"Antimicrobial Stewardship at St James’s Hospital: A Four Year Retrospective Audit"
Principal Presenter: Gerry Hughes
Keywords: Antimicrobial Resistance, Antimicrobial Stewardship, Clinical Audit
Antimicrobial stewardship (AMS) is an evidence-based set of interventions to optimise the use of antimicrobial agents, in the context of mitigating antimicrobial resistance. There is increasing international research on the differences in antimicrobial prescribing practice between clinical specialities and the impact of electronic healthcare systems on AMS. There is a paucity of such research in Irish acute hospitals. This study sought to evaluate AMS quality metrics over a four-year period (2016-2019) at a large urban tertiary referral centre.
The study was conducted at St James’s Hospital (SJH), the largest public academic teaching hospital in Ireland. A retrospective review of the institutional AMS database was conducted between the years 2016-2019. The Health Service Executive national AMS key performance indicators (KPIs) were used to benchmark data. These KPIs were compared across surgical and non-surgical specialities and pre- and post-introduction of the electronic patient record (EPR) in 2018. Data were collated in Microsoft Excel® and analysed using SPSS v25. Chi-squared tests were used to determine relationships between categorical variables, using odds to measure these associations. The study was approved by the SJH research and innovation programme.
Antimicrobial prescribing prevalence at ward level was available for 136 AMS ward visits between 2016 and 2019, representing a mean prevalence of 43.69% (95% CI 41.47%-45.94%). A median of nine antimicrobials were reviewed at each ward visit (IQR 6-12). With the exception of antimicrobial duration, national KPIs were not met. Documentation to support the rationale for antimicrobial therapy was three times more likely to be included by medical prescribers than surgical prescribers (95% CI, 2.19-4.1, p<0.001). The odds of optimal antimicrobial agent choice was approximately one and a half times higher in medical specialities compared to surgical specialities (95% CI, 1.2-1.82, p<0.001). Inclusion of a documented indication was over twice as likely to occur after EPR implementation than before (95% CI, 1.18-4.35, p=0.013). Optimal antimicrobial agent choice was also more likely to occur after the implementation of EPR (OR 1.45, 95% CI 1.13-1.80, p=0.002).
Antimicrobial prescribing within medical specialities achieved greater adherence to selected KPIs in comparison to surgical specialities. EPR had a positive impact on certain AMS KPIs but not others. These findings are generally in agreement with the published literature. A greater AMS focus on antimicrobial prescribing for surgical patients is warranted, while the benefits of electronic prescribing platforms on AMS should continue to be leveraged.Download #2021168 (782.89 KB)
"Telehealth Rehabilitation for the Management of Long Covid Symptoms"
Principal Presenter: Gillian Collins
Keywords: Covid, MDT, Virtual
National and international guidelines recommend a multidisciplinary approach to Long Covid rehabilitation including use of self-management support and information. This study assessed the effectiveness of an occupational therapy and physiotherapy led virtual program in managing the symptoms of Long Covid sufferers.
42 participants attending the UHG Post Covid Clinic in July 2021, and who met the accepted definition of Long Covid were invited to participate in a 4 week virtual rehabilitation program. 20 participants completed the program. Content addressed the most common symptoms of fatigue, breathlessness and cognitive dysfunction. Pre and post program assessment included the brief DePaul Symptom and Nijmegen questionnaires, COPM, MOCA, MFIS and GAD7.
Of the 20 participants who received this intervention, 25% (n=5) were male and median age was 47 years. Fatigue was the most common symptom reported by 85% (n=17) of participants (85%); cognitive dysfunction was the second most commonly reported symptom in 80% (n=16). A goal of return to work or phased increase in hours of work was identified for 70% (n=14) of participants. Sleep disturbance was reported by 55% (n=11). All participants were screen for PEM using the brief De Paul questionnaire, which was positive in 85% (n=17). As a result, graded exercise was not included as a treatment recommendation.
75% of participants showed improvements in fatigue scores. Average pre group score on MFIS was 57.68 and on D/C the average score reduced to 46.38 (higher scores reflect higher levels of fatigue). Similar results were seen in the MOCA whereby 90% of patients demonstrated improvement in cognition, at an average improvement of 2.43 points. GAD7 scored improved on average by 3.08 points, and the Nijmegen showed an average pre/post test result improvement of 1.53 points. 75% made improvements on their goals, as measured by the COPM.
A virtually delivered an occupational therapy and physiotherapy rehabilitation program is an effective means of providing symptom management to Long Covid patients.Download #2021167 (604.52 KB)
"The burden of infection in homeless adults"
Principal Presenter: Ciara Anderson
Keywords: Homeless, Infections, MDRO
Inclusion health is a discipline that provides integrated, trauma-informed care for people who are socially excluded. We know from previous research in our centre that homeless people have higher rates of Emergency Department attendance and longer inpatient stays when compared to the housed population. This study aims to characterise acute infections in homeless adults admitted to hospital, with particular emphasis on sites of infection, identified pathogens, and rates of multi-drug resistant organisms (MDROs).
All patients admitted under, or referred to the inclusion health team were identified from the electronic healthcare record between 01/07/2022 and 31/12/2022. Patients with proven or suspected bacterial infections were identified by chart review. Data relating to demographics, length of stay, and infection were collected for all patients. Data was analysed using SPSS version 26.
52 patients of the 398(13%) patients to inclusion health had acute infections. 47(90.4%) were male and median age was 47 (range 22- 76).
As for sites of infection 25(48.1%) were treated for skin and soft tissue infection (SSTI). 17 (32.7%) for respiratory tract infection. 4 (7.7%) for urinary tract infection and 4 for bone and joint infection. Multisite infections made up the remaining 2 (3.8%) of infections.
Pathogens were identified in 33 patients. Of these 33, Staphylococcus aureus was identified in 15 (45.5%) of infections, Streptococcal species in 11 (33.3%), gram negative bacilli in 9 (27.3%) and polymicrobial infections were identified in 8 (24.2%).
13(25%) of patients were colonised with one or more drug resistant organisms. 6(11.5%) VRE, 5 (9.6%) MRSA, and 3 (5.8%) ESBL.
18 (34.6%) were positive for hepatitis C antibody, and 8 (44.4%) of those had active infection. 6 (11.5%) were seropositive for HIV.
27 (51.9%) were active drug users and 25 (48.1%) were established on methadone.
Infections are a significant cause of hospital admission among people experiencing homelessness with a high average length of stay. The most common causative pathogen was S. aureus, followed by streptococci. Polymicrobial infection was common. MDRO colonisation was high in the sampled population, despite the overall low rates of MDROs in Ireland. This may be a result of high antimicrobial exposure in this cohort and/or because of environmental spread of MDROs in either congregate homeless accommodation or during previous hospital admissions. Active drug use is common among patients admitted with infections despite high uptake of methadone. Homeless patients presenting to acute hospitals should be assessed for the presence of infection and screening for drug resistant organisms should be performed.Download #2021166 (638.72 KB)
"‘Every Day Counts': An Evaluation of Antibiotic Duration at Time of Hospital Discharge at St James’s Hospital"
Principal Presenter: Marion Murphy
Keywords: antimicrobial stewardship, antibiotic duration, hospital discharge
Background: The overuse of antibiotics is one of the key drivers of antimicrobial resistance. Antibiotics are commonly prescribed to patients on discharge to complete a course of treatment. The Antimicrobial Stewardship (AMS) programme in St James's Hospital monitors in-patient hospital antimicrobial prescribing. Heretofore, discharge prescriptions were not reviewed. The purpose of this study was to evaluate total antibiotic duration of therapy at time of hospital discharge. The study focused on three conditions: skin/soft tissue infection (SSTI), uncomplicated urinary tract infection (UTI) and community-acquired pneumonia (CAP).
Methods: A retrospective Electronic Patient Record (EPR) review was conducted for January 2022, patients were identified if they had received an antibiotic for one of the following indications: SSTI, UTI, CAP. A full chart review was performed if an antibiotic was continued at discharge. Patients were excluded if on review received antibiotics for an alternate indication, discharged on parenteral antibiotics, or had complicating infection factors such as immunosuppression, bone/joint infections, diabetic foot infections or urological abnormalities. The number of days of therapy of each inpatient and outpatient antibiotic prescribed was collected and compared to St James’s Hospital antimicrobial guidelines (SSTI: 7-10 days, uncomplicated UTI: 3 days, CAP: 5 days).
Results: 483 in-patients were started on antibiotic therapy for SSTI, UTI or CAP; a third were continued at discharge (33.5%, n=162) and 110 patients (22.8%) were excluded due to study exclusion criteria. CAP was the most common diagnosis (67.3%, n=35) followed by SSTI (19.2%, n=10) and uncomplicated UTI (13.5%, n=7). Duration of antibiotics for 30 out of 35 CAP cases (85.7%) exceeded the guideline of 5 days therapy, median duration of overprescribing was 2.5 days. For the SSTI group, 4 patients (40.0%) exceeded the guidelines of the upper duration 10 days therapy; median duration of overprescribing was 3.5 days. For uncomplicated UTI, all 7 patients exceeded the guidelines of 3 days therapy; median duration of overprescribing was 4 days. In total, for all three indications, 41 out of 52 patients (78.8%) exceeded the St James Hospital guidelines by a median 3 days.
Conclusion: Despite the complex process of hospital discharge, this pilot data highlights an opportune moment to optimise antimicrobial prescribing. A targeted intervention is planned to reduce unnecessary prolonged antibiotic usage.Download #2021165 (666.81 KB)
"Changing demographics and immunity to vaccine preventable diseases in people with HIV in Ireland"
Principal Presenter: Colm Kerr
Keywords: HIV, Vaccine, Serology
HIV infection is associated with an increased risk of morbidity and mortality from vaccine preventable infections. This research describes, in the context of changing patient demographics and seroprevalence of vaccine preventable viral infections among attendees of the largest centre for HIV positive patients in Ireland.
Baseline serum IgG results for measles, mumps, rubella, varicella zoster virus (VZV) & hepatitis A, as well as hepatitis B sAg, cAb and sAb results were retrieved for 2534 clinic attendees in 2018. Results were available for between 990 and 2363 attendees (39% - 93%), depending on the test, and were compared with 2013 clinic data.
Over 5 years, there was a 35% increase in attendance. The largest increase was in attendees of South American origin. In 2018, 48% of attendees were MSM and males accounted for 73% of the cohort. 47% of attendees were originally from Ireland. Among those tested, 33% were susceptible to at least one component of the MMR vaccine. 5% were VZV non-immune (significantly associated with younger age and PWID status). 21% were hepatitis A non-immune (significantly associated with younger age and European or South American origin). 32% were hepatitis B cAb positive (significantly associated with older age, African origin and PWID status). 3% demonstrated hepatitis B sAg positivity. 64% had hepatitis B sAb ≥ 10mIU.
In a cohort of attendees to an HIV clinic in a large urban setting, the susceptibility to several common vaccine preventable viral infections, in particular MMR and hepatitis A, was high. Healthcare staff and patients should be counselled on prevalence of susceptibility against these vaccine preventable viruses.Download #2021162 (373.3 KB)
"ANAL HPV MOLECULAR & CYTOLOGICAL FINDINGS FROM HIV POSITIVE AND NEGATIVE MSM IN IRELAND"
Principal Presenter: Colm Kerr
Keywords: HPV, MSM, HIV
Almost 90% of anal cancers globally are attributable to HPV infection. While rare amongst the general population, men who have sex with men (MSM), particularly HIV positive MSM, are far more at risk for the development of anal cancer. This research aimed to describe the anal cytology and molecular findings from HIV positive and negative MSM in Ireland.
Methods: 252 MSM participants were recruited to this study. Anal swabs were collected from participants and placed in PreservCyt. hrHPV DNA testing was performed using the Cobas HPV test on the Cobas 4800 Platform (Roche
diagnostics). HPV mRNA testing was performed using the Aptima HPV assay (Hologic). Samples also underwent anal pap staining for cytological analysis. Samples that tested positive for the presence of hrHPV DNA underwent further analysis using P16/Ki67 dual staining. 148 participants underwent repeat testing at 1 year.
234 participants had valid baseline samples for HPV16 DNA analysis. 52 (22%) tested positive for HPV16 DNA.
232 had valid baseline samples for HPV18 DNA analysis of which 22 (9%) tested positive.
238 participants had valid baseline samples for other hrHPV DNA analysis of which 139 (58%) tested positive.
HIV positivity was statistically significantly
associated with the presence of other hrHPV DNA on multivariate analysis (OR 2.87, 95% CI 1.34 - 6.14, p=0.007).
Overall, 240 participants had valid baseline samples for any hrHPV DNA analysis, of which 153 (64%) tested positive for at least one hrHPV type. HIV positivity was statistically significantly associated with the presence of any hrHPV DNA on multivariate analysis (OR 2.71, 95% CI 1.29 - 5.70, p=0.008).
252 participants had valid baseline samples for hrHPV mRNA analysis, of
which 101 (40%) tested positive. Current smoking was statistically significantly associated with hrHPV mRNA positivity on multivariate analysis (OR 2.02, 95% CI 1.11 - 3.68, p=0.022).
245 samples were valid for cytological analysis. 110 (45%) were reported as normal, 81 (33%) were reported as AIN1 (LSIL), 46 (19%) were reported as AIN2 (HSIL) and 8 (3%) were reported as AIN3 (HSIL).
Receptive anal intercourse (RAI) was statistically significantly associated with the presence of HSIL (OR 8.81, 95% CI 1.91 - 40.65, p=0.005).
145 returned valid P16-Ki67 dual staining results. 50 (34%) of these samples were positive for P16/Ki-67 dual staining. Being originally from Ireland was significantly associated with lower rates of dual staining positivity on multivariate analysis (OR 0.25, 95% CI 0.10 - 0.60, p=0.002).
At 1 year follow up, hr HPV mRNA persistence was seen in 60% of participants (29/48). HPV16 DNA persistence was seen in 77% (17/22), HPV18 DNA
persistence was seen in 44% (4/9), and other hrHPV DNA in 77% (58/75). Overall, persistence of any hrHPV DNA was seen in 79% (63/80). HSIL persistence was present in 22% (7/32), with AIN3 persistence seen in 17% (1/6). Persistent dual staining positivity at 1 year was seen in 57% (8/14).
Conclusions: This study demonstrates the molecular burden of hrHPV infection and persistence of hrHPV infection in this high risk group in an Irish context for the first time. It also demonstrates the burden of cytological HPV disease in this high
risk cohort. In light of recent data showing the benefit of treating anal cancer precursor lesions in HIV positive MSM, this study supports calls for the consideration of the currently unmet need in Ireland for anal cancer screening in this high risk population.Download #2021161 (213.63 KB)
"Meropenem Associated Aseptic Meningitis - Muddying the Waters, and the CSF"
Principal Presenter: Ellen Walsh
Keywords: Drug-induced aseptic meningitis, Beta-lactam allergy
Background:Drug-induced aseptic meningitis is an uncommon hypersensitivity reaction. It is associated with many drugs including anti-rheumatic medications and non-steroidal anti-inflammatories. It has also been reported in the setting of antibiotic therapy. We describe the case of a 22 year old male presenting with multiple drug hypersensitivity reactions to antimicrobial therapy including drug-induced aseptic meningitis associated with meropenem administration.
Case: A 22 year-old male presented with an penetrating injury to his right foot acquired on holiday in Germany. Initial empiric therapy consisted of flucloxacillin and clindamycin. Features at time of surgery were consistent with osteomyelitis of the right fourth metatarsal. Pseudomonas aeruginosa was subsequently isolated and he was commenced on Piperacillin-Tazobactam and discharged home on Outpatient Antimicrobial Therapy. He presented again to hospital 6 days later with fever, rash, thrombocytopaenia and raised liver transaminases. Blood cultures were sterile and no infective cause was identified. Symptoms and lab abnormalities resolved following discontinuation of Piperacillin-Tazobactam. He was switched to Ciprofloxacin, which was later discontinued due to the development of a rash, and switched to Meropenem. Following three days of Meropenem therapy, he developed a headache, increasing in intensity over a number of days. He subsequently developed signs and symptoms of raised intracranial pressure including vomiting and bilateral cranial nerve VI palsies. Neuroimaging identified no cause. Lumbar puncture was performed showing a raised opening pressure of greater than 40H2O. CSF pleocytosis was present with a predominantly lymphocytic pattern and CSF glucose was 1.4mmol/L with a matched serum sample of 5.9. Viral, bacterial, mycobacterial, fungal and autoimmune work-up was negative. Cytology was negative for malignancy and no cause identified on serial neuroimaging. A diagnosis of drug-induced aseptic meningitis was made. Symptoms resolved with cessation of antimicrobial therapy and serial lumbar punctures with CSF removal.
