UK Tertiary Referral Hospital Research Articles

Three-years of dalbavancin use at a UK tertiary referral hospital serving a population with high numbers of people who inject drugs

Three-years of dalbavancin use at a UK tertiary referral hospital serving a population with high numbers of people who inject drugs

MULTIFACTORIAL MENINGITIS IN A PATIENT WITH PREVIOUS EPSTEIN BARR VIRUS ENCEPHALITIS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Gram negative bacillary meningitis is rare and mostly occurs in patients with recent neurosurgery. We present such a case of bacterial meningitis combined with other etiologies in a patient with previous Epstein Barr Virus (EBV) encephalitis. CASE PRESENTATION: 62-year-old male with history of diabetes, stroke and EBV encephalitis (1 month ago) presented with altered mentation. Lumbar puncture (LP) showed neutrophil predominant leukocytosis but cerebrospinal fluid (CSF) culture was negative. Brain imaging showed developing hydrocephalus. He was started on empiric meningitis coverage with antibacterial, antifungal and antitubercular regimen (due to basilar changes on imaging and mildly elevated adenosine deaminase in the CSF). He underwent right craniotomy with ventriculo-peritoneal (VP) shunt placement. Course complicated by worsening mentation requiring intubation for airway protection. Due to concern of hospital acquired pneumonia (HAP), piperacillin-tazobactam was added. Repeat LP showed improved leukocyte count but culture was again negative. He had persistent fevers after finishing piperacillin-tazobactam course; subsequent sputum culture and 3rd CSF culture now grew pseudomonas aeruginosa. He finished 21 days of systemic cefepime and 7 days of intrathecal tobramycin for pseudomonas; and 14 days of empiric amphotericin B (although fungal CSF culture was negative). He remains on empiric antitubercular regimen (isoniazid/rifampin/pyrazinamide/ethambutol) - culture negative. Mentation remains poor and family is currently deciding on aggressive care with tracheostomy or palliative care approach. DISCUSSION: In our case, meningitis on admission was likely some bacterial superinfection after viral encephalitis. After neurosurgery, 2nd CSF culture was negative likely due to ongoing antibiotics for HAP. 3rd CSF culture grew pseudomonas as patient was now off of piperacillin-tazobactam. Pseudomonas meningitis is rare and can occur as complication of neurosurgery, chronic cranial osteomyelitis, mastoiditis or trauma. The mortality rate ranges from 40 to 80%. Complications include hydrocephalus, brain abscesses, seizures, ventriculitis etc. The CSF gram stain is positive in 50% of cases with a positive culture result. Bacteremia is also present in about 50% of the cases. The usual empiric meningitis regimen does not cover pseudomonas and antipseudomonal agents can be added in patients with above risk factors. Cefepime/ceftazidime are empiric therapy and should be adjusted based on sensitivities. Dual therapy with intrathecal/intraventricular regimens can be started in resistant cases. Adjuvant steroids have shown no benefit. CONCLUSIONS: Timely recognition of risk factors for gram negative bacillary meningitis and starting empiric treatment regimen can improve the prognosis of such patients. REFERENCE #1: Berk SL, McCabe WR. Meningitis caused by gram-negative bacilli. Ann Intern Med. 1980;93(2):253. REFERENCE #2: Rahal JJ, Simberkoff MS. Host defense and antimicrobial therapy in adult gram-negative bacillary meningitis. Ann Intern Med. 1982;96(4):468. REFERENCE #3: S. Pai, L. Bedford et al. Pseudomonas aeruginosa meningitis/ventriculitis in a UK tertiary referral hospital. An International Journal of Medicine, Volume 109, Issue 2, February 2016, Pages 85–89, https://doi.org/10.1093/qjmed/hcv094 DISCLOSURES: No relevant relationships by Sahib Singh, source. Web Response no disclosure on file for Parth Jamindar

Healthcare staff perceptions towards influenza and potential COVID-19 vaccination in the 2020 pandemic context

