Can books change our life? 
Dr.T.V.Rao MD We live in a complex world everyone is busy with their own problems and limitations, today very few talk to others on their problems, AND LITTLE TIME TO OTHERS to listen to others, it just means everyone has to put up with their own challenges, as it means that we are living in isolation however in time of crisis and left with few to understand our concerns, take to a book it still talks to you Reading helps you remain calm. Books, especially good ones, have that sort of power. If you let them, they can change your life, serve as another compass or guide, or give you a lift when you need it most. Today many waste time with ignorance, thinking oneself to be great Some people truly believe that they know everything. They go through their entire life thinking that they’ve learned everything that they need to know Such people make the matters worse and never allow any one progress to I’m sure you can think of at least one book that fundamentally changed you as a human being It’s as therapeutic as anything else. Once you start digging into a book that’s caught your attention, time ceases to exist, your mind is completely immersed in what is in front of you. As with anything that fully engages your attention, reading makes you stop rushing or running from one point to the next. Instead, you are where you need to be, right here, doing this, and all other things are secondary. The worries, anguish, fears, and ambitions of a moment ago are boxed away in a container that read “for later.” Your only worry is flipping to the next page to find out what’s next. Reading is Imagination! Imagination helps us to have an opened mind and help us with our writing. When you find life, a blank place put little constructive words in Google you are in reach with enlightened minds and ideas Many People think that reading is just a hobby that someone does when they are bored. Really Books are a life style, they change our lives in different ways and some are explainable. Many studies prove those read good books even old make a better world for self and others and keep the life going despite many limitations, Can books change our life? YES
HOPE WE ALL CAN START READING A CLASSIC OF OUR CHOICE
 Ref Collected thoughts on Reading
Dr.T.V.Rao MD

LIVING WITH POSITIVE THINKING – The life is a never-ending game, we are born to fight the matters, on our own. We love positive changes, but we dread the bad ones. However, it’s a lot about how we look at things. No change is either bad or good, it’s what we do with it. Because change is really the only constant thing in our lives, we should strive to make peace with it and even embrace it. It can uplift us and make us want more from life but only if we decide to come to terms with it. Life continues to be a dream to be fulfilled Do whatever you can to achieve your dreams. We make all decisions with great exceptions as no body wishes to take failing ventures however the matters may not remain constant You may never know what’s out there before you take the big leap towards achieving your goals. Develop positive thinking. I put this first because I think it’s the keystone habit that will help you form the other important habits. Sure, positive thinking by itself won’t lead to success, but it certainly goes a long way to motivate you to do the other things required. Walk out of negativism Start by becoming more aware of your negative self-talk — do a little tally sheet throughout the day, marking a tally each time you notice a negative thought. Soon you’ll recognize them, and you can squash them.
WALKING TO FUTURE WITH POSITIVE THINKING IS A GREAT IDEA IF YOU LOVE LIFE 
Dr.T.V.Rao MD

MALDI-TOF MS IN BLOOD STREAM INFECTION 
Dr.T.V.Rao MD 
 A TOPIC FOR POST GRADUATES IN LABORATORY MEDICINE 
Question – Why we need to use newer methods in diagnosis of septicemia and write a note on MALDI-TOF MS? With advances In Technology the Microbiologists should walk to future, with technology, , The study of microbiology is undergoing a renaissance owing to the development and application of a diverse range of new technologies, Soon the matters we are all well versed in traditional microbiology will be obsolete in critical care of the patients, Increasingly sophisticated sequencing approaches, coupled with improved analytical and computational tools, allow us to rapidly identify pathogens, track infectious disease outbreaks and identify links between microorganisms and disease. Rapid identification of microorganisms in the clinical microbiology laboratory can be of great value for selection of optimal patient management strategies for infections caused by bacteria, viruses, fungi, mycobacteria, and parasites. Rapid identification of microorganisms in clinical samples enables expedient de-escalation from broad-spectrum agents to targeted antimicrobial therapy We certainly need the revamp in critical conditions as septic shock where every minute to life counts, Rapid identification of BSIs and the associated condition known as sepsis syndrome are of importance because of associated morbidity and mortality. Despite the evidence showing that the rapid administration of an effective antibiotic saves lives tools in clinical microbiology are primarily based on techniques that evolved 30 to 40 years ago, We certainly receive at least double digit numbers of blood for culturing, I am certain 5- 10% of the specimens get contaminant, majority are sterile even after 1 week of incubation, leading to greater disappointment of clinicians who unfortunately depended on Microbiology in the last hour of crisis . The automated BacT/ALERT® 3D system allows rapid bacterial detection of positive blood cultures in cases of septicemia. however, there is an urgent need for new technologies in microbiology to circumvent the issue of lag time for reports from positive blood cultures and other cultures. Sepsis, a common sequela of BSIs, ranks among the top 10 causes of death in the United States, where over 600 patients die each day. We have no proper statistics. According to the literature, the risk of death from septic shock increases by over 7% with every hour that passes from the onset of shock until the start of targeted therapy. Several other studies confirm the urgency of rapid identification of pathogens and its benefit to survival and costs and the effective targeting of antimicrobial therapy, Unfortunately, when laboratory methods rely solely on cultivation of pathogens and traditional phenotypic methods of pathogen characterization, physicians are forced to deduce the presence of BSI based on clinical symptoms, which are often nonspecific. Subsequently, antibiotic therapy is initiated based on clinical and epidemiological profiles rather than on laboratory evidence. Typically, within 1 to 3 days a microscopic Gram stain category (Gram-positive bacteria, Gram-negative bacteria, or fungi) provides physicians with a general direction for antibiotic therapy. I always insisted observation of gram stain is priority whenever you find little of turbidity in culture bottles in resource poor laboratories. if we can identify whether it is a gram positive or negative gives a greater idea in choosing the Antibiotics, However the world is going to newer technologies in all BSI (Blood stream Infections) which carry higher mortality. Much of the western hospitals are taking the advantage new technologies as priority much newer to the world is MALDI-TOF MS. The advent of MALDI-TOF Mass Spectrometry for the rapid ID of pathogens was a breakthrough in microbiology. Recently, this method was combined with extraction methods for pathogens directly from positive blood cultures recently it is widely used because of its high accuracy, low consumable cost, and speed of analysis. It is estimated that MALDI-TOF MS requires about 105 of colony forming units (cfu) to have an enough bacterial ribosomal protein to obtain a reliable protein pattern, which is specific for a certain pathogen. A typical experiment consists of outgrowth of bacteria, colony selection and placement on a target, addition of matrix, and analysis with MALDI-TOF MS. Mass spectrometry identification is broadband such that the method can measure multiple analyses simultaneously, does not require prior knowledge about the organism, and is both fast and sensitive in that it does not require a prefabrication step. It generally measures all m/z between 2 and 20 kDa. Several reviews are available on this topic for a more in-depth overview, by cost, complexity, and throughput, many of the newly developed technologies will only be affordable for large reference or university-based diagnostic laboratories. The working group strongly urges the development of platforms that could have utility for hospitals, regardless of their size. In a country like India it is not possible start a MALDI-TOF MS in individual laboratories, we can certainly to have pooled system of laboratories and the samples can be sent to the available laboratory for care of critically ill patients in Sepsis.
HOWEVER, IT IS A GREAT PRIORITY TO MOVE FROM TRADITIONAL TO TECHNOLOGICAL ADVANCES OR ELSE THE LIFE IN CRISIS IN CRITICAL CARE SETTINGS
 Ref New Technologies in Clinical Microbiology Donna M. Wolk1,* and W. Michael Dunne Jr. journal of Clinical Microbiology J. Clin. Microbiol. September 2011 vol. 49 no. 9 Supplement S62-S6
Created for on line resources on INFECTIOUS DIESEASES
Dr.T.V.Rao MD Freelance Reporter on Infectious diseases

