Clinical Signs Of Infection Research Articles

A lesser scaup (Aythya affinis) naturally infected with Eurasian 2.3.4.4 highly pathogenic H5N1 avian influenza virus: Movement ecology and host factors.

Despite the recognized role of wild waterfowl in the potential dispersal and transmission of highly pathogenic avian influenza (HPAI) virus, little is known about how infection affects these birds. This lack of information limits our ability to estimate viral spread in the event of an HPAI outbreak, thereby limiting our abilities to estimate and communicate risk. Here, we present telemetry data from a wild Lesser Scaup (Aythya affinis), captured during a separate ecology study in the Chesapeake Bay, Maryland. This bird tested positive for infection with clade 2.3.4.4 HPAI virus of the A/goose/Guangdong/1/1996 (Gs/GD) H5N1 lineage (results received post-release) during the 2021-2022 ongoing outbreaks in North America. While the infected bird was somewhat lighter than other adult males surgically implanted with transmitters (790g, x̅=868g, n=11), it showed no clinical signs of infection at capture, during surgery, nor upon release. The bird died 3days later-pathology undetermined as the specimen was not able to be recovered. Analysis of movement data within the 3-day window showed that the infected individual's maximum and average hourly movements (3894.3 and 428.8m, respectively) were noticeably lower than noninfected conspecifics tagged and released the same day (x̅=21,594.5 and 1097.9m, respectively; n=4). We identified four instances where the infected bird had close contact (fixes located within 25m and 15min) with another marked bird during this time. Collectively, these data suggest that the HPAI-positive bird observed in this study may have been shedding virus for some period prior to death, with opportunities for direct bird-to-bird or environmental transmission. Although limited by low sample size and proximity to the time of tagging, we hope that these data will provide useful information as managers continue to respond to this ongoing outbreak event.

Development of a chromatographic lateral flow immunoassay for detection of African swine fever virus antigen in blood

African swine fever (ASF) is a highly lethal disease of domestic and wild swine caused by African swine fever virus (ASFV). The disease currently circulates in Africa, Europe, Asia and on the island of Hispaniola. The ongoing epizootics in Europe and Asia have produced millions of animal deaths and severe economic losses. No effective vaccine is available for ASF, making rapid and accurate detection of ASFV essential for disease mitigation strategies. Currently available diagnostics for ASFV possess significant limitations related to assay performance, deployability, and/or turn-around time; therefore there is an unmet need for pen-side diagnostic tests with sufficient sensitivity and specificity. A chromatographic lateral flow immunoassay (LFIA) was developed for the detection of ASFV antigen in EDTA-treated whole blood using monoclonal antibodies targeting the viral p30 protein. The assay requires only water to perform and provides results in 25 min, making it well-suited for field use. The LFIA was capable of detecting genotype I and genotype II strains of ASFV in EDTA blood from experimentally infected pigs at varying time-points after infection, though it was unable to detect a genotype X ASFV strain. Diagnostic sensitivity correlated with clinical disease severity, body temperature, and viral DNA levels, and was over 90% in animals showing moderate to severe ASF-related symptoms after challenge with virulent genotype II virus. The LFIA also showed a robust diagnostic specificity of over 98%, which is essential to field testing for a high consequence to foregin animal disease. The LFIA targeting the viral p30 protein can reliably detect ASFV in whole blood from animals showing moderate to severe clinical signs of infection with virulent genotype I and II isolates, making it a promising candidate for use as a field-deployable antigen detection assay. Additional evaluation using field samples and different virus strains is required to further assess the utility of this rapid diagnostic test.

Lokaltherapeutisches Vorgehen bei Blasen der Haut: Ein Positionspapier der Initiative Chronische Wunden (ICW) e. V.

Blasen an der Haut können durch sehr unterschiedliche Krankheitsbilder verursacht werden. Daher handelt es sich hierbei um eine interdisziplinär und interprofessionell relevante Herausforderung. Im klinischen Alltag werden derzeit verschiedene lokaltherapeutische Vorgehensweisen praktiziert. Entweder wird die Blase belassen oder die Blase wird punktiert und das Blasendach wird belassen, alternativ wird das komplette Blasendach abtragen. Jede dieser Vorgehensweisen hat potenzielle Vor- und Nachteile. Es erfolgte die Durchsicht der aktuellen Literatur und Konsensfindung durch die Expert*innen der Initiative Chronische Wunden (ICW) e. V. Folgende Vorgehensweisen werden empfohlen: unkomplizierte Blasen ohne Druckschmerz: Blasen belassen; druckschmerzhafte sowie palmar und plantar lokalisierte Blasen: Blase punktieren und Dach belassen; rupturierte Blasen ohne klinische Infektionszeichen: Reste des Blasendachs belassen; rupturierte Blasen mit klinischen Infektionszeichen: Reste des Blasendachs abtragen; Blasen bei Verbrennungen ab Grad 2a oder bei unklarer Verbrennungstiefe oder bei chemischer Verbrennung: Blasendach abtragen. Anschließend erfolgt jeweils die Anlage eines sterilen Wundverbandes. Beim Auftreten von Blasen an der Haut gibt es nicht die eine richtige lokaltherapeutische Vorgehensweise. Bei der Planung eines Behandlungskonzepts sollte die Genese der Blasen geklärt werden, ggf. sollte eine kausale Behandlung erfolgen. Die Lokaltherapie orientiert sich dann an verschiedenen individuellen Faktoren. Somit kann das gemeinsam mit den Patient*innen gewählte Vorgehen interindividuell sehr unterschiedlich sein.

