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Background Following a global shortage of piperacillin/tazobactam in 2017, a formulary decision was taken at a large District General Hospital in the East of England to partly replace piperacillin/tazobactam with either temocillin as monotherapy or as part of a combination regimen. A retrospective audit was then conducted to assess the clinical effectiveness of temocillin therapy. Methods Data from patients admitted to Watford General Hospital between May and August 2017 and treated with temocillin were reviewed retrospectively. Clinical characteristics of patients, data related to the episode of infection, clinical success, tolerance and mortality were analysed. Results Temocillin was used in 126 patients with median age of 73 years. Infection episodes mostly originated from the abdomen (n = 46), the lung (n = 40) and the urinary tract (n = 21). Seventy-seven patients received temocillin as first-line therapy and 106 received it empirically, with temocillin prescribed in combination with another antibiotic in 82% of the empirically treated cases. Clinical success was observed in 88.9% of cases with no difference between patients treated empirically and others (89.6% versus 85%) or in efficacy among abdominal (91%), pulmonary (87.5%) and urinary (81%) infections. One case of Clostridioides difficile infection was reported in a patient treated with four different antibiotics. During the shortage period, the hospital’s standardized mortality ratio was significantly lower when compared with the same period of the preceding year (85 versus 96). Conclusions Using temocillin as part of an empirical strategy is feasible and safe as long as appropriate antibiotic combination is recommended based upon the indication and the likely bacterial pathogen.

ObjectivesTo assess the real-world diagnostic accuracy of the Livzon point-of-care rapid test for antibodies to SARS-COV-2DesignProspective cohort studySettingDistrict general hospital in EnglandParticipants173 Patients and 224 hospital staff with a history of COVID-19 symptoms, and who underwent PCR and/or reference antibody testing for COVID-19.InterventionsThe Livzon point-of-care (POC) lateral flow immunoassay rapid antibody test (IgM and IgG) was conducted at least 7 days after onset of symptoms and compared to the composite reference standard of PCR for SARS-COV-2 plus reference laboratory testing for antibodies to SARS-COV-2. The SARS-CoV-2 RT-PCR was tested using the available molecular technology during the study time (PHE laboratories, GeneXpert®system Xpert, Xpress SARS-CoV-2 and Source bioscience laboratory). All molecular platforms/assays were PHE/NHSE approved. The reference antibody test was the Elecsys Anti-SARS-CoV-2 assay (Roche diagnostics GmBH).Main outcome measuresSensitivity and specificity of the rapid antibody testResultsThe reference antibody test was positive in 190/268 (70.9%) of participants with a history of symptoms suggestive of COVID-19; in the majority (n=312) the POC test was taken 35 days or more after onset of symptoms. The POC antibody test had an overall sensitivity of 90.1% (292/328, 95% CI 86.3 – 93.1) and specificity of 100% (68/68, 95% CI 94.7 - 100) for confirming prior SARS-CoV-2 infection when compared to the composite reference standard. Sensitivity was 97.8% (89/92, 95% CI 92.3% to 99.7%) in participants who had been admitted to hospital and 84.4% (124/147, 95% CI 77.5% to 89.8%) in those with milder illness who had never been seen in hospital.ConclusionsThe Livzon point-of-care antibody test had comparable sensitivity and specificity to the reference laboratory antibody test, so could be used in clinical settings to support decision-making about patients presenting with more than 10 days of symptoms of COVID-19.What is already known on this topic-Presence of IgG and IgM antibodies to SARS-COV-2 indicates that the person was infected at least 7 days previously and is usually no longer infectious.-Rapid point-of-care tests for antibodies to SARS-COV-2 are widely available, cheap and easy to use-Preliminary evaluations suggested that rapid antibody tests may have insufficient accuracy to be useful for testing individual patients.What this study adds-The rapid point-of-care test for antibodies to SARS-COV-2 was 90.1% sensitive and 100% specific compared to reference standards for prior infection with COVID-19.-This is comparable to reference antibody tests-The point-of-care test evaluated in this study could be used to support clinical decision-making in real time, for patients presenting with symptoms of possible COVID-19 with at least 10 days of symptoms.

