Optimising Chlamydia testing within constrained funding.
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Adolescent↗
Biomedical subjects
Arthur J Morris
Publications and source records attributed to Arthur J Morris.
Antimicrobial susceptibility of anaerobic bacteria in New Zealand: 1999-2003.
OBJECTIVES: Routine susceptibility testing of all anaerobic organisms is not advocated, but it is useful for laboratories to test periodically for anaerobic organisms and provide local susceptibility data to guide therapy. This study reports the national trend of antibiotic susceptibility of clinically significant anaerobes in New Zealand. METHODS: Clinical isolates were tested using standardized methods against a range of antibiotics commonly used to treat anaerobic infections. Susceptibility was determined using NCCLS criteria. The change in susceptibility trends between this study and earlier studies was measured by comparing the geometric mean of the MIC. RESULTS: A total of 364 anaerobes were tested. Penicillin had poor activity against Bacteroides spp., Prevotella spp., Eubacterium spp., Clostridium tertium and Veillonella spp. In general, Fusobacterium spp., Bacteroides ureolyticus, Propionibacterium spp., Clostridium perfringens and anaerobic streptococci isolates, with the exception of Peptostreptococcus anaerobius, were penicillin susceptible. Amoxicillin/clavulanate showed good activity against most anaerobes, but resistance was seen with Bacteroides fragilis group and P. anaerobius isolates. Cefoxitin was more active than cefotetan, particularly against non-B. fragilis species, Eubacterium spp. and P. anaerobius. Meropenem and imipenem showed good activity against all anaerobes, with only 2 and 4% of Bacteroides spp., respectively, showing resistance. With the exception of Propionibacterium acnes isolates, which are predictably resistant, metronidazole was active against all anaerobes tested. There has been little change in susceptibility since 1997. CONCLUSIONS: Metronidazole, cefoxitin, piperacillin/tazobactam and amoxicillin/clavulanate remain good empirical choices when anaerobes are expected in our setting. No clinically relevant changes in susceptibility over time were found.
Anti-Bacterial Agents↗
Bacteriological outcome after valve surgery for active infective endocarditis: implications for duration of treatment after surgery.
BACKGROUND: There has been no systematic evaluation of outcome after surgery for infective endocarditis with respect to duration of antibiotic treatment. METHODS: We performed a retrospective chart review of episodes of valve surgery for active infective endocarditis at Green Lane Hospital (Auckland, New Zealand) for 1963-1999. We recorded the duration of antibiotic treatment before and after valve surgery; the extent of infection at operation; Gram stain, culture, and histopathological testing results for valve samples; and the bacteriological outcome after surgery. The primary outcome measure was relapse, defined as endocarditis due to the same species within 1 year after surgery. RESULTS: For the 358 patients in our study, the median duration of follow-up was 4.8 years. Thirty-two patients (9%) had 36 subsequent episodes of endocarditis. Relapse occurred after 3 (0.8%) of the operations (95% CI, 0.2%-2.0%). Relapse of infection was unrelated to the duration of antibiotic treatment before or after surgery, positive valve culture results, positive Gram stain results, or perivalvular infection. Since 1994, we have reduced the duration of antibiotic treatment by approximately 7 days for those with positive valve culture results and by approximately 14 days for those with negative valve culture results, without any increase in the number of relapses. CONCLUSIONS: Relapse is an uncommon event following surgery for endocarditis. Commonly suggested indications for prolonging postoperative treatment are not associated with higher relapse rates, and their relevance is debatable. We conclude that it is unnecessary to continue treatment for patients with negative valve culture results for an arbitrary 4-6-week period after surgery. Two weeks of treatment appears to be sufficient, and, for those operated on near the end of the standard period of treatment, simply completing the planned course should suffice.
Aged↗
Culture results of heart valves resected because of streptococcal endocarditis: insights into duration of treatment to achieve valve sterilization.
