Abstracts
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#2024108
"Naloxone use and access in patients presenting to MMUH ED with drug overdoses"
Principal Presenter: Tina Gillespie
Keywords: naloxone, harm reduction, peerTrack: Diversity & Inclusion
Background
An escalation in drug overdose presentations to MMUH has been observed in recent years, with the emergence of new potent synthetic opioids underpinning the urgency of addressing this trend. Harm reduction through education and increased naloxone access is key to mitigating morbidity and mortality associated with opioid overdoses. The WHO recommends people likely to witness opioid overdoses should have access to naloxone and training in its administration [1]. Recent Irish data suggests most naloxone administered prior to emergency services or hospital attendance is by service provider staff (94%), with peers comprising a much smaller proportion (3%) [2]. People who use drugs (PWUD) and their peers should be prioritised for naloxone training. A proactive and opportunistic harm reduction intervention during hospital attendance for drug overdoses is planned by the MMUH Inclusion Health team in conjunction with local advocacy group UISCE to increase naloxone training and access. A review of drug overdose presentations was conducted to inform and optimise this intervention.
Methods
A retrospective review of presentations to MMUH where naloxone was given pre-hospital between July and November 2023 was conducted. The route of naloxone administered and by whom, substances leading to overdose, patients’ current accommodation status, and whether they remained in hospital during the Inclusion Health team working hours to avail of the prospective intervention was recorded.
Results
There were 105 presentations between July and November 2023 where naloxone was administered pre-hospital for suspected opioid overdoses, 50 had taken opioids and 50 had taken benzodiazepams, with 61 cases of polysubstance use identified. In 66 cases, naloxone was administered by emergency services, 21 by service providers/hostel staff, and 8 patients received naloxone from both. Of the 105 presentations, the accommodation status of 15 patients was unknown, 33 were people with homes, 9 resided in long-term supported homeless accommodation, 21 in temporary supported accommodation and 13 in private emergency accommodation. 13 individuals were homeless and not currently accessing emergency accommodation. 71 presentations (67%) overlapped with the Inclusion Health working hours.
Conclusion
Most pre-hospital naloxone given to those presenting to MMUH ED with suspected overdoses is administered by emergency services and service provider staff with no documented peer naloxone administration in this cohort. The Inclusion Health team is well placed to deliver a harm reduction intervention to increase naloxone training and access to PWUD and their peers during hospital attendances. The information gathered in this evaluation will inform the approach in delivering this harm reduction intervention.
[1] WHO. (2014). Community management of opioid overdose. World Health Organization. https://www.who.int/publications-detail-redirect/9789241548816
[2] HRB. (2023). Focal Point Ireland: National report for 2022 – Harms and harm reduction [Report]. Health Research Board. https://www.drugsandalcohol.ie/25259/ -
#2024107
"A complex upper limb infection"
Principal Presenter: Aimee McGreal-Bellone
Keywords: Prosthetic join infection, OPAT, AllograftTrack: General Infectious Diseases
Background
Bone allograft may be used in upper limb surgery where there is a deficit of bone; for example, with a fracture non-union or bony lesion. Despite steps to decontaminate bone allografts, there are reports of contamination rates of up to 12.6%.
Case Summary
A 45-year-old woman sustained a proximal humerus fracture following a fall while on holidays in the Canary Islands, requiring open reduction and internal fixation (ORIF). One month after surgery, she developed signs of infection at the surgical site and was treated empirically with oral antibiotics. Her symptoms recurred and eight weeks after the fall she underwent an incision and drainage of the surgical site. Cross sectional imaging at the time showed a possible organising haematoma around the neck of the humerus but no osteomyelitis. Microbiological culture grew Moraxella osloensis. She was treated with oral coamoxiclav for a surgical site infection. Signs of infection recurred and a washout and debridement was performed four months after initial injury, surgical specimens showed light growth of Cutibacterium acnes and Staphylococcus epidermidis and she was treated with ceftriaxone and daptomycin outpatient parenteral antimicrobial therapy (OPAT). While on antibiotics her wound started to discharge and further cross sectional imaging was performed, revealing rectangular shaped material in the marrow cavity of the humerus consistent with a freeze dried fibular strut allograft which had not previously been appreciated. All metalwork was explanted. The bone allograft could not be removed. Intraoperative specimens grew Staphylococcus lugdunensis. The patient experienced ongoing discharge after surgery and follow up magnetic resonance imaging demonstrated evidence of septic arthritis at the glenohumeral joint. She was treated with 12 weeks of ceftriaxone and daptomycin OPAT. One year following completion of this course of antimicrobials the patient remains well without evidence of recrudescence of infection.
Conclusion
While cadavaric bone allografts are not commonly used in Ireland they remain part of standard practice in some regions of Europe. Bone allografts may be contaminated and have been associated with infection in the graft recipient, one study found contamination rates as high as 18% in bone bank specimens. Control of infection in this case was only achieved with removal of all metal work and prolonged intravenous antibiotic therapy. -
#2024106
"HIV Community Testing in Ireland in 2021"
Principal Presenter: Ralph Hurley O'Dwyer
Keywords: HIV, Sexual Health, EpidemiologyTrack: Epidemiology & Population Health
Background
HIV community testing refers to HIV testing which occurs outside established healthcare facilities. It is designed to make testing more accessible, particularly to communities most vulnerable to HIV acquisition. This study presents a summary of HIV community testing in Ireland in 2021 including the number of tests performed, the reactivity rate for those tested, and the demographic characteristics of those both accessing community testing and those with a reactive test.
Methods
Five partner organisations, in addition to the HSE-run direct provision centre at Balseskin, performed HIV community testing in Ireland in 2021. In October 2022, the HPSC requested anonymous disaggregated data from its partners relating to HIV community testing performed in 2021. Each partner collected data electronically using a standardised template. These data were then validated using a standard operating procedure at the HPSC before being collated and analysed using Microsoft Excel in 2023.
Results
2,327 community-based HIV tests were performed in Ireland in 2021, which represents a 21% decrease in testing numbers compared to 2020 (n=2,925). 1,249 (87.2%) were performed using rapid point-of-care testing and 189 (12.8%) using standard laboratory methods. Forty-four people (1.9%) had a positive/reactive HIV test. The test reactivity rate was highest (3.3%) in international protection applicant/direct provision settings. Demographic data was available for 1,433 tests (61.6%). Of these 1,433 tests, the test reactivity rate was highest among migrants coming from areas of high HIV prevalence (1.0%), and among gay, bisexual and other men who have sex with men (gbMSM) (0.8%). Of these 1,433 tests, four hundred and twenty-four (29.6%) were reported as occurring in individuals with no prior history of HIV testing.
Conclusion
The COVID-19 pandemic substantially affected HIV community testing in Ireland with the lengthy closure of many testing sites in 2021. Furthermore, one prior community testing partner was excluded from 2021 data due to changes in its structure. These factors partly explain a 58.5% decrease in HIV community testing numbers in Ireland between 2019 and 2021. The considerable proportion of those accessing HIV community testing (29.6%) in 2021 who had no prior history of HIV testing suggests that HIV community testing may reach those less likely to test in traditional environments. HIV community testing remains at present an important tool in HIV prevention in Ireland.
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#2024105
"Mpox Vaccination Rates among MSM Patients Attending an Outpatient HIV Clinic"
Principal Presenter: Zoe Weber Hall
Track: Epidemiology & Population Health
Background
Mpox vaccination is recommended to all MSM (men who have sex with men). Mpox is known to cause more severe infection in PLWHIV (People living with HIV). This audit aimed to evaluate Mpox vaccination uptake amongst eligible patients attending HIV outpatient clinics in Galway University Hospital.
Methods
A retrospective review of the clinical notes of HIV clinic attendees, between April and November 2023, was carried out. A sample of 30 was chosen randomly from a database of patient identification numbers (PIDs). Data collected included sex, age, number of sexual partners, bacterial STI in the past 6 months, chemsex, groupsex, HIV VL, CD4 count, ARV therapy, previous Mpox diagnosis and vaccination record. This information was gathered with a view to quantify vaccine uptake and identify patients at risk of Mpox.
Results
Of the 30 PIDs, 26 patients attended their appointments and 4 did not. From this sample of 26, participants had a median age of 46 (IQR 43 – 54). All patients had an undetectable HIV viral load (<40) with a median CD4 count of 747.5, and all patients had a CD4 count above 200. We found that only 7.7% (2/26) of attendees received Mpox vaccine in clinic. Of the remainder, 7.7% (2/26) declined vaccination, 11.5% (3/26) will consider it at their next appointment and for the remainder 73% (19/26), it was not documented in the clinical notes whether the patient was offered mpox vaccination. 7.7% (2/26) of study participants had newly acquired a bacterial sexually transmitted infection within the past 6 months. 19.8% (5/26) of patients had previously refused other vaccines and 80.2% (21/26) were otherwise up to date with all their other recommended vaccinations, with the exception of Mpox.
Conclusion
Mpox vaccination uptake within this sample was low . Additionally, we found there was limited documentation of risk factors for Mpox, (e.g. sexual partners/recent bacterial STI) which may guide who should be prioritised for vaccination. There was also limited documentation in the clinical notes on Mpox vaccination status, thus participants who received Mpox vaccine outside of clinic may not have captured. Many factors account for the low rates of vaccination and efforts must be made to reduce barriers to vaccination. Interventions prior to follow up audit will focus on improved documentation of vaccination status, patient counselling regarding vaccination and catch up vaccination where appropriate.
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#2024104
"Increase In Cases Of Non-Tuberculosis Mycobacterial Lymphadenitis Presenting To Children's Health Ireland – Results Of A 15 Year Retrosepctive Case Review"
Principal Presenter: Jennifer Cox
Track: General Infectious Diseases
Background:
An increase in Non-Tuberculous Mycobacterial (NTM) lymphadenitis presentations to the Paediatric Infectious Disease service at Children’s Health Ireland (CHI) was noted. NTM is not a notifiable disease and the epidemiology of this condition in Ireland is unknown. Our aim is to describe the clinical characteristics, diagnostic approach and outcomes of NTM lymphadenitis in children presenting to CHI.
Methods:
Retrospective cohort study of children presenting to CHI with NTM lymphadenitis from 2007 to 2022 inclusive.
Patients were identified by searching;
- Correspondence of the PID and ENT teams for key words such as “adenitis” and “non-tuberculous”
- Records of the Mycobacterial Reference Laboratory for growth of NTM samples
- Histopathological database for evidence of NTM from lymph node samples
Results:
We identified 37 patients with a median of one patient presenting per year between 2007-2019 and a steady increase thereafter (Figure). Median age was 3 years (1.5-10yrs) and 24 (65%) were female. The median duration of symptoms was 2 months (1 day – 11 months). The majority of children were systemically well with fever (25%), night sweats (6%) and weight loss (3%) uncommonly reported. Thirty-one (86%) had at least one course of antimicrobials for bacterial lymphadenitis prior to diagnosis. Twenty two (60%) had surgical intervention, however only four (11%) had a full excision. Only nine patients had a causative organism identified, eight with Mycobaterium avium and one with M abscessus. Four (11%) patients had specific anti-NTM therapy. Spontaneous drainage was documented in twenty-two patients (60%) for a median duration of 3 months (range 0.5-7 months)
Conclusion:
There has been an unexplained increase in NTM lymphadenitis presenting to CHI in recent years, perhaps related to the cessation of BCG or post Covid lockdowns. The majority of cases undergo surgical intervention but only 11% were recognised early enough for curative excision. Long term antimicrobial therapy is rarely required. Increased awareness and early ENT referral is recommended.
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#2024103
"The Impact of Migration on Immune Status to MMR in Newly-presenting Patients Living with HIV Infection to a Dublin hospital"
Principal Presenter: Ciara Anderson
Keywords: Immunisation, Migration, HIVTrack: Epidemiology & Population Health
Background;
Global migration plays a role in disease spread and changes in patterns of infectious disease worldwide. In 2022, there was an increase in the number of new HIV diagnoses in Ireland, largely attributable to increased migration, with the majority of patients having a pre-existing diagnosis made outside of Ireland. In 2023, 141,600 people immigrated to Ireland, of these 29600 returning Irish citizens, 26100 other EU citizens and 4800 UK citizens, the remaining 81,100 were citizens of other countries.
There has been a recent outbreak of measles in Ireland, occurring at a time of decreased uptake of MMR1 and MMR2 in the general population to <90% (below the 95% recommended by WHO).
Methods;
Data for all new attendees to the HIV clinics in 2023 was obtained through the electronic medical record, including new diagnosis HIV and transfer of HIV care from other centres, within Ireland and abroad. Data was collected pertaining to demographics namely; country of origin, CD4 count and viral load at presentation, measles IgG, rubella IgG, whether the MMR was appropriately given. The department hosts an in—house vaccine unit, established in 2002.
Results;
327 new patients living with HIV infection attending in 2023. (199 included in review to date). 57/199(22.6%) Sub-Saharan Africa, 48/199(24.1%) Eastern Europe, 45/199(22.6%) South America, 28/199(14.1%) Ireland, 11/199 (5.5%)North America, 7/199(3.2%) Asia, 3/199(1.5%) Western Europe. 42/197(21%) measles IgG negative, 2(1%) having not been tested. Rubella IgG negative 17/195(9%), 4(2%) not tested. MMR was indicated in 49 patients, 25/49(51%) received vaccine. To date 24/49 have not received MMR booster 7 had contraindications (4 were pregnant, 3 had CD<200) and 3 patients declined despite advice. To date 14/49 have not received MMR. By demographic: Eastern European 79% Measles IgG-positive. For Irish patients’ measles IgG positivity was 93% and in patient from South America measles IgG positivity was 67%.
Conclusion;
With increased global migration, the population of patients living with HIV infection in Ireland is expanding, predominantly with the transfer of care of those diagnosed with HIV infection abroad. In our cohort, measles immunity was 78%. When further characterised by country of origin, there was apparent disproportionate low level of immunity in patients migrating from outside of Ireland, however no single demographic, appears thus far to achieve 95% immunity. The main reason for those non-immune not receiving MMR to date is non-referral, contraindication and patient refusal. Targeted measures have been introduced to provide vaccination to those non-immune who have no contraindication to vaccine or have not declined receipt despite advice
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#2024102
"HIV Testing in the West of Ireland – A Survey Assessing Opportunities and Barriers in General Practice"
Principal Presenter: Bearach Reynolds
Track: Epidemiology & Population Health
Background
2022 saw the largest number of HIV cases diagnosed in Ireland on record with a 122% increase on the previous year. Late-stage diagnosis and difficulties accessing HIV testing services are more commonly experienced among people who live outside of Dublin. The aim of this survey was to assess the barriers and facilitators to testing in general practice in the west of Ireland. A similar survey was carried out in 2013, with the comparison of results forming a 10-year narrative on HIV testing in primary care in the west of Ireland.
Methods
A postal survey was sent to general practitioners (GPs) working in the west of Ireland.
Results
The 2023 survey received a 21.4% response rate, (n=136). 79.4% reported having a registered patient living with HIV. In terms of diagnosis location, 27.2% of GPs had a patient who was diagnosed in their own practice, 19.9% in an STI clinic, 19.9% in secondary care and 17.7% in the migration process. 98.5% had tested a patient for HIV. In terms of indication, 65.4% of GPs reported they had sent a test based on patient request, 80.9% due to sexual history, 36.7% due to a patient originating from a country of high incidence and 30.2% because of symptoms of HIV. 2.9% routinely screened new patients for HIV. 24.3% believed a HIV test should be sent for every patient attending a doctor at least once. 19.1% reported using guidelines for testing, 80.2% were aware of PEP guidelines and 77.9% were aware of PrEP and its uses. 56.6% were familiar with the concept of U=U. Seven themes were identified from qualitative analysis of GP’s responses. These included ‘Concern regarding undertesting’, ‘Stigma and concern regarding offending the patient’, and ‘Desire for national guidelines and policy’.
Compared to rural GPs, Urban GPs were more likely to have sent a HIV test based on patient request (p=0.01) and more likely to use guidelines for testing (p=0.004).
The response rate was lower in 2023 compared to 2013 (21.42% vs 47.9%). More respondents had patients living with HIV attending their practice in 2023 than 2013 (79.41% vs 56%). Rates of guidelines usage were similar between years.
Conclusion
GPs report a positive attitude to HIV testing but have concerns regarding undertesting and significant work pressures in General Practice. There did not appear to be support for universal testing in this population. National guidelines would be welcomed by GPs but if any increased testing policies were fully resourced.
ORAL PRESENTATION -
#2024101
"Persistent endoleak post-endovascular aortic repair for mycotic aneurysm requiring definitive treatment with bovine aortic graft"
Principal Presenter: Gavin Francis Kelly
Keywords: Aortic Graft Infection, Xenograft, Bovine GraftTrack: General Infectious Diseases
Background
We report the case of a patient with a persistent endoleak and pseudoaneurysm formation post-endovascular aortic repair (EVAR) for mycotic aneurysm, ultimately requiring further surgical procedure for microbiological diagnosis, and a bovine graft for definitive treatment.
Case Description
A 74-year-old female with a background of multiple myeloma in remission, presented to the Emergency Department with acute abdominal pain, fever and diarrhoea. Laboratory results were notable for WCC 11.9cells/L, with neutrophilic predominance, and CRP of 300mg/L. A CT aortogram revealed a ruptured infra-renal abdominal aortic aneurysm with surrounding stranding and retroperitoneal haematoma. Blood cultures were negative. She underwent an EVAR with typical synthetic graft. She was commenced on empiric Piperacillin/Tazobactam and Daptomycin for mycotic aneurysm, with a plan to complete 6 weeks of intravenous therapy and long-term oral suppression thereafter.
One month post-operatively she developed rising inflammatory markers. Repeat imaging revealed an endoleak at the proximal ostium of the stent with periaortic fat stranding. A PET CT scan showed heterogenous FDG uptake at the superior aspect of the stent, SUV 6.3, with adjacent periaortic fat stranding. Further serial imaging revealed the development of a pseudoaneurysm arising from the origin of the left renal artery. A stent was placed across the origin of this pseudoaneurysm, however, follow up imaging demonstrated refilling and persistent expansion. She was subsequently transferred to a specialist vascular centre where she underwent explantation of the graft, bovine reconstruction of the aorta, and reimplantation of left renal artery with a venous conduit. 16sRNA from aortic thrombus and aortic tissue was positive for Streptococcus pyogenes DNA. She was commenced on Ceftriaxone with plan for 6 weeks intravenous therapy, followed by 6 weeks of oral Amoxicillin. Follow up PET CT at four months is planned.
Discussion
This case demonstrates the complexity of treating those with mycotic aneurysms and endovascular graft infections. The necessity of repeat procedures for ultimate microbiological diagnosis, and the importance of 16sRNA when cultures have been negative cannot be understated. Finally, bovine grafts are an emerging and proven option for those with graft infection.
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#2024100
"Optimisation of Vancomycin Therapeutic Drug Monitoring in St James’s Hospital - Results of Hospital-Wide Audit and Quality Improvement Initiatives"
Principal Presenter: Stephen Connolly
Track: General Infectious Diseases
Background
Vancomycin remains a first-line agent for the treatment of a variety of resistant organisms, including MRSA and enterococcal infections. Variable pharmacokinetics and narrow therapeutic range necessitate “trough” levels to guide dosing. Inaccurate dosing risks development of on-treatment resistance, toxicity and increased medical expenditure. Trough levels are advised to be taken within one hour prior to the scheduled dose to adequately reflect drug levels.
Prior Antimicrobial Stewardship Team-led audits in 2022 identified trough levels being measured appropriately within 2 hours in only 40% of samples. Particular error was found in relation to samples taken by phlebotomy teams, whose rounds rarely coincided with scheduled dosing of vancomycin. Multi-faceted interventions such as ward staff education, computer banners and the removal of the ability to order vancomycin troughs with phlebotomy improved post-intervention appropriate sampling to 78% in 2022.
Re-audit was undertaken in 2023 to establish whether improvements persisted beyond staff changeover and if further education/communication efforts were necessary to maintain adherence to sampling guidelines.
Method
Electronic medical records were interrogated identifying all vancomycin levels ordered in SJH during August 2023. Data relating to dose timing, trough timing and staff discipline (NCHD, nursing staff etc.) were collected, with descriptive statistics and univariate analysis performed via SPSS. Interventions following audit included staff communication and electronic ward posters highlighting sampling guidelines.
Result
Data were collected pertaining to 255 samples from 72 patients. Median interval to sampling was 1.5 hours (IQR 0.5-3.0). Of the samples taken, 32.2%and 67.8% of samples were taken within 1 and 2 hours of the scheduled next vancomycin dose respectively; while 90.2% of samples were within 5 hours. No statistically-significant difference was noted between accuracy of trough timing when taken by nursing staff versus NCHDs (51% within one of hour of dose administration versus 12%; p = 0.065).
Discussion
These data correspond with other international studies, such as Swartling et al. who showed that only 36% of vancomycin trough samples were taken within the appropriate time in their institution. Nursing staff appear to draw troughs more reliably within the advised time frame than NCHDs, however this failed to show statistical significance. Low numbers of NCHD-taken samples (20 versus 205 samples) potentially explain this. Improvement is significantly attributed to removal of vancomycin troughs being performed by phlebotomy. Improved adherence to sampling guidelines appears to have been largely sustained from baseline, however the relative reduction since the 2022 intervention data indicates a further role in ongoing, multi-modal interventions to maintain guideline adherence and effective use of vancomycin in our institution.
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#2024099
"An education QIP, “Bug Bytes”: Using Artificial Intelligence (AI) generated graphics as a medium for medical education, specifically in the context of Infectious Diseases and Antimicrobial Stewardship"
Principal Presenter: Rob Shannon
Keywords: Artificial intelligence, Education, Quality Improvement ProjectTrack: General Infectious Diseases
Background:
Medical education can be delivered in a variety of modalities. Traditionally, this has involved didactic lectures, bedside or small group tutorials and reviewing textbooks or medical literature. In the digital age we have come to realise that both students and clinicians are now availing of non-traditional ways to acquire medical knowledge – e.g. accessing podcasts, YouTube or blogsites. As educators, it makes sense to try to move with this flow and evolve the way we impart our knowledge. The graphic novel has become a more mainstream form of literature in recent years in both fiction and non-fiction. It can also be used in medical education, demonstrating research findings, or easily communicating knowledge to medical communities or even non-medical practitioners. Artificial Intelligence (AI) has recently come to the fore of society via several publicly accessible tools – i.e. ChatGPT, Socratic etc; and can now be used to generate images without the need of an illustrator.Method:
Our goal was to use ChatGPT Pro in combination with DALL-E word-to-image software to develop educational “comics” that demonstrate a variety of medical case scenarios. These comics were inspired by real-life events encountered by an Infectious Diseases service and informed by medical literature and guidelines. The process of collating these comics into a teaching portfolio involved a team approach at multiple staff levels, storyboarding, editorial oversight, and output selection.Results:
Please see demonstration poster. Multiple cases represented including Dengue Fever, Cellulitis, on-treatment antimicrobial resistance, and “Meropen-man”.Conclusion:
We demonstrated that with modern AI technology, it is possible to develop novel, yet effective ways of imparting medical knowledge, in this case using comics / graphic novels as a medium for Infectious Disease or Antimicrobial Stewardship themed scenarios. While seemingly simplistic on the surface, we also show that familiarity with the toolkit and defined editorial standards are required in order to maintain consistency and quality with the products. Future qualitative analysis will allow us to assess the effectiveness of this venture in medical education going forward. -
#2024098
"Two Linked Cases of Severe Skin and Soft Tissue Infections Secondary to Gluteal Cosmetic Filler Injections"
Principal Presenter: Stephen Connolly
Track: Epidemiology & Population Health
As invasive cosmetic procedures continue to grow in popularity and accessibility, there is an urgent need for awareness of their potential complications amongst clinicians, aesthetic practitioners and the general public. We present two linked cases of severe skin and soft tissue infections in females admitted to different hospitals, having attended the same aesthetics clinic for gluteal hyaluronic acid cosmetic filler injections, in a procedure also known as non-surgical Brazilian Butt Lift (BBL). The cases were managed though a collaboration between Infectious Diseases, Clinical Microbiology and Public Health
Patient 1 attended St. James’s Hospital with a three-day history of buttock pain, chills and fevers that started within 12 hours of undergoing a BBL procedure. Aspiration of the buttock mass yielded 20ml of pus, culturing methicillin-sensitive Staphylococcus aureus (MSSA). Having documented her experience extensively on social media, Patient 1 was contacted by another female who had undergone the BBL procedure in the same aesthetics clinic on the same day as Patient 1, and had been admitted to another Dublin hospital also requiring drainage of an abscess, ultimately culturing MSSA. Patients 1 and 2 required an 11-day and 7-day hospital stay respectively, before successfully completing therapy at home.
Given the potential risk to further clients, the Department of Public Health (DPH) Dublin/Midlands were contacted. Cultures from the aspirates were referred to the National MRSA Reference Laboratory for epidemiological typing by spa typing and whole-genome sequencing. Both isolates were negative for the Panton Valentine Leucocidin (PVL) toxin, and assigned to spa type t701, multi-locus sequence typing ST6 and clonal complex 5. Core genome MLST revealed only a single allelic difference between the isolates, suggesting they were very closely related.
The Department of Public Health conducted a site visit to the aesthetics clinic, liaising also with the Health Products Regulatory Authority regarding the products used. While no evidence of batch contamination or counterfeit filler products was found, unsatisfactory injecting practices were evident, and this clinic agreed to indefinitely cease performing BBL procedures and to implement infection prevention recommendations. Presentations were then made to the office of the Chief Medical Officer, to highlight the risks of such procedures and to advocate for regulation.
Cosmetic filler injections can be associated with severe complications, with currently no restrictions on who can administer such procedures in Ireland. We have presented the cases of two previously-healthy females who were hospitalised due to complications. These cases highlight an effective collaboration between Public Health and infection clinicians; as well as the urgent need for public and provider awareness of the risks of these procedures, as well as government regulation and enforcement in this area.
ORAL PRESENTATION -
#2024097
"Paediatric Invasive Pneumococcal Disease in the Republic of Ireland; a Retrospective Review of Serotypes, Antimicrobial Resistance, Vaccination Failures and Immunological Investigations 2021-2023"
Principal Presenter: Bryony Treston
Track: General Infectious Diseases
Background: Paediatric invasive pneumococcal disease (IPD) is evolving in response to changes in vaccination. With authorisation of two new extended valency pneumococcal conjugate vaccines (PCV), serotype surveillance is imperative to inform health policy. Additionally IPD can serve as the initial manifestation of underlying immunodeficiency, however there is no internationally agreed clinical practice guideline available to guide immunological investigation of paediatric IPD patients.
Methods: A retrospective review of all cases of culture positive paediatric IPD in the Republic of Ireland (ROI) between July 2021 and June 2023 was conducted. Serotyping and antimicrobial resistance (AMR) profiles were analysed in available isolates. Additionally, a retrospective clinical audit of immunological investigations was undertaken in cases of IPD, identified by either culture or PCR who had received care at Children’s Health Ireland Crumlin and Temple St.
Results: 99 cases of IPD were identified, with 37 isolates available for serotyping and AMR assessment, and 82 cases included in the audit of immunological investigations. Respiratory cases predominated (64.6%, n=64). 37.8% (n=14) of isolates were PCV13 serotypes, over half of which represented vaccination failure. Over a quarter of serotypes (27%, n=10) were serotypes not included in PCV13 but included in PCV20, whereas PCV 15 extended cover to an additional 5% (n=2) of cases. Penicillin non-susceptibility was reported in 35% of isolates. Immunological investigations were undertaken in 70% of cases with considerable variation in the extent of investigation. Six patients received a new diagnosis precipitating their IPD presentation; two of which were haemato-oncological, four of which were primary immunodeficiencies.
Conclusion: IPD continues to evolve with changes in demographic, serotype and AMR patterns observed in ROI in the post pandemic era. While PCV20 may extend coverage to recently observed serotypes, the utility of PCV15 appears more limited in ROI. Clinical practice regarding immunological investigations following IPD in ROI is quite heterogenous highlighting the need for an agreed clinical practice guideline.
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#2024096
"Hepatitis A Booster Vaccination in People Living with HIV: An Audit from Ireland's Largest HIV Clinic"
Principal Presenter: Seán Donohue
Keywords: hepatitis A, vaccination, HIVTrack: Virology
Background:
Hepatitis A virus (HAV) is spread person-to-person by the faecal-oral route. Those at risk of acquiring infection include men who have sex with men, people who inject drugs, and travellers to areas where HAV is endemic. Infection severity increases with age, but fulminant hepatitis is rare. Those with chronic liver disease are at increased risk of severe infection. HAV vaccination is recommended in people living with HIV (PKWH) with risk factors for acquiring the virus. The efficacy of HAV vaccination is reduced in PLWH and immunity is likely shorter lasting. NIAC and BHIVA recommend vaccinating those at risk with the monovalent HAV vaccine at 0 and 6 months. For those with a CD4 count <350, a third vaccine is recommended. Booster vaccination is recommended every 10 years.
Methods:
Using the electronic patient record (EPR), we reviewed all those patients who received their primary HAV vaccine in the years 2012 to 2014 as they will now be due a booster. We assessed whether they had received their booster as the recommended time.
Results:
There were 78 patients in total included. 23 (29.5%) of these received the recommended booster vaccine, 30 (38.5%) no longer attend our clinic, and 3 (3.8%) have died in the intervening decade. 22 (28.2%) are due booster vaccination, but have not yet received this. For this latter group, we entered a reminder on the EPR for clinicians to offer booster vaccination to those at risk at next visit.
Conclusion:
HAV is a vaccine preventable disease. Many of our PLWH cohort are at ongoing risk of acquisition. Rates of booster vaccination in our group were lower than desired. We will reassess this in six months to evaluate if our EPR intervention was successful.
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#2024095
"Lower Motor Neuron Facial Nerve Palsy in 13 Month Old due to Acute Otitis Media and its Challenges: a Case Report"
Principal Presenter: Harish Chaudhary
Track: General Infectious Diseases
Lower Motor Neuron Facial Nerve Palsy in 13 month old due to Acute Otitis Media and its Challenges: a Case Report
Background:
Facial nerve palsy (FNP) is a rare occurrence in children, yet it poses significant stress for both parents and affected children. A comprehensive evaluation involving a multidisciplinary team is crucial for accurate diagnosis and effective treatment. In the era of antibiotics, the rarity of facial nerve palsy following acute otitis media (AOM) has prompted debates on treatment approaches, including the need for surgical intervention, steroid administration, and radiological imaging.Case report:
In this case report, we illustrate the presentation of a 13 month old previously healthy girl who developed acute FNP three days after the onset of upper respiratory tract symptoms, concomitantly manifesting AOM upon examination and subsequently underwent treatment with antibiotics, oral steroids, myringotomy, and grommet insertion for drainage.
Discussion and Conclusion:
Facial paralysis is very rare complication of acute otitis media that requires thorough work up and proper care. As emphasised in our report, the treatment of facial nerve palsy secondary to otitis media in toddlers involved antibiotics, a short course of corticosteroids (which is debatable), and myringotomy with grommet insertion when spontaneous perforation of the tympanic membrane is not present. The use of corticosteroids in children for facial nerve palsy is based largely on adult studies; however, recent findings from a new randomized controlled trial indicate strong evidence against their use in children. We support using CT scans as the primary examination for patients without clinical improvement after conservative therapy and myringotomy.
