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Enteric Fever treated via Outpatient Parenteral Antibiotic Therapy (OPAT): Experience from a UK Infectious Diseases Unit
e58
Introduction Candida species have emerged as significant pathogens causing blood stream infections over the last 10 years, with a mortality rate of approximately 40%. There is also increasing antifungal resistance in the azole class of antifungals among some species of Candida. The identification and sensitivity testing of yeasts has traditionally been labour intensive and slow to yield results. More rapid testing has been desirable to assist in rationalising empirical prescribing of antifungals and prompt initiation of therapy for proven invasive candidiasis. At Monklands Hospital, the API20C AUX system (Biomerieux) was used for identification of yeasts and Fungitest (BIORAD) used for sensitivity testing of yeasts to antifungals. Both these methods require a minimum of 48 hours incubation. Evidence from studies carried out in 2006, demonstrates that a delay in starting appropriate antifungal therapy of 12-24 hours, resulted in a 2-3 times higher mortality rate compared to cases where antifungals were administered before this time period. Recent guidance also advises that the species of Candida isolate should be determined as this can influence whether to use fluconazole or an echinocandin antifungal as first line empirical treatment. It was therefore undertaken to trial the new VITEK 2 Advanced Colourimetry Yeast Identification (YST) card (Biomerieux), and the Yeast Susceptibility Card (YS01) and compare its performance against our existing methods with regard to accuracy and turnaround times.
Scientific findings Twenty Candida isolates were analysed. There was good correlation between the VITEK 2 and API20C AUX results for Candida speciation. There was much less correlation between the results of VITEK 2, API20C AUX and use of chromogenic agar for speciation. There is a significant time saving using VITEK2 compared to the use of API20 CAUX identification (p < 0.0001) of over a day. Compared to Fungitest sensitivity testing, there is also a significant saving of time to a final result (p <0.0001) of over a day. Susceptibility testing for azole antifungals proved most difficult for C glabrata isolates.
Discussion The VITEK 2 is significantly faster at generating accurate identification of Candida species and antifungal sensitivity results compared to API AUXC and Fungitests. As "non-albicans" species of Candida are as common as C. albicans, and resistance to azole antifungals is possible in both categories (Odds et al, 2007), this arbitrary distinction is no longer clinically useful. The VITEK 2 results are not open to inter-observer error as the sensitivity results have a clear MIC end-point. More rapid antifungal sensitivity testing allows de-escalation in treatment sooner, with consequent reduction in the cost of treatment of invasive Candida infections.
Abstracts
Conclusions Rapid speciation and sensitivity testing of Candida isolates using VITEK 2 is accurate for most Candida species and can improve informed decision making regarding rational antifungal prescribing.
WITHDRAWN ENTERIC FEVER TREATED VIA OUTPATIENT PARENTERAL ANTIBIOTIC THERAPY (OPAT): EXPERIENCE FROM A UK INFECTIOUS DISEASES UNITCATEGORY: CLINICAL LESSON C Sykes 1, JE Coia 2, H Mather 2, RA Seaton
1
1
Brownlee Centre, Gartnavel General Hospital, Glasgow, United Kingdom 2 Scottish Salmonella, Shigella and C.difficile Reference Laboratory., Glasgow, United Kingdom
Introduction Enteric fever is an important cause of morbidity in the returning traveller to the UK, with an incidence of approximately 500 cases per year in England and Wales. Most infections are acquired in the Indian Sub-continent where quinolone resistance is common in both Salmonella typhi (70%) and S. paratyphi (96%). Ceftriaxone is the preferred parenteral agent for enteric fever in our unit. Courses of 10-14 days are recommended to prevent relapse. OPAT has been used in our unit to facilitate earlier discharge.
Scientific findings Between 2001-2010 49 cases of s.typhi or s.paratyphi in adults were diagnosed via our Salmonella reference laboratory. Seventeen (34.7%) received OPAT. Reviewing our OPAT database we identified another 10 patients. Four were culture positive. Twenty-seven were treated via OPAT for enteric fever (13 paratyphoid, 8 typhoid, 6 culture negative). 23 acquired infection in South Asia. 1 had deep seated infection. 16/17 (94%) had quinolone resistance (MIC 0.125mg/l); all were ceftriaxone-sensitive. 26 were treated with ceftriaxone;1 with ertapenem and gentamicin. Follow-up data was available for 18 patients (median 37 days). 17 were well at follow up. There were 2 readmissions; neither case had relapsed disease.
