Deep learning enables the automation of grading histological tissue engineered cartilage images for quality control standardization.

OBJECTIVE: To automate the grading of histological images of engineered cartilage tissues using deep learning. METHODS: Cartilaginous tissues were engineered from various cell sources. Safranin O and fast green stained histological images of the tissues were graded for chondrogenic quality according to the Modified Bern Score, which ranks images on a scale from zero to six according to the intensity of staining and cell morphology. The whole images were tiled, and the tiles were graded by two experts and grouped into four categories with the following grades: 0, 1-2, 3-4, and 5-6. Deep learning was used to train models to classify images into these histological score groups. Finally, the tile grades per donor were averaged. The root mean square errors (RMSEs) were calculated between each user and the model. RESULTS: Transfer learning using a pretrained DenseNet model was selected. The RMSEs of the model predictions and 95% confidence intervals were 0.49 (0.37, 0.61) and 0.78 (0.57, 0.99) for each user, which was in the same range as the inter-user RMSE of 0.71 (0.51, 0.93). CONCLUSION: Using supervised deep learning, we could automate the scoring of histological images of engineered cartilage and achieve results with errors comparable to inter-user error. Thus, the model could enable the automation and standardization of assessments currently used for experimental studies as well as release criteria that ensure the quality of manufactured clinical grafts and compliance with regulatory requirements.

Breast infections - Microbiology and treatment in an era of antibiotic resistance.

INTRODUCTION: Primary breast abscesses occur in <1% of non-lactating women, rising to 11% in women with lactational mastitis. In patients undergoing breast cancer surgery, the inflammatory response to post-operative surgical site infection (SSI) has been implicated in recurrence. Anti-microbial resistance increasingly hampers treatment in each group. AIMS: Describe the demographic and predisposing characteristics of patients with primary breast abscesses and secondary infections, identify the microbial and antimicrobial patterns and formulate an evidence-based protocol for treating breast infections. METHODS: Retrospective cohort study of all breast infections (primary and post-operative) treated at UHL from 2014 to 2017. Data collected from microbiology databases and patient records was analysed using Minitab V18. RESULTS: 537 cultures from 108 patients were analysed. 47 (43.5%) had primary abscesses, 12 (11.1%) were lactational and 49 (45.4%) were post-operative SSI. For primary infections, the mean age was 41.9 (±12.2) and reinfection rate 33%. For SSIs the mean age was 51.8 (±14.52) and reinfection rate 11.8%. Overall, 29.3% were smokers, 6.4% diabetic and 2.9% pregnant. 60 (43%) patients required radiological drainage and 2 (1%) surgical drainage. 57.5% had mixed growth. The most common isolate was Staphylococcus aureus; cultured in 16.7% of primary abscesses and 24% of SSIs. 13 empiric antibiotic regimes were prescribed before 26.4% of patients changed to 12 different targeted regimes. CONCLUSION: Breast infections are frequently polymicrobial with a wide variety of organisms isolated, suggesting the need for broad spectrum coverage until culture results become available. Based on our local culture results, the addition of clindamycin to flucloxacillin would provide excellent empiric coverage for all categories of breast infection. An evidence-based treatment guideline is required and should be formulated in close collaboration with microbiology specialists.

Key findings on legal and regulatory barriers to HIV testing and access to care across Europe.

OBJECTIVE: The aim of this work within OptTEST by HiE has been to demonstrate the role of legal and regulatory barriers in hindering access to HIV testing, treatment and care across Europe and to produce tools to help dismantle them. METHODS: An online survey to assess country-specific data on legal and regulatory barriers distributed widely across the WHO Europe region. Literature reviews conducted in January-October 2015 in English, in November 2015 in Russian, and updated in April 2017. Semi-structured interviews were conducted with 25 key actors within the HIV field to feed into case studies and tip sheets on how to dismantle legal and regulatory barriers. RESULTS: More than 160 individuals and organisations from 49 countries across the WHO European region provided responses which were analysed and cross checked with other data sources and a searchable database produced (legalbarriers.peoplewithhiveurope.org). The conducted literature reviews yielded 88 papers and reports which identify legal and regulatory barriers to key populations' access to HV testing and care. Based on the interviews with key actors, ranging from PLHIV activists to government officials, on lessons-learned, a series of tip sheets and ten case studies were written-up intended to inform and inspire the HIV community to address and overcome existing barriers (opttest.eu/Tools). CONCLUSION: While some of the barriers identified may require major changes to wider health systems, or long term legal reform, many are open to a simple change in regulations or custom and practice. We have the tools. Why can't we finish the job?

