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An analysis of the Clinical Excellence Commissions response to COVID-19 prevention and protection measures identified the need to build on the existing governance process to achieve a more structured and methodical approach. The infection prevention and control measures and strategies implemented within health and nonhealth care, proved to be effective and sustainable with the ability to build additional clinician capacity even during an ongoing pandemic.

The use of fit tested respirators in the workplace is required to protect health workers against airborne pathogens. The COVID-19 pandemic required rapid upscaling of fit testing which was achieved using the framework of a respiratory protection program. Implementing and sustaining such a program in the midst of a pandemic was challenging and required clear direction from a lead agency combined with stakeholder engagement.

Beyond the use of policy and system-focused approaches, it has been established globally that patients can play a role in enhancing the health care landscape. However, efforts to meaningfully translate patient engagement strategies that promote participation by hospitalized patients in relevant infection prevention and antimicrobial stewardship activities have not yet been realized. This study mapped the key factors acting as barriers and facilitators of patient engagement using a theoretical framework to identify potential new approaches to promote engagement.Semistructured interviews were conducted with 36 patients from 3 major hospitals in Sydney, Australia, in 2019. Transcripts were inductively analyzed, with the resulting themes categorized into the components of the Capability-Opportunity-Motivation-Behavior model.The themes regarding barriers to patient engagement with relevant infection prevention and antimicrobial stewardship activities were: (1) Capability: misunderstanding and knowledge gaps about antimicrobial resistance; (2) Opportunity: strong family/patient support networks and good relationships with nursing staff provide an opportunity to support engagement; (3) Motivation: those who have some level of understanding or experience see the benefit and are most likely to engage actively.Assuming patients are inclined to participate in efforts, a logical starting point would be to build awareness amongst patients and providers; however, education will not suffice. There needs to be a system and policy shift to ensure that patient engagement is recognized as a worthy endeavor.

Objectives\ud\udWe analysed the concordance of rectal swab isolates and blood culture for Gram-negative bacteria (GNB) isolates in neonates with a suspicion of neonatal sepsis admitted to a neonatal care unit in Haiti.\udMethods\ud\udWe matched pairs of blood and rectal samples taken on the date of suspected sepsis onset in the same neonate. We calculated the proportion of rectal isolates in concordance with the blood isolates by species and genus. We calculated the negative predictive value (NPV) for GNB and extended-spectrum β-lactamase (ESBL)-producing GNB for all rectal and blood isolate pairs in neonates with suspected sepsis.\udResults\ud\udWe identified 238 blood and rectal samples pairs, with 238 blood isolate results and 309 rectal isolate results. The overall concordance in genus and species between blood and rectal isolates was 22.3% [95% confidence interval (CI) 17.4–28.0%] and 20.6% (95% CI 16.0–26.2%), respectively. The highest concordance between blood and rectal isolates was observed for samples with no bacterial growth (65%), followed byKlebsiella pneumoniae (18%) and Klebsiella oxytoca (12%). The NPV of detecting GNB bacterial isolates in rectal samples compared with those in blood samples was 81.6% and the NPV for ESBL-positive GNB was 92.6%.\udConclusions\ud\udThe NPV of rectal swab GNB isolates was high in all patient groups and was even higher for ESBL-positive GNB. Clinicians can use the results from rectal swabs when taken simultaneously with blood samples during outbreaks to inform the (de-)escalation of antibiotic therapy in those neonates that have an ongoing sepsis profile.

Objective To determine whether rapid polymerase chain reaction (PCR) testing for influenza and respiratory syncytial viruses (RSV) in emergency departments (EDs) is associated with better patient and laboratory outcomes than standard multiplex PCR testing. Design, setting A before‐and‐after study in four metropolitan EDs in New South Wales. Participants 1491 consecutive patients tested by standard multiplex PCR during July–December 2016, and 2250 tested by rapid PCR during July–December 2017. Main outcome measures Hospital admissions; ED length of stay (LOS); test turnaround time; patient receiving test result before leaving the ED; ordering of other laboratory tests. Results Compared with those tested by standard PCR, fewer patients tested by rapid PCR were admitted to hospital (73.3% v 77.7%; P

