bluuebunny/crossref_metadata_2025 huggingface dataset:
715 Early Ambulation for Enhanced Recovery After Burn Surgery: A Systematic Review and Meta-analysis
Authors: Lagziel Tomer , Ramos Margarita , Klifto Kevin M , Steal Stella , Caffrey Julie , Hultman C Scott , Asif Mohammed
Published: March 2020

Introduction

Accurate models are a fundamental prognostic tool for risk stratification, therapy guidance, resource allocation, and comparative effectiveness research. Enhanced recovery after surgery protocols are developed to increase early post-operative recovery rates in surgical patients. Due to the unique nature of burn injuries and post-operative care, there is a need to develop a protocol unique to burn surgery, enhanced recovery after burn surgery.

Methods

The PubMed, Embase, Cochrane, and Web of Science databases were systematically searched. Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) and Cochrane guidelines were strictly followed throughout the study. Search terms were utilized to capture the relevant studies relating to early ambulation of adult burn patients (>18 years of age) and their post-surgical outcomes such as graft take, time to discharge, pain levels, VTEs, and length-of-stay.

Results

Thirteen of 888 studies retrieved from the search query were eligible for systematic review and meta-analysis. Patients with delayed ambulation, after 5 or more days were found to have increased pain levels at rest (p=0.02) and when ambulating (p=0.08). One study found an increased infection rate in late ambulatory patients (p=0.22). Most results from studies did not have significant data that was relevant to our extraction. For example, only one study assessed pain levels and only three studies notes zero venous thromboembolisms (without statistical significance).

Conclusions

Limited evidence exists relating to thromboembolic events and time-to-ambulation in post-operative burn patients. There are no significant differences in the number of events between early and late ambulation groups. Early ambulation should be included as part of the ERABS protocol for lower risks of hospital-acquired infections due to shorter lengths-of-stay. Decreased associated pain levels could lead to decreased risk for opioid dependence. Due to limited literature references, these conclusions are immature and more studies should be performed in order to develop more accurate and effective protocols.

Applicability of Research to Practice

Burn surgery recovery patients are unique. Therefore, specialized protocols must be developed to enhance their post-operative care.
720 Scalds and Contact Burns: Are They Really Different?
Authors: Singer Adam , Baer Evyatar , Thode Henry
Published: March 2020

Introduction

Prior studies comparing scalds and contact burns rarely address the affect of burn etiology on burn depth. However, it is commonly believed that scalds tend to heal faster than similarly sized contact and flame burns. As a result, expectant therapy is often preferred after scald injuries. We compared the percentages of full-thickness burns based on burn etiology controlling for burn size, location and patient age. We hypothesized that the percentage of full thickness burns would be lower after scalds compared with contact and flame burns.

Methods

We performed a retrospective chart review of a prospectively collected burn registry of all patients admitted to a regional burn center between 2000–2010. Data collection included patient and burn characteristics including age, gender, body location, and burn etiology. We compared the percentages of full thickness burns among scald, contact and flame burns using Chi-square tests. Stepwise logistic regression was used to adjust for age, location, and burn size.

Results

There were 1038 patients in the study with either scald (n=537, 52%), fire/flame (n=434, 42%) or contact (n=67, 6%) burn. Mean (SD) age was 29 (25); 75% were male. Mean (SD) total body surface area (TBSA) was 11 (13)%. Mean (SD) length of stay was 10 (18) days. The percentages of full thickness burns by etiology were scalds 13.1%, fire/flame 34%, and contact burns 45% (P< 0.001). Patients with scalds were younger (22+/-24) than patients with contacts (32+/-28) and fire/flame (38+/-22) burns. Multivariate analysis for predicting full thickness burns found that compared with contact burns, scalds were less likely full thickness (OR 0.23, 95%CI 0.11–0.48) while fire/flame burns were as likely to be full thickness (OR 0.54, 95%CI 0.26–1.15). TBSA and age were also associated with full thickness burns (OR 1.06, 95%CI 1.04–1.09 and OR 1.015, 95%CI 1.007–1.024, respectively). Burns on the head and neck were less likely to be full thickness (OR 0.30, 95%CI, 0.11–0.82).

Conclusions

Scald burns are significantly less likely to be full thickness than contact or fire/flame burns.

