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O'Brien A, Hart J, Higgins A, Arthur I, Lee GH, Leung M, Kennedy K, Bradbury S, Foster S, Warren S, Korman TM, Abbott IJ, Heney C, Bletchley C, Warner M, Wells N, Wilson D, Varadhan H, Stevens R, Lahra M, Newton P, Maley M, van Hal S, Ingram PR. Nocardia species distribution and antimicrobial susceptibility within Australia. Intern Med J 2024; 54:613-619. [PMID: 37929813 DOI: 10.1111/imj.16234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/29/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Nocardia is a ubiquitous saprophyte capable of causing human disease. Disease is primarily respiratory or cutaneous, usually acquired via inhalation or inoculation. Under the influence of environmental and host factors, Nocardia incidence and species distribution demonstrate geographical variation. AIMS To examine for differences in Nocardia incidence within Western Australia (WA) and analyse species distribution in the context of prior published studies. To analyse antibiogram data from a nationwide passive antimicrobial resistance surveillance program. METHODS Retrospective extraction of laboratory data for Western Australian Nocardia isolates over a 21-year period. Analysis of Nocardia antimicrobial susceptibility testing data submitted to the Australian Passive Antimicrobial Resistance Surveillance (APAS) program between 2005 and 2022. RESULTS Nine hundred sixty WA isolates were identified, giving an annual incidence of 3.03 per 100 000 population with apparent latitudinal variation. The four most common species identified within WA and amongst APAS isolates were N. nova, N. cyriacigeorgica, N. brasiliensis and N. farcinica. APAS data demonstrated that all species exhibited high rates of susceptibility to linezolid (100%) and trimethoprim-sulfamethoxazole (98%). Amikacin (>90% susceptibility for all species except N. transvalensis) was the next most active parenteral agent, superior to both carbapenems and third-generation cephalosporins. Susceptibility to oral antimicrobials (other than linezolid) demonstrated significant interspecies variation. CONCLUSIONS We demonstrate geographical variation in the distribution of Nocardia incidence. Four species predominate in the Australian setting, and nationwide data confirm a high in vitro susceptibility to trimethoprim-sulphamethoxazole and linezolid, justifying their ongoing role as part of first-line empiric therapy.
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Affiliation(s)
- Aine O'Brien
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Julie Hart
- Department of Infectious Diseases, Sir Charles Gardiner Hospital, Perth, Western Australia, Australia
| | - Ammie Higgins
- PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - Ian Arthur
- PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - Gar-Hing Lee
- PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - Michael Leung
- PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Perth, Western Australia, Australia
| | - Karina Kennedy
- ACT Health, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Susan Bradbury
- ACT Health, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Sarah Foster
- Launceston General Hospital, Tasmanian Health Service (THS), Hobart, Tasmania, Australia
| | - Sanchia Warren
- Royal Hobart Hospital, Department of Microbiology and Infectious Diseases, Hobart, Tasmania, Australia
| | - Tony M Korman
- Monash Health, Monash Infectious Diseases, Melbourne, Victoria, Australia
| | | | - Claire Heney
- Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | | | - Morgyn Warner
- Infectious Diseases and Microbiology Department, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Nicholas Wells
- South Australia Pathology, Adelaide, South Australia, Australia
| | - Desley Wilson
- South Australia Pathology, Adelaide, South Australia, Australia
| | - Hemalatha Varadhan
- Hunter New England, NSW Health Pathology, Newcastle, New South Wales, Australia
| | - Robert Stevens
- South Eastern Sydney, NSW Health Pathology, Sydney, New South Wales, Australia
- School of Biomedical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Monica Lahra
- NSW Health Pathology, Newcastle, New South Wales, Australia
| | - Peter Newton
- Illawarra-Shoalhaven, NSW Health Pathology, Wollongong, New South Wales, Australia
| | - Michael Maley
- South Western Sydney, NSW Health Pathology, Sydney, New South Wales, Australia
- Microbiology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Sebastian van Hal
- NSW Health Pathology, Newcastle, New South Wales, Australia
- Infectious Diseases and Microbiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Paul R Ingram
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia
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Schubert JP, Ingram PR, Warner MS, Rayner CK, Roberts-Thomson IC, Costello SP, Bryant RV. Author reply to Hettiarachchi et al. (re Helicobacter pylori resistance in Australia…). Intern Med J 2024; 54:356-357. [PMID: 38350658 DOI: 10.1111/imj.16333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 02/15/2024]
Affiliation(s)
- Jonathon P Schubert
- Faculty of Health Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Paul R Ingram
- Department of Microbiology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
- School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Morgyn S Warner
- Faculty of Health Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Microbiology and Infectious Diseases Directorate, SA Pathology, Adelaide, South Australia, Australia
| | - Christopher K Rayner
- Faculty of Health Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ian C Roberts-Thomson
- Faculty of Health Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Samuel P Costello
- Faculty of Health Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Robert V Bryant
- Faculty of Health Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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Ingram PR, Jones EE, Allen B, Murray RJ, Keehner TJ, Whitmore TJ. Omadacycline therapy for Mycobacterium abscessus species infections. Intern Med J 2023; 53:2257-2263. [PMID: 36917124 DOI: 10.1111/imj.16071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 03/10/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Antimicrobial resistance and therapy-related adverse effects make Mycobacterium abscessus treatment challenging. Omadacycline is a novel, bioavailable aminomethylcycline with favourable in vitro activity against M. abscessus. AIMS To describe a case report and review the published literature describing outcomes for M. abscessus infections treated with omadacycline. METHODS Systematic literature review. RESULTS We identified three articles that, in addition to our case report, describe 18 patients. Pulmonary infections were most frequent. Minimum inhibitory concentrations were reported for two isolates (0.25 and 0.5 mg/L). Despite half the patients starting omadacycline because of failure of prior therapy, 15 (83%) had a favourable outcome, defined as 'cure', 'improvement' or 'clinical success' as determined by the primary study authors. One patient (6%) discontinued omadacycline because of gastrointestinal intolerance. CONCLUSIONS Although the limited observational data and in vitro susceptibility results are encouraging, randomised control trials are required to determine the role of omadacycline as part of combination therapy for this most difficult-to-treat pathogen.
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Affiliation(s)
- Paul R Ingram
- Royal Perth Hospital, Perth, Western Australia, Australia
- PathWest Laboratory Medicine, Perth, Western Australia, Australia
- University of Western Australia, Perth, Western Australia, Australia
| | - Eva E Jones
- Royal Perth Hospital, Perth, Western Australia, Australia
| | - Bethwyn Allen
- Royal Perth Hospital, Perth, Western Australia, Australia
| | - Ronan J Murray
- PathWest Laboratory Medicine, Perth, Western Australia, Australia
- University of Western Australia, Perth, Western Australia, Australia
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | | | - Timothy J Whitmore
- Royal Perth Hospital, Perth, Western Australia, Australia
- Anita Clayton Centre, Perth, Western Australia, Australia
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4
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Schubert JP, Ingram PR, Warner MS, Rayner CK, Roberts-Thomson IC, Costello SP, Bryant RV. Refractory Helicobacter pylori infection in Australia: updated multicentre antimicrobial resistance. Intern Med J 2023; 53:1972-1978. [PMID: 37705320 DOI: 10.1111/imj.16226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/11/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND AND AIM Helicobacter pylori infection is responsible for considerable morbidity and mortality worldwide and eradication rates are falling globally because of increasing antimicrobial resistance. However, there is a paucity of local data to guide the choice of eradication therapy in Australia. This study aimed to evaluate current Australian rates of H. pylori antibiotic resistance in patients who had failed prior eradication therapy. METHODS A retrospective analysis of routine culture and antibiotic susceptibility data from two pathology laboratories servicing multiple tertiary referral hospitals in Western Australia (WA) and South Australia (SA), between 2018 and 2022, was performed. Rates of antimicrobial resistance and prevalence of multiresistant isolates in both SA and WA were calculated and comparison of temporal trends and differences between the two states was conducted. RESULTS A total of 796 H. pylori isolates revealed a clarithromycin resistance rate of 82%, metronidazole 68%, amoxicillin 4.4% and tetracycline 0.5%. Resistance to levofloxacin was observed in 22% and rifampicin 14%. Rates of resistance to clarithromycin were lower in SA compared with WA (incidence rate ratio [IRR]: 0.69, P = 0.0001). Multiresistant isolates were discovered in 63% of patients, with lower rates in SA compared with WA (IRR: 0.74, P = 0.002). CONCLUSION This first multicentre, multistate study of H. pylori resistance in Australian patients exposed to prior therapy demonstrated high rates of antimicrobial resistance, including levofloxacin (>20%). This raises concern about recommending levofloxacin in empirical second-line therapies. Increased monitoring and awareness of current H. pylori resistance rates in Australia are needed to guide local eradication practices.