Discussion This observational study demonstrates that OPAT is a viable mode of treatment for selected patients with enteric fever and is commonly used in this patient population reflecting patterns of referral to our ID unit. Widespread quinolone resistance in South Asia means oral treatment in often
Abstracts inappropriate for our population. Ceftriaxone is the preferred choice but usually requires a prolonged inpatient stay. OPAT treatment allows earlier discharge, which improves patient choice, and reduces the likelihood of hospital acquired morbidity.
Conclusions OPAT with ceftriaxone is commonly and effectively used in the management of imported enteric fever in Glasgow.
CLOSTRIDIUM DIFFICILE INFECTION IN ELDERLY LANARKSHIRE PRIMARY CARE PATIENTSCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL Leigh Williams, Maybeth Magowan, Anne Marie Burns, Irene Winning, Donald Inverarity
e59 hygiene and other infection control interventions which has resulted in a dramatic fall in the incidence of CDI in both hospital and community settings.
Conclusions Elderly patients in primary care in Lanarkshire appear to develop CDI despite appearing to be at no greater exposure to antibiotics or hospitalization than matched controls with diarrhoea not due to CDI. It is unlikely though that this work could be realistically repeated in this health board due to the infrequency of CDI cases currently detected from primary care.
THE BENEFITS OF AN INFECTIOUS DISEASE/ RADIOLOGY MULTIDISCIPLINARY TEAM MEETINGCATEGORY: SCIENTIFIC FREE PAPER
NHS Lanarkshire, Airdrie, United Kingdom
Introduction The epidemiology of Clostridium difficile infection (CDI) in Lanarkshire has changed dramatically in recent years. A rising incidence of CDI during the 1990s and early 21st century has begun to decline. Patient populations, previously considered at less risk of CDI than hospitalized patients, have been noted to have an appreciable incidence of CDI such as the elderly in community settings. We assessed 48 episodes of non outbreak related CDI relating to 45 patients living in Lanarkshire in primary care from July to November 2008.
Scientific findings The median patient age was 78 (range 65 to 95 years). 10 patients with CDI were resident in Care Homes while the rest were resident in their own homes. In 7 cases the patient died within 30 days of diagnosis of CDI. There were no significant differences between patients with CDI and matched controls with diarrhoea regarding hospitalization rates (p ¼ 0.62), exposure to antibiotics (p ¼ 0.33), exposure to antacids (p ¼ 0.46) or exposure to proton pump inhibitors (p ¼ 0.65). Ribotype 106 was the commonest ribotype identified.
Discussion Although these elderly patients with CDI had recognized risk factors, there was no appreciable difference in risk when compared with matched patients with diarrhoea but no CDI. 16% of elderly patients did not survive a month after diagnosis of CDI. This audit relates to a period in Lanarkshire when the incidence of CDI was much higher than it is currently. In July 2008 NHS Lanarkshire began a multifaceted programme of antimicrobial stewardship, hand
Haider Ali, Tom Fletcher, Chris Ryall, Nick J Beeching, Liz Joekes, Penny Lewthwaite Royal Liverpool University Hospital, Liverpool, United Kingdom
Introduction Multidisciplinary teams (MDT) bring together health-care professionals to plan the management of complex clinical problems. They now form the cornerstone of cancer services in almost every discipline, with clear survival benefits. However, their use in the management of other conditions is not well reported. In Liverpool, the Tropical and Infectious Disease Unit (TIDU) and Radiology Department have held a weekly joint meeting for over 20 years, attended by clinical staff from 3 TIDU ward teams and led by a Consultant Radiologist with an interest in infection. Following detailed review of radiological investigations and clinical discussion, consensus agreement is reached. These sessions, lasting an hour per week, also serve as a useful training forum for staff in all disciplines. This MDT meeting primarily has a diagnostic purpose, unlike many MDTs which formulate therapeutic decisions. It aims to improve patient management by narrowing differential diagnoses and focusing further investigation, and to minimise risk to the patient by avoiding unnecessary investigations or treatments. Despite the time resources allocated to the MDT, the degree to which the discussions influence the management of infectious disease patients was unknown prior to this review. The aim of this study was to determine what impact MDT meetings have on the clinical management of patients in a tertiary infectious diseases unit. 11 meetings were analysed prospectively (at random) during a 6 month period from January 2010 to July 2010. Senior staff involved in most of the discussion and decision making were not aware which meetings were being evaluated.
