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What is known and objective Interventions intended to slow the emergence and spread of antibacterial resistance through enhanced antimicrobial stewardship will be more effective if informed by an accurate knowledge of current patterns of antibacterial consumption. For example, knowledge of the relative magnitude of community antibacterial consumption in relation to hospital antibacterial consumption within each nation or region should help guide decisions about the relative importance of community and hospital antimicrobial stewardship programmes. It is commonly stated that community antibacterial consumption comprises approximately 80% of total national antibacterial consumption. We aimed to determine this proportion across a large range of nations. Methods We measured community and hospital antibacterial consumption in New Zealand during 2015, from both reimbursement and purchase data, and compared the New Zealand data with those reported from a large range of other nations during similar time periods. Results and discussion Community antibacterial consumption comprised approximately 85%-95% of total antibacterial consumption in all nations for which data were available, and in New Zealand comprised a higher proportion than in any other nation. The proportion of total antibacterial consumption comprised by community consumption was significantly higher in countries with relatively high levels of total antibacterial consumption than in countries with relatively low levels of total antibacterial consumption. What is new and conclusion The high proportion of total antibacterial consumption comprised by community antibacterial consumption suggests devoting particular attention to improved community antimicrobial stewardship. These results suggest that improving antimicrobial stewardship in the community may provide greater overall benefits in combating antibacterial resistance than improving antimicrobial stewardship in hospitals. [ABSTRACT FROM AUTHOR]

Background: The aims of this study were to determine the clinical characteristics on arrival and the subsequent clinical outcome of HIV-infected UN quota refugees who settled in New Zealand during the last 11 years and to estimate their rate of HIV transmission. Methods: A population study was conducted. Data were provided by the Mangere Refugee Resettlement Centre, the infectious disease physicians caring for the subjects, the New Zealand AIDS Epidemiology Group and laboratories carrying out HIV viral load assays. Results: One hundred of 7732 (1.3%) UN quota refugees were HIV positive; mean age 30 years, 56% were men, median initial CD4 count was 320 (range 20–1358). HIV infection was most commonly acquired by heterosexual intercourse (74%). The median follow up was 5.0 years (range 1 month to 9.7 years). Five died and 15 subjects had 16 AIDS-defining illnesses, most commonly tuberculosis ( n = 10). Sixty subjects commenced highly active antiretroviral therapy of whom 36/59 (61%) had an undetectable HIV viral load after 1 year of treatment. None of the six children born to HIV-infected women in New Zealand were infected. There were two known cases of horizontal transmission of HIV infection. Conclusion: Although HIV-infected quota refugees often have to overcome severe social, cultural and financial handicaps, their clinical outcome is generally very good, with response rates to highly active antiretroviral therapy that are similar to other patient groups. Furthermore, they have not been a significant source of transmission of HIV infection after resettlement in New Zealand. [ABSTRACT FROM AUTHOR]

Our aim was to describe the epidemiology and incidence of community-onset invasive S. aureus disease in children presenting to our hospital, and to compare the clonal complexes and virulence genes of S. aureus strains causing invasive and non-invasive disease. The virulence gene repertoire of invasive disease isolates was characterized using DNA microarray and compared with the virulence gene repertoire of non-invasive S. aureus isolates. Over the study period, 163 children had an invasive S. aureus infection. There was no difference in the distribution of clonal complexes or in the prevalence of genes encoding virulence factors between invasive and non-invasive isolates. Future research should include a strong focus on identifying the host and environmental factors that, along with organism virulence factors, are contributing to the patterns of invasive S. aureus disease observed in New Zealand.

Mortality and serious long-term sequelae still occur in about 50% of patients with tuberculous meningitis. The frequency and the clinical features of neurological and systemic complications were determined in a retrospective review of 104 patients with tuberculous meningitis. Complications occurred in 81 patients (78%). The most common complications were: hyponatraemia 49%, hydrocephalus 42%, stroke 33%, cranial nerve palsies 29%, epileptic seizures 28%, diabetes insipidus 6%, tuberculoma 3%, myeloradiculopathy 3% and hypothalamic syndrome 3%. The most common iatrogenic complication was hepatotoxicity related to anti-tuberculosis treatment in seven patients. Twenty-three patients (22%) died. At last follow-up one patient (1%) remained in a persistent vegetative state, 14 patients (13%) had severe disability and 12 patients (12%) were moderately disabled. The most common complications in the 81 long-term survivors were cognitive impairment (12%) and epilepsy (11%). Neurological and systemic complications of tuberculous meningitis were common and were important causes of mortality and long-term morbidity., (Copyright 2010 Elsevier Ltd. All rights reserved.)