The COVID-19 pandemic generated renewed focus on infectious disease transmission in healthcare settings. This study aimed to evaluate staff perceptions towards influenza vaccination in the COVID-19 context. All healthcare workers within a major UK tertiary referral hospital were invited to answer a survey conducted from September 2nd to 13th, 2020. In all, 593 responses were received across a spectrum of roles; 44% reported they were more likely to get an influenza vaccine this year due to COVID-19; however, 10% felt that an influenza vaccine was less important due to social distancing. Additional questions evaluated intention to receive COVID-19 vaccination. There were substantial differences of opinion between staff groups.

A novel approach to support implementation of biosimilars within a UK tertiary hospital.

We analysed data collected prospectively in a hospital-based registry in a large NHS tertiary referral hospital in the UK. The registry was administered by the hospital's BSG, which considered requests for patients to remain on or revert to originator products. The registry contained prospectively collected data on patients switching therapy from an originator to a biosimilar. The data included clinical circumstances or rationale for each request, whether it was granted, and the results of clinical reviews at 3-6 months. In a 12-month period, we identified 1299 patients who could switch to the respective biosimilar and, of these, 1196 (92%) did so. Of the 260 patients taking infliximab, 250 (96%) switched to infliximab biosimilar; of the 390 patients taking etanercept 50 mg, 298 (76%) switched to etanercept 50 mg biosimilar; and of the 649 patients taking rituximab, 648 (99%) switched to rituximab biosimilar. The BSG received 39 applications: 12 (out of 39) applications were to remain on the originator and 27 (out of 39) were to switch back to the originator. Of the applications to remain on the originator 10 (out of 12) were approved. At 3-6 month review, 2 of these approvals reported continued efficacy, 3 switched to the biosimilar, 3 switched to an alternative therapy and 2 stopped treatment. Two (out of 10) applications were not approved, both applicants reported efficacy with the biosimilar at follow up. Of the 27 applications to switch back to the originator, 16 (out of 27) applications were approved. At 3-6 months, 9 (out of 16) applicants reported regain of efficacy, 6 (out of 16) reported cessation of reported adverse effects and 1 (out of 16) switched to alternative therapy. Eight (out of 27) applications were not approved, and, at point of follow up, 50% reported efficacy with the biosimilar and 50% had switched to an alternative therapy. Three (out of 27) applications were withdrawn by the clinical team as efficacy was achieved with the biosimilar. We have set up a system within a busy NHS clinical practice to successfully switch patients to biosimilars, and established a mechanism to guide decisions on continuing with or reverting back to the originator. Such a system could be of use more broadly within the NHS and other health care systems.

Effect of QUiPP prediction algorithm on treatment decisions in women with a previous preterm birth: a prospective cohort study.

The QUiPP algorithm combines cervical length, quantitative fetal fibronectin (qfFN) and medical history to quantify risk of preterm birth. We assessed the utility of QUiPP to inform preterm birth prevention treatment decisions. A prospective cohort study with a subsequent impact assessment using the QUiPP risk of birth before 34weeks' gestation. A UK tertiary referral hospital. In all, 119 women with previous spontaneous preterm birth (sPTB) or preterm premature rupture of membranes (PPROM) before 34weeks' gestation. Cervical length and qfFN were measured at 19+0 to 23+0 weeks' gestation. Clinical management was based on history and cervical length. After birth, clinicians were unblinded to qfFN results and QUiPP analysis was undertaken. Predictive statistics of QUiPP algorithm using 10% risk of sPTB before 34+0 weeks as treatment threshold. Fifteen of 119 women (13%) had PPROM or sPTB before 34weeks. Of these, 53% (8/15) had QUiPP risk of sPTB before 34+0 weeks above 10%. Applying this treatment threshold in practice would have doubled our treatment rate (20 versus 42%). QUIPP threshold of 10% had positive likelihood ratio (LR) of 1.3 (95% CI 0.76-2.18), and negative LR of 0.8 (95% CI 0.45-1.40) for predicting sPTB before 34+0 weeks. Use of the QUiPP algorithm in this population may lead to substantial increase in interventions without evidence that currently available treatment options are beneficial for this particular group. Independent study finds that the QUiPP algorithm could lead to substantial increases in treatment without evidence of benefit.

