bluuebunny/crossref_metadata_2025 huggingface dataset:
Cruising for bruising
Authors: Schwab Uli
Published: March 2020

A 83 year old man presents with anorexia, rigors and cough after a cruise along the Scandinavian coast/British Isles. Febrile 38.7C, tachycardic but haemodynamically stable, with marked thrombocytopenia(41), abnormal PT(15), renal impairment, raisedCRP, normal WC's including differential and CXR. Throat swab, serial blood cultures, MSU culture-negative. Despite IVfluids, broad spectrum antibiotics for presumed lower respiratory tract infection with AKI and delirium pyrexia persists, CRP rises to 223, and he develops abdominal pain, jaundice (Bilirubin158, AST249, ALT94, AlkP277), worsening renal function (Crea543) oliguria, anaemia (Hb7.6, haptoglobin<0.03g/l) with worsening confusion and bruising suggestive of a hepato-renal syndrome with DIC prompting transfer to the regional ID unit. PMH includes AVR/TAVI, PUD, Waldenstroem's macroglobulinaemia previously receiving IVIG's and Rituximab, last 3 months prior. Extensive travel history, Nigeria ('60ties,'90 and 2003)), Kenya, Malaysia/Taiwan, Indian Subcontinent ('70ties), South Africa ('97) Korea (2011). A blood film suggest malaria 20-30%parasitaemia, posing speciation difficulty. Of note he spent most summers on Great pond/Belgrade(Maine/USA), most recently 4 weeks before presentation, pointing towards epidemiological Babesiosis exposure particularly in an immunocompromised individual with a negative RDT for P.falciparum, later confirmed as 22% parasitaemia, B.microti ELISA+ve, IFAT+ve1:320 (negative blood-borne-virus-screen, Leptospira-DNA, Hantavirus-IF, B.burgdorferi and Anaplasma-IF). Despite IV Cefotaxime, Artesunate, po Doxycycline, Atovaquone/Azithromycin together with IVClindamycin/Quinine, - a pan-reactive auto-Ab panel, prevented Exchange transfusion-, he deteriorates rapidly despite full organ support and dies from multi-organ-failure. Ferritin elevation >
16.000 suggests Haemophagocytic Lymphohistiocytosis confirmed on post-mortem. Epidemiology, diagnosis, prognosis and treatment of Babesiosis will be discussed.
Towards a harmonised approach to Carbapenemase-producing Enterobacteriaceae (CPE) screening and patient management in North East and Cumbria hospitals
Authors: Love Nicola , Darke Joanne , Howard Simon , Davison Paul , Denton Miles , Samuel Julie , Manley Petra
Published: March 2020

In mid-2018, a Carbapenemase-producing Enterobacteriaceae (CPE) cluster was investigated in the North East of England, in which transmission had occurred across several hospital trusts. We undertook a survey of current CPE detection and management practices in North East and Cumbria (NEC) trusts to inform a harmonised approach that could be adopted across the region.

A semi-structured survey was carried out with one consultant microbiologist per trust by telephone interview (n=6) or electronic questionnaire (n=3) to determine CPE screening procedures, laboratory techniques and patient management practices.

Screening policies were in place in all trusts, including screening protocols for patients previously admitted outside of the UK or those known to be CPE positive, in accordance with PHE guidelines. Policies for screening patients who had been admitted to other UK hospitals varied across trusts, as did laboratory methods used. Over 80% of trusts communicated CPE status to patients and contacts by information leaflet. However, there was no uniform way of communicating CPE status to social care settings, GPs and other hospital trusts in the event of discharge or inter-hospital transfer.

The results of the survey suggest improvements could be made to the way information on patient CPE status is shared to ensure that the risk of transmission is reduced. This includes improved communication with residential settings, primary care and other hospital trusts in the event of a discharge or inter-hospital transfer. In addition, this work will inform further discussions across NEC towards developing a single regional Infection Prevention and control strategy for CPE.
Real-world experience with Isavuconazole therapy in a large tertiary hospital in Cambridge, UK
Authors: Enoch David , Tyler Netta , Micallef Christianne , Wong Vanessa
Published: March 2020

Background: Isavuconazole (ISV) is a second-generation triazole antifungal used for invasive fungal infections (IFIs). Here, we describe our experiences of ISV.

Methods: This single-centre retrospective study included all patients who commenced a course of ISV over a 3-year period (1/7/16-30/6/19). ISV was used for the treatment of IFIs when no alternative was suitable. Demographics, clinical details and antimicrobial history were obtained from our integrated electronic health record and laboratory system (EPIC).

Results: Twenty-four patients, aged between 17–78 years (median 54), received ISV in the study period. Sixteen (67%) were haematology patients. Using EORTC criteria, six had possible invasive aspergillosis (IA), 1 had a possible yeast infection, 13 had probable IA, 3 had proven IA and one had a proven yeast infection. Four were neutropenic (neutrophil count <0.5x109/L) and 7 had renal impairment. Half of the patients (12/24; 50%) had received a transplant prior to commencing (nine allografts, one kidney, one lung, one multi-visceral) and a further two underwent an allograft whilst receiving ISV. ISV pre-dose levels ranged from 1.29–7.7mg/L (median 2.73mg/L; IQR 2.1 – 3.13mg/L). ISV was given for 1–733 days (median 42 days). In patients who were still alive during therapy, the treatment duration ranged from 3–342 days (median 97 days). Ten were dead within 42-84 days of commencing therapy; 6 had died by the end of therapy.

