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Background Sodium-glucose co-transporter 2 (SGLT2) inhibitors are novel hypoglycemic agents which reduce reabsorption of glucose at the renal proximal tubule, resulting in significant glycosuria and increased risk of genital mycotic infections (GMI). These infections are typically not severe as reported in large systematic reviews and meta-analyses of the medications. These reviews have also demonstrated significant cardiovascular benefits through other mechanisms of action, making them attractive options for the management of Type 2 diabetes mellitus (T2DM). We present two cases with underlying abnormalities of the urogenital tract in which the GMI were complicated and necessitated cessation of the SGLT2 inhibitor. Case presentations Both cases are patients with T2DM on empagliflozin, an SGLT2 inhibitor. The first case is a 64 year old man with Candida albicans balanitis and candidemia who was found to have an obstructing renal calculus and prostatic abscess requiring operative management. The second case describes a 72 year old man with Candida glabrata candidemia who was found to have prostatomegaly, balanitis xerotica obliterans with significant urethral stricture and bladder diverticulae. His treatment was more complex due to fluconazole resistance and concerns about urinary tract penetration of other antifungals. Both patients recovered following prolonged courses of antifungal therapy and in both cases the SGLT2 inhibitor was ceased. Conclusions Despite their cardiovascular benefits, SGLT2 inhibitors can be associated with complicated fungal infections including candidemia and patients with anatomical abnormalities of the urogenital tract may be more susceptible to these infections as demonstrated in these cases. Clinicians should be aware of their mechanism of action and associated risk of infection and prior to prescription, assessment of urogenital anatomical abnormalities should be performed to identify patients who may be at risk of complicated infection.

Influenza is a common cause of acute respiratory infection, and is a major cause of morbidity and mortality. This report summarises the epidemiology of hospitalisations with laboratory-confirmed influenza during the 2019 influenza season. The Influenza Complications Alert Network (FluCAN) is a sentinel hospital-based surveillance program that operates at sites in all jurisdictions in Australia. Cases were defined as patients hospitalised at any of the 17 sentinel hospitals with influenza confirmed by nucleic acid detection. Data were also collected on a frequency matched control group of influenza-negative patients admitted with acute respiratory infection. During the period 1 April to 31 October 2019 (the 2019 influenza season), there were 4,154 patients admitted with confirmed influenza to one of 17 FluCAN sentinel hospitals. Of these, 44% were elderly (≥ 65 years), 21% were children (< 16 years), 7.7% were Aboriginal and Torres Strait Islander peoples, 1.7% were pregnant and 73% had chronic comorbidities. Most admissions were due to influenza A infection (85%). Estimated vaccine coverage was 75% in the elderly, 49% in non-elderly adults with medical comorbidities, and 27% in young children (< 5 years). The estimated vaccine effectiveness in the target adult population was 42% (95% confidence interval [95% CI]: 36%, 49%). There were a larger number of hospital admissions detected with confirmed influenza in this national observational surveillance system in 2019 than in 2018.

Introduction Influenza is a common cause of acute respiratory infection, and is a major cause of morbidity and mortality. Coronavirus disease 2019 (COVID-19) is an acute respiratory infection that emerged as a pandemic worldwide before the start of the 2020 Australian influenza season. This report summarises the epidemiology of hospitalisations with laboratory-confirmed influenza and COVID-19 during the 2020 influenza season in a sentinel surveillance system. Methods The Influenza Complications Alert Network (FluCAN) is a sentinel hospital-based surveillance program that operates at sites in all jurisdictions in Australia. Influenza and COVID-19 cases were defined as patients hospitalised at sentinel hospitals and confirmed by nucleic acid detection. Results There were 448 patients with COVID-19 admitted between 16 March and 31 December 2020, and only 20 patients with influenza admitted between 1 April and 30 November 2020, to one of 22 FluCAN hospitals. Of the COVID-19 cases, 173 (39%) were > 65 years of age, 36 (8%) were children (< 16 years), 6 (1%) were Aboriginal and Torres Strait Islander peoples, 4 (1%) were pregnant and 289 (65%) had chronic comorbidities. COVID-19 hospital admissions peaked between weeks 13 and 15 (first wave) nationally, and again between weeks 31 and 35 (Victoria), with most admissions represented by those above 40 years of age. Discussion There was an unusually low number of hospital admissions with laboratory-confirmed influenza in this season, compared to recent seasons. This is likely to be due to effective public health interventions and international border closures as a result of a rise in COVID-19 respiratory infections and associated hospitalisations.