The value of the infection prevention and control nurse led MRSA ward round

Meticillin-resistant S. aureus (MRSA) is prevalent in most parts of the world. The study took place at Queen Elizabeth Hospital Birmingham (QEHB) a UK tertiary referral hospital. At QEHB innovative nurse led daily ward rounds for patients that acquire hospital acquired MRSA during their hospital stay are undertaken. The aim is to optimise care delivered for these patients whilst at QEHB, thereby reducing the risk of infection in patients with healthcare-acquired MRSA. A segmented Poisson regression model suggests that the MRSA bacteraemia rate was affected where an 88.94% reduction (p = 0.0561) in bacteraemias was seen by the introduction of these ward rounds. We describe a nurse led MRSA ward round which was associated with a lower rate of MRSA bacteraemias.

Micafungin use in a UK tertiary referral hospital.

Here we sought to describe the real-life usage of micafungin in a UK tertiary referral hospital. A prospective, non-interventional, observational surveillance study was performed. Micafungin was commenced in 174 courses involving 148 patients to treat invasive candidiasis and candidaemia (132 courses) and aspergillosis in situations where alternatives such as voriconazole or liposomal amphotericin B could not be used (42 courses). Fungal infection was defined as proven as per European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) guidelines in 84 courses (48.3%). Micafungin was well tolerated; 10 patients (6.8%) developed a rise in alanine aminotransferase (ALT) and only 1 patient stopped therapy due to this. Therapy was rationalised to fluconazole in 77 courses (44.3%). There were no differences in intensive care unit admission or deaths when comparing all 174 courses where patients received micafungin for Aspergillus and Candida infection, respectively [49% vs. 42% (P=0.82) and 24% vs. 15% (P=0.186)]. One patient developed disseminated mucormycosis and four patients had recurrent candidaemia (attributed to poor source control) while receiving micafungin. Micafungin was clinically effective for the treatment of invasive Candida and Aspergillus infections, and usage did not increase the risk of liver dysfunction even in patients with abnormal ALT at baseline.

Quantifying alcohol-related emergency admissions in a UK tertiary referral hospital: a cross-sectional study of chronic alcohol dependency and acute alcohol intoxication

ObjectivesAlcohol is responsible for a proportion of emergency admissions to hospital, with acute alcohol intoxication and chronic alcohol dependency (CAD) implicated. This study aims to quantify the proportion of hospital...

Prevalence and antimicrobial resistance of canine urinary tract pathogens

This study aims to describe the incidence and risk factors for positive urinary tract culture, the prevalence of urinary tract pathogens in single organism and mixed cultures and changes in their antimicrobial resistance over 10 years. A retrospective review of computer records detailing canine urine samples submitted between August 1999 and September 2009 for culture and sensitivity in a UK tertiary referral hospital is described. 17.5 per cent of 5923 samples (670of4530 dogs) were positive cultures. 85.3 per cent of cultures yielded a single isolate. The prevalence of bacterial species differed between mixed and single isolate cultures. Entire and neutered female dogs were more likely to return positive cultures than male dogs (OR=2.5 and 1.5, respectively). Escherichia coli was most commonly isolated (53.9 per cent) and affected female dogs, older dogs and neutered dogs more. There was an increase in the antimicrobial resistance of Enterococcus faecalis and Pseudomonas Aeruginosa, and a decrease in the effectiveness of enrofloxacin, cephalexin and oxytetracycline. The prevalence of urinary bacterial isolates is described for a large group of dogs. Monitoring changes in antimicrobial efficacy and microbial resistance guides the empirical use of antimicrobials for the treatment of urinary tract infection and helps formulate strategic plans to limit drug resistance.

