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Malarial Retinopathy in Adults
494
Abstracts
Introduction
Conclusions
Hospital inpatients are at increased risk of venous thromboembolism (VTE) compared to the general population: this risk can be reduced by thromboprophylaxis with subcutaneous heparin. There is now increasing recognition that ill patients in the community are also at increased risk. This risk is increased by factors such as increasing age, restricted mobility and acute infection. Outpatient Parenteral Antibiotic Therapy (OPAT) allows patients who require intravenous (IV) antibiotics to receive home/outpatient-based care as an alternative to hospital admission. Such patients are at increased risk of VTE, but no data exist as to the extent of this risk compared to hospital inpatients or community patients receiving oral antibiotic therapy. Furthermore, the optimal strategy with respect to thromboprophylaxis for OPAT patients has not been determined. This study assessed a cohort of patients receiving OPAT for cellulitis regarding VTE risk and use of thromboprophylaxis. All patients who were treated for cellulitis through the Sheffield OPAT service in 2009 were identified from the OPAT database. Case notes of patients over the age of 40 years were reviewed and data collected regarding age, gender, site of cellulitis, treatment duration, risk factors for VTE and documentation of a VTE risk assessment as an inpatient or during OPAT. Risk of VTE was assessed from the case notes using the Sheffield Teaching Hospitals Trust inpatient algorithm.
OPAT patients are at increased risk of VTE but further research is required to determine the level of risk compared to patients being treated for acute infections in other settings. There is a need to develop an OPAT-specific VTE risk protocol, with subsequent prospective evaluation.
MALARIAL RETINOPATHY IN ADULTS Richard Maude 1,2, Abdullah Abu Sayeed 3, Nicholas Beare 4, Prakaykaew Charunwatthana 1, M Abul Faiz 5, Amir Hossain 3, Emran Bin Yunus 3, M Gofranul Hoque 3, Mahtab Uddin Hasan 3, Nicholas White 1,2, Nicholas Day 1,2, Arjen Dondorp 1,2 1 Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand 2 Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, CCVTM, University of Oxford, Churchill Hospital, Old Road, Oxford, United Kingdom 3 Chittagong Medical College Hospital, Chittagong, Bangladesh 4 St Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom 5 Sir Salimullah Medical College, Dhaka, Bangladesh
Introduction Scientific findings 151 patients with cellulitis were treated through the OPAT service in 2009, of whom 100 were over 40 years of age. 61/100 were referred to OPAT following an inpatient stay, whereas 39/100 were referred direct from the community. 28/100 met the inpatient criteria for thromboprophylaxis: of these only 6 received this during OPAT. Of the 61 patients who had been inpatients prior to OPAT, 17 met the inpatient criteria for thromboprophylaxis but only 8 had received it as inpatients, and an additional 3 patients received thromboprophylaxis without a clear indication. No patient developed VTE over mean follow-up of 4 weeks.
Discussion VTE prophylaxis is an integral component of care for medical and surgical inpatients. Patients with acute infections are at increased risk; this risk is increased by other factors including age over 40 years. Recent inpatient VTE guidelines have been published by the National Institute for Health and Clinical Excellence, but to date there are no data on VTE risk in patients receiving OPAT, and no model for VTE risk assessment. In this study 28/100 of OPAT patients being treated for cellulitis were retrospectively assessed as requiring thromboprophylaxis, but only 6/28 received this. Inpatient assessment of VTE risk was also suboptimal.
A specific retinopathy has been described in African children with cerebral malaria, but in adults this has not been extensively studied. It has great potential as a diagnostic and prognostic tool and pathogenetic marker. Since the structure and function of the retinal vasculature greatly resembles the cerebral vasculature, study of retinal changes can reveal insights into the pathogenesis of cerebral malaria. Obstruction of microcirculatory blood flow is thought to be important in causing both malarial retinopathy and cerebral malaria. A detailed observational study of malarial retinopathy in Bangladeshi adults with P. falciparum malaria was performed using a portable retinal camera. The aims were to establish the prevalence, spectrum and time to resolution of retinal findings in malaria, their effect on visual function and to investigate the role of obstruction of microcirculatory blood flow in its pathogenesis. All smear positive adult patients admitted to Chittagong Medical College Hospital, Chittagong, Bangladesh, during the malaria seasons of 2008-2010 were eligible for the study. Control groups were febrile encephalopathy, sepsis and healthy volunteers and children with malaria. Patients were photographed daily until discharge then weekly until complete resolution of retinal changes. In adults, severity of retinal findings was correlated with markers of microcirculatory blood flow obstruction (blood lactate and rectal capillary blood flow (Microscan)) and rheological factors important in microcirculatory obstruction (P. falciparum histidine rich protein 2 (PfHRP2) and red blood cell deformability (LORCA)).
