"Barrier-free Testing of Health Care Workers during a surge in COVID-19 cases: Role and Utility"
Principal Presenter: Sarah Hunter
Keywords: Walk-in, COVID-19, Testing
Barrier-free Testing of Health Care Workers during a surge in COVID- 19 cases: Role and Utility.
Hunter S1, Kidd P2, Scarry M1, Freeman, J1, Keane L1, Fleming C1, Gallagher1 D.
1. Dept. of Infectious Diseases, Galway University Hospitals.
2. Pharmacy Department, Galway University Hospitals.
During the third wave of COVID -19 in Galway University Hospitals, there was approximately 900 requests per week for Covid- 19 testing amongst staff in the hospital. To combat this overwhelming workload for the occupational health department and to maximise available staffing levels, the Infectious Diseases department set up a walk-in, no barrier service for healthcare worker (HCW) Covid-19 testing.
A healthcare systems engineering to redesigning the COVID-19 testing service was undertaken in November 2020 to create resilience in the service. Barrier-free, walk-in COVID-19 testing was introduced from January 4th 2021. Data was collected from a prospectively maintained database of all HCWs being tested in Galway University Hospital for COVID-19 between January 4th 2021 and May 2nd 2021. Data was obtained from both Occupational Health referrals and the ‘walk in’ clinic including both negative and positive test results in each referral pathway.
In January 2021 system capacity trebled to handle a peak of 900 requests per week. From January 4th to May 2nd 2021, 3858 HCWs were tested, 3265 (84.6%) in the walk in service and 593(15.4%) via occupational health referral system with an overall positivity rate of 4.59%.
Of the 177 who tested positive for Covid-19, 117 (66.1%) were diagnosed from the walk in clinic versus 60 (33.9%) from occupational health referral system. Overall, 3.58% of the walk-in HCWs were positive and 10.11% of the Occupational Health referrals were positive.
During peak demand (week beginning 11th January), 858 HCWs were tested for COVID-19, with 54/665 (8.1%) walk-in HCWs testing postive whilst 15/124 (12%) occupational health referred HCWS tested positive.
COVID-19 HCW testing is a crucial component in maintaining the safety of staff and patient care. Our data highlights the important role of removing barriers to testing, as evidenced by the uptake rates and positivity rates of HCWs availing of the walk-in service, especially during peak surge periods. Barrier-free COVID-19 testing has a role and utility as demonstrated in this abstract.Download #2021077 (265.25 KB)
"A retrospective analysis of re admissions and thromboembolic events in hospitalized patients with COVID-19 in Galway University Hospital"
Principal Presenter: Julie Donnellan
Keywords: COVID-19, Thrombosis, Re-admissions
Concerns exist regarding the association of COVID-19 (C19) with venous thromboembolism (VTE).
A database of inpatient admissions with COVID-19 in GUH from the 1st of August 2020 to the 1st of April 2021 was accessed. Community acquired C19 (CA) was defined as a new positive PCR test within 14 days of presentation to hospital, including nursing home patients. Hospital associated C19 (HACI) was defined as (A) a new positive test 7 days post admission or within 14 days of discharge or (B) a case in which symptoms began on hospital days 3-7 in a patient with a probable COVID-19 exposure since admission. Charts were reviewed for baseline characteristics, re-admission post discharge, and subsequent diagnosis of VTE. Univariate analysis was performed.
468 cases were identified, 309/468 (66%) were CA and 159/468 (33%) HACI. Mean length of stay was 21 days.267/ 468 (57%) were male, median age 68 years (range 15 to 101). 183/468 (39%) did not require oxygen: 136/468 (29%) < 4L/min; 119/468 (25%) high flow oxygen or non invasive ventilation; and 74/468 (16%) ICU care. 83/468 patients (17%) died; mortality rate of CA was 32/309 (10%) vs 51/159 (32%) of HACI (p < .0001). 385/468 (83%) patients were discharged of whom 318/385 (81%) are now > three months post discharge. 61/385 (16%) patients have been re admitted to hospital within three months of discharge, with no significant difference between CA (40/277 (14%)) vs HACI ( 21/108 (19%)). Age over 60 was significantly associated with readmission (p =0.027) however gender (p=26), prior ICU admission (p = .39) or high flow oxygen use (p =0.17[U1] ) were not.
17/468 (3.63%) cases were diagnosed with acute thromboembolism during first admission; 16 pulmonary embolism (PE), 1 hepatic vein thrombosis. The mortality rate for those diagnosed with PE during first admission was 3/16(20%). Of the re-admitted cases, 4/61 presented with VTE on readmission, with PE in all cases, representing 1% of discharged C19 patients. No statistically significant predictor for VTE was found.
Hospitalisation with C19 infection was associated with high mortality and readmission rates in our patient population. While in hospital acquisition of C19 was associated with significantly higher mortality it did not predict higher readmission, with the main risk being older age. 4% of acute C19 cases had concurrent VTE but the risk post discharge was low (1%) supporting our current treatment guidelines of VTE prophylaxis for all C19 patients admitted and its cessation at the time of discharge.
[U1]Any data on indication for readmission or comorbidities – interesting data on intensity of care and no signal.Download #2021076 (346.42 KB)
"Case Report: Tuberculoma and disseminated tuberculosis presenting as status epilepticus."
Principal Presenter: Ryan Crawford
In this article we describe an unusual presentation of extrapulmonary tuberculosis infection in a 42 gentleman who presented with seizures. We also discuss the importance of maintaining a broad differential of infectious aetiologies for patients with new intracranial lesions.