Conclusion: Our findings suggest that ISV is used infrequently, predominantly in haematology. More data is needed to determine optimal treatment course and the role of therapeutic drug monitoring.
Occurrence and Evaluation of Antimicrobial Susceptibility of Staphylococcus aureus Isolated from Chicken Eggs, Eastern Ethiopia
Authors: Kemal Jelalu , Beji Wakene , Tesfamariam Gebregeorgis
Published: March 2020

A total of 335 egg samples were obtained from open market (n = 174) and poultry farm (n = 161) to isolate Staphylococcus aureus present on eggs, and determine antimicrobial susceptibility patterns. A sterile cotton swab was used to sample the surface of eggs. After sterilizing the shells, the egg contents were sampled. Isolation of Staphylococcus aureus was done based on culture characteristics, Gram staining and biochemical tests. The isolates were subjected to antimicrobial susceptibility testing using disc diffusion method. Out of the total 335 eggs sample examined, 93(27.8%) samples yielded S. aureus. Out of these, 28(17.4%) were from poultry farm while 65(37.4%) were obtained from open market. Similarly, 63(18.8%) were from the shell while 30(8.9%) were from the content. The occurrence of S. aureus in the egg shell collected from open market was significantly higher than egg shell obtained from poultry farm (P = 0.021). The level of S. aureus in egg contents was also significantly higher in the open market (P = 0.003). All 76 S. aureus isolates were resistant to at least one of the antimicrobials tested with overall 3.9-92.0% level of resistance pattern showing higher resistant to penicillin (92%), ampicillin (89.5%) and amoxicillin (55.3%). Multiple drug resistance to more than two antimicrobial agents was detected in 86.8% of the total S. aureus isolates. The study showed high level of S. aureus with considerable antimicrobial resistant pattern. Further study is needed to better define bacterial resistance to antimicrobial agents with emphasis on surveillance of multiple drug resistant.
In-Vitro Antibacterial Therapy of Ficus exasperata, Securinega virosa and Tamarindus indica Leaf Extract on Bacterial Isolate from Otitis Media effusion
Authors: Ojo Abidemi , Ojo Olugbenga , Adebajo Seun , Oladotun Biola , Sodunke Ganiyat , Ejilude Oluwaseun
Published: March 2020

Background:

Antibiotics resistance which is a global health challenge is no longer a future threat but a present challenge to all facet of clinical settings. Thus, treatment of Otitis media effusion in this regards is a major concern.

Objectives:

The aim of this study was to determine the efficacy of three medicinal plant extract in the treatment of Otitis media as an alternative therapy.

Methods:

The antibacterial effect of absolute methanol leaf extract of Ficus exasperate, Securinega virosa,and Tamarindus indica on organisms isolated from otitis media effusion was determined using agar well diffusion method. The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) was also determined using the double fold dilution technique. Treatment means were compared with Duncan’s New Multiple Range Test at 5% level of significance using Statistical Analysis System

Results:

Bacteria isolated include Staphylococcus aureus 19(39.58%), Klebsiella pneumonia 15(31.25%), Pseudomonas aeruginosa 10(20.83%), Proteus mirabilis3(6.25%) and Streptococcus pneumoniae 1(2.08%). At 1.0mg/ml concentration, At 1.0 mg/ml concentration, Tamarindus indicainhibited all the isolates; For Ficus exasperate,the MIC was 0.39 mg/ml and MBC was 0.78 mg/ml against Pseudomonas aeruginosa; Securinega virosa MIC was 0.78mg/ml and MCB 1.56mg/ml against Staphylococcus aureus, Pseudomonas aeruginosaand Klebsiella pneumoniae. Tamrindus indica lowest MIC was 0.39 mg/ml and MBC of 1.56 mg/ml against streptococcus pneumoniae. The antimicrobial activity of the three extracts shows significant (P<0.05) inhibition for the organisms.

Conclusion:

This study showed the potentials of the aforementioned extracts as treatment options for cases of OME.
Pharmacodynamic evaluation of intermittent versus prolonged infusion dosing regimens of piperacillin/tazobactam in a hollow-fiber infection model against two susceptible Klebsiella pneumoniae clinical isolates
Authors: Sumi Chandra Datta , B.Sime Fekade , Heffernan Aaron J. , Naicker Saiyuri , Islam Kamrul , Cottrell Kyra , Harris Patrick N.A. , Roberts Jason A.
Published: March 2020

Background - This study aims to compare the bacterial killing and suppression of resistance emergence of intermittent and prolonged infusions of piperacillin/tazobactam (PTZ) against clinical K. pneumoniae isolates.

Methods - Two clinical isolates, CTX-M-14 producing #69 (MIC 1 mg/L), and DHA-1, SHV-106 producing #68 (MIC 8 mg/L), were studied in a dynamic hollow-fiber infection model over 7 days (initial inoculum 107 CFU/mL). Three piperacillin doses (4/0.5g over 0.5h, and 4h infusion 8 hourly; 12/1.5g continuous infusion 24h) against #69, and six dosages of piperacillin (4/0.5g over 0.5h, and 4h infusion 8 hourly, and 12/1.5g continuous infusion 24h; 4/0.5g over 0.5h, and 3h infusion 6 hourly, and 16/2g continuous infusion 24h) against #68 were tested. The total and less-susceptible bacterial populations were determined.

Results - For all PTZ dosing regimens against #69, there were ∼4 logs of bacterial killing over 8h. The amplification of less-susceptible subpopulation were associated with intermittent infusion (T>MIC 90%, Cmin/MIC = 0.4) after 24h, and with extended infusion (T>MIC 100%, Cmin/MIC = 2.76) after 72h. However, continuous infusion (Cmin/MIC = 35) prevented drug resistance amplification and sterilized the model system. For #68, there was a similar initial bacterial killing profile; however, all regimens were associated with the emergence of a resistant subpopulation after 8h. The MIC of resistant subpopulations exceeded 256 mg/L.

