19 pandemic periods. Hospitals identified healthcare-associated candidaemia and central line associated candidaemia and reported clinical and microbiological data to the network as per established and previously published protocols., Results: A total of 401,601 patient days and 126,051 central line days were reported during the study period. A total of 377 events of candidaemia were recorded. The overall rate of candidaemia in our network was 0.93/1000 patient days. The rate of candidaemia in COVID-19 ICUs (2.52/1000 patient days) was significantly higher than in non-COVID-19 ICUs (1.05/patient days) during the pandemic period. The rate of central line associated candidaemia in COVID-19 ICUs (4.53/1000 central line days) was also significantly higher than in non-COVID-19 ICUs (1.73/1000 central line days) during the pandemic period. Mortality in COVID-19 ICUs associated with candidaemia (61%) was higher than that in non-COVID-19 ICUs (41%). A total of 435 Candida spp. were isolated. C. tropicalis (26.7%) was the most common species. C. auris accounted for 17.5% of all isolates and had a high mortality., Conclusion: Patients in ICUs with COVID-19 infections have a much higher risk of candidaemia, CLAC and its associated mortality. Network level data helps in understanding the true burden of candidaemia and will help in framing infection control policies for the country., (© 2024 Wiley‐VCH GmbH. Published by John Wiley & Sons Ltd.)

This study included 21 newly isolated clinical samples of Streptococcus agalactiae (Group B Streptococcus) screened in patients (six male, fifteen female) from various states of India with different infections (urinary tract infections, blood, pus and eye infections). All isolates were identified as Group B Streptococcus (GBS) using hemolytic properties, serogrouping and MALDI-TOF-MS analysis. Six virulence genes, cfb (100%), cylE (90.4%), lmp (85.7%), bca (71.4%), rib (38%) and bac (4.7%) were detected via polymerase chain reaction (PCR). Distribution studies of these six genes revealed five isolates containing five virulence genes (23.8%), followed by ten isolates containing four virulence genes (47.6%). The twenty GBS isolates selected on the glass surface included non-biofilm producers (n = 6, 30%), weak (n = 11, 55%) and moderate biofilm producers (n = 3, 15%). On the polystyrene surface, weak (n = 4, 20%), moderate (n = 2, 10%) and strong (n = 14, 70%) biofilm producers were detected. Live-dead cell staining revealed that more viable cells accumulated in the S. ag 7420 isolate than in the AH1 isolate. Scanning electron microscope (SEM) biofilm analysis showed S. ag AH1 cells appeared as chain-like structures, whereas the S. ag 7420 isolate biofilm cells appeared as fork-like structures on the glass surface. Biofilm elements were analyzed using Energy Dispersive X-Ray Analysis (EDAX) for both isolates and 13 elements with different orders of composition were found. Thus, virulence gene detection, distribution and biofilm formation by these new clinical isolates suggested the virulent nature of these pathogens, which might cause different levels of disease severity in humans., 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 © 2023 Elsevier B.V. All rights reserved.)

Talaromycosis is a disseminated disease caused by Talaromyces (Penicillium) marneffei, mainly seen in acquired immunodeficiency syndrome (AIDS) patients. Its distribution is restricted to southeast Asian countries; a small pocket of endemicity exists in the northeast Indian state of Manipur. Here, we present a series of five cases presenting to our tertiary care hospital, originating from non-endemic states neighboring Manipur. In addition to the geographical distinction, a variety of unique features were noted in our cases, including human immunodeficiency virus (HIV)-negative hosts, the absence of typical skin lesions, presentation as pneumonia and generalized lymphadenopathy. Our series highlights the importance of distinguishing this disease from histoplasmosis and tuberculosis, both endemic in India.

Introduction: Antimicrobial-resistant HAI (Healthcare associated infection) are a global challenge due to their impact on patient outcome. Implementation of antimicrobial stewardship programmes (AMSP) is needed at institutional and national levels. Assessment of core capacities for AMSP is an important starting point to initiate nationwide AMSP. We conducted an assessment of the core capacities for AMSP in a network of Indian hospitals, which are part of the Global Health Security Agenda-funded work on capacity building for AMR-HAIs., Subjects and Methods: The Centers for Disease Control and Prevention's core assessment checklist was modified as per inputs received from the Indian network. The assessment tool was filled by twenty hospitals as a self-administered questionnaire. The results were entered into a database. The cumulative score for each question was generated as average percentage. The scores generated by the database were then used for analysis., Results and Conclusion: The hospitals included a mix of public and private sector hospitals. The network average of positive responses for leadership support was 45%, for accountability; the score was 53% and for key support for AMSP, 58%. Policies to support optimal antibiotic use were present in 59% of respondents, policies for procurement were present in 79% and broad interventions to improve antibiotic use were scored as 33%. A score of 52% was generated for prescription-specific interventions to improve antibiotic use. Written policies for antibiotic use for hospitalised patients and outpatients were present on an average in 72% and 48% conditions, respectively. Presence of process measures and outcome measures was scored at 40% and 49%, respectively, and feedback and education got a score of 53% and 40%, respectively. Thus, Indian hospitals can start with low-hanging fruits such as developing prescription policies, restricting the usage of high antibiotics, enforcing education and ultimately providing the much-needed leadership support., Competing Interests: None

