Oral amoxicillin challenge for low-risk penicillin allergic patients.

BACKGROUND: Penicillin allergy is the most reported adverse drug reaction (ADR). Being labelled with 'penicillin allergy' is associated with suboptimal antibiotic therapy and poor patient outcomes. Most labelled with 'penicillin allergy' are at low risk of harm from penicillins and guidelines recommend testing for accurate diagnosis. Although skin testing is recommended to exclude immunoglobulin E (IgE)-mediated reactions, there is limited access in most settings. AIMS: To evaluate oral amoxicillin challenge without prior skin testing for patients labelled with 'penicillin allergy' assessed as low risk during hospital admission. METHODS: General Medical inpatients with a 'penicillin allergy' label were assessed. For those who had tolerated a penicillin since the index event, the ADR label was removed. Those assessed as 'low risk' were administered 250 mg amoxicillin orally without prior skin testing. The durability of de-labelling was subsequently assessed by review of clinical records. RESULTS: Of 224 patients with a history of a penicillin ADR, 162 (72%) were low risk. A further 12 were excluded and of the remaining 150, 56 (37%) had tolerated penicillins since their index reaction and were de-labelled without challenge, 15 (10%) with a non-allergic history were de-labelled. The remaining 79 were offered an oral amoxicillin challenge; 38 declined and 41 tolerated amoxicillin. Overall, 112 of the 224 (50%) patients had their ADR label removed. CONCLUSIONS: A careful ADR history enables de-labelling of many patients. An oral amoxicillin challenge without prior skin testing is safe and feasible for low-risk penicillin allergic patients while in hospital.

Assessing the impact of a 'bundle of care' approach to Staphylococcus aureus bacteraemia in a tertiary hospital.

BACKGROUND: Staphylococcus aureus bacteraemia is associated with significant morbidity and mortality. There is evidence that standardised care bundle implementation may improve the rates of appropriate investigations and improve overall management. A S. aureus bacteraemia care bundle was introduced at Christchurch Hospital, New Zealand in early 2014. We assessed the impact of the intervention on the management and outcome of S. aureus bacteraemia. METHODS: A cohort study of cases of S. aureus bacteraemia was conducted following standardised care bundle introduction. Prospective enrolment of post-intervention patients occurred from 1st January 2014 to 30th June 2015, with retrospective review of pre-intervention cases from 1st January 2009 to 31st December 2013. RESULTS: In the pre-intervention period 447 patients had at least one episode of S. aureus bacteraemia compared to 151 patients in the post-intervention period. The two groups were similar by gender, ethnicity, and age. Significant increases in Infectious Diseases consultation rate (86.6% vs 94.8%; p=0.009), echocardiography (76.3% vs 96.3%; p<0.001), urine culture (74.0% vs 91.9%; p<0.001), follow up blood cultures (44.2% vs 83.0%; p<0.001), and at least 2 weeks of parenteral therapy (83.5% vs 92.9%; p=0.014) were observed after introduction of the bundle. There were no significant differences in rates 30-day mortality (18.6% vs. 20.5%; p=0.596), but there was a reduction in episodes of relapsed infection in the post-intervention cohort (7.4% vs 1.3%; p=0.004). CONCLUSION: An integrated care bundle for the management of S. aureus bacteraemia resulted in increased use of quality of care indicators and infectious diseases review and improved patient outcome.

Outpatient parenteral antimicrobial therapy (OPAT) in Christchurch: 18 years on.

AIM: Outpatient parenteral antimicrobial therapy (OPAT) has become an established option for management infections requiring intravenous therapy. As the uptake of OPAT has increased, the clinical governance has changed and is now managed via virtual clinics and increased use of district nurses in addition to specialist outpatient review. The aim of this study was to report the characteristics, diagnoses, treatment and outcomes of patients managed by the service over 12 months in 2015/6 and compared these features with those of patients treated with OPAT in 1999. METHODS: Cases for 2015/6 were identified from the OPAT service database which records prospectively all information on diagnosis, antibiotic choice and duration of treatment, complications and requirement for review by the ID physicians and OPAT nurses prospectively. The outcomes, complications and readmissions were found by reviewing computerised records of Christchurch Hospital. All results were entered into a Microsoft® Excel database for analysis. Statistical analyses were performed using OpenEpi software. Data for 1999 was taken from an earlier publication. RESULTS: OPAT treatment in 12 months from 1 July 2015 was administered 407 times to 385 patients, which represented a 2.7 times increase in treatment courses than in 1999. The median age was 55 years in 1999 and 61 in 2015/6. There was a substantial increase in the proportion of bone and joint, abdominal and urinary tract infections but a fall in cellulitis and soft tissue infection. The number and proportion of patients treated with broad spectrum agents including piperacillin + tazobactam, ceftriaxone and carbapenems increased from 1% in 1999 to 20% in 2015/6. Unplanned readmission to hospital increased from 15 (10%) in 1999 to 62 patients (15%) in 2015/6. The most common reason for readmission in 2015/6 was for ongoing symptoms or progression of the infection requiring OPAT. Eight patients (2%) required readmission from adverse reactions to antimicrobial therapy. Two patients on palliative care died while on OPAT and 35 (9%) within 12 months of the index admission. CONCLUSION: OPAT use has increased and is used to treat patients with comorbidities, who are older, and with a different case-mix than 1999. Safety has not been compromised but the risk of treatment failure has increased. A better understanding of the reasons for treatment failure would improve patient selection and management with OPAT.

