A randomised single-blind comparison of the effectiveness of Tristel Fuse (chlorine dioxide) as an office-based fluid soak, with Cidex OPA (ortho-phthaldehyde) using an automated endoscopic reprocessor (AER) as high-level disinfection for flexible cystoscopes.

OBJECTIVE: To compare the effectiveness, safety and cost of Tristel Fuse (chlorine dioxide) with Cidex OPA (ortho-phthaldehyde; 1,2-benzenedicarboxaldehyde) in an automated endoscopic reprocessor (AER) for high-level disinfection of flexible cystoscopes. PATIENTS AND METHODS: A randomised single-blind study comparing the high-level disinfectants Tristel Fuse as a simple office-based soak and Cidex OPA using an AER was performed. Participants were 'blinded' to the agent used for disinfection of the flexible cystoscopes. All patients had negative mid-stream urine at baseline, (MSU) no symptoms suggestive of urinary tract infection (UTI) on the day of investigation, no recent antibiotic use or current indwelling urinary catheter. Patients who underwent cystoscopic biopsy during the procedure were excluded. A urine analysis was done before and 3-5 days after cystoscopy and multiple equipment cultures were performed. The Urogenital Distress Inventory (UDI-6 + two questions from the 'long-form'), symptom and quality-of-life scores were assessed before and after cystoscopy as were ease-of-use assessments and a full cost analysis. RESULTS: In all, 180 of 465 screened participants were randomised 1:1 and the mean age was 72.1 years, 17% were females and 57% of procedures were performed for bladder tumour surveillance. The urine analysis was positive in 5.4% of patients in each group and 29% (Tristel) vs 20% (Cidex) of patients had urinary leukocyturia (p = ns) after cystoscopy. The turnover (minutes per cycle) was 7.5 (Tristel) vs 26.7 (Cidex). The per-procedure costs were $11.67 (American dollars) for Tristel Fuse and $21.82 for Cidex OPA with fixed costs of $4788 for Tristel Fuse and $60,514 for Cidex OPA. CONCLUSIONS: Tristel Fuse appears to be as effective and more cost-effective than Cidex OPA for high-level disinfection of flexible cystoscopes. This has significant cost implications for the office urologist.

Epidural abscess caused by Streptobacillus moniliformis.

We present an interesting case of a patient who developed an epidural abscess caused by Streptobacillus moniliformis. This is the first report in the medical literature of a spinal epidural abscess associated with this organism. Diagnosis of S. moniliformis infection requires a high degree of suspicion, and a delay may be inevitable when a relevant clinical history is lacking.

A national audit of performance standards for blood cultures in Aotearoa New Zealand: opportunities for improvement.

AIMS: To audit key quality indicators for blood culture (BC) practices across Aotearoa New Zealand to facilitate national BC practice peer review and promote BC quality improvement interventions. METHOD: Microbiology laboratories providing diagnostic services to district health board (DHB) hospitals were invited to participate. Practice was compared against published BC recommendations. Laboratories were required to submit data for BC positivity and contamination rates, BC bottle fill volume and the proportion of BC received as a single set. RESULTS: Laboratories serving 15 of the 20 DHBs participated in the audit. Nine DHBs (60%) demonstrated a positivity rate within the target range of 8% to 15%. Eight DHBs (53%) reported a contamination rate lower than the accepted 3%, but seven (47%) DHBs exceeded this target and two reported a contamination rate greater than 5%. Mean BC bottle fill volumes were generally greater than the target of 8mL, but this volume was not reached by three DHBs and a further three were unable to provide fill volume data. No DHB met the audit standard for single-set BCs representing <20%, and for six DHBs single-set BC comprised more than half of all samples. No DHB failed all audit targets. CONCLUSION: This audit demonstrates wide variation in BC performance across New Zealand. In most instances an inadequate volume of blood is being collected, lowering the chance of culturing a pathogen. A significant opportunity for improvement exists; clinical services and laboratories are encouraged to work together to implement targeted quality improvement processes to correct deficiencies in practice.

Lemierre syndrome: two cases and a review.

OBJECTIVES: Lemierre syndrome is usually caused by an acute oropharyngeal infection in previously healthy young adults, resulting in thrombophlebitis of the internal jugular vein, leading to metastatic septic embolization and bacteraemia. The usual organism is Fusobacterium necrophorum. Lemierre syndrome, not so long ago labeled as the "forgotten disease," is on the rise. Today with increasing antibiotic-resistant organisms, and decreasing awareness of the syndrome, subsequent re-emergence of this "forgotten disease" is becoming more common in clinical settings. Lemierre syndrome has significant morbidity. Cranial nerve complications associated with the condition have been increasingly diagnosed in the last few years. Looking back at literature on Lemierre syndrome, there have been review articles in medical and microbiology journals but rarely in otolaryngology journals. By presenting our cases we demonstrate the diverse presentations and severity of the illness. METHODS: A review of the literature and a case report on two cases seen in our institution in the last year are presented. Each of these had varied presentations and neurologic complications-one developed 9th to 12th cranial nerve palsies and Horner syndrome, which have not been described in previous literature, and the other developed polyneuropathy and a frontal lobe infarct among other multisystem complications. CONCLUSIONS: Diagnosis of Lemierre syndrome is not always straightforward as clinical features are variable and blood cultures are often negative. Awareness of the syndrome and a high degree of suspicion are needed.

Impact of universal hepatitis B vaccination on antenatal hepatitis B prevalence in the Midlands region of the North Island, New Zealand.

AIM: Universal hepatitis B vaccination has now been in place in New Zealand for 22 years. A retrospective laboratory data study has been carried out to give objective evidence of the impact that this is having on hepatitis B prevalence in the antenatal population. METHOD: A retrospective data search was performed of all antenatal hepatitis B surface antigen (HepBsAg) tests carried out at Pathlab Laboratories between 1997 and 2009. RESULTS: When the change in prevalence with time is examined, there is a clear downwards trend in antenatal hepatitis B prevalence rates from 1997 to 2009. Dividing the antenatal population into different age groups, the downward trend is most marked for those aged =20 years. CONCLUSION: The prevalence of hepatitis B infection in the antenatal population in the Midlands region of New Zealand is now declining and is likely to be as a result of the introduction of the hepatitis B vaccine onto the universal schedule throughout New Zealand in 1988. This would also explain why the decrease is most marked in antenatal women below the age of 20.