Background: Infection/colonization due to carbapenem-resistant enterobacteriaceae (CRE) are emerging as an important challenge, particularly in high risk patients due to widespread use of Carbapenems. Therefore, preventing both CRE infections and their transmission has become an important infection control objective., Aims and Objective: Determine the proportion of asymptomatic carriers of CRE among patients admitted to our critical care unit (CCU) from the community and other health care facilities. Enumerate risk factors and guide implementation of infection control interventions., Methods: This prospective surveillance study was done in a 24 bed CCU of a tertiary care hospital, at Chennai, India between August2017 through December 2017. Patients were screened based on a composed questionnaire framed from Centers for Diseases Control and Prevention CRE tool-kit. Two rectal swabs were collected from each patient. They were processed in microbiology laboratory., Results: A total of 102 patients were included. CRE colonization were identified in 8 (7.8%) of the total samples. Among 8 CRE colonized patients 3 (37.5%) patients developed systemic infection. Patients who were exposed to high end antibiotic and past history of surgery had significant association with CRE colonization of (P = 0.0029) and (P = 0.0167) respectively., Conclusion: Overall CRE colonization rates among our CCU patients were found to be low. Risk factors associated with CRE colonization were high end antibiotic exposure and surgery in past 90 days. Hence rectal screening should be a risk factor-based active surveillance. Association of systemic infection among CRE colonizers was more significant. This study led us to modify our infection control practices in CCU., Competing Interests: None

Streptococcus pyogenes causes a variety of diseases ranging from mild diseases to severe invasive infections which result in significant morbidity and mortality. This study focuses on the antibiotic resistance of S. pyogenes and their interaction with cysteine protease. Around 36 beta-hemolytic isolates were collected from the clinical lab, of which seven isolates (19.4%) were identified as Streptococcus pyogenes . One of the seven isolates was collected from a urinary tract infection, which was identified by antibody agglutination and MALTI-TOF-MS, and it is designated as S. pyogenes NBMKU12. Around 8.3 to 66.6 % of the isolates were found to be resistant to one or more antimicrobial agents, especially, penicillin-G resistance was exhibited by 29.1% of the isolates. In the NBMKU12 isolate, the beta lactem ( TEM ) gene was detected among the 13 antibiotic genes for which it was tested. Furthermore, when analysis for presence of 13 virulence genes were carried out in NBMKU12 isolate, only speJ and speB were detected. The speB (streptococcal pyrogenic exotoxin B) encoding cysteine protease gene was cloned. This was followed by performing DNA sequencing to understand the putative cysteine protease interaction with antibiotics, inhibitors, and substrate. The speB gene consists of 1197 nucleotides and encodes a protein with multiple domains, including a signal peptide (aa 1-22), an inhibitor region (aa 27-156), and a catalytic cysteine domain (aa 160-367). The signal peptide cleavage site is predicted between Ala22 and Asn23. The putative 398 amino acid residues were found to have a theoretical pI of 8.76 and a molecular mass of 43,204.36 Da. The tested culture supernatants of NBMKU12 isolate exhibited the proteolytic activity against casein, papaya and pineapple used as substrates. The proteolytic activity suggests the expression of speB gene. Molecular docking analysis of cysteine protease showed that erythromycin (bond length 2.41 Å), followed by chloramphenicol (2.51 Å), exhibited a strong interaction; while penicillin-G (3.24 Å) exhibited a weak interaction, and this factor could be considered as a cause for penicillin-G resistance. The present study contributes to a better understanding of speB gene encoding cysteine protease, antibiotic resistance, and their interaction in the isolate, S. pyogenes NBMKU12. The antibiotics and cysteine protease interaction study confirms the resistance or sensitivity of S. pyogenes . Hence, it could be hypothesized that the isolate NBMKU12 is resistant to most of the tested antibiotics, and this resistance might be a cause for mutation.

