"Evaluating the Outcomes of an Integrated Multidisciplinary COVID-19 Recovery Care Clinic"
Principal Presenter: Christine Kelly
Keywords: COVID-19, COVID-19 complications, COVID-19 clinic
In January 2020, the WHO declared the SARS-CoV-2 outbreak a public health emergency, by March 11th a pandemic was declared. To date in Ireland, over 3,300 patients have been admitted to acute hospitals as a result of infection with COVID-19. Here we describe a single centre prospective cohort study which follows patients longitudinally with both virtual and in-person clinic.
The COVID-19 recovery clinic established in Beaumont Hospital is a multi-disciplinary service for comprehensive follow up of patients with a hospital diagnosis of COVID-19 pneumonia. This initiative is supported by respiratory, critical care, infectious diseases, psychiatry and psychology services. The assessment includes standardised blood tests, chest x-ray, quality of life scores and a novel mental health assessment tool. Clinical follow-up data are collected prospectively with a standardised tool.
Three month follow-up visits have been conducted for all ICU admissions, and is underway for severe hospital cases. Investigations have predominantly revealed radiographic improvement of pneumonia, and in many cases complete resolution of bilateral infiltrates. However, cases of persistent infiltrates, myocarditis and ongoing physical and psychological sequelae of COVID-19 were identified.
Beaumont Hospital COVID-19 recovery clinic has demonstrated a significant burden of ongoing disease amongst hospital patients. We propose a standardised clinical framework for management of these patients in an acute hospital setting.Download #2020560 (597.58 KB)
"SARS-CoV-1-NSP14 and MERS-CoV-NSP2 block anti-viral IFN-α-mediated JAK/STAT signalling."
Principal Presenter: Yamei Zhang
Interferon (IFN)-α signals via the Janus kinase signal transducer and activation of transcription (JAK/STAT) pathway, inducing hundreds of anti-viral genes that are essential for host defence. The JAK/STAT pathway is often antagonized by viruses through a plethora of immune evasion mechanisms. Since 2002, deadly coronavirus (CoV) strains have emerged globally, including Middle East Respiratory Syndrome (MERS)-CoV, which was first observed in 2012, SARS-CoV-1, which appeared in 2002, and SARS-CoV-2, which is currently causing a global pandemic. Unfortunately, studies with therapeutic IFN-α have shown disappointingly weak clinical response against MERS-CoV that IFN-α treatment did not improve the recovery rate. Others have shown that IFN-α did not effectively inhibit SARS-CoV-1 replication in vitro. In our study, we show that expression of MERS-CoV-Non-Structural Protein (NSP)2 and SARS-CoV-1-NSP14, in the epithelial A549 cells, significantly enhanced STAT1 and STAT2, but not STAT3 protein expression. Both these viral proteins also significantly enhanced levels of STAT1 and STAT2 tyrosine phosphorylation, but as with STAT3, neither protein induced STAT3 tyrosine phosphorylation. Interestingly, while IFN-ɑ-induced phosphorylation of STAT1, STAT2 and STAT3 was clearly observed in Empty Vector (EV)-transfected control cells, expression of MERS-CoV-NSP2 or SARS-CoV-1-NSP14 stunted the ability of IFN-α to induce this normal phosphorylation. Furthermore, while levels of the ISGs, MxA, MxB and ISG15, were increased upon expression of MERS-CoV-NSP2 or SARS-CoV-1-NSP14, ISG upregulation, after IFN-ɑ treatment, was blocked in the presence of either viral protein. While MERS-CoV-NSP2 and SARS-CoV-1-NSP14 expression had no effect on JAK1 or Tyk2 protein levels, SARS-CoV-1-NSP14 (but not MERS-CoV-NSP2) expression reduced IFN-α Receptor chain 1 (IFNAR1) protein levels, suggesting its role in reducing IFN-ɑ responsiveness. Additionally, Suppressor of cytokine signalling (SOCS)-1 and -3, which are key negative regulators of JAK/STAT pathway, were found to be induced by MERS-CoV-NSP2 and SARS-CoV-1-NSP14, indicating their role in this novel viral immune evasion mechanism. Collectively, our findings indicate that both MERS-CoV and SARS-CoV-1 use these NSPs to block epithelial cell responsiveness to IFN-α, which may enhance their overall viral infection and replication capabilities. Overall, our findings suggest that coronaviruses counteract the effect of IFN-ɑ responses by inhibition of the JAK/STAT signalling pathwayDownload #2020558 (1.97 MB)
"Cholesterol metabolism gene expression in People Living with HIV is similar to risk factor matched uninfected controls: The HIV UBPEAT CAD Substudy"
Principal Presenter: Padraig McGettrick
Keywords: HIV, Comorbidities, Cholesterol
People living with HIV (PLWH) have an increased risk of coronary artery disease (CAD) with previous studies reporting monocyte gene expression consistent with high intracellular cholesterol in treatment naïve PLWH which improves but does not normalise with ART. We aimed to examine differences in cholesterol metabolism gene expression in a cohort of treated PLWH with CAD risk factor (CADRF) matched uninfected controls.
The UPBEAT CAD substudy, examining CAD risk in PLWH, enrolled participants matched on HIV status and traditional CADRF. Quantitative Polymerase Chain Reaction (qPCR) was used to assess expression of 17 cholesterol sensing, synthesis and efflux genes. Data are reported as median (IQR). Between group differences and association with HIV status was assessed using Mann-Whitney-U test and ANCOVA respectively (SPSS vers24).
99 participants were included in the analysis. Median age was 49.8 (45.6, 55.8) years, 73.5% male, 76.5% Caucasian and 22.4% were current smokers. PLWH had lower HDL cholesterol (HIV+ 1.27 (1.0, 1.3); HIV- 1.4 (1.1, 1.6) p=0.017) and more likely to be on statin therapy (HIV+ 49%, HIV- 12%, p<0.01). Other demographics and CVDRF were similar between groups.
There was no significant difference between groups in expression of cholesterol sensing [SCAP: HIV- 0.07 (0.05,0.11), HIV+ 0.07 (0.05, 0.08), p=0.425, SREBF1: HIV- 0.013 (0.01,0.02), HIV+ 0.010 (0.01, 0.02), p=0.28, MBTPS 1: HIV- 0.03 (0.02, 0.04), HIV+ 0.025 (0.02, 0.05) p=0.49 , PPARA: HIV- 0.006 (0.004, 0.014), HIV+ 0.005 (0.003, 0.015) p=0.34 , NR1H3: HIV- 0.004 (0.002, 0.006), HIV+ 0.004 (0.002, 0.006) p= 0.93, LPL: HIV- 0.0017 (0.0006, 0.0037), HIV+ 0.0015 (0.0006, 0.0060) p=0.67], cholesterol uptake [LDLR: HIV- 0.0435 (0.0300, 0.0532), HIV+ 0.0400 (0.0254, 0.0548) p=0.79, CD36: HIV- 0.0175 (0.0058, 0.0460) HIV+ 0.0320 (0.0054, 0.0933) p=0.67], synthesis [HMGCR: HIV- 0.0141 (0.0499, 0.0378) HIV+ 0.0175 (0.0046, 0.0782), p=0.72, PMVK: HIV- 0.0146 (0.0099, 0.0318) HIV+ 0.0150 (0.0107, 0.0239) p=0.72, ACAT2: HIV- 0.0097 (0.0066, 0.0136), HIV+ 0.0105 (0.0065, 0.0150), p=0.737] or efflux genes [ABCA1: HIV- 0.0006 (0.0002, 0.0014), HIV+ 0.0007 (0.0003, 0.0018), p=0.323, ABCG1: HIV- 0.0047 (0.0033, 0.0094), HIV+ 0.0069 (0.0029, 0.0094) p=0.978, SCARB: HIV- 0.0214 (0.0146, 0.0344), HIV+ 0.0200 (0.0147, 0.0305), p=0.722].
After adjustment for HDL and statin use, there remained no significant association between HIV serostatus and cholesterol metabolism gene expression.
In a cohort of treated PLWH and CADRF matched controls, there was no significant difference in monocyte cholesterol gene expression suggesting persistent dysfunctional intracellular cholesterol metabolism may not contribute to increased risk of CAD in PLWH.Download #2020557 (1.49 MB)
"Dietary Habits and Impact on Cardiovascular Disease Risk in HIV Infection"
Principal Presenter: Padraig McGettrick
Keywords: HIV, Comorbidities, CVD
People living with HIV (PLWH) have twice the risk of cardiovascular disease (CVD) compared to the general population with data on dietary intake, a measure of socioeconomic status and contributor to CVD risk, limited in PLWH.
We aimed to investigate differences in dietary intake, calculated by food frequency questionnaire (FFQ), between PLWH and CVD-risk matched controls and examine associations between HIV and subclinical CVD measured by coronary CT angiography (CCTA), adjusting for these differences.
The UPBEAT CAD substudy, examining CVD risk in PLWH, enrolled participants over 40 years with no CVD history, matched on HIV status and CVD risk factors. Participants underwent a FFQ and CCTA to assess for subclinical CVD. Nutritional data were calculated using Nutritics dietetics software (Dublin 2020). Data are reported as median (IQR). Between group comparisons and associations between variables and subclinical CVD were calculated using Mann Whitney U test and logistic regression respectively (SPSS vers24).
99 participants were included in the analysis. Median age was 49.8 (45.6, 55.8) years, 73.5% male, 76.5% Caucasian and 22.4% were current smokers. PLWH had lower HDL [HIV+ 1.27 (1.0, 1.3); HIV- 1.4 (1.1, 1.6) p=0.017], were less likely to have a family history of CVD (HIV+37%, HIV- 58%, p= 0.036) and more likely to be on statin therapy (HIV+ 49%, HIV- 12%, p<0.01). Other demographics and cardiovascular risk factors were similar between the groups.
Based on FFQ, PLWH had less daily intake of protein [HIV+ 93.2 (83.7, 141.6)g; HIV- 127.2 (98.8, 181.4)g, p=0.043], caffeine [ HIV+ 382.7 (235, 1197) mg; HIV- 3325 (123,18633) mg, p= 0.049], and alcohol [4 (0.02, 13.48)g; HIV- 8.9 (2.9, 15.39)g, p= 0.035]. There was no difference in total daily calorie, carbohydrate, sugar, fibre, cholesterol and fat intake between groups.
Presence of total coronary plaque were similar between the two groups (PLWH; 33% versus uninfected controls; 40% p-value: 0.494). On univariate analysis there was no association between either food group intake (data not shown) or HIV status with total plaque (OR 0.75 [95% CI 0.329, 1.711]) or non-calcified plaque [OR 3.1 (95% CI 0.712, 13.6) p=0.132]. Adjusting for difference in dietary intake in multivariate models, HIV status remained not associated with subclinical CVD (OR 0.874 [95% CI 0.351, 2.181]).
These results, the first to examine dietary impact on CVD risk in PLWH, suggest differences in dietary intake may not predict subclinical CVD in PLWH.Download #2020556 (1.01 MB)
"Immune Risk Profile Characterised by Systemic Inflammation and Endothelian Activation is Predictive of Comorbidities in Treated PLWH"
Principal Presenter: Padraig McGettrick
Keywords: HIV, Comorbidities, Inflammation
Although inflammation and immune dysfunction are implicated in the pathogenesis of comorbidities in people with HIV (PWH), whether an immune risk profile can predict PWH at higher risk of comorbidities is unclear.
In the UCD Infectious Diseases Cohort Study of PWH on antiretroviral therapy (ART), we measured 24 biomarkers using bead-based quantitative ELISA, covering pathways of systemic inflammation (hsCRP, Il-6, TNFR1,2, TNF-a), innate immune activation (sCD14,sCD163, MCP-1, MIP-1, sCD40), endothelial function (P-selectin, E-selectin, sVCAM, sICAM-1), coagulation (D dimer, vWF) and intestinal permeability (IL18, LBP). We performed principal component analysis followed by unsupervised hierarchical clustering to partition subjects into biomarker-derived clusters and logistic regression to assess associations between clusters and prevalent comormidities (cardiovascular, kidney, liver disease, hypertension, dyslipidemia). Data are median [IQR] or odds ratio (OR) [95% CI].
We included 99 PWH, age 41 (36.8, 48.0); years 44.5% male; 54.5% African; 93.9% with HIVVL <40cps/ml, duration of ART 7.1 years (2.3, 10.8)).
We observed three distinct clusters, two characterized by higher inflammation; cluster 2 (19% subjects) reflecting platelet/macrophage pathways and cluster 3 (34% subjects), systemic, vascular and endothelial pathways. PWH in cluster 3 were older, more likely male and Caucasian.
Although prevalence of comorbidities was higher in cluster 2 (42%) and 3(48.9%) versus cluster 1 (20%), only cluster 3 was associated with prevalent comorbidities in regression analysis (OR 3.1 [1.09, 8.28], p= 0.034). This association remained significant after adjustment for CMV seropositivity, smoking and CD4:CD8 ratio, (OR 3.3 [1.131, 9.813], p=0.029). Further adjustment for age, gender and ethnicity attenuated this relationship (OR 2.37 [0.712, 7.87], p=0.16).
Conversely Cluster 1, characterized by lower levels of inflammation, was associated with reduced risk of comorbidities (OR 0.28 [0.10, 0.74]), an association which persisted after adjustment for age, gender and ethnicity (OR 0.32 [0.11, 0.90], p=0.03).
We have identified distinct inflammatory patterns in treated PWH that predict prevalent co-morbidities. That these patterns, characterized by pathways including systemic and vascular inflammation, remain associated with comorbidities even after correction for CMV and CD4:CD8 ratio suggests a number of distinct pathways may contribute to comorbidities in PWH.Download #2020555 (896.31 KB)
"Incidence of Malignancy Among Patients Living With HIV in Beaumont Hospital 2016-2020: a Retrospective, Single-centre Audit"
Principal Presenter: Ryan Crawford
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"Antimicrobial neurotoxicity: an under-recognised cause of delirium"
Principal Presenter: David Moynan
Keywords: encephalopathy, delirium, neurotoxicity
Antimicrobial associated encephalopathy (AAE) is a well-documented, though under recognised, adverse event associated with antimicrobial use 1. Clinical manifestations of AAE are varied, ranging from myoclonus and seizure to an encephalopathy with cerebellar signs 1. The phenotypic presentation of the encephalopathy syndrome is, in general, governed by the antimicrobial in question. Given its apparent rarity in everyday clinical practice, awareness of AAE is crucial for physicians.
We describe a reversible encephalopathy characterised by confusion, progressive myoclonus and stupor in a 76 year old gentleman with stage 3A chronic kidney disease on antimicrobial therapy for a peri-rectal abscess. While the patient’s initial antimicrobial course was uneventful and clinically successful on intravenous cefuroxime, oral metronidazole and intravenous daptomycin (based on prior sensitivities), fifteen days into therapy the patient became progressively more confused. Peripheral myoclonus was noted in the arms with normal tone, reflexes and bilateral down-going plantars. Over 24 hours, the patient deteriorated and the myoclonus progressed proximally. Plantar reflexes were up-going bilaterally. Neuroimaging including CT brain, intracranial angiogram and MRI brain failed to identify an acute abnormality. In the clinical context, a working diagnosis of antimicrobial associated encephalopathy (AAE) was established. Upon withdrawal of the offending drugs, the patient’s condition improved dramatically with resolution of neurological deficits. Given the reluctance to restart antimicrobials, compounded by the patient’s unsuitability for surgery, source control was obtained with the insertion of a urinary catheter into the rectum. Interval imaging noted resolution of the collection.
This patient’s neurology, characterised by myoclonus and stupor, is in keeping with a cephalosporin-induced AAE which is frequently seen in the context of renal impairment 1,2,3. While the exact mechanism behind AAE is not fully understood, the myoclonus that develops from beta-lactam antimicrobials is believed to arise from a disruption of inhibitory synaptic transmission leading to excitotoxicity 1. The pathophysiology rests with the beta-lactam ring itself, which has the capacity to bind to the ligand-gated ion channel γ-aminobutyric acid class A receptor (GABAAR), impeding the inhibitory neurotransmission with subsequent excitotoxicity 3,4. This case serves as a reminder to broaden the differential in the setting of a delirium and to consider AAE as a possibility. Not only is this encephalopathy easily reversible, but it is an entity whose outcome is entirely dependent on a timely diagnosis and appropriate withdrawal of drugs.
1. Bhattacharyya, S., Darby, R. R., Raibagkar, P., Gonzalez Castro, L. N. & Berkowitz, A. L. Antimicrobial-associated encephalopathy. Neurology 86, 963–971 (2016).
2. Herishanu, Y. O. et al. Cefuroxime-induced encephalopathy. Neurology 50, 1873–5 (1998).
3. Grill, M. F. & Maganti, R. Cephalosporin-Induced Neurotoxicity: Clinical Manifestations, Potential Pathogenic Mechanisms, and the Role of Electroencephalographic Monitoring. Ann. Pharmacother. 42, 1843–1850 (2008).
4. Akahane, K., Tsutomi, Y., Kimura, Y. & Kitano, Y. Levofloxacin, an Optical Isomer of Ofloxacin, Has Attenuated Epileptogenic Activity in Mice and Inhibitory Potency in GABA Receptor Binding. Chemotherapy 40, 412–417 (1994).Download #2020553 (389.5 KB)
"Intravesical Amikacin Instillation for Treatment of Resistant Urinary Tract Infections"
Principal Presenter: Niamh Reidy
Antimicrobial resistance leads to difficulties with management of recurrent urinary tract infections, with patients often requiring hospitalisation and intravenous antimicrobial therapy. Intravesical gentamicin has been used safely as a treatment to reduce the burden of recurrent urinary tract infections, however little is known about the effectiveness or safety of intravesical amikacin as therapy in this setting. To our knowledge, it has rarely been used in the setting of renal transplantation. We describe a new protocol for management of recurrent multi-drug resistant urinary tract infections with intravesical amikacin instillations.
