Nicholas Withers

Zinc therapy for night blindness in cystic fibrosis

This is the first report of a supplemented CF patient presenting with clinical vitamin A deficiency to be successfully treated with zinc therapy alone. Therefore in addition to retinol supplementation, normalizing serum zinc levels may be important in maintaining the vitamin A status of CF patients. The interactions and synergistic effects between the two micronutrients are discussed.

Molecular epidemiology of Pseudomonas aeruginosa in an unsegregated bronchiectasis cohort sharing hospital facilities with a cystic fibrosis cohort

While Pseudomonas aeruginosa (PA) cross-infection is well documented among patients with cystic fibrosis (CF), the equivalent risk among patients with non-CF bronchiectasis (NCFB) is unclear, particularly those managed alongside patients with CF. We performed analysis of PA within a single centre that manages an unsegregated NCFB cohort alongside a segregated CF cohort. We found no evidence of cross-infection between the two cohorts or within the segregated CF cohort. However, within the unsegregated NCFB cohort, evidence of cross-infection was found between three (of 46) patients. While we do not presently advocate any change in the management of our NCFB cohort, longitudinal surveillance is clearly warranted.

S113 An Epidemiological Review of Strains of Pseudomonas aeruginosa in a Non-Cystic Fibrosis Bronchiectasis Cohort

Introduction and objectives Pseudomonas aeruginosa (Pa) is a significant respiratory pathogen. Research in Cystic Fibrosis cohorts has revealed transmissible strains, leading to heightened infection control protocols due to concerns of cross-infection. In patients with Non-Cystic Fibrosis Bronchiectasis (NCFB), the research is more limited. Our objectives were to investigate the strains found in our local NCFB population, and assess the occurrence of shared strains. Methods Patients with NCFB and previous Pa in sputum culture consented to providing sputum for the study and review of their medical notes. Sputum samples from patients were processed in the usual manner and if Pa was isolated, 10 representative colonies per patient were stored for strain typing. Isolates were subjected to Random Amplification of Polymorphic DNA (RAPD). Distinct RAPD types were verified by electrophoresis on an Agilent Bioanalyzer and subsequent cluster analysis using GelCompar II software, and further investigated by Multi-Locus Sequence Typing (MLST). Results Pa was obtained from 46 patients over 12 months providing 459 isolates. Co-existence of multiple strains was observed in two patients. Twenty patients (43%) had unique strains by RAPD and the remaining patients were clustered into 7 subgroups, defined as ≥90% homology by RAPD, using Pearson’s correlation analysis. The largest cluster showed a predominance of one MLST strain type identified as ST-17 (also known as “Clone C”) on the MLST database. In our cohort, 8 patients (17%) harboured Clone C, which is a higher prevalence than observed in previous UK studies of various patient cohorts (typically 2–6% prevalence). MLST analysis of smaller RAPD clusters identified other MLST strain types shared by 2 or 3 patients. As with Clone C, all the observed shared MLST strain types are globally distributed. MLST did not reveal any novel shared strains. Conclusions Our cohort of patients with NCFB shows evidence of shared strains of Pa including a high prevalence of Clone C compared to previous national reports. Whilst the occurrence of shared strains may reflect their global distribution, we cannot rule out cross-infection between patients.

The use of home intravenous antibiotics in adult non-CF bronchiectasis

The use of home intravenous (IV) antibiotics is well-established in patients with Cystic Fibrosis (Balaguer, A. & Gonzalez de Dios, J. The Cochrane Library 2008; 3:CD001917). However, it is not common practice in adult patients with non-CF bronchiectasis (NCFB), who may be older, with increased co-morbidities and lower functional status. We evaluated a new home IV antibiotic program for NCFB through a retrospective case note review of patients receiving a course of home IV antibiotics at the Royal Devon and Exeter Hospital (UK) between November 2013 and June 2014. Antibiotic used, nurse appointments incurred, readmission rates (and reason) and other problems were recorded. Ten patients were eligible, 7 female. Average age was 64 (range 34 to 75). There were 16 inpatient and 18 home IV courses. The average home IV course was 9.2 days. There were 130 inpatient (including readmission) and 151 home IV treatment days. The home IV treatment included 39 nurse clinic appointments. Time of initiation of treatment to discharge improved from 5.3 to 3 days for subsequent home IV courses compared to first. Based on the average cost of an inpatient medical bed of £300.68 per day, the service saved £45,402 over 7 months, equivalent to £6,486 per month. Adverse events included four readmissions: two due to worsening symptoms despite antibiotics, one antibiotic reaction and one unrelated. There were two vascular access problems (leaking midlines) and one patient found home IV antibiotics tiring. Home IV antibiotics have generally been well-tolerated and resulted in significant inpatient days saved. Further evaluation of impact on quality of life, patient satisfaction and time to next IV antibiotic course is planned.

