Claire Dendle

Consensus guidelines for diagnosis, prophylaxis and management of Pneumocystis jirovecii pneumonia in patients with haematological and solid malignancies, 2014.

Pneumocystis jirovecii infection (PJP) is a common cause of pneumonia in patients with cancer-related immunosuppression. There are well-defined patients who are at risk of PJP due to the status of their underlying malignancy, treatment-related immunosuppression and/or concomitant use of corticosteroids. Prophylaxis is highly effective and should be given to all patients at moderate to high risk of PJP. Trimethoprim-sulfamethoxazole is the drug of choice for prophylaxis and treatment, although several alternative agents are available.

Half of All Peripheral Intravenous Lines in an Australian Tertiary Emergency Department Are Unused: Pain With No Gain?

STUDY OBJECTIVE Our study aims to determine the incidence of unused peripheral intravenous cannulas inserted in the emergency department (ED). METHODS A retrospective cohort study using a structured electronic medical record review was performed in a 640-bed tertiary care hospital in Melbourne, Australia. During a 30-day period, all patients who had a peripheral intravenous cannula recorded as a procedure on their electronic medical record in the ED were included in this study. RESULTS Fifty percent of peripheral intravenous cannulas inserted in the ED were unused. Patients presenting with obstetric and gynecologic and neurologic symptoms were significantly more likely to have an unused cannula. Forty-three percent of patients admitted to the hospital with unused peripheral intravenous cannulas in the ED continued to have them unused 72 hours later. CONCLUSION There is a high incidence of unused peripheral intravenous cannulas inserted in the ED. The risk of having an unused peripheral intravenous cannula is associated with the patients presenting complaint. Efforts should be directed to reduce this rate of unused peripheral intravenous cannula insertion, especially in patients being admitted, to minimize the risk of complications.

Review article: Animal bites: an update for management with a focus on infections.

Animal bites are a significant public health problem, with an estimated 2% of the population bitten each year. The majority of bites are from dogs and risk factors include young children, men, certain dog breeds and unrestrained dogs. The risk of infection following bites differs among animal species and is dependent on animal dentition and oral flora. Recent studies have demonstrated a broad range of pathogens isolated from infected bite wounds, with Pasteurella species being the predominant isolate from dog and cat bite wounds. Controversy exists about the use of prophylactic antibiotics; however, they are currently only recommended for high‐risk bite wounds. Two fatal cases of Australian bat lyssavirus have been reported and bats are the only identified reservoir in Australia. All bat bites are of high risk and should receive post‐exposure prophylaxis for rabies. Workers handling bats should be offered routine immunization.

Influenza vaccination uptake amongst pregnant women and maternal care providers is suboptimal

OBJECTIVE To assess the uptake of influenza vaccination by pregnant women and maternity care providers and explore their attitudes towards influenza vaccination. DESIGN, SETTING AND PARTICIPANTS Cross-sectional survey administered in a Victorian tertiary level public hospital to 337 pregnant women and 96 maternity care providers. RESULTS 31.3% of patients planned to or had received influenza vaccination this year, but only a quarter had received education about influenza. Women were more likely to receive influenza vaccination if they had been vaccinated in the last two years (RR 4.5, 95% CI: 3.1-6.4, p<0.001), received education about influenza (RR 2.3, 95% CI: 1.6-3.2, p<0.001) or believed that they were at high risk of influenza-related complications while pregnant (RR 2.0, 95% CI: 1.4-2.7, p<0.001). While only 56.8% of maternity care providers believed pregnant women were at high risk of influenza-related complications, 72.9% would recommend influenza vaccination to all pregnant women. Of the maternity care providers studied, 69% planned to or had been vaccinated in 2011, with this group more likely to recommend vaccination to their patients (RR 2.0, 95% CI: 1.3-3.0, p<0.001). Significantly more maternity care providers indicated that they would routinely recommend influenza vaccination than the proportion of patients who reported receiving education. CONCLUSIONS Influenza vaccination rates in pregnant women are low, reflecting inadequate patient education despite most maternity care providers indicating that they would routinely recommend influenza vaccination. Increasing influenza vaccination uptake by women in pregnancy will require better education of both women and maternity care providers.

