Jonathan Darby

“Vaginal seeding” of infants born by caesarean section

How should health professionals engage with this increasingly popular but unproved practice?

Implementation of an antimicrobial stewardship program in an Australian metropolitan private hospital: lessons learned

Abstract Introduction While there is literature on the implementation and efficacy of antimicrobial stewardship (AMS) programs in the public hospital setting, there is little concerning their implementation in the private hospital setting. Resources to guide the implementation of such programs often fail to take into consideration the resource limitations and cultural barriers faced by private hospitals. In this paper we discuss the main obstacles encountered when implementing an AMS program at a private hospital and methods that were used to overcome them. Methods In 2012, St Vincents Private Hospital Melbourne implemented an AMS program that was tailored to suit the requirements and limitations faced by private hospitals. Baseline data was collected to determine areas of priority. Cultural barriers were overcome by forming relationships between AMS and non-AMS personnel, involving key clinical stakeholders when developing hospital policies, and having ample support from hospital executives. We also modified our approach to conventional AMS interventions so that typically resource-intensive projects could be carried out with minimal resources, such as the restriction of antimicrobials via a two-stage post-prescription review model. Results Through our AMS program, we have been able to implement multiple initiatives including a formulary restriction, significantly reduce aminoglycoside use, develop hospital guidelines and regularly contribute data to national surveillance programs. Conclusion While there are guidelines available to help develop an AMS program, these guidelines need to be adapted to suit different hospital settings. Private hospitals present a unique challenge in the implementation of AMS programs. Identifying and addressing barriers specific to an individual institution is vital.

A case of massive gastrointestinal haemorrhage: an important consideration in travellers

An 18-year-old man presented to a tertiary hospital in Melbourne with 2 weeks malaise, anorexia, fever and generalized abdominal pain. He emigrated from Punjab, India 20 days earlier. He described vomiting and haematochezia the previous day and no significant past medical history. He was afebrile and haemodynamically stable. There was mild abdominal tenderness but no hepatosplenomegaly or lymphadenopathy. Rectal examination revealed bright blood. Plasma investigations were unremarkable except for mild anaemia (haemoglobin level 108g/L (reference range 130–180 g/L)) and elevated C-reactive protein of 82 mg/L (reference range n < 5 mg/L). The patient had a massive bleed per rectum of approximately 1 L, dropping haemoglobin to 54 g/L and requiring 2-L crystalloid resuscitation and 4 units packed red blood cells. An urgent abdominal CT angiogram showed large volume active haemorrhage arising from the terminal ileum and passing into the caecum (Fig. 1). At laparotomy, the terminal ileum appeared thickened. A 1.5-cm nodular mass was noted in the terminal ileum, with enlarged lymph nodes throughout the small bowel mesentery. There was blood in the colon and terminal ileum and no evidence of perforation. An ileocolic resection with primary anastomosis was performed. Multiple blood products were required during his 3-day stay in the intensive care unit. Histopathology showed multiple areas of ulceration centred on Peyer’s patches and transmural mononuclear cell infiltrates of lymphoid cells, epithelioid histiocytes, plasma cells and neutrophils. There were focal non-necrotizing granulomas in Peyer’s patches (Figs 2,3). Blood cultures taken on presentation became positive with a Gram-negative rod, subsequently identified as Salmonella typhi, sensitive to ceftriaxone. He remained afebrile and made an uneventful recovery, receiving intravenous ceftriaxone and metronidazole for 2 weeks, followed by 2 weeks of oral trimethoprimsulphamethoxazole. An HIV test was negative. He was discharged on day 15 and remains well. A diagnosis of enteric fever causing

An Australian perspective on the relationship between young women, spinning and rhabdomyolysis

1 Jones CL, Koios J. Algorithm for the treatment of status epilepticus: an Australian perspective. Intern Med J 2016; 46: 500–3. 2 Calmeil LF. De l’épilepsie étudiée sous la rapport de son siège et de son influence sur la production de l’aliénation mentale. Paris: Thèse de Université de Paris; 1824. 3 Bergin P, Jayabal J, Walker E, Davies S, Jones P, Dalziel S et al. Use of epinet database for observational study of status epilepticus in Auckland. J Neurol Sci 2015; 357: e143–4. 4 Trinka E, Cock H, Hesdorffer D, Rossetti AO, Scheffer IE, Shinnar S et al. A definition and classification of status epilepticus – report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia 2015; 56: 1515–23. 5 Rosemergy I, Bergin P, Jones P, Walker E, Davis S, Jones P et al. Seizure management at Auckland City Hospital Emergency Department between July and December 2009: time for a change? Intern Med J 2012; 42: 1023–9. 6 Glauser T, Shinnar S, Gloss D, Alldredge B, Arya R, Bainbridge J et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults report of the guideline committee of the American Epilepsy Society. Epilepsy Curr 2016; 16: 48–61. 7 Alvarez V, Januel J, Burnand B, Rossetti AO. Second-line status epilepticus treatment: comparison of phenytoin, valproate and levetiracetam. Epilepsia 2011; 52: 1292–6. 8 Bleck T, Cock H, Chamberlain J, Cloyd J, Connor J, Elm J et al. The established status epilepticus trial. Epilepsia 2013; 54(Suppl 6): 89–92. 9 Brodie MJ, Kwan P. Newer drugs for focal epilepsy in adults. BMJ 2012; 344: e345. 10 Smith D, Defalla BA, Chadwick DW. The misdiagnosis of epilepsy and the management of refractory epilepsy in a specialist clinic. QJM 1999; 92: 15–23. 11 National Ambulance Sector Clinical Working Group. Saint John First of Care. Clinical Procedures and Guidelines – Comprehensive Edition 2013–2015. Doc CDT507. Wellington: National Ambulance Sector Clinical Working Group, Ambulance New Zealand. 12 Status Epilepticus in Adults. Clinical Guideline. Palmerston North Hospital. Palmerston North: MidCentral DHB. 2014–2015. Available from URL: http:// staffintranet.midcentraldhb.govt.nz

