- Volume 2, Issue 2, 2020

Phenotypic and genotypic diversity of vaginal bacteria Gardnerella vaginalis resulted in its classification into genotypic subgroups. The virulence potential of these subgroups was evaluated.

Methods

G. vaginalis clinical isolates were subtyped on the basis of subgroup-specific genes by PCR. The virulence-related phenotypic characteristics of the isolates were evaluated assessing their in vitro ability to grow as biofilm on abiotic surfaces, produce the toxin vaginolysin, and express sialidase activity. Vaginolysin in the supernatant of the cultures was quantified using toxin-specific antibodies by sandwich ELISA. Sialidase activity was tested using fluorogenic substrate. Cloning and expression of the sialidase gene of G. vaginalis in E. coli was performed. Differences in the expression of phenotypic properties of the isolates were evaluated by agglomerative hierarchical clustering and principal component analysis.

Thirty-five clinical isolates of G. vaginalis were subtyped into three subgroups 1, 2 and 4. Analysis of sialidase activity indicated statistically significant differences among the subgroups. All isolates were grouped into three clusters by the methods of statistical analysis. The distinct profile of each cluster was based on the phenotypic characteristics of isolates. Subgroup 4 was the most homogenous group, as all isolates were found in the same cluster, which was characterized by the low production of all studied virulence factors. Subgroup 2 isolates were mainly distributed between two clusters, whereas subgroup 1 isolates were found in all three clusters.

G. vaginalis subgroups with different virulence potential might play distinct roles in vaginal microbiota.

Reported Antimicrobial Stewardship (AMS) ward rounds and review initiatives utilise consultant microbiologists or consultant ID physicians with or without senior antimicrobial pharmacists (AMP). There is sparse evidence regarding AMS ward rounds led by more junior members of staff.

Methods

AMS ward rounds were launched on the acute medical unit at Leicester Royal Infirmary, attended by a band 7 AMP and an Infectious Diseases registrar (ST3-5). Patient details and recommendations were recorded for each patient seen and followed-up to determine if recommendations were followed and the impact on treatment duration (TD), length of stay (LOS), and 28-day readmission rate (RR).

104 patient reviews were recorded, of which 87% received at least one recommendation regarding their care (median 2, SD±1.4, Range 0-6), totalling 224 recommendations. Change of antimicrobial was advised for 35 patients (33.7%), whereas stopping antimicrobials was recommended for 18 patients (17.3%). Parenteral to enteral switch was recommended for 12.5% of patients. Although all contributions supported AMS, 41.2% also supported medicines optimisation. An alternative diagnosis was also suggested in 15 patients (14.4%).

All patients were followed-up. Ward clinicians changed treatment in line with recommendations in 70.6% of instances. There was no difference in TD, median LOS was 12-hours shorter for patients whose treatment was changed in line with recommendations, and RR was 9.5% lower for those whose treatment changed in line with recommendations.

Junior staff provide valuable input regarding patient care and optimising antimicrobial therapy. There was a trend towards shorter LOS and reduced RR.

The British Society for Antimicrobial Chemotherapy (BSAC) Bacteraemia Resistance Surveillance Programme monitors the antimicrobial susceptibility of organisms causing bacteraemias in the UK and Ireland. We review data for Escherichia coli, Klebsiella, Enterobacter, Proteeae, and Serratia collected between 2007-2017.

Consecutive isolates causing clinically significant bacteraemia were tested; participating laboratories (n=24-40) collected 7-20 isolates/species per year. Minimum inhibitory concentrations were determined centrally by BSAC agar dilution.

Rates of resistance in the UK and Ireland remained largely stable over the 11-year period, during which 14,206 isolates were tested [(E. coli, n=5364; Klebsiella, n=3016; Proteeae, n=2423; Enterobacter, n=1819, and Serratia, n=1584)]. A decrease in resistance to piperacillin/tazobactam was noted among all species, except K. aerogenes. A decrease in resistance to ciprofloxacin was seen among E. coli and Enterobacter. Average rates of resistance to ceftolozane/tazobactam ranged from 0.2% (E. coli)to 9.2%(E. cloacae), whereas rates of resistance to ceftobiprole were higher [10% (E. coli) and 20% (E. cloacae)]. Rates of colistin resistance were low among E. coli (0.5%), and Klebsiella (1.2%); however, rates were higher, and increasing among Enterobacter (6.1% in 2011 to 13.4% in 2017). Rates of ESBL production were stable over time; higher among E. coli (9.6%), Enterobacter (10.4%), and Klebsiella (14.7%), compared with <1% among Proteeae and Serratia. Carbapenemase producers remained rare (n=16 over 11 years, without trend).

