Consensus demonstrates four indicators needed to standardize burn wound infection reporting across trials in a single-country study (ICon-B study).

INTRODUCTION: Evidence-based interventions are needed to treat burn wound infection (BWI). Evidence syntheses have been limited by heterogeneity of indicators used to report BWI across trials. Consistent reporting of BWI would be facilitated by an agreed minimum set of indicators. The Infection Consensus in Burns study aimed to achieve expert consensus about a core indicator set (CIS) for BWI. METHODS: The CIS was established through development of a long list of BWI indicators identified from a systematic review and expert input. In a Delphi survey, UK expert participants rated the indicators according to use in everyday practice, importance for diagnosis and frequency of observation in patients with BWI. Indicators were included in the CIS if ≥75% of participants agreed it was important for diagnosis and used in everyday practice, and ≥50% of participants rated it as frequently observed in patients with BWI. RESULTS: One hundred and ninety-five indicators were identified from the systematic review and reduced to 29 survey items through merging of items with the same meaning. Seventy-five UK experts participated in the Delphi survey. Following a single survey round and a consensus meeting with an expert panel, four items were included in the CIS: pyrexia, spreading erythema, change in white cell count, and presence of pathogenic microbes. DISCUSSION AND CONCLUSIONS: To facilitate evidence synthesis, a single-country systematic, expert-informed approach was taken to develop a CIS to be reported consistently across trials reporting BWI as an outcome. Future work requires verification of the CIS with international experts.

Control and management of multidrug resistant Acinetobacter baumannii: A review of the evidence and proposal of novel approaches.

Hospital-acquired infections are on the rise and are a substantial cause of clinical and financial burden for healthcare systems. While infection control plays a major role in curtailing the spread of outbreak organisms, it is not always successful. One organism of particular concern is Acinetobacter baumannii, due to both its persistence in the hospital setting and its ability to acquire antibiotic resistance. A. baumannii has emerged as a nosocomial pathogen that exhibits high levels of resistance to antibiotics, and remains resilient against traditional cleaning measures with resistance to Colistin increasingly reported. Given the magnitude and costs associated with hospital acquired infections, and the increase in multidrug-resistant organisms, it is worth re-evaluating our current approaches and looking for alternatives or adjuncts to traditional antibiotics therapies. The aims of this review are to look at how this organism is spread within the hospital setting, discuss current treatment modalities, and propose alternative methods of outbreak management.

Acinetobacter - the trojan horse of infection control?

BACKGROUND: Five cases of multi-resistant Acinetobacter baumanii (MRA) producing OXA-23 and OXA-51 occurred in a regional burn intensive care unit (BICU). Three were repatriated from other parts of the world (Dubai and Mumbai) and colonized on admission. Despite optimal precautions, two patients acquired MRA. Both had been nursed in the same room. METHODS: Multi-disciplinary outbreak investigation of MRA in a regional BICU. FINDINGS: The mechanism of transfer for the first case is thought to have been contaminated air from theatre activity releasing MRA bacteria into the communal corridor. No MRA patients went to theatre between the first and second acquired cases. The mechanism of transfer for the second case is thought to have been via a shower unit that was decontaminated inadequately between patients. CONCLUSION: In an outbreak where contact precautions and environmental cleaning are optimal, it is important to give careful consideration to other mechanisms of spread. If there is a failure to do this, it is likely that the true causes of transmission will not be addressed and the problem will recur. It is recommended that burn theatres within burn facilities should be designed to operate at negative pressure; this is the opposite of normal operating theatre ventilation. Where showers are used, both the shower head and the hose should be changed after a patient with a resistant organism. The role of non-contact disinfection (e.g. hydrogen peroxide dispersal) should be reconsidered, and constant vigilance should be given to any 'trojan horse' item in the room.

Seasonal variation of Pseudomonas aeruginosa in culture positive otitis externa in South East England.