Author's response: A case of massive gastrointestinal haemorrhage (ANZ J. Surg. 2010: 80; 190–1)

I was interested to read the paper on ‘A case of massive gastrointestinal haemorrhage: an important consideration in travellers’ (ANZ J. Surg. 2010: 80; 190–1). Bleeding and perforation presents a formidable challenge in patients’ with typhoid fever. Bleeding is due to erosion of blood vessel in the peyer’s patches and 10–20% of patients present with haematochezia in absence of the appropriate treatment. In addition to the test mentioned by the authors, Widal test that detects the presence of agglutinins to O and H antigens of Salmonella typhi (S. typhi) is still performed in India. Few other tests like the Multi-Test Dip-S-Ticks (detects IgM), Tubex (detects IgG) and TyphiDot (detects IgM and IgG) are particularly useful when blood cultures are negative due to prior administration of antibiotics. Those surgeons who are practising in the non-endemic area should have a high index of suspicion for the surgical complications of typhoid fever like paralytic ileus (most common), ileal perforation and haemorrhage. Early diagnosis and prompt institution of appropriate antibiotic are essential for optimum management of typhoid fever. Prompt administration of the appropriate therapy prevents severe complications of typhoid fever and results in a mortality rate of <1%. I do not agree with the authors’ duration of treatment which they had given as the additional 2 weeks of trimethoprimsulphamethoxazole (SMX-TMP) after completion of optimal duration of therapy with ceftriaxone (2 weeks) is not the standard practice. Optimal duration of treatment in patients with typhoid is 2 weeks. Prolongation of treatment does not help in reducing the rate of complications or carriers. Eradication of carrier is considered for those with persistently positive stool cultures and those who are engaged with food handling. Recommended treatment for carriers includes ciprofloxacin for 4 weeks, SMX-TMP for 6 weeks and amoxicillin for 6 weeks.

Author's response: A case of massive gastrointestinal haemorrhage (ANZ J. Surg. 2010: 80; 190-1): Letters to the editor

I was interested to read the paper on ‘A case of massive gastrointestinal haemorrhage: an important consideration in travellers’ (ANZ J. Surg. 2010: 80; 190–1). Bleeding and perforation presents a formidable challenge in patients’ with typhoid fever. Bleeding is due to erosion of blood vessel in the peyer’s patches and 10–20% of patients present with haematochezia in absence of the appropriate treatment. In addition to the test mentioned by the authors, Widal test that detects the presence of agglutinins to O and H antigens of Salmonella typhi (S. typhi) is still performed in India. Few other tests like the Multi-Test Dip-S-Ticks (detects IgM), Tubex (detects IgG) and TyphiDot (detects IgM and IgG) are particularly useful when blood cultures are negative due to prior administration of antibiotics. Those surgeons who are practising in the non-endemic area should have a high index of suspicion for the surgical complications of typhoid fever like paralytic ileus (most common), ileal perforation and haemorrhage. Early diagnosis and prompt institution of appropriate antibiotic are essential for optimum management of typhoid fever. Prompt administration of the appropriate therapy prevents severe complications of typhoid fever and results in a mortality rate of <1%. I do not agree with the authors’ duration of treatment which they had given as the additional 2 weeks of trimethoprimsulphamethoxazole (SMX-TMP) after completion of optimal duration of therapy with ceftriaxone (2 weeks) is not the standard practice. Optimal duration of treatment in patients with typhoid is 2 weeks. Prolongation of treatment does not help in reducing the rate of complications or carriers. Eradication of carrier is considered for those with persistently positive stool cultures and those who are engaged with food handling. Recommended treatment for carriers includes ciprofloxacin for 4 weeks, SMX-TMP for 6 weeks and amoxicillin for 6 weeks.