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Skin and soft tissue infections
A10
FIS 99 Abstracts
3.2 SKIN AND SOFT TISSUE INFECTIONS mShiranee Hammersmith Hospital, London Gram positive bacteria account for the vast majority of skin and soft tissue infections; a combined medical and surgical approach is often warranted in the most serious cases. Empiric management regimens are largely based upon accumulated clinical experience. As with many ‘old fashioned’ infections, there are in fact no controlled trials on which to base therapy. Even as new therapies become available, there are few trials which directly compare efficacy of newer therapies with standard treatment. This presentation will focus on those bacterial skin and soft tissue infections which require hospitalisation; the evidence which underlies our approach to cellulitis, recurrent cellulitis, fasciitis, and gangrene will be discussed. It is apparent that, at present, there are no clear data to support use of widely recommended options such as intravenous immunoglobin for invasive streptococcal infection or hyperbaric oxygen for gangrene. In the future, management is likely to be complicated by antimicrobial resistance.
Workshop la OUTBREAK DETECTION: EVIDENCE FOR ACTION M CatchDole, H Heine, C Wroath, Communicable Disease Surveillance Centre, London ‘Surveillance should provide evidence for action’ has become the axiom for those that are concerned with the collection, analysis and dissemination of communicable disease data. One of the most important actions in respect of communicable disease control and prevention is outbreak detection and the ensuing intervention. Modern surveillance must provide all those that need to take action that is required to prevent, detect and control outbreaks with evidence that is suitable in terms of its content, presentation and timeliness. Recent developments in information technology provide great opportunities for more effective and more efficient outbreak management. The PHLS Communicable Disease Surveillance Centre (CDSC) has developed systems to facilitate the identification of outbreaks and exceptional events, using Poisson regression techniques and new groupware application software. It is also involved in ongoing development work that will provide a wide constituency of professionals concerned in the management of outbreaks with access to up to the minute surveillance data using web browser technologies over Extranet links.
Workshop 1 b GEOGRAPHY AND ANTIBIOTIC RESISTANCE Dr Anthony Howard, University Hospital of Wales, Card@ Bacteria exist in a vast and infinitely complex ecosystem. Million of years of evolution has led to adaptations that have allowed these organisms to exploit all niches available to them on the globe. This has required a capacity to accommodate exposure to a wide variety of physical, biological and chemical conditions. The nature of these adaptations provides insight into the biology of these organisms and their immediate environment. This presentation will examine variations in antibiotic resistance that are encountered in populations in different geographical locations and will examine some of the factors that such differences highlight. It will focus on recent data that has explored antibiotic resistance in population at regional and community level in Wales and will discuss the potential influence of antibiotic prescribing on these results.
Workshop 2 EMERGING THREATS TO DRINKING WATER SUPPLIES R Hunter, Countess of Chester Health Park, Chester The provision of a safe clean water supply is the prerequisite of urban civilisation. It can be argued that modem Public Health Dr Paul
Medicine owes its inception to the impact of waterborne disease. Nevertheless, despite the importance of waterborne disease, it is a commodity which western civilisation is at risk of becoming too complacent about the safety and reliability of its water sources. Whilst some diseases such as cholera and typhoid have long been known to be waterborne, many pathogens described in the last 30 years are associated with water. Examples include cryptosporidium, cyclospora, campylobacter and enterohaemorrhagic E. coli. This presentation considers some of the emerging threats to water supplies. Undoubtedly the greatest emergent threat to drinking water supplies is the increasing demand for water from a rapidly world growing population, exacerbated by climatic change. Even in Europe, a region with an apparently plentiful supply of freshwater, the condition of some of our water sources is degrading due to over abstraction or pollution. In certain circumstances the effect of pollution on water quality is indirect through promotion of potentially toxic algae. This is seen in the case of cyanobacterial and dianoflagelate blooms. Both of these groups of microorganisms can lead to potentially serious effects on human health. Given the great importance of water to human civilisation there is the potential that water may be involved in conflicts. Water may become both a reason for war and a strategic weapon deliberately contaminated with agents injurious to health. As with other weapons water may also be the vehicle for terrorist action. The threat of terrorism against drinking water supplies was raised earlier this year when a threat was made to poison drinking water supplies in the UK. Other emergent threats to our water supply come from a variety of directions. In the developed world there is concern over Mycobacteria in water supplies posing a threat to human health. In particular, M. avium complex infections have been linked with drinking water in AIDS patients. Another potentially emerging threat relates to toxoplasmosis, outbreaks of which have been associated with drinking water on a couple of occasions. No outbreaks have been detected in the UK, though given that there is no systematic screening for this pathogen, this is not surprising.
