Whanau Maori and Pacific peoples' knowledge, perceptions, expectations and solutions regarding antibiotic treatment of upper respiratory tract infections: a qualitative study.

INTRODUCTION: The rate of community antibiotic use is high in Aotearoa New Zealand (NZ) when compared to other nations, and in NZ, as in most other nations, antibiotics are very commonly prescribed for self-limiting upper respiratory tract infections (URTIs). Resources that build knowledge, perceptions and understanding can potentially reduce unnecessary antibiotic consumption. METHODS: To inform the content of educational resources, we conducted an in-depth qualitative study with 47 participants via 6 focus groups of the knowledge, attitudes, and expectations of whanau Maori and Pacific peoples about antibiotics and URTIs. RESULTS: Focus groups with 47 participants identified four themes: Knowledge that might influence expectations to receive antibiotics for URTIs; Perceptions - the factors that influence when and why to seek medical care for URTI; Expectations - the features of successful medical care for URTI; Solutions - how to build community knowledge about URTI and their treatment and prevention. Knowledge that might reduce expectations to receive antibiotics for URTI included confidence in the use of alternative remedies, knowledge that URTI are usually caused by viruses, and concerns about antibiotic adverse effects. Participants commonly reported that they would confidently accept their doctor's recommendation that an antibiotic was not necessary for an URTI, provided that a thorough assessment had been performed and that treatment decisions were clearly communicated. CONCLUSION: These findings suggest that building patients' knowledge and skills about when antibiotics are necessary, and increasing doctors' confidence and willingness not to prescribe an antibiotic for patients with an URTI, could significantly reduce inappropriate antibiotic prescribing in NZ.

A protracted outbreak of difficult-to-treat resistant Pseudomonas aeruginosa in a haematology unit: a matched case-control study demonstrating increased risk with use of fluoroquinolone.

BACKGROUND: Between September 2016 and November 2020, 17 cases of difficult-to-treat resistant Pseudomonas aeruginosa (DTR-PA) were reported in haematology patients at a tertiary referral hospital in the North of England. AIM: A retrospective case-control study was conducted to investigate the association between DTR-PA infection and clinical interventions, patient movement, antimicrobial use and comorbidities. METHODS: Cases were patients colonized or infected with the outbreak strain of DTR-PA who had been admitted to hospital prior to their positive specimen. Exposures were extracted from medical records, and cases were compared with controls using conditional logistic regression. Environmental and microbiological investigations were also conducted. FINDINGS: Seventeen cases and 51 controls were included. The final model included age [>65 years, adjusted OR (aOR) 6.85, P=0.232], sex (aOR 0.60, P=0.688), admission under the transplant team (aOR 14.27, P=0.43) and use of ciprofloxacin (aOR 102.13, P=0.030). Investigations did not indicate case-to-case transmission or a point source, although a common environmental source was highly likely. CONCLUSION: This study found that the use of fluoroquinolones is an independent risk factor for DTR-PA in haematology patients. Antimicrobial stewardship and review of fluoroquinolone prophylaxis should be considered as part of PA outbreak investigations in addition to standard infection control interventions.

Higher sociability leads to lower reproductive success in female kangaroos.

In social mammals, social integration is generally assumed to improve females' reproductive success. Most species demonstrating this relationship exhibit complex forms of social bonds and interactions. However, female eastern grey kangaroos (Macropus giganteus) exhibit differentiated social relationships, yet do not appear to cooperate directly. It is unclear what the fitness consequences of such sociability could be in species that do not exhibit obvious forms of cooperation. Using 4 years of life history, spatial and social data from a wild population of approximately 200 individually recognizable female eastern grey kangaroos, we tested whether higher levels of sociability are associated with greater reproductive success. Contrary to expectations, we found that the size of a female's social network, her numbers of preferential associations with other females and her group sizes all negatively influenced her reproductive success. These factors influenced the survival of dependent young that had left the pouch rather than those that were still in the pouch. We also show that primiparous females (first-time breeders) were less likely to have surviving young. Our findings suggest that social bonds are not always beneficial for reproductive success in group-living species, and that female kangaroos may experience trade-offs between successfully rearing young and maintaining affiliative relationships.

