Skin and soft tissue infections and current antimicrobial prescribing practices in Australian aged care residents.

To determine the burden of skin and soft tissue infections (SSTI), the nature of antimicrobial prescribing and factors contributing to inappropriate prescribing for SSTIs in Australian aged care facilities, SSTI and antimicrobial prescribing data were collected via a standardised national survey. The proportion of residents prescribed ⩾1 antimicrobial for presumed SSTI and the proportion whose infections met McGeer et al. surveillance definitions were determined. Antimicrobial choice was compared to national prescribing guidelines and prescription duration analysed using a negative binomial mixed-effects regression model. Of 12 319 surveyed residents, 452 (3.7%) were prescribed an antimicrobial for a SSTI and 29% of these residents had confirmed infection. Topical clotrimazole was most frequently prescribed, often for unspecified indications. Where an indication was documented, antimicrobial choice was generally aligned with recommendations. Duration of prescribing (in days) was associated with use of an agent for prophylaxis (rate ratio (RR) 1.63, 95% confidence interval (CI) 1.08-2.52), PRN orders (RR 2.10, 95% CI 1.42-3.11) and prescription of a topical agent (RR 1.47, 95% CI 1.08-2.02), while documentation of a review or stop date was associated with reduced duration of prescribing (RR 0.33, 95% CI 0.25-0.43). Antimicrobial prescribing for SSTI is frequent in aged care facilities in Australia. Methods to enhance appropriate prescribing, including clinician documentation, are required.

Infection prevention quality indicators in aged care: ready for a national approach.

Accreditation standards for Australian aged care homes include the requirement for programs to ensure infections are controlled. Effective infection prevention programs are supported by surveillance data providing the impetus for quality improvement and facilitating evaluation of interventions at the facility level. In 2016, infection control professionals employed in Victorian public-sector residential aged care services were surveyed to examine the nature and resourcing of local infection prevention programs and monitoring activities. Overall, 164 services participated (90% response rate). A high proportion (84%) reported executive support for infection surveillance, with mean allocation of 12h per fortnight per facility for infection prevention activities. Current surveillance activities included monitoring of infections and antimicrobial use (90%), influenza vaccination compliance for staff (96%) and residents (76%) and monitoring of infection due to significant organisms (84%). A successful statewide program including eight quality indicators has subsequently been implemented in Victoria. We suggest that a national focus could strengthen this framework, ensuring a uniform strategy with enhanced benchmarking capacity. Stakeholder engagement and refinement of appropriate indicators for monitoring quality improvement in public, not-for-profit and private sectors within aged care is required.

Validation of healthcare-associated infection surveillance in smaller Australian hospitals.

A validation study was conducted in smaller (<100 acute beds) Victorian hospitals to evaluate case detection for Staphylococcus aureus bloodstream (SAB), meticillin-resistant S. aureus (MRSA) and vancomycin-resistant enterococci (VRE) infections. Overall, 142 infections were identified in 20 hospitals. For routine surveillance of SAB events, sensitivity was 74.4% and specificity was 100.0%. For MRSA infections, sensitivity was 47.5% and specificity was 90.9%. All confirmed VRE infections were reported correctly. Of unreported SAB and MRSA infections, 80% (N = 16) and 83.9% (N = 26) were community-associated infections, respectively. Future programme refinements include targeted education to ensure appropriate application of case definitions, particularly those including community onset.

Compliance with surgical antibiotic prophylaxis--reporting from a statewide surveillance programme in Victoria, Australia.

A statewide assessment of the compliance of surgical antibiotic prophylaxis (SAP) with guidelines was undertaken for large public hospitals in Victoria, Australia. This was carried out using data collected as part of a surveillance system for hospital-acquired infections. The study population comprised patients in Victorian public hospitals with >100 beds (N=27) undergoing cardiac surgical procedures, hip or knee arthroplasty, cholecystectomy, appendectomy, colon surgery or hysterectomy over a 21-month period. Australian guidelines recommend SAP for all 10 643 surgical procedures included in this study. Combining all procedures, 87% received SAP, the choice of antibiotic was concordant with guidelines for 53.3% of procedures, and the choice of antibiotic was considered to be 'adequate but not concordant' for 23.9% of procedures. SAP was considered to be inadequate for 18.9% of procedures. A large number of antibiotic regimens were utilized for cardiac and orthopaedic surgery. Documentation of timing of administration was not submitted for more than half of all procedures. Timing was concordant with guidelines for 76.4% of procedures when documented. Prophylactic antibiotic choice was generally more concordant with guidelines for cardiac and orthopaedic procedures than for other types of surgery. However, even for these procedures, where infections carry high morbidity, SAP was sometimes inadequate. Regular reporting on SAP compliance from data collected during surveillance for hospital-acquired infections is achievable. This should lead to improvements in both compliance and documentation.