The clinical features, investigations, treatment and outcome were studied in 104 patients with definite or probable tuberculous meningitis. The diagnosis of definite tuberculous meningitis required the growth of Mycobacterium tuberculosis from cultures, or a positive polymerase chain reaction (PCR) assay for M. tuberculosis. In probable tuberculous meningitis, cultures and the PCR assay were negative, but other causes of meningitis were excluded and there was a response to anti-tuberculosis treatment. Of the 104 patients, 36% had a poor outcome (severe disability, persistent vegetative state or death), 12% moderate disability and 52% good recovery. A diagnosis of definite tuberculous meningitis, the severity of the symptoms at presentation and the occurrence of a stroke were significant predictors of a poor outcome. The most common reasons for a delayed diagnosis were presentation with mild symptoms wrongly attributed to a systemic infection, incorrectly attributing CSF abnormalities to non-tuberculous bacterial meningitis and failure to diagnose extraneural tuberculosis associated with meningitis. Recognition of the difficulties in making a diagnosis of tuberculous meningitis may facilitate earlier diagnosis in the future., (Copyright 2010 Elsevier Ltd. All rights reserved.)

Background: Staphylococcus aureus bacteraemia (SAB) is a common complication of S. aureus infection and is associated with a high mortality., Aims: To document prospectively the pattern of illness associated with SAB in New Zealand and, by recording patient demographic factors and clinical features, to identify risk factors associated with a poor outcome., Methods: From 1 July 1996 to 31 December 1997, adults with SAB were prospectively studied in six tertiary care hospitals. All information obtained from patients' records was recorded on worksheets and transferred to a computerized spreadsheet for analysis., Results: There were 424 patients with SAB. Maori (relative risk (RR)= 1.8, 95% confidence interval (CI) = 1.3-2.6) and Pacific Island people (RR = 4.0, 95% CI = 3.1-5.3) were significantly more likely than people of European descent to acquire SAB, but not to die from the infection. Fifty per cent of cases were community acquired. A source was identified for 85%: intravenous catheter (31%), primarily hospital acquired, and skin/soft tissue (22%), primarily community acquired, were the most common foci. The 30-day mortality was 19%, 83% of whom died within 2 weeks. Risk factors for a poor outcome were: increasing age above 60, female sex (RR = 1.4, 95% CI = 1.0-2.1), diabetes mellitus (RR = 1.5, 95% CI = 1.0-2.4), immunosuppression (RR = 1.5, 95% CI = 1.0-2.4), pre-existing renal impairment (RR = 1.8, 95% CI = 1.2-2.7), malignancy (RR= 2.2, 95% CI = 1.4-3.5), lung as a source (RR = 2.8, 95% CI = 1.9-4.2) and unknown source (RR = 2.3, 95% CI = 1.5-3.3). Mortality was also accurately predicted by two multifactor scoring systems. There was a low rate of methicillin resistance (5%)., Conclusions: Staphylococcus aureus bacteraemia is more likely to occur in certain ethnic groups, while mortality is associated with other identifiable risk factors and continues to be high. Intravenous catheters remain the most common and most preventable cause of SAB.

Aims: To determine the incidence, demography, clinical features, treatments and outcome for patients with tuberculosis and human immunodeficiency virus (HIV) infection in Auckland., Methods: We reviewed the notes of all patients with HIV infection and tuberculosis seen by the Infectious Disease Unit, at Auckland Hospital since the onset of the HIV epidemic in New Zealand in 1984 until 31 December 1995., Results: Eleven patients have had HIV infection and tuberculosis, 2.4% of all those with HIV infection cared for by this unit. Ten were male and eight homosexual. The median age was 30 years (range 24-57). The incidence in Pakeha was 1.2% (3 of 234), in Maori 20% (5 of 25) and in African 27% (3 of 11). Until 1990 we saw one case every two years and since then one or two cases per year. Six patients had normal chest x-rays and five had abnormal chest x-rays; of the latter, three were typical of tuberculosis and two atypical. Ten of the eleven strains of Mycobacterium tuberculosis cultured were fully sensitive but one was resistant to both rifampicin and isoniazid. Conventional treatment regimens were used. Seven patients have died of HIV infection, three continue treatment and one returned to Africa. One patient relapsed with fully sensitive tuberculosis. Three patients had major side effects to rifampicin necessitating alternative treatment., Conclusions: Tuberculosis is uncommon amongst those with HIV infection in Auckland but the incidence has risen in recent years. The risks amongst Maori and Africans are high. Multidrug resistant tuberculosis is uncommon. Those caring for patients with tuberculosis need to be mindful of HIV infection: those caring for patients with HIV infection need to be increasingly alert for tuberculosis.