Conclusions – To maximize bacterial killing and suppress the emergence of resistance of multiple-beta-lactamases producing K. pneumoniae isolates with higher MIC alternative therapeutic strategies are required.
Positive Serum (1,3)-β-D-Glucan Testing in Surgical Patients across the Bristol Area
Authors: Hodgson Sam , Hamilton Fergus , Jacobson Kim
Published: March 2020

Background:

An evidence gap exists in anti-fungal diagnostic practice following abdominal surgery, especially when compared to haem-oncology counterparts. In light of the recent Anti-fungal Stewardship CQUIN, our study addresses the utility of serum (1,3)-β-D-Glucan (BDG) testing post-gastrointestinal surgery.

Method:

We identified positive BDG results (>/=80pg/mL) on ITU and surgical wards in 3 major institutions in the Bristol area. Those with a ‘history of abdominal surgery </=30 days previous’ were identified using electronic health records. Other variables included number of days from surgery to testing, value of the result, and past medical history.

Results:

110 patients with positive results were identified. 19 (17.3%) of these had a history of abdominal surgery. By surgical type, 6 (31.6%) had major abdominal surgery. 6 (31.6%) had pancreatic surgery and 5 (26.3%) small bowel resection. 2 had other types of surgery. The mean BDG score was 286pg/mL. 1 patient had risk factors other than gastrointestinal surgery for a positive BDG result.

Only 1 patient died within 28 days. Patients tested between 0-9, 10-19 or 20-30 days of surgery had mean BDG scores of 329pg/mL, 302pg/mL and 390pg/mL respectively. 40% were tested within 9 days of surgery. There was no clear evidence of invasive fungal infections.

Conclusion:

Positive BDG testing is common after surgery, but does not appear to be associated with a significant mortality burden. Ensuring appropriate anti-fungal therapy is essential for treatment, risk reduction and cost containment. More research is needed to identify appropriate testing strategies in patients with abdominal surgery.
Anti-biofilm potential of peptides against foodborne pathogens
Authors: Shen Cunkuan , Kubo Rinka , Masuda Yoshimitsu , Honjoh Ken-ichi , Miyamoto Takahisa
Published: March 2020

Background:

Biofilm is defined as a community where bacterial cells encased in a matrix of extracellular polymeric substances adhere to each other and/or to a surface. In food industry, foodborne pathogens like Salmonella are capable of forming biofilms on open surfaces. We have shown anti-biofilm effects of ε-poly-lysine (PL) and milk serum protein (MSP) against various bacteria. In this study, peptides derived from egg was investigated for anti-biofilm effects on foodborne pathogens.

Methods:

Effects of several kinds of peptides, including 3 kinds of hydrolysates derived from egg, together with PL and MSP, on biofilm formation of 4 kinds of foodborne pathogens (Escherichia coli O157:H7, S. Typhimurium, Staphylococcus aureus and Listeria monocytogenes) were investigated on microtiter plates through biomass quantification with crystal violet staining.

Results:

Both 0.01% PL and 0.25% MSP significantly decrease biofilm formation of all the pathogens, while PL was more effective than MSP against gram-negative bacteria. All the hydrolysates showed considerable effect under high concentration (1%), among them hydrolysate 2 was more effective than the others since it inhibited biofilm formation of S.Typhimurium, even under concentration of 0.1%.

Conclusion:

The egg white hydrolysate contains some antibacterial peptides that could modulate biofilm formation of S.Typhimurium and other pathogens, which could be beneficial to develop new strategies to combat biofilm infections.
Characterization and utilization of phages specific to Campylobacter coli
Authors: Huang Hung-Hsin , Hoang Minh Duc , Masuda Yoshimitsu , Honjoh Ken-ichi , Miyamoto Takahisa
Published: March 2020

Campylobacter spp. are commonly found in raw meat especially poultry meat. Control of Campylobacterin poultry meat is difficult due to therate of contamination and viable counts of Campylobacter. Bacteriophages (phages) have been increasingly exploited to combat the bacterial contamination in food. This study demonstrated the isolation, characterization and application of lytic phages against Campylobacter coli (C. coli). From 23 different raw beef and chicken meat samples, a total of 16 lytic phages against C. coli were successfully isolated and purified. Among these phages, CAM-P21, isolated from beef mince, was morphologically characterized as aunique member of the Siphoviridaefamily, with a broad host range, a higher titer and great stability under various stress conditions. Phage CAM-P21 seems unique since almost all Campylobacterphages isolated so far are members of the Myoviridaefamily. One-step growth curve indicated that phage CAM-P21 had a latent period of 60 min and a burst size of 20 PFU/cell. DNA purification and gel electrophoresis revealed that the genome sizes of phage CAM-P21 was estimated to be approximately 15–17 kb. The phage CAM-P21 significantly reduced (P< 0.05) the viable counts of C. coli in vitroby 2.11 log after 12 h of incubation at 42°C, 2.67 log after 24 h at 37°C and 1.09 log after 48 h at 8°C, compared with untreated controls. These findings suggest that phage CAM-P21 seems to be a potential and promising agent for biocontrol of C. coli in food.
An Assessment of Point-of-Care PCR Testing for the Diagnosis and Management of Meningo-Encephalitis
Authors: Gamio-Izasmendi Diana , Cooke Benjamin
Published: March 2020

BACKGROUND

Meningitis and Encephalitis are potentially fatal infections. When suspected, empirical treatment is started, and only safely discontinued once excluded. The impact of current CSF investigations is prolonged inpatient stay, and exposure to broad-spectrum antimicrobials. Biofire Filmarray is a point-of-care PCR system. Our aim was to assess time to BioFire result, and its impact on clinical management.

