- Volume 2, Issue 2, 2020

Background– Candida aurisis an emerging fungus which has caused nosocomial outbreaks worldwide. Screening for surveillance is challenging as it’s a slow grower, samples may have multiple candida spp and many commercial assays have limited accuracy. Following an outbreak in 2016, a real-time PCR was developed for rapid patient and environmental screening. Laboratory parameters, results and pitfalls from Jan 2018 to March 2019 are described.

Methods– Evaluation was performed using EQA panels and validated on clinical swabs and urine samples. Patient screening was performed in high risk clinical areas from nose, throat, axilla and groin swabs and catheter urine. Environmental screening was done in areas where transmission was detected. Positive or indeterminate samples were cultured and colonies identified on the Vitek 2 and confirmed by PHE reference laboratory.

Results–The Limit of detection was 100 organisms/ml. Sensitivity, specificity, PPV and NPV were 100.00%, 99.35%, 85.71%, and 100.00%. 4,792 urines and 10,819pooled swabs were tested. 21 colonised patients were identified in two outbreaks and two isolated transmission events. Median turn-around time for positive results was 24h30min (range 04:22-96:46h) and 143h14min (range 75-406h) for PCR and culture respectively. Urine samples did not add to the overall sensitivity of screening.C. aurisDNA was detected in 30/84 (35%) environmental swabs but C. auris isolated in only 2/84. Drawbacks of the PCR include reagent contamination seen on two occasions.

Conclusion – C. auris screening by PCR is a rapid means of detection in both patients and environment but prudent use of culture is required to help determine infectivity.

A 83 year old man presents with anorexia, rigors and cough after a cruise along the Scandinavian coast/British Isles. Febrile 38.7C, tachycardic but haemodynamically stable, with marked thrombocytopenia(41), abnormal PT(15), renal impairment, raisedCRP, normal WC's including differential and CXR. Throat swab, serial blood cultures, MSU culture-negative. Despite IVfluids, broad spectrum antibiotics for presumed lower respiratory tract infection with AKI and delirium pyrexia persists, CRP rises to 223, and he develops abdominal pain, jaundice (Bilirubin158, AST249, ALT94, AlkP277), worsening renal function (Crea543) oliguria, anaemia (Hb7.6, haptoglobin<0.03g/l) with worsening confusion and bruising suggestive of a hepato-renal syndrome with DIC prompting transfer to the regional ID unit. PMH includes AVR/TAVI, PUD, Waldenstroem's macroglobulinaemia previously receiving IVIG's and Rituximab, last 3 months prior. Extensive travel history, Nigeria ('60ties,'90 and 2003)), Kenya, Malaysia/Taiwan, Indian Subcontinent ('70ties), South Africa ('97) Korea (2011). A blood film suggest malaria 20-30%parasitaemia, posing speciation difficulty. Of note he spent most summers on Great pond/Belgrade(Maine/USA), most recently 4 weeks before presentation, pointing towards epidemiological Babesiosis exposure particularly in an immunocompromised individual with a negative RDT for P.falciparum, later confirmed as 22% parasitaemia, B.microti ELISA+ve, IFAT+ve1:320 (negative blood-borne-virus-screen, Leptospira-DNA, Hantavirus-IF, B.burgdorferi and Anaplasma-IF). Despite IV Cefotaxime, Artesunate, po Doxycycline, Atovaquone/Azithromycin together with IVClindamycin/Quinine, - a pan-reactive auto-Ab panel, prevented Exchange transfusion-, he deteriorates rapidly despite full organ support and dies from multi-organ-failure. Ferritin elevation > 16.000 suggests Haemophagocytic Lymphohistiocytosis confirmed on post-mortem. Epidemiology, diagnosis, prognosis and treatment of Babesiosis will be discussed.

Background: Previous regional antimicrobial meetings identified duplication of antimicrobial stewardship work in Acute trusts. In 2018, collation of guidelines for hospital acquired pneumonia, community acquired pneumonia and urinary tract infections led to creation of exemplar guidelines. All documents were emailed, which was inefficient due to volume, with no central repository that could be accessed across sites. Given the regional shortage of microbiologists, easy access to job descriptions and business cases was considered essential to improvement of pharmacy staff resources regionally.