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Affiliation(s)
- Jonathon P Schubert
- Faculty of Health Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Paul R Ingram
- Department of Microbiology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
- School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Morgyn S Warner
- Faculty of Health Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Microbiology and Infectious Diseases Directorate, SA Pathology, Adelaide, South Australia, Australia
| | - Christopher K Rayner
- Faculty of Health Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ian C Roberts-Thomson
- Faculty of Health Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Samuel P Costello
- Faculty of Health Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Robert V Bryant
- Faculty of Health Sciences, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Department of Gastroenterology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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5
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Bazargani S, Rawlins MD, Mclellan DG, Ingram PR, Dyer JR. Moving to telehealth antimicrobial stewardship during the Covid-19 pandemic - impact on activity and adherence. Intern Med J 2022; 52:2199-2200. [PMID: 36000382 PMCID: PMC9538967 DOI: 10.1111/imj.15906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/09/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Shiva Bazargani
- Department of Pharmacy, Fiona Stanley Hospital, 11 Robin Warren drive, Perth, WA
| | - Matthew Dm Rawlins
- Department of Pharmacy, Fiona Stanley Hospital, 11 Robin Warren drive, Perth, WA
| | - Duncan Gj Mclellan
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren drive, Perth, WA
| | - Paul R Ingram
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren drive, Perth, WA.,PathWest Laboratory Medicine, Department of Microbiology, Perth, WA.,School of Pathology and Laboratory Medicine, University of Western Australia, Perth, WA
| | - John R Dyer
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren drive, Perth, WA
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6
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Chew SM, Heath CH, Petursson C, Boan PA, Robinson JO, Italiano CM, Dyer JR, Manning L, Ingram PR. Antifungal use via outpatient parenteral antimicrobial therapy. Mycoses 2022; 65:946-952. [PMID: 35923125 DOI: 10.1111/myc.13513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/27/2022] [Accepted: 08/01/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Antifungal administration via outpatient parenteral antimicrobial therapy (OPAT) is infrequent. As patients with invasive fungal infections (IFIs) receiving OPAT are at high risk of readmissions, careful, risk based patient selection and monitoring is important. OBJECTIVES To describe our experience managing IFIs via OPAT, including assessment of risk factors associated with unplanned readmissions. PATIENTS AND METHODS A retrospective cohort study of outpatients from two tertiary hospitals in Western Australia managed with parenteral antifungals for the treatment of IFIs from 2012 to 2020. Outcomes assessed were unplanned OPAT-related readmissions, adverse events and achievement of treatment aims at the completion of OPAT. RESULTS Forty six patients were included, encompassing 696 OPAT days. Twenty three (50%) patients received intravenous (IV) liposomal amphotericin B (L-AmB), 23 (50%) received IV echinocandins and one (2%) patient received IV fluconazole. One patient received both IV L-AmB and an echinocandin. Unplanned OPAT-related readmissions occurred in 13 (28%) patients and any adverse event occurred in 19 (41%), most commonly nephrotoxicity amongst patients receiving L-AmB. On univariate analysis, unplanned OPAT-related readmissions were more common in Mucorales infection, L-AmB doses of ≥5mg/kg and otorhinolaryngologic (ENT) infections. At the completion of OPAT, attainment of treatment aims occurred in 28 (61%) patients. CONCLUSIONS Patients receiving parenteral antifungals via OPAT experience high rates of unplanned readmissions and adverse events. Risk factor identification may facilitate optimal patient selection and establishment of treatment aims.
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Affiliation(s)
- Su M Chew
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia
| | - Christopher H Heath
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Victoria Square, Perth, Western Australia.,PathWest Laboratory Medicine WA, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,School of Pathology and Laboratory Medicine, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia, Australia
| | - Cecilia Petursson
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Victoria Square, Perth, Western Australia
| | - Peter A Boan
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Victoria Square, Perth, Western Australia.,PathWest Laboratory Medicine WA, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia
| | - James Owen Robinson
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Victoria Square, Perth, Western Australia.,PathWest Laboratory Medicine WA, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,Antimicrobial Resistance and Infectious Diseases Research Laboratory, School of Veterinary and Life Sciences, Murdoch University, Murdoch, Western Australia
| | - Claire M Italiano
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Victoria Square, Perth, Western Australia
| | - John R Dyer
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia
| | - Laurens Manning
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,Medical School, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia, Australia
| | - Paul R Ingram
- Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Victoria Square, Perth, Western Australia.,PathWest Laboratory Medicine WA, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia.,School of Pathology and Laboratory Medicine, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia, Australia
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7
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Hiew J, Whitmore T, McEvoy M, Weatherall D, Ingram PR, Manning L. Subcutaneous ertapenem delivered by an Australian outpatient parenteral antimicrobial therapy service: a retrospective comparative efficacy study. Intern Med J 2021; 51:1717-1721. [PMID: 34664365 DOI: 10.1111/imj.15511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 02/06/2023]
Abstract
Subcutaneous (SC) administration of ertapenem in outpatient parenteral antimicrobial therapy (OPAT) services may be a practical alternative to intravenous delivery for complicated infections. The clinical features and outcomes according to route of administration were compared from a large Australian OPAT service. Chronic renal impairment was more common in the SC group, reflecting an opportunity for route of administration as a vein preservation strategy. Adverse events were uncommon and successful outcomes were not different between the groups.
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Affiliation(s)
- Jonathan Hiew
- Multidisciplinary Diabetic Foot Ulcer Service, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Podiatry, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Timothy Whitmore
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Mahalia McEvoy
- Multidisciplinary Diabetic Foot Ulcer Service, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Podiatry, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Deborah Weatherall
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Silver Chain Home Hospital, Perth, Western Australia, Australia
| | - Paul R Ingram
- Multidisciplinary Diabetic Foot Ulcer Service, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Medical School, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Laurens Manning
- Multidisciplinary Diabetic Foot Ulcer Service, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Medical School, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, Perth, Western Australia, Australia
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Ingram PR, Ng J, Mathieson C, Mowlaboccus S, Coombs G, Raby E, Dyer J. A clinical and in vitro assessment of outpatient parenteral benzylpenicillin and ceftriaxone combination therapy for enterococcal endovascular infections. JAC Antimicrob Resist 2021; 3:dlab128. [PMID: 34377984 PMCID: PMC8346702 DOI: 10.1093/jacamr/dlab128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/20/2021] [Accepted: 07/19/2021] [Indexed: 01/21/2023] Open
Abstract
Background Amoxicillin plus ceftriaxone combination therapy is now standard of care for enterococcal endocarditis. Due to amoxicillin instability in infusion devices, benzylpenicillin plus ceftriaxone may be substituted to facilitate outpatient parenteral antimicrobial therapy (OPAT) delivery, despite lack of guideline endorsement. Objectives To assess the clinical efficacy of benzylpenicillin plus ceftriaxone for the management of enterococcal endovascular infections, in addition to assessing this combination’s in vitro synergy. Patients and methods Retrospective cohort study assessing unplanned readmissions, relapses and mortality for 20 patients with endovascular Enterococcus faecalis infections treated with benzylpenicillin plus ceftriaxone delivered via OPAT. For a subset of isolates, synergism for both amoxicillin and benzylpenicillin in combination with ceftriaxone was calculated using a chequerboard method. Results Patients had endovascular infections of native cardiac valves (n = 11), mechanical or bioprosthetic cardiac valves (n = 7), pacemaker leads (n = 1) or left ventricular assistant devices (n = 1). The median duration of OPAT was 22 days, and the most frequent antimicrobial regimen was benzylpenicillin 14 g/day via continuous infusion and ceftriaxone 4 g once daily via short infusion. Rates of unplanned readmissions were high (30%), although rates of relapsed bacteraemia (5%) and 1 year mortality (15%) were comparable to the published literature. Benzylpenicillin less frequently displayed a synergistic interaction with ceftriaxone when compared with amoxicillin (3 versus 4 out of 6 isolates). Conclusions Lower rates of synergistic antimicrobial interaction and a significant proportion of unplanned readmissions suggest clinicians should exercise caution when treating enterococcal endovascular infection utilizing a combination of benzylpenicillin and ceftriaxone via OPAT.
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Affiliation(s)
- Paul R Ingram
- Department Infectious Diseases, Fiona Stanley Hospital, Perth, Australia.,School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Murdoch, Western Australia, Australia
| | - Jacinta Ng
- Department Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
| | - Claire Mathieson
- Department of Microbiology, PathWest Laboratory Medicine, Murdoch, Western Australia, Australia
| | - Shakeel Mowlaboccus
- Department of Microbiology, PathWest Laboratory Medicine, Murdoch, Western Australia, Australia.,College of Science, Health, Engineering and Education, Murdoch University, Perth, Australia
| | - Geoffrey Coombs
- Department of Microbiology, PathWest Laboratory Medicine, Murdoch, Western Australia, Australia.,College of Science, Health, Engineering and Education, Murdoch University, Perth, Australia
| | - Edward Raby
- Department Infectious Diseases, Fiona Stanley Hospital, Perth, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Murdoch, Western Australia, Australia
| | - John Dyer
- Department Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
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Ingram PR, Kilgarriff S, Grzelak M, Jackson G, Carr P, Boan P, Italiano C, Dyer J, Raby E. Risk factors for catheter related thrombosis during outpatient parenteral antimicrobial therapy. J Vasc Access 2021; 23:738-742. [PMID: 33845663 DOI: 10.1177/11297298211009361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Outpatient parenteral antimicrobial therapy (OPAT) delivery using peripherally inserted central catheters is associated with a risk of catheter related thrombosis (CRT). Individualised preventative interventions may reduce this occurrence, however patient selection is hampered by a lack of understanding of risk factors. We aimed to identify patient, infection or treatment related risk factors for CRT in the OPAT setting. METHODS Retrospective case control study (1:3 matching) within OPAT services at two tertiary hospitals within Australia. RESULTS Over a 2 year period, encompassing OPAT delivery to 1803 patients, there were 19 cases of CRT, giving a prevalence of 1.1% and incidence of 0.58/1000 catheter days. Amongst the cases of CRT, there were nine (47%) unplanned readmissions and two (11%) pulmonary emboli. Compared to controls, cases had a higher frequency of malposition of the catheter tip (4/19 (21%) vs 0/57 (0%), p = 0.003) and complicated catheter insertion (3/19 (16%) vs 1/57 (2%), p = 0.046). CONCLUSIONS Although CRTs during OPAT are infrequent, they often have clinically significant sequelae. Identification of modifiable vascular access related predictors of CRT should assist with patient risk stratification and guide risk reduction strategies.
