Megatrends in Infectious Diseases: The Next 10 to 15 Years

It has been about 100 years since the Spanish influenza pandemic of 1918-19 that killed an estimated 50 million individuals globally. While we have made remarkable progress in reducing infection-related mortality, infections still account for 13 to 15 million deaths annually. This estimate is projected to remain unchanged until 2050. We have identified 4 megatrends in infectious diseases and these are "emerging and re-emerging infections", "antimicrobial resistance", "demographic changes" and "technological advances". Understanding these trends and challenges should lead to opportunites for the medical community to reshape the future. Further inroads will also require broad approaches involving surveillance, public health and translating scientific discoveries into disease control efforts.

Survey of Respiratory Virus in Patients Hospitalised for Acute Exacerbations of Heart Failure - A Prospective Observational Study

INTRODUCTION@#Respiratory virus (RV) infections have been implicated in acute exacerbation cardiopulmunary conditions. This study aimed to determine the prevalence of RV infections in patients admitted to the cardiology unit with acute decompensated heart failure (ADHF) in a tertiary hospitals in Singapore.@*MATERIALS AND METHODS@#This was a single-centre, prospective observational study. A total of 194 adults (aged >21) admitted to the Singapore General Hospital with ADHF were recruited. A nasopharyngeal swab was taken for multiplex polymerase chain reaction (PCR) detection of influenza virus, rhinovirus, parainfluenza virus (HPIV), human coronavirus (HcoV), adenoviurs, human bocavirus (HboV), human metapneumovirus (hMPV), and respiratory syncytial virus (RSV).@*RESULTS@#Twenty-five (13%) had RVs detected by RV multiplex PCR. There comprised 9 rhinoviruses (36%), 4 influenza A viruses (16%), 3 HPIV (12%), 3 HCoV (12%), 2 adenoviruses (8%), 1 human HBoV (4%), 1 hMPV (4%), and 1 RSV (4%). Symptoms-wise, cough was significantly more common in the PCR-positive group (48% vs 24%, = 0.02). There were no statistically significant differences in laboratory investigations (haemoglobin, leukocytes, platelets, creatine kinase, creatine kinase-muscle/brain, troponin T), and radiology findings between RV PCR-positive and -negative groups. The PCR-positive group did not have increased mortality or length of hospital stay.@*CONCLUSION@#This study identified a considerable burden of RVs in our ADHF cohort, and highlights the need for prevention of RVs in this group of patients. We also recognised the difficulty with clinical diagnosis of RVs in ADHF patients.

Subcutaneous abscess due to Pyrenochaeta romeroi in a renal transplant recipient

An infective aetiology, including fungal infection, should be considered in the differential diagnosis of immunocompromised patients presenting with skin lesions. Dematiaceous fungi are recognised as pathogens in organ transplant recipients. Herein, we describe a rare case of a chronic necrotising granulomatous skin lesion caused by Pyrenochaeta romeroi in a renal transplant recipient, and review the existing literature on the topic. To the best of our knowledge, this is the first report of such a case in Singapore. Recognition of infections caused by dematiaceous fungi is important because some strains are difficult to identify and require special molecular diagnostic techniques. Treatment involves surgical excision and long-term antifungal therapy. Data on the optimal antifungal regimen in such a diagnosis is limited.

Selection of resistant fungi in liver transplant recipients during use of newer antifungal agents -- a report of two cases

<p><b>INTRODUCTION</b>Because invasive fungal infections cause significant morbidity and mortality in liver transplant recipients, the use of antifungal prophylaxis, and the early empirical use of antifungal agents, is widespread on liver transplant units. The new-generation azoles such as voriconazole and the echinocandins have been welcome additions to the antifungal armamentarium. These agents have become the leading options for prophylaxis in liver transplant units, despite the absence of strong data for their efficacy in this setting.</p><p><b>CLINICAL PICTURE</b>We report two recipients of living-donor liver transplants who became infected/colonised with fungi resistant to an echinocandin and the azoles after exposure to these agents. One patient developed trichosporonosis while on caspofungin and the other became infected/ colonised with Candida glabrata that was resistant to voriconazole and posaconazole.</p><p><b>CONCLUSION</b>We report these to highlight some of the consequences of using the newer antifungal agents.</p>