Intravesical amikacin was used to prevent recurrent multi-resistant urinary infections in a female patient with a renal transplant. Full urological work-up was undertaken in this patient and revealed no underlying issue, and immunosuppressive therapy had been minimised. The main urinary isolate was found to be gentamicin-resistant on multiple samples. Limited oral antimicrobial options were available, and provided short-lived clinical benefit when prescribed; thus intravesical amikacin therapy was chosen. Amikacin 250mg was dissolved in 50ml of 0.9% normal saline and instilled into the urinary bladder via self-intermittent catheterisation. Amikacin was instilled daily for two weeks, then alternate-daily for ten weeks, followed by twice weekly for twelve weeks. Amikacin levels were checked routinely to ensure no systemic absorption of the drug, and renal function was monitored.
There were no adverse events relating to the administration of intravesical amikacin in this patient. Blood amikacin levels were undetectable throughout the course of treatment, reflecting a lack of systemic absorption of the drug. There were no sequelae of colonisation with multi-resistant organisms or emergence of isolate resistance to amikacin. Frequency of symptomatic urinary tract infections decreased from weekly to monthly, while severity and duration of lower urinary tract symptoms also subjectively improved in this patient. Renal transplant graft function remained stable throughout treatment with intravesical aminoglycoside.
Intravesical amikacin instillation is a safe, well-tolerated treatment for recurrent multi-resistant urinary tract infections, with no deleterious effects in this patient with previous renal transplant. Intravesical amikacin was moderately successful in improving quality of life and reducing burden of symptomatic urinary tract infections, and provides an option for treatment in cases with gentamicin resistance.Download #2020552 (505.3 KB)
"IRIS Associated CNS Toxoplasmosis in a new diagnosis of HIV infection"
Principal Presenter: Annemarie Lanigan
Immune reconstitution inflammatory syndrome (IRIS) describes a syndrome of aberrant reconstituted immunity, often seen in patients with uncontrolled HIV infection. It is characterised by a hyperactive inflammatory response to an infectious or non-infectious agent, leading to a dysregulated immune response against an infecting opportunistic pathogen and the host. Toxoplasmic encephalitis associated with IRIS is rarely described and usually occurs in an unmasking, rather than paradoxical form.
A 54 year old Caucasian male smoker was admitted to hospital with a six week history of exertional dyspnoea, dry cough, fatigue and four stone weight loss. Initial CXR demonstrated a left upper lobe infiltrate concerning for atypical pneumonia versus underlying malignancy. Patient was commenced on IV antimicrobials and CT imaging confirmed the presence of a groundglass opacity with bronchoscopy arranged. Bronchoalveolar lavage washings sent for PCR were positive for CMV.
On day 11 of admission, patient developed diffuse maculopapular rash and acute decline in cognition. Infectious Diseases team were consulted and HIV screen sent was confirmed positive. CD4 count 33 cells/uL at time of diagnosis. Serology for Toxoplasma IgG also returned positive.
Patient was commenced on prophylactic dose co-trimoxazole and treatment dose IV valganciclovir given high CMV viral load noted on BAL PCR.
Lumbar puncture performed demonstrated positive CSF PCR for toxoplasma gondii which, along with MR imaging of brain demonstrating the presence of multiple ring enhancing lesions, confirmed a diagnosis of Toxoplasmic encephalitis. CSF PCR for JC virus was negative. Treatment with high dose IV co-trimoxazole was commenced along with ART combination of tenofovir alafenamide fumarate, emtriciabine and bictegravir.
Nine days after commencement of ART therapy, patient developed acute neurological deterioration with GCS 9 and evidence of hypertonia and limb weakness on examination. ICU admission was required for management of condition. Repeat MR imaging demonstrated an increase in the number of ring enhancing lesions compared to previous. Treatment continued along with the addition of IV dexamethasone and after a period of two weeks in ICU, a gradual improvement in cognitive function was observed. Following an intensive rehabilitation period at ward level, patient was discharged to a community rehabilitation facility where he continues to improve.
Our case highlights the importance of HIV screening in patients presenting with atypical infections in an Irish hospital setting. It also describes the challenges of managing CNS paradoxical IRIS and the importance of MDT input in improving patients neurological and overall outcome.Download #2020551 (906.32 KB)
"Cryptococcus neoformans a very rare cause of acute cardiac tamponade post lung transplantation."
Principal Presenter: Aoife Sheila Murray
Cryptococcus neoformans, a very rare cause of acute cardiac tamponade post lung transplantation.
AS Murray1, S Green1, E Hunt1, M Kooblall1, B Lynch2, M Hannan2, J Kleinerova1, M Murray1
1 Heart and Lung Transplant Department, Mater Misericordiae University Hospital, Eccles Street, Dublin 7.
2 Microbiology Department, Mater Misericordiae University Hospital, Eccles Street, Dublin 7.
Lung transplantation is an increasing option for end-stage lung disease. Life-long immunosuppression is a sequela, and patients are predisposed to a broad range of infections. Cryptococcus neoformans is an invasive fungal organism, which targets immunocompromised hosts. Sites of involvement include CSF and lungs. Involvement of pericardium is extremely rare. We report the third case of Cryptococcal infection causing isolated acute pericarditis post lung transplantation, and discuss treatment options (1).
A thirty-eight year old male, had a double lung transplant for end-stage sarcoidosis in 2017. Post-transplation he had one episode of CMV viraemia, but was otherwise well. Two years post transplantation he presented to a regional hospital with cough, diarrhoea and vomiting which rapidly progressed to chest pain and a vasovagal episode, requiring ICU admission. He was commenced empirically on Piperacillin-Tazobactam, with further escalation to Meropenem and Vancomycin. An echocardiogram revealed a large pericardial effusion and he was transferred to the national transplant centre.
Laboratory investigations identified an AKI on background of CKD, with creatinine peaking at 450, deranged LFTs, and non-elevated serial troponins. A second echocardiogram confirmed persistent effusion and therapeutic pericardiocentesis was performed. This revealed 400mls of serosanguinous fluid with an opening pressure of 30mmHg, confirming physiological cardiac tamponade. The fluid cultured Cryptococcus neoformans. Serum Cryptococcal antigen was positive. CT scans of thorax/abdomen/pelvis, MRI brain, lumbar puncture and pleurocentesis excluded disseminated disease. As a result his antimicrobial regime was changed to Amphotericin B 5mg/kg and Flucytosine 25mg/kg , switching to Fluconazole 200mg QDS for 1 year on discharge, with close follow up due to possible complication of pericardial fibrosis (2).
Management of patients post transplantation is complex and requires multidisciplinary input. In addition to conventional causes of pericardial effusions including malignancy, autoimmune disease, and myocardial infarction, atypical infections should be considered in this population. Early diagnosis is crucial.
1. Cryptococcus neoformans pericarditis in a lung transplant recipient: Case report, literature review and pearls. EL Helou G, Hellinger W. Transplant Infectious Disease 2019 Oct;21(5):e13137. Doi: 10.1111/tid. 13137. Epub 2019 Jul 18.
2. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america. Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ, Harrison TS, Larsen RA, Lortholary O, Nguyen MH, Pappas PG, Powderly WG, Singh N, Sobel JD, Sorrell TC. Clin Infect Dis 2010 Feb 1:50(3):291-322. Doi: 10.1086/649858.
"Parvimonas micra as a cause of Paraspinal Abscess in a Patient with Dental Caries"
Principal Presenter: Dr. Adam Kelly
Paraspinal abscesses are rare clinical emergencies associated with considerable morbidity and mortality. Risk factors include spinal trauma or surgery, intravenous drug use and epidural anaesthetic procedures. Parvimonas micra is a gram positive anaerobic organism and an innate coloniser of the oral cavity. The organism is frequently isolated in patients with dental caries and periodontitis and rarely causes severe infections. Despite being capable of infections outside of the oral cavity, there remains a paucity of documented cases of Parvimonas micra as a cause of paraspinal abscess and vertebral disease.
We describe the case of a 39 year old male admitted to an Irish hospital after presenting to the Emergency Department with a three week history of worsening thoracic back pain, left upper limb radiculopathy and subjective fevers.
Clinical examination on admission demonstrated left upper limb weakness with sensory disturbance with no evidence of haemodynamic instability. Examination of the oral cavity revealed multiple dental caries and abscesses.
Initial x-ray of cervical and thoracic spine demonstrated no obvious abnormalities. Subsequent MR imaging of spine revealed an infiltrative paraspinal process of the left side impinging on the 8th cervical nerve. IR guided drainage of abscess was deemed too high risk and patient was taken to theatre to undergo an anterior cervical approach incision and drainage of the paraspinal collection. Isolates from bone biopsy were positive for Parvimonas micra and Fusobacterium nucleatum. Three separate sets of blood cultures were positive after five days incubation with Parvimonas micra identified on anaerobic culture, which was fully sensitive to metronidazole.Download #2020549 (443.43 KB)
"COVID-19 Clinical Outcomes Amongst a Population of Hospitalised Adults in a Large Tertiary Hospital in Dublin"
Principal Presenter: Niamh Reidy
Beaumont Hospital is one of the largest acute hospitals in Ireland with 820 inpatient beds and 3,000 staff. Here we aim to describe the clinical outcomes of patients admitted to Beaumont Hospital with Covid-19, admitted between March 13th and May 31st 2020.
All admitted patients with a diagnosis of COVID-19 were prospectively captured in an electronic monitoring system. Data was obtained from this in conjunction with medical notes and entered onto a standardised database. Three clinical outcomes were assessed: i) mortality ii) clinical adverse events (composite death or ICU or non-invasive ventilation or high flow nasal oxygen) iii) nosocomial infection. Multivariate logistic regression was performed to identify risk factors for clinical outcomes.
For 399 adults, the median (IQR) age was 70 years (53 – 80) with 150 (38%) women, and 101 (26%) from lower socio-economic areas. 195 (49%) patients were categorised as a nosocomial infection. 52 (13%) patients required non-invasive ventilation (CPAP or BiPAP) and 12 (3%) received high flow nasal oxygen. 40 (10%) of patients were admitted to the intensive care unit. The median (IQR) length of stay in ICU was 7 days (5 – 13). 90 (23%) patients died.
The strongest independent predictors of mortality were nosocomial transmission, dementia and respiratory disease (aOR [95% CI] 10.91 [2.15 – 55.20], p<0.01; 10.82 [1.74 – 67.33], p=0.01; 6.36 [1.42 – 28.52], p=0.01 respectively). Nosocomial transmission and respiratory disease remained important predictors for adverse clinical events, with high BMI and hypertension now also predictive (aOR [95% CI] 3.84 [1.25- 11.77], p=0.02; 3.33 [1.19 – 9.29], p=0.04; 1.09 [1.01 – 1.18], p=0.03; 3.04 [1.04 – 8.92], p=0.04 respectively).
We then examined characteristics of patients with nosocomial transmission and identified frailty and immunosuppression as the most strongly associated factors (aOR [95% CI] 1.39 per point increase on the rockwood score [1.04 – 1.85], p=0.03; and 4.04 [1.15 – 14.11], p=0.03 respectively). Interestingly, patients with nosocomial infection were less likely to have a respiratory disorder and had a lower BMI (aOR [95% CI] 0.26 [0.09 – 0.78], p=0.02; 0.90 per Kg/m2 increase [0.83 – 0.98], p=0.01 respectively)
COVID-19 caused a high toll of adverse outcomes amongst inpatients in Beaumont hospital. In particular, those who acquire infection in hospital are particularly vulnerable and demonstrate a different set of risk factors. Resources should be specifically allocated to mechanisms that will prevent hospital acquired COVID-19 infection.
"Epidemiology of SARS-CoV-2 in Healthcare Workers following the First Wave of the COVID-19 Pandemic"
Principal Presenter: Eamonn Faller
Healthcare workers (HCWs) are at an increased risk of COVID-19 infection and account for almost one third of cases in Ireland. The aim of our study was to determine seroprevalence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) antibodies in five pre-specified HCW subgroups in our institution following the first wave of the pandemic.
HCWs were recruited from each of the following subgroups:
1. HCWs who had RT-PCR confirmed COVID-19 infection (>1 month post positive RT-PCR)
2. HCWs identified as close contacts of persons with COVID-19 infection who developed symptoms (RT-PCR not detected on swab)
3. HCWs identified as close contacts of COVID-19 cases who remained asymptomatic (not screened by RT-PCR)
4. HCWs not included in the above groups working in areas determined as high risk clinical areas
5. HCWs not included in the above groups working in areas determined as low risk clinical areas
Participants were recruited over a 4 week period in June-July 2020. HCWs from nearby institutions were recruited to group 1 as the number of staff who had RT-PCR confirmed infection in our institution was small. Basic demographic data was collected by means of a self-administered questionnaire. Serum was collected for SARS-CoV-2 IgG testing (Abbott ARCHITECT SARS-CoV-2 IgG CMIA®), saliva for SARS-CoV-2 RT-PCR and fingerprick blood sampling for point of care lateral flow assay SARS-CoV-2 IgG and IgM testing.
Results presented are those of the laboratory SARS-CoV-2 IgG testing.
503 HCWs (77.14% female, age range 20-65 years) were recruited with an overall SARS-CoV-2 IgG positivity of 15%.
In group 1, 72 of 99 (72.73%) HCWs with previous positive SARS-CoV-2 RT-PCR were seropositive (73.6% female, age range 20-65 years).
Of the 4 groups who had not had a previous RT-PCR positive, 5 of 403 (1.24%) HCWs were seropositive, 2/106 in group 2, 1/90 in group 3, 0/100 in group 4 and 2/107 in group 5. There was no significant difference between clinical area of work and detectable SARS-CoV-2 IgG.
We report seroprevalence of SARS-CoV-2 IgG in HCWs not previously diagnosed with COVID-19 at 1.24%. The recent national population seroprevalence study (SCOPI) estimated seroprevalence in the general population at 1.7% during the same period. Seroprevalence in our HCW study is lower than that reported in international HCW studies.
"The Clinical Course of Patients Hospitalised for COVID-19 Treatment Ireland: a Retrospective Cohort Study in Dublin’s North Inner City (the ‘Mater 100’)"
Principal Presenter: Robert Browne
Keywords: COVID-19, Coronavirus, Clinical Characteristics
Background: Since March 2020, Ireland has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To date, our understanding remains limited, with no data describing the epidemiological and clinical characteristics of patients with COVID-19 in Ireland. To improve our understanding of the clinical characteristics of this emerging infection, we carried out a retrospective review of patient data to examine the clinical characteristics of patients admitted for COVID-19 hospital treatment.
Methods: Demographic, clinical and laboratory data on the first 100 adult patients admitted to Mater Misericordiae University Hospital (MMUH) for inpatient COVID-19 treatment after onset of the outbreak in March 2020 was extracted from clinical and administrative records. Missing data were excluded from the analysis.
Results: Fifty-eight per cent were male, 63% were Irish nationals, 29% were GMS eligible, and median age was 45 years (interquartile range [IQR] =34-64 years). Patients had symptoms for a median of five days prior to diagnosis (IQR=2.5-7 days). Most common symptoms were cough (72%), fever (65%), dyspnoea (37%), fatigue (28%), myalgia (27%) and headache (24%). Of all cases, 54 had at least one pre-existing chronic illness, most commonly hypertension (16%), diabetes mellitus (12%), or asthma (11%). At initial assessment, the most common abnormal findings were: C-reactive protein >7.0mg/L (74%), ferritin >247μg/L (women) or >275μg/L (men) (62%), D-dimer >0.5μg/dL (62%), chest imaging (59%), NEWS Score (modified) of ≥3 (55%) and heart rate >90/min (51%). Twenty-seven required supplemental oxygen, of which 17 were admitted to the intensive care unit, with 14 requiring ventilation. Forty received antiviral treatment (most commonly hydroxychloroquine or lopinavir/ritonavir). Four patients died, 17 were admitted to intensive care, and 74 were discharged home, with a median hospital stay of nine days (IQR=6-11).
Conclusion: Our findings reinforce the emerging worldwide consensus of COVID-19 as an acute life-threatening disease. Furthermore this research highlights the importance of laboratory (ferritin, C-reactive protein, D-dimer) and radiological parameters, in addition to clinical parameters. Further cohort studies involving larger samples followed longitudinally are a priority for future research.Download #2020546 (1.44 MB)
"The Impact of the COVID-19 Pandemic on referrals to the National OPAT Programme"
Principal Presenter: Robert Browne
Keywords: OPAT, COVID-19, Coronavirus
Background: Outpatient Parenteral Antimicrobial Therapy has been shown to be a safe, effective and cost efficient means of completing long courses of intravenous antibiotics. With the spread of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), healthcare systems worldwide find themselves under unprecedented pressure. Nosocomial outbreaks of SARS CoV-2 are well described and OPAT offers a way to safely treat patients away from the acute hospital setting. We aimed to determine the impact of the COVID-19 pandemic on referrals to the National OPAT programme.
Methods: A retrospective analysis was carried out on all referrals to the National OPAT programme in Ireland between the September 1st 2019 and 31st August 2020. Anonymous Data were collected including hospital referral, mode of OPAT delivery, infection site, antimicrobial choice and duration of treatment. Statistical analyses were carried out using SPSS.