Contains fulltext : 244043.pdf (Publisher’s version ) (Open Access) Pediatric community-acquired bloodstream infections (CA-BSIs) in sub Saharan African humanitarian contexts are rarely documented. Effective treatment of these infections is additionally complicated by increasing rates of antimicrobial resistance. We describe the findings from epidemiological and microbiological surveillance implemented in pediatric patients with suspected CA-BSIs presenting for care at a secondary hospital in the conflict affected area of Zamfara state, Nigeria. Any child (> 2 months of age) presenting to Anka General Hospital from November 2018 to August 2020 with clinical severe sepsis at admission had clinical and epidemiological information and a blood culture collected at admission. Bacterial isolates were tested for antibiotic susceptibility. We calculated frequencies of epidemiological, microbiological and clinical parameters. We explored risk factors for death amongst severe sepsis cases using univariable and multivariable Poisson regression, adjusting for time between admission and hospital exit. We included 234 severe sepsis patients with 195 blood culture results. There were 39 positive blood cultures. Of the bacterial isolates, 14 were Gram positive and 18 were Gram negative; 5 were resistant to empiric antibiotics: methicillin-resistant Staphylococcus aureus (MRSA; n = 2) and Extended Spectrum Beta-Lactamase positive enterobacterales (n = 3). We identified no significant association between sex, age-group, ward, CA-BSI, appropriate intravenous antibiotic, malaria positivity at admission, suspected focus of sepsis, clinical severity and death in the multivariable regression. There is an urgent need for access to good clinical microbiological services, including point of care methods, and awareness and practice around rational antibiotic in healthcare staff in humanitarian settings to reduce morbidity and mortality from sepsis in children.

Introduction Healthcare acquired infections (HAIs) are associated with increased mortality, morbidity and prolonged hospital stays. Microbiological contamination of the hospital environment directly contributes to HAIs. Optimising environmental cleaning reduces transmission of HAIs. The hyperbaric chamber poses a specific challenge for infection control as certain disinfectants and alcohol-based hand sanitisers are prohibited due to fire risk. Patients often possess multiple risk factors for HAIs. This study compared the bacteria remaining on a surface (bioburden) after a standard clean and after adjunctive disinfection with an ultraviolet-C (UV-C) robot. Methods Internal hyperbaric chamber surfaces were first manually cleaned with Clinell® universal wipes and the floor was mopped with Whiteley neutral detergent. Allocated surfaces were swabbed using sterile cotton swabs and processed using a standard microbial culture and a bacteria-specific rapid metabolic assay. Bacterial contamination was also measured by direct contact plating on flat surfaces. The plexiglass ports were covered to protect from potential UV-C mediated damage and used as a negative control. A UV-C disinfection robot was then used to disinfect the chamber for 30 min, whereafter surfaces were swabbed again. Results There was a significantly greater mean reduction in bioburden following adjunctive UV-C disinfection than with standard cleaning alone. The surfaces not routinely manually cleaned (e.g., bench, phone) showed greatest reduction in bacterial load following UV-C cleaning. Conclusions There was a significant reduction in the bacterial load in the chamber following an adjunctive UV-C clean compared with that of a standard clean. Adjunctive cleaning of the hyperbaric chamber environment with a non-touch UV-C device shows promise as a method to reduce HAIs.

There is a global outbreak of infections due to Mycobacterium chimaera associated with cardiac surgery. The most serious infections involve prosthetic material implantation, and all have followed surgical procedures involving cardiopulmonary bypass. We describe a cluster of four cases following cardiac surgery at a tertiary referral centre in Sydney, Australia. We report novel clinical findings, including haemolysis and kidney rupture possibly related to immune reconstitution inflammatory syndrome. The positive effect of corticosteroids on haemodynamic function in two cases and the failure of currently recommended antimicrobial therapy to sterilise prosthetic valve material in the absence of surgery despite months of treatment are also critically examined. Positron emission tomography was positive in two cases despite normal transoesophageal echocardiograms. The proportion of cases with M. chimaera infection after aortic valve replacement (4/890, 0.45%; 95% confidence interval 0.18-1.15%) was significantly higher than after all other cardiothoracic surgical procedures (0/2433, 0%; 95% confidence interval 0-0.16%).