Severe infection with H1N1 requiring intensive care--lessons for preparedness programmes

<p><b>INTRODUCTION</b>The influenza pandemic has generated much interest in the press and the medical world. We report our experience with 15 cases of severe novel influenza A H1N1 (2009) infections requiring intensive care. The aim of this review is to improve our preparedness for epidemics and pandemics by studying the most severely affected patients.</p><p><b>CLINICAL PICTURE</b>During the epidemic, hospitals were required to provide data on all confirmed H1N1 cases admitted to an intensive care unit (ICU) to the Ministry of Health. We abstracted information from this dataset for this report. To highlight learning points, we reviewed the case notes of, and report, the fi ve most instructive cases.</p><p><b>TREATMENT</b>There were 15 cases admitted to an ICU from July 4, 2009 to August 30, 2009. Two patients died.</p><p><b>CONCLUSIONS</b>The lessons we wish to share include the following: preparedness should include having intermediate-care facilities that also provide single room isolation and skilled nursing abilities, stringent visitor screening should be implemented and influenza may trigger an acute myocardial infarction in persons with risk factors.</p>

Attitudes of patients, visitors and healthcare workers at a tertiary hospital towards influenza A (H1N1) response measures

<p><b>INTRODUCTION</b>We sought to determine the opinions of patients, their visitors and healthcare workers regarding Influenza A (H1N1) response measures instituted within a tertiary hospital in Singapore.</p><p><b>MATERIALS AND METHODS</b>This questionnaire study was undertaken from 21 May 2009 to 31 August 2009.</p><p><b>RESULTS</b>There were 92 respondents, ranging in age from 15 to 77 years. Of the 90 who identified their role, 35.6% were patients, 12.2% visitors and 52.2% health care professionals. About 23% of respondents disagreed that one could have H1N1 without fever or fl u-like symptoms, while 14.3% thought influenza could not be caught from an asymptomatic infected person. About 30% perceived the H1N1 death rate as high. From this study, 82.2% of respondents agreed or strongly agreed that Singapore's H1N1 responses were essential, while 14.6% found it overdone. In particular, healthcare workers and doctors found their professional work to be inconvenienced. Although more than two-thirds of doctors held this view, an equal proportion agreed the outbreak response was essential.</p><p><b>CONCLUSIONS</b>There was a high level of acceptance of response measures as essential, despite the perceived inconvenience. We propose that the success of containment measures requires unity of purpose and understanding among stakeholders at all levels.</p>

Use of antibiotics in a haematology ward--an audit

<p><b>INTRODUCTION</b>Rising rates of antibiotic resistance prompted a review of antibiotic use policies hospitalwide. The Department of Haematology established a new set of consensus guidelines in 2002 for antibiotic use in febrile neutropenia. The aim of our study was to audit adherence to the guidelines established for febrile neutropenia in patients treated for haematologic malignancies.</p><p><b>MATERIALS AND METHODS</b>An antibiotic escalation pathway was developed by haematologists and infectious disease physicians. Adherence to the guidelines was audited. Patients with acute myeloid leukaemia (AML) or acute lymphocytic leukaemia (ALL) who had febrile neutropenia after chemotherapy were reviewed. The audit was performed by a retrospective review of casenotes.</p><p><b>RESULTS</b>Forty patients with 100 episodes of febrile neutropenia were surveyed. Thirty-two had AML, 7 had ALL and 1 had undifferentiated leukaemia. In 76% of episodes, fever developed within the first 14 days of neutropenia. In 31 episodes, cefepime was started as the first-line agent; hence, compliance with the first-line agent was 31%. Fever defervesced in 13 episodes. The most common reason for switching antibiotics was persistent fever. There were clinical indications for non-compliance with the use of the first-line agent in all cases. There were 3 deaths - none related to non-compliance with or strict adherence to the guidelines. Four patients had proven fungal infections.</p><p><b>CONCLUSIONS</b>Given the complex nature of the cases, compliance was reasonable, as there were valid reasons in all cases where the guidelines were not adhered to. Based on our findings, the guidelines could be simplified.</p>