Discussion: Neurotoxicity is a reported uncommon side-effect of carbapenem antibiotics, however drug-induced aseptic meningitis is not a documented side-effect. We propose this to be a manifestation of a severe beta-lactam allergy in a sensitised patient following administration of other beta-lactam antibiotics. This case further highlights the diagnostic and therapeutic challenges of drug-induced aseptic meningitis in a patient on antimicrobial therapy for infection at another site.Download #2021160 (242.19 KB)
"Bone Disease in People Living With HIV: An Audit of Tertiary Centre Outpatient Assessment"
Principal Presenter: Ellen Newman
Keywords: HIV, Bone Health, Secondary Risk Prevention
People Living With HIV (PLWH) are more likely to suffer from osteopenia, osteoporosis and low impact fracture than the general population. As such it is important for providers of HIV care to identify modifiable risk factors and treat where appropriate.
This was a retrospective review of 64 charts of PLWH who attended the Outpatient Department over a two week period. It looked at identifiable risk factors for bone disease as per EACS guidelines, including: post-menopausal women, men age 50 years or older, >20% FRAX score, history of low impact fracture, prolonged course of steroids. This audit also evaluated whether FRAX scores had been calculated in patients >40, Vitamin D levels checked in at-risk patients, DEXA scans ordered and treatment (vitamin D or bisphosphonates) initiated where appropriate.
Of the 64 patients, 62 had a bone profile checked in the last 6-12 months (96.8%). 36 (56.25%) were eligible for FRAX assessment. 1 other patient was under the age of 40 but had a classic risk factor that warranted DEXA. No patients had a FRAX score documented in 2 years. No patients were assessed for falls risk.
Of those 36 patients, 16 had 1 or more risk factors that warranted DEXA; 3 were post-menopausal women, 11 were men age 50 years or older, 3 had a history of low-impact fractures, and 1 patient was on long term steroids. Of the 17 patients who warranted DEXA scanning only 2 (7.6%) had a scan performed in the last two years, (influenced by lack of availability to DEXA scanning due to the COVID-19 pandemic). No patients were on bisphosphonates. Of the 64 patients, 20 had serum vitamin D checked in the prior 2 years. 2 were identified as deficient, and both patients were on replacement therapy.
Bone disease in PLWH is under-assessed, and scoring tools eg FRAX underestimate those who warrant DEXA. It’s important for HIV clinicians to both utilise screening tools and to identify individual patient risk factors for bone disease as part of routine HIV care. Busy clinics may focus on acute issues over chronic risk factor management, particularly during the COVID19 pandemic, where services prioritised aRT supply and viral suppression. Use of a template or proforma for secondary risks in HIV clinic may help increase the number of assessments, streamline the evaluation, and help reduce cognitive burden on the clinician.Download #2021159 (531.26 KB)
"A Retrospective Analysis of Antibiotic Treatment Duration for Bone and Joint Infections in Saint James's Hospital."
Principal Presenter: Jane Fagan
Keywords: Osteomyelitis, Antibiotics, Stewardship
Bone and joint infections [BJI] are associated with high rates of morbidity and are often subject to long durations of both IV or PO antibiotics. The aim of this study was to assess appropriateness of antibiotic treatment duration for acute native bone and joint infections in our institution. We compared practices in our institution to IDSA guidelines on management of vertebral osteomyelitis and IWGDF guidelines on management of diabetic foot osteomyelitis.
We conducted a retrospective review of the electronic patient record of 140 patients who were treated for BJI during the period of October 2021 to February 2022. We then excluded patients with insufficient evidence of osteomyelitis on MRI or cultures, those with hardware-associated infections, those who underwent curative surgical management, those being treated for acute-on-chronic osteomyelitis and those who died prior to completing their antibiotic course. Antibiotic agents used as well as IV and PO antibiotic durations were documented.
A total of 28 patients were included in the final analysis. The average total duration of antibiotic therapy in these patients was 77.5 days with an average IV duration of 57.4 days. Of the cohort being treated for vertebral osteomyelitis, average total duration was 84.6 days and average IV duration was 66.4 days.
Our data would suggest that average antibiotic therapy durations in our institution for these infections are considerably longer than those suggested by both IDSA and IWGDF.Download #2021158 (1.55 MB)
"Case Report: Assessing the Range of Factors that Contribute to a Possible PrEP Failure"
Principal Presenter: Bearach Reynolds
Keywords: PrEP, HIV Resistance, Sexual Health
Pre-Exposure Prophylaxis (PrEP) is highly effective in the prevention of HIV transmission.
We present the case of a patient who is MSM (men who have sex with men) who attended a PrEP service in a tertiary centre. On attendance, he reported no new symptoms or history of seroconversion illness. He was compliant with event-based dosing. A fourth generation HIV test was weakly p24 antigen positive and antibody negative. A repeat test demonstrated a weakly positive antibody and HIV viral load was 960. The patient disclosed intermittent adherence to PrEP at subsequent visits. Genotypic testing did not demonstrate any resistance. The patient was not able to commence antiretroviral therapy (ART) immediately and returned several weeks later where his HIV antibody was still weakly positive with a HIV viral load of 417. Repeat genotypic resistance testing was negative. The patient was commenced on Truvada and Dolutegravir and was undetectable 4 weeks later with detectable viral load since then.
HIV seroconversion has been described in the context of intermittent compliance with PrEP. In this case, incomplete antibody seroconversion with a low HIV viral load was suggestive of seroconversion in the presence of low levels of ART. HIV acquisition in this context is frequently associated with resistance with either M184V and/or K65R resistance mutations These was not demonstrated genotypically and the patient suppressed with ART. This case highlights the range of factors that need to be considered when assessing possible PrEP failure including the importance of adherence and assessment of risk for HIV resistance.Download #2021157 (1.09 MB)
"A Case of Multidrug resitanant Mycoplasma Genitalium Infection"
Principal Presenter: Bearach Reynolds
Keywords: Mycoplasma genitalium, Antimicrobial Resistance, Sexual Health
Mycoplasma genitalium (M gen) is a small, intracellular pathogen associated with urethritis and pelvic inflammatory disease. It is not a notifiable disease in Ireland and its role as a sexually transmitted infection is not fully understood. As it is not notifiable, the true prevalence of this infection in Ireland is uncertain. One prevalence study in Ireland reported a rate of 3% prevalence in MSM, with macrolide resistance detected in 75% and fluroquinolone resistance detected in 33% of positive samples respectively.
We present the case of a 30-year-old patient, attending the PrEP service, with recurrent episodes of symptomatic urethritis. The patient presented with urethritis with a negative C trachomatis (CT) and N gonorrhoea (GC) nucleic acid amplication test (NAAT). Subsequently, the patient was diagnosed with M genitalium on PCR with evidence of macrolide resistance. The patient was treated with moxifloxacin 400mg OD for 10 days. Thereafter, there was concern of reinfection with recurrence of symptoms and he was treated with another course of moxifloxacin in another sexual health service. His symptoms initially improved but returned after completing his antimicrobial therapy. NAATs were negative for CT and GC, positive for M genitalium and demonstrated detection of 23SrRNA and parC genes, associated with macrolide and fluoroquinolone resistance respectively. GyrA is routinely tested for surveillance purposes but not reported due to lack of association with treatment failure. As per international guidelines, a course of doxycycline 100mg BD for 7 days followed by pristinamycin 1g QID PO for 10 days
The true prevalence of M genitalium is uncertain in Ireland as it is not a notifiable infection.. In the limited data available it appears that increasing drug resistance is common. Given the safety profile of fluoroquinolones, resistance to moxifloxacin should be considered when patients fail therapy. There is currently no availability for the detection of resistance within Ireland. Notification and the development of resistance testing within Ireland would support a better understanding of the epidemiology of this infection.Download #2021156 (856.43 KB)
"Tuberculosis Therapy Audit - Preventive and Curative Therapy Monitor"
Principal Presenter: Tessa O' Gorman
Keywords: Tuberculosis, Audit
Background:In 2019, 267 TB cases were notified to the HPSC in Ireland. The National TB advisory Committee established National Guidelines on TB Prevention and Control in 2010. This audit aims to evaluate the care of TB patients in the Mater Hospital against the TB Therapy Audit Form recommended by the guideline.
Methods:Patients with positive TB cultures or clinically suspected TB from January to mid-December 2021 and commenced on treatment by an ID Consultant were included in the analysis. A retrospective chart and electronic patient record review using the HPSC TB Therapy Audit Form was performed at monthly visits for 6 months following commencement of treatment. Data is presented as n(%) and median(IQR).
Results:18 patients were identified with 15(83.3%) audit forms completed. 12(80%) were male, median age was 45(32-50) years. 7(46.7%) had pulmonary disease. 2(13.3%) cases were clinically suspected, and 13(86.7%) were laboratory-confirmed (Mycobacterium tuberculosis(12,92.3%), Mycobacterium africanum(1,7.7%)). Of 13 laboratory-confirmed cases,11(84.6%) were pan-sensitive, 1(7.7%) had indeterminate resistance to pyrazinamide and 1(7.7%) had insufficient sampling for testing.
10(66.6%) completed at least 6 months treatment, 2(13.3%) were lost to follow-up before completion of treatment, 1(6.7%) died, 1(6.7%) ceased treatment as directed by the clinician and 1(6.7%) patient’s treatment was interrupted due to patient compliance. There were 72 patient attendances, median attendance was 6 visits(4-6). Medication compliance was documented as assessed at 66.2% of visits.
Fever was the most frequently assessed symptom at 77.9% of visits. Rash and jaundice were the least frequently documented symptoms, assessed at 26.5% of visits each. LFTs were performed at 98.6% of the visits. Of 72 LFTs performed, there was only one occurrence of elevated ALT(1.4%).
Conclusion:This audit highlights the need for quality improvement measures (e.g. dedicated registry and MDT, proforma assessment documentation) to monitor the safety and efficacy of TB treatment. This audit is limited by the low numbers of patients included. It is possible that this relates to the impact of COVID-19 on inward migration and delayed presentations. In addition, the local patient list may not have captured all patients e.g. transferred from other centres or with suspected rather than microbiologically proven disease. Nonetheless this audit highlights the need for a local and national dedicated TB registry to support reporting safety monitoring and efficacy reporting of TB treatment.Download #2021155 (231.75 KB)
"Accuracy of Vancomycin Prescribing in an Irish Teaching Hospital"
Principal Presenter: Susannah Staunton
Keywords: Vancomycin, Antibiotics, Pharmacology
Background: Vancomycin dosing is initially calculated based on body weight and renal function and thereafter guided by therapeutic drug monitoring. An online calculator and detailed prescribing guidelines are available in our hospital. Correct dosing is important to ensure both adequate treatment of the infection and to prevent toxicity.
Methods: Retrospective analysis was performed of drug charts and medical notes of a random selection of patients prescribed intravenous vancomycin between 01/09/2021-31/10/2021. ICU and dialysis-dependent patients were excluded from the study.
Results: Twenty-six patient charts were assessed. Weight and height were documented for 76.9% (n=20) and 69.2% (n=18) respectively. Vancomycin was prescribed empirically for 76.9% (n=20). Prescribing was either in line with local guidelines or direct microbiology advice for 73.1% (n=19). Dose calculation via the online calculator was possible for 88.5% (n=23) patients. Of these, loading doses were prescribed correctly for 69.6% (n=16) and maintenance doses were prescribed correctly for 52.2% (n=12). Of the 22 patients whose treatment continued for long enough to require drug monitoring, 72.7% (n=16) had their initial levels taken on the correct day. A dose change was required in 10 cases and was changed in line with local guidelines in 80% (n=8) of these.
Conclusion: Despite the availability of an online vancomycin prescribing calculator in our hospital, vancomycin is frequently prescribed at incorrect doses. Compliance with vancomycin calculator use could be improved by making it accessible on mobile devices.Download #2021154 (163.19 KB)
"Outcomes after switch to DTG/3TC in PLWH: A single centre study"
Principal Presenter: Matthew Blair Matthew Blair
Keywords: HIV, Dual therapy, lipids
Dual therapy with DTG/3TC has been demonstrated to be safe and efficacious in three RCTs. In addition, TAF-containing regimens are increasingly used due to the adverse metabolic outcomes (bone and renal effects) associated with TDF. Previous studies have shown an improvement in lipid parameters in patients switched to DTG/3TC. We performed a single-centre, real-world study of lipid outcomes in patients switched to DTG/3TC.
Patients prescribed DTG/3TC were identified from pharmacy records. Indications for change to DTG/3TC were collected. Numbers continuing on treatment at the end of the study period and reasons for any discontinuations were collected. Apparent effect of DTG/3TC on lipids was reviewed by reviewing results of random lipid profile before and after the switch.
The primary outcome of the study was reasons for switch and continuation on treatment with DTG/3TC. We used paired t-tests to assess difference in mean lipid levels at six, twelve and eighteen months post switch.
92 patients were switched to DTG/3TC during the study period and were included for analysis. Prior to switch, 60% were on an INSTI-based regimen, 25% on NNRTI based regimen and 15% on PI based regimen. The most common reasons for switch to DTG/3TC were side effects to current regimen (33%), DDIs (14%) and weight gain (12%). 84 patients remained on treatment at end of study. The main reason for discontinuation was side effects in 6 (75%) of patients. Viral blips were identified in 4 patients, but none were associated with virological failure or development of resistance.
There a significant decrease in random TC at six months (-0.34 CI 0.092 – 0.59, p=0.008) but not at 18 months (-0.091, CI-0.28 – 0.46, p=.50). There was a significant decrease in TG at six months(-0.31,CI 0.04 – 0.59, p=0.025), but not at 12 months (-0.11, CI -0.14 – 0.37, p=0.39) or 18 months (0.33, CI -0.91 – 0.23, p=0.23). There was a non-significant decrease in LDL at 6 months (-0.206, CI –0.01 – 0.42, p=0.06), 12 months (-0.20, CI 0.01 – 0.42, p=0.06) and 18 months(-0.25, CI -0.063 – 0.572, p=0.11). There was a non-significant decrease in the HDL at 6 months(-0.034, CI -0.027 – 0.095, p=0.27), increase at 12 months (0.02, CI -0.10 – 0.059, p = 0.6) and increase 18 months(0.08, CI -0.20 – 0.041, p=0.18). There was a non-significant decrease in TC/HDL ratio at six months (-0.11, CI -0.051 – 0.27, p=0.18) and 12 months (-0.097, CI -0.105 – 0.299, p=0.34) and a significant decrease at 18 months (-0.31, CI .08 – 0.54, p=0.01).
The vast majority of patients tolerated DTG/3TC and remained on therapy at end of study. Most patients were switched to DTG/3TC due to issues with their current regimen rather than metabolic risks or lack of efficacy. There was an improvement in TC and LDL at 6 months, but this difference was not significant at 18 months. There was a sustained decrease in TC/HDL at 18 months. Further research is required on the metabolic changes in patients switched to DTG/3TC.Download #2021153 (199.09 KB)
"Audit of Surgical Antibiotic Prophylaxis in St James’s Hospital"
Principal Presenter: Audrey Rice
Keywords: surgical antibiotic prophylaxis, antibiotic prescribing, antimicrobial stewardship
The HSE defines surgical antibiotic prophylaxis as the “planned administration of antibiotics to a patient, who does not have confirmed or suspected infection, for the purpose of reducing the risk that the patient develops infection at the surgical site post-operatively”. It is imperative to select the correct agent and duration. Most procedures require a single dose of an appropriate agent. Extending duration does not reduce the risk of surgical site infection (SSI) and may be associated with increased harm including c.difficile. Importantly, having a drain post-operatively is not an indication to extend duration of antibiotics.
A joint statement on surgical antibiotic prophylaxis duration was developed by HSE and the NCPS in October 2021. In addition St James’s Hospital has local guidelines (Medicines Guide) for surgical antibiotic prophylaxis.
