"HIV Models Of Care – When One Size Does Not Fit All"
Principal Presenter: Elizabeth O'Donoghue
Keywords: HIV, Psychosocial, Inclusion
Background: Most people living with HIV (PLWHIV) take antiretroviral treatment (ART) daily to suppress replication of the virus. In Ireland, these medications require prescription by an Infectious Diseases (ID) or Genitourinary Medicine (GUM) specialist and are dispensed only from pharmacies integrated into HIV outpatient clinics located in hospitals. ART is not available in community pharmacies. Medications are dispensed for one to six months at a time, depending on parameters such as HIV viral load, engagement in care and stability of co-morbidities. Patients with complex psychosocial issues are more likely to miss clinic appointments, run out of medications , and more ave other comorbidities requiring more frequent monitoring. However, for this same reason, these patients are less likely to be able to attend more frequently, and therefore the requirement to attend monthly until viral load is suppressed may inadvertently make it less like the patient will remain virologically suppressed.
Methods: We reviewed patient records for three PLWHIV who were admitted to St James’s Hospital for inpatient care in April 2023 with complex social needs and a history of disengagement from HIV care. We examined their HIV viral loads and clinic attendance over a 12 year period from 2011 to 2022 inclusive.
Results: All three were female with a long history of intermittent attendance to OPD and intermittent compliance with ART. All three were intermittently dependent on drugs. All had achieved HIV virological suppression at least once over the 10 year period. All three patient had been viraemic more often than virally suppressed and had more DNAs to clinic than clinic attendances. They had 4,7 and 14 hospital admissions respectively over the 12 year period.
Discussion: These 3 cases of PLWHIV illustrate a pattern of recurrent disengagement from HIV outpatient care, repeated periods of HIV viraemia and multiple hospital admissions for inpatient care on a background of complex psychosocial needs. Despite this pattern, there was no flexibility in the system to offer a different model of care. This has led to the development of a Clinical Nurse Specialist Assertive Engagement Chronic (AEC) Illness Management programme as part of a Slaintecare funded Inclusion Health Programme, to follow complex cases and re-engage and retain people experiencing homelessness in HIV treatment.Download #2021267 (154.49 KB)
"The diagnostic challenge of a rare central nervous system infection mimic: neuro-Behçet’s disease"
Principal Presenter: Vera Papp
Keywords: infection, meningitis, Behcet's disease
Behçet’s disease is a systemic vasculitis syndrome, a rare but gave manifestation of the disease is neuro-Behçet’s disease (NBD) involving the central nervous system. The diagnosis of neuro-Behçet’s disease depends on clinical criteria, however atypical presentations such as our case of a pyrexia of unknown origin pose a diagnostic challenge.
A 35-year-old man presented to the emergency department with abdominal pain, vomiting and generalised weakness. He had a history of fever, night sweats, weight loss for five months and cough with haemoptysis for three weeks.
He had progressive decreased power and hyperreflexia in the lower limbs bilaterally on examination. After one week of admission, the patient suddenly developed a generalised headache accompanied by fever and meningeal signs.
By the time of admission to our hospital he already had a negative quantiferon test two, negative HIV serologies and a CT thorax abdomen and pelvis that revealed no explanation for his recurrent fevers. In our hospital metabolic, infectious, serum electrophoresis and autoimmune screens were non-diagnostic. His second quantiferon test was indeterminate.
Cerebrospinal fluid (CSF) examination showed high white cell count (462-406-544, normal range: 0 to 10; 99% polymorphs), high protein (268 mg/dl, normal range: 15-45 mg/dl) and low glucose (1.4 mmol/l, normal range 2.2 to 3.9 mmol/l), which improved by the second lumbar puncture. BioFire meningitis PCR panel was negative and tuberculosis GenXpert on CSF was also negative. CT brain showed nil acute. MRI brain revealed a tiny focus suspicious for ventriculitis.
He was initially treated as aseptic meningitis. He clinically improved but his neurological deficit remained the same. Therefore he was commenced on treatment for tuberculous meningitis but represented in 3 months with fevers. Multidisciplinary reviews were organised. Revisiting the patient’s history revealed he had oral ulcerations some months ago. Clinical suspicion of neuro-Behçet’s disease was raised, high dose steroids and Infliximab were introduced. His tuberculosis treatment was discontinued. The patient continuously imrpoved after introduction of steroids.
The case study presented demonstrates the challenges associated with diagnosing neuro-Behçet’s disease, which requires careful consideration of the patient's clinical presentation and medical history, as well as appropriate use of diagnostic tools such as cerebrospinal fluid analysis and neuroimaging. Given the potential similarity of neuro-Behçet's disease to other medical conditions a multidisciplinary team approach is essential for timely diagnosis and appropriate treatment.Download #2021266 (384.33 KB)
"Purpura Fulminans and Disseminated Intravascular Coagulation secondary to Invasive Pneumococcal Disease in an Immunocompetent Individual."
Principal Presenter: Niamh McDonnell
Keywords: Purpura Fulminans, DIC, Invasive pneumococcal disease
Purpura fulminans is a rare, life-threatening disorder. Despite aggressive management of sepsis, this condition still carries a 43% mortality rate. It is a rapidly progressive condition of microvascular thrombosis leading to purpuric lesions and haemorrhagic necrosis often in the setting of DIC and represents a dermatological emergency.
A 44-year-old female presented to the emergency department with a three-day history of headache, vomiting and pyrexia. She presented in septic shock with a temperature of 40°C, tachycardia of 110 bpm and hypotension of 78/55mmHg. She was a current smoker with a 15 pack year smoking history. Initial investigations showed raised inflammatory markers but no obvious source of infection. Broad-spectrum antibiotics were given and within six hours blood cultures flagged positive for Gram Positive Cocci. A reticular/reticuloform purpuric rash developed on her legs with mottling of skin on the tips of her nose and ears. The clinical features, and histological findings of microthrombi on the skin biopsy, confirmed a diagnosis of purpura fulminans. The septic shock, confirmed to be secondary to Streptococcus Pneumoniae (Serotype 22F), was complicated by Disseminated intravascular coagulation. Recent sinusitis in the preceding two weeks was the likely source of infection. Supportive care in the Intensive Care unit in conjunction with targeted antibiotics was required. The patient recovered well from the acute phase of her illness; however, she developed critical limb ischaemia with bilateral lower limb dry gangrene that will require a left transmetatarsal amputation.
This case demonstrates the devastating sequela of sepsis including, septic shock, purpura fulminans, disseminated intravascular coagulopathy, hyperlactaemia, hyopglycaemia, and hypocomplimentaemia and supports further research into these complications to further sepsis managment. The serotype identified in this case was 22F which is vaccine preventable with the Pneumococcal Polysaccharide Vaccine (PPV23). The Centre for Disease Control has recently expanded their recommended recipients of the PPV to include current smokers. Research suggests that cigarette smoke can have a key role in the pathogenesis of invasive pneumococcal disease in this group of people, however, this has not yet been incorporated into Irelands recommendations.Download #2021265 (1.7 MB)
"Inclusion Health Inpatient Service at St. James’ Hospital; increased resources result in reduced length of hospital stay and better discharge location for rough sleepers"
Principal Presenter: Anna McAleer
The Inclusion Health (IH) service at St. James’ Hospital (SJH), which is one of the first of its kind worldwide, aims to combat health inequities of patients who are homeless or otherwise marginalised, using a holistic and multidisciplinary approach to address complex medical and psychosocial needs (1) (2). The service provides inpatient care for patients with infections or general medical conditions and a consult service for patients admitted under surgical, haematology/oncology, and, in certain circumstances, psychiatric services. The aim of this study was to describe the IH service users in terms of demographics and clinical presentation, with particular focus on housing status and whether contact with the IH service resulted in an improved housing situation.
Demographic and clinical data were collected from the electronic patient health record for all discharges from the IH service over a three-month period (September-November 2022 inclusive).
There were 96 discharges over the study period. All patients were homeless, 76 (79.2%) were male, with a median age of 47 (range 21-71). There were 88 (91.7%) medical admissions, 6 (6.3%) psychiatric admissions and 2 (2.1%) surgical admissions. The median length of stay (LOS) was 6 days. Thirty (30.2%) patients were readmitted during the study period. Skin and soft tissue infection was the most common single reason for admission (9/96, 9.4%), followed by lower respiratory tract infections (8/96 8.3%). Overall infection was the most common reason for admission in those with a single presenting issue (30/83, 34.1%). Drug overdose also accounted for 8/96 (8.3%) of admissions. Thirteen patients (13.5%) discharged themselves against medical advice (AMA).
Each patient’s housing situation on admission was compared to discharge destination. Short term accommodation (homeless hostels) was the most common type of housing both on admission (35/96, 36.5%) and discharge (33/96, 34.4%). Rough sleeping was the second most common situation at time of admission (14/96 ,14.6%), however dropped to only one (1%) as discharge destination. No discharge destination was recorded for 17/96 (17.7%) patients but this was primarily accounted for by 13/17 discharges against medical advice. Ten patients (10.4%) were discharged to step down services for ongoing medical support, and five (5.2%) were discharged to drug stabilisation centres.
The majority of admissions were young men with infections. Admission under the SJH IH team was associated with a reduction in rough-sleeping at least in the short-term. LOS during the study period was shorter than LOS in the IH patient cohort from 2015-2020 (6 days vs 12 days), and the discharge AMA rate was also lower (13% vs 32%) (3). The improvement in these key performance indicators is likely due to the expansion of the IH team and its resources to include a dedicated inpatient service, and a widened community network, including step-down facilities, to help facilitate more rapid and appropriate discharge. Readmission rate was also reduced compared to 2015-2020 data, during which 45% of patients were re-admitted within 30 days (3). Next steps include 3-month follow-up of discharged patients to assess whether IH intervention resulted in a durable reduction in rough sleeping. Follow-up of patients who have discharged AMA needs to be factored in to service capacity.
1. Ní Cheallaigh C et al. The Development of an Inclusion Health Integrated Care Programme for Homeless Adults in Dublin, Ireland
3. Sears J et al. Disease Patterns and Hospital Utilisation in Inclusion Health Patients in Dublin, Ireland. A 5-year retrospective study
"An Audit of the Management of Infections Related to Implantable Cardiac Devices (ICEDs) in a Tertiary Hospital over 5 years."
Principal Presenter: Irene O'Dea
Keywords: Cardiac Device, Infection, Endocarditis
Although rare, Infections related to Implantable Cardiac Electronic Devices (ICEDs) including pacemakers, implantable cardiac defibrillators and cardiac resynchronisation therapy devices are associated with significant morbidity and mortality. These devices have both intravascular and extravascular components and infection can involve the generator; device leads and endocardium in various combinations.
Standards were identified by consulting the British Society for Antimicrobial Chemotherapy (BSAC) Guidelines for the diagnosis, prevention, and management of implantable cardiac electronic device infection.
A list of adult patients with ICED infections was generated by searching HIPE codes included in discharge summaries over five years from 2017-2022. Data was collected using a pro forma with a review of charts, Microbiological results and records and cardiac imaging. In addition, baseline characteristics and risk factors were recorded.
All of the patients were male, with an average age of 65. 25% (n=3) had an ICD, 42% (n=5) had a PPM, 25% (n=3) had an ICD/PPM, and 8% (n=1) had a CRT-D. In terms of co-morbidities, 58% (n=7) had congestive cardiac failure, 25% (n=3) had renal failure, 33% (n=4) had Diabetes Mellitus, 58%(n=7) had anticoagulant use. 25% (n=4) presented with fever, and 8% (n=1) had signs of pocket inflammation.
Of the 12 cases, 75%(n=9) had evidence of device-lead infection, 58% (n=7) had evidence of endocardial infection, and 8%(n=1) had evidence of pocket infection. Blood cultures were taken from all patients (n=12). TOE was performed in 92% (n=11). Causative pathogens were predominantly gram-positive and staphylococcal species: 25% (n=4) of cultures grew staphylococcus aureus with 8% (n=1) methicillin-resistant staphylococcus aureus, 42% (n=5) grew staphylococcus epidermidis and coagulase-negative staphylococcal species, 8% (n=1) grew enterococcus faecalis, 8% (n=1) was culture negative. 42% (n=5) had their device extracted. Salvage therapy was attempted in 25% (n=4).
In patients with their device extracted, the average time from diagnosis to device extraction was 4.6 days. The average duration of antibiotics post-device extraction was 27 days. From these results, we excluded one patient who failed salvage therapy and had their device removed 60 days later.
The duration of antimicrobial therapy should be tailored to specific cases. The presence of a generator, lead or endocardial infection determines the duration of treatment. A multidisciplinary approach between specialities is needed.Download #2021263 (530.24 KB)
"A Neglected Cause of Seizures - An Imported Case of Disseminated Cysticercosis"
Principal Presenter: Kate Jackson
Keywords: NTD, Cysticercosis, CNS infection
Cysticercosis, caused by infection with Taenia solium, is endemic in sub-Saharan Africa, Central and South America and Asia. It is suspected to cause up to 30% of epilepsy in affected regions. We present a case of disseminated cysticercosis in a non-endemic region.
A 36 year old gentleman presented with a collapse episode in October 2022. He had recently moved to Ireland from Sub-Saharan Africa. He gave a history of recurrent headaches and recurrent collapse episodes over the preceding five years, but had no known past medical history and was not taking any medication. He denied drug or alcohol consumption. While being assessed, he had a tonic-clonic seizure and proceeded to have neuroimaging which showed multiple intracranial cystic lesions within both cerebral hemispheres and his cerebellum. Axial imaging of the chest, abdomen and pelvis showed further cystic lesions in the lungs, liver, pancreas, myocardium, pericardium and subcutaneous nodules in the torso, limbs and scrotum.
MR imaging of his brain was consistent with Neurocysticercosis and cysticercal antigen was positive in peripheral blood. His case was discussed with Parasitology at the Hospital for Tropical Diseases in London, and he was transferred to a hospital with a neurosurgical unit to begin treatment. He was commenced on Dexamethasone and subsequently a 2 week course of high-dose Albendazole and stat dose of Niclosamide. Strongyloides stercoralis and HIV serology were negative, but IGRA was positive and he was commenced on Isoniazid monotherapy for latent TB infection.
Aside from headaches and seizure episodes before and shortly after his admission, the patient was well and symptoms resolved on commencing treatment. He was discharged to continue a tapering course of steroids over 6 weeks, with weekly outpatient review. He developed a pustular skin eruption which coincided with the commencement of a PPI but was felt more likely to be caused by Isoniazid or Dexamethasone. Unfortunately, he developed further seizures on down-titration of steroid therapy and required admission and a further 8 week course of oral steroids.
On cessation of the second course of steroids, he had a series of tonic-clonic seizures and was brought to hospital with a reduced Glasgow Coma Score, requiring intubation and ventilation. Serial EEGs and clinical assessment indicated non-convulsive status epilepticus and he required multiple agents for seizure control. He was commenced on Methylprednisolone intravenously. Repeat cysticercal antigen and rediscussion at the Neuroparasitology MDT are pending.Download #2021262 (530.82 KB)
"Effective Disinfection of Debrided Diabetic Foot Ulcer Tissue by Immersion in 200 ppm of the Electrochemically Activated Solution Anolyte"
Principal Presenter: Liam Grealy
Background: Diabetic foot ulcer (DFU) infections are predominantly caused by Staphylococcus aureus and are the leading cause of lower limb amputations and reduced quality of life. Anolyte is a non-toxic, environmentally friendly electrochemically generated hypochlorous acid solution with powerful antimicrobial properties that has shown great promise in wound disinfection. This study evaluates immersion in anolyte as an alternative to antibiotic-based DFU treatment.
Methods: Fifty-one ulcer samples were collected from patients with DFUs undergoing routine debridement. Clinical DFU features and any prior interventions were recorded. Tissues were divided into two aliquots according to wet weight and comparatively treated by immersion in equal volumes of either 200 parts per million (ppm) anolyte or sterile saline. Samples Ano1-Ano20 were immersed in 1 ml treatment volumes, whereas samples Ano21-Ano51 were immersed in 10 ml volumes. Microbial loads of treated tissues were quantified and compared following aerobic, anaerobic, and staphylococcal-selective incubation conditions. Bacteria were identified based on 16S rRNA sequences and representative S. aureus isolates were subjected to whole genome sequencing (WGS).
Results: The microbial loads of tissues immersed in 1 ml of anolyte were an average of 1065 fold (2.0 log) lower than the corresponding saline-treated tissues (Z -3.92, P<0.0005). The microbial loads of tissues immersed in 10 ml of anolyte were an average of 8216 fold (2.1 log) lower than the corresponding anolyte-treated tissues (Z-4.86, P<0.00001). The median microbial load in tissue samples treated in 10 ml anolyte was significantly lower than samples treated in 1 ml volumes of anolyte following incubation in aerobic and anaerobic conditions (P>0.05). Staphylococcus aureus was the predominant species identified. Other organisms commonly recovered were identified as Enterococcus, Streptococcus and Proteus species. Fifty S. aureus strains from 30 distinct tissues underwent WGS. Isolates were predominantly identified as sequence types 1, 5, 15 and 30. The methicillin resistance-encoding (mecA) and Panton-Valentine Leukocidin (pvl) genes were not detected.
Conclusions: Immersion in anolyte is a highly effective treatment for the disinfection of debrided foot ulcer tissue, resulting in an average 99% (2 log) reduction in the microbial loads when compared to saline-treated tissues. As this study investigated debrided tissues, patient-specific immunity, healing capabilities and antibiotic treatments did not influence the research outcome. The predominant species recovered from ulcer tissues was S. aureus. Methicillin-resistant Staphylococcus aureus (MRSA) was not detected.
"Audit of assessment and management of community-acquired needlestick injuries (CANSI)"
Principal Presenter: Pádraig Morrissey
Keywords: HIV, PEP, HBV
We have observed a slight uptrend in referrals to ID clinic for HIV post-exposure prophylaxis following community-acquired needle stick injuries. From our experience, there has been some variance in management. We gathered objective data on the assessment and management of community-acquired needle stick injuries with a view to optimising patient safety and outcomes.
Retrospective chart review of referrals to Beaumont Hospital Infectious Diseases Clinic for BBV PEP from September 2021 to February 2022.
Information collected related to the exposure, source status, recipient status, initial management in the emergency department, and followup in the ID clinic.
34 Referrals were received to the ID Clinic for BBV PEP Management between September 2021 and February 2022. Of these, 32 were from Beaumont Hospital ED. The mean age was 29 years +/- 12.4 years.
The majority of exposures were needlestick injuries (n=16, 47% ) followed by unprotected sexual intercourse (n=14, 41%)
10 of these NSIs were associated with a suspected drug spiking incident, 4 were from accidental injuries with discarded needles.
28 (82%) were within 72 hours of exposure at time of ED review
HIV PEP was indicated in 14 cases, it was prescribed in 100% of these
However, HIV PEP was prescribed in 7 cases where it was not indicated i.e. > 72 hours post exposure, or not significant risk
HBV vaccine was indicated in 85% of cases and was given appropriately in ED in all of these cases.
Provision of HIV PEP information was poor. 88% were not counselled on sex avoidance where warranted. PEP information leaflet was not supplied in 76% of cases.
76% of all referrals had an ID appointment within 2 weeks of ED review.
9 people had 3 month follow-up bloods in ID clinic. Of these, none underwent BBV seroconversion
• Community acquired needle stick injuries represent a significant proportion of PEP prescriptions.
• There is a knowledge deficit on injury risk stratification, PEP indications and management.
• May unnecessary investigations are being ordered such as BBV screening in cases where HIV PEP is not indicated and exposure is not considered high risk. If patients are considered high risk enough to arrange follow-up bloods they are high risk enough to warrant HIV PEP, unless otherwise contraindicated.
• Adherence to accelerated course of HBV vaccination for HBV PEP is poor.
• Many targets for improvement were identified in this audit.Download #2021260 (405.7 KB)
"Missed opportunity: Delays in HIV diagnosis in HSE West"
Principal Presenter: Ellen Walsh
2022 saw the highest number of late presentations of HIV to our service since it was established in 2004. While notifications remain highest per population in HSE East, HPSC data show that the proportion of patients presenting with advanced HIV at diagnosis is higher outside HSE East and among those aged over 40. 23 notifications of AIDS-defining illness at time of diagnosis were reported in 2018; 26% were referred to us for care. Advanced HIV diagnoses are associated with significant morbidity and mortality, increased healthcare cost and resource utility. Regional differences in presentation with advanced infection have not been explored.
New diagnoses of HIV presenting to Galway University Hospitals from January 2017 to December 2022 were reviewed and those with advanced HIV infection were identified. This was defined this as CD4 of<200/mm3 or AIDS-defining illness at diagnosis. Those with previous diagnoses elsewhere reengaging in care were not included. Prior hospital attendances and outcomes were explored.
There were 49 new diagnoses of advanced HIV. 35 (71.4%) were male. Median age was 46 years (range 21–76). 5 (10.2%) patients were over the age of 65. 24(49%) were from Galway, 8(16.3%) from Donegal and the remainder were from other counties in HSE West, Northwest (16.3%), and Midwest (8.1%). Median CD4 count was 43/mm3(IQR 14-128). 4(8.2%) patients died during acute HIV presentation. 29(59.2%) required hospitalisation at diagnosis; older age was associated with inpatient stay(p<0.001). Median length of stay was 17 days [IQR 10-26]. 6 (12.2%) patients were admitted to ICU at index presentation; one requiring ECMO. Median ICU stay was 15.5 days [IQR 9-29]. 23 (46.9%) patients presented to our hospital at least once prior to diagnosis. 10 (20.4%) were diagnosed in general practice; 33 (67.4%) were diagnosed in secondary or tertiary care, who were older than those diagnosed in primary care (mean 51 vs 37 years), p=0.04. There was a non-significant association between county of residence and age at diagnosis (p=0.06). 6% presented to haematology services before diagnosis.
Delayed diagnosis of HIV is of particular concern in our catchment area given a high proportion of diagnoses occurring at advanced stage. 46.9% of these advanced cases presented to our hospital at least once representing missed opportunity for HIV testing and prevention of significant morbidity and mortality. We argue that these data strongly aid a call for routine screening of all hospital admissions in HSE West to reduce late diagnoses.
"Brain Abscess in an Irish Cohort: an Update on Aetiology and Microbiology"
Principal Presenter: Emily Glynn
Keywords: Brain abscess, CNS infection, Streptococcus intermedius
Brain abscess is an uncommon diagnosis associated with significant morbidity. This single-centre study describes the epidemiology, microbiology and outcomes of patients presenting with bacterial intracranial abscess.
An eleven year retrospective review of patients admitted with a bacterial intracranial abscess between 01.01.2010 – 31.12.2021. Radiology, laboratory and electronic patient records were reviewed. Fungal and mycobacterial cases were excluded.
Of 163 patients, 110 were male (67.5%); median age at diagnosis was 48 years (interquartile range [IQR] 31) and community-acquisition occurred in 158 (97%). A preceding or concurrent ENT (sinusitis or mastoiditis) or dental infection was identified in 41% (n=67), infective endocarditis in 17% (n=28) and a prior neurosurgical procedure in 13% (n=21). No attributable risk factor was identified in 18% (n=30). A solitary intracranial lesion was present in 85% (n=139). Solitary lesions were more common in those with dental or ENT infections (46% [n=64] versus 12.5% [n=3] of those with multiple lesions; p=0.02). Infective endocarditis was more common in those with multiple lesions (37.5% [n=19] versus 13.7% [n=9] of those with solitary lesions; p=0.004). Immunosuppressed patients were more likely to hiave multiple rather than solitary lesions (37.5% [n=9] versus 4.3% [n=6]; p<0.001). The frontal lobe was the most common site for solitary lesions (38%, n=53). Neurosurgical drainage was performed in 92% (n=150). A single isolate was cultured in 68 patients (42%); Streptococcus intermedius most common (n=31). Polymicrobial infection occurred in 28.3% (n=46), culturing S. intermedius (n=15) anaerobes (n=34) and Gram-negatives (n=9). Of 35 culture-negative specimens, 20 were referred for 16S PCR; an organism detected in nine cases. Median length-of-stay was 21 days (IQR 15.5). In-hospital mortality was 1.2%.
The predominant presentation of brain abscess was that of community-acquired abscess in a male with a solitary frontal lobe lesion associated with an ENT or dental infection. Observed in-hospital mortality was rare. S.intermedius was the most cultured pathogen.Download #2021258 (228.67 KB)
"Use of dolutegravir/lamivudine (DTG/3TC) in the Genitourinary and Infectious Diseases Clinic in St. James’ Hospital."
Principal Presenter: Adam Kelly
Keywords: HIV, Anti-retroviral therapy, Audit
Dolutegravir/lamivudine (DTG/3TC) is a two-drug antiretroviral treatment (ART). DTG/3TC is approved for both first-line ART and to facilitate ART switches. DTG/3TC as a single-tablet regimen became available at St. James’s Hospital (SJH) in 2019. The aim of this audit was to characterise the patients with HIV on DTG/3TC receiving care at SJH.
Pharmacy and clinical records were reviewed for all patients prescribed DTG/3TC from 2019 until December 2022. Demographic and clinical data were collected; standard descriptive statistics was used to summarise the findings.
Since 2019, 130 patients were prescribed DTG/3TC: 3/130 (2.3%) in 2019, 14/130 (10.8%) in 2020, 39/130 (30%) in 2021 and 74/130 (56.9%) in 2022. The median age was 49 years old (range 23-76);13/130 (10%) patients were female and 117/130 (90%) were male.
All patients prescribed DTG/3TC at SJH were ART-experienced. Previous ART regimens included: 59/130(45.4%) ABC/3TC/DTG, 22/130 (16.9%) other integrase inhibitors (INSTI)-based regimens, 21/130 (16.2%) non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens, 9/130 (6.9%) protease inhibitor (PI)-based regimens, and 18/130 (13.8%) were on DTG/3TC when they transferred care to SJH.
Reason for switch was available for 103/130 (79.2%) cases. Concerns over cardiovascular risk were associated with 58/103 (56.3%) of switches, 8/103 (7.8%) due to drug-drug interactions, 3/103 (2.9%) due to renal toxicity, 5/103 (4.9%) due to osteoporosis/osteopaenia, 21/103 (20.4%) due to other confirmed or suspected drug toxicity, and 8/103 (7.8%) for only regimen simplification. Of those that started DTG/3TC in SJH, 110/112 (98.2%) were virally suppressed at time of switch. 5/112 (4.5%) were
not followed due to transfer of care. Of those followed, 104/107 (97.2%) were virally suppressed at next follow-up. 2/107 (1.9%) were not virally suppressed at next follow-up. 1/107 (0.9%) patient switched back to their prior regimen before follow-up viral load could be done on treatment.
11/107 (10.3%) discontinued DTG/3TC at next follow-up. 4/59 (6.8%) patients who switched from ABC/3TC/DTG did not tolerate DTG/3TC. According to NHS pricing, DTG/3TC is more expensive than NNRTI-based regimens but cheaper than the
INSTI and PI ART regimens studied. Using these estimates, switching 84 patients to DTG/3TC will result in yearly drug savings of greater than €150,000.