Pathogenesis and transmission of human seasonal and swine-origin A(H1) influenza viruses in the ferret model

ABSTRACT Influenza A viruses (IAVs) in the swine reservoir constantly evolve, resulting in expanding genetic and antigenic diversity of strains that occasionally cause infections in humans and pose a threat of emerging as a strain capable of human-to-human transmission. For these reasons, there is an ongoing need for surveillance and characterization of newly emerging strains to aid pandemic preparedness efforts, particularly for the selection of candidate vaccine viruses and conducting risk assessments. Here, we performed a parallel comparison of the pathogenesis and transmission of genetically and antigenically diverse swine-origin A(H1N1) variant (v) and A(H1N2)v, and human seasonal A(H1N1)pdm09 IAVs using the ferret model. Both groups of viruses were capable of replication in the ferret upper respiratory tract; however, variant viruses were more frequently isolated from the lower respiratory tract as compared to the human-adapted viruses. Regardless of virus origin, observed clinical signs of infection differed greatly between strains, with some viruses causing nasal discharge, sneezing and, in some instances, diarrhea in ferrets. The most striking difference between the viruses was the ability to transmit through the air. Human-adapted viruses were capable of airborne transmission between all ferret pairs. In contrast, only one out of the four tested variant viruses was able to transmit via the air as efficiently as the human-adapted viruses. Overall, this work highlights the need for sustained monitoring of emerging swine IAVs to identify strains of concern such as those that are antigenically different from vaccine strains and that possess adaptations required for efficient respiratory droplet transmission in mammals.

P199 PROCALCITONIN PREDICTS BACTERIAL INFECTION, BUT NOT LONG–TERM OCCURRENCE OF ADVERSE EVENTS IN PATIENTS WITH ACUTE CORONARY SYNDROME

Abstract Background Procalcitonin (PCT) is an acute phase protein which plasma levels raise also in sterile inflammation. For this reason, its role in the acute coronary syndrome (ACS) setting would be twofold: as a marker of infection and also as a prognosticator of generic inflammation. High PCT values have been related to worse prognosis in patients with cardiogenic shock. If PCT values may predict the risk of bacterial infections and long–term outcome in patients with acute coronary syndromes has been less investigated. Methods Consecutive patients with a diagnosis of ACS with PCT level assessed during the first 24 hours of hospitalization were enrolled. The primary outcome was the occurrence of bacterial infection defined by the occurrence of fever and of at least one positive blood or urinary culture with clinical signs of infection. The secondary outcome was the 1–year occurrence of the composite outcome all–cause mortality, stroke and myocardial infarction. Results Overall 569 patients have been enrolled (mean age 69.37±14 years, 30% females): 44 (8%) of them met criteria for bacterial infection. Age, female sex, smoking habit, heart rate, systolic blood pressure (SBP), heart failure after admission, coronary angiography, hemoglobin, creatinine clearance and PCT above the cut–off value were predictors of the outcome. After multivariate analysis, PCT and SBP resulted as independent predictors of bacterial infections (OR for PCT above the cut–off 2.67, 95%CI 1.09–6.53, p = 0.032; OR for SBP 0.98, 95%CI 0.97–0.99, p = 0.043). At 1–year, the composite outcome of all–cause death, MI and stroke occurred in 104 patients (18%). PCT did not result as an independent predictor of the composite outcome. Conclusions In patients with ACS PCT levels at hospital admission are predictor of bacterial infection but not of the composite lomg–term outcome of all–cause mortality, stroke and myocardial infarction.

