bluuebunny/crossref_metadata_2025_split huggingface dataset:
Myroides odoratimimus necrotising fasciitis and recurrent bacteraemia in an immunosuppressed patient with chronic leg ulcers: an emerging pattern?
Authors: Ainarozidou Aikaterini , Evans Andree 
Published: March 2020

Introduction: A 58yr old with inflammatory arthritis and diabetes, taking biologics, methotrexate and prednisolone, presented unconscious, hypotensive in acute renal failure. She had chronic leg ulcers and blistering, necrotic skin on both legs. After resuscitation, empiric meropenem and clindamycin, and urgent surgical debridement of her legs, she spent 2 days on ITU. A rapid recovery followed with discharge home after 7 days.
Methods: Histological samples were consistent with necrotising fasciitis. Blood and tissue cultures grew a yellow pigmented, oxidase positive, Gram negative bacillus with a distinctive fruity smell. 16S PCR confirmed Myroides odoratimimus.
The patient was readmitted 3 months later with unhealed leg ulcers, sepsis and blistering cellulitis
Blood cultures again grew Myroidesspp.
She recovered with meropenem and avoided ITU admission.
Discussion: Review of laboratory isolates over 2 years revealed a previous fatal case of Myroides bacteraemia in an 87year old woman with leg ulcers and possible necrotising fasciitis
Two further isolates were recovered from community samples:
* A cat bite in a 55 year old woman with alcohol excess.
* A chronic diabetic foot infection in an 80year old man.
Neither patient was admitted to hospital.
A PubMed search for “Myroides “ yielded 107 results. Most detailed the wide environmental distribution, multiple antibiotic resistance, and biofilm forming ability of the genus - worrying attributes in organisms causing infection in immunosuppressed patients.
Eleven of the twenty-three clinical papers described SSTI in patients with diabetes, renal disease, cirrhosis or other immunosuppression, including 3 of the 4 reported bacteraemias. Our cases fit well with this pattern.
Airborne Decontamination of an Intensive Care Isolation Room using 405 nm Antimicrobial Light Technology
Authors: Dougall Laura , Booth Malcolm , Anderson John , MacGregor Scott , Maclean Michelle 
Published: March 2020

Lighting systems which incorporate antimicrobial 405nm light have been developed for safe continuous, environmental decontamination, with previous studies demonstrating efficacy for decontamination of frequently-touched surfaces around clinical areas. This study provides first direct evidence of the effects of this decontamination system for control of airborne contamination.
The study was conducted in a patient-occupied ICU isolation room over a 15-day period, with air samples collected at set times (before, during and after daily use of the decontamination system). Samples were also collected in the empty room prior to occupation. Environmental monitoring occurred every second day using a sieve-impactor sampler (500L air samples collected every 10-min over 2-hr (n=13)). Room activity was logged and bacterial contamination levels recorded as cfu/m3of air.
After 2-day use of the system, airborne contamination significantly decreased from a mean of 905.2 cfu/m3 to 48.8 cfu/m3 (P=0.002). Levels then remained fairly consistent over the remaining period of system use (48.8-189.8 cfu/m3) before significantly rising after the system was turned off for 3-days (P=0.001). Additional samples collected in isolation rooms without the decontamination system demonstrate that the levels of airborne bioburden tend to increase upon increasing patient stay, however low levels were maintained as patient occupation increased when the system was in use.
This study provides first direct evidence of the susceptibility of airborne bacteria to 405nm light within a clinical setting. This patient-safe technology has the potential to improve infection control strategies by complementing existing measures, which could reduce the number of infections arising from environmental sources.
Combination of Bedaquiline plus Delaminid within a treatment regimen for Pre-XDR TB; experience of a tolerable regimen and acceptable safety profile for the first time in Scotland
Authors: Cobb Katherine , Wilson Aline , Rae Nikolas , Stevenson Neil 
Published: March 2020