Environmental contamination by bacteria in hospital washrooms according to hand-drying method: a multi-centre study.

BACKGROUND: Hand hygiene is a fundamental component of infection prevention, but few studies have examined whether hand-drying method affects the risk of dissemination of potential pathogens. AIM: To perform a multi-centre, internal-crossover study comparing bacterial contamination levels in washrooms with hand-drying by either paper towels (PT) or jet air dryer (JAD; Dyson). METHODS: A total of 120 sampling sessions occurred over 12 weeks in each of three hospitals (UK, France, Italy). Bacteria were cultured from air, multiple surfaces, and dust. Washroom footfall (patients/visitors/staff) was monitored externally. FINDINGS: Footfall was nine times higher in UK washrooms. Bacterial contamination was lower in PT versus JAD washrooms; contamination was similar in France and the UK, but markedly lower in Italian washrooms. Total bacterial recovery was significantly greater from JAD versus PT dispenser surfaces at all sites (median: 100-300 vs 0-10 cfu; all P < 0.0001). In the UK and France, significantly more bacteria were recovered from JAD washroom floors (median: 24 vs 191 cfu, P < 0.00001). UK meticillin-susceptible Staphylococcus aureus recovery was three times more frequent and six-fold higher for JAD vs PT surfaces (both P < 0.0001). UK meticillin-resistant S. aureus recovery was three times more frequent (21 vs 7 cfu) from JAD versus PT surfaces or floors. Significantly more enterococci and extended-spectrum ß-lactamase (ESBL)-producing bacteria were recovered from UK JAD versus PT washroom floors (P < 0.0001). In France, ESBL-producing bacteria were recovered from dust twice as often during JAD versus PT use. CONCLUSION: Multiple examples of significant differences in surface bacterial contamination, including by faecal and antibiotic-resistant bacteria, were observed, with higher levels in JAD versus PT washrooms. Hand-drying method affects the risk of (airborne) dissemination of bacteria in real-world settings.

The potential of alcohol release doorplates to reduce surface contamination during hand contact.

BACKGROUND: Optimal hand hygiene may be compromised by contact with contaminated environmental surfaces. AIM: To investigate the in-vitro efficacy of a novel alcohol-release doorplate to reduce surface contamination during hand contact. METHODS: Prototype, horizontally held, Surfaceskins, alcohol gel-impregnated and control (aluminium) doorplates were challenged (N = 72 per micro-organism) with Staphylococcus aureus-, Eschericia coli-, Enterococcus faecalis-, or Clostridium difficile-contaminated fingers. S. aureus and E. faecalis were used for challenges (90 per micro-organism) of vertical (modified design) doorplates, on days 0, 3, 4, 6, and 7. Surface contamination was measured pre and immediately post challenges using agar contact plates. FINDINGS: Horizontal test, but not control, doorplates demonstrated bacterial killing of S. aureus, E. faecalis and E. coli, but not of C. difficile; hence, only testing of S. aureus and E. faecalis was continued. Vertical Surfaceskins, but not control, doorplates demonstrated rapid killing of S. aureus over seven days. There were significant reductions (>90% up to day 6; P ≤ 0.01) of surface bacterial colony counts compared with controls immediately post challenge. There were also significant reductions in Surfaceskins doorplate enterococcal colony counts compared with controls on every day of testing (P ≤ 0.004). There was no evidence that bacterial recovery was greater from the tops of Surfaceskins doorplates (i.e. due to pooling of contents). CONCLUSION: Surfaceskins doorplates were efficient at reducing surface contamination by S. aureus, E. faecalis, and E. coli. Reducing microbial contamination of frequently touched door surfaces, and so bacterial transfer via hands, could feasibly reduce the risk of healthcare-associated and other infections.

Pneumopericardium as a complication of laparoscopy for ovariectomy.

A one-year-old poodle×cocker spaniel bitch was presented for laparoscopic ovariectomy. Pre-operative examination was unremarkable. The left ovariectomy was performed uneventfully. Following insufflation of the abdomen and repositioning of the patient, signs consistent with cardiac tamponade developed, resulting in death. Post-mortem radiography demonstrated pneumopericardium.

