Evidence-informed healthcare through integration of health research.

A foundational element of modern healthcare is an evidence-based practice. However, the conduct of research to generate evidence and the subsequent application of research findings are viewed by many Canadian healthcare organizations as separate from healthcare delivery. This mindset impedes effective translation of knowledge into practice. In this article, underlying issues that enable this disintegrated model to persist are described, and strategies to help healthcare organizations achieve integration of research are summarized.

Yersinia enterocolitica biotype 2 serotype O9 septicaemia in a previously fit man, raw goats' milk having been the apparent vehicle of infection: a cautionary tale.

A previously fit 66-year-old man presented with a 2 weeks' history of malaise, fever and vomiting which led to a septicaemic illness. Yersinia enterocolitica biotype 2 serotype O9 was isolated from the patient's blood and from raw goats' milk remaining in a bottle after the patient had consumed some of the contents. He also produced antibodies to this serotype. Careful history taking, however, revealed that the bottle of milk had been purchased after the patient became ill. Milk from the same bottle was consumed by his wife who neither became ill nor seroconverted. Furthermore, the organism was not isolated from further samples from the same supplier. The milk consumed by the patient was probably contaminated by him so that initial enthusiasm in attributing his infection to the consumption of raw goats' milk is not supported by the facts. This case illustrates some of the pitfalls of trying to determine the vehicle of infection in a single case.

An atypical case of Corynebacterium diphtheriae endocarditis and subsequent outbreak control measures.

An atypical case of Corynebacterium diphtheriae endocarditis with severe rhabdomyolysis and cerebral emboli is presented. The patient underwent successful mitral and aortic valve replacements and is only the third reported case with a successful outcome following surgery. Outbreak control measures were complicated by an equivocal result from guinea pig toxin tests.

European Antimicrobial Resistance Surveillance System (EARSS): objectives and organisation.

Effective European surveillance must have the agreement and active involvement of all participants, concluded a European Union (EU) conference on the need for surveillance of resistant microorganisms (the microbial threat), held in September 1998 in De

Bacteraemia and antibiotic resistance of its pathogens reported in England and Wales between 1990 and 1998: trend analysis.

OBJECTIVES: Determination of causes, trends, and antibiotic resistance in reports of bacterial pathogens isolated from blood in England and Wales from 1990 to 1998. DESIGN: Description of bacterial isolates from blood, judged to be clinically significant by microbiology staff, reported to the Communicable Disease Surveillance Centre. SETTING: Microbiology laboratories in England and Wales. SUBJECTS: Patients yielding clinically significant isolates from blood. MAIN OUTCOME MEASURES: Frequency and Poisson regression analyses for trend of reported causes of bacteraemia and proportions of antibiotic resistant isolates. RESULTS: There was an upward trend in total numbers of reports of bacteraemia. The five most cited organisms accounted for over 60% of reports each year. There was a substantial increase in the proportion of reports of Staphylococcus aureus resistant to methicillin, Streptococcus pneumoniae resistance to penicillin and erythromycin, and Enterococcus faecalis and Enterococcus faecium resistance to vancomycin. No increase was seen in resistance of Escherichia coli to gentamicin. CONCLUSIONS: Reports from laboratories provide valuable information on trends and antibiotic resistance in bacteraemia and show a worrying increase in resistance to important antibiotics.

Changing carriage rate of Neisseria meningitidis among university students during the first week of term: cross sectional study.

OBJECTIVE: To determine the rates of, and risk factors for, meningococcal carriage and acquisition among university students. DESIGN: Repeated cross sectional study. PARTICIPANTS: 2,507 students in their first year at university. MAIN OUTCOME MEASURES: Prevalence of carriage of meningococci and risk factors for carriage and acquisition of meningococci. RESULTS: Carriage rates for meningoccoci increased rapidly in the first week of term from 6.9% on day 1, to 11.2% on day 2, to 19.0% on day 3, and to 23.1% on day 4. The average carriage rate during the first week of term in October among students living in catered halls was 13.9%. By November this had risen to 31.0% and in December it had reached 34. 2%. Independent associations for acquisition of meningococci in the autumn term were frequency of visits to a hall bar (5-7 visits: odds ratio 2.7, 95% confidence interval 1.5 to 4.8), active smoking (1.6, 1.0 to 2.6), being male (1.6, 1.2 to 2.2), visits to night clubs (1. 3, 1.0 to 1.6), and intimate kissing (1.4, 1.0 to 1.8). Lower rates of acquisition were found in female only halls (0.5, 0.3 to 0.9). The most commonly acquired meningococcal strain was C2a P1.5 (P1.2), which has been implicated in clusters of invasive meningococcal disease at other UK universities. CONCLUSIONS: Carriage rates of meningococci among university students increase rapidly in the first week of term, with further increases during the term. The rapid rate of acquisition may explain the increased risk of invasive meningococcal disease and the timing of cases and outbreaks in university students.

