bluuebunny/crossref_metadata_2025_split huggingface dataset:
Paediatric Clostridium difficile infection: rarer than we think?
Authors: Hindocha Avni , Hatcher Jim , Lyall Hermione , Satta Giovanni 
Published: March 2020

Background
In view of the new IDSA clinical practice guidelines, we investigated C. difficile infection (CDI) rates and performance against the key standards in our infants and immunosuppressed paediatric patients.

Methods
Using electronic patient notes and microbiology systems, we collected data on every positive PCR result between June 2016 and March 2018 in our paediatric population. Information included risk factors, markers of severity and medical management.

Results
48 samples were sent for C. difficile testing, from which 22 patients had positive results at an average age of 7.4 years. Only five samples were sent from patients under 2 year olds, of which four were PCR positive but toxin negative. Out of 22 positive patient samples, 9 were toxin positive. Risk factors for CDI included previous antibiotics or inpatient stay in the last 3 months, as well as recent PPI use. Only one patient had toxin positive CDI with severe disease. Overall the management of CDI in both toxin positive and negative patients was appropriate in terms of antibiotic choice and duration, and was tailored to specific patient circumstances. A high proportion of CDI patients were immunosuppressed or had recently undergone bone marrow transplants, but often showed no signs of severe infection (fever, raised inflammatory markers).

Conclusion
There should be a low threshold in testing patients who are immunosuppressed, as they are more likely to develop CDI. There were no toxin positive cases in patients under two years of age, which confirms that the test is not useful in this population.
Management of methicillin sensitive Staphylococcus aureus bacteraemia in an antimicrobial stewardship age
Authors: Platts Stephen , Payne Brendan , Price David , Schwab Ulrich 
Published: March 2020

Background: Methicillin sensitive Staphylococcus aureus bacteremia (MS-SAB) is associated with significant morbidity and mortality. Long courses of intravenous antibiotics are the traditionally recommended mainstay of treatment but are often not completed in clinical practice. Shorter courses are potentially attractive from an antimicrobial stewardship and resource perspective, but require a good evidence base.
Methods: A retrospective audit of MS-SAB management within Newcastle-upon-Tyne Hospitals NHS Foundation Trust (2016-17). Laboratory database was used to identify all cases of MS-SAB. Demographic details, risk factors and management were recorded from patient records. Outcomes were defined as 90d recurrence-free survival, 30d mortality, 30-90d mortality and recurrence before 90d.
Results: A total of 281 adult cases were identified with adequate data available for review. Predictors of early (30d) mortality were: age, 71.4y vs 58y p<0.001; HAI, 21.4% vs 8.6% p=0.003; osteo-articular infections, 2.5% vs 17.1% p=0.016; but not antibiotic choice. In cases surviving 30d (n=238), median antibiotic durations were: intravenous 10d (range, 0-115), total 18d (0-316). 83% received ≥14d total, 41% received ≥14d intravenous. Receiving <9d intravenous (OR 3.33 (95%CI 1.01- 10.95) or <14d total therapy (OR 4.19 (1.37-12.84) was predictive of recurrent bacteraemia, as was non-beta-lactam therapy (16% vs 4%, p=0.006), and poor CRP response at end of intravenous therapy (68% vs 35% of peak CRP, p<0.001).
Conclusions: These data suggest lower durations (9-14d) of intravenous therapy could be safe in MS-SAB, however very short courses (<9d) are associated with worse outcomes. This new evidence helps inform guidelines, balancing optimised patient outcomes alongside improved antimicrobial stewardship.
‘The Mould that Changed the World’: Quantitative and Qualitative Analysis of Knowledge and Behavioural Change following Participation in an Antimicrobial Resistance Musical
Authors: Hall Jennifer , Jones Leah , Robertson Gail , Hiley Robin , Nathwani Dilip , Perry Meghan 
Published: March 2020

