bluuebunny/crossref_metadata_2025 huggingface dataset:
White Supervisor and Subordinate Beliefs about Black/White Inequality: Implications for Understanding and Reducing Workplace Racial Disparities
Authors: Smith Ryan A , Hunt Matthew O
Published: March 2020

This study examines the racial stratification beliefs of white Americans who have decision-making power at work (managers and supervisors) and of those (subordinates) who lack such power. We focus on whether these groups vary in overall levels of support for, and in determinants of, beliefs about racial inequality. Pooled cross-sectional analyses of data from the 1977 to 2014 General Social Surveys (GSS) reveal that, among both white supervisors and subordinates, support is greatest for a motivation-based explanation of black disadvantage, followed by (in order) explanations focusing on blacks’ lesser educational chances, discrimination against blacks, and finally, blacks’ supposed lesser ability. In line with Group Position Theory, our multivariate analyses reveal few differences across the supervisory divide in levels of support for, or in the determinants of, whites’ beliefs about black disadvantage. Differences that do exist align with alternative perspectives including Social Dominance Theory, a Group Self-Interest Model, and Intergroup Contact Theory. We conclude by discussing the theoretical and methodological implications of our findings for future research pertaining to what does and does not work to ameliorate racial inequality in the workplace.
Parent, Child, and Adoption Characteristics Associated with Post-Adoption Support Needs
Authors: Lee Bethany R , Wyman Battalen Adeline , Brodzinsky David M , Goldberg Abbie E
Published: March 2020

The purpose of this study is to (a) identify whether there are meaningful subgroups of families with distinct post-adoption needs and (b) determine which parent, youth, and adoption characteristics are associated with these collections of needs. Using data from the Modern Adoptive Families study, authors conducted a three-step latent class analysis with a sample of 1,414 families who rated the importance of 16 areas of parent education and support, based on their current level of need. A five-class solution best fit the data. Descriptively, the classes reflect families with low needs, families with needs related to adoption adjustment, families with adoption-specific needs, families wanting support specific to their youths’ special needs, and families with needs that are both adoption-specific and related to youth special needs. Results from the multinomial logistic regression model found class membership differences based on parent, youth, and adoption characteristics. These classes may help adoption professionals to recognize the types of post-adoption services different families may need and to develop targeted interventions for specific types of families.
Toxicity testing is evolving!
Authors: Fischer Ida , Milton Catherine , Wallace Heather
Published: March 2020

The efficient management of the continuously increasing number of chemical substances used in today’s society is assuming greater importance than ever before. Toxicity testing plays a key role in the regulatory decisions of agencies and governments that aim to protect the public and the environment from the potentially harmful or adverse effects of these multitudinous chemicals. Therefore, there is a critical need for reliable toxicity-testing methods to identify, assess and interpret the hazardous properties of any substance. Traditionally, toxicity-testing approaches have been based on studies in experimental animals. However, in the last 20 years, there has been increasing concern regarding the sustainability of these methodologies. This has created a real need for the development of new approach methodologies (NAMs) that satisfy the regulatory requirements and are acceptable and affordable to society. Numerous initiatives have been launched worldwide in attempts to address this critical need. However, although the science to support this is now available, the legislation and the pace of NAMs acceptance is lagging behind. This review will consider some of the various initiatives in Europe to identify NAMs to replace or refine the current toxicity-testing methods for pharmaceuticals. This paper also presents a novel systematic approach to support the desired toxicity-testing methodologies that the 21st century deserves.
Resistance trends among Enterobacterales from bacteraemias in the UK and Ireland, 2007 - 2017
Authors: Aliabadi Shirin , Horner Carolyne , Mushtaq Shazad , Livermore David
Published: March 2020

Background

The British Society for Antimicrobial Chemotherapy (BSAC) Bacteraemia Resistance Surveillance Programme monitors the antimicrobial susceptibility of organisms causing bacteraemias in the UK and Ireland. We review data for Escherichia coli, Klebsiella, Enterobacter, Proteeae, and Serratia collected between 2007-2017.

Methods

Consecutive isolates causing clinically significant bacteraemia were tested; participating laboratories (n=24-40) collected 7-20 isolates/species per year. Minimum inhibitory concentrations were determined centrally by BSAC agar dilution.

Results

Rates of resistance in the UK and Ireland remained largely stable over the 11-year period, during which 14,206 isolates were tested [(E. coli, n=5364; Klebsiella, n=3016; Proteeae, n=2423; Enterobacter, n=1819, and Serratia, n=1584)]. A decrease in resistance to piperacillin/tazobactam was noted among all species, except K. aerogenes. A decrease in resistance to ciprofloxacin was seen among E. coli and Enterobacter. Average rates of resistance to ceftolozane/tazobactam ranged from 0.2% (E. coli)to 9.2%(E. cloacae), whereas rates of resistance to ceftobiprole were higher [10% (E. coli) and 20% (E. cloacae)]. Rates of colistin resistance were low among E. coli (0.5%), and Klebsiella (1.2%); however, rates were higher, and increasing among Enterobacter (6.1% in 2011 to 13.4% in 2017). Rates of ESBL production were stable over time; higher among E. coli (9.6%), Enterobacter (10.4%), and Klebsiella (14.7%), compared with <1% among Proteeae and Serratia. Carbapenemase producers remained rare (n=16 over 11 years, without trend).