Acute Cystitis Caused by Commensal Neisseria oralis: A Case Report and Review of the Literature.

BACKGROUND: Neisseria are usually harmless inhabitants of otherwise asymptomatic persons' upper respiratory mucosal surfaces. METHOD: It is, therefore, expected that a disturbance in the physiology leads to nongonococcal, non-meningococcal Neisseria becoming pathogenic. RESULT: We report the case of a diabetic man who initially presented with nonspecific symptoms and was later found to have cystitis caused by N. oralis. CONCLUSION: We also review the pertinent literature and discuss available evidence on pathophysiological mechanisms of infection with such commensal bacteria.

Legionnaires' disease caused by Legionella longbeachae: Clinical features and outcomes of 107 cases from an endemic area.

BACKGROUND AND OBJECTIVE: Legionella longbeachae is a predominant cause of Legionnaires' disease in some parts of the world, particularly in Australasia. Clinical reports of L. longbeachae infection are limited to case reports or small case series, and culture-confirmed cases. METHODS: We reviewed the clinical characteristics and outcomes of L. longbeachae pneumonia in a large case series from Christchurch, New Zealand during a 4-year period when both PCR and cultures were used as routine diagnostic tools for Legionnaires' disease. Cases of Legionella pneumophila pneumonia were reviewed for comparison. RESULTS: A total of 107 cases of L. longbeachae infection were identified by PCR and/or culture. The median age was 65 years (range 25-90 years), 63% were male, and most became unwell during spring or summer. Presenting clinical features were similar to those reported for community-acquired pneumonia, with headache, myalgia and diarrhoea being common. Elevated C-reactive protein, hyponatraemia and abnormal liver function tests were also common. History of productive cough, involvement of both lungs, and high bacterial load were independently associated with culture of Legionella from lower respiratory samples. One quarter required intensive care unit admission, and 5% died. Among patients given antimicrobial therapy before admission, those given agents without anti-Legionella activity were more likely to be admitted to the intensive care unit. Limited comparisons were made with the 19 L. pneumophila cases over the same time period. CONCLUSION: Characteristics of L. longbeachae pneumonia are broadly similar to those reported for community-acquired pneumonia from a variety of other populations, except for the spring/summer seasonality.

A case of extensive cutaneous Mycobacterium marinum infection in a Pacific Islander living in New Zealand.

Mycobacterium marinum is a rare cause of cutaneous infection. The typical clinical picture consists of one or more discrete well circumscribed lesions affecting the upper limbs. However, a more exuberant form has been described in the South Pacific, where it is sometimes entitled 'Spam disease' given the infected skin's similar appearance to the canned food. We describe a case of this more extensive infection in a South Pacific Islander who appears to have acquired the infection in New Zealand, and remained undiagnosed for many years.

Prevalence of concurrent deep vein thrombosis in patients with lower limb cellulitis: a prospective cohort study.

BACKGROUND: Lower limb cellulitis and deep vein thrombosis share clinical features and investigation of patients with cellulitis for concurrent DVT is common. The prevalence of DVT in this group is uncertain. This study aimed to determine the prevalence of deep vein thrombosis (DVT) in patients with lower limb cellulitis and to investigate the utility of applying the Wells algorithm to this patient group. METHODS: Patients admitted with lower limb cellulitis prospectively underwent a likelihood assessment for DVT using the Wells criteria followed by investigation with D-dimer and ultrasonography of ipsilateral femoral veins as appropriate. Diagnoses of contralateral DVT or pulmonary embolism during admission were recorded. RESULTS: 200 patients assessed for DVT. 20% of subjects were high risk by Wells criteria. D-dimer was elevated in 74% and 79% underwent insonation of the affected leg. Ipsilateral DVT was found in 1 patient (0.5%) and non-ipsilateral VTE in a further 2 (1%). CONCLUSIONS: Deep vein thrombosis rarely occurs concurrently with lower limb cellulitis. The Wells score substantially overestimates the likelihood of DVT due to an overlap of clinical signs. Investigation for DVT in patients with cellulitis is likely to yield few diagnoses and is not warranted in the absence of a hypercoaguable state. TRIAL REGISTRATION: ACTRN: 12610000792022 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=320662).