Approximately 90% of patients switched to DTG/3TC maintained this treatment at next follow-up. Switch to DTG/3TC may have significant cost savings in suitable patients.Download #2021257 (1.29 MB)
"The First 200 Consults: Utilisation of a New Infectious Diseases Inpatient Consult Service across a Level 4 Irish Hospital"
Principal Presenter: Eilís Margaret Ní Chinnéide
Keywords: Consult, Service evaluation, Quality improvement
Infectious Diseases consultation services are associated with improved patient outcomes, referrer satisfaction, antimicrobial stewardship and cost-effectiveness. We evaluated the quality of electronic consult requests to the newly established Infectious Diseases service in Tallaght University Hospital with the aim of improving the overall quality of requests.
Project was commenced after approval from the QI department. Retrospective evaluation of consult requests via the hospital electronic patient record system was carried out. Data was collected from the beginning of the service in June 2022 up to April 2023 representing a sample size of 204. Data was recorded and analysed using Microsoft Excel. Twelve separate data points were analysed based on HIQA guidelines and pre-existing literature.
Patient demographics, referrer contact details and patient location were included in 100% (n=204) of referrals. Grade of referring doctor was indicated in 7% (n=15) of referrals. Microbiological results were indicated in 41% (n=84) of referrals, while current antimicrobials were included in 57% (n=116) of referrals. Urgency of consult request was stated in 4% (n=9) of referrals. Past medical history was recorded in 55% (n=113) of cases. Examination findings were included in 23% (n=47) of referrals, and a working diagnosis was indicated in 68% (n=138) of referrals. Medical specialities accounted for most of the referrals.
A number of areas could be improved upon when requesting Infectious Diseases consults. The majority of requests did not specify the urgency required for the review or grade of referring doctor. Remarkably, less than half of consults included relevant microbiological results and examination findings. Patient identifiers, location and team contact details were available in all cases. Potential interventions include discussions with the most common referring specialities, starting a regular meeting with these specialities and making certain sections of the electronic consult request mandatory.Download #2021256 (175 KB)
"Vaccination Rates and Uptake in new referrals to Galway University Hospital HIV Clinic"
Principal Presenter: Micheal Clancy
Keywords: HIV, Vaccinology
The prevalence of HIV in Ireland is approximately 10 per 100,000. Rates of HIV diagnoses are increasing, with the largest number to date recorded in 2022 due to increased screening in the post-pandemic period and inward migration of PLWH, particularly from Ukraine. . Numbers attending our clinic have increased by 32 % over the last 12 months. PLWH may experience increased risk of infection and more severe morbidity following exposure to vaccine-preventable diseases compared with HIV uninfected individuals. Vaccination rates vary internationally, and of note, vaccination uptake in the general Ukrainian population being amongst the lowest in Europe.
We audited the vaccination status and documentation of status of new referrals to the Galway University Hospital HIV service from January to December 2022 using evolve and clinical notes, when compared to the standard as set out by NIAC.
98 new referrals to the HIV service in 2022 were included; median age was 41 (IQR 34-45.75), 60.2% were male, 73.5% heterosexual. Ukrainian nationals accounted for the majority of referrals at 32.7% followed by Sub-Saharan African (29.6%), South American (13.3%), Irish(11.2%), Eastern European (9.2%) and Asian (4%). Median CD4 count was 705.5 (IQR 443 – 1031) and 74.5% were virally suppressed.
82.7% were immune to Hepatitis B, with 35.8% having serology consistent with previous infection. 7.14% were non-immune to Hepatitis B, of which 77.7% declined vaccination. Status of 10.2% was not assessed. 67% had received primary vaccination for SARS-CoV-2, with 34.3% of these declining booster vaccination. 31.25% of Ukrainian’s declined primary vaccination compared to 15.4% of the remaining population. Of those who had not received pneumococcal vaccination, it was declined in 21.9% of Ukrainian’s compared with 7.7% of the remaining population. 64.3% were measles immune, 66% immune to mumps, 71.4% immune to rubella. Of note, 74.4% of non-immune Ukrainian’s declined MMR vaccination. 90.5% of those indicated for HPV vaccination were vaccinated. Monkey pox vaccination was indicated in 8%; 25% were vaccinated and 12.5% declined.
Our review highlights lower vaccination for SARS-CoV-2 than the general Irish population. Refusal rates of MMR vaccination was notable and of concern in the Ukrainian cohort from a public health perspective. Difficulties in assessing pneumococcal vaccination status in transferred patients without relevant documentation was highlighted. A new documentation tool and strategies to increase vaccination rates have been implemented since conducting this reviewDownload #2021255 (251.17 KB)
"Evaluation of first 6 months of OPAT Service in Tallaght University Hospital under governance of newly established Infectious Diseases Department"
Principal Presenter: Aarti Gupta
Background:OPAT (Outpatient Parenteral Antimicrobial therapy) service started in Tallaght University Hospital in 2013 and patients were discharged under governance of their primary teams since that time. The newly established Infectious Diseases (ID) department commenced the governance of OPAT Service at TUH on Sept 9th 2022 and all patients since then are followed up by ID during their OPAT course.A six month evaluation of service was undertaken using National guidelines as the standard and to estimate the hospital bed days saved and financial saving via OPAT Service under the new governance.
Methods:The project was commenced after ethical approval from QI department. Data was collected prospectively from the OPAT patient database maintained securely for all patients discharged between 09/09/2022-31/03/2023.
Results: Forty-eight patients were discharged on OPAT during the analyzed duration with 85.4% (n=41) discharged on H-OPAT and 14.5% (n=7) on S-OPAT. Most of the patients 95.8% (n=46) were discharged within 48 hours of OPAT referral and PICC line was used for intravenous access in 95.8 % (n=46). Bone and Joint infections was the most common indication for OPAT in 54.16% (n=26), followed by Neurological infections (12.5%, n=6), Skin & Soft tissue infections (10.41%, n=5), Urinary Tract Infections (6.8% n=3), Bacteraemia (2.08% n=1), and Graft Infections (2.08% n=1). Other infections such as Renal abscess, septic thrombophlebitis and Ovarian abscess constituted for 12.5% (n=6). Among the anti-microbial agents Ceftriaxone and Daptomycin were the most commonly used. Frequency of polypharmacy was 56.2% (n=27) and excessive polypharmacy was recorded in 14.5% (n=7). 62.5% (n=30) patients received targeted culture based therapy whereas 37.5% (n=18) were culture negative and treated empirically. Overall 91% (n=44) patients completed their planned OPAT treatment course. Two (4.15%) patients were readmitted for OPAT related causes and 5 (10.4%) patients were reviewed by ID for acute problems. Approximately,1252 bed days were saved equating to approximate cost saving of 1,194,408 euros.
Conclusion: Overall OPAT was demonstrated to be safe and cost saving service for treatment of patients under governance of ID. Study also indicated that for patients on OPAT, hospital readmissions can be avoided with regular dedicated follow up in the OPAT clinic and by having clinical space and resources for unscheduled reviews if any problems arise on the days other than the OPAT clinic days. Overall H-OPAT was utilised more commonly than S-OPAT. The barriers to S-OPAT will continue to be explored and addressed in the future.
"Inclusion Health Inpatient Service at St. James’ Hospital ; increased resources have reduced length of hospital stay and improved discharge location for rough sleepers"
Principal Presenter: Anna Mc Aleer
The Inclusion Health (IH) service at St. James’ Hospital (SJH), which is one of the first of its kind worldwide, aims to combat health inequities of patients who are homeless or otherwise marginalised, using a holistic, multidisciplinary approach to address complex medical and psychosocial needs. The aim of this study was to describe the IH service users in terms of demographics and clinical presentation, with particular focus on housing status and whether contact with the service resulted in an improved housing situation.
Demographic and clinical data were collected from the electronic patient health record for all discharges from the service over a three-month period (September-November 2022 inclusive).
There were 96 discharges over the study period. All patients were homeless, 76 (79.2%) were male, with a median age of 47 (range 21-71). There were 88 (91.7%) medical admissions, 6 (6.3%) psychiatric and 2 (2.1%) surgical. The median length of stay was 6 days. Thirty (30.2%) patients were readmitted during the study period. Skin and soft tissue infection was the most common single reason for admission (9/96, 9.4%), followed by lower respiratory tract infections (8/96 8.3%). Overall infection was the most common reason for admission in those with a single presenting issue (30/83, 34.1%). Drug overdose also accounted for 8/96 (8.3%) of admissions. Thirteen patients (13.5%) discharged against medical advice (AMA).
Each patient’s housing situation on admission was compared to discharge destination. Short term accommodation (homeless hostels) was the most common housing both on admission (35/96, 36.5%) and discharge (33/96, 34.4%). Rough sleeping was the second most common situation at time of admission (14/96 ,14.6%), however dropped to only one (1%) at discharge. There was an increase in unknown housing status from admission (8/96, 8.3%) to discharge (17/96, 17.7%) but this was primarily accounted for by discharges against medical advice, where discharge destination was unclear. Ten patients (10.4%) were discharged to step down services for ongoing medical support, and five (5.2%) to drug stabilisation centres.
The majority of admissions under the IH team were young men with infections. Admission under the service was associated with a reduction in rough-sleeping at least in the short-term. Length of stay was shorter than IH LOS from 2015-2020 (6 days versus 12 days), and that AMA rate was also lower (13% versus 32%). These improved key performance indicators are likely due to the expansion of IH team and its resources, and a widened community network including, step-down facilities, to help facilitate more rapid and appropriate discharge. Readmission rate was also reduced compared to 2015-2020 data, during which 45% of patients were re-admitted within 30 days. Next steps include 3-month follow-up of discharged patients to assess whether IH intervention resulted in a durable reduction in rough sleeping. Follow-up of patients who have discharged AMA needs to be factored in to service capacity.
"COVID-19 Booster Vaccine Uptake amongst Healthcare Workers in Ireland: Results from PRECISE-5"
Principal Presenter: Gavin Francis Kelly
Keywords: SARS-CoV-2, Healthcare workers (HCWs), Vaccination Hesitancy
COVID-19 vaccination has proven effective at reducing the incidence and severity of SARS-CoV-2 infection. Amongst healthcare workers (HCWs) in Ireland, uptake of the primary vaccination course has been high. However, vaccine hesitancy remains a significant barrier to booster uptake in this population. The aim of this study was to assess the demographic factors associated with full booster uptake amongst the subgroup of HCWs who participated in PRECISE-5.
This was a sub-study of PRECISE-5: a prospective observational cohort study conducted across two large teaching hospitals in Ireland. Participants were enrolled over a 12 day period in November 2022. An online survey was conducted, with participants providing a self-reported vaccination history and other demographic details. Those who were fully boosted with 2 or more boosters were then compared with those who had received a primary vaccination course only.
562 participants, a subgroup of HCWs at both sites, were included in this univariate analysis, of which 76.5% (n=430) were female, 23.1% (n=130) were male, and 0.4% (n=2) preferred not to say. Of the 562, 77.4% (n=435) were fully boosted with 2 or more boosters, while 22.6% (n=127) had a primary vaccination course only.
A clinical role was associated with higher full booster uptake (81.9% vs 65.1%, p<0.001). The job roles most likely to be fully boosted included Doctor 92.6% (n=87), Allied Health Professional 86.5% (n=64), and Nursing 78.6% (n=121). The job roles least likely to have been fully boosted included Porter 28.6% (n=2), Catering 33.3% (n=2), and Healthcare Attendant 52.4% (n=11).
Older age was associated with higher full booster uptake (p<0.001), as was male sex (85.4% vs 75.1%, p=0.032), and employment site (Hospital 1- 82.1% vs Hospital 2- 72%, p=0.005).
Ethnicity, and risk factors for severe disease did not have a significant association with booster uptake.
This is the first data assessing COVID-19 vaccination and booster uptake amongst HCWs in Ireland. In this study, while the initial vaccination rate was high, only 3 in 4 reported a full uptake of subsequent booster doses. Reduced uptake of boosters reveal an emergence of vaccine hesitancy amongst HCWs as the pandemic progressed. Disparities amongst demographic subgroups were also evident, with HCWs in clinical roles and with higher educational attainment more likely to receive booster doses. This data will help to inform future COVID-19 and seasonal vaccination programmes in the healthcare service, as well as identifying subgroups where strategies are needed to modify attitudes towards vaccination.Download #2021252 (288.87 KB)
"Hospital Antimicrobial Prudent Prescribing Interventions (HAPPIs) can Improve compliance with Antimicrobial Stewardship KPIs"
Principal Presenter: Marita Barrett
Measurement is a key component of ongoing quality improvement in Antimicrobial Stewardship (AMS) and the Health Service Executive have recommended the implementation of Key Performance Indicators (KPI) for AMS in acute hospitals in Ireland to measure the effectiveness of AMS activities.
The aim of this study was to assess the impact of targeted educational interventions to improve compliance with AMS KPIs.
Quarterly KPI audits termed HAPPIs - Hospital Antimicrobial Prudent Prescribing Indicators were implemented from April 2021 to April 2022 across 4 acute wards with the highest antimicrobial use. 13 KPI’s were measured, including compliance with antimicrobial guidelines and restricted antibiotic policy and documentation of penicillin allergy, antimicrobial indication and duration. 'Non-compliance' with KPI was determined as >10% below KPI target of 90%.
Run charts of the compliance results were shared with participating wards, and intensive AMS and educational interventions were made based on the results of each KPI audit.
Four KPI audits were completed at interval including 205 patients during a one year period.
Compliance with empiric antimicrobial choice was good overal ranging from 73-86% during the course of the study.
Improvements in several KPIs were observed during the study period. Seven KPIs in Audit 4 were ‘compliant’ compared to two in Audit 1. A significant decrease in 'non compliance' with KPIs was observed between Audit 1 and Audit 4; only one KPI in Audit 4 was ‘non-compliant’ compared to seven in Audit 1 (p<0.05).
Educational interventions included a focus on (i) ‘Double Anaerobic Cover’ to reduce metronidazole use, (ii) ‘Community Acquired Pneumonia Antibiotic Choice’ to reduce piperacillin/tazobactam for this indication, and (iii) ‘Documentation of Antimicrobial Indication and Duration’.
Documentation of indication and duration remained ‘non-compliant’ throughout the KPI project.
Implementation of the AMS KPIs and associated targeted AMS interventions resulted in improvement in AMS process measures over time. Continuous and repeated education interventions are required to maintain compliance with KPIs particularly with changeover of perscribers during the study period. Longer term surveillance should be considered to evaluate the impact on antimicrobial consumption patterns and clinical outcome.
"Impact of Long COVID on health and quality of life"
Principal Presenter: Matthew Blair
Keywords: Long COVID, Survey, Quality of life
Background: The aim of this study was to measure the impact of post-acute sequelae of COVID-19 (PASC) on quality of life, mental health, ability to work and return to baseline health in an Irish cohort.
Methods: We invited individuals with symptoms of COVID-19 lasting more than 14 days to participate in an anonymous online questionnaire. Basic demographic data and self-reported symptoms were recorded. Internationally validated instruments including the patient health questionnaire somatic, anxiety and depressive symptom scales (PHQ-SADS), the Patient Health Questionnaire-15 (PHQ-15) and Chadler fatigue scale (CFQ) were used.
Results: We analysed responses from 988 participants with self-reported confirmed (diagnostic/antibody positive; 81%) or suspected (diagnostic/antibody negative or untested; 9%) COVID-19. The majority of respondents were female (88%), white (98%), with a median age of 43.0 (range 15 – 88 years old) and a median BMI of 26.0 (range 16 – 60). At the time of completing this survey, 89% of respondents reported that they have not returned to their pre-COVID-19 level of health. The median number of symptoms reported was 8 (range 0 to 33 symptoms), with a median duration of 12 months (range 1 to 20 months) since time of acute infection. A high proportion of PASC patients reported that they have a moderate or severe limitation in their ability to carry out their usual activities, 38% report their ability to work is severely limited and 33% report a moderate, or higher, level of anxiety or depression.
Conclusion: The results of this survey of an Irish cohort with PASC are in line with reports from other settings, and we confirm that patients with PASC reported prolonged, multi-system symptoms which can significantly impact quality of life, affect ability to work and cause significant disability. Dedicated multidisciplinary, cross specialty supports are required to improve outcomes of this patient group.Download #2021250 (590.21 KB)
"Investigation Outcomes From Long Covid Clinic"
Principal Presenter: Fara Shila Salleh
Keywords: Long covid, Infectious disease
Background: Post Covid-19 condition, which is “the continuation or development of new symptoms 3 months after the initial SARS-CoV-2 infection”, can present with a variety of symptoms. As per NICE guidelines, minimum investigations for fatigue alone includes a wide range of blood tests. The audit aims to measure adherence to NICE guidelines in terms of investigations sent on patients referred to our Long Covid (LC) clinic, and the utility of these tests in identifying an alternative diagnosis.
Method: A retrospective chart review of patients who were seen in Long Covid clinic in Mercy University Hospital (MUH) between July to January was done. Only patients seen on first assessment were included. Investigations that were carried out on the first clinic visit and by the referring general practitioner within the previous 6 months were documented and noted as either normal or abnormal.
Results: A total of 73 patients were included in the audit, 74% of which (n=54) were female, with a median age of 51 (range of 17 to 78 years old). The mean period between initial Covid-19 infection and first review in LC clinic was 13 months. The percentage of patients that had baseline investigations as per the NICE recommendations, either by the GP or at LC clinic, are as follows: FBC (97%), renal function (97%), LFT (95%), TFT (82%), autoimmune (86%) and adrenal insufficiency screening (60%), HbA1C (34%), and immunoglobulin levels (51%). No clinically significant abnormalities were identified on these investigations. CRP was sent in 82% of patients, 18% (n=11) came back above the normal reference range, but not deemed clinically significant. A smaller percentage of patients had other investigations such as full haematinics (48%; 4 returned abnormal), and vitamin D (29%; 3 were abnormal). 63% of patients had investigations repeated in clinic despite the same tests already been done by their GP.
Conclusion The audit shows an overall low yield from the investigations ordered in patients with post covid-19 condition. They do serve as a reassurance to both patients and medical provider and is still warranted to look for other potential diagnosis. However, with an average cost of care per patient in LC clinic estimated at €781, more discretion is needed in ordering investigations, especially those that had been done in GP practice. Resources potentially could be directed towards building a more accessible community-based multidisciplinary rehabilitation programme instead.Download #2021249 (215.13 KB)
"HIV Screening in Acute Medical Patients Presenting with an Indicator Condition – Why are we not testing?"
Principal Presenter: Dr Jay Gokul Corinna Sadlier
In Ireland up to 50% of newly diagnosed HIV positive patients are diagnosed and enter care late (CD4 count <350cells/ul). Late diagnosis is associated with increased HIV related morbidity and mortality, poorer treatment response, increased health care costs and increased transmission rates. International guidelines recommend HIV testing for individuals presenting to healthcare with specific indicator conditions such as pneumonia, thrombocytopenia, weight loss. We previously audited adherence to HIV testing guidelines in acute medical patients in November 2017 and found poor adherence. The aim of this study was to reaudit adherence to international HIV testing guidelines in clinical practice.
A retrospective audit was undertaken to evaluate adherence to NICE HIV testing guidelines. Acute medical patients admitted to a tertiary referral centre in Ireland during the month of November 2021 were included. Basic demographic data including age, gender and specific HIV test indicator conditions such as pneumonia that requires hospital admission, weight loss, acute neurological symptoms/parathesia, diarrheal illness, abnormal liver function tests, jaundice, persistent lymphopenia/neutropenia/thrombocytopenia, isolated lymphadenopathy, newly diagnosed lung cancer and Hodgkin’s lymphoma) were recorded. The study was approved by CREC ECM 4 (ss) 22/02/2022..
During the one month study period (November 2021), 111 of 566 (20%) patients admitted under acute medical services presented with an indicator condition for HIV testing 65 (59%) were male, 77 (69%) over 60 years.
13 of 111 (12%) underwent HIV testing. All patients tested negative for HIV.
Pneumonia (56%) was the most common presenting indicator condition followed by sepsis (20%) and weight loss (9%). Patients under the age of 60 years of age presenting with indicator conditions were significantly more likely to be tested for HIV p<0.05.
During the one month study period of November 2017, 28 of 206 (14%) patients aged 16-60 years included in the study presented to an acute medical assessment unit with an indicator condition for HIV testing. 9 of 28 (32%) patients underwent HIV testing. All patients tested negative for HIV.
While the overall rate of HIV testing was lower in 2021 compared to 2017, there was no significant difference in HIV testing in patients <60 years 32% 2017 versus 28% 2021.
Adherence to HIV testing recommendations in acute medical patients presenting with indicator conditions is suboptimal. Further research is warrented to identify barriers to HIV testing outside of routine screening programmes.
"Infective endocarditis managed through the national OPAT programme; a review from 2021 – 2023 at a single tertiary centre"
Principal Presenter: Rhea O'Regan
Keywords: infective endocarditis, OPAT
The national outpatient parenteral antibiotic therapy (OPAT) programme was formally established in 2013 and has successfully managed patients with a wide variety of infections. OPAT programmes are being increasingly used to manage uncomplicated cases of infective endocarditis (IE). We reviewed a cohort of patients treated for IE over a three year period (2021 – 2023) in a tertiary teaching hospital that shares access to specialist cardiothoracic and cardiology services. We aim to describe the clinical epidemiology, definitive management and outcomes, interrogating the appropriate use of OPAT in these high risk infections.
Data was collected and retrospectively analysed from the national OPAT portal using STATA/SE version 17.0. All patients with a recorded diagnosis of Infective Endocarditis were included. Data is presented as median (interquartile range).
During the three year period, there were 26 patients (aged 48 [38-58] years, 26.9% female) that were treated on OPAT for IE. Healthcare-OPAT (H-OPAT) was utilised in 18/26 (69.2%), 6/26 (23.1%) self-OPAT (S-OPAT) and 2/26 (7.7%) on co-OPAT. Transoesophageal echocardiography was performed in 17/26 (65.4%) patients, 9/26 (34.6%) had a transthoracic echocardiography. A native valve was infected in 18/26 cases (69.2%), and a bioprosthesis in 8/26 cases (30.8%). Where valve was known, 16/26 (69.6%) were left sided, with the majority, 10/26 (43.5%), involving the aortic valve. Overall, 14/26 (53.8%) subsequently underwent a valve replacement. Organisms cultured include: methicillin-susceptible Staphylococcus aureus (7/27, 26.9%), Streptococci [mitis, sanguinis] (7/26, 26.9%), Coagulase-negative Staphylococci [haemolyticus, epidermidis, capitus] (4/26, 15.4%), E. coli (2/26, 7.7%), methicillin-resistant Staphylococcus aureus (1/26, 3.8%), and Enterococci [faecalis, avium] (1/26, 3.8%). There were 5 that were culture-negative. The most commonly prescribed antibiotics were ceftriaxone (16/26, 61.5%) and daptomycin (6/26, 23.1%). Duration of treatment was 42 (42-42) days, with 22 (16.25-29.5) days of those on OPAT. There were 2 deaths in this cohort, the remainder achieved a cure.
Almost 70% of all cases of IE in our facility were left sided; however OPAT was still felt appropriate given high rates of cure achieved. Factors which likely contributed to this success include a three week lead time of inpatient intravenous therapy, predominance of native valves and a higher utility of H-OPAT. A significant selection bias is present.Download #2021247 (185.65 KB)
"A Retrospective Audit of the Diagnostic Testing and Management of Adults Presenting with Suspected Central Nervous System Infections"
Principal Presenter: Gavin Francis Kelly
Keywords: Antimicrobial Stewardship, Central Nervous System Infections, Audit
The aim of this audit was to assess standard practice of care in adults presenting with suspected central nervous system (CNS) infections over a one year period.
Patients investigated for suspected CNS infections at University Hospital Galway were identified retrospectively via cerebrospinal fluid (CSF) samples received in the laboratory from 1st November 2021 to 31st October 2022. Clinical notes were reviewed using the online electronic patient record. The clinical presentation, investigations and antimicrobial management were assessed, and adherence to Infectious Diseases Society of America and local prescribing guidelines were investigated.
79 patients had lumbar punctures performed for investigation of suspected CNS infection, of whom 49.4% were males, and 50.6% were females. 19% had a clinical diagnosis of meningitis, but only 8.9% had a confirmed microbiological diagnosis (6 cases of Enterovirus and 1 case of Herpes simplex virus 2). 8.9% had a clinical diagnosis of encephalitis, none of whom had a microbiological diagnosis. Infectious diseases or microbiological specialties were only consulted in 60%.
73.4% had blood cultures taken, and 48.7% had a HIV test sent. 34.2% had a paired glucose taken, and 8.9% had an opening pressure recorded. 94.9% had a CT brain performed prior to lumbar puncture, of which 16% had a noted pathology.
74.7% were prescribed antibiotics, of which 11.9% were prescribed after CSF results were returned. 54.2% were prescribed antibiotics that were not in accordance with local prescribing guidelines. 2.1% had the incorrect dosage of antibiotic prescribed, and 18.7% had the incorrect frequency of antibiotic prescribed.
62% were prescribed Aciclvoir, of which 32.7% were prescribed after CSF results were returned. 28.6% were prescribed Aciclovir despite not displaying features of encephalopathy. 25.6% had features of encephalopathy but were not prescribed Aciclovir. In those prescribed Aciclovir, 100% had the correct dosage and frequency prescribed.
This study demonstrates incomplete compliance with local antimicrobial prescribing guidelines for both suspected meningitis and encephalitis. It also showed incomplete adherence to international guidelines in the investigation of suspected CNS infections, particularly in regards to blood culture sampling, and other adjunctive testing.Download #2021246 (257.56 KB)
"Primary Pyogenic Ventriculitis caused by Neisseria meningitidis Serogroup Y: a Case Report"
Principal Presenter: Gavin Francis Kelly
Keywords: Primary Pyogenic Ventriculitis, Neisseria meningitidis, Meningococcal serogroup Y
Ventriculitis is defined as an infection of the ventricular ependymal lining of the brain and is characterised by the presence of suppurative fluid in the ventricles. It is a recognised complication of ventricular catheterisation and may also complicate ruptured brain abscesses and meningitis. Primary pyogenic ventriculitis (PPV) is a rare clinical entity, with less than 25 adult cases reported in the literature. To date only four cases of PPV in adults have been attributed to Neisseria meningitidis. We report the fifth case, the first in an Irish patient, and the first ascribed to Meningococcal serogroup Y.
A 64-year-old female with a past medical history of diabetes mellitus, hypothyroidism, hypertension, dyslipidaemia, and previous breast cancer, presented to the Emergency Department with a one day history of agitation, diaphoresis, myalgias, and episodes of vomiting. This was on a background of general unwellness over the preceding eight weeks with headaches, unsteady gait, and diaphoretic episodes. Approximately six weeks prior to this presentation she had an episode of convulsive syncope for which she was worked up in the same institution. On examination she was afebrile, GCS 12, with no focal neurology or signs of meningeal irritation.
Laboratory results were notable for WCC 179 cells/L, with neutrophilic predominance, and CRP of 401 mg/L. CT Brain was unremarkable. MRI Brain revealed layering debris in the occipital horns of the lateral ventricles, concerning for pus within the ventricles. There was no periventricular enhancement on post-contrast imaging. Unfortunately, lumbar puncture was delayed and only performed six days after commencement of antibiotics. This revealed protein 2.43 g/L, glucose 0.8 mmol/L, RBCs 400 /cmm, and WBCs 2950 /cmm (50% polymorphs, 50% mononuclear cells). CSF culture was negative. CSF PCR was positive for N. meningitidis, with subsequent typing showing this to be Meningococcal serogroup Y. Blood cultures taken prior to antibiotics were negative. The patient was commenced on high dose Ceftriaxone and has made a significant clinical improvement. She is planned for six weeks of antimicrobial treatment, and is currently undergoing further immune workup.
