The challenges as we strive towards universal health coverage are many, but the need for an improved health workforce is chief among them. Unfortunately the global deficit in skilled professionals ...continues to increase. Nevertheless, there are potential solutions, and success stories are well documented when the approach is on system building and sustainability. As we approach 2015 and the Millennium Development Goals, we must shift our focus to a more distant time point in order to achieve the dramatic gains in global health that are possible. However, we must understand that there can be no health without a workforce.
•Outpatient parenteral antibiotic therapy (OPAT) can be used safely in the management of infective endocarditis (IE).•IE caused by high-virulence organisms such as Staphylococcus aureus can be ...managed with OPAT.•Patients with prosthetic valve IE can be considered for OPAT.•OPAT has the potential to reduce the impact of IE on over-burdened health systems.
We examined the safety and clinical outcomes of outpatient parenteral antibiotic therapy (OPAT) for patients with infective endocarditis (IE) in Christchurch, New Zealand.
Demographic and clinical data were collected from all adult patients treated for IE over 5 years. Outcomes were stratified by receipt of at least partial OPAT vs entirely hospital-based parenteral therapy.
There were 172 episodes of IE between 2014 and 2018. OPAT was administered in 115 cases (67%) for a median of 27 days after a median of 12 days of inpatient treatment. In the OPAT cohort, viridans group streptococci were the commonest causative pathogens (35%) followed by Staphylococcus aureus (25%) and Enterococcus faecalis (11%). There were six (5%) antibiotic-related adverse events and 26 (23%) readmissions in the OPAT treatment group. Mortality in OPAT patients was 6% (7/115) at 6 months and 10% (11/114) at 1 year and for patients receiving wholly inpatient parenteral therapy was 56% (31/56) and 58% (33/56), respectively. Three patients (3%) in the OPAT group had a relapse of IE during the 1-year follow-up period.
OPAT can be used safely in patients with IE, even in selected cases with complicated or difficult-to-treat infections.
•Therapeutic drug monitoring can improve the probability of pharmacological target attainment.•Standard dosing of flucloxacillin and cefazolin may result in below target plasma levels.•Below target ...levels occurred more frequently in patients receiving flucloxacillin than cefazolin.•Patient characteristics may help to predict those at risk of below target plasma levels.
The proportion of patients with invasive methicillin-susceptible Staphylococcus aureus (MSSA) infection who achieve target concentrations of flucloxacillin or cefazolin with standard dosing regimens is uncertain. This study measured drug concentrations in a prospective cohort of patients with invasive S. aureus infections to determine the frequency of target concentration attainment, and risk factors for failure to achieve target concentrations.
Unbound flucloxacillin and cefazolin plasma concentrations were measured at the midpoint between intravenous doses. Adequate and optimal targets were defined as an unbound plasma concentration of ≥1 and ≥2 times the minimum inhibitory concentration (MIC) (flucloxacillin 0.5 mg/L, cefazolin 2 mg/L), respectively (50%fT≥1MIC, 50%fT≥2MIC).
There were 50 patients in each of the flucloxacillin and cefazolin groups. Eighty-five (85%) patients met the target of 50%fT≥2MIC and 95 (95%) patients met the target of 50%fT≥1MIC. The median unbound flucloxacillin concentration was 2.6 mg/L interquartile range (IQR) 1.0–8.1. The median unbound cefazolin concentration was 15.4 mg/L (IQR 8.8–28.2). A higher proportion of patients in the flucloxacillin group failed to achieve the optimal target compared with the cefazolin group 13 (26%) vs 2 (4%); P=0.002. Younger age and higher creatinine clearance were associated with lower plasma concentrations.
Standard dosing of flucloxacillin and cefazolin in the treatment of invasive MSSA infections may not achieve target plasma concentrations for a subgroup of patients. Measuring drug concentrations identifies this subgroup and facilitates dose individualization.
Here, we describe a small enterovirus outbreak including nine cases of aseptic meningitis in a New Zealand hospital in 2017. Most patients had a lymphocytic predominance in the CSF, their length of ...stay was short, and there were no paediatric cases or ICU admissions. VP1 genotyping revealed that the outbreak was caused by an echovirus E30 strain closely related to strains reported from the US, UK, Brazil, and Denmark. They all form a separate cluster within lineage "h", which leads to the proposal of establishing a new lineage tentatively named "j" for this group of echovirus E30 strains. However, whole genome sequencing and reference mapping to echovirus E30 sequences showed very poor mapping of reads to the 3' half of the genome. Further bioinformatic analysis indicated that the causative agent of this outbreak might be a mosaic triple-recombinant enterovirus composed of echovirus E6, echovirus E11, and echovirus E30 genome segments.
•Nephrotoxicity occurred in only 3.4% of outpatients on vancomycin infusions.•Previous studies reported an incidence of 15–17%.•Lower incidence in this study may be due to more frequent ...monitoring.•Improved dosing strategies may further reduce the risk of acute kidney injury.
