Prevention of infection in voluntary surgical contraception

The prevention of infections requires serious attention from personnel of voluntary surgical contraception programs. Preoperative antisepsis of the skin, use of careful surgical handwashing, sterilization of high-level disinfection of surgical equipment, and meticulous surgical technique are essential to prevent the occurrence of all types of infection. Screening clients for pre-existing infection, especially tubal infection, is important. Preferred antiseptics for both the surgical scrub and skin preparation of the patient are iodophors such as Betadine and chlorhexidine preparation such as Hibitane. Also effective are hexochlorophene (e.g., pHisoHex) for the surgical scrub and tincture of iodine for the operative site. Thorough cleaning and steam autoclaving to sterilize heat stable items and glutaraldehyde soaking to disinfect laparoscopes have become accepted standards. Small incisions, careful nontraumatic tissue handling, and excellent hemostasis all contribute to reduce infection risks. If unsuspected active pelvic infection is encountered at the time of minilaparotomy or laparoscopy, the tubes should not be occluded. Clients undergoing surgical sterilization should be instructed in how to care for their incision, what side effects to expect, when to resume normal activity, and what to do if complications develop. Clients must understand the importance of seeking immediate medical care if the incision becomes inflamed or tender, if there is bleeding, or if fever develops. Good follow up and reporting of infections will also produce data that can identify programs with excessive rates of poststerilization infection so that remedial measures can be taken.     

From Phisohex to Hibiscrub

In a field trial of three disinfectant-detergent preparations for the surgical scrub Hibiscrub (a 4% chlorhexidine detergent solution) maintained a significantly greater residual antibacterial action on the skin of the gloved hands of an operating team than was obtained with Disadine (povidone-iodine detergent preparation) (P<0·001). In comparison with Phisohex (3% hexachlorophane in detergent cream), the established surgical scrub of the operating team for many years, Hibiscrub maintained marginally more significant residual disinfection (P 0·05). Of the three preparations the members of the team found Hibiscrub to be more acceptable for use than either Disadine or Phisohex.     

Comparative antimicrobial activity, in vitro and in vivo, of soft N-chloramine systems and chlorhexidine.

Antimicrobial activity of the following four new N-chloramine compounds was evaluated: two chlorinated simple amino acids, a chlorinated half-ester of succinic acid, and a chlorinated half-ester of glutaric acid. For comparison, the known bactericidal agents 3-chloro-4,4-dimethyl-2-oxazolidinone and chlorhexidine were evaluated by the same procedure. The contact germicidal efficiency screen was used to examine the in vitro bactericidal activity of all six compounds in the absence and presence of 5% horse serum or 5% Triton X-100. The four new compounds were found to have greater germicidal activity than the other compounds tested and to exhibit low toxicity and skin irritation values. The in vivo bactericidal activity was evaluated in two studies. In the occlusion test, three of the four new compounds plus chlorhexidine diacetate were tested. The N-chloramines were significantly superior to chlorhexidine in preventing the expansion of the normal flora under occlusion. In the scrub test, a gloved-hand wash method was used to compare the antimicrobial effect of a 1% solution of the chlorinated half-ester of succinic acid in triacetin with that of a commercial germicidal hand wash containing 4% chlorhexidine gluconate. The two preparations exhibited essentially the same hand-degerming activity.     

Effect of antimicrobial soap containing chlorhexidine on the microbial flora of skin.

The qualitative and semiquantitative changes in the aerobic microbial flora of normal skin with the prolonged use of a chlorhexidine scrub (6 months) were investigated. More samples in the chlorhexidine scrub group had gram-negative bacilli in their axilla (63 of 96, 66%) and groin (36 of 96, 38%) than the controls (32 of 66, 49%, for axilla and 7 of 66, 11%, for groin; P = 0.01). Klebsiella and Enterobacter were the predominant organisms in the control and chlorhexidine groups, respectively. The chlorhexidine scrub produced a reduction in the total aerobic counts in the axilla, groin, and between the toes and the fingers. Fewer samples from the chlorhexidine-treated areas revealed the presence of lipophilic diphtheroids than did the controls. Lipophilic diphteroids were also reduced quantitatively in the groin and axilla with chlorhexidine treatment. No consistent pattern for the other major groups of bacteria was noted between the treatments.     