Influenza B, Q fever, and the consequences of febrile illness occurring during jungle warfare training: a clinical and serological study.

Seventy-one Royal Marines undergoing jungle warfare training were studied clinically and serologically to determine the incidence and consequences of febrile illness. During acclimatization and the early part of the deployment the incidence of illness having an impact on training was low; during the latter part an outbreak of influenza B occurred, with 25 cases diagnosed clinically. Only 12 of these were confirmed serologically, probably because the outbreak was still in progress when the second samples were taken. A further four subclinical cases were uncovered by the serological study. Five cases of heat exhaustion occurred, one Marine suffering two episodes. Four patients required case-vac from the jungle. Three Marines were found to have serological evidence of previous acute Q fever, including the patient who had two episodes of heat exhaustion. This incidence is higher than expected, and warrants further investigation.

Early management of meningococcal disease.

Sixty-eight cases of meningococcal disease were ascertained at a district hospital in Wessex region over a four year period. Forty-seven of the 68 patients were reported to have a haemorrhagic rash on admission to hospital, three of whom died. Twelve of the 47 had received parenteral antibiotic treatment before admission, and none of these died. The overall case fatality was 4% (3/68). Sixty-three patients were referred by general practitioners. In 19 of the 63 a haemorrhagic rash was described at referral, and a haemorrhagic rash was described in 42 on hospital admission. Thirteen of the 63 received parenteral antibiotic treatment before admission. Such treatment was significantly more likely when the referral letter described a haemorrhagic rash and appeared to be less likely in child cases and when patients had received earlier oral antibiotics.

Turbidimetric response of Staphylococcus aureus and Enterococcus faecalis to daptomycin.

The response to daptomycin of three strains of Staphylococcus aureus (one of which was methicillin-resistant) and a strain of Enterococcus faecalis was investigated by continuous turbidimetric monitoring. Daptomycin caused partial inhibition of bacterial growth at concentrations well below those suppressing growth overnight. The activity of the drug was more than 200-fold greater in the presence of a physiological concentration of calcium (2.5 mmol/l) than in its absence. Variants present in cultures inhibited by daptomycin were shown to exhibit decreased susceptibility to the drug and the susceptibility declined further on repeat exposure; however, there was a slow but incomplete reversion to susceptibility on sequential subculture in drug-free broth. Resistance was difficult to induce when the concentration of calcium in the broth exceeded 2.5 mmol/l.

The effect of cultural conditions on the activity of LY146032 against staphylococci and streptococci.

The antibacterial activity of LY146032 was greatly potentiated in the presence of calcium ions. In the presence of a physiological concentration of calcium (ca 100 mg/l: 2.5 mM) the new compound was more active than vancomycin or teicoplanin against a selection of clinical isolates of staphylococci and streptococci. The requirement for calcium could not be satisfied by magnesium. The activity of LY146032 varied when tested in different culture media, including batches of Mueller-Hinton agar from different manufacturers. The highest minimum inhibitory concentrations of LY146032 were observed in tests on Iso-Sensitest agar, which contains little calcium. Supplementation of Iso-Sensitest agar with increasing concentrations of calcium caused a proportionate fall in the MIC of LY146032. Saponin-lysed horse blood; incubation in a CO2-rich atmosphere; and an increase in the bacterial inoculum from 10(3) to 10(6) cfu/spot had little effect on the activity of LY146032 in the presence or absence of calcium.

Sustained reduction in the carriage of Neisseria meningitidis as a result of a community meningococcal disease control programme.

The effect of a community intervention programme of antibiotics and meningitis vaccine on pharyngeal carriage of Neisseria meningitidis was investigated. Carriage rates were determined in pupils at both secondary schools (ages 11-18 years) included in the community intervention programme and compared with two schools outside the area matched for socio-economic status. A total of 1869 pupils were studied 6 months after the programmes, and 2457 pupils after 11 months. Six months after the programme was completed there was a 72% reduction in pharyngeal carriage of Neisseria meningitidis in pupils attending the schools in the intervention area compared with pupils in the control schools. After 11 months this difference persisted in the 11-14 age group but not in the 15-18 age group. No resistance to the antibiotics used in the programme was found. A community intervention programme of antibiotics and vaccine for the control of meningococcal disease led to a long-term reduction in Neisseria meningitidis carriage in some age groups.