Applicability of Research to Practice

Based on these results, expectant therapy may be more appropriate for scalds than contact or fire/flame burns.
735 Advantages of Biocellulose for Burn Injures
Authors: Sanches-Pinto Debora C , Mota Wellington M , Gomez David S , Gemperli Rolf
Published: March 2020

Introduction

Facial burns are extremely important biological dressings have been developed as temporary substitutes for human skin to avoid infection and accelerate tissue repair, with comfort to the patient. The biocellulose film is produced by the bacterium Acetobacter xylinium. After dehydration process, the obtained product turns into a film. We also use the celluloses film hydrated. Aim: To show the experience of the use of a biocellulose membrane in our hospital, for facial superficial second degree burns.x’x’

Methods

This study took place from January 2009 till December 2017. We selected forty five patients with facial superficial second degree burns treated with a biocellulose film since day one post burn. It remained on the face until the complete epithelialization and spontaneous detachment. We studied 45 patients (25 children and 20 adults). We evaluated the final healing time, the pain, the dressing changes and the facility of application (notes from 0 to 10).

Results

The evaluation note for the ease of application varied from 7 and 8 (40%) and 9 to 10 (60%). We saw spontaneous detachment of the dressing in all cases till day 10. The grade of pain varied from 0 to 2. After day 4 no one referred pain. The full epithelization occurred in 8 days in 90% of children and in 10 days in the other 10% of the children. The restoration in the adults followed t the same pattern.

Conclusions

The biocellulose dressing seems to be a good option for superficial facial burns. It is painless, easy to apply and has a good cost benefit relation. The authors suggest longer randomized studies.

Applicability of Research to Practice

New technologies that are cheape, less painfull and efective can be of a great value not only for us but for everyone who work with burn patients.
744 Shrove Tuesday Related Injuries in Children, 8 Years’ Experience of Single Paediatric Burns Centre
Authors: Bednarz Bartlomiej , Thakkar Mehul , Sen Sankhya
Published: March 2020

Introduction

Shrove Tuesday, also known as Pancake Day is one of the Christian traditions in many countries and marks the beginning of Lent. Many families cook pancakes together by frying batter. It is considered to be a fun and simple activity. Children often get heavily involved. This creates a danger of pancake related burn injuries. We have noticed a significant number of burns around Pancake Day and herein report our observed epidemiology of these injuries.

Methods

Burns admissions/assessments during the period around Shrove Tuesday were identified from our burns database over an eight year period (2011–2019). Pancake related injuries were identified and then reviewed to look for commonalities.

Results

52 patients were identified. The age ranged from 20 months to 15 years (average 5.94 years, median 6, mode 3). 50 (96.1%) of these injuries were contact burns with pan/hob. The remaining 2 (3.9%) were minor scalds form hot oil. 47 patients (90.3%) had burns localised to the hands. 16 (30.7%) patients had burns involving the index finger, which was usually an isolated injury. 14 (26.9%) patients were burnt whilst trying to toss the pancake. The average age of the patient differed depending on the causative mechanism: 3.63 years for touching hob, 5.71 years from touching the frying pan, 7.21 years for burns associated with pancake tossing. The average burn size was 0.2% TBSA. None required admission, excision or grafting.

Conclusions

This research consolidates the knowledge about Shrove Tuesday related injuries in children: the need for close supervision of children in kitchen is highlighted. The causative mechanism changes as children grow up.

Applicability of Research to Practice

This knowledge can be used in targeting prevention strategies and campaigns, particularly at the beginning of Lent.
846 Effects of Ceragenins on Pseudomonas Aeruginosa Biofilm Formation in Burn Wounds in a Porcine Model
Authors: Savage Paul B
Published: March 2020

Introduction

Damage from burn wounds compromises the protective function of the skin, increasing susceptibility to bacterial and fungal infections and sepsis. Pseudomonas aeruginosa is commonly infects burn injuries and is associated with high morbidity, especially in large total burn surface area injuries. Silver sulfadiazine (SSD), the standard topical antimicrobial used for burn wounds, has been associated with irritation, scarring and other adverse effects creating a need for alternative treatment options. Ceragenins are small-molecule mimics of endogenous antimicrobial peptides. In this pilot study, two ceragenins, CSA-44 and CSA-144 were assessed for their ability to reduce P. aeruginosa in a porcine burn wound model.

