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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.

Background:The global pandemic has mandated the development of innovative online learning tools for clinical year medical students, who have traditionally learned through clinical clerkship models. There is limited evidence as to whether curriculum delivery through a student co-designed online learning platform would ​​be beneficial to student satisfaction, engagement and academic progression for clinical year medical students. Methods:A mixed methods research method was used to explore the impact of a student co-designed learning pathway. Baseline thematic analysis of semi-structured interviews were firstly conducted to identify unmet e-learning needs in a cohort of 1500 medical students. Subsequent student co-creation of a novel online resource for 500 medical students undertaking their first clinical year was developed utilizing learning software (Sophya). Post implementation, anonymous evaluation surveys were distributed and in-built engagement statistics from Sophya were analysed.Results:Semi-structured interviews identified a significant unmet need for multimodal, student-centred, personalised learning methods that are accessible, relevant and centralised. Students most engaged with the online resource achieved higher grades (average 4.1% difference) compared to those least engaged. Student and faculty academics used the Sophya platform to curate 364 learning items across twelve core medicine and surgery domains through interactive modules, video tutorials, revision and self-assessment puzzles and quizzes. Within one semester, 72% of the student cohort had engaged with the platform, 946.2 hours were spent on the pathway, 11,480 learning activities completed and 1070 flashcards reviewed. Evaluation demonstrated students valued the structure and content of the resource (average rating 4.2 and 4.1 out of 5, respectively). 90.8% of respondents agreed the platform helped their learning, with video materials on clinical application most heavily utilized. Conclusion:Student co-created learning pathways, utilising interactive educational software in addition to current learning management systems, can assist faculty academics better support student learning needs and create a sustainable online platform that benefits clinical student training.

The objective of this study was to review the design and delivery of medical ethics (ME) education within medical programs across Australia and New Zealand (ANZ), how current teaching has been informed by the proposed core curriculum published in 2001 by the ATEAM (Braunack-Mayer et al. 2001) and how it could look moving forward. We conducted a mixed methods study using an online questionnaire consisting of 51 items. This included both binary and open-ended questions to categorise and explore similarities and differences in medical ethics curricula in medical programs accredited by the Australian Medical Council (AMC) across ANZ. Participants were asked about curriculum design format, duration, goals, assessments, content areas of their own ME curriculum. Convenors from 18 universities responded (78%). The main commonality was that ME curricula were integrated both longitudinally and laterally with other content. There was also commonality in content areas addressed. The goals, format, educators, and assessments of the ME curricula were highly variable. Most respondents described a curriculum which prioritised knowledge and skill development related to ME. Although the core goals of including knowledge, skills, and attitudinal development in ME curricula are still present, there is no uniformity in terms of format, delivery, or assessment across medical programs in ANZ. This is an area for collaborative development.

Background Periprosthetic joint infection (PJI) is a devastating condition and there is a lack of evidence to guide its management. We hypothesized that treatment success is independently associated with modifiable variables in surgical and antibiotic management. Methods The is a prospective, observational study at 27 hospitals across Australia and New Zealand. Newly diagnosed large joint PJIs were eligible. Data were collected at baseline and at 3, 12, and 24 months. The main outcome measures at 24 months were clinical cure (defined as all of the following: alive, absence of clinical or microbiological evidence of infection, and not requiring ongoing antibiotic therapy) and treatment success (clinical cure plus index prosthesis still in place). Results Twenty-four-month outcome data were available for 653 patients. Overall, 449 patients (69%) experienced clinical cure and 350 (54%) had treatment success. The most common treatment strategy was debridement and implant retention (DAIR), with success rates highest in early postimplant infections (119 of 160, 74%) and lower in late acute (132 of 267, 49%) and chronic (63 of 142, 44%) infections. Selected comorbidities, knee joint, and Staphylococcus aureus infections were independently associated with treatment failure, but antibiotic choice and duration (including rifampicin use) and extent of debridement were not. Conclusions Treatment success in PJI is associated with (1) selecting the appropriate treatment strategy and (2) nonmodifiable patient and infection factors. Interdisciplinary decision making that matches an individual patient to an appropriate management strategy is a critical step for PJI management. Randomized controlled trials are needed to determine the role of rifampicin in patients managed with DAIR and the optimal surgical strategy for late-acute PJI.