Use of 4% Chlorhexidine Detergent Solution (Hibiscrub) and Other Methods of Skin Disinfection

In a comparison of three antiseptic detergent preparations for hand washing, Hibiscrub, a 4% chlorhexidine detergent solution, caused a significantly greater estimated immediate reduction of skin flora (86·7% ± 3·0) than was obtained with Dermofax, a 0·75% chlorhexidine detergent solution (55·5% ± 5·1), or with Disadine scrub, a povidone iodine detergent preparation (68% ± 6·8). After six applications the mean estimated reductions of skin flora were 99·2% ± 0·2 for Hibiscrub, 97·7% ± 0·7 for povidone iodine, and 91·8% ± 1·6 for Dermofax.After a series of hand washings with Hibiscrub, as with a hexachlorophane detergent preparation, a further large reduction of skin flora, shown by bacterial counts of hand sampling, was obtained by a second phase of disinfection consisting of two minutes'' application on gauze swabs of 0·5% chlorhexidine digluconate in 70% ethanol; a further wash with Hibiscrub, in place of alcoholic chlorhexidine, for the second phase of disinfection caused an increase rather than a reduction in the yield of bacteria on skin sampling. Unlike this “two-phase” disinfection, the application for 30 minutes of compresses soaked in 10% aqueous povidone iodine or in 0·5% aqueous chlorhexidine digluconate did not cause a greater reduction in skin flora than that obtained by the conventional two minutes'' application on gauze of 0·5% chlorhexidine in 70% ethanol.Chlorocresol (0·3%) liquid soap (the base used for Ster-Zac liquid hexachlorophane soap) caused a mean reduction of skin flora when used for hand washing of 29% after one application and 72% after six applications spread over two days. This formulation, though less active and more variable as a detergent skin antiseptic than chlorhexidine, hexachlorophane, or povidone iodine detergent preparations, is an inexpensive disinfectant soap which could be useful in catering establishments. Alcoholic cetrimide applied as for disinfection of an operation site caused a reduction of skin flora greater than that shown by aqueous cetrimide but comparable to that shown by 70% ethyl alcohol in previous experiments.     

Standardized method for evaluation of hand disinfection by surgical scrub formulations.

A standardized protocol for the evaluation of hand disinfection by surgical scrub formulations was applied to volunteers in a multicenter trial. Povidone iodine (PVI), chlorhexidine (CHX), and a nonmedicated soap (NMS) were tested. The scrubbing procedure involved three daily hand washings for five consecutive days; surviving bacteria were counted daily after being collected in a suitable neutralizing solution. Immediate efficacy (IE), cumulative efficacy (CE), and remanent effect (RE) were calculated by reference to the control hand. Statistical analyses of IE, CE, and RE showed significant differences among the three scrub formulations. IEs of PVI and CHX were equivalent and different from IE of NMS; CE and RE of CHX were higher than those of PVI and NMS. On the basis of the statistical analysis, the population size required for further studies aimed at detecting significant differences between surgical scrub formulations could be estimated.     

Standardized method for evaluation of hand disinfection by surgical scrub formulations

A standardized protocol for the evaluation of hand disinfection by surgical scrub formulations was applied to volunteers in a multicenter trial. Povidone iodine (PVI), chlorhexidine (CHX), and a nonmedicated soap (NMS) were tested. The scrubbing procedure involved three daily hand washings for five consecutive days; surviving bacteria were counted daily after being collected in a suitable neutralizing solution. Immediate efficacy (IE), cumulative efficacy (CE), and remanent effect (RE) were calculated by reference to the control hand. Statistical analyses of IE, CE, and RE showed significant differences among the three scrub formulations. IEs of PVI and CHX were equivalent and different from IE of NMS; CE and RE of CHX were higher than those of PVI and NMS. On the basis of the statistical analysis, the population size required for further studies aimed at detecting significant differences between surgical scrub formulations could be estimated.     

