S166
Indian Journal of Medical Microbiology
vol. 33, Supplement 1
References 1. 2.
3.
*P Sharma, VK Mehta, RC Guleria, D Singh, A Kanga, S Mohindroo
Figure 1: Granular necrotic amorphous debris (MGG) May-Grünwald Giemsa: 10
Lowenstein-Jensen medium after 42 days. On MPT64 immunochromatographic card test, growth was identified as M. tuberculosis complex. Detailed examination ruled out any primary focus in the body. Directly observed treatment short course (DOTS) was started[2] and patient has shown improvement with complete regression of the thoracic mass.
Morris BS, Maheshwari M, Chalwa A. Chest wall tuberculosis: A review of CT appearances. Br J Radiol 2004;77:449-57. WHO Stop TB Department. Strategy and framework for effective tuberculosis control. Treatment of tuberculosis: Guidelines for national programs. 3rd ed. Geneva: World Health Organization; 2003. (document WHO/CDS/TB/2003.313). Tanaka S, Aoki M, Nakanishi T, Otake Y, Matsumoto M, Sakurai T, et al. Retrospective case series analysing the clinical data and treatment options of patients with a tubercular abscess of the chest wall. Interact Cardiovasc Thorac Surg 2012;14:249-52.
Departments of Microbiology (PS, VKM, RCG, DS, AK), Pathology (SM), Indira Gandhi Medical College, Shimla, Himachal Pradesh, India *Corresponding author (email: ) Received: 22-02-2014 Accepted: 01-07-2014
Atypical presentation, paucibacillary nature and negative AFB smear makes the diagnosis difficult and time consuming, thereby, delaying the initiation of treatment leading to complications and mortality in a treatable disease.[3] This case emphasises that tuberculosis should be kept in mind as differential diagnosis when a case present with isolated thoracic wall abscess, in immunocompetent persons in endemic areas.
Access this article online Quick Response Code:
Website: www.ijmm.org PMID: *** DOI: 10.4103/0255-0857.150971
Vancomycin-resistant enterococcus (VRE) vs Methicillin-resistant Staphylococcus Aureus (MRSA) Dear Editor, Antimicrobial resistance is a major concern in a clinical set-up. Newer pathogens are emerging day by day which pose a major threat in treating hospitalised patients. This correspondence highlights the bacteria which so far considered as a commensal has reached the status of highly virulent pathogen. The vancomycin-resistant enterococcus (VRE) is attaining virulence as Methicillin-resistant Staphylococcus aureus (MRSA). The incidence is more compared to MRSA. The key message is to highlight the importance of VRE strains that is increasingly seen in wound infections. Enterococcus was normally ignored by many clinicians in clinical samples as it is normal flora. But now it stands individually in most of the recurrent infections
and interferes with the healing of wound. The source is always noted to be the faecal flora. The recent studies show that VRE is emerging as a major threat in postoperative sepsis, which delays the process of wound healing. It is of utmost concern because it is a part of the normal flora in our body and in most sepsis, its occurrence is from an endogenous source only. This is evident in cases which show recurrence of sepsis with the bacterial strains with almost same sensitivity patterns. A comparison of the incidence rates of VRE and MRSA were analysed based on four categories from previous studies and the results were attained. Based on percentage of resistant strains isolated in the study by National Nosocomial Infections
www.ijmm.org
February
S167
Correspondence
Table 1: Comparison of VRE and MRSA incidents Reports MRSA VRE incidents incidents 40-60% (↑) 24.9-28.5% (↑) Based on percentage of resistant strains isolated[1]; From (1990s-2003) 210-260 3-15 Based on number bacteremias (↑) bacteremias (↑) of bacteremias[2]; between (2003-2004) 5.89 5.44 Based on rate of infection incidences[3]; CNISP rate per 10,000 inpatient days (1995-2009) 0.6 0.5 BSI incidence rates by hospital category [4]; Pooled mean rate (April 2010 to March 2011) MRSA: Methicillin-resistant staphylococcus aureus, VRE: Vancomycin-resistant enterococcus, CNISP: Canadian nosocomial infection surveillance program, BSI: Blood stream infection
Surveillance (NNIS) System, USA, VRE-resistant Enterococi among intensive care unit (ICU) patients, 1995-2004, the percent of S. aureus infections caused by methicillin-resistant strains increased from approximately 40-60% and similarly when we compare the VRE percentage rates, it also showed an increase from approximately 24.9-28.5% which is quiet significant when compared individually.[1] Based on number of bacteremias in a study by Ontario Medical Association, MRSA and VRE Bacteremias in Ontario, 1992-2004, Canada, the MRSA and VRE incidence rates based on number of bacteremias between the years 2003-2004 were analysed. It revealed a slight increase in the number of MRSA bacteremias, whereas the VRE bacteremia incidents increased many folds compared to MRSA.[2] Similarly based on rate of infection incidences in a study by Dr. Elizabeth Bryce et al., Vancover Coastal Health Infection Control Annual Report 2010-2011, the 2009 National Canadian Nosocomial Infection Surveillance Program (CNISP) rate for MRSA is 5.89 per 10,000 inpatient days, whereas the 2009 national CNISP rate for VRE is 5.44 per 10,000 inpatient days[3] and finally according to the Blood Stream Infection (BSI) incidence rates by hospital category in the study by California Department of Public Health Technical Report, from overall among 361 reporting hospitals, reporting at least 10 months of data, there were 908 MRSA and 788 VRE BSIs during 16,207,201 patient days. The pooled mean incidence rate of MRSA BSIs and VRE BSIs per 10,000 patient days was 0.6 and 0.5, respectively.[4] The cumulative data from the various studies analysed are tabulated in Table 1.
