April-June 2015
327
Correspondence
produce a reservoir pool of the pathogen. Increasing age and underlying co‑morbidities increase the risk of acquiring CDI. Among the underlying co‑morbidities identified in the present analysis, gastrointestinal diseases were the commonest, followed by surgical conditions, renal diseases and cancers, and CDT positivity was found in 17-21% of them. Antibiotics like nitroimidazole, penicillin, fluoroquinolones, glycopeptides, carbapenems and drugs like proton pump inhibitors, immunosuppressives and chemotherapeutics were found to be associated with CDT positivity in the present study. Thus, it is important to identify patients who are at high risk for severe CDI early in the course of their infection thereby decreasing the responsibility of the clinicians and improving the patient condition. Apart from this, only diarrhoeal stools should be tested for C. difficile or its toxins[4] and in case of non‑diarrhoeal stools, the patient’s records must be reviewed to make certain that the patient has symptoms of CDI.[5] The clinical suspicion for CDI should be based on development of nosocomial diarrhoea with or without accompanying abdominal pain and fever, presence of underlying co‑morbidities, exposure to antibiotics and other drugs, and the age of the patient. Readily available clinical data and CDT status can be correlated with severe CDI.
2. 3.
4.
5.
in experimental Clostridium difficile infection in mice. Microbiol Immunol 2007;51:1209‑14. Kaur S, Vaishnavi C, Ray P, Kochhar R, Prasad KK. Effect of biotherapeutics on cyclosporin‑induced Clostridium difficile infection in mice. J Gastroenterol Hepatol 2010;25:832‑8. Planche T, Aghaizu A, Holliman R, Riley P, Poloniecki J, Breathnach A, et al. Diagnosis of C. difficile infection by toxin detection kits: A systemic review. Lancet Infect Dis 2008;8:777‑84. Dubberke ER, Reske KA, Olsen MA, McDonald LC, Fraser VJ. Short and long term attributable cost of Clostridium difficile-associated disease in non‑surgical patients. Clin Infect Dis 2008;46:497‑504. Fekety R. Guidelines for the diagnosis and management of Clostridium difficile‑associated diarrhea and colitis. American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 1997;92:739‑50.
*C Vaishnavi, M Singh, P Kapoor, R Kochhar Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India *Corresponding author ( email: ) Received: 19‑03‑2014 Accepted: 05‑09‑2014
Access this article online
Acknowledgement
Quick Response Code:
The authors are grateful to Dr. Ajay Prakash for statistical analysis of the data.
Website: www.ijmm.org
References
DOI: 10.4103/0255-0857.153570
1. Kaur S, Vaishnavi C, Prasad KK, Ray P, Kochhar R. Comparative role of antibiotic and proton pump inhibitor
Prevalence of inducible clindamycin resistance among Staphylococcal isolates in a tertiary care hospital in North India Dear Editor, This is regarding one article by Aleksandra AD, Misic MS, Violeta NM, Dragana IT, Zoran BM, Dejan VS, Milanko SD, Dejan BD ‘Prevalence of inducible clindamycin resistance among community‑associated Staphylococcal isolates in central Serbia’ 2014;32:49‑52[1] published in the Indian Journal of Medical Microbiology. In this article, the authors prospectively analyzed 482 community‑associated Staphylococcal isolates, of which 395 were Staphylococcus aureus and 87 were coagulase‑negative Staphylococcus species. They performed their susceptibility testing by standard disk
diffusion method according to CLSI standards.[2] All erythromycin‑resistant clindamycin susceptible isolates were further tested for inducible clindamycin resistance with D test.[3] Following this, phenotypic categorization was done into MSB phenotype, iMLSB (inducible clindamycin resistance) resistance phenotype and cMLSB (constitutive clindamycin resistance) resistance phenotype, where MSB phenotype demonstrated a circular clindamycin zone, iMLSB resistance phenotype isolates demonstrated flattening of the clindamycin zone and cMLSB resistance phenotype isolates showed resistance to both erythromycin and clindamycin. Considering the results of their analysis on only the S. aureus isolates in
www.ijmm.org
328
Indian Journal of Medical Microbiology
their study, findings were that out of 395 S. aureus isolates, 129 (32.66%) were resistant to erythromycin, of which 24% (n = 31) showed MSB phenotype, 50% (n = 64) iMLSB resistance phenotype and 26% (n = 34) showed cMLSB resistance phenotype. We also did a similar study in a tertiary care hospital in North India where we analyzed 750 S. aureus isolates from different clinical samples received in the microbiology laboratory over a period of 6 months. With similar material and methods, phenotypic detection of MSB phenotype, iMLSB resistance phenotype and cMLSB resistance phenotype was performed. Our results showed some differences in the prevalence of these phenotypes in our isolates from the above mentioned study. Out of 750 S. aureus isolates, 441 (58.8%) were resistant to erythromycin, of which 20.13% (n = 151) showed MSB phenotype, 20.27% (n = 152) iMLSB resistance phenotype and 18.40% (n = 138) showed cMLSB resistance phenotype. The prevalence of MSB phenotype and cMLSB resistance phenotype in both the studies are nearly same; however, there is a marked difference between the prevalence of iMLSB resistance phenotype in the two studies. This difference may be due to the different geography and varying epidemiological factors or may be due the origin of isolates, which were solely community associated in their study as compared to our study, which might be of hospital or community origin. Hence, periodic surveillance is necessary for determination of the prevailing phenotypes in different geographical regions to direct the antibiotic guidelines accordingly.
vol. 33, No. 2
References 1. Aleksandra AD, Misic MS, Violeta NM, Dragana IT, Zoran BM, Dejan VS, et al. Prevalence of inducible clindamycin resistance among community‑associated staphylococcal isolates in central Serbia. Indian J Med Microbiol 2014;32:49‑52. 2. Clinical Laboratory Standards Institute (CLSI) guidelines. Performance standards for antimicrobial susceptibility testing: Nineteenth informational supplement. CLSI Document M100‑S19. Clinical and Laboratory Standards institute. Pennsylvania: Wayne; 2009. p. 59 3. Woods CR. Macrolide inducible resistance to clindamycin and D‑test. Pediatr Infect Dis J 2009;28:1115‑8.
S Tyagi, *A Oberoi Department of Microbiology (ST, AO), Christian Medical College and Hospital, Ludhiana, Punjab, India. *Corresponding Author: (email: ) Received: 16‑04‑2014 Accepted: 03-07-2014 Access this article online Quick Response Code:
Website: www.ijmm.org
DOI: 110.4103/0255-0857.153576
Cases of “Measles” in adult age group of St. John’s Medical College Boy’s Hostel, Bangalore, South India Dear Editor, In the months of November to December 2013, we investigated measles suspected cases under St. John’s Medical College Boy’s Hostel, Bangalore (SJMCBHB) of the Karnataka state. On 1st week of November 2013, a Disease Surveillance Officer reported suspected measles cases in the SJMCBHB which is situated in the centre of city. The objectives of confirming the diagnosis of disease and recommendations for their prevention and control is provided. Based on the initial report of first case with fever, cough, coryza, conjuctivitis and rash meeting the clinical description of suspected measles from the SJMCBHB. Urine and blood samples were collected from all the cases. A total 16 samples of eight cases were taken for diagnosis of measles virus. Since the cases were adults, the recorded
immunisation programme was not available. Measles serological results showed out of eight adults two were positive for measles IgM antibodies tested by MAC‑ELISA. Urine samples were taken for detecting the measles virus by RT‑PCR.[1,2] Two urine cases were positive for measles‑specific RT‑PCR and sequencing results. Measles sequencing results of two urine measles‑positive samples sequence identity revealed that the “D8 genotype” matching with the Measles virus genotype D8 strain (Genbank acc. KF015992). According to case data, the age‑group affected with this outbreak was 17‑27 years. Five were males and the rest three were females. There was no history of travel outside the city or villages in the preceding month by all the affected adults. A report of measles among health care researchers has been documented in the
www.ijmm.org
Copyright of Indian Journal of Medical Microbiology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
327
Correspondence
produce a reservoir pool of the pathogen. Increasing age and underlying co‑morbidities increase the risk of acquiring CDI. Among the underlying co‑morbidities identified in the present analysis, gastrointestinal diseases were the commonest, followed by surgical conditions, renal diseases and cancers, and CDT positivity was found in 17-21% of them. Antibiotics like nitroimidazole, penicillin, fluoroquinolones, glycopeptides, carbapenems and drugs like proton pump inhibitors, immunosuppressives and chemotherapeutics were found to be associated with CDT positivity in the present study. Thus, it is important to identify patients who are at high risk for severe CDI early in the course of their infection thereby decreasing the responsibility of the clinicians and improving the patient condition. Apart from this, only diarrhoeal stools should be tested for C. difficile or its toxins[4] and in case of non‑diarrhoeal stools, the patient’s records must be reviewed to make certain that the patient has symptoms of CDI.[5] The clinical suspicion for CDI should be based on development of nosocomial diarrhoea with or without accompanying abdominal pain and fever, presence of underlying co‑morbidities, exposure to antibiotics and other drugs, and the age of the patient. Readily available clinical data and CDT status can be correlated with severe CDI.