Results: A total of 1,563 referrals were made between 1st September 2019 and 31st of August 2020; 1129 (72%) were for Healthcare Personnel Provided OPAT (H-OPAT) and the mean duration of therapy was 20.2 days. There were 422 (27%) patients referred between September-December 2019, 412 (26.4%) December-March 2020. Referrals were at their lowest between March–May 2020, with 329 referrals (21%) and 400 (25.6%) referrals between June-August 2020. Compared to the first six months, a mean 21.3% decrease in referrals to the OPAT service across all centres is observed between March – May 2020 (H-OPAT-18.2%; S-OPAT-28.5%). There was an a mean decrease of 25.1% among the seven largest OPAT centres during this time, however these centres showed large variation in referrals (range - -41.4% to +3.6%). There was no significant association between whether a referral came from an ID centre or non-ID centre and quarter of the year, X2 (3, N = 1563) = 0.57, p = 2.01.
There is an estimated 50-80% decline in outpatient, routine diagnostics and screening services due to COVID 19. The Irish OPAT service continued to operate during the peak of the pandemic and showed only a small decline in numbers of patients treated, especially via H-OPAT mode of delivery. Furthermore, OPAT services resumed to normal capacity just three months after the first cases of COVID 19 entered Irish hospitals. Faced with a possible “second wave” of infection, the above findings indicate the OPAT service is a vital part of hospital infrastructure which limits vulnerable patients exposure to the acute hospital system.Download #2020545 (1.24 MB)
"Amiodarone-Induced Pleural Effusion: A Case Report"
Principal Presenter: Mahab Al Zadjali
Keywords: Amiodarone, Pleuritis, Pleural effusion
Use of amiodarone is frequently limited by pulmonary toxicity. Amiodarone induced pulmonary disease can present as interstitial pneumonitis, organising pneumonia, pulmonary nodules or pleural effusion. Usually, amiodarone induced pulmonary disease occurs with chronic use of amiodarone, or subacutely when used at high doses.
The patient's inpatient and outpatient chart was reviewed.
A 75 year old man presented to the emergency department with pleuritic chest pain without cough, dyspnoea or fever. His past medical history was significant for atrial fibrillation, implanted defibrillator, myocardial infarction, life-long tobacco smoking, and prostate adenocarcinoma with bone and lymph node metastases. His CRP and WCC were elevated at 34mg/L and 8.3 x 10^9/L respectively. ECG showed a normal sinus rhythm with no acute changes. Pulmonary embolism was among the differential diagnoses, and CTPa was performed. This revealed bilateral pleural effusions without emboli. The left-sided effusion was tapped and revealed a lymphocytic exudative effusion. Gram staining and 16s PCR on the fluid was negative. The patient had multiple troponins and ECGs during both admissions which did not reveal any dynamic change. The patient self-discharged on day 8. He was readmitted on day 11 with recurrence of the chest pain. The ECGs consistently showed T-wave inversions on the precordial leads, which predated this admission by many years.
At this point we had no evidence of infection, a negative autoinflammatory screen, and no evidence of pulmonary or pleuritic malignancy, and so we interrogated his medications. The patient had been taking amiodarone for 30 years twice a month, whenever he felt he had palpitations. For the past two years he increased the frequency of the amiodarone to twice a week, due to his perception that his palpitations were more frequent. At time of self-discharge his amiodarone was mistakenly charted once daily. During his second admission he was initially not given his amiodarone, and this was reintroduced on day 17. Within one day of amiodarone reintroduction the patient had recurrence of both his pleuritic pain and an inflammatory response with CRP of 236mg/L. A presumptive diagnosis of amiodarone induced pleuritis was made, amiodarone was discontinued and the patient was started on prednisolone 40mg OD. Within one week of this his CRP had reduced to 16mg/L, and he remains symptom free.
Amiodarone induced pleuritis may occur many years after initial use, and with low doses of amiodarone.Download #2020544 (586.57 KB)
"A Puzzling Presentation of COVID-19: Cardiac and Renal Failure Without Overt Respiratory Failure."
Principal Presenter: Gillian Madders
Keywords: Covid, cardiomyopathy, cytokine
The new Coronavirus-disease-19 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus2 (Sars-CoV2) has led to a world health emergency. As the name of the virus would suggest, this disease preferentially targets the lungs but other organ involvement has been widely described. Direct viral injury via Angiotensin Converting Enzyme 2 (ACE2), immune dysregulation and hypercoagulability are thought to be involved in disease pathogenesis. This case demonstrates the multiorgan impact of COVID-19 and may represent a case of cytokine mediated cardiac and renal dysfunction.
A 37 year old male presented with fevers and myalgia. He was mildly hypoxic requiring 2litres of oxygen. He tested positive for COVID-19. Chest Xray showed bilateral infiltrates in keeping with atypical pneumonia. Due to a persistent tachycardia, an echocardiogram was carried out which showed an ejection fraction (EF) of 10-15%. Interestingly, serial troponins and electrocardiograms were normal and the patient was euvolemic. Bloods revealed evidence of hyperinflammation with a CRP of 114 and a Ferritin of 664. Shortly after admission, he developed a rapidly progressive AKI. The aetiology of this was unclear as he had no overt hypotension and was not on any nephrotoxins. He commenced haemodialysis with a gradual improvement of his renal function. A renal biopsy was carried out which showed acute tubular injury without viral cytopathy or microangiopathy. He was prescribed Bisoprolol and Ramipril and followed by serial echocardiography, which showed a gradual improvement in EF to 40-45%. A cardiac MRI was later carried out which showed changes in keeping with postinfectious cardiomyopathy but a return to normal function.
This case encapsulates the multiorgan impact of Covid-19 and highlights that severe disease can spare the lungs. Cell infectivity by SarsCoV2 depends on the expression of ACE2 receptors on many organs. Binding of the virus to this enzyme triggers multiple downstream effects which result in organ injury. One distinct mechanism of injury to consider is cytokine-mediated. Cytokine-mediated myocardial depression syndrome as well as cytokine-mediated renal tubular injury were described in this case. These are important entities to recognise as they are potentially reversible but can have longterm consequences.
This is an unusual presentation of COVID-19 in a young gentleman without comorbidities. Further studies are necessary to better understand disease pathology and it’s chronic complications so we can prepare for what could be another facet of the pandemic.Download #2020543 (317.24 KB)
"Improving the timely IV-PO switch of antimicrobials: A Quality Improvement Initiative"
Principal Presenter: Dr Marion Murphy
The timely switch from intravenous (IV) to oral antibiotics has many benefits, including: earlier discharge, reduced risk of acquiring a hospital infection, increased comfort/mobility for the patient, reduced costs of antimicrobials and associated administration costs. A study has shown that up to 24 % of IV/oral switches are delayed and could be performed on average two days earlier (1). A 2018 survey of 174 UCHG doctors of all grades identified that visual prompts and reminders from nursing/pharmacy staff could potentially promote earlier IV to oral switch (2). The aim of the study was to reduce the number of patients receiving an antibiotic via intravenous route which fits oral switch or stop criteria by 50% on a surgical Ward in 3 months January to April 2020.
A surgical ward was chosen to pilot the study. Baseline point prevalence data was collected for four weeks prior to intervention. Patient kardexes were reviewed to quantify number of patients on IV antimicrobials who were suitable for oral switch as per local guidelines.
A collaborative approach was used to develop multifaceted interventions and perform several PDSA cycles:
PDSA Cycle 1: The development of visual prompts to be placed on a Kardex/notes.
PDSA Cycle 2: Assessment and feedback of the prompts.
PDSA Cycle 3: Education – nurses/interns.
PDSA Cycle 4: Communication to surgical directorate.
PDSA Cycle 5: Hospital awareness day.
PDSA Cycle 6: Use of nursing board rounds.
PDSA Cycle 7: Modification of data collection.
Prior to the intervention, 123 kardexes were reviewed over 4 weeks, 35.0% (n=43) were on IV antimicrobials, 34.9% (n=15) of which were suitable for oral switch as per the local criteria policy. Since the initiation of the intervention in January 2020, 122 kardexes have been reviewed over 4 weeks, 36.0% (n=44) were on IV antimicrobials and 22.7% (n=10) were deemed suitable for oral switch, a reduction of 35.0%.
The proportion of patients on iv antimicrobials suitable for po switch has reduced by 35%. Based on the lessons learned, the process will continue to evolve and spread to other wards in the hospital.
1. Hogan-Murphy D et al. A baseline prospective audit on compliance with antimicrobial intravenous to oral switch guidelines in a Model 4 teaching hospital. Poster presentation. One Health Event, 2018
2. Hogan-Murphy D et al. What Stops Doctors Switching from Intravenous to Oral Antibiotics? Ir Med J; Vol 112; No. 8; P987
"An Audit on the Investigation of COVID-19 Infection in Patients with Negative SARS-CoV-2 PCR Swab Results and Ongoing Clinical Suspicion, With a Focus on the Use of Chest CT, as Compared to World Health Organisation Recommendations"
Principal Presenter: Jonathan McGrath
BACKGROUND: Detection of SARS-CoV-2 RNA via real-time reverse transcription polymerase chain reaction (RT-PCR) is the gold standard for diagnosing suspected cases of COVID-19. Comprehensive guidelines on the use of chest computed tomography (CT) in the diagnosis of COVID-19 are lacking. In clinical practice, chest CT has become a valuable adjunct to diagnosis, however its value in PCR-negative COVID-19 cases has yet to be fully established. In June 2020, the World Health Organisation (WHO) published ‘Use of chest imaging in COVID-19 – A Rapid Advice Guide’ making recommendations for the use of chest imaging in acute care of adult patients with suspected, probable or confirmed COVID-19.
METHODS: We undertook a clinical audit in the Mater Misericordiae University Hospital examining the evaluation of suspected COVID-19 cases with negative SARS-CoV-2 PCR results, with comparison made to recommendations published by the WHO. A retrospective chart review was undertaken for 90 patients examining investigations, in particular computed tomography (CT), recommended following specialist multidisciplinary team (MDT) input.
RESULTS: 90 patients underwent additional investigation following MDT guidance between March 28th and May 4th 2020. For the relevant recommendations made by the WHO, 75% adherence was observed. 52 (57.78%) males and 38 (42.22%) females were investigated, with a median age of 69 years (range 20-96 years). 79 chest CTs (CT & CTPA) were performed with positive, indeterminate and negative rates for COVID-19 of 3.79%, 24.1% and 72.15% respectively. 5 (5.5%) patients with indeterminate CT findings and consistent symptoms were treated clinically as COVID-19. 2 (2.2%) patients treated as COVID-19 positive had consistent symptoms and Chest X-Ray findings. 3 (3.33%) patients had discordant swab results with initially negative and subsequently positive results for SARS-CoV-2, resulting in a false negative rate of 3.33%. 4 (4.44%) patients were treated clinically as COVID-19 without definitive CT/CXR findings. The mean number of days from first swab to CT scan was 2.2 days. The mean time from CT scan to leaving the hospital ‘COVID pathway’ in negative patients was 1.35 days (median 1, Range 0 to 4 days).
CONCLUSION: 75% adherence to WHO recommendations was observed. Further evidence is needed to fully determine the utility of chest CT in the diagnosis of COVID-19, particularly with false negative RT-PCR results. Re-audit will be performed as diagnostic algorithms and guidelines are refined.
"Inflammatory markers in COVID-19 infection in Galway University Hospital"
Principal Presenter: Dr Marion Murphy
Keywords: Inflammatory markers, SARS-CoV-2, COVID-19
The coronavirus disease (COVID-19) pandemic is characterised by a broad spectrum of clinical presentations of varying severity. In Ireland to date, 11% of cases have been hospitalised, of these 13% of cases required admission to the intensive care unit (ICU) (1). It has been suggested that severe cases are associated with a cytokine release syndrome which plays a role in the pathology of COVID-19 (2). The aim of this preliminary study was to assess variables of confirmed COVID-19 patients that may aid prediction of severe infection.
A cross-sectional study was conducted from March 6th to May 1st 2020, of all patients presenting to Galway University Hospital who were found to have a detected PCR COVID-19 infection. Baseline clinical and laboratory data were collected and data was anonymised. Categorical variables were compared with the chi2-test and numerical variables were tested with the Mann-Whitney-U-test (Stata software v15); p-value of <0.05 was considered significant.
There were 70 patients admitted with detected COVID-19 infection, 29.0% (n=20) required ICU care and the ceiling of care for 9% (n=6) was ward level. On admission high levels of C-reactive protein (median 87 mg/L v 14.3 mg/L, p<0.005), ferritin (median 939 mg/L v 408 mg/L, p<0.005) and interleukin-6 (median 73 pg/l v 19 pg/l, p<0.005) were associated with requiring ICU admission compared to ward level. Over a quarter of patients (27.1%) had oxygen saturations >94% on admission and this was also associated with high interleukin-6 levels (62 pg/l v 20 pg/l, p=0.018) compared to patients with oxygen saturations <94%.
Further research is required but data suggests that high inflammatory markers early in the admission to hospital is associated with severe infection.
1. Health Protection Surveillance Centre. Epidemiology of COVID-19 in Ireland Report prepared by HPSC on for National Public Health Emergency Team. 27/09/2020
2. Mehta et al. COVID-19: Consider Cytokine Storm Syndromes and Immunosuppression. The Lancet. Vol 395:10229, P1033-1034, March 28, 2020.Download #2020540 (141.62 KB)
"Recurrent Clostridium perfringens Cellulitis Successfully Managed Conservatively"
Principal Presenter: Riona Kivlehan
Keywords: Cellulitis, SSTI, Clostridium perfringens
Clostridium perfringens is an organism that may cause significant human disease. It may commonly cause outbreaks of food-borne illness and skin and soft tissue infections(SSTI). C. perfringens causes SSTI in three discrete clinical entities; simple wound colonisation or contamination, anaerobic cellulitis, and clostridial gas gangrene. Less commonly, it can cause bacteraemia, and such cases are associated with significant mortality. C. perfringens spores may lay dormant after initial infection and cause significant disease when the spores reactivate. This can occur many years after initial infection. We present the case of an elderly man who presented with recurrent C. perfringens anaerobic cellulitis two years after being treated for a similar episode.
The patients notes from both admissions were reviewed and a literature review of C. perfringens infection was conducted.
An 80 year old man presented with a five week history of a painful rash affecting the right lower limb. His past medical history includes complete congenital hearing loss, mutism, lower limb lymphoedema, ischaemic heart disease, chronic kidney disease stage 3, gout, and previous admission with diffuse cellulitis affecting both lower limbs and C. perfringens bacteraemia. On examination, the right leg was found to be extremely tender, with raised red patches and pustules on the overlying skin, blisters, and crepitus. He was tachycardic, tachypneoic and hypotensive and was found to have a white cell count of 20.4 and a CRP of 342. There was concern for necrotising fascitis and the on-call surgical team recommended urgent wound exploration and debridement. The patient refused surgical intervention, and so the case was managed conservatively. He was admitted to the high dependency unit and was deemed unsuitable for cardiopulmonary resuscitation due to his advanced age, and low likelihood of surviving the infection without definitive surgical management. He was treated with broad spectrum antimicrobials as diffuse cellulitis, with radiographic evidence of fasciitis, with vancomycin, clindamycin, and meropenem. Wound swabs taken from the affected area at presentation subsequently grew C. perfringens. Within two days of admission he had made a dramatic clinical improvement and he was subsequently discharged home after a prolonged antibiotic course.
C. perfringens may present as anaerobic cellulitis, which carries significantly better mortality compared with invasive gas gangrene. C. perfringens may also recur due to ongoing colonisation or reactivation of dormant spores.Download #2020539 (167.97 KB)
"HIV Service Effectiveness and Performance in University Hospital Limerick: Re-audit Three Years on"
Principal Presenter: Jamie McGettigan
Keywords: HIV, Audit, Quality Improvement
An expert panel convened by the National Committee for Quality Assurance (NCQA) in 2007 drafted seventeen performance measures for HIV care.
A 2016 audit of the ambulatory HIV service at University Hospital Limerick (UHL) showed good adherence rates with these measures and outlined. This audit focused on the period March 1st 2019 to March 1st 2020. This preceded the national lockdown in response to the Covid-19 crisis.
A retrospective review of HIV case records was performed. Inclusion criteria were clinic attendance at least once during study period and retention in care (defined as at least one subsequent visit following the audit period). Data on 171 patients were entered into an Excel Spreadsheet and percentages calculated. P-values were calculated using Chi-squared tests comparing data from both audits in Graphpad Prism 8.4.3.
The reaudit figures demonstrate show a patient number increase by 27 to 171 since 2016. Average patient age was 43 years. 35.67% of the patients were female (35% in 2016, p=0.86).
92.98%, n=159 of patients had undetectable viral load. Included in this were those with a viral load result of <40 (8.18%, n=14). The proportions of patients with undetectable viral load were similar between audits (92% in 2016, p = 0.66).
The adherence rates to the standards were as follows: CD4 counts at least 6-monthly (95.32%, n=163 vs 100% 2016, p=0.0086); Screening for co-infections including syphilis (97.66%, n=167), hepatitis B (98.25%, n=168), hepatitis C (90.64%, n=155), Gonorrhoea & Chlamydia (96.49%, n=165); Vaccination rates for hepatitis B (5.26%, n=9 have vaccine outstanding while 77.77%, n=133 have had at least one vaccine; vaccination was not indicated due to previous immunity or Core Ab positivity in 16.96%, n=29), Influenza (84.21% 2019/20 vs 97% 2019, p=<0.01) and Pneumococcal (88.89% vs 98.6% 2016, p=<0.001). TB screening between cycles was similar (78% 2016 vs 86% 2019/20, p=0.08).
