Treatment 'cultures', sexually transmitted infections and the rise of antimicrobial resistance.

In this article, we examine the current management of sexually transmitted infections (STIs), in the context of rising antimicrobial resistance (AMR), through the lens of 'treatment cultures'. Prevailing treatment cultures-including the prominence of syndromic care for STIs-foster certain possibilities and foreclose others, with important consequences for countering AMR. Drawing on qualitative interviews with STI professionals, experts and industry representatives, we unpack these stakeholders' accounts of STI treatment cultures, drawing out the importance of socio-historical (i.e. taboo and stigma), political-economic (i.e. perceptions of significance, profit-making and prioritisation) and subjective (i.e. patient contexts and reflexivity) dimensions therein. In developing this critical account of how treatment cultures are formed, reproduced and indeed resisted, we reveal how such discourses and practices render the reining in of AMR and shifting antibiotic use difficult, and yet, how productive engagement remains key to any proposed solutions. As such, the article contributes to our understanding of AMR as a highly diversified field, through our exploration of the bio-social dimensions of resistance as they relate to the case of STIs.

Regulating antimicrobial use within hospitals: A qualitative study.

OBJECTIVES: To examine how regulatory structures and processes focused on antimicrobial stewardship and antimicrobial resistance are experienced by hospital managers and clinicians. METHODS: Forty-two hospital managers and clinicians working within accreditation and antimicrobial stewardship teams in three Australian hospitals participated in individual in-depth interviews. Thematic analysis was performed. RESULTS: Thematic analysis revealed participants' experiences of hospital antimicrobial regulation and their perceptions of what would be required for meaningful antimicrobial optimisation. Theme 1: Experience of regulation of antimicrobials within hospitals: Participants described an increased profile of antimicrobial resistance with inclusion in regulatory requirements, but also the risks of bureaucratic manoeuvring to meet standards rather than governance-inducing systemic changes. Theme 2: Growth of accreditation processes and hospitals over time: Both regulatory requirements and hospitals were described as evolving over time, each manoeuvring in response to each other (e.g. development of short notice accreditation). Theme 3: Perceived requirements for change: Participants perceived a need for top-down buy-in, resource prioritisation, complex understanding of power and influence on clinician behaviour, and a critical need for medical engagement. CONCLUSIONS: This study around antimicrobials shows the tension and dynamic relationship between regulatory processes and hospital responses, bringing to light the enduring balance of a system that positions itself to meet regulatory requirements and emerging "demands", without necessarily addressing the key underlying concerns. Antimicrobial resistance-related solutions are perceived as likely to require further resourcing and buy-in across multiple levels, engagement across professional streams and require strategies that consider complex systems change in order for regulatory structures to have potency.

To swab or not to swab? A qualitative study of pathology testing, interpretation, and value in diabetes-related foot ulceration.

BACKGROUND: Diagnostic testing has been proposed as a key strategy to tackle escalating antimicrobial resistance (AMR). However, effectiveness of testing is limited by the complexities of the hospital environment, including human factors. OBJECTIVES: To examine swab-testing in diabetes-related foot infections as a case study of the factors impacting microbiology testing use, efficacy, and antimicrobial resistance. METHODS: Seventeen clinicians involved in the management of diabetes-related foot infections, including podiatrists, nurses, and doctors, participated in in-depth individual interviews conducted by a qualitative researcher on the investigation and management of diabetes-related foot infections. Thematic analysis was performed. RESULTS: The multilayered and evolving features of the human-diagnostic interface were described by participants as potential barriers to effective swab-testing in clinical care, including diagnostic training and interpretation deficits; communication difficulties; interpretation deficits and diagnostic assumptions; the influence of inter-professional dynamics; and flow-on consequences for patient decisions and care. CONCLUSIONS: Swab-testing has been used for over 100 years, and yet there remain substantial factors that limit their effective use in clinical practice as demonstrated by this study. A focus on upscaling diagnostic testing, particularly with escalating AMR, without considering complex implementation and human factors is likely to have limited impact on practice improvement. This study identified vulnerability points in the human-diagnostic interaction which should be considered in the implementation of other microbiological tests. This study on the simple wound swab has implications for future diagnostic upscaling and investment, including its role in address antimicrobial resistance.

Investigating rates and predictors of viral blips, low-level viraemia and virological failure in the Australian HIV observational database.

