No abstract

IntroductionAmong the several newer beta lactam+beta lactase inhibitors (BL/BLI), ceftazidime-avibactam is the only drug showing activity against OXA-48-like producers. Hence, it is being increasingly used in India to treat infections caused by carbapenem-resistant Enterobacteriaceae (CRE), especially as a colistin-sparing agent. We have used ceftazidime-avibactam in patients suspected and confirmed to have CRE infections in our center, and present a retrospective analysis of our experience. MethodsWe conducted a single-center, retrospective study involving all patients who were treated with ceftazidimeavibactam for suspected and proven CRE infections during a one-year period at our 500-bedded hospital. Our primary objective for this study was taken as all-cause mortality. The secondary objectives were to determine the clinical cure, defined as the end of the treatment regimen with a resolution of primary infection and resistance to ceftazidime-avibactam in patients who underwent the Epsilometer test (E-test). ResultsA total of 103 patients who received ceftazidime-avibactam were identified. The all-cause mortality was 27% while a clinical cure was achieved in 73%. Fifty-two patients received empirical therapy and 51 patients received ceftazidime-avibactam for confirmed CRE infection. Forty-eight patients had an E-test done, out of which 79% of patients had CREs sensitive to ceftazidime-avibactam, and 21% of patients had ceftazidimeavibactam resistant CREs. A higher Sequential Organ Failure Assessment (SOFA) score, Charlson comorbidity index (CCI) score, intensive care unit (ICU) admission, inotrope requirement, and lower days of therapy (DOT) with ceftazidime-avibactam were found to be associated with increased mortality. ConclusionColistin has been considered to be the last-line agent in CRE infections, but there are concerns about its adverse effects and the emergence of resistance. Given our relatively low mortality of 27% in CRE infections treated with ceftazidime-avibactam, coupled with the high susceptibility of the tested isolates, there may be a role for the empirical use of this drug in infections caused by CRE, especially in a setting where colistin may not be ideal.

gCases of invasive mycosis due to Blastobotrys serpentis and B. proliferans identified by sequencing in a preterm patient and a rhabdomyosarcoma patient, respectively, are reported. Both species revealed elevated fluconazole and echinocandin MICs by the CLSI broth microdilution method. Additionally, B. serpentis exhibited high amphotericin B MICs, thus posing serious therapeutic challenges. CASE REPORTSC ase 1. A 29-week gestation preterm male infant at birth was admitted on 24 April 2013 because of respiratory distress. The infant was born by normal vaginal delivery to a 24-year-old primigravida mother. On admission at day 1, the child was not active and had tachypnoea with a respiratory rate of 68/min and his chest X-ray showed mild haziness. Examination of the cardiovascular system revealed no abnormal heart sounds and equal bilateral peripheral pulses. The abdomen was soft, with no organomegaly noted. On day 5, a loud murmur was detected and an echocardiography revealed a large patent ductus arteriosus of 2.2 mm in size which was surgically closed. His total leukocyte count was elevated (24,000 cells/l), and his C-reactive protein level was 0.1 mg/liter. Two days later, the infant developed abdominal distension and the X-ray revealed a pneumoperitoneum. This was managed with a peritoneal drainage followed by laparotomy. During surgery, a gangrenous gastric fundus with a sloughed greater curvature, leading to an approximately 40% to 45% loss of stomach volume, was seen. The necrotic tissues were removed; gastric anastomosis was done with placement of a gastrojejunal feeding tube via gastrotomy. The child underwent operation twice again, on days 14 and 29 of admission, because of anastomotic leakage and perforation due to a gangrenous bowel. Histopathological examination of tissue biopsy specimens of the distal ileum, terminal ileum, and stoma showed active inflammatory changes, but no granuloma and ganglion cells were present, ruling out Hirschsprung disease. The child was empirically treated with ampicillin and gentamicin starting from day 1 of admission along with prophylactic fluconazole (3 mg/kg of body weight twice weekly) due to a high risk for invasive candidiasis. Further during the course of treatment, meropenem therapy was included on day 3, cefoperazone-sulbactam therapy a week later, and ofloxacin therapy on day 17. The clinical course and the therapy instituted are depicted in Fig. 1. Cultures of the discharge from the laprotomy incision site on day 15 of admission grew yeasts identified as Stephanoascus ciferrii (identification, 86%) by the use of a Vitek2 yeast ID system (bioMérieux, Marcy l'Etoile, France) which exhibited a high fluconazole MIC (Ͼ64 g/ml) by AST-YS06 (bioMérieux). Blood cultures in Bactec Peds Plus/F vials taken on days 16, 18, 21, 23, and 26 of admission grew fluconazole-resistant S. ciferrii after 2 to 3 days of incubation at 37°C. The endotracheal aspirate collected on day 23 also grew S. ciferrii. The patient had already received fluconazole (6 mg/kg) for 17 days; the trea...

