Predicting community acquired bloodstream infection in infants using full blood count parameters and C-reactive protein; a machine learning study.

Early recognition of bloodstream infection (BSI) in infants can be difficult, as symptoms may be non-specific, and culture can take up to 48 h. As a result, many infants receive unneeded antibiotic treatment while awaiting the culture results. In this study, we aimed to develop a model that can reliably identify infants who do not have positive blood cultures (and, by extension, BSI) based on the full blood count (FBC) and C-reactive protein (CRP) values. Several models (i.e. multivariable logistic regression, linear discriminant analysis, K nearest neighbors, support vector machine, random forest model and decision tree) were trained using FBC and CRP values of 2693 infants aged 7 to 60 days with suspected BSI between 2005 and 2022 in a tertiary paediatric hospital in Dublin, Ireland. All models tested showed similar sensitivities (range 47% - 62%) and specificities (range 85%-95%). A trained decision tree and random forest model were applied to the full dataset and to a dataset containing infants with suspected BSI in 2023 and showed good segregation of a low-risk and high-risk group. Negative predictive values for these two models were high for the full dataset (> 99%) and for the 2023 dataset (> 97%), while positive predictive values were low in both dataset (4%-20%).   Conclusion: We identified several models that can predict positive blood cultures in infants with suspected BSI aged 7 to 60 days. Application of these models could prevent administration of antimicrobial treatment and burdensome diagnostics in infants who do not need them. What is Known: • Bloodstream infection (BSI) in infants cause non-specific symptoms and may be difficult to diagnose. • Results of blood cultures can take up to 48 hours. What is New: • Machine learning models can contribute to clinical decision making on BSI in infants while blood culture results are not yet known.

Antenatal pyelonephritis: a three-year retrospective cohort study of two Irish maternity centres.

Pyelonephritis affects 1-2% of pregnant women, and is associated with significant maternal and fetal morbidity. Antenatal pyelonephritis has been associated with PPROM (preterm premature rupture of membranes), preterm labour, low birth weight (LBW) and prematurity. A three-year retrospective dual-centre cohort study of antenatal pyelonephritis cases was conducted in two neighbouring Irish maternity hospitals - the Rotunda Hospital (RH) and the National Maternity Hospital (NMH). Patient demographics, clinical presentation, investigations, management and maternal/neonatal outcomes were recorded. A total of 47,676 deliveries (24,768 RH; 22,908 NMH) were assessed. 158 cases of antenatal pyelonephritis were identified (n = 88 RH, n = 70 NMH), with an incidence of 0.33%. The median age was 28 years. The median gestation was 27 + 6 weeks, with 51% presenting before 28 weeks' gestation. Risk factors included; obesity (18.4%), diabetes mellitus (13.3%) and self-reported clinical history of recurrent urinary tract infection (28.5%). Rate of relapse with UTI in the same pregnancy was 8.2%. Renal ultrasound was performed in 30.4%. Predominant uropathogens were Escherichia coli (60%), Klebsiella pneumoniae (11%) and Proteus mirabilis (5%). 7.5% of cases had a concurrent bloodstream infection, 13.3% of cases were complicated by sepsis and 1.9% with septic shock. Complications including PPROM (6.3%), preterm delivery < 37 weeks' gestation (11%), LBW < 2,500 g (8.2%) were comparable between sites. Delivery within 72 hours of diagnosis was noted in 7% (n = 11) of patients, of which three were preterm and one had LBW. Appropriate and prompt investigation and management of antenatal pyelonephritis is essential given the associated maternal and neonatal morbidity.

The full blood count in screening asymptomatic infants for early-onset sepsis: A cross-sectional study.

