bluuebunny/crossref_metadata_2025 huggingface dataset:
A Paradoxical Puzzle: Delayed reaction during treatment for disseminated BCG
Authors: Anpalakhan Shobana , Schwab Uli
Published: March 2020

A 74-year-old man with no previous history of tuberculosis presented with malaise, pyrexia (39°C) and 35kg weight loss, 16 months after TURBT for transitional cell carcinoma of the bladder and BCG instillation. He was pancytopaenic (Hb 84, Plt 99, WCC 2.94) and CT imaging showed splenomegaly, small pleural effusions and a sinusoidal lesion which on biopsy was not malignant. He did not have any promiment lymphadenopathy or pulmonary consolidation. Autoimmune and HIV screening were negative (CD4 310 (57%)) and both TTE and TOE showed no vegetations. IGRA/Quantiferon-Gold testing was positive and bone marrow biopsy yielded granuloma but no AFB on histology. Standard quadruple therapy was commenced for suspected disseminated mycobacterial disease. Mycobacterial cultures of early morning urine, blood and bone marrow were all positive and later identified as BCG on whole genome sequencing, sensitive to Rifampicin, Isoniazid, Amikacin and Moxifloxacin with undetermined Ethambutol sensitivity. Fully compliant with treatment, he developed a solid part cystic irregular enhancing 35mmmass encasing his left internal carotid artery seven months into treatment. ϒ-IFN-axis testing showed adequate responses to IL12 and IFN stimulation. Biopsy revealed AFB-positive granulomata leading to additional steroids for a presumed paradoxical reaction as well as treatment intensification with Moxifloxacin and Amikacin whilst awaiting cultures, the latter of which was discontinued following negative culture results and clinical and radiological improvement. Paradoxical reactions occur not infrequently (2-23%) and can present delayed (14-270 days) following initiation of treatment. He gained 25kg and made an uneventful recovery having received 18 months of BCG treatment.
Modelling Staphylococcus aureus biofilm on infected chronic wounds
Authors: Cheng Yanyan , Bank Paul De , Bolhuis Albert
Published: March 2020

Chronic wounds, for instance venous, pressure, arterial and diabetic ulcers, are a major health problem throughout the world. Compared with normal wounds, those that take more than four weeks to heal are defined as chronic. Interestingly, the numbers of patients suffering from chronic wounds and the cost for treatment have been increasing during the past two decades. There is increasing evidence that suggests that bacteria infect those chronic wounds and there exist as a biofilm, which affects the wound healing and success of wound treatment. The aim of this project is to develop a dynamic ex vivomodel to mimic Staphylococcus aureus biofilm on infected chronic wound using artificial wound fluid, 3D printing and porcine skin. This dynamic model also will be used to determine drug delivery from commercial antibiotic discs and poly-ε-caprolactone (PCL) electrospun fibrous matrices. The results indicated that our new developed dynamic model was succeed with mimicking S. aureus biofilm on infected chronic wounds. Compared our flow system with traditional colony biofilm assay (CBA), it had generated an air-liquid-solid interface, which is more approach to real conditions. Meanwhile, drug delivery from PCL electrospun matrices had been tested with both CBA and flow system. The results provided further strong evidence on the benefaction of our new developed ex vivomodel. In summary, this new developed easily application model will be potentially significant on improving studying treatments of biofilms on infected chronic wounds.
Scrub typhus causing acute undifferentiated febrile illness and its association with clinical outcomes: An observational hospital based study from tertiary care center in North India
Authors: Shah Dhara , Singh Avinash , Tiwari Dinesh , Sahu Chinmoy , Misra Richa , Prasad Kashi Nath
Published: March 2020

Background: The clinical presentation of Scrub typhus mimics other acute undifferentiated febrile illnesses (AUFI) thus making it difficult to diagnose clinically.

Methods: Patients hospitalized with acute febrile illness (2-21 days) along with clinical suspicion for scrub typhus were evaluated for specific IgM antibodies against O. tsutsugamushi by ELISA and details of demographic, clinical, laboratory and clinical complication/outcomes related parameters collected for
statistical analysis.

Results: Scrub typhus IgM antibodies by ELISA were detected in 88 (18.1%) patients out of 486 patients hospitalized with acute febrile illness and clinically suspected for Scrub typhus between September 2015 and January 2017. The majority sero-positive cases were found in July-December (p=0.02). Out of 88, twenty nine sero-positive Scrub typhus patients had serological evidence of co-infections. Eschar was observed in 11 (12.5%) sero-positive patients. Of 88, 23 sero-positive Scrub typhus patients died. A low platelet count (RR: 0.99; 95% CI:0.98-1.00, p=0.02), requirement of intensive care (RR: 2.26; 95% CI: 0.19-26.5, p = 0.01), need for mechanical ventilation (RR: 3.8, 95% CI: 1.35-10.86, p =0.003) and metabolic acidosis (RR: 3.47; 95% CI: 0.9-13.4, p = 0.03) were associated with mortality among sero-positive Scrub typhus patients. An appropriate antibiotic administration (n=46/88) was associated with clinical recovery/discharge (n=42/46; p=0.002).

