- Volume 2, Issue 2, 2020

Pneumococcus remains the most common cause of bacterial meningitis with high morbidity and mortality. Adjuvant corticosteroids with early antibiotics have been shown to reduce the neurological morbidity and mortality respectively and this is reflected in British Infection Society (BIS) guidance.

Aim

To assess how closely BIS guidelines were followed regarding antibiotic and adjuvant corticosteroid administration in management of pneumococcal meningitis.

Methods

Newcastle Upon Tyne Hospital case-notes of pneumococcal meningitis from a 7-year-period(2012-2019) were audited. Patients were identified using microbiological records and case-notes. Data was collected on intervals from initial-assessment to commencing antibiotics and corticosteroids.

Eighteen cases were identified of whom three(17%) presented with the classic triad (fever, meningism, reduced GCS). All patients received appropriate antibiotics: 3/18(17%) within first hour of assessment. The median time to antibiotics was 5h 8mins (range:21-7129min). Eight patients(44%) received antibiotics >6h after assessment. Twelve patients(67%) received corticosteroids; only six(33%) at the recommended dose and duration. Mean time from antibiotics to corticosteroids was 6h1min. Five deaths occurred in the cohort with three attributable to pneumococcal sepsis (all had late presentations). 6/18 had significant neurological sequelae, irrespective of whether they received corticosteroids.

Discussion

The significant morbidity and mortality of pneumococcal meningitis demands a high index of suspicion. BIS guideline targets are repeatedly not met; long delays exist between assessment and antibiotic and corticosteroid administration. Integrated electronic prescribing and clinical Early Warning Systems have potential to ameliorate this with meningitis-tailored order sets to prompt consideration of meningitis and guide correct prescribing.

Clostridiodes difficile (C. difficile) colonisation rates have been reported as ranging from 4-15% in healthy adults to 4-51% in long term care facilities. Inappropriate treatment for C. difficile colonisation alters gut microbiota and can consequently result in C. difficileInfection (CDI). Laboratory testing needs to aid diagnosis while at the same time minimising risk of overdiagnosis and overtreatment.

Methods

An audit was conducted of the number of patients with indeterminate and positive results between 01.09.16 and 31.08.18 to determine the impact of Scottish National C. difficile laboratory testing and CDI case definition Guidance re-inforcement in September/October 2017. A question was also added at sample requesting stage re Pseudomembranous colitis/Toxic megacolon to ensure appropriate testing.

After Guidance re-inforcement, a rapid fall in number of indeterminate results (av. 34/month to 15/month) was observed. Decrease was most marked for GP patients (av. 12/month to 3/month). There was also a decrease in the number of patients with confirmed positive results (av. 9/month to 5/month).

Alignment with National Guidance resulted in significant reduction in patient indeterminate and positive results and assisted clinicians in the clinical diagnosis of CDI. There was also a reduction in the number of laboratory tests and repeat tests for indeterminate results. Therefore, this alignment with National Guidance resulted in Infection Prevention and Control Team, clinical and laboratory time and cost savings.

Procalcitonin (PCT) testing is used as a biomarker for bacterial infection. We assessed the impact of using a PCT-guided algorithm in Ninewells hospital & Medical School (Dundee, Scotland, UK).

We conducted a retrospective analysis of the use of PCT-testing to evaluate the escalation or de-escalation of antibiotic therapy. For this, we analysed patients admitted to the intensive care unit (ICU) and surgical high dependency unit (SHDU) from November 2018 to April 2019.

We analysed a dataset of 235 adult patients, 23% of which were at the hospital’s ICU and 77% at the SHDU. Within the ICU, 49% of admitted patients were already on antibacterial therapy, compared to 93% at SHDU. The PCT results influenced the prescription of antibiotics in 33% of total patients (89% and 16% of all ICU and SHDU patients, respectively). Escalation of the antimicrobial therapy was prescribed to 34% of ICU patients after PCT testing, compared to 20% of SHDU patients. Continuation of the previously-established antibacterial scheme was more pronounced in SHDU patients (43% against 23% ICU). In contrast, while discontinuation of the therapy was observed in similar levels on both units (27% SHDU, 28% ICU).

