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Extended spectrum beta lactamases (ESBLs) are rapidly evolving plasmid mediated; TEM and SHV derived enzymes, capable of hydrolyzing oxyimino- cephalosporins and monobactams. Bacteria producing ESBLs remain an important cause for failure of therapy with cephalosporins and other antibiotics. ESBL testing is useful for epidemiological or infection control purposes.Aims: The present study was conducted to detect ESBLs in strains of Escherichia coli isolated from various clinical samples in a tertiary care hospital. Material and Methods: A total of 272 non enteric randomly chosen non repetitive E.coli isolates obtained over the period of one year from both outpatient and hospitalized patients were studied. Out of 272 isolates, 191 (70.22%) were screened as ESBL producing. They were further studied for ESBL production by phenotypic confirmatory disc diffusion test (PCDDT). Results: It was observed that not all screen positive isolates were confirmed as ESBL producers. Of the total 191 ESBL positive isolates, the PCDDT method detected 168 (87.95%) cases. Overall prevalence of ESBL in E.coli was found to be 61.76%. Only 4 strains (1.47%) were found resistant to imipenem and 11 strains (4.04%) were found resistant to meropenem. Conclusions: The present study shows that any of the three screening agents can be used to detect potential ESBL producers. The routine antibiotic sensitivity test may fail to detect ESBL mediated resistance. Therefore, screening for detection of ESBL and confirmation of the same should be carried out by PCDDT method as it is simple, reproducible, cost effective and sensitive method. ESBL detection studies help to formulate an empirical antibiotic policy to treat Gram negative infections in respective hospitals.

[1] Bradford PA. Extended spectrum beta lactamases in 21st century; Characterization, Epidemiology, and Detection of this important resistance threat. Clin Microbiol Rev, 14:933-951, 2001 [2] Shukla I, Tiwari R, Agrawal M. Prevalence of Extended spectrum beta lactamase producing Klebsiella pneumoniae in a tertiary care hospital. Indian J Med Microbiol, 22:87-91, 2004 [3] Kumar MS, Lakshmi V, Rajagopalan R. Occurrence of Extended spectrum beta lactamases among Enterobacteriaceae spp. isolated at a tertiary care institute. Indian J Med Microbiol, 24(3); 208-211, 2006 [4] Kader AA, Kumar A, Krishna A et al An Accelerated Method f or detection of Extended Spectrum -Beta Lactamases in Urinary Isolates of Escherichia coli and Klebsiella pneumoniae Saudi J Kidney Dis Transplant, 17 (4) :535-539, 2006 [5] Mackie TJ, McCartney JE. Practical medical microbiology. 14th Ed. New York: Churchill Livingstone, 363, 1996. [6] Bauer AN, Kirby WMM, Sherries JG. Antibiotic Sensitivity testing by standardized single disc method, Am J Clin Pathol, 45:493-96,1966. [7] CLSI. Performance Standards for Antimicrobial Susceptibility Testing; Twentieth Informational Supplement. CLSI document M100-S20. Wayne, PA: Clinical and Laboratory Standards Institute; 2010. [8] Jain A, Roy I, Gupta MK, Kumar M, Agarwal SK. Prevalence of extended-spectrum beta-lactamase- producing Gram-negative bacteria in septicaemic neonates in a tertiary care hospital. J Med Microbiol, 52:421-5, 2003. [9] Babypadmini S, Appalaraju B. Extended spectrum β- lactamases in urinary isolates of Escherichia coli and Klebsiella pneumoniae – prevalence and susceptibility pattern in a tertiary care hospital. Indian J Med Microbiol, 22:172-4, 2004. [10] Singhal S, Mathur T, Khan S et al. Evaluation of Methods for AmpC Beta Lactamases in Gram Negative Clinical Isolates from Tertiary Care Hospitals. Indian J Med Microbiol, 23 (2): 120-124, 2005. [11] Sridhar Rao PN, Basavarajappa KG, Leela Krishna G. Detection of extended spectrum beta lactamases from clinical isolates in Davangere. Indian J Pathol Microbiol, 51(4):497-499, 2008. [12] Sinha P, Sharma R, Rishi S et al. Prevalence of Extended spectrum beta lactamase and AmpC beta lactamase producers among Escherichia coli isolates in a tertiary care hospital in Jaipur. Indian J Pathol Microbiol, 51 (3):367-369, 2008. [13] Aggarwal R, Chaudhary U, Sikka R. Detection of Extended Spectrum β-lactamase Production among Uropathogens. J Lab Physicians, Vol 1, issue 1:7-9, 2009. [14] Manoharan A, Premalatha K, Chatterjee S et al. Correlation of TEM, SHV and CTX-M extended spectrum beta lactamases among Enterobacteriaceae with their in vitro antimicrobial susceptibility. Indian J Med Microbiol, 29 (2):161-4, 2011. [15] Metri BC, Jyothi P, Peerapur BV. The Prevalence of ESBL among Enterobacteriaceae in a Tertiary Care Hospital of North Karnataka, India. J Clin Diag Res, Vol 5(3):470-475, 2011. [16] Giriyapur RS, Nandihal NW, Krishna BVS et al. Comparison of Disc Diffusion Methods for the Detection of Extended spectrum beta lactamase producing Enterobacteriaceae. J Lab Physicians, Vol 3; Issue 1:33- 36, 2011. [17] Umadevi S, Kandhakumari G, Joseph NM et al. Prevalence and antimicrobial susceptibility pattern of ESBL producing Gram negative bacilli. J Clin Diag Res, Vol 5(2):236-239, 2011. [18] Vandana KE, Honnavar P. AmpC Beta lactamases among ESBL producing Escherichia coli and Klebsiella pneumoniae- if you don’t look, you don’t find. J Clin Diag Res, (3): 1653-1656, 2009. [19] Shobha KL, Ramchandra L, Rao G et al. Extended spectrum beta lactamases (ESBL) in Gram negative bacilli at a tertiary care hospital. J Clin Diag Res, (3): 1307-1312, 2009. [20] Agrawal P, Ghosh AN, Kumar S et al. Prevalence of extended spectrum β lactamases among Escherichia coli and Klebsiella pneumoniae isolates in a tertiary care hospital. Ind J Pathol Microbiol, 51 (1): 139-142, 2008. [21] Shiju MP, Yashavanth R, Narendra N. Detection of Extended spectrum beta lactamase production and multidrug resistance in clinical isolates of E.coli and K.pneumoniae in Mangalore. J Clin Diag Res, (4): 2442- 2445, 2010. [22] Gupta E, Mohanty S, Sood S et al. Emerging resistance to carbapenems in a tertiary care hospital in north India. Indian J Med Res, 124:95-98,2006. [23] Livermore DM, Patterson DL. Pocket guide to extended spectrum β lactamases in resistance. New Delhi: Springer (India) Private Limited; 2006. [24] Arakawa Y, Kurokawa H, Yagi T et al. Worldwide proliferation of carbapenem-resistant gram negative bacteria. The Lancet. Vol. 354:955, 1999. [25] Rawat D, Nair D. Extended spectrum β lactamases in gram negative bacteria. J Glob Infect Dis, 2(3):263-74, 2010.