Objectives There have been efforts to promote timely antimicrobial administration for patients with sepsis, but the importance for other infections is uncertain. This study analysed whether time to first antimicrobial dose (TFAD) in patients with lower limb cellulitis influenced outcome measures such as acute length of stay (LOS) in hospital and 30-day hospital readmission rates for cellulitis. Methods Medical records of patients admitted with lower limb cellulitis or erysipelas over a 15-month period (1 May 2019 to 30 November 2019 and 1 March 2020 to 31 October 2020) were reviewed. Patients requiring intensive care unit (ICU) admission were excluded. The TFAD was the difference (in minutes) between the emergency department triage time and the time that the antimicrobial was first recorded as administered. Analysis included log-transformed linear regression (for LOS) and logistic regression (for 30-day readmission with cellulitis), controlling for confounders where possible. Results The study included 282 patients with lower limb cellulitis. The median TFAD was 177 min (interquartile range, 98–290 min). Linear regression suggested a weak association between TFAD and LOS (P = 0.05; adjusted R2 = 0.01), which was non-significant after adjusting for confounders (P = 0.18). There were too few patients readmitted within 30 days with cellulitis for meaningful analysis. Conclusion After controlling for confounders, no association between increased TFAD and increased acute LOS was identified for patients with lower limb cellulitis who did not require ICU admission (i.e. without septic shock). Conclusions could not be made for 30-day readmission rates for cellulitis.

Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing ‘big data’ on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.

Background and objectives The approach to performing COVID-19 testing in general practice has been going through an evolution and is variable. The aim of this study was to determine what underlying factors, if any, impeded onsite COVID-19 testing in general practices for patients during the second wave of the pandemic in Victoria. Method This study was conducted during August 2020 and October 2020. Fourteen semi-structured interviews with general practitioners, practice nurses and practice managers were conducted. Results Barriers to performing onsite testing for COVID-19 were identified as: 1) individual, 2) practitioner perception of fear, 3) lack of personal protective equipment, 4) inappropriate clinic design/location, 5) risk of patient avoidance, 6) financial risk, 7) a lack of knowledge and 8) lack of guidelines. Discussion This study's findings relate to a unique period in Victoria, which at the time accounted for 70% of the nation's total cases and 90% of deaths. Therefore, the barriers identified in this study may help inform policymakers in regard to planning for future responses to similar situations.

Objectives To develop and validate a clinical model to identify patients admitted to hospital with community-acquired infection (CAI) caused by pathogens resistant to antimicrobials recommended in current CAI treatment guidelines. Methods International prospective cohort study of consecutive patients admitted with bacterial infection. Logistic regression was used to associate risk factors with infection by a resistant organism. The final model was validated in an independent cohort. Results There were 527 patients in the derivation and 89 in the validation cohort. Independent risk factors identified were: atherosclerosis with functional impairment (Karnofsky index Conclusions For patients hospitalized with CAI and none of the following risk factors: atherosclerosis with functional impairment; previous invasive procedures; antimicrobial therapy; or MDRO colonization, CAI guidelines can safely be applied. Whereas, for those with some of these risk factors, particularly if more than one, alternative antimicrobial regimens should be considered.

The current Australian Medical Association doctors in training enterprise agreement dictates that hours beyond 38 or 43 ordinary hours per week incur overtime. Costly overtime has led to strict adherence to ordinary hours with dramatically reduced rostered and unrostered overtime. The stringent regulation over ordinary hours may protect doctors at a cost to training and potentially patient safety. Reduced shift duration adds to the number of clinical handovers, while reduced exposure to patients and training opportunities may prolong training time. Now is the time for renegotiation of working hours, which are most favourable for doctor training and well-being.

Background Antibiotics are highly effective in curing Mycobacterium ulcerans lesions, but are associated with significant toxicity. In those not undergoing surgery, we compared 6 weeks with the currently recommended 8 weeks of combination antibiotic therapy for small M. ulcerans lesions. Methods Mycobacterium ulcerans cases from an observational cohort at Barwon Health, Victoria, treated with antibiotics alone from 1 October 2010 to 31 March 2018 were included. The 6-week antibiotic group received ≥28 days and ≤42 days and the 8-week antibiotic group received ≥56 days of antibiotic therapy, respectively. Only World Health Organization category 1 lesions were included. Results 207 patients were included; 53 (25.6%) in the 6-week group and 154 (74.4%) in the 8-week group. The median age of patients was 53 years (interquartile range [IQR], 33–69 years) and 100 (48.3%) were female. Lesions were ≤900 mm2 in size in 79.7% of patients and 93.2% were ulcerative. Fifty-three patients (100%) achieved treatment cure in the 6-week group compared with 153 (99.4%) in the 8-week group (P = .56). No patients died or were lost to follow-up during the study. Median time to heal was 70 days (IQR, 60–96 days) in the 6-week group and 128 days (IQR, 95–173 days) in the 8-week group (P < .001). Two (3.8%) patients in the 6-week group experienced a paradoxical reaction compared with 39 (25.3%) patients in the 8-week group (P = .001). Conclusions For selected small M. ulcerans lesions, 6 weeks may be as effective as 8 weeks of combined antibiotic therapy in curing lesions without surgery.

