Appropriateness of acute-care antibiotic prescriptions for community-acquired infections and surgical antibiotic prophylaxis in England: analysis of 2016 national point prevalence survey data

BACKGROUND

Estimates of inappropriate prescribing can highlight key target areas for antimicrobial stewardship (AMS) and inform national targets.

OBJECTIVES

To (1) define and (2) produce estimates of inappropriate antibiotic prescribing levels within acute hospital trusts in England.

METHODS

The 2016 national Healthcare-Associated Infections (HAI), Antimicrobial Use (AMU) and AMS point prevalence survey (PPS) was used to derive estimates of inappropriate prescribing, focusing on the four most reported community-acquired antibiotic indications (CAIs) in the PPS and surgical prophylaxis. Definitions of appropriate antibiotic therapy for each indication were developed through the compilation of national treatment guidelines. A Likert-scale system of appropriateness coding was validated and refined through a two-stage expert review process.

RESULTS

Antimicrobial usage prevalence data were collected for 25,741 individual antibiotic prescriptions, representing 17,884 patients and 213 hospitals in England. 30.4% of prescriptions for the four CAIs of interest were estimated to be inappropriate (2054 prescriptions). The highest percentage of inappropriate prescribing occurred in uncomplicated cystitis prescriptions (62.5%), followed by bronchitis (48%). For surgical prophylaxis, 30.8% of prescriptions were inappropriate in terms of dose number, and 21.3% in terms of excess prophylaxis duration.

CONCLUSIONS

The 2016 prevalence of inappropriate antibiotic prescribing in hospitals in England was approximated to be 30.4%; this establishes a baseline prevalence and provided indication of where AMS interventions should be prioritized. Our definitions appraised antibiotic choice, treatment duration and dose number (surgical prophylaxis only); however, they did not consider other aspects of appropriateness, such as combination therapy - this is an important area for future work.

Exploration of the physical properties of the newly synthesized kagome superconductor LaIr3Ga2 using different exchange-correlation functionals

LaIr₃Ga₂ is a kagome superconductor with a superconducting temperature (T_c) of 5.16 K. Here, we present the physical properties of the LaIr₃Ga₂ kagome superconductor computed via the DFT method wherein six different exchange-correlation functionals were used. The lattice parameters obtained using different functionals are reasonable, with a slight variation compared to experimental values. The bonding nature was explored. The elastic constants (C_ij), moduli (B, G, Y), and Vickers hardness (H_v) were computed to disclose the mechanical behavior. The H_v values were estimated to be 2.56-3.16 GPa using various exchange-correlation functionals, indicating the softness of the kagome material. The Pugh ratio, Poisson's ratio, and Cauchy pressure revealed the ductile nature. In addition, mechanical stability was ensured based on the estimated elastic constants. The anisotropic mechanical behavior was confirmed via different anisotropic indices. The Debye temperature (Θ_D), melting temperature (T_m), and minimum thermal conductivity (k_min) were calculated to characterize the thermal properties and predict the potential of LaIr₃Ga₂ as a thermal barrier coating material. The electronic density of states was investigated in detail. The McMillan equation was used to estimate T_c, and the electron-phonon coupling constant (λ) was calculated to explore the superconducting nature. The important optical constants were also calculated to explore its possible optoelectronic applications. The values of reflectivity in the IR-visible region are about 62% to 80%, indicating that the compound under study is suitable as a coating to reduce solar heating. The obtained parameters were compared with previously reported parameters, where available.

Barriers for using amoxycillin dispersible tablet in pediatric pneumonia treatment in Bangladesh

 

World Health Organization recommends guideline for integrated management of childhood illnesses (IMCI) where Amoxicillin Dispersible Tablet (DT) appears as the first drug of choice for treating childhood pneumonia. The Government of Bangladesh adopted the IMCI strategy in 1998, and scaled it up nationwide by 2014. But, even today, the use of Amoxicillin DT, either in public or private sector, for managing childhood pneumonia is a rare event in Bangladesh. We conducted this exploratory study to understand the existing barriers, both in public and private sector, those have influences on reduced availability of Amoxicillin DT and non-compliance of health service providers to follow IMCI guideline by using Amoxicillin DT for treating a child with pneumonia, in Bangladesh. We conducted desk review of relevant strategy and policy documents, key informant interviews with 19 key individuals from Ministry of Health and national / international NGOs. Collected information were analyzed and interpreted using thematic analysis method. Identified barriers through this study pointed to inadequate policy level focus on IMCI implementation, non-inclusion of Amoxicillin DT in the national essential drug list, single source of Amoxicillin DT producing pharmaceutical in the country coupled with bureaucracy and procurement procedural complexity, lack of training of health service providers and abundant availability of antibiotic over the counter. Study respondents recommended for policy level strengthening of IMCI program, increasing coverage of training for health care provider, including practicing pediatricians both at public and private sectors, facilitating production and procurement procedures and prohibiting antibiotic sell over the counter.

