Managing a nosocomial outbreak of carbapenem-resistant Klebsiella pneumoniae: an early Australian hospital experience.

BACKGROUND: Carbapenems are traditionally reserved as the last line of defence for treatment of serious infections with multiresistant Gram-negative bacilli. Reports of Klebsiella pneumoniae carbapenemase (KPC)-producing organisms have been emerging globally, but rare in Australasia to date. We describe an outbreak of KPC-2 producing K. pneumoniae at an Australian hospital. METHODS: After initial detection in October 2012, a retrospective review of patients with meropenem-resistant K. pneumoniae to June 2012, and ongoing prospective surveillance, was undertaken. Included patients were admitted to the hospital after June 2012 and had meropenem-resistant K. pneumoniae isolated from any site. Available isolates underwent detection of the KPC-2 gene by polymerase chain reaction and molecular typing was performed to determine genetic relatedness between isolates. Point-prevalence screening was performed on selected wards to detect asymptomatic carriage. Infection control procedures were implemented to contain the outbreak. RESULTS: Ten cases were identified in the initial cluster. Eight were localised to a single inpatient ward. Point-prevalence screening revealed one extra case. After temporary containment, re-emergence of KPC-producing isolates was observed post October 2013 with 18 further cases identified. Four K. pneumoniae isolates in the 2012 cluster and 16 from the 2013-2014 cluster were referred for further testing. All carried the KPC-2 beta-lactamase gene. The 2012 isolates were genetically similar to the 2014 isolates. CONCLUSION: KPC-2 mediated resistance is an emerging threat in Australia. The re-emergence of KPC despite initial containment emphasises the need for constant vigilance in the microbiology laboratory and ongoing maintenance of infection control and antimicrobial stewardship activity.

Physical health trajectories of young people commenced on clozapine.

OBJECTIVES: Clozapine is the most effective antipsychotic medication, but it has the highest propensity for metabolic side effects. A clozapine clinic was established within an early intervention for psychosis service to facilitate the timely commencement of clozapine and to manage the associated adverse effects. This study describes the changes in the weight, body mass index (BMI), waist circumference and blood pressure after 6 months in young people commenced on clozapine. METHOD: This was a prospective cohort study of all young people, aged 15-24 years, commenced on clozapine within an early intervention service in Melbourne, Australia, between 01.04.2016 and 30.06.2018. Continuous data were analyzed with paired t-test and categorical with Wilcoxon signed-rank test. RESULTS: Twenty-six young people received 6 months of treatment with clozapine, of whom the mean age was 19.8 years (s.d. ±3.1) and 66.7% were male. After 6 months, the mean weight gain was 5.1 kg (s.d. ±10.1 kg) and over half (53.8%) gained clinically significant weight. The proportion of young people classified as either overweight or obese rose from 69.2% to 88.5% (p = 0.006). The proportion of young people with a waist circumference above the recommended parameters increased from 57.9% to 78.9% (p = 0.008). Hypertension was present in 30%, and after 6 months, 45% had hypertension (p = 0.64). Metformin was prescribed to 34.6%, typically to those with the greatest and most rapid weight gain. CONCLUSION: Among young people with treatment resistant psychosis, clozapine is associated with significant metabolic side effects in the early stages of commencement. More interventions aimed at attenuating this weight gain are needed.

Cognitively oriented psychotherapy for early psychosis (COPE): a 1-year follow-up.

OBJECTIVES: Cognitively oriented psychotherapy for early psychosis (COPE) is aimed at facilitating the adjustment of the person, and at preventing or alleviating secondary morbidity in the wake of the first psychotic episode. DESIGN: A total of 80 people participated in the initial trial and completed assessments on a range of outcome measures. Post-treatment assessment results from a non-randomized controlled trial of COPE have been previously reported. The present paper describes the results obtained from 51 patients who attended a follow-up assessment 1 year subsequent to the end-of-treatment assessment. METHOD: The 51 patients formed three groups: (1) those who were offered and accepted COPE; (2) those who were offered COPE but refused it, and continued to receive other services from the Early Psychosis Prevention and Intervention Centre (EPPIC) (refusal subjects); and (3) those who were offered neither COPE nor any other continuing treatment from EPPIC (control subjects). RESULTS: At 1-year follow-up, there was only one significant difference and this was between the COPE and refusal groups on the Integration/Sealing Over (I/SO) measure (p = .008). End-of-treatment differences were mostly sustained over the 1-year follow-up period. When the complete sample of 80 was considered, there were no differences between the three groups in terms of hospital admissions, community episodes, or time taken to first in-patient re-admission. CONCLUSIONS: The study was weakened by the poor follow-up rates in the two control groups. This reduced power to detect differences between groups on the seven major measures. However, the relapse data gathered on the complete set of 80 patients were discouraging and suggest that the present formulation of COPE does not confer any advantage to those patients receiving the therapy over those not receiving the therapy.