Screening for chronic comorbid diseases in people with HIV: the need for a strategic approach.

Among people living with HIV, the proportion of deaths attributed to chronic noninfectious comorbid diseases has increased over the past 15 years. This is partly a result of increased longevity in the era of highly active antiretroviral therapy (HAART), and also because HIV infection is related, causally or otherwise, to several chronic conditions. These comorbidities include conditions that are strongly associated with modifiable risk factors, such as cardiovascular disease (CVD), diabetes, and renal and bone diseases, and increasingly management guidelines for HIV recommend risk evaluation for these conditions. The uptake of these screening approaches is often limited by the resources required for their application, and hence the management of risk reduction in most HIV-infected populations falls below a reasonable standard. The situation is compounded by the fact that few risk calculators have been adjusted for specific use in HIV infection. There is substantial overlap of risk factors for the four common comorbid diseases listed above that are especially relevant in HIV infection, and this offers an opportunity to develop a simple screening approach that encompasses the key risk factors for lifestyle-related chronic disease in people with HIV infection. This would identify those patients who require more in-depth investigation, and facilitate a stepwise approach to targeted management. Such a tool could improve communication between patient and clinician. A significant proportion of people with HIV are sufficiently engaged with their care to participate in health promotion and take the lead in using patient-centric screening measures. Health-based social networking offers a mechanism for dissemination of such a tool and is able to embed educational messages and support within the process.

First report of IMI-1-producing colistin-resistant Enterobacter clinical isolate in Ireland, March 2013.

We report the first case in Ireland of an IMI-1 carbapenemase-producing Enterobacter asburiae, which was resistant to both colistin and fosfomycin. The circumstances under which this isolate was acquired were unclear. Several reports of IMI-producing Enterobacter spp. have emerged in recent years, and colistin resistance in Enterobacteriaceae is also increasingly reported. Laboratories should be aware of the unusual antibiograms of IMI-producing isolates.

Radiographers' experiences and educational needs in relation to caring for suicidal patients during radiology examinations.

INTRODUCTION: Researchers have explored the experiences, attitudes, and educational needs of several healthcare professional groups in relation to caring for suicidal patients. However, radiographers have not been included in these studies. Radiographers are likely to encounter these patients when they present for diagnostic imaging following suicide attempts. METHODS: An online questionnaire exploring radiographers' experiences and educational needs in caring for suicidal patients was circulated to radiographers working in 23 acute hospitals across Ireland and posted to a Facebook page targeting Irish-based radiographers. Closed-ended questions were used to capture respondents' demographics and five-point Likert scale questions to establish their confidence levels in imaging suicidal patients. Open-ended questions were used to explore their experiences and educational needs. Quantitative data was analysed using descriptives statistics, and qualitative data thematically analysed. RESULTS: One hundred and four radiographers responded to the questionnaire, 96% of whom had imaged suicidal patients. Radiographers were confident in justifying and optimising these radiographic examinations, however, less confident in communicating with and caring for these patients. Radiographers reported insufficient patient history on imaging referrals and challenges in communicating with suicidal patients, which many attributed to lack of training. Radiographers expressed interest in further education related to caring for patients who've attempted suicide, which they felt should include an introduction to psychiatry, strategies for communicating with suicidal patients and building resilience. CONCLUSION: Radiographers' experiences of imaging suicidal patients have been reported along with several challenges which could be addressed through further education. IMPLICATIONS FOR PRACTICE: Further education in caring for suicidal patients should be offered to radiographers which aligns with their educational needs. Referring clinicians should be reminded of the importance of informing radiographers of patients' suicide attempt when referring them for diagnostic imaging.