Disinfection of the Skin: An Assessment of Some New Preparations

Repeated hand washing with a detergent solution containing 0·75% chlorhexidine digluconate was found to cause a large reduction in the resident skin flora which was slightly though significantly smaller than that caused by the use of 3% hexachlorophane liquid soap containing a phenolic preservative, chlorocresol 0·3%. Both agents caused a greater immediate reduction of bacteria after a single hand washing than the hexachlorophane liquid soap without a phenolic additive had shown in earlier experiments; the soap base containing chlorocresol 0·3% but no hexachlorophane was also found to cause a large reduction in skin flora. The chlorhexidine detergent solution had no residual disinfectant action on the skin after rinsing and drying the hands.Disinfection of an operation site for two minutes with povidone-iodine containing 1% available iodine in 70% ethyl alcohol caused about as great a reduction in resident flora as a similar treatment with alcoholic 0·5% chlorhexidine. Both treatments were more effective than disinfection with aqueous 1% cetrimide or 0·1% benzalkonium chloride solutions.     

Adaptation and growth of Serratia marcescens in contact lens disinfectant solutions containing chlorhexidine gluconate.

Serratia marcescens (11 of 12 strains) demonstrated an ability to grow in certain chlorhexidine-based disinfecting solutions recommended for rigid gas-permeable contact lenses. For a representative strain, cells that were grown in nutrient-rich medium, washed, and inoculated into disinfecting solution went into a nonrecoverable phase within 24 h. However, after 4 days, cells that had the ability to grow in the disinfectant (doubling time, g = 5.7 h) emerged. Solutions supporting growth of S. marcescens were filter sterilized. These solutions, even after removal of the cells, showed bactericidal activity against Pseudomonas aeruginosa and a biphasic survival curve when rechallenged with S. marcescens. Adaptation to chlorhexidine by S. marcescens was not observed in solutions formulated with borate ions. For chlorhexidine-adapted cells, the MIC of chlorhexidine in saline was eightfold higher than that for unadapted cells. Cells adapted to chlorhexidine showed alterations in the proteins of the outer membrane and increased adherence to polyethylene. Cells adapted to chlorhexidine persisted or grew in several other contact lens solutions with different antimicrobial agents, including benzalkonium chloride.     

Effectiveness of Septisol Antiseptic Foam as a Surgical Scrub Agent

Septisol antiseptic foam (0.23% hexachlorophene in a 46% ethyl alcohol base) is a new surgical scrub agent for both primary and re-entry use that is designed to minimize the harsh effects to the skin of the conventional scrub while retaining effective antibacterial properties. A preliminary surgical scrub study of 1-week duration yielded an immediate reduction in resident flora of 92% from an average single scrub coupled with a residual bacteriostatic effect from repeated use that gave a plateau at 57% of the pretest resident population level. A separate study demonstrated complete elimination of both gram-positive and gram-negative transients from the skin with a single application of the product. In an 8-week surgical scrub study, equal effectiveness was shown between Septisol antiseptic foam and a standard 3% hexachlorophene detergent. However, Septisol antiseptic foam offers considerable advantage in minimizing the harsh effects to the skin of the conventional surgical scrub and results in a substantially lower hemic level of hexachlorophene in the user than that obtained with 3% hexachlorophene detergent. Sampling was conducted by the fingerprint impression plate technique of Gale.     

