The management and outcomes of Staphylococcus aureus bacteraemia at a South African referral hospital: A prospective observational study

OBJECTIVES

Data on the management and outcomes of Staphylococcus aureus bacteraemia (SAB) in resource-limited settings are limited. The aim of this study was to describe a cohort of South African patients with SAB, and explore the factors associated with complicated infection and death.

METHODS

This was a prospective observational study of patients over the age of 13 years admitted to a South African referral hospital with SAB.

RESULTS

One hundred SAB infection episodes occurring in 98 patients were included. SAB was healthcare-associated in 68.4%; 24.0% of all cases were caused by methicillin-resistant S. aureus (MRSA). Ninety-day mortality was 47.0%, with 83.3% of deaths attributable to SAB. There was a trend towards increased 90-day mortality with MRSA infection (odds ratio (OR) 1.28, 95% confidence interval (CI) 1.0-15.1) and the presence of comorbidities (OR 4.1, 95% CI 1.0-21.6). The risk of complicated infection was higher with non-optimal definitive antibiotic therapy (OR 8.5, 95% CI 1.8-52.4), female sex (OR 3.8, 95% CI 1.1-16.3), and community-acquired infection (OR 7.4, 95% CI 2.0-33.1). Definitive antibiotic therapy was non-optimal in 22.6% of all cases.

CONCLUSIONS

SAB-related mortality was high. A large proportion of cases may be preventable, and there is a need for improved antibiotic management.

Engaging medical students in leadership and quality improvement through a formal educational programme

This article was migrated. The article was not marked as recommended. Background: Undergraduate medical training in medical leadership is limited, and there is a general negative perception among medical professionals towards leadership and management. Aims: To improve perceptions of leadership training and encourage leadership activity amongst medical students. Method: A leadership student-selected component (SSC) was designed offering formal leadership education and engagement of students onto leadership and quality improvement projects. The initial cohort consisted of 8 third year medical students. Students were given questionnaires exploring their attitudes and perceptions towards leadership before and after the SSC. Results: The students had no previous formal undergraduate education in leadership. Engagement in the SSC considerably enhanced the perception of leadership and management among students. The students also reported having more confidence in engaging with leadership projects and reported feeling more likely to be involved with leadership projects in future. Conclusions: A formal leadership educational programme which engages students in real leadership and quality improvement work enhances the perception of leadership and inspires students to undertake leadership roles in future.

Speeding up laboratory test reporting in Medical Emergency and Cardiac Arrest calls: a quality improvement project

Many hospitals deploy Medical Emergency (MET) and Cardiac Arrest teams to improve the management and treatment of patients who become critically ill. In many cases, blood results are key in allowing the clinicians involved in these teams to make definitive management decisions for these patients. Following anecdotal reports that these results were often delayed, we assessed the process of blood tests being reported in emergency calls, identified the key factors causing delays and sought to make improvements.

The initial intervention involved implementing a new blood form that specified the nature of the call, the tests required and a contact number for laboratory staff to contact the clinical team with results. We also developed a streamlined process within the laboratory for these samples to be fast-tracked. Successive improvement cycles sought to increase awareness of the project, improve accessibility to the new forms and embed spontaneous practices that contributed to improvement.

Results demonstrated an overall reduction in the time taken for blood samples in emergencies to be reported from 130 minutes to 97 minutes.

This project demonstrates that using a specific blood request form for emergency calls, and tying this to a specified laboratory process, improves the time taken for these tests to be reported. In addition, the project provides some insight into challenges faced when implementing change in new departments.

Mucosal T-cell responses to chronic viral infections: Implications for vaccine design

Mucosal surfaces that line the respiratory, gastrointestinal and genitourinary tracts are the major interfaces between the immune system and the environment. Their unique immunological landscape is characterized by the necessity of balancing tolerance to commensal microorganisms and other innocuous exposures against protection from pathogenic threats such as viruses. Numerous pathogenic viruses, including herpesviruses and retroviruses, exploit this environment to establish chronic infection. Effector and regulatory T-cell populations, including effector and resident memory T cells, play instrumental roles in mediating the transition from acute to chronic infection, where a degree of viral replication is tolerated to minimize immunopathology. Persistent antigen exposure during chronic viral infection leads to the evolution and divergence of these responses. In this review, we discuss advances in the understanding of mucosal T-cell immunity during chronic viral infections and how features of T-cell responses develop in different chronic viral infections of the mucosa. We consider how insights into T-cell immunity at mucosal surfaces could inform vaccine strategies: not only to protect hosts from chronic viral infections but also to exploit viruses that can persist within mucosal surfaces as vaccine vectors.

Psychosocial Health Among Young Adults With Kidney Failure: A Longitudinal Follow-up of the SPEAK (Surveying Patients Experiencing Young Adult Kidney Failure) Study

Rationale & Objective

There have been no longitudinal studies examining the evolution of psychosocial health of young adults with kidney failure as they age. We aimed to address this in the Surveying Patients Experiencing Young Adult Kidney Failure-2 (SPEAK-2) study.

