- Volume 2, Issue 2, 2020

Background: The appropriate use of antimicrobials has implications on individual patient care, drug resistance and worldwide public health. Learning to prescribe antimicrobials is therefore an important part of medical education. The aim of this study was to evaluate novice prescribers’ readiness to use antimicrobials, in order to design valid educational activities.

Methods: A mixed methods study was carried out amongst final year students at Queen’s University Belfast and foundation year 1 (FY1) doctors working in a Northern Ireland hospital. Data was initially collected using a survey, comprised of quantitative and qualitative elements. This was supplemented by semi-structured interviews.

Results: One hundred and fifty-eight students and eighteen doctors participated in the survey. Two students and two doctors were interviewed. Both groups appeared to feel only moderately prepared to prescribe antimicrobials. Agreement with survey statements relating to knowledge and confidence was 61% and 73% for students and FY1 doctors respectively. More focused contextual teaching and practical learning opportunities were felt to be required. Students perceived a long time gap between teaching and clinical exposure. Both groups conveyed the strong influence of the working environment and local prescribing culture. These were sometimes seen as barriers to optimal prescribing. Feedback on prescribing was felt to be useful but lacking.

Conclusion: This study suggests that medical students and foundation doctors do not feel adequately prepared to prescribe antimicrobials, which may lead them to be overly influenced by suboptimal prescribing cultures. A number of curriculum development and quality improvement initiatives are suggested as a result.

Many countries have developed antimicrobial stewardship programmes with strategies to optimise antimicrobial prescribing. There remains a need for behaviour change interventions at clinician level to promote appropriate prescribing. Theories should be used for developing and evaluating interventions to change human behaviour.

Aim / Objectives:The aim of this review was to critically appraise, synthesise and present the available evidence for theoretical approaches in the development and evaluation of behaviour change interventions designed to improve clinicians' antimicrobial prescribing.

Design & Methodology:

The systematic review protocol was developed and registered with the International Prospective Register of Systematic Reviews (CRD42018098586).

Two review authors independently extracted data and assessed study quality. Clinical and methodological heterogeneity limited data synthesis.

Introduction

Meropenem is a broad spectrum antibiotic used to treat a variety of bacterial infections. There are no clear standards nationally for the use of meropenem. The purpose of this study is to audit the appropriateness of Meropenem prescription at West Hertfordshire NHS trust

METHODOLOGY

Patients started on meropenem were identified via the hospital pharmacy in the period from 1st January 2019 to 31st March 2019. Patients’ clinical notes, drug charts and blood tests were reviewed. Appropriateness of meropenem prescription was judged based on the following: indication, penicillin allergy and its nature, pathogen antibiogram, microbiologists approval, indications for escalation and duration of treatment

RESULTS

forty-eight patients were identified during the study period. The main indications were hospital-acquired/community-acquired pneumonia and UTI. Penicillin allergy was documented in 31%, the nature of allergy was intolerance in 13% and not known in 20%. Of note, in 42% of these, treatment was not pathogen guided. In 45.5% of non-penicillin allergic patients, escalation to meropenem were neither supported by antibiogram nor by microbiologists. The main driver was raised inflammatory markers (62.5%). Of the 37 patients who completed their treatment during the study period, 21.6% had > 7 days with only 50% recommended by Microbiologists.

CONCLUSION:

In third of the patients, meropenem use was driven by penicillin allergy, however the nature of allergy did not justify its use in many of these cases. Lack of microbiology approval, failure to de-escalate and long courses of meropenem were additional areas identified to target in our antimicrobial stewardship programme

Multidrug-resistant organisms (MDROs) are a global challenge especially in long-term care facilities (LTCFs). Older people are more vulnerable to infection due to the senescence of their immune system, resulting in more frequent and longer hospitalization increased cost of care, hence greater workload. Even in the strict hospital environment, less than half of the environmental surfaces sampled were not properly cleaned and this poses a significant risk of disease transmission.

In this study, new light-based surface disinfection technology can complement existing hospital practices to address an important public health problem. Its strategy is based on high-intensity narrow-wavelength (Hi-NW) light sources for surface decontamination of microorganisms commonly found in health care environments using synergic effects of blue LEDs at 405 & 470 nm and UV LED at 278nm, which were not previously investigated together.

A retrospective review of MDRO records has been conducted throughout the study period. Organisms were identified using special agar media and treatment with Hi-NW prototype was tested in the LTCF surfaces.

The prototype results show 99.9% & 88.9% bactericidal rate against MDROs for 5minutes and 2 minutes exposure time on flat surfaces, respectively. Work is still in progress for the 30-second cycle exposure of prototype.