Silos and rigid processes: Barriers to the successful implementation of the Older prisoner Health and Social Care Assessment and Plan.

Older adults are the fastest growing sub-group in prisons. They have complex health, social care and custodial needs and often the support they receive is sub-optimal. The Older prisoner Health and Social Care Assessment and Plan (OHSCAP) aimed to better meet these inter-related needs. As part of a wider study, a randomised controlled trial was conducted to evaluate the OHSCAPs effectiveness in meeting older prisoners' health, social care and custodial needs in comparison to treatment as usual. This article describes the nested qualitative study which aimed to explore the barriers and facilitators to the effective implementation of the OHSCAP. Semi-structured interviews were conducted with older adults (n = 14) and staff members t (n = 12). Data was analysed using the framework method. Three overarching key themes were identified. These were: (1) balancing care and custodial requirements; (2) prison, health and social care silos; and (3) rigid prison processes. Prison is an important opportunity to engage residents and improve public health. Cultural and strategic change is required for health, social care and custodial interventions, such as the OHSCAP, to be successfully implemented into prison settings.

Microbial epidemiology and clinical risk factors of carbapenemase-producing Enterobacterales amongst Irish patients from first detection in 2009 until 2020.

Background: Carbapenemase producing Enterobacterales (CPE) are major public health threats. Aim: To review microbial epidemiology of CPE, as well as clinical risk factors and infections, amongst CPE positive patients over 12 years in an Irish tertiary hospital. Methods: Retrospective observational study of data extracted from a laboratory CPE database, electronic healthcare records and manual review of patient charts. Common risk factors, treatment regimens for all CPE related infections, and clinical outcomes were ascertained. Findings: Among CPE strains isolated from 460 patients, Klebsiella pneumoniae carbapenemase (KPC) was the carbapenemase most frequently detected, accounting for 87.4% (459) of all CPE enzymes. Citrobacter species 177 (33.7%) were the most common species harbouring this enzyme. 428 CPE positive patients (93%) were identified in the acute hospital setting; the most common risk factor for CPE acquisition was history of hospitalisation, observed in 305 (66%) cases. Thirty patients (6.5%) had confirmed infections post-acquisition, of which four were bloodstream infections. There were 19 subsequent episodes of non CPE-related bacteraemia in this cohort. All causal mortality at 30 days was 41 patients (8.9%). However, clinical review determined that CPE was an indirect associative factor in 8 patient deaths. Conclusions: In this tertiary hospital setting, microbial epidemiology is changing; with both OXA-48 enzymes and KPC-producing Citrobacter species becoming more prevalent. Whilst the burden of CPE related infections, especially bacteraemia, was low over the study period, it remains critical that basic infection prevention and control practices are adhered to lest the observed changes in epidemiology result in an increase in clinical manifestations.

Association between tocilizumab treatment of hyperinflammatory patients with COVID-19 in a critical care setting and elevated incidence of hospital-acquired bacterial and invasive fungal infections.