Mechanisms of killing of spores of Bacillus subtilis by iodine, glutaraldehyde and nitrous acid

Treatment of wild-type spores of Bacillus subtilis with glutaraldehyde or an iodine-based disinfectant (Betadine) did not cause detectable mutagenesis, and spores (termed alpha-beta-) lacking the major DNA-protective alpha/beta-type, small, acid-soluble proteins (SASP) exhibited similar sensitivity to these agents. A recA mutation did not sensitize wild-type or alpha-beta- spores to Betadine or glutaraldehyde, nor did spore treatment with these agents result in significant expression of a recA-lacZ fusion when the treated spores germinated. Spore glutaraldehyde sensitivity was increased dramatically by removal of much spore coat protein, but this treatment had no effect on Betadine sensitivity. In contrast, nitrous acid treatment of wild-type and alpha-beta- spores caused significant mutagenesis, with alpha-beta- spores being much more sensitive to this agent. A recA mutation further sensitized both wild-type and alpha-beta- spores to nitrous acid, and there was significant expression of a recA-lacZ fusion when nitrous acid-treated spores germinated. These results indicate that: (a) nitrous acid kills B. subtilis spores at least in part by DNA damage, and alpha/beta-type SASP protect against this DNA damage; (b) killing of spores by glutaraldehyde or Betadine is not due to DNA damage; and (c) the spore coat protects spores against killing by glutaraldehyde but not Betadine. Further analysis also demonstrated that spores treated with nitrous acid still germinated normally, while those treated with glutaraldehyde or Betadine did not.     

Induced Sporicidal Activity of Chlorhexidine against Clostridium difficile Spores under Altered Physical and Chemical Conditions

Background

Chlorhexidine is a broad-spectrum antimicrobial commonly used to disinfect the skin of patients to reduce the risk of healthcare-associated infections. Because chlorhexidine is not sporicidal, it is not anticipated that it would have an impact on skin contamination with Clostridium difficile, the most important cause of healthcare-associated diarrhea. However, although chlorhexidine is not sporicidal as it is used in healthcare settings, it has been reported to kill spores of Bacillus species under altered physical and chemical conditions that disrupt the spore’s protective barriers (e.g., heat, ultrasonication, alcohol, or elevated pH). Here, we tested the hypothesis that similarly altered physical and chemical conditions result in enhanced sporicidal activity of chlorhexidine against C. difficile spores.

Principal Findings

C. difficile spores became susceptible to heat killing at 80°C within 15 minutes in the presence of chlorhexidine, as opposed to spores suspended in water which remained viable. The extent to which the spores were reduced was directly proportional to the concentration of chlorhexidine in solution, with no viable spores recovered after 15 minutes of incubation in 0.04%–0.0004% w/v chlorhexidine solutions at 80°C. Reduction of spores exposed to 4% w/v chlorhexidine solutions at moderate temperatures (37°C and 55°C) was enhanced by the presence of 70% ethanol. However, complete elimination of spores was not achieved until 3 hours of incubation at 55°C. Elevating the pH to ≥9.5 significantly enhanced the killing of spores in either aqueous or alcoholic chlorhexidine solutions.

Conclusions

Physical and chemical conditions that alter the protective barriers of C. difficile spores convey sporicidal activity to chlorhexidine. Further studies are necessary to identify additional agents that may allow chlorhexidine to reach its target within the spore.     

Bacteria of Porcine Skin, Xenografts, and Treatment with Neomycin Sulfate

Homogenized 4-mm punch biopsies were taken from pigs and bacteriologically evaluated to determine the efficacy of surgical scrub procedures and the subsequent treatment of tissue with 0.5% neomycin sulfate-sodium bisulfite (neomycin-bisulfite) as a decontaminating agent. The majority of the lots of porcine skin taken directly from animals for xenografts in the treatment of burns contained viable bacteria at the time of grafting although scrubbing procedures substantially reduced the skin bacteria. The porcine bacteria consisted primarily of coagulase-negative staphylococci with most strains exhibiting caseinolytic and elastase activity. Staphylococci were the only abundant bacteria found in postscrub biopsies and in saline solutions used to wash the dermatome during its use. After an overnight exposure of grafting tissue soaked in neomycin-bisulfite, the spent neomycin-bisulfite solutions were tested for bacteriostatic and bactericidal activity by comparison to unused neomycin. All solutions tested were equal in bacteriostatic strength, but the bactericidal action of some spent solutions was decreased. Neomycin alone exerted a more lethal effect on sensitive bacteria than the neomycin-bisulfite solution. The desirability of having viable porcine skin for a xenograft necessitated using or discarding the tissue after storage in neomycin-bisulfite at 4 C for a maximum of 72 hr. Certain contaminating microorganisms were unaffected by antibiotic treatment, and the prolonged use of neomycin without bisulfite would have primarily eradicated only the porcine coagulase-negative staphylococci. Neither the presence of this group in grafting tissue nor their proteolytic activity had any observed adverse effect on xenografting success.     

