bluuebunny/crossref_metadata_2025 huggingface dataset:
In-vitro activity of cefiderocol against multidrug-resistant Enterobacterales, Pseudomonas aeruginosa and Acinetobacter baumannii isolates from the UK
Authors: Mushtaq Shazad , Sadouki Zahra , Vickers Anna , Livermore David , Woodford Neil
Published: March 2020

Background.

Cefiderocol is a parenteral siderophore cephalosporin, with a catechol-containing 3’ side chain. We evaluated its activity against MDR Gram-negative bacteria

Methods.

MICs of cefiderocol, meropenem, ceftolozane-tazobactam, cefepime, ceftazidime, aztreonam, ciprofloxacin, ceftazidime-avibactam, amikacin and colistin were determined in cation-adjusted Mueller-Hinton broth; the medium was iron depleted for cefiderocol only. The panel comprised 305 Enterobacterales, 111 P. aeruginosa and 99 A. baumannii selected for carbapenemases, ESBL production or carbapenem resistance via combinations of porin-loss with AmpC or ESBL.

Results.

The activity of cefiderocol was unrelated to Enterobacterales species. At 4mg/L cefiderocol inhibited 92.1% of all Enterobacterales, with rates of 95-100% for isolates with AmpC+porin-loss, VIM, IMP, OXA-48-like, KPC, GES, SME or IMI. Only isolates with NDM (72.1%) or ESBL+porin-loss (88.5%) had lower rates. No comparator agent inhibited >90% of isolates at EUCAST breakpoint.

Cefiderocol 4mg/L inhibited 86.5% of all P. aeruginosa, with rates of 80-100% for those with VIM, IMP, GES or VEB beta-lactamases. Lower rates were seen for those with NDM (72.7%) and PER (73.3%) enzymes. No comparator inhibited >85% of isolates at breakpoint.

Cefiderocol 4mg/L also inhibited 88.9% of A. baumannii isolates with rates >85% for those with OXA-51, -23, -24, or -58. A lower rate (80%) was seen for those with NDM carbapenemases. A concentration of 16mg/L was needed to inhibit ≥90% of A. baumannii.

Conclusions.

Cefiderocol was widely active at low concentrations against MDR Enterobacterales, P. aeruginosa and A. baumannii. MICs for isolates with NDM enzymes nonetheless were higher than for those with other carbapenemases.
A diarrhoeal blast from the past
Authors: Gallacher Stuart , Khalsa Kamaljit , Deshpande Ashutosh , Ritchie Neil
Published: March 2020

Introduction:

Diarrhoea is a common presentation in travellers. This case highlights the importance of providing the microbiology laboratory with necessary clinical information so that special media can be inoculated in order to establish a prompt diagnosis.

Case Report:

A 29 year-old male was admitted in Glasgow, UK with a 24 hour history of profuse watery diarrhoea. He was travelling from Mumbai, India. He reported no relevant sick or healthcare contacts. On admission he was dehydrated, tachycardic, and hypotensive. Blood testing revealed normal electrolytes but lactic acidosis, a severe AKI, neutrophilia, and raised CRP. Treatment was initiated with IV fluids, empirical IV ceftriaxone and azithromycin. Urine, faeces and blood cultures were collected and rectal screening for CPE was performed. More than 6L of diarrhoea was passed in the first 12 hours.

Over the subsequent 48 hours diarrhoea continued while urine output and biochemistry normalised with IV fluids. Yellow colonies were grown from faecal cultures on TCSB agar. Gram stain revealed short, ‘comma-shaped’ gram negative aerobic rods. These were identified asVibrio choleraeusing MALDI-TOF and later confirmed to be serotype 01 El Tor. Rectal swabs returned positive for NDM-1 producing Escherichia coli. By the third day his diarrhoea resolved, antibiotics and IV fluids were discontinued and he was discharged.

Conclusion:

This case highlights the challenge of managing V. cholerae infection in a traveller. Cholera should be considered in the differential diagnosis of diarrhoea in any traveller and specific laboratory testing is required to make a positive diagnosis.
Streptococcus agalactiae macrolide/lincosamide resistance; implications for puerperal antimicrobial therapy
Authors: Davidson Alex , Hughes Stephen , Mughal Nabeela , Moore Luke
Published: March 2020

Introduction

There is no routine screening for antenatal Group B Streptococcus (GBS) carriage in the UK. However where GBS is identified from clinical urine/vaginal samples, peri-partum antimicrobial therapy is advised. The changing pattern of antimicrobial resistance among GBS, particularly for macrolides/lincosamides, has implications for peri-partum antimicrobial for beta-lactam allergic patients.

Method

We undertook a retrospective observational study at a central London teaching hospital to investigate GBS antimicrobial resistance and peri-partum prescribing between 1st April 2016 and 31st March 2019.

Results

939 obstetric patients had GBS identified at Chelsea & Westminster Hospital during the study period. 31% (279(263 resistant and 16 intermediate)/900) were erythromycin resistant and 27% (246/911) clindamycin resistant. 5.6% (51/900) had incongruent erythromycin/clindamycin resistance, presumed erm mediated.

390 women received peri-partum antimicrobials for GBS. The majority of patients received benzylpenicillin therapy (70.2%, 274/390), with cefuroxime (23.1%, 90/390), clindamycin (5.6%,22/390) and teicoplanin (1%,4/390) based therapies also used. 40.9% (9/22) were given clindamycin despite known GBS resistance.

