- Volume 2, Issue 2, 2020
Volume 2, Issue 2, 2020
- Abstracts from the Federation of Infection Societies Conference 2019
-
- Poster Presentation
-
-
Easy to get, but not always easy to treat - Clinical and serological failure with Azithromycin in Syphilis: Time to adapt national guidelines?
More LessBackgroundData since 2014 has shown a rise in the incidence of Syphilis especially amongst heterosexuals. In national guidelines, Macrolides remain an alternative treatment option although their efficacy has been long disputed.
We describe a case of a patient with clinical and serological failure with Azithromycin treatment.
Methods
A 46 year old female presented with painful genital ulceration confirmed as primary syphilis. Sexual transmission infection testing was negative. She described an allergy (rash) to Amoxicillin and was given Doxycycline 100mg twice daily for 14 days. On day 5 she developed an urticarial rash and was changed to Azithromycin, 2g stat and 500mg daily for 10 days.
ResultsThere was initial serological response in her rapid plasma reagin (RPR) to 1:2 from 1:8 at 1 month, but at 5 months an RPR of 1:64 was seen with signs of secondary syphilis - a rash and a sore mouth. Re-infection was ruled out, she was re-treated with Azithromycin and her RPR reduced to 1:2, but she had a persistent macular rash.
Following review by Infectious Diseases, 14 days of intravenous Ceftriaxone 1g daily was given. On day 10, her RPR rose to 1:64 but 3 months after fell to 1:4 and has been serofast since without further signs of Syphilis.
ConclusionPatients treated with Macrolides should be closely monitored. Consideration should be given for desensitisation in patients with reported Penicillin allergy. As with pregnancy, consideration should be given to the removal of Azithromycin as an alternative treatment in national guidelines.
-
-
-
A 1 year Tertiary Centre experience of Clostridium difficile infection
More LessBackgroundClostridium difficile infection (CDI) adversely affects patient outcomes. CDI 30-day mortality is 15.2% nationally with some regional variation, but data on recurrence is limited. We assessed outcomes of CDI, in particular recurrence and mortality at Addenbrooke’s Hospital.
Methods
We performed a retrospective analysis of all patients who developed CDI between April 2017 and March 2018. All-cause mortality was assessed at 30 days and 1 year. Recurrence was defined as recurrence of symptoms withC. difficiletoxin positive stool or initiationof C. difficile treatment within 1-year after onset of first/previous episode. First-line therapy was metronidazole or vancomycin according to severity.
Clinical data was collected using a standardised proforma. Risk of recurrence was calculated using Cox’s Hazard method in R.
Results143 cases of CDI in 103 patients were identified. The median age was 70 years (range 2-98). Recurrence rate was 24.6% at 12-weeks and 30.3% at 1-year. 30-day and 1-year mortality was 14.4% and 39.8%, respectively. Recurrences had longer mean length of stay compared to 1stepisodes (40.3 vs. 18 days, respectively, p<0.05). On univariate analysis, no factors predicted recurrence; acute kidney injury, C-reactive protein, toxic megacolon, Charlson comorbidity score and age predicted mortality.
Conclusions
CDI carries a significant mortality and recurrence rate placing a large burden on hospital resources. The majority of recurrences occur within 12 weeks of 1stepisode, and patients’ risk could not be accurately defined in this sample. Newer therapies with reported lower recurrence rates should be considered as 1stline therapy within our Trust.
-
-
-
Outcomes of an admission avoidance scheme for diabetic foot infections via OPAT
More LessBackgroundThe 2019 National Diabetes Foot Care Audit shows 2.7% of patients with a diabetic foot ulcer underwent major amputation within six months and 14% died within twelve months. Our OPAT service treats such patients referred from inpatient wards and via the limb salvage clinic as an admission avoidance scheme. A review compared outcomes between these referrals and the national data.
MethodsThe OPAT database identified patients referred via an inpatient ward and the clinic. Each patient was then reviewed for each of the following criteria:
1. Was the patient alive and ulcer free at 12 weeks?
2. Had the patient had a major amputation within six months?
3. Was the patient still alive after 12 months?
Results100 patients were reviewed; 50 referred by inpatient wards and 50 referred by the clinic as admission avoidance patients.
In both categories, 94% of patients were alive after twelve weeks, with 12% being ulcer-free in the inpatient category compared with 18% in the admission avoidance group. 6% had a major amputation within six months in the inpatient group, compared with none in the admission avoidance group. 16% of patients in the inpatient group had died within 12 months of treatment, compared with 10% of admission avoidance patients.
DiscussionOPAT patients receiving treatment for diabetic foot infections have similar outcomes to those in the national audit. No extra harm is being done to those referred to OPAT without hospital admission.
-
-
-
Positive Serum (1,3)-β-D-Glucan Testing in Surgical Patients across the Bristol Area
More LessBackground:An evidence gap exists in anti-fungal diagnostic practice following abdominal surgery, especially when compared to haem-oncology counterparts. In light of the recent Anti-fungal Stewardship CQUIN, our study addresses the utility of serum (1,3)-β-D-Glucan (BDG) testing post-gastrointestinal surgery.
Method:We identified positive BDG results (>/=80pg/mL) on ITU and surgical wards in 3 major institutions in the Bristol area. Those with a ‘history of abdominal surgery =30 days previous’ were identified using electronic health records. Other variables included number of days from surgery to testing, value of the result, and past medical history.
Results:110 patients with positive results were identified. 19 (17.3%) of these had a history of abdominal surgery. By surgical type, 6 (31.6%) had major abdominal surgery. 6 (31.6%) had pancreatic surgery and 5 (26.3%) small bowel resection. 2 had other types of surgery. The mean BDG score was 286pg/mL. 1 patient had risk factors other than gastrointestinal surgery for a positive BDG result.
Only 1 patient died within 28 days. Patients tested between 0-9, 10-19 or 20-30 days of surgery had mean BDG scores of 329pg/mL, 302pg/mL and 390pg/mL respectively. 40% were tested within 9 days of surgery. There was no clear evidence of invasive fungal infections.
Conclusion:Positive BDG testing is common after surgery, but does not appear to be associated with a significant mortality burden. Ensuring appropriate anti-fungal therapy is essential for treatment, risk reduction and cost containment. More research is needed to identify appropriate testing strategies in patients with abdominal surgery.
-
-
-
Influenza Testing in the Emergency Department (ED): A Quality improvement project (QIP)
More LessBackgroundRespiratory illness contributes significantly to higher ED attendance during winter months. Polymerase chain reaction (PCR) testing of nasopharyngeal swabs (NPS) for respiratory viruses is a key investigation, with positive influenza results having both clinical and infection control implications. In response to ED colleagues requesting clear and concise guidance, we undertook a QIP to improve management of seasonal influenza.
Methods
A survey of 10 questions was sent to all Doctors and Advanced Care Practitioners (ACPs) working in the ED, and the results collated.
ResultsThere were 21 survey respondents, the majority were registrars. 81% correctly identified how to request influenza testing and 95% knew the symptoms. 90% identified which risk groups should be treated, which personal protective equipment (PPE) should be donned, and suggested Oseltamavir as their treatment of choice. However only 29% of respondents knew where to find the trust guidelines and only 10% correctly prescribed prophylaxis to contacts. 95% would review a discharged case found to have influenza on testing and 67% would treat this case if they were in an at risk group.
Discussion and Conclusions
The results show that the majority of staff surveyed correctly identified the symptoms of flu, infection control precautions and those requiring treatment. However, knowledge regarding the location of guidelines, management of contacts and the use of agents other than oseltamivir was low. Based on these results we developed a single-page influenza testing algorithm aiming to improve management in A&E, and will reassess staff knowledge following the introduction of this.
-
-
-
Pre-operative antibiotics and elective colonic resections: Do they reduce surgical site infection and anastomotic leak rates?
Background: Surgical site infections (SSI) and anastomotic leaks (AL) are a significant source of morbidity in patients undergoing elective colorectal surgery. There is evidence for use of pre-operative oral antibiotics (OAB), in combination with mechanical bowel preparation (MBP), to reduce SSI and AL rates in this population. We aimed to determine whether the use of OAB pre-operatively reduced our local SSI rate in elective left-sided colonic resections.
Methods: A pre-post intervention study was conducted in a large regional hospital from September 2018 to July 2019. Following approval by the Trust’s Medicines Optimisation Group, patients received oral metronidazole 400mg and oral neomycin 1g at 06:00, 14:00 and 22:00 on the day before surgery. The rates of SSI and AL at 30 days were compared with pre-intervention patients. Standard induction intravenous antibiotics were given to both groups but MBP practices were disparate among the consultant body and were outside the scope of this project. Chi Square and Independent T-tests were used to analyse the data.
Results: Data on 100 pre-intervention patients and 47 post-intervention patients showed similar baseline characteristics. SSI rates were 17% (17/100) in the pre-intervention group and 8.5% (4/47) in the post-intervention group (p=0.170). Anastomotic leak rates were 7.0% (7/100) and 2.1% (1/47) respectively (p=0.225).
Conclusion: The use of pre-operative OAB was associated with a reduction in SSI and anastomotic leak rates, although these did not reach statistical significance. Possible reasons for this include low patient numbers and inconsistent use of MBP.
-
-
-
Anti-biofilm potential of peptides against foodborne pathogens
More LessBackground:Biofilm is defined as a community where bacterial cells encased in a matrix of extracellular polymeric substances adhere to each other and/or to a surface. In food industry, foodborne pathogens like Salmonella are capable of forming biofilms on open surfaces. We have shown anti-biofilm effects of ε-poly-lysine (PL) and milk serum protein (MSP) against various bacteria. In this study, peptides derived from egg was investigated for anti-biofilm effects on foodborne pathogens.
Methods:Effects of several kinds of peptides, including 3 kinds of hydrolysates derived from egg, together with PL and MSP, on biofilm formation of 4 kinds of foodborne pathogens (Escherichia coli O157:H7, S. Typhimurium, Staphylococcus aureus and Listeria monocytogenes) were investigated on microtiter plates through biomass quantification with crystal violet staining.
Results:Both 0.01% PL and 0.25% MSP significantly decrease biofilm formation of all the pathogens, while PL was more effective than MSP against gram-negative bacteria. All the hydrolysates showed considerable effect under high concentration (1%), among them hydrolysate 2 was more effective than the others since it inhibited biofilm formation of S.Typhimurium, even under concentration of 0.1%.
Conclusion:The egg white hydrolysate contains some antibacterial peptides that could modulate biofilm formation of S.Typhimurium and other pathogens, which could be beneficial to develop new strategies to combat biofilm infections.
-
-
-
Effects of Bacteriophage on Inhibition and Removal of Multispecies Biofilms of Escherichia coli O157 and Non-O157
More LessShiga toxin-producing Escherichia coli, especially E. coli O157 is an important foodborne pathogen capable ofcoexisting in multispecies biofilms found in almost all the natural environments. Biofilm cells are usually more resistant than planktonic cells against environmental stresses. Thus, E. coli O157 in biofilms is a serious food safety concern. This study describes the characterization of a bacteriophage FP43 isolated from bovine intestine and the ability of FP43 to inhibit and remove multi species biofilms of E. coli O157 strain 196 and non-O157 strain 104. Phage FP43 has a short latent period of 15 min and a large burst size of 98 PFU/cell, with great stability at temperatures ranging from 4 to 60°C and pH from 4 to 9.
To evaluate the effects of FP43 on E. coli,in microplate, biofilm formation was determined by crystal violet stainingas well as viable counts of biofilm and planktonic cells by conventional plating method. Phage FP43 decreased biofilm adhesionof E. coli cells with equal proportions of E. coli O157 and non-O157 by 82.4%. Viable counts were also reduced by 2.76 and 2.85 log in E. coli O157 and total biofilm cells after 6-h infection, respectively, compared with control. In planktonic cells, E. coli O157 and total counts decreased by 3.44 and 3.62 log after a 4-h phage treatment, respectively. Moreover, after a 6-h exposure to phage FP43, more than 60% of established biofilms were removed, and E. coli O157 and total viable counts in biofilm were decreased by 2.07 and 1.93 log, respectively. These findings suggest that phage FP43 seems to be a potential agent against E. coli O157 in multi species biofilms.
-
-
-
Characterization and utilization of phages specific to Campylobacter coli
More LessCampylobacter spp. are commonly found in raw meat especially poultry meat. Control of Campylobacterin poultry meat is difficult due to therate of contamination and viable counts of Campylobacter. Bacteriophages (phages) have been increasingly exploited to combat the bacterial contamination in food. This study demonstrated the isolation, characterization and application of lytic phages against Campylobacter coli (C. coli). From 23 different raw beef and chicken meat samples, a total of 16 lytic phages against C. coli were successfully isolated and purified. Among these phages, CAM-P21, isolated from beef mince, was morphologically characterized as aunique member of the Siphoviridaefamily, with a broad host range, a higher titer and great stability under various stress conditions. Phage CAM-P21 seems unique since almost all Campylobacterphages isolated so far are members of the Myoviridaefamily. One-step growth curve indicated that phage CAM-P21 had a latent period of 60 min and a burst size of 20 PFU/cell. DNA purification and gel electrophoresis revealed that the genome sizes of phage CAM-P21 was estimated to be approximately 15–17 kb. The phage CAM-P21 significantly reduced (P< 0.05) the viable counts of C. coli in vitroby 2.11 log after 12 h of incubation at 42°C, 2.67 log after 24 h at 37°C and 1.09 log after 48 h at 8°C, compared with untreated controls. These findings suggest that phage CAM-P21 seems to be a potential and promising agent for biocontrol of C. coli in food.
-
-
-
An Assessment of Point-of-Care PCR Testing for the Diagnosis and Management of Meningo-Encephalitis
More LessBACKGROUND
Meningitis and Encephalitis are potentially fatal infections. When suspected, empirical treatment is started, and only safely discontinued once excluded. The impact of current CSF investigations is prolonged inpatient stay, and exposure to broad-spectrum antimicrobials. Biofire Filmarray is a point-of-care PCR system. Our aim was to assess time to BioFire result, and its impact on clinical management.
METHOD
BioFire was implemented, in addition to current practice, on CSF samples with WCC ≥10 and all neonatal samples processed between November 2018 and February 2019. Data was collected prospectively for: patient demographics, sampling time, time to result of BioFire and current PCR, antimicrobial regime, and early discharge. Percentage agreement between BioFire and current PCR, mean time to result, percentage cases with reduction in antimicrobials, and mean length of stay for those discharged based on BioFire, were calculated.
RESULTS
There were 22 samples analysed. There was an 86.4% agreement between BioFire and current PCR. In cases of disagreement, BioFire identified pathogens where standard PCR had not. One sample was insufficient for virology PCR however, a full array was obtained from BioFire. Mean time to BioFire result authorization was 17.8 hours, compared to 316 for virology PCR and 331.2 for bacteriology PCR. BioFire allowed narrowing of antimicrobial therapy in 22.7% of patients, discontinuation in 41.0%, and early discharge in 27.3%.
CONCLUSION
BioFire provides comparable diagnosis of meningo-encephalitis faster than current practice. With the current focus on rising bed pressures and antimicrobial stewardship, BioFire allows targeted therapy and safe early discharge where infection is excluded.
-
-
-
Lack of evidence of association between antimicrobial resistance in E coli and deprivation in Scottish Borders
More LessBackgroundMany health issues are associated with deprivation and some evidence exists that antimicrobial prescribing is higher in deprived groups. This study examined the relationship between antimicrobial resistance in E coli isolates from the population of the Scottish Borders and deprivation as assessed by the Scottish Index of Multiple Deprivation.
MethodsData regarding urine samples submitted for diagnostic purposes which had been reported as growing E coli was extracted. Antimicrobials for which susceptibility testing had been performed were mapped to standardised antimicrobial categories definitions to produce an index of overall antimicrobial resistance. UK postcode data linked to the specimen data was mapped to data zones. The proportion of E. coli isolates within each datazone with different categories of overall resistance was calculated and plotted against its associated Scottish Index of Multiple Deprivation decile.
ResultsNo association was found between overall antimicrobial resistance in E. coli urinary isolates and SIMD.
ConclusionDuring this time period in the Scottish Borders, antimicrobial resistance in E. coli does not show an association with deprivation.
-
-
-
Escherichia coli blood stream infection in cancer patients: a multicentre, multidisciplinary collaborative audit to identify risk factors in order to target preventative strategies for improvement of patient care and outcomes
BackgroundEscherichia coli is a common cause of blood stream infections (BSI) in the UK. Published figures for E. coli BSI show higher rates in specialist cancer centres than in other hospitals, but the aetiology in oncology patients is not fully understood.
Methods
Five UK cancer centres coll aborated to review how E. coli affects oncology patients. A key part of this work has been an audit of all cases of E.coli BSI in patients in 2019 that met UK HCAI surveillance definitions. A multidisciplinary team of clinicians, nurses and pharmacists designed the audit to include >60 variables which may affect cancer patients.
ResultsThe risk factors for E. coli BSI among these cancer patients showed marked differences from those seen in the general UK population. The affected population was younger; there was higher rate of hospital-onset infections ; and, taking into account a number of healthcare interactions, the potential for healthcare associated infections was much higher. There was also a higher associated 30-day mortality and high rates of antimicrobial resistance in BSI isolates. Common univariate risk factors associated with BSI included use of SACT, neutropaenia, presence of acute kidney injury, presence of an invasive device, antimicrobial therapy, use of PPIs and a lack of independent hydration. By contrast, haematopoietic stem cell transplantation, mucositis and recent surgery were less common associations.
ConclusionThis audit demonstrates differences between risk factors seen in cancer patients with E.coli BSI and may explain why rates are higher in cancer centres.
-
-
-
It’s not the tool you use. It’s how you use it
More LessBackgroundWorldwide, several clinical screening tools (including EWS, SOFA, qSOFA, SIRS and CURB65) are used on admission to identify patients at risk of sepsis-related mortality. However their ability to accurately predict mortality remains controversial. The purpose of this study was to evaluate whether the predictive performance of these tools is affected by the timing of their use.
Methods
A systematic literature search was performed using PubMed, identifying studies in adult patients with a suspected admission diagnosis of infection, sepsis or pneumonia, in which screening tools were used to predict mortality. Meta-regression analysis was performed on included studies to identify factors affecting the tool’s ability to predict mortality, with a focus on score timing.
ResultsFrom 3901 abstracts screened, 49 studies met inclusion criteria, comprising 421,006 patients and 13 clinical screening tools. No significant difference was found between any predictive tool and mortality. Of all variables considered (size of study, setting, diagnostic group, timing), only the timing related to admission affected predictive value of the tool. Studies that reported using purely physiological measures were less sensitive, marginally more specific, but had generally poorer predictive ability than those which included additional biochemical measures.
ConclusionClinicians must recognise that the performance of clinical screening tools is largely related to when they are used, not the individual tool. Given such tools are used on admission to identify risk of sepsis-related mortality, future studies must consider admission scores rather than those further into patients’ admission, to avoid over-reporting any tool’s predictive ability.
-
-
-
Safe, sustained reduction in meropenem and piperacillin/tazobactam use in a medical high dependency unit
There is widespread overuse of ultra-broad spectrum antibiotics (UBSA) such as meropenem and piperacillin/tazobactam (PTZ). Reductions in their use are needed to preserve their effectiveness.
