Valuing antibiotics: The role of the hospital clinician

The global public health threat of antibiotic-resistant infections as well as the lack of new treatments in clinical development is a critical issue. Reasons for this include diminished commercial incentives for pharmaceutical companies to develop new antibiotics, which part-reflects a shift in antibiotic marketing paradigm from broad deployment to targeted therapy in relatively small patient populations. Such changes are encouraged by antimicrobial stewardship (AMS). Other factors include a lack of recognition in the traditional assessment of new antibiotics by regulators, health technology assessors and payers of the broad range of benefits of new agents, particularly their value to health care, economies and society. Recognising the seriousness of the situation, there have been recent changes and proposals by regulators for modification of the assessment process to accommodate a broader range of acceptable data supporting new drug applications. There is also increasing recognition by some payers of the societal benefit of new antibiotics and the need for financial incentives for those developing high-priority antibiotics. However, progress is slow, with recent publications focusing on industry and strategic perspectives rather than clinical implications. In this opinion piece, we therefore focus on clinicians and the practical steps they can take to drive and contribute to increasing awareness and understanding of the value of antibiotics. This includes identifying and gathering appropriate alternative data sources, educating on AMS and prescribing habits, and contributing to international antibiotic susceptibility surveillance models.

European perspective and update on the management of nosocomial pneumonia due to methicillin-resistant Staphylococcus aureus after more than 10 years of experience with linezolid

Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of antimicrobial-resistant hospital-acquired infections worldwide and remains a public health priority in Europe. Nosocomial pneumonia (NP) involving MRSA often affects patients in intensive care units with substantial morbidity, mortality and associated costs. A guideline-based approach to empirical treatment with an antibacterial agent active against MRSA can improve the outcome of patients with MRSA NP, including those with ventilator-associated pneumonia. New methods may allow more rapid or sensitive diagnosis of NP or microbiological confirmation in patients with MRSA NP, allowing early de-escalation of treatment once the pathogen is known. In Europe, available antibacterial agents for the treatment of MRSA NP include the glycopeptides (vancomycin and teicoplanin) and linezolid (available as an intravenous or oral treatment). Vancomycin has remained a standard of care in many European hospitals; however, there is evidence that it may be a suboptimal therapeutic option in critically ill patients with NP because of concerns about its limited intrapulmonary penetration, increased nephrotoxicity with higher doses, as well as the emergence of resistant strains that may result in increased clinical failure. Linezolid has demonstrated high penetration into the epithelial lining fluid of patients with ventilator-associated pneumonia and shown statistically superior clinical efficacy versus vancomycin in the treatment of MRSA NP in a phase IV, randomized, controlled study. This review focuses on the disease burden and clinical management of MRSA NP, and the use of linezolid after more than 10 years of clinical experience.

Evaluating the cost-effectiveness of strategies to prevent vascular access device infections

The evidence clearly indicates that a care-bundle approach is needed to prevent catheter-related bloodstream infections (CRBSIs). Such an approach includes the need for education, training and adequate staffing, sterile barrier precautions, skin preparation, use of intravenous dressings and antimicrobial prophylaxis. Care bundles advise which aspects must be given priority and what procedures will produce optimum outcomes. All of these activities come at a cost, yet very few studies have investigated the extent to which they are cost-effective. As a result, it is difficult to make evidence-based decisions on the potential cost savings that may be achieved with a care-bundle approach. This article describes the existing health-economic evidence on strategies to prevent CRBSIs and outlines the criteria for future research.

De-escalation from micafungin is a cost-effective alternative to traditional escalation from fluconazole in the treatment of patients with systemic Candida infections

BACKGROUND

Systemic Candida infections (SCI) occur predominantly in intensive care unit patients and are a common cause of morbidity and mortality. Recently, changes in Candida epidemiology with an increasing prevalence of SCI caused by Candida non-albicans species have been reported. Resistance to fluconazole and azoles in general is not uncommon for non-albicans species. Despite guidelines recommending initial treatment with broad-spectrum antifungals such as echinocandins with subsequent switch to fluconazole if isolates are sensitive (de-escalation strategy), fluconazole is still the preferred first-line antifungal (escalation) in many clinical practice settings. After diagnosis of the pathogen, the initial therapy with fluconazole is switched to a broad-spectrum antifungal if a non-albicans is identified.