A 42 year old Indian national presented to hospital by ambulance in status epilepticus on a background of ongoing alcohol abuse. Routine laboratory investigations showed mild pancytopaenia with profound lymphopaenia. CT brain showed vasogenic oedema within the inferolateral right frontal lobe and some surrounding ill-defined enhancement.
Due to reduced state of consciousness the patient required intubation and admission to ICU for close monitoring and was commenced on IV ceftriaxone/vancomycin/metronidazole and also IV dexamethasone for cerebral oedema as per the neurosurgical team. He was also commenced on chlordiazepoxide and IV thiamine for alcohol withdrawal.
CSF showed raised protein with normal white cell count and no bacterial or fungal growth. Viral PCR panel was negative for HSV1, HSV2, EBV and Enterovirus.
MRI revealed one 2cm intra-axial ring enhancing lesion in the subcortical white matter of the right frontal lobe and a small lesion in the left thalamus. His HIV test was negative, immunoglobulin counts were in normal range and lymphocyte subsets revealed deficiency in all subgroups.
CT revealed mediastinal and right supraclavicular lymphadenopathy. The right supraclavicular node was TB PCR positive and negative for rifampicin-resistance gene. Bronchoscopy/EBUS was sought to obtain a sample for culture and sensitivity. Bone marrow biopsy was carried out to further evaluate the lymphopaenia.
This case highlights the importance of including a wide differential for cerebral lesions that includes infectious, inflammatory and malignant causes. In terms of infectious causes the aetiology can be subdivided into bacterial, fungal and protozoal causes. A high index of suspicion for Mycobacterial infection is needed for patients from endemic areas, poor social circumstances and the immunocompromised host.
Tuberculosis infection can be associated with several haematological complications. In 2% of cases disseminated tuberculosis may be complicated by bone marrow infiltration, hypersplenism and haemolytic anaemia.   
Prompt tissue diagnosis is required to confirm diagnosis through PCR testing, culture and histology. It should also be noted that CSF may not yield microbiological diagnosis for lesions contained within the parenchyma.
1. Hiding in the bone: a case of miliary tuberculosis with bone marrow involvement. Tahir et al. AME Case Reports. July 2018.
2. Disseminated tuberculosis: interesting hematological observations. J Assoc Physicians India. April 2010.
3. Myelofibrosis: An unusual presentation of disseminated tuberculosis. Sharma et al. May 2020. International Journal of Mycobacteriology.Download #2021075 (462.8 KB)
"Beaumont initiative in barrier-free SARS-CoV-2 testing."
Principal Presenter: Benson Jacob
Keywords: Barrier- free SARS-CoV-2 testing, Healthcare workers, Beaumont hospital
The ongoing SARS-CoV-2 pandemic has resulted in an unprecedented amount of healthcare workers and their household members being infected with SARS-CoV-2. The role of hospital-acquired SARS- CoV-2 infection is now increasingly established in recent times. To respond to the need for a broad appropriation of an efficient and easily accessible screening program for health care workers in a patient-facing role, Beaumont hospital in Dublin has adopted a barrier-free testing approach from October 2020. Before switching to swift queue enabled barrier-free testing, 94% of staff who reported to the occupational health with symptoms were referred for screening. Analysis of total testing figures for 2 months before swift queue showed, out of 277 referrals the average waiting time was 21.41 (4-79) hrs for initial contact with occupational health by staff and the lab results. Contrastingly 3146 staff testing were carried out by the end of January through the swift queue system, 1009 of them were noted as symptomatic and 128 of them came back with a positive test result. Though the maximum time lag between booking an appointment and having a result was 23 hours, average time lag is considered well below 20 hours. Minimal misuse of testing pods by staff was noticed at some points, even though that behaviour is categorized under misuse in an institutional setup, those timely screening might have protected many family members of the vulnerable group from contracting the virus from a health care worker who had to refrain from visiting their loved ones due to a positive test result. Nevertheless, those incidences of misuse might have been there in the previous screening system as well in which staff reporting symptoms to occupational health before they refer to the testing pod after making an appointment for a screening test. Frequent testing of HCW regardless of symptomatology and aggressive contact tracing to identify and monitoring individual staff members are the key aspect of infection control policy in any healthcare institutions. A barrier-free testing system provides rapid and effective access to healthcare staffs irrespective of their symptoms, additionally, a screening system without gatekeepers could generate a habit of frequent Covid -19 screening among individual hospital staff which in turn protects even healthcare staff working in other healthcare settings who is cohabiting with them.Download #2021074 (595.26 KB)
"Cost Effectiveness Analysis of Chagas Disease Screening in Latin American Migrants in Ireland: A Markov Model Analysis"
Principal Presenter: Paul Reidy
Chagas Disease, a neglected tropical disease caused by the parasite Trypanosoma Cruzi, affects 7 million people worldwide and is endemic in many parts of the Americas causing 12,000 deaths a year.
Global migration patterns have led to chronic cases of Chagas disease being increasingly reported in the US and Europe, in migrants from Latin America. Although it has rarely been reported in Ireland, numbers are likely to be underestimated based on migration data and the prevalence of the disease in endemic countries. In Ireland, where immigration from South America, particularly Brazil, is the fastest growing demographic, there is little recognition of the disease among the public and health services.
We constructed a decision tree model that compared the test option i.e., screening of asymptomatic individuals, treatment with benznidazole, and follow-up of positive cases, with the no-test option i.e., no screening of migrant population but treatment of symptomatic individuals presenting with sequelae of chagas disease in secondary care.
