Paediatric focal intracranial suppurative infection: a UK single-centre retrospective cohort study.

BACKGROUND: Paediatric focal intracranial suppurative infections are uncommon but cause significant mortality and morbidity. There are no uniform guidelines regarding antibiotic treatment. This study reviewed management in a tertiary healthcare centre in the United Kingdom and considers suggestions for empirical treatment. METHODS: A retrospective, single-centre cohort review of 95 children (< 18 years of age) with focal intracranial suppurative infection admitted between January 2001 and June 2016 in Newcastle upon Tyne, United Kingdom. Microbiological profiles and empirical antibiotic regimens were analysed for coverage, administration and duration of use. Mortality and neurological morbidity were reviewed. Data was analysed using t-tests, Mann-Whitney U tests, independent-samples median tests, and χ2-tests where appropriate. P-values < 0.05 were considered statistically significant. RESULTS: Estimated annual incidence was 8.79 per million. Age was bimodally distributed. Predisposing factors were identified in 90.5%, most commonly sinusitis (42.1%) and meningitis (23.2%). Sinusitis was associated with older children (p < 0.001) and meningitis with younger children (p < 0.001). The classic triad was present in 14.0%. 43.8% of 114 isolates were Streptococcus spp., most commonly Streptococcus milleri group organisms. Twelve patients cultured anaerobes. Thirty one empirical antibiotic regimens were used, most often a third-generation cephalosporin plus metronidazole and amoxicillin (32.2%). 90.5% would have sufficient cover with a third generation cephalosporin plus metronidazole. 66.3% converted to oral antibiotics. Median total antibiotic treatment duration was 90 days (interquartile range, 60-115.50 days). Mortality was 3.2, 38.5% had short-term and 24.2% long-term neurological sequelae. CONCLUSIONS: Paediatric focal intracranial suppurative infection has a higher regional incidence than predicted from national estimates and still causes significant mortality and morbidity. We recommend a third-generation cephalosporin plus metronidazole as first-choice empirical treatment. In infants with negative anaerobic cultures metronidazole may be discontinued.

Spontaneous Clostridium perfringens Meningitis and Brain Abscess in a Neonate.

This case describes a neonate who presented with spontaneous Clostridium perfringens meningitis and brain abscess. The abscess was drained, and the infant completed a 6-week course of antibiotics. Throughout this time the infant remained well with no need for intensive care. C. perfringens central nervous system infections are associated with trauma and poor outcomes. This case highlights that the spectrum of disease can include spontaneous infection with a relatively mildly clinical course demonstrating the importance of 16s polymerase chain reaction in culture-negative cases and its role in detecting rare causes of central nervous system infections such as C. perfringens .

Oral step-down for Staphylococcus aureus bacteraemia: an opportunity for antimicrobial stewardship?

Objectives: Long courses of intravenous antimicrobial therapy are traditionally recommended for the treatment of methicillin sensitive Staphylococcus aureus bacteraemia (MS-SAB), but are not always completed in clinical practice. Early intravenous to oral antibiotic switch is a key component of antimicrobial stewardship. This study aimed to identify whether intravenous antibiotic duration may be safely reduced in MS-SAB. Methods: We performed a single-centre retrospective study of MS-SAB management. Successful outcome was defined as 90-day recurrence-free survival. Effect of intravenous antibiotic duration on 90-day recurrence risk was examined. Results: 281 adult cases of MS-SAB were evaluated, of which 208 (74%) had a successful outcome. 176 cases (63%) received less than 14 days of intravenous antimicrobial therapy. Very short durations of intravenous therapy were associated with increased risk of recurrence (<7 days iv, 9.8% recurrence; 7-13 days, 1.4%; ≥14 days, 2.9%; p 0.005). This effect was robust to sensitivity analysis for total antimicrobial therapy duration of 14 days. CRP reduction of at least 37% from peak value at intravenous to oral antibiotic switch was associated with decreased risk of recurrence (<37% CRP reduction, 12% recurrence; >37%, 2.0%; p 0.001). Conclusions: Oral antimicrobial switch may allow safe reductions in duration of intravenous therapy in MS-SAB.

Neonatal Thoracic Infection with Mixta.