Workshop 5 MALARIAL DISEASE AND IMMUNITY IN MALARIA Professor Dominic Kwiatkowski, John Radcliffe Hospital, Oxford Although over a million African children die each year of malaria, this represents only a minority of the total number of infections. We still have a very incomplete understanding of why some infections are fatal while others resolve uneventfully. At least part of the explanation lies in host genetic diversity. Erythrocyte polymorphisms such as haemoglobin S and Duffy antigen negativity provide classical examples of how the evolutionary pressure of infectious disease may select for specific host genotypes. Over ten putative malaria susceptibility determinants have already been defined, including several in immunological mediators, and it is likely that very many more have yet to be discovered. The human genome contains a vast number of DNA polymorphisms which may lead to phenotypic variation in many immunological and biochemical pathways. Ongoing advances in DNA technology will ultimately allow us to screen thousands of candidate genes for association with susceptibility to severe malaria in large multi-centre studies. using both case-control and family-based statistical techniques. TO understand the functional basis of the genetic associations that such ‘an exercise will generate, it will be necessary to carry out saturation mapping of candidate gene regions, and to combine this with detailed molecular analysis of disease associated polymorphisms at the cellular level. Although this will be a large undertaking, it may be the most direct route to gain a molecular understanding of immune and pathogenic processes that influence clinical outcome in different epidemiological settings, and may ultimately lead to fundamentally new approaches to the treatment and prevention of severe malaria.
FIS 99 Abstracts
3.2 SKIN AND SOFT TISSUE INFECTIONS mShiranee Hammersmith Hospital, London Gram positive bacteria account for the vast majority of skin and soft tissue infections; a combined medical and surgical approach is often warranted in the most serious cases. Empiric management regimens are largely based upon accumulated clinical experience. As with many ‘old fashioned’ infections, there are in fact no controlled trials on which to base therapy. Even as new therapies become available, there are few trials which directly compare efficacy of newer therapies with standard treatment. This presentation will focus on those bacterial skin and soft tissue infections which require hospitalisation; the evidence which underlies our approach to cellulitis, recurrent cellulitis, fasciitis, and gangrene will be discussed. It is apparent that, at present, there are no clear data to support use of widely recommended options such as intravenous immunoglobin for invasive streptococcal infection or hyperbaric oxygen for gangrene. In the future, management is likely to be complicated by antimicrobial resistance.
Workshop la OUTBREAK DETECTION: EVIDENCE FOR ACTION M CatchDole, H Heine, C Wroath, Communicable Disease Surveillance Centre, London ‘Surveillance should provide evidence for action’ has become the axiom for those that are concerned with the collection, analysis and dissemination of communicable disease data. One of the most important actions in respect of communicable disease control and prevention is outbreak detection and the ensuing intervention. Modern surveillance must provide all those that need to take action that is required to prevent, detect and control outbreaks with evidence that is suitable in terms of its content, presentation and timeliness. Recent developments in information technology provide great opportunities for more effective and more efficient outbreak management. The PHLS Communicable Disease Surveillance Centre (CDSC) has developed systems to facilitate the identification of outbreaks and exceptional events, using Poisson regression techniques and new groupware application software. It is also involved in ongoing development work that will provide a wide constituency of professionals concerned in the management of outbreaks with access to up to the minute surveillance data using web browser technologies over Extranet links.