AIM: The full blood count (FBC) is commonly measured as part of a partial septic work-up in asymptomatic infants at increased risk of early-onset neonatal sepsis (EOS). To determine the impact of FBC parameters on infants' subsequent management a retrospective cross-sectional study was performed. METHODS: Infants, born at ≥34 weeks gestation, asymptomatic at birth, undergoing a partial septic work-up and receiving prophylactic antibiotics due to increased risk of EOS in a single centre over a 2-year period, were included. The primary outcome measure was frequency of FBC result impacting on duration of antibiotic therapy. Secondary outcome measures included frequency of FBC parameters outside of the reference range and incidental diagnoses. RESULTS: In total, 16 726 live-born infants were delivered during the study period. A total of 802 (4.8%) were included. Thirteen infants (1.6%) received a prolonged course of antibiotics due to suspicion for EOS. Two of these infants had elevated white cell counts. All had normal neutrophil counts. In no case did the FBC result influence the decision to prolong the antibiotic course. CONCLUSION: In a cohort of 802 infants, asymptomatic at birth and at increased risk of EOS, the FBC result did not impact on the decision to prolong the course of antibiotics for suspicion of EOS.

Platelets in pediatric and neonatal sepsis: novel mediators of the inflammatory cascade.

Sepsis, a dysregulated host response to infection, has been difficult to accurately define in children. Despite a higher incidence, especially in neonates, a non-specific clinical presentation alongside a lack of verified biomarkers has prevented a common understanding of this condition. Platelets, traditionally regarded as mediators of haemostasis and thrombosis, are increasingly associated with functions in the immune system with involvement across the spectrum of innate and adaptive immunity. The large number of circulating platelets (approx. 150,000 cells per microlitre) mean they outnumber traditional immune cells and are often the first to encounter a pathogen at a site of injury. There are also well-described physiological differences between platelets in children and adults. The purpose of this review is to place into context the platelet and its role in immunology and examine the evidence where available for its role as an immune cell in childhood sepsis. It will examine how the platelet interacts with both humoral and cellular components of the immune system and finally discuss the role the platelet proteome, releasate and extracellular vesicles may play in childhood sepsis. This review also examines how platelet transfusions may interfere with the complex relationships between immune cells in infection. IMPACT: Platelets are increasingly being recognised as important "first responders" to immune threats. Differences in adult and paediatric platelets may contribute to differing immune response to infections. Adult platelet transfusions may affect infant immune responses to inflammatory/infectious stimuli.

Neurological involvement in children with hemolytic uremic syndrome.

Our objective was to establish the rate of neurological involvement in Shiga toxin-producing Escherichia coli-hemolytic uremic syndrome (STEC-HUS) and describe the clinical presentation, management and outcome. A retrospective chart review of children aged ≤ 16 years with STEC-HUS in Children's Health Ireland from 2005 to 2018 was conducted. Laboratory confirmation of STEC infection was required for inclusion. Neurological involvement was defined as encephalopathy, focal neurological deficit, and/or seizure activity. Data on clinical presentation, management, and outcome were collected. We identified 240 children with HUS; 202 had confirmed STEC infection. Neurological involvement occurred in 22 (11%). The most common presentation was seizures (73%). In the neurological group, 19 (86%) were treated with plasma exchange and/or eculizumab. Of the 21 surviving children with neurological involvement, 19 (91%) achieved a complete neurological recovery. A higher proportion of children in the neurological group had renal sequelae (27% vs. 12%, P = .031). One patient died from multi-organ failure.Conclusion: We have identified the rate of neurological involvement in a large cohort of children with STEC-HUS as 11%. Neurological involvement in STEC-HUS is associated with good long-term outcome (complete neurological recovery in 91%) and a low case-fatality rate (4.5%) in our cohort. What is Known: • HUS is associated with neurological involvement in up to 30% of cases. • Neurological involvement has been reported as predictor of poor outcome, with associated increased morbidity and mortality. What is New: • The incidence of neurological involvement in STEC-HUS is 11%. • Neurological involvement is associated with predominantly good long-term outcome (90%) and a reduced case-fatality rate (4.5%) compared to older reports.

Cardiac Arrest Quality Improvement: A Single-Center Evaluation of Resuscitations Using Defibrillator, Feedback Device, and Survey Data.