METHOD

BioFire was implemented, in addition to current practice, on CSF samples with WCC ≥10 and all neonatal samples processed between November 2018 and February 2019. Data was collected prospectively for: patient demographics, sampling time, time to result of BioFire and current PCR, antimicrobial regime, and early discharge. Percentage agreement between BioFire and current PCR, mean time to result, percentage cases with reduction in antimicrobials, and mean length of stay for those discharged based on BioFire, were calculated.

RESULTS

There were 22 samples analysed. There was an 86.4% agreement between BioFire and current PCR. In cases of disagreement, BioFire identified pathogens where standard PCR had not. One sample was insufficient for virology PCR however, a full array was obtained from BioFire. Mean time to BioFire result authorization was 17.8 hours, compared to 316 for virology PCR and 331.2 for bacteriology PCR. BioFire allowed narrowing of antimicrobial therapy in 22.7% of patients, discontinuation in 41.0%, and early discharge in 27.3%.

CONCLUSION

BioFire provides comparable diagnosis of meningo-encephalitis faster than current practice. With the current focus on rising bed pressures and antimicrobial stewardship, BioFire allows targeted therapy and safe early discharge where infection is excluded.
Myroides odoratimimus necrotising fasciitis and recurrent bacteraemia in an immunosuppressed patient with chronic leg ulcers: an emerging pattern?
Authors: Ainarozidou Aikaterini , Evans Andree
Published: March 2020

Introduction: A 58yr old with inflammatory arthritis and diabetes, taking biologics, methotrexate and prednisolone, presented unconscious, hypotensive in acute renal failure. She had chronic leg ulcers and blistering, necrotic skin on both legs. After resuscitation, empiric meropenem and clindamycin, and urgent surgical debridement of her legs, she spent 2 days on ITU. A rapid recovery followed with discharge home after 7 days.

Methods: Histological samples were consistent with necrotising fasciitis. Blood and tissue cultures grew a yellow pigmented, oxidase positive, Gram negative bacillus with a distinctive fruity smell. 16S PCR confirmed Myroides odoratimimus.

The patient was readmitted 3 months later with unhealed leg ulcers, sepsis and blistering cellulitis

Blood cultures again grew Myroidesspp.

She recovered with meropenem and avoided ITU admission.

Discussion: Review of laboratory isolates over 2 years revealed a previous fatal case of Myroides bacteraemia in an 87year old woman with leg ulcers and possible necrotising fasciitis

Two further isolates were recovered from community samples:

* A cat bite in a 55 year old woman with alcohol excess.

* A chronic diabetic foot infection in an 80year old man.

Neither patient was admitted to hospital.

A PubMed search for “Myroides “ yielded 107 results. Most detailed the wide environmental distribution, multiple antibiotic resistance, and biofilm forming ability of the genus - worrying attributes in organisms causing infection in immunosuppressed patients.

Eleven of the twenty-three clinical papers described SSTI in patients with diabetes, renal disease, cirrhosis or other immunosuppression, including 3 of the 4 reported bacteraemias. Our cases fit well with this pattern.
Airborne Decontamination of an Intensive Care Isolation Room using 405 nm Antimicrobial Light Technology
Authors: Dougall Laura , Booth Malcolm , Anderson John , MacGregor Scott , Maclean Michelle
Published: March 2020

Lighting systems which incorporate antimicrobial 405nm light have been developed for safe continuous, environmental decontamination, with previous studies demonstrating efficacy for decontamination of frequently-touched surfaces around clinical areas. This study provides first direct evidence of the effects of this decontamination system for control of airborne contamination.

The study was conducted in a patient-occupied ICU isolation room over a 15-day period, with air samples collected at set times (before, during and after daily use of the decontamination system). Samples were also collected in the empty room prior to occupation. Environmental monitoring occurred every second day using a sieve-impactor sampler (500L air samples collected every 10-min over 2-hr (n=13)). Room activity was logged and bacterial contamination levels recorded as cfu/m3of air.

After 2-day use of the system, airborne contamination significantly decreased from a mean of 905.2 cfu/m3 to 48.8 cfu/m3 (P=0.002). Levels then remained fairly consistent over the remaining period of system use (48.8-189.8 cfu/m3) before significantly rising after the system was turned off for 3-days (P=0.001). Additional samples collected in isolation rooms without the decontamination system demonstrate that the levels of airborne bioburden tend to increase upon increasing patient stay, however low levels were maintained as patient occupation increased when the system was in use.

This study provides first direct evidence of the susceptibility of airborne bacteria to 405nm light within a clinical setting. This patient-safe technology has the potential to improve infection control strategies by complementing existing measures, which could reduce the number of infections arising from environmental sources.
Candida aurisexhibits resilient biofilm characteristics in vitro: implications for environmental persistence
Authors: Short Bryn , Delaney Christophe , Sherry Leighann , Kean Ryan , MacKay William , Williams Craig , Ramage Gordon
Published: March 2020

