INDIAN JOURNAL OF MEDICAL MICROBIOLOGY

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1 108 Indian Journal of Medical Microbiology INDIAN JOURNAL OF MEDICAL MICROBIOLOGY (Publication of Indian Association of Medical Microbiologists) ISSN Volume 26 Number 1 January-March, 2008 CONTENTS Page No. Guest Editorial Novel HIV Prevention Strategies: The Case for Andhra Pradesh JA Schneider...1 Review Article Chikungunya Fever: A Re-emerging Viral Infection M Chhabra, V Mittal, D Bhattacharya, UVS Rana, S Lal...5 Special Article Fabrication and Evaluation of a Sequence-specific Oligonucleotide Miniarray for Molecular Genotyping J Iqbal, F Hänel, A Ruryk, GV Limmon, A Tretiakov, M Dürst, HP Saluz...13 Original Articles A Comparison of PCR Detection of Meca with Oxacillin Disk Susceptibility Testing in Different Media and Sceptor Automated System for both Staphylococcus aureus and Coagulase-negative Staphylococci Isolates S Ercis, B Sancak, G Hasçelik...21 Effect of Exposure to Hydrogen Peroxide on the Virulence of Escherichia coli A Hegde, GK Bhat, S Mallya...25 A Low Molecular Weight Es-20 Protein Released In Vivo and In Vitro with Diagnostic Potential in Lymph Node Tuberculosis N Shende, V Upadhye, S Kumar, BC Harinath...29 Community-based Study on Seroprevalence of Herpes Simplex Virus Type 2 Infection in New Delhi R Chawla, P Bhalla, K Bhalla, M Meghachandra Singh, S Garg...34 Changing Patterns of Vibrio cholerae in Sevagram Between 1990 and 2005 P Narang, DK Mendiratta, VS Deotale, R Narang...40 Rapid Serodiagnosis of Leptospirosis by Latex Agglutination Test and Flow-through Assay TMA Senthilkumar, M Subathra, M Phil, P Ramadass, V Ramaswamy...45 High Level Ciprofloxacin Resistance in Salmonella enterica Isolated from Blood R Raveendran, C Wattal, A Sharma, JK Oberoi, KJ Prasad, S Datta...50 Role of Enteric Fever in Ileal Perforations: An Overstated Problem in Tropics? MR Capoor, D Nair, MS Chintamani, J Khanna, P Aggarwal, D Bhatnagar...54

2 January-March Brief Communications Evaluation of a Modified Double-disc Synergy Test for Detection of Extended Spectrum β-lactamases in Ampc β-lactamase-producing Proteus mirabilis MKR Khan, SS Thukral, R Gaind...58 Antimicrobial Susceptibility Profile of Neisseria gonorrhoeae at STI Clinic C Shilpee, VG Ramachandran, S Das, SN Bhattacharya...62 Detection of Extra-cellular Enzymes of Anaerobic Gram-negative Bacteria from Clinically Diseased and Healthy Sites JM Nagmoti, CS Patil, MB Nagmoti, MB Mutnal...65 Haemagglutination and Siderophore Production as the Urovirulence Markers of Uropathogenic Escherichia coli MA Vagarali, SG Karadesai, CS Patil, SC Metgud, MB Mutnal...68 The use of Dried Blood Spots on Filter Paper for the Diagnosis of HIV-1 in Infants Born to HIV Seropositive Women S Mini Jacob, D Anitha, R Vishwanath, S Parameshwari, NM Samuel...71 Evaluation of the Usefulness of Phage Amplification Technology in the Diagnosis of Patients with Paucibacillary Tuberculosis D Biswas, A Deb, P Gupta, R Prasad, KS Negi...75 Case Reports Cytomegalovirus Oesophagitis in a Patient with Non-hodgkin s Lymphoma SS Hingmire, G Biswas, A Bakshi, S Desai, S Dighe, R Nair, S Gupta, PM Parikh...79 Hydatid Cyst of Mediastinum S Sehgal, B Mishra, A Thakur, V Dogra, PS Loomba, A Banerjee...80 Ochrobactrum anthropi Septicaemia U Arora, S Kaur, P Devi...81 Intestinal Myiasis Caused by Muscina stabulans S Shivekar, K Senthil, R Srinivasan, L Sureshbabu, P Chand, J Shanmugam, R Gopal...83 Pyopericardium Due To Group D Streptococcus K Karthikeyan, KR Rajesh, H Poornima, R Bharathidasan, KN Brahmadathan, R Indra Priyadharsini...85 Pleural Effusion: A Rare Complication of Hepatitis A A Bukulmez, R Koken, H Melek, O Dogru, F Ovali...87 Correspondence Prevalence of Inducible AmpC β-lactamase-producing Pseudomonas aeruginosa in a Tertiary Care Hospital in Northern India A Bhattacharjee, S Anupurba, A Gaur, MR Sen...89 Parental History of Ulcer and the Prevalence of Helicobacter pylori Infection in their Offspring KS Ahmed, AA Khan, JD Ahi, CM Habibullah...90