This discovery will support the use of the device as a high material compatibility technology with hospital items, or in other common areas, such as public areas and homes, where frequently touched surfaces play an important role in disease transmission. There is an utmost need for this tool to prevent the proliferation of MDROs

A 49-year-old Indian gentleman attended A&E reporting a three-day history of fever, rigors and lower back pain. A CT KUB incidentally revealed a left adrenal mass and widespread abdominal lymphadenopathy. A subsequent CT NCAP showed lymphadenopathy above and below the hemidiaphragm with bilateral adrenal masses. A PET scan showed avidity in these locations. A right axillary lymph node biopsy revealed granulomatous lymphadenitis with focal necrosis. No microorganisms, including acid-fast bacilli were seen on staining. His Mantoux test was positive (34mm). Given his epidemiological risks factors, positive Mantoux test and evidence of necrotising granulomas on biopsy, tuberculosis was considered the most likely diagnosis, although lymphoma remained within the differential. He commenced standard first-line anti-tuberculosis treatment. One week later he re-presented reporting fever, dyspnoea, vomiting, generalised abdominal pain and increased skin pigmentation. He was tachycardic, hypotensive and hypoglycaemic (HR 129, BP 105/73, BM 3.8). Investigations showed a marked hyponatraemia, metabolic acidosis (Na+ 115, pH 7.24) and deranged liver function tests (ALT 510). ACTH was raised (869 ng/L) and a short Synacthen test showed no rise in serum cortisol. His tuberculosis medication was held and he was treated for Addisonian crisis with intravenous hydrocortisone and oral fludrocortisone. It is likely that commencing rifampicin induced metabolism of endogenous steroid, thus precipitating the crisis. Potentially, he was already compensating for low endogenous steroid production prior to initiation of rifampicin, caused by adrenal tuberculosis. He subsequently improved and was discharged with oral hydrocortisone and fludrocortisone. His tuberculosis medications with be restarted as an Outpatient.

Hepatitis E Virus is an RNA virus of the Hepeviridae family that affects hepatocytes and seriously impacts the health of immunocompromised patients. Genotypes 3 and 4 have been circulating in animal populations such as swine and deer in developed countries, causing food borne infections associated with consumption of contaminated animal food products. While HEV has been circulating in European deer populations and causing food borne infections in Asia, its presence in Scottish venison food products has not been investigated. This study assesses 4 ready-to-eat venison charcuterie products for HEV by performing RNA extraction on duplicate samples with a Qiagen RNeasy Midi kit and using Mengovirus as a process control to determine virus recovery by RT-qPCR. This was followed by RT-PCR with previously described HEV primers, and ligation of the suspected positive fragments in a recombinant pGEMT Easy Vector system which was then cloned in competent E. coli cells for propagation. Recombinant plasmids were isolated and subjected to Sanger sequencing. An average RNA extraction efficiency of 5.02% was achieved across all samples, but large deviations between duplicates suggests that further optimisation is necessary in RNA extraction from food products with complex matrices. HEV-sized PCR fragments were detected in 3 out of 4 food products, but the sequencing data showed inefficient ligation of the fragments in the vector, possibly due to low RNA amount and excess of dimerised primers. The likelihood of HEV presence in Scottish venison needs to be investigated further for the detection of transmission routes and the implementation of improved surveillance policies.

Acinetobacter are Gram-negative bacteria belonging to the sub-phyla Gammaproteobacteria , commonly associated with soils, animal feeds and water. Some members of the Acinetobacter have been implicated in hospital-acquired infections, with broad-spectrum antibiotic resistance. Here we report the whole-genome sequence of LC510, an Acinetobacter species isolated from deep within a pristine location of the Lechuguilla Cave. Pairwise nucleotide comparison to three type strains within the genus Acinetobacter assigned LC510 as an Acinetobacter pittii isolate. Scanning of the LC510 genome identified two genes coding for b-lactamase resistance, despite the fact that LC510 was isolated from a portion of the cave not previously visited by humans and protected from anthropogenic input. The ability to produce acyl-homoserine lactone (AHL) signal in culture medium, an observation that is consistent with the identification of the luxI and luxR homologues in its genome, suggests that cell-to-cell communication remains important in an isolated cave ecosystem.

Bacillus cereus is a common laboratory and environmental contaminant. Reports of severe infections are mainly limited to immunocompromised individuals. In reported cases, the time interval between bacteraemia and neuro-invasion appears to be very short, highlighting the importance of rapid and definitive identification and susceptibility testing of invasive B. cereus . We report a case of a neonatal B. cereus bacteraemia complicated by a brain abscess from a neonatal intensive care unit. The neonate presented with bradycardia and desaturations with increased oxygen requirements. Initial blood culture detected B. cereus but was considered a contaminant. Repeated culturing of the Gram-positive rod was subsequently considered to be significant. Initial ultrasound head scans revealed echogenicity in the right posterior deep white matter. A large central cavity (5 mm diameter) could eventually be observed. The brain abscess resolved after surgical drainage and an extensive 6 weeks of antimicrobial therapy. This case study describes a rare event that illustrates the importance of rapid identification and susceptibility testing of invasive B. cereus isolates from immunocompromised patients.