Study Design

5-year follow-up longitudinal survey of the original SPEAK cohort.

Setting & Participants

16- to 30-year-olds in the UK receiving kidney replacement therapy (KRT) between 2015 and 2017 who participated in the SPEAK study.

Exposure

Kidney failure and KRT modality.

Outcomes

Psychosocial health and lifestyle behaviors.

Analytical Approach

Within-cohort changes in psychosocial health were analyzed using the paired t test, Wilcoxon signed-rank test and McNemar's test. We compared responses to the age-matched population and examined the impact of changes in KRT modality on psychological health using linear regression for continuous outcome variables as well as logistic, ordered logistic and multinomial logistic regression for binary, ordered categorical and unordered categorical variables, respectively.

Results

We obtained 158 survey responses; 129 had previously responded to SPEAK. Of these, 90% had a kidney transplant. Compared to the general population, respondents were less likely to be married or have children and were more likely to be living with their parents. Respondents had nearly 15 times greater odds of being unable to work due to health (odds ratio [OR] = 14.41; 95% confidence interval [CI], 8.0-26.01; P < 0.001). Respondents had poorer quality of life and mental wellbeing and were more likely to report psychological problems (OR = 5.37; 95% CI, 3.45-8.35; P < 0.001). A negative association between remaining on or moving to dialysis and psychosocial health was observed, although this was attenuated when controlling for the psychosocial state in SPEAK.

Limitations

Low response rate resulting in imprecise and potentially biased estimates and impact of COVID-19 pandemic while survey was active on psychosocial health.

Conclusions

Young adults with kidney failure have persistent poorer psychosocial health compared to their healthy peers as they age. Our findings also suggest a potential causal relationship between KRT modality and psychosocial health.

The experiences of UK-Chinese individuals during the COVID-19 pandemic: A qualitative interview study

Infectious disease outbreaks have historically been associated with stigmatisation towards minority groups, specifically those associated with the geographical region that the disease was first identified. We aimed to investigate how the emerging COVID-19 pandemic was experienced by UK-resident individuals of Chinese ethnicity: how their perceived cultural and ethnic identity influenced their experiences, and how early insights into the pandemic in China influenced attitudes and behaviours. We undertook in-depth semi-structured interviews with individuals who self-identified as UK-Chinese. Participants were recruited from three cities in the UK. Interviews were undertaken over the telephone between 9th April 2020 and 16th July 2020. Interviews were digitally recorded and transcribed verbatim. Transcripts were coded using NVivo software and analysed using inductive thematic analysis. Sixteen individuals were interviewed. Three main themes were identified: (1) Attribution of stigma, (2) Pandemic legacies, and (3) Individual versus societal responses. These reflected six sub-themes: (1) Stigmatisation through (mis)identity, (2) Markers of pandemic awareness, (3) Legacies of previous pandemics, (4) Ascription of blame, (5) Extent of freedom, and (6) Implicit faith in government. Experiences of xenophobia included accounts of physical violence. UK-Chinese individuals experienced and perceived widespread xenophobia, in the context of media representations that ascribed blame and exacerbated stigmatisation. Prior experience of respiratory epidemics, and insight into the governmental and societal response in China, contributed to the early adoption of face masks. This in turn marked UK-Chinese individuals as targets for abuse. Awareness is needed to safeguard stigmatized groups from social and economic harm in future infectious disease pandemics.

Expectations of a new opt-out system of consent for deceased organ donation in England: A qualitative interview study

Introduction

In 2020 England moved to an opt‐out deceased donation law. We aimed to investigate the views of a mixed stakeholder group comprising people with kidney disease, family members and healthcare practitioners towards the change in legislation. We investigated the expected impacts of the new legislation on deceased‐donor and living‐donor transplantation, and views on media campaigns regarding the law change.

Methods

We undertook in‐depth qualitative interviews with people with kidney disease (n = 13), their family members (n = 4) and healthcare practitioners (n = 15). Purposive sampling was used to ensure diversity for patients and healthcare practitioners. Family members were recruited through snowball sampling and posters. Interviews were audio‐recorded and transcribed verbatim. Transcripts were analysed using thematic analysis.

Results

Three themes with six subthemes were identified: (i) Expectations of impact (Hopeful patients; Cautious healthcare professionals), (ii) Living‐donor transplantation (Divergent views; Unchanged clinical recommendations), (iii) Media campaigns (Single message; Highlighting recipient benefits). Patients expected the law change would result in more deceased‐donor transplant opportunities.

Conclusions

Clinicians should ensure patients and families are aware of the current evidence regarding the impact of opt‐out consent: expectations of an increased likelihood of receiving a deceased‐donor transplant are not currently supported by the evidence. This may help to prevent a decline in living‐donor transplantation seen in other countries with similar legislation. Media campaigns should include a focus on the impact of organ receipt.

Patient or Public Contribution

Two patient representatives from the Kidney Disease Health Integration Team, Primrose Granville and Soumeya Bouacida, contributed to the content and design of the study documents.

