Clinical and microbiological characteristics of Staphylococcus lugdunensis.

PURPOSE OF REVIEW: This review provides an update on recent findings about the clinical and microbiological characteristics of Staphylococcus lugdunensis . RECENT FINDINGS: European Committee on Antimicrobial Susceptibility Testing (EUCAST) and Clinical and Laboratory Standards Institute (CLSI) differ in their methodology and breakpoints for the detection of penicillin and oxacillin resistance in S. lugdunensis . The EUCAST method for beta-lactamase detection recommends a 1-unit penicillin disk and has demonstrated superior performance compared to the 10-unit penicillin disk recommended by CLSI. A similar outcome has been previously reported in Staphylococcus aureus. In addition, there is emerging oxacillin resistance in some geographical areas. Of particular concern is that oxacillin resistance in mecA positive isolates may not be reliably detected by current cefoxitin breakpoints. SUMMARY: Coagulase negative staphylococci are now recognised as a heterogenous group of organisms that do not microbiologically or clinically behave the same way. The spectrum of clinical disease is species dependent and is particularly true for S. lugdunensis , which causes an array of clinical infections like that of S. aureus. Further studies are needed to assess the performance of phenotypic tests to detect resistance, to ensure that appropriate antimicrobial therapy is delivered to patients.

E-learning communication skills training for physiotherapy students: A two phased sequential mixed methods study.

OBJECTIVE: Test whether a single e-learning session can improve empathy and communication across pre-registration and postgraduate physiotherapy students. METHODS: Design: Two-phase sequential mixed methods study. Phase 1: Pilot randomised control trial. Phase 2: Qualitative study using interpretive phenomenological analysis. SAMPLING: A purposive sample for both phases. OUTCOME MEASURES: Phase 1: At baseline, post and 6-week follow up. Demographics. PRIMARY OUTCOME: Inter-personal Reactivity Index (IRI). Phase 2: Demographics and interview schedule. INTERVENTION: An e-learning (E) narrative intervention group or active control condition. ANALYSIS: Phase 1: Descriptive statistics and confidence intervals. Mann-Whitney U test to compare across group change. Phase 2: Thematic analysis. RESULTS: Thirty-nine participants took part in the mixed methods study (Phase 1 n = 25; Phase 2 n = 14). Phase 1: No significant differences between groups were identified. Potentially importance changes across time were found for the intervention group and control group. Phase 2 results identified 5 themes and 12 sub-themes. CONCLUSION: The e-learning groups identified an increase in the perceived ability to handle distressing communication. Other important findings from the e-learning are discussed. Further research is warranted. Practical Implications Novel e-learning intervention may have an important role in curriculum development and clinical practice to promote therapeutic communication. PRACTICAL IMPLICATIONS: Novel e-learning intervention may have an important role in curriculum development and clinical practice to promote therapeutic communication.

Treatment of disseminated histoplasmosis in advanced HIV using itraconazole with increased bioavailability.

Disseminated histoplasmosis (DH), an endemic mycosis caused by the dimorphic fungus Histoplasma capsulatum, is a life-threatening infection in immunocompromised hosts. A patient with newly-diagnosed human immunodeficiency virus (HIV) infection presented with a violaceous, raised, indurated, pruritic rash over the face, arms and trunk on a background of significant weight loss, fevers with sweats, diarrhoea and worsening shortness of breath. His CD4+ T cell count was 14 cells/µl (12%). Histoplasmosis was diagnosed from histology, fungal stain and culture of skin biopsy. In addition to DH, he was found to have Pneumocystis jiroveci pneumonia and multi-resistant Salmonella choleraesuis bacteraemia. He improved with treatment with antibiotics and was commenced on conventional itraconazole, orally. Antiretroviral therapy was commenced soon after. He was unable to achieve therapeutic levels with the conventional formulation due to gastrointestinal side effects and had ongoing fevers. A newer formulation of oral itraconazole with improved bioavailability was commenced. He achieved therapeutic drug levels and had no further intolerance. His fevers settled and the rash improved. He has now completed one year of treatment and is well. To our knowledge this is the first case of moderate DH in an advanced HIV patient treated successfully with oral itraconazole with improved bioavailability.

Activity of Ceftolozane-Tazobactam against Burkholderia pseudomallei.

We investigated the in vitro activity of a novel fifth-generation cephalosporin-tazobactam combination, ceftolozane-tazobactam against Burkholderia pseudomallei, the etiological agent of melioidosis. Using both disc diffusion and minimum inhibitory concentration (MIC) strip techniques against 56 clinical isolates and an national collection of type cultures (NCTC) strain, the MIC to ceftolozane-tazobactam was found to be between 0.75 and 4 mcg/mL. The MIC50 was found to be 1.5 mcg/mL and MIC90 was 2.0 mcg/mL. This study provides initial evidence of ceftolozane-tazobactam as a novel agent in the management of melioidosis.

Translating genomics into practice for real-time surveillance and response to carbapenemase-producing Enterobacteriaceae: evidence from a complex multi-institutional KPC outbreak.