This service continues to show good adherence to international standards. There are still areas which can be improved including influenza & pneumococcal vaccination rates and ensuring at least 6-monthly CD4 counts.
Further education to departmental staff regarding opportunistic screening and vaccination should be carried out to further improve the adherence to HIV care quality measures.Download #2020538 (214.35 KB)
"COVID-19 Know-How: Assessing Levels of COVID-19 Knowledge amongst Doctors Working in St. Vincent’s University Hospital."
Principal Presenter: David McCormack
Keywords: COVID-19, Questionnaire, Knowledge
As of the 25/09/2020, there have been 34,315 confirmed cases of COVID-19 in Ireland, along with 1,797 COVID-19 related deaths. The dynamic and profound effects of COVID-19 on the Irish health service are mirrored by the equally dynamic progression of COVID-19 research.
Using a web-based questionnaire, we aimed to assess how well best practice guidelines derived from up to date COVID-19 research have permeated the knowledge base of doctors working in St. Vincent’s Hospital Dublin. Additionally, we aimed to provide a brief educational intervention by supplying an answer key following closure of the questionnaire.
A true/false web-based questionnaire was distributed to all doctors working in SVUH over a 3-day period in the third week of September 2020. The results from this questionnaire were analysed using Le Sphinx MEA software. An answer key was subsequently provided to all doctors working in the hospital.
Overall, 93 responses were obtained. Interns (n=31) and consultants (n=31) both accounted for 33% of respondents, senior house officers (n=15) accounted for 16%, while registrars and specialist registrars (n=15) accounted for 16%. Overall, questions pertaining to the clinical features and medical management of Covid-19 were answered with slightly greater accuracy (80%-94%) than those related to hospital precautions and preventative measures (62%-100%).
20% (n=19) of respondents incorrectly answered “true” to the question “Suspected COVID-19 patients can be accommodated on a 6-bed cohort ward”. Additionally, 13% (n=12) of respondents incorrectly believed removing PPE in the following sequence was correct “mask, gown, goggles, gloves”. However, 100% (n=93) recognised that a face covering visor cannot be “used instead of a medical mask when coming into contact with a patient suspected of having COVID-19”.
87% (n=81) of respondents knew that “prophylactic anticoagulation is recommended in patients who test positive for COVID-19 and have risk factors for severe disease”. A further 87% (n=81) correctly recognised that “In patients with confirmed COVID-19, the development of dyspnoea indicates an increased risk of severe infection”
As COVID-19 hospitalisations once again rise, it is essential to assess the preparedness of medical staff. We believe questionnaires such as this can expose potential deficits of knowledge which may then be resolved using targeted educational interventions.Download #2020537 (302.95 KB)
"Klebsiella pneumonia Liver Abscess: a Case Series of 2 Patients Presenting Over a 12-Week Period in a Tertiary Referral Centre"
Principal Presenter: Aimee McGreal-Bellone
Keywords: Liver, Klebsiellapneumonia, Abscess
Klebsiella pneumoniae (KP) is a recognised cause of community-acquired mono-microbial pyogenic liver abscess (PLA). Initially identified in Asia, KP now accounts for a large proportion of PLA in Europe and the United States. Unlike other PLA, Klebsiella liver abscesses (KLA) are more often cryptogenic and may be caused by hyper-virulent strains of the bacteria which have a higher resistance to phagocytosis by neutrophils.
Clinical data about patient demographics, presentation, investigation and management was extracted from electronic and written patient records.
Case #1 A 40-year-old Chinese woman, resident in Ireland a decade, presented with a three-week history of intermittent fevers and dry cough. Her past medical history was unremarkable. The patient had been swabbed for COVID-19 in the community with a negative result. She was admitted with a presumed lower respiratory tract infection under the COVID pathway and underwent radiological investigation for a suspected pulmonary embolus. Cross-sectional imaging revealed an incompletely visualised liver lesion, concerning for a hepatic abscess. Dedicated contrast-enhanced computed tomography (CT) showed an 11 cm enhancing lesion, most consistent with an abscess. The lesion was drained under radiological guidance.
Microscopy and culture identified a highly-sensitive KP, only resistant to amoxicillin, with a mucoid appearance. The patient underwent treatment with 14 days of intravenous (IV) ceftriaxone and four weeks of oral co-amoxiclav with an excellent clinical outcome.
Case #2 A 58-year-old Zimbabwean man, resident in Ireland for three years, presented with a 24-hour history of rigors, shortness of breath and epigastric/chest pain following a recent course of antibiotics for a soft tissue infection of the lower limb. His background history was significant for diabetes and alcoholic cirrhosis. A CT abdomen-pelvis performed on admission revealed an enhancing 6.4 cm hepatic lesion, consistent with an abscess. Ultrasound-guided aspiration of the lesion grew KP, resistant to amoxicillin. This patient received 14-days of piperacillin-tazobactam and has been rationalised to IV co-amoxiclav at present.
Genetic testing of these samples is underway for markers of hyper-virulent KP strains.
Initially identified in Asian populations, KP is now a significant pathogen in mono-microbial liver abscesses in Europe. Risk factors demonstrated in these cases include Asian ethnicity, diabetes and recent antibiotic use. Our cases illustrate how these infections can present atypically, highlighting the importance of a broad differential in an undifferentiated patient.
Download #2020536 (240.19 KB)
"Neutralizing Anti-Interleukin 6 Autoantibodies in a Patient with Recurrent Aseptic Meningitis"
Principal Presenter: Ksenia Davenport
Keywords: interleukin-6, IL-6 autoantibodies, viral meningitis
Background: Interleukin-6 (IL6) is a cytokine produced in response to noxious stimuli such as infections. Activation of the IL6 receptor triggers production of acute phase reactants, e.g. C-reactive protein (CRP), which in turn promote innate immune responses including opsonisation, phagocytosis, chemotaxis and complement activation. Defects in this pathway are associated with recurrent bacterial infections characterised by an absent acute phase response, but there are no reports pertaining to viral infections.
Methods: Case report
Results: Herein we describe a 50-year-old lady with history of three episodes of aseptic meningitis (1997,2008,2018) presenting with fever, headaches, neck stiffness and photophobia, with no features of encephalitis. Erythrocyte sedimentation rate was 2mmHg/h on the first occasion, and CRP <1mg/L on the subsequent two. On all occasions, cerebrospinal fluid (CSF) demonstrated lymphocytic pleocytosis, raised protein, marginally low glucose, and negative microscopy and bacterial/mycobacterial cultures. Herpes simplex virus 2 (HSV2) DNA was detected in CSF on one occasion, other bacterial/viral targets were not detected. Serum HSV2 IgG was positive in the absence of clinical history of herpetic lesions. There was no other significant medical history of note, and an unremarkable Bacillus Calmette-Guérin vaccination scar was present. Mantoux test and HIV serology were negative. Immunological investigations demonstrated normal immunoglobulins and IgG subclasses, adequate specific antibody responses to Streptococcus pneumoniae/tetanus/Haemophilus influenzae, and normal extended T/B lymphocyte subsets. Complement activity was normal for both classical and alternative pathways. Cytokine studies, undertaken in search for defects associated with susceptibility to herpetic infections, revealed severely and selectively impaired IL6 production due to presence of neutralizing anti-IL6 antibodies. Functional testing of peripheral blood monocytes in the absence of autologous serum demonstrated normalization of the IL6 response. No abnormalities were detected in the interferon gamma or interleukin-12 signalling.
Conclusion: This case describes severely impaired IL6 response due to presence of neutralizing anti-IL6 autoantibodies in a patient with recurrent, likely viral, meningitis. Inhibited IL-6 function explains her inability to mount an acute phase response, and may have contributed to the recurrent nature of infections. Significant viral infections have not, to date, been reported among patients with anti-IL6 antibodies, and as such our patient extends the previously described phenotype. Furthermore, concept of autologous anti-IL6 antibodies is of particular interest in the context of current COVID-19 pandemic and pharmacological use of a monoclonal antibody against IL6, tocilizumab.Download #2020535 (614.2 KB)
"Attitudes towards Influenza Vaccination amongst staff in a Tertiary Care Irish University Hospital"
Principal Presenter: Emma Kearns
E Kearns1, I Callanan2, A O’Reilly3, A Purcell3, N Tuohy3, A Smyth4, E Bairead4, S Fitzgerald5, E Feeney6, S Waqas6.
1. St. Vincent’s University Hospital, Dublin, Ireland.
2. Department of Clinical Audit, St. Vincent’s University Hospital, Dublin, Ireland.
3. Department of Occupational Health, St. Vincent’s University Hospital, Dublin, Ireland.
4. Department of Quality and Patient Safety, St. Vincent’s University Hospital, Dublin, Ireland.
5. Department of Microbiology, St. Vincent’s University Hospital, Dublin, Ireland.
6. Department of Infectious Diseases, St. Vincent’s University Hospital, Dublin, Ireland.
Healthcare workers (HCWs) are encouraged annually to get vaccinated against influenza. This year in view of COVID-19 pandemic, attitudes of HCWs towards vaccination is particularly important. An audit was undertaken to understand how to best encourage and facilitate the vaccination of HCWs.
An online survey was created in our institution. The survey was disseminated to all hospital staff (N=~3,500) via electronic channels. The clinical audit sphinx software was used for data collection and analysis.
The total number of responses was n=728, almost double the rate from 2019 (N=393). The majority of participants were female (79.1%,N=569), and between the ages of 30-49 years (59.64%,N=430). Responses were spread across divisions between doctors (20.28%,N=146), nurses (20.0%,N=144), allied health professionals (AHPs) (23.33%,N=168), management/administration (23.47%,N=169), general support services (5.14%,N=37) and other patient care i.e. HCAs (7.08%,N=51). 77.6% (N=551) of participants got vaccinated last year. 93.8% (N=677) of participants reported their intention to be vaccinated this year. The main barriers listed were being unable to find time (32.1%,N=36), side effects (29.5%,N=33), and not thinking that it works (20.5%,N=23). This differed from 2019’s results, with side effects as the main reason (65.2%,N=15), compared to being unable to find time (17.4%,N=4). Of those who weren’t vaccinated this year, staff in administration/management were the worst at getting vaccinated (30.38%,N=48), while nurses (18.99%,N=30) and AHPs (18.35%,N=29) were second. Of those who don’t intend to get vaccinated this year (N=45), management/administrative staff also made up the majority of participants (33.33%,N=15), followed by nurses (24.44%,N=11). The most popular suggestions for how to increase uptake were more mobile immunisation clinics (72.4%,N=517), more information on the vaccine (50.4%,N=360), and text reminders (50.3%,N=359). 82.06% of participants (N=590) agreed that healthcare workers should be vaccinated, with 56.4% (N=405) agreeing that it should be mandatory. The majority (32.96%,N=238) reported that they could neither agree nor disagree that COVID-19 had changed their opinion on influenza immunisation. However, when focusing on those who weren’t vaccinated last year, the percentages of those who agreed increased to 39.87% (N=63), with a further 11.39% (N=18) strongly agreeing.
In light of the increasing number of survey participants, more staff are interested in flu vaccination this year than ever before. The COVID-19 pandemic has had some influence on staff’s likelihood to be vaccinated. Feasibility of immunization and education pose the largest barriers to HCW vaccination.
"The impact of SARS-CoV-2 on healthcare workers in Galway University Hospitals"
Principal Presenter: Dr Marcella O'Callaghan
Healthcare workers (HCWs) are on the frontline of managing the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, and have been since it was first discovered in 2019. This has led to transformations in work practices. Gaining information from healthcare workers on the impact of SARS-CoV-2 will provide valuable lessons for future outbreaks and pandemics.
A web-based questionnaire was distributed to HCWs in Galway University Hospitals from May 2020 to July 2020. Three areas were assessed: the concerns of the SARS-CoV-2 pandemic healthcare workers, impact on personal life and preparedness of the workplace.
There were 218 valid web-surveys completed; the majority were female (75%, n=163), Irish ethnicity (88.5%, n=194) and aged between 20-29 years (34.4%, n=75). Whilst 84.4% (n=184) accepted the risk of contracting SARS-CoV-2 as part of their job; 75.7%, (n=165) were concerned regarding contracting the virus themselves and greater concern for their close contacts (89.5%, n=195). Stress (75.7%, n=165), increased work load (61.9%, n=135) and a negative work environment were commonly reported (60.6%, n=132). The majority of respondents (72%, n=157) felt that their workplace was prepared to deal with SARS-CoV-2 and a similar number (71.1%, n=155) were confident with the level of training received about treating patients. One quarter of participants stated that would prefer not to treat SARS-CoV-2 patients (25.2%, n=55). Concerns regarding contracting the virus for both themselves and their close contacts were the most common reasons why HCWs did not want to treat infected patients.
Despite the difficulties of increased stress and workload, HCWs in this facility feel prepared and adequately trained to treat SARS-CoV-2 patients. It is encouraging that most HCWs accepted the risk of treating SARS-CoV-2 patients as part of their job description, however there was a high level of concern regarding contracting the infection and transmitting to their close contacts.
"A Complex Case of HIV-mediated CD8+ Encephalitis"
Principal Presenter: Jessica Lowry
Keywords: HIV, CD8 Encephalitis, Steroids
A Complex Case of HIV-mediated CD8+ Encephalitis
Authors: J Lowry, P Carey, J McGettigan, , S O’Connell
Department of Infectious Diseases, University Hospital Limerick
The presentation of acute encephalopathy in the HIV-positive patient represents both diagnostic and therapeutic challenges. This is compounded by the possibility that these neurological manifestations may represent multiple pathologies in the immunosuppressed. CD8+ encephalitis is a severe form of HIV-related acute encephalopathy that with early commencement of high-dose-corticosteroids can provide promising neurological outcomes . We report the clinical and pathological features associated with this case of CD8+ encephalitis to sensitise clinicians to its early recognition.
We present the case of a fourty-one year-old male from Zimbabwe who presented with a three-week history of reduced power in the right upper and lower-limbs associated with confusion and expressive dysphasia. He was diagnosed with HIV ten years previously and had a complex social history with resultant disengagement from care and non-compliance with therapy. Once re-engaged in care, he was re-commenced on Tenofovir/Emtricitabine, Darunavir/Ritonavir.
On presentation, laboratory investigations revealed a viral-load of 78,929 and a CD4 count of 77. MRI-imaging of the brain displayed “Multifocal T2 hyperintensities throughout the frontal and parietal lobes with hyperintensity of the left caudate nucleus.”, most suggestive of opportunistic infection, namely toxoplasmosis versus neoplastic processes such as lymphoma. The decision was made to commence empiric cerebral toxoplasmosis treatment while awaiting definitive histopathological diagnosis. Initial right-parietal biopsy demonstrated non-specific inflammation alone, with PCR negative for bacteria, TB and fungi.
He continued to deteriorate with worsening hemiparesis and new-onset urinary retention despite initial treatment. Further imaging raised concern for lymphoma; and a second biopsy of the left-temporal-area showed ‘lymphocytic inflammation, microglial activation and astroglial reaction with CD8+ predominant population’ – hallmarks of CD8+ encephalitis . High-dose corticosteroids were commenced resulting in marginal clinical response associated with lessening of oedema on MRI but enlargement of the caudate lesion. Furthermore, anti-fungal cover was started with Amphotericin-B. This combination resulted in considerable clinical and radiological improvement with near-complete resolution of the hyperintensities on repeat imaging.
CD8+ encephalitis is an emerging clinical entity which has demonstrated variable prognoses with high-dose steroids in the literature. One case series of fourteen patients showed five patients making a full recovery, four surviving with residual cognitive impairment and five dying . Indeed, more data is required regarding its treatment and long-term outcomes.
This case demonstrates diagnostic and treatment challenges that arise in the context of immunosuppression. CD8+ encephalitis is a severe CNS complication of HIV that if detected early can have a favourable prognosis with corticosteroid therapy.
 Zarkali A, Gorgoraptis N, Miller R, John L, Merve A, Thust S et al. CD8+ encephalitis: a severe but treatable HIV-related acute encephalopathy. Practical Neurology. 2016;17(1):42-46.
 Gray F, Lescure F, Adle-Biassette H, Polivka M, Gallien S, Pialoux G et al. Encephalitis with Infiltration by CD8+ Lymphocytes in HIV Patients Receiving Combination Antiretroviral Treatment. Brain Pathology. 2013;23(5):525-533.
 Lescure F, Moulignier A, Savatovsky J, Amiel C, Carcelain G, Molina J et al. CD8 Encephalitis in HIV-Infected Patients Receiving cART: A Treatable Entity. Clinical Infectious Diseases. 2013;57(1):101-108.Download #2020532 (478.33 KB)
"An Audit of Community-Acquired Pneumonia Antimicrobial Compliance Using an Intervention Bundle in an Irish Hospital"
Principal Presenter: Brendan O'Kelly
Keywords: community acquired pneumonia, audit, mobile audience response system
Background: Hospitalisations with community acquired pneumonia (CAP) are often not managed in accordance with antimicrobial guidelines. The aim of this study was to assess if guideline driven antimicrobial prescribing for CAP can be improved using an intervention bundle. Secondary measures assessed were duration of iv antibiotics and total antibiotic duration, length of stay, mortality, improving uptake of appropriate investigations and documentation of CURB65.
