Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
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Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2011 | Month : November | Volume : 5 | Issue : 6 | Page : 1169 - 1172

Pulmonary Bacterial and Fungal Infections in Cancer Patients with Neutropaenia

Meena Dias M.D., Shreevidya K.

MD, Associate professor, Department of Microbiology, Fr. Muller Medical College. MBBS Resident, Department of Microbiology, Fr. Muller Medical College.

Correspondence Address :
Meena Dias
Associate professor, Department of Microbiology
Fr. Muller Medical College, Kankanady
Mangalore, India - 575002
Phone: 0824 2238273
E-mail: drmeenadias@gmail.com

Abstract

Background: The term, “immunocompromised host” describes a patient who is at an increased risk of life-threatening infections as the consequence of a decrease in the immunity. This study dealt with patients who were on radiotherapy or chemotherapy for underlying malignancies. A pulmonary infection is the most common complication in these patients. This study was conducted with the objective of recording the occurrence of opportunistic pulmonary infections in immunocompromised patients.

Materials and Methods: A total number of 100 cancer patients who were undergoing chemotherapy and radiotherapy, with neutropaenia, who were clinically diagnosed to have lower respiratory tract infections, who attended a medical college hospital, were included in the study during December 2008 to May 2010. Their sputum was collected and processed for the detection of various bacteria and fungi.

Results: Out of 100 patients, the cultures of 44 patients showed significiant growth. Among the isolates, Pseudomonas aeruginosa was the predominant pathogen which was found to cause pneumonia. Other pathogens which were found were gram negative bacilli and Methicillin Resistant Staphylococcus aureus. . A rare bacterium, Corynebacterium macginleyi, was isolated from a patient with carcinoma of the lung.

Interpretation and Conclusion: Patients with malignancy are prone to get infected with highly resistant strains of various bacteria which make the treatment difficult and increase the morbidity and mortality. We need to look out for rare organisms which cause pneumonia in immunocompromised patients.

Keywords

Immunocompromised, Malignancy, Neutropaenia, Pulmonary infections

The term, “immunocompromised host” describes a patient who is at an increased risk for life-threatening infections as the consequence of a decrease in the immunity (1). During the past few years, the population of immunocompromised hosts has expanded enormously, thus reflecting the increased use of immunosuppressive agents for the treatment of malignancies and collagen vascular diseases, the prevention of rejection in organ transplant recipients and also an increased incidence of HIV infections and malignancies. Unfortunately, the gain in years of useful life through the successful management and treatment of diseases is offset by serious effects on the immune system. As a result, infections, rather than the primary illness, become the leading cause of death in immunocompromised patients. There are many factors which predispose to infections in this patient population, including local factors due to the tumour, specific deficiencies in the host defense mechanisms due to certain malignant processes, and deficiencies in the host defense mechanisms which are secondary to cancer chemotherapy. Neutropaenia is probably the most important factor which predisposes to infections in cancer patients (1). The lung is one of the most frequently involved organs in a variety of complications, infections being one of the most common ones and they account for about 75% of the pulmonary complications and are associated with high morbidity and mortality (2). Pneumonia, which is caused by gram negative bacilli, is a major problem for neutropaenic patients and as they cannot mount an adequate inflammatory response, the pulmonary infection may spread rapidly, resulting in extensive necrosis and a high fatality rate.

The present study was undertaken to record the occurrence of various bacterial and fungal agents which caused lower respiratory infections in malignant patients who were on radiotherapy and chemotherapy, with neutropaenia. No viral pathogens were included due to lack of diagnostic facilities.

Material and Methods

A total number of 100 cancer patients who were on chemotherapy and radiotherapy, with neutropaenia, who were clinically diagnosed to have lower respiratory tract infections, who attended a medical college hospital, formed the study group. The study was conducted during December 2008 to May 2010. Out of 100 sputum samples, 44 showed significant growth.