Aim: To create an open access regional hub for antimicrobial resources within Yorkshire and the Humber using the Specialist Pharmacy Service (SPS) website.

Methods: The Yorkshire and Humber Antimicrobial Pharmacy Group’s objective is to continuously improve antimicrobial stewardship and infection management through networking, sharing best practice, learning, peer support and joint working/initiatives. Starting in March 2019, resources were submitted to the SPS website.

Results: A total of nine job descriptions were uploaded, along with members of the group, educational links such as the #todipornottodip campaign, terms of reference, annual workplan, meeting agendas and a brief summary of the group’s objectives and regional geography.

Conclusion: The SPS website has facilitated a more efficient sharing of regional antimicrobial stewardship resources. Further work is warranted for sharing education resources, and business cases that don’t contain commercial information. As the site is open access, a decision was made to continue emailing meeting minutes.

Introduction

The pathological invasion of a joint and subsequent inflammation is known as septic arthritis. The hip and knee are the most frequently involved joints. Staphylococcus aureus is the most common cause of septic arthritis in children. In clinical practice, the diagnosis of septic arthritis is based on isolation of causative organism from the joint fluid or positive blood cultures plus clinical and/or radiological signs and symptoms consistent with septic arthritis.

Methods

A retrospective analysis was undertaken of paediatric joint infections presenting to the Gold Coast Orthopaedic Department between January 2008 and December 2017.

In mid-2018, a Carbapenemase-producing Enterobacteriaceae (CPE) cluster was investigated in the North East of England, in which transmission had occurred across several hospital trusts. We undertook a survey of current CPE detection and management practices in North East and Cumbria (NEC) trusts to inform a harmonised approach that could be adopted across the region.

A semi-structured survey was carried out with one consultant microbiologist per trust by telephone interview (n=6) or electronic questionnaire (n=3) to determine CPE screening procedures, laboratory techniques and patient management practices.

Screening policies were in place in all trusts, including screening protocols for patients previously admitted outside of the UK or those known to be CPE positive, in accordance with PHE guidelines. Policies for screening patients who had been admitted to other UK hospitals varied across trusts, as did laboratory methods used. Over 80% of trusts communicated CPE status to patients and contacts by information leaflet. However, there was no uniform way of communicating CPE status to social care settings, GPs and other hospital trusts in the event of discharge or inter-hospital transfer.

The results of the survey suggest improvements could be made to the way information on patient CPE status is shared to ensure that the risk of transmission is reduced. This includes improved communication with residential settings, primary care and other hospital trusts in the event of a discharge or inter-hospital transfer. In addition, this work will inform further discussions across NEC towards developing a single regional Infection Prevention and control strategy for CPE.

Background: Isavuconazole (ISV) is a second-generation triazole antifungal used for invasive fungal infections (IFIs). Here, we describe our experiences of ISV.

Methods: This single-centre retrospective study included all patients who commenced a course of ISV over a 3-year period (1/7/16-30/6/19). ISV was used for the treatment of IFIs when no alternative was suitable. Demographics, clinical details and antimicrobial history were obtained from our integrated electronic health record and laboratory system (EPIC).

Results: Twenty-four patients, aged between 17–78 years (median 54), received ISV in the study period. Sixteen (67%) were haematology patients. Using EORTC criteria, six had possible invasive aspergillosis (IA), 1 had a possible yeast infection, 13 had probable IA, 3 had proven IA and one had a proven yeast infection. Four were neutropenic (neutrophil count <0.5x109/L) and 7 had renal impairment. Half of the patients (12/24; 50%) had received a transplant prior to commencing (nine allografts, one kidney, one lung, one multi-visceral) and a further two underwent an allograft whilst receiving ISV. ISV pre-dose levels ranged from 1.29–7.7mg/L (median 2.73mg/L; IQR 2.1 – 3.13mg/L). ISV was given for 1–733 days (median 42 days). In patients who were still alive during therapy, the treatment duration ranged from 3–342 days (median 97 days). Ten were dead within 42-84 days of commencing therapy; 6 had died by the end of therapy.

