International Society of Cardiovascular Infectious Diseases Guidelines for the Diagnosis, Treatment and Prevention of Disseminated Mycobacterium chimaera Infection Following Cardiac Surgery with Cardiopulmonary Bypass.

Mycobacterial infection-related morbidity and mortality in patients following cardiopulmonary bypass surgery is high and there is a growing need for a consensus-based expert opinion to provide international guidance for diagnosing, preventing and treating in these patients. In this document the International Society for Cardiovascular Infectious Diseases (ISCVID) covers aspects of prevention (field of hospital epidemiology), clinical management (infectious disease specialists, cardiac surgeons, ophthalmologists, others), laboratory diagnostics (microbiologists, molecular diagnostics), device management (perfusionists, cardiac surgeons) and public health aspects.

Measurement of Humoral Immune Competence and the Risk of Sinopulmonary Infection in a Cohort of Kidney Transplant Recipients.

PURPOSE: The aim of this study was to determine if measurement of B cell protective immunity was associated with susceptibility to sinopulmonary infection in kidney transplant recipients. METHODS AND MATERIALS: A prospective cohort of 168 patients with stable graft function (median 4.1 years) underwent assessment of B-lymphocyte antigen CD19 (CD19+) cell number, immunoglobulin G concentration, and seroresponses to influenza vaccination upon study entry. Patients received a single dose of a trivalent, seasonal influenza vaccine. RESULTS: After 2 years follow-up, 31 patients (18%) developed sinopulmonary infection. CD19+ cell number was strongly associated with future sinopulmonary infection. A higher proportion of patients with CD19+ cell counts below the fifth percentile for controls developed sinopulmonary infections than those above the fifth percentile, 30% (23 of 77 patients) compared with 9% (7 of 79 patients; P = .001). There was a trend toward a higher proportion of patients with reduced immunoglobulin G concentrations developing infections than in the normal range for controls, 29% (14 of 48 patients) compared with 15% (16 of 108 patients; P = .060). Influenza vaccination seroresponses were poor in patients and controls such that they could not be used to identify a subgroup of patients at high risk for the development of severe pulmonary infection. CONCLUSIONS: Monitoring B-cell numbers represents a simple, inexpensive means of stratifying transplant recipients' risk of sinopulmonary infection.

Adenosine triphosphate bioluminescence to validate decontamination of endoscopes.

The reports of outbreaks involving carbapenemase-resistant Enterobacteriaceae (CRE) associated with gastrointestinal endoscopy prompted a review and study of a novel method of assessing cleaning. This study assessed adenosine triphosphate (ATP) bioluminescence to demonstrate cleanliness prior to endoscopy. ATP testing was compared with microbiological monitoring for 127 endoscopes. Samples were taken after cleaning, reprocessing and storage, but immediately before the endoscopy procedure. We recommend implementing ATP testing prior to endoscopy procedures as an alternative to microbiological testing at periodic intervals. ATP testing provides a convenient assessment of endoscopy hygiene to demonstrate safety and quality assurance.

Ebola virus disease: An update on current prevention and management strategies.

Ebola virus disease (EVD) is characterised by systemic viral replication, immuno-suppression, abnormal inflammatory responses, large volume fluid and electrolyte losses, and high mortality in under-resourced settings. There are various therapeutic strategies targeting EVD including vaccines utilizing different antigen delivery methods, antibody-based therapies and antiviral drugs. These therapies remain experimental, but received attention following their use particularly in cases treated outside West Africa during the 2014-15 outbreak, in which 20 (80%) out of 25 patients survived. Emerging data from current trials look promising and are undergoing further study, however optimised supportive care remains the key to reducing mortality from EVD.

Effects of fractionated colostrum replacer and vitamins A, D, and E on haptoglobin and clinical health in neonatal Holstein calves challenged with Mycobacterium avium ssp. paratuberculosis.