BACKGROUND: High-quality cardiopulmonary resuscitation is foundational to cardiac arrest care. Visual feedback devices can improve chest compression quality, but are infrequently used. Quality improvement data were examined to determine whether handheld visual feedback and backboard use improved chest compression quality, whether resuscitation team size affected resuscitation indicators, and whether feedback sources are comparable. METHODS: From August 2019 to December 2020, data from 50 resuscitations were collected using a handheld device (n = 35), defibrillator (n = 23), and surveys (n = 35) and shared with providers. Aggregated and individual case data, along with education and research, were distributed to staff as quality improvement measures. RESULTS: The mean duration of resuscitation was 1080 compressions (SD = 858); there were no differences in the durations of resuscitations that did or did not use handheld feedback; 50% of resuscitations used handheld feedback and had more compressions at target rate (74.68% vs 42.18%, t(21) = 2.99, P = .007). Moreover, 25% of resuscitations used backboards; these had more chest compressions at target depth (72.92% vs 48.73%, t(25) = 2.08, P = .048). Team size was not associated with duration of resuscitation or chest compressions quality. There was no improvement in other quality indicators (leadership, family presence, or debriefing) during the data collection period. Feedback sources (defibrillator and feedback device) had good agreement and correlation (r = 0.77, P = .01). CONCLUSIONS: Incorporating handheld feedback and backboards improved chest compressions quality. Further work to improve the frequency of device use and to examine their relationship to patient-specific outcomes is needed. Study is needed to find interventions that improve other teamwork metrics, inclusion of family during the resuscitation, referral for tissue donation, and rates of postevent debriefing.

Erythromycin compared to amoxicillin and azithromycin for antimicrobial prophylaxis for preterm premature rupture of the membranes: a retrospective study.

Antimicrobial prophylaxis is widely recommended for pregnant women who have preterm premature rupture of the membranes. Erythromycin prophylaxis was used during an initial period (control) and then changed to intravenous amoxicillin for 48 h, followed by 5 days of oral amoxicillin along with a single dose of azithromycin (case). Healthcare records were reviewed retrospectively. The primary outcome was latency (between membrane rupture and delivery) and the secondary outcomes were mode of delivery, maternal high dependency unit (HDU) admission, and several laboratory parameters. There were 78 women in the case group (amoxicillin and azithromycin) and controls were selected on a 1:1 ratio. There was no statistically significant difference between cases and controls with respect to group B Streptococcus or E.coli carriage, previous preterm birth, assissted fertility and parity. No babies had a positive blood culture with Group B Streptococcus. There was a longer latency to delivery for those prescribed amoxicillin and azithromycin (median = 5.5 days), compared with controls on erythromycin (median = 2 days, p < .001). There was no difference in the mode of delivery or maternal HDU admission. Given the potential sequelae of preterm birth, this warrants further prospective investigation in a randomised control trial.IMPACT STATEMENTWhat is already known on this subject? Antimicrobial prophylaxis is recommended for women who have preterm premature rupture of the membranes (PPROM). It has been shown to increase latency of delivery. However there are different regimens recommended in North America (amoxicillin and a macrolide) and the United Kingdom (macrolide monotherapy).What do the results of this study add? This study has shown that in our population, women who were prescribed the PPROM regimen of amoxicillin with azithromycin had a longer median latency from time of rupture of membranes to delivery, than women in a historical control group who were prescribed erythromycin monotherapy.What are the implications of these findings for clinical practice and/or further research? This retrospective study has shown that there may be a difference in latency between different antimicrobial prophylaxis regimens for PPROM. A randomised control trial, with sufficient patient numbers, is needed to determine the best regimen for prophylaxis, and would allow harmonisation of international guidelines.

Epidemiology of Haemophilus influenzae in the Republic of Ireland, 2010-2018.