100 patients were identified prospectively for inclusion by surgical interns. over 11 surgical specialities over a 2 month period. A documentation audit tool was created based on the HSE Surgical Antibiotic Prophylaxis Audit Tool. Data collectors were made familiar with local guidelines, available on the St James’s Medicines Guide. Each patient’s Electronic Patient Record (EPR) was accessed to collect data prospectively.
118 antibiotic prescriptions were recorded for the 100 patients.91 (77.12%) of prescriptions were as per guidance, 24 (20.34%) were not compliant with guidance. For 3 prescriptions guidelines were not applicable (due to presence of infection).73 (61.9%) met guidelines for duration, 43 (36.44%) did not meet guidelines for duration.Planned duration was documented for 31 (26.3%) prescriptions, but none for 88 (81.5%) prescriptions. A stop date was on the EPR prescription for 23 (21.3%), with none for 88 (81.5%).
Of the 45 prescriptions that were prolonged, 30 (66.67%) had no identifiable reason for a prolonged course. 8 were prolonged due to a drain being in-situ, 1 had a post-operative infection confirmed/suspected. 3 had pre-operative infections confirmed/suspected and 1 fit into the “other” category.
Most prescriptions selected an appropriate antibiotic. Adherence to duration of recommended prophylaxis can be targeted. The documentation of planned duration and the reason for extension of antibiotics was poor; A drain remaining post-operatively was the most common reason given. This is not sufficient reason to continue antibiotic therapy. Based on the results of this audit, interventions will be planned to improve adherence to national and local guidance.Download #2021150 (377.8 KB)
"Kaposi’s Sarcoma in people living with HIV who are virally suppressed : A Case series"
Principal Presenter: Amy Keane
Keywords: Kaposi Sarcoma, HIV, Fully suppressed HIV
Kaposi’s sarcoma (KS) is an AIDs defining illness and, in most cases is related to immunosuppression, a low CD4 count and HIV viral replication. A decline in KS has been seen since the introduction and widespread use of effective antiretroviral therapy(ART). However Kaposi sarcoma is still a concern amongst people living with HIV who are fully virally suppressed and have a robust CD4 count . There are varying hypothesis for why this occurs including, chronic HHV8 antigen exposure, lower responses to HHV8 specific antigens and lower specific HHV8 CD8 T cells responses. A decrease in CD4/CD8 T cells has also been seen in these patients. Here we present a case series of three people living with HIV (PLHIV) who developed KS while virally suppressed on antiretroviral therapy with robust CD4 counts
Approval was received from the research and innovation department in St James Hospital. Cases of Kaposi sarcoma were identified from the electronic patient record system (EPR). EPR was used to review the patients charts for year of HIV diagnosis, CD4 count at diagnosis, Year of KS diagnosis, CD4/CD8 ratio at KS diagnosis, ART regimens, viral suppression and medication adherence.
Three patients within our cohort developed Kaposi sarcoma while virally suppressed. They all had robust CD4 counts between 800 – 1400 cell/mm3 , all patients had excellent adherence to ART and excellent viral control. All patients had cutaneous KS lesions, none had visceral involvement of KS. One patient had KS at diagnosis years earlier followed by 2 recurrences when virally suppressed. Two patients had a CD4/CD8 ratio >1 , one had a CD4/CD8 ratio <1.
KS in virally suppressed PLHIV is an emerging and important clinical entity. It is important to consider KS as a diagnosis amongst virally suppressed patients. Further research and exploration of immunological pathways is important in learning more about this emerging clinical problem.Download #2021149 (99.71 KB)
"A Micro-costing Analysis on Resource Utilisation in Ambulatory Care of Long-COVID Patients in a Regional Infectious Diseases Centre in Ireland"
Principal Presenter: Hridya Agnus Moorthiraj
Keywords: Long COVID, Micro costing, Infectious Diseases
Background: The phenomenon of “Long-COVID” has been used to describe patients who remain symptomatic >42 days after diagnosis of COVID-19 infection. Many of these patients require assessment in hospital clinics. The exact burden on healthcare system should be quantifiable with a micro-costing analysis and can help inform service provision and patient flow. Patients are currently being assessed for this “Long-COVID syndrome” in the general Infectious Diseases clinic in the Mercy University Hospital, Cork.
Methods: Patients presenting with “Long-COVID” have a workup to exclude ongoing organ damage, inflammation, thrombosis and are screened for other medical conditions which may present in a similar way. A micro-costing study was carried out on a cohort of the first 45 outpatients assessed for Long-COVID that have completed follow-up at the Mercy University Hospital, Cork, Ireland. The costs per person were calculated based on patient flow pathway, staff grade, time, and types of investigations done, with discussion with hospital administration to calculate individual component costs. All hospital resources used in the assessment of these patients were identified from service analysis and patient notes retrospectively. Associations between baseline patient characteristics and costs per patient (in 2022 euros) were examined using univariate and multivariate analyses.
Results: The average cost of providing care was found to be €781 (95% confidence interval €639-923) per patient prior to discharge including the cost of staffing and cost for associated tests. The breakdown of costings was 1% non-medical staffing, 26% medical staffing, 29% bloods, 11% imaging, and 33% other investigations. Out of the 45 patients included in the study, the work-up for 36 patients did not show significant abnormalities. 6 patients were referred for further Obstructive Sleep Apnoea (OSA) assessment and 2 patients were referred for assessment for possible cardiomyopathy. Most of the finances were spent on performing the routine blood tests as per our local Long-COVID protocol. 50% of our cohort was overweight or obese, and 45% had pre-existing anxiety disorder.
Conclusions: These data are valuable for planning services at a local level and informing national policy. The identification of patient-specific factors associated with resource use gives valuable prognostic information. Describing the characteristics of our cohort of patients attending for “Long-COVID” allows focus and investment in managing possible co-morbidities. Our data allows for planning for increased staffing and increased patient output with time.Download #2021148 (552.05 KB)
"Descriptive Analysis of the Irish National Outpatient Parenteral Antimicrobial Therapy (OPAT) Programme"
Principal Presenter: Paul Reidy
Keywords: OPAT, Antimicrobial, Stewardship
The Irish Outpatient Parenteral Antimicrobial Therapy (OPAT) programme, a national centrally administered outpatient antibiotic provision service was established in 2013 within the public hospital system and operated by the Health Service Executive (HSE). Local community intervention teams and two private companies provide medication delivery and administration with all patients registered on a national secure online portal.
Here we describe the programme usage to date and outline how the data can be used to help improve the service delivery and identify important trends in national antimicrobial usage.
Using data extracted from the national electronic portal we describe total summary statistics from 2017 to end of August 2021 (56 months).
This data encompasses prescribing information from 36 hospitals involved in the OPAT programme.
Over the 56-month period 8884 OPAT episodes were facilitated between 36 hospitals. 6279 episodes were home OPAT delivered by a healthcare worker vs 2605 self OPAT where patients were taught to administer the antimicrobials.
The median OPAT duration of therapy was 18 days with an average of 21.
Average age of a referred patient was 56 years.
The top five diagnoses of osteomyelitis, abscesses, bacteraemia, cellulitis, and pyelonephritis accounted for 53.6% of referrals. 89.6% of patients were prescribed a single antimicrobial, 10% two agents and 0.4% prescribed three. Four antibiotics – ceftriaxone, daptomycin, flucloxacillin continuous infusion and cefazolin account for 59% of 143 antimicrobial choices; choices largely made to cover presumptive gram-positive cocci
Five of the 36 hospitals accounted for 57.9% of all OPAT prescriptions. The number of beds in a hospital was not the strongest predictor of OPAT usage with OPAT utilisation rates differing between hospitals. The total number of bed days saved in 56 months was 148,577 within a health system capacity that operates on 11,171 beds available per day for a population just exceeding 5 million. Per the HSE the average daily cost of running an inpatient acute hospital bed is €878 resulting in significant cost savings.
A national OPAT programme can contribute to significant bed day and consequent financial savings. Factors predicting and explaining OPAT usage need to be further examined to maximise health system utility.Download #2021147 (110.79 KB)
"Aseptic Meningoencephalitis and Myelitis Temporally Associated with SARS-CoV-2 Vaccination"
Principal Presenter: Michelle Madden
Keywords: Covid-19, Vaccination, Encephalitis
A thirty-five year old South African gentleman presented with systemic symptoms, confusion and headache.
He returned from South Africa thirty-five days prior to presentation, having spent four weeks there in an urban centre. He did not take malaria prophylaxis and denied contact with animals, insect bites, or sick contacts. He was well during his stay and remained well for sixteen days on return. Fourteen days prior to presentation he received a booster dose of the Pfizer-BioNTech SARS-CoV-2 vaccine; he previously received Pfizer-BioNTech for the initial two doses and on both occasions he developed fever and prominent headache lasting several days. There was no history of primary SARS-CoV-2 infection. He was in a monogamous heterosexual relationship with his wife and denied intravenous drug use.
Headaches, fevers and myalgia persisted for two weeks following vaccination and new-onset confusion prompted presentation. He was febrile on examination, disorientated to person and place with nuchal rigidity. Within 48 hours he developed a rapid ascending flaccid paralysis with bulbar involvement and features of autonomic instability. He was transferred to ICU requiring intubation.
Initial lumbar puncture showed 134 white blood cells with a lymphocytic predominance (90%), CSF protein was 2.55g/L and glucose was 1.9mmol/L (serum glucose 5.2mmol/L). MRI brain and spine showed diffuse abnormal signal within the sulci, leptomeningeal enhancement and long segment hyperintense signal with associated oedema in the cord, suggestive of meningomyelitis.
He commenced on empiric antimicrobial cover for bacterial, viral, rickettsial and mycobacterium tuberculosis infections pending results. Blood cultures on day 1 of admission were positive for Fusobacterium. CT angiogram of the neck vessels was normal. Extended autoantibody testing was unremarkable.
With a negative work-up for infectious aetiology and concern about an immune-mediated phenomenon, high-dose methylprednisolone and intravenous immunoglobulin treatment was commenced. There was complete recovery of cognition but persistent flaccid paralysis. Plasmapheresis was trialled with marked improvement of power in the distal upper limbs. After seven weeks in hospital, the patient returned to South Africa for rehabilitation.
Guillain-Barre Syndrome has been reported post-vaccination, including SARS-CoV-2 vaccination. There are several case reports in the literature describing encephalitis post SARS-CoV-2vaccination; all responded well to glucocorticoids, IVIG and plasmapheresis. In this case the temporal association with vaccination and absence of alternative diagnosis highly suggests an immune-mediated meningoencephalomyelitis triggered by SARS-CoV-2 vaccination. To our knowledge this is the first such report in Ireland and has not been reported previously following a booster dose.Download #2021146 (449.5 KB)
"Novel Pathogen unmasks old Infection: COVID-19 Infection triggers Erythema Nodosum Leprosum Reaction"
Principal Presenter: Maria McWalter
Keywords: Mycobacterial infection, COVID-19
Leprosy is a chronic mycobacterial infection which affects the skin and peripheral nerves. Varied clinical presentations can be provoked by acute immunoreactive states. SARS-CoV-2 infection has emerged as a pro-inflammatory catalyst and in this case triggered an exaggerated host response leading to a new diagnosis of erythema nodosum leprosum (ENL) complicating lepromatous leprosy (LL), which has not previously been described.
A 30-year-old gentleman with no previous medical history reported a 5-day history of dry cough, fevers and headache. Nasopharyngeal swab confirmed COVID-19 infection.
He also reported progressive swelling of his hands and face and on further questioning had experienced intermittent burning pain in his hands and feet in the months preceding. Examination revealed a facial rash with malar hypopigmentation and distal loss of pinprick sensation on neurological exam.
A skin biopsy was undertaken to further evaluate the facial rash and demonstrated non-necrotising epithelioid granulomas within the dermis with a concurrent inflammatory process appearing to involve cutaneous nerves. Ziehl-Neelson stain showed numerous bacilli within granulomas in keeping with a mycobacterial infection. The clinical features and histological findings pointed towards a diagnosis of erythema nodosum leprosum complicating borderline or lepromatous multibacillary subtype of leprosy possibly precipitated by COVID-19 infection. As per the WHO treatment recommendations, he was commenced on a 12-month regimen of clofazimine 300mg monthly and 50mg daily, dapsone 100mg daily and rifampicin 600mg monthly. He was also started on oral prednisolone 60mg for erythema nodosum leprosum.
We postulate that acute COVID-19 infection unmasked a chronic lepromatous infection with an inflammatory complication, namely erythema nodosum leprosum. His acute liver injury on initiating anti-mycobacterial and steroid treatment posed a major challenge. It was unclear if the erythema nodosum leprosum inflammatory reaction triggered an acute hepatitis or if the anti-mycobacterial therapy could be contributing. We were able to restart therapy after steroid treatment and improvement in liver enzymes. Despite treatment, this gentleman had residual impairment of hand function which demonstrates the debilitating effects of leprosy infection.
The most striking part of this case is the way in which the novel COVID-19 pathogen had a catalytic effect on the manifestations of leprosy, one of the oldest known infectious diseases. Both can cause an immunoreactive inflammatory reaction and the underlying mechanism is unclear. This has not been reported in the literature previously.Download #2021145 (1.64 MB)
"An Audit of Syphilis screening on an annual basis in a single-centre outpatient setting for people living with HIV infection"
Principal Presenter: Maria McWalter
Keywords: Syphilis, HIV, Audit
Syphilis is a sexually transmitted infection caused by the spirochete bacterium Treponema Pallidum. Syphilis can manifest in symptoms such as a chancre in early primary infection, rash or uveitis in secondary infection and tertiary cardiovascular or neuro-ocular sequelae in later stages if left untreated. Syphilis screening consists of serological testing which is widely available in the Infectious Diseases outpatient setting as part of the standard of care for people living with HIV infection. People living with HIV may be at risk of developing more severe presentations of syphilis infection. Therefore, we decided to perform an audit of opportunistic syphilis screening in an outpatient setting for people living with HIV compared to the standard outlined by the 2021 European AIDS Clinical Society (EACS) Guidelines which recommends annual testing.
Details for patients on anti-retroviral therapy attending the clinic were obtained from the Infectious Diseases Pharmacy. Audit approval was obtained locally. Those included had a known diagnosis of HIV infection and had attended the Infectious Diseases Clinic as part of their routine review from January to December 2021. The electronic patient record was analysed to see which patients had a syphilis serology screen ordered as part of their routine blood tests. The audit tool utilised was a password protected Excel Spreadsheet which was populated by Dr Maria McWalter and Dr Ann Marie White. Data was rendered anonymous by the collection process and analysed using Microsoft Excel software.
A total of 1187 patients satisfied inclusion criteria. The mean age of patients was 44 years and the mean number of attendances was 2.15. 607 patients (51.1%) had a syphilis serology checked in the year 2021. Of which, 177 were female (29.1%) and 430 (70.9%) were male. 405 (66.7%) patients had a previous negative syphilis serology and 178 (29.3%) had known prior infection. 16(2.6%) had a new syphilis diagnosis and 13(2.1%) had evidence of re-infection
Identifying syphilis infection in an outpatient setting is an important means of instigating early treatment for those attending the HIV clinic and curtailing further transmission of syphilis infection in the community.
Opportunistic screening for syphilis infection as part of the routine blood tests for people living for HIV was suboptimal. Further efforts can be made to improve screening rates by providing education for those working in the Infectious Diseases Clinic with further re-audit to evaluate for improvements in screening.Download #2021144 (114.38 KB)
"A multi-centre evaluation of anti-microbial usage based on national data from 2017-2021 for patients diagnosed with bacteraemia enrolled on OPAT in Ireland"
Principal Presenter: Maria McWalter
Keywords: OPAT, Anti-Microbial stewardship
Outpatient anti-microbial parenteral therapy (OPAT) is a safe cost-effective treatment option for patients requiring extended courses of intravenous anti-microbials. It enables treatment at home where patients are well enough not to require inpatient hospital care. OPAT is a multi-disciplinary service with an Infectious Diseases Physician at the helm in terms of anti-microbial management and stewardship.