The largely unchanging or reducing resistance rates among Enterobacterales causing bacteraemia are reassuring and may reflect interventions to reduce inappropriate use of antimicrobials implemented across the countries surveyed.

Rheumatoid arthritis (RA) is now recognised as the end point of a disease continuum. Anti-citrullinated peptide antibodies (ACPA) mark the presence of RA-related systemic autoimmunity, but the production of auto-antibodies alone is not sufficient to develop disease. Data on progression between the stages of RA disease are limited, but accumulating evidence suggests a microbial dysbiosis in the gut may trigger RA development. Using a prospective ‘at-risk’ cohort of ACPA positive individuals without arthritis, we investigated for the presence of a gut dysbiosis before the onset of RA.

Materials/methods:

Faecal samples from 25 ACPA-positive individuals, with non-specific musculoskeletal pain, were sequenced using16S rRNA gene. A control population was selected from publicly available data on the NCBI database, matched for rRNA V4 amplification region, sequencing technique, and approximately for age, gender, diet and ethnicity. Taxonomic analysis was performed using QIIME and MEGAN, and statistical analysis using R software.

Comparison of the ACPA-positive and control populations shows large clustering at bacterial family level. The ACPA population has an abundance of Lachnospiraceae, Helicobacteraceae, Ruminococcaceae, Erysipelotrichaceae and Bifidobacteriaceae, and a lower abundance of Bacteroidaceae, Barnesiellaceae, Methanobacteriaceae amongst others. The relative abundance of bacterial taxa between the ACPA positive and control population was significantly different (P value 0.01, permutation MANOVA).

Conclusions:

The gut microbiome of individuals ‘at-risk’ of developing RA is distinct from heathy controls. These pilot data can inform further studies, and are an important step in the attribution of causality to the gut microbiome in the development of RA.

Diarrhoea is a common presentation in travellers. This case highlights the importance of providing the microbiology laboratory with necessary clinical information so that special media can be inoculated in order to establish a prompt diagnosis.

A 29 year-old male was admitted in Glasgow, UK with a 24 hour history of profuse watery diarrhoea. He was travelling from Mumbai, India. He reported no relevant sick or healthcare contacts. On admission he was dehydrated, tachycardic, and hypotensive. Blood testing revealed normal electrolytes but lactic acidosis, a severe AKI, neutrophilia, and raised CRP. Treatment was initiated with IV fluids, empirical IV ceftriaxone and azithromycin. Urine, faeces and blood cultures were collected and rectal screening for CPE was performed. More than 6L of diarrhoea was passed in the first 12 hours.

Over the subsequent 48 hours diarrhoea continued while urine output and biochemistry normalised with IV fluids. Yellow colonies were grown from faecal cultures on TCSB agar. Gram stain revealed short, ‘comma-shaped’ gram negative aerobic rods. These were identified asVibrio choleraeusing MALDI-TOF and later confirmed to be serotype 01 El Tor. Rectal swabs returned positive for NDM-1 producing Escherichia coli. By the third day his diarrhoea resolved, antibiotics and IV fluids were discontinued and he was discharged.

This case highlights the challenge of managing V. cholerae infection in a traveller. Cholera should be considered in the differential diagnosis of diarrhoea in any traveller and specific laboratory testing is required to make a positive diagnosis.

Guidelines recommend HIV testing in indicator conditions in which the prevalence of undiagnosed HIV exceeds 0.1%. We assessed adherence to national recommendations on HIV testing within the acute medical unit in NHS Fife. Secondly, we performed a look-back exercise to identify missed opportunities for HIV diagnosis in individuals who presented at a late stage of infection.

Data were collected on admissions over a 24-hour-period during four consecutive weeks in 2018. Case records were reviewed and diagnoses were screened against a list of indicators. Additionally, data were obtained from HPS on late HIV diagnoses within NHS Fife from 2013-2018. Records were interrogated for presentations to healthcare services within the 5 years prior to HIV diagnosis.