We report the fifth case of PPV secondary to N. meningitidis, the first in an Irish patient, and the first attributed to Meningococcal serogroup Y. PPV is a rare and heterogeneous clinical entity. The spectrum of presentation ranges from an indolent course to headache, fevers, and confusion, with signs of meningeal irritation occurring less commonly. Treatment consists of targeted antimicrobials, though optimal duration is unclear.Download #2021245 (232.7 KB)
"It's Not Always Water Under the Bridge- A Chronic Case of Schistosomiasis Mansoni"
Principal Presenter: Fiona Murphy
Keywords: Schistosomiasis, Chronic Disease, Endemic
Schistosomiasis is a parasitic infectious disease caused by schistosomes. Its geographical distribution is widespread, with endemic regions in Africa, South America and Asia. In Africa, colonic disease is generally associated with Schistosomiasis Mansoni infection. Patients are infected after direct contact with water contaminated with snails carrying the parasite. It can be under diagnosed in non-endemic regions. Clinical presentations can be non-specific. Predominant symptoms include diarrhoea, abdominal discomfort, fatigue, and weight loss. It can often be mistaken for other pathologies such as inflammatory bowel disease or malignancy.
Mrs X is a 65 year old retired primary school principal. She described a 20-year history of abdominal discomfort. She was labelled with a diagnosis of Coeliac Disease in 2004. Physical exam was normal. Blood results showed a normal full blood count, normal eosinophils, normal renal function, mildly deranged LFTs (ALP 129, Bilirubin 5, GGT 28). She underwent annual blood tests for coeliac serology and three yearly oesophago-gastro-duodenoscopy (OGD) and colonoscopies.
Her initial workup in 2004 included an OGD and coeliac serology. Her coeliac serology has been negative annually including from time of labelled diagnosis. Her initial duodenal biopsy showed normal villous architecture with focal increase in intraepithelial lymphocytes. She was labelled as having Coeliac Disease and was advised to commence on a gluten free diet. In 2022 her repeat colonic histology showed well established granulomas in association with refractile non polarisable foreign material. The background architecture had no features of chronicity to suggestive inflammatory bowel disease.
Her travel history was significant for two years working in Zambia from 1981-1983. Of note her travel brought her to Lake Malawai where she undertook in recreational water activities.
Further review of her histology showed a distinctive mansoni spike. Her stool and urine sample were negative for ova. Her serology was positive; level 5 optical density (scale 1-9)
Mrs X had a compatible travel history and serology for Schistosomiasis Mansoni. She received one stat dose of 40mg/kg of Praziquantal. Her symptoms have improved. This case highlights the importance of epidemiology in creating a differential diagnosis. Colonic schistosomiasis is a rare disease that should be considered a differential diagnosis in those that have travelled to endemic regions. Endoscopic appearances can be non-specific as initially demonsteated but can progress to distinctive granulomas containing Schistomas. Histopathological and stool examinations have a significant role in diagnosis.Download #2021244 (324.99 KB)
"Diagnostic Stewardship in People Living with HIV"
Principal Presenter: Sophie Coalter
Keywords: HIV, CD4, BHIVA
T-lymphocyte subsets are an important test in the initial assessment and treatment response of people living with HIV (PLWH). The British HIV Association (BHIVA) Guidelines recommend for patients newly diagnosed with HIV whose CD4 is >350cells/mm3 further CD4 testing should only be done if HIV related symptoms develop. Similarly they recommend patients with a CD4 of >200cells/mm3 who remain virally suppressed for greater than one year do not require further CD4 testing. This audit examines our compliance with the recommendations.
Pharmacy and clinical records were reviewed for all patients who newly presented for HIV management between 1st April 2021 and 1st April 2022. Demographic and clinical data were collected; standard descriptive statistics was used to summarise the findings. Only patients who had at least 12 months of follow-up in SJH were included in the initial review.
112 patients attended SJH for HIV care for the first time. Of these 95 (84.8%) were male. The median age was 35 years (range 19-68).
21/112 (18.8%) had an initial CD4 below 200 at presentation, 16/112(14.3%) had an initial CD4 of 200-350, and 75/112(67%) had an initial CD4 count greater than 350. 60/112(53.6%) had a detectable HIV viral load (VL) at first presentation. Of those with a detectable VL 40/60 (66.7%) achieved an undetectable VL within 2 months, and 56/60 (93.3%) achieved an undetectable VL within 6 months.
Of 16 patients with CD4 200-350 at presentation, 3/16 (18.8%) were virally suppressed and the remaining 13 achieved viral suppression within 4 months of treatment initiation. Despite this the patients had a mean of 3.9 (Range 2-5) T-lymphocyte subset tests within the first 12 months of treatment in SJH.
Of 75 patients with CD4 >350 at presentation, 47/75 (62.7%) were virally suppressed and the remaining 28 achieved viral suppression within 9 months of treatment initiation (median <1 month). Despite this the patients had a mean of 2.5 (Range 1-5) T-lymphocyte subset tests within the first 12 months of treatment in SJH.
T-lymphocyte subset surveillance testing may be over utilised in PLWH in our centre. Closer compliance with BHIVA guidelines could generate significant cost savings. For the next steps we intend on developing a quality improvement project to reduce T-lymphocyte subset testing in our clinic.Download #2021243 (420.04 KB)
"The Epidemiology and Investigation of Invasive Fungal Disease in Paediatric Patients With Burkitt Lymphoma in Ireland"
Principal Presenter: Jennifer Cox
Keywords: fungal, malignancy, paediatric
Background; Invasive fungal disease (IFD) is a major cause of morbidity and mortality among paediatric patients with a hematological malignancy. Anti-fungal prophylaxis has been shown to reduce morbidity and mortality in high-risk groups. There is a lack of data on the incidence of IFD in patients with Burkitt lymphoma (BL).
Aim; To describe invasive fungal infection rates and epidemiology in patients with BL attending a tertiary paediatric hospital. This will help to determine if prophylaxis for fungal infections is warranted in this group.
Methods; Retrospective audit of patients with Burkitt lymphoma attending Children’s Health Ireland in Crumlin over a 10-year period (2012-2022). Data was collected from the electronic radiology and laboratory systems at CHI in Crumlin. Data collected included demographics (age at diagnosis, gender), cancer diagnosis and treatment protocol, host factors associated with fungal disease if present – such as neutropenia, solid organ transplant, prolonged use of corticosteroids, T cell immunosuppressants and B cell immunosuppressants. Investigations for fungal disease including fluid cultures (blood, broncheoalveolar lavage, cerebrospinal fluid), polymerase chain reaction for fungal nucleic acid, histology (from biopsies), relevant imaging (ultrasound or CT) and treatment with anti-fungal therapy were also recorded.
The consensus definitions from European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium (EORTC/MSGERC) 2019 were used as the standard for comparison. These definitions outline the criteria for proven, probable and possible IFD.
Results; Thirty-eight patients were included in the audit. There were three times as many males as females. Age range was between 2.2 years and 15.6 years at diagnosis. None of the patients reached the criteria for proven, probable or possible IFD. Four of the 38 patients (10.5%) were investigated for IFD and treated empirically with Liposomal amphotericin B during an episode of febrile neutropenia and during the induction phase of their chemotherapy treatment.
Conclusion; The results of this audit show that this is a low risk group for IFD and anti-fungal prophylaxis is not currently warranted as part of routine therapy in our institution.Download #2021242 (657.53 KB)
"Immunosenescence Among Those Living with HIV"
Principal Presenter: Kesidha Raajakesary
Keywords: HIV, Social Exclusion, Immunosenscence
Background: Immunosenescence is a process of immune dysfunction that occurs with increasing age and results in increased susceptibility to infection, cancer and autoimmune diseases. An inversion of the normal CD4+: CD8+ T-cell ratio is one marker of immunosenescence. Some people living with HIV (PLWHIV) develop Immunosenescence at a younger age than expected. Known risk factors for immunosenescence in PLWHIV include older age, treatment with thymidine analogues, and lower CD4+ T-cell nadir. We hypothesized that PLWHIV who have experienced social exclusion (homelessness, incarceration, injecting drug use) have a more marked inversion of CD4+: CD8+ T-cell ratio.
Methods: We performed a retrospective cross-sectional observational study using the electronic patient records of patients receiving HIV care at St. James’s Hospital in Dublin, Ireland. 85 PLWHIV were identified from referrals to the HIV Assertive Engagement Clinic. An additional 215 patients were selected randomly from a database of all patients with HIV attending SJH. Mann-whitney and One-way Anova tests were used to test the significance of differences in the CD4/CD8 ratio between the control group and those that were considered socially excluded.
Results: 85/300 PLWHIV had experienced social exclusion, of these 70/85 had experienced homelessness, 50/85 had injected drugs and 30/85 had been incarcerated. The median age of the PLWHIV who had experienced social exclusion was 43 (range 25- 63) compared to 40 years (22-76) for those who had not experienced social exclusion. 29/85 (34%) of PLWHIV who had experienced social exclusion were female compared to 54/215 (25%) of those who had not. 78/85 PLWHIV who had experienced social exclusion had inversion of their CD4+: CD8+ T-cell ratio, compared to 125/215 of PLWHIV who had not experienced social exclusion. The difference in CD4+:CD8+ T-cell ratio between groups was statistically significant using Fisher’s exact test. The mean CD4+:CD8+ T-cell ratio in PLWHIV who had experienced social exclusion was 0.57 compared to 0.97 in those who had not, this difference was statistically significant (p<0.001) when compared using a one-way ANOVA.
Discussion: PLWHIV who have experienced social exclusion are more likely to have immunosenescence as defined by CD4+:CD8+ T-cell ratio to a greater degree than those who have not. They may be at higher risk of infection, cancer, and earlier development of frailty.Download #2021241 (151.58 KB)
"Utility of PET CT imaging in Infectious Diseases"
Principal Presenter: Patrick Carey
The utilisation of PET CT imaging is becoming increasingly more common in the practice of Infectious Disease medicine. PET CT capacity and patient throughput is comparatively lower than that of conventional diagnostics therefore is it important that it’s use is applied appropriately. For this reason, we examined Cork University Hospitals PET CT requests, results and application over a ten year period.
We collected data on 30 patients who underwent a PET CT scan in CUH ordered by the infectious disease department. Using the Royal College of Radiology 2022 PET CT guidelines, we audited the CUH PET CT requests. Aside from basic biographical data we also examined whether the PET CT results affected management of each patient, be that by assisting in diagnosis or by altering treatment.
21/30 requests met the Royal College of radiology guidelines. Of the 30 requests 20 were for diagnostic purposes of which 7 had utility. The remaining 10 requests were for further evaluating already known pathology, the results of which altered management in 6/10 patients. Overall, 13/30 PET CT’s ordered by the infectious disease department were useful.
Although there is definite utility for the diagnosis and management of patients with infectious diseases as demonstrated here. PET CT imaging is a valuable commodity and should be ordered appropriately. As it becomes more common place in infectious disease practice I feel it is important our requests adhere as closely as possible to guideline recommendations.
"Prospective evaluation of the potential for avoidance of Acute Medical Assessment Unit admissions via OPAT in a Level 4 Irish Hospital"
Principal Presenter: Vera Papp
Keywords: OPAT, audit, admission avoidance
Background: Irish hospitals come under increasing pressure for bed availability. It is crucial to identify patients who are suitable for admission avoidance early in their course and outpatient parenteral antimicrobial therapy (OPAT) can provide this opportunity.
We evaluated patient assessed in the AMAU (Acute Medical Assessment Unit) of Tallaght University Hospital over one month to identify OPAT-suitable patients who could have avoided admission if initiated on OPAT on presentation.
Methods: The project was commenced after approval from the QI department. All adult patients who were assessed in the AMAU between August 29th 2022 and September 23rd of 2022 were included. Prospective data was collected from the hospital's electronic patient record system and by manually reviewing the medical records. The inclusion and exclusion criteria of the National OPAT Guidelines was used to assess for OPAT eligibility and the grey cases were where there was ambiguity in OPAT eligibility were discussed with the Infectious Diseases’ Consultant for the decision.
Results: 256 in-patient admissions were included in the study and 48 had infections (18.75%) diagnosed on admission. Respiratory tract infection was the commonest infective diagnosis (29, 65.5%), with a smaller number diagnosed with urinary tract infections, soft tissue infections and gastrointestinal infections. One case of septic arthritis and one case of viral meningitis was identified.
Delays in diagnostic work up and non-availability of microbiological susceptibility results, impaired potential admission avoidance via OPAT for most patients. For some cases where the OPAT treatment regime could be finalised on presentation, patients clinically were not stable to be discharged by admission avoidance. No OPAT-suitable patients were identified during the study.
Conclusion: The audit results indicated that medical patients with infective diagnosis who were admitted via the AMAU during the study had often multiple co-morbidities and required workup that couldn’t be completed on the same day and thus were appropriately getting admitted via the AMAU for their work up and management indicating that AMAU admission triage process was working efficiently. Limitation of the study was the one month period of study and results might be different if study is repeated in another period or for longer duration. A similar study will be planned again in future to identify patients whose admission could be avoided via OPAT both from the AMAU and from the Emergency Department.Download #2021239 (282.31 KB)
"Incidence of COVID-19 in Irish Healthcare Workers: Preliminary Results from the Prevalence of COVID-19 in Irish Healthcare Workers (PRECISE)-5 Study"
Principal Presenter: Claire Kenny
Healthcare workers (HCW) are the ideal population to track the evolving epidemiology of SARS-CoV-2. Surges in SARS-CoV-2 infection and quarantine regulations leads to staff absence at a time when hospital resources are already burdened.
All HCWs in two large teaching hospitals were invited to participate in this prospective longitudinal cohort study in November 2022. Information on demographics, SARS-CoV-2 infection history and COVID-19 vaccination dates/brands was collected. Baseline serology for anti-Nucleocapsid (N) and anti-Spike (S) antibodies was performed. Cohort seroprevalence was compared to a prior study phase (PRECISE4, November 2021). Monthly follow-up e-surveys collected information relating to incident SARS-CoV-2 infections, duration of symptoms and rostered days of work missed.
1261 participants were enrolled (Hospital 1- 639 (50.7%), Hospital 2- 622 (49.3%)). Participants were predominantly female (79.4%), with nursing (31.6%), administration (16.9%) and medical (14.7%) being the most commonly reported job roles. 25/1261 (0.08%) were unvaccinated. 1103/1261 (87.5%) had received a primary vaccine series and at least one booster.
1260/1261 (99.9%) of participants were anti-S seropositive. 1008/1261 (79.9%) participants were anti-N seropositive, in comparison to November 2021 anti-N seropositivity of 23.4% (p<.0001). 377/1261 (29.9%) participants denied having had a prior SARS-CoV-2 infection; of these, 178/377 (47.21%) were anti-N seropositive suggestive of previously undiagnosed infection.
Response rate to monthly e-surveys over the first 14 weeks of the study (Weeks 45-52 of 2022 and Weeks 01-06 of 2023) was 54.3%. 121/1261 (9.6%) of participants reported a positive SARS-CoV-2 test (PCR or Antigen). Incident infections peaked at Weeks 50-52 of 2022. This was reflective of national SARS-CoV-2 incidence rates. 41/122 (33.6%) reported a symptomatic infection, with mean symptom duration of 10.5 days (median 7.5 days). Over 14 weeks, the total number of rostered days missed secondary to SARS-CoV-2 infection was 589 days, with median 5 days missed per HCW.
In this interim analysis, 9.6% of participants reported an incident SARS-CoV-2 infection over 14 weeks. This was in the context of a high baseline seropositivity for anti-N antibody and vaccination uptake. This suggests that SARS-CoV-2 continues to circulate widely. While morbidity and mortality is low, there are significant consequences including working days lost, potentially impacting patient care.
"Epidemiology of COVID-19 Cases in Irish Healthcare Workers During the Delta and Omicron Waves: Results from the Prevalence of COVID-19 in Irish Healthcare Workers (PRECISE)-3 Study"
Principal Presenter: Claire Kenny
COVID-19 vaccination has changed the clinical severity of disease, however infections still occur. This study aimed to describe the epidemiology of COVID-19 cases in healthcare workers (HCWs) as the first booster vaccines were rolled-out and new SARSCoV2 variants emerged. The study was conducted at two tertiary care hospitals by the PRECISE study team.
HCWs testing positive for SARSCoV2 by PCR between 09/10/2021-12/01/2022 were included. Information on demographics, occupation, COVID-19 diagnosis/vaccination history was collected. Positive nasopharyngeal samples were analysed using Whole Genome Sequencing (WGS).
474 participants enrolled - Hospital 1: n=252 (53.2%); Hospital 2: n=222 (46.8%). Median age was 34 years, with 77% female participants. The majority of cases were nurses/midwifes (31.6%), followed by administrative staff (19.8%). Slight variation in attendance to ED and hospital admission was observed between the two sites (ED: Hospital 1 2.8%, Hospital 2 1.4%, p=0.448; Hospital admission: Hospital 1 0.8%, Hospital 2 0.5% p=1.0). 92.8% completed a primary vaccination series (PVS), of which 46.4% received a booster vaccine dose; 1.3% were unvaccinated.
Mean time from first vaccine dose to positive PCR test was 315.5 (SD 52.8) days for those receiving Comirnaty PVS versus 283.7 (SD 35.5) days for those receiving Vaxzevria PVS (p<0.001). Mean time between booster vaccine and positive PCR test was 47.6 (SD 22.1) days for those who received Comirnaty PVS and (any) booster versus 32.9 (SD 17.7) days for those who received Vaxzevria PVS and (any) booster (p<0.001). Mean time from last vaccine dose and positive PCR test was 209.7 (SD 87.1) days during the Delta wave versus 93.6 (SD 95.0) days during the Omicron wave (p<0.001). WGS was performed on 48.9% of positive samples. An initial wave of Delta cases was observed, followed by a rapid increase and peak in Omicron cases, similar to the national epidemiological profile.
Despite high vaccination coverage in both hospital sites, including booster vaccination, 479 COVID-19 cases were detected. The Omicron variant was associated with a rapid increase in cases. Time from vaccine dose to SARSCoV2 infection was shorter in those who received Vaxzevria PVS versus Comirnaty PVS. The high number of cases resulted in working days lost and potential risk for vulnerable patients, highlighting the need for continued vigilance in the healthcare setting as new variants emerge.Download #2021237 (1.02 MB)
"An audit of laboratory testing among patients attending the HIV clinic in Beaumont Hospital"
Principal Presenter: Fergal Howley
Keywords: HIV, CD4 count, Laboratory testing
Beaumont hospital serves a population of approximately 800 people living with HIV (PLWHIV). Stable patients are reviewed every six months, typically undergoing laboratory testing on each visit. The European AIDS Clinical Society (EACS) guidelines provide recommendations regarding intervals for blood testing. We sought to establish compliance with European guidelines regarding serological, hematological and biochemical surveillance of PLWHIV.
Patients were randomly selected based on availability of charts prior to outpatient clinics. We collected data from January 2021 – December 2022. Those who first attended the clinic prior to January 2021, with regular attendance (at least annual attendance), and who had achieved virological suppression were included. Patients with less than one attendance per year were excluded. Data were obtained from medical charts and the hospital online blood results portal. Data regarding age, gender, medication, frequency of attendance, and frequency of blood testing (including viral load, CD4 count, FBC, renal/liver/bone profile, HbA1c, PSA and lipid profile) were collected. The statistical method used is descriptive data.
80 patients were included, comprising 37 females and 43 males, age 25-65 years. 76% were on integrase inhibitor-based regimens. Patients had an average of 4.2 attendances over the two-year period (range 3-8). 12.5% of patients had at least one detectable viral load during this period. From the total of 337 attendances, at least one blood test was taken on 327 visits. 75/80 of patients had at least one CD4 count >350 cell/microlitre, 97.5% of whom had CD4 testing more than once per year. FBC was tested 98.5% of visits, with renal and liver profiles on 97.5% of visits. 32/80 had the recommended annual glucose or HbA1c testing, 41/80 had annual lipid screening, while only 2/26 men >50 years old had prostate-specific antigen (PSA) testing during the two-year period.
The majority of patients attending HIV clinic on a regular basis are virally suppressed. Viral load testing is performed at appropriate intervals in the majority, though CD4 counts, FBC, and renal/liver/bone profiles are often tested with unnecessary regularity. Glucose, lipid and PSA testing are not being done in accordance with EACS guidelines, though the appropriateness of annual screening in otherwise healthy individuals can be debated. There is potential for cost-saving measures by educating healthcare providers regarding the necessary frequency of laboratory testing in patients with stable HIV.Download #2021236 (184.31 KB)
"Laboratory Diagnostic Pathway for Viral Haemorrhagic Fevers in Ireland - Quality Improvement Project"
Principal Presenter: Anna Garami
Keywords: HCID, NIU, viral haemorrhagic fever
Viral haemorrhagic fevers (VHF) are considered High Consequence Infectious Diseases (HCID). As the opening of the new National Isolation Unit (NIU) is imminent, this is an opportune time to refine Irish VHF guidelines to ensure adequate preparedness.
This Quality Improvement Project aims to revise the algorithm for VHF diagnostics in line with international best practice, and to improve the process of isolating and testing suspected cases locally, with NIU support. Prompt confirmation/exclusion of a VHF diagnosis is required for timely and appropriate NIU activation/transfer, or management of alternate diagnoses.
Irish VHF laboratory diagnosis guidelines were reviewed. Each step of the process was compared to relevant international guidance identified through National Health Protection agencies and web-based search.
Problem areas of current practice were identified, root causes analysed, and recommendations for improvement proposed.
Irish guidelines on initial risk assessment (using clinical and epidemiological factors) align with international guidance. While the NIU Consultant must be involved early in ‘High Risk’ presentations, there is no explicit guidance on specialist involvement in other cases. A referral/consult pathway is clearly defined is most international guidelines.
VHF testing is performed in the National Virus Reference Laboratory (NVRL). Urgent VHF testing is advised in ‘High Risk’ cases, this is currently not available out-of-hours in Ireland.
Laboratory testing, biosafety, sample packaging/transport recommendations are in line with international guidance; routine and inactivated samples can be handled at BSL-2 in the laboratory with added precautions.
Irish guidelines advise urgent malaria testing, however do not clarify the process of doing so; testing for other alternative diagnoses is not covered. In most international guidelines, test panels for VHF and other causes are devised by a dedicated specialist service/reference laboratory.
There is a risk of delayed diagnosis (VHF or alternative causes), sub-standard clinical care due to delayed baseline laboratory investigations, delayed transfer to the NIU, and excessive resources maintaining isolation if VHF results are delayed.
Suggestions for improvement:
- Local specialist to discuss all cases with NIU where VHF testing is considered
- NIU to liaise with NVRL regarding testing panel (VHF/alternate causes)
- Dedicated regional laboratories resourced and supported in processing routine and malaria samples
- Establish out-of-hours VHF-testing capacity
Refining the VHF diagnostic process would improve patient management and ensure efficient use of resources. Consensus will be sought from stakeholders on necessary updates to Irish guidelines.Download #2021235 (335.48 KB)
"B Cell responses determine protection from SARS-CoV-2 infection following third dose SARS-CoV-2 vaccine"
Principal Presenter: Joanne Byrne
Which components of the immune response to SARS-CoV-2 vaccination best protect against subsequent infection remains unclear. We explored SARS-CoV-2 specific antibody and B cell responses pre and post 3rd dose vaccine and their relationship to incident SARS-CoV-2 infection.
We performed a prospective multicentre cohort study of healthcare workers. Paired serum and peripheral blood mononuclear cell (PBMC) samples were collected prior to 3rd dose vaccination and approximately 14 days post vaccination (Pfizer-BioNTech BNT162b2 vaccine). All participants received the monovalent Pfizer-BioNTech BNT162b2 as their third dose vaccine. Study participants were followed up at 22 weeks to assess for incident self-reported SARS-CoV-2 infection. Anti- SARS-CoV-2 immunoassays were used for the quantitative detection of total antibodies against the SARS-CoV-2 spike subunit S1 and S2 and receptor-binding domain (RBD) proteins. RBD and S antigen-specific memory B-cells and plasma cells were analysed on a subgroup of participants with ELISpot. We compared between group differences by Wilcoxon signed rank or Mann–Whitney U tests.
There was 132 participants in this study aged 43(32-50)*, of which 81% were female. 47 of the 132 participiants (36%) reported incident COVID-19 infection post 3rd vaccine. Antibody titres, plasma cell and memory B-cell responses all increased significantly at day 14 post 3rd vaccine (all p<0.001).Day 14 antibody titres did not differ in those with and without incident infection. There was 76 subjects in the B cell substudy aged 39(32-50)*, 74% female. Lower day 14 RBD plasma cells and lower RBD and full spike memory B cell responses were observed in those with incident COVID-19 infection (all p<0.05). Similar results were observed with pre third dose RBD and full spike memory B-cell responses.
Lower day 14 B cell responses, but not antibody titres were associated with incident COVID-19 infection suggesting B cell responses better predict protection against COVID-19 infection. This study is the first to describe which components of the immunological response to SARS-CoV-2 vaccination could predict protection from SARS-CoV-2 infection.
"Incidence of Breakthrough SARS-CoV-2 Infections in a Highly Vaccinated Healthcare Worker Cohort in Two Tertiary Irish Hospitals"
Principal Presenter: Conor Moran
Healthcare workers (HCWs) are at high-risk for SARS-CoV-2 infection. HCWs in Ireland have a high rate of COVID-19 vaccination. Primary objectives of this European-wide study were to evaluate incidence of breakthrough SARS-CoV-2 infections amongst HCWs and to calculate relative vaccine effectiveness of booster vaccination.
HCWs in St James’s Hospital Dublin (SJH) and Galway University Hospital (GUH) were recruited as part of the Vaccine Effectiveness, Burden and Impact Studies (VEBIS) of COVID-19. Recruited HCWs underwent weekly nasopharyngeal PCR testing and questionnaires collecting demographic, clinical, community and work-related data.
In SJH, between April 2022 - March 2023, 211 HCWs were recruited. In GUH from April 2022 – December 2022, 109 HCWs were recruited. There were similar baseline demographic and clinical characteristics between the GUH, SJH and the overall VEBIS cohorts, although significantly more participants in GUH and SJH had received booster vaccinations.
In SJH there were 3,538 PCR tests done, with 102 SARS-CoV-2 positive results. 58 (57%) infections were asymptomatic, incidence of infection was 4.7/1000 HCW days. In GUH from there were 1533 tests done, with 37 SARS-CoV-2 positive results, 22 (59%) were asymptomatic with an incidence of 3.8/1000 HCW days. Overall VEBIS reported 64,380 PCR tests done with 907 confirmed SARS-CoV-2 infections, 307 (34%) were asymptomatic, with an average incidence of 3.4/1000 HCW days.
Sample size and incidence of COVID-19 infection in SJH and GUH were too small to calculate relative effectiveness of booster vaccines.
This study, conducted during Omicron variant circulation, suggests a high incidence of SARS-CoV-2 infections in a highly vaccinated HCW cohort. Incidence was higher than in other VEBIS HCW study sites despite higher rates of booster vaccination. There was also a higher proportion of asymptomatic infections. This may be due to frequency of testing, high-exposure HCW job roles and interlaboratory variability in cycle threshold value for SARS-CoV-2 PCR positivity.