Key words: Lower motor neuron facial nerve palsy, Facial nerve palsy, corticosteroid, myringotomy, grommets and CT scans
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#2024094
"Lower Motor Neuron Facial Nerve Palsy in 13 Month Old due to Acute Otitis Media and its Challenges: a Case Report"
Principal Presenter: Harish Chaudhary
Keywords: Lower Motor Neuron Facial Nerve Palsy, Acute Otitis Media, SteroidTrack: General Infectious Diseases
Lower Motor Neuron Facial Nerve Palsy in 13 month old due to Acute Otitis Media and its Challenges: a Case Report
Background:
Facial nerve palsy (FNP) is a rare occurrence in children, yet it poses significant stress for both parents and affected children. A comprehensive evaluation involving a multidisciplinary team is crucial for accurate diagnosis and effective treatment. In the era of antibiotics, the rarity of facial nerve palsy following acute otitis media (AOM) has prompted debates on treatment approaches, including the need for surgical intervention, steroid administration, and radiological imaging.Case report:
In this case report, we illustrate the presentation of a 13 month old previously healthy girl who developed acute FNP three days after the onset of upper respiratory tract symptoms, concomitantly manifesting AOM upon examination and subsequently underwent treatment with antibiotics, oral steroids, myringotomy, and grommet insertion for drainage.
Discussion and Conclusion:
Facial paralysis is very rare complication of acute otitis media that requires thorough work up and proper care. As emphasised in our report, the treatment of facial nerve palsy secondary to otitis media in toddlers involved antibiotics, a short course of corticosteroids (which is debatable), and myringotomy with grommet insertion when spontaneous perforation of the tympanic membrane is not present. The use of corticosteroids in children for facial nerve palsy is based largely on adult studies; however, recent findings from a new randomized controlled trial indicate strong evidence against their use in children. We support using CT scans as the primary examination for patients without clinical improvement after conservative therapy and myringotomy.
Key words: Lower motor neuron facial nerve palsy, Facial nerve palsy, corticosteroid, myringotomy, grommets and CT scans
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#2024093
"Portrayal of homelessness in the Irish media: a mixed-methods analysis."
Principal Presenter: Orly Mahoney
Track: Diversity & Inclusion
Background
Stigma contributes to increased allostatic load, worsening health outcomes and shortening life expectancy. People experiencing homelessness (PEH) are profoundly stigmatised and uniquely vulnerable to the associated health impacts. This paper seeks to evaluate the media representation of homelessness quantitatively through news article data collection, as well as qualitatively through semi-structured interviews with PEH.
Methods
The websites of five Irish news and media publications were searched for the word 'homeless'. The first 100 articles presented were selected for analysis. Articles were reviewed separately by the authors & data was collected on article content, including article type, primary focus, portrayal of Irish homelessness, and portrayal of PEH, categorized as positive, negative, or neutral. Conflicts were resolved through inter-author discussion, results were summarised using descriptive statistics, and correlations assessed using Spearman's rho. Additionally, eight PEH were recruited from the inpatient population of the Inclusion Health department of St James's Hospital. Semi-structured interviews were conducted and common themes identified and collated.
Results
8% of articles reviewed portrayed PEH negatively, 79% neutrally, and 12% positively. Negative portrayals included details of assaults and other antisocial behaviour by PEH, and positive portrayals described prosocial behaviour. Articles that focussed directly on homelessness were more likely to rank negative in article character (68.6% vs 41.6%, p<0.001). First-hand accounts from PEH were included in 26% of all articles reviewed, and there was a statistically significant association between the inclusion of a first hand account and positive reporting on PEH (9.3% vs 23.8%, p<0.001). Consistent themes identified in the semi-structured interviews include perceived inadequacies in reporting on homelessness and underrepresentation of PEH in the media, perceptions of negative judgement and shame in the media, and dissatisfaction with the government. 50% of patients expressed anger and frustration with how homelessness was represented in the media, with 50% also expressing hopelessness about the news around homelessness.
Conclusion
Depictions of PEH in Irish media were broadly neutral, while Irish homelessness as a whole was depicted as mostly negative. PEH reported experiencing stigma, both societal and internalised, in response to media reports. Much of this perceived stigma could arise from a disconnect between the lived experience of PEH and the reporting on it, supported by the low rate of inclusion of first-hand accounts from PEH. These findings underscore the importance of including the voices of PEH in efforts to combat stigma.
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#2024092
"Phase 2 Study of Switch to Daily BIC + LEN in Individuals on a Multi-tablet HIV Treatment Regimen"
Principal Presenter: Conor Moran
Keywords: Lenacapavir, Bictegravir, switchTrack: Virology
Background:
The combination of bictegravir (BIC), an integrase strand transfer inhibitor, and lenacapavir (LEN), a first-in-class capsid inhibitor, could simplify treatment in virologically suppressed (VS) people with HIV (PWH) for whom single tablet regimens are not indicated. We report the Phase 2, 24-Week primary outcomes for BIC + LEN versus stable baseline regimen (SBR) in VS PWH on a complex regimen.
Methods:
ARTISTRY-1 is an ongoing, randomised, open-label, multicentre Phase 2/3 study. In Phase 2, 128 participants on SBR (≥6 months prior to screening) were randomised 2:2:1 to receive once-daily oral BIC 75 mg + LEN 25 mg, oral BIC 75 mg + LEN 50 mg or continue SBR. All participants receiving BIC + LEN received an oral loading dose of LEN 600 mg on Days 1 and 2 of treatment. Primary endpoint was the proportion of participants with HIV RNA ≥50 copies/mL (FDA Snapshot) at Week 24. Secondary endpoints included the proportion with HIV RNA <50 copies/mL, and proportion with treatment emergent adverse events (TEAEs) up to Week 24.
Results:
51 and 52 participants received BIC 75 mg + LEN 25 mg or BIC 75 mg + LEN 50 mg, respectively, and 25 continued SBR. At baseline, 19% were female, 31% were Black; median (Q1, Q3) age was 60 (56, 65) years and participants were taking a median (range) of 3 (2–9) tablets per day. HIV-1 RNA was ≥50 copies/mL in 0/51 of participants in the BIC 75 mg + LEN 25 mg group, 1/52 (2%) in the BIC 75 mg + LEN 50 mg group (later suppressed to <50 copies/mL without regimen change) and 0/25 in the SBR group. The most common TEAEs in the two BIC + LEN treatment groups up to Week 24 were diarrhoea (7%), COVID-19 (6%) and constipation (5%). Drug-related TEAEs occurred in 18%, 6% and 0% of participants, respectively.
Conclusion:
Bictegravir + lenacapavir was highly effective in maintaining viral suppression in participants switching from an multi tablet regimen, with similar safety profiles observed in the two BIC + LEN treatment groups. These data support the further development of BIC and LEN in combination to simplify treatment in VS PWH who are receiving complex regimens.
Funding: Gilead Sciences
Medical writing support was provided by Anna Chapman-Barnes, PhD (Aspire Scientific Ltd, U.K.), and was funded by Gilead.
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#2024091
"Does making condoms freely available on a university campus reduce the percentage of students diagnosed with chlamydia or gonorrhea?"
Principal Presenter: claire kearns
Track: Other
Background
Among professionals in the field of sexual health there is a consensus of opinion that - Condoms are a critical component in a comprehensive and sustainable approach to the prevention of HIV and other sexually transmitted infections.
Aim;
This pilot study will assess the impact of condoms which were made freely available to students in 2019
Methodology
Participated in a HSE initiative providing free condoms having identified a need.
Used data collected through screening in the Student Health Centre (SHC).
Data related only to those positive for chlamydia/gonorrhea used.
Data presented from February 2017 to November 2017(pre condom distribution )
Data presented February 2019 to November 2019 (during distribution).
Highlight numbers of condoms distributed
Results
February 2017 to November 2017.number of students screened 733, 51, tested positive representing 6.9%. 37 chlamydia, 14 gonorrhea
February 2019 to November 2019, 641 students were screened. During this period 13,000 condoms were distributed. 68 students tested positive, representing 10.6 %.This identifies an increase of 3.7%. 58 chlamydia, 10 gonorrhea
Points for Discussion;
It is a plausible possibility that reduced sexual sensitivity is a factor precluding condom use for males and therefore the reluctance is more related to lack of appeal than cost, Also the fact that young females in this group may not feel confident enough to speak up due to the power imbalance that exists.
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#2024090
"Compost and Charcoal Culture in a Challenging Case of Legionnaires Disease"
Principal Presenter: Stewart Crowe
Keywords: Marlins, Ohope, WhakapappaTrack: General Infectious Diseases
A healthy 69 year old keen gardener presented to the emergency department with severe
community acquired pneumonia. On day 2 following initial improvement with empirical
antibiotics and a negative legionella urinary antigen test, clarithromycin was stopped.
Over the subsequent week the patient deteriorated developing a necrotizing pneumonia
requiring intubation and intensive care management. Diagnostic tests including multiple
legionella urinary antigens, bronchoalveolar lavage (BAL) cultures and multiplex PCR
remained negative.
On day 13 of admission, a BAL sample on buffered charcoal yeast extract agar (BCYE) grew
colonies, identified as Legionella longbeachae by MALDI-TOF mass spectrometry. This was
later confirmed using whole genome sequencing (WGS). Moxifloxacin was started and the
patient made a good recovery.
Legionella longbeachae is a fastidious, gram negative rod of the Legionellaceae family, and a
rare cause of Legionnaires disease. First reported in 1980 in a patient with pneumonia in
Long Beach, California, USA, L. longbeachae pneumonia is associated with compost and soil
exposure and case detection in Europe is rising.
Legionella urinary antigen only detects L. pneumophilia serogroup 1, the causative serogroup of over 80% of Legionnaires disease, while Respiratory multiplex PCR vary in which Legionella species they detect. Legionella species require selective BCYE agar to culture, usually taking 5-10 days.
This case illustrates the diagnostic challenges in non–L. pneumophila serogroup 1
Legionnaires disease, an underdiagnosed cause of severe pneumonia in Europe.
New legionella urinary antigen tests targeting non-L. pneumophila serogroup 1 antigens are
being clinically evaluated. Along with whole genome sequencing of selected lower
respiratory tract samples, these measures could rapidly improve diagnosis, management and
antimicrobial stewardship of severe community acquired pneumonia in the future. -
#2024089
"Actinotignum schaalii bacteraemia in a young, immunocompetent male with a urological condition"
Principal Presenter: Daragh McGee
Keywords: Anaerobe, Bacteraemia, Urinary tract infectionTrack: General Infectious Diseases
Background
Actinotignum schaalii, a Gram-positive coccoid rod, is a rare but emerging pathogen in humans, most commonly causing urinary tract infections (UTIs). It is thought to be an underestimated pathogen in this context as it is fastidious with usual media and cannot be identified using phenotypic methods such as API, requiring blood-enriched agar, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF) or other molecular-based methods for identification.
Case description
We report a case of Actinotignum schaalii bacteraemia in a 22-year-old gentleman with a background of a urethral stricture following a circumcision for phimosis, managed with intermittent self-catherisation for the last 2 years. He presented to the emergency department with a five day history of chills and headaches, and was pyrexial. Inflammatory markers (white cell count 25.18x10^9/L, neutrophils 22.29x10^9/L, CRP 32mg/L) and serum creatinine (111 umol/L) were elevated. Point-of-care testing for SARS-CoV-2 was positive, and he was discharged home. He was re-called to the hospital when Actinotignum schaalii was identified in blood cultures on MALDI-TOF at 29 hours. Penicillin MIC was 0.008mg/L. Urinalysis revealed a pyuria (white cell count >100/uL) and subsequently cultured Actinotignum schaalii on blood agar. 4th generation testing for HIV was negative. Ultrasound of the renal tract revealed nephrolithiasis without obstruction and no structural abnormality. He received two weeks Ceftriaxone via the Outpatient Parenteral Antimicrobial Treatment (OPAT) service and made an uncomplicated recovery.
Discussion
Actinotignum schaalii has been highlighted in population-based studies as having the potential to cause severe infections. Bacteraemia typical occur in elderly men with medical co-morbidities, and are associated with a high mortality. However urological conditions such as catherisation have been implicated as a risk factor, as seen in our patient. Importantly, Actinotignum schaalii is resistant to trimethoprim/sulfamethoxazole and second-generation quinolones that are widely used in the treatment of UTIs. We recommend a higher clinical suspicion in patients with predisposing factors and sterile pyuria, and the addition of blood agar media incubated under 5% CO2 or culture under an anaerobic atmosphere for 48 hours when Gram stain reveals small coccoid rods on urine samples.
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#2024088
"Switching to bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) in treatment-experienced (TE) people with HIV with baseline symptoms of depression, anxiety or insomnia (DAI) in the observational BICSTaR study"
Principal Presenter: Conor Moran
Keywords: Bictegravir, mental health, switchTrack: Virology
Background:
Neuropsychiatric disorders are common among people with HIV (PWH). Data on integrase strand transfer inhibitor use in people with neuropsychiatric disorders are limited. We describe outcomes in TE PWH with depression, anxiety or insomnia (DAI) at baseline (BL) switching to B/F/TAF in the real-world BICSTaR observational cohort study.
Methods:
We included data from PWH with DAI (according to BL comedication[s]; BL-DAI) from BICSTaR cohorts (Europe/Canada/Israel). Outcomes up to 24 months (M) included: virologic effectiveness (HIV‐1 RNA <50 copies/mL; missing=excluded); initiation/change/stopping of DAI comedication(s); drug-related DAI-related adverse events (DAI AEs) (according to MedDRA classification); patient-reported outcomes (symptoms, quality of life [QoL], treatment satisfaction).
Results:
Of 822 PWH with 24M data, this analysis included 123 (15%) who had BL-DAI. 85% were male; 85% were White; median age was 52 years.
At 24M, 120 (98%) BL-DAI participants were still on ≥1 BL DAI medication. New DAI medications (in addition to BL-DAI) were started in 16 (13%). 8 (7%) changed their DAI medications. 3 (2%) stopped all DAI medications.
Virologic effectiveness remained high through 24M - Baseline: 93.5% (101/108) HIV‐1 RNA <50 copies/mL, 12M: 94.2% (97/103), 24M: 93.6% (88/103).
DAI AEs occurred in 26 (21%) participants with BL-DAI, of whom 19 (73%) only had AEs that were not considered drug related. 7 (6%) participants had drug-related DAI AEs; these resolved in 5 participants (in 2 participants, they resolved on switching antiretroviral treatment [ART]). 4 (3%) participants had drug-related DAI AEs leading to B/F/TAF discontinuation (switched to another ART). There were no drug-related, serious DAI AEs.
There was no worsening of three self-reported symptoms associated with DAI over the course of B/F/TAF treatment, or in physical/mental QoL. Treatment satisfaction increased through 24M (no statistical testing)
Conclusion:
In this cohort of PWH with BL-DAI switching to B/F/TAF, virologic effectiveness remained high through 24M, with few discontinuations due to drug-related DAI-related AEs. Self-reported mental health remained stable. These real-world data support B/F/TAF use in this population.
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#2024087
"Lenacapavir Plus bNAbs for People with HIV and Sensitivity to either Teropavimab or Zinlirvimab"
Principal Presenter: Conor Moran
Keywords: bNAbs, antibody, long-actingTrack: Virology
Background:
Lenacapavir (LEN) (long-acting HIV-1 capsid inhibitor) with teropavimab (TAB) & zinlirvimab (ZAB) (long-acting broadly neutralising antibodies [bNAbs], targeting the CD4-binding site & V3 loop of gp120, respectively) maintained virologic suppression (VS) for 6 months in 18/20 participants with HIV with high-level sensitivity to both bNAbs in a phase 1b study. We evaluated safety & efficacy of LEN+TAB+ZAB in a cohort who met viral sensitivity criteria to either TAB or ZAB.
Methods:
Virologically suppressed adults with HIV on antiretroviral therapy (ART; HIV-1 RNA <50 copies/mL for ≥18 months), with high-level sensitivity to TAB or ZAB but not both by HIV proviral DNA phenotype (PhenoSense monoclonal antibody assay IC90 ≤2µg/mL), a CD4 nadir of ≥350 cells/µL, & CD4 ≥500 cells/µL at baseline were randomised 1:1 to one of two active treatment groups: LEN (927 mg subcutaneously after oral loading) + TAB (30 mg/kg intravenously [IV]) + ZAB (Group 1, 10 mg/kg IV; Group 2, 30 mg/kg IV). Primary endpoint was incidence of treatment-emergent serious adverse events (AEs) at Week 26; secondary endpoints included virologic outcomes (VS or ≥50 copies/mL) at Week 26 by FDA Snapshot analysis.
Results:
Eleven participants were randomised & treated (Group 1, n=5; Group 2, n=6). Age range 28–63 years; 3 female; 4 were Black; median CD4 was 916 cells/µL. There was 1 serious AE (soft tissue infection) not related to study treatment. No AEs led to study drug discontinuation. Safety outcomes were similar between groups. One participant restarted baseline ART due to protocol violation (chronic hepatitis B infection) & was excluded from efficacy analyses. At Week 26, 8/10 participants maintained VS. Of the two participants in Group 1 with virologic rebound, one had sensitivity to TAB with acute COVID-19 at the time of rebound, & one had sensitivity to ZAB & rebounded at Week 26; both had HIV RNA <100 copies/mL.
Conclusion:
Long-acting LEN+TAB+ZAB was well tolerated, with a favorable safety profile. All participants in the higher ZAB dose group maintained VS for 6 months, suggesting that more inclusive sensitivity criteria may be appropriate for treatment studies of LEN+TAB+ZAB when higher bNAb levels are maintained.
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#2024086
"Skip the Dip for UTI in over 65s Quality Improvement Initiative"
Principal Presenter: Mala Shah
Keywords: urinary tract infection, urine dipstick tests, antimicrobial stewardshipTrack: Other
Background
Inappropriate use of urine dipstick tests can lead to unnecessary antibiotic prescribing, contributing to adverse effects and antimicrobial resistance. Dipstick urinalysis is not recommended for assessment of evidence of urinary tract infection (UTI) in people aged 65 years and over.
Aim
The ‘SKIP THE DIP for UTI in over 65s’ quality improvement initiative raises awareness of best practice in the management of suspected UTI in HSE OP RCFs, to reduce inappropriate antibiotic prescribing.
Methods
A survey to determine dipstick urinalysis practice was administered to all 119 HSE OP RCFs. Focus groups with nursing staff were held to identify facilitators and barriers for this initiative. Monthly monitoring of antibiotic use for UTI was established in HSE OPS RCFs. Staff handbooks, resident leaflets and other initiative materials were developed and antimicrobial pharmacist-delivered workshops commenced in August 2023. The RCF survey on dipstick urinalysis will be repeated in spring 2024. Trends in antibiotic use for UTI will be monitored throughout this initiative.
Results
Baseline data from antimicrobial surveys in HSE OPS RCFs in 2020/21 show 2.6% residents (114/4446) were on an antibiotic for the treatment of UTI. Monthly monitoring of antibiotic use in these RCFs show a reduction of prevalence of antibiotics for treatment of UTI to 1.5% (66/4321) in January 2024 following the introduction of the ‘Skip the Dip for UTI in over 65s’ initiative. A survey indicated 53% (57/107) RCFs performed dipstick urinalysis for residents with symptoms of UTI in March 2023. Repeat survey results are anticipated in May 2024 to assess the number of RCFs that have ceased practice of performing dipstick urinalysis for assessment of UTI since the introduction of this initiative. Focus groups with nurses identified local champions to support the initiative. Barriers to change included current documentation requirements, residents’ and families’ concerns and doctors requesting dipstick urinalysis.
Conclusion
A decrease in antibiotic use for treatment of UTI in the HSE OP RCFs has been noted since the ‘Skip the Dip for UTI in over 65s’ initiative commenced. The ongoing evaluation of this initiative will inform wider implementation beyond HSE OP RCFs.
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#2024085
"Helicobacter pylori testing in Ireland 2023-2024."
Principal Presenter: Katerina Hutchinson
Keywords: stool H. pylori antigens test, serum Helicobacter Pylori IgG antibodies, H. Pylori in IrelandTrack: Epidemiology & Population Health
Background:
Helicobacter pylori (H. pylori) infection is a public health issue. It remains one of the most common infections in adults in Ireland and is associated with significant disease as the main cause of stomach ulcers and stomach cancers. Currently, H. pylori infection is managed almost exclusively by general practitioners (GPs). Diagnosis of H. pylori infection is one of the most important steps in infection management.
Methods:
We have performed an audit of stool H. pylori antigens test (ImmunoCard STAT! HpSA, rapid lateral flow immunoassay) and serum Helicobacter Pylori IgG antibodies (HPAB: CLIA Chemiluminescence, Liaison XL/Diasorin) in Irish patients from GPs’ practices during 2023-2024 (for HpSA: total n=13.970: F=8.038, M=5.352; for HPAB: total n=3.368: F=1.936, M=1.432). The software used for the statistical analysis was GraphPad Prism 5, Version 10.2.0. The positivity rate and the concentrations of H. pylori tests were analysed overall (and specifically in relation to sex and age groups <18; 18-40;40-60 and >60).
Results:
The positivity rate for stool H. pylori antigens test in males was 13.5% and 12.3% in females. The 40-60 age group had highest number of positive results for both males and females, 43% and 41%, respectively; in the <18 age group: M=7.5%, F=5%; 18-40: M=30%, F=34% and in the >60: M=19.5%, F=20%. The overall positivity rate for H. pylori antibody test was 35%, more prevalent in males (M=38.5%; F=31.5%), in the age group 40-60 years old M=45% and F=44%; 18-40: M=37% and F=34% (p = 0.0001).
Conclusion:This study demonstrated a high prevalence of H. pylori infection in the Irish population, but with a decreased tendency then previously reported. We also confirmed associations between H. pylori infection, age, and sex. The lower rate of positivity for stool H. pylori antigen tests may be the result of the poor sensitivity of the diagnostic kits. Other factors may include quality of specimen tested and/ or intermittent shedding of the H. pylori antigens.
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#2024084
"RESULTS OF A NATIONAL PUBLIC HEALTH INVESTIGATION OF PAEDIATRIC CASES OF INVASIVE GROUP A STREPTOCOCCUS DURING THE 2022-2023 OUTBREAK"
Principal Presenter: Deirdre Foley
Track: Epidemiology & Population Health
Background
From October 2022 to June 2023, there was a four-fold increase in invasive Group A Streptococcus cases (iGAS) in the Republic of Ireland, similar to trends across Europe, with 45% occurring in children.
Method
All cases of iGAS notified to Public Health in children under 16 years from October 2022 to June 2023 inclusive were collated. A clinical case review of every death and hospitalisation was performed by paediatric teams across the country under the auspices of the National Incident Management team. Data was collected using an online questionnaire.
Results
183 cases of iGAS in children were notified to Public Health. Clinical data was collected on 94% of cases. 75 of 167 (45%) had a previous health care attendance before admission. The breakdown of presenting diagnoses is presented in the figure. 48 (69%) of the 70 patients with SSTI had varicella co-infection. 69 (38%) of patients had ≥1 viral co-infection. 38% of patients were documented as having sepsis or in septic shock and 76 (47%) patients required procedural intervention. 22 (14%) required PICU admission, 2 of whom required ECMO. Of the 12 patients who died, eight had an out-of-hospital cardiac arrest. The majority (83%) of patients who died had necrotizing pneumonia.
Conclusions/Learning Points
Case fatality rate was 6.5% in children with iGAS infection. Most survivors (84%) had no adverse outcomes at follow-up. The rapidity and severity of secondary deterioration and death in children with iGAS highlights the importance of sepsis awareness in primary and secondary care. The high prevalence of viral co-infection with iGAS emphasizes the importance of current vaccine uptake rates and supports the expansion of the national schedule to include varicella immunisation.
ORAL PRESENTATION -
#2024083
"Kingella kingae - a rare cause of paediatric infective endocarditis"
Principal Presenter: Bryony Treston
Track: General Infectious Diseases
Kingella kingae (K. kingae) is a fastidious Gram-negative coccobacillus. It is part of the commensal oropharyngeal flora in children and is the leading cause of osteomyelitis and septic arthritis in children under 36 months. However, it is a rare cause of infective endocarditis. K. kingae secretes RtxA cytolytic toxin which is a key virulence factor in disrupting respiratory mucosa and facilitating bacteraemia and endocarditis.
Case description
A 1-year-old, previously well, girl presented to hospital with a one-week history of fever, coryza, periorbital stomatitis, diarrhoea and a diffuse rash. RSV, rhino/enterovius and parainfluezae viruses were detected on multiplex respiratory PCR, and norovirus on stool PCR. On auscultation a new grade 4 murmur was audible, and the child was urgently transferred to a specialist paediatric cardiac centre. Cefotaxime and vancomycin were empirically commenced. Echocardiogram revealed two large vegetations on the mitral valve on sessile stalks and an abscess between the leaflets and atrium. K. kingae was identified from admission blood cultures after 3 days, and from admission blood by PCR. All subsequent blood cultures were negative. She underwent urgent cardiothoracic surgery involving a novel method of mitral valve reconstruction; a new valve was fashioned with a pericardial patch.
The rtxA gene target, present in K. kingae and K. negevensis, was detected by PCR from pericardial fluid, pleural fluid and mitral valve tissue. The blood culture isolate was typed by the national reference laboratory (IMSRL); the cpn60 gene, which is specific to K. kingae was detected. Further characterisation of the capsular gene identified serotype b. The isolate was resistant to penicillin and susceptible to ceftriaxone (MIC 0.047, MIC 0.008 respectively, EUCAST) completing 6 weeks of the latter as an outpatient.
Discussion
This 1-year-old girl presented with fulminant K. kingae infective endocarditis. Mouth ulcers have frequently been described with K. kingae endocarditis and likely represent the portal of translocation in this case. The risk of neurological involvement such as stroke or meningitis in this clinical context is as high as 30%. An urgent, novel surgical approach was undertaken preventing neurological sequalae and the child had normal mitral valve imaging and functionwas well at her last follow up.
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#2024082
"EVAR graft removal and bovine neo aortic reconstruction for an infected EVAR"
Principal Presenter: Max White
Track: General Infectious Diseases
Background
Ruptured abdominal aortic aneurysms (AAA) are a rare surgical emergency associated with high mortality. According to the Irish Vascular Society either an open repair or endovascular aortic repair (EVAR) must be performed within 90 minutes of symptom onset to minimize mortality. Mycotic aneurysms are an important cause of AAA and are important to consider prior to the commencement of antibiotics. Such aneurysms pose an increased risk of graft infection – a rare but serious complication of EVAR, with few treatment options.
Case description
We present the case of a 66 year old female transferred from Cavan General Hospital with a ruptured mycotic aneurysm, managed with an emergency EVAR & post-operative empiric antibiotics. No microbiological diagnosis was made at this point.
Her past medical history was significant for multiple myeloma.She represented following 6 weeks of outpatient antimicrobial therapy, with a type I endoleak and expanding aortic aneurysm suggesting ongoing graft infection.
Following careful consideration and discussion at local and international MDT, our patient was accepted to St . Guys and St Thomas’ London for a second opinion including consideration for graft explanation. In London, our patient had a successful graft explanation and reconstruction with a bovine neo-aortic graft. She completed 3 months of post-operative antibiotics and is now doing well off antibiotics.
The explanted graft did not grow anything from a microbiological perspective. 16S and 18S were negative however a group A streptococcal-specific PCR was positive.
Discussion
This case demonstrates the importance of collaboration between vascular, microbiology, and infectious disease in the management of complicated EVAR infections. Local and international collaboration is beneficial.
This case also demonstrates the difficulties in curing infected endovascular material. It is likely that if the graft was not removed our patient would have died of overwhelming sepsis or a ruptured EVAR graft.
To our knowledge, a patient has never been referred from Ireland to London for aortic graft removal. It should be noted that this procedure carries a high mortality and morbidity but should be considered in certain cases. -
#2024081
"Gonorrhoea Trends in the West of Ireland"
Principal Presenter: Fiona Murphy
Keywords: Gonorrhoea, Test of CureTrack: General Infectious Diseases
Background
Gonorrhoea is a pressing public health concern in Europe, with Ireland experiencing a significant rise in cases. In 2022, Ireland reported the highest incidence of gonorrhoea in Europe, with 3,812 confirmed cases. WHO 2025 targets a 20% reduction in incidence for of gonorrhoea. As such, this study aimed to provide valuable insights into the epidemiology, resistance patterns, and management strategies of gonorrhoea in the West of Ireland.
Methods
A retrospective case series was conducted at Galway University Hospital over a 12-month period, encompassing all diagnosed cases of gonorrhoea. Demographic data including gender, age, sexual orientation, and HIV status were collected, along with information on the site of infection, resistance profiles, and test of cure results. The study sought to comprehensively examine the epidemiology of gonorrhoea in the region, identify prevalent resistance patterns, and assess the efficacy of current treatment protocols.
Results
Analysis of 142 enrolled patients revealed a predominance of male cases (81.7%), with a median age of 28 years. Graim stain positive in 38% of cases. Culture positive in 42% of cases. PCR was positive in 68% of cases. Notably, a substantial proportion of patients identified as men who have sex with men (MSM), comprising 95% of male cases. Multi-site infections were prevalent, with 42% of patients presenting with infections in more than one clinical site. Resistance to ciprofloxacin was notably high, with 62% of male patients exhibiting resistance, compared to 30% among females. All patients were treated with ceftriaxone. The majority of patients (90%) tested negative for gonorrhoea in the test of cure (TOC) at three weeks. Of those with positive test of cures, this was seen most commonly in pharyngeal infections (70%) and required second treatment with ceftriaxone.
Conclusion
The study's findings shed light on key epidemiological trends in gonorrhoea management in the West of Ireland. The disproportionately high burden of gonorrhoea among MSM underscores the importance of targeted prevention and intervention efforts within this demographic group. Furthermore, the high prevalence of ciprofloxacin resistance highlights the urgency of surveillance and judicious antimicrobial use to combat the spread of resistant strains. While the TOC yielded promising outcomes, its routine implementation warrants further evaluation to assess its cost-effectiveness and necessity in clinical practice. Overall, addressing the challenges posed by antimicrobial resistance and tailoring interventions to high-risk populations are crucial steps in mitigating the burden of gonorrhoea and safeguarding public health in the region.
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#2024080
"Progressive Multifocal Leukoencephalopathy: Undiagnosed Risk Factors"
Principal Presenter: Aoife Maher
Keywords: PML, Viral infections, HaematologyTrack: Virology
Background
Progressive multifocal leukoencephalopathy (PML) is a neurological disorder characterised by destruction of oligodendrocytes secondary to the polyomavirus JC. 85% of the population have latent JC virus. PML is secondary to reactivation of the JC virus, and almost exclusively occurs in patients who are immunocompromised, such as patients with HIV, lymphoma, or autoimmune conditions. It presents with ataxia, dysarthria, and cognitive impairment. Diagnosis is based on a clinical syndrome consistent with PML, neuroimaging and isolation of JC virus from CSF or in brain tissue.
Case description
We report a case of PML in a 74-year-old female with a background history of breast cancer managed with surgery, radiation, and chemotherapy, who had finished all treatment in 2018. She presented with a subacute cognitive decline with no history of fevers, weight loss or bone pain. She was admitted to hospital for assessment. MRI brain showed an ill-defined enhancing focus most extensive in the right frontal lobe with extension across the corpus callosum into anterior left frontal lobe and posterior extension into the insula. Following a biopsy there was a deterioration in clinical status and a repeat CT brain showed acute right frontal and basal ganglia haematoma, acute and extensive subarachnoid haemorrhage, and acute intraventricular haemorrhage. A left frontal external ventricular drain (EVD) was inserted, and she was transferred to ICU. A full investigatory panel was completed including a lumbar puncture, vasculitic, immunomodulatory and connective tissue screen CT-TAP and were within normal limits. There was one abnormal result with a IgM Kappa band present in the gamma region in-keeping with possible myeloma or monoclonal gammopathy of undetermined significance (MGUS)S, but a normal FBC. CT-Brain 6 days post insertion of lLeft EVD showed a mild decrease in haemorrhage volume but new bilateral MCA territory infarcts. Whilst awaiting biopsy result the differential was a glioma or primary haematological malignancy. The brain biopsy however showed features of PML, specifically, it stained positive for SV40 which is consistent with PML. Unfortunately, the patient was made palliative and died 2 days later.