P115 Epidemiology, Characteristics and Management of Non Tuberculous Mycobacteria in a Devon Population

Introduction and Objectives Non-Tuberculous Mycobacteria (NTM) are ubiquitous species typically residing in soil and water. Their presentation as pathogens in disease is believed to be rising with the most common site of isolation being pulmonary. We have examined the epidemiology and characteristics of NTM presenting to our clinic over the period 2005–2012. Method Our database, including all patients with at least one identification of an NTM during the period of 2005–2012, was reviewed. Data presented includes all incidences documented from 2009 onwards, with additional data from before 2009 used to gain further demographic information about the population. Those who were non-resident in the area were excluded. The data was collected from Clinical Letters, Radiology and Pathology records, with data being reviewed by the lead investigator and one other in cases where information was uncertain. Results Data was obtained from 74 new isolations, with a total of 11 different species of NTM identified. Patients presenting had a median age of 68 and a range of 8–88 years. 39(53%) were female and 46 (62%) were “one-off” isolates. M. Avium-intracellulare (MAI) was the most frequently reported isolate (42 cases, 57%) followed by M. Chelonae (8, 11%) and M. Xenopi (6, 8%). The majority (68, 92%) of isolates were pulmonary with 45(66%) of these found in standard sputum culture. Most frequently recorded co-morbidities were bronchiectasis (35 cases, 47%) and COPD (20, 27%). Of the total of 74 cases only 24 (32%) had received treatment by the time of our survey. The overall rates for eradication and subsequent relapse in those treated patients were 50% and 25% respectively for the total population and 57% and 38% for those with MAI. At completion of the study the mortality rate within 2 years of the first positive sample was 18%. Conclusion In keeping with previous UK surveys, the majority of isolates in our population were pulmonary with MAI being the most frequently seen species of NTM. In those in whom treatment was indicated low eradication rates and significant relapse rates confirm complexity of managing this population of patients. Abstract P115 Figure 1

P105 Outpatient survey of patient experience of hypertonic saline use in non-cystic fibrosis bronchiectasis

Introduction and Objectives Hypertonic Saline (HTS) is known to accelerate tracheobronchial clearance and is felt to provide a useful adjunct to physiotherapy for airway clearance in bronchiectasis1. Previous studies have demonstrated improvement in lung function, quality of life and healthcare utilisation with the use of HTS in non-CF bronchiectasis2. We have surveyed use and patient experience of HTS in our non-CF bronchiectasis clinic. Method All patients seen in our non-CF Bronchiectasis clinic over a four month period were invited to answer a questionnaire. Questionnaires were filled in anonymously and either returned to a box in clinic or by post. Results A total of 96 patients returned a questionnaire. Overall 114 patients were invited to respond, resulting in a response rate was 84%. 55 respondents (57%) were current or past users of HTS, with 36 (65%) of these still using HTS. 49 (89%) of those who had used HTS had done so for at least a month. The percentage of patients using HTS who indicated an improvement in Airway Clearance, Breathlessness and Quality of Life, were 80%, 60% and 67% respectively. Of the 19 patients who had stopped treatment, only 6 (32%) did so due to side effects. The total number of patients who had experienced side effects was 10 (18%). Conclusion Our survey demonstrates that a significant proportion of attendees to our non-CF Bronchiectasis clinic are taking, or have taken HTS treatment. Continued treatment is supported by positive feedback by patients on impact on symptoms and quality of life, as well as reasonable tolerability and side effect profile. References Kellett F, Redfern J, Niven RM. Evaluation of nebulised hypertonic saline (7%) as an adjunct to physiotherapy in patients with stable bronchiectasis. Respir Med 2005;99:27e31. Kellett F, Robert NM. Nebulised 7% hypertonic saline improves lung function and quality of life in bronchiectasis. Respir Med. 2011 Dec;105(12):1831–5