Susceptibility of Clostridium difficile isolates from a Phase 2 clinical trial of cadazolid and vancomycin in C. difficile infection.

OBJECTIVES: The aim of this study was to evaluate the susceptibilities of Clostridium difficile isolates to cadazolid, a novel antibiotic for the treatment of C. difficile infection. METHODS: Ribotyping and susceptibilities were determined for C. difficile isolates from a multicentre, double-blind, Phase 2 study of oral cadazolid in patients with C. difficile infection (NCT01222702, ClinicalTrials.gov; EudraCT 2010-020941-29, European Clinical Trials Database). Patients were randomized to receive 250, 500 or 1000 mg of cadazolid twice daily or 125 mg of vancomycin four times daily, for 10 days. MICs of cadazolid, vancomycin, fidaxomicin, linezolid and moxifloxacin were determined at baseline for all patients and post-baseline for patients with clinical failure or recurrence, using the agar dilution method. RESULTS: Seventy-eight of 84 patients had an evaluable toxigenic C. difficile isolate at baseline. The most frequent PCR ribotype was 027 (15.4%). Cadazolid MICs for baseline isolates (including epidemic strain 027) ranged from 0.06 to 0.25 mg/L. Baseline cadazolid MICs were similar to those of fidaxomicin and lower than those of vancomycin, linezolid and moxifloxacin. For each clinical outcome group (clinical cure, clinical failure, sustained clinical response and clinical failure or recurrence), the baseline cadazolid MIC range was 0.06-0.25 mg/L. Mean (min-max) cadazolid faecal concentration (µg/g) on day 5 was 884 (101-2710), 1706 (204-4230) and 3226 (1481-12 600) for the doses 250, 500 and 1000 mg, respectively. CONCLUSIONS: For all cadazolid doses, the faecal concentration was in excess of several thousand-fold the MIC90 for C. difficile. The MIC of cadazolid for all C. difficile isolates, including epidemic strains, was low and in the same narrow range regardless of treatment outcome.

Inguinal enterocutaneous fistula in a dog.

A two-year-old Jack Russell terrier presented with a chronic history of weight loss and the recent development of a discharging wound in the left inguinal region that was confirmed by ultrasound and contrast radiography to be an enterocutaneous fistula. One day following admission the dog displayed signs of abdominal pain and the general condition deteriorated. At exploratory coeliotomy there was evidence of septic peritonitis and a segment of jejunum was found firmly adhered to the left inguinal canal. The affected jejunal segment was excised and an end-to-end anastomosis performed. A penrose drain was placed in the inguinal wound which was subsequently managed with open drainage. The inguinal wound healed successfully by second intention and the dog returned to normal body condition. The left testis became atrophic and castration was performed several weeks later. To the authors' knowledge this is the first veterinary case report of an inguinal enterocutaneous fistula.

Comparison of different hand-drying methods: the potential for airborne microbe dispersal and contamination.

Efficient washing and drying of hands is important in prevention of the transfer of micro-organisms. However, knowledge surrounding the potential for microbial contamination according to hand-drying methods is limited. This study assessed the potential for airborne microbe dispersal during hand drying by four methods (paper towels, roller towel, warm air and jet air dryer) using three different models. The jet air dryer dispersed liquid from users' hands further and over a greater range (up to 1.5m) than the other drying methods (up to 0.75 m), demonstrating the differing potential risks for airborne microbe dissemination, particularly if handwashing is suboptimal.

Microbiological comparison of hand-drying methods: the potential for contamination of the environment, user, and bystander.

