Carbapenemase-producing Enterobacteriaceae (CPE) patient notification exercise

Issue

CPE has become endemic in many European countries. Scotland has few locally acquired cases at present and interventions are aimed at minimising transmission of CPE into acute hospital settings.

Description of the problem

NHS Lothian held an incident management team (IMT) following the transmission of CPE in an inpatient setting. Initial management of the incident included informing and screening all inpatient contacts, enhanced infection control precautions and staff education. The IMT considered whether to inform and screen patient contacts who had been discharged. A literature review was carried out and teams in the UK who had considered patient notification exercises for CPE were contacted. This highlighted variation in approach.

The IMT assessed whether a patient notification exercise was required and considered: The need to reduce the risk of CPE transmission in acute hospitals by screening and isolating community contacts on readmission to hospital.The ethics of raising patient anxiety around CPE transmission with limited options for effective treatment.Risk stratification to identify contacts at highest risk.Information Governance: electronic tagging of case notes if patients have not been informed.

Results

The IMT agreed that a patient notification was appropriate. Contacts were risk assessed to determine those at greatest risk of CPE transmission. After speaking to GPs, 33 patients were sent letters. No screening of community contacts was advised unless they were re-admitted to an acute hospital or resided in a care facility. No further CPE reports have been linked to the situation.

Lessons

The IMT worked through the issues systematically to protect the public’s health without infringing their rights. The IMT advised that the Scottish CPE toolkit should be revised to support future Incidents including how to analyse transmission pathways, undertake patient notification exercises and meet public health ethics standards.

Key messages

There needs to be clear guidance on how to manage contacts of patients with CPE once discharged from hospital. Team work between Public health and Infection control is essential in manageing incidents of CPE in hospitals.

Hepatitis E virus is the leading cause of acute viral hepatitis in Lothian, Scotland

Acute viral hepatitis affects all ages worldwide. Hepatitis E virus (HEV) is increasingly recognized as a major cause of acute hepatitis in Europe. Because knowledge of its characteristics is limited, we conducted a retrospective study to outline demographic and clinical features of acute HEV in comparison to hepatitis A, B and C in Lothian over 28 months (January 2012 to April 2014). A total of 3204 blood samples from patients with suspected acute hepatitis were screened for hepatitis A, B and C virus; 913 of these samples were also screened for HEV. Demographic and clinical information on patients with positive samples was gathered from electronic patient records. Confirmed HEV samples were genotyped. Of 82 patients with confirmed viral hepatitis, 48 (59%) had acute HEV. These patients were older than those infected by hepatitis A, B or C viruses, were more often male and typically presented with jaundice, nausea, vomiting and/or malaise. Most HEV cases (70%) had eaten pork or game meat in the few months before infection, and 14 HEV patients (29%) had a recent history of foreign travel. The majority of samples were HEV genotype 3 (27/30, 90%); three were genotype 1. Acute HEV infection is currently the predominant cause of acute viral hepatitis in Lothian and presents clinically in older men. Most of these infections are autochthonous, and further studies confirming the sources of infection (i.e. food or blood transfusion) are required.

Atypical hand, foot, and mouth disease associated with coxsackievirus A6 infection, Edinburgh, United Kingdom, January to February 2014

In January to February 2014, 16 hand, foot and mouth disease (HFMD) cases were identified in Edinburgh, United Kingdom. All presented with atypical features, with most (n=13) resembling eczema herpeticum or chickenpox. Coxsackievirus A6 (CV-A6) was identified in all the typed cases (n=11). As atypical forms of HFMD associated with CV-A6 are likely to emerge throughout Europe, clinicians should be alert to unusual clinical presentations of HFMD and virologists aware of effective diagnostic testing and enterovirus typing methods.

Coevolution of antibiotic production and counter-resistance in soil bacteria

We present evidence for the coexistence and coevolution of antibiotic resistance and biosynthesis genes in soil bacteria. The distribution of the streptomycin (strA) and viomycin (vph) resistance genes was examined in Streptomyces isolates. strA and vph were found either within a biosynthetic gene cluster or independently. Streptomyces griseus strains possessing the streptomycin cluster formed part of a clonal complex. All S. griseus strains possessing solely strA belonged to two clades; both were closely related to the streptomycin producers. Other more distantly related S. griseus strains did not contain strA. S. griseus strains with only vph also formed two clades, but they were more distantly related to the producers and to one another. The expression of the strA gene was constitutive in a resistance-only strain whereas streptomycin producers showed peak strA expression in late log phase that correlates with the switch on of streptomycin biosynthesis. While there is evidence that antibiotics have diverse roles in nature, our data clearly support the coevolution of resistance in the presence of antibiotic biosynthetic capability within closely related soil dwelling bacteria. This reinforces the view that, for some antibiotics at least, the primary role is one of antibiosis during competition in soil for resources.

Toward a clinical test of lumbar spine kinesthesia

Poor lumbar spine kinesthetic awareness is often observed in low back pain patients and is usually evaluated qualitatively in the clinical situation. The purpose of this study was to investigate a simple, kinesthetic test for the lumbar spine. The experimental protocol utilized a 3Space Fastrak to determine the error, within and between days, of 10 healthy subjects in reproducing a neutral lumbopelvic (T10-S2) position following movement into flexion. The mean value of the repositioning error for the sagittal plane movement (flexion/extension) over the three repetitions within day 1 was 2.6 +/- 1.2 degrees and for day 2 was 2.6 +/- 1.7 degrees. No statistically significant difference existed between days. These repositioning errors were well within the ranges described by other authors for various asymptomatic joint complexes. These results provide a basis for further evaluation of this test on patients with low back pain to investigate its ability to detect any kinesthetic deficit.

Measurement of shoulder joint kinaesthesia

SUMMARY. Loss of kinaesthesia has been identified as a factor in recurrent or persistent problems following glenohumeral dislocation. However, accurate measurement of shoulder kinaesthesia remains a difficult task in the clinical setting. This study investigated the use of the Kincom dynamometer for measuring the ability of a subject to reproduce a shoulder joint angle with a passive and active test. The tests were applied to two subject groups, (normal and patient) and the results were compared with those of a standard clinical test. The results of the Kincom tests demonstrate a statistically significant difference between the normal and patient groups (F((1,140)) = 53.0; P < 0.001). The difference between the means for the two groups was 1.2 degrees which indicates the precision of shoulder kinaesthetic sense. All subjects were more accurate with the active test compared to the passive test (F((1,140)) = 36.5; P < 0.001). Reliability of the Kincom tests was evaluated over 3 days and a significant difference was found between day one and day three for both groups (F((2,140)) = 3.5; P < 0.05) suggesting a learning effect had occurred. There was no significant difference between the Kincom active test and the clinical test (F((1,28)) = 1.86; P = 0.18); however, the difference between the Kincom passive test and the clinical test was significant (F((1,28)) = 10.74; P < 0.01). The clinical test did not demonstrate a statistically significant difference between the two subject groups (t(28 = 1); P = 0.05). Copyright 1996 Harcourt Publishers Ltd.