PCT has become a useful tool in antimicrobial stewardship. Its use aided the prescription of antibiotics in 33% of the overall total cases in ICU and SHDU. Further work should be carried out to assess its role in other clinical environments.

Hydradenitis suppurativa (HS) is a chronic inflammatory skin disease. The UK prevalence is estimated at between 1-4%. There is an approximate 3:1 female: male preponderance and it is associated with smoking, obesity, type 2 diabetes mellitus. The pathogenesis of HS is poorly understood. Clinical features vary in extent and the axillae, inguinal and anogenital areas are typically affected. It has a significant impact on quality of life, with high rates of depression amongst sufferers.

Current UK treatment guidelines focus on lifestyle interventions, as well as targeted use of oral antibiotics, however microbiological sampling is usually not helpful. Where these are unsuccessful anti-TNF agents and surgical intervention may be indicated. Despite their absence from these guidelines, there is growing evidence to support the role of intravenous (IV) antibiotics in treating HS. It is not known whether the treatment response seen with IV antibiotics is due to their antibacterial or an anti-inflammatory effect. We present a series of HS patients managed under the OPAT team at University Hospitals of Leicester.

Cases

To date 8 patients have completed treatment (7F/1M). All received at least 6 weeks of therapy with IV ertapenem (+/- teicoplanin). Significant improvement in both clinical signs and symptoms was achieved in all cases. However, disease relapse was seen in three cases after cessation of IVs, requiring additional courses of treatment. Antibiotics were well tolerated with one adverse drug reaction secondary to teicoplanin.

Intravenous antibiotics are an effective adjunctive treatment in selected cases of hidradenitis suppurativa.

Increasing global incidence of serious fungal infections (SFI) requires increasing access to high quality medical mycology education to improve their identification and decrease associated mortality.

An online course was developed by two infectious diseases (ID) specialists. The course aimed to improve diagnosis of SFI and was delivered from April-June 2019. The course consisted of 9 online interactive sessions every week. Sessions were streamed by a hospital in Mexico and local participants gather there every week. Other participants connected independently online. Participants took one exam at the start and another after the course was completed. Feedback was collected during the course. A final evaluation of the impact on diagnosis will be collected in October 2019.

A total of 137 people registered for the course. Registrants were from four different countries, Mexico (126, 92%), Ecuador (9, 6.6%), Australia (1, 0.7%) and Bolivia (1, 0.7%). Mexican participants connected from 15 of the 32 regions (47%) in Mexico and 45 (33%) attended the course at host hospital. Most participants were physicians (76%), 54 were ID specialists and 19 were ID residents. Sixty participants (60/137, 44%) completed the course, with greater completion by those attending in person (33/45, 73%) compared with online attendance (27/92, 29%). The exams results improved 30% after the course. Clinical urgent calls limited attendance.

This online course allowed a broad geographical participation. Learning as group lead to better completion rates. Recorded sessions will be available on demand and may allow the completion of the course.

We undertook a retrospective audit of patients presenting over 6 years with a radiological diagnosis of discitis with the primary objective of determining the proportion of patients who had appropriate microbiological investigation either via blood culture or biopsy.

42 patients met the inclusion criteria. Blood cultures were positive with organisms likely to be the causative agent in 50% of patients. Of the 50% of patients with negative blood cultures, 57% went on to have a successful spinal biopsy. Biopsies proved positive in 75% of cases. 8 patients with negative blood cultures did not progress to biopsy at the time of diagnosis and four suffered some degree of harm. One of these patients failed empirical anti-staphylococcal therapy and later required spinal stabilization due to destruction of the spinal disc was proven to have pseudomonas infection at the time of the corrective surgery.