Methods: A retrospective cohort of hospitalised CAP patients from August -September 2018 was compared with a post intervention prospective cohort from May-June 2019. Intervention bundle included a mobile audience response system (MARS) session, promotion of the antimicrobial app, development of a physical card with local guidelines and incorporating CURB65 into the unscheduled admission hospital proforma. Local guidelines are in keeping with BTS CAP guidelines. The chi-squared test was used for categorical data. The Mann–Whitney U-test was performed on non-normally distributed nominal data (LOS, duration of antibiotics), and the Kruskal–Wallis test was used for non-normally distributed ordinal/nominal data related to a scale (i.e. time to antibiotics for given CURB-65 score).
Results: 69 patients were included in the study (37 retrospective, 32 prospective). Overall compliance with local CAP guidelines improved from 21% to 62.5% (p<0.001). No difference in initial intravenous antibiotic duration was seen 4.1 vs 4.2 days (p=0.73), total antibiotic duration was significantly shorter in the post intervention group, 9.4 vs 7.3 days (p=.01). No difference in length of stay or mortality was seen between the groups. Documentation of CURB65 improved from 5.6% to 46.9% (p<0.01). Uptake of performing streptococcal urinary antigen improved from 18.9% to 40.6% (p=.024).
Conclusions: A simple low-cost quality improvement bundle featuring a MARS can significantly increase appropriate antimicrobial prescribing and shorten total length of antibiotics.Download #2020531 (524.63 KB)
"An Atypical Case of Amoebiasis Presenting with Constipation, Hepatic Abscess and Pleuropulmonary Disease"
Principal Presenter: Micheál Doyle
Keywords: Amoebiasis, Entameoba, Abscess
Entamoeba histolytica is estimated to cause over 100,000 deaths annually. Amoebiasis is uncommon in developed countries, with cases limited to travel or migration from endemic areas. While exposure most commonly results in asymptomatic infection, dysentery and extraintestinal complications are well-described. Constipation however is an atypical manifestation of amoebiasis. We report an unusual case of amoebiasis, presenting with liver abscess and constipation with radiological evidence of pleuropulmonary involvement.
The medical record relating to the patient’s admission and follow-up was reviewed. This was followed by a systematic review of the literature concerning amoebiasis and constipation.
A 28-year-old man, previously well, presented with a two-week history of right upper quadrant (RUQ) pain and constipation. The pain was severe and pleuritic, with radiation to the right scapula. Constipation was profound, with the patient reporting 3 to 4 days between bowel motions. Notably, he had returned from a trip to India 7 months previously. Examination confirmed RUQ and right flank tenderness. Murphy’s sign was negative. The patient was apyrexial and stable at presentation. CT abdomen and pelvis revealed active colitis of the caecum, a 3.3cm fluid-filled hepatic lesion in segment 6 suggestive of abscess, and bibasal consolidative lung changes. Severe constipation created a diagnostic challenge as a faeces sample could not be sent for ova, cysts and parasites (OCP). The patient was commenced on piperacillin/tazobactam and metronidazole to cover both amoebic and bacterial causes of liver abscess. A faeces sample, when acquired on day 5 of admission following multiple doses of laxatives, was negative for OCP by microscopy but positive for verotoxigenic Escherichia coli (VTEC) by polymerase chain reaction, suggesting a diagnosis of pyogenic abscess. Rapid clinical and biochemical improvement was achieved with empiric antimicrobial therapy. Ultrasound performed on day 11 of admission revealed a largely resolved liver lesion, yielding ~1mL of serosanguinous fluid on aspiration which was negative for bacterial 16S rDNA. Serology was subsequently strongly positive for Entamoeba histolytica, consistent with active amoebiasis. The patient was discharged on day 12 to complete a course of metronidazole and paromomycin, and reported no recurrence of symptoms when seen in clinic one week later.
Constipation, a rare complaint in the setting of intestinal amoebiasis, and the VTEC finding complicated the diagnosis in this patient. In summary, this case demonstrates an atypical presentation of amoebiasis, manifesting with constipation, liver abscess and asymptomatic pleuropulmonary involvement.Download #2020530 (79 KB)
"Rapid and Laboratory Based SARS-CoV-2 Antibody Testing in Asymptomatic High-risk Hospital Associated Cohorts, a Validation and Epidemiological Study"
Principal Presenter: Brendan O'Kelly
Background: Many high-risk patients including those with malignancy and those requiring haemodialysis have been unable to isolate sufficiently during the COVID-19 pandemic due to the need for essential life-saving care. Healthcare workers in the hospital setting are also at risk due to the nature of their work. We aim to use commercially available SARS-CoV-2 antibody tests to assess the prevalence of asymptomatic infection in these high-risk cohorts.
Methods: In a single centre, study participants had a SARS-CoV-2 rapid antibody testing in combination with three commercially available validated laboratory serology tests: Superbio Colloidal Gold IgM/IgG rapid diagnostic test (RDT), Roche Elecsys® Anti-SARS-CoV-2 (RE), ABBOTT Architect i2000SR IgG (AAr), and ABBOTT Alinity IgG (AAl). Asymptomatic participants with no previous confirmation of COVID-19 were recruited. Participants were recruited over three days; a single day in the haematology/oncology (H/O) directorate including all healthcare workers (HCWs), in-patients and day-ward patients, and two days in the haemodialysis unit. McNemar’s test was used to compare the RDT to individual laboratory assays.
Results: 157 subjects were recruited, of whom 103 (65.6%) were female, 137 (87.3%) were caucasian and with a median age of 50 years (range 19-90). Forty-nine (31.2%) participants were H/O patients, 71 (45.2%) were HCWs, 37 (23.6%) were HD patients. Nine participants were IgG seropositive in laboratory assays. Seven positive results were seen in HCWs, indicating a prevalence of 9.9% of asymptomatic infection. One H/O patients tested IgG positive (2%). A single (2.7%) patient receiving HD was positive. Five patients were IgM positive on the RDT, all were negative on subsequent SARS-CoV-2 polymerase chain reaction (PCR) testing from nasopharyngeal swab. Eighteen (11.5%) tests positive on the RDT were found to be negative on laboratory tests. A statistically significant difference was seen when comparing seroprevalence using the RDT to laboratory tests (RDT vs RA p<0.001, RDT vs Aal/AAr p<0.001)
Conclusion: High prevalence of asymptomatic infection was seen in HCWs. There was good agreeability between commercially available laboratory assays AAl/AAr and RE (97.5%) The RDT used likely has a high false positive rate, the role of RDTs for SARS-CoV-2 detection is yet to be determined.
"HIV Care Delivery in Newly Attending Patients – Influence of Age"
Principal Presenter: Nadra Nurdin
Keywords: HIV Ageing, Frailty
Significant advances in the understanding and care of HIV infection have resulted in the progression of HIV from a fatal disease to a complex chronic condition with a normal life expectancy. Thus, the HIV population is ageing.
A reterospective analysis of all patients newly attending the HIV clinic at St James’s Hospital in 2018 was performed, looking at differences in defined care metrics for patients >45 years old, and patients <45 years of age. Data was collected from patients Electronic Patient Record. Chi2 test (n-1) was used for statistical analysis.
253 new patients attended the HIV Clinic in 2018; 50 were >45 years old (median age 52, 86% male) and 203 were <45 years (median age 32, 88% male). Modes of HIV acquisition in the >45 group were: 61% MSM, 33% Heterosexual, 6% IDU. HIV acquisition n <45 group 81.5% MSM, 17% Heterosexual, 0.5% IDU. Geographical origin in >45 group was 31% Irish, 26.5% Sub-Saharan African (SSA), 22.5% European, 6% South American, 12% other. In the <45 group, 18.5% of patients were Irish, 41% South American, 18% European, 12% SSA, 11.5% other. There were no statistically significant differences in retention in care, CD4 count on presentation (510 vs 519), percentage patients with a detectable viral load on presentation (43% both groups p=1.00), or viral suppression at >6 months (96% vs 97.5% p =0.56). Regarding vaccination; 55% patients >45 had documented influenza vaccination at the clinic, vs. 82.5% <45 group (p=<0.0001), 44% patients > 45years received the pneumococcal conjugate vaccine vs. 69% <45years group (p=0.011). Patients >45years were more likely to have a chest radiograph (65% vs 49% p=0.04). The >45year age group was less likely to have; screening for chlamydia and gonorrhea (58% vs 75% p=0.0258, no difference in STI rates), syphilis antibody testing (94% vs 99% p=0.0248) with no difference in antibody ositivity and were less likely to be asked about drug use history (57% vs 80.5% p=.0006) and high risk sexual behaviour (75% vs 90% p=0.006).
In addition to demographic differences, we describe differences in care metrics provided to older people living with HIV, particularly regarding social history documentation and STI screening. Vaccination discrepancies may be explained by the older patients more likely to have access to a GP and to receiving vaccinations at primary care centres. Introduction of a vaccine passport would support the monitoring of preventative health interventions.Download #2020528 (421.82 KB)
"An Audit on Osteoporosis Screening, Diagnosis and Management in Ageing Patients Living with HIV"
Principal Presenter: Nadra Nurdin
Keywords: Osteoporosis, HIV
As people living with HIV (PLWHIV) live longer, chronic disease management and preventative care interventions are becoming an increasingly important aspect of their care. PLWHIV have a higher prevalence and earlier onset of osteopoenia and osteoporosis. Research suggests multifactorial risk factors, including direct viral effects, antiretroviral initiation, particularly with Tenofovir disoproxil (TDF) and protease inhibitors, as well as traditional risk factors including smoking and alcohol excess.
European AIDS Clinical Society guidelines recommend screening postmenopausal women and men age >50 for osteoporosis. We undertook a retrospective chart review for 436 patients aged 50 – 55 attending the HIV clinic at St James’s Hospital, Dublin. Data collected included patient demographics, referral for and performance of DEXA scan, osteoporosis risk factors and subsequent management guided by DEXA report. This audit is part of a larger study being undertaken in the department evaluating care metrics in all HIV-positive patients over 50 years.
Preliminary results: mean CD4 count was 687 (range 49 – 1663), 3.5% had a CD4 count <200cells/mm3, and 12.5% <350cells/mm3. Viral load was undetectable/<40cpm/ml in 96%. 50% of patients had a baseline DEXA scan, with a further 16% booked for a DEXA scan. Of patients that had DEXA scan, 13% were identified to have osteoporosis and 31% found to be osteopenic. Vitamin D level was assessed in 55% of all patients, with 34% of patients vitamin D insufficient (50-30nmol/L) and 11% vitamin D deficient (<30nmol/L). 46% of patients with Vitamin D deficiency or insufficiency were documented to be taking vitamin D supplementation. 42% of the total cohort are current or ex-smokers and 10% had a reported history of alcohol excess. Receipt of bisphosphonates therapy was documented for 36% of patients with osteoporosis, 11% were referred to a bone health specialist for further management. 8% of patients identified to have osteoporosis/osteopenia were currently on TDF-containing antiretroviral regimen, 73% of patients were switched from a TDF-containing ARV regimen when found to have reduced bone mineral density on DEXA scan.
This audit demonstrated moderate adherence to EACS guideline recommendations for osteoporosis screening (66% referred). Initial analysis suggests a significant prevalence of osteoporosis and osteopenia. The interpretation of bisphosphanate treatment rates may be impacted by prescribing through GP, a limitation of this study at this time is that we did not have access to these records. This audit highlights the need for bone health assessment and management in HIV-positive patients, including documentation of osteoporosis management.Download #2020527 (1.47 MB)
"Hallucinations, headaches, and flank pain; nonbacterial thrombotic endocarditis secondary to pulmonary adenocarcinoma."
Principal Presenter: Nicholas Power
A minority of blood culture negative endocarditis (BCNIE) is the result of non-infectious causes. Non-bacterial thrombotic endocarditis (NBTE) can occur in the setting of inflammatory disorders, auto-immune disorders or malignancy. Rarely NBTE can occur before the widespread dissemination of a cancer.
A 53 year old woman presented to the emergency department with a one day history of severe right flank pain. Her vitals on admission were all within normal limits. Physical exam revealed a soft, systolic murmur and right sided abdominal tenderness. Admission bloods showed a mildly elevated CRP of 9 and WCC of 15. The patient’s past medical history was significant for a 20 pack year smoking history, hypertension, suspected inflammatory arthritis, and migraines.
On day two her CRP increased to 270 and her WCC remained elevated at 17.8. There was no clinical deterioration or temperature elevation. CT abdomen pelvis was performed which showed areas of infarction to both kidneys and spleen consistent with emboli. A presumptive diagnosis of endocarditis with emboli was made.
The patients TTE was clear of vegetation. The patient then revealed that she had been diagnosed with a possible inflammatory arthropathy six months earlier, but her investigations for this had so far been negative. She had some symptomatic benefit with NSAIDs. One month earlier she had also presented to another emergency department with unilateral headache and visual disturbances. CT brain and angiography was clear and a diagnosis of atypical migraine was made. She also had concurrent visual hallucinations that appeared as "cogwheels turning" throughout all fields of vision.
TOE revealed a small mitral valve lesion. The vegetation on TOE and emboli seen on CT-AP together meet 1 major and 1 minor Duke’s criteria i.e. possible endocarditis. However a CT thorax was ordered due to the smoking history and diagnostic uncertainty. This revealed a 7mm lung nodule, and pathological mediastinal lymph nodes. Lymph node biopsy revealed lung adenocarcinoma staged at T1aN3M0.
The patient's hallucinations and arthralgia resolved with a short course of dexamethasone 4mg OD. She was started on high dose enoxaparin to prevent further thrombosis. Chemotherapy could not be used as cisplatin is pro-thrombotic and the patient was deemed high risk for further thrombosis. She underwent curative radiotherapy. She has not had any further clinical thrombosis.
NBTE can rarely present with diffuse thrombosis and should be considered in cases of BCNIE where there is diagnostic uncertainty.
"‘Co-Vit D’ – A retrospective review of Vitamin D as a variable in clinical severity and disease outcome of SARS-CoV-2 infection in an an acute Dublin hospital"
Principal Presenter: Bearach Reynolds
Keywords: Covid-19, Vitamin D, Prevention
Vitamin D has an important and established role in innate immunity. Previous retrospective studies have demonstrated the correlation between Vitamin D deficiency and increased mortality rates in acute viral respiratory tract infections. Although the mechanism for this is unclear, it is felt to be as a result of direct inhibition with viral replication or through anti-inflammatory and immunomodulatory pathways.
With the emergence of SARS-Co-2 infection, preventative health measures which may reduce the risk of severity and disease outcome are increasingly needed.
The purpose of this study is to determine the prevalence of Vitamin D deficiency and to assess its association with clinical outcomes in a diverse population group.
All patients admitted with confirmed PCR positive SARS-CoV-2 infection to Connolly Hospital Blanchardstown between March-May 2020 were identified. Clinical presentation, treatment and outcomes as well as biochemical data including serum Vitamin D levels were collected. This data was analysed using SPSS. Vitamin D levels were classified into adequate (>50), moderate deficiency (<50) and severe deficiency (<30).
Of 116 patients, 73 patients were male and 62 female (M:F 1.7:1). The average age was 54 years. The median duration of symptoms prior to presentation was 6 days.
The median length of stay in patients was 5 days (IQR 3,10) with 26 (22%) admitted to the intensive care unit. 22 patients died during admission (18%).
Vitamin D levels were recorded in 84 (72%). The average vitamin D level was 36 (low). With 45 patients classified as severe deficiency (53.5%), 20 (23.8%) as moderate deficiency and only 19 (22.6%) with adequate levels. Mean Vitamin D levels were lower in those who died from SARS-CoV-2 infection with a mean value of 25 compared to 38 (p<0.055). On statistical analysis there was no significant difference between Vitamin D levels in the Irish vs. BAME population or between males and females.
An association between Vitamin D deficiency and COVID-19 disease mortality has been demonstrated in previous epidemiological studies. We found a higher than expected prevalence of Vitamin D deficiency amongst hospitalised patients with SARS-CoV-2 infection.
The relationship between death and deficiency is evident here even with a modest sample size. National data on Vitamin D deficiency found severe deficiency in a quarter of over 55s. Our population groups are not directly comparable, however the prevalence of severe Vitamin D deficiency (53.5%) in this population is notable.
In the absence of large scale randomised control trials Vitamin D supplementation is a reasonable recommendation, particularly for vulnerable populations, due to its potential role in limiting severity of acute respiratory conditions such as COVID-19.Download #2020525 (425.37 KB)
"Weight and Lipid Changes after Switch to Dolutegravir-based Regimens in IDU and Non-IDU within the UCD ID Cohort"
Principal Presenter: Aoife Heeney
Keywords: Weight, Dolutegravir, IDU
Increasing evidence from clinical trials and observational studies shows an association between use of Integrase Strand Transfer Inhibitors (INSTI), especially Dolutegravir (DTG), and weight gain in people with HIV (PWH). However, some studies suggest that weight gain might be limited to female subjects and people of African origin, and data on people with a history of intravenous drug use (IDU) is lacking.
The aim of this study was to evaluate weight and lipid changes following switch to DTG over 96 weeks in IDU and non-IDU.
We conducted an observational, retrospective analysis on all subjects enrolled in the UCD ID cohort who were switched to DTG. Weight and lipids (total cholesterol, LDL, HDL, total cholesterol/HDL ratio) were recorded at baseline, 48 and 96 weeks, alongside subject’s demographic and clinical data.
Paired sample t test was used to analyse weight and lipid changes within each group at 48 and 96 weeks post switch. Non-parametric Mann-Whitney test was used to assess the difference in weight and lipid changes.