Naidispora caidianensis n. gen. n. sp. infecting coelomocytes of oligochaete Branchiura sowerbyi (Oligochaeta: Naididae) in China

A new microsporidian parasite, Naidispora caidianensis n. gen. n. sp. was found in coelomocytes of oligochaete Branchiura sowerbyi Beddard, 1892 from Wuhan city, Hubei Province, China. Opaque, hypertrophied coelomocytes (0.17–0.24 mm in diameter) depicted clinical signs of infection. Electron microscopy revealed a microsporidian with monokaryotic life stages. Rounded uninucleate meronts subsequently transformed into multinucleate merogonial plasmodia with masses of electron-dense projections on their plasma membrane. Electron–dense sporogonial plasmodia separated into uninucleate sporonts through rosette-like budding, and further developed into sporoblasts, enclosed by a sporophorous vesicle. Uninucleate mature spores were pyriform, measured 4.1 ± 0.1 (3.9–4.3) μm × 2.1 ± 0.07 (1.9–2.2) μm (average ± SE, range, n = 50), and contained a mushroom-like anchoring disk, bipartite polaroplast, electron-lucent posterior vacuole, trilaminar spore wall and 12–14 turns of an isofilar polar filament arranged in 2–3 ranks. The 1542 bp sequence from B. soweryi showed the highest similarity (below 80 %) with Nematocenator marisprofundi (accession number: JX463178). SSU rRNA gene-based phylogenetic analysis demonstrated that the novel taxon formed an independent clade from known microsporidian parasites. Based on the ultrastructural features and SSU rRNA gene sequence, we propose the establishment of a novel genus (Naidispora n. gen.) and species (Naidispora caidianensis n. sp.) to contain this parasite.

Circulating Microbiota in Cardiometabolic Disease.

The rapid expansion of microbiota research has significantly advanced our understanding of the complex interactions between gut microbiota and cardiovascular, metabolic, and renal system regulation. Low-grade chronic inflammation has long been implicated as one of the key mechanisms underlying cardiometabolic disease risk and progression, even before the insights provided by gut microbiota research in the past decade. Microbial translocation into the bloodstream can occur via different routes, including through the oral and/or intestinal mucosa, and may contribute to chronic inflammation in cardiometabolic disease. Among several gut-derived products identifiable in the systemic circulation, bacterial endotoxins and metabolites have been extensively studied, however recent advances in microbial DNA sequencing have further allowed us to identify highly diverse communities of microorganisms in the bloodstream from an -omics standpoint, which is termed “circulating microbiota.” While detecting microorganisms in the bloodstream was historically considered as an indication of infection, evidence on the circulating microbiota is continually accumulating in various patient populations without clinical signs of infection and even in otherwise healthy individuals. Moreover, both quantitative and compositional alterations of the circulating microbiota have recently been implicated in the pathogenesis of chronic inflammatory conditions, potentially through their immunostimulatory, atherogenic, and cardiotoxic properties. In this mini review, we aim to provide recent evidence on the characteristics and roles of circulating microbiota in several cardiometabolic diseases, such as type 2 diabetes, cardiovascular disease, and chronic kidney disease, with highlights of our emerging findings on circulating microbiota in patients with end-stage kidney disease undergoing hemodialysis.

Successful Intervention to Teach Antimicrobial Pharmacology to Medical Students

BackgroundGraduating students at the Herbert Wertheim College of Medicine (HWCOM) expressed a lack of confidence in prescribing and utilizing antimicrobial agents. A challenge for early learners is developing a framework for relating antimicrobial pharmacology to emerging clinical knowledge. We developed a longitudinal curriculum incorporating a visual tool and spaced repetition through team based CBL (TB‐CBL) to foster deliberate practice of a 3‐step process to help learners: 1) Recognize localizing clinical signs of infection, 2) Identify most likely infectious agents, and 3) Prescribe appropriate antimicrobial coverage. We studied the outcomes of this curriculum on medical student knowledge and confidence.MethodsThe new curriculum was launched in 2017 with the CO 2021. Prior to 2017, all students participated in traditional lecture‐based learning of antimicrobial pharmacology. With the new flipped‐classroom curriculum, students review a series of short videos prior to 2 TB‐CBL sessions during the 1st year pharmacology course and 5 TB‐CBL sessions across the 2nd year organ systems courses. During sessions, students participate in a series of cases to utilize the visual tool and work together to practice the 3‐step method. A pocket card version of the visual tool is provided to students prior to entering clerkships when they participate in an additional TB‐CBL. In the 3rd year, students participate in didactic sessions during the 8‐week Family Medicine and Internal Medicine clerkships and complete a note‐based exercise on antibiotic management. Outcomes were measured at the end of the 4th year, just prior to graduation. Knowledge outcomes were assessed by voluntary non‐graded 20‐question MCQ quiz administered to the CO 2021 (intervention) and the CO 2017 (control). Each MCQ was mapped to either basic pharmacology objectives (mechanism of action, adverse drug reactions, spectrum of activity, and mechanisms of resistance) or to clinical pharmacology objectives (treatment of choice and/or causative microorganism). Student confidence was assessed through a voluntary 6‐question survey.Results114 students in the CO 2017 (91.2%) and 113 students in the CO 2021 (100%) participated in the end of 4th year knowledge assessment and confidence survey. Mean overall performance for students participating in the new curriculum was 82.39% (SD 15.27) compared with 66.7% (SD 15.82) for the control group (p < 0.0001, Figure 1). Mean performance on basic pharmacology questions was 82% (SD 0.38) for CO 2021 vs. 62% (SD 0.49) for CO 2017 (p<0.0001). Mean performance on clinical pharmacology questions was 82% (SD 0.49) for CO 2021 vs. 70% (SD 0.46) for CO 2017 (p<0.0001). Mean overall confidence for students in the CO 2021 was 3.83 (SD 0.72) compared with 2.95 (SD 0.99) for the CO 2017 (p <0.0001, 5‐point Likert Scale, Table 1).ConclusionThe use of a longitudinal antimicrobial curriculum incorporating a visual tool, active learning, spaced repetition, and deliberate practice led to improvements in medical student knowledge and confidence. This innovative approach may be used to teach antimicrobial pharmacology to medical students. Future studies should focus on retention and impacts on patient care.