Conclusion

Our data support the national guidelines, with high erythromycin/clindamycin resistance reported locally. Updated UK guidelines for GBS colonised patients recommend the use of vancomycin for beta-lactam allergic patients. Yet where sensitivities are known, clindamycin may still be used for 70% of beta-lactam allergic patients. Vancomycin, more challenging to administer and monitor, can be reserved for beta-lactam allergic, clindamycin resistant GBS carriers which account for a minority of the population (2.8%). Developing a working pathway implementation is challenging as evident with the inappropriate clindamycin use in 9 patients locally.
Endogenous endophthalmitis as a secondary bacterial infection following viral disruption of the blood-ocular barrier?Case report of 2 renal transplant patients
Authors: Price Vivien , Li Mark , Canning Benjamin
Published: March 2020

Background: Endogenous endophthalmitis is a rare but serious ocular infection. Seeding is usually haematogenous, and the visual prognosis is poor. We present 2 cases of bacterial endophthalmitis rapidly following viral retinitis in patients with a history of renal transplantation and no systemic symptoms of bacteraemia.

Case 1:

A 47 year old woman presented with features of bilateral panuveitis with retinitis, with no systemic symptoms.She had a history of renal transplantation. Escherichia coli had been isolated from multiple previous blood and urine cultures in the preceding months. A diagnosis of cytomegalovirus (CMV) retinitis was made on the basis of positive PCR from aqueous humour, and antiviral treatment commenced. Her left eye vision subsequently deteriorated. A repeat sample grew E. coli with a matching antibiogram to her previous isolates.

Case 2:

A 55 year old man presented with features of right-sided panuveitis and acute retinal necrosis, with no systemic symptoms. He had a history of renal transplantation. A diagnosis of varicella zoster virus (VZV) retinitis was made on the basis of positive PCR from the aqueous humour, and antiviral treatment commenced. His symptoms deteriorated, and Streptococcus pneumoniae was isolated by culture from a repeat sample. Imaging of the sinuses revealed inflammatory changes.

Conclusions:

We hypothesise that endophthalmitis in these two immunocompromised patients may have been opportunistically enabled by disruption of the blood-ocular barrier by the preceding viral infection, allowing a transient bacteraemia to seed. Whether there may be any role for prophylactic antibiotics in this context would benefit from further study.
Fusobacterium nucleatum brain and liver abscesses following sigmoid diverticulum perforation in an immunocompetent patient
Authors: Ghavami-Kia Bijan , Tomlinson Ben , Li Ang , Widdrington John , Chadwick David , Mohamed Saffwan , Aziz Farooq , Martin Jessica , Kubelka Igor
Published: March 2020

We report a case of disseminated Fusobacterium nucleatum likely secondary to an undiagnosed perforated sigmoid diverticulum. A 50-year old male, (past history of COPD, schizophrenia and diverticulosis) presented with fever, seizures and progressive leg weakness over 4 days. Examination revealed left leg weakness and hepatomegaly. CT-brain showed bilateral supra-tentorial lesions with sulcal effacement; MRI findings were consistent with abscesses. Initial management included burr-hole drainage of 2 intra-cranial lesions and treatment with ceftriaxone and metronidazole. The patient defervesced post-operatively.

Blood cultures (day 1) and cerebral pus (day 3) grew Fusobacterium nucleatum after 5 days. HIV Ab/Ag negative. Subsequent imaging excluded endocarditis, intra-cardiac shunting and jugular vein thrombosis. CT revealed pulmonary emboli, liver abscess (68x46x42 mm, inaccessible to drainage) and localised sigmoid perforation. Later, the patient admitted to a 5-day period of severe self-limiting abdominal pain 2-weeks prior to admission, probably relating to sigmoid perforation.

The patient required further neurosurgical drainage (day 10) due to fluctuating consciousness; intra-operative samples were culture negative. Neurological improvement occurred during 4 weeks treatment. Total antibiotic duration will be determined by follow-up imaging.

Fusobacterium spp.are fastidious Gram-negative rods. Microscopy can differentiate the main pathogenic species showing tapered ends (F. nucleatum) or pleomorphic rods (F. necrophorum). Malignancy, diabetes and immunosuppression/HIV are associated, but none are present here. Presentations include abscesses, bacteraemia, thrombophlebitis, osteomyelitis and endocarditis. This case highlights the need for early sampling, careful history regarding source, covering at least 2-4 weeks preceding presentation, and demonstrates paradoxical deterioration after antibiotics and drainage, likely due to post-treatment inflammatory reaction.
Acute haemorrhagic leukoencephalitis secondary to Chikungunya infection
Authors: Jenkins Megan , Hudson Alyssa , Heys Izak , Moran Ed
Published: March 2020

Background:

Neurological sequelae are a rare but recognised complication of Chikungunya infection. We report a case of acute haemorrhagic leukoencephalitis secondary to Chikungunya infection.

Case description:

A 59 year old male presented to the acute medical unit 5 days after returning from a 4 week trip to Kinghasa in the Democratic Republic of Congo complaining of a sudden onset headache with fluctuating confusion and left sided weakness. 1 week previously he had been complaining of fever and fatigue with arthralgia. Whilst in DRC he visited family with no travel outside Kinghasa and no infectious contacts or high risk activities. A malaria film was negative and a lumber puncture on admission demonstrated 296/mm3 white cells with 75% polymorphs and 25% lymphocytes, protein of 1.5 g/L and glucose of 4.2 mmol/L ( serum 7.4 mmol/L).