Rat-bite fever septic arthritis: illustrative case and literature review

Rat-bite fever is a rare zoonotic infection caused by Streptobacillus moniliformis or Spirillum minus, which is characterised by fever, rash and arthritis. The arthritis has previously been described as non-suppurative and isolation of the organism from synovial fluid as very uncommon. This article reports a case of septic arthritis diagnosed as rat-bite fever when the organism was cultured from synovial fluid and reviews another 15 cases of S. moniliformis septic arthritis reported in the worldwide literature since 1985. Articles were included in this review if S. moniliformis was cultured from synovial fluid. Of the published cases, 88% presented with polyarthritis, affecting small and large joints although two had monoarticular hip sepsis. Fever was present in 88%, rash in 25% and 56% had extra-articular features. Synovial fluid analysis revealed high cell counts in all cases (mean 51,000 × 109/l) with a predominance of polymorphonuclear leucocytes, and organisms were found on Gram stain in only 50%. Penicillin was used for treatment in 56% of cases and surgery was required in 30%. All patients recovered. Rat-bite fever arthritis can be suppurative and attempts should be made to isolate the organism from synovial fluid. The diagnosis should be considered when there is arthritis and a high synovial fluid cell count but no apparent organism, especially when the patient has had contact with rats.

Splenectomy sequelae: an analysis of infectious outcomes among adults in Victoria.

Objective: To determine the risk and timing of a broad range of infective outcomes and mortality after splenectomy.

International travel in the immunocompromised patient: a cross-sectional survey of travel advice in 254 consecutive patients

Our primary aim was to determine the rate of overseas travel in immunocompromised individuals attending appropriate clinics at an Australian tertiary care hospital. We also aimed to characterise health‐seeking behaviour prior to travel and investigated sources of pre‐travel advice, compared travel patterns and activities between three specific immunosuppressed groups, and examined pre‐immunosuppression patient serology.