Parallels of diabetic foot infections antibiotic resistance at inpatient and outpatient stages of treatment

Introduction. The risk of infectious complications in patients with diabetic foot syndrome (DFS) is 25.2 to 58%, the risk of hospitalization among the patients with complications of DFI is 56 times, and the risk of amputation is 155 times higher than non-diabetics. Detection of the etiologic agent has a crucial role in effective treatment, prevention of dissemination of the infection, and avoiding amputation.Aim of the study: to analyze the specific characteristics of the severe diabetic foot infection and antibiotic resistance of the pathogens during the inpatient and outpatient stages of treatment.Materials and methods. We included 62 type 2 diabetic inpatients (38 male and 24 female, group 1) with severe foot infection in to the study. 102 diabetic foot outpatients (56 male and 46 female, group 2) with postoperative wounds were included after discharged from the hospital. Cultures were obtained after surgery interventions immediately and on 14 days of hospitalization in group 1 of patients and in group 2 of patients with clinical signs of infection. Microbe species and resistant of pathogens to antibiotic were assessed.Results. There were prevalence of multidrug resistant Staphilococcus aureus (MRSA), Enterobacterales and Acinetobacter baumannii both outpatient and inpatient stages of diabetic foot infections treatment. The multidrug resistant pathogens were associated with ineffective empiric antibiotic therapy, delay of wound healing and amputations. The presence of multidrug resistant pathogens should be expected in cases of wound size more than 18 sm2, history of diabetic foot amputations, chronic osteomyelitis and time before wound professional care more than 14 weeks.Conclusion. The multidrug resistant pathogens were the main risk factor of amputations in diabetic foot inpatients with severe infections. At the outpatient stage of treatment multidrug resistant pathogens along with chronic osteomyelitis lead to delay of wound healing and new cases of foot amputations in diabetic patients.

Development and Validation of a Risk Score for Predicting Invasive Candidiasis in Intensive Care Unit Patients by Incorporating Clinical Risk Factors and Lymphocyte Subtyping.

ObjectiveTo develop and validate a rapid invasive candidiasis (IC)-predictive risk score in intensive care unit (ICU) patients by incorporating clinical risk factors and parameters of lymphocyte subtyping.MethodsA prospective cohort study of 1054 consecutive patients admitted to ICU was performed. We assessed the clinical characteristics and parameters of lymphocyte subtyping at the onset of clinical signs of infection and their potential influence on IC diagnosis. A risk score for early diagnosis of IC was developed and validated based on a logistic regression model.ResultsSixty-nine patients (6.5%) had IC. Patients in the cohort (N=1054) were randomly divided into a development (n=703) or validation (n=351) cohorts. Multivariate logistic regression identified that CD8+ T-cell count ≤143 cells/mm3, receipt of high-dose corticosteroids (dose ≥50 mg prednisolone equivalent), receipt of carbapenem/tigecycline, APACHE II score≥15, (1,3)-β-D-glucan (BDG) positivity and emergency gastrointestinal/hepatobiliary (GIT/HPB) surgery were significantly related with IC. IC risk score was calculated using the following formula: CD8+ T-cell count ≤143 cells/mm3 + receipt of high-dose corticosteroids + receipt of carbapenem/tigecycline + APACHE II score ≥15 + BDG positivity + emergency GIT/HPB surgery ×2. The risk scoring system had good discrimination and calibration with area under the receiver operating characteristic (AUROC) curve of 0.820 and 0.807, and a non-significant Hosmer-Lemeshow test P=0.356 and P=0.531 in the development and validation cohorts, respectively. We categorized patients into three groups according to risk score: low risk (0-2 points), moderate risk (3-4 points) and high risk (5-7 points). IC risk was highly and positively associated with risk score (Pearson contingency coefficient=0.852, P for trend=0.007). Candida score had a moderate predicting efficacy for early IC diagnosis. The AUROC of the risk score was significantly larger than that of Candida score (0.820 versus 0.711, Z=2.013, P=0.044).ConclusionsThe predictive scoring system, which used both clinical factors and CD8+ T cell count, served as a clinically useful predictive model for rapid IC diagnosis in this cohort of ICU patients.Clinical Trial Registrationchictr.org.cn, identifier ChiCTR-ROC-17010750.