Over the next 24 hours his GCS dropped and he needed intubation. The appearance of the MRI head was highly unusual and the neuroradiologist felt this was most likely an acute haemorrhagic leukoencephalitis (AHLE) confirmed later on brain biopsy. All subsequent investigations were negative except viral serology demonstrating a positive chikungunya IgM with later IgG seroconversion.

The patient received steroids, anti tuberculous treatment, antibiotics and plasma exchange with little neurological improvement.

Conclusion

With the increasing incidence of chikungunya, more neurological complications are being recognised. AHLE is a very rare form of acute disseminated encephalomyelitis usually triggered by an infection; however there have been no case reports of chikungunya causing AHLE leading us to believe this may be the first case.
Cardiobacterium hominis endocarditis complicated by Aortic root abscess: A case report
Authors: Holden Rob , Pasztor Monika , Lewkebandara Rashmi , Okonkwo Ekene Kenneth
Published: March 2020

The present report describes a case of infective endocarditis complicated with aortic root abscess caused by Cardiobacterium hominis (C. hominis) in a 56 year old man. C. hominis is amicroaerophilic, pleomorphic Gram-negative bacillusand member of the HACEK group (Haemophilusspecies, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens and Kingella kingae) a group of bacteria known to be a rare cause of endocarditis. With prompt diagnosis and initiation of antimicrobial and surgical management, a successful outcome was achieved.
Focal brain lesions in an HIV infected patient : A Diagnostic dilemma
Authors: Vaidya Viplov , Dhir Aruna Alahari , Sawant Sheela , Daddi Anuprita
Published: March 2020

Background—

Focal brain lesions associated with HIV infection can be due to cerebrovascular diseases, primary CNS lymphoma, toxoplasmosis, progressive multifocal leukoencephalopathy or other opportunistic infections. We report a challenging case of an adult HIV infected male with focal brain lesions.

Case Description--

A 62 years old male, presented with history of cough with mucoid expectoration for 3 months and abnormal behaviour for 2 weeks.

Clinical examination revealed delayed obeying of commands and no other sensorimotor deficits. MRI brain revealed ill-defined space occupying lesions involving bilateral frontal lobes. HIV antibodies and HBsAg tests were positive. CT chest revealed multiple cavitatory lesions in left upper lobe. Pharyngeal candidiasis was seen during bronchoscopy. Bronchoscopic alveolar lavage revealed Nocardia species. Tests for MTB were negative.

Lung biopsy showed Cytomegalovirus pneumonitis with Aspergillosis. PET scan revealed non FDG avid gliotic changes in brain. CSF and bone-marrow examinations were normal. Brain lesion was considered to be a manifestation of Nocardiosis and biopsy was planned. CD4 count was 103/mm3. Intravenous ceftriaxone, ganciclovir, caspofungin, fluconazole and oral septran were started. Patient was started on HAART(Tenofovir, lamivudine, efavirenz) 1 week later, after explaining the risk of Immune reconstitution inflammatory syndrome. CNS lesion biopsy revealed High grade B-cell Non- Hodgkin’s lymphoma. Palliative external Radiotherapy to whole brain was given. The patient has improved clinically and is on regular follow up from 1 year.

Conclusion—

Extensive evaluation and work up is required in cases of focal brain lesions in patients with HIV. Brain biopsy often provides the definitive diagnosis.
Experience of pharmacist-led antimicrobial stewardship ward rounds in a regional hospital
Authors: Bond Stuart , Ashton Kathryn , Lee-Milner Jade , Mustapha Damilola , Hinchliffe Rachael , Walker Nicola
Published: March 2020

Background:

Antimicrobial stewardship ward rounds and phone advice are fundamental to improvement of infection treatment and prevention in hospitals. In response to a local and national shortage of consultant medical microbiologists, a pharmacist-led antimicrobial stewardship service was established.

Methods:

Antimicrobial stewardship interventions in a large regional hospital were analysed from 8 January 2018 to 14 March 2019. Collaborative ward rounds were conducted with infection prevention and control nurses, and microbiology staff when available. Ad hoc ward rounds and phone interventions (via a dedicated “antibiotic advice hotline”) were also conducted, with most referrals coming from junior doctors and ward pharmacists. The commonest clinical areas visited were elderly care, respiratory and general surgery.

Results:

1507 antimicrobials were reviewed from 1006 interventions (16 per week). Antimicrobials most reviewed were piperacillin/tazobactam (n=152; 10%), metronidazole (n=152), co-amoxiclav (n=140; 9%), teicoplanin (n=137, 9%) and gentamicin (n=116; 8%). The commonest organisms were Escherichia coli (n=115), Staphylococcus aureus (n=95) and Clostridium difficile (n=52). The most common recommendations were intravenous to oral switch (n=185; 18%), continue (n=175; 17%), escalate (n=136; 14%) and review dose (n=97; 10%). Antimicrobials were optimised for discharge in 270 cases, through oral switch, home intravenous antimicrobial referral or cessation.

Conclusion:

The results demonstrate the value of novel antimicrobial stewardship approaches that are required in today’s NHS given shifts in staff availability and recognising advanced clinical practice among non-medical staff. Future planned interventions will focus on improving the home intravenous antimicrobial referral and review process.
Impact of Integrase Inhibitors on Weight
Authors: Varadarajan Maithili , Thaker Hiten , Samson Anda , Adams Kate , Harrison Sarah , Cullen Lorraine
Published: March 2020

Current evidence suggests that Integrase Strand Transfer Inhibitors (INSTI) are associated with excess weight gain. These increases are particularly significant for black people and women.