The Effect of Povidone-Iodine (Betadine) on Serum Protein-Bound Iodine,When Used as a Surgical Preparation on Intact Skin

A study was undertaken to determine whether the use of povidone-iodine (Betadine) as a skin disinfectant prior to surgery would affect the protein-bound iodine (PBI) and so invalidate this parameter of thyroid function.Ninety-seven consecutive patients were chosen who had no thyroid disease and who had not recently been exposed to iodine in any form. Their serum PBI levels were determined before and after a wide variety of surgical operations. Povidone-iodine was used as a skin disinfectant in the operating room in all cases. Care was taken to avoid contact of the povidone-iodine with the mucous membranes.No significant change in the protein-bound iodine could be detected and it was concluded that there could be no objection to the use of povidone-iodine on the ground of its possible effect on the protein-bound iodine.     

Inhibition of Staphylococcus aureus Adhesion to the Surface of a Reticular Heavyweight Polypropylene Mesh Soaked in a Combination of Chlorhexidine and Allicin: An In vitro Study

Introduction

Presoaking meshes for hernia repair with antiseptics prior to implantation could decrease the adhesion of microorganisms to the material surface and reduce the risk of antibiotic resistances. In this work, we evaluate chlorhexidine and allicin (natural antiseptic not yet tested for these purposes) against vancomycin as antiseptics to be used in the pretreatment of a heavyweight polypropylene mesh using an in vitro model of bacterial contamination.

Methods

Solutions of saline, vancomycin (40 µg/mL), allicin (1,000 µg/mL), chlorhexidine (2%-0.05%) and the combination allicin-chlorhexidine (900 µg/mL-0.05%) were analyzed with agar diffusion tests in the presence of 10⁶ CFU Staphylococcus aureus ATCC25923. Additionally, sterile fragments of Surgipro (1 cm²) were soaked with the solutions and cultured onto contaminated agar plates for 24/48/72 h. The antimicrobial material DualMesh Plus was utilized as positive control. At every time, the inhibition zones were measured and the bacterial adhesion to the mesh surface quantified (sonication, scanning electron microscopy). Cytotoxicity of the treatments was examined (alamarBlue) using rabbit skin fibroblasts.

Results

The largest zones of inhibition were created by allicin-chlorhexidine. Chlorhexidine was more effective than vancomycin, and allicin lost its effectiveness after 24 h. No bacteria adhered to the surface of the DualMesh Plus or the meshes soaked with vancomycin, chlorhexidine and allicin-chlorhexidine. On the contrary, saline and allicin allowed adherence of high loads of bacteria. Vancomycin had no toxic effects on fibroblasts, while allicin and chlorhexidine exerted high toxicity. Cytotoxicity was significantly reduced with the allicin-chlorhexidine combination.

Conclusions

The use of antiseptics such as chlorhexidine, alone or combined with others like allicin, could represent an adequate prophylactic strategy to be used for hernia repair materials because soaking with these agents provides the mesh with similar antibacterial properties to those observed after soaking with vancomycin, similar to the effect of DualMesh Plus.     