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Affiliation(s)
- Paul R Ingram
- School of Pathology and Laboratory Medicine, University of Western Australia, Crawley, WA, Australia.,Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, WA, Australia.,Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Sinead Kilgarriff
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia
| | | | - Gavin Jackson
- Peripherally Inserted Central Catheter service, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Peter Carr
- School of Nursing and Midwifery, National University of Ireland, Galway, Ireland.,Menzies Health Institute, Griffith University, Queensland, Australia
| | - Peter Boan
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Claire Italiano
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, WA, Australia
| | - John Dyer
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Edward Raby
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, WA, Australia.,Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, WA, Australia
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Henderson A, Paterson DL, Chatfield MD, Tambyah PA, Lye DC, De PP, Lin RTP, Chew KL, Yin M, Lee TH, Yilmaz M, Cakmak R, Alenazi TH, Arabi YM, Falcone M, Bassetti M, Righi E, Ba R, Kanj SS, Bhally H, Iredell J, Mendelson M, Boyles TH, Looke DFM, Runnegar NJ, Miyakis S, Walls G, Ai Khamis M, Zikri A, Crowe A, Ingram PR, Daneman NN, Griffin P, Athan E, Roberts L, Beatson SA, Peleg AY, Cottrell KK, Bauer MJ, Tan E, Chaw K, Nimmo GR, Harris-Brown T, Harris PNA. Association between minimum inhibitory concentration, beta-lactamase genes and mortality for patients treated with piperacillin/tazobactam or meropenem from the MERINO study. Clin Infect Dis 2020; 73:e3842-e3850. [PMID: 33106863 DOI: 10.1093/cid/ciaa1479] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION This study aims to assess the association of piperacillin/tazobactam and meropenem minimum inhibitory concentration (MIC) and beta-lactam resistance genes with mortality in the MERINO trial. METHODS Blood culture isolates from enrolled patients were tested by broth microdilution and whole genome sequencing at a central laboratory. Multivariate logistic regression was performed to account for confounders. Absolute risk increase for 30-day mortality between treatment groups was calculated for the primary analysis (PA) and the microbiologic assessable (MA) populations. RESULTS 320 isolates from 379 enrolled patients were available with susceptibility to piperacillin/tazobactam 94% and meropenem 100%. The piperacillin/tazobactam non-susceptible breakpoint (MIC > 16 mg/L) best predicted 30-day mortality after accounting for confounders (odds ratio 14.9, 95% CI 2.8 - 87.2). The absolute risk increase for 30-day mortality for patients treated with piperacillin/tazobactam compared with meropenem was 9% (95% CI 3% - 15%) and 8% (95% CI 2% - 15%) for the original PA population and the post-hoc MA populations, which reduced to 5% (95% CI -1% - 10%) after excluding strains with piperacillin/tazobactam MIC values > 16 mg/L. Isolates co-harboring ESBL and OXA-1 genes were associated with elevated piperacillin/tazobactam MICs and the highest risk increase in 30-mortality of 14% (95% CI 2% - 28%). CONCLUSION After excluding non-susceptible strains, the 30-day mortality difference was from the MERINO trial was less pronounced for piperacillin/tazobactam. Poor reliability in susceptibility testing performance for piperacillin/tazobactam and the high prevalence of OXA co-harboring ESBLs suggests meropenem remains the preferred choice for definitive treatment of ceftriaxone non-susceptible E. coli and Klebsiella.
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Affiliation(s)
- A Henderson
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia.,Infection Management Services, Princess Alexandra Hospital, Brisbane, QLD
| | - D L Paterson
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - M D Chatfield
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - P A Tambyah
- Department of Infectious Diseases, National University Hospital, Singapore
| | - D C Lye
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore,Hospital, Singapore
| | - P P De
- Department of Laboratory Medicine, Tan Tock Seng Hospital, Singapore
| | - R T P Lin
- Department of Laboratory Medicine, National University Hospital, Singapore
| | - K L Chew
- Division of Microbiology, National University Hospital, Singapore
| | - M Yin
- Department of Infectious Diseases, National University Hospital, Singapore
| | - T H Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - M Yilmaz
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - R Cakmak
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - T H Alenazi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Y M Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - M Falcone
- Division of Infectious Diseases, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - M Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa and Ospedale Policlinico San Martino Genoa, Italy
| | - E Righi
- Infectious Diseases Clinic, Department of Medicine University of Udine and Santa Maria Misericordia Hospital, Udine, Italy.,Infectious Diseases, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Rogers Ba
- Monash University, Centre for Inflammatory Diseases, Victoria, Australia.,Monash Infectious Diseases, Monash Health, Victoria, Australia
| | - S S Kanj
- Department of Internal Medicine, Division of Infectious Diseases, American University of Beirut Medical Center, Beirut, Lebanon
| | - H Bhally
- Department of Medicine and Infectious Diseases, North Shore Hospital, Auckland
| | - J Iredell
- Marie Bashir Institute for Infectious Disease and Biosecurity, University of Sydney, Sydney, Australia.,Centre for Infectious Diseases and Microbiology, Westmead Hospital, Westmead, Australia
| | - M Mendelson
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - T H Boyles
- Division of Infectious Diseases & HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - D F M Looke
- Infection Management Services, Princess Alexandra Hospital, Brisbane, QLD.,University of Queensland, Brisbane, Australia
| | - N J Runnegar
- Infection Management Services, Princess Alexandra Hospital, Brisbane, QLD.,University of Queensland, Brisbane, Australia
| | - S Miyakis
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia.,Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia.,Department of Infectious Diseases, Wollongong Hospital, Wollongong, New South Wales, Australia
| | - G Walls
- Department of Infectious Diseases, Middlemore Hospital, Auckland, New Zealand
| | - M Ai Khamis
- King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - A Zikri
- King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - A Crowe
- Department of Infectious Diseases, St Vincent's Hospital, Melbourne, Australia.,Department of Microbiology, St Vincent's Hospital, Melbourne, Australia
| | - P R Ingram
- School of Pathology and Laboratory Medicine, The University of Western Australia, Crawley, Australia.,Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch , Australia.,Department of Microbiology, PathWest Laboratory Medicine, Perth, Western Australia
| | - N N Daneman
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - P Griffin
- University of Queensland, Brisbane, Australia.,Department of Medicine and Infectious Diseases, Mater Hospital and Mater Medical Research Institute, Brisbane, Australia.,QIMR Berghofer, Brisbane, Queensland, Australia
| | - E Athan
- Department of Infectious Diseases, Barwon Health and Deakin University, Geelong, Victoria, Australia
| | - L Roberts
- Australian Centre for Ecogenomics, School of Chemistry and Molecular Biosciences, The University of Queensland, Queensland, Australia
| | - S A Beatson
- Australian Centre for Ecogenomics, School of Chemistry and Molecular Biosciences, The University of Queensland, Queensland, Australia
| | - A Y Peleg
- Infection & Immunity Program, Biomedicine Discovery Institute, Monash University, Clayton, Australia.,Department of Microbiology, Monash University, Clayton, Australia
| | - K K Cottrell
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - M J Bauer
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - E Tan
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - K Chaw
- Department of Microbiology, Pathology Queensland, Toowoomba Laboratory, Australia.,Department of Microbiology, Mater Pathology, Australia.,Infectious Diseases Department, Redcliffe Hospital, Australia
| | - G R Nimmo
- Department of Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - T Harris-Brown
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia
| | - P N A Harris
- University of Queensland, UQ Centre for Clinical Research, Brisbane, Australia.,Department of Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia
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11
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Ingram PR, Carrello TL, Jones AL, McCann MJ, Lan NSR, Judkins C, Larbalestier R, Manning LA, Dyer JR. Impact of adherence to surgical and non-surgical components of infective endocarditis guidelines and recommendations. J Infect Chemother 2020; 26:923-927. [PMID: 32354601 DOI: 10.1016/j.jiac.2020.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/14/2020] [Accepted: 04/08/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Infective endocarditis (IE) is associated with significant morbidity and mortality. Non-adherence to IE guidelines and recommendations is frequent, and may adversely impact patient outcomes. AIM To assess the impact of non-adherence to components of existing IE guidelines and recommendations on a composite outcome consisting of any of the following: mortality, unplanned cardiac surgery, embolic event or relapse of positive blood culture within six months of diagnosis. METHODS A single centre, retrospective cohort study. RESULTS Amongst 157 patients, there was inconsistent adherence to: initial diagnosis of an infective condition (87%), timely administration of antimicrobial therapy (82%), appropriateness of predominant antimicrobial regime (94%), appropriate management of the portal of entry (86%), multidisciplinary input (75%), end of antimicrobial therapy repeat echocardiography (60%) and adherence to indications for surgery (76%). Inpatient mortality was 12.1% (n = 19) and the composite adverse outcome occurred in 36 (22.9%) patients. In multivariate logistic regression analysis, infection of prosthetic device (adjusted odds ratio [95% confidence interval]; 2.43 [1.07-5.50]) and non-adherence to surgical guidelines (aOR 3.67 [1.60-8.47]) were significantly associated with an adverse outcome. CONCLUSIONS Our data suggests that adherence to differing components of IE management guidelines and recommendations varies and that non-adherence to surgical aspects of guidelines has the biggest impact in determining outcomes.
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Affiliation(s)
- Paul R Ingram
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia; Department of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia; Department of Microbiology, PathWest Laboratory Medicine, Fiona Stanley Hospital, Perth, Australia
| | - Thomas L Carrello
- School of Medicine, University of Western Australia, Perth, Australia
| | - Aimee Lee Jones
- School of Medicine, University of Western Australia, Perth, Australia
| | | | - Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, Australia.
| | | | - Robert Larbalestier
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, Australia
| | - Laurens A Manning
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia; Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - John R Dyer
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Australia
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12
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Horton CD, Rawlins MDM, Manning L, Ingram PR. Non-adherence to antimicrobial stewardship prospective audit and feedback advice: Risk factors and clinical consequences. J Infect Chemother 2019; 25:485-488. [PMID: 30904463 DOI: 10.1016/j.jiac.2019.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/24/2018] [Accepted: 02/20/2019] [Indexed: 11/25/2022]
Abstract
Amongst 325 patients receiving restricted antimicrobials whose management was subject to antimicrobial stewardship prospective audit and feedback, adherence to advice was 78%. Non-adherence was associated with diabetic patients, giving more than 1 piece of advice and receipt of piperacillin/tazobactam therapy, and was inversely associated with liver disease. Adherence to advice was associated with a one third reduction in duration of antimicrobial use without adversely impacting other infection-related patient outcomes.
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Affiliation(s)
- Christopher D Horton
- Medical School, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia, 6009, Australia
| | - Matthew D M Rawlins
- Department of Pharmacy, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Laurens Manning
- Medical School, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia, 6150, Australia; Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Paul R Ingram
- Medical School, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia, 6009, Australia; Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia, 6150, Australia; Department of Microbiology, PathWest Laboratory Medicine, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, Western Australia, 6150, Australia.