Aim: To determine the number of people with malaria in Auckland in 1993 and determine species, sources, exposure history, use of chemoprophylaxis, outcome and geographic attack rates., Methods: We prospectively obtained the numbers of people with laboratory diagnosed malaria from all haematology departments in Auckland and then contacted the patients and their doctors to elicit further details., Results: Forty three people, 30 men and 13 women, had malaria. Twenty eight were New Zealanders, 10 migrants, three temporary visitors and two not determined. Thirty two had P vivax infection, 11 P falciparum: none had complications. The highest attack rate was in travellers to the Solomon Islands. Eighty two per cent took prophylaxis., Conclusions: Malaria is an uncommon diagnosis in Auckland. Most patients took prophylaxis. The disease is undernotified. No one died of malaria in 1993 in Auckland.

Aims: To determine the clinical features, management and outcome for patients admitted to hospital with tetanus in Auckland., Methods: Medical records of all patients with tetanus admitted to hospitals in Auckland between January 1982 and December 1992 were retrospectively reviewed., Results: Fifteen patients were admitted to hospital during the study period. All patients were more than 40 years old and no patient had a history of more than one tetanus toxoid immunisation before the injury presumed responsible for tetanus. Failure to consider the diagnosis led to delay in starting appropriate treatment in most patients. Eleven patients required mechanical ventilation. The median duration of hospital stay was 44 days. All patients survived., Conclusions: Tetanus is rare in Auckland and almost exclusively affects those born before 1960 when universal childhood immunisation against tetanus was started. The disease causes significant morbidity which could be avoided by increased efforts to ensure that all persons have completed a full course of immunisation. Universal vaccination against tetanus with regular boosters to maintain immunity would also circumvent the problems encountered with postexposure tetanus prophylaxis.

Aims: To assess the survival of Auckland residents diagnosed with AIDS between 1983 and 1989., Methods: Retrospective case review, Results: Sixty nine Auckland residents were diagnosed with AIDS between 1983 and the end of 1989, and were cared for by the infectious disease unit, Auckland Hospital. The overall median survival was 289 days with 48% and 20% surviving at one and two years respectively. Survival was longer among those who were infected through homosexual contact, were younger, and not known to the infectious disease unit prior to the diagnosis of AIDS. Although survival was longer for those diagnosed in 1988 compared to earlier years, it was shorter again for those diagnosed in 1989. Pneumocystis carinii pneumonia, the AIDS defining condition in 63.8% of people, was found less frequently in 1989, and overall was associated with a longer survival than most of the other AIDS-defining diagnoses. A quarter of the people were not known to be infected with HIV prior to the AIDS-defining condition., Conclusion: In New Zealand, as in other countries, changes in treatment strategies of people with HIV infection may impinge on the survival of people with AIDS.

We surveyed annual expenditure on antimicrobial agents and the use of antimicrobial restriction policies. Restriction policies were in use in 25 of 27 of the hospitals surveyed. Restrictions on the use of antimicrobials were extended into specialty intensive care or haematology units in only 13 of 20 hospitals which had such units. Antimicrobial restriction policies were, for the most part, similar amongst the hospitals surveyed. Use of restriction policies within specialist units was associated with reduced total hospital antibiotic expenditure per bed per year.

Twenty-six patients with cryptococcal meningitis were seen in Auckland between 1969 and 1989. The incidence of cryptococcal meningitis in Auckland residents was 0.12 cases/100,000/year. Ten (38%) of the patients were Maori or Pacific Island Polynesians. Nineteen (73%) had a predisposing cause, including immunosuppressive therapy in nine and the acquired immunodeficiency syndrome (AIDS) in seven. The most common presenting syndrome was a subacute or chronic meningitis. Other clinical syndromes included a slowly progressive ataxia, polyradiculopathy, and headache with vomiting. In two patients, the symptoms of meningitis were overshadowed by those of systemic cryptococcal infection. Delay in making the diagnosis was common. The most sensitive method for diagnosing cryptococcal meningitis was the cerebrospinal fluid cryptococcal antigen test. Antifungal therapy cured 17 of the 25 (68%) treated patients overall, 15 of the 19 (79%) without AIDS and six of the seven with no underlying disease.

Thirteen episodes of intravascular cannula-related sepsis were seen during a two year period. Staphylococcus aureus was the most common pathogen. Fungaemia occurred in four patients all receiving total parenteral nutrition. Culture of the cannula tip and swabs of the insertion site were useful in confirming the diagnosis. Three patients with infection due to S aureus died while receiving treatment for their infections. Care with insertion and maintenance of intravascular cannulae should reduce the frequency of this iatrogenic infection.

An assessment was made of the probability of HLA B27 associated disease in 74 patients who had recently been tested. Six patients had definite, 31 possible, and 37 very unlikely HLA B27 associated disease. Thirteen patients were HLA B27 positive. Fourteen tests were ordered by rheumatologists (43% HLA B27 + ve) and 60 by other doctors (12% HLA B27 + ve) p less than 0.01. Non-rheumatologists ordered an excessive number of tests in patients with a low probability of HLA B27 associated disease.