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Clinical Course and Outcomes of Varicella-Zoster Virus Meningitis
e108 source of considerable distress and can result in long-term psychological sequelae. Appropriate initial first aid management of the injury is likely to reduce incidence of transmission and specific measures such as hepatitis B immunoglobulin (HBIG) and vaccination and HIV postexposure prophylaxis (PEP) can prevent transmission of specific infections. In Glasgow, guidelines exist to assist those involved in managing such exposures to potentially infected body fluids. Advice can be sought from the regional infectious diseases unit, which can also arrange follow up when required. The nature of referrals for advice and the advice or treatment given was recorded as part of local audit over 3 months from September to November 2008. Any request for advice was included, regardless of the referral source, except where the case involved sexual exposure, as these cases were referred to the genitourinary medicine service. Advice given included an assessment of the injury and risk factors of the source before suggesting treatment and follow-up. Follow up of patients commenced on PEP was undertaken at the infectious diseases unit.
Scientific findings 32 requests for advice were received but 3 excluded (1 duplicate, 2 sexual exposures). Of 29 remaining, 24% came from occupational health, while 59% were from A&E. 14% were self-referrals and 3% from primary care. 58% involved HCW, 17% other occupational exposures and 24% nonoccupational. 4 injuries involved discarded needles in the community. The median time from injury to presentation was 2 hours. 3 patients received HBIG and 6 patients received vaccine. 12 patients began PEP, of which 8 discontinued after the source was found to be HIV negative. 2 patients elected to discontinue PEP due to side-effects.
Discussion Most patients affected by exposure to body fluids can be reassured that the risk of infection is extremely low with HBIG and PEP not required. The majority of patients treated with PEP were subsequently able to discontinue it reflecting the relatively low HIV seroprevalence in Glasgow, even among those conventionally regarded as at risk (the most common risk factor among source-patients was intravenous drug use). 50% of those continuing PEP discontinued due to side effects. A high rate of adverse effects has been noted before. Both patients discontinuing received injuries in which the source was unavailable for testing.
Conclusions Exposure to potentially infected body fluids was a common reason for requests for advice from the infectious diseases unit. Most affected cases can be managed with first aid and follow up testing only but some patients require HBIG/
Abstracts vaccination or HIV PEP. Testing of source patients, where possible, is vitally important as most patients can subsequently discontinue HIV PEP and adverse effects of antiretroviral therapy are common.
CLINICAL COURSE AND OUTCOMES OF VARICELLA-ZOSTER VIRUS MENINGITISCATEGORY: SCIENTIFIC FREE PAPER Nicholas Anagnostou 1, Iain Gosbell
2
1
Liverpool Hospital, Sydney, New South Wales, Australia University of Western Sydney, Sydney, New South Wales, Australia 2
Introduction Reactivation of latent varicella-zoster virus (VZV) infection most commonly manifests as herpes zoster. A range of other manifestations of reactivation of VZV infection has been described. Reports of acute meningitis due to VZV reactivation have increased in recent years, in the context of the increasing use of polymerase chain reaction (PCR) for detection of VZV in cerebrospinal fluid (CSF). VZV reactivation accounts for approximately 5-11% of cases of acute aseptic meningitis. The natural history of VZV meningitis and the role of antiviral therapy are poorly defined. We sought to contribute to the knowledge of the natural history of VZV meningitis and the role of antiviral therapy by reviewing the clinical course, treatment, and outcomes of a series of consecutive patients with this condition. The records of two diagnostic clinical microbiology laboratories in Sydney were searched for positive results of VZV PCR on CSF specimens in the period March 2004 to October 2009. These laboratories serve hospitals with a catchment area with approximately 1.3 million people. All clinical, laboratory and radiographic data was retrospectively reviewed for patients meeting the case definition of VZV meningitis, and for other patients with VZV reactivation. The temporal course of symptoms and signs, antiviral therapy, occurrence of complications, follow up and sequelae were described.
