bluuebunny/crossref_metadata_2025_split huggingface dataset:
Pre-operative antibiotics and elective colonic resections: Do they reduce surgical site infection and anastomotic leak rates?
Authors: Murray James , Husnoo Nilofer , Bond Stuart , Wroe Nicholas , Shabir Wasim , Murray Rebecca , Sarveswaran Janahan , Basheer Mohamed 
Published: March 2020

Background: Surgical site infections (SSI) and anastomotic leaks (AL) are a significant source of morbidity in patients undergoing elective colorectal surgery. There is evidence for use of pre-operative oral antibiotics (OAB), in combination with mechanical bowel preparation (MBP), to reduce SSI and AL rates in this population. We aimed to determine whether the use of OAB pre-operatively reduced our local SSI rate in elective left-sided colonic resections.
Methods: A pre-post intervention study was conducted in a large regional hospital from September 2018 to July 2019. Following approval by the Trust’s Medicines Optimisation Group, patients received oral metronidazole 400mg and oral neomycin 1g at 06:00, 14:00 and 22:00 on the day before surgery. The rates of SSI and AL at 30 days were compared with pre-intervention patients. Standard induction intravenous antibiotics were given to both groups but MBP practices were disparate among the consultant body and were outside the scope of this project. Chi Square and Independent T-tests were used to analyse the data.
Results: Data on 100 pre-intervention patients and 47 post-intervention patients showed similar baseline characteristics. SSI rates were 17% (17/100) in the pre-intervention group and 8.5% (4/47) in the post-intervention group (p=0.170). Anastomotic leak rates were 7.0% (7/100) and 2.1% (1/47) respectively (p=0.225).
Conclusion: The use of pre-operative OAB was associated with a reduction in SSI and anastomotic leak rates, although these did not reach statistical significance. Possible reasons for this include low patient numbers and inconsistent use of MBP.
The management of adult patients with meningitis at Arrowe Park Hospital – A complete audit cycle
Authors: Ejere Elshadai , Harvey David 
Published: March 2020

Background:
Anecdotal experience suggested there were areas for improvement in meningitis management. To address this, we conducted a complete audit cycle of the management of meningitis in adult patients at Arrowe Park Hospital.
Method:
We utilised the abbreviated audit tool from the McGill et al 2016 meningitis guidelines.
Time period: 1/1/2017 to 31/12/2017. Cases audited: 20
A series of interventions were made.
Time period for second cycle: 1/2/2019 to 31/5/2019. Cases audited: 6

Results:
Audit standards were met for 1 out of 14 criteria for the first cycle and 2 out of 14 criteria for the second cycle.
Of note, there was reasonable compliance with empiric choice of antibiotic (80% à 83%), definitive choice of antimicrobials (95% à83%) and duration of antimicrobials (84% à 100%).
Improvements in investigations were seen in the second cycle:
1.Pneumococcal and Meningococcal EDTA PCR was sent (15% à 67%)
2.CSF glucose with concurrent plasma glucose sent (6.3% à 67%)
3.CSF for pneumococci and meningococci sent in all cases of suspected bacterial meningitis (22% à 67%)
The re-audit identified no improvement in the following areas:
1.Blood cultures taken within 1 h of arrival at hospital (30% à 33%)
2.LP performed within 1 h of arrival at hospital provided that it is safe to do so (0% à 0%)
3.Antibiotics started within 1 hr of arrival in hospital (35% à 33%)
In both audit cycles, 0% of patients were made aware of voluntary sector support.