Methods

One pathogen-free female pig was appropriately prepared and 48 burn wounds were generated, under general anesthesia, on the back and flank area by direct contact with a heated brass rod. Wounds were inoculated with P. aeruginosa and biofilm was allowed to form for 24 hours. Four of the wounds were analyzed 24 hours post inoculation to establish baseline bacterial counts. R emaining wounds were treated with a vehicle control, SSD (positive control) or formulations of CSA-44 and CSA-144 in gel, cream and aqueous forms. After 7 days of treatment, tissue samples from the wounds were excised and bacterial counts were determined (colony forming units per milliliter of tissue). Percent decreases in bacterial counts were evaluated for each wound. The wounds were also observed for erythema and irritation over the course of the study.

Results

The greatest reductions in bacterial counts after treatment were seen in wounds treated with aqueous CSA-44 at 0.05 % (99.6% reduction) and aqueous CSA-144 at 0.05% (98.4% reduction), which were both greater than the bacterial reductions seen in wounds treated with SSD. Additionally, after the second day of treatment, wounds treated with aqueous CSA-44 and CSA-144 showed reduced erythema, while wounds treated with SSD continued to show swelling and redness.

Conclusions

This study demonstrates the effective antimicrobial action of aqueous formulations of ceragenins CSA-44 and CSA-144. The bacterial reduction seen with aqueous CSA-44 and CSA-144 were greater than the positive control (SSD). Furthermore, treatment with CSA-44 showed reduced signs of irritation, which were not observed with SSD. Even within this small sample size, the superior antimicrobial ability of ceragenins, without the negative effects of SSD becomes apparent.

Applicability of Research to Practice

Ceragenins provide a means of replacing endogenous defenses against infection in burn wounds.
Feature-based translation of CAD models with macro-parametric approach: issues of feature mapping, persistent naming, and constraint translation
Authors: Safdar Mutahar , Jauhar Tahir Abbas , Kim Youngki , Lee Hanra , Noh Chiho , Kim Hyebin , Lee Inhwan , Kim Imgyu , Kwon Soonjo , Han Soonhung
Published: March 2020

Feature-based translation of computer-aided design (CAD) models allows designers to preserve the modeling history as a series of modeling operations. Modeling operations or features contain information that is required to modify CAD models to create different variants. Conventional formats, including the standard for the exchange of product model data or the initial graphics exchange specification, cannot preserve design intent and only geometric models can be exchanged. As a result, it is not possible to modify these models after their exchange. Macro-parametric approach (MPA) is a method for exchanging feature-based CAD models among heterogeneous CAD systems. TransCAD, a CAD system for inter-CAD translation, is based on this approach. Translators based on MPA were implemented and tested for exchange between two commercial CAD systems. The issues found during the test rallies are reported and analyzed in this work. MPA can be further extended to remaining features and constraints for exchange between commercial CAD systems.
Relative Insect Frequency and Species Richness on Sun-Exposed and Shaded Rabbit Carrions
Authors: Mashaly Ashraf , Mahmoud Ahmed , Ebaid Hossam
Published: March 2020

On rabbit carcasses (Oryctolagus cuniculus L.) exposed in open and shaded habitats, the relative abundance of insects and species richness were observed. The decomposition process was classified into four stages: fresh, bloated, decayed, and dry. Except for the decayed stage, the elapsed time for each stage of decomposition was similar between open and shaded habitats, with all carcasses reaching dryness in 13 and 14 d, respectively. In total, 2009 insects were collected during the decomposition process with 1,863 flies belonging to seven families and 15 species, and 146 beetles belonging to six species and three families. Insect abundances rose between the fresh and decay stages. The dominant families of insects included Calliphoridae and Muscidae (80.9% of the collected insects) and accounting for 38.07% of the species richness, whereas Histeridae accounted for 4.3% of the collected insects and 14.29% of the species richness. The open habitat attracted 1,233 insects belonging to 18 families, including 1,142 flies and 91 beetles, whereas the shaded habitat attracted 776 insects belonging to 18 families, including 721 flies and 55 beetles. Diversity level and ratios of exclusive species are also reported for each habitat (open 61.4%; shaded 38.6%). Between habitats, there were substantially separate insect communities, however. In addition, there was a substantial difference in the insect number and species between decomposition stages. This study demonstrates that the exposure status needs to be evaluated and examined when estimating the time since death.
Using GARDEN-NET and ChAseR to explore human haematopoietic 3D chromatin interaction networks
Authors: Madrid-Mencía Miguel , Raineri Emanuele , Cao Tran Bich Ngoc , Pancaldi Vera
Published: March 2020