Using electronic prescribing data we recorded administrations of meropenem and PTZ per month in a 12-bed medical high dependency unit (HDU) from April 2016 to March 2019. During this time there were three interventions (an antimicrobial stewardship round began in March 2017, PTZ was removed from empirical prescribing guidelines in May 2017, and a restricted antimicrobial audit began in June 2017). The latter two interventions were prompted by a national PTZ shortage.
In 2016/17 meropenem and PTZ use was 56 and 113 daily defined doses/100 acute occupied bed days (AOBD) respectively, falling to 32 and 60 in 2017/18, and to 25 and 38 in 2018/19. This represented a 55% reduction in meropenem use and a 77% reduction in PTZ use over 2 years. The drop in use was due to both fewer patients being started on UBSA and shorter durations of treatment. The use of 4C antibiotics (clindamycin, cephalosporins, co-amoxiclav and ciprofloxacin/levofloxacin) did not increase. There was no increase in unit mortality, or change in the prevalence of ESBL-producing organisms.
We describe a multi-modal intervention that, coupled with strong clinical engagement, resulted in a safe, sustained reduction in both meropenem and PTZ use in a medical HDU, without using more 4C antibiotics. We hypothesize that “top down” policies helped reduce UBSA initiation, whereas a “bottom-up” ward-based initiative helped review and stop unnecessary use.
-
-
-
Genetic diversity of urogenital Chlamydia trachomatis before and after mass drug administration for trachoma
BackgroundThe WHO recommends treatment of trachoma with community-wide mass drug administration (MDA) with a single dose of azithromycin as part of the SAFE strategy (surgery, antibiotics, facial cleanliness and environmental improvement). In the Solomon Islands, this programme had demonstrable collateral benefit by reducing the prevalence of urogenital Chlamydia trachomatis(Ct) infections. We evaluated the impact of this treatment on population genetics of urogenital Ct.
Methods
Two vaginal swabs were collected from consecutive women attending antenatal clinics during cross-sectional surveys before and after MDA. For every swab positive for Ctinfection, DNA was extracted from the second swab, enriched and sequenced using paired-end sequencing. Whole-genome sequences were aligned against selected references. Diversity was assessed using genome-wide pairwise diversity and a high-resolution multi-locus sequence typing (hr-MLST-6) scheme. ARIBA software was used to test for evidence of antimicrobial resistance to macrolides.
ResultsWhole-genome sequence data was obtained from 23/49 (47%) pre-MDA and 32/41 (78%) post-MDA Ct-positive samples. Most strains were serotype E and F, and tissue tropism genes were consistent with their urogenital nature. Genetic diversity of Ctwas lower by both pairwise and hr-MLST-6 diversity metrics in the post-MDA sample than the pre-MDA sample. There was no evidence of mutations known to confer resistance to macrolides in any of the samples collected.
Conclusions
Reduced diversity after MDA may represent selection pressure from mass antibiotic delivery. The absence of antimicrobial resistance is encouraging. The collateral impact (both positive and negative) of large-scale preventative chemotherapy programmes should be considered when deciding whether should be implemented.
-
-
-
Snorting Staphylococcus Aureus
More LessRates of cocaine use in the UK remain high and Physicians need to be familiar with pleuropulmonary complications associated with illicit use. Respiratory symptoms (e.g cough productive of carbonaceous material/chest pain/dyspnoea/haemoptysis/wheeze) are quite common after cocaine exposure and can lead to barotrauma/asthma/ischaemic-airways-necrosis/pneumonia/interstitial-lung-disease/pulmonary-hypertension, not only after smoking volatilized crack cocaine and the combustion products/associated substances (tobacco/heroin/talc).
Proposed mechanisms that cause this, relate to the effect of cocaine on alveolar macrophages, intermixed substances and bacterial contamination.
A normally well, HIV-negative female who habitually snorts cocaine, presents with 40C°fever, chest pain and sweats. Although a smoker, she denies IVDU/smoking crack-cocaine. CXR shows a 5.5 cm thick walled left upper lobe lung abscess, associated with surrounding ground-glass consolidation, broadly based on the anterior pleura, but originating in the lung, infiltrating the anterior chest wall with reactive intercostal muscle changes on CT. She had no evidence of, nor risk factors for S. Aureus bacteraemia such as skin disorder, prosthetic devices, or immunosuppression. S. Aureus was isolated only on transcutaneous aspiration of abscess. Good therapeutic clinical/biochemical/radiological response to 6 weeks of antibiotics via OPAT.
Nasal insufflation of cocaine may cause lung complications such as lung abscess via primary infection of the lung rather than haematogenous spread. This may be due to contamination of cocaine when mixing it with other substances or the effects of cocaine on alveolar macrophages.
-
-
-
Myroides odoratimimus necrotising fasciitis and recurrent bacteraemia in an immunosuppressed patient with chronic leg ulcers: an emerging pattern?
More LessIntroduction: A 58yr old with inflammatory arthritis and diabetes, taking biologics, methotrexate and prednisolone, presented unconscious, hypotensive in acute renal failure. She had chronic leg ulcers and blistering, necrotic skin on both legs. After resuscitation, empiric meropenem and clindamycin, and urgent surgical debridement of her legs, she spent 2 days on ITU. A rapid recovery followed with discharge home after 7 days.
Methods: Histological samples were consistent with necrotising fasciitis. Blood and tissue cultures grew a yellow pigmented, oxidase positive, Gram negative bacillus with a distinctive fruity smell. 16S PCR confirmed Myroides odoratimimus.
The patient was readmitted 3 months later with unhealed leg ulcers, sepsis and blistering cellulitis
Blood cultures again grew Myroidesspp.
She recovered with meropenem and avoided ITU admission.
Discussion: Review of laboratory isolates over 2 years revealed a previous fatal case of Myroides bacteraemia in an 87year old woman with leg ulcers and possible necrotising fasciitis
Two further isolates were recovered from community samples:
* A cat bite in a 55 year old woman with alcohol excess.
* A chronic diabetic foot infection in an 80year old man.
Neither patient was admitted to hospital.
A PubMed search for “Myroides “ yielded 107 results. Most detailed the wide environmental distribution, multiple antibiotic resistance, and biofilm forming ability of the genus - worrying attributes in organisms causing infection in immunosuppressed patients.
Eleven of the twenty-three clinical papers described SSTI in patients with diabetes, renal disease, cirrhosis or other immunosuppression, including 3 of the 4 reported bacteraemias. Our cases fit well with this pattern.
-
-
-
Evaluation of molecular rapid diagnosis of enteric bacterial infection in patients with diarrhoeal disease and its clinical and infection control impact at a large district hospital, UK
More LessIntroduction:Acute diarrhoeal syndromes are usually self-limiting, but diagnostic testing and treatment may be required in some instances. Stool cultures require a significant level of technologist expertise and are labour intensive. The BD MAX™ Enteric Bacterial Panel detects over 90% of bacteria causing infectious gastroenteritis and provide rapid diagnosis. The aim of this study is to assess the diagnostic and clinical value of this rapid diagnostic tool.
Methods:Fresh stool samples received from 68 patients were cultured according to SMI methods, and by BD MAX™ Enteric. Further 25 frozen samples were processed by both methods. Any discrepancies between the two methods where sent to reference laboratory for confirmation.
Results:Five samples (4 fresh and one frozen) were excluded from the study due to PCR inhibition. The turnaround time was 48 hours and 4-5 days for negative and positive culture respectively. BD MAX™ Enteric provided same day result. The sensitivity of BD MAX™ Enteric was 100% for fresh samples but this was reduced to 66% if performed on frozen samples. The rapid availability of negative results guided further clinical investigation and management. While the positive results allowed timely implementation of infection control management and guided antibiotic decision process.
Conclusion:BD MAX™ is sensitive and provides same-day results. This allowed implementation of infection control measures in timely manner and guided further patient management. However, as this panel is restricted to bacterial causes of diarrhoea, if PCR there will be a need for further testing to exclude other possible infectious causes
-
-
-
The management of adult patients with meningitis at Arrowe Park Hospital – A complete audit cycle
More LessBackground:Anecdotal experience suggested there were areas for improvement in meningitis management. To address this, we conducted a complete audit cycle of the management of meningitis in adult patients at Arrowe Park Hospital.
Method:
We utilised the abbreviated audit tool from the McGill et al 2016 meningitis guidelines.
Time period: 1/1/2017 to 31/12/2017. Cases audited: 20
A series of interventions were made.
Time period for second cycle: 1/2/2019 to 31/5/2019. Cases audited: 6
Results:Audit standards were met for 1 out of 14 criteria for the first cycle and 2 out of 14 criteria for the second cycle.
Of note, there was reasonable compliance with empiric choice of antibiotic (80% à 83%), definitive choice of antimicrobials (95% à83%) and duration of antimicrobials (84% à 100%).
Improvements in investigations were seen in the second cycle:
1.Pneumococcal and Meningococcal EDTA PCR was sent (15% à 67%)
2.CSF glucose with concurrent plasma glucose sent (6.3% à 67%)
3.CSF for pneumococci and meningococci sent in all cases of suspected bacterial meningitis (22% à 67%)
The re-audit identified no improvement in the following areas:
1.Blood cultures taken within 1 h of arrival at hospital (30% à 33%)
2.LP performed within 1 h of arrival at hospital provided that it is safe to do so (0% à 0%)
3.Antibiotics started within 1 hr of arrival in hospital (35% à 33%)
In both audit cycles, 0% of patients were made aware of voluntary sector support.
Conclusion:Whilst improvements were achieved, there remains considerable scope for further improvement.
-
-
-
Outcomes of Staphylococcus aureus bacteraemia attributed to blood culture contamination
More LessStaphylococcus aureus is a common skin commensal and leading cause of bloodstream infection. Given the formidable mortality and morbidity associated with S. aureus bacteraemia (SAB), it is uncertain whether S. aureus can be viewed safely as a blood culture contaminant.
19 episodes of SAB over two years were identified that were prospectively attributed as contaminants using Health Protection Scotland criteria and compared these with 168 cases of genuine SAB. All cases were assessed by an infection specialist and underwent multidisciplinary review to agree the source. Follow-up was a minimum of six months.
Female sex, cognitive impairment and chronic skin conditions were more common in the contaminant group. No single clinical or laboratory feature reliably predicted contamination. No patients in the contaminant group subsequently developed a SAB or metastatic complications associated with SAB. Eighteen patients (95%) survived to hospital discharge. Compared to patients with genuine SAB surviving to discharge, the contaminant group had a shorter duration of hospital stay (median 14 days versus 19.5 days), a briefer exposure to intravenous antibiotics (median 1 day versus 14 days) and received less total antibiotic (median 7 days versus 19 days). Twelve patients received at least five days of antibiotics active against their SAB, though none would have been deemed appropriate SAB treatment under current guidelines.
The careful attribution of SAB as a contaminant by an infection specialist, combined with appropriate follow-up, is associated with favourable clinical outcomes, shorter hospital stay and reduced antibiotic use. A more robust definition of genuine SAB is needed.
-
-
-
Airborne Decontamination of an Intensive Care Isolation Room using 405 nm Antimicrobial Light Technology
More LessLighting systems which incorporate antimicrobial 405nm light have been developed for safe continuous, environmental decontamination, with previous studies demonstrating efficacy for decontamination of frequently-touched surfaces around clinical areas. This study provides first direct evidence of the effects of this decontamination system for control of airborne contamination.
The study was conducted in a patient-occupied ICU isolation room over a 15-day period, with air samples collected at set times (before, during and after daily use of the decontamination system). Samples were also collected in the empty room prior to occupation. Environmental monitoring occurred every second day using a sieve-impactor sampler (500L air samples collected every 10-min over 2-hr (n=13)). Room activity was logged and bacterial contamination levels recorded as cfu/m3of air.
After 2-day use of the system, airborne contamination significantly decreased from a mean of 905.2 cfu/m3 to 48.8 cfu/m3 (P=0.002). Levels then remained fairly consistent over the remaining period of system use (48.8-189.8 cfu/m3) before significantly rising after the system was turned off for 3-days (P=0.001). Additional samples collected in isolation rooms without the decontamination system demonstrate that the levels of airborne bioburden tend to increase upon increasing patient stay, however low levels were maintained as patient occupation increased when the system was in use.
This study provides first direct evidence of the susceptibility of airborne bacteria to 405nm light within a clinical setting. This patient-safe technology has the potential to improve infection control strategies by complementing existing measures, which could reduce the number of infections arising from environmental sources.
-
-
-
An unusual case of Mycobacterium chelonae infection
More LessIntroduction: A 32 year old lady developed multiple distinct, purple, raised, itchy lesions on her limbs, during a prolonged hospital admission. The lesions developed over six to eight weeks with no evidence of improvement. One lesion was biopsied and sent for analysis.
The patient had a background of end stage renal failure from Anti-glomerular basement membrane (Anti-GBM) disease and she went on to receive a renal transplant. Eleven months prior to her hospital admission her transplant failed from de-novo focal segmental glomerulosclerosis. She had been admitted for 9 months with an eating disorder and malnutrition. She had been off any immunosuppressive agents for 6 months at the time that the lesions appeared.
Methods: The lesion biopsied was consistent with a dermal abscess. The Ziehl-Neelsen stain was negative but a mycobacterium was cultured. This was confirmed to be Mycobacterium chelonae on reference lab testing (sensitivities awaited). She had no other lesions of concern on imaging.
Results:Due to the disseminated nature of the lesions she was started on a 2 week course of intravenous amikacin with oral azithromycin and levofloxacin; the oral components to be continued for 2 to 6 months dependent on clinical response.
Discussion:Mycobacterium chelonae is a nontuberculous mycobacterium abundant throughout the environment. It commonly causes skin lesions or cellulitis as well respiratory disease and urinary catheter colonization. It is a less common Rapidly Growing Mycobacterium (RGM) which usually occurs in patients on immunosuppression. The immunosuppressed state in this case was that caused by dialysis and malnutrition.
-
-
-
Intravenous drug use causing Enterococcus Faecalis bacteraemia, mycotic pulmonary artery aneurysm and suspected Mucormycosis
More LessBackground33 year old previously fit and well lady with a history of previous drug use presented generally unwell with shortness of breath and cough.
Methods
Initial investigations demonstrated marked inflammatory response with bilateral pneumonia on chest xray. She was initially treated for severe community acquired pneumonia. On day 3 of admission blood cultures isolated Enterococcus faecalis, which was later also isolated in sputum.
ResultsTransthoracic echo demonstrated no evidence of vegetations to suggest endocarditis. Despite appropriate antibiotic switch inflammatory markers increased, and a groin abscess was suspected on clinical examination leading to CT angiogram in addition to CT thorax. Imaging demonstrated left ileofemoral DVT and a large pulmonary artery aneurysm with multiple cavitating pulmonary lesions. Following discussion with cardiothoracics the patient was transferred to a cardiothoracic centre for left lower lobectomy and lingulectomy. Histopathological perioperative samples showed branching fungal hyphae within multiple blood vessels, although 18s PCR returned as negative. The patient had a good clinical response with IV Amoxicillin and antifungal therapy - Oral Posaconazole was used as she suffered an adverse reaction to liposomal Amphotericin B.
Discussion
Final impression was of mycotic pulmonary artery aneurysm caused by Enterococcus faecalis with suspected mucormycosis as result of intravenous drug use. This case highlights the increased risk of mucormycosis in people who inject drugs.
-
-
-
Candida aurisexhibits resilient biofilm characteristics in vitro: implications for environmental persistence
In the decade since its discovery, Candida auris has rapidly became a serious problem within healthcare environments. This fungal pathogen readily colonises skin and is responsible for numerous hospital outbreaks in different continents presenting high morbidity and mortality rates. However, the mechanisms it uses to spread throughout nosocomial settings still remains enigmatic. C. auris biofilm formation was monitored in real-time and the transcriptome of these biofilms were identified using RNA-sequencing and the ability of C. auris to persist on a polymer surface and tolerate treatment with a commonly used disinfectant in sodium hypochlorite (NaOCl) was assessed. Contrary to previous findings, C. auris biofilms were found to be heterogeneous and not dependent on cell phenotype. Through transcriptomic analysis and assigning transcripts into GO terms, a large number of genes involved in cell components, specifically fungal cell wall and cell membrane. Genes involved in these components were also up-regulated in dry biofilms of aggregating fungal cells compared to their single-cell counterparts. Aggregating C. auris biofilms were able to persist and tolerate disinfectant treatments more successfully than single-cell biofilms. These findings show that the aggregating phenotype of C. auris likely helps drive its survival and spread throughut hospital wards during outbreaks. Nonetheless there are still caveats in our understanding of C. auris biology and filling these holes will help in the development of more effective decontamination and infection control protocols for this emerging and deadly pathogen.
-
-
-
Vancomycin continuous infusion - review of use on our adult intensive care unit and establishing therapeutic loading dose
More LessBackgroundReviewing compliance to our Trust guidelines on AICU led us to investigate whether the loading dose prior to continuous infusion was sufficient to achieve therapeutic levels at first measurement.
Methods
Retrospective data was pulled (January 2011 - June 2017) from a data interrogation system (SAS Enterprise Guide) which linked patients receiving continuous infusion vancomycin at a concentration of 500mg/50ml. This was presented into Excel spreadsheets, additional headings added for data interpretation, then manipulated into pivot tables to determine objectives.
ResultsIn 82 courses of vancomycin continuous infusions in 70 patients, 53 received correct loading doses. 31 courses had continuous infusion started within 2 hours of loading dose finishing. 13 courses started at the correct rate. 12/13 courses had vancomycin levels taken. Only one course reached therapeutic range at the first level taken (19.5mg/kg). Of the remaining 11 courses which were out of range, 7 were titrated appropriately – 6 became therapeutic, one remained out of range and was stopped. 3 were not titrated correctly and remained out of range or not titrated at all.
Conclusion16% (13/82) of all continuous vancomycin infusions on AICU complied with guidelines. Only one patient who received the highest weight-based loading dose of 19.5mg/kg reached therapeutic range at the first level monitored, suggesting that doses of ≥20mg/kg at loading are required.
-
-
-
Utilisation of Antimicrobial Stewardship (AMS) Electronic Interventions (i-Vents) as a metric of pharmacy AMS at Cambridge University Hospitals (CUH) NHS Foundation Trust
More LessBackground: The aim of the project was to identify the contribution clinical pharmacists make to antimicrobial stewardship (AMS) at CUH. The EPIC e-hospital system in place allows pharmacists to record interventions (i-Vents) electronically; these can be used as a metric of pharmacist AMS.
Method:A bespoke electronic report of all AMS i-Vents which occurred in April 2018 was generated using EPIC.Each i-Vent was categorised by type, clinical speciality, grade of pharmacist making the i-Vent and whether the i-Vent was following on from a previous one. The antimicrobials(s) mentioned in each i-Vent were also recorded.
Results:During April 2018 554 pharmacist i-Vents were recorded. I-Vent types included therapeutic drug monitoring (31%), dose optimisation (22%), course length optimisation (12%), interaction and contraindication management (2%) and patient counselling (0.2%). AMS i-Vents were recorded for patients under the care of 42 clinical specialties including neonatology (12%), diabetes and endocrinology (11%) and respiratory (8%). I-vent numbers increased with seniority of pharmacist with band 8 pharmacists making the most interventions (44%) and band 6 pharmacists making the fewest (16%). There were 645 separate references to a total of 53 individual antimicrobial agents. The top three drugs mentioned in i-Vents were vancomycin (30%), gentamicin (12%), and ciprofloxacin (8%). Follow-up i-Vents constituted 111 (20%) of all recorded i-Vents.