MO692: A Four-Year Analysis on Home Dialysis at the North Bristol NHS Trust—What to Do Next?

BACKGROUND AND AIMS

Home dialysis, including peritoneal dialysis (PD) and home hemodialysis (HHD), has been associated with improved patient autonomy, quality of life and overall cost effectiveness (Weinhandl et al. Propensity matched mortality comparison of incident hemodialysis and peritoneal dialysis patients. J Am Soc Nephrol. 2010; 21: 499–506). The 2021 Get It Right First Time (GIRFT) Renal report revealed that home dialysis patients were at a lower risk of contracting and dying of coronavirus disease 2019 (COVID-19), compared to those who received in-center hemodialysis (ICHD) (2).

Despite these advantages, uptake of home dialysis is still lower than that of ICHD. The aim of our study was to analyse the numbers and reasons for home dialysis withdrawal at the North Bristol NHS Trust between 2018 and 2021.

METHOD

All patients on PD and HHD between 2018 and 2021 were included. Analysis of the episodes that led to home dialysis cessation was carried out. As some patients required withdrawal more than once during the 4-year period, each episode of dropout was considered separately. The prevalence rate of patients on home dialysis was calculated.

RESULTS

The total number of patients on home dialysis increased from 74 in 2018 to 98 in 2021. The male: female ratio of patients was 3:2 with an average age of 58.3. The number of patients on PD increased from 58 at the end of 2018 to 82 in 2021. The number of patients on HHD remained stable over the years, with an average of 16. The prevalence rate of home dialysis was 17.1% at the end of 2021.

Figure 1 shows the total number of patients who started and dropped out of home dialysis every year. The number of patients initiating PD was 58 in 2018, 55 in 2019, 37 in 2020 and 59 in 2021. The number of dropouts was 57 in 2018, 41 in 2019, 29 in 2020 and 43 in 2021.

The dip in number of patients initiated on PD in 2020 can be attributed to the start of the COVID-19 pandemic, when elective procedures were temporarily withheld. On the other hand, a lower number dropped out during 2020. This may be explained by the emphasis given to self-isolation rules and persistence with home dialysis during the outbreak.

The overall increase in PD uptake in 2021 may be explained by the establishment of a new specialist clinic that promotes the uptake of home dialysis. The initiation of a new peer support service group in 2021 may also have contributed.

The number of patients initiating and withdrawing from HHD followed the same pattern, with a significant dip in 2020.

Figure 2 demonstrates the reasons for withdrawal from PD over the study period. The most prevalent reasons were PD-related infections and transplantation. The observed figures for transplantation reflect the continuous efforts involved in the maintenance of a successful transplant programme. The figure also shows that termination of PD due to failure was highest in 2021. The authors postulate that this surge might be due to the previous year's low PD dropout rate.

The leading reason for stopping HHD was transplantation. Other reasons included recovery of renal function and switching to conservative management. Death led to one dropout/year in 2018–20, but none in 2021.

CONCLUSION

Around 17% of the NBT’s total dialysis population is currently on home dialysis. The commonest reasons for termination of home dialysis were transplantation and PD-related infections.

The GIRFT report recommends that all adult renal units in the UK should reach a minimum prevalence rate of 20% of their dialysis population on home dialysis by the end of 2024 (Lipkin et al. Renal medicine: Get It Right First Time (GIRFT) Programme National Specialty Report. March 2021. NHS England and NHS Improvement). Whereas our statistic falls slightly short of this, we aim to reach this target through various strategies. These include continued audit, home dialysis campaign, continued psychological services and a reduction in waiting time for PD catheter insertion.

BK Polyomavirus-associated nephropathy - diagnostic and treatment standard

BK polyomavirus (BKPyV) is recognized as a significant viral complication of kidney transplantation. Prompt immunosuppression reduction reduces early graft failure rates due to BK polyomavirus-associated nephropathy (BKPyVAN), however, modulation of immunosuppression can lead to acute rejection. Medium-to-long-term graft outcomes are negatively affected by BKPyVAN, probably due to a combination of virus-induced graft damage and host immune responses against graft alloantigens potentiated by immunosuppression reduction. Kidney biopsy remains the gold-standard diagnostic test, however, false-negative findings are common due to the focal nature of BKPyVAN. BKPyV DNAemia, as measured by quantitative polymerase chain reaction, is established as a screening test but there is at present no (inter)national standardization of these assays to allow collation and comparison of data between centres. Randomized controlled trials are lacking both in terms of optimal immunosuppression reduction strategies, and for the medications variably used to attempt treatment in clinical practice. Much of the fundamental biology of BKPyV is not yet understood, and further elucidation is required to promote rational direct-acting antiviral drug design. Insights into the role of adaptive immunity in control of BKPyV have informed the design of novel treatments such as adoptive immunotherapies and neutralizing antibodies that require evaluation in clinical studies. Here, we review the current standards of diagnosis and treatment of BKPyVAN and discuss novel developments in the pathophysiology, diagnosis, outcome prediction, and management.