Microbiological Workup
Early morning, expectorated sputum samples were collected from all the patients in separate, sterile, wide mouthed, screw-capped and disposable plastic containers.

The samples were processed immediately in the Microbiology laboratory. The expectorated sputum was used to detect bacterial and fungal pathogens. The quality of the expectorated sputum was assessed both by macroscopic and microscopic examination. Specimens which were clear, thin and watery, with no purulent material, were rejected. Microscopically, Bartlett’s scoring method 3 was used to assess the quality of the sputum.

Smears were prepared and subjected to Gram’s staining, Ziehl Neelsen staining [20% H2SO4 and1% H2SO4] and Toluidine O staining. A KOH mount was done for the fungi.

T(h2e) specimens were cultured on( 35)% Sheep Blood agar, Mac- Conkey’s agar, heated Blood agar, Lowenstein Jensen Medium and Sabouraud’s dextrose agar. The plates were incubated at 370 C for 18-24 hours in humid air plus 5-10% CO2. Sabouraud’s Dextrose agar slopes were incubated in duplicates, one in room temperature and the other at 370C for 4 weeks and they were observed for growth at intervals. The Lowenstein Jensen Medium was incubated at 370C for 4 weeks and it was observed for growth. The identification of the organisms was conducted according to standard laboratory methods (3), (4).

Antibiotic sensitivity testing was done by the Kirby Bauer disc diffusion method according to the CLSI guidelines (5). The antibiotic discs were selected as per the CLSI guidelines.

Candida, which was present in the direct smear of the sputum, on Gram’s staining, appeared as gram positive yeast like budding cells with pseudohyphae. It was regarded as a pathogen after obtaining the same strain in three repeated samples as pure growth, after observing numerous polymorphonuclear leucocytes on Gram’s staining of the sputum samples with pseudohyphae (thus showing its invasive nature), and after the patients who were treated with antifungals recovered. All the Candida which were obtained in the Sabouraud’s Dextrose agar, were then processed for the identification of the species. The germ tube test was done. All Candida were inoculated on corn meal agar and incubated at 250C to demonstrate chlamydospore formation and to look for the typical morphology. The sugar assimilation test was done on Yeast Nitrogen Base agar for further speciation, by using the following sugars- glucose, maltose, sucrose, lactose, trehalose, raffinose and galactose.

A rare Corynebacterium isolate was obtained from a patient with carcinoma of the larynx. This was isolated in the pure form from the same patient in 3 different samples and the gram staining morphology gave a clue to its pathogenicity. It was identified as lipophilic Corynebacterium in our laboratory and was sent to the L.V. Prasad Eye Institute, Hyderabad, for identification by the commercial API-Coryne System for the confirmation of the strain. It was thus identified as Corynebacterium macginleyi with a very good profile acceptance of 99.4%.

Nocardia was suspected when gram positive, thin, branching filaments were observed on Gram’s staining of the sputum smears. Ziehl Neelsen staining with 1% H2SO4 was done, which showed acid fast bacilli with branching filaments. The specimen was then inoculated on Lowenstein Jensen medium and Sabouraud’s Dextrose agar without antibiotics. The colonies which were obtained were white, glabrous, chalky and wrinkled.

Statistical Methods
The results were statistically analyzed by using the SPSS version13 software for MS- Windows.

Results

All the 100 patients who were included in this study were on chemotherapy or radiotherapy and had a low neutrophil count, which contributed to their immunosuppression, out of which 44 showed significiant growth. Most of the patients belonged to the age group of 51-60 years (47.7%), followed by those who were of the age group of 41-50 years (15.9%). 10(22.4%) were of the above 60 years age group. A majority of the infections were seen in the 51-60 years age group. Males were more affected (63.6%) than females (36.4%).

(Table/Fig 1) shows the overall rank order of the organisms which were isolated.