All patients enrolled on the OPAT service are registered on a national database. Patient demographics are included on the database which include a unique patient identifier number, age, diagnosis, anti-microbial agent, frequency of doses, duration of anti-microbial therapy and length of inpatient stay. For this evaluation, the national database was interrogated based on hospital site and anti-microbial agent for patients being treated for bacteraemia. Patients included were enrolled on an OPAT programme and met the inclusion criteria defined by the Irish National OPAT guidelines. Those who had a blood stream infection or bacteraemia caused by a particular pathogen were identified. The number of patients on OPAT with bacteraemia were compared across 25 Irish Hospital sites and the anti-microbial usage
Data was obtained for 745 patients from 25 different Irish hospital sites with an established OPAT service. Patients listed as having confirmed a bacteraemia on the national OPAT database from 2017-2021 were included in the analysis. 621 OPAT prescriptions were obtained from eight hospital sites (83.35%) where it was most utilised with Beaumont Hospital (101/745, 13.5%), St Vincent’s University Hospital (93/745, 12.5%) and Cork University Hospital (89/745, 11.9%) accounting for the highest uptake per site. There were 24 unique anti-microbial preparations utilised nationally and on average there were 5.36 different anti-microbials used per site. Flucloxacillin via continuous infusion(211/745, 28.3%) , Ceftriaxone (191/745,25.6%) and Daptomycin were the most commonly used anti-microbials across all hospital sites. The vast majority of anti-microbials used were for once daily dosing (577/745, 77.4%). For anti-microbials requiring multiple daily dosing, 68.4% (115/168) were administered with the assistance of a specialised healthcare provider (H-OPAT)
There is a geographical disparity in the numbers of patients with bacteraemia being treated on OPAT from the years 2017 to 2021. Anti-microbials which require once daily dosing are the most predominantly used regimens for patients on OPAT. Larger centres with a formal OPAT service used a wider range of anti-microbials.Download #2021143 (1.42 MB)
"Risk Factors for SARS-CoV-2 Infection in Healthcare Workers Following an Identified Nosocomial COVID-19 Exposure During Waves 1-3 of the Pandemic in Ireland"
Principal Presenter: Jonathan McGrath
Keywords: SARS-CoV-2, Healthcare Worker, Nosocomial Infection
Healthcare workers (HCW) have increased exposure and subsequent risk of infection with SARSCoV2. Many identified risk factors for HCW infection are derived from seroprevalence studies which measure cumulative risk over time and may be influenced by social factors. The HERD Study investigated contemporaneous work-related risks associated with confirmed SARSCoV2 infection amongst HCWs following in-work exposure to a confirmed case during Waves 1-3 of the pandemic.
A retrospective case-control study involving HCWs identified through on-site contact tracing following in-work exposure to a confirmed COVID-19 case was undertaken. Risk factors associated with the exposure that resulted in SARS-CoV-2 infection or non-infection were investigated. Univariate and multivariable logistic regression were used to determine adjusted odds ratios (aOR) for risk factors associated with infection.
Outcomes for 1,822 interactions occurring between March 2020 and April 2021 were analysed with 285 (15.6%) resultant positive SARS-CoV-2 cases and 1537 (84.4%) resultant negative controls. 78.5% (n=1430) of HCWs were female and age range was 20-67 years (median 36 years). Irish nationality (n=1,099;60.3%) was most common followed by Indian (n=244;13.4%) and Filipino (n=206;11.3%). Nursing was the most common job role (n=955;52.4%) followed by HCA (n=237;13%). Factors associated with increased infection risk following exposure included: male sex (aOR 1.45, 95%CI 1.04-2.02, p=0.026), Eastern European nationality (aOR 2.68, 95%CI 1.31-5.49, p= 0.007), nursing job role (aOR 1.68, 95%CI 1.01-2.82, p=0.046), administration/office setting (aOR 3.85, 95%CI 1.04-14.26, p= 0.044) and COVID-19 wards (aOR 5.16, 95%CI 2.19-12.16, p<0.001). PPE use (aOR 0.58, 95%CI 0.37-0.92, p= 0.021) and receipt of at least one vaccine dose (aOR 0.4, 95%CI 0.22-0.75, p= 0.004) were associated with decreased risk of infection following exposure. Risk reduced as the pandemic progressed with exposures during Waves 2 (aOR 0.21, 95%CI 0.13-0.14, p<0.001) and Wave 3 (aOR 0.24, 95%CI 0.17-0.34, p<0.001) being significantly less likely than Wave 1 to result in infection.
Outcomes following nosocomial SARSCoV2 exposure are impacted by sex, nationality, job role and location. PPE use is essential in non-clinical as well as clinical settings and benefits persist even in the context of COVID-19 vaccinations.Download #2021142 (617.8 KB)
"Human Papilloma Virus (HPV) Vaccine Uptake in Infectious Disease (ID) and STI Clinics"
Principal Presenter: Fara Shila Salleh
Keywords: HPV, vaccine, STI
Background: Human papilloma virus (HPV) infection is known to be associated with anogenital, and head and neck cancers. People living with HIV (PLHIV) are not only more likely to be positive for more than one HPV serotypes, but also to be infected with high-risk serotypes. HPV vaccination service targeting this high-risk group have been available in HSE since 2017. Our previous audit showed a low uptake amongst patients who attend our service, but this subsequently improved following the appointment of a dedicated vaccination nurse specialist (VNS). A reaudit was done to ensure a high level of vaccine uptake amongst this high-risk cohort is maintained.
Methods: The audit was done six months after our initial audit. Data was collected retrospectively from electronic medical records (EMR), medical notes and pharmacy records. Number of eligible patients attending ID and STI clinic over a period of 4 weeks in June 2021, and their vaccination status, was assessed. The reason for patients being unvaccinated was noted. Data from previous audit cohort was also re-examined to determine if they have subsequently received HPV vaccination.
Results: Data from previous audit showed that in January 2020, 33 patients (41%) out of 81 eligible patients who attended the service received HPV vaccination. After a reaudit, the number of eligible patients was revised to 74 (STI n=6, ID n=68), with 53 (72%) have now received vaccination, an increase of 31% from the first audit. In December 2020, following the appointment of a VNS, 152 (89%) out of 170 eligible patients (STI n=42, ID n=128) were vaccinated. In the reaudit, we found a further 8 patients have subsequently received vaccination, an increase to 94%. In June 2021, 108 eligible individuals attended ID/STI clinics (STI n=36, ID n=72). Of these, 92 patients (85%) have received vaccination. Explanations for the remaining 15% unvaccinated patients includes refusal, uncontactable/did not attend, or still awaiting appointment.
Conclusion: There is an increase in number of patients from previous cohort who are subsequently vaccinated. The availability of a VNS ensures that a high proportion of eligible patients receive their vaccination. This audit not only highlights the need for a VNS, but also the ongoing demand for the service from patients attending STI and ID service. Future audits are recommended to ensure adequate vaccine delivery to patients attending the service.Download #2021139 (977.75 KB)
"Native Tricuspid Valve Infective Endocarditis Case Presentation"
Principal Presenter: Orlaith Casey
Keywords: Infective endocarditis, Pulmonary abscess, MSSA
Clinical Case presentation:
A 40-year-old lady presented with a 2-day history of fevers preceded by a two-week history of productive cough and shortness of breath. She had completed a short course of steroids and antibiotics in the community for a presumed upper respiratory tract infection without improvement. She had no significant past medical history apart from a 25-pack year smoking history. She did not have a history of intravenous drug use and had no history of preceding medical or dental procedures.
She was afebrile on presentation. Respiratory exam was significant for wheeze, scattered crackles and grade 2 clubbing of her fingers. She had elevated inflammatory markers with a white cell count of 6.5 109L, neutrophil count of 4.8 109L and a CRP of 260.8mg/L and a normocytic anaemia of 8.8g/dL. There was 2+ blood on urinary dipstick. Serology was negative for HIV, hepatitis B virus and hepatitis C virus.
Blood cultures taken on presentation grew methicillin sensitive Staphylococcus aureus (MSSA). Sputum culture also grew MSSA. A chest X-ray showed numerous bilateral cavitating pulmonary parenchymal lesions, some of which showed cavitation, consistent with pulmonary abscesses. An initial transthoracic echocardiogram was normal but subsequent trans-oesophageal echocardiogram on day 20 showed a new mobile vegetation noted on the tricuspid valve with mild tricuspid regurgitation, leading to the diagnosis of native tricuspid valve infective endocarditis (IE) complicated by septic pulmonary emboli.
The patient was treated with intravenous flucloxacillin (2g QDS) for 4 weeks. Her blood cultures became negative after 4 days. She had an uneventful recovery and was well on OPD follow-up in 2 weeks
Isolated right-sided IE is responsible for approximately 10% of all IE cases. In right-sided IE, the tricuspid valve is involved more frequently than the pulmonic valve. Risk factors for right-sided IE include injection drug use, presence of a cardiac implantable electronic device or presence of an underlying right-sided cardiac anomaly. Right-sided IE is attributable to Staphylococcus aureus in up to 70% of cases.
Streptococci and enterococci are the next most common pathogens, accounting for 5-30% and 2-5% of cases respectively.
This patient represents a case of isolated native valve right-sided IE in the absence of typical risk factors. Patients with uncomplicated MSSA tricuspid native valve endocarditis can be treated with an appropriate beta-lactam antibiotic for two weeks. Complicated right-sided IE requires intravenous antibiotic treatment for four to six weeks.Download #2021138 (1.93 MB)
"HIV gp120 Alters the Human Macrophage Immunometabolic Response to Mycobacterium tuberculosis, and Impairs TNFα Secretion"
Principal Presenter: Kevin Brown
Keywords: HIV, Tuberculosis, Immunometabolism
Tuberculosis is one of the deadliest human diseases, with an annual incidence of 10 million cases and ~1.5 million deaths. Co-infection with HIV represents one of the greatest challenges to controlling the TB pandemic. Moreover, people living with HIV experience higher rates of TB and more complicated disease.
The early host immune response to Mycobacterium tuberculosis (Mtb) is a critical determinant of whether a host will develop TB disease, latent TB or clear the pathogen. Immunometabolism describes how changes in cellular metabolism can affect the immune response. A critical paradigm of an effective anti-tuberculous immune response involves glycolytic reprogramming of alveolar macrophages during the host-Mtb interaction. Alveolar macrophages are a known reservoir for HIV, yet the effect of concurrent HIV infection in human macrophages on the anti-tuberculous immunometabolic response remains largely unknown.
In the current study, the host immunometabolic anti-tuberculous response in human macrophages was examined in the context of HIV infection. Two different invitro models of chronic HIV were used to establish models of Mtb/HIV co-infection: HIV gp120, which is a surface protein on the HIV virion, was used to stimulate human monocyte-derived macrophages; and chronically HIV-infected U1 cells were used as a cell line model to characterise changes in gene expression profiles with virulent Mtb infection.
We found that HIV gp120 pre-treatment changed the macrophage immunometabolic response to Mtb. Specifically, HIV gp120 pre-treated macrophages no longer exhibited the same glycolytic reprogramming seen in control macrophages, instead exhibiting a more energetic phenotype characterised by comparatively increased oxygen consumption and reduced extracellular acidification rates. Concurrently, we found that these HIV gp120 pre-treated macrophages secreted significantly lower levels of TNFα in response to Mtb – a critical anti-tuberculous cytokine. Furthermore, we found that chronically HIV-infected U1 cells demonstrated altered gene expression profiles of enzymes integral to cellular glycolytic flux.
Understanding key components of the host anti-tuberculous immune response will be critical in any endeavour to embellish that response, through the development of novel host-directed therapies. These future therapies are likely to represent a cornerstone in the management of infectious diseases as we face into increasing antibiotic resistance, and may prove an effective therapy in the management of people with TB/HIV co-infection beyond ART.Download #2021137 (927.71 KB)
"SARS-CoV-2 Point of Care Antibody Testing - an emerging diagnostic to inform therapeutic and vaccine intervention"
Principal Presenter: Laura O'Doherty
Keywords: POCT, Antibody, SARS-CoV-2
As the COVID-19 pandemic progresses, identifying which populations will benefit from public health preventative and therapeutic interventions is becoming increasingly important. Determining SARS-CoV-2 antibody serostatus has multiple roles including assessment of community prevalence of infection, response to vaccination and in emerging COVID-19 therapeutics. Standard laboratory assays are not universally accessible, are time-intensive and in low-resource populations may be cost-prohibitive. We investigated the use of a lateral flow point of care test (POCT) for SARS-CoV-2 spike antibodies in comparison to a standard laboratory assay as part of the PRECISE Study, a cross sectional seroprevalence study of SARS-CoV-2 antibodies in Irish healthcare workers (HCW).
Serology samples were analysed using the Roche Elecsys-S Anti-SARS-CoV-2 assay for the qualitative and quantitative detection of total (IgG/A/M) anti-spike(S) antibodies. The Healgen SARS-CoV-2 Antibody Rapid Test Cassette, a lateral flow POCT was used to determine the qualitative presence of anti-S antibodies. Prepandemic serology samples were also tested via the POCT to serve as negative controls. Participant samples were analysed on both platforms to assess sensitivity and specificity of the POCT.
1512 samples were analysed. 1509 (99.8%) samples demonstrated anti-S positivity using the Roche assay with concordant results in 1475 samples (97.5%) via the Healgen POCT. 34 (2.2%) samples identified as positive via the laboratory assay returned discordant negative results via POCT. Concordant negative results in both platforms were seen for 3 samples (0.2%). All pre-pandemic negative control sera returned negative anti-S results via POCT. Sensitivity of the POCT was 97.5% and specificity 100% however the small negative sample size may affect these results.
We demonstrate robust sensitivity and specificity of the Healgen POCT for the qualitative identification of anti-S antibodies with a high level of correlation with a standard laboratory assay. Wider accessibility to SARS-CoV-2 antibody testing may be used to help identify high risk populations for SARS-CoV-2 infection and assess requirement for COVID-19 vaccines, including booster dosing. Rapid determination of individual SARS-CoV-2 serostatus may additionally aid decisions relating to antiviral therapeutics. POCT are likely to become an important part of our disease management and control strategy through the possible future waves of this COVID19 pandemic.Download #2021135 (1.11 MB)
"A Case of Emphysematous Pyelonephritis"
Principal Presenter: Annie O' Regan
Keywords: emphysematous, pyelonephritis
A 59 year old lady with no known medical history presented with a short illness characterised by fevers and left sided flank pain.
She was hypotensive requiring a noradrenaline infusion. Her abdomen was distended and tender in the left upper and lower quadrants. Laboratory analysis revealed a WCC of 11.1(109/L), CRP in excess of 700mg/L, urea of 25.8mmol/L and creatinine of 216umol/L. Her blood glucose was 38 and met criteria for diabetic ketoacidosis. She was commenced empirically on intravenous meropenem and gentamicin for sepsis.
Chest X-ray showed free gas in the left upper quadrant of her abdomen. CT imaging identified destruction of over 75% of the left renal parenchyma with gas fluid levels in the perinephric space. A diagnosis of emphysematous pyelonephritis (EPN) was made, and a left sided nephrostomy was placed.
A pure growth of Escherichia coli was isolated from blood and urine cultures and she received ongoing management with intravenous ciprofloxacin for planned treatment duration of 4 weeks based on antimicrobial sensitivities.
She responded well clinically to treatment and biochemically with a reduction in CRP and improvement in renal indices. Her HBA1C was 160 mmol/L and a new diagnosis of diabetes mellitus was made.
EPN is a rare necrotising infection characterised by the presence of gas in the renal parenchyma and surrounding tissues. EPN can progress to sepsis and multi organ failure without appropriate management. It is an important diagnosis to consider, particularly in those with suspected pyelonephritis, who fail to respond to conventional treatment.
EPN is associated with poorly controlled diabetes mellitus. High concentrations of glucose within the renal tissues, and the ischaemic environment created in the context of an associated microvascular nephropathy, aid in potentiating the growth of gas producing microorganisms. Over 90% of EPN cases are caused by the glucose fermenting Escherichia coli. Other responsible microorganisms include Proteus mirabilis, Klebsiella pneumonia and Pseudomonas aeruginosa.
Recognition of EPN represents a significant diagnostic challenge. Renal ultrasound has poor sensitivity in the identification of gas pathognomonic of EPN. CT remains the gold standard, with an ability to identity the presence and distribution of gas and evaluating the extent of damage to the renal parenchyma.
Medical management with appropriate antimicrobials and sepsis management with percutaneous drainage of retroperitoneal collections is often first line. Nephrectomy may be considered on those whom conservative management has failed.Download #2021134 (373.33 KB)
"COVID-19 inpatients eligible for sotrovimab: a single day review in a tertiary university hospital"
Principal Presenter: Siobhán O'Regan
Keywords: COVID-19, sotrovimab, COVID therapeutics
Ireland experienced the peak of the fifth wave of the COVID-19 pandemic in January 2022. Several novel COVID-19 therapies were introduced at this time.