Highlights • Nurse-initiated polymerase chain reaction testing is feasible in nursing homes. • Viruses are common among nursing home residents. • Nurse-initiated respiratory specimen testing is useful for infection prevention. • Further resources are required to impact antibiotic prescribing., Background Diagnostic testing using polymerase chain reaction (PCR) is infrequently initiated for diagnosis of respiratory tract infections (RTIs) in nursing homes. The objectives of this study were to determine the feasibility of implementing nurse-initiated PCR testing of respiratory specimens in nursing home settings and to compare antibiotic prescribing prior to and during the implementation. Methods This was a pragmatic, historically controlled study in 3 nursing homes (181 total beds) in Melbourne, Australia. Results The number of PCR tests of respiratory specimens (over 12 months) increased from 5 to 67 when nurses could initiate the tests. Residents with RTI symptoms had a virus identified by PCR in 50.7% of tests, including 14 positive for influenza. Six outbreaks were identified. When clustering was taken into consideration, incidence rates of antibiotic days of therapy did not change (incidence rate ratio = 0.94, 95% confidence interval, 0.25-3.35, P = .92) despite identification of more viral pathogens. Conclusions In nursing homes, nurse-initiated PCR testing of respiratory specimens is feasible and useful in terms of identifying the cause of many RTIs and outbreaks, and viruses are common in this context. However, the current study suggests the availability of these test results alone does not impact antibiotic prescribing.

Researchers have hypothesized that mosquitoes are vectors involved in Mycobacterium ulcerans transmission. Previous findings of a correlation between incidence of M. ulcerans, which causes Buruli ulcer, and locally acquired vectorborne diseases in southeastern Australia further strengthened this argument. However, our updated data indicate that this correlation has not continued beyond 2008.

Objective This study evaluated whether a consumer codesigned leaflet about the common skin infection cellulitis would improve patient satisfaction. Methods A patient information leaflet was codesigned with consumers incorporating health literacy principles and attached to a new adult lower limb cellulitis management plan launched in three regional Victorian health services. Health service staff were educated to provide the leaflet during hospital care. Patients discharged with a diagnosis of cellulitis in an 8-month period were followed-up via telephone between 31 and 60 days after their discharge. Each patient was asked to provide feedback on the utility of the leaflet (if received) and their overall satisfaction with the information provided to them using a five-point scale (with scores of 4 or 5 considered to indicate satisfaction). Results In all, 81 of 127 (64%) patients (or carers) were contactable, consented to the study and answered the questions. Of these, 27% (n = 22) reported receiving, accepting and reading the leaflet. The proportion of patients who were satisfied with the information provided to them about cellulitis was 100% for those who received the leaflet, compared with 78% for those who did not receive the leaflet (95% confidence interval 4.8–34%; P = 0.02). Conclusion The provision of a consumer codesigned leaflet increased patient satisfaction with the information received about cellulitis. Real-world strategies to embed the delivery of such resources are required to ensure that more patients receive the benefit. What is known about the topic? There are known deficiencies in the information provided to patients about the common skin condition cellulitis. There is little published evaluation of strategies to address these knowledge deficiencies. What does this paper add? This study evaluated a simple strategy to address patient knowledge deficiencies on cellulitis. It highlights that pertinent information delivered in an accessible way can significantly increase patient satisfaction with the information provided to them. What are the implications for practitioners? These findings are a timely reminder for practitioners that even a simple intervention, such a providing a hard copy information leaflet, can improve patient satisfaction. A national repository of similar consumer codesigned materials would be valuable and could minimise existing duplication of effort in resource development across health sectors. Real-world strategies to embed the delivery of such resources is required to ensure that more patients receive the benefit.

BackgroundAntimicrobial stewardship programmes are important in driving safety and quality of antimicrobial prescribing. The National Antimicrobial Prescribing Survey (NAPS) is a point-prevalence audit of inpatient antimicrobial prescribing in Australian hospitals.ObjectivesTo design and adapt the NAPS tool for use in the outpatient parenteral antimicrobial therapy (OPAT) and hospital-in-the-home (HITH) setting.MethodsAn inter-disciplinary working group with expertise in OPAT and HITH services was established to adapt the NAPS template for use in the OPAT setting—called HITH-NAPS. This was initially trialled in 5 HITH services, subsequently adapted following participant feedback, then offered nationally to 50 services in 2017.ResultsThere were 1154 prescriptions for 715 patients audited via the HITH-NAPS. The most common antimicrobials prescribed were cefazolin (22%), flucloxacillin (12%), piperacillin/tazobactam (10%) and ceftriaxone (10%). The most common infections treated were cellulitis (30%) and respiratory tract infections (14%). Eighty-seven percent of prescriptions were assessed as appropriate, 11% inappropriate and 2% not assessable. Prolonged durations of antimicrobials and unnecessarily broad-spectrum antibiotics were used in 9% of prescriptions.ConclusionsThe HITH-NAPS pilot project revealed that auditing of this type is feasible in HITH. It showed that antibiotic use in these HITH services was generally appropriate, but there are some areas for improvement. A national OPAT/HITH-NAPS can facilitate benchmarking between services, identify potentially inappropriate prescribing and help guide quality improvement.