2. 3.
4.
5.
in experimental Clostridium difficile infection in mice. Microbiol Immunol 2007;51:1209‑14. Kaur S, Vaishnavi C, Ray P, Kochhar R, Prasad KK. Effect of biotherapeutics on cyclosporin‑induced Clostridium difficile infection in mice. J Gastroenterol Hepatol 2010;25:832‑8. Planche T, Aghaizu A, Holliman R, Riley P, Poloniecki J, Breathnach A, et al. Diagnosis of C. difficile infection by toxin detection kits: A systemic review. Lancet Infect Dis 2008;8:777‑84. Dubberke ER, Reske KA, Olsen MA, McDonald LC, Fraser VJ. Short and long term attributable cost of Clostridium difficile-associated disease in non‑surgical patients. Clin Infect Dis 2008;46:497‑504. Fekety R. Guidelines for the diagnosis and management of Clostridium difficile‑associated diarrhea and colitis. American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol 1997;92:739‑50.
*C Vaishnavi, M Singh, P Kapoor, R Kochhar Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India *Corresponding author ( email: ) Received: 19‑03‑2014 Accepted: 05‑09‑2014
Access this article online
Acknowledgement
Quick Response Code:
The authors are grateful to Dr. Ajay Prakash for statistical analysis of the data.
Website: www.ijmm.org
References
DOI: 10.4103/0255-0857.153570
1. Kaur S, Vaishnavi C, Prasad KK, Ray P, Kochhar R. Comparative role of antibiotic and proton pump inhibitor
Prevalence of inducible clindamycin resistance among Staphylococcal isolates in a tertiary care hospital in North India Dear Editor, This is regarding one article by Aleksandra AD, Misic MS, Violeta NM, Dragana IT, Zoran BM, Dejan VS, Milanko SD, Dejan BD ‘Prevalence of inducible clindamycin resistance among community‑associated Staphylococcal isolates in central Serbia’ 2014;32:49‑52[1] published in the Indian Journal of Medical Microbiology. In this article, the authors prospectively analyzed 482 community‑associated Staphylococcal isolates, of which 395 were Staphylococcus aureus and 87 were coagulase‑negative Staphylococcus species. They performed their susceptibility testing by standard disk
diffusion method according to CLSI standards.[2] All erythromycin‑resistant clindamycin susceptible isolates were further tested for inducible clindamycin resistance with D test.[3] Following this, phenotypic categorization was done into MSB phenotype, iMLSB (inducible clindamycin resistance) resistance phenotype and cMLSB (constitutive clindamycin resistance) resistance phenotype, where MSB phenotype demonstrated a circular clindamycin zone, iMLSB resistance phenotype isolates demonstrated flattening of the clindamycin zone and cMLSB resistance phenotype isolates showed resistance to both erythromycin and clindamycin. Considering the results of their analysis on only the S. aureus isolates in
www.ijmm.org
328
Indian Journal of Medical Microbiology
their study, findings were that out of 395 S. aureus isolates, 129 (32.66%) were resistant to erythromycin, of which 24% (n = 31) showed MSB phenotype, 50% (n = 64) iMLSB resistance phenotype and 26% (n = 34) showed cMLSB resistance phenotype. We also did a similar study in a tertiary care hospital in North India where we analyzed 750 S. aureus isolates from different clinical samples received in the microbiology laboratory over a period of 6 months. With similar material and methods, phenotypic detection of MSB phenotype, iMLSB resistance phenotype and cMLSB resistance phenotype was performed. Our results showed some differences in the prevalence of these phenotypes in our isolates from the above mentioned study. Out of 750 S. aureus isolates, 441 (58.8%) were