- Volume 2, Issue 2, 2020
Volume 2, Issue 2, 2020
- Abstracts from the Federation of Infection Societies Conference 2019
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- Poster Presentation
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Airborne Decontamination of an Intensive Care Isolation Room using 405 nm Antimicrobial Light Technology
More LessLighting systems which incorporate antimicrobial 405nm light have been developed for safe continuous, environmental decontamination, with previous studies demonstrating efficacy for decontamination of frequently-touched surfaces around clinical areas. This study provides first direct evidence of the effects of this decontamination system for control of airborne contamination.
The study was conducted in a patient-occupied ICU isolation room over a 15-day period, with air samples collected at set times (before, during and after daily use of the decontamination system). Samples were also collected in the empty room prior to occupation. Environmental monitoring occurred every second day using a sieve-impactor sampler (500L air samples collected every 10-min over 2-hr (n=13)). Room activity was logged and bacterial contamination levels recorded as cfu/m3of air.
After 2-day use of the system, airborne contamination significantly decreased from a mean of 905.2 cfu/m3 to 48.8 cfu/m3 (P=0.002). Levels then remained fairly consistent over the remaining period of system use (48.8-189.8 cfu/m3) before significantly rising after the system was turned off for 3-days (P=0.001). Additional samples collected in isolation rooms without the decontamination system demonstrate that the levels of airborne bioburden tend to increase upon increasing patient stay, however low levels were maintained as patient occupation increased when the system was in use.
This study provides first direct evidence of the susceptibility of airborne bacteria to 405nm light within a clinical setting. This patient-safe technology has the potential to improve infection control strategies by complementing existing measures, which could reduce the number of infections arising from environmental sources.
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An unusual case of Mycobacterium chelonae infection
More LessIntroduction: A 32 year old lady developed multiple distinct, purple, raised, itchy lesions on her limbs, during a prolonged hospital admission. The lesions developed over six to eight weeks with no evidence of improvement. One lesion was biopsied and sent for analysis.
The patient had a background of end stage renal failure from Anti-glomerular basement membrane (Anti-GBM) disease and she went on to receive a renal transplant. Eleven months prior to her hospital admission her transplant failed from de-novo focal segmental glomerulosclerosis. She had been admitted for 9 months with an eating disorder and malnutrition. She had been off any immunosuppressive agents for 6 months at the time that the lesions appeared.
Methods: The lesion biopsied was consistent with a dermal abscess. The Ziehl-Neelsen stain was negative but a mycobacterium was cultured. This was confirmed to be Mycobacterium chelonae on reference lab testing (sensitivities awaited). She had no other lesions of concern on imaging.
Results:Due to the disseminated nature of the lesions she was started on a 2 week course of intravenous amikacin with oral azithromycin and levofloxacin; the oral components to be continued for 2 to 6 months dependent on clinical response.
Discussion:Mycobacterium chelonae is a nontuberculous mycobacterium abundant throughout the environment. It commonly causes skin lesions or cellulitis as well respiratory disease and urinary catheter colonization. It is a less common Rapidly Growing Mycobacterium (RGM) which usually occurs in patients on immunosuppression. The immunosuppressed state in this case was that caused by dialysis and malnutrition.
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Intravenous drug use causing Enterococcus Faecalis bacteraemia, mycotic pulmonary artery aneurysm and suspected Mucormycosis
More LessBackground33 year old previously fit and well lady with a history of previous drug use presented generally unwell with shortness of breath and cough.
Methods
Initial investigations demonstrated marked inflammatory response with bilateral pneumonia on chest xray. She was initially treated for severe community acquired pneumonia. On day 3 of admission blood cultures isolated Enterococcus faecalis, which was later also isolated in sputum.