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13
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Tan SJ, Ingram PR, Rothnie AJ, Whitmore TJ, Robinson JO, Hatch JB, Italiano CM, Heath CH. Successful outpatient parenteral antibiotic therapy delivery via telemedicine. J Antimicrob Chemother 2018; 72:2898-2901. [PMID: 29091189 DOI: 10.1093/jac/dkx203] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/25/2017] [Indexed: 11/14/2022] Open
Abstract
Objectives Most outpatient parenteral antimicrobial therapy (OPAT) services use a hospital-based model of care in which patients remain in proximity to large hospitals facilitating clinical review. We aimed to evaluate clinical outcomes and complication rates for patients living in geographically isolated locations managed by telemedicine-supported OPAT. Methods: This was a retrospective cohort study. Results Between 2011 and 2015, we delivered 88 episodes of care involving 83 adult patients resulting in 2261 days of OPAT. The median age was 56 years, 8 of 83 (10%) were indigenous Australian and the median Charlson comorbidity index score was 2 (IQR 1-4). The median distance of patients' residence from our hospital was 288 km (IQR 201-715) and the median duration on the programme was 26 days (IQR 14-34). Bone and joint infections accounted for 75% of infections treated. Favourable clinical outcomes (improvement or cure) were achieved in 87% of patients and the unplanned, OPAT-related readmission rate was 8%. Nineteen percent and 10% of patients had drug-related and line-related adverse effects, respectively. Conclusions Despite a complex case mix, our adverse event and readmission rates are similar to the published literature describing a non-telemedicine model to deliver OPAT. High rates of favourable clinical outcomes and likely cost benefits suggest that telemedicine-supported OPAT is an efficacious and safe substitute for inpatient care in our setting.
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Affiliation(s)
- Shu J Tan
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Paul R Ingram
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia.,School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Western Australia, Australia.,Department of Microbiology (PathWest Laboratory Medicine), Fiona Stanley Hospital Network, Murdoch, Western Australia, Australia
| | - Alison J Rothnie
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Timothy J Whitmore
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia
| | - James O Robinson
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia.,Department of Microbiology (PathWest Laboratory Medicine), Fiona Stanley Hospital Network, Murdoch, Western Australia, Australia.,Australian Collaborating Centre for Enterococcus and Staphylococcus species Typing and Research, School of Veterinary and Life Sciences, Murdoch University and School of Biomedical Sciences, Curtin University, Perth, Western Australia, Australia
| | - Jillian B Hatch
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Claire M Italiano
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Christopher H Heath
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia.,Department of Microbiology (PathWest Laboratory Medicine), Fiona Stanley Hospital Network, Murdoch, Western Australia, Australia.,School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
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14
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Commons RJ, Raby E, Athan E, Bhally H, Chen S, Guy S, Ingram PR, Lai K, Lemoh C, Lim LL, Manning L, Miyakis S, O'Reilly M, Roberts A, Sehu M, Torda A, Vicaretti M, Lazzarini PA. Managing diabetic foot infections: a survey of Australasian infectious diseases clinicians. J Foot Ankle Res 2018; 11:13. [PMID: 29651304 PMCID: PMC5894166 DOI: 10.1186/s13047-018-0256-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/29/2018] [Indexed: 11/10/2022] Open
Abstract
Background Diabetic foot infections (DFI) present a major morbidity, mortality and economic challenge for the tertiary health sector. However, lack of high quality evidence for specific treatment regimens for patients with DFIs may result in inconsistent management. This study aimed to identify DFI caseload proportion and patterns of clinical practice of Infectious Diseases (ID) Physicians and Trainees within Australia and New Zealand. Methods A cross-sectional online survey of Australian and New Zealand ID Physicians and Trainees was undertaken, to estimate the overall ID caseload devoted to patients with DFIs and assess clinicians' management practices of patients with DFIs. Results Approximately 28% (142/499) of ID Physicians and Trainees from Australia and New Zealand responded to the survey. DFI made up 19.2% of all ID consultations. Involvement in multidisciplinary teams (MDT) was common as 77.5% (93/120) of those responding indicated their patients had access to an inpatient or outpatient MDT. Significant heterogeneity of antimicrobial treatments was reported, with 82 unique treatment regimens used by 102 respondents in one scenario and 76 unique treatment regimens used by 101 respondents in the second scenario. The duration of therapy and the choice of antibiotics for microorganisms isolated from superficial swabs also varied widely. Conclusions Patients with DFIs represent a significant proportion of an ID clinician's caseload. This should be reflected in the ID training program. Large heterogeneity in practice between clinicians reflects a lack of evidence from well-designed clinical trials for patients with DFI and highlights the need for management guidelines informed by future trials.
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Affiliation(s)
- Robert J Commons
- 1Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Tiwi, Casuarina, Northern Territory Australia
| | - Edward Raby
- 2Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Dr, Murdoch, WA Australia
| | - Eugene Athan
- 3Department of Infectious Diseases, Barwon Health, Deakin University, Geelong, VIC Australia
| | - Hasan Bhally
- 4Department of Infectious Diseases, North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand
| | - Sharon Chen
- 5Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, Westmead Hospital, The University of Sydney, Westmead, NSW Australia
| | - Stephen Guy
- 6Department of Infectious Diseases, Western Health, 160 Gordon St, Footscray, VIC Australia.,7Department of Medicine, Melbourne Medical School - Western Precint, The University of Melbourne, St Albans, VIC Australia
| | - Paul R Ingram
- 2Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Dr, Murdoch, WA Australia.,8School of Pathology and Laboratory Medicine, University of Western Australia, Crawley, WA Australia
| | - Katy Lai
- 9Department of Infectious Diseases, John Hunter Hospital, Lookout Rd, New Lambton Heights, NSW Australia
| | - Chris Lemoh
- 10Monash Infectious Diseases, Dandenong Hospital, 135 David St, Dandenong, VIC Australia
| | - Lyn-Li Lim
- 11Department of Infectious Diseases, Eastern Health, 8 Arnold St, Box Hill, VIC Australia
| | - Laurens Manning
- 12School of Medicine and Pharmacology, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, PO Box 404, Bull Creek, WA Australia
| | - Spiros Miyakis
- 13Department of Infectious Diseases, The Wollongong Hospital, Loftus St, Wollongong, NSW Australia
| | - Mary O'Reilly
- 11Department of Infectious Diseases, Eastern Health, 8 Arnold St, Box Hill, VIC Australia
| | - Adam Roberts
- 14Department of Endocrinology, University Hospital Geelong, Bellerine St, Geelong, VIC Australia
| | - Marjoree Sehu
- 15Infection Management Service, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, QLD Australia.,16University of Queensland, St Lucia, QLD Australia
| | - Adrienne Torda
- 17Department of Infectious Diseases, Prince of Wales Hospital, Barker St, Randwick, NSW Australia
| | - Mauro Vicaretti
- 18Department of Vascular Surgery, Westmead Hospital, Hawkesbury Rd & Darcy Rd, Westmead, NSW Australia
| | - Peter A Lazzarini
- 19School of Clinical Sciences, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD Australia
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15
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Rawlins MDM, Sanfilippo FM, Ingram PR, McLellan DGJ, Crawford C, D'Orsogna L, Dyer J. Optimizing adherence to advice from antimicrobial stewardship audit and feedback rounds. J Chemother 2017; 30:59-62. [PMID: 28580878 DOI: 10.1080/1120009x.2017.1336318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We examined adherence to antimicrobial stewardship prospective audit and feedback rounds in a rehabilitation service compared with the remainder of the acute hospital, and explored the reasons for this. Between October 2014 and December 2015, we retrospectively assessed the rate of non-adherence to advice from antimicrobial stewardship prospective audit and feedback rounds between the rehabilitation service and the acute hospital, along with the source of the patient referral. Compared with the rehabilitation service, acute hospital medical staff were almost twice as likely to not adhere to advice provided on antimicrobial stewardship prospective audit and feedback rounds (13.8% vs. 7.6%, p < 0.0001, relative risk 1.8 [95% confidence interval 1.3, 2.5]). In the rehabilitation service, referrals were more likely to come from medical staff (61.9% vs. 16.3%, p < 0.0001). These findings may be explained by regular, direct engagement of the antimicrobial stewardship team with the rehabilitation service clinical team, a model potentially applicable to other settings.
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Affiliation(s)
| | - Frank M Sanfilippo
- b Pharmacy Department , Royal Perth Hospital , Perth , Australia.,c School of Population Health , The University of Western Australia , Crawley , Australia
| | - Paul R Ingram
- d School of Pathology and Laboratory Medicine , The University of Western Australia , Crawley , Australia.,e Department of Infectious Diseases , Fiona Stanley Hospital , Murdoch , Australia
| | - Duncan G J McLellan
- e Department of Infectious Diseases , Fiona Stanley Hospital , Murdoch , Australia.,f Western Diagnostic Pathology , Myaree , Australia
| | - Colin Crawford
- g State Rehabilitation Service , Fiona Stanley Hospital , Murdoch , Australia
| | - Luca D'Orsogna
- g State Rehabilitation Service , Fiona Stanley Hospital , Murdoch , Australia
| | - John Dyer
- e Department of Infectious Diseases , Fiona Stanley Hospital , Murdoch , Australia
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16
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Vangchhia B, Abraham S, Bell JM, Collignon P, Gibson JS, Ingram PR, Johnson JR, Kennedy K, Trott DJ, Turnidge JD, Gordon DM. Phylogenetic diversity, antimicrobial susceptibility and virulence characteristics of phylogroup F Escherichia coli in Australia. Microbiology (Reading) 2016; 162:1904-1912. [PMID: 27666313 DOI: 10.1099/mic.0.000367] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Unlike Escherichia coli strains belonging to phylogroup B2, the clinical significance of strains belonging to phylogroup F is not well understood. Here we report on a collection of phylogroup F strains recovered in Australia from faeces and extra-intestinal sites from humans, companion animals and native animals, as well as from poultry meat and water samples. The distribution of sequence types was clearly non-random with respect to isolate source. The antimicrobial resistance and virulence trait profiles also varied with the sequence type of the isolate. Phylogroup F strains tended to lack the virulence traits typically associated with phylogroup B2 strains responsible for extra-intestinal infection in humans. Resistance to fluoroquinolones and/or expanded-spectrum cephalosporins was common within ST648, ST354 and ST3711. Although ST354 and ST3711 are part of the same clonal complex, the ST3711 isolates were only recovered from native birds being cared for in a single wildlife rehabilitation centre, whereas the ST354 isolates were from faeces and extra-intestinal sites of dogs and humans, as well as from poultry meat. Although ST354 isolates from chicken meat in Western Australia were distinct from all other ST354 isolates, those from poultry meat samples collected in eastern Australia shared many similarities with other ST354 isolates from humans and companion animals.