Key messages

• Facilitation of production and procurement procedure coupled with enforcement of law prohibiting antibiotics availability over the counter are urgent needs.

• Policy level support emphasizing full compliance of service providers for quality of implementation of IMCI program in Bangladesh (and similar other settings) is also important.

Evaluation of a collaborative pharmacy service initiative for people with intellectual disabilities in residential care homes

Introduction

People with Intellectual Disabilities (ID) often have complex care needs and increased likelihood of premature death.1 The NHS has committed to improving the use of psychotropic medicines in people with ID with the Stopping the Over-Medication of People with Learning Disabilities (STOMP) programme.2 In the Wirral a cross-sector, collaborative service initiative involving community pharmacists and a specialist mental health pharmacist was developed to provide pharmaceutical care reviews for ID care home residents, which included an evaluation of the initiative.

Aim

This study aimed to determine the number and type of pharmacists’ interventions and GP recommendations in this service initiative.

Methods

Pharmacists provided pharmaceutical care reviews for ID care home residents using a framework and where applicable made interventions or recommendations to residents’ GPs or consultant psychiatrist. The framework was devised by the lead Consultant, Mental Health Trust lead pharmacist and Local Pharmaceutical Committee representatives to align with national ID priorities.1 Pharmacists were recruited via expressions of interest and direct recruitment by the mental health trust. Using anonymised, aggregated, Clinical Commissioning Group data, an Oversight Group divided all ID care homes in the locality into two groups: homes with residents with low psychotropic medicines use were primarily assigned to community pharmacists, whilst those with higher psychotropic use were assigned to the specialist mental health pharmacist. Pharmacists contacted care home managers and arranged reviews with all residents, sharing learnings in weekly reviews. Community pharmacists identified residents who would benefit from specialist mental health pharmacist review and referred them. Data collected included patient demographic details, medication history, results of assessments completed and interventions/recommendations. Following institutional ethical approval, this data was downloaded from PharmOutcomes into Microsoft Excel and personally identifiable data removed. The data underwent descriptive statistical analysis in SPSS, including frequency counting interventions by type.

Results

The pharmacists conducted reviews with 160 residents (76 by community pharmacists and 84 by the specialist mental health pharmacist) from November 2019 – May 2020, reflecting all residents in visited care homes. These residents were prescribed 1207 medicines, 74% were prescribed 5 or more medicines (i.e. polypharmacy) and 507 interventions or recommendations were made, averaging 3.3 per resident. Table 1 shows that the highest proportion (30.4%) of these were public health related, whilst changing and stopping medicines accounted for 17.9% and 12.8% respectively. The majority (63%) of interventions made by community pharmacists were public health related, whilst those made by the mental health specialist pharmacist most frequently concerned changing medicines (25%), stopping medicines (18%), and blood monitoring (13%).

Conclusion

The study findings indicate a high level of polypharmacy among the ID residents and a high number of interventions / recommendations were needed to improve care, in line with national priorities.1,2 The small scale of the study is acknowledged, and further research is warranted. However, the findings suggest that this service model may be an effective use of the respective skill sets of the pharmacists involved and suitable for wider adoption, with community pharmacists focusing on holistic care and specialist mental health making specialist medicines interventions.

References

1. University of Bristol Norah Fry Centre for Learning Disability Studies. The Learning Disability Mortality Review (LeDeR) Programme Annual Report 2018. Available at: https://www.hqip.org.uk/wp-content/uploads/2019/05/LeDeR-Annual-Report-Final-21-May-2019.pdf (last accessed 12/10/20).

2. NHS England. Stopping over medication of people with a learning disability, autism or both (STOMP). https://www.england.nhs.uk/learning-disabilities/improving-health/stomp/ (last accessed 12/10/20).