Clinic notes of 84 patients stable on INSTI for at least 18 months and attending HIV outpatient clinics at Castle Hill Hospital, Hull Royal Infirmary, Grimsby Hospital and Scunthorpe Hospital were included. Data including height and weight was collected at 18, 30, 42 and 54 months, following commencement of INSTI. Statistical analysis was performed using STATA.

65% of patients were male. The mean age at baseline was 50 and the mean age at diagnosis was 40. Median CD4 count was 669 and viral load was 0 within the last 6 months. 64% of patients were White British, 7% White Other, 21% Black and 9% other.

At 30 months, mean weight increased by 1.41kg, statistically significant at p<0.0065. At 42 months, mean weight increased by 2.53kg, significant at p= 0.0056. At 54 months, mean weight increased by 1.33kg; however this was not significant. Differences in weight amongst the sexes, different ethnicities and different categories of infection as classified by the CDC was observed but was not statistically significant.

Two adverse events- myocardial infarction and stroke were reported but no patient on INSTI died.

Patients stable on INSTI gained weight but the clinical significance of this is unclear, especially as weight changes in patients stable on other antiretrovirals have not been compared. Further research to assess cardiometabolic impact of weight gain following INSTI is required.
What’s in a label? Can use of a questionnaire-based tool identify patients that may benefit from antimicrobial allergy ‘de-labelling’
Authors: Elliott Laura , Auyeung Vivian , Wade Paul
Published: March 2020

Background

Being labelled as “allergic” to an antimicrobial (commonly penicillins) can lead to worse clinical outcomes and increase antimicrobial resistance. Unclear or inappropriate allergy documentation contributes to this issue so clarifying “allergy” status is important to optimise clinical outcomes.

Methods

The study was conducted at St Thomas’ Hospital, a large teaching hospital in London. An antimicrobial allergy assessment process, consisting of a researcher-developed and administered questionnaire, a review of patient medical records and categorisation of the drug allergy ‘label’, was applied to eligible patients from selected wards. Recommendations for allergy ‘de-labelling’ and referrals were given based on patient categorisation.

Results

Sixty assessments were completed during the study. Six patients (10%) were identified as unlikely to have a true allergy and could potentially be ‘de-labelled’. A further thirty-seven patients (61.7%) were identified as eligible for allergy referral and testing. The allergy ‘labels’ of twenty-seven patients (45%) led to them receiving second-line antibiotic therapy. Twenty-two patients (34.7%) had inconsistencies in their allergy documentation across the 3 main electronic clinical systems.

Conclusion

This study demonstrated that the use of a simple, standardized, pharmacy-led approach to antimicrobial allergy assessment could lead to some patients being 'de-labelled' outside of specialist allergy settings. The implementation of this approach could immediately bring about improvements in antimicrobial usage and patient outcome.
Audit to assess adequacy of Screening of latent TB in Newly diagnosed HIV patients
Authors: Bristow Clare , Schwab Uli
Published: March 2020

Introduction

Patients with Human Immunodeficiency Virus (HIV) are at an increased risk of latent Tuberculosis (TB) reactivation. HIV TB concurrent infection increases mortality and reduces patient quality of life. Screening for latent TB allows treatment to commence, preventing reactivation. In accordance with British HIV association guidelines, all patients should have a Chest X-ray (CXR) at diagnosis. If patients are determined to be at a high risk of TB, an Interferon Gamma Release Assay (IGRA) test should be done to determine previous exposure to TB.

Methods

95 HIV positive patients diagnosed between 2012-2017 at the Royal Victoria Infirmary (RVI) were assessed for inclusion. 4 patients excluded as they had active TB, n=91. Patients were determined to be high risk if they were from an African or Asian country of origin, or if they had a CD4 count below 200 cells/mm3. Clinic letters and results on eRecord were reviewed (n=95) between 16/02/2019- 21/03/2019.

Results

61.5% of patients had a CXR at diagnosis. 72.5% of patients had a CXR or a CT scan. 8 patients had an IGRA test performed, of which 2 were inconclusive. 20% of patients from Africa and 0% of patients from Asia had an IGRA test. Of those patients with a CD4 count below 200 cells/mm3 9.1% had an IGRA test.

Discussion

An assessment of patient TB risk may need to be undertaken to allow thorough latent TB screening using IGRA tests. Automatic IGRA tests could be done on all patients with a CD4 count <200 cells/mm3.
Biofilm profile of Candida isolated from clinical specimens at a Tertiary Care hospital in India
Authors: Samaddar Arghadip , Tendolkar Uma , Baveja Sujata
Published: March 2020

Introduction

Candida species are a leading cause of infections in immunocompromised hosts. Usage of indwelling medical devices provides ample opportunity for Candida biofilms to set up a nidus for infection that is not easily amenable to conventional antifungal therapy.

Materials and Methods

A total of 100 Candida isolates from patients with suspected candidiasis were tested for production of biofilm. Based on clinical history, 62% of the patients were found to have clinically significant infection with Candida while in 38% of the patients, Candida isolates represented commensals. Biofilm production was detected and graded by visual (test tube) and spectrophotometric (microtiter plate) methods.