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Affiliation(s)
- Belinda Vangchhia
- Evolution, Ecology and Genetics, Research School of Biology, Australian National University, 116 Daley Road, Acton, Australian Capital Territory 2601, Australia
| | - Sam Abraham
- School of Veterinary and Life Sciences, Murdoch University, Murdoch, Western Australia 6150, Australia
| | - Jan M Bell
- Microbiology and Infectious Disease, SA Pathology, Adelaide, South Australia 5000, Australia
| | - Peter Collignon
- Infectious Disease and Microbiology, Canberra Hospital, Woden, Australian Capital Territory 2606, Australia.,Medical School, Australian National University, Canberra, Australian Capital Territory 0200, Australia.,ACT Pathology, Canberra, Australian Capital Territory, Australia
| | - Justine S Gibson
- School of Veterinary Science, University of Queensland, Gatton, Queensland 4343, Australia
| | - Paul R Ingram
- Department of Microbiology, PathWest, Fiona Stanley Hospital, Perth, Australia.,School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia
| | - James R Johnson
- VA Medical Center and Department of Medicine, University of Minnesota, Infectious Diseases (111F), 1 Veterans Drive, Minneapolis, MN 55417, USA
| | - Karina Kennedy
- Infectious Disease and Microbiology, Canberra Hospital, Woden, Australian Capital Territory 2606, Australia.,Medical School, Australian National University, Canberra, Australian Capital Territory 0200, Australia
| | - Darren J Trott
- School of Animal and Veterinary Science, University of Adelaide, Roseworthy, South Australia 5371, Australia
| | - John D Turnidge
- Australian Commission on Safety and Quality in Health Care, New South Wales, Australia.,School of Biological Sciences, University of Adelaide, Adelaide, South Australia 5005, Australia
| | - David M Gordon
- Evolution, Ecology and Genetics, Research School of Biology, Australian National University, 116 Daley Road, Acton, Australian Capital Territory 2601, Australia
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17
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Goire N, Harnett GB, O'Reilly LC, Ingram PR, Leung MJ, Speers DJ, Healy PE, Inglis TJJ. Erratum to "The implications of endemic IMP-4 carbapenemase for clinical laboratory susceptibility testing" [J. Microbiol. Methods 124 (2016) 10-12]. J Microbiol Methods 2016; 128:130. [PMID: 27393044 DOI: 10.1016/j.mimet.2016.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Namraj Goire
- Department of Microbiology, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Hospital Avenue, Nedlands, Western Australia 6009, Australia
| | - Gerald B Harnett
- Department of Microbiology, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Hospital Avenue, Nedlands, Western Australia 6009, Australia
| | - Lyn C O'Reilly
- Department of Microbiology, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Hospital Avenue, Nedlands, Western Australia 6009, Australia. Lyn.O'
| | - Paul R Ingram
- Department of Microbiology, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, Western Australia 6150, Australia; School of Pathology and Laboratory Medicine, University of Western Australia, Crawley, Western Australia 6009, Australia
| | - Michael J Leung
- Department of Microbiology, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Hospital Avenue, Nedlands, Western Australia 6009, Australia; School of Pathology and Laboratory Medicine, University of Western Australia, Crawley, Western Australia 6009, Australia
| | - David J Speers
- Department of Microbiology, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Hospital Avenue, Nedlands, Western Australia 6009, Australia; School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia 6009, Australia
| | - Paul E Healy
- Department of Microbiology, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Hospital Avenue, Nedlands, Western Australia 6009, Australia
| | - Timothy J J Inglis
- Department of Microbiology, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Hospital Avenue, Nedlands, Western Australia 6009, Australia; School of Pathology and Laboratory Medicine, University of Western Australia, Crawley, Western Australia 6009, Australia
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18
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Ingram PR, Rawlins MDM, Murray RJ, Roberts JA, Manning L. Tigecycline use in the outpatient parenteral antibiotic therapy setting. Eur J Clin Microbiol Infect Dis 2016; 35:1673-7. [PMID: 27325439 DOI: 10.1007/s10096-016-2709-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 06/06/2016] [Indexed: 11/26/2022]
Abstract
In the context of globally increasing antimicrobial resistance, tigecycline appears to be a useful therapeutic option. The need for prolonged courses for complex infections has prompted consideration of its use via outpatient parenteral antibiotic therapy (OPAT) programmes, although clinical outcomes when used in this setting remain unknown. We retrospectively reviewed the patient characteristics and outcomes of 11 patients who received tigecycline, most commonly delivered as 100 mg once daily, via OPAT at three tertiary Australian hospitals. Rates of co-morbidity and prior antibiotic use were high. Patients had a wide range of infections including bone and/or joint (n = 5), intra-abdominal (n = 3), lower respiratory tract (n = 2) and parapharyngeal abscess (n = 1). Mycobacterial species (n = 5) were the most frequent pathogen, and multi-resistant organisms were common (n = 4). The median OPAT duration was 14 days (IQR 6-30). Nausea was encountered in 45 % of cases. At completion of OPAT, 1 patient (9 %) was cured, 2 (18 %) had improved and 8 (73 %) failed therapy. Failure occurred due to either progression or non-response of infection (n = 4), re-admission (n = 3), premature cessation of tigecycline due to nausea (n = 3) or death (n = 1). Whilst OPAT delivery of tigecycline is a therapeutic option, when used as second-line therapy for complex, often multi-resistant infections in patients with multiple comorbidities, high rates of clinical failure, readmissions and adverse effects, especially nausea, should be anticipated.
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Affiliation(s)
- P R Ingram
- School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia.
- Department of Infectious Diseases and Microbiology, Royal Perth Hospital, Perth, WA, Australia.
| | - M D M Rawlins
- Pharmacy Department, Fiona Stanley Hospital, Perth, WA, Australia
| | - R J Murray
- School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia
- Department of Infectious Diseases, Sir Charles Gairdner Hospital, Queen Elizabeth II Medical Centre, Perth, WA, Australia
- Department of Microbiology, PathWest Laboratory Medicine WA Queen Elizabeth II Medical Centre, Perth, WA, Australia
| | - J A Roberts
- Burns, Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia
- School of Pharmacy, The University of Queensland, Brisbane, Australia
| | - L Manning
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia
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Hall JM, Ingram PR, O'Reilly LC, Inglis TJJ. Temporal flux in β-lactam resistance among Klebsiella pneumoniae in Western Australia. J Med Microbiol 2016; 65:429-437. [PMID: 26944048 DOI: 10.1099/jmm.0.000242] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Our aim was to identify long-term β-lactam resistance trends in local Klebsiella pneumoniae isolates, which are a common cause of sepsis in Western Australia. We studied three collections of K. pneumoniae isolates from Western Australia between 1977 and 2015 comprising contemporary blood culture (n = 98), multiresistant (n = 21) and historical (n = 50) isolates. Antimicrobial resistance was determined by Clinical and Laboratory Standards Institute agar dilution methods. PCR DNA sequencing identified β-lactamase variants and porin mutations contributing to β-lactam resistance. Isolates were genotyped by PFGE, multilocus sequence typing and a variable number tandem repeat method. From 1989 onwards, we detected the SHV-2a extended-spectrum β-lactamase (ESBL) in ceftriaxone-resistant isolates, and in ceftazidime- and aztreonam-resistant isolates from 1993. Ceftriaxone, ceftazidime and aztreonam resistance persisted, with blaCTX-M types becoming the dominant ESBLs by 2010. CTX-M-15 was encountered in both multiresistant and blood culture isolates. Meropenem resistance was detected for the first time in 2011 in a locally isolated blaIMP-4-positive K. pneumoniae. We found sequence types ST23 and ST86 that occurred in multiple isolates from invasive infections. ST86 was the most common and maintained a high degree (90 %) of similarity by PFGE since 1977. Ceftazidime-resistant K. pneumoniae sequence types have caused invasive infections in Western Australia since 1993. Invasive isolates producing CTX-M-14 and CTX-M-15 appeared in Western Australia during the last decade, before the appearance of carbapenemases. The diversity of β-lactam resistance and β-lactamase resistance mechanisms in Western Australian K. pneumoniae has increased since ESBLs were first described locally.
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Affiliation(s)
- Jarrad M Hall
- The Marshall Centre for Infectious Diseases, School of Pathology and Laboratory Medicine, University of Western Australia,Nedlands, Western Australia,Australia
| | - Paul R Ingram
- The Marshall Centre for Infectious Diseases, School of Pathology and Laboratory Medicine, University of Western Australia,Nedlands, Western Australia,Australia.,PathWest Laboratory Medicine, Fiona Stanley Hospital,Murdoch, Western Australia,Australia
| | - Lyn C O'Reilly
- PathWest Laboratory Medicine, QEII Medical Centre,Nedlands, Western Australia,Australia
| | - Timothy J J Inglis
- The Marshall Centre for Infectious Diseases, School of Pathology and Laboratory Medicine, University of Western Australia,Nedlands, Western Australia,Australia.,PathWest Laboratory Medicine, QEII Medical Centre,Nedlands, Western Australia,Australia
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Goire N, Harnett GB, O'Reilly LC, Ingram PR, Leung MJ, Speers DJ, Healy PE, Inglis TJJ. The implications of endemic IMP-4 carbapenemase for clinical laboratory susceptibility testing. J Microbiol Methods 2016; 124:10-2. [PMID: 26945518 DOI: 10.1016/j.mimet.2016.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 10/22/2022]
Abstract
A local predominance of carbapenemase producing Enterobacteriaceae with low minimum inhibitory concentrations (MIC) to meropenem prompted a review of methods available for carbapenemase detection. We report on results using two selective media, temocillin discs, CarbaNP test, GeneXpert Carba-R assay and an in-house PCR assay.
