Evolving epidemiology of carbapenemase-producing Enterobacterales: one hospital's infection prevention and control response over nine years

BACKGROUND

Preventing carbapenemase-producing Enterobacterales (CPE) transmission is a significant challenge for hospital infection prevention and control teams (IPCTs). Control measures include screening at-risk patients, contact tracing, and the isolation of carriers with contact precautions.

AIM

The evolution of infection prevention and control measures was assessed in a tertiary acute care hospital with predominately multi-bedded patient accommodation, from 2011 to 2019 as cases of CPE increased. The implications for, and the response and actions of, the IPCT were also reviewed.

METHODS

CPE data collected prospectively from our laboratory, IPCT, and outbreak meeting records were reviewed to assess how the IPCT adapted to the changing epidemiology, from sporadic cases, to outbreaks and to localized endemic CPE.

FINDINGS

Of 178 cases, 152 (85%) were healthcare-associated and there was a marked increase in cases from 2017. The number of screening samples tested annually increased from 1190 in 2011 to 16,837 in 2019, and six outbreaks were documented, with larger outbreaks identified in later years. OXA-48 carbapenemase was detected in 88% of isolates and attendance at outbreak meetings alone accounted for 463.5 h of IPCT members, and related staff time.

CONCLUSION

Despite considerable efforts and time invested by the IPCT, the number of CPE cases is increasing year-on-year, with more outbreaks being reported in later years, albeit partly in response to increased screening requirements. Infrastructural deficits, the changing epidemiology of CPE, and national policy are major factors in the increasing number of cases.

Dementia palliative care: A multi-site survey of long term care STAFF'S education needs and readiness to change

Many people with dementia reside in long-term care, where limited staff knowledge of dementia palliative care has been identified, along with poor awareness that a palliative approach can assist in identifying unmet care needs. Evidence-based guidance in palliative care for people with dementia is available however, implementing this guidance requires staff engagement and a tailored educational approach. This pre-implementation situational analysis informed a tailored staff education intervention to support the implementation of national guidance on dementia palliative care in long term care. Using a cross-sectional study design, underpinned by the Consolidated Framework for Implementation Research, survey data were collected on site profile, staff demographics, learning needs, and readiness-to change at three residential care sites for older people in Ireland. In total, 69 staff (predominantly nurses and healthcare attendants) completed the surveys. Medication management and management of pain were the most frequently identified learning needs. Staff were confident in their ability to implement change but de-motivation and powerlessness were substantial factors as only one-third of staff were "ready for change". Staffing levels, managing risk during change and perceived reluctance in others were common barriers. These results informed an educational intervention to address the specific care context, staff learning needs and barriers to change prior to implementation.

0918 Quebec Adolescents’ Insomnia Symptoms, Mental Health & Access to Sleep Care

Introduction

Our school boards are part of the Quebec Center Of Excellence For Mental Health, and are thus mandated to identify and then prevent/treat factors that could negatively affect the mental health of their students. As part of this mission, we conducted a study that aimed 1) to examine the prevalence of insomnia in typically developing students in Quebec and their associations with students’ mental health, and; 2) to assess student access to behavioral sleep interventions in Quebec.

Methods

145 (Age 15.53+1; 75 Girls, 70 Boys) typically developing students. Insomnia symptoms were measured using the Insomnia Severity Index. Sleep was measured by Actigraphy. The Youth Self Report was used to measure students mental health. Access to care was measured using a detailed questionnaire.

Results

The key findings were: 1) 45% of the students reported poor sleep quality, dysfunction during the day due to sleepiness, difficulty falling or staying asleep, and excessive daytime sleepiness. Total scores on self-reports sleep measures were positively significantly correlated with Actigraphy measures of sleep duration and quality and with each other; 2) Robust positive associations were found between insomnia and psychiatric symptoms after adjusting for common risk factors, including age, socioeconomic status, and gender; 3) None of the students had access to sleep care and 25% of them reported using over-the counter sleep aids with minimal success.

Conclusion

These findings are alarming because they show that: 1) insomnia symptoms are prevalent in Quebec students and are strongly associated with the symptomatology of mental distress in students who do not meet the diagnostic criteria of a psychological disorder, and; 2) these students do not have access to insomnia care. These findings suggest that treatment of insomnia could offer an incredible opportunity to protect and improve the sleep and the mental health of these students.