Prolonged recovery in first-episode psychosis.

BACKGROUND: Early identification and specialised treatment of individuals with enduring positive symptoms may assist in alleviating symptoms and has the potential to change the course of illness. METHOD: Prevalence and descriptive data on enduring positive symptoms in two first-episode samples are outlined. Attempts to incorporate the focus of early intervention for persisting psychosis into routine clinical care of individuals with first-episode psychosis are described. RESULTS: Of the 227 individuals with first-episode psychosis who were assessed using the Brief Psychiatric Rating Scale at 3/6 months and 12 months following initial stabilisation (from a total sample of 347), 6.6% experienced enduring positive symptoms at all three time points. When the analysis was restricted to schizophrenia, schizophreniform and schizoaffective disorders (n = 158) the percentage increased to 8.9%. These patients had significantly longer mean duration of untreated psychosis prior to initiation of treatment and, at 12-month follow-up, significantly higher depression and poorer psychosocial functioning. CONCLUSIONS: The association of untreated psychosis with treatment resistance supports the argument for early intervention as soon as possible following the onset of psychotic symptoms.

Cognitively-oriented psychotherapy for early psychosis (COPE). Preliminary results.

BACKGROUND: The present study describes the results of the pilot testing of a therapy we have developed for people with first-episode psychosis. Cognitively-oriented psychotherapy for early psychosis (COPE) is aimed at facilitating the adjustment of the person, and at preventing or alleviating secondary morbidity in the wake of the first psychotic episode. METHOD: Eighty people formed three groups: those who were offered and accepted COPE (COPE subjects); those who refused COPE (refusal subjects); and those who were offered neither COPE nor any other continuing treatment from our service (control subjects). The individuals were assessed prior to, and at the end of, COPE treatment (a 12-month period) on the Integration/Sealing Over, Explanatory Model, Scale for the Assessment of Negative Symptoms, Brief Psychiatric Rating Scale, Quality of Life, SCL-90-R, and Beck Depression Inventory measures. RESULTS: People who received COPE obtained significantly superior scores (P < 0.05) to the control group on four of the seven measures but only significantly out-performed the refusal group on one of the seven measures (P < 0.05). The COPE group performed significantly worse on the BDI than the refusal group (P < 0.05). Effect sizes are also provided for each measure. CONCLUSIONS: There seems to be a place for psychological therapy in this group of people but our results need to be replicated in a more definitive randomised controlled trial and such a study is now in progress.

Evaluation of the biological efficacy of hydrogen peroxide vapour decontamination in wards of an Australian hospital.

This study assessed the efficacy of a 'dry' hydrogen peroxide vapour decontamination in an Australian hospital via a two-armed study. The in vivo arm examined the baseline bacterial counts in high-touch zones within wards and evaluated the efficacy of cleaning with a neutral detergent followed by either hydrogen peroxide vapour decontamination, or a manual terminal clean with bleach or Det-Sol 500. The in vitro arm examined the efficacy of hydrogen peroxide vapour decontamination on a variety of different surfaces commonly found in the wards of an Australian hospital, deliberately seeded with a known concentration of vancomycin-resistant enterococci (VRE). All bacterial counts were evaluated by a protocol of contact plate method. In the in vivo arm, 33.3% of the high-touch areas assessed had aerobic bacterial count below the detection limit (i.e. no bacteria recoverable) post hydrogen peroxide decontamination, and in all circumstances the highest microbial density was ≤3 cfu/cm(2), while in the in vitro arm there was at least a reduction in bacterial load by a factor of 10 at all surfaces investigated. These results showed that dry hydrogen peroxide vapour room decontamination is highly effective on a range of surfaces, although the cleanliness data obtained by these methods cannot be easily compared among the different surfaces as recovery of organisms is affected by the nature of the surface.

Randomized Controlled Trial of Clozapine and CBT for First-Episode Psychosis with Enduring Positive Symptoms: A Pilot Study.