Continuing this study and gathering further data on sick leave, presenteeism and persistent symptoms will provide useful information for workforce planning particularly as infection control measures evolve. This study may act as a model for expansion of surveillance testing for other viral illnesses such as influenza. The continuation of this study to include time since vaccination will enable a greater understanding of relative effectiveness of booster vaccination for SARS-CoV-2 infections.
"Probable Hafnia and Delftia Discitis and Vertebral Osteomyelitis in a Person Who Injects Drugs"
Principal Presenter: Adam Bowden
Keywords: Discitis, Osteomyelitis, Inclusion Health
A 40-year-old male was admitted with subacute GI obstruction related to duodenal and oesophageal strictures from adhesions post-pancreatitis. His past medical history was significant for pancreatogenic diabetes mellitus, traumatic brain injury, untreated hepatitis C, and active alcohol excess and intravenous drug use. During this admission he underwent oesophageal dilatation, and supplemental TPN feeding. He was also treated for recurrent aspiration pneumonias due to post-prandial vomiting.
On day 9 post-admission he had a PICC line inserted for TPN feeding. On day 25 post-admission he developed a febrile illness, and PICC cultures were positive after one day with four Candida sp.(albicans, tropicalis, dubliniensis, and glabrata), a vancomycin resistant Enterococcus faecium, and Hafnia alvei. The PICC line was removed the next day, and the tip cultures subsequently grew C. albicans, C. tropicalis, and Acinetobacter sp. (non-baumanii). Anidulafungin was started for Candidaemia, and piperacillin-tazobactam was continued as the Hafnia sp. was sensitive. The decision was made not to treat the VRE.
The patient was managed with peripheral lines due to suspicion of PICC access for recreational drug use. On day 37 post-admission he developed a new febrile illness associated with back pain. Piperacillin-tazobactam was stopped and Meropenem 1g TDS IV was started. Peripheral blood cultures revealed Hafnia alvei and Delftia acidovorans. MRI spine revealed a C5/C6 discitis with a small epidural collection without associated osteomyelitis. Given onset of pain coincided with these positive cultures we assume that one or both of these is the responsible pathogen.
Two weeks later a repeat MRI was requested. This revealed new, extensive osteomyelitis in the vertebral bodies of C5 and C6. The meropenem was increased to 2g TDS IV and daptomycin was started to cover the VRE identified 1 month earlier. Unfortunately, the patient’s condition deteriorated despite these changes, and the decision was made to move to comfort care on day 61 since admission.
The patient denied active drug use while in hospital, but was found with unmarked syringes on two occasions. Given the variety of organisms found in the various samples our assumption is that the patient’s heroin was contaminated with soil, either through improper sterilisation, or buried in an unsealed container. Our case illustrates the importance of sterile injecting practice, and the need for close monitoring of people who are suspected of intravenous drug use in hospital.Download #2021231 (281.88 KB)
"Only a wearer knows where the shoe pinches! Patient satisfaction survey from the OPAT service of level 4 Irish Hospital"
Principal Presenter: Aarti Gupta
Keywords: Satisfaction, Survey, .
Background: The newly established Infectious diseases department commenced governance of OPAT (Out-patient Parenteral Antimicrobial Therapy) service at Tallaght University Hospital from September 9th 2022. To evaluate the service performance, a patient satisfaction survey was conducted on all patients who had utilized OPAT until 31st March 2023.
Methods: Feedback was sought from patients on a questionnaire consisting of 15 questions aimed at collecting demographic data, OPAT related data, evaluating communication with the ID Team and clinical waste management during the OPAT treatment course. The survey was conducted between 16/03/2023 and 31/03/2023 and was initiated after approval from the QI department.
Results: Total patients discharged on OPAT during the surveyed period was 48 and the response rate was 77.07% (n=37) with 54.05% (n=20) males & 45.95% (n=17) females. The patients’ age ranged from 16 years and above. 89.9% (n= 33) had H-OPAT (Healthcare provided OPAT) and 10.8% (n=4) were on S-OPAT (Self OPAT) with average OPAT duration between 2-4 weeks for 48.6% (n=18) and 4-6 weeks for 37.8% (n=14) patients. Twenty-five (67.5%) had no side effects, while 32.4% (n=12) experienced minor side effects such as nausea and indigestion. None of the patients experienced any major adverse drug reactions such as breathlessness/tongue swelling or widespread rash. In terms of unscheduled hospital visits, 16.2% (n=6) were reviewed as urgent by ID team in the hospital A 100% (n-37) satisfactory response rate was achieved in the areas of communication, satisfaction with OPAT Clinic Visit and in terms of recommendation of OPAT service to themselves (if ever needed again) and to others in future. One area requiring improvement was highlighted by 43.3% (n=16) people regarding clinical waste collection especially after the end of OPAT.
Conclusion: Overall patients expressed satisfaction with the OPAT service. Results indicated that improvement was needed in clinical waste management collection after the OPAT completion and this was subsequently highlighted to the National OPAT program. Such surveys will be repeated at regular intervals at our centre to ensure continued improvement in our OPAT service and would be useful to gauge national patient satisfaction from the OPAT service if similar surveys on OPAT are duplicated at other centres as well.Download #2021230 (408.04 KB)
"A retrospective review of resource utilization over a 6 month period and patient demographics at a COVID clinic at a tertiary referral centre"
Principal Presenter: Peter Conlon
Keywords: Long COVID
In St James’s, the COVID clinic combines both ‘post-acute COVID’ and ‘long covid’ and is serviced by the Respiratory and Infectious Disease departments in conjunction with the physiotherapy department, occupational therapy department and the department of Neurology.
We aim to define our patient cohort and to determine what resources are being used to allow future planning for the clinic.
From October 2022 – March 2023, we prospectively completed a survey form for each patient. This included referral source, whether the patient was new or returning, planned referrals to physio, occupational therapy, psychological medicine, and otherwise. It also included investigations planning, including; phlebotomy, ECG, Holter, echocardiography, chest x-ray, CT thorax, PFTs, and sleep studies.
We retrospectively analyzed this data to determine how many investigations returned an abnormal.
In the last 6 months, the St James’s COVID clinic saw a total of 328 patients. 68% (n=224) were female, the median age was 48 years old.
45% (n=148) are new patients and 44.8% are GP referrals. 24% (n=81) of patients were discharged in these 6 months. The median follow-up appointment was 4 months.
This data demonstrates the growing nature of the Covid clinic. 148 new referrals were accepted, 60% (N=90) of which came from GPs. 81 patients were discharged from clinic in the last 6 months resulting in a net gain of 67 patients. With a median follow-up appointment of 4 months, the total number of patients attending appointments is growing.
13 CT thoraxes were ordered, of which 38% (n=5) were abnormal. Of these 5 abnormal CTs 60% (n=3) had normal PFTs.
A total of 40 Holters or echocardiograms were ordered, only 3 of which had been completed in this period. Prolonged waiting times for cardiology investigations may play a role in the delay in discharging patients from the clinic.
72 requests were made to the respiratory lab for PFTs and only 4% (n=3) were abnormal based on DLCO. However we recognize that this doesn’t capture those with reactive ariways disease. This may represent the changing dynamics of the Omicron variant of COVID-19.
The COVID clinic is seeing growing numbers of patients in St James’s and is using a wide variety of resources including physiotherapy, occupational therapy, and neurology. The bulk of the investigations that we request come from the cardiology and respiratory department. This data will help plan for the future of the COVID clinicDownload #2021229 (876.48 KB)
"The management of Diabetic Foot Infection on OPAT a single centre experience."
Principal Presenter: Colette O'Connor
Keywords: Management, Diabetic foot infection, OPAT
Diabetic foot infections (DFI) are a frequent clinical problem in patients with diabetes mellitus. While many can be treated with oral antimicrobials others have complex wounds with polymicrobial infections which require IV therapy. In our centre, patients under the care of the diabetes service who develop DFI are given rapid access to the ID clinic (within 7 days), reviewed by a senior podiatrist, a consultant in infectious diseases and an outpatient parenteral antimicrobial clinical nurse specialist. The aim of this study was to review patients treated with DFI via the OPAT service to identify areas for quality improvement.
Patients treated via OPAT for DFI during 2022 were identified. Patient demographics, treatment plans, and clinical outcomes were recorded.
There were 29 OPAT episodes for DFI in 2022, and 24 patients were treated; 8/24 (33%) were women, mean age 62 years (range 30-84 years), 20/24 (83%) were Irish. In four OPAT episodes the patient had no inpatient stay prior to initiation of OPAT, in a further 5 the inpatient stay was less than a week (range 1-6 days, median 2 days). The remaining inpatient stays prior to OPAT ranged from 8-24 days, median 12 days. The mean number of days on OPAT was 25, range 4-50 days. All patients were treated via HOPAT and all but one had a PICC inserted. Culture data was available for 22 of the OPAT episodes; 12 patients had polymicrobial cultures, and 10 had a single organism identified; in 6 instances this was methicillin susceptible S. aureus, 1 cultured methicillin resistant S. aureus, in one patient a Pseudomonas spp was identified and in 2 patients Coagulase negative Staphylococcus spp. The most commonly used antimicrobial was ceftriaxone either alone or in conjunction with another agent (19/29 (65%) episodes). In 10 OPAT (34%) episodes a patient required readmission, a change in therapy, or an extension of therapy. There were 4 readmissions, one of which was OPAT related, 4 changes to therapy due to side effects, clinical progression, or compliance with OPAT follow up, and 2 extensions to therapy one due to slow resolution and another due to COVID interrupting patient follow up.
The use of OPAT in complex DFI can reduce reliance on inpatient bed days. Development of formal pathways between endocrine and ID services, incorporating podiatry services can lead to prompt patient care in the outpatient setting.
Download #2021228 (179.99 KB)
"OPAT is an Effective Admission Avoidance Strategy for the Management of Stable Diabetic Foot Infections"
Principal Presenter: Pauline Wilson
Aim: Aim: The use of intravenous antibiotics is recommended for the management of moderate to severe DFI. In the absence of surgical resection extended courses of intravenous antibiotics are often used thus increasing patient’s length of hospital stay. Outpatient antibiotic therapy (OPAT) allows for such services to be delivered to stable patients at home thus reducing the burden on inpatient services.Method: Data was collected between 2013 and 2021 and retrospectively reviewed for length of treatments; number of patients with DFI; bed days saved and overall cost savings. Results / Discussion: The results show that using OPAT in conjunction with other standards of care was useful in admission avoidance for DFI during the period. The number of bed days saved and costs are presented in the table below. The average cost saving is € 21362 per patient. No complications were observed in any of the participants related to the OPAT treatment. During the COVID-19 pandemic in 2020 the use of OPAT was increased to ensure vulnerable patients were managed solely in an outpatient capacity. Those in need of surgery during this period were managed in the private hospitals utilising public funding. The use of OPAT facilitated a multi-disciplinary team across multiple locations to achieve optimal care.
2013 2014 2015 2016 2017 2018 2019 2020 2021Bed days saved 356 472 216 209 213 363 290 589 368Mean length of OPAT 29.66 29.5 30.8 26.12 21.3 28 32 28 31Patients treated with OPAT 12 16 7 8 16 13 9 22 12Cost saving@ €895 per night 318620 422440 193320 187055 190635 324885 259550 527155 329360Mean cost saving per patient (€) 26551 26402 27617 23381 11914 24991 28838 23961 27446
Conclusion: The use of OPAT for stable moderate and severe infections is an effective admission avoidance strategy in those with DFI and yields significant cost savings.Download #2021227 (1.29 MB)
"Infrared thermometry as a Diagnostic Aid in the Discernment of Diabetic Foot Infection."
Principal Presenter: Pauline Wilson
Diabetic foot infection is a cause of significant morbidity and is associated with the need for lower extremity amputation. The diagnosis of infection is a clinical one and the classical signs of infection are often absent in those with DM due to concomitant immunopathy.
We utilised the FLIR E6 infrared camera to assist in the clinical diagnosis of foot infections across 20 patients with suspected signs of infection in order to guide therapy. We utilised a 2.2 oC temperature difference between feet in order to inform the presence of infection or to refer onwards for inflammatory marker testing. The use of thermometry was an aid to clinical diagnosis in the absences of cardinal signs of infection.
We found that the use of infrared thermometry was a good clinical aid in those who did not have overt signs of infection and no systemic symptoms. In 85% (n=17) patients no further need for assessment of systemic inflammatory markers was required. By utilising this point of care test we were able to reduce the number of patients referred for blood tests confirm clinical diagnosis.
The use of infrared thermometry is a useful diagnostic aid for the presence of DFI in those where the clinical diagnosis is uncertain reducing the need for further testing of inflammatory biomarkers.Download #2021226 (793.21 KB)
"Interferon-gamma deficiency leading to disseminated invasive aspergillus infection"
Principal Presenter: Maria McWalter
Keywords: Fungal infections, Immunocompromised Host, CNS infection
Aspergillus fumigatus species can be pathological in immunocompromised hosts. It may disseminate in an angio-invasive manner to involve other organ systems including the central nervous system. Aspergillosis involving the central nervous system may cause focal neurological deficits and cerebral abscesses are demonstrated as ring-enhancing lesions on brain imaging. Interferon gamma deficiency can predispose patients to developing atypical fungal infections.
A 36 year old female patient was admitted to ICU with Type 1 Respiratory failure. She was two weeks post-emergency C section at 31 weeks for suspected pre-eclampsia.
Past medical history included asthma, depression, an atrial septal defect with patent foramen ovale and well-controlled epilepsy. She had no history of childhood infections.
On day 3 of admission to the Intesnive Care Unit, she had a PEA cardiac arrest. A CT Pulmonary Angiogram demonstrated a pulmonary embolus with right heart strain and diffuse ground glass opacification with evidence of superimposed infection.
A sputum sample cultured Aspergillus Fumigatus complex which was sensitive to Amphotericin B, fluconazole and voriconazole. She developed left sided hemiparesis.
MRI brain showed multiple haemorrhagic intracranial abscesses consistent with septic emboli with ventriculitis. A Transoesophageal Echocardiogram was unremarkable. Beta D glucan levels were elevated at 293 while Aspergillus IgG titres were 74.
In addition to broad spectrum antibiotics she was commenced on voriconazole with a good clinical response. Follow up MRI brain 3 months later showed improving appearances apart from a frontal abscess which had increased in size. Frontal brain biopsy showed perivascular lymphohistiocytic inflammation suggestive of CNS aspergillosis. 6 months into treatment, she was switched to isavuconazole therapy due to alopecia and liver function test derangement on voriconzole.
Immunology services established a diagnosis of interferon gamma deficiency. Interferon gamma therapy was initiated but was stopped after 6 weeks due to associated fatigue and myalgia. She continues on isavuconazole with slow improvement in MRI brain changes and normalisation of serum Beta D Glucan levels.
Aspergillus Fumigatus is an angio-invasive disease which can cause significant multi-organ dysfunction including neurological sequelae in immunocompromised hosts. It can lead to aggressive presentations of cerebro-pulmonary infection. A thorough work-up showed be performed to elicit any underlying immune dysfunction. Interferon-gamma deficiency precipitated Disseminated Aspergillus infection in this case.Download #2021225 (80.1 KB)
"First detection and infection caused by the novel human pathogen Kalamiella piersonii in Ireland"
Principal Presenter: Georgios Miliotis
Kalamiella is a novel genus in the Enterobacterales order that currently consists of a single species; Kalamiella piersonii. Kalamiella is so far the only bacterial genus to be initially characterized aboard the International Space Station (ISS) in 2019. Initial bioinformatic analysis of the type strain showed no genetic markers of virulence. In 2020 a first clinical case of K. piersonii was reported in India. Since then, clinical cases of bacteraemia, meningitis, pneumonia, kidney, and wound infections have been reported in over 7 countries. In late 2022, we incidentally detected a multidrug (MDR) K. piersonii isolate from saliva of an outpatient during a research study. We fully resolved its genome providing the first complete genome for the genera/species. In early 2023, an MDR strain of K. piersonii was detected from blood culture in a patient with central venous catheter related infection.
The isolates were initially identified as K. piersonii using MALDI-ToF. The antimicroibial susceptibility profile was determined using the clinical breakpoints provided by EUCAST (v.12.0, 2022). Biofilm formation was determined using the Dojindo Biofilm Formation Assay kit. The bacterial structure was resolved using electron microscopy. Long and short read sequencing were used to fully resolve the genomes and associated plasmids, while bionformatics and phylogenetic analysis was conducted to identify virulence factors, antimicrobial resistance genes and place the Irish isolates in a global epidemiological context.
K. piersonii was confirmed to be able a biofilm former. All isolates were MDR with resistance to aminopenicillins with clavulanate, quinolone, 2nd and 3rd generation cephalosporins. The isolates carried three plasmids, one of which (513,647 bp) is a virulence associated plasmid encoding for homologues of the siderophores aerobactin and vibriobactin as well as transcriptional virulence regulators. These virulence plasmid appears to be present to all K. piersonii isolates sequenced so far. We also identified resistance genes to heavy metals, UV and commonly used disinfectants. Using phylogenomic analysis we reported that the clinical strains from India, USA and Ireland appear to be genomically distinct from the ISS strains.
Further characterisation of these strains is in progress together with characterisation of a global collection of over 40 K. piersonii isolates from ISS and clinical origines. K. piersonii is a novel species that is associated with human infection. Characterisation of a larger number of clinical isolates is required to improve our understanding of the diversity, pathogenicity and antimicrobial resistance of this species.
"Inpatient healthcare utilisation by people with human immune deficiency virus (HIV) in Ireland, a national retrospective evaluation"
Principal Presenter: Aimee McGreal-Bellone
Background: HIV represents a chronic disease treated in the outpatient setting. We sought to characterise inpatient care by this cohort; in the first such report to be undertaken in Ireland.
Methods: A retrospective analysis of all adult patients with HIV discharged from Irish public hospitals between January 2017 and January 2022 was performed. Data was obtained from the National Quality Assurance Improvement System (NQAIS) Clinical, a national electronic database of hospital discharges, descriptive analysis was performed.
Results: During the study period, 242 inpatient episodes of care were captured, 22 elective with 220 emergent, mean of 46 admission episodes per annum, 95% (232) were public patients, 11 were private, 165 (68%) were male. The median age was 41 (IQR 33-49). Regional distribution; Dublin 116 (47.9%); Cork 19(7.9%) and Galway 12 (5%).
The mean length of stay was 16.9 days, median 9 (IQR 5-17.7 days), 24 episodes were same-day discharges. Over 90% of admissions were to centres with infectious diseases and HIV services. Reason for admission; opportunistic infection 114 (46.9%); acute HIV infection syndrome 18 (7.4%) ; HIV resulting in other conditions 19 (7.8%); HIV-related malignancy 12 (4.9%); unspecified HIV disease 71 (29%); asymptomatic HIV infection 9 (3.7%).
Admission to ICU was recorded for 19 (7.8%) episodes of care; 12 (65%) were male; median age of 40; median length of stay in ICU was 5 days (IQR 2.75-15.25), and the total median length of stay was 24 days (IQR 6.7-64.5). Reason for ICU admission was, respiratory infection for 15 patients, 5 with tuberculosis and 5 with pneumocystis, 14 required intubation and ventilation, the remainder having bloodstream or central nervous system infections. The mean cost of admission to the ICU for these patients was €53296, with a median cost of €26435.
Conclusions: Results reflect HIV data from the Irish health protection surveillance centre with male preponderance and Dublin focus however, the age profile of those admitted was higher. The high rate of admissions for opportunistic infections suggests an ongoing need for earlier case finding and treatment initiation.
Download #2021223 (550.41 KB)
"Longitudinal Seroprevalence of SARS-CoV-2 Antibodies of an Inner-City Dublin Hospital using a Qualitative Antinucleocapsid Assay- Results from the "SORTED" Study"
Principal Presenter: Stephen Connolly
Healthcare workers (HCWs) in Ireland bore a particularly high burden of SARS-CoV-2 infections, at one point representing over 30% of infections during the pandemic’s initial wave. We describe the COVID-19 seroprevalence in HCWs with and without prior SARS-CoV-2 infection and factors associated with positive serostatus, correlating with likelihood of re-infection.
The Seroprevalence, Seroconversion Rates and Transmission Dynamics of SARS-CoV-2 among Healthcare Workers (‘SORTeD’) study was a longitudinal cohort study of HCWs working in an inner-city hospital in Dublin. Participants had either a prior history of PCR-confirmed SARS-CoV-2 (Group 1) or no prior history of SARS-CoV-2 (Group 2). Serum samples were obtained at weeks 0, 12 and 48, and tested for SARS-CoV-2 nucleocapsid (NC) antibody using a qualitative immunoassay (Abbott Alinity®); results were reported as ‘detected’ or ‘not detected’ based on a refractive index > than 1.4. Seroprevalence rates are presented, with univariate analysis examining associations between participant characteristics, SARS-CoV-2 IgG status and refractive index in Group 1. Odds ratios for re-infection were calculated for those with detectable IgG at baseline and/or retained their IgG positivity at the end of follow-up. Data is presented as n (%) or median (interquartile range (IQR)) where appropriate.
Of the 395 HCWs who were recruited, 304 (77%) were female, aged 33 (45-28) years, and 343 (86.8%) had patient-facing clinical roles. In those with prior SARS-CoV-2 infection (Group 1), time from illness onset to sampling was 173 (144.0-202.0) days. Seroprevalence of IgG in Group 1 at 0, 12 and 48 weeks was 47.4%, 19.0% and 7.3%, respectively; while seroprevalence in Group 2 was 5.4%, 4.3% and 2.6%, respectively. OR of re-infection during the study period in those who did not have a detectable IgG at the end of their study period was 1.47 (95% CI 0.285-7.595). A lower refractive index was seen in higher sampling intervals (r = -0.5, 95% CI -0.576 to -0.427; p<0.001).
Our study shows a low seroprevalence in prior confirmed cases among our HCW population, possibly explained by observed reduced sensitivity of this particular assay with increasing time from SARS-CoV-2 exposure. Additional, confirmatory testing with a quantitative assay would help understand the true seroprevalence of SARS-CoV-2 IgG in this cohort.
"Nurse led Utilisation of Fibroscan in a Viral Hepatitis Clinic"
Principal Presenter: Stephanie Denieffe
Keywords: Nurse-led, Fibroscan, Viral Hepatitis
Liver disease is an emerging cause of significant morbidity and mortality. Consequently, staging liver disease is essential in disease management. A Fibroscan is a convenient non-invasive tool for classification of Liver Stiffness (KPA) and fat component (CAP). With an increasing burden of hepatitis patients, our Infectious Disease department has redesigned service delivery to optimise resources which has led to the introduction of a new Nurse-led Fibroscan service. This study examines the diagnostic accuracy of Nurse-led Fibroscan in staging fibrosis in chronic liver disease compared with conventional modalities in the management of liver disease.
106 patients were referred to the Nurse-led Fibroscan service from January 2022 to December 2022. The Fibroscan readings were then compared to Ultrasound scan (USS) and biochemistry results. Of the 105 referrals, 74% were male and 26% were female. 79 patients had hepatitis B, 25 had hepatitis C and 1 had no evidence of viral hepatitis. The average age was 41years. The Fibroscan results were classified into normal, fatty liver, fibrosis and cirrhosis based on KPA. An average ALT of 37u/l was seen. Fibroscan results showed normal=79, fatty liver=13, fibrosis=6 and cirrhosis =7. These results were then compared to ultrasound. Of the 105 patients screened, 67 had an ultrasound. Of the 33 who had a normal ultrasound, 2 had fatty liver and 2 had evidence of fibrosis on Fibroscan showing a 12% (n=4) variance of diagnosis indicating a worsening stage of liver disease. Of the 16 patients who had fatty liver on USS, 10 had the same diagnosis on Fibroscan. There was a variance of 31.25% (n=5) with 4 showing a better diagnosis having a normal Fibroscan and 1 subject showing fibrosis indicating a worse prognosis.17 had fibrosis or early cirrhosis reported on USS, 8 were reported as normal on Fibroscan, 5 reported as fatty liver, 1 fibrosis and 3 cirrhosis indicating the variance to be 76% (n=13) towards a more favourable prognosis.
A Nurse-led Fibroscan service highlights the increasing role and broader scope of practice that nurses play in viral hepatitis. Fibroscan results are reliable and reproducible, increasing patient access to care and providing cost effective high quality stream lined care. Fibroscan also allows risk stratification within the viral hepatitis cohort, allowing timely referral to hepatology services for those at higher risk for development of HCC.
Download #2021220 (478.02 KB)
"Acute Kawasaki Disease in an Adult: An important Infectious Disease Mimic"
Principal Presenter: Stephanie Denieffe
Kawasaki disease is predominantly a disease of childhood and often presents as an acute multi system vasculitis with associated cervical lymphadenopathy, mucosal inflammation, rash, and oedema. Severe cases are associated with coronary artery aneurysms. Here we report the rare case of Kawasaki disease in an adult.
This is the case of a 40 year old male who presented with persistent fever, rash and unilateral neck swelling. The patient required ICU admission for septic shock secondary to left neck necrotizing lymphadenitis with presumed infective aetiology at this time. Lymph node biopsies and molecular testing failed to yield a microbiological diagnosis however histology suggested Kawasaki disease as a differential diagnosis. The patient received IVIG on day 4 of his ICU admission and improved gradually with empiric antimicrobial coverage. Following the suggestion of Kawasaki disease at biopsy the patient then began to develop some of the hallmark features of the disease including evidence of desquamation of the patients skin and erythema of his lips and oral mucosa, and conjunctivitis. The patients admission was further complicated by development of a pericardial effusion, pericarditis and myocarditis. The diagnosis of Kawasaki disease was confirmed by CT coronary angiogram which demonstrated aneurysmal segments in both the LAD and right coronary artery.
Kawasaki disease is often considered a diagnosis of childhood and rarely presents in adults. Timely diagnostics and multidisciplinary team input are key in establishing the diagnosis as many of the characteristic features of the disease are nonspecific and common in other infectious diseases.
"The Impact of an Infectious Diseases - Supervised OPAT service in a Model Three Hospital"
Principal Presenter: Danijela Bozic Kitic
Keywords: OPAT, Model Three Hospital, Infectious Diseases
Equitable access to OPAT depends on both community and hospital resources. Midland Regional Hospital Tullamore (MRHT) is a model three hospital with 200 inpatient beds and a strong community health team. MRHTs first OPAT nurse was appointed in 2019 with 850 and 820 bed days saved in 2019 and 2020 respectively. This is the first review of the OPAT service in MRHT since an Infectious Diseases (ID) consultant started in January 2022
Patients were identified using the OPAT portal and local database between Feb 2022 and March 2023. Outcomes recorded conformed with national and BSAC guidelines.
One hundred and twenty seven patients received at least one day of antibiotics through the OPAT programme from January 2022 to March 2023.
Most patients were male (63%; 80/127) with a mean age of 65. The most common indications were bone and joint infections (68%; 86/127) followed by skin and soft tissue infections (SSTI) 17%; (22/127). Antimicrobial duration ranged from 1-41 days with the average duration of 22 days. Just over one fifth (22%) of patients had an antibiotic course shorter than 10 days. There were 2752 bed days saved (2138 for year ending 2021) with eight patients completely avoiding a hospital admission.
Targeted antimicrobials were prescribed in over three quarters of patients (77%; 99/133). The most commonly prescribed antimicrobial was Ceftriaxone as a single agent or in combination (37%; 47/127), followed by Daptomycin (26%; 33/127). Flucloxacillin was prescribed in 25 patients. Few adverse drug effects were recorded (5%; 6/127). Line complications were reported in twelve patients (9%), with a PICC line thrombus complicating four cases. Nearly two thirds (63%; 79/127) of patients had antibiotics administered by a health professional (H-OPAT). Over one quarter of H-OPAT (24%; 19/79) had an IV cannula thus not eligible for self-OPAT.