Conclusion:Our findings demonstrate that pharmacists contribute significantly to AMS at CUH, especially on therapeutic drug monitoring and dose-optimisation issues.We suggest that AMS i-Vents are a reliable metric for monitoring AMS pharmacist activities, related directly to patient care.
-
-
-
Combination of Bedaquiline plus Delaminid within a treatment regimen for Pre-XDR TB; experience of a tolerable regimen and acceptable safety profile for the first time in Scotland
More LessIntroduction: A 29 year old female of Pakistani origin was diagnosed with MDR-TB affecting cervical nodes, with pulmonary and laryngeal disease demonstrated on CT. Genotypic (and subsequent phenotypic) testing demonstrated pre-XDR resistance pattern with Izoniazid, Rifampicin, Ethambutol & Fluroquinolone resistance.
Methods: Following commencement of induction regimen with Amikacin, Cycloserine, Prothionamide, Pyrazinamide, Linezolid and Clofazimine, borderline ototoxicity developed after 6 months, necessitating a switch from Amikacin to Bedaquiline. After around 10 months, Linezolid and Cycloserine were discontinued sequentially due to progressively debilitating peripheral neuropathy, PAS was subsequently added to the regimen which was poorly tolerated. PAS was substituted for Delaminid (used with Bedaquiline, Clofazimine and Pyrazinamide) despite concerns regarding potential cumulative QTc prolongation effects. Patient was counselled regarding risk of cardiac arrhythmias; fortnightly ECG monitoring was agreed to for three months, then monthly thereafter. Manual calculations of QTc were performed using Fredericia formula.
Results: QTc rose maximally to 491 ms (89ms greater than baseline). Clinical and radiological monitoring demonstrated favourable improvement in condition. No further adverse events or toxicities were reported. The patient continues to tolerate the regimen well with no components of the regimen requiring discontinuation.
Dicussion: Bedaquiline and Delamanid are rarely used together in combination due to risk of QTc prolongation; in this clinical case they were used with no concerns being raised regarding safety or tolerability. Our experience corresponds with the international data produced by Ferlazzo et al. Whilst further large volume safety data is awaited, compassionate use of alternative drug regimens within strict monitoring guidelines should be considered.
-
-
-
A 12 month follow-up looking at improvements to adult inpatient gentamicin prescribing and the role of the antimicrobial pharmacist
More LessBackgroundAudits at Mid Yorkshire NHS Trust have identified inappropriate prescribing of gentamicin. Antimicrobial stewardship (AMS) interventions in hospital have increased adherence to antimicrobial prescribing policies2.
MethodsPre-intervention data were collected by the antimicrobial pharmacist in January 2018. Interventions were then completed and included: oral presentations, targeted reviews and teaching sessions. Inappropriate indications or doses received routine AMS intervention. Following interventions a second audit was completed in May 2018 to measure improvements in prescribing. A second intervention was the introduction of a 5 day review service of prescribed gentamicin and a third audit was completed in August 2019 to demonstrate a sustained improvement.
ResultsIn total, 25 patients were audited in January 2018, 24 patients in May 2018 and 29 patients in August 2019. The three groups were similar for age, sex and reason for admission. The proportion of patients receiving an appropriate initial dose of gentamicin increased from 13/25 patients (54%) to 19/24 patients (79%) and again to 27/29 patients (93%). The proportion of patients that had the subsequent dose of gentamicin prescribed appropriately increased from 9/25 patients (36%) to 20/24 patients (83%) and again to 29/29 patients (100%).
ConclusionsThis project demonstrated a sustained improvement in gentamicin prescribing following a series of pharmacist-led education and training sessions, one to one training, presentations at governance group meetings and the introduction of a 5 day pharmacist review service. The sample was limited to those patients who had levels taken.
-
-
-
A large-scale pragmatic automated audit of the appropriateness of antibiotics initiated for presumed community-acquired pneumonia using a novel algorithmic approach
BackgroundAudit is a fundamental part of antimicrobial stewardship, but this has traditionally been labour-intensive. The advent of fully electronic records (EPIC) at Cambridge University Hospitals (CUH) presents novel opportunities for large-scale automated data analyses and feedback. We developed and validated an algorithm to audit the appropriateness of prescriptions initiated for presumed community-acquired pneumonia (CAP).
Methods
We developed an algorithm that extracts prescription and clinical data from EPIC, calculates CURB-65 scores, and assesses the appropriateness of antibiotics with an indication of CAP against Trust guidelines based on predefined rules. Clinical data included age, gender, blood results, vital signs, NEWS-2 score, MRSA status, penicillin allergy and pregnancy status. Prescriptions were limited to 48 hours from admission. The accuracy of the algorithm was validated in a representative sample of 30 patients.
We present data on all prescriptions initiated for CAP admitted to CUH between September 2018 and June 2019.
ResultsOn validation, the algorithm calculated the CURB-65 score with an accuracy of 97% and correctly categorised antibiotic appropriateness in 98.5% of cases. Only 15% of patients had a CURB-65 score documented in the notes.
The algorithm evaluated 4,307 prescriptions in 2,198 patients. Appropriateness was significantly better in CURB-65 scores of 2-5 (83.7%) versus 0-1 (33.5%) largely due to over-prescription of co-amoxiclav in the latter.
ConclusionThis algorithm enables large-scale analysis of prescriptions initiated for CAP with high accuracy automating the audit cycle. An automatically calculated CURB-65 score has the potential to reduce over-prescribing of co-amoxiclav and should be evaluated in the future.
-
-
-
Experience of adopting a standardised nomogram for gentamicin monitoring- an audit
More LessBackground:Gentamicin, an aminoglycoside antibiotic, requires therapeutic drug monitoring to decrease the risk of nephrotoxicity and ototoxicity. We audited compliance with our dosing and monitoring guidelines since adoption of the Barnes-Jewish Nomogram for once daily 5mg/kg dosing in September 2018.
Methods:We retrospectively reviewed 62 patients who received 171 gentamicin doses with 173 accompanying levels taken between 1/11/18 and 31/1/19.
Results:The audit demonstrated overall poor adherence to guidelines. Only 50% of patients received the correctly calculated dose. 40% of gentamicin levels were taken between 6-14 hours resulting in a large number of uninterpretable levels requiring additional actions e.g. repeat levels. 50% of follow up doses were given in the correct time frame. For patients with normal renal function twice weekly monitoring is recommended. In all cases (n=35) where this applied levels were monitored more frequently that indicated. U&Es were regularly monitored for all patients and we did not identify any acute kidney injury.
Conclusion:The Barnes-Jewish nomogram was adopted to provide a standardised evidence based monitoring system for gentamicin. However our audit demonstrates the guidance was not well executed clinically. There appeared to be a lack of appreciation and responsibility for monitoring and interpretation of levels. This resulted in erratic sampling, unnecessary levels, and delayed doses. As a result of this audit we intend to adopt a simpler trough level system based on the gentamicin SPC. Our audit demonstrates the need to evaluate service improvement implementations since theoretical benefits do not always translate in to clinical practice
-
-
-
National Audit of Meningitis Management (NAMM): a National Infection Trainee Collaborative for Audit and Research (NITCAR) audit of adherence to the 2016 UK joint specialist societies’ guideline on the diagnosis and management of acute meningitis in adults
BackgroundBacterial meningitis has significant mortality but frontline doctors will see it infrequently. Therefore, UK guidance on meningitis in adults, with auditable standards, was revised in 2016. We undertook a national audit to assess adherence to the guidelines.
Methods
Patients with community acquired meningitis were identified through coding or laboratory data. Audit standards, including immediate management, diagnostics and treatment, were evaluated by notes review.
ResultsNotes from 1472 patients with meningitis were reviewed – 309/1472 (21%) had bacterial aetiology, 615/1472 (42%) viral, 548/1472 (37%) unidentified aetiology. Only 50% of patients had blood cultures taken within one hour of admission and just 2% had a lumbar puncture (LP) within the first hour. 27% received antibiotics within one hour. Most patients received ceftriaxone or cefotaxime but only 37% of over-60s received empirical anti-listeria antibiotics. 26% of patients who had antibiotics were given adjunctive steroids. Half had CSF microscopy within two hours of LP. Less than a third had pneumococcal and/or meningococcal PCR on cerebrospinal fluid. Only 44% had an HIV test. 62% had unnecessary neuroimaging before LP. Overall mortality was 3% - 16% in pneumococcal disease and 8% in meningococcal meningitis. There was a trend toward improved survival in patients with pneumococcal meningitis who received dexamethasone [85/96 (88%)] compared to those who did not [57/73 (78%)] (p=0.066).
Conclusions
Adherence to the meningitis guidelines is inadequate, potentially compromising patient safety. Improvements in guideline dissemination, novel educational resources and clinician and patient engagement are required if we are to increase guideline adherence and improve outcome.
-
-
-
Sepsis Six implementation on a general surgical ward. More work to be done
Background: Sepsis can lead to significant morbidity and mortality if not recognised and managed early. On the basis of national mortality reports, Irish guidelines recommend that patients at risk of neutropenia, patients with sepsis or those with a systemic inflammatory response (SIRS) with one plus co-morbidity should receive Sepsis Six. We assessed the implementation of the Sepsis Six on a surgical ward in our institution.
Methods: All inpatients on a surgical ward in July 2018 were prospectively assessed for the presence of infection and sepsis. If the Sepsis Six was required, implementation of each of the Sepsis Six elements was recorded.
Results: Of 164 patients, 40.2% (66/164) developed an infection of whom 47% (31/66), met the criteria for requiring Sepsis Six. Of these, 7.3% (12/164) patients had sepsis, with 3% (5/164) developing septic shock. Patients required Sepsis Six for the following reasons: ³1 co-morbidity and ³2 SIRS criteria(n=19); new onset organ failure (n=12) and neutropenic risk(n=0).Only 12.9% (4/31) patients received all of the Sepsis Six elements within one hour; 77.4% (24/31) received some and 9.67% (3/31) did not receive any elements. Blood cultures were taken in 54.8% (17/31) of cases but only 32.3% (10/31) patients had their lactate level checked.
Conclusion: Further research action is required to better understand and improve Sepsis Six implementation. This should facilitate improved sepsis recognition and enhance patient care.
-
-
-
Gram-negative Galore and the Gut
More LessAn 81-year-old diabetic man with PAF, pleural thickening due to benign fibrous pleuritis and a PPM developed rigors/pyrexia (39°C) with no localising signs of infection. Blood cultures grew Pseudomonas aeruginosa (May 2017) and Enterococcus faecalis (November 2017), MSU was negative and imaging was normal. Readmitted in May 2018 and discharged clinically well with CRP 40 and no acute abnormalities on investigations, he returned with further rigors the following day with E. coli and Enterococcus faecium bacteraemia, treated with Tazocin/Tigecycline. CT colonography revealed a primary recto-sigmoid tumour with high-grade dysplasia on biopsy. In July 2018,he developed a Pseudomonas aeruginosa bacteraemia responding to Tazocin/Ciprofloxacin. Planned surgery was delayed due to anaesthetic instigated pre-operative cardiac rehab optimisation. In August 2018, further rigors/pyrexia were empirically treated with Tazocin/Teicoplanin/Amoxicillin for 3 weeks covering a Staph epidermis/capitis bacteraemia. He underwent an open Hartmann’s with total mesorectal excision two weeks later, complicated by pre-sacral collections drained transcutaneously. Suboptimal antibiotic cover however led to further pseudomonas bacteraemia three weeks later and pseudomonal bacterial peritonitis three months later, managed with prolonged meropenem/ciprofloxacin therapy. TTE two months post-discharge showed a 1cmx0.5cm mass on the RV lead of his pacemaker leading to its removal. Repeat TTE showed tricuspid valve endocarditis with a 2.2cmx0.3cm mobile mass and severe TR. Six weeks of Meropenem therapy achieved sterilisation without further complications. Infectious diseases specialist input should be sought early and can be pivotal in appropriate source control and adequate antibiotic management following organism identification.
-
-
-
Difficile but not impossible: Improving documentation to improve outcomes for Clostridium difficile infections in NHS Ayrshire and Arran
More LessBackgroundClostridium Difficile Infection (CDI) varies in severity and presents challenges in management. Whilst incidence is decreasing, the mortality rate in NHS Ayrshire & Arran is 10%. We evaluated if a new infection severity assessment sheet improved management.
MethodA retrospective case note review was performed on all cases of CDI, confirmed by clinical symptoms and laboratory sampling. Our audit assessed both predisposing factors and management. The first cycle ran from January-March 2018. The second cycle ran May-November 2018 after the introduction of the new severity assessment sheet.
ResultsThere were 20 episodes of CDI in the first cycle, and 38 episodes in the second cycle (n=58). Following introduction of the new severity assessment sheet CDI diagnosis, management and documentation improved. High-risk antibiotic use prior to CDI fell from 65% in the first cycle to 34% in the second cycle. Discussion of CDI diagnosis with relatives increased from 70% to 86.8%. Documentation of day 1 and 5 infection severity scores improved (50% to 57.9% and 10% to 31.6%, respectively). Improvements were noted in prompt stool sampling after symptoms (90% to 97.4%), fluid balance chart use (80% to 89.5%), stopping unnecessary antibiotics (58.3% to 81.3%) and documentation of daily assessment (5% to 23.7%).
ConclusionThe results highlight positive improvement in outcomes following a well-publicised introduction of an improved CDI proforma. Despite this, further intervention and monitoring is required to improve documentation of daily assessment in CDI. Additionally, there is still progress to be made to prevent unnecessary use of high risk antibiotics.
-
-
-
Key factors around successful management of CPE infection in a patient with pancreatic collection
More LessCarbapenemase-Producing Enterobacterales (CPE) are threat to public health as they are resistant to one of the broad-spectrum antibiotic classes (Carbapenems) in clinical use.
In this report we highlight the need for optimal choice and duration of antimicrobial therapy in combination with source control for successful management of CPE infection.
A 52-year old male was admitted under general surgery with CT confirmed severe pancreatitis. He was commenced on cefuroxime and metronidazole for associated cholecystitis based on local guidelines. Treatment was gradually escalated to Meropenem due to intermittent pyrexia and inadequate response to standard antimicrobial therapies with no obvious source control solution. Following 39 days of Meropenem the fifth CT scan showed drainable peri-pancreatic collections. The drained pus sample grew Escherichia coli and Bacteroides species. The Escherichia coli were confirmed to be CPE gene (KPC) positive by PCR and sensitive to Tigecycline and Gentamicin but resistant to Meropenem and Ciprofloxacin based on MicroScan automated sensitivity panel.
Initially Tigecycline was commenced, however, due to unsatisfactory clinical progress treatment escalated to Ceftazidime/Avibactam and Co-Trimoxazole and patient completed a three-week course. The percutaneous drain was upgraded twice to facilitate drainage. Follow-up CT showed reduction of collection and patient discharged after 115-day stay.
This case demonstrated that CPE infection should be suspected in patients with persistent fever after a prolonged course of carbapenem treatment. A prompt laboratory diagnosis and effective multidisciplinary collaboration among microbiologists, surgeons and radiologists proved to be successful in achieving source control of CPE infection in this case.
-
-
-
Awareness of Primary Health Care Providers about Vaccination in Eastern regions of Ukraine
More LessBackground. A dramatic drop in routine immunization coverage is observed in Ukraine during recent years. Ukraine has the lowest rate of vaccination in Europe that imposes a high risk of communicable diseases on a population. More than 56.000 people sickened with measles from 2018-2019 yrs. Although Primary Health Care providers (PHCPs) in Ukraine play an important role in administering vaccines to their patients the data about PHCP's awareness regarding immunization are lacking.
Methods. A self-administered survey among 265 PHCPs (44 doctors, 221 nurses) was conducted during Public Health Trainings from 01 March to 31 April 2019 in three Eastern Ukrainian regions (Zaporizhia, Dnipro, Kharkiv). The level of basic knowledge on vaccines schedule, safety and efficacy of vaccination, communication skills ect (totally ten statements and ten questions) were evaluated.
Results. Overall 264 (99.6%) PHCPs highlighted the obvious need in strengthening evidence-based knowledge related to immunization topics and communication skills. Right answers regarding safety and efficacy of vaccines were obtained in 21% participants, 47% PHCPs had doubts for vaccine's safety and contradictions. Only 8% of participants were convinced in aspects of effective communication. Physicians had higher knowledge scores in routine vaccines schedule (32; 73%), compared to nurses (105; 47.5%), p=0.0016; but did not differ in aspects of vaccine's safety: 16% among physicians’ vs 17% among nurses (p>0,05).
Conclusion. The majority of PHCPs in Eastern regions of Ukraine have concerns about vaccines safety and efficacy, as well as lack of communication knowledge. Effective continuing evidence-based education of providers may help address these concerns.
-
-
-
Tayside TB Pathway: A Quality Improvement Project
More LessAims:The aim of this project was to look at our local practice of identifying and managing patients with mycobacterium tuberculosis (MTB) and non pulmonary NTM. In Tayside, the care of patients with MTB is shared between the Infectious Diseases physicians and the Respiratory physicians. We aim to improve communication and identify any issues with continuity of care and create solutions to standardise the care our patients receive.
Methods:We performed an initial audit of patients that were currently receiving or had recently completed treatment for MTB and non pulmonary NTM. We collected data from 26 patients between January 2017 - July 2018.
Results:Some of the results are as follows: Out of the 26 patients, only 14 (53.8%) of those had a documented start date of treatment on the initial clinic letter. 92.3% had a documented treatment regime on clinic letter. 88.4% (23 out of 26 patients) had a documented diagnosis (specifying site) on clinic letter. Only 46% had a complete BBV screen, 35% had an incomplete BBV screen and 19% had none.
Outcome:After performing the initial audit and assessing the areas of improvement, we were able to create our “Tayside TB Pathway”. The idea behind this was to create a more cohesive and streamlined approach to TB care whilst involving all members of the MDT. The pathway was created to be straightforward and allow us to have a “centralised hub” to oversee the important steps involved in the management and prompt these to be performed where needed.
-
-
-
From bedside to bench – optimising the local blood culture pathway
More LessBackgroundOptimising the blood culture (BC) pathway is essential to ensure maximal benefits for patients. There are national standards for expected turnaround times. At our acute teaching hospital, there was limited data on this. We aimed to map the local BC pathway to identify obstacles and areas for improvement in the process.
Methods
In this prospective study, all BCs taken from adult patients in the Emergency Department (ED) on allocated days over three months were included. Study days were chosen to reflect the whole working week, including out of hours. Information was gathered from multiple stakeholders, including ED clinical staff, porters, microbiology laboratory staff and clinicians. BCs were trailed from when the sample was taken until results were reported. The time taken for each stage was compared against national standards (SMIB37).
Results107 BCs were included in the study. Only 23% achieved the 4hr target between collection and incubation; times ranged from 50 mins–27hrs8mins. None of 43 samples taken at the weekend achieved the target. Process mapping allowed the following problems to be identified: fixed, infrequent transport by porters; delays between the general laboratory and the microbiology receptions; and delay in loading the analyser. BC bottles could not be transported via the vacuum system and the analyser was only accessible when the microbiology laboratory was open, which is not 24/7.