Conclusion: Our results emphasize early diagnosis and administration of appropriate antibiotic for the management of scrub typhus in view of multiple etiologies in the initial diagnostic workup of patients presenting with AUFI. Thrombocytopenia, metabolic acidosis, need for mechanical ventilation and intensive care were associated with adverse clinical outcome among patients with Scrub typhus.
Development and Initial Evaluation of a national Infection Prevention and Antimicrobial Resistance programme for UK Girlguiding and Scouts
Authors: Hayes Catherine , Eley Charlotte , Hamilton Ryan , Ashiru-Oredope Diane , McNulty Cliodna
Published: March 2020

Background

Between 2016-18, infection prevention (IP) and antimicrobial resistance (AMR) projects were developed independently by Girlguiding and Scout groups across four UK regions. The UK 5-year AMR Action Plan outlines the importance of public engagement. This abstract describes the development, pilot and initial evaluation of a national infection prevention (IP) and AMR resource pack for Girlguiding and Scouts.

Methods

Early 2019, PHE developed a national working-group, including local pilot individuals, and Girlguiding and Scout volunteers interested in IP and AMR to agree on the content of a national programme through a consensus approach. Summer 2019, the programme was piloted across the UK. Initial evaluation included course leader feedback and an age-appropriate survey.

Results

The consensus process concluded that the programme should include interactive e-Bug activities regarding microbes; hand, respiratory and food hygiene; antimicrobials and AMR. To consolidate learning, participants would create posters, make Antibiotic Guardian pledges, and share these with their families. A draft resource pack was developed to enable the programme to be delivered by leaders without a science/health background. Initial evaluation with over 150 children will be presented, to include enjoyment, acquisition of knowledge, and intentions to change health behaviours (i.e. improve hand and respiratory hygiene, and only use antibiotics when needed). Feedback from children and leaders will be used to update the resource pack prior to launch.

Conclusion

This national programme is engaging and delivers key IP and AMR messages. The programme will be launched for World Antibiotics Awareness Week 2019. Full evaluation planned for 2020.
The Half-Life of Maternal Transplacental Antibodies in infants from mothers vaccinated with diphtheria, tetanus and pertussis: An individual participant data meta-analysis
Authors: Oguti Blanche , Assad Ali , Andrews Nick , Barug Daantje , Dang Duc Anh , Halperin Scott , Hoang Ha , Holder Beth , Kampmann Beate , Kazi Momin , Langley Joanne , Leuridan Elke , Madavan Naomi , Maertens Kirsten , Miller Elizabeth , Munoz Flor , Omer Saad , Pollard Andrew , Rice Tom , Rots Nynke
Published: March 2020

Aim: There are no reliable estimates of the half-lives of maternal antibodies to the antigens found in the primary series vaccines. We aimed to calculate the half-lives of passively acquired antibodies in infants born to mothers participating in studies of tetanus, diphtheria and acellular pertussis (Tdap) vaccination during pregnancy. We aimed to determine whether decay rates varied according to maternal age, birthweight, sex, socioeconomic status, country, or vaccine received.

Methods: De-identified individual participant data from infants born to women taking part in 9 studies of maternal immunization, in 8 countries (UK, Belgium, Thailand, Vietnam, Canada, Pakistan, USA and the Netherlands) were combined. Blood samples were taken at two timepoints before any Tdap containing vaccines were received by the infant: at birth and at 2-months of age. Decay rates for each antigen were log2-transformed and meta-analysis performed. Half-lives were calculated by taking the reciprocal of the absolute value of the mean decay rates.

Results: A total of 4,091 samples were included in the analysis and there was significant variation between studies. There was significant variation in the half-lives of the 6 antigens of interest (p<0.001), with estimates ranging from 28.1 days for diphtheria to 35.6 days for filamentous haemagglutinin. The decay of maternal antibodies did not significantly differ by country-level socioeconomic status, maternal age, sex, birthweight or maternal vaccination.

Conclusion: Maternal antibodies decay at different rates for the different antigens, however the magnitude of the differences are small. Differences in laboratory techniques may account for some of the variability between studies.
Cohort study of Faecal Microbiota Transplantation for patient’s colonised with MDROs - successful prevention of invasive disease despite low decolonisation rates
Authors: Ghani Rohma , Mullish Benjamin , Mcdonald Julie , Williams Horace , Gilchrist Mark , Brannigan Eimear , Satta Giovanni , Taube David , Duncan Neil , Pavlu Jiri , Ghazy Anan , Thursz Mark , Davies Frances , Marchesi Julian
Published: March 2020

Faecal Microbiota Transplantation (FMT) is widely utilised for recurrent Clostridioides difficile infection. Use of FMT for the intestinal eradication of multidrug-resistant organisms (MDROs) has been described in the literature with decolonisation rates from 37.5% to 87.5%. We perform FMT via naso-gastric tube using donor stool prepared anaerobically, using prevention of invasive disease as an endpoint.

FMT was considered for either; 1) Patients who were colonised with >1 MDRO (carbapenem-resistant Enterobacteriaceae, vancomycin resistant Enterococci or extended-spectrum beta lactamase (ESBL) and at risk of invasive MDRO disease or 2) patients who had recurrent MDRO-mediated invasive disease.

Sixteen MDRO colonised/infected patients underwent FMT. Nine patients had a haematological disorder. Eight of these patients had had prolonged admissions (range 6-20 weeks) complicated by septic episodes (5/9 had a MDR bacteraemia) pre-FMT. Post FMT all patients had shorter admissions including five who received higher intensity immunosuppression. Only 1/9 developed MDRO-mediated invasive disease.

Seven FMT patients had recurrent ESBL urinary tract infections (UTIs). 4/7 were renal transplant patients. Following FMT the 3 non-transplant patients had no further UTIs up to six month period. Four transplant patients had reduced number of infections, admissions and use of antibiotics.

