Spectrum of human Pasteurella species infections in tropical Australia.

BACKGROUND: Acquired zoonotic infections with Pasteurella bacterial species have a wide clinical spectrum of disease from invasive infections to localised bite-wound infections. METHODS: This study reviewed the spectrum of the demographic, clinical, temporal, and microbiological trends of laboratory confirmed Pasteurella species infections presenting to a single-centre tropical tertiary hospital over a twenty-year period. RESULTS: 195 episodes from 190 patients were included. 51.3% patients were female, and 20.5% Aboriginal or Torres Strait Islander peoples. Crude incidence of Pasteurella spp. infections increased from 1.5 per 100,000 population in 2000, to 11.4 per 100,000 population in 2021. There were 22 (11.3%) bloodstream infections, 22 (11.3%) invasive, 34 (17.4%) deep local, 98 (50.2%) superficial infections, and 19 (9.7%) other or unknown. Adults over 65 years of age accounted for the majority of bacteraemias (63.7%). More severe infections, including bacteraemia, invasive and deep local infections, were more common in lower limb infections and in those with underlying comorbidities. Animal contact with cats was more common in bloodstream infections (36.4%), but dog bites more common in invasive, deep local and superficial infections. 30-day all-cause mortality was low at 1.0%. Pasteurella multocida was most commonly identified (61.1%), but P. canis, P. dagmatis, and other Pasteurella infections were also noted. 67.7% of specimens were polymicrobial, with other significant organisms being Staphylococcus aureus, Streptococcus pyogenes, Group G Streptococcus and Pseudomonas aeruginosa. CONCLUSION: Pasteurella species remain clinically important pathogens, with the ability to cause severe and invasive infections with associated morbidity. Presentations to hospital are becoming more common, and the polymicrobial nature of bites wounds has implications for empiric antibiotic guidelines.

The 'hub and spoke model' for the management of surgical patients during the COVID-19 pandemic.

During the on-going COVID-19 pandemic a number of key public health services have been severely impacted. These include elective surgical services due to the synergetic resources required to provide both perioperative surgical care whilst also treating acute COVID-19 patients and also the poor outcomes associated with surgical patients who develop COVID-19 in the perioperative period. This article discusses the important principles and concepts for providing important surgical services during the COVID-19 pandemic based on the model of the RMCancerSurgHub which is providing surgical cancer services for a population of approximately 2 million people across London during the pandemic. The model focusses on creating local and regional hub centres which provide urgent treatment for surgical patients in an environment that is relatively protected from the burden of COVID-19 illness. The model extensively utilises the extended multidisciplinary team to allow for a flexible approach with core services delivered in 'clean' sites which can adapt to viral surges. A key requirement is that of a clinical prioritisation process which allows for equity in access within and between specialties ensuring that patients are treated on the basis of greatest need, while at the same time protecting those whose conditions can safely wait from exposure to the virus. Importantly, this model has the ability to scale-up activity and lead units and networks into the recovery phase. The model discussed is also broadly applicable to providing surgical services during any viral pandemic.

Infective Endocarditis in Children in Queensland, Australia: Epidemiology, Clinical Features and Outcome.