In the decade since its discovery, Candida auris has rapidly became a serious problem within healthcare environments. This fungal pathogen readily colonises skin and is responsible for numerous hospital outbreaks in different continents presenting high morbidity and mortality rates. However, the mechanisms it uses to spread throughout nosocomial settings still remains enigmatic. C. auris biofilm formation was monitored in real-time and the transcriptome of these biofilms were identified using RNA-sequencing and the ability of C. auris to persist on a polymer surface and tolerate treatment with a commonly used disinfectant in sodium hypochlorite (NaOCl) was assessed. Contrary to previous findings, C. auris biofilms were found to be heterogeneous and not dependent on cell phenotype. Through transcriptomic analysis and assigning transcripts into GO terms, a large number of genes involved in cell components, specifically fungal cell wall and cell membrane. Genes involved in these components were also up-regulated in dry biofilms of aggregating fungal cells compared to their single-cell counterparts. Aggregating C. auris biofilms were able to persist and tolerate disinfectant treatments more successfully than single-cell biofilms. These findings show that the aggregating phenotype of C. auris likely helps drive its survival and spread throughut hospital wards during outbreaks. Nonetheless there are still caveats in our understanding of C. auris biology and filling these holes will help in the development of more effective decontamination and infection control protocols for this emerging and deadly pathogen.
Combination of Bedaquiline plus Delaminid within a treatment regimen for Pre-XDR TB; experience of a tolerable regimen and acceptable safety profile for the first time in Scotland
Authors: Cobb Katherine , Wilson Aline , Rae Nikolas , Stevenson Neil
Published: March 2020

Introduction: A 29 year old female of Pakistani origin was diagnosed with MDR-TB affecting cervical nodes, with pulmonary and laryngeal disease demonstrated on CT. Genotypic (and subsequent phenotypic) testing demonstrated pre-XDR resistance pattern with Izoniazid, Rifampicin, Ethambutol & Fluroquinolone resistance.

Methods: Following commencement of induction regimen with Amikacin, Cycloserine, Prothionamide, Pyrazinamide, Linezolid and Clofazimine, borderline ototoxicity developed after 6 months, necessitating a switch from Amikacin to Bedaquiline. After around 10 months, Linezolid and Cycloserine were discontinued sequentially due to progressively debilitating peripheral neuropathy, PAS was subsequently added to the regimen which was poorly tolerated. PAS was substituted for Delaminid (used with Bedaquiline, Clofazimine and Pyrazinamide) despite concerns regarding potential cumulative QTc prolongation effects. Patient was counselled regarding risk of cardiac arrhythmias; fortnightly ECG monitoring was agreed to for three months, then monthly thereafter. Manual calculations of QTc were performed using Fredericia formula.

Results: QTc rose maximally to 491 ms (89ms greater than baseline). Clinical and radiological monitoring demonstrated favourable improvement in condition. No further adverse events or toxicities were reported. The patient continues to tolerate the regimen well with no components of the regimen requiring discontinuation.

Dicussion: Bedaquiline and Delamanid are rarely used together in combination due to risk of QTc prolongation; in this clinical case they were used with no concerns being raised regarding safety or tolerability. Our experience corresponds with the international data produced by Ferlazzo et al. Whilst further large volume safety data is awaited, compassionate use of alternative drug regimens within strict monitoring guidelines should be considered.
Gram-negative Galore and the Gut
Authors: Anpalakhan Shobana , Schwab Uli
Published: March 2020

An 81-year-old diabetic man with PAF, pleural thickening due to benign fibrous pleuritis and a PPM developed rigors/pyrexia (39°C) with no localising signs of infection. Blood cultures grew Pseudomonas aeruginosa (May 2017) and Enterococcus faecalis (November 2017), MSU was negative and imaging was normal. Readmitted in May 2018 and discharged clinically well with CRP 40 and no acute abnormalities on investigations, he returned with further rigors the following day with E. coli and Enterococcus faecium bacteraemia, treated with Tazocin/Tigecycline. CT colonography revealed a primary recto-sigmoid tumour with high-grade dysplasia on biopsy. In July 2018,he developed a Pseudomonas aeruginosa bacteraemia responding to Tazocin/Ciprofloxacin. Planned surgery was delayed due to anaesthetic instigated pre-operative cardiac rehab optimisation. In August 2018, further rigors/pyrexia were empirically treated with Tazocin/Teicoplanin/Amoxicillin for 3 weeks covering a Staph epidermis/capitis bacteraemia. He underwent an open Hartmann’s with total mesorectal excision two weeks later, complicated by pre-sacral collections drained transcutaneously. Suboptimal antibiotic cover however led to further pseudomonas bacteraemia three weeks later and pseudomonal bacterial peritonitis three months later, managed with prolonged meropenem/ciprofloxacin therapy. TTE two months post-discharge showed a 1cmx0.5cm mass on the RV lead of his pacemaker leading to its removal. Repeat TTE showed tricuspid valve endocarditis with a 2.2cmx0.3cm mobile mass and severe TR. Six weeks of Meropenem therapy achieved sterilisation without further complications. Infectious diseases specialist input should be sought early and can be pivotal in appropriate source control and adequate antibiotic management following organism identification.
Difficile but not impossible: Improving documentation to improve outcomes for Clostridium difficile infections in NHS Ayrshire and Arran
Authors: Keane Chloe , Doran Niamh , Lavery Clare , Sutcliffe Liam , Davis Peter
Published: March 2020

Background

Clostridium Difficile Infection (CDI) varies in severity and presents challenges in management. Whilst incidence is decreasing, the mortality rate in NHS Ayrshire & Arran is 10%. We evaluated if a new infection severity assessment sheet improved management.

Method

A retrospective case note review was performed on all cases of CDI, confirmed by clinical symptoms and laboratory sampling. Our audit assessed both predisposing factors and management. The first cycle ran from January-March 2018. The second cycle ran May-November 2018 after the introduction of the new severity assessment sheet.