Infection cure was the treatment aim in over three quarters of patients (77%; 98/127) and was achieved for most (93%; 91/98). OPAT outcome was a success in 100 patients (79%) patients, a further eight patients (6%) had a partial success where antimicrobial was changed but readmission avoided.
OPAT activity in MRHT has increased 2.5 fold since arrival of an ID consultant. Outcomes were successful in most patients consistent with other centres. This emphasises the importance of the ID profession in the development of OPAT services and suggests that the geographical disparity of OPAT availability nationwide is due to an unmet need as opposed to the lack of need.Download #2021218 (1.71 MB)
"Leptospirosis in Ireland, national testing patterns and inpatient care utilisation"
Principal Presenter: Aimee McGreal-Bellone
Background: Leptospirosis is a zoonotic infection caused by the spirochete Leptospira interrogans. This study was carried out to better understand the testing patterns for Leptospirosis in Ireland and the spatial relationship to episodes of inpatient care.
Methods: Leptospirosis testing and care episodes in the Republic of Ireland from January 2017 to August 2021 were reviewed. Testing data was obtained from the National Virus Reference Laboratory in Dublin Clinical care episodes were extracted from the electronic National hospital discharge coding via The National Quality Assurance Improvement System (NQAIS).
Results: In total, 6198 samples were tested for leptospirosis during the study period; 3786 were from males. Hospital samples accounted for 5998 (97%) and 200 were from primary care, 28% (1597) of samples were from the Dublin region. There were 133 positive results with a positivity rate of 2.15% equating to a crude incidence rate (CIR) of 0.55 per 100,000 population, when duplicate positive tests were removed (40) the CIR was 0.38 per 100,000.
Of the positive tests, the mean age was 46,(range of 12-96), 70 males. Dublin hospitals accounted for the 27 (29%) positive tests, followed by Cork 15 (16%).
During this period, there were 76 inpatient episodes of care relating to leptospirosis, 57 (75%) male, mean age 44 (range 16-71), median duration of stay was nine days (IQR 5-21 days), 28 (36.8%) of admissions were In Dublin hospitals. National case hospitalisation rate was 0.31 per 100,000 population, region specific hospitalisation varied with the highest rate in Laoise 1.01 admissions per 100,000 population, followed by Kerry (0.73), Wexford (0.72) and Cork (CRI 0.59), Dublin had a lower hospitalisation rate (0.38).
Thirty-two cases (42%) required ICU, median ICU stay was 5 days, 14 (43%) required mechanical ventilation.
Conclusions: Leptospirosis testing patterns roughly mirrors data about inpatient episodes of care in terms of geographical distribution, sex and age profile. Our study shows testing positivity is in line with published data from the National Health Protection and Surveillance centre 2018 report, CRI of 0.4 per 100,000; however, there appears to be greater variability in hospitalisation rates by region.Download #2021217 (380.46 KB)
"Inflammatory Pathways Associated with COVID19 Severity Differ Based on Obesity Status"
Principal Presenter: Stefano Savinelli
Background: Severe COVID-19 and obesity are characterized by higher inflammation. We aimed to examine early inflammatory patterns in people with (Ob) and without (NOb) obesity and COVID-19 and relations to disease severity.
Methods: Ob (BMI>30 Kg/m2) and NOb with early COVID-19 were matched for age, sex and WHO disease severity. Immunoassays measured 57 biomarkers reflecting innate immune and endothelial activation, systemic inflammation, coagulation, metabolism and microbial translocation. Between-group differences were assessed by Mann-Whitney. Associations between maximal COVID-19 severity (mild vs moderate/severe/critical) and biomarkers were explored by logistic regression adjusted for age, sex, hypertension (HTN) and diabetes (DM). Data are median pg/mL [IQR] or n [%] unless stated.
Results: Of 100 subjects (50 Ob and 50 Nob) characteristics (Ob vs Nob) included: age 65[23-91] vs 65[21-95]; female sex 27 (48%) vs 28 (56%); BMI 33.7 [30.0-71.8] vs 23.3 [15.3-25.9]; disease severity mild 22 [48%] vs 23 [46%], moderate 15 [30%] vs 13 [26%], severe 6[12%] vs 7[14%]; HTN 30(60%) vs 17(34%); DM 19[38%] vs 6[12%]; days from symptom onset 7[2-17] vs 8[1-15]; vaccinated 3 (6%) vs 0 (0%).
Ob had higher IFN-α (1.8[0.6; 11] vs 0.9[0.1; 4.7]), CRP (10 mAU/mL[9.6; 10.2] vs 9.7[7.2; 10]), IL-1RA (197[122; 399] vs 138[88; 253]), IL-4 (288 AU/mL [161; 424] vs 205 [82; 333]), vWF (252 [166; 383] vs 163 [96; 318]), Zonulin (114 ng/mL [77; 131] vs 57 [18; 106]), Resistin (956 [569; 1153] vs 727 [712; 1525]), Leptin (3482 [1513; 5738] vs 848 [249; 2114]), and lower Adiponectin (1.12 mg/L [0.09; 1.5] vs 1.5 [1.18; 1.93]), all p<0.05.
In both groups higher IL-18 and lower levels of anti-inflammatory CCL22 and IL-5 were associated with disease severity, and lower E-selectin with higher disease severity only in Ob. However, in NOb higher type 3 interferons (IL-28A), macrophage activation (sCD163, CCL3) and vascular inflammation markers (ICAM-1, VCAM-1), along with higher S100B, GM-CSF and leptin were also associated with disease severity, a pattern not observed in Ob.
Conclusions: Although Ob had higher levels of inflammation than NOb, few biomarkers predicted subsequent COVID-19 severity in Ob. Differential inflammatory patterns suggest dysregulated immune responses in Ob with COVID-19.
"Clinical audit of prosthetic joint infection diagnosis and treatment at Cork University Hospital"
Principal Presenter: Matthew Blair
Keywords: Prosthetic joint infection, Diagnostics, Audit
Prosthetic joint infection (PJI) is an infrequent but serious complication of
joint arthroplasty. Adherence to international guidelines is essential for
identifying the causative pathogen and appropriate use of antibiotics. We
conducted a retrospective audit of PJI at our institution. The Infectious
Diseases Society of America clinical practice guidelines (2013) and the UK
Standards for Microbiology Investigations (2016) were used as the quality
benchmark. The aim was to assess pre-operative, operative
and laboratory processes for diagnosis of PJI.
Patients were identified from theatre records. We included patients who
met consensus criteria and underwent procedure for PJI between
September 2020 and September 2021. We collected demographic data
and culture results to characterise local microbiology and antimicrobial
resistance. Variables of interest included (1) specimen quantity and types,
(2) timing and appropriateness of antibiotics, and (3) duration of laboratory
50 unique episodes of surgery for PJI were included. The most common
pathogen groups were coagulase-negative Staphylococci (35%), S. aureus
(29%) and gram-negative organisms (25%). 26% of cases showed no
growth from operative specimens. Most cases (84%) had sufficient (at least
3) specimens sent. Specimen types were predominantly tissue (50%),
followed by swab (32%) and fluid (15%). Most cases (61%) incorrectly
received antibiotics in theatre prior to sampling and 10% of cases received
peri-operative antibiotics discordant with subsequent culture results.
The current SOP (Standard Operating Procedure) in our microbiology
laboratory is to perform enrichment culture for 5 days on tissue samples
only. Since a significant proportion of our samples were swabs and fluid
samples, many samples did not receive prolonged incubation.
We found higher rates of gram-negative and culture-negative infections in
our audit compared to previous reports. We identified opportunities to
enhance our sampling methods with respect to tissue type and intra-
operative methods to reduce risk of contamination. Some patients received
antibiotics discordant with culture results, suggesting a need for a
protocolised regimen tailored to local microbiology. Review of the laboratory protocol to include fluid and tissue inoculation into blood cultures
is being proposed. This method has been shown to increase sensitivity and
optimises identification of pathogens.This audit will inform a local policy for PJI diagnosis and treatment.
Introduction of a sampling kit is planned to improve adherence to guidelines
for sterile technique. We are planning a multi-modal educational
intervention for Orthopaedic and laboratory staff to ensure compliance with
best practice. A repeat audit is planned to assess the effect of this
intervention.Download #2021215 (654.49 KB)
"Spatial epidemiological trends in the isolation of non-tuberculous mycobacteria: a 15-year study in the Northern Ireland Regional Mycobacterial Reference Laboratory"
Principal Presenter: Timothy Shaw
The rise of non-tuberculous mycobacterial (NTM) infections in high-income countries is widely reported. Regional variations in dominant NTM species have been described across Europe, as well as differences in environmental and social risk factors. However, NTM infections in Northern Ireland remain poorly characterised. We aimed to estimate the disease burden of NTM infection in Northern Ireland and characterise the contribution of spatial epidemiological factors.
All positive mycobacteria isolates processed by the Northern Ireland Regional Mycobacteria Laboratory (NIRML) from 2007-2021 were analysed by species, tissue source, patient gender, age decile and local government district. Population density and socio-economic measures for each local government district were obtained from the Northern Ireland Statistics and Research Agency. Mean annual precipitation data was obtained from the UK Meteorological Office.
Changes in isolate numbers over time was analysed by non-linear (Poisson) regression. The contributions of age, sex, population density, mean annual precipitation, income deprivation rate and employment deprivation rate to the incidence of NTM isolation over time were analysed by simple linear regression. The Mann Whitney U test was to compare incidence between male and female at different age groups.
2354 mycobacterial isolates from 89,096 clinical specimens were captured. Isolation rates of pathogenic NTM rose two-fold in the study period, overtaking M. tuberculosis in 2015 (p<0.05). This was driven by increasing Mycobacterium avium complex (MAC) isolates from pulmonary specimens, rising from 1.6 to 3.8 per 100,000 population. Rates of pulmonary MAC isolation were particularly high in older patients (10.4 and 9.4 per 100,000 for males and females >50 years old respectively). The 15-year incidence was higher in the north-east compared to the other regions combined (median 121 per 100,000 people over 50 years old, IQR 101-165 versus 76, IQR 59-99, p=0.02). The rising incidence of pulmonary MAC isolation correlated with local government districts with higher employment rates and income status (p<0.05 for both). There was no correlation between MAC isolation and population density or mean annual precipitation.
NTM are a rapidly emerging pathogen in Northern Ireland, driven by increasing pulmonary MAC isolates from older patients in areas of higher socioeconomic status. To better anticipate service needs and identify research priorities, further work should characterise the environmental, social and patient factors in clinically-confirmed cases of NTM infection.
"Retreatment of patients experiencing failure with Hepatitis C direct-acting antivirals"
Principal Presenter: Nessa Quinn
Background: The sustained virological response (SVR) rate for first line direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) infection in Ireland surpasses 95%. Factors associated with the limited number of treatment failures include incomplete adherence, advanced cirrhosis (Child Pugh class B and C), and the presence of resistance associated substitutions (RASs). The aim of this study was to determine the frequency of treatment failure in patients treated in St James Hospital (SJH), Dublin and to review retreatment regimens and outcomes.
Methods: Data was extracted from hospital HCV treatment records and the National Hepatitis C Treatment Registry to identify patients who received all-oral DAA treatment for HCV from 2014 to 2021 in SJH. Exclusion criteria included patients who did not complete the initial treatment course and those for whom SVR results are still pending.
Results: A total of 2,015 patients received at least one course of all-oral DAA treatment for HCV. A total of 1,589 patients achieved SVR (97.9%) (per protocol analysis). Twenty-five patients failed to achieve SVR, twenty of whom had RASs detected. The most common RASs conferring reduced susceptibility to treatment included NS5A RASs at positions Q30 and Y93 and NS3 RASs at position Q80. Eight patients had > 1 NS5A mutation and / or dual class resistance. Of 23 patients who were retreated, 18 achieved SVR (14 of whom received triple therapy with sofosbuvir / velpatasvir / voxilaprevir (SOF / VEL / VOX) or sofosbuvir / glecaprevir / pibrentasvir (SOF / G / P) and nine of whom received concurrent ribavirin). Five patients failed to achieve SVR with retreatment, two of whom were successfully treated with a third course of DAAs. The remaining three patients are awaiting third line treatment.
Conclusion: Three class DAA regimens are a highly effective retreatment for HCV even in the presence of multiple NS5A and NS3 mutations.
"An Audit of the Beta D Glucan Test by the Department of Infectious Diseases at the Mater Misericordiae University Hospital"
Principal Presenter: Eimear O'Donovan
Keywords: antimicrobial stewardship, fungal marker testing, clinical audit
Beta-D-glucan is a panfungal marker which can be a useful tool in the diagnosis of invasive fungal disease. The assay was introduced to the Mater Misericordiae University Hospital (MMUH) in 2021 as an in-house test. The aim of this audit was to evaluate the appropriateness of beta D glucan use by the department of Infectious diseases (ID).
All beta D glucan tests requested in the MMUH between January 2021 and December 2021 were identified. Those tests initiated by the ID service were examined via retrospective analysis of patient digital records.
Indications for testing were categorised as follows:
1) Investigation of sepsis in ICU,
2) Follow up for known fungal infection,
3) Investigation of intraabdominal infections,
4) Query PCP,
5) Investigation of probable invasive pulmonary fungal infection,
6) PUO/investigation of fever,
7) Malignant otitis externa,
Groups 1, 2 and 3 were supported by the guidelines and we considered groups 4 and 5 to be appropriate also.
The total number of beta D glucan samples 760 ordered from 412 patients. 180 (24%) were positive. 353 were under the guidance of the ID team – 182 were ordered under the direct care of the ID team and 171 were ordered on consultation. Thirty percent of tests sent by ID were positive.
The number of tests done for each indication is as follows; investigation of sepsis in ICU 166, follow up for known fungal infection 91, investigation of intraabdominal infections 13, query PCP 8, investigation of probable invasive pulmonary fungal infection 34, PUO 18. The proportion of these tests which were positive is; investigation of sepsis in ICU 38 (23%) of which 69 had cultures positive for fungal species, follow up for known fungal infection 60 (67%); 53 had positive cultures, investigation of intraabdominal infections 2 (15%); 3 had positive cultures, query PCP 1 (12.5%) and 1 had a positive culture, investigation of probable invasive pulmonary fungal infection 3 (9%); 10 had positive cultures, PUO 3 (16.7%); 5 had cultures positive for fungal species.
A large proportion of beta-D-glucan testing is initiated by the ID service. In the vast majority these tests are clinically indicated; which is reflected by a higher proportion of positive results. Beta-D-glucan is a useful adjunctive test in the diagnosis of invasive fungal infection and use should be guided by infection specialists to ensure good laboratory stewardship.Download #2021211 (320.45 KB)
"An audit on outpatient parenteral antimicrobial therapy (OPAT) for diabetic foot infections, in terms of outcomes and cost effectiveness"
Principal Presenter: MUHAMMAD LEEL
Keywords: HSE, NHS, UHS
Diabetic foot infection is becoming a very common and dreadful complication in diabetic population with high risk of morbidity, mortality and lower extremity amputation. The aim of this study was to assess frequency of diabetic foot infection presenting to our outpatient parenteral antimicrobial therapy(OPAT) services in UHL from year of 2022 and to evaluate effectiveness, outcomes and cost savings with OPAT services.
Objective: Effectiveness of OPAT in diabetic foot infection
Data was collected retrospectively from OPAT patients enrolled at UHL in year of 2022. Data was collected regarding their diagnosis, referring specialties, microbiology and sensitivities, antibiotics given, outcomes, self OPAT(SOPAT) vs Health-care associated OPAT (HOPAT) and hospital bed days saved. Data was analysed with SPSS 21.
Total 306 patient being given OPAT during 2022. Of them 58 were with DFI.
Most of cases being reffered by vascular surgery (79.3%) followed by GIM 15.5, general surgery(3.5%) and orthopedics(1.7%)
Most common bacterias isolated were methicillin sensitive Staph aureus (MSSA) 41.4%, followed by Streptococcus (15.5% ), MRSA (10.3% ) , Enterococcus (8.6%) Pseudomonas species (6.9%) , mixed microorganisms ( 8.6% ) and Proteus (6.9%).
The most common antibiotics used were flucloxacillin (32.8% ) , followed by pieracillin-tazobactam ( 34.5
%) , ceftriaxone (10.3 %) ,daptomycin (8.6%) , ertapenum ( 8.6%) , and mixed antimicrobial therapy in 5.7%.
The outcome of this management showed 14 % of the patients who failed the OPAT because of readmission requiring surgical intervention.
SOPAT(self outpatient antibiotic therapy) was observed in 3.5% of the patients.
After a year,the service resulted in 993 beds saved through the provision of OPAT only for the patients with diabetic foot infection.14 % of patients were permanently terminated OPAT due to readmission requiring surgical intervention.
Overall, OPAT is being found to be a safe, practical and cost effective approach in management of diabetic foot infection and found to be best alternative to long term hospital admission for getting intravenous antibiotics and spring the hospital resources. OPAT limits exposure to nosocomial pathogens.Self administration is low so we should promote more in future for suitable patients.
Keywords: Outpatient antibiotic therapy (OPAT) in DFI(diabetic foot infection).Download #2021210 (629.69 KB)
"Efficacy and Safety of Remdesivir In People With Moderately and Severely Reduced Kidney Function Hospitalised for COVID-19: The REDPINE Study"
Principal Presenter: Ross Hamilton-Shaw
Keywords: remdesivir, renal, dialysis
Background: Remdesivir is approved for treating COVID-19 in patients with estimated glomerular filtration rate (eGFR) ≥30mL/min/1.73 m2. Remdesivir is not recommended for patients with eGFR <30mL/min/1.73 m2 due to lack of data and the concern for potential accumulation of the main metabolite, GS-441524, or the vehicle, sulfobutylether-beta-cyclodextrin (SBECD). This study evaluated the efficacy and safety of remdesivir in patients with moderately and severely reduced kidney function hospitalised for COVID-19, a population with increased COVID-19-related mortality.
Methods: REDPINE was a phase 3, randomised, double-blind, placebo-controlled, parallel-group, multicentre study in participants aged ≥12 years with chronic kidney disease with eGFR <30mL/min/1.73m2 or sustained acute kidney injury (AKI) who were hospitalised for COVID-19 and had pneumonia. Participants were randomised 2:1 to intravenous (IV) remdesivir (200 mg on Day 1; 100 mg daily up to Day 5) or IV saline. The primary efficacy endpoint was the composite of all-cause mortality or invasive mechanical ventilation (IMV) through Day 29. Treatment-emergent adverse events (TEAEs), serious TEAEs, and TEAEs leading to discontinuation were also evaluated.
Results: Overall, 243 participants were randomised and treated (remdesivir, n=163; placebo, n=80); 139(57.2%) were male. Mean(SD) age was 68(14.1) and 71(13.0) years in the remdesivir and placebo groups, respectively. Mean(SD) baseline serum creatinine was 4.94(3.66) and 4.51(2.85) mg/dL in the remdesivir and placebo groups, respectively. 89/243(36.6%) participants had end stage kidney disease (ESKD) requiring chronic dialysis at baseline (remdesivir, 59/163[36.2%]; placebo, 30/80[37.5%]). The Day 29 Kaplan-Meier estimate of all-cause mortality or IMV was 30.2% with remdesivir and 33.5% with placebo (P=0.61). TEAEs were 80.4% with remdesivir vs 77.5% with placebo (most common: hypotension, respiratory failure, constipation [all <10% of overall participants]); serious TEAEs, 50.3% vs 50.0%; TEAEs leading to discontinuation, 4.9% vs 1.3%. Similar proportions of participants without ESKD at baseline had AKI Stage 2 or 3, renal replacement therapy, or death by Day 29 (remdesivir, 35/104[33.7%]; placebo, 18/50[36.0%]; P=0.77).
Conclusions: Although underpowered for efficacy, remdesivir safety analyses showed similar treatment-emergent adverse event profiles versus placebo in patients with moderately and severely reduced kidney function hospitalised for COVID-19.Download #2021209 (862.03 KB)
"Panton-Valentine Leucocidin- An outbreak and case review"
Principal Presenter: Majella Bradley
Keywords: PVL, MRSA, Outbreak
Background:Panton-Valentine Leucocidin community acquired Methicillin resistant Staphylococcus Aureus(PVL-CA-MRSA) is increasingly associated with frequent importation to and outbreaks in hospitals. PVL is a toxin produced by MRSA and associated with increased virulence with higher morbidity and mortality. PVL-CA-MRSA is not notifiable however an outbreak should be notified to Public Health(PH). Since November 2022 PH Area D have been notified of three community cases and one community outbreak. Prior to this PH Area D had not dealt with any such cases. This increase highlights the need for updated guidance on the recognition, investigation and management of PVL-CA-MRSA cases in the community.
Method:A review was undertaken of laboratory results notified to PH. Case notes, communication and feedback sought from families were reviewed. A search of the departmental database and internet of all available information on PVL-MRSA for healthcare workers and the public was performed.
Results:Whole genome typing showed linked ST-SPA Type-T657 in both cases with potential resistance to aminoglycoside and macrolide classes of antibiotics. The time lag between initial presentation to GP, date swab was taken and results suggests a lack of awareness around the prevalence, testing and treatment of PVL MRSA. A national, accessible patient information leaflet on PVL MRSA was difficult to find and was sourced from United Kingdom (UK) National Health Service and UK dermatological association. A quick guide on PVL MRSA management targeted to healthcare professionals is an evident gap. Given that healthcare workers are in the contact risk category this is a priority.
Conclusion:There has been a worldwide increase in community associated CA-MRSA infections, yet in Ireland there is no formal surveillance system to monitor CA-MRSA cases. Equally pertinent in 2020 and 2021 saw PVL-MRSA as the most frequently requested test in the National MRSA Reference Laboratory. This outbreak review highlights challenges in delivering timely information to prevent or minimise onward spread. The importance of patient education is evident. There were two linked cases within the community outbreak however the wider family unit encompassed nine potential persons at risk. Access to a plain language patient information leaflet is important to support the Public Health advice and critical in effective CA-PVL-MRSA management. Education materials could be developed to heighten awareness among GP’s. These interventions should assist in curbing transmission of CA-PVL-MRSA and reducing prescription of antibiotics for infection management.Download #2021208 (364.34 KB)
"A Review of Clinical Trial Data on the Recombinant Zoster Vaccine"
Principal Presenter: Claire O'Reilly
Keywords: Herpes zoster, Recombinant zoster vaccine, ZOE-50/-70
The pivotal phase 3 ZOE-50 (Lal, 2015) and ZOE-70 (Cunningham, 2016) trials (referred to as the ZOE studies) reported recombinant zoster vaccine (RZV) efficacy against herpes zoster (HZ) of >90% in adults aged ≥50 years and ≥70 years, respectively. We reviewed the published clinical trial data on RZV following the ZOE-50/-70 trials.
PubMed was searched for clinical trial data on the RZV published after 2015 (the year the ZOE studies). For this review, real-world data generated post-licensure were excluded.
Forty-five publications were deemed relevant to the scope of our review. Seven publications reported RZV efficacy in older adults against HZ, post-herpetic neuralgia (PHN), and non-PHN complications. Additional analyses also confirmed RZV efficacy and safety in individuals with frailty and in those with pre-existing potentially immune-mediated disease. RZV efficacy and safety was shown to be unaffected by geographic regions or ethnicity. Cross-over vaccination of individuals from placebo arms of the ZOE trials confirmed the safety profile was as expected and consistent with that from the parent trials. Pooled analyses of the ZOE trials supported the favourable benefit-risk profile of RZV. RZV safety and immunogenicity profile was not affected in individuals with prior HZ, those with prior live-zoster vaccine administration and those who received RZV co-administered with other vaccines. Among adults from age 50, RZV immunogenicity has been shown to be maintained for at least 10 years post-vaccination. Efficacy was shown to be maintained to >84% annually, based on interim data up to Year 8 post‑vaccination.
RZV clinical studies have also been completed across several immunocompromised populations. Patient‑reported outcome studies have confirmed that RZV prevented quality of life deterioration by preventing HZ, or by reducing its severity in immunocompetent and immunocompromised individuals.
RZV was developed to prevent HZ and its complications in individuals with an age-related decline in immunity, as well as in those with immunosuppressive treatments or diseases. The results of this review demonstrate that RZV immunogenicity and efficacy are maintained in a broad range of populations and conditions and remains sustained over time. RZV safety profile also appears clinically acceptable across those populations.
This abstract was previously presented at the European Congress of Clinical Microbiology & Infectious Diseases 2022.Download #2021207 (397.18 KB)
"Barriers and enablers of safe sexual practices relating to oral transmission of STIs in Transgender women of Malaysia; a qualitative report"
Principal Presenter: Lahari Telang
Keywords: Transgender women, Oral sex, STI
Transgender women (TGW) in Malaysia experience unique social and interpersonal challenges that contribute immensely to their risk of acquiring HIV and sexually transmitted infections (STIs). A qualitative study was undertaken to understand the experiences of this vulnerable population for determining the barriers and enablers of safe sexual practices particularly relating to oral transmission of STIs.
Participants were recruited through a snow-balling method of sampling with the help of TGW community advocates. Semi-structured in-depth interviews and Focus group discussion with key participants gave insights into the needs of the community. The data obtained was coded, transcribed and subjected to thematic analysis to interpret and derive major themes and subthemes. The results informed the planning and analysis of an intervention that was guided by the Information, Motivation and Behavioural skills (IMB) theory.
All participants (n=20 TGW, mean age= 39 (27-58 years)) reported experiencing high levels of stigma and discrimination in daily life. Majority had secondary school level of education 16(80%); 6(30%) engaged in sex work for a living and 2(10%) were using pre-exposure prophylaxis (PrEP). Routine engagement in oral sex practices (20(100%)) was reported with multiple partners (12(60%)) with a perceived low level of risk of transmission of STIs through this practice (16(80%)). Almost all (18(90%)) never used barriers or inconsistently used them during oral sexual practices. Additionally, low utilization of dental services was reported with the majority (16(80%)) not having visited a dentist in the past 12 months. The major themes that emerged through qualitative analysis were: ‘Access to care’, ‘Role of support network’, ‘HIV/STI awareness’, ‘Perception of low risk’, ‘Attitudes and beliefs’ and ‘Socio-economic status’. The results identified gaps in awareness of oral transmission of STIs among TGW and lack of condom use during oral sex. Self-medication / non-professional treatments and lack of utilization of dental services was a concern.
The importance of social support in positively influencing health promotion as well as improving health care and dental care utilization was highlighted. The areas of concern identified through this qualitative research will inform the design and development of an educational intervention aimed at addressing these concerns and providing support. Developing a customised, culturally sensitive, peer reviewed educational intervention that will be delivered through a widely popular social media platform is proposed.
Key words: Transgender women, HIV/STI, Oral transmission, Qualitative analysisDownload #2021206 (1.43 MB)
"Reintroducing Pen and Leaving Quin-Alone. Examining the Impact of a Penicillin Allergy De-labelling project on Antibiotic prescribing in a Hospital setting."
