Effect of ethnicity on care pathway and outcomes in patients hospitalized with influenza A(H1N1)pdm09 in the UK.

Data were extracted from the case records of UK patients admitted with laboratory-confirmed influenza A(H1N1)pdm09. White and non-White patients were characterized by age, sex, socioeconomic status, pandemic wave and indicators of pre-morbid health status. Logistic regression examined differences by ethnicity in patient characteristics, care pathway and clinical outcomes; multivariable models controlled for potential confounders. Whites (n = 630) and non-Whites (n = 510) differed by age, socioeconomic status, pandemic wave of admission, pregnancy, recorded obesity, previous and current smoking, and presence of chronic obstructive pulmonary disease. After adjustment for a priori confounders non-Whites were less likely to have received pre-admission antibiotics [adjusted odds ratio (aOR) 0·43, 95% confidence interval (CI) 0·28-0·68, P < 0·001) but more likely to receive antiviral drugs as in-patients (aOR 1·53, 95% CI 1·08-2·18, P = 0·018). However, there were no significant differences by ethnicity in delayed admission, severity at presentation for admission, or likelihood of severe outcome.

Transportation capacity for patients with highly infectious diseases in Europe: a survey in 16 nations.

Highly infectious diseases (HIDs) are defined as being transmissible from person to person, causing life-threatening illnesses and presenting a serious public health hazard. In most European Union member states specialized isolation facilities are responsible for the management of such cases. Ground ambulances are often affiliated with those facilities because rapid relocation of patients is most desirable. To date, no pooled data on the accessibility, technical specifications and operational procedures for such transport capacities are available. During 2009, the 'European Network for HIDs' conducted a cross-sectional analysis of hospitals responsible for HID patients in Europe including an assessment of (a) legal aspects; (b) technical and infrastructure aspects; and (c) operational procedures for ground ambulances used for HID transport. Overall, 48 isolation facilities in 16 European countries were evaluated and feedback rates ranged from 78% to 100% (n = 37 to n = 48 centres). Only 46.8% (22/47) of all centres have both national and local guidelines regulating HID patient transport. If recommended, specific equipment is found in 90% of centres (9/10), but standard ambulances in only 6/13 centres (46%). Exclusive entrances (32/45; 71%) and pathways (30/44; 68.2%) for patient admission, as well as protocols for disinfection of ambulances (34/47; 72.3%) and equipment (30/43; 69.8%) exist in most centres. In conclusion, the availability and technical specifications of ambulances broadly differ, reflecting different preparedness levels within the European Union. Hence, regulations for technical specifications and operational procedures should be harmonized to promote patient and healthcare worker safety.

A curriculum for training healthcare workers in the management of highly infectious diseases.

The SARS epidemic, the threat of bioterrorism, and recent examples of imported highly infectious diseases (HID) in Europe have all highlighted the importance of competent clinical and public health management of infectious disease emergencies. Although the European Union of Medical Specialists in Europe and the Infectious Diseases Society of America have developed curricula for training in infectious disease medicine, neither of those mentions training in the management of HIDs. The European Network for Infectious Diseases (EUNID, http://www.eunid.com) is a European Commission co-funded network of experts in HID management, created to help improve the preparedness for HID emergencies within Europe. One of EUNID's agreed tasks is the development of a curriculum for such a training. Between April 2005 and September 2006, EUNID developed a curriculum and accompanying training course on the basis of a questionnaire that was sent to all country representatives and discussion, followed by amendment of drafts shared through the project website, and a final consensus meeting. The resulting curriculum consists of a two-module course covering the core knowledge and skills that healthcare workers need to safely treat a patient who has, or who may have, an HID. The first module introduces theoretical aspects of HID management, including disease-specific knowledge, infection control, and the public health response, through didactic teaching and class-based discussion. The second module involves a "skill station" and a clinical scenario, and equips trainees with relevant practical skills, including the use of specialised equipment and teamwork practice in patient management. Together, the curriculum and course contribute to the creation of a common framework for training healthcare professionals in Europe, and although they are designed primarily for clinicians that are directly involved in patient care, they are relevant also to public health professionals and others who may be involved in HID management and emergency response.

Management of patients with epidemic methicillin-resistant Staphylococcus aureus: experience at an infectious diseases unit.

