Nosocomial outbreak of staphyloccocal scalded skin syndrome in neonates in England, December 2012 to March 2013.

Staphylococcal scalded skin syndrome (SSSS) is a blistering skin condition caused by exfoliative toxin-producing strains of Staphylococcus aureus. Outbreaks of SSSS in maternity settings are rarely reported. We describe an outbreak of SSSS that occurred among neonates born at a maternity unit in England during December 2012 to March 2013. Detailed epidemiological and microbiological investigations were undertaken. Eight neonates were found to be infected with the outbreak strain of S. aureus, of spa type t346, representing a single pulsotype. All eight isolates contained genes encoding exfoliative toxin A (eta) and six of them contained genes encoding toxin B (etb). Nasal swabs taken during targeted staff screening yielded a staphylococcal carriage rate of 21% (17/80), but none contained the outbreak strain. Mass screening involving multi-site swabbing and pooled, enrichment culture identified a healthcare worker (HCW) with the outbreak strain. This HCW was known to have a chronic skin condition and their initial nasal screen was negative. The outbreak ended when they were excluded from work. This outbreak highlights the need for implementing robust swabbing and culture methodswhen conventional techniques are unsuccessful in identifying staff carrier(s). This study adds to the growing body of evidence on the role of HCWs in nosocomial transmission of S. aureus.

Campylobacteriosis outbreak associated with consumption of undercooked chicken liver pâté in the East of England, September 2011: identification of a dose-response risk.

A foodborne outbreak with 49 cases (22 culture positive for Campylobacter sp.) following a wedding party in the East of England was investigated. A retrospective cohort study identified an association between consumption of chicken liver pâté and infection with Campylobacter jejuni/coli. There was a statistically significant association between dose (amount of chicken liver pâté eaten) and the risk of disease ['tasted': odds ratio (OR) 1·5, 95% confidence interval (CI) 0·04-∞; 'partly eaten': OR 8·4, 95% CI 1·4-87·5; 'most or all eaten': OR 36·1, 95% CI 3·3-2119). The local authority found evidence that the preparation of chicken livers breached Food Standards Agency's guidelines. This epidemiological investigation established a clear dose-response relationship between consumption of chicken liver pâté and the risk of infection with Campylobacter. The continuing need to raise public awareness of the risk to human health posed by undercooked chicken liver is evident.

Streptococcus pyogenes cluster in a care home in England April to June 2010.

Two fatal cases of Streptococcus pyogenes emm st22.6 bacteraemia occurred in a care home in England during April and June 2010, initiating a cluster investigation. The first case had left the home 13 days before the second case took up residence. We sought further cases and carriers. We swabbed throat and chronic skin lesions from residents and staff and examined these specimens for the presence of S. pyogenes. 61 specimens were taken from 18 of 19 residents and 39 of 39 staff. All results from swabbing were culture negative. We observed infection control practices and the environment at the care home for deficiencies. Issues were identified relating to the correct use of personal protective equipment, hand hygiene, clinical waste and laundry. Infection control practices were improved and training given. Infection control practices and the environment at a care home should be examined as part of the investigation of a S. pyogenes cluster. Screening for carriage of S. pyogenes should be done before antibiotic chemoprophylaxis is issued to care home residents and staff.

Five hepatitis B outbreaks in care homes in the UK associated with deficiencies in infection control practice in blood glucose monitoring.

Healthcare-associated hepatitis B virus (HBV) outbreaks have been reported in the USA and from several countries in Europe. Patient-to-patient transmission of HBV in these settings has been linked to several different types of exposure but one of the most common exposures implicated is the use of 'finger-stick' lancet devices for blood glucose testing. This article is an account of the investigations into a series of HBV outbreaks linked to the use of lancing devices in community healthcare settings in the UK. Between February 2004 and December 2006, nine individuals with acute HBV infection were reported to five local units of the Health Protection Agency. Investigations identified a further 12 individuals with HBV infection in residents in these settings. The epidemiological and environmental evidence suggests that HBV transmission occurred mostly from a significant breakdown in infection control measures in blood glucose testing. The occurrence of these outbreaks has highlighted the confusion that exists and the need for clear recommendations regarding the use of such devices in the UK.

Behavioural, biochemical, and pathological responses of possums (Trichosurus vulpecula) poisoned with phosphorus paste.