Thirty Holstein calves were obtained from 2 dairy farms in central Iowa at birth and randomly assigned to 1 of 6 treatment groups: (1) colostrum deprived (CD), no vitamins; (2) colostrum replacer (CR), no vitamins; (3) CR, vitamin A; (4) CR, vitamin D3; (5) CR, vitamin E; and (6) CR, vitamins A, D3, E, with 5 calves per treatment in a 14-d study. Calves were fed pasteurized whole milk (CD) or fractionated colostrum replacer (CR) at birth (d 0) and injected with vitamins according to treatment group. From d 1 through d 14 of the study, all calves were fed pasteurized whole milk (PWM) supplemented with vitamins as assigned. All calves were inoculated with Mycobacterium avium ssp. paratuberculosis on d 1 and 3 of age. Calves fed CR acquired IgG1 and haptoglobin in serum within 24 h of birth, whereas CD calves did not. The CR-fed calves were 2.5 times less likely to develop scours, and CR calves supplemented with vitamins D3 and E also demonstrated a decreased incidence of scours. Serum vitamin levels of A, D, and E increased within treatment group by d 7 and 14 of the study. Interestingly, synergistic effects of supplemental vitamins A, D3, and E on serum 25-(OH)-vitamin D were observed at d 7, resulting in higher levels than in calves administered vitamin D only. Further, vitamin D3 deficiency was observed in CD and CR calves fed a basal diet of pasteurized whole milk and no supplemental vitamins. Colonization of tissues with Mycobacterium avium ssp. paratuberculosis was negligible and was not affected by colostrum feeding or vitamin supplementation. Results demonstrated passive transfer of haptoglobin to neonatal calves, and potential health benefits of supplemental vitamins D3 and E to calves fed pasteurized whole milk.

Low rates of endocarditis in healthcare-associated Staphylococcus aureus bacteremia suggest that echocardiography might not always be required.

Healthcare-associated Staphylococcus aureus bacteremia (HA-SAB) is an increasingly frequently observed complication of medical treatment. Current guidelines recommend evaluation with echocardiography and preferably transesophageal echocardiography for the exclusion of infectious endocarditis (IE). We performed a retrospective analysis of all patients with HA-SAB between 1 January 2007 and 31 July 2012. Patients were divided into those with a high degree of clinical suspicion of IE (prosthetic intracardiac device, hemodialysis or positive blood cultures for 4 days or more) or those with a low degree of clinical suspicion of IE (absence of high-risk features based on previous literature as strong indicators of endocarditis). Three hundred and fifty-eight patients with HA-SAB were evaluated to determine the prevalence of IE, including 298 (83 %) who had echocardiography. Fourteen patients (4 %) had a final diagnosis of IE after echocardiography. In the group with a high degree of clinical suspicion 11 out of 84 patients (13 %) had IE. In the group with a low degree of clinical suspicion group 3 out 274 patients (1.1 %) had IE. HA-SAB has a low rate of IE, especially in the absence of high-risk features such as prolonged bacteremia, intracardiac prosthetic devices, and hemodialysis. Echocardiographic imaging in this low-risk population of patients is rarely helpful and may generally be avoided, although careful clinical follow-up is warranted. Patients with HA-SAB who have mechanical valves, intracardiac devices, prolonged bacteremia or dialysis dependency have a high incidence of IE and should be evaluated thoroughly using echocardiography.

Temporal plasma vitamin concentrations are altered by fat-soluble vitamin administration in suckling pigs.