The National Therapeutics Advisory Group’s(TAG) Clinical Prioritisation Framework guides decisions on allocation of limited COVID-19 therapies to higher risk individuals. Using this framework, we aimed to assess the proportion of inpatients with COVID-19 at a given timepoint who meet eligibility criteria for novel monoclonal antibody sotrovimab(acute COVID-19, not requiring oxygen therapy, high risk for progression to severe infection)to support its use in the treatment of hospitalised patients.
Data gathered for a Health Service Executive National Clinical Programme COVID-19 inpatient prevalence study were analysed. This involved a single-day chart review of inpatients at Beaumont Hospital with COVID-19 on January 11th 2022. Demographics, COVID-19 vaccination status, date of first laboratory confirmation of COVID-19, underlying conditions, medications, and disease severity were recorded. Severity was classified using the World Health Organisation COVID-19 Clinical Progression Scale. WHO level on day of review was recorded as well as maximum previous WHO level. Using the TAG Clinical Prioritisation Framework, patients not requiring oxygen were divided into four separate risk tiers based on age, vaccination status, and underlying conditions.
There were 65 COVID-19 inpatients on January 11th 2022, 6% of all hospitalised cases nationally. Of these, 6 were in ICU. Hospital-onset COVID-19 infection accounted for 29% (19/65). 25% had no prior COVID-19 vaccination (16/65).
Those who had no oxygen requirement to date accounted for 68%(44/65) i.e. WHO level 4 with no higher WHO level previously.
Of these; Tier 1 = 41%(18/44), Tier 2 = 0%, Tier 3 = 45%(20/44), Tier 4 = 5%(2/44), and 10% did not meet any risk criteria for clinical prioritisation(4/44). First laboratory confirmation of COVID-19 was within previous 5 days in 45% of these patients(18/40), of which 7 were Tier 1. Ultimately, only one patient received sotrovimab.
The majority of those with no oxygen requirement were at high risk for progression to severe COVID-19 and represent potential candidates for sotrovimab and other novel monoclonal antibody therapies. These data support the need to ensure adequate supply and infrastructure for the rollout of these COVID-19 therapies both in the hospital and outpatient setting.Download #2021133 (245.64 KB)
"An Audit of Cardiovascular Risk and Weight Assessment in an Irish Tertiary Referral HIV Clinic"
Principal Presenter: Aoife Heeney
Keywords: HIV, Cardiovascular, Weight
People living with HIV (PLWH) are at increased risk of cardiovascular disease. Weight gain is also an increasing issue amongst PLWH and has been shown to be associated with female sex, black race, tenofovir alafenamide (TAF) and integrase strand transfer inhibitors (INSTIs). INSTI associated weight gain has been shown to be greatest among women and non-whites.
The European AIDS Clinical Society (EACS) guidelines recommend an annual cardiovascular assessment with diabetic and lipid screen, blood pressure (BP) and BMI measurement, and smoking assessment. The aim of this audit was to investigate the adherence of Beaumont Hospital's HIV clinic with these guidelines.
We conducted a retrospective chart review of patients attending the clinic over 3 consecutive weeks in November 2021. A descriptive analysis was performed.
Data were collected on 60 patients. The median age was 46 (IQR 39-51). 48% were female (N=29) and 27 patients were of black race (45%). The median CD4 count was 704 (IQR 479-885) and 90% (N=54) had an undetectable viral load. 18% (N=11) of patients had hypertension (HTN), 30% (N=18) had dyslipidaemia, 7% (N=4) had diabetes mellitus and 2% (N=1) had ischaemic heart disease.
Over the previous 1 year 19 patients (32%) had their BP measured and 15 (25%) had their weight checked. Of note 30 patients (50%) had never had their weight checked in clinic. No patients had BMI recorded. Lipids were checked in 45 patients (75%), HbA1C in 42 patients (70%) and smoking status was documented for 24 patients (40%).
42 (70%) patients were on an INSTI, 41 (68%) on TAF and 33 (55%) on both an INSTI and TAF. 41 patients had been on a previous antiretroviral regimen which we compared to their current regimen to assess prescribing trends. The rate of INSTI prescribing had increased from 6 (15%) to 29 (71%), TAF from 8 (20%) to 30 (73%) and INSTI/TAF combination from 2(55%) to 22 (54%).
There was a low prevalence of cardiovascular disease in our cohort. We demonstrated reasonable compliance with lipid and HbA1C monitoring but poor compliance with BP and weight assessments and smoking status documentation. We demonstrated increasing rates of TAF and INSTI prescribing in a cohort with a high proportion of patients of black race. Efforts should focus on blood pressure and weight measurement in these high risk groups going forward.Download #2021129 (1.2 MB)
"Bone Mineral Density and Direct-Acting Antiviral Treatment of Hepatitis C; Data from the TRACER Cohort"
Principal Presenter: Daragh McGee
Chronic hepatitis C (CHC) infection and cirrhosis are independent risk factors for osteoporosis. Prior treatments for CHC were associated with a negative impact on bone mineral density (BMD), but the impact of direct-acting antivirals (DAA) is unknown. We aim to describe BMD in those treated with DAA for CHC.
This is a sub-study of a longitudinal cohort study investigating clinical and radiological outcomes of CHC treated with DAAs. Study visits including clinical, laboratory assessments, Fibroscan™ and Dual-energy X-ray absorptiometry (DXA) were completed before and after DAA therapy. Lower than anticipated for age was defined as Z score ≤−2.0. Baseline Lumbar Spine (LS) and Femoral Neck (FN) BMD are described with non-parametric exploratory analysis for associations with variables of interest. Change in BMD were assessed with Wilcoxon signed rank test. Data is presented as median (IQR).
Of 17 participants, 70.5% were male, aged 43 years (37.5-46). 52.9% were cirrhotic, 88.2% reported ever having used heroin, 41.1% were on methadone, 13.3% were alcohol dependent. None were co-infected with HIV or reported chronic kidney disease (eGFRs ≥60mL/min/1.73m2). Baseline LS and FN BMD were 1.118g/cm2 (1.004-1.205) and 0.945g/cm2 (0.817-1.106) respectively. 17.6% and 11.8% scored lower than anticipated for age at LS and FN respectively (Z scores: -0.8 (-1.6-[-0.02]) and -0.2 (-1.3-0.8)). Heroin use ever was associated with a 0.265g/cm2 lower LS BMD (1.083 vs 1.348g/cm2, P=0.04). Participants in employment had a 0.207g/cm2 higher LS BMD than those who were unemployed (1.213 vs 1.06g/cm2, p=0.03). Underweight/healthy weight participants had a 0.096g/cm2 lower LS BMD than overweight/obese participants (1.036 vs 1.132g/cm2, p=0.04). Participants with F4 fibrosis had a 0.165g/cm2 higher FN BMD (1.105 vs 0.886g/cm2, P=0.03). 52.9% had repeat DXA scans after therapy, interval between scans 524 days (409.5-662.5), with no significant change in BMD at LS (1.162 vs 1.164g/cm2, p=0.68) or FN (0.978 vs 0.992g/cm2, p=0.18).
Lower than expected BMD for age was common. Although underpowered due to attrition, we did not observe a significant change in FN or LS BMD after DAA therapy. Further research is needed to address bone metabolism in this vulnerable population with multiple risk factors.
"A National Campaign for Global Equity in SARS-CoV-2 Vaccination: Lessons for Pandemic Preparedness"
Principal Presenter: Ciara Conlan
Keywords: Vaccine, Equity, SARS-CoV-2
A first course of vaccination remains the single most effective intervention for protection against severe disease and death due to SARS-CoV-2 infection. Marked challenges in global vaccination roll out have resulted in over 3 billion people world-wide remaining unprotected from this vaccine preventable disease over one year after vaccine became available. WHO targets aim for 70% of populations to be vaccinated in order to protect against disease, as well as to reduce global viral load, break transmission and decrease risk of new variants. Here we report on our experience within a national campaign for equitable global vaccination and summarise lessons that can be applied to pandemic preparedness.
The Doctors for Vaccine Equity(DVE) group formed in partnership with a wide multi-disciplinary group including civil organisations and academics from fields such as business and intellectual property law. We complemented a national campaign for vaccine equity by providing technical expertise and applying medical orientated advocacy.
DVE launched an online platform in conjunction with Global Health partners in September 2021 and received official support from individuals and medical organisations. We carried out a live, cross discipline webinar including representatives from medical, scientific, population data, law and business fields. We raised public awareness by publishing in national press and providing interviews for national media. Political engagement garnered cross party support for our overall aims.
We identified several critical lessons applicable to future pandemic preparedness from our cross-disciplinary engagement.
Firstly, central global co-ordination and distribution of a new effective therapeutic intervention during a large scale infectious disease outbreak is critical to prevent severe disease and death as well as to bring transmission under control. We recommend consolidated national support for the World Health Organisation and their distribution initiatives.
Secondly, consideration should be given to how barriers to the procurement and distribution of critical therapeutics during infectious disease outbreaks could be overcome. We recommend examining public-private funding relationships such as pull/push models.
Lastly, reflection upon the extent to which global perspectives are incorporated within national public health policy during an international infectious disease outbreak would be beneficial. We recommend that platforms aiming to rapidly implement new therapeutic products in the future incorporate provision for the needs of global populations.
Medical advocacy work provides insights into cross-disciplinary frameworks for implementation of therpeutics during an international infectious disease outbreak. Lessons learned can support pandemic preparedness.Download #2021123 (756.26 KB)
"Introduction of Structured AMS Interventions by Clinical Pharmacists at an Irish teaching hospital"
Principal Presenter: Roisin O'Connor
Keywords: antimicrobial stewardship, pharmacist, e-prescribing
The threat of antimicrobial resistance is a global public health concern. Clinical pharmacists in acute healthcare settings have the expertise in medicines leadership to propose interventions and advise on effective antimicrobial therapy1,2.
To standardise antimicrobial stewardship (AMS) interventions made by clinical pharmacists, evaluate types of interventions made and uptake of recommendations.
Two training sessions were carried out in June 2019 with the clinical pharmacists at St James’s Hospital (SJH). A set of AMS intervention notes were given to the pharmacists, focusing on, duration of treatment, switching from IV to oral therapy and review/cessation of surgical prophylaxis. These notes could be saved on the e-prescribing system , including electronic Patient record and adjusted for the individual patient. The notes referenced parameters such as duration, C-reactive protein (CRP), white cell count (WCC), temperature and percentage bioavailability of certain antimicrobial agents. Pharmacists were encouraged to use these notes when querying antimicrobials for patients on their wards with the medical/surgical teams. Pharmacists were asked to log their interventions for the AMS team. The AMS team followed these interventions and if the advice was followed within 24 hours, the intervention was classed as “Accepted”.
There were 1346 interventions made by clinical pharmacists over 100 weeks. The most common intervention type was to consideration to “Discontinue” antimicrobial therapy, with an acceptance rate of 72% (Figure 2). Uptake of recommendations was > 60 % for all intervention types (Figure 2). The majority of the interventions (1117, 83%) were in the medical and surgical directorates.Download #2021120 (517.98 KB)
"Delayed haemolysis after IV Artesunate therapy for P. falciparum"
Principal Presenter: Roisin O'Connor
Keywords: malaria, artesunate, haemolysis
Background Malaria is the most serious parasitic infection worldwide. Early recognition and
appropriate prompt treatment is essential in order to reduce mortality and prevent onward
transmission. At our institution malaria is relatively uncommon with an average of 7 cases per
year from 2014 to 2018. Nationally 81 cases were notified in Ireland in 2019.Reports have been
published worldwide of delayed haemolytic anaemia related to artesunate use also known as
post-artemisinin or artesunate delayed hemolysis (PADH). This case represents the first report in
the Republic of Ireland of a patient with delayed haemolysis post IV artesunate.
Case(s) description A 27-year-old male presented to the emergency department with high
grade fever, myalgia, and headaches after returning to Ireland from a short visit home to
Angola.His initial parasite count was 14% (image 1) . He was diagnosed with severe P.
falciparum infection. He was treated initially with IV artesunate followed by oral
artemether/lumefantrine and discharged after 7 days.He was seen a week later in the infectious
diseases (ID) outpatient clinic where he complained of dizziness, shortness of breath and
palpitations. His haemoglobin (Hb) had decreased from 14.8g/dL to 9.8g/dL since first
admitted.He was subsequently admitted the following week with a Hb concentration of 8.0g/dL.
Total bilirubin was elevated at 52 μmol/L (conjugate bilirubin 16 μmol/L), reticulocyte count was
elevated (11.7%), LDH was high (703IU/L) and haptoglobins were low (<0.24g/L) in keeping with
a diagnosis of haemolytic anaemia. He had normal G6PD levels and his thalassaemia and sickle
cell screens were negative. He had a weakly positive Direct Coombes Test. No other cause of
haemolysis was identified.He was transfused 1 pool of platelets. His Hb concentration improved
and recovered within 9 days. This presumed adverse drug event was reported to Health
Products Regulation Authority.
Discussion Delayed Haemolysis is an under recognised, but reported side effect of artemisinbased
derivatives. This case highlights
the importance of follow-up monitoring of Hb
concentrations of patients treated with IV artesunate for up to 4 weeks post treatment. This
adverse event is usually self limiting in nature and should not deter clinicians from using this very
effective drug.Download #2021119 (1.19 MB)
"Vaccination and antimicrobial prophylaxis in post splenectomy patients"
Principal Presenter: Roisin O'Connor
Keywords: splenectomy, vaccination, antimicrobial prophylaxis
Background Asplenic patients or patients with hyposplenia are at a significantly increased risk
of serious infection with encapsulated bacteria. A previous audit in our institution identified that
there was a gap in care for patients post splenectomy with regard to education and
vaccination. Following this a service was developed to include referral to Infectious Disease (ID)
service for vaccination advice and education (information leaflet/alert card) by ID pharmacist and
nurse specialist. Patients are also offered follow-up of their booster vaccines either in our clinic or
by their General Practitioner (GP). An information letter is sent to GPs on discharge.To review
our multidisciplinary service we conducted this study to determine the rate of appropriate
vaccination and antibiotic prophylaxis in this cohort over a one year period.
Methods Patients who underwent a splenectomy from October 2018 to October 2019 were
identified using the patient’s Electronic Patient Record (EPR).
Results A total of 13 patients were referred to ID service post splenectomy during this study
period. Nine patients (69%) were followed up for vaccines in the ID outpatient clinic; the
remaining 4 patients (31%) were followed up by GP’s. 100% of patients referred to the ID clinic
for follow up received the appropriate vaccination course. For the 4 patients referred to GP for
follow up information was only available for one patient whom received all required vaccines.
100% (n=13) of patients received prophylactic antibiotics on discharge.12 (92%) of patients
received phenoxymethylpenicllin 666mg BD; while one patient (8%) received amoxicillin 500mg
OD. Only one patient was discharged with a standby emergency prescription for antibiotics
(Amoxicillin 1g) in the event of any signs of infection. Nine patients (70%) had the appropriate
documentation of immunization on the patients discharge summary.
Conclusions All patients who received vaccinations in the ID clinic were appropriately followed
up. Re-education regarding the importance of emergency antibiotics in addition to collaboration
with primary care to improve documentation and communication is required to further reduce
infection risk in these immunocompromised patients. A national splenectomy register would also
be a useful tool to identify patients who have not received vaccines or antibiotic prophylaxisDownload #2021117 (656.59 KB)
"Antimicrobial Stewardship and Antimicrobial Inpatient Prescribing during COVID-19"
Principal Presenter: Roisin O'Connor
Keywords: antimicrobial stewardship, covid 19, antibiotics
Background Current research suggests that only a small proportion of COVD-19 patients will
have a bacterial co-infection at presentation (typically less than 10%). A previous study in our
institution found that prolonged durations of antimicrobials were prescribed during wave 1 of
COVID-19 when there was a paucity of literature in this area.Appropriate use of antibiotics in line
with antimicrobial stewardship (AMS) principles is important to prevent unnecessary overuse of
these medicines, to avoid unnecessary toxicities and to reduce the risk of emergence of
Methods Inpatients with SARS-COV-2 PCR positive results reported during second wave of
COVID-19 i.e. from 02.08.20 to 14.12.20 were studied. Microbiological samples taken and
clinical condition were recorded. An antimicrobial stewardship (AMS) pharmacist clinically
reviewed antibiotic use during this time period and actively highlighted appropriate PO switches
and antibiotic duration review to the primary medical team.