Background Studies evaluating antimicrobial stewardship programmes (ASPs) supported by computerized clinical decision support systems (CDSSs) have predominantly been conducted in single site metropolitan hospitals. Objectives To examine outcomes of multisite ASP implementation supported by a centrally deployed CDSS. Methods An interrupted time series study was conducted across five hospitals in New South Wales, Australia, from 2010 to 2014. Outcomes analysed were: effect of the intervention on targeted antimicrobial use, antimicrobial costs and healthcare-associated Clostridium difficile infection (HCA-CDI) rates. Infection-related length of stay (LOS) and standardized mortality ratios (SMRs) were also assessed. Results Post-intervention, antimicrobials targeted for increased use rose from 223 to 293 defined daily doses (DDDs)/1000 occupied bed days (OBDs)/month (+32%, P < 0.01). Conversely, antimicrobials targeted for decreased use fell from 254 to 196 DDDs/1000 OBDs/month (-23%; P < 0.01). These effects diminished over time. Antimicrobial costs decreased initially (-AUD$64551/month; P < 0.01), then increased (+AUD$7273/month; P < 0.01). HCA-CDI rates decreased post-intervention (-0.2 cases/10 000 OBDs/month; P < 0.01). Proportional LOS reductions for key infections (respiratory from 4.8 to 4.3 days, P < 0.01; septicaemia 6.8 to 6.1 days, P < 0.01) were similar to background LOS reductions (2.1 to 1.9 days). Similarly, infection-related SMRs (observed/expected deaths) decreased (respiratory from 1.1 to 0.75; septicaemia 1.25 to 0.8; background rate 1.19 to 0.90. Conclusions Implementation of a collaborative multisite ASP supported by a centrally deployed CDSS was associated with changes in targeted antimicrobial use, decreased antimicrobial costs, decreased HCA-CDI rates, and no observable increase in LOS or mortality. Ongoing targeted interventions are suggested to promote sustainability.

Background Inappropriate antimicrobial prescribing may harm patients and drive antimicrobial resistance. Junior doctors’ knowledge of infectious diseases and antimicrobial prescribing is inadequate. Online spaced case-based learning can improve knowledge. Objective To develop infectious diseases and antimicrobial prescribing course content for online spaced education and assess its effectiveness and feasibility for junior doctors. Methods Infectious diseases and antimicrobial course content was developed for an online spaced education platform (Qstream Inc., Burlington, MA). Junior doctors (postgraduate years 1–3) at two tertiary teaching hospitals in Sydney participated in the study. Course content was provided with Qstream at one hospital and at the other hospital via two face-to-face (FTF) tutorials from August to October 2017. Knowledge and self-confidence were compared before and after training within and between both cohorts. Results Participation in the course was higher in the Qstream cohort with 48/127 (37.8%) completing the course compared with 44/110 (40%) attending one or both FTF sessions, of whom 22/110 (20%) attended both. Improvement in mean knowledge score from 69.7% to 81.5% in the Qstream cohort was significantly greater than the FTF cohort's minimal improvement from 67.6% to 67.9% (95% CI 2.79–20.33; P = 0.01). In the Qstream cohort mean confidence rating (0–10) improvement from 5.14 to 6.55 was greater than the FTF group improvement from 5.37 to 5.85 (95% CI 0.132–1.171; P = 0.02). Qstream feedback was very positive. Conclusions Online spaced education in infectious diseases and antimicrobial prescribing was feasible, acceptable and effective for junior doctors. It has potential to reduce inappropriate antimicrobial prescribing and warrants further investigation.

Background Antibiotic allergy labels have a direct impact on individual patient care and on the consumption of broad-spectrum antibiotics. Objective Our aim was to establish the prevalence of antibiotic allergies and to determine whether patients with documented antibiotic allergy labels received guideline concordant antimicrobial therapy. Additionally we wanted to evaluate the quality of allergy documentation in the medical record. Methods Prospective audit of all patients presenting to the Emergency Department of an adult teaching hospital in Sydney over a 4 month period. Documented allergy labels, diagnoses, antibiotic administration and outcomes were recorded. Appropriateness of antibiotic choice was based on the Australian National Antimicrobial Prescribing Survey. Results 9.9% of presentations had at least one antibiotic allergy recorded. Significantly more women than men had antibiotic allergies documented. One third of patients with documented antibiotic allergies were prescibed inappropriate antibiotic therapy and some had significant adverse events. Conclusions The documentation of antibiotic allergy labels and choice of antibiotic treatment can be significantly improved. Strategies to safely de-label people with documented allergies who are not truly allergic need to be implemented.