STAY LEARNING – WE ARE NEVER OLD
Dr.T.V.Rao MD The life is a process to be enriched every day with talents and knowledge, many of us are satisfied with little of our qualifications, and a secure Job, and never think of improving. However the matters have affected many lives, including well qualified professionals and in turn having impact institutions. It is not enough to be content with what you already know. In order to reach your maximum potential, you must attempt to deepen your understanding of the world around you. Many of us have stagnated; in turn we are not contributing anything to the society. If you want work life balance, in the modern stream you need to learn something new every day. It doesn't have to be how to speak a new language or build the next great electronic gadget. It could be something small like how to shoot a photo on your Phone, and capturing some real time event and share it on how to use a new feature on Facebook. Most of us have one or two areas of knowledge that we strive to know very well — things related to our jobs, of course, and maybe a hobby or two. But while it’s important to develop a deep understanding of the things that matter most to us, it is just as important to develop a broad understanding of the world in general. There are a lot of good, practical reasons to make learning something new a part of your daily routine, but the best reason has nothing to do with practicality — we are learning creatures, and the lifelong practice of learning is what makes us humans and our lives worthwhile. If that idealistic musing’s not enough, here are some more down-to-earth benefits: Learning across a wide range of subjects gives us a range of perspectives to call on in our own narrow day-to-day areas of specialization.
Learning helps us more easily and readily adapt to new situations.
A broad knowledge of unfamiliar situations feeds innovation by inspiring us to think creatively and providing examples to follow.
Learning deepens our character and makes us more inspiring to those around us.
Learning makes us more confident.
Learning installs an understanding of the historical, social, and natural processes that impact and limit our lives.
And, as it is said, there’s the whole “making life worth living” thing.
On peer reviewed studies 42% of all college graduates never read another book again. Ever. But continuous learning is vital to making the most of what the world has to offer. You could say that it’s what separates us from the animals. And there is evidence to suggest that it plays a role in staving off mental diseases such as Alzheimer’s. Never forget to read somebody’s thoughts obviously, we already do this. There are countless people out there sharing their knowledge on a huge range of niches, and anyone can find plenty of blogs that interest them. Twitter makes matters simple many times realistic, because you can leave comments, and blogging offers a level of interaction that can’t be matched by books. Read books, we have wonderful libraries around if you just go there and read one book; you’ll be ahead of 42% of all college graduates. If you prefer to read the latest books and have a little money, there’s no shortage of bookstores, Reading is a cheap form of entertainment with practically no risk of injury, and it boosts your brain power a lot more than watching TV. If you have no resources are away from main just read newspapers on Scams and Corruption but here you can read insightful articles on a wide variety of topics that you might not know much about. Best of all, you can read it without feeling depressed. And while you probably spent many years looking forward to that, it’s important to realize that learning is a big part of what makes life interesting. When your learning is self-directed, it can be a lot more fun than school was. You were given a large brain for a reason. Use it. Learn to contribute positive thoughts on World Wide Web as nobody will appreciate negative or mindless thoughts. Stay learning you are never old (Many good thoughts)
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Dr.T.V.Rao MD Professor of Microbiology – Freelance writer

LIFE IS ALWAYS NEW - Nothings makes us new except our own actions to live better and to be creative, today many become arrogant with little of many materialistic things they possess , and soon people become less creative when they assume to be very learned or rich, the life is a mission to be creative , Create. The world is full of distractions, but very few are as important as creating. In my job as a teacher , there is nothing that comes close to being as crucial as creating, think as a teacher every day is a great opportunity to share with the world we live and connected, In my life, creating is one of the few things that has given me meaning. You might feel like there’s a huge mass of time ahead of you, but it passes much faster than you think. It is a better world if I realise I have a lot left to learn. If I’ve learned anything, it’s that I know almost nothing, and that I’m often wrong about what I think I know as a Teacher we truly cannot motivate students by verbal actions or authority however the best you can hope for is to inspire them with your actions,
Life is always new when you accept we have to learn new act new
Dr.T.V.Rao MD

TOXOPLASMOSIS - ERROR PRONE DIAGNOSIS 
Dr.T.V.Rao MD 
It was my young years as a Microbiologist at a corporate hospital at Chennai , heading the department and responsible for supervising 100’s diagnostic serology reports, A real challenge came when Dr Mrs JAYA RAGHAVAN ( name Changed ) running 3 rd month of pregnancy (34 years )a Paediatrician working in USA walks to my chamber with report signed by me as Toxoplasma serology positive for IgG and IgM the test was done by the senior technologist with Abbott Tube ELISA system the kits were imported from Singapore and made in USA . She wishes to know can she go for termination of pregnancy on this report a great puzzle for me, I am frank enough to say, I sign nearly hundreds of reports with a trust in my technicians, and quality of materials available and I can not let down the kits which are really precious, I said kindly get the test in another laboratory accredited with quality control, I have sent her to Dr Ramamurthy's pathology diagnostic center Chennai , and she returned after two day with a negative result for IgM and IgG, She never complained on matter, about the test, I said Madam I will repeat the test myself in the next run I did it, the result is truly negative , I said sorry we disturbed your peace, she accepted the serological tests are deceptive, and error prone and need the good support of clinical Microbiologist I realised very soon we should have a good cooperation and quality controls when we do any serological test and none of the laboratories are 100% accurate in diagnosis. Technical errors are subject to correction needs the attention of supervisory staff for better reporting .
I have followed up with many serological tests in my career , and serology continues to be very difficult division and results need to be repeated whenever we pronounce a positive diagnosis when the decision may be catastrophic , as it is the termination of pregnancy with Toxoplasmosis in pregnancy in the early term, or HIV serology reporting
 I realised that Clinicians order the tests at random on the effluence of the patients, however one should be cautious when you do a screening for Infections which can damage a fetus during pregnancy as many are doing To/R/C/H screening
Testing for Toxoplasmosis is fraught with errors look to the literature
When might a blood test be recommended?
The blood test for toxoplasmosis may be carried out if there's a chance you have the condition and you have symptoms of the infection, or you're at risk of serious complications of toxoplasmosis, people living with Cat as their pet Animal For example, the test may be recommended if you're diagnosed with HIV or are scheduled to have an organ transplant. In the UK, and many developed countries testing for toxoplasmosis isn't routinely carried out during pregnancy because the risk of picking up the infection while you're pregnant is very small and there are some concerns about the reliability of the test in pregnant women. It is true in many developing countries, where we do not get truly precise diagnostic kits, due to lack of sufficient workload few control parameters are used, and many private run laboratories use out dated kits, with false negatives, losing the value of test It's also not clear exactly how effective treatment during pregnancy is in stopping the infection spreading to the baby.A positive result means you've been infected with toxoplasmosis at some point, but doesn't necessarily mean you have an active infection. Catch 22 situation for clinician whether to recommend a termination of pregnancy if it is early trimester,
WHAT SEROLOGY REPORT MEANS IgG antibodies will stay in blood for life, protecting one from being infected again. IgM antibodies appear soon after you have been infected and then disappear, usually over a period of a few months.
If you have IgM antibodies, this indicates you have been infected relatively recently (probably within the past year), although it still doesn't determine for certain whether any symptoms you have are caused by toxoplasmosis.
Diagnosis during pregnancy
If pregnant and blood tests confirm you have a recent toxoplasmosis infection, you may need a further test to determine whether your unborn baby is also infected.
Amniocentesis is the most effective and commonly used test, and can be carried out any time from 15 weeks of pregnancy onwards. The sample will be tested for toxoplasmosis.India at the present have few centers to perform the testing and truly risky if done by a inexperienced professional Amniocentesis carries around a 1% risk of causing a miscarriage. The procedure can confirm whether your baby has the infection, but it can't determine whether the infection has caused any serious damage.
Diagnosis in people with a weak immune system
If one has a weakened immune system, routine blood tests for antibodies can produce a false-negative result. This is because it's possible your immune system won't produce antibodies to fight the infection. So often we get negative serology in AIDS patients with Active infection with Toxoplasmosis. And many are empirically treated with clinical experience
NEVER TO FORGET EVERY SEROLOGICAL TEST TO BE DONE WITH A PURPOSE Casual testing is counterproductive and to be done with wisdom
NO SEROLOGICAL TEST IS A GOLD STANDARD NEEDS WISDOM OF LABORATORY AND CLINICIAN To MAKE MAJOR DECISIONS
 References Toxoplasmosis - Diagnosis NHS Choices
Dr.T.V.Rao MD Freelance reporter on Clinical microbiology