METHODS

The cost-effectiveness of initial treatment with micafungin (de-escalation) vs fluconazole (escalation) in patients with SCI was estimated using decision analysis based on clinical and microbiological data from pertinent studies. The model horizon was 42 days, and was extrapolated to cover a lifetime horizon. All costs were analyzed from the UK NHS perspective. Several assumptions were taken to address uncertainties; the limitations of these assumptions are discussed in the article.

RESULTS

In patients with fluconazole-resistant isolates, initial treatment with micafungin avoids 30% more deaths and successfully treats 23% more patients than initial treatment with fluconazole, with cost savings of £1621 per treated patient. In the overall SCI population, de-escalation results in 1.2% fewer deaths at a marginal cost of £740 per patient. Over a lifetime horizon, the incremental cost-effectiveness of de-escalation vs escalation was £15,522 per life-year and £25,673 per QALY.

CONCLUSIONS

De-escalation from micafungin may improve clinical outcomes and overall survival, particularly among patients with fluconazole-resistant Candida strains. De-escalation from initial treatment with micafungin is a cost-effective alternative to escalation from a UK NHS perspective, with a differential cost per QALY below the 'willingness-to-pay' threshold of £30,000.

Approaches to improving antibiotic management

New information is available to improve antibiotic outcomes in severe sepsis where increasing resistance and reducing novel compound development make reaching the right decisions ever more difficult and important.

Guidelines for UK practice for the diagnosis and management of methicillin-resistant Staphylococcus aureus (MRSA) infections presenting in the community

These guidelines have been developed by a Working Party convened on behalf of the British Society for Antimicrobial Chemotherapy. Their aim is to provide general practitioners and other community- and hospital-based healthcare professionals with pragmatic advice about when to suspect MRSA infection in the community, when and what cultures should be performed and what should be the management options, including the need for hospitalization.

Indicators of bacterial infection in patients with acute exacerbation of chronic bronchitis for application in clinical trials of antibacterial drugs

OBJECTIVES

This study examined the accuracy of: (a) patient symptoms; (b) microscopic examination of sputum purulence (>25 WBCs and <10 epithelial cells) and (c) microscopic examination of morphological bacterial cell types, in identifying bacterial infection in patients with an acute exacerbation of chronic bronchitis (AECB) for entry to clinical trials.

METHODS

Subjects had a worsening of at least two symptoms from: dyspnoea, sputum volume, and sputum purulence (Anthonisen Type 1 or 2 exacerbation). Sputum samples were collected from all subjects.

RESULTS

A total of 97 sputum samples were evaluated. Overall, 58 (60%) subjects were culture-positive; 22 of 29 (76%) subjects with Type 2 exacerbation had a bacterial pathogen isolated compared with 36 of 68 (53%) Type 1 subjects. This difference was not statistically significant. Microscopically purulent samples were found to be significantly more likely to be culture-positive than non-purulent samples. However, the sensitivity (60%) and specificity (67%); and the positive predictive value (73%) and negative predictive value (53%) observed, means that this is not an ideal predictive test for clinical trials. A semi-quantitative approach to Gram staining was identified as a potential indicator of bacterial infection. Sputum specimens with one bacterial cell type present at >10 cells per field, or more than one cell type present with at least one type at a concentration of >25 cells per field, had a high proportion (91%) of culture-positive specimens.

CONCLUSIONS

Symptoms alone are a poor indicator of bacterial infection. A semi-quantitative examination of a Gram-stained sputum preparation was the best indicator of bacterial infection. This finding may have relevance in the design of clinical trials of antibacterial drugs in AECB.