5/13 (39%) patients were not MDRO colonised on rectal screens post-FMT (follow up range 12 weeks – 24 months).

Although decolonisation rates were low, patient outcomes post-FMT were apparently improved. Mechanisms of FMT have not fully been established, improvement of colonisation resistance by restoration of microbiota composition or functionality in at risk groups could be more important than intestinal eradication.
Developing a novel paperless E-referral pathway for Infection clinic at a large teaching hospital, community and primary care in northwest England: A novel strategy to spearhead the trust antimicrobial stewardship programme
Authors: Guleri Achyut , Sharma Rashmi , Moon Jill
Published: March 2020

BACKGROUND: UK’s 5y (2019-24) national action plan on antimicrobial resistance(AMR) projects 1 death/3 seconds(global) by 2050, if AMR rise not tackled. Accurate diagnosis of infectious condition and prompt optimal antibiotic/s are corner stones of any antimicrobial stewardship(AMS), sepsis programme and reducing mortality. We present our experience of developing a novel paperless E-referral pathway for all infection consultations from hospital and primary care to spearhead the hospital AMS and sepsis programmes.

MATERIAL/METHODS: Hospital webdesigners customized existing software application (www.nervecentresoft [http://www.nervecentresoft/]ware.com) & developed user friendly E-referral system (includes basic clinical details, referral urgency/coloured flag and grade/contact of submitter); it auto populates patient demographics and ward location from patient information system. Reports can be generated to query agreed parameters (&KPI). E-referrals accessible both on hospital computers or iPhone/iPAD.

RESULTS: AMS (Apr18-Mar19): >13K ward/phone AMS interventions; total referrals:13,312; 9438(70.1%) responded in 60-min;11923(90%)120min; E-referrals/d: 30-80; Referral Peaks: 3pm & 11am; Referrals from hospital [10,709(80.2%)], GP/prim care [2654 (19.8%)]; Clinical areas: [eg. male cardiac:491(3.6%); HDU:793(5.9%), etc]; E-referrals addressed/consultant [eg. Consultant A(4590(34.3%), etc]. Details & graphs to be presented.

CONCLUSION: E-referral pathway has spearheaded trust AMS & sepsis programmes. Urgent referrals are picked without delay; KPI of referral response within 60mins; significant reduction in calls for consultant Infection via switch board or medical secretaries; auditable workload figures for team to inform UKAS inspection, new consultant business cases or quality matrix; improved accountability and informs annual appraisal / job plan.
Do junior doctors have the knowledge to safely prescribe antibiotics in the context of known penicillin allergy?
Authors: Cheetham Laura
Published: March 2020

The drug class most frequently associated with allergic reactions are the penicillins. Yet penicillins have a vital role in being important treatment options for many common and uncommon infections.

Junior doctors undertake the majority of hospital-based prescribing. Evidence suggests foundation doctors make the most prescribing-based errors.

A questionnaire was designed to ascertain whether junior doctors displayed an adequate level of knowledge regarding individual and antibiotic class identification, use of trade names, beta lactam cross sensitivity and symptoms of type I and IV hypersensitivity reactions.

Three quarters of respondents stated they had received allergy/non-allergic drug reaction teaching as an undergraduate but only just over a half had as a postgraduate. The Junior doctor responded group demonstrated adequate knowledge of correct identification of individual penicillins and non-penicillins and symptoms of a type I hypersensitivity reaction. There was inadequate knowledge of cephalosporin and carbapenem prescribing in the context of penicillin-associated anaphylaxis and of type IV hypersensitivity reaction symptoms. More core and higher specialty trainees correctly chose to prescribe in generic name form than foundation doctors.

This survey suggests that there may be key elements of knowledge required to safely prescribe antibiotics in the context of penicillin that, overall, as a group, junior doctors may lack adequate knowledge of, with this inadequacy being most pronounced in foundation doctors.

This suggests that junior doctors, and foundation trainees in particular, may need more education and training early in their careers to help support safe prescribing in the context of penicillin allergies.
Collation of resources within a regional antimicrobial pharmacy group
Authors: Bond Stuart , Lee-Milner Jade
Published: March 2020

Background: Previous regional antimicrobial meetings identified duplication of antimicrobial stewardship work in Acute trusts. In 2018, collation of guidelines for hospital acquired pneumonia, community acquired pneumonia and urinary tract infections led to creation of exemplar guidelines. All documents were emailed, which was inefficient due to volume, with no central repository that could be accessed across sites. Given the regional shortage of microbiologists, easy access to job descriptions and business cases was considered essential to improvement of pharmacy staff resources regionally.

Aim: To create an open access regional hub for antimicrobial resources within Yorkshire and the Humber using the Specialist Pharmacy Service (SPS) website.

Methods: The Yorkshire and Humber Antimicrobial Pharmacy Group’s objective is to continuously improve antimicrobial stewardship and infection management through networking, sharing best practice, learning, peer support and joint working/initiatives. Starting in March 2019, resources were submitted to the SPS website.

Results: A total of nine job descriptions were uploaded, along with members of the group, educational links such as the #todipornottodip campaign, terms of reference, annual workplan, meeting agendas and a brief summary of the group’s objectives and regional geography.