Background: The (1,3)-β-D-glucan assay (BDG) is recommended for the early diagnosis of invasive candidiasis (IC)., Methods: Records of 154 critically ill adults with suspected IC, on whom BDG was done, were analyzed. Patients were divided into three groups: Group A (confirmed IC), Group B (alternative diagnosis or cause of severe sepsis), and Group C (high candidal score and positive BDG [>80 pg/mL] but without a confirmed diagnosis of IC)., Results: Mean BDG levels were significantly higher in Group A ( n = 32) as compared to Group B ( n = 60) and Group C ( n = 62) (448.75 ± 88.30 vs. 144.46 ± 82.49 vs. 292.90 ± 137.0 pg/mL; P < 0.001). Discontinuation of empiric antifungal therapy based on a value <80 resulted in cost savings of 14,000 INR per day per patient., Conclusion: A BDG value of <80 pg/ml facilitates early discontinuation of empirical antifungal therapy, with considerable cost savings., Competing Interests: There are no conflicts of interest.

Background: Melioidosis caused by the gram-negative bacterium Burkholderia pseudomallei is endemic in Southeast Asia but may be under-diagnosed and under-reported in the Indian subcontinent. This study was undertaken to analyse the clinical presentation and epidemiological risk factors for melioidosis in India., Methods: We carried out a retrospective study of 32 culture proven cases of melioidosis at a tertiary care hospital in South India between 2005 and 2010., Results: Thirty two culture confirmed cases of melioidosis were included in the study. Patient age varied from 4 to 60 years with a median age of 42.5 years. Males constituted 75% of cases and 78.12% of cases were from rural areas. Three-fourth (24 of 32) had at least one risk factor that predisposed to melioidosis: diabetes (43.75%) followed by alcoholism (21.87%) were the commonest. Fever was the most common symptom (68.75%) and mean duration of symptoms was 2.34 months before diagnosis. More than half of the cases (56.25%) presented as disseminated disease with the remainder having localised disease, usually septic arthritis or abscesses. Three fourth of patients (75%) were treated successfully on follow-up, with a regimen of parenteral ceftazidime followed by oral doxycycline and cotrimoxazole., Conclusion: Melioidosis is an emerging infection in India especially in males from rural areas, with diabetes and alcoholism being the commonest risk factors. Both sepsis with bacteraemia and localised disease involving joints or focal abscess were common presentations. Diagnosis is readily made by culturing the organism from appropriate clinical specimens and identifying non-fermenting Gram negative bacteria to the species level. As there was an excellent response in 75% of patients, early suspicion, culture confirmation and therapy is warranted in India.

Background: Mucormycosis (Zygomycosis) is a life-threatening infection. We attempted to analyse clinical features and risk factors of Mucormycosis cases in a tertiary care referral institution in India, in patients without underlying malignancy., Methods: We retrospectively analyzed data of patients diagnosed as having Mucormycosis over a 10 year period of 2000-2010. Patients with a histopathology report and/or a Microbiology report of Zygomycetes or Mucor from a biopsy specimen were included in the study., Results: Out of the 27 cases, rhino-orbital/rhino-cerebral involvement occurred in 12 (44.4%) patients, pulmonary involvement in 3 (11.1%) cases, soft tissue involvement in 11 (40.7%) cases and gastrointestinal involvement in one patient (3.7%). Diabetes mellitus is the main risk factor, followed by renal failure and trauma. Mean ESR value of these patients was 118 mm/1 hour. Mean WBC count was 20 x 10(9)/L, and neutrophil count 82%. The mean absolute neutrophil count (ANC) was 16.8 x 10(9)/L., Conclusion: The interesting finding in our study was the presence of neutrophilic leucocytosis and high ESR in most of the patients. In a predisposed individual, especially in a diabetic, in countries with high environmental fungal burden; presence of high ESR and neutrophilic leucocytosis with a compatible clinical presentation should raise suspicion of Mucormycosis.

Background & Objectives: Salmonella enterica serovars Typhi and Paratyphi are predominantly known to cause enteric fever. Multidrug resistance in S. Tphi and S. Paratyphi has emerged as a cause of concern. This study was done to evaluate status in antimicrobial susceptibility patterns of Salmonella enterica serovar Typhi (S. Typhi) and S. Paratyphi obtained from blood culture in a tertiary care hospital in south India., Methods: Blood isolates of Salmonella species over a two year period between May 2009 and June 2011 were studied. A total of 322 isolates of Salmonella species were tested for antimicrobial susceptibility by Kirby-Bauer disc diffusion method. The MIC of ciprofloxacin was obtained by E-test, and azithromycin MIC was confirmed by agar dilution method for a limited number of isolates., Results: Of the total of 322 isolates studied, 186 (57.8%) were S. Typhi, 134 (41.6%) were S. Paratyphi A, and two were S. Paratyphi B. Of these, 44(13.66%) were resistant to ciprofloxacin (MIC <0.50 μg/ml) and 296 (91.9%) were nalidixic acid resistant. Of these 296 nalidixic acid resistant isolates, 278 (94%) were susceptible to ciprofloxacin by MIC criteria (<0.5 μg/ml). Of the 262 isolates tested for azithromycin sensitivity, only 120 (46%) were susceptible, whereas 81 (31%) were resistant and 55 (21%) showed intermediate susceptibility. Of the isolates, 322 (90%) were susceptible to ampicillin and (95%) were susceptible to co-trimoxazole. However, all the isolates were susceptible to chloramphenicol and ceftriaxone., Interpretation & Conclusions: Nalidixic acid resistance screening is not a reliable surrogate indicator of ciprofloxacin resistance. Ciprofloxacin MIC should to be routinely done. Azithromycin resistance appears to be emerging. However, isolates showed a high degree of susceptibility to ampicillin, co-trimoxazole and chloramphenicol. Thus, antibiotics like ampicillin and co-trimoxazole may once again be useful for the management of enteric fever in southern India.