OBJECTIVES: Australia has made significant progress towards achieving the UNAIDS's 95-95-95 cascade targets including HIV viral suppression. To investigate the burden of HIV viraemia, we assessed viral blips, low-level viraemia (LLV) and virologic failure (VF) in an Australian cohort. METHODS: We studied the proportion of people with viral suppression, viral blips, LLV and VF in the Australian HIV observational database (AHOD) between 2010 and 2021. The association between blips or LLV, and VF was investigated using Cox regression, and predictors of viral blips and LLV were assessed using repeated-measured logistic regression. RESULTS: Among 2544 AHOD participants who were in follow-up and on antiretroviral therapy (ART) from 1 January 2010 (88.7% male), 444 had experienced VF (incidence rate: 2.45 [95% CI: 2.23-2.69] per 100 person-years [PY]) during 18,125 PY of follow-up (a median of 7.6 years). The proportion of people with VF decreased over time, whereas rates of blips and LLV remained stable. Participants with blips (hazard ratio, 2.89; 95% CI: 2.31-3.61) and LLV (4.46; 95% CI: 3.38-5.89) were at increased risk of VF. Hepatitis B co-infection, longer documented treatment interruption duration, younger age and lower CD4 at ART initiation, and protease inhibitors-based initial regimen were associated with an increased risk of VF. Common predictors of blips and LLV such as higher HIV-1 RNA and lower CD4 at ART initiation, longer treatment interruption, more VL testing and types of care settings (hospitals vs. sexual health services) were identified. CONCLUSIONS: Blips and LLV predict subsequent VF development. We identified important predictors of HIV viraemia including VF among individuals on INSTI-based regimens to help direct HIV management plans.

Multidisciplinary team meetings in prosthetic joint infection management: A qualitative study.

BACKGROUND: Prosthetic joint infections (PJIs) cause substantial morbidity to patients and are extremely challenging for clinicians. Their management can include multiple operations, antibiotics, and prolonged hospital admissions. Multidisciplinary team meetings (MDTM) are increasingly used for collaborative decision-making around the management of PJIs, but thus far there has been no examination of the role of MDTM in decisions and management. This study aimed to examine interactions in a PJI MDTM to identify the dynamics in decision-making, and inter-specialty relationships more broadly. METHODS: Twelve MDTMs over 7 months at an Australian tertiary referral hospital were video recorded, transcribed, and thematic analysis was performed. RESULTS: Thematic analysis revealed four key areas of collaborative discussion 1. Achieving Inter-specialty Balance: The role of the multidisciplinary team discussion in providing balance between specialty views, and traversing the barriers between specialty interactions. 2. Negotiating Grey zones: there was frequent discussion of the limits of tests, interpretation of symptoms, and the limits of proposed operative strategies, and the resultant tensions of balancing ideal care vs pragmatic decision-making, and divergent goals of care. 3. Tailoring Treatment: identification of individual patient factors (both physiological and behavioural) and risks into collaborative decision-making. 4. Affording Failure: creating affordances in communication to openly discuss 'failure' to eliminate infection and likely negative outcomes. CONCLUSIONS: MDTM in the management of prosthetic joint infections serve multiple functions including: achieving interdisciplinary balance; effective grey zone management, tailoring reconfigured care; and most critically, recognition of 'failure' to eliminate infection, a communicative affordance most likely leading to better care.

Nursing experiences in antimicrobial optimisation in the intensive care unit: A convergent analysis of a national survey.

BACKGROUND: Recent evidence highlights the need for an interdisciplinary approach to antimicrobial stewardship (AMS). Nursing involvement in optimising antimicrobials in the intensive care unit (ICU) remains understudied. OBJECTIVE: The objective of this study was to explore nurses' perceptions and experiences of antimicrobial optimisation or stewardship in ICUs in Australia. METHODS: An anonymous web-based survey was deployed nationally in early 2021 through two ICU nursing networks. Associations between survey responses were analysed descriptively and by using nonparametric tests (with statistical significance established at p ≤ 0.05). Free-text survey responses underwent qualitative thematic analysis. Interpretation and reporting of quantitative and qualitative data were integrated. RESULTS: A total of 226 ICU nurses completed the survey. The majority (197/226; 87%) responded that lack of education limits engagement in AMS. Only 13% (30/226) reported the presence of AMS education and training for nurses in their ICUs. Only about half (108/226; 48%) of the nurses were confident to question prescribers when they considered that the antimicrobial prescribed was unnecessary, with nurses in senior roles more likely to do so than nurses providing bedside care (p < 0.05). Gaps in education (including unfamiliarity with AMS roles), noninclusive antimicrobial discussions, moral distress, and potential workload burden were seen as potential barriers/challenges to engagement. CONCLUSION: The multifactorial barriers identified that inhibit nurses from performing AMS tasks could be addressed by strengthening interprofessional education at all levels and by applying practical AMS interventions that are inclusive for nursing participation. A purposeful culture change that fosters psychological safety and collaborative practice is paramount to supporting nurses in these roles.