Combination antibiotic therapy is highly effective in curing Buruli ulcer (BU) caused by Mycobacterium ulcerans. Treatment failures have been uncommonly reported with the recommended 56 days of antibiotics, and little is known about risk factors for treatment failure. We analyzed treatment failures among BU patients treated with ≥56 days of antibiotics from a prospective observational cohort at Barwon Health, Victoria, from 1 January 1998 to 31 December 2018. Treatment failure was defined as culture-positive recurrence within 12 months of commencing antibiotics under the following conditions: (i) following failure to heal the initial lesion or (ii) a new lesion developing at the original or at a new site. A total of 430 patients received ≥56 days of antibiotic therapy, with a median duration of 56 days (interquartile range [IQR], 56 to 80). Seven (1.6%) patients experienced treatment failure. For six adult patients experiencing treatment failure, all were male, weighed >90 kg, did not have surgery, and received combination rifampin-clarithromycin (median rifampin dose, 5.6 mg per kg of body weight per day; median clarithromycin dose, 8.1 mg/kg/day). When compared to those who did not fail treatment on univariate analysis, treatment failure was significantly associated with a weight of >90 kg (P 90 kg, those with immune suppression, and those taking rifampin-clarithromycin antibiotic regimens, but future pharmacokinetic and pharmacodynamics studies are required to determine the validity of these hypotheses.

What makes a good doctor probably depends on whom you ask. Patients value interpersonal relations, and being involved in decisions about their care. In contrast, hospital executives place an emphasis on the ability to meet key performance indicators critical to the flow of patients through hospitals.

Recording patient weight is a standard practice for all hospital admissions, with this measurement influencing other daily practices that rely on the delivery of safe and effective patient care. Patient weight is important in the areas of medication prescribing, fluid balance and assessment of nutrition. In particular, prescribing narrow therapeutic index medications may result in significant harm as a potential consequence of inaccurate dosing. Despite its importance, it is evident that bodyweight measurements are recorded in only 13.5-55% of hospital patients, in a variety of settings including the emergency department, intensive care unit, medical and surgical wards. Barriers to compliance of healthcare staff include additional workload, patient handling and availability of appropriate weighing equipment. Hospitals and patients would benefit from enhancing compliance with the systematic weighing of patients, staff training and removing barriers to performing this task.

Reported cases of Mycobacterium ulcerans disease (Buruli ulcer) have been increasing in southeastern Australia and spreading into new geographic areas. We analyzed 426 cases of M. ulcerans disease during January 1998–May 2017 in the established disease-endemic region of the Bellarine Peninsula and the emerging endemic region of the Mornington Peninsula. A total of 20.4% of cases patients had severe disease. Over time, there has been an increase in the number of cases managed per year and the proportion associated with severe disease. Risk factors associated with severe disease included age, time period (range of years of diagnosis), and location of lesions over a joint. We highlight the changing epidemiology and pathogenicity of M. ulcerans disease in Australia. Further research, including genomic studies of emergent strains with increased pathogenicity, is urgently needed to improve the understanding of this disease to facilitate implementation of effective public health measures to halt its spread.

Despite the availability of evidence-based guidelines, antibiotics for cellulitis remain inappropriately prescribed. This evidence–practice gap is more evident in low-resource settings, such as rural hospitals. This implementation study developed and introduced a cellulitis management plan to improve antibiotic prescribing for cellulitis in three health services in regional Australia. Appropriateness of antibiotic prescribing for cellulitis at Day 1 was the primary outcome measure. Adults with ICD-10-AM codes for lower-limb cellulitis admitted as inpatients of the three health services between May and November 2019 (baseline, n = 165) and March and October 2020 (post-implementation, n = 127) were included in the assessment. The uptake of the cellulitis management plan was 29.1% (37/127). The appropriateness of antibiotic prescribing for cellulitis at Day 1 was similar at baseline (78.7%, 144/183) and in the intention-to-treat post-implementation group (81.8%, 126/154) [95% CI −5.6% to 11.3%, p = 0.50]. Commencement of the cellulitis management plan resulted in a non-statistically significant increase in antibiotic appropriateness at Day 1 compared to when a cellulitis management plan was not commenced (88.1% vs. 79.5%, 95% CI −5.6% to 19.8%, p = 0.20) Evaluation of more real-world strategies to address evidence–practice gaps, such as the appropriateness of antibiotic prescribing for cellulitis, is required.

Background Antibiotics are the recommended first-line treatment for Mycobacterium ulcerans disease. Antibiotic toxicity is common in Australian patients, yet antibiotic complication rates and their risk factors have not been determined. Aim To determine the incidence rate and risk factors for antibiotic toxicity in Australian patients treated for M. ulcerans disease. Methods An analysis of severe antibiotic complications was performed using data from a prospective cohort of M. ulcerans cases managed at Barwon Health from 1 January 1998 to 30 June 2016. A severe antibiotic complication was defined as an antibiotic adverse event that required its cessation. Antibiotic complication rates and their associations were assessed using a Poisson regression model. Results A total of 337 patients was included; 184 (54.6%) males and median age 57 years (interquartile range (IQR) 36–73 years). Median antibiotic treatment duration was 56 days (IQR 49–76 days). Seventy-five (22.2%) patients experienced severe antibiotic complications after a median 28 days (IQR 17–45 days) at a rate of 141.53 per 100 person-years (95% confidence interval (CI) 112.86–177.47). Eleven (14.7%) patients required hospitalisation. Compared with rifampicin/clarithromycin combinations, severe complication rates were not increased for rifampicin/ciprofloxacin (rate ratio (RR) 1.49, 95% CI 0.89–2.50, P = 0.13) or rifampicin/moxifloxacin (RR 2.54, 95% CI 0.76–8.50, P = 0.13) combinations, but were significantly increased for ‘other’ combinations (RR 2.53, 95% CI 1.13–5.68, P = 0.03). In a multivariable analysis, severe complication rates were significantly increased with reduced estimated glomerular filtration rates (EGFR) (adjusted rate ratio (aRR) 2.65, 95% CI 1.24–5.65 for EGFR 60–89 mL/min and aRR 1.31, 95% CI 0.49–3.53 for EGFR 0–59 mL/min compared with EGFR ≥90 mL/min, P

We conducted epidemiologic and genetic analyses of family clusters of Mycobacterium ulcerans (Buruli ulcer) disease in southeastern Australia. We found that the incidence of M. ulcerans disease in family members was increased. However, the risk for exposure appeared short-term and not related to human-human transmission.