Background: Gram-negative Enterobacteriaceae with resistance to carbapenem conferred by New Delhi metallo-beta-lactamase 1 (NDM-1) are potentially a major global health problem. We investigated the prevalence of NDM-1, in multidrug-resistant Enterobacteriaceae in India, Pakistan, and the UK., Methods: Enterobacteriaceae isolates were studied from two major centres in India--Chennai (south India), Haryana (north India)--and those referred to the UK's national reference laboratory. Antibiotic susceptibilities were assessed, and the presence of the carbapenem resistance gene bla(NDM-1) was established by PCR. Isolates were typed by pulsed-field gel electrophoresis of XbaI-restricted genomic DNA. Plasmids were analysed by S1 nuclease digestion and PCR typing. Case data for UK patients were reviewed for evidence of travel and recent admission to hospitals in India or Pakistan., Findings: We identified 44 isolates with NDM-1 in Chennai, 26 in Haryana, 37 in the UK, and 73 in other sites in India and Pakistan. NDM-1 was mostly found among Escherichia coli (36) and Klebsiella pneumoniae (111), which were highly resistant to all antibiotics except to tigecycline and colistin. K pneumoniae isolates from Haryana were clonal but NDM-1 producers from the UK and Chennai were clonally diverse. Most isolates carried the NDM-1 gene on plasmids: those from UK and Chennai were readily transferable whereas those from Haryana were not conjugative. Many of the UK NDM-1 positive patients had travelled to India or Pakistan within the past year, or had links with these countries., Interpretation: The potential of NDM-1 to be a worldwide public health problem is great, and co-ordinated international surveillance is needed., (Copyright (c) 2010 Elsevier Ltd. All rights reserved.)

A total of 149 clinical isolates of Candida species isolated from immunocompromised patients were examined to ascertain their esterase activity by the Tween 80 opacity test, which is a biochemical test used mainly to differentiate between Candida albicans and Candida dubliniensis. Our results showed that C. albicans (92.3%), Candida tropicalis (92.3%), Candida parapsilosis (25%), C. dubliniensis (16.6%), Candida inconspicua (100%), and Candida lipolytica (100%) produced opacity halos through the 10-day post-inoculation period. The remaining Candida species did not produce a positive test response. These findings indicate that Tween 80 opacity test cannot be used as the sole phenotypic trait in the differentiation of C. albicans and C. dubliniensis.

Measuring the vertical displacement of the center of mass (COM) of the body during walking may provide useful information about the energy required to walk. Four methods of varying complexity to estimate the vertical displacement of the COM were compared in 25 able-bodied, female subjects. The first method, the sacral marker method, utilized an external marker on the sacrum as representative of the COM of the body. The second method, the reconstructed pelvis method, which also utilized a marker over the sacrum, theoretically controlled for pelvic tilt motion. The third method, the segmental analysis method, involved measuring motion of the trunk and limb segments. The fourth method, the forceplate method, involved estimating the COM displacement from ground reaction force measurements. A two-tailed paired t-test within an ANOVA showed no statistically significant difference between the sacral marker and the reconstructed pelvis methods (p = 0.839). There was also no statistically significant difference between the sacral marker and the segmental analysis method (p = 0.119) or between the reconstructed pelvis and the segmental analysis method (p = 0.174). It follows that the first method, which is the most simple, can provide essentially the same estimate of the vertical displacement of the COM as the more complicated second and third measures. The forceplate method produced data with a lower range and a different distribution than the other three methods. There was a statistically significant difference between the forceplate method and the other methods (p < 0.01 for each of the three comparisons). The forceplate method provides information that is statistically significantly different from the results of the kinematic methods. The magnitude of the difference is large enough to be physiologically significant and further studies to define the sources of the differences and the relative validity of the two approaches are warranted.