Conclusion: Our findings suggest that ISV is used infrequently, predominantly in haematology. More data is needed to determine optimal treatment course and the role of therapeutic drug monitoring.

Background: Sepsis develops when the initial, appropriate host response to an infection becomes amplified and subsequently dysregulated. Recent research has shown that the pathogenesis of sepsis can only partially be explained by an aberrant inflammatory response, metabolic deregulation also plays a vital role. Here we have investigated the role of a novel metabolite in sepsis pathophysiology.

Methods: Urine was obtained from an LPS mouse model of sepsis and human septic patients. A colorimetric assay and mass-spectroscopy were performed to determine the expression levels of metabolite X (mX). Furthermore, mice were implanted with radiotelemetry probes and the effect of supplementation with mX on clinical symptomology was determined. Following co-administration of LPS and mX real-time measurements of temperature, heart-rate and blood pressure were obtained.

Results: The urinary excretion of mX is significantly reduced in both a mouse model of LPS-induced sepsis, and in samples taken from human septic patients. Subsequent data showed that this is due to enhanced activation of the enzyme responsible for mX degradation. Moreover, co-administration of LPS and mX in mice modulates a number of aspects of physiological responses to sepsis, and in particular, protects against sepsis-induced hypothermia. The mechanism underlying this protective effect is due to suppressed nitric-oxide signalling.

Conclusion: Our results identify a novel role for mX in sepsis pathophysiology and suggest that this metabolite is a critical diagnostic and therapeutic target for sepsis. Future studies will fully elucidate the mechanisms underlying our observations.

mX not disclosed due to IP application but will be disclosed for presentation.

A total of 335 egg samples were obtained from open market (n = 174) and poultry farm (n = 161) to isolate Staphylococcus aureus present on eggs, and determine antimicrobial susceptibility patterns. A sterile cotton swab was used to sample the surface of eggs. After sterilizing the shells, the egg contents were sampled. Isolation of Staphylococcus aureus was done based on culture characteristics, Gram staining and biochemical tests. The isolates were subjected to antimicrobial susceptibility testing using disc diffusion method. Out of the total 335 eggs sample examined, 93(27.8%) samples yielded S. aureus. Out of these, 28(17.4%) were from poultry farm while 65(37.4%) were obtained from open market. Similarly, 63(18.8%) were from the shell while 30(8.9%) were from the content. The occurrence of S. aureus in the egg shell collected from open market was significantly higher than egg shell obtained from poultry farm (P = 0.021). The level of S. aureus in egg contents was also significantly higher in the open market (P = 0.003). All 76 S. aureus isolates were resistant to at least one of the antimicrobials tested with overall 3.9-92.0% level of resistance pattern showing higher resistant to penicillin (92%), ampicillin (89.5%) and amoxicillin (55.3%). Multiple drug resistance to more than two antimicrobial agents was detected in 86.8% of the total S. aureus isolates. The study showed high level of S. aureus with considerable antimicrobial resistant pattern. Further study is needed to better define bacterial resistance to antimicrobial agents with emphasis on surveillance of multiple drug resistant.

Multi disciplinary antimicrobial ward rounds have been demonstrated to be effective in promoting good antimicrobial stewardship (AMS) within hospitals. The ability to review patients’ current antibiotic treatment and intervene in a timely fashion is essential in this process. Hospital Electronic Prescribing and Medicines Administration (HEPMA), where available, is an invaluable aid in this but, for many Health Boards, its introduction is still a long time in the future.

In the absence of HEPMA, other surrogates can be used, such as pharmacy stock software, to identify patients requiring AMS review e.g. for use of “alert” antibiotics. These systems would not, however, provide patient-level information from stock issues to ward areas.