Background Major disruptions imposed on medical education by the COVID-19 pandemic and the rapid shift to online teaching in medical programs, necessitated need for evaluation of this format. In this study we directly compared knowledge outcomes, social outcomes, and wellbeing of first year student small group teaching in either face to face (f2f) or online format. Methods At the end of the first course of our medical program, students were invited to participate in an online questionnaire with 10 quantitative items and 1 qualitative item. These were analysed using Factor Analysis Pattern Matrix and linear regression to group items and assess relatedness. Qualitative responses were thematized using Qualtrics software (Qualtrics, Provo, UT, USA). Summative assessment results were compared, both between current cohorts to historical cohorts. Results From a cohort of 298 students there was a 77% response rate. Overall, there were no differences in knowledge gains, either between groups or when compared to historical cohorts. Questionnaire items fell reliably into groups that related to either learning outcomes, social outcomes, or wellbeing. Independent T tests showed that format for teaching (online versus f2f) had an impact on social outcomes but no direct impact on learning outcomes. Linear regression revealed that the social outcomes have a direct impact on wellbeing and almost the double the impact on learning outcomes than mode of learning i.e.. F2f or online (β = .448 and β = .232 respectively). Conclusion In this study, we were able to show with statistical strength that social outcomes for students such as engaging with peers and facilitator, contributing to the group, and making friends have a direct impact on wellbeing and indirectly impact learning outcomes (such as motivation, satisfaction, integration of knowledge). In a rapidly changing educational landscape, in our opinion, it is vital that these aspects are a focus of design and delivery of medical education. The data from this study supports the notion that activity design and the expertise of the teacher in facilitating the small group activities, has greater impact than the mode of educational delivery itself on students’ learning processes.

BackgroundMajor disruptions imposed on medical education by the COVID-19 pandemic and the rapid shift to online teaching in medical programs, necessitated need for evaluation of this format. In this study we directly compared knowledge outcomes, social outcomes, and wellbeing of first year student small group teaching in either face to face (f2f) or online format.MethodsAt the end of the first course of our medical program, students were invited to participate in an online questionnaire with 10 quantitative items and 1 qualitative item. These were analysed using Factor Analysis Pattern Matrix and linear regression to group items and assess relatedness. Qualitative responses were thematized using Qualtrics software (Qualtrics, Provo, UT, USA). Summative assessment results were compared, both between current cohorts to historical cohorts.ResultsFrom a cohort of 298 students there was a 77% response rate. Overall, there were no differences in knowledge gains, either between groups or when compared to historical cohorts. Questionnaire items fell reliably into groups that related to either learning outcomes, social outcomes, or wellbeing. Independent T tests showed that format for teaching (online versus f2f) had an impact on social outcomes but no direct impact on learning outcomes. Linear regression revealed that the social outcomes have a direct impact on wellbeing and almost the double the impact on learning outcomes than mode of learning ie. F2f or online (β=.448 and β=.232 respectively). ConclusionIn this study, we were able to show with statistical strength that social outcomes for students such as engaging with peers and facilitator, contributing to the group, and making friends have a direct impact on wellbeing and indirectly impact learning outcomes (such as motivation, satisfaction, integration of knowledge). In a rapidly changing educational landscape, it is vital that these aspects are a focus of design and delivery of medical education. The data from this study supports the notion that activity design and the expertise of the teacher in facilitating the small group activities, is more important than the mode of educational delivery itself.

Background Complexities of ethics education, combined with socio-cultural issues specific to the medical curricula of the developing country context, have created resource constraints that impact medical ethics education delivery in countries like Pakistan and Saudi Arabia. These constraints include the dearth of contextually relevant texts, shortage of trained teachers and confines in institutional regulations in the regions. Focused strategies are required to address these constraints. Workbook-based ethics learning (WBEL) is one such strategy based on a contextually relevant ethics education model. Purpose This study aimed to evaluate the effectiveness of ethics education, delivered through the WBEL strategy, on students’ learning and satisfaction in medical colleges of Pakistan and Saudi Arabia. Methods A pre-post-test intervention study was conducted in two medical colleges, Jinnah Sindh Medical University, Pakistan and King Abdulaziz University, Saudi Arabia. An ethics course was structured using the WBEL strategy and delivered to early clinical years medical students. The impact on student learning was measured by pre-and-post administration of a set of Key Feature Questions (KFQ) and a Script Concordance Test (SCT). A twenty-eight-item course feedback questionnaire was developed to collect students’ perceptions regarding the WBEL strategy. Results Of the total 125 students who consented, 90 (72%) completed the pre-and post-test measures, and 103 returned the feedback forms at the two sites. The post-test scores in KFQs were significantly higher than pretest scores in both Pakistani and Saudi students (p-value