                                                                             WHY I LOVE MY TIME   
                                                                                     Dr.T.V.Rao MD                                                                                                                                                                                                TIME continues to be my master and friend which guides me how to live in the conflict ridden world, Today few are interested to put very little of them to the world which they live,I always practice to be follower of the TIME To establish communication with and be on really good terms with Time we should always be close to him, Never forget the TIME alone is my great friend which guides my life just as with people with whom we want good relationships. With passing of years in life I realize what I am Today was what I have made the best use of TIME I realise that the people who do not know the value of TIME are old to the tomorrows world ,Since as it is well known that Time "flies", we should move together with him.What is special with Time is that he moves straight ahead and never returns. The best idea moved my life when Late Swami Ranganandha former President of Sri Ramakrishna Mutt Calcutta was traveling with a Japanese Citizen in Hyderabad, Japanese person told here everybody has a Watch nobody follows the TIME however in Japan in we have no importance for a personal watch, we produce the watches to improve our country's Economy ( Speech quotes by Swami on Lecture of Philosophy of Work) but we follow the punctuality as per the Clock installed by the organization we work One of my Teacher used to tell you lose anything you will find one day back in your hands but never the TIME While you are moving with Time, there are usually no problems continuing this motion. The problems, stress and crises arise when we let Time pass us by and then are trying to catch up with him. Sometimes it is simply impossible. "There is time for everything" but unfortunately not forever.First, as stated earlier, people have no reliable sense of Time and somebody or something should remind them that they should move with Time before it is too late. It would be easier to remember if our movement in concert with time were always one-directional. Actually, we usually remember about some of the directions. The problem is that we should move with Time in all of the important directions. A strict schedule is not what I need - I need to know priorities. I need to know what to do first when I have a choice. I need to know when a particular activity has been seriously neglected - even dangerously so. Then, I can give that activity special attention. I need a dynamic time manager such as I had never seen before.Best of my friends who made it to the top are TIME sense people who made best of the life just with respecting the Time One tends to drift back into time-wasting on trivia. Time use does improve with practice, but only constant efforts at managing time can prevent drifting." (Peter Drucker) Second, the tools that help us to move with Time effectively were not available, our curriculum teaches very little of TIME management I always put my best efforts to take a lecture to my Students ON TIME MANAGEMENT, as many Teachers practice teaching without much thinking on their future and even the clear understanding that they are needed was absent. Honestly, I do not know of any other tool capable of helping you to keep pace with the multi-task demands your life and the constraints of time place upon you except for Activities and Priorities , which I initially made for my personal use.I am move with Time with a little thinking with following i positive ideas Activities and Priorities does not require much time. A couple of minutes every morning is not much, is it? Why doesn't it require very much time? Well, because, first there are not that many important activities in our lives - usually not more than 3 to 7. Activities are not the numerous everyday problems. Activities are the important parts of our lives - like health, work, and relations with people. Also, you don't have to remember time spent exactly because of the tolerance built into AAP. I, for example, just enter every morning what I remember about the previous day and do not bother or worry about small errors.somebody made, as even I make mistakes, Today I learnt to read few of best of the Autobiographies or any other book and my KINDLE e-reader reminds to keep reading the best of the past of the many who achieved their goals in LIFE, IF YOU WISH TO PROGRESS KEEP READING AND PRACTICE LITTLE OF THE GOOD YOU LEARN DON'T WASTE TIME TIME FLIES IN FRONT OF OUR EYES
Dr.T.V.Rao Professor of Microbiology Freelance writer

BUGS TO SUPER BUGS
Dr.T.V.Rao MD The last true revolution in infection control occurred in 1867 when British surgeon Joseph Lister began using carbolic acid as an antiseptic, significantly reducing mortality rates from infection by 30 percent within a decade. There is now a genuine threat of humanity returning to an era where mortality due to common infections is rife. Common types of drug-resistant bacteria include MRSA (methicillin-resistant Staphylococcus aureus), VRSA (vancomycin-resistant S. aureus), ESBL (extended spectrum beta-lactamase), VRE (vancomycin-resistant Enterococcus) and MRAB (multidrug-resistant A. baumannii). While mostly hospital acquired infections, some are transmitted in the community. In the simplest cases, drug-resistant organisms may have acquired resistance to first-line antibiotics, thereby necessitating the use of second-line agents. Now many are aware that our Antibiotic pipe line has become narrow and little is flowing out, as few firms are interested to develop new Antibiotics as they lose efficacy due to irrational use of Antibiotics. One patient out of every 20 admitted to hospital contracts a nosocomial infection, (an infection the patient did not have when they entered the facility), and with 1.8 million people per year acquiring an infection during their hospital stays (USA). More than 99,000 Americans die annually — that’s 270 deaths every day. The elderly and immunocompromised patients are particularly at risk. If this was the incidence imagine how many are dying in a country like India, it is not death of a person many resistant strains are spread in the Hospital environment keeping very one guessing who will be infected and die with the consequences. While the threats have grown more sophisticated, the methods of controlling and preventing these life-threatening infections have not grown to the emerging challenges.
Current HAI prevention practices include:
• Isolating infected patients.
• Requiring staff to wash their hands after each patient examination.
• Wearing protective gowns, masks, gloves and other equipment.
• Cleaning rooms with harsh chemicals such as hydrogen peroxide.

There is now a genuine threat of humanity returning to an era where mortality due to common infections is rife,"
While microbes typically developed resistance to drugs in hospitals and health care facilities, a concerning trend was the increased number of people acquiring antibiotic-resistant infections in their communities. The Alberta patient who was diagnosed in the summer of 2010 with the infection of an NDM-1 strain super bug from an Indian hospital has attracted much media attention and alarm in the medical community. Only two NDM-1 cases have been reported in Canada and a handful of cases have been reported worldwide, but experts fear that this strain of bacteria can threaten patients in hospitals globally. Many organisms, known as super bugs, were now resistant to multiple drugs. Drug-resistant microbes also entered the country with travelers, and no single country can be blamed for the events as it is a Global concern need health care efforts to reduce the incidence
The most common life threating infection types are respiratory tract infections such as pneumonia and infections of the bloodstream. These are often caused by Klebsiella pneumoniae and E.coli bacteria, both of which have shown an ability to develop resistance to some of the most powerful antibiotics. Among many reported health care-associated infections, surgical site infections and urinary tract infections are also common. Many of the infections are also found to be drug-resistant "super bugs", as per our observation, We have proposed for analyzing the patients who are staying in the hospitals for various reasons for more than 2 weeks, and on Antibiotics, as they are important group of patients who are likely to be put on several antibiotics, and most likely harbor the drug resistant bacteria, which need more evaluations and health care awareness to reduce to spread to other patients, Regardless of MRSA or NDM-1, the overuse or misuse of antibiotics contributes to the formation of these super bugs. When antibiotics are used for things other than bacterial infections, like flu, or not taken as the doctor prescribed (e.g., stopping taking the antibiotics earlier than the intended full course of treatment), they will become less effective for future bacterial infections and possibly acquire resistance genes. As more bacteria become resistant to antibiotics, the risk of complications and death is increased. Doctors will have to resort to less commonly used antibiotics, many of which are more expensive and are associated with severe side effects, without necessarily being able to treat the infection. Anybody with wisdom will perceive control of Infection continues to be priority in not only patients but hospital establishments. Never forget the survival of Hospitals is at risk with emerging drug resistant SUPER BUGS in many Health care establishments. SUPER BUGS ARE TRUE CREATURES AND NOT FICTION THEY TAKE ADVANTAGE OF OUR LAPSES IN HEALTH CARE. Dr.T.V.Rao. MD Professor of Microbiology, Freelance writer