204 subjects were eligible for the study. Of these, 96 (53 IDU and 43 non-IDU) had weight recorded at baseline and 48 weeks, and 90 (43 IDU and 47 non-IDU) had weight recorded at baseline and 96 weeks.
The median weight at 48 weeks was significantly higher than at baseline in both groups (IDU: 65kg (56.3; 76.9) to 69.5kg (59.7; 81.6), p 0.007, Non IDU: 73.45kg (66.82; 82.45) to 74.25kg (67.02; 86.87), p 0.003). The median weight at 96 weeks was significantly higher in non-IDU only (73.4kg (66.3; 82) to 77.6kg (70.55; 86.7), p <0.001).
There was not a significant between-group difference in % weight change between baseline and 48 weeks (IDU: 2.26% (-3.81; 14.93), non-IDU: 3.43% (-0.88; 8.12), p 0.954), and between baseline and 96 weeks (IDU: -0.48% (-6.06; 10), non-IDU: 5.52% (0.72; 13.33), p 0.346). Of note, weight change in non-IDU at 96 weeks was >5%, which is generally considered clinically significant. No significant change in lipid parameters between baseline and 48/96 weeks was observed in IDU and non-IDU.
Switch to DTG resulted in a significant median weight gain at 48 weeks in both IDU and non-IDU, without any difference in % weight change between the groups. Our results suggest that weight change following switch to DTG might be widespread among different socio-demographic groups.Download #2020524 (441.45 KB)
"An Audit of Anti-Microbial Prescribing Practices in an Acute Medical Unit of a Tertiary Care University Hospital"
Principal Presenter: Tara Hamilton
Keywords: anti-microbial, perscribing, tertiary care
Introduction: Adherence to anti-microbial prescribing guidelines as a pillar of antimicrobial stewardship is essential in ensuring safe and effective management of infections and to limit the emergence of resistant organisms. To determine the extent to which the local guidelines were being adhered to, we carried out an audit of the anti-microbial prescribing practices for patients being admitted to the AMU of our hospital.
Methods: Prospective data by convenience sampling over one month was gathered on 30 patients who were on antimicrobials.
Results: 60.7% (N=17) of initial antimicrobials were prescribed on presentation to the emergency department while 25% (N=7) started by the admitting team and 14.3% (N=4) were started by the staff in the acute medical unit. For two other patients it was unclear as to who had started antimicrobials. 55.2% (N=16) were prescribed in accordance to the SVUH local guidelines. 58.6% (N=17) of those included in the audit had blood cultures taken prior to commencing antimicrobial therapy and 80% (N=24) had a relevant microbiological specimen sent. Twenty-five (83.3%) of patients identified did not have an antimicrobial review date or duration date documented. Two (6.7%) patients received antimicrobial therapy within 1 hour of admission.
Conclusion: Overall the adherence to antimicrobial prescribing guidelines was moderate. Need for improvement in documentation of antimicrobial duration and of review plan was also identified. Awareness of staff needs to be increased to prevent delay in administration of first dose of antibiotics. Educational sessions on these aspects for relevant staff have been planned both at their induction and periodically afterwards.Download #2020523 (1.51 MB)
"Review of Patient Characteristics and Outcomes of Outpatient Parenteral Antimicrobial Therapy in UHL"
Principal Presenter: Alvina Zanib
Outpatient parenteral antimicrobial therapy (OPAT) is a safe and effective alternative to hospitalization for many patients who require prolonged intravenous antibiotic therapy. The objective of this study was to describe the OPAT experience at UHL in 2019.
Data was collected from OPAT patients enrolled in January 2019 to December 2019 regarding their age, gender, referring specialties, diagnoses, causative organisms, microbial resistant, chosen antibiotics, expected treatment durations, SOPAT versus HOPAT, outcomes for OPAT, switch to oral treatment, and number of bed days saved. Data analysis done via SPSS 21.
During the one year period from January to December 2019, 199 patients were referred for OPAT assessment and 131 were found to be suitable for OPAT. Mean age was 60.21+16.47 SD (range 17-91years). Of these, 61 originated from medical and 70 originated from surgical admissions. Total bed days saved in 2019 were 2964. Infections encountered were related to bone and joint involvement (50.8 %), skin (13.6%), septicemia (12.1%), abdomino-pelvic (8%), urinary tract (4%), respiratory (3.5%), cardiac (3%) and CNS (2%). The most commonly used antibiotic (31.2%) was from penicillin group (flucloxacillin/tazocin), followed by cephalosporin (19.1%), daptomycin (17.6%), and carbapenem (8%). Less frequently used agents’ incuded teicoplanin (3.5%), vancomycin (1.5%) acyclovir (0.5%), and caspofungin (3%). VRE was found in 8.5%, MRSA in 7.5%, CPE in 2.5%, & KPC in 1% of patient. OPAT was successfully completed in 77.6% of patients & 20.6 % required an oral switch afterwards. Almost 22.4 % of patient couldn’t complete OPAT program due to a combination of factors including recurrence of infection, side effects to antibiotic therapy and additional factors. Average expected OPAT duration was 3.35 weeks (range 1-6 weeks) and in 14.1% treatment duration was extended beyond initial planned duration. Health care provided OPAT cases were 97% versus only 3 % of Self OPAT cases. Of note wheel chair transport was required in 57.2% of the OPAT patients, highlighting the ongoing requirement for a ground-floor clinic with wheelchair access, outside the current ID department.
OPAT appears to be a safe, effective and practical approach for long term antimicrobial therapy with benefits of efficient bed utilization, reduction in health care costs and provision of appropriate antimicrobial therapy with a particular emphasis on anti-microbial stewardship. However, rates of SOPAT are low; a further move from HOPAT to SOPAT for suitable patients will further help with the sparing of CIT resources and in certain cases, patient satisfaction.
OPAT ; Outpatient parenteral antimicrobial therapy. SOPAT: self OPAT, HOPAT: health care OPAT, UHL: university hospital limerick, VRE: vancomycin resistant enterococci, MRSA: methicillin resistant staph aureus, CPE: Carbapenemase Producing Enterobacteriaceae, KPC; Klebsiella pneumoniae carbapenemase.Download #2020522 (363.65 KB)
"Demographic Profile of Patients with COVID-19 at Mater Misericordiae University Hospital: A Cross Sectional Study"
Principal Presenter: David Connellan
Keywords: COVID-19, Demographic, Length of Hospital Stay
It is recognised that a considerable proportion of people with COVID-19 infection will develop an illness that requires hospitalised treatment. It was our objective to improve our understanding of patients with COVID-19 who require hospital treatment by examining the demographic characteristics of patients admitted to Mater Misericordiae University Hospital (MMUH).
We conducted a retrospective, observational study of patients admitted to MMUH for treatment of COVID-19 from the onset of the outbreak (28th February 2020) until May 31st 2020. Data was collected on patient demographics including age, gender, date of admission and discharge, length of hospital stay and deaths. Patients included in the study were identified as clinical cases of COVID-19 under the care of a ‘COVID team’ or otherwise.
A total of 433 patients were included in the study. With regard to patient characteristics, 237 (54.4%) were male and 196 (45%) were female. The median age was 63 years (IQR: 46-78). The highest number of hospital admissions (87, 20.1%) by age group was the 75-84 year old age group.
With regards to length of hospital stay, the median length of stay was 11 days, IQR: 6-25, mean 20.6 and mode seven. Twenty-four patients (5.5%) were inpatients for less than 48 hours; 76 (17.6%) patients were admitted for 2-5 days, 95 (21.9%) for 6-10 days, 110 (25.4%) for 11-20 days, 63 (14.5%) for 21-40 days and 55 (12.7%) for greater than 40 days. 10 patients (2.3%) remained inpatients at time of data collection.
Sixty-one patients (14%) died during their hospital admission. Of patients who died, the median age was 77 years and median length of hospital stay was 16 days prior to death. Of those who died, 19 (26%) were in the 75-84 year old age group.
Our findings demonstrate the demographic characteristics of patients treated for COVID-19 in MMUH between March 2020 and May 2020. When compared to the national data, our study sample appears to be older and include a higher proportion of males. MMUH had a higher median age of 63 years compared to 48 years nationally. In our sample, 237 (54.4%) were male, compared to 42.6% of that nationally. The median length of stay (11 days; IQR: 6-25) observed in our sample is similar to that reported in the early stages of the pandemic in Wuhan.
We hope that our evaluation of patient demographics and outcomes with COVID-19 will be used to inform clinical practice and service planning as cases of COVID-19 continue to increase. Further research examining longer term clinical outcomes of this cohort is required.Download #2020521 (436.35 KB)
"Cohort of Haemodialysis Patients with COVID-19 in an Irish Nephrology Centre"
Principal Presenter: Josephine Hebert
Keywords: COVID-19, Haemodialysis, Frailty
COVID-19 has a mortality of up to 29-41% in patients on haemodialysis (HD), compared to 2% in the general population. We report a 50% mortality rate from COVID-19 in our HD patients across our primary dialysis centre and 2 satellite units, driven by a nosocomial outbreak early in the pandemic course.
In this retrospective observational study, we looked at HD patients from our centres who had positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nasopharyngeal swabs between 18/03/20-15/05/20, and collected data regarding their demographic and clinical characteristics.
20/296 HD patients were infected with SARS-CoV-2, 10 of whom died. These cases represent 20/87 (23%) of HD patients with COVID-19 nationally across 24 centres and 37% of the deaths (10/27). Non-survivors were more likely to present with upper respiratory tract symptoms and had a longer HD vintage (46.1 months versus 34.1 months). Underlying frailty was associated with increased mortality in our cohort. Higher white cell counts (WCC), C-reactive protein (CRP) and more profound lymphopenia were also associated with poorer outcomes.
The Irish National Renal Office (NRO) implemented recommendations for HD centres from the 16/3/20 resulting in a sustained decrease in new cases.
Dialysis patients remain susceptible to critical COVID-19 illness. As cases of COVID-19 continue to rise across Ireland, efforts made to reduce its spread, such as isolation measures within the HD centre and inpatient dialysis, and separate COVID-19 teams are crucial to mitigating disease and reducing mortality in this population.Download #2020520 (464.36 KB)
"An Audit of OPAT service at St Vincent’s University Hospital in 2019"
Principal Presenter: Ms Deepa Rajendran
Out Patient Antimicrobial Therapy (OPAT) has the potential to save numerous bed days for hospitals. An audit was conducted on all inpatients discharged from SVUH on OPAT during the year 2019 against national and international standards1,2
A retrospective audit was conducted on all inpatients discharged from SVUH on OPAT during the year 2019 after approval from the clinical audit department. Data was collected and analysed in MS Excel.
Total inpatient OPAT discharges were 174. Average age was 61.2. Of the 174 patients discharged on OPAT, two thirds (67%) were male and only one third (33%) female. The most common infections treated was bone and joint infections with Ceftriaxone as the most commonly used antimicrobial. An overwhelming majority of OPAT was administered by healthcare professionals as H-OPAT (159 patients including 3 in dialysis). S-OPAT (self-administered) made up 8.6% of OPAT discharges. PICC lines (90%) were the most commonly used intravenous access device. Total Hospital Bed days saved: 3616 approximating to total saving of €3,091,680 (Based on €855 per HBD). The treatment aim was attained in 85% of OPAT patients. There were 22 readmissions of OPAT patients in SVUH in 2019. Of these 15 were OPAT-related and 7 non-OPAT-related. The OPAT related readmission rate was therefore 8.6%, which is below the international benchmark of 10% but does not meet the Irish national target of <5%.
OPAT is a very cost-effective use of resources. There was above €3million saving in 2019 at SVUH because of the OPAT program. Continued investment in the key components of the OPAT system is vital to ensure adequate monitoring of patients on OPAT, appropriate patient selection and appropriate antimicrobial use and stewardship. Regular auditing of OPAT outcomes and readmission rates will be continued to ensure optimisation of OPAT program in the hospital
1. Sweeney, E., 2019. Irish National Guidelines on the Provision of Outpatient Parenteral Antimicrobial Therapy (OPAT) (Doctoral dissertation, Department of Infectious Diseases, University Hospital Limerick).
2. Chapman, A.L., Patel, S., Horner, C., Green, H., Guleri, A., Hedderwick, S., Snape, S., Statham, J., Wilson, E., Gilchrist, M. and Seaton, R.A., 2019. Updated good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults and children in the UK. JAC-Antimicrobial Resistance, 1(2), p.dlz026.Download #2020519 (1.04 MB)
"An Audit on physical distancing and face mask guidelines compliance amongst health care workers in a tertiary care Irish hospital during COVID-19"
Principal Presenter: Alveena Ishtiaq
Keywords: Physical distance, Face mask, Healthcare quality improvement
Irish health care system has been affected by COVID-19 similar to other European countries. More than quarter of COVID-19 cases in Ireland were amongst Health care workers (HCW) 32.1% (n=8453) till the start of August, 2020. National Guidelines recommended following physical distance and the use of face masks in an appropriate setting to prevent transmission of SARS-COV-2 amongst HCW. An audit cycle was completed to assess and improve compliance with the national guidelines within our hospital.
Data was gathered over a three-month period with quality improvement interventions in between the two arms of audit cycle. Prospective Cross-Sectional convenience sampling was undertaken at varying times and locations to minimise selection bias. HCWs were observed if they were maintaining physical distance and using face-mask appropriately. Adequate physical distance was approximated as at least 2 meters (6.5feet) and face-mask use was considered as a requirement for all encounters, lasting 15 minutes or longer, with other HCWs where a distance of 2m could not be maintained. Quality improvement interventions included signboards at the hospital entrance, floorings in overcrowded areas, outside lifts and changing areas, a ‘keep to the left’ walking system in the hospital, modification of seating arrangements to ensure physical distance and regular communication and reminders to all HCWs
A total of 375 HCWs were observed during the audit cycle. 175 HCWs were observed during 42 encounters in the initial audit and 200 HCWs were observed during 57 encounters in the re-audit. After the implementation of quality improvement interventions, compliance with the social distancing guidelines improved from 31.5% (n=55) to 55% (n=110) and compliance with face mask guidelines improved from 14% (n=12) to 52% (n=29).
Improvement in compliance with face mask and physical distancing guidelines was observed after various interventions were undertaken within the hospital. Ongoing interventions to improve compliance and audits of these interventions are consistently needed to ensure adherence with COVID-19 prevention guidelines amongst HCW as Ireland continues to face the risk of further COVID-19 surges.Download #2020518 (675.68 KB)
"A Cost of Illness Study of Tuberculosis in the Republic of Ireland"
Principal Presenter: James O'Connell
The ROI should be aiming to eliminate tuberculosis (TB) and meet World Health Organisation End TB targets given we are a high-income country with a low incidence of TB. The national TB clinical practice guidelines recommended the establishment of specialist-led TB clinics. The clinical and cost effectvieness of these is central to the effectiveness of our national TB program.
Our aim was to evaluate our service in terms of treatment outcomes, patient safety and cost. Our second aim was to estimate the cost of illness due to TB in the ROI by extrapolating on data from our clinic.
We performed a retrospective review of all patients seen in the infectious diseases clinic who were referred to evaluate signs and symptoms of TB. Incldued patients had to have attended the clinic at least once in the period 01/07/2018-31/12/2019. We estimated the direct costs of TB (staff, TB drugs, investigations) and indirect cost of TB (productivity losses, disability-adjusted life years).
Fifty-four patients were assessed for TB in our OPD in the reference period. 69% (37/54) were diagnosed with TB. The most prevalent risk factor was being from a country of high TB incidence (60% (22/37)). 14% (5/37) of TB patients were healthcare workers. Patients were referred to the clinic most frequently from the emergency department (48% (26/51)), but 49% (25/51) of patients first presented to primary care. The median time from symptom onset to diagnosis was 14.1 weeks (IQR 5.3-30) in patients with respiratory TB compared to 25.9 weeks( IQR 6.3-55.9) in patients with non-respiratory TB. No patients had multi-drug resistant TB. All patients completed treatment. The median cost of care per TB patient was €7374 (IQR €3898-19538). Providing inpatient care to patients with TB was the most costly means of care (median cost per TB patient €5924 (IQR €839-17588)). We estimate that the direct cost of care for patients with TB in the ROI in 2018 and 2019 was €10,620,178 and €9,023,827 respectively. The value of productivtiy losses and disability-adjusted life years due to TB in the ROI was €26,655,558 in 2018 and €13,652,347 in 2019.
The cost of TB in the ROI is high. Earlier disease diagnosis, enhanced latent TB screening and admission prevention may reduce the cost of TB.
"A prospective cohort study of Malawian children presenting with fever"
Principal Presenter: Fergal Howley
Keywords: Malaria, Febrile illness, Malawi
Of an estimated 4.3 million cases of malaria in Malawi in 2017, the majority of malaria-related deaths occurred in children. Differentiating causes of childhood fever in rural clinics is challenging. Greater understanding of clinical features that differentiate malaria from other causes of fever may improve triage of febrile children in these settings. This study aimed to analyse clinical features associated with malaria and parental perceptions on causation of fever in a rural clinic in Malawi.
This prospective cohort study included 313 children presenting with fever to a charity-funded clinic in rural Malawi between the months of March and June 2019. Children underwent tympanic temperature measurement and malaria rapid diagnostic testing (MRDT). Blood films were not routinely performed. Clinical assessment was performed, and brief interviews conducted with the child’s parent or guardian.