The purpose of this study was to investigate H. influenzae epidemiology in the Republic of Ireland. We performed serotyping, multi-locus sequence typing (MLST) and susceptibility testing on H. influenzae isolates received by the Irish Meningitis and Sepsis Reference Laboratory from 2010 to 2018. Three hundred sixty-seven invasive and 41 non-invasive infection (NII) isolates were received. Invasive isolates were mostly recovered from paediatric (21%) and elderly (42%) populations. Invasive disease was more prevalent in females of childbearing age (72%) compared with males the same age (28%). Non-typeable H. influenzae (NTHi) predominated among invasive (83%) and NII (95%). Invasive Hib disease isolates were infrequent (4%, n = 15). Among invasive disease, Hif was the commonest encapsulated serotype (10%, n = 37), and the only encapsulated serotype detected in NII (5%, 2/41). The first PCR-confirmed serotypes d and a in Ireland were characterised among invasive disease in 2017 and 2018, respectively. MLST revealed a diverse NTHi population, while encapsulated serotypes were clonal. Sequence type (ST) 103 (n = 14) occurred exclusively in invasive NTHi disease. Ampicillin resistance (AmpR) was 18% among invasive isolates and 22% in NII. ß-Lactamase production was the main source of ampicillin resistance in invasive and NII isolates. We detected ß-lactamase negative ampicillin resistance (BLNAR) among invasive isolates. We report an NTHi fluoroquinolone-resistant clone: ST1524 among invasive (n = 2) and NII isolates (n = 2). The Hib vaccine has positively impacted on Hib disease in Ireland, given the low frequency of Hib. The dominance of NTHi, emergence of serotypes a and d and BLNAR suggest a changing H. influenzae epidemiology in Ireland.

Screening for group B Streptococcus (GBS) at labour onset using PCR: accuracy and potential impact - a pilot study.

This pilot study assessed the diagnostic accuracy and potential impact of a rapid PCR-based screening test for the detection of group B Streptococcus (GBS) at the onset of labour for the purpose of optimising intrapartum antibiotic prophylaxis (IAP). Vaginal and rectal swabs from a convenience sample of 158 women were analysed by conventional broth-enriched culture and a rapid PCR test. Overall, GBS carriage was 18.98% by culture and 19.62% by PCR. PCR for the detection of GBS had a sensitivity of 93.1%, specificity of 96.67% and area under the curve (AUC) of 0.95. Only 19.3% GBS-positive women received IAP. Three-fourths of babies born to GBS-positive mothers did not receive surveillance for early-onset GBS disease. Of the women who received IAP, only 32.5% were GBS carriers. Seventy-four percent of the GBS-positive mothers delivered more than 5 h after recruitment, which gives adequate swab to delivery interval for appropriate antibiotic prophylaxis in labour. Impact statement What is already known about this subject: Appropriate intra-partum treatment of colonized mothers reduces the risk of GBS transmission to neonates. Universal ante partum screening of pregnant women or IAP based on risk factors in labour for GBS prevention fail to accurately identify and treat the woman who actually harbors GBS in the birth canal in labour. A PCR based rapid test, allows for real-time assessment of GBS carriage in labour. WHAT THIS STUDY ADDS: This study highlights the fact that a large number of GBS carriers in labour, who could potentially infect their babies, do not receive IAP, and most of their babies do not receive added surveillance in the neonatal period for EOGBS disease. It also confirms that PCR testing at onset of labour is a highly sensitive and reliable test that identifies the women who are GBS carriers in labour and hence need IAP. What the implications are of these findings for clinical practice and/or further research: Timely provision of IAP for the appropriate woman is possible by adopting universal GBS screening at the onset of labor using GBS-PCR. This would involve additional costs to health care facilities and added work to laboratory personnel.

Challenges in Preparation of Cumulative Antibiogram Reports for Community Hospitals.

Knowledge of local antimicrobial resistance is critical for management of infectious diseases. Community hospitals' compliance with Clinical and Laboratory Standards Institute (CLSI) guidance for creation of cumulative antibiograms is uncertain. This descriptive cohort study of antibiogram reporting practices included community hospitals enrolled in the Duke Infection Control Outreach Network. Cumulative antibiograms from 2012 were reviewed for criteria on reporting practices and compliance with CLSI guidelines. Microbiology personnel were sent a voluntary, electronic survey on antibiogram preparation practices. Data were compiled using descriptive statistics. Thirty-two of 37 (86%) hospitals provided antibiograms; 26 of 37 (70%) also provided survey responses. Twelve (38%) antibiograms specified methods used for compiling data and exclusion of duplicates. Eight (25%) reported only species with >30 isolates. Of the 24 that did not follow the 30-isolate rule, 3 (13%) included footnotes to indicate impaired statistical validity. Twenty (63%) reported at least 1 pathogen-drug combination not recommended for primary or supplemental testing per CLSI. Thirteen (41%) separately reported methicillin-resistant and -susceptible Staphylococcus aureus. Complete compliance with CLSI guidelines was observed in only 3 (9%) antibiograms. Survey respondents' self-assessment of full or partial compliance with CLSI guidelines was 50% and 15%, respectively; 33% reported uncertainty with CLSI guidelines. Full adherence to CLSI guidelines for hospital antibiograms was uncommon. Uncertainty about CLSI guidelines was common. Alternate strategies, such as regional antibiograms using pooled data and educational outreach efforts, are needed to provide reliable and appropriate susceptibility estimates for community hospitals.