BACKGROUND: Tocilizumab is an interleukin-6 inhibitor that reduces mortality and the need for invasive mechanical ventilation, while increasing the possibility of successful hospital discharge for hyperinflammatory patients with severe coronavirus disease 2019 (COVID-19). No increase in adverse events or serious infections has been reported previously. AIM: To describe the characteristics and outcomes of patients with severe COVID-19 in critical care who received tocilizumab, and to compare mortality and length of hospital stay for patients who received tocilizumab (N=41) with those who did not (N=33). METHODS: Retrospective review of data related to patients with COVID-19 who received tocilizumab in a critical care setting from 1st January to 31st December 2021. FINDINGS: Amongst COVID-19 survivors, those who had received tocilizumab had longer intensive care unit (ICU) stays (median length 21 vs 9 days) and hospital stays (45 vs 34 days) compared with those who had not received tocilizumab. Thirty-day mortality (29% vs 36%; P=0.5196) and 60-day mortality (37% and 42%; P=0.6138) were not significantly lower in patients who received tocilizumab. Serious bacterial and fungal infections occurred at higher frequency amongst patients who received tocilizumab [odds ratio (OR) 2.67, 95% confidence interval (CI) 1.04-6.86; P=0.042], and at significantly higher frequency than in non-COVID-19 ICU admissions (OR 5.26, 95% CI 3.08-9.00; P<0.0001). CONCLUSIONS: In this single-centre study, patients in critical care with severe COVID-19 who received tocilizumab had a greater number of serious bacterial and fungal infections, but this may not have been a direct effect of tocilizumab treatment.

Repeated transmission of SARS-CoV-2 in an overcrowded Irish emergency department elucidated by whole-genome sequencing.

AIM: To provide a detailed genomic-epidemiological description of a complex multi-ward SARS-CoV-2 outbreak, which originated in the crowded emergency department (ED) in our hospital during the third wave of the COVID-19 pandemic, and was elucidated promptly by local whole-genome sequencing (WGS). METHODS: SARS-CoV-2 was detected by reverse transcriptase real-time polymerase chain reaction on viral RNA extracted from nasopharyngeal swabs. WGS was performed using an Oxford MinION Mk1C instrument following the ARTIC v3 sequencing protocol. High-quality consensus genomes were assembled with the artic-ncov2019 bioinformatics pipeline and viral phylogenetic trees were built, inferred by maximum-likelihood. Clusters were defined using a threshold of 0-1 single nucleotide polymorphisms (SNPs) between epidemiologically linked sequences. RESULTS: In April 2021, outbreaks of COVID-19 were declared on two wards at University Hospital Limerick after 4 healthcare-associated SARS-CoV-2 infections were detected by post-admission surveillance testing. Contact tracing identified 12 further connected cases; all with direct or indirect links to the ED 'COVID Zone'. All sequences were assigned to the Pangolin B.1.1.7 lineage by WGS, and SNP-level analysis revealed two distinct but simultaneous clusters of infections. Repeated transmission in the ED was demonstrated, involving patients accommodated on trolleys in crowded areas, resulting in multiple generations of infections across three inpatient hospital wards and subsequently to the local community. These findings informed mitigation efforts to prevent cross-transmission in the ED. CONCLUSION: Cross-transmission of SARS-CoV-2 occurred repeatedly in an overcrowded emergency department. Viral WGS elucidated complex viral transmission networks in our hospital and informed infection, prevention and control practice.

Time to positivity (TTP) of neonatal blood cultures: a trend analysis over a decade from Ireland.