BACKGROUND: The efficiency of hand drying is important in preventing pathogen spread, but knowledge surrounding which drying methods contribute least towards contamination of the environment and users is limited. AIM: To compare the propensity of three common hand-drying methods (jet air, warm air dryers, and paper towels) to contaminate the environment, users, and bystanders. METHODS: Hands were coated in lactobacilli to simulate poorly washed, contaminated hands, and dried. The investigation comprised 120 air-sampling tests (60 tests and 60 controls), divided into close and 1m proximity from the drying process. Separate tests used hands coated in paint to visualize droplet dispersal. FINDINGS: Air bacterial counts in close proximity to hand drying were 4.5-fold higher for the jet air dryer (70.7 cfu) compared with the warm air dryer (15.7 cfu) (P=0.001), and 27-fold higher compared with use of paper towels (2.6 cfu) (P<0.001). Airborne counts were also significantly different during use of towel drying versus warm air dryer (P=0.001). A similar pattern was seen for bacterial counts at 1m away. Visualization experiments demonstrated that the jet air dryer caused the most droplet dispersal. CONCLUSION: Jet air and warm air dryers result in increased bacterial aerosolization when drying hands. These results suggest that air dryers may be unsuitable for use in healthcare settings, as they may facilitate microbial cross-contamination via airborne dissemination to the environment or bathroom visitors.

Effectiveness of deep cleaning followed by hydrogen peroxide decontamination during high Clostridium difficile infection incidence.

BACKGROUND: Clostridium difficile infection (CDI) remains an infection control challenge, especially when environmental spore contamination and suboptimal cleaning may increase transmission risk. AIM: To substantiate the long-term effectiveness throughout a stroke rehabilitation unit (SRU) of deep cleaning and hydrogen peroxide decontamination (HPD), following a high incidence of CDI. METHODS: Extensive environmental sampling (342 sites on each occasion) for C. difficile using sponge wipes was performed: before and after deep cleaning with detergent/chlorine agent; immediately following HPD; and on two further occasions, 19 days and 20 weeks following HPD. C. difficile isolates underwent polymerase chain reaction ribotyping and multi-locus variable repeat analysis (MLVA). FINDINGS: C. difficile was recovered from 10.8%, 6.1%, 0.9%, 0% and 3.5% of sites at baseline, following deep cleaning, immediately after HPD, and 19 days and 20 weeks after HPD, respectively. C. difficile ribotypes recovered after deep cleaning matched those from CDI cases in the SRU during the previous 10 months. Similarly, 10/12 of the positive sites identified at 20 weeks post-HPD harboured the same C. difficile ribotype (002) and MLVA pattern as the isolate from the first post-HPD CDI case. CDI incidence [number of cases on SRU per 10 months (January-October 2011)] declined from 20 before to seven after the intervention. CONCLUSION: HPD, after deep cleaning with a detergent/chlorine agent, was highly effective for removing environmental C. difficile contamination. Long-term follow-up demonstrated that a CDI symptomatic patient can rapidly recontaminate the immediate environment. Determining a role for HPD should include long-term cost-effectiveness evaluations.

Comparison of multilocus variable-number tandem-repeat analysis and whole-genome sequencing for investigation of Clostridium difficile transmission.

No study to date has compared multilocus variable-number tandem-repeat analysis (MLVA) and whole-genome sequencing (WGS) in an investigation of the transmission of Clostridium difficile infection. Isolates from 61 adults with ongoing and/or recurrent C. difficile infections and 17 asymptomatic carriage episodes in children (201 samples), as well as from 61 suspected outbreaks affecting 2 to 41 patients in 31 hospitals in the United Kingdom (300 samples), underwent 7-locus MLVA and WGS in parallel. When the first and last samples from the same individual taken for a median (interquartile range [IQR]) of 63 days (43 to 105 days) apart were compared, the estimated rates of the evolution of single nucleotide variants (SNVs), summed tandem-repeat differences (STRDs), and locus variants (LVs) were 0.79 (95% confidence interval [CI], 0.00 to 1.75), 1.63 (95% CI, 0.00 to 3.59), and 1.21 (95% CI, 0.00 to 2.67)/called genome/year, respectively. Differences of >2 SNVs and >10 STRDs have been used to exclude direct case-to-case transmission. With the first serial sample per individual being used to assess discriminatory power, across all pairs of samples sharing a PCR ribotype, 192/283 (68%) differed by >10 STRDs and 217/283 (77%) by >2 SNVs. Among all pairs of cases from the same suspected outbreak, 1,190/1,488 (80%) pairs had concordant results using >2 SNVs and >10 STRDs to exclude transmission. For the discordant pairs, 229 (15%) had ≥2 SNVs but ≤10 STRDs, and 69 (5%) had ≤2 SNVs but ≥10 STRDs. Discordant pairs had higher numbers of LVs than concordant pairs, supporting the more diverse measure in each type of discordant pair. Conclusions on whether the potential outbreaks were confirmed were concordant in 58/61 (95%) investigations. Overall findings using MLVA and WGS were very similar despite the fact that they analyzed different parts of the bacterial genome. With improvements in WGS technology, it is likely that MLVA locus data will be available from WGS in the near future.