Piglets are born with purportedly low plasma vitamin D levels. The objective of this study was to investigate the effect of fat-soluble vitamin administration, primarily vitamin D, by different administration routes on plasma vitamin concentrations in suckling pigs. A total of 45 pigs from 5 litters were allotted at birth to 3 treatments within each litter. Pigs were administered 400 IU of α-tocopherol, 40,000 IU of retinyl palmitate, and 40,000 IU of vitamin D at d 1 of age either orally or by i.m. injection and compared with control pigs with no supplemental vitamin administration. Blood samples were collected at d 0 (initial), 1, 2, 3, 4, 6, 9, 14, and 20 after administration. Plasma 25-hydroxycholecalciferol (25OHD), α-tocopherol, retinyl palmitate, and retinol concentrations were analyzed. Except for retinol, the effects of treatment, day, and day × treatment interaction ( < 0.01) were observed on plasma vitamin concentrations. Plasma concentrations of 25OHD and α-tocopherol increased immediately regardless of administration routes to peak at d 2 and 1 after administration, respectively. Plasma retinyl palmitate concentrations increased only with the injection treatment, with the peak at d 1 after administration. Plasma concentrations of 25OHD in both administration treatments and α-tocopherol in the injection treatment were maintained at greater levels than those in the control treatment until d 20 after administration. With regard to the pharmacokinetic parameters for plasma 25OHD concentrations, the injection treatment had greater elimination half-life ( < 0.01), maximum plasma concentrations ( < 0.05), and all area under the curve parameters ( < 0.01) but a lower elimination rate constant ( < 0.01) than the oral treatment. Relative bioavailability of oral administration compared with injection administration was 55.26%. These results indicate that plasma status of 25OHD,α-tocopherol, and retinyl palmitate are differentially changed between types of vitamins administered and between administration routes and that the injection route had a greater increase and slower disappearance of plasma vitamin levels than the oral route during the suckling period.

Survey of infection control and antimicrobial stewardship practices in Australian residential aged-care facilities.

This study assessed infection prevention and antimicrobial stewardship (AMS) practices in Australian residential aged-care facilities (RACF). Two hundred and sixty-five surveys (15.6%) were completed with all states represented and the majority (177 (67.3%)) privately run. Only 30.6% RACF had infection control trained staff on site. Few facilities had AMS policies, only 14% had antimicrobial prescribing restrictions. Most facilities offered vaccination to residents (influenza vaccination rates >75% in 73% of facilities), but pneumococcal vaccination was poor.

Emergence and spread of predominantly community-onset Clostridium difficile PCR ribotype 244 infection in Australia, 2010 to 2012.

We describe an Australia-wide Clostridium difficile outbreak in 2011 and 2012 involving the previously uncommon ribotype 244. In Western Australia, 14 of 25 cases were community-associated, 11 were detected in patients younger than 65 years, 14 presented to emergency/outpatient departments, and 14 to non-tertiary/community hospitals. Using whole genome sequencing, we confirm ribotype 244 is from the same C. difficile clade as the epidemic ribotype 027. Like ribotype 027, it produces toxins A, B, and binary toxin, however it is fluoroquinolone-susceptible and thousands of single nucleotide variants distinct from ribotype 027. Fifteen outbreak isolates from across Australia were sequenced. Despite their geographic separation, all were genetically highly related without evidence of geographic clustering, consistent with a point source, for example affecting the national food chain. Comparison with reference laboratory strains revealed the outbreak clone shared a common ancestor with isolates from the United States and United Kingdom (UK). A strain obtained in the UK was phylogenetically related to our outbreak. Follow-up of that case revealed the patient had recently returned from Australia. Our data demonstrate new C. difficile strains are an on-going threat, with potential for rapid spread. Active surveillance is needed to identify and control emerging lineages.

Who really knows their patients' penicillin adverse drug reaction status? A cross-sectional survey.

This cross-sectional survey of patients with adverse drug reactions (ADR) to penicillin and their treating doctor, nurse and pharmacist was undertaken to identify the extent of healthcare workers (HCW) awareness of their patients' ADR, and antibiotic use in hospital. There were 23 (38%) doctors, 53 (87%) nurses and 40 (66%) pharmacists who were aware of their patient's penicillin ADR, despite more than half of their patients receiving antibiotics. Interventions encouraging 'double checking' may improve antibiovigilance.

The Effects of Fat-soluble Vitamin Administration on Plasma Vitamin Status of Nursing Pigs Differ When Provided by Oral Administration or Injection.