Paradoxes of pandemic infection control: Proximity, pace and care within and beyond SARS-CoV-2.

From the adoption of mask-wearing in public settings to the omnipresence of hand-sanitising, the SARS-CoV-2 pandemic has brought unprecedented cultural attention to infection prevention and control (IPC) in everyday life. At the same time, the pandemic threat has enlivened and unsettled hospital IPC processes, fracturing confidence, demanding new forms of evidence, and ultimately involving a rapid reassembling of what constitutes safe care. Here, drawing on semi-structured interviews with 63 frontline healthcare workers from two states in Australia, interviewed between September 2020 and March 2021, we illuminate some of the affective dimensions of IPC at a time of rapid change and evolving uncertainty. We track how a collective sense of risk and safety is relationally produced, redefining attitudes and practices around infective risk, and transforming accepted paradigms of care and self-protection. Drawing on Puig de la Bellacasa's formulation, we propose the notion of IPC as a multidimensional matter of care. Highlighting the complex negotiation of space and time in relation to infection control and care illustrates a series of paradoxes, the understanding of which helps illuminate not only how IPC works, in practice, but also what it means to those working on the frontline of the pandemic.

The lived experience of haemodialysis patients managed with transmission-based precautions for MDRO colonisation: A qualitative study.

BACKGROUND: Patients undergoing haemodialysis colonised with multi-drug resistant organisms (MDROs) are commonly managed with transmission-based precautions (TBP) to prevent nosocomial transmission. TBP have been linked to mixed effects on patient psychological well-being and clinical care. This study was designed to report the lived experience of dialysis patients managed with TBP. METHODS: A qualitative study of 15 patients undergoing haemodialysis managed with TBP was performed. Participants took part in individual semi-structured interviews. Data was analysed utilising an interpretive phenomenological approach. RESULTS: Four themes were identified. 1. Communication of what MDRO screening meant, the results, and implications of MDRO positivity was perceived by many patients as insufficient and inconsistent. 2. Experiences of care in isolation were described, with both positive (privacy) and negative (reduced interaction) experiences identified. 3. Psychosocial and emotional responses including concern about health implications and stigma were reported, but also screening was described by some as increasing their perception of being cared for by health care workers, as they felt all health risks were being managed. 4. Confusion around perceived inconsistencies of management, particularly across different environments (eg hospital vs home) and staff. CONCLUSION: TBP have complex positive and negative impacts on patients which should be considered when developing MDRO management policy and communication around such policy. Strategies to improve communication, patient and staff education, and remove (or explain) perceived inconsistencies of practice may reduce the negative consequences of TBP leading to improved delivery of quality, person-centred care.

Myocarditis and Cardiac Complications Associated With COVID-19 and mRNA Vaccination: A Pragmatic Narrative Review to Guide Clinical Practice.

Coronavirus disease 2019 (COVID-19) caused by the SARS-CoV-2 virus is likely to remain endemic globally despite widespread vaccination. There is increasing concern for myocardial involvement and ensuing cardiac complications due to COVID-19, however, the available evidence suggests these risks are low. Pandemic publishing has resulted in rapid manuscript availability though pre-print servers. Subsequent article retractions, a lack of standardised definitions, over-reliance on isolated troponin elevation and the heterogeneity of studied patient groups (i.e. severe vs. symptomatic vs all infections) resulted in early concern for high rates of myocarditis in patients with and recovering from COVID-19. The estimated incidence of myocarditis in COVID-19 infection is 11 cases per 100,000 infections compared with an estimated 2.7 cases per 100,000 persons following mRNA vaccination. For substantiated cases, the clinical course of myocarditis related to COVID-19 or mRNA vaccination appears mild and self-limiting, with reports of severe/fulminant myocarditis being rare. There is limited data available on the management of myocarditis in these settings. Clinical guidance for appropriate use of cardiac investigations and monitoring in COVID-19 is needed for effective risk stratification and efficient use of cardiac resources in Australia. An amalgamation of national and international position statements and guidelines is helpful for guiding clinical practice. This paper reviews the current available evidence and guidelines and provides a summary of the risks and potential use of cardiac investigations and monitoring for patients with COVID-19.