47.3% of children had positive MRDTs and were treated for malaria as per WHO guidelines. Children with a history of vomiting were more likely to have a positive MRDT. This association increased when combined with a history of headache. Negative MRDTs were predicted by rash and upper respiratory tract symptoms. There was no significant difference in time to presentation between MRDT positive and negative children. The likelihood of a positive MRDT was not significantly different where parents predicted a diagnosis of malaria as the cause of symptoms. There was a strong correlation between recorded temperature up to 40˚c and likelihood of positive MRDT. Temperature >40˚c did not predict positive MRDT.
A diagnosis of malaria was predicted by symptoms of vomiting and headache, and by objectively elevated temperatures up to 40˚c. Parents did not reliably differentiate the cause of symptoms at time of presentation, and children with malaria did not present earlier. This data should inform triage and malaria testing of febrile children and guide community education regarding malaria symptomatology.Download #2020516 (186.07 KB)
"A Service Evaluation of adherence with antimicrobial guidelines in the treatment of community acquired pneumonia (CAP) before and during the SARS-CoV-2 outbreak"
Principal Presenter: Fergal Howley
Keywords: Community acquired pneumonia, CURB-65, Antimicrobial stewardship
Appropriate antimicrobial prescribing practices are important in reducing antimicrobial resistance, preventing unnecessary healthcare costs, reducing the burden of intravenous antibiotic administration and, most importantly, ensuring good patient care.
Following the SARS-CoV-2 outbreak, medical patients presenting with features of a respiratory infection were more commonly being reviewed by an infectious disease (ID) or respiratory specialist, within twenty-four hours of admission.
This project aims to assess how this change in service provision, namely the increased frequency of specialist review during the SARS-CoV-2 outbreak, affected antimicrobial stewardship and prescribing practices.
Patients treated for CAP from the months March-April 2020 were included. Retrospective data collected from electronic patient records included demographics, documentation of CURB-65 score, microbiology/radiology results, and antimicrobial treatment (including whether the antimicrobial initiated was appropriate in the clinical context, escalation and de-escalation of antimicrobials, and duration of antimicrobial treatment).
Data were compared with a similar cohort of patients treated for CAP between November 2019 and January 2020.
Inclusion criteria were patients admitted under a medical team with a clinical or radiological diagnosis of CAP, or where the patient received treatment for presumed CAP before an alternative diagnosis was reached.
Exclusion criteria patients meeting the criteria for hospital-acquired or healthcare-acquired pneumonia, or those diagnosed with infective exacerbation of COPD without clinical or radiological features of pneumonia, were excluded.
76 patients were included from March-April, with 77 from November-January for comparison.
In each cohort, less than 20% were started on antibiotics that were compliant with CURB-65 guidelines, though compliance was higher among those with higher CURB-65 scores.
75% of cases from March-April were started on antibiotics that were deemed ‘appropriate’ in the clinical context, compared with 69% in the earlier group.
46% of those from the March-April cohort were reviewed or had their care taken over by specialist ID or respiratory physicians within 24 hours. Of those, 97% were appropriately escalated or de-escalated on antibiotics during their admission, compared with 68% in the cohort not seen by a specialist.
Furthermore, 49% of those reviewed by a specialist were continued on antimicrobial therapy for an appropriate duration, compared with 36% of those not reviewed (and only 33% in the November-January group).
Compliance with antimicrobial guidelines in CAP is low. However, the antimicrobials initiated are often appropriate when considered in the clinical context
Specialist review by an infectious disease or respiratory specialist increased rates of appropriate antimicrobial prescribing and treatment duration.Download #2020515 (426.01 KB)
"An Audit of Influenza Vaccine Uptake in the Dialysis Unit of a Tertiary Care University Hospital"
Principal Presenter: Michelle Clince
Keywords: Influenza, Vaccination, Dialysis
An Audit of Influenza Vaccine Uptake in the Dialysis Unit of a Tertiary Care University Hospital
M.Clince, A.O'Farrell-Tyler, C.O’Sullivan, A.O’Riordan, J.Holian, A.Watson, S.Waqas
Department of Nephrology, St. Vincent’s University Hospital, Elm Park, Dublin 4
Correspondance to: firstname.lastname@example.org
The Influenza chapter of the National Immunisation Advisory Committee Immunisation Guidelines for Ireland recommends the quadrivalent influenza vaccine for all those with chronic kidney disease (CKD). Vaccination has been shown to reduce morbidity and mortality in those with chronic diseases, including CKD. We aimed to evaluate the rate of the 2019 influenza vaccine uptake and assess the reasons for vaccine rejection and hesitancy.
A prospective cross-sectional audit was undertaken between 11/11/2019 and 29/11/2019 after hospital audit committee approval. Data was collected from patients individually attending dialysis sessions in St Vincent’s University Hospital, on a questionnaire using convenience sampling, after a pilot trial questionnaire. Demographic information, length of time that the patients had been on dialysis, vaccination status and reasons for non-vaccination were recorded. Patients’ knowledge about the flu vaccine, place where they received the information and vaccination, and whether they would avail of the vaccine if it was offered in the Dialysis Unit were also noted.
A total of 46 patients were included in the audit. The total uptake of the influenza vaccine was 69.6% (N=32). Most patients (78.1% N=36) received the vaccination from their GP practice. Out of the 30.4% (N=14) patients who declined the influenza vaccine, the most common reason was worry regarding possible side effects (42.9%). Other reasons included lack of awareness of vaccine recommendation (21.4%), and inconvenience attending GP practice (21.4%). The majority (84.4%) expressed that they would receive the flu vaccine if it was available in the Dialysis Unit in 2020.
The audit showed that while there is good uptake of the influenza vaccination in our hospital’s Dialysis Unit, it can be improved further. We would like to take these results, and campaign for the flu vaccine to be available for dialysis patients attending St Vincent’s hospital during winter 2020.
Download #2020514 (159.19 KB)
"Verotoxigenic Escherichia Coli resulting in Haemolytic Uraemic Syndrome: A Case Report"
Principal Presenter: Siobhan Hulston
Keywords: VTEC, HUS, E Coli
Introduction: Infection with E.coli 0157 can present with a variety of symptoms including bloody diarrhoea and abdominal cramps. This infection is often linked with HUS. HUS is a clinical syndrome characterized by the triad of thrombotic microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury. Supportive therapy remains the mainstay of treatment.
Case Details: A 20-year-old female presented to the emergency department with a three-day history of bloody diarrhoea, abdominal cramps and vomiting. The cramps were worse on passing stool and were a 7/10 in pain. She was apyrexial on admission and reported no subjective fevers. She had no history of recent travel or sick contacts. On admission, her bloods were grossly normal with only a mildly elevated CRP. Differential diagnoses included infective gastroenteritis and new diagnosis of IBD. A stool sample was sent for evaluation and sigmoidoscopy was performed. Sigmoidoscopy showed severe inflammation extending from the proximal descending colon to the sigmoid, with marked oedema and ulcer-like lesions. The stool was positive for Verotoxigenic E.coli 0157. The public health department was notified. The patient was isolated and treated conservatively with IV fluids and antibiotics were avoided. She remained stable and was discharged with verbal advice. Unfortunately, six days after discharge, RK was readmitted with persistent nausea and vomiting, epigastric pain and two episodes of haematemesis. Her diarrhoea had resolved, and she was passing stool and urine normally. This time she was anaemic (Hb=5.6), thrombocytopaenic (platelets=115) and had a severe AKI (Urea=25.7 and Creatinine=165). She was diagnosed with HUS and taken over care by the renal team. She was transfused two units of red cells and managed conservatively.
Discussion: This case highlights how it can be difficult to avoid the progression of VTEC to HUS. Even though antibiotics were avoided, and the patient was stable on discharge, she still developed this complication.Download #2020513 (1.09 MB)
"A misdiagnosis of Mumps"
Principal Presenter: Caoimhe Ward
Keywords: Mumps, Septic Arthritis, Rugby
Background: A seventeen year old, previous healthy rugby player presented to a private Emergency Department with a two week history of groin pain, and leg stiffness. He had no sexual partners and was fully vaccinated. His brother had been diagnosed with mumps eight months previous. His CRP was elevated and he was febrile. Mumps Ig G was positive but Ig M was negative. He was diagnosed with mumps orchitis and discharged home on seven days of amoxicillin.
Case Description: Ten days later he presented to the Emergency Department of SVUH with a worsening limp and fevers of 38.6°C. He was tender suprapubically and in the left iliac fossa. Testicular examination was normal. His CRP was elevated at 190mg/l and an STI screen (including HIV and syphilis), blood and urine cultures were negative. Mumps serology was consistent with previous infection or vaccination. CT abdomen revealed thickening of the urinary bladder wall and surrounding infiltration of the perivesical fat. A MRI demonstrated septic arthritis of the symphysis pubis. Due to the location of the process and the absence of a drainable collection no sample was taken. He was commenced on empiric ceftriaxone 2g IV daily and had a clinical and biochemical response with falling CRP. He was discharged on Outpatient Antibiotic Therapy to complete a six week regimen. A repeat MRI performed at three months revealed complete resolution.
Conclusion: Pubic symphysis septic arthritis is rare. Although cultures were negative, Staphylococcus aureus is the main causative organism, presumably from haematogenous spread. It is most common in young athletes particularly football players owing to repetitive over adduction and twisting. It is likely the previous antibiotics in this patient prevented the bacteria growing in blood cultures. Diagnosis requires a high index of suspicion as symptoms can mimic other conditions which occurred in this case.Download #2020512 (1.02 MB)
"An audit of the routine monitoring and assessment of people living with HIV in St. Vincent’s University Hospital."
Principal Presenter: Caoimhe Ward
Keywords: HIV, Sexual Health, EACS
Background: The European AIDS Clinical Society (EACS) guidelines were created to promote consistency and excellence in HIV care. HIV is a chronic but treatable condition however the key to active management lies in monitoring co-morbidities and complications of treatment
Method: An audit of adults who attended SVUH for specialist HIV care over a three month period was performed. Data was collected manually and included demographic details (age and sex) and whether thirty-six pre-defined data points, as listed in the EACS guidelines were measured or recorded over the previous year. These included medications, co-morbidities, vaccination, social and occupational history, sexual and reproductive health, CD4 count, viral load, and assessment of bone and cardiovascular health.
Results: Data was collected on 50 patients attending SVUH for specialist HIV Care. 76% were male and 24% were female. The strengths highlighted in this audit included medications and co-morbidities which were documented in 92% and 86% of cases. Bone health was the weakest variable featured, where although a bone profile was measured in 80%, no patients had a recorded FRAX scan in the previous year.
As regards sexual and reproductive health, syphilis testing was performed in 66% of patients and an annual sexually transmitted infection screen was recorded in 44%. When broken down by gender only 15% of females had documented STI screens in comparison to 54% of males. A sexual history was referenced in 74% and a partner/children was acknowledged in 80% of cases.
In relation to cardiovascular health; only 12% of subjects had a documented 10-year CVD risk. Lipids, glucose and smoking history were documented in 74%, 26% and 86% respectively.
Conclusion: This audit highlights various areas that require improvement in documentation and monitoring of HIV patients attending SVUH including STI testing in females and assessment of bone and cardiovascular health.Download #2020511 (1.43 MB)
"An Evaluation of Latent TB Screening and Management at a Tertiary Referral Centre in the Republic of Ireland"
Principal Presenter: James O'Connell
Keywords: latent tuberculosis infection, cost, screening
Establishing systematic screening for LTBI in the Republic of Ireland will require prior risk group-specific knowledge of the prevalence of LTBI and the cost of identifying LTBI.
We performed a survey of LTBI screening practices in our centre and a retrospective review of IGRA tests performed in our tertiary referral centre.
The response rate to the survey was 21/47 (45%). 8/15 (53%) said that they found it difficult to access LTBI testing. 12/21 (57%) respondents reported that they have treated patients for LTBI without referring to a TB specialist. 9/21 (43%) responded that there was not a clear referral pathway for patients that they would like specialist input on.
Of all patients, 164/1507 (10.9%) were identified as being non-Irish nationals, of which 20/164 (12.2%) had a positive test. In the non-Irish cohort, 112/181 (61.9%) tests were performed to screen for LTBI, 55/181 (30.4%) were performed during an investigation for active TB and 14/181 (7.7%) had an unknown indication for testing.
1343/1507 (89.1%) of patients tested were identified as being of Irish nationality, of which 53/1343 (3.9%) had a positive test. In this cohort, 1251/1500 (83.4%) tests were performed to screen for LTBI, 226/1500 (15.1%) were performed during an investigation for active TB and 23/1500 (1.5%) had an unknown indication.
When considering patients who had no history of TB infection and where the indication for screening was known, 12/138 (8.7% 95% CI 4.6-14.7%) of the non-Irish cohort had LTBI, compared to 46/1303 (3.5% 95% CI 2.6-4.7%) of the Irish cohort. Patients who were non-Irish were significantly more likely to have LTBI (8.7% vs. 3.5%, OR 2.6 95% 1.3-5.0, P<0.001).
Overall, 40 patients had LTBI and an indication for treatment. 8/40 (20%) patients with LTBI and an indication for treatment were not offered treatment by the healthcare provider, 1/40 (2.5%) did not accept treatment when offered and 4/40 (10%) did not complete treatment when started. The prevalence of LTBI in patients screened using an IGRA was 4.3% and cost €2048 per case to identify.
Improvements are needed in the cascade of LTBI care, access to LTBI testing and results and access to specialist TB services in our centre.Download #2020510 (138.83 KB)
"A novel role for neutrophils in anti-viral immunity"
Principal Presenter: Richard Wubben
Pathogen recognition receptors (PRRs) are a class of germline encoded receptors that recognise pathogen associated molecular patterns (PAMPs). Activation of these receptors results in the activation of the innate immune response through the production of proinflammatory and anti-viral cytokines. The cytokine, Interferon (IFN)-α mediates potent anti-viral responses via activation of the JAK/STAT pathway, which leads to the expression of >500 Interferon Stimulated Genes (ISGs), that promote viral clearance. Neutrophils are the first immune cells recruited to the site of infection, however, while their protective anti-bacterial and anti-fungal roles are well characterised, little is known about their anti-viral role. Therefore, this project aims to ascertain the role of neutrophils during a viral infection and specifically investigate the pathogen recognition receptor and JAK/STAT pathways in primary human neutrophils challenged with viral ssRNA or IFN-a. Using Western Blotting and qRT-PCR, we measured levels of phosphorylated STAT, total STAT and ISG induction (ISG15/MxA/IFIT1/IFIT2/IFIT3) in primary human neutrophils from healthy individuals. We observed that neutrophils responded to IFN-a via prolonged phosphorylation of STAT1, which is in stark contrast to the transient and quick signalling in PBMCs. IFN-a also stimulated the transcription of virus restricting ISGs (IFIT1/2/3, MxA, ISG15), indicating for the first time that neutrophils respond to Type 1 IFNs via the JAK/STAT pathway. Additionally, we investigated the immunomodulatory capacity of neutrophils through their secretion of cytokines including IL-6, IL-23, TNF, IL-12, IL-10, IL-1 and IFN-α. We show that through the expression of TNF, virally activated neutrophils drive the maturation of dendritic cells, which subsequently promotes a strong Th1 CD4 T-cell response, highlighting a novel mechanism by which neutrophils control cellular immune responses during a viral infection. These findings not only identify neutrophils as immediate responders to viral stimuli and anti-viral cytokine, but also reveal them to be key in controlling a wider anti-viral immune response, via cellular crosstalk, processes that may be harnesses in future anti-viral treatments.Download #2020509 (1.01 MB)
"Anxiety Amongst Patients Admitted In A City Centre Hospital On A ‘COVID-19 Pathway’"
Principal Presenter: Fiona O'Riordan
Keywords: Covid-19, Anxiety, Information source
Our aim was to assess the prevalence of anxiety amongst patients on a COVID-19 pathway. We also sought to evaluate the impact of gender, age, co-morbidity, pre-existing anxiety and sources of information used for COVID-19 on anxiety levels.
A prospective single-centre study. Patients >18years, commenced on a COVID pathway between April-July 2020 were eligible. A COVID pathway was initiated if patients met clinical criteria. Data obtained included age, sex, history of respiratory disease, hypertension, cardiovascular disease, diabetes, immunosuppression and sources of information used.
Sixty-five patients were included. Mean age was 66y, 47(72%) were >60years, 33(51%) were male. Sixty-one (94%) had at least one co-morbidity, the most common being respiratory disease[40(62%)]. Overall, 41(63%) had mild-severe anxiety and 19(29%) had moderate-severe. The older group had a higher proportion with anxiety[>60years 40(85%) vs <60years 11(61%), P=0.0370] with no difference between sexes [Females (21(65%)) vs Males (20(60%)) P=0.6795]. Mean anxiety scores were similar between all co-morbidity groups; (F(4,116)=0.2795, P=0.8907). Patients with pre-existing anxiety had a higher proportion with anxiety than those without [13(87%) vs 28(56%),(P=0.0363)].
TV 53(82%) and radio 25(55%) were the most commonly used information source with no difference in age groups [TV; >60years 40(85%) vs <60years 13(72%), P=0.2341], [Radio; >60years 28(60%) vs <60years 8(44%), P=0.2737]. Online resources (26%) and social media (23%) were the least commonly used with higher usage in the younger group [Social Media;>60years 5(11%) vs <60years 10(55.6%), P=0.0001], [Online;>60years 7(15%) vs <60years 10(55.6%), P=0.0009]. Mean anxiety scores were similar between all information sources (F(6,194)=0.1796, P=0.98216).
