P17 National antimicrobial point prevalence survey in adult inpatient mental health facilities in Ireland

Background

Antimicrobial use in mental health inpatient settings has not been extensively examined in Ireland. The Healthcare-Associated Infection and Antimicrobial Use in Long-Term Care Facilities (HALT) study 2016 found that Irish long-term care facilities caring for residents with psychiatric conditions had an antimicrobial prevalence rate of 7.7%, higher than the European average of 4.9%. National community antimicrobial prescribing guidelines are available at www.antibioticprescribing.ie. In addition, a preferred antibiotic initiative for community settings advocates prescribers to choose ‘Green’ (preferred) antibiotics over ‘Red’ (reserved) agents. Reserved agents are considered to have more adverse effects, drug interactions and potential for development of antimicrobial resistance. The patient safety implications of antimicrobial stewardship along with an ageing population, and potential drug–drug interactions between many antimicrobials and psychotropic medications prompted a review of antimicrobial use practices in mental health services.

Methods

A sample of adult inpatient mental health facilities (MHF) operated by the state's Health Service Executive (HSE) were surveyed by community antimicrobial pharmacists (AMPs) between November 2021 and January 2022. AMPs reviewed patients’ medication charts for systemic antimicrobial prescriptions in the previous 30 days in addition to medical notes and laboratory results (where available). Adherence to HSE National community antimicrobial guidelines and the systems and structures in place to support antimicrobial stewardship were assessed.

Results

In total, 1003 patients in 51 MHFs were surveyed. At the time of survey, 6.3% (n=66) patients were on a systemic antimicrobial and 15% (n=153) had received a systemic antimicrobial within the previous 30 days. Prophylaxis accounted for 50% of antibiotic use (3.3% of all patients), with the most common indication being the prevention of urinary tract infection (UTI) (58%). Prophylaxis duration exceeded six months in 61% of prescriptions. The median duration of treatment courses was seven days. The proportion of ‘Green’ (preferred) antimicrobials versus ‘Red’ (reserved) antimicrobials was 58% versus 38%. Co-amoxiclav, a ‘Red’ agent was the most commonly prescribed antibiotic for treatment of infection (31%). Adherence with choice of antimicrobial agent as per national antimicrobial guidelines was 76%; adherence of dosing regimen was 75% and adherence with recommended duration was 46%. The main themes for non-adherence with choice of agent were use of unnecessarily broad spectrum agents, nitrofurantoin prescribed in renal impairment and inappropriate formulation of nitrofurantoin chosen. Dipstick urinalysis was performed routinely (on admission and/or at designated intervals) for persons asymptomatic of UTI in 53% (n=27) of MHFs.

Conclusions

This PPS established antimicrobial use practices in HSE MHFs and identified opportunities for improvement relating to the safe and optimal use of antimicrobials. Key national recommendations from this survey were:

O02 Improving antimicrobial use in HSE older persons residential care facilities

Background

Antimicrobial use in Irish older persons residential care facilities (OP RCFs) is higher than in other European countries. In 2020/21, for the first time, an antimicrobial pharmacist (AMP) was appointed to each community healthcare organization (CHO) to monitor, develop and promote antimicrobial stewardship in community settings.

Objectives

To establish baseline antibiotic use, develop antimicrobial stewardship tools for OP RCFs, promote best practice in relation to antimicrobial stewardship (AMS) and monitor trends in antimicrobial use in HSE (state-run) OP RCFs.

Methods

A baseline point prevalence survey (PPS) of antimicrobial use was conducted across all HSE OP RCFs between October 2020 and August 2021. Following the survey, key national recommendations and AMS resources were developed in collaboration with the national Antimicrobial Resistance and Infection Control Programme. Feedback was provided to participating facilities by CHO AMPs with antimicrobial stewardship support and education for nursing and medical staff. In September 2021, monthly monitoring of antibiotic use was established in HSE OP RCFs in collaboration with local managers, to capture the proportion of antibiotics used for prophylaxis or treatment each month.

Results

A baseline PPS of antimicrobial use in 2020/21 showed that 11.9% (528/4446) of residents were on a systemic antibiotic, with 6.3% on antibiotic prophylaxis. Urinary tract infection accounted for 51% of antibiotic prescriptions. Following the baseline PPS, CHO AMPs developed an AMS toolkit for OP RCFs, engaged with nursing and medical staff to communicate PPS results, AMS resources and support implementation of AMS recommendations. Subsequently, monthly self-reporting of antimicrobial use in HSE OP RCFs was commenced in September 2021 and showed a sustained decrease in antimicrobial use with 7.9% residents on an antibiotic in Quarter 2 2022, with 2.7% on antibiotic prophylaxis.