Scientific findings Sixteen immunocompetent patients, mean age 36 years, had VZV meningitis. Clinical features resolved within two weeks for the fourteen patients with complete data for the acute episode, whether antiviral therapy (intravenous aciclovir) was given or not. No complications or sequelae were identified. One patient had VZV CNS vasculopathy, and seven had acute illnesses with encephalopathy for which the pathologic basis could not be confidently ascribed. Of the latter patients, all had inflammatory CSF profiles, the mean age was 63 years, three were immunocompromised including one who had VZV meningitis at presentation without encephalopathy, two died and two had other complications.
Abstracts
Discussion VZV meningitis in these immunocompetent and relatively young persons appeared to have a benign course, corroborating the bulk of previous case descriptions. Our descriptions are limited by the retrospective study design and poor patient follow up. Cases of VZV meningitis with complications and sequelae have been reported previously. In general amongst patients with CNS disease in the setting of VZV reactivation, older age and immunocompromise were associated with more severe disease and worse outcomes.
Conclusions Although the use of antiviral therapy for VZV meningitis is largely empiric, our findings suggest that careful attention should be paid to the age and immunocompetence of the patient in deciding on the management of patients with VZV meningitis. Prospective studies are required to better understand the course and outcomes of VZV meningitis and controlled data concerning the role of antiviral therapy would be valuable.
EVALUATION OF THE USE OF XPERT MRSA PCR ASSAY AS A POINT OF CARE TEST IN TWO CLINICAL AREASCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL Benjamin Parcell, Gabby Phillips NHS Tayside, Dundee, United Kingdom
Introduction Methicillin resistant Staphylococcus aureus (MRSA) is a major cause of nosocomial infection and is associated with prolonged hospital stay, poor outcome and increased healthcare costs. Patients colonised with MRSA are 15 times more likely to develop infections. The United Kingdom is known to have high levels of healthcare associated MRSA infections and Health Protection Scotland has recently completed a study examining the benefits of screening for MRSA. It is believed that rapid identification, decolonisation and isolation of patients colonised with MRSA will reduce infections and transmission. Currently, screening involves taking swabs from the nose, axilla and groin of patients. These swabs are then sent for culture. This method has a turnaround time of approximately 48 hours. The average length of hospital stay for patients is 3 days and therefore the current turnaround time of MRSA screening may cause delay and difficulty implementing decolonisation and isolation. Point of care testing for MRSA carriage has been developed using a PCR method, GeneXpert systems (Cepheid). This newer method provides results within 66 minutes and may therefore allow early identification and reduce colonisation, infection and bacteraemia rates. This study aims to assess whether rapid screening for
e109 MRSA using the Xpert MRSA PCR assay could be used in preadmission clinics and on the ward. Patients in an orthopaedic preadmission clinic and on a vascular ward were screened for MRSA using the Xpert MSRA PCR assay. Duplicate swabs were taken for culture. Results for each method were then compared in these two clinical settings.
Scientific findings In clinic, 752 swabs were processed, with 48 (6%) invalid results, 21 (3%) positives and 683 (91%) negatives. Of the 21 positives, 6 were confirmed on culture, while 2 of 683 negative results were culture positive. Using culture as the reference method, sensitivity of the Cepheid system was 75%, specificity 97.8%, positive predictive value (PPV) 30% and negative predictive value (NPV) 99.7%. Of 454 ward swabs, 24 (5%) were invalid, 16 (4%) positive and 414 (91%) negative. Four positive results were confirmed on culture. One negative PCR was culture positive. Sensitivity was 80%, specificity 97%, PPV 25% and NPV 99.7%.
Discussion We found that the specificity and NPV of this rapid screening tool were in keeping with previous studies. Although previous studies have shown that rapid testing has a lower sensitivity and PPV, our results were particularly low. This may be due to the small number of positive test results in the study population. A patient can be screened within 2 hours of admission or in clinic, allowing earlier isolation and implementation of infection control procedures. Staff were provided with training and found screening with Xpert PCR straightforward. Despite these advantages, some results were inconsistent and sensitivity and PPV were low.
Conclusions Rapid screening using the Xpert MRSA PCR assay provides many benefits for patient as well as staff. Sensitivity and specificity for detection of MRSA were similar in both ward and clinic settings. PCR testing may be useful in identifying MRSA negative cases, allowing a reduction in the number of swabs being sent to the laboratory for culture. However, we recommend that positive PCR results should be confirmed by culture. Further research should be carried out on cost of testing and effect on clinical outcomes.
