Dilip Nathwani

Epidemiology and antibiotic susceptibility of bacteria causing skin and soft tissue infections in the USA and Europe: a guide to appropriate antimicrobial therapy

Susceptibility data for all organisms associated with a range of skin and soft tissue infections (SSTI) in hospitalised patients were studied. Data were reported by clinical laboratories in the USA, France, Germany, Italy and Spain during 2001 which participate in The Surveillance Network (TSN). Staphylococcus aureus, Enterococcus spp. and coagulase-negative staphylococci (CNS), Escherichia coli and Pseudomonas aeruginosa were the most prevalent pathogens in all countries. MRSA was detected in 44.4, 34.7, 12.4, 41.8 and 32. 4% of S. aureus in each country, respectively. The majority of MRSA were cross resistant to other compound classes tested except for vancomycin (100% susceptible) trimethoprim-sulphamethoxazole with range 1.7% (France) to 15.9% (Italy) resistant, and gentamicin with range 12.2% (France) to 87.0% (Italy) resistant. More than 99.0% of MSSA tested susceptible to ceftriaxone and >94.9% to trimethoprim-sulphamethoxazole. 87.2% (France) to 94.6% of MSSA (Germany) were ciprofloxacin susceptible; 73.2% (USA) to 86.6% (Spain) were erythromycin susceptible; 85.4% (Italy) to 99.2% (France) were gentamicin susceptible. MSSA were more frequently found and generally more antibiotic susceptible from out patients. Overall, 100% of Streptococcus agalactiae and Streptococcus pyogenes were susceptible to penicillin, ceftriaxone and cefotaxime. Macrolide resistance was common among S. agalactiae (20.7%, Germany to 10%, Italy and Spain), S. pyogenes (19.2%, France to 11.1%, USA) and viridans streptococci (25.7%, France to 14.1%, Germany). Vancomycin-resistant Enterococcus spp. were uncommon outside the USA (17.5%) and Italy (7.4%). For all countries susceptibility of E. coli was 100% to imipenem, >98.7% to amikacin, >96.0% to ceftriaxone and cefotaxime. Susceptibility of E. coli isolates to ciprofloxacin was 77.6% in Spain to 94.3% in Germany. Klebsiella spp., Proteus spp., Citrobacter spp. and Enterobacter spp. displayed varying susceptibilities between countries to drugs tested. Putative extended spectrum beta-lactamase expression in E. coli remained rare comprising 4-5% of isolates in USA, Italy and Spain and in France and Germany <2%. For P. aeruginosa piperacillin-tazobactam, amikacin, imipenem and ceftazidime were the most active compounds tested irrespective of region. Surveillance data should be considered when selecting empirical therapy for treating SSTI.

The Management of Skin and Soft Tissue Infections: Outpatient Parenteral Antibiotic Therapy in the United Kingdom

In a study in Scotland, skin and soft tissue infections (SSTIs) accounted for 10% of hospitalizations, with mean stays of approximately 5 days, and were the second most common reason for hospital-based intravenous antibiotic therapy lasting more than 48 h. A total of 125 patients with SSTIs were recently treated using an outpatient parenteral antibiotic therapy (OPAT) service. The patients received intravenous antibiotic therapy for a mean duration of 5.32 days. The two primary agents administered were once-daily ceftriaxone and teicoplanin. Of the 125 patients, 123 (98.4%) were cured or improved; 2 worsened and required surgery. Patient satisfaction was very high. OPAT saved the inpatient facility 665 bed days. Economic benefits were realized despite use of more expensive agents. Data indicate that if the hospital stay of patients with SSTIs were reduced by only 1 day, savings would amount to £½–1 million per year. OPAT is a feasible alternative to inpatient management of SSTIs and may safely, effectively and cost-effectively reduce the number of hospital days for these infections.

