Best Antibiotic to Treat UTI in Female

    

     Females in their reproductive years 15-45 often suffer from acute UTI due to sexual activities, short urethra etc. Even UTIs are not uncommon in pregnancy, in which Staphylococcus saprophyticus is often the culprit organism along with other Enterobacteriaceae and Non Fermenters Gram Negative Rods. 

      Patient presents to the doctor with complaints of difficulty in micturition, increased frequency, lower abdominal pain , febrile paroxysmal spikes with chills & rigor , nausea etc. Routine urine microscopy will often reveal pus cells >20/hpf with or without RBCs presence of which may denote upper UTI or pyelonephritis. Urine Culture sample is asked before initiation of 1st dose of emperical antibiotic so that antibiotics doesnot hamper the growth of offending organism thereby limiting its identification and related antibiogram. 

   Now comes the talk of the day ..

Which is best antibiotic to select in UTI in females ? 

     Nitrofurantoin has been the drug of choice in acute uncomplicated cystitis in females as well as children. It's renal tubular secretion is maximum and thereby it attains maximum peak concentration in urine producing optimal therapeutic outcome. Dose is 100 mg twice daily x 7 days for adult females. Common side effects include metallic taste, nausea vomiting, abdominal cramps. 

      Recently Fosfomycin has emerged as a    wonderful drug in treating UTIs in female as it comes as single dose 3 gm sachet to be consumed with 1 glass water which produces execllent therapeutic effect against most of the uropathogens like E.coli, Klebsiella, Proteus etc. Being a Category B drug it is considered safe in pregnancy as well. 

      However, the final antibiotic should always be selected once the culture sensitivity report ( with data of Minimum Inhibitory Concentration/MIC) is available.

Based on antibiogram either an escalating or deescalating approach is adopted to bring out optimal therapeutic outcome following principles of antibiotic stewardship. 

No New COVID -19 variants emerged in China in 2022 : International Forum

      

     An investigation published in The Lancet found that the recent rise in infections in China following the suspension of the nation's zero-COVID policy did not involve the emergence of any new COVID-19 variations.

    The Lancet reported that a genome analysis of 413 new infections in Beijing since the stringent pandemic safeguards were loosened indicates they were all brought on by pre-existing strands.

      The Lancet reported that between November 14 and December 20, 2022, "more than 90% of local infections in Beijing contained Omicron sub-variants BA.5.2 or BF.7." The majority of imported cases during that time period involved variations from those that were prevalent in Beijing.

      According to reports, China abandoned its zero-COVID policies in December. Targeted lockdowns, massive testing, and quarantines were some of them. The Lancet reported that there have been an increase in cases, prompting fears that new variations may appear.

Is Fungal infection making your skin itchy ? A comprehensive synopsis

Itchy skin can be attributed to different etiological agents. Amongst those the most common is Dermatophytes which implies superficial fungal skin infection. These Dermatophytes belong to the genera Trichophyton, Epidermophyton and Microsporum. Interestingly, these three genera in order do not affect Skin, Hair & Nail respectively. Different terminologies have been coined to denote site specific involvement like Tinea Corporis( Torso), Tinea Capitis( Scalp), Tinea Cruris( Groin) , Tinea Pedis( Foot) , Tinea Mannum ( Fingers, Hand etc). The most consistent risk factor for Tinea remains poor personal hygiene, moisture due to excessive sweats, tight fitting garments , immune compromised state leading to altered host response like Diabetes Mellitus, Haematological Malignancy, patients receiving chemotherapy, DMARDs, immunomodulatory agents etc. 

Tinea spread through direct contact with infected humans or animals as well as contaminated fomites or vegetative matters. No age group is spared however there is a slight preponderance amongst post pubertal children and young adults probably due to physiological increase in sebum secretion secondary to androgen surge.

      It has been seen that most of the time clinical features of tinea e.g. maculopapular scaly erethamatous lesions with or without central clearing considerably overlap with other dermatological conditions and pose a challenge to clinch the diagnosis. The following chart illustrates the in & out of tinea corporis in an easy to understand format.

So here we go..

Tinea Corporis -

■Clinical Features 

Red scaly margin 

Papules & pustules

Mild prutitis

Asymmetrical lesions

■Clinical variants 

  ◇Kerion common in children and associated with scalp abscess

◇ Majocchi granuloma common in females around hair & hair follicles of legs

◇ Tinea incognito - Steroid modified tinea mainly found over trunks, limbs etc.

