Contemporaneous management of ampicillin infusions in the outpatient setting through the use of therapeutic drug monitoring.

The use of ampicillin in the outpatient setting has traditionally been avoided because of the short half-life and instability in solution of this drug. However, recent in vitro data and two case series support the safe and effective administration of ampicillin by continuous infusion in the community. Therapeutic drug monitoring (TDM) of beta-lactam antibiotics can be used to optimise antibiotic exposure and ensure adequate clinical responses. A case series is presented of patients receiving ampicillin via prolonged infusion in the outpatient setting, with TDM to ensure adequate plasma antibiotic levels were achieved. Three patients who received ampicillin by continuous infusion under the Outpatient Parenteral Antimicrobial Therapy (OPAT) program are described, including details of antibiotic dose and steady-state plasma drug concentration as measured by high-performance liquid chromatography. All three patients had an infection with ampicillin-susceptible Enterococcus faecalis; one patient had post-partum endometritis, one had urosepsis and one had a complex polymicrobial bone and joint infection. Adequate plasma drug levels were achieved in all patients. Management of the antibiotic temperature and infusion times, and appropriate timing of drug levels in the community were required. Two patients achieved clinical cure, while the third required further surgical debridement and antibiotic therapy. TDM in this setting enabled the contemporaneous management and dose alteration of ampicillin. Ampicillin may be a safe and effective drug when administered by continuous infusion with appropriate TDM in the community setting.

Activity of Ceftolozane-Tazobactam against Burkholderia pseudomallei.

We investigated the in vitro activity of a novel fifth-generation cephalosporin-tazobactam combination, ceftolozane-tazobactam against Burkholderia pseudomallei, the etiological agent of melioidosis. Using both disc diffusion and minimum inhibitory concentration (MIC) strip techniques against 56 clinical isolates and an national collection of type cultures (NCTC) strain, the MIC to ceftolozane-tazobactam was found to be between 0.75 and 4 mcg/mL. The MIC50 was found to be 1.5 mcg/mL and MIC90 was 2.0 mcg/mL. This study provides initial evidence of ceftolozane-tazobactam as a novel agent in the management of melioidosis.

Primary amoebic meningoencephalitis in North Queensland: the paediatric experience.

Primary amoebic meningoencephalitis (PAM) is a fulminant, diffuse haemorrhagic meningoencephalitis caused by Naegleria fowleri, with an almost invariably fatal outcome. In Australia and the developed world, PAM remains a rare disease, although it is very likely that large numbers of cases go undetected in developing countries. N. fowleri is a thermophilic, free-living amoeba with a worldwide distribution. It is acquired when contaminated fresh water is flushed into the nose and penetrates the central nervous system via the cribriform plate. Clinical features are similar to those of bacterial meningitis, but it does not respond to standard therapy and rapid progression to death occurs in most cases. Some survivors have been reported; these patients received early treatment with amphotericin B in combination with a variety of other medications. Our review describes the local and worldwide experience of this disease and its clinical features, and discusses the associated diagnostic challenges. We hope that by detailing the local response to a recent case, and the outcomes of our public health campaign, we can improve the knowledge of this rare disease for doctors working in rural and remote Australia.

More parasitic myositis cases in humans in Australia, and the definition of genetic markers for the causative agents as a basis for molecular diagnosis.

Since 1998, there have been six reported human cases of myositis in Australia, attributable to infection with the nematode Haycocknema perplexum. However, an unequivocal diagnosis of H. perplexum infection and associated disease has been seriously compromised by a lack of molecular markers for this nematode. Here, we report new cases of disseminated myositis in two male patients from the states of Queensland and Tasmania in Australia, respectively; genetically characterize the causative agent from each case; and, also establish a PCR-based sequencing approach as a tool to support the diagnosis of future cases and to underpin epidemiological studies.

Frailty and Geriatric Syndromes in Vascular Surgical Ward Patients.

BACKGROUND: Preoperative frailty is an important predictor of poor outcomes but the relationship between frailty and geriatric syndromes is less clear. The aims of this study were to describe the prevalence of frailty and incidence of geriatric syndromes in a cohort of older vascular surgical ward patients, and investigate the association of frailty and other key risk factors with the occurrence of one or more geriatric syndromes (delirium, functional decline, falls, and/or pressure ulcers) and two hospital outcomes (acute length of stay and discharge destination). METHODS: This prospective cohort study was conducted in a vascular surgical ward in a tertiary teaching hospital in Brisbane, Australia. Consecutive patients aged ≥65 years, admitted for ≥72 hr, were eligible for inclusion. Frailty was defined as one or more of functional dependency, cognitive impairment, or nutritional impairment at admission. Delirium was identified using the Confusion Assessment Method and a validated chart extraction tool. Functional decline from admission to discharge was identified from daily nursing documentation of activities of daily living. Falls were identified according to documentation in the medical record cross-checked with the incident reporting system. Pressure ulcers, acute length of stay, and discharge destination were identified by documentation in the medical record. Risk factors associated with geriatric syndromes, acute length of stay, and discharge destination were assessed using multivariable logistic regression models. RESULTS: Of 110 participants, 43 (39%) patients were frail and geriatric syndromes occurred in 40 (36%). Functional decline occurred in 25% of participants, followed by delirium (20%), pressure ulcers (12%), and falls (4%). In multivariable logistic analysis, frailty [odds ratio (OR) 6.7, 95% confidence interval (CI) 2.0-22.1, P = 0.002], nonelective admission (OR 7.2, 95% CI 2.2-25.3, P = 0.002), higher physiological severity (OR 5.5, 95% CI 1.1-26.8, P = 0.03), and operative severity (OR 4.6, 95% CI 1.2-17.7, P = 0.03) increased the likelihood of any geriatric syndrome. Frailty was an important predictor of longer length of stay (OR 2.6, 95% CI 1.0-6.8, P = 0.06) and discharge destination (OR 4.2, 95% CI 1.2-13.8, P = 0.02). Nonelective admission significantly increased the likelihood of discharge to a higher level of care (OR 5.3, 95% CI 1.3-21.6, P = 0.02). CONCLUSIONS: Frailty and geriatric syndromes were common in elderly vascular surgical ward patients. Frail patients and nonelective admissions were more likely to develop geriatric syndromes, have a longer length of stay, and be discharged to a higher level of care.