Treatment for cutaneous infection from Mycobacterium abscessus is fraught with poorly established evidence. Given its antibiotic multi-resistance, surgical intervention is often recommended. We report a case of cutaneous M. abscessus infection that was successfully managed with medical therapy alone. A 55-year-old immunocompetent woman from the Bellarine peninsula in Victoria, Australia presented to our hospital with a 2-week history of a non-healing ulcer on her left forearm. The patient had no history of trauma or procedures to the skin. On presentation, the patient had a punch biopsy, which was culture positive for M. abscessus. The isolate was susceptible to clarithromycin and amikacin, had intermediate susceptibility to ciprofloxacin, cefoxitin and linezolid and was resistant to doxycycline, imipenem, cotrimoxazole and moxifloxacin. The tigecycline MIC was 0.25 μg/ml. The patient received a total of 12 weeks of oral clarithromycin 500 mg twice daily, 4 weeks of intravenous amikacin 500 mg daily, 6 weeks of intravenous tigecycline 100 mg over 24 hours via Baxter pump, and 4 weeks of oral clofazimine 100 mg daily. The patient made a good clinical recovery and had her medical therapy ceased after 12 weeks. M. abscessus cutaneous infection in an immunocompetent individual without antecedent trauma or surgery is rare. Our case illustrates the successful treatment of a deep M. abscessus cutaneous ulcer with relatively short duration macrolide-based antibiotic therapy without any surgical intervention.

Treatment for cutaneous infection from Mycobacterium abscessus is fraught with poorly established evidence. Given its antibiotic multi-resistance, surgical intervention is often recommended. We report a case of cutaneous M. abscessus infection that was successfully managed with medical therapy alone. A 55-year-old immunocompetent woman from the Bellarine peninsula in Victoria, Australia presented to our hospital with a 2-week history of a non-healing ulcer on her left forearm. The patient had no history of trauma or procedures to the skin. On presentation, the patient had a punch biopsy, which was culture positive for M. abscessus. The isolate was susceptible to clarithromycin and amikacin, had intermediate susceptibility to ciprofloxacin, cefoxitin and linezolid and was resistant to doxycycline, imipenem, cotrimoxazole and moxifloxacin. The tigecycline MIC was 0.25 μg/ml. The patient received a total of 12 weeks of oral clarithromycin 500 mg twice daily, 4 weeks of intravenous amikacin 500 mg daily, 6 weeks of intravenous tigecycline 100 mg over 24 hours via Baxter pump, and 4 weeks of oral clofazimine 100 mg daily. The patient made a good clinical recovery and had her medical therapy ceased after 12 weeks. M. abscessus cutaneous infection in an immunocompetent individual without antecedent trauma or surgery is rare. Our case illustrates the successful treatment of a deep M. abscessus cutaneous ulcer with relatively short duration macrolide-based antibiotic therapy without any surgical intervention. Keywords: Nontuberculous Mycobacteria, Clarithromycin, Amikacin, Tigecycline, Clofazimine

The Influenza Complications Alert Network (FluCAN) is a sentinel hospital-based surveillance program that operates at sites in all jurisdictions in Australia. This report summarises the epidemiology of hospitalisations with laboratory-confirmed influenza during the 2018 influenza season. In this observational surveillance system, cases were defined as patients admitted to any of the 17 sentinel hospitals with influenza confirmed by nucleic acid detection. Data were also collected on a frequency-matched control group of influenza-negative patients admitted with acute respiratory infection. During the period 3 April to 31 October 2018 (the 2018 influenza season), 769 patients were admitted with confirmed influenza to one of 17 FluCAN sentinel hospitals. Of these, 30% were elderly (≥65 years), 28% were children (

Background The objective of this study was to understand how aged care home health professionals perceive antimicrobial use near the end of life and how they perceive potential antimicrobial stewardship activities near the end of life in aged care homes. Methods Qualitative semi-structured interviews were undertaken with general practitioners, nurses, and pharmacists who provide routine care in aged care homes in Victoria, Australia. Interviews were coded using frameworks for understanding behavior change. Results Themes were established within 14 interviews, and an additional 6 interviews were undertaken to ensure thematic saturation. Two major themes emerged: (i) Antimicrobial stewardship activities near the end of life in aged care homes need to enable aged care home nurses to make decisions substantiated by evidence-based clinical knowledge. Antimicrobial stewardship should clearly be part of an aged care home nurse's role, and accreditation standards provide powerful motivation for behavior change. (ii) Antimicrobial stewardship activities near the end of life in aged care homes must address family confidence in resident wellbeing. Antimicrobial stewardship activities should be inclusive of family involvement, and messages should highlight the point that antimicrobial stewardship improves care. Conclusions Antimicrobial stewardship activities that reinforce evidence-based clinical decision-making by aged care home nurses and address family confidence in resident wellbeing are required near the end of life in aged care homes. Accreditation standards are important motivators for behavior change in aged care homes.