Abstracts
Scientific findings Of 234 adults recruited, 51/60 (85%) cerebral, 18/27 (67%) noncerebral and 28/59 (47%) uncomplicated malaria had retinopathy. Mostly mild changes were found in 9/29 (31%) encephalopathy, 11/28 (39%) sepsis and 4/31 (13%) healthy volunteers. Moderate-severe retinopathy was in 67% fatal, 62% cerebral, 41% noncerebral and 12% uncomplicated malaria, 14% encephalopathy, 0% sepsis and healthy. Excluding papilloedema, moderate-severe retinopathy was specific for malaria (98%), and cerebral malaria in comatose patients (93%). Resolution of signs took median 14, and visual function 4 days. Severity of retinopathy correlated with severity of malaria, coma recovery time and markers of, and rheological factors important in, microcirculatory obstruction.
Discussion Malarial retinopathy is highly specific for malaria and was present in the majority of adults with severe disease, particularly cerebral and fatal, but was prominent in very few with uncomplicated disease. It thus has diagnostic and prognostic utility at the bedside. Retinal findings were similar in adults and children. The strong correlation with markers of, and rheological factors important in, microvascular obstruction suggest an important role of microvascular obstruction in the pathogenesis of both malarial retinopathy and cerebral malaria. Although malarial retinopathy lasted around two weeks, impairment of colour vision and acuity resolved much more rapidly.
Conclusions Malarial retinopathy has potential as a bedside tool to aid diagnosis and prognosis in adults with malaria. Prominent retinal changes are highly suggestive of severe disease, particularly cerebral and fatal. Findings in adults were very similar to those in children both in the present study and in Africa.The correlation of severity of retinopathy with impaired microcirculatory blood flow suggest this process is central to the pathogenesis of both malarial retinopathy, and cerebral malaria. Studies using fluorescein angiography and magnetic resonance imaging to investigate this further are currently underway.
495 in September 2006, other encapsulated H. influenzae infections are now more common than Hib. The Health Protection Agency routinely follow-up all cases of invasive H. influenzae infections in England and Wales. The objective of ths study was to describe the epidemiology, clinical presentation and outcome of invasive non-type b encapsulated H. influenzae between January 2009 and March 2010.
Scientific findings Over the 15-month period, there were 92 cases of Hif (n¼66) and Hie (n¼26) reported. The median age at onset of disease was 62 years . Of the 82 cases with completed questionnaires, 46% presented with pneumonia and 18% with meningitis. Overall, 79% had co-morbidities, with 55% having >1 co-morbidity, mainly chronic heart or lung disease, malignancy or immunosuppression. Twenty-four patients are known to have died, with 12 deaths occurring within 7 days, 17 within 30 days and 21 within 3 months of infection. The median age at death was 77 years, with two deaths occurring in children aged <15 years.
Discussion Hif has now overtaken Hib as the most common encapsulated serotype causing invasive H. influenzae infection in England and Wales. The epidemiology and clinical presentations of Hif and Hie are significantly different to that of Hib, with most cases occuring among the elderly and pneumonia being the most common clinical presentation. Case fatality is also significantly higher than the <5% reported for invasive Hib disease.
