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Antimalarial drug efficacy is monitored through various methods in vivo and in vitro. The in vivo methods include therapeutic efficacy studies(TES) which track clinical and parasitological outcomes among patients receiving antimalarial treatment whereas the invitro methods aims at detecting mutations in the drug targets in the parasite which can render the parasite resistant to the drug. This study is aimed at detecting the mutation patterns in the parasite that confer resistance to the common antimalarial agents used in India. A total of 27 Plasmodium vivax isolates collected over a three year period were sequenced to detect mutations in the genes pvmdr1, pvdhfr, pvdhps and pvk12 which serve as the molecular targets to detect resistance to chloroquine, pyrimethamine, sulfadoxine and artemisinin respectively. The study found T958M F1076L double mutants of pvmdr1 in 52%(14/27) isolates, S58R S117N double mutants of pvdhfr in 67% (18/27) isolates, A383G A553G double mutant pvdhps in 59% (16/27) isolates and wild type of pvk12 gene in all the isolates. There was a rise in the double mutants of pvmdr1 and pvdhfr over time. Those cases with double mutant pvmdr1 gene in their isolates were found to have a prolonged hospital stay compared to those without, indicating reduced clinical response to chloroquine.

Splenic abcess is a rare but potentially life threatening condition which can be less frequently caused by gram negative saprophytes, Burkholderia pseudomallei. Because of the challenges faced in the identification of this organism, it is often under diagnosed or misdiagnosed. Here, we report a case of splenic abcess eventually leading to disseminated melioidosis caused by Burkholderia pseudomallei in a 40 year old diabetic male from a tertiary-care hospital in southern India, who presented with fever and pain over left upper abdomen.

Melioidosis, caused by a non-fermenting gram negative bacilli Burkholderia pseudomallei, can mimic a variety of diseases due to its diverse clinical presentation. The incidence of cardiac involvement in melioidosis is less than 1%. We report a rare case of melioidosis in a 65 year old male with chronic kidney disease who presented with fever and pericardial effusion which was misdiagnosed and treated as tuberculous pericardial effusion. Later, on isolation of Burkholderia pseudomallei from paired blood culture samples, pericardial fluid and also from pleural fluid confirmed the diagnosis of disseminated melioidosis. The patient was treated with intravenous ceftazidime after which clinical improvement was observed. Cardiac melioidosis should always be considered in the differential diagnosis of tuberculous pericardial effusion and it should be ruled out before the start of anti-tubercular treatment. This will prevent unnecessary exposure to anti-tubercular drugs and also aids to start early treatment for melioidosis thereby reducing the mortality. Keywords: Melioidosis, Pericardial effusion, Burkholderia pseudomallei.

Coryneforms other than Corynebacterium diphtheriae are often ignored when isolated from clinical laboratories as in most instances they represent the normal commensals of skin. Corynebacterium jeikeium was initially considered only as commensal, later it was identified as the causative agent for severe sepsis in immunocompromised patients. Here, we present a case of meningoencephalitis caused by Corynebacterium jeikeium in a 30 year old adult male with HIV and tuberculosis co-infection. Serial cerebrospinal fluid from external ventricular drainage had grown Corynebacterium jeikeium which was identified by automated MALDI-TOF system which aided in the timely diagnosis and prompt management of the patient. Keywords: Corynebacterium jeikeium, Meningoencephalitis, HIV tuberculosis co-infection, External ventricular drainage.

Battle against malaria has been going on since time immemorial. Understanding the true burden of disease and the determinants of its transmission are important for implementing adequate control measures. This study intends to explore the local epidemiology and burden of malaria in Puducherry, a coastal Union territory located in Southern part of India over a period of 7 years.A retrospective record-based study was conducted from 2015 to 2021, where details from all samples tested positive for malaria by peripheral blood examination or rapid card test, from suspected cases were collected and analyzed. The overall prevalence of malaria over the 7 years was 1.7% (257/14888). Majority of the patients were males (75.88%) and the major age group affected was from 21 to 40 years (56.03%). Disease was maximum seen during the monsoon season followed by the post monsoon season. Vivax malaria predominated irrespective of the gender, seasonal change and different age groups except in children Plasmodium falciparum (3/4).This study shows a declining trend of malaria transmission over the years. There is no change in the predominant species affected or seasonal trends over the years. The possibility of underestimation of cases due to various factors cannot be ignored.