Among the pulmonary infections, bacterial infections accounted for the maximum number of cases [42 (94.64%)] and fungal infections accounted for 2 cases (5.36%). Gram negative bacilli were the predominant group, accounting for 36 (81%) of the isolates, Pseudomonas aeruginosa ( 23.21%) being the most common one. Candida albicans was only fungus which was isolated.

The antibiotic sensitivity of the bacterial isolates was as follows: Among the Staphylococcus aureus strains (21.42%), 10.71% were Methicillin resistant Staphylococcus aureus (MRSA). All the strains were susceptible to amikacin, vancomycin, teicoplanin and linezolid.

Gram negative bacilli showed a wide variety of susceptibilities. The Pseudomonas strains showed a wide variety of susceptibilities. Most of them (76.9%) were resistant to piperacillin, 46.2% were resistant to ceftazidime, 23.1% were resistant to piperacillintazobactum, 7.7% were resistant to cefoperazone-sulbactum, 30.8% were resistant to carbapenems and 15.4% were resistant to monobactum-aztreonam. The least resistance was seen against the drug, cefoperazone-sulbactum and thus it helped in the treatment. The resistant strains of Pseudomonas led to a bad prognosis by making the treatment difficult.

Klebsiella is known for its ESBL production. 50% of the Klebsiella strains were resistant to gentamicin, while the resistance to amikacin was only 10%. 40% were resistant to ciprofloxacin, but the resistance to gatifloxacin was only 30%. A resistance to carbapenems (40%) and cefoperazone-sulbactum (40%) was also observed.

The Escherichia coli strains were also resistant, with all the strains being resistant to penicillins, the 2nd and 3rd generation cephalosporins, the β-lactum β-lactamase inhibitor combination, trimethoprimsuphamethoxazole and ciprofloxacin. 33.3% were resistant to gatifloxacin and 66.7% were resistant to gentamicin, but all were sensitive to amikacin, 16.7% were resistant to imipenem and meropenem and 33.3% were resistant to cefoperazone-sulbactum.

Acinetobacter baumanii, which is known for its inherent capability of high degree resistance, caused severe damage to this groupof patients. All were resistant to the first line drugs. Among the carbapenems, all the strains were resistant to imipenem but only 25% were resistant to meropenem. This (Line missing).

The polymicrobial aetiology of pneumonia was noted in 18.18% of the patients and it was more commonly associated with MRSA, which increased the morbidity of the patients. Most of these were reported from the 51-60 years age group.

Discussion

These patients are defined by their susceptibility to infections which are caused by organisms of low native virulence for the immunologically normal hosts. The survival has improved with the availability of newer antimicrobial agents including azole antifungals, macrolides, antivirals and antiretroviral drugs. Despite these advances, pulmonary infection remains the most common form of tissue-invasive infection in these hosts.

Respiratory infections are very common in cancer patients and are known for their bad prognosis. Granulocytopaenia is the major factor which predisposes to the infections (6), chiefly the bacterial infections. The next most important factor which predisposes to infections is the alteration of the anatomical barriers. Mucosal and skin protection is compromised by tumours, radiotherapy, chemotherapy, surgical diagnostic procedures and therapeutic procedures and intravenous lines and other devices.

In our study, among the pulmonary infections, bacterial infections accounted for the maximum number of infections, followed by fungal infections. Pseudomonas aeruginosa was the predominant pathogen which caused pneumonia, followed by Staphylococcus aureus and then, Klebsiella pneumoniae. This correlated well with the findings of previous studies (7), (8), (9). The other bacteria which caused infections were Escherichia coli, Acinetobacter baumanii, Streptococcus pyogenes, Citrobacter koseri, Streptococcus pneumonia and Corynebacterium macginleyi. Candida albicans was the fungus which was isolated. In a study which was done by Sandro et al (8) on lung infections after cancer chemotherapy, it was found that 49% of the patients had bacterial infections. Among the bacterial infections, the pathogens which were identified most commonly were Pseudomonas aeruginosa and Staphylococcus aureus, followed by Escherichia coli.