Background: Antimicrobial resistance (AMR) is driven by antimicrobial exposure. Engaging the general public with this issue is vital in order to shape attitudes and change behaviour. A primary school musical (‘The Mould that Changed the World’) was developed as a novel educational strategy with the explicit aim of engaging the public in the fight against AMR.
Methods: The musical was implemented in two primary schools as workshops followed by public performances. There were 166 child participants aged 9 to 11 years. Quantitative data was collected through a classroom questionnaire before the musical, two weeks after, and six months after. Qualitative data were collected through children’s focus groups before the musical and two weeks after.
Results: Knowledge of the key messages of the musical had increased two weeks after the musical (proportion test, 0.65, 0.77, p<0.001) and this gain in knowledge was sustained six months later (proportion test, 0.65, 0.82, p<0.001). Children recognised factors contributing to AMR, felt empowered to change their own health behaviours and demonstrated antimicrobial stewardship with intention to reduce antibiotic use. They suggested the musical had stimulated discussion around these topics at home. The musical was perceived as an enjoyable and memorable way to learn about AMR.
Conclusion: This study demonstrates potential for the use of musical theatre in this field as a novel device to improve long-term knowledge, change attitudes and emotionally engage the general public through children. Alongside existing interventions, it represents a further unique and valuable tool in the fight against AMR.
Understanding antimicrobial prescribing in suspected ventilator-associated pneumonia: a prospective cohort study
Authors: Docherty Callum , White Iain , Bannard-Smith Jonathan , Morton Ben , Walters Ingeborg , Xu Yun , Roberts Stephen , McMullan Ronan , Goodacre Roy , Dark Paul , Fowler Stephen , Felton Timothy 
Published: March 2020

Background
Ventilator-associated pneumonia (VAP) is associated with significant healthcare cost, morbidity, and mortality, but can be difficult to identify, resulting in over-diagnosis and excessive use of broad-spectrum antimicrobial therapy. In addition, some organisms commonly cultured from the airways of critically ill patients, in particular Candida species, are of unknown clinical significance.
Methods
A prospective cohort study was conducted across five intensive care units in the North-West of England. Participants were enrolled within 24 hours of commencing antimicrobial therapy for suspected VAP. Laboratory-confirmed VAP was defined by quantitative culture of a known pneumonia-causing pathogen above predetermined growth thresholds.
Univariate logistic regression was used to determine the impact of laboratory-confirmed VAP, APACHE II, culture of Staphylococcus aureus, and culture of Candida species on 30-day mortality.

Results
The prevalence of laboratory-confirmed VAP was 43/96 (44%), and the median number of antimicrobials prescribed for VAP was 1 (range: 1-4). Candida species were identified in 32/96 patients (33%).
The overall 30-day mortality was 22/96 (26%). None of the variables analysed were associated with 30-day mortality, except for culture of Candida species, which was associated with survival (odds ratio 0.26, 95% CI 0.07 to 0.98; p= 0.047).
Conclusions
Ventilator-associated pneumonia was confirmed in under half the patients commenced on antimicrobial therapy for suspected VAP, which highlights the urgent need for improved diagnostic strategies. In our clinical practice, Candida species are not treated as pathogenic in VAP, and in this study, growth of Candida species was not associated with excess 30-day mortality.
Stroke secondary to hip ulcer and Septic emboli
Authors: Choudhry Taimour Rashid 
Published: March 2020

Background
Strokes are frequently seen in older patients mainly due to long standing hypertension, diabetes mellitus and hyper cholesterolemia. It is not common in younger adults especially when there is no obvious cause. The workup to find the cause is often difficult in such cases.
Case Description
A 38-year-old paraplegic male presented in Emergency Department with the complaints of fever, headache, haematuria and awaiting closure of left hip wound; however, it seemed non infected. Regarding his medical history, he had ASD associated with pulmonary hypertension and type 1 diabetes mellitus. Besides, after 24hrs of admission he developed right sided neglect. On examination, he was febrile with increased heart rate and respiratory rate. Moreover, he had right homonymous hemianopia and NIHSS score was 3. CT PA was done to rule out pulmonary embolism. Additionally, CT CAP and CT head showed splenic infarct and occipital infarct, respectively. Therefore, a diagnosis of paradoxical embolus was made and treated accordingly. Later, blood culture revealed beta haemolytic streptococci and the underlying cause of septic stroke was thought to be hip ulcer extending to bone. This was followed by CT pelvis, on which bone destruction was seen. Therefore, antibiotics were commenced and left hemiarthoplasty was done.