Conclusion

The largely unchanging or reducing resistance rates among Enterobacterales causing bacteraemia are reassuring and may reflect interventions to reduce inappropriate use of antimicrobials implemented across the countries surveyed.
A decade on from the publication of the British HIV Association's National HIV Testing Guidelines: are opportunities to increase the uptake of HIV testing still being missed?
Authors: Bulteel Naomi , Bularga Anda , Baker Kerri , Sloan Derek , Banerjee Indranil
Published: March 2020

Background:

Guidelines recommend HIV testing in indicator conditions in which the prevalence of undiagnosed HIV exceeds 0.1%. We assessed adherence to national recommendations on HIV testing within the acute medical unit in NHS Fife. Secondly, we performed a look-back exercise to identify missed opportunities for HIV diagnosis in individuals who presented at a late stage of infection.

Methods:

Data were collected on admissions over a 24-hour-period during four consecutive weeks in 2018. Case records were reviewed and diagnoses were screened against a list of indicators. Additionally, data were obtained from HPS on late HIV diagnoses within NHS Fife from 2013-2018. Records were interrogated for presentations to healthcare services within the 5 years prior to HIV diagnosis.

Results:

In total, 226 patients were admitted during the study period. All patients were white, with median age 68yrs. 101 indicator conditions were identified, relating to 83 patients (36.7%). Bacterial pneumonia was the most frequently identified indicator (n=40). Only 3 patients were offered HIV testing (3.6%).

From 2013-2018, 23 patients were diagnosed with HIV at late stage. The median age at diagnosis was 41yrs and the median CD4 count was 161 cells/mm3. Fifteen patients (65.2%) had presented to hospital in the 5 years preceding diagnosis with an indicator. The most frequently missed indicator was chronic diarrhoea (n=6). Three patients (13%) have died since diagnosis.

Conclusions:

* Opportunities to increase uptake of HIV testing among people who may have undiagnosed HIV are being missed

* Further educational initiatives and review of local HIV testing protocols are indicated
To screen or not to screen?
Authors: Lowe Abigail , Sarian Arni , Russell Katherine , Gibani Malick , Moore Luke , Mughal Nabeela , Donaldson Hugo
Published: March 2020

Introduction

Screening for carbapenem resistant organisms (CROs) enables early isolation and prevention of transmission in inpatient healthcare settings. In 2013, the UK Department of Health detailed a national approach to screening for CROs. Implementation of this policy has been variable and the growing numbers of patients who meet screening criteria likely exceeds capacity for isolation.

Method

We undertook a point prevalence study across two London hospitals to ascertain the frequency of per-policy screening. We assessed the screening of acutely admitted patients in March 2019 at hospital 1 and July 2019 at Hospital 2. We then modelled variations in screening approaches to optimise risk assessments in the context of isolation room availability.

Results

A total of 199 patients (112 patients at hospital 1 and 87 patients at hospital 2) were included in the analysis. Overall, 27/112 (24%) and 32/87 (37%) met the criteria for CRO screening according to current guidelines. Of these, 0/27 (0%) of patients at hospital 1 and 5/32 (16%) at hospital 2 had a CRO screen performed [p=0.06]. Across both hospitals, the principal risk factors for CRO carriage included: admission to a UK hospital in a high risk area (63/199;32%); admission to a non-UK hospital (3/199/;2%) and previous CRO carriage (1/199;0.5%) albeit with some variation between sites

Conclusion

Six years after the roll out of the national toolkit, CRO screening is still variable. Reworking of the risk stratification is needed, and we suggest technological approaches with electronic healthcare records may enable more robust screening strategies.
Facial Nerve Palsy – Do people think about Lyme Disease?
Authors: Fourie Benjamin , Costa Elisa , McGoldrick Claire
Published: March 2020

Background

Borrelia burgdorferi, the micro-organism responsible for Lyme borreliosis, is known to be endemic in Scotland, with 4.2% sero-prevalence in Scottish blood donors. Facial nerve palsy can be a manifestation of the illness. The aim was to establish how often Lyme is considered as a potential cause in one Scottish health board.

Methods

Patients, aged four and above, presenting to secondary care with facial nerve palsy from 2016-2018 were identified using ICD-10 codes. A retrospective analysis of case notes and laboratory records was undertaken to establish whether a cause for nerve palsy had been found, whether a potential tick exposure history was taken, and if Lyme testing had been done. Microsoft Excel was used for analysis.

Results

173 patients with confirmed facial nerve palsy were identified. Consideration of Lyme disease was made in 9.2% (16/173). Of these, 43.8% (7/16), were asked about possible insect bites (four of whom were asked specifically about tick bites). 43.8% (7/16) were tested based on clinical presentation. 6.3% (1/16) had “no Lyme risks” documented and another 6.3% (1/16) had an occupational risk. Of the sixteen, 50% (8/16) had Lyme serology undertaken, although 2/8 had a confirmed alternative cause.

Conclusion

Possibility of Lyme disease is not commonly considered when individuals present with facial nerve palsy. This is despite endemnicity in Scotland, and opportunities for tick exposure being common, with outdoor activities and countryside trips. Educational initiatives are therefore required.
Paediatric Clostridium difficile infection: rarer than we think?
Authors: Hindocha Avni , Hatcher Jim , Lyall Hermione , Satta Giovanni
Published: March 2020

Background

In view of the new IDSA clinical practice guidelines, we investigated C. difficile infection (CDI) rates and performance against the key standards in our infants and immunosuppressed paediatric patients.