DOCUMENTATION OF ANTIBIOGRAMS WITH WHONET
Dr.T.V.Rao MD Antibiotics are considered as one of the strengths of modern Medicine, and have helped the humans to progress to the present stage, along with several other advances in Medicine. Continuous surveillance of local antimicrobial susceptibility patterns is a must for combating emerging antimicrobial resistance. WHONET is an effective computerized microbiology laboratory data management and analysis program that can provide guidance for empiric therapy of infections, alert clinicians of trends of antimicrobial resistance, guide drug-policy decisions and preventive measures. Drug resistance develops naturally, but careless practices in drug supply and use are hastening it unnecessarily, we certainly need a system to document the results of antibiotic sensitivity and resistance patterns arising in our Institution, which can be documented with WHONET. It is unfortunate few laboratories in India use WHONET and opt for commercial systems of software and none proved better than WHONET.
WHONET is free Windows-based database software developed for the management and analysis of microbiology laboratory data with a special focus on the analysis of antimicrobial susceptibility test results. These tools enable microbiology laboratory to put its test results into a database and conduct analysis to support local infection control and antibiotic usage at our hospital.
The software has been developed since 1989 by the WHO Collaborating Center for Surveillance of Antimicrobial Resistance based at the Brigham and Women's Hospital in Boston, and is used by clinical, public health, veterinary, and food laboratories in over 90 countries to support local and national surveillance programs. Laboratories can also upload files created by WHONET, to feed into national or other multi-center surveillance networks and to strengthen our Drug policy. Such surveillance programs are now in place in many countries and part of accreditation standards in India.
How we can Progress with WHONET?
We can enhance the local data for local needs: clinical decision support, antimicrobial use policy, infection control and outbreak detection, identifying laboratory test performance, and characterization of local microbial and resistance epidemiology and to promote local, national, regional, and global collaborations through the exchange of data and sharing of experiences.
The WHONET experience suggests that pattern of drug resistance data can be collected and analyzed in resource-constrained settings, using core microbiology, if local laboratories are given appropriate support. Strengthening these laboratories is therefore a potentially cost-effective contribution to both treating drug resistant disease and preventing its further spread. Microbiologists, clinicians and infection control workers may use this software to enhance monitoring of drug resistance in their hospitals and communities and to merge their files into national, regional, and global networks for surveillance of drug resistance. WHONET can also analyze stored data. From a single screen, a WHONET user selects the type of analysis to run, the species of bacteria to analyze, the subsets of isolates Every patient in our hospital or its community carries a complex bacterial ecosystem and each patient care unit within the center and ultimately the center itself may be an aggregated ecosystem. Resistance genes and the strains they make resistant move through these systems, selectively accelerated by specific antimicrobial agents given to specific patients and retarded by infection control practices. Both strategic and day-to-day management of those practices and the selection of those agents need optimal, current information about the linkages of the resistance genes and the deployment of the strains. The Microbiology laboratory at the hospitals also needs continuing analysis of its susceptibility test and quality control results. Each laboratory tests hundreds of different combinations of bacterial species and antimicrobial agents. Variations in the usual distributions of measurements for any of the combinations, and particularly of those that impinge upon breakpoints may signal either problems in test performance or new types of resistance.
Thus, WHONET helps our hospitals
Creates profile of the Bacterial Infections at our Hospital.
Helps to know the Antibiograms pattern of the different isolates.
Observe trends in MRSA, and patterns of drug resistance in several GNB strains.
Alert the physicians on uncommon, clinically important bacterial pathogens.
Helps faculty to present data at academic associations and in publishing papers as per editorial guidelines
WHONET is a useful and productive tool which help not only in routine microbiology laboratory data management but also generate valuable information about antimicrobial susceptibility patterns over a place or time to provide the basis for and assess the effectiveness of prevention programs and policy decisions on Antibiotic
Other Uses
In addition to making and updating the antibiogram, you can use WHONET to answer more specific infection control questions. For example, you could analyze a specific organism. Or you can click on “Isolates” when setting up data analysis to set more specific criteria for your results (for example, to look at only one floor or one ward). See the WHONET and Backlink Tutorials for more detailed information.
ALWAYS UPDATE SOFT WARE - One other thing to check is that you are using the most current form of your database. This is particularly important if you have ever renamed the database or saved it in multiple locations. NEVER FORGET WITH A CLICK OF A MOUSE YOU HAVE THE DATA OF ANTIBIOTIC RESISTANCE OF YOUR HOSPITAL ON THE SCREEN, AND ELIMINATES ALL THE TIME CONSUMING CALCULATION AND SAVE THE PAPER
I WISH THIS TOPIC TO BE INCORPORATED IN THE MD (Microbiology Syllabus )
Revised and Edited
Ref! 1 Web Resources on WHONET
2 Concise Antibiogram Toolkit Using WHONET to Create Your Antibiogram Agency for Healthcare AHRQ Research and Quality
Dr.T.V.Rao MD
Photo 3 is Archives from Department of Microbiology TMC Kollam

EMERGING SUPERBUGS IN HEALTH CARE 
A post graduate question for Medical post gradates in a Developing country What are the Current emerging Drug resistant bacterial isolates, What are minimal precautions the Clinical personal should practice
Answered and Formulated by Dr.T.V.Rao MD The concerns on spread of superbugs is a priority for many countries, the US taken the priority in detection and effective use of Antibiotic resistance with optimal methods, The World Health Organization has drawn up a list of the drug-resistant bacteria that pose the biggest threat to human health. Top of the list are gram-negative bugs, such as E. coli, which can cause lethal bloodstream infections and pneumonia in frail hospital patients. Our Diagnostic Microbiology departments should gear to the needs of the patients, still we have no effective Infection control measures and Antibiotic Policy The WHO advised to grade the bacterial as per the growing pattern of resistance as per the following, All the teaching hospitals to be lead players and reference center to serve many catering health clinics
 CRITICAL
Acinetobacter baumannii (carbapenem-resistant) - can cause serious chest and blood infections
Pseudomonas aeruginosa (carbapenem-resistant) - can cause serious chest and blood infections
Enterobacteriaceae, including Klebsiella, E. coli, Serratia, and Proteus (carbapenem-resistant, ESBL-producing strains) - can cause serious chest, blood and urine infections
HIGH PRIORITY
Enterococcus faecium (vancomycin-resistant) - can cause serious wound and blood infections
Staphylococcus aureus (methicillin-resistant, vancomycin-intermediate and resistant) - can cause serious chest, blood, urine and wound infections
Helicobacter pylori (clarithromycin-resistant) - infection linked to stomach ulcers
Campylobacter spp. (fluoroquinolone-resistant) - can cause diarrheal disease and bloodstream infections
Salmonellae (fluoroquinolone-resistant) - can cause diarrheal disease and blood stream infection
Neisseria gonorrhoeae (cephalosporin-resistant, fluoroquinolone-resistant) - a sexually transmitted infection that can cause infertility and, rarely, can spread to the blood and joints
MEDIUM PRIORITY
Streptococcus pneumoniae (penicillin-non-susceptible) - can cause serious chest infections and meningitis as well as blood poisoning
Haemophilus influenza (ampicillin-resistant) - can cause serious chest infections and meningitis as well as blood poisoning and skin and joint infections
Shigella spp. (fluoroquinolone-resistant) - a diarrheal disease that can lead to serious complications, including kidney failure
According to the CDC, “pan-resistant” bacteria are very uncommon, and “infection control contact precautions” are important in such situations, meaning patients will be isolated.
Sources
Standard precaution apriority to stop spread -Standard infection control precautions consist of appropriate hand hygiene and the use of gloves, gown, mask and eye protection or face shield. Clinicians should wash hands for a minimum of 10-15 seconds at the beginning and end of each shift, before and after each patient, before and after wearing gloves, prior to invasive procedures, after potential contact with microorganisms and whenever soiled.
CDC: http://www.cdc.gov/drugresistance/biggest_threats.html
Live Science: http://www.livescience.com/50041-cre-symptoms-treatment.html
Dr.T.V.Rao MD Freelance Microbiology Reporter on Global resources on hygiene and health care

HOW PEOPLE MISUSING POWER ? -
Dr.T.V.Rao MD Today Abuse of power is more than corruption, as it makes the people with poor knowledge become arrogant and bend the system to their advantage, In the past people had self respect and humble with power and today power is a choice to bend the system to their needs , Today many conscious people are not willing to take major responsibilities leaving the matters to medicores, As we see today in educational system People who feel inferior often seek out positions of power to make themselves feel better. Whereas most people derive self esteem from accomplishments, intelligence or likeability, some people lack these characteristics so they need to get in power positions to increase their self-esteem. People who are sadistic need a platform to yield their power over others, I had many encounters at many places, if one is in power they think it is entitlement to relax and creating confusion in the system so they seek out situations that will give them this power. Today we see many terrible creatures occupying administrative chairs Today many of the private educational Institutes are loaded with substandard people only aim is remain stay top and need not follow any rules and create problems with inefficiency and people love to do what they want. It's not the power that corrupts, it's the corrupt seeking the power.However the Medical education system under scanner for many wrong reason from MCI corruption to manipulation in our Medical colleges, and seniors enjoy the boot with regulation of MCI The only way power could be not corrupting of the individuals is to have checks and balances, which is not happenings,
WHAT REALLY SEE TODAY Generally, people who abuse power who are simply parents, teachers, or guards, are people who somehow have come to believe that they cannot do their jobs well, without such abuse. However this continues to be great reason our educational system at low at its best and system can never improve without accountability on the substandard people who ultimately kills the future of many organizations
Today it is great misuse of powers by few destroying the system with self interests, Certainly we need change of educational system producing most substandard generation of Doctors or manpower .
We blame all the Politicians but our teachers Doctors are no better ?