In-silico functional annotation of a hypothetical protein from Edwardsiella tarda revealed Proline metabolism and apoptosis in fish

Edwardsiella tarda is one of the most widespread pathogens in aquatic species. A wide variety of diseases can be caused by this microbe, including Edwardsiella septicaemia but clinical signs of infection differ between species of fish. The fact that the bacteria is resistant to a wide range of antimicrobials is extremely important. Furthermore, several proteins in its genome are classified as hypothetical proteins (HPs). As a result, the current work sought to elucidate the roles of a HP found in the genome of E.tarda. To determine the structure and function of this protein, many bioinformatics methods were used. To locate the homologous protein, the sequence similarity was searched across the available bioinformatics databases. Quality evaluation methods were used to predict and confirm the secondary and tertiary structure. Additionally, the active site and interacting proteins were examined using CASTp and the STRING server. An important biological activity of the HP is that it contains single functional domains that may be responsible for host-cell invasion and autolysis. Further, protein-protein interactions within selected HP revealed several functional partners that are essential for bacterial survival. One such partner is the proline dehydrogenase/delta-1-pyrroline-5-carboxylate dehydrogenase (putA) of E. tarda. In addition, molecular docking and simulation results showed stable bonding between HP and Proline metabolism protein. Finally, the current work shows that the annotated HP is associated with possible mitochondrial metabolism and autolysis formation activities, as well as having a stable binding with the putA protein, which might be of significant relevance to future bacterial genetics research.

Susceptibility of common family Anatidae bird species to clade 2.3.4.4e H5N6 high pathogenicity avian influenza virus: an experimental infection study

BackgroundThere were large outbreaks of high pathogenicity avian influenza (HPAI) caused by clade 2.3.4.4e H5N6 viruses in the winter of 2016–2017 in Japan, which caused large numbers of deaths among several endangered bird species including cranes, raptors, and birds in Family Anatidae. In this study, susceptibility of common Anatidae to a clade 2.3.4.4e H5N6 HPAI virus was assessed to evaluate their potential to be a source of infection for other birds. Eurasian wigeons (Mareca penelope), mallards (Anas platyrhynchos), and Northern pintails (Anas acuta) were intranasally inoculated with 106, 104, or 102 50% egg infectious dose (EID50) of clade 2.3.4.4e A/teal/Tottori/1/2016 (H5N6).ResultsAll birds survived for 10 days without showing any clinical signs of infection. Most ducks inoculated with ≥ 104 EID50 of virus seroconverted within 10 days post-inoculation (dpi). Virus was mainly shed via the oral route for a maximum of 10 days, followed by cloacal route in late phase of infection. Virus remained in the pancreas of some ducks at 10 dpi. Viremia was observed in some ducks euthanized at 3 dpi, and ≤ 106.3 EID50 of virus was recovered from systemic tissues and swab samples including eyeballs and conjunctival swabs.ConclusionsThese results indicate that the subject duck species have a potential to be a source of infection of clade 2.3.4.4e HPAI virus to the environment and other birds sharing their habitats. Captive ducks should be reared under isolated or separated circumstances during the HPAI epidemic season to prevent infection and further viral dissemination.

Efficacy and Toxicity Studies of Oxytetracycline-loaded Calcium Carbonate Nanoparticles in Corynebacterium pseudotuberculosis Infected BALB/C Mice

Background: Caseous Lymphadenitis (CLA) is an important bacterial disease in goats, caused by Corynebacterium pseudotuberculosis. The disease is highly prevalent worldwide and causes significant economic losses to the cattle industry. Currently, the treatment of this disease with antibiotics remains largely unsuccessful due to the nature of the bacteria and the resultant resistance to the drugs. Methods: Thirty apparently healthy female BALB/c mice, aged 5-6 weeks old were used to assess the efficacy of oxytetracycline loaded in calcium carbonate nanoparticle (OTC-CS-CaCO3NP) and toxicity of calcium carbonate nanoparticle (CS-CaCO3NP). The mice were randomly divided into five groups of six each and were exposed to the following treatments: Group 1: received sterile distilled water; Group 2: received 0.2 ml C. pseudotuberculosis; Group 3: received 0.2 ml C. pseudotuberculosis and 10mg/kg OTC; Group 4: was given 0.2 ml C. pseudotuberculosis and 10mg/kg OTC-CS-CaCO3NP; and Group 5: was administered 20mg/kg CS-CaCO3NP. Results: The clinical signs of infection with C. pseudotuberculosis in the mice were significantly reduced after treatment with OTC-CS-CaCO3NP. The haematology results showed an insignificant reduction in the mean RBC count, Hb and haematocrit levels in Group 2 (infected controls) compared to the mice treated with oxytetracycline loaded nanoparticles. The biochemical analyses revealed no significant changes among the treatment groups. No histopathological lesions were found in the organs of the mice, treated with 20mg/kg CS-CaCO3NP, suggesting the absence of toxicity in vivo. Conclusion: The results from this study indicate the potentials of OTC-CS-CaCO3NP as becoming a nano-antibiotic formulation for the treatment of caseous lymphadenitis infection in mice.