Four experiments were conducted to investigate the effect of fat-soluble vitamin administration to sows or newborn pigs on plasma vitamin status. In Exp. 1 and 2, a total of 24 and 43 newborn pigs were allotted to control and vitamin treatments (vitamin D3 with variable addition of vitamins A and E) orally or by i.m. injection. In Exp. 3, pigs from Exp. 2 were allotted to 2 treatments (±vitamins D3 and E in drinking water) for 14 d postweaning. In Exp. 4, twenty-four gestating sows were used for 2 treatments (±injection of a vitamin D3/A/E product 2 wk prepartum). In Exp. 1 and 2, when vitamin D3 was administrated orally or by i.m. injection on d 1 of age, pigs had increased plasma 25-hydroxycholecalciferol (25-OH D3) concentration 10 d after administration compared with control pigs (p<0.05). The injectable administration with vitamin D3 and E was able to achieve higher plasma 25-OH D3 (p<0.05) and α-tocopherol (p<0.05) concentrations than oral administration. At weaning, the pigs in the injection group had higher plasma 25-OH D3 concentration than those in the other groups in both studies (p<0.05). In Exp. 3, water supplementation of vitamin D3 and E postweaning increased plasma 25-OH D3 and α-tocopherol concentrations at d 14 postweaning (p<0.01). In Exp. 4, when sows were injected with the vitamin D3 product prepartum, serum 25-OH D3 concentrations of sows at farrowing (p<0.01), and in their progeny at birth (p<0.01) and weaning (p<0.05) were increased. These results demonstrated that fat-soluble vitamin administration to newborn pigs increased plasma 25-OH D3 concentration regardless of administration routes and α-tocopherol concentration by the injectable route, and that water supplementation of vitamin D3 and E to nursery pigs increased plasma 25-OH D3 and α-tocopherol concentrations. Additionally, injecting sows with vitamin D3 prepartum increased 25-OH D3 in sows and their offspring. If continued research demonstrates that the serum levels of 25-OH D3 are critical in weanling pigs, a variety of means to increase those levels are available to swine producers.

Effects of d-α-tocopherol and dietary energy on growth and health of preruminant dairy calves.

To observe the effects of supplemental dietary d-α-tocopherol in relation to dietary energy on growth and immune status in dairy calves, 32 newborn Holstein bull calves were assigned to 1 of 4 treatments for 5 wk in a 2 × 2 factorial, randomized complete block, split-plot design. Calves received moderate growth (MG) or low growth (LG) all-milk dietary treatments, formulated to support daily gains of 0.5 or 0.25 kg/d, respectively, per the dietary energy recommendation for milk-fed calves according to the National Research Council's Nutrient Requirements of Dairy Cattle. Calves in both groups were either injected i.m. with Vital E-A+D (injectable solution of vitamins E, A, and D) on d 1 and supplemented with Emcelle Tocopherol (micellized vitamin E) via milk daily (MG-S and LG-S), or were not supplemented (MG-C and LG-C) during the study period. Total weight gain of MG calves was greater than that of LG calves and tended to be greater in MG-S calves than in MG-C calves. Calves receiving vitamin supplementation demonstrated greater concentrations of plasma α-tocopherol, retinol, and 25-(OH)-vitamin D than did control calves, whereas MG calves demonstrated a lower concentration of plasma α-tocopherol than did LG calves. The apparent increased utilization of α-tocopherol by MG calves was accompanied by a rise in serum haptoglobin, a positive acute-phase protein and indicator of inflammation, especially in MG-C calves. Serum amyloid A, also a positive acute-phase protein, was not different among groups, but was elevated from baseline in all groups during wk 1 through 3. Plasma IgG1 concentrations were higher in MG-S and LG-S calves than in their nonsupplemented dietary counterparts, whereas plasma IgG2, IgA, and IgM concentrations were not different among groups. In summary, dietary supplementation of d-α-tocopherol improved plasma α-tocopherol status and tended to increase growth in calves fed for 0.5 kg of average daily gain. Vitamin supplementation ameliorated the rise of serum haptoglobin associated with acute inflammation in MG calves, and may have improved passive transfer of maternal antibody. These results indicate a role for α-tocopherol in prevention of proinflammatory state associated with greater dietary energy and onset of infectious disease.

Hampered by historical paradigms--echinocandins and the treatment of Candida endocarditis.