A Retrospective Audit of Clinically Significant Maternal Bacteraemia in a Specialist Maternity Hospital from 2001 to 2014.

Maternal sepsis is a significant problem in obstetrics, with almost one in four maternal deaths related to severe sepsis. We carried out a retrospective review of clinically significant bacteraemia in obstetric patients attending Rotunda Hospital over 14 years. From 2001 to 2014, there were 252 clinically significant positive blood culture episodes in obstetric patients. There were 112,361 live births>500 g during the study period giving an overall rate of 2.24 clinically significant positive maternal blood culture episodes per 1000 live births>500 g. The median rate over the 14 years was 2.12 episodes per 1000 live births>500 g, with an interquartile range of 1.74-2.43 per 1000 live births>500 g. There was no discernable increasing or decreasing trend over the 14 years. E. coli was the most commonly isolated organism (n=92/252, 37%), followed by group B Streptococcus (n=64/252, 25%), Staphylococcus aureus (n=28/252, 11%), and anaerobes (n=11/252, 4%). These top four organisms represented three-quarters of all positive blood culture episodes (n=195/252, 77.3%). Of note, there were only five cases of listeriosis, representing a rate of 4.4 cases per 100,000 live births>500 g. The rate of invasive group A streptococcal infection was also very low at 5.3 cases per 100,000 live births>500 g.

Pregnancy Outcomes of Mothers with Detectable CMV-Specific IgM Antibodies: A Three-Year Review in a Large Irish Tertiary Referral Maternity Hospital.

A retrospective audit was performed for all obstetric patients who had positive CMV IgM results between January 2012 and December 2014 in the Rotunda Hospital, Ireland. In total, 622 CMV IgM positive tests were performed on samples from 572 patients. Thirty-seven patients had a positive CMV IgM result (5.9%) on the Architect system as part of the initial screening. Three patients were excluded as they were not obstetric patients. Of the 34 pregnant women with CMV IgM positive results on initial screening, 16 (47%) had CMV IgM positivity confirmed on the second platform (VIDAS) and 18 (53%) did not. In the 16 patients with confirmed positive CMV IgM results, four (25%) had acute infection, two (12.5%) had infection of uncertain timing, and ten (62.5%) had infection more than three months prior to sampling as determined by the CMV IgG avidity index. Two of the four neonates of women with low avidity IgG had CMV DNA detected in urine. Both these cases had severe neurological damage and the indication for testing their mothers was because the biparietal diameter (BPD) was less than the 5th centile at the routine 20-week gestation anomaly scan.

How to use... eye swabs.

Conjunctivitis is a very common presentation to general practitioners and general paediatricians. The investigation of conjunctivitis can be a significant cost to microbiology laboratories due to the high volume of samples that can be submitted, particularly from patients in the community. The key issue is to send eye swabs in clinical situations where it can make a difference to management, and limiting the use of eye swabs in routine cases of conjunctivitis which are likely to be due to viruses. For investigation of neonatal conjunctivitis we recommend sending a bacterial swab for routine culture, and also a swab for molecular detection of Chlamydia trachomatis and Neisseria gonorrhoeae. In older children with mild conjunctivitis no swab is necessary unless there is marked conjunctival injection. In this article we also highlight patient populations that require specialist tests to be sent as part of their assessment such as contact lens wearers and sexually active teenagers.

Antimicrobial treatment options for neurosurgical ventricular shunt infections in children from 1993 to 2012: a systematic review.