Background The excessive use of antimicrobials in aged-care homes is a widely recognised phenomenon. This is problematic because it can harm residents, and is detrimental to public health. Residents in the final month of life are increasingly likely to be prescribed an antimicrobial, commonly without having signs and symptoms of infection that support antimicrobial use. Objectives We aimed to describe the perspectives of health professionals on antimicrobial use near the end of life in aged-care homes and investigate the potential opportunities for nurses to undertake antimicrobial stewardship activities near the end of life in aged-care homes. Design One-on-one, semi-structured, qualitative interviews. Settings and participants Twelve nurses, six general practitioners and two pharmacists providing routine care to residents of aged-care homes in Victoria, Australia were interviewed. Diversity in terms of years of experience, aged-care funding type (government, private-for-profits and not-for-profits) and location (metropolitan and regional) were sought. Methods Interviews were transcribed and open coded in a descriptive manner using validated frameworks for understanding behaviour change. The descriptive code was then used to build an interpretive code structure based on questions founded in grounded theory. Results Thematic saturation was reached after fourteen interviews, and an additional six interviews were conducted to ensure emergent themes were consistent and definitive. There are opportunities for aged-care home nurses to undertake antimicrobial stewardship activities near the end of life in the provision of routine care. Aged-care home nurses are influential in antimicrobial decisions near the end of life in routine care because of their leadership in advance care planning, care co-ordination and care provision in an environment with stopgap and visiting medical resources. Nurses also have social influence among residents, families and medical professionals during critical conversations near the end of life. Past negative social interactions within the aged-care home environment between nurses and families can result in ‘fear-based’ social influences on antimicrobial prescribing. Conclusions The work of facilitating advance care planning, care coordination, care delivery, and communicating with families and medical professionals provide important opportunities for aged-care home nurses to lead appropriate antimicrobial stewardship activities near the end of life.

Background Since 2015 the Aged Care National Antimicrobial Prescribing Survey has collected and reported data on antibiotic use in Australian aged care homes (ACHs) as part of the Australian Commission on Safety and Quality in Health Care's Antimicrobial Use and Resistance in Australia project. The objective of this study was to analyze this data source with regards to prescribing for urinary tract infections (UTIs) to improve the use of antibiotics. Methods This cross-sectional study analyzed the 2016 and 2017 survey data. Antibiotic prescribing for urinary tract indications was compared with national guideline recommendations. Results A total of 662 antibiotic prescriptions from 247 ACHs were analyzed. For all prophylactic antibiotics for UTI, 51.8% were prescribed for longer than 6 months, contrary to the guideline recommendation. Most antibiotics prescribed for treatment (71.6%) were for cystitis. Cefalexin was most frequently selected for treatment of cystitis, with 10.4% of these prescriptions being concordant with the recommendations. Prescribing additional daily doses of cefalexin occurred in 63.2% of prescriptions. Conclusions Antimicrobial stewardship activities targeting UTI prophylaxis for durations longer than 6 months, and excessive daily doses of cefalexin to treat cystitis could yield significant reductions in unnecessary antibiotic consumption among Australian residents of ACHs.

Background The diagnosis of cellulitis is made clinically without a gold standard diagnostic test, and cellulitis has many disease mimics. There is currently no consensus for optimal antimicrobial treatment duration or method of antimicrobial delivery. Methods This was a randomized controlled open-label multicenter trial to determine the safety and efficacy of 24 hours of intravenous (IV) therapy compared with ≥72 hours of IV therapy, both followed by oral therapy to a maximum of 7–10 days’ duration for the treatment of lower limb cellulitis. Results Over 40 months, 80 patients were recruited. Thirty-nine patients were assigned to 24 hours of IV antibiotics and 41 to ≥72 hours of IV antibiotics. The mean duration (range) of IV antibiotics in the 24-hour group was 25.5 (17–40) hours, and in the ≥72-hour group it was 78 (41.5–210) hours. Three patients in the 24-hour arm and 4 patients in the ≥72-hour arm were excluded from the analysis due to withdrawal from the trial. Analysis of the remaining patients revealed that 6 patients (4 in the intervention arm and 2 in the control arm) did not achieve an adequate response to therapy. Only 1 patient experienced self-limiting adverse effects of treatment. Conclusions The noninferiority of short-course IV therapy cannot be determined from this trial. Challenges included resource limitations for recruitment, misdiagnosis, participant withdrawal, and subjective responses to therapy based on visual assessment by treating clinicians. Further studies are needed to determine if short-course IV therapy is a suitable treatment option. Australia Council of Clinical Trials Registry No ACTRN12613001366741.