Discussion
Our case report highlights that an apparently immunocompetent 74-year-old female can develop PML. The only possible risk factor was a questionable diagnosis of a haematological malignancy; however, the level of IgM was more in keeping with MGUS. This case highlights the importance of early imaging in patients presenting with neurological symptoms and in maintaining a wide differential even if no risk factors are initially identifiable from the clinical history, whilst awaiting biopsy results.
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#2024079
"Frailty in Beaumont Hospital’s HIV clinic"
Principal Presenter: Peter Conlon
Track: Virology
Background
Frailty is of growing interest among persons living with HIV (PLWHIV) as our cohorts live longer lives. PLWHIV are at greater risk of frailty and age-related comorbidities including osteoporosis and polypharmacy. Additionally, PLWHIV attend hospital more frequently and have a large pill burden
Methods
We audited all PLWHIV attending the Beaumont service to evaluate for evidence of frailty
Results
Beaumont Hospital has 40 PLWHIV over the age of 65. The average bill burden is 6.6 tablets/day. The average number of hospital attendances was 3.9, with one person attending 26 times in one year. 58% of patients had a vitamin D level checked in the preceding 5 years and 45% of patients had a Dexa scan performed in the preceding 5 years.
Only 10 percent of our patients were linked with a geriatric service in our hospital
Discussion
As our cohort of PLWHIV are aging frailty is an important consideration. A large number of patients are attending hospital on a regular basis. There may be a role for co-locating clinic appointments with other services in order to reduce the number of hospital visits.
Attention to bill burden is an important consideration in the HIV OPD setting and consideration should be made to deprescribing.
As our patients age and are at risk of frailty, the involvement of our medicine for the elderly colleagues should be considered with a view to making plans for later life, including advanced care directives.
These results are limited by the fact that Beaumont’s HIV clinic services a wide geographic location and as a result, we may not have access to information surrounding linkage to medicine for the elderly and DEXA results.
ORAL PRESENTATION -
#2024078
"Beaumont Hospital’s experience after 1 year of using long acting injectables (LAI) for the treatment of HIV"
Principal Presenter: Peter Conlon
Track: Virology
Background
Cabotegivir and rilpivirine have been licensed in Ireland as an LAI formulation for the treatment of HIV since 2021. Beaumont Hospital began offering LAI outside the setting of clinical trials in 2023
Some patients opt for LAI to provide more flexibility in daily life. Patients like not having to take tablets every day and it allows patients more autonomy.Elevated BMI (>30kg/m^2) is considered a relative contraindication for LAI therapy, especially in the presence of another risk factor for failure. The other risk factors for failure are uncertain treatment history, including uncertain resistance, and HIV subtype A6/A1
Methods
We audited the use of LAI in Beaumont Hospital over the last 12 months. Of particular interest were patient BMI and virologic failureResults
Beaumont Hospital has 17 patients on LAI therapy at present. There were 21 patients screened for LAI therapy consideration. 1 patient was not accepted due to inconsistent attendance and detectable viral load while on a rilpivirine regimen. The other 3 patients were not accepted due to achieved resistance mutations (G190A and E138k)
To date, no patient has experienced virological failure. This includes patients who had risk factors for failure.
Over 70% of patients had a BMI >30 and one patient had a BMI >46.
Discussion
LAI therapy is an excellent therapeutic option for some patients. BMI >30 kg/m^2 has been considered a relative contraindication for therapy. However, none of our patients have experienced virologic failure.
Our small sample size and retrospective nature are limitations of this study.
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#2024077
"The Kiss of Death' returns – two case reports of Corynebacterium diphtheriae in the Republic of Ireland"
Principal Presenter: Aileen Conway
Track: Epidemiology & Population Health
Diphtheria, previously known as ‘The Kiss of Death' in the 1800’s, is rarely seen in EU/EEA countries since the introduction of vaccination. WHO data suggests that diphtheria, tetanus toxoid and pertussis (DTP3) uptake rates in Europe range from 85% to 99%. In 2022, 228 cases of imported Corynebacterium diphtheriae were reported throughout Europe, mainly originating from migrant-related facilities, with three fatalities. In the Republic of Ireland DTP3 has been included in the childhood vaccination programme since 1952. Over a period of forty-seven years there were no cases until two cases were seen over 2015 to 2016.
We present two cases of Corynebacterium diphtheriae identified in St. James’ Hospital, Dublin in August 2023. Our aim is to raise awareness amongst clinicians of the increased potential for diphtheria cases, particularly in the population at risk of absent/incomplete vaccination and the need to treat clinically symptomatic cases with anti-toxin while awaiting toxin assay results.
Case one was a 19-year-old East African male from a migrant housing facility who presented to his GP with pharyngitis. His GP clinically diagnosed a pseudomembrane on his pharynx and was immediately suspicious for diphtheria. Corynebacterium diphtheriae was subsequently cultured from his throat swab and he was electively admitted to St. James' Hospital, Dublin. He was treated with anti-toxin while awaiting a result from the toxin PCR assay. Case two was a 38-year-old gentleman originally from Poland who presented to St James’ Hospital with a non-healing skin lesion on his lower limb from which Corynebacterium diphtheriae also cultured. Both patients were subsequently found to have non-toxigenic strains of diphtheria.
These cases prompted a review of internal policies at St. James’ Hospital with regard to the management of cases presenting with suspected diphtheria from a biosafety, clinical and public health point of view. With increasing migration into Ireland and other high income European countries from states with jeopardised vaccination programs we wish to highlight the potential for imported cases into congregated settings with a high risk of transmission in a population with possible suboptimal vaccination.
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#2024076
"Challenges of and opportunities for Carbapenem-sparing Antimicrobial Stewardship(AMS) Interventions in the real world clinical setting (CASC Study): A focus on Meropenem Courses Started Without pre-Authorization"
Principal Presenter: Maria McWalter
Keywords: Anti-microbial stewardship, Clinical audit, Bacterial InfectionsTrack: General Infectious Diseases
Background
Meropenem is a restricted antimicrobial. Pre-authorisation and prospective review of meropenem prescription are undertaken at our institution as standard of care. A multidisciplinary AMS team, which includes infectious diseases specialists, clinic microbiology and hospital pharmacists determine if prescription is appropriate or inappropriate based on clinical scenario, microbiological isolates and local treatment guidelines.
The aim of this study was to review clinical characteristics and indication for meropenem courses prescribed. Where Meropenem prescription was not pre-authorised, we reviewed appropriateness of prescription and acceptance of AMS team recommendations.
Methods
Meropenem prescriptions from the time-period January to December 2022 were retrospectively reviewed in a 1000 bed, tertiary referral university hospital. Patient demographics, clinical indication, microbiological isolates and 30 day mortality was reviewed. The study was approved by the Cork Clinical Research Ethics Committee.
Results
During the study period, 676 meropenem prescriptions were reviewed in 527 patients (mean age 64 years [SD 16.6], 62.6% male). Source of infection was recorded as respiratory in 48%, urinary in 8.6% and intra-abdominal in 6.8%. Meropenem was prescribed as initial choice in 82%(n=552). Prescription was empiric in 62%(n=326). 76.1%(n=512) of patients were under medical specialties.
Meropenem prescription which were not pre-authorised in 78 (11.5%) patients (median age was 76 years (range 31-92), 54% male); most of these patients (75%, n=58) were under the care of medical teams. Documented source of infection was respiratory (46%), urinary (21%), intra-abdominal (10%) and skin/soft tissue (5.1%), with no identified source of infection in 7.7% of patients. Meropenem was prescribed empirically in 73%(n=57) and 42%(n=33) received meropenem as their initial antibiotic. Median duration of treatment was 7 days(range 1-26). Overall 30-day mortality rate was 29%. Multi-drug resistant organisms (including ESBL producers) were found in 23%. Meropenem prescription was determined to be appropriate in 38%(n=30), inappropriate in 46%(n=36) and unknown in 15%(n=12). A recommendation to stop or de-escalate antibiotics was made in 41(53%). Acceptance of recommendation to stop or de-escalate occurred in 28 of the 41 patients (68%).
Conclusions:
Most cases of non authorised meropenem prescription were inappropriate. Acceptance of recommendations to stop or de-escalate antibiotics was low. Further research will focus on factors influencing acceptance of AMS interventions.
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#2024075
"An Audit of Documentation of Influenza Vaccine Receipt in the Outpatient Department of Genitourinary Medicine and Infectious Diseases in St. James’s Hospital during the 2023/2024 Influenza Season"
Principal Presenter: Stefania Stroiescu
Keywords: influenza, vaccination, auditTrack: General Infectious Diseases
Background:
There are approximately 4000 outpatient visits to the GUIDe department in St James’s Hospital from October to March each year for treatment of HIV and viral hepatitis infection. Annual influenza vaccination is recommended by the National Immunization Advisory Committee for attendees of these clinics given increased risk of morbidity and mortality among this cohort.
Methods:
This was a retrospective audit of documented rates of influenza vaccine receipt during the 2023/2024 influenza season. Vaccination status of each patient was recorded in the electronic patient record at each clinic visit between October 2nd and March 22nd. Data was collected and analysed in an Excel spreadsheet. Results were compared between clinics and with previous influenza seasons.
Results:
Out of 3948 total clinic visits, 60% of visits (n=2394) resulted in documentation of influenza vaccine receipt in our clinic, at a previous clinic or elsewhere. Vaccination was recorded as declined at 11% of visits (n=423) or was not recorded as offered at 20% of visits (n=869). November had the highest record of vaccine receipt (65% of visits), with a steady decline in documentation over the following months (57% of visits in March).
In comparison to previous years, there was a gradual decrease in documentation of vaccine receipt since the 2018/2019 season, when over 81% of patient visits (n=3327) had vaccine receipt recorded. Furthermore, vaccines are increasingly being recorded as declined since the 2018/2019 season (4% of visits, n=155). Our data also demonstrates that more patients are receiving their influenza vaccine elsewhere (16% of visits in 2023/2024 vs 9% in 2018/2019).
Conclusion:
Despite weekly reminders to providers of vaccine referral rates at each clinic, there was a gradual decline in documented referrals since the 2018/2019 influenza season. Our data relies on accurate recording of vaccine receipt, which can vary among providers. Moreover, the documented rate of declined vaccines may reflect increasing number of patients from countries with higher rates of historic vaccine hesitancy. Our results also highlight increased alternate options for patients to access vaccines.
The above issues could be addressed through patient engagement and education, surveys to determine barriers to vaccination, reminders to providers to refer for vaccination and pop-up notifications on a patient’s record to document influenza vaccine receipt. Continued surveillance of vaccination rates will allow us to capture trends and identify methods to increase vaccination.
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#2024074
"An Audit of CD4+ T cell Monitoring in People Living with HIV attending the Mater Misericordiae University Hospital's Infectious Diseases Clinic"
Principal Presenter: Aoife Heeney
Track: Virology
Background
Studies have shown that People living with HIV (PWH) on suppressive antiretroviral therapy with good CD4+ T cell recovery do not benefit from frequent CD4+ T cell monitoring. International HIV management guidelines incorporate recommendations reflecting this with the European AIDS Clinical Society (EACS) advising annual CD4+ T cell monitoring if HIV viral load is undetectable and CD4+ count is >350 cells/uL, while the British HIV association (BHIVA) recommends that no further CD4+ T cell monitoring is required, if virally suppressed and CD4+ count is >350 cells/uL on two occasions >1 year apart. We aim to assess adherence of the Mater Misericordiae University Hospital (MMUH) Infectious Diseases Clinic with these established guidelines.
Methods
We carried out a retrospective review of PWH attending the MMUH Infectious Diseases Clinic over 7 consecutive clinics. Patient demographics and laboratory data were described and adherence to guidelines reviewed.
Results
132 PWH attended over a 2 week period with 97 engaged in care for 1 year or more. 62 patients were virally suppressed for at least 6 months prior to clinic visit and had a CD4+ count >350 cells/uL. Of these 62 patients 39 (63%) were male and the median age was 45 years (IQR 36-54).
CD4+ T cell monitoring was carried out a median of 3 times per patient over the preceding year. 59 (95%) individuals had CD4+ count checked twice or more despite being virally suppressed with CD4+ count >350 cells/ml. An excess of 113 tests were performed, according to EACS criteria.
56 patients were virally suppressed with CD4+ count of >350 cells/uL on two occasions at least one year apart, fulfilling BHIVA criteria for no further monitoring. However despite this 54 (96%) of these individuals had CD4+ T cell monitoring carried out twice or more over the preceding year with a total of 156 tests performed.
A T cell panel costs €35 in MMUH, therefore adherence to EACS guidelines would result in a cost-saving of €3955 in this group. Adherence to BHIVA guidelines would result in a cost-saving of €5460.
Conclusion
We observed excessive CD4+ T cell monitoring in our clinic according to international guidelines. Adherence to these guidelines would result in significant cost-saving benefits and reduce unnecessary testing.
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#2024073
"Quality Improvement Intervention to Accelerate Diagnosis of Congenital Syphilis"
Principal Presenter: Victoria Wilson
Keywords: Congenital syphilis, Paediatric Infectious Disease, Quality Improvement InterventionTrack: General Infectious Diseases
Background
Congenital syphilis can produce a range of clinical presentations and may be difficult to diagnose. Antenatally, syphilis screening is normally carried out at 12-weeks gestation. Testing is only repeated if subsequent risk factors are identified. Recently, syphilis cases have increased in the United Kingdom (UK) and in 2022 were at their highest level since 1948. Although a rare occurrence, a case of congenital syphilis in Northern Ireland (NI) was diagnosed in a patient aged 20 months. This case triggered a review of existing practice and prompted this quality improvement intervention.
This child was admitted unwell at 4 months with significant hepatosplenomegaly, anaemia and unremitting napkin dermatitis. This prompted HIV and toxoplasmosis testing, but syphilis was not considered as antenatal screening had been negative. The child improved after 6 days of Ceftriaxone. The diagnosis was only reached at 20 months of age after the child’s mother tested positive in a subsequent pregnancy.
Methods
The case was assessed locally at a Multidisciplinary Team (MDT) meeting and nationally by the Integrated Screening Outcomes Surveillance Service (ISOSS) Clinical Expert Review Panel (CERP). This panel included public health, virology, antenatal screening co-ordinators, and paediatrics. Opportunities were explored to facilitate earlier diagnosis and prevention of congenital syphilis. Current NI and UK practices were also compared to guidelines and best practice in different areas to explore the feasibility of expanding the provision of syphilis testing.
Results
The CERP felt that this case was not unique and suggested that we look at the possibility of testing for both syphilis and HIV when HIV is requested. Links were made with a HSC trust in England already doing this and a local MDT meeting was convened to discuss costs and feasibility. It has been agreed that in future when HIV testing is requested for infants, syphilis testing will be carried out automatically. Additionally, as per current UK Health Security Agency (UKHSA) guidelines, antenatal patients with a rash will also be tested for syphilis.
Conclusion
Case review showed that, while the current diagnostic protocol had been followed, there was a delay in diagnosis. To improve surveillance for congenital syphilis, HIV and syphilis tests will be performed together on unwell infants in NI. Additionally, antenatal patients presenting with a rash will be tested for syphilis as per updated UKHSA guidance. The implementation of these measures will help to ensure more timely diagnosis and treatment of congenital syphilis in NI. -
#2024072
"Assessment of Outpatient Parenteral Antimicrobial Therapy (OPAT) at UHL and Primary Contributors to its Ineffectiveness"
Principal Presenter: Alvina Zanib
Keywords: Alvina Zanib, OPAT, UHLTrack: General Infectious Diseases
Introduction:
Outpatient Parenteral Antibiotic Therapy (OPAT) has consistently proven to be a highly effective treatment for combating life-threatening infections and reducing hospital-related expenses. However, regrettably, OPAT failures are not uncommon and can be attributed to various factors. This audit was designed to identify factors contributing to OPAT failures.
Methods:
The data was gathered from OPAT patients registered with the Infectious Diseases Department at University Hospital Limerick spanning from January 2023 to December 2023. Analysis of the data was conducted using SPSS software.
Results:
Between January 2023 and December 2023, a total of 143patients were enrolled in OPAT with mean age of 64 +SD 17 years. The majority, 88%, of cases were referred from within the hospital, while 12% were referred from external sources. Surgical referrals accounted for 68% of cases, with medical referrals making up the remaining 32%. In terms of infections, 67% were related to bone and joint infections, while 33% were cases involving soft tissue infections. Gram-positive cocci, including streptococci and staphylococci, as well as enterococci, were isolated in 43% of cases. Gram-negative bacteria such as E. coli, Pseudomonas, and Klebsiella were found in 22% of cases. Mixed growth was observed in 6% of cases, fungal growth in 1%, and no growth in 28% of cases.Resistant bacteria, including MRSA, VRE, and ESBL-producing organisms, were detected in 16% of cases. The antibiotics used included flucloxacillin in 27% of cases, daptomycin in 26%, piperacillin-tazobactam in 20%, cephalosporins in 13%, ertapenem in 13%, gentamicin in 1%, and combination antibiotics in 6% of cases. The success rate of OPAT was 88%, with a failure rate of 12%. Reasons for failure included antibiotic side effects in 44% of cases, readmission due to other medical conditions in 31%, and readmission related to surgery as antibiotic treatment was not sufficient in 25% of cases. Among antibiotic side effects, 85% of failures were attributed to side effects associated with daptomycin while 15% were secondary to tazocin.
Conclusion:
In conclusion, this audit has helped us understand the many reasons why OPAT sometimes doesn't work well, even though it's usually successful in treating infections and saving money for the hospital by enabling patient to get treatment at home.By addressing these challenges, we can optimize the delivery of OPAT services and further improve patient care at University Hospital Limerick.
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#2024071
"A case report: Fusobacterium necrophorum causing Liver Abscesses in a Healthy Teenager."
Principal Presenter: Louise O'Halloran
Keywords: Fusobacterium Necrophorum, Liver Abscess, PaediatricsTrack: General Infectious Diseases
A case report: Fusobacterium necrophorum causing Liver Abscesses in a Healthy Teenager.
Background: Fucibacterium necrophorum is an obligate anaerobic, gram-negative bacillus. Infections due to Fucibacterium necrophorum primarily affect the head and neck in the pediatric population, including lemierre’s syndrome. Fusobacterium necrophorum causing liver abscesses is a rare disease and only a few cases have been reported.
Case report:
A 14 yo boy, previously fit and healthy, presented with acute onset severe abdominal pain and rigors. He had a recent diagnosis of infectious mononucleosis but otherwise had no prior medical history. Computed tomography of his abdomen demonstrated a large hepatic abscess. His blood culture subsequently grew Fusibacterium necrophorum within 24 hours. He proceeded for IR drainage of the abscess. After initial improvement following drainage, he deteriorated again with increasing inflammatory markers, worsening pain and ongoing temperatures. Due to his clinical deterioration his care was escalated to the local intensive care unit. Further imaging revealed two drainable hepatic collections and he underwent repeat IR drainage. 16S RNA from the abscess was also positive for F. Necrophorum. After prolonged anti-microbial therapy he achieved complete remission and remains well. An immune work up on this athletic teenager including oxidative burst test for Chronic Granulomatous Disease showed no abnormalities.
Conclusion: Liver abscesses are a rare presentation in the paediatric population. Fusobacterium necrophorum infection is also rare in paediatrics. It is a virulent and invasive bacteria that can cause significant morbidity in an immunocompetent host.
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#2024070
"Title: Voices Heard: Enhancing OPAT Care through Patient Feedback""
Principal Presenter: Aarti Gupta Sarmad Waqas
Track: General Infectious Diseases
Title: Voices Heard: Enhancing OPAT Care through Patient Feedback"
Background: A follow-up patient satisfaction survey (PSS) was conducted to identify areas of improvement in the OPAT service of our institution after the initial survey that targeted the period from September 9th, 2022, until March 31st, 2023. This recent second survey covered the patients on OPAT service from April 2023 to February 2024.
Methods: A questionnaire consisting of fifteen questions was used to gather the patients’ feedback. It gathered anonymous demographic information and looked at the patients’ experiences, communication and OPAT clinical waste management. The survey was commenced after approval from the Quality Improvement (QI) department.
Findings: A total of 93 patients were managed on OPAT during the surveyed period, with 67 respondents (72.04%) completing the questionnaire. Other patients were either unreachable or preoccupied with other commitments, one patient had passed away by the time of the survey. When asked about adverse effects, 74.6% of respondents (n = 50) reported none, while 25.3% (n = 17) reported experiencing symptoms such as vomiting, nausea, and indigestion. No significant adverse medication reactions were reported. A 100% satisfactory response rate was achieved in areas concerning communication, satisfaction with the OPAT clinic visit, and willingness to recommend the OPAT service to themselves or others in the future. However, 41.7% of respondents (n = 28) identified delayed clinical waste collection as an area requiring improvement. Additionally, the concept of home treatment was relatively novel for 97.01% of patients (n = 65), who expressed satisfaction with receiving treatment in this setting.
A previous survey highlighted that 43.3% (n = 16) of people had problems with clinical waste collection. The matter was reported to the relevant authorities, and steps were taken to improve the identified area. The findings of this survey align with those of the previous survey, indicating that improvement is needed in clinical waste management pathways.
Conclusion: In general, patients appeared content with the OPAT service provided; however, the survey results highlighted the ongoing need to improve clinical waste management collection pathways. Results of the survey have been relayed to the relevant stake holders so as to improve the areas requiring improvement.
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#2024069
"An Audit of Did-Not-Attends (DNAs) in an Infectious Disease Outpatient Service of a Tertiary Level Hospital in Ireland"
Principal Presenter: Kei Yen (Ginny) Chan
Keywords: DNA, Clinic, OutpatientTrack: General Infectious Diseases
BACKGROUND: HIV and Hepatitis B are chronic diseases requiring active surveillance. Patients who Did-Not-Attend (DNA) their follow-up clinic appointment are potentially at higher risk of poorer healthcare outcomes. Non-attendance is a nationwide occurrence. The HSE has previously published a key performance indicator target for outpatient services, to have a DNA rate of < 10%. The aim of this audit is to measure the rate of DNAs in a tertiary infectious disease outpatient clinic, and to investigate the reasons of non-attendance. We hypothesise that external influences such as distance to clinic and extreme weather events may have an impact on DNA rates.
METHODS: A retrospective audit was conducted using data of patients attending the HIV and Hepatitis B clinic in Cork University Hospital between January 2021 to January 2022. A total of 2986 patient visits were assessed. Details of clinic appointments and patient demographics were extracted from computerised medical record system. Weather information on temperature range, rainfall and weather alerts were retrieved from the Irish Meteorological Service database. Comorbidities were assessed from patient electronic letters. The primary outcome measured was the rate of non-attendance. We further examined the association between age and clinic attendance with a logistic regression model.
RESULTS: 623 of 2986 scheduled visits (21%) were missed and classified as DNA. Of the 396 patients who DNA, 38% failed to attend more than once in the year. 6% were first-visits, and 94% were return visits. The median age was 40 years old, with 54.5% of patients in the 31 to 45 age group, and 59.6% males. Patient’s distance from clinic and weather alerts did not appear to have a negative impact on DNA. A logistic regression analysis revealed age was a significant predictor of clinic attendance (p < 0.0001), and gender was not a significant predictor of attendance (p=0.652).
CONCLUSION: There was a high non-attendance rate of 21% in our HIV and Hepatitis B clinic. Non-attendance was found to be more frequent in those with follow-up visits, younger age group and male gender. Distance did not appear to have an impact as a predominance (55%) of those who DNA were within 30 kilometres from the clinic. Logistic regression analysis suggests a significant positive association between age and the probability of clinic attendance, independent of gender. Further interventions could target certain group of patients to optimise attendance rate. -
#2024068
"HIV Testing in the West of Ireland – A Survey Assessing Opportunities and Barriers in General Practice"
Principal Presenter: Bearach Reynolds
Keywords: HIV, Primary Care, Public healthTrack: General Infectious Diseases
Background
2022 saw the largest number of HIV cases diagnosed in Ireland on record with a 122% increase on the previous year. Late-stage diagnosis and difficulties accessing HIV testing services are more commonly experienced among people who live outside of Dublin. The aim of this survey was to assess the barriers and facilitators to testing in general practice in the west of Ireland. A similar survey was carried out in 2013, with the comparison of results forming a 10-year narrative on HIV testing in primary care in the west of Ireland.
Methods
A postal survey was sent to general practitioners (GPs) working in the west of Ireland. The survey was designed to capture attitudes, familiarity, barriers, and facilitators to HIV testing in this region.
Results
The 2023 survey received a 21.4% response rate, with 136 responses. This compared to a 47.9% response rate in 2013.
In 2023, GPs working in urban settings were significantly more likely to have performed a HIV test because of patient requests and symptoms of HIV compared to rural GPs. GPs who use guidelines were more likely to have sent a HIV test on a patient based on migration from higher incidence countries compared to those who do not use guidelines.
Seven key themes were identified from thematic analysis of qualitative results in the 2023 survey. GPs frequently cited cost and patient offense as barriers to testing. Many reported a desire for national guidelines and targets.
In 2013, 56% of GPs reported having a patient registered with their practice living with HIV compared with 79.41% in 2023. In 2013 it was established that GPs working in urban settings were significantly more likely to test for HIV than their rural or mixed setting colleagues. In 2023, there was no significant difference between the groups having tested a patient for HIV. A minority of GPs believed every patient should be tested at least once for HIV in both surveys. 61.9% of GPs did not support the view in 2013, while 75.74% did not support the view in 2023.
Conclusion
GPs report a positive attitude to HIV testing but have concerns regarding undertesting and significant work pressures in General Practice. There did not appear to be support for universal testing in this population. National guidelines would be welcomed by GPs but if any increased testing policies were to be implemented through General Practice, they would need to be fully resourced.
ORAL PRESENTATIONPDF (615.86 KB) -
#2024067
"Audit of HIV-post exposure prophylaxis at the Mater Misericordiae University Hospital, Dublin, in 2022"
Principal Presenter: Sarah Pearce
Keywords: HIV, PEP, PrEPTrack: General Infectious Diseases
Background
HIV post-exposure prophylaxis (PEP) is the provision of antiretroviral therapy to prevent infection following potential exposure. This audit aims to identify whether PEP prescribing at the Mater Hospital (MMUH) is in line with national guidelines (Emergency Medicine Ireland (EMI) 2018).
Methods
All patients dispensed PEP during 2022 were identified from ID pharmacy records. Data was collected from electronic health records. Data was analysed in Microsoft Excel, and presented as n (%) and median (IQR) unless otherwise stated. The audit was approved by the clinical audit committee MMUH.
Results
203 patients were dispensed PEP; 163 (80.3%) with sufficient data for analysis. 108 (66.3%) were male, aged 32 (28-38) years. Referral was primarily via the emergency department (n=136, 83%) and the Sexual Assault and Trauma Unit (n=9, 6%). Patients mostly presented within 48 hours (n=113, 69%) or 48-72 hours (n=26, 16%). Exposures were sexual (n=91, 56%), needlestick injury (n=54, 33%), bite (n=8, 5%), and splash (n=4, 2%). At initial presentation, HIV and Hepatitis B screening was performed in 148 (91%) and 132 (81%) of patients; hepatitis B testing was lower in SATU than ED referrals (33% vs 88%). Of sexual exposures, 9 (9%) received an STI screen. Tenofovir disoproxil/Emtricitabine (TDF/FTC) with Raltegravir was the predominant regimen (n=139, 85%), 1 patient (1%) received TDF/FTC with Dolutegravir. Other prophylaxes included hepatitis B vaccine (n=57, 35%), tetanus vaccine (n=25, 15%), post-bite antibiotics (n=7, 4%), and emergency contraception (n=6, 7%). No patients seroconverted to HIV. Thirteen (8%) were referred for pre-exposure prophylaxis (PrEP). Compared with guidelines, PEP prescribing was recommended in 23% of cases (n=37), considered in 11% (n=18), and not recommended in 20% (n=33). Of those not recommended PEP, 3 (9%) completed the course, 2 (6%) self-discontinued, 2 (6%) completed against advice, and there was insufficient data on the remainder.
Conclusion
PEP is primarily prescribed to young males in ED, following sexual exposures, which may highlight the need for more PrEP services. Baseline testing of HIV and hepatitis B was reasonable (91 and 81% respectively), while STI testing was low (9%).
20% were dispensed PEP against guideline recommendation; there was insufficient follow-up data to determine the proportion of these discontinued at ID clinic. -
#2024066
"Impact of Implementation of Nurse-Led Services on EACS Guideline Compliance for the Management of People Living with HIV in an Irish Tertiary Care Hospital"
Principal Presenter: Matthew Hunter
Keywords: Nurse, HIV, EACSTrack: General Infectious Diseases
· Background
Preventative healthcare and screening programmes are crucial for care of people living with HIV (PLWH). This patient population is at higher risk of infectious and non-communicable diseases. An audit was conducted in St. Vincent’s University Hospital (SVUH) in 2019 aiming to investigate clinical compliance with European AIDS Clinical Society (EACS) guidelines for the management of PLWH. Audit results indicated the need for improvements in the provision of vaccinations and cervical smears to patients attending the service, leading to the creation of dedicated nursing staff positions for these procedures.
· Methods
A re-audit of the outpatient PLWH service was undertaken in 2023. Chart review of 250 patients occurred over 3 months reviewing 55 datapoints. Data was collected following EACS guidelines v11.1, including demographic information (age, gender, sexual orientation), comprehensive health metrics (medical history, medications, BMI, cholesterol, haematology, and biochemistry), and HIV-specific metrics (CD4+ count, viral load). Amongst this information was a review of patient immunisation against preventable diseases listed by EACS as high priority, and a record of cervical smears conducted via national screening programmes or by hospital staff.
Vaccination status recorded for pneumococcus (Prevnar/pneumovax), human papilloma virus (HPV), influenza, hepatitis viruses (HAV/HBV), measles, mumps, and rubella (MMR). Immune status recorded as equivalent to vaccination for MMR, HAV, and HBV, where recorded and positive.
Cervical smear status recorded as conducted, not conducted, or not applicable. Inclusion criteria was female patients over 21 years old.
Descriptive statistics were used to compare datasets from 2019 and 2023.
· Results
2019: 50 outpatients audited, age 25-86 (52% >50 years), all 15 female patients included for cervical smear (30%)
2023: 250 outpatients audited, age 18-90 (24.4% >50 years), all 76 female patients included for cervical smear (30.4%)
All patients had a documented viral load and CD4 count, and all except one received ART (elite controller). All patients were included in vaccination metrics.
Change in Procedure Uptake 2019-2023:
o Prevnar and Pneumovax: +18.2%
o HPV: +42.8%
o Influenza: -15.2% (attributed to patient refusal and/or GP provision)
o MMR: +71.2%
o HAV and HBV: +21.0%
o Cervical Smear: +44.5%
· Conclusion
This data reveals substantial improvement in vaccine and cervical smear uptake since the introduction of dedicated nursing staff. It shows the efficacy of nurse-led services in providing high-volume procedural care that may be unfeasible for other healthcare practitioners.
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#2024065
"The use of dalbavancin in place of inpatient or outpatient intravenous antimicrobial therapy in a socially vulnerable patient group"
Principal Presenter: Tina Gillespie
Track: Diversity & Inclusion
Background
Dalbavancin is a long-acting lipoglycopeptide antibiotic with a spectrum of cover across gram positive cocci commonly implicated in skin and soft tissue infections (SSTIs), including MRSA (Dunne et al., 2016). It is an attractive alternative to prolonged inpatient courses of intravenous antibiotics for infections including osteomyelitis, endovascular infections and blood stream infections (BSIs) in socially vulnerable patients who would not be candidates for Outpatient Antimicrobial Therapy (OPAT) (Bork et al, 2019).