Biomonitoring and assessment of monomethylmercury exposure in aqueous systems using the DGT technique.

A series of laboratory experiments was conducted under realistic environmental conditions to test the ability of the Diffusive Gradient in Thin film (DGT) technique to mimic monomethylmercury (MMHg) bioaccumulation by a clam (Macoma balthica, Baltic clam). Using isotope enriched MMHg as tracers, bioavailability was determined by comparing the rate of MMHg uptake by novel DGT devices and sentinel organism over time. Experiments were conducted under varying conditions of salinity and MMHg speciation. Depending on MMHg level and speciation in the dissolved phase, MMHg uptake rates by the sentinel organism varied greatly from 0.4 to 2.4Lg(-1)d(-1). Reproducibilities of MMHg uptakes by DGT and clams were estimated at 7 and 38%, respectively. A significant linear relationship (log basis) between MMHg accumulation by DGT and clams was observed (r(2)=0.89). The study demonstrates that DGT results reasonably predict MMHg uptake by clams from the aqueous phase and provide the basis for application of the DGT device as a surrogate for sentinel organism for monitoring bioavailable MMHg.

MEG-SIM: a web portal for testing MEG analysis methods using realistic simulated and empirical data.

MEG and EEG measure electrophysiological activity in the brain with exquisite temporal resolution. Because of this unique strength relative to noninvasive hemodynamic-based measures (fMRI, PET), the complementary nature of hemodynamic and electrophysiological techniques is becoming more widely recognized (e.g., Human Connectome Project). However, the available analysis methods for solving the inverse problem for MEG and EEG have not been compared and standardized to the extent that they have for fMRI/PET. A number of factors, including the non-uniqueness of the solution to the inverse problem for MEG/EEG, have led to multiple analysis techniques which have not been tested on consistent datasets, making direct comparisons of techniques challenging (or impossible). Since each of the methods is known to have their own set of strengths and weaknesses, it would be beneficial to quantify them. Toward this end, we are announcing the establishment of a website containing an extensive series of realistic simulated data for testing purposes ( http://cobre.mrn.org/megsim/ ). Here, we present: 1) a brief overview of the basic types of inverse procedures; 2) the rationale and description of the testbed created; and 3) cases emphasizing functional connectivity (e.g., oscillatory activity) suitable for a wide assortment of analyses including independent component analysis (ICA), Granger Causality/Directed transfer function, and single-trial analysis.

Potential for aerosolization of Clostridium difficile after flushing toilets: the role of toilet lids in reducing environmental contamination risk.

BACKGROUND: Toilet facilities in healthcare settings vary widely, but patient toilets are commonly shared and do not have lids. When a toilet is flushed without the lid closed, aerosol production may lead to surface contamination within the toilet environment. AIM: To substantiate the risks of airborne dissemination of C. difficile following flushing a toilet, in particular when lids are not fitted. METHODS: We performed in-situ testing, using faecal suspensions of C. difficile to simulate the bacterial burden found during disease, to measure C. difficile aerosolization. We also measured the extent of splashing occurring during flushing of two different toilet types commonly used in hospitals. FINDINGS: C. difficile was recoverable from air sampled at heights up to 25 cm above the toilet seat. The highest numbers of C. difficile were recovered from air sampled immediately following flushing, and then declined 8-fold after 60 min and a further 3-fold after 90 min. Surface contamination with C. difficile occurred within 90 min after flushing, demonstrating that relatively large droplets are released which then contaminate the immediate environment. The mean numbers of droplets emitted upon flushing by the lidless toilets in clinical areas were 15-47, depending on design. C. difficile aerosolization and surrounding environmental contamination occur when a lidless toilet is flushed. CONCLUSION: Lidless conventional toilets increase the risk of C. difficile environmental contamination, and we suggest that their use is discouraged, particularly in settings where CDI is common.