Introduction. Shigellosis has a gastrointestinal presentation of variable severity in which bacteraemia is uncommon. We describe the first reported case of Shigella sonnei bacteraemia and intestinal coinfection with Clostridioides difficile in a cystic fibrosis patient. The literature on S. sonnei bacteraemia in adult and paediatric populations is also reviewed.

Case presentation. A 29-year-old male with cystic fibrosis presented with profuse acute watery diarrhoea, abdominal pain, shivering and fever. The patient showed mixed cardiogenic and septic shock. Despite antibiotic therapy, volume replacement therapy and vasoactive drugs, the patient showed biventricular dysfunction and multiple organ failure requiring implantation of an intra-aortic balloon pump (IABP) with extracorporeal membrane oxygenation (ECMO). C. difficile and S. sonnei were detected in the stools. Escherichia coli was identified in the blood by matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry, although after re-evaluation with biochemical and antiserum agglutination tests, the isolate was confirmed as S. sonnei . After adjustment of the antibiotic therapy to vancomycin, meropenem, amikacin and metronidazole and continuing with ECMO and IABP support for 8 days, the patient improved and was finally discharged after 44 days.

Conclusion. S. sonnei bacteraemia is an unusual entity that should be kept in mind because of the severity of its presentation and high mortality. In acute gastroenteritis and fever, especially in paediatric patients under 5 years old and adults with criteria for immunosuppression or chronic diseases, blood and stool cultures provide simple information that is nonetheless very important for the management and prognosis of these patients.

Abscesses caused by the genus Nocardia spp are relatively rare, accounting for approximately 2 % of all brain abscesses, but with a significantly higher mortality. Special stains of brain abscess material from a 60-year-old man showed Gram-positive branching bacilli and the presence of long, acid-fast branching filamentous bacilli suggesting Nocardia infection. Presented here is a case of multidisciplinary management of a patient who developed cerebral abscesses by Nocardia farcinica , confirmed by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), that was susceptible to trimethoprim/sulfamethoxazole, linezolid, imipenem and not susceptible to minocycline. This case highlights the importance of performing subtyping and antimicrobial testing in order to improve clinical and treatment outcomes due to patterns of antibiotics resistance among Nocardia species.

Introduction. Post-operative meningitis (POM) is a life-threatening complication of neurosurgery. Diagnosis is often difficult due to pre-existing inflammation and antecedent antimicrobial use. Bacterial cerebrospinal fluid (CSF) cultures may reveal no growth, but empiric antibiotics are typically given due to the high morbidity and mortality associated with POM. 16S rRNA gene PCR/sequencing is a molecular methodology that can identify the presence of bacteria regardless of viability for culture.

Case Presentation. A patient presented with a rapid onset of fever associated with headache, neck pain, nausea and altered mental status 11 days after undergoing laser interstitial thermal therapy for treatment of recurrent astrocytoma at another hospital. Based on clinical presentation and imaging, POM was suspected, and empiric antibacterial therapy was started. Microbiological stains and cultures of CSF were negative. Due to persistent fevers, 16S rRNA gene PCR/sequencing was done on CSF; it detected a member of the order Enterobacteriales most closely resembling Serratia species. All antimicrobials were stopped except for cefepime, which was given for 2 weeks. The patient’s mental status fully recovered.

Conclusion. The application of 16S rRNA gene PCR/sequencing in the setting of POM is of value by improving the quality of patient care and decreasing costs by antimicrobial de-escalation. Further studies regarding the positive and negative predictive values of this test are required.

We report a case of catheter-associated Elizabethkingia miricola bacteraemia in a haemodialysis patient. The patient was a 73-year-old home haemodialysis patient who presented with a history of recurrent falls and fevers. Blood cultures grew Gram-negative bacilli identified by MALDI-TOF MS (matrix-assisted laser desorption/ionization time-of-flight mass spectrometry 6903 MSP Library) and 16S rRNA gene sequencing as E. miricola. E. miricola is an emerging human pathogen and is multidrug-resistant, making the choice of antimicrobial therapy challenging. There are only a small number of case reports of human infection worldwide and this is the second reported case of catheter-related bacteraemia. It has also been found in the hospital environment in South Korea and is pathogenic in black-spotted frogs.