Methods
Pre-approval from hospital management was sought for fifteen dalbavancin treatment courses for people experiencing homelessness, people who inject drugs, prisoners, international protection applicants, or otherwise socially vulnerable patients requiring prolonged antibiotics for SSTIs, bone and joint infections and BSIs. The clinical outcomes for these patients, types of infections treated, discharge destinations, pre-dalbavancin antibiotics received, approximate number of bed days saved and cost savings were evaluated. The bed days saved were determined based on current Infectious Diseases Society of America and Sanford guidelines for the respective infections.
Results
Fifteen patients within the Inclusion Health patient cohort in MMUH received dalbavancin in 2023, fourteen patients were considered cured with a treatment success rate of 93%. Seven patients were treated for complicated bacteraemias and endovascular infections, four patients for bone and joint infections and four patients for skin and soft tissue infections. The most frequently encountered pathogens were methicillin-sensitive staphylococcus aureus and polymicrobial infections. Up to 205 bed days were saved through the intervention, with an approximate cost saving of €182,450. Eleven patients avoided PICC line insertions, which cost €570 per procedure in MMUH. Median bed days saved for bone and joint infections was 18 days, 4.5 days for SSTIs and 14 days for complicated bacteraemias and endovascular infections. The cost of the drug for the fifteen patients was €49,770.
Conclusion
Dalbavancin offers an effective treatment alternative for SSTIs, bone and joint infections and BSIs with amenable underlying pathogens in socially vulnerable patients. There was a high treatment success rate and 100% attendance at follow up appointments for subsequent doses. Substantial cost savings were made through reduced length of stay and PICC avoidance. The most significant bed day savings were in patients with bone and joint infections, followed by complicated bacteraemias and endovascular infections. The success of this small pilot cohort supports increased use of dalbavancin in socially vulnerable patients and will guide future care delivery in the Inclusion Health service in MMUH.
References:
Bork JT, Heil EL, Berry S, Lopes E, Davé R, Gilliam BL, Amoroso A. Dalbavancin Use in Vulnerable Patients Receiving Outpatient Parenteral Antibiotic Therapy for Invasive Gram-Positive Infections. Infect Dis Ther. 2019 Jun;8(2):171-184. doi: 10.1007/s40121-019-0247-0. Epub 2019 May 3. PMID: 31054088; PMCID: PMC6522607.
Dunne MW, Puttagunta S, Giordano P, Krievins D, Zelasky M, Baldassarre J. A Randomizd Clinical Trial of Single-Dose Versus Weekly Dalbavancin for Treatment of Acute Bacterial Skin and Skin Structure Infection. Clin Infect Dis. 2016 Mar 1;62(5):545-51. doi: 10.1093/cid/civ982. Epub 2015 Nov 26. PMID: 26611777; PMCID: PMC4741365.
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#2024064
"Screening Practices, Prevalence, and Treatment Patterns for Osteoporosis in Patients Living with HIV: Results from Ireland's Largest HIV Clinic"
Principal Presenter: Seán Donohue
Track: Virology
Background
As a result of improved survival and life expectancy, osteoporosis is becoming more common among people living with HIV (PLWH). HIV is a well described risk factor for osteoporosis (1) and in this population, densitometry (DXA) is recommended by EACS in postmenopausal women and men aged ≥50 (2). In this study we explore the screening, prevalence and treatment patterns for osteoporosis in PLWH aged ≥50 years.
Methods
This was a retrospective review of PLWH ≥50 years attending the HIV clinic in St James's Hospital. We examined the proportion of patients referred for bone health evaluation with DXA performed, as well as the prevalence of osteoporosis based on the lowest T-score recorded at the lumbar spine, neck of femur or total hip. We examined the relationship between osteoporosis and age using ANOVA in males and females.
Results
Of 3156 patients attending the clinic, 978 were ≥50 and included. The mean age was 56.9 ± 6.0 years and 74.1% were male. 94.6% were referred for DXA, which was completed in 80.5% of the total cohort. Based on DXA, 20.0% of females and 11.3% of males had osteoporosis, while 33% of females had osteopenia compared to 40.5% of males. Of those with osteoporosis, 57.5% were on pharmacological treatment for osteoporosis. Osteoporosis was significantly associated with older age in women (p<0.001), but not in men (p=0.751).
Conclusion
There was a high level of screening for osteoporosis with DXA. 20% of female and 11.3% of male PLWH had osteoporosis by DXA criteria, substantially more prevalent than that reported in the general population. A significant relationship with older age and osteoporosis was found in females but not males. Similar to the general population, there is a significant treatment gap with over a third of PLWH with osteoporosis untreated (3). As a result of this audit, we have developed a treatment and referral algorithm in conjunction with our colleagues in the St James's Bone Health Clinic.References
1. Borderi M, Gibellini D, et al. Metabolic bone disease in HIV infection. AIDS. 2009 Jul 17;23(11):1297-310
2. European AIDS Clinical Society (EACS): Guidelines Version 12.0 (2023)
3. Kanis JA, Norton N, et al. SCOPE 2021: a new scorecard for osteoporosis in Europe. Arch Osteoporos. 2021 Jun 2;16(1):82
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#2024063
"“A Good Start Is Half the Battle”- Review of a Community Acquired Measles Breakthrough Case"
Principal Presenter: Elizabeth O'Donoghue
Track: Virology
Background
Measles is an acute highly infectious viral disease typically causing fever and rash that spreads rapidly among non-immune individuals. MMR (Measles, Mumps, Rubella) vaccine was introduced to the Irish childhood immunisation schedule in 1988. MMR uptake in Ireland is suboptimal and less than the 95% target set by the WHO. Nationally, uptake has declined to below 90% since the beginning of the COVID-19 pandemic. In March 2024 Ireland launched a MMR Vaccine Catch-up programme amid the growing number of measles cases across Europe.
Breakthrough infection is defined as a case of an illness in an individual who previously developed immunity, through vaccination or natural infection.
Methods
Confirmed measles in a 26 year-old Romanian male was notified to the Department of Public Health Dublin and North East in March 2024. The case presented acutely to an out-of-hours GP service with a two day history of cough and malaise, and a one day history of fever and maculopapular rash. The case required hospitalisation and treatment for pneumonia. Oral fluid analysis detected measles RNA and a weak positive measles-specific IgM. The case had documented evidence of vaccination, no recent history of travel to measles-affected areas and no known contact with suspected/confirmed cases.
Results:
Three exposed close contacts were age-appropriately vaccinated and remained well; none had a history of travel.
Subsequent sequence analysis indicated a link to Romanian measles virus strains, suggesting a separate importation event involving an unknown source, with further investigation revealing a potential source (religious congregation) during the incubation period, albeit no explicit reports of compatible illness could be ascribed. Measles serology showed a weak positive IgG & a positive anti-IgM.
In both the primary care and hospital settings, prompt recognition and activation of pathways for the management of highly suspect cases occurred - case isolated immediately; no patient contacts generated; appropriate IPC and PPE protocols instigated.
Discussion:
This scenario highlights the positive impact and value of increased awareness of measles amongst all sectors of the healthcare system and provides an exemplar for best practice in mitigating the risk of viral transmission.
Investigation of this case proved challenging due to a language barrier. It demonstrated the importance of availability of reliable and timely translation services and re-interviewing cases to obtain further epidemiological data.
Appropriately-timed serological analysis allowed for the characterisation of this case a breakthrough measles infection.
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#2024062
"LineLight: Epidemiology and Management of Tunnelled Central Venous Catheter-related Infections in a Haemodialysis Unit at a Tertiary Hospital: A Three-year Observational Study."
Principal Presenter: Caoimhe Ryan
Keywords: line infection, haemodialysisTrack: General Infectious Diseases
Background:
Tunnelled Central Venous Catheter (tCVC) related infections and bacteraemia are significant nosocomial infections that contribute to patient morbidity, mortality, prolonged hospital stay and healthcare-related costs. Understanding the nature of these infections, including causative pathogens and management strategies, is crucial for optimising patient care. This observational study aims to provide a detailed analysis of tCVC infections within the haemodialysis unit of a tertiary hospital.
Methods:
A retrospective review was performed including all patients with tCVCs at a haemodialysis unit in a tertiary hospital in Dublin from January 2022 – March 2024. Data was collected from a local prospective database, clinical documentation, electronic patient records and the hospital’s radiology database. Statistical analysis was performed to identify tCVC infections and analyse infection characteristics(nature, severity, complications, pathogen distribution), and management approaches.
Results:
During the study period, 40 tCVCs were inserted, 64 were removed/exchanged, and 9 were adjusted/reviewed. Notably, 34 catheter-related infections were identified with 67.65(n=23) classified as new infections and 32%(n=11) as recurrent. 52.94%(n=18) of infections were exit site/tunnel infections, while suspected infections, bloodstream infections, and metastatic infections accounted for 20.59%(n=7), 20.59%(n=7) and 5.88(n=2) respectively. To treat infection, catheter removal/exchange was performed in 41.18%(n=14) of all infective cases, primarily through line exchange(20.59%, n=7). Line removal/exchange occurred in 27.77%(n=5), 71.42%(n=5), 100%(n=2) and 100%(n=2) of exit site/tunnel, bloodstream, suspected, and metastatic infections respectively. In 58.82%(n=20) of infections (majority exit site/tunnel infections), the tCVC remained in situ and the infection was treated primarily with antibiotics. Ten infections resulted in inpatient admissions with average LOS of 22 days. Methicillin-sensitive Staphylococcus aureus (20.59%, n=7) and Staphylococcus epidermis (20.59%, n=7) were the most common cultured pathogens. Other organisms included MRSA, Proteus Mirabilis, Pantoea agglomerans and Diphtheroids.
Conclusion:
This study contributes valuable data on the incidence, nature and management of tCVC infections to the existing literature. It suggests areas where practice can be improved and emphasises that efforts to minimize the protracted use of tCVCs for haemodialysis are warranted due to observed infection rates. Promoting arteriovenous fistulas as optimal access for hemodialysis could help mitigate these complications and improve patient outcomes.
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#2024061
"Beaumont Hospital’s experience in accepting kidney donations from donors considered at high risk of blood-borne viruses."
Principal Presenter: Peter Conlon
Keywords: Transplant Infectious Disease, Virology, NephrologyTrack: Virology
Background
In Ireland, over 2,000 patients are living with end-stage kidney disease (ESKD) and on haemodialysis (HD). This number is increasing on an annual basis. By the end of 2023, 535 individuals were waiting for a kidney transplant. By comparison, there were 189 kidney transplants performed nationally.
The practice of accepting kidney donations from donors who have a blood-borne virus (BBV), including hepatitis B, hepatitis C or HIV, is well-described internationally.
In 2023 Beaumont Hospital adopted a policy of considering kidney donation from deceased donors who either had hepatitis B or C, or who were considered ‘high risk of a blood-borne virus’.
Methods
In 2023 the Beaumont Hospital Renal Transplant Department and Infectious Disease Department collaborated to draft a protocol to facilitate kidney donation from deceased persons who were considered to be ‘high risk of having a blood-borne virus’ or who had positive serology for Hepatitis B or C. This included those with evidence of active infection or previous infection.
Results
To date, 8 kidneys have been donated by 4 deceased donors. This includes two donors who had serological evidence of previous hepatitis C, 1 donor who had serological evidence of previous hepatitis B, and one donor who had active hepatitis B.
The recipients of these kidneys are followed closely with regular blood-borne virus screening. Those who received a kidney from a patient with active hepatitis B were started on entecavir post-op.
Thus far there has been no evidence of donor-derived BBV infection.
Discussion
8 persons have received a renal transplant from a donor who previously would not have been considered a candidate for donation. This is a direct result of in close collaboration of the Renal Transplant service and the Infectious Disease department. One of the major benefits of receiving a kidney from this model is that the kidney tends to be from a younger individual and as a result lasts a lot longer.
With further planning, the number of kidneys accepted from donors is likely to rise as a result of the involvement of the Infectious Disease team.
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#2024060
"Deep Brain Stimulator Related Infections: A Case Series"
Principal Presenter: Nadra Nurdin
Track: General Infectious Diseases
Deep brain stimulators (DBS) have been approved for treatment of movement disorders such as Parkinson’s Disease, dystonia and essential tremor since the 1990s, with their use becoming increasingly more widespread. It involves the surgical placement of electrodes adjacent to deep structures within the brain, with connection to a pulse generator which is implanted subcutaneously within the chest wall. Infection is a recognised complication of DBS, the literature reports variable rates from 2-10%. Management has traditionally been with systemic antibiotics, debridement and explanting of devices if possible.
Methods:
We retrospectively reviewed all cases of patients who attended MMUH Infectious Diseases clinic for management of deep brain stimulator related infections.
Results:
Of 100 patients with DBS inserted at MMUH, 5 patients were treated for related infections; one female, four male with a mean age of 68 (range 62 - 72). Three patients presented with signs infection within 2 weeks of implantation, two presented 2 months post implantation. All five patients presented with localising symptoms of infection with a non-healing wound, erythema and discharge. One patient presented with systemic symptoms and an elevated CRP (206mg/L).
Four of the patients’ wounds cultured methicillin sensitive Staphylococcus aureus (MSSA), one patients wound cultured Serratia marcescens. One patient, who developed a late relapse of infection with an intracranial collection, initially grew MSSA and subsequently isolated Klebsiella oxytoca from later intra-operative samples. Three of the five patients were treated with IV antibiotics initially, with two patients treated with oral antibiotics. One patient treated with oral antibiotics required IV treatment subsequently.
Three patients went on to have surgery, with one having a wound debridement, one a battery site washout with re-siting of the battery, and one having a cranial lead removed with pulse generator re-siting. Of these three, two went on to have their device removed, one due to persistence of wound symptoms, the other due to development of an intracranial collection causing seizures. These two patients who have had their devices removed are now off antibiotics. The other three retained the DBS devices and remain on suppressive antibiotics, two with doxycycline, one with co-trimoxazole.
Conclusions:
This retrospective review highlights the variability in presentation and treatment approaches with DBS infections. Patients who had retention of their device required suppressive therapy, with cure only achieved with device removal. Further research is needed to guide optimal management strategies and whether there is benefit to early use of intravenous antibiotic therapy.
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#2024059
"Management of HIV and Chronic Hepatitis B Co-infection in Beaumont Hospital 2018-2023"
Principal Presenter: Tess Coyne
Track: Virology
Background
Owing to common methods of transmission and reduced rates of clearance in people living with human immunodeficiency virus (HIV) (PLWH), rates of chronic infection with hepatitis B virus (HBV) are higher amongst PLWH compared with the general population, and alteration to provision of routine HIV care is required. We aim to audit outpatient assessment and management of patients living with HIV/HBV co-infection in Beaumont Hospital.
Methods
A database of co-infected patients has been maintained by ID clinical nurse specialists since 2018. An excel data collection tool was developed to collect clinical and virological data points from electronic medical records. Data collected is recorded as n (%) or median (IQR) unless otherwise stated.
Results
52 patients were identified by service providers, 38 (73.1%) had sufficient electronic health record data available. 10 (26.3%) were female, age 51.1 year (37-65). 10 (26.3%) were European, 13 were African (34.2%). 8 (21.1%) had a positive hepatitis C (HCV) Ab, 6 (15.8%) had an AIDS-defining illness. Where known, the largest acquisition risk was injecting drug use; 6 patients (15.8%).
2 patients (5.3%) had a detectable HIV viral load, and 8 (21.1%) had a detectable HBV viral load [median 1555 (IQR 688-160170) copies/ml]. CD4+ cell count was 454 cells/uL (median, IQR 353-689).
18 (47.4%) were HbsAg positive, and of these 5 (13.2%) were HbeAg positive. Within the HbsAg positive group, 1 (5.6%) was not receiving tenofovir (as part of ART regimen) or entecavir, and 3 (16.7%) were tested for hepatitis D virus (HDV).
21 (55.3%) of patients had no radiological evidence of liver disease, and 5 (13.2%) had documented cirrhosis. 3 patients (7.9%) did not have any ultrasonography.
Conclusion
We observe high rates of infection with HCV, cirrhosis and loss to follow-up in this relatively young cohort. We also observe high rates of circulating HBV surface antigen in patients with HIV virologic suppression. Testing for HDV in patients with a positive HbsAg was low. Patients are largely on appropriate antiviral therapy for HBV.
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#2024058
"Disseminated miliary tuberculosis in a 43 year old Irish man in a low endemicity setting"
Principal Presenter: Peter Conlon
Track: Other
Background
Tuberculosis (TB) is an infection of huge global importance. However in Ireland, the incidence of TB, is relatively low at 4.3/100,000 population . A significant number of these cases are imported. The diagnosis of TB in the low-endemicity setting requires a high degree of clinical suspicion and presents with a variety of clinical syndromes.
Case description
A 43-year-old caucasian Irish man presented to hospital with progressive shortness of breath and back pain. He complained of decreased appetite, weight loss and night sweats. He had a mild headache for three days and was febrile on admission. He had been admitted to hospital with a parapneumonic effusion which required drainage 6 months earlier in Wales. TB testing was not performed on this sample.
He had a past history of asymptomatic pulmonary sarcoidosis diagnosed in 2017 following a chest x-ray which demonstrated perihilar adenopathy and mediastinal lymph node biopsy which demonstrated non-caseating granulomas on biopsy. ZN staining was negative. He had not required treatment. He had no significant travel history.
Chest X-ray showed a diffuse micronodular miliary pattern and CT thorax demonstrated bilateral ground glass opacity with calcified mediastinal lymph nodes. MRI spine demonstrated a T2-T3 discitis and epidural abscess. Broncho-alveolar lavage demonstrated acid-fast bacilli and TB GeneXpert identified Mycobacterium tuberculosis complex without genetic evidence of rifampicin resistance. A lumbar puncture demonstrated 50 white cells/mm3 (39% lymphocytes, 61% neutrophils), glucose 2.5 mmol/L, protein 95mg/dl, GeneXpert was also positive for Mycobacterium tuberculosis complex. HIV serology was non-reactive. He was lymphopenic at 0.4 x10^9/L and the CD4 count was 95 cells/mm^3
He was commenced on treatment with rifampicin, isoniazid, pyrazinamide and ethambutol and high dose steroids with resolution of headache and fever within five days.
Discussion
This is an unusual case of miliary TB with pulmonary, spinal, epidural and meningeal infection. To the best of our knowledge, underlying sarcoidosis has not been described as a risk factor for disseminated TB in the absence of immunomodulatory therapy. This case highlights the need to maintain a high index of suspicion to diagnose TB in the low-endemicity setting. There was a missed opportunity to make a diagnosis when he presented with a large pleural effusion 6 months previously at an external institution Idiopathic CD4 lymphopenia is a consideration here, however, lymphocyte subsets will need to be repeated when the acute infection has resolved.
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#2024057
"A single-centre Outpatient Parenteral Antimicrobial Therapy (OPAT) management experience over 18 months for severe pelvic inflammatory disease."
Principal Presenter: Kaitlyn O'Brien
Keywords: OPAT, severe pelvic inflammatory disease, tubo-ovarian abscessTrack: General Infectious Diseases
A single-centre Outpatient Parenteral Antimicrobial Therapy (OPAT) management experience over 18 months for severe pelvic inflammatory disease.
K O’Brien 1, A Delmonte Sen 1,4, A O’Neill 2, A DeMaio2, P Govender3, M Brassil3, S Maher2, S Waqas 1,4
Departments of 1. Infectious Diseases2. Gynaecology and 3. Radiology, Tallaght University Hospital 4: Clinical Medicine TUH, School of Medicine, Trinity College Dublin, Dublin, Ireland.
Background:
Pelvic inflammatory disease (PID) is a clinical syndrome defined by inflammation of the upper genital tract in females and can present as endometritis, tubo-ovarian abscesses, salpingitis or oophoritis. PID can be associated with adverse long term outcomes including pelvic adhesions, infertility, chronic pelvic pain and increased risk of ectopic pregnancy.
This study aimed to review patient outcomes and compared the management of severe PID at our institute with the international guidelines in terms of diagnostic tests, radiological imaging, antimicrobials choices and interventional or non-interventional management.
Methodology:
We evaluated the management of severe PID discharged on OPAT from our institute between July 2022 and December 2023. Study was commenced after approval from the institution’s ethics department (Project ID: 4219). The OPAT clinical database, which is maintained on the secure hospital intranet, was accessed to identify the patients who were diagnosed with PID and discharged on OPAT during the study period. Electronic patient records were then reviewed to gather data.
Results:
Twelve patients were discharged on OPAT between July 2022 and December 2023. 11/12 (92%) of patients had high vaginal and endocervical swabs taken on admission. 1 (8%) was positive for Neisseria gonorrhoea and 1 (8%) for Chlamydia trachomatis. Three (25%) swabs detected bacterial vaginosis, 1 (8%) Candida and Staphylococcus aureus, 1 (8%) Escherichia coli and Streptococcus sanguinis and 1 (8%) detected Streptococcus agalactiae (group B).
One (8%) patient, underwent interventional radiology (IR) drainage of pelvic abscess prior to discharge on OPAT. Four (33%) patients required re-admission during their OPAT course, 3 (25%) for suboptimal response to conservative management underwent radiologically guided drainage and 1 (8%) for an adverse drug reaction to antibiotics. 100% of patients were discharged on ceftriaxone Intravenous (IV), Oral (PO) metronidazole and PO doxycycline, with 11/12 (92%) discharged initially on 6 weeks of IV antimicrobials.
All patients underwent a follow up scan prior to end of planned initial OPAT course and 3 patients required an extension of their antimicrobial course as a result of repeat scan.
None of the patients were readmitted for any indication since final discharge from OPAT service.
Number of total hospital bed days saved for these patients via OPAT was 473 days that resulted in an estimated total saving of 510,840 euros.
Conclusion:
This study demonstrated the benefit and feasibility of the management of severe PID patients with OPAT and indicated necessity of individualised patient management to achieve successful clinical outcomes.
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#2024056
"Chronic diarrhoea and failure of oral therapy; treatment of strongyloides hyperinfection with subcutaneous ivermectin in an immunocompromised patient"
Principal Presenter: Peter Conlon
Keywords: Parasitic infections, Strongyloides, Subcutaneous ivermectinTrack: Other
Background:
Ivermectin is an effective treatment for strongyloidiasis. However, it’s use is limited in the malabsorptive state. Subcutaneous administration is supported in the literature however it is only licensed per os in Ireland.
We describe the use of subcutaneous ivermectin in the treatment of strongyloides hyperinfection in a man with hypogammaglobulinaemia, diarrhoea and a malabsorptive state and discuss the complex diagnostic and therapeutic journey.
Case description:
A 52 year old man presented to an Irish hospital in April 2022 with chronic diarrhoea . He has a past medical history of eosinophilic cardiomyopathy and atrial fibrillation. He has also been experiencing housing instability for the last 5 years.
Initial investigations demonstrated anaemia (11.3 gm/dl) with eosinophilia (1.13 x109). He was investigated with a CT abdomen and pelvis which demonstrated features of acute colonic inflammation and mesenteric lymphadenopathy. This was followed with endoscopic evaluation by colonoscopy, gastroscopy and capsule endoscopy. There was macroscopic features of erosions and inflammation with histological features of eosinophilic chronic inflammatory changes and evidence of parasitic organisms suspected to be strongyloides. He was hypogammaglobulinaemic, however GI protein loss was thought to be a possible cause. Strongyloides serology was negative and several stool samples were reported to have no ova or parasites.
He was treated with oral albendazole and ivermectin and commenced on intravenous immunoglobulin replacement. Months later he was admitted with macrocytic anaemia and persistent diarrhoea. He was folate and iron deficient. Intravenous vitamin and nutrient replacement resolved his anaemia. Further stool samples revealed larvae of Strongyloides stercoarlis. Following complex procurement and approvals, he was treated with subcutaneous veterinary ivermectin leading to rapid improvement of diarrhoea and energy, clearance of strongyloides from his stool and reduction in peripheral eosinophilia.
Discussion:
Diagnosis of intestinal parasitic infections requires close collaboration with laboratory colleagues. Malabsorption greatly impacts efficacy of medications. The use of subcutaneous ivermectin has a role outside of disseminated disease. Serology is of limited value in patients with hypogammaglobulinemia. This case highlights the diagnostic and therapeutic challenges of enteric parasites and differentiating primary versus secondary immunodeficiency and the social challenges associated with patients experiencing housing instability and chronic diarrhea.
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#2024055
"Associations between the gut microbiome, diet, inflammation and cardiovascular profiles in People with HIV (PWH)."
Principal Presenter: Rachel Mac Cann
Track: Virology
Background:
Systemic inflammation and innate immune activation are associated with chronic HIV infection, despite effective antiretroviral therapy. Although alterations in gut microbiota are linked to systemic inflammation, the relationships between the gut microbiome, systemic inflammation, diet and HIV remain ill-defined and further characterising these associations was the main aim of our study.
Methods:
The UPBEAT-CAD sub-study, examining cardiovascular disease (CVD) risk in people with HIV (PWH), enrolled participants matched on HIV status and traditional CVD risk factors. Participants underwent coronary computed tomography angiography (CCTA) to assess subclinical CAD. Microbiota compositions of biobanked stool samples were analysed using 16S rRNA gene sequencing, and 34 inflammatory biomarkers were measured by bead-based ELISA (Luminex) and chemiluminescence (MesoScale Devices). Dietary data were collected using a food frequency questionnaire (FFQ) and a Healthy Food Diversity Index (HFD) was calculated for each participant. Correlations between biomarkers, dietary data, metadata and DA species was conducted using Spearman correlation. All analysis was conducted in R version 4.3.2.
Results:
Of the 81 participants included in the analysis, the median age was 51 (46,56), three-quarters were male (73%), caucasian (74%) and PWH had a higher prevalence of hypercholesterolaemia (p <0.025) and statin use (P<0.001). Overall, 37% (n = 30) of the cohort had subclinical CAD on CCTA.
A significant difference in β-diversity but not α-diversity was observed between PWH and HIV negative participants. ANCOM-BC analysis identified 42 DA species, with depletion of 17 and enrichment of 25 species. In PWH, a significant positive correlation was seen between I-FABP and enrichment of bacteria associated with CVD (Megasphaera micronuciformis, Alloprevotella rava, Streptococcus spp). Furthermore, a depletion of several butyrate-producing bacteria (Bacteroides spp, Allistepes spp,Rumminococcus bromii), which have an important influence in maintaining normal intestinal homeostasis, were correlated with upregulation of inflammatory markers (hsCRP, d-dimer, LBP), endothelial markers (vWF, VCAM, E-selectin) and CVD markers (HDL, cholesterol). In contrast, the HIV negative group have an overall less inflamed biomarker and gut bacterial pattern. Interestingly, an increased abundance of the beneficial bacteria, Bifidobacterium pseudocatenulatum was associated with a lower Agatson score, Calcium volume score, a lower calcified plaque and any plaque presence as well as a lower percentage of overall stenosis. A higher HFD also correlated with specific beneficial microbial species.
Conclusion:
This study describes distinct microbiome associations between diet and biomarker patterns linked with CVD risk in PWH.
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#2024054
"A Review of Malaria Diagnosis and Management 2019-2023 University Hospital Galway (UHG)"
Principal Presenter: Ellen Sugrue
Track: General Infectious Diseases
Malaria is a potentially life threatening infection that is imported by travel in Ireland, with 53 cases reported nationally in 2022. Given its relative rarity and the serious consequences of delayed diagnosis and treatment, we reviewed cases over 5 years at UHG.
Methods
All malaria testing requests submitted to UHG haematology lab January 2019- December 2023 were reviewed. For positive cases request forms, reference laboratory reports and clinical notes were reviewed.
Results
24 cases were identified. 4 in 2019, 0 in 2020, 4 in 2021, 5 in 2022, 11 in 2023. 1 case was excluded due to lack of information. All cases were unrelated.
17 of 23 (74%), cases were male. Mean age was 38 years (range 10-58), 2 cases were pregnant, 4 were < 16 years old. 17/23 (74%) reported reason for travel was visiting friends and relatives (VFR) with most frequent country of travel being Nigeria (12/23,52%).79% acquired infection in country of birth. 13% were born in Ireland. 5/23(22%) took malaria chemoprophylaxis. 3 reported full compliance. The mean time from symptoms onset to presentation was 6 days. The most common presenting symptom was fever (22/23,96%).
P.Falciparum was identified in 20/23 cases (87%) and P.Ovale in 3/23 (13%), no mixed infections. Parasitaemia on initial film was reviewed and results were >2% parasitaemia in 3 cases , 1-3% in 3, <1% in 17 cases.
20 cases were tested on admission with 1 tested in first 24 hours, 1 on Day 3 of admission and one on day 4. The average length of stay (LOS) was 5.7 days with 132 bed days used over 5 years. ICU Admission was required in 6 cases. Mean ICU LOS was 4 days
15 patients received IV and PO treatment, 8 PO treatment only. No treatment failures were documented. There was 1 adverse reaction to artesunate. All made full recovery.
100% of cases were advised follow-up. 2 patients did not attend. 11 cases had documented advice re future travel chemoprophylaxis.
Discussion
This review identifies several challenges related to the diagnosis, management and follow up of malaria. Increased travel post-lockdown has resulted in corresponding increase in cases but lack of appropriate chemoprophylaxis. Results are in keeping with nationally and internationally reported data on patient cohorts, risk factors and parasite species. Post-treatment follow up was as per national guidelines. Areas for quality improvement identified through this review include pre-travel screening and risk modification strategies amongst VFRs.
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#2024053
"Circulating Antibody Titres Predict Infection and Severity in COVID-19 Close Contacts"
Principal Presenter: Joanne Byrne
Keywords: COVID-19Track: Virology
Background
Higher anti-receptor binding domain (RBD) IgG antibodies are associated with greater host neutralisation against SARS-CoV-2, with a RBD threshold of 456IU/mL predicting host neutralising capacity. We aimed to explore whether higher RBD titres offered protection against infection in exposed individuals and establish a humoral correlate of protection from COVID-19, including against severe disease within a real-world setting.
Methods
A multicentre, prospective cohort study enrolled close contacts of confirmed COVID-19 cases during hospital outbreaks from October 2021 to February 2022. All subjects were SARS-CoV-2 PCR negative and provided blood samples at exposure. Subjects were serially SARS-CoV-2 PCR tested over 14 days post exposure. Analysis was restricted to outbreaks where confirmed COVID-19 transmission occurred, assessing disease severity as per World Health Organisation guidelines. Plasma RBD and full-spike (S) IgG were measured by electrochemiluminescence. Chi-squared test and Mann-Whitney U test compared categorical variables and antibody titres, respectively. Kaplan-Meier and Cox proportional hazard ratio (HR) assessed survival analysis. Data is reported as median (interquartile range) or (n(%)) unless specified.
Results
We identified 44 close contacts, aged 77(63-83) years, 61% female, of whom 26(59%) became infected at 4.5(2-7) days, with 6(14%) experiencing moderate/severe COVID-19. No significant differences were observed in clinical comorbidities, or index case CT value between those who did and did not become infected.
Subjects who became infected had significantly lower S and RBD titres than those who did not: S; 1714[544-4286]IU/ml versus 12246[2798-34441]IU/ml, p=0.006 and RBD; 3610[1100-6239]IU/ml versus 25676[5149-64216]IU/ml) p=0.015. In addition, an RBD IgG >456IU/ml (35(80%) subjects), was associated with an 84% risk reduction of developing moderate or severe COVID-19 (HR 0.16 (95%CI 0.03-0.87), p=0.03). This risk reduction strengthened with adjustment for age, sex, and prior COVID-19 (HR 0.09 (95%CI 0.01-0.55), p=0.01).
Conclusion:
In individuals exposed to SARS-CoV-2, higher spike and RBD IgG antibody titres were associated with protection from infection. An RBD IgG titre >456IU/ml, was associated with an 84% reduced risk of developing moderate/severe COVID19, further supporting this threshold as a clinically relevant correlate of protection. This finding carries implications for prioritising COVID-19 therapeutics.