A standard multiplex PCR offers comprehensive testing for respiratory viruses. However, it has traditionally been performed in a referral laboratory with a lengthy turnaround time, which can reduce patient flow through the hospital. We aimed to determine whether the introduction of a rapid PCR, but with limited targets (Cepheid Xpert Flu/RSV XC), was associated with improved outcomes for adults hospitalized with respiratory illness. A controlled quasi-experimental study was conducted across three hospitals in New South Wales, Australia. Intervention groups received standard multiplex PCR during the preimplementation, July to December 2016 (n = 953), and rapid PCR during the postimplementation, July to December 2017 (n = 1,209). Control groups (preimplementation, n = 937, and postimplementation, n = 1,102) were randomly selected from adults hospitalized with respiratory illness during the same periods. The outcomes were hospital length of stay (LOS) and microbiology test utilization (blood culture, urine culture, sputum culture, and respiratory bacterial and virus serologies). The introduction of rapid PCR was associated with a nonsignificant 8.9-h reduction in median LOS (95% confidence interval [CI], -21.5 h to 3.7 h; P = 0.17) for all patients and a significant 21.5-h reduction in median LOS (95% CI, -36.8 h to -6.2 h; P < 0.01) among patients with positive test results in an adjusted difference-in-differences analysis. For patients receiving test results before disposition, rapid PCR use was associated with a significant reduction in LOS, irrespective of test results. Compared with standard PCR testing, rapid PCR use was significantly associated with fewer blood culture (adjusted odds ratio [aOR], 0.67; 95% CI, 0.5 to 0.82; P < 0.001), sputum culture (aOR, 0.56; 95% CI, 0.47 to 0.68, P < 0.001), bacterial serology (aOR, 0.44; 95% CI, 0.35 to 0.55, P < 0.001) and viral serology (aOR, 0.42; 95% CI, 0.33 to 0.53, P < 0.001) tests, but not with fewer urine culture tests (aOR, 0.94; 95% CI, 0.78 to 1.12, P = 0.48). Rapid PCR testing of adults hospitalized with respiratory illnesses can deliver benefits to patients and reduce resource utilization. Future research should consider a formal economic analysis and assess its potential impacts on clinical decision making.

We describe an outbreak of respiratory syncytial virus (RSV) infection on a hematology ward without allogeneic stem cell transplant patients. Twelve patients and one staff member infected with RSV were identified from the laboratory database. Five patients had lower respiratory tract infection, seven had upper respiratory tract infection, one was asymptomatic, and there were two (15.4%) deaths. Most patients had overlapping periods of potential infectiousness on the ward. Sequencing was possible on eight specimens and five of these had identical sequences. Results were consistent with transmission occurring both on the ward and by introduction of RSV from the community. J. Med. Virol. 88:1827-1831, 2016. © 2016 Wiley Periodicals, Inc.

Study design: Randomised double-blind factorial-design placebo-controlled trial. Objective: Urinary tract infections (UTIs) are common in people with spinal cord injury (SCI). UTIs are increasingly difficult to treat due to emergence of multi-resistant organisms. Probiotics are efficacious in preventing UTIs in post-menopausal women. We aimed to determine whether probiotic therapy with Lactobacillus reuteri RC-14+Lactobacillus GR-1 (RC14-GR1) and/or Lactobacillus rhamnosus GG+Bifidobacterium BB-12 (LGG-BB12) are effective in preventing UTI in people with SCI. Setting: Spinal units in New South Wales, Australia with their rural affiliations. Methods: We recruited 207 eligible participants with SCI and stable neurogenic bladder management. They were randomised to one of four arms: RC14-GR1+LGG-BB12, RC14-GR1+placebo, LGG-BB12+ placebo or double placebos for 6 months. Randomisation was stratified by bladder management type and inpatient or outpatient status. The primary outcome was time to occurrence of symptomatic UTI. Results: Analysis was based on intention to treat. Participants randomised to RC14-GR1 had a similar risk of UTI as those not on RC14-GR1 (HR 0.67; 95% CI: 0.39–1.18; P = 0.17) after allowing for pre-specified covariates. Participants randomised to LGG-BB12 also had a similar risk of UTI as those not on LGG-BB12 (HR 1.29; 95% CI: 0.74–2.25; P = 0.37). Multivariable post hoc survival analysis for RC14-GR1 only vs. the other three groups showed a potential protective effect (HR 0.46; 95% CI: 0.21–0.99; P = 0.03), but this result would need to be confirmed before clinical application. Conclusion: In this RCT, there was no effect of RC14-GR1 or LGG-BB12 in preventing UTI in people with SCI. Published version National Health and Medical Research Council (NHMRC) is the organisation responsible for funding the supply of probiotics and matching placebo selected by the researchers for this study and budgeted within the NHMRC grant. CHR Hansen, Horsholm, Denmark has been paid commercial rates for providing the intervention product and placebo. The company had no input into the design of the trial.