The decision tree included a Markov model with five states, related to the chronic stage of the disease: indeterminate, cardiac, gastrointestinal, response to treatment, and death. The model started with a population of 10,000, of which 1.0%, a pooled prevalence rate derived against Irish migration data, were estimated to be infected by Trypanosoma Cruzi in the base case.
Costs were taken from an Irish health system perspective. Micro-costing was used to identify costs to the health system from screening activities. Irish Diagnosis Related Groups were used to identify costs in secondary care.
Utility weights that were used to construct QALY’s were taken from the published literature.
The primary outcome was the incremental cost effectiveness ratio between the test and the no test option. Deterministic and probabilistic analyses were performed in the uncertainty analysis.
In the base case total costs in the test option and no test option were €4,633,227 and €2,514,324 respectively, a difference of €2,118,903.
The respective number of QALY’s in the test option and no test option were 1682 and 1524, respectively, a difference of 158 QALYs.
Therefore, the Incremental Cost Effectiveness Ratio was €13,417 in the base case.
The findings of our model suggest that a screening program for Chagas disease in migrant asymptomatic Latin American adults in Ireland is a cost-effective strategy.
"Staphylococcus Aureus Bacteraemia (SAB) Management Over 1 year In A Tertiary Care University Hospital."
Principal Presenter: Eoin Conlon
Keywords: Staphylococcus Aureus, Echochardiogram, Methicillin Resistant Staphylococcus Aureus
Staphylococcus Aureus Bacteraemia (SAB) is a serious bloodstream infection; and one of the commonest causes of endocarditis and deep-seated infections, with mortality ranging from 20-40%. We conducted a retrospective audit on the management of SAB. The aim was to assess compliance to local guidelines and international quality of care indicators for the management and treatment of SAB.
We conducted a retrospective audit of the management of all SAB at our institute from September 2019 to September 2020 inclusive.
Data was collected and analysed in Microsoft- Excel following approval from the hospital audit committee, in line with GDPR.
68 patients were diagnosed with SAB over the study period; but only 58 were included in the analysis, as six died before a repeat blood culture could have been obtained, and four were lost to follow-up from the Emergency Department. The majority of SAB were community-acquired (58.6%, n=34); and sources of infection included septic arthritis (24%, n=14), and osteomyelitis (12%, n=7) among others. Methicillin-Resistant Staphylococcus Aureus was isolated in five cases (8.6%).
Repeat blood cultures within 24-48 hours and 48-96 hours of the initial positive culture were obtained in 94.8% (n=55) and 5.2% (n=3) respectively. Early appropriate antimicrobial treatment was administered in all cases - the majority with flucloxacillin (46.6%, n=27) and vancomycin (37.9%, n=22). Vancomycin was used as definitive therapy in all cases of methicillin-resistant SAB, with drug levels adjusted as per local policy to attain a steady trough of 15-20mg/L. Most patients received a minimum 14-day course of IV antibiotics (91.3%, n=53).
Echocardiograms were performed for 55 patients (94.8%) - 54 receiving a transthoracic echocardiogram (TTE) and 5 receiving both a TTE and transesophageal echocardiogram (TOE). Infective endocarditis was confirmed in one case; while a further four were treated as presumptive endocarditis with a normal TTE. Mortality within one month of diagnosis was 15.5% (n=9) and within one year was 24.1% (n=14).
Adherence to local and international standards for the management of SAB was optimal in our institute. Interventions would be undertaken to further improve compliance with the standards before re-auditing.
 López-Cortés LE, Del Toro MD, Gálvez-Acebal J, et al. Impact of an evidence-based bundle intervention in the quality-of-care management and outcome of Staphylococcus aureus bacteremia. Clin Infect Dis. 2013;57(9):1225-1233. doi:10.1093/cid/cit499Download #2021072 (110 KB)
"Healthcare Workers' Acceptability of Serial SARS-CoV-2 Testing: A Quality Improvement Initiative"
Principal Presenter: Síle Kelly
Keywords: Testing, Antigen, COVID-19
Testing for SARS-CoV-2 is a vital public health strategy in managing COVID-19. Infections transmit rapidly in high-risk closed environments, including healthcare facilities. Methods to mitigate this, with a view to protecting patients and maintaining workforce staffing levels, include increased testing for SARS-CoV-2 in healthcare workers (HCWs). An integral component of a successful testing programme is uptake of available tests. The aim of this work is to assess acceptability of serial testing for SARS-CoV-2 among HCWs in order to inform practices.
A 20-item questionnaire with 5-point and 10-point Likert scales, as well as free-text responses, was developed iteratively to identify HCWs perceptions on serial SARS-CoV-2 testing. Perceived importance, acceptability of sampling methods and frequency, comfort levels of self-administered tests, and additional factors that may influence attitudes to testing were assessed.
157 HCWs across 29 facilities rated serial SARS-CoV-2 testing as highly important, with a median score of 9 out of 10 (mean 8.43) supported by concurrent qualitative analysis. No significant difference was found based on profession, age, previous COVID-19 or vaccination status. Nasopharyngeal and mid-nasal swab sampling methods had high acceptability.