Between January 1983 and April 1984 60 patients completed their admission to an infectious diseases unit for management of methicillin-resistant Staphylococcus aureus. All had been shown to be colonized with a particular epidemic strain (EMRSA), and most isolates were from the nose or from broken skin sites. Eight patients were thought to have systemic EMRSA infection, of whom three had bacteraemia. Ten of the 60 patients died of severe underlying disease, eight were discharged home well but still colonized with EMRSA, four never had positive isolates after admission, and the remaining 38 cleared their EMRSA colonization in an average of 2 months. Five patients had further isolates of EMRSA after three negative, weekly screening tests and one after four negative screenings. No patients had further isolates after five or more negative screening tests.

Surveillance of methicillin-resistant Staphylococcus aureus in England and Wales, 1986-1990.

The incidence of methicillin-resistant Staphylococcus aureus in England and Wales was monitored by a weekly reporting scheme from early 1986 to March 1990. Potential coverage was approximately two-thirds of hospital beds. Reporting centres fell from a peak of 210 in 1986 to a low of 101 centres early in 1989 with later recovery. There were 2367 positive reports in 1986, 2174 in 1987, 1700 in 1988, 1701 in 1989 and 632 in the first quarter of 1990. Colonizations outnumbered infections by 2:1. There were marked regional differences: North-East Thames was dominant in 1986 and 1987, and then declined; South-East Thames showed a dramatic increase in 1988 which continued. Other regions showed less significant changes but there were continuing problems in the South-Western Region and in the West Midlands. Some of these changes were related to the decline of EMRSA-1, possibly due to the introduction of effective control measures, and to the emergence of EMRSA-3 in South-East Thames and its spread to Wessex.

Liver function tests in adults with Plasmodium falciparum infection.

This study examines the levels of serum bilirubin, aspartate transaminase and alkaline phosphatase in adults with Plasmodium falciparum malaria. One hundred and six sets of liver function tests were obtained, and 63 (59.4%) patients had one of the above indices elevated outside the local reference range. Serum bilirubin and aspartate transaminase were relatively higher than alkaline phosphatase. Neither duration of illness nor severity of infection showed any significant correlation with any of the indices measured.

Review of 26 years' hospital admissions for chickenpox in North London.

The epidemiology of chickenpox admissions to an Infectious Diseases Unit was studied over 26 years. Risk factors, markers of disease severity, and complications were analysed in patients admitted during the last 5 years. Some 613 patients were admitted with chickenpox over three 5-year periods between 1968 and 1993. There was a 2.23-fold increase in the number of adults admitted from home between the first and last period. Patients of European origin showed a three-fold increase. The mean age of adults rose from 26.2 to 34.3 years. Some 23% of adults had varicella pneumonitis. Smokers were six times more susceptible to pneumonitis than were non-smokers. Adult asthmatics were not at increased risk, whereas 42% of asthmatic children had chest complications. Seventeen of the 18 immunocompromised patients had a relatively uncomplicated course. Of the children, 32% had secondary skin infections, with no excess complications among those with eczema. Thrombocytopenia and elevated aspartate transaminases were four times and twice, more frequent in adults than children, respectively. These features occurred mostly in males. The male-to-female admission ratio was 2:1 in adults, and 1.2:1 in children. Males in both age groups showed a trend to more severe disease and more primary complications than did females. Our data showed an increase in adult chickenpox admissions. We have identified asthma as a risk factor for pulmonary complications in children, but not adults, and male gender as an independent risk factor for severe chickenpox.

Acute transverse myelitis associated with Chlamydia psittaci infection.

We report a case of transverse myelitis presenting with fever and rapidly deteriorating neurological signs associated with Chlamydia psittaci infection. It resolved with no long-standing neurological consequences. Only one previous report has described transverse myelitis in association with psittacosis, and this resulted in permanent neurological sequelae.

Listeria monocytogenes meningitis associated with eating soft cheese.

A 36-year-old woman became ill with meningitis caused by Listeria monocytogenes. She had eaten soft cheese from which a similar organism was isolated.

The effect of Schick testing on diphtheria antitoxin status.

Twenty-nine healthy persons were Schick tested as part of their occupational health examination. All but three of them had been previously immunised against diphtheria. One unimmunised person had a history of diphtheria. Blood samples were taken before and at varied intervals after the Schick tests in order to determine whether the Schick test antigen was immunogenic. Of the 29 persons tested, 21 were Schick-negative, three were Schick-positive. Four pseudoreactors were Schick-negative, one pseudoreactor was Schick-positive. Only four of the 29 had any significant rise in antitoxin titre after Schick testing. Three of these were Schick-negative, while one was a pseudoreactor who was negative at a later reading. We conclude that Schick testing is not reliably immunogenic and that, contrary to expectation, it cannot be assumed to elicit a useful booster response in previously immunised persons.