Fatal Human Rabies Caused by European Bat Lyssavirus Type 2a Infection in Scotland

We wish to report the first recorded case of indigenous human rabies caused by a bat bite in the United Kingdom in 100 years. This instructive case report highlights a number of key lessons: first, bites from insectivorous bats indiginous to the United Kingdom can cause rabies in humans; second, rabies immunization is essential for bat-handlers, and postexposure treatment for rabies is essential for patients bitten by bats; third, patients able to give a history who present with acute flaccid paralysis and/or presumptive viral encephalitis should be asked if they have been bitten by bats, irrespective of travel history, or this history should be obtained from family or friends; fourth, antemortem diagnosis of bat rabies (EBLV type 2a infection) in humans is possible using RT-PCR.

Use of Indicators to Evaluate the Quality of Community-Acquired Pneumonia Management

Quality-assessment indicators for community-acquired pneumonia (CAP) founded on health care structure, process, and outcome have been recommended as a potential audit tool to evaluate the delivery of care. We prospectively audited the treatment of 205 patients admitted with CAP to 2 hospitals in Dundee against some of these key standards. Patients with severe CAP were more likely to die (mortality rate, 42% versus 7%) and to receive antibiotics by the intravenous route (relative risk [RR], 1.81; 95% confidence interval [CI], 1.38-2.37) and within 4 hours of admission to the hospital (RR, 1.22; 95% CI, 0.92-1.62). There was a lack of uniformity regarding the amount of oxygen prescribed, with evidence of poor case record and drug prescription chart documentation related to oxygen therapy. Adherence to the recommended antibiotic policy was associated with reduced risk of death or readmission to the hospital (RR, 0.58; 95% CI, 0.34-1.00). However, in a multivariate analysis, severity of pneumonia was the strongest predictor of death or readmission (P=.004), and adherence to the antibiotic policy was not statistically significant (P=.154). Our study has confirmed the value of quality indicators in evaluating our CAP management and has stimulated the development and implementation of a local hospital-based integrated care pathway.

Evaluation of the performance of CURB-65 with increasing age

There has been concern about the performance of CURB-65 in older patients with community-acquired pneumonia (CAP) and that younger patients who subsequently die are initially misclassified as having non-severe CAP. The purpose of this study was to evaluate the effect of age on the performance of CURB-65. We analysed data prospectively, collected in two UK hospitals. Patients were stratified into four age cohorts. Mortality in each cohort was then stratified by CURB-65 score. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the receiver operating curve (AUROC) were calculated. Four hundred and twenty-eight patients were included. Misclassification of patients who subsequently died as non-severe CAP patients (CURB-65 score of < or =2) increased with increasing age (from 3% in the <65-year cohort to 27% in those aged >85 years). There were no deaths (0/105) in those aged <65 years who had a CURB-65 score of 0 or 1. At the British Thoracic Society cut-off for severe CAP (CURB-65 score of > or =3), CURB-65 performed best in 16-64-year-olds (PPV 0.4, NPV 0.97). The AUROC was significantly higher for the <65-year cohort in comparison with older patients (0.93 vs. 0.7, p <0.05). Clinicians should interpret the CURB-65 score with care in older patients referred to hospital with CAP. In those aged <65 years, however, CURB-65 appears to be able to identify a cohort of patients (CURB-65 score of 0 or 1) with very low mortality.

Feasibility of an outpatient and home parenteral antibiotic therapy (OHPAT) programme in Tayside, Scotland

Outpatient and home parenteral antibiotic therapy (OHPAT) is under-utilized in the U.K. We performed a feasibility study over a 5-month period in a regional U.K. infection unit. After exclusions, 183 antibiotic treated patients were evaluated. Ninety-five received intravenous (i.v.) therapy, of whom 32 received at least 4 days. Prolonged i.v. therapy was most frequent in soft tissue infections. In these patients, length of stay and duration of i.v. treatment were correlated (r = 0.74, 0.51-0.87). Eighty-three (86%) of patients who received IV therapy judged OHPAT to be an acceptable alternative to hospitalization. Those who did not were older (mean age 64 vs. 46 years, P<0.001) and were less likely to have a carer willing to administer the antibiotic at home (8/28 vs. 117/151, P<0.001). Twenty-five of 32 (79%) patients treated with prolonged parenteral therapy and 27/95 (28%) treated with any length of parenteral therapy met criteria for OHPAT. Thirteen of these were safely and successfully managed as outpatients by ward staff, OHPAT is an acceptable alternative to inpatient therapy in Tayside and may reduce the duration of hospitalization or prevent admission in certain patients.