There is a high level of acceptability for regular SARS-CoV-2 testing amongst HCWs, irrespective of the testing modality, indeed there is an expectation of greater testing. Motivation to engage with serial testing was primarily for the protection of others. The findings of this study should inform stakeholders in design and implementation of testing programmes.Download #2021071 (643.78 KB)
"Beware the pseudo-IBD flare – An atypical cause of colitis, pancytopaenia and splenic abscesses in a young patient on anti-TNF therapy for ulcerative colitis"
Principal Presenter: Kate Jackson
Keywords: Yersinia, HLH, colitis
Background: A 23 year old male patient with a ten year history of ulcerative colitis treated with Mesalazine and Adalimumab, and recurrent Clostridioides difficile infection, presented with six weeks of lethargy, weight loss, PR bleeding and subjective fevers.
Management: On examination the patient was septic, pyrexic and admitted under the emergency surgical team. He was commenced on empiric broad spectrum antibiotics (Piperacillin-tazobactam and Gentamicin) and proceeded to have imaging which showed colitis and multi-focal areas of hypoattenuation in the spleen in keeping with abscesses. An antifungal was added to his regimen given imaging findings and immunosuppression was held. Unfortunately he developed pancytopaenia and deteriorated clinically despite antimicrobial therapy. He proceeded to have a laparotomy with subtotal colectomy, concurrent splenic biopsy and bone marrow aspiration.
Microbiology: Three sets of blood cultures taken over a 36hour period from admission yielded Yersinia Pseudotuberculosis, Streptococcus gordonii and Staphylococcus epidermidis (the latter presumed contaminant). Yersinia pseudotuberculosis was posed as a potential unifying diagnosis to account for his clinical syndrome, however he had failed to improve despite over 72 hours of antimicrobial therapy, including escalation of his antimicrobials. Therefore he proceeded to surgical intervention. Histological analysis of colonic and splenic biopsies were in keeping with Yersinia infection, with appendiceal inflammation and pus, as well as predominantly right-sided ulceration and colitis present on macroscopic pathological analysis. Haemophagocytic lymphohistiocytosis (HLH) was confirmed, based on blood markers, bone marrow analysis and ‘H’ score, and presumed to be secondary to infection in this case.
Treatment and Outcome: The patient was treated with Anakinra, IV immunoglobulin, IV Ceftriaxone and Metronidazole for several weeks. He was discharged home with OPAT and was clinically well on review, with normal inflammatory markers, blood counts and ferritin. He is being investigated by Immunology as an outpatient, but thus far has no evidence of primary underlying immunodeficiency.
Conclusion: This case highlights the difficulty of distinguishing an acute exacerbation of inflammatory bowel disease from invasive infection, and the need for input from multiple specialties. This is especially true in the context of immunosuppression and previous Clostridioides difficile infection. A high index of suspicion and early liaison with Haematology specialists was important in the diagnosis and management of HLH as it can also present similarly to bacterial sepsis.Download #2021070 (280.18 KB)
"Latent TB - The Great Confounder. A Case Report Of Neutrophilic Pericarditis and Diagnostic Uncertainty."
Principal Presenter: Ellen Newman
Keywords: Latent TB, Pericarditis
Mycobacterium Tuberculosis is often referred to as the Great Imitator, alongside syphilis and others, due to its capacity to mimic other disease processes. However here we would like to describe a case whereby latent TB in a patient with pericarditis contributed to diagnostic uncertainty due to the atypical course of this patient’s disease.
A 29 year old man presented to the emergency department with two a two day history of chest pain and dyspnoea. His chest pain was sharp, pleuritic, and was eased by leaning forward. He underwent CT PA which showed a large pericardial effusion, as well as a right middle lobe granuloma. His inflammatory markers were elevated, with a WCC 13.4 and CRP 264, although he was apyrexic. High sensitivity troponins were negative. His past medical history was significant for polio in childhood, and he was originally from Romania.
Colchicine and ibuprofen were started empirically. He was admitted and underwent pericardiocentesis while remaining off antibiotics. The pericardial fluid cell count was reported with 1100 WCC, with 89% polymorph predominance. This neutrophilic effusion was most in keeping with a bacterial pericarditis, but the patient’s presentation was atypical for such, given his lack of pyrexia and clinical stability in the absence of antimicrobials several days into admission.
The patient did become pyrexic several hours post pericardiocentesis, with a temperature of 38.8oC. He was commenced on piperacillin-tazobactam for sepsis of unknown origin. IGRA test came back positive, but the patient was quickly responsive to his antimicrobials, with defervescence and decreasing inflammatory markers. Pericardial fluid was negative on auramine stain, and his clinical response to piperacillin-tazobactam did not support a TB pericarditis diagnosis. However he had no positive bacterial cultures and viral PCR was negative, and so a GenXpert PCR for TB was undertaken on the pericardial fluid sample.
This was also negative. A CT scan of the abdomen and pelvis outruled other foci of MTB infection, as the patient was originally from a country with the highest incidence of TB in the European Union.
The patient was discharged after repeat TTE showed no recurrence of effusion. His WCC was normal of discharge, with CRP 47, and he was to complete his antimicrobials orally. The cause of his pericarditis is still unclear, with negative 16s PCR, but his latent TB diagnosis was a confounder during his work up that necessitated additional laboratory and radiological testing.Download #2021069 (825.31 KB)
"A curious case of chronic Q fever: a case report of protracted diagnosis of C. burnetii chronic infection"
Principal Presenter: Adam Kelly
Keywords: Q fever
Q fever is a zoonotic infection caused by the pathogen Coxiella burnetii. First described in 1937, sheep, goats and cattle remain the main reservoir of infection with transmission primarily through direct contact or inhalation of aerosolised spore-like particles and droplets. Incidence of Q fever traditionally peaks during winter and spring (lambing season) with approximately 15 cases reported annually in Ireland.