Corynebacterium diphtheriae endocarditis: a case series and review of the treatment approach.

OBJECTIVES: Infective endocarditis due to non-toxigenic Corynebacterium diphtheriae is uncommon; we report 10 cases occurring over a 14-year period in Auckland, New Zealand and review the approach for treatment. CASE SERIES: Eight of the 10 patients had known prosthetic valves or homografts in situ. Three patients required surgical intervention for infective endocarditis. Seven patients were treated with a combination of ß-lactam and aminoglycoside, and one each was treated with a combination of vancomycin and an aminoglycoside, a ß-lactam alone, and vancomycin alone. All patients survived and none relapsed. REVIEW OF LITERATURE: The antibiotic treatment of 46 previously reported cases was reviewed; patients treated with a ß-lactam and aminoglycoside (n=25), and without the addition of an aminoglycoside (n=11) were compared. The differences in length of treatment within each group make the comparison of outcome (mortality, need for surgical intervention, disease and treatment complications) difficult. However, regardless of the length of treatment, there was no difference in mortality or need for surgical intervention between the two groups in the currently published cases. CONCLUSIONS: Current evidence suggests that endocarditis of either native or prosthetic valves, caused by penicillin-susceptible C. diphtheriae, demonstrates a favorable outcome when treated with either a ß-lactam alone or in combination with an aminoglycoside. Patient-specific factors will determine which approach is more appropriate for each individual patient.

Multiple-locus variable-number tandem repeat analysis of Salmonella enterica subsp. enterica serovar Typhimurium: comparison of isolates from pigs, poultry and cases of human gastroenteritis.

AIMS: Pulsed-field gel electrophoresis (PFGE) and variable number tandem repeat (VNTR) profiles of 195 epidemiologically unrelated Salmonella Typhimurium strains isolated in 1997-2004 from pigs were analysed and the results compared to establish the discriminatory ability of each method. In order to investigate the epidemiology of S. Typhimurium from different populations, the VNTR profiles from pigs were compared with those obtained from 190 S. Typhimurium strains isolated from poultry and 186 strains isolated from human cases of gastroenteritis. METHODS AND RESULTS: A total of 195 strains of S. Typhimurium were tested by PFGE and VNTR. For PFGE, the restriction enzyme XbaI was used, and for VNTR, the number of repeats at five loci (STTR 9, 5, 6, 10pl and 3) were counted and assigned an allele number based on an established VNTR scheme. The results obtained showed improved discrimination of VNTR when compared with PFGE with 34 PFGE profiles identified compared with 96 different VNTR profiles for the pig isolates and 56 different VNTR types within the most common PFGE type. Within the three different populations, VNTR showed distinct subpopulations of VNTR type related not only to source, but also demonstrated common VNTR types within samples obtained from humans, poultry and pigs, especially in strains of phage type DT104. CONCLUSIONS: VNTR has taken the discrimination to a further level than that obtained through PFGE, and demonstrated an overlap in the genetic diversity of isolates tested across the three different populations, confirming previous suggestions that animals have an involvement in the dissemination of S. Typhimurium through the food chain. SIGNIFICANCE AND IMPACT OF THE STUDY: Salmonella Typhimurium remains an important concern as a food-borne zoonotic agent. The VNTR strategy described provides an accurate method of tracing strain dissemination, and adds a further level of discrimination to the PFGE type, providing potential benefits to epidemiological studies and the possibility of deciphering source attribution of cases.

Stability of multiple-locus variable-number tandem repeats in Salmonella enterica serovar typhimurium.

Variable-number tandem repeats (VNTRs) may evolve so rapidly that multiple profiles emerge during an outbreak. A total of 190 isolates from eight Salmonella enterica serovar Typhimurium outbreaks and 15 isolates from seven patients were analyzed by pulsed-field gel electrophoresis and VNTR typing. Small changes in loci were noted; otherwise, the VNTR profiles were stable during the course of the outbreaks.