Comparison of fitness of two isolates of Mycobacterium tuberculosis, one of which had developed multi-drug resistance during the course of treatment.

OBJECTIVES: We report the cases of two patients, brother and sister, both with pulmonary tuberculosis. Both patients complied poorly with treatment. One developed multi-drug resistant disease, whilst the other did not. We aimed to show that the two infecting strains were the same, and then to compare the fitness of the resistant strain to that of the sensitive strain. METHODS: The isolates were typed by RFLP. The fitness of the multi-drug resistant tuberculosis strain was determined by calculating the ratio of generation produced by the drug-resistant and a drug-susceptible strain in a mixed culture. The number of bacteria present in this broth culture was estimated using the Miles and Misra technique. The number of drug-resistant bacteria present was determined by inoculating aliquots of broth onto Middlebrook 7H10 agar with 5mg/l rifampicin. RESULTS: The infecting strain of Mycobacterium tuberculosis was shown to be the same on RFLP typing in both cases. It was found that the multi-drug resistant organism had decreased fitness compared to the sensitive organism. CONCLUSION: The decreased relative fitness of the resistant strain implies a physiologic cal cost for the development of drug resistance.

The public health response to a case of Lassa fever in London in 2000.

OBJECTIVES: Evaluation of the Department of Health 1996 guidance, the Memorandum on the Management and Control of Viral Haemorrhagic Fevers. METHODS: Description of the public health management in 2000 of the fifth UK patient confirmed to have Lassa fever. RESULTS: Delayed risk categorisation of the patient occurred for a variety of reasons. DH Guidance was followed once infection control advice was sought. Active surveillance of 125 contacts was extremely resource intense, involving over 3000 communications. Self-monitoring by healthcare workers should be considered in future. Advice on use of ribavirin prophylaxis is not included in the Memorandum, nor advice or templates for information sheets for contacts. Information sheets are now available from the Health Protection Agency in the event of future cases. International aspects not adequately addressed include the need for reliable risk assessment to be carried out before patients are medically evacuated from the country of origin, and the steps required to repatriate UK nationals. Effective and efficient communication is required between national and international organisations involved in such incidents. CONCLUSIONS: If guidelines are unclear or impracticable they will not be followed. It is important that lessons are learned and documented and that national guidance be regularly reviewed.

Protorubradirin, an antibiotic containing a C-nitroso-sugar fragment, is the true secondary metabolite produced by Streptomyces achromogenes var. rubradiris. Rubradirin, described earlier, is its photo-oxidation product.

In an attempt to improve the isolation of the antibiotic rubradirin from fermentations of Streptomyces achromogenes var. rubradiris, the use of preparative reversed-phase chromatography was investigated. The product isolated was a mixture of rubradirin and a new antibiotic named protorubradirin, of extremely similar structure, which is converted into rubradirin on exposure to light and air. Methanolysis of protorubradirin in the dark yields an anomeric mixture of methyl glycosides of a C-nitroso-sugar, converted photo-oxidatively into the methyl rubranitrosides derived from rubradirin. Thus, protorubradirin is the C-nitroso-analogue of rubradirin. It is suggested that the same relationship between protorubradirin and rubradirin may apply to the anthracycline antibiotics viriplanin A and viriplanin D.

Infection control practices in facilities for highly infectious diseases across Europe.

BACKGROUND: The management of patients with highly infectious diseases (HIDs) is a challenge for healthcare provision requiring a high level of care without compromising the safety of other patients and healthcare workers. AIM: To study the infection control practice in isolation facilities participating in the European Network for Highly Infectious Diseases (EuroNHID) project. METHODS: A survey was conducted during 2009 of 48 isolation facilities caring for patients with HIDs in 16 European countries. Checklists and standard evaluation forms were used to collect and interpret data on hand hygiene, routine hygiene and disinfection, and waste management. FINDINGS: Forty percent of HIDs had no non-hand-operated sinks or alcohol-based antiseptic distributors, while 27% did not have procedures for routine hygiene, final disinfection, or safe discarding of non-disposable objects or equipment. There was considerable variation in the management of waste and in the training of housekeeping personnel. EuroNHID has developed recommendations for hand hygiene, disinfection, routine hygiene, and waste management. CONCLUSIONS: Most aspects of hand hygiene, routine hygiene and disinfection, and waste management were considered at least partially adequate in the majority of European isolation facilities dedicated for the care of patients with HIDs. But considerable variability was observed, with management of waste and training of housekeeping personnel being generally less satisfactory.