Candida spp. Deep Sternal Wound Infections: A Consequence of Antibiotic use?

A cluster of deep sternal wound infections caused by Candida spp. occurred at our institution. Investigation did not disclose a common environmental source. We postulate that broad-spectrum antibiotic surgical prophylaxis and liberal use of antibiotics contributed to these infections.

Use of Infliximab to Treat Paradoxical Tuberculous Meningitis Reactions.

We documented dramatic responses to infliximab in 4 tuberculous meningitis cases with severe paradoxical reactions after effective antibacterial treatment, despite high-dose steroids. In every instance, infliximab was used as a last resort after all other options were exhausted, resulting in delayed initiation that may have adversely affected patient outcomes.

Management of pyogenic liver abscess: a South Australian experience.

BACKGROUND: There have been declining mortality rates associated with pyogenic liver abscess (PLA) in recent decades due to improvements in percutaneous drainage techniques, access to imaging and improvements in supportive care. The aim of this study was to analyse the aetiology, management and outcome of PLA at a tertiary hospital in Adelaide. METHODS: Data was collected retrospectively from 80 patients who were admitted with a PLA between 2011 and 2018. The data points covered demographic variables, presumed aetiology, microbiology results, abscess imaging characteristics, interventions, antibiotic treatment, complications and mortality. RESULTS: The majority of patients were Caucasian (86%) and the most common predisposing conditions were biliary tract disease (39%), intra-abdominal infection (20%) and diabetes (18%). Escherichia coli (21%), Klebsiella species (18%), Streptococcus anginosus group (14%) and anaerobes (18%) were the most frequent pathogens isolated. Fifty-one percent of patients were bacteraemic. Percutaneous catheter insertion (45%) was the most common form of drainage followed by percutaneous aspiration (13%), surgery (11%) and endoscopic retrograde cholangiopancreatography (6%), while 25% of patients did not undergo any form of drainage. Twenty-four patients (30%) suffered a complication with the highest proportion occurring in the medically managed group. The overall mortality rate was 9% with only 1% mortality rate attributable to PLA. CONCLUSION: This study demonstrates a continued preference for percutaneous drainage techniques over surgery in the management of PLA. A significant proportion of patients did not undergo abscess drainage and the risk of subsequent complications appeared to concentrate in this group, although the mortality rate from PLA was low.

Safety and Clinical Outcomes of Hospital in the Home.

OBJECTIVES: The aim of the study was to evaluate clinical outcomes and adverse events (AEs) experienced by patients treated within the Hospital in the Home (HITH) service of a major metropolitan hospital in South Australia. METHODS: A retrospective case note audit of 100 HITH episodes among adults who received continuous intravenous antimicrobial therapy via an elastomeric or electronic infusion device was undertaken. Age- and sex-adjusted binomial logistic regression analyses were undertaken to identify factors associated with major and minor AEs. RESULTS: Of the 100 patients included, 71 were male and the mean (SD) patient age was 62.8 (17.19) years. Elastomeric infusion devices were used for 98 patients. The mean (SD) HITH treatment duration was 20.1 (11.9) days. Overall, 130 AEs were documented for 72 patients (72%), of whom 12 patients experienced a major AE and 68 patients experienced a minor AE. There were 45 occasions among 23 patients where an infusion administered through an elastomeric device did not run to completion. Fifteen patients were readmitted to hospital. Minor AEs were more likely among people with more vascular line days (adjusted odds ratio [aOR] = 1.05; 95% confidence interval (CI) = 1.01-1.10 per day increase) and females (aOR = 4.43; 95% CI = 1.14-17.17). An increased number of vascular line days was associated with an increased likelihood of an incomplete infusion (aOR = 1.05; 95% CI = 1.01-1.09). Hospital readmission was more likely with increasing age (aOR = 1.06; 95% CI = 1.01-1.11 per year increase). CONCLUSIONS: Adverse events need to be monitored carefully when HITH treatment is provided for extended periods.

Very early-onset of Cryptococcus neoformans disease following liver transplantation: Report of two cases and a review of the literature.

Cryptococcosis is the third most common invasive fungal infection following solid organ transplantation, and mortality is high. Most cases occur late and are due to reactivation of latent infection; however, very early reactivation and donor-derived transmission can occur. Routine screening pre-transplant and antifungal prophylaxis for cryptococcosis post-transplant in solid organ transplantation are not standard practice. We present two cases of very early-onset Cryptococcus neoformans disease following liver transplantation to highlight the need to consider individualized pre-transplant screening and be aware that reactivation of Cryptococcosis neoformans can occur in the immediate post-transplant period.

Case report: Identification of intra-laboratory blood culture contamination with Staphylococcus aureus by whole genome sequencing.

Staphylococcus aureus in blood cultures is rarely considered a contaminant. We report a case of intra-laboratory contamination between blood culture bottles which was confirmed by whole genome sequencing, highlighting the importance of molecular analysis in the clinical laboratory setting.

Nocardia farcinica bacteraemia presenting as a prostate abscess.

Nocardia is characterised as a Gram positive filamentous rod and is found worldwide in soil, decaying vegetable matter and aquatic environments. Localised pulmonary infection is the most common clinical presentation. However, Nocardia can present in a wide variety of clinical manifestations, especially in the immunocompromised individual. We present the first case of a prostate abscess caused by Nocardia farcinica in a man with a history of severe psoriasis and psoriatic arthritis. He had been on long term immunosuppression for this with prednisolone and etanercept. His Nocardia was likely contracted through direct skin inoculation while gardening with haematological dissemination to the prostate. He responded well to long term sulfamethoxazole and trimethoprim.

INITIAT-E.D.: Impact of timing of INITIation of Antibiotic Therapy on mortality of patients presenting to an Emergency Department with sepsis.

OBJECTIVES: To analyse the association between time from triage to administration of initial antibiotics and mortality in all patients presenting with sepsis to a tertiary hospital ED. METHODS: A retrospective review of patients presenting to the ED with sepsis from January to December 2012 was conducted at Flinders Medical Centre, South Australia. Outcome measures were: time elapsed from triage to administration of initial antibiotic therapy and in-hospital mortality. RESULTS: A total of 220 patients presented with sepsis, comprising 102 cases of uncomplicated sepsis and 118 severe sepsis. The median time to antibiotic administration was 3.5 h (interquartile range [IQR] 1.7-6.6) and in-hospital mortality was 28.6% (95% CI 22.6-34.6%). There was no association observed between delays to antibiotics and mortality in the total patient population. When stratified by presenting severity, patients with severe sepsis demonstrated a trend towards increased mortality when delays to antibiotics exceeded 6 h from triage (HR = 2.25, 95% CI 0.91-5.59, P = 0.08) in comparison with <1 h. Significant delays to antibiotic administration occurred when initial agents were charted as a 'regular medicine' (9.4 h, IQR 5.1-16.6) in comparison with a 'once only order' (3.4 h, IQR 1.7-6.7), P < 0.001. CONCLUSIONS: Early administration of antibiotics specifically in patients with severe sepsis might be beneficial. Further studies within the ED are warranted to establish the effect of delayed antibiotics in a generalised sepsis cohort.