Ref Why do people abuse power when they get it?QUORA
Dr.T.V.Rao MD

ANTIBIOTIC SENSITIVITY REPORTS WITH DISK DIFFUSION METHODS (Believe it or Not) Dr.T.V.Rao MD 
A TOPIC FOR POST GRADUATE DISCUSSION
The greater strengths of Bacteriology lies with optimal isolation of the clinical pathogens and differentiating the Normal flora from infectious pathogens, The goals of testing are to detect possible drug resistance in common pathogens and to assure susceptibility to drugs of choice for particular infections We have several methods to perform and evaluate Antibiotic sensitivity patterns in our isolates as DILUTION METHODS, E-TEST, AUTOMATED ANTIMICROBIAL SUSCEPTIBILITY TESTING SYSTEMS MECHANISM-SPECIFIC TESTS, GENOTYPIC METHODS however we all do the DISK DIFFUSION METHOD as economical, technically not demanding method to evaluate our isolates Because of convenience, efficiency and cost, the disk diffusion method is probably the most widely used method for determining antimicrobial resistance in private and public Institutions .
 A growth medium, usually Mueller-Hinton agar, is first evenly seeded throughout the plate with the isolate of interest that has been diluted at a standard concentration (approximately 1 to 2 x 108 colony forming units per ml). It can be created with Barium sulphate using the basic dilution of the compound to obtain the desire concentration and compared with growth of isolate. Today we all use commercially prepared disks, each of which are pre-impregnated with a standard concentration of a antibiotic, are then evenly dispensed and lightly pressed onto the agar surface. The test antibiotic immediately begins to diffuse outward from the disks, creating a gradient of antibiotic concentration in the agar such that the highest concentration is found close to the disk with decreasing concentrations further away from the disk. After an overnight incubation, the bacterial growth around each disc is observed. If the test isolate is susceptible to a antibiotic, a clear area of “no growth” will be observed around that particular disk.
 The zone around an antibiotic disk that has no growth is referred to as the zone of inhibition since this approximates the minimum antibiotic concentration sufficient to prevent growth of the test isolate. This zone is then measured in mm and compared to a standard interpretation chart used to categorize the isolate as susceptible, or resistant. The word of Intermediate resistance is deceptive to take scientific decisions many do not report the isolate is INTERMEDIATE SENSITIIVTY, However MIC measurement cannot be determined from this qualitative test, which simply classifies the isolate as susceptible, resistant. Presence of zone of inhibition is not automatically interpreted as susceptibility to the antibiotic; the zone width must be measured and compared against a reference standard which contains measurement ranges and their equivalent qualitative categories susceptible or resistant. The advantages of the disk method are the test simplicity that does not require any special equipment, the provision of categorical results easily interpreted by all clinicians, and flexibility in selection of disks for testing. The disadvantages of the disk test are the lack of mechanization or automation of the test. The zones of growth inhibition around each of the antibiotic disks are measured to the nearest millimeter. The diameter of the zone is related to the susceptibility of the isolate and to the diffusion rate of the drug through the agar medium. The zone diameters of each drug are interpreted using the criteria published by the Clinical and Laboratory Standards Institute (CLSI, formerly the National Committee for Clinical Laboratory Standards or NCCLS)
It is important that the tables used for susceptibility test interpretations represent the most current criteria. Indeed, the CLSI documents are reviewed and updated frequently, usually once per year. Use of old or outdated information from the original editions of FDA-approved drug labels or older CLSI tables could represent a serious shortcoming in the reporting of patients' results.
The greater concerns to many Seniors and Technically knowledged Microbiologists- many of our laboratories in particular COMMERCIALLY RUNNING PRIVATE LABORATOREIS do not invest in isolation of true pathogen and randomly process all possible BACTERIAL ISOLATES, above all the ignorant clinicians want Sensitivity to all bacteria to be tested for all Available Antibiotics in store IT IS CERTAINLYY KILLING THE SPIRIT AND SCIENTIFIC ROLE MICROBIOLOGY STANDARDS AND IN FUTURE KILL MANY PATIETNS AND CAUSE OF SPREAD OF ANTIBIOTIC RESISTANCE SPREADING ALL OVER THE CLINICAL LOCATIONS . I WISH THERE SHOULD BE MORE EDUCATION TO MICROBIOLOGISTS AND CLINICANS HOW TO DEAL AND IDENTIFY STANDARDS IN MICROBIOLOGY AND PROCESS TO INITIATE ANTIBIOTIC POLOCY NEVER FORGET MANY ANTIBIOTICS CAN BE SENSITVE IN VITRO (IN THE LABOTORY 0 AND NEVER WORK IN VIVO THAT IS HUMAN BODY.
I WISH THE CLINICIANS SHOULD THINK ONCE BEFORE BELEIVING EVERY REPORT ARISING OF MANY VAGARIES AND SHOULD THINK TWICE BEFORE PRESCRING A ANTIBIOTIC.
I wish many young Microbiologists to learn from following well written articles
 1 Antimicrobial Susceptibility Testing: A Review of General Principles and Contemporary Practices. Barth Reller, Section Editor and Melvin Weinstein, Section Editor – Clinical infectious diseases Clin Infect Dis. (2009) 49 (11): 1749-1755.
Dr.T.V.Rao MD Professor of Microbiology Freelance writer

A TOPIC FOR POST GRADUATE DISCUSSION
The greater strengths of Bacteriology lies with optimal isolation of the clinical pathogens and differentiating the Normal flora from infectious pathogens, The goals of testing are to detect possible drug resistance in common pathogens and to assure susceptibility to drugs of choice for particular infections We have several methods to perform and evaluate Antibiotic sensitivity patterns in our isolates as DILUTION METHODS, E-TEST, AUTOMATED ANTIMICROBIAL SUSCEPTIBILITY TESTING SYSTEMS MECHANISM-SPECIFIC TESTS, GENOTYPIC METHODS however we all do the DISK DIFFUSION METHOD as economical, technically not demanding method to evaluate our isolates Because of convenience, efficiency and cost, the disk diffusion method is probably the most widely used method for determining antimicrobial resistance in private and public Institutions .
 A growth medium, usually Mueller-Hinton agar, is first evenly seeded throughout the plate with the isolate of interest that has been diluted at a standard concentration (approximately 1 to 2 x 108 colony forming units per ml). It can be created with Barium sulphate using the basic dilution of the compound to obtain the desire concentration and compared with growth of isolate. Today we all use commercially prepared disks, each of which are pre-impregnated with a standard concentration of a antibiotic, are then evenly dispensed and lightly pressed onto the agar surface. The test antibiotic immediately begins to diffuse outward from the disks, creating a gradient of antibiotic concentration in the agar such that the highest concentration is found close to the disk with decreasing concentrations further away from the disk. After an overnight incubation, the bacterial growth around each disc is observed. If the test isolate is susceptible to a antibiotic, a clear area of “no growth” will be observed around that particular disk.
 The zone around an antibiotic disk that has no growth is referred to as the zone of inhibition since this approximates the minimum antibiotic concentration sufficient to prevent growth of the test isolate. This zone is then measured in mm and compared to a standard interpretation chart used to categorize the isolate as susceptible, or resistant. The word of Intermediate resistance is deceptive to take scientific decisions many do not report the isolate is INTERMEDIATE SENSITIIVTY, However MIC measurement cannot be determined from this qualitative test, which simply classifies the isolate as susceptible, resistant. Presence of zone of inhibition is not automatically interpreted as susceptibility to the antibiotic; the zone width must be measured and compared against a reference standard which contains measurement ranges and their equivalent qualitative categories susceptible or resistant. The advantages of the disk method are the test simplicity that does not require any special equipment, the provision of categorical results easily interpreted by all clinicians, and flexibility in selection of disks for testing. The disadvantages of the disk test are the lack of mechanization or automation of the test. The zones of growth inhibition around each of the antibiotic disks are measured to the nearest millimeter. The diameter of the zone is related to the susceptibility of the isolate and to the diffusion rate of the drug through the agar medium. The zone diameters of each drug are interpreted using the criteria published by the Clinical and Laboratory Standards Institute (CLSI, formerly the National Committee for Clinical Laboratory Standards or NCCLS)
It is important that the tables used for susceptibility test interpretations represent the most current criteria. Indeed, the CLSI documents are reviewed and updated frequently, usually once per year. Use of old or outdated information from the original editions of FDA-approved drug labels or older CLSI tables could represent a serious shortcoming in the reporting of patients' results.
The greater concerns to many Seniors and Technically knowledged Microbiologists- many of our laboratories in particular COMMERCIALLY RUNNING PRIVATE LABORATOREIS do not invest in isolation of true pathogen and randomly process all possible BACTERIAL ISOLATES, above all the ignorant clinicians want Sensitivity to all bacteria to be tested for all Available Antibiotics in store IT IS CERTAINLYY KILLING THE SPIRIT AND SCIENTIFIC ROLE MICROBIOLOGY STANDARDS AND IN FUTURE KILL MANY PATIETNS AND CAUSE OF SPREAD OF ANTIBIOTIC RESISTANCE SPREADING ALL OVER THE CLINICAL LOCATIONS . I WISH THERE SHOULD BE MORE EDUCATION TO MICROBIOLOGISTS AND CLINICANS HOW TO DEAL AND IDENTIFY STANDARDS IN MICROBIOLOGY AND PROCESS TO INITIATE ANTIBIOTIC POLOCY NEVER FORGET MANY ANTIBIOTICS CAN BE SENSITVE IN VITRO (IN THE LABOTORY 0 AND NEVER WORK IN VIVO THAT IS HUMAN BODY.
I WISH THE CLINICIANS SHOULD THINK ONCE BEFORE BELEIVING EVERY REPORT ARISING OF MANY VAGARIES AND SHOULD THINK TWICE BEFORE PRESCRING A ANTIBIOTIC.
I wish many young Microbiologists to learn from following well written articles
 1 Antimicrobial Susceptibility Testing: A Review of General Principles and Contemporary Practices. Barth Reller, Section Editor and Melvin Weinstein, Section Editor – Clinical infectious diseases Clin Infect Dis. (2009) 49 (11): 1749-1755.
Dr.T.V.Rao MD Professor of Microbiology Freelance writer