PURPOSE: The aim of this systematic review was to review studies that existed from 1993 to 2012 regarding antimicrobial treatment options of paediatric neurosurgical shunt. METHODS: Studies were identified from MEDLINE, Scopus and Cochrane databases using a search strategy that was registered on the PROSPERO database. Studies were included if they had two or more patients, aged less than 18 years, and also specified the organism and antimicrobial treatment that was used. RESULTS: The search yielded 2,985 articles, and 76 articles were suitable for full review. In the final qualitative analysis, only eight studies were included, involving 86 participants. The most common antimicrobial regimens for Gram-positive infections was intravenous and intrathecal vancomycin (n = 7), followed by intravenous vancomycin monotherapy. CONCLUSION: This systematic review has shown that there are no prospective randomised studies of antimicrobial treatment options for paediatric neurosurgical patients in the last 20 years, and larger prospective studies are urgently required for this serious infection. There is some limited case series showing the benefits of certain antimicrobials such as vancomycin and ceftriaxone, but a larger case series or randomised controlled trial is required, particularly to establish the benefit, if any, of additional intraventricular antimicrobials.

Treatment of Mycoplasma genitalium infection in pregnancy: A systematic review of international guidelines.

BACKGROUND: Mycoplasma genitalium is an emerging pathogen, which has been linked to cervicitis, urethritis and pelvic inflammatory disease (PID). With the advent of multiplex polymerase chain reaction (PCR) panels for sexually transmitted infections, it is increasingly being identified in pregnant women. OBJECTIVES: The aim was to review international guidelines, which had explicit recommendations for treatment of M. genitalium infection in pregnancy and breastfeeding. SEARCH STRATEGY: PubMed, EMBASE and Cochrane databases were reviewed with no age, species, language or date restrictions. SELECTION CRITERIA: Studies were included if they had an explicit recommendation for treatment of M. genitalium in pregnancy. Studies were excluded if there was no recommendation in pregnancy, if they referred to other international guideline recommendations or were historical versions of guidelines. DATA COLLECTION AND ANALYSIS: References were manually reviewed and 50 papers were selected for review. Only four guidelines were included in the final analysis and they were from Europe, UK, Australia and Aotearoa New Zealand. MAIN RESULTS: All studies recommended azithromycin as first-line treatment, and advised against moxifloxacin use. The dosing schedule of azithromycin, varied between guidelines, as did the utility/safety of pristinamycin for macrolide resistant infections. Safety data was generally reassuring for azithromycin but inconsistent for pristinamycin. CONCLUSIONS: Azithromycin is the first-line treatment for macrolide susceptible or unknown resistance infections, but there is a lack of consistency regarding dosing of azithromycin or the utility/safety of pristinamycin for macrolide resistant infections in pregnancy/lactation.

Evaluating the Impact of the BioFire FilmArray in Childhood Meningitis: An Observational Cohort Study.

BACKGROUND: Multiplex polymerase chain reaction assays have the potential to reduce antibiotic use and shorten length of inpatient stay in children with suspected central nervous system infection by obtaining an early microbiological diagnosis. The clinical impact of the implementation of the BioFire FilmArray Meningitis/Encephalitis Panel on the management of childhood meningitis was evaluated at the John Radcliffe Hospital in Oxford and Children's Health Ireland at Temple Street in Dublin. METHODS: Children who had lumbar punctures performed as part of a septic screen were identified retrospectively through clinical discharge coding and microbiology databases from April 2017 to December 2018. Anonymized clinical and laboratory data were collected. Comparison of antibiotic use, length of stay and outcome at discharge was made with a historical cohort in Oxford (2012-2016), presenting before implementation of the FilmArray. RESULTS: The study included 460 children who had a lumbar puncture as part of an evaluation for suspected central nervous system infection. Twelve bacterial cases were identified on the FilmArray that were not detected by conventional bacterial culture. Bacterial culture identified one additional case of bacterial meningitis, caused by Escherichia coli , which had not been identified on the FilmArray. Duration of antibiotics was shorter in children when FilmArray was used than before its implementation; enterovirus meningitis (median: 4 vs. 5 days), human parechovirus meningitis (median: 4 vs. 4.5 days) and culture/FilmArray-negative cerebrospinal fluid (median: 4 vs. 6 days). CONCLUSIONS: The use of a FilmArray can identify additional bacterial cases of meningitis in children that had been negative by traditional culture methods. Children with viral meningitis and culture-negative meningitis received shorter courses of antibiotics and had shorter hospital stays when FilmArray was used. Large studies to evaluate the clinical impact and cost effectiveness of incorporating the FilmArray into routine testing are warranted.