In total, 226 patients were admitted during the study period. All patients were white, with median age 68yrs. 101 indicator conditions were identified, relating to 83 patients (36.7%). Bacterial pneumonia was the most frequently identified indicator (n=40). Only 3 patients were offered HIV testing (3.6%).

From 2013-2018, 23 patients were diagnosed with HIV at late stage. The median age at diagnosis was 41yrs and the median CD4 count was 161 cells/mm3. Fifteen patients (65.2%) had presented to hospital in the 5 years preceding diagnosis with an indicator. The most frequently missed indicator was chronic diarrhoea (n=6). Three patients (13%) have died since diagnosis.

Conclusions:

* Opportunities to increase uptake of HIV testing among people who may have undiagnosed HIV are being missed

* Further educational initiatives and review of local HIV testing protocols are indicated

Current surveillance data suggests that vaccine coverage rates (VCRs) in children are declining, potentially contributing towards outbreaks of vaccine-preventable diseases at levels not commonplace in the UK in recent years. This observed decline in VCRs can be attributed to a number of reasons, one of which is the increasing momentum in vaccine hesitancy.

Insights we have obtained from healthcare professionals (HCPs) demonstrated a paucity of accessible medical education specifically addressing this complex issue. This led Sanofi Pasteur to develop a contemporary, non-promotional ‘Vaccination Educational Initiative’ for HCPs, called Lumiere, part of which focuses on increasing vaccine confidence and addressing vaccine hesitancy.

Objective

Equip HCPs with evidence-based techniques which help them address the concerns of the public and improve vaccine confidence amongst patients.

Five symposia were held across the UK. The faculty comprised both academic experts and specialist nurses with relevant clinical experience who presented proven techniques that can help increase vaccine confidence.

Attendee feedback from the first symposium suggested additional examples on how to apply these techniques in clinical practice would be helpful. Subsequent symposia were modified to include real life cases.

Summary of results

The symposia attracted a total of 443 attendees of which 37% (162) completed evaluation forms.

92% of respondents rated the symposia as good or excellent with 93% indicating they would change clinical practice based on their learnings.

From the initial roll out of Lumiere we have demonstrated that medical education can help support HCPs play an active role in restoring vaccine confidence.

In the U.K., doxycycline is widely recommended as first-line empiric treatment for mild HAP, however this practice is based on expert opinion and we are aware of no data describing the outcomes of patients treated with doxycycline. Here we describe the outcomes of non-ICU patients treated empirically with doxycycline for low-severity HAP.

Methods

1680 inpatient chest x-rays were manually screened to identify cases of HAP. HAP was defined as new or progressive CXR consolidation occurring ³48 hours after admission, combined with compatible symptoms or signs. Treatment failure was defined as requirement for antimicrobial escalation, HAP recurrence or mortality attributed to HAP. We compared groups according to treatment outcome using the Kruskal-Wallis test and receiver operator characteristic (ROC) analysis.

Forty-nine patients who received doxycycline were included in the analysis. The median age was 78 years and 63% had >2 co-morbidities. Hypoxia was common (57%) but extra-pulmonary organ dysfunction was uncommon. 71% of patients were successfully treated with doxycycline as first-line empiric therapy. Treatment failure was associated with increased duration of hospitalisation prior to HAP onset (median 21.5 vs. 10 days, p=0.03) and higher neutrophil count (10.1 vs. 6.1 x109L-1, p=0.04). ROC analysis identified HAP onset >14 days after admission as the optimum cut-off for predicting treatment failure.

Conclusions

In this cohort, the majority of patients with low-severity HAP were successfully treated with doxycycline. Treatment failure was associated with prolonged hospitalisation prior to HAP onset with 14d identified as a potential surrogate marker for patients requiring antimicrobials against Gram-negative organisms.

Intravenous antibiotics should be reviewed at day three and a decision made whether to continue, stop, switch to oral or refer to OPAT. Clinicians struggle to undertake this review due to the demands of the daily ward round and patients are inappropriately left on broad spectrum intravenous antibiotics, which can cause harm and increase antimicrobial resistance. A pharmacist-led virtual ward round was initiated to review these patients to decrease the number of patients on broad-spectrum IV antibiotics and support regular review of these.

Patients on day three or more of intravenous antibiotics were identified using an electronic prescribing report and reviewed using an electronic antimicrobial review tool by a pharmacist on a weekly basis.

Recommendations were made via the tool and added to the patient’s electronic record and then followed up after 24 hours to review the prescription and identify whether advice had been followed.

