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Although the epidemiology and the impact of Acute Kidney Injury on outcomes are wellknown in the Western literature, good data is lacking from India. Most studies published from India have not evaluated epidemiology of Acute Kidney Injury in the Intensive Care Unit setting and/or have not used validated criteria. In our observational study of 250 patients, admitted to a tertiary level ICU, we have explored the epidemiology of Acute Kidney Injury using both RIFLE and AKIN criteria and have validated them. We have also demonstrated that the severity of AKI is an independent predictor of mortality in critically ill patients. Our results are very much comparable to other studies and we feel that this study will remain as an epidemiological reference point for Indian clinicians dealing with AKI.

BackgroundAntimicrobial resistance by bacteria poses a substantial threat to the success in the treatment of acute bacterial skin and skin structure infections (ABSSSI). Levonadifloxacin is a novel benzoquinolizine subclass of quinolone which has a broad spectrum of activity, available in both oral and intravenous formulations for the treatment of skin structure infections caused by Gram-positive pathogens including methicillin-resistant Staphylococcus aureus (MRSA). Patients and methodsThis prescription event monitoring study captured data of 227 patients receiving levonadifloxacin (oral and/or IV) in a real-world setting to assess the safety and efficacy in the treatment of ABSSSI. Study outcomes were a clinical and microbial success at the end of therapy and safety was assessed based on adverse events reported. ResultsOne hundred and forty patients received IV levonadifloxacin therapy, 76 patients received oral alalevonadifloxacin, and 11 received IV followed by oral therapy. The mean duration of therapy was 7.3 days. Out of 227 patients, MRSA isolates were identified in 79 patients. Clinical success rates with oral, IV, and IV followed by oral levonadifloxacin therapy were 97.3%, 97.8%, and 100% respectively. The overall microbial success rate was 99.2% and only two patients reported two adverse events. ConclusionsThe excellent safety and efficacy profile of levonadifloxacin on oral and/or intravenous therapy, makes it a desirable treatment modality for management of ABSSSI. Unique features of levonadifloxacin such as availability of both IV and oral form, minimal drug-drug interactions, exemption from dosage adjustment in renal and hepatic impaired patients and a broad spectrum of coverage, makes it a suitable agent meeting several unmet clinical needs in contemporary patients.

A bstract In a resource-limited country like India, rationing of scarce critical care resources might be required to ensure appropriate delivery of care to the critically ill patients suffering from COVID-19 infection. Most of these patients require critical care support because of respiratory failure or presence of multiorgan dysfunction syndrome. As there is no pharmacological therapy available, respiratory support in the form of supplemental oxygen, noninvasive ventilation, and invasive mechanical ventilation remains mainstay of care in intensive care units. As there is still dearth of direct evidence, most of the data are extrapolated from the experience gained from the management of general critical care patients. How to cite this article: Juneja D, Savio RD, Srinivasan S, Pandit RA, Ramasubban S, Reddy PK, et al. Basic Critical Care for Management of COVID-19 Patients: Position Paper of the Indian Society of Critical Care Medicine, Part II. Indian J Crit Care Med 2020;24(Suppl 5):S254–S262.

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India has been titled the capital of antimicrobial resistance in the world with the centre for disease dynamics, economics and policy (CDDEP) predicting two million deaths in India by 2050. As per the World Health Organisation’s global priority pathogen list of 2017, methicillin resistant Staphylococcus aureus (MRSA) has been classified as a ‘high priority’ pathogen due to its association with increased mortality rate, rising prevalence of resistance and increased burden on healthcare settings. A recent report by Indian Council of Medical Research signifies the exponential rise in the prevalence of MRSA in India, from 29% in 2009 to 39% in 2018. Serious MRSA infections are commonly associated with poor clinical outcomes coupled with increased hospitalisation stay and cost. Therefore, early identification and appropriate empiric treatment of MRSA plays a crucial role in healthcare settings. However, the constant rise in multi-drug resistance to the currently available anti-MRSA agents as well as their compromised safety profile limits its clinical use to manage severe MRSA infections. This review article explores the implications of severe MRSA infections and inappropriate empirical therapy on the clinical as well as economic outcomes. In addition, it also highlights limitations of the currently available anti-MRSA agents and the need for newer agents to manage multi drug resistant (MDR) gram positive infections.

Tetanus is uncommon in developed countries. The majority of tetanus cases occur in third world countries and 50% of these cases occur in neonates. There are more than 800,000 deaths due to tetanus each year in the world. We present a case of 40-year-old male patient diagnosed to have very severe tetanus - Grade IV as per Ablett classification of severity, managed in our hospital with aggressive treatment for 27-days and use of intrathecal baclofen he showed drastic improvement in this status.  He was discharged in neurological intact conditions with hemodynamic stability.

INTRODUCTION:Anaplasma phagocytophilum is a tick-borne obligate intracellular bacterium that belongs to the genus Ehrlichia and is the causative agent of human granulocytic anaplasmosis (HGA). A. pharocytophilum is transmitted via the Ixodes tick most commonly in spring and summer. The classic presentation of HGA includes fevers, nonspecific symptoms, leukopenia, anemia, thrombocytopenia and transaminitis. Symptoms begin 5-14 d after exposure to tick bite. Diagnosis is based on clinical suspicion and confirmatory lab testing. Empiric treatment should not be delayed. Diagnostic testing includes serologies, peripheral smear with morulae and PCR. 1,2 DESCRIPTION: 33y healthy woman presented during the Minnesota summer with abdominal pain and SOB 1 month after an asymptomatic positive COVID-19 test. She was febrile at 102.4°F, tachycardic, tachypneic and hypoxemic (SpO2 70% on RA). Work up revealed mild transaminitis, leukopenia, and thrombocytopenia. A CT showed LUL and RLL opacities. She was treated for sepsis with fluids and broad-spectrum antibiotics. She worked on a farm and rode horses as a hobby so doxycycline was initiated. A peripheral blood smear was sent, revealing morulae. COVID-19 PCR was again positive. She rapidly developed shock and ARDS requiring intubation and pressors. Infiltrates and hypoxemia worsened. Cultures remained negative. The RT-PCR cycling threshold for her COVID was >35. She was more than 30d from her initial positive, making it unlikely that her illness was due to COVID.3 She extubated on day 4 of ARDS protocol. DISCUSSION: This is a rare clinical presentation of HGA with ARDS. Prior case reports of ARDS due to HGA noted improvement with steroids in addition to doxycycline. 4,5,6 This patient improved on monotherapy of doxycycline. Early initiation of therapy improves outcomes in HGA infections7. There is evidence that some of the mechanism of injury leading to ARDS in patients with HGA is similar to COVID with macrophage activation and excessive cytokine production.8 A thorough social history and avoiding anchoring heuristics can guide diagnosis. Early recognition and treatment with doxycycline can reduce overall morbidity and mortality.