Otitis externa is the inflammation of the external auditory canal. The disease is common and shows a seasonal variation with a greater incidence in warmer months. Pseudomonas aeruginosa is a common pathogen in otitis externa and in this retrospective study, we show a corresponding seasonal variation in the proportional incidence of P. aeruginosa isolates from otitis externa in South East England. In total 7770 patients were diagnosed with otitis externa over a period of 9 years from January 2008 to December 2016. P. aeruginosa was isolated from 2802 patients (proportional incidence of 36%). Incidence was higher in the months of August, September and October and in patients between 5 and 15 years of age. We postulate a combination of increased contact with water during warm weather in the holiday season and increased rainfall in the preceding season as a putative mechanism for the seasonal trends.

Prevention and control of carbapenemase-producing organisms at a regional burns centre.

In many parts of the world, carbapenemase-producing organisms (CPOs) are endemic. The transfer of medical patients from such countries to the UK requires us to have control systems in place to avoid onward transmission. This report describes the experience of a regional burns centre challenged by its first four cases of CPO in two separate incidents. Key learning from our experience was the importance of CPOs being considered in empirical antibiotics for any patient from an endemic area. Using contact plates, we demonstrated high bacterial counts after cleaning and we describe a terminal cleaning strategy along with the importance of continuing staff engagement and education.

Service evaluation of selected risk factors for extended-spectrum beta-lactamase Escherichia coli urinary tract infections: a case-control study.

In the context of the increasing incidence of extended-spectrum beta-lactamase (ESBL) Escherichia coli infection, this prospective frequency-matched case-control study aimed to identify risk factors that would provide information and guidance for local clinical practice. One hundred and twelve participants were recruited: 54 cases and 58 controls. Univariate analysis indicated that isolation of an ESBL-producing E. coli in the previous 12 months and diabetes were significantly associated with the outcome. This study demonstrates the utility of service evaluation studies for producing epidemiological information to inform clinical practice.

Mycobacterium kanasii flexor tenosynovitis of the finger.

We report an extreme case of Mycobacterium kanasii flexor tenosynovitis with flexor tendon rupture in a healthy 65-year-old left-hand dominant Caucasian housewife. This case highlights the diagnostic conundrum of atypical mycobacteria infections due to their insidious presentation, the need for a high index of suspicion to prevent worsening or delaying the diagnosis from inappropriate steroid use and that these infections can occur in otherwise healthy individuals.

Legionella pneumophila serogroup 1 in a birthing pool.

This report describes a risk assessment and subsequent actions following isolation of Legionella pneumophila serogroup 1 in the water supply to a birthing pool during a planned maintenance programme. A literature search for cases of neonatal legionellosis identified 24 reports of cases among babies aged <2 months, two of which were associated with water births. On this basis, the pool was closed until Legionella spp. were undetectable. Control proved difficult as hyperchlorination failed, and a filter fitted to the thermostatic mixer tap supplying the pool slowed filling so much that additional taps were required to achieve a satisfactory flow rate.

Lung and pharyngeal abscess caused by enterotoxin G- and I-producing Staphylococcus aureus.

We report a particularly serious case of extensive meticillin sensitive Staphylococcal lung and pharyngeal abscess. Our patient had no significant risk factors for severe infection. The detection of enterotoxin G and I here suggest that when present together, these toxins work synergistically to produce a more virulent strain of Staphylococcus aureus.

Outbreak of Panton-Valentine leucocidin-positive meticillin-resistant Staphylococcus aureus in a regional burns unit.

Over a 16 month period, 30 individuals (19 patients, one relative and 10 members of staff) on a regional burns and plastics unit became colonised or infected with a single strain of Panton-Valentine leucocidin-producing meticillin-resistant Staphylococcus aureus (PVL-MRSA). The strain was resistant to ciprofloxacin, neomycin and gentamicin and belonged to a community-associated MRSA lineage known to be circulating in the UK. The outbreak occurred in four stages, the first being in burns outpatients, the second and third being on the burns unit itself and the final stage on a plastics ward. In spite of closing the affected unit and deep cleaning, including steam cleaning and hydrogen peroxide treatment, the outbreak continued. It was not until staff carriage was fully addressed that the outbreak was controlled.