ConclusionThe BC pathway at the hospital fails to ensure that national standards are met. Identifying key bottlenecks impeding flow will help enable the trust to make essential changes.
-
-
-
Voriconazole – are we doing what we think we are? A review of voriconazole use and monitoring in respiratory patients in a London hospital
More LessBackgroundVoriconazole is increasingly used in treatment and prophylaxis of respiratory fungal infections, but therapy carries a risk of significant side effects. Outpatient therapy has additional challenges for ensuring pre-treatment counselling of patients and fulfilling therapeutic drug monitoring (TDM) requirements. A review of local practice was performed.
Methods
Electronic patient records for adult Respiratory outpatients on voriconazole from November 2005 to January 2019 were retrospectively reviewed. Data was collected on patient demographics, pre-treatment counselling and TDM. Based on the results, targeted interventions were proposed.
Results21 patients commenced voriconazole between 2005 and 2019, majority (n=10/21, 47.2%) for chronic pulmonary aspergillosis. Of the 21 patients, counselling was variable regarding the risks of hepatotoxicity (12, 57.1%) and phototoxicity (13,61.9%), signs indicating hepatotoxicity (6, 28.6%) and phototoxicity (11, 52.4%), and taking photo-protective precautions (13, 61.9%). 60% (n=12/20) of patients had liver function tests measured weekly in their first month of commencing treatment, while phototoxicity was reviewed in only 10% (n=2/20) of patients at follow-up appointments. In 57.1% of patients (n=12/21), none of the 3 checklists available (HCP checklist and 2 local proformas) were used when commencing treatment.
ConclusionOur findings revealed a lack of consistency in information given to patients, documentation by clinicians, and in TDM, in spite of the existing checklists available. We propose an individual written management plan to empower patients to manage their treatment and guide clinicians in pre-treatment counselling and subsequent follow up of patients. A re-audit is planned for 6 months to assess the efficacy of this intervention.
-
-
-
Early laboratory markers may reflect the severity of pyogenic liver abscess infection: Retrospective cohort study
Background:Liver abscess carries significant morbidity and mortality rate due to its complications. We aimed to identify laboratory markers associated with septic shock related to pyogenic liver abscess.
Methods:The study was conducted at Hamad General Hospital, a tertiary hospital in Qatar. Data were collected retrospectively. All patients diagnosed with pyogenic liver abscess between 2013 and 2017 were included. Liver abscess was diagnosed based on clinical presentation and radiological finding with or without microbiological evidence. Septic shock defined as the need of vasopressors to maintain mean arterial pressure > 60 mmHg. Data has been collected on admission time. Descriptive data were presented in mean ± SD and percentages. Normally distributed data were analyzed by T-test otherwise Mann–Whitney was used.Fisher Exact test was used for categorical data. The level of significance was set at P<0.05.
Results:Pyogenic liver abscess has been identified in 78 patients. 89.9% were males. 48.7% of the patients were diabetic. Nine patients (11.5%) developed septic shock. Patients who developed septic shock had higher procalcitonin level (Hazard ratio [HR] 1.025, 95% CI 1.006-1.044, p0.009) but lower level of hemoglobin (HR 0.744, 95% CI 0.581-0.952, P. 0.019), protein(HR 0.867, 95% CI 0.779-0.966, p 0.009) and platelet (HR 0.994, 95% CI 0.988-1.000, p 0.035)
Conclusion:Measurement of baseline procalcitonin, hemoglobin, protein, and platelet in pyogenic liver abscess may provide early information about the severity of the infection and the need for early aggressive management. However, a larger sample size is needed to achieve more statistical significance.
-
-
-
CPE in Beaumont Hospital – Trying to understand an increasing and challenging pathogen
More LessBackgroundThe prevention and control of carbapenemase-producing Enterobacteriales (CPE) cross-infection is increasingly difficult worldwide. Patients exposed to a CPE positive patient in our institution are informed, offered CPE screening and their clinical records flagged on our hospital information system since mid-2017 as recommended nationally. However, no assessment of the numbers of CPE contacts has been performed prior to this.
Objective / AimsTo retrospectively identify and quantify CPE contacts patients in Beaumont Hospital between 2011 and mid-2017.
MethodsPatients with an exposure to CPE positive patients while an inpatient were identified retrospectively. Each CPE contact was evaluated for: number of CPE screens taken, mortality, existing multidrug resistant colonisation, duration of CPE exposure, recurrent hospitalisation after CPE exposure and CPE colonisation within this group.
ResultsTwenty-eight CPE positive patients were identified from January 2011 – May 2017. This included 22 OXA-48, six KPC and four NDM patients; two patients had OXA 48 and NDM genes. A total of 237 patients were identified as CPE contacts of whom 124 (52.7%) had 190 CPE screens. Four CPE contact patients were identified as CPE positive (all OXA-48), however, only three (1.2%) were associated with exposure to one of the 28 CPE positive patients.
ConclusionsThe identification of potential CPE contacts and subsequent CPE positive patients is essential to prevent further cross-transmission. Of the CPE contacts screened, only three CPE positive patients were associated with exposure to the index patients, which may indicate good adherence with infection control precautions or low sensitivity of culture-based screening.
-
-
-
Cytomegalovirus reactivation, risk factors and associated clinical outcomes among non-immunosuppressed critically ill cirrhotic adults: a longitudinal observational study
More LessBackground: Although Cytomegalovirus (CMV) reactivation is not uncommon in critically ill patients, it has not been studied for cirrhotic patients in Liver-ICU.
Methods: CMV reactivation (CMV-plasma-DNAemia; ≥ 500 IU/ml), risk factors and clinical outcomes were assessed among sero-positive non-immunosuppressed critically ill cirrhotic adults at day 0, 7, 14 and 21 in Liver-ICU.
Results: Of 94 consecutive patients in Liver-ICU monitored, 55(48 men) patients were enrolled. Overall, 20 critically ill cirrhotic adults showed CMV reactivation with a median day for follow-up of 11 (IQR: 8 to 18). Majority (n=17/55, 30.9%; CI: 19.1-44.8) showed CMV reactivation at day 7. During 21-day follow-up, incidence rate/density of CMV reactivation was 2.75% per person-day (95% CI: 1.68 - 4.26% per person-day).Total leucocyte count (day 0) was an independent risk factor for CMV reactivation (adjusted OR: 1.15, 95% CI: 1. 00-1. 32, p=0.04) with cut-off point of 19.05 (AUROC: 0.696, 95% CI: 0.547-0.844, p=0.017). Increased nosocomial infection (p=0.009), SIRS (p=0.01) and ARDS (p=0.04) were observed at day 7, coinciding with CMV reactivation during Liver-ICU stay. ICU-Mortality (61.8%) did not significantly differ with and without CMV reactivation. (55 % vs. 65.7%, p= 0.43). Patients with CMV reactivation experienced early death and slightly longer stay in Liver-ICU. (Log rank p=0.06 and 0.17, respectively).
Conclusions: CMV reactivation occurs frequently with leucocytosis being an independent risk factor among critically ill non-immunosuppressed cirrhotic adults. Although CMV reactivation was associated with more severe organ dysfunction during Liver-ICU stay, it did not significantly influence ICU-mortality and Length of Liver-ICU stay.
-
-
-
Expedient management of Listeria monocytogenes endovascular graft infection in an immunosuppressed patient
More LessIntroduction
Listeria monocytogenes is a rare cause of infection following endovascular aneurysm repair (EVAR); there remains lack of consensus on the optimal management strategy, in particular the need for life-long suppression. Despite this organism’s increased pathogenicity amongst immunosuppressed hosts, to date no EVAR infections have been described in this cohort.
Here we describe the first case ofListeria monocytogenesEVAR infection in an immunocompromised host.
Case description
A 75-year-old gentleman presented with a 5-day history of back pain, fever and dysuria despite 3 days of oral co-amoxiclav for presumed urinary tract infection. There was no recent gastrointestinal upset. Admission blood and urine cultures were negative.
Past medical history included on-going methotrexate therapy for rheumatoid arthritis and EVAR of the infra-renal aorta in 2013.
A CT abdomen, performed to exclude intra-abdominal pathology, revealed an enlarged aneurysmal sac and fat stranding, secondary to inflammation. A CT-guided sample of aneurysmal fluid was obtained before commencing empirical piperacillin-tazobactam and vancomycin; Listeria monocytogeneswas isolated from subculture after 5 days broth enrichment. The EVAR was removed and replaced 7 days after admission and antimicrobials rationalised to intravenous amoxicillin, ciprofloxacin and metronidazole.
The patient completed 6 weeks intravenous therapy, then commenced lifelong suppressive therapy with oral co-trimoxazole 960mg OD.
Discussion
Listeria monocytogenesEVAR infection has been described in only 8 patients; this is the first in an immunosuppressed patient. This case adds to the literature by outlining a putative management strategy, involving explanation and life-long antimicrobials, for immunocompromised patients with Listeria monocytogenes EVAR infection.
-
-
-
Hubris Haemoptysis - Mycobacterium kansasii , are you taking the piss?
More LessBackground: A 33 year old HIV-negative Gambian, who hadn’t left the UK for 7 years, presents with haemoptysis, 6 month cough, sweats, and weight loss. He completed standard treatment for presumed pulmonary TB in Banjul (2006), with a completely normal CXR (2015). He was normotensive, with low grade fever, Hb 110, normal clotting, mild neutropenia, CRP 11, ESR 88, with bilateral cavitating lesions in upper lobes, calcified cavity in the left apex, and tree-on bud appearance throughout left lung, suggestive of active TB. He acutely deteriorated with projectile haemoptysis, leading to haemodynamic compromise requiring tranexamic acid and embolisation of bronchial arteries.
Investigations: IGRA negative. CD4 634 (44%). The ϒ-IFN axis was tested, excluding a complete defect in the IL12-signalling-pathway. Bronchial-alveolar-lavage smear and PCR negative for MTB. Serial induced-sputa however, cultured and identified M.Kansasii, a Non-Tuberculous-Mycobacterium (NTM) on Whole-Genome-Sequencing.
Management: In absence of any radiological structural lung disease, with apparent immune-competence, the source of acquisition remains elusive. Empirical treatment included Ethambutol/Rifampicin/Isoniazid/Moxifloxacin/Clarithromycin and intravenous Amikacin for 6 weeks, to cover for reinfection/relapse with resistant-MTB, as well as NTB. Rifamycin, which is the critical component for treatment success, had to be stopped due to transminitis after 1 month. We rationalised to a multi-drug regime containing ≥3 active agents as an effective course, based on analogy of patients with rifampin-resistance. This led to normalisation of ESR and 2.2kg weight gain, plus radiological resolution 8 months into treatment. He continues to receive a minimum of twelve months after culture-conversion.
-
-
-
Associations between declining antimicrobial use in primary care in Scotland and patient satisfaction and hospitalisation due to infection: a longitudinal study of greater than five million patients
More LessBackground. Scottish antimicrobial prescribing in the community has fallen since 2012, but this could have unintended consequences. The aim was to examine associations between changes in antibiotic prescribing in primary care and hospital admissions and patient satisfaction.
Methods. Data for 877 Scottish general practices with 5.1 million patients were provided by NHS National Services Scotland. Practices were classified into four equal groups (quartiles) in terms of change in total antibiotic prescribing (rate/1000 registered patients in each quarter) 2012-2018. Changes in hospital admission with infection were examined comparing the four groups. Multivariate regression examined associations between change in antibiotic prescribing and patient satisfaction with the practice using national survey data.
Results. Across Scotland, primary care antibiotic prescribing decreased by 15% from 194.1 (95%CI 193.8-194.4) in Q1 2012 to 165.3 (95%CI 165.0-165.6 ) in Q2 2012, with considerable variation between practices (non-significant increase of 0.22 prescriptions/1000/quarter [p=0.49] for the quartile of practices with least reduction in antibiotic prescribing, vs reduction of -2.95 prescriptions/1000/quarter [p<0.001] for quartile with the largest reduction). Rates of hospital admissions with infection increased over the time period but there were no significant association with changes in antibiotic prescribing. Patient satisfaction decreased over the period, but change in antibiotic prescribing was not associated with patient satisfaction.
Conclusion. There have been clinically significant reductions in Scottish primary care antibiotic use since 2012, varying considerably between practices. Longitudinal analysis of Scotland-wide practice level data found no associations between practice-level reductions in primary care antibiotic prescribing and hospital admissions or patient satisfaction.
-
-
-
Cast the net wide: Assessing the root causes of malaria transmission through the knowledge, attitude and practice of treated inpatients in rural western Uganda
More LessIntroductionDespite significant progress malaria entails a significant public health concern in western Uganda. This qualitative cross-sectional study explores the knowledge, attitude and practice pertaining to malaria in rural Uganda.
MethodsWith ethical approval from the management committee fifty patients were recruited between March-May 2018 at Kagando Hospital, western Uganda. Those with evidence of malaria transmission were recruited, at random prior to discharge, from the medical, paediatric (parents) and maternity wards. Participants were consented and briefed by a translator prior to answering a standardised semi-structured questionnaire. Answers were anonymised before being tabulated and analysed electronically.
ResultsParticipants were commonly, primary-school educated, subsistence farmers (56%). Knowledge of symptoms, mosquito breeding sites and feeding habits was generally good, yet dichotomous causes of malaria were common (mosquito n=43 and“unsafe drinking water” n=25). Malaria was “normal” to 40% of respondents and 92% acknowledge that it “kills”. Ten-percent accessed herbalists and 74% self-medicated with 30% admitting to not completing the treatment. Eighty-two percent of patients received governmental net donation but household use was variable and often infrequent. Indoor residual spraying (IRS) was practiced by two participants with just 30% aware of it. Stagnant water was present in 46% of communities without any knowledge of community spraying.
ConclusionsParticipants demonstrated reasonable knowledge on vector/disease characteristics and treatment. Net access was within governmental target level but household practice was highly variable. Notably there was almost no IRS and no targeted spraying. A more integrated approach to vector control could represent an appealing strategy.
-
-
-
An audit of the diagnosis and treatment of infective endocarditis
More LessBackgroundInfective endocarditis (IE) is associated with a high incidence of mortality and morbidity and guidelines exist on appropriate diagnosis and treatment. The aim of the study was to evaluate adherence with national guidance and identify relevant learning experiences if indicated.
Methods
We performed a retrospective review of admissions to a district general hospital with a diagnosis of IE over a 1-year period from January 2018 to December 2018. Individual cases were identified during inpatient admission and notes reviewed to establish adherence to a published national audit tool.
Information regarding initial investigation, and management was gathered from the medical notes and microbiology reporting of samples was also examined.
ResultsOf the 16 cases identified: 93% did not have blood cultures taken appropriately before treatment was started and only 50% received the recommended empirical antibiotics.
Only 43% had a transthoracic echocardiogram performed in the first 24 hours.
A surgical opinion was sought in just 2 of 4 cases of prosthetic valve endocarditis.
The three culture negative IE cases had no further recommended testing performed.
ConclusionWe highlighted a need for improved investigation and treatment of IE.
Timeliness of transthoracic echocardiograms will be improved by a change to the request form to indicate if IE is suspected so scans can be prioritised.
Clinicians will be informed if blood cultures are negative so further testing can be arranged if there is still a high clinical suspicion.
A weekly microbiology ward round has been established to review all suspected cases of IE.
-
-
-
Dalbavancin: A “silver bullet” against gram positive infections in PWID
More LessIntroduction: Dalbavancin is a novel lipoglycopeptide antibiotic which provides gram positive cover including MRSA and enterococci for up to six weeks with two doses. We report the use of Dalbavancin at the Royal Sussex County Hospital in Brighton from 2018-2019.
Methods: Patients were given dalbavancin after approval by a consultant microbiologist on a case by case basis.
Results: 20 patients in total received dalbavancin during this time period. 11 out of 20 patients were male with a mean sample age of 54. 14 patients were ex or current IVDUs. The most frequent dose of dalbavancin given was 1.5g single dose in 11 out of 20 patients.
14 patients had a confirmed bacteraemia. There were 8 cases of MSSA, 1 case of MRSA, 1 CNS, 2 IGAS, 1 Group C Streptococcus and 2 Streptococcus dysgalactiae bacteraemias (one patient had 2 organisms identified in blood cultures). The commonest source of infection was skin and soft tissue, identified in 11 out of 20 patients.
Patients had received a median of 2 (range 1-5) different antibiotics prior to use of dalbavancin with a median course of 14 (range 1 – 27) days Abx prior to Dalbavancin. Patients were admitted for a mean of 15 days with a mean of 12 bed days saved per patient. There was one readmission during this time period which was due to a gram-negative sepsis.
Discussion:Given the challenges of managing severe infections in PWID, dalbavancin can be a “silver bullet” to facilitate effective treatment of important gram-positive pathogens.
-
-
-
Empyema: do we know enough?
More LessIntroduction
Pleural empyema is an uncommon but serious condition defined by infected fluid in the pleural space. These patients are often given long courses of empirical broad-spectrum antibiotics as the yield from conventional culture methods is notoriously low. The literature shows that with conventional culture methods of the pleural fluid up to 40-60% of causative pathogens remain unidentified. In recent years methods such as DNA analysis have been developed in an attempt to increase identification rates of pathogens. This paper aims to review the literature to determine the additional benefit of DNA analysis methods above conventional culture of fluid in pleural empyema.
Methods
A review of the literature searching for studies investigating bacteria present in pleural fluid in patients with empyema was carried out. Studies in which adult patients had a diagnosis of empyema and where conventional culture and molecular methods were used to identify the causative bacteria were included. Descriptive statistics were used to compare the increased yield from molecular methods.
ResultsFive studies which compared conventional culture techniques and molecular methods for identification of the pathogen in pleural empyema cases were identified. The mean culture-positive rate and molecular-positive rate in these studies was 37.5% (range 10-58%) and 80.0% (range 22.5-82%) respectively. All the studies concluded that molecular techniques provided a greater identification rate than conventional culture techniques.
ConclusionPleural empyema is often culture negative leading to broad-spectrum antibiotic use. This review shows that molecular methods significantly increase the yield of causative bacteria present in pleural fluid.
-
-
-
Once bitten, twice shy
More LessA 48yr old man presented with a 1-2 week history of diarrhoea and fever. He took occasional ibuprofen for migraines but took no regular medications and was fit and active. On presentation to A+E blood tests revealed severe AKI with hyperkalaemia, low platelets and anaemia with raised inflammatory markers. He complained of shortness of breath with a CXR consistent with ARDS. He was commenced on IV antibiotics and was transferred to ITU for further management. While on ITU his blood film revealed evidence of haemolysis, in addition to an LDH of >2600. He had persistenly low platelets (14 at its nadir), requiring platelet transfusion. His renal failure was managed with haemofiltration and he was transfused to maintain his Hb above 80. The diagnosis was of haemolytic uraemic syndrome due to a presumed infectious origin. Blood cultures came back positive for a fastidious, slow-growing Gram-negative rod, identified as Capnocytophaga canimorsus. Further questioning revealed the presence of a dog bite to his R. index finger two months previously. The patient's antibiotic regimen was changed to Ceftriaxone 2g IV OD and metronidazole 500mg IV TDS and he was transferred to the Royal Free Hospital to commence haemodilaysis and for specialist renal management.