Amelioration of N,N'-dimethylhydrazine induced colon toxicity by epigallocatechin gallate in Wistar rats

Colon cancer is a life-threatening disease all over the world and is linked to constant oxidative stress and inflammation. Epigallocatechin gallate (EGCG), is a naturally occurring flavone possessing health benefiting pharmacological properties including antioxidant, anti-inflammatory and free radical scavenging properties. Our study investigates the role of EGCG on N,N'-dimethylhydrazine (DMH), a toxic environmental pollutant, induced colon toxicity. To investigate the effect of EGCG, Wistar rats were given EGCG for 7 days at the two doses of 10 and 20 mg/kg body weight and DMH was injected on the seventh day in all the group rats except the control. Our results indicate that DMH administration increased the oxidative stress (MDA) and depleted the glutathione and antioxidant enzyme activities (SOD, CAT, GR, GST and GPx) which was significantly ameliorated by EGCG treatment. Additionally DMH treatment upregulated inflammatory markers expression (NF-κB, COX-2 and IL-6) and enhanced mucosal damage in the colon. EGCG treatment significantly reduced inflammation and restored the normal histoarchitecture of the colon. We can conclude from the present study findings that EGCG protects the colon from DMH toxicity through its antioxidant and anti-inflammatory potential.

Protective role of diosmin against testosterone propionate-induced prostatic hyperplasia in Wistar rats: Plausible role of oxidative stress and inflammation

Benign prostatic hyperplasia (BPH) is an important key health concern for aging men. Polyphenolic compounds have been found to possess important roles in the inhibition of numerous ailments that involve reactive oxygen species and inflammation. Diosmin is a citrus flavone that possesses antioxidant, anti-inflammatory, antiproliferative, and anticancer activities, so based on these properties of diosmin, we decided to evaluate its effect on testosterone propionate (TP)-induced BPH. A total of 30 Wistar rats were randomly assigned to five groups having six animals in each. This study was of 28 days in which TP (5 mg kg−1) was administered to induce BPH in the last 10 days of the study. It was found that diosmin at the doses of 20 and 40 mg kg−1significantly reduced malondialdehyde and xanthine oxidase formation in a dose-dependent manner; however, it replenished catalase, glutathione (GSH), and GSH-dependent enzymes, that is, glutathione peroxidase, glutathione reductase, and glutathione- S-transferase significantly against TP-induced BPH. Further, immunohistochemical study showed that diosmin alleviated inflammatory markers (nuclear factor kappa-light-chain-enhancer of activated B cells, cyclooxygenase-2, and interleukin-6). It was also found that diosmin downregulated the expression of androgen receptor and decreased the prostate-specific antigen concentration dose-dependently, significantly against TP-induced BPH. Diosmin also restored histoarchitecture of the prostate in a dose-dependent manner. Findings from the present study revealed the protective role of diosmin against TP-induced BPH in Wistar rats.

A national quality incentive scheme to reduce antibiotic overuse in hospitals: evaluation of perceptions and impact

Background

In 2016/2017, a financially linked antibiotic prescribing quality improvement initiative Commissioning for Quality and Innovation (AMR-CQUIN) was introduced across acute hospitals in England. This aimed for >1% reductions in DDDs/1000 admissions of total antibiotics, piperacillin/tazobactam and carbapenems compared with 2013/2014 and improved review of empirical antibiotic prescriptions.

Objectives

To assess perceptions of staff leading antimicrobial stewardship activity regarding the AMR-CQUIN, the investments made by hospitals to achieve it and how these related to achieving reductions in antibiotic use.

Methods

We invited antimicrobial stewardship leads at acute hospitals across England to complete a web-based survey. Antibiotic prescribing data were downloaded from the PHE Antimicrobial Resistance Local Indicators resource.

Results

Responses were received from 116/155 (75%) acute hospitals. Owing to yearly increases in antibiotic use, most trusts needed to make >5% reductions in antibiotic consumption to achieve the AMR-CQUIN goal of 1% reduction. Additional funding was made available at 23/113 (20%) trusts and, in 18 (78%), this was <10% of the AMR-CQUIN value. Nationally, the annual trend for increased antibiotic use reversed in 2016/2017. In 2014/2015, year-on-year changes were +3.7% (IQR -0.8%, +8.4%), +9.4% (+0.2%, +19.5%) and +5.8% (-6.2%, +18.2%) for total antibiotics, piperacillin/tazobactam and carbapenems, respectively, and +0.1% (-5.4%, +4.0%), -4.8% (-16.9%, +3.2%) and -8.0% (-20.2%, +4.0%) in 2016/2017. Hospitals where staff believed they could reduce antibiotic use were more likely to do so (P < 0.001).

Conclusions

Introducing the AMR-CQUIN was associated with a reduction in antibiotic use. For individual hospitals, achieving the AMR-CQUIN was associated with favourable perceptions of staff and not availability of funding.

