Clinical activity at the UK military level 2 hospital in Bentiu, South Sudan during Op TRENTON from June to September 2017.

INTRODUCTION: Diseases and non-battle injuries (DNBIs) are common on UK military deployments, but the collection and analysis of clinically useful data on these remain a challenge. Standard medical returns do not provide adequate clinical information, and clinician-led approaches have been laudable, but not integrated nor standardised nor used long-term. Op TRENTON is a novel UK military humanitarian operation in support of the United Nations Mission in South Sudan, which included the deployment of UK military level 1 and level 2 medical treatment facilities at Bentiu to provide healthcare for UK and United Nations (UN) personnel. METHODS: A service evaluation of patient consultations and admissions at the UK military level 2 hospital was performed using two data sets collected by the emergency department (ED) and medicine (MED) teams. RESULTS: Over a three-month (13-week) period, 286 cases were seen, of which 51% were UK troops, 29% were UN civilians and 20% were UN troops. The ED team saw 175 cases (61%) and provided definitive care for 113 (40%), whereas the MED team saw and provided definitive care for 128 cases (45%). Overall, there were 75% with diseases and 25% with non-battle injuries. The most common diagnoses seen by the ED team were musculoskeletal injuries (17%), unidentified non-malarial undifferentiated febrile illness (UNMUFI) (17%), malaria (13%), chemical pneumonitis (13%) and wounds (8%). The most common diagnoses seen by the MED team were acute gastroenteritis (AGE) (56%), UNMUFI (12%) and malaria (9%). AGE was due to viruses (31%), diarrhoeagenic Escherichia coli (32%), other bacteria (6%) and protozoa (12%). CONCLUSION: Data collection on DNBIs during the initial phase of this deployment was clinically useful and integrated between different departments. However, a standardised, long-term solution that is embedded into deployed healthcare is required. The clinical activity recorded here should be used for planning, training, service development and targeted research.

Infection Prevention and Control Lead Link Practitioner: a new deployed role piloted on Exercise SAIF SAREEA 3.

Disease non-battle injury has plagued British expeditionary forces through the ages. While in recent years significant mortality has reduced, it has had a large impact on operational effectiveness, at times leading to closure of major medical treatment facilities (MTFs).Infection Prevention and Control (IPC) benefits from a subject matter expert and champion to ensure it remains at the front of people's minds and to be on hand to manage acute and dynamic situations. To mitigate the lack of an IPC Nursing Officer, we piloted a deployed military IPC Lead Link Practitioner (IPC-LL) for the first time on a large-scale overseas exercise (SAIF SAREEA 3). An experienced generalist nurse deploying as the IPC-LL (after specific training) provided pre-deployment IPC education and preparation, deployed IPC advice, undertook mandatory audits and monitored IPC compliance throughout the MTFs on the exercise. Data from 22 IPC audits conducted on the exercise showed that the presence of the IPC-LL improved IPC compliance and standards overall in the MTF where based, compared with others. In addition, a gastroenteritis outbreak occurred and was successfully managed with significant input from the IPC-LL. The IPC-LL was also able to add value by pre-empting potential IPC problems from occurring.There is a small pool of deployable Infection Prevention and Control Nursing Officers, so this new IPC-LL role could help to fill the capability gap. The IPC-LL could be the dedicated person focusing on IPC elements, reducing the IPC risk within the deployed field hospital setting where deployed experts are not available.

Gram-negative bacteraemia; a multi-centre prospective evaluation of empiric antibiotic therapy and outcome in English acute hospitals.

Increasing antibiotic resistance makes choosing antibiotics for suspected Gram-negative infection challenging. This study set out to identify key determinants of mortality among patients with Gram-negative bacteraemia, focusing particularly on the importance of appropriate empiric antibiotic treatment. We conducted a prospective observational study of 679 unselected adults with Gram-negative bacteraemia at ten acute english hospitals between October 2013 and March 2014. Appropriate empiric antibiotic treatment was defined as intravenous treatment on the day of blood culture collection with an antibiotic to which the cultured organism was sensitive in vitro. Mortality analyses were adjusted for patient demographics, co-morbidities and illness severity. The majority of bacteraemias were community-onset (70%); most were caused by Escherichia coli (65%), Klebsiella spp. (15%) or Pseudomonas spp. (7%). Main foci of infection were urinary tract (51%), abdomen/biliary tract (20%) and lower respiratory tract (14%). The main antibiotics used were co-amoxiclav (32%) and piperacillin-tazobactam (30%) with 34% receiving combination therapy (predominantly aminoglycosides). Empiric treatment was inappropriate in 34%. All-cause mortality was 8% at 7 days and 15% at 30 days. Independent predictors of mortality (p <0.05) included older age, greater burden of co-morbid disease, severity of illness at presentation and inflammatory response. Inappropriate empiric antibiotic therapy was not associated with mortality at either time-point (adjusted OR 0.82; 95% CI 0.35-1.94 and adjusted OR 0.92; 95% CI 0.50-1.66, respectively). Although our study does not exclude an impact of empiric antibiotic choice on survival in Gram-negative bacteraemia, outcome is determined primarily by patient and disease factors.

Reduction in Clostridium difficile environmental contamination by hospitalized patients treated with fidaxomicin.

Fidaxomicin is sporicidal and may be associated with a reduced time to resolution of diarrhoea when used to treat patients with Clostridium difficile infection (CDI). This study investigated whether fidaxomicin for treatment of all patients with CDI reduced C. difficile environmental contamination. Surfaces in the rooms of 66 hospitalized patients treated with metronidazole and/or vancomycin and 68 hospitalized patients treated with fidaxomicin were sampled. Patients treated with fidaxomicin were less likely to contaminate their environment (25/68, 36.8%) than patients treated with metronidazole and/or vancomycin (38/66 57.6%) (P = 0.02). Treatment with fidaxomicin was associated with reduced environmental contamination with C. difficile.

A parallel diagnostic accuracy study of three molecular panels for the detection of bacterial gastroenteritis.

Culture-dependent detection of gastroenteric bacteria is labour-intensive and does not provide results in a clinically relevant time frame. Several commercially available multiplex molecular panels are now available which may be more sensitive and could potentially provide rapid results. We compared the diagnostic accuracy, turnaround time and ease of use of three such molecular panels: the RIDA®GENE Bacterial Stool and EHEC/EPEC Panels (R-Biopharm AG, Darmstadt, Germany), the FTD® Bacterial Gastroenteritis Panel (Fast Track Diagnostics, Junglinster, Luxembourg) and the BD MAX™ Enteric Bacterial Panel (Becton Dickinson GmbH, Heidelberg, Germany). The results from 116 retrospective selected and 318 prospective unselected stool samples were compared with conventional culture-based techniques using a gold standard for a positive test of either culture or agreement in two of the three molecular panels. For most targets, the molecular panels were more sensitive than culture, detecting an additional 13 cases that culture missed. The laboratory turnaround time was under 3 h for all molecular panels, compared with 66.5 h for culture. The BD MAX™ panel was the fastest, easiest to use and most flexible.