This study investigated the potential of ward electronic medicine dispensing cabinets to provide patient-level data on alert antibiotic use in a hospital where HEPMA was not in use. Daily reports on “alert” antibiotic issues were sent via automated message to the Consultant Microbiologist and Antimicrobial Pharmacist. Patients’ antibiotic use was then reviewed and documented using ICNET software.

Data from AMS ward rounds over a period prior to and after the introduction of electronic cabinet reporting were analysed. A 50% increase in the identification of alert antibiotic issues was seen after the introduction of electronic cabinet reporting. Over a one month period, time for AMS intervention was reduced by an average of 8h (range 3.5-28.5h) with the use of cabinet reporting.

Electronic cabinet reporting has been shown to be a useful tool for facilitating good antimicrobial stewardship in a general hospital.

Introduction: Clostridium difficile is the leading cause of hospital-acquired diarrhoea, driven mainly by the consumption of 4C antibiotics (co-amoxiclav, clindamycin, cephalosporins and ciprofloxacin). In order to support secondary care clinicians in prescribing antibiotics, an algorithm helping to identify patients at high risk of contracting Clostridium difficile infections (CDI) has been created. The aim of this study was to identify factors that are influencing the implementation of a risk predictive tool in secondary care, focusing on podiatrist as potential users.

Methods: Four podiatrists from NHS Fife were interviewed to gather their perception of CDI, the antibiotic prescription process, and the usefulness of a CDI tool in supporting their antibiotic prescribing decisions. The interviews were thematically analysed in NVivo using the consolidated framework for implementation research.

Result: A facilitator emerged during the interviews suggested that, although podiatrists tend to not prescribe 4C antibiotics, they comprehend the risks involved with CDI. Therefore, for patient’s safety netting purposes, the use of the CDI tool during consultations was considered useful. However, a barrier emerged suggested that, although implementing the tool into their electronic system was deemed favourable, this isn't feasible, due to patient data in secondary care being allocated in different systems. Therefore, standalone app or website platforms were perceived as more appropriate to develop the CDI tool.

Conclusion: In general it was understood that podiatrists are supportive in having a CDI tool, however, due to the impossibility of implementation of the tool into their system, a website or app will be developed.

Intro:

Co-amoxiclav use in Forth Valley Royal Hospital is significantly higher than any other acute hospital site in Scotland. The drug is metabolised and excreted renally and its dosage is dependent on renal function.

Background - This study aims to compare the bacterial killing and suppression of resistance emergence of intermittent and prolonged infusions of piperacillin/tazobactam (PTZ) against clinical K. pneumoniae isolates.

Methods - Two clinical isolates, CTX-M-14 producing #69 (MIC 1 mg/L), and DHA-1, SHV-106 producing #68 (MIC 8 mg/L), were studied in a dynamic hollow-fiber infection model over 7 days (initial inoculum 107 CFU/mL). Three piperacillin doses (4/0.5g over 0.5h, and 4h infusion 8 hourly; 12/1.5g continuous infusion 24h) against #69, and six dosages of piperacillin (4/0.5g over 0.5h, and 4h infusion 8 hourly, and 12/1.5g continuous infusion 24h; 4/0.5g over 0.5h, and 3h infusion 6 hourly, and 16/2g continuous infusion 24h) against #68 were tested. The total and less-susceptible bacterial populations were determined.

Results - For all PTZ dosing regimens against #69, there were ∼4 logs of bacterial killing over 8h. The amplification of less-susceptible subpopulation were associated with intermittent infusion (T>MIC 90%, Cmin/MIC = 0.4) after 24h, and with extended infusion (T>MIC 100%, Cmin/MIC = 2.76) after 72h. However, continuous infusion (Cmin/MIC = 35) prevented drug resistance amplification and sterilized the model system. For #68, there was a similar initial bacterial killing profile; however, all regimens were associated with the emergence of a resistant subpopulation after 8h. The MIC of resistant subpopulations exceeded 256 mg/L.

Conclusions – To maximize bacterial killing and suppress the emergence of resistance of multiple-beta-lactamases producing K. pneumoniae isolates with higher MIC alternative therapeutic strategies are required.