Escherichia coli bloodstream infection outcomes and preventability: a six-month prospective observational study.

BACKGROUND: Escherichia coli bloodstream infection (BSI) is a common and serious problem, and incidence and antibiotic resistance are increasing. AIM: To understand the drivers of outcomes and factors associated with preventable cases at the study institution. METHODS: Between 1st November 2017 and 30th April 2018, cases of E. coli BSI in adults treated as inpatients at the study institution were included in a prospective cohort. Clinical, demographic and laboratory features were recorded, with seven-, 30- and 90-day mortality and length of hospital stay post BSI. Qualitative data on preventability were reviewed independently by two infection specialists. FINDINGS: In total, 195 cases in 188 patients were included in the analysis. Empirical antibiotics showed in-vitro resistance in 30.9% of cases. Thirty-day mortality was 23.6%, with a median length of hospital stay of seven days. On multi-variable analysis, 30-day mortality was associated with higher Charlson score, residential home residency, higher respiratory rate and higher serum urea, whilst prolonged length of stay was associated with hospital-acquired E. coli BSI. Fifty patients were felt to have avoidable BSI, all of which were health care associated; urinary catheter use, antibiotic-related and procedural complications were the areas of preventability. CONCLUSIONS: E. coli BSI has an appreciable mortality, with little in the way of modifiable risk factors for mortality or prolonged hospital stay. Attention to urinary catheter use is likely to be the most useful way to reduce the incidence, but current UK reduction targets may be unachievable.

Macrophage-sensory neuronal interaction in HIV-1 gp120-induced neurotoxicity‡.

BACKGROUND: Human immunodeficiency virus (HIV)-associated sensory neuropathy (SN) is the most frequent neurological complication of HIV disease. Among the probable mechanisms underlying HIV-SN are neurotoxicity induced by the HIV glycoprotein gp120 and antiretroviral therapies (ART). Since HIV-SN prevalence remains high in patients who have not been exposed to toxic ART drugs, here we focused on gp120-mediated mechanisms underlying HIV-SN. METHODS: We hypothesized that a direct gp120-sensory neurone interaction is not the cause of neurite degeneration; rather, an indirect interaction of gp120 with sensory neurones involving macrophages underlies axonal degeneration. Rat dorsal root ganglion (DRG) cultures were used to assess gp120 neurotoxicity. Rat bone marrow-derived macrophage (BMDM) cultures and qPCR array were used to assess gp120-associated gene expression changes. RESULTS: gp120 induced significant, but latent onset, neurite degeneration until 24 h after application. gp120-neurone interaction occurred within 1 h of application in <10% of DRG neurones, despite neurite degeneration having a global effect. Application of culture media from gp120-exposed BMDMs induced a significant reduction in DRG neurite outgrowth. Furthermore, gp120 significantly increased the expression of 25 cytokine-related genes in primary BMDMs, some of which have been implicated in other painful polyneuropathies. The C-C chemokine receptor type 5 (CCR5) antagonist, maraviroc, concentration-dependently inhibited gp120-induced tumour necrosis factor-α gene expression, indicating that these effects occurred via gp120 activation of CCR5. CONCLUSIONS: Our findings highlight macrophages in the pathogenesis of HIV-SN and upstream modulation of macrophage response as a promising therapeutic strategy.

Oral voriconazole for invasive fungal skull base infection.

BACKGROUND: Intravenous amphotericin or intravenous voriconazole, both followed by oral voriconazole, have previously been given to treat invasive aspergillosis of the skull base. CASE REPORT: Exclusively oral voriconazole was used in an immunocompetent patient with biopsy-proven, invasive aspergillosis. She had a large, erosive lesion extending from the central skull base to the right orbit and ethmoid sinus, and displacing the right internal carotid artery. After four months of oral treatment as an out-patient, a repeated computed tomography scan showed a fully treated infection with post-infectious changes only, and treatment was terminated. Two years later, there had been no recurrence. CONCLUSION: Substantial cost savings were made by using exclusively oral treatment, compared with the use of intravenous voriconazole or amphotericin, or a switch strategy.

Special needs children in the public schools: perceptions of school nurses and school teachers.

Schools are faced with the challenges presented by special needs children (SNC) because the law requires that they must provide educational opportunities to all children--those who have no handicapping conditions as well as those who do, no matter how severe those conditions. The need exists for adequately prepared health care professionals in the school setting. Using a convenience sample of school teachers and school nurses, this investigation focused on the perceptions of school teachers and nurses regarding the challenges and demands of having these children in the public school. Two surveys were conducted to study those perceptions. Quantitative and qualitative data analyses showed that the needs of both groups of providers--school nurses and school teachers--can be summed up in three categories: information dissemination, communication, and resource integration. Infrastructure development involves the establishment of an effective information management system, effective use of such a system in establishing communications between all participants, and adequate administrative support to facilitate the development of the school providers' sense of competence in the care of SNC. A well-planned and adequately supported program goes a long way toward changing people's attitudes toward the inclusion of SNC in the classroom.

Prolonged cryptosporidiosis during primary HIV infection.

Primary infection with the human immunodeficiency virus causes profound immunosuppression with a decrease in lymphocyte numbers and function. However, this immunosuppression is transient and most individuals regain normal immune function. Infection with opportunist pathogens during the period of immunosuppression is rare. We report a case of severe prolonged cryptosporidiosis complicating primary HIV infection. This has not previously been described. A review of other cases of opportunist infections in primary HIV infection suggests that various pathogens may take advantage of the transient immunosuppression. This has important implications for the diagnosis and management of acute HIV infection, and for the diagnostic criteria currently used for AIDS.

Primary group A streptococcal peritonitis.

Primary peritonitis caused by Group A beta-haemolytic streptococci (GAS) is extremely rare and is usually only seen in the presence of underlying disease. This report describes the case of a previously fit young woman who developed primary GAS peritonitis. She had a laparotomy performed at which large amounts of intra-peritoneal pus was identified but no focus of infection was found. Broad spectrum antibiotics were initially used, these were changed to intravenous benzylpenicillin when GAS was isolated. She made a good recovery and was discharged 2 weeks after admission on oral amoxycillin. The organism was serotyped as T3/M3/R3 (opacity factor negative) and it is interesting that the same serotype was isolated from a throat swab taken from her daughter. We also discuss the possible routes of infection and the epidemiology of invasive GAS disease.