Evaluation of a virtual ward model of care and readmission characteristics during the COVID-19 pandemic within an Australian tertiary hospital.

BACKGROUND: Virtual ward (VW) models of care established during the coronavirus disease 2019 (COVID-19) pandemic provided safe and equitable provision of ambulatory care for low-risk patients; however, little is known about patients who require escalation of care to hospitals from VWs. AIM: To assess our VW model of care and describe the characteristics of patients admitted to the hospital from the VW. METHODS: Observational study of all patients admitted to a tertiary hospital COVID-19 VW between 1 December 2021 and 30 June 2022. Utilisation and epidemiological characteristics were assessed for all patients while additional demographics, assessments, treatments and outcomes were assessed for patients admitted to the hospital from the VW. RESULTS: Of 9494 patient admissions, 269 (2.83%) patients identified as Aboriginal and Torres Strait Islander and 1774 (18.69%) were unvaccinated. The median length of stay was 5.10 days and the mean Index of Relative Socio-economic Advantage and Disadvantage decile was 5.73. One hundred sixty (1.69%) patients were admitted to the hospital from the VW, of which 25 were adults admitted to medical wards. Of this cohort, prominent comorbidities were obesity, hypertension, asthma and frailty, while the main symptoms on admission to the VW were cough, fatigue, nausea and sore throat. High Pandemic Respiratory Infection Emergency System Triage (PRIEST), Veterans Health Administration COVID-19 (VACO), COVID Home Safely Now (CHOSEN) and 4C mortality scores existed for those readmitted. CONCLUSIONS: This VW model of care was both safe and effective when applied to a broad socioeconomic population during the COVID-19 pandemic. While readmission to the hospital was low, this study identified key characteristics of such presentations, which may assist future triaging, escalation and resource allocation within VWs during the COVID-19 pandemic and beyond.

Home nursing and self-administered outpatient parenteral antimicrobial treatment: a comparison of demographics and outcomes from a large regional hospital in Queensland, Australia.

BACKGROUND: Outpatient parenteral antimicrobial treatment (OPAT) is a safe and effective therapy used in several settings across Australia. As OPAT services expand their inclusion criteria to include complex patient populations, there is an increased need for selecting appropriate patients to receive either healthcare-administered OPAT (H-OPAT) or self-administered OPAT (S-OPAT). AIMS: To describe patient demographics, diagnosis, microbiology and outcomes of patients treated by H-OPAT and S-OPAT within the Sunshine Coast Hospital and Health Service, Australia. METHODS: Data on demographics, diagnoses, treatment and outcomes on all patients treated by H-OPAT and S-OPAT from March 2017 to December 2019 were collected retrospectively. RESULTS: One hundred and sixty-five patients (62.26%) were enrolled in H-OPAT and 100 patients (37.74%) in S-OPAT. S-OPAT patients were significantly younger. H-OPAT patients were more comorbid. Bone and joint infections were the most treated infections and were more likely to be treated by S-OPAT. There was no difference in treatment duration, cure and complication rates between S-OPAT and H-OPAT. Longer duration of therapy was associated with more complications. Treatment failure was associated with infections due to multiple organisms, number of comorbidities and treatment of surgical site, skin and soft tissue infections. CONCLUSIONS: There were significant differences in demographics between H-OPAT and S-OPAT without any difference in outcomes. Overall failure and complication rates were low. Higher rates of treatment failure were predicted by the diagnosis, number of comorbidities and number of organisms treated.

Emergency inserted peripheral intravenous catheters: a quality improvement project.

Vascular access devices are common and necessary in healthcare provision but their use poses a significant risk of acquiring an infection. Ambulance/emergency inserted peripheral intravenous catheters (PIVCs) potentially have higher risks of catheter-related bloodstream infection (CRBSI) because of the inability to maintain asepsis during the insertion procedure. Local guidelines (Queensland, Australia) recommend the removal or replacement of PIVCs inserted in these situations within 24 hours. Routine clinical audits performed within the authors' health service demonstrated a delay in removing ambulance/emergency inserted PIVCs beyond acceptable dwell times. Ambulance/emergency inserted PIVCs were not being recognised as requiring removal by ward staff. A quality improvement project involving key stakeholder engagement, the roll out of a sticker to readily identify ambulance/emergency inserted PIVCs and education of ward staff was introduced to enable identification of this high-risk group. Post-implementation audits demonstrated a significant reduction in numbers of ambulance/emergency PIVCs remaining in situ for longer than 24 hours.

To swab or not to swab? A qualitative study of pathology testing, interpretation, and value in diabetes-related foot ulceration.