Results

Fifty five percent of the Candida isolates produced biofilm. Biofilm producing abilities of clinically significant isolates (80%) was found to be significantly higher than commensals (20%). Biofilm positive Candida isolates were most commonly obtained from blood (34.5%). Biofilm production in non-albicans Candida (67.9%) was found to be significantly higher than C. albicans (38.6%). Majority of the biofilm positive Candida isolates produced Grade 2 (moderate) biofilm. Candida tropicalis accounted for maximum biofilm production comprising 20% Grade 4, 53.8% Grade 3 and 50% Grade 2 biofilm. Concordance in grading between the two methods was observed in 72.7% of the isolates. Spectrophotometric method was found to be more sensitive than visual method for detection of Candida biofilm.

Conclusion

The importance of studying Candida biofilms is to ascertain new therapeutics and techniques to manage these infections clinically and improve the outcome as these are associated with high morbidity, mortality and resistance to antifungal drugs.
Pulmonary infection due to Acrophialophora fusispora in a patient with underlying mixed connective tissue disease and chronic pulmonary aspergillosis
Authors: Samaddar Arghadip , Sharma Anuradha
Published: March 2020

BACKGROUND

Acrophialophora fusispora is an emerging opportunistic fungus rarely implicated in human infections. Here, we report the first case of pulmonary infection due to A. fusispora from India.

CASE DESCRIPTION

A 59-year-old male, farmer by occupation was admitted to AIIMS, Jodhpur, Rajasthan, India, with complaints of cough and expectoration of yellowish sputum for last one month and gradually progressive shortness of breath for 20 days. He had past history of pulmonary tuberculosis and was a known case of COPD for last five years. He was diagnosed with mixed connective tissue disease (MCTD) for which he had been receiving treatment with azathioprine and prednisolone for 3 months. CECT of chest revealed cystic bronchiectatic changes with findings suggestive of aspergilloma. Serum Aspergillus fumigatus specific IgG levels were elevated suggestive of chronic pulmonary aspergillosis (CPA). He was tested positive for influenza A (H1N1) by RT-PCR and received treatment with oral oseltamivir but to no clinical benefit. Culture of sputum on two subsequent occasions showed growth of a fungus which was identified as Acrophialophora fusispora based on characteristic microscopic morphology and rDNA ITS sequencing. Treatment with oral itraconazole showed marked symptomatic improvement. He was discharged from the hospital with oral itraconazole to be continued for 6 months. Follow-up visit after 3 months showed significant clinical and radiological improvement.

CONCLUSION

Molecular sequencing can reliably identify A. fusispora which is crucial for initiating specific antifungal therapy. Further studies are encouraged to determine the prevalence of such infections so as to plan optimal management and improve patient outcomes.
The power is in our hands: a QI project for sustainable hand hygiene
Authors: Mohammadi-Zaniani Ghazaleh , Wales Lucy
Published: March 2020

Background

Methicillin Sensitive Staphylococcus Aureus (MSSA) is a commensal associated with hospital acquired infection (HAI). MSSA HAI is associated with significant morbidity, and hand hygiene has been identified as a prominent component of HAI prevention strategies.

Methods

A project using Quality Improvement methodology was devised to improve rates within the surgical department: a locally identified MSSA HAI hotspot. Baseline monitoring was done using WHO checklists and departmental education presented on hand hygiene. Continued weekly auditing and feedback was carried out by the multidisciplinary team (MDT) on one ward over a four-month period, and adherence was prompted by verbal reminders and departmental education. A long-term strategy was employed for regular monitoring with a nominated member of the MDT to maintain improvements.

Results

Baseline audit revealed adherence of 10-52% for registrar-led rounds, and 22-62% for consultant-led, across the 5 points of hand hygiene. Particular weakness was noted before patient contact and entry to clinical areas, which was addressed with departmental education. Initial adherence after education was low (6-38%), but subsequent improvement was seen the following month (74-93%). Some of this was maintained over the final two months of data collection (50%-100%), and a PDSA cycle was employed to address this variability. As such, an MDT-wide monitoring schedule was put in place at the end of the data collection period.

Conclusion

This QI project sought to achieve sustainable change in adherence to hand hygiene. An MDT-wide system of monitoring and education effected this, and may prove an effective strategy in similar inpatient settings.
Epidemiology of paediatric infection a 10 year experience on the Gold Coast, Queensland, Australia
Authors: Fairbairn William
Published: March 2020

Introduction

The pathological invasion of a joint and subsequent inflammation is known as septic arthritis. The hip and knee are the most frequently involved joints. Staphylococcus aureus is the most common cause of septic arthritis in children. In clinical practice, the diagnosis of septic arthritis is based on isolation of causative organism from the joint fluid or positive blood cultures plus clinical and/or radiological signs and symptoms consistent with septic arthritis.

Methods

A retrospective analysis was undertaken of paediatric joint infections presenting to the Gold Coast Orthopaedic Department between January 2008 and December 2017.

Results

A total of 155 children < 17 years old fulfilled the recruitment criteria for inclusion. 93 patients were excluded for coding issues, incorrect diagnosis and multiple encounters of the same patient with different medical teams.

Of the 62 patients in the cohort the hip was the most common joint involved (23) following by knee (16), elbow (8), ankle (6), foot (5), shoulder (2) and wrist (2). Two of the organisms were confirmed from ward aspirates and 59 from intraoperative samples. Of the microbes identified aseptic was the most common (48%) followed by MSSA (29%), step pyogenes (5%), MRSA (3%), strep pneumonia (3%), pseudomonas (3%), kingella kingae (3%), serratia marcescens (3%), haemophilus parainfuenzae (2%).