Use of antibiotic-cement coated locking plates in the setting of periprosthetic infection and infected nonunion

IntroductionIn the setting of periprosthetic total hip and knee arthroplasty (THA/TKA) infection, plating of the femur may be necessary for fracture fixation, prophylactic fixation of the femur, poor bone quality, or infected femoral shaft nonunion. The purpose of this study was to investigate infection control rates and fracture healing in patients receiving antibiotic cement coated plates in the setting of infected nonunion and periprosthetic infections. MethodsWe retrospectively reviewed a series of ten patients who had an antibiotic coated plate placed in the setting of periprosthetic infection or infected nonunion with a minimum follow-up of six months. 80 g of Simplex bone cement (Stryker, Mahwah, NJ) were mixed with 4 g of powdered vancomycin and 4.8 g of powdered tobramycin and applied to a dynamic compression plate with locking screw guides in every hole. The antibiotic loaded cement was allowed to harden before implantation. Outcome measures were designed to assess for fracture healing defined as three out of four cortices united on radiographs along with bearing full weight without pain and evidence of infection control defined as normalized erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in the absence of antibiotic treatment with no clinical signs of infection. ResultsTen patients were treated with an antibiotic cement coated plate in the settings of infectious nonunion and periprosthetic infection and followed for an average of three years (mean 21.4 months, seven months to 61 months). Eight patients (80%) went on to successful control of infection after initial procedure. Two patients developed chronic drainage and had a second antibiotic spacer with antibiotic cement coated plate placed before the infection was controlled. All patients obtained successful control of infection at latest follow-up showing no clinical signs of infection, normalized laboratory markers, and negative culture results. There were no reported mechanical failures of the implant, fractures of the femur, or soft tissue complications. ConclusionAn antibiotic cement coated plating technique is a viable option for periprosthetic THA and TKA infections requiring plating of the femur or in patients with an infected nonunion.

A Multipathogen Bile Sample-based PCR Assay Can Guide Empirical Antimicrobial Strategies in Cholestatic Liver Diseases.

Background and objectivesPolymerase chain reaction (PCR) techniques provide rapid detection of pathogens. This pilot study evaluated the diagnostic utility and clinical impact of multiplex real-time PCR (mRT-PCR, SeptiFast) vs. conventional microbial culture (CMC) in bile samples of patients with chronic cholestatic liver diseases (cCLDs), endoscopic retrograde cholangio-pancreatography (ERCP), and peri-interventional-antimicrobial-prophylaxis (pAP).MethodsWe prospectively collected bile samples from 26 patients for microbiological analysis by CMC and mRT-PCR. Concordance of the results of both methods was determined by Krippendorff's alpha (α) for inter-rater reliability and the Jaccard index of similarity.ResultsmRT-PCRbile and CMCbile results were concordant for only Candida albicans (α=0.8406; Jaccard index=0.8181). mRT-PCRbile detected pathogens in 8/8 cases (100%), CMCbile in 7/8 (87.5%), and CMCblood in 5/8 (62.5%) with clinical signs of infection. mRT-PCRbile, CMCbile, and CMCblood had identical detection results in 3/8 (37.5%) with clinical signs of infection (two Klebsiella spp. and one Enterococcus faecium). The total pathogen count was significantly higher with mRT-PCRbile than with CMCbile (62 vs. 31; χ2=30.031, p<0.001). However, pathogens detected by mRT-PCRbile were more often susceptible to pAP according to the patient infection/colonization history (PI/CH) and surveillance data for antibiotic resistance in our clinic (DARC). Pathogens identified by mRT-PCRbile and resistant to pAP by PI/CH and DARC were likely to be clinically relevant.ConclusionsmRT-PCR in conjunction with CMCs for bile analysis increased diagnostic sensitivity and may benefit infection management in patients with cholestatic diseases. Implementation of mRT-PCR in a bile sample-based diagnostic routine can support more rapid and targeted use of antimicrobial agents in cCLD-patients undergoing ERCP and reduce the rate/length of unnecessary administration of broad-spectrum antibiotics.