Background The COVID-19 pandemic and the consequent social distancing measures caused unprecedented disruption for medical and healthcare education. This study examined medical teachers’ experience with emergency remote teaching during the pandemic and their acceptance of online teaching after the pandemic. Methods In this sequential mixed methods study, online surveys were disseminated to teachers (n = 139) at two Asia–Pacific medical schools to evaluate their experience with emergency remote teaching during the pandemic. Subsequently, in-depth interviews were conducted with teachers from both institutions (n = 13). Each interviewee was classified into an adopter category based on Rogers’ Diffusion of Innovations Theory. Interview transcripts were analyzed thematically, and the descriptive themes were mapped to broader themes partly based on the Technology Acceptance Model and these included: (i) perceived usefulness of online teaching, (ii) perceived ease of delivering online teaching, (iii) experience with institutional support and (iv) acceptance of online teaching after the pandemic. Results Our participants described accounts of successes with their emergency remote teaching and difficulties they experienced. In general, most participants found it difficult to deliver clinical skills teaching remotely and manage large groups of students in synchronous online classes. With regards to institutional support, teachers with lower technological literacy required just-in-time technical support, while teachers who were innovative in their online teaching practices found that IT support alone could not fully address their needs. It was also found that teachers’ acceptance of online teaching after the pandemic was influenced by their belief about the usefulness of online teaching. Conclusions This study demonstrated that our participants managed to adapt to emergency remote teaching during this pandemic, and it also identified a myriad of drivers and blockers to online teaching adoption for medical teachers. It highlights the need for institutes to better support their teaching staff with diverse needs in their online teaching.

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%).

BackgroundDelivery of medical ethics education is complex due to various reasons, compounded by the context-dependent nature of the content. The scarcity of relevant resources in the contexts of some developing countries adds a further layer of difficulty to ethics education in these contexts. We used a consultative approach with students, teachers and external experts to develop a practical approach to medical ethics education. This study aimed to develop and refine a contextually relevant approach to ethics education in the region of Saudi Arabia.MethodsThe study utilised an explorative qualitative methodology to seek views of students and faculty of Rabigh Faculty of Medicine, Saudi Arabia, and international experts in the field of ethics and education to review and enhance a new ethics learning strategy which included a workbook-based tool. Three focus groups with 12 students, in-depth interviews with four faculty members and qualitative feedback from eleven external experts enabled the study participants to objectively critique the WBEL and provide feedback to enhance its quality. Thematic content analysis of the data was done to draw inferences which were used to refine the educational strategy.ResultsThe analysis generated twenty-one sub-themes within four main themes: design features, content, teaching methods and assessment. These findings helped to design the educational strategy to improve its effectiveness in the given context.ConclusionThe study drew on the views of students, faculty and external experts to systematically develop a novel approach to ethics education for countries like Saudi Arabia. It also demonstrated the use of the consultative approach for informing a culturally relevant educational strategy in the Middle East context.

Background Periprosthetic joint infection (PJI) is a devastating complication of joint replacement surgery. Most observational studies of PJI are retrospective or single-center, and reported management approaches and outcomes vary widely. We hypothesized that there would be substantial heterogeneity in PJI management and that most PJIs would present as late acute infections occurring as a consequence of bloodstream infections. Methods The Prosthetic joint Infection in Australia and New Zealand, Observational (PIANO) study is a prospective study at 27 hospitals. From July 2014 through December 2017, we enrolled all adults with a newly diagnosed PJI of a large joint. We collected data on demographics, microbiology, and surgical and antibiotic management over the first 3 months postpresentation. Results We enrolled 783 patients (427 knee, 323 hip, 25 shoulder, 6 elbow, and 2 ankle). The mode of presentation was late acute (>30 days postimplantation and 30 days postimplantation with ≥30 days of symptoms; 148, 19%). Debridement, antibiotics, irrigation, and implant retention constituted the commonest initial management approach (565, 72%), but debridement was moderate or less in 142 (25%) and the polyethylene liner was not exchanged in 104 (23%). Conclusions In contrast to most studies, late acute infection was the most common mode of presentation, likely reflecting hematogenous seeding. Management was heterogeneous, reflecting the poor evidence base and the need for randomized controlled trials., We enrolled 783 patients in a prospective, observational binational study of peri-prosthetic joint infection. Late, acute infections were the commonest mode of presentation. Microbiological causes differed according to affected joint and the timing of the infection. Management approaches were heterogeneous.