AIM: To investigate the behavioural, biochemical and pathological responses of possums following poisoning with phosphorus paste, in order to assess the implications for the welfare of possums. METHODS: After ingestion of phosphorus paste by wild-caught possums (18 high dose, nine low dose, and 12 non-poisoned controls), behavioural observations were made at 15-min intervals for 24 h or until death. Serum biochemistry, and gross and microscopic pathology were assessed at 3-hourly intervals in a further 21 possums. RESULTS: Possums that ingested phosphorus paste developed an abnormal posture (high incidence of crouching after 4-8 h), mild congestion of the gastric mucosa, and elevated levels of creatine kinase (CK) in serum after 3-6 h. Retching was observed in 67% possums, and 44% vomited at least once. Possums were prostrate from about 18 h after eating the poison, and the response to handling, an indicator of consciousness, was lost at about 24 h, followed by death at 25 h. CONCLUSION: The main welfare concern was the possibility of discomfort or pain caused by the congestion of the gastric mucosa, as indicated by the crouched posture adopted by poisoned possums. Retching and vomiting may also have caused pain and distress. The degree of pain or discomfort would depend on the degree of congestion of the gastric mucosa, which was typically mild, and on the duration and severity of retching and vomiting, which were typically short and mild. Possums remained conscious until 1 h before death, implying that they were able to experience pain and distress from the effects of ingestion of phosphorus for almost the entire period of illness, which lasted for approximately one day.

Trichinellosis acquired in the United Kingdom.

An outbreak of trichinellosis that occurred in the United Kingdom is described. Members of four households consumed pork salami from northern Serbia, the Federal Republic of Yugoslavia. Eight cases of trichinellosis occurred. Clinical and laboratory features of the cases were typical with myalgia (7 cases), fever (6), headache (5), periorbital oedema (4), non-specific ST/T wave changes on electrocardiogram (3), Trichinella antibodies (6), eosinophilia (7) and raised serum creatine kinase (3). All recovered. Trichinella larvae were detected in the salami. During pre-travel counselling, travellers should be advised about possible risk from cured pork products which have been produced locally in Trichinella endemic areas.

Difficulties in assessing the relationship, if any, between mumps vaccination and diabetes mellitus in childhood.

This paper considers the hypothesis that mumps vaccine may be an environmental factor for childhood diabetes and the difficulties assessing the available information about this. A review was undertaken of the published literature about mumps or mumps vaccine and diabetes mellitus in childhood. There has been considerable speculation about the role of wild mumps virus and mumps vaccine in the onset of childhood diabetes. Available data about this is incomplete and difficult to interpret partly as several factors are thought to be involved in the development of childhood diabetes. Well-designed and long-term studies about the use of mumps vaccine and incidence of childhood diabetes could be done. The general approach used in this paper could be applied to study the health effects of other vaccines.

Escherichia coli O157 incident associated with a farm open to members of the public.

Three children, one who lived on an open farm and two who visited the farm in school parties, developed Vero cytotoxin producing Escherichia coli (VTEC) O157 infection in 1997. All had been in direct contact with animals. All were admitted to hospital with diarrhoea and two developed the haemolytic uraemic syndrome, one of whom developed severe neurological impairment. E.coli O157 phage type 21 that produced Vero cytotoxin 2 were isolated from the three children and from a goat paddock and two cows at the farm. The isolates were indistinguishable by molecular typing. The farm closed voluntarily for six weeks while recommendations to reduce the exposure of visitors to faecal contamination and to improve hygiene procedures (especially handwashing) were implemented. More research is needed into all aspects of VTEC O157 on farms, including the natural history of carriage in animals, the organism prevalence and factors that affect infectivity to humans. Further consideration is needed about the role of open farms in zoonoses, and how open farms can be assisted in reducing risks for visitors. The public need to be educated about the risks and about their responsibilities, which include the need to wash hands thoroughly and to avoid hand to mouth contact when visiting farms.

Effect of potassium cyanide on behaviour and time to death in possums.

AIM: To assess the sickness behaviours of possums after eating a lethal dose of potassium cyanide. METHOD: Spontaneous behaviour and the time to loss of physical responses were examined. RESULTS: Cyanide ingestion caused a short-lasting period of mild respiratory stimulation. There was no salivation, retching or vomiting. Convulsions occurred in 73% of the possums. After the ingestion of cyanide, the average time to onset of ataxia was 3 minutes, the average time to overall loss of consciousness was 6.5 minutes, and the time to cessation of breathing was 18 minutes. CONCLUSION: Cyanide is a rapid-acting toxin with few undesirable signs from the welfare perspective.