Conclusion:
Whilst improvements were achieved, there remains considerable scope for further improvement.
Outcomes of Staphylococcus aureus bacteraemia attributed to blood culture contamination
Authors: Robertson Paul 
Published: March 2020

Staphylococcus aureus is a common skin commensal and leading cause of bloodstream infection. Given the formidable mortality and morbidity associated with S. aureus bacteraemia (SAB), it is uncertain whether S. aureus can be viewed safely as a blood culture contaminant.
19 episodes of SAB over two years were identified that were prospectively attributed as contaminants using Health Protection Scotland criteria and compared these with 168 cases of genuine SAB. All cases were assessed by an infection specialist and underwent multidisciplinary review to agree the source. Follow-up was a minimum of six months.
Female sex, cognitive impairment and chronic skin conditions were more common in the contaminant group. No single clinical or laboratory feature reliably predicted contamination. No patients in the contaminant group subsequently developed a SAB or metastatic complications associated with SAB. Eighteen patients (95%) survived to hospital discharge. Compared to patients with genuine SAB surviving to discharge, the contaminant group had a shorter duration of hospital stay (median 14 days versus 19.5 days), a briefer exposure to intravenous antibiotics (median 1 day versus 14 days) and received less total antibiotic (median 7 days versus 19 days). Twelve patients received at least five days of antibiotics active against their SAB, though none would have been deemed appropriate SAB treatment under current guidelines.
The careful attribution of SAB as a contaminant by an infection specialist, combined with appropriate follow-up, is associated with favourable clinical outcomes, shorter hospital stay and reduced antibiotic use. A more robust definition of genuine SAB is needed.
An unusual case of Mycobacterium chelonae infection
Authors: Shorrocks Ruth , Hayward Samantha , Moran Ed 
Published: March 2020

Introduction: A 32 year old lady developed multiple distinct, purple, raised, itchy lesions on her limbs, during a prolonged hospital admission. The lesions developed over six to eight weeks with no evidence of improvement. One lesion was biopsied and sent for analysis.
The patient had a background of end stage renal failure from Anti-glomerular basement membrane (Anti-GBM) disease and she went on to receive a renal transplant. Eleven months prior to her hospital admission her transplant failed from de-novo focal segmental glomerulosclerosis. She had been admitted for 9 months with an eating disorder and malnutrition. She had been off any immunosuppressive agents for 6 months at the time that the lesions appeared.
Methods: The lesion biopsied was consistent with a dermal abscess. The Ziehl-Neelsen stain was negative but a mycobacterium was cultured. This was confirmed to be Mycobacterium chelonae on reference lab testing (sensitivities awaited). She had no other lesions of concern on imaging.
Results:Due to the disseminated nature of the lesions she was started on a 2 week course of intravenous amikacin with oral azithromycin and levofloxacin; the oral components to be continued for 2 to 6 months dependent on clinical response.
Discussion:Mycobacterium chelonae is a nontuberculous mycobacterium abundant throughout the environment. It commonly causes skin lesions or cellulitis as well respiratory disease and urinary catheter colonization. It is a less common Rapidly Growing Mycobacterium (RGM) which usually occurs in patients on immunosuppression. The immunosuppressed state in this case was that caused by dialysis and malnutrition.
Voriconazole – are we doing what we think we are? A review of voriconazole use and monitoring in respiratory patients in a London hospital
Authors: Chia Germaine , Davies Frances , Coleman Meg 
Published: March 2020

Background
Voriconazole is increasingly used in treatment and prophylaxis of respiratory fungal infections, but therapy carries a risk of significant side effects. Outpatient therapy has additional challenges for ensuring pre-treatment counselling of patients and fulfilling therapeutic drug monitoring (TDM) requirements. A review of local practice was performed.
Methods
Electronic patient records for adult Respiratory outpatients on voriconazole from November 2005 to January 2019 were retrospectively reviewed. Data was collected on patient demographics, pre-treatment counselling and TDM. Based on the results, targeted interventions were proposed.

Results
21 patients commenced voriconazole between 2005 and 2019, majority (n=10/21, 47.2%) for chronic pulmonary aspergillosis. Of the 21 patients, counselling was variable regarding the risks of hepatotoxicity (12, 57.1%) and phototoxicity (13,61.9%), signs indicating hepatotoxicity (6, 28.6%) and phototoxicity (11, 52.4%), and taking photo-protective precautions (13, 61.9%). 60% (n=12/20) of patients had liver function tests measured weekly in their first month of commencing treatment, while phototoxicity was reviewed in only 10% (n=2/20) of patients at follow-up appointments. In 57.1% of patients (n=12/21), none of the 3 checklists available (HCP checklist and 2 local proformas) were used when commencing treatment.