19% of patients with discitis did not have appropriate disc sampling prior to commencement of antibiotic therapy. 50% of these suffered some degree of harm. This strengthens the case for recommending appropriate sampling prior to initiation of therapy, unless absolutely contraindicated.

Response to pneumococcal 23-valent polysaccharide vaccine (PPV23) is poor in patients with pulmonary aspergillosis, pneumococcal 13-valent polysaccharide vaccine (PCV13) is believed to be more antigenic. Thus practice at the national aspergillosis centre (NAC), Manchester University NHS foundation trust (MFT) is to give PCV13. However, response to PCV13 has not been studied.

Methods

We conducted a retrospective, observational study of patients with pulmonary aspergillosis at the NAC, MFT. Patients who had non-protective pre-vaccine levels, and received PCV13 between January-2015 and July-2019 with serology available within 3 months after vaccination were included.

Serotype-specific pneumococcal IgG antibodies were quantified for 12 pneumococcal serotypes. Non-protective immunity was defined as pre-vaccine level <0.35μg/mL to > 6 out of 12 serotypes. Protective response was defined as level >1.3μg/mL, or an increase in concentration ≥4-fold for at least 9 of 12 serotypes within 3 months.

47 of 144 patients receiving PCV13 had non-protective pre-vaccination levels and repeat serology within 3 months post-vaccination. 52% and 20%, of patients who received 2 and 1 doses (respectively) developed protective immunity; χ2(1)=2.987,p= 0.084. 42.86%, 69.23%, 42.86%, 50%, and 0% of patients with chronic pulmonary aspergillosis (CPA), allergic bronchopulmonary aspergillosis (ABPA), severe asthma with fungal sensitisation, aspergillus bronchitis, and mixed ABPA and CPA developed protective immunity; χ2(4)=6.329,p=0.176.

Patients with CPA respond poorly to PCV13 compared to ABPA. Response to two doses of PCV13 is comparable to one dose of PPV-231. Patients with pulmonary aspergillosis should receive two doses of PCV13 rather than one dose.

Teicoplanin is a glycopeptide antibiotic which is frequently used in preference to vancomycin because it does not require such regular TDM as the association between concentration and toxicity has not been fully established. TDM is however, recommended to help optimise therapy in some patients. In our hospital there was an observation of frequent sub-therapeutic levels which prompted an audit of TDM results.

Retrospective review of TDM results August 2015- March 2017 at Homerton Hospital with analysis of dose, renal function, patients’ weight and type of infection.

We analysed 54 samples from 33 patients. The most common dose was 600 mg OD which equated to a mean dose of 8.68 mg/Kg with under-dosing in all weight groups but with lowest levels in the group between 110-120 Kg. A 24hr dosing regimen was the most common and other dosing regimens (48hrly or 72hrly) more frequently associated with sub-therapeutic levels.

Overall, the mean level was 27.8 +/- 11.9 mg/L but 41% (n=22) of levels were sub-therapeutic for the type of infection treated including 4 patients with bacteraemia, 7 patients with bone and joint infections (n=10 samples) and 3 patients (n=6 samples) with prosthetic joint infections. There was only one patient with teicoplanin levels >60 mg/L who was on treatment for a streptococcal endocarditis. She did not report any side effects.

The current dosing regimen recommended by the BNF frequently results in sub-therapeutic levels. TDM is essential in managing complex infections to ensure therapeutic levels are achieved.

We present 2 studies conducted on Chlamydia trachomatis(CT) and Trichomonas vaginalis(TV) testing in NHSG, leading to streamlining of NAATs of Neisseria gonorrhoeae, CT and TV in triplex.

Formerly, positive CT-NAATs needed confirmation by repeat testing on the same sample using same platform. According to SMI guidelines, when confirmatory testing results are consistently concordant following audit, confirmation may be unnecessary. CT testing over 3 years (2015-2017) was analysed to review outcomes of confirmatory testing.