Conclusion: The SPS website has facilitated a more efficient sharing of regional antimicrobial stewardship resources. Further work is warranted for sharing education resources, and business cases that don’t contain commercial information. As the site is open access, a decision was made to continue emailing meeting minutes.
Clinical validity of enterovirus PCR testing of skin swabs samples
Authors: Price Vivien , Osman Husam , Bosworth Andrew
Published: March 2020

Background:

Enteroviruses cause a diverse spectrum of diseases. In 2018, enterovirus PCR was included in the standard panel of skin swabs investigations, which already included HSV and VZV. Here we show evidence that positive PCR results for enterovirus correlate with clinical data obtained through retrospective review.

Method:

A retrospective search of laboratory records for all skin swabs between July 18 and March 19 was performed. Enterovirus PCR positive results were correlated with clinical information from request forms and electronic patient records. A subset of positive samples was sent to the reference laboratory for genotyping by Sanger sequencing of the VP1 gene.

Results:

Of 1159 specimens tested, 108 were positive for enterovirus, 194 were positive for HSV 1, 70 for HSV 2, 167 for VZV. Median age for enterovirus positive patients was 1 year, compared with 29 years for HSV and VZV positive patients. 99 enterovirus positive results correlated clinically, 2 did not correlate, and 7 had no clinical information available. Those with clinical correlation had a higher PCR cycle threshold (CT), than those without (mean 27.4 vs. 38).

12 samples were sent to the reference laboratory. Of the 6 that could be successfully genotyped, all were Coxsackie A6.

Conclusions

Positive enterovirus PCR in skin swabs correlated well with clinical signs, demonstrating validity. The identification of Coxsackie A6 on all sub-typed isolates further supports the validity of a positive result, as does the younger median patient age for patients testing positive for enterovirus compared to other viral infections.
Genetic diversity of urogenital Chlamydia trachomatis before and after mass drug administration for trachoma
Authors: Baltas Ioannis , Pickering Harry , Beale Mathew , Holland Martin , Versteeg Aalbartus , Mabey David , Roberts Chrissy H. , Kako Henry , Solomon Anthony , Thompson Nick , Marks Michael , Butcher Robert
Published: March 2020

Background

The WHO recommends treatment of trachoma with community-wide mass drug administration (MDA) with a single dose of azithromycin as part of the SAFE strategy (surgery, antibiotics, facial cleanliness and environmental improvement). In the Solomon Islands, this programme had demonstrable collateral benefit by reducing the prevalence of urogenital Chlamydia trachomatis(Ct) infections. We evaluated the impact of this treatment on population genetics of urogenital Ct.

Methods

Two vaginal swabs were collected from consecutive women attending antenatal clinics during cross-sectional surveys before and after MDA. For every swab positive for Ctinfection, DNA was extracted from the second swab, enriched and sequenced using paired-end sequencing. Whole-genome sequences were aligned against selected references. Diversity was assessed using genome-wide pairwise diversity and a high-resolution multi-locus sequence typing (hr-MLST-6) scheme. ARIBA software was used to test for evidence of antimicrobial resistance to macrolides.

Results

Whole-genome sequence data was obtained from 23/49 (47%) pre-MDA and 32/41 (78%) post-MDA Ct-positive samples. Most strains were serotype E and F, and tissue tropism genes were consistent with their urogenital nature. Genetic diversity of Ctwas lower by both pairwise and hr-MLST-6 diversity metrics in the post-MDA sample than the pre-MDA sample. There was no evidence of mutations known to confer resistance to macrolides in any of the samples collected.

Conclusions

Reduced diversity after MDA may represent selection pressure from mass antibiotic delivery. The absence of antimicrobial resistance is encouraging. The collateral impact (both positive and negative) of large-scale preventative chemotherapy programmes should be considered when deciding whether should be implemented.
A 12 month follow-up looking at improvements to adult inpatient gentamicin prescribing and the role of the antimicrobial pharmacist
Authors: Hinchliffe Rachael
Published: March 2020

Background

Audits at Mid Yorkshire NHS Trust have identified inappropriate prescribing of gentamicin. Antimicrobial stewardship (AMS) interventions in hospital have increased adherence to antimicrobial prescribing policies2.

Methods

Pre-intervention data were collected by the antimicrobial pharmacist in January 2018. Interventions were then completed and included: oral presentations, targeted reviews and teaching sessions. Inappropriate indications or doses received routine AMS intervention. Following interventions a second audit was completed in May 2018 to measure improvements in prescribing. A second intervention was the introduction of a 5 day review service of prescribed gentamicin and a third audit was completed in August 2019 to demonstrate a sustained improvement.

Results

In total, 25 patients were audited in January 2018, 24 patients in May 2018 and 29 patients in August 2019. The three groups were similar for age, sex and reason for admission. The proportion of patients receiving an appropriate initial dose of gentamicin increased from 13/25 patients (54%) to 19/24 patients (79%) and again to 27/29 patients (93%). The proportion of patients that had the subsequent dose of gentamicin prescribed appropriately increased from 9/25 patients (36%) to 20/24 patients (83%) and again to 29/29 patients (100%).

Conclusions

This project demonstrated a sustained improvement in gentamicin prescribing following a series of pharmacist-led education and training sessions, one to one training, presentations at governance group meetings and the introduction of a 5 day pharmacist review service. The sample was limited to those patients who had levels taken.
Experience of adopting a standardised nomogram for gentamicin monitoring- an audit
Authors: Brookfield Charlotte , Clark Rebecca , Reddy Suganya
Published: March 2020

Background:

Gentamicin, an aminoglycoside antibiotic, requires therapeutic drug monitoring to decrease the risk of nephrotoxicity and ototoxicity. We audited compliance with our dosing and monitoring guidelines since adoption of the Barnes-Jewish Nomogram for once daily 5mg/kg dosing in September 2018.