Report of oral clarithromycin desensitization

Antibiotic hypersensitivity can lead to significant morbidity, mortality and suboptimal treatment options. Rapid desensitization induces temporary immunological tolerance in a host with type 1 hypersensitivity reaction. We report a case of oral desensitization to clarithromycin. To our knowledge, this is the first protocol published for desensitization to macrolides. A 68-year-old female with a history of giant cell arteritis treated with oral corticosteroids and steroid-induced diabetes presented with small nodules and ulcers on the pre-tibial surface of her legs. Despite multiple courses of oral and parenteral antibiotics for cellulitis, the lesions continued to develop. Skin biopsy of the lesion demonstrated suppurative granuloma formation with acid-fast bacilli on microscopy. The patient reported anaphylaxis to erythromycin 20 years previously and bronchospasm to roxithromycin 5 years previously. She was commenced on rifampicin and moxifloxacin for mycobacterial skin infection, and Mycobacterium chelonaewas subsequently cultured. There was further clinical deterioration and her treatment was changed to doxycycline, intravenous amikacin and intravenous imipenem. Antibiotic susceptibility testing subsequently revealed the isolate was resistant to imipenem, so this was substituted with linezolid. Unfortunately, this was discontinued due to diarrhoea. Intravenous amikacin was not desired as a long-term treatment option due to risk of renal and ototoxicity. Clarithromycin is the treatment of choice for M. chelonae infection [1], but the patient had a strong history of type 1 hypersensitivity with macrolide antibiotics. No published protocol for rapid drug desensitization was available for clarithromycin, so a clarithromycin desensitization protocol was developed (Table 1). The protocol was administered in an intensive care unit with careful observation on a medical ward for 36 h afterwards. No adverse reaction was noted. Table 1 Oral clarithromycin desensitization protocol The patient continued doxycycline and clarithromycin for a total of 18 months. There was an excellent clinical response and no adverse drug reactions were recorded. Serious adverse drug reactions occur in 6.7% of hospitalized patients and rank from the fourth to sixth leading cause of death in these patients [2]. Since 1998 there has been a 2.6-fold increase in serious adverse drug reactions reported to the US Food and Drug Administration [3]. Type 1 (immediate) hypersensitivity reactions occur within minutes to hours of drug administration due to release of vasoactive substances from mast cells and basophils (often IgE-mediated). Clinical manifestations range from urticaria to life-threatening angio-oedema and anaphylaxis. Desensitization procedures were first developed in the 1960s [4]. Rapid desensitization involves incremental exposure to drug antigens at increasing concentrations leading to a therapeutic dose. Antigen-specific mast cell desensitization is thought to be the underlying mechanism for drug desensitization [5]. By inducing temporary clinical and immunological tolerance, patients are able to receive optimal treatment while avoiding or minimizing anaphylaxis and anaphylactoid reactions. Tolerance is maintained only if drug antigens are administered at regular intervals, and repeated desensitizations can also be given [6]. Desensitization protocols have been developed for a variety of drugs including penicillins, cephalosporins, vancomycin, sulfonamides, rifampicin, nonsteroidal anti-inflammatory drugs and chemotherapeutic agents (taxanes, platins). As specific skin prick testing to clarithromycin was not performed in our patient, we cannot be certain that an immediate hypersensitivity reaction would have occurred. However, given her previous immediate hypersensitivity reactions to other 14-membered macrolides erythromycin and roxithromycin, we felt that desensitization to clarithromycin was warranted. Skin prick testing has been well described for penicillins and cephalosporins, and is considered accurate for diagnosing penicillin allergy, as antigenic determinants have been well characterized [7]. Cross-sensitivity within the same antibiotic class is variable, however. There is little information available for diagnostic tests for macrolide allergy, as immediate hypersensitivity reactions are uncommon [8]. A patient in the literature with roxithromycin immediate hypersensitivity demonstrated positive skin prick testing to erythromycin and clarithromycin [9]. These macrolides have a similar chemical structure comprising a 14-membered carbon ring, compared with 15-membered macrolides (azithromycin) and 16-membered macrolides (spiramycin). Use of first-line antibiotics in certain conditions have been shown to have greater efficacy, for example trimethoprim + sulfamethoxazole for Pneumocystis jiroveci pneumonia [10, 11] or penicillin for syphilis, especially in HIV-infected individuals [12]. Macrolide antibiotics have an important role in the treatment of nontuberculous mycobacterial infections [13]. In our case report clarithromycin was a desirable treatment option, and rapid oral desensitization to clarithromycin was successful with no adverse events reported. We believe this is the first published protocol for desensitization to macrolide antibiotics and anticipate that its use can be extended to other centres worldwide.

Can We Expect Patients to Question Health Care Workers' Hand Hygiene Compliance?

Can We Expect Patients to Question Health Care Workers’ Hand Hygiene Compliance?Author(s): Natalie Reid, Jason Moghaddas, Michael Loftus, Rhonda L. Stuart, Despina Kotsanas,Carmel Scott, Claire DendleReviewed work(s):Source: Infection Control and Hospital Epidemiology, Vol. 33, No. 5 (May 2012), pp. 531-532Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology ofAmericaStable URL: http://www.jstor.org/stable/10.1086/665309 .Accessed: 05/04/2012 07:01

A Real-Life Snapshot of the Use and Abuse of Urinary Catheters on General Medical Wards

An observational study was performed on 2 wards in a tertiary hospital to determine staff awareness, knowledge, and documentation of catheter use and the effects these have on duration of catheterization. Overall, there was poor knowledge of the indications and date of catheterization. Doctor awareness decreases duration of catheterization.