Background Patients colonized or infected with methicillin-resistant Staphylococcus aureus and or vancomycin-resistant Enterococcus are placed under contact precautions. Contact precautions require patients to be placed in single rooms and their health care workers (HCWs) to wear gowns, aprons and gloves on entry and doffing on exit. Glove use is widely accepted to be associated with poor hand hygiene compliance. We trailed the removal of gloves for contact precautions for contacts not expected to involve body fluids to improve hand hygiene between multiple contacts of the patient and patient zone. Methods We have conducted a 5 phase study of the removal of gloves for contacts without body fluids in 250 HCWs using pretrial focus groups (N = 12), hand microbiology (N = 40) (reported elsewhere), development of a modified contact precautions poster, trial of modified poster (n = 100), posttrial focus group discussion (n = 22), and a survey of HCWs postrollout in additional locations (n = 76). Results Pretrial focus groups identified 4 themes, and the leading theme identified as the facilitator for glove use as self-protection. HCWs viewed current contact precaution guidelines as preventing them from making their own judgement regarding the need for gloving for patient contacts, leading continuous glove use without changing gloves between multiple contacts. Participants believed that the trial empowered them to make their own clinical judgment for gloves and to consciously use hand hygiene between dry (no body fluid) contacts. Four themes were discussed during the posttrial focus groups and although self-protection remained the central theme, hand hygiene replaced glove use. Participants spoke of an appreciation of and increased trust in hand hygiene during nonglove use for dry contacts. The survey responses from additional sites were mostly positive for the safety of nonglove use for dry contacts, it improved hand hygiene and that the adoption of the modified guidelines was empowering. Conclusions The trial of nonglove use for expected dry contact, while caring for patients under contact precautions for methicillin-resistant S aureus and or vancomycin-resistant Enterococcus, was successful in refocusing HCWs reliance on hand hygiene for self-protection. Mandatory glove use for contact precautions was believed to contribute to their failure to change gloves between procedures on the same patient and patient zone, with HCWs now recognizing multiple contacts with the same gloves as a risk for contamination.

There is a global outbreak of infections due to Mycobacterium chimaera associated with cardiac surgery. The most serious infections involve prosthetic material implantation, and all have followed surgical procedures involving cardiopulmonary bypass. We describe a cluster of four cases following cardiac surgery at a tertiary referral centre in Sydney, Australia. We report novel clinical findings, including haemolysis and kidney rupture possibly related to immune reconstitution inflammatory syndrome. The positive effect of corticosteroids on haemodynamic function in two cases and the failure of currently recommended antimicrobial therapy to sterilise prosthetic valve material in the absence of surgery despite months of treatment are also critically examined. Positron emission tomography was positive in two cases despite normal transoesophageal echocardiograms. The proportion of cases with M. chimaera infection after aortic valve replacement (4/890, 0.45%; 95% confidence interval 0.18-1.15%) was significantly higher than after all other cardiothoracic surgical procedures (0/2433, 0%; 95% confidence interval 0-0.16%).

Background Routine hand hygiene effectively removes methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin resistant Enterococcus (VRE) from the ungloved hands of healthcare workers (HCWs) who are caring for patients under contact precautions, when exposure to bodily fluids is not expected. Methods HCWs' ungloved hands were cultured after hand hygiene with alcohol-based hand rub (ABHR) or soap-and-water wash after routine clinical care of patients known to be colonized or infected with MRSA or VRE. Results Two hundred forty samples from 40 HCWs were tested and found to be culture negative for either MRSA or VRE after contact with patients when 3 pumps of ABHR (0/80) or plain soap-and-water wash (0/80) were used. No VRE was observed in any of the 120 samples collected. Two plates (2/40) grew 1 colony-forming unit of MRSA after 2 pumps of ABHR. Two HCWs with positive plates were cultured negative on retesting. Conclusion We showed that appropriate hand hygiene was effective in removing MRSA and VRE even when gloves were not used for routine clinical care, despite contact with patients known to be colonized with MRSA or VRE. A modified approach to glove use for dry contact with patients on contact precautions might improve patient safety within healthcare settings.