Here we report the results of a pilot study investigating the relative and combined effects of a 12 week course of clozapine and CBT in first-episode psychosis patients with prominent ongoing positive symptoms following their initial treatment. Patients from our early psychosis service who met the inclusion criteria (n = 48) were randomized to one of four treatment groups: clozapine, clozapine plus CBT, thioridazine, or thioridazine plus CBT. The degree of psychopathology and functionality of all participants was measured at baseline then again at 6, 12 and 24 weeks, and the treatment outcomes for each group determined by statistical analysis. A substantial proportion (52%) of those treated with clozapine achieved symptomatic remission, as compared to 35% of those who were treated with thioridazine. Overall, those who received clozapine responded more rapidly to treatment than those receiving the alternative treatments. Interestingly, during the early treatment phase CBT appeared to reduce the intensity of both positive and negative symptoms and thus the time taken to respond to treatment, as well having as a stabilizing effect over time.

Perforated peptic ulcer--the changing scene.

There is a changing scene with perforated peptic ulcer. The older age of presentation, the increased association with non-steroidal anti-inflammatory drugs, associated increased debility, and resulting higher mortality in the elderly, are causing a rethink in management protocols. Whereas years ago most discussion was on whether urgent definitive surgery was the most effective therapy, nowadays there is a tendency to less invasive measures. A 'deliberative' approach, wherein not all patients require surgery, is detailed, and there may be an increasing role for laparoscopic perforation-sealing techniques in the remainder. Anti-secretory and anti-helicobacter drugs have an important role in post-operative care following lesser procedures than definitive surgery.

Laparoscopic inguinal hernioplasty: a comparison between transperitoneal and extraperitoneal techniques.

BACKGROUND: This study sequentially compares the results of 148 transperitoneal inguinal hernioplasties in 129 patients with 313 totally extraperitoneal hernioplasties in 254 patients. METHODS: Patients were entered into the study prospectively and reviewed postoperatively at 1 day, 1 week, 5 weeks and 1 year. RESULTS: There was no difference in length of hospital stay, postoperative analgesia requirements or the rate of early or late operative complications. The operating time was shorter and the return to normal activities was earlier for the totally extraperitoneal group. There were no intraperitoneal complications following the totally extraperitoneal operation. CONCLUSIONS: The extraperitoneal technique is favoured over the transperitoneal technique for laparoscopic inguinal hernioplasty.

Comparison of length of stay after hernia repair in two Victorian hospitals. Standards Sub-committee of the Victorian State Committee of the Royal Australasian College of Surgeons.

The objective of this study was to ascertain factors which determine the length of stay in relation to adult patients admitted for hernia surgery in two different hospitals. It was conducted prospectively on a total of 141 patients, 82 in a central hospital and 59 in a district hospital. There were no significant differences with regard to age, sex, type of hernia, pre-existing disease and postoperative complications. There was a significant difference between the average length of stay in the two hospitals (6.7 days in the central hospital and 3.9 days in the district hospital). There was a longer pre-operative stay in the central hospital through administrative problems, availability of operating time and admission for pre-operative investigations. In the postoperative period there was a significant difference between the day of operation and the time the surgeon stated that the patient could be discharged (i.e. the surgically advised discharge (SAD) date). This period was 4 days at the central hospital, as against 2 days at the district hospital. Once the SAD date was determined, there was no difference between the two hospitals with regard to placement. Consideration should be given to improving admission practices, including patient 'work-up' in the preadmission phase and to shortening the postoperative stay after hernia surgery.

Partial gastrectomy for haemorrhage.

An analysis was made of the results of 566 partial gastrectomies for haemorrhage from gastroduodenal ulceration between 1953 and 1962 with regard to mortality, morbidity, and long-term follow up. With rigid criteria for selection of patients for surgery, the overall mortality rate for ulcerative gastroduodenal haemorrhage was 8.6%. The actual operative mortality rate more than doubles if an emergency operation is performed later than four days after the patient's admission with haemorrhage. Postoperative and later bleeding complications occurred in 5% of patients. Regardless of the length of ulcerative history, over 92% of patients have clinically satisfactory long-term results. Six per cent required further operation, after which, they too had clinically satisfactory results.

Fractured neck of the femur (DRG 210/211): prospective outcome study.