LIVING WITH CHALLENGES 
Dr.T.V.Rao MD No day goes without a challenge, but some accept it to improve the lives, others blame the matters on others to stay in the system with or without purpose, However if we do not accept a challenge we are more dead than living, Every day I wake up to think what is my role to the world, can I do well, many told me your struggles are associated with your views to be perfect, it may not happen and also the system will disintegrate if left to Mediocre and gossipers system will soon fall and day is certain we alone reap what we have created, We find most unhappy and incompetent live blaming others, we all know Whenever you point a finger at someone else, there are three fingers pointing back at you. The truth to live better is contribute to the system, Instead of always focusing on what you want from the world, start thinking about what you have to offer. Life is not about taking. Please, do yourself a favor and start giving more. But don’t be surprised if you also receive more, If you practice the religion the Bhagwat Gita says the results out of selfless action are much bigger than what we do with business reciprocation,
 VALUE THE TIME - Time Is More Valuable Than Money But why do we spend time like we have an unlimited supply of it? God was kind to give everyone equal hours to life, Do you ever stop and think about how much time you have left on this earth? Let’s say you get to live to 70 - 80 years. Just do the math. It’s not that long if you keep wasting your time,
ACCEPTING LIFE AS IT COMES - Instead of wishing that things were different, accept the circumstances of your life. No matter how bad they are. Things are what they are. Look at it this way: Regardless of where you are in life, you are there for some reason. God, the universe, invisible forces.
SUCCESS IS MOVING FORWARD Life keeps moving forward — it doesn’t care what I think or do, so I might as well not waste my time on stuff I can’t control. If you look at it from a practical point of view, it doesn’t make sense to question the things that happen in our life — we just must keep moving forward. And above all living with challenges is a great choice
THE TRUTH OF LIFE IS WHAT YOU GIVE ONLY SUSTAINS WITH YOU REST VANISHES WITH TIME
Dr.T.V.Rao MD

n Interesting reply to my article published with title Falling standards in medical microbiology In India Medical Times Monday, August 11, 2014
Comment by Rajwardhan Yadav
2014-10-11 02:16:11
Dear Dr. Rao,
I appreciate you taking the time to write your opinion. Your honesty is humbling. We are facing with a scare of Ebola in the US and the media is going bonkers with the coverage. One death to date in Dallas and the entire town is on the edge. The big wigs at the CDC and Department of Public Health are having sleepless nights. Microbiologists and infectious disease specialist are providing their opinions through most of the media outlets. You have brought up two main issues, first being the age old, stereotyped and non-pragmatic education (microbiology) system that exists in most of the medical schools in India and the second being the if an individual infected with Ebola were to come to one of the metropolitan cities of in India and transmit the virus to various individuals he comes in contact with and the chain reaction that it would set in, is unimaginable. I wonder what can be done about these issues. The regulatory body overlooking medical education in India is in the news only when the Courts give directives and when disproportionate assets are recovered from the official (s)/aficionados. It just appears that there is no accountability. Dr. Rao, people like you with a conscience need to advice how to make subjects like microbiology attractive and lure the bright medical graduates towards the field. Microbes are evolving, novel mutations are resulting in antigenic shifts and drifts. Genomic exchanges are taking place within and across species and serotypes. When evolution is occurring even among viruses and bacteria why is so difficult for our MCI to evolve. Intelligence and brightness is inherent within the students who join our medical schools. We have to provide the optimal learning environment for them to flourish. A start that comes to my mind is to provide good training to the faculty who teach our students. In today’s world of molecular and personalized medicine we need to expose our students to the tools of modern medicine and how they can utilize them to provide better health care to the Indian people. Just to end, I hope the Indian government has a plan in place to screen individuals coming out of West Africa otherwise we are going to have a public health crisis on our hands in the subcontinent. After reading your opinion I just had to applaud you for the candidness in which you expressed your thoughts and also write a few of my thoughts. Good luck.
Raj Yadav MD, PhD
Division of Rheumatology
Yale School of Medicine
New Haven CT
I WISH MANY TEACHERS AND DOCTORS TO READ THE INTERESTING COOMENTS BY RAJ YADAV PhD it just lies with us to make the matters interesting regarding the teaching the infectious diseases to our students I reality what the virus we take either Ebola, Zika we can prevent rather than cure the problem
Dr.T.V.Rao MD Professor of Microbiology Freelance writer

FAKE RESEARCH – CAN WE STOP IT? Today many developing as well developed countries under scanner on the issues related Misconduct in science and Medicine, with huge population of more than 1.3 billion with many qualified people wish to improve their career with no facilities try achieving the goals by fraudulent methods. The consequences of scientific misconduct can be damaging for both perpetrators and any individual who exposes it. In a country like India no body like to expose the fraud going in their own departments, there are many ways to bypass, as many online journals support the fraudulent authors by collecting huge sums to publish and ultimately no body complains and fraud goes on,
WHY THE FRAUD CANNOT BE STOPPED In many scientific fields, results are often difficult to reproduce accurately, being obscured by noise, artifacts, and other extraneous data. That means that even if a scientist does falsify data, they can expect to get away with it – or at least claim innocence if their results conflict with others in the same field.
HOW THE FRAUD GOES ON
Some academics believe that scientific colleagues who suspect scientific misconduct should consider taking informal action themselves, or reporting their concerns. This question is of great importance since much research suggests that it is very difficult for people to act or come forward when they see unacceptable behavior, unless they have help from their organizations, however in India the people who complain the fraud are at disadvantage as we see in many or our Medical colleges many people with fraudulent research and substandard degrees are occupying higher chairs, Today many private universities are collaborating fraudulent research for financial gains, UGC recognition and creating pay and take PhD degrees, Much of the papers from unethical online publishers are no value and many are advocating not believe the outcomes of the research following the matters with purity dangerous to humans and animals too, The potentially severe consequences for individuals who are found to have engaged in misconduct also reflect on the institutions that host or employ them and also on the participants in any peer review process that has allowed the publication of questionable research, I we see today the people indulging in fraud can go to protect the cheating and only those expose will be in trouble as we see around, in addition there are public health implications attached to the promotion of medical or other interventions based on dubious research findings, Ease of fabrication, There are no "scientific police" who are trained to fight scientific crimes; all investigations are made by experts in science but amateurs in dealing with criminals. It is relatively easy to cheat although difficult to know exactly how many scientists fabricate data, publishing fake research for award of degrees.
CERTAINLY WE CANNOT STOP FAKE RESEARCH?
READ A CONFESSION BY NOBEL PRIZE WINNER THAT MUCH OF THE RESEARCH IS FAKED TO SUIT INDUSTRY
MANY ONLINE JOURNALS ARE PERISHING BECAUSE OF FRADULANT PUBLICATIONS
Ref Wikipedia Scientific misconduct
Dr.T.V.Rao MD

HOW TO DEAL WITH A MRSA COLONISED HEALTH CARE WORKERS?