An audit of venous duplex ultrasonography in patients with lower limb cellulitis.

AIMS: To audit the use and value of venous duplex ultrasound in patients hospitalised for cellulitis at Christchurch Hospital, New Zealand. METHODS: The case notes of all patients with the discharge diagnosis of lower limb cellulitis admitted between January 2002 and December 2004 were reviewed for evidence of having undergone lower limb duplex ultrasonography. The presence of deep vein thrombosis (DVT) at this time was recorded and those who had thrombosis were reviewed in more depth to assess the presence of known risk factors. RESULTS: 240 of the 1515 patients with lower limb cellulitis underwent ultrasonography of the lower limb. Of these, 15 demonstrated deep venous thrombosis; in only 3 of these 15 were the two conditions thought to have occurred concurrently. Two of the three patients with concurrent DVT and cellulitis had active malignancy, and the third had injected battery acid into the affected leg. CONCLUSIONS: Concurrent DVT and cellulitis is rare and this study suggests that investigation with ultrasonography in the absence of risk factors for DVT has a low yield.

Influenza H1N1 2009 in Canterbury: a case study in pandemic response co-ordination.

BACKGROUND AND CONTEXT: Reviews of overseas pandemic responses have suggested that stronger links between primary care and other parts of the health sector are required. The influenza A (H1N1) 2009 ('H1N1 09') pandemic was the first real test of New Zealand's pandemic preparedness. ASSESSMENT OF PROBLEM: In the six months from May to October 2009, there were 595 confirmed cases of H1N1 09 in Canterbury, with 187 hospitalisations and three deaths. This paper describes the way a range of Canterbury agencies worked together in a co-ordinated health-led response aimed at minimising the impact of H1N1 09 in the community and maintaining effective health care services for both influenza and non-influenza patients. STRATEGIES FOR IMPROVEMENT: Key strategies included sector-wide response co-ordination, intelligence and communications, a combined public health/primary care response during the 'containment' phase, and universal red/green streaming supported by dedicated 'flu centres and an 0800 call centre during the 'manage it' phase. LESSONS: Despite the considerable impact of the H1N1 09 virus in Canterbury, health care services were not overwhelmed. The key lesson learned from the Canterbury H1N1 09 response has been the importance of preparing and working together across the sector.

Corynebacterium accolens-associated pelvic osteomyelitis.

Corynebacterium accolens is a rare human pathogen. We encountered a case of C. accolens isolated from a thigh collection in a man with osteomyelitis of the adjacent pubic symphysis.

Outpatient intravenous treatment for infective endocarditis: safety, effectiveness and one-year outcomes.

OBJECTIVES: To describe the use and outcomes of outpatient antimicrobial therapy (OPAT) for infective endocarditis (IE) within the Canterbury region of New Zealand over an 8 year period. METHODS: All cases of IE admitted to Christchurch Hospital were reviewed. Prospectively collected data from our OPAT service's database and retrospective data from case notes were analysed. RESULTS: There were 213 episodes of IE meeting modified Duke Criteria over this time. Patients received OPAT in 100 episodes. Viridans streptococci were the infecting organism in 34, Staphylococcus aureus in 27, and enterococci in 10. Adverse events were encountered in 27 episodes. Of these, 24 were related to intravenous lines, infusion devices or adverse drug reactions which resolved with change of treatment. There were 3 serious adverse events which were likely to have occurred in hospital. During 12-month follow-up there were 5 further episodes of IE and 2 deaths unlikely to be directly related to the episode of IE. CONCLUSIONS: Despite significant co-morbidities and complications, nearly half of all patients with IE, including those with disease due to S. aureus and enterococci, successfully completed their treatment as outpatients. Continuous infusion devices were successfully used in 32 patients, including 22 with disease due to S. aureus.

The levator aponeurosis exposed.

A case of bilateral upper eyelid ptosis in an HIV-infected patient with severe antiretroviral-associated facial lipodystrophy is presented. The features, treatment, and outcome are discussed. Dehiscence of the levator aponeurosis may be directly associated with highly active antiretroviral therapy-induced lipodystrophy.

A prospective double-blind randomized trial comparing intraluminal ethanol with heparinized saline for the prevention of catheter-associated bloodstream infection in immunosuppressed haematology patients.