Capnocytophaga canimorsus is an encapsulated organism known for its potential to cause disseminated and fatal infection in asplenic or immunocompromised patients, which were risk factors not present in our case. It is a rare cause of HUS and highlights the need for thorough history if an infective agent is presumed.
-
-
-
North by Northeast - a case of CNS Aspergilloma mistaken for pituitary tumour
More LessBackgroundFungal pituitary sellar infection is a rare condition and can resemble a pituitary tumour. Our patient required two debridements across two continents.
CaseA 47-year-old diabetic man presented with history of headaches and sudden visual loss, on neuroimaging found to have an infiltrative sella lesion compressing the optic nerves. He had an incomplete transsphenoidal resection in Nigeria, with a histological diagnosis of chordoma. Ten months prior he suffered a gunshot wound destroying his femur, initially managed with an intramedullary nail, subsequently requiring implant removal, multiple debridements antibiotic spacer, ultimately leading to a Girdlestone’s. Endoscopic redo-transphenoidal-resection at Newcastle-Upon-Tyne, for cystic/solid inflammatory changes in the pituitary fossa/sphenoid-sinus/suprasellar-cisterns suggestive of residual tumour, however did not show any neoplasm. Instead, histology yielded a chronic necrotising fungal infection, morphologically suggestive of Aspergillus on Grocott/PAS-stains, with septate branching hyphae and fruiting bodies. Culture and 18s PCR of sphenoid tissue was negative. Good therapeutic response to longterm voriconazole therapy with TDM confirming adequate levels >2 mg/L, and hormone substitution for pan-hypopituitarism. He underwent further 2-stage-arthroplasty of the hip due to polymicrobial bacterial osteomyelitis but negative fungal cultures/histology.
DiscussionAspergillus infection of the pituitary fossa is rare and a recognised mimic of macroadenoma/tumour. The original lesion is likely to have been aspergillus, with diabetes as a well-established risk factor for primary paranasal fungal infection, rather than iatrogenic inoculation during surgery. Radiological/microbiological features from Girdlestones’ pointed against haematogenous spread from the osteomyelitic hip.
-
-
-
Knowledge of nursing staff and healthcare assistants on the diagnosis of urinary tract infections in patients with urinary catheters
More LessBackgroundAsymptomatic bacteriuria is common in patients with urinary catheters. Current clinicalguidelines advise against dipstick testing or treating urine culture results in asymptomatic catheterised patients which can promote the development of antimicrobial resistance and present an unnecessary risk to patients. This study aimed to assess the knowledge of nurses and healthcare assistants (HCAs) on the diagnosis of urinary tract infections (UTIs) in patients with urinary catheters.
Methods
This study employed a cross sectional survey of opportunistically sampled nursing staff and healthcare assistants working at Northwick Park Hospital in May 2018. Results were analysed descriptively.
Results134 participants were included in the final analysis of whom 90% (N=120) were nurses and 10% (N=14) were HCAs. The majority of staff (38.6%, N=51) worked in a medical speciality and had over 15 years of work experience (45.3%, N=58). 79 participants (66%) believed that a positive dipstick result was diagnostic of a catheter associated urinary tract infection (CAUTI). A positive dipstick result was the most frequently selected indication (91% of respondents, N=108) for sending urine for culture in a catheterised patient, and was also the most frequently selected reason for sending urine for culture across staff of all years of experience and all specialities.
ConclusionThere is a need to improve the level of knowledge of nursing and HCA staff on the diagnosis of CAUTIs including misconceptions on the diagnostic value of dipstick testing in catheterised patients. The findings of this research will inform a quality improvement project to address these gaps in knowledge.
-
-
-
Evaluation of Microbiological Sampling Practice in Community Acquired Pneumonia at a South London Trust: The Cheaper, the Better?
More LessNICE guidelines suggest cases of community acquired pneumonia (CAP) in hospital have blood and sputum cultures and legionella and pneumococcal antigen tests be considered in specific cases. Local guidelines advise respiratory viral swabs, sputum and blood culture in specific cases and urinary antigen tests only in severe cases. We assessed the frequency and appropriateness of microbiological testing in CAP.
Methods:The electronic records of admissions to St Thomas’ Hospital, London in January 2019 were scrutinised to identify cases of CAP. The severity of each case was categorized using CRB65 scoring. Microbiological tests and their results were analysed.
Results:64 cases of CAP were identified. Severe disease (CRB>/= 2) was present in 31%. Respiratory viral/flu swabs were sent in 76% of cases and were positive in 39% of these cases [12 (63%) were influenza]. Sputum culture was collected in 39% of cases and revealed pathogens in 24% of these. Urinary pneumococcal antigen was sent in 7 cases of non-severe disease and 1 case of severe disease and was positive in 25% of those tested. Legionella urinary antigen tests were sent in 6 cases, only 2 of whom had reasons documented for sending the test; all were negative. Blood cultures were sent in 69% of cases (44 patients) and none revealed pathogens.
Discussion:
During the influenza season the most useful microbiological test was the respiratory viral swab. Sputum culture is a cheap test that could be used more often. Expensive legionella antigen tests were performed inappropriately.
-
-
-
405-nm Light for Bacterial Reduction in Blood Plasma: Preliminary investigations into antimicrobial efficacy and plasma protein integrity
More LessBackground:Pathogen reduction technologies (PRT) for blood products can reduce the incidence of transfusion-transmitted infection and associated wastage of blood products. Visible 405nm-light has been shown to inactivate bacteria in situ in bagged blood plasma without the addition of photo-sensitive chemicals. However, threshold levels for plasma protein compatibility and optimal bactericidal activity are currently unknown. This study investigates different treatment conditions and their suitability for safely inactivating bacteria in blood plasma.
Method:Plasma seeded with Staphylococcus aureus (102–105CFU/ml) was exposed to 405nm-light at low and high irradiances (10, 100mW/cm2) with treatment times ranging between 0.2–7-hr (≤252 Jcm-2). SDS-PAGE was then used to assess the light effect in terms of antimicrobial treatment levels on plasma protein integrity.
Results:High and low intensity treatment regimens achieved significant bacterial inactivation (P=<0.05) with doses of 252 Jcm-2 achieving ≥99.3% reduction. Results suggest that lower irradiances have greater germicidal efficiency, with use of 10mWcm-2 achieving up to 30% greater inactivation than equivalent doses using 100mWcm-2. SDS-PAGE analysis demonstrated no major detrimental impact on protein integrity with any of the treatment conditions investigated. Minimal changes in protein bands (≈28kDa) were observed relative to positive control samples after application of doses >144 Jcm-2.
Conclusion:The results of this study have highlighted the safety potential of 405nm-light treatment on blood plasma. Further research is required to determine the upper and lower threshold treatment levels and functionality of plasma proteins post-exposure for further development of this technology as a PRT tool for application in transfusion medicine.
-
-
-
Enough is enough – is it time for the Scottish Antimicrobial Prescribing Group (SAPG) to develop the third age of antimicrobial stewardship in primary care in Scotland?
More LessBackgroundFrom 2008 the SAPG focused on ‘what to prescribe’ to tackle Clostridium difficile infection and from 2013 on ‘whether to prescribe’ to tackle unnecessary prescribing for self-limiting infections. Following these successes SAPG is now moving to the age of ‘how much to prescribe’ to ensure correct duration of therapy. We aimed to compare current prescribing practice with guidance from Public Health England (PHE)/NICE which recommends five days’ treatment for most common community respiratory infections (RTI).
MethodsThe durations of antibiotic courses for treatment of respiratory tract infections was derived from data on dispensed prescriptions in 2018 from the Prescribing Information System, a national database of all NHS prescriptions dispensed in Scotland. Observed course durations were compared to course lengths recommended by PHE/NICE and modelling was undertaken on the impact on antibiotic use if durations were in line with guidance.
ResultsFor antibiotics recommended for RTI, the most common length of treatment used was seven days. For amoxicillin the proportion of five day prescriptions varied across health boards from 1.8% to 68.7%. Modelling estimated if 75% of seven day prescriptions for antibiotics recommended for RTI were changed to five days this would deliver a 4.1% reduction in antibiotic use.
ConclusionSAPG has agreed to lead work to encourage the use of five day courses of antibiotics where indicated. Switching to five day courses would support reduction in total antibiotic use to achieve the ambitions of the UK AMR National Action Plan.
-
-
-
Knowledge, Attitude, Practice and Implementation of community pharmacists role in treating tuberculosis patients in south India Region
More LessBackground: Knowledge, attitude, practice and implementation of community pharmacist role in treating tuberculosis patients. Community Pharmacy education in India faces many challenges. An assessment of the challenges and opportunities of community pharmacist role in eradication of Tuberculosis in India has not been conducted.
Methods: This was a cross sectional study A one-day training was conducted in 6th may 2019 in Belagavi , Karnataka state, India. A selected sample of stake holders was invited experts Like Medical education expert in the field of tuberculosis, District Tuberculosis controller officer, Deputy Drugs controller, Assistant Drugs controller. The training Program was conducted by Dept. of Pharmacy Practice, KLE college of Pharmacy, Belagavi in association with District Tuberculosis center Belagavi and Regional office of Deputy Drugs Controller, Belagavi, India.
Results: A total of 60 community pharmacists are responded. The lowest number of correct answers were to the questions were Patients with active TB disease can infect people by talking (56.7%), TB is often spread from person to person through sex (53.3%), aware of Public Private mix (PPM) for Tuberculosis control and care (35%), Anti-TB drugs which are contraindicated in pregnancy (35%).
Conclusion: There are significant gap in knowledge, Attitude and practice on TB infection and control among community pharmacist. Proper training is essential to overcome the gap between community pharmacist and Government sector to eradicate TB by 2025 from India.
-
-
-
Carbapenem stewardship in a large teaching English hospital - are we improving?
More LessBackground:Overuse of antibiotics has been linked to the global growth of antimicrobial resistance (AMR). In 2018, increase in meropenem usage in our hospital revealed that we achieved the “Start Smart” but not “Then Focus” element. Following revised carbapenem stewardship, we aimed to evaluate the adherence to guidelines, by monitoring patients initiated on meropenem.
Methods:As part of the antimicrobial stewardship (AMS) at our 1800-bed teaching hospital, carbanepem stewardship was revised in September 2018 and required consultant approval for all carbapenem initiation or continuation following specialist advice. Meropenem prescriptions in adult and paediatric patients were generated from the electronic prescription system and reviewed daily for one week in August 2019 to ascertain if prescribed in line with guideline recommendations or on the advice of microbiology or infectious diseases.
Results:Sixty patients were reviewed. Microbiology or Infectious Diseases recommendation was obtained in 37% of patients. 95% had samples taken where blood cultures accounted for 85% but over a third of these had no growth reported. Meropenem was initiated empirically in 50% of patients mainly for neutropenic sepsis while 28% were culture directed. 35% of patients were escalated from piperacillin-tazobactam of which 57% had neutropenia while de-escalation occurred in 10%.
Conclusion:AMR is related directly to antibiotic use at a patient level. Our revised strategy resulted in a reduction of total carbapenem DDD/1000 Admission from 128 (June 2018) to 87 (June 2019) through improved adherence to guideline and infection specialists recommendations however more work is required to promote switch to narrower-spectrum choice.
-
-
-
Do Results from the Microbiology Laboratory lead to Appropriate Management of Uncomplicated Lower Urinary Tract Infections?
More LessBACKGROUND
There has been a national drive to improve antimicrobial stewardship in the diagnosis and management of uncomplicated lower urinary tract infections (UTIs). While much attention has been paid to the initial management in hospital, there is little evidence of how treatment is rationalised or altered in response to results from the laboratory.
METHODS
We undertook a retrospective analysis of medical records, including patients diagnosed with uncomplicated lower UTI whilst in hospital. Data was collected on whether a urine sample was sent to the laboratory, the result was documented, which subsequent actions were taken by clinical teams and their appropriateness.
RESULTS
All the patients received antibiotics for a lower UTI. 55% of patients had documented symptoms of a UTI, the remainder were commenced due to a suspected UTI in the absence of localising clinical symptoms. 86% had an MSU sample sent to the laboratory. In all cases, clinicians had viewed these results. In 57%, the findings of the MSU were documented. 38% of all results were not acted on appropriately, with 19% of those continuing antibiotics unnecessarily, 24% not narrowing down therapy and 12% not changing antibiotics in response to resistant isolates.
CONCLUSION
Whilst correct clinical investigations may be sent and reviewed in the management of uncomplicated UTIs, the results of these are often not documented in the patient’s record and a significant proportion of these results are not acted on appropriately.
-
-
-
Host and pathogen biomarkers to predict bacterial sepsis
More LessSepsis is defined as life threatening organ dysfunction caused by a dysregulated host response to infection, and is responsible for 52,000 deaths in the UK per year. Approximately 50% of sepsis episodes are related to bacteria where the Gram-negative bacteria Escherichia coli is a leading causative agent. Our previous work with the Hywel Dda Health Board has identified a high level of E. coli sepsis and in the current work, we aim to identify genetic (genes) and host biomarkers (e.g. IL-6) to discriminate E. coli sepsis isolates based on original source of infection.
E. coli isolates (n=100) from blood cultures in patients with defined sources of infection (urinary, biliary, intra-abdominal or unknown) were used to investigate potential biomarkers using next generation sequencing, whole blood modelling and molecular microbiology phenotyping.
Sequencing of isolates is underway. Growth curve analysis demonstrated that human serum could modulate E. coli growth to three phenotype groups; i) no growth, ii) retarded / decreased growth and iii) unaffected growth (compared to LB control). Whole blood modelling over 6 hours confirmed 4 hours to be the optimal time point to study IL-6 expression. Grouping isolates by source of infection showed that those from the urinary tract and ‘unknown’ sources produced significantly more IL-6 than E. coli K12. Completion of phenotyping will allow association studies to bacterial genotype.
These results will help define new biomarkers associated with the host and genetic biomarkers associated with E. coli that will better predict and inform the diagnosis and treatment of sepsis.
-
-
-
Coinfection Mechanisms ofCampylobacter andEscherichia coli in Human and Chicken Epithelial cells
More LessCampylobacter jejuniis the world’s most common food-borne pathogen. Campylobacterpathogenesis involves translocation across the intestinal epithelial cell barrier in both humans and chickens and previous work has suggested that strains of E. coli (ExPEC / APEC) may facilitate this process. This study aims to determine the effect that this relationship may have upon the invasive and adhesive potential of the two microbes using our recently published human and avian in vitromodel.
Invasiveness of C. jejuni and E. coli strains were measured using human (Caco-2) and avian (8E-11) epithelial cell lines derived from the gastrointestinal tract and were characterised by epifluorescent and confocal microscopy. Adhesion and invasion assays were carried out to determine the pathogenicity of the different bacteria. Metabolic activity of Caco-2 and 8E-11 together with bacterial strains using alamar blue assay.
Confocal and epifluorescence microscopy determined the strong presence of cytokeratin in Caco-2 cells whilst weak to medium signals were detected in 8E-11 cells. Optimal doses and times for of gentamicin across all strains was 0.02mg/ml for 90 minutes which did not affect metabolic activity of epithelial cells. Significant diversity was found in the adhesive/invasive potential of bacteria when exposed to human and avian cell types. The metabolic rate of C. jejuni (11168) and E. coli (K12) was investigated with the presence of K12 having negative impacts upon the activity of 11168.
The model described here will provide opportunity to improve our understanding of Campylobacterinvasion mechanisms in human and chickens so that improved strategies to negate these consequences may be designed.
-
-
-
Audit of compliance to SEPSIS 6 criteria in Emergency Department admissions
More LessINTRODUCTION
The timely diagnosis of sepsis is the essential first step that activates life-saving pathways. The aim of our study was to assess the accuracy of the ‘sepsis flag’ assigned to patients presenting to our hospital’s Emergency Department (ED).
METHOD
A retrospective two week review (18/03/19 to 25/03/19 and 07/05/19 to14/05/19) was performed in a District General Hospital in London, assessing the medical records of all adult patients assigned a sepsis flag in ED (n=21), in order to assess if SEPSIS 6 criteria were met. For comparison, patients admitted to ED with gram negative bacteraemias (n=8) in the same period were reviewed to check if they were included in the SEPSIS 6 group.
RESULTS
Ten out of twenty one patients with a ‘sepsis flag’ fulfilled criteria. Six other patients had one criterion (T>38oC) for sepsis. Blood cultures were sent in all patients. Four out of ten patients were administered IV antibiotics within one hour. During this period, none of the eight patients admitted with gram negative bacteraemias were assigned a ‘sepsis flag’, despite five of them meeting SEPSIS 6 criteria (two or more criteria) and having evidence of infection. However, the majority (7/8) received IV antibiotics within one hour.
CONCLUSION
Our review highlights the difficulties in the diagnosis of sepsis and the limitations of the SEPSIS 6 criteria for detection of septic patients in triage. However, we have demonstrated that the vast majority of patients had appropriate investigations and prompt antibiotic treatment, irrespective of the ‘sepsis flag’.
-
-
-
Validation and Implementation of the Roche FLOW System in a Large Routine Molecular Diagnostic Laboratory
Background - The PHE Public Health Laboratory, Birmingham at Heartlands hospital has an annual turn-over in excess of 750,000 specimens, 41,000 of which are processed using real-time PCR in the molecular section. In 2017, due to the age of existing instrumentation, the laboratory began a programme of replacement.
Methods - During 2017-19 the entire molecular service was replaced with a new high-throughput automated Roche FLOW system, consisting of a primary sample handler (PSU), two MagNA Pure 96 instruments, a PCR set-up unit (PSU), three 384-well LightCycler 480 II instruments and overarching FLOW software responsible for automated data handling, specimen tracking and workflow between the instruments.
Results - The bulk of the in-house developed assay repertoire, representing 34 viral, bacterial and fungal targets was re-optimised in 19 multiplexes. These were fully validated against existing molecular tests and were introduced into routine diagnostic service in June 2018. The FLOW software was successfully interfaced with the LIMS system, allowing rapid two-way communication of test requests and results. Over the following ten months, the service was expanded with an additional seven targets. The new system and assays were audited by UKAS in April 2019 and achieved accreditation to ISO:15189:2012 in August 2019.
Conclusion – The Roche FLOW system was successfully validated and introduced into routine diagnostic service and now offers significant improvements in assay performance, sample throughput and turnaround time. Details of the validation process, post-implementation modifications, trouble-shooting and lessons learnt will be of value to other diagnostic laboratories considering the introduction of this technology.
-
-
-
Review of antibiotic prophylaxis for the prevention of surgical site infection in low and middle income countries (LMICs)
More LessBackgroundThe Scottish Antimicrobial Prescribing Group (SAPG) is supporting two hospitals in Ghana via a Fleming Fund healthcare partnership to develop antimicrobial stewardship. Initial intelligence gathering suggests that antibiotic prophylaxis to prevent surgical site infection (SSI) is suboptimal. To inform a quality improvement programme we have reviewed the evidence for use of surgical prophylaxis in LMICs including staff behaviours and attitudes.
MethodsMEDLINE, Embase, Cochrane, CINHAL and Google Scholar were searched from inception to 22 July 2019 for trials, audits, guidelines and systematic review in English. Grey literature, websites and reference lists of included studies were searched. The following data were extracted; study characteristics, interventions, outcomes and recommendations. In view of heterogeneity between studies descriptive analysis was conducted.