Results A total of 77 patients were reviewed; 67 were prescribed antimicrobial therapy for lower
respiratory tract infections and a total of 132 antibiotic courses were prescribed. Respiratory
pathogens were identified in 6 patients; a total of 70 patients had appropriate microbiological
samples sent. The median duration of total antimicrobial therapy was 5 days.Compared to
antimicrobial prescribing in wave 1 (without active AMS review) overall duration of antimicrobial
therapy reduced from 7 to 5 days (p <0.0001); duration of IV reduced from 6 to 4 (p =0.0002). IV
to PO switch of antibiotics occurred more frequently in subsequent waves with active AMS
review; 76 cases versus 34 cases in wave 1.
Conclusions Active antimicrobial stewardship intervention in COVID-19 cases improved metrics
for appropriate antimicrobial prescribing.Download #2021116 (586.48 KB)
"An Audit of Hepatitis A booster vaccination status among HIV patients: A tertiary hospital experience in Ireland"
Principal Presenter: Sultan Al lawati
Keywords: Hepatitis A vaccine, Booster, People living with HIV
Background: People living with HIV(PLWH) are more vulnerable to vaccine preventable infections such as Hepatitis A, Hepatitis B, Streptococcus pneumonia. Recently, the National Immunisation Advisory Committee(NIAC) advised Hepatitis A vaccine booster every 10 years for fully vaccinated HIV patients who have an ongoing exposure risk.
Methods/Materials: A retrospective audit was conducted of the hepatitis A vaccination records of outpatients who attending the HIV clinic at St James's Hospital, Dublin. Data were collected using the Electronic Patient Record System (EPR).
Results: 593 current attendees of the HIV outpatients service were identified as having received hepatitis A vaccination at the clinic. Of the 593 patients involved in this analysis, 246 (41.5%) were from Ireland and 347 (58.5%) were from countries outside of Ireland. The HIV acquisition risk for the majority of attendees was MSM 416 (70%) with the acquisition risk of only 50 attendees (8.4%)identified as PWID. Regarding vaccination status, 417 attendees (70.3%) received a Hepatitis A vaccine within the last 10 years. 176 patients (29.7%) will require a booster as per the new recommendation from NIAC.
Conclusion: To our knowledge, this is the first audit of Hepatitis A vaccination booster receipt among HIV patients in Ireland.The majority of our patients received their vaccine within 10 years. Those who still require a booster dose will be identified and recalled to receive vaccination via the clinic’s outpatient vaccination service.Download #2021115 (377.75 KB)
"The Risks of the Frontline: An Audit of COVID-19 Infections Among Healthcare Workers in Midwest Ireland"
Principal Presenter: Alvina Zanb
Keywords: COVID, Infection, Healthcare
Since the onset of the coronavirus pandemic in 2019, caused by the novel SARS‐CoV‐2, healthcare workers (HCWs) have continued to work in high-risk environments and are among the largest groups in danger of developing COVID-19 infection. Despite high vaccination uptake, post-vaccination infection remains an ongoing issue. This study aims to collect data regarding COVID-19 infection in fully vaccinated healthcare workers to better quantify this risk.
Data was collected through a voluntary online questionnaire distributed to HCWs currently employed in University Hospital Limerick in Ireland. Data was collected regarding age, gender, profession (doctor/nurse), grade (Consultant, Registrar/Senior House Officer (SHO)/Intern/Ward Nurse/Clinical Nurse Manager (CNM)), COVID-19 vaccination and booster dose status, post-vaccine COVID-19 infection, diagnostic modality used and severity of symptoms.
A total of 83 HCWs participated in this study. Mean age of the participants was 36.86 + SD 9.8 (range of 25-62 years). 52 were female (62.7%) while 31 (37.3%) were male. Categorization into profession showed 91.6% doctors and 8.4% nurses. Further sub-categorization into grades found 38.6% were registrars, 22.9% SHOs, 18.1% interns, 12% consultants, 6% ward nurses and 2.4% Clinical Nurse Managers (CNMs). 100% of the participants were fully vaccinated with two doses of COVID-19 vaccination while 86.7% also had a third booster dose. 37 (44.6%) HCWs reported Covid-19 infection post-vaccination. Among them, 29 tested positive with PCR, 7 with rapid antigen testing and 1 with both PCR and antigen. The majority of HCWs who contracted COVID-19 (94.5%) had mild symptoms of infection. 2.7% were completely asymptomatic, while 2.7% required hospital admission due to the severity of symptoms. Data analysis found more cases of COVID-19 infection in HCWs without a third booster dose, with a significant p-value of <0.05. Consultants followed by interns had the highest rate of Covid-19 infection, although no statistically significant relationship was noted. No statistically significant relationship between vaccination status and severity of infection was found.
COVID-19 vaccination has led to a significant reduction in the severity of COVID-19 infection, as demonstrated by the high rate of mild or asymptomatic infection found amongst fully vaccinated HCWs in this study. However, HCWs remain at high risk of contraction due to daily close patient contact. The possibility of severe infection in some individuals therefore continues to occur. This study highlights the importance of compliance with recommended precautionary measures to reduce transmission of infection and in the efficacy of vaccination in the reduction of symptom severity.Download #2021113 (301.56 KB)
"Differentially-expressed immunological genes in mild and severe cases of COVID19"
Principal Presenter: Gabriel Gonzalez
Keywords: COVID19 early severity determinants, Downregulation of inflammation, Expression analysis in severe COVID19 patients
Background: Coronavirus disease 2019 (COVID19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has varied clinical presentations from mild subclinical to severe disease with high mortality. Our aim was to determine whether examining immune-related gene expression early in infection could predict progression to severe disease. Methods: In subjects of the All Ireland Infectious Diseases Cohort study, we analysed expression of 579 genes with the NanoString nCounter Immunology panel in peripheral blood mononuclear cells in those with confirmed SARS-CoV-2 infection collected within 5 days of symptom onset and matched SARS-CoV-2 negative controls with respiratory infection. Subsequent maximum COVID19 disease severity was classified as mild or severe. Read counts were normalized using panel housekeeping genes. Expression changes in severity groups were estimated against the control baseline. Results: Between April and July of 2020, we recruited 120 subjects, 62 with COVID19 and 58 controls, with average age 59 y.o. (IQR 34-88), 66% males and 69% Caucasian ethnicity. Maximal disease severity was used to separate COVID19 cases into mild (n=31) and severe (n=31). We identified 20 significantly deregulated genes between those with COVID19 and controls (|log2 fold|>0.5, p<0.05, Benjamin-Yekutieli p-adjustment). Function of 12 of these genes related to cytokine signaling, 9 upregulated genes to type I interferon signaling (MX1, IRF7, IFITM1, IFI35, STAT2, IRF4, PML, BST2, STAT1), while 7 downregulated genes mapped to innate immune function (IRF7, ICAM2, SERPING1, IFI16, BST2, FCER1A, PTK2). Expression in the severe group showed downregulation of FCER1A (innate immunity regulation), IL1B and TNF (inflammatory cytokines), and PTGS2 (inflammatory mediator) and greater upregulation of TNFSF4 (cytokine signaling) and PTK2 (innate immunity). Mild cases presented higher upregulation of IFIT2 (type I interferon signaling). Conclusions: Observed early downregulation of regulators and mediators of inflammation in those who developed severe COVID19, suggested dysregulation of inflammation. Specifically, IFIT2 upregulation in mild cases and FCER1A downregulation in severe cases, points to early differences in host responses centered on deregulation of the interferon and inflammation responses. Whether these patterns reflect delayed interferon involvement in pathways to control the infection and contribute to pathological inflammation and cytokine storms observed in severe COVID19 requires further research.Download #2021111 (641.76 KB)
"A comparison St James' VZV vaccination practices with international standards"
Principal Presenter: Dr Peter Conlon
Keywords: HIV, Vaccines, Varicella
People living with HIV (PLWHIV) are at increased risk of infection and suffer greater morbidity from vaccine-preventable diseases. This includes varicella-zoster (VZV) which can cause severe cutaneous rashes and life-threatening pneumonia, hepatitis, and meningitis amongst PLWHIV.
Last year we presented data at IDSI demonstrating the effectiveness of the VZV vaccination programme for PLWHIV. As part of this project, we identified a subset of patients who failed to mount an immunological response to VZV vaccination. Part of the subgroup analysis identified a cohort from this group who were not virally suppressed at the time of vaccination.
International best practice dictates that patients should have a CD4 count of greater than 200 cells/ml3  at the time of vaccination.
In order to further investigate this, we examined all patients who received the varicella-zoster virus vaccine between 2008 and 2021 to determine if their HIV was appropriately controlled at the time of vaccination.
This is particularly pertinent in the context of a live virus vaccine.
We examined the records of all patients vaccinated against VZV (Varivax vaccine). We identified 100 patients vaccinated between 2008 and January 2021. We cross-referenced the date of vaccination with our lab system and the National Virus Reference Lab’s (NVRL) records to identify if vaccination occurred when the patient’s CD 4 count was >200 cells/mml3. We also examined the patient’s HIV viral load at the time of vaccination (although HIVVL is not referenced in the BHIVA guidelines)
We used a CD4 count and HIVVL within 6 months of vaccination and considered <200 copies/ml to be virally suppressed. 
· Of the 100 patients recruited 83% had a CD4 count recorded within 6 months of vaccination. Of these patients 100% had a CD4 count greater than >200 cells/mml3
· 82% of patients whose CD4 was not available had a HIVVL <200 copies/ml
· Of the 100 patients recruited 82% had an HIV viral load recorded within 6 months of vaccination.
· 86.5% of patients whose HIVVL was available were virally suppressed at time of vaccination
Last year we presented our audit entitled ‘A retrospective analysis of the vaccination practices amongst the HIV population at St. James’s Hospital'. This project reported the effectiveness of the VZV vaccination programme with over 70% of those found to be non-immune vaccinated appropriately. A subgroup analysis identified a small number of patients who failed to mount an immunological response to vaccination. We hypothesized that these patients may not have been virally suppressed at the time of vaccination.
This lead us to complete this audit of the last 100 patients vaccinated for VZV between 2008 and 2021. We demonstrate that the vaccination clinic in St James’s GUIDe department has excellent compliance with international guidelines. 100% of our patients who had CD4 counts recorded within 6 months of vaccination had a CD 4 count >200 cells/mml3 at the time of vaccination.
17% (17 patients) of our patients didn’t have a CD4 count recorded within 6 months of vaccination. However, of these 17 patients 86% per virally suppressed (HIVVL<200 copies/ml). Viral suppression can be used as a surrogate marker for CD 4 count in this context
Compliance with these international standards is particularly important in the context of VZV vaccination as it is a live virus due to the risk vaccine-related zoster infection or shingles reactivation.Download #2021106 (1.26 MB)
"SARS-CoV-2 vaccination amongst people living with HIV: an Irish perspective"
Principal Presenter: Grace Buckley
Keywords: SARS-CoV-2, SARS-CoV-2 Vaccination, HIV
There is sparse data surrounding SARS-CoV-2 vaccination rates amongst people living with HIV (PLWH). While SARS-CoV-2 vaccination rates in Ireland were high, there remains a substantial degree of vaccine hesitancy among the population. There is evidence that SARS-CoV-2 and vaccination mistrust may be more prevalent for PLWH.This study aimed to establish SARS-CoV-2 vaccination rates, demographics of vaccination and to explore attitudes towards SARS-CoV-2 vaccination in PLWH in a tertiary centre.
Participants were recruited on attendance to the HIV out-patient clinic in University Hospital Limerick, a large centre in South-West Ireland. Data collection was performed via paper survey. Demographic data was analysed using MicrosoftExcel. Patient free-form responses to open-ended questions regarding reasons to ‘receive’ or ‘not receive’ the vaccine were read, discussed between authors and thematic categories which emerged identified. Free-form responses were then assigned to a category if the response fitted the category criteria in language or theme. Each response in a category represented n=1.
Thus far, the response rate was 30%. Twenty-two responses in total have been collected to date(n=22). Of responders, 21 (95%) were fully vaccinated. 1 patient (5%) was not fully vaccinated. Most patients were vaccinated in May 2021, with booster vaccines in December 2021. The most common vaccination setting was public vaccination centres. Of reasons listed for receiving the vaccine, prevalent response was to ‘protect myself’ (n=6) and to ‘avoid the side effects, complications or severity of COVID-19’ (n=6). Four responders listed receiving the vaccine due to their ‘immunocompromisation or immune status’. Within reasons to not be vaccinated, one response noted ‘not wishing to receive the vaccine’. Other themes which emerged were support for vaccination, trust in science and trust in the vaccine (n=5).
While studies to date show higher prevalence of SARS-CoV-2 vaccination mistrust in PLWH, this study has shown high levels of uptake. Limitations include possible reluctance of those who are not vaccinated to participate. As the pathophysiology of SARS-CoV-2 infection for PLWH remains undefined, interventions to mitigate risk in this population are an important public health measure. These interventions should include ongoing, open dialogue with PLWH to encourage vaccination.Download #2021105 (287.57 KB)
"EXTERNAL VALIDATION OF BIOMARKER CLUSTERS BASED ON PROTEIN BIOMARKERS"
Principal Presenter: Alejandro Garcia
People with HIV (PWH) exhibit chronic inflammation which may contribute to comorbidities. Using data from the POPPY study, we validate biomarker patterns identified in a previous independent smaller cohort of PWH and HIV-negative controls (McGettrick, CROI 2021).
The POPPY cohort includes 3 groups (PWH 50 yrs, PWH<50 yrs and HIV-ve controls 50 yrs) in England/Ireland. We measured 31 biomarkers, covering inflammatory pathways of systemic inflammation, axonal injury, immune regulation, microbial translocation, innate immune activation, endothelial function, coagulation and atherosclerosis. Following Principal Component Analysis of the log-transformed biomarkers, agglomerative clustering was used to group participants based on component scores. Between-cluster demographic and clinical differences were assessed for significance using Kruskal-Wallis/Chi-squared tests.
The 465 included participants (236 PWH 50, 107 PWH<50, 122 HIV-ve) had a median (interquartile range [IQR]) age 54 [50-60] years, 80% were male, 88% white, 71% men having sex with men (MSM) and median [IQR] CD4+ T-cell count (for PWH) was 610 [470-785] cells/mm3. Three clusters displaying distinct patterns of inflammatory biomarkers were identified: Cluster 1 (n=209, 45% of subjects) included those with generally low levels of inflammation; Cluster 2 (n=47, 10%) included those with increased markers associated with T-cell and B-cell activation and proliferation, and Cluster 3 (n=209, 45%) identified those with elevated levels of biomarkers across a range of inflammatory pathways (Figure). Those in each cluster were similar for most demographic/lifestyle variables: median age (54, 56 and 55 yrs, p=0.08); male (82%, 68%, 81%, p=0.08); white (90%, 87%, 85%, p=0.26); MSM (74%, 64%, 70%, p=0.33); and current alcohol use (84%, 87%, 80%, p=0.45). However, there were significant differences for HIV status (73%, 60%, 78%, p=0.03); obesity (BMI 30 kg/m2) (11%, 21%, 24%, p=0.002); median systolic blood pressure (126, 135, 126 mmHg, p=0.002); and history of cardiovascular disease (39%, 28%, 53%, p=0.001) and arthritis of knee/hip (8%, 9%, 16%, p=0.02).
The 3 clusters of distinct inflammatory patterns, associated with differences in important cardiometabolic features suggest the presence of biological phenotypes that may contribute to clinical outcomes. Whether this personalized approach can inform disease prevention and improved treatment for PWH with multimorbidity requires further studyDownload #2021104 (711.73 KB)
"Red Eye – Don’t Know Why? The Case for Including Inclusion Conjunctivitis in Your Differential Diagnosis"
Principal Presenter: Micheal Troy
Keywords: Chlamydia, Conjunctivitis, STI
A 24 year old gentleman presented to our service with a 9 month history of bilateral, recurrent, red, irritated eyes with watery discharge having been treated for conjunctivitis on multiple occasions in the interim. The patient denied any sexual contacts but stated that his symptoms began after sleeping on a “dirty couch”.
On examination he had large follicles prominent in the inferior fornix and also in the upper tarsal conjunctiva. There was superficial punctate keratitis bilaterally. Of note, he also had significant bilateral preauricular lymphadenopathy.
