RESUMEN
A 68-year-old-gentleman presented with left hip pain, night sweats, fatigue, and weight loss. He had previously experienced pain with white discharge until he underwent an arthroscopic washout and reduction. The left lower limb was shortened and wasted with limited hip movements. He had recently travelled to Zambia, his country of origin. Imaging demonstrated a large mass with chronic erosions of the acetabulum and femoral head. Synovial biopsy grew Mycobacterium tuberculosis, which was treated with rifampicin, isoniazid, pyrazinamide, and ethambutol for 2 months then 4 months of rifampicin and isoniazid. Whole genome sequencing indicated full sensitivity. Complex reconstructive surgery is scheduled, with a custom femoral head and acetabulum. This case illustrates the importance of considering tuberculosis in patients with erosive joint pathology and a multidisciplinary approach as delayed diagnosis results in high morbidity. Prompt diagnosis using newer modalities such as whole genome sequencing on synovial fluid can enable timely treatment.
RESUMEN
Objectives: A novel 'subscription-type' funding model was launched in England in July 2022 for ceftazidime/avibactam and cefiderocol. We explored the views of infection consultants on important aspects of the delinked antimicrobial funding model. Methods: An online survey was sent to all infection consultants in NHS acute hospitals in England. Results: The response rate was 31.2% (235/753). Most consultants agreed the model is a welcome development (69.8%, 164/235), will improve treatment of drug-resistant infections (68.5%, 161/235) and will stimulate research and development of new antimicrobials (57.9%, 136/235). Consultants disagreed that the model would lead to reduced carbapenem use and reported increased use of cefiderocol post-implementation. The presence of an antimicrobial pharmacy team, requirement for preauthorization by infection specialists, antimicrobial stewardship ward rounds and education of infection specialists were considered the most effective antimicrobial stewardship interventions. Under the new model, 42.1% (99/235) of consultants would use these antimicrobials empirically, if risk factors for antimicrobial resistance were present (previous infection, colonization, treatment failure with carbapenems, ward outbreak, recent admission to a high-prevalence setting).Significantly higher insurance and diversity values were given to model antimicrobials compared with established treatments for carbapenem-resistant infections, while meropenem recorded the highest enablement value. Use of both 'subscription-type' model drugs for a wide range of infection sites was reported. Respondents prioritized ceftazidime/avibactam for infections by bacteria producing OXA-48 and KPC and cefiderocol for those producing MBLs and infections with Stenotrophomonas maltophilia, Acinetobacter spp. and Burkholderia cepacia. Conclusions: The 'subscription-type' model was viewed favourably by infection consultants in England.