Conclusion
This case illustrate that in younger population, often soft tissue and bone infection can lead to pro-thrombotic events resulting into septic emboli, a potential cause of stroke (especially when accompanied by ASD). Early assessment and management is valuable as it can lead to serious complications and increased morbidity.
A case of recurrent aerococcus urinae infective endocarditis with associated cerebral embolic phenomena
Authors: Ravji Pooja , Brown Nicholas 
Published: March 2020

Aerococcus urinae is a gram positive, alpha haemolytic cocci that rarely is associated with urinary tract infections, bacteraemia and infective endocarditis. We describe a case of recurrent aerococcus urinae endocarditis with associated cerebral embolic phenomena.
A 76 year old man presented with sudden onset right sided weakness and dysphasia. CT and MRI head imaging showed infarcts in the left pons and cerebellum suspicious of embolic aetiology.
He had a background of a prosthetic mitral valve replacement following an episode of culture negative infective endocarditis associated with discitis and a psoas abscess 3 years previously. A 16S rRNA PCR on valve tissue had yielded an aerococcus urinae.
The anaerobic bottle of a blood culture taken on his present admission flagged positive at 48 hours but no organisms were seen on gram stain. However, Matrix-assisted laser desorption ionization time-of-flight mass spectrometry (MALDI – TOF MS) identified an aerococcus urinae 4 hours later. The same organism was also identified in the aerobic bottle which had flagged positive later the same day with gram positive cocci in clusters. Susceptibility testing revealed a MIC (Minimum Inhibitory Concentration) of 0.032, 1 and 8mg/L for penicillin, vancomycin and gentamicin respectively.
A transthoracic echocardiogram confirmed reoccurrence of endocarditis with a 1.5cm lesion on the mitral valve. There was no evidence of other embolic phenomena. The patient was managed medically with initial treatment with intravenous vancomycin and gentamicin followed by benzylpenicillin and gentamicin for 6 weeks. The patient made slow rehabilitative progress and remained debilitated by his right sided hemiparesis.
Using health literacy techniques to develop patient information for counselling on antibiotics courses
Authors: Beck Kiyah , Ioannou Koulla , Ahmed Sidrah , Zaman Syeda Nadia , Hawksworth Gill , Afzal Saima , Frank Sarah , Howard Philip 
Published: March 2020

Introduction
Increased education may improve awareness of antimicrobial resistance (AMR), however 43% of people aged 16-65 in England lack skills to understand health information1.This study aimed to improve patient knowledge on short course antibiotics using a patient information leaflet (PIL) incorporating Health Literacy (HL) techniques supporting the Governments’ 5 year 2019 AMR strategy.

Method
This study received ethics approval. A revised Royal Pharmaceutical Society (RPS) checklist for Community Pharmacy PIL incorporating HL techniques was piloted, then used for 5-weeks as a counselling tool by 8 consenting community pharmacists. It was handed to patients during dispensing of short-course antibiotics, after which the pharmacists filled out a questionnaire. Patients receiving counselling using the PIL completed face to face questionnaires.

Results
106 patient questionnaires were completed.
94% of patients had taken antibiotics previously and 90% of these thought the counselling received using the PIL was easier to understand than previous counselling.
96% of patients agreed the PIL improved their knowledge on appropriate antibiotic use. 81% of patients intended to change their behaviour and thought the PIL had improved their antibiotic knowledge especially to “always finish a prescribed course of antibiotics”. All patients stated the PIL was easy to follow.

Conclusion
This pilot suggests that patient behaviour can be influenced using structured counselling on AMR drawing on HL techniques.
References
1 Rowlands G, Protheroe J, et al. A mismatch between population health literacy and the complexity of health information: an observational study. British Journal of General Practice. 2015;65(635):e379-e386.
Using health literacy techniques to support pharmacist practice when counselling on antibiotics courses
Authors: Beck Kiyah , Ioannou Koulla , Ahmed Sidrah , Zaman Syeda Nadia , Hawksworth Gill , Afzal Saima , Frank Sarah , Howard Philip 
Published: March 2020

Introduction
Increased education may improve awareness of antimicrobial resistance (AMR)1 however 43% of people aged 16-65 in England lack skills to understand health information2. This study aimed to improve patient knowledge on short course antibiotics using a patient information leaflet (PIL) incorporating Health Literacy (HL) techniques supporting the governments’ 5 year 2019 AMR strategy.