Results

There were 20 episodes of CDI in the first cycle, and 38 episodes in the second cycle (n=58). Following introduction of the new severity assessment sheet CDI diagnosis, management and documentation improved. High-risk antibiotic use prior to CDI fell from 65% in the first cycle to 34% in the second cycle. Discussion of CDI diagnosis with relatives increased from 70% to 86.8%. Documentation of day 1 and 5 infection severity scores improved (50% to 57.9% and 10% to 31.6%, respectively). Improvements were noted in prompt stool sampling after symptoms (90% to 97.4%), fluid balance chart use (80% to 89.5%), stopping unnecessary antibiotics (58.3% to 81.3%) and documentation of daily assessment (5% to 23.7%).

Conclusion

The results highlight positive improvement in outcomes following a well-publicised introduction of an improved CDI proforma. Despite this, further intervention and monitoring is required to improve documentation of daily assessment in CDI. Additionally, there is still progress to be made to prevent unnecessary use of high risk antibiotics.
Key factors around successful management of CPE infection in a patient with pancreatic collection
Authors: Zhou Zhaowei , Hasnie Sulman
Published: March 2020

Carbapenemase-Producing Enterobacterales (CPE) are threat to public health as they are resistant to one of the broad-spectrum antibiotic classes (Carbapenems) in clinical use.

In this report we highlight the need for optimal choice and duration of antimicrobial therapy in combination with source control for successful management of CPE infection.

A 52-year old male was admitted under general surgery with CT confirmed severe pancreatitis. He was commenced on cefuroxime and metronidazole for associated cholecystitis based on local guidelines. Treatment was gradually escalated to Meropenem due to intermittent pyrexia and inadequate response to standard antimicrobial therapies with no obvious source control solution. Following 39 days of Meropenem the fifth CT scan showed drainable peri-pancreatic collections. The drained pus sample grew Escherichia coli and Bacteroides species. The Escherichia coli were confirmed to be CPE gene (KPC) positive by PCR and sensitive to Tigecycline and Gentamicin but resistant to Meropenem and Ciprofloxacin based on MicroScan automated sensitivity panel.

Initially Tigecycline was commenced, however, due to unsatisfactory clinical progress treatment escalated to Ceftazidime/Avibactam and Co-Trimoxazole and patient completed a three-week course. The percutaneous drain was upgraded twice to facilitate drainage. Follow-up CT showed reduction of collection and patient discharged after 115-day stay.

This case demonstrated that CPE infection should be suspected in patients with persistent fever after a prolonged course of carbapenem treatment. A prompt laboratory diagnosis and effective multidisciplinary collaboration among microbiologists, surgeons and radiologists proved to be successful in achieving source control of CPE infection in this case.
Cytomegalovirus reactivation, risk factors and associated clinical outcomes among non-immunosuppressed critically ill cirrhotic adults: a longitudinal observational study
Authors: Shah Dhara , Gupta Ekta , Pasupuleti Samba Siva Rao  Pasupuleti , Mitra Lalita Gouri , Maiwall Rakhi
Published: March 2020

Background: Although Cytomegalovirus (CMV) reactivation is not uncommon in critically ill patients, it has not been studied for cirrhotic patients in Liver-ICU.

Methods: CMV reactivation (CMV-plasma-DNAemia; ≥ 500 IU/ml), risk factors and clinical outcomes were assessed among sero-positive non-immunosuppressed critically ill cirrhotic adults at day 0, 7, 14 and 21 in Liver-ICU.

Results: Of 94 consecutive patients in Liver-ICU monitored, 55(48 men) patients were enrolled. Overall, 20 critically ill cirrhotic adults showed CMV reactivation with a median day for follow-up of 11 (IQR: 8 to 18). Majority (n=17/55, 30.9%; CI: 19.1-44.8) showed CMV reactivation at day 7. During 21-day follow-up, incidence rate/density of CMV reactivation was 2.75% per person-day (95% CI: 1.68 - 4.26% per person-day).Total leucocyte count (day 0) was an independent risk factor for CMV reactivation (adjusted OR: 1.15, 95% CI: 1. 00-1. 32, p=0.04) with cut-off point of 19.05 (AUROC: 0.696, 95% CI: 0.547-0.844, p=0.017). Increased nosocomial infection (p=0.009), SIRS (p=0.01) and ARDS (p=0.04) were observed at day 7, coinciding with CMV reactivation during Liver-ICU stay. ICU-Mortality (61.8%) did not significantly differ with and without CMV reactivation. (55 % vs. 65.7%, p= 0.43). Patients with CMV reactivation experienced early death and slightly longer stay in Liver-ICU. (Log rank p=0.06 and 0.17, respectively).

Conclusions: CMV reactivation occurs frequently with leucocytosis being an independent risk factor among critically ill non-immunosuppressed cirrhotic adults. Although CMV reactivation was associated with more severe organ dysfunction during Liver-ICU stay, it did not significantly influence ICU-mortality and Length of Liver-ICU stay.
Expedient management of Listeria monocytogenes endovascular graft infection in an immunosuppressed patient
Authors: McCormick Hannah , Lau Louis , Hunter Michael , Bond Helena , Troughton Judith
Published: March 2020

Introduction

Listeria monocytogenes is a rare cause of infection following endovascular aneurysm repair (EVAR); there remains lack of consensus on the optimal management strategy, in particular the need for life-long suppression. Despite this organism’s increased pathogenicity amongst immunosuppressed hosts, to date no EVAR infections have been described in this cohort.

Here we describe the first case ofListeria monocytogenesEVAR infection in an immunocompromised host.

Case description

A 75-year-old gentleman presented with a 5-day history of back pain, fever and dysuria despite 3 days of oral co-amoxiclav for presumed urinary tract infection. There was no recent gastrointestinal upset. Admission blood and urine cultures were negative.

Past medical history included on-going methotrexate therapy for rheumatoid arthritis and EVAR of the infra-renal aorta in 2013.