Epidemiological and genetic characteristics of vancomycin-resistant Enterococcus faecium isolates in a University Children's Hospital in Germany: 2019 to 2020

BackgroundVancomycin-resistant Enterococcus faecium (VREfm) strains are one of the most important pathogens causing nosocomial infections in Germany. Due to limited treatment options and an increased risk for acquisition in immunocompromised children, surveillance to monitor occurrence of VREfm in paediatric clinical facilities is of critical importance. Following an unusual accumulation of VREfm positive patients between April 2019 and August 2020 at Dr. von Hauner Children’s Hospital in Munich, Germany, our study aimed to identify dynamics and routes of transmission, and analyse the affected population in view of previously described host risk factors for VREfm colonisation or infection.MethodsThe hospital database was used to collect epidemiological and clinical data of VREfm cases. Descriptive statistical analyses were conducted to outline patient characteristics and depict possible differences between VREfm-colonised and -infected children. An outbreak investigation determining genetic relatedness among VREfm isolates was performed by core genome multilocus sequence typing (cgMLST). To examine potential transmission pathways, results of genome analysis were compared with epidemiological and clinical data of VREfm positive patients.ResultsVREfm acquisition was documented in a total of 33 children (< 18 years). Seven VREfm-colonised patients (21.2%), especially those with a haemato-oncological disease (4/7; p = 0.011), showed signs of clinical infection. cgMLST analysis revealed seven distinct clusters, demonstrating a possible connection within each clonal lineage. Additional eight singletons were identified. Comparison with epidemiological and clinical data provided strong evidence for a link between several VREfm positive patients within the hospital.ConclusionsA nosocomial spread—at least in part—was the most likely reason for the unusual accumulation of VREfm cases. The study highlights that there is a constant need to increase efforts in hygiene measures, infection control and antibiotic stewardship to combat VREfm transmission events within German paediatric hospitals. Continuous monitoring of adherence to respective policies might reduce the occurrence of clustered cases and prevent future outbreaks.

P04 An evaluation of antimicrobial stewardship education in the School of Pharmacy of an Irish university—a mixed methods study

BackgroundAntimicrobial stewardship (AMS) is essential to control the emergence of antimicrobial resistance (AMR) which has become an international health priority. Education of undergraduate students on AMS and AMR is a strategic objective in the WHO Global Action Plan on AMR and Ireland's National Action Plan.1,2 Research on AMS/AMR education has focused primarily on medical students with less emphasis on those from other healthcare profession including pharmacy students.ObjectivesTo investigate AMS and AMR education in the Pharmacy undergraduate programme in the School of Pharmacy of an Irish University.MethodsA mixed methods study was conducted. Ten semi-structured interviews were conducted in October 2019 with academic staff to capture their views on AMS education. Participants included staff members from different disciplines, those identified as involved in teaching elements of infectious disease, antibiotics, AMS and related topics, and those involved in curriculum design and approval within the School of Pharmacy. Interview transcripts were analysed by thematic analysis. An electronic survey of 17 questions was emailed to all second to fifth year UCC Pharmacy students in October 2019 to gather students’ views and experiences of AMS education. The survey contained four sections which addressed demographics, AMS, resources and education using open-ended, closed-ended or Likert-scale questions. Ethical approval was obtained.ResultsSix key themes were identified from the ten interviews: (i) curriculum priorities and capacity; (ii) housing of the subject, fragmentation and cohesion; (iii) integration; (iv) communication; (v) teaching methods; and (vi) assessment methods. 113 students participated in the survey (32.3% response rate). 96% agree that a strong knowledge of antimicrobials for their future careers is important, and over 89% of students desire more education on AMR and AMS. Only 43% of students found their AMS education provided sufficient preparation for practice. Students felt most prepared to recognize clinical signs of infection and least prepared for IV to oral switching, interpreting biological marker and de-escalation of antimicrobials. Over 50% of students never used or were not familiar with the national primary care antimicrobial guidelines: www.antibioticprescribing.ie.ConclusionsPharmacy students and staff agree that AMS and AMR are important and need enhanced educational focus. Students feel there are gaps in their AMS education and expressed a desire for more education in this area. Improved communication and identification of curriculum priorities by staff could help to establish a more cohesive and comprehensive educational approach to this area.

Fatal toxoplasmosis in Little Penguins (Eudyptula minor) from Penguin Island, Western Australia.

Routine post mortems of deceased penguins from Penguin Island, Western Australia, found that a temporal cluster of cases presented with characteristic gross and microscopic changes, namely birds in good body condition with hepatomegaly and splenomegaly, multifocal hepatic and splenic necrosis and numerous, 1–2 μm diameter protozoan parasites within the necrotic foci.Electron microscopy identified the protozoa as belonging to the phylum Apicomplexa. Molecular investigations by PCR gave inconsistent results. PCR performed by an external laboratory identified a novel Haemoproteus spp. organism in samples from 4 of 10 cases from this group, while PCR at Murdoch University identified Toxoplasma gondii in 12 of 13 cases (including 9 of the 10 assayed at the external laboratory). Immunohistochemistry of formalin fixed tissues also identified Toxoplasma in the hepatic and splenic lesions.The distinctive mortalities which were observed in this group of penguins are attributed to a fulminant toxoplasmosis, with a concurrent Haemoproteus infection in some cases. Though the clinical signs of infection are unknown, the gross and microscopic appearance at post mortem is sufficiently characteristic to allow a diagnosis to be made on these features. Definitive confirmation of Toxoplasma infection can be made by immunohistochemistry or PCR.