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Affiliation(s)
- Namraj Goire
- Department of Microbiology, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Hospital Avenue, Nedlands, Western Australia 6009, Australia
| | - Gerald B Harnett
- Department of Microbiology, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Hospital Avenue, Nedlands, Western Australia 6009, Australia
| | - Lyn C O'Reilly
- Department of Microbiology, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Hospital Avenue, Nedlands, Western Australia 6009, Australia. Lyn.O'
| | - Paul R Ingram
- Department of Microbiology, PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Perth, Western Australia 6150, Australia; School of Pathology and Laboratory Medicine, University of Western Australia, Crawley, Western Australia 6009, Australia
| | - Michael J Leung
- Department of Microbiology, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Hospital Avenue, Nedlands, Western Australia 6009, Australia; School of Pathology and Laboratory Medicine, University of Western Australia, Crawley, Western Australia 6009, Australia
| | - David J Speers
- Department of Microbiology, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Hospital Avenue, Nedlands, Western Australia 6009, Australia; School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia 6009, Australia
| | - Paul E Healy
- Department of Microbiology, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Hospital Avenue, Nedlands, Western Australia 6009, Australia
| | - Timothy J J Inglis
- Department of Microbiology, PathWest Laboratory Medicine WA, Queen Elizabeth II Medical Centre, Hospital Avenue, Nedlands, Western Australia 6009, Australia; School of Pathology and Laboratory Medicine, University of Western Australia, Crawley, Western Australia 6009, Australia
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Blyth CC, Walls T, Cheng AC, Murray RJ, Fisher DA, Ingram PR, Davis JS. A comparison of paediatric and adult infectious diseases consultations in Australia and New Zealand. Eur J Clin Microbiol Infect Dis 2015; 34:1589-92. [PMID: 25920492 DOI: 10.1007/s10096-015-2391-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 04/15/2015] [Indexed: 11/24/2022]
Abstract
The objective of this paper is to describe paediatric infectious diseases consultations across Australia and New Zealand. We surveyed infectious diseases physicians at 51 hospitals over a period of 2 weeks in 2012. Compared with adult consults, paediatric consults were more frequently received from general paediatricians/physicians and intensive care, yet less frequently from surgeons and emergency. Respiratory, skin/soft tissue and bone/joint infections were the most frequent consultations in children. These data demonstrate the breadth of formal infectious diseases consults in children. Differences between paediatric and infectious diseases consultations need to be considered when planning both paediatric and adult physician training and future curriculum development.
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Affiliation(s)
- C C Blyth
- School of Paediatrics and Child Health, University of Western Australia, Perth, Australia
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Harris PNA, Peleg AY, Iredell J, Ingram PR, Miyakis S, Stewardson AJ, Rogers BA, McBryde ES, Roberts JA, Lipman J, Athan E, Paul SK, Baker P, Harris-Brown T, Paterson DL. Meropenem versus piperacillin-tazobactam for definitive treatment of bloodstream infections due to ceftriaxone non-susceptible Escherichia coli and Klebsiella spp (the MERINO trial): study protocol for a randomised controlled trial. Trials 2015; 16:24. [PMID: 25623485 PMCID: PMC4311465 DOI: 10.1186/s13063-014-0541-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 12/22/2014] [Indexed: 12/20/2022] Open
Abstract
Background Gram-negative bacteria such as Escherichia coli or Klebsiella spp. frequently cause bloodstream infections. There has been a worldwide increase in resistance in these species to antibiotics such as third generation cephalosporins, largely driven by the acquisition of extended-spectrum beta-lactamase or plasmid-mediated AmpC enzymes. Carbapenems have been considered the most effective therapy for serious infections caused by such resistant bacteria; however, increased use creates selection pressure for carbapenem resistance, an emerging threat arising predominantly from the dissemination of genes encoding carbapenemases. Recent retrospective data suggest that beta-lactam/beta-lactamase inhibitor combinations, such as piperacillin-tazobactam, may be non-inferior to carbapenems for the treatment of bloodstream infection caused by extended-spectrum beta-lactamase-producers, if susceptible in vitro. This study aims to test this hypothesis in an effort to define carbapenem-sparing alternatives for these infections. Methods/Design The study will use a multicentre randomised controlled open-label non-inferiority trial design comparing two treatments, meropenem (standard arm) and piperacillin-tazobactam (carbapenem-sparing arm) in adult patients with bacteraemia caused by E. coli or Klebsiella spp. demonstrating non-susceptibility to third generation cephalosporins. Recruitment is planned to occur in sites across three countries (Australia, New Zealand and Singapore). A total sample size of 454 patients will be required to achieve 80% power to determine non-inferiority with a margin of 5%. Once randomised, definitive treatment will be for a minimum of 4 days, but up to 14 days with total duration determined by treating clinicians. Data describing demographic information, antibiotic use, co-morbid conditions, illness severity, source of infection and other risk factors will be collected. Vital signs, white cell count, use of vasopressors and days to bacteraemia clearance will be recorded up to day 7. The primary outcome measure will be mortality at 30 days, with secondary outcomes including days to clinical and microbiological resolution, microbiological failure or relapse, isolation of a multi-resistant organism or Clostridium difficile infection. Trial registration The MERINO trial is registered under the Australian New Zealand Clinical Trials Register (ANZCTR), reference number: ACTRN12613000532707 (registered 13 May 2013) and the US National Institute of Health ClinicalTrials.gov register, reference number: NCT02176122 (registered 24 June 2014). Electronic supplementary material The online version of this article (doi:10.1186/s13063-014-0541-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Patrick N A Harris
- University of Queensland Centre for Clinical Research, Building 71/918 Royal Brisbane & Women's Hospital Campus, Herston, 4029, Brisbane, QLD, Australia.
| | - Anton Y Peleg
- Department of Infectious Diseases, The Alfred Hospital, Melbourne, VIC, Australia.
| | - Jon Iredell
- Westmead Millenium Institute for Medical Research, Westmead Hospital, Sydney, NSW, Australia.
| | - Paul R Ingram
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, WA, Australia. .,School of Pathology and Laboratory Medicine, University of Western Australia, Crawley, WA, Australia.
| | - Spiros Miyakis
- Department of Infectious Diseases, School of Medicine, University of Wollongong and The Wollongong Hospital, Wollongong, NSW, Australia.
| | - Andrew J Stewardson
- Department of Infectious Diseases, Austin Health, Melbourne, VIC, Australia.
| | | | - Emma S McBryde
- Victorian Infectious Diseases Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia.
| | - Jason A Roberts
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia.
| | - Jeff Lipman
- Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, QLD, Australia.
| | - Eugene Athan
- Department of Infectious Disease, Barwon Health, Deakin University, Geelong, VIC, Australia.
| | - Sanjoy K Paul
- Clinical Trials & Biostatistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia.
| | - Peter Baker
- Queensland Clinical Trials and Biostatistics Centre, University of Queensland, Brisbane, QLD, Australia.
| | - Tiffany Harris-Brown
- University of Queensland Centre for Clinical Research, Building 71/918 Royal Brisbane & Women's Hospital Campus, Herston, 4029, Brisbane, QLD, Australia.
| | - David L Paterson
- University of Queensland Centre for Clinical Research, Building 71/918 Royal Brisbane & Women's Hospital Campus, Herston, 4029, Brisbane, QLD, Australia.
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O'Brien AP, Rawlins MDM, Ingram PR. Appropriateness and determinants of antibiotic prescribing in an Australian emergency department. Emerg Med Australas 2015; 27:83-4. [PMID: 25627572 DOI: 10.1111/1742-6723.12346] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Aine P O'Brien
- Emergency Department, Royal Perth Hospital, Perth, Western Australia, Australia
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Ingram PR, Suthananthan AE, Rajan R, Pryce TM, Sieunarine K, Gardam DJ, Heath CH. Cutaneous mucormycosis and motor vehicle accidents: Findings from an Australian case series. Med Mycol 2014; 52:819-25. [PMID: 25288654 DOI: 10.1093/mmy/myu054] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cutaneous disease is the third most frequent manifestation of mucormycosis. The clinical manifestations of and subsequent mortality due to cutaneous mucormycosis are dependent on the mode of acquisition and the host immune status. Here, we describe the epidemiology, clinical presentation, microbiology, and outcomes of 16 cutaneous mucormycosis infections managed in an Australian tertiary hospital over a 15-year period. The proportion with localized (56%), deep (38%), and disseminated (6%) cutaneous disease as well as the overall mortality (25%) were consistent with findings reported in the published literature. Two novel forms of hospital-acquired infection were reported following a sacral pressure sore and insertion of a foreign body during a bone graft procedure. The majority of patients were immunocompetent (75%) and/or suffered trauma (56%) with associated environmental contamination. A novel finding was that motor vehicle accidents (MVAs) accounted for 78% of all trauma-related cases, suggesting MVAs should receive greater recognition as a potential precipitant of cutaneous mucormycosis. Aggressive decontamination and debridement of devitalized tissue following trauma is therefore likely to play an important role in the prevention of this rare but potentially devastating infection.
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Affiliation(s)
- Paul R Ingram
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Australia School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia
| | | | - Ruben Rajan
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Todd M Pryce
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Australia
| | | | - Dianne J Gardam
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Australia
| | - Christopher H Heath
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Australia School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
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25
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Manning L, Wright C, Ingram PR, Whitmore TJ, Heath CH, Manson I, Page-Sharp M, Salman S, Dyer J, Davis TME. Continuous infusions of meropenem in ambulatory care: clinical efficacy, safety and stability. PLoS One 2014; 9:e102023. [PMID: 25019523 PMCID: PMC4096762 DOI: 10.1371/journal.pone.0102023] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 06/14/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Concerns regarding the clinical impact of meropenem instability in continuous infusion (CI) devices may contribute to inconsistent uptake of this method of administration across outpatient parenteral antimicrobial therapy (OPAT) services. METHODS We retrospectively reviewed the clinical efficacy and safety of CIs of meropenem in two Australian tertiary hospitals and assessed its stability under simulated OPAT conditions including in elastomeric infusion devices containing 1% (2.4 g) or 2% (4.8 g) concentrations at either 'room temperature' or 'cooled' conditions. Infusate aliquots were assayed at different time-points over 24 hours. RESULTS Forty-one (82%) of 50 patients had clinical improvement or were cured. Adverse patient outcomes including hemato-, hepato- and nephrotoxicity were infrequent. Cooled infusers with 1% meropenem had a mean 24-hour recovery of 90.3%. Recoveries of 1% and 2% meropenem at room temperature and 2% under cooled conditions were 88%, 83% and 87%, respectively. Patients receiving 1% meropenem are likely to receive >95% of the maximum deliverable dose (MDD) over a 24-hour period whilst patients receiving 2% meropenem should receive 93% and 87% of the MDD under cooled and room temperature conditions, respectively. CONCLUSIONS Meropenem infusers are likely to deliver ∼95% MDD and maintain effective plasma concentrations throughout the dosing period. These data reflect our local favourable clinical experience with meropenem CIs.