Assessing the risk of tuberculosis infection among healthcare workers: the Melbourne Mantoux Study. Melbourne Mantoux Study Group.

OBJECTIVE: To determine the potential prevalence of nosocomial infection with Mycobacterium tuberculosis among hospital employees in teaching hospitals in Melbourne. DESIGN: Cross-sectional survey of positive tuberculin skin test (Mantoux) responses among employees in 14 public hospitals in Melbourne, January 1996 to April 1999. PARTICIPANTS: All consenting employees in participating hospitals (4,070 healthcare and 4,298 non-healthcare workers; participation rates, 13%-66%). OUTCOME MEASURES: Prevalence of positive responses to tuberculin skin tests among healthcare and non-healthcare workers and association with employee and hospital characteristics. RESULTS: Healthcare workers were significantly more likely to have a positive tuberculin response than non-healthcare workers (19.3% versus 13.7%; odds ratio, 1.5; 95% CI, 1.3-1.7; P<0.001). Multivariable analysis revealed that age, country of birth (high versus low tuberculosis [TB] prevalence), history of BCG (bacille Calmette-Guérin) vaccination, years since last BCG, occupation (healthcare versus non-healthcare worker) and years of hospital employment were all significantly associated with a positive response. Rates of positive responses among employees varied greatly between hospitals (6%-35%). These differences were not explained by employee characteristics, hospital TB patient load (number of admissions or bed-days) or percentage of hospital patients from countries with high TB prevalence. The hospital with the highest rate of positive responses was notable for its lack of negative-pressure isolation rooms for TB patients. CONCLUSIONS: Positive tuberculin responses are relatively common among hospital employees in Melbourne, with rates varying between hospitals and being higher among healthcare than non-healthcare workers. Employee characteristics, such as age, country of birth and past BCG status, explain little of this variation. More emphasis on TB infection control measures and regular staff screening may be needed.

Herpes simplex virus mediated nerve growth factor expression in bladder and afferent neurons: potential treatment for diabetic bladder dysfunction.

PURPOSE: Diabetic cystopathy resulting from sensory neuropathy may potentially be treated by direct gene therapy. It has been suggested that nerve growth factor (NGF) has an ameliorative effect in preventing the death in diabetes of afferent dorsal root ganglion neurons, which control bladder function. We investigated NGF gene transfer to the bladder and bladder afferent pathways for treating diabetic cystopathy. We used replication competent and replication defective herpes simplex virus type 1 (HSV-1) vectors that express a functionally active form of the beta-subunit of mouse NGF (beta-NGF) to examine the level and duration of therapeutic gene expression after administration of the vectors. MATERIALS AND METHODS: NGF expression during acute (3 days) and latent (21 days) infections was assessed by enzyme-linked immunosorbent assay (ELISA) and immunohistochemical testing after the injection of 1 x 106 to 1 x 108 pfu HSV-NGF expression vectors into the bladder wall of adult rats. RESULTS: HSV vectors with the strong human cytomegalovirus immediate early promoter used to drive beta-NGF gene expression exhibited increased NGF 3 days after infection in the bladder and L6 to S1 dorsal root ganglia, where bladder afferent neurons are located. ELISA analysis revealed that NGF in the bladder tissue and dorsal root ganglia was increased 7 to 9 and 2 to 4-fold, respectively, over the control vector. Increased NGF expression in L6 to S1 dorsal root ganglia neurons was also detected by immunohistochemical staining with antiNGF antibodies. Extended NGF expression was detected by ELISA 21 days after injection. Replication defective vectors containing HSV-1 latency promoter (LAP-2) driving NGF expressed NGF in the bladder and dorsal root ganglia 21 days after bladder injection. ELISA analysis confirmed an approximate 2 to 3-fold increase of NGF expression in the bladder and L6 to S1 dorsal root ganglia. CONCLUSIONS: The NGF gene may be transferred and expressed in the bladder and bladder afferent pathways using HSV vectors. To our knowledge our study represents the first demonstration of the effectiveness of gene therapy for altering neurotrophic expression in visceral sensory neurons. This technique of gene transfer may be useful for treating certain types of neurogenic bladder dysfunction, such as diabetic cystopathy, in which decreased NGF transport may be a causative factor.