Background Neuropathic or neurogenic bladder describes a process of dysfunctional voiding as the result of injury in the brain, spinal cord or nerves innervating the bladder. People with neuropathic bladder, such as from spinal cord injury (SCI), are at significant risk of morbidity from urinary tract infections (UTI). Effective methods to prevent UTI in people with SCI have been sought for many years. Probiotics (micro-organisms that exert beneficial health effects in the host) have been recommended for bacterial interference of the urological tract to reduce colonisation by uropathogen and to manage the dual problems of infection and antibiotic resistance. Objectives This review looked at the benefits and harms of probiotics in preventing symptomatic UTI in people with neuropathic bladder compared with placebo, no therapy, or non-antibiotic prophylaxis (cranberry juice, methenamine hippurate, topical oestrogen). Search methods We searched the Cochrane Kidney and Transplant Specialised Register up to 10 March 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. Selection criteria All randomised controlled trials (RCTs), quasi-RCTs and cross-over RCTs looking at the use of probiotics for the prophylaxis of UTI in people with neuropathic bladders was considered for inclusion. Men, women and children of all ages with neuropathic bladders from neurological injury such as suprapontine, supra sacral and sacral aetiologies was included. All bladder management types, including reflex voiding, time voiding, indwelling and intermittent catheterization were eligible for this review. Studies comparing probiotics to placebo, no treatment or other non-antibiotic prophylaxis was included. Studies comparing probiotics with antibiotics or in combination with antibiotics were excluded. Data collection and analysis Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) or standardised mean difference (SMD) and 95% CI were planned for continuous outcomes. Main results This review includes a total of three studies (one cross-over and two parallel RCTs) which involved 110 participants. All three studies looked at intravesical instillation of a low virulent Escherichia coli (E. coli) strain in reducing the risk of symptomatic UTI in participants with neuropathic bladder, predominantly from SCI. Two studies used the E. coli 83972 strain and one study used the E. coli HU2117 strain. We did not find any RCTs involving other probiotics or other routes of administration for preventing UTI in people with neuropathic bladder. There was consistency in definition of symptomatic UTI in all three studies. Symptoms that all studies considered were relevant to diagnose UTI were adequately defined. All three studies defined microbiological diagnosis of symptomatic UTI. Asymptomatic bacteriuria was not considered an outcome measure in any of the included studies; however it was defined in two studies to establish successful inoculation. It is uncertain if the risk of symptomatic UTI is reduced with bladder inoculation using E. coli because the certainty of the evidence is very low (3 studies, 110 participants: RR 0.32, 95% CI 0.08 to 1.19; I2 = 82%). Two studies reported adverse events. One study reported one episode of autonomic dysreflexia. One study reported three symptomatic UTI occurring in two patients, and two studies mentioned the absence of septicaemia and pyelonephritis. Intravesical instillation was reported as "generally safe". One study reported high attrition rates in participants due to the need to adhere to strict instillation protocols. The overall quality of the studies was poor. All three studies had high risk of attrition bias due to failure of an intention-to-treat analysis which undermines the randomisation process and weakened the results of the studies. All three studies also had high risk of reporting bias. Authors' conclusions In this review, there were no studies identified addressing oral probiotics in preventing UTI in people with neuropathic bladder. It is uncertain if the risk of symptomatic UTI is reduced in people with neuropathic bladders via intravesical instillation of non-pathogenic E. coli as data were derived from small studies with high risk of bias. Although very minimal levels of harm was reported with this procedure, due to variable success rates, the need for strict adherence to instillation protocols together with high attrition rates in these studies, it is doubtful bladder instillation will be a widely accepted intervention in its current form. It is recommended that further appropriately powered RCTs with more robust methodological reporting be carried out.