Method
This study received ethics approval. A revised Royal Pharmaceutical Society (RPS) checklist for Community Pharmacy PIL incorporating HL techniques was piloted then used for 5-weeks as a counselling tool by 8 consenting community pharmacists. It was handed to patients during the dispensing of short-course antibiotics after which the pharmacists filled out a questionnaire.

Results
106 patients were counselled and all 8 pharmacists completed questionnaires on how the PIL supported their practice.
On a scale of 1 (not at all) to 5 (improved a lot), pharmacists scored how much they thought the PIL could improve patient’s knowledge on appropriate antibiotic use. 63% of pharmacists (5/8) scored the PIL ‘5’ or ‘4’.
63% of pharmacists (5/8) did not feel that the PIL took longer than their standard counselling. 66% (2/3) felt that the extra time was worthwhile.

Conclusion
Pharmacists believed written information using HL techniques led to improved AMR education at the point of antibiotic dispensing.
References
1.Health Education England. Tackling antimicrobial resistance: educational priorities London; 2018.
2. Rowlands G, et al. A mismatch between population health literacy and the complexity of health information: an observational study. British Journal of General Practice [Internet]. 2015;65(635):e379-e386.
How well are we doing in diagnosing and treating UTI in older people?
Authors: Malkin Joanne , Ross Jill 
Published: March 2020

Background
There is very good evidence that the use of a urine dipstick in the diagnosis of UTI in older people is not of value and may indeed cause harm (e.g. inappropriate courses of antibiotics, missed alternative diagnoses, etc.) This year’s AMR CQUIN has focussed on compliance with NICE / PHE guidelines. The results presented here are for the first quarter at CDDFT hospitals.

Methods
Patients were initially identified prospectively by ward pharmacists. However, this yielded too few patients and our data collection method was amended to retrospective collection, based on a primary discharge code of N39.0.

Results
* 60% urine dipstick used inappropriately (target <10%)
* 52% treatment follows NICE guidelines / based on recent sensitivities / local guidelines (target >90%)
* 60% patients were prescribed coamoxiclav despite not being in NICE / PHE guidelines for lower UTI
* 86% MSU sent (target >90%)
* 84% diagnosis based on symptoms / signs consistent with UTI (target >90%)

Conclusion
Despite numerous efforts (posters, walk-arounds, teaching) over the last 2 years to educate staff regarding appropriate use of urine dipsticks and antibiotics, our results were unsatisfactory. To remedy this, we have implemented the action plan described below, aimed at engendering an improvement in compliance with the guidelines and patient management.
1. Educational screensavers on computers
2. Removal of dipstick stickers from MAU clerking
3. Change of dipsticks to ones with no leucocytes and nitrites
4. Education and engagement of MAU & ED ward staff
5. Additional of new category to antibiotic formulary (?UTI/?LRTI not septic) to counter excessive coamoxiclav use
Low or no CRP at the point of admission to a medical admissions unit is associated with a low rate of 48-hour antimicrobial review amongst patients prescribed antibiotics
Authors: Hill Amanda , Hamon Eloise , Nana Melanie , Price Sian , Craine Noel , Healy Brendon 
Published: March 2020

Introduction: Antibiotic resistance is rising and multi-resistant organisms are readily being identified; therefore fear of mortality rates rising due to infection is becoming a genuine prospect. We sought to measure clinical review post antimicrobial prescription in two acute hospitals in Wales to establish whether review is undertaken at 48-hours and whether likelihood of clinical review taking place depends on C reactive protein (CRP) levels on admission.
Methods: An audit across two hospitals in South Wales assessing compliance of antimicrobial review as recommended by NICE guidelines was undertaken over a three week period. In addition, univariate odds ratios for 48-hour referral stratified by CRP test results (excluding patients with no CRP test) were calculated in a logistic regression model using the high CRP group as the referent. Following initial results intervention (education and prompt stickers) were introduced to prompt 48-hour review.
Results: 139 patients were included in the pre-intervention audit from both sites. 53% were reviewed at 48 hours. Initial interventions demonstrated an improvement in compliance in all CRP categories. In the logistic regression analysis setting the highest CRP group (CRP <=100) as referent showed that the likelihood of a 48 hour review was lower in patients with lower CRP test results, or no CRP test than those with a CRP of >=100.
Conclusion: Patients with low or no CRP on admission are less likely to have their antimicrobial prescriptions reviewed when compared 48 hours. Intervention should continue to be sought to raise awareness of this.
A retrospective review of vancomycin dosing in paediatric patients
Authors: Bolina Anita , Hughes Stephen 
Published: March 2020