                                                                               Dr.T.V.Rao MD

 A complex question to many health care establishments what are implication of health care workers practicing critical care procedures, with MRSA positive nasal swabs, In a good organization with strict health care practices and effective housekeeping practices we listen to both positive and negative voices on concern with MRSA as we are aware Methicillin-resistant Staphylococcus aureus (MRSA) refers to types of staph that are resistant to a type of antibiotic methicillin however it is no more used in testing and the testing method replaced with Cefoxitin , MRSA is often resistant to other antibiotics, as well. While 33% of the population is colonized with staph (meaning that bacteria are present, but not causing an infection with staph), it is the true problem when we randomly screen all the Health care workers attending a procedure as in Surgical operation theater or a critical care, however approximately 1% is colonized with MRSA in Workers who are in frequent contact with MRSA and staph-infected people and animals are at risk of infection. These included those in hospitals and healthcare facilities, correctional facilities, daycare facilities, livestock settings, and veterinary clinics. The rights of the people to continue to work with MRSA as they subscribe they got infected from the work place ie the Hospitals, Although studies have demonstrated that patients colonized with MRSA are at a higher risk of subsequent MRSA infection due to their own flora, than the colonized, Major studies proving healthcare workers (HCWs) are rarely the source of MRSA transmission to patients. In fact, literature review found that only 1.6% of 191 MRSA outbreaks in a nosocomial setting were associated with asymptomatic HCWs. (Ref 1) I wish to state that I am associated with at least 5 to 6 major studies at several work places, there was never major our break with MRSA in any critical care or surgical patients, even though 0.5 to 1% isolation of MRSA, Today most of the Indian establishments are loaded with Superbugs as ESBL and Carbapenem resistant gram negative bacteria as the trends change with more use of broad spectrum antibiotics to deal with Gram negative bacteria, In comparison with the issues related with MRSA are lesser threat than many gram negative bacteria, and certainly one fells with much pressure on Gram negative both as commensals and pathogen trends are changing and many are less concerned with MRSA when we have options to decide which needs a priority, However today many peer reviewed surveys think Routine screening of asymptomatic HCWs for MRSA colonization is thus not warranted. Of note, when HCWs are implicated in MRSA transmission, this is more likely due to poor hand hygiene resulting in patient-to-patient transmission, Although MRSA is still a major patient threat, a CDC study published in the Journal of the American Medical Association Internal Medicine showed that invasive life-threatening) MRSA infections in healthcare settings are declining. Invasive MRSA infections that began in hospitals declined 54% between 2005 and 2011, with 30,800 fewer severe MRSA infections. In addition, the study showed 9,000 fewer deaths in hospital patients in 2011 versus 2005. ( Ref 2 )Routine decolonization of HCWs who are asymptomatic MRSA carriers is not recommended. However, if a HCW is identified as the source of a MRSA outbreak, as happens when multiple cases infected by the surgeon or a regular care taking nurse then decolonization is considered in combination with a full infection control management plan. In this situation, the HCW should avoid direct patient care activities until culture results are negative. In situations where decolonization is necessary, the optimal pharmacologic regimen has not been firmly established. Options include topical decolonization of the nares alone; topical nasal and whole body decolonization; and topical decolonization plus oral antimicrobial agents. Mupirocin remains the only medication approved by the US Food and Drug Administration for nasal decolonization. However, other topical products such as bacitracin are under investigation for mupirocin-resistant MRSA strains. Mupirocin is commonly used with antiseptic body washes such as chlorhexidine, with or without oral agents such as rifampin, tetracyclines, or trimethoprim-sulfamethoxazole. Two recent reviews provide a detailed discussion of the evidence for each therapy and are useful resources. Importantly, investigations to date have not addressed key areas such as the long-term effect of decolonization on infection recurrence, rates of re-colonization after a pharmacologic intervention, or the effect of decolonization on drug resistance

In summary, given that asymptomatic MRSA-colonized HCWs rarely transmit MRSA to patients, US guidelines do not recommend routine screening of or decolonization for asymptomatic HCWs. Similarly, guidelines do not recommend restricting work activities unless colonized HCWs are found to be the source of MRSA transmission and causing work place infections with MRSA Although pharmacologic decolonization is an important tool in clinical management of MRSA colonization in certain situations, it cannot replace the importance of consistent hand hygiene.

This article is created for the benefit of post graduates on basic understanding, need to track the matters in their own work place with coordination of the Clinicians and outcomes of the MRSA isolations in Laboratories with quality controls

YET THERE IS NO BETTER WAY THAN HAND WASHING

Ref 1 and adopted from -Should Healthcare Workers Colonized with MRSA Avoid Patients? Kimberly K. Scarsi, PharmD, MS Medscape

Ref 2 MRSA Tracking CDC Atlanta USA guidelines on new trends

Dr.T.V.Rao MD Freelance Clinical Microbiologist and Reporter on Infectious diseases

SUPERBUGS – WHO PAYS THE PRICE GROWING CONCERNS WITH MISUSE OF ANTIBIOTICS 

Dr.T.V.Rao. MD India consumes more antibiotics than any other country. Coupled with poor sanitation and overcrowding, the nation is the perfect breeding ground for antibiotic-resistant bacteria. bacteria that produce carbapenemases are popularly referred to as superbugs because they are difficult to treat and result in the infection spreading easily within the body, especially in people who are ill or recuperating from an illness or a surgery. In India's neonatal hospital wards intensive care units, and critically cared patients, they struggle for life - sick infants battling untreatable "superbugs Tens of thousands of them lose their lives every year. EVERYONE HAS A ROLE This is the frontline in the fight against antibiotic-resistant bacteria, one of the most serious threats to global health of our time, as per the World Health Organization. Today we find many messages literature and press reporting on the matters of increase of SUPERBUGS however many wishes to know are they super in actions or more harmful the truth is Bugs are designated as Superbugs, on scientific basis then Super at what? It just means they have deviated from the path from fellow bugs and under pressure of Unnecessary and irregular use of Antibiotics and increasing to cause more hospital concerns Virulent, drug resistant, hospital associated infections which makes the public concerned about them when they get admitted to the hospitals , rich countries too faces the problem with MRSA methicillin resistant Staphylococcus aureus GRE Glycopeptide resistant Enterococcus (mostly vancomycin, More Virulent bacteria entering the hospitals Clostridium difficile cases rising, Virulent, drug resistant, community associated infections as in poor countries with Resistant Streptococcus pneumonia MDR tuberculosis rising? Isoniazid resistance TOO in London
WHO COMES TO RESCUE -The WHO list of drug-resistant bacteria is divided into three categories. The most critical group includes multidrug-resistant bacteria that pose a threat in hospitals, nursing homes and among patients whose care requires devices such as ventilators and blood catheters. These include Acinetobacter, Pseudomonas and various Enterobacteriaceae (including Klebsiella, E coli, Serratia and Proteus). They can cause severe and often deadly infections such as bloodstream infections and pneumonia. These bacteria have become resistant to many antibiotics, including carbapenems and third-generation cephalosporins - the best available antibiotics for treating multidrug-resistant bacteria.
ARE OUR HOSPITALS SOURCE OF NDM-1 NDM-1 (New Delhi Metallo-beta-lactamase-1) is an enzyme that makes bacteria resistant to a wide range of powerful antibiotics, including the carbapenem class of antibiotics that are used to treat multidrug-resistant infections. The gene for NDM-1 encodes beta-lactamase enzymes called carbapenemase, which makes bacteria resistant to antibiotics, including carbapenems LIFE AND DEATH ARE EXPENSIVE, as Per a global review on antimicrobial resistance (AMR), drug-resistant infections are "one of the biggest health threats that mankind currently faces" and there are fears of pandemics becoming more of a norm as antibiotics lose their efficacy. Even today, 700,000 people die of resistant infections every year, Drug-resistant infections - or "superbugs" – could claim 10 million lives a year and could cost a cumulative $100 trillion of economic output by 2050 if the world does not act to slow down the rise of drug resistance,
IF YOU WEREN’T taking antibiotic resistance seriously before, now would be a good time to start. A country like India many are below the poverty line and pay for their life and many die spending their wealth on using the Antibiotics which however fail to work in spite of best efforts,
However, it is time our Microbiology departments to gear up to the WHO described SUPERBUGS and should have a audit what really happening in our own hospitals, I wish NABL and NABH should give weightage to the Hospitals in minting updated methods in reporting, caring, preventing the spread SUPERBUGS
WE ARE ALREADY PAYING THE PRICE FOR MISSUE OF ANTIBIOITCS
TIME TO CONTROL WITH BETTER UNDERSTANDING
STILL THE HAND WASHING IS THE BEST VACCINE TO PREVETN THE SPREAD THE SUPERBUGS
Ref WHO concerns on Antibiotic resistance
Dr.T.V.Rao MD Freelance Clinical Microbiologist, Reporter on As Infection matters to developing countries