Here, we describe the case of a 66 year old Caucasian male admitted to an Irish hospital in December 2019 following referral from his GP for further investigation of an iron deficient anaemia, 9 kg weight loss and intermittent pyrexia over a 4 month period.
OGD and colonoscopy yielded no obvious pathology as a cause for anaemia. CT TAP revealed multiple bilateral renal hypodensities and hilar lymphadenopathy. Follow up renal biopsy was significant for necrotising granulomatous inflammation concerning for either infectious aetiology versus a systemic granulomatous disease.
Patient continued to exhibit peristent weight loss and intermittent pyrexic episodes. Subsequent renal biopsy specimens sent for TB and panfungal PCR testing were negative as were Quantiferon, Rickettsia and Brucella serology. On further questioning, patient reported history of exposure to lambs as well as previous travel to Australia. Subsequent C. burnetti serology sent returned positive and a diagnosis of chronic Q fever was considered.
Patient was commenced on doxycyline 100mg po BD and hydroychloroquine 200mg po TDS. He reported a gradual improvement in symptoms over several months on first line antimicrobial therapy. Clinical improvement was complemented by follow up decrease in titre serology levels with CT imaging revealing amelioration of previously noted diseased areas.
With an incubation period of about 2-3 weeks, the main manifestations of acute Q fever infection include recurring fevers, headache, pneumonia and hepatitis. Occasionally, chronic infection may ensue presenting as endocarditis, vasculitis and osteomyelitis. Failure to promptly recognise and commence appropriate antimicrobial therapy may result in protracted symptoms and even fatal outcomes.
This case serves to remind clinicians of the elusive presentations of chronic infection with C. burnetti and the challenges faced in making the diagnosis. It also underscores the importance of maintaining a high index of suspicion for C. burnetti infection especially in patients with signifcant risk factors for same.Download #2021068 (177.26 KB)
"Acute Pulmonary Embolism: Investigation and diagnosis in the COVID 19 pandemic"
Principal Presenter: Aidan McLaverty
Keywords: Pulmonary embolism, CT pulmonary angiography, COVID 19
Title: Acute Pulmonary Embolism: Investigation and diagnosis in the COVID 19 pandemic
Authors: Aidan McLaverty1, Padraig McGettrick1,2, Brendan O’Kelly1, Aoife Cotter1,2, Tara McGinty1,2, Eavan Muldoon1,2, Gerard Sheehan1, Jack Lambert1,2
1. Department of Infectious Diseases, Mater Misericordiae University Hospital, Dublin
2. Centre for Pathogen Host Research, UCD School of Medicine, Dublin
Declaration: This study was part funded by Health Research Board (HRB) [COV19-2020-123].
Pulmonary embolism (PE) has emerged as an important and frequent complication of COVID-19 infection. Covid-19 complicated by PE can exhibit significant overlap with disease in which no evidence of PE is found, creating a difficult clinical dilemma when prioritising patients for further assessment with CT pulmonary angiography (CTPA). In this study we examine the clinical characteristics and predictors of (i) COVID-19 patients undergoing CTPA for suspected acute PE and (ii) those diagnosed with PE on CTPA.
Patients confirmed to have COVID-19 by polymerase chain reaction (PCR) and admitted to the Mater Misericordiae University Hospital between 10th March and 19th of May 2020 were retrospectively analysed. Data regarding patient demographics, clinical characteristics, and in-hospital outcomes - including diagnosis with PE - were collected. Between-group comparison was made between those who underwent CTPA and those who did not and again between those diagnosed with PE or not using Mann Whitney U and Chi square testing. Regression analysis was used to assess predictors of PE diagnosis. Data are median (IQR) unless stated.
Among 300 patients with COVID-19 [age 60 (44-76) years], 32 (10.7%) underwent CTPA. CRP [69 (40-131) vs 42 (14-113) p=0.048], ferritin [769 (385-2350) vs 428 (181-1021) p=0.004] and d-dimer [1.54 (0.86-3.32) vs 0.57 (0.38-1.14) p<0.001] were significantly higher in those undergoing CTPA with SP02% lower [93 (82-96) vs 96 (94-98) p=0.003]. Critical care patients made up a greater proportion of the CTPA group than the non-CTPA [10/32 (30.3%) vs 25/268 (9.3%) p<0.001].
Among those with CTPA, 5 (15.6%) were diagnosed with PE. CRP [202 (116-246) vs 57 (17-122) p=0.04], d-dimer [7.13 (2.00-7.20) vs 1.09 (0.66-2.60) p=0.015], neutrophils [9.93 (9.60-17.10) vs 4.18 (2.38-6.70) p<0.001] and troponin levels [39 (31-71) vs 10 (0-20) p=0.023] were found to be significantly higher in patients with confirmed PE.
The strongest predictors of PE diagnosis in this cohort were critical care admission [OR 14.0 (95% CI 1.3, 150.0) p=0.03], raised CRP [OR 1.01 (95% CI 1.0, 1.03) p=0.05] and D-Dimer [OR 1.25 (95% CI 0.98, 1.6) p=0.06]. Higher SPO2 on admission was seen to be protective [OR 0.92 (95% CI 0.86, 0.99) p=0.03].