Introduction: A 29 year old female of Pakistani origin was diagnosed with MDR-TB affecting cervical nodes, with pulmonary and laryngeal disease demonstrated on CT. Genotypic (and subsequent phenotypic) testing demonstrated pre-XDR resistance pattern with Izoniazid, Rifampicin, Ethambutol & Fluroquinolone resistance.
Methods: Following commencement of induction regimen with Amikacin, Cycloserine, Prothionamide, Pyrazinamide, Linezolid and Clofazimine, borderline ototoxicity developed after 6 months, necessitating a switch from Amikacin to Bedaquiline. After around 10 months, Linezolid and Cycloserine were discontinued sequentially due to progressively debilitating peripheral neuropathy, PAS was subsequently added to the regimen which was poorly tolerated. PAS was substituted for Delaminid (used with Bedaquiline, Clofazimine and Pyrazinamide) despite concerns regarding potential cumulative QTc prolongation effects. Patient was counselled regarding risk of cardiac arrhythmias; fortnightly ECG monitoring was agreed to for three months, then monthly thereafter. Manual calculations of QTc were performed using Fredericia formula.
Results: QTc rose maximally to 491 ms (89ms greater than baseline). Clinical and radiological monitoring demonstrated favourable improvement in condition. No further adverse events or toxicities were reported. The patient continues to tolerate the regimen well with no components of the regimen requiring discontinuation.
Dicussion: Bedaquiline and Delamanid are rarely used together in combination due to risk of QTc prolongation; in this clinical case they were used with no concerns being raised regarding safety or tolerability. Our experience corresponds with the international data produced by Ferlazzo et al. Whilst further large volume safety data is awaited, compassionate use of alternative drug regimens within strict monitoring guidelines should be considered.
Difficile but not impossible: Improving documentation to improve outcomes for Clostridium difficile infections in NHS Ayrshire and Arran
Authors: Keane Chloe , Doran Niamh , Lavery Clare , Sutcliffe Liam , Davis Peter 
Published: March 2020

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

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

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

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

Carbapenemase-Producing Enterobacterales (CPE) are threat to public health as they are resistant to one of the broad-spectrum antibiotic classes (Carbapenems) in clinical use.
In this report we highlight the need for optimal choice and duration of antimicrobial therapy in combination with source control for successful management of CPE infection.
A 52-year old male was admitted under general surgery with CT confirmed severe pancreatitis. He was commenced on cefuroxime and metronidazole for associated cholecystitis based on local guidelines. Treatment was gradually escalated to Meropenem due to intermittent pyrexia and inadequate response to standard antimicrobial therapies with no obvious source control solution. Following 39 days of Meropenem the fifth CT scan showed drainable peri-pancreatic collections. The drained pus sample grew Escherichia coli and Bacteroides species. The Escherichia coli were confirmed to be CPE gene (KPC) positive by PCR and sensitive to Tigecycline and Gentamicin but resistant to Meropenem and Ciprofloxacin based on MicroScan automated sensitivity panel.
Initially Tigecycline was commenced, however, due to unsatisfactory clinical progress treatment escalated to Ceftazidime/Avibactam and Co-Trimoxazole and patient completed a three-week course. The percutaneous drain was upgraded twice to facilitate drainage. Follow-up CT showed reduction of collection and patient discharged after 115-day stay.
This case demonstrated that CPE infection should be suspected in patients with persistent fever after a prolonged course of carbapenem treatment. A prompt laboratory diagnosis and effective multidisciplinary collaboration among microbiologists, surgeons and radiologists proved to be successful in achieving source control of CPE infection in this case.
Cytomegalovirus reactivation, risk factors and associated clinical outcomes among non-immunosuppressed critically ill cirrhotic adults: a longitudinal observational study
Authors: Shah Dhara , Gupta Ekta , Pasupuleti Samba Siva Rao  Pasupuleti , Mitra Lalita Gouri , Maiwall Rakhi 
Published: March 2020