Antimicrobial resistance is a common iatrogenic complication of both modern life and medical care. Certain multidrug resistant and extensively drug resistant Gram-negative organisms pose the biggest challenges to health care today, predominantly owing to a lack of therapeutic options. Containing the spread of these organisms is challenging, and in reality, the application of multiple control measures during an evolving outbreak makes it difficult to measure the relative impact of each measure. This article reviews the usefulness of various infection control measures in containing the spread of multidrug-resistant Gram-negative bacilli.

Buruli ulcer (BU) is a necrotizing infection of subcutaneous tissue that is caused by Mycobacterium ulcerans and is responsible for disfiguring skin lesions. The disease is endemic to specific geographic regions in the state of Victoria in southeastern Australia. Growing evidence of the effectiveness of antibiotic therapy for M. ulcerans disease has evolved our practice to the use of primarily oral medical therapy. An observational cohort study was performed on all confirmed M. ulcerans cases treated with primary rifampin-based medical therapy at Barwon Health between October 2010 and December 2014 and receiving 12 months of follow-up. One hundred thirty-two patients were managed with primary medical therapy. The median age of patients was 49 years, and nearly 10% had diabetes mellitus. Lesions were ulcerative in 83.3% of patients and at WHO stage 1 in 78.8% of patients. The median duration of therapy was 56 days, with 22 patients (16.7%) completing fewer than 56 days of antimicrobial treatment. Antibiotic-associated complications requiring cessation of one or more antibiotics occurred in 21 (15.9%) patients. Limited surgical debridement was performed on 30 of these medically managed patients (22.7%). Cure was achieved, with healing within 12 months, in 131 of 132 patients (99.2%), and cosmetic outcomes were excellent. Primary rifampin-based oral medical therapy for M. ulcerans disease, combined with either clarithromycin or a fluoroquinolone, has an excellent rate of cure and an acceptable toxicity profile in Australian patients. We advocate for further research to determine the optimal and safest minimum duration of medical therapy for BU.

Background Acute infections of the diabetic foot (DFI) are a common and complex condition. Patients are generally managed in the ambulatory setting and epidemiological data pertaining to hospitalized patients is lacking. The aim of this study was to analyze the epidemiology, microbiology and outcomes of hospitalized patients with DFI, who are managed at a referral center equipped with hyperbaric oxygen (HBO) therapy. Methods A retrospective cohort study of adult patients admitted to a tertiary referral center with DFI over a six-month period in 2013 was undertaken. Predictors of clinical outcomes and efficacy of treatment modalities were analyzed by Cox regression. Results Sixty-one patients with DFI were identified. Most patients were elderly (67 ± 13 years), with long-standing (17 ± 9 years), poorly controlled (HbA1c 9 ± 3%) diabetes. Most patients had polymicrobial infection (80%); specifically, anaerobic (39%) and multi or extensively-drug resistant organisms (61%). Administration of appropriate antimicrobials was delayed for >48 h in 83%. Advanced age was associated with worse outcomes. Sicker patients with severe peripheral vascular disease were managed with HBO. The use of HBO was associated with higher costs and increased functional deterioration, and did not prevent future limb amputation. Conclusions Our study illustrates the descriptive epidemiology of hospitalized adults with DFI predominantly of polymicrobial etiology. MDROs and anaerobic organisms are common causative pathogens, and appropriate antibiotics were frequently delayed. HBO treatment may delay the need for limb amputation, but not obviate this eventual outcome.

Background Health care–associated infection (HcAI) is a term frequently used to describe community-onset infections likely to be caused by multidrug-resistant organisms (MDROs). The most frequently used definition was developed at Duke University Medical Center in 2002 (Duke-2002). Although some professional societies have based management recommendations on Duke-2002 (or modifications thereof), neither Duke-2002 nor other variations have had their performance measured. Methods A case–control study was conducted at Assaf Harofeh Medical Center (AHMC) of consecutive adult bloodstream infections (BSIs). A multivariable model was used to develop a prediction score for HcAI, measured by the presence of MDRO infection on admission. The performances of this new score and previously developed definitions at predicting MDRO infection on admission were measured. Results Of the 504 BSI patients enrolled, 315 had a BSI on admission and 189 had a nosocomial BSI. Patients with MDRO-BSI on admission (n = 100) resembled patients with nosocomial infections (n = 189) in terms of epidemiological characteristics, illness acuity, and outcomes more than patients with non-MDRO-BSI on admission (n = 215). The performances of both the newly developed score and the Duke-2002 definition to predict MDRO infection on admission were suboptimal (area under the receiver operating characteric curve, 0.76 and 0.68, respectively). Conclusions Although the term HcAI is frequently used, its definition does not perform well at predicting MDRO infection present on admission to the hospital. A validated score that calculates the risk of MDRO infection on admission is still needed to guide daily practice and improve patient outcomes.