We introduce an R package and a web-based visualization tool for the representation, analysis and integration of epigenomic data in the context of 3D chromatin interaction networks. GARDEN-NET allows for the projection of user-submitted genomic features on pre-loaded chromatin interaction networks, exploiting the functionalities of the ChAseR package to explore the features in combination with chromatin network topology properties. We demonstrate the approach using published epigenomic and chromatin structure datasets in haematopoietic cells, including a collection of gene expression, DNA methylation and histone modifications data in primary healthy myeloid cells from hundreds of individuals. These datasets allow us to test the robustness of chromatin assortativity, which highlights which epigenomic features, alone or in combination, are more strongly associated with 3D genome architecture. We find evidence for genomic regions with specific histone modifications, DNA methylation, and gene expression levels to be forming preferential contacts in 3D nuclear space, to a different extent depending on the cell type and lineage. Finally, we examine replication timing data and find it to be the genomic feature most strongly associated with overall 3D chromatin organization at multiple scales, consistent with previous results from the literature.
In-Hospital Illicit Drug Use and Patient-Directed Discharge: Barriers to Care for Patients With Injection-Related Infections
Authors: Eaton Ellen F , Westfall Andrew O , McClesky Brandi , Paddock Cayce S , Lane Peter S , Cropsey Karen L , Lee Rachael A
Published: March 2020

Background

Hospitalized persons who inject drugs are at a greater risk of adverse hospital outcomes including discharge against medical advice, inpatient illicit drug use, overdose, and death. However, there are limited data on the frequency and outcomes of these events in the United States.

Methods

This retrospective analysis included patients with injection-related infections receiving a protocol for injection drug use (IDU) at University of Alabama at Birmingham Hospital from 2016 to 2017. In-hospital IDU was suspected or reported drug usage plus confirmatory drug screen, and documented discharges “against medical advice” were deemed patient-directed discharges (PDD). We analyzed the frequency of and associations between in-hospital IDU, PDD, 30-day readmission, and deaths (between 2016 and 2019) using McNemar’s tests. Logistic regression models evaluated the association between PDD, in-hospital IDU, readmission, and death.

Results

Overall, 83 patients met inclusion criteria: 28 (34%) with in-hospital IDU, 12 (14%) PDD, 9 (11%) died, and 12 (14%) 30-day readmission. In-hospital IDU was significantly associated with PDD (P = .003), 30-day readmission (P = .005), and death (P = .0003). Patient-directed discharges and 30-day readmission were not significantly associated with death nor with each other.

Conclusions

In a cohort of patients receiving inpatient care for injection-related infections, illicit drug use, PDD, 30-day readmissions, and death were common. Furthermore, patients who use illicit drugs while hospitalized are significantly more likely to leave early, be readmitted, and/or die. We must design models of care that prevent adverse outcomes, including drug use and PDD, to reduce barriers to evidence-based treatment of infections.
Effect of expanding nanocellulose sponge on nasal mucosal defects in an animal model
Authors: Kim Ji Won , Woo Kyungbae , Kim Jeong Mi , Choi Mi Eun , Kim Young-Mo , Yang Su-Geun , Shim Bong Sup , Choi Jeong-Seok
Published: March 2020