Optimizing design of research to evaluate antibiotic stewardship interventions: consensus recommendations of a multinational working group

BACKGROUND

Antimicrobial stewardship interventions and programmes aim to ensure effective treatment while minimizing antimicrobial-associated harms including resistance. Practice in this vital area is undermined by the poor quality of research addressing both what specific antimicrobial use interventions are effective and how antimicrobial use improvement strategies can be implemented into practice. In 2016 we established a working party to identify the key design features that limit translation of existing research into practice and then to make recommendations for how future studies in this field should be optimally designed. The first part of this work has been published as a systematic review. Here we present the working group's final recommendations.

METHODS

An international working group for design of antimicrobial stewardship intervention evaluations was convened in response to the fourth call for leading expert network proposals by the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR). The group comprised clinical and academic specialists in antimicrobial stewardship and clinical trial design from six European countries. Group members completed a structured questionnaire to establish the scope of work and key issues to develop ahead of a first face-to-face meeting that (a) identified the need for a comprehensive systematic review of study designs in the literature and (b) prioritized key areas where research design considerations restrict translation of findings into practice. The working group's initial outputs were reviewed by independent advisors and additional expertise was sought in specific clinical areas. At a second face-to-face meeting the working group developed a theoretical framework and specific recommendations to support optimal study design. These were finalized by the working group co-ordinators and agreed by all working group members.

RESULTS

We propose a theoretical framework in which consideration of the intervention rationale the intervention setting, intervention features and the intervention aims inform selection and prioritization of outcome measures, whether the research sets out to determine superiority or non-inferiority of the intervention measured by its primary outcome(s), the most appropriate study design (e.g. experimental or quasi- experimental) and the detailed design features. We make 18 specific recommendation in three domains: outcomes, objectives and study design.

CONCLUSIONS

Researchers, funders and practitioners will be able to draw on our recommendations to most efficiently evaluate antimicrobial stewardship interventions.

Adaptation and implementation of the ARK (Antibiotic Review Kit) intervention to safely and substantially reduce antibiotic use in hospitals: a feasibility study

BACKGROUND

Antimicrobial stewardship initiatives in secondary care depend on clinicians undertaking antibiotic prescription reviews but decisions to limit antibiotic treatment at review are complex.

AIM

To assess the feasibility and acceptability of implementing ARK (Antibiotic Review Kit), a behaviour change intervention made up of four components (brief online tool, prescribing decision aid, regular data collection and feedback process, and patient leaflet) to support stopping antibiotic treatment when it is safe to do so among hospitalized patients; before definitive evaluation through a stepped-wedge cluster-randomized controlled trial.

METHODS

Acceptability of the different intervention elements was assessed for a period of 12 weeks by uptake of the online tool, adoption of the decision aid into prescribing practice, and rates of decisions to stop antibiotics at review (assessed through repeated point-prevalence surveys). Patient perceptions of the information leaflet were assessed through a brief questionnaire.

FINDINGS

All elements of the intervention were successfully introduced into practice. A total of 132 staff encompassing a broad range of prescribers and non-prescribers completed the online tool (19.4 per 100 acute beds), including 97% (32/33) of the pre-specified essential clinical staff. Among 588 prescription charts evaluated in seven point-prevalence surveys over the 12-week implementation period, 82% overall (76-90% at each survey) used the decision aid. The median antibiotic stop rate post implementation was 36% (range: 29-40% at each survey) compared with 9% pre implementation (P < 0.001).

CONCLUSION

ARK provides a feasible and acceptable mechanism to support stopping antibiotics safely at post-prescription reviews in an acute hospital setting.

Management of Spinal Injuries in Polytrauma Patients: An Experience of Tertiary Care Hospital

Spine injuries, a common component in Polytrauma are usually affects the young people and is a major cause of morbidity and poses a significant health care expenditure and considerable threats to survival and quality of life. We retrospectively assess the demographics, incidence, mode of trauma, associated spine injuries, complications, neurological improvement and mortality. Records of total 1695 admitted patients, spinal injuries were 262 patients. Among them 30(11.45%) patients were associated with Polytrauma victims. Eleven patients (36.67%) were admitted through Ortho emergency dept, 14(46.67%) patients through Intensive care unit (ICU), 5(16.66%) patients through other department (CVS, Urology). Most (56%) of the patients were young in the age range of 16 to 40 years. Cervical spines were most commonly (44%) affected followed by lumbar (31%), thoracic (13%), thoraco-lumbar (9%) and Cervico-thoracic (3%) spines. Road traffic accident was the common cause (80%). Twelve patients (40%) had problems at various steps of management and maximum problems occur in step III. Nineteen patients (63.33%) management needs co-ordination between various specialties. Significant number of patients (76.67%) required operative treatment (p<0.05) and 13.33% were managed conservatively. Mortality rate (10%) was insignificant (p>0.05%). Of these patients, 73.33% had shown neurological improvement of at least one ASIA grade. The treatment of spinal injury in polytrauma patient should follow the principle of Advanced Trauma Life Support (ATLS). Once life and limb-threatening injuries have been identified and addressed, suspected spinal cord injury patients should be immobilized as early as possible to reduced the secondary injury, improve motor and sensory function as well as reduced the extend of permanent paralysis.