Background: Vancomycin has antimicrobial activity against most Gram-positive pathogens. Reduced susceptibility of vancomycin to many microbes has necessitated higher target vancomycin trough levels (VTL) of 10-20mg/L. Paediatric dosing algorithms have remained unchanged despite higher VTL targets; increased doses are required. The study outcomes were to assess the impact of new dosing guidelines on VTL, time to target VTL and vancomycin-associated acute kidney injury (vAKI).
Methods: A single-centre review assessed 63 vancomycin treatment episodes between Apr-2016 and Feb-2019. Demographic data, treatment duration, daily vancomycin dosing and VTL were collected. Episodes were grouped as high-dose vancomycin (HDV) (≥60mg/kg/day) and low-dose vancomycin (LDV) (<60mg/kg/day). Target VTL was 10-20mg/L. AKI was defined by modified pRIFLE criteria as ≥50% increase in baseline creatinine within 7 days of treatment commencement. The project was registered with the local audit team.
Results: Initial VTL were significantly higher in the HDV group (mean 10.4, SD±4.7mg/L; n=20) than LDV (mean 7.9,SD±4.0mg/L;n=43), p=0.0397. Whilst time-taken to reach target VTL was improved in the HDV group (53.5±22.3 hours vs 66.1±37.1hours), this was statistically insignificant (p=0.2675). Paired t-tests revealed no significant changes to baseline creatinine in HDV (p=0.1267) and LDV (p=0.2006). No differences in vAKI incidence between the two groups were noted (p>0.05).
Conclusion: Increasing vancomycin dosages improved initial VTL but was insufficient to improve the length of time to reach target VTL. Reassuringly, there was no increase in vAKI incidence with HDV. The study suggests loading doses in paediatrics may be needed to improve time to target VTL.
Rapid Determination of Antimicrobial Susceptibility of Gram-Negative Bacteria from Positive Blood Cultures Using an Innovative Method
Authors: Falconer Kerry , Parcell Ben , Hammond Robert , Gillespie Stephen 
Published: March 2020

Introduction:
A blood stream infection (BSI) presents a complex and serious health problem and is growing in light of the eminent antimicrobial resistance threat. Progress must be made towards rapid BSI diagnosis and antimicrobial susceptibility testing (AST) to reduce preventable death in BSI.

Methods:
Positive blood cultures from Ninewells Hospital, Dundee were studied prospectively. Flagged positive blood cultures were processed by Gram-staining, Vitek identification and AST or disc diffusion for ceftriaxone susceptibility and by scattered light integrated collection device (SLIC). Susceptibility to a panel of five antibiotics as defined by EUCAST breakpointswere compared.The time to AST result and AST categorical agreement was compared for standard methods and SLIC, any discrepancies were resolved by the EUCAST broth micro-dilution reference method.

Results:
A total of 505 bacterial-antimicrobial combinations were analysed. A categorical agreement of 95.45% (482/505) was achieved between SLIC and Vitek/disk diffusion. The remaining 23 discrepancies were resolved by broth micro-dilution with 10 AST results agreeing with the SLIC result and 13 in agreement of Vitek/disk diffusion. Thus the overall AST agreement of the standard workflow was 98.01% (495/505) compared to 97.43% (492/505) using SLIC. The mean time for AST was 1.94 + 0.02 h and 10.53 + 0.46 h for SLIC and Vitek respectively. Overall SLIC was calculated to save 25hrs from positive blood culture to AST outcome.

Conclusion:
SLIC has the capacity to provide AST at the same time as Gram stain or MALDI-TOF identification.This could improve the value of blood culture in clinical practice.