Cascade of care and rapid treatment pathway at Auckland City Hospital for patients with a new diagnosis of HIV infection, 2015-2019.

AIMS: Legislative changes in 2017 enabled subsidised HIV care for all people living with HIV in New Zealand. This enabled a rapid treatment pathway (RTP) to be developed at Auckland City Hospital (ACH). Our aims were to document the cascade of care for people referred with newly diagnosed HIV infection and evaluate the effect of the RTP. METHODS: People with newly diagnosed HIV infection in New Zealand referred to ACH between 2015 and 2019 were included in the cascade of care. The 2-year periods before (2015 and 2016) and after (2018 and 2019) the RTP were compared for initiation of antiretroviral therapy (ART) and attainment of HIV viral suppression. RESULTS: There were 240 people with newly diagnosed HIV infection referred. Of these, 197/200 (98.5%) were on ART and 195/197 (99%) had documented viral suppression. ART was initiated within 6 weeks of referral for 41/120 (34.2%) in the pre-RTP and 76/79 (96.2%) in the RTP periods (p<0.0001). Viral suppression was achieved within 6 months of diagnosis for 66/118 (55.9%) in the pre-RTP and 73/75 (97.3%) in the RTP periods (p<0.0001). CONCLUSIONS: A high proportion of people referred with newly diagnosed HIV infection were commenced on ART and achieved viral suppression. The RTP facilitated earlier initiation of ART and achievement of viral suppression.

A clinical review of mpox for the Aotearoa New Zealand clinician.

The World Health Organization declared mpox (formerly monkeypox) a Public Health Emergency of International Concern in July 2022. Aotearoa New Zealand has reported cases of mpox since July, with reports of locally acquired cases since October 2022. The 2022 global mpox outbreak highlights many features of the illness not previously described, including at-risk populations, mode of transmission, atypical clinical features, and complications. It is important that all clinicians are familiar with the variety of clinical manifestations, as patients may present to different healthcare providers, and taking lessons from the HIV pandemic, that all patients are managed without stigma or discrimination. There have been numerous publications since the outbreak began. Our narrative clinical review attempts to bring together the current clinical evidence for the New Zealand clinician.

Aspergillus fumigatus cerebral abscess and sphenoid sinus osteomyelitis in an immunocompetent patient following previous nasopharyngeal carcinoma and radiotherapy.

Cerebral mycosis is extremely rare in immunocompetent patients. A 61-year-old male presented with a 3-month history of worsening left-sided headaches and 3-week history of left-sided upper lip paraesthesia. Magnetic resonance imaging revealed an enhancing lesion in the left temporal lobe. Histopathology of this lesion revealed what initially resembled a zygomycete but additional cultures obtained on further surgical debridement revealed the infection to be Aspergillus fumigatus with associated sphenoid sinus osteomyelitis. We postulate that the presentation was related to the patient's previous radiotherapy for nasopharyngeal carcinoma. To the best of our knowledge, this is the only report of such a case.

Carbapenems and subsequent multiresistant bloodstream infection: does treatment duration matter?

It has been proposed that initial empirical broad-spectrum antibiotic therapy will result in better clinical outcomes and that shorter courses will reduce the 'collateral damage' of promoting antibiotic resistance. There are few data from Intensive Care Units (ICUs) that support this latter conclusion. A prospective observational study was undertaken at the National University Hospital, Singapore, to examine the relationship between duration of carbapenem therapy and subsequent nosocomial multidrug-resistant (MDR) bloodstream infection (BSI). Over a 2-year period, 415 ICU patients receiving empirical carbapenem therapy were prospectively followed. MDR BSI occurred on 35 occasions in 31 patients, comprising 21 carbapenem-resistant Acinetobacter baumannii, 3 carbapenem-resistant Pseudomonas aeruginosa and 11 meticillin-resistant Staphylococcus aureus (MRSA). There was no difference in the duration of carbapenems for those who developed MDR BSI compared with those who did not [median duration 8 days (range 3-23 days) vs. 9 days (range 3-59 days); P=0.78]. On multivariate analysis using the Cox proportional hazard model the hazard ratio was 0.935 (P=0.070). In this cohort of critically ill patients, a shorter duration of carbapenem therapy was not shown to protect against subsequent development of MDR BSI. Strategies that depend primarily on reducing broad-spectrum antibiotic duration may be inadequate in preventing the emergence of MDR organisms.

Multifocal cutaneous mucormycosis complicating polymicrobial wound infections in a tsunami survivor from Sri Lanka.

A man injured in the tsunami of Dec 26, 2004, returned to Sydney for management of his soft-tissue injuries. Despite broad-spectrum antibiotics, surgical wound debridement, and vigilant wound care, his condition worsened. Muscle and fat necrosis developed in a previously debrided thigh wound, and necrotising lesions arose from previous abrasions. Histological analysis showed mucormycosis in three non-contiguous sites, and Apophysomyces elegans was isolated from excised wound tissue. Wound infections, both bacterial and fungal, will undoubtedly add to the morbidity and mortality already recorded in tsunami-affected areas. Other cases [correction] of cutaneous mucormycosis might develop in survivors, but this disease can be difficult to diagnose and even harder to treat, particularly in those remaining in affected regions.

A case of desquamating rash associated with methadone use.

A man who had been taking prescribed methadone for many years presented with a desquamating rash (predominantly affecting the hands and feet) complicated by cellulitis of the right leg. There have now been multiple reports of a similar rash among methadone users in Sydney. The cause remains unknown.