Improving practice the Hospital Pharmacy Initiative revisited

The Hospital Pharmacy Initiative was a 12 million pounds sterling scheme introduced in England in 2003 and aimed at improving antimicrobial prescribing. Although significant successes have been claimed for the scheme, there is evidence which demonstrates that the untargeted and essentially undirected investment where no clear objectives were set has resulted in extremely variable developments with arguably minimal gains attributable to the programme. This contrasts strongly with the Scottish approach where form and function has been detailed with a focus on service sustainability in the ongoing challenge of improving prudent antimicrobial prescribing.

Trends in antimicrobial susceptibility in UK centres: the MYSTIC Programme (1997–2002)

Trends in antimicrobial susceptibilities in three UK centres participating in the MYSTIC Programme were examined from 1997 to 2002. Isolates were tested using standard methodology to determine the susceptibility breakpoints of meropenem and several other antimicrobial agents including imipenem, ceftazidime, piperacillin/tazobactam, ciprofloxacin and gentamicin. Data are grouped in 2-year blocks. The carbapenems were the most active agents tested against the Enterobacteriaceae (99-100% and 98-100% susceptibility to meropenem and imipenem, respectively) and non-fermenters, including Pseudomonas spp. and Acinetobacter spp. With the exception of susceptibility to ciprofloxacin, which decreased among Enterobacteriaceae at the end of the 6-year period, all antibiotics tested retained their levels of activity. The proportion of extended-spectrum beta-lactamase (ESBL)- and AmpC-producing Enterobacteriaceae increased during the study (4.8% and 11.3% in 1997-1998; 7.4% and 16.7% in 2001-2002, respectively). Both meropenem and imipenem retained their potency against these ESBL- and AmpC-producing isolates (100% for all time periods). All the other antimicrobial agents tested had much lower susceptibility against these resistant isolates and this decreased further over the 6-year period, with the exception of tazobactam, which maintained its low levels. Although all antibiotics tested retained acceptable activity, the carbapenems remained the most active antimicrobial agents against Gram-negative bacteria, including ESBL- and AmpC-producing isolates.

The OPTAMA programme: utilizing MYSTIC (2002) to predict critical pharmacodynamic target attainment against nosocomial pathogens in Europe

OBJECTIVES

The Optimising Pharmacodynamic Target Attainment using the MYSTIC (Meropenem Yearly Susceptibility Test Information Collection) Antibiogram (OPTAMA) programme identifies antibiotic regimens with the highest probability of attaining critical pharmacodynamic targets, accounting for the inherent variability in pharmacokinetics, dosages and MIC distributions.

METHODS

European MIC data were obtained from the MYSTIC programme. Pharmacodynamic target attainment was calculated by Monte Carlo simulation for meropenem, imipenem, ceftazidime, cefepime, piperacillin/tazobactam and ciprofloxacin against Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa.

RESULTS

Significant differences in probability of target attainment were found, with Northern Europe demonstrating the highest probabilities of target attainment and Eastern Europe the lowest. The carbapenems had the highest target attainments and susceptibility levels across all regions and pathogens. The cephalosporins demonstrated high target attainments and susceptibility results against E. coli and K. pneumoniae in Northern and Southern Europe. Piperacillin/tazobactam and ciprofloxacin had the lowest levels for both parameters in all regions. Desirable target attainment was not achieved (except for carbapenems in Northern Europe) for A. baumannii and P. aeruginosa; thus, combination therapy may be appropriate empirical therapy for these pathogens in Southern and Eastern Europe. The closest correlations between target attainment and susceptibility were for meropenem 1 g every 8 h, imipenem 0.5 g every 6 h and ceftazidime 1 g every 8 h.

CONCLUSIONS

The study highlighted significant overestimations between the probability of target attainment and the reported percentage susceptibility, particularly for piperacillin/tazobactam and ciprofloxacin. The approach of the OPTAMA programme provides a novel tool which complements susceptibility data to help in the selection of appropriate empirical antibiotic therapy.

Antibiotic cycling: more than it might seem?