Conclusions

Newly appointed CHO AMPs have successfully promoted AMS across HSE OP RCFs. Following audit, feedback, education, development and promotion of antimicrobial stewardship resources, there was a sustained decrease in the proportion of residents on antibiotics used for treatment and prophylaxis of infection.

88 NATIONAL ANTIMICROBIAL POINT PREVALENCE SURVEY IN HSE OLDER PERSONS RESIDENTIAL CARE FACILITIES (OPS-RCFS)

Background

The HALT study in 2016 found that residents in Irish OPS RCFs were twice as likely to be on systemic antimicrobial compared with European average (10% v 5%). National antibiotic prescribing guidelines are available at www.antibioticprescribing.ie and prescribers are encouraged to choose ‘green’ (preferred) over ‘red’ (reserved) agents. HSE Community Antimicrobial Pharmacists (AMPs) have been employed since 2020. We aimed to establish the quality and quantity of antimicrobial prescribing in OPS-RCFs to inform antimicrobial stewardship activities.

Methods

All residents in HSE OPS-RCFs were surveyed between October 2020 and August 2021. AMPs reviewed all medication charts for systemic antimicrobials prescribed within previous 30 days. Medical notes +/- laboratory results were reviewed for persons on antimicrobials. Adherence to guidelines was assessed and information obtained on practices related to antimicrobial use.

Results

The survey included 4,448 individuals in 121 OPS RCFs. 12% were on systemic antimicrobial at time of survey. 27% received an antimicrobial in the previous 30 days. 50% of antibiotic use on survey day was for prophylaxis (6.3% of all residents). Prophylaxis exceeded 6 months in 66% persons, and 12 months in 57%. There was high usage of green versus red agents (65% vs 30%). Co-amoxiclav (red) was most commonly prescribed antimicrobial to treat infection (19%). 42% of sites reported routine use of dipstick urinalysis to support diagnosis of UTI in asymptomatic residents. 36% of sites did not have onsite electronic laboratory access. 61% of facilities did not record residents’ pneumococcal vaccination status.

Conclusion

Key national recommendations: Review all UTI prophylaxis within 6 months of initiation with view to de-prescribing.Cease routine use of dipstick urinalysis to support diagnosis of UTI for asymptomatic persons.Electronic access to laboratory results on-site required to support timely decision-making.All staff should be aware of the national antimicrobial guidelines.Pneumococcal vaccine status should be determined, and provided as necessary.

The effect of lockdown during SARS-CoV-2 pandemic on maxillofacial injuries in a level I trauma centre: a comparative study

INTRODUCTION

The SARS-CoV-2 pandemic forced many governments to impose nation-wide lockdowns. Government legislation forced limited travel on the population with restrictions on the normal way of life to limit spread of the SARS-CoV-2 virus. The aim of this study is to explore the effects of lockdown on the presentation of maxillofacial trauma in a level I trauma centre.

METHODS

Comparative analysis was carried out using prospective and retrospective review of all consecutive patients admitted with any maxillofacial fracture in the lockdown period between 15th March and 15th June 2020 with the same period in 2019 to a Regional Trauma Maxillofacial Surgery Unit. Data included basic demographics and mechanism of injury including alcohol/drug influence, polytrauma, site of injury and treatment modality including escalation of care.

RESULTS

Across both periods, there were a total of one hundred and five (n = 105) recorded episodes of traumatic fractures with fifty-three (n = 53) in the pre-lockdown cohort and fifty-two (n = 52) in the lockdown. Included patients were significantly (p = 0.024) older during lockdown (mean age 41.44 years SD 20.70, range 5-96) with no differences in gender distribution between cohorts (p = 0.270). Patients in lockdown were more likely to be involved in polytrauma (p < 0.05) and have sustained their injury by cycling/running or any outdoor related activity (p = 0.013). Lockdown saw a significant reduction in alcohol and drug related violence (p < 0.05). Significantly more patients required operative management (p = 0.038).

CONCLUSION

Local lockdowns form part of the governments public health strategy for managing future outbreaks of SARS-CoV-2. Our study showed no significant reduction in volume of trauma during lockdown. It is vital that hospitals maintain trauma capacity to ensure that patients are treated in a timely manner.