3 110 Indian Journal of Medical Microbiology Ciprofloxacin Breakpoints in Enteric Fever - Time to Revise our Susceptibility Criteria C Rodrigues, N Jai Kumar, J Lalwani, A Mehta...91 West Nile Virus in the Blood Donors in UAE M Alfaresi, A Elkoush Estimation of Antibodies To HBsAg in Vaccinated Health Care Workers TV Rao, IJ Suseela, KA Sathiavathy Seroprevalence of Rubella Among Urban and Rural Bangladeshi Women Emphasises the Need for Rubella Vaccination of Pre-pubertal Girls A Nessa, MN Islam, S Tabassum, SU Munshi, M Ahmed, R Karim...94 Novel Digestion Patterns with Hepatitis B Virus Strains from the Indian Subcontinent Detected using Restriction Fragment Length Polymorphism P Vivekanandan, HDJ Daniel, S Raghuraman, D Daniel, RV Shaji, G Sridharan, G Chandy, P Abraham...96 Acute Urticaria Associated with Dicrocoelium dendriticum Infestation A Sing, K Tybus, I Fackler...97 Book Reviews Guidelines to Authors The copies of the journal to members of the association are sent by ordinary post. The editorial board, association or publisher will not be responsible for non-receipt of copies. If any of the members wish to receive the copies by registered post or courier, kindly contact the journal s / publisher s offi ce. If a copy returns due to incomplete, incorrect or changed address of a member on two consecutive occasions, the names of such members will be deleted from the mailing list of the journal. Providing complete, correct and up-to-date address is the responsibility of the members. Copies are sent to subscribers and members directly from the publisher s address; it is illegal to acquire copies from any other source. If a copy is received for personal use as a member of the association/society, one cannot resale or giveaway the copy for commercial or library use.

4 62 Indian Journal of Medical Microbiology, (2008) 26(1): Indian 62-4 Journal of Medical Microbiology Brief Communication ANTIMICROBIAL SUSCEPTIBILITY PROFILE OF NEISSERIA GONORRHOEAE AT STI CLINIC *C Shilpee, VG Ramachandran, S Das, SN Bhattacharya Abstract A total of 100 consecutive patients who attended a sexually transmitted infections clinic were studied. Thirteen had gonococcal urethritis, of which 10 showed growth of Neisseria gonorrhoeae on culture. All the isolates were tested for antimicrobial susceptibility by Australian Gonococcal Surveillance Programme (AGSP) method and beta lactamase production by chromogenic cephalosporin test. Four patients were co-infected with each of the following: HIV, HBV and Chlamydia trachomatis. Gonococcal urethritis (13%) was found more in male patients. Ten percent gonococcal isolates were penicillinase-producing N. gonorrhoeae, and another 10% were tetracycline-resistant N. gonorrhoeae. Key words: Neisseria gonorrhoeae, penicillin resistant, tetracycline resistant Gonorrhoea, a disease well documented from ancient times, continues to defy man s attempt to control it. Gonococcal infections and their complications are amongst the most frequent communicable diseases in many countries. [1] Gonococci have been adept at developing resistance to several commonly used antimicrobials. The failure to cure a case of gonorrhoea has public health implications due to the potential for continued transmission and rapid emergence of antimicrobial resistance. Moreover, a number of sexually transmitted infections (STIs) have been identiþed as facilitating the spread of HIV. Presently, more than 5.26 million people in India are HIV seropositive. The present study was done to isolate Neisseria gonorrhoeae from the patients attending STI clinic at a large tertiary care hospital in East Delhi, which caters to the semi-urban and migratory population. Antimicrobial susceptibility was assessed to determine the sensitivity pattern of these isolates. The correlation of N. gonorrhoeae with other STIs, including HIV and their inßuence on phenotypic behaviour of N. gonorrhoeae, has also been studied. Materials and Methods Hundred consecutive patients who attended the STI clinic at Guru Teg Bahadur Hospital, Delhi, were included as subjects. The subjects reported one or more of the complaints as enunciated by WHO in the syndromic approach to the diagnosis of STIs. Detailed history, demographical and clinical features were recorded. Urethral