A retrospective observational study on enterococcal bacteraemia and endocarditis at a regional hospital in New South Wales, Australia.

BACKGROUND: Enterococcal infection poses a major clinical problem due to increasing antibiotic resistance and rising numbers of health care related infections. It is also associated with high morbidity and mortality. The aim of this study is to examine demographic characteristics, co-morbidities and clinical outcomes of the patients as well as susceptibility spectrum of all Enterococcal bacteraemia and endocarditis. METHODS: A retrospective observational study was performed on cases of Enterococcal bacteraemia and endocarditis at Port Macquarie Base Hospital, New South Wales, Australia from 1st January 2012 till 31st December 2018. RESULTS: Out of 75 patients with Enterococcal bacteraemia, about 70% were male. E.faecalis was responsible for about two-thirds of bacteraemia. E.faecalis most commonly presented as infective endocarditis whereas intraabdominal infection was the most common presentation for E.faecium. 90-day all-cause mortality for all Enterococcal bacteraemia was 29.3% (22 out of 75) with a higher mortality rate with E.faecium bacteraemia in comparison to E.faecalis bacteraemia (47.8% Vs 20.8%). Vancomycin resistance was noted only in 17.4% of E.faecium species. There were 18 patients with infective endocarditis over 7 years period with a yearly prevalence rate of 2.6%. Readmission was 78% and mortality was 16.7% within 90 days of admission. Regarding the use of echocardiogram, about 41.3% of Enterococcal bacteraemia did not have echocardiograms. CONCLUSION: Enterococcal bacteraemia was associated with high morbidity and mortality, particularly secondary to E.faecium bacteraemia. Enterococcal IE was associated with high rates of complications, readmissions, and prolonged inpatient stay.

A survey of medical staff attitudes to an antibiotic approval and stewardship programme.

BACKGROUND: Antibiotic stewardship programmes (ASPs) are advocated to ensure appropriate antimicrobial use; with short-term evidence they may improve outcomes, limit adverse effects, encourage cost-effectiveness and reduce antibiotic resistance. At Concord Hospital, a 450-bed acute care hospital, we have used a telephone-based ASP for 15 years. There may be differences in attitudes to the ASP by prescribers, which may influence its long-term efficacy. METHOD: A 40-item self-administered questionnaire was sent to 190 junior and 250 specialist medical staff. We aimed to elicit medical staff attitudes to the ASP's utility, educational value, effect on patient care and ease of use. RESULTS: One hundred and sixty-four completed questionnaires were returned. Most (82%, 95% confidence interval (95%CI) 75-87%) clinicians had used the ASP, 98% of whom believed it to be a reasonable system. Most staff (85%, 95%CI 79-90%) believed that seeking approval made teams think carefully about antibiotic choice, agreed it provided helpful advice (91%, 95%CI 85-95%) and that the approval system provided useful advice and was educational (88%, 95%CI 81-92%). The ASP was felt time-consuming and detracting from clinical duties by 33% (95%CI 26-41%), while 10% (95%CI 5.8-15.7%) believed it undervalued intuition and experience. Few (19%, 95%CI 13-25%, P < 0.0001) clinicians believed it infringed their autonomy. The advice given through the ASP was believed by most (89%, 95%CI 81-92%) to improve patient outcomes. CONCLUSION: The ASP was surprisingly well supported by all levels of staff, and reinforced the benefits of maintaining an ASP policy.

Neurosurgical management of cerebellar haematoma and infarct.

The clinical features, treatment, and outcome were reviewed for 48 patients with a haematoma and 71 patients with an infarct in the posterior fossa in order to develop a rational plan of management. Clinical features alone were insufficient to make a diagnosis in about half of the series. Patients with a haematoma were referred more quickly to the neurosurgical unit, were more often in coma, and more often had CT evidence of brain stem compression and acute hydrocephalus. Ultimately, 75% of the patients with a haematoma required an operation. By contrast, most patients with an infarct were managed successfully conservatively. Early surgical management in both cerebellar haemorrhage and infarct (either external ventricular drainage or evacuation of the lesion), associated with early presentation and CT signs of brain stem compression and acute hydrocephalus, led to a good outcome in most patients. Of the patients with cerebellar haematoma initially treated by external drainage, over half subsequently required craniectomy and evacuation of the lesion; but, in some cases, this failed to reverse the deterioration. In patients with a cerebellar infarct, external drainage was more often successful. The guidelines, findings, and recommendations for future management of patients with posterior fossa stroke are discussed.