In the present battle against the rising tide of resistance, several interventions have been proposed to help control the situation. One of these is a process of planned antibiotic restriction, introduced through cycling drug selection based on local surveillance. Although such antibiotic cycling has been the subject of much discussion for 20 years, there are relatively few data available to assess its worth. A recent systematic review found only four studies worthy of inclusion and concluded that antibiotic cycling could not, at present, be promoted as a methodology to control resistance. This paper considers the complete literature and through demonstrating consistent benefits across the breadth and depth of the findings, suggests that whereas further work is required, nevertheless antibiotic cycling-as part of a suite of control measures-is a valid option.

Investigation into the selection frequency of resistant mutants and the bacterial kill rate by levofloxacin and ciprofloxacin in non-mucoid Pseudomonas aeruginosa isolates from cystic fibrosis patients

The frequency by which resistant Pseudomonas aeruginosa strains could be selected was compared for two antibiotics, levofloxacin and ciprofloxacin. Seven distinct strains were cultured on plates containing 1x, 2x, 4x and 8x the minimum inhibitory concentration (MIC) of the antibiotic under investigation. Resistant mutants were more readily isolated by growth on culture plates that contained ciprofloxacin, and the resulting MIC of the resistant mutant was also more frequently increased. Time-kill studies on comparable strains where the MIC for both antibiotics had increased by at least fourfold showed no difference between the two agents.

Randomized, double-blind study comparing 5- and 7-day regimens of oral levofloxacin in patients with acute exacerbation of chronic bronchitis

A randomized, double-blind, multicentre study was conducted in adult patients with acute exacerbation of chronic bronchitis (AECB), to compare the efficacy of a 5-day course of levofloxacin 500 mg once daily, with the standard 7-day regimen at the same dose. Five hundred and thirty-two patients from 48 centres in 10 countries were randomized to receive levofloxacin: 268 and 264 received the 5- and 7-day courses, respectively. The primary efficacy analysis was the clinical response at 7-10 days post-treatment in the per-protocol (PP) population. Clinical success rates in the primary PP analysis of 482 patients were 82.8% (197/238) for the 5-day group and 84.8% (207/244) for the 7-day group. The difference in success rates was -2.1% with a 95% CI of (-9.1 to 4.9%). The bacteriological response showed eradication rates of 82.1% (92/112) and 83.2% (84/101) in the 5- and 7-day groups, respectively. Both treatments were well tolerated. These results show that for patients with AECB levofloxacin 500 mg once daily for 5 days provides equivalent clinical and bacteriological success to the same dose given for 7 days irrespective of the patient's age, the frequency of exacerbations or the presence of co-existing cardiopulmonary or chronic obstructive airways disease.

Surveillance studies: how can they help the management of infection?

The increase in antimicrobial resistance has led to predictions of doom in the international press and to depression in the medical community. It has focused attention upon measures for fighting resistance, foremost of which is susceptibility surveillance. Until recently, global efforts at surveillance have been largely uncoordinated and random. This scene is rapidly changing with the World Health Organization (WHO), among others, leading multidisciplinary, targeted initiatives. In terms of individual surveillance programmes, much has been learned about their design. The best of these, the Meropenem Yearly Susceptibility Test Information Collection (MYSTIC), SENTRY and the Alexander Project, involve well-defined patient and organism groups against key denominators, and use standardized, internationally recognized methods that are quality-controlled, explore susceptibility quantitatively and include investigation of resistance mechanisms. Results are rapidly returned to the user. Evidence shows that surveillance, when used to guide policies on antibiotic use and infection control, can be helpful in the fight to control the development and spread of resistance. Further work is required to demonstrate these benefits and quantify them fully.

Worthwhile infection control information? A report from the 38th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), San Diego, California: 24-27 September 1998

A review is presented of some of the presentations delivered at ICAAC 1998. These cover the subjects of handwashing, occupational infections risk exposure for healthcare workers and alterations in catheter practice to reduce both intra-venous and urinary infections.

New quinolones: their role in clinical practice

The starting point for the development of the new family of quinolones — with the recently released products grepafloxacin and levofloxacin shortly to be joined by trovafloxacin, and with others such as moxifloxacin and clinafloxacin in development — was recognition of the shortcomings of the existing preparations. The key question for the new quinolones is how well they address these deficiencies.