Support

Canadian Institute of Health Research grant to Reut Gruber

Have developments in palliative care services impacted on place of death of colorectal cancer patients in Ireland? A population-based study

BACKGROUND

Whether developments in palliative care have impacted on where cancer patients die is unknown. We investigated time trends in place of death for colorectal cancer.

METHODS

Details were abstracted on 10,175 colorectal cancer deaths during 1994-2004. Time trends were analysed by joinpoint regression.

RESULTS

Nearly half (49%) of deaths occurred in acute hospitals, 29% at home, 13% in hospices and 7% in nursing homes. Hospital deaths were unchanged over time. Hospice deaths rose from 6% in 1994 to 17% in 2003. Home deaths decreased significantly, but only in health boards with hospices [estimated annual percentage change (EAPC) = -3.6%, 95%CI -4.19 to -2.97%, p < 0.001]. Nursing home deaths rose significantly in areas without hospices (EAPC = 8.0%, 95%CI 2.27 to -13.94%, p = 0.011).

CONCLUSIONS

Most colorectal cancer deaths occur in hospital. Availability of hospice facilities is a key determinant of where the burden of death falls. The results suggest unmet demand for hospice care in Ireland.

Comparison of arterial and venous blood gases and the effects of analysis delay and air contamination on arterial samples in patients with chronic obstructive pulmonary disease and healthy controls

BACKGROUND

Arterial blood gases (ABGs) are often sampled incorrectly, leading to a 'mixed' or venous sample. Delays in analysis and air contamination are common.

OBJECTIVES

We measured the effects of these errors in patients with chronic obstructive pulmonary disease (COPD) exacerbations and controls.

METHODS

Arterial and venous samples were analyzed from 30 patients with COPD exacerbation and 30 controls. Venous samples were analysed immediately and arterial samples separated into non-air-contaminated and air-contaminated specimens and analysed at 0, 30, 60, 90 and 180 min.

RESULTS

Mean venous pH was 7.371 and arterial pH was 7.407 (p < 0.0001). There was a correlation between venous and arterial pH (r = 0.5347, p < 0.0001). The regression equation to predict arterial pH was: arterial pH = 4.2289 + 0.43113 · venous pH. There were no clinically significant differences in arterial PO₂ associated with analysis delay. A statistically significant decline in pH was detected at 30 min in patients with COPD exacerbation (p = 0.0042) and 90 min in controls (p < 0.0001). A clinically significant decline in pH emerged at 73 min in patients with COPD exacerbation and 87 min in controls. Air contamination was associated with a clinically significant increase in PO₂ in all samples, including those that were immediately analyzed.

CONCLUSIONS

Arterial and venous pH differ significantly. Venous pH cannot accurately replace arterial pH. Temporal delays in ABG analysis result in a significant decline in measured pH. ABGs should be analysed within 30 min. Air contamination leads to an immediate increase in measured PO₂, indicating that air-contaminated ABGs should be discarded.

Quantification of selected aroma-active compounds in strawberries by headspace solid-phase microextraction gas chromatography and correlation with sensory descriptive analysis

Selected aroma-active compounds in strawberries were quantified using headspace solid-phase microextraction and gas chromatography. Ten strawberry cultivars grown in California and Oregon were studied. The standard curves were built in a synthetic matrix and quantification was achieved using multiple internal standards. Odor activity values (OAVs) of the aroma compounds were calculated to understand their contribution to the overall aroma. Although the concentrations of the aroma compounds varied depending on the cultivars, in general, ethyl butanoate, mesifurane, ethyl hexanoate, ethyl 3-methylbutanoate, hexyl acetate, and gamma-dodecalactone had the highest OAVs. Descriptive sensory analysis was performed by a trained panel of 10 members. A PCA plot was built to understand the aroma contribution of principal components. The chemical results were compared with sensory data. The OAV of esters correlated well with the floral, pineapple, and banana notes. The green notes did not correlate with the concentration or OAVs of aldehydes or C6 alcohols. It is assumed that the higher amounts of green, sulfur, musty, and waxy notes in some cultivars were due to the lack of fruity notes.

