Background Vaccine-induced thrombotic thrombocytopenia (VITT) is a rare but devastating adverse event following adenoviral vector-based vaccinations for COVID-19, resulting in thrombosis, especially of the cerebral and splanchnic vasculature. Despite the progress in laboratory techniques for early diagnosis, VITT remains a clinical diagnosis supplemented by coagulation studies. We report on VITT for the first time from India. Case We describe cortical venous sinus thrombosis and intracerebral bleed associated with severe thrombocytopenia in two young men who had no other contributory cause besides a recent ChAdOx1 nCoV-19 vaccination. The diagnosis was supported with PF-4 antibodies in one patient. The second patient’s test could not be processed to technical limitations. Both patients were treated with IVIG at 1 g/kg for 2 days and anticoagulation (Apixaban). One patient fully recovered with no residual deficits, and the other is under treatment and recovering. Conclusion VITT can cause devastating fatality and morbidity in otherwise healthy patients via potential immune-mediated effects. Clinicians should have a high suspicion index and treat VITT in the appropriate setting even if the PF-4 antibody testing by ELISA is unavailable or delayed. Though counterintuitive, clinicians must not delay the administration of non-heparin anticoagulation, IVIG and restrict platelet transfusion even in the presence of intracerebral haemorrhage.

Purpose Urinary tract infections (UTI) are common infections in otherwise healthy young women and there is considerable heterogeneity in antibiotic prescribing practices contributing to increased health expenditure, hospitalization, and collateral damage with the unprecedented use of fluoroquinolones and beta-lactams leading to the increase in MRSA strains and gram-negative bacilli. This study was designed to study the appropriateness of empirical antimicrobial therapy with clinical outcomes among outpatients and analyze antibiotic susceptibility patterns. Methods A longitudinal study involving women clinically diagnosed with uncomplicated UTI as per IDSA guidelines across a study period of 18 months was conducted from 2008-2020. Antibiotic appropriateness was analyzed with respect to IDSA guidelines with subgroup analysis of culture- proven UTI. Results Among 105 cases of uncomplicated UTI, fluoroquinolones were prescribed the most (41%) followed by Beta-Lactams (30.5%). Choice of antimicrobial agent was appropriate in 60 (57%) cases and duration in 30 (28.5%) cases. Subgroup Analysis of 25 culture-proven cases revealed most common organism isolated was E. coli (60%) with prevalence of MDR organisms being 36%. The susceptibility pattern revealed similar levels of resistance between fluoroquinolones (38%), beta- lactams (36%), Nitrofurantoin(32%), Trimethoprim-sulfamethoxazole (32%), and Fosfomycin (20%) with clinical cure rates non-inferior among those prescribed the latter group of antibiotics (84.2% vs 96.6%) Conclusion The spectrum of uropathogens in our clinical setting is evolving with a substantial rise in MDR pathogens due to inappropriate antibiotic prescribing practices. The use of antibiotics such as Nitrofurantoin, Trimethoprim-sulfamethoxazole, and Fosfomycin in accordance with local antibiograms must be encouraged as empirical therapy for uncomplicated UTI. Keywords Urinary tract infection, antibiotic stewardship, Nitrofurantoin, Cotrimoxazole, Fosfomycin

Vaccine induced thrombotic thrombocytopenia (VITT) is a rare but devastating adverse event following adenoviral vector based vaccinations for COVID-19. Guidance statements and available reports lack clarity on the choice of imaging modalities and emphasize on the need for specialized tests as a requisite criterion. Such tests have practical limitations of availability likely to restrict the treatment and reporting of such catastrophic events and need reconsideration. We describe two young men with VITT who had no other contributory cause besides a recent ChAdOx1 nCoV-19 vaccination. They were treated with IVIG and full dose anticoagulation. In both our cases the primary neuroimaging was normal and the recommended PF-4 testing was not reported due to technical limitations. Diagnosis was based on a 4T inspired score. Clinicians should report and though counter intuitive; not delay the institution of full dose anticoagulation, IVIG and limit platelet transfusion in the appropriate setting.

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