■Clinical Microbiology Lab Diagnosis : 

10% KOH for morphological identification of fungal etiology with seeding on SDA, PDA for culture confirmation with Fungal AST

Vitek 2 Compact can be employed for Fungal AST with MIC from pure culture growth from SDA/ PDA

■Differential Diagnosis of Tinea Corporis:

a) Discoid eczema ( nummular)

Less likely to have central clearing with more confluent scales 

b) Urticaria 

     Erethematous, pruritic with erethamatous wheal 

c) Contact Dermatitis

 

Well demarcated, erethematous lesion localised to the area of contact

d) Erethema marginatum

    

Flat erethamatous

e) Atopic Dermatitis 

Highly pruritic, lichenification in chronic lesions and also chronically relapsing

f) Plaque psoriasis

Annular , erethematous round or oval, pruritic plaques. Family History is positive. Nail pitting , arthritis , uveitis

g) Pityriasis rosea

Herald patch progressing to generalised rash 

h) Secondary syphillis 

Diffuse pattern, Symmetrical round or oval, pink -reddish macules 

i) Lichen Planus 

Pruritic papules/plaques

We hope to see you with another interesting Medical blog. Till then eat healthy, sleep well and see you soon ! 

 

 

Rotaviral Diarrhoea in Children - A Detail Analysis

The present study entitled, “A study of Molecular Epidemiology of Rotavirus Gastroenteritis among children under Five Years attending NEIGRIHMS, Shillong” was conducted in the Department of Microbiology, NEIGRIHMS from January 2017 to December 2018 with the following objectives: -

1. Understanding the incidence of Rotavirus Gastroenteritis among the children below five years with acute diarrhea attending NEIGRIHMS

2. Molecular characterization of Rotaviruses associated with acute gastroenteritis in children under

five years

3. Study of the clinico-epidemiological profile of Rotaviral Gastroenteritis in children under five years

4. Understanding the correlation between clinical and epidemiological conditions with circulating genotypes of rotaviruses

 In this study, a total of 55 cases of diarrhea fulfilling the case definition were included. Stool samples were collected and each sample was immediately aliquoted up to 3 collection tubes with

proper levelling. 1st set was kept at 2-4 degree Celsius for Rotavirus Group A antigen-based ELISA and others were for kept at -80 degree Celsius for studying the molecular epidemiological pattern

by SDS-PAGE analysis and nested RT-PCR. Childhood diarrhea due to rotavirus can cause significant mortality and morbidity among under five children but unfortunately most of the time

it remains undiagnosed. Moreover, enormous genomic diversity of rotavirus strains is seen across different geographical regions which can challenge the efficacy of currently available rotavirus

vaccines.

The summary of the results and observations made in our study are as follows-

•Amongst a total of 55 under five children, the most common age group that presented to the hospital was 7-9 months which included 13 (23.63%) children. •Rotavirus infection was found to be present in 22(40%) out of 55 total cases. •The highest 9(40.9%) positivity was

again seen in the age group of 7-9 months followed by 4(18.18%) children in the age group of 4-6 months.

•Statistically significant gender specific preponderance was not seen in rotavirus infected children.

•Amongst 22 Rotavirus positive cases, majority 15 (68.18%) was from Meghalaya and Assam 4 (18.18%). Urban and rural distribution of rotavirus positive cases was not found to be significant. Therefore, the present study reaffirms the current concept that Rotavirus is a ‘Democratic Virus’ which can infect children irrespective of the socioeconomic

background of their parents and families.

•In our study, Rotavirus gastroenteritis was found to be most common during the winter months with low temperature and relative humidity. 19(86.36%) rotavirus gastroenteritis cases presented during the months of January to March followed by 3(13.63%) cases who presented between October to December.

•Diarrhea (90%), vomiting (95.45%), fever (90.9%), dehydration’ (90.9%), irritability

(100%), lethargy (100%), were seen as constant clinical features in all the rotavirus gastroenteritis children and found to be statistically significant. 1(4.5%) rotavirus infected child had two episodes of convulsions and loss of consciousness. Dyselectrolytemia in the

form of Hypernatremia (Na+ >145 meq/L) was seen in 16 (72.72%) children while

hypokalemia (K+ <3.5 meq/L) was present in 6(27.27%) children out of 22 Rotavirus

positive gastroenteritis cases. Both these findings were statistically significant.

•This study showed that exclusive breastfeeding per se till the age of 6 months does not confer any overall protection against rotavirus infection.

• A total of 55 stool samples were subjected to sandwich ELISA for Rotavirus Antigen.Rotavirus antigen was positive in 22 (40%) samples. All the ELISA positive samples were subjected to SDS-PAGE electrophoresis in which 11(50%) samples were electropherotyped and characteristic 4:2:3:2 pattern of Rotavirus dsRNA was

demonstrated. All these 11 samples which were electrophoresed showed ‘long

electropherotype’ of Rotaviral dsRNA. ‘Short electropherotype’ of rotavirus was not detected in our study based on the relative mobility pattern of the 11th segment of dsRNA.

• There was no statistically significant age, gender and clinical feature specific difference in the distribution of ‘long electropherotypes’ in our study. No concrete comment could be made in our

study regarding the seasonal distribution of ‘long electropherotype’ of rotavirus.

•All 22 Rotavirus ELISA positive stool samples were subjected to nested RT-PCR for G and P genotyping irrespective of the results obtained in SDS-PAGE electrophoresis.