Nanocellulose has emerged for a wide range of applications in biomedical engineering because of its water absorption capacity, appropriate elasticity. We investigated the hemostatic and regenerative abilities of an expanding polyvinyl alcohol (PVA)-nanocellulose sponge on nasal mucosal defects. A 3 mm-diameter nasal defect was made in experimental rabbits. Rabbits were divided into four groups with control, vaseline, PVA and PVA-nanocellulose packing groups. After the defect was created, bleeding times and amounts were monitored. Packing materials were removed on experimental day (ED) 2. On ED 3, 7 and 14, histological analysis and immunohistochemical study for neutrophils were performed. Inflammatory cells were counted and epithelial thicknesses were evaluated. Bleeding amounts and times in the vaseline packing group were smaller than in the PVA groups. PVA-nanocellulose group showed less neutrophils than in the other groups on ED 7. Average epithelium thickness in the PVA-nanocellulose group was significantly smaller than in the control group at ED 7, but at ED 14, there was no significant intergroup difference. PVA-nanocellulose group had a significant lower inflammatory cell count than the control group on ED 7. PVA-nanocellulose sponge applied to nasal mucosal defects can significantly enhance mucosal regeneration during early wound healing.
Investigating the microbial composition of Recurrent Vulvovaginal Candidiasis samples and biofilm formation of Candida clinical isolates
Authors: McKloud Emily , Sherry Leighann , Kean Ryan , Delaney Christopher , Metcalfe Rebecca , Ramage Gordon
Published: March 2020

Recurrent vulvovaginal candidiasis (RVVC) is a chronic and debilitating condition that is estimated to affect 138 million women annually. In spite of this high prevalence and its associated economic burden, pathogenesis of disease is poorly understood. The biofilm-forming yeast Candida albicans is reported as the causative pathogen in up to 90% of VVC cases and around 50% in RVVC disease. Despite the identification of Candidabiofilms on the vaginal mucosa, their associated therapeutic challenge in RVVC is still disputed.

A panel of 100 HVS and cervico-vaginal lavage (CVL) samples were obtained for this trial. Patient questionnaires collected data on patient’s vaginal thrush history, treatments and any contraception currently used. Microbiological screening of clinical samples was performed, and microbiome analysis was utilized to determine predominant microbes present in each cohort.

Non-C. albicans species (NCAS) such as intrinsically azole-resistant C. glabrata were found to account for 27% of RVVC cases, notably higher than historically reported. Additionally, microbiome analysis showed a reduction in Lactobacillus species associated with a healthy microbiome in RVVC compared to health.

This study supports a previous clinical trial by our group using 300 HVS to investigate the epidemiology of RVVC showing an increasing prevalence of NCAS responsible for disease. Additionally, this work strengthens the hypothesis that formation of Candida biofilms on the vaginal mucosa could negatively impact clinical treatment. Further research to identify triggers for RVVC, and the pathogenesis of the predominant microbes involved, could considerably improve prevention and treatment options for women with recurrent, azole-resistant infections.
Hepatitis E diagnostics: immunocompetent and IgM-negative implies PCR negative
Authors: Skittrall Jordan , Jalal Hamid
Published: March 2020

Hepatitis E virus has, over the past few years, been increasingly recognised as a cause of acute hepatitis in the western world. The first hepatitis E Standard for Microbiology Investigations (SMI) was issued in November 2018 and recommends cascading testing in immunocompetent individuals, with RNA assays clarifying results of antibody assays. We investigated all clinical samples tested for hepatitis E in our regional laboratory between October 2014 and October 2018 (12671 IgM, 10738 IgG and 2290 RNA assays). In 495 cases, samples collected within 24 hours from a patient underwent IgM assays (DS2 platform) and PCR assays (in-house). 7 pairs, corresponding to 5 patients, of 404 pairs with negative or low-positive IgM results, had detectable RNA. 4 of those 5 patients were demonstrably immunocompromised; the final sample came from general practice without further details. 3/5 patients had reactive IgG assays, and one of the two remaining patients had a rise in IgM titre between two successive samples. We conclude that, in our sample population, hepatitis E RNA PCR testing adds minimal diagnostic information in immunocompetent individuals with negative or low-positive IgM results. This finding supports current testing cascade recommendations. We discuss our sample population’s demographics and external validity of findings: in particular, we saw few tests sent by neurologists. Finally, we briefly discuss other IgM/IgG/PCR result scenarios and our findings in relation to current SMI recommendations, and speculate how our findings affect understanding of antibody response and viraemia in hepatitis E infection.
Development of a licenced Faecal Microbiota Transplantation service for the treatment of patients in the NHS
Authors: McCune Victoria , Manzoor Susan , Shabir Sahida , Quraishi Mohammed Nabil , Sharma Naveen , Hawkey Peter , Iqbal Tariq
Published: March 2020

Introduction: Faecal microbiota transplantation (FMT) is an effective and licensed treatment for recurrent and refractory Clostridium difficile infection (CDI) and has shown encouraging signals for treatment of ulcerative colitis (UC). Access to FMT has been limited by the introduction of new regulations in the UK. Centres producing FMT are now required to hold a manufacturing licence from the Medicines and Healthcare products Regulatory Agency (MHRA).