The effect of specimen processing delay on borate urine preservation

AIM

To investigate the effect on urine culture results and their clinical interpretation of delaying the processing of urine samples in which boric acid had been used as a preservative.

METHODS

792 mid-stream specimens of urine from patients attending their general practitioner were received in borate containing plastic jars. The specimens were cultured upon receipt, stored at room temperature, and then recultured the following morning.

RESULTS

After overnight delayed culture, the results were altered in 16% of samples and the clinical interpretation of these findings differed in 8% of specimens. In 28 samples (3.5%) the bacterium isolated on initial culture was not the same as that obtained by culture after overnight storage.

CONCLUSIONS

Boric acid urine preservation used for overnight delayed processing of samples is associated with a significant alteration in culture results and the attendant clinical interpretation of such specimens. Rapid transportation/processing of urine specimens must remain the optimum procedure.

Investigation of infection in the neutropenic patient with fever

Episodes of infection occurring in neutropenic patients are often associated with high levels of morbidity and mortality and prompt, accurate diagnosis allowing the rapid instigation of appropriate treatment can lead to an improved outcome. Recent developments in laboratory technology have increased the range of investigations available to the physician. The improved sensitivity of traditional microbiological culture, methods for antigen and antibody detection and the advances in molecular biology are among the reasons for an increased ability to detect both familiar and novel pathogens. This article describes the current methods available for determining the aetiology of an infectious episode in these patients. A plan of management for investigation of febrile episodes in neutropenic patients is suggested.

Lactobacillus rhamnosus infection in a child following bone marrow transplant

We report a case where Lactobacillus rhamnosus was isolated from pericardial effusion and blood in a child following a bone marrow transplant for aplastic anaemia. A resume of cases in which this organism has been implicated as a pathogen is also presented.

Immunisation of armed service medical personnel against hepatitis B infection

Clinical and laboratory staff of the Army and RAF medical services at risk of acquiring infection with hepatitis B were immunised against the virus with a recombinant vaccine. Vaccine was administered in Service hospitals and medical centres located throughout the world. After a primary course of vaccine, 73% of personnel developed anti-HBs titres > or = 100 IU/L to hepatitis B surface antigen and were considered protected; 11% were non-responders (anti-HBs < 10 IU/l). A significantly higher proportion of females than males, and vaccinees under 40 years of age, produced a good response. Among those achieving a good response, antibody titres were higher in the younger age group and in females. After a fourth (booster) dose of vaccine, 87.2% of the poor responders and 37% non-responders, developed anti-HBs titres > or = 100 IU/L.

High-dosage co-amoxiclav in a single dose versus 7 days of co-trimoxazole as treatment of uncomplicated lower urinary tract infection in women

The efficacy and adverse event profile of a single 3.25 g dose of co-amoxiclav as treatment of acute uncomplicated lower urinary tract infection in women was compared with that of co-trimoxazole 960 mg bd for 7 days in a prospective, randomized, double-blind multicentre clinical trial. Of the 666 patients enrolled, 279 (144 in the co-amoxiclav group and 135 in the co-trimoxazole group) were eligible for evaluation of clinical and bacteriological responses. At the follow-up assessment 42 days after study entry, the successful clinical response rate was 73.8% for patients who received co-amoxiclav, compared with 85.1% for patients given co-trimoxazole (P < or = 0.05); the corresponding rates for successful bacteriological response were 64.1% and 79.6% (P < or = 0.05). Both treatment regimens were well-tolerated, with 15% of patients in the co amoxiclav group and 12% of patients in the co-trimoxazole group reporting adverse events (P > or = 0.05). The adverse event profiles for the two groups differed, gastrointestinal disturbances predominating amongst patients who received co-amoxiclav and rashes being commonest amongst those given co-trimoxazole.