Methods

Using electronic patient notes and microbiology systems, we collected data on every positive PCR result between June 2016 and March 2018 in our paediatric population. Information included risk factors, markers of severity and medical management.

Results

48 samples were sent for C. difficile testing, from which 22 patients had positive results at an average age of 7.4 years. Only five samples were sent from patients under 2 year olds, of which four were PCR positive but toxin negative. Out of 22 positive patient samples, 9 were toxin positive. Risk factors for CDI included previous antibiotics or inpatient stay in the last 3 months, as well as recent PPI use. Only one patient had toxin positive CDI with severe disease. Overall the management of CDI in both toxin positive and negative patients was appropriate in terms of antibiotic choice and duration, and was tailored to specific patient circumstances. A high proportion of CDI patients were immunosuppressed or had recently undergone bone marrow transplants, but often showed no signs of severe infection (fever, raised inflammatory markers).

Conclusion

There should be a low threshold in testing patients who are immunosuppressed, as they are more likely to develop CDI. There were no toxin positive cases in patients under two years of age, which confirms that the test is not useful in this population.
Management of methicillin sensitive Staphylococcus aureus bacteraemia in an antimicrobial stewardship age
Authors: Platts Stephen , Payne Brendan , Price David , Schwab Ulrich
Published: March 2020

Background: Methicillin sensitive Staphylococcus aureus bacteremia (MS-SAB) is associated with significant morbidity and mortality. Long courses of intravenous antibiotics are the traditionally recommended mainstay of treatment but are often not completed in clinical practice. Shorter courses are potentially attractive from an antimicrobial stewardship and resource perspective, but require a good evidence base.

Methods: A retrospective audit of MS-SAB management within Newcastle-upon-Tyne Hospitals NHS Foundation Trust (2016-17). Laboratory database was used to identify all cases of MS-SAB. Demographic details, risk factors and management were recorded from patient records. Outcomes were defined as 90d recurrence-free survival, 30d mortality, 30-90d mortality and recurrence before 90d.

Results: A total of 281 adult cases were identified with adequate data available for review. Predictors of early (30d) mortality were: age, 71.4y vs 58y p<0.001; HAI, 21.4% vs 8.6% p=0.003; osteo-articular infections, 2.5% vs 17.1% p=0.016; but not antibiotic choice. In cases surviving 30d (n=238), median antibiotic durations were: intravenous 10d (range, 0-115), total 18d (0-316). 83% received ≥14d total, 41% received ≥14d intravenous. Receiving <9d intravenous (OR 3.33 (95%CI 1.01- 10.95) or <14d total therapy (OR 4.19 (1.37-12.84) was predictive of recurrent bacteraemia, as was non-beta-lactam therapy (16% vs 4%, p=0.006), and poor CRP response at end of intravenous therapy (68% vs 35% of peak CRP, p<0.001).

Conclusions: These data suggest lower durations (9-14d) of intravenous therapy could be safe in MS-SAB, however very short courses (<9d) are associated with worse outcomes. This new evidence helps inform guidelines, balancing optimised patient outcomes alongside improved antimicrobial stewardship.
‘The Mould that Changed the World’: Quantitative and Qualitative Analysis of Knowledge and Behavioural Change following Participation in an Antimicrobial Resistance Musical
Authors: Hall Jennifer , Jones Leah , Robertson Gail , Hiley Robin , Nathwani Dilip , Perry Meghan
Published: March 2020

Background: Antimicrobial resistance (AMR) is driven by antimicrobial exposure. Engaging the general public with this issue is vital in order to shape attitudes and change behaviour. A primary school musical (‘The Mould that Changed the World’) was developed as a novel educational strategy with the explicit aim of engaging the public in the fight against AMR.

Methods: The musical was implemented in two primary schools as workshops followed by public performances. There were 166 child participants aged 9 to 11 years. Quantitative data was collected through a classroom questionnaire before the musical, two weeks after, and six months after. Qualitative data were collected through children’s focus groups before the musical and two weeks after.

Results: Knowledge of the key messages of the musical had increased two weeks after the musical (proportion test, 0.65, 0.77, p<0.001) and this gain in knowledge was sustained six months later (proportion test, 0.65, 0.82, p<0.001). Children recognised factors contributing to AMR, felt empowered to change their own health behaviours and demonstrated antimicrobial stewardship with intention to reduce antibiotic use. They suggested the musical had stimulated discussion around these topics at home. The musical was perceived as an enjoyable and memorable way to learn about AMR.

Conclusion: This study demonstrates potential for the use of musical theatre in this field as a novel device to improve long-term knowledge, change attitudes and emotionally engage the general public through children. Alongside existing interventions, it represents a further unique and valuable tool in the fight against AMR.
Understanding antimicrobial prescribing in suspected ventilator-associated pneumonia: a prospective cohort study
Authors: Docherty Callum , White Iain , Bannard-Smith Jonathan , Morton Ben , Walters Ingeborg , Xu Yun , Roberts Stephen , McMullan Ronan , Goodacre Roy , Dark Paul , Fowler Stephen , Felton Timothy
Published: March 2020

Background

Ventilator-associated pneumonia (VAP) is associated with significant healthcare cost, morbidity, and mortality, but can be difficult to identify, resulting in over-diagnosis and excessive use of broad-spectrum antimicrobial therapy. In addition, some organisms commonly cultured from the airways of critically ill patients, in particular Candida species, are of unknown clinical significance.