From the analysis of various reports, we see that in most of the cases reported earlier, the MRSA incident were higher and was considered seriously whereas the VRE incidences were neglected. But in the recent reports and reviews, we find out that the VRE incidents have risen up at alarming rates and are almost equal to the MRSA incidence rates. If this rate is continued we will finally have no antibiotics at all to protect us at all. Preventive measures like washing the hands, dressing of wound, etc., if followed properly the incidence of MRSA and VRE rates can definitely be reduced. So the probable sustainable solution is to stop uncontrolled and unwarranted use of antibiotics and use antibiotics with justification!! References 1.
2.
3.
4.
Erika D’Agata, Modelling Outbreaks of Antibiotic Resistance in Hospitals [Power Point slides]. Available from: http://www. ncsu.edu/cqsb/presentations/Webb.ppt. [Last accessed on 2014 Jun 30]. Data from Quality Management Program - Laboratory Services (QMP-LS) [Graph]. Available from: http:// microbiology.mtsinai.on.ca/data/qmpls/#figure5. [Last accessed on 2014 Jun 30]. Elizabeth Bryce, Patrick O’Connor, Linda Dempster, Dermot Kelly , Claire O’Quinn , Dr. Kellé Payne, et al. Vancover Coastal Health Infection Control Annual Report 20102011. Available from: http:// http://www.vch.ca/media/ [Last InfectionControlAnnualReport_2010_2011.pdf. accessed on 2014 Jun 30]. California Department of Public Health. Technical Report: Healthcare-Associated MRSA and VRE Bloodstream Infections in California Hospitals, April 2010 through March 2011.
*KS Ashwin, NP Muralidharan Department of Microbiology (KSA, NPM), Saveetha Dental College, Chennai, Tamil Nadu, India *Corresponding author (email: ) Received: 25-08-2013 Accepted: 05-06-2014
www.ijmm.org
Access this article online Quick Response Code:
Website: www.ijmm.org PMID: *** DOI: 10.4103/0255-0857.150976
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.
Indian Journal of Medical Microbiology
vol. 33, Supplement 1
References 1. 2.
3.
*P Sharma, VK Mehta, RC Guleria, D Singh, A Kanga, S Mohindroo
Figure 1: Granular necrotic amorphous debris (MGG) May-Grünwald Giemsa: 10
Lowenstein-Jensen medium after 42 days. On MPT64 immunochromatographic card test, growth was identified as M. tuberculosis complex. Detailed examination ruled out any primary focus in the body. Directly observed treatment short course (DOTS) was started[2] and patient has shown improvement with complete regression of the thoracic mass.
Morris BS, Maheshwari M, Chalwa A. Chest wall tuberculosis: A review of CT appearances. Br J Radiol 2004;77:449-57. WHO Stop TB Department. Strategy and framework for effective tuberculosis control. Treatment of tuberculosis: Guidelines for national programs. 3rd ed. Geneva: World Health Organization; 2003. (document WHO/CDS/TB/2003.313). Tanaka S, Aoki M, Nakanishi T, Otake Y, Matsumoto M, Sakurai T, et al. Retrospective case series analysing the clinical data and treatment options of patients with a tubercular abscess of the chest wall. Interact Cardiovasc Thorac Surg 2012;14:249-52.
Departments of Microbiology (PS, VKM, RCG, DS, AK), Pathology (SM), Indira Gandhi Medical College, Shimla, Himachal Pradesh, India *Corresponding author (email: ) Received: 22-02-2014 Accepted: 01-07-2014
Atypical presentation, paucibacillary nature and negative AFB smear makes the diagnosis difficult and time consuming, thereby, delaying the initiation of treatment leading to complications and mortality in a treatable disease.[3] This case emphasises that tuberculosis should be kept in mind as differential diagnosis when a case present with isolated thoracic wall abscess, in immunocompetent persons in endemic areas.