Rapid diagnostic card tests (RDTs) enable timely and appropriate diagnosis of malaria especially in remote areas. Plasmodium falciparum histidine rich protein 2 (PFHRP2) is the most targeted antigen for the detection of Plasmodium falciparum infections by rapid diagnostic card test. Genetic mutations and gene deletions are important emerging factors for false-negative RDTs, which may delay the provision of life-saving treatment for the patients. Hence, we would like to evaluate for the existence of pfhrp2/3 gene deleted P.falciparum parasites in our health care setting. This study was conducted for a period of 2 years in a tertiary care centre in South India. Blood samples that are microscopically confirmed as P. falciparum but negative by RDT were assessed for the presence of pfhrp2, pfhrp3, and their flanking genes using conventional PCR. Follow up of the clinical outcomes were also done for these patients. Of the 63 positive samples collected (50 /63) 79.4% were P.vivax and (13/63) 20.6% were P.falciparum by PCR. Among the 13P.falciparum positive samples, 4 samples (4/13), (95% CI -10.36–61.11%)were found to be RDT negative but microscopically positive.Pfhrp2,pfhrp3 and their flanking genes were amplified for these 4 samples. All 4 samples were found to be negative for both pfhrp2-2 & pfhrp2-3 exon regions and also varying patterns of flanking gene deletions were also noted.This study provides molecular evidence for the existence of pfhrp2 & pfhrp3 deleted P. falciparum parasites in a tertiary care centre in South India warranting periodic evaluation of pfhrp2 based RDT use. Only pfhrp2/3 RDT based decision on diagnosis of P.falciparum malaria should always be reconsidered especially in remote areas. Brief running title : Pfhrp2/3 gene deletion

Rapid diagnostic card tests (RDTs) enable timely and appropriate diagnosis of malaria especially in remote areas.

Introduction: Vancomycin-resistant enterococci (VRE) are emerging as an important multidrug-resistant pathogen causing nosocomial infections, predominantly bacteremia and urinary tract infections. VRE bacteremia has caused a significant increase in the duration of the hospital stay and mortality and had caused high public health threat due to limited treatment options. Materials and methods: Between October 2017 and September 2020, all consecutive patients with culture-proven bloodstream infection with Enterococcus species, isolated for the first time, were included in the study. A total of 427 Enterococcus species were identified, and antimicrobial susceptibility tests were performed and interpreted using Clinical and Laboratory Standard Institute guidelines. Results: Of the total 427 Enterococcus species isolated, 63 (45.6%) were VRE. Among them, 51/63 (81%) were Enterococcus faecium (E. faecium) and 5/63 (8%) were Enterococcus faecalis. There was an increased trend of VRE rate in the bloodstream infections of 6.12% (2018), 13.2% (2019), and 19.2% (2020). The majority of the VRE patients [43/63 (68%)] were admitted to the intensive care units (ICUs). Vancomycin A (VanA) is the most common phenotype isolated from 51/63(81%) patients. Conclusion: This increasing trend of VRE bacteremia is a red alert to the clinicians and the infection control practitioners, so that strict antibiotic policies and proper adherence to the infection control practices can be initiated to reduce the VRE rate. How to cite this article: Sivaradjy M, Gunalan A, Priyadarshi K, Madigubba H, Rajshekar D, Sastry AS. Increasing Trend of Vancomycin-resistant Enterococci Bacteremia in a Tertiary Care Hospital of South India: A Three-year Prospective Study. Indian J Crit Care Med 2021;25(8):881–885.