A CT abdomen, performed to exclude intra-abdominal pathology, revealed an enlarged aneurysmal sac and fat stranding, secondary to inflammation. A CT-guided sample of aneurysmal fluid was obtained before commencing empirical piperacillin-tazobactam and vancomycin; Listeria monocytogeneswas isolated from subculture after 5 days broth enrichment. The EVAR was removed and replaced 7 days after admission and antimicrobials rationalised to intravenous amoxicillin, ciprofloxacin and metronidazole.

The patient completed 6 weeks intravenous therapy, then commenced lifelong suppressive therapy with oral co-trimoxazole 960mg OD.

Discussion

Listeria monocytogenesEVAR infection has been described in only 8 patients; this is the first in an immunosuppressed patient. This case adds to the literature by outlining a putative management strategy, involving explanation and life-long antimicrobials, for immunocompromised patients with Listeria monocytogenes EVAR infection.
Hubris Haemoptysis - Mycobacterium kansasii , are you taking the piss?
Authors: Peters Francesca , Schwab Uli
Published: March 2020

Background: A 33 year old HIV-negative Gambian, who hadn’t left the UK for 7 years, presents with haemoptysis, 6 month cough, sweats, and weight loss. He completed standard treatment for presumed pulmonary TB in Banjul (2006), with a completely normal CXR (2015). He was normotensive, with low grade fever, Hb 110, normal clotting, mild neutropenia, CRP 11, ESR 88, with bilateral cavitating lesions in upper lobes, calcified cavity in the left apex, and tree-on bud appearance throughout left lung, suggestive of active TB. He acutely deteriorated with projectile haemoptysis, leading to haemodynamic compromise requiring tranexamic acid and embolisation of bronchial arteries.

Investigations: IGRA negative. CD4 634 (44%). The ϒ-IFN axis was tested, excluding a complete defect in the IL12-signalling-pathway. Bronchial-alveolar-lavage smear and PCR negative for MTB. Serial induced-sputa however, cultured and identified M.Kansasii, a Non-Tuberculous-Mycobacterium (NTM) on Whole-Genome-Sequencing.

Management: In absence of any radiological structural lung disease, with apparent immune-competence, the source of acquisition remains elusive. Empirical treatment included Ethambutol/Rifampicin/Isoniazid/Moxifloxacin/Clarithromycin and intravenous Amikacin for 6 weeks, to cover for reinfection/relapse with resistant-MTB, as well as NTB. Rifamycin, which is the critical component for treatment success, had to be stopped due to transminitis after 1 month. We rationalised to a multi-drug regime containing ≥3 active agents as an effective course, based on analogy of patients with rifampin-resistance. This led to normalisation of ESR and 2.2kg weight gain, plus radiological resolution 8 months into treatment. He continues to receive a minimum of twelve months after culture-conversion.
North by Northeast - a case of CNS Aspergilloma mistaken for pituitary tumour
Authors: Srirathan Vino , Schwab Uli
Published: March 2020

Background

Fungal pituitary sellar infection is a rare condition and can resemble a pituitary tumour. Our patient required two debridements across two continents.

Case

A 47-year-old diabetic man presented with history of headaches and sudden visual loss, on neuroimaging found to have an infiltrative sella lesion compressing the optic nerves. He had an incomplete transsphenoidal resection in Nigeria, with a histological diagnosis of chordoma. Ten months prior he suffered a gunshot wound destroying his femur, initially managed with an intramedullary nail, subsequently requiring implant removal, multiple debridements antibiotic spacer, ultimately leading to a Girdlestone’s. Endoscopic redo-transphenoidal-resection at Newcastle-Upon-Tyne, for cystic/solid inflammatory changes in the pituitary fossa/sphenoid-sinus/suprasellar-cisterns suggestive of residual tumour, however did not show any neoplasm. Instead, histology yielded a chronic necrotising fungal infection, morphologically suggestive of Aspergillus on Grocott/PAS-stains, with septate branching hyphae and fruiting bodies. Culture and 18s PCR of sphenoid tissue was negative. Good therapeutic response to longterm voriconazole therapy with TDM confirming adequate levels >2 mg/L, and hormone substitution for pan-hypopituitarism. He underwent further 2-stage-arthroplasty of the hip due to polymicrobial bacterial osteomyelitis but negative fungal cultures/histology.

Discussion

Aspergillus infection of the pituitary fossa is rare and a recognised mimic of macroadenoma/tumour. The original lesion is likely to have been aspergillus, with diabetes as a well-established risk factor for primary paranasal fungal infection, rather than iatrogenic inoculation during surgery. Radiological/microbiological features from Girdlestones’ pointed against haematogenous spread from the osteomyelitic hip.
405-nm Light for Bacterial Reduction in Blood Plasma: Preliminary investigations into antimicrobial efficacy and plasma protein integrity
Authors: Stewart Caitlin , Sinclair Lucy , Maclean Michelle , MacGregor Scott , Atreya Chintamani
Published: March 2020

Background:

Pathogen reduction technologies (PRT) for blood products can reduce the incidence of transfusion-transmitted infection and associated wastage of blood products. Visible 405nm-light has been shown to inactivate bacteria in situ in bagged blood plasma without the addition of photo-sensitive chemicals. However, threshold levels for plasma protein compatibility and optimal bactericidal activity are currently unknown. This study investigates different treatment conditions and their suitability for safely inactivating bacteria in blood plasma.

Method:

Plasma seeded with Staphylococcus aureus (102–105CFU/ml) was exposed to 405nm-light at low and high irradiances (10, 100mW/cm2) with treatment times ranging between 0.2–7-hr (≤252 Jcm-2). SDS-PAGE was then used to assess the light effect in terms of antimicrobial treatment levels on plasma protein integrity.