BACKGROUND: An ageing population will increase the need for resources to treat patients with a fractured neck of femur (DRG 210/211). Provision of these resources will be helped by a better understanding of current practices. METHODS: A prospective study of outcome at discharge for 100 consecutive patients with DRG 210/211 was conducted at five Victorian metropolitan teaching hospitals to assess length of stay and the reasons for any variations. RESULTS: The major influences on timing of discharge were: delayed availability of rehabilitation beds; the timing of referral and assessment by the Geriatric Assessment Team; delay in surgery more than 24 h after admission; and development of postoperative complications. CONCLUSION: The efficient management of patients with DRG 210/211 requires a strong protocol of treatment and referral strategies with adequate resources.

Developing clinical indicators for cholecystectomy.

This study sets out to develop a set of clinical indicators for the frequently performed procedure, simple cholecystectomy. Four hundred consecutive cases of cholecystectomy were reviewed retrospectively and data were collected regarding the pre-operative condition of the patient as well as any postoperative complications. From this database a set of clinical indicators for simple cholecystectomy are recommended: wound infection rate 4.5%, re-operation or performance of another therapeutic procedure 3.5%, length of stay 7 days, and mortality < 0.025%. These threshold figures are to serve only as a 'flag' to possible problems.

Perforated peptic ulcer: a deliberative approach.

Between 1966 and 1987, 116 patients with 119 episodes of perforation were admitted to Box Hill Hospital into one surgical unit, and 91 patients with 92 episodes were admitted into the other, with patients being admitted in alternate weeks. In the former unit, in order to avoid surgery in those patients whose ulcers had sealed spontaneously, a deliberative approach was followed according to a strict protocol--involving a deliberate time delay in surgical decision-making. In the latter unit, a more conventional approach was adopted, and patients in that unit are used as a retrospective comparison. In the first unit, of 115 episodes which followed the protocol, six were unresuscitable, 15 needed immediate surgery and 94 followed a delayed approach. Of that 94, 12 needed surgery at 4-6 h, and a further eight needed later surgery. Seventy-four (68% of 'operable' patients) did not require corrective surgery at all, for their episode of perforation. The operable mortality rate was lower (6% compared with 13%), the bedstay was shorter, the prolonged bedstay rate was lower, and the morbidity was no worse, than those patients treated more conventionally in the second unit.

Bile duct injury during laparoscopic cholecystectomy: a report of the Standards Sub-committee of the Victorian State Committee of the Royal Australasian College of Surgeons.

A survey of Victorian surgeons performing laparoscopic cholecystectomy was carried out. This report discusses the bile duct injuries identified in the survey. Twelve injuries were recorded, a rate of 0.2%. Three of the 12 required formal repair, the other 9 being treated by T-tube alone. Possible mechanisms of these injuries, the experience of the surgeon, the role of operative cholangiography and delays in recognition of the injury are discussed.

Colorectal resection in Victoria:a comparison of hospital based and individual audit.

BACKGROUND: The results of personal audit have not been tested against a hospital-based audit previously and the results of two such audits of colorectal resection in the State of Victoria have provided this opportunity. In addition, data reflecting the results of colorectal resection across a range of hospitals and surgeons in the Victorian community have been obtained. METHODS: A total of 535 patients undergoing a colorectal resection, with an anastomosis performed, were studied in two serially conducted prospective audits arranged by the Standards Sub-Committee of the Victorian State Committee. One study was public hospital-based and the second was based on voluntary reporting by individual surgeons. RESULTS: Similar results were obtained in each study, demonstrating the accuracy of individual reporting. The combined results (wound infection rate 12.3%, anastomotic leak rate 3.7% and mortality 4.5%) are compared to previously published data. CONCLUSIONS: In the State of Victoria the results of audit by individual surgeons performing colorectal resection were similar to the hospital-based audit. The results obtained compare favourably with previously published data.

Clinical indicators in colorectal surgery.

Two studies conducted in the state of Victoria have tested potential clinical indicators and the suggested thresholds for resection of colorectal carcinoma where an anastomosis has been performed. These studies involving 535 patients were independent of one another: one hospital based and one surgeon based. Threshold figures for these draft indicators have been compared with the study figures and found to be similar. It is suggested that wound infection (elective operation without formation of a stoma), anastomotic leak (clinically recognized) and mortality (elective operations in patients under the age of 80 years) are the most appropriate clinical indicators of colorectal resection for carcinoma.