Workshop 1 b GEOGRAPHY AND ANTIBIOTIC RESISTANCE Dr Anthony Howard, University Hospital of Wales, Card@ Bacteria exist in a vast and infinitely complex ecosystem. Million of years of evolution has led to adaptations that have allowed these organisms to exploit all niches available to them on the globe. This has required a capacity to accommodate exposure to a wide variety of physical, biological and chemical conditions. The nature of these adaptations provides insight into the biology of these organisms and their immediate environment. This presentation will examine variations in antibiotic resistance that are encountered in populations in different geographical locations and will examine some of the factors that such differences highlight. It will focus on recent data that has explored antibiotic resistance in population at regional and community level in Wales and will discuss the potential influence of antibiotic prescribing on these results.
Workshop 2 EMERGING THREATS TO DRINKING WATER SUPPLIES R Hunter, Countess of Chester Health Park, Chester The provision of a safe clean water supply is the prerequisite of urban civilisation. It can be argued that modem Public Health Dr Paul
Medicine owes its inception to the impact of waterborne disease. Nevertheless, despite the importance of waterborne disease, it is a commodity which western civilisation is at risk of becoming too complacent about the safety and reliability of its water sources. Whilst some diseases such as cholera and typhoid have long been known to be waterborne, many pathogens described in the last 30 years are associated with water. Examples include cryptosporidium, cyclospora, campylobacter and enterohaemorrhagic E. coli. This presentation considers some of the emerging threats to water supplies. Undoubtedly the greatest emergent threat to drinking water supplies is the increasing demand for water from a rapidly world growing population, exacerbated by climatic change. Even in Europe, a region with an apparently plentiful supply of freshwater, the condition of some of our water sources is degrading due to over abstraction or pollution. In certain circumstances the effect of pollution on water quality is indirect through promotion of potentially toxic algae. This is seen in the case of cyanobacterial and dianoflagelate blooms. Both of these groups of microorganisms can lead to potentially serious effects on human health. Given the great importance of water to human civilisation there is the potential that water may be involved in conflicts. Water may become both a reason for war and a strategic weapon deliberately contaminated with agents injurious to health. As with other weapons water may also be the vehicle for terrorist action. The threat of terrorism against drinking water supplies was raised earlier this year when a threat was made to poison drinking water supplies in the UK. Other emergent threats to our water supply come from a variety of directions. In the developed world there is concern over Mycobacteria in water supplies posing a threat to human health. In particular, M. avium complex infections have been linked with drinking water in AIDS patients. Another potentially emerging threat relates to toxoplasmosis, outbreaks of which have been associated with drinking water on a couple of occasions. No outbreaks have been detected in the UK, though given that there is no systematic screening for this pathogen, this is not surprising.
Workshop 5 MALARIAL DISEASE AND IMMUNITY IN MALARIA Professor Dominic Kwiatkowski, John Radcliffe Hospital, Oxford Although over a million African children die each year of malaria, this represents only a minority of the total number of infections. We still have a very incomplete understanding of why some infections are fatal while others resolve uneventfully. At least part of the explanation lies in host genetic diversity. Erythrocyte polymorphisms such as haemoglobin S and Duffy antigen negativity provide classical examples of how the evolutionary pressure of infectious disease may select for specific host genotypes. Over ten putative malaria susceptibility determinants have already been defined, including several in immunological mediators, and it is likely that very many more have yet to be discovered. The human genome contains a vast number of DNA polymorphisms which may lead to phenotypic variation in many immunological and biochemical pathways. Ongoing advances in DNA technology will ultimately allow us to screen thousands of candidate genes for association with susceptibility to severe malaria in large multi-centre studies. using both case-control and family-based statistical techniques. TO understand the functional basis of the genetic associations that such ‘an exercise will generate, it will be necessary to carry out saturation mapping of candidate gene regions, and to combine this with detailed molecular analysis of disease associated polymorphisms at the cellular level. Although this will be a large undertaking, it may be the most direct route to gain a molecular understanding of immune and pathogenic processes that influence clinical outcome in different epidemiological settings, and may ultimately lead to fundamentally new approaches to the treatment and prevention of severe malaria.