Tracking the Salmonella status of pigs and pork from lairage through the slaughter process in the Republic of Ireland

Salmonella Typhimurium is the predominant serotype isolated from humans in Europe. Pork and pork products are recognized vehicles of Salmonella and are responsible for outbreaks of human salmonellosis. Pigs can become infected with Salmonella on the breeding or fattening farm and during transport, lairage, and slaughter. The aim of this study was to investigate selected points of Salmonella contamination from the time pigs entered the lairage to the time the carcass was processed in the boning hall and to determine the importance of different sources of Salmonella along the Irish pork production chain. A second objective was to evaluate whether the serological status or category of a herd influenced the levels of bacteriological contamination detected on individual carcasses and pork cuts during slaughter and dressing operations. All samples were tested for the presence and numbers of Salmonella. Enterobacteriaceae numbers were also determined. Serotype, phage type, and pulsed-field gel electrophoresis were utilized to determine similarity among Salmonella isolates. Lairage was a major source of cross-contamination with Salmonella as were the hands of evisceration operatives, conveyor belts, and equipment in the boning hall. Cross-contamination within the slaughter plant environment accounted for up to 69 % of Salmonella carcass contamination. In general, herd category reflected the bacteriological status of carcasses and pork cuts. Major findings were a strong association (P < 0.01) between Enterobacteriaceae counts and Salmonella occurrence on prechill carcasses and a significant association (P < 0.05) between Enterobacteriaceae counts and Salmonella occurrence on pork cut samples.

Immigrant patients with type 2 diabetes mellitus have poorer initial and on-going glycemic control than a matched population of Irish patients

We compared the glycemic and cardiovascular risk status of non-Caucasian patients with type 2 diabetes mellitus (T2DM) who recently emigrated to Ireland with a matched population of Irish patients. We identified 105 non-Caucasian patients with T2DM who recently emigrated to Ireland and compared them with 105 Irish patients with T2DM, who were matched for age, sex and duration of diabetes. Immigrants with T2DM had significantly worse initial (9.8% vs 9.1%, p<0.05) and on-going (8.3% vs 7.1, p<0.05) glycemic control and higher microalbumin to creatinine ratio compared to the Irish patients. A greater proportion of immigrants with T2DM were on insulin therapy for their diabetes. Irish patients had significantly higher fasting triglyceride concentrations compared to the immigrants (1.9+/-0.1 mmol/l vs 1.6+/-0.1 mmol/l, p<0.05). This vulnerable population of immigrants with T2DM is currently at higher risk of complications of diabetes and warrants greater attention to glycemic control and control of other risk factors.

Efficacy of cleaning and disinfection on pig farms in Ireland

Little is known about the effectiveness of the cleaning and disinfection methods used on commercial pig farms either in Ireland or worldwide. A National Salmonella Control Programme was implemented in Ireland in August 2002 to monitor and control the infection of pigs with Salmonella species. Commercial pig herds must be categorised according to their Salmonella status as either category 1, 2 or 3, having a serological prevalence of infection with Salmonella serotypes up to 10 per cent, between 10 and 50 per cent or more than 50 per cent, respectively. The aim of this study was to assess the efficacy of washing and disinfecting finisher units on category 1 and category 3 farms in reducing or eliminating the levels of contamination. Counts of Enterobacteriaceae were used as indicators of the contamination of the environment with enteric bacteria, which could include Salmonella species. Samples were taken from the pen floors, feeders and drinkers of seven category 1 and seven category 3 farms, and Enterobacteriaceae and salmonellae were enumerated in each sample. The results suggested that intensive cleaning and disinfection was effective at reducing levels of Enterobacteriaceae on the pen floors of both categories, but that residual contamination remained on the surfaces of the feeders and drinkers on all the farms, particularly on the category 3 farms.

Allelic losses at 3p and 11p are detected in both epithelial and stromal components of cervical small-cell neuroendocrine carcinoma

Microdissected epithelial and stromal cells from 15 cervical small-cell carcinoma patients and 9 healthy control subjects were assessed for loss of heterozygosity with polymorphic DNA markers at chromosomes 3p and 11p. Among malignant lesions assessed with 7 markers at 3p, 21 allelic losses were detected from 193 informative samples. Of losses, 20 were in epithelial and 1 was in normal-appearing stromal cells. Among losses in epithelial cells, 16 were from 44 samples informative for 3 markers within 3p21.2-p14.2 (0.36 loss/sample), whereas only 4 were from 54 samples informative for 4 markers outside the region (0.09 loss/sample), suggesting a "hot spot" of genetic alterations within 3p21.2-p14.2. Among malignant lesions assessed with 2 markers within 11p14-p12, 15 losses were seen in 52 informative samples. Of losses, 10 were in epithelial and 5 were in normal-appearing stromal cells. Of 10 epithelial samples showing losses within 11p14-p12, 8 also displayed losses within 3p21.2-p14.2, suggesting a concurrent involvement of these loci in tumor development or progression. The five losses in stromal cells were in four cases that showed no loss in epithelial cells with same markers, suggesting that stromal cells might play initiative roles in tumor development.