BACKGROUND: Infective endocarditis (IE) is a rare entity in children associated with significant morbidity and mortality. To optimize management, it is important to understand local epidemiology, risk factors, clinical features and outcome. These are investigated in this retrospective 10-year study of endocarditis in children in Queensland. METHODS: Children <18 years with IE were identified from the state-wide pediatric cardiology center (Mater Children's Hospital, 2009-2014; Queensland Children's Hospital, 2014-2018) through International Classification of Diseases codes and local cardiology database. Clinical records were assessed by a clinician and echocardiograms by a cardiologist. Incidence was calculated using Australian Bureau of Statistics Queensland Estimated Resident Population data, 2019. RESULTS: Fifty-one children were identified, with an overall estimated incidence of 0.84 per 100,000 per year; 0.69 per 100,000 in 2009-2013 and 0.99 per 100,000 in 2014-2018, respectively. Twenty-four (47.1%) children were male and 10 (19.6%) were identified as Aboriginal or Torres Strait Islander peoples. Underlying cardiac conditions were present in 29 (56.9%): 25 congenital heart disease, 3 rheumatic heart disease and 1 cardiomyopathy. A causative pathogen was identified in 46 (90.2%) children with Staphylococcus aureus most common. Thirty-six (70.6%) met criteria for "Definite IE" as per modified Duke criteria, with the remainder "Possible IE." Surgery was required in 26 (51%). Median duration of antibiotics was 42 (interquartile range = 32-51) days and hospitalization 49 (interquartile range = 34-75) days. One child died due to IE. CONCLUSIONS: IE in children in Queensland is increasing in incidence and is higher than the reported incidence in New Zealand and the United States. Congenital heart disease is the most common risk factor and S. aureus is the commonest responsible organism. Aboriginal or Torres Strait Islander children are over-represented. Mortality remains low.

Improving intravenous-to-oral antibiotic switch in children: a team-based audit and implementation approach.

Children in hospital are frequently prescribed intravenous antibiotics for longer than needed. Programmes to optimise timely intravenous-to-oral antibiotic switch may limit excessive in-hospital antibiotic use, minimise complications of intravenous therapy and allow children to go home faster. Here, we describe a quality improvement approach to implement a guideline, with team-based education, audit and feedback, for timely, safe switch from intravenous-to-oral antibiotics in hospitalised children. Eligibility for switch was based on evidence-based guidelines and supported by education and feedback. The project was conducted over 12 months in a tertiary paediatric hospital. Primary outcomes assessed were the proportion of eligible children admitted under paediatric and surgical teams switched within 24 hours, and switch timing prior to and after guideline launch. Secondary outcomes were hospital length of stay, recommencement of intravenous therapy or readmission. The percentage of children switched within 24 hours of eligibility significantly increased from 32/50 (64%) at baseline to 203/249 (82%) post-implementation (p=0.006). The median time to switch fell from 15 hours 42 min to 4 hours 20 min (p=0.0006). In addition, there was a 14-hour median reduction in hospital length of stay (p=0.008). Readmission to hospital and recommencement of intravenous therapy did not significantly change postimplementation. This education, audit and feedback approach improved timely intravenous-to-oral switch in children and also allowed for more timely discharge from hospital. The study demonstrates proof of concept for this implementation with a methodology that can be readily adapted to other paediatric inpatient settings.

The role of CT chest in screening for asymptomatic COVID-19 infection in self-isolating patients prior to elective oncological surgery: findings from a UK Cancer Hub.

OBJECTIVES: In accordance with initial guidance from the Royal College of Surgeons and Royal College of Radiologists, we evaluated the utility of CT of the chest in the exclusion of asymptomatic COVID-19 infection prior to elective cancer surgery on self-isolating patients during the pandemic. METHODS: All surgical referrals without symptoms of COVID-19 infection in April and May 2020 were included. Patient records were retrospectively reviewed. Screening included CT chest for major thoracic and abdominal surgery. CTs were reported according to British Society of Thoracic Imaging guidelines and correlated with reverse transcriptase polymerase chain reaction (RT-PCR) and surgical outcomes. RESULTS: The prevalence of RT-PCR confirmed COVID-19 infection in our screened population was 0.7% (5/681). 240 pre-operative CTs were performed. 3.8% (9/240) of CTs were reported as abnormal, only one of which was RT-PCR positive. 2% (5/240) of cases had surgery postponed based on CT results. All nine patients with CTs reported as abnormal have had surgery, all without complication. CONCLUSION: The prevalence of asymptomatic COVID-19 infection in our screened population was low. The pre-test probability of CT chest in asymptomatic, self-isolating patients is consequently low. CT can produce false positives in this setting, introducing unnecessary delay in surgery for a small proportion of cases. ADVANCES IN KNOWLEDGE: Self-isolation, clinical assessment and RT-PCR are effective at minimising COVID-19 related surgical risk. The addition of CT chest is unhelpful. Our data have particular relevance during the second wave of infection and in the recovery phase.