Conclusions As the incidence of invasive Hib disease continues to decline because of effective national immunisation programmes, it is important to understand the epidemiology of other H. influenzae serotypes in order to guide future prevention strategies. This study highlights the importance of continued surveillance for all invasive H. influenzae infections across all age groups
THE EPIDEMIOLOGY OF INVASIVE NON-TYPE B ENCAPSULATED HAEMOPHILUS INFLUENZAE DISEASE IN ENGLAND & WALES IN THE ERA OF ROUTINE HIB IMMUNISATION
ISONIAZID-RESISTANT TUBERCULOSIS IN BIRMINGHAM, 1999e2009
Carina Crawford, Shamez Ladhani, Mary Ramsay, Mary Slack
Birmingham Heartlands Hospital, Birmingham, United Kingdom
Health Protection Agency Centre for Infections, London, United Kingdom
Introduction Following the introduction of the routine 12 month Hib booster in the national childhood immunisation programme
Mimie Kariuki, Melinda Munang, Anna Last, Martin Dedicoat
Introduction Resistance to isoniazid is the commonest type of drug resistance in the UK, involving 6% of Mycobacterium tuberculosis isolates reported to national tuberculosis (TB) surveillance programmes in 2008. The optimal regimen and
Abstracts
Introduction
Conclusions
Hospital inpatients are at increased risk of venous thromboembolism (VTE) compared to the general population: this risk can be reduced by thromboprophylaxis with subcutaneous heparin. There is now increasing recognition that ill patients in the community are also at increased risk. This risk is increased by factors such as increasing age, restricted mobility and acute infection. Outpatient Parenteral Antibiotic Therapy (OPAT) allows patients who require intravenous (IV) antibiotics to receive home/outpatient-based care as an alternative to hospital admission. Such patients are at increased risk of VTE, but no data exist as to the extent of this risk compared to hospital inpatients or community patients receiving oral antibiotic therapy. Furthermore, the optimal strategy with respect to thromboprophylaxis for OPAT patients has not been determined. This study assessed a cohort of patients receiving OPAT for cellulitis regarding VTE risk and use of thromboprophylaxis. All patients who were treated for cellulitis through the Sheffield OPAT service in 2009 were identified from the OPAT database. Case notes of patients over the age of 40 years were reviewed and data collected regarding age, gender, site of cellulitis, treatment duration, risk factors for VTE and documentation of a VTE risk assessment as an inpatient or during OPAT. Risk of VTE was assessed from the case notes using the Sheffield Teaching Hospitals Trust inpatient algorithm.
OPAT patients are at increased risk of VTE but further research is required to determine the level of risk compared to patients being treated for acute infections in other settings. There is a need to develop an OPAT-specific VTE risk protocol, with subsequent prospective evaluation.
MALARIAL RETINOPATHY IN ADULTS Richard Maude 1,2, Abdullah Abu Sayeed 3, Nicholas Beare 4, Prakaykaew Charunwatthana 1, M Abul Faiz 5, Amir Hossain 3, Emran Bin Yunus 3, M Gofranul Hoque 3, Mahtab Uddin Hasan 3, Nicholas White 1,2, Nicholas Day 1,2, Arjen Dondorp 1,2 1 Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand 2 Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, CCVTM, University of Oxford, Churchill Hospital, Old Road, Oxford, United Kingdom 3 Chittagong Medical College Hospital, Chittagong, Bangladesh 4 St Paul’s Eye Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom 5 Sir Salimullah Medical College, Dhaka, Bangladesh
Introduction Scientific findings 151 patients with cellulitis were treated through the OPAT service in 2009, of whom 100 were over 40 years of age. 61/100 were referred to OPAT following an inpatient stay, whereas 39/100 were referred direct from the community. 28/100 met the inpatient criteria for thromboprophylaxis: of these only 6 received this during OPAT. Of the 61 patients who had been inpatients prior to OPAT, 17 met the inpatient criteria for thromboprophylaxis but only 8 had received it as inpatients, and an additional 3 patients received thromboprophylaxis without a clear indication. No patient developed VTE over mean follow-up of 4 weeks.
Discussion VTE prophylaxis is an integral component of care for medical and surgical inpatients. Patients with acute infections are at increased risk; this risk is increased by other factors including age over 40 years. Recent inpatient VTE guidelines have been published by the National Institute for Health and Clinical Excellence, but to date there are no data on VTE risk in patients receiving OPAT, and no model for VTE risk assessment. In this study 28/100 of OPAT patients being treated for cellulitis were retrospectively assessed as requiring thromboprophylaxis, but only 6/28 received this. Inpatient assessment of VTE risk was also suboptimal.
A specific retinopathy has been described in African children with cerebral malaria, but in adults this has not been extensively studied. It has great potential as a diagnostic and prognostic tool and pathogenetic marker. Since the structure and function of the retinal vasculature greatly resembles the cerebral vasculature, study of retinal changes can reveal insights into the pathogenesis of cerebral malaria. Obstruction of microcirculatory blood flow is thought to be important in causing both malarial retinopathy and cerebral malaria. A detailed observational study of malarial retinopathy in Bangladeshi adults with P. falciparum malaria was performed using a portable retinal camera. The aims were to establish the prevalence, spectrum and time to resolution of retinal findings in malaria, their effect on visual function and to investigate the role of obstruction of microcirculatory blood flow in its pathogenesis. All smear positive adult patients admitted to Chittagong Medical College Hospital, Chittagong, Bangladesh, during the malaria seasons of 2008-2010 were eligible for the study. Control groups were febrile encephalopathy, sepsis and healthy volunteers and children with malaria. Patients were photographed daily until discharge then weekly until complete resolution of retinal changes. In adults, severity of retinal findings was correlated with markers of microcirculatory blood flow obstruction (blood lactate and rectal capillary blood flow (Microscan)) and rheological factors important in microcirculatory obstruction (P. falciparum histidine rich protein 2 (PfHRP2) and red blood cell deformability (LORCA)).