Background: Urinary tract infections (UTIs) are caused by variety of microorganisms. The frequency of different bacterial isolates and their susceptibility to antibiotics may differ widely, particularly in hospitalized patients. The study of susceptibility pattern becomes obligatory for a proper selection of antibiotics. Aim: To evaluate antimicrobial susceptibility pattern of the Gram negative organisms isolated from urine cultures in hospitalized patients. Material and Methods: The present study was conducted in Yashwantrao Chavan Rural Hospital, Latur over a period of one year from June 2010 to May 2011. A total of 500 urine samples from hospitalized patients which showed significant bacteriuria were studied. Samples were inoculated on Blood agar and MacConckey agar. Further identification of organisms was done by standard Microbiological methods. Antimicrobial Susceptibility pattern was studied by Modified Kirby- Bauer’s disc diffusion method with the panel of 15 drugs as per Clinical Laboratories Standard Institute (CLSI) guidelines. Results: UTIs were found more common in females 296 (59.2%). Commonest organism found was Escherichia coli 252 (50.2%) followed by Klebsiella spp. 123 (24.6%), Pseudomonas spp. 49 (9.8%), Proteus spp. 42 (8.4%), Citrobacter spp. 27(5.4%) and Acinetobacter spp. 8 (1.6%). Majority of the strains were found sensitive to nitrofurantoin 404 (80.8%) followed by amikacin 357 (71.4%), piperacillin-tazobactam 325 (65.2%) and co- trimoxazole 254 (50.8%). Commonly prescribed fluroquinolones were found least effective for treatment of UTI. All the strains were found sensitive to imipenem. Extended spectrum beta lactamase (ESBL) was noted in 169 (67.33%) E.coli and 87 (70.73%) in Klebsiella spp. Conclusions: To discourage the indiscriminate use of antibiotics and to prevent further development of bacterial drug resistance, proper knowledge of susceptibility pattern of uropathogens in particular area is very important before prescribing empirical antibiotic therapy.