Use of colistin in treating multi-resistant Gram-negative organisms in a specialised burns unit.

Patients with burns are at an increased risk of infection which can affect their outcome-duration of hospital stay, intensive care requirements, organ support, inotrope requirements, renal replacement therapy, ventilatory requirements and overall mortality. Our study aimed to evaluate the use of colistin in our burns intensive care unit (ICU) in treating multi-resistant Gram-negative infections. This was a retrospective study carried out in a regional referral centre for burns and plastics, Chelmsford, UK. We looked at data from patients admitted to our intensive care over a two-year period from November 2003 to November 2005. All patients who received colistin were included in the study. Admission data included demographic data and burn data, other relevant medical history, and blood results. We also recorded: length of ICU stay, ultimate outcome, total dose of colistin, repeated doses, and mode of drug delivery, organ support, organisms grown and their resistance. Response to colistin was judged by improvement in clinical status, decrease in white blood cell count (WCC) and inflammatory markers and no growth on cultures. The data were subjected to non-parametric Wilcoxon Signed Rank Test using SPSS version 14. Twenty-nine patients were included in the study all of whom received colistin in one form or the other. The average total dose of colistin was 69 million units (range 1-268). Of these, 17 patients survived (58.6%) and 12 died (41.4%). Twenty patients improved (69%) and 9 did not improve (31%) after administration of colistin. We also compared creatinine levels on admission and post colistin. We used non-parametric Wilcoxon Signed Rank test which showed no difference in the two groups (p=0.38). We found colistin to be safe and effective in treating multi-resistant Gram-negative infections in burns patients and we did not see any statistically significant impairment of renal function.

Corynebacterium septic arthritis of the knee presenting as a ruptured septic popliteal cyst.

A rare case of a septic knee arthritis presenting as an infected ruptured popliteal cyst is described. Infection of a popliteal cyst is an uncommon complication of septic arthritis and presentation can mimic that of an acute deep vein thrombosis, leading to delay in diagnosis and treatment. Of interest, the typical hallmarks of infection and haematological markers of inflammation were all unremarkable in the current case. This case was of additional interest in that there have been no reports in the literature of Corynebacterium spp. being isolated from an infected popliteal cyst. Invasive infections caused by Corynebacterium spp. seem to have a predilection for patients who are immunocompromised. It is especially important in this subset of patients that delays in diagnosis are avoided by including it in the differential of an immunocompromised patient presenting with unilateral lower-extremity pain and swelling.

Meningitis in a butcher.

Streptococcus suis is a common pathogen in swine and infection in humans is rarely reported. When it does occur, it is considered an occupational risk associated with the handling of carcasses. Meningitis is one of the most life-threatening manifestations of S suis infection. This case of meningitis in a butcher is reported to create awareness of this zoonotic disease. The report highlights the importance of an occupational history and a meticulous general physical examination looking for cuts and abrasions in patients with suspicion of meningitis.

Cannabinoids in multiple sclerosis (CAMS) study: safety and efficacy data for 12 months follow up.

