bluuebunny/crossref_metadata_2025_split huggingface dataset:
It may be a stroke, it may be meningo-encephalitis
Authors: Pan Daniel , Bridges Leslie , Cosgrove Catherine , Zhang Liqun 
Published: March 2020

An 85-year old lady originally from Gujurat presented to the emergency department with sudden onset left sided weakness and slurred speech. Stroke was suspected. Computed tomography (CT) of the head showed bilateral multiple cortical and subcortical hypodense lesions; magnetic resonance imaging revealed that these lesions were ring enhancing with oedema. Lumbar puncture found an opening pressure of 22cm H2O, 98% lymphocytes (60x106/L) in the cerebrospinal fluid with a normal glucose (6.1mg/L) and high protein (0.66 mg/L). Cerebrospinal fluid culture, PCR and cytology were all negative. The patient was started on empirical therapy for tuberculous meningitis. A subsequent CT chest, abdomen and pelvis however did not find any other significant pathology.
Unfortunately, soon after her investigations, the woman rapidly deteriorated. A joint medical decision was made to shift focus of treatment to palliative care. After death, post-mortem found multiple irregular haemorrhagic solid lesions with dark brown edges. Histopathology confirmed extensive areas of necrosis, within which there were multiple amoebic trophozoites and cysts. A diagnosis of amoebic (it may be) meningo-encephalitis was made. These were thought to be free-living amoebae.
Free-living amoebae are ubiquitous to the environment, and exposure is common. The incidence of amoebic encephalitis however is rare and usually occurs in immunocompromised patients. Portal of entry, especially in cases where the cerebrospinal fluid protein is only mildly raised or normal, is thought to be through the nose or eyes (for example, Acanthamoeba keratitis from contact lenses). Clinicians should consider this as a differential diagnosis for any patient with multiple brain abscesses.
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.
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.