Conclusion

This study is the first to publish the epidemiological profile of paediatric joint infections on the Gold Coast Australia and highlights the most common identified pathogens but also highlights the variety of organisms implicated in the condition.
Improving Antibiotic Prescribing for UTIs in Renal Impairment
Authors: Nicolson Andrew , Aiyegbusi Oshorenua , Baggott Amy
Published: March 2020

Background:

Urinary Tract Infections (UTIs) are the most common bacterial infections in the elderly. First line antibiotic therapy includes Trimethoprim and Nitrofurantoin, both of which should be used with caution in renal impairment. The project aim was to improve antibiotic prescribing in UTIs for patients with renal impairment.

Methods:

Initially an online questionnaire was sent to prescribers working in Forth Valley Hospital to ascertain their knowledge of antibiotic prescribing in renal failure. Quantitative data was obtained reviewing Trimethoprim and Nitrofurantoin prescriptions over 1 month (19/02/19-19/03/19) using HEPMA electronic prescribing system. These results were cross matched with patients renal function collected from SciStore database.

Results:

Despite 95% of medical staff having experience of prescribing in renal failure, 35% of those still did not feel confident in prescribing the correct antibiotic dosage with 90% of the opinion that prescribing guidance was necessary. Quantitative data showed that 12.9% (28/217) of patients treated with either trimethoprim or nitrofurantoin had renal impairment. Of these 79% had an Acute Kidney Injury and 71% a degree of Chronic Kidney Injury. 78% of the patients on Trimthoprim had an AKI and 38% of these developed hyperkalaemia. Those prescribed Nitrofurantoin 100% of this group had a concurrent Acute on Chronic Kidney Disease.

Conclusion:

79% of patients prescribed Trimthoprim or Nitrofurantoin had a degree of renal impairment leading to potential undertreatment or renal damage in the patient. As a result NHS Forth Valley has now updated prescribing guidelines regarding UTI treatment in patients with renal impairment advising alternative antibiotic therapy.
Effects of Bacteriophage on Inhibition and Removal of Multispecies Biofilms of Escherichia coli O157 and Non-O157
Authors: Zhang Yu , Hoang Minh Duc , Masuda Yoshimitsu , Honjoh Ken-ichi , Miyamoto Takahisa
Published: March 2020

Shiga toxin-producing Escherichia coli, especially E. coli O157 is an important foodborne pathogen capable ofcoexisting in multispecies biofilms found in almost all the natural environments. Biofilm cells are usually more resistant than planktonic cells against environmental stresses. Thus, E. coli O157 in biofilms is a serious food safety concern. This study describes the characterization of a bacteriophage FP43 isolated from bovine intestine and the ability of FP43 to inhibit and remove multi species biofilms of E. coli O157 strain 196 and non-O157 strain 104. Phage FP43 has a short latent period of 15 min and a large burst size of 98 PFU/cell, with great stability at temperatures ranging from 4 to 60°C and pH from 4 to 9.

To evaluate the effects of FP43 on E. coli,in microplate, biofilm formation was determined by crystal violet stainingas well as viable counts of biofilm and planktonic cells by conventional plating method. Phage FP43 decreased biofilm adhesionof E. coli cells with equal proportions of E. coli O157 and non-O157 by 82.4%. Viable counts were also reduced by 2.76 and 2.85 log in E. coli O157 and total biofilm cells after 6-h infection, respectively, compared with control. In planktonic cells, E. coli O157 and total counts decreased by 3.44 and 3.62 log after a 4-h phage treatment, respectively. Moreover, after a 6-h exposure to phage FP43, more than 60% of established biofilms were removed, and E. coli O157 and total viable counts in biofilm were decreased by 2.07 and 1.93 log, respectively. These findings suggest that phage FP43 seems to be a potential agent against E. coli O157 in multi species biofilms.
Escherichia coli blood stream infection in cancer patients: a multicentre, multidisciplinary collaborative audit to identify risk factors in order to target preventative strategies for improvement of patient care and outcomes
Authors: Cattini Pat , Chadwick Paul , Thirkell Gary , McManamon Catriona , Kretzer Deborah , Davies Frances , Stewart Eilidh
Published: March 2020

Background

Escherichia coli is a common cause of blood stream infections (BSI) in the UK. Published figures for E. coli BSI show higher rates in specialist cancer centres than in other hospitals, but the aetiology in oncology patients is not fully understood.

Methods

Five UK cancer centres coll aborated to review how E. coli affects oncology patients. A key part of this work has been an audit of all cases of E.coli BSI in patients in 2019 that met UK HCAI surveillance definitions. A multidisciplinary team of clinicians, nurses and pharmacists designed the audit to include >60 variables which may affect cancer patients.

Results

The risk factors for E. coli BSI among these cancer patients showed marked differences from those seen in the general UK population. The affected population was younger; there was higher rate of hospital-onset infections ; and, taking into account a number of healthcare interactions, the potential for healthcare associated infections was much higher. There was also a higher associated 30-day mortality and high rates of antimicrobial resistance in BSI isolates. Common univariate risk factors associated with BSI included use of SACT, neutropaenia, presence of acute kidney injury, presence of an invasive device, antimicrobial therapy, use of PPIs and a lack of independent hydration. By contrast, haematopoietic stem cell transplantation, mucositis and recent surgery were less common associations.

Conclusion

This audit demonstrates differences between risk factors seen in cancer patients with E.coli BSI and may explain why rates are higher in cancer centres.
It’s not the tool you use. It’s how you use it
Authors: Flint Molly , Hettle David , Hamilton Fergus
Published: March 2020

Background

Worldwide, several clinical screening tools (including EWS, SOFA, qSOFA, SIRS and CURB65) are used on admission to identify patients at risk of sepsis-related mortality. However their ability to accurately predict mortality remains controversial. The purpose of this study was to evaluate whether the predictive performance of these tools is affected by the timing of their use.