Abstracts
Scientific findings Of 234 adults recruited, 51/60 (85%) cerebral, 18/27 (67%) noncerebral and 28/59 (47%) uncomplicated malaria had retinopathy. Mostly mild changes were found in 9/29 (31%) encephalopathy, 11/28 (39%) sepsis and 4/31 (13%) healthy volunteers. Moderate-severe retinopathy was in 67% fatal, 62% cerebral, 41% noncerebral and 12% uncomplicated malaria, 14% encephalopathy, 0% sepsis and healthy. Excluding papilloedema, moderate-severe retinopathy was specific for malaria (98%), and cerebral malaria in comatose patients (93%). Resolution of signs took median 14, and visual function 4 days. Severity of retinopathy correlated with severity of malaria, coma recovery time and markers of, and rheological factors important in, microcirculatory obstruction.
Discussion Malarial retinopathy is highly specific for malaria and was present in the majority of adults with severe disease, particularly cerebral and fatal, but was prominent in very few with uncomplicated disease. It thus has diagnostic and prognostic utility at the bedside. Retinal findings were similar in adults and children. The strong correlation with markers of, and rheological factors important in, microvascular obstruction suggest an important role of microvascular obstruction in the pathogenesis of both malarial retinopathy and cerebral malaria. Although malarial retinopathy lasted around two weeks, impairment of colour vision and acuity resolved much more rapidly.
Conclusions Malarial retinopathy has potential as a bedside tool to aid diagnosis and prognosis in adults with malaria. Prominent retinal changes are highly suggestive of severe disease, particularly cerebral and fatal. Findings in adults were very similar to those in children both in the present study and in Africa.The correlation of severity of retinopathy with impaired microcirculatory blood flow suggest this process is central to the pathogenesis of both malarial retinopathy, and cerebral malaria. Studies using fluorescein angiography and magnetic resonance imaging to investigate this further are currently underway.
495 in September 2006, other encapsulated H. influenzae infections are now more common than Hib. The Health Protection Agency routinely follow-up all cases of invasive H. influenzae infections in England and Wales. The objective of ths study was to describe the epidemiology, clinical presentation and outcome of invasive non-type b encapsulated H. influenzae between January 2009 and March 2010.
Scientific findings Over the 15-month period, there were 92 cases of Hif (n¼66) and Hie (n¼26) reported. The median age at onset of disease was 62 years . Of the 82 cases with completed questionnaires, 46% presented with pneumonia and 18% with meningitis. Overall, 79% had co-morbidities, with 55% having >1 co-morbidity, mainly chronic heart or lung disease, malignancy or immunosuppression. Twenty-four patients are known to have died, with 12 deaths occurring within 7 days, 17 within 30 days and 21 within 3 months of infection. The median age at death was 77 years, with two deaths occurring in children aged <15 years.
Discussion Hif has now overtaken Hib as the most common encapsulated serotype causing invasive H. influenzae infection in England and Wales. The epidemiology and clinical presentations of Hif and Hie are significantly different to that of Hib, with most cases occuring among the elderly and pneumonia being the most common clinical presentation. Case fatality is also significantly higher than the <5% reported for invasive Hib disease.
Conclusions As the incidence of invasive Hib disease continues to decline because of effective national immunisation programmes, it is important to understand the epidemiology of other H. influenzae serotypes in order to guide future prevention strategies. This study highlights the importance of continued surveillance for all invasive H. influenzae infections across all age groups
THE EPIDEMIOLOGY OF INVASIVE NON-TYPE B ENCAPSULATED HAEMOPHILUS INFLUENZAE DISEASE IN ENGLAND & WALES IN THE ERA OF ROUTINE HIB IMMUNISATION
ISONIAZID-RESISTANT TUBERCULOSIS IN BIRMINGHAM, 1999e2009
Carina Crawford, Shamez Ladhani, Mary Ramsay, Mary Slack
Birmingham Heartlands Hospital, Birmingham, United Kingdom
Health Protection Agency Centre for Infections, London, United Kingdom
Introduction Following the introduction of the routine 12 month Hib booster in the national childhood immunisation programme
Mimie Kariuki, Melinda Munang, Anna Last, Martin Dedicoat
Introduction Resistance to isoniazid is the commonest type of drug resistance in the UK, involving 6% of Mycobacterium tuberculosis isolates reported to national tuberculosis (TB) surveillance programmes in 2008. The optimal regimen and