Background Diabetic foot infections (DFI) present a major morbidity, mortality and economic challenge for the tertiary health sector. However, lack of high quality evidence for specific treatment regimens for patients with DFIs may result in inconsistent management. This study aimed to identify DFI caseload proportion and patterns of clinical practice of Infectious Diseases (ID) Physicians and Trainees within Australia and New Zealand. Methods A cross-sectional online survey of Australian and New Zealand ID Physicians and Trainees was undertaken, to estimate the overall ID caseload devoted to patients with DFIs and assess clinicians’ management practices of patients with DFIs. Results Approximately 28% (142/499) of ID Physicians and Trainees from Australia and New Zealand responded to the survey. DFI made up 19.2% of all ID consultations. Involvement in multidisciplinary teams (MDT) was common as 77.5% (93/120) of those responding indicated their patients had access to an inpatient or outpatient MDT. Significant heterogeneity of antimicrobial treatments was reported, with 82 unique treatment regimens used by 102 respondents in one scenario and 76 unique treatment regimens used by 101 respondents in the second scenario. The duration of therapy and the choice of antibiotics for microorganisms isolated from superficial swabs also varied widely. Conclusions Patients with DFIs represent a significant proportion of an ID clinician’s caseload. This should be reflected in the ID training program. Large heterogeneity in practice between clinicians reflects a lack of evidence from well-designed clinical trials for patients with DFI and highlights the need for management guidelines informed by future trials. Electronic supplementary material The online version of this article (10.1186/s13047-018-0256-3) contains supplementary material, which is available to authorized users.

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.

The world is geographically divided into hemispheres, continents and countries, with varying cultures in different regions. Asia, the largest of continents, has a variety of philosophically distinctive cultures and lifestyles, informing the norms of societies that are much different from cultures in other continents. These complexities in the societal norms in Asian cultures have created unique issues in development of ethics education in the region. This paper looks in to the distinctions in what is generally referred to as the "non-western" Asian culture, the importance of cultural context and how it influences the ethics curriculum in the region.

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%).

Objective To provide an overview of existing literature regarding ethics in undergraduate medical education around the world, and to identify gaps in literature for recommending areas for future research. Methods The scoping review was conducted in March 2016. PubMed and Web of Science search engines were used to identify English language literature on ethics in undergraduate medical education published over the preceding 20 years. Google search was used for grey literature. Two reviewers independently screened eligible studies for final study selection and review. Descriptive analysis of data was performed with mutual consensus. Results Of the 199 items located, 56(28%) were included; 37(33%) of 112 studies, and 19(22%) of 87 pieces of grey literature. Papers covered almost all regions of the world, including North and South America, Europe, Africa, and different Asian regions like Middle East, central, south-east and far east. The analysis identified several curriculum designs and teaching methods used for ethics education. Conclusions The review identified gaps in evidence that required further research. These areas include theoretical underpinning of ethics curriculum, role of educators, standardisation and validation of teaching and learning strategies, and relevance to cultural context in the development and delivery of ethics curriculum, especially in Asian regions.

Increasing numbers of women are choosing to travel during pregnancy. In the presence of an altered immune state, exposure to certain microbes can be particularly harmful. We have undertaken a review of the literature in order to provide strategies to minimize the infectious disease risks of pregnant travel. Included is a discussion of common immunizing agents and their safety in pregnancy.