A study by Sureyya et al (9) on 181 patients of lung cancer showed infections in 84 patients. Most of them suffered from sputum production (65%), cough (59%), auscultation findings (31%) and fever (31%). Gram negative bacteria were the most frequent pathogens which were isolated by culturing the samples. All our patients had presented with fever as an indicator of infection. 84.1% had cough, which indicated respiratory tract infections. 36.4% presented with breathlessness, thus indicating the severity of the infections which involved the lower respiratory tract.

Most of the bacterial strains were resistant to the first line drugs, thus making the treatment difficult. In patients from whom Acinetobacter baumanii was isolated, the treatment was difficult because of its inherent resistance to several drugs.

The isolation of a rare pathogen, Corynebacterium macginleyi, showed that immunocompromised patients are prone for a wide variety of opportunistic pathogens. Corynebacterium species, other than C.diphtheriae, have been referred to as diphtheroids and are considered as colonizers or contaminants. Emerging infections due to diphtheroids, mainly in immunocompromisedpatients, necessitate an awareness among the microbiologists to speciate them rather than discard them as contaminants.

Less virulent organisms including normal skin flora, commensal bacteria of the oral pharynx or the GIT , environmental fungi and the common community viruses of low level pathogenicity can cause severe, life threatening illnesses in immunocompromised patients. For this reason, a close communication with the diagnostic laboratory is critical, so that the laboratory does not disregard the normal flora and the organisms which are considered to be contaminants, as being unimportant.

Pneumonia is known to get complicated by the infectious agent being able to disseminate easily into the bloodstream and to thus spread to the other organ systems of the body. This makes the treatment difficult and can lead to a bad prognosis.

In the present study, 20.5% of the cases had bacteraemia. The same bacteria with the same susceptibility pattern were isolated from the blood culture of these patients, thus indicating the origin of bacteraemia. Similarly, lung pathogens were isolated from pus samples (11.4%) which were collected from certain wounds in the patient’s body. 4.6% of the patients had urinary tract infections which were caused by their lung pathogens, thus suggesting the dissemination of the bacteria.

Four patients with bacteraemia expired, thus suggesting the severity of the primary pathogen.

Conclusion

A study on pulmonary infections in immunocompromised individuals showed that they are susceptible to a wide variety of organisms. Individuals with malignancies and those on immunosuppressive therapy are prone to develop pulmonary infections due to highly resistant strains of various bacteria, Pseudomonas aeruginosa being the most common one.

Criteria for inclusion
Dr. Meena Dias and Dr. Shreevidya were involved in conducting and analyzing the study, the manuscript preparation, the editing and the reviewing.

References

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Donnelly JP, De Pauw BE. Infections in the immunocompromised host: General Principles In Mandell L.G, Douglas, Bennet’s, Principles and Practice of Infectious Diseases, Elsevier Inc 2005, 6th edition; 3421-31.
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Oh W Y, Effmann L, Godwin J. Pulmonary infections in immunocompromised hosts: The importance of correlating the conventional radiological appearance with the clinical setting. Radiology 2000; 217: 647-56.
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Washington Jr,. Introduction to Microbiology : part 1 ; The Role of the Microbiology Laboratory in the Diagnosis of Infectious Diseases: Guidelines to Practice and Management; In Koneman’s Colour Atlas and Textbook of Diagnostic Microbiology, Philadelphia, PA; Lippincott Williams and Wilkins, 2006, 6th edn; 1-66.
4.
Forbes BA, Sahm DF, Weissfeld AS. Specimen Management. In Bailey and Scott’s Diagnostic Microbiology, 12th edition Elsevier. 2006; 62-77.
5.
CLSI. Performance Standards for Antimicrobial Susceptibility testing; Nineteenth Informational Supplement. CLSI document M100-S19. Wayne, PA: Clinical and Laboratory Standards Institute; 2009.
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Tables and Figures
[Table / Fig - 1]
DOI and Others

JCDR/2011/1595

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