Principal Presenter: Lisa Duffy
Keywords: Antimicrobial stewardship, Penicillin Allergy, Allergy De-labelling
The label of penicillin allergy is carried by between 8 and 25% of all patients (1) . Alternative antibiotics may not be as efficacious, can be more expensive and lead to more adverse effects (2). Interrogation of a penicillin allergy is an important stewardship intervention considering only 1-10% of these patients are truly allergic to penicillin (1). The aim of this study was to investigate if a penicillin allergy de-labelling project altered antibiotics subsequently prescribed in a hospital setting.
A review was carried out of 75 patients identified as part of a penicillin allergy de-labelling project in Galway University Hospital over a 15 month period. Self-reported penicillin allergy by hospitalised patients was investigated and clarified by a collaboration from pharmacy, immunology and infectious diseases. Allergy labels were either reinforced, immediately de-labelled or further investigated with skin testing or oral challenge. Antibiotics prescribed prior to allergy de-labelling and following allergy clarification were noted. This information was obtained from the electronic hospital record.
In total, 118 patients had penicillin allergy assessment. 75 patients had their penicillin allergy de-labelled. 44 patients were de-labelled from history, 22 were de-labelled after skin testing and oral challenge and 9 were de-labelled following an oral challenge only. 47 patients (63%) received penicillin post de-labelling. Out of these 47 patients, 27 had been previously treated with fluoroquinolones (57%), 4 had received teicoplanin surgical prophylaxis for surgical procedures (9%), 4 had received linezolid, 2 had received ceftazidime and 2 had been seemingly prescribed meropenem based on allergy.
These results demonstrate that appropriate de-labelling of penicillin allergy has a positive impact on future antibiotic prescription in a hospital setting. It results in reduced use of fluoroquinolones as well as other restricted antibiotics with higher risk of adverse effects and is a useful antimicrobial stewardship tool.
1. Stone CA, Trubiano J, Coleman DT, Rukasin CRF, Phillips EJ. The challenge of de-labeling penicillin allergy. Allergy (Copenhagen). 2020;75(2):273–88.
2. Krishna MT, Huissoon AP, Li M, Richter A, Pillay DG, Sambanthan D, et al. Enhancing antibiotic stewardship by tackling “spurious” penicillin allergy. Clinical & Experimental Allergy. 2017 Nov 1;47(11):1362–73.Download #2021205 (261.62 KB)
"A Case of Necrotising Fasciitis/Myositis Secondary to Self Harm Injury"
Principal Presenter: Laura O'Doherty
Keywords: Necrotising Fasciitis, Necrotising Myositis
Background: Necrotising fasciitis or myositis is a potentially fatal condition with mortality from 6%–80%. Although it is a surgical emergency it is often difficult to diagnose and delays in diagnosis are common. We describe an unusual case necrotising fasciitis and myositis of the deltoid muscle secondary to the self injection of tap water in an otherwise well young woman.
Methods: A retrospective review of this patient’s clinical notes was carried out. We also performed a review of the literature surrounding necrotising fasciitis/myositis.
Results: A 23 year old female presented with a three day history of pain and swelling of her left upper arm secondary to self injection of tap water. Three days prior to presentation she had held tap water in her mouth before drawing it up with a clean needle and syringe and injecting it into her left upper arm. She gave a past history of post traumatic stress disorder and previous admissions with self harm injuries. A plain film of her humerus on admission showed air locules in the deltoid muscle. Computerised tomography of the arm on day two of admission showed a large swollen left deltoid with extensive gas locules. C reactive protein was raised at 444mg/L. She was taken to theatre for emergency washout 18 hours post presentation and had two subsequent washouts/debridements resulting in the loss of the posterior portion of her deltoid muscle. Microbiological samples grew streptococcus anginosis, mixed anaerobes, Actinomyces odontolyticis and Staphylcoccus aureus. She was treated initially with clindamycin, vancomycin and tazocin. This was soon rationalised to tazocin then to oral co-amoxiclav. The patient required pain team input for her initial severe postoperative pain and has ongoing engagement with physiotherapy due to her significant muscle loss.
Conclusion: Necrotising fasciitis/myositis is an uncommon but potentially fatal condition that may present to medical teams on call. Delays in diagnosis can result from the non-specific presentation of the illness. This case demonstrates an unusual manifestation of the disease, with microbiological samples reflecting oral flora, in keeping with water having been held in the patient's mouth prior to being injected.Download #2021204 (168.46 KB)
"Estimation of Respiratory Syncytial Virus (RSV) burden for Infants in Secondary Care Hospital Records in Ireland 2017-2021 using ICD-10 Diagnosis Codes."
Principal Presenter: Sean Brennan
Keywords: RSV, Respiratory Syncytial Virus, Hospital
Background: RSV has been a notifiable disease in Ireland since 2012 and is the second most common respiratory virus after influenza [1, 2]. RSV is a leading cause of lower respiratory tract infections (LRTI) (primarily bronchiolitis and pneumonia) and hospitalisations in children worldwide resulting in a substantial clinical and economic burden [3-6]. Hospitalisations due to RSV may be under-reported in Ireland because not all children hospitalised with a LRTI undergo laboratory testing to identify the causal pathogen. However, there has been a significant increase in RSV notifications in Ireland since 2012/13 with 5,356 notifications in 2022/23: 50% of which were in infants <2 years .
Objective: To describe RSV-related inpatient hospitalisations and estimate direct healthcare costs in infants <2 years of age in Ireland.
Methods: Data for inpatient hospitalisations due to RSV in infants <2 years of age between 2017–2021 in Ireland were obtained from the Hospital Inpatient Enquiry (HIPE) database based on RSV-specific ICD-10 codes (J12.1/J20.5/J21.0/B97.4) . Additional bronchiolitis ICD-10 codes (J21.1/J21.8/J21.9) are also useful for capturing LRTI hospitalisations . Hospital costs were estimated by applying unit costs to the the number of hospitalisations. Unit costs were based on the cost per day for an inpatient stay from the ABF 2022 admitted price list for minor respiratory infection (€2,719.70) [7, 8].
Results: The number of RSV-specific hospitalisations in infants <2 years of age was 2,073 in 2021, compared to 1,200 notifications in 2017. This represents a 73% increase in discharges due to RSV from 2017 to 2021. In addition, 949 hospitalisations were reported under non-RSV-specific ICD-10 codes in infants <2 years in 2021. The corresponding cost of secondary care admissions for laboratory-confirmed RSV was €3,263,641 in 2017 rising to €5,637,940 in 2021. However, these costs could be as high as €8,218,936 in 2021 if discharges due to bronchiolitis are considered.
Conclusion: RSV imposes a major economic burden on hospitals in Ireland. However, this burden maybe underestimated due to under-reporting of RSV. The data presented in this study does not include GP, emergency or outpatient department visits, which means that the full economic burden of RSV in Ireland remains unknown. Therefore, further studies are required to understand the true burden of RSV to inform future policy decisions.Download #2021203 (84.49 KB)
"The Infectious Disease Needs of Ukrainian Refugees in a Tertiary Center in Ireland"
Principal Presenter: Siobhan Quirke
Keywords: Ukrainian refugees, migrant health
Introduction: According to the United Nations High Commissioner for Refugees (UNHCR), since the outbreak of war in Ukraine, more than 7.9 million individuals have fled the country with an additional 6 million internally displaced. Ireland has granted international protection to 74’458 Ukrainian refugees. The West of Ireland has become home to a significant proportion of these individuals, with 2’707 living in Galway county alone. With the prevalence of tuberculosis (TB), multidrug resistant tuberculosis (MDR-TB) and human immunodeficiency virus (HIV) being so high in Ukraine, the increased demands on infectious disease (ID) services in Ireland is significant. The objective of our study is to identify the ID needs of Ukrainian war refugees newly attending our service.
Methods: Ethical approval was sought and granted by the local Clinical Research & Ethics Committee. We compiled a list of Ukrainian refugees newly attending our service since the outbreak of war. Data was collected by accessing laboratory & radiology results on the electronic patient system.
Results: We present data collected during the first year of the Russo-Ukrainian War. Since 7th April 2022, 52 Ukrainian war refugees have attended our service. We have identified that 27 (51.9%) have a single chronic viral infection while 22 (42.3%) are co-infected. Of the 41 (78.8%) individuals who tested positive for HIV, 40 (97.5%) had an existing diagnosis, 1(1.9%) person has been newly diagnosed since arrival to Ireland. Thirteen (31.7%) were viraemic on first blood testing. 26 (63.4%) individuals required change of antiretroviral therapy, most commonly a switch from lamivudine (3TC) to emtricitabine (FTC). 21 (40.38%) have Hepatitis C infection, with 5 (23.8%) new diagnoses. Twenty (38.46%) have previous Hepatitis B while 3 (5.7%) have chronic Hep B infection, 1 of these patients is on treatment with tenofovir (TDF) as part of ART regimen. We have treated 3 (5.7%) patients with TB since arrival to Ireland, 2 cases of pulmonary infection and 1 CNS infection. Both pulmonary cases were MDR isolates. Six (11.5%) have been diagnosed with Latent TB Infection (LTBI), none of these patients have commenced treatment to date.
Discussion: It is important we identify how our services must adapt to better cater for this vulnerable patient group. This study identified healthcare barriers and areas for service improvement.Download #2021202 (978.99 KB)
"Impact of Variants of Concern and Vaccination on Long COVID phenotype"
Principal Presenter: Grace Kenny
Keywords: Long COVID, SARS-CoV-2, SARS-CoV-2 Variants of Concern
Defining patterns of symptoms in long COVID is necessary to advance therapies for this heterogeneous condition. Here we aimed to describe clusters of symptoms in individuals with long COVID and explore the impact of the emergence of variants of concern (VOCs) and vaccination on these clusters.
Individuals with symptoms persisting >4 weeks from acute, PCR-confirmed COVID-19 from the All-Ireland Infectious Diseases Cohort were divided into two groups based on timing of acute infection; individuals infected prior to 26th December 2020 (pre-Alpha VOC, denoted wild type (WT) group and individuals infected after this date (incorporating alpha and delta dominant periods) in the VOC group. We used multiple correspondence analysis (MCA) and hierarchical clustering on self-reported symptoms in the WT and VOC groups to identify symptom clusters. We then used logistic regression to explore factors associated with individual symptoms, considering demographic variables, acute disease severity, time from symptoms onset, vaccination status and infection group for incorporation in multivariable models. Data are median (IQR) unless specified.
A total of 419 individuals were included in the analysis, 268 in WT and 149 in VOC groups respectively. In both groups MCA identified three similar clusters; a musculoskeletal (MSK) cluster characterised by joint pain and myalgia, a cardiorespiratory cluster characterised by dyspnea, chest pain, palpitations or cough and a less symptomatic cluster where fatigue and dyspnea were the most common symptoms but these were less prevalent than in the MSK or cardiorespiratory cluster.
Differences in characteristic symptoms were only seen in the cardiorespiratory cluster where a decrease in the frequency of palpitations (10% vs 34% p = 0.008) and an increase in cough (63% vs 17% p<0.001) in the VOC compared to WT groups was observed. Analysis of the frequency of individual symptoms showed significantly lower frequency of both chest pain (25% vs 39% p = 0.004) and palpitations (12% vs 32% p <0.001) in the VOC group compared to the WT group. In univariate analysis, age, more severe acute disease and being in the VOC group were significantly associated with reduced odds of both palpitations or chest pain while being vaccinated was additionally associated with reduced odds of palpitations (OR (95% CI) 0.46 (0.28-0.76) p = 0.003). In adjusted analysis increasing age ( 0.98 (0.96-0.99) p = 0.02) and being in the VOC group ( 0.5 (0.29-0.87), p = 0.02) remained significantly associated with a lower odds of chest pain, while only being in the VOC group (0.37 (0.18-0.71), p = 0.004) but not vaccination (0.59 (0.33-1.04) p = 0.08), was associated with less reported palpitations.
This study suggests changes in long COVID phenotype in individuals infected later in the pandemic, with less palpitations and chest pain reported. Adjusted analyses suggest that these effects are mediated through introduction of variants rather than an effect from vaccination.Download #2021201 (341.72 KB)
"Early Inflammatory Profiles Predict Maximal Disease Severity in COVID-19"
Principal Presenter: Grace Kenny
Improved understanding of host systemic inflammatory changes that precede development of severe COVID-19 could improve the delivery of available antiviral and immunomodulatory therapies, and provide insights for the development of new therapies.
In plasma from individuals with PCR confirmed COVID-19, sampled ≤10 days from symptom onset from the All-Ireland Infectious Diseases Cohort study, we measured 61 biomarkers, including markers of innate immune and T cell activation, coagulation, tissue repair, lung injury, and immune regulation. We used principal component analysis (PCA) and k-means clustering to derive biomarker clusters, and univariate and multivariate ordinal logistic regression to explore association between cluster membership and maximal disease severity, adjusting for factors known to modify risk of severe COVID-19, including age, sex, ethnicity, BMI, hypertension, diabetes, immunosuppression, smoking and baseline anticoagulant use.
Between March 2020-April 2021, we included 312 individuals, (median (IQR) age 62 (48-77) years, 7 (4-9) days from symptom onset, 54% male) in the analysis. PCA and clustering derived 4 clusters. Compared to cluster 1, clusters 2-4 were significantly older and of higher BMI but no significant differences in sex or ethnicity was observed. Cluster 1 was characterised by low levels of inflammation, cluster 2 was characterised by higher levels of markers of tissue repair and endothelial activation (EGF, VEGF, PDGF, TGFα, serpin E1 and p-selectin). Cluster 3 and 4 were both characterised by higher overall inflammation; Cluster 4 had the highest levels of most markers including markers of innate immune activation (IL6, procalcitonin, CRP, TNFα), and coagulation (Ddimer, TPO). Compared to cluster 4, cluster 3 had downregulation of growth factors, markers of endothelial activation, and immune regulation (IL10, PDL1), but higher alveolar epithelial injury markers (RAGE, ST2). In univariate analysis, compared to cluster 1, cluster 3 had the highest odds of severe disease (OR (95% CI) 9.02 (4.62-18.3), followed by cluster 4: 5.59 (2.75-11.72) then cluster 2: 4.5 (2.38-8.81), all p <0.05). Cluster 3 remained most strongly associated with severe disease in fully adjusted analyses; cluster 3: OR(95% CI) 5.99 (2.69-13.35), cluster 2: 3.14 (1.54-6.42), cluster 4: 3.13 (1.36-7.19), all p<0.05).
Distinct early inflammatory profiles predicted maximal disease severity independent of known risk factors for severe COVID-19. Interestingly, a cluster characterised by relative downregulation of growth factor and endothelial markers, with early evidence of alveolar epithelial injury, was associated with highest risk of disease progression. Whether this inflammatory pattern reflects a dysregulated inflammatory response to SARS-CoV-2 that could improve targeted treatment requires further study.
"Diagnostic challenges in a case life-threatening thrombosis and fever of unknown origin"
Principal Presenter: Peter Conlon
Keywords: Fever of unknown origin, Behcet's Disease
Diagnostic challenges in a case of life-threatening thrombosis and fever of unknown origin
Infection mimics pose a challenge in the realm of Infectious Diseases. Fever of unknown origin requires careful consideration for a broad range of diagnoses. The answer often lies in a careful history and dedicated clinical exam. A delay in diagnosis can result in greater morbidity and potential mortality for the patient. We present the diagnostic challenges, of an infection mimic, Bechet’s disease, who presented with recurrent venous thromboembolism (VTE) and fevers of unknown origin (FUO).
A of a53-year-old gentleman of Irish Caucasian ethnicity presented with a history of fevers and recurrent VTE at a university hospital in Dublin, Ireland. Past medical history includes schistosomiasis which was treated following a trip to sub-Saharan Africa. Our patient was previously diagnosed with a provoked deep vein thrombosis (DVT). He went on to experience 4 subsequent episodes of VTE, including DVT, pulmonary embolism (PE), and cerebral venous sinus thrombosis (CVST) while on different forms of anticoagulation. On each of these occasions, there was a concern for sepsis due to fevers >38 degrees and a CRP >200.
The infectious workup included routine labs, blood and urine cultures, CT abdomen/pelvis, echocardiogram, and PET CT, all of which were unrevealing.
However, a focused clinical exam revealed evidence of subtle scrotal and oral ulceration, pustulation, and erythema at several sites in his upper limb following venesection and cannulation. In this context, a diagnosis of Bechet's disease was considered.
A diagnosis of Bechet's can only be confidently made after the exclusion of other potential etiologies. In this case, we had to consider a broad range of infectious (malaria, schistosomiasis, rickettsial disease, endocarditis) and noninfectious diseases (malignancy, anti-phospholipid syndrome, myeloproliferative disorders, paroxysmal nocturnal hemoglobinuria).
A delay in diagnosis comes at the cost of increased morbidity and mortality for the patient. A detailed history and clinical exam are key, in addition to a high index of suspicion.
Following induction of high-dose steroid, our patient is doing very well on maintenance Adalimumab. From an anticoagulation perspective, he is warfarinised and has not had any further episodes of VTE.Download #2021199 (505.87 KB)
"Retrospective analysis of Dalbavancin use at St James's Hospital"
Principal Presenter: Peter Conlon Ciaran Bannan
Keywords: Dalbavancin, Novel therapy, Anti bacterial therapy
Dalbavancin is second-generation lipoglycopeptide antibiotic. It is licensed in Ireland and the United Kingdom for the management of acute skin and soft tissue infections. International colleagues report treatment success in its use for patients who are unable to stay in hospital for prolonged periods and not suitable for OPAT . We reviewed the use of Dalbavancin at St James's Hospital Dublin, which is the largest hospital in Ireland with over 700 acute beds. We are located in Dublin’s inner city which experiences significant socio-economic deprivation.
We used the electronic patient records at St James's hospital to capture all uses of Dalbavancin from August 2018 to September 2022.
We established baseline demographics, indication, and microbiological characteristics if there was an oversight by ID/micro, safety and treatment outcomes.
We considered how many hospital days were saved if a patient was changed to Dalbavancin and discharged home compared to how long they would have been required to stay in the hospital to pursue conventional treatment. One hospital day in an acute bed is estimated to cost 800€.
· We identified 23 patients who met the inclusion criteria
· Baseline demographics:
Male 19 (82.6%)
Average age 42
On label (SSTI and non bacteremic) 4 (17.3%)
Unstable housing 11 (47.8%)
PWID 18 (78.3%)
PLWHIV 3 (13%)
Followed up 18 (78.3%)
Bacteraemic 9 (39%)
Adverse drug reaction 0 (0%)
Treatment success 16 (69.5%)
· The most common indication was endovascular infection (35%) and skin and soft tissue infection (35%).
· Most patients were not bacteremic. Staph aureus was the most common organism identified on blood culture
· 322 hospital bed were saved which equates to 257,600 euro
· 0 patients had an adverse drug reaction
· 100% of cases were discussed with micro or ID
Dalbavancin is a safe and effective drug. It is another tool that can be used when caring for patients who are experiencing unstable housing and challenging social circumstances. Our experience has found 0 adverse events, 69% of patients experienced treatment success (this increases to 88.8% if we exclude those lost to follow up). This is an important finding considering on 17% of indications were considered ‘on label’.
Dalbavancin can save money on hospital beds and also reduces non-recyclable plastic associated with repeated doses of IV antibiotics.Download #2021198 (876.48 KB)
"Outpatient Parenteral Antimicrobial Therapy (OPAT) for Mycobacterial infections in the Republic of Ireland from 2013 - 2021"
Principal Presenter: David Moynan
Keywords: mycobacterium, OPAT, TB
Mycobacterial infections represent some of the most complex and difficult to treat diseases observed in humans, often refractory to many conventional antimicrobials. Drug-resistant tuberculosis is frequently managed with the addition of an injectable antimicrobial. Non-tuberculous mycobacteria (NTM) are infections of varying virulence and can also require injectable antimicrobials for significant duration. Since its initiation, the national OPAT programme has facilitated the outpatient management of intravenous antimicrobials for mycobacterial infections. It is a cost-effective and patient-centred programme enabling home therapy for patients no longer requiring inpatient care, saving hospital bed-days. This study aims to describe the clinical epidemiology of patients on OPAT for mycobacterial infections.
A retrospective analysis of patients commenced on OPAT between 1/1/2013 to 31/8/2021 was performed using data from the national OPAT portal, focusing on those with a mycobacterial infection. The data were anonymised and analysed using STATA/SE version 17.0. A two-sample t-test compared means and a chi-square examined the relationship between categorical variables.
From 1/1/2013 until 31/8/2021 there were 14,749 patients managed through the national OPAT programme, 20.7% (99/14749) of which were mycobacterial infections. NTM accounted for 30/99 (30%) while 69/99 (70%) were M. tuberculosis (TB) infections. The mean age was 38.4 years (SD 12.4 years, 95% CI 36 – 41). While 56/99 (57%) were H-OPAT (healthcare-administered), 43/99 (43%) were S-OPAT (self-administered). The majority of those with NTM (23/30; 77%) were managed using S-OPAT compared with less than one third (20/69; 29%) in those with TB (p <0.001). Patients with NTM on S-OPAT were statistically younger than those on H-OPAT (35 years versus 48 years, p<0.0001 95% CI 35.3 – 41.3). The median duration on OPAT was 42 days in NTM and TB (IQR 24-73 days and 21-44 days, respectively). Two intravenous antimicrobials were used in 16/99 (16%). Amikacin was the most common antimicrobial prescribed (78/99; 79%). A total of 3,378 hospital bed days were saved.
The national OPAT programme can be used to facilitate a discharge, or admission avoidance, in those requiring intravenous therapy for mycobacterial infections. Advancements in TB research have, however, demonstrated efficacy in injection-free, all oral regimens for drug resistant disease. Our data show that OPAT is implemented most commonly for TB disease, though rising cases of NTM and all-oral regimens for drug-resistant TB are likely to change this paradigm. Given the duration of therapy required in these infections, facilitating OPAT, where appropriate, is in the interest of both the patient and the hospital.Download #2021197 (390.45 KB)
"Outpatient Parenteral Antimicrobial Therapy (OPAT) for periprosthetic joint infections in the Republic of Ireland from 2013 - 2021"
Principal Presenter: David Moynan
Keywords: OPAT, orthopaedic infection, prosthetic device
Periprosthetic joint infection (PJI) is a complication of joint arthroplasty that is seen in 1-2% of primary and 4% of revision arthroplasty cases. In the Republic of Ireland, between 2013 – 2021, there were 67,353 hip and knee arthroplasties performed in public hospitals and the demand for this procedure is rising. Since its initiation in 2013, the national OPAT programme has facilitated the outpatient management of intravenous antimicrobials for periprosthetic joint infections. It is a safe, cost-effective and patient-centred programme that enables treatment at home for patients who no longer require inpatient care, thus saving hospital bed-days. This study aims to describe the clinical epidemiology of patients on OPAT with PJI between the years 2013 and 2021.
A retrospective analysis of patients commenced on OPAT between 1/1/2013 to 31/8/2021 was performed using data available from the national OPAT portal, a database to which all patients are enrolled prior to discharge. Variables including patient demographics, diagnosis, antimicrobial agent(s) used, duration of therapy and method of OPAT delivery were collected. This study focused on those with a PJI. The data were anonymised and analysed using STATA/SE version 17.0. A two-sample t-test was used to compare means.
From 1/1/2013 until 31/8/2021 there were 14,749 patients managed through the national OPAT programme, 8.35% (1232/14749) of which were PJI. Of these, 53% (653/1232) were hip arthroplasty, 22.7% (280/1232) knee arthroplasty and 24.3% (299/1232) other. The mean age was 64.5 years (SD 14.15 years). Of those on OPAT, 66.15% (815/1232) were H-OPAT (healthcare-administered) while 33.85% (417/1232) were S-OPAT (self-administered). Patients on S-OPAT were statistically younger than those on H-OPAT (61 years versus 66 years, p<0.001, 95% CI 14.1 – 63.6). The most common antimicrobial prescribed was daptomycin (35.8%; 441/1232) followed by ceftriaxone (21.2%; 262/1232) and flucloxacillin (15.8%; 195/1232). Two antimicrobials were prescribed in 9% (111/1232). The median duration on the OPAT programme was 27 days (IQR 14.5 – 35 days).
The role of the national OPAT programme in the outpatient management of PJI is growing. Cumulatively, it has saved 26,992 hospital bed days in those with PJI. While S-OPAT is the preferred strategy and should be considered for all patients, our data demonstrate that H-OPAT is required more frequently in the older person. As such, the availability of H-OPAT must be retained nationwide given the increasing utility of primary arthroplasty, particularly among older adults who may require treatment for PJI.Download #2021196 (377.39 KB)
"The reactivation of herpesviruses in severe COVID-19; a retrospective analysis of a critical care cohort"
Principal Presenter: David Moynan
SARS-CoV-2 and its association with secondary infections is well described, however the reactivation of latent viral infections in the setting of COVID-19 is becoming increasingly recognised. The Herpesviridae family in particular has been a focus of much review, the five most commonly implicated including cytomegalovirus (CMV), Ebstein-Barr virus (EBV), varicella zoster virus (VZV) and herpes simplex virus (HSV) 1 and 2. We examined the frequency of CMV, EBV, VZV and HSV 1 and 2 reactivation among patients with COVID-19 requiring critical care.
A retrospective analysis of all patients with COVID-19 requiring admission to the intensive care (ICU) and high dependency unit (HDU) at our institution from March 2020 until December 2021 was performed. EBV and CMV infection were defined by the detection of DNA in blood using quantitative PCR. VZV and HSV infection was defined by the presence of DNA on a viral skin swab. The nadir-lymphocyte count and peak c-reactive protein (CRP) for each patient was collected. Data was analysed using STATA version 17.0. Chi-square test was used to examine categorical variables and student t-test compared means.
From March 2020 to December 2021 there were 295 patients with COVID-19 that required management in the ICU/HDU. Of these, 40% (117/295) were female with a mean age of 55 years (standard deviation (SD) 15.1 years). Of the 67 patients screened for CMV infection, 22.3% (15/67) were positive. There was a significant relationship between CMV infection and mechanical ventilation (p<0.0001). Longer time was spent on a ventilator in those positive for CMV infection compared with those who tested negative (mean 879 hours vs. 301 hours, p<0.0001). There was no association between CMV infection and death (p=0.807). EBV infection was detected in 26% (7/27) of the 27 patients tested. Collectively, 9% (26/296) of the cohort tested positive for HSV-1 (92%; 24/26) and VZV (8%; 2/26) on viral swabs of a skin lesion. The mean nadir-lymphocyte count was 0.62 x10 9/L (SD 0.43, 95% 0.58 – 0.69 x109/L). Lower lymphocyte counts were seen in those with EBV infection, a finding also seen among those with a positive viral swab. The mean peak-CRP was higher in all episodes of presumed viral reactivation.
We believe that the reactivation of herpesviruses in the setting of SARS-CoV-2 infection warrants further research, with the virus itself capable of stimulating other infections and potentially contributing to an enhanced disease severity and a protracted symptom course.
"The treatment of fungal infections in the Republic of Ireland using outpatient parental antifungal therapy: A Retrospective Review 2013-2021"
Principal Presenter: Rhea O'Regan
Keywords: OPAT, fungal infection
Outpatient parenteral antimicrobial therapy (OPAT) has been recognised as a safe and cost-effective alternative to inpatient treatment. However, there is little published data on the efficacy and safety of antifungal therapy on OPAT. We aimed assess the number of people treated using OPAT for a fungal infection through the National OPAT programme in the Republic of Ireland between 2013 and 2021.
A retrospective analysis of all patients with fungal infections discharged on outpatient antifungal therapy between 1/1/2013 to 31/8/2021 was performed using information available from the national OPAT database. Data collected was anonymised and analysed using STATA/SE version 17.0.