Abstract. Systemic endemic mycoses, such as blastomycosis, are rare in Asia and have been reported as health risks among travelers who visit or reside in an endemic area. Adrenal involvement is rarely seen in blastomycosis and has never been reported from Asia. We report the first case of blastomycosis with bilateral involvement of the adrenals in a diabetic patient residing in the state of Arunachal Pradesh, India.

Central nervous system trichosporonosis is a rare clinical entity and so far only six cases including three each of brain abscess and meningitis has been on record. We report a rare case of chronic meningo-ventriculitis and intraventricular fungal ball due to Trichosporon asahii in an 18-year-old immunocompetent male from Burundi, east Africa. Neuroendoscopy showed multiple nodules and a fungal ball within the ventricle, which on culture grew T. asahii. He was initially empirically treated with liposomal amphotericin B. However, the antifungal susceptibility testing of T. asahii isolate revealed high minimum inhibitory concentration for amphotericin B (2 μg ml⁻¹), flucytosine (16 μg ml⁻¹) and caspofungin (2 μg ml⁻¹) but exhibited potent activity for voriconazole, posaconazole, itraconazole and fluconazole. The patient rapidly succumbed to cardiac arrest before antifungal therapy could be changed. Although disseminated trichosporonosis has been increasingly reported the diagnosis represents a challenge especially in rare clinical settings such as intraventricular fungal ball in the present case, which has not been described previously.

Nocardial brain abscess is a rare central nervous system infection with high morbidity and mortality. Most of the human infections, i.e., about 90%, are due to Nocardia asteroides group comprising N. asteroides complex, Nocardia farcinica , and Nocardia nova . Other species rarely cause human infections. Here, we report a case of left parieto-occipital abscess caused by a rare species, Nocardia araoensis , its diagnosis, treatment options, and review of literature. A 73-year-old male, known case of diabetes mellitus, on prolonged oral corticosteroid for autoimmune hemolytic anemia presented with a 1-month history of memory deficit and gait imbalance. On examination, he had a right inferior quadrantanopia and hemiparesis. Magnetic resonance imaging showed a multiloculated ring-enhancing lesion in the left parieto-occipital region. Navigation-assisted biopsy was done. The organism isolated was N. araoensis . He was treated successfully with prolonged course of antibiotics which resulted in complete clinical and radiological resolution. N. araoensis is a rare cause of brain abscess and needs to be suspected in immunocompromised individuals. Early diagnosis and prolonged treatment can result in complete clinical and radiological resolution.

No abstract

BackgroundAntibiotic consumption data are scarce in the subcontinent. Defined Daily Doses (Doses) and Days of Therapy (DOT)-based metrics both have inherent disadvantages limiting their application in resource-limited settings primarily in terms of resource hours.. Point Prevalence Study (PPS) offers an offer an initial feasible step for describing antimicrobial use and identifying targets to reduce inappropriate use. Aim of the present study was to use PPS to identify quantitative and qualitative aspects of antimicrobial consumption.MethodsA cross-sectional hospital-based PPS was conducted in 4 tertiary care hospitals—Aster Medcity (Kochi, Kerala), Aster MIMS (Calicut, Kerala), Aster Ramesh (Guntur, Andhra Pradesh), and Aster CMI (Bengaluru, Karnataka)—based on a standardized format derived from the GLOBAL-PPS initiative and WHO resources.ResultsThe total number of patients surveyed was 944.42.7% patients had a standing antibiotic order, out of which 19.80%patients were receiving reserve antimicrobials (WHO classification). 76.23% of prescriptions were used empirically, 16.08% were used as prophylaxis meanwhile 7.67% had a culture-based indication. The overall DOT (per 1000 patient-days) for all antimicrobials in the 4 centers were 86.54, 64.19, 93.71 and 85.93 respectively with a cumulative mean DOT of 82.59. Reserve antimicrobials DOT were 26.28, 14.83, 28.08 and 19.61, respectively, with a mean of 22.2. The most common class of antimicrobial prescribed was β lactam -β lactamase inhibitors (BL/BLI) 27.3% while Carbapenems (8.16%) was the most common amongst reserve antimicrobials. Out of all the prescriptions only 7.67% had indications documented. Documented errors of dosing were seen in 8 patients. Adherence to monitoring for ADE was done in 92.57%.ConclusionThe study reveals antibiotic use in almost 40% of patients under survey with a DOT of 82.59 per 1000 patient-days. Improving empirical use of antimicrobials, BL/BLI focused intervention and improved documentation has been identified as potential areas for intervention based on this study.The study also highlights the scope of PPS as an effective tool in resource-limited setting to define and refine antimicrobial use and contribute toward antimicrobial stewardship as well as other activities aimed reducing antimicrobial resistance across a range of settings. Disclosures All authors: No reported disclosures.