IntroductionSeveral viral respiratory infections - notably influenza - are associated with secondary bacterial infection and additional pathology. The extent to which this applies for COVID-19 is unknown. Accordingly, we aimed to define the bacteria causing secondary pneumonias in COVID-19 ICU patients using the FilmArray Pneumonia Panel, and to determine this test’s potential in COVID-19 management.MethodsCOVID-19 ICU patients with clinically-suspected secondary infection at 5 UK hospitals were tested with the FilmArray at point of care. We collected patient demographic data and compared FilmArray results with routine culture.ResultsWe report results of 110 FilmArray tests on 94 patients (16 had 2 tests): 69 patients (73%) were male, the median age was 59 yrs; 92 were ventilated. Median hospital stay before testing was 14 days (range 1-38). Fifty-nine (54%) tests were positive, with 141 bacteria detected. Most were Enterobacterales (n=55, includingKlebsiellaspp. [n= 35]) orStaphylococcus aureus(n=13), as is typical of hospital and ventilator pneumonia. Community pathogens, includingHaemophilus influenzae(n=8) andStreptococcus pneumoniae(n=1), were rarer. FilmArray detected one additional virus (Rhinovirus/Enterovirus) and no atypical bacteria. Fewer samples (28 % vs. 54%) were positive by routine culture, and fewer species were reported per sample;Klebsiellaspecies remained the most prevalent pathogens.ConclusionFilmArray had a higher diagnostic yield than culture for ICU COVID-19 patients with suspected secondary pneumonias. The bacteria found mostly were Enterobacterales,S. aureusandP. aeruginosa, as in typical HAP/VAP, but withKlebsiellaspp. more prominent. We found almost no viral co-infection. Turnaround from sample to results is around 1h 15 min compared with the usual 72h for culture, giving prescribers earlier data to inform antimicrobial decisions.

Introduction Meropenem is a broad spectrum antibiotic used to treat a variety of bacterial infections. There are no clear standards nationally for the use of meropenem. The purpose of this study is to audit the appropriateness of Meropenem prescription at West Hertfordshire NHS trust METHODOLOGY Patients started on meropenem were identified via the hospital pharmacy in the period from 1st January 2019 to 31st March 2019. Patients’ clinical notes, drug charts and blood tests were reviewed. Appropriateness of meropenem prescription was judged based on the following: indication, penicillin allergy and its nature, pathogen antibiogram, microbiologists approval, indications for escalation and duration of treatment RESULTS forty-eight patients were identified during the study period. The main indications were hospital-acquired/community-acquired pneumonia and UTI. Penicillin allergy was documented in 31%, the nature of allergy was intolerance in 13% and not known in 20%. Of note, in 42% of these, treatment was not pathogen guided. In 45.5% of non-penicillin allergic patients, escalation to meropenem were neither supported by antibiogram nor by microbiologists. The main driver was raised inflammatory markers (62.5%). Of the 37 patients who completed their treatment during the study period, 21.6% had > 7 days with only 50% recommended by Microbiologists. CONCLUSION: In third of the patients, meropenem use was driven by penicillin allergy, however the nature of allergy did not justify its use in many of these cases. Lack of microbiology approval, failure to de-escalate and long courses of meropenem were additional areas identified to target in our antimicrobial stewardship programme

Since the emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), millions have been diagnosed with COVID-19. The major clinical manifestations of SARS-CoV-2 infection are pulmonary, however reports of COVID-19-associated central nervous system complications emerged.1 2 We report a case of encephalitis in a pulmonologically asymptomatic patient with COVID-19. A 66-year-old female presented in mid-March 2020, with a few hours history of confusion. She was completely well until the day of admission. There was no medical, infectious or behavioural prodrome. There was no alcohol or nutritional history. She had travelled to Spain, the USA and Mexico in the 3 months prior, but had been home for 19 days. She suddenly complained that her head ‘felt funny’. She carried on normal tasks but, within an hour, became confused, amnestic and was unaware of why social distancing measures were being observed. On admission, her temperature was 37.9°C. Other observations were normal. She was lymphopaenic at 0.4×109/L (0.8–3.1). Full blood count was otherwise normal. C-reactive protein (CRP) was 14.5 mg/L (0–5). Routine blood tests, including renal function, liver function and clotting, were normal. A brain CT was unremarkable. Six hours after admission, she had a single, spontaneously resolving, generalised tonic-clonic seizure. Her postictal Glasgow Coma Scale (GCS) was 6/15 (E1/V1/M4). This remained unchanged for 48 hours. Postictal neurological examination showed equal, reactive pupils, no response to visual menace, no vestibulo-ocular reflex, normal tone bilaterally, symmetrical brisk reflexes and extensor plantars. She remained febrile (37.9°C) for 48 hours. Oxygen saturation dropped to 93% on air only once during her 4-week admission. She never developed breathlessness, cough or tachypnoea. An MRI of the brain on day 2 showed non-enhancing, symmetrical T2 and FLAIR …

