A 6-month-old male infant from North Delhi area brought to Hindu Rao Hospital in December 2013, belonging to low socio-economic status presented with multiple episodes of watery diarrhea, vomiting, high grade fever, dry cough and difficulty in breathing from past one week. Infant was immunized appropriately for age and was born in hospital as a full term child with a birth weight of 2.5 kg. The child was on bottle feed along with breast feeding. On physical examination, the infant weighing 4.66 kg was ill looking, malnourished, lethargic, abdomen distended and with peripheral cyanosis. The heart rate was 160/min, respiratory rate 68/min and BP was not recordable on examination [Table/ Fig-1]. On auscultation crepitations and ronchi were noticed. Infant developed seizures on the day of admission. The infant was treated in the emergency ward with mechanical ventilation, intravenous antibiotics (amikacin, amoxicillin/clavulanic acid), anticonvulsants, fluids and ionotropics. Later on vancomycin, meropenem and metronidazole was added to the treatment regime. The infant subsequently received two units of blood along with fresh frozen plasma and platelet transfusion. Blood culture was performed using BACTEC 9120 and identification and susceptibility testing was done by Vitek 2C. Considering septic shock, blood culture, stool culture and other relevant investigations were done. Stool as well as blood culture yielded Shigella flexneri. The isolates were resistant to cotrimoxazole (>320µg/ml), piperacillin (MIC> 128µg/ml), piperacillin-tazobactam (MIC>128µg/ml) combination, cefotaxime (MIC 32µg/ml), ceftriaxone (MIC 8µg/ml), cefepime (MIC 64µg/ml), aztreonam (MIC>64µg/ml), imipenem (MIC 4µg/ml), amikacin (MIC 16µg/ml), gentamicin (MIC 4µg/ml), tobramycin (MIC 4µg/ml), ciprofloxacin (MIC>4µg/ml), levofloxacin (MIC>8 µg/ml) and sensitive to ertapenem (MIC< 0.5µg/ml), meropenem (MIC 0.5µg/ ml) and tigecycline (MIC< 0.5µg/ml). However the patient expired. DISCUSSIONShigellosis is mainly caused by Shigella dysentery, Shigella flexneri, Shigella boydi, and Shigella sonnei. Shigella dysentery type 1 and Shigella flexneri are among the most toxic of serotypes associated with septicemia [1,2]. Infection is transmitted through feco-oral route with incubation time of 12 hours to one week. Clinically, the infection can result into mild to severe and fatal disease. Risk factors for developing septicemia in shigellosis include young age, malnutrition and immune-suppression. There are limited reports available in India regarding Septicaemia due to Shigella species [2][3][4][5][6]. Shigella infection is generally restricted to the gastrointestinal tract. Bloodstream invasion is rare and is reported to occur in 0.4%-7% of patients [1,4]. Blood cultures are not routinely done in diarrhoea or dysentery patients which may account for apparently lower incidence of septicemia due to Shigella sp. Young age and malnutrition are the two most important risk factors associated with bacteremia [1]. It is locally invasive due to effect of enterotoxi...
Introduction Burkholderia cepacia complex is a ubiquitous organism with a high virulence potential. It is found most commonly in moist environments. Hospital outbreaks have been reported from diverse sources such as contaminated faucets, nebulizers, disinfectant solutions, multidose antibiotic vials, tap water, bottled water, nasal sprays, and ultrasound gels. In this article, we present our experience in investigating and successfully managing an outbreak of nosocomial transmission of Burkholderia cepacia sepsis in the neonatal intensive care unit at SGT Hospital, Haryana, India. Case presentation During the month of March, multiple Burkholderia cepacia complex isolates were recovered from blood cultures of Caucasian babies admitted to the neonatal intensive care unit of our hospital. The organisms were multidrug-resistant, with in vitro sensitivity to meropenem alone (minimum inhibitory concentration = 4 μg/ml). An outbreak was suspected, and the neonatal intensive care unit in-charge and hospital infection control teams were alerted. Outbreak investigation was initiated, and surveillance samples were collected. Burkholderia cepacia complex was successfully isolated from suction apparatus. The isolates were phenotypically typed (biotyping and antimicrobial susceptibility testing) and found to be identical. Conclusions In our study, the index case might have been exposed to infection due to a physiological state of low immunity (preterm, low birth weight, and mechanical ventilation). The rest of the cases might have been exposed to this organism due to inadequate hand hygiene/improper cleaning and disinfection practices. Timely reporting and implementation of infection control measures played a significant role in curtailing this outbreak.
Evidence concerning prescription audits conducted in developing countries like India is scarce, especially from the rural parts of the country. Therefore, the present prescription audit was undertaken in a rural tertiary care hospital to investigate prescriptions for their completeness, in format of prescription, legibility of writing and it was assessed against the World Health Organization (WHO) recommendation of core indicators for prescription writing in order to investigate the rational usage of drugs. A total of 200 prescriptions were randomly selected, irrespective of clinical departments, patient characteristics and diagnosis over a period of six months. All the prescriptions were prospectively analyzed and conferred to an assessment of the quality of prescribing practice, general details, medical components, WHO core drug use indicators and legibility. Amongst the 200 prescriptions precisely monitored, we found that 100% prescriptions had general details of the patients such as name, age, gender, OPD/IPD registration number, hospital name & address and consulting unit/department. While evaluating the handwriting of the doctors, 83.5% (177/200) of the prescriptions had legible handwriting, wherein the degree of legibility showed 68.5% (137/200) prescriptions with easy legibility, 20% (40/200) difficult legibility while 11.5% (23/200) were illegible. Along with the different types of drugs obtained from the selected prescriptions, we found that antibiotics were prescribed in 51.5% (103/200) of the prescriptions. A prescription audit is a good tool to systemically review the day to day work, maintenance of records and assessment of accuracy of the diagnosis given by doctors and also the outcome of the treatment received.
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