Background and aims: Blood culture (BC) remains gold standard for the evaluation and diagnosis of neonatal sepsis. Time when BC becomes positive and the type of microorganism isolated are crucial in deciding the antimicrobial management. Likely pathogenicity of organisms growing in BC could potentially be predicted based on the "time to positivity" (TTP). We aimed to estimate the predictive value of isolating a likely pathogenic organism depending on TTP; evaluate the aetiological trend and neonatal mortality rate due to culture-proven neonatal sepsis for over a decade and verify whether the application of a "36 hour rule" to discontinue empiric antibiotics in well newborn infants with negative BC would be safe.Methods: Retrospective review of BC results over a 14-year period from a regional neonatal unit in Ireland. Laboratory data were independently extracted in relation to BC results from the laboratory information management system (LIMS-iLAB). Neonatal mortality data were collected from multiple sources. Statistical analysis included logistic regression, chi-square, and Mann-Whitney U-test.Results: Over a 14-year period 11,432 neonatal BC specimens were incubated of which 605 (5.3%) turned positive. Overall, the commonest organism grown was coagulase-negative Staphylococcus (CoNS), 416 (68.8%). Main pathogenic organisms were Staphylococcus aureus 23 (3.8%), Enterococcus spp. 22 (3.6%), E.coli 21 (3.5%), group B Streptococcus (GBS) 18 (3.0%), and Klebsiella species 9 (1.5%). Gram-negative organisms had the shortest TTP, with Klebsiella spp. having a median TTP of 10 h and E. coli 11 h. For Gram-positives, GBS had a median TTP of 12 h, Enterococcus species 14 h, with S. aureus growing at a median time of 15 h. All of the Klebsiella spp. and other Coliforms were detected within 24 h, with, 95.2% of E.coli, 94.4% of GBS, 95.5% of Enterococci, and 95.7% of S. aureus, flagging positive in 24 h. Using logistic regression the omnibus test of the coefficients in the resulting model was significant (p < .001). Our observed coefficient (ß) for TTP was 0.144; shorter the TTP higher was the likelihood of isolating a pathogenic organism, with an odds ratio (OR) of 1.155. We also report a relatively low blood culture proven sepsis-specific neonatal mortality rate of 0.403/1000 live births and in all such instances observed TTP was less than 24 h.Conclusion: Duration of this study exceeds that of most of the neonatal blood culture TTP analysis published to-date. A shorter TTP is an important adjunct to suggest the growth of a pathogenic organism while managing suspected neonatal sepsis. TTP if < 24 h per se would not necessarily confirm the growth of a highly pathogenic organism; however, if a positive growth is likely to happen for a significant neonatal pathogen, in more than 98% the TTP would be within 24 h. This offers the clinician more of negative predictive value than a positive one; when there is no growth in BC. Our observation on TTP reiterate the National Institute of Health and Care Excellence (NICE) guideline of discontinuation of empiric antibiotics after 36 h in and clinically well and BC negative newborn infants.

Clinical characteristics and treatment choice in vestibular migraine.

This retrospective review aims to survey the clinical characteristics and management of vestibular migraine (VM) patients seen in a tertiary hospital multi-disciplinary balance disorders clinic, and how this aligns with the evidence base in the literature. A single investigator reviewed the medical records of the patients who presented to a tertiary hospital balance disorders clinic over a four month period and identified 90 cases of VM. The mean age of patients with a diagnosis of VM was 50 years (range of 17-84) and 72 (80%) were female. Vertigo (96%) and headache (60%) were the predominate symptoms. Vestibular function testing abnormalities included six (5%) with a positive video head impulse test and seven (6%) with oculomotor abnormalities. Pizotifen (30%) and amitriptyline (21%) were the two most commonly used medications whilst only 14 (16%) received vestibular physiotherapy. This study suggests that VM is a very common presentation to a tertiary balance disorders clinic, but there is little consensus in choice of initial management and vestibular rehabilitation is underutilized. This data may be valuable in informing the practice of neuro-otology as well as in the planning of future service provision.

Dose response to intrathecal diamorphine for elective caesarean section and compliance with a national audit standard.

BACKGROUND: This double-blind randomised controlled trial investigated the most appropriate dose of intrathecal diamorphine to use with high-dose diclofenac as part of a multimodal analgesic regimen for caesarean section under subarachnoid block. We also wished to establish whether it was possible to satisfy the Royal College of Anaesthetists postoperative pain audit recommendation for this patient group. METHODS: One hundred and twenty patients presenting for elective caesarean section under subarachnoid block were recruited and divided into four groups. Treatment was standard except that patients were given either placebo or one of three different doses of intrathecal diamorphine (100 microg, 200 microg or 300 microg). All patients were given regular paracetamol, high-dose diclofenac and an hourly subcutaneous diamorphine regimen for breakthrough pain. RESULTS: There was a dose-dependent improvement in analgesia with intrathecal diamorphine. Only 37.9% of patients given 300 microg of intrathecal diamorphine had a visual analogue pain score of 3/10 or less throughout the study. There was a dose-dependent increase in the incidence of itching with intrathecal diamorphine although the incidence of nausea and vomiting was similar between groups. CONCLUSIONS: We found that for elective caesarean section under subarachnoid block with high dose diclofenac, analgesia was optimal with 300 microg of intrathecal diamorphine. Even the highest dose of intrathecal diamorphine did not achieve the Royal College of Anaesthetists postoperative audit target that 90% of patients should have a pain score of no more than 3/10. We believe that this target is too arduous.