Our results show that a high proportion of patients on a COVID pathway experience anxiety. Patients of older age or with pre-existing anxiety had a higher rate of anxiety. Neither gender nor co-morbidities affected anxiety. TV and Radio were the most commonly used information source irrespective of age. Social media and online resources were infrequently used with higher use in the younger group. The source of information used did not affect anxiety levels.Download #2020508 (356.42 KB)
"Late Presentation of ‘Lemierre’s Syndrome’: how a delay in seeking healthcare and reduced access to routine services result in widely disseminated necrophorum fusobacterium infection iduring the global COVID-19 pandemic"
Principal Presenter: Fergal Howley
Keywords: Fusobacterium necrophorum, Lemierre's syndrome, Pandemic
The SARS-CoV-2 outbreak has disrupted the delivery of routine healthcare services on a global scale. With many regions suspending the provision of non-essential healthcare services, there is a risk that patients with common treatable illnesses do not receive prompt treatment, leading to more serious and complex presentations at a later date.
Lemierre’s syndrome is a potentially life-threatening and under-recognised sequela of an oropharyngeal or dental infection. It is characterised by septic embolisation of the gram-negative bacillus Fusobacterium Necrophorum to a variety of different organs, most commonly to the lungs. Thrombophlebitis of the internal jugular vein is frequently identified.
We describe a severe case of Lemierre’s syndrome, requiring ICU admission and intubation, where presentation and initiation of treatment were delayed by the SARS-CoV-2 pandemic. Our case is unusual in having spread from a periodontal infection, involving the brain, liver, musculoskeletal system, and lungs. Intracranial involvement was clinically and radiologically apparent, initially in the absence of radiological evidence of internal jugular vein thrombosis. This could represent intracranial seeding of septic emboli via a patent foramen ovale. Initiation of anticoagulation did not result in detectable increase in embolic events, and a good clinical response was achieved with antimicrobial therapy, abscess drainage and source control.
This case highlights the importance of providing medical and dental services during a public health emergency or pandemic; failure to do so may result in hospital admissions with severe illnesses that might otherwise have been treatable in an outpatient setting. It also demonstrates the importance of considering Lemierre’s syndrome arising from periodontal infection, and how source control should be considered along with antimicrobial therapy and drainage of accessible collections.Download #2020507 (1.17 MB)
"Starting or switching to bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) in clinical practice: pooled 12-month (12M) results from the global BICSTaR study"
Principal Presenter: Ross Hamilton-Shaw
Keywords: Bictegravir, Tenofovir, Real world data
Background: The ongoing observational BICSTaR study aims to demonstrate effectiveness, safety and tolerability of B/F/TAF in routine clinical practice in at least 1400 antiretroviral treatment (ART)‐naïve (TN) and ART‐experienced (TE) people living with HIV (PLHIV).
Materials and Methods: This 12M analysis of PLHIV receiving B/F/TAF in Europe and Canada assessed HIV‐1 RNA (missing data=excluded analysis), drug‐related (DR) adverse events (AEs), persistence and weight/body-mass index (BMI) change.
Results: At the time of data cut-off (Mar 2020), 513 participants (n=84 TN/n=429 TE) completed a 12M visit. Most were male (91%) and white (89%); the median age was 38 (TN) and 49 (TE) years. Prevalence of comorbidities at baseline was 76%; the most common were neuropsychiatric (28%), hyperlipidemia (18%) and hypertension (18%). 71%/18%/13% of TE participants switched from INSTI/NNRTI/PI-based regimens, respectively (26% TDF); 8% had a history of prior virologic failure. Baseline primary resistance prevalence by historical genotype was 9% (n=43/513; 5% had resistance mutations associated with NNRTIs, 3% PIs, 3% NRTIs [n=8 M184V/I, n=1 K65R] and 0.2% with INSTIs [n=1 G140S]).
At M12, 100% of TN (n=74/74) and 96% (n=357/373) TE participants had viral load (VL) <50 copies/ml. Comparable and high effectiveness was observed in both male and female participants, including older individuals (Table). No major resistance substitutions to the components of B/F/TAF emerged.
DRAEs occurred in 14% (n=12/84) of TN and 15% (n=64/429) of TE participants, with the most common being gastrointestinal (5%) and neuropsychiatric (4%); discontinuations due to DRAE were low (TN 3.6% and 7.2% TE) and 90% of study participants remained on B/F/TAF (n=462/513). Serious DRAEs were rare (0.4%; all in TE participants [n=2 depression]).
At 12M, median (Q1, Q3) weight change was +2.5 kg (0.5, 6.3) for TN (n=48) and +0.9 kg (−1.0, 3.0) for TE (n=269), with small changes in BMI of +0.8 kg/m2 (0.1, 1.9) for TN and +0.3 kg/m2 (−0.3, 1.0) for TE. Weight increase >10% was observed in 19% (n=9/48) and 5% (n=15/269) of TN and TE participants, respectively.Download #2020506 (253.1 KB)
"Pooled Analysis of 4 International Trials of Bictegravir/Emtricitabine/Tenofovir Alafenamide (B/F/TAF) in Adults Aged >65 or Older Demonstrating Safety and Efficacy: Week 48 Results"
Principal Presenter: Ross Hamilton-Shaw
Keywords: Bictegravir, Tenofovir, Ageing
As life expectancy for people with HIV increases, optimising antiretroviral therapy to fit the needs of older adults, including those with comorbidities and multiple medications, is paramount. B/F/TAF is a small single-tablet regimen with few drug-drug interactions, a high barrier to resistance and may provide a beneficial option for older patients.
In this pooled analysis of 4 international trials (Studies 1844, 1878, 4030 and 4449) of virologically suppressed (HIV-1 RNA<50 copies/mL), treatment-experienced adults, we evaluated the efficacy and safety of switching to B/F/TAF for participants ≥65 years. Primary endpoint was HIV-1 RNA<50 copies/mL at Week 48 as defined by the Food and Drug Administration Snapshot algorithm.
140 participants were age ≥65 years at study enrollment. Median age (Q1, Q3) was 68 years (66, 72), 14% were female, and 88% were White. Medical history at baseline was significant for diabetes 22%, hypertension 55%, cardiovascular disease 24% and dyslipidemia 59%.
At W48, the proportion with HIV RNA<50 copies/mL was 92% (129/140); 11 (8%) had no virologic data in window (5 discontinued study drug due to AE but had last available HIV-1 RNA<50 copies/mL; 6 had missing data but were still on study drug). No participant had virologic failure. Most common adverse events (AEs) were nasopharyngitis and arthralgia (7% each). Eleven participants (8%) had a study drug related AE, all were either Grade 1 or Grade 2. There were no Grade 3-4 study drug-related AEs. Four participants had AEs that led to premature study drug discontinuation: abdominal discomfort, drug withdrawal syndrome, device related infection, and alcohol withdrawal syndrome. Median changes from baseline in fasting lipids were: total fasting cholesterol (-7mg/dL), LDL (-2mg/dL), HDL (0mg/dL), triglycerides (-15mg/dL) and total cholesterol:HDL (-0.1). Median weight change was 1.0 kg (IQR -0.9, 3.0). Ten percent (14/140) of participants had Grade 3 or 4 laboratory abnormalities.
Switching to B/F/TAF in older adults was well tolerated and safe while maintaining high rates of virologic suppression through 48 weeks. These data support the use of B/F/TAF for treatment of adults ≥65 years who could benefit from a small tablet with few drug-drug interactions and an established safety profile.Download #2020505 (277.96 KB)
"Tocilizumab therapy in individuals with COVID ‐19 infection and hyperinflammatory state"
Principal Presenter: Rachel MacCann
Tocilizumab therapy in individuals with COVID ‐19 infection and hyperinflammatory state
Coronavirus disease 2019 (COVID-19), an illness caused by severe acute respiratory coronavirus 2 (SARS-CoV-2), has spread rapidly worldwide resulting in a global pandemic. A subset of individuals with COVID-19 present with severe pneumonia, evolving in some cases to acute respiratory distress syndrome (ARDS), coupled with clinical and biochemical features of hyperinflammatory syndrome. This in turn may reflect circulating IL-6, possibly a key driver of a dysregulated inflammatory response in COVID-19. Tocilizumab is a humanized monoclonal antibody targeting the IL-6 receptor. Current data on the use of Toculizumab in the COVID-19 setting is scarce.
Our aim was to describe our experience of using tocilizumab to treat severe COVID-19 pneumonia with hyperinflammatory syndrome.
Between 7 March and 7 April 2020, 193 patients were admitted with confirmed COVID-19 infection to St. Vincent’s University Hospital and enrolled into the All-Ireland Infectious Diseases Cohort Study. Patients were considered for tocilizumab at a multidisciplinary team (MDT) meeting and selected based on the presence of severe COVID-19 pneumonia and evidence of hyperinflammatory response.
Of the 193 cases, 8 (4.1%) were considered for tocilizumab therapy of whom 6 patients were treated with a single dose of intravenous tocilizumab at 8 mg/kg (maximum dose: 800 mg). All patients met the criteria for hyperinflammatory state, evident by increased CRP (median: 126.6 mg/L, IQR: 103.2–242.2 mg//L), ferritin (median: 3451.5 mg/L, IQR: 2950–4138.2 mg/L) and fibrinogen (median: 6.33 g/L, IQR: 5.96–6.93 g/L) (figure 1). All patients had progression of pulmonary infitrates on chest radiograph (figure 2) from the time of admission and SpO2:FiO2 ratio had deteriorated (median: 236 mmHg, IQR: 226–247 mm Hg). Treatment with toculizimab resulted in a rapid decline in inflammatory markers and decreased oxygen requirements in all six patients. Two patients were subsequently admitted to the intensive care unit (ICU). All patients were discharged home at a median of 7 days (IQR: 7–8 days) post-tocilizumab.
In summary, tocilizumab was well tolerated and effective in this cohort and associated with a positive outcome. Randomized, controlled trials are needed to determine the true efficacy and safety of tocilizumab in COVID-19.
"Cabotegravir (CAB) + Rilpivirine (RPV) Every 2 Months is Noninferior to Monthly: ATLAS-2M Study"
Principal Presenter: Ciara Ní Mhurchú
Keywords: Cabotegravir, Rilpivirine, Long-acting
Background: The 2-drug regimen of long-acting (LA) CAB and RPV dosed i.m. every 4 weeks (Q4W) was noninferior to daily oral 3-drug ART in Phase 3 studies. Long-term Phase 2 data (LATTE-2) provide the rationale for evaluation of a longer and potentially more convenient 8-week dosing interval (Q8W).
Methods: ATLAS-2M is a multicenter, open-label, Phase 3b noninferiority (NI) study of CAB+RPV LA maintenance therapy administered Q8W or Q4W to treatment-experienced, HIV-infected adults. Virologically suppressed individuals on CAB+RPV LA Q4W (ATLAS study rollover) or oral ART were randomized 1:1 to receive CAB+RPV LA Q8W or Q4W. The primary endpoint at Week 48 was the proportion with plasma HIV-1 RNA ≥50 c/mL (Snapshot, ITT-exposed [ITTe]). The key secondary endpoint was the proportion with HIV-1 RNA <50 c/mL (Snapshot, ITTe).
Results: 1045 participants were randomized to CAB+RPV LA Q8W (n=522) or Q4W (n=523); 27% were female; 63% were naive to CAB+RPV LA. CAB+RPV LA Q8W was noninferior to Q4W dosing in both the primary (1.7% vs 1.0%; adjusted difference [95% CI], 0.8 [−0.6, 2.2]) and secondary analysis (94.3% vs 93.5%; adjusted difference [95% CI], 0.8 [−2.1, 3.7]). There were 8 and 2 confirmed virologic failures (CVFs; 2 sequential measures ≥200 c/mL) on Q8W and Q4W dosing, respectively; 5 and 0 CVFs, respectively, had archived resistance-associated mutations (RAMs) to RPV, either alone (n=3) or with CAB RAMs (n=1) in baseline peripheral blood mononuclear cells (PBMCs). On-treatment RAMs to RPV, CAB, or both not present in baseline PBMCs were found in 6/8 Q8W CVFs and both Q4W CVFs. The safety profile was similar for Q4W and Q8W dosing, and serious adverse events were reported in 5% of participants in the Q8W group (n=26) vs 4% in the Q4W group (n=19). Injection site reactions (ISRs) were mostly mild or moderate (98% overall) with a median duration of 3 days. Discontinuation for an adverse event occurred in 2% of participants (Q8W, n=8; Q4W, n=10), with 6 (1%) and 11 (2%) in each group due to ISRs. There was 1 death (Q8W; sepsis). Of those treated Q8W in ATLAS-2M after ≥48 weeks of Q4W dosing in ATLAS, 94% (180/191) preferred Q8W dosing.
Conclusions: Q8W dosing of CAB+RPV LA was noninferior to Q4W dosing and well tolerated. These results support the therapeutic potential of CAB+RPV LA administered every 2 months.Download #2020503 (262.34 KB)
"DTG+3TC vs DTG+TDF/FTC (GEMINI-1&-2): Confirmed Virologic Withdrawals (CVWs) Through Week 96"
Principal Presenter: Ciara Ní Mhurchú
Keywords: Dolutegravir, 2 Drug Regimen, Confirmed Virologic Withdrawal
Background: In GEMINI-1&-2, the DTG+3TC 2-drug regimen (2DR) is non-inferior to the DTG+TDF/FTC 3-drug regimen (3DR) in HIV-1–infected ART-naive participants at Weeks 48/96. Eleven participants on 2DR and 7 on 3DR met protocol-defined CVW criteria through Week 96. We present a detailed description of these CVWs.
Methods: Participants were stratified by viral load (VL) ≤/>100,000 c/mL and CD4+ ≤/>200 cells/mm3. Participants were not eligible if screening HIV-1 genotype showed major RT/PR resistance mutations. CVW was defined as 2 consecutive VLs meeting virologic non-response (VL ≥200 c/mL after Week 24 or <1.0 log decline in VL by Week 12 unless HIV-1 RNA is <200 c/mL) or virologic rebound criteria (≥200 c/mL after prior suppression to <200 c/mL). Monogram Biosciences performed integrase and RT/PR genotypic and phenotypic resistance testing on Day 1 and CVW timepoint samples. We evaluated CVW participant baseline (BL) VL and CD4+ characteristics, adherence, study drug interruption, resistance, and VL progression through the study course.
Results: In GEMINI-1&-2, 3 participants screen failed due to M184I/V resistance. Overall, 11 participants on DTG+3TC and 7 on DTG+TDF/FTC met CVW criteria through Week 96. Of these, 5 vs 2 CVWs occurred after Week 48. All CVWs experienced virologic rebound; none had VL blips (VLs between 50-<200 c/mL with adjacent values <50 c/mL) that preceded CVW. One DTG+3TC participant never suppressed to <50 c/mL. For participants with VLs at withdrawal (WD), VL decreased ≥2 fold for 8/9 participants on DTG+3TC and 3/5 on DTG+TDF/FTC between CVW and WD timepoints. Six of 11 CVWs on DTG+3TC and 1/7 on DTG+TDF/FTC appeared to be associated with adherence or treatment interruption issues. Among the 11 and 7 participants on DTG+3TC vs DTG+TDF/FTC, respectively: 9 vs 7 had HIV-1 subtype B; 3 vs 2 had BL CD4+ <200 cells/mm3; and 5 vs 3 had BL HIV-1 VL >100,000 c/mL. Resistance data were available for all samples except 2 cases on DTG+TDF/FTC where testing failed with HIV-1 VL below the assay cut-off; no treatment-emergent genotypic or phenotypic resistance in IN or RT was observed in any CVWs.
Conclusions: In GEMINI-1&-2, there were low and comparable numbers of participants meeting CVW through 96 weeks in the DTG+3TC and DTG+TDF/FTC arms without apparent predisposition by BL VL or CD4+; no emergent genotypic/phenotypic resistance to INSTI/NRTIs was observed. These data further support the potency and durability of DTG+3TC.Download #2020502 (619.32 KB)
"HepCare Ireland – A Service Innovation Project"
Principal Presenter: Stephen Connolly
Hepatitis C remains a major cause of morbidity worldwide and as many as 20,100-42,000 people may be infected in Ireland. Our country to date has fallen short of the WHO targets to eliminate HCV as an public threat. New developments in both diagnosis and treatment of HCV however have made such goals more achievable- should a suitable infrastructure be created. HepCare Europe was an EU-sponsored project across four member states that sought to develop, implement and evaluate interventions to improve HCV outcomes. Our report describes the Irish component of the HepCare project.
In HepCare Ireland we demonstrate five integrated work packages; HepCheck, HepLink, HepFriend, HepEd and HepCost. Interventions included intensive screening, community-based assessments, specialist referrals, peer support, training for health care professionals and cost-effectiveness analysis, respectively.
812 participants were recruited across all packages. 257 (34.9%) participants were HCV antibody positive. 162 (63.0%) of these participants tested positive for HCV RNA. 103 (63.5%) of RNA-positive patient linked to care were subsequently put on treatment. 59 (57.3%) of the participants put on treatment achieved SVR, while 44 (42.7%) are still undergoing treatment. Cost effectiveness was demonstrated at the government’s current willingness-to-pay threshold of €30,000 per QALY.
In HepCheck, HepLink. HepEd and HepFriend we demonstrate three scalable and impactful interventions in improving HCV outcomes in Ireland, with the cost effectiveness of HepLink demonstrated effectively in HepCost. We propose that if these interventions are expanded upon Ireland will make meaningful progress in achieving the targets set by the World Health Organisation in eliminating HCV by 2030.Download #2020501 (1.47 MB)