Conclusion
Our findings revealed a lack of consistency in information given to patients, documentation by clinicians, and in TDM, in spite of the existing checklists available. We propose an individual written management plan to empower patients to manage their treatment and guide clinicians in pre-treatment counselling and subsequent follow up of patients. A re-audit is planned for 6 months to assess the efficacy of this intervention.
Associations between declining antimicrobial use in primary care in Scotland and patient satisfaction and hospitalisation due to infection: a longitudinal study of greater than five million patients
Authors: Guthrie Isobel , Marwick Charis 
Published: March 2020

Background. Scottish antimicrobial prescribing in the community has fallen since 2012, but this could have unintended consequences. The aim was to examine associations between changes in antibiotic prescribing in primary care and hospital admissions and patient satisfaction.
Methods. Data for 877 Scottish general practices with 5.1 million patients were provided by NHS National Services Scotland. Practices were classified into four equal groups (quartiles) in terms of change in total antibiotic prescribing (rate/1000 registered patients in each quarter) 2012-2018. Changes in hospital admission with infection were examined comparing the four groups. Multivariate regression examined associations between change in antibiotic prescribing and patient satisfaction with the practice using national survey data.
Results. Across Scotland, primary care antibiotic prescribing decreased by 15% from 194.1 (95%CI 193.8-194.4) in Q1 2012 to 165.3 (95%CI 165.0-165.6 ) in Q2 2012, with considerable variation between practices (non-significant increase of 0.22 prescriptions/1000/quarter [p=0.49] for the quartile of practices with least reduction in antibiotic prescribing, vs reduction of -2.95 prescriptions/1000/quarter [p<0.001] for quartile with the largest reduction). Rates of hospital admissions with infection increased over the time period but there were no significant association with changes in antibiotic prescribing. Patient satisfaction decreased over the period, but change in antibiotic prescribing was not associated with patient satisfaction.
Conclusion. There have been clinically significant reductions in Scottish primary care antibiotic use since 2012, varying considerably between practices. Longitudinal analysis of Scotland-wide practice level data found no associations between practice-level reductions in primary care antibiotic prescribing and hospital admissions or patient satisfaction.
Knowledge of nursing staff and healthcare assistants on the diagnosis of urinary tract infections in patients with urinary catheters
Authors: Mekonnen Ellen , Khanna Priya , Rao Gopal 
Published: March 2020

Background
Asymptomatic bacteriuria is common in patients with urinary catheters. Current clinicalguidelines advise against dipstick testing or treating urine culture results in asymptomatic catheterised patients which can promote the development of antimicrobial resistance and present an unnecessary risk to patients. This study aimed to assess the knowledge of nurses and healthcare assistants (HCAs) on the diagnosis of urinary tract infections (UTIs) in patients with urinary catheters.
Methods
This study employed a cross sectional survey of opportunistically sampled nursing staff and healthcare assistants working at Northwick Park Hospital in May 2018. Results were analysed descriptively.

Results
134 participants were included in the final analysis of whom 90% (N=120) were nurses and 10% (N=14) were HCAs. The majority of staff (38.6%, N=51) worked in a medical speciality and had over 15 years of work experience (45.3%, N=58). 79 participants (66%) believed that a positive dipstick result was diagnostic of a catheter associated urinary tract infection (CAUTI). A positive dipstick result was the most frequently selected indication (91% of respondents, N=108) for sending urine for culture in a catheterised patient, and was also the most frequently selected reason for sending urine for culture across staff of all years of experience and all specialities.

Conclusion
There is a need to improve the level of knowledge of nursing and HCA staff on the diagnosis of CAUTIs including misconceptions on the diagnostic value of dipstick testing in catheterised patients. The findings of this research will inform a quality improvement project to address these gaps in knowledge.
Enough is enough – is it time for the Scottish Antimicrobial Prescribing Group (SAPG) to develop the third age of antimicrobial stewardship in primary care in Scotland?
Authors: Malcolm William , Baxter Linsey , McNicol Megan , Sneddon Jacqueline 
Published: March 2020

Background
From 2008 the SAPG focused on ‘what to prescribe’ to tackle Clostridium difficile infection and from 2013 on ‘whether to prescribe’ to tackle unnecessary prescribing for self-limiting infections. Following these successes SAPG is now moving to the age of ‘how much to prescribe’ to ensure correct duration of therapy. We aimed to compare current prescribing practice with guidance from Public Health England (PHE)/NICE which recommends five days’ treatment for most common community respiratory infections (RTI).