Multidrug-resistant organisms in urinary tract infections in children.

The global spread of multidrug-resistant organisms has led to an increase in urinary tract infections (UTIs) in children that are difficult to treat. This review explores the current literature regarding multidrug-resistant UTIs in childhood and proposes an approach to management. Multidrug-resistant organisms include a wide range of potential urinary tract pathogens and, while most literature on drug resistance in UTIs during childhood has focused on extended-spectrum beta-lactamase producing organisms, in this review, we have included a discussion of multidrug resistance including and beyond beta-lactamase production. We provide definitions for multidrug-resistant organisms in line with current consensus guidelines and summarise clinically relevant mechanisms of resistance. Additionally, in this review, we outline the global epidemiology of multidrug-resistant UTIs in children, summarising published prevalence rates, which range from 5 to 90% in different settings. Finally, we also critically review the evidence on risk factors for colonisation and infection of the urinary tract with multidrug-resistant organisms, including prior antibiotic use, hospitalisation and underlying urological malformations. We also highlight multidrug-resistant UTI occurring in children without any identifiable risk factors, reflecting an increasing prevalence of colonisation with these organisms in the general community. Taken as a whole, this emphasises a need for careful and evidence-based use of antibiotics when treating UTIs in children and, to aide clinicians, we have outlined here potential management strategies for when infection with a multidrug-resistant organism is suspected or confirmed.

The Home Observation Measure of the Environment is associated with symptoms of ADHD and oppositionality in a CAMHS sample.

BACKGROUND: Severe early deprivation has a causal role in attention-deficit/hyperactivity disorder (ADHD). Adversity in the home is associated with increased ADHD and oppositional symptoms in children with ADHD. We aimed to replicate this in an independent clinic sample. METHODS: A total of 247 sequential families with a child referred to child and adolescent mental health services (CAMHS) were invited to participate; 100 families completed the study. The Home Observation Measure of the Environment (HOME) assessment was completed in the family home; parents completed the Conners' Rating Scale. RESULTS: A less supportive home was associated with more symptoms of inattention ( r = .33, p = .001), hyperactivity/impulsivity ( r = -.22, p = .028) and oppositionality ( r = -.48, significant at p < .000001). CONCLUSION: The HOME correlates with ADHD and oppositional symptom severity in a clinic sample; more research is required to ascertain whether this is a causal association and the direction of causation. If causal, then the modification of the home environment may be a treatment strategy for ADHD.

Understanding the Villain: DMBA-induced preantral ovotoxicity involves selective follicular destruction and primordial follicle activation through PI3K/Akt and mTOR signaling.

7,12-Dimethylbenz-[a]anthracene (DMBA) is an environmental carcinogen which has a potent ovotoxic affect on rat and mouse ovaries, causing complete follicular depletion resulting in premature ovarian failure. Although the overall effects of DMBA on ovarian folliculogenesis are well known, little is known about the exact molecular mechanisms behind its ovotoxicity. In this study, we characterized the mechanisms behind DMBA-induced ovotoxicity in immature follicles. Microarray analysis of neonatal mouse ovaries exposed to DMBA in vitro revealed a multilayered mechanism of DMBA-induced neonatal ovotoxicity involving a distinct cohort of genes and ovarian signaling pathways primarily associated with follicular atresia, tumorigenesis, and follicular growth. Histomorphological and immunohistological analysis supported the microarray data, showing evidence of primordial follicle activation and preantral follicle atresia both in vitro and in vivo. Further immunohistological analysis identified increased Akt1 phosphorylation, mTOR activation, and decreased FOXO3a expression in DMBA-treated primordial oocytes. Our results reveal a novel mechanism of DMBA-induced preantral ovotoxicity involving selective immature follicle destruction and primordial follicle activation involving downstream members of the PI3K/Akt and mTOR signaling pathways.