OBJECTIVES: To analyse the culture results of heart valves removed following streptococcal endocarditis in order to gain insight into the duration of treatment required for valve sterilization. PATIENTS AND METHODS: Retrospective review of 131 episodes of streptococcal endocarditis: 94 due to alpha-haemolytic streptococci; 15 due to beta-haemolytic streptococci; 10 due to nutritionally deficient streptococci; eight due to the Streptococcus anginosus group and four due to Streptococcus pneumoniae. Patients had their valves removed during antimicrobial treatment. Culture results were analysed with respect to duration of treatment before surgery. RESULTS: For alpha-haemolytic streptococci, 17 (18%) valves were culture-positive and 77 (82%) culture-negative after a median (range) of 4 (1-20) and 16 (4-58) days of treatment, respectively, P < 0.001. For beta-haemolytic streptococci, two valves (13%) were culture-positive; both patients had received < or = 4 days of treatment. Four patients (40%) with nutritionally deficient streptococci were culture-positive, and had received < or = 8 days of treatment. For the S. anginosus group, two valves (25%) were culture-positive; both patients had received < or = 4 days of treatment before operation. Overall, only one of 131 (0.8%) valves was culture-positive after 14 days of treatment. All valves infected with beta-haemolytic streptococci, nutritionally deficient streptococci and the S. anginosus group, who were treated for more than 8 days before surgery, were culture-negative. CONCLUSIONS: Our findings support current treatment guidelines for endocarditis caused by alpha-haemolytic streptococci. We suggest that the recommended duration of treatment for endocarditis resulting from other streptococci may be excessive and treatment trials evaluating 2 and 4 week regimens are justified.
Adult↗
Staphylococcal post-sternotomy mediastinitis: five year audit.
BACKGROUND: The reported rate of post-sternotomy mediastinitis is between 0.8 and 2.3%, with up to 79% of cases caused by staphylococci. Mediastinitis is associated with significant morbidity and mortality. Obesity and diabetes are the only risk factors consistently identified. The aims of the present study were to determine the incidence and risk factors for staphylococci post-sternotomy mediastinitis and to audit its management. METHODS: The clinical records of patients with staphylococcal post-sternotomy mediastinitis between 1 January 1998 and 31 May 2003 were retrospectively reviewed. Information collected included patient demographics, comorbidities, operation type, microbiology findings, surgical and medical management, and outcome. Data collected on cases were compared with data collected in a prospective database of all patients undergoing cardiac surgery. RESULTS: The incidence of staphylococcal post-sternotomy mediastinitis was 1.2% (60 cases in 5176 median sternotomies). Staphylococcus aureus was isolated in 49 (82%) cases and coagulase-negative staphylococci in 11 (18%) cases. Eight (16%) S. aureus isolates were methicillin-resistant. Risk factors associated with mediastinitis were ethnicity, diabetes mellitus, emergency surgery, ejection fraction and length of preoperative hospital stay. In-hospital mortality was 15%. Eighteen per cent of cases were not cured by initial therapy. CONCLUSION: Staphylococcal mediastinitis is a serious complication with significant rates of relapse and mortality. This audit has lead to an evaluation of our clinical pathways to ensure that prevention and management of surgical site infection is optimized.
Adult↗
Fluconazole MIC and the fluconazole dose/MIC ratio correlate with therapeutic response among patients with candidemia.
We tested 32 Candida isolates recovered in the early 1990s from the bloodstreams of patients with candidemia for in vitro susceptibility to fluconazole and determined if MIC and/or the daily dose of fluconazole/MIC ratio correlated with the response to therapy. This is a unique data set since 87.5% (28/32) of patients were treated with fluconazole doses now considered to be inadequate (</=200 mg), which contributed to high therapeutic failure rates (53% [17/32]). The geometric mean MIC and dose/MIC ratio for isolates associated with therapeutic failure (11.55 mug/ml and 14.3, respectively) differed significantly from values associated with therapeutic success (0.95 mug/ml and 219.36 [P = 0.0009 and 0.0004, respectively]). The therapeutic success rates among patients infected with susceptible (MIC </= 8 mug/ml), susceptible-dose dependent (S-DD) (MIC = 16 or 32 mug/ml), and resistant (MIC >/= 64 mug/ml) isolates were 67% (14/21), 20% (1/5), and 0% (0/6), respectively. A dose/MIC ratio >50 was associated with a success rate of 74% (14/19), compared to 8% (1/13) for a dose/MIC ratio </=50 (P = 0.0003). Our data suggest that both fluconazole MIC and dose/MIC ratio correlate with the therapeutic response to fluconazole among patients with candidemia. In clinical practice, dose/MIC ratio might prove easier to interpret than breakpoint MICs, since it quantitates the effects of increasing fluconazole doses that are alluded to in the S-DD designation.
