Clinical case presentation- Rh incompatibility.pptx

This is a clinical case with Rh incompatibility. A 10 days baby diagnosed with Rh incompatibility and also having Bacteremia and Klebsiella pneumoniae is causing nosocomial infection in NICU

1. Clinical Case Presentation Department of microbiology Arpita Chandra

2. Patient ID ADMISSION DATE- 07/11/22 AGE/GENDER – 10 day/Male WARD- NICU REG NO- 1677467 PATHO NO- 70 SAMPLE- Blood (for Microbiological Investigation) – On 08/11/22

3. History of patient Chief Complaints Baby of Roli Delivered by NVD (Weight- 3.720 Kg) Maternal blood group- A- ve Baby’s blood group- B + ve Diagnosis - Rh In- compatibilty

4. Physical Examination GC - good Pulse- 130bmp Temp- Afebrile R/R - 49/min SO2 - 99%MPA Pallor- Neg Icterus- Neg Cyanosis- Neg

5. Cardiovascular System H/R- 130bpm Apex beat- (+) S1 S2- (+) Any Murmur- (-) Peripheral pulses- Palpable

6. Respiratory system- Lungs clear Crepts Ronchi Wheezing sound Pleural fluid ------Negative

7. CNS Concious - yes Altered sensorium- Neg Pupils Reflex Planter- Neg

8. Abdomen Liver and Spleen- NAD Distension Presence of free fluid Ascits ----- Negative

9. 2 nd DAY - On 08 Nov 2022 GC- Poor Yellowish discoloration of face Phototherapy started- 8 Nov Stopped on – 12 Nov Suggestive for Investigations of CBC, CRP Blood culture and sensitivity Direct Coombs Test (DCT)

10. 4 th DAY – On 10 Nov 2022 Icterus – Positive Blood culture – Reported Klebsiella pneumoniae Treatment Rx- IV Ceftriaxone-200mg BD IV Amikacin – 28 mg BD

11. BABY DIAGNOSED WITH Rh-INCOMPATIBILITY

12. Rh factor In 1940 discovered by Landsteiner and Wiener from the blood of rhesus monkey.

13. Blood group positive = Rhesus factor present Blood group negative = Rhesus factor absent The worldwide frequency of Rh- positive – 94% Rh- negative -6%

14. Rh disease Rh disease is a condition where antibodies in a pregnant women’s blood destroy her baby’s blood cells. It’s also known as Hemolytic disease of the fetus and new born (HDFN)

15. Sign and Symptoms Jaundice- Yellow discoloration of skin Because of much more destruction of RBCs in liver Which produces excess Bilirubin Fast heart rate (Tachycardia) Fast breathing (tachypnea) Weakness Enlargement of liver or spleen Severe swelling of the body

16. Blood Specimen collection Preparation of the site – Require proper disinfection of the vein from which the blood is to be drawn If a patient has an existing IV line Blood should be drawn below the existing line Blood drawn above the line It will be diluted with fluid being infused

17. Antisepsis Once a vein is selected Site is defatted with 70% alcohol To kill surface and subsurface bacteria Because blood culture medium enhance the growth of any stray contaminating bacterium Such as- normal flora of skin

18. Specimen Volume Adults- For many years, it has been recognized that most bacterimias in adults have a low number of colony forming units (CFU) / mL of blood. Fewer than 30 CFU/ mL of blood were commonly found in patients with clinically significant bacteremia . 10-20 mL blood – For Adults Media volume- 70 ml

19. Children - Not safe to take large sample of blood from children, particularly infants. - Infants with more serious disease usually yield more 10 CFU of bacteria/ mL of blood. 1 to 5 mL blood- For infants and small children Media Volume- 20mL

20. Number of Blood Culture Because periodicity of microorganisms in the blood stream may be characteristics for some diseases, continuous for some, and random in others In patients with endocarditis who have not received antibiotics Single blood culture is positive (90-95% cases)

21. W ho have received prior antibiotic therapy 3 separate blood collections of 10-20 mL each Detects most etiologic agents of endocarditis Without endocarditis – 80% to 92% (detected by first blood culture) 90-99% - First two cultures 99.6% - At least one of the first three cultures

22. Blood Culture media- composition Trypticase soy broth Brain heart infusion broth Supplemented peptone or thioglycolate broth Most specialized broth base include Columbia or Brucella broth.

23. Blood drawn for culture can be inoculated directly into blood culture broth media If Culture media bottle NOT AVAILABLE

24. Anticoagulant Blood drawn into a blood collection tube Containing an anticoagulant for transport to lab Use Sodium polyanethol sulfonate (SPS, Liqoid ) – 0.025% to 0.03% (Best anticoagulant) Today - 0.03% to 0.05% SPS Heparin, Ethylenediaminetetraacetic acid (EDTA), Citrate inhibits numerous org.