ResultsOf 185 records screened, 26 studies related to SSI and timing of antibiotic prophylaxis in LMICs were included. The incidence of SSI is significantly higher in LMICs compared with high income countries, recording of infection surveillance data is poor and a lack of local guidelines for antibiotic prophylaxis. Several projects in Africa have reported reduction in SSI with single dose preoperative antibiotic use compared with post-operative prophylaxis and a reduction in cost and nurse time. Despite evidence to the contrary, many surgeons continue to use post-operative antibiotic prophylaxis.
ConclusionEducation to improve incidence of SSI in LMICs through appropriate antibiotic prophylaxis can be successful. Interventions must include local context and address strongly held beliefs. The establishment of local multidisciplinary teams will promote ownership and sustainability of change.
-
-
-
Impact of the Scottish Reduction in Antimicrobial Prescribing (ScRAP) Programme on primary care prescribing for urinary tract infection (UTI)
More LessIntroduction
The ScRAP programme was developed as a national initiative to support improvements in managing patients presenting with symptoms of UTI. The programme comprises educational content plus improvement ideas. It was implemented in one large, mainly urban, NHS board region covering 21% of the Scottish population via Prescribing Support Pharmacists working with individual GP Practices. A key aim was to reduce unnecessary antibiotic use.
MethodA facilitated learning session was delivered and all clinical and non-clinical GP Practice staff, were invited to attend. Evidence supporting best practice in managing UTI, local prescribing data and local practice was considered and discussed. The session concluded with action planning to reflect on current practice and identify areas for improvement.
National data held by NHS National Services Scotland was used to evaluate prescribing across all NHS board regions in Scotland focusing on total use of antibiotics and use of trimethoprim and nitrofurantoin which are used solely for UTI.
ResultsAnalysis of national prescribing data comparing the implementation region with the rest of Scotland suggests the intervention has been successful. Comparing data from prior to and for one year after the intervention period reductions for the intervention board versus the rest of Scotland were as follows: all antibiotics 7.29% vs 6.11%; trimethoprim 6.14% vs 3.73%; nitrofurantoin 3.92% vs 0.56%.
ConclusionQuantitative evaluation provides evidence of the impact of ScRAP on prescribing rates. This suggests that improved practice has led to reduction in unnecessary use of antibiotics for acute and recurrent UTI.
-
-
-
Evaluation of the impact of Scottish Reduction in Antimicrobial Prescribing (ScRAP) Programme on GP Practice management of patients with suspected urinary tract infection (UTI)
More LessIntroduction
The ScRAP programme was developed as a national initiative to improve management of UTI by optimising use of diagnostic tests and prescribing of antibiotics. It comprised educational content plus improvement ideas, audit tools, good practice guides, patient information and decision aids.
MethodA facilitated learning session was delivered, usually by a Prescribing Support pharmacist. All GP Practice staff, both clinical and non-clinical, were invited to attend to promote a team approach to change. Local practice was considered using process mapping and each GP practice completed an action plan with changes they intended to implement. Facilitators and participants were encouraged to complete an on-line feedback survey about the learning session. Action plans from 200 GP Practices in one health board region (21% of Scottish population) were analysed using NVivo 12 software to identify key themes.
ResultsCompleted surveys from facilitators and participants showed both groups were positive about the content, approach and length of the session. Action planning was welcomed as a way to embed learning in practice. Some minor changes to content were suggested. Changes in practice included patient education to promote self-management and a reduction in the number of urine specimens sent to microbiology laboratories. A whole team approach to management of patients with suspected UTI increased the success and impact of the changes made.
ConclusionEvaluation of action plans will be helpful for other GP Practice teams seeking to make improvements. Feedback from facilitators and participants will be used to inform update of the programme content.
-
-
-
S. bovis urinary tract infection, management and associations
More LessBackgroundAs part of a move to improve antimicrobial stewardship NHS GGC recently implemented identification to species level and Vitek 2 sensitivity testing on all urinary isolates. As part of this we have noticed an increased number of isolates of the Streptococcus bovis group in urinary samples. It is possible that these were previously labelled as Enterococcus spp. The significance of S. bovis isolates in urinary tract is uncertain.
Methods
We reviewed a year of S. bovis urinary isolates to ascertain whether there is any association with GI malignancy or endocarditis as is recognised with blood culture isolates of this group.
Results54 isolates were reviewed dating between Feb 2018 and 2019 allowing at least 6 months follow up. 94% of cases were in females. 46% of isolates were mixed usually with a member of the Enterobactereaceales. There were no cases of either known or newly diagnosed endocarditis amongst this patient cohort. 9% of cases had a known GI malignancy.
Conclusion9% of our urinary isolates of S. bovis were associated with a known GI malignancy. This is compared with 11% of blood culture isolates also from our unit in 2016.
-
-
-
Lessons learned from a mandatory Irish Carbapenemase producing Enterobacterales (CPE) contact communication programme at University of Limerick Hospitals Group (ULHG)
Background: ULHG first detected CPE in 2009. A decision was made at the outset to flag CPE contacts on the surveillance software system (ICNet) rather than write to discharged contacts. CPE was declared a national public health emergency, October 2017. In September 2018, the Irish CPE Expert Group mandated that all hospitals write to CPE contacts, as per open disclosure policy, to inform them of their status. Screening was also offered. An eligible contact was defined as one who did not have 4 negative screens since exposure.
Methods: An ICNet search was conducted to detect all CPE contacts, cross-checking with the national death registry before delineating the number of CPE screens tested via the Laboratory Information System. Processes were put in place to address queries from patients; a generic helpline and a recorded telephone line for clinical concerns or complaints. Screening packs were developed. National template letters were posted to patients, their GPs and consultants.
Results: 2016 CPE contacts were identified from Feb 2009 to Sept 2018. 422 patients contacted the generic helpline; 347 requested call-back from the CPE nursing expert. 115 requested testing packs with 103 delisted as contacts. Patients voiced many concerns including anger for the untimely notification, upset at the potential risk of CPE acquisition and criticism regarding the letter content.
Conclusions: The decision to inform patients is appropriate but it must be timely with access to understandable information and support from a suitably trained professional. The communication programme continues prospectively in the setting of CPE endemicity.
-
-
-
Culture-independent Multilocus Sequence Typing (MLST) screening for Haemophilus influenzae cross-infection in non-cystic fibrosis bronchiectasis (NCFB)
More LessBackgroundThere is some evidence of Pseudomonas aeruginos across-infection between patients with non-cystic fibrosis bronchiectasis (NCFB), and clear evidence in Cystic Fibrosis. Haemophilus influenzae (H. influenzae) is the more common pathogen in NFCB patients, yet cross-infectionremains unexplored. We present the novel application of culture-independent Multilocus Sequence Typing (MLST) to screen for cross-infection of H. influenzae in NCFB in both culture-positive and -negative samples.
Methods
We interrogated DNA from 32 sputum samples (26 patients) in our NCFB biorepository, who were known to have H.influenzae in their sputum by preceding 16S rRNA sequencing. Fragments of 7 H. influenzae housekeeping genes were amplified and sequenced. Sequence types were allocated via the MLST scheme. For 5 patients, multiple sputum samples taken at least 4 months apart were assessed longitudinally.
ResultsCulture-independent MLST identified 31 of 32 sputum samples as harboring H. influenzae. Of these, 26 were positive for H. influenzae using culture methods. 25 of the 26 culture-positive samples were MLST positive. All 6 culture-negative samples were MLST positive. A MLST sequence type (ST) was allocated to 27 of 32 sputum samples. Five patients had multiple sputum samples with matching STs, indicating strain stability and the consistency of MLST. Two patients who were known household contacts had matching STs and possibly transmitted H.influenzae in their household. The remaining 15 STs were unique, suggesting no evidence of cross-infection.
ConclusionCulture-independent MLST identifies H. influenzae in culture-negative patients with NCFB and is a potential screening tool for cross-infection. This study did not reveal potential cross-infection events in this cohort.
-
-
-
Developing a national indicator of intravenous antibiotic use to support timely review of antibiotics in Scottish hospitals
More LessBackgroundTo address increasing antibiotic use in acute hospitals, the Scottish Antimicrobial Prescribing Group developed a quality improvement (QI) initiative to support reliable review of patients started on intravenous (IV) antibiotics within 72 hours. This will reduce unnecessary continuation of antibiotics, ensure personalised treatment and appropriate IV to oral switch with associated benefits for patients of reduced risk of device related infections and potential for earlier discharge from hospital.
Methods
Using data obtained from the Hospital Medicines Utilisation Database, a national database of secondary care medicines use in Scotland, we examined trends in IV antibiotic use between 2013 and 2017. We then projected the current trend forward to 2021 to inform development of national indicator to optimise IV antibiotic use.
ResultsIn 2017, IV antibiotics accounted for 32.9% of all antibiotic use in Scottish hospitals. Annual IV antibiotic use (defined daily doses per 1000 population per day) increased by 20.5% between 2013 and 2017. We estimated a further projected increase of 12.5% between 2018 and 2021. To measure the impact of our QI initiative SAPG agreed to employ a national indicator with a target that ‘use of IV antibiotics in hospitals will be no higher in 2021 than it was in 2018’.
ConclusionThis national indicator will evaluate progress with achieving reliable and timely review of IV antibiotic therapy to reduce hospital antibiotic use and contribute to reduction in total antibiotic use in humans which is a key ambition of the UK AMR National Action Plan.
-
-
-
An audit of antimicrobial usage in perioperative period of adult patients undergoing appendectomy
More LessIntroduction
Antimicrobials are prescribed at appropriate dose and in a timely fashion, to reduce post-operative infections in adult patients undergoing appendectomy. It is desirable to establish the shortest and most effective prophylaxis. To assess this, we reviewed a sample of adult patients that have appendectomy procedure completed at the CWFT to assess antimicrobial prescribing in line with local prescribing guidelines.
MethodWe undertook a retrospective observational study at a central London teaching hospital to investigate antimicrobial prescribing in adult patients undergoing appendectomy between Jan2019 and Jun2019.
Results.
A total of 173 patients [median age 31year] were analysed; 7 and 167 had undergone an elective and urgent appendectomy respectively. 163/173 [94.2%] received antimicrobials peri-operatively. Compliance with local guidelines was 40.5%; a lack of aminoglycoside in combination with beta-lactam was common (58%). 126/173(72.8%) patients received antimicrobials on discharge, median 7.0 days total antimicrobials. Readmission rates within 30 days of surgery were 6.4% but unrelated to antimicrobial prescribing (p=0.8). Enterobacteriaceae was the most commonly identified pathogen (n=45), with high co-amoxiclav resistance reported (31%).
Conclusions
Combination co-amoxiclav plus aminoglycoside is advised peri-operatively for appendectomies yet adherence is poor. Despite local co-amoxiclav resistance, aminoglycosides are often omitted. The number of patients treated with post-op antimicrobials and the duration of therapy is greater than comparable published studies. Lack of standard definitions for complicated appendectomies makes it difficult to identify patients that do benefit from post-operative antimicrobials thus overprescribing occurs. Agreement on the optimum duration of treatment also is unclear and results in likely excessive prescribing.
-
-
-
Incidence of Group B Streptococcus bacteraemia in mum and newborn following antimicrobial prophylaxis- To screen or not to screen?
More LessIntroduction
There is no routine screening for antenatal Group B Streptococcus (GBS) carriage in the UK. However invasive GBS in newborns, whilst rare (0.57/1000 births), is associated with mortality (5%) and long-term disability (9%). Antimicrobialsperi-partum can reduce the risk of invasive infection.
MethodWe undertook a retrospective observational study at a London teaching hospital to investigate the incidence of invasive GBS peri-partum in both mother and child between 1/4/16 and 31/3/19.
ResultsThere were 16,869 live births recorded at Chelsea & Westminster Hospital during the study period. Operative, caesarean and spontaneous delivery accounted for 16.7%, 34.9% and 48.2%; with incidence of neonatal GBS bacteraemia being 0.18%, 0.08% and 0.11%, respectively. 20 (0.12%) neonates had invasive GBS infections, with 7/20 neonates having concurrent maternal GBS bacteraemia. 34(0.22%) ladies had GBS bacteraemia peri-partum; none had GBS isolated prior to delivery. 543 women had a positive GBS clinical isolate prior to labour;69.1% received GBS prophylaxis peri-partum with no invasive GBS transmission. Despite no prophylaxis in 168/543 GBS colonised women, no invasive GBS neonatal cases were identified.
Conclusions
Our local data identifies a low prevalence (0.12%) of invasive GBS infection in newborns. Maternal GBS bacteraemia is more frequently observed and associated with concurrent newborn GBS bacteraemia. Antimicrobial prophylaxis adherence peripartum although recommended is suboptimal, even though no invasive GBS transmission was identified. All invasive GBS infections were not known to be colonised pre-delivery. The current recommendations for targeting recent GBS culture do not appear to be a sensitive predictor of invasive peri-partum GBS infection.
-
-
-
Spontaneous Bacterial Peritonitis at University Hospitals of North Midlands NHS Trust: A Retrospective Study
More LessBackgroundSpontaneous bacterial peritonitis is an acute infection of ascitic fluid that is not related to an underlying intra-abdominal pathology.
MethodsThis is a retrospective study of data on ascitic fluid samples taken during the period of January to December 2017 to assess the management of SBP patients and associated mortality. Kaplan-Meir method was used to estimate survival probability at 30 and 90 days. Cox proportional models were used to evaluate aetiology and causative organism in predicting mortality. Analyses were done using R: A language and environment for statistical computing.
ResultsTotal of 53 patients were identified as having SBP based on ascitic fluid cultures. Sixteen of these also fulfilled the national criteria of ascitic neutrophil count of more than 250 or total cell count of more than 500.
Thirty-three (62.8%) samples grew pathogenic organisms. The most common pathogenic organisms were E coli (30.3%) followed by Enterococcus (21.2%) – in which four were ESBL tagged – Klebsiella (6%) and Staph Aureus (6%). In majority of the patients, the underlying aetiology of ascites was secondary to ALD (68.9%), Malignancy (11.8%) and NASH cirrhosis (11.8%). In this cohort, the overall 30-day survival was 64.2% and 90-day survival was 43.4%. About half mortality occurred during the same admission to hospital.
ConclusionE coli was the most commonly isolated organism. Alcoholic Liver Disease was the most common underlying aetiology in SBP patients. SBP is associated with a high 30-day and 90-day mortality. Isolation of pathogenic organisms was associated with a four-fold higher mortality than non-pathogenic organisms.
-
-
-
Staphylococcus aureus bacteraemia management in a busy London DGH; is early switch to ceftriaxone safe?
More LessBackground:Standard of care for management of Staphylococcus aureus bacteraemia (SAB) is 2-4 weeks intravenous (IV) flucloxacillin or glycopeptide. Ceftriaxone (CRO) is used to facilitate management of SAB under out-patient antimicrobial therapy (OPAT) services once patients are medically stable, however published data on this approach are limited.
Methods:Retrospective review of SAB cases at Homerton Hospital: 1st August 2015 to 31st July 2018. Cases were identified from the microbiology database and clinical data retrospectively collected from electronic patient records.
Results:83 cases of SAB were included. Median age was 56 years (IQR 45-74); 53 (63.9%) were male. 70 (84.3%) had complicated SAB, 4 (4.8%) had MRSA bacteraemia and 11/80 (13.8%) were PVL positive. After excluding patients who died or were transferred whilst on IV therapy; 8/11 (72.7%) uncomplicated SAB patients and 29/55 (52.7%) complicated SAB patients received the standard duration of IV anti-staphylococcal therapy. Median length of stay (LOS) was 32 days (IQR 16-52.5). 30-day mortality was 9.6%; in hospital mortality was 14.5%.
Eight (8/83, 9.6%) patients switched to CRO prior to completion of standard IV flucloxacillin therapy to facilitate OPAT. Median length of IV flucloxacillin in this group was 12 days (IQR 7-16). Ceftriaxone MIC was performed on 1/8 isolates (3mg/L). 7/8 had complicated SAB. Median LOS was 13 days (IQR 9-17). There were no deaths or relapsed infections. 1 patient developed C. difficileinfection on CRO.
Conclusion:In this cohort ceftriaxone was a safe and effective follow-on therapy from flucloxacillin for management of SAB and allowed reduced LOS.
-
-
-
A tricky trochanter
More LessA 24-year-old previously well female presented with a discharging thigh abscess after travel to Ghana. She reported malaise but was otherwise systemically well. Further history revealed 2 years of intermittent left thigh pain, which had been attributed to a large trochanteric bursa identified on ultrasound in 2017. On examination she was afebrile with a deep, undermined ulcer discharging pus in the left antero-lateral thigh. Femoral X-ray was unremarkable.
She underwent surgical debridement and intra-operatively infection was found to track to the greater trochanter. Tissue specimens grew Gemella morbillorum, Klebsiella pneumoniae, Enterobacter cloacae, Streptococcus anginosus and mixed anaerobes. She responded well to 4 weeks of ciprofloxacin, metronidazole and amoxicillin. Histological examination of the ulcer edge revealed non-necrotising granulomata (Ziehl-Neelsen stain negative).Mycobacterium tuberculosis(MTB) was subsequently isolated on mycobacterial culture from the same site. MRI demonstrated osteomyelitis of the greater trochanter with a 2cm intramedullary abscess and an adjacent soft tissue collection. Macroscopically caseous material was found on further debridement and tissue samples were AAFB smear negative but MTB complex was detected by PCR and culture of intra-medullary bone.
This case demonstrates that bacteria and mycobacteria may be co-pathogens, and that M. tuberculosis bone infection may present with no systemic symptoms. It is a reminder of the importance of cross-sectional imaging and mycobacterial culture in deep soft tissue infections with a long or unusual history.
-
-
-
A case of the ‘unusual’ in the ‘usual’
More LessBackgroundOnly five cases of Salmonella paratyphi infective endocarditis (IE) have been previously reported. Two were paediatric patients, one other had an underlying cardiac lesion, and all were living in endemic areas. Here we present the first case of salmonella paratyphi IE in a returning traveller.
CaseA 61 year old Indian born British national with no significant past medical history or recent dental procedures presented with a 4 week history of fever and weight loss following travel to India. Whilst abroad she had a self-limiting episode of diarrhoea with fever for 1 week with no antimicrobials. Three weeks after her return the fever returned (without diarrhoea) and she presented to hospital 4 weeks later.
Examinations findings were; haemodynamically stable, temperature 39.5°C, no splinter haemorrhages, no lymphadenopathy, soft systolic murmur best heard at parasternal edge.
Investigations revealed raised inflammatory markers (CRP 80) and blood cultures grew gram negative bacilli within 24 hours which cultured as Salmonella paratyphi A.
Trans-thoracic Echocardiogram showed echo-bright thickening of the non-coronary cusp of the aortic valve, which was confirmed as a small vegetation (0.5cm x0.2cm) on trans-oesophageal echocardiogram.
IV antibiotics were given for a total of 6 weeks and repeated TOE at 1 month showed a healing vegetation. Repeated imaging is awaited.
ConclusionsThis interesting case in an otherwise healthy patient highlights the need to be vigilant for unusual organisms causing infective endocarditis – a relatively common condition - in returning travellers.
-
-
-
Modernising respiratory diagnostics: the impact of biofire FilmArray pneumonia panel plus and respiratory panel on the detection of viruses and atypical bacteria
More LessBACKGROUND
The incidence of pneumonia is high within our local patient population and it is a significant cause of morbidity and mortality. The adoption of rapid molecular technology enables targeted clinical interventions and the initiation of appropriate antimicrobial and antiviral therapy.