A 77 year old man presented with a four month history of weight loss and night sweats and one month of abdominal distension. There was …

Background Many patients admitted to hospital have an antibiotic allergy (AAL) documented in their medical record. In many of these, the reaction is not a hypersensitivity reaction or may no longer be relevant. Despite this, the label adversely affects patient care directly in terms of antibiotic selection, and indirectly in terms of patient costs and the development of antimicrobial resistance. Aims To estimate the prevalence of AALs in a cohort of hospitalised patients, to investigate the feasibility of de-labelling through re-challenge based solely upon clinical grounds. Design This is a cross-sectional study conducted over a 6-month period on adult inpatients. An allergy history was taken from each patient and compared with medical record data regarding allergy. Antibiotic selection data were collected (if relevant). It was then determined whether immediate de-labelling was appropriate, if direct provocation test (DPT) could be relatively safely performed, and if antibiotic selection was appropriate. Results Three thousand eight hundred and fifty five patients were screened, 553 (14.35%) had an AAL, and 352 were interviewed. There were 426 AALs; 276 (64.8%) towards a penicillin. After taking a detailed clinical history of the type of reaction, approximately 20% could be immediately de-labelled and educated (non-allergic, non-severe reactions) and another 38% with either a definite or vague history of mild cutaneous reaction would be suitable for an attempt at clinical de-labelling DPT. Conclusions These simple measures to 'de-label' patients appropriately, would increase the quality of care of this group known to have higher costs, infection with more resistant bacteria and worse health outcomes that 'non-labelled' patients.

Asplenic or hyposplenic patients are at risk of fulminant sepsis. This entity has a mortality of up to 50%. The spectrum of causative organisms is evolving as are recommended preventive strategies, which include education, prophylactic and standby antibiotics, preventive immunizations, optimal antimalarial advice when visiting endemic countries and early management of animal bites. However, there is evidence that adherence to these strategies is poor. Consensus-updated guidelines have been developed to help Australian and New Zealand clinicians and patients in the prevention of sepsis in asplenic and hyposplenic patients.

Background Up to 25% of patients admitted to hospital have an antibiotic allergy label (AAL), most of which are towards penicillin. However, up to 90% of patients who claim to be allergic to penicillin are actually able to tolerate them1. Whilst skin testing is safe and efficacious in de-labeling patients with a penicillin allergy label, it is usually not widely available. Therefore, we investigated the feasibility of de-labeling based solely upon clinical grounds. Quality of allergy documentation and subsequent antibiotic use was also assessed. Methods This was a cross-sectional study assessing all patients admitted to a tertiary referral teaching hospital over a 5-month period in 2016. All newly admitted patients were prospectively screened for the presence of an antibiotic allergy documented in their electronic medical record. Unless unable to participate, patients were interviewed regarding the detailed nature of their antibiotic allergy. Information regarding allergy documentation, medical condition and antibiotic use was obtained from medical records. Results 3855 patients were screened, 553 (14.35%) had an AAL, and 352 were interviewed. There were 426 allergies, 276 (64.8%) towards a penicillin. Only 52% of patients had a convincing history consistent with antibiotic allergy, and 48% of these were mild cutaneous reactions. It was felt that de-labeling and direct re-challenge would be relatively safe in 70% (298/42) of AALs (if the mild cutaneous allergic group were included). In patients who were prescribed antibiotics during study admission, 25.6% (41/160) of antibiotic prescriptions in our cohort were found to be inappropriate in patients with AALs. Conclusion Direct re-challenge based upon clinical grounds appears to be a feasible clinical option in many patients with AALs and would allow de-labeling of these patients. The major barriers continue to be patient acceptance and risk of severe adverse reactions. Our study also found that major improvements could be made in the specific documentation of allergy and also in selection of guideline-recommended alternate antibiotics. 1. Joint Task Force on Practice Parameters. Drug Allergy: An Updated Practice Parameter. Ann Allergy Asthma Immunol. 2010; 105(4): p. 259–273. Disclosures All authors: No reported disclosures.