BACKGROUND: Until recently, Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae were rarely identified in Australia. Following an increase in the number of incident cases across the state of Victoria, we undertook a real-time combined genomic and epidemiological investigation. The scope of this study included identifying risk factors and routes of transmission, and investigating the utility of genomics to enhance traditional field epidemiology for informing management of established widespread outbreaks. METHODS: All KPC-producing Enterobacteriaceae isolates referred to the state reference laboratory from 2012 onwards were included. Whole-genome sequencing was performed in parallel with a detailed descriptive epidemiological investigation of each case, using Illumina sequencing on each isolate. This was complemented with PacBio long-read sequencing on selected isolates to establish high-quality reference sequences and interrogate characteristics of KPC-encoding plasmids. RESULTS: Initial investigations indicated that the outbreak was widespread, with 86 KPC-producing Enterobacteriaceae isolates (K. pneumoniae 92%) identified from 35 different locations across metropolitan and rural Victoria between 2012 and 2015. Initial combined analyses of the epidemiological and genomic data resolved the outbreak into distinct nosocomial transmission networks, and identified healthcare facilities at the epicentre of KPC transmission. New cases were assigned to transmission networks in real-time, allowing focussed infection control efforts. PacBio sequencing confirmed a secondary transmission network arising from inter-species plasmid transmission. Insights from Bayesian transmission inference and analyses of within-host diversity informed the development of state-wide public health and infection control guidelines, including interventions such as an intensive approach to screening contacts following new case detection to minimise unrecognised colonisation. CONCLUSION: A real-time combined epidemiological and genomic investigation proved critical to identifying and defining multiple transmission networks of KPC Enterobacteriaceae, while data from either investigation alone were inconclusive. The investigation was fundamental to informing infection control measures in real-time and the development of state-wide public health guidelines on carbapenemase-producing Enterobacteriaceae surveillance and management.

Criteria for Identifying Patients With Staphylococcus aureus Bacteremia Who Are at Low Risk of Endocarditis: A Systematic Review.

This systematic review examines the methods and results of recent studies reporting clinical criteria able to identify patients with Staphylococcus aureus bacteremia who are at very low risk of endocarditis. We searched PubMed, EMBASE, and the Cochrane Collaboration CENTRAL database for articles published after March 1994 using a combination of MeSH and free text search terms for S. aureus AND bacteremia AND endocarditis. Studies were included if they presented a combination of clinical and microbiological criteria with a negative likelihood ratio of ≤0.20 for endocarditis. We found 8 studies employing various criteria and reference standards whose criteria were associated with negative likelihood ratios between 0.00 and 0.19 (corresponding to 0%-5% risk of endocarditis at 20% background prevalence). The benefit of echocardiography for patients fulfilling these criteria is uncertain.

Human Trafficking Identification and Service Provision in the Medical and Social Service Sectors.

The medical sector presents a unique opportunity for identification and service to victims of human trafficking. In this article, we describe local and site-specific efforts to develop an intervention tool to be used in an urban hospital's emergency department in the midwestern United States. In the development of our tool, we focused on both identification and intervention to assist trafficked persons, through a largely collaborative process in which we engaged local stakeholders for developing site-specific points of intervention. In the process of developing our intervention, we highlight the importance of using existing resources and services in a specific community to address critical gaps in coverage for trafficked persons. For example, we focus on those who are victims of labor trafficking, in addition to those who are victims of sex trafficking. We offer a framework informed by rights-based approaches to anti-trafficking efforts that addresses the practical challenges of human trafficking victim identification while simultaneously working to provide resources and disseminate services to those victims.

The role of advocacy in occasioning community and organizational change in a medical-legal partnership.

Health disparities among low-income individuals remain a significant problem. A number of social determinants are associated with adverse health outcomes. Medical-legal partnerships address legal concerns of low-income individuals to improve health and wellness in adults and children. The Medical-Legal Partnership at Legal Aid of Western Missouri provides free direct legal services for patients with legal concerns affecting health. There is limited evidence regarding the association between advocacy-related efforts and changes within both the medical-legal partnership structure and in health-care facilities. Three health-care organizations in Kansas City, MO participated in implementing the medical-legal partnership model between 2007 and 2010. Advocacy efforts conducted by key medical-legal partnership personnel were strongly associated with changes in health-care organizations and within the medical-legal partnership structure. This study extends the current evidence base by examining the types of advocacy efforts required to bring about community and organizational changes.

Integrating social workers into medical-legal partnerships: comprehensive problem solving for patients.

Medical-legal partnerships (MLPs) integrate legal services into the health care setting to resolve legal issues that have a negative impact on patient health. These partnerships between attorneys and health care professionals have traditionally focused on physicians. Despite early success and expansion of the MLP model, the literature is only beginning to explore the significant role that social workers can play in an MLP's development, process, and success. This article argues that MLPs are greatly enhanced when they seek the active engagement of a health center's social workers. All members of the MLP, however, should be aware of differing ethical and legal obligations in the medical, social work, and legal profession as well as differences in professional cultures that can affect the work of the partnership.