Enterococcus faecalis bacteraemia and infective endocarditis - what are we missing?

Introduction: Enterococcus faecalis is an increasingly common cause of infective endocarditis, with a recent study by Dahl et al demonstrating a prevalence of 26% of IE when transoesophageal echo was routinely undertaken. Another study undertaken by Østergaard et al found that 16.7% of patients with E. faecalis bacteraemia developed endocarditis. Based on these findings we examined the rates of IE diagnosed in our own health board to determine if our current practice is potentially missing cases of IE and if we could improve our management of these bacteraemias. Methods: All blood cultures in patients over 18 which were positive for E. faecalis from October 2017 to March 2022 were reviewed. We analysed the patient characteristics, clinical outcomes and included a follow up period of 6 months to assess for recrudescence and treatment failure. Results: The rate of patients with E. faecalis bacteraemia diagnosed with IE was 7.1%. If polymicrobial blood cultures were excluded this rose to 13.0%. Community acquisition, patient cardiac or immune risk factors, monomicrobial culture and multiple positive blood cultures all were associated with IE. 62.1% of patients with E. faecalis bacteraemia did not have an echocardiogram during their admission, due to a variety of reasons. Discussion: The lower reported rate of IE in our cohort may be explained by higher proportion of CVC related infections. However, given the low rates of echocardiography and poor correlation of echocardiography use with IE risk factors, it is likely that cases of IE are being missed, particularly in those with multiple risk factors. Despite this, there was no difference in one-year survival between those diagnosed with IE vs without IE. We have delivered education sessions and introduced a multidisciplinary team meeting to discuss infective endocarditis cases to address these issues.

A Multinational Case Series Describing Successful Treatment of Persistent Severe Acute Respiratory Syndrome Coronavirus 2 Infection Caused by Omicron Sublineages With Prolonged Courses of Nirmatrelvir/Ritonavir.

The optimum treatment for persistent infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is not known. Our case series, across 5 hospitals in 3 countries, describes 11 cases where persistent SARS-CoV-2 infection was successfully treated with prolonged courses (median, 10 days [range, 10-18 days]) of nirmatrelvir/ritonavir (Paxlovid). Most cases (9/11) had hematological malignancy and 10 (10/11) had received CD20-depleting therapy. The median duration of infection was 103 days (interquartile range, 85-138 days). The majority (10/11) were hospitalized, and 7 (7/11) had severe/critical disease. All survived and 9 of 11 demonstrated viral clearance, almost half (4/9) of whom received nirmatrelvir/ritonavir as monotherapy. This case series suggests that prolonged nirmatrelvir/ritonavir has a role in treating persistent infection.

Cefiderocol to manage chronic, multi-drug-resistant Burkholderia cepacia complex infection in a patient with cystic fibrosis: a case report.

In cystic fibrosis (CF) patients, Gram-negative Burkholderia cepacia complex (Bcc) infections are associated with recurrent pulmonary exacerbations. Bcc organisms are innately resistant to many antibiotics, and infection with B. cenocepacia is a contraindication to lung transplantation. We report a CF patient with severe lung disease, colonized with Bcc, with a history of around nine exacerbations per year for over 10 years, for whom antibiotic regimens (including targeted and broad-spectrum antibiotics) had not cleared infection or extended the interval between exacerbations. After receiving a 2 week cefiderocol-containing regimen, the patient remained stable for more than 5 months without the need for additional antibiotics or hospital admissions for respiratory exacerbations.

Acute kidney injury; improving the communication from secondary to primary care.

Acute kidney injury (AKI) is a common but preventable event in secondary care. It is known to be associated with poorer outcomes for the patient's future health. Patients therefore require specific after-care in the community following an AKI, both in the short and long term. However, information about an inpatient AKI is often not communicated to primary care at discharge. Only 11.0% of discharge summaries contained full information about an AKI (including stage of AKI, changes to medications and follow-up required) in August 2015. We aimed to improve communication about AKI on discharge summaries via implementation of a series of interventions between June 2015 and March 2016. A specific section was added to the discharge summary software to prompt inclusion of information regarding AKI. An automatic warning message was added later as an additional prompt. A programme of education was provided for the junior doctors. A ward-based campaign was rolled out using the animated character 'Ned the Nephron,' using posters, emails and screen savers. We also introduced an AKI warning sticker for drug charts, which reminds the discharging doctor that the patient has had an AKI during the admission. Our primary outcome was the percentage of discharge summaries that had the AKI section completed, as this contained all the desired information, including stage of AKI and frequency of follow up blood tests in primary care. Monthly data collections showed that this gradually increased from 4.7% in September 2015 to 35.0% in January 2016. We expect further increases with the recent introduction of the drug chart sticker.