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#2024052
"An audit of pre-vaccination serology immunity screening for HIV patients new to the Mater Misericordiae University Hospital Infectious Diseases Outpatient Clinic"
Principal Presenter: Catherine Uhomoibhi
Keywords: Vaccines, HIV, ImmunologyTrack: Epidemiology & Population Health
Background
People living with human immunodeficiency virus(PLWH) are at risk of acquiring or suffering increased morbidity and mortality from vaccine-preventable diseases(1). The National Immunisation Advisory Committee recommends that HIV-positive adults receive a range of specified vaccines(2). Based on this, the Mater Misericordiae University Hospital Infectious Diseases Department has developed a protocol for HIV patients new to the clinic that recommends serology screening for immunity for the following diseases, and vaccination to be given where non-immune: measles, mumps, rubella, varicella, hepatitis A, hepatitis B. In Ireland, the majority of new HIV diagnoses are among people who have acquired their infection abroad(3) where vaccine coverage may vary significantly. Additionally, research has shown impaired immune responses to many vaccines(4) and faster diminishment of vaccine-induced antibodies in HIV patients(5). In light of this and the recent rise in measles cases in Europe(6), this study aimed to assess our Infectious Diseases clinic’s compliance with initial pre-vaccination serology screening for immunity to vaccine-preventable diseases in HIV patients new to the clinic. It also aimed to analyse the seroprotection rates of these diseases in this patient cohort.
Methods
We carried out a retrospective audit of HIV patients new to the Infectious Diseases outpatient clinic of MMUH between July and December 2023. We analysed the number of patients who received initial pre-vaccination serology screening for immunity for the following vaccine-preventable diseases at their initial clinic visits: Measles, Mumps, Rubella, Varicella, Hepatitis A, and Hepatitis B. Seroprotection was defined as positive IgG antibody result for measles, mumps, rubella, varicella, and hepatitis A; and hepatitis B surface antibody (anti-HBs) level above 10 mIU/ml or hepatitis B core antibody positive without evidence of active infection (acute or chronic).
Results
Between July and December 2023, 94 HIV patients were newly registered to the Infectious Diseases clinic in MMUH. Of the 50 patients analysed, 38 patients (76%) received complete initial serology screening. 9 patients (18%) had partial or incomplete screening performed, and 3 patients (6%) had no immunity screening performed. Of the patients who received initial serology screening, 85.4% were seroprotected against measles, 90% against mumps, 92.5% against rubella, 97.7% against varicella, 77.8% against hepatitis A, and 86.5% against hepatitis B.
Conclusion
Thus, routine screening for immunity to vaccine-preventable diseases is an important aspect of care for HIV patients and provides an opportunity for catch-up vaccination for patients new to the country who may not have received them in their home country. The measles seroprotection rate was considerably lower than previously reported in PLWH (92% in 2019) (7), and well below the 95% rate recommended for herd immunity which is a public health concern. This audit suggests that the majority of our new HIV patients receive the recommended initial immunity screening, though not all. Improvements can be made through education sessions and posters for clinical staff to order these tests at patients’ first visits. This should be followed by a re-audit to assess for improved screening rates.
References
1. De Vito A, Colpani A, Trunfio M, Fiore V, Moi G, Fois M, Leoni N, Ruiu S, Babudieri S, Calcagno A, et al. Living with HIV and Getting Vaccinated: A Narrative Review. Vaccines. 2023; 11(5):896. https://doi.org/10.3390/vaccines11050896
2. Royal College of Physicians of Ireland. National Immunisation Advisory Committee (NIAC). NIAC Immunisation Guidelines. Chapter 3. Immunisation of the Immunocompromised.2023.https://rcpi.access.preservica.com/uncategorized/IO_58401d43-5ce9-4aa0-858f-e5236cad3e27/
3. Health Service Executive-Health Protection Surveillance Centre. HIV Slideset 2022. Dublin: HPSC; November 2023.https://www.hpsc.ie/a-z/hivandaids/hivdataandreports/HIV_trends_to%20end%202022_final.pdf
4. Geretti AM, Doyle T. Immunization for HIV-positive individuals. Curr Opin Infect Dis. 2010;23(1):32-38. doi:10.1097/QCO.0b013e328334fec4
5. Kernéis S, Launay O, Turbelin C, Batteux F, Hanslik T, Boëlle PY. Long-term immune responses to vaccination in HIV-infected patients: a systematic review and meta-analysis. Clin Infect Dis. 2014;58(8):1130-1139. doi:10.1093/cid/cit937
6. European Centre for Disease Prevention and Control. Measles on the rise in the EU/EEA: considerations for public health response. 16 February 2024. Stockholm: ECDC; 2024 https://www.ecdc.europa.eu/sites/default/files/documents/measles-eu-threat-assessment-brief-february-2024.pdf
7. Loevinsohn G, Rosman L, Moss WJ. Measles Seroprevalence and Vaccine Responses in Human Immunodeficiency Virus-infected Adolescents and Adults: A Systematic Review. Clin Infect Dis. 2019;69(5):836-844. doi:10.1093/cid/ciy980
ORAL PRESENTATIONPDF (852.22 KB) -
#2024051
"Lipid Profile and CVS Risk among People Living With HIV taking Boosted Protease Inhibitors"
Principal Presenter: Karen Garvey
Track: Diversity & Inclusion
Background: Boosted protease inhibitor (PI) medications are commonly prescribed for people living with HIV (PLWHIV). They have a recognised side effect of dyslipidaemia and it has been shown that changing off this medication to alternative medication can help resolve dyslipidaemia (NEAT022). Specifically boosted PIs have been shown to increase LDL and decrease HDL levels. Current guidelines for treatment of HIV outline a 3-drug regimen at least consisting of 2 nucleoside or nucleotide reverse transcriptase inhibitors, and one PI or non-nucleoside reverse transcriptase inhibitor.
Aims: To establish lipid levels and QRISKs of 20 patients taking boosted PIs as part of their HIV treatment, and thus identify patients who may benefit from change of ARV therapy to promote cardiovascular health.
Methods: We analysed data of 20 patients including their age, current HIV regimen, cardiovascular risk factors, lipid levels including LDL and HDL and QRISK3. We included only patients who were compliant with their medications, who had a high CD4 count and whose viral load was suppressed, ie. <50.
Results: A total of twenty patients were analysed and showed an average QRISK of 5.47%. 45% of the cohort had a QRISK > 5%, and 25% of the cohort had a QRISK >10%. Our study shows that 8/20 of patients taking boosted PIs had dyslipidaemia and these patients should be assessed for alternative non-lipid raising regimens. We also note that this patient cohort had a high QRISK score but this may even be underestimated as HIV is an independent risk factor for cardiac disease.
Conclusions: Our results show that PLWHIV taking boosted PIs are at increased cardiovascular risk and as they are already at increased cardiovascular risk due to their diagnosis, these patients should be assessed for alternative non-lipid raising regimens.
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#2024050
"Introduction of Midlines for OPAT in Midland Regional Hospital Tullamore : A Retrospective Review"
Principal Presenter: Huma Razzaqe
Keywords: Midlines, OPAT, Midland Regional Hospital TullamoreTrack: General Infectious Diseases
Background: Outpatient Parenteral Antibiotic Therapy (OPAT) programs provide intravenous (IV) antibiotics to patients at home, improving outcomes and reducing healthcare costs. Timely hospital discharge however can be delayed due to wait times for peripherally inserted central catheters (PICC). Midline catheters are an alternative vascular access option for OPAT, potentially streamlining discharge discharges and ambulatory pathways. Midlines have been available in Midland Regional Hospital Tullamore (MRHT) since January 2023. This review aims to describe the experience of midlines in MRHT between July and December 2023.
Methods: A retrospective review of patient records from the local OPAT portal identified all patients discharged on OPAT during the study period. Data collected included patient demographics, vascular access used, complications, readmissions, and use of continuous infusion (CI) antibiotics.
Results: There were ninety-five OPAT discharges in MRHT between July and December 2023. Males accounted for 63% (60/95) of patients. Mean age was 64 (range from 20 – 89 years). Midlines (42/95; 44%) and PICC (41/95; 43%) were the most used vascular access devices, with a small proportion using IV cannulas (IVC) (12/95; 13%). OPAT complications of any severity were reported in nine (22%) patients with PICC and seven (17%) with midlines. Overall, there was a low re-admission rate (15/95; 16%) with nine cases being in PICC group (9/15; 60%) and the remainder in midline group (6/42;40%). No readmissions were due to line-related complications in any group. Line complications which required replacement were noted in nine midlines (9/42; 21%) and no PICC or IVC. Five midlines were re-inserted due to mechanical dislodgement and four due to phlebitis. All patients who suffered midline phlebitis were receiving CI flucloxacillin. Overall, CI antibiotics (Flucloxacillin or Piperacillin/Tazobactam) were prescribed in one third of patients (31/95; 33%) who were discharged with PICC lines 18/31 (58%) with the remainder having midlines (13/41; 42%). Flucloxacillin was prescribed in 14 patients with a PICC and six with midlines.
Conclusion: Overall, the introduction of midlines for OPAT in MRHT has been successful. While complication rates were similar, there is a need to delve further into line related complications. Replacement midlines were required in over one fifth of midlines inserted; (21% vs. 0% for PICC). Dislodged midlines have been addressed by increasing patient and community team awareness. Although numbers are small, the association between midline phlebitis and CI flucloxacillin (4/6;67%) warrants further exploration as well as the cost-effectiveness of midlines compared to PICC.
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#2024049
"Acute HIV infection presenting as encephalitis"
Principal Presenter: Pádraig Morrissey
Keywords: HIV, Virology, EncephalitisTrack: Virology
Background
A 37 year old theatre nurse presented with general malaise, lower back pain, and headaches ongoing for 2 weeks. This was in the context of a recent Emergency Department presentation with subjective symptoms of urinary tract infection, for which she received antibiotics 1 week earlier and was discharged. There was no significant background history and no regular medications. No history of recent travel, zoonotic exposure, or needle stick injury. The patient is in a closed monogamous relationship with her husband with whom she was sexually active and trying to conceive with. During her in-patient stay she developed confusion, acute behavioural disturbance and seizure and required sedation, intubation and transfer to intensive care.
Methods
Initial results at the time of admission showed hepatitis and raised C-reactive protein. Microbiological sampling of urine showed no growth and no leukocytes. Blood cultures were negative. A broad panel of testing included leptospirosis, malaria, HIV, Hepatitis A, Hepatitis B, hepatitis C, HIV, and autoimmune encephalitis panel on serum and CSF Neuroimaging included and non-contrast CT brain and MRI brain both of which did not demonstrate any abnormality. A lumbar puncture was done which showed cerebrospinal fluid white cell count of 28 (98% lymphocytes), glucose 4.5, and protein of 2850mg/L.
Results
Virological sampling was reported six days after admission. Testing for hepatitis A,B,C was all negative. The Abbott Architect® HIV serology was positive and subsequent VIDAS® testing was p24 antigen positive, and HIV 1/2 antibody negative. Subsequent confirmatory testing for p24 antigen was also positive. Confirmatory testing on the INNOLIA®platform did subsequently show a band for p24 antigen antibody. HIV serum viral load was 526,000 copies/ml3 and CSF viral load was 32,136 copies/ml3 prior to treatment. The patient was commenced on dolutegravir(DTG) 50mg twice daily, zodivudine(AZT) 300mg twice daily, tenofovir disoproxil fumarate(TDF) 245mg, and emtricitabine(FTC) 200mg daily. After 6 days of antiretroviral therapy the patient was weaned off sedation completely and had a rapid improvement. ART was further rationalised to TDF/FTC/DTG once stepped-down to the general ward.
Conclusion
In the context of behaviour change, seizure and confirmation of HIV on testing a diagnosis of acute HIV with encephalitis was made. HIV was further down the differential diagnostic list given the atypical presentation and emergence of diagnostics that are not typical of viral meningoencephalitis including high protein. Casting a wide net to include HIV diagnostics in complex neurological cases of unclear aetiology is an important consideration. -
#2024048
"An Insidious Presentation of Iron Deficiency Anaemia"
Principal Presenter: Arifa Salim
Keywords: infective endocarditis, iron defficieny anaemia, septic emboliTrack: General Infectious Diseases
A 19-year-old lady presented to the emergency department following a referral from her general practicioner due to profound iron deficiency anemia. She reported experiencing fatigue, anorexia, insomnia and weight loss over the past three months.
On admission, she was febrile with temperature 38.0°C and tachycardic. On auscultation, a systolic murmur was heard throughout the precordium. Three sets of blood cultures were positve for Streptococccus sanguinis. She was commenced on broad spectrum antimicrobials.By the third day of admission, she developed acute pulmonary oedema requiring adult flow nasal therapy (AIRVO) . An urgent transesophageal echocardiogram revealed mobile vegetations of mitral and tricuspid valve with severe mitral and tricuspid regurgitation.
Regrettably, on the fifth day of her admission, she experienced severe abdominal pain . A computed topography (CT) scan revealed a left common iliac artery aneurysm rupture with active hemorrhage into left psoas muscle. An emergency laparotomy was performed to stop the hemorrhage, and her left common iliac artery were successfully ligated. Within a day of the laparotomy, she was promptly transferred to a national cardiothoracic center for urgent mechanical mitral valve replacement and tricuspid valve repair.
Following surgery, she was noted to have left lower limb weakness which prompted a CT brain. Unfortunately, the CT showed a rapidly enlarging 9mm left middle cerebral artery (MCA) cortical branch aneurysm with a high risk of cerebral hemorrhage. Consequently, she was transferred to neurosurgical center for urgent embolization.
On the 43rd day of her admission, she complained of severe colicky abdominal pains which led to a CT angiography, revealing a splenic abscess, a right hepatic lobe artery aneurysm and a right common femoral artery aneurysm, all of which were larger in size compared to the initial imaging.
After undergoing surgical intervention for the repair of the right femoral artery, she subsequently received an embolization of the superior mesenteric artery (SMA) hepatic artery branch . With regards to the splenic abscess and left psoas abscess, a conservative management approach was implemented with intravenous antibiotics. A post-antibiotic completion CT surveillance revealed complete resolution of the abscess.
This case highlights the need to consider infective endocarditis in patients presenting with symptoms like iron deficiency anemia, as its symptoms can overlap. Early diagnosis is crucial for timely intervention and preventing complications. This case further emphasizes the significance of a multidisciplinary team in managing such complex cases.
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#2024047
"Strongyloides in MSM"
Principal Presenter: Mustapha Kamal Aziz
Keywords: Strongyloides, MSMTrack: General Infectious Diseases
Background
An 80 year old Irish male presented with a two week history of abdominal pain and profuse watery diarrhoea. There were no other symptoms of melena, fever, rash, dysentery, or lower urinary tract symptoms. The patient was not taking any regular medication and had not received antibiotics recently. He had no recollection of sick contacts and was not in contact with healthcare environments. The patient disclosed that he had attended a sex party while abroad in United Kingdom and had multiple episodes of receptive and insertive oral sex with casual male partners. He was not taking pre-exposure prophylaxis for HIV. The patient had no history of travelling to endemic areas know to harbour Strongyliodes stercoralis. He had no unlicenced exotic pets.
Methods
The patients attended the Emergency Department and was isolated pending investigations. Patient white cell count was noted to be eosinophilic. Stool PCR testing was negative for Enterotoxigenic E coli, Salmonella, Shigella, Campylobacter, and Clostridium difficile. C-reactive protein was raised. Rectal nucleic acid amplification testing was negative for Neisseria gonorrhea and Chlamydia trachomatis. Further testing for stool ova and parasites was sent to Cherry Orchard Hospital. Strongyliodes stercoralis larvae were identified in stool. HIV, Hepatitis B, Hepatitis C and syphilis testing was subsequently found to be negative.
Results
The patient was treated with ivermectin 200µg/kg/day orally for two days for intestinal disease. As the patient was not otherwise immunocompromised there were no signs suggestive of a hyperinfection syndrome. The patient recovered promptly with treatment and was counselled on the importance of protected sexual practices.
Conclusion
Emerging infectious diseases and outbreaks in the context of multiple sexual partners has been identified previously; lymphogranuloma venerum, shigella. Strongyliodes stercoralis is a rare entity in this context but however is most certainly emerging as a novel pathogen, one report of 7 men who have sex with men (MSM) with human immunodeficiency virus (HIV) was reported in recent times (1). The trajectory of this phenomenon remains to be seen but practitioners should consider this pathogen in patients with symptoms and high risk sexual exposure.
(1) Ross, S. A., Pintilie, H., Hatcher, J., Dosekun, O., Cooke, G. S., & Bailey, A. C. (2020). Strongyloides stercoralis infection in HIV-positive men who have sex with men. International journal of STD & AIDS, 31(5), 398–401. https://doi.org/10.1177/0956462420910048
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#2024046
"Secondary anti-viral prophylaxis in solid organ transplant recipients for the prevention of CMV relapse: a systematic review and meta-analysis"
Principal Presenter: David Moynan
Track: Other
Background:
Cytomegalovirus (CMV) is a significant cause of morbidity and mortality in solid organ transplant recipients (SOTRs). Evidence about the efficacy of secondary antiviral prophylaxis (SP) in SOTRs after CMV infection is unclear.
Methods:
We performed a systematic review and meta-analysis of SP in adult SOTRs with CMV infection. The primary outcome was CMV relapse, defined as recurrence of viraemia. Secondary outcomes included graft loss, mortality and haematological toxicity. A comprehensive search of English language publications up to September 2023 was conducted by a medical librarian. Study selection was managed using the Covidence platform. Risk of bias assessment was performed using the Newcastle-Ottawa Scale for comparative observational studies. A meta-analysis was conducted using a random-effects model. The systematic review protocol is registered in PROSPERO (no. CRD42022357028).
Results:
The literature search results are presented in the PRISMA flow diagram (figure 1). Of the 777 studies screened, six retrospective comparative studies were included. A total of 727 SOTRs were included in the analysis, of which 520 received SP with valganciclovir and 207 did not. The median duration of treatment was 50.5 days (interquartile range, 19.5 days). Meta-analysis did not demonstrate a significant difference in CMV relapse between the two groups (OR 1.15, 95% confidence interval (CI) 0.79 – 2.63). The heterogeneity between the studies was low (I2 = 0%, p=0.57). While data were not available in all studies, there was a significant difference in mortality between the groups (OR 0.2, 95% CI 0.07 – 0.54) but not graft loss (OR 0.67, 0.17 – 2.63). Analysis restricted to kidney-specific SOTRs also did not demonstrate a significant difference in relapse (OR 1.38, 95% CI 0.65 – 2.96). The estimates of effect were very imprecise due to the small number of events and warrant very low certainty.
Discussion:
The current evidence derived from six nonrandomized studies about SP in SOTRs is limited and cannot support a recommendation for or against SP. Awaiting future larger studies, the decision about SP should depend on individualized risk-profile assessment of patients by experienced transplant and infectious diseases clinicians. -
#2024045
"Malaria Management at St. Vincent's University Hospital: A 10-Year Retrospective Review"
Principal Presenter: Siobhán O'Regan
Keywords: malaria, global health, tropical medicineTrack: Other
Background:
Malaria, although uncommon in Ireland, presents a significant risk of mortality, primarily due to Plasmodium falciparum infections. Prompt diagnosis is crucial, and hospital admission for at least 24 hours is recommended in Ireland due to rapid deterioration potential. Awareness of proper management protocols is crucial for physicians in emergency and acute care settings.
Methods:
Positive malaria blood films from 2013 to 2023 at SVUH Haematology laboratory were reviewed. Audit assessed Emergency Department management and admission follow-up against 2017 HPSC Clinical Guidelines for Suspected Malaria. Notably, the audit covers a period predating the establishment of these national guidelines.
Results:
33 cases of malaria presented to SVUH over 10 years.
Malaria chemoprophylaxis use was documented in 22 (67%) of cases. However, none were taking appropriate chemoprophylaxis.
Plasmodium falciparum constituted 82% of cases, with 12% of these exhibiting parasitaemia >5%.
Of the 33 cases, 16 (48%) did not have sufficient information to clinically stratify as severe or non-severe malaria. Of the remaining 17 cases with sufficient information, 7 (41%) were classified as severe P. falciparum malaria and appropriately treated with IV artesunate. 46% of these also received doxycycline.
Follow-on and stepdown therapy was appropriate in most cases with doxycycline being the preferred oral switch therapy, only 30% received an artemisinin-based combination therapy.
IV artesunate was prescribed in 6 cases of uncomplicated malaria. However, this treatment decision could reflect patient’s ability to take oral medications or delay in availability of percentage parasitaemia, information which was not assessed.
Treatment of uncomplicated P.falciparum malaria was otherwise appropriate although regimens varied. 16% were prescribed an artemisinin-based combination therapy.
Admission rate was 77%. Of 23 admissions, 35% (n=8) were admitted under Infectious Diseases or care transferred on next working day. Of those cases who were not taken over by Infectious Diseases, 80% received Infectious Diseases consult advice (n=12).
ICU care was required for 2 cases, resulting in 1 death. Daily blood film monitoring occurred in 48% of cases, while adherence to laboratory monitoring recommendations varied.
Conclusion:
Overall, malaria case management at SVUH is good. Haematology lab records are thorough. Emergency Department documentation is missing some components of severity stratification, potentially affecting treatment appropriateness. Adherence to admission guidelines and inpatient monitoring varies, but initial and stepdown treatment is generally appropriate. These findings underscore the importance of improved adherence to guidelines, enhanced awareness among healthcare providers, and standardised protocols for the management of malaria in the hospital setting.
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#2024044
"Competing differentials may coexistent in patient living with HIV; Guillain Barre and Burkitt lymphoma"
Principal Presenter: Mustapha Kamal Aziz
Keywords: HIV, TB, Gullain-BarreTrack: General Infectious Diseases
Background
68 year old Ukranian man presenting with lower limb weakness,breathlessness and general fatigue worsening over two week period.His background history included a new HIV diagnosis 5 months previously and he was also diagnosed with stage 4 diffuse large b-cell lymphoma (DLBCL) at that time. CD4 nadir was 17(4%) cells/mm3 . He was commenced on bictegravir,tenofovir,alafenamide and emtricitabine and received 6 cycles of rituximab, cyclophosphamide,doxorubicin hydrochloride, vincristine and prednisolone (R-CHOP) chemotherapy. Positron Emission Tomography (PET) CT done two weeks prior showed complete remission. His CD4 count was 48 (38.2%) cells/mm3 and his HIV viral load not detected at routine HIV out-patient appointment two weeks prior to presentation.On examination he had global limb weakness,worse in lower limbs with absent reflexes. Bilateral lateral rectus palsy was noted and work of breathing continued to increase with rising arterial pCO2 requiring intubation. Neither the patients wife nor children were aware of his HIV status at his request.
Methods
Clinically findings were consistent with Guillain Barre Syndrome(GBS) and ocular
involvement suggested Miller-Fisher variant. Serological samples including EBV, CMV
serology and autoantibodies including antiganglioside, anti-GQ1b were taken prior to
the initiation of intravenous immunoglobulin. Lumbar puncture was done on day one of
admission,cerebrospinal fluid examination showed 810 WCC/mm, predominantly
lymphocytic (60%), raised protein (7959mg/l), low glucose (<0.1mmol/l). An MRI brain and whole spine was done urgently on transit from ED to the intensive care unit reported
normal age related changes. Campylobacter jejuni was confirmed on stool polymerase chain reaction. Serum Anti-ganglioside antibodies were positive.Results
The initial very high protein was not consistent with GBS, and given the patients
epidemiology,HIV status,persistent immunosuppression with chemotherapy, and recent
remission status it was felt mycobacterium tuberculosis(TB) meningitis must be out ruled
and treatment with rifampicin, isoniazid, ethambutol and pyrazinamide was commenced
until TB diagnostics were complete. Flow cytometry subsequently identified Burkitt’s
lymphoma and CSF EBV was 24,760,676 copies/ml. Findings confirm diagnosis of Burkitt
lymphoma and a decision to palliate the patient was made, as combined pathology
rendered him unfit for intrathecal chemotherapy and with no meaningful chance of
recovery.Conclusion
Multiple coexistent pathologies should be considered in patients living with advanced HIV.
Managing, discussing these issues with family members who are unaware of the patients status can be challenging, particularly in patients approaching end of life. -
#2024043
"Latent tuberculosis infection (LTBI) in an urban homeless population"
Principal Presenter: David Moynan
Track: Diversity & Inclusion
Background:
Persons experiencing homelessness (PEH) are at a higher risk for latent TB-infection (LTBI) and subsequent progression to active TB disease than the general population. The prevalence of LTBI in PEH varies on the setting, ranging from 16.5% in the United Kingdom to 36.7% in Poland. Ireland, as a low TB-incidence country (5.6 cases per 100,000 population in 2019) should be aiming for TB elimination (fewer than 1 case per million of population), which requires high quality LTBI screening. Recommendations from the World Health Organisation (WHO) suggest that in low TB-incidence countries, the systematic screening for LTBI should be considered in prisoners, immigrants from countries with a high TB burden, PEH and those who use illicit drugs. This study aimed to examine the prevalence of LTBI among hospitalised PEH over a three month period.
Methods:
The St. James’s Hospital inclusion health service is a multidisciplinary team that provides inpatient care to PEH. From November 10th 2023 to January 30th 2024, inpatients of the inclusion health service were offered screening for LTBI using an interferon gamma release assay (IGRA). People living with HIV (PLWH) were not included in this study. Patient demographics were collected including age, country of origin, prison history, illicit drug use and TB-history. This study was registered and approved by the Research and Innovation office at St James’s Hospital, Dublin.
Results:
There were 49 patients included in this study, with a mean age of 46 years (SD 12 years; 95% CI 43 – 49 years). The majority (42/49; 85%) were Irish nationals. All patients were experiencing homelessness; one third were unsheltered/sleeping rough. A large proportion (26/49; 53%) were previously incarcerated and there were high rates of substance and alcohol use disorder, with 14/49 (29%) of patients disclosing active injection drug use and 32/49 (65%) problem drinking. Four patients had a positive IGRA (4/49; 8.2%) with no clinical concern for active TB disease. All four patients were Irish nationals who denied any prior history of TB or previous TB exposure.
Conclusion:
While this study was not powered to determine a true prevalence of LTBI among PEH in Ireland, the prevalence noted is similar to that from studies in comparable European populations and double that of the general population. This figure, however, excludes PLWH. We believe a larger study should be undertaken, including PLWH, to inform a framework for the appropriate screening and treatment initiation for PEH in Ireland. -
#2024042
"Gathering Unintended Baggage On The Way: Malaria, Scabies And Lyme Co-infection In An Asylum-Seeker"
Principal Presenter: Nalisu Mazubane
Track: Diversity & Inclusion
Background:
Asylum seekers who make hazardous journeys to Europe face many hazards, including exposure to communicable disease.
Method:
We present a case of a foreign national who presented with malaria, Lyme disease and scabies co-infection.
Results:
A 21 year male, was admitted with one week history of headache, myalgia, fever, vomiting for two days, as well as itching. He was an asylum-seeker from South-Central Asia and had recently travelled into Ireland via France; traversing through jungles, and had been exposed to mosquito and insect bites during his journey. He also reported receiving treatment for malaria in France six weeks prior.
On presentation, he was noted to have an altered level of consciousness, decreased urine output and hypotension. He tested positive for Plasmodium vivax malaria, and schizonts were noted on blood film. IV Artesunate was commenced to treat severe malaria.
Scabies lesions were also noted on his skin, and he was treated with Ivermectin for scabies during his admission. The patient responded well to malaria and scabies treatment. He was planned to receive Plasmodium vivax hypnozoite (liver phase) eradication treatment as an out-patient with Primaquine, pending G6PD results. On the day of his discharge, his screening test for Borrelia burgdorferi IgG report also came back as positive, awaiting confirmation.
Prior to the planned clinic follow up, he re-presented with another relapse of Plasmodium vivax malaria. He was readmitted and completed malaria treatment along with Primaquine eradication. The confirmatory Lyme disease results were also positive, for which he received four days of intravenous Ceftriaxone and was then discharged on oral Doxycycline to complete the therapy. He was clinically well on subsequent follow up.
In this case, the patient possibly contracted malaria in South-Central Asia, and most likely contracted Lyme disease on his way to Ireland, while a scabies outbreak was ongoing in the asylum centre locally at the time he arrived.
Conclusion:
Malaria and B. Burgdorferi co-infection is rare. A 2017 Clinical Case Report published in the Wiley Online Library was the first ever reported case of malaria and B. Burgdorferi co-infection(1). Prior to this, the only documented cases in the literature were of co-infection with B. recurrentis. This case of malaria, Lyme and scabies co-infection underscores the infectious hazards asylum seekers expose themselves to and reminds clinicians of the multiple co-infection considerations in such persons.
ORAL PRESENTATIONPDF (127.33 KB) -
#2024041
"Endogenous Endophthalmitis in Myelodysplastic Syndrome: A Presentation with Streptococcus Dysgalactiae and Infective Endocarditis - A Case Report and Literature Review"
Principal Presenter: Salman Keraidi
Keywords: Endophthalmitis, Myelodysplastic, DysgalactiaeTrack: General Infectious Diseases
Abstract:
Background: Endogenous endophthalmitis, a severe intraocular infection, is rarely associated with myelodysplastic syndrome and Streptococcus dysgalactiae. This report aims to present a rare case of endogenous endophthalmitis in a patient with myelodysplastic syndrome and concurrent infective endocarditis caused by Streptococcus dysgalactiae, and to review literature to elucidate the association between myelodysplastic syndrome, Streptococcus dysgalactiae, and endogenous endophthalmitis.Case Presentation: A 56-year-old welder with a history of myelodysplastic syndrome presented with acute, painful, unilateral vision loss in the left eye, progressing to complete vision loss and fever. Diagnostic investigations revealed S. dysgalactiae as the causative agent, with subsequent identification of infective endocarditis necessitating aortic valve replacement. Despite aggressive treatment, the patient suffered significant morbidity, resulting in eye enucleation and prosthesis implantation. A systematic search was performed on PubMed, utilizing the search phrases "endophthalmitis myelodysplastic," "endophthalmitis dysgalactiae," "endophthalmitis myelodysplasia," "dysgalactiae myelodysplasia," and "dysgalactiae myelodysplastic." This approach identified 15 relevant articles. Two articles centred on exogenous endophthalmitis were subsequently removed from consideration.
Conclusion: The literature review revealed a scarcity of reports linking endogenous endophthalmitis with myelodysplastic syndrome and Streptococcus dysgalactiae. This case report and literature review underscore the importance of considering myelodysplastic syndrome as a significant risk factor for endogenous endophthalmitis, especially when caused by atypical pathogens like Streptococcus dysgalactiae. The co-occurrence with infective endocarditis adds a layer of complexity to diagnosis and management. This rare confluence of conditions necessitates a high degree of clinical vigilance and awareness among clinicians for atypical pathogens and risk factors in patients presenting with endophthalmitis, especially those with complex medical histories.
Keywords: Endogenous endophthalmitis; Myelodysplastic syndrome; Streptococcus dysgalactiae; Infective endocarditis; Case report; Literature review. -
#2024040
"Use of high-fidelity in-situ simulation to evaluate the operational readiness of Ireland’s National Isolation Unit for High Consequence Infectious Diseases"
Principal Presenter: Catherine Uhomoibhi
Keywords: High-consequence infectious diseases, Infection Control, SimulationTrack: General Infectious Diseases
Background
The Mater Misericordiae University Hospital (MMUH) is constructing a state of the art high- level isolation unit (HLIU) as part of the national strategy for emerging health threats preparedness. A number of cross-agency simulation exercises are underway as part of the preparation phase for the new facility. Ireland’s Health Protection Surveillance Centre’s guidelines on the management of viral haemorrhagic fevers (VHF)(1) and MMUH’s National Isolation Unit’s (NIU) activation protocol provide standards against which NIU activation can be assessed. HLIUs face distinct operational challenges related to the large multidisciplinary teams involved, extensive training required, and infrequent nature of HCID events(2). In-situ simulation is an established tool for evaluating healthcare and emergency preparedness(3) including the management of VHF and other HCIDs(4,5). It has an educational role for staff participants and observers through experiential learning and the optimisation of work structures and processes(6).