Immunosuppression is a risk factor for serious infection in humans., The insect microsporidian Anncaliia algerae was first described in 2004 as a cause of fatal myositis in an immunosuppressed person from Pennsylvania, USA. Two cases were subsequently reported, and we detail 2 additional cases, including the only nonfatal case. We reviewed all 5 case histories with respect to clinical characteristics, diagnosis, and management and summarized organism life cycle and epidemiology. Before infection, all case-patients were using immunosuppressive medications for rheumatoid arthritis or solid-organ transplantation. Four of the 5 case-patients were from Australia. All diagnoses were confirmed by skeletal muscle biopsy; however, peripheral nerves and other tissues may be infected. The surviving patient received albendazole and had a reduction of immunosuppressive medications and measures to prevent complications. Although insects are the natural hosts for A. algerae, human contact with water contaminated by spores may be a mode of transmission. A. algerae has emerged as a cause of myositis, particularly in coastal Australia.

Background Seasonal interpandemic influenza causes >200,000 annual hospitalizations in the United States. Optimal antiviral treatment in hospitalized patients is not established. Methods During three interpandemic influenza seasons, 137 patients hospitalized with suspected acute influenza were randomized to 5-day treatment with intravenous peramivir 400 mg or 200 mg once daily or oral oseltamivir 75 mg twice daily. Time to clinical stability and quantitative changes in viral titres from nasopharyngeal specimens were primary and key secondary end points, respectively. Results Infection was confirmed in 122 patients with influenza A (H1N1), influenza A (H3N2) or influenza B. Median times (95% CI) to clinical stability were 37.0 h (22.0, 48.7) with peramivir 400 mg, 23.7 h (16.0, 38.9) with peramivir 200 mg and 28.1 h (22.0, 37.0) with oseltamivir ( P=0.306). Patients ( n=97) who were clinically unstable at enrolment had median times (95% CI) to clinical stability of 24.3 h (21.2, 47.5) with peramivir 400 mg, 31.0 h (17.2, 47.7) with peramivir 200 mg and 35.5 h (23.3, 37.9) with oseltamivir ( P=0.541). Titres of influenza A viruses in nasopharyngeal specimens decreased similarly across treatments, but more rapid decreases in titres of influenza B occurred with peramivir treatment. There were no deaths among patients with confirmed influenza and the incidence of adverse events was low and generally similar among treatment groups. Conclusions Treatment of acute seasonal influenza in hospitalized adults with either peramivir or oseltamivir resulted in generally similar clinical outcomes. Treatment with peramivir was generally safe and well tolerated and could be of benefit in this population.

We describe an outbreak of respiratory syncytial virus (RSV) infection on a hematology ward without allogeneic stem cell transplant patients. Twelve patients and one staff member infected with RSV were identified from the laboratory database. Five patients had lower respiratory tract infection, seven had upper respiratory tract infection, one was asymptomatic, and there were two (15.4%) deaths. Most patients had overlapping periods of potential infectiousness on the ward. Sequencing was possible on eight specimens and five of these had identical sequences. Results were consistent with transmission occurring both on the ward and by introduction of RSV from the community. J. Med. Virol. 88:1827-1831, 2016. © 2016 Wiley Periodicals, Inc.

Long-term outcomes of HIV-infected patients admitted to the intensive care unit (ICU) since the advent of combination antiretroviral therapy (cART) have not been well described. We reviewed the long-term outcomes and clinical follow-up of HIV-infected patients admitted to the Prince of Wales Hospital ICU between 1999 and 2005 by a retrospective medical record review. Mortality was assessed in the ICU, in hospital and in the long-term. Twenty-four HIV-infected male patients underwent 26 ICU admissions. Their ICU and in-hospital mortalities were 33% and 46%, respectively. Higher APACHE (acute physiology and chronic health evaluation) II scores (median 27 versus 12, P < 0.001), lower CD4 cell counts (median 45 versus 335 cells/μL, P = 0.041) and longer hospitalization times prior to ICU admission (median 4 versus 1 day, P = 0.02) were significantly associated with in-hospital mortality. We found 85% of the subjects who survived hospital admission were still alive at a median of 41 months (4 months to 5 years) of follow-up, all of who were functionally independent. HIV-infected patients who survived ICU admission at our institution had good long-term outcomes in the cART era.