resistant to erythromycin, of which 20.13% (n = 151) showed MSB phenotype, 20.27% (n = 152) iMLSB resistance phenotype and 18.40% (n = 138) showed cMLSB resistance phenotype. The prevalence of MSB phenotype and cMLSB resistance phenotype in both the studies are nearly same; however, there is a marked difference between the prevalence of iMLSB resistance phenotype in the two studies. This difference may be due to the different geography and varying epidemiological factors or may be due the origin of isolates, which were solely community associated in their study as compared to our study, which might be of hospital or community origin. Hence, periodic surveillance is necessary for determination of the prevailing phenotypes in different geographical regions to direct the antibiotic guidelines accordingly.
vol. 33, No. 2
References 1. Aleksandra AD, Misic MS, Violeta NM, Dragana IT, Zoran BM, Dejan VS, et al. Prevalence of inducible clindamycin resistance among community‑associated staphylococcal isolates in central Serbia. Indian J Med Microbiol 2014;32:49‑52. 2. Clinical Laboratory Standards Institute (CLSI) guidelines. Performance standards for antimicrobial susceptibility testing: Nineteenth informational supplement. CLSI Document M100‑S19. Clinical and Laboratory Standards institute. Pennsylvania: Wayne; 2009. p. 59 3. Woods CR. Macrolide inducible resistance to clindamycin and D‑test. Pediatr Infect Dis J 2009;28:1115‑8.
S Tyagi, *A Oberoi Department of Microbiology (ST, AO), Christian Medical College and Hospital, Ludhiana, Punjab, India. *Corresponding Author: (email: ) Received: 16‑04‑2014 Accepted: 03-07-2014 Access this article online Quick Response Code:
Website: www.ijmm.org
DOI: 110.4103/0255-0857.153576
Cases of “Measles” in adult age group of St. John’s Medical College Boy’s Hostel, Bangalore, South India Dear Editor, In the months of November to December 2013, we investigated measles suspected cases under St. John’s Medical College Boy’s Hostel, Bangalore (SJMCBHB) of the Karnataka state. On 1st week of November 2013, a Disease Surveillance Officer reported suspected measles cases in the SJMCBHB which is situated in the centre of city. The objectives of confirming the diagnosis of disease and recommendations for their prevention and control is provided. Based on the initial report of first case with fever, cough, coryza, conjuctivitis and rash meeting the clinical description of suspected measles from the SJMCBHB. Urine and blood samples were collected from all the cases. A total 16 samples of eight cases were taken for diagnosis of measles virus. Since the cases were adults, the recorded
immunisation programme was not available. Measles serological results showed out of eight adults two were positive for measles IgM antibodies tested by MAC‑ELISA. Urine samples were taken for detecting the measles virus by RT‑PCR.[1,2] Two urine cases were positive for measles‑specific RT‑PCR and sequencing results. Measles sequencing results of two urine measles‑positive samples sequence identity revealed that the “D8 genotype” matching with the Measles virus genotype D8 strain (Genbank acc. KF015992). According to case data, the age‑group affected with this outbreak was 17‑27 years. Five were males and the rest three were females. There was no history of travel outside the city or villages in the preceding month by all the affected adults. A report of measles among health care researchers has been documented in the
www.ijmm.org
Copyright of Indian Journal of Medical Microbiology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