An optimized work-flow to reduce time-to-detection of carbapenemase-producing Enterobacteriaceae (CPE) using direct testing from rectal swabs.

Rapid detection of patients with carbapenemase-producing Enterobacteriaceae (CPE) is essential for the prevention of nosocomial cross-transmission, allocation of isolation facilities and to protect patient safety. Here, we aimed to design a new laboratory work-flow, utilizing existing laboratory resources, in order to reduce time-to-diagnosis of CPE. A review of the current CPE testing processes and of the literature was performed to identify a real-time commercial polymerase chain reaction (PCR) assay that could facilitate batch testing of CPE clinical specimens, with adequate CPE gene coverage. Stool specimens (210) were collected; CPE-positive inpatients (n = 10) and anonymized community stool specimens (n = 200). Rectal swabs (eSwab™) were inoculated from collected stool specimens and a manual DNA extraction method (QIAamp® DNA Stool Mini Kit) was employed. Extracted DNA was then processed on the Check-Direct CPE® assay. The three step process of making the eSwab™, extracting DNA manually and running the Check-Direct CPE® assay, took <5 min, 1 h 30 min and 1 h 50 min, respectively. It was time efficient with a result available in under 4 h, comparing favourably with the existing method of CPE screening; average time-to-diagnosis of 48/72 h. Utilizing this CPE work-flow would allow a 'same-day' result. Antimicrobial susceptibility testing results, as is current practice, would remain a 'next-day' result. In conclusion, the Check-Direct CPE® assay was easily integrated into a local laboratory work-flow and could facilitate a large volume of CPE screening specimens in a single batch, making it cost-effective and convenient for daily CPE testing.

Colonisation with extended-spectrum beta-lactamase (ESBL) not detected in a prevalence study.

BACKGROUND: The Mid-West of Ireland has higher than average national rates of invasive extended-spectrum beta-lactamase (ESBL) bloodstream infections and carbapenemase-producing Enterobacteriaceae (CPE), with increasing numbers of ESBL isolates detected in community-dwelling patients. AIMS: To conduct a point prevalence study in a convenience sample of the Mid-West population with the aim of determining the extent of ESBL colonisation. METHODS: Utilising anonymised community stool samples that had completed routine analysis, we conducted a point prevalence study over a 4-week period on all samples that met defined inclusion and exclusion criteria. Limited epidemiological data was recorded: (1) age of patient, (2) gender, and (3) sender location. From these stool specimens, rectal swabs were inoculated (eSwab™ 480CE, Copan, Italy), which were subsequently cultured on selective chromogenic agar (Colorex™ ESBL). Culture plates were incubated aerobically at 37 °C for 24 h. RESULTS: Of 195 samples processed, 58 % (n = 112) were from females. The median patient age was 62.4 years (range 20-94 years). 186 samples (95 %) originated from general practitioner clinics. During the study period, only nine eligible stool samples were received from LTCF (6 public). From 195 Colorex™ ESBL chromogenic agar plates cultured, no ESBL-producing organisms were detected. CONCLUSIONS: This community point prevalence study did not identify ESBL colonisation despite high numbers of patients with invasive ESBL bloodstream infections presenting for admission in our institution. We believe this may be because of our small sample size. Data regarding antimicrobial exposure and other risk factors for ESBL colonisation were also not available. We remain vigilant for ESBL-producing organisms.

Preoperative anxiety and postoperative satisfaction in women undergoing elective caesarean section.