Predicting mortality in patients with community-acquired pneumonia and low CURB-65 scores

Some patients classified as having non-severe community-acquired pneumonia (CAP) by CURB-65 subsequently die. The objective of this study was to identify risk factors for mortality in non-severe patients and to test how risk factors might be used. Patients who had a CURB-65 score of 0–2 on admission to hospital and were alive at 30xa0days were compared with those who died. Identified risk factors were included in new variations of CURB-65 and new management strategies. Age >65xa0years, blood urea >7xa0mmol/l, bilateral/multi-lobar appearance of the chest radiograph (CXR), social situation (living alone/no fixed abode or residential/nursing care) and temperature <36°C were associated with mortality (pu2009<u20090.05). A two-step approach, with initial use of CURB-65 followed by the above non-CURB-65 criteria, increased the proportion of patients correctly classified as having severe CAP who subsequently died from 54/76 (71%, 95% confidence interval [CI] 61% to 81%) to 72/76 (95%, 95% CI 90% to 100%). The consideration of additional risk factors in a two-step approach can improve the stratification of mortality by CURB-65. Physicians should be cautious about managing patients with CAP as outpatients if they have a CURB-65 score of 1 (or more) and have at least one of the three additional risk factors identified.

Unnecessary peripheral intravenous catheterisation on an acute medical admissions unit: a preliminary study

BACKGROUND: The ability to secure peripheral intravenous access is regarded as a basic medical skill that is often required for the management of patients admitted to acute medical admission wards. The decision to insert a peripheral intravenous catheter (PIC) is usually taken by relatively inexperienced members of the acute medical team and is primarily based on traditional or routine practice, rather than on an assessment of need. Furthermore, there appears to be little recognition of the potentially serious adverse events associated with PIC insertion. METHOD: We conducted a prospective study to evaluate unnecessary PIC insertion in a United Kingdom teaching hospitals acute medical admissions unit. RESULTS: Of the 338 patients included in the study, 272 (80.5%) received a PIC. Of these, 179 patients (66%) received a PIC that had been used by the post-on-call ward round. Of the 93 patients (34%) with an unused PIC, 30 patients (11%) had been catheterised inappropriately by the study criteria. CONCLUSIONS: Despite our use of conservative criteria for PIC insertion, a notable level of inappropriate peripheral intravenous catheterisation was identified. A hypothetical cost-minimisation analysis is presented and a care pathway for best practice proposed.

Design, implementation and evaluation of a medical education programme using the ambulatory diagnostic and treatment centre

Background: In the UK a central government initiative is seeking to transfer aspects of specialist NHS care to community settings using ambulatory diagnostic and treatment centres (ADTCs). Aims: Following the redevelopment of a district general hospital as an ADTC, we were interested in the feasibility of using this new facility to deliver a structured programme for undergraduate medical students. Method: Twenty self-selected fifth year medical students at the University of Dundee, together with teaching and administration staff in the ADTC, took part in the study during the academic year 2005–2006. Results: One hundred percent of students and 73% of staff responded to a questionnaire pitched at the level of reaction to the course. The key findings were that the students found the teaching venues useful, the general environment conducive to learning, and the content appropriate to their needs. Staff felt that patients were not unhappy or disturbed by having students present and did not think the presence of students inhibited their clinical work. They appreciated the new opportunity to teach. Conclusions: An ADTC is a viable setting for structured teaching of undergraduate medical students. It provides a context for medical student leaning away from the main teaching hospital.

Some clinical data

We read with interest recent letters on the potential benefit of fever in infection.1 2 In keeping with previously published data,3 we recently found that hypothermia (<36oC) on admission to hospital was significantly associated with 30 day mortality in …