Methods:

We retrospectively reviewed 62 patients who received 171 gentamicin doses with 173 accompanying levels taken between 1/11/18 and 31/1/19.

Results:

The audit demonstrated overall poor adherence to guidelines. Only 50% of patients received the correctly calculated dose. 40% of gentamicin levels were taken between 6-14 hours resulting in a large number of uninterpretable levels requiring additional actions e.g. repeat levels. 50% of follow up doses were given in the correct time frame. For patients with normal renal function twice weekly monitoring is recommended. In all cases (n=35) where this applied levels were monitored more frequently that indicated. U&Es were regularly monitored for all patients and we did not identify any acute kidney injury.

Conclusion:

The Barnes-Jewish nomogram was adopted to provide a standardised evidence based monitoring system for gentamicin. However our audit demonstrates the guidance was not well executed clinically. There appeared to be a lack of appreciation and responsibility for monitoring and interpretation of levels. This resulted in erratic sampling, unnecessary levels, and delayed doses. As a result of this audit we intend to adopt a simpler trough level system based on the gentamicin SPC. Our audit demonstrates the need to evaluate service improvement implementations since theoretical benefits do not always translate in to clinical practice
Tayside TB Pathway: A Quality Improvement Project
Authors: Wilson Aline , Jordan Rose
Published: March 2020

Aims:

The aim of this project was to look at our local practice of identifying and managing patients with mycobacterium tuberculosis (MTB) and non pulmonary NTM. In Tayside, the care of patients with MTB is shared between the Infectious Diseases physicians and the Respiratory physicians. We aim to improve communication and identify any issues with continuity of care and create solutions to standardise the care our patients receive.

Methods:

We performed an initial audit of patients that were currently receiving or had recently completed treatment for MTB and non pulmonary NTM. We collected data from 26 patients between January 2017 - July 2018.

Results:

Some of the results are as follows: Out of the 26 patients, only 14 (53.8%) of those had a documented start date of treatment on the initial clinic letter. 92.3% had a documented treatment regime on clinic letter. 88.4% (23 out of 26 patients) had a documented diagnosis (specifying site) on clinic letter. Only 46% had a complete BBV screen, 35% had an incomplete BBV screen and 19% had none.

Outcome:

After performing the initial audit and assessing the areas of improvement, we were able to create our “Tayside TB Pathway”. The idea behind this was to create a more cohesive and streamlined approach to TB care whilst involving all members of the MDT. The pathway was created to be straightforward and allow us to have a “centralised hub” to oversee the important steps involved in the management and prompt these to be performed where needed.
Early laboratory markers may reflect the severity of pyogenic liver abscess infection: Retrospective cohort study
Authors: Husain Ahmed , Mohd Mahmoud , Elmekaty Eman , Mulla Abdalrazig El , Adam Mohammad , Al-Khal Abdullatif , Maslamani Muna Al
Published: March 2020

Background:

Liver abscess carries significant morbidity and mortality rate due to its complications. We aimed to identify laboratory markers associated with septic shock related to pyogenic liver abscess.

Methods:

The study was conducted at Hamad General Hospital, a tertiary hospital in Qatar. Data were collected retrospectively. All patients diagnosed with pyogenic liver abscess between 2013 and 2017 were included. Liver abscess was diagnosed based on clinical presentation and radiological finding with or without microbiological evidence. Septic shock defined as the need of vasopressors to maintain mean arterial pressure > 60 mmHg. Data has been collected on admission time. Descriptive data were presented in mean ± SD and percentages. Normally distributed data were analyzed by T-test otherwise Mann–Whitney was used.Fisher Exact test was used for categorical data. The level of significance was set at P<0.05.

Results:

Pyogenic liver abscess has been identified in 78 patients. 89.9% were males. 48.7% of the patients were diabetic. Nine patients (11.5%) developed septic shock. Patients who developed septic shock had higher procalcitonin level (Hazard ratio [HR] 1.025, 95% CI 1.006-1.044, p0.009) but lower level of hemoglobin (HR 0.744, 95% CI 0.581-0.952, P. 0.019), protein(HR 0.867, 95% CI 0.779-0.966, p 0.009) and platelet (HR 0.994, 95% CI 0.988-1.000, p 0.035)

Conclusion:

Measurement of baseline procalcitonin, hemoglobin, protein, and platelet in pyogenic liver abscess may provide early information about the severity of the infection and the need for early aggressive management. However, a larger sample size is needed to achieve more statistical significance.
CPE in Beaumont Hospital – Trying to understand an increasing and challenging pathogen
Authors: Skelly Emma , Foley Margaret , Skally Mairead , Reilly Aoife , Humphreys Hilary , Fitzpatrick Fidelma
Published: March 2020

Background

The prevention and control of carbapenemase-producing Enterobacteriales (CPE) cross-infection is increasingly difficult worldwide. Patients exposed to a CPE positive patient in our institution are informed, offered CPE screening and their clinical records flagged on our hospital information system since mid-2017 as recommended nationally. However, no assessment of the numbers of CPE contacts has been performed prior to this.

Objective / Aims

To retrospectively identify and quantify CPE contacts patients in Beaumont Hospital between 2011 and mid-2017.