The quality of studies evaluating antimicrobial stewardship interventions: a systematic review

BACKGROUND

Antimicrobial stewardship aims to optimize antibiotic use and minimize selection of antimicrobial resistance. The methodological quality of published studies in this field is unknown.

AIMS

Our objective was to perform a comprehensive systematic review of antimicrobial stewardship research design and identify features which limit validity and translation of research findings into clinical practice.

SOURCES

The following online database was searched: PubMed.

STUDY ELIGIBILITY CRITERIA

Studies published between January 1950 and January 2017, evaluating any antimicrobial stewardship intervention in the community or hospital setting, without restriction on study design or outcome.

CONTENT

We extracted data on pre-specified design quality features and factors that may influence design choices including (1) clinical setting, (2) age group studied, (3) when the study was conducted, (4) geographical region, and (5) financial support received. The initial search yielded 17 382 articles; 1008 were selected for full-text screening, of which 825 were included. Most studies (675/825, 82%) were non-experimental; 104 (15%) used interrupted time series analysis, 41 (6%) used external controls, and 19 (3%) used both. Studies in the community setting fulfilled a median of five out of 10 quality features (IQR 3-7) and 3 (IQR 2-4) in the hospital setting. Community setting studies (25%, 205/825) were significantly more likely to use randomization (OR 5.9; 95% CI 3.8-9.2), external controls (OR 5.6; 95% CI 3.6-8.5), and multiple centres (OR 10.5; 95% CI 7.1-15.7). From all studies, only 48% (398/825) reported clinical and 23% (190/825) reported microbiological outcomes. Quality did not improve over time.

IMPLICATIONS

Overall quality of antimicrobial stewardship studies is low and has not improved over time. Most studies do not report clinical and microbiological outcome data. Studies conducted in the community setting were associated with better quality. These limitations should inform the design of future stewardship evaluations so that a robust evidence base can be built to guide clinical practice.

Outcomes for cervicomediastinal vascular trauma managed by a vascular subspecialistled vascular trauma service

BACKGROUND

The management of cervicomediastinal vascular trauma is challenging. We report on our experience with the condition in a newly established vascular trauma service unit, and compare the outcomes to those reported in our parent vascular surgery department.

METHOD

The details of patients with cervicomediastinal vascular injuries from January 2012 to June 2014 were retrieved for analysis from a prospective database.

RESULTS

Ninety-three patients were identified, 84 of whom were male (90%), with an average age of 29 years. Most were penetrating injuries (89%), and 87% of these were due to stab wounds. There were 107 vascular injuries, 88 cervical and 19 mediastinal. Of these, 87 were arterial and 20 venous injuries. The most common arterial injury involved the subclavian artery (24%), followed by the common carotid artery (22%). Management was multimodal, and included conservative (8%), stenting and embolisation (8%), referral to a higher centre (8%), vascular repair (64%) and ligation (12%). Nineteen per cent required median sternotomy or thoracotomy. Eight patients died postoperatively (9%). Seven of them presented in extremis and died within 24 hours, and one died after a week from associated abdominal injuries. Postoperative complications were 9%. There was no incidence of a stroke or limb loss despite ligation of the arteries, including ligation of four internal carotids.

CONCLUSION

The development of endovascular techniques would allow for noninvasive management of a significant number of patients. Open surgery is still necessary, and associated with significant morbidity. Comparable results were reported in our newly established vascular trauma service unit to those obtained in our parent vascular surgery department in Durban.

Blood, sweat, and tears: developing clinically relevant protein biosensors for integrated body fluid analysis

Biosensors are being developed to provide rapid, quantitative, diagnostic information to clinicians in order to help guide patient treatment, without the need for centralised laboratory assays. The success of glucose monitoring is a key example of where technology innovation has met a clinical need at multiple levels – from the pathology laboratory all the way to the patient's home. However, few other biosensor devices are currently in routine use. Here we review the challenges and opportunities regarding the integration of biosensor techniques into body fluid sampling approaches, with emphasis on the point-of-care setting.