In COVID-19 infected individuals, people with higher inflammatory markers were more likely to undergo CTPA imaging, with critical care admission and raised CRP most associated with PE diagnosis. This reflects the significant risk of the hyperinflammatory phenotype for PE diagnosis in Covid-19 infection.Download #2021067 (282.64 KB)
"A retrospective analysis of the vaccination practices at Ireland's largest dedicated HIV vaccination clinic"
Principal Presenter: Peter Conlon
We conducted a retrospective analysis of the varicella and rubella vaccination programme amongst the HIV population at Ireland’s largest dedicated HIV vaccination centre, St James's hospital. This follows work done in 2018 to recruit non-immune patients for vaccination for varicella and rubella.
We retrospectively analysed the HIV vaccination records to assess if HIV patients had been vaccinated successfully for varicella and rubella following a seronegative result. And if not had they been enrolled in a vaccination catch-up programme?
Sixty nine percent of those found to varicella non-immune were successfully enrolled in a vaccination catch-up programme.
We also identified a cohort of patients who, despite appropriate vaccination did not mount a serological response.
Fifty percent of those found to varicella non-immune were successfully enrolled in a vaccination catch-up programme.
Of those rubella non-immune, sixteen patients were of childbearing age.
St James's manages a large cohort of HIV patients. The majority of whom are immune to varicella and rubella. Of those who are non-immune, an active recruitment programme has successfully captured those vulnerable to varicella and rubella. We have also identified a subset of patients who did not mount a serological response to the varicella vaccine. We have two hypotheses for this.
Amongst others, a digital vaccination passport is a strong recommendation going forward to facilitate easy identification of those requiring vaccinationDownload #2021066 (328.58 KB)
"An Audit of Nicotine Replacement Therapy Prescribing in HIV+ Patients in Outpatient Clinic Setting."
Principal Presenter: Aisling O'Donnell
Background: The rate of cardiovascular disease among people living with HIV (PLMH) and on treatment is double that of the general population. (1)Smoking cessation can reduce the rate of non-AIDS defining cancers by 24% and the rate of MI by up to 37%. (2) The European AIDS Clinical Society Guidelines 2019 suggest that Nicotine Replacement Therapy (NRT) should be offered to PLWH who continue to smoke along with other interventions. (3)
Methods: All PLWH who attended outpatients between 10/11/2020 and 13/11/2020 were identified from chart review and smoking status and NRT prescription was recorded. The results were presented to the Infectious Diseases junior doctors as an educational session which also included information on how to prescribe NRT. Posters with information on NRT prescribing were put in each clinic room. The same parameters were then reaudited for the following two weeks. We did a final audit 5 months to review the longevity of our intervention.
Results: Pre intervention (n=48): 56% of patients had their smoking status recorded. 21% of patients were current smokers (mean cigarettes/day: 14). No one was offered NRT. Post intervention (n=54): 61.1% of patients had their smoking status recorded. 14.8% of patients were current smokers (mean cigarettes/day 13.6). 50% of patients who were current smokers were offered and received NRT. Reaudit after 5 months (n=35): 60% of patients had their smoking status recorded. 25.9% of patients were current smokers. 44.44% of patients who were current smokers were offered NRT.
Conclusion: A significant number of PLWH smoke. However, many patients are willing to try smoking cessation therapy. Of those patients who weren’t offered NRT one of the main reasons was that patients did not smoke enough cigarettes each day to require NRT (for example ‘social smokers’). In other patients, NRT wasn’t offered as patients had active alcohol or drug abuse issues. On review, their doctors felt that it was more pertinent to address their need for methadone programmes or rehab. We showed the durability of our intervention with almost half of current smokers being offered NRT 5 months after our original intervention. While it is challenging for HCPs to fit discussions on smoking into the time constraints of a clinic slot, it is clearly a worthwhile intervention.
"Clinical Performance of the Celltrion DiaTrust™ COVID-19 Rapid Antigen Test: A Prospective Study"
Principal Presenter: Matthew Blair
Rapid antigen diagnostic tests (RADT) have been regarded as lacking sensitivity when compared to the ‘gold standard’ of PCR in the diagnosis of COVID19. The Celltrion DiaTrust™ COVID-19 Ag Rapid Test is a one-step, lateral flow, immunoassay that detects SARS-CoV-2 nucleocapsid and spike antigen proteins. It is amenable to use as a point-of-care assay (POC) and has a reported sensitivity of 95.5% (107/112) (95% CI: 90%-91.1%) and specificity of 100.00% (191/191) (95% CI: 98%-100%). This study aimed to assess the performance of a SARS-CoV-2 RADT in a clinical setting.
We conducted a prospective study of use of the DiaTrust™ assay on respiratory samples from subjects with confirmed SARS-CoV-2 infection. Subjects were recruited from the All-Ireland Infectious Diseases (AIID) cohort. Subjects provided two nasopharyngeal (NP) respiratory samples for matched PCR and RADT. Samples for RADT were used for simultaneous POC and laboratory (LAB) RADT. We estimated sensitivity by comparing positivity rates of DiaTrust™ against RT-PCR assays, using a cycle threshold (CT) value of <37 as a positive result and a CT>37 as a negative result. Parallel testing in a sample size of 100 subjects provided 95% power to detect 92% sensitivity with a lower 95% confidence interval of 80%.
We completed analyses on 99 sample sets, median (IQR) age 62 (53-74), 40% male. Of these, 99 had completed POC RADT results and 96 had completed LAB RADT results. Overall sensitivity of the assay based on CT value <37 was 73.8% for POC and 74.7% for LAB (see Table 1). Specificity based on a CT <27 was higher at 93.8% for POC and 97.8% for LAB. Sequencing performed on 49 samples showed a preponderance of variant B.1.177 (48.9%).