Methods

Patients with an exposure to CPE positive patients while an inpatient were identified retrospectively. Each CPE contact was evaluated for: number of CPE screens taken, mortality, existing multidrug resistant colonisation, duration of CPE exposure, recurrent hospitalisation after CPE exposure and CPE colonisation within this group.

Results

Twenty-eight CPE positive patients were identified from January 2011 – May 2017. This included 22 OXA-48, six KPC and four NDM patients; two patients had OXA 48 and NDM genes. A total of 237 patients were identified as CPE contacts of whom 124 (52.7%) had 190 CPE screens. Four CPE contact patients were identified as CPE positive (all OXA-48), however, only three (1.2%) were associated with exposure to one of the 28 CPE positive patients.

Conclusions

The identification of potential CPE contacts and subsequent CPE positive patients is essential to prevent further cross-transmission. Of the CPE contacts screened, only three CPE positive patients were associated with exposure to the index patients, which may indicate good adherence with infection control precautions or low sensitivity of culture-based screening.
A tricky trochanter
Authors: McGuire Emma , Charambous Alexander , Gulati Vivek , Boyd Aileen , Woods Kate
Published: March 2020

A 24-year-old previously well female presented with a discharging thigh abscess after travel to Ghana. She reported malaise but was otherwise systemically well. Further history revealed 2 years of intermittent left thigh pain, which had been attributed to a large trochanteric bursa identified on ultrasound in 2017. On examination she was afebrile with a deep, undermined ulcer discharging pus in the left antero-lateral thigh. Femoral X-ray was unremarkable.

She underwent surgical debridement and intra-operatively infection was found to track to the greater trochanter. Tissue specimens grew Gemella morbillorum, Klebsiella pneumoniae, Enterobacter cloacae, Streptococcus anginosus and mixed anaerobes. She responded well to 4 weeks of ciprofloxacin, metronidazole and amoxicillin. Histological examination of the ulcer edge revealed non-necrotising granulomata (Ziehl-Neelsen stain negative).Mycobacterium tuberculosis(MTB) was subsequently isolated on mycobacterial culture from the same site. MRI demonstrated osteomyelitis of the greater trochanter with a 2cm intramedullary abscess and an adjacent soft tissue collection. Macroscopically caseous material was found on further debridement and tissue samples were AAFB smear negative but MTB complex was detected by PCR and culture of intra-medullary bone.

This case demonstrates that bacteria and mycobacteria may be co-pathogens, and that M. tuberculosis bone infection may present with no systemic symptoms. It is a reminder of the importance of cross-sectional imaging and mycobacterial culture in deep soft tissue infections with a long or unusual history.
Analysis of outpatient and home parenteral intravenous antibiotic therapy (OHPAT) cases at the Newcastle upon Tyne Hospitals NHS Foundation Trust from April 2017 to June 2019
Authors: Pinedo Joshua , Schwab Uli
Published: March 2020

Introduction and Methods

Newcastle’s OHPAT service has been operating since 2011, providing intravenous antimicrobials on outpatient basis for deep seated infections (DSI) and skin and soft tissue infections (SSTI); either provided at the OHPAT service in hospital (H-OPAT), delivered to the patient’s home (C-OPAT) or self-administered by an instructed patient (S-OPAT). The service aims to reduce admissions and inpatient bed days. Data from a prospective database was analysed to determine bed days saved, admissions avoided, location and success rate of treatment and adverse outcomes.

Results

292 patients (174 male, 118 female) median age 54 (range 17– 97) April 2017-June 2019. 148 patients with SSTI and 143 DSI. 140 patients previously treated as inpatients. 141 admissions avoided; 3540 bed days saved; 267 patients treated with H-OPAT; 21 C-OPAT; 4 S-OPAT. High cure rate of 100% in SSTI and 97% in DSI (3 re-admissions, 1 self-discharge). Low complication rate with no death, MSSA/other bacteraemia or CDT-associated diarrhoea. Low complication rate of 0.7%: rash in 1 patient (on ceftriaxone) and line blockage in 1 patient.

Conclusion

The aim of the OHPAT service is equality of effectiveness and safety compared to inpatient care. This has been achieved in the ongoing low rate of complications and adverse outcomes. The service treated a wide range of DSI which contribute a larger proportion of bed days for much fewer cases than SSTI. Significant numbers of hospital stays were avoided or shortened. OHPAT has been able provide complex regimes with home delivered and self-administered dosing.
Prevention of Nebulised Drug Dispersal using an Extractor Tent
Authors: Fennelly Mehael , Keane Joseph , Dolan Lorraine , Plant Barry , Sodeau John , Prentice Michael
Published: March 2020

Nebulisers convert liquids into a fine mist of suspended particles that are inhalable into the respiratory tract. They are used to deliver drug therapy by the respiratory route, for example bronchodilators, or to aid production of diagnostic sputum samples (sputum induction). On continuous monitoring of biological airborne particles in a respiratory ward over 4 weeks using a biological particle detector (WIBS) the majority of detected particles were attributable to nebuliser therapy. Tents with extractor/filter devices are indicated for infection control purposes in collection of induced sputum from patients with suspected tuberculosis. We tested the efficacy of an extractor tent (Demistifier 2000, Peace Medical) on reducing detectable aerosols from nebulised bronchodilator drugs by continuously monitoring a room outside a tent containing a nebuliser. The mean fluorescent particle count per m3 was 0.63 and 0.31 (equivalent to background levels pre-nebuliser) for nebulised Ventolin and Ipramol, respectively, when they were nebulised within the tent. Removing the tent and nebulising directly into room air resulted in a 2.56×104 and 4.64×104-fold increase in particle concentrations for Ventolin and Ipramol, respectively, over background levels. WIBS monitoring therefore showed 100 % efficacy of the tent in restricting spread of nebulised drug particles. Extractor tents can prevent spread of drug particles from nebulised therapy. The implications of this will be discussed.
Comedones and carbapenems: hydradenitis suppurativa in the OPAT clinic
Authors: Rogers Benedict , Harman Karen , White Helena
Published: March 2020