Context: Acute undifferentiated febrile illness (AUFI) is characterized by a sudden onset of raised body temperature and is a common cause of hospital admission though not recognized as a disease state by the World Health Organization. Epstein-Barr virus (EBV) is reported to account for a significant occurrence of AUFI cases. Aim: To know the role of EBV infection as a cause of acute undifferentiated febrile illness (AUFI). Settings and design: We have used the combination of EBV serological assays to establish the role of the Epstein-Barr virus as the cause of acute undifferentiated febrile illness. Methods and material: A total of 721 suspected cases of acute undifferentiated febrile illness which were tested negative for other common causes of acute febrile illness were selected for the study. Serum samples collected from these cases were tested for the presence of the EBV viral capsid antigen (VCA) IgM antibody. All positive serum samples were tested for the presence of EBV Epstein-Barr nuclear antigen (EBNA) IgG. Statistical analysis used: Statistical analysis was performed with the help of Microsoft Excel software (Microsoft Corporation, Redmond, USA). Results: Out of 721 suspected AUFI cases tested for EBV VCA IgM antibodies, 117 samples were positive and 604 were negative. All these 117 samples were tested for EBV EBNA IgG antibodies in which 88 were positive and 29 were negative. In our study, we found that around 4% (positive for VCA IgM and negative for EBNA IgG) of AUFI cases can be attributed to primary acute EBV infection. Conclusions: EBV infection should be considered particularly in AUFI cases of less than five years of age even in those who do not meet the typical presentation of fever, lymphadenopathy and sore throat. Our study should help to raise awareness regarding the possibility of EBV infection particularly in AUFI cases. A high index of suspicion and timely diagnosis will definitely help clinicians to avoid a battery of investigations and misuse of antibiotics in cases of AUFI.

Background In the era of COVID-19 pandemic, there is an upsurge of healthcare-associated infections (HAI) in COVID intensive care units (ICUs), which can be reduced by following proper hand hygiene (HH) practice. Performing HH auditing in COVID ICU and providing timely feedback to the stake holders is crucial to reduce HAIs. Methods From November 2020- April 2021, HH audit was conducted in COVID ICUs. HH complete adherence rate (HHCAR), HH partial adherence rate (HHPAR) and HH total adherence rate (HHTAR) were analyzed. Profession-specific HHTAR and moment-specific HHTAR (for each WHO moment) were also calculated. Results HHCAR, HHPAR and HHTAR were found as 30.8%, 34.5% and 65.3% respectively. There was a significant increase in the monthly HHTAR from 26.7% to 68.4% (P < .001). The profession-specific HHAR was found to be highest among doctors (67.5%) and nurses (66.4%). As the HHTAR increases there is a significant decrease in device associated infection (DAI) rate from 24.7 to 11.5 per 1,000 device days. Conclusions Auditing HH and providing timely feedback significantly improved HH compliance. The need of the hour is to regularly conduct HH audit in COVID locations of all healthcare facilities to reduce HAI rate among the COVID- 19 infected patients in ICUs.

Corynebacterium diphtheriae usually causes respiratory diphtheria, which is considered as a disease of toxemia but never bacteremia. Over the last few decades, cutaneous diphtheria has been increasingly reported owing to the emergence of the non-toxigenic strain, which causes locally necrotic and ulcerative lesions. Bacteremia is very rare, but the existing evidence in the literature suggests that the organism can rarely cause invasive infections such as septicemia, endocarditis, and osteoarthritis. Here, we present a rare case of C. diphtheriae causing bloodstream infections in an elderly diabetic with peripheral vascular disease, which was diagnosed incidentally on routine blood culture owing to automated identification systems viz matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) confirmed with conventional methods, and susceptibility was performed using automated VITEK 2 system (BioMérieux, Marcy-l'Étoile, France), which has aided in the timely management.