Adolescent↗
Antifungal susceptibility of non-albicans Candida species causing fingernail onychomycosis.
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Antifungal Agents↗
Combination antibiotic therapy lowers mortality among severely ill patients with pneumococcal bacteremia.
Retrospective studies have suggested that combination antibiotic therapy for severe bacteremic pneumococcal pneumonia may reduce mortality. We assessed this issue in a prospective, multicenter, international observational study of 844 adult patients with bacteremia due to Streptococcus pneumoniae. The effect of combination antibiotic therapy versus monotherapy on mortality was examined by univariate analyses and by logistic regression models. The 14-day mortality was not significantly different for the two groups. However, among critically ill patients, combination antibiotic therapy was associated with lower 14-day mortality (23.4 versus 55.3%, p = 0.0015). This improvement in survival was independent of country of origin, intensive care unit support, class of antibiotics, or in vitro activity of the antibiotics prescribed. Combination antibiotic therapy improved survival among critically ill patients with bacteremic pneumococcal illness.
Adolescent↗
Treatment outcomes for serious infections caused by methicillin-resistant Staphylococcus aureus with reduced vancomycin susceptibility.
Although infections caused by methicillin-resistant Staphylococcus aureus with reduced vancomycin susceptibility (SA-RVS) have been reported from a number of countries, including Australia, the optimal therapy is unknown. We reviewed the clinical features, therapy, and outcome of 25 patients with serious infections due to SA-RVS in Australia and New Zealand. Eight patients had endocarditis, 9 had bacteremia associated with deep-seated infection, 6 had osteomyelitis or septic arthritis, and 2 had empyema. All patients had received vancomycin before the isolation of SA-RVS, and glycopeptide treatment had failed for 19 patients (76%). Twenty-one patients subsequently received active treatment, which was effective for 16 patients (76%). Eighteen patients received linezolid, which was effective in 14 (78%), including 4 patients with endocarditis. Twelve patients received a combination of rifampicin and fusidic acid. Surgical intervention was required for 15 patients (60%). Antibiotic therapy, especially linezolid with or without rifampicin and fusidic acid, in conjunction with surgical debulking is effective therapy for the majority of patients with serious infections (including endocarditis) caused by SA-RVS.
Acetamides↗
Escherichia coli: a growing problem in early onset neonatal sepsis.
AIMS: To review the demographic characteristics, antecedents and outcome for early neonatal Escherichia coli sepsis. Secondary aims were to identify antenatal antibiotic use and to review the antimicrobial susceptibility. METHODS: A retrospective chart review was performed for all infants with a positive culture for E. coli from either blood or CSF samples obtained between January 1998 and October 2002. RESULTS: Nineteen liveborn infants with early onset sepsis and one stillborn baby with a positive maternal blood culture for E. coli were identified. Pregnancy complications included multiple pregnancy in five (25%), preterm rupture of membranes 10 (50%) and maternal urinary tract infection in five (25%). Eighteen of the cases were born preterm and two at term. The mortality was 8/20 (40%), and for nine cases with developmental outcome data available, 67% were within normal limits and 33% were abnormal. Of the 20 E. coli isolates 11 (55%) were resistant to amoxycillin and 1 (5%) was resistant to gentamicin. CONCLUSIONS: Infants with early onset E. coli sepsis had a poor outcome with high mortality and a third of the survivors manifesting neurodevelopmental impairment. Although amoxycillin resistance is common, there is a low prevalence of gentamicin resistance in local isolates.
Adult↗
Clinical benefit of recovering dermatophytes from skin swabs sent for bacterial culture.
We incubated Sabouraud dextrose agar plates to recover dermatophytes from skin swabs sent for bacterial culture. Dermatophytes were recovered from 66 (0.3%) of 22,613 cultures. Twenty-one patients received specific antifungal treatment when their dermatophyte was reported. Most clinicians thought recovering and reporting the dermatophyte contributed to patient management.