ResultsTransthoracic echo demonstrated no evidence of vegetations to suggest endocarditis. Despite appropriate antibiotic switch inflammatory markers increased, and a groin abscess was suspected on clinical examination leading to CT angiogram in addition to CT thorax. Imaging demonstrated left ileofemoral DVT and a large pulmonary artery aneurysm with multiple cavitating pulmonary lesions. Following discussion with cardiothoracics the patient was transferred to a cardiothoracic centre for left lower lobectomy and lingulectomy. Histopathological perioperative samples showed branching fungal hyphae within multiple blood vessels, although 18s PCR returned as negative. The patient had a good clinical response with IV Amoxicillin and antifungal therapy - Oral Posaconazole was used as she suffered an adverse reaction to liposomal Amphotericin B.
Discussion
Final impression was of mycotic pulmonary artery aneurysm caused by Enterococcus faecalis with suspected mucormycosis as result of intravenous drug use. This case highlights the increased risk of mucormycosis in people who inject drugs.
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Candida aurisexhibits resilient biofilm characteristics in vitro: implications for environmental persistence
In the decade since its discovery, Candida auris has rapidly became a serious problem within healthcare environments. This fungal pathogen readily colonises skin and is responsible for numerous hospital outbreaks in different continents presenting high morbidity and mortality rates. However, the mechanisms it uses to spread throughout nosocomial settings still remains enigmatic. C. auris biofilm formation was monitored in real-time and the transcriptome of these biofilms were identified using RNA-sequencing and the ability of C. auris to persist on a polymer surface and tolerate treatment with a commonly used disinfectant in sodium hypochlorite (NaOCl) was assessed. Contrary to previous findings, C. auris biofilms were found to be heterogeneous and not dependent on cell phenotype. Through transcriptomic analysis and assigning transcripts into GO terms, a large number of genes involved in cell components, specifically fungal cell wall and cell membrane. Genes involved in these components were also up-regulated in dry biofilms of aggregating fungal cells compared to their single-cell counterparts. Aggregating C. auris biofilms were able to persist and tolerate disinfectant treatments more successfully than single-cell biofilms. These findings show that the aggregating phenotype of C. auris likely helps drive its survival and spread throughut hospital wards during outbreaks. Nonetheless there are still caveats in our understanding of C. auris biology and filling these holes will help in the development of more effective decontamination and infection control protocols for this emerging and deadly pathogen.
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Vancomycin continuous infusion - review of use on our adult intensive care unit and establishing therapeutic loading dose
More LessBackgroundReviewing compliance to our Trust guidelines on AICU led us to investigate whether the loading dose prior to continuous infusion was sufficient to achieve therapeutic levels at first measurement.
Methods
Retrospective data was pulled (January 2011 - June 2017) from a data interrogation system (SAS Enterprise Guide) which linked patients receiving continuous infusion vancomycin at a concentration of 500mg/50ml. This was presented into Excel spreadsheets, additional headings added for data interpretation, then manipulated into pivot tables to determine objectives.
ResultsIn 82 courses of vancomycin continuous infusions in 70 patients, 53 received correct loading doses. 31 courses had continuous infusion started within 2 hours of loading dose finishing. 13 courses started at the correct rate. 12/13 courses had vancomycin levels taken. Only one course reached therapeutic range at the first level taken (19.5mg/kg). Of the remaining 11 courses which were out of range, 7 were titrated appropriately – 6 became therapeutic, one remained out of range and was stopped. 3 were not titrated correctly and remained out of range or not titrated at all.
Conclusion16% (13/82) of all continuous vancomycin infusions on AICU complied with guidelines. Only one patient who received the highest weight-based loading dose of 19.5mg/kg reached therapeutic range at the first level monitored, suggesting that doses of ≥20mg/kg at loading are required.
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Utilisation of Antimicrobial Stewardship (AMS) Electronic Interventions (i-Vents) as a metric of pharmacy AMS at Cambridge University Hospitals (CUH) NHS Foundation Trust
More LessBackground: The aim of the project was to identify the contribution clinical pharmacists make to antimicrobial stewardship (AMS) at CUH. The EPIC e-hospital system in place allows pharmacists to record interventions (i-Vents) electronically; these can be used as a metric of pharmacist AMS.
Method:A bespoke electronic report of all AMS i-Vents which occurred in April 2018 was generated using EPIC.Each i-Vent was categorised by type, clinical speciality, grade of pharmacist making the i-Vent and whether the i-Vent was following on from a previous one. The antimicrobials(s) mentioned in each i-Vent were also recorded.
Results:During April 2018 554 pharmacist i-Vents were recorded. I-Vent types included therapeutic drug monitoring (31%), dose optimisation (22%), course length optimisation (12%), interaction and contraindication management (2%) and patient counselling (0.2%). AMS i-Vents were recorded for patients under the care of 42 clinical specialties including neonatology (12%), diabetes and endocrinology (11%) and respiratory (8%). I-vent numbers increased with seniority of pharmacist with band 8 pharmacists making the most interventions (44%) and band 6 pharmacists making the fewest (16%). There were 645 separate references to a total of 53 individual antimicrobial agents. The top three drugs mentioned in i-Vents were vancomycin (30%), gentamicin (12%), and ciprofloxacin (8%). Follow-up i-Vents constituted 111 (20%) of all recorded i-Vents.
Conclusion:Our findings demonstrate that pharmacists contribute significantly to AMS at CUH, especially on therapeutic drug monitoring and dose-optimisation issues.We suggest that AMS i-Vents are a reliable metric for monitoring AMS pharmacist activities, related directly to patient care.
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Combination of Bedaquiline plus Delaminid within a treatment regimen for Pre-XDR TB; experience of a tolerable regimen and acceptable safety profile for the first time in Scotland
More LessIntroduction: A 29 year old female of Pakistani origin was diagnosed with MDR-TB affecting cervical nodes, with pulmonary and laryngeal disease demonstrated on CT. Genotypic (and subsequent phenotypic) testing demonstrated pre-XDR resistance pattern with Izoniazid, Rifampicin, Ethambutol & Fluroquinolone resistance.
Methods: Following commencement of induction regimen with Amikacin, Cycloserine, Prothionamide, Pyrazinamide, Linezolid and Clofazimine, borderline ototoxicity developed after 6 months, necessitating a switch from Amikacin to Bedaquiline. After around 10 months, Linezolid and Cycloserine were discontinued sequentially due to progressively debilitating peripheral neuropathy, PAS was subsequently added to the regimen which was poorly tolerated. PAS was substituted for Delaminid (used with Bedaquiline, Clofazimine and Pyrazinamide) despite concerns regarding potential cumulative QTc prolongation effects. Patient was counselled regarding risk of cardiac arrhythmias; fortnightly ECG monitoring was agreed to for three months, then monthly thereafter. Manual calculations of QTc were performed using Fredericia formula.
Results: QTc rose maximally to 491 ms (89ms greater than baseline). Clinical and radiological monitoring demonstrated favourable improvement in condition. No further adverse events or toxicities were reported. The patient continues to tolerate the regimen well with no components of the regimen requiring discontinuation.
Dicussion: Bedaquiline and Delamanid are rarely used together in combination due to risk of QTc prolongation; in this clinical case they were used with no concerns being raised regarding safety or tolerability. Our experience corresponds with the international data produced by Ferlazzo et al. Whilst further large volume safety data is awaited, compassionate use of alternative drug regimens within strict monitoring guidelines should be considered.
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A 12 month follow-up looking at improvements to adult inpatient gentamicin prescribing and the role of the antimicrobial pharmacist
More LessBackgroundAudits at Mid Yorkshire NHS Trust have identified inappropriate prescribing of gentamicin. Antimicrobial stewardship (AMS) interventions in hospital have increased adherence to antimicrobial prescribing policies2.
MethodsPre-intervention data were collected by the antimicrobial pharmacist in January 2018. Interventions were then completed and included: oral presentations, targeted reviews and teaching sessions. Inappropriate indications or doses received routine AMS intervention. Following interventions a second audit was completed in May 2018 to measure improvements in prescribing. A second intervention was the introduction of a 5 day review service of prescribed gentamicin and a third audit was completed in August 2019 to demonstrate a sustained improvement.
ResultsIn total, 25 patients were audited in January 2018, 24 patients in May 2018 and 29 patients in August 2019. The three groups were similar for age, sex and reason for admission. The proportion of patients receiving an appropriate initial dose of gentamicin increased from 13/25 patients (54%) to 19/24 patients (79%) and again to 27/29 patients (93%). The proportion of patients that had the subsequent dose of gentamicin prescribed appropriately increased from 9/25 patients (36%) to 20/24 patients (83%) and again to 29/29 patients (100%).
ConclusionsThis project demonstrated a sustained improvement in gentamicin prescribing following a series of pharmacist-led education and training sessions, one to one training, presentations at governance group meetings and the introduction of a 5 day pharmacist review service. The sample was limited to those patients who had levels taken.
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A large-scale pragmatic automated audit of the appropriateness of antibiotics initiated for presumed community-acquired pneumonia using a novel algorithmic approach
BackgroundAudit is a fundamental part of antimicrobial stewardship, but this has traditionally been labour-intensive. The advent of fully electronic records (EPIC) at Cambridge University Hospitals (CUH) presents novel opportunities for large-scale automated data analyses and feedback. We developed and validated an algorithm to audit the appropriateness of prescriptions initiated for presumed community-acquired pneumonia (CAP).
Methods
We developed an algorithm that extracts prescription and clinical data from EPIC, calculates CURB-65 scores, and assesses the appropriateness of antibiotics with an indication of CAP against Trust guidelines based on predefined rules. Clinical data included age, gender, blood results, vital signs, NEWS-2 score, MRSA status, penicillin allergy and pregnancy status. Prescriptions were limited to 48 hours from admission. The accuracy of the algorithm was validated in a representative sample of 30 patients.
We present data on all prescriptions initiated for CAP admitted to CUH between September 2018 and June 2019.
ResultsOn validation, the algorithm calculated the CURB-65 score with an accuracy of 97% and correctly categorised antibiotic appropriateness in 98.5% of cases. Only 15% of patients had a CURB-65 score documented in the notes.
The algorithm evaluated 4,307 prescriptions in 2,198 patients. Appropriateness was significantly better in CURB-65 scores of 2-5 (83.7%) versus 0-1 (33.5%) largely due to over-prescription of co-amoxiclav in the latter.
ConclusionThis algorithm enables large-scale analysis of prescriptions initiated for CAP with high accuracy automating the audit cycle. An automatically calculated CURB-65 score has the potential to reduce over-prescribing of co-amoxiclav and should be evaluated in the future.
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Experience of adopting a standardised nomogram for gentamicin monitoring- an audit
More LessBackground:Gentamicin, an aminoglycoside antibiotic, requires therapeutic drug monitoring to decrease the risk of nephrotoxicity and ototoxicity. We audited compliance with our dosing and monitoring guidelines since adoption of the Barnes-Jewish Nomogram for once daily 5mg/kg dosing in September 2018.
Methods:We retrospectively reviewed 62 patients who received 171 gentamicin doses with 173 accompanying levels taken between 1/11/18 and 31/1/19.
Results:The audit demonstrated overall poor adherence to guidelines. Only 50% of patients received the correctly calculated dose. 40% of gentamicin levels were taken between 6-14 hours resulting in a large number of uninterpretable levels requiring additional actions e.g. repeat levels. 50% of follow up doses were given in the correct time frame. For patients with normal renal function twice weekly monitoring is recommended. In all cases (n=35) where this applied levels were monitored more frequently that indicated. U&Es were regularly monitored for all patients and we did not identify any acute kidney injury.
Conclusion:The Barnes-Jewish nomogram was adopted to provide a standardised evidence based monitoring system for gentamicin. However our audit demonstrates the guidance was not well executed clinically. There appeared to be a lack of appreciation and responsibility for monitoring and interpretation of levels. This resulted in erratic sampling, unnecessary levels, and delayed doses. As a result of this audit we intend to adopt a simpler trough level system based on the gentamicin SPC. Our audit demonstrates the need to evaluate service improvement implementations since theoretical benefits do not always translate in to clinical practice
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National Audit of Meningitis Management (NAMM): a National Infection Trainee Collaborative for Audit and Research (NITCAR) audit of adherence to the 2016 UK joint specialist societies’ guideline on the diagnosis and management of acute meningitis in adults
BackgroundBacterial meningitis has significant mortality but frontline doctors will see it infrequently. Therefore, UK guidance on meningitis in adults, with auditable standards, was revised in 2016. We undertook a national audit to assess adherence to the guidelines.
Methods
Patients with community acquired meningitis were identified through coding or laboratory data. Audit standards, including immediate management, diagnostics and treatment, were evaluated by notes review.
ResultsNotes from 1472 patients with meningitis were reviewed – 309/1472 (21%) had bacterial aetiology, 615/1472 (42%) viral, 548/1472 (37%) unidentified aetiology. Only 50% of patients had blood cultures taken within one hour of admission and just 2% had a lumbar puncture (LP) within the first hour. 27% received antibiotics within one hour. Most patients received ceftriaxone or cefotaxime but only 37% of over-60s received empirical anti-listeria antibiotics. 26% of patients who had antibiotics were given adjunctive steroids. Half had CSF microscopy within two hours of LP. Less than a third had pneumococcal and/or meningococcal PCR on cerebrospinal fluid. Only 44% had an HIV test. 62% had unnecessary neuroimaging before LP. Overall mortality was 3% - 16% in pneumococcal disease and 8% in meningococcal meningitis. There was a trend toward improved survival in patients with pneumococcal meningitis who received dexamethasone [85/96 (88%)] compared to those who did not [57/73 (78%)] (p=0.066).
Conclusions
Adherence to the meningitis guidelines is inadequate, potentially compromising patient safety. Improvements in guideline dissemination, novel educational resources and clinician and patient engagement are required if we are to increase guideline adherence and improve outcome.
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Sepsis Six implementation on a general surgical ward. More work to be done
Background: Sepsis can lead to significant morbidity and mortality if not recognised and managed early. On the basis of national mortality reports, Irish guidelines recommend that patients at risk of neutropenia, patients with sepsis or those with a systemic inflammatory response (SIRS) with one plus co-morbidity should receive Sepsis Six. We assessed the implementation of the Sepsis Six on a surgical ward in our institution.
Methods: All inpatients on a surgical ward in July 2018 were prospectively assessed for the presence of infection and sepsis. If the Sepsis Six was required, implementation of each of the Sepsis Six elements was recorded.
Results: Of 164 patients, 40.2% (66/164) developed an infection of whom 47% (31/66), met the criteria for requiring Sepsis Six. Of these, 7.3% (12/164) patients had sepsis, with 3% (5/164) developing septic shock. Patients required Sepsis Six for the following reasons: ³1 co-morbidity and ³2 SIRS criteria(n=19); new onset organ failure (n=12) and neutropenic risk(n=0).Only 12.9% (4/31) patients received all of the Sepsis Six elements within one hour; 77.4% (24/31) received some and 9.67% (3/31) did not receive any elements. Blood cultures were taken in 54.8% (17/31) of cases but only 32.3% (10/31) patients had their lactate level checked.
Conclusion: Further research action is required to better understand and improve Sepsis Six implementation. This should facilitate improved sepsis recognition and enhance patient care.
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Gram-negative Galore and the Gut
More LessAn 81-year-old diabetic man with PAF, pleural thickening due to benign fibrous pleuritis and a PPM developed rigors/pyrexia (39°C) with no localising signs of infection. Blood cultures grew Pseudomonas aeruginosa (May 2017) and Enterococcus faecalis (November 2017), MSU was negative and imaging was normal. Readmitted in May 2018 and discharged clinically well with CRP 40 and no acute abnormalities on investigations, he returned with further rigors the following day with E. coli and Enterococcus faecium bacteraemia, treated with Tazocin/Tigecycline. CT colonography revealed a primary recto-sigmoid tumour with high-grade dysplasia on biopsy. In July 2018,he developed a Pseudomonas aeruginosa bacteraemia responding to Tazocin/Ciprofloxacin. Planned surgery was delayed due to anaesthetic instigated pre-operative cardiac rehab optimisation. In August 2018, further rigors/pyrexia were empirically treated with Tazocin/Teicoplanin/Amoxicillin for 3 weeks covering a Staph epidermis/capitis bacteraemia. He underwent an open Hartmann’s with total mesorectal excision two weeks later, complicated by pre-sacral collections drained transcutaneously. Suboptimal antibiotic cover however led to further pseudomonas bacteraemia three weeks later and pseudomonal bacterial peritonitis three months later, managed with prolonged meropenem/ciprofloxacin therapy. TTE two months post-discharge showed a 1cmx0.5cm mass on the RV lead of his pacemaker leading to its removal. Repeat TTE showed tricuspid valve endocarditis with a 2.2cmx0.3cm mobile mass and severe TR. Six weeks of Meropenem therapy achieved sterilisation without further complications. Infectious diseases specialist input should be sought early and can be pivotal in appropriate source control and adequate antibiotic management following organism identification.
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Difficile but not impossible: Improving documentation to improve outcomes for Clostridium difficile infections in NHS Ayrshire and Arran
More LessBackgroundClostridium Difficile Infection (CDI) varies in severity and presents challenges in management. Whilst incidence is decreasing, the mortality rate in NHS Ayrshire & Arran is 10%. We evaluated if a new infection severity assessment sheet improved management.
MethodA retrospective case note review was performed on all cases of CDI, confirmed by clinical symptoms and laboratory sampling. Our audit assessed both predisposing factors and management. The first cycle ran from January-March 2018. The second cycle ran May-November 2018 after the introduction of the new severity assessment sheet.
ResultsThere were 20 episodes of CDI in the first cycle, and 38 episodes in the second cycle (n=58). Following introduction of the new severity assessment sheet CDI diagnosis, management and documentation improved. High-risk antibiotic use prior to CDI fell from 65% in the first cycle to 34% in the second cycle. Discussion of CDI diagnosis with relatives increased from 70% to 86.8%. Documentation of day 1 and 5 infection severity scores improved (50% to 57.9% and 10% to 31.6%, respectively). Improvements were noted in prompt stool sampling after symptoms (90% to 97.4%), fluid balance chart use (80% to 89.5%), stopping unnecessary antibiotics (58.3% to 81.3%) and documentation of daily assessment (5% to 23.7%).
ConclusionThe results highlight positive improvement in outcomes following a well-publicised introduction of an improved CDI proforma. Despite this, further intervention and monitoring is required to improve documentation of daily assessment in CDI. Additionally, there is still progress to be made to prevent unnecessary use of high risk antibiotics.
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Key factors around successful management of CPE infection in a patient with pancreatic collection
More LessCarbapenemase-Producing Enterobacterales (CPE) are threat to public health as they are resistant to one of the broad-spectrum antibiotic classes (Carbapenems) in clinical use.
In this report we highlight the need for optimal choice and duration of antimicrobial therapy in combination with source control for successful management of CPE infection.
A 52-year old male was admitted under general surgery with CT confirmed severe pancreatitis. He was commenced on cefuroxime and metronidazole for associated cholecystitis based on local guidelines. Treatment was gradually escalated to Meropenem due to intermittent pyrexia and inadequate response to standard antimicrobial therapies with no obvious source control solution. Following 39 days of Meropenem the fifth CT scan showed drainable peri-pancreatic collections. The drained pus sample grew Escherichia coli and Bacteroides species. The Escherichia coli were confirmed to be CPE gene (KPC) positive by PCR and sensitive to Tigecycline and Gentamicin but resistant to Meropenem and Ciprofloxacin based on MicroScan automated sensitivity panel.
Initially Tigecycline was commenced, however, due to unsatisfactory clinical progress treatment escalated to Ceftazidime/Avibactam and Co-Trimoxazole and patient completed a three-week course. The percutaneous drain was upgraded twice to facilitate drainage. Follow-up CT showed reduction of collection and patient discharged after 115-day stay.
This case demonstrated that CPE infection should be suspected in patients with persistent fever after a prolonged course of carbapenem treatment. A prompt laboratory diagnosis and effective multidisciplinary collaboration among microbiologists, surgeons and radiologists proved to be successful in achieving source control of CPE infection in this case.
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Awareness of Primary Health Care Providers about Vaccination in Eastern regions of Ukraine
More LessBackground. A dramatic drop in routine immunization coverage is observed in Ukraine during recent years. Ukraine has the lowest rate of vaccination in Europe that imposes a high risk of communicable diseases on a population. More than 56.000 people sickened with measles from 2018-2019 yrs. Although Primary Health Care providers (PHCPs) in Ukraine play an important role in administering vaccines to their patients the data about PHCP's awareness regarding immunization are lacking.
Methods. A self-administered survey among 265 PHCPs (44 doctors, 221 nurses) was conducted during Public Health Trainings from 01 March to 31 April 2019 in three Eastern Ukrainian regions (Zaporizhia, Dnipro, Kharkiv). The level of basic knowledge on vaccines schedule, safety and efficacy of vaccination, communication skills ect (totally ten statements and ten questions) were evaluated.
Results. Overall 264 (99.6%) PHCPs highlighted the obvious need in strengthening evidence-based knowledge related to immunization topics and communication skills. Right answers regarding safety and efficacy of vaccines were obtained in 21% participants, 47% PHCPs had doubts for vaccine's safety and contradictions. Only 8% of participants were convinced in aspects of effective communication. Physicians had higher knowledge scores in routine vaccines schedule (32; 73%), compared to nurses (105; 47.5%), p=0.0016; but did not differ in aspects of vaccine's safety: 16% among physicians’ vs 17% among nurses (p>0,05).
Conclusion. The majority of PHCPs in Eastern regions of Ukraine have concerns about vaccines safety and efficacy, as well as lack of communication knowledge. Effective continuing evidence-based education of providers may help address these concerns.
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Tayside TB Pathway: A Quality Improvement Project
More LessAims:The aim of this project was to look at our local practice of identifying and managing patients with mycobacterium tuberculosis (MTB) and non pulmonary NTM. In Tayside, the care of patients with MTB is shared between the Infectious Diseases physicians and the Respiratory physicians. We aim to improve communication and identify any issues with continuity of care and create solutions to standardise the care our patients receive.
Methods:We performed an initial audit of patients that were currently receiving or had recently completed treatment for MTB and non pulmonary NTM. We collected data from 26 patients between January 2017 - July 2018.
Results:Some of the results are as follows: Out of the 26 patients, only 14 (53.8%) of those had a documented start date of treatment on the initial clinic letter. 92.3% had a documented treatment regime on clinic letter. 88.4% (23 out of 26 patients) had a documented diagnosis (specifying site) on clinic letter. Only 46% had a complete BBV screen, 35% had an incomplete BBV screen and 19% had none.
Outcome:After performing the initial audit and assessing the areas of improvement, we were able to create our “Tayside TB Pathway”. The idea behind this was to create a more cohesive and streamlined approach to TB care whilst involving all members of the MDT. The pathway was created to be straightforward and allow us to have a “centralised hub” to oversee the important steps involved in the management and prompt these to be performed where needed.
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From bedside to bench – optimising the local blood culture pathway
More LessBackgroundOptimising the blood culture (BC) pathway is essential to ensure maximal benefits for patients. There are national standards for expected turnaround times. At our acute teaching hospital, there was limited data on this. We aimed to map the local BC pathway to identify obstacles and areas for improvement in the process.
Methods
In this prospective study, all BCs taken from adult patients in the Emergency Department (ED) on allocated days over three months were included. Study days were chosen to reflect the whole working week, including out of hours. Information was gathered from multiple stakeholders, including ED clinical staff, porters, microbiology laboratory staff and clinicians. BCs were trailed from when the sample was taken until results were reported. The time taken for each stage was compared against national standards (SMIB37).
Results107 BCs were included in the study. Only 23% achieved the 4hr target between collection and incubation; times ranged from 50 mins–27hrs8mins. None of 43 samples taken at the weekend achieved the target. Process mapping allowed the following problems to be identified: fixed, infrequent transport by porters; delays between the general laboratory and the microbiology receptions; and delay in loading the analyser. BC bottles could not be transported via the vacuum system and the analyser was only accessible when the microbiology laboratory was open, which is not 24/7.
ConclusionThe BC pathway at the hospital fails to ensure that national standards are met. Identifying key bottlenecks impeding flow will help enable the trust to make essential changes.
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Voriconazole – are we doing what we think we are? A review of voriconazole use and monitoring in respiratory patients in a London hospital
More LessBackgroundVoriconazole is increasingly used in treatment and prophylaxis of respiratory fungal infections, but therapy carries a risk of significant side effects. Outpatient therapy has additional challenges for ensuring pre-treatment counselling of patients and fulfilling therapeutic drug monitoring (TDM) requirements. A review of local practice was performed.
Methods
Electronic patient records for adult Respiratory outpatients on voriconazole from November 2005 to January 2019 were retrospectively reviewed. Data was collected on patient demographics, pre-treatment counselling and TDM. Based on the results, targeted interventions were proposed.
Results21 patients commenced voriconazole between 2005 and 2019, majority (n=10/21, 47.2%) for chronic pulmonary aspergillosis. Of the 21 patients, counselling was variable regarding the risks of hepatotoxicity (12, 57.1%) and phototoxicity (13,61.9%), signs indicating hepatotoxicity (6, 28.6%) and phototoxicity (11, 52.4%), and taking photo-protective precautions (13, 61.9%). 60% (n=12/20) of patients had liver function tests measured weekly in their first month of commencing treatment, while phototoxicity was reviewed in only 10% (n=2/20) of patients at follow-up appointments. In 57.1% of patients (n=12/21), none of the 3 checklists available (HCP checklist and 2 local proformas) were used when commencing treatment.
ConclusionOur findings revealed a lack of consistency in information given to patients, documentation by clinicians, and in TDM, in spite of the existing checklists available. We propose an individual written management plan to empower patients to manage their treatment and guide clinicians in pre-treatment counselling and subsequent follow up of patients. A re-audit is planned for 6 months to assess the efficacy of this intervention.
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Early laboratory markers may reflect the severity of pyogenic liver abscess infection: Retrospective cohort study
Background:Liver abscess carries significant morbidity and mortality rate due to its complications. We aimed to identify laboratory markers associated with septic shock related to pyogenic liver abscess.
Methods:The study was conducted at Hamad General Hospital, a tertiary hospital in Qatar. Data were collected retrospectively. All patients diagnosed with pyogenic liver abscess between 2013 and 2017 were included. Liver abscess was diagnosed based on clinical presentation and radiological finding with or without microbiological evidence. Septic shock defined as the need of vasopressors to maintain mean arterial pressure > 60 mmHg. Data has been collected on admission time. Descriptive data were presented in mean ± SD and percentages. Normally distributed data were analyzed by T-test otherwise Mann–Whitney was used.Fisher Exact test was used for categorical data. The level of significance was set at P<0.05.
Results:Pyogenic liver abscess has been identified in 78 patients. 89.9% were males. 48.7% of the patients were diabetic. Nine patients (11.5%) developed septic shock. Patients who developed septic shock had higher procalcitonin level (Hazard ratio [HR] 1.025, 95% CI 1.006-1.044, p0.009) but lower level of hemoglobin (HR 0.744, 95% CI 0.581-0.952, P. 0.019), protein(HR 0.867, 95% CI 0.779-0.966, p 0.009) and platelet (HR 0.994, 95% CI 0.988-1.000, p 0.035)
Conclusion:Measurement of baseline procalcitonin, hemoglobin, protein, and platelet in pyogenic liver abscess may provide early information about the severity of the infection and the need for early aggressive management. However, a larger sample size is needed to achieve more statistical significance.
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