Background: Although Cytomegalovirus (CMV) reactivation is not uncommon in critically ill patients, it has not been studied for cirrhotic patients in Liver-ICU.
Methods: CMV reactivation (CMV-plasma-DNAemia; ≥ 500 IU/ml), risk factors and clinical outcomes were assessed among sero-positive non-immunosuppressed critically ill cirrhotic adults at day 0, 7, 14 and 21 in Liver-ICU.
Results: Of 94 consecutive patients in Liver-ICU monitored, 55(48 men) patients were enrolled. Overall, 20 critically ill cirrhotic adults showed CMV reactivation with a median day for follow-up of 11 (IQR: 8 to 18). Majority (n=17/55, 30.9%; CI: 19.1-44.8) showed CMV reactivation at day 7. During 21-day follow-up, incidence rate/density of CMV reactivation was 2.75% per person-day (95% CI: 1.68 - 4.26% per person-day).Total leucocyte count (day 0) was an independent risk factor for CMV reactivation (adjusted OR: 1.15, 95% CI: 1. 00-1. 32, p=0.04) with cut-off point of 19.05 (AUROC: 0.696, 95% CI: 0.547-0.844, p=0.017). Increased nosocomial infection (p=0.009), SIRS (p=0.01) and ARDS (p=0.04) were observed at day 7, coinciding with CMV reactivation during Liver-ICU stay. ICU-Mortality (61.8%) did not significantly differ with and without CMV reactivation. (55 % vs. 65.7%, p= 0.43). Patients with CMV reactivation experienced early death and slightly longer stay in Liver-ICU. (Log rank p=0.06 and 0.17, respectively).
Conclusions: CMV reactivation occurs frequently with leucocytosis being an independent risk factor among critically ill non-immunosuppressed cirrhotic adults. Although CMV reactivation was associated with more severe organ dysfunction during Liver-ICU stay, it did not significantly influence ICU-mortality and Length of Liver-ICU stay.
Expedient management of Listeria monocytogenes endovascular graft infection in an immunosuppressed patient
Authors: McCormick Hannah , Lau Louis , Hunter Michael , Bond Helena , Troughton Judith 
Published: March 2020

Introduction
Listeria monocytogenes is a rare cause of infection following endovascular aneurysm repair (EVAR); there remains lack of consensus on the optimal management strategy, in particular the need for life-long suppression. Despite this organism’s increased pathogenicity amongst immunosuppressed hosts, to date no EVAR infections have been described in this cohort.
Here we describe the first case ofListeria monocytogenesEVAR infection in an immunocompromised host.
Case description
A 75-year-old gentleman presented with a 5-day history of back pain, fever and dysuria despite 3 days of oral co-amoxiclav for presumed urinary tract infection. There was no recent gastrointestinal upset. Admission blood and urine cultures were negative.
Past medical history included on-going methotrexate therapy for rheumatoid arthritis and EVAR of the infra-renal aorta in 2013.
A CT abdomen, performed to exclude intra-abdominal pathology, revealed an enlarged aneurysmal sac and fat stranding, secondary to inflammation. A CT-guided sample of aneurysmal fluid was obtained before commencing empirical piperacillin-tazobactam and vancomycin; Listeria monocytogeneswas isolated from subculture after 5 days broth enrichment. The EVAR was removed and replaced 7 days after admission and antimicrobials rationalised to intravenous amoxicillin, ciprofloxacin and metronidazole.
The patient completed 6 weeks intravenous therapy, then commenced lifelong suppressive therapy with oral co-trimoxazole 960mg OD.
Discussion
Listeria monocytogenesEVAR infection has been described in only 8 patients; this is the first in an immunosuppressed patient. This case adds to the literature by outlining a putative management strategy, involving explanation and life-long antimicrobials, for immunocompromised patients with Listeria monocytogenes EVAR infection.
Hubris Haemoptysis - Mycobacterium kansasii , are you taking the piss?
Authors: Peters Francesca , Schwab Uli 
Published: March 2020