Mammary "comedo"-DCIS: apoptosis, oncosis, and necrosis: an electron microscopic examination of 8 cases

The terms apoptosis and necrosis are commonly used to imply two distinct types of cell death. Apoptosis reflects a genetically mediated. ATP-dependent form of cell death. A passive form of cell death (oncosis) also occurs, often in response to some form of injury. Both pathways can lead to necrosis (postmortem autolytic cell changes). The nature of intraluminal necrosis in mammary ductal carcinoma in situ (DCIS) was evaluated using ultrastructural analysis on paraffin-embedded material of 8 cases with "comedo"-DCIS. In each case, intraepithelial proliferation zones and intraluminal zones (peripheral and central luminal zones) were examined. All cases with "comedo"-DCIS revealed abundant apoptosis, characterized by apoptotic cells showing chromatin condensation and margination with sharply circumscribed, uniformly dense crescents, as well as cytoplasmic condensation. Numerous membrane-bound apoptotic bodies with condensed cytoplasm (with or without nuclear fragments) were also observed. The central luminal zones of "comedo"-DCIS, however, revealed necrotic debris characterized by severe degradative changes, largely devoid of recognizable cell structures. In addition, two cases displayed features of oncosis, characterized by nuclear and cytoplasmic swelling, vacuolization of cytoplasm, and mitochondrial swelling with occasional dense bodies. The results indicate that necrosis (postmortem, secondary degradative cell changes) in "comedo"-DCIS is the end result of either apoptosis (programmed cell death) alone or a combination of apoptosis and oncosis (passive or "accidental" cell death).

Sex cord-stromal and steroid cell tumors of the ovary

Gonadal cell types that derive from the coelomic epithelium (sex cords) or mesenchymal cells of the embryonic gonads include granulosa cells, theca cells, fibroblasts, Leydig cells, and Sertoli cells. Ovarian tumors of these cell types are called sex cord-stromal tumors. This group of tumors represents approximately 8% of ovarian neoplasms and affects all age groups. The more common types are granulosa cell tumors (GCTs), fibrothecomas, and Sertoli-Leydig cell tumors. Sex cord-stromal tumors are of interest partly because of their hormonal effects, which are rare for other ovarian neoplasms. These effects include estrogenic effects (pseudoprecocious puberty, endometrial bleeding, endometrial hyperplasia and carcinoma) and virilization. The variety of gross appearances of these tumors, ranging from large multicystic masses to small solid masses, would appear to preclude a specific radiologic diagnosis. However, in many patients, both clinical and radiologic clues can suggest the diagnosis, including predominantly fibrous content at ultrasound or magnetic resonance imaging (fibrothecoma), large hemorrhagic multicystic mass in a child with pseudoprecocious puberty (juvenile GCT), and associated syndromes such as Peutz-Jeghers syndrome (sex cord tumor with annular tubules) or Ollier disease and Maffucci syndrome (juvenile GCT).

Endocrine tumors of the cervix: morphologic assessment, expression of human papillomavirus, and evaluation for loss of heterozygosity on 1p,3p, 11q, and 17p

BACKGROUND

Cervical endocrine tumors are rare lesions, with a varied diagnostic nomenclature. A recent consensus meeting proposed a standardized terminology. This study evaluated: 1) applicability of histopathologic guidelines; 2) evidence of loss of heterozygosity (LOH) at selected sites; and 3) the presence of human papillomavirus (HPV) detected by nonisotopic in situ hybridization (ISH).

METHODS

Thirty-eight cases (patient age range, 19-88 years; mean, 48 years) were retrieved. Outcome data were available for 32 patients. Classification was based on architectural and cytologic features. Tissue was available from 15 cases for LOH analysis with D3S1234(3p14), D3S1289(3p21), THRB(3p24), TP53(17p13), D1S468(1p36), and INT-2(11q13). In ten cases, tissue was analyzed by nonisotopic ISH with HPV probes for types 6/11, 16/18, and 31/33.