Introduction Candida species have emerged as significant pathogens causing blood stream infections over the last 10 years, with a mortality rate of approximately 40%. There is also increasing antifungal resistance in the azole class of antifungals among some species of Candida. The identification and sensitivity testing of yeasts has traditionally been labour intensive and slow to yield results. More rapid testing has been desirable to assist in rationalising empirical prescribing of antifungals and prompt initiation of therapy for proven invasive candidiasis. At Monklands Hospital, the API20C AUX system (Biomerieux) was used for identification of yeasts and Fungitest (BIORAD) used for sensitivity testing of yeasts to antifungals. Both these methods require a minimum of 48 hours incubation. Evidence from studies carried out in 2006, demonstrates that a delay in starting appropriate antifungal therapy of 12-24 hours, resulted in a 2-3 times higher mortality rate compared to cases where antifungals were administered before this time period. Recent guidance also advises that the species of Candida isolate should be determined as this can influence whether to use fluconazole or an echinocandin antifungal as first line empirical treatment. It was therefore undertaken to trial the new VITEK 2 Advanced Colourimetry Yeast Identification (YST) card (Biomerieux), and the Yeast Susceptibility Card (YS01) and compare its performance against our existing methods with regard to accuracy and turnaround times.
Scientific findings Twenty Candida isolates were analysed. There was good correlation between the VITEK 2 and API20C AUX results for Candida speciation. There was much less correlation between the results of VITEK 2, API20C AUX and use of chromogenic agar for speciation. There is a significant time saving using VITEK2 compared to the use of API20 CAUX identification (p < 0.0001) of over a day. Compared to Fungitest sensitivity testing, there is also a significant saving of time to a final result (p <0.0001) of over a day. Susceptibility testing for azole antifungals proved most difficult for C glabrata isolates.
Discussion The VITEK 2 is significantly faster at generating accurate identification of Candida species and antifungal sensitivity results compared to API AUXC and Fungitests. As "non-albicans" species of Candida are as common as C. albicans, and resistance to azole antifungals is possible in both categories (Odds et al, 2007), this arbitrary distinction is no longer clinically useful. The VITEK 2 results are not open to inter-observer error as the sensitivity results have a clear MIC end-point. More rapid antifungal sensitivity testing allows de-escalation in treatment sooner, with consequent reduction in the cost of treatment of invasive Candida infections.
Abstracts
Conclusions Rapid speciation and sensitivity testing of Candida isolates using VITEK 2 is accurate for most Candida species and can improve informed decision making regarding rational antifungal prescribing.
WITHDRAWN ENTERIC FEVER TREATED VIA OUTPATIENT PARENTERAL ANTIBIOTIC THERAPY (OPAT): EXPERIENCE FROM A UK INFECTIOUS DISEASES UNITCATEGORY: CLINICAL LESSON C Sykes 1, JE Coia 2, H Mather 2, RA Seaton
1
1
Brownlee Centre, Gartnavel General Hospital, Glasgow, United Kingdom 2 Scottish Salmonella, Shigella and C.difficile Reference Laboratory., Glasgow, United Kingdom
Introduction Enteric fever is an important cause of morbidity in the returning traveller to the UK, with an incidence of approximately 500 cases per year in England and Wales. Most infections are acquired in the Indian Sub-continent where quinolone resistance is common in both Salmonella typhi (70%) and S. paratyphi (96%). Ceftriaxone is the preferred parenteral agent for enteric fever in our unit. Courses of 10-14 days are recommended to prevent relapse. OPAT has been used in our unit to facilitate earlier discharge.
Scientific findings Between 2001-2010 49 cases of s.typhi or s.paratyphi in adults were diagnosed via our Salmonella reference laboratory. Seventeen (34.7%) received OPAT. Reviewing our OPAT database we identified another 10 patients. Four were culture positive. Twenty-seven were treated via OPAT for enteric fever (13 paratyphoid, 8 typhoid, 6 culture negative). 23 acquired infection in South Asia. 1 had deep seated infection. 16/17 (94%) had quinolone resistance (MIC 0.125mg/l); all were ceftriaxone-sensitive. 26 were treated with ceftriaxone;1 with ertapenem and gentamicin. Follow-up data was available for 18 patients (median 37 days). 17 were well at follow up. There were 2 readmissions; neither case had relapsed disease.
