COVID-19: public health management of the first two confirmed cases identified in the UK.

We report key learning from the public health management of the first two confirmed cases of COVID-19 identified in the UK. The first case imported, and the second associated with probable person-to-person transmission within the UK. Contact tracing was complex and fast-moving. Potential exposures for both cases were reviewed, and 52 contacts were identified. No further confirmed COVID-19 cases have been linked epidemiologically to these two cases. As steps are made to enhance contact tracing across the UK, the lessons learned from earlier contact tracing during the country's containment phase are particularly important and timely.

Comparing scoring systems for prediction of mortality in patients with bloodstream infection.

BACKGROUND: Blood stream infections (BSIs) are associated with significant short-term mortality. There are many different scoring systems for assessing the severity of BSI. AIM: We studied confusion, urea, respiratory rate, blood pressure, age 65(CURB65), Confusion Respiratory Rate, Blood pressure, age 65(CRB65), quick sequential organ failure assessment (qSOFA), systemic inflammatory response syndrome (SIRS) and National Early Warning Score (NEWS) and assessed how effective they were at predicting 30-day mortality across three separate BSI cohorts. DESIGN: A retrospective analysis was performed on three established BSI cohorts: (i) All cause BSI, (ii) Escherichia coli and (iii) Streptococcus pneumoniae. METHODS: The performance characteristics (sensitivity, specificity, positive predictive value, negative predictive value and area under receiver operating curve [AUROC]) for the prediction of 30-day mortality were calculated for the 5 scores using clinically relevant cut-offs. RESULTS: 528 patients were included: All cause BSI-148, E. coli-191 and S. pneumoniae-189. Overall, 30-day mortality was 22%. In predicting mortality, the AUROC for CURB65 and CRB65 were superior compared with qSOFA, SIRS and NEWS in the all cause BSI (0.72, 0.70, 0.66, 0.51 and 0.53) and E. coli cohorts (0.81, 0.76, 0.73, 0.55 and 0.71). In the pneumococcal cohort, CURB65, CRB65, qSOFA and NEWS were broadly equal (0.63, 0.65, 0.66 and 0.62), but all were superior to SIRS (0.57). CURB65, CRB65 and qSOFA had considerably higher accuracy than SIRS or NEWS across all cohorts. CONCLUSION: CURB65 was superior to other scores in predicting 30-day mortality in the E. coli and all cause BSI cohorts. Further research is required to assess the potential of broadening the application of CURB65 beyond pneumonia.

Escherichia coli bloodstream infection outcomes and preventability: a six-month prospective observational study.

BACKGROUND: Escherichia coli bloodstream infection (BSI) is a common and serious problem, and incidence and antibiotic resistance are increasing. AIM: To understand the drivers of outcomes and factors associated with preventable cases at the study institution. METHODS: Between 1st November 2017 and 30th April 2018, cases of E. coli BSI in adults treated as inpatients at the study institution were included in a prospective cohort. Clinical, demographic and laboratory features were recorded, with seven-, 30- and 90-day mortality and length of hospital stay post BSI. Qualitative data on preventability were reviewed independently by two infection specialists. FINDINGS: In total, 195 cases in 188 patients were included in the analysis. Empirical antibiotics showed in-vitro resistance in 30.9% of cases. Thirty-day mortality was 23.6%, with a median length of hospital stay of seven days. On multi-variable analysis, 30-day mortality was associated with higher Charlson score, residential home residency, higher respiratory rate and higher serum urea, whilst prolonged length of stay was associated with hospital-acquired E. coli BSI. Fifty patients were felt to have avoidable BSI, all of which were health care associated; urinary catheter use, antibiotic-related and procedural complications were the areas of preventability. CONCLUSIONS: E. coli BSI has an appreciable mortality, with little in the way of modifiable risk factors for mortality or prolonged hospital stay. Attention to urinary catheter use is likely to be the most useful way to reduce the incidence, but current UK reduction targets may be unachievable.

Long-term mortality following bloodstream infection.

Bloodstream infection is associated with significant short-term mortality, but less is known about long-term outcome. We describe factors affecting mortality up to 3 years after bloodstream infection in a cohort of patients reviewed at the bedside by an infection specialist. Patients seen by the bacteraemia service of our infectious diseases department between June 2005 and November 2008 were included in analyses. Routine clinical data collected at the time of consultation, together with laboratory, demographic and outcome data were analysed to identify factors predicting death at 30 days and 3 years after bloodstream infection. Cox regression models for both time-points were constructed, together with Kaplan-Meier survival curves. In all, 322 bloodstream infections were recorded in 304 patients. The 30-day mortality was 15%, with a 3-year mortality of 49%. At 30 days after bacteraemia, in the Cox regression model, increasing age (p 0.003) and lower serum albumin (p 0.014) were predictive of death. At 3 years, age (p <0.0001) and albumin (p 0.004) remained significant predictors of death, with the presence of vascular disease (p 0.05) also significantly associated with mortality. If temperature was treated as a continuous variable then urea was significant (p 0.044); however, if temperature was categorized into hypothermia and non-hypothermia, then the presence of hypothermia (p 0.008) and chronic renal disease (p 0.034) became significant. There is an appreciable and gradual increase in mortality after an episode of bloodstream infection. Although many factors may not be amenable to intervention, patients at high risk of long-term mortality might require further follow up and assessment for potentially modifiable factors.