BACKGROUND: Diagnostic testing has been proposed as a key strategy to tackle escalating antimicrobial resistance (AMR). However, effectiveness of testing is limited by the complexities of the hospital environment, including human factors. OBJECTIVES: To examine swab-testing in diabetes-related foot infections as a case study of the factors impacting microbiology testing use, efficacy, and antimicrobial resistance. METHODS: Seventeen clinicians involved in the management of diabetes-related foot infections, including podiatrists, nurses, and doctors, participated in in-depth individual interviews conducted by a qualitative researcher on the investigation and management of diabetes-related foot infections. Thematic analysis was performed. RESULTS: The multilayered and evolving features of the human-diagnostic interface were described by participants as potential barriers to effective swab-testing in clinical care, including diagnostic training and interpretation deficits; communication difficulties; interpretation deficits and diagnostic assumptions; the influence of inter-professional dynamics; and flow-on consequences for patient decisions and care. CONCLUSIONS: Swab-testing has been used for over 100 years, and yet there remain substantial factors that limit their effective use in clinical practice as demonstrated by this study. A focus on upscaling diagnostic testing, particularly with escalating AMR, without considering complex implementation and human factors is likely to have limited impact on practice improvement. This study identified vulnerability points in the human-diagnostic interaction which should be considered in the implementation of other microbiological tests. This study on the simple wound swab has implications for future diagnostic upscaling and investment, including its role in address antimicrobial resistance.

Central Skull Base Osteomyelitis in Queensland, Australia, 2010-2020.

Background: Central skull base osteomyelitis (CSBO) is an incompletely defined, life-threatening infection of the bones of the cranial vault. We describe the clinical features and outcomes of CSBO in Queensland, Australia, over an 11-year period. Methods: Medical record coding enquiries identified cases of CSBO across 6 tertiary hospitals in Queensland, Australia, from January 2010 to December 2020. Epidemiological, demographic, diagnostic, management, and outcome data were collected from each identified case. Results: Twenty-two cases of CSBO were identified within the study period; the median age was 73 years with a male predominance (73%). High rates of comorbid disease were detected, with a median Charlson Comorbidity Index score of 5. Diabetes mellitus was the most frequently observed condition. Six cases had bone sampling for microbiological diagnosis while the remainder had superficial sampling of contiguous structures. The most common pathogen isolated was Pseudomonas aeruginosa followed by Staphylococcus aureus, with only 1 case of fungal infection. This series demonstrated a mortality rate of 31.8%, with 45.5% of cases left with long-term sequelae including persistent pain and cranial nerve deficits. Conclusions: Four key observations emerged in this series: (1) advanced age and diabetes mellitus are common risk factors for CSBO, (2) limited surgical intervention occurred, (3) microbiological diagnoses relied primarily on superficial sampling, and (4) significant mortality and morbidity was observed. Prospective studies are needed to better understand the optimal approach to the diagnosis and management of CSBO and to improve clinical outcomes.

Rapid fluoroquinolone resistance detection in Pseudomonas aeruginosa using mismatch amplification mutation assay-based real-time PCR.

Background. Antimicrobial resistance (AMR) is an ever-increasing global health concern. One crucial facet in tackling the AMR epidemic is earlier and more accurate AMR diagnosis, particularly in the dangerous and highly multi-drug-resistant ESKAPE pathogen, Pseudomonas aeruginosa.Objectives. We aimed to develop two SYBR Green-based mismatch amplification mutation assays (SYBR-MAMAs) targeting GyrA T83I (gyrA248) and GyrA D87N, D87Y and D87H (gyrA259). Together, these variants cause the majority of fluoroquinolone (FQ) AMR in P. aeruginosa.Methods. Following assay validation, the gyrA248 and gyrA259 SYBR-MAMAs were tested on 84 Australian clinical P. aeruginosa isolates, 46 of which demonstrated intermediate/full ciprofloxacin resistance according to antimicrobial susceptibility testing.Results. Our two SYBR-MAMAs correctly predicted an AMR phenotype in the majority (83%) of isolates with intermediate/full FQ resistance. All FQ-sensitive strains were predicted to have a sensitive phenotype. Whole-genome sequencing confirmed 100 % concordance with SYBR-MAMA genotypes.Conclusions. Our GyrA SYBR-MAMAs provide a rapid and cost-effective method for same-day identification of FQ AMR in P. aeruginosa. An additional SYBR-MAMA targeting the GyrB S466Y/S466F variants would increase FQ AMR prediction to 91 %. Clinical implementation of our assays will permit more timely treatment alterations in cases where decreased FQ susceptibility is identified, leading to improved patient outcomes and antimicrobial stewardship.

Mycotic aortic aneurysm formation following intravesical BCG treatment for transitional cell carcinoma of the bladder.