Defining clinical diagnosis and treatment of puerperal metritis in dairy cows: A scoping review

Although puerperal metritis (PM) is a common infectious disease in dairy cattle, there are currently discrepancies between clinical case definitions within and between available peer-reviewed literature and on-farms practices. The inconsistent use of PM criteria across studies and on-farms practices can result in disparities related to recommendations for treating cows, affecting judicious use of antimicrobials. The objective of this study was to systematically review the peer-reviewed literature for clinical signs used for case definition of PM. The criteria used included local (e.g., vaginal discharge) and systemic clinical signs of infection (e.g., fever, drop in milk). The Preferred Reporting Items for Systematic Review and Meta-Analysis extension for scoping reviews protocols were used to screen commonly used databases. Following this protocol, one reviewer screened title and abstract for eligibility (n = 2,096), followed by full-text screening of selected articles (n = 396) by 2 reviewers to confirm eligible articles (n = 174). The most frequently cited reference article (37.5%) for the definition of PM was published in 2006, followed by articles published between 1998 and 2009 (13%). In 40.2% of articles, no reference was provided for definition of PM; vaginal discharge was described in terms of color, odor, and viscosity when related to the PM definition. Terms used for description of vaginal discharge color were red-brown (61.4%), red (5.1%), brown (8.6%), chocolate (4%), white (1.7%), yellow (0.5%), pink (5.7%), or gray (0.5%); vaginal discharge color was not reported in 24.1% articles. The vaginal discharge odor was described as fetid (75.8%), putrid (5.1%), foul (10.3%), or other (5.7%; e.g., abnormal, malodorous, odoriferous); odor was not mentioned in 7.4% of articles. The vaginal discharge viscosity was described as watery (74.1%), purulent (27%), mucopurulent (8.6%), thin (4%), serous (2.8%), or abnormal (2.3%) and was not mentioned in 11.5% of articles. Fever was included in 59.7% of articles as a criterion for PM diagnosis. The most used rectal temperature threshold was ≥39.5°C (56.8%), followed by ≥39.2°C (2.8%). Approaches used for vaginal discharge evaluation included rectal palpation (37.3%), intravaginal exploration with a gloved hand (18.4%), Metricheck (9.8%), or speculum (5.7%); and in 28.7% of articles, diagnostic tools used were not mentioned. Many of the color and odor vaginal discharge descriptions observed in the literature, used synonymous words to describe the same vaginal discharge sample, highlighting a lack of terminology consensus that could result in disagreements, especially due to the subjective character of these clinical evaluations of vaginal discharge color and odor. Although select consensus articles are available, it is common for studies to disregard a reference when defining PM cases. Furthermore, our findings highlight the need for a robust and clear consensus on criteria and terminology used to diagnose PM.

Bromhexine Hydrochloride Prophylaxis of COVID-19 for Medical Personnel: A Randomized Open-Label Study.

Background Bromhexine hydrochloride has been suggested as a TMPRSS2 protease blocker that precludes the penetration of SARS-CoV-2 into cells. We aimed to assess the preventive potential of regular bromhexine hydrochloride intake for COVID-19 risk reduction in medical staff actively involved in the evaluation and treatment of patients with confirmed or suspected SARS-CoV-2 infection. Methods In a single-centre randomized open-label study, medical staff managing patients with suspected and confirmed COVID-19 were enrolled and followed up for 8 weeks. The study began at the initiation of COVID-19 management in the clinic. The study was prematurely terminated after the enrollment of 50 participants without a history of SARS-CoV-2 infection: 25 were assigned to bromhexine hydrochloride treatment (8 mg 3 times per day), and 25 were controls. The composite primary endpoint was a positive nasopharyngeal swab polymerase chain reaction (PCR) test for SARS-CoV-2 or signs of clinical infection within 28 days and at week 8. Secondary endpoints included time from the first contact with a person with COVID-19 to the appearance of respiratory infection symptoms; the number of days before a first positive SARS-CoV-2 test; the number of asymptomatic participants with a positive nasopharyngeal swab test; the number of symptomatic COVID-19 cases; and adverse events. Results The rate of the combined primary endpoint did not differ significantly between the active treatment group (2/25 [8%]) and control group (7/25 [28%]); P=0.07. A fewer number of participants developed symptomatic COVID-19 in the treatment group compared to controls (0/25 vs. 5/25; P=0.02). Conclusion Although the study was underpowered, it showed that Bromhexine hydrochloride prophylaxis was associated with a reduced rate of symptomatic COVID-19. The prophylactic treatment was not associated with a lower combined primary endpoint rate, a positive swab PCR test, or COVID-19 (ClinicalTrials.gov number, NCT04405999).