Methods:The first licenced FMT service in UK - University of Birmingham Microbiome Treatment Centre (UoBMTC) was launched in 2017. Policies and procedures were developed in accordance with MHRA ‘Good Manufacturing Practice’ guide.

Results: Since August 2018, 132 FMT aliquots have been supplied for recurrent and refractory CDI to 39 NHS Trusts across UK. Twenty-nine of these Trusts did not have access / perform FMT prior to this service. In all cases, FMT was delivered within 48 hours (unless delayed delivery was requested). The service is the sole supplier of FMT since 2018 via an NHS Innovation and Technology Tariff. UoBMTC has also to date supplied 360 FMT aliquots for a multi-centre trial of FMT in UC (STOP-Colitis). Furthermore, the service has provided FMT to other refractory conditions within clinical settings.

Conclusions: Development of a licenced FMT facility has greatly enhanced equality of access for this treatment across the NHS. FMT is provided at a zero-cost model for CDI and is available within 48 hours of request. UoBMTC continues to facilitate research in this field by providing FMT for clinical trials exploring its use for other indications.
The clinical impact of swabbing positive for multiple respiratory viruses
Authors: Shahi Farah , Asif Ammara , Hamilton David
Published: March 2020

Little data exists on the clinical impact on adults who swab positive for more than one respiratory virus at once. Should this be associated with higher morbidity/mortality, there would be implications for patient care and potentially infection prevention measures. We reviewed 190 throat/nasopharyngeal swabs positive for respiratory viruses in York Teaching Hospitals NHS Foundation trust between October 2017 and February 2018. Data, collected from the hospital inpatient computer records, included: age, admission/discharge dates, presenting complaint, past medical history, time to swab (from admission), use of oseltamivir, flucloxacillin and other antibiotics, positive microbiology, highest recorded MEWS (excluding ITU), length of ITU stay and discharge status. The modal length of stay was 2-10 days. 69% of patients were aged over 40. There was no difference between admission to ITU and single/multiple respiratory viruses. The presence of influenza virus was higher in patients with a pre-existing cardiac comorbidity compared with pre-existing respiratory or other comorbidities. There did not appear to be a correlation between the number of patients with any comorbidity having multiple respiratory viruses. Interestingly, 18% of patients with multiple respiratory viruses died, compared with 10% of patients with singular viruses. Given the small numbers of patients included, further work is needed. A repeat review is planned across two hospital trusts in the near future.
UK Paediatric Antimicrobial Stewardship: a call for action
Authors: Vergnano Stefania , Chappell Faye , Bamford Alasdair , Demirjian Alicia , Doerholt Katja , Emonts Marieke , Goenka Anu , Jones Laura , Herberg Jethro Herberg , Hinds Lucy Hinds , McGarrity Orlagh , Moriarty Paul , Patel Mitul , Paulus Stephane , Porter David , Stock Kate , Patel Sanjay
Published: March 2020

Background:

Paediatric antimicrobial stewardship (PAS) networks exist in the USA and Australia but not in the UK. We sought to capture a snapshot of the current PAS landscape across UK children’s hospitals.

Methods:

A survey of PAS activities was conducted in tertiary children’s hospitals.