Overall sensitivity of the Celltrion® RADT assay is 73.8% to 74.7%. The RADT assay detected confirmed SARS-C0V-2 PCR positive cases with the greatest sensitivity at a CT value <27. There was broad concordance between POC and LAB performed RADT assays, supporting use of this assay as a POC assay.
"Assessment of Perception of Clostridium difficile Infection among clinicians at University Hospital Galway"
Principal Presenter: Amenah Dhannoon
Keywords: Clostridioides difficile (C. diff), Infection Control, Clinical Education
Background: Clostridioides (formerly Clostridium) difficile is responsible for one of the most common nosocomial infection. It is widely distributed in soil and intestinal tracts of human resulting in a spectrum of clinical features ranging from asymptomatic colonisation or mild diarrhoea to more severe symptoms of ileus, toxic megacolon and shock. In 2019, there was 562 cases reported in Irish hospitals with 385 being hospital acquired. Of these 88% were characterised as new infection. Prevention of this infection relies of the healthcare staff adherence to the national guidelines The objective of this study was to identify gaps in hospital doctors’ knowledge and practices towards C difficile infection (CDI) and respond to this by providing appropriate educational tools to bridge the gaps.
Methods: We surveyed clinical staff at University Hospital Galway via an online survey that was sent by email. The survey included questions regarding risk factors, diagnosis, testing, management options and prevention measures of CDI. Ethical approval was obtained from the Ethical Review Committee (ERC) prior to conducting the study.
Results: There were 78 responses to our survey among consultants, SpRs, registrars, senior house officers and interns. Looking at the data, the most concerning findings were identified under Risk factors as awareness was deficit with only 58% recognising gastric acid suppression as risk factors and 35% only were able to identify previous Gastric surgery. Only 31% recognised that 1 episode of loose stool warrant stool sampling in those with high risk with 49% mistakenly agreed that a formed stool sample could be sent to microbiology lab to for cdifficile screening. There was an overall good awareness regarding interpretation of the lab results for C difficile in terms of cdifficile toxin and gene, however 47% of participants thought a test results suggestive of C difficile colonisation would not require treatment. Participants were asked about their suggestions to raise awareness and improve knowledge towards CDI, education and poster for display in clinical areas were among the most popular suggestions.
Conclusion: knowledge gaps exist among clinician of different grades, the survey identified the preferred methods to take action and fill-in the gaps. We offered a short oral presentation with posters based on the SIGHT Protocol (Suspect, Isolate, Gloves and Apron, Hand washing, Testing) set out by the NCEC CDIFF guidelines as an intervention for our study.Download #2021063 (1.23 MB)
"Outpatient Parenteral Antimicrobial Therapy (OPAT) readmissions over 1 year in a Tertiary Care University Hospital."
Principal Presenter: Robert Lyons
Keywords: OPAT, readmission, rate
Outpatient Parenteral Antimicrobial Therapy (OPAT) readmissions over 1 year in a Tertiary Care University Hospital.
Authors: Robert Lyons1, Claire Kenny1, Clarence Soliman1, Deepa Rajendran1, Eoin Feeney1, Stefano Savinelli1, Cathal O’Broin1, Patrick Mallon1, Sarmad Waqas1
1. Infectious Diseases Department, St. Vincent’s University Hospital; Dublin, Ireland.
Background and Aim: OPAT is increasingly being utilized to facilitate early discharge of patients from hospital. This study was designed to compare our OPAT readmission rate with the national target of <5% in our institution over the last year and to analyse causes of these readmissions.
Methods: A retrospective review of all OPAT readmissions during 2020 was undertaken. All data was recorded and analysed confidentially in MS-Excel in line with GDPR after approval from the local audit committee.
Results: Twenty-nine (17%) of St. Vincent’s University Hospital OPAT patients were readmitted during the course of their antimicrobial therapy out of a total of 171. The national average was a 10% readmission rate during this period. The readmissions involved 26 patients as three patients were readmitted twice. There were 15 male patients (57.6%). The mean age of patients was 66 years (42-88). Microbiological data to guide therapy was available for 96.5% (n=28). The most common indication for OPAT was bone and joint infections 69% (n=20), infected intra-abdominal collections 17% (n=5) and blood stream infections 7% (n=2). The most common referring primary teams were vascular surgery 24% (n=7), infectious diseases 20% (n=6) and orthopaedic surgery 14% (n=4).
The reasons for readmission were non-OPAT related medical or surgical illnesses in 45% (n=13), persistent infection or progression in 31% (n=9) and OPAT related reasons 24% (n=7).
The patients admitted for OPAT related reasons had spent on average 7 (2-11) days on OPAT prior to readmission. OPAT related reasons for readmission were blocked or partially pulled PICC 43% (n=3), elevated Vancomycin levels with renal injury in 29% (n=2), nausea and anorexia secondary to Flucloxacillin in 14% (n=1) and sepsis secondary to severe C.difficile colitis in 14% (n=1). After readmission the patients spent on average 10 (1-20) days in hospital and 57% (n=4) out of those were re-referred for OPAT on their discharge.
Conclusions: Readmissions while on OPAT were common during the last year in our institution and higher than both the national target and the national average. The majority of readmissions were because of general medical and surgical problems. Older age and patients’ multiple co-morbidities could be contributors which underscores the needs for optimisation of underlying medical and surgical problems before discharge of patients on OPAT.Download #2021062 (211.82 KB)
"Delirium in Covid-19. A Single Centre Audit of Incidence of Delirium Among Patients Presenting with Covid-19 to Beaumont Hospital and Standard Management Received."