The Erwiniaceae are a family of gram-negative, aerobic coliforms which are pathogenic to a number of plants. Recently described within this family are the Pantoea, strains of which have been associated with infection in immunocompromised children and post-surgical meningitis but also colonisation of a healthy human subject's gastrointestinal tract, as well as a variety of agricultural diseases. In 2015, a further clade of this family was established as the genus Mixta. In this case report, we describe infection of the pleural space and lung parenchyma with members of Mixta in a term neonate following an anastomic leak post-primary repair of congenital trache-oesophageal fistula, causing a respiratory and cardiovascular deterioration. Mixta were identified by MALDI-TOF. The child made a full recovery with use of intravenous piperacillin-tazobactam. The Mixta genus must be added to a list of opportunistic pathogens responsible for infection following perforation of the gastrointestinal tract.

SARS-CoV-2 Testing of 11,884 Healthcare Workers at an Acute NHS Hospital Trust in England: A Retrospective Analysis.

Healthcare workers (HCWs) are known to be at increased risk of infection with SARS-CoV-2, although whether these risks are equal across all roles is uncertain. Here we report a retrospective analysis of a large real-world dataset obtained from 10 March to 6 July 2020 in an NHS Foundation Trust in England with 17,126 employees. 3,338 HCWs underwent symptomatic PCR testing (14.4% positive, 2.8% of all staff) and 11,103 HCWs underwent serological testing for SARS-CoV-2 IgG (8.4% positive, 5.5% of all staff). Seropositivity was lower than other hospital settings in England but higher than community estimates. Increased test positivity rates were observed in HCWs from BAME backgrounds and residents in areas of higher social deprivation. A multiple logistic regression model adjusting for ethnicity and social deprivation confirmed statistically significant increases in the odds of testing positive in certain occupational groups, most notably domestic services staff, nurses, and health-care assistants. PCR testing of symptomatic HCWs appeared to underestimate overall infection levels, probably due to asymptomatic seroconversion. Clinical outcomes were reassuring, with only a small minority of HCWs with COVID-19 requiring hospitalization (2.3%) or ICU management (0.7%) and with no deaths. Despite a relatively low level of HCW infection compared to other UK cohorts, there were nevertheless important differences in test positivity rates between occupational groups, robust to adjustment for demographic factors such as ethnic background and social deprivation. Quantitative and qualitative studies are needed to better understand the factors contributing to this risk. Robust informatics solutions for HCW exposure data are essential to inform occupational monitoring.

COVID-19 Management in a UK NHS Foundation Trust with a High Consequence Infectious Diseases Centre: A Retrospective Analysis.

Recent large national and international cohorts describe the baseline characteristics and outcome of hospitalised patients with COVID-19, however there is limited granularity to these reports. We aimed to provide a detailed description of a UK COVID-19 cohort, focusing on management and outcome. We performed a retrospective single-centre analysis of clinical management and 28-day outcomes of consecutive adult inpatients with SARS-CoV-2 PCR-confirmed COVID-19 from 31 January to 16 April 2020 inclusive. In total, 316 cases were identified. Most patients were elderly (median age 75) with multiple comorbidities. One quarter were admitted from residential or nursing care. Mortality was 84 out of 316 (26.6%). Most deaths occurred in patients in whom a ceiling of inpatient treatment had been determined and for whom end of life care and specialist palliative care input was provided where appropriate. No deaths occurred in patients aged under 56 years. Decisions to initiate respiratory support were individualised after consideration of patient wishes, premorbid frailty and comorbidities. In total, 59 (18%) patients were admitted to intensive care, of which 31 (10% overall cohort) required intubation. Multiple logistic regression identified associations between death and age, frailty, and disease severity, with age as the most significant factor (odds ratio 1.07 [95% CI 1.03-1.10] per year increase, p < 0.001). These findings provide important clinical context to outcome data. Mortality was associated with increasing age. Most deaths were anticipated and occurred in patients with advance decisions on ceilings of treatment.

The incidence and importance of bacterial contaminants of cadaveric renal perfusion fluid.

Infections represent a significant risk in the postoperative transplant recipient. The perfusion fluid used to perfuse and preserve the kidneys prior to transplantation represents a potential medium in which organisms can grow. The aim of this study was to determine the incidence and clinical relevance of bacterial contamination of perfusion fluid. A total of 4 centres participated in the study and 269 perfusion fluid samples were taken for microbiological analysis. Organisms were isolated from 38 out of 218 (17.4%) perfusion fluid samples taken prior to allograft implantation and 23 out of 51 (45%) samples taken at procurement. Low virulence organisms predominated although Staphylococcus aureus, Pseudomonas aeruginosa and Escherichia coli were also isolated. Although infective complications were not seen in the allograft recipients, given the frequency with which contamination occurs and the variation in unit antibiotic protocols, we recommend the routine culturing of perfusion fluid to ensure that any potentially significant organisms are identified and treated appropriately.