Methods

A prospective cohort study was conducted across five intensive care units in the North-West of England. Participants were enrolled within 24 hours of commencing antimicrobial therapy for suspected VAP. Laboratory-confirmed VAP was defined by quantitative culture of a known pneumonia-causing pathogen above predetermined growth thresholds.

Univariate logistic regression was used to determine the impact of laboratory-confirmed VAP, APACHE II, culture of Staphylococcus aureus, and culture of Candida species on 30-day mortality.

Results

The prevalence of laboratory-confirmed VAP was 43/96 (44%), and the median number of antimicrobials prescribed for VAP was 1 (range: 1-4). Candida species were identified in 32/96 patients (33%).

The overall 30-day mortality was 22/96 (26%). None of the variables analysed were associated with 30-day mortality, except for culture of Candida species, which was associated with survival (odds ratio 0.26, 95% CI 0.07 to 0.98; p= 0.047).

Conclusions

Ventilator-associated pneumonia was confirmed in under half the patients commenced on antimicrobial therapy for suspected VAP, which highlights the urgent need for improved diagnostic strategies. In our clinical practice, Candida species are not treated as pathogenic in VAP, and in this study, growth of Candida species was not associated with excess 30-day mortality.
Stroke secondary to hip ulcer and Septic emboli
Authors: Choudhry Taimour Rashid
Published: March 2020

Background

Strokes are frequently seen in older patients mainly due to long standing hypertension, diabetes mellitus and hyper cholesterolemia. It is not common in younger adults especially when there is no obvious cause. The workup to find the cause is often difficult in such cases.

Case Description

A 38-year-old paraplegic male presented in Emergency Department with the complaints of fever, headache, haematuria and awaiting closure of left hip wound; however, it seemed non infected. Regarding his medical history, he had ASD associated with pulmonary hypertension and type 1 diabetes mellitus. Besides, after 24hrs of admission he developed right sided neglect. On examination, he was febrile with increased heart rate and respiratory rate. Moreover, he had right homonymous hemianopia and NIHSS score was 3. CT PA was done to rule out pulmonary embolism. Additionally, CT CAP and CT head showed splenic infarct and occipital infarct, respectively. Therefore, a diagnosis of paradoxical embolus was made and treated accordingly. Later, blood culture revealed beta haemolytic streptococci and the underlying cause of septic stroke was thought to be hip ulcer extending to bone. This was followed by CT pelvis, on which bone destruction was seen. Therefore, antibiotics were commenced and left hemiarthoplasty was done.

Conclusion

This case illustrate that in younger population, often soft tissue and bone infection can lead to pro-thrombotic events resulting into septic emboli, a potential cause of stroke (especially when accompanied by ASD). Early assessment and management is valuable as it can lead to serious complications and increased morbidity.
A case of recurrent aerococcus urinae infective endocarditis with associated cerebral embolic phenomena
Authors: Ravji Pooja , Brown Nicholas
Published: March 2020

Aerococcus urinae is a gram positive, alpha haemolytic cocci that rarely is associated with urinary tract infections, bacteraemia and infective endocarditis. We describe a case of recurrent aerococcus urinae endocarditis with associated cerebral embolic phenomena.

A 76 year old man presented with sudden onset right sided weakness and dysphasia. CT and MRI head imaging showed infarcts in the left pons and cerebellum suspicious of embolic aetiology.

He had a background of a prosthetic mitral valve replacement following an episode of culture negative infective endocarditis associated with discitis and a psoas abscess 3 years previously. A 16S rRNA PCR on valve tissue had yielded an aerococcus urinae.

The anaerobic bottle of a blood culture taken on his present admission flagged positive at 48 hours but no organisms were seen on gram stain. However, Matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI – TOF MS) identified an aerococcus urinae 4 hours later. The same organism was also identified in the aerobic bottle which had flagged positive later the same day with gram positive cocci in clusters. Susceptibility testing revealed a MIC (Minimum Inhibitory Concentration) of 0.032, 1 and 8mg/L for penicillin, vancomycin and gentamicin respectively.

A transthoracic echocardiogram confirmed reoccurrence of endocarditis with a 1.5cm lesion on the mitral valve. There was no evidence of other embolic phenomena. The patient was managed medically with initial treatment with intravenous vancomycin and gentamicin followed by benzylpenicillin and gentamicin for 6 weeks. The patient made slow rehabilitative progress and remained debilitated by his right sided hemiparesis.
Is the amniotic fluid really sterile? A study of Microbial Invasion of the Amniotic Cavity (MIAC) in a tertiary center, Khartoum, Sudan
Authors: Abdelrahman Azza , Elhaj Kamal
Published: March 2020