Results:

High and low intensity treatment regimens achieved significant bacterial inactivation (P=<0.05) with doses of 252 Jcm-2 achieving ≥99.3% reduction. Results suggest that lower irradiances have greater germicidal efficiency, with use of 10mWcm-2 achieving up to 30% greater inactivation than equivalent doses using 100mWcm-2. SDS-PAGE analysis demonstrated no major detrimental impact on protein integrity with any of the treatment conditions investigated. Minimal changes in protein bands (≈28kDa) were observed relative to positive control samples after application of doses >144 Jcm-2.

Conclusion:

The results of this study have highlighted the safety potential of 405nm-light treatment on blood plasma. Further research is required to determine the upper and lower threshold treatment levels and functionality of plasma proteins post-exposure for further development of this technology as a PRT tool for application in transfusion medicine.
Do Results from the Microbiology Laboratory lead to Appropriate Management of Uncomplicated Lower Urinary Tract Infections?
Authors: Brammar Lucas , Baker Isabel
Published: March 2020

BACKGROUND

There has been a national drive to improve antimicrobial stewardship in the diagnosis and management of uncomplicated lower urinary tract infections (UTIs). While much attention has been paid to the initial management in hospital, there is little evidence of how treatment is rationalised or altered in response to results from the laboratory.

METHODS

We undertook a retrospective analysis of medical records, including patients diagnosed with uncomplicated lower UTI whilst in hospital. Data was collected on whether a urine sample was sent to the laboratory, the result was documented, which subsequent actions were taken by clinical teams and their appropriateness.

RESULTS

All the patients received antibiotics for a lower UTI. 55% of patients had documented symptoms of a UTI, the remainder were commenced due to a suspected UTI in the absence of localising clinical symptoms. 86% had an MSU sample sent to the laboratory. In all cases, clinicians had viewed these results. In 57%, the findings of the MSU were documented. 38% of all results were not acted on appropriately, with 19% of those continuing antibiotics unnecessarily, 24% not narrowing down therapy and 12% not changing antibiotics in response to resistant isolates.

CONCLUSION

Whilst correct clinical investigations may be sent and reviewed in the management of uncomplicated UTIs, the results of these are often not documented in the patient’s record and a significant proportion of these results are not acted on appropriately.
Host and pathogen biomarkers to predict bacterial sepsis
Authors: Lewis Matthew , Chick Heather , Harris Llinos , Jenkins Rowena , Wilkinson Thomas S.
Published: March 2020

Sepsis is defined as life threatening organ dysfunction caused by a dysregulated host response to infection, and is responsible for 52,000 deaths in the UK per year. Approximately 50% of sepsis episodes are related to bacteria where the Gram-negative bacteria Escherichia coli is a leading causative agent. Our previous work with the Hywel Dda Health Board has identified a high level of E. coli sepsis and in the current work, we aim to identify genetic (genes) and host biomarkers (e.g. IL-6) to discriminate E. coli sepsis isolates based on original source of infection.

E. coli isolates (n=100) from blood cultures in patients with defined sources of infection (urinary, biliary, intra-abdominal or unknown) were used to investigate potential biomarkers using next generation sequencing, whole blood modelling and molecular microbiology phenotyping.

Sequencing of isolates is underway. Growth curve analysis demonstrated that human serum could modulate E. coli growth to three phenotype groups; i) no growth, ii) retarded / decreased growth and iii) unaffected growth (compared to LB control). Whole blood modelling over 6 hours confirmed 4 hours to be the optimal time point to study IL-6 expression. Grouping isolates by source of infection showed that those from the urinary tract and ‘unknown’ sources produced significantly more IL-6 than E. coli K12. Completion of phenotyping will allow association studies to bacterial genotype.

These results will help define new biomarkers associated with the host and genetic biomarkers associated with E. coli that will better predict and inform the diagnosis and treatment of sepsis.
Audit of compliance to SEPSIS 6 criteria in Emergency Department admissions
Authors: Carvalho Lara Silva de , Sivaramakrishnan Anand , Bharathan Binutha , Patel Kirta
Published: March 2020

INTRODUCTION

The timely diagnosis of sepsis is the essential first step that activates life-saving pathways. The aim of our study was to assess the accuracy of the ‘sepsis flag’ assigned to patients presenting to our hospital’s Emergency Department (ED).

METHOD

A retrospective two week review (18/03/19 to 25/03/19 and 07/05/19 to14/05/19) was performed in a District General Hospital in London, assessing the medical records of all adult patients assigned a sepsis flag in ED (n=21), in order to assess if SEPSIS 6 criteria were met. For comparison, patients admitted to ED with gram negative bacteraemias (n=8) in the same period were reviewed to check if they were included in the SEPSIS 6 group.

RESULTS

Ten out of twenty one patients with a ‘sepsis flag’ fulfilled criteria. Six other patients had one criterion (T>38oC) for sepsis. Blood cultures were sent in all patients. Four out of ten patients were administered IV antibiotics within one hour. During this period, none of the eight patients admitted with gram negative bacteraemias were assigned a ‘sepsis flag’, despite five of them meeting SEPSIS 6 criteria (two or more criteria) and having evidence of infection. However, the majority (7/8) received IV antibiotics within one hour.

CONCLUSION

Our review highlights the difficulties in the diagnosis of sepsis and the limitations of the SEPSIS 6 criteria for detection of septic patients in triage. However, we have demonstrated that the vast majority of patients had appropriate investigations and prompt antibiotic treatment, irrespective of the ‘sepsis flag’.