Methods
The durations of antibiotic courses for treatment of respiratory tract infections was derived from data on dispensed prescriptions in 2018 from the Prescribing Information System, a national database of all NHS prescriptions dispensed in Scotland. Observed course durations were compared to course lengths recommended by PHE/NICE and modelling was undertaken on the impact on antibiotic use if durations were in line with guidance.

Results
For antibiotics recommended for RTI, the most common length of treatment used was seven days. For amoxicillin the proportion of five day prescriptions varied across health boards from 1.8% to 68.7%. Modelling estimated if 75% of seven day prescriptions for antibiotics recommended for RTI were changed to five days this would deliver a 4.1% reduction in antibiotic use.

Conclusion
SAPG has agreed to lead work to encourage the use of five day courses of antibiotics where indicated. Switching to five day courses would support reduction in total antibiotic use to achieve the ambitions of the UK AMR National Action Plan.
Coinfection Mechanisms ofCampylobacter andEscherichia coli in Human and Chicken Epithelial cells
Authors: Hanford Taylor , Wilkinson Thomas , Williams Lisa , Humphrey Thomas 
Published: March 2020

Campylobacter jejuniis the world’s most common food-borne pathogen. Campylobacterpathogenesis involves translocation across the intestinal epithelial cell barrier in both humans and chickens and previous work has suggested that strains of E. coli (ExPEC / APEC) may facilitate this process. This study aims to determine the effect that this relationship may have upon the invasive and adhesive potential of the two microbes using our recently published human and avian in vitromodel.
Invasiveness of C. jejuni and E. coli strains were measured using human (Caco-2) and avian (8E-11) epithelial cell lines derived from the gastrointestinal tract and were characterised by epifluorescent and confocal microscopy. Adhesion and invasion assays were carried out to determine the pathogenicity of the different bacteria. Metabolic activity of Caco-2 and 8E-11 together with bacterial strains using alamar blue assay.
Confocal and epifluorescence microscopy determined the strong presence of cytokeratin in Caco-2 cells whilst weak to medium signals were detected in 8E-11 cells. Optimal doses and times for of gentamicin across all strains was 0.02mg/ml for 90 minutes which did not affect metabolic activity of epithelial cells. Significant diversity was found in the adhesive/invasive potential of bacteria when exposed to human and avian cell types. The metabolic rate of C. jejuni (11168) and E. coli (K12) was investigated with the presence of K12 having negative impacts upon the activity of 11168.
The model described here will provide opportunity to improve our understanding of Campylobacterinvasion mechanisms in human and chickens so that improved strategies to negate these consequences may be designed.
Culture-independent Multilocus Sequence Typing (MLST) screening for Haemophilus influenzae cross-infection in non-cystic fibrosis bronchiectasis (NCFB)
Authors: Wilson Catherine , Mitchelmore Philip , Brown Alan 
Published: March 2020

Background
There is some evidence of Pseudomonas aeruginos across-infection between patients with non-cystic fibrosis bronchiectasis (NCFB), and clear evidence in Cystic Fibrosis. Haemophilus influenzae (H. influenzae) is the more common pathogen in NFCB patients, yet cross-infectionremains unexplored. We present the novel application of culture-independent Multilocus Sequence Typing (MLST) to screen for cross-infection of H. influenzae in NCFB in both culture-positive and -negative samples.
Methods
We interrogated DNA from 32 sputum samples (26 patients) in our NCFB biorepository, who were known to have H.influenzae in their sputum by preceding 16S rRNA sequencing. Fragments of 7 H. influenzae housekeeping genes were amplified and sequenced. Sequence types were allocated via the MLST scheme. For 5 patients, multiple sputum samples taken at least 4 months apart were assessed longitudinally.