Comparison between superficial femoral artery stenting and bypass surgery in severe lower-limb ischaemia: a retrospective study

BACKGROUND

Symptomatic femoro-popliteal disease is treated by bypass surgery or angioplasty with or without stenting. The aim of this study was to compare the results of stenting and bypass surgery with regard to limb salvage in patients with severe leg ischaemia.

METHODS

A total of 213 patients with femoro-popliteal disease presenting with severe claudication or critical limb ischaemia between January 2009 and December 2013 were evaluated; 118 patients (139 limbs) had stents placed and 95 patients (104 limbs) had bypass surgery. Most (60%) presented with critical limb ischaemia (rest pain 40%, tissue necrosis 20%), and the remainder with severe claudication. The treatment groups had matching risk factors.

RESULTS

The average age was 66 years and 73% were male. Tissue necrosis was found in 26% of the stent group and 12% of the bypass group (p = 0.009). In the stent group 26% had adjunctive procedures, compared to 16% in the bypass group (p = 0.138). During the one-year follow up, there were 30 stent occlusions (22%) and 18 graft occlusions (17%) (p = 0.42). There were 14 major amputations (10%) in the stent group, and 13 (13%) in the bypass group (p = 0.68). Limb salvage rate was 90% in the stent group, and 88% in the bypass group (p = 0.68). There were no peri-operative deaths in the stent group, but one in the bypass group (1%). One-year mortality rate was equal (8%) in both groups (p = 1.00).

CONCLUSION

One-year outcome was comparable in both groups with regard to mortality, stent or graft patency and limb salvage rates.

Tailoring the Optoelectronic Properties of Nano-Metal Oxides Using Anthocyanins and Lanthanide

Here we report a simple and effective method in tailoring the optoelectronic properties of semi-conducting metal oxide for suitable device application. Sol-gel synthesis was used to synthesize manganese doped TiO2 nanopowder and commercially available TiO2 nanopowder was used as reference material. Thick films of these powder were screen printed on FTO coated glass and annealed at 450 degrees C in ambient air. Separately, 60 μL of neodymium chloride prepared from neodymium oxide, 60 μL of ruthenium based commercial dye (N719) and 60 μL of extracts of calendula orange and dog flower were used as sensitizer to improve the photoconductance properties. Elemental analysis confirmed synthesis of composite material of Mn and TiO2. Morphological observation showed a uniform particles of 25 to 50 nm diameter. Optoelectronic properties were studied by using thick films of these powders as working electrode as a function of wavelength from 430 to 750 nm and the cyclic voltammogram were obtained by scanning potential from -1.5 V to +1.5 V at the illumination intensity of 1000 Wm(-2). Sensitization resulted in additional absorption and functional bands. Oxidation peak current was found decreasing with increasing wavelength. Sensitization with flower extract resulted in increased oxidation current at higher wavelength indicating the improved photoconduction in comparison with N719 and neodymium.

Gram-negative bacteraemia; a multi-centre prospective evaluation of empiric antibiotic therapy and outcome in English acute hospitals

Increasing antibiotic resistance makes choosing antibiotics for suspected Gram-negative infection challenging. This study set out to identify key determinants of mortality among patients with Gram-negative bacteraemia, focusing particularly on the importance of appropriate empiric antibiotic treatment. We conducted a prospective observational study of 679 unselected adults with Gram-negative bacteraemia at ten acute english hospitals between October 2013 and March 2014. Appropriate empiric antibiotic treatment was defined as intravenous treatment on the day of blood culture collection with an antibiotic to which the cultured organism was sensitive in vitro. Mortality analyses were adjusted for patient demographics, co-morbidities and illness severity. The majority of bacteraemias were community-onset (70%); most were caused by Escherichia coli (65%), Klebsiella spp. (15%) or Pseudomonas spp. (7%). Main foci of infection were urinary tract (51%), abdomen/biliary tract (20%) and lower respiratory tract (14%). The main antibiotics used were co-amoxiclav (32%) and piperacillin-tazobactam (30%) with 34% receiving combination therapy (predominantly aminoglycosides). Empiric treatment was inappropriate in 34%. All-cause mortality was 8% at 7 days and 15% at 30 days. Independent predictors of mortality (p <0.05) included older age, greater burden of co-morbid disease, severity of illness at presentation and inflammatory response. Inappropriate empiric antibiotic therapy was not associated with mortality at either time-point (adjusted OR 0.82; 95% CI 0.35-1.94 and adjusted OR 0.92; 95% CI 0.50-1.66, respectively). Although our study does not exclude an impact of empiric antibiotic choice on survival in Gram-negative bacteraemia, outcome is determined primarily by patient and disease factors.