"One minute it's an airborne virus, then it's a droplet virus, and then it's like nobody really knows ": Experiences of pandemic PPE amongst Australian healthcare workers.

BACKGROUND: The SARS-CoV-2 pandemic has challenged health systems globally. A key controversy has been how to protect healthcare workers (HCWs) using personal protective equipment (PPE). METHODS: Interviews were performed with 63 HCWs across two states in Australia to explore their experiences of PPE during the SARS-CoV-2 pandemic. Thematic analysis was performed. RESULTS: Four themes were identified with respect to HCWs' experience of pandemic PPE: 1. Risk, fear and uncertainty: HCWs experienced considerable fear and heightened personal and professional risk, reporting anxiety about the adequacy of PPE and the resultant risk to themselves and their families. 2. Evidence and the ambiguities of evolving guidelines: forms of evidence, its interpretation, and the perception of rapidly changing guidelines heightened distress amongst HCWs. 3. Trust and care: Access to PPE signified organisational support and care, and restrictions on PPE use were considered a breach of trust. 4. Non-compliant practice in the context of social upheaval: despite communication of evidence-based guidelines, an environment of mistrust, personal risk, and organisational uncertainty resulted in variable compliance. CONCLUSION: PPE preferences and usage offer a material signifier of the broader, evolving pandemic context, reflecting HCWs' fear, mistrust, sense of inequity and social solidarity (or breakdown). PPE therefore represents the affective (emotional) demands of professional care, as well as a technical challenge of infection prevention and control. If rationing of PPE is necessary, policymakers need to take account of how HCWs will perceive restrictions or conflicting recommendations and build trust through effective communication (including of uncertainty).

Institutional governance and responsiveness to antimicrobial resistance: a qualitative study of Australian hospital executives.

OBJECTIVES: Despite escalating antimicrobial resistance (AMR), implementing effective antimicrobial optimisation within healthcare settings has been hampered by institutional impediments. This study sought to examine, from a hospital management and governance perspective, why healthcare providers may find it challenging to enact changes needed to address rising AMR. DESIGN: Semistructured qualitative interviews around their experiences of antimicrobial stewardship (AMS) and responsiveness to the requirement for optimisation. Data were analysed using the framework approach. SETTING: Two metropolitan tertiary-referral hospitals in Australia. PARTICIPANTS: Twenty hospital managers and executives from the organisational level of department head and above, spanning a range of professional backgrounds and in both clinical and non-clinical roles, and different professional streams were represented. RESULTS: Thematic analysis demonstrated three key domains which managers and executives describe, and which might function to delimit institutional responsiveness to present and future AMR solutions. First, the primacy of 'political' priorities. AMR was perceived as a secondary priority, overshadowed by political priorities determined beyond the hospital by state health departments/ministries and election cycles. Second, the limits of accreditation as a mechanism for change. Hospital accreditation processes and regulatory structures were not sufficient to induce efficacious AMS. Third, a culture of acute problem 'solving' rather than future proofing. A culture of reactivity was described across government and healthcare institutions, precluding longer term objectives, like addressing the AMR crisis. CONCLUSION: There are dynamics between political and health service institutions, as well as enduring governance norms, that may significantly shape capacity to enact AMS and respond to AMR. Until these issues are addressed, and the field moves beyond individual behaviour modification models, antimicrobial misuse will likely continue, and stewardship is likely to have a limited impact.

Entanglements of affect, space, and evidence in pandemic healthcare: An analysis of Australian healthcare workers' experiences of COVID-19.

The COVID-19 pandemic continues to highlight both global interconnectedness and schisms across place, context and peoples. While countries such as Australia have securitised their borders in response to the global spread of disease, flows of information and collective affect continue to permeate these boundaries. Drawing on interviews with Australian healthcare workers, we examine how their experiences of the pandemic are shaped by affect and evidence 'traveling' across time and space. Our analysis points to the limitations of global health crisis responses that focus solely on material risk and spatial separation. Institutional responses must, we suggest, also consider the affective and discursive dimensions of health-related risk environments.

The modern hospital executive, micro improvements, and the rise of antimicrobial resistance.