Swabs were sent for RNA-based nucleic acid amplification testing (Aptima Combo 2) which confirmed the diagnosis of chlamydia trachomatosis and the patient was started on empirical treatment with azithromycin topically and orally. The patient had no symptoms of urethritis and, interestingly, urine sampling failed to detect chlamydia.
He was referred to the Infectious Disease team for assessment and after three weeks of treatment his symptoms had greatly improved.
Chlamydia trachomatis is an obligate intracellular bacteria. It is responsible for trachoma, inclusion conjunctivitis, and lymphogranuloma venereum. The adult inclusion conjunctivitis is caused by serotypes D-K. Chlamydia trachomatis is the most common cause of chronic follicular conjunctivitis. It is a sexually transmitted disease occurring most commonly in young adults, females being more susceptible than males. The disease is usually transmitted via the hand-to-eye spread of secretions from the genitals and has an incubation time of one to two weeks. Due to the fact that the presenting features of chlamydia conjunctivitis mimic those of viral and other bacterial conjunctivitis, many of these patients tend to have been previously treated with topical antibiotics without any symptomatic relief. Chlamydia may resolve spontaneously and this may be the reason for the failure to detect chlamydia on urine testing in this case. Upon diagnosis, sexual partners of the patient should be contacted and evaluated. Coinfection with other sexually transmitted diseases should also be considered.Download #2021103 (119.36 KB)
"Dermatology patient vaccination uptake, over sixty-five years old, on Biological Treatment."
Principal Presenter: Dr. Aisling Egan
Keywords: Biological Therapy, Elderly patients, Vaccinations
Dermatology patient vaccination uptake, over sixty-five years old, on Biological Treatment.
Biologic and immunosuppressive therapies play important roles in the management of a wide variety of dermatologic diseases. However, immunotherapies can negatively affect normal immune functioning, placing these patients at high risk of infection. The strength of the immune system also declines with increasing age. Thus, in accordance with the British Association of Dermatology (BAD) guidelines (August 2021), patients taking biologic therapy can and should have their covid, influenza and pneumococcal vaccinations.
We conducted a retrospective audit of all patients over the age of 65 years on biological therapy in the dermatology clinic between March 2021 to March 2022. Data on vaccination status was obtained from Dermatology database and patients medical records.
18 patients over the age of 65 years, were on biological therapy in the Dermatology Department, between March 2021 to March 2022. The mean age was found to be 71 years with a standard deviation of 5.2 and there was equal gender distribution.
100% (n=18) had all three of their covid-19 vaccines. 50% (n=8) are awaiting their 4th covid vaccination. 94% (n=17) of patients had their influenza vaccine. 66% (n=12) had their pneumococcal vaccination, the patients who had not had their pneumococcal vaccination were recommended and advised to have it.
This audit confirms dermatology patients over the age of sixty-five years, are compliant on receiving their covid vaccinations, as recommended by the BAD. However, only 66% of patients had their pneumococcal vaccination and 94% had their influenza vaccine, illustrating the need for educational intervention on the importance of vaccination. This will then be followed by a reaudit next year to complete the audit cycle.
1. Gresham LM, et al. An evidence-based guide to SARS-CoV-2 vaccination of patients on immunotherapies in dermatology.J Am Acad Dermatol.2021;84(6):1652-1666. doi:10.1016/j.jaad.2021.01.047
2.British Association of Dermatology, ‘Immunisation recommendations for children and adult patients treated with Immune-suppressing Medicines’, May 2018, https://www.bad.org.uk/shared/get-file.ashx?id=210&itemtype=document,Accessed 30th March 2022.
3. Tumelty, M., et al. (2022). COVID-19 Vaccination and Legal Preparedness: Lessons from Ireland. European Journal of Health Law (published online ahead of print 2022), Available From:Brill https://doi.org/10.1163/15718093-bja10064[Accessed 30 March 2022]
4. British Association of Dermatology, ‘Dermatology Advice regarding self-isolation and immunosuppressed patients’, August 2021, https://www.bad.org.uk/shared/get-file.ashx?itemtype=document&id=7234,Accessed 30th March 2022.Download #2021102 (223.54 KB)
"The complexities in diagnosing and treating endophthalmitis in the post stem cell transplant setting."
Principal Presenter: Dr Peter Conlon
Keywords: Transplant, Diagnostics, Haematology
Endophthalmitis is a rare but sight-threatening manifestation of systemic infection. Immunosuppression is a well-recognized risk factor for the development of endophthalmitis. Determining the aetiology can be complex, particularly in post stem cell transplant setting.
We present the diagnostic and treatment dilemmas associated with a patient who complains of blurred vision 2 weeks following an allogeneic stem cell transplant for refractory stage IIB Hodgkin’s lymphoma. We demonstrate that in the context of immunosuppression post-stem cell transplantation a broad differential should be maintained until a microbiological diagnosis can be confirmed. In particular, we evaluate how clinical suspicion can diverge from typical fundoscopic findings in the diagnosis of endophthalmitis.
The use of molecular diagnostics allowed us to make a diagnosis of Staphylococcal aureus endophthalmitis despite the fundoscopic appearance being typical of a fungal aetiology. A 12-day course of IV Meropenem and IV linezolid resulted in the resolution of infection resulting in a return to normal vision for our patient.
In the post-transplant setting, with a sight-threatening condition, it is important to maintain a broad differential until a microbiological diagnosis can be secured. Any new visual symptoms warrant an opinion from an ophthalmologist.
It is important to recognize that not all systemic antimicrobials penetrate into the intraocular space and there is limited data on intravitreal concentrations of systemic antibiotics.
Ultimately, a diagnosis was secured with the use of molecular diagnostics. The importance of input from microbiology or infectious disease specialists in advising on laboratory testing in complex cases such as this cannot be underestimated.Download #2021100 (220.35 KB)
"Candidaemia and the Eye: to Screen or not to Screen?"
Principal Presenter: Brian Woods
Keywords: candidaemia, endophthalmitis, guidelines
Endogenous ocular involvement is a rare but sight-threatening complication of candida bloodstream infection (BSI). Recent studies have shown that the prevalence of ocular candidiasis is much lower than previously reported. New guidelines from the Royal College of Ophthalmology and the American Academy of Ophthalmology do not recommend routine ocular screening for all patients with candida blood stream infection as was previously advised, rather targeted screening of those at increased risk or those with symptoms/signs of ocular involvement. In accordance with international infectious disease guidelines however, an ophthalmology consult is advised in St Vincent’s University Hospital (SVUH) for all patients with candida BSI. We wished to determine the proportion of patients with candida BSI that were seen by ophthalmology in SVUH, and establish the prevalence of ocular involvement.
A retrospective chart review was carried out on all patients who had candida BSI in SVUH over a one-year period.
There were 79 positive blood cultures for candida in 38 patients in 2018. Data was available for 89% patients. 66.7% were treated with fluconazole. Ophthalmology were consulted on 55.9% patients. The majority of patients not seen had died prior to consult. 26.3% patients seen were sedated and intubated in ICU, the remainder were alert. None of the patients were noted to have new visual symptoms. 68% patients had a completely normal ocular exam. No patients had evidence of candida endophthalmitis or chorioretinitis. 32% had unrelated incidental ocular findings.
Routine screening of all patients with candidaemia for ocular involvement is a low-value care practise. Based on our results and international recommendations, we are proposing new guidelines for ocular screening in the setting of candidaemia. We recommend ophthalmology consultation in the following cases: alert patients with new onset decreased vision in either eye or an abnormal bedside examination, and non-alert patients with an abnormal bedside examination or increased risk factors. Selective screening of patients on a case-by-case basis should reduce unnecessary examination and intervention which could cause harm.Download #2021093 (1004.45 KB)
"Bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) for the treatment of people living with HIV (PLWH): 12-month (12M) effectiveness, persistence, and safety in a multi-country cohort study"
Principal Presenter: John Jack Lambert
Keywords: biktarvy, bictegravir, INSTI
Purpose: BICSTaR is an ongoing, multi-national, observational cohort study evaluating real-world effectiveness and safety of B/F/TAF in ART-naïve (TN) and ART-experienced (TE) PLWH.
Methods: This 12M pooled analysis included PLWH starting B/F/TAF in clinical practice from June 2018 to September 2020 (latterly during the COVID-19 pandemic) in Europe/Israel/Canada. Outcomes included virological effectiveness (HIV-1 RNA <50 copies/ml [missing=excluded]), persistence, drug-related adverse events (DRAEs), and laboratory parameters.
Results: 1,135 PLWH were included. The TE group had older median age than TN. Of TE participants, 65%/20%/16% switched from INSTI/NNRTI/PI-based regimens (36% TDF/46% TAF/13% ABC); 12% had prior virologic failure. Baseline resistance was documented in 124/535 participants (NRTI / NNRTI / PI / INSTI = 6%/6%/3%/0.2%). Prevalence of comorbidities (47%/72% TN/TE) and concomitant medication usage was high.
At 12M, 97% (149/154) of TN and 96% (771/800) of TE participants had HIV-1 RNA <50 copies/ml, and persistence on B/F/TAF was high (91% [1032/1135]). Effectiveness measures are reported for subgroups. In a multivariable analysis, TE participants with neuropsychiatric disorder ongoing at baseline had lower odds for viral suppression (odds ratio=0.45, 95% CI 0.21-0.96). There was no emergence of resistance to the components of B/F/TAF. DRAEs occurred in 13% (148/1135) of participants; gastrointestinal and neuropsychiatric DRAEs were the most common (3% each). Discontinuations due to DRAEs were low (TN 4%; TE 6%). Serious DRAEs were rare (0.2%; 2 TE participants with depression).
Conclusion: B/F/TAF was associated with high levels of effectiveness and persistence after 12M in this large real-world cohort of TN and TE PLWH with a high comorbidity burden. Effectiveness was demonstrated across key subgroups (females, older participants, late presenters). Importantly, there were no new or unexpected safety findings. Collectively, these real-world data continue to support the use of B/F/TAF in clinical practice.Download #2021091 (566.84 KB)
"Long Covid - Prevalence, Symptoms & Risk Factors. A Literature Review."
Principal Presenter: Harry Sheehy
Keywords: Long Covid, SARS-CoV-2, COVID-19
Background and Aims: COVID-19 is caused by infection with the SARS-CoV-2 virus strain, which is believed to have emerged in late 2019 in Wuhan, China. Long-COVID is a condition characterised by persistence of symptoms beyond recovery from acute SARS-CoV-2 infection (12 weeks after the onset of acute illness), with symptoms that last for at least two months and cannot be explained by an alternative diagnosis. Frequently reported post-acute COVID symptoms include fatigue, dyspnoea, anosmia and cognitive dysfunction. In this systematic review, our aim was to review currently available literature and determine the prevalence, common symptoms and possible risk factors associated with the development of long-COVID.
Methods: We searched five electronic databases - PubMed, Medline, Embase, Cochrane, Web of Science and Scopus for the following keywords: “Long-COVID”, “post-COVID19 syndrome” and “post-COVID condition”. Strict inclusion and exclusion criteria were applied. High quality observational cohort studies only were included.
Results: After screening the titles and abstracts of 369 results yielded by our search, 28 papers were extracted for full text review. A total of 9 studies were included in the analysis of this review. The studies reported on a total of 8,092 subjects, and included those with mild, moderate and severe COVID-19 infections. All studies reported at least one symptom persisting beyond four weeks after the onset of acute illness. In general, over 15 symptoms were reported and most commonly, fatigue, anosmia, and dyspnoea. Some studies found positive correlations between age, gender, a higher number of symptoms or the severity of the acute illness and the development of lingering symptoms. However, these findings were not consistent.
Conclusion: Long-COVID is a complex condition with varying symptoms and degrees of severity. It can be concluded from this review, that the likelihood of developing long-COVID increases with the increasing age, and in those who reported a higher burden of symptoms in the acute phase of illness, or those who had severe disease and required hospitalisation.Download #2021090 (259.56 KB)
"National Antimicrobial Point Prevalence Survey in Older Persons Residential Care Facilities (RCFs)"
Principal Presenter: Aisling Clancy
Keywords: Older Persons, antimicrobial, prophylaxis
Background: HALT study 2016 found residents in Irish RCFs were twice as likely to be on systemic antimicrobial compared with the European average (10% versus 5% prevalence). National antibiotic prescribing guidelines are available at www.antibioticprescribing.ie and prescribers in community settings are encouraged to choose ‘green’ (preferred) antibiotics over ‘red’ (reserved) agents. HSE Community Antimicrobial Pharmacists (AMPs) were employed for the first time in community settings in 2020. We aimed to establish the quality and quantity of antimicrobial prescribing in older persons RCFs to inform antimicrobial stewardship activities in this setting going forward.
Methods: All residents in HSE older persons RCFs were surveyed by AMPs between October 2020 and August 2021. All medication charts were reviewed for systemic antimicrobials prescribed within previous 30 days. Medical notes, and laboratory results if possible, were reviewed for persons on antimicrobials. Adherence to guidelines was assessed. Information was obtained from the person in charge on practices related to antimicrobial use.
Results: A total of 4448 individuals in 121 facilities across the country were surveyed. 12% of persons were on systemic antimicrobial at time of survey. 27% of persons received an antimicrobial within the last 30 days. 50% of antibiotic use on day of survey was for prophylaxis (6.3% of all residents). Prophylactic antibiotic use exceeded 6 months in 66% persons, and exceeded 12 months in 57%. There was high usage of green versus red agents (65% vs 30%). Co-amoxiclav (red) was most commonly prescribed agent for treatment of infection (19%). 42% of sites reported routine use of dipstick urinalysis to support diagnosis of urinary tract infection (UTI) in asymptomatic residents. One third of facilities (36%) did not have onsite electronic access to laboratory results. Only 7% of nursing staff were aware of national community antimicrobial prescribing guidelines. 61% of facilities did not record residents’ pneumococcal vaccination status.
Conclusion: Antimicrobial use, particularly for prophylaxis, is prevalent in older persons RCFs. Key national recommendations for antimicrobial stewardship in older persons RCFs:
1. Review all UTI prophylaxis within 6 months of initiation with view to de-prescribing.
2. Cease practice of routine use of dipstick urinalysis to support diagnosis of UTI for asymptomatic persons.
3. Electronic access to laboratory results on-site required to support timely decision-making for optimal use of antimicrobials.
4. All staff should be aware of the national antimicrobial guidelines.
5. Pneumococcal vaccine status should be determined, with vaccination provided as necessary.Download #2021089 (567.45 KB)
"Trends in the detection of bovine respiratory viruses in Ireland between 2011 and 2021, with an emphasis on bovine corona virus (BoCoV)."
Principal Presenter: Dr Damien Barrett
The recent emergence of SARS-COV-2 has increased interest in the epidemiology of corona viruses in various species. Bovine respiratory disease (BRD) is one of the most significant endemic disease affecting the cattle industry. Bovine Corona Virus (BoCoV) is a ubiquitous pathogen of cattle in several countries and has assumed a greater importance in Bovine respiratory disease in recent years. The purpose of this study is to examine trends in the detection of bovine respiratory viruses with a particular emphasis on BoCoV in samples submitted to the Central Veterinary Laboratory between 2011 and 2021.
Private veterinary practitioners submitted swabs to the Dept of Agriculture’s Veterinary Laboratory service for respiratory virus PCR to identify the causative agents in outbreaks of bovine respiratory disease. The client details and test results were recorded into the Laboratory Information Management System. These data were downloaded into excel spreadsheets and a descriptive analysis was carried out.
Between 2011 and 2021, respiratory viruses were detected in 6,095 of the 13,037 samples submitted to Virology Division. BoCoV was the most common isolate from calves (n=852, 19.2%), BRSV from weanlings (n=410, 25.9%), BHV1 from one to two year old cattle (n=143, 17.8%) and adult cattle (n=366, 14.6%).
Over the ten year period, BoCoV was the most commonly detected (n=1955), followed by BRSV (n=1938), BHV 1 (n=1,840) and PIV3 (n=1169). However, there was considerable year on year variation in the relative importance of each of the respiratory viruses. The relative importance of BHV1 has declined over the period, falling from 350 in 2011 to 103 in 2021. By contrast, the detection of BoCoV has been quite cyclical, falling from a high of 296 in 2011 to a low of 6 in 2015, and rebounding to a high of 339 in 2019. BRSV showed a similar pattern, with a high of 268 in 2012 to a low of 34 in 2015, increasing to 263 in 2019.
