City-wide wastewater genomic surveillance through the successive emergence of SARS-CoV-2 Alpha and Delta variants.

Genomic surveillance of SARS-CoV-2 has provided a critical evidence base for public health decisions throughout the pandemic. Sequencing data from clinical cases has helped to understand disease transmission and the spread of novel variants. Genomic wastewater surveillance can offer important, complementary information by providing frequency estimates of all variants circulating in a population without sampling biases. Here we show that genomic SARS-CoV-2 wastewater surveillance can detect fine-scale differences within urban centres, specifically within the city of Liverpool, UK, during the emergence of Alpha and Delta variants between November 2020 and June 2021. Furthermore, wastewater and clinical sequencing match well in the estimated timing of new variant rises and the first detection of a new variant in a given area may occur in either clinical or wastewater samples. The study's main limitation was sample quality when infection prevalence was low in spring 2021, resulting in a lower resolution of the rise of the Delta variant compared to the rise of the Alpha variant in the previous winter. The correspondence between wastewater and clinical variant frequencies demonstrates the reliability of wastewater surveillance. However, discrepancies in the first detection of the Alpha variant between the two approaches highlight that wastewater monitoring can also capture missing information, possibly resulting from asymptomatic cases or communities less engaged with testing programmes, as found by a simultaneous surge testing effort across the city.

The use of procalcitonin testing to improve antibiotic stewardship in all cause respiratory admissions: a retrospective analysis

Background Improving antibiotic stewardship whilst simultaneously optimizing patient safety is a perpetually vexing clinical conundrum, which has been compounded by the current COVID-19 pandemic. Procalcitonin (PCT) measurement has previously demonstrated utility in this regard, when combined with routine clinical investigation, in certain patient populations. Objectives To assess whether the inclusion of PCT measurement as part of routine clinical care, instituted during a quality improvement project (QIP), increases the appropriateness of antibiotic administration. Methods A retrospective analysis was performed on 6 month interim data obtained from May to October 2021 during a QIP, which assessed the effect of PCT measurement on antimicrobial stewardship. All patients included had a primary diagnosis of respiratory illness and were analysed both together and as COVID-19 and non-COVID-19 subgroups to assess how often antibiotics were commenced on admission, duration of treatment and appropriateness of use. Finally, as sending microbiological samples made up part of the protocol, sample sending frequency was also studied. Results Thirty patients were included in both the COVID-19 and non-COVID-19 baseline subgroups who did not have PCT testing performed. Fifty-two patients were included in the PCT subgroup (27 COVID-19 positive and 25 COVID-19 negative). Following introduction of PCT testing, commencement of antibiotics on admission was reduced overall and in the COVID-19 positive subgroup (P = 0.0426 and P = 0.0446, respectively) with a significant decrease in inappropriate antibiotic prescribing in these two groups (P = 0.011 and P = 0.0157, respectively) and a trend towards reduced prescribing of AWaRe watch group antibiotics such as ceftriaxone. However, once prescribed, there was no difference in duration of antibiotic treatment or the frequency of microbiological sampling. Conclusions The data from this interim data analysis demonstrate that PCT measurement, when combined with routine clinical investigations in the acute respiratory setting, can be used to reduce inappropriate antibiotic prescribing. This was significantly reduced overall and in the COVID-19 positive subgroup but lost statistical significance in the COVID-19 negative subgroup, where it could be hypothesized that heterogeneity and inclusion of respiratory diseases where PCT has previously encountered difficulty in determining the presence of acute bacterial infection may be the cause. The significant effect demonstrated in the COVID-19 positive subgroup suggests particular utility in this patient population.

Otitis externa: a roundtable discussion

Otitis externa is a common problem in both primary care and referral practice. A wide range of factors contribute to the successful management of disease. A logical approach and investigation are important and should always include an appreciation of underlying primary causes, predisposing and perpetuating factors, and secondary infection. Cytology is essential to help choose appropriate therapy and represents an opportunity to use the expertise of the nurses within the veterinary team. COVID-19 has forced many veterinary professionals to use remote consultation techniques to provide care for patients and it may be that some of the lessons we have learned during lockdown can be applied to our working practices to improve the level of veterinary care in the future. The selection of appropriate topical anti-microbial and anti-inflammatory drugs is, of course, important but without good levels of owner compliance even the best therapy is ineffective. This article presents the outcome of a workshop in which a group of experts discussed many of these topics.