Antimicrobial resistance (AMR) is now recognised as a social, cultural, economic and political phenomenon, positioning the social sciences as central in responding to this global health threat. Yet efforts to address AMR within hospital settings, for example through antimicrobial stewardship (AMS) programs, continue to focus primarily on the prescribing practices of individual clinicians, often with little effect. There has been less attention to the role of healthcare administration, and managerialism therein, in explaining the limited progress to date in reining in antimicrobial misuse. To explore this, drawing on interviews with senior executives and managers from two Australian hospitals, we examine how these stakeholders navigate between management practice and AMR solutions, revealing that antimicrobial optimisation is frequently obscured by accountability structures attuned to other agendas. This has led, we argue, to the institutionalisation of micro-improvements that frequently 'tick the box' of having an AMS program, yet do little to effectively counteract rising AMR. Our analysis illustrates how sociological attention to the structural and ideological settings within which prescribing behaviour is carried out will be crucial to any attempts to successfully rein in AMR.

Barriers-enablers-ownership approach: a mixed methods analysis of a social intervention to improve surgical antibiotic prescribing in hospitals.

OBJECTIVES: To assess an intervention for surgical antibiotic prophylaxis (SAP) improvement within surgical teams focused on addressing barriers and fostering enablers and ownership of guideline compliance. DESIGN: The Queensland Surgical Antibiotic Prophylaxis (QSAP) study was a multicentre, mixed methods study designed to address barriers and enablers to SAP compliance and facilitate engagement in self-directed audit/feedback and assess the efficacy of the intervention in improving compliance with SAP guidelines. The implementation was assessed using a 24-month interrupted time series design coupled with a qualitative evaluation. SETTING: The study was undertaken at three hospitals (one regional, two metropolitan) in Australia. PARTICIPANTS: SAP-prescribing decisions for 1757 patients undergoing general surgical procedures from three health services were included. Six bimonthly time points, pre-implementation and post implementation of the intervention, were measured. Qualitative interviews were performed with 29 clinical team members. SAP improvements varied across site and time periods. INTERVENTION: QSAP embedded ownership of quality improvement in SAP within surgical teams and used known social influences to address barriers to and enablers of optimal SAP prescribing. RESULTS: The site that reported senior surgeon engagement showed steady and consistent improvement in prescribing over 24 months (prestudy and poststudy). Multiple factors, including resource issues, influenced engagement and sites/time points where these were present had no improvement in guideline compliance. CONCLUSIONS: The barriers-enablers-ownership model shows promise in its ability to facilitate prescribing improvements and could be expanded into other areas of antimicrobial stewardship. Senior ownership was a predictor of success (or failure) of the intervention across sites and time periods. The key role of senior leaders in change leadership indicates the critical need to engage other specialties in the stewardship agenda. The influence of contextual factors in limiting engagement clearly identifies issues of resource distributions/inequalities within health systems as limiting antimicrobial optimisation potential.

Antimicrobial overuse in India: A symptom of broader societal issues including resource limitations and financial pressures.

India and the global community are facing a critical crisis of antimicrobial resistance (AMR), significantly contributed to by on-going and increasing antimicrobial misuse. Information as to what drives misuse of antimicrobials within India is essential to inform strategies to address the crisis. This papers aims to identify perceived influences on antimicrobial use in Hyderabad, India. We conducted semi-structured qualitative interviews conducted with thirty participants (15 doctors, 15 pharmacists) around their experiences of antimicrobials in Hyderabad, India. Thematic analysis was performed and four themes identified around (1) Perceptions of the problem of resistance and antimicrobial use; (2) Social pressures to prescribe/dispense; (3) Financial pressures driving antimicrobial over-use; and (4) Lack of regulation around training and qualifications. We conclude that antimicrobial use within India is embedded with, and occurs as a result of, complex social and economic factors including issues of resource limitation, structural/governance limitations and social relationships. Strategies to address misuse without acknowledging and addressing the critical driving forces of use will be unlikely to induce significant change.

Reconsidering the nursing role in antimicrobial stewardship: a multisite qualitative interview study.