Adolescent↗
Antibiotic susceptibility of Haemophilus influenzae isolates from four New Zealand sites.
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Drug Resistance, Bacterial↗
Bacteriological outcome of combination versus single-agent treatment for staphylococcal endocarditis.
OBJECTIVE: To analyse the bacteriological outcome of combination versus single-agent antimicrobial treatment in staphylococcal endocarditis. PATIENTS AND METHODS: Retrospective review of 152 episodes: 91 cases of native valve endocarditis (NVE), 74 due to Staphylococcus aureus and 17 due to coagulase-negative staphylococci (CoNS); and 61 cases of prosthetic valve endocarditis (PVE), 29 due to S. aureus and 32 due to CoNS. RESULTS: Valves from patients with S. aureus NVE treated with any kind of combination antibiotic treatment were no more likely to be culture-negative than those treated with a single agent [19 (45%) of 42 versus 13 (41%) of 32; P = 0.69]. This finding remained unchanged when cases of CoNS NVE were added to the S. aureus group. In PVE, after adjusting for duration of treatment, valves from patients receiving any kind of combination treatment were 5.9 times (95% confidence interval 1.3-27.5) more likely to be culture-negative than those receiving monotherapy (P = 0.024). Patients treated for >14 days were more likely to be culture-negative than those treated for <or=14 days [49 (83%) of 59 versus 29 (31%) of 93; P < 0.001]. CONCLUSIONS: In staphylococcal NVE, combination treatment is not superior to monotherapy in sterilizing infected valves, but in PVE combination treatment confers an advantage.
Anti-Bacterial Agents↗
An international prospective study of pneumococcal bacteremia: correlation with in vitro resistance, antibiotics administered, and clinical outcome.
We performed a prospective, international, observational study of 844 hospitalized patients with blood cultures positive for Streptococcus pneumoniae. Fifteen percent of isolates had in vitro intermediate susceptibility to penicillin (minimum inhibitory concentration [MIC], 0.12-1 microg/mL), and 9.6% of isolates were resistant (MIC, >or=2 microg/mL). Age, severity of illness, and underlying disease with immunosuppression were significantly associated with mortality; penicillin resistance was not a risk factor for mortality. The impact of concordant antibiotic therapy (i.e., receipt of a single antibiotic with in vitro activity against S. pneumoniae) versus discordant therapy (inactive in vitro) on mortality was assessed at 14 days. Discordant therapy with penicillins, cefotaxime, and ceftriaxone (but not cefuroxime) did not result in a higher mortality rate. Similarly, time required for defervescence and frequency of suppurative complications were not associated with concordance of beta-lactam antibiotic therapy. beta-Lactam antibiotics should still be useful for treatment of pneumococcal infections that do not involve cerebrospinal fluid, regardless of in vitro susceptibility, as determined by current NCCLS breakpoints.
Adolescent↗
Gram stain, culture, and histopathological examination findings for heart valves removed because of infective endocarditis.
Retrospective chart review was undertaken for 480 patients who underwent a total of 506 valve replacements or repair procedures for infective endocarditis. The influence of preoperative antimicrobial treatment on culture, Gram stain, and histopathological examination findings for resected valve specimens was examined. When valves were removed before the end of treatment, organisms were seen on the Gram stain of ground valve material performed in the microbiology laboratory and on Gram-stained histopathological sections in 231 (81%) of 285 and 140 (67%) of 208 specimens, respectively (P=.0007). Gram-positive cocci were either cultured from or observed in excised valve tissue in 42 (67%) of 63 episodes involving negative preoperative blood cultures. Positive Gram stain results for microbiological specimens should be reintroduced into the definite pathological criteria for infective endocarditis. When deciding on how long to continue antimicrobial therapy after valve replacement for endocarditis, valve culture results should be the only laboratory finding taken into account, because it takes months for dead bacteria to be removed from sterile vegetations.
Endocarditis, Bacterial↗
Epidemiology of dermatophyte infection in Auckland, New Zealand.