METHOD
From February 2019, all lower respiratory samples submitted for microbiological analysis were examined to assess if a Pneumonia FilmArray would be a suitable investigation; indications for testing included radiological evidence of pneumonia or relevant clinical information suggesting atypical infection. Nasal pharyngeal swabs could be requested by clinicians across the hospital based on presenting signs and symptoms.
RESULTS
In total 883 nasal pharyngeal swabs and 175 lower respiratory tract samples from 927 patients were tested, 514 positive results were obtained; 450 from nasal pharyngeal swabs and 64 from lower respiratory tract samples.
Notably, two Bordetella pertussis and two Legionella pneumophiliaand five Mycoplasma pneumoniae were detected. One of the Bordetella pertussis was confirmed by culture, 9 days after the molecular result and the other case was detected in a neutropenic adult within an oncology, enabling rapif infection control intervention. Both Legionella cases were confirmed with urinary antigen testing, however neither grew on culture.
CONCLUSION
FilmArray technology enables the rapid identification of the causative agents of viral and atypical pneumonia, it is a useful adjunct to traditional testing and it enables rapid clinical and infection control intervention.
-
-
-
Analysis of outpatient and home parenteral intravenous antibiotic therapy (OHPAT) cases at the Newcastle upon Tyne Hospitals NHS Foundation Trust from April 2017 to June 2019
More LessIntroduction and Methods
Newcastle’s OHPAT service has been operating since 2011, providing intravenous antimicrobials on outpatient basis for deep seated infections (DSI) and skin and soft tissue infections (SSTI); either provided at the OHPAT service in hospital (H-OPAT), delivered to the patient’s home (C-OPAT) or self-administered by an instructed patient (S-OPAT). The service aims to reduce admissions and inpatient bed days. Data from a prospective database was analysed to determine bed days saved, admissions avoided, location and success rate of treatment and adverse outcomes.
Results292 patients (174 male, 118 female) median age 54 (range 17– 97) April 2017-June 2019. 148 patients with SSTI and 143 DSI. 140 patients previously treated as inpatients. 141 admissions avoided; 3540 bed days saved; 267 patients treated with H-OPAT; 21 C-OPAT; 4 S-OPAT. High cure rate of 100% in SSTI and 97% in DSI (3 re-admissions, 1 self-discharge). Low complication rate with no death, MSSA/other bacteraemia or CDT-associated diarrhoea. Low complication rate of 0.7%: rash in 1 patient (on ceftriaxone) and line blockage in 1 patient.
ConclusionThe aim of the OHPAT service is equality of effectiveness and safety compared to inpatient care. This has been achieved in the ongoing low rate of complications and adverse outcomes. The service treated a wide range of DSI which contribute a larger proportion of bed days for much fewer cases than SSTI. Significant numbers of hospital stays were avoided or shortened. OHPAT has been able provide complex regimes with home delivered and self-administered dosing.
-
-
-
Unravelling the benefits and barriers to utilising whole-genome sequencing in the investigation of outbreaks
More LessBackgroundThis prospective study was established to develop and evaluate methods to harness pathogen sequencing in the clinical microbiology environment. We describe new insights into the clinical benefits of using whole-genome sequencing (WGS) for outbreak investigation with solutions for the practical barriers to implementation in clinical settings.
Methods
Surveillance software (ICNet) and statistical process control charts (SPCs) detected potential outbreaks of meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), carbapenem-resistant Enterobacteriaceae (CRE), Enterobacteriaceae producing extended spectrum β-lactamases (ESBLs), Listeriaspp. and optrAgene positive enterococci. Isolates were sent to reference laboratories for conventional typing and the Infection Group, School of Medicine, University of St Andrews for WGS (Illumina Inc, San Diego, CA, USA) and bioinformatic data analysis.
ResultsOver 400 isolates have been sequenced to date. WGS replaced multiple typing techniques in a Pseudomonas aeruginosa ICU outbreak. It confirmed two patient’s Listeria spp. isolates were indistinguishable prompting hospital kitchen inspections, identified a patient to be carrying two strains of VRE and confirmed that vancomycin-sensitive Enterococcus faecium isolates related to a VRE cluster. We observed five main barriers to implementing WGS (infrastructure, performance/quality assessment of data, isolate selection, clinical result interpretation and database management).
ConclusionWGS is beneficial in outbreaks of uncommon organisms and when conventional typing cannot show whether isolates are linked or not. Identifying barriers assisted us in developing a clinical decision aid that can be used by clinicians when applying WGS to outbreak investigations.
-
-
-
Demographics of new diagnoses of leprosy in the UK over 23 years: a retrospective study of cases at the Hospital for Tropical Diseases, London
More LessBACKGROUND: Leprosy is rare in the UK, but migration from endemic countries results in new diagnoses annually. Early recognition, diagnosis and treatment can prevent harmful stigma and disability.
METHODS: We conducted retrospective analysis from a database of new cases of leprosy seen at the Hospital for Tropical Diseases, London from 1995 to 2018. We aimed to identify typical demographics of patients presenting with leprosy and identify causes and consequences of delayed diagnosis.
RESULTS: 157 cases were included. A large proportion were male (67.5%) with a median age of 34 years. Most were non-UK born and migrated in adulthood. 41.3% of cases were acquired in India, Sri Lanka or Bangladesh. Borderline tuberculoid (43.9%) was the most common type, followed by lepromatous leprosy (33.8%). The mean time between arrival in the UK and symptom onset was 5.87 years (SD 10.33). It took over 5 years for 12.8% of patients to be diagnosed. 93.6% of patients completed multidrug treatment following diagnosis.
CONCLUSION: Male predominance and age at diagnosis reflects global epidemiology of leprosy. Patterns of acquisition reflect trends in UK migration from endemic countries. The typical patient presenting to the clinician is a young male who has migrated as an adult and developed symptoms in the years surrounding migration. Many patients may have developed disability before treatment commences as the time to diagnosis can be prolonged. Once diagnosed in the UK, treatment is of high quality, readily available, and effective: earlier recognition by clinicians can prevent disability and reduce the risk of transmission.
-
-
-
The Unexpected Streptococcus
More LessWe report a case of Abiotrophia defectiva blood stream infection in a 45 year old male, renal transplant patient. Abiotrophia defectiva is a Gram positive coccus, classified as a nutritionally variant streptococcus secondary to its fastidious growth and culture media requirements. Further testing using the Staph aureus streak method exhibited satellitism, characteristic of this class of streptococci. This species is associated with endovascular infection with high rates of embolization and treatment failure secondary to its inherent resistance to antibiotics. Despite culturing Abiotrophia defectiva from four blood cultures we could not confidently prove underlying endocarditis despite repeated trans-oesphageal echocardiograms separated one week apart. The patient also reported the presence of a PTFE aorto-venous (AV) graft in situ and a brachiocephalic stent which was inserted 4 years ago following complications post-renal transplant insertion. This led to further investigation with FDG PET-CT to help ascertain any possible underlying source of infection. The only tracer uptake was exhibited in this patient’s PTFE AV graft. This prompted surgical removal of the AV graft which did not culture Abiotrophia defectiva. 16S PCR detected the presence of Staphylococcus epidermidis but was unable to detect Abiotrophia. A pragmatic antibiotic regime of 4 weeks of IV Benzylpenicillin 2.4g 4 hourly was used. Gentamicin was avoided in view of his history of renal transplant. A further four week course of oral high dose Amoxicillin was prescribed. Despite this unorthodox antibiotic therapy the patient remains well two months after cessation of therapy.
-
-
-
An Uncommon Infection in Common Variable Immunodeficiency
More LessCryptococcus neoformanscan cause life-threatening disease in both immunocompromised and healthy patients. We report a case of cryptococcal meningoencephalitis in a 68 year old patient with a history of common variable immunodeficiency due to a NFKB1 gene mutation and indeterminate colitis.
Our patient was admitted following a fall where he fractured his left humerus. During his admission, a persistent fever was noted despite broad spectrum antibiotic therapy. His neurological condition deteriorated over four weeks, with impaired cognition progressing to aphasia and obtundation. Following initial concerns over an ischaemic stroke, he was found to be serum cryptococcal antigen positive, and subsequent cerebrospinal fluid analysis confirmed CNS cryptococcosis by culture. His neurological condition improved with combination of liposomal amphotericin and flucytosine and he is currently undergoing rehabilitation.
The NFKB1 mutation is associated with common variable immunodeficiency and hypogammaglobulinaemia. Our patient was on weekly subcutaneous immunoglobulin replacement, but also required long term glucocorticoids (prednisolone 20mg daily) to control his colitis.
To our knowledge, this is the first description of cryptococcal meningoencephalitis in a patient with the NFKB1 mutation. Cryptococcal disease is an important differential diagnosis in immunosuppressed patients with fever and neurological symptoms and full recovery is possible with prompt recognition and treatment.
-
-
-
In vitro activity of fosfomycin, and synergy in combination, against Gram negative bloodstream infection isolates in a UK hospital
Background:Fosfomycin has retained activity against many multi-drug resistant (MDR) Gram-negatives, and may be useful against extended spectrum beta-lactamase (ESBL) producing and carbapenem-resistant Enterobacteriaceae. There are few data from the UK on the susceptibility of invasive Gram-negative isolates to fosfomycin, especially in the era of increasing use of oral fosfomycin for UTIs.
Materials/methods:
1. We evaluated, in 100 consecutive Gram-negative bloodstream infections (BSI), the in-vitro activity of fosfomycin. Disc diffusion and MIC test strip methods applying revised EUCAST guidelines for fosfomycin were used.
2. A secondary objective was testing for synergy in combination with 10 further antibiotics. Isolates were selected if:
a) Fosfomycin resistant
b) AMP-C/ESBL/carbapenemase producers (or carbapenem resistant)
c) ‘MDR’: defined as ‘resistance to ≥3 classes of antibiotics’ (based on prior routine sensitivity testing).
For eligible isolates, MICs were determined individually, and subsequently in combination using the MTS ‘cross’ synergy method.
Results:96/100 isolates were susceptible to fosfomycin by MIC test strip. 30/100 isolates were eligible for synergy testing. Synergy was most commonly detected between fosfomycin and piperacillin/tazobactam (32.1%), ceftazidime/avibactam (30%), and temocillin (28.5%). An additive effect was most commonly detected with aztreonam (85.7%) and meropenem (82.1%), but 100% indifference was found with tigecycline. No antagonism was identified.
Conclusions:Synergistic or additive effects were detected for beta-lactam/fosfomycin combinations in a high proportion of isolates; >80% for all suggesting such combinations should be preferred when using fosfomycin combination therapy. Agents with a different site of antibiotic action, were more likely to result in indifference.
-
-
-
Antibiotics & adjuvant corticosteroids in management of pneumococcal meningitis: a retrospective case-notes audit
More LessBackgroundPneumococcus remains the most common cause of bacterial meningitis with high morbidity and mortality. Adjuvant corticosteroids with early antibiotics have been shown to reduce the neurological morbidity and mortality respectively and this is reflected in British Infection Society (BIS) guidance.
Aim
To assess how closely BIS guidelines were followed regarding antibiotic and adjuvant corticosteroid administration in management of pneumococcal meningitis.
Methods
Newcastle Upon Tyne Hospital case-notes of pneumococcal meningitis from a 7-year-period(2012-2019) were audited. Patients were identified using microbiological records and case-notes. Data was collected on intervals from initial-assessment to commencing antibiotics and corticosteroids.
ResultsEighteen cases were identified of whom three(17%) presented with the classic triad (fever, meningism, reduced GCS). All patients received appropriate antibiotics: 3/18(17%) within first hour of assessment. The median time to antibiotics was 5h 8mins (range:21-7129min). Eight patients(44%) received antibiotics >6h after assessment. Twelve patients(67%) received corticosteroids; only six(33%) at the recommended dose and duration. Mean time from antibiotics to corticosteroids was 6h1min. Five deaths occurred in the cohort with three attributable to pneumococcal sepsis (all had late presentations). 6/18 had significant neurological sequelae, irrespective of whether they received corticosteroids.
Discussion
The significant morbidity and mortality of pneumococcal meningitis demands a high index of suspicion. BIS guideline targets are repeatedly not met; long delays exist between assessment and antibiotic and corticosteroid administration. Integrated electronic prescribing and clinical Early Warning Systems have potential to ameliorate this with meningitis-tailored order sets to prompt consideration of meningitis and guide correct prescribing.
-
-
-
Clostridiodes difficile: Colonisation versus Infection - The importance of appropriate laboratory testing to minimise risk of overdiagnosis and overtreatment
More LessBackgroundClostridiodes difficile (C. difficile) colonisation rates have been reported as ranging from 4-15% in healthy adults to 4-51% in long term care facilities. Inappropriate treatment for C. difficile colonisation alters gut microbiota and can consequently result in C. difficileInfection (CDI). Laboratory testing needs to aid diagnosis while at the same time minimising risk of overdiagnosis and overtreatment.
Methods
An audit was conducted of the number of patients with indeterminate and positive results between 01.09.16 and 31.08.18 to determine the impact of Scottish National C. difficile laboratory testing and CDI case definition Guidance re-inforcement in September/October 2017. A question was also added at sample requesting stage re Pseudomembranous colitis/Toxic megacolon to ensure appropriate testing.
ResultsAfter Guidance re-inforcement, a rapid fall in number of indeterminate results (av. 34/month to 15/month) was observed. Decrease was most marked for GP patients (av. 12/month to 3/month). There was also a decrease in the number of patients with confirmed positive results (av. 9/month to 5/month).
ConclusionAlignment with National Guidance resulted in significant reduction in patient indeterminate and positive results and assisted clinicians in the clinical diagnosis of CDI. There was also a reduction in the number of laboratory tests and repeat tests for indeterminate results. Therefore, this alignment with National Guidance resulted in Infection Prevention and Control Team, clinical and laboratory time and cost savings.
-
-
-
Managing seasonal influenza in hospitalized patients - without an influenza point-of-care test
More LessBackground: National guidelines recommend isolation and commencing empirical antiviral therapy for suspected influenza in the inpatient setting, however this is not always done in practice. There are many reasons why influenza may be diagnosed late, and in order to minimise potential harm, rapid results are therefore required.
Methods: During the 2018-19 influenza season, we instigated a policy of calling out all new influenza positives during normal working hours. As well as informing clinical teams of results, we also recorded clinical information, including whether the patient was:
* isolated,
* already on antivirals,
* discharged (and if so on what therapy)
Results: In the peak season (January 1st - March 31st 2019), 179 calls to clinical teams were made. The median time from sample collection to reporting was 28 hours and 33 minutes. 44% of patients were not on antivirals at the time of the result, and 28% were not isolated. Based on these numbers, we estimated that 141-235 inpatients may have been exposed to influenza on our wards. 25% of a total of 309 positive influenza samples were from patients who were discharged at the time of the result. 65% of these patients were discharged with antibiotics, 54% with antivirals, and 37% with both antivirals and antibiotics.
Conclusion: Based on our data, and that of other studies, we hypothesise that rapid influenza results would lead to better infection control practices, reduced spread of infection, and improved antimicrobial stewardship. Molecular point-of-care tests have the potential to resolve some of the issues with late influenza diagnosis.
-
-
-
Impact of serum procalcitonin on antibiotic stewardship in surgical high-dependency unit and intensive care unit settings
BackgroundProcalcitonin (PCT) testing is used as a biomarker for bacterial infection. We assessed the impact of using a PCT-guided algorithm in Ninewells hospital & Medical School (Dundee, Scotland, UK).
MethodsWe conducted a retrospective analysis of the use of PCT-testing to evaluate the escalation or de-escalation of antibiotic therapy. For this, we analysed patients admitted to the intensive care unit (ICU) and surgical high dependency unit (SHDU) from November 2018 to April 2019.
ResultsWe analysed a dataset of 235 adult patients, 23% of which were at the hospital’s ICU and 77% at the SHDU. Within the ICU, 49% of admitted patients were already on antibacterial therapy, compared to 93% at SHDU. The PCT results influenced the prescription of antibiotics in 33% of total patients (89% and 16% of all ICU and SHDU patients, respectively). Escalation of the antimicrobial therapy was prescribed to 34% of ICU patients after PCT testing, compared to 20% of SHDU patients. Continuation of the previously-established antibacterial scheme was more pronounced in SHDU patients (43% against 23% ICU). In contrast, while discontinuation of the therapy was observed in similar levels on both units (27% SHDU, 28% ICU).
ConclusionPCT has become a useful tool in antimicrobial stewardship. Its use aided the prescription of antibiotics in 33% of the overall total cases in ICU and SHDU. Further work should be carried out to assess its role in other clinical environments.
-
-
-
Real-time Monitoring of Aerosols Generated from Toilet Flushing
More LessFlushing toilets generate visible droplets from turbulent flow, but also produce numerous smaller airborne droplets (∼micrometres in size) through atomisation. Flushing may aerosolise pathogens from stool or urine, spreading disease. This study continuously monitored aerosols in a shared office lavatory over a week using a biological particle detector, the Wideband Integrated Bioaerosol Sensor (WIBS). This instrument monitors individual particle sizes and numbers and identifies fluorescent particles likely to be droplets containing bacteria.
The toilet was a standard wash-down design, (Armitage Shanks), with a lid. No statistically significant variation between fluorescent particle counts was found between periods prior to flushing. Fluorescent particle numbers and intensity increased with toilet flushing, remaining above background for 5 minutes post-flushing on average. Placing the toilet lid down significantly (P<0.001) reduced total and fluorescent particle counts during and after flushing by 30-50%. Lid usage significantly increased (P<0.001) particle diameter from 1.5 μm to 2.1 μm and increased particle fluorescence intensity (P<0.001) during flushing and after flushing, intensity remaining above background for 16 minutes.
This suggests standard lid usage reduces but does not eliminate flush-related bioaerosols. Lid-use changes their characteristics and apparently prolongs their residence time in room air. The aerosol change could represent particle agglomeration by a pressure-related Kelvin effect or particle re-aerosolisation from different surfaces in the toilet rather than exclusively originating from droplet generation. Previous studies reporting the effect of toilet lids have found that they prevent the spread of visible droplets on flushing, however the effect on smaller particles is less clear cut.
-
-
-
Prevention of Nebulised Drug Dispersal using an Extractor Tent
More LessNebulisers convert liquids into a fine mist of suspended particles that are inhalable into the respiratory tract. They are used to deliver drug therapy by the respiratory route, for example bronchodilators, or to aid production of diagnostic sputum samples (sputum induction). On continuous monitoring of biological airborne particles in a respiratory ward over 4 weeks using a biological particle detector (WIBS) the majority of detected particles were attributable to nebuliser therapy. Tents with extractor/filter devices are indicated for infection control purposes in collection of induced sputum from patients with suspected tuberculosis. We tested the efficacy of an extractor tent (Demistifier 2000, Peace Medical) on reducing detectable aerosols from nebulised bronchodilator drugs by continuously monitoring a room outside a tent containing a nebuliser. The mean fluorescent particle count per m3 was 0.63 and 0.31 (equivalent to background levels pre-nebuliser) for nebulised Ventolin and Ipramol, respectively, when they were nebulised within the tent. Removing the tent and nebulising directly into room air resulted in a 2.56×104 and 4.64×104-fold increase in particle concentrations for Ventolin and Ipramol, respectively, over background levels. WIBS monitoring therefore showed 100 % efficacy of the tent in restricting spread of nebulised drug particles. Extractor tents can prevent spread of drug particles from nebulised therapy. The implications of this will be discussed.