RESULTS

Tumors were divided into four groups: small cell carcinoma (SCC) (n=25); large cell neuroendocrine carcinoma (LCNC) (n=5); SCC with focal LCNC differentiation (n=3), and carcinoid tumor (n=5). Tumors defined as exclusively or predominantly SCC had a particularly poor prognosis, with 20 patients dead of disease (<6 years after diagnosis) and 6 alive with disease (after <3 years of follow-up). LOH at various 3p loci (3p14, 3p21, and 3p24) was observed in eight cases. One patient demonstrated LOH on 17p(TP53). Eight of ten cases assessed by ISH showed nuclear staining using a combined HPV-16/18 probe.

CONCLUSIONS

Cervical endocrine tumors are highly aggressive and can be subdivided into definable categories. LOH at 3p loci is a frequent finding, as is nuclear staining with a combined HPV-16/18 probe. LOH at 17p(TP53 locus) appears to be relatively uncommon, suggesting that p53 mutations may not be developmentally significant.

American Society of Clinical Pathologists--Resident Physician Section. Results of autopsy survey (Winter 1994-1995)

The recent debate on autopsy and the role of this unique doctor-patient relationship in the modern medical profession prompted the Resident Physician Section of the American Society of Clinical Pathologists to conduct a survey on postmortem practice as it relates to pathology residents. A total of 102 of 176 (58%) Resident Physician Section (RPS) liaisons from pathology residency programs in the United States, Canada, and Puerto Rico responded to a survey that consisted of 30 questions. The findings of the survey confirm the decrease in autopsy numbers, highlighting the problem of providing sufficient autopsy training to pathology residents. Interestingly, the majority of programs showed a striking similarity with regard to basic autopsy protocol procedures. Liaisons identified incorporation of clinical pathology, basic science, and clinicopathologic interaction as areas of weakness. In the final analysis, the majority of liaisons had a favorable opinion of their autopsy experience.

Intestinal pseudo-obstruction and ischemia secondary to both beta 2-microglobulin and serum A amyloid deposition

We present the case of a 61-year-old man on long-term hemodialysis in whom early colonic ischemia and pseudo- obstruction were caused by amyloid deposition of both the beta 2-microglobulin and AA type. The light microscopic diagnosis of amyloidosis was confirmed by Congo red birefringence, immunohistochemistry, and electron microscopy. The two types of amyloid had separate distributions within the colon. While both types affected submucosal and serosal blood vessels, the beta 2- microglobulin amyloid also formed large masses that displaced smooth muscle cells and was associated with Class II major histocompatibility-positive multinucleated giant cells. The pathogenesis of this uncommon occurrence of two amyloids and the role of chronic inflammation in amyloidogenesis are discussed.

Audit of open cholecystectomy in a district general hospital

This retrospective study audited all non-malignant biliary surgery carried out in a district general hospital between January 1985 and December 1990. Surgery was performed on 722 patients: 555 (77 per cent) were women and 167 (23 per cent) were men. The mean(s.d.) age of the patients was 49(16) years. Elective admissions accounted for 70 per cent of cases and 30 per cent were emergency admissions. Ultrasonography confirmed the diagnosis in 93 per cent of cases. An elective operation was performed in 542 patients and 180 patients underwent an urgent or emergency operation. Simple cholecystectomy was performed on 616 patients (85 per cent); 92 (13 per cent) also underwent common bile duct exploration and 14 (2 per cent) had an additional unrelated procedure. The mean(s.d.) hospital stay was 12.3(6.3) (range 4-34) days. There was one perioperative death. The general overall morbidity rate was 25 per cent and the procedure-related morbidity rate was 7 per cent. For simple cholecystectomy (n = 630) there were no deaths; the general morbidity rate was 15 per cent and the procedure-related rate was 3 per cent.

Pheromone-induced aggregation of ixodid ticks before host contact

The presence of a pre-feeding aggregation pheromone was demonstrated in the species Dermacentor variabilis, Dermacentor andersoni, Dermacentor parumapertus, Amblyomma americanum and Haemaphysalis leporispalustris by assay within a petri dish. However, Amblyomma maculatum and Amblyomma cajennense did not aggregate in the sector containing discs of presumed pheromone within the hour period. D. andersoni and A. americanum recognized each other's pheromone and A. americanum recognized that of H. leporispalustris. Preliminary experiments with guanine and hemin as possible aggregating factors have thus far given inconsistent results.