Methods

A systematic literature search was performed using PubMed, identifying studies in adult patients with a suspected admission diagnosis of infection, sepsis or pneumonia, in which screening tools were used to predict mortality. Meta-regression analysis was performed on included studies to identify factors affecting the tool’s ability to predict mortality, with a focus on score timing.

Results

From 3901 abstracts screened, 49 studies met inclusion criteria, comprising 421,006 patients and 13 clinical screening tools. No significant difference was found between any predictive tool and mortality. Of all variables considered (size of study, setting, diagnostic group, timing), only the timing related to admission affected predictive value of the tool. Studies that reported using purely physiological measures were less sensitive, marginally more specific, but had generally poorer predictive ability than those which included additional biochemical measures.

Conclusion

Clinicians must recognise that the performance of clinical screening tools is largely related to when they are used, not the individual tool. Given such tools are used on admission to identify risk of sepsis-related mortality, future studies must consider admission scores rather than those further into patients’ admission, to avoid over-reporting any tool’s predictive ability.
Snorting Staphylococcus Aureus
Authors: Belfield Amy , Schwab Uli
Published: March 2020

Rates of cocaine use in the UK remain high and Physicians need to be familiar with pleuropulmonary complications associated with illicit use. Respiratory symptoms (e.g cough productive of carbonaceous material/chest pain/dyspnoea/haemoptysis/wheeze) are quite common after cocaine exposure and can lead to barotrauma/asthma/ischaemic-airways-necrosis/pneumonia/interstitial-lung-disease/pulmonary-hypertension, not only after smoking volatilized crack cocaine and the combustion products/associated substances (tobacco/heroin/talc).

Proposed mechanisms that cause this, relate to the effect of cocaine on alveolar macrophages, intermixed substances and bacterial contamination.

A normally well, HIV-negative female who habitually snorts cocaine, presents with 40C°fever, chest pain and sweats. Although a smoker, she denies IVDU/smoking crack-cocaine. CXR shows a 5.5 cm thick walled left upper lobe lung abscess, associated with surrounding ground-glass consolidation, broadly based on the anterior pleura, but originating in the lung, infiltrating the anterior chest wall with reactive intercostal muscle changes on CT. She had no evidence of, nor risk factors for S. Aureus bacteraemia such as skin disorder, prosthetic devices, or immunosuppression. S. Aureus was isolated only on transcutaneous aspiration of abscess. Good therapeutic clinical/biochemical/radiological response to 6 weeks of antibiotics via OPAT.

Nasal insufflation of cocaine may cause lung complications such as lung abscess via primary infection of the lung rather than haematogenous spread. This may be due to contamination of cocaine when mixing it with other substances or the effects of cocaine on alveolar macrophages.
Evaluation of molecular rapid diagnosis of enteric bacterial infection in patients with diarrhoeal disease and its clinical and infection control impact at a large district hospital, UK
Authors: Mehta Grishma , Kandil Hala
Published: March 2020

Introduction:

Acute diarrhoeal syndromes are usually self-limiting, but diagnostic testing and treatment may be required in some instances. Stool cultures require a significant level of technologist expertise and are labour intensive. The BD MAX™ Enteric Bacterial Panel detects over 90% of bacteria causing infectious gastroenteritis and provide rapid diagnosis. The aim of this study is to assess the diagnostic and clinical value of this rapid diagnostic tool.

Methods:

Fresh stool samples received from 68 patients were cultured according to SMI methods, and by BD MAX™ Enteric. Further 25 frozen samples were processed by both methods. Any discrepancies between the two methods where sent to reference laboratory for confirmation.

Results:

Five samples (4 fresh and one frozen) were excluded from the study due to PCR inhibition. The turnaround time was 48 hours and 4-5 days for negative and positive culture respectively. BD MAX™ Enteric provided same day result. The sensitivity of BD MAX™ Enteric was 100% for fresh samples but this was reduced to 66% if performed on frozen samples. The rapid availability of negative results guided further clinical investigation and management. While the positive results allowed timely implementation of infection control management and guided antibiotic decision process.

Conclusion:

BD MAX™ is sensitive and provides same-day results. This allowed implementation of infection control measures in timely manner and guided further patient management. However, as this panel is restricted to bacterial causes of diarrhoea, if PCR there will be a need for further testing to exclude other possible infectious causes
Awareness of Primary Health Care Providers about Vaccination in Eastern regions of Ukraine
Authors: Voloshyna Iryna , Lapii Fedir
Published: March 2020

Background. A dramatic drop in routine immunization coverage is observed in Ukraine during recent years. Ukraine has the lowest rate of vaccination in Europe that imposes a high risk of communicable diseases on a population. More than 56.000 people sickened with measles from 2018-2019 yrs. Although Primary Health Care providers (PHCPs) in Ukraine play an important role in administering vaccines to their patients the data about PHCP's awareness regarding immunization are lacking.

Methods. A self-administered survey among 265 PHCPs (44 doctors, 221 nurses) was conducted during Public Health Trainings from 01 March to 31 April 2019 in three Eastern Ukrainian regions (Zaporizhia, Dnipro, Kharkiv). The level of basic knowledge on vaccines schedule, safety and efficacy of vaccination, communication skills ect (totally ten statements and ten questions) were evaluated.