Results:

Infectious disease or microbiology consultants responded to the survey (n=15). All hospitals had neonatal, paediatric intensive care and surgical patients.All centres provided a PAS education programme for doctors, 7 for nurses and 9 for pharmacists as well. All centres had empirical antimicrobial prescribing guidelines. All centres with a paediatric infectious diseases (PID) team (11/15) used “audit and feedback” rounds, although their frequency and coverage varied. The PAS teams mostly included a PID consultant and/or microbiology consultants and a pharmacist. Three centres also had a nurse covering also the paediatric out-patient antibiotic treatment programme. Funding for PAS were inconsistent: Great Ormond Street Hospital had secured a dedicated full-time paediatric microbiologist, antimicrobial pharmacist and PID consultant with a ratio of 1/453 in-patient beds. 9 centres did not have dedicated funding for a paediatric antimicrobial pharmacist, 7 did not have funding for a paediatric infectious disease consultant. Only 2 hospitals had microbiology consultant time for paediatric audit and feedback.

Conclusion:

PAS programmes in the UK are limited, funding is inconsistent and their set up is variable, even in tertiary children’s hospitals with a strong interest in infectious diseases. We propose a national PAS network to advocate for more consistency and research into the implementation of PAS programmes.
A qualitative study on factors influencing the implementation of a Clostridium difficile risk prediction tool in the Scottish secondary care setting
Authors: A. Ansu Joseph , Kurdi Amanj , Bennie Marion
Published: March 2020

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

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

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

Conclusion: In general it was understood that podiatrists are supportive in having a CDI tool, however, due to the impossibility of implementation of the tool into their system, a website or app will be developed.
Co-Amoxiclav Prescribing in Renal Impairment
Authors: Nicolson Andrew , Baggott Amy
Published: March 2020

Intro:

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

Methods:

An online questionnaire was sent to clinicans to ascertain their prescribing knowledge in renal impairment. Following this a review of all prescriptions of Co-Amoxiclav over a one month (19/02/19-19/03/19) period was reviewed and cross matched with patients renal function to determine those with a degree of kidney injury. Standard of dosing was compared against the BNF as most clinicians replied that this was their main prescribing resource.

Results:

774 patients were prescribed Co-Amoxiclav; 11.8 % (92) of these with a degree of renal impairment. Only 54% (50) of these patients were prescribed the correct dose of Co-Amoxiclav. 78 patients had an acute kidney injury (AKI) with 58% (45) prescribed the correct dose. In comparison 51% (47) of patients had a Chronic Kidney Injury (CKD) with only 33% (15) prescribed the correct dosage. This number is equally low in patients with an acute on chronic kidney injury; 35.8 % (33) patients with 30% (9) on the correct dose.

Conclusion:

46% of patients with a degree of kidney injury are being prescribed the wrong dosage of Co-Amoxiclav which may potentially result in patient harm or under treatment of their condition. Further education is required within the trust to ensure prescribers use correct sources including the Renal Handbook and consider alternative antibiotics in patients with renal impairment.
Easy to get, but not always easy to treat - Clinical and serological failure with Azithromycin in Syphilis: Time to adapt national guidelines?
Authors: Ogbonmwan Daisy , Schwab Uli
Published: March 2020

Background

Data 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.

Results

There 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.

Conclusion

Patients 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
Authors: Walker Ieuan , Beinortas Tumas , Enoch David , Gouliouris Theodore
Published: March 2020

Background

Clostridium 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.

Results

143 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.
Influenza Testing in the Emergency Department (ED): A Quality improvement project (QIP)
Authors: Patterson Charlotte , Sturdy Ann , Irish Dianne , Connor Hilary
Published: March 2020

Background

Respiratory 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.

Results

There 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?
Authors: Murray James , Husnoo Nilofer , Bond Stuart , Wroe Nicholas , Shabir Wasim , Murray Rebecca , Sarveswaran Janahan , Basheer Mohamed
Published: March 2020

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.
The management of adult patients with meningitis at Arrowe Park Hospital – A complete audit cycle
Authors: Ejere Elshadai , Harvey David
Published: March 2020

Background:

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
Authors: Robertson Paul
Published: March 2020

Staphylococcus 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.
An unusual case of Mycobacterium chelonae infection
Authors: Shorrocks Ruth , Hayward Samantha , Moran Ed
Published: March 2020

Introduction: 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.
Voriconazole – are we doing what we think we are? A review of voriconazole use and monitoring in respiratory patients in a London hospital
Authors: Chia Germaine , Davies Frances , Coleman Meg
Published: March 2020

Background

Voriconazole 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.

Results

21 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.

Conclusion

Our 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.