Infective endocarditis due to Candida sp. has a high mortality rate. Traditionally, management involves early surgery and prolonged amphotericin ± flucytosine. We report a case of Candida parapsilosis bileaflet mitral valve endocarditis cured with anidulafungin and fluconazole, and review the role of echinocandins in the management of Candida endocarditis.

Vancomycin-resistant enterococci colonization does not increase mortality in end-stage kidney failure: a case-control study.

BACKGROUND: Vancomycin-resistant enterococci (VRE) colonization is a frequent occurrence in patients with renal failure. Understanding the impact of VRE colonization on this group of patients has considerable clinical applicability. AIM: To understand whether VRE colonization in renal patients has an impact on number of admissions to hospital, length of stay, and mortality. METHODS: A retrospective case-control study of renal dialysis patients was performed between 2000 and 2010. Cases were 134 VRE-colonized patients requiring renal replacement therapy and matched controls were 137 non-colonized patients with the same baseline characteristics. Matched cases and controls were analysed for differences in number of admissions, length of stay, and mortality. FINDINGS: There was no difference in mortality between colonized and non-colonized patients (hazard ratio: 1.14; 95% confidence interval: 0.78-1.69; P = 0.49). Length of stay for colonized patients was 7.29 days compared with 4.14 days (P < 0.001). The number of admissions for VRE-colonized patients was not significantly different compared with controls (9.34 vs 8.33, P = 0.78). CONCLUSION: VRE colonization did not increase mortality in renal patients but did contribute to increased length of stay.

Antibiotic use and misuse in residential aged care facilities.

BACKGROUND: The prevention and control of transmission of antimicrobial-resistant pathogens in residential aged care facilities (RACF) is an area that has been neglected yet has significant implications for health services. AIMS: The aims of this study were to describe the prevalence and appropriateness of antibiotic use within five RACF associated with our health service. METHODS: Demographic data on each RACF and all residents were obtained, and antibiotics prescribed (the type, indication and duration) at the time of the survey were recorded. The appropriateness of antibiotic prescribing was assessed using well-established criteria. RESULTS: Of the 257 residents, 28% were greater than 85 years of age, almost 50% were male and 71% had been in their RACF for more than a year. Sixty-seven per cent were incontinent of urine or faeces, and 80% had some degree of cognitive impairment. Among the residents, 23 (9%) were receiving antibiotics at the time of the survey. Seventeen (74%) were for treatment, while six (26%) were given for prophylactic reasons. Data on the appropriateness of antibiotic use were available for the preceding 26-month period. During this time, there were 988 antibiotic courses administered; of these, 392 (39.7%) did not fulfil the criteria for bacterial infection. CONCLUSION: This Australian study is one of the first to report on the use of antibiotics within RACF, shows a high rate of antimicrobial prescribing and inappropriate antibiotic use. Antibiotic stewardship is of paramount importance in RACF. Programmes to promote the rational use of antibiotics and minimise the emergence of resistant pathogens are urgently required in Australian RACF.

New HIV diagnosis after occupational exposure screening: the importance of reporting needlestick injuries.

We describe three new diagnosis of HIV infection as a direct result of testing following occupational exposures (NSIs) in a low-prevalence setting. In each case the finding was unexpected. Our series provides a reminder of the importance of prompt reporting of NSIs by healthcare workers, access to rapid HIV testing and post-exposure prophylaxis with antiretrovirals to prevent transmission.

A bundle of care to reduce colorectal surgical infections: an Australian experience.

Use of 'bundles of care' to improve patient outcomes is becoming more widespread; however, their use is more common internationally than in Australia. The objective of this study was to assess the feasibility of implementing a bundle of care for patients undergoing colorectal surgery with the aim of reducing surgical site infections. Each component of the bundle was evidence based, focusing on normothermia, normoglycaemia, oxygen delivery and use of appropriate antibiotics. Implementation required extensive consultation and education, together with a checklist to accompany patients and record whether processes were followed and outcomes achieved. Difficulties were experienced with achieving compliance with processes, although some improvements were seen. There was a link between the use of warming devices and improved maintenance of normothermia. The infection rate fell from 15% [95% confidence interval (CI) 10.4-20.2] before the project to 7% (95% CI 3.4-12.6) 12 months after the project. While the small sample size does not allow definitive conclusions to be drawn, the results are promising. Potential reasons for low compliance with individual components of the bundle of care are discussed. In conclusion, introduction of a bundle of care for patients undergoing colorectal surgery into an Australian hospital was only modestly successful. Despite this, infection rates decreased over the 12 months following introduction of the bundle.