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Affiliation(s)
- Laurens Manning
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
- Department of Infectious Diseases, Fremantle Hospital and Health Service, Fremantle, Western Australia, Australia
- * E-mail:
| | - Cameron Wright
- Pharmacy Department, Fremantle Hospital and Health Service, Fremantle, Western Australia, Australia
| | - Paul R. Ingram
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia
- School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Timothy J. Whitmore
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Christopher H. Heath
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia
- School of Medicine and Pharmacology, University of Western Australia, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Ingrid Manson
- Pharmacy Department, Fremantle Hospital and Health Service, Fremantle, Western Australia, Australia
| | - Madhu Page-Sharp
- School of Pharmacy, Curtin University, Bentley, Western Australia, Australia
| | - Sam Salman
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - John Dyer
- Department of Infectious Diseases, Fremantle Hospital and Health Service, Fremantle, Western Australia, Australia
| | - Timothy M. E. Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
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Norton K, Ingram PR, Heath CH, Manning L. Neutropenia is rare in patients receiving continuous infusions of vancomycin in an Australian Hospital in the Home setting. Intern Med J 2014; 43:954-5. [PMID: 23919343 DOI: 10.1111/imj.12213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 05/05/2013] [Indexed: 11/29/2022]
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Pfister R, Kochanek M, Leygeber T, Brun-Buisson C, Cuquemelle E, Machado MB, Piacentini E, Hammond NE, Ingram PR, Michels G. Procalcitonin for diagnosis of bacterial pneumonia in critically ill patients during 2009 H1N1 influenza pandemic: a prospective cohort study, systematic review and individual patient data meta-analysis. Crit Care 2014; 18:R44. [PMID: 24612487 PMCID: PMC4056761 DOI: 10.1186/cc13760] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 03/06/2014] [Indexed: 12/23/2022]
Abstract
Introduction Procalcitonin (PCT) is helpful for diagnosing bacterial infections. The diagnostic utility of PCT has not been examined thoroughly in critically ill patients with suspected H1N1 influenza. Methods Clinical characteristics and PCT were prospectively assessed in 46 patients with pneumonia admitted to medical ICUs during the 2009 and 2010 influenza seasons. An individual patient data meta-analysis was performed by combining our data with data from five other studies on the diagnostic utility of PCT in ICU patients with suspected 2009 pandemic influenza A(H1N1) virus infection identified by performing a systematic literature search. Results PCT levels, measured within 24 hours of ICU admission, were significantly elevated in patients with bacterial pneumonia (isolated or coinfection with H1N1; n = 77) (median = 6.2 μg/L, interquartile range (IQR) = 0.9 to 20) than in patients with isolated H1N1 influenza pneumonia (n = 84; median = 0.56 μg/L, IQR = 0.18 to 3.33). The area under the curve of the receiver operating characteristic curve of PCT was 0.72 (95% confidence interval (CI) = 0.64 to 0.80; P < 0.0001) for diagnosis of bacterial pneumonia, but increased to 0.76 (95% CI = 0.68 to 0.85; P < 0.0001) when patients with hospital-acquired pneumonia and immune-compromising disorders were excluded. PCT at a cut-off of 0.5 μg/L had a sensitivity (95% CI) and a negative predictive value of 80.5% (69.9 to 88.7) and 73.2% (59.7 to 84.2) for diagnosis of bacterial pneumonia, respectively, which increased to 85.5% (73.3 to 93.5) and 82.2% (68.0 to 92.0) in patients without hospital acquired pneumonia or immune-compromising disorder. Conclusions In critically ill patients with pneumonia during the influenza season, PCT is a reasonably accurate marker for detection of bacterial pneumonia, particularly in patients with community-acquired disease and without immune-compromising disorders, but it might not be sufficient as a stand-alone marker for withholding antibiotic treatment.
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Ingram PR, Iredell J. Active screening for multiresistant Enterobacteriaceae. Microbiol Aust 2014. [DOI: 10.1071/ma14005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Norton K, Ingram PR, Heath CH, Manning L. Risk factors for nephrotoxicity in patients receiving outpatient continuous infusions of vancomycin in an Australian tertiary hospital. J Antimicrob Chemother 2013; 69:805-8. [PMID: 24107387 DOI: 10.1093/jac/dkt402] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To assess the risk factors for nephrotoxicity caused by vancomycin continuous infusion in a predominantly Caucasian outpatient population. METHODS This was a retrospective cohort study of 155 patient episodes from December 2006 to December 2011. RESULTS Vancomycin-associated nephrotoxicity (VN) occurred in 26 of 155 (17%) patient episodes. After adjustment for baseline renal function, maximum steady-state vancomycin concentrations ≥32 mg/L [OR 8.7 (95% CI 3.1-29.6), P < 0.001] and angiotensin receptor blockade [OR 9.78 (95% CI 3.1-39.4), P < 0.001] were independently associated with VN. The cumulative dose and duration of vancomycin therapy were not independent predictors of VN. CONCLUSIONS Cessation of angiotensin receptor-blocking medications in selected patient groups, enhanced monitoring and establishing target steady-state concentrations <30 mg/L to avoid excessive vancomycin exposure may reduce the risk of VN.
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Affiliation(s)
- Katherine Norton
- Department of Microbiology and Infectious Diseases, Royal Perth Hospital, Perth, Western Australia (WA), Australia
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Abstract
A point-prevalence study at a tertiary Australian hospital found 199 of 462 inpatients (43%) to be receiving antibiotic therapy. Forty-seven per cent of antibiotic use was discordant with guidelines or microbiological results and hence considered inappropriate. Risk factors for inappropriate antibiotic prescribing included bone/joint infections, the absence of infection, creatinine level >120 µmol/L, carbapenem or macrolide use and being under the care of the aged care/rehabilitation team. In the setting of finite antimicrobial stewardship resources, identification of local determinants for inappropriate antibiotic use may enable more targeted interventions.
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Affiliation(s)
- P R Ingram
- Department of Infectious Diseases and Microbiology, Royal Perth Hospital, Perth, WA 6000, Australia.
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Hewison CJ, Heath CH, Ingram PR. Stool culture. Aust Fam Physician 2012; 41:775-779. [PMID: 23210099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Stool culture is a laboratory test used to determine the aetiology of infective, bacterial diarrhoea. It refers to the inoculation of selective agar plates with faeces and incubation for 1-2 days to detect the presence of pathogenic bacteria within the bowel flora.
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Ingram PR, Inglis TJJ, Vanzetti TR, Henderson BA, Harnett GB, Murray RJ. Comparison of methods for AmpC β-lactamase detection in Enterobacteriaceae. J Med Microbiol 2011; 60:715-721. [PMID: 21372181 DOI: 10.1099/jmm.0.029140-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
AmpC β-lactamases (Bla(AmpC)) are an emerging group of antimicrobial resistance determinants. The lack of an agreed Bla(AmpC) detection method hinders investigation of their epidemiology and understanding of their clinical significance. This study compared the sensitivity and specificity of phenotypic methods of Bla(AmpC) detection in a collection of 246 Enterobacteriaceae with a diverse range of β-lactam resistance profiles. The Bla(AmpC) screening methods evaluated were based on cephamycin, ceftazidime and cefepime susceptibility. These were compared with Bla(AmpC) screening using conventional ESBL detection methods. The confirmatory methods evaluated were biologically based assays, inhibitor-based assays, an AmpC Etest and a rapid chromogenic assay. A multiplex nucleic acid amplification test and the three-dimensional enzyme extraction assay were used as reference methods. Bla(AmpC) activity was present in 74 isolates. The majority of the enzymes were plasmid-encoded and belonged to the CMY, DHA and EBC families. The screening methods had sensitivities between 47 and 99 % and specificities of 45-95 %. The performance of confirmatory tests varied widely, ranging in sensitivity from 19 % to 97 % and in specificity from 88 % to 100 %. Only the Tris-EDTA and MAST ID D68C disc tests had a sensitivity and a specificity above 90 %. Further investigation is needed to establish the most suitable enzyme substrates, inhibitor types, inhibitor concentrations and interpretative cut-offs in order to refine the inhibitor-based methods. A simple disc-based protocol using cefoxitin non-susceptibility as a screening tool, followed by the Tris-EDTA method for confirmation, detects Bla(AmpC) activity with 95 % sensitivity and 98 % specificity.
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Affiliation(s)
- Paul R Ingram
- Department of Microbiology, PathWest Laboratory Medicine, QEII Medical Centre, Nedlands, WA 6009, Australia
| | - Tim J J Inglis
- Department of Microbiology, PathWest Laboratory Medicine, QEII Medical Centre, Nedlands, WA 6009, Australia
| | - Tessa R Vanzetti
- Department of Microbiology, PathWest Laboratory Medicine, QEII Medical Centre, Nedlands, WA 6009, Australia
| | - Barbara A Henderson
- Department of Microbiology, PathWest Laboratory Medicine, QEII Medical Centre, Nedlands, WA 6009, Australia
| | - Gerald B Harnett
- Department of Microbiology, PathWest Laboratory Medicine, QEII Medical Centre, Nedlands, WA 6009, Australia
| | - Ronan J Murray
- Department of Microbiology, PathWest Laboratory Medicine, QEII Medical Centre, Nedlands, WA 6009, Australia
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Ingram PR, Bremner P, Inglis TJ, Murray RJ, Cousins DV. Zoonotic tuberculosis: on the decline. Commun Dis Intell Q Rep 2010; 34:339-341. [PMID: 21090190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Mycobacterium bovis is a zoonotic member of the Mycobacterium tuberculosis complex responsible for a clinical syndrome indistinguishable from that due to M. tuberculosis. In Australia, infection with M. bovis has historically been associated with employment in the livestock industry or immigration from countries in which animal disease is endemic. It currently accounts for 0.2% of all human cases of tuberculosis within Australia. This paper describes a case of pulmonary M. bovis in a butcher and reviews factors responsible for the declining incidence of this disease in Australia.
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Affiliation(s)
- Paul R Ingram
- Division of Microbiology and Infectious Diseases, PathWest Laboratory, Sir Charles Gairdner Hospital, Western Australia.