Principal Presenter: Thomas Doran
Keywords: Covid, Delirium, Elderly
Delirium in Covid-19. A Single Centre Audit of Incidence of Delirium Among Patients Presenting with Covid-19 to Beaumont Hospital and Standard Management Received.
To identify the incidence and work-up of Covid-19 associated delirium in patients aged 65 years or older presenting to Beaumont Hospital and to compare it with standards set in the JAMA article “Delirium in Older Patients With Covid-19 Presenting to the Emergency Department” (Kennedy M et al.).
Delirium is the most common complication of hospitalization in older adults. It is associated with increased mortality and longer hospital stays. Recent studies showed delirium to be a common presentation in older adults with Covid-19 and was associated with poor hospital outcomes.
This is a single centre cohort study in Beaumont hospital. The participants were all inpatients under the care of the Infectious Diseases team aged 65 or older who tested positive for Covid-19 between January 1st 2021 and March 15th 2021. Data was collected from patients’ medical charts.
Overall there were 36 patients included in our cohort. The average age was 80.4, with an average length of stay (LOS) of 17 days. Delirium was documented in 17.4% of cases. On analyses there was no significant difference in LOS between the delirium group and no delirium cohort (13.4 vs 18.07, p=0.373). This must be taken in context, as there were significantly poorer outcomes in the delirium group. 71.4% of patients in the delirium group died compared to 7.2% in the no delirium cohort (p=0.0012).
Results should be viewed with caution due to the small number of patients included. However, in our audit, delirium appears to be an extremely poor prognostic indicator for patients aged 65 or older with Covid-19.Download #2021061 (148.33 KB)
"Assessing the impact of COVID-19 on Quality of Life"
Principal Presenter: Conor Moran
Keywords: COVID-19, Quality of life, Long COVID
Persistent symptoms post COVID-19 infection are increasingly recognised. Evaluating longer-term impacts of COVID-19 on health related quality of life (HRQOL) will benefit patient care.
We undertook a cross-sectional study of HRQOL among COVID-19 positive patients in Galway University Hospital. Inclusion criteria were COVID-19 infection in adults between March 1st - May 31st 2020. Ethical approval was granted. Identified participants were sent a consent form, study information leaflet. Consented participants submitted an anonymised HRQOL survey.
The SF-36 survey was used as a standardised measure of HRQOL across 8 domains: limitations in physical functioning (PF), role limitations from physical health problems (RP), role limitations from emotional problems (RE), energy and fatigue (EF), emotional well-being (EWB), social functioning (SF), bodily pain (BP) and general health perceptions (GH). Questions were scored from 0-100, with 100 representing the highest level of functioning. The averages of these 8 domain scores were compared with normative Irish SF-36 data. Unpaired t-test was used to test for statistical significance between continuous variables. Those with low SF-36 scores ( < 75 in 4 domains or < 50 in 2) were invited to repeat the survey.
136 COVID-19 positive individuals were identified. 88/136 (65%) were able to and agreed to participate. 59/88 (67% response rate) returned fully completed surveys. 27/55 (49%) were female, 32/55 (58%) were male, average age was 52 years (range 24-86). The average time post Covid-19 diagnosis was 12 weeks (range 4-20).
Participants reported worse overall HRQOL scores compared to normative Irish SF-36 data. Statistically significant differences were recorded in the domains of; RP (68.6 vs 80.5, p-value 0.019), EF (54.8 vs 64.6, p-value 0.037), SF (75.2 vs 84.1, p-value 0.009) and GH (65.8 vs 73.8, p-value 0.009). Males reported better, but non-statistically significant HRQOL than females. Hospitalised patients reported strongly statistically significantly worse overall scores than outpatients in every domain except for EF and EWB.
Repeat SF-36 were administered 6-9 months post diagnosis for those with the lowest HRQOL (n=28), the repeat surveys received (n=13) showed improvement but persistently significant impairments, particularly in physical limitations and energy levels.
Three months after COVID-19 diagnosis, HRQOL was impaired, most marked in those who were hospitalised. This persisted at 6-9 months in those with the lowest HRQOL. The impact of COVID-19 restrictions may have contributed to some of the HRQOL domains, however this study illustrates the significant and prolonged effect of COVID-19 on HRQOL.Download #2021060 (1.05 MB)
"Treatment of HIV-associated Cryptococcal Meningitis and Central Nervous System Cryptococcoma with Isavuconazole"
Principal Presenter: Siobhan O'Regan
Keywords: HIV, Cryptococcal Meningitis, Isavuconazole
The opportunistic fungal infection cryptococcal meningitis (CM) has a poor prognosis even with treatment. Guidelines recommend amphotericin B and flucytosine induction therapy for 2 weeks. The efficacy, oral administration and safety profile over prolonged periods of fluconazole make it the recommendation for subsequent consolidation and maintenance phases. With increasing fluconazole resistance, alternative antifungals are needed. Itraconazole is less effective than fluconazole and recommended only as second line therapy. Voriconazole’s CNS penetration is excellent, but it can be quite toxic and requires close monitoring. Isavuconazole also penetrates the CNS but is less toxic than voriconazole and so offers promise as an alternative to fluconazole for CM.
A 39-year-old man from sub-Saharan Africa with uncontrolled HIV presented with a 2-week history of occipital headache, blurred vision, fevers, and malaise. He had no objective neurological deficits. Serