- Volume 2, Issue 2, 2020
Volume 2, Issue 2, 2020
- Abstracts from the Federation of Infection Societies Conference 2019
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- Oral Abstract
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Mobile Phone Contamination in Clinical Environments ‘The True Extent’
More LessSmart phones are integral , especially within healthcare. However, there are increasing concerns regarding their contamination and potential infection control risk. Bacteria under selective pressure can rapidly acquire resistant mechanisms leading to the assumption; mobile phones used within clinical environment may harbour bacteria associated with a higher infection mortality rate.
Using next generation sequencing technology, characterise the true extent of bacterial contamination on mobile phones of hospital staff and determine the presence of multi-drug resistant bacteria associated with hospital acquired infections.
DNA was extracted from the swab tips of 450 Particpant’s mobile phones. 16S rRNA primers were used to characterise and compare the microbiome on devices from the hospital staff and a control group. Staphylococcus aureus and Enterococcus faecalis underwent Kirby Baur disc diffusion.
Results The microbiome revealed the extent of contamination far exceeds anything previously reported. In particular, gram-negative bacteria (including several important potential pathogens) were grossly under detected. 198 bacteria genus were discovered on mobile phones of which 34 were unique to the hospital. Differences were also detected between hospital departments. MRSA, VRSA and VRE were only detected within the hospital group.
Our results indicate traditional culture-dependent swabbing methods don’t provide an accurate account of mobile phone contamination. This may also be true in other areas relevant to infection control. Used within clinical environments could expose patients to unknown levels of multi drug resistant bacteria. Decontamination between patient contact should be a necessity to prevent the undermining of hand hygiene and the transmission of MDR bacteria.
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Phenotypic variation of Gardnerella vaginalis subgroups in relation to virulence potential
More LessBackgroundPhenotypic 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.
ResultsThirty-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.
ConclusionG. vaginalis subgroups with different virulence potential might play distinct roles in vaginal microbiota.
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It may be a stroke, it may be meningo-encephalitis
More LessAn 85-year old lady originally from Gujurat presented to the emergency department with sudden onset left sided weakness and slurred speech. Stroke was suspected. Computed tomography (CT) of the head showed bilateral multiple cortical and subcortical hypodense lesions; magnetic resonance imaging revealed that these lesions were ring enhancing with oedema. Lumbar puncture found an opening pressure of 22cm H2O, 98% lymphocytes (60x106/L) in the cerebrospinal fluid with a normal glucose (6.1mg/L) and high protein (0.66 mg/L). Cerebrospinal fluid culture, PCR and cytology were all negative. The patient was started on empirical therapy for tuberculous meningitis. A subsequent CT chest, abdomen and pelvis however did not find any other significant pathology.
Unfortunately, soon after her investigations, the woman rapidly deteriorated. A joint medical decision was made to shift focus of treatment to palliative care. After death, post-mortem found multiple irregular haemorrhagic solid lesions with dark brown edges. Histopathology confirmed extensive areas of necrosis, within which there were multiple amoebic trophozoites and cysts. A diagnosis of amoebic (it may be) meningo-encephalitis was made. These were thought to be free-living amoebae.
Free-living amoebae are ubiquitous to the environment, and exposure is common. The incidence of amoebic encephalitis however is rare and usually occurs in immunocompromised patients. Portal of entry, especially in cases where the cerebrospinal fluid protein is only mildly raised or normal, is thought to be through the nose or eyes (for example, Acanthamoeba keratitis from contact lenses). Clinicians should consider this as a differential diagnosis for any patient with multiple brain abscesses.
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Antimicrobial stewardship ward rounds led by junior members of the healthcare team improve patient care
More LessBackgroundReported 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).
Results104 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.
ConclusionJunior staff provide valuable input regarding patient care and optimising antimicrobial therapy. There was a trend towards shorter LOS and reduced RR.
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The link between ocular infection with non-chlamydial bacteria and trachomatous eye changes
Introduction Globally, C. trachomatis is the leading infectious cause of blindness. There is evidence to suggest that trachomatous inflammation may be linked to ocular infection with other pathogenic organisms.
Methods Conjunctival swab samples from 472 Tanzanian children who participated in a 4-year longitudinal study were analysed using optimised duplex qPCR assays to assess carriage of H. influenzae, CNS, S. pneumoniae and Adenovirus spp. in each sample. The presence of C. trachomatis (Ct) in the conjunctiva had previously been recorded. Logistic regression analysis, adjusted for age and sex, was performed to identify associations between the prevalence of bacterial infection and (1) progressive scarring trachoma, and (2) active trachoma (defined as the presence of follicular trachoma (TF) or trachomatous inflammation (TI)).
Results Logistic regression identified no significant associations between (1) progressive scarring trachoma and Ct;and (2) progressive scarring trachoma and non-chlamydial bacterial infection. Active trachoma was only associated with conjunctival infection with H. influenzae. Logistic regression found that patients with ocular H. influenzae infection were more likely to demonstrate clinically-graded active trachoma (TF + TI) (OR = 1.96, 95% CI: 1.11 – 3.56, p = 0.023). Individual analyses of TF or TI and their associations with H. influenzae found (1) a strong association between ocular H. influenzae infection and TF (OR = 2.21, p = 0.0095); (2) no association between ocular H. influenzae infection and TI (OR = 2.19, p = 0.19).
Conclusion These results indicate that H. influenzae might contribute to the TF phenotype. TF is widely used to assess population levels of trachoma.
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Campylobacter lari associated Prosthetic Joint Infection
More LessCampylobacter lariis a rare cause of extraintestinal infection in humans. There has only been one prior case report of prosthetic joint infection in an immunocompetent adult, which was rapidly fatal. We can identify no previous case reports of successful management of this condition.
We discuss our management of a 63 year old stable manager that presented with 1 week history of right prosthetic knee pain and swelling. Following two washouts the patient underwent a first-stage revision of his knee. Post-operative antibiotic choice was empirical, and 28-day outcome has been promising, with complete resolution of inflammatory markers and resolution of symptoms. Outcome following planned second-stage revision will be discussed at FIS 2019.
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Resistance trends among Enterobacterales from bacteraemias in the UK and Ireland, 2007 - 2017
More LessBackgroundThe 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.
MethodsConsecutive 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.
ResultsRates 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).
ConclusionThe 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.
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In-vitro activity of cefiderocol against multidrug-resistant Enterobacterales, Pseudomonas aeruginosa and Acinetobacter baumannii isolates from the UK
More LessBackground.
Cefiderocol is a parenteral siderophore cephalosporin, with a catechol-containing 3’ side chain. We evaluated its activity against MDR Gram-negative bacteria
Methods.
MICs of cefiderocol, meropenem, ceftolozane-tazobactam, cefepime, ceftazidime, aztreonam, ciprofloxacin, ceftazidime-avibactam, amikacin and colistin were determined in cation-adjusted Mueller-Hinton broth; the medium was iron depleted for cefiderocol only. The panel comprised 305 Enterobacterales, 111 P. aeruginosa and 99 A. baumannii selected for carbapenemases, ESBL production or carbapenem resistance via combinations of porin-loss with AmpC or ESBL.
Results.
The activity of cefiderocol was unrelated to Enterobacterales species. At 4mg/L cefiderocol inhibited 92.1% of all Enterobacterales, with rates of 95-100% for isolates with AmpC+porin-loss, VIM, IMP, OXA-48-like, KPC, GES, SME or IMI. Only isolates with NDM (72.1%) or ESBL+porin-loss (88.5%) had lower rates. No comparator agent inhibited >90% of isolates at EUCAST breakpoint.
Cefiderocol 4mg/L inhibited 86.5% of all P. aeruginosa, with rates of 80-100% for those with VIM, IMP, GES or VEB beta-lactamases. Lower rates were seen for those with NDM (72.7%) and PER (73.3%) enzymes. No comparator inhibited >85% of isolates at breakpoint.
Cefiderocol 4mg/L also inhibited 88.9% of A. baumannii isolates with rates >85% for those with OXA-51, -23, -24, or -58. A lower rate (80%) was seen for those with NDM carbapenemases. A concentration of 16mg/L was needed to inhibit ≥90% of A. baumannii.
Conclusions.
Cefiderocol was widely active at low concentrations against MDR Enterobacterales, P. aeruginosa and A. baumannii. MICs for isolates with NDM enzymes nonetheless were higher than for those with other carbapenemases.
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Investigating the role of the gut microbiome as a trigger for arthritis development in individuals at risk of rheumatoid arthritis
Background: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.
Results: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.
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Is hand surface coverage a good measure of hand hygiene effectiveness?
More LessBackground: Effective hand hygiene (HH) is fundamental to the prevention of healthcare-associated infections. One of the commonly used ways for assessing the effectiveness of HH procedure is measuring the extent of hand surface coverage with alcohol-based handrub (ABHR).
Methods: In this Latin square design study, handrubbing with ABHR was performed seven times by each of the 35 volunteers. Volunteers’ hands were contaminated with the Escherichia coli K12 strain as per EN 1500 guidelines. Glove juice samples were collected from their hands before and after each ABHR application and surface coverage was measured using Hand-in-Scan® scanner. The relationship between the bacterial log10 reduction and percent surface coverage was analysed using Spearman’s Rank Order Correlation and simple linear regression.
Results: Surface coverage ranged from 49.38% to 100% (N= 208, Mdn: 97,33%, IQR= 83.52 – 99.93), while the E. coli reduction ranged from 0.96 to 5.92 log10 (N= 221, M: 3.07, SD= 0.94). The Spearman’s Rank Order Correlation results showed no significant correlation between percent hand surface coverage and E. coli log10 reduction [r= -0.009, n= 198, p= 0.905]. The lack of correlation was further confirmed by the linear regression.
Conclusions: These findings suggest that the rate of surface coverage does not correlate with reduction in bacterial load on hands following HH. Although visual feedback on surface coverage can be a good approach to teaching the correct HH technique, these findings suggest that surface coverage alone is not a reliable measure of HH effectiveness.
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A diarrhoeal blast from the past
More LessIntroduction: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.
Case Report: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.
Conclusion: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.
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A decade on from the publication of the British HIV Association's National HIV Testing Guidelines: are opportunities to increase the uptake of HIV testing still being missed?
More LessBackground: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.
Methods: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.
Results: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
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How can a medical educational initiative address the evolving problem of vaccine hesitancy?
More LessBackgroundCurrent 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.
MethodFive 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.
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Doxycycline for the empiric treatment of low-severity hospital acquired pneumonia
More LessBackgroundIn 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.
ResultsForty-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.
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Encouraging Day Three Reviews via a Pharmacist-led Antimicrobial Stewardship Ward Round
More LessBackgroundIntravenous 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.
MethodsPatients 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.
ResultsOver 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.
DiscussionThe 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.
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To screen or not to screen?
Introduction
Screening for carbapenem resistant organisms (CROs) enables early isolation and prevention of transmission in inpatient healthcare settings. In 2013, the UK Department of Health detailed a national approach to screening for CROs. Implementation of this policy has been variable and the growing numbers of patients who meet screening criteria likely exceeds capacity for isolation.
MethodWe 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.
ResultsA 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
ConclusionSix 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.
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Missed opportunities for HIV testing in a Scottish Health Board
More LessBackgroundEarly 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.
Results16 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.
ConclusionEducational 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.
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Investigating the microbial composition of Recurrent Vulvovaginal Candidiasis samples and biofilm formation of Candida clinical isolates
More LessRecurrent vulvovaginal candidiasis (RVVC) is a chronic and debilitating condition that is estimated to affect 138 million women annually. In spite of this high prevalence and its associated economic burden, pathogenesis of disease is poorly understood. The biofilm-forming yeast Candida albicans is reported as the causative pathogen in up to 90% of VVC cases and around 50% in RVVC disease. Despite the identification of Candidabiofilms on the vaginal mucosa, their associated therapeutic challenge in RVVC is still disputed.
A panel of 100 HVS and cervico-vaginal lavage (CVL) samples were obtained for this trial. Patient questionnaires collected data on patient’s vaginal thrush history, treatments and any contraception currently used. Microbiological screening of clinical samples was performed, and microbiome analysis was utilized to determine predominant microbes present in each cohort.
Non-C. albicans species (NCAS) such as intrinsically azole-resistant C. glabrata were found to account for 27% of RVVC cases, notably higher than historically reported. Additionally, microbiome analysis showed a reduction in Lactobacillus species associated with a healthy microbiome in RVVC compared to health.
This study supports a previous clinical trial by our group using 300 HVS to investigate the epidemiology of RVVC showing an increasing prevalence of NCAS responsible for disease. Additionally, this work strengthens the hypothesis that formation of Candida biofilms on the vaginal mucosa could negatively impact clinical treatment. Further research to identify triggers for RVVC, and the pathogenesis of the predominant microbes involved, could considerably improve prevention and treatment options for women with recurrent, azole-resistant infections.
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Rifampicin-eluting biodegradable PLGA coatings can significantly inhibit in vitro biofilm formation for 10 weeks
More LessBiofilm infection is a challenging complication of implanted medical devices due to difficulties in delivering a concentrated dose of antimicrobial to the infection site. To prevent biofilm pathogenesis, a local drug-delivery method, such as drug-eluting technology using biodegradable polymers to coat implantable devices, may be favourable.
Implantable medical-grade polyester was coated in formulations of Poly(lactic-co-glycolic acid) and rifampicin (50:50, 60:40) and placed in PBS (37°C; 120rpm). To characterise release, media was collected periodically over 10 weeks and analysed (UV-spectrophotometry; 334nm). To examine biofilm inhibition, material was removed and submerged in Staphylococcus aureus and Escherichia coli suspensions (37°C; 24hrs) to stimulate biofilm formation. Biofilms were recovered using agitation/sonication, and enumerated.
Release data revealed that both formulations had an initial burst-release phase during the first 24 hours, releasing 92% (50:50) and 88% (60:40) of their respective rifampicin loads. For both formulations, this was followed by slow-release for the remainder of the examined time, reaching 98.9% (50:50) and 97.9% release (60:40). Despite a small fraction of loaded rifampicin remaining, the formulations were able to significantly inhibit S. aureus biofilm formation (up to 99%) for 10 weeks, and E. coli biofilm formation (up to 57%) for 6 weeks.
Drug-eluting polymer technology has already seen success in medical devices, such as coronary stents, to prevent restenosis. Here it has been indicated that this technology has potential in the field of infection prevention, by demonstrating the ability to inhibit in vitro biofilm formation to a significant degree for up to 10 weeks.
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Facial Nerve Palsy – Do people think about Lyme Disease?
More LessBackgroundBorrelia 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.
Results173 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.
ConclusionPossibility 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.
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A Paradoxical Puzzle: Delayed reaction during treatment for disseminated BCG
More LessA 74-year-old man with no previous history of tuberculosis presented with malaise, pyrexia (39°C) and 35kg weight loss, 16 months after TURBT for transitional cell carcinoma of the bladder and BCG instillation. He was pancytopaenic (Hb 84, Plt 99, WCC 2.94) and CT imaging showed splenomegaly, small pleural effusions and a sinusoidal lesion which on biopsy was not malignant. He did not have any promiment lymphadenopathy or pulmonary consolidation. Autoimmune and HIV screening were negative (CD4 310 (57%)) and both TTE and TOE showed no vegetations. IGRA/Quantiferon-Gold testing was positive and bone marrow biopsy yielded granuloma but no AFB on histology. Standard quadruple therapy was commenced for suspected disseminated mycobacterial disease. Mycobacterial cultures of early morning urine, blood and bone marrow were all positive and later identified as BCG on whole genome sequencing, sensitive to Rifampicin, Isoniazid, Amikacin and Moxifloxacin with undetermined Ethambutol sensitivity. Fully compliant with treatment, he developed a solid part cystic irregular enhancing 35mmmass encasing his left internal carotid artery seven months into treatment. ϒ-IFN-axis testing showed adequate responses to IL12 and IFN stimulation. Biopsy revealed AFB-positive granulomata leading to additional steroids for a presumed paradoxical reaction as well as treatment intensification with Moxifloxacin and Amikacin whilst awaiting cultures, the latter of which was discontinued following negative culture results and clinical and radiological improvement. Paradoxical reactions occur not infrequently (2-23%) and can present delayed (14-270 days) following initiation of treatment. He gained 25kg and made an uneventful recovery having received 18 months of BCG treatment.
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Streptococcus agalactiae macrolide/lincosamide resistance; implications for puerperal antimicrobial therapy
More LessIntroduction
There is no routine screening for antenatal Group B Streptococcus (GBS) carriage in the UK. However where GBS is identified from clinical urine/vaginal samples, peri-partum antimicrobial therapy is advised. The changing pattern of antimicrobial resistance among GBS, particularly for macrolides/lincosamides, has implications for peri-partum antimicrobial for beta-lactam allergic patients.
MethodWe undertook a retrospective observational study at a central London teaching hospital to investigate GBS antimicrobial resistance and peri-partum prescribing between 1st April 2016 and 31st March 2019.
Results939 obstetric patients had GBS identified at Chelsea & Westminster Hospital during the study period. 31% (279(263 resistant and 16 intermediate)/900) were erythromycin resistant and 27% (246/911) clindamycin resistant. 5.6% (51/900) had incongruent erythromycin/clindamycin resistance, presumed erm mediated.
390 women received peri-partum antimicrobials for GBS. The majority of patients received benzylpenicillin therapy (70.2%, 274/390), with cefuroxime (23.1%, 90/390), clindamycin (5.6%,22/390) and teicoplanin (1%,4/390) based therapies also used. 40.9% (9/22) were given clindamycin despite known GBS resistance.
ConclusionOur data support the national guidelines, with high erythromycin/clindamycin resistance reported locally. Updated UK guidelines for GBS colonised patients recommend the use of vancomycin for beta-lactam allergic patients. Yet where sensitivities are known, clindamycin may still be used for 70% of beta-lactam allergic patients. Vancomycin, more challenging to administer and monitor, can be reserved for beta-lactam allergic, clindamycin resistant GBS carriers which account for a minority of the population (2.8%). Developing a working pathway implementation is challenging as evident with the inappropriate clindamycin use in 9 patients locally.
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Treatment Failure in a Case of Fully Susceptible Tuberculous Lymphadenitis; Time to Consider Dual Pathology
More LessBackgroundThe clinical presentation of tuberculous lymphadenitis (TBL) can mimic that of other pathologies; obtaining a tissue diagnosis is therefore essential. Dual pathology can manifest as apparent treatment failure and rare cases of coexistent lymphoma have been reported.
Case descriptionA 54-year-old fit and well man of African-Caribbean origin presented with an 8-week history of dysphagia, breathlessness and weight loss. He was tachypnoeic and thin with right supraclavicular and axillary lymphadenopathy.
An HIV test was negative. A CT thorax demonstrated clear lung fields and a 7.2cm mediastinal soft tissue mass compressing the oesophagus and trachea.
US-guided core biopsies of a supraclavicular lymph node showed necrotising granulomatous inflammation. There was no evidence of lymphoma on immunohistochemistry. An acid-fast bacillus was seen on Wade-Fite staining.
Voractiv was commenced for suspected TBL. Tissue culture subsequently grew Mycobacterium tuberculosis. Susceptibility to treatment was confirmed by whole genome sequencing.
After two months of treatment he remained symptomatic with continued weight loss. The possibility of dual pathology was considered, and the index biopsy revisited. Steroids were commenced for a possible paradoxical reaction, resulting in some initial clinical improvement.
Ten weeks into treatment, he further deteriorated requiring artificial nutrition and tracheal stenting. Repeat CT imaging showed enlargement of the mediastinal mass, now extending into the oesophageal lumen. Oesophageal biopsy demonstrated adenocarcinoma.
ConclusionsWe report a case of TBL with coexistent adenocarcinoma, which whilst rare highlights the importance of reassessment for dual pathology in cases of biopsy proven TBL that fails to respond to appropriate anti-tuberculous therapy.
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Paediatric Clostridium difficile infection: rarer than we think?
More LessBackgroundIn view of the new IDSA clinical practice guidelines, we investigated C. difficile infection (CDI) rates and performance against the key standards in our infants and immunosuppressed paediatric patients.
MethodsUsing electronic patient notes and microbiology systems, we collected data on every positive PCR result between June 2016 and March 2018 in our paediatric population. Information included risk factors, markers of severity and medical management.
Results48 samples were sent for C. difficile testing, from which 22 patients had positive results at an average age of 7.4 years. Only five samples were sent from patients under 2 year olds, of which four were PCR positive but toxin negative. Out of 22 positive patient samples, 9 were toxin positive. Risk factors for CDI included previous antibiotics or inpatient stay in the last 3 months, as well as recent PPI use. Only one patient had toxin positive CDI with severe disease. Overall the management of CDI in both toxin positive and negative patients was appropriate in terms of antibiotic choice and duration, and was tailored to specific patient circumstances. A high proportion of CDI patients were immunosuppressed or had recently undergone bone marrow transplants, but often showed no signs of severe infection (fever, raised inflammatory markers).
ConclusionThere should be a low threshold in testing patients who are immunosuppressed, as they are more likely to develop CDI. There were no toxin positive cases in patients under two years of age, which confirms that the test is not useful in this population.
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Physician-initiated HIV testing leads to missed opportunities in an East London Hospital Acute Admissions Unit
BackgroundThe United Kingdom National Guidelines for Human Immunodeficiency Virus (HIV) Testing 2008 suggest that an HIV test should be considered in all general medical admissions, when diagnosed HIV prevalence exceeds 2 in 1000 in the local population. We evaluated physician-initiated HIV testing rates in the Acute Assessment Unit of an East London hospital.
Methods
All acute presentations over one month were reviewed retrospectively, using electronic records. Patients with confirmed HIV were identified and the requested diagnostic HIV tests were measured. The number of patients with clinical indicator conditions for adult HIV infection, as defined in the United Kingdom National Guidelines for HIV Testing 2008, who did not receive appropriate testing, was calculated.
ResultsIn the cohort of 1023 patients, two patients had known HIV. 58 diagnostic HIV tests were performed, including 40 tests in patients with no clinical indicator diseases. There were five admissions with ‘AIDS-defining conditions’, all of which were pulmonary tuberculosis and four out of five (80.0%) were tested. There were 118 admissions with ‘conditions where HIV testing should be offered’, 14 of which (11.9%) were tested. All HIV tests were negative.
ConclusionPhysician-initiated HIV testing was inadequate for such a high prevalence area, even in clinical indicator diseases. Physician-initiated HIV testing should be replaced with routine opt-out HIV testing in acute medical admissions units in areas of high HIV prevalence, as suggested by BHIVA (British HIV Association) guidelines, as we progress towards ending the HIV epidemic in the United Kingdom.
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Modelling Staphylococcus aureus biofilm on infected chronic wounds
More LessChronic wounds, for instance venous, pressure, arterial and diabetic ulcers, are a major health problem throughout the world. Compared with normal wounds, those that take more than four weeks to heal are defined as chronic. Interestingly, the numbers of patients suffering from chronic wounds and the cost for treatment have been increasing during the past two decades. There is increasing evidence that suggests that bacteria infect those chronic wounds and there exist as a biofilm, which affects the wound healing and success of wound treatment. The aim of this project is to develop a dynamic ex vivomodel to mimic Staphylococcus aureus biofilm on infected chronic wound using artificial wound fluid, 3D printing and porcine skin. This dynamic model also will be used to determine drug delivery from commercial antibiotic discs and poly-ε-caprolactone (PCL) electrospun fibrous matrices. The results indicated that our new developed dynamic model was succeed with mimicking S. aureus biofilm on infected chronic wounds. Compared our flow system with traditional colony biofilm assay (CBA), it had generated an air-liquid-solid interface, which is more approach to real conditions. Meanwhile, drug delivery from PCL electrospun matrices had been tested with both CBA and flow system. The results provided further strong evidence on the benefaction of our new developed ex vivomodel. In summary, this new developed easily application model will be potentially significant on improving studying treatments of biofilms on infected chronic wounds.
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Scrub typhus causing acute undifferentiated febrile illness and its association with clinical outcomes: An observational hospital based study from tertiary care center in North India
More LessBackground: The clinical presentation of Scrub typhus mimics other acute undifferentiated febrile illnesses (AUFI) thus making it difficult to diagnose clinically.
Methods: Patients hospitalized with acute febrile illness (2-21 days) along with clinical suspicion for scrub typhus were evaluated for specific IgM antibodies against O. tsutsugamushi by ELISA and details of demographic, clinical, laboratory and clinical complication/outcomes related parameters collected for statistical analysis.
Results: Scrub typhus IgM antibodies by ELISA were detected in 88 (18.1%) patients out of 486 patients hospitalized with acute febrile illness and clinically suspected for Scrub typhus between September 2015 and January 2017. The majority sero-positive cases were found in July-December (p=0.02). Out of 88, twenty nine sero-positive Scrub typhus patients had serological evidence of co-infections. Eschar was observed in 11 (12.5%) sero-positive patients. Of 88, 23 sero-positive Scrub typhus patients died. A low platelet count (RR: 0.99; 95% CI:0.98-1.00, p=0.02), requirement of intensive care (RR: 2.26; 95% CI: 0.19-26.5, p = 0.01), need for mechanical ventilation (RR: 3.8, 95% CI: 1.35-10.86, p =0.003) and metabolic acidosis (RR: 3.47; 95% CI: 0.9-13.4, p = 0.03) were associated with mortality among sero-positive Scrub typhus patients. An appropriate antibiotic administration (n=46/88) was associated with clinical recovery/discharge (n=42/46; p=0.002).
Conclusion: Our results emphasize early diagnosis and administration of appropriate antibiotic for the management of scrub typhus in view of multiple etiologies in the initial diagnostic workup of patients presenting with AUFI. Thrombocytopenia, metabolic acidosis, need for mechanical ventilation and intensive care were associated with adverse clinical outcome among patients with Scrub typhus.
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Recurrent Urinary Tract Infections: old story, new frontiers
More LessBackgroundUrinary tract infections (UTIs) are common and frequently recur. Successful management is challenging, with UTIs responsible for 14% of community antibiotic prescriptions. Improving the management of recurrent UTIs is a national priority carrying major implications for antimicrobial stewardship.
Methods
We have introduced a multi-specialty clinic with a personalized approach to antimicrobial prescribing. Together a consultant medical microbiologist and a consultant urologist assess each patient’s pre-disposing risk factors and symptomatic burden. Anatomical and functional urological factors, and issues such as poor sample quality and lifestyle are investigated. Choice of antimicrobial agent, as well as the mode and frequency of administration, is made in accordance with patient preferences, resistance patterns, and risk factors.
Primary and secondary care data was collected for the year preceding and the year following initial clinic attendance. The impact of attendance on acute admissions, antibiotic prescribing, diagnostics utilization, and primary care workload was assessed.
ResultsWe assessed the impact of 36 clinic attendances. We noted a 91% reduction in acute admissions, a 73% drop in UTI related primary care attendances, a 57% fall in antibiotic prescriptions, and a 61% reduction in the number of MSUs sent. Qualitative data also indicates a substantial impact on patient quality of life.
ConclusionTo our knowledge we are the first center to utilize a multi-speciality recurrent UTI clinic to personalize antimicrobial and surgical therapy in tandem. Improvement in clinical outcomes is matched by reduced workload. Further study will assess long-term impact and will support regional adoption of this stratagem.
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Post-influenza meningitis in an immunosuppressed man
More LessBackground:We report a case of post-influenza invasive aspergillosis causing ventriculitis in a patient immunosuppressed on methotrexate for rheumatoid arthritis.
Summary:A 63-year-old male with a positive H1N1 throat swab presented with increasing dyspnoea and pyrexia that failed to improve despite broad-spectrum antibiotics and zanamivir. Imaging of his chest showed cavitating lung disease and a possible post influenza fungal infection. He was initiated on antifungal treatment that was stopped after 10 days following a negative bronchoalveolar lavage and serum galactomann test. Respiratory symptoms and inflammatory markers improved but he developed confusion and falls. Computed tomography of the head showed hydrocephalus but there was no papilloedema. Examination of the cerebrospinal fluid (CSF) showed lymphocytosis with elevated proteins but negative initial investigations. Subsequent magnetic resonance imaging of the head with contrast showed obstructing hydrocephalus with ventriculitis. He underwent an urgent ventriculostomy by the neurosurgeons which demonstrated purulent CSF. CSF testing was strongly positive for beta-D glucan, a positive PCR result for aspergillus in CSF was received from the initial lumbar puncture and histology from operative samples showed fungal hyphae. Dual antifungal treatment was recommenced but the patient’s conditioned worsened, and he died on ITU.
Conclusion:Whilst invasive pulmonary aspergillosis is a recognised complication of influenza, extrapulmonary infection is less well documented. This is the first case in the literature in which ventriculitis due to aspergillus is described as a sequel to infection with influenza. Clinicians should remain vigilant for fungal infection in patients with influenza who are immunosuppressed.
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Management of methicillin sensitive Staphylococcus aureus bacteraemia in an antimicrobial stewardship age
More LessBackground: Methicillin sensitive Staphylococcus aureus bacteremia (MS-SAB) is associated with significant morbidity and mortality. Long courses of intravenous antibiotics are the traditionally recommended mainstay of treatment but are often not completed in clinical practice. Shorter courses are potentially attractive from an antimicrobial stewardship and resource perspective, but require a good evidence base.
Methods: A retrospective audit of MS-SAB management within Newcastle-upon-Tyne Hospitals NHS Foundation Trust (2016-17). Laboratory database was used to identify all cases of MS-SAB. Demographic details, risk factors and management were recorded from patient records. Outcomes were defined as 90d recurrence-free survival, 30d mortality, 30-90d mortality and recurrence before 90d.
Results: A total of 281 adult cases were identified with adequate data available for review. Predictors of early (30d) mortality were: age, 71.4y vs 58y p<0.001; HAI, 21.4% vs 8.6% p=0.003; osteo-articular infections, 2.5% vs 17.1% p=0.016; but not antibiotic choice. In cases surviving 30d (n=238), median antibiotic durations were: intravenous 10d (range, 0-115), total 18d (0-316). 83% received ≥14d total, 41% received ≥14d intravenous. Receiving <9d intravenous (OR 3.33 (95%CI 1.01- 10.95) or <14d total therapy (OR 4.19 (1.37-12.84) was predictive of recurrent bacteraemia, as was non-beta-lactam therapy (16% vs 4%, p=0.006), and poor CRP response at end of intravenous therapy (68% vs 35% of peak CRP, p<0.001).
Conclusions: These data suggest lower durations (9-14d) of intravenous therapy could be safe in MS-SAB, however very short courses (<9d) are associated with worse outcomes. This new evidence helps inform guidelines, balancing optimised patient outcomes alongside improved antimicrobial stewardship.
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‘The Mould that Changed the World’: Quantitative and Qualitative Analysis of Knowledge and Behavioural Change following Participation in an Antimicrobial Resistance Musical
More LessBackground: Antimicrobial resistance (AMR) is driven by antimicrobial exposure. Engaging the general public with this issue is vital in order to shape attitudes and change behaviour. A primary school musical (‘The Mould that Changed the World’) was developed as a novel educational strategy with the explicit aim of engaging the public in the fight against AMR.
Methods: The musical was implemented in two primary schools as workshops followed by public performances. There were 166 child participants aged 9 to 11 years. Quantitative data was collected through a classroom questionnaire before the musical, two weeks after, and six months after. Qualitative data were collected through children’s focus groups before the musical and two weeks after.
Results: Knowledge of the key messages of the musical had increased two weeks after the musical (proportion test, 0.65, 0.77, p<0.001) and this gain in knowledge was sustained six months later (proportion test, 0.65, 0.82, p<0.001). Children recognised factors contributing to AMR, felt empowered to change their own health behaviours and demonstrated antimicrobial stewardship with intention to reduce antibiotic use. They suggested the musical had stimulated discussion around these topics at home. The musical was perceived as an enjoyable and memorable way to learn about AMR.
Conclusion: This study demonstrates potential for the use of musical theatre in this field as a novel device to improve long-term knowledge, change attitudes and emotionally engage the general public through children. Alongside existing interventions, it represents a further unique and valuable tool in the fight against AMR.
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Developing a quality assurance system for the use of stimulan beads in a diabetic foot clinic
More LessBackgroundDiabetic foot infections are an increasing healthcare issue and managing these infections can be difficult. A recent innovation in the way they are managed in the Hull clinic is the use of antibiotic impregnated (generally Gentamicin and Vancomycin) STIMULAN beads. Often only a couple of beads can be used in a foot wound making it a very uneconomical strategy if the beads can’t be stored and used on other wounds. There is no recommended quality assurance method provided by the manufacturers to validate this practice leading to this study.
Methods
Five beads were removed from a batch; at 1, 4, 8 and 12 week intervals for testing:
Bacterial Challenge: a 10mL spot of bead suspension was placed on Mueller Hinton seeded with Staphylococcus aureus ATCC 29213 and E. coli ATCC 25922 and incubated in Air, at 35±1ºC for 18±2hrs; zones of inhibition were read and recorded.
TDM: Vancomycin and Gentamicin levels present in each bead was established by analysing 50mL of suspension (1:5 DF) using a therapeutic drug monitoring assay.
ResultsBeads were microbiologically active for 12 weeks with no notable loss of potency.
Bacterial challenge: Staphylococcus aureus range 17-23mm, av. 20.4mm and E. coli range 11-20mm, av. 17.5mm.
TDM Assay: Vancomycin range 62.01 – 110.18 Av. 88.88mg/L, Gentamicin range 20.38 – 27.41 Av.23.20mg/L.
ConclusionQuality assurance of the STIMULAN beads can be established using standard TDM assays and microbiological activity, enabling a kit to be used for up to 12 weeks with clinical confidence.
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Chronicle of migrant hyperinfective Strongyloides stercolaris larvae and associated bacteremia in a patient suffering from Idiopathic Thrombocytopenic Purpura
More LessBackground:Strongyloidiasis is a neglected nematode infestation and can lead to hyperinfection syndrome. The onset of strongyloides hyper-infection syndrome is associated with a myriad of seemingly unrelated symptoms including diarrhoea, abdominal pain, urticaria, anaemia, sepsis and acute respiratory distress syndrome.
Case report:A 65-year-old female patient presenting with chief complaints of nausea, vomiting, abdominal cramps, diarrhea, fever and cough and was admitted to a teaching hospital on 2nd May 2019. The patient was a diagnosed case of idiopathic thrombocytopenic purpura on Azathioprine (50mg, BD) and oral corticosteroid therapy (Prednisolone 60mg, OD) and was on treatment from the same hospital. The patient developed these symptoms after 23 days of immunosuppressive therapy. Patient was continued with previous medication along with supportive management after admission. Blood and urine sample was received in the department of Microbiology on 3rd May 2019 for culture and sensitivity testing. Urine sample was sterile after 24 hours of aerobic incubation. Escherichia coli grew in blood culture and the isolate was susceptible to gentamicin, amikacin and colistin. Stool sample was received on 6th of May 2019 for routine microscopy. With wet mount preparation of stool specimen, numerous larvae of Strongyloides stercoralis were seen. Modified Ziehl-Neelsen staining was performed and oocysts of Cryptosporidium species were also seen. Wet mount preparation of sputum sample was also performed in which few larvae of S. stercoralis were seen.
Conclusion:As corticosteroid is the mainstay of treatment in idiopathic thrombocytopenic purpura an early diagnosis and prompt specific anti-parasitic therapy is required to eradicate these infections
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Development and Initial Evaluation of a national Infection Prevention and Antimicrobial Resistance programme for UK Girlguiding and Scouts
More LessBackgroundBetween 2016-18, infection prevention (IP) and antimicrobial resistance (AMR) projects were developed independently by Girlguiding and Scout groups across four UK regions. The UK 5-year AMR Action Plan outlines the importance of public engagement. This abstract describes the development, pilot and initial evaluation of a national infection prevention (IP) and AMR resource pack for Girlguiding and Scouts.
MethodsEarly 2019, PHE developed a national working-group, including local pilot individuals, and Girlguiding and Scout volunteers interested in IP and AMR to agree on the content of a national programme through a consensus approach. Summer 2019, the programme was piloted across the UK. Initial evaluation included course leader feedback and an age-appropriate survey.
ResultsThe consensus process concluded that the programme should include interactive e-Bug activities regarding microbes; hand, respiratory and food hygiene; antimicrobials and AMR. To consolidate learning, participants would create posters, make Antibiotic Guardian pledges, and share these with their families. A draft resource pack was developed to enable the programme to be delivered by leaders without a science/health background. Initial evaluation with over 150 children will be presented, to include enjoyment, acquisition of knowledge, and intentions to change health behaviours (i.e. improve hand and respiratory hygiene, and only use antibiotics when needed). Feedback from children and leaders will be used to update the resource pack prior to launch.
ConclusionThis national programme is engaging and delivers key IP and AMR messages. The programme will be launched for World Antibiotics Awareness Week 2019. Full evaluation planned for 2020.
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Endogenous endophthalmitis as a secondary bacterial infection following viral disruption of the blood-ocular barrier?Case report of 2 renal transplant patients
More LessBackground: Endogenous endophthalmitis is a rare but serious ocular infection. Seeding is usually haematogenous, and the visual prognosis is poor. We present 2 cases of bacterial endophthalmitis rapidly following viral retinitis in patients with a history of renal transplantation and no systemic symptoms of bacteraemia.
Case 1:
A 47 year old woman presented with features of bilateral panuveitis with retinitis, with no systemic symptoms.She had a history of renal transplantation. Escherichia coli had been isolated from multiple previous blood and urine cultures in the preceding months. A diagnosis of cytomegalovirus (CMV) retinitis was made on the basis of positive PCR from aqueous humour, and antiviral treatment commenced. Her left eye vision subsequently deteriorated. A repeat sample grew E. coli with a matching antibiogram to her previous isolates.
Case 2:
A 55 year old man presented with features of right-sided panuveitis and acute retinal necrosis, with no systemic symptoms. He had a history of renal transplantation. A diagnosis of varicella zoster virus (VZV) retinitis was made on the basis of positive PCR from the aqueous humour, and antiviral treatment commenced. His symptoms deteriorated, and Streptococcus pneumoniae was isolated by culture from a repeat sample. Imaging of the sinuses revealed inflammatory changes.
Conclusions:
We hypothesise that endophthalmitis in these two immunocompromised patients may have been opportunistically enabled by disruption of the blood-ocular barrier by the preceding viral infection, allowing a transient bacteraemia to seed. Whether there may be any role for prophylactic antibiotics in this context would benefit from further study.
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Brewer’s Yeast as a cause of infective endocarditis
More LessBackground: Molecular tests are increasingly used in culture negative endocarditis and may be helpful adjuncts to diagnosis; here we report the case of Saccharomyces cerevisiae mitral valve endocarditis in an immunocompetent patient.
Case History: A previously well 63 year old man presented with a ten day history of fever, nights sweats and progressive shortness of breath. On arrival, he was in acute respiratory distress, in pulmonary oedema and had a pansystolic murmur. A transoesophageal echocardiogram showed severe mitral regurgitation and a mass on the posterior leaflet of the mitral valve. He was treated for a presumed native valve endocarditis with Amoxicillin, Flucloxacillin and Gentamicin. He had a minimally invasive mitral valve repair; a vegetation was noted. All initial cultures and serologies were negative. He improved and was discharged on ceftriaxone and doxycycline on OPAT. Results three weeks post-surgery showed a Beta D Glucan of >500pg/mL (cut off 80) and an 18S PCR on the valve positive for Saccharomyces cerevisiae. No histology was available from the vegetation and fungal cultures were negative. He was much improved at that point and received 6 weeks of voriconazole to treat invasive infection; his Beta D Glucan fell to less than 30 and he was well on follow-up.
Conclusion: Saccharomyces cerevisae is an unusual cause of an endocarditis in an immunocompetent patient. This case illustrates the importance of considering non-bacterial causes of endocarditis in such cases and the utility of molecular diagnostics as adjuncts to traditional culture techniques.
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Fusobacterium nucleatum brain and liver abscesses following sigmoid diverticulum perforation in an immunocompetent patient
We report a case of disseminated Fusobacterium nucleatum likely secondary to an undiagnosed perforated sigmoid diverticulum. A 50-year old male, (past history of COPD, schizophrenia and diverticulosis) presented with fever, seizures and progressive leg weakness over 4 days. Examination revealed left leg weakness and hepatomegaly. CT-brain showed bilateral supra-tentorial lesions with sulcal effacement; MRI findings were consistent with abscesses. Initial management included burr-hole drainage of 2 intra-cranial lesions and treatment with ceftriaxone and metronidazole. The patient defervesced post-operatively.
Blood cultures (day 1) and cerebral pus (day 3) grew Fusobacterium nucleatum after 5 days. HIV Ab/Ag negative. Subsequent imaging excluded endocarditis, intra-cardiac shunting and jugular vein thrombosis. CT revealed pulmonary emboli, liver abscess (68x46x42 mm, inaccessible to drainage) and localised sigmoid perforation. Later, the patient admitted to a 5-day period of severe self-limiting abdominal pain 2-weeks prior to admission, probably relating to sigmoid perforation.
The patient required further neurosurgical drainage (day 10) due to fluctuating consciousness; intra-operative samples were culture negative. Neurological improvement occurred during 4 weeks treatment. Total antibiotic duration will be determined by follow-up imaging.
Fusobacterium spp.are fastidious Gram-negative rods. Microscopy can differentiate the main pathogenic species showing tapered ends (F. nucleatum) or pleomorphic rods (F. necrophorum). Malignancy, diabetes and immunosuppression/HIV are associated, but none are present here. Presentations include abscesses, bacteraemia, thrombophlebitis, osteomyelitis and endocarditis. This case highlights the need for early sampling, careful history regarding source, covering at least 2-4 weeks preceding presentation, and demonstrates paradoxical deterioration after antibiotics and drainage, likely due to post-treatment inflammatory reaction.
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Hepatitis E diagnostics: immunocompetent and IgM-negative implies PCR negative
More LessHepatitis E virus has, over the past few years, been increasingly recognised as a cause of acute hepatitis in the western world. The first hepatitis E Standard for Microbiology Investigations (SMI) was issued in November 2018 and recommends cascading testing in immunocompetent individuals, with RNA assays clarifying results of antibody assays. We investigated all clinical samples tested for hepatitis E in our regional laboratory between October 2014 and October 2018 (12671 IgM, 10738 IgG and 2290 RNA assays). In 495 cases, samples collected within 24 hours from a patient underwent IgM assays (DS2 platform) and PCR assays (in-house). 7 pairs, corresponding to 5 patients, of 404 pairs with negative or low-positive IgM results, had detectable RNA. 4 of those 5 patients were demonstrably immunocompromised; the final sample came from general practice without further details. 3/5 patients had reactive IgG assays, and one of the two remaining patients had a rise in IgM titre between two successive samples. We conclude that, in our sample population, hepatitis E RNA PCR testing adds minimal diagnostic information in immunocompetent individuals with negative or low-positive IgM results. This finding supports current testing cascade recommendations. We discuss our sample population’s demographics and external validity of findings: in particular, we saw few tests sent by neurologists. Finally, we briefly discuss other IgM/IgG/PCR result scenarios and our findings in relation to current SMI recommendations, and speculate how our findings affect understanding of antibody response and viraemia in hepatitis E infection.
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Is prior antibiotic exposure a risk factor for the development of bacteraemia in bone marrow transplant patients?
More LessBackground: Bone marrow transplantation (BMT) is a unique immunosuppressed state, and the consequences of infection are often severe. We hypothesized that disruption of the faecal microbiota (such as with use of broad spectrum antibiotics) may predispose to gastrointestinal related sepsis post bone marrow transplantation.
Methods: We reviewed the laboratory data from all BMT patients between January 2016 and August 2018 and recorded the presence of bacteraemia. We matched these patients to controls with no recorded bacteraemia. We then recorded antibiotic exposure in the immediate pre-transplant period.
Results: 238 records were reviewed (81 allografts, 157 autografts). We identified 28 patients with bacteraemia from gastrointestinal related pathogens. 28 controls with no positive blood cultures were matched according to the type of BMT. In both groups there were 18 allografts, 12 of which were matched unrelated donors. In the bacteraemic group there were a total of 12 antibiotic episodes (60 days) pre-transplant, compared with 6 (41 days) in the control group. The most common antibiotics used were meropenem (47 days in the bacteraemic group, 24 control) and piperacillin/tazobactan (13 days in the bacteraemic group, 3 control).
Conclusion: Our results support the hypothesis that broad spectrum antibiotics pre-transplant may predispose to post-transplant sepsis. Although the small population size limits this study, further studies are necessary to confirm this finding, and to investigate which components of the faecal microbiota are the most important to preserve prior to BMT. This may open the door to novel therapeutics in this patient group, such as faecal microbiota transplant.
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Understanding antimicrobial prescribing in suspected ventilator-associated pneumonia: a prospective cohort study
BackgroundVentilator-associated pneumonia (VAP) is associated with significant healthcare cost, morbidity, and mortality, but can be difficult to identify, resulting in over-diagnosis and excessive use of broad-spectrum antimicrobial therapy. In addition, some organisms commonly cultured from the airways of critically ill patients, in particular Candida species, are of unknown clinical significance.
Methods
A prospective cohort study was conducted across five intensive care units in the North-West of England. Participants were enrolled within 24 hours of commencing antimicrobial therapy for suspected VAP. Laboratory-confirmed VAP was defined by quantitative culture of a known pneumonia-causing pathogen above predetermined growth thresholds.
Univariate logistic regression was used to determine the impact of laboratory-confirmed VAP, APACHE II, culture of Staphylococcus aureus, and culture of Candida species on 30-day mortality.
ResultsThe prevalence of laboratory-confirmed VAP was 43/96 (44%), and the median number of antimicrobials prescribed for VAP was 1 (range: 1-4). Candida species were identified in 32/96 patients (33%).
The overall 30-day mortality was 22/96 (26%). None of the variables analysed were associated with 30-day mortality, except for culture of Candida species, which was associated with survival (odds ratio 0.26, 95% CI 0.07 to 0.98; p= 0.047).
Conclusions
Ventilator-associated pneumonia was confirmed in under half the patients commenced on antimicrobial therapy for suspected VAP, which highlights the urgent need for improved diagnostic strategies. In our clinical practice, Candida species are not treated as pathogenic in VAP, and in this study, growth of Candida species was not associated with excess 30-day mortality.
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Pharmacokinetics of TKM-130803 in Ebola virus disease in Sierra Leonean subjects
TKM-130803 is a specific anti-EBOV therapeutic comprising of two small interfering RNAs (siRNA) siLpol-2 and siVP35-2. The pharmacokinetics (PK) of these siRNAs was defined in Ebola virus disease (EVD) patients. The relationship between PK and patient survival was explored.
Plasma concentration of siRNA was compared to survival at 14 days for seven subjects with EVD in Sierra Leone who received 0.3 mg/kg of TKM-130803 by intravenous infusion over 2 hours daily for up to 7 days. PKdatawere fitted to two-compartment models then Monte Carlo simulated PK profiles were compared to ET (Cmax 0.04-0.57 ng/mL and mean concentration 1.43 ng/mL), and TT (3000 ng/mL).
siRNA was in quantitative excess of virus genomes throughout treatment, but the 95% percentile exceeded TT. Plasma concentration of both siRNAs were higher in subjects who died compared to subjects who survived (p<0.025 both siRNAs).The maximum AUC for which the 95% percentile remained under TT was a continuous infusion of 0.15mg/kg/day.
TKM-130803 was circulating at sufficient concentrations, considered needed for efficacy but given extremely high viral loads it seems likely that the patients died because they were physiologically beyond the point of no return. Subjects who died exhibited some indication of impaired drug clearance, justifying caution in dosing strategies for such patients. This analysis has given a useful insight into the pharmacokinetics of the siRNA in the disease state andillustrates the valueof designing PKPD studies into future clinical trials in epidemic situations.
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Acute haemorrhagic leukoencephalitis secondary to Chikungunya infection
More LessBackground:Neurological sequelae are a rare but recognised complication of Chikungunya infection. We report a case of acute haemorrhagic leukoencephalitis secondary to Chikungunya infection.
Case description:A 59 year old male presented to the acute medical unit 5 days after returning from a 4 week trip to Kinghasa in the Democratic Republic of Congo complaining of a sudden onset headache with fluctuating confusion and left sided weakness. 1 week previously he had been complaining of fever and fatigue with arthralgia. Whilst in DRC he visited family with no travel outside Kinghasa and no infectious contacts or high risk activities. A malaria film was negative and a lumber puncture on admission demonstrated 296/mm3 white cells with 75% polymorphs and 25% lymphocytes, protein of 1.5 g/L and glucose of 4.2 mmol/L ( serum 7.4 mmol/L).
Over the next 24 hours his GCS dropped and he needed intubation. The appearance of the MRI head was highly unusual and the neuroradiologist felt this was most likely an acute haemorrhagic leukoencephalitis (AHLE) confirmed later on brain biopsy. All subsequent investigations were negative except viral serology demonstrating a positive chikungunya IgM with later IgG seroconversion.
The patient received steroids, anti tuberculous treatment, antibiotics and plasma exchange with little neurological improvement.
ConclusionWith the increasing incidence of chikungunya, more neurological complications are being recognised. AHLE is a very rare form of acute disseminated encephalomyelitis usually triggered by an infection; however there have been no case reports of chikungunya causing AHLE leading us to believe this may be the first case.
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Development of a licenced Faecal Microbiota Transplantation service for the treatment of patients in the NHS
Introduction: Faecal microbiota transplantation (FMT) is an effective and licensed treatment for recurrent and refractory Clostridium difficile infection (CDI) and has shown encouraging signals for treatment of ulcerative colitis (UC). Access to FMT has been limited by the introduction of new regulations in the UK. Centres producing FMT are now required to hold a manufacturing licence from the Medicines and Healthcare products Regulatory Agency (MHRA).
Methods:The first licenced FMT service in UK - University of Birmingham Microbiome Treatment Centre (UoBMTC) was launched in 2017. Policies and procedures were developed in accordance with MHRA ‘Good Manufacturing Practice’ guide.
Results: Since August 2018, 132 FMT aliquots have been supplied for recurrent and refractory CDI to 39 NHS Trusts across UK. Twenty-nine of these Trusts did not have access / perform FMT prior to this service. In all cases, FMT was delivered within 48 hours (unless delayed delivery was requested). The service is the sole supplier of FMT since 2018 via an NHS Innovation and Technology Tariff. UoBMTC has also to date supplied 360 FMT aliquots for a multi-centre trial of FMT in UC (STOP-Colitis). Furthermore, the service has provided FMT to other refractory conditions within clinical settings.
Conclusions: Development of a licenced FMT facility has greatly enhanced equality of access for this treatment across the NHS. FMT is provided at a zero-cost model for CDI and is available within 48 hours of request. UoBMTC continues to facilitate research in this field by providing FMT for clinical trials exploring its use for other indications.
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Developing a PCR-Based Diagnostic Method of Detecting the Prevalence of Emerging Tick-Borne Diseases in Scotland
More LessTicks are able to transmit zoonotic pathogens to humans including the most frequently reported Borrelia burgdorferi, and the lesser known Anaplasma phagocytophilum, Borrelia miyamotoi, Babesia spp., and Rickettsia spp. Ticks also play an important role in the spread and maintenance of disease lifecycles. Lyme disease is currently the only tick-borne disease monitored by health professionals in Scotland, however, it is still underreported and misdiagnosed. In this study adult female ticks from 32 hedgehogs from various locations in Scotland were tested for the presence of tick-borne infections using PCR and confirmed by sequencing. PCR results showed there was an 18.75% incidence of B. burgdorferi, 34.38% of B. miyamotoi, 12.5% of Rickettsia spp., 3.13% of A. phagocytophilum, and 3.13% of Babesia spp. 100% of the ticks were confirmed as Ixodes ricinusand from hedgehog hosts. A co-infection of B. burgdorferi and B. miyamotoi was found by PCR and has not been previously reported in the UK. B. burgdorferi was confirmed by sequencing as B. afzelii, however, B. miyamotoi has not been confirmed by sequencing. Another co-infection of B. miyamotoi, Babesia spp., and Rickettsia spp. was found by PCR, however, not confirmed by sequencing. Detection of co-infections in human cases is difficult due to the similar nature of the infections, making it difficult to differentiate between pathogens. This study aims to develop a methodology capable of distinguishing between pathogens, identify the tick and host species, and determine the prevalence of tick-borne disease in Scotland by PCR.
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The Half-Life of Maternal Transplacental Antibodies in infants from mothers vaccinated with diphtheria, tetanus and pertussis: An individual participant data meta-analysis
Aim: There are no reliable estimates of the half-lives of maternal antibodies to the antigens found in the primary series vaccines. We aimed to calculate the half-lives of passively acquired antibodies in infants born to mothers participating in studies of tetanus, diphtheria and acellular pertussis (Tdap) vaccination during pregnancy. We aimed to determine whether decay rates varied according to maternal age, birthweight, sex, socioeconomic status, country, or vaccine received.
Methods: De-identified individual participant data from infants born to women taking part in 9 studies of maternal immunization, in 8 countries (UK, Belgium, Thailand, Vietnam, Canada, Pakistan, USA and the Netherlands) were combined. Blood samples were taken at two timepoints before any Tdap containing vaccines were received by the infant: at birth and at 2-months of age. Decay rates for each antigen were log2-transformed and meta-analysis performed. Half-lives were calculated by taking the reciprocal of the absolute value of the mean decay rates.
Results: A total of 4,091 samples were included in the analysis and there was significant variation between studies. There was significant variation in the half-lives of the 6 antigens of interest (p<0.001), with estimates ranging from 28.1 days for diphtheria to 35.6 days for filamentous haemagglutinin. The decay of maternal antibodies did not significantly differ by country-level socioeconomic status, maternal age, sex, birthweight or maternal vaccination.
Conclusion: Maternal antibodies decay at different rates for the different antigens, however the magnitude of the differences are small. Differences in laboratory techniques may account for some of the variability between studies.
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Case-control study of recurrent Extended-Spectrum Beta Lactamase Enterobacteriaceae Urinary Tract Infections (ESBL UTIs): the management challenges
More LessRecurrent UTIs are associated with increased hospitalisation and antibiotic use. We investigated patients with recurrent ESBL versus non-ESBL UTIs to identify risk factors and potential treatments.
A30 month retrospective case-control study was performed in patients with recurrent EBSL versus non-ESBL UTI. Definition :1) > three in a year (>two weeks apart) or 2) > two in six months (>one week apart) with the same profile. 3) ESBL UTIs were Enterobacteriaceae resistant to cefalexin AND ceftazadime/ceftriaxone.
281/1449 “recurrent UTI” patients were ESBLs. Patients were more likely to be older, male, with associated bacteraemia, colonisation with carbapenemase-producing Enterobacteriaceae (CPE) and higher resistance rates to non beta-lactam antibiotics. 75% of renal patients were transplant cases, 81% of urology patients had a tube insertion.
Recurrent ESBL UTIRecurrent non-ESBL UTIp value
Number (%)Number (%)(Chi-squared test)
Patients 281 1168
Organism Klebsiella spp (%)42 (14.9) 10 (0.8) <0.001
E coli (%)199 (70.8)811 (69.4)0.665
Demographics Age (mean, SD)64.1, 19 58.7, 22 <0.001
Male 137 (48.8)328 (28) <0.001
Associations Gram negative bacteraemia 35 (12.4) 37 (3.1) 0.001
Colonisation with CPE 21 (7.5) 31 (2.7) <0.001
Speciality Renal 84 (30.0) 196 (16.8)<0.001
Urology 47 (16.7) 104 (8.9) <0.001
Resistance Trimethoprim 219 (77.9)354 (30.3)<0.001
Ciprofloxacin 214 (76.2)160 (13.7)<0.001
Gentamicin135 (48). 64 (5.5) <0.001
ESBL infection is associated with worse outcomes and significant premorbid conditions. The oral crossover resistance prevented long term prophylaxis.
Options are needed to reduce colonisation burden of resistant organisms such as faecal microbiota transplantation.
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Cohort study of Faecal Microbiota Transplantation for patient’s colonised with MDROs - successful prevention of invasive disease despite low decolonisation rates
Faecal Microbiota Transplantation (FMT) is widely utilised for recurrent Clostridioides difficile infection. Use of FMT for the intestinal eradication of multidrug-resistant organisms (MDROs) has been described in the literature with decolonisation rates from 37.5% to 87.5%. We perform FMT via naso-gastric tube using donor stool prepared anaerobically, using prevention of invasive disease as an endpoint.
FMT was considered for either; 1) Patients who were colonised with >1 MDRO (carbapenem-resistant Enterobacteriaceae, vancomycin resistant Enterococci or extended-spectrum beta lactamase (ESBL) and at risk of invasive MDRO disease or 2) patients who had recurrent MDRO-mediated invasive disease.
Sixteen MDRO colonised/infected patients underwent FMT. Nine patients had a haematological disorder. Eight of these patients had had prolonged admissions (range 6-20 weeks) complicated by septic episodes (5/9 had a MDR bacteraemia) pre-FMT. Post FMT all patients had shorter admissions including five who received higher intensity immunosuppression. Only 1/9 developed MDRO-mediated invasive disease.
Seven FMT patients had recurrent ESBL urinary tract infections (UTIs). 4/7 were renal transplant patients. Following FMT the 3 non-transplant patients had no further UTIs up to six month period. Four transplant patients had reduced number of infections, admissions and use of antibiotics.
5/13 (39%) patients were not MDRO colonised on rectal screens post-FMT (follow up range 12 weeks – 24 months).
Although decolonisation rates were low, patient outcomes post-FMT were apparently improved. Mechanisms of FMT have not fully been established, improvement of colonisation resistance by restoration of microbiota composition or functionality in at risk groups could be more important than intestinal eradication.
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Stroke secondary to hip ulcer and Septic emboli
More LessBackgroundStrokes are frequently seen in older patients mainly due to long standing hypertension, diabetes mellitus and hyper cholesterolemia. It is not common in younger adults especially when there is no obvious cause. The workup to find the cause is often difficult in such cases.
Case Description
A 38-year-old paraplegic male presented in Emergency Department with the complaints of fever, headache, haematuria and awaiting closure of left hip wound; however, it seemed non infected. Regarding his medical history, he had ASD associated with pulmonary hypertension and type 1 diabetes mellitus. Besides, after 24hrs of admission he developed right sided neglect. On examination, he was febrile with increased heart rate and respiratory rate. Moreover, he had right homonymous hemianopia and NIHSS score was 3. CT PA was done to rule out pulmonary embolism. Additionally, CT CAP and CT head showed splenic infarct and occipital infarct, respectively. Therefore, a diagnosis of paradoxical embolus was made and treated accordingly. Later, blood culture revealed beta haemolytic streptococci and the underlying cause of septic stroke was thought to be hip ulcer extending to bone. This was followed by CT pelvis, on which bone destruction was seen. Therefore, antibiotics were commenced and left hemiarthoplasty was done.
ConclusionThis case illustrate that in younger population, often soft tissue and bone infection can lead to pro-thrombotic events resulting into septic emboli, a potential cause of stroke (especially when accompanied by ASD). Early assessment and management is valuable as it can lead to serious complications and increased morbidity.
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Nanoplexes molecular patterns for vancomycin efficacy against methicillin-resistance Staphylococcus aureus
More LessThe difficulty in treating life-threatening infections caused by MRSA is a global problem and conventional antibiotics are failing to provide effective therapy due to resistance development thus the need for innovative strategies to combat the problem... Nanoplexes are drug nanoparticles which form complex with oppositely charged polyelectrolyte and have shown to be effective drug delivery of antibiotics. The aim of this study is toexplore the in vitromolecular pattern of vancomycin (VCM) and dextran (VCM-DXT)nanoplexes in fluorescence emission enhancement, maximized membrane disruption, decrease protein concentration and DNA concentration inMRSA for a mechanistic understanding of VCM-DXT elimination of the bacteria. The nanoplexes were characterized for their in vitro electrical conductivity, membrane disruption, protein concentration determination and DNA quantification.The in vitroelectrical conductivity of the VCM-DXT-nanoplexes demonstrated an increase in the electrical conductivity from 0.321 ± 0.01 to 0.39 ± 0.11 mS cm-1. These indicatean increase in membrane permeability of bacteria by destroying the cell membrane leading to the leakage of cellular substance in combating infectious diseases. Furthermore, the VCM-DXT-nanoplexes revealed a maximum MRSA membrane destruction and high emission enhancement intensity of the biofilm obtained from high-resolution transmission microscopy and fluorescence microscopy respectively. The VCM-DXT-nanoplexes demonstrated 3-fold and 1.98-fold decreased in protein concentration and DNA quantification respectively compared to the control. The novel VCM-DXTnanoplexes could be a promising delivery system of VCM by effectively eliminating MRSA infections and prevention of emergence of resistance. This could go a long way in preserving the potency of VCM and extending the time-lapse before the development of resistance.
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Developing a novel paperless E-referral pathway for Infection clinic at a large teaching hospital, community and primary care in northwest England: A novel strategy to spearhead the trust antimicrobial stewardship programme
More LessBACKGROUND: UK’s 5y (2019-24) national action plan on antimicrobial resistance(AMR) projects 1 death/3 seconds(global) by 2050, if AMR rise not tackled. Accurate diagnosis of infectious condition and prompt optimal antibiotic/s are corner stones of any antimicrobial stewardship(AMS), sepsis programme and reducing mortality. We present our experience of developing a novel paperless E-referral pathway for all infection consultations from hospital and primary care to spearhead the hospital AMS and sepsis programmes.
MATERIAL/METHODS: Hospital webdesigners customized existing software application (www.nervecentresoft [http://www.nervecentresoft/]ware.com) & developed user friendly E-referral system (includes basic clinical details, referral urgency/coloured flag and grade/contact of submitter); it auto populates patient demographics and ward location from patient information system. Reports can be generated to query agreed parameters (&KPI). E-referrals accessible both on hospital computers or iPhone/iPAD.
RESULTS: AMS (Apr18-Mar19): >13K ward/phone AMS interventions; total referrals:13,312; 9438(70.1%) responded in 60-min;11923(90%)120min; E-referrals/d: 30-80; Referral Peaks: 3pm & 11am; Referrals from hospital [10,709(80.2%)], GP/prim care [2654 (19.8%)]; Clinical areas: [eg. male cardiac:491(3.6%); HDU:793(5.9%), etc]; E-referrals addressed/consultant [eg. Consultant A(4590(34.3%), etc]. Details & graphs to be presented.
CONCLUSION: E-referral pathway has spearheaded trust AMS & sepsis programmes. Urgent referrals are picked without delay; KPI of referral response within 60mins; significant reduction in calls for consultant Infection via switch board or medical secretaries; auditable workload figures for team to inform UKAS inspection, new consultant business cases or quality matrix; improved accountability and informs annual appraisal / job plan.
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A case of recurrent aerococcus urinae infective endocarditis with associated cerebral embolic phenomena
More LessAerococcus urinae is a gram positive, alpha haemolytic cocci that rarely is associated with urinary tract infections, bacteraemia and infective endocarditis. We describe a case of recurrent aerococcus urinae endocarditis with associated cerebral embolic phenomena.
A 76 year old man presented with sudden onset right sided weakness and dysphasia. CT and MRI head imaging showed infarcts in the left pons and cerebellum suspicious of embolic aetiology.
He had a background of a prosthetic mitral valve replacement following an episode of culture negative infective endocarditis associated with discitis and a psoas abscess 3 years previously. A 16S rRNA PCR on valve tissue had yielded an aerococcus urinae.
The anaerobic bottle of a blood culture taken on his present admission flagged positive at 48 hours but no organisms were seen on gram stain. However, Matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI – TOF MS) identified an aerococcus urinae 4 hours later. The same organism was also identified in the aerobic bottle which had flagged positive later the same day with gram positive cocci in clusters. Susceptibility testing revealed a MIC (Minimum Inhibitory Concentration) of 0.032, 1 and 8mg/L for penicillin, vancomycin and gentamicin respectively.
A transthoracic echocardiogram confirmed reoccurrence of endocarditis with a 1.5cm lesion on the mitral valve. There was no evidence of other embolic phenomena. The patient was managed medically with initial treatment with intravenous vancomycin and gentamicin followed by benzylpenicillin and gentamicin for 6 weeks. The patient made slow rehabilitative progress and remained debilitated by his right sided hemiparesis.
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Cardiobacterium hominis endocarditis complicated by Aortic root abscess: A case report
More LessThe present report describes a case of infective endocarditis complicated with aortic root abscess caused by Cardiobacterium hominis (C. hominis) in a 56 year old man. C. hominis is amicroaerophilic, pleomorphic Gram-negative bacillusand member of the HACEK group (Haemophilusspecies, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens and Kingella kingae) a group of bacteria known to be a rare cause of endocarditis. With prompt diagnosis and initiation of antimicrobial and surgical management, a successful outcome was achieved.
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Study of the clinical and microbiological profile of patients with endocarditis and cancer – A case series from Tertiary care cancer hospital in Western India
More LessBackground:Endocarditis is rare and can be life-threatening in patients with cancer. We sought to evaluate the clinical and microbiological profile of patients of cancer who developed endocarditis.
Methods:We retrospectively analyzed transthoracic echocardiograms done in our hospital along with the clinical data stored in computerized medical records between 2016-2018. Infective Endocarditis was diagnosed by using modified Duke criteria. Patients with valvular verrucae and sterile blood cultures were considered to have culture-negative endocarditis.
Results:There were 10 patients of cancer who were diagnosed with endocarditis. All patients had developed endocarditis after the diagnosis of cancer. 5(50%) patients had hematological malignancy. The aortic valve was involved in 5 (50%) patients. Blood cultures were sterile in 7(70%) patients. Out of the 3 patients with positive blood cultures, 2 were positive for Klebsiella pneumoniae and 1 grew Candida tropicalis.
5 (50%) patients had concurrent pneumonia. The most common intravenous antibiotics given were cefoperazone plus sulbactam, teicoplanin, and meropenem, while most common antifungals given were caspofungin and voriconazole. The patient with Candidemia underwent surgical removal of vegetation as advised by a cardiologist. Histopathological examination and staining of the excised vegetation of this patient revealed Cryptococcus species. 6 (60%) patients developed congestive cardiac failure. 4(40%) died within 4 weeks of diagnosis of endocarditis, out of which 3 were culture-negative endocarditis.
Conclusions:In our case series, none of the blood cultures grew gram-positive bacteria and an increased proportion of culture-negative endocarditis was noted. The mortality is high in patients of cancer with endocarditis.
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Is the amniotic fluid really sterile? A study of Microbial Invasion of the Amniotic Cavity (MIAC) in a tertiary center, Khartoum, Sudan
More LessMicrobial Invasion of the Amniotic Cavity (MIAC) is a term used to describe positive amniotic fluid culture for bacteria or genital mycoplasmas. MIAC can affect both mother and fetus. It is a common cause of preterm labour with intact membranes and prelabour rupture of membranes. It is also associated with cervical insufficiency, an asymptomatic short cervix, idiopathic vaginal bleeding, placenta previa, and clinical chorioamnionitis at term. It is also related to neonatal sepsis, pneumonia and respiratory distress syndrome (RDS) and cerebral palsy. the objective of this study is to determine the etiology of Intraamniotic Infections among women delivered in Soba University Hospital, Khartoum Sudan in February- March 2016. In this cross sectional study, 246 deliveries were included samples of the amniotic fluid were taken after delivery. MIAC is detected 31.3% of the women under study. Staphylococcus aureus constitutes the major isolates (62.1%) followed by E. coli and Klebsiella spp. None of the isolates were Streptococcus agalactiae. There is a statistically significant association between MIAC and maternal infection during the third trimester, mode of delivery and birth asphyxia but not neonatal sepsis.
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Using health literacy techniques to develop patient information for counselling on antibiotics courses
Introduction
Increased education may improve awareness of antimicrobial resistance (AMR), however 43% of people aged 16-65 in England lack skills to understand health information1.This study aimed to improve patient knowledge on short course antibiotics using a patient information leaflet (PIL) incorporating Health Literacy (HL) techniques supporting the Governments’ 5 year 2019 AMR strategy.
MethodThis study received ethics approval. A revised Royal Pharmaceutical Society (RPS) checklist for Community Pharmacy PIL incorporating HL techniques was piloted, then used for 5-weeks as a counselling tool by 8 consenting community pharmacists. It was handed to patients during dispensing of short-course antibiotics, after which the pharmacists filled out a questionnaire. Patients receiving counselling using the PIL completed face to face questionnaires.
Results106 patient questionnaires were completed.
94% of patients had taken antibiotics previously and 90% of these thought the counselling received using the PIL was easier to understand than previous counselling.
96% of patients agreed the PIL improved their knowledge on appropriate antibiotic use. 81% of patients intended to change their behaviour and thought the PIL had improved their antibiotic knowledge especially to “always finish a prescribed course of antibiotics”. All patients stated the PIL was easy to follow.
ConclusionThis pilot suggests that patient behaviour can be influenced using structured counselling on AMR drawing on HL techniques.
References
1 Rowlands G, Protheroe J, et al. A mismatch between population health literacy and the complexity of health information: an observational study. British Journal of General Practice. 2015;65(635):e379-e386.
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Using health literacy techniques to support pharmacist practice when counselling on antibiotics courses
Introduction
Increased education may improve awareness of antimicrobial resistance (AMR)1 however 43% of people aged 16-65 in England lack skills to understand health information2. This study aimed to improve patient knowledge on short course antibiotics using a patient information leaflet (PIL) incorporating Health Literacy (HL) techniques supporting the governments’ 5 year 2019 AMR strategy.
MethodThis study received ethics approval. A revised Royal Pharmaceutical Society (RPS) checklist for Community Pharmacy PIL incorporating HL techniques was piloted then used for 5-weeks as a counselling tool by 8 consenting community pharmacists. It was handed to patients during the dispensing of short-course antibiotics after which the pharmacists filled out a questionnaire.
Results106 patients were counselled and all 8 pharmacists completed questionnaires on how the PIL supported their practice.
On a scale of 1 (not at all) to 5 (improved a lot), pharmacists scored how much they thought the PIL could improve patient’s knowledge on appropriate antibiotic use. 63% of pharmacists (5/8) scored the PIL ‘5’ or ‘4’.
63% of pharmacists (5/8) did not feel that the PIL took longer than their standard counselling. 66% (2/3) felt that the extra time was worthwhile.
ConclusionPharmacists believed written information using HL techniques led to improved AMR education at the point of antibiotic dispensing.
References
1.Health Education England. Tackling antimicrobial resistance: educational priorities London; 2018.
2. Rowlands G, et al. A mismatch between population health literacy and the complexity of health information: an observational study. British Journal of General Practice [Internet]. 2015;65(635):e379-e386.
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Evaluation of the potency of antibiotic formulations in the Egyptian market
More LessInterest in searching and developing new antimicrobial agents to combat microbial resistance has been growing recently. Therefore, a greater attention has been paid to both screening and evaluation methods of antibiotics activity. The present study aimed to evaluate the potency of some antibiotics containing pharmaceutical products of some Egyptian market companies using microbiological assay based on agar diffusion method and using standard strains in order to determine their therapeutic efficacy.
These antibiotics such as gentamicin, ciprofloxacin, doxycycline, amoxicillin and ceftriaxone were purchased from local pharmacies and evaluated in the current study.
The results of this study showed the relative potency of gentamicin was 41.4%-120% and 28%-41% for ciprofloxacin. While for doxycycline relative potency was 26%-72.6% and 16%-88% for Amoxicillin. As well as ceftriaxone potency was ranged between 48%-97.4%. One product of ceftriaxone, two products from gentamicin and two from amoxicillin were estimated to be within the acceptable range of bioequivalence (80%-120%), while the other products showed unacceptable relative potency. A complaint reporting system about quality and effectiveness problems needs to be considered as a priority source of such information to inform decision-makers.
Key words: antimicrobial resistance, antibiotices, evaluation, microbiological assay, agar diffusion method, potency
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The clinical impact of swabbing positive for multiple respiratory viruses
More LessLittle data exists on the clinical impact on adults who swab positive for more than one respiratory virus at once. Should this be associated with higher morbidity/mortality, there would be implications for patient care and potentially infection prevention measures. We reviewed 190 throat/nasopharyngeal swabs positive for respiratory viruses in York Teaching Hospitals NHS Foundation trust between October 2017 and February 2018. Data, collected from the hospital inpatient computer records, included: age, admission/discharge dates, presenting complaint, past medical history, time to swab (from admission), use of oseltamivir, flucloxacillin and other antibiotics, positive microbiology, highest recorded MEWS (excluding ITU), length of ITU stay and discharge status. The modal length of stay was 2-10 days. 69% of patients were aged over 40. There was no difference between admission to ITU and single/multiple respiratory viruses. The presence of influenza virus was higher in patients with a pre-existing cardiac comorbidity compared with pre-existing respiratory or other comorbidities. There did not appear to be a correlation between the number of patients with any comorbidity having multiple respiratory viruses. Interestingly, 18% of patients with multiple respiratory viruses died, compared with 10% of patients with singular viruses. Given the small numbers of patients included, further work is needed. A repeat review is planned across two hospital trusts in the near future.
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How well are we doing in diagnosing and treating UTI in older people?
More LessBackgroundThere is very good evidence that the use of a urine dipstick in the diagnosis of UTI in older people is not of value and may indeed cause harm (e.g. inappropriate courses of antibiotics, missed alternative diagnoses, etc.) This year’s AMR CQUIN has focussed on compliance with NICE / PHE guidelines. The results presented here are for the first quarter at CDDFT hospitals.
MethodsPatients were initially identified prospectively by ward pharmacists. However, this yielded too few patients and our data collection method was amended to retrospective collection, based on a primary discharge code of N39.0.
Results* 60% urine dipstick used inappropriately (target <10%)
* 52% treatment follows NICE guidelines / based on recent sensitivities / local guidelines (target >90%)
* 60% patients were prescribed coamoxiclav despite not being in NICE / PHE guidelines for lower UTI
* 86% MSU sent (target >90%)
* 84% diagnosis based on symptoms / signs consistent with UTI (target >90%)
ConclusionDespite numerous efforts (posters, walk-arounds, teaching) over the last 2 years to educate staff regarding appropriate use of urine dipsticks and antibiotics, our results were unsatisfactory. To remedy this, we have implemented the action plan described below, aimed at engendering an improvement in compliance with the guidelines and patient management.
1. Educational screensavers on computers
2. Removal of dipstick stickers from MAU clerking
3. Change of dipsticks to ones with no leucocytes and nitrites
4. Education and engagement of MAU & ED ward staff
5. Additional of new category to antibiotic formulary (?UTI/?LRTI not septic) to counter excessive coamoxiclav use
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Focal brain lesions in an HIV infected patient : A Diagnostic dilemma
More LessBackground—
Focal brain lesions associated with HIV infection can be due to cerebrovascular diseases, primary CNS lymphoma, toxoplasmosis, progressive multifocal leukoencephalopathy or other opportunistic infections. We report a challenging case of an adult HIV infected male with focal brain lesions.
Case Description--
A 62 years old male, presented with history of cough with mucoid expectoration for 3 months and abnormal behaviour for 2 weeks.
Clinical examination revealed delayed obeying of commands and no other sensorimotor deficits. MRI brain revealed ill-defined space occupying lesions involving bilateral frontal lobes. HIV antibodies and HBsAg tests were positive. CT chest revealed multiple cavitatory lesions in left upper lobe. Pharyngeal candidiasis was seen during bronchoscopy. Bronchoscopic alveolar lavage revealed Nocardia species. Tests for MTB were negative.
Lung biopsy showed Cytomegalovirus pneumonitis with Aspergillosis. PET scan revealed non FDG avid gliotic changes in brain. CSF and bone-marrow examinations were normal. Brain lesion was considered to be a manifestation of Nocardiosis and biopsy was planned. CD4 count was 103/mm3. Intravenous ceftriaxone, ganciclovir, caspofungin, fluconazole and oral septran were started. Patient was started on HAART(Tenofovir, lamivudine, efavirenz) 1 week later, after explaining the risk of Immune reconstitution inflammatory syndrome. CNS lesion biopsy revealed High grade B-cell Non- Hodgkin’s lymphoma. Palliative external Radiotherapy to whole brain was given. The patient has improved clinically and is on regular follow up from 1 year.
Conclusion—
Extensive evaluation and work up is required in cases of focal brain lesions in patients with HIV. Brain biopsy often provides the definitive diagnosis.
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Do junior doctors have the knowledge to safely prescribe antibiotics in the context of known penicillin allergy?
More LessThe drug class most frequently associated with allergic reactions are the penicillins. Yet penicillins have a vital role in being important treatment options for many common and uncommon infections.
Junior doctors undertake the majority of hospital-based prescribing. Evidence suggests foundation doctors make the most prescribing-based errors.
A questionnaire was designed to ascertain whether junior doctors displayed an adequate level of knowledge regarding individual and antibiotic class identification, use of trade names, beta lactam cross sensitivity and symptoms of type I and IV hypersensitivity reactions.
Three quarters of respondents stated they had received allergy/non-allergic drug reaction teaching as an undergraduate but only just over a half had as a postgraduate. The Junior doctor responded group demonstrated adequate knowledge of correct identification of individual penicillins and non-penicillins and symptoms of a type I hypersensitivity reaction. There was inadequate knowledge of cephalosporin and carbapenem prescribing in the context of penicillin-associated anaphylaxis and of type IV hypersensitivity reaction symptoms. More core and higher specialty trainees correctly chose to prescribe in generic name form than foundation doctors.
This survey suggests that there may be key elements of knowledge required to safely prescribe antibiotics in the context of penicillin that, overall, as a group, junior doctors may lack adequate knowledge of, with this inadequacy being most pronounced in foundation doctors.
This suggests that junior doctors, and foundation trainees in particular, may need more education and training early in their careers to help support safe prescribing in the context of penicillin allergies.
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Role of Climatic factors influencing Dengue incidence in central India: A model for Dengue prediction
More LessIntroduction:Dengue is caused an arbovirus and transmitted by Aedes mosquito. The mosquito lifecycle is influenced by various climatic factors This study was carried out to examine whether the climatic factors data can be used to predict yearly dengue cases .
Methods:Monthly reported dengue cases and climate data for the years 2012–2016 were obtained from the Chief Medical and Health officer,Bhopal and Meteorological Department , respectively. One-way analysis of variance was used to analyse whether the climatic parameters differed significantly among seasons. Four models were developed using negative binomial generalized linear model analysis. Monthly rainfall, temperature, were used as independent variables, and the number of dengue cases reported monthly was used as the dependent variable. The first model consider data from the same month, while the other three models involved incorporating data with a lag phase of 1, 2, and 3 months, respectively.
Results:Climatic factors, rainfall and maximum temperature were significantly correlated with monthly dengue cases. The greatest number of cases was reported during the post-monsoon period. Temperature, rainfall, and humidity varied significantly across the pre-monsoon, monsoon, and post-monsoon periods. The best correlation between these climatic factors and dengue occurrence was at a time lag of 2 months.
Conclusions:
The climate had a major effect on the occurrence of dengue infection in Bhopal city of central India. Though the prediction model had some limitations in predicting dengue cases, it could forecast possible outbreak two months in advance with considerable accuracy, and can act as early warning system.
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Experience of pharmacist-led antimicrobial stewardship ward rounds in a regional hospital
Background:Antimicrobial stewardship ward rounds and phone advice are fundamental to improvement of infection treatment and prevention in hospitals. In response to a local and national shortage of consultant medical microbiologists, a pharmacist-led antimicrobial stewardship service was established.
Methods:Antimicrobial stewardship interventions in a large regional hospital were analysed from 8 January 2018 to 14 March 2019. Collaborative ward rounds were conducted with infection prevention and control nurses, and microbiology staff when available. Ad hoc ward rounds and phone interventions (via a dedicated “antibiotic advice hotline”) were also conducted, with most referrals coming from junior doctors and ward pharmacists. The commonest clinical areas visited were elderly care, respiratory and general surgery.
Results:1507 antimicrobials were reviewed from 1006 interventions (16 per week). Antimicrobials most reviewed were piperacillin/tazobactam (n=152; 10%), metronidazole (n=152), co-amoxiclav (n=140; 9%), teicoplanin (n=137, 9%) and gentamicin (n=116; 8%). The commonest organisms were Escherichia coli (n=115), Staphylococcus aureus (n=95) and Clostridium difficile (n=52). The most common recommendations were intravenous to oral switch (n=185; 18%), continue (n=175; 17%), escalate (n=136; 14%) and review dose (n=97; 10%). Antimicrobials were optimised for discharge in 270 cases, through oral switch, home intravenous antimicrobial referral or cessation.
Conclusion:The results demonstrate the value of novel antimicrobial stewardship approaches that are required in today’s NHS given shifts in staff availability and recognising advanced clinical practice among non-medical staff. Future planned interventions will focus on improving the home intravenous antimicrobial referral and review process.
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Low or no CRP at the point of admission to a medical admissions unit is associated with a low rate of 48-hour antimicrobial review amongst patients prescribed antibiotics
More LessIntroduction: Antibiotic resistance is rising and multi-resistant organisms are readily being identified; therefore fear of mortality rates rising due to infection is becoming a genuine prospect. We sought to measure clinical review post antimicrobial prescription in two acute hospitals in Wales to establish whether review is undertaken at 48-hours and whether likelihood of clinical review taking place depends on C reactive protein (CRP) levels on admission.
Methods: An audit across two hospitals in South Wales assessing compliance of antimicrobial review as recommended by NICE guidelines was undertaken over a three week period. In addition, univariate odds ratios for 48-hour referral stratified by CRP test results (excluding patients with no CRP test) were calculated in a logistic regression model using the high CRP group as the referent. Following initial results intervention (education and prompt stickers) were introduced to prompt 48-hour review.
Results: 139 patients were included in the pre-intervention audit from both sites. 53% were reviewed at 48 hours. Initial interventions demonstrated an improvement in compliance in all CRP categories. In the logistic regression analysis setting the highest CRP group (CRP <=100) as referent showed that the likelihood of a 48 hour review was lower in patients with lower CRP test results, or no CRP test than those with a CRP of >=100.
Conclusion: Patients with low or no CRP on admission are less likely to have their antimicrobial prescriptions reviewed when compared 48 hours. Intervention should continue to be sought to raise awareness of this.
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Utilising data held within ePACT2 to monitor and influence antimicrobial prescribing within secondary care outpatient clinics
More LessBackgroundAssurance and intervention is needed around antimicrobial prescribing in secondary care outpatient settings, which has increased by 21% in 5-years. Use of NHS FP10 prescriptions impedes timely monitoring of prescribing. This project aimed to develop an efficient method for monitoring and reporting outpatient prescribing on FP10 forms.
Methods
A Microsoft Excel spreadsheet was developed to allow direct importing of antimicrobial prescribing data from ePACT2, which then automatically updates charts of prescribing activity using VLookup formulae and pivot charts. Reports were developed in Microsoft Word that directly pull updated charts from the spreadsheet described.
ResultsThe method allows rapid calculation and collation of DDDs and creates charts for assessing monthly antimicrobial prescribing trends. The reports highlight areas for review and action, which have driven engagement in antimicrobial stewardship across the organisation. Unexpectedly, these reports heightened nurses’ awareness of antimicrobial stewardship (AMS), who now seek reassurance on, and challenge, antimicrobial prescribing at the time of prescribing. The process takes less than 20-minutes on average (versus 3-hours previously), freeing up antimicrobial pharmacists’ time to interrogate prescribing trends and undertake clinical duties. This method also allows potentially inappropriate prescriptions to be identified and pulled from NHS BSA sooner, so that individual prescribers and teams can be targeted for intervention and reflection.
ConclusionThis method allows efficient reporting of antimicrobial prescribing, enables stewardship teams to focus interventions on prescribers and teams, and drives engagement in antimicrobial stewardship. This method could be adapted by other organisations to monitor and interrogate antimicrobial prescribing.
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Impact of Integrase Inhibitors on Weight
More LessCurrent evidence suggests that Integrase Strand Transfer Inhibitors (INSTI) are associated with excess weight gain. These increases are particularly significant for black people and women.
Clinic notes of 84 patients stable on INSTI for at least 18 months and attending HIV outpatient clinics at Castle Hill Hospital, Hull Royal Infirmary, Grimsby Hospital and Scunthorpe Hospital were included. Data including height and weight was collected at 18, 30, 42 and 54 months, following commencement of INSTI. Statistical analysis was performed using STATA.
65% of patients were male. The mean age at baseline was 50 and the mean age at diagnosis was 40. Median CD4 count was 669 and viral load was 0 within the last 6 months. 64% of patients were White British, 7% White Other, 21% Black and 9% other.
At 30 months, mean weight increased by 1.41kg, statistically significant at p<0.0065. At 42 months, mean weight increased by 2.53kg, significant at p= 0.0056. At 54 months, mean weight increased by 1.33kg; however this was not significant. Differences in weight amongst the sexes, different ethnicities and different categories of infection as classified by the CDC was observed but was not statistically significant.
Two adverse events- myocardial infarction and stroke were reported but no patient on INSTI died.
Patients stable on INSTI gained weight but the clinical significance of this is unclear, especially as weight changes in patients stable on other antiretrovirals have not been compared. Further research to assess cardiometabolic impact of weight gain following INSTI is required.
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Predicting Cotrimoxazole-Associated Acute Kidney Injury and Hyperkalaemia
More LessBackground:Increasing antimicrobial resistance has renewed interest in older, infrequently used antimicrobials. Cotrimoxazole shows future promise; however, acute kidney injury (AKI) and hyperkalaemia are potential complications. Recognising risk factors for cotrimoxazole-associated AKI and hyperkalaemia, and quantifying the impact, are required for safe use against future antimicrobial resistance.
Method:A single-centre retrospective observational study using electronic-healthcare records of patients prescribed cotrimoxazole was conducted. Patient risk factors were identified, and serum creatinine and potassium levels were analysed over the subsequent 21-days from prescription. Univariate and multiple logistic regression analyses were performed. The project was registered locally with the clinical governance team as service evaluation [Ref: CSS033].
Results:Of 214 patients, 42 (20%) developed AKI and 33 (15.4%) developed hyperkalaemia. Low baseline eGFR (<60mls/min/1,73m2, OR = 7.78, 95%CI 3.57-16.13, p<0.0001) and pre-existing cardiac disorders (OR = 2.40, 95%CI 1.17-4.82, p=0.011) significantly predicted AKI. Early serum creatinine increases within 2-4 days of therapy predicted future AKI (OR = 3.65, 95%CI 1.73-7.41, p = 0.001). A low baseline eGFR also significantly predicted future hyperkalaemia (<60mls/min/1.73m2, OR = 6.80, 95%CI 3.09-15.06, p<0.0001). Low-dose cotrimoxazole (<1920mg/day) was associated with lower AKI and hyperkalaemia risk (p = 0.007 and 0.019, respectively).
Conclusions:Cotrimoxazole-associated AKI and hyperkalaemia is frequent and dose-dependant. Renal function and pre-existing cardiac disorders should be carefully evaluated before prescribing cotrimoxazole. Serum creatinine should be monitored in the first 2-4 days of treatment to identify susceptible patients, and low-doses considered if AKI or hyperkalaemia is suspected.
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A retrospective review of vancomycin dosing in paediatric patients
More LessBackground: Vancomycin has antimicrobial activity against most Gram-positive pathogens. Reduced susceptibility of vancomycin to many microbes has necessitated higher target vancomycin trough levels (VTL) of 10-20mg/L. Paediatric dosing algorithms have remained unchanged despite higher VTL targets; increased doses are required. The study outcomes were to assess the impact of new dosing guidelines on VTL, time to target VTL and vancomycin-associated acute kidney injury (vAKI).
Methods: A single-centre review assessed 63 vancomycin treatment episodes between Apr-2016 and Feb-2019. Demographic data, treatment duration, daily vancomycin dosing and VTL were collected. Episodes were grouped as high-dose vancomycin (HDV) (≥60mg/kg/day) and low-dose vancomycin (LDV) (<60mg/kg/day). Target VTL was 10-20mg/L. AKI was defined by modified pRIFLE criteria as ≥50% increase in baseline creatinine within 7 days of treatment commencement. The project was registered with the local audit team.
Results: Initial VTL were significantly higher in the HDV group (mean 10.4, SD±4.7mg/L; n=20) than LDV (mean 7.9,SD±4.0mg/L;n=43), p=0.0397. Whilst time-taken to reach target VTL was improved in the HDV group (53.5±22.3 hours vs 66.1±37.1hours), this was statistically insignificant (p=0.2675). Paired t-tests revealed no significant changes to baseline creatinine in HDV (p=0.1267) and LDV (p=0.2006). No differences in vAKI incidence between the two groups were noted (p>0.05).
Conclusion: Increasing vancomycin dosages improved initial VTL but was insufficient to improve the length of time to reach target VTL. Reassuringly, there was no increase in vAKI incidence with HDV. The study suggests loading doses in paediatrics may be needed to improve time to target VTL.
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Rapid Determination of Antimicrobial Susceptibility of Gram-Negative Bacteria from Positive Blood Cultures Using an Innovative Method
More LessIntroduction:A blood stream infection (BSI) presents a complex and serious health problem and is growing in light of the eminent antimicrobial resistance threat. Progress must be made towards rapid BSI diagnosis and antimicrobial susceptibility testing (AST) to reduce preventable death in BSI.
Methods:Positive blood cultures from Ninewells Hospital, Dundee were studied prospectively. Flagged positive blood cultures were processed by Gram-staining, Vitek identification and AST or disc diffusion for ceftriaxone susceptibility and by scattered light integrated collection device (SLIC). Susceptibility to a panel of five antibiotics as defined by EUCAST breakpointswere compared.The time to AST result and AST categorical agreement was compared for standard methods and SLIC, any discrepancies were resolved by the EUCAST broth micro-dilution reference method.
Results:A total of 505 bacterial-antimicrobial combinations were analysed. A categorical agreement of 95.45% (482/505) was achieved between SLIC and Vitek/disk diffusion. The remaining 23 discrepancies were resolved by broth micro-dilution with 10 AST results agreeing with the SLIC result and 13 in agreement of Vitek/disk diffusion. Thus the overall AST agreement of the standard workflow was 98.01% (495/505) compared to 97.43% (492/505) using SLIC. The mean time for AST was 1.94 + 0.02 h and 10.53 + 0.46 h for SLIC and Vitek respectively. Overall SLIC was calculated to save 25hrs from positive blood culture to AST outcome.
Conclusion:SLIC has the capacity to provide AST at the same time as Gram stain or MALDI-TOF identification.This could improve the value of blood culture in clinical practice.
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Laboratory lessons in identifying Pasteurella bettyae
More LessIntroduction:We discuss the phenotypic features of a clinically significant blood culture isolate that was ultimately identified as Pasteurella bettyae, with important laboratory learning points.
Laboratory diagnosis:The blood culture from a female patient with septic shock from an unknown source grew a Gram-negative, oxidase-positive, coccobacillus that was initially identified by API® NH as Haemophilus influenzae (%ID=99.8; T=0.75). A respiratory source was therefore investigated for. The MALDI-TOF result, which was returned to the laboratory 4 weeks after blood culture became positive, revealed the isolate to be Pasteurella bettyae (score=2.305). P. bettyae is an unusual organism associated with gynaecological infections, such as Bartholin’s abscess. Local source control, such as incision and drainage of a Bartholin’s abscess, may accelerate resolution of sepsis. The laboratory misclassification of P. bettyae as H. influenzae using API® NH may lead to misidentification of the source of infection.
Learning points:1. Correctly identifying P. bettyae as the cause of a Gram-negative coccobacillus bacteremia can prompt suspicion of a gynaecological source of sepsis.
2. P. bettyae and H. influenzae, as members of the same family Pasteurellaceae, have overlapping morphological and biochemical features that can lead to laboratory misclassification. A catalase test and x+v plates can clearly differentiate the isolates (discussed further in poster). It is recommended that laboratories perform both tests, with MALDI-TOF confirmation if possible, rather than rely solely on the result of an API® NH.
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What’s in a label? Can use of a questionnaire-based tool identify patients that may benefit from antimicrobial allergy ‘de-labelling’
More LessBackgroundBeing labelled as “allergic” to an antimicrobial (commonly penicillins) can lead to worse clinical outcomes and increase antimicrobial resistance. Unclear or inappropriate allergy documentation contributes to this issue so clarifying “allergy” status is important to optimise clinical outcomes.
Methods
The study was conducted at St Thomas’ Hospital, a large teaching hospital in London. An antimicrobial allergy assessment process, consisting of a researcher-developed and administered questionnaire, a review of patient medical records and categorisation of the drug allergy ‘label’, was applied to eligible patients from selected wards. Recommendations for allergy ‘de-labelling’ and referrals were given based on patient categorisation.
ResultsSixty assessments were completed during the study. Six patients (10%) were identified as unlikely to have a true allergy and could potentially be ‘de-labelled’. A further thirty-seven patients (61.7%) were identified as eligible for allergy referral and testing. The allergy ‘labels’ of twenty-seven patients (45%) led to them receiving second-line antibiotic therapy. Twenty-two patients (34.7%) had inconsistencies in their allergy documentation across the 3 main electronic clinical systems.
ConclusionThis study demonstrated that the use of a simple, standardized, pharmacy-led approach to antimicrobial allergy assessment could lead to some patients being 'de-labelled' outside of specialist allergy settings. The implementation of this approach could immediately bring about improvements in antimicrobial usage and patient outcome.
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Audit to assess adequacy of Screening of latent TB in Newly diagnosed HIV patients
More LessIntroduction
Patients with Human Immunodeficiency Virus (HIV) are at an increased risk of latent Tuberculosis (TB) reactivation. HIV TB concurrent infection increases mortality and reduces patient quality of life. Screening for latent TB allows treatment to commence, preventing reactivation. In accordance with British HIV association guidelines, all patients should have a Chest X-ray (CXR) at diagnosis. If patients are determined to be at a high risk of TB, an Interferon Gamma Release Assay (IGRA) test should be done to determine previous exposure to TB.
Methods
95 HIV positive patients diagnosed between 2012-2017 at the Royal Victoria Infirmary (RVI) were assessed for inclusion. 4 patients excluded as they had active TB, n=91. Patients were determined to be high risk if they were from an African or Asian country of origin, or if they had a CD4 count below 200 cells/mm3. Clinic letters and results on eRecord were reviewed (n=95) between 16/02/2019- 21/03/2019.
Results61.5% of patients had a CXR at diagnosis. 72.5% of patients had a CXR or a CT scan. 8 patients had an IGRA test performed, of which 2 were inconclusive. 20% of patients from Africa and 0% of patients from Asia had an IGRA test. Of those patients with a CD4 count below 200 cells/mm3 9.1% had an IGRA test.
Discussion
An assessment of patient TB risk may need to be undertaken to allow thorough latent TB screening using IGRA tests. Automatic IGRA tests could be done on all patients with a CD4 count <200 cells/mm3.
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A review of the utility of PET imaging in Staphylococcus aureus bacteraemia (SAB) using electronic data
More LessIntroduction:If the infectious focus is not identified, there is an associated higher mortality in Staphylococcus aureus bacteraemia (SAB) [1]. A retrospective observational study found patients with high-risk SAB who had a PET scan had a 67% reduction in mortality compared to those who did not [2]. We used electronic data to determine the range of infectious foci in SAB and the use of PET in our trust.
Methods:From 1/1/13 to 31/12/18 all patients with SAB at St Thomas’ Hospital, London, were reviewed by the infectious diseases team and data collected prospectively using an Access database. A retrospective analysis of this database, electronic records, radiology and nuclear imaging was conducted.
Results:355 episodes of SAB affected 296 patients. 28 (8%) episodes were MRSA in 24 (8%) of patients. Infectious sources found included bone and joint (23%), IV access (15%), vascular infection (15%), no infective focus (13%), SSTI (12%) and endocarditis (9%). Imaging used to determine the focus of infection included MRI (18%), CT (26%) and PET scan (10%). In-hospital mortality was significantly lower in those who had a PET scan than in those who did not (1/31, 3% v. 50/265 patients (last episode), 19%, P=0.03).
Conclusions:
Mortality was lower in those who had PET at our trust. This is consistent with data published from other centres and requires further investigation. A prospective trial of PET in SAB is urgently needed.
References:
[1] PMID: 30179645
[2] PMID: 28336786
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Multidrug-Resistant Vibrio species recovered from some Freshwater Resources in Southwest Nigeria: a public health concern
More LessGlobally, pathogens that cause infectious water-related diseases such as diarrhea and cholera are beginning to manifest with unusual antibiotic resistance characteristics and virulence, posing a huge threat to public health. Vibrio species are a leading cause of water-and food-borne outbreaks and is widely distributed in the water environments making it a significant threat to human health worldwide. A total of 315 Vibrioisolates recovered from different freshwater resources in southwest Nigeria were confirmed by simplex PCR using toxR gene. All confirmed isolates were tested for In vitro susceptibility to 18 antibiotics using agar disc-diffusion assay and the phenotypic tetracycline-resistant isolates were further profiled for their genotypic antimicrobial resistance determinants by PCR assay. The isolates were variously susceptible to the antibiotics tested as follows: norfloxacin 308 (98%), ciprofloxacin 293 (93%), meropenem 287 (91%), cefotaxime 279 (88%), amikacin 238 (75%). Conversely, resistance to erythromycin 300 (95%), sulphamethoxazole 297 (94%), rifampicin 289 (92%), doxycycline 260 (82%), tetracycline 237 (75%) were equally observed. Tetracycline resistance isolates were assessed for resistance determinant and the following prevalence were obtained; tetA (28), tetE (20), and tet39 (3). The MAR index across the sampling locations of 0.8 to 0.94 exceeds the threshold value of 0.2, suggesting excessive antimicrobial usage at the sample source. Our findings reveal high incidence ofVibrio species in the selected freshwater resources and also signify high resistance towards some conventionally used antibiotics. Consequently, this portends that the waters are unfit for domestic, industrial and recreational purposes and a reservoir of antibiotic resistance determinants in the environment.
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UK Paediatric Antimicrobial Stewardship: a call for action
Background:Paediatric antimicrobial stewardship (PAS) networks exist in the USA and Australia but not in the UK. We sought to capture a snapshot of the current PAS landscape across UK children’s hospitals.
Methods:A survey of PAS activities was conducted in tertiary children’s hospitals.
Results:Infectious disease or microbiology consultants responded to the survey (n=15). All hospitals had neonatal, paediatric intensive care and surgical patients.All centres provided a PAS education programme for doctors, 7 for nurses and 9 for pharmacists as well. All centres had empirical antimicrobial prescribing guidelines. All centres with a paediatric infectious diseases (PID) team (11/15) used “audit and feedback” rounds, although their frequency and coverage varied. The PAS teams mostly included a PID consultant and/or microbiology consultants and a pharmacist. Three centres also had a nurse covering also the paediatric out-patient antibiotic treatment programme. Funding for PAS were inconsistent: Great Ormond Street Hospital had secured a dedicated full-time paediatric microbiologist, antimicrobial pharmacist and PID consultant with a ratio of 1/453 in-patient beds. 9 centres did not have dedicated funding for a paediatric antimicrobial pharmacist, 7 did not have funding for a paediatric infectious disease consultant. Only 2 hospitals had microbiology consultant time for paediatric audit and feedback.
Conclusion:PAS programmes in the UK are limited, funding is inconsistent and their set up is variable, even in tertiary children’s hospitals with a strong interest in infectious diseases. We propose a national PAS network to advocate for more consistency and research into the implementation of PAS programmes.
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The Accuracy of 1,3-B-D-glucan testing in diagnosing Fungal Infections: A comparison of high-risk groups within the ICU setting
More Less1,3-B-D-Glucan [BDG] is found in the cell wall of most fungii species and BDG testing is currently used as an adjunct for diagnosing fungal infections in immunocompromised patients. Guidelines on use of BDG testing is still unclear due to uncertainties on its reliability as a diagnostic tool. We aimed to determine the accuracy of BDG testing for diagnosing fungal infections and observed general patient demographics for those more at-risk of infection within the ICU setting. A case control study was carried out on 158 patients who had BDG tests requested in UH Bristol. This was further divided into 69 positive BDG result group and 89 negative BDG result control. Patient BDG results were compared to gold standard diagnostic criteria of positive signs on CT scans, BAL PCR and Blood or sputum cultures to confirm presence of fungal infection. Control group implied negative BDG test results consistent with negative gold standard diagnostic testing results in order to determine true negative cases. We determined BDG to have Sensitivity of 89.2%, Specificity of 66.9%, Positive predictive value of 36.3% and Negative Predictive value of 97.8%. Majority of ICU patients affected by fungal infections requiring BDG testing included stem cell transplant, neutropenic, GI surgical and Haematology admissions. In conclusion, BDG has a large Negative Predictive Value and is a good test to use in excluding fungal infections. However, it has limited sensitivity and positive BDG is not helpful in confirming presence of fungal infections.
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Optimising the diagnosis of UTI in patients with mixed growth bacteriuria
More LessBackground: Leeds Teaching Hospitals NHS Trust (LTHT) Microbiology department report urine cultures with >1 isolate as ‘mixed growth’ (MG). The clinical significance of this remains controversial. We aimed to describe MG and explore how clinicians interpret MG reports.
Methods: Urine culture data (2018) were retrospectively collected from the LTHT laboratory information system. Urine cultures reported as MG from a one-week period in 2019 underwent further laboratory analysis. Semi-structured interviews of eight NHS clinicians were explored for emergent themes around MG using framework analysis. Clinicians were also provided with data in existing MG report formats and alternative reports including organism identities and sensitivities; and clinician propensity to diagnose/treat urinary tract infection (UTI) was noted.
Results: Of 115664 cultured specimens, 12% were MG with rates highest in patients >65yrs (19.3%, n=41760) and <1yr old (18.7%, n=2727). Of 459 isolates from 200 MG cultures, Enterococcus species (30.1%) and E. coli (27.5%) were most frequently isolated and the most frequent organism combination (24%). 65.5% of cultures contained 2 organisms, with 82.5% having at least one Enterobacteriales. Many clinicians believed MG statements represented detection of many commensal bacteria which did not represent infection. When given alternative reports including organism identities/sensitivities, (cf. report of MG only), more were likely to diagnose and treat a UTI
Conclusions: MG in urines is common. Most MGs include Enterobacteriales, an important cause of UTI. Reporting two species as MG only can be misleading, resulting in failure to treat clinically apparent infections.
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Biofilm profile of Candida isolated from clinical specimens at a Tertiary Care hospital in India
More LessIntroduction
Candida species are a leading cause of infections in immunocompromised hosts. Usage of indwelling medical devices provides ample opportunity for Candida biofilms to set up a nidus for infection that is not easily amenable to conventional antifungal therapy.
Materials and Methods
A total of 100 Candida isolates from patients with suspected candidiasis were tested for production of biofilm. Based on clinical history, 62% of the patients were found to have clinically significant infection with Candida while in 38% of the patients, Candida isolates represented commensals. Biofilm production was detected and graded by visual (test tube) and spectrophotometric (microtiter plate) methods.
ResultsFifty five percent of the Candida isolates produced biofilm. Biofilm producing abilities of clinically significant isolates (80%) was found to be significantly higher than commensals (20%). Biofilm positive Candida isolates were most commonly obtained from blood (34.5%). Biofilm production in non-albicans Candida (67.9%) was found to be significantly higher than C. albicans (38.6%). Majority of the biofilm positive Candida isolates produced Grade 2 (moderate) biofilm. Candida tropicalis accounted for maximum biofilm production comprising 20% Grade 4, 53.8% Grade 3 and 50% Grade 2 biofilm. Concordance in grading between the two methods was observed in 72.7% of the isolates. Spectrophotometric method was found to be more sensitive than visual method for detection of Candida biofilm.
ConclusionThe importance of studying Candida biofilms is to ascertain new therapeutics and techniques to manage these infections clinically and improve the outcome as these are associated with high morbidity, mortality and resistance to antifungal drugs.
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Evaluation of Xpert® Xpress Strep A Test for detection of Group A streptococcus in throat swabs
More LessBackgroundStreptococcus pyogenes (Group A β -hemolytic Streptococcus) infections in humans range from mild pharyngitis to life-threatening infections such as septicaemia and necrotizing fasciitis. We assessed the diagnostic accuracy of the Xpert® Xpress Strep A Assay, a new automated real-time polymerase chain reaction (PCR) that can detect this pathogen.
Methods
We evaluated the diagnostic accuracy (sensitivity, specificity PPV and NPV) of Xpert® Xpress Strep A Test (Cepheid, Maurens-Scopont, France) for the detection of Group A Streptococcus in throat swabs using Copan virus transport medium at Ninewells Hospital & Medical School (Dundee, Scotland, UK). The performance of Xpert t® Xpress Strep A Assay was compared with routine culture (gold standard method).
ResultsA total of 323 clinical throat swab samples were tested. The sensitivity of Xpert ® Xpress Strep A Assay was found to be 95% (95% CI, 75.13% -99.87); specificity 96.5% (95% CI 93.83% -98.36%);PPV 65.5% (95% CI 50.61% -77.89%); and NPV 99%(95% CI 97.68% -99.95%). Overall, there were eleven discrepant results, of these 10 were positive by PCR and not confirmed by culture and one sample was recorded positive by culture and negative by PCR. The turnaround time (TAT) was 24 minutes for negative samples and 18 minutes for positive samples.
ConclusionThe Xpert® Xpress Strep A Assay for detection of Streptococcus pyogenes in throat swabs had high sensitivity, specificity and rapid TAT. Use of this technology as a point-of-care test could be explored further to assess its impact on antimicrobial prescribing and infection prevention and control measures.
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Pulmonary infection due to Acrophialophora fusispora in a patient with underlying mixed connective tissue disease and chronic pulmonary aspergillosis
More LessBACKGROUND
Acrophialophora fusispora is an emerging opportunistic fungus rarely implicated in human infections. Here, we report the first case of pulmonary infection due to A. fusispora from India.
CASE DESCRIPTION
A 59-year-old male, farmer by occupation was admitted to AIIMS, Jodhpur, Rajasthan, India, with complaints of cough and expectoration of yellowish sputum for last one month and gradually progressive shortness of breath for 20 days. He had past history of pulmonary tuberculosis and was a known case of COPD for last five years. He was diagnosed with mixed connective tissue disease (MCTD) for which he had been receiving treatment with azathioprine and prednisolone for 3 months. CECT of chest revealed cystic bronchiectatic changes with findings suggestive of aspergilloma. Serum Aspergillus fumigatus specific IgG levels were elevated suggestive of chronic pulmonary aspergillosis (CPA). He was tested positive for influenza A (H1N1) by RT-PCR and received treatment with oral oseltamivir but to no clinical benefit. Culture of sputum on two subsequent occasions showed growth of a fungus which was identified as Acrophialophora fusispora based on characteristic microscopic morphology and rDNA ITS sequencing. Treatment with oral itraconazole showed marked symptomatic improvement. He was discharged from the hospital with oral itraconazole to be continued for 6 months. Follow-up visit after 3 months showed significant clinical and radiological improvement.
CONCLUSION
Molecular sequencing can reliably identify A. fusispora which is crucial for initiating specific antifungal therapy. Further studies are encouraged to determine the prevalence of such infections so as to plan optimal management and improve patient outcomes.
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The public health task force in the management of the Mycobacterium chimaera case in the Vicenza hospital, Italy
BACKGROUND
Since 2013, an ongoing global outbreak of Mycobacterium chimaera among patients who underwent open-chest surgery has been recognized with all cases linked to contamination of a specific brand of heater-cooler device (HCD). Nine cases were diagnosed with disseminated M. chimaera infectionin our hospital. Following the first cases HCD was changed with different technology assuring no release of contaminated particles. The potentially at-risk population was managed throughout a multidisciplinary task force.