Two high-fidelity in-situ simulations of NIU activation took place on 19th September 2023 and 15th February 2024. The aim was to test the operational effectiveness and readiness of our staff and facility. Two further cross-agency national and international transfer exercises are planned on 27th March 2024 and 10th April 2024 to ensure interoperability with national authorities and transfer agencies.
Methods
The initial exercise was organised by the MMUH NIU Operations Sub-Committee. The simulation focused on the activation process from initial notification to patient admission to the NIU. The simulation session was followed by a feedback and debrief session with participants, observers and relevant stakeholders. Changes were made to the activation protocol and tested through a follow-up simulation on 15th February 2024.
Results
The NIU end-to-end activation process was evaluated. The exercise highlighted aspects of the NIU pathway that worked effectively such as a structured operations activation meeting, infection control-compliant use of personal protective equipment (PPE), and respectful communication and teamwork between clinical and management staff. It also revealed a number of operational deficiencies including failure of the Saadian alert system to notify all necessary personnel, inadequate room preparation prior to patient arrival, unclear protocol for infection control-compliant specimen packaging for transport to the National Virus Reference Laboratory, and operational risks around the numbers of staff available to activate the unit. Corrective measures and protocol amendments were proposed during the debrief, and reviewed by the NIU Operations Sub-Committee for final approval. The improved process was successfully tested at the follow-up February simulation.
Conclusion
Simulation is an important evaluative and educational tool for HCID preparedness. This process provided invaluable feedback and informed changes to the NIU policies and guidelines.
References
1. Health Protection Surveillance Centre.Viral Haemorrhagic Fever Guidance. Published: 2022 Dec 02 . https://www.hpsc.ie/a-z/vectorborne/viralhaemorrhagicfever/guidance/
2. Herstein JJ, Stern K, Flinn J, Garland JA, Lowe AE, Sauer LM. Challenges and Approaches to High-Level Isolation Unit Staffing and Just-in-Time Training: A Meeting Report. Open Forum Infect Dis. 2023 Mar 23;10(4):ofad152. doi: 10.1093/ofid/ofad152. PMID: 37035492; PMCID: PMC10077825.
3. Miller JL, Rambeck JH, Snyder A. Improving Emergency Preparedness System Readiness through Simulation and Interprofessional Education. Public Health Reports. 2014;129(6_suppl4):129-135. doi:10.1177/00333549141296S417
4. Biddell EA, Vandersall BL, Bailes SA, Estephan SA, Ferrara LA, Nagy KM, O'Connell JL, Patterson MD. Use of Simulation to Gauge Preparedness for Ebola at a Free-Standing Children's Hospital. Simul Healthc. 2016 Apr;11(2):94-9. doi: 10.1097/SIH.0000000000000134. PMID: 27043094.
5. Fregene TE, Nadarajah P, Buckley JF, Bigham S, Nangalia V. Use of in situ simulation to evaluate the operational readiness of a high-consequence infectious disease intensive care unit. Anaesthesia. 2020 Jun;75(6):733-738. doi: 10.1111/anae.15048. Epub 2020 Mar 30. PMID: 32221964.
6. Dieckmann P, Torgeirsen K, Qvindesland SA, Thomas L, Bushell V, Langli Ersdal H. The use of simulation to prepare and improve responses to infectious disease outbreaks like COVID-19: practical tips and resources from Norway, Denmark, and the UK. Adv Simul (Lond). 2020 Apr 16;5:3. doi: 10.1186/s41077-020-00121-5. PMID: 32308988; PMCID: PMC7160610.
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#2024039
"TURNAROUND TIME OF OUTPATIENT PARENTERAL ANTIMICROBIAL THERAPY (OPAT) : QUALITY PROJECT IN CORK UNIVERSITY HOSPITAL AND MERCY UNIVERSITY HOSPITAL, FROM DEC 2023 TO JAN 2024"
Principal Presenter: Samata Al Dowaiki
Keywords: OPAT, TURNAROUND TIME, CUH, MUHTrack: General Infectious Diseases
The National Outpatient Anti-Microbial Therapy (OPAT) programme has standardized care pathways and guideline for either S-OPAT (self-admin) or H-OPAT (Healthcare admin) in Ireland. Turnaround time is the time from the initial OPAT referral within hospital to the actual patient discharge. Optimum patient flow is facilitated by timely turnaround time, the capacity of Community Intervention Team (CIT), Point of Care (POC), and pharmaceutical preparation. This prospective study was conducted at Cork University Hospital (CUH) and Mercy University Hospital (MUH) to assess the current turnaround time of OPAT, and to identify factors contributing to delays in the OPAT commencement.
Methods: All patients referred for OPAT from both CUH and MUH were included prospectively, from Dec 2023 to Jan 2024. Data Collected were Patient(initials), MRN, Date of birth, OPAT type (S-OPAT or H-OPAT); date and time the referral for OPAT is submitted; Date OPAT is requested to commence, and confirmation of OPAT set up from national programme. Factors contributed to the delay in commencing OPAT were recorded. The results were analysed quantitatively in assessing time intervals and qualitatively to identify causes of delays.
Results: A total of 35 referrals for OPAT were recorded, with 29 originating from CUH and 6 from MUH during the period from Dec 1st, 2023, to Jan 31st, 2024. Among these, 14 were for S-OPAT, while 21 were for H-OPAT including 4 for continuous infusers. Turnaround time for OPAT initiation was computed excluding Saturdays and Sundays. Average turnaround time was 24 hrs, 6 cases had turnaround time < 6 hrs where the minimum time was 3 hrs. Maximum Turnaround time was 78 hrs. No delay in commencement of OPAT was noted in 46% of patients, Delay by 1-3 days was reported in 29% of the cases, and >= 4 days of delay was reported in 25% of them. Total bed-days lost due to the delay was 78 days. Of which, 34 days were attributed to pharmaceutical production of the anti-microbial therapy, 37 days were attributed to CIT, and 4 lost Bed-days were attributed to POC. Combining CIT and Baxter both contributed to 3 bed-days delay.
Conclusion: This study showed that OPAT service efficiently provided care to 46% of the cases without any delay and with an average turnaround time of 24 hrs. However, 54% of OPAT referrals were delayed by 1 or more days in its commencement which resulted in 78 bed-days loss as a total. This highlights the need for increased capacity by pharmaceutical manufacturer, CIT and POC to minimize waiting time and ensure optimal care for OPAT patients.
Recommendations: We recommend increasing capacity of CIT, POC, and pharmaceutical manufacturer to accommodate OPAT requests. Audit findings were shared with the local OPAT team and the National OPAT program chairman for further action and improvement initiatives.
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#2024038
"African tick bite fever: a multi-pronged approach for diagnostic evaluation"
Principal Presenter: Catherine Uhomoibhi
Keywords: African Tick Bite Fever, Rickettsia, Tropical / Travel MedicineTrack: General Infectious Diseases
Background
African tick bite fever is an emerging spotted fever group rickettsial disease increasingly seen in international travelers returning from sub-Saharan Africa. It is characterised by an acute influenza-like illness with single or multiple inoculation eschars and associated regional lymphadenopathy. Diagnosis is usually confirmed through serology or tissue-based detection of rickettsiae from an eschar biopsy. Increasingly, eschar crust and swab samples have been used for PCR-based molecular detection of rickettsiae(1).
Case Description
We present 2 cases of African tick bite fever in adults following foreign travel within sub-Saharan Africa. The first case involved a young Irish couple presenting with fevers, pruritic rash, and tender inguinal lymphadenopathy, following recent travel along the ‘Garden route’ of Cape Town, South Africa where they underwent a safari. The second case involved a young Irish male presenting with fevers, myalgia, and headache, following recent travel from a rural village in Uganda near Lake Victoria.
Discussion
In the first case, a diagnosis was confirmed using serology testing. In the second case, however, the diagnosis was confirmed using DNA PCR testing of both eschar crust and swab specimens. Additionally, both patients had undergone skin punch biopsies with histology, which showed typical features of perivasculitis and inflammatory cell infiltrates that were supportive of the diagnosis(2). Both cases were successfully treated with a two-week course of doxycycline.
Conclusion
This case series highlights the various supportive and confirmatory diagnostic tests available for the diagnosis of African tick bite fever, particularly the value of using combined eschar crust and swab specimens, which is a simple, non-invasive diagnostic method that can be performed in a variety of clinical settings compared to traditional skin biopsy.
References:
1. Parola P, Paddock CD, Socolovschi C, et al. Update on tick-borne rickettsioses around the world: a geographic approach. Clin Microbiol Rev 2013; 26: 657-702.
2. Lepidi H, Fournier PE, Raoult D. Histologic features and immunodetection of African tick-bite fever eschar. Emerg Infect Dis. 2006;12(9):1332-7.
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#2024037
"A Case of Erythema Nodosum Leprosum (ENL) in Treated Multibacillary Leprosy"
Principal Presenter: Aina Fuad
Track: General Infectious Diseases
Background
Leprosy or also known as Hansen’s disease is caused by a bacteria called Mycobacterium Lepromatosis or Mycobacterium Leprae and it affects multiple organs mainly the skin and peripheral nerves. The Ridley-Jopling system classifies it into tuberculoid disease or paucibacillary and lepromatous disease or multibacillary, further subdivided into borderline tuberculoid, mid borderline, borderline lepromatous, and indeterminate based on the burden of organisms and immune response. It is treated with 1 year of multi drug therapy (MDT) consisting of clofazimine, rifampicin and dapsone as per WHO guideline. Patients may suffer from sequelae or reaction towards the disease during or post treatment and they are called type 1, the reversal reaction (RR) or type 2, Erythema Nodosum Leprosum (ENL) reaction respectively.
Case report
We report a case of ENL in a Brazilian man in his forties who presented to the hospital with systemic symptoms - fever, night sweats, lymphadenopathy as well as skin nodules and peripheral oedema, two months after completing treatment for cutaneous borderline multibacillary leprosy. He was diagnosed with ENL after discussion among infectious diseases and dermatology team and was promptly commenced on treatment with systemic corticosteroids. He showed tremendous clinical improvement within 24 hours and was subsequently switched to Thalidomide which has a better side effect profile as compared to steroids. Fever, facial and limb swelling as well as skin nodules resolved within a few days of starting treatment.
Conclusion
Leprosy is very rare in Ireland or any European countries in general, it is vital to recognize and be cognizant of the disease and its sequelae with the current era of globalization that causes movement of people from countries where Leprosy is endemic to countries where it is not. ENL is a challenging diagnosis and delayed treatment may lead to permanent disabilities which includes permanent nerve damage and deformities. Another challenge in these patients is planning a treatment that will effectively manage the reaction without causing significant side-effects to patients. Most treatments for both type 1 and type 2 reactions include high dose systemic corticosteroids, which carry significant risks on prolonged course, or immunomodulators as steroid-sparing agents.
ORAL PRESENTATION -
#2024036
"Establishing a dashboard at the Health Protection Surveillance Centre (HPSC): The development, impact, challenges and lessons learned"
Principal Presenter: Mairead Madigan
Track: Epidemiology & Population Health
Background: Public health dashboards are a key communication tool bringing valuable surveillance information to the public. Dashboards use visual analytics (e.g graphs, histograms and bar charts), maps and infographics to display, share and communicate key public health messages to the public. They are dynamic (updated regularly with data) and interactive (allowing selection and filtering). Dashboards are effective tools used to analyse large volumes of data. They help stakeholders identify trends, make evidence-based decisions which influence public health policy.
During the emergency phase of the COVID-19 pandemic, when HPSC experienced an unprecedented demand for epidemiological data, a daily COVID-19 Data hub was created. This has evolved into a Respiratory Virus Notification data hub. This displays weekly epidemiological data of COVID-19, influenza and respiratory syncytial virus (RSV). We detail the development, challenges, impact as well as lessons learned while establishing the dashboard.
Methods: Creating the dashboard required the formation of collaboration partnerships between statisticians, infectious disease modelling experts, data analysts, communications specialists and epidemiologists across the HPSC, HSE and Department of Health. A data pipeline was formed from the Computerised Infectious Disease Reporting system (CIDR) which provided laboratory confirmed cases. Data management was done through Statistical Package R. The data hub was built, designed and maintained using the ArcGIS hub.
Results: The COVID-19 hub launched to the public in April 2021. On November 22nd 2023, the COVID-19 hub migrated to the newly developed Respiratory Virus Notification data hub. It displays weekly confirmed cases, cases by age group and county, hospitalisations, deaths and ICU cases as well as outbreaks. So far this winter season, the Respiratory hub has been viewed 26,413 times. The highest monthly record was set in October 2023 with 8,344 views. The open-source data has had 194 downloads.
Conclusion: The HPSC dashboard provided timely and accurate information to the public, media, clinical staff and Public Health colleagues. It is valuable resource for presenting key public health messages to the public. The Respiratory virus hub demonstrates the usefulness of viewing multiple pathogens in single space, showing the totality of these viruses during the winter season. This project relied heavily on the skillset of various public health experts. The dashboard had diverse challenges such as the HSE Cyber-attack, case surges, changes in Public Health priority, testing practice and migrating to a multiple disease hub. Further adaptations to the hub will be required as we enter a new phase and into the future.
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#2024035
"Quality Improvement Project Of COVID-19 Therapeutics Prescribing"
Principal Presenter: Ahmed Al Badi
Keywords: COVID, Prescribing, AntiviralTrack: Virology
Background
Since the WHO declared the end of the coronavirus disease COVID-19 pandemic clinicians are seeing less hospitalised COVID-19 patients. This quality improvement project aims to provide a quick reference tool to clinicians on pharmacological therapeutic strategies for COVID-19 as well as education sessions and to assess their impact on prescribing. We also assessed the volume of COVID-19 related consults to the infectious diseases team before and after our intervention.Methods
We assessed COVID-19 therapeutics prescribing among patients with a confirmed COVID-19 polymerase chain reaction test (PCR) result admitted to an isolation ward University Hospital Galway in August 2023 (baseline data). The patients were stratified to the risk tier list suggested by COVID-19 therapeutic guidelines. Prescribing data of antivirals (nirmatrelvir/ritonavir and remdesivir), corticosteroids and venous thromboembolism prophylaxis was collected and compared with HSE guidelines. A new quick reference sheet was designed and distributed to wards and IT systems. COVID-19 therapeutics agents were discussed in dedicated teaching sessions for nursing and medical staff. Following this intervention, data was recollected and analysed.Results
In the first stage of the quality improvement project 27 patients were identified with a mean patient age of 80 years (SD±15.33). Four of these patients were admitted under the infectious diseases team. Five (25%) required an infectious diseases consult on COVID-19 therapeutic agents. Twelve (44.44%) patients required pharmacist intervention including advice regarding dosing, what agents are indicated and correction of prescribing errors. The prescribing of VTE prophylaxis and corticosteroids was correct in 92.59% (n=25) patients. The prescribing of nirmatrelvir/ritonavir and remdesivir was appropriate in 74.07% (n=20) patients. Seven patients (25.93%) were prescribed the wrong antiviral or were eligible and did not receive it.In the second phase of the quality improvement project after our intervention, we collected data on 24 patients. The patient population was slightly younger with a mean age of 74.58 years (SD±10.76). Of the 20 patients not under the infectious diseases team there were no infectious diseases consults. Appropriateness of VTE prophylaxis and corticosteroid prescribing remained similar at 91.67% (n=22). Prescribing of the appropriate antiviral for eligible patients went up to 100% (n=24).
Conclusion
This quality improvement project has resulted in improved prescribing of therapeutics agents for COVID-19 by implementing a quick reference algorithm for clinicians and education sessions for staff. We also demonstrated a reduction in formal infectious diseases consultation for COVID-19 therapeutics. We will next focus on sustainability of our improvements. -
#2024034
"Seroprevalence of Chronic Hepatitis C Virus in Ireland: Informing Birth Cohort HCV Screening Policy"
Principal Presenter: Jane Finucane
Track: Epidemiology & Population Health
Background:
Treatment of Hepatitis C virus (HCV) infection with direct-acting antivirals can safely and effectively cure 95% of infections. The 2017 Hepatitis C Screening, National Clinical Guideline (1) identified the 1965-1985 birth cohort as a possible group for screening. The Health Information and Quality Authority (HIQA) subsequently published a Health Technology Assessment (HTA) recommending the introduction of once-off testing for HCV for the birth cohort, assuming a minimum level of HCV prevalence, and undertaking a pilot initially, given the uncertainties in the prevalence estimates
The aim of this collaborative study between the National Serosurveillance Programme (NSP) and the HSE National Hepatitis C Treatment Programme was to identify HCV seroprevalence in the Irish adult population to inform future national HCV screening strategies.
Methods:
Between June 2022 and May 2023 anonymised residual sera samples were collected in seven regional hospitals participating in the NSP Laboratory Surveillance Network. The samples were sourced from primary care adult patients.
HCV antibody testing, and if positive further HCV antigen testing, was undertaken in the National Viral Reference Laboratory. The HCV Ab Architect Abbott HCV assay (Abbott Diagnostics, Wiesbaden, Germany), Fujirebio Innotest Ab IV assay (Fujirebio Europe N.V., Gent, Belgium), Bio-Rad Monolisa anti-HCV Plus vs 3.0 (Bio-Rad, Marnes-la-Coquette, France) and Fujirebio INNO-LIA HCV score line immunoassay (Fujirebio Europe N.V., Gent, Belgium) were used to confirm and characterise HCV infection
Seroprevalence was calculated overall, for the birth cohort (1965 – 1985) and by sex, with confidence intervals calculated for each estimate. All statistical analysis was performed using R (https://www.r-project.org/).
Results:
A total of 8,029 samples, comprising of 4,022 females and 4,007 males were tested. Of these, 3,176 (39.6%) samples fell within the birth cohort (1965 to 1985) 50% of whom were males.
The seroprevalence of HCV (antigen positive) was 0.12%, 95%CI [0.07%, 0.23%] (10/8029); in males 0.20%, 95%CI [0.1%, 0.39%] and females 0.05%, 95%CI [0.01%, 0.18%]. For adults born between 1965-1985, the prevalence estimate was 0.19%, 95%CI [0.09%, 0.41%].
Conclusion:
Birth cohort (1985-1965) testing was proposed in 2017 to target people living in Ireland with undiagnosed HCV and was recommended by HIQA in 2021 following a full HTA to establish cost effectiveness. In December 2023 HIQA updated their recommendations to the Department of Health regarding Birth Cohort Testing for Hepatitis C (2). The report included the NSP results in addition to other recent HCV seroprevalence studies and will inform the decision on future HCV screening in Ireland.
References:
1.DOH 2017 gov.ie - Hepatitis C Screening (www.gov.ie)
2.HIQA 2023 https://www.hiqa.ie/sites/default/files/2024-02/HTA-of-birth-cohort-testing-HCV-update.pdf
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#2024033
"Inclusion Health Service Development in the West of Ireland"
Principal Presenter: Siobhan Quirke
Track: Diversity & Inclusion
Background:
We present results of a needs assessment undertaken to guide development of the first tertiary Inclusion Health service in the West of Ireland.
Methods:
Patients reviewed during 5 month (10/2023 – 02/2024) pilot of inpatient consultations were included. Additionally, we performed a cross-sectional analysis of medical and surgical admissions in 01/2024 to identify those with IH needs but for whom a consult was not requested. We calculated cost of delayed discharges based on most recent bed day cost of €1’268.
Results:
We have identified 80 individuals with IH needs, 47 consults and 33 admissions; 30 (37.5%) females, 49 (61%) males and 1 (1%) transgender individual. Median age is 30 for females (23 - 74) and 48 for males (16 - 80). 49/80 (61%) are Irish born. Of non-nationals, common countries of origin are Ukraine (11, 14%), Poland (7, 9%) and Zimbabwe (3, 4%). 31 (39%) are homeless (PEH), 19 (61.3%) of them have an addiction. Alcohol is the most common drug of misuse; 46 (57%) of total cohort, of whom 34 (74%) have had a related admission and 37 (80%) have a related morbidity. 3/80 (3.75%) have previously injected drugs. 8 (10%) are seeking asylum and 11 (13.8%) are Ukrainian refugees. An interpreter is required for 23/80 (29%), Ukrainian is the language most commonly requested.
Most recent discharge diagnoses were grouped into 6 categories; alcohol related (22, 28%), community acquired respiratory infection (12, 15%), uncontrolled chronic disease (excluding alcohol disorders) (2, 2.5%), infectious diseases (7, 9%), social admission (3, 4%) and other (34, 42.5%).
5 (6.25%) remain hospitalized at time of data collection. Within the cohort, average length of stay (LOS) for most recent admission was 15.5 days (1 - 196). 11(13.8%) had a delayed discharge using 204 bed days (1 - 77). Approximate cost of this is €258,672.
10 (12.5%) accounted for 26 unscheduled presentations within 30 days of discharge, 5 required readmission. This cohort (80) accounted for 134 missed outpatient appointments over past 2 years. Excluding those admitted at present, 75 patients have required total of 1,714 bed days over past 5 years (LOS range 1 - 202).Conclusion:
Having identified a multimorbid group of patients with social complexity we present a contrasting population in the West when compared to existing hospital based IH services. An IH service could better meet needs and reduce rates of unscheduled care and bed days used.
ORAL PRESENTATION -
#2024032
"Navigating Scopulariopsis Infection in an Immunocompromised Host"
Principal Presenter: Fiona Murphy
Track: General Infectious Diseases
Background
A 59-year-old male with a history of relapsed refractory Chronic Lymphocytic Leukemia and associated hypogammaglobulinemia presented to our medical service with neutropenic fever, a skin lesion, and progressive pulmonary infiltrates. He had been evaluated for cough and neutropenic fever 7 weeks prior. He was receiving chemotherapy with rituximab, etoposide phosphate, vincristine sulfate, cyclophosphamide, and doxorubicin (R-EPOCH), in addition to ibrutinib. Antimicrobial prophylaxis regimen included voriconazole, trimethoprim-sulfamethoxazole, and acyclovir. Computed tomography (CT) of the chest demonstrated bilateral multifocal areas of consolidation and nodularity
Methods
Pertinent prior work-up included negative bacterial and fungal cultures from blood and a bronchoalveolar lavage (BAL) specimen, negative serum and BAL Aspergillus antigen, negative pneumocystis polymerase chain reaction and cryptococcal antigen from BAL, negative serological testing for endemic fungi, and a serum (1,3)-β-D-glucan of 124 pg/mL (reference range < 60 pg/mL). After five days of broad-spectrum antimicrobial therapy there was no clinical or radiographic improvement.
Results
Repeat bacterial and fungal blood and sputum cultures were negative. Serum (1,3)-β-D-glucan was 71 pg/mL, and serum aspergillus antigen remained undetectable. Repeat Bronchoalveolar lavage (BAL) was performed, and after three days of incubation there was growth of a filamentous fungus on fungal cultures. Subsequent fungal cultures obtained from a biopsy of the papular lesion grew the same organism. He was commenced on
Conclusion
A diagnosis of disseminated Scopulariopsis sp. infection was confirmed via matrix-assisted light desorption ionization-time of flight mass spectrometry. The patient was escalated to combination therapy with liposomal amphotericin B and caspofungin. Terbinafine was subsequently added. Profound neutropenia persisted in the setting of refractory CLL, and his pulmonary infiltrates progressed. This case challenges the physician to identity the etiology of an invasive mold infection (IMI) involving the lungs and skin. While rare, infections with Scopulariopsis sp. are increasing. Characteristic features of Scopulariopsis sp. include dual lung and skin involvement, rapid growth of flat dark brown colonies on fungal cultures and the presence of septate hyphae with characteristic conidiogenous cells observed on microscopy. The most effective treatment for Scopulariopsis sp. has not been determined due to instrinsic resistance to many antifungals. Invasive infections may require surgical and combination antifungal medical treatment
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#2024031
"Strengthening Preparedness through a Nurse-led High-Level Isolation Unit PPE Training Programme at Mater Misericordiae University Hospital's National Isolation Unit"
Principal Presenter: Stephenn Hernandez
Keywords: HLIU, Mater, NIUTrack: General Infectious Diseases
Introduction: The emergence of high-consequence infectious diseases (HCID) underscores the critical importance of robust preparedness and response strategies within healthcare institutions. Mater Misericordiae University Hospital recognises the importance of equipping its healthcare professionals with the knowledge and skills to manage HCID cases effectively. This study describes the efficacy of a nurse-led High-Level Isolation Unit (HLIU) Personal Protective Equipment (PPE) training program at the hospital, targeting multidisciplinary healthcare personnel, including Infectious Diseases Consultants, Infectious Diseases Registrars, nurses, and healthcare assistants.
Methods: A structured training program was developed and implemented over two months, incorporating theoretical instruction and practical exercises. Each session, lasting three hours, was organised to accommodate optimal attendance, with a maximum of ten and a minimum of six participants per session. The training sessions were facilitated by experienced Clinical Nurse Manager 2 and Staff Development Facilitators, ensuring alignment with existing policies and procedures within the HLIU. The curriculum focused on the National Isolation Unit (NIU) Activation Overview and PPE donning and doffing procedures, essential for effective HCID management.
Results: 100% (45) nurses from Infectious Diseases Wards, 83%(5) Infectious Diseases Registrars, 40%(4) Infectious Disease Consultants and 50%(5) Healthcare Assistants completed the training program. Feedback responses from participants revealed significant improvements in participants' knowledge and skills related to HCID management and PPE utilisation. The interactive nature of the sessions fostered active engagement and facilitated effective learning among participants.
Conclusion: Implementing a comprehensive HLIU PPE training program at Mater Misericordiae University Hospital underscores the institution's commitment to enhancing preparedness for managing HCID outbreaks. By equipping healthcare professionals with the necessary expertise, the aim is to ensure a prompt and effective response to potential outbreaks, protecting healthcare workers' and patients' health and safety. Continued investment in regular training, adherence to established protocols, and ongoing evaluation are essential for sustaining readiness and resilience in the face of emerging infectious disease threats.
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#2024030
"A Surprise Cestode: an Unexpected Case of Neurocystircercosis"
Principal Presenter: Daragh McGee
Track: General Infectious Diseases
Background
Neurocysticercosis (NCC) is a central nervous system infection with the larval stage of Taenia solium, the pork tapeworm. Cases are rarely reported in Northern Europe and typically occur in people who have lived in or travelled to endemic regions, which include Central/South America, sub-Saharan Africa, India, and Asia.
Case description
We present a case of NCC in a 34 year old lady who was born in Ireland, with no history of travel to an endemic region. She presented following a first generalized tonic-clonic seizure. She had no past medical history. She works in IT and lives with her Irish partner and two children. Her travel history was limited to Europe and North America. Her mother grew up in Lebanon and made several trips to Sierra Leone prior to our patient's birth. She had a GCS of 15 with no focal neurological deficits at presentation. Routine bloodwork was unremarkable, without eosinophilia. Cross-sectional imaging demonstrated a rim enhancing lesion in the left frontal lobe within the superior frontal gyrus measuring 9 x 10 x 10 mm, with moderate vasogenic oedema. The initial suspicion based on imaging and presentation was a primary intracranial neoplasm. She underwent a craniotomy for complete excision of the lesion, which was noted by neurosurgery to have an atypical 'rubbery' consistency. The histology reported the presence of a cestode with a typical three layered cyst membrane, without a visualised scolex. Subsequent circulating cysticercosis antigen and cysticercosis serology (Immunoblot and ELISA [antigen index 0.462]) were negative. Ophthalmology outruled ocular cysticercosis and imaging of the thorax, abdomen and pelvis did not reveal additional cysticerci. Family stool screening for ova/parasites were negative. Serology for HIV, echinococcosis, strongyloides and toxoplasma were negative.
Discussion
Cases of NCC outside of endemic regions are the result of contact with taenia carriers from endemic regions with fecal-oral transmission. Although no infection was proven in our patient's mother, we suspect this is the direct or indirect epidemiological link. This highlights the importance of a broad travel history that includes household contacts, particularly for infections with an intermediate host. Additionally, serological tests for cysticercosis were negative. The sensitivity of immunoblot is reduced to approximately 50% in patients with a single cysticercus, and detection of antigen is reliant on active infections with lesions predominate in the subarachnoid space or ventricular system. This case demonstrates some of the challenges in the diagnosis of NCC. -
#2024029
"Overcoming hurdles: Antimicrobial Dosing Dynamics and Drug Level Complexities"
Principal Presenter: Marco D. Smit
Keywords: Antimicrobial, Dose adjustment, Trough levelTrack: General Infectious Diseases
INTRODUCTION
Aminoglycoside and glycopeptide antibiotics are vital for treating severe bacterial infections, but clinicians face challenges in achieving therapeutic levels, especially in critically ill, obese, and elderly patients(1,2). Aminoglycosides can lead to nephrotoxicity, with rates ranging from 5% to 25%, influenced by factors like dosage and duration of administration(3). Vancomycin trough levels are monitored to ensure adequate dosing and prevent treatment failure and toxicity-related complications(3). Adjusting subtherapeutic levels is crucial to prevent antimicrobial resistance and hospital acquired infections(1).
METHOD
An audit conducted on 31/07/2023 reviewed a convenience sample of 20 currently admitted patients across medical, surgical, and gynaecological departments, who received vancomycin (IV), gentamicin, or amikacin during their stay. The audit followed international guidelines for prescription and monitoring(3, 4). Data, collected through an electronic tool, included pseudonymized demographic details, weight, last weight date, antibiotic used, therapy duration, trough levels, creatinine levels, and dose adjustments.
RESULTS
This audit involved 20 patients (13 males, median age 63). Gentamicin was prescribed to 8 patients, vancomycin to 12, and none received amikacin. Therapy duration ranged from 1 to 9 days (median=2.5). Antibiotic adjustments were made in 4 cases, not in 9, and stopped early in 7. Creatinine clearance (CrCl) calculated using the Cockcroft-Gault equation showed 3 patients with CrCl <50. Trough levels were collected in 14 patients; 4 required adjustments, with one supratherapeutic and 3 subtherapeutic. Weight hadn't been repeated since starting antibiotics in 5 cases, including all 3 patients with CrCl <50.
DISCUSSIONT
The audit revealed moderate adherence to reccomended practices. Trough levels were collected appropriately in most cases (19/20), and weights were recorded within 2 weeks before therapy, facilitating CrCl calculation. However, one case lacked weight data after 4 days of therapy. Antibiotic adjustments were infrequent (4 cases), potentially due to the small sample size. Notably, adjustments were based on trough levels in 3 out of 4 cases. Concerningly, two cases may have required adjustments based on CrCl or trough levels, but lacked necessary data. Similar issues were observed in a retrospective review of a Belgian tertiary hospital(5). This audit reflects day-to-day practices across multiple wards, underscoring the importance of precise weight-based dosing for optimal therapy. Recommendations include improved attention to dosing adjustments based on CrCl and trough levels, alongside regular monitoring of weight and renal function to enhance patient safety and treatment efficacy.
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#2024028
"Urosepsis and Emphysematous Osteomyelitis: A Case Report"
Principal Presenter: Kate O'Shea
Keywords: osteomyelitis, Emphysematous, DiabetesTrack: General Infectious Diseases
Emphysematous osteomyelitis is a rare but potentially fatal infection. It is caused by gas-forming organisms and is characterized by the presence of intraosseous gas. A 78-year-old man presented with a one-week history of flu-like symptoms, and a four-day history of lower back and gluteal pain, with associated lower limb weakness. He had a history of type 2diabetes mellitus and underwent a prostatectomy for prostate cancer 10 years previously.