AN INVESTIGATION INTO THE MOLECULAR BASIS OF STREPTOCOCCUS PNEUMONIAE OF DIFFERENT ISOLATESCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL Shueh Hao Lim, Phil Cash University of Aberdeen, Aberdeen, United Kingdom
Scientific findings 32 requests for advice were received but 3 excluded (1 duplicate, 2 sexual exposures). Of 29 remaining, 24% came from occupational health, while 59% were from A&E. 14% were self-referrals and 3% from primary care. 58% involved HCW, 17% other occupational exposures and 24% nonoccupational. 4 injuries involved discarded needles in the community. The median time from injury to presentation was 2 hours. 3 patients received HBIG and 6 patients received vaccine. 12 patients began PEP, of which 8 discontinued after the source was found to be HIV negative. 2 patients elected to discontinue PEP due to side-effects.
Discussion Most patients affected by exposure to body fluids can be reassured that the risk of infection is extremely low with HBIG and PEP not required. The majority of patients treated with PEP were subsequently able to discontinue it reflecting the relatively low HIV seroprevalence in Glasgow, even among those conventionally regarded as at risk (the most common risk factor among source-patients was intravenous drug use). 50% of those continuing PEP discontinued due to side effects. A high rate of adverse effects has been noted before. Both patients discontinuing received injuries in which the source was unavailable for testing.
Conclusions Exposure to potentially infected body fluids was a common reason for requests for advice from the infectious diseases unit. Most affected cases can be managed with first aid and follow up testing only but some patients require HBIG/
Abstracts vaccination or HIV PEP. Testing of source patients, where possible, is vitally important as most patients can subsequently discontinue HIV PEP and adverse effects of antiretroviral therapy are common.
CLINICAL COURSE AND OUTCOMES OF VARICELLA-ZOSTER VIRUS MENINGITISCATEGORY: SCIENTIFIC FREE PAPER Nicholas Anagnostou 1, Iain Gosbell
2
1
Liverpool Hospital, Sydney, New South Wales, Australia University of Western Sydney, Sydney, New South Wales, Australia 2
Introduction Reactivation of latent varicella-zoster virus (VZV) infection most commonly manifests as herpes zoster. A range of other manifestations of reactivation of VZV infection has been described. Reports of acute meningitis due to VZV reactivation have increased in recent years, in the context of the increasing use of polymerase chain reaction (PCR) for detection of VZV in cerebrospinal fluid (CSF). VZV reactivation accounts for approximately 5-11% of cases of acute aseptic meningitis. The natural history of VZV meningitis and the role of antiviral therapy are poorly defined. We sought to contribute to the knowledge of the natural history of VZV meningitis and the role of antiviral therapy by reviewing the clinical course, treatment, and outcomes of a series of consecutive patients with this condition. The records of two diagnostic clinical microbiology laboratories in Sydney were searched for positive results of VZV PCR on CSF specimens in the period March 2004 to October 2009. These laboratories serve hospitals with a catchment area with approximately 1.3 million people. All clinical, laboratory and radiographic data was retrospectively reviewed for patients meeting the case definition of VZV meningitis, and for other patients with VZV reactivation. The temporal course of symptoms and signs, antiviral therapy, occurrence of complications, follow up and sequelae were described.
Scientific findings Sixteen immunocompetent patients, mean age 36 years, had VZV meningitis. Clinical features resolved within two weeks for the fourteen patients with complete data for the acute episode, whether antiviral therapy (intravenous aciclovir) was given or not. No complications or sequelae were identified. One patient had VZV CNS vasculopathy, and seven had acute illnesses with encephalopathy for which the pathologic basis could not be confidently ascribed. Of the latter patients, all had inflammatory CSF profiles, the mean age was 63 years, three were immunocompromised including one who had VZV meningitis at presentation without encephalopathy, two died and two had other complications.