Microbial Invasion of the Amniotic Cavity (MIAC) is a term used to describe positive amniotic fluid culture for bacteria or genital mycoplasmas. MIAC can affect both mother and fetus. It is a common cause of preterm labour with intact membranes and prelabour rupture of membranes. It is also associated with cervical insufficiency, an asymptomatic short cervix, idiopathic vaginal bleeding, placenta previa, and clinical chorioamnionitis at term. It is also related to neonatal sepsis, pneumonia and respiratory distress syndrome (RDS) and cerebral palsy. the objective of this study is to determine the etiology of Intraamniotic Infections among women delivered in Soba University Hospital, Khartoum Sudan in February- March 2016. In this cross sectional study, 246 deliveries were included samples of the amniotic fluid were taken after delivery. MIAC is detected 31.3% of the women under study. Staphylococcus aureus constitutes the major isolates (62.1%) followed by E. coli and Klebsiella spp. None of the isolates were Streptococcus agalactiae. There is a statistically significant association between MIAC and maternal infection during the third trimester, mode of delivery and birth asphyxia but not neonatal sepsis.
Using health literacy techniques to develop patient information for counselling on antibiotics courses
Authors: Beck Kiyah , Ioannou Koulla , Ahmed Sidrah , Zaman Syeda Nadia , Hawksworth Gill , Afzal Saima , Frank Sarah , Howard Philip
Published: March 2020

Introduction

Increased education may improve awareness of antimicrobial resistance (AMR), however 43% of people aged 16-65 in England lack skills to understand health information1.This study aimed to improve patient knowledge on short course antibiotics using a patient information leaflet (PIL) incorporating Health Literacy (HL) techniques supporting the Governments’ 5 year 2019 AMR strategy.

Method

This study received ethics approval. A revised Royal Pharmaceutical Society (RPS) checklist for Community Pharmacy PIL incorporating HL techniques was piloted, then used for 5-weeks as a counselling tool by 8 consenting community pharmacists. It was handed to patients during dispensing of short-course antibiotics, after which the pharmacists filled out a questionnaire. Patients receiving counselling using the PIL completed face to face questionnaires.

Results

106 patient questionnaires were completed.

94% of patients had taken antibiotics previously and 90% of these thought the counselling received using the PIL was easier to understand than previous counselling.

96% of patients agreed the PIL improved their knowledge on appropriate antibiotic use. 81% of patients intended to change their behaviour and thought the PIL had improved their antibiotic knowledge especially to “always finish a prescribed course of antibiotics”. All patients stated the PIL was easy to follow.

Conclusion

This pilot suggests that patient behaviour can be influenced using structured counselling on AMR drawing on HL techniques.

References

1 Rowlands G, Protheroe J, et al. A mismatch between population health literacy and the complexity of health information: an observational study. British Journal of General Practice. 2015;65(635):e379-e386.
Using health literacy techniques to support pharmacist practice when counselling on antibiotics courses
Authors: Beck Kiyah , Ioannou Koulla , Ahmed Sidrah , Zaman Syeda Nadia , Hawksworth Gill , Afzal Saima , Frank Sarah , Howard Philip
Published: March 2020

Introduction

Increased education may improve awareness of antimicrobial resistance (AMR)1 however 43% of people aged 16-65 in England lack skills to understand health information2. This study aimed to improve patient knowledge on short course antibiotics using a patient information leaflet (PIL) incorporating Health Literacy (HL) techniques supporting the governments’ 5 year 2019 AMR strategy.

Method

This study received ethics approval. A revised Royal Pharmaceutical Society (RPS) checklist for Community Pharmacy PIL incorporating HL techniques was piloted then used for 5-weeks as a counselling tool by 8 consenting community pharmacists. It was handed to patients during the dispensing of short-course antibiotics after which the pharmacists filled out a questionnaire.

Results

106 patients were counselled and all 8 pharmacists completed questionnaires on how the PIL supported their practice.

On a scale of 1 (not at all) to 5 (improved a lot), pharmacists scored how much they thought the PIL could improve patient’s knowledge on appropriate antibiotic use. 63% of pharmacists (5/8) scored the PIL ‘5’ or ‘4’.

63% of pharmacists (5/8) did not feel that the PIL took longer than their standard counselling. 66% (2/3) felt that the extra time was worthwhile.

Conclusion

Pharmacists believed written information using HL techniques led to improved AMR education at the point of antibiotic dispensing.

References

1.Health Education England. Tackling antimicrobial resistance: educational priorities London; 2018.

2. Rowlands G, et al. A mismatch between population health literacy and the complexity of health information: an observational study. British Journal of General Practice [Internet]. 2015;65(635):e379-e386.
How well are we doing in diagnosing and treating UTI in older people?
Authors: Malkin Joanne , Ross Jill
Published: March 2020

Background

There is very good evidence that the use of a urine dipstick in the diagnosis of UTI in older people is not of value and may indeed cause harm (e.g. inappropriate courses of antibiotics, missed alternative diagnoses, etc.) This year’s AMR CQUIN has focussed on compliance with NICE / PHE guidelines. The results presented here are for the first quarter at CDDFT hospitals.

Methods

Patients were initially identified prospectively by ward pharmacists. However, this yielded too few patients and our data collection method was amended to retrospective collection, based on a primary discharge code of N39.0.