Cardiac compromise in a patient with Down's Syndrome: a lesson learnt.

A 49 year old burn victim with Down's Syndrome (Trisomy 21) was admitted with 15% body surface area (BSA) superficial burns. This was complicated by a large atrioseptal defect. Her course was stormy with difficulties encountered in managing her fluid status. Adequate fluid resuscitation was difficult to maintain with a fragile compromise between pulmonary insufficiency and renal impairment. She expired 12 days post-injury. Cardiac anomalies are not uncommon in the subgroup of patients with major burns who respond poorly to fluid resuscitation.

Dermabrasion--a novel concept in the surgical management of sulphur mustard injuries.

Since its first use on the battlefields of Northern France during the First World War (1914-1918), sulphur mustard has remained a significant chemical threat to military forces around the world. Progress towards an effective treatment for these injuries has been slow due to the lack of suitable animal models upon which to study the toxicology and pathology. However, porcine and human skin are similar in structure and exposures to sulphur mustard vapour have been performed on porcine models to define the development and subsequent resolution of mustard-induced skin injuries. Yucatan miniature (n = 12) and large white (n = 6) pig models were used to assess the usefulness of mechanical dermabrasion in accelerating the naturally slow rate of healing of sulphur mustard vapour-induced injuries to the skin. Burn injuries underwent debridement at 4 days post-exposure and the resulting lesions were assessed at various time points up to 8 weeks post-abrasion. Rates of re-epithelialisation were accelerated in the dermabrasion (treated) vs the control (untreated) group by up to a factor of three (ANOVA: p = .0196, Yucatan; p = 0.165, large white pig). It was concluded that dermabrasion of sulphur mustard burns is a valuable procedure in the surgical management of these injuries.

A burn-like lesion caused by a testosterone transdermal system.

A wide range of drugs are capable of being administered as transdermal drug delivery systems (TDDS). Despite their advantages, these systems are known to have adverse effects. This report describes localised skin reactions with reference to a burn-like lesion on the shoulder of a patient caused by a testosterone TDDS. Patients should be advised of the potential adverse effects of these systems and also of suitable application sites, avoiding areas liable to prolonged pressure.

The use of laser Doppler imaging as an aid in clinical management decision making in the treatment of vesicant burns.

Vesicants are a group of chemicals recognised, under the terms of the Chemical Weapons Convention, as potential chemical warfare agents whose prime effect on the skin is to cause burns and blistering. Experience of the clinical management of these injuries is not readily available and therefore an accurate assessment of the severity of the lesion and extent of tissue involvement is an important factor when determining the subsequent clinical management strategy for such lesions. This study was performed to assess the use of laser Doppler imaging (LDI) as a noninvasive means of assessing wound microvascular perfusion following challenge with the vesicant agents (sulphur mustard or lewisite) by comparing the images obtained with histopathological analysis of the lesion. Large white pigs were challenged with sulphur mustard (1.91 mg cm(-2)) or lewisite (0.3 mg.cm(-2)) vapour for periods of up to 6 h At intervals of between 1 h and 7 days following vesicant challenge, LDI images were acquired and samples for routine histopathology were taken. The results from this study suggest that LDI was: (i) a simple, reproducible and noninvasive means of assessing changes in tissue perfusion, and hence tissue viability, in developing and healing vesicant burns; (ii) the LDI images correlates well with histopathological assessment of the resulting lesions and the technique was sufficiently sensitive enough to discriminate between skin lesions of different aetiology. These attributes suggest that LDI would be a useful investigative tool that could aid clinical management decision making in the early treatment of vesicant agent-induced skin burns.