Treatment and outcome of 104 hospitalized patients with legionnaires' disease.

BACKGROUND: Large outbreaks of Legionella pneumonia are rare, but when they occur provide an opportunity to assess predictors of mortality and efficacy of drug therapy. Although erythromycin has been the treatment of choice for many years, newer antimicrobials with increased activity against Legionella are available. A large outbreak of legionnaires' disease associated with the Melbourne Aquarium occurred in April 2000. AIM: To describe the patterns and impact of Legionella therapy, and predictors of outcome in a large group of hospitalized patients with legionnaires' disease. METHODS: A 6-month retrospective audit of hospitalized patients with proven legionnaires' disease around the time of the Melbourne Aquarium outbreak was conducted. Statistical analysis was performed using SAS version 8.0 (SAS Institute Inc., NC, USA). RESULTS: Data were obtained on 104 patients (71 aquarium related, 33 not related). There were six deaths (mortality rate 5.8%), three of which were attributable directly to progressive legionnaires' disease. The major predictors of death were pre-existing cardiac failure (P = 0.0035) and renal disease (P = 0.026). Erythro-mycin is still the most commonly used antibiotic (80% received i.v. erythromycin) with clinicians prescribing more than one active Legionella drug in the majority of cases (76%). Choice of initial antibiotic therapy did not statistically affect outcome as measured by death, length of hospital stay or time to defervescence, although there was a trend towards improved survival with i.v. erythromycin (P = 0.063). Intravenous erythromycin was associated with a 19% rate of phlebitis, whereas side-effects from other antibiotics were uncommon. CONCLUSION: The most commonly used Legionella therapy in Australia remains erythromycin. This continues to be an effective agent, however, side-effects are common.

Assessing the risk of tuberculosis infection among healthcare workers: the Melbourne Mantoux Study. Melbourne Mantoux Study Group.

OBJECTIVE: To determine the potential prevalence of nosocomial infection with Mycobacterium tuberculosis among hospital employees in teaching hospitals in Melbourne. DESIGN: Cross-sectional survey of positive tuberculin skin test (Mantoux) responses among employees in 14 public hospitals in Melbourne, January 1996 to April 1999. PARTICIPANTS: All consenting employees in participating hospitals (4,070 healthcare and 4,298 non-healthcare workers; participation rates, 13%-66%). OUTCOME MEASURES: Prevalence of positive responses to tuberculin skin tests among healthcare and non-healthcare workers and association with employee and hospital characteristics. RESULTS: Healthcare workers were significantly more likely to have a positive tuberculin response than non-healthcare workers (19.3% versus 13.7%; odds ratio, 1.5; 95% CI, 1.3-1.7; P<0.001). Multivariable analysis revealed that age, country of birth (high versus low tuberculosis [TB] prevalence), history of BCG (bacille Calmette-Guérin) vaccination, years since last BCG, occupation (healthcare versus non-healthcare worker) and years of hospital employment were all significantly associated with a positive response. Rates of positive responses among employees varied greatly between hospitals (6%-35%). These differences were not explained by employee characteristics, hospital TB patient load (number of admissions or bed-days) or percentage of hospital patients from countries with high TB prevalence. The hospital with the highest rate of positive responses was notable for its lack of negative-pressure isolation rooms for TB patients. CONCLUSIONS: Positive tuberculin responses are relatively common among hospital employees in Melbourne, with rates varying between hospitals and being higher among healthcare than non-healthcare workers. Employee characteristics, such as age, country of birth and past BCG status, explain little of this variation. More emphasis on TB infection control measures and regular staff screening may be needed.