METHODS
In November 2018, following an infected patient’ death, a huge impact on public opinion was registered following mass media publicity of the case. A task force was built up to face the concern of the population: apress release [https://context.reverso.net/traduzione/inglese-italiano/press+release]and an official note were publicly released addressing risk factors and critical symptoms and a call center was activated. The notice was transmitted to general practitioners too. People complaining symptoms suggestive for infection, primarily screened by an expert group through telephone interview, were addressed to an infectious consultation.
RESULTS
The official note was delivered to 2181 potentially at risk patients chosen by cardio surgery registry and 567 of them called back the call center and were interviewed. 66 patients were judged to need infectious specialist consultation: 12 were submitted to further microbiological analysis and 4 required hospitalization. No new cases of infectious were detected.
CONCLUSION
The public health task force promptly activated granted safety measures for the population; furthermore HCD will soon be settled in separated place out from operating room.
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Candida auris real-time PCR for surveillance of patients and environment
More LessBackground– 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.
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Application of the Bruker IR Biotyper for Strain Typing During An Outbreak
More LessBackgroundMolecular typing methods such as whole genome sequencing are relatively time-consuming and expensive. Here we demonstrate the effectiveness of the Bruker IR biotyper in strain typing.
Methods
Isolates of multi-resistant Enterobacteriacae from clinical samples were typed using the Bruker IR Biotyper. The relationships between isolates were analysed using the Bruker IR biotyper software (version 2.1.0.195).
ResultsOn dendrogram analysis, the 13 E. coli isolates mostly clustered independently with all 5 replicates. Two isolates (RFH035 and RFH007) clustered together, their replicates spanning across 3 clusters, indicating that they are the same isolate. This was confirmed on Principle Component Analysis (PCA).
EightK. pneumoniaeisolates segregated into 7 clusters. Two isolates (RFH033 and RFH006) clustered together initially but separated on the PCA plot.
Discussion
RFH035 and RFH007 both came from patients infected with NDM-producing E. coli. Their PFGE profiles are indistinguishable. Both patients were admitted to hospital and were on the same ward simultaneously, reflecting the co-clustering seen with the Bruker IR biotyper.
Both RFH033 and 006 were NDM producers, but RFH033 co-produced OXA48. They had almost indistinguishable VNTR profiles with only one difference. This relatedness but difference in resistance profile is reflected in the close relationship seen on dendrogram but separation by PCA seen with the Bruker IR biotyper.
The Bruker IR biotyper is therefore able to reliably demonstrate relatedness and discrimination between strains of E. coli and K. pneumoniae. This methodology has much faster turnaround times than conventional methodology, and therefore has the potential to inform outbreak management in a more timely manner.
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The power is in our hands: a QI project for sustainable hand hygiene
More LessBackgroundMethicillin Sensitive Staphylococcus Aureus (MSSA) is a commensal associated with hospital acquired infection (HAI). MSSA HAI is associated with significant morbidity, and hand hygiene has been identified as a prominent component of HAI prevention strategies.
MethodsA project using Quality Improvement methodology was devised to improve rates within the surgical department: a locally identified MSSA HAI hotspot. Baseline monitoring was done using WHO checklists and departmental education presented on hand hygiene. Continued weekly auditing and feedback was carried out by the multidisciplinary team (MDT) on one ward over a four-month period, and adherence was prompted by verbal reminders and departmental education. A long-term strategy was employed for regular monitoring with a nominated member of the MDT to maintain improvements.
ResultsBaseline audit revealed adherence of 10-52% for registrar-led rounds, and 22-62% for consultant-led, across the 5 points of hand hygiene. Particular weakness was noted before patient contact and entry to clinical areas, which was addressed with departmental education. Initial adherence after education was low (6-38%), but subsequent improvement was seen the following month (74-93%). Some of this was maintained over the final two months of data collection (50%-100%), and a PDSA cycle was employed to address this variability. As such, an MDT-wide monitoring schedule was put in place at the end of the data collection period.
ConclusionThis QI project sought to achieve sustainable change in adherence to hand hygiene. An MDT-wide system of monitoring and education effected this, and may prove an effective strategy in similar inpatient settings.
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Cruising for bruising
More LessA 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.
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Collation of resources within a regional antimicrobial pharmacy group
More LessBackground: 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.
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Epidemiology of paediatric infection a 10 year experience on the Gold Coast, Queensland, Australia
More LessIntroduction
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.
ResultsA total of 155 children < 17 years old fulfilled the recruitment criteria for inclusion. 93 patients were excluded for coding issues, incorrect diagnosis and multiple encounters of the same patient with different medical teams.
Of the 62 patients in the cohort the hip was the most common joint involved (23) following by knee (16), elbow (8), ankle (6), foot (5), shoulder (2) and wrist (2). Two of the organisms were confirmed from ward aspirates and 59 from intraoperative samples. Of the microbes identified aseptic was the most common (48%) followed by MSSA (29%), step pyogenes (5%), MRSA (3%), strep pneumonia (3%), pseudomonas (3%), kingella kingae (3%), serratia marcescens (3%), haemophilus parainfuenzae (2%).
ConclusionThis study is the first to publish the epidemiological profile of paediatric joint infections on the Gold Coast Australia and highlights the most common identified pathogens but also highlights the variety of organisms implicated in the condition.
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Towards a harmonised approach to Carbapenemase-producing Enterobacteriaceae (CPE) screening and patient management in North East and Cumbria hospitals
More LessIn 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.
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Clinical validity of enterovirus PCR testing of skin swabs samples
More LessBackground:Enteroviruses cause a diverse spectrum of diseases. In 2018, enterovirus PCR was included in the standard panel of skin swabs investigations, which already included HSV and VZV. Here we show evidence that positive PCR results for enterovirus correlate with clinical data obtained through retrospective review.
Method:
A retrospective search of laboratory records for all skin swabs between July 18 and March 19 was performed. Enterovirus PCR positive results were correlated with clinical information from request forms and electronic patient records. A subset of positive samples was sent to the reference laboratory for genotyping by Sanger sequencing of the VP1 gene.
Results:Of 1159 specimens tested, 108 were positive for enterovirus, 194 were positive for HSV 1, 70 for HSV 2, 167 for VZV. Median age for enterovirus positive patients was 1 year, compared with 29 years for HSV and VZV positive patients. 99 enterovirus positive results correlated clinically, 2 did not correlate, and 7 had no clinical information available. Those with clinical correlation had a higher PCR cycle threshold (CT), than those without (mean 27.4 vs. 38).
12 samples were sent to the reference laboratory. Of the 6 that could be successfully genotyped, all were Coxsackie A6.
Conclusions
Positive enterovirus PCR in skin swabs correlated well with clinical signs, demonstrating validity. The identification of Coxsackie A6 on all sub-typed isolates further supports the validity of a positive result, as does the younger median patient age for patients testing positive for enterovirus compared to other viral infections.
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Real-world experience with Isavuconazole therapy in a large tertiary hospital in Cambridge, UK
More LessBackground: 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.
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Metabolite X is a novel biomarker for sepsis diagnosis and treatment
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.
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Occurrence and Evaluation of Antimicrobial Susceptibility of Staphylococcus aureus Isolated from Chicken Eggs, Eastern Ethiopia
More LessA 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.
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In-Vitro Antibacterial Therapy of Ficus exasperata, Securinega virosa and Tamarindus indica Leaf Extract on Bacterial Isolate from Otitis Media effusion
More LessBackground:Antibiotics resistance which is a global health challenge is no longer a future threat but a present challenge to all facet of clinical settings. Thus, treatment of Otitis media effusion in this regards is a major concern.
Objectives:The aim of this study was to determine the efficacy of three medicinal plant extract in the treatment of Otitis media as an alternative therapy.
Methods:The antibacterial effect of absolute methanol leaf extract of Ficus exasperate, Securinega virosa,and Tamarindus indica on organisms isolated from otitis media effusion was determined using agar well diffusion method. The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) was also determined using the double fold dilution technique. Treatment means were compared with Duncan’s New Multiple Range Test at 5% level of significance using Statistical Analysis System
Results:Bacteria isolated include Staphylococcus aureus 19(39.58%), Klebsiella pneumonia 15(31.25%), Pseudomonas aeruginosa 10(20.83%), Proteus mirabilis3(6.25%) and Streptococcus pneumoniae 1(2.08%). At 1.0mg/ml concentration, At 1.0 mg/ml concentration, Tamarindus indicainhibited all the isolates; For Ficus exasperate,the MIC was 0.39 mg/ml and MBC was 0.78 mg/ml against Pseudomonas aeruginosa; Securinega virosa MIC was 0.78mg/ml and MCB 1.56mg/ml against Staphylococcus aureus, Pseudomonas aeruginosaand Klebsiella pneumoniae. Tamrindus indica lowest MIC was 0.39 mg/ml and MBC of 1.56 mg/ml against streptococcus pneumoniae. The antimicrobial activity of the three extracts shows significant (P<0.05) inhibition for the organisms.
Conclusion:This study showed the potentials of the aforementioned extracts as treatment options for cases of OME.
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A retrospective study to evaluate the epidemiology, standard of care, outcomes and resource utilization in patients with confirmed or suspected infection by a carbapenem resistant Gram-negative organism in the UK – the CARBAR study - Epidemiology of Gram negative organisms
Background:Antimicrobial resistance is a global threat with potentially devastating consequences and significant costs to society. Carbapenems are customarily reserved for difficult-to-treat Gram-negative (GN) infections, but resistance is increasing; hence WHO classified carbapenem-resistant (CR) strains of Acinetobacter baumannii (CRAB), Pseudomonas aeruginosa (CRPA), and Enterobacteriaceae as critical priority.
CR-GN infections have few effective treatment options, with variable outcomes and scarce clinical trial evidence. In this analysis, we describe the epidemiology of patients infected with CR-GN organisms.
Methods:Retrospective chart review from 10 sites in UK. Adult patients admitted to hospital between April 2017-March 2018 were included if they had a confirmed GN bacterial infection and/or positive screening isolate for CR-GN bacteria colonisation. Data collection included microbiological results and patient demographics.
Results:36,078 patients were included, representing 42,310 GN isolates, of which 3,063 (7%) were CR-GN. Mean age was 59.9 years; 60.2% were female.
The most prevalent GN species were E. coli representing 51.8% of all isolates, followed by P. aeruginosa (12.0%), and K. pneumoniae (8.7%).
Within CR-GN isolates CRPA represented 26.6%, E. coli 21.5%, and other bacteria 51.9% (including CRAB and Stenotrophomonas maltophilia).
Conclusion:GN isolates are frequent across the UK, and 7% are CR-GN, representing a small important segment of this population. Understanding the real-world prevalence of GN and particularly CR-GN infections, where there is the highest unmet need, can help optimise antimicrobial stewardship and infection control programmes and ultimately improve overall patient’s and healthcare system’s outcomes, which is the focus of this study’s next phase.
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Electronic medicine dispensing cabinet usage reporting as a tool for hospital antimicrobial stewardship
More LessMulti 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.
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A qualitative study on factors influencing the implementation of a Clostridium difficile risk prediction tool in the Scottish secondary care setting
More LessIntroduction: 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.
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Improving Antibiotic Prescribing for UTIs in Renal Impairment
More LessBackground:Urinary Tract Infections (UTIs) are the most common bacterial infections in the elderly. First line antibiotic therapy includes Trimethoprim and Nitrofurantoin, both of which should be used with caution in renal impairment. The project aim was to improve antibiotic prescribing in UTIs for patients with renal impairment.
Methods:Initially an online questionnaire was sent to prescribers working in Forth Valley Hospital to ascertain their knowledge of antibiotic prescribing in renal failure. Quantitative data was obtained reviewing Trimethoprim and Nitrofurantoin prescriptions over 1 month (19/02/19-19/03/19) using HEPMA electronic prescribing system. These results were cross matched with patients renal function collected from SciStore database.
Results:Despite 95% of medical staff having experience of prescribing in renal failure, 35% of those still did not feel confident in prescribing the correct antibiotic dosage with 90% of the opinion that prescribing guidance was necessary. Quantitative data showed that 12.9% (28/217) of patients treated with either trimethoprim or nitrofurantoin had renal impairment. Of these 79% had an Acute Kidney Injury and 71% a degree of Chronic Kidney Injury. 78% of the patients on Trimthoprim had an AKI and 38% of these developed hyperkalaemia. Those prescribed Nitrofurantoin 100% of this group had a concurrent Acute on Chronic Kidney Disease.
Conclusion:79% of patients prescribed Trimthoprim or Nitrofurantoin had a degree of renal impairment leading to potential undertreatment or renal damage in the patient. As a result NHS Forth Valley has now updated prescribing guidelines regarding UTI treatment in patients with renal impairment advising alternative antibiotic therapy.
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Co-Amoxiclav Prescribing in Renal Impairment
More LessIntro:
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.
Methods:An online questionnaire was sent to clinicans to ascertain their prescribing knowledge in renal impairment. Following this a review of all prescriptions of Co-Amoxiclav over a one month (19/02/19-19/03/19) period was reviewed and cross matched with patients renal function to determine those with a degree of kidney injury. Standard of dosing was compared against the BNF as most clinicians replied that this was their main prescribing resource.
Results:774 patients were prescribed Co-Amoxiclav; 11.8 % (92) of these with a degree of renal impairment. Only 54% (50) of these patients were prescribed the correct dose of Co-Amoxiclav. 78 patients had an acute kidney injury (AKI) with 58% (45) prescribed the correct dose. In comparison 51% (47) of patients had a Chronic Kidney Injury (CKD) with only 33% (15) prescribed the correct dosage. This number is equally low in patients with an acute on chronic kidney injury; 35.8 % (33) patients with 30% (9) on the correct dose.
Conclusion:46% of patients with a degree of kidney injury are being prescribed the wrong dosage of Co-Amoxiclav which may potentially result in patient harm or under treatment of their condition. Further education is required within the trust to ensure prescribers use correct sources including the Renal Handbook and consider alternative antibiotics in patients with renal impairment.
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A lateral flow strip in combination with microfluidic device and polymerase chain amplification for rapid and visual detection of lymphatic filarial infection
Background:Lymphatic filariasis (LF) is a neglected tropical disease caused by the filarial nematode parasites which is transmitted by the bites of infective mosquitoes. The diagnosis of LF traditionally relies on the detection of circulating microfilariae (mf) using Giemsa-stained thick blood smears which has several limitations.
Materials and methods:In the present study, we developed a lateral flow (LF) strip to be used in combination with a novel microfluidic device and polymerase chain reaction (PCR) for a rapid and visual detection of lymphatic filariae, Brugia malayi/ Wuchereria bancrofti infection in human blood samples.
Results:The assay targets B. malayi HhaI gene and W. bancrofti Ssp gene. Prior to perform the assay, no DNA product clean up step required, thus, it can shorten time and reduce cost. The LF strip can detect as low as 10 pg of DNA product and no cross-reactivity with DNA of other parasites such as Gnathostoma spinigerum, cysticercisis soliumnor with DNA of other filariae i.e. Brugia pahangi, Dirofilaria immitis andD. repens.
Conclusions:The developed LF strip shows high sensitivity and specificity, in combination with a novel microfluidic device and PCR, can be used as an alternative tool for the diagnosis of lymphatic filariasis.
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Pharmacodynamic evaluation of intermittent versus prolonged infusion dosing regimens of piperacillin/tazobactam in a hollow-fiber infection model against two susceptible Klebsiella pneumoniae clinical isolates
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.
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