OBJECTIVES: This study responds to calls for greater focus on nursing roles, and the need for nursing integration within the antimicrobial optimisation agenda. The objective of this study was to explore Australian hospital nurses' views on antimicrobial resistance and antimicrobial stewardship (AMS) in a hospital setting, in order to better understand the opportunities for and challenges to integration of nursing staff in antimicrobial optimisation within hospital settings. DESIGN: Qualitative one-on-one, semistructured interviews. Interview transcripts were digitally audio-recorded and transcribed verbatim. Data were subject to thematic analysis supported by the framework approach and informed by sociological methods and theory. SETTING: Four hospitals (three public and one private), across metropolitan, regional and remote areas, in two Australian states. PARTICIPANTS: 86 nurses (77 females, 9 males), from a range of hospital departments, at a range of career stages. RESULTS: Findings were organised into three thematic domains: (1) the current peripheral role of nurses in AMS; (2) the importance of AMS as a collaborative effort, and current tensions around interprofessional roles and (3) how nurses can bolster antimicrobial optimisation within AMS and beyond. CONCLUSION: Nursing staff are central to infection management within the hospital and are thus ideally located to enhance antibiotic optimisation and contribute to AMS governance. However, without increased interprofessional cooperation, education and integration in the AMS agenda, as well as addressing organisational/resource constraints in the hospital, the nursing role in stewardship will remain limited.

SARS-CoV-2: The viral shedding vs infectivity dilemma.

Since December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected over four million people worldwide. There are multiple reports of prolonged viral shedding in people infected with SARS-CoV-2 but the presence of viral RNA on a test does not necessarily correlate with infectivity. The duration of quarantine required after clinical recovery to definitively prevent transmission is therefore uncertain. In addition, asymptomatic and presymptomatic transmission may occur, and infectivity may be highest early after onset of symptoms, meaning that contact tracing, isolation of exposed individuals and social distancing are essential public health measures to prevent further spread. This review aimed to summarise the evidence around viral shedding vs infectivity of SARS-CoV-2.

Acute kidney injury in acute Q fever.

Coxiella burnetii infection is not known to involve directly the kidneys. Kidney injury associated with Q fever usually manifests in the setting of chronic infection or endocarditis with development of immune complex deposition. Acute kidney injury (AKI) in the context of acute Q fever infection may be more pathologically heterogeneous. We describe two cases of severe AKI secondary to acute Q fever infection, each with marked differences in pathological characteristics, and clinical course.

Facilitating treatment of HCV in primary care in regional Australia: closing the access gap.

BACKGROUND: Australia has unrestricted access to direct-acting antivirals (DAA) for hepatitis C virus (HCV) treatment. In order to increase access to treatment, primary care providers are able to prescribe DAA after fibrosis assessment and specialist consultation. Transient elastography (TE) is recommended prior to commencement of HCV treatment; however, TE is rarely available outside secondary care centres in Australia and therefore a requirement for TE could represent a barrier to access to HCV treatment in primary care. OBJECTIVES: In order to bridge this access gap, we developed a community-based TE service across the Sunshine Coast and Wide Bay areas of Queensland. DESIGN: Retrospective analysis of a prospectively recorded HCV treatment database. INTERVENTIONS: A nurse-led service equipped with two mobile Fibroscan units assesses patients in eight locations across regional Queensland. Patients are referred into the service via primary care and undergo nurse-led TE at a location convenient to the patient. Patients are discussed at a weekly multidisciplinary team meeting and a treatment recommendation made to the referring GP. Treatment is initiated and monitored in primary care. Patients with cirrhosis are offered follow-up in secondary care. RESULTS: 327 patients have undergone assessment and commenced treatment in primary care. Median age 48 years (IQR 38-56), 66% male. 57% genotype 1, 40% genotype 3; 82% treatment naïve; 10% had cirrhosis (liver stiffness >12.5 kPa). The majority were treated with sofosbuvir-based regimens. 26% treated with 8-week regimens. All patients had treatment prescribed and monitored in primary care. Telephone follow-up to confirm sustained virological response (SVR) was performed by clinic nurses. 147 patients remain on treatment. 180 patients have completed treatment. SVR data were not available for 19 patients (lost to follow-up). Intention-to-treat SVR rate was 85.5%. In patients with complete data SVR rate was 95.6%. CONCLUSION: Community-based TE assessment facilitates access to HCV treatment in primary care with excellent SVR rates.

Inflammatory bowel disease masquerading as traveller's diarrhoea.

Diarrhoea that occurs during or after recent travel is predominantly infectious in nature; however, in atypical or prolonged cases a broader range of aetiologies for diarrhoea must be considered, and a careful history and examination may reveal clues to more sinister causes of diarrhoea. We report two cases in which a recent travel history and a positive stool culture or polymerase chain reaction testing for bacterial pathogens delayed the diagnosis of ulcerative colitis. As a result of severe inflammatory bowel disease, colectomy was the final result in both cases. Early consideration of causes other than infection for traveller's diarrhoea may prevent unnecessary morbidity in young patients.