Discussion This observational study demonstrates that OPAT is a viable mode of treatment for selected patients with enteric fever and is commonly used in this patient population reflecting patterns of referral to our ID unit. Widespread quinolone resistance in South Asia means oral treatment in often
Abstracts inappropriate for our population. Ceftriaxone is the preferred choice but usually requires a prolonged inpatient stay. OPAT treatment allows earlier discharge, which improves patient choice, and reduces the likelihood of hospital acquired morbidity.
Conclusions OPAT with ceftriaxone is commonly and effectively used in the management of imported enteric fever in Glasgow.
CLOSTRIDIUM DIFFICILE INFECTION IN ELDERLY LANARKSHIRE PRIMARY CARE PATIENTSCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL Leigh Williams, Maybeth Magowan, Anne Marie Burns, Irene Winning, Donald Inverarity
e59 hygiene and other infection control interventions which has resulted in a dramatic fall in the incidence of CDI in both hospital and community settings.
Conclusions Elderly patients in primary care in Lanarkshire appear to develop CDI despite appearing to be at no greater exposure to antibiotics or hospitalization than matched controls with diarrhoea not due to CDI. It is unlikely though that this work could be realistically repeated in this health board due to the infrequency of CDI cases currently detected from primary care.
THE BENEFITS OF AN INFECTIOUS DISEASE/ RADIOLOGY MULTIDISCIPLINARY TEAM MEETINGCATEGORY: SCIENTIFIC FREE PAPER
NHS Lanarkshire, Airdrie, United Kingdom
Introduction The epidemiology of Clostridium difficile infection (CDI) in Lanarkshire has changed dramatically in recent years. A rising incidence of CDI during the 1990s and early 21st century has begun to decline. Patient populations, previously considered at less risk of CDI than hospitalized patients, have been noted to have an appreciable incidence of CDI such as the elderly in community settings. We assessed 48 episodes of non outbreak related CDI relating to 45 patients living in Lanarkshire in primary care from July to November 2008.
Scientific findings The median patient age was 78 (range 65 to 95 years). 10 patients with CDI were resident in Care Homes while the rest were resident in their own homes. In 7 cases the patient died within 30 days of diagnosis of CDI. There were no significant differences between patients with CDI and matched controls with diarrhoea regarding hospitalization rates (p ¼ 0.62), exposure to antibiotics (p ¼ 0.33), exposure to antacids (p ¼ 0.46) or exposure to proton pump inhibitors (p ¼ 0.65). Ribotype 106 was the commonest ribotype identified.
Discussion Although these elderly patients with CDI had recognized risk factors, there was no appreciable difference in risk when compared with matched patients with diarrhoea but no CDI. 16% of elderly patients did not survive a month after diagnosis of CDI. This audit relates to a period in Lanarkshire when the incidence of CDI was much higher than it is currently. In July 2008 NHS Lanarkshire began a multifaceted programme of antimicrobial stewardship, hand
Haider Ali, Tom Fletcher, Chris Ryall, Nick J Beeching, Liz Joekes, Penny Lewthwaite Royal Liverpool University Hospital, Liverpool, United Kingdom
Introduction Multidisciplinary teams (MDT) bring together health-care professionals to plan the management of complex clinical problems. They now form the cornerstone of cancer services in almost every discipline, with clear survival benefits. However, their use in the management of other conditions is not well reported. In Liverpool, the Tropical and Infectious Disease Unit (TIDU) and Radiology Department have held a weekly joint meeting for over 20 years, attended by clinical staff from 3 TIDU ward teams and led by a Consultant Radiologist with an interest in infection. Following detailed review of radiological investigations and clinical discussion, consensus agreement is reached. These sessions, lasting an hour per week, also serve as a useful training forum for staff in all disciplines. This MDT meeting primarily has a diagnostic purpose, unlike many MDTs which formulate therapeutic decisions. It aims to improve patient management by narrowing differential diagnoses and focusing further investigation, and to minimise risk to the patient by avoiding unnecessary investigations or treatments. Despite the time resources allocated to the MDT, the degree to which the discussions influence the management of infectious disease patients was unknown prior to this review. The aim of this study was to determine what impact MDT meetings have on the clinical management of patients in a tertiary infectious diseases unit. 11 meetings were analysed prospectively (at random) during a 6 month period from January 2010 to July 2010. Senior staff involved in most of the discussion and decision making were not aware which meetings were being evaluated.