Mycotic aneurysms are rare and if left untreated, can have devastating outcomes. In this case, a 72-year-old man presented to hospital with fevers, night sweats and abdominal pain. A CT scan revealed the development an infrarenal pseudoaneurysm over the course of 8 weeks, increasing from 2.8 cm to a 3.1 cm. The aneurysm was not present on a CT scan performed 6 months earlier. The patient underwent an emergency endovascular repair of the aortic aneurysm (EVAR) and was placed on broad-spectrum antibiotics. Intra-aortic blood cultures aspirated adjacent to the aneurysm and tissue biopsy confirmed tuberculosis bovis as the cause of the mycotic aneurysm. The patient had been treated with intravesical BCG for transitional cell carcinoma of the bladder several months prior. The patient was treated with an extended course of antituberculosis medication. He recovered well and was back to his baseline function within weeks.

Aciclovir-resistant herpes keratitis.

Herpes simplex virus (HSV) keratitis is a common cause of ocular morbidity. Resistance to aciclovir is probably under recognized. We describe three cases of aciclovir-resistant herpes simplex virus keratitis treated with systemic foscarnet and present a review of the pharmacological options available to manage this condition.

COVID-19 in a complex obstetric patient with cystic fibrosis.

We report the first case of COVID-19 in a pregnant patient with cystic fibrosis. We describe the diagnosis, clinical course and management of the patient and their family with regards to clinical, social and infection control measures around delivery. This case highlights the importance of the cooperation of multidisciplinary teams to achieve good clinical outcomes in complex patients with COVID-19.

A Case of Japanese Encephalitis with a Fatal Outcome in an Australian Who Traveled from Bali in 2019.

A severe case of Japanese encephalitis virus (JEV) infection, resulting in fatality, occurred in an unvaccinated Australian male traveler from Bali, Indonesia, in 2019. During hospitalisation in Australia, patient cerebrospinal fluid (CSF) yielded JEV-specific IgM antibodies and RNA, and an isolate of the virus. Ongoing transmission of JEV in Bali underscores this pathogen as a public health risk and the importance of appropriate health, vaccination and mosquito avoidance advice to prospective travelers to the region.

Iatrogenic neuropsychiatric syndromes.

BACKGROUND: Although tramadol induced neuropsychiatric toxicity, dependence and withdrawal have been extensively reported in chronic pain sufferers, such cases continue to surface in clinical practice. OBJECTIVE: We describe two cases of atypical withdrawal after abrupt discontinuation of tramadol and a case of serotonin syndrome. The outcome was favourable in all three cases. DISCUSSION: Patients and prescribers are reminded of the risk of severe morbidity including seizures associated with tramadol withdrawal. Serotonin syndrome can be precipitated with tramadol use especially in combination with other serotonergic drugs.

An unusual skin lesion caused by Lasiodiplodia theobromae.

We describe a case of subcutaneous infection as a result of traumatic implantation caused by the fungus Lasiodiplodia theobromae. It was isolated in multiple swabs from the foot of an active healthy male. The fungus was identified by traditional mycology culture methods though this was slow with much time required for sporulation on only one of the agars used. Identification was confirmed by DNA sequencing. The patient was successfully treated with Voriconizole.

Nontraumatic paecilomyces anterior segment infection: a pathognomonic clinical appearance.

PURPOSE: The aim of this study was to review a series of consecutive cases of corneal and scleral infection by Paecilomyces spp. and to identify features of clinical presentation and assess treatment modalities. METHODS: This retrospective review of a case series included 22 patients with nontraumatic Paecilomyces anterior segment infections who were seen in a tertiary referral practice. Outcome measures were the number of eyes that were lost and visual acuity in eyes that were saved. RESULTS: Twenty-two patients with Paecilomyces corneal or scleral infection with no significant history of trauma or surgery were identified over a 20-year period. Two distinct clinical presentations were noted with 17 presenting with corneal infection and 5 initially presenting with scleral infection, and all demonstrated a classical endothelial plaque and deep stromal infiltrate. Almost all required single or multiple anterior segment reconstructive surgeries together with systemic and topical antifungal agents. The first 10 patients were treated with amphotericin B, whereas the remaining 12 patients were treated with voriconazole and 21 of 22 patients underwent surgery. Paecilomyces spp. was identified from most intraocular specimens although corneal fungal growth was noted only from deep corneal biopsies or corneal buttons removed during corneal transplantation. Outcomes were better in the last 12 patients treated with voriconazole. CONCLUSIONS: Nontraumatic Paecilomyces anterior segment infection presents with a pathognomonic clinical picture when the cornea is the initial site of infection and later in scleral infections. Early identification and aggressive treatment with extirpative surgery and voriconazole may result in retention of the eye with useful vision.