Background: A 33 year old HIV-negative Gambian, who hadn’t left the UK for 7 years, presents with haemoptysis, 6 month cough, sweats, and weight loss. He completed standard treatment for presumed pulmonary TB in Banjul (2006), with a completely normal CXR (2015). He was normotensive, with low grade fever, Hb 110, normal clotting, mild neutropenia, CRP 11, ESR 88, with bilateral cavitating lesions in upper lobes, calcified cavity in the left apex, and tree-on bud appearance throughout left lung, suggestive of active TB. He acutely deteriorated with projectile haemoptysis, leading to haemodynamic compromise requiring tranexamic acid and embolisation of bronchial arteries.
Investigations: IGRA negative. CD4 634 (44%). The ϒ-IFN axis was tested, excluding a complete defect in the IL12-signalling-pathway. Bronchial-alveolar-lavage smear and PCR negative for MTB. Serial induced-sputa however, cultured and identified M.Kansasii, a Non-Tuberculous-Mycobacterium (NTM) on Whole-Genome-Sequencing.
Management: In absence of any radiological structural lung disease, with apparent immune-competence, the source of acquisition remains elusive. Empirical treatment included Ethambutol/Rifampicin/Isoniazid/Moxifloxacin/Clarithromycin and intravenous Amikacin for 6 weeks, to cover for reinfection/relapse with resistant-MTB, as well as NTB. Rifamycin, which is the critical component for treatment success, had to be stopped due to transminitis after 1 month. We rationalised to a multi-drug regime containing ≥3 active agents as an effective course, based on analogy of patients with rifampin-resistance. This led to normalisation of ESR and 2.2kg weight gain, plus radiological resolution 8 months into treatment. He continues to receive a minimum of twelve months after culture-conversion.
North by Northeast - a case of CNS Aspergilloma mistaken for pituitary tumour
Authors: Srirathan Vino , Schwab Uli 
Published: March 2020

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

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

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

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

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

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

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

BACKGROUND
There has been a national drive to improve antimicrobial stewardship in the diagnosis and management of uncomplicated lower urinary tract infections (UTIs). While much attention has been paid to the initial management in hospital, there is little evidence of how treatment is rationalised or altered in response to results from the laboratory.
METHODS
We undertook a retrospective analysis of medical records, including patients diagnosed with uncomplicated lower UTI whilst in hospital. Data was collected on whether a urine sample was sent to the laboratory, the result was documented, which subsequent actions were taken by clinical teams and their appropriateness.
RESULTS
All the patients received antibiotics for a lower UTI. 55% of patients had documented symptoms of a UTI, the remainder were commenced due to a suspected UTI in the absence of localising clinical symptoms. 86% had an MSU sample sent to the laboratory. In all cases, clinicians had viewed these results. In 57%, the findings of the MSU were documented. 38% of all results were not acted on appropriately, with 19% of those continuing antibiotics unnecessarily, 24% not narrowing down therapy and 12% not changing antibiotics in response to resistant isolates.
CONCLUSION
Whilst correct clinical investigations may be sent and reviewed in the management of uncomplicated UTIs, the results of these are often not documented in the patient’s record and a significant proportion of these results are not acted on appropriately.
Host and pathogen biomarkers to predict bacterial sepsis
Authors: Lewis Matthew , Chick Heather , Harris Llinos , Jenkins Rowena , Wilkinson Thomas S. 
Published: March 2020

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

E. coli isolates (n=100) from blood cultures in patients with defined sources of infection (urinary, biliary, intra-abdominal or unknown) were used to investigate potential biomarkers using next generation sequencing, whole blood modelling and molecular microbiology phenotyping.
Sequencing of isolates is underway. Growth curve analysis demonstrated that human serum could modulate E. coli growth to three phenotype groups; i) no growth, ii) retarded / decreased growth and iii) unaffected growth (compared to LB control). Whole blood modelling over 6 hours confirmed 4 hours to be the optimal time point to study IL-6 expression. Grouping isolates by source of infection showed that those from the urinary tract and ‘unknown’ sources produced significantly more IL-6 than E. coli K12. Completion of phenotyping will allow association studies to bacterial genotype.
These results will help define new biomarkers associated with the host and genetic biomarkers associated with E. coli that will better predict and inform the diagnosis and treatment of sepsis.