The role of the humoral immune response to Clostridium difficile toxins A and B in susceptibility to C. difficile infection: a case-control study

Antibody levels to Clostridium difficile toxin A (TcdA), but not toxin B (TcdB), have been found to determine risk of C. difficile infection (CDI). Historically, TcdA was thought to be the key virulence factor; however the importance of TcdB in disease is now established. We re-evaluated the role of antibodies to TcdA and TcdB in determining patient susceptibility to CDI in two separate patient cohorts. In contrast to earlier studies, we find that CDI patients have lower pre-existing IgA titres to TcdB, but not TcdA, when compared to control patients. Our findings suggest that mucosal immunity to TcdB may be important in the early stages of infection and identifies a possible target for preventing CDI progression.

Lessons from emergency laparotomy for abdominal tuberculosis in the HIV/AIDS era

BACKGROUND

The rising incidence of HIV/AIDS has resulted in a resurgence of abdominal tuberculosis (TB) in HIV-positive patients in South Africa. These often debilitated patients frequently present with acute complications requiring surgery.

METHODS

A prospective audit of all patients with abdominal TB undergoing emergency laparotomy was conducted. From January 2008 to June 2010, 49 patients had emergency laparotomy and specimens obtained from them were diagnostic of TB. Twenty-five were males and 24 females, with a median age of 32 years (range 2 - 62). Thirty-nine patients were HIV-positive (79.6%).

RESULTS

Intra-operative findings were bowel perforations in 13 cases, small-bowel obstruction in seven, a frozen abdomen in ten, and enlarged lymph nodes and an ileocaecal mass in 19. Eleven patients (22.4%) underwent small-bowel resection and eight (16.3%) right hemicolectomy. Eighteen patients (36.7%) ended up with stomas, 14 (28.6%) had re-laparotomies, and 18 (36.7%) were admitted to the intensive care unit. Twenty-three patients (46.9%) required blood transfusion and 15 (30.6%) total parenteral nutrition. Three patients (6.1%) developed an enterocutaneous fistula and 19 (38.8%) died. Pre-operative illness severity indices of acidosis, anaemia and hypo-albuminaemia were significant predictors of death, but mode of presentation and surgical interventions were not.

CONCLUSION

Laparotomy as currently practised for the 'acute abdomen' in patients with suspected HIV and abdominal TB is associated with very high morbidity and mortality, which is related to pre-operative severity indices. More liberal use of imaging may define cases in which a more conservative approach could improve outcome.

Influence of cohorting patients with Clostridium difficile infection on risk of symptomatic recurrence

BACKGROUND

Cohorting of patients with Clostridium difficile infection (CDI) is recommended when single side-rooms are unavailable. Although patients may remain infectious after cessation of diarrhoea, continued cohorting may place them at increased risk of reinfection.

AIM

To identify risk factors for CDI recurrence and to determine whether cohorting of patients is associated with increased risk of recurrence.

METHODS

Data describing patient demographics, comorbidity, CDI severity and treatment were collected for 248 CDI patients at our hospital between October 2008 and June 2011. The primary outcome was symptomatic recurrence within 30 days of diagnosis.

FINDINGS

One hundred and thirty-eight (55.6%) CDI patients were admitted to the cohort ward. These patients were more likely to have severe CDI (odds ratio: 1.95; 95% confidence interval: 1.10-3.46; P = 0.022) and receive vancomycin (1.59; 0.94-2.68; P = 0.083) than patients who were not cohorted. Twenty-six patients (10.5%) suffered recurrence (21 cohorted and five not cohorted). Urinary infection on admission (5.16; 2.10-12.64; P < 0.001), cohorting (3.77; 1.37-10.35; P = 0.01) and concomitant antibiotics (2.07; 0.91-4.72; P = 0.083) were associated with increased risk of recurrence. On multivariate analysis, cohorting (3.94; 1.23-12.65; P = 0.021) and urinary infection (4.27; 1.62-11.24; P = 0.003) were significant predictors of recurrence.

CONCLUSION

Patients admitted to a C. difficile cohort ward may be at increased risk of recurrence because they are at increased risk of reinfection. Hospitals using cohort wards to control C. difficile should manage patient flow through the cohort to minimize this risk.