Over eight weeks, 75 patients had their IV antibiotics reviewed by the pharmacist. 20 recommendations were made to continue, 15 to stop, 33 for IVOS and 10 for OPAT referral. After 24 hours, 80% of patients were continued, 47% were stopped, 61% of patients were switched to oral, and 40% of patients were referred to OPAT as per the recommendations.

The pharmacist-led virtual ward round appeared to have a positive impact on the reduction of IV antibiotics being continued after day three. Additionally, reviewing patients virtually allowed for more patients to be reviewed, increasing the impact of the stewardship round.

We undertook a point prevalence study across two London hospitals to ascertain the frequency of per-policy screening. We assessed the screening of acutely admitted patients in March 2019 at hospital 1 and July 2019 at Hospital 2. We then modelled variations in screening approaches to optimise risk assessments in the context of isolation room availability.

A total of 199 patients (112 patients at hospital 1 and 87 patients at hospital 2) were included in the analysis. Overall, 27/112 (24%) and 32/87 (37%) met the criteria for CRO screening according to current guidelines. Of these, 0/27 (0%) of patients at hospital 1 and 5/32 (16%) at hospital 2 had a CRO screen performed [p=0.06]. Across both hospitals, the principal risk factors for CRO carriage included: admission to a UK hospital in a high risk area (63/199;32%); admission to a non-UK hospital (3/199/;2%) and previous CRO carriage (1/199;0.5%) albeit with some variation between sites

Six years after the roll out of the national toolkit, CRO screening is still variable. Reworking of the risk stratification is needed, and we suggest technological approaches with electronic healthcare records may enable more robust screening strategies.

Early diagnosis of HIV allows commencement of combination antiretroviral therapy, reducing morbidity and mortality, as well as transmission. In 2010, 64.3% of new patients diagnosed with HIV in Lanarkshire had missed opportunities for earlier diagnosis, leading to various educational initiatives. Their success in reducing missed opportunities is examined here.

Methods

People who were newly diagnosed with HIV in 2017 were identified. For each person, NHS Lanarkshire hospital records, dating back ten years, were analysed to identify missed opportunities for testing. These were defined as episodes of care with potential HIV indicator conditions (shown in the British HIV Association testing guideline), that did not lead to an HIV test. Comparisons were made to 2010 data.

16 patients who were newly diagnosed with HIV in 2017 were identified. 43.8% (7/16) had missed opportunities for earlier diagnosis compared to 64.3% (9/14) in 2010. One presented with an AIDS-defining illness, compared with 3 in 2010. Blood dyscrasia was the most common clinical indicator that failed to prompt testing, although other commonly missed indicators were pneumonia and mononucleosis-like syndrome.

Educational initiatives are effective in improving appropriate HIV testing, however are not enough in isolation. Quality improvement strategies to increase testing, that are applicable to any Health Board/Trust, are currently being used. These include engagement with haematologists to provide testing prompts in reports, and opt-out testing in presumed high-prevalence clinical areas.

Borrelia burgdorferi, the micro-organism responsible for Lyme borreliosis, is known to be endemic in Scotland, with 4.2% sero-prevalence in Scottish blood donors. Facial nerve palsy can be a manifestation of the illness. The aim was to establish how often Lyme is considered as a potential cause in one Scottish health board.

Methods

Patients, aged four and above, presenting to secondary care with facial nerve palsy from 2016-2018 were identified using ICD-10 codes. A retrospective analysis of case notes and laboratory records was undertaken to establish whether a cause for nerve palsy had been found, whether a potential tick exposure history was taken, and if Lyme testing had been done. Microsoft Excel was used for analysis.

173 patients with confirmed facial nerve palsy were identified. Consideration of Lyme disease was made in 9.2% (16/173). Of these, 43.8% (7/16), were asked about possible insect bites (four of whom were asked specifically about tick bites). 43.8% (7/16) were tested based on clinical presentation. 6.3% (1/16) had “no Lyme risks” documented and another 6.3% (1/16) had an occupational risk. Of the sixteen, 50% (8/16) had Lyme serology undertaken, although 2/8 had a confirmed alternative cause.

Possibility of Lyme disease is not commonly considered when individuals present with facial nerve palsy. This is despite endemnicity in Scotland, and opportunities for tick exposure being common, with outdoor activities and countryside trips. Educational initiatives are therefore required.