Results
Culture-independent MLST identified 31 of 32 sputum samples as harboring H. influenzae. Of these, 26 were positive for H. influenzae using culture methods. 25 of the 26 culture-positive samples were MLST positive. All 6 culture-negative samples were MLST positive. A MLST sequence type (ST) was allocated to 27 of 32 sputum samples. Five patients had multiple sputum samples with matching STs, indicating strain stability and the consistency of MLST. Two patients who were known household contacts had matching STs and possibly transmitted H.influenzae in their household. The remaining 15 STs were unique, suggesting no evidence of cross-infection.

Conclusion
Culture-independent MLST identifies H. influenzae in culture-negative patients with NCFB and is a potential screening tool for cross-infection. This study did not reveal potential cross-infection events in this cohort.
Spontaneous Bacterial Peritonitis at University Hospitals of North Midlands NHS Trust: A Retrospective Study
Authors: Ziada Ahmed , Behzadnia Alireza , Khalid Junaid , Desai Seema 
Published: March 2020

Background
Spontaneous bacterial peritonitis is an acute infection of ascitic fluid that is not related to an underlying intra-abdominal pathology.

Methods
This is a retrospective study of data on ascitic fluid samples taken during the period of January to December 2017 to assess the management of SBP patients and associated mortality. Kaplan-Meir method was used to estimate survival probability at 30 and 90 days. Cox proportional models were used to evaluate aetiology and causative organism in predicting mortality. Analyses were done using R: A language and environment for statistical computing.

Results
Total of 53 patients were identified as having SBP based on ascitic fluid cultures. Sixteen of these also fulfilled the national criteria of ascitic neutrophil count of more than 250 or total cell count of more than 500.
Thirty-three (62.8%) samples grew pathogenic organisms. The most common pathogenic organisms were E coli (30.3%) followed by Enterococcus (21.2%) – in which four were ESBL tagged – Klebsiella (6%) and Staph Aureus (6%). In majority of the patients, the underlying aetiology of ascites was secondary to ALD (68.9%), Malignancy (11.8%) and NASH cirrhosis (11.8%). In this cohort, the overall 30-day survival was 64.2% and 90-day survival was 43.4%. About half mortality occurred during the same admission to hospital.

Conclusion
E coli was the most commonly isolated organism. Alcoholic Liver Disease was the most common underlying aetiology in SBP patients. SBP is associated with a high 30-day and 90-day mortality. Isolation of pathogenic organisms was associated with a four-fold higher mortality than non-pathogenic organisms.
A case of the ‘unusual’ in the ‘usual’
Authors: Williams Caroline , Sahota Amandip , Pareek Manish 
Published: March 2020

Background
Only five cases of Salmonella paratyphi infective endocarditis (IE) have been previously reported. Two were paediatric patients, one other had an underlying cardiac lesion, and all were living in endemic areas. Here we present the first case of salmonella paratyphi IE in a returning traveller.

Case
A 61 year old Indian born British national with no significant past medical history or recent dental procedures presented with a 4 week history of fever and weight loss following travel to India. Whilst abroad she had a self-limiting episode of diarrhoea with fever for 1 week with no antimicrobials. Three weeks after her return the fever returned (without diarrhoea) and she presented to hospital 4 weeks later.
Examinations findings were; haemodynamically stable, temperature 39.5°C, no splinter haemorrhages, no lymphadenopathy, soft systolic murmur best heard at parasternal edge.
Investigations revealed raised inflammatory markers (CRP 80) and blood cultures grew gram negative bacilli within 24 hours which cultured as Salmonella paratyphi A.
Trans-thoracic Echocardiogram showed echo-bright thickening of the non-coronary cusp of the aortic valve, which was confirmed as a small vegetation (0.5cm x0.2cm) on trans-oesophageal echocardiogram.
IV antibiotics were given for a total of 6 weeks and repeated TOE at 1 month showed a healing vegetation. Repeated imaging is awaited.

Conclusions
This interesting case in an otherwise healthy patient highlights the need to be vigilant for unusual organisms causing infective endocarditis – a relatively common condition - in returning travellers.