Where to start? The Irish Emergency Department Antimicrobial Discharge (EDAD) study: a multicentre, prospective cohort analysis.

Objectives: To determine the percentage of patients across Ireland who are discharged from the Emergency Department (ED) with an antimicrobial prescription, the indication, classification of infections, and guideline compliance. To identify potential areas for antimicrobial stewardship (AMS) interventions in the ED. Patients and methods: A multicentre, prospective cohort analysis study in EDs across eight hospitals in Ireland. At each site, patients aged 1 month and older who presented to the ED and were discharged directly from the ED were included. A random selection of records of patients discharged from the ED were reviewed until a minimum of 30 records with an infection diagnosis resulting in an antibiotic prescription were obtained per hospital. The number of patient discharges with no antibiotic prescriptions were included to calculate the denominator. The indication, infection classification and guideline compliance data were collected on the 30 prescriptions in the participating hospitals. Results: A total of 2619 patient records were reviewed. Of these, 249 (9.5%) patients were discharged with antimicrobial prescriptions from the ED. Most (158; 63%) were classified as probable bacterial infection, 21 (8%) as probable viral, and 18 (7%) had no documented evidence of infection. Three indications accounted for 73% of antimicrobial prescriptions: skin/soft tissue infection; ear, nose and throat infection; and urinary tract infection. Overall guideline compliance was 64%. Conclusions: Several areas for AMS interventions to optimize antimicrobial prescribing in the ED were identified, including targeted local and national guideline reviews, delayed prescribing, improved point-of-care testing and prescriber and patient education.

Low beta diversity of herbivorous insects in tropical forests.

Recent advances in understanding insect communities in tropical forests have contributed little to our knowledge of large-scale patterns of insect diversity, because incomplete taxonomic knowledge of many tropical species hinders the mapping of their distribution records. This impedes an understanding of global biodiversity patterns and explains why tropical insects are under-represented in conservation biology. Our study of approximately 500 species from three herbivorous guilds feeding on foliage (caterpillars, Lepidoptera), wood (ambrosia beetles, Coleoptera) and fruit (fruitflies, Diptera) found a low rate of change in species composition (beta diversity) across 75,000 square kilometres of contiguous lowland rainforest in Papua New Guinea, as most species were widely distributed. For caterpillars feeding on large plant genera, most species fed on multiple host species, so that even locally restricted plant species did not support endemic herbivores. Large plant genera represented a continuously distributed resource easily colonized by moths and butterflies over hundreds of kilometres. Low beta diversity was also documented in groups with differing host specificity (fruitflies and ambrosia beetles), suggesting that dispersal limitation does not have a substantial role in shaping the distribution of insect species in New Guinea lowland rainforests. Similar patterns of low beta diversity can be expected in other tropical lowland rainforests, as they are typically situated in the extensive low basins of major tropical rivers similar to the Sepik-Ramu region of New Guinea studied here.

Enterovirus Central Nervous System Infection in Infancy, the Value of Routine Testing.

BACKGROUND: Human nonpolio enterovirus (EV) is a major cause of infection in neonates and infants; however, the clinical presentation and cerebrospinal fluid findings vary significantly. Infection caused by EV in patients under 1 year of age can present with a broad clinical spectrum, from fever to severe systemic and/or neurological disease. METHODS: Retrospective cohort analysis of infants with EV central nervous system (CNS) infection presenting to a tertiary center between January 2017 and December 2022. We recorded patient demographics, parent-reported symptoms at presentation, and blood and cerebrospinal fluid (CSF) testing at presentation. RESULTS: Seventy-eight patients were included in the final study. Forty-one percent of infants with an EV CNS infection had a normal CSF white blood cell count. Clinical presentation was similar in infants with and without CSF pleocytosis. Median C-reactive protein was higher in cases of EV CNS infection without pleocytosis. CONCLUSION: EV CNS infection commonly presents without CSF pleocytosis. Testing for EV should be considered in febrile infants with no source regardless of CSF parameters.