Comparison of two automated quantitative immunoassays for the determination of C reactive protein concentrations

Two quantitative, automated methods for the determination of C reactive protein (CRP) were compared: turbidimetry (Cobas Fara II, Roche, Welwyn Garden City, UK) and fluorescence polarisation TDx, Abbott, Wokingham, UK). One hundred and twenty routine serum samples submitted for measurement of CRP were tested using both procedures. The results were compared using regression line analysis and showed a high degree of correlation (r2 = 0.99, X coefficient = 1.01, constant = 0.11). C reactive protein can be accurately measured using the automated turbidimetric method which can be recommended as an alternative to fluorescence polarisation.

Primary meningococcal conjunctivitis and the need for prophylaxis in close contacts

We present three cases of primary meningococcal conjunctivitis associated with systemic sepsis. The management of such patients should include combined topical and parenteral therapy with appropriate chemoprophylaxis for close contacts of cases.

Rapid organism identification from Bactec NR blood culture media in a diagnostic microbiology laboratory

AIMS

To evaluate rapid organism identification on positive blood culture Bactec NR media (phial types 26, 27, 42 and 17), and to assess the usefulness of these procedures in a diagnostic microbiology laboratory.

METHODS

Two hundred and sixty, first positive, blood culture bottles from individual patients were tested by rapid identification methods selected on the basis of Gram film organism morphology. Tube coagulase and latex agglutination were applied to presumptive staphylococci; latex agglutination antigen detection methods to suspected pneumococci, Neisseria and Haemophilus sp; and latex agglutination grouping tests for cultures thought to be non-pneumococcal streptococci.

RESULTS

Media type did not influence test performance (p > 0.05 for all comparisons). Misapplication of methods occurred on eight occasions and there were 14 false positive results, nine involving the latex reagents for group C streptococci and pneumococci. The positive predictive values for tube coagulase tests and latex reactions for H influenzae type b, and N meningitidis groups B and C were 100%. The pneumococcal and staphylococcal latex tests gave positive predictive values of 94.1% and 62.5%, respectively, and the corresponding figure for streptococcal grouping reactions was 75.9%. With the exception of staphylococcal latex testing (80%) all investigation negative predictive values were > 90%.

CONCLUSIONS

The performance of the staphylococcal latex agglutination method was unsatisfactory and it is not appropriate for use with the media studied. In view of the cross-reactions observed with the tests used to identify group C streptococci and pneumococci, positive findings must be interpreted with caution. In all other regards the protocol evaluated produced rapid, reliable, clinically useful information and, subject to local experience, is recommended to users of Bactec NR media.

Prevalence of immunity to hepatitis A in recruits to the British Army and Royal Air Force

Between 1989 and 1992, 92% of a sample of 2790 Service recruits aged between 17 and 35 years (mean age 19 years 7 months) were found not to be immune to infection by hepatitis A virus. The proportion of males with immunity was consistently greater than that for females. There was a significantly increased probability of immunity if individuals originated from Northern England, the Midlands and Scotland, in particular the suburbs. Among male recruits there were significantly increased probabilities of immunity associated with travel to Southern and Eastern Europe or to the Tropics, and for females with travel to North West Europe or to Southern and Eastern Europe.

Sexually transmitted diseases in transient British forces in the tropics

OBJECTIVE

To compare the incidence of sexually transmitted diseases (STD) in British troops in the tropics with that in a standard population.

DESIGN

Retrospective analysis of STD clinic records over one calendar year.

SETTING

A British Military Hospital in the Tropics serving 1441 resident personnel.

SUBJECTS

All patients attending a STD clinic.

MAIN FINDINGS

815 cases of STD were recorded during the study period, giving incidence rate of 56,558 per 100,000 population per year. When compared with a matched population from England and Wales, the age standardised relative risk for STD amongst tropical troops was 25.0 (95% confidence interval 24.9 to 25.1). Thirty nine percent of cases reported prostitute contact as a source of their disease. Of patients questioned about condom usage, 70% reported that they did not normally use a condom.