From a cohort of 14,749 patients, 112 (<1%) were treated for fungal infections using OPAT during the study period. The mean age of patients on treatment was 45 years (SD 18). Thirty patients (27%) undertook self-OPAT while 82 (73%) patients were registered as healthcare administered. The most commonly treated infection was aspergillosis (50/112; 44%), followed by Candida sp infection (13/112; 12%) and mucormycosis (7/112; 6%). The remainder were documented as undifferentiated fungal infection (42/112; 38%). Amphotericin B was prescribed most frequently (57/112; 51%) followed by caspofungin (45/112; 40%), anidulafungin (5/112; 4.5%) and fluconazole (5/112; 4.5%). Two patients (2/112; 2%) received dual antifungal therapy, while two others received concomitant antimicrobial therapy. The mean number of days of treatment was 34 (IQR 14-42 days) in 75% patients.
Antifungal administration via OPAT for invasive fungal infections is infreqent yet increasing in Ireland with the expansion of nationwide OPAT services. Our data demonstrates that it is both an effective method of treatment for patients with complex fungal infections while also reducing length of hospital stay. As the number of invasive fungal infections diagnosed continue to rise with the advent of emerging mycoses, it is crucial that investment is made in continuing to expand this specialist service. Our study may also demonstrate this model of care could be implemented in other countries where OPAT services for invasive fungal infections has not yet been developed.Download #2021194 (1.34 MB)
"SOLAR 12-Month Results – Randomized Switch Trial of CAB+RPV LA vs Oral B/FTC/TAF"
Principal Presenter: Tahera Khorakiwala
Keywords: #HIV, #SOLAR
Background: Cabotegravir (CAB)+rilpivirine (RPV) administered monthly or Q2M is a complete long-acting (LA) regimen for maintaining HIV-1 suppression. We present results from SOLAR, the first randomized comparison of CAB+RPV LA Q2M vs. continued daily oral bictegravir/emtricitabine/tenofovir alafenamide (B/FTC/TAF).
Methods: SOLAR (NCT04542070) is a Phase 3b, randomized (2:1), open-label, multicenter, noninferiority (NI) study assessing switching virologically suppressed adults to CAB+RPV LA (with/without oral lead-in [OLI]) Q2M vs continuing B/FTC/TAF. The primary analysis was based on the pre-specified modified intention-to-treat exposed (mITT-E) population (n=11 excluded from the ITT-E for protocol deviation). The primary endpoint was the proportion with plasma HIV-1 RNA ≥50 c/mL (FDA Snapshot, 4% NI margin) at M11 (LA without OLI)/M12 (LA with OLI and B/FTC/TAF). Other endpoints were the proportion with plasma HIV-1 RNA <50 c/mL (FDA Snapshot, –12% NI margin), incidence of confirmed virologic failure (CVF; 2 consecutive HIV-1 RNA ≥200 c/mL), safety, tolerability, treatment satisfaction (HIV Treatment Satisfaction Questionnaire status version [HIVTSQs]), and preference.
Results: Of 670 participants (mITT-E), 447 switched to LA (n=173 [39%] with OLI; n=274 [61%] without OLI) and 223 (33%) continued B/FTC/TAF. Baseline (BL) characteristics were similar between arms. At M11/12, noninferior efficacy of LA vs B/FTC/TAF was demonstrated for the proportion with HIV-1 RNA ≥50 c/mL (5/447 [1%] vs 1/223; [<1%]]; adjusted difference [95% CI] 0.7 [–0.7, 2.0]). Overall, 2/447 (0.4%) and 3/454 (0.6%) participants receiving LA had CVF in the mITT-E and ITT-E populations, respectively; all developed resistance at failure. Excluding injection site reactions (ISRs), AEs and serious AEs were comparable between arms; drug-related AEs were more frequent in the LA arm (90/454 [20%] vs 2/227 [<1%]). More LA arm participants had AEs leading to withdrawal (25/454 [6%] vs 2/227 [<1%]). Most ISRs were Grade 1 or 2. Mean adjusted HIVTSQs scores for LA vs B/FTC/TAF participants improved significantly from BL to M11/12 and most participants preferred LA vs oral therapy at M11/12 or withdrawal.
Conclusion: At M11/12, CAB+RPV LA Q2M demonstrated noninferior virologic efficacy vs. B/FTC/TAF. Switching to CAB+RPV LA from B/FTC/TAF was efficacious, well tolerated, improved treatment satisfaction, and was preferred by most participants.
Previous presentation: Data included in this abstract will be presented in full at the 30th Conference on Retroviruses and Opportunistic Infections; February 19-22, 2023; Seattle, WA, USA; Oral Presentation 191Download #2021193 (288.15 KB)
"Weight and Metabolic Changes With Cabotegravir+Rilpivirine Long-Acting or Bictegravir"
Principal Presenter: Tahera Khorakiwala
Keywords: #HIV, #SOLAR
Background: Integrase strand transfer inhibitors (INSTIs) and tenofovir alafenamide–based regimens are potentially associated with weight gain and metabolic perturbations in people living with HIV (PLWH). Cabotegravir (CAB), an INSTI, plus rilpivirine (RPV), a non-nucleoside reverse transcriptase inhibitor, administered monthly or every 2 months (Q2M) is the first complete long-acting (LA) regimen recommended by treatment guidelines for the maintenance of HIV-1 virologic suppression. Modest body weight and lipid changes have been observed in participants receiving CAB+RPV LA therapy in Phase 3/3b studies. SOLAR (NCT04542070) is a Phase 3b noninferiority efficacy study, also evaluating weight and metabolic changes from baseline (BL) to Month (M)11/12 as additional endpoints, in PLWH switching to CAB+RPV LA Q2M vs. continuing on bictegravir/emtricitabine/tenofovir alafenamide (B/FTC/TAF).
Methods: Among 687 participants randomized (2:1;n=6 not dosed), 454 switched to CAB+RPV LA Q2M (175 elected for oral lead-in [OLI] and 279 elected for therapy without an OLI) and 227 continued on B/FTC/TAF. Changes from BL in body weight, body mass index (BMI) category, waist and hip circumferences (WC, HC), waist-to-height ratio (WHtR), waist-to-hip ratio (WHR), muscle mass, total body fat, and proportion of participants with insulin resistance or metabolic syndrome were analyzed at M11 (LA without OLI)/M12 (LA with OLI and B/FTC/TAF).
Results: Median (interquartile range) change in body weight from BL was –0.40 kg (–2.95, 2.10) in the LA arm and +0.05 kg (–2.30, 1.95) in the B/FTC/TAF arm at M11/12 . Mean (standard deviation) change in WC and HC was +0.19 cm (8.01) and +0.26 cm (7.81) in the LA arm, and +1.64 cm (9.19) and +0.51 cm (11.44) in the B/FTC/TAF arm at M11/12. There were no clinically relevant changes from BL to M11/12 in participants’ WHtR, WHR, or the proportion of participants with metabolic syndrome, abdominal obesity, or insulin resistance in either arm.
Conclusion: This is the first randomized Phase 3b study to compare weight, anthropometric, and metabolic changes in a standardized manner among PLWH switching to CAB+RPV LA Q2M or continuing B/FTC/TAF. Changes in weight, BMI, and body composition measurements were minor and similar between treatment arms through M11/M12. There were no clinically relevant changes in the proportion of participants with metabolic syndrome, abdominal obesity, or insulin resistance between arms at M11/12.
Previous presentation: Data included in this abstract will be presented in full at the 30th Conference on Retroviruses and Opportunistic Infections; February 19-22, 2023; Seattle, WA, USA; Oral Presentation 146Download #2021192 (239.69 KB)
"Implementation of cabotegravir and rilpivirine long-acting (CAB+RPV LA): primary results from the CAB+RPV Implementation Study in European Locations (CARISEL)"
Principal Presenter: Tahera Khorakiwala
Keywords: #HIV, #CARISEL
Background: CARISEL examines the acceptability, appropriateness, and feasibility of cabotegravir (CAB) + rilpivirine (RPV) long-acting (LA) administered every 2 months for virologically suppressed people living with HIV-1, and implementation support for staff study participants (SSPs) in HIV centers across Europe.
Methods: 18 clinics were randomized to implementation support packages: Enhanced Arm (Arm-E) and Standard Arm (Arm-S). Arm-E included skilled wrap-around team meetings, face-to-face injection training, continuous quality improvement, and provider/patient toolkits. Arm-S included video injection trainings and provider/patient toolkits. SSPs provided quantitative/qualitative feedback, and patient study participant (PSP) clinical data were collected over 12 months. SSPs completed questionnaires on acceptability (AIM), appropriateness (IAM), and feasibility (FIM) of implementation and intervention, rated on 1–5 Likert scale.
Results: 13/18 (72%) clinics had no previous CAB+RPV LA experience and were generally distributed equally across arms. 60 SSPs responded at Month (M) 1 and M12. Mean AIM/IAM/FIM scores were ≥3.8 at M12 for implementation- and intervention-based measures. All implementation measures improved over time. An ANCOVA controlling for provider type showed no significant difference between arms. Interview data showed that: CAB+RPV treatment attributes (e.g., reduced dosing frequency) were the strongest drivers of SSP acceptability, PSPs found CAB+RPV LA appropriate, and feasibility facilitators outnumbered barriers. 56% (n=35/62) of SSPs reported optimal implementation within 1–3 months, with more Arm-S SSPs (22%, n=7/32) still working on implementation than Arm-E (13%, n=4/30) at M12. Most (71%, n=24/34) SSPs in France and Spain reached optimal implementation in 1–3 months. Time spent in the clinic across study visits averaged 67.2 minutes in Arm-E and 65.1 minutes in Arm-S. At M12, 68% (n=42/62) of SSPs thought the time spent in clinic was “very” or “extremely acceptable” across arms. Most injections occurred within ±7 days of the target date. At M12, 87% (n=373/430) of PSPs maintained HIV-1 RNA <50 copies/mL, and the proportion with HIV-1 RNA ≥50 copies/mL was 0.7% (n=3/430; FDA Snapshot).
Conclusion: In CARISEL, most European clinics had no prior CAB+RPV LA experience. Despite this, high implementation acceptability, appropriateness, and feasibility levels were seen regardless of implementation arm. Implementation measures improved over time. CAB+RPV LA demonstrated high effectiveness and a low rate of viral failure.
Previous presentation: Data included in this abstract have been previously presented in full at HIV Drug Therapy Glasgow; October 23-26, 2022; Virtual and Glasgow, Scotland; Poster P069.Download #2021191 (218.7 KB)
"Mobile Harm Reduction and HIV Testing - An Experience in Warsaw"
Principal Presenter: Siobhan Quirke
Keywords: BBV testing, marginalised groups, inclusion health
Inequality and inequity within our health systems is perpetuated by barriers to healthcare access and retention in care for marginalized groups in our society. We know that the most vulnerable populations experience the worst health outcomes. Without focused interventions to reach these individuals and deconstruct the structural violence they experience within health systems, the cycle of adversity continues. I present an experience of a mobile harm reduction and point of care HIV testing unit in Warsaw.
Warsaw is home to approximately 1.7 million people.  A report from 2019 states more than 30’000 people are experiencing homelessness in Poland. Lack of affordable housing, substance misuse and addiction are primary contributors. In 2015, almost 7% of all homeless people (or 2’516 individuals) in Poland lived in Warsaw.  The Foundation for Social Education has been working in Warsaw for 20 years with the aim of broadening societal knowledge regarding substance misuse, sexually transmitted infection and sexual health as well as offering free, anonymous blood borne virus testing and counseling. 
The mobile harm reduction service has been in operation as part of the Foundation since 2017. Financial support is provided by the National Center for Addiction Prevention, Warsaw City Hall and is partially funded by pharmaceutical companies. The process involves three weekly visits by the mobile unit and team to an economically deprived area of the city. Clients self-present, provide their date of birth and can avail of the needle exchange service, they are offered and can opt in to have point of care HIV, Hepatitis C and syphilis testing. If an individual’s test is positive, staff provide counseling, education and advice about how to access confirmatory testing and seek appropriate medical care. In 2021, 819 individuals presented to the service (208 female [25.3%], 611 [74.6%] male). Of these, 352 (42.9%) underwent point of care HIV testing with no new individuals diagnosed, 11 had an existing diagnosis. Point of care HCV testing was performed on 258 (31.5%) individuals with 26 new diagnoses. Syphilis testing was positive for 2 individuals of 358 (43.7%) tested. In 2022, 1’463 individuals presented, 289 (19.75%) females & 1’174 (80.2%) males. Point of care HIV testing was performed for 161 (11%) individuals with 1 new diagnosis. 137 (16.7%) were tested for Hepatitis C with 9 new diagnoses and 169 (11.55%) were tested for syphilis with no new positive cases identified.Download #2021190 (186.65 KB)
"Rate of Seroconversion and Seroclearance in Patients with Chronic Hepatitis B Infection"
Principal Presenter: Caitlin Patterson
Keywords: Hepatitis B Virus, Seroconversion, Tenofovir
Infection with Hepatitis B Virus (HBV) remains a significant public health concern. The main goals of treatment are to avoid outcomes such as cirrhosis and hepatocellular carcinoma (HCC) by achieving suppression of HBV DNA loads, seroconversion of hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg), and ultimately seroclearance of HBsAg and HBeAg. The aim of this study was to determine the rate of seroconversion and seroclearance in patients with Chronic Hepatitis B (CHB) undergoing review in University Hospital Limerick (UHL).
Data was collected retrospectively from medical records of patients with CHB under follow up in the Infectious Disease Department in UHL (Limerick, Ireland). Information regarding age, gender, viral load, hepatitis serology, treatment and duration, and comorbidities was obtained. Seroconversion was defined as the loss of HBsAg/HBeAg for greater than 6 months and seroclearance was defined as two consecutive negative HBsAg/HBeAg results 6 months apart. Data was analyzed using SPSS version 21.
72 patients were analyzed. Three patients were excluded due to concomitant viral infections. Of the remaining 69 patients, the mean age was 42.93+10 SD. 66.7% were males and 33.3% were females. All were HBsAg positive cases. HBeAg was positive in 11.6% of patients and negative in 88.4%. Viral load was raised in 71% and undetectable in 29%. 71% of patients were not on antiviral treatment at the time of study, while 29% were (21.7% on tenofovir and 7.2% on entacavir). The average treatment duration was 4 years. In the treatment group, one patient (1.4%) showed seroconversion of HBsAg in response to tenofovir disoproxil fumarate (TDF). HBeAg seroconversion and spontaneous seroconversion in the non-treatment group were not seen.
Inadequately treated CHB increases the risk of transmission and developing complications. While progression to these long-term sequelae is multifactorial, viral load, delayed seroconversion, and HBV reactivation are thought to have the greatest influence on the risk. Unfortunately, only one patient (1.4%) in our treatment group achieved HBsAg seroconversion, likely secondary to a limited number of participants. Seroclearance was not able to be determined as this patient was followed thereafter in a different centre. No HBeAg or spontaneous seroconversion was noted. Even after seroconversion, some patients can experience reactivation. This study therefore highlights the importance of diligent and continued surveillance of patients with Chronic Hepatitis B infection in working to prevent long-term complications of the disease.Download #2021189 (232.35 KB)
"Surveillance Practices for HCC In Patients with Chronic Hepatitis B; a Single Centre Audit"
Principal Presenter: Nada Ibrahim
Keywords: Hepatitis B, Hepatocellular carcinoma, Screening
Hepatitis B patients are at increased risk of developing hepatocellular carcinoma (HCC). International guidelines recommend regular surveillance for high-risk patients. However, the European Association for the study of the liver (EASL) and American Association for the study of the liver (AASLD) guidelines differ on who is at high risk.
The study aims to gather data on Hepatitis B surveillance practices to determine if high-risk patients are being identified and screening requested in compliance with international guidelines.
We assessed 117 patients attending the hepatitis B clinic over 2 months at Cork University Hospital from April 2021. Demographics, frequency of Ultrasound (US) requests, and Alpha-fetoprotein (AFP) were collected. Eligibility for surveillance was determined by AASLD and EASL guidelines.
All patients had AFP recorded: partial screening was completed in all. As per AASLD, 17(14.4%) patients were identified as a high risk compared to 15 (12.8%) as per EASL. Of 17 eligible by AASLD, only 3 (17%) were referred for US. Of 15 eligible by EASL, 1 (6%) was referred for screening. Over 80% of high-risk patients had US in the preceding 5 years.
HCC screening is complex. We need better identification of high-risk patients and better pathways/protocols to facilitate repeated ultrasounds. Despite universal adherence to AFP testing, US screening was sub-optimal. The standard of 6 monthly screening is a high bar to achieve in our setting. No new cases of HCC were identified in this cohort.Download #2021188 (594.33 KB)
"Frequency of renal tubular dysfunction in patients with chronic hepatitis B on antiviral treatment"
Principal Presenter: Alvina Zanib
Keywords: Tenofovir, Renal tubular dysfunction, Hepatitis B
Chronic hepatitis B (CHB) continues to constitute a formidable health concern worldwide as a leading cause of cirrhosis and hepatocellular carcinoma. Tenofovir Disoproxil Fumarate (TDF) remains a mainstay treatment for many patients. The study of TDF-associated nephrotoxicity is therefore of rising importance. This results in proximal tubular dysfunction leading to proteinuria, hypophosphatemia, raised GFR and low vitamin D levels. The aim of our study is to determine the frequency of TDF-associated renal tubular dysfunction (RTD) in CHB patients.
Data was collected retrospectively from patients undergoing follow up for CHB in University Hospital Limerick in Ireland.Information regarding age, gender, hepatitis B virus (HBV) viral load, antiviral therapy, phosphate/creatinine/vitamin D levels, urine dipstick, and urine protein:creatinine ratio (UPCR) were obtained. Proteinuria was defined as a UPCR >15g/mol. Renal tubular dysfunction was labelled as the presence of all four of proteinuria, hypophosphatemia, raised GFR and low vitamin D. Data was analyzed using SPSS 21 version.
69 patients were analyzed. Mean age of participants was 42.93 +10SD. 67% were males and 33% were females. All were HbsAg positive. HbeAg was positive in 11.6% of patients. Viral load was detectable >40 copies in 71%. 29% of patients were on treatment, while 71% were not. Of the treatment population, 75% were on TDF and 25% were on entacavir. The average treatment duration was 4 years. In the treatment population, proteinuria was detectable in 20% of patients by urine dipstick while follow up UPCR was high in only 5% of the population. Similarly, high GFR was seen in 5% of patients on treatment. Hypophosphatemia was seen in 15% of the treatment population. Vitamin D was low in 11.6% and was normal in 8.7%. It was not assessed in 79.7% of patients as it was not routine practice in this clinic.
TDF is a potent antiviral agent available for the management of CHB. However, its potential effects on renal insufficiency are still questionable. True renal tubular dysfunction defined by the presence of proteinuria, hypophosphatemia, raised GFR and low vitamin D levels was only seen in 5% of CHB patients in our study. All were on treatment with TDF. These cases were referred to the nephrology service for assessment of the cause of proteinuria and to guide the decision regarding alternative treatment. This study highlights the need for further investigation regarding the effect of TDF on renal function.Download #2021187 (838.25 KB)
"The Development of an Online Resource for OPAT Patient Education to Enhance OPAT Patient Experience: A Collaborative Project with a Local Third Level Education Institution"
Principal Presenter: Liz Forde
To start on the OPAT service, a shared decision-making process between provider and patient involves providing an overview of the OPAT service including the options available. With the advent of COVID, wearing facemasks interrupted effective communication making assessments and shared decision making more difficult for patients. As there were no visitors, additional phone calls to carers were needed to complete a holistic assessment. This has resulted in more time consuming assessments.
In addition, there was no relevant OPAT online resource available to which we could refer patients and their relatives.
Under the SPARK Covid Call, OPAT Clinical Nurse Specialists supported by the Infectious Disease Consultant OPAT Clinical Lead were successful in their application for funding of development of an online resource and received €2000 in April 2021.
The agreed purpose would be to provide patients and carers with an overview of the service, an introduction to team members, the OPAT options available and the OPAT process. This resource would enhance their experience and manage expectations. Conditions of the funding were that the resource would reflect the national programme and not be site specific so that there was potential for it to be adopted nationally. An additional suggestion was to approach third level institutions locally to collaborate with to develop the resource.
Supported by Nursing Management, in June 2021 we approached Cork College of Further Education, Douglas Street Campus who embraced the project as an innovative learning experience for their second year Creative Digital Media Course students.
From September 2021 to May 2022, there was engagement between students, OPAT CNSs and college teams. The project included script writing, storyboarding, dry run interviews on-site, three final video recordings, a voice-over recording with animation, creation of graphics followed by animation and editing.
The completed online resource includes an animated information video with voice over and three separate videos with an ID consultant and OPAT nurses explaining the OPAT service.
· “OPAT-Your Path Home” – A short animation
· OPAT - Before You Go Home – Video
· OPAT -When You Go Home - Video
· OPAT – Role of Infectious Disease Consultant – Video
This inter-professional project developed in collaboration with College of Further Education has produced high quality, but simple videos explaining the OPAT service to enhance the patient experience.
This collaborative initiative won the Further Education category of the Cork Lifelong Learning Awards for “Innovative Inter-agency Lifelong Learning Endeavours”.
"Investigation of the impact of microbiome composition and immune activation in COVID-19 patients."
Principal Presenter: Rachel MacCann
Keywords: COVID-19, Microbiome, Inflammation
Systemic inflammation and innate immune activation are associated with COVID-19 disease severity. Although alterations in gut microbiota are linked to systemic inflammation, the relationships between the gut microbiome, inflammation and COVID-19 disease severity remain ill-defined and further characterizing these associations was the main aim of our study.
Subjects with PCR confirmed COVID-19 were recruited to the All-Ireland Infectious Diseases Cohort Study. Gut microbial diversity was explored by 16SrDNA analysis of stool, taxonomic repertoires derived, and alpha diversity (Shannon indices) and beta diversity (Envfit-based analysis of principal coordinates) measured. We correlated these profiles to 36 circulating inflammatory biomarkers plasma measured by bead-based ELISA and chemiluminescence. Hierarchical clustering on principal components analysis (PCA) identified biomarker-derived inflammatory clusters. Associations of microbial diversity and inflammatory biomarkers on maximal COVID-19 severity (mild, moderate v severe/critical) was explored using logistic regression and weighted gene correlation network analysis (WGCNA).
Of 79 subjects, the median (IQR) age was 64 (51,77) years, 58.8% of subjects were male; 88% Caucasian and 36% experienced mild, 22% moderate and 40% severe/critical disease respectively. In microbiome analysis, only beta-diversity differed between severity groups and 14 species significantly differentiated (p< 0.05) in severe/critical disease. Biomarker analysis revealed distinct inflammatory clusters that were found to correlate with modules of microbiome profiles and clinical outcomes using WGNA. These modules related to specific clinical phenotypes, with modules 3 and 4 associated with an older population who experienced severe/critical disease outcomes. These modules were enriched in pathogenic and inflammatory bacteria together with higher levels of circulating inflammatory biomarkers such as IL-6, TNF-a, PDL-1, S100B, GM-CSF, D-dimer, E-selectin and IL-8 as well as activated innate immune markers MCP-1 and GM-CSF and the antiviral interferon lambda 2 and 3. Conversely, module 1, an uninflamed group with downregulation of inflammatory biomarkers (IL-4, IL-6, IL-2, GM- CSF, MCP-1, IFN-l and IFN-beta levels) and enrichment of anti-inflammatory bacteria, was composed of a younger population associated with mild/ moderate disease outcomes.
This study uncovers new insights into the links between host inflammatory and microbial factors that likely contribute to COVID-19 disease severity with distinct inflammatory clusters identified. Further understanding of these host-immune interactions will help us stratify those most at risk and lead to better, targeted therapies.Download #2021185 (1.17 MB)
"Case series: Skull base osteomyelitis in MMUH"
Principal Presenter: Daragh McGee
Skull base osteomyelitis (SBO) is a rare clinical entity, occurring as an extension of infection in neighbouring tissues or from haematogenous spread, with mortality approaching 10%. Infection can be polymicrobial, requiring prolonged culture-directed antimicrobials. We aim to summarise the diagnosis and management of SBO in the Mater Hospital.
Cases of SBO treated during 2022 were identified by OPAT service providers. Data was obtained via electronic patient records/chart review and analysed using Microsoft Excel. Data is presented as median (IQR).
There were 5 patients (aged 74 [66-75] years, 4 male) were treated for SBO in 2022. The most common comorbidities were diabetes (n=4), HTN (n=4), CKD (n=3), IHD (n=3) and active malignancy (n=2). Bony erosions were identified on MRI imaging in four patients. 2 were confirmed histologically. Deep sampling for microbiology was obtained in 2 (1 bone biopsy, 1 fluid aspirate), the remainder had superficial swabs. All cases were polymicrobial (≥3 organisms isolated on cultures) with Pseudomonas spp isolated in 3, and a positive fungal culture in 2 (Candida spp [undifferentiated, parapsilosis], Aspergillus spp [fumigatus, flavus], and Rhodotorula spp). Other isolates include gram positive (3 coagulase-negative Staphylococci, 2 Enterococci, 2 Actinomyces neuii, 1 Corynebacterium spp), gram negative (2 Prevotella [bivia, intermedia]) and 3 anaerobic bacteria [Finegoldia magna, mixed]. All had an empiric regimen targeting Pseudomonas spp, one treatment failure was due to resistance. None had empiric anti-fungal agents, with two subsequent treatment failures. Length of initial antimicrobial treatment was 10 (8-12) weeks, of which 6 (2-6) weeks were intravenous. 4 had at least one recurrence in symptoms requiring further treatment, 2 had a second recurrence. Cumulative length of treatment was 27 (12-44) weeks. 3 had surgical interventions (2 mastoidectomy, 2 grommet insertion, 1 myringotomy). None received hyperbaric oxygen therapy.
Insufficient rates of critical specimens like bone biopsy to outrule malignancy and for microbiological sampling were observed. MRI is the preferred imaging modality and was appropriately utilised. High rates of recurrence could be attributable to relatively short initial treatment durations compared with 3-6 months recommended in literature, or lack of adjunctive therapies like hyperbaric oxygen which may reduce treatment failure rates by reducing tissue hypoperfusion.
"Examination of the increased rate of new HIV notifications in Cork and Kerry (2012 – 2022)"
Principal Presenter: Michael Hanrahan
Keywords: HIV, Public Health, Migrant Health
Ireland has seen a significant increase in immigration from regions with a high prevalence of Human Immunodeficiency Virus (HIV) in the past year. The number of new notifications of HIV made to the Health Protection Surveillance Centre increased by more than 65% in 2022 compared to any year in the last decade. The aim of this research was to examine how the epidemiology of HIV has changed in Cork and Kerry between 2012 and 2022 in order to inform service planning and public health response.
Data relating to HIV notifications within Cork and Kerry from 2012 to 2022 was extracted from the Computerised Infectious Disease Reporting system on 08/03/2023. Additional data on HIV viral load was extracted from the local laboratory system. Migration status for individuals was assigned based on patient ethnicity and addresses of known Direct Provision Centres/ Ukrainian Accommodation Centres.