Accuracy of routine laboratory diagnosis of malaria in the United Kingdom.

AIMS: To study the accuracy of routine laboratory diagnosis of malaria with the aim of improving accuracy in diagnosis in the future. METHODS: A comparative study was made of all blood films submitted to two laboratories in London providing a slide-diagnostic service for malaria. RESULTS: There were 17 Plasmodium ovale infections, and of these only five (29.4%) were correctly diagnosed by the submitting laboratory; whereas of 210 other single species infections, 162 (77.1%) were correctly diagnosed (chi 2 = 18.4, p < 0.0001). There were six patients with mixed infections; only one (16.7%) was correctly diagnosed, whereas of 227 single species infections, 167 (73.6%) were correctly diagnosed (p = 0.007, using Fisher's exact test). There was no significant association between the presence of technical faults or numerous platelets and incorrect diagnosis. CONCLUSIONS: Plasmodium ovale and mixed infections were diagnosed incorrectly significantly more often than other species. The presence of technical faults or numerous platelets had no significant effect on whether or not submitting laboratories correctly diagnosed malaria.

Effects of culture media on detection of methicillin resistance in Staphylococcus aureus and coagulase negative staphylococci by disc diffusion methods.

AIMS: To test 10 culture media for their ability to detect resistance and sensitivity of staphylococci to methicillin by disc diffusion. METHODS: Fifty strains of Staphylococcus aureus and 135 strains of coagulase negative staphylococci were tested using Columbia, Diagnostic Sensitivity Test, Mueller Hinton, Sensitest and Iso-sensitest agars with and without 5% added sodium chloride. Cultures were examined after 18 and 40 hours of incubation. The diameter of the zone and its characteristics were recorded and these media were assessed for their ability to produce clear, readable zones of inhibition. Changes in the variables which determined resistance were investigated. Results were analysed allowing a zone diameter reduction of 8 mm and 10 mm compared with the control in addition to the standard 6 mm. RESULTS: Columbia agar with added sodium chloride supported the growth of all strains, detected the highest number of resistant strains, and was the easiest to read. Resistance was detected after 18 hours in most resistant strains, but some required 40 hours of incubation. There was poor agreement, however, on this medium (63-94%) between disc diffusion and the reference MIC method for sensitive strains. Allowing a greater reduction in zone size resulted in more agreement with sensitive strains but with consequently lowered detection of resistant strains. The other media showed some growth failures and more zones that were difficult to read. More resistance was detected when incubation was prolonged to 40 hours but this was consistently less than on Columbia agar with added salt. CONCLUSIONS: None of the media detected all of the resistant strains. Columbia agar with added salt was the most satisfactory medium in this respect, but it misidentified up to 37% of the sensitive strains as resistant. Methicillin susceptibility testing by disc diffusion testing is unreliable.

Neonatal infections with Haemophilus species.

During a 27 month study seven nonserotypable strains of Haemophilus influenzae and two of Haemophilus parainfluenzae were isolated from nine neonates. Seven had early infection associated with respiratory distress or conjunctivitis; three had septicaemia one of whom died. The incidence of haemophilus septicaemia was 0.23 per 1000 live births.

Comparison of culture media for detecting methicillin resistance in Staphylococcus aureus and coagulase negative staphylococci.

The detection of methicillin resistance was examined in 51 strains of Staphylococcus aureus and 135 strains of coagulase negative staphylococci using Isosensitest, Diagnostic Sensitivity Test (DST), Mueller-Hinton (MH), Columbia, and Sensitest agars. MH agar with 5% added sodium chloride incubated at 35 degrees C was the most effective in detecting resistance in S aureus, and Columbia agar with 5% added sodium chloride incubated at 35 degrees C was most effective for coagulase negative staphylococci. For clinical purposes, a provisional report of sensitivity for S aureus could be issued after 18 hours; with coagulase negative staphylococci, only resistant strains could be reported at this time. For definitive results cultures must be examined after 40 hours of incubation.

Rat-bite acquired leptospirosis.

We report a case of leptospirosis in a boy following a rat-bite, an unusual mode of transmission for this infection. The use of antibiotics for fever following a rat-bite is discussed.