Context The significant global upsurge in antimicrobial resistance, particularly among Enterobacteriaceae, represents a serious threat to health care systems. The implications for urologic practice are of particular concern. Objective To review trends in antibiotic resistance in urologic practice. Evidence acquisition We report current European trends of resistance in Gram-negative uropathogens. Evidence synthesis In addition to β-lactam resistance, Gram-negative pathogens are often resistant to multiple drug classes, including aminoglycosides, fluoroquinolones, and carbapenems, commonly used to treat urologic infections. Interest is renewed in old antibiotics, and several new antibiotics are in the pipeline to meet the challenge of treating these infections. In this review, we summarise emerging trends in antimicrobial resistance and its impact on urologic practice. We also review current guidelines on the treatment and prevention of urologic infections with these organisms, and some key antibiotics in the era of resistance. Conclusions Increasing antimicrobial resistance represents a challenge to urologic practice for both treatment and prophylaxis. Antibiotic choice should be determined according to risk factors for multidrug resistance. Good knowledge of the local microbial prevalence and resistance profile is required to guide antimicrobial therapy. Patient summary Antimicrobial resistance represents a challenge in urology. We summarise emerging trends in antimicrobial resistance and review current guidelines on the treatment and prevention of urologic infections, as well as some key antibiotics in the era of resistance.

Arteriovenous fistula (AVF) is the preferred access for hemodialysis (HD). Buttonhole (BH) needling has increased following the introduction of "blunt" fistula needles. Although some reported advantages for BH needling, others have reported increased infection risk. As such we reviewed our center practice, and the effect of both nasal screening and eradication and re-education and training programs. We audited the outcomes of 881 HD patients dialyzed between November 2009 and May 2012, divided into three groups: 175 dialyzing exclusively by central venous catheter (CVC), 478 exclusively by area needling AVF (AVF) and 219 by BH. There were 31 Staphylococcus aureus bacteremias (SABs); 14 (45.2%) dialyzing with CVCs, 12 (38.7%) BH and five (16.1%) AVF. The 30 day mortality rate for SAB was 7.5% with a complication rate of 22.6%. The hazard ratio for first SAB was significantly greater for both CVC and BH access compared to AVF (5.3 (95% CI -1.9-18.6), P

Introduction: This winter has seen the worst flu epidemic in 7 years and exacerbated pressure on hospitals. Early diagnosis in the emergency department (ED) should prevent transmission to other patients in hospitals, help avoid bed closures for infection control (IC) purposes, and allow rapid treatment to be delivered. Aims & Objectives: To determine whether POCT alters the following, in patients with possible influenza: 1. Time to diagnosis (rule in/out of influenza) 2. Proportion of patients admitted from outset to a bed with appropriate level of isolation (by rapid POCT confirmation) thereby avoiding subsequent bed moves. Methods: All patients presenting with possible influenza underwent POCT (Filmarray Biofire) as part of their initial assessment. We present findings from the first 2 weeks after implementation of this novel service. Results: Of 130 patients tested, 57 cases of influenza were identified, of the following strains: 41 B, 14 A H3 and 2 A H1 2009. The average time from receipt of sample to test result was 12 hours for n = 25 samples sent to the microbiology lab via the traditional method. In contrast, POCT results were available in 43 minutes. 29 of 57 influenza patients underwent POCT whilst in ED prior to admission, of whom 22 could be appropriately admitted as per infection control (IC) measures and 7 safely discharged. Of the 50 admitted, 32 were discharged home without any bed/ward moves as they had been correctly placed in the appropriate IC cohort bay from the outset. None required ITU. Discussion: We have demonstrated that POCT leads to rapid confirmation of influenza and allows informed early decision making, reducing flu contacts and bed closures.

Arteriovenous fistula (AVF) is the preferred access for hemodialysis (HD). Buttonhole (BH) needling has increased following the introduction of "blunt" fistula needles. Although some reported advantages for BH needling, others have reported increased infection risk. As such we reviewed our center practice, and the effect of both nasal screening and eradication and re-education and training programs. We audited the outcomes of 881 HD patients dialyzed between November 2009 and May 2012, divided into three groups: 175 dialyzing exclusively by central venous catheter (CVC), 478 exclusively by area needling AVF (AVF) and 219 by BH. There were 31 Staphylococcus aureus bacteremias (SABs); 14 (45.2%) dialyzing with CVCs, 12 (38.7%) BH and five (16.1%) AVF. The 30 day mortality rate for SAB was 7.5% with a complication rate of 22.6%. The hazard ratio for first SAB was significantly greater for both CVC and BH access compared to AVF (5.3 (95% CI -1.9-18.6), P 0.001 and 3.6 (1.3-96), P = 0.011, respectively). During the study SAB rates per 1000 CVC days were 0.21, compared to 0.15 for BH. After major re-education and asepsis technique campaigns the SAB rate for BH fell to 0.06, but quickly returned to 0.17. Extending BH needling to all our dialysis centers, SAB infection rates increased to those not dissimilar to CVC access. Despite re-education programs coupled with a strict asepsis policy and active SA eradication, followed by audit cycles, the increased infection risk with BH remained, such that we have limited BH to self-care patients.