Background and objective: Refugees in Australia present with conditions different to those of the general population. The aim of this study was to review the reasons for referral, prevalence of conditions and treatment outcomes for refugee patients attending a specialist referral clinic in regional Victoria. Methods: A retrospective review was undertaken of patients attending the refugee health clinic at University Hospital Geelong from January 2007 to December 2012. Results: Two hundred and ninety-one refugee patients attended the clinic over the six-year period. Latent tuberculosis infection (LTBI) (54.6%), vitamin deficiencies (15.8%), hepatitis B (11%) and schistosomiasis (11%) were the most common diagnoses. Less than two-thirds of the patients completed LTBI treatment; 35.4% of patients attended all scheduled clinic appointments. Discussion: LTBI, vitamin deficiencies, parasitic infections and hepatitis B were the most common diagnoses among refugees referred to the University Hospital Geelong (UHG) Refugee Health Clinic from January 2007 to December 2012. General practitioners play an important role in the care of refugees, guiding referral to specialist services when necessary and recognising the potential implications of suboptimal clinic attendance and treatment completion.

With the demonstration of the effectiveness of antibiotic treatment, the management of Mycobacterium ulcerans disease has changed from a predominantly surgically to a predominantly medically treated disease. However, research among Australian patients has revealed that antibiotic treatment alone is associated with prolonged wound healing times, high rates of treatment toxicity, and the potential for significant tissue destruction associated with severe paradoxical reactions. We present the current state of M. ulcerans management in Barwon Health, Australia, where a close working relationship exists between the Plastic Surgical and Infectious Diseases units. Here treatment has evolved based on nearly 20 years of experience gained from managing more around 600 patients from a M. ulcerans epidemic on the nearby Bellarine and Mornington Peninsulas. In our experience, surgery has re-emerged to play an important role in the treatment of M. ulcerans in improving the rate of wound healing, minimizing antibiotic associated toxicity and preventing further tissue loss associated with severe paradoxical reactions. For selected small lesions surgery without antibiotics may also be an effective treatment option, however aggressive surgical resection of lesions with wide margins through uninvolved tissue should no longer be performed. Furthermore, extensive excisional surgery that will require the use of split skin grafts and vascularized tissue flaps to repair skin defects should be avoided if possible.

What makes a good doctor probably depends on whom you ask. Patients value interpersonal relations, and being involved in decisions about their care. In contrast, hospital executives place an emphasis on the ability to meet key performance indicators critical to the flow of patients through hospitals.

Background Buruli ulcer (BU), caused by Mycobacterium ulcerans, is increasing in incidence in Victoria, Australia. To improve understanding of disease transmission, we aimed to map the location of BU lesions on the human body. Methods Using notification data and clinical records review, we conducted a retrospective observational study of patients diagnosed with BU in Victoria from 1998–2015. We created electronic density maps of lesion locations using spatial analysis software and compared lesion distribution by age, gender, presence of multiple lesions and month of infection. Findings We examined 579 patients with 649 lesions; 32 (5.5%) patients had multiple lesions. Lesions were predominantly located on lower (70.0%) and upper (27.1%) limbs, and showed a non-random distribution with strong predilection for the ankles, elbows and calves. When stratified by gender, upper limb lesions were more common (OR 1·97, 95% CI 1·38–2·82, p, Author summary Buruli ulcer is an emerging tropical disease that is also increasingly common in the temperate Australian state of Victoria. The mode of transmission of this geographically restricted infection remains elusive. We have accurately mapped the location of 649 PCR-confirmed Buruli lesions affecting 579 patients and displayed their position on front and back human body diagrams. Lesion distribution density was assessed with computer-generated heat-maps. Buruli lesion distribution was most common on exposed parts of the body (distal limbs). However, even on exposed areas, lesion distribution was highly unevenly distributed and focused towards ankles, backs of calves and elbows. The palmar and plantar surfaces of hands and feet were rarely affected. We propose that targeting behavior by biting insects rather than direct contact with a contaminated environment best explains the lesion distribution we observed.

The clinical and economic burden of infectious diseases is a substantial public health problem. The determination of the relative contributions of these diseases to the overall healthcare burden can inform priority setting, planning, and decision-making in healthcare and establish a baseline for future comparisons. Few recent studies have presented definitive data on the incidence of infectious diseases requiring hospitalisation in the Southern Hemisphere. We identified the age-specific number of hospitalisations and severe infections requiring intensive care unit admissions in the Geelong region. This was then extrapolated to calculate incidence data of these selected infectious diseases in Australia. Methods: This observational study was performed in Geelong, the second largest city in Victoria (population of 194,566 adults ≥ 20 years). University Hospital Geelong is a public hospital with the only emergency department in Geelong during the years 2011 and 2013. Patients were identified using the International Classification of Diseases, 10th Revision Australian Modification discharge codes and diagnoses were confirmed using clinical, radiological and laboratory criteria. Results: Between 2011 and 2013, there were 1,506 admissions for community-acquired pneumonia (CAP) (245.3 per 100,000 person years), 1,613 admissions for skin and soft tissue infections (SSTIs) (271.2 per 100,000 person years), 479 for pyelonephritis (79.7 per 100,000 person years), 131 for influenza (22.4 per 100,000 person years), and 52 for meningitis (8.9 per 100,000 person years). Conclusion: SSTI, CAP, and pyelonephritis are common syndromes responsible for admission to hospital in Australia, with an incidence that increases with age. CAP is a major cause of morbidity and mortality in the Australian population. Influenza is associated with the greatest percentage of severe infections requiring intensive care unit admission.