Spatiotemporal Dynamics of Scrub Typhus Transmission in Mainland China, 2006-2014

BackgroundScrub typhus is endemic in the Asia-Pacific region including China, and the number of reported cases has increased dramatically in the past decade. However, the spatial-temporal dynamics and the potential risk factors in transmission of scrub typhus in mainland China have yet to be characterized.ObjectiveThis study aims to explore the spatiotemporal dynamics of reported scrub typhus cases in mainland China between January 2006 and December 2014, to detect the location of high risk spatiotemporal clusters of scrub typhus cases, and identify the potential risk factors affecting the re-emergence of the disease.MethodMonthly cases of scrub typhus reported at the county level between 2006 and 2014 were obtained from the Chinese Center for Diseases Control and Prevention. Time-series analyses, spatiotemporal cluster analyses, and spatial scan statistics were used to explore the characteristics of the scrub typhus incidence. To explore the association between scrub typhus incidence and environmental variables panel Poisson regression analysis was conducted.ResultsDuring the time period between 2006 and 2014 a total of 54,558 scrub typhus cases were reported in mainland China, which grew exponentially. The majority of cases were reported each year between July and November, with peak incidence during October every year. The spatiotemporal dynamics of scrub typhus varied over the study period with high-risk clusters identified in southwest, southern, and middle-eastern part of China. Scrub typhus incidence was positively correlated with the percentage of shrub and meteorological variables including temperature and precipitation.ConclusionsThe results of this study demonstrate areas in China that could be targeted with public health interventions to mitigate the growing threat of scrub typhus in the country.     

Risk mapping of scrub typhus infections in Qingdao city,China

BackgroundThe emergence and re-emergence of scrub typhus has been reported in the past decade in many global regions. In this study, we aim to identify potential scrub typhus infection risk zones with high spatial resolution in Qingdao city, in which scrub typhus is endemic, to guide local prevention and control strategies.Methodology/Principal findingsScrub typhus cases in Qingdao city during 2006–2018 were retrieved from the Chinese National Infectious Diseases Reporting System. We divided Qingdao city into 1,101 gridded squares and classified them into two categories: areas with and without recorded scrub typhus cases. A boosted regression tree model was used to explore environmental and socioeconomic covariates associated with scrub typhus occurrence and predict the risk of scrub typhus infection across the whole area of Qingdao city. A total of 989 scrub typhus cases were reported in Qingdao from 2006–2018, with most cases located in rural and suburban areas. The predicted risk map generated by the boosted regression tree models indicated that the highest infection risk areas were mainly concentrated in the mid-east and northeast regions of Qingdao, with gross domestic product (20.9%±1.8% standard error) and annual cumulative precipitation (20.3%±1.1%) contributing the most to the variation in the models. By using a threshold environmental suitability value of 0.26, we identified 757 squares (68.7% of the total) with a favourable environment for scrub typhus infection; 66.2% (501/757) of the squares had not yet recorded cases. It is estimated that 6.32 million people (72.5% of the total population) reside in areas with a high risk of scrub typhus infection.Conclusions/SignificanceMany locations in Qingdao city with no recorded scrub typhus cases were identified as being at risk for scrub typhus occurrence. In these at-risk areas, awareness and capacity for case diagnosis and treatment should be enhanced in the local medical service institutes.     

Susceptibility of antibiotic-resistant gram-negative bacteria to biocides: a perspective from the study of catheter biofilms

Bacteria resistant to both the agents deployed to prevent infections and those used to treat infections would be formidable nosocomial pathogens. The aim of this paper is to review the evidence that gram-negative bacteria resistant to antibiotics and biocides have emerged and been responsible for catheter-associated urinary tract infection. A study of patients undergoing intermittent bladder catheterization revealed that the frequent application of the antiseptic chlorhexidine to the perineal skin prior to the insertion of the catheter was effective against the normal gram-positive skin flora but not against the gram-negative organisms that subsequently colonized this site. Organisms such as Providencia stuartii, Pseudomonas aeruginosa and Proteus mirabilis were repeatedly isolated from the skin of these patients and inevitably went on to cause urinary infections. The minimum inhibitory concentration (MIC) of chlorhexidine for many of these strains proved to be 200-800 microg ml(-1) compared with the 10-50 microg ml(-1) recorded for reference strains of gram-negative species. A subsequent survey of over 800 gram-negative isolates from urinary tract infections in patients from both hospitals and the community revealed that chlorhexidine resistance was not a widespread phenomenon, but was restricted to these species and to units where the care of catheterized patients involved the extensive use of chlorhexidine. Analysis of the antibiotic resistance patterns revealed that the chlorhexidine-resistant strains were also multidrug resistant. Other clinical studies also reported catheter-associated infections with chlorhexidine- and multidrug-resistant strains of Pr. mirabilis when chlorhexidine was being used extensively. This species poses particular problems to the catheterized patient. Chlorhexidine thus proved counterproductive in the care of catheters and its use in this context has been largely abandoned. Suggestions of reintroducing this agent in the form of biocide-impregnated catheters should be resisted.     