BACKGROUND: The primary aim was to investigate whether preoperative anxiety in women undergoing elective caesarean section predicts postoperative maternal satisfaction with the process, perceptions of recovery, analgesic use or length of hospital stay. Other factors that might influence postoperative satisfaction were also explored. METHOD: In 85 women awaiting elective caesarean section, anxiety, social support and aspects of preparation were measured in the 24 hours preceding surgery. Maternal satisfaction and perceptions of recovery were assessed around the third postoperative day. Satisfaction with the preoperative information from the anaesthetist and postoperative pain relief were also measured at this time. Medical notes were used to gather information on analgesia use and length of hospital stay. RESULTS: Preoperative anxiety scores were comparable with those of general surgical/medical patients. Preoperative trait anxiety and state anxiety were inversely associated with postoperative maternal satisfaction. State anxiety was also inversely associated with better recovery. Preoperative anxiety was not associated with analgesic use or length of hospital stay. Linear regression analysis indicated the degree of satisfaction with information from the anaesthetist and perceived emotional support from the partner explained 52% of the variance in postoperative maternal satisfaction. CONCLUSION: Lower preoperative anxiety is associated with greater maternal satisfaction with elective caesarean section and better recovery. Information provided by anaesthetists and perceived emotional support are also of importance. It may be possible to identify women with high anxiety and facilitate satisfaction and recovery through providing additional supportive input.

Combined education and skin antisepsis intervention for persistently high blood-culture contamination rates in neonatal intensive care.

Contaminated blood cultures represent challenges regarding diagnosis, duration of hospitalization, antimicrobial use, pharmacy and laboratory costs. Facing problematic neonatal blood culture contamination (3.8%), we instigated a successful intervention combining skin antisepsis using sterile applicators with 2% chlorhexidine gluconate in 70% isopropanol prior to phlebotomy (replacing 70% isopropanol) and staff education. In the six months prior to intervention, 364 neonatal peripheral blood samples were collected. Fourteen (3.8%) were contaminated. In the post-intervention six months, 314 samples were collected. Three (0.96%) were contaminated, representing significant improvement (Fisher's exact test: P = 0.0259). No dermatological sequelae were observed. The improvement has been sustained.

An Irish outbreak of New Delhi metallo-ß-lactamase (NDM)-1 carbapenemase-producing Enterobacteriaceae: increasing but unrecognized prevalence.

BACKGROUND: Carbapenemase-producing Enterobacteriaceae (CPE) may cause healthcare-associated infections with high mortality rates. New Delhi metallo-ß-lactamase-1 (NDM-1) is among the most recently discovered carbapenemases. AIM: To report the first outbreak of NDM-1 CPE in Ireland, including microbiological and epidemiological characteristics, and assessing the impact of infection prevention and control measures. METHODS: This was a retrospective microbiological and epidemiological review. Cases were defined as patients with a CPE-positive culture. Contacts were designated as roommates or ward mates. FINDINGS: This outbreak involved 10 patients with a median age of 71 years (range: 45-90), located in three separate but affiliated healthcare facilities. One patient was infected (the index case); the nine others were colonized. Nine NDM-1-producing Klebsiella pneumoniae, an NDM-1-producing Escherichia coli and a K. pneumoniae carbapenemase (KPC)-producing Enterobacter cloacae were detected between week 24, 2014 and week 37, 2014. Pulsed-field gel electrophoresis demonstrated similarity. NDM-1-positive isolates were meropenem resistant with minimum inhibitory concentrations (MICs) ranging from 12 to 32 µg/mL. All were tigecycline susceptible (MICs ≤1 µg/mL). One isolate was colistin resistant (MIC 4.0 µg/mL; mcr-1 gene not detected). In 2015, four further NDM-1 isolates were detected. CONCLUSION: The successful management of this outbreak was achieved via the prompt implementation of enhanced infection prevention and control practices to prevent transmission. These patients did not have a history of travel outside of Ireland, but several had frequent hospitalizations in Ireland, raising concerns regarding the possibility of increasing but unrecognized prevalence of NDM-1 and potential decline in value of travel history as a marker of colonization risk.