GROWING UNREST IN MEDICAL EDUCATION INDIA If we observe keenly there is growing challenges unrest and revolt in Medical education system which is never controlled like our own Nations health, Many Medical nursing and dental colleges established in private sector without minimal infrastructure and many flourished and in the process we have started producing substandard professionals, It needs a courage to fail the students if they are not doing well, sometimes it is right to pass the examination in many private medical colleges, same culture is creeping in public institutes in the name of caste Creed and religion I am very courageous to say totally the practical examinations have become big joke practically everybody passes by default. The grave concern to the Nation remain with GHOST TEACHERS it is not just the teachers who are absent from the campus but the senior teachers who take huge salaries have no accountability they will threaten the management if they are asked to do anything relevant, the concentrate on private practice and private Laboratories, or just a resting time for many non-clinical Teachers because the college may lose recognition from Medical Council of India. When I was Post graduate Student in Andhra Medical College, Visakhapatnam the Senior most teachers will take the most difficult topics, and few easier topics are taken by juniors, I am observing many teachers in many famous Institutes do not take classes, just come to enjoy the seniority of living in the chair in the name f encouraging the post graduate students, in this process many postgraduate students will act like professors from 2nd year onwards and unlimited politics will arise as inexperienced people are encouraged in the system. It has become the responsibility of the MSc in many non-clinical subjects people to teach and do anything beyond there capacities as the seniors live in comfort zones, I do not know how much justice will be done to the medical education. The raise of retirement age benefited many seniors to serve up to 70 and has created unrest in many private colleges as the opportunities are shrinking great area of conflicts between seniors and people aspiring to become Professors. The rule to allow the publications to give early promotions has created hoax research today INTERNET loaded with many fake publication from India, however it makes the India as center of plagiarism many popular sites expressed to ignore the research papers on on line journals. There is growing revolt from students they do not wish to be detained when they fail to fulfil the rules to appear for examination it is certainly indicates complex factors in these issues, as they are more related to the absent teachers, inefficient teachers and some teachers exploiting the position they occupy, and encouraging and prompting unworthy students to cover-up their absence from the college and efficiency. Today Medical Council of India wish to tag the Teacher whether in the campus or not however it may bring the Physical accountability and not moral accountability, Radio trackers on campuses A circular issued to all medical colleges says that the MCI will install radio trackers on all these campuses and upload the correct employee list after two levels of verification by a project coordinator whom the college concerned will appoint. In case fraudulent information is submitted, the college will be accountable. How method will work The Medical Council of India will install biometric radio trackers on campuses after preparing a correct employee list based on verification by a college-appointed coordinator. For false information, the college will be accountable. The devices will be networked on line for daily monitoring. For fingerprint authentication, the teachers’ database will be Aadhaar-linked.It makes us like criminals in this process the Students will gain upper hand and black mail even the good teachers, I have worked in a deemed university our Vice-chancellor used to tell you should monitor and council non performing students however it time the college principals if they are competent and regular? Should council many senior and non performing teacher as everybody is equal in the Democracy when they do not follow the rules. Our Education system is reaching to stage of point of no return. I wish Medical council of India will bring in more accountability on ethics and regulation or else the examination we conduct and degrees will be a fatal joke on the innocent people. Above all the student can expose the teachers and system with more determination as The Supreme Court on Tuesday declared Section 66A of Information Technology Act as unconstitutional and struck it down. IT WILL CERTAINLY HAVE GREAT INFLUENCE ON OUR EDUCATIONAL SYSTEM MANY FACTS WILL BE EXPOSED WITHOUT FEAR OR FAVOR A TIME TO WATCH EVENTS ? HOWEVER WE CANNOT HIDE THE TRUTH FOR LONG ON HAPPENINGS IN MEDICAL EDUCATION
Dr.T.V.Rao MD Professor of Microbiology Freelance writer

LABORATORY MADE SUPERBUGS – Today India is flooded with thousands of private laboratories may be substandard Laboratory professionals in every place, they are run by unscrupulous ill knowledged people without any recognized qualification, it has become racket to steal many innocent people, Sometimes Doctors get up to 50% commission and many times tests are not done, only the gaps are filled in reports, with the understanding of the doctors. However today many young generation of Doctors rarely do any clinical examination and write diagnostic tests and at the end believe the reports, I wish the young generation of Doctors should use the rationalism in using the tests in culturing bacteriology specimens , ultimately the Doctors loses the reputation, It is most dangerous as many reports created in some private bacteriology laboratories, when they start processing the E.coli from Vaginal, stool cultures from adults and report the Antibiotic sensitivity testing patterns I think this is how the Super bugs created in our society when the laboratory technicians do not know what is pathogenic what is NORMAL FLORA and the Clinicians chose to treat patients with new generation of Cephalosporins and creating SUPERBUGS.
Dr.T.V.Rao MD Professor of Microbiology

WHAT MICROBIOLOGISTS AND CLINICIANS SHOULD KNOW ABOUT CULTURING WOUND SWABS 
Dr.T.V.Rao MD I am certain that we receive 10% of the swabs or discharges for culturing of wounds, the great limitation is who collected, and how it is collected, because it certainly hampers the results, it is most of the times entrusted to junior nursing staff or nursing students without much inputs on what a hound is what is the anatomy of wound, however these matters to be addressed by the Infection control committee,
Clinicians (including nurses, doctors and professionals allied to medicine) have responsibility for the collection and safe transportation of samples to the laboratory. The validity of test results largely depends on good practice in the “pre-test” stage and it is essential that documentation is accurate and comprehensive (Higgins 1994).
ONE MUST FOLLOW THE INSTRUCTIONS AS
Use universal precautions for collecting and handling all specimens.
Obtain the specimen prior to any dressing or cleaning procedure of the wound. This will maximize the material obtained and prevent killing of the organism by the use of antiseptics.
Use a sterile swab and gently rotate on the area to collect exudate from the wound and place into transport medium. Where there is, pus collect as much as possible in a sterile syringe or sterile container (do not use a swab) and send to the laboratory.
For detection of Mycobacterium tuberculosis, pus collected neat in to a pot or tissue biopsy is preferred, however a calcium alginate swab can be used. The alginate swab gradually dissolves maximizing the isolation of the organism as the number of organisms are usually small.
 Whenever possible, collect all culture specimens prior to administration of any antimicrobial agents.
When collecting pus, specimens or impressions of wounds obtain as much material as possible as this increases the chance of isolating micro-organisms which may be difficult to grow or are minimal in number e.g. tuberculosis. Pus should be sent in a sterile specimen container, not on a swab
MICROBIOLOGISTS SHOULD NEVER RECEIVE THE SPECIMEN FOR ACID FAST BACILLI ON SWABS .
Specimens should be in tightly sealed, leak proof containers and transported in sealable, leak-proof plastic bags. Specimens for TB should be double bagged. Specimens should not be externally contaminated. Specimens grossly contaminated or compromised may be rejected.
Avoid contamination with indigenous flora. IT IS IMPORTANT IN WOUND SWABS as the surrounding of the wounds are necrotic, we get the bacteria like pseudomonas may be just colonizers and may not be true pathogens, and today many laboratories without quality controls report as drug resistant pseudomonas, Proteus, Serratia Atypical Mycobacteria and many others And it is important make some standard operating procedures, A positive wound culture does not confirm a wound infection. Opportunistic microorganisms may colonize any wound. Wound exudate, which is naturally bactericidal, inhibits the spread of surface contamination from becoming a deep wound infection. However, when wound ischemia or systemic immune compromise supervenes, pathogenic microorganisms propagate until an excessive concentration of bacteria in the wound precludes healing. This heralds a true wound infection. Multidrug resistant organisms are becoming increasingly common.
ALL ILL UNDERSTOOD COLONES TO BE STAINED AND MICROSCOPIC OBSERVATIONS TO BE MADE BEFORE PROCESSING AS PATHOGENS
WHAT CLINICIANS TO UNDERSTAND FROM MICROBIOLOGY REPORTS
 Microbiological tests are not as standardized as some other lab tests; the way in which a sample is processed and the results are interpreted depend heavily on the information provided with the specimen.
Please read more at
Ref Specimen collection - microbiology and virology The great Ormond street NHS Hospital for children NHS foundation trust
Dr.T.V.Rao MD Freelance Clinical Microbiologist

WHAT MAKES A TEACHER 
Dr.T.V.Rao MD If one goes to earlier editions of Harrison's the renowned text of Medicine says DOCTOR IS ONE WHO TEACHES it just MEANS anybody can be a Doctor if he teaches with a passion to teach and change the ways the people in matters which are concerned, Unfortunately many things went wrong with our education with all the potentials to change the education still our returns are poor on the money we have invested on education, John Hattie, the ‘go to guru’ of evidence-based education, believes 1 that the best teachers are passionate people. They love what they teach, they love being a teacher, and they love the challenge of helping each of their students learn. Their passion is contagious, and they infect their students with a love of learning., The true understanding about other humans I learnt when I was doing my post graduation at Spastic Society of India in Bombay in Cerebral palsy (1986) if we understand the students everyone has some potentials to learn and in spite of many limitation and true role of a teachers lies in understanding the less abled ones as we all know a very intellect student do not need our much efforts but less privileged people do need more of us, The first lesson in our lives to be passionate to life and many others it is great opportunity we live as Teachers and God made few people as teachers Passion is what drives us to put so much energy into our teaching. Many times, I am disturbed when they indifferent to learning, carry on your mission as a teacher It stops us from giving up when things get hard, and it motivates us to learn ways to improve our craft – no matter how good we already are. You cannot be a great teacher without a passion for helping children and students learn., I find much of the Medical students have a great passion to carry on the mission when he treat them with passion and love, Be a passionate teachers irrespective of your status be a link in a reaction to make the profession interesting and helpful to many, Never forget no body truly cares what you are in a system unless you are passionate to their needs.
 THE great message BE SIMPLE HUMBLE AND PASSIONATE WHAT YOU DO
Dr.T.V.Rao MD