Vancomycin continuous infusion (VCI) is used to treat serious Gram-positive infections in outpatients. This study was conducted to retrospectively investigate the rate of nephrotoxicity and associated risk factors in out-patients on VCI between May 2013 and November 2018. Vancomycin concentration was monitored twice-weekly to ensure adequate concentrations while avoiding high concentrations linked to nephrotoxicity (a rise in serum creatinine of ≥50% or 44 µmol/L from baseline). The likelihood of developing nephrotoxicity was evaluated using multivariable logistic regression. The 223 patients treated had a mean (standard deviation) age of 61 (16.7) years, baseline serum creatinine of 83.9 (21.2) µmol/L and estimated glomerular filtration rate (eGFR) of 80.6 (20.1) mL/min/1.73m2. Most patients (66%) were treated for bone and joint infections. Eight patients (3.6%) developed nephrotoxicity. In the most parsimonious model, nephrotoxicity was independently associated with an increased median (interquartile range) weighted-average serum vancomycin concentration (28.0 24.3–32.6 vs. 22.4 20.2–24.5 mg/L; odds ratio OR 1.25; 95% confidence interval 95% CI 1.09–1.46; P<0.002) and Charlson co-morbidity index (OR 1.62; 95% CI 1.07–2.47; P=0.02). Post-hoc analysis identified 26 patients with a lower nephrotoxicity threshold (rise in serum creatinine of ≥30% or 27 μmol/L). Independent predictors of nephrotoxicity in this group were an increased weighted-average vancomycin concentration, diabetes, con-gestive heart failure and exposure to non-loop diuretics. The nephrotoxicity rate during VCI in this study was lower than previously reported (3.6% vs 15.0–17.0%). Reducing the weighted-average serum vancomycin concentration may reduce nephrotoxicity while maintaining efficacy.
Abdominal tuberculosis presents with non-specific symptoms, including generalised abdominal pain. Prompt and accurate diagnosis is critical to improving outcomes and avoiding complications. We ...conducted a retrospective review of cases of abdominal tuberculosis presenting to Christchurch Hospital to explore the epidemiology, clinical features and diagnostic modalities used.
Cases were identified by searching for relevant ICD discharge codes from January 1996 to January 2016. Data on age, clinical presentation, investigations and microbiological results were obtained.
There were 20 patients diagnosed with abdominal tuberculosis over the study period. The median age was 34. Thirteen patients were male (65%), seven female (35%). The majority (11) were from Asia (predominantly India), five were African, and three were New Zealand Europeans. Abdominal pain was the most common presenting symptom (70%) followed by fevers (50%) and night sweats (50%). The C-reactive protein was elevated in 15 patients (75%), anaemia was found in 11 (55%) and nine had abnormal liver function tests (45%). Abdominal ultrasound (US) and computed tomography (CT) showed generic inflammatory change in all patients in this series (100%). Laparoscopy was undertaken in 10 (50%) patients, all of which had positive laparoscopic biopsies. Ascitic fluid was obtained in nine, with stains for acid-fast bacilli uniformly negative, however three (33%) had mycobacterial growth from culture. Six colonoscopies were performed: in three (50%) culture and/or histology was positive. Three lymph node biopsies and two formal laparotomies were the remaining diagnostic techniques employed with two biopsies and one laparotomy yielding positive results. Overall, of the 20 cases, 15 (75%) were able to be definitively confirmed, with the remaining five treated presumptively for probable abdominal tuberculosis.
Abdominal tuberculosis is an uncommon presentation at our institution, with an average of one case each year. The typical patient was a young immigrant from Asia or Africa. Diagnostic laparoscopy was the most common and uniformly reliable means of obtaining a definitive diagnosis.
To determine the nature and appropriateness of antimicrobial prescribing in adult inpatients at Canterbury District Health Board (CDHB).
Multidisciplinary teams collected clinical details for all ...adult inpatients on antimicrobial therapy at three CDHB facilities (~1,100 beds) and made standardised assessments based on the Australian National Antimicrobial Prescribing Survey (http://naps.org.au) against local guidelines and national funding criteria.
Antimicrobial therapy was prescribed to 42% of inpatients (322/760), usually to treat infections 377/480 prescriptions (79%), with amoxicillin+clavulanic acid the agent most commonly prescribed 72/480 prescriptions (15%). Of assessable prescriptions, 74% (205/278) were guideline compliant, 98% (469/480) were funding criteria compliant, and 83% (375/451) were appropriate clinically. Prescriptions for the most common indications-surgical prophylaxis 66/480 (14%) and community-acquired pneumonia 56/480 (12%)-were often non-compliant with guidelines (32% and 41%, respectively) and inappropriate (18% and 21%, respectively). Overall, the indication was documented in 353/480 (74%) prescriptions, the review/stop date documented in 145/480 (30%) prescriptions, and surgical prophylaxis stopped within 24 hours in 53/66 (80%) prescriptions.
Most antimicrobial prescriptions were appropriate and complied with guidelines. Compliance with key quality indicators (indication documented, review/stop date documented, and surgical prophylaxis ceased within 24 hours) were well below target (>95%) and needs improvement.