BoCo was most commonly detected among calves and was the predominate isolate among calves. It was the second most common isolate among weanlings. Since 2019, BoCoV has been the most commonly detected bovine respiratory virus. There has marked year on year variation in the incidence of BoCoV. Increased incidence may be related to the emergence of new variants and reduced incidence may be related to increased population immunity
"Setting up a National Serosurveillance Programme in Ireland Using Residual Sera Sourced from General Practice – Pilot Evaluation"
Principal Presenter: Dr Thomas Roux
Keywords: Serosurveillance, COVID-19, Pilot evaluation
The need for timely serosurveillance of infectious diseases of public health importance was evident during the COVID-19 pandemic. However, representative population-based seroprevalence studies are time and resource intensive. Under direction of Ireland’s National Department of Health, the Health Protection Surveillance Centre (HPSC) proposed a National Serosurveillance Programme using residual General Practice (GP) sera samples. A pilot phase of the programme was evaluated to determine feasibility, acceptability and practicality of proposed processes.
An expression of interest (EOI) survey was circulated to all hospital laboratories in Ireland in July 2021. Interested respondents were invited to bilateral virtual meetings with the Programme to develop and refine standard processes (SOPs) in collaboration with clinical leaders during August and September, 2021. Using agreed SOPs, laboratories participated in a one-week pilot collection of 100 residual samples in October, 2021. Following SARS-CoV-2 antibody testing in the National Virus Reference Laboratory (NVRL), and analysis in the HPSC, an evaluation of the overall process was conducted in November, 2021. Evaluation involved a Qualtrics survey of the participating laboratories assessing all steps of the SOPs with an option for follow up meeting, and document review during virtual workshops using semi-structured topic guides with NVRL and HPSC respectively.
Eighteen of thirty-nine hospitals responded to the EOI survey. Eight hospitals agreed to participate in the pilot. In all, 791 of 800 expected samples were collected over a one-week period. The largest challenge identified by participating laboratories was staffing due to resource intensive need for manual anonymisation of specimens, with average 18-person work hours needed to collect 100 specimens (range: 6-40 hours), at an average cost of €528 per 100 specimens (range: €300-€1,000). Six of the eight participants indicated willingness to participate in further collection rounds, with an average 150 specimens per collection week possible (range: 100-300). Only minor documentation edits were identified as changes required to facilitate the process at HPSC and NVRL.
The pilot phase successfully showed that surveillance using residual GP specimens is a feasible alternative to population based seroprevalence studies, despite varied laboratory practices. Utilising a partnership approach with active engagement throughout the pilot kept laboratories on board, even at a time of increased laboratory work load and staff shortages due to the pandemic. Residual sera serosurveillance is more timely, less resource intensive and more feasible to repeat on a regular basis. The Irish National Serosurveillance Programme has now been implemented following this successful pilot.Download #2021087 (219.17 KB)
"BVD seroprevalence in the Irish cattle population as we approach BVD freedom"
Principal Presenter: Dr Damien Barrett
Bovine Viral Diarrhoea Virus (BVDV) infection remains endemic in many countries worldwide. In recent years there has been progress in several countries, including Ireland, in the control and eradication of BVDV. Managing such eradication programmes requires careful monitoring of diseases prevalence and understanding factors associated with BVD
exposure to ensure eradication programmes remain evidence based and tailored to the evolving epidemiological situation.
In this study, we explore the seroprevalence of BVDV exposure over a four-year period (2017 to 2020) in Ireland from a cohort of animals (n = 6,449) under 30 months of age sampled at slaughter, who were born subsequent to the commencement of a compulsory national eradication programme. Temporal trends and risk factor analysis were undertaken
using multilevel logit regression models.
There was a declining temporal trend in seroprevalence over the sample years of the study, and risk varied at both county and herd levels. The unadjusted marginal animal-level seroprevalence reduced from 9.1 % in 2017 to 2020 (95 %; CI: 7.2 - 10.9) to 3.9 % (95 %; CI: 3.2 - 4.6). The final model suggested that seropositivity in study cattle was strongly
related with the presence of a PI animal in the herd during the year of the animal’s birth, and to a lesser extent the status of the herd from which the animal was slaughtered. The risk of seroconversion increased significantly with increasing herd size, in females relative to males,
and in dairy relative to suckler herds.
This study has shown that the BVD serostatus of cattle at slaughter is well correlated to the BVD infection history of the herd into which the animal was born and the herd from which it was slaughtered. Herd location, increased herd size and dairy production were associated with increased probability of serconversion. These findings may be used to inform the targeting of surveillance strategies once BVDV freedom has been achieved.
"B/F/TAF five-year outcomes in treatment-naïve adults"
Principal Presenter: Samm Kabagambe
Keywords: bictegravir, long-term, biktarvy
Background: Bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) is a guidelines-recommended regimen for people with HIV-1 (PWLH). We present 5-year cumulative outcomes of two phase 3 studies of B/F/TAF in treatment-naïve PWLH.
Methods: We conducted 2 randomised, double-blind, phase 3 studies of B/F/TAF in treatment-naïve adults – Study 1489 (1489) vs DTG/ABC/3TC and Study 1490 (1490) vs DTG+F/TAF. After 144W of blinded treatment, participants were offered continuation of B/F/TAF for 96W in open-label extensions (OLEs). Efficacy was assessed as proportion with HIV-1 RNA <50 copies/mL at each visit after starting B/F/TAF using missing=excluded analysis); safety by adverse events (AEs) and laboratory results. Bone mineral density (BMD) was measured in 1489 only. We present cumulative results for participants treated with B/F/TAF in randomised and/or OLE phases through a maximum of 240W of follow up.
Results: 314 participants in 1489 and 320 in 1490 randomised to B/F/TAF with 252 and 254 enrolled in OLE, respectively. 315 randomised to DTG/ABC/3TC in 1489 and 325 randomised to DTG+F/TAF in 1490 and 254 and 265 enrolled in OLE, respectively. Baseline (BL) demographics of B/F/TAF participants in 1489 and 1490 include: median age 31 and 33, 9% and 13% female, 37% and 30% Black/African descent, respectively. Efficacy was >98% after W48 at each study visit through W240 in both studies. No resistance to components of B/F/TAF was detected. During the OLE, 6/504 B/F/TAF participants experienced an AE that led to drug discontinuation, none were renal; ≤1.6% had a Grade 3 or 4 drug-related AE. Among B/F/TAF participants through W240, median changes in eGFR: -8.2 mL/min (1489) and -8.5 mL/min (1490). Median change in weight from BL to W240 was 6.1kg in B/F/TAF participants; median weight change for comparators at W144: 3.5kg (1489) and 5.0kg (1490), with 2.4kg and 1.3kg additional gains observed between W144 to W240, respectively. Mean % changes (SD) in hip and spine BMD through W240 in B/F/TAF participants were -0.29% (5.29) and -0.23% (5.16), respectively.
Conclusion: Over 5 years of follow up in treatment-naïve persons living with HIV, B/F/TAF was well tolerated and highly efficacious. These results confirm long term safety and efficacy of B/F/TAF.Download #2021085 (287.21 KB)
"Long acting lenacapavir in people with multi-drug resistant HIV-1: Week 52 results"
Principal Presenter: Ross Hamilton-Shaw
Keywords: lenacapavir, HIV, long-acting
Background: Lenacapavir (LEN), a potent first-in-class inhibitor of HIV-1 capsid function, is in development for treatment and prevention of HIV-1 infection. CAPELLA is an ongoing, phase 2/3 study in heavily treatment-experienced (HTE) people with HIV-1 (PWLH) with multidrug-resistance and ongoing viremia (≥ 400 c/mL).
Methods: In the randomised cohort (Cohort 1), participants were assigned (2:1) to add oral LEN or placebo to their failing regimen. At D15, those on oral LEN received subcutaneous (SC) LEN 927 mg every 6 months; those on placebo started the 2-week oral lead-in, followed by SC Q6M. All randomised participants initiated an investigator-selected, OBR at D15. In the non-randomised cohort (Cohort 2), participants started OBR concurrent with LEN (oral lead-in → SC). We report the secondary endpoint of W52 efficacy by FDA-snapshot algorithm in the randomised cohort and additional available efficacy and safety from both cohorts.
Results: 72 participants were enrolled: 36 in each cohort. Overall, 25% were female, 38% Black, median age 52 years, 19% VL > 100,000 c/mL, 64% CD4 <200 cells/μL, 46% had HIV-1 resistance to all 4 major classes, and 17% had no fully active agents in OBR. At W52, in Cohort 1 83% (30/36) had VL< 50 c/mL; most in Cohort 2 have not reached W52 yet. At W52, CD4 count increased by a median 74 cells/μL (Q1 to Q3: 21 to 142, n=37). Eight participants had emergent LEN resistance (4 in Cohort 1 and 4 in Cohort 2); other than 1 who died at W10 (previously reported), all 7 either had evidence of poor adherence to the OBR (n=4) or had no fully active agents in the OBR (n=3). No participant experienced a study drug-related serious adverse event. One participant discontinued LEN at W52 due to a Grade 1 injection site nodule. LEN-related injection site reactions (ISRs) occurred in 63% (45/72) and were mostly mild or moderate (43/45). The most common non-ISR AEs were nausea and diarrhoea (13% each) and COVID-19 (11%).
Conclusion: Subcutaneous LEN in combination with OBR led to high rates of virologic suppression and immunologic recovery in HTE PWLH at one year and was well tolerated.Download #2021084 (720.59 KB)
"Haemolysis in Severe Malaria - Disease or Drug"
Principal Presenter: Siobhan Quirke
Keywords: Falciparum Malaria, Anaemia, Antimicrobial
We present the case of a 41 year old male who was treated for severe Falciparum Malaria in our facility.
A 41 year old Filipino male, travelled to Ireland by sea from South Africa. He presented with a ten day history of pyrexia and feeling generally unwell. Initial blood film revealed a parasitaemia level of 17%, highly suspicious morphologically for Falciparum species, this was later confirmed. SARS- CoV- 2 PCR and several sets of blood cultures were negative.Initial blood tests revealed several complications including hyponatraemia, hypocalcaemia, acute kidney injury, thrombocytopenia and lactic acidosis. According to local guidelines he received intravenous artesunate and empiric ceftriaxone. He was later switched to oral Artemether/Lumefantrine once he had clinically improved. On day 4, while still paristaemic, our patient developed acute haemolytic anaemia (Hb 7 g/dL). Lactate dehydrogenase (LDH) was elevated and reached a peak of 1’679 mmol/L . Reticulocyte count was also increased and peaked at 476 10^9/L (19.6%). Bilirubin was normal, as were iron studies, B12, ferritin and mean corpuscular volume (MCV). He had a negative faecal occult blood test and no clinical signs of bleeding. His hemoglobin partially recovered but he had a second acute drop to 5.7 g/dL on day 12 of admission (following completion of parenteral artesunate and parasite clearance). This was associated with recurrent pyrexia and the development of haemoglobinuria on day 14. He required five blood transfusions to maintain a Hb level greater than 7 g/dL and was commenced on folic acid replacement. After a 21 day hospital admission his Hb stabilised above 8 g/dl and haemoglobinuria resolved.
Anaemia is a well recognised complication of severe malaria and can be caused by the parasite itself or anti-malarial medications. The pathophysiology of anaemia in falciparum malaria is complex and multifactorial. Malaria can cause haemolysis by two main mechanisms; immune mediated or non-immune mediated. The main cause is non-immune, which results from direct destruction of red blood cells by the parasite. Haemolysis has also been associated with parenteral artesunate use with a proportion of patients experiencing ongoing or delayed haemolysis after parasitological cure. This has been termed post-artemisinin delayed haemolysis (PADH). This case highlights diagnostic uncertainty with this complication of disease, but also demonstrates the increased morbidity and prolonged lenght of hospital stay associated with anemia in severe malaria.Download #2021083 (386.82 KB)
"The Impact of HIV Teaching Sessions for Junior Physicians"
Principal Presenter: Siobhan Quirke
Keywords: HIV, Medical education, NCHD
In 2021 we marked the 40th anniversary of the first official reporting of HIV/AIDS, we paused to reflect on how far we have come and to remember the more than 32-million lives lost from HIV related illnesses. Despite the progress we have made, HIV persists to be a serious public health challenge globally. The gap between achievements to date and the goal of ending the HIV epidemic remains wide and this year we fell short of UNAIDS 2020 targets. The new Fast Track targets for 2030 will endeavour to close these gaps and focus on a global effort to end this epidemic. Early testing, access to care facilities, education and addressing stigma are at the heart of this effort.
Amidst a renewed global commitment to ending HIV transmission it is a crucial time to increase our testing rates and continue to work towards reducing stigma. Non-consultant hospital doctors (NCHDs) are at the frontline of our health service in Ireland. They are often the first point of contact for a patient who attends the emergency department or to a clinic, deciding what initial investigations are performed and what treatment is commenced. Educating NCHDs is a crucial step to increase HIV testing rates and to tackle stigma amongst healthcare workers. I delivered two hour long teaching sessions on HIV to the intern and senior house officer (SHO) groups in my current hospital. My aim was to provide a basic overview with an emphasis on the importance of testing asymptomatic at risk individuals or those with HIV indicator conditions.
I surveyed each group before and after the teaching session. The survey was composed of eighteen questions. The topics varied from HIV epidemiology to testing guidelines and HIV indicator conditions. Amongst the intern group 37 responded to the survey prior to the teaching session and 26 repeated it after the session as requested. They achieved an average mark of 57.7% prior to the session compared to 83.9% afterwards. Amongst the SHO group 20 completed the survey beforehand, and 6 repeated it afterwards. This group achieved an average mark of 61.6% before the session and 91.6% afterwards.
This small scale study demonstrates the positive impact of an introductory HIV teaching session for junior physicians. This is a drop in the ocean in terms of the global effort to end the epidemic but medical education is an important part of our contribution.Download #2021082 (128.39 KB)
"An Epidemiological Profile of Chronic Hepatitis B Patients Attending an Irish Tertiary Centre with Subset Analysis of Adherence to EASL Treatment Guidelines"
Principal Presenter: Dylan O'Donovan
Keywords: CHB, EASL, Migrant
Introduction: Chronic hepatitis B (CHB) virus infection is a globally prevalent disease that can result in significant life-altering sequelae. Epidemiological data published by multiple regulatory bodies have identified that a significant proportion of Irish CHB prevalence is attributable to migrant populations. The European Association for the study of the Liver (EASL) publish guidelines regarding the recommended treatment of CHB patients based on viral load, alanine aminotransferase levels, and liver biopsy results.
Aims: To evaluate the epidemiological profile of patients attending a tertiary centre in Ireland over a 5-year period to identify trends or anomalies. To examine local adherence to EASL treatment guidelines in a subset of patients who had a liver biopsy performed over a 7-year period.
Methods: A retrospective cross-sectional study in which demographic details of 299 patients were extracted from a local database to create an epidemiological profile of those who attended for primary assessment during a 5-year period. A retrospective chart review was conducted to collect demographic information pertaining to liver biopsy cases and to identify if patients had commenced anti-viral treatment. The EASL guidelines were used to assign patients to a group based on whether treatment was indicated or not based on strict adherence to the guidelines. This was compared against whether treatment had commenced in clinical practice. Statiscal analysis was conducted using SPSS v28.0 software. This included descriptive statistics, Fisher's exact test, chi-square test of independence, and binomial logistic regression.
Results: The patient population (n=299) had the following characteristics: 63.5% were male, with 84% in the age range of 25-55, 98.3% were chronically infected, and 85.3% of cases were associated with migrant populations with no significant annual variation over the 5-year period. The liver biopsy subpopulation (n=44) demonstrated a similar demographic profile. Strict adherence to EASL guidelines indicates treatment in 11.4% (n=5) of cases. In practice, 36.4% (n=16) had commenced antiviral therapy. This was a statistically significant difference based on Fisher’s exact test (p = 0.004)
Conclusion: The demographic results highlight the importance of intensive screening within migrant populations from high prevalence areas to identify those who will need to be appropriately managed within Ireland to prevent progressive disease and complications. There is not strict adherence to treatment by the EASL guidelines within our centre and this will require further study to evaluate the clinical reasoning behind this.Download #2021081 (231.98 KB)