He was found to be in diabetic ketoacidosis, with raised inflammatory markers, thrombocytopenia and an acute kidney injury. Klebsiella pneumoniae was isolated in blood and urine cultures.
Imaging was performed, as lower back pain was the patient's only localizing symptom. Computed Tomography showed extensive pockets of air centered on the L4 and L5 vertebral bodies, with extension into the adjacent iliopsoas muscles bilaterally as well as the anterior epidural space from L3-S1. Magnetic resonance imaging showed an epidural abscess along the posterior body of L5, with disk bulge causing severe canal and bilateral foraminal stenosis. Findings were consistent with emphysematous osteomyelitis and an iliopsoas abscess. Urosepsis with lymphovascular drainage to the lumbar region is considered the likely route of transmission.
The patient has been managed medically, with escalation to surgical management planned only in the event of cord compression or non-response to treatment. The initial treatment was with 9 days of IV cefotaxime, which was switched to IV aztreonam due to worsening liver function tests.
The main challenges in his management have been the anatomical location of the osteomyelitis, the slow response to antimicrobial treatment (with interval increase in the size of his iliopsoas abscess), pain management, sepsis-associated thrombocytopenia, and side effects of antimicrobial therapy.
Though one of the most common gram-negative species causing invasive infection, Klebsiella Pneumoniae is not commonly associated with osteomyelitis. Typical associations with urinary tract, respiratory, intra-abdominal and intra-cranial infections are well documented. However, a literature review of emphysematous osteomyelitis identified Klebsiella Pneumoniaeas the causative agent in 20% of all reported cases in the English literature. Diabetes was a predisposing factor in 34% of cases. Nearly half of all cases involved the vertebrae. This case highlights a rare but severe complication of invasive Klebsiella Pneumoniae infection and emphasizes the importance of cross-sectional imaging in patients with new onset back pain in the setting of Klebsiella bloodstream infection.
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#2024027
"Safety and efficacy of daptomycin for Outpatient Parenteral Antimicrobial therapy (OPAT) patients in a level 4 Irish Hospital over 1 year."
Principal Presenter: Kaitlyn O'Brien
Keywords: daptomycin, OPAT, eosinophilic pneumonitisTrack: General Infectious Diseases
Safety and efficacy of daptomycin for Outpatient Parenteral Antimicrobial therapy (OPAT) patients in a level 4 Irish Hospital over 1 year.
K O’Brien 1, L Colclough 2, P Mitchell 3,4 , B Shah 5, E Moloney 3,4, S Waqas 1,4.
Departments of 1. Infectious Diseases2. Pharmacy and 3. Respiratory Medicine, Tallaght University Hospital 4: Clinical Medicine TUH, School of Medicine, Trinity College Dublin, Dublin, Ireland. 5: Histology department St James Hospital.
Background:
Daptomycin is a cyclic lipopeptide antibiotic commonly used in Outpatient Parenteral Antimicrobial therapy (OPAT) to treat gram positive bacterial infections such as MRSA and VRE.
Clinicians should be aware of potential adverse effects including asymptomatic rise in creatinine kinase (CK), rhabdomyolysis and eosinophilic pneumonitis. The co-prescribing of a statin with daptomycin can lead to increased rates of complications. Irish HPRA guidelines recommend CK monitoring at baseline and weekly thereafter (1).
Methodology:
The study was commenced after local Quality improvement office approval. The OPAT clinical database maintained on secure hospital intranet drive was accessed to gather data on the patients who were prescribed daptomycin between August 2022 and August 2023.
Results:
During the study period 93 patients were discharged on OPAT with 26 (28%) of these prescribed daptomycin either alone or in combination with other antimicrobials. The age range of these patients were 23 to 82 with a median of 66.5. The most common (23%) diagnosis was prosthetic joint infection. All patients on Daptomycin had their CK monitored during their OPAT course with 19 patients (73%) having it monitored weekly. Abnormal CK levels developed in 7 (27%) patients while on daptomycin, and in 1 (3.9%) patient it was significantly greater than 5 times the ULN necessitating a change in antibiotic.
Two patients developed complications attributable to daptomycin; one developed eosinophilic pneumonitis and another had atypical sarcoid reaction. Five patients in total required readmission while on daptomycin on OPAT, one of which, eosinophilic pneumonitis was secondary to daptomycin. At six months post discharge from hospital, 25 (96%) of patients were alive and well with one patient (4%) passed away following discharge from OPAT clinic due to a pre-existing medical condition.
Conclusion:
This study found that all OPAT patients prescribed daptomycin (n=26) had their baseline CK monitored. Nineteen (73%) out of these had it monitored weekly thereafter while on OPAT. The rates of 3.9% significant rise in CK while on daptomycin was in line with the published literature (2). Infections for which daptomycin was prescribed either on its’ own or with other antimicrobials responded as expected and readmission rate due to adverse effects of daptomycin was low pointing to the safety and efficacy of daptomycin for these OPAT patients.
1. Summary of product characteristics - HPRA, Daptomycin [Internet]. 2017 [cited 2023 Nov 28]. Available from: https://www.hpra.ie/img/uploaded/swedocuments/LicenseSPC_PA0126-286-001_08092017134051.pdf
2. Gonzalez-Ruiz A, Beiras-Fernandez A, Lehmkuhl H, Seaton RA, Loeffler J, Chaves RL. Clinical experience with Daptomycin in Europe: The first 2.5 years. Journal of Antimicrobial Chemotherapy. 2011;66(4):912–9. doi:10.1093/jac/dkq528
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#2024026
"Pyogenic Cerebral Abscess Secondary to Streptococcus Anginosus"
Principal Presenter: Adam Kelly
Keywords: Abscess, Cerebral, StreptococcusTrack: General Infectious Diseases
Brain abscesses have an incidence of 0.3–1.3 / 100,000 population with 2–5% being dental in origin1. Streptococcus Anginosus is a pathogen widely associated with cerebral abscess. S.Anginosus is a highly virulent α-hemolytic gram-positive member of the Streptococci Viridans group, also known as the Streptococcus Milleri group. S.Anginosus is a commensal microbe of the oropharynx, gastrointestinal and urogenital tract. While cerebral abscesses are rare, risk factors for infection include immunosuppression, penetrating trauma and invasive neurosurgical procedures. Contiguous spread to the brain is classically associated with a focus of infection within the oral cavity, sinusitis, and mastoiditis. S.Anginosus has a predilection for cerebral tissue adherence and abscess formation. It’s pathogenicity is mediated by various virulence factors including biofilm, hydrolytic enzymes and encapsulation. Compared to other Streptococci species, S.Anginosus cerebral abscesses invariably require aggressive neurosurgical intervention and prolonged courses of antimicrobial therapy. S.Viridans species are typically susceptible to penicillin and beta lactams are generally effective.We report the case of a 60 year old Aboriginal gentleman presenting to a tertiary Australian hospital with a 24 history of right upper limb weakness, worsening confusion and headache. Neurological exam was notable for a right inferior quadrantanopia. A non contrast CT brain was performed revealing a 2.2cm x 3cm x 3cm multilobulated lesion in the left occipital lobe. Follow up MRI brain confirmed a left occipital lobe abscess. Chest x-ray demonstrated bilateral patchy opacification with dense left upper lobe consolidation. Patient was commenced on empiric IV Meropenem 2g three times daily to cover a possible Mellioid or Nocardia infection as a cause of synchronous cerebral and pulmonary lesions. Admission bloods were notable for WCC 13 and CRP 95. Three sets of peripheral blood cultures were negative as were toxoplasma, aspergillosis, cryptococcal antigen, HIV, Hepatitis B and C. Nocardia and Mellioid serology were negative. A short interval MRI Brain revealed progressive enlargement of the lobulated abscess with moderate surrounding vasogenic oedema. Patient underwent left occipital burr hole with resection of the abscess capsule and evacuation of contents. Pus extracted from the abscess intraoperatively cultured abundant growth of S.Anginosus. Pathogen was susceptible to ceftriaxone and metronidazole. Patient was discharged home on OPAT and completed a six week total duration of IV therapy. A follow up MRI brain revealed near complete resolution of the abscess and patient continues to do well.Streptococci species including S.Anginosus remain a common cause of cerebral abscess. Clinicians should keep a high index of suspicion for S.Anginosus as a causative organism of cerebral abscess especially in those with poor dentition. This case underscores the value of a multidisciplinary approach as well as timely, targeted antimicrobial therapy to ensure optimal clinical outcome.
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#2024025
"Immigrants reported high levels of trust in Irish healthcare services, but faced challenges regarding accessibility and privacy"
Principal Presenter: Fergal Howley
Track: Diversity & Inclusion
Background
Migrants, particularly those seeking asylum and refugees, often have complex healthcare needs and a higher burden of infectious diseases. A lack of formal support and healthcare services for this cohort of patients has been identified in Ireland. This service evaluation sought to identify barriers to treatment and areas of strength and weakness in provision of care for migrant populations.
Methods
Patients who had immigrated to Ireland and attended the infectious diseases clinic in a tertiary centre were included in this service evaluation. Participants recorded their experiences of accessing healthcare in Ireland using a questionnaire. We used recommendations from a Royal College of Physicians of Ireland position paper on Migrant Health as a standard against which the service evaluation was conducted.
Results
76 patients participated in this study, with a mean age of 44 years. The majority of participants were from Africa. More than 60% described their migrant status on arrival in Ireland as ‘refugee’ or ‘asylum seeker’. Despite just 18% of participants listing English as their native language, the majority reported good communication from healthcare providers, with <5% reporting they had ever left an appointment without understanding their illness or with unanswered questions. The level of trust patients had in healthcare providers was high (88%). Nearly one third of patients had attended clinic four times or more in the past year, with 26% reporting that their commute to our facility took more than two hours. 14.5% reported being unable to access healthcare in Ireland at one time due to cost, while nearly 20% had no general practitioner. 47% described having to hide their medications from people they were living with; this figure rose to 71% among those living in direct provision.
Conclusions
Confidence and trust in healthcare providers was high among migrants attending infectious diseases services, and patients generally reported being satisfied with levels of communication in clinic. Long commuting times and frequent attendances were among the challenges faced by patients, while a significant proportion of patients did not have a general practitioner. Patients living in direct provision were less likely to have a general practitioner, and more likely to have experienced challenges in preserving their privacy regarding medical conditions. This service evaluation can help inform decision-making regarding allocation of resources, and identify areas for further research regarding the complex care needs of migrants to help instruct policy at a national level.ORAL PRESENTATION -
#2024024
"An Audit of the Use of Antibiotics in End of Life Care"
Principal Presenter: Fergal Howley
Keywords: Palliative care, Antimicrobial stewardship, End of life careTrack: Other
Background:
Antibiotic prescribing at end of life (EOL) is common, with potential harm as well as benefit. We describe the use of antibiotics in patients approaching EOL in a Model 2 hospital, comparing our practice against the Good Practice Recommendations as outlined by the Scottish Antimicrobial Prescribing Group.
Methods:
A retrospective chart review was carried out on patients who had died in hospital during the year 2022. Data regarding antimicrobial use, indication for use, microbiologist advice, and EOL planning was gathered from the Kardex and medical notes.
Results:
28 patients were included (57% female), with an average age of 87 years. The median length of stay was 24 days.
The most common presenting complaint was confusion (29%), with general decline, falls, weakness, pain and infective symptoms (diarrhoea, respiratory symptoms) making up the rest.
23 patients (82%) received antibiotics in their last four weeks of life (excluding pre-hospitalisation). Of these, 15 received two or more courses during their final weeks of life. Antimicrobial therapy was escalated in 12 cases (52%). All but two patients received intravenous antibiotics. 11/23 (48%) received antibiotics to within one day of their death.
Specialist microbiology review of antibiotics occurred in 16 cases, and in ten of these cases (63%) the antibiotic was deemed inappropriate (either wrong choice, inappropriate duration, or inappropriate indication for the antibiotic).
Clear ceilings of care were established in 21/28 cases, but plans regarding future antibiotic prescribing were documented in only 12 cases.
Conclusions:
Rates of antibiotic use were high among patients approaching EOL care. Irish data for comparison regarding antibiotic use in EOL care is lacking. One audit in an Irish hospital found that, among those receiving antibiotics when approaching EOL, 42% were continued on antibiotics despite EOL being recognised, with 28% receiving antibiotics until they died. This compared with 48% in our audit receiving antibiotics to within one day of death. Though high, this compares favourably with certain international studies. In an Australian study, 63% of patients received antibiotics at end of life care. While sometimes initiated in an attempt to change the clinical outcome, the use or choice of antibiotic was often deemed inappropriate by a specialist. Documentation of ceilings of care was common, but rarely recorded whether future antibiotics would be appropriate as the patient approached EOL.
While infection is often the cause, or a complication, of a person approaching the end of their life, clinicians should consider the relative benefits and risks of prescribing antibiotics and document the rationale for their use. -
#2024023
"Novel Biomarkers for Distinguishing Bacterial from Non-bacterial Infection: A Systematic Review"
Principal Presenter: Holly Drummond
Keywords: biomarker, infection, reviewTrack: General Infectious Diseases
Background: Distinguishing between serious and invasive bacterial infections and non-bacterial aetiologies is challenging, particularly in high-risk groups such as febrile infants under 90 days old. As such, clinicians tend to adopt a cautious approach, potentially leading to the overuse of antibiotics. Existing biomarkers, e.g. C-reactive protein (CRP) and procalcitonin have significant limitations in differentiating bacterial infection and a number of novel biomarkers are emerging to aid this diagnostic process. We present a systematic review of novel biomarkers of bacterial infection.
Methods: A literature search was performed in Medline Ovid using predefined terms. Included articles reported the diagnostic utility of novel host blood plasma or serum biomarkers for discriminating bacterial infection from other aetiologies, with no age restrictions. Following published guidelines for minimal diagnostic performance requirements, biomarkers with a sensitivity ≥90% and specificity ≥80%, or an area under the curve (AUC) ≥0.9 were selected. Studies assessing these biomarkers were required to demonstrate minimal bias.
Results: Our initial search identified 2,236 publications. Following screening and full-text review, 47 articles met the inclusion criteria and were subjected to final analysis. Three individual biomarkers and two grouped signatures met the specified thresholds. The individual biomarkers include interferon-gamma (IFN-γ), interferon-alpha (IFN-a) and lipocalin-2 (LCN2). One grouped signature comprises tumour necrosis factor-related apoptosis-inducing ligand (TRAIL)+interferon gamma-induced protein 10 (IP-10)+CRP and the other grouped signature comprises E-selectin (SELE)+interferon-18 (IL18)+neural cell adhesion molecule 1 (NCAM1)+galectin-3-binding protein (LG3BP)+LCN2+IFN-γ.
IFN-γ, studied in six publications encompassing 962 subjects, exhibited an AUC ≥0.9 (0.94) in one study. IFN-a, in one publication with 101 subjects, showed an AUC of 0.93. LCN2 had AUCs of 0.97 and 0.91, meeting the threshold in two out of the nine relevant publications and was studied in a total of 2,220 subjects. The TRAIL+IP-10+CRP signature, investigated in eight publications in a total of 2,638 subjects, exceeded the threshold in six publications, with AUCs of 0.94 and 0.90, sensitivities ranging from 93.5% to 98.1% and specificities between 88.0% and 94.3%. The SELE+IL18+NCAM1+LG3BP+LCN2+IFN-γ signature, studied in a single publication comprising 306 subjects had a sensitivity of 90.4% and a specificity of 89.6%.
Conclusion: Our review identified three promising individual biomarkers and two grouped signatures for differentiating bacterial from non-bacterial infection. Among these, the TRAIL+IP-10+CRP signature demonstrated promise across the greatest number of subjects. To assess the diagnostic efficacy of the novel biomarkers and grouped signatures in discriminating bacterial infection, further validation is necessary in specific cohorts such as febrile infants.
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#2024022
"ESTIMATION OF RESPIRATORY SYNCYTIAL VIRUS (RSV) BURDEN FOR INFANTS IN SECONDARY CARE HOSPITAL RECORDS IN IRELAND, 2017 -2022"
Principal Presenter: Sean Brennan
Keywords: RSV, Virus, HospitalTrack: Epidemiology & Population Health
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 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 7,835 notifications in 2023, and the 0-4 years age group the most affected. [2].
To describe RSV-related inpatient hospitalisations and estimate direct healthcare costs in infants <2 years of age in Ireland over a 5-year period, from 2017-2022.
Data for inpatient hospitalisations due to RSV in infants <2 years of age between 2017–2022 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) [7]. Additional bronchiolitis ICD-10 codes (J21.1/J21.8/J21.9) are also useful for capturing LRTI hospitalisations [7]. Hospital costs were estimated by applying unit costs to the number of hospitalisations. Unit costs were based on the cost per day for an inpatient stay from the ABF* 2023 admitted price list for minor respiratory infection (€3972) [7, 8].
The number of RSV-specific hospitalisations in infants <2 years of age was 2,727 in 2022, compared to 1,200 notifications in 2017. This represents a 127% increase in discharges due to RSV from 2017 to 2022. In addition, 1,430 hospitalisations were reported under non-RSV-specific ICD-10 codes in infants <2 years in 2022. The corresponding cost of secondary care admissions for laboratory-confirmed RSV was €4,766,400 in 2017 rising to €10,831,644 in 2022. However, these costs could be as high as €16,511,604 in 2022 if discharges due to bronchiolitis are considered.
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, regarding potential preventative options for RSV.
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#2024021
"Treatment Outcome of Active Mycobacterial Cases and Case Closeout with Public Health - A Two-Year Retrospective Audit"
Principal Presenter: Melva Tan
Keywords: TB, Mycobacterial infection, Public health HPSCTrack: General Infectious Diseases
Background: According to ECDC data, the percentage of treatment success after 12 months among new and relapse TB cases notified during 2019-2020 in Ireland was below 5% compared to over 70% when combing all the EU/EEA countries. This is attributed to paucity of data captured by the HPSC. This audit aims to evaluate the treatment outcome of active mycobacterial cases and identify data gaps in the Public Health at case closeout.
Methods: Patients at our tertiary site treated for TB and patients with positive mycobacterial cultures from January 2022 to December 2023 inclusive were included in the analysis. A retrospective review of paper and digital records was carried out to evaluate demographic data, HIV testing, site of disease, and details of treatment. Upon treatment completion, letters to Public Health, if any, were also reviewed via electronic system.
Results: 40 mycobacterial cases were studied. 53% (N=21) were males, mean age 39 years (range 18-78). The highest proportion of region of origin was Asia (N=17). 97.5% cases had HIV testing done, positive (N=4); two were known prior, two were newly diagnosed. Sites of disease were extra-pulmonary 26 (65%), pulmonary 11 (27.5%), and both 3 (7.5%). Four were PCR positive only, 16 were positive by both PCR and culture, 10 were positive by culture only, and 10 were not microbiologically confirmed. Of the 26 culture positive cases, five were NTM and 21 were MTB complex; 14 were pansensitive. 31 cases underwent treatment; three died before treatment was commenced, three discontinued due to alternative diagnoses and three were NTM which did not meet criteria for treatment. Treatment was standard RHZE for 2 months followed by RH for 4 months in the majority of cases (N=21), of which four were treated with second-line regimen. Three were treated for 9 months with Rifampicin free regimens and seven received 12 months for CNS or disseminated disease. Treatment was well tolerated (N=19), transient side effects (N=8), and significant adverse effects such as DILI (N=3) and IRIS (N=2). Out of the 23 cases who completed treatment, 11 had case closeout letter communicated to Public Health, of which five had missing information such as HIV testing and DST.
Conclusion: With a dedicated centralised TB/mycobacteria service, this audit is working towards building a systemic proforma with comprehensive assessment and documentation, at both initial diagnosis and upon treatment completion. In the interim, Public Health link directly with the service to address data gaps and improve outcome reporting to the HPSC.
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#2024020
"Systematic Literature Review of Real-world Experience with the 2-Drug Regimen Dolutegravir + Lamivudine (DTG + 3TC) in People with HIV-1 Aged ≥50 Years"
Principal Presenter: Tahera Khorakiwala
Keywords: Dovato, Aging PLHIVTrack: Other
Background: Despite representing >50% of people with HIV-1 in Europe and North America (>20% globally), those aged ≥50 years are underrepresented in HIV-1 clinical studies. DTG + 3TC demonstrated high efficacy and good safety in phase 3 randomized controlled trials (RCTs), with comparable outcomes in participants aged ≥50 vs <50 years among treatment-naive (GEMINI-1/-2 at Week 144) and suppressed-switch populations (pooled SALSA/TANGO at W48). Supplementing RCT data from people with HIV-1 aged ≥50 years with real-world evidence can help assess DTG + 3TC clinical outcomes in this understudied population.
Methods: A systematic literature review was conducted following PRISMA guidelines. Publications from January 2013 to March 2023 reporting DTG + 3TC data for real-world populations aged ≥50 years were obtained from Embase®, Ovid MEDLINE®, MEDLINE® In-Process (via PubMed), and Cochrane databases and relevant conferences. Individuals from a single cohort overlapping across publications were not double-counted; however, all potential overlap cannot be ruled out.
Results: The literature review identified 187 publications representing 146 studies, 67 cohorts, and 36,313 people with HIV-1 using DTG + 3TC; of these, 13 lead publications representing 13 unique cohorts reported baseline data and DTG + 3TC use in 1727 individuals aged ≥50 years. Five lead publications (N=833) reported outcomes for treatment-naive (n=68), treatment-experienced (n=386), and mixed naive/experienced populations (n=379). Overall, 8 studies reported DTG + 3TC effectiveness outcomes, 3 reported safety, and 4 reported tolerability. High virologic suppression rates (<50 years: 92.6%-99.0%; ≥50 years: 95.5%-99.6%; <60 years: 100%; ≥60 years: 96.9%) and few virologic failures were observed across studies. One regression analysis found no association between virologic suppression and age ≥50 years (n=36; treatment-naive). No treatment-emergent resistance mutations were reported at failure. DTG + 3TC had a good safety profile with few treatment-associated discontinuations.
Conclusion: Initial real-world studies of DTG + 3TC in people with HIV-1 aged ≥50 years show high effectiveness and a safety and tolerability profile consistent with RCTs.
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#2024019
"Real-world Effectiveness of Dolutegravir + Lamivudine (DTG + 3TC) in Treatment-Naive People with HIV-1 and Low CD4+ Cell Count or High Viral Load at Baseline: a Systematic Literature Review"
Principal Presenter: Tahera Khorakiwala
Keywords: Dovato, High VL, Low CD4Track: Other
Background: Low CD4+ cell count or high viral load (VL) remain important considerations when initiating therapy in treatment-naive people with HIV-1. DTG + 3TC was effective in achieving virologic suppression among these populations in the GEMINI-1/-2 and STAT trials. To complement existing clinical trial data and support treatment decisions, we summarize real-life data on DTG + 3TC effectiveness in treatment-naive people with HIV-1 with low CD4+ cell count or high VL.
Methods: A systematic literature review was conducted using PRISMA guidelines. Studies published between January 2013 and March 2023 were retrieved from Ovid MEDLINE®, Embase®, PubMed, Cochrane library, and international conference proceedings.
Results: We identified 187 publications reporting results from 146 studies of 67 cohorts (N=36,313). Ten and 14 non-overlapping studies included treatment-naive people with HIV-1 with CD4+ cell count <200 cells/mm3 (low CD4+ cell count; n=215) or VL ≥100,000 copies/mL (high VL; n=502) at baseline, respectively. Six and 10 studies reported virologic effectiveness for individuals with low CD4+ cell count (n=122) or high VL (n=315), respectively. Overall, 86% (54/63) of people with baseline CD4+ cell count <200 cells/mm3 were virologically suppressed at Week 24, 94% (46/49) at Week 48, and 70% (7/10) at Week 96. Among the 4 studies reporting outcomes for N ≥10 individuals with low baseline CD4+ cell count, 88% (45/51) achieved VL <50 copies/mL at Week 24, 94% (30/32 and 16/17) at Week 48, and 70% (7/10) at Week 96. For individuals with baseline VL ≥100,000 copies/mL, 50% (5/10) and 88% (37/42) had <50 copies/mL at Week 24, 100% (14/14) and 100% (152/152) at Week 48, and 87% (39/45) at Week 96. In the 2 cohorts with N ≥10 individuals with baseline VL ≥500,000 copies/mL, 59% (13/22) and 89% (16/18) achieved suppression at Week 24 and 95% (21/22) at Week 48.
Conclusion: Consistent with data from the GEMINI-1/-2 and STAT clinical trials, initial real-world evidence from treatment-naive individuals initiating DTG + 3TC shows high rates of virologic suppression regardless of CD4+ cell count or VL at baseline. An ongoing clinical trial will provide additional DTG + 3TC efficacy data in these subpopulations.
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#2024018
"Retrospective Study on the Prevalence of Cardiovascular Disease in People Living with HIV"
Principal Presenter: Donnchá O'Herlihy
Keywords: HIV, Cardiovascular Disease, HypertensionTrack: Epidemiology & Population Health
Background: Since the success of antiretroviral therapy in the 80s, people living with HIV (PLHIV) can now expect to have a life expectancy near or equal to that of individuals without HIV. However, with an ageing population comes other comorbidities that would also be expected in the non-infected HIV population. Studies suggest that PLHIV have an increased risk of cardiovascular disease compared to those without HIV. This project has the possibility of demonstrating that PLHIV in the CUH have an increased risk of cardiovascular disease.
The aim of this study was to assess whether cardiovascular risk is increased or decreased by the patient’s sociodemographic characteristics and to examine the relationship between years lived with HIV or years exposed to antiretroviral therapy and cardiovascular disease
Methods: The files of PLHIV aged 40+ (n=100) attending the outpatients department were collected in the Department of Infectious Diseases, CUH. SPSS version 28 was used for analyses. Descriptive statistics was used to determine population characteristics. Years lived with HIV and years exposed to antiretrovirals compared to cardiovascular events were analysed using the Independent-Samples t-test. Sociodemographic characteristics by cardiovascular events were analysed using the Chi-Squared Test. When assumptions were violated, the likelihood ratio was used instead, with p < 0.05 being considered significant.
Results: 6% of patients had a cardiovascular event (TIA, myocardial infarction and stroke). 30% had hypertension, 41% had hypercholesterolaemia, and 54% had at least one or more of these variables. There was significance between age group and hypertension (p=0.009). No statistically significant association was found between years lived with HIV and hypertension (p=0.677), hypercholesterolaemia (p=0.386), cardiovascular events (p=0.855) or combined (p=0.48). No statistically significant association was found between years of exposure to antiretroviral and hypertension (p=0.715), hypercholesterolaemia (p=0.214), cardiovascular events (p=0.573) or combined (p=0.653).
Conclusion: Cardiovascular risk factors were seen in over half of patients over 40 with HIV in the CUH. It suggests a significance between age and hypertension. However, further evidence is needed to clarify if there is an association between years lived with HIV and cardiovascular disease as well as years exposed to ART and cardiovascular disease. Cardiovascular disease is common in PLHIV and it is the duty of the healthcare professional to adequately screen, promptly identify and efficiently treat those who are at risk. -
#2024017
"Rates of Completion of Treatment for Latent TB Infection in Healthcare Workers in University Hospital Galway."
Principal Presenter: Aoife Hehir
Keywords: Latent TB infection, Healthcare Workers, University Hospital GalwayTrack: General Infectious Diseases
Background
23% of the world’s population have latent TB infection (LTBI); Healthcare workers (HCWs) have a higher risk. LTBI treatment reduces reactivation. WHO End TB Strategy prioritises LTBI screening and treatment in high-risk groups, including HCWs.
WHO recommend 6 or 9 months of isoniazid or 3-4 months of rifampicin as monotherapy options for treatment.
The TB clinic in UHG is providing care of new entrant HCWs referred by occupational health (OH) with LTBI. The aim of this study was to determine rates of treatment completion for LTBI in HCWs in this clinic.Methods
A retrospective chart review was undertaken in the TB clinic and approved by ethics committee. Included were HCWs with LTBI referred by OH from Jan-Dec 2023, defined by a positive IGRA test and a normal chest xray. Comparative analysis was conducted using Chi square and student t test.Results
94 HCWs were referred to the clinic in 2023. Age range was 20-62 years (Mean 36.5, SD 7.8). 61% were female, 39% male. 59/94 (63%) were originally from India, 16/94 (17%) Pakistan, 7/94 (7%) Philippines, 5/94 (5%) Nepal, 4/94 (4%) Zimbabwe, 2/94 (2%) Brazil, and one person each from Nigeria and Somalia. 76/94 (81%) were nurses, 15/94 (16%) doctors, 1/94 (1%) HCA, and 2/94 (2%) medical students.
13/94 (14%) did not attend (DNA) an initial appointment. 81/94 (86%) attended. Of these 63/81 (78%) commenced treatment; 56/63 (88%) commenced Rifampicin and 7/63 (12%) Isoniazid monotherapy. 6/81 (7%) deferred treatment and 12/81 (15%) declined treatment. 6/63 (10%) DNA'd following treatment commencement. 44/63 (70%) have completed their treatment and 8/63 (13%) remain on treatment.
Treatment completion was not associated with gender (p .075) or country of birth (p .074). Treatment completion rate was associated with HCW type (p .023), with non-medical staff more likely to complete treatment than doctors (p .008). Treatment completion was not associated with age (p .272).Conclusion
LTBI among HCW is increasing, likely reflecting increased screening and changing demographics of HCW in Ireland.
This study highlights high rates of clinic non-attendance and low treatment completion rates in HCW who were referred to a dedicated clinic. Doctors had significantly lower treatment completion rates.
Interventions, including education, and reviewing our traditional approach to hospital based outpatient clinics may be required to address this. -
#2024016
"Comparative Analysis of COVID-19 Outbreaks in Healthcare Settings During Distinct SARS-CoV-2 Variant Epidemiological Waves in Ireland"
Principal Presenter: Brenda McManus
Keywords: SARS-CoV-2, COVID-19 Outbreaks, Health and care settingsTrack: Epidemiology & Population Health
Background:
SARS-CoV-2, the causative virus of the COVID-19 pandemic, was first detected in Ireland in March 2020. The emergence of distinct SARS-CoV-2 variants is a considerable driving force behind COVID-19 wave activity and outbreaks. Several COVID-19 waves have been observed in Ireland, during which circulating SARS-CoV-2 variants were identified via the National SARS-CoV-2 Whole Genome Sequencing Surveillance program. COVID-19 outbreak investigations have consistently been prioritised for those at higher risk of severe disease and in settings that benefit most from public health interventions (such as healthcare and long-term care settings). This approach means that outbreaks in these settings are less influenced by testing and reporting variations than those in non-healthcare settings. As such, the current study sought to compare outbreaks that occurred in Nursing Homes, Residential Care Facilities (such as centres for children, older people or those with disabilities), Hospitals and Community Hospitals/Long stay units during winter COVID-19 waves predominantly associated with specific SARS-CoV-2 lineages.
Methods:
The number, size and case fatality rates of COVID-19 outbreaks that occurred in healthcare settings during winter waves (week 40 – week 20 inclusive) were compared. Wave threshold dates were determined based on available genomic data indicated variant dominance i.e. >50% prevalence. Waves were named according to the predominant SARS-CoV-2 variant in circulation.
Results:
Eight distinct SARS-CoV-2 winter-based COVID-19 waves were observed. Linear relationships were observed between the numbers of COVID-19 outbreaks, outbreak-associated cases and deaths for distinct SARS-CoV-2 variants, indicating that COVID-19 outbreaks are influenced by SARS-CoV-2 lineages. The highest mean numbers of outbreak-associated cases and deaths (18 cases, two deaths) were recorded during the first two waves (wild-type and Alpha variants). Comparatively fewer cases and deaths occurred during the subsequent Delta wave (mean eight cases, 0.4 deaths), likely as a direct consequence of vaccination of residents in nursing homes. Subsequent waves have been driven by Omicron lineages, and recombinants thereof, within which the mean number of outbreak-associated cases ranged between 5 and 14. Of these, the Omicron BA.1 lineage was associated with the highest number of outbreaks, cases and deaths (mean 14 cases, 0.3 deaths). Deaths have remained consistently low (mean < 0.3) since the administration of COVID-19 vaccinations in Ireland.