Off label use of devices and drugs in interventional radiology

To establish how often off-label device and drug use occurs in interventional radiology (IR) in a UK tertiary referral hospital and consider the wider implications for the interventional radiologist. Prospective data were collected during interventional procedures for 1 working week in a university hospital. Out-of-hours procedures and procedures outside the department were excluded. Operators were asked to record the drugs and devices used, the indication, and method of use. The instructions for use/summary of product characteristics were then studied for each device/drug used to assess if the use was on or off-label. During the study period 52 cases were performed and data were available on 26 cases (50%). In 22 of the 26 cases (84%) there was evidence of off-label use of devices or drugs. Off-label use of drugs included treatment of venous malformations with Fibrovein(©) (sodium tetradecyl sulphate), which is licensed for the treatment of varicose veins in the leg, and intra-arterial injection of heparin, which is licensed for intravenous and subcutaneous use. Off-label device use included placing vascular sheaths in the urinary tract, using angiographic catheters to guide wires in the urinary tract, using sheaths for thrombosuction, reshaping of the tip of most guidewires, and using angioplasty balloons to dislodge the arterial plug at fistula thrombectomy. Off-label device and drugs use is common in a UK tertiary hospital IR department and literature suggests this is common in the wider IR community. There are important clinical and legal implications for off-label use for patients and physicians.

Retinal Arteriolar Geometry is Associated with Cerebral White Matter Hyperintensities on Magnetic Resonance Imaging

BackgroundCerebral small vessel disease (lacunar stroke and cerebral white matter hyperintensities) is caused by vessel abnormalities of unknown aetiology. Retinal vessels show developmental and pathophysiological similarities to cerebral small vessels and microvessel geometry may influence vascular efficiency.HypothesisRetinal arteriolar branching angles or coefficients (the ratio of the sum of the cross-sectional areas of the two daughter vessels to the cross-sectional area of the parent vessel at an arteriolar bifurcation) may be associated with cerebral small vessel disease.MethodsWe performed a cross-sectional observational study in a UK tertiary referral hospital. An experienced stroke physician recruited consecutive patients presenting with lacunar ischaemic stroke with a control group consisting of patients with minor cortical ischaemic stroke. We performed brain magnetic resonance imaging to assess the recent infarct and periventricular and deep white matter hyperintensities. We subtyped stroke with clinical and radiological findings. We took digital retinal photographs to assess retinal arteriolar branching coefficients and branching angles using a semi-automated technique.ResultsTwo hundred and five patients were recruited (104 lacunar stroke, 101 cortical stroke), mean age 68-years (standard deviation 12). With multivariate analysis, increased branching coefficient was associated with periventricular white matter hyperintensities (P=0·006) and ischaemic heart disease (P<0·001), and decreased branching coefficient with deep white matter hyperintensities (P=0·003), but not with lacunar stroke subtype (P=0·96). We found no associations with retinal branching angles.ConclusionsRetinal arteriolar geometry differs between cerebral small vessel phenotypes. Further research is needed to ascertain the clinical significance of these findings.

726 The Paediatric Early Warning Tool in Combination with a Nurse-Led Outreach Team: Impact on Outcomes for Critically Ill Children