CONCLUSIONS

British troops spending short periods of time in a tropical environment are significantly more likely to acquire a STD than men in the same age groups in England and Wales. The proportions of cases who reported that they did not use condoms and the number who cited prostitute contact as a source of infection indicate that even greater sexual education of troops on deployment overseas may be required.

Evaluation of new streptococcal latex grouping kit

AIMS

To evaluate a new streptococcal latex grouping kit (Shield Diagnostics Ltd) and compare it against an established latex agglutination method (Streptex; Wellcome Diagnostics).

METHODS

Two hundred and forty seven strains of streptococci and enterococci were tested with each kit by one operator and according to the manufacturer's instructions. Strains failing to group or giving discordant results were identified to species level.

RESULTS

Two discrepant grouping results were observed and 13 non-beta haemolytic streptococci failed to group with either product. The Shield kit successfully identified 232 isolates at 15 minutes of enzyme extraction incubation compared with 224 and 233 on short (15 minutes) and long (1 hour) incubations, respectively, for Streptex (p > 0.23 for both comparisons). On short incubation only, the Shield kit detected significantly more strains of Enterococcus faecium (p = 0.007). The reaction strengths were similar for both kits (p > 0.16). No cross-reactions were observed but the Streptex kit produced significantly fewer tests with visible granularity (p < 0.003).

CONCLUSIONS

Although the Shield product appeared to detect group D antigen more readily, overall no important differences in performance were observed. Prospective users of the new method should first become familiar with its characteristics.

Cross infection in an intensive care unit by Klebsiella pneumoniae from ventilator condensate

Klebsiella pneumoniae serotype K28 was cultured from six patients over 5 weeks in a general Intensive Care Unit. Colonized condensate in the ventilator expiratory water traps was the probable source of the organism, and hand carriage the vehicle of transmission. Although the cross-infection hazard of ventilator tubing condensate is recognized, there is no report in the literature of an outbreak caused by such fluid. Ventilator tubing condensate should be viewed as contaminated clinical waste and dealt with accordingly.

Hepatitis A immunity and travel history

Travel histories were taken from 1111 British travellers. Serological testing showed that increasing age and a past history of jaundice were associated with a greater likelihood of travellers being immune to hepatitis A. Neither travel to nor the duration of stay in areas of increased hepatitis A endemicity influenced the level of hepatitis A immunity. It is concluded that travel histories from British citizens normally resident in the U.K. cannot be used to identify those travellers in whom serological prescreening would be of value prior to immunoglobulin prophylaxis.

West African malaria

Plasmodium falciparum malaria poses an increasing risk to travellers to West Africa. The development of chloroquine resistant in West Africa has further compounded the risk. Two cases of falciparum malaria from Sierra Leone are presented. One represents the classic missed case and the other a probable case of chloroquine resistant (RI vide infra) falciparum malaria. These cases highlight the danger of the missed or late diagnosis; the need for chemoprophylaxis, even in emigrants; the threat posed to the international traveller by malaria; and the problem of chloroquine resistant Plasmodium falciparum (CRPF) malaria from West Africa. The position of Plasmodium falciparum malaria in West Africa is reviewed along with the problem caused by chloroquine resistance.

Perineal cleansing and midstream urine specimens in ambulatory women

A prospective trial is reported of an assessment of perineal cleansing as a means of reducing bacterial contamination of midstream urine samples. One hundred and ninety-two asymptomatic antenatal ambulatory patients were randomly allocated into cleansing and non-cleansing cohorts. Quantitative urine microscopy and culture showed no significant differences between the groups. It is concluded that perineal cleansing has no role to play in the collection of midstream urine specimens from ambulatory women.

Specimen transport audit

A specimen transport audit was performed at a routine and reference laboratory. Over the survey period (1986-89) the percentage of specimens received and assessed as hazardous (inadequately packed, misidentified, or contaminated by leakage) fell significantly from 12.0 to 2.8%. Specimen transport audit identified technical and logistical faults associated with sample transmission. It is concluded that no type of hazard should exceed 0.5% of samples, with the total being less than 1% of specimens received. Specimen transport audit is an additional laboratory performance indicator.