•Amongst a total of 22 Rotavirus ELISA positive samples, first round of nested RT-PCR for G genotyping gave VP7 amplicon(1062bp) in 11(50%) samples. G genotype was successfully assigned to all these 11 samples (50%) in second round amplification of nested RT-PCR using G- genotype specific primers for G1, G2, G3, G4, G9. All these 11 samples (100%) revealed the presence of G1 genotype. Rest of the 11 samples remained negative in both first and second rounds of nested RT- PCR.

  First round of nested RT-PCR on 22 Rotavirus ELISA positive samples for P genotyping showed VP4 amplicon(663bp) in 10(45.45%) samples. Rest of the 12 samples failed to yield VP4 amplicon (663bp) in our study. Second round of nested RT-PCR was done on all 22 samples using P-genotype specific primers for P[4],P[6],P[8],P[9],P[10]. Amongst 10 samples which gave VP4 amplicons in first round amplification, P [8] genotype was detected in 7 samples (70%) and P [4] was detected in 3 samples (30%). Remaining 12 samples negative in first round, also failed to demonstrate any P-genotype specific amplicon in second round of nested RT-PCR.

•Amongst different combination of G and P genotypes, the most common genotype found in our study was G1P [8] (38.46%) followed by G1P [4] (23.07%).

•Three samples (23.07%) with G1 genotype remained untypeable for P genotypes (VP4 gene).Two samples (15.38%) with P [8] genotype were untypeable for G-Genotype.

  

    Amongst 22 ELISA positive samples, 11 remained untypeable for both VP7 and VP4 genes.

•Definite remarks could not be made regarding the correlation of demographic and clinical features with different G and P genotypes of rotavirus found in our study.

•This study highlighted the different genotypes of rotavirus presently circulating amongst the under five years age children from different north eastern states attending NEIGRIHMS, Shillong.

     

      In our study we observed that amongst 55 under five years age children suffering from diarrhea ,22 (40%) came positive for Rotavirus Group A Antigen by sandwich ELISA. The most common clinical features in these 22 rotavirus infected cases were diarrhea (90.9%), vomiting(95.45%), ‘some dehydration’ (90.09%), fever (90.9%).

       Molecular analysis of these 22 ELISA positive samples was done by SDS-PAGE

electrophoresis in which 11 samples (50%) were electropherotyped and all of them revealed ‘long electropherotype’ pattern of rotavirus dsRNA. Nested RT-PCR carried out on 22 rotavirus ELISA positive samples successfully assigned G -genotype to 11 samples and P- genotype to 10 samples.

All these 11 samples revealed G1 genotype while amongst 10 samples for P-genotyping P[8] was seen in 7 (70%) samples and P[4] in rest 3 (30%) samples. Analysis of different G and P genotype

combinations was also done in our study. The most common genotype combination found was G1P[8] ( 38.46% ) followed by G1 P[4] (23.07%). Rotavirus with genotypes G1P[8] and G1P[4] were found to be consistently associated with diarrhea (100%), vomiting (100%), ‘some

dehydration’(100%), lethargy (100%) and irritability (100%).

     Our study successfully revealed one type of G -Genotype (G1) and two types of P-Genotype (P[4], P[8] ) with the combination of G1P [8], G1P[4] circulating amongst the under five children with rotaviral gastroenteritis attending NEIGRIHMS Shillong .The outcome of our study will be helpful for better understanding of the detail molecular epidemiology of the circulating genotypes of rotaviruses in this region with inclusion of larger sample size for designing the appropriate strategy in control and prevention of Rotavirus gastroenteritis among under five years age children. Further in-depth study in this regard will also help in identifying the appropriate vaccine candidate for development of safe and effective vaccine against rotavirus associated childhood diarrhea.

Are Antibiotics needed in common cold ? Myth vs Facts

    When winter had come can spring be far behind ? Well we all are gearing up to welcome spring which symbolises colour and festivity. Spring also happens to be the time when there is surge of numerous viral infections. This sudden spike is mostly due to gradual increase in environmental temperature and humidity which fundamentally favours the growth of different environmental pathogens. 

    

    Common Cold is most commonly due to seasonal strains of Influenza, Rhino, Adeno , Respiratory Synctial Virus which cause nasal discharge, sneezing, mild prodromal fever with bodyache etc. This is self limiting in most of the cases within 7 days of onset of symptoms. Paracetamol, Antihistaminics like Montelukast, levocetrizine, Bilastine etc do most of the job. However, in certain individuals like patients having comorbid conditions like Diabetes, Hypertension, Pre-existing interstial lung diseases may require antibiotics like Amoxycillin, Cepodoxime Proxetil , Azithromycin as a precautionary measure to prevent secondary bacterial infection. 

     Western literature and AMR surveillance programmes often advise against use of antibiotics in viral infections, however this concept cannot be generalised and clinician has to take in consideration of invidual patient aspects, local epidemiological pattern and investigation parameters. However, antibiotics if used in seasonal viral infections should be restricted to first line ones to combat antibiotic resistance. Also OTC availability of antibiotics should be stopped to prevent its irrational uses. 

    Stay tuned for updates on more medical vignettes. 

Graphics acknowledgement : CDC