Introduction: Paediatric early warning tools (PEWT) were developed to identify clinical deterioration in acutely ill patients. Deviations from defined physiological parameters are used to initiate medical review and intervention. PEWT was incorporated into observation charts at a UK tertiary referral hospital and an outreach response team was trialled providing immediate high dependency care. Aims: An audit was undertaken to determine the effectiveness of the outreach team combined with PEWT and assess the impact on patient outcome. Method: A nurse-led outreach team was trialled for 3 months during 2009. Patient observation charts were reviewed for all inpatients over one week. Data was collected to determine: number of patient triggers, actions taken and patient outcome (133 patient observation charts reviewed). Data collection was repeated once the trial had finished (n=167). Results: 28% (n=37) of patients triggered when team available ((133 charts); mean age 6.3 years (SD=5.5)) which was comparable to the period without the team 28% (47/167, p=0.1); 5.8 years (SD=5.6)) when triggered. Help was requested on 12 (32%) occasions compared with 8 (17%, p< 0.05) with and without teams respectively. No arrest calls occurred during the period with the team; 2 occurred during the period without. A reduction in critical incident reporting was observed during team availability. Conclusions: Decreased emergency team calls and critical incidents were observed by introduction of an outreach team and PEWT. The outreach team received a positive response from all staff, providing immediate high dependency care. Use of the PEWT allowed earlier review and prompt medical intervention.

Analysis of the off-licence use of recombinant activated factor VII for patients with uncontrolled haemorrhage in a UK tertiary referral hospital

Recombinant activated factor VII (rFVIIa) is increasingly used for the treatment of acquired coagulopathies associated with uncontrolled haemorrhage. Consensus guidelines [1] have been published for the administration of rFVIIa in this setting. We examined the off-licence use of rFVIIa in our 1,071-bed tertiary referral hospital.

Trends in bacteraemia on the haematology and oncology units of a UK tertiary referral hospital

As part of ongoing surveillance of infection in the haematology and oncology units at Belfast City Hospital, microbiologically documented bloodstream infections over three 12-month periods 1994/5, 1998/9 and 1999/00 were reviewed. Gram-positive organisms were the most common cause of blood stream infection in the haematology unit causing 66%, 56% and 64% of episodes of monomicrobial bacteraemia in 1994/5, 1998/9 and 1999/00, respectively. In haematology patients, enterococci have emerged as an important cause of bacteraemia, with increasing levels of glycopeptide resistance, and the ‘non-fermenting Gram-negative rods other than Pseudomonas aeruginosa’ are an increasingly common cause of monomicrobial and polymicrobial bacteraemia. In oncology patients, Gram-negative organisms (predominantly enterobacteriaceae) were more common than Gram-positive organisms, causing 50% and 54% of monomicrobial bacteraemia in 1998/9 and 1999/00, respectively. Changes in patient population, underlying diseases and chemotherapeutic agents may explain these findings. The spectrum of infection seen in haematology and oncology patients changes as management evolves. Ongoing co-operation between haematologists, oncologists and microbiologists is important to detect trends in epidemiology, which can be used to design empirical antibiotic regimens and guide infection control policies.

Comparison of the Oxoid Clostridium difficile toxin A detection kit with cytotoxin detection by a cytopathic effect method examined at 4, 6, 24 and 48 h

Objective To evaluate the Oxoid Toxin A test in comparison with a rapid cytotoxin method for the diagnosis of Clostridium difficile diarrhea in a UK tertiary referral hospital. Methods One hundred previously tested samples were examined using a cytopathic effect (CPE) method and the Oxoid Toxin A test. Culture and toxin B titer measurement of the samples were performed to evaluate discrepancies between the tests. Results The sensitivity and specificity of the Oxoid Toxin A test were 72% and 94%, respectively. This was similar to the CPE method read at 6 h: 67% and 94% in comparison. At 48 h, the sensitivity and specificity of the CPE method reached 98% and 100%. Toxigenic strains of C. difficile were cultured from 58 of 100 samples, and toxin was detected in 48 of 58. Following 4 weeks of storage at −20°C, seven of 47 previously toxin B-positive stool filtrates had no detectable toxin. Conclusions The Oxoid Toxin A test does not demonstrate a high enough sensitivity and specificity to be used as a primary test for C. difficile in hospitals where CPE testing is possible. Toxigenic strains of C. difficile can be cultured from a significant number of samples where no toxins are detected. Toxin B titers in fecal samples and especially in stool filtrates, stored at − 20°C, diminish after thawing.