Results

* 60% urine dipstick used inappropriately (target <10%)

* 52% treatment follows NICE guidelines / based on recent sensitivities / local guidelines (target >90%)

* 60% patients were prescribed coamoxiclav despite not being in NICE / PHE guidelines for lower UTI

* 86% MSU sent (target >90%)

* 84% diagnosis based on symptoms / signs consistent with UTI (target >90%)

Conclusion

Despite numerous efforts (posters, walk-arounds, teaching) over the last 2 years to educate staff regarding appropriate use of urine dipsticks and antibiotics, our results were unsatisfactory. To remedy this, we have implemented the action plan described below, aimed at engendering an improvement in compliance with the guidelines and patient management.

1. Educational screensavers on computers

2. Removal of dipstick stickers from MAU clerking

3. Change of dipsticks to ones with no leucocytes and nitrites

4. Education and engagement of MAU & ED ward staff

5. Additional of new category to antibiotic formulary (?UTI/?LRTI not septic) to counter excessive coamoxiclav use
Low or no CRP at the point of admission to a medical admissions unit is associated with a low rate of 48-hour antimicrobial review amongst patients prescribed antibiotics
Authors: Hill Amanda , Hamon Eloise , Nana Melanie , Price Sian , Craine Noel , Healy Brendon
Published: March 2020

Introduction: Antibiotic resistance is rising and multi-resistant organisms are readily being identified; therefore fear of mortality rates rising due to infection is becoming a genuine prospect. We sought to measure clinical review post antimicrobial prescription in two acute hospitals in Wales to establish whether review is undertaken at 48-hours and whether likelihood of clinical review taking place depends on C reactive protein (CRP) levels on admission.

Methods: An audit across two hospitals in South Wales assessing compliance of antimicrobial review as recommended by NICE guidelines was undertaken over a three week period. In addition, univariate odds ratios for 48-hour referral stratified by CRP test results (excluding patients with no CRP test) were calculated in a logistic regression model using the high CRP group as the referent. Following initial results intervention (education and prompt stickers) were introduced to prompt 48-hour review.

Results: 139 patients were included in the pre-intervention audit from both sites. 53% were reviewed at 48 hours. Initial interventions demonstrated an improvement in compliance in all CRP categories. In the logistic regression analysis setting the highest CRP group (CRP <=100) as referent showed that the likelihood of a 48 hour review was lower in patients with lower CRP test results, or no CRP test than those with a CRP of >=100.

Conclusion: Patients with low or no CRP on admission are less likely to have their antimicrobial prescriptions reviewed when compared 48 hours. Intervention should continue to be sought to raise awareness of this.
A retrospective review of vancomycin dosing in paediatric patients
Authors: Bolina Anita , Hughes Stephen
Published: March 2020

Background: Vancomycin has antimicrobial activity against most Gram-positive pathogens. Reduced susceptibility of vancomycin to many microbes has necessitated higher target vancomycin trough levels (VTL) of 10-20mg/L. Paediatric dosing algorithms have remained unchanged despite higher VTL targets; increased doses are required. The study outcomes were to assess the impact of new dosing guidelines on VTL, time to target VTL and vancomycin-associated acute kidney injury (vAKI).

Methods: A single-centre review assessed 63 vancomycin treatment episodes between Apr-2016 and Feb-2019. Demographic data, treatment duration, daily vancomycin dosing and VTL were collected. Episodes were grouped as high-dose vancomycin (HDV) (≥60mg/kg/day) and low-dose vancomycin (LDV) (<60mg/kg/day). Target VTL was 10-20mg/L. AKI was defined by modified pRIFLE criteria as ≥50% increase in baseline creatinine within 7 days of treatment commencement. The project was registered with the local audit team.

Results: Initial VTL were significantly higher in the HDV group (mean 10.4, SD±4.7mg/L; n=20) than LDV (mean 7.9,SD±4.0mg/L;n=43), p=0.0397. Whilst time-taken to reach target VTL was improved in the HDV group (53.5±22.3 hours vs 66.1±37.1hours), this was statistically insignificant (p=0.2675). Paired t-tests revealed no significant changes to baseline creatinine in HDV (p=0.1267) and LDV (p=0.2006). No differences in vAKI incidence between the two groups were noted (p>0.05).

Conclusion: Increasing vancomycin dosages improved initial VTL but was insufficient to improve the length of time to reach target VTL. Reassuringly, there was no increase in vAKI incidence with HDV. The study suggests loading doses in paediatrics may be needed to improve time to target VTL.
Rapid Determination of Antimicrobial Susceptibility of Gram-Negative Bacteria from Positive Blood Cultures Using an Innovative Method
Authors: Falconer Kerry , Parcell Ben , Hammond Robert , Gillespie Stephen
Published: March 2020

Introduction:

A blood stream infection (BSI) presents a complex and serious health problem and is growing in light of the eminent antimicrobial resistance threat. Progress must be made towards rapid BSI diagnosis and antimicrobial susceptibility testing (AST) to reduce preventable death in BSI.

Methods:

Positive blood cultures from Ninewells Hospital, Dundee were studied prospectively. Flagged positive blood cultures were processed by Gram-staining, Vitek identification and AST or disc diffusion for ceftriaxone susceptibility and by scattered light integrated collection device (SLIC). Susceptibility to a panel of five antibiotics as defined by EUCAST breakpointswere compared.The time to AST result and AST categorical agreement was compared for standard methods and SLIC, any discrepancies were resolved by the EUCAST broth micro-dilution reference method.