A pilot study was conducted on TV-NAAT testing in comparison with TV-microscopy. In addition, TV testing data over 30months (29/07/2016-31/01/2019) was analysed.

A total of 88533 samples were tested for CT-NAAT over 3 years: 7059 were positive, 81321 negative. A total of 153 were equivocal (initially positive, negative on repeat) which were reanalysed with results on receival of repeat samples. Over the years, percentage of equivocal tests out of the total positives remained at 0.2%; rates for positive-repeats and tests-not-repeated fluctuated; negative-repeats increased from 18 to 38.

TV-NAAT was more sensitive/ specific compared to TV-microscopy (relative specificity was 99.6%, relative sensitivity was 92.8%), and was adopted for routine testing. A total of 44407 samples were tested for TV NAATs over 30 months. Of this, 433 were positive and 43796 negative. Further cross-sectional analyses were done.

We concluded that positive CT-NAATs do not require repeat testing for confirmation. TV-NAAT testing proved more sensitive/specific than TV-microscopy and was useful to adopt as routine testing and help streamlining testing on one molecular platform.

NECROTIZING OTITIS EXTERNA (NOE) IS A SEVERE, LIFE THREATENING PROPAGATING OSTEOMYELITIS OF THE SKULL BASE THAT ORIGINATES FROM A SEVERE OTITIS EXTERNA. THIS RARE CONDITION MAY NOT BE AS UNCOMMON AS ONCE UNDERSTOOD. EPIDEMIOLOGIC DATA REVEALS AN UNEXPECTED AND DRASTIC RISE IN THE NUMBER OF REPORTED CASES OVER THE LAST 15 YEARS. USING NATIONAL DATA AND PUBLISHED LITERATURE, WE EXPLORE FOUR THEORIES BEHIND THE RISE IN INCIDENCE OF THIS CONDITION.

A quantitative descriptive study was undertaken using epidemiological data obtained from the Hospital Episode Statistics (HES) database. NOE cases reported between 2002 – 2017 were compiled and analyzed. Using these results and current evidence within the published literature, four theories were formulated and explored to explain the upward trend in incidence.

There were a total of 7,327 NOE cases reported within the 15-year time period. The majority of cases (60%) occurred in the elderly (Age 75+) with a 5:2 male predominance. Mean length of stay and mean total bed days were 16.3 and 5,019 days, respectively.

The number of NOE cases has increased by more than 1000% within the 15-year time period, from 123 cases in 2002 to 1,405 in 2017. We theorize that this increase maybe due to:

(1) the rising prevalence of diabetes

(2) the increase in antibiotic resistance

(3) the rising ageing population

(4) improved physician awareness of NOE

Clinical manifestations of dengue vary from mild febrile illnesses to shock and organ failure. However, severe symptoms may not be clinically evident immediately, making it difficult for early detection of patients at risk for poor outcomes. Several biomarkers, particularly C-reactive protein (CRP), were revealed to be highly predictive of dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS). This systematic review aims to determine a relationship between CRP levels and the probability of developing DHF/DSS.

Methods

Multiple electronic databases were searched for English literature from January 2007 to August 2017. Four reviewers independently extracted data from eligible studies using the standardized critical appraisal tool from JBI-MAStARI. Articles that scored six and above were included.

Three cohort and two cross-sectional studies were reviewed. Sample sizes ranged from 70 to 235 participants. The cohort studies measured CRP levels at point of diagnosis, but were re-measured at different time points in the subjects’ admission. However, regardless of the time difference, they all showed that increased CRP levels exhibited a trend towards development of DSS/DHF. The studies also identified a possible “golden period” for measuring CRP levels that can accurately predict development of DHF/DSS. The cross-sectional studies also saw a similar trend, but have measured this in median values of the CRP levels.

This systematic review showed that increased CRP levels appeared to have a trend towards a higher probability of developing DHF/DSS. A larger population and more studies are needed to further establish a statistically significant relationship.