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admin | Herbal Remedies For Bv | 12.02.2015
One week beets have you peeing pink, and the next asparagus has you running from the stench. Not that you always check the toilet after you tinkle, but for those who do, this color is exactly what you expect to find.
Moving on to the Physical Exam General ? Pallor, diaphoresis, general appearance, level of distress or discomfort, is the patient lying still or moving around in the bed Vital Signs ? Orthostatic VS when volume depletion is suspected Cardiac ? Arrhythmias Lungs ? Pneumonia Abdomen ? Look for distention, scars, masses ? Auscultate – hyperactive or obstructive BS increase likelihood of SBO fivefold – otherwise not very helpful ? Palpate for tenderness, masses, aortic aneurysm, organomegaly, rebound, guarding, rigidity ? Percuss for tympany ? Look for hernias! Case #3 46 yo M with hx of alcohol abuse with 3 days of severe upper abd pain, vomiting, subjective fevers. Pancreatitis Risk Factors ? Alcohol ? Gallstones ? Drugs Amiodarone, antivirals, diuretics, NSAIDs, antibiotics, more…..
Case #4 72 yo M with hx of CAD on aspirin and Plavix with several days of dull upper abd pain and now with worsening pain “in entire abdomen” today. Background : Carbapenems are among the few useful antibiotics against multidrug resistant gram negative bacteria particularly those with extended spectrum beta lactamase.
Objective : To assess the production of NDM-1 type Metallo beta lactamase enzyme in Enterobacteriaceae at a tertiary care centre in Mumbai. Materials and Methods : Consecutive carbapenem resistant Enterobacteriaceae isolates were collected from August 2009 to November 2009.
Results and Conclusions : Modified Hodge test was positive for all carbapenem resistant isolates.
Carbapenems are the agents of last resort against many multi drug resistant, gram negative bacteria. An alert issued in the UK in 2009 warned of an increasing number of carbapenem resistant Enterobacteriaceae strains identified in UK hospital patients.1 Many of them were recently hospitalized in India and Pakistan and had a new type of metallo beta lactamase designated as NDM-1 (New Delhi Metallo-1).
Phenotypic detection of carbapenemase production : The modified Hodge test was performed on all isolates on Mueller Hinton agar. Molecular analysis technique : DNA was extracted from all the strains by heat boil method and this DNA was subjected to single target PCR. A total of 24 carbapenem resistant gram negative organisms were collected in a period of 3 months.
Amongst the 22 NDM producing organisms 10 were Klebsiella spp while 9 were Escherichia coli (Table 1).
Resistance to carbapenems is of great concern as carbapenems are considered to be antibiotics of last resort to combat infections by multidrug resistant bacteria, especially in ICUs and high risk wards.
We sought to identify NDM-1 positive strains among the carbapenem resistant Enterobacteriaceae isolates at our tertiary care centre.
Although NDM-1 organisms have been reported in UK among patients recently hospitalized in India or Pakistan, to our knowledge, this is the first report of NDM-1 producing enzyme in India.


Carbapenemases in Enterobacteriaceae may not be detected as their MICs can sometimes be below the current breakpoints. In the UK report, the NDM-1 producing isolates were clonally diverse, indicating parallel evolution of resistance, doubtlessly under antibiotic pressure. Multi-resistant hospital bacteria linked to India and Pakistan, Health Protection Report Vol.
But even if you’re a pro at identifying the reason, finding different colors in the bowl can still be shocking. However resistance to carbapenems occurs and is mediated by mechanisms like loss of outer membrane proteins and production of beta lactamase that is capable of hydrolyzing carbapenems.
Of 24 carbapenem resistant Enterobacteriaceae 22 were NDM producers while 2 were NDM non producers. Resistance to carbapenems is mediated by mechanisms like loss of outer membrane proteins, and production of carbapenemases that are capable of hydrolyzing the carbapenems.
After overnight incubation the plates were observed for clover leaf-type indentation at the intersection of the test organism and the standard strain, within the zone of inhibition of the carbapenem susceptibility disc.
While carbapenem resistance in Pseudomonas and Acinetobacter spp is well known, resistance among Enterobacteriaceae is increasing.
This NDM beta lactamase is one type of metallo beta lactamase which is found only in members of Enterobacteriaceae and differs from other beta lactamases as Extended Spectrum Beta Lactamases (ESBLs) and Amp C by being resistant to the carbapenems. Outbreak of infection with multidrug-resistant Klebsiella pneumoniae carrying bla(IMP-8) in a university medical center in Taiwan. Outcome of treating infections due to ESBL producing organisms with non carbapenem antimicrobials. Amongst the 22 NDM producing organisms 10 were Klebsiella spp, 9 were Escherichia coli, 2 were Enterobacter spp and 1was Morganella morganii. The growing incidence and also the diversity of carbapenemase producing strains is therefore a major concern. Due to lack of epidemiological data within India, the exact prevalence of NDM-1 enzyme is not known. Carbapenem resistance in Enterobacteriaceae has increased from 0% in 2006 to 8% in Jan – Aug 2009 (Fig 3) in ICU blood cultures. KPC is also a beta lactamase that is a serine beta lactamase which is resistant to carbapenems. The physicians at our institute follow the hospital antibiotic policy and do not indiscriminately use carbapenems. Many of them were recently hospitalized in India and Pakistan and had new type of metallo beta lactamase designated as New Delhi Metallo-1 (NDM-1).


This high number in a relatively short span is a worrisome trend that compromises the treatment options with the carbapenems. We studied carbapenem resistant Enterobacteriaceae at our tertiary centre in Mumbai to find if NDM-1 was found among them. Of these, 11 samples were urine samples, 4 were sputum, 3 were blood and one each from tracheal secretion, stool, bronchoalveolar lavage (BAL), swab, endotracheal secretion and pus. NDM-1 was strongly linked to India and Pakistan and many of the UK cases had recent medical exposure in the Indian subcontinent.
Program & Abstracts of the 45th Annul meeting of the Infectious Disease Society of America, San Diego, California, Oct 3-7, 2007 (Abstract # 1100). The emergence of carbapenemases in Enterobacteriaceae provides an added risk of dissemination in the community. Organisms with this resistance determinant will be difficult to treat as therapeutic options are limited.
It is for this very reason that our group had studied and reported the outcome of treating infections due to ESBL (Extended Spectrum Beta Lactamases) producing organisms with non carbapenem antimicrobials.5 It was concluded in this observational study that it is possible to successfully treat at least the less severe infections with ESBL producing organisms with non carbapenem drugs. These enzymes confer resistance to the other beta-lactam agents as well, including extended spectrum cephalosporins. There were two isolates that tested positive by Modified Hodge test and were negative by NDM PCR. This, we hoped, would help preserve the efficacy of carbapenems against increasingly resistant organisms. Metallo beta lactamases (MBLs) are one such type of carbapenemase, that are characterized by the ability to hydrolyze carbapenems and are inhibited by EDTA, chelators of Zn2+.
NDM-1 being present among Enterobacteriaceae has the potential for further dissemination in the community. Only two Klebsiella pneumoniae carbapenem resistant strains were not producers of NDM-1 enzyme. Such dissemination may endanger patients undergoing major treatment at centres in India and this may have adverse implications for medical tourism. The mechanism of resistance of these two isolates could be due to production of other Metallo beta lactamases or KPC enzymes. Besides stringent infection control in hospitals, good sanitation in the community is also needed to contain the spread of such clones.




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