Background Allogeneic hematopoietic stem cell transplantation (alloHSCT) recipients are at high risk of invasive pneumococcal disease (IPD). We investigated the incidence and risk factors of IPD in alloHSCT recipients from 4 regional transplant centers over an 11-year period. This study aimed to inform future improvements in post-transplant care. Methods We conducted a retrospective nested 1:2 case–control study in patients aged ≥18 years who underwent alloHSCT between 2001 and 2011 in 4 major allogeneic transplant centers. Controls were matched with IPD cases on the basis of conditioning intensity and donor relationship (related or unrelated). Demographics and clinical characteristics of cases and controls were summarized. Univariate analysis of risk factors in matched case–control sets, and multivariate conditional logistic regression to control for confounding, were performed. Results In 23 alloHSCT recipients, 26 IPD episodes were identified. The cumulative incidence over 11 years was 2.3% (95% confidence interval [CI] 1.45–3.15) and the incidence density 956 per 100,000 transplant years of follow-up (95% CI 580–1321). Multivariate risk factor analysis and backwards elimination showed a significant positive association between mycophenolate mofetil (MMF), hyposplenism/asplenia, and IPD, whereas trimethoprim-sulfamethoxazole (TMP/SMX) prophylaxis for Pneumocystis jirovecii pneumonia (PJP) was associated with lower odds of IPD cases. Of alloHSCT recipients with IPD, 38.5% required intensive care, and, of deaths documented in cases over the period of review, 30% were attributable to IPD. Serotypes causing IPD matched currently available vaccines in 15/22 (68.1%) episodes. Conclusions The incidence of IPD in alloHSCT recipients is an important cause of morbidity and mortality, with rates of disease being many fold higher than the general population. Patients with evidence of hyposplenism/asplenia define a high-risk group in the alloHSCT population for IPD, and the independent association with IPD and MMF in the adjusted model from this study requires further evaluation. The occurrence of post-transplant IPD may be reduced by measures such as vaccination with both 13-valent and 23-valent pneumococcal vaccines. TMP/SMX prophylaxis for the prevention of PJP may offer incidental protection against IPD in alloHSCT recipients.

Objective To evaluate the immune status and vaccination needs of first-year medical students in relation to bloodborne viruses and common vaccine-preventable diseases. Design, setting and participants Survey of first-year medical students at the University of New South Wales, Sydney, NSW, attending a mandatory screening and vaccination clinic, 2002-2005. Main outcome measures Self-reported history of vaccination or natural infection; serological evidence of immunity to measles, mumps, rubella and varicella (presence of specific IgG) and hepatitis B (presence of hepatitis B virus surface antibodies) or infection with hepatitis B and C viruses and HIV; and Mantoux test results. Results 733 students attended the clinic (85% of those enrolled). Four students were positive for HBsAg and four had hepatitis C antibodies. None were HIV-positive. Twenty-nine per cent (216/733) were not immune to hepatitis B, 33% (238/724) to mumps, 26% (190/724) to measles, 13% (91/724) to rubella and 10% (75/724) to varicella. About 23% (91/237) needed further testing for tuberculosis. Immunity corresponded poorly with self-reported history of vaccination. More students reported vaccination against rubella (96%), measles (81%) and mumps (80%) than were immune, and fewer reported vaccination against hepatitis B (44%). Conclusions Many students were not immune to vaccine-preventable diseases, and a small number had a previously undiagnosed bloodborne virus infection (hepatitis B or C). The level of immunity to vaccine-preventable infections was unacceptable and justified the provision of an easily accessible program for screening and vaccination.

Background: Vaccination following bone marrow transplant (BMT) is an important part of ongoing care and disease prevention. The aim of the study was to investigate vaccination procedures in BMT recipients and identify what systems are in place throughout Australia to remind and alert patients concerning their need for vaccination. Methods: Questionnaires were sent to haematologists managing BMT recipients in Australia to examine post-BMT vaccination practices in hospitals and outpatient clinics. Questionnaires were also sent to BMT recipients in New South Wales, who had their transplants (either allogeneic or autologous) in the past 5 years to determine what vaccinations they had received and what vaccination reminder systems had been used. Results: Vaccine recommendations and practices by BMT physicians showed little consensus. They also differed greatly between autologous and allogeneic transplant recipients. Only just more than half of the physicians had an effective reminder system in place and only 12 of 34 patients had received vaccination reminders. One-third of all patients were not aware of any need for revaccination. Conclusion: The disparity in physician practice regarding revaccination is significant and may reflect the lack of data available regarding efficacy of revaccination in this setting and/or a lack of knowledge about recommendations. Because of this, a national immunization schedule for post-BMT patients founded on evidence-based studies is required to provide optimal patient care. The lack of effective follow up and reminder systems ensuring patient completion of vaccination schedules is also an area needing improvement.