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Ingram PR, Lye DC, Fisher DA, Goh WP, Tam VH. Nephrotoxicity of continuous versus intermittent infusion of vancomycin in outpatient parenteral antimicrobial therapy. Int J Antimicrob Agents 2009; 34:570-4. [DOI: 10.1016/j.ijantimicag.2009.07.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Revised: 07/20/2009] [Accepted: 07/21/2009] [Indexed: 10/20/2022]
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Henriquez FL, McBride J, Campbell SJ, Ramos T, Ingram PR, Roberts F, Tinney S, Roberts CW. Acanthamoeba alternative oxidase genes: Identification, characterisation and potential as antimicrobial targets. Int J Parasitol 2009; 39:1417-24. [DOI: 10.1016/j.ijpara.2009.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2009] [Revised: 04/15/2009] [Accepted: 04/28/2009] [Indexed: 11/24/2022]
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Affiliation(s)
- Paul R Ingram
- Department of Medicine, National University Hospital, Singapore, Singapore
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Abstract
BACKGROUND AND OBJECTIVE This study examined the potential utility of outpatient parenteral antibiotic therapy (OPAT) as a means of reducing the excessive number of patients hospitalized with low-risk community-acquired pneumonia (CAP). METHODS A prospective feasibility study was conducted, in which a selection algorithm was applied to a cohort of patients admitted with suspected CAP, to identify a group in whom admission may have been prevented by the use of OPAT. Numbers of potentially suitable patients, inpatient bed days saved and frequency of adverse events that may have led to readmission were measured. RESULTS There were 118 inpatients treated with confirmed CAP during the study period, of whom 27 had low-risk disease (Pneumonia Severity Index grades I-III). Application of the selection algorithm identified eight (30% of those with low-risk disease) patients who were potentially suitable for OPAT, and this group commonly experienced adverse events during follow up which may have resulted in readmission to hospital. CONCLUSIONS In many hospitalized patients with CAP, outpatient therapy is precluded by either disease severity or active medical and psychosocial factors. This limits the role of OPAT as a tool for reducing the inpatient burden of CAP.
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Affiliation(s)
- Paul R Ingram
- Infectious Diseases Service, Fremantle, Western Australia, Australia
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Ingram PR, Mahadevan M, Fisher DA. Dengue management: practical and safe hospital-based outpatient care. Trans R Soc Trop Med Hyg 2008; 103:203-5. [PMID: 18760815 DOI: 10.1016/j.trstmh.2008.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Revised: 07/18/2008] [Accepted: 07/18/2008] [Indexed: 10/21/2022] Open
Abstract
Service provision for a population with endemic dengue is difficult because of its variable incidence and its unpredictable clinical course in individuals. We describe a novel hospital-based outpatient dengue management clinic that is sustainable both during and outside epidemic periods. Pre-defined selection criteria based on demographic, clinical and laboratory prognostic factors were applied. In the first five months, this predominantly nurse-operated, protocol-based clinic enrolled 118 adults, or 35% of patients who would have ordinarily received inpatient care. This resulted in 207 bed-days saved without adverse events.
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Affiliation(s)
- Paul R Ingram
- Department of Medicine, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
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Ingram PR, Howman R, Leahy MF, Dyer JR. Cryptococcal immune reconstitution inflammatory syndrome following alemtuzumab therapy. Clin Infect Dis 2007; 44:e115-7. [PMID: 17516390 DOI: 10.1086/518168] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Accepted: 03/05/2007] [Indexed: 02/03/2023] Open
Abstract
Alemtuzumab is a lymphocyte ablative agent that may cause susceptibility to severe opportunistic infections similar to those seen in AIDS. Pathogen-specific immune reconstitution syndromes can complicate antiretroviral therapy and immune recovery in HIV-infected patients. We present the first reported case of immune reconstitution syndrome associated with T lymphocyte recovery after alemtuzumab therapy.
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MESH Headings
- Alemtuzumab
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal, Humanized
- Antibodies, Neoplasm/adverse effects
- Antineoplastic Agents/adverse effects
- Cryptococcus neoformans/immunology
- Cryptococcus neoformans/pathogenicity
- Humans
- Immune System Diseases/immunology
- Immune System Diseases/microbiology
- Leukemia, Prolymphocytic/complications
- Leukemia, Prolymphocytic/drug therapy
- Leukemia, Prolymphocytic/immunology
- Leukemia, T-Cell/complications
- Leukemia, T-Cell/drug therapy
- Leukemia, T-Cell/immunology
- Male
- Middle Aged
- Salvage Therapy/adverse effects
- Syndrome
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Affiliation(s)
- Paul R Ingram
- Department of Infectious Diseases, Fremantle Hospital, Fremantle, Western Australia, Australia
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McBride J, Ingram PR, Henriquez FL, Roberts CW. Development of colorimetric microtiter plate assay for assessment of antimicrobials against Acanthamoeba. J Clin Microbiol 2005; 43:629-34. [PMID: 15695656 PMCID: PMC548097 DOI: 10.1128/jcm.43.2.629-634.2005] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We have developed and optimized a 96-well microtiter plate assay, based on the reduction of alamarBlue, to assess the efficacies of much needed new antimicrobials against Acanthamoeba species. This assay has been optimized for determination of drug efficacy against two potentially pathogenic species, Acanthamoeba castellanii and Acanthamoeba polyphaga, and has been validated by comparison of their relative susceptibilities to chlorhexidine, a drug widely used to treat Acanthamoeba keratitis. The results demonstrate that the assay is comparable to a manual counting assay and that A. polyphaga is more resistant to chlorhexidine than A. castellanii. Thus, by use of the manual counting assay, 3.125 microM chlorohexidine was almost completely effective against A. castellanii, whereas this concentration was less than 20% effective against A. polyphaga. Similar results were obtained by the alamarBlue assay. The new assay was used to determine the relative susceptibilities of A. castellanii and A. polyphaga to the alkylphosphocholines (APCs) hexadecylphosphocholine (hexadecyl-PC; miltefosine) and octadecylphosphocholine (octadecyl-PC) as well as an alkylgycerolphosphocholine, edelfosine. Both APCs studied were equally effective against A. castellanii, but octadecyl-PC was less effective than hexadecyl-PC against A. polyphaga. Both APCs were more effective than edelfosine against both Acanthamoeba species. A. polyphaga was found to be significantly less susceptible to each of the phosphocholine analogues. The newly described assay offers a number of advantages over those described previously. It is less labor-intensive than previously described assays and is sensitive and rapid, and the results can be read in a nonsubjective manner. As it is based on a standard 96-well, microtiter plate, it is amenable to automation and high throughput.
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Affiliation(s)
- James McBride
- Department of Immunology, Strathclyde Institute for Biomedical Sciences, University of Strathclyde, 27 Taylor St., Glasgow, Scotland, UK
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Ingram PR, Pitt AR, Wilson CG, Olejnik O, Spickett CM. A comparison of the effects of ocular preservatives on mammalian and microbial ATP and glutathione levels. Free Radic Res 2005; 38:739-50. [PMID: 15453639 DOI: 10.1080/10715760410001712773] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The aim of this study was to investigate the mechanism of action of the preservative sodium chlorite (NaClO2), and the relationship with intracellular glutathione depletion. A detailed comparison of the dose responses of two cultured ocular epithelial cell types and four species of microorganism was carried out, and comparisons were also made with the quaternary ammonium compound benzalkonium chloride (BAK), and the oxidant hydrogen peroxide (H2O2). The viability of mammalian and microbial cells was assessed in the same way, by the measurement of intracellular ATP using a bioluminescence method. Intracellular total glutathione was measured by reaction with 5,5'-dithiobis-2-nitrobenzoic acid in a glutathione reductase-dependent recycling assay. BAK and H2O2 caused complete toxicity to conjunctival and corneal epithelial cells at approximately 25 ppm, in contrast to NaClO2, where > 100 ppm was required. The fungi Candida albicans and Alternaria alternata had a higher resistance to NaClO2 than the bacteria Staphyloccus aureus and Pseudomonas aeruginosa, but the bacteria were extremely resistant to H2O2. NaClO2 caused substantial depletion of intracellular glutathione in all cell types, at concentrations ranging from < 10 ppm in Pseudomonas, 25-100 ppm in epithelial cells, to > 500 ppm in fungal cells. The mechanisms of cytotoxicity of NaClO2, H2O2 and BAK all appeared to differ. NaClO2 was found to have the best balance of high antibacterial toxicity with low ocular toxicity. The lower toxicity of NaClO2 to the ocular cells, compared with BAK and H2O2, is in agreement with fewer reported adverse effects of application in the eye.
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Affiliation(s)
- Paul R Ingram
- Department of Immunology, University of Strathclyde, Glasgow, UK
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Ingram PR, Homer NZM, Smith RA, Pitt AR, Wilson CG, Olejnik O, Spickett CM. The interaction of sodium chlorite with phospholipids and glutathione: a comparison of effects in vitro, in mammalian and in microbial cells. Arch Biochem Biophys 2003; 410:121-33. [PMID: 12559984 DOI: 10.1016/s0003-9861(02)00659-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In this study the interaction of the preservative sodium chlorite with unsaturated lipids and glutathione was investigated, in comparison with peroxides, sodium hypochlorite, and benzalkonium chloride. The aim was to determine whether the action of sodium chlorite could involve membrane lipid damage or antioxidant depletion, and how this related to toxicity in both mammalian and microbial cells. The treatment of phospholipids with chlorite yielded low levels of hydroperoxides, but sodium chlorite oxidized the thiol-containing antioxidant glutathione to its disulfide form very readily in vitro, with a 1:4 oxidant:GSH stoichiometry. In cultured cells, sodium chlorite also caused a substantial depletion of intracellular glutathione, whereas lipid oxidation was not very prominent. Sodium chlorite had a lower toxicity to ocular mammalian cells than benzalkonium chloride, which could be responsible for the different effects of long-term application in the eye. The fungal cells, which were most resistant to sodium chlorite, maintained higher percentage levels of intracellular glutathione during treatment than the mammalian cells. The results show that sodium chlorite can cause oxidative stress in cells, and suggest that cell damage is more likely to be due to interaction with thiol compounds than with cell membrane lipids. The study also provides important information about the differential resistance of ocular cells and microbes to various preservatives and oxidants.
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Affiliation(s)
- Paul R Ingram
- Department of Immunology, University of Strathclyde, 27 Taylor Street, G4 ONR Glasgow, UK
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