Access this article online Quick Response Code:
Website: www.ijmm.org PMID: *** DOI: 10.4103/0255-0857.150971
Vancomycin-resistant enterococcus (VRE) vs Methicillin-resistant Staphylococcus Aureus (MRSA) Dear Editor, Antimicrobial resistance is a major concern in a clinical set-up. Newer pathogens are emerging day by day which pose a major threat in treating hospitalised patients. This correspondence highlights the bacteria which so far considered as a commensal has reached the status of highly virulent pathogen. The vancomycin-resistant enterococcus (VRE) is attaining virulence as Methicillin-resistant Staphylococcus aureus (MRSA). The incidence is more compared to MRSA. The key message is to highlight the importance of VRE strains that is increasingly seen in wound infections. Enterococcus was normally ignored by many clinicians in clinical samples as it is normal flora. But now it stands individually in most of the recurrent infections
and interferes with the healing of wound. The source is always noted to be the faecal flora. The recent studies show that VRE is emerging as a major threat in postoperative sepsis, which delays the process of wound healing. It is of utmost concern because it is a part of the normal flora in our body and in most sepsis, its occurrence is from an endogenous source only. This is evident in cases which show recurrence of sepsis with the bacterial strains with almost same sensitivity patterns. A comparison of the incidence rates of VRE and MRSA were analysed based on four categories from previous studies and the results were attained. Based on percentage of resistant strains isolated in the study by National Nosocomial Infections
www.ijmm.org
February
S167
Correspondence
Table 1: Comparison of VRE and MRSA incidents Reports MRSA VRE incidents incidents 40-60% (↑) 24.9-28.5% (↑) Based on percentage of resistant strains isolated[1]; From (1990s-2003) 210-260 3-15 Based on number bacteremias (↑) bacteremias (↑) of bacteremias[2]; between (2003-2004) 5.89 5.44 Based on rate of infection incidences[3]; CNISP rate per 10,000 inpatient days (1995-2009) 0.6 0.5 BSI incidence rates by hospital category [4]; Pooled mean rate (April 2010 to March 2011) MRSA: Methicillin-resistant staphylococcus aureus, VRE: Vancomycin-resistant enterococcus, CNISP: Canadian nosocomial infection surveillance program, BSI: Blood stream infection
Surveillance (NNIS) System, USA, VRE-resistant Enterococi among intensive care unit (ICU) patients, 1995-2004, the percent of S. aureus infections caused by methicillin-resistant strains increased from approximately 40-60% and similarly when we compare the VRE percentage rates, it also showed an increase from approximately 24.9-28.5% which is quiet significant when compared individually.[1] Based on number of bacteremias in a study by Ontario Medical Association, MRSA and VRE Bacteremias in Ontario, 1992-2004, Canada, the MRSA and VRE incidence rates based on number of bacteremias between the years 2003-2004 were analysed. It revealed a slight increase in the number of MRSA bacteremias, whereas the VRE bacteremia incidents increased many folds compared to MRSA.[2] Similarly based on rate of infection incidences in a study by Dr. Elizabeth Bryce et al., Vancover Coastal Health Infection Control Annual Report 2010-2011, the 2009 National Canadian Nosocomial Infection Surveillance Program (CNISP) rate for MRSA is 5.89 per 10,000 inpatient days, whereas the 2009 national CNISP rate for VRE is 5.44 per 10,000 inpatient days[3] and finally according to the Blood Stream Infection (BSI) incidence rates by hospital category in the study by California Department of Public Health Technical Report, from overall among 361 reporting hospitals, reporting at least 10 months of data, there were 908 MRSA and 788 VRE BSIs during 16,207,201 patient days. The pooled mean incidence rate of MRSA BSIs and VRE BSIs per 10,000 patient days was 0.6 and 0.5, respectively.[4] The cumulative data from the various studies analysed are tabulated in Table 1.
From the analysis of various reports, we see that in most of the cases reported earlier, the MRSA incident were higher and was considered seriously whereas the VRE incidences were neglected. But in the recent reports and reviews, we find out that the VRE incidents have risen up at alarming rates and are almost equal to the MRSA incidence rates. If this rate is continued we will finally have no antibiotics at all to protect us at all. Preventive measures like washing the hands, dressing of wound, etc., if followed properly the incidence of MRSA and VRE rates can definitely be reduced. So the probable sustainable solution is to stop uncontrolled and unwarranted use of antibiotics and use antibiotics with justification!! References 1.
2.
3.
4.
Erika D’Agata, Modelling Outbreaks of Antibiotic Resistance in Hospitals [Power Point slides]. Available from: http://www. ncsu.edu/cqsb/presentations/Webb.ppt. [Last accessed on 2014 Jun 30]. Data from Quality Management Program - Laboratory Services (QMP-LS) [Graph]. Available from: http:// microbiology.mtsinai.on.ca/data/qmpls/#figure5. [Last accessed on 2014 Jun 30]. Elizabeth Bryce, Patrick O’Connor, Linda Dempster, Dermot Kelly , Claire O’Quinn , Dr. Kellé Payne, et al. Vancover Coastal Health Infection Control Annual Report 20102011. Available from: http:// http://www.vch.ca/media/ [Last InfectionControlAnnualReport_2010_2011.pdf. accessed on 2014 Jun 30]. California Department of Public Health. Technical Report: Healthcare-Associated MRSA and VRE Bloodstream Infections in California Hospitals, April 2010 through March 2011.
*KS Ashwin, NP Muralidharan Department of Microbiology (KSA, NPM), Saveetha Dental College, Chennai, Tamil Nadu, India *Corresponding author (email: ) Received: 25-08-2013 Accepted: 05-06-2014
www.ijmm.org
Access this article online Quick Response Code:
Website: www.ijmm.org PMID: *** DOI: 10.4103/0255-0857.150976
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.