OBJECTIVES: The aim of this study was to prospectively evaluate the use of intraluminal ethanol for the prevention of catheter-associated bloodstream infection (CABSI) in immunosuppressed haematology patients. PATIENTS AND METHODS: Patients receiving chemotherapy for haematological malignancy or haematopoietic cell transplantation were randomized in a double-blinded manner to receive either intraluminal 70% ethanol/water or heparinized saline locks on a daily basis throughout a prophylactic treatment period. The primary endpoint was an episode of CABSI (defined as 'bacteraemia in a febrile patient with a central venous catheter that was in use within the preceding 48 h and with no other identified focus of infection'). The trial was registered with the Australian Clinical Trials Register: number ACTRN012605000383662. RESULTS: There were 34 and 30 prophylactic treatment periods in the ethanol and control groups, respectively. CABSI occurred in 3 (9%, 0.60/100 catheter-days) and 11 (37%, 3.11/100 catheter-days) prophylactic treatment periods in the ethanol and control groups, respectively (OR = 0.18, 95% CI 0.05-0.65, P = 0.008). Eleven (32%) and 5 (17%) patients in the ethanol and control groups, respectively, remained afebrile throughout the prophylactic treatment (P = 0.18). CONCLUSIONS: The daily administration of ethanol locks into lumens of central venous catheters effectively reduces the incidence of CABSI.

Ethanol lock therapy to treat tunnelled central venous catheter-associated blood stream infections: results from a prospective trial.

In order to assess the efficacy of 70% ethanol locks in addition to antibiotic therapy to treat tunnelled central venous catheter-associated bloodstream infections, a pilot study of 19 patients was performed prospectively using ethanol locks for 5 d in addition to antibiotic therapy to treat tunnelled central venous catheter-associated bacteraemia. 12 patients had mono-microbial infections and 7 had polymicrobial isolates. 17 of 19 patients completed ethanol lock therapy. 15 of 17 patients completing ethanol lock therapy had no recurrence of the original organism and retained their catheter for a median of 36 and an average of 47 d following initiation of ethanol lock therapy. These results demonstrate the safety and potential efficacy of this technique against a broad range of potentially virulent organisms. The intervention was acceptable to both staff and patients with no significant side-effects. These preliminary results from our prospective pilot study suggest that ethanol lock therapy is safe and easily integrated into clinical practice, and may have utility in treating central venous catheter-associated infections, avoiding removal of catheters in patients requiring long-term venous access.

Treatment of Staphylococcus epidermidis central vascular catheter infection with 70% ethanol locks: efficacy in a sheep model.

OBJECTIVES: To determine whether a single treatment with ethanol/water (70:30) will sterilize infected vascular catheters. METHODS: A double-blinded, block-randomized trial was conducted in a sheep model comparing the efficacy of one 3 h treatment with ethanol/water (70:30) with heparinized saline for treatment of Hickman vascular catheters infected with Staphylococcus epidermidis. Catheters were cultured using endoluminal brushes, blood cultures, roll plates of catheter tip, broth flushed through the catheter and hub swabs. RESULTS: There were significantly more sterile catheters in the ethanol treatment group than the saline treatment group (9/11 versus 0/11, P < 0.01, McNemar's chi(2) test). The median number of positive cultures in the ethanol treatment group was less than in the saline treatment group (0 versus 5, P = 0.009, Wilcoxon signed-rank test). CONCLUSIONS: A single treatment of 70% ethanol is effective and clinical trials are warranted for treatment of infected vascular catheters using this regimen.

Randomised controlled trial of intravenous antibiotic treatment for cellulitis at home compared with hospital.

OBJECTIVES: To compare the efficacy, safety, and acceptability of treatment with intravenous antibiotics for cellulitis at home and in hospital. DESIGN: Prospective randomised controlled trial. SETTING: Christchurch, New Zealand. PARTICIPANTS: 200 patients presenting or referred to the only emergency department in Christchurch who were thought to require intravenous antibiotic treatment for cellulitis and who did not have any contraindications to home care were randomly assigned to receive treatment either at home or in hospital. MAIN OUTCOME MEASURES: Days to no advancement of cellulitis was the primary outcome measure. Days on intravenous and oral antibiotics, days in hospital or in the home care programme, complications, degree of functioning and pain, and satisfaction with site of care were also recorded. RESULTS: The two treatment groups did not differ significantly for the primary outcome of days to no advancement of cellulitis, with a mean of 1.50 days (SD 0.11) for the group receiving treatment at home and 1.49 days (SD 0.10) for the group receiving treatment in hospital (mean difference 0.01 days, 95% confidence interval -0.3 to 0.28). None of the other outcome measures differed significantly except for patients' satisfaction, which was greater in patients treated at home. CONCLUSIONS: Treatment of cellulitis requiring intravenous antibiotics can be safely delivered at home. Patients prefer home treatment, but in this study only about one third of patients presenting at hospital for intravenous treatment of cellulitis were considered suitable for home treatment.

Use of ethanol locks to prevent recurrent central line sepsis.

Catheter-related sepsis (CRS) is a common complication of long-term parenteral nutrition. Conventional antibiotic therapy is often effective in the short-term but, because of poor activity against intraluminal microbial biofilms, may not prevent relapse. Ethanol is an effective antiseptic. We describe a case of a patient with recurrent CRS successfully treated with 70% ethanol locks.