Background

Hydradenitis suppurativa (HS) is a chronic inflammatory skin disease. The UK prevalence is estimated at between 1-4%. There is an approximate 3:1 female: male preponderance and it is associated with smoking, obesity, type 2 diabetes mellitus. The pathogenesis of HS is poorly understood. Clinical features vary in extent and the axillae, inguinal and anogenital areas are typically affected. It has a significant impact on quality of life, with high rates of depression amongst sufferers.

Current UK treatment guidelines focus on lifestyle interventions, as well as targeted use of oral antibiotics, however microbiological sampling is usually not helpful. Where these are unsuccessful anti-TNF agents and surgical intervention may be indicated. Despite their absence from these guidelines, there is growing evidence to support the role of intravenous (IV) antibiotics in treating HS. It is not known whether the treatment response seen with IV antibiotics is due to their antibacterial or an anti-inflammatory effect. We present a series of HS patients managed under the OPAT team at University Hospitals of Leicester.

Cases

To date 8 patients have completed treatment (7F/1M). All received at least 6 weeks of therapy with IV ertapenem (+/- teicoplanin). Significant improvement in both clinical signs and symptoms was achieved in all cases. However, disease relapse was seen in three cases after cessation of IVs, requiring additional courses of treatment. Antibiotics were well tolerated with one adverse drug reaction secondary to teicoplanin.

Conclusion

Intravenous antibiotics are an effective adjunctive treatment in selected cases of hidradenitis suppurativa.
Online continuous medical education: Diagnosing fungal infections from a distance
Authors: Corzo-leon Dora E. , Rivera-Martinez Norma E.
Published: March 2020

Background

Increasing global incidence of serious fungal infections (SFI) requires increasing access to high quality medical mycology education to improve their identification and decrease associated mortality.

Methods

An online course was developed by two infectious diseases (ID) specialists. The course aimed to improve diagnosis of SFI and was delivered from April-June 2019. The course consisted of 9 online interactive sessions every week. Sessions were streamed by a hospital in Mexico and local participants gather there every week. Other participants connected independently online. Participants took one exam at the start and another after the course was completed. Feedback was collected during the course. A final evaluation of the impact on diagnosis will be collected in October 2019.

Results

A total of 137 people registered for the course. Registrants were from four different countries, Mexico (126, 92%), Ecuador (9, 6.6%), Australia (1, 0.7%) and Bolivia (1, 0.7%). Mexican participants connected from 15 of the 32 regions (47%) in Mexico and 45 (33%) attended the course at host hospital. Most participants were physicians (76%), 54 were ID specialists and 19 were ID residents. Sixty participants (60/137, 44%) completed the course, with greater completion by those attending in person (33/45, 73%) compared with online attendance (27/92, 29%). The exams results improved 30% after the course. Clinical urgent calls limited attendance.

Conclusions

This online course allowed a broad geographical participation. Learning as group lead to better completion rates. Recorded sessions will be available on demand and may allow the completion of the course.
Teicoplanin therapeutic drug monitoring (TDM) – excessive or essential?
Authors: Boyd Aileen , Brasa Carmen Cabeza
Published: March 2020

Background:

Teicoplanin is a glycopeptide antibiotic which is frequently used in preference to vancomycin because it does not require such regular TDM as the association between concentration and toxicity has not been fully established. TDM is however, recommended to help optimise therapy in some patients. In our hospital there was an observation of frequent sub-therapeutic levels which prompted an audit of TDM results.

Methods:

Retrospective review of TDM results August 2015- March 2017 at Homerton Hospital with analysis of dose, renal function, patients’ weight and type of infection.

Results:

We analysed 54 samples from 33 patients. The most common dose was 600 mg OD which equated to a mean dose of 8.68 mg/Kg with under-dosing in all weight groups but with lowest levels in the group between 110-120 Kg. A 24hr dosing regimen was the most common and other dosing regimens (48hrly or 72hrly) more frequently associated with sub-therapeutic levels.

Overall, the mean level was 27.8 +/- 11.9 mg/L but 41% (n=22) of levels were sub-therapeutic for the type of infection treated including 4 patients with bacteraemia, 7 patients with bone and joint infections (n=10 samples) and 3 patients (n=6 samples) with prosthetic joint infections. There was only one patient with teicoplanin levels >60 mg/L who was on treatment for a streptococcal endocarditis. She did not report any side effects.

Conclusion:

The current dosing regimen recommended by the BNF frequently results in sub-therapeutic levels. TDM is essential in managing complex infections to ensure therapeutic levels are achieved.
In-house azithromycin MIC estimation by gradient strip in Salmonella enterica var Typhi and Paratyphi: Do you believe it?
Authors: Goldblatt Jennifer , Ward Andrew , Day Martin , Godbole Gauri , Morris-Jones Stephen
Published: March 2020

Background: Dependence upon azithromycin in the treatment of enteric fever is increasing, particularly with the emergence of Salmonella typhi strains with extended spectrum β-lactamase activity and the already high prevalence of quinolone resistance. Accurate determination of azithromycin susceptibility is crucial and underlined by recent reports of azithromycin resistance. We investigated concerns of discordance in azithromycin susceptibility estimation between local and reference laboratories.