-
-
-
Comedones and carbapenems: hydradenitis suppurativa in the OPAT clinic
More LessBackgroundHydradenitis suppurativa (HS) is a chronic inflammatory skin disease. The UK prevalence is estimated at between 1-4%. There is an approximate 3:1 female: male preponderance and it is associated with smoking, obesity, type 2 diabetes mellitus. The pathogenesis of HS is poorly understood. Clinical features vary in extent and the axillae, inguinal and anogenital areas are typically affected. It has a significant impact on quality of life, with high rates of depression amongst sufferers.
Current UK treatment guidelines focus on lifestyle interventions, as well as targeted use of oral antibiotics, however microbiological sampling is usually not helpful. Where these are unsuccessful anti-TNF agents and surgical intervention may be indicated. Despite their absence from these guidelines, there is growing evidence to support the role of intravenous (IV) antibiotics in treating HS. It is not known whether the treatment response seen with IV antibiotics is due to their antibacterial or an anti-inflammatory effect. We present a series of HS patients managed under the OPAT team at University Hospitals of Leicester.
Cases
To date 8 patients have completed treatment (7F/1M). All received at least 6 weeks of therapy with IV ertapenem (+/- teicoplanin). Significant improvement in both clinical signs and symptoms was achieved in all cases. However, disease relapse was seen in three cases after cessation of IVs, requiring additional courses of treatment. Antibiotics were well tolerated with one adverse drug reaction secondary to teicoplanin.
ConclusionIntravenous antibiotics are an effective adjunctive treatment in selected cases of hidradenitis suppurativa.
-
-
-
Online continuous medical education: Diagnosing fungal infections from a distance
More LessBackgroundIncreasing global incidence of serious fungal infections (SFI) requires increasing access to high quality medical mycology education to improve their identification and decrease associated mortality.
MethodsAn online course was developed by two infectious diseases (ID) specialists. The course aimed to improve diagnosis of SFI and was delivered from April-June 2019. The course consisted of 9 online interactive sessions every week. Sessions were streamed by a hospital in Mexico and local participants gather there every week. Other participants connected independently online. Participants took one exam at the start and another after the course was completed. Feedback was collected during the course. A final evaluation of the impact on diagnosis will be collected in October 2019.
ResultsA total of 137 people registered for the course. Registrants were from four different countries, Mexico (126, 92%), Ecuador (9, 6.6%), Australia (1, 0.7%) and Bolivia (1, 0.7%). Mexican participants connected from 15 of the 32 regions (47%) in Mexico and 45 (33%) attended the course at host hospital. Most participants were physicians (76%), 54 were ID specialists and 19 were ID residents. Sixty participants (60/137, 44%) completed the course, with greater completion by those attending in person (33/45, 73%) compared with online attendance (27/92, 29%). The exams results improved 30% after the course. Clinical urgent calls limited attendance.
ConclusionsThis online course allowed a broad geographical participation. Learning as group lead to better completion rates. Recorded sessions will be available on demand and may allow the completion of the course.
-
-
-
A retrospective audit of microbiological sampling for spondylodiscitis at the Royal Devon and Exeter Hospital (RD&E)
More LessIntroduction
Spondylodiscitis is an increasingly diagnosed condition with significant morbidity and mortality. A key aspect of management is a protracted course of targeted antimicrobial therapy, ideally tailored to the organisms isolated from appropriate microbiological specimens in accordance with Infectious Diseases Society of America (IDSA) guidelines (2015). When consulted regarding possible discitis, we routinely recommend blood cultures and disc biopsy, particularly if blood cultures are negative.
MethodWe undertook a retrospective audit of patients presenting over 6 years with a radiological diagnosis of discitis with the primary objective of determining the proportion of patients who had appropriate microbiological investigation either via blood culture or biopsy.
Results42 patients met the inclusion criteria. Blood cultures were positive with organisms likely to be the causative agent in 50% of patients. Of the 50% of patients with negative blood cultures, 57% went on to have a successful spinal biopsy. Biopsies proved positive in 75% of cases. 8 patients with negative blood cultures did not progress to biopsy at the time of diagnosis and four suffered some degree of harm. One of these patients failed empirical anti-staphylococcal therapy and later required spinal stabilization due to destruction of the spinal disc was proven to have pseudomonas infection at the time of the corrective surgery.
Conclusion19% of patients with discitis did not have appropriate disc sampling prior to commencement of antibiotic therapy. 50% of these suffered some degree of harm. This strengthens the case for recommending appropriate sampling prior to initiation of therapy, unless absolutely contraindicated.
-
-
-
Pneumococcal 13-valent polysaccharide vaccination (PCV13) response in patients with pulmonary aspergillosis
More LessBackgroundResponse to pneumococcal 23-valent polysaccharide vaccine (PPV23) is poor in patients with pulmonary aspergillosis, pneumococcal 13-valent polysaccharide vaccine (PCV13) is believed to be more antigenic. Thus practice at the national aspergillosis centre (NAC), Manchester University NHS foundation trust (MFT) is to give PCV13. However, response to PCV13 has not been studied.
Methods
We conducted a retrospective, observational study of patients with pulmonary aspergillosis at the NAC, MFT. Patients who had non-protective pre-vaccine levels, and received PCV13 between January-2015 and July-2019 with serology available within 3 months after vaccination were included.
Serotype-specific pneumococcal IgG antibodies were quantified for 12 pneumococcal serotypes. Non-protective immunity was defined as pre-vaccine level <0.35μg/mL to > 6 out of 12 serotypes. Protective response was defined as level >1.3μg/mL, or an increase in concentration ≥4-fold for at least 9 of 12 serotypes within 3 months.
Results47 of 144 patients receiving PCV13 had non-protective pre-vaccination levels and repeat serology within 3 months post-vaccination. 52% and 20%, of patients who received 2 and 1 doses (respectively) developed protective immunity; χ2(1)=2.987,p= 0.084. 42.86%, 69.23%, 42.86%, 50%, and 0% of patients with chronic pulmonary aspergillosis (CPA), allergic bronchopulmonary aspergillosis (ABPA), severe asthma with fungal sensitisation, aspergillus bronchitis, and mixed ABPA and CPA developed protective immunity; χ2(4)=6.329,p=0.176.
ConclusionPatients with CPA respond poorly to PCV13 compared to ABPA. Response to two doses of PCV13 is comparable to one dose of PPV-231. Patients with pulmonary aspergillosis should receive two doses of PCV13 rather than one dose.
-
-
-
Sanitisation effects of selected medicinal plant extracts against Escherichia coliO157:H7 and Salmonella enterica subsp.enterica(Serovar Typhi) on Malus pumila Mill. fruit surfaces
More LessRaw fruit and vegetables have become a major risk factor for diarrhoea outbreaks across the world. Salmonella enterica and Shiga toxin-producing Escherichia coli account for 21% and 10% of all diarrhoeal outbreaks around the globe. Despite these statistics, the quantitative risk of consuming RTEFV remains unknown. The potential utility of medicinal plant extracts as disinfectants of RTEFV has remained unexplored. This study sought to assess the efficacy of extracts of Vernonia amygdalina and Ximenia caffra in the removal of Salmonella typhi and E. coli on Malus pumilaMill. fruit surfaces. Two-cm2 square sections of apple epidermal tissues from apples spiked with S. typhi and E. coli were soaked in prepared extracts for 90 minutes. Microbial loads on washed surfaces were determined using conventional agar plate based techniques. Washing of apple surfaces with ethanolic extracts of freshly crushed leaves of X. caffra (X-FLEE) and dry leaves of V. amygdalina (V-DLEE) achieved at least 7 log reductions in counts of E. coli and S. typhi without changes in surface morphology and colour. The selected extracts were shown to be rich in alkaloids, tannins and flavonoids, which are known to harbour antimicrobial activities (inhibitory and cidal effects). Extracts from the selected plants, especially ethanolic extracts of X. caffra and V. amygdalina have potential as sanitisers of apples against diarrhoeagenic E. coli and S. typhi. We therefore recommend the use of ethanol as a solvent of choice in obtaining plant extracts for use-, as well as the use of as well as vinegar, chlorinated water or bicarbonate of soda as sanitisers of fresh apple surfaces.
-
-
-
Teicoplanin therapeutic drug monitoring (TDM) – excessive or essential?
More LessBackground:Teicoplanin is a glycopeptide antibiotic which is frequently used in preference to vancomycin because it does not require such regular TDM as the association between concentration and toxicity has not been fully established. TDM is however, recommended to help optimise therapy in some patients. In our hospital there was an observation of frequent sub-therapeutic levels which prompted an audit of TDM results.
Methods:Retrospective review of TDM results August 2015- March 2017 at Homerton Hospital with analysis of dose, renal function, patients’ weight and type of infection.
Results:We analysed 54 samples from 33 patients. The most common dose was 600 mg OD which equated to a mean dose of 8.68 mg/Kg with under-dosing in all weight groups but with lowest levels in the group between 110-120 Kg. A 24hr dosing regimen was the most common and other dosing regimens (48hrly or 72hrly) more frequently associated with sub-therapeutic levels.
Overall, the mean level was 27.8 +/- 11.9 mg/L but 41% (n=22) of levels were sub-therapeutic for the type of infection treated including 4 patients with bacteraemia, 7 patients with bone and joint infections (n=10 samples) and 3 patients (n=6 samples) with prosthetic joint infections. There was only one patient with teicoplanin levels >60 mg/L who was on treatment for a streptococcal endocarditis. She did not report any side effects.
Conclusion:The current dosing regimen recommended by the BNF frequently results in sub-therapeutic levels. TDM is essential in managing complex infections to ensure therapeutic levels are achieved.
-
-
-
In-house azithromycin MIC estimation by gradient strip in Salmonella enterica var Typhi and Paratyphi: Do you believe it?
More LessBackground: Dependence upon azithromycin in the treatment of enteric fever is increasing, particularly with the emergence of Salmonella typhi strains with extended spectrum β-lactamase activity and the already high prevalence of quinolone resistance. Accurate determination of azithromycin susceptibility is crucial and underlined by recent reports of azithromycin resistance. We investigated concerns of discordance in azithromycin susceptibility estimation between local and reference laboratories.
Methods: Retrospective audit of isolates from patients attending a central London hospital with enteric fever (May 2011-April 2019). Estimations of azithromycin and ciprofloxacin MICs by the local and reference laboratories were compared. Genomic data and laboratory practices were reviewed.
Results: In isolates with matched clinical and reference laboratory MICs (n=19), there was poor inter-laboratory concordance: 5/19 MICs concordant (weighted κ = 0.190, adjusted for concordance within 1 log2 dilution); susceptibility interpretation concordant in 8/19 (κ=0). All isolates reported locally as resistant were found to be sensitive by the reference laboratory. No azithromycin resistance genes were detected. By contrast, for ciprofloxacin: 13/18 MIC gradient strip results concordant (weighted κ=0.823); susceptibility interpretation concordant in 17/18 (κ=0.85). Of the possible sources of variation identified, we believe that variable interpretation of “trailing edge” MIC estimation was key, mitigated in the reference laboratory by a “second reader” system.
Conclusions: There is marked variation in azithromycin MIC gradient strip reporting between a local laboratory and the national reference laboratory, particularly over-reporting of resistance by the local laboratory. We would advise clinical laboratories to review their experience and consider adopting a “second reader” system.
-
-
-
Nucleic acid amplification tests (NAATs) for diagnosing sexually transmitted infections (STIs): NHS Grampian (NHSG) experience
More LessBackground:We present 2 studies conducted on Chlamydia trachomatis(CT) and Trichomonas vaginalis(TV) testing in NHSG, leading to streamlining of NAATs of Neisseria gonorrhoeae, CT and TV in triplex.
Methods:Formerly, positive CT-NAATs needed confirmation by repeat testing on the same sample using same platform. According to SMI guidelines, when confirmatory testing results are consistently concordant following audit, confirmation may be unnecessary. CT testing over 3 years (2015-2017) was analysed to review outcomes of confirmatory testing.
A pilot study was conducted on TV-NAAT testing in comparison with TV-microscopy. In addition, TV testing data over 30months (29/07/2016-31/01/2019) was analysed.
Results:A total of 88533 samples were tested for CT-NAAT over 3 years: 7059 were positive, 81321 negative. A total of 153 were equivocal (initially positive, negative on repeat) which were reanalysed with results on receival of repeat samples. Over the years, percentage of equivocal tests out of the total positives remained at 0.2%; rates for positive-repeats and tests-not-repeated fluctuated; negative-repeats increased from 18 to 38.
TV-NAAT was more sensitive/ specific compared to TV-microscopy (relative specificity was 99.6%, relative sensitivity was 92.8%), and was adopted for routine testing. A total of 44407 samples were tested for TV NAATs over 30 months. Of this, 433 were positive and 43796 negative. Further cross-sectional analyses were done.
Conclusions:We concluded that positive CT-NAATs do not require repeat testing for confirmation. TV-NAAT testing proved more sensitive/specific than TV-microscopy and was useful to adopt as routine testing and help streamlining testing on one molecular platform.
-
-
-
Susceptibility of microorganisms isolated from otitis media pus to cigarette capsule and Nicotiana tabacum
More LessOtitis media is a perforation of the middle ear caused by pathogenic microorganisms which leads to hearing impairment. There is a need for alternative methods to the use of antibiotics in combatting the impairment owing to the challenge of antibiotics resistance. This study is aimed at identifying and determining susceptibility pattern of bacterial isolates from otitis media patients to cigarette capsule and Nicotiana tabacum extract. Forty eight samples were collected from a tertiary hospital in Abeokuta Ogun state- 28 (58.33%) from males and 20 (41.67%) from females with highest occurrence in children below the age of 5 (60%).Klebsiella pneumonia, Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus pneumoniaeandProteus mirabiliswere isolated. The two different products of cigarette capsules used showed significant (P < 0.05) zones of inhibition onPseudomonas aeruginosa and Streptococcus pneumonia respectively. Results also revealed that Nicotiana tabacum extract had significant effect (P < 0.05) onKlebsiella pneumonia, Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureusandStreptococcus pneumonia at 0.5 mg, 1.0mg and 2.0mg. This study shows the antibacterial activity of Nicotiana tabacum methanolic leaf extract making it a promising raw material in the production of new classes of antibiotics against otitis media infection.
-
-
-
Necrotizing Otitis Externa: Four theories behind the 15-year astronomic rise of this uncommon infection
More LessINTRODUCTION:NECROTIZING OTITIS EXTERNA (NOE) IS A SEVERE, LIFE THREATENING PROPAGATING OSTEOMYELITIS OF THE SKULL BASE THAT ORIGINATES FROM A SEVERE OTITIS EXTERNA. THIS RARE CONDITION MAY NOT BE AS UNCOMMON AS ONCE UNDERSTOOD. EPIDEMIOLOGIC DATA REVEALS AN UNEXPECTED AND DRASTIC RISE IN THE NUMBER OF REPORTED CASES OVER THE LAST 15 YEARS. USING NATIONAL DATA AND PUBLISHED LITERATURE, WE EXPLORE FOUR THEORIES BEHIND THE RISE IN INCIDENCE OF THIS CONDITION.
Methods:A quantitative descriptive study was undertaken using epidemiological data obtained from the Hospital Episode Statistics (HES) database. NOE cases reported between 2002 – 2017 were compiled and analyzed. Using these results and current evidence within the published literature, four theories were formulated and explored to explain the upward trend in incidence.
Results:There were a total of 7,327 NOE cases reported within the 15-year time period. The majority of cases (60%) occurred in the elderly (Age 75+) with a 5:2 male predominance. Mean length of stay and mean total bed days were 16.3 and 5,019 days, respectively.
Discussion:The number of NOE cases has increased by more than 1000% within the 15-year time period, from 123 cases in 2002 to 1,405 in 2017. We theorize that this increase maybe due to:
(1) the rising prevalence of diabetes
(2) the increase in antibiotic resistance
(3) the rising ageing population
(4) improved physician awareness of NOE
-
-
-
The Reliability of C-Reactive Protein Levels in Predicting Dengue Severity: A Systematic Review
BackgroundClinical manifestations of dengue vary from mild febrile illnesses to shock and organ failure. However, severe symptoms may not be clinically evident immediately, making it difficult for early detection of patients at risk for poor outcomes. Several biomarkers, particularly C-reactive protein (CRP), were revealed to be highly predictive of dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS). This systematic review aims to determine a relationship between CRP levels and the probability of developing DHF/DSS.
Methods
Multiple electronic databases were searched for English literature from January 2007 to August 2017. Four reviewers independently extracted data from eligible studies using the standardized critical appraisal tool from JBI-MAStARI. Articles that scored six and above were included.
ResultsThree cohort and two cross-sectional studies were reviewed. Sample sizes ranged from 70 to 235 participants. The cohort studies measured CRP levels at point of diagnosis, but were re-measured at different time points in the subjects’ admission. However, regardless of the time difference, they all showed that increased CRP levels exhibited a trend towards development of DSS/DHF. The studies also identified a possible “golden period” for measuring CRP levels that can accurately predict development of DHF/DSS. The cross-sectional studies also saw a similar trend, but have measured this in median values of the CRP levels.
ConclusionThis systematic review showed that increased CRP levels appeared to have a trend towards a higher probability of developing DHF/DSS. A larger population and more studies are needed to further establish a statistically significant relationship.
-
-
-
Haemophagocytic lymphohistiocytosis secondary to disseminated adenovirus infection twenty-five years post heart-lung transplant
More LessDisseminated adenovirus infection is recognised in transplant patients, often occurring early and associated with a high mortality rate. Treatment options are poorly understood and potentially toxic. Haemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyper-inflammatory response.
A 75-year-old ex-banker presented following a fall, with a 2-week history of fevers, cough and high stoma output after a recent cruise. Past medical history included heart-lung transplant (25 years previously), diverticular disease and diabetes mellitus. Initially, he was febrile and tachycardic and blood tests showed an acute kidney injury (AKI), transaminitis and pancytopenia. Chest radiograph and urinalysis were unremarkable. Initial treatment was with co-amoxiclav and intravenous fluids for neutropenic sepsis. Computerised tomography of thorax and abdomen showed moderate splenomegaly with no lymphadenopathy or pneumonitis.
After 48 hours, he remained febrile with worsening renal and hepatic function. Nasopharyngeal swabs returned positive for adenovirus. Blood cultures were negative with undetectable serum cytomegalovirus (CMV) and Epstein-Barr virus (EBV) DNA.
On day 4 he developed fulminant multi-organ failure. Further investigations were suggestive of HLH. Cidofovir/Brincidofovir were discussed as potential treatments but were difficult to obtain with concern regarding toxicity. On day 6, intravenous immunoglobulins for HLH was commenced. On day 8 he died. Adenovirus was later isolated from urine, stool and serum samples.
Early diagnosis and treatment for infection in immunosuppressed patients is crucial. The 25-year interval between transplant and disseminated adenovirus infection in this case is unprecedented. Difficulty in obtaining adenovirus treatment combined with their toxicity and uncertainty of effectiveness prevented their immediate use in this patient.
-