Caitlin Keighley

Changing epidemiology of candidaemia in Australia

Objectives Knowledge of contemporary epidemiology of candidaemia is essential. We aimed to identify changes since 2004 in incidence, species epidemiology and antifungal susceptibilities of Candida spp. causing candidaemia in Australia. Methods These data were collected from nationwide active laboratory-based surveillance for candidaemia over 1 year (within 2014-2015). Isolate identification was by MALDI-TOF MS supplemented by DNA sequencing. Antifungal susceptibility testing was performed using Sensititre YeastOne™. Results A total of 527 candidaemia episodes (yielding 548 isolates) were evaluable. The mean annual incidence was 2.41/105 population. The median patient age was 63 years (56% of cases occurred in males). Of 498 isolates with confirmed species identity, Candida albicans was the most common (44.4%) followed by Candida glabrata complex (26.7%) and Candida parapsilosis complex (16.5%). Uncommon Candida species comprised 25 (5%) isolates. Overall, C. albicans (>99%) and C. parapsilosis (98.8%) were fluconazole susceptible. However, 16.7% (4 of 24) of Candida tropicalis were fluconazole- and voriconazole-resistant and were non-WT to posaconazole. Of C. glabrata isolates, 6.8% were resistant/non-WT to azoles; only one isolate was classed as resistant to caspofungin (MIC of 0.5 mg/L) by CLSI criteria, but was micafungin and anidulafungin susceptible. There was no azole/echinocandin co-resistance. Conclusions We report an almost 1.7-fold proportional increase in C. glabrata candidaemia (26.7% versus 16% in 2004) in Australia. Antifungal resistance was generally uncommon, but azole resistance (16.7% of isolates) amongst C. tropicalis may be emerging.

Use of an Innovative Personality-Mindset Profiling Tool to Guide Culture-Change Strategies among Different Healthcare Worker Groups

Introduction Important culture-change initiatives (e.g. improving hand hygiene compliance) are frequently associated with variable uptake among different healthcare worker (HCW) categories. Inherent personality differences between these groups may explain change uptake and help improve future intervention design. Materials and Methods We used an innovative personality-profiling tool (ColourGrid®) to assess personality differences among standard HCW categories at five large Australian hospitals using two data sources (HCW participant surveys [PS] and generic institution-wide human resource [HR] data) to: a) compare the relative accuracy of these two sources; b) identify differences between HCW groups and c) use the observed profiles to guide design strategies to improve uptake of three clinically-important initiatives (improved hand hygiene, antimicrobial stewardship and isolation procedure adherence). Results Results from 34,243 HCWs (HR data) and 1045 survey participants (PS data) suggest that HCWs were different from the general population, displaying more individualism, lower power distance, less uncertainty avoidance and greater cynicism about advertising messages. HR and PS data were highly concordant in identifying differences between the three key HCW categories (doctors, nursing/allied-health, support services) and predicting appropriate implementation strategies. Among doctors, the data suggest that key messaging should differ between full-time vs part-time (visiting) senior medical officers (SMO, VMO) and junior hospital medical officers (HMO), with SMO messaging focused on evidence-based compliance, VMO initiatives emphasising structured mandatory controls and prestige loss for non-adherence, and for HMOs focusing on leadership opportunity and future career risk for non-adherence. Discussion Compared to current standardised approaches, targeted interventions based on personality differences between HCW categories should result in improved infection control-related culture-change uptake. Personality profiling based on HR data may represent a useful means of developing a national culture-change “blueprint” for HCW education.

Implant salvage in breast reconstruction with severe peri-prosthetic infection.

Although treatment of mild peri‐prosthetic infection in implant‐based breast reconstruction results in high rates of resolution, successful management of severe peri‐prosthetic infection remains a significant challenge.

Tatlockia maceachernii endocarditis diagnosed on 16s rRNA sequencing of explanted aortic valve tissue

to a NZ hospital with a diagnosis of viral illness. He was readmitted 3 days later due to increased respiratory distress. Examination revealed tachypnoea and wheezing, but the chest was clear on x-ray. The initial two blood cultures detected no growth. Trans-oesophageal echocardiogram showed severe bulky vegetations on the right side of the heart and pacing leads. Urgent surgery was performed and specimens were sent to the laboratory. Microbiology: The specimens, which showed septate hyphae on Calcofluor white stain, were sent for fungal culture. Voriconazole was given for the suspected Aspergillus endocarditis. Phenotypic features and DNA-nucleotide sequencing of the isolate confirmed the diagnosis of Microascus cinereus endocarditis. Discussion: Fungal endocarditis needs to be considered in culture-negative infective endocarditis patients with no response to antimicrobial therapy. Antifungal susceptibility testing is important in choosing the appropriate antifungal treatment. Acknowledgements: Many thanks to Dr Sally Roberts and Dr Joshua Freeman for their guidance, and to the LabPlus Scientists for the sequencing and confirmation of the fungus.

Modern technology and infectious diseases activity data: how can we use this for service planning?

We read with interest the article by Bursle et al. describing the infectious diseases (ID) experience at a tertiary hospital with a 25-bed intensive care unit (ICU). Our institution is a 975-bed tertiary hospital with 38 ICU beds, trauma, organ transplant and high-risk haemopoietic stem cell transplant services. We recently conducted an audit of our workload using a customdesigned iPad database from February to August 2014. Although Bursle et al. and Ingram et al. have reported new consultation rates of 10 and 11.5 per week, respectively, our number of formal consultations per trainee was higher (median 31, interquartile range 26–36). The number of consults per occupied bed days (OBD) was similar to Bursle et al., thus our rate is due to higher patient numbers. At our institution, 30% of referrals come from the ICU or haematology service (19/1000 OBD), contrasting 8.6– 10% and 11/1000 OBD reported in other Australian institutions. Since all provide proactive ID consultative ward rounds, there must be an alternative explanation for the higher rate in our centre. Formal ID consultations are associated with improved patient outcomes compared to informal advice, and in a quaternary centre with a large number of high-acuity patients this must be considered in service planning. Current diagnosis-related group-based funding models are based on inpatient admissions. In our unit, admissions have increased by 17% over 2013–2014. However, we found that 70% of formal inpatient interactions were consultations. Thus, our funding accounts for up to 30% of the department workload in a direct patient interaction. Neither Bursle et al. or Ingram et al. assessed the contribution of informal advice to workload. We also evaluated data for all consulting registrar interactions; 30% of these involved informal telephone advice. We recently implemented the use of a mobile telephone to facilitate data collection and analysis of the time spent on the calls. The time spent on formal and informal consultative work is important to inform funding models. This analysis of our departmental activities has led to structural change. We have introduced an antimicrobial stewardship (AMS) team that has been shown to streamline consultative work and improve patient care. AMS and ID consultation at the time of patient admission has the capacity to enhance this effect over and above a more reactive intervention after 24–72 h, and would require increases in staffing. The use of electronic devices to document accurately the departmental workload has facilitated strategic planning. Data could also be used for quality activities such as clinical audits, and as a basis to request extra funding where necessary.