Eighty-eight cases of HIV were notified within Cork and Kerry in 2022. This is 3.1 times greater than the number of HIV notifications in 2021 and 2.3 times greater than pre-pandemic levels reported in 2019. The largest increase was seen among adults aged 31-40 years who accounted for 45% of new HIV notifications in 2022. Females accounted for 41% of HIV notifications in 2022 compared to 26% in 2019. There has been a 6.2 fold increase in HIV notifications among people previously diagnosed outside of Ireland in 2022 compared to 2021 and represent the majority (85%) of cases, where known. Of those previously diagnosed abroad 82% presented with an undetectable/low viral load. People born in Ireland represented 14% of new HIV notifications, Ukrainians accounted for 29%, International Protection Applicants accounted for 15% and other migrants represented 42%. Those from Ukraine and living in Direct Provision were predominantly female and reported heterosexual contact as the most likely route of infection while those who were born in Ireland/ other migrants were predominately male and reported gbMSM contact as the most likely route of infection.
The epidemiology of HIV has changed within Cork and Kerry. Many migrants who come to Ireland with HIV know their status and seek out treatment. However, individuals who have not been previously diagnosed may not be aware of their HIV status and therefore not seek treatment/ may not know how to access treatment. Measures should be taken to screen migrants for HIV in order to prevent deterioration of health and onward transmission.Download #2021183 (256.69 KB)
"Extensive Condylomata with Malignant Transformation Complicated by Compounding Socioeconomic Barriers"
Principal Presenter: Siti Mardhiah Muhamad Fauzi
Keywords: HPV, Anal intraepithelial neoplasia
This case reports a male in his mid-forties presenting with a worsening growth in his perianal area for the past two years. He is a smoker and there is a background of significant alcoholism, of approximately 140 units a week and self-neglect and recluse. He does not engage in sexual intercourse with men. Upon presentation to Emergency Department, he was significantly anemic with a hemoglobin of 3 g/dl. There was an extensive ulcerating, malodorous condylomatous mass covering majority of his perianal and bilateral buttock area including his perineum and medial thigh area. The clinical appearance was of an extensive, out-of-control condylomata with likelihood of malignant transformation.
Diagnostic workup revealed an extensive locally invasive tumor in the perianal and perineal regions extending into muscles of the pelvic floor with no distant metastases radiologically on CTTAP and MRI pelvis. HIV, syphilis screen and PCR for varicella and herpes zoster were negative. Histology revealed stage III anal intraepithelial neoplasia (AIN).
The patient underwent a defunctioning loop colostomy to divert fecal stream. He was discussed at the colorectal multidisciplinary meeting. As the lesion was too extensive, it was deemed unresectable due to extensive margins. Medical and radiation oncologists were hesitant to offer treatment due to non-invasive nature of disease on histology.
This case was complicated by the patient's abscondment and reduced engagement with health service. He represented 6 months afterwards with deterioration in his status. He was found confused, wandering in the hallway by his family with a burst colostomy bag, leaving trails of blood and feces. Repeat histology and a second opinion for the histology confirmed squamous cell carcinoma. Repeat imaging with CTTAP showed progression of disease locally. At this moment, the patient was too unwell to receive chemotherapy or radiotherapy. He was made palliative and passed within 2 months.
This case demonstrates the awareness needed in regards to AIN and possible malignant transformation. At present, international guidelines recommend cytological screening and monitoring for AIN due to risk of progressing to malignant transformation in ‘high-risk’ population. This case also demonstrates the possible malignant transformation of condylomata acuminata, especially if there are risk factors compounding possible co-infection of various HPV subtypes. Lastly, this case highlights that socioeconomic issues can hinder appropriate and time-sensitive monitoring and treatment which may lead to significant progression of disease.Download #2021182 (536.84 KB)
"Effects of Age on Human Alveolar Macrophage Responses to SARS-CoV-2 Antigens"
Principal Presenter: Conor Grant
Advanced age is the strongest risk factor for COVID-19 severity and mortality. Human alveolar macrophages (AMs) are likely the first professional immune cells to interact with SARS-CoV-2 during the earliest phase of natural infection. It is unknown if human AMs recognise SARS-CoV-2 antigens, which antigens are recognised, by which Toll-Like Receptors (TLRs) and which cytokines are produced in response. It is also unknown if these cytokine responses differ by age.
Human AMs were retrieved from patients undergoing routine bronchoscopy at our hospital. The AMs were treated with blocking antibodies of TLR2, TLR4 or an isotype control for 1 hour and then stimulated with SARS-CoV-2 spike protein, envelope protein or unstimulated. LPS was used as a positive control. Supernatant was taken 24 hours post-stimulation and the concentration of IFNγ, IL-6, IL-8, IL-1β, TNF⍺, IL-10 and IL-12p70 were measured using an MSD multiplex assay. Cytokine responses were compared between AMs from patients aged older or younger than 75 years old.
SARS-CoV-2 envelope protein, but not spike protein, induced cytokine secretion from human AMs, in particular IL-6, IL-1β, TNF⍺, IL-10 and IL-12p70. Blocking antibodies against TLR4 but not TLR2 reduced these cytokine responses. AMs from patients older than 75 had significantly higher IL-6, IL-1β and IL-10 secretion than younger patients.
In the earliest phase of SARS-CoV-2 infection, AMs from older patients likely produce significantly more IL-6, IL-1β and IL-10 following the recognition of SARS-CoV-2 envelope protein by TLR4. This early effect may partly explain the worse clinical trajectories followed by these older patients. The inclusion of envelope protein as an antigen in COVID-19 vaccines may improve their efficacy in older patients.
"Antibiotic-induced Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome in a Patient with Complex Prosthesis Joint Infection"
Principal Presenter: Siti Mardhiah Muhamad Fauzi
Keywords: antibiotic reaction, prosthesis joint infection
This case reports a male in his fifties who presented with an early prosthesis joint infection (PJI) approximately four weeks after his emergency right shoulder replacement. He underwent a debridement and washout for the PJI. He was commenced on empirical Vancomycin, Ceftriaxone and Metronidazole.
Intraoperative samples were positive for polymicrobial growth - Enterococcus faecalis, Corynebacterium striatium, Stenotrophomonas maltophilia, Candida paprapsilosis, Pseudomonas aeruginosa and Anaerobes.
His antimicrobial regimen was tailored to targeted therapy once microorganisms and susceptibilities were known. He was switched to a twelve weeks course of Piperacillin-Tazobactam, Fluconazole, Doxycyline and Cotrimoxazole. He was discharged on Outpatient Parenteral Antimicrobial Therapy (OPAT).
The patient represented one day post-discharge with a temperature of 39oC. The Peripherally Inserted Central Cannula (PICC) was removed due to concern of line-related infection. Despite this, the patient was still experiencing recurrent pyrexia.
His antimicrobial regimen was escalated to Meropenem and Vancomycin for broader coverage while the Cotrimoxazole and Fluconazole were continued. The patient continued to experience pyretic episodes despite escalation in antimicrobials. Two days after admission, he developed a wheeze and a rash on his upper thigh which rapidly spread, involving approximately 90% of his body surface area. He developed respiratory distress.
Dermatology was asked to review in light of the rash and suspected severe drug reaction. At this stage, biochemical investigation revealed eosinophilia, acute transaminitis, acute kidney injury and elevated proBNP and creatinine kinase (CK).
Dermatology advised to hold all antimicrobials and to commence the patient on systemic and topical steroids. Once antimicrobials were held, the patient did not have any further fevers and his biochemical picture improved.
The clinical features of rash with systemic symptoms, resolution with cessation of antimicrobials and oral steroids correlated with a diagnosis of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome.
This case highlights the importance of monitoring patients on OPAT, particularly in complex infections such as this case, due to possible complications either relating to infection, treatment or line-related issues. This case also highlights the importance of considering other causes of pyrexia.
It was difficult to ascertain the offending agent causing the DRESS syndrome in this patient. From an infection perspective, the patient had a complex PJI with polymicrobial involvement, including gram negative organisms. When the patient's antimicrobial regimen was held, he had been on approximately 10 weeks of the regimen. It was decided to hold his antimicrobials and monitor for further signs of infection.Download #2021180 (186.96 KB)
"Rate of Adherence to Anti-Infective Prophylaxis in Patients undergoing Splenectomy in University Hospital Waterford"
Principal Presenter: Siti Mardhiah Muhamad Fauzi
Patients who underwent splenectomy are at increased risk of overwhelming sepsis due to their acquired immunodeficiency state. Thus, this cohort has additional anti-infective prophylaxis recommended as per national guidelines from National Immunisation Advisory Committee (NIAC).
This audit aimed to investigate the rate of adherence to recommended vaccinations and chemoprophylaxis by NIAC for patients who underwent splenectomies locally in University Hospital Waterford (UHW).
This was a retrospective audit. Patients who underwent splenectomy in UHW from 2006 to 2021 were identified through Health In-Patient Enquire (HIPE). Information regarding demographic factors, indication and setting of splenectomy were collected from the medical records. Timing of vaccinations in relation to splenectomy was collected as well. Rate of prescription of chemoprophylaxis was also recorded. Data collected was subsequently analysed to assess compliance rates from a vaccination and chemoprophylaxis perspective. NIAC guidelines were used as reference.
There was a total of 67 splenectomies done in UHW in the past 15 years. 38 splenectomies (56.7%) were done electively and 29 splenectomies (43.2%) were done in an emergency setting.
From an anti-infective prophylaxis perspective, rate of vaccinations were analysed and also whether prophylactic antibiotics were prescribed on discharge.
42 patients who underwent splenectomies (62.7%) had appropriate vaccinations. 24 of these were given pre-operatively (57.1%) while 18 patients had appropriate vaccinations post-operatively (42.9%). All 42 patients received vaccinations providing protection against N. meningitidis, Strep. pneumoniae and Haemophilus Influenzae.
35 patients were discharged on prophylactic antibiotics (52%). Only one patient’s reason on not commencing on chemoprophylaxis was documented, which was due to allergy.
NIAC has released guidelines for this population recommending additional anti-infective prophylaxis as these patients are at risk of overwhelming sepsis, especially from encapsulated organisms.
From results mentioned, only 62.7% of patients who underwent splenectomies received appropriate vaccinations and 52% was discharged on prophylactic antibiotics.
There is no formal pathway within UHW to identify patients who are either electively planned for splenectomy or underwent splenectomy in an emergency setting. Recommendations from this audit include introducing a formal pathway for patients undergoing splenectomy with the involvement of surgical teams and hospital pharmacy so that appropriate vaccinations and chemoprophylaxis are commenced. An education session with the patients involving mentioned stakeholders is also important for raising patient awareness and self-empowerment in their condition.
"Predictors of hepatitis B treatment response in people with HIV and HBV initiating treatment"
Principal Presenter: Ross Hamilton-Shaw
Keywords: Bictegravir, Hepatitis, TAF
Background: Response to hepatitis B treatment in people with HIV-1/HBV varies by baseline (BL) HBV DNA level and HBeAg status. We present a subanalysis of 48W outcomes from a phase 3 study (ALLIANCE) comparing bictegravir/emtricitabine/tenofovir alafenamide (B-F-TAF) vs dolutegravir + emtricitabine/tenofovir disoproxil fumarate (DTG+F-TDF) in participants initiating treatment for HIV-1 and HBV to examine HBV DNA suppression and predictors of HBs/eAg loss in this population.
Methods: Adults with HIV-1/HBV were randomised 1:1 to initiate blinded treatment with B-F-TAF or DTG+ F-TDF. Coprimary endpoints were proportion with HIV-1 RNA <50 copies/mL (Snapshot) and HBV DNA <29 IU/mL (missing=failure) at W48 and previously reported . Subgroup analyses determined the proportion with HBV DNA <29 IU/mL stratified by BL HBV DNA levels and HBeAg status. A multivariate analysis (MVA) was conducted to evaluate predictors of HBV DNA <29 IU/mL and HBs/eAg loss.
Results: 243 participants were randomised/treated (121 B-F-TAF, 122 DTG+F-TDF). HBV DNA <29 IU/mL was achieved by 53% (63% B-F-TAF, 43% DTG+F-TDF), HBsAg loss by 9% (13% B-F-TAF, 6% DTG+F-TDF) and HBeAg loss by 20% (26% B-F-TAF, 14% DTG+F-TDF). Subgroup analyses showed significantly more participants with BL HBV DNA <8 log10 IU/mL or BL HBeAg+ achieved HBV DNA <29 IU/mL with B-F-TAF compared to DTG+F-TDF (Table). Baseline predictors of HBV DNA <29 IU/mL were: HBeAg-, HBV DNA <8 log10 IU/mL, ALT >ULN and treatment with B-F-TAF; BL predictors of HBs/eAg loss included BL ALT >ULN and BL CD4 ≥200 cells/µL.
Conclusion: In adults with HIV-1/HBV initiating therapy, B-F-TAF resulted in superior HBV DNA suppression compared to DTG+F-TDF. In MVA B-F-TAF treatment was an independent predictor of HBV DNA suppression.Download #2021178 (382.68 KB)
"24-month (24M) effectiveness and safety profile of bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) in treatment-naïve and treatment-experienced people living with HIV in the BICSTaR study"
Principal Presenter: John Lambert
Keywords: Bictegravir, Real-world data, TAF
Background: BICSTaR is an ongoing, multi-country, observational cohort study evaluating real-world effectiveness/safety of B/F/TAF in treatment-naïve (TN) and treatment-experienced (TE) people with HIV
Methods: Data were pooled from BICSTaR Europe/Canada/Israel/Japan (Feb-2022). Outcomes included HIV‐1 RNA <50 copies/mL, safety, and patient-reported outcomes: physical/mental health (Short Form-36 questionnaire: Physical/Mental Component Summary [PCS/MCS] scores) and HIV-Symptom Index.
Results: Among 1145 enrolled individuals there was a high overall prevalence of concomitant medication (57%)/comorbidities (69% overall; neuropsychiatric disorders 24%/hyperlipidemia 19%/hypertension 17%). TE: 66%/18%/16% switched from INSTI/NNRTI/PI-based regimens; prior TDF/TAF/ABC use: 35%/46%/14%. At 24M, 98% (139/142) TN and 96% (713/745) TE individuals had HIV-1 RNA <50 copies/mL (M=E). Drug-related adverse events occurred in 15% of participants, leading to B/F/TAF withdrawal in 7% (TN, 4%; TE, 7%); weight increase (2%), depression (<1%), and fatigue (<1%) were most common reasons for B/F/TAF withdrawal. There were 2 (TN) and 9 (TE) deaths, considered unrelated to B/F/TAF. PCS/MCS scores improved in TN individuals at 24M (versus baseline) (median [Q1,Q3] change: +2.2 [−2.3,9.4]; P<0.001/+2.5 [−3.9,13.6]; P<0.01) and were stable in TE individuals (−0.2 [−3.5,3.6]; P=0.618/+0.4 [−4.3,5.7]; P=0.074). Bothersome symptom counts decreased at 24M (versus baseline) in TN (median [Q1,Q3] change: −2.0 [−5.0,0.0]; P<0.001) but were unchanged in TE.
Conclusion: These longer-term data continue to demonstrate B/F/TAF effectiveness and tolerability in a real-life, international cohort of people with HIV in routine clinical care.Download #2021177 (512.65 KB)
"Implementation of a High-Level Isolation Unit readiness checklist in an Irish setting."
Principal Presenter: Samata Al Dowaiki
High Consequence Infectious Diseases (HCID) are becoming increasingly common in Europe due in part to the changing distribution of emerging pathogens. The HLIU at the Mater Misericordiae University Hospital (MMUH) is Ireland’s principal referral center. Developing a system to maintain a state of readiness is imperative to the safe activation of the facility.
The objectives of this audit were to (i) Adopt an HLIU readiness checklist appropriate for the Irish system (ii) Implement the checklist and identify domains that require improvement, (iii) Establish the readiness capability required to facilitate rapid activation of the HLIU
Methods: The audit was conducted in the existing HLIU during the period 1st to 7th of November 2022. A readiness checklist using six domains was adopted from a tool used by the HLIU at Johns Hopkins Hospital. The six domains were Waste management, Personal Protective Equipment (PPE), Staffing, Training, Air handling, and General facilities. Activation categories “Ready”, “Not Ready” or “Ready with Considerations” were used to describe the level of risk. The audit was conducted through direct inspection of the HLIU and retrospective review of training logs.
Results: Four of the six domains were deficient therefore impeding safe activation of the HLIU. Waste management and infrastructure domains were “Not Ready” due to the absence of an autoclave and on-site Biosafety Level (BSL)-3 laboratory primarily. The air handling system was “Ready with Consideration” requiring more frequent calibration. The Staffing domain was “Ready with Considerations” because only 75 % of staffing was immediately available. Training and PPE domains were “Ready” as at least 75% of available staff were trained and a 7-day supply of PPE was accessible.
Conclusion: Recommendations included establishing two autoclaves, onsite BSL-3 laboratory, and a bespoke waste water treatment system. A new HLIU is under construction to overcome key infrastructural deficiencies and will be of Intensive Care Unit (I)-level specification. Staff recruitment would be improved through monetary incentivization of the activation rota and by increasing the pool of available nurses through a more open recruitment strategy, i.e. including non-Infectious Diseases (ID) nursing staff. A re-audit of the national HLIU will take place six-monthly. This checklist will be incorporated into the Quality Dashboard of the new HLIU.
"A Phase 1, Randomized, Double-Blind Study to Evaluate the Safety, Tolerability, and Immunogenicity of a 21-Valent Pneumococcal Conjugate Vaccine (PCV) (V116) in Adults"
Principal Presenter: Stacey Jamieson
Keywords: Pneumococcal infections, Pneumococcal vaccines, Clinical trial
Background: V116, an investigational 21-valent PCV, contains the following pneumococcal polysaccharides (PnPs): 3, 6A, 7F, 8, 9N, 10A, 11A, 12F, 15A, 16F, 17F, 19A, 20, 22F, 23A, 23B, 24F, 31, 33F, 35B, and a de-O-acetylated 15B (deOAc15B). This phase 1 study evaluated the safety, tolerability, and immunogenicity of V116 in pneumococcal vaccine-naïve adults compared with the 23-valent polysaccharide pneumococcal vaccine (PPSV23).
Methods: Adults (n=90) 18-49 years were randomized 1:1:1 to receive a single dose of V116-1 (2 μg dose/each PnPS, V116-2 (4 μg dose/PnPS) or PPSV23. Adverse events (AEs) were collected following vaccination. Pneumococcal serotype-specific opsonophagocytic activity (OPA) was measured prior to and 30 days postvaccination (Day 30).
Results: There were no serious AEs, deaths, or discontinuations due to AEs. Immune responses at Day 30 in the V116-1 and V116-2 groups were generally comparable to PPSV23 for the common serotypes and higher than PPSV23 for the unique serotypes. At Day 30, the OPA GMTs were higher in the V116-2 group compared to the V116-1 group for all serotypes except 9N. The OPA geometric mean titre ratio (95% CI) (V116-2/PPSV23) ranged from 0.89 (0.58, 3.51) to 2.40 (1.24, 4.62) for all common serotypes and 2.80 (1.64, 4.79) to 58.07 (25.10, 134.33) for all unique serotypes; the lower bound of the 95% CI for the OPA GMT ratio (V116-2/PPSV23) was > 0.5 for all common serotypes and >1.0 for all unique serotypes.
Conclusion: These safety and immunogenicity data support the continued development of V116 for the prevention of pneumococcal disease in adults.Download #2021174 (1.16 MB)
"Safety, Tolerability, and Immunogenicity of V114 Compared with PCV13 in Preterm Infants: A Pooled Subgroup Analysis of Four Phase III Studies"
Principal Presenter: Stacey Jamieson
Keywords: Pneumococcal infections, Pneumococcal vaccines, Paediatric clinical trial
Background: Risk of invasive pneumococcal disease is 3-fold higher in preterm vs full-term infants, mainly due to underlying comorbidities and immunological immaturity. V114 is a 15-valent pneumococcal conjugate vaccine (PCV) containing the 13 serotypes in 13-valent PCV (PCV13) plus two additional serotypes, 22F and 33F. A pooled subgroup analysis was performed in preterm infants (<37 weeks gestational age) enrolled in 4 paediatric phase III studies evaluating the safety and immunogenicity of different 4-dose regimens of V114 or PCV13.
Methods: Safety was evaluated as the proportion of participants with AEs following each vaccination. Serotype-specific anti-pneumococcal IgG GMCs, IgG response rates, and OPA GMTs were measured at 30 days post-primary series (PPS; post-dose 3 [PD3]), pre-toddler dose, and 30 days post-toddler dose (PTD; post-dose 4 [PD4]).
Results: 174 and 180 participants received V114 and PCV13, respectively. Mean gestational age was 35.4 weeks (range: 27–37 weeks). Proportions of participants with any AE were comparable between vaccination groups following each vaccination; most solicited AEs were transient (≤3 days) and of mild-to-moderate intensity. V114-elicited IgG GMCs, IgG response rates, and OPA GMTs were generally comparable to PCV13 for the 13 shared serotypes and higher for serotypes 22F and 33F at 30 days PPS (PD3) and PTD (PD4).
Conclusions: In preterm infants, vaccination with V114 has an acceptable safety profile, is well tolerated, and induces comparable immune responses to PCV13 for the 13 shared serotypes and higher immune responses to V114 serotypes 22F and 33F. Study results support use of V114 in preterm infants.Download #2021173 (604.94 KB)
"The 15-Valent Pneumococcal Conjugate Vaccine (PCV) V114 Induces Cross-Reactive Antibodies Against Pneumococcal Serotype 6C"
Principal Presenter: Stacey Jamieson
Keywords: Pneumococcal infections, Pneumococcal vaccines, Clinical trial
Background: Pneumococcal serotype 6C has structural similarity with serotype 6A and, to a lesser degree, serotype 6B. The 13-valent PCV (PCV13), which contains serotypes 6A and 6B, induces cross-reactive opsonophagocytic killing activity (OPA) antibodies to serotype 6C, with an observed decline in 6C disease incidence. V114 is a 15-valent PCV containing the 13 serotypes in PCV13 and two unique serotypes (22F and 33F). This study evaluated whether V114 elicits cross-reactive OPA antibodies to serotype 6C.
Methods: OPA antibodies to serotypes 6A, 6B, and 6C were evaluated in serum samples taken pre-vaccination and 30 days post-vaccination (single dose) from adults ≥50 years of age, and 30 days pre- and post-dose 4 from toddlers 12–15 months of age at fourth dose, who received V114 or PCV13 in the adult and paediatric V114 phase II proof-of-concept studies, respectively. The degree of inhibition of OPA antibody activity for serotypes 6A, 6B, and 6C after adsorption with serogroup 6 polysaccharides was evaluated in adult samples.
Results: Samples from 250 adults (V114, n=150; PCV13, n=100) and 150 paediatric participants (V114, n=100; PCV13, n=50) were included. In both the adult and paediatric populations, observed OPA geometric mean titres (GMTs) to serotypes 6A, 6B, and 6C were comparable across vaccination groups; however, the cross-reactive response to serotype 6C was stronger in infants than adults. The inhibition analysis demonstrated the specificity of antibody responses.
Conclusions: V114 induces cross-reactive antibodies to serotype 6C in adult and paediatric populations that are specific and comparable to those induced by PCV13.Download #2021172 (458.9 KB)
"Phase 3 Study of Safety, Tolerability and Immunogenicity of V114 Compared with PCV13 in a 2+1 Regimen in Healthy Infants (PNEU-PED-EU-1)"
Principal Presenter: Stacey Jamieson
Keywords: Pneumococcal infections, Pneumococcal vaccines, Clinical trial
Background: Despite widespread use of pneumococcal conjugate vaccines (PCVs) in children, pneumococcal disease caused by non-vaccine serotypes remains a concern. V114 is a 15-valent PCV containing the 13 serotypes in 13-valent PCV (PCV13) plus two additional serotypes (22F and 33F). This study evaluated safety and immunogenicity of V114 compared with PCV13 in healthy infants, and concomitant administration with DTaP/IPV/Hib/HepB and rotavirus vaccines.
Methods: Safety was evaluated as the proportion of participants with adverse events (AEs; Days 1–14 post-vaccination). Serotype-specific anti-pneumococcal immunoglobulin G (IgG) and opsonophagocytic activity (OPA) were measured 30 days post-primary series (post-dose 2 for full-term infants; post-dose 3 for preterm infants), immediately prior to the toddler dose and 30 days post-toddler dose (PTD) of V114 or PCV13 (post-dose 3 for full-term infants; post-dose 4 for preterm infants).
Results: 1184 healthy infants 42–90 days of age were randomised 1:1 to V114 (n=591) or PCV13 (n=593) as a 2+1 (full-term; n=1116) or 3+1 (preterm; n=68) regimen. Proportions of participants with solicited AEs and serious AEs were comparable between vaccination groups. V114 met non-inferiority criteria for all 13 shared serotypes and superiority criteria for serotypes 22F and 33F, as assessed by IgG response rates and geometric mean concentrations at 30 days PTD. Immune responses elicited by DTaP/IPV/Hib/HepB and rotavirus vaccines administered concomitantly with V114 were non-inferior to those following concomitant administration with PCV13.
Conclusion: In healthy infants, V114 was well tolerated, with a safety profile generally comparable to PCV13. Compared with PCV13, V114 provided non-inferior immune responses to the 13 shared serotypes and superior immune responses to the additional serotypes 22F and 33F.Download #2021171 (569.5 KB)
"Phase 3 Study of Safety, Tolerability and Immunogenicity of V114 Pneumococcal Vaccine Compared with PCV13 in a 2+1 Regimen In Healthy Infants (PNEU-PED-EU-2)"
Principal Presenter: Stacey Jamieson
Keywords: Pneumococcal infections, Pneumococcal vaccines, Clinical trial
Background: Despite the availability of pneumococcal conjugate vaccines (PCVs) in children, significant burden of pneumococcal disease caused by non-vaccine serotypes remains a concern. V114 is a 15-valent PCV containing the 13 serotypes in 13-valent PCV (PCV13) plus two additional serotypes (22F and 33F). This study evaluated safety and immunogenicity of a 2+1 regimen of V114 compared with PCV13 in healthy infants, and concomitant administration of V114 or PCV13 with diphtheria, tetanus, pertussis (DTaP)/inactivated poliovirus (IPV)/Haemophilus influenzae type b (Hib)/hepatitis B (HepB) vaccine administered at 3, 5 and 12 months of age.
Methods: Proportions of patients with adverse events (AEs) were reported from Days 1–14 post-vaccination. Serotype-specific anti-pneumococcal polysaccharide immunoglobulin G (IgG) and opsonophagocytic activity were measured at 30 days post-dose 2, pre-dose 3 and 30 days post-dose 3 (PD3). Antigen-specific response rates to DTaP/IPV/Hib/Hep B vaccine were also measured.
Results: Overall, 1191 healthy infants 70–111 days of age were randomised 1:1 to V114 (n=595) or PCV13 (n=596). Proportions of participants with solicited AEs and serious AEs were comparable between vaccination groups. V114 met non-inferiority criteria for all 13 shared serotypes and superiority criteria for serotypes 22F and 33F, as assessed by IgG response rates (Table) and geometric mean concentrations at 30 days PD3. Immune responses elicited by DTaP/IPV/Hib/Hep B vaccine administered concomitantly with V114 were non-inferior to those following concomitant administration with PCV13.
Conclusion: In healthy infants, V114 was well tolerated, with a safety profile generally comparable to PCV13. Compared with PCV13, V114 provided non-inferior immune responses to the 13 shared serotypes and superior immune responses to unique serotypes 22F and 33F.Download #2021170 (821.56 KB)