[1] Ronald AR, Pattulo MS. The natural history of urinary infection in adults. Med Clin North Ann. 75:299-312, 1991. [2] Gold HS, Moellering RC. Antimicrobial drug resistance. N Eng J Med. 335:1445-53, 1996. [3] Kader AA, Kumar A, Dass SM. Antimicrobial resistance pattern of Gram-negative Bacteria isolated from Urine cultures at a general hospital. Saudi J Kidny Dis Transpl. 15:135-9, 2004. [4] Kass EH, Asymptomatic infection of urinary tract.Trans Assc.Am.physicians. 69:56-64, 1956. [5] Collee JG, Miles RS, Watt B. Tests for the identification of Bacteria. In : Mackie and Mc Cartney Practical Medical Microbiology. 14th edn. Collee JG, Fraser AG, Marmiom BP, Simmons A, editors. London: Churchill Livingstone. 131-50, 1996. [6] CLSI. Performance standards for Antimicrobial susceptibility Testing ; Twenth Informational Supplement. CLSI document M100- 520.Wayne,PA:Clinical and Laboratory Standards Institute;2010. [7] Tankhiwale SS, Jalgawkar SV, Ahamad S,Hassani U. Evaluation of extended spectrum beta lactamase in urinary isolates. Indian J. Med. Res. 120(6):55-6, 2004. [8] Bran JL, Levison ME, Kaye D. Entrance of bacteria in female urinary bladder. N. Engl J. Med. 286(12):626-31, 1972. [9] Gupta K, Scholes D, Stamm WE.Increasing prevalence of antimicrobial resistance among uropathogens causing acute uncomplicated cystitis in women. JAMA 281(8):736-8, 1999. [10] Eshwarappa M, Dosegowda R, Vrithmani I et al. Clinico-microbiological profile of urinary tract infection in South India. Indian J Nephrol. Vol 21(1):30-36, 2011. [11] Akram M, Shahid M, Khan AU. Etiology and antibiotic resistant patterns of community acquired urinary tract infections in JNMC Hospital Aligarh, India. Ann Clin Microbiol Antimicrob. 6:4, 2007. [12] Goetz A, Yu VL. The intensiv care unit: the hottest zone. Curr Opin Infec Dis. 10:319-23, 1997. [13] Das RN, Chandrashekhar TS, Joshi HS et al. Frequency and susceptibility profile of pathogens causing urinary tract infections at tertiary care hospital in western Nepal . Singapore Med J. 47:281-5, 2006. [14] Jones RN, Kugler KC, Pfaller MA, Winokur PL.Characteristics of pathogens causing urinary tract infections in hospitals in north America results from the SENTRY Antimicrobial Surveillance Programme,1997;Diagn Microbiol Infect Dis. 35:55-63, 1999. [15] Kahlmeter G:ECOSENS. An international survey of the antimicrobial susceptibility of pathogens from uncomplicated urinary tract infections; the ECOSENS Project. J. Antimicrob Chemother. 51:69-76, 2003. [16] Allison EE , Melinda MN, David TB, John PQ, Susan LP, Extended-spectrum beta- lactamases:frequency, risk factors, and outcomes. Pharmacotherapy. 22(1):14-20, 2002. [17] American society for microbiology; Report of the ASM Task Force on Antibiotic Resistance.Washington,DC,1994. [18] Al Sweith N, Jamal W, Rotimi VO. Spectrum and antibiotic resistance of uropathogens isolated from hospital and community patients with urinary tract infections in two large hospitals in Kuwait . Med Prince Pract. 14:401-7, 2005.

Musculocutaneous nerve is one of the terminal branches of lateral cord of brachial plexus. This nerve is responsible for innervation of flexor compartment of arm and for cutaneous innervation on lateral surface of forearm. Its absence has been described previously but its real prevalence is unknown. A case of absence of Musculocutaneous nerve along with presence of accessory head of biceps brachii was observed during routine undergraduate dissection of right arm of a male cadaver. In this case the muscles which are usually innervated by musculocutaneous nerve were innervated by median nerve. Medical concerns related with these variations include, anaesthetic blocks, surgical approaches, interpreting tumour or traumatic nerve compressions having unexplained clinical symptoms. There is also possibility of injury to the muscular branches of median nerve in arm by surgeon as usually this nerve does not give branches in arm. Hence this case report was studied and reported.

[1] Buch-Han-sen (1955)1 Buch-Hansen K. Uber varietaten des nervus medianusund des nervus musculocutaneous und deren beziehungen.Anat Anz 102:187–203, 1955. [2] Susan Standring. Gray’s anatomy. In: Neil RB, Jeremiah CH, Patricia C, David J, Alan RC, Vishy M, Michael AG, Richard LMN, Caroline BW, The anatomical basis of clinical practice. 40th Ed., London, Churchill Livingstone Elsevier. 828-829, 2008. [3] W. Henry Holinshed. Anatomy for surgeons: vol.3 (The Back And Limbs). 3rd Ed., Philadelphia, Harper & Row. 366, 1982. [4] Prasada Rao PV, Chaudhary SC. Communication of the musculocutaneous nerve with the median nerve. East Afr. Med. J. 77: 498–503, 2000. [5] Beheiry. Anatomical variations of the median nerve distribution and communication in the arm. Folia Morphol. 63, 3: 313-318, 2004. [6] Arora and Dhingra R. Absence of musculocutaneous nerve and accessory head of biceps brachii: a case report. Indian Journal of Plastic Surgery. 38, 2: 144-146, 2005. [7] Satheesha Nayak. Absence of musculocutaneous nerve associated with clinically important variations in the formation, course and distribution of the median nerve – a case report. Neuroanatomy. 6: 49-50, 2007. [8] Rajendrakumar virupakshi. Absence of musculocutaneous nerve in the left axilla. International Journal of Anatomical Variations. 2: 140–142, 2009. [9] W. Henry Holinshed. Anatomy for surgeons: vol.3 (The Back And Limbs). 3rd Ed., Philadelphia, Harper & Row. 354, 1982.