Strongyloidiasis in Auckland: A ten-year retrospective study of diagnosis, treatment and outcomes of a predominantly Polynesian and Fijian migrant cohort.

BACKGROUND: Strongyloides stercoralis is not endemic in Aotearoa New Zealand (AoNZ). However, approximately one third of Auckland residents are born in endemic countries. This study aimed to describe the epidemiology and management of strongyloidiasis in Auckland, with a focus on migrants from Pacific Island Countries and Territories. METHODS: This study retrospectively reviewed clinical, laboratory and pharmacy records data for all people diagnosed with strongyloidiasis in the Auckland region between July 2012 and June 2022. People with negative Strongyloides serology were included to estimate seropositivity rate by country of birth. FINDINGS: Over ten years, 691 people were diagnosed with strongyloidiasis. Most diagnoses were made by serology alone (622, 90%). The median age was 63 years (range 15-92), 500 (72%) were male, and the majority were born in Polynesia (350, 51%), Fiji (130, 19%) or were of Pasifika ethnicity (an additional 7%). Twelve participants (1.7%) had severe strongyloidiasis at diagnosis. The total proportion treated with ivermectin was only 70% (484/691), with no differences between immunocompromised and immunocompetent participants, nor by ethnicity. The outcome of treatment (based on a combination of serology and/or eosinophilia and/or stool microscopy) could only be determined in 50% of the treated cohort. One participant failed treatment with ivermectin, experiencing recurrent strongyloidiasis, and another participant died in association with severe strongyloidiasis. The rate of 'positive' Strongyloides serology was highest among participants born in Samoa (48%), Fiji (39%), and Southeast Asian countries (34%). INTERPRETATION: Strongyloidiasis was common and under-treated in Auckland during the study period. Clinicians should have a low threshold for considering strongyloidiasis in migrants from endemic countries, including Polynesia and Fiji.

Diagnosis and management of paediatric Clostridioides difficile infection in a tertiary centre: A prospective audit.

AIM: The optimisation of diagnosis and management of paediatric Clostridioides (formerly Clostridium) difficile (C. difficile) infection (CDI) has importance on multiple levels, from individual patient to population disease management and infection control. This study aimed to evaluate current practice at a paediatric tertiary hospital against Australasian Society for Infectious Diseases 2016 guidelines. METHODS: Prospective audit was undertaken. All positive C. difficile tests (by two step immunoassay then polymerase chain reaction) over 6 month period were reviewed for appropriateness of testing, including review of clinical characteristics and treatment of appropriately requested positive tests (CDI cases). Consecutive test requests for C. difficile over 2 month period were reviewed for appropriateness of testing. RESULTS: Of 70 consecutive test requests, 64 met laboratory criteria for processing. Of these, 31 (48%) out of 64 were asymptomatic or had clinically insignificant or laxative-associated diarrhoea. Overall, 44 (63%) out of 70 were deemed inappropriate requests. Of 45 positive tests, 17 (38%) were appropriately requested. Amongst inappropriate requests, 13 (46%) out of 28 were treated; those aged >2 years were significantly more likely to be treated (P < 0.05). Thirteen children were treated unnecessarily. Only one out of seven positive tests in infants (<1 year) was appropriately requested. Haematology/oncology patients accounted for 41% of cases. Treatment was in accordance with guidelines in 58% of cases. CONCLUSIONS: Inappropriate testing for C. difficile and variable clinical response to positive tests have sequelae including unnecessary antibiotics for hospitalised children. Areas for improvement have been identified and this study confirms the need for establishment of national paediatric CDI guidelines with increased awareness of these by clinicians.

Improved detection of toxigenic Clostridium difficile using the Cepheid Xpert C difficile assay and impact on C difficile infection rates in a tertiary hospital: a double-edged sword.

Recent recommendations suggest implementation of a 2-step diagnostic algorithm for the laboratory detection of toxigenic Clostridium difficile. We found that the rate of toxigenic C difficile detection in our laboratory doubled after the introduction of an algorithm that incorporated polymerase chain reaction testing. This led to an abrupt 70% increase in the overall rate of C difficile infection in our institution.

Molecular epidemiology and susceptibility profiles of Clostridium difficile in New Zealand, 2009.

AIM: The aim of this study was to provide baseline information on the molecular epidemiology and the antimicrobial susceptibility of Clostridium difficile (C. difficile) clinical isolates from patients throughout New Zealand. METHODS: Faecal specimens that were C. difficile-toxin positive by EIA assay were cultured for C. difficile. Antimicrobial susceptibility testing was carried out using the agar dilution minimum inhibitory concentration method. The following antibiotics were tested: penicillin, piperacillin/tazobactam, vancomycin, ciprofloxacin, moxifloxacin, clindamycin, clarithromycin, meropenem and metronidazole. Molecular typing by PCR-ribotyping was performed on all isolates. RESULTS: C. difficile was isolated from 108 of 159 submitted faecal specimens. After excluding the repeats, there were 101 isolates from 97 patients. Most isolates were fully susceptible to the range of antibiotics tested. Thirty-two PCR-ribotypes were identified among the 101 isolates. The most common ribotypes were 014 (18 isolates), 002 (11) and 005 (10). No PCR-ribotype 027 isolates were identified, but one isolate of another hypervirulent strain, PCR-ribotype 078, was identified. CONCLUSION: There is a wide range of C. difficile PCR-ribotypes circulating in New Zealand and antimicrobial resistance is uncommon. Ongoing surveillance for hypervirulent strains of C. difficile is essential to prevent the dissemination of these strains within New Zealand hospitals.