Conclusions:
The numbers of COVID-19 outbreaks, associated cases and deaths in healthcare settings were influenced by distinct SARS-CoV-2 lineages but were reduced by population immunity, either resulting from natural infection or the timely administration of COVID-19 vaccinations and adapted SARS-CoV-2 booster vaccines.
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#2024015
"The National SARS-CoV-2 Whole Genome Sequencing Programme"
Principal Presenter: Sarah McGarry
Keywords: genomics, COVID-19, variantsTrack: Epidemiology & Population Health
Background:
The National SARS-CoV-2 Whole Genome Sequencing Programme (NSWGSP) was established in 2021, in response to the COVID-19 pandemic in Ireland. The goal was to develop a national strategy for SARS-CoV-2 genomic epidemiology and to inform the public health response to COVID-19.
Description:
The programme functions as a ‘hub and spoke’ model, led by the Health Protection Surveillance Centre and the National Virus Reference Laboratory (hub), and seven acute hospital laboratories (spokes), which represent Ireland’s six Regional Health Areas and Children’s Health Ireland Hospitals. The focus of the NSWGSP is to sequence laboratory confirmed SARS-CoV-2 cases from nationally representative surveillance systems, including all hospitalisations, ICU cases, and deaths processed in spoke laboratories. The goal is to identify variants associated with severe disease and death, outbreaks in healthcare settings, and changes in SARS-CoV-2 characteristics such as transmissibility. Samples from sentinel surveillance systems, such as sentinel GP and severe acute respiratory infection cases, are also captured.
Results:
As of 20/02/2024, 108,819 SARS-CoV-2 positive specimens have been sequenced in Ireland, contributing to local incident and outbreak management and national public health policy on an ongoing basis. Furthermore, Irish sequencing data collected by the NSWGSP is shared with international partners and represents Ireland’s contribution to global SARS-CoV-2 epidemiology. Ireland ranked 1st among all EU/EEA member states contributing data to the ECDC for SARS-CoV-2 sequencing timeliness and ranked 3rd for sequencing volume in week 5 2024.
Main Messages:
The NSWGSP is an efficient, sustainable, and scalable model for a laboratory public health programme. It ensures regional equity, and builds capacity both nationally and regionally, increasing resilience and expertise throughout the country. Going forward, major objectives of the programme include increasing its operational capacity, developing genomic sequencing education opportunities, and broadening the sequencing remit to include other pathogens in order to fully integrate WGS into standard public health practice.
ORAL PRESENTATIONPDF (392.49 KB) -
#2024014
"Calculating direct healthcare salary costs and factors associated with healthcare personnel workdays lost due to COVID-19 infection in the age of widespread vaccine availability"
Principal Presenter: Liam Townsend
Track: Epidemiology & Population Health
Background
The COVID-19 pandemic placed an unprecedented burden on societal systems, including the healthcare setting, with economic consequences. Healthcare worker (HCW) illness and workdays lost due to SARS-CoV-2 infection exacerbated the strain on healthcare systems. Vaccination against COVID-19 can mitigate the burden of HCW infection. We investigate the burden of HCW illness and its associated direct healthcare personnel costs in the setting of widespread vaccine availability and explore factors influencing these outcomes.
Methods
This multi-centre prospective study followed HCWs over an eight-month period from January 2023 – August 2023, as part of the Prevalence of Antibodies to SARS-CoV-2 in Irish HCWs (PRECISE) study. Data recorded included incident COVID-19 infection, symptom burden and work days missed during the study period, as well as vaccine history. Workdays lost due to illness were used to calculate direct healthcare personnel costs due to COVID-19 infection, using published salary scales. Univariate analysis and multivariable regression investigated the factors associated with workdays lost and direct healthcare personnel.
Results
1,218 participants were enrolled and followed for 8 months, with 266 incidents of SARS-CoV-2 infection, 1,191 workdays lost and healthcare personnel costs of €397,974 during this period. Multivariable regression revealed that workdays lost were associated with incomplete primary COVID-19 vaccination course. There was also seasonal variation, with June having significantly fewer days of absence compared to January. Increased healthcare personnel costs were associated with being unvaccinated, of older age, and of male sex. Seasonal variation was again seen, with higher costs in March and lower costs in June.
Conclusions
Healthcare workdays lost remain a significant issue and are associated with healthcare system burden despite vaccine availability. These can be mitigated via targeted implementation of vaccine programmes. Seasonal variation in healthcare workdays lost should inform workforce planning to accommodate surge periods.
ORAL PRESENTATION -
#2024013
"Sustained Improvements in Biomarkers Observed with Fostemsavir in Heavily Treatment-Experienced Adults with Multidrug-Resistant HIV-1 from the Phase 3 BRIGHTE Study through Week 240"
Principal Presenter: Tahera Khorakiwala
Keywords: fostemsavir, BRIGHTE, ViiVTrack: Other
Background: The phase 3 BRIGHTE study demonstrated durable virologic and immunologic responses in heavily treatment-experienced (HTE) adults with multidrug-resistant HIV-1 through 240 weeks of treatment with fostemsavir + optimized background therapy (OBT). However, its long-term impact on inflammation in the HTE population has not been studied. Here, we assessed changes in immunologic parameters (CD4+/CD8+ ratio) and biomarkers of coagulopathy, immune activation, and inflammation (D-dimer, soluble CD14 [sCD14], and soluble CD163 [sCD163]) in BRIGHTE through Week 240.
Methods: Participants with 1 or 2 fully active antiretroviral agents available at screening were assigned to the Randomized Cohort (RC; N=272) and received fostemsavir 600 mg twice daily (n=203) or placebo (n=69) + their failing regimen for 8 days followed by open-label fostemsavir + OBT. CD4+/CD8+ ratio and concentrations of D-dimer, sCD14, and sCD163 were monitored among all participants in the RC as exploratory outcomes. Results were summarized using descriptive statistics and reported as mean change from baseline.
Results: Mean (SD) CD4+ and CD8+ T-cell counts increased from baseline to Week 240 by 296.4 (227.5) and 105.9 (446.7) cells/mm3, respectively. Mean (SD) CD4+/CD8+ ratio improved steadily at each time point assessed, increasing from 0.20 (0.24) at baseline to 0.60 (0.39) at Week 240. D-dimer, sCD14, and sCD163 decreased from baseline at Week 240, and other than a transient increase from baseline in D-dimer at Week 192, were consistently below baseline. At Week 240, mean (SD) change from baseline in D-dimer was −0.073 (0.508) mg/L FEU (baseline mean, 0.488 [0.379] mg/L FEU), change in sCD14 was −195.4 (920.7) µg/L (baseline mean, 2502.5 [1034.6] µg/L), and change in sCD163 was −146.7 (190.5) µg/L (baseline mean, 545.2 [212.5] µg/L).
Conclusion: Through 240 weeks of treatment with fostemsavir + OBT, HTE people with multidrug-resistant HIV-1 demonstrated continuous improvements in CD4+/CD8+ ratio and decreased levels of D-dimer, sCD14, and sCD163.
Prior presentation: Data included in this abstract have previously been presented in full at the 19th European AIDS Conference; October 18-21, 2023; Warsaw, Poland; Poster eP.A.092.
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#2024012
"Successfully treating MSSA brain abscesses with oral Co- Trimoxazole."
Principal Presenter: Costandi Fasheh
Keywords: MSSA, Co-trimoxazole, Brain abscessTrack: General Infectious Diseases
A 50 year old man with a background of stable schizophrenia was admitted for investigation of drowsiness 24hrs post a bronchoscopy. The bronchoscopy was performed for investigation of a lung mass. On imaging he had two further brain masses. There were no lesions seen on bronchoscopy and histology was negative for malignant cells. Culture from the biopsy was positive for methicillin sensitive Staphylococcus aureus (MSSA). Blood cultures at the time were negative.
He wascommenced on IV flucloxacillin but developed a drug related rash requiring a switch to vancomycin. Repeat imaging 2 weeks later showed an increase in the size of one of the brain abscess and he was transferred for
neurosurgical drainage of the lesions. There was no growth from the microbiological sample.The patient was refusing to remain in hospital for prolonged IV antimicrobial therapy and due to social circumstances was not a suitable OPAT candidate. After long discussions with the patient and his family he was commenced on Co-trimoxazole 960mg BD orally. He was followed up at regular intervals in clinic. Although he missed a number of appointments. He was followed with serial MRI brains to assess to complete resolution of the abscesses. His antibiotics were discontinued when complete resolution was achieved.
He was followed post discontinuation of his antibiotics without recurrence of his symptoms.
Literature on successfully using Co-Trimoxazole for MSSA brain abscesses is undocumented. However, previous studies on Nocardia brain abscesses suggest its effectiveness among immunodeficient individuals.
This case emphasizes the importance of treatment strategies and underscores the necessity for reporting the potential role of oral antibiotics in managing brain abscesses caused by MSSA. While not first line, this case study demonstrates the successful use of oral Co-Trimoxazole in treating MSSA brain abscesses.
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#2024011
"Severe Adenovirus Infection in an Immunocompetent Host."
Principal Presenter: AHMED ABDALLA
Keywords: Severe, Adenovirus infection, immunocompetentTrack: General Infectious Diseases
Adenovirus is a frequent cause of mild respiratory tract infection and gastroenteritis in children, it can cause severe respiratory illness in immunocompromised patients. Outbreaks and aggressive respiratory symptoms have been reported in military camps. Epidemics are well known to occur in close or crowded settings.
We report a case of severe adenovirus pneumonia in a young 38 year old immunocompetent female who lives in a refugee camp in Co. Wexford. Ireland. She presented with fever associated with mild respiratory symptoms that progressed rapidly to severe pneumonia with bilateral consolidation on chest x ray and ground glass opacities on high resolution Computed tomography.
On admission, she was febrile at 40oC, other vital signs were normal, she did not require oxygen support. Initial bloods showed high C – reactive protein with normal White Cell counts and differential and Chest X ray showed patchy right lower lobe infiltration. Full cultures, throat swab, Pneumococcal and legionella urinary antigen in addition to viral serology and immunoglobulin levels were requested, and she was started on broad spectrum antibiotics. 48 hours later, she deteriorated clinically and required oxygen support, she was continuously spiking fever and her chest x ray showed worsening of the pneumonic patches to multilobar pneumonia. By day 4 of admission, she required high flow oxygen with Fi02 up to 80 % to maintain her partial pressure of oxygen around 10. High resolution CT thorax showed multiple ground glass opacities. Echocardiography excluded any cardiogenic causes for her respiratory deterioration. Adenovirus was detected in the nasopharyngeal swab with adenovirus PCR DNA of 1.31x10^7 in serum. Sputum culture and serial blood cultures were negative .Tuberculosis cultures and B-D glucan level / galactomannan level were negative. Serum immunoglobulins and HIV test were negative. HBA1c was normal. Our patient improved successfully, she recovered by day 15 with supportive management, no antiviral was given.
Severe adenovirus infection is rare in immunocompetent adults. This case demonstrates a rapidly progressive respiratory course. Specific groups including refugee camps, military recruits etc, should be evaluated and assessed cautiously to prevent outbreak and poor outcomes. Signs of mild viral illness in the population should be handled carefully with a high index of suspicion and early isolation of specific groups including immunocompromised patients is advisable.
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#2024010
"Is rehabilitation effective in improving long COVID symptoms"
Principal Presenter: Gillian Collins
Track: General Infectious Diseases
Background
Our study aimed to build on our previous research (Daly, 2022) by measuring the effectiveness of a non-pharmacological rehabilitation program for patients with long covid, against a control group, at the Galway University Hospital Long COVID clinic. This study set out to compare a group of people against themselves a) before intervention and b) after they received intervention.
Methods
This was a prospective cohort study where we focused on following a group of people (with long COVID) over a period of 6 months. Of the 117 individuals that were invited to participate, 48 patients engaged with the study and their outcomes were tracked using the COVID 19 Yorkshire Rehabilitation Scale modified (C19YRSm), and the Modified Fatigue Impact Scale (MFIS) in order to investigate the association between their exposure to rehabilitation and their improvement on outcome measurements. Our rehabilitation program is based on the World Health Organisation recommendations for long COVID rehabilitation, and we used a multidisciplinary team approach for delivery of this program.
Results
Results showed no significant change in patient’s outcome measurements without intervention on the C19YRSm p=0.34; and the MFIS p=0.18, whereas results showed statically significant improvement in patients results after they recived intervention across both assessment scales, p<0.001. Our results showed the extent of change effected by our rehabilitation program as being significant: C19yrsm 28; 20, MFIS 56; 37. Our findings showed significant results after only 6 weeks of intervention using our rehabilitation program. Our results also showed that the most prevalent long COVID symptoms are fatigue, brain fog, pain and post exertional malaise (PEM).
Conclusion
Our rehabilitation program helps people recover from long covid. This program should be utilised nationally to facilitate long COVID recovery. Our findings in relation to the most common symptoms of long COVID indicate that the national program for long COVID recovery in Ireland should reduce their focus on respiratory rehabilitation and focus on recovery of fatigue, brain fog, pain and PEM.
The rehabilitation program we utilised was developed locally and provided on a digital platform, therefore making it a service with huge potential for scalability.
ORAL PRESENTATION -
#2024009
"“One man’s waste is another man’s treasure” - the National Wastewater Surveillance Programme"
Principal Presenter: Gwendoline Deslyper
Track: Epidemiology & Population Health
Background
The National Wastewater Surveillance Programme (NWSP) was established in 2021 in response to the COVID-19 pandemic. It is increasingly recognised as a valuable public health resource. We describe the NWSP and plans for its development.
Methods
We include 30 wastewater catchment areas, covering approximately 70% of the population connected to public wastewater treatment plants (WWTPs). We sample from the WWTP inlet through 24-hour composite or grab samples weekly, with influent to Ireland’s largest wastewater facility in Ringsend (~40% national load) sampled twice weekly. We analyse samples for SARS-CoV-2 viral load using quantitative PCR (qPCR) and digital PCR (ddPCR) for specified SARS-CoV-2 variants. Since November 2023, we perform sequence analysis of the receptor binding domain of the SARS-CoV-2 spike protein gene on Ringsend samples to determine the circulating SARS-CoV-2 lineages in Ireland. Since February 2023 we test Ringsend samples for poliovirus type 2 (PV2) by ddPCR.
During June 2020–August 2022, the Ringsend samples were tested, using qPCR and ddPCR, for human adenovirus F type 41 (HAdV-F41) and adeno-associated virus type 2 (AAV2) to explore an association with an outbreak of severe acute hepatitis of unknown etiology (SAHUE).
Results
We will present a selection of NWSP outputs to demonstrate how SARS-CoV-2 viral loads in wastewater correlated with other COVID-19 indicator activity. We will also demonstrate the early detection of emerging SARS-CoV-2 variants in wastewater compared to clinical samples, such as the detection of BA.2.75 by ddPCR two weeks prior to the first clinical sample, and the growth of JN.1 in sequenced reads in late 2023. To date, we have not detected PV2.
During the SAHUE outbreak, a strong positive temporal correlation was found between the daily cases and daily viral load of HAdV-F41 and SAHUE.
Conclusion
Wastewater surveillance of SARS-CoV-2 and its variants has complemented other community surveillance methods, particularly as clinical testing has become more targeted. PV2 testing strengthens activities to maintain Ireland’s polio-free status.
Additionally, wastewater testing has a complimentary role in the surveillance of respiratory adenovirus species.
From 2025, the proposed Urban Wastewater Treatment Directive will mandate wastewater surveillance for specified targets. This requirement, and collaboration with the EU-WISH (Wastewater Integrated Surveillance for Public Health) European Commission initiative, will support the NWSP to incorporate wastewater surveillance more systematically in national surveillance strategies.
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#2024008
"Sexually Transmitted Infections and Adverse Neonatal Outcomes in Malawi; an Analysis of Epidemiological and Operation research to inform interventions and policy."
Principal Presenter: Bridget Freyne
Track: Epidemiology & Population Health
Background
In addition to contributing to poor reproductive health, sexually transmitted infections (STI) are associated with adverse neonatal outcomes. These effects are greatest in low income settings. There is a paucity of data on the epidemiology of STI in pregnancy in sub-Saharan Africa to inform interventions. Data is presented from two studies in Malawi to adress WHO defined research priorities in this area.
Methods
The DIPLO_STI study was a case-control study which aimed to determine the prevalence (R-prevalence package) of STI in pregnant women and used multiple logistic regression (SPSS) to test associations between peri-partum STI including N.gonhorrea (NG), C. trachomatis (CT), T.vaginalis (TV) and T.pallidum (TP) and a composite adverse birth outcome. The SYPH_STAT study was a mixed methods observational study which used a combination of quantitative health systems bottleneck analysis and a grounded theory analysis of semi-strcutured interviews to describe the barriers to PMTCT of syphilis.
Results
510 mother-infant pairs were recruited to the DIPLO_STI study. Multiplex PCR on high vaginal swabs (n=507) and RPR on maternal serum (n=510) were done and the prevalence of NG, CT, TV and TP were 3.1%, 2.7%, 17.1% and 10.3% respectively. Maternal HIV, TP and NG infection were positively associated with a composite adverse birth outcome, with aORs of 3.31 (95%CI 1.1-9.91), 7.13(95% CI 0.87-58.39) and 4.18 (95%CI 1.13-15.43). The Syph_STAT study used 14,365 exit interviews with pregnant women across 3 regions of Malawi to identify health systems bottlenecks related to antenatal screening, maternal treatment provision, partner notification and identification of congenital syphilis. Qualitative enquiry identified community, maternal and healthcare worker perceptions which contributed to these bottlenecks. In addition fragmentation of funding streams and procurement practices were identified as modifiable barriers.
Conclusions
Bacterial STI are a highly modifiable cause of adverse birth outcomes in Malawi. Identification and management of STI in pregnancy is lagging behind PMTCT of HIV. Multidisciplinary approaches which combine epidemiological, operational and implementation research methodologies are required to inform interventions to combat the effects of STI in low resource settings. In addition, research which generates reliable context specific data is a powerful tool for policy advocacy in this setting.
ORAL PRESENTATION -
#2024007
"All trans Retinoic Acid as a Host-directed Therapy for Nontuberculous Mycobacteria"
Principal Presenter: Conor Grant
Track: General Infectious Diseases
Background
All trans retinoic acid (ATRA) improves the ability of macrophages to kill Mycobacterium tuberculosis (Mtb) by promoting phagolysosomal maturation, restricting cholesterol and reducing IL-10 production. ATRA may also affect macrophage metabolic responses. Nontuberculous mycobacteria (NTMs) such as the slow grower M. chimaera and the rapid grower M. abscessus cause infections that are difficult to treat and are characterised by frequent drug resistance and treatment failure. Consequently, there is a need to investigate new approaches to treatment, including the use of adjunctive host-directed therapies (HDT). We aimed to understand if ATRA improves the ability of macrophages to kill M. chimaera and M. abscessus, its effects on intracellular cholesterol, cytokine production and metabolic responses in NTM infection.
Methods
The effect of ATRA (10µM) on the intracellular growth of M. chimaera and M. abscessus within THP-1 macrophages was assessed using CFU assays. ATRAs effect on axenic growth of M. chimaera and M. abscessus was assessed using the BACT/Alert culture system. Intracellular cholesterol and secreted cytokines were measured. Metabolic analyses were performed using a Seahorse analyser and human alveolar macrophages (AMs).
Results
ATRA improved the ability of THP-1s to kill M. chimaera but not M. abscessus. ATRA did not affect the growth of M. chimaera in axenic culture. ATRA did not affect intracellular cholesterol concentrations. Macrophages infected with M. chimaera or M. abscessus increased their rate of extracellular acidification indicating an increased rate of glycolytic flux. ATRA prevented the glycolytic response of AMs to NTM infection. ATRA reduced IL-10 production in M. chimaera infected THP-1 macrophages but had no effect on secretion of IL-10 in M. abscessus infected cells.
Conclusion
ATRA decreases intracellular survival of M. chimaera by acting on the host cell. This decrease in intracellular mycobacterial growth was associated with reduced macrophage IL-10 secretion. ATRA may hold promise as a HDT for NTM disease. This is the first direct evidence of an effective HDT for a species of the M. avium complex. -
#2024006
"Antibiotic prophylaxis in a new orthoplastic limb trauma service for Ireland: deviation from the BOA/BAPRAS standards for open fractures in a Major Trauma Centre"
Principal Presenter: Robert Milling
Keywords: lower limb trauma, antibiotic prophylaxis, orthoplasticsTrack: General Infectious Diseases
Background
The orthoplastic approach to open limb trauma is predicated by its ability to reduce deep infection rates. Appropriate antibiotic treatment at all points along the pathway of treating these complex injuries is imperative, and minimises the possibility of antibiotic resistance. This study aims to quantify compliance with the BOA/BAPRAS standards for antibiotic use, as our Major Trauma Centre evolves.
Methods
A retrospective analysis of a prospectively collated database of open lower limb fractures attending from January 2023 to January 2024 was performed. We examined the patterns of antibiotic administration under the following headings: “Pre-hospital”, “Initial fracture debridement” , “Definitive reconstruction”. We compared antibiotics used with the BOA/BAPRAS standard in each category.
Results
29 open lower limb fractures were managed during the period examined.
In 79% of cases, no retrievable documentation of antibiotic administration pre-hospital was found.
The BOA/BAPRAS standard for initial debridement was not followed in 79% of cases.
At definitive reconstruction, the recommended antibiotic was used in 33%.
Overall there were 6 different antibiotics combinations used at debridement and 8 at reconstruction across 29 cases.
Conclusion
There is a lack of awareness of the antibiotic guidance contained in the BOA/BAPRAS standards among orthopaedic, plastic surgery, and anaesthesiology team members. Our data demonstrates the need for local antimicrobial guidelines for of open fractures.
Presentation of this data at our orthoplastic MDT resulted in agreed local guidelines and this will be published on our hospital intranet and posters in all trauma theatres. These categories will be re-audited regularly
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#2024005
"Notification of Case of Cholera to Public Health Dublin/ North East"
Principal Presenter: Barbara Gilmer
Track: Epidemiology & Population Health
Background
Cholera is a notifiable infectious disease caused by the bacterium vibrio cholera. Over 950,000 cases and 5,500 deaths were reported globally in 2023[1]. It causes acute watery diarrhoea, and in its severe form can lead to severe dehydration and death within hours if left untreated. Cholera transmission is linked to inadequate access to safe drinking water and sanitation facilities. The short incubation period can result in rapid growth in case numbers. With rapid, appropriate treatment the case fatality ratio (CFR) should remain below 1%. We present the first case of cholera notified in Ireland since 2002.
Case Report
On New Year’s Day 2024, the Department of Public Health Dublin and North East received notification of cholera in 12-year-old boy with previous history of lymphoma who had spent a month in Pakistan. He developed diarrhoea two days prior to returning to Ireland on 29/12/2023. Public health risk assessment did not identify any risk factors. He had no contact with anyone with diarrhoeal symptoms and drank bottled water exclusively on holiday. He received supportive and antimicrobial therapy at a paediatric hospital and subsequently recovered.
Diagnosis was confirmed by culture and stool sample sent to UK for further testing. All family members were well and did not require microbiological clearance. Enteric precautions and infection prevention control measures were advised.
Prevention of cholera
Measures to prevent cholera include provision of clean water and appropriate sanitation to populations without access to basic services[2]. Three oral cholera vaccines are approved by the World Health Organization for use in areas with endemic cholera and during humanitarian crises or cholera outbreaks[3]. Vaccination may also be recommended for travellers at higher risk. Control measures include identifying linked cases suggestive of an outbreak and clinical surveillance of contacts with similar food and water exposures[4].
[1] ECDC, 2024. Cholera worldwide overview [online]. https://www.ecdc.europa.eu/en/all-topics-z/cholera/surveillance-and-disease-data/cholera-monthly
[2]WHO, 2023. Cholera Factsheet [online]. https://www.who.int/news-room/fact-sheets/detail/cholera
[3] Cholera vaccines: WHO position paper – August 2017. Weekly Epidemiological Record 25 August 2017, No 34, 2017, 92, 477–500. http://apps.who.int/iris/bitstream/10665/258764/1/WER9234-477-498.pdf
[4] HPSC, 2012. Infectious Intestinal Disease: Public Health & Clinical Guidance. https://www.hpsc.ie/a-z/gastroenteric/gastroenteritisoriid/guidance/File,13492,en.pdf -
#2024004
"Audit of PET-CT practices of Cork University Hospital (CUH) Infectious Disease Department."
Principal Presenter: Patrick Carey
Keywords: PET CT, Infectious DiseaseTrack: General Infectious Diseases
Abstract: This audit aims to evaluate and analyse the utilization of Positron Emission Tomography-Computed Tomography (PET-CT) imaging within the Infectious Disease Department of a tertiary Irish hospital. The study focuses on assessing the appropriateness of each request compared to the Royal College of Radiology 2022 guidelines. It will also examine if its use in diagnosing and altering management in the infectious disease patient cohort.
Methods: 55 patients, comprising of both General Medical and Infectious Disease patients, underwent PET CT imaging in CUH from 2014 until 2023. We carried out a retrospective study examining these requests, results and clinical outcomes.
Results: Of the 55 PET CT’s undertaken, 41(75%) met guideline indications. Of those that met the indications, the most common reason for request was for investigation of malignancy (19, 46%) and pyrexia of unknown origin (PUO) (17, 41%). 45 patients (82%) had no diagnosis at the time of imaging, of these PET CT contributed to a diagnosis in 15 (33%). Of the patients where a diagnosis was reached after PET CT the most common diagnosis was Malignancy (7/15, 47%) following by TB (3/15, 20%). Of the PET CT imaging undertaken for PUO, a diagnosis was only reached in 2 of 17 (12%). The findings on 20 of the 55 scans altered patient management. Of the 55 patients imaged, a diagnosis was made and/or management altered in 25 (45%) of patients.
Conclusion: PET CT is typically utilised when more conventional imaging and investigation techniques have not heralded a diagnosis, these are often challenging cases. For 45% of PET CT results to have either led to a diagnosis or altered patient management emphasises its utility in the Infectious disease cohort. This figure could be improved with further adherence to guideline based requests and improved patient selection to ensure optimal usage of this valuable resource.
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#2024003
"A Three Month Service Evaluation of Pneumococcal Vaccine (Prevenar and Pneumovax ) Uptake Among an HIV Positive Cohort of Patients"
Principal Presenter: Jeffrey Harte
Keywords: HIV, Vaccines, AuditTrack: Virology
Pneumococcal infections, specifically invasive disease such as pneumonia, bacteraemia and meningitis have been a major cause of morbidity and mortality since the beginning of the HIV epidemic. As a result, many experts endorse the use of the Pneumococcal vaccine for primary prevention in patients with HIV. Local and international guidelines recommend that people living with HIV should receive a single dose of PCV 13 followed by a booster vaccination of PPV 23. In order to ensure high vaccine uptake amongst our high-risk cohort, it is important to continually review our vaccine practices in order to evaluate Pneumococcal vaccine uptake in our HIV patients, to examine barriers to vaccination in the future and to increase awareness amongst NCHD to prescribe and advocate pneumococcal vaccines as required.
Data was collected during patient visits from the 3rd of October 2023 until the 22nd of December 2023 and patients’ vaccination histories were also reviewed retrospectively from electronic medical records and medical notes who attended the ID clinic over that time. In total, there were 804 HIV positive patients who attended the ID clinic during the time period, and all were included in the audit.
804 HIV patients were identified from October to December 2023. Among this cohorts, 679 were up to date and fully vaccinated with Pneumococcal vaccines, both Prevenar and Pneumovax. There were 125 who have an incomplete course of Pneumococcal vaccines; of which, 26 patients were new to clinic and vaccine history has not been fully reviewed. They will be reviewed when they attend clinic again. Despite encouragement and vaccine counselling, there were 30 patients who refused vaccines. It is also noted that 1 patient was currently unwell and dealing with other co-morbidities and not had the vaccine yet while another patient has a complicated psychiatric history, which left him unable to consent for vaccination. Lastly, 52 patients are due Pneumovax at their next OPD visit.
The audit showed that 84.4 % of patients who attended over the time period were fully vaccinated with both Prevenar and Pneumovax and 15.5 % amongst the positive HIV cohorts have an incomplete course of Prevenar and Pneumovax vaccination. The reason of having incomplete vaccination status includes: the vaccine is not being due until next clinic appointment, individuals being new service users, vaccine refusal and being clinically unwell. Future audits are recommended to ensure adequate vaccine delivery to patients attending the MMUH ID service.
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#2024002
"Crosstalk on One Health and the Pandemic in Uganda: Perspectives from Policymakers and Implications for Neglected Tropical Diseases"
Principal Presenter: Keneth Iceland Kasozi
Track: Epidemiology & Population Health
Background: The pandemic has created an opportunity to review the strengths and threats to the One Health (OH) approach which has widely been promoted in several African countries. In this survey, we assessed the relevance of OH with the objective of understanding the underlying drivers to its poor implementation during the pandemic period by using Uganda as a case study. Methods: This was a key informant interview (KII) survey conducted across multiple districts in Uganda. We held in-person, virtual and phone calls with study participants and data was analysed and presented using a SWOT framework. Results: The study involved 12 participants, the majority from the central region, males, and senior officers, from the health and veterinary industries. Almost everyone got OH right by theoretical definition, with disciplinary collaborations being more common than multi-interdisciplinary collaborations. Major threats to OH were associated with working in silos, and the lack of a National One Health Policy thus making it challenging to mobilize national funding and coordination of OH activities in the country. Conflicts due to corruption in administrative offices are major barriers to multidisciplinary collaboration. The pandemic has provided more avenues to foster multi-interdisciplinary collaborations, and opportunities to gain budgetary support from the Ugandan government for OH activities. Conclusion: A lack of data-sharing initiatives among the ministries and limited advocacy for OH activities in rural communities are challenges that need to be addressed in strengthening national systems for future epidemics.
ORAL PRESENTATION -
#2024001
"C difficile: An overview of the Irish surveillance system including the importance of whole genome sequencing"
Principal Presenter: Mairead O' Hanlon
Keywords: C difficile, surveillance, WGSTrack: Epidemiology & Population Health
C. difficile is a notifiable disease in Irish hospitals since 2009. In addition to laboratories reporting cases to public health, 98% of hospitals also participate in a voluntary enhanced C. difficile programme coordinated by the Health Protection Surveillance Centre ( HPSC).The C. difficile National Reference Laboratory (NRL) based in Public Health Laboratory Dublin, started providing whole genome sequencing (WGS) service to all hospitals in 2022. The HPSC and NRL work closely together and provide a joint biannual report on CDI surveillance in Ireland to all hospitals in the programme.
With this programme valuable additional information is collected regarding the epidemiology and burden of CDI in Ireland. In 2022, 2,216 cases of CDI were notified to public health. Of these, 1,829 (83%) were classified as new cases, 149 (7%) as recurrent and 238 (11%) as unknown case type. In the enhanced programme 1,717 cases were reported in 2022, 1,477 (86%) were new, 9% recurrent and 5% of unknown case type. In the latter half of 2022 cases sent to the HPSC and NRL were matched and WGS sequence profile the most common sequence types are now reported
This surveillance programme provides hospitals with CDI incidence rates, assesses the burden of CDI (new and recurrent cases) and provides hospitals with a standardised measuring tool to monitor rates which can be compared to similar hospitals. The WGS results significantly adds to the understanding of the epidemiology of this infection and ultimately influence priority areas for future interventions to prevent and control HAI and for antimicrobial stewardship