Leiomyosarcoma of the broad ligament: a case report and literature review

Primary leiomyosarcoma of the broad ligament is a very rare, rapidly progressive and highly malignant gynaecological tumor. There are only 11 cases reported so far in the literature. An 87-year-old Caucasian lady with leiomyosarcoma of the broad ligament is presented. Treatment consisted of resection and total abdominal hysterectomy with bilateral salpingo-oopphorectomy. Unusually, she developed large recurrent pelvic disease in the absence of disseminated metastasis following surgery. She died within 8 weeks of primary surgery. This highlights the unknown behavior of this tumor and the need for more research into management.

Indium-111-leukocyte imaging in Gaucher's disease

A 29-yr-old man with Gaucher's disease and fever of unknown origin underwent 111In-labeled mixed autologous leukocyte scintigraphy. Although no focus of infection was identified, the resulting images were most unusual and were characterized by massive hepatomegaly, lack of central marrow activity and extensive lymph node uptake of labeled leukocytes. All of these findings could be explained on the basis of the patient's underlying disease. Hepatomegaly and absent central marrow activity correlated with extensive infiltration of these organs by Gaucher cells, while the lymph node findings were attributed to the presence of extramedullary hematopoiesis.

Carbon dioxide laser treatment for vulval papillomatosis (vulvodynia)

Genital papillomatosis accompanied by distressing vulval symptoms is often termed vulvodynia. Common presenting symptoms are vulvar burning, pruritus and dyspareunia. Sixteen patients with vulval papillomatosis (vulvodynia) have been treated by carbon dioxide laser therapy over a 4-year period. Initial responses at 6 weeks appeared encouraging but with follow-up it became apparent that the relapse rate was high, with a mean symptom-free interval of 4.6 months. Of the 16 patients treated, only three remain symptom free. In view of our findings, we recommend that laser therapy should not be offered as a primary procedure, if at all, for patients with vulval papillomatosis.

Tumour cell activity markers in epithelial ovarian cancer: are biochemical and cytometric indices complementary?

Flow cytometry has enabled the objective assessment of cellular morphology and activity, which can also be biochemically evaluated by measuring products of cellular metabolism, such as cyclic 3'5' guanosine monophosphate (cGMP). Using paraffin-embedded formalin-fixed material obtained from the primary operation, an analysis of the correlation between nuclear ploidy and the proliferative index (PI) as quantified by flow cytometry with pre-treatment urinary cGMP was performed in 40 epithelial ovarian cancer (EOC) patients. The majority of the study group had advanced disease (28 FIGO III/IV) and residual disease (31). All but three (stage I) patients received single agent high dose cisplatinum as first-line therapy (100 mg m-2 x 5); in patients with evaluable disease there was a response rate of 64%. Thirty-one patients have died; the median survival of the study population being 27 months. There was a significant association between cGMP and PI. Significantly more aneuploid tumours had elevated PI values (P = 0.02). No variable predicted response. An initial univariate log rank analysis identified stage, the amount of residual disease, cGMP and PI as prognostic factors. Because of the interrelation between these and other factors and because PI did not conform to the proportional hazards model, a multivariate stepwise discriminant analysis was performed using survival at 36 months (the minimum follow-up for surviving patients) as the end-point. On the basis of this analysis, stage and residual disease were the most important prognostic factors, but cyclic GMP continued to have prognostic value even when these other factors were entered into the predictive model. However, the additional information gained has little clinical relevance.

Anti-fertility effect of passive immunization against progesterone is influenced by genotype

The anti-fertility effect of a monoclonal progesterone antibody injected i.p. 32 h after mating is influenced by genotype since a single dose of 5.7 nmol immunoglobulin G successfully blocked the establishment of pregnancy in BALB/c but not in F1 hybrid mice (CBA male X BALB/c female). Progesterone concentrations in circulation were significantly higher at days 3 and 4 after mating in F1 females compared with those of the BALB/c stock. Moreover, the pattern of mitotic activity in the endometrium after passive immunization differed between the two genotypes. In treated BALB/c mice there was no increase in mitotic activity in stromal cells at days 3, 4 and 5 after mating (in contrast to BALB/c control females in which the number of stromal mitoses increased sharply). In F1 females there was a transient effect of antibody at day 3 (no increase in stromal mitoses but enhanced mitotic activity in the glandular epithelium compared with F1 control females), and subsequently a normal increase in mitotic divisions in stromal cells. The hypothesis is proposed that passive immunization against progesterone at 32 h after mating will only block the establishment of pregnancy in genotypes in which there is a gradual, rather than a steep rise in circulating progesterone concentrations during the preimplantation period. In F1 mice, high concentrations of circulating progesterone at days 3 and 4 of pregnancy apparently over-ride the effect of antibody and facilitate the normal development of stromal mitotic activity associated with the onset of implantation.