Results:

A total of 505 bacterial-antimicrobial combinations were analysed. A categorical agreement of 95.45% (482/505) was achieved between SLIC and Vitek/disk diffusion. The remaining 23 discrepancies were resolved by broth micro-dilution with 10 AST results agreeing with the SLIC result and 13 in agreement of Vitek/disk diffusion. Thus the overall AST agreement of the standard workflow was 98.01% (495/505) compared to 97.43% (492/505) using SLIC. The mean time for AST was 1.94 + 0.02 h and 10.53 + 0.46 h for SLIC and Vitek respectively. Overall SLIC was calculated to save 25hrs from positive blood culture to AST outcome.

Conclusion:

SLIC has the capacity to provide AST at the same time as Gram stain or MALDI-TOF identification.This could improve the value of blood culture in clinical practice.
Laboratory lessons in identifying Pasteurella bettyae
Authors: Lee Marco , Justin Winston , Bishop William
Published: March 2020

Introduction:

We discuss the phenotypic features of a clinically significant blood culture isolate that was ultimately identified as Pasteurella bettyae, with important laboratory learning points.

Laboratory diagnosis:

The blood culture from a female patient with septic shock from an unknown source grew a Gram-negative, oxidase-positive, coccobacillus that was initially identified by API® NH as Haemophilus influenzae (%ID=99.8; T=0.75). A respiratory source was therefore investigated for. The MALDI-TOF result, which was returned to the laboratory 4 weeks after blood culture became positive, revealed the isolate to be Pasteurella bettyae (score=2.305). P. bettyae is an unusual organism associated with gynaecological infections, such as Bartholin’s abscess. Local source control, such as incision and drainage of a Bartholin’s abscess, may accelerate resolution of sepsis. The laboratory misclassification of P. bettyae as H. influenzae using API® NH may lead to misidentification of the source of infection.

Learning points:

1. Correctly identifying P. bettyae as the cause of a Gram-negative coccobacillus bacteremia can prompt suspicion of a gynaecological source of sepsis.

2. P. bettyae and H. influenzae, as members of the same family Pasteurellaceae, have overlapping morphological and biochemical features that can lead to laboratory misclassification. A catalase test and x+v plates can clearly differentiate the isolates (discussed further in poster). It is recommended that laboratories perform both tests, with MALDI-TOF confirmation if possible, rather than rely solely on the result of an API® NH.
A review of the utility of PET imaging in Staphylococcus aureus bacteraemia (SAB) using electronic data
Authors: Cavaliere Chiara , Klein John , Goodman Anna
Published: March 2020

Introduction:

If the infectious focus is not identified, there is an associated higher mortality in Staphylococcus aureus bacteraemia (SAB) [1]. A retrospective observational study found patients with high-risk SAB who had a PET scan had a 67% reduction in mortality compared to those who did not [2]. We used electronic data to determine the range of infectious foci in SAB and the use of PET in our trust.

Methods:

From 1/1/13 to 31/12/18 all patients with SAB at St Thomas’ Hospital, London, were reviewed by the infectious diseases team and data collected prospectively using an Access database. A retrospective analysis of this database, electronic records, radiology and nuclear imaging was conducted.

Results:

355 episodes of SAB affected 296 patients. 28 (8%) episodes were MRSA in 24 (8%) of patients. Infectious sources found included bone and joint (23%), IV access (15%), vascular infection (15%), no infective focus (13%), SSTI (12%) and endocarditis (9%). Imaging used to determine the focus of infection included MRI (18%), CT (26%) and PET scan (10%). In-hospital mortality was significantly lower in those who had a PET scan than in those who did not (1/31, 3% v. 50/265 patients (last episode), 19%, P=0.03).

Conclusions:

Mortality was lower in those who had PET at our trust. This is consistent with data published from other centres and requires further investigation. A prospective trial of PET in SAB is urgently needed.

References:

[1] PMID: 30179645

[2] PMID: 28336786
The Accuracy of 1,3-B-D-glucan testing in diagnosing Fungal Infections: A comparison of high-risk groups within the ICU setting
Authors: Chang Jan , Hamilton Fergus
Published: March 2020

1,3-B-D-Glucan [BDG] is found in the cell wall of most fungii species and BDG testing is currently used as an adjunct for diagnosing fungal infections in immunocompromised patients. Guidelines on use of BDG testing is still unclear due to uncertainties on its reliability as a diagnostic tool. We aimed to determine the accuracy of BDG testing for diagnosing fungal infections and observed general patient demographics for those more at-risk of infection within the ICU setting. A case control study was carried out on 158 patients who had BDG tests requested in UH Bristol. This was further divided into 69 positive BDG result group and 89 negative BDG result control. Patient BDG results were compared to gold standard diagnostic criteria of positive signs on CT scans, BAL PCR and Blood or sputum cultures to confirm presence of fungal infection. Control group implied negative BDG test results consistent with negative gold standard diagnostic testing results in order to determine true negative cases. We determined BDG to have Sensitivity of 89.2%, Specificity of 66.9%, Positive predictive value of 36.3% and Negative Predictive value of 97.8%. Majority of ICU patients affected by fungal infections requiring BDG testing included stem cell transplant, neutropenic, GI surgical and Haematology admissions. In conclusion, BDG has a large Negative Predictive Value and is a good test to use in excluding fungal infections. However, it has limited sensitivity and positive BDG is not helpful in confirming presence of fungal infections.
Evaluation of Xpert® Xpress Strep A Test for detection of Group A streptococcus in throat swabs
Authors: Eldirdiri Sahar , Omojola James , MacDonald Shona , Carmichael Ian , Parcell Ben
Published: March 2020

Background

Streptococcus pyogenes (Group A β -hemolytic Streptococcus) infections in humans range from mild pharyngitis to life-threatening infections such as septicaemia and necrotizing fasciitis. We assessed the diagnostic accuracy of the Xpert® Xpress Strep A Assay, a new automated real-time polymerase chain reaction (PCR) that can detect this pathogen.