How far has the pendulum swung in the surgical management of sigmoid volvulus? Experience from the KwaZulu-Natal Teaching Hospitals and review of the literature

AIM

Sigmoid volvulus is common in sub-Saharan Africa. The aim of the study was to document the clinicopathological patterns of sigmoid volvulus in KwaZulu-Natal.

METHOD

Analysis was performed of prospectively collected data of patients presenting with sigmoid volvulus at the KwaZulu-Natal Teaching Hospitals from 2000 to 2009. Data collected included demographics, clinical presentation, operative findings, management and outcome.

RESULTS

There were 135 patients (122 male) of mean age 39.3 ± 17 years. Management was by emergency surgery (103), elective surgery (23), no surgery (9). The level of the twist was at the pelvic brim. Fifty-four patients had gangrenous bowel and 81 had viable bowel. Resection was accompanied by primary anastomosis (80) and Hartmann's procedure (46). Complication and mortality rates were 47% and 17% respectively. Mortality rates for emergency and elective surgery were 19% and 9% (P = 0.330), and those for primary anastomosis and Hartmann's procedure were 14% and 24% respectively (P = 0.305). Mortality rates for gangrenous and viable bowel were 21% and 15% respectively (P = 0.624). Twenty-eight (22%) patients required intensive care in the intensive care unit (ICU) with an ICU stay of 8.8 ± 8 days. Hospital stay was 10.5 ± 14.4 days.

CONCLUSION

The clinicopathological picture of sigmoid volvulus resembles that in the rest of Africa in that it affects predominantly young African males. The level of the twist is at the pelvic brim. The timing of surgery, the type of anastomosis and the viability of the bowel does not influence outcome.

Physician attitudes toward palliative care at a community teaching hospital

The goals of the study were to explore physicians' attitudes and opinions about palliative care and its implementation. Four focus groups composed of attending physicians were conducted by a professional facilitator at a community teaching hospital. The audio-tapes of the groups were carefully transcribed and analyzed according to rigorous qualitative methodology. Physicians perceived palliative care and pain control as important. Problems they perceived were a lack of education for physicians, residents, other health care professionals, and the general public; a lack of hospital support systems to implement palliative care appropriately, and a lack of knowledge and support regarding legal considerations. They believed that a palliative care unit was a reasonable tool to overcome many obstacles to good end-of-life care.

Landholding, wealth and risk of blinding malnutrition in rural Bangladeshi households

The 1982-1983 Bangladesh nutritional blindness study visited 11,618 rural households and examined 18,660 preschool-age children in an effort to determine the prevalence and determinants of eye lesions and loss of sight due to vitamin A deficiency (xerophthalmia). Risk of xerophthalmia was significantly higher for children from households without any of the indicators of relative wealth used. Almost 80% of blind children from landless households, and even a very small garden reduced considerably the chances of a household having a xerophthalmic child. Poorer households with access to less than 0.3 acres land or no garden or without a tin roof, wristwatch, radio or cycle were at least twice as likely as their more fortunate neighbours to have a young child with any type of xerophthalmia. Taking account of such socio-environmental risk factor weightings would direct the scarce resources of intervention programmes to households and children who most need them.

Serum triglyceride level in type 2 diabetes mellitus patients with or without Frozen shoulder

Background: Musculoskeletal disorders are very common among the diabetic patients and frozen shoulder is one of the disabling conditions. The present study was conducted to compare the serum triglyceride level among the patients of type 2 diabetic presented with and without frozen shoulder.Methodology: This case control study was conducted from January 2008 to December 2009, in the department of Physical Medicine and Rehabilitation, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka with an aim to compare the serum triglyceride level among diabetic patients presented with, and without frozen shoulder. Thirty types 2 diabetic patients with frozen shoulder were selected as cases and similar number well matched type 2 diabetic patients without frozen shoulder were selected as control.Results: We prospectively studied 30 diabetes mellitus (type 2) patients with the diagnosis of frozen shoulder. The blood sugar both fasting and 2 hours after breakfast, HbA1c and serum triglyceride levels were measured in all patients and compared with those in 30 diabetic patients without frozen shoulder. The blood sugar, fasting and 2 hours after breakfast, HbA1C and serum triglyceride levels were significantly elevated in the frozen-shoulder group (fasting blood sugar p = 0.012; blood sugar 2 hours after breakfast p<0.01; HbA1C p<0.05; and triglyceride p < 0.001).Conclusion: Diabetic type 2 patients presented with frozen shoulder had higher serum triglyceride level compare to the diabetic type 2 patients without frozen shoulder. DOI: 10.3329/bmrcb.v36i2.6990Bangladesh Med Res Counc Bull 2010; 36: 64-67