Determination of uracil and thymine and their nucleosides and nucleotides in picomole amounts by gas chromatography mass spectrometry selected ion monitoring

A stable isotope dilution method is presented by which uracil (Ura) and thymine (Thy) can be determined with high precision and sensitivity at the picomole level utilizing stable isotope dilution and gas chromatography electron impact mass spectrometry in the selected ion monitoring mode. [15N2]Ura and [2H3]Thy served as internal standards. The molecular ions as well as the [M-CH3]+ ion fragments of silylated Ura and Thy (Ura-TMS and Thy-TMS) were suitable for the assay which provides evidence of specificity, if identical results are obtained at both ions. Nucleosides and nucleotides of Ura and Thy were determined following quantitative hydrolysis in 6 N HCl at 180 degrees C for two hours. Other hydrolysis procedures did not give satisfactory results. Levels of free Ura and Thy were measured in human and rat plasma after solvent extraction with a sensitivity of 20-40 pm ml-1 demonstrating ready applicability of the assay method to biological samples. The potential physiological role of circulating Ura and Thy is discussed.

Chemical structure and aldosterone receptor affinity of canrenoate-potassium metabolites in rabbits

Two new major metabolites of canrenoate-potassium (III) were isolated from rabbit livers, in addition to the known metabolite canrenone (II). One metabolite (MA) contains two additional oxygen atoms of unknown location. The second metabolite (MB), which was previously shown to interfere with a plasma aldosterone radioimmunoassay, is identified as 20-hydroxy canrenone. Canrenone (II) and metabolite MB showed significant affinity to rat kidney cytosol aldosterone receptors and might both contribute to the pharmacological effects of canrenoate-K (III).

Determination of ftorafur and 5-fluorouracil levels in plasma and urine

A gas chromatographic method was developed for ftorafur (Ft) detection in plasma and urine with a sensitivity of 1 mug/ml. Specific determination of its metabolite 5-fluorouracil (FU) with a sensitivity of 1 ng/ml was achieved by column chromatographic separation from Ft and subsequent gas chromatography-mass spectrometry of bis-silyl-FU in the selected ion mode (GC-MS-SIM) using bis-15N-FU as internal standard. Intravenous injections of 2-14C-Ft and 2',5'-14C-Ft were given to rats and rabbits respectively, and plasma and urine were analyzed for Ft, and 14C activity. Unchanged Ft accounted for most of the 14C activity in plasma, while FU concentrations were below 0.15% and 0.4% relative to Ft concentrations in the rabbit and the rat, respectively. 30-60% of the urinary 14C activity was unchanged Ft and less than 0.2% FU. The significance or low FU levels is discussed in view of the hypothesis that Ft acts as a transport form of its metabolite FU.

Determination of (plus or minus)-1, 2-bis(3, 5-dioxopiperazinyl) propane plasma levels in rats, rabbits, and humans by GLC and mass fragmentography

Specific assay procedures were developed to measure plasma concentrations of (plus or minus)-1, 2-bis(3, 5-dioxopiperazinyl) propane (1) by GLC using flame-ionization detection with a sensitivity limit of 5 mug/ml and by GLC-mass fragmentography with a sensitivity limit of 0.2 mug/ml. Applicability of the assay procedures was demonstrated in rats, rabbits, and humans. Plasma concentration-time curves of total 14-C activity and intact I was obtained in rats and rabbits following oral and intravenous administration of 14-C-I. Plasma elimination half-lives of I in the first 2 hr following intravenous doses in rats were 40 and 45 min in two rats. Plasma levels of I were measured over 6 hr after an intravenous dose in rabbits and followed a two-compartment open model with a terminal loglinear plasma half-life of 85 min. Significantly higher total 14-C levels compared to intact I plasma concentrations indicated rapid biotransformation in both rats and rabbits to unknown metabolites. The oral bioavailability appeared to be limited in both species relative to intravenous administration. Two patients receiving 3 g I/m-2 in tablets orally showed plasma levels of I similar to those obtained after oral doses in rats and rabbits, with peak concentrations at 2 hr after the dose (3.8 mug/ml) and with still measurable levels 12 hr after the dose (0.4 mug/ml).