and endocervical swabs were collected from males and *Corresponding author ( <shilpee_77@yahoo.com>) Department of Microbiology (CS, VGR, SD), University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, New Delhi ; and Department of Dermatology and STD (SNB), UCMS and GTB Hospital, Dilshad Garden, New Delhi , India Received: Accepted: females, respectively, and subjected to direct examination of Gram staining and culture plate inoculation. A presumptive diagnosis of gonococcal infection was made on observing polymorphonuclear leucocytes (PMNLs) with gram-negative intracellular diplococci (ICDC). If the smear showed four or more PMNLs in the absence of gram-negative ICDC, a presumptive diagnosis of non-gonococcal urethritis (NGU) was made. [2] For the isolation of N. gonorrhoeae, the swabs were directly inoculated on chocolate agar plate containing vancomycin, colistin and amphotericin-b and incubated in 5-10% carbon dioxide for hours. The isolates were identiþed as N. gonorrhoeae on the basis of colony morphology, Gram staining, oxidase test and rapid carbohydrate utilization test (RCUT). [3] Antimicrobial susceptibility testing of N. gonorrhoeae was done by disc diffusion technique following the AGSP method. [3] The antimicrobial discs used were penicillin (0.5 IU), nalidixic acid (30 µg), ciproßoxacin (1 µg), ceftriaxone (0.5 µg), spectinomycin (100 µg) and tetracycline (10 µg). All the isolates were also tested for beta lactamase production by chromogenic cephalosporin method. [3] Results A total of 13 patients were found to have gonococcal infection of which 11 were males and 2 females. The ages varied between 15 and 40 years, and a majority were in the age group of years. There was a history of promiscuity in all male patients and one female patient. Patients with gonorrhoea (10/13) mainly presented with profuse, thick, yellow discharge. In seven patients, N. gonorrhoeae could be detected both by microscopy and culture, whereas three patients were detected positive by microscopy only and rest by culture alone. In our study, 20% gonococcal isolates were penicillin resistant and 10% produced penicillinase (Table 1). The trends of antimicrobial susceptibility pattern of N. gonorrhoeae

5 January-March 2008 Shilpee et al - Antibiotic Susceptibility ProÞle of N. gonorrhoeae 63 Table 1: Antibiotic susceptibility pattern of N. gonorrhoeae Antibiotic Sensitive % Resistance % (n = 10) (n = 10) Penicillin (1 PPNG*) 20 Tetracycline Ceftriaxone Nalidixic acid Spectinomycin Ciproßoxacin *PPNG - Penicillinase-producing N. gonorrhoeae as documented in various studies carried out in India are depicted in Table 2. Concomitant infection was seen in four male patients having gonococcal urethritis. One was seropositive for HIV; two for HBsAg, and in one patient, chlamydial antigen was detected. Discussion In our study, gonococcal urethritis (13%) was found more in male patients in the age group of years with promiscuous behaviour and predominantly presented with profuse, thick, yellow discharge. The importance of Gram stained smear in the diagnosis of gonorrhoea was also well highlighted, with a sensitivity of 77% (10/13). Acquisition of multiple STIs is a widespread problem and has been attributed to behavioural risk factors. Thirty percent (4/13) of patients with gonococcal infections in the present study were found to be co-infected with HIV, Chlamydia and HBV. All these patients had recurrent episodes of gonococcal infections, although clinical manifestation was same as that of patients with gonococcal infection alone. Such recurrence of gonococcal infection in patients with multiple STIs highlights the vulnerability of such population in acquiring STIs and eventually becoming reservoir of drug-resistant organisms. Our observation also reinforces the emergence of penicillin, quinolone and tetracycline resistance in N. gonorrhoeae isolates. In our study population, 10% (1/10) gonococcal isolates were penicillinase-producing N. gonorrhoeae (PPNG) as compared to % reported from other parts of India. Ten percent (1/10) isolates were found to be resistant to both ciproßoxacin and nalidixic acid, and another 