OBJECTIVE: To test the effectiveness and long term safety of cannabinoids in multiple sclerosis (MS), in a follow up to the main Cannabinoids in Multiple Sclerosis (CAMS) study. METHODS: In total, 630 patients with stable MS with muscle spasticity from 33 UK centres were randomised to receive oral Delta(9)-tetrahydrocannabinol (Delta(9)-THC), cannabis extract, or placebo in the main 15 week CAMS study. The primary outcome was change in the Ashworth spasticity scale. Secondary outcomes were the Rivermead Mobility Index, timed 10 metre walk, UK Neurological Disability Score, postal Barthel Index, General Health Questionnaire-30, and a series of nine category rating scales. Following the main study, patients were invited to continue medication, double blinded, for up to 12 months in the follow up study reported here. RESULTS: Intention to treat analysis of data from the 80% of patients followed up for 12 months showed evidence of a small treatment effect on muscle spasticity as measured by change in Ashworth score from baseline to 12 months (Delta(9)-THC mean reduction 1.82 (n = 154, 95% confidence interval (CI) 0.53 to 3.12), cannabis extract 0.10 (n = 172, 95% CI -0.99 to 1.19), placebo -0.23 (n = 176, 95% CI -1.41 to 0.94); p = 0.04 unadjusted for ambulatory status and centre, p = 0.01 adjusted). There was suggestive evidence for treatment effects of Delta(9)-THC on some aspects of disability. There were no major safety concerns. Overall, patients felt that these drugs were helpful in treating their disease. CONCLUSIONS: These data provide limited evidence for a longer term treatment effect of cannabinoids. A long term placebo controlled study is now needed to establish whether cannabinoids may have a role beyond symptom amelioration in MS.

Cannabis for dyskinesia in Parkinson disease: a randomized double-blind crossover study.

BACKGROUND: The long-term treatment of Parkinson disease (PD) may be complicated by the development of levodopa-induced dyskinesia. Clinical and animal model data support the view that modulation of cannabinoid function may exert an antidyskinetic effect. The authors conducted a randomized, double-blind, placebo-controlled crossover trial to examine the hypothesis that cannabis may have a beneficial effect on dyskinesia in PD. METHODS: A 4-week dose escalation study was performed to assess the safety and tolerability of cannabis in six PD patients with levodopa-induced dyskinesia. Then a randomized placebo-controlled crossover study (RCT) was performed, in which 19 PD patients were randomized to receive oral cannabis extract followed by placebo or vice versa. Each treatment phase lasted for 4 weeks with an intervening 2-week washout phase. The primary outcome measure was a change in Unified Parkinson's Disease Rating Scale (UPDRS) (items 32 to 34) dyskinesia score. Secondary outcome measures included the Rush scale, Bain scale, tablet arm drawing task, and total UPDRS score following a levodopa challenge, as well as patient-completed measures of a dyskinesia activities of daily living (ADL) scale, the PDQ-39, on-off diaries, and a range of category rating scales. RESULTS: Seventeen patients completed the RCT. Cannabis was well tolerated, and had no pro- or antiparkinsonian action. There was no evidence for a treatment effect on levodopa-induced dyskinesia as assessed by the UPDRS, or any of the secondary outcome measures. CONCLUSIONS: Orally administered cannabis extract resulted in no objective or subjective improvement in dyskinesias or parkinsonism.

Stroke in Devon: knowledge was good, but action was poor.

BACKGROUND AND AIM: Effective implementation of early treatment strategies for stroke requires prompt admission to hospital. There are several reasons for delayed admission. Good awareness should facilitate early admission. We identified local targets for education. METHODS: Four groups, each of 40 people, completed questionnaires to determine their knowledge of stroke symptoms and risk factors, and the action they took or would take in the event of a stroke. The groups were: patients with a diagnosis of stroke or TIA (within 48 hrs of admission); patients at risk of stroke; the general population; and nurses. RESULTS: Forty per cent of stroke patients identified their stroke. Median time from onset of symptoms to seeking medical help was 30 minutes. Medical help was sought by the patient themselves in only 15% of cases. In 80% of cases the GP was called rather than an ambulance. Of the at risk group, 93% were able to list at least one symptom of acute stroke, as were 88% of the general population. An ambulance would be called by 73% of the at risk group in the event of a stroke. Patients with self reported risk factors for stroke were largely unaware of their increased risk. Only 7.5% of at risk patients acquired their stroke information from the medical profession. CONCLUSIONS: Public knowledge about stroke is good. However, stroke patients access acute services poorly. At risk patients have limited awareness of their increased risk. A campaign should target people at risk, reinforcing the diagnosis of stroke and access to medical services.