The burden of scrub typhus in India: A systematic review

BackgroundScrub typhus, a vector-borne zoonotic infection caused by the bacteria Orientia tsutsugamushi, is one of the most common and clinically important rickettsial infections worldwide. An estimated one million cases occur annually with a high case fatality rate. Although scrub typhus is a major public health threat in India, the burden and distribution remains unclear. We aimed to estimate the burden of scrub typhus in India.MethodologyWe performed a systematic review of published literature on scrub typhus from India to extract information on epidemiology, morbidity, and mortality. Important databases were searched using keywords and appropriate combinations. We identified observational, interventional, and population-based studies and extracted the data to evaluate the number of cases diagnosed using serology or PCR and the number of deaths due to scrub typhus. We conducted a systematic narrative synthesis to summarize included studies.Principal findingsIn the last decade, there were 18,781 confirmed scrub typhus cases reported in 138 hospital-based studies and two community-based studies. IgM ELISA was used in 122 studies to confirm the cases in majority (89%). The proportion of scrub typhus among acute undifferentiated febrile illness (AUFI) studies was 25.3%, and community seroprevalence was 34.2%. Ninety studies had data published on multiple organ involvement out of which 17.4% of cases had multiple organ dysfunction syndromes, 20.4% patients required ICU admission, and 19.1% needed ventilation. The overall case-fatality rate was 6.3%, and the mortality among those with multi-organ dysfunction syndrome was as high as 38.9%.Conclusion/significanceScrub typhus, a common acute febrile illness in India causing severe morbidity, accounts for a large number of deaths. The burden of the disease has been underappreciated. Early diagnosis and prompt treatment can significantly reduce complications and mortality. Establishing good surveillance and instituting appropriate control measures are urgently needed.     

Diagnostic validation of selected serological tests for detecting scrub typhus

Clinical diagnosis of scrub typhus is often difficult because the symptoms are very similar to those of other febrile illness such as dengue, leptospirosis, malaria and other viral hemorrhagic fevers. Though better diagnostic tests are available for rickettsial diseases and scrub typhus elsewhere, the Weil–Felix test is still commonly used in India, mainly because microimmunofluorescence assays (M‐IFA) were not available in India till recently and relevant staff had insufficient training. The present study was performed to investigate the performance of M‐IFA, IgM ELISA, and Weil–Felix test on 546 non‐repeated serum samples from subjects suspected of having scrub typhus. One hundred and forty‐three of these 546 samples were positive by M‐IFA; these cases were also confirmed clinically to have scrub typhus based on their dramatic responses to doxycycline therapy. IgM ELISA was positive in 122 of the 143 M‐IFA positive cases and the Weil–Felix test in 96. Though the Weil–Felix test is a heterophile agglutination test, it was found in this study to have good specificity but far too little sensitivity to use as a routine diagnostic test. IgM ELISA can be a good substitute for M‐IFA. Incorporation of multiple prototype antigens on M‐IFA slides is likely one of the reasons for its superior performance. As newer and better diagnostic assays become available for scrub typhus diagnosis in developed countries, it will be imperative to also use such tests in other endemic countries to prevent over‐ or under‐diagnosis of scrub typhus.