Abstracts
Discussion VZV meningitis in these immunocompetent and relatively young persons appeared to have a benign course, corroborating the bulk of previous case descriptions. Our descriptions are limited by the retrospective study design and poor patient follow up. Cases of VZV meningitis with complications and sequelae have been reported previously. In general amongst patients with CNS disease in the setting of VZV reactivation, older age and immunocompromise were associated with more severe disease and worse outcomes.
Conclusions Although the use of antiviral therapy for VZV meningitis is largely empiric, our findings suggest that careful attention should be paid to the age and immunocompetence of the patient in deciding on the management of patients with VZV meningitis. Prospective studies are required to better understand the course and outcomes of VZV meningitis and controlled data concerning the role of antiviral therapy would be valuable.
EVALUATION OF THE USE OF XPERT MRSA PCR ASSAY AS A POINT OF CARE TEST IN TWO CLINICAL AREASCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL Benjamin Parcell, Gabby Phillips NHS Tayside, Dundee, United Kingdom
Introduction Methicillin resistant Staphylococcus aureus (MRSA) is a major cause of nosocomial infection and is associated with prolonged hospital stay, poor outcome and increased healthcare costs. Patients colonised with MRSA are 15 times more likely to develop infections. The United Kingdom is known to have high levels of healthcare associated MRSA infections and Health Protection Scotland has recently completed a study examining the benefits of screening for MRSA. It is believed that rapid identification, decolonisation and isolation of patients colonised with MRSA will reduce infections and transmission. Currently, screening involves taking swabs from the nose, axilla and groin of patients. These swabs are then sent for culture. This method has a turnaround time of approximately 48 hours. The average length of hospital stay for patients is 3 days and therefore the current turnaround time of MRSA screening may cause delay and difficulty implementing decolonisation and isolation. Point of care testing for MRSA carriage has been developed using a PCR method, GeneXpert systems (Cepheid). This newer method provides results within 66 minutes and may therefore allow early identification and reduce colonisation, infection and bacteraemia rates. This study aims to assess whether rapid screening for
e109 MRSA using the Xpert MRSA PCR assay could be used in preadmission clinics and on the ward. Patients in an orthopaedic preadmission clinic and on a vascular ward were screened for MRSA using the Xpert MSRA PCR assay. Duplicate swabs were taken for culture. Results for each method were then compared in these two clinical settings.
Scientific findings In clinic, 752 swabs were processed, with 48 (6%) invalid results, 21 (3%) positives and 683 (91%) negatives. Of the 21 positives, 6 were confirmed on culture, while 2 of 683 negative results were culture positive. Using culture as the reference method, sensitivity of the Cepheid system was 75%, specificity 97.8%, positive predictive value (PPV) 30% and negative predictive value (NPV) 99.7%. Of 454 ward swabs, 24 (5%) were invalid, 16 (4%) positive and 414 (91%) negative. Four positive results were confirmed on culture. One negative PCR was culture positive. Sensitivity was 80%, specificity 97%, PPV 25% and NPV 99.7%.
Discussion We found that the specificity and NPV of this rapid screening tool were in keeping with previous studies. Although previous studies have shown that rapid testing has a lower sensitivity and PPV, our results were particularly low. This may be due to the small number of positive test results in the study population. A patient can be screened within 2 hours of admission or in clinic, allowing earlier isolation and implementation of infection control procedures. Staff were provided with training and found screening with Xpert PCR straightforward. Despite these advantages, some results were inconsistent and sensitivity and PPV were low.
Conclusions Rapid screening using the Xpert MRSA PCR assay provides many benefits for patient as well as staff. Sensitivity and specificity for detection of MRSA were similar in both ward and clinic settings. PCR testing may be useful in identifying MRSA negative cases, allowing a reduction in the number of swabs being sent to the laboratory for culture. However, we recommend that positive PCR results should be confirmed by culture. Further research should be carried out on cost of testing and effect on clinical outcomes.
AN INVESTIGATION INTO THE MOLECULAR BASIS OF STREPTOCOCCUS PNEUMONIAE OF DIFFERENT ISOLATESCATEGORY: LESSON IN MICROBIOLOGY & INFECTION CONTROL Shueh Hao Lim, Phil Cash University of Aberdeen, Aberdeen, United Kingdom