10% (1/10) were tetracycline-resistant N. gonorrhoeae (TRNG). All strains were sensitive to spectinomycin and ceftriaxone. PPNG isolates from Asia are proline auxotrophs and carry a 4.4 MDa plasmid. [10] There is an additional conjugative 24.5 MDa large plasmid associated with it. The presence of the associated conjugative plasmid in Asian strain is responsible for rapid spread of resistance to other gonococci. Tetracycline resistance in gonococci may be mediated by chromosomal or plasmid determinants. The location of the tet M gene on the transferable plasmid has perhaps served to enhance the transmission efþciency of tetracycline resistance in N. gonorrhoeae strains, causing the rapid spread of TRNG. In our study, the percentage resistance of N. gonorrhoeae isolates to the panel of antibiotics (Pn, TC, Cip, NA) differs from isolates of the same organism from other part of Delhi (Table 2), suggesting the existence of different clones of gonococcal strain circulating in and around Delhi. The failure to cure a case of gonorrhoea has public health implications due to its potential for continued transmission and rapid emergence of antimicrobial resistance. It is said that regimens for the treatment of gonorrhoea should have efþcacies that approach 100%, and treatment with efþcacies less than 95% should never be used. [11] Hence, continuous surveillance of antibiotic resistance pattern is necessary for guiding therapy in highrisk population. Moreover, the prevalent trend of gonococcal infection suggests the existence of heterogeneous population depending upon the local pattern of their high-risk behaviour. Therefore, reduction in the severity of the disease will be possible by adopting preventive measures and continuous education of safer sexual behaviour through health care authorities. References 1. World Health Organization (Geneva). Neisseria gonorrhoeae and gonococcal infections. TRS 616. WHO: Geneva; Bowie WR. Comparison of gram staining and Þrst voided urine sediment in the diagnosis of urethritis. Sex Transm Dis 1978;5: Table 2: Antimicrobial susceptibility testing carried out in India Source Region Year No. tested Sensitivity % Jain SK [4] Mumbai Pn 82.12, Cip 100, PPNG Bhalla P [5] Delhi TC 72, Cro 100, PPNG 8 Gupta CM [6] Pune Pn 61.7, Cip 94.1 Bhalla P [7] Delhi Pn 33.3, Cip 8.3, Cro 100, TC 63.9, PPNG 11.1 Bala M [8] Delhi Pn 10.1, Cip 3, Cro 96.1 Chowdhary S [9] Delhi Pn 40, Cip 5.7, TC 65.7, Cro 100 Present study Delhi Pn 80, Cip 90, TC 90, Cro 100, NA 90, ST 100, PPNG 10 Pn - Penicillin, Cip - Ciproßoxacin, Cro - Ceftriaxone, TC - Tetracycline, ST - Spectinomycin, NA - Nalidixic acid, PPNG- Penicillinaseproducing N. gonorrhoeae

6 64 Indian Journal of Medical Microbiology 3. Laboratory diagnosis of gonorrhoea. WHO regional publication: South-East Asia. New Delhi, India; Jain SK, Kulkarni MG, Banker DD. Antibiotic susceptibility pattern of gonococcal isolates. Indian J Med Sci 1994;48: Bhalla P, Sethi K, Reddy BS, Mathur MD. Antimicrobial susceptibility and plasmid proþle of Neisseria gonorrhoeae in India (New Delhi). Sex Transm Infect 1998;74: Gupta CM, Sanghi S, Sayal SK, Das AL, Prasad GK. Clinical and bacteriological study of urethral discharge. Indian J Dermatol Venereol Leprol 2001;67: Bhalla P, Vidhani S, Reddy BS, Chowdhry S, Mathur MD. Rising quinolone resistance in Neisseria gonorrhoeae isolates from New Delhi. Indian J Med Res 2002;115: Bala M, Ray K, Gupta SM. Comparison of disc diffusion results with minimum inhibitory concentration (MIC) values for antimicrobial susceptibility testing of Neisseria gonorrhoeae. Indian J Med Res 2005;122: Chowdhry S, Pandhi D, Vidhani S, Bhalla P, Reddy BS. High incidence of treatment failure of Neisseria gonorrhoeae isolates to ciproßoxacin in male gonococci urethritis in Delhi. Int J STD AIDS 2002;13: Sparling PF. Biology of Neisseria gonorrhoeae. In: Holmes KK, Mardh PA, Sparling PF, Lemon SM, Piot P, et al, editors. Sexually transmitted diseases, 3 rd ed. McGraw Hill: New York; p Agrawal S, Garg VK, Agarwalla A, Joshi A, Ramachandran VG. Nepal J Dermatol Venerol Leprol 2002;2:17-9. Source of Support: Nil, Conflict of Interest: None declared.