In the event of an influenza pandemic, many ethical issues will arise in terms of health risks, resource allocation, and management decisions. Planning decisions may be controversial, such as rationing of antivirals, resource allocation (including hospital beds and vaccinations), occupational risk, rostering of staff, responsibilities of health care workers, quarantine measures, and governance issues. A clear ethical framework is needed to enable understanding of the decision-making process and optimise acceptance of decisions by health care workers and other members of an affected community. Planning decisions need to start being examined now, and will require input from a broad group of experts: health care providers, infrastructure managers, lawyers, ethicists, public health physicians, and community members. The process will need to be open, honest and dynamic.

It is a long-standing tradition in medicine that doctors have an ethical duty to care for all patients who fall within the scope of their skill base. This duty reflects the value system of many doctors and the type of typical dedication to their craft that has long been expected and given. The modern doctor, however, may have other additional roles -- such as those of parent, researcher, business person and many others. What about the duties that accompany these other activities and what if these duties come into conflict with the duty to care for patients? How does a doctor decide how far the duty to care for patients extends? This article explores this question of duty and discusses how the notion of the traditional doctor's duty to care may need to be amended in light of the kinds of lives that doctors now lead.

Human infection by Cryptococcus neoformans var. neoformans is well characterised and usually occurs in immunocompromised patients. Less is known about infection by Cryptococcus neoformans var. gattii, which usually produces disease in previously normal individuals. In two cases of human pulmonary infection by Cryptococcus neoformans var. gattii, we observed a mixed inflammatory pattern, including granulomas associated with numerous T lymphocytes and a lymphocytic interstitial pneumonitis with B lymphocytes and formation of follicles. We also established a murine model of pulmonary infection by Cryptococcus neoformans var. gattii, which reproduced most of these features. This model is likely to prove useful in studies of the pathogenesis of this infection.

A case of necrotizing cutaneous infection in an immunocompetent host caused by the dematiaceous fungus, Curvularia brachyspora is presented. A 58-year-old man was transferred to the Prince Henry Hospital for treatment of necrotizing cellulitis involving both thighs that developed following cryotherapy. The patient did not respond to antibacterial therapy and hyperbaric oxygen. He was empirically commenced on intravenous amphotericin B and began to respond even before the pathogen C. brachyspora was identified.

The diagnosis of vertebral osteomyelitis is easily missed, particularly for the elderly in whom signs of sepsis may not manifest. The case records of 20 patients with vertebral osteomyelitis who were treated at our hospital between January 1989 and April 1993 were reviewed. The average age of the patients was 72 years. Infection was most commonly due to intravenous cannula-related sepsis. Eighty-five percent of patients presented with back pain, and only 30% had a fever. Computerized tomography and magnetic resonance imaging were the most useful radiological investigations; nuclear scanning was sensitive but insufficiently specific. Staphylococcus aureus was the infecting organism in 13 of 16 patients whose microbiological diagnosis was made by blood or bone cultures. Six (45%) of these 13 patients were infected with methicillin-resistant S. aureus (MRSA). Nosocomial infection occurred in 12 (60%) of the patients studied, including all patients with MRSA infections. Vertebral osteomyelitis may be largely preventable if infection-control aspects of intravenous cannulation are improved, attempts at reducing and preventing MRSA colonization are made, and therapy for bacteremias is optimized.

The causes of diarrhoea in people returning from travelling can be infective and non-infective, and the duration of symptoms is an important factor in identifying the cause. The article outlines the appropriate investigations

Toxoplasmosis is a zoonotic infection caused by the parasite Toxoplasma gondii. It would appear to be one of the commonest human infections, but is usually asymptomatic. It is only problematic if the patient is pregnant or immunosuppressed.To discuss the epidemiology, clinical features, diagnosis, treatment and prevention of toxoplasmosis.Cats have long been blamed for playing a major role as the reservoir of this infection. To some extent, this is true, although contact with infected raw meat is probably a more important cause of human infection in many countries. Direct contact with pet cats is also a less common risk factor for infection than ingestion of the oocyst from faecally contaminated hands (often via soil).