Results. Overall 264 (99.6%) PHCPs highlighted the obvious need in strengthening evidence-based knowledge related to immunization topics and communication skills. Right answers regarding safety and efficacy of vaccines were obtained in 21% participants, 47% PHCPs had doubts for vaccine's safety and contradictions. Only 8% of participants were convinced in aspects of effective communication. Physicians had higher knowledge scores in routine vaccines schedule (32; 73%), compared to nurses (105; 47.5%), p=0.0016; but did not differ in aspects of vaccine's safety: 16% among physicians’ vs 17% among nurses (p>0,05).

Conclusion. The majority of PHCPs in Eastern regions of Ukraine have concerns about vaccines safety and efficacy, as well as lack of communication knowledge. Effective continuing evidence-based education of providers may help address these concerns.
Cast the net wide: Assessing the root causes of malaria transmission through the knowledge, attitude and practice of treated inpatients in rural western Uganda
Authors: Davies Peter , Tanner Maia , Jemari Bwambale , Henderson-Howat Susanna
Published: March 2020

Introduction

Despite significant progress malaria entails a significant public health concern in western Uganda. This qualitative cross-sectional study explores the knowledge, attitude and practice pertaining to malaria in rural Uganda.

Methods

With ethical approval from the management committee fifty patients were recruited between March-May 2018 at Kagando Hospital, western Uganda. Those with evidence of malaria transmission were recruited, at random prior to discharge, from the medical, paediatric (parents) and maternity wards. Participants were consented and briefed by a translator prior to answering a standardised semi-structured questionnaire. Answers were anonymised before being tabulated and analysed electronically.

Results

Participants were commonly, primary-school educated, subsistence farmers (56%). Knowledge of symptoms, mosquito breeding sites and feeding habits was generally good, yet dichotomous causes of malaria were common (mosquito n=43 and“unsafe drinking water” n=25). Malaria was “normal” to 40% of respondents and 92% acknowledge that it “kills”. Ten-percent accessed herbalists and 74% self-medicated with 30% admitting to not completing the treatment. Eighty-two percent of patients received governmental net donation but household use was variable and often infrequent. Indoor residual spraying (IRS) was practiced by two participants with just 30% aware of it. Stagnant water was present in 46% of communities without any knowledge of community spraying.

Conclusions

Participants demonstrated reasonable knowledge on vector/disease characteristics and treatment. Net access was within governmental target level but household practice was highly variable. Notably there was almost no IRS and no targeted spraying. A more integrated approach to vector control could represent an appealing strategy.
An audit of the diagnosis and treatment of infective endocarditis
Authors: Roth Katie , Ross Sam , Awad Sawsan
Published: March 2020

Background

Infective endocarditis (IE) is associated with a high incidence of mortality and morbidity and guidelines exist on appropriate diagnosis and treatment. The aim of the study was to evaluate adherence with national guidance and identify relevant learning experiences if indicated.

Methods

We performed a retrospective review of admissions to a district general hospital with a diagnosis of IE over a 1-year period from January 2018 to December 2018. Individual cases were identified during inpatient admission and notes reviewed to establish adherence to a published national audit tool.

Information regarding initial investigation, and management was gathered from the medical notes and microbiology reporting of samples was also examined.

Results

Of the 16 cases identified: 93% did not have blood cultures taken appropriately before treatment was started and only 50% received the recommended empirical antibiotics.

Only 43% had a transthoracic echocardiogram performed in the first 24 hours.

A surgical opinion was sought in just 2 of 4 cases of prosthetic valve endocarditis.

The three culture negative IE cases had no further recommended testing performed.

Conclusion

We highlighted a need for improved investigation and treatment of IE.

Timeliness of transthoracic echocardiograms will be improved by a change to the request form to indicate if IE is suspected so scans can be prioritised.

Clinicians will be informed if blood cultures are negative so further testing can be arranged if there is still a high clinical suspicion.

A weekly microbiology ward round has been established to review all suspected cases of IE.
Dalbavancin: A “silver bullet” against gram positive infections in PWID
Authors: Taylor Stuart , Sharp Harriet , Lippett Samantha
Published: March 2020

Introduction: Dalbavancin is a novel lipoglycopeptide antibiotic which provides gram positive cover including MRSA and enterococci for up to six weeks with two doses. We report the use of Dalbavancin at the Royal Sussex County Hospital in Brighton from 2018-2019.

Methods: Patients were given dalbavancin after approval by a consultant microbiologist on a case by case basis.

Results: 20 patients in total received dalbavancin during this time period. 11 out of 20 patients were male with a mean sample age of 54. 14 patients were ex or current IVDUs. The most frequent dose of dalbavancin given was 1.5g single dose in 11 out of 20 patients.

14 patients had a confirmed bacteraemia. There were 8 cases of MSSA, 1 case of MRSA, 1 CNS, 2 IGAS, 1 Group C Streptococcus and 2 Streptococcus dysgalactiae bacteraemias (one patient had 2 organisms identified in blood cultures). The commonest source of infection was skin and soft tissue, identified in 11 out of 20 patients.

Patients had received a median of 2 (range 1-5) different antibiotics prior to use of dalbavancin with a median course of 14 (range 1 – 27) days Abx prior to Dalbavancin. Patients were admitted for a mean of 15 days with a mean of 12 bed days saved per patient. There was one readmission during this time period which was due to a gram-negative sepsis.

Discussion:Given the challenges of managing severe infections in PWID, dalbavancin can be a “silver bullet” to facilitate effective treatment of important gram-positive pathogens.