This report describes the epidemiology of culture-proven dermatophyte infection in Auckland, New Zealand. The authors undertook a retrospective review of laboratory data for the period from June 1999 to July 2002. There were 10 004 dermatophyte isolates. The most common isolates were Trichophyton rubrum (69%) and Trichophyton mentagrophytes (19%). Microsporum canis was mainly isolated from children. The prevalence of T. mentagrophytes increased with patient age (P < 0.001). Trichophyton rubrum was most common in those aged between 20 and 59 years. The incidence of culture-proven dermatophyte infection was 2.9/1000 population for the year 2000, and the incidence increased with patient age (P < 0.001). It is concluded that dermatophytes causing superficial mycoses in the Auckland region are essentially similar to Australia and other Western countries, although some new organisms are seen as a result of the migration of people from other countries. The incidence of local dermatophyte infection increases with age.
Adolescent↗
The prevalence and estimates of the cumulative incidence of hospital-acquired infections among patients admitted to Auckland District Health Board Hospitals in New Zealand.
OBJECTIVES: To report the pooled results of seven prevalence surveys of hospital-acquired infections conducted between November 1996 and November 1999, and to use the data to predict the cumulative incidence of hospital-acquired infections in the same patient group. DESIGN: The summary and modeling of data gathered from the routine surveillance of the point prevalence of hospital-acquired infections. SETTING: Auckland District Health Board Hospitals (Auckland DHBH), the largest publicly funded hospital group in New Zealand supplying secondary and tertiary services. PATIENTS: All inpatients. METHOD: Point-prevalence surveys were conducted including all patients in Auckland DHBH. Standard definitions of hospital-acquired infection were used. The data from the seven surveys were pooled and used in a modeling exercise to predict the cumulative incidence of hospital-acquired infection. An existing method for the conversion of prevalence to cumulative incidence was applied. Results are presented for all patients and stratified by clinical service and site of hospital-acquired infection. RESULTS: The underlying patterns of hospital-acquired infection by site and service were stable during the seven time periods. The prevalence rate for all patients was 9.5%, with 553 patients identified with one or more hospital-acquired infections from a population of 5,819. The predicted cumulative incidence for all patients was 6.33% (95% confidence interval, 6.20% to 6.46%). CONCLUSIONS: The prevalence and the predicted cumulative incidence are similar to rates reported in the international literature. The validity of the predicted cumulative incidence derived here is not known. If it were accurate, then the application of this method would represent a cost-effective alternative to incidence studies.
Cross Infection↗
Modeling the costs of hospital-acquired infections in New Zealand.
OBJECTIVE: To model the economic costs of hospital-acquired infections (HAIs) in New Zealand, by type of HAI. DESIGN: Monte Carlo simulation model. SETTING: Auckland District Health Board Hospitals (DHBH), the largest publicly funded hospital group in New Zealand supplying secondary and tertiary services. Costs are also estimated for predicted HAIs in admissions to all hospitals in New Zealand. PATIENTS: All adults admitted to general medical and general surgical services. METHOD: Data on the number of cases of HAI were combined with data on the estimated prolongation of hospital stay due to HAI to produce an estimate of the number of bed days attributable to HAI. A cost per bed day value was applied to provide an estimate of the economic cost. Costs were estimated for predicted infections of the urinary tract, surgical wounds, the lower and upper respiratory tracts, the bloodstream, and other sites, and for cases of multiple sites of infection. Sensitivity analyses were undertaken for input variables. RESULTS: The estimated costs of predicted HAIs in medical and surgical admissions to Auckland DHBH were dollar 10.12 (US dollar 4.56) million and dollar 8.64 (US dollar 3.90) million, respectively. They were dollar 51.35 (US dollar 23.16) million and dollar 85.26 (US dollar 38.47) million, respectively, for medical and surgical admissions to all hospitals in New Zealand. CONCLUSIONS: The method used produces results that are less precise than those of a specifically designed study using primary data collection, but has been applied at a lower cost The estimated cost of HAIs is substantial but only a proportion of infections can be avoided. Further work is required to identify the most cost-effective strategies for the prevention of HAI.
Costs and Cost Analysis↗