25. Properties of SPS Anti-complementary Anti-phagocytic Interferes with the activity of some Antibiotics EX- Aminoglycosides It inhibits the growth- Neisseria spp. Gardnerella vaginalis , Streptobacillus moniliforms and all strains of Peptostreptococcus anaerobius . Addition of 1.2% gelatin – Counteract this inhibitory action of SPS

26. Conventional Blood Cultures In blood culture bottles Low oxidation reduction potential Permitting the growth of (Facultative aerobic and Some anaerobic org.) For encouragement of growth of obligate (strict) aerobes Such as- yeast & Pseudomonas aeruginosa , transient venting of the bottles with a sterile, cotton plugged needle may be necessary.

27. Growth Detection ON CULTURE PLATE (Aerobic) Take a few drops of well mixed medium Spreading this inoculum onto Mac- Conkey agar Blood agar Chocolate agar Incubate it at 35°C for 48 hours

28. ON CULTURE MEDIA BOTTLE (Anaerobic ) Stationary bottles by visual inspection – RBCs Hemolysis, Gas bubbles, Turbidity , Small aggregates of bacterial and fungal growth Incubated culture bottles for – 7 days

29. If growth is detected in the anaerobic bottles Subcultures are made Incubated Both anaerobically and aerobically After 48 hours of incubation A second blind subculture or acridine orange stain may be performed.

30. Automated system BD Septi Chek system, Becton Drickson Microbiology System, BacT /Alert Microbial detection system Lysis Centrifugation VITAL

31. Probable contaminant Growth of Bacillus spp , Corynebacterium spp , Propionibacterium acnes or CONS Polymicrobial bacteremia is uncommon Organism causing primary site of infection is not same as that isolated from the blood culture

32. Probable pathogen Same organism=Repeated cultures= at different times Endocarditis suspected patients= Enterococcus Gram negative rods = Gram negative sepsis Enterobacteriaceae , Streptococcus pneumoniae & pyogens Isolation of commensal microbial flora = Immuno -suppressed patients

33. Processing in Microbiology Lab Sample came to the lab After incubation of 24 hours First subculture on cled agar Also can be streak on – Mac- Conkey agar, Blood agar and Chocolate agar

34. ( After 24 hrs of incubation at 37°C Observe Colony Morphology From Culture plate (CLED Agar) ( Lactose Fermenting, Mucoid pink colour colonies )

35. Marked isolated colonies for smear   Smear preparation & Gram stain Examine under oil immersion (100X) GNB (Short thick bacilli)   Catalase (+ ve ) Oxidase (- ve ) Enterobacteriaceae

36. Hanging drop Non Motile Lactose fermenting bacteria (suspected) Klebsiella spp. (Gram neg. Bacteria) GNB process with All biochemical and AST

37. AFTER 24 HRS OF INCUBATION ( OBSERVE ALL BIOCHEMICALS AND AST) Indole test (- ve ) Urease test(+ ve ) Mannitol - NM/F

38. Citrate test(+ ve ) TSI (Triple sugar iron) A/A with gas

39. ANTIBIOTIC SENSITIVITY TEST Sensitive to - CPM, C, CFS, CX, MRP, IPM, PIT, TGC, OF, CL, PB, LE, AK, CPT Resistance to - TOB, A/S, GEN, PI, AT, CIP, COT, CTX, NET, CTR Inrinsic Resistance to - Ampicillin, Ticarcillin Organism Isolated- Klebsiella pneumoniae

40. CRITICAL ALERT IMMEDIATELY WE INFORMED TO CLINICIAN

41. RECENT RESISTANCE PATTERN IN K. PNEUMONIAE (2017) - From a cross sectional study observed a significant increase in antibiotic resistance (>40%) to the following antibiotics: cefazolin , amoxicillin- clavulanic acid, cefuroxime, cefepime , ceftriaxone, and ceftazidime - The rate of bacterial ESBL production has been steadily increasing about 39.66 % ± 12.46 % > 30% resistance to ciprofloxacin The rates of resistance to I mipenem and M eropenem were 5.1% and 3.4%, respectively [3]

42. Klebsiella pneumoniae An opportunistic Pathogen is a leading cause of neonatal sepsis It causes nosocomial infection or Hospital aquired infection and also causes pneumonia in intensive care units (ICUs) Other infections - Severe bronchopneumoniae UTI Wound infections Septicaemia Meningitis and rarely Diarrhoea

43. Nosocomial infection in neonatal intensive care unit (NICU) Risk of nosocomial infection in neonates is very higher due to severity in their prematurity, illness, systemic infection, congenital defects, invasive monitoring, no judiciary use of antibiotics and no proper use of disinfections Nurses are the primary caregivers for infants in the NICU and their hands (without proper disinfection) also one of the common source of infection [2] .

44. ON 14 th NOV 2022 PATIENT DISCHARGED WITH GOOD HEALTH

45. REFERENCES C. P. BAVEJA (Textbook of Microbiology) BAILEY & SCOTT’S (Diagnostic Microbiology) [2]- Kahraman EP, Çiftcia IH ( 2017) The Antibiotic Resistance Patterns of Klebsiella pneumoniae Clinic Isolates: A Comprehensive Meta-Analysis. Open J Bac 1(1): 021-026. [3] https://www.jehp.net//text.asp?2022/11/1/158/347162

46. THANKS A LOT