Management of Multidrug-Resistant Infections in Cirrhosis.

The World Health Organization describes antimicrobial resistance as one of the biggest threats to global health, food security, and development with indiscriminate use of antimicrobials globally driving the emergence of multidrug-resistant bacteria, resistant to 60% of antimicrobials in some countries. Infections with multidrug-resistant organisms (MDROs) have increased in recent decades in patients with cirrhosis, who are frequently prescribed antibiotics, regularly undergo invasive procedures such as large volume paracentesis, and have recurrent hospitalizations, posing a particular risk in this already immunocompromised cohort of patients. In this review, we explore mechanisms underlying this vulnerability to MDRO infection; the effect of bacterial infections on disease course in cirrhosis; prevalence of MDROs in patients with cirrhosis; outcomes following MDRO infection; fungal infections; antibiotics and their efficacy; and management of MDRO infections in terms of detection, antimicrobial and nonantimicrobial treatments, prophylaxis, antibiotic stewardship, the gut microbiome, and technological interventions.

The St Thomas' Hospital Emergency Department Homeless Health Initiative: improving the quality, safety and equity of healthcare provided for homeless patients attending the ED.

We carried out a quality improvement (QI) project (QIP), aiming to improve the quality, safety and equity of healthcare provided for homeless patients attending the emergency department (ED). We used QI methodology to identify areas for improvement, and introduced and modified interventions over four Plan, Do, Study, Act cycles. We launched a departmental 'Homeless Health Initiative' (HHI), the chief intervention being the provision of 'Homeless Health Boxes' in the ED, which contained a 'Safe Discharge Checklist for Homeless Patients', maps to specialist homeless general practitioner surgeries and homeless day centres, information on other inclusion health services, copies of a local rough sleepers' magazine and oral hygiene supplies. Voluntary Homeless Link Nurses and a number of informal 'Homeless Health Champions' were appointed. The HHI was embedded in departmental awareness through regular presentations to staff and incorporation into the induction programme for new doctors. Staff satisfaction, in terms of how satisfied staff members were with the care they were able to provide for homeless patients in the ED on a 0-10 scale, improved modestly over the course of the QIP from median 6/10 to median 7/10. The number of staff who were severely dissatisfied with the care they were able to provide for homeless patients improved more markedly: first quartile staff satisfaction improved from 3.875/10 to 6.125/10. Staff compliance with the checklist was poor, with full compliance observed in only 15% of cases by the end of the QIP. An HHI is a cheap and worthwhile QI project, with the potential to significantly improve the quality, safety and equity of healthcare provided for homeless patients, while improving staff satisfaction concurrently. Similar initiatives should be considered in any ED which sees a significant number of homeless patients.

Spontaneous Heterotopic Pregnancy Associated with Massive Intraperitoneal Haemorrhage and a Normal Heart Rate, Illustrating the Concept of Relative Bradycardia.

A 28-year-old, 9 and a half weeks pregnant (spontaneous conception) multigravida presented with abdominal pain and vaginal bleeding. On examination, her abdomen was diffusely tender, particularly in the right iliac fossa, though guarding was absent. Transabdominal and transvaginal ultrasonography demonstrated a viable intrauterine pregnancy and large-volume intraperitoneal haemoperitoneum; the right ovary could not be identified. The patient became hypotensive with decreased responsiveness, yet her heart rate remained normal. She proceeded to surgery where a ruptured right tubal ectopic pregnancy was identified and right salpingectomy was performed. Estimated blood loss was 3900ml. Postoperative recovery was uneventful. Ultrasound 3 days after surgery demonstrated a viable intrauterine pregnancy of gestational age 9 weeks + 1 day. The patient remains well. Her anomaly scan at 20 weeks and 6 days showed normal growth, amniotic fluid, and Dopplers with no obvious structural defects. She is currently 27 weeks pregnant and will be rescanned at 36 weeks.

Community-acquired Pseudomonas aeruginosa meningitis.

Gram-negative bacilli such as Pseudomonas aeruginosa are a rare cause of meningitis. Patients developing P. aeruginosa meningitis most commonly have a history of neurosurgical procedures. We report a patient who presented with community-acquired chronic meningitis secondary to P. aeruginosa, related to surgery for otosclerosis 5 years previously.