Objective Clostridium difficile infection (CDI) is a significant cause of antibiotic-associated diarrhoea and is associated with significant morbidity and mortality. This prospective, observational study of CDI aims to describe its clinical features and management in an Australian tertiary hospital and adherence to infection control procedures by staff. Methodology Twenty-six subjects over the age of 18 years with a positive test for C. difficile were included in the study. Subjects were interviewed at 0, 7 and 30 days with regard to risk factors, duration of symptoms, severity of illness and outcomes. Details of management were extracted from the medical record, and laboratory parameters were recorded. Adherence to infection control procedures was observed. Results Subjects had severe and debilitating disease, with a mortality of 18% at 30 days. The median duration of symptoms was 12 days, and the median length of hospital stay was 31 days. Medical monitoring for complications of the disease was not optimal. Eighty percent of patients were treated in accordance with recommendations in the Australian Antibiotic Guidelines. There was reasonable adherence to isolation and use of personal protective equipment after CDI was diagnosed, but not when it was suspected. Adherence to the guidelines for hand hygiene was poor. Conclusions CDI causes severe and morbid disease in hospitalised patients. Adherence to infection control needs to be improved. Consideration should be given to a pilot study of monitoring rates and outcomes of CDI in Australian hospitals.

In this report, we present 11 cases of HIV infection where, in hindsight, there was a missed opportunity to diagnose HIV at an earlier stage of infection and therefore commence antiretroviral therapy earlier...

Rationale: Bacterial pneumonia is a major cause of morbidity for HIV-infected persons and contributes to excess mortality in this population. Objectives: To evaluate the frequency and risk factors for occurrence of bacterial pneumonia in the present era of potent antiretroviral therapy. Methods: We evaluated data from a randomized trial of episodic antiretroviral therapy. The study, Strategies for Management of Antiretroviral Therapy, enrolled 5,472 participants at 318 sites in 33 countries. Study patients had more than 350 CD4 cells at baseline. Diagnosis of bacterial pneumonia was confirmed by a blinded clinical-events committee. Measurements and Main Results: During a mean follow-up of 16 months, 116 participants (2.2%) developed at least one episode of bacterial pneumonia. Patients randomized to receive episodic antiretroviral therapy were significantly more likely to develop pneumonia than patients randomized to receive continuous antiretroviral therapy (hazard ratio, 1.55; 95% confidence interval, 1.07–2.25; P = 0.02). Cigarette smoking was a major risk factor: Current-smokers had more than an 80% higher risk of pneumonia compared with never-smokers (hazard ratio, 1.82; 95% confidence interval, 1.09–3.04; P = 0.02). Participants who were on continuous HIV treatment and were current smokers were three times more likely to develop bacterial pneumonia than nonsmokers. Current smoking status was significant, but a past history of smoking was not. Conclusions: Bacterial pneumonia is a major source of morbidity, even for persons on potent antiretroviral therapy, including those with high CD4 cells. Efforts to reduce this illness should stress the importance of uninterrupted antiretroviral therapy and attainment and/or maintenance of nonsmoking status. Clinical trial registered with www.clinicaltrials.gov (NCT 00027352).

Influenza is an acute febrile illness caused by influenza A or B viruses. It occurs mainly in winter in temperate climates, and throughout the year in tropical Australia. It is highly contagious and of considerable public health concern because of the rapidity with which epidemics evolve and the associated morbidity and mortality. Most influenza illnesses resolve over about 1 week without specific medical intervention. People at particular risk for complicated infection are those65 or5 years old, those with chronic medical comorbidities, residents of chronic care facilities (including nursing homes), and women in the second or third trimester of pregnancy. Complicated influenza infection most commonly manifests as primary viral pneumonia, combined viral and bacterial pneumonia, and secondary bacterial pneumonia. Rare but serious complications of influenza include central nervous system involvement (eg, encephalitis, transverse myelitis, aseptic meningitis, and Guillain-Barré syndrome). The recent emergence of avian influenza A/H5N1 and confirmation of sporadic cases of human H5N1 infection have heightened concern about an impending human influenza pandemic, either from a human form of H5N1 or a primary new human influenza strain. H5N1 infection in humans has been associated with severe illness and a50% mortality rate, with high mortality in people aged 10-39 years.

Gay men with HIV often belong to strong mutually supportive groups, but many women with HIV experience the disease in relative isolation. Informed primary care doctors can make a valuable difference to their management.

The initial impact of HIV infection on the practising obstetrician and gynaecologist was specifically related to the treatment of HIV positive women who were pregnant. The current North American experience suggests that HIV will be an important consideration in gynaecology from now on.