Methods

We evaluated the diagnostic accuracy (sensitivity, specificity PPV and NPV) of Xpert® Xpress Strep A Test (Cepheid, Maurens-Scopont, France) for the detection of Group A Streptococcus in throat swabs using Copan virus transport medium at Ninewells Hospital & Medical School (Dundee, Scotland, UK). The performance of Xpert t® Xpress Strep A Assay was compared with routine culture (gold standard method).

Results

A total of 323 clinical throat swab samples were tested. The sensitivity of Xpert ® Xpress Strep A Assay was found to be 95% (95% CI, 75.13% -99.87); specificity 96.5% (95% CI 93.83% -98.36%);PPV 65.5% (95% CI 50.61% -77.89%); and NPV 99%(95% CI 97.68% -99.95%). Overall, there were eleven discrepant results, of these 10 were positive by PCR and not confirmed by culture and one sample was recorded positive by culture and negative by PCR. The turnaround time (TAT) was 24 minutes for negative samples and 18 minutes for positive samples.

Conclusion

The Xpert® Xpress Strep A Assay for detection of Streptococcus pyogenes in throat swabs had high sensitivity, specificity and rapid TAT. Use of this technology as a point-of-care test could be explored further to assess its impact on antimicrobial prescribing and infection prevention and control measures.
The public health task force in the management of the Mycobacterium chimaera case in the Vicenza hospital, Italy
Authors: mondino Sara , Manfrin Vinicio , Rassu Mario , Fallico Loredana , Mantoan Paola , Zanon Maria Paola , Cazzaro Romina , Barra Salvatore
Published: March 2020

BACKGROUND

Since 2013, an ongoing global outbreak of Mycobacterium chimaera among patients who underwent open-chest surgery has been recognized with all cases linked to contamination of a specific brand of heater-cooler device (HCD). Nine cases were diagnosed with disseminated M. chimaera infectionin our hospital. Following the first cases HCD was changed with different technology assuring no release of contaminated particles. The potentially at-risk population was managed throughout a multidisciplinary task force.

METHODS

In November 2018, following an infected patient’ death, a huge impact on public opinion was registered following mass media publicity of the case. A task force was built up to face the concern of the population: apress release [https://context.reverso.net/traduzione/inglese-italiano/press+release]and an official note were publicly released addressing risk factors and critical symptoms and a call center was activated. The notice was transmitted to general practitioners too. People complaining symptoms suggestive for infection, primarily screened by an expert group through telephone interview, were addressed to an infectious consultation.

RESULTS

The official note was delivered to 2181 potentially at risk patients chosen by cardio surgery registry and 567 of them called back the call center and were interviewed. 66 patients were judged to need infectious specialist consultation: 12 were submitted to further microbiological analysis and 4 required hospitalization. No new cases of infectious were detected.

CONCLUSION

The public health task force promptly activated granted safety measures for the population; furthermore HCD will soon be settled in separated place out from operating room.
Application of the Bruker IR Biotyper for Strain Typing During An Outbreak
Authors: Alhasabi Jenan , Balakrishnan Indran , Wey Emmanuel
Published: March 2020

Background

Molecular typing methods such as whole genome sequencing are relatively time-consuming and expensive. Here we demonstrate the effectiveness of the Bruker IR biotyper in strain typing.

Methods

Isolates of multi-resistant Enterobacteriacae from clinical samples were typed using the Bruker IR Biotyper. The relationships between isolates were analysed using the Bruker IR biotyper software (version 2.1.0.195).

Results

On dendrogram analysis, the 13 E. coli isolates mostly clustered independently with all 5 replicates. Two isolates (RFH035 and RFH007) clustered together, their replicates spanning across 3 clusters, indicating that they are the same isolate. This was confirmed on Principle Component Analysis (PCA).

EightK. pneumoniaeisolates segregated into 7 clusters. Two isolates (RFH033 and RFH006) clustered together initially but separated on the PCA plot.

Discussion

RFH035 and RFH007 both came from patients infected with NDM-producing E. coli. Their PFGE profiles are indistinguishable. Both patients were admitted to hospital and were on the same ward simultaneously, reflecting the co-clustering seen with the Bruker IR biotyper.

Both RFH033 and 006 were NDM producers, but RFH033 co-produced OXA48. They had almost indistinguishable VNTR profiles with only one difference. This relatedness but difference in resistance profile is reflected in the close relationship seen on dendrogram but separation by PCA seen with the Bruker IR biotyper.

The Bruker IR biotyper is therefore able to reliably demonstrate relatedness and discrimination between strains of E. coli and K. pneumoniae. This methodology has much faster turnaround times than conventional methodology, and therefore has the potential to inform outbreak management in a more timely manner.