Methods: Retrospective audit of isolates from patients attending a central London hospital with enteric fever (May 2011-April 2019). Estimations of azithromycin and ciprofloxacin MICs by the local and reference laboratories were compared. Genomic data and laboratory practices were reviewed.

Results: In isolates with matched clinical and reference laboratory MICs (n=19), there was poor inter-laboratory concordance: 5/19 MICs concordant (weighted κ = 0.190, adjusted for concordance within 1 log2 dilution); susceptibility interpretation concordant in 8/19 (κ=0). All isolates reported locally as resistant were found to be sensitive by the reference laboratory. No azithromycin resistance genes were detected. By contrast, for ciprofloxacin: 13/18 MIC gradient strip results concordant (weighted κ=0.823); susceptibility interpretation concordant in 17/18 (κ=0.85). Of the possible sources of variation identified, we believe that variable interpretation of “trailing edge” MIC estimation was key, mitigated in the reference laboratory by a “second reader” system.

Conclusions: There is marked variation in azithromycin MIC gradient strip reporting between a local laboratory and the national reference laboratory, particularly over-reporting of resistance by the local laboratory. We would advise clinical laboratories to review their experience and consider adopting a “second reader” system.
Prevalence of MRSA colonisation amongst patients undergoing elective orthopaedic implant surgery at North Bristol NHS Trust
Authors: Nye Clemency , Webb Jason , Hammond Fiona , Darley Elizabeth
Published: March 2020

Introduction:

National guidelines recommend MRSA screening of all patients before elective orthopaedic implant procedures (EOIP) as a measure to reduce risk of MRSA surgical site infection (SSI). With low prevalence of MRSA in UK currently, this universal approach of screening all EOIP patients may be unnecessary.

Objectives

To determine MRSA colonisation rate of EOIP patients pre surgery and number of MRSA-positive patients developing surgical site infection (SSI) within 30 days.

Methods:

North Bristol NHS Trust is the largest Orthopaedic unit in Southwest England. It performs over 6000 elective Orthopaedic operations annually, including 2000 hip and knee joint replacements. All major elective cases are reviewed in a pre-operative assessment clinic where MRSA screening, amongst other tests, is performed.

The pathology IT system was interrogated to identify data on patients screened for MRSA in the orthopaedic pre-assessment clinic from 1st January to 31st March 2019. Routinely collected SSI data was reviewed for details of any SSI in these patients.

Results:

439 patients were screened in the pre-operative clinic. 4/439 patients (0.9%) had positive screens. Applying national MRSA screening criteria, 2/4 patients had recognised risk factors for MRSA colonisation (including one patient previously MRSA colonised), and 2/4 did not. All 4 patients were decolonised pre-surgery and none developed SSI. No patient developed MRSA SSI.

Conclusions:

Approximately 1%, of patients attending for EOIP are colonised with MRSA in this Trust. No patient developed MRSA SSI in the 3month period. There may be potential to rationalise the approach to MRSA screening in EOIP patients.
The trend in HIV internet search activity over a 5-year period and the impact of AIDS awareness day
Authors: Carter Emma
Published: March 2020

Background

Worldwide there are an estimated 36.9 million people with HIV of which 25% do not know their status. The following study assesses the effect of AIDS awareness day on internet search activity for HIV, and analyses other causes of spikes in internet search activity.

Methods

Google trends was used to examine search trends for HIV, over the past 5 years. These were correlated with ‘’AIDS’ awareness day’’ to assess the effect of this campaign on public interest. Search trends for the United Kingdom were also analysed. Repeated measures ANOVA and Tukey post-hoc analyses were performed to assess for significant differences in activity.

Results

There are increased levels of search activity for HIV in the two weeks surrounding AIDS awareness day on a worldwide level consistently over a 5-year period (p<0.0001). However, in the United Kingdom there is no significant increase compared to the rest of the year. The event corresponding to the largest spike in HIV search activity was the announcement by Charlie Sheen of his HIV status. A spike in search activity was also seen in the United Kingdom corresponding with the MP Lloyd Russell-Moyle announcing his HIV-positive status, this was higher than observed on AIDS awareness day in the UK 2 days later.

Conclusions

On a worldwide level AIDS awareness week is achieving it’s aims of increasing public interest in HIV. However, in the United Kingdom, the announcement by public figures of their HIV-positive status appears to have a greater effect on stimulating public interest.
Proposal to reclassify Streptobacillus hongkongensis into a novel genus as Pseudostreptobacillus hongkongensis gen. nov., comb. nov.
Authors: Eisenberg Tobias , Glaeser Stefanie P. , Blom Jochen , Kämpfer Peter
Published: March 2020

The reclassification of

Streptobacillus hongkongensis

as Pseudostreptobacillus hongkongensis gen. nov., comb. nov. is proposed because of the separate phylogenetic position on the basis of the 16S rRNA gene sequence phylogeny, the combined analysis of the three protein-coding housekeeping genes groEL, gyrB and recA and a core genome sequence phylogeny to all other

Streptobacillus

species that is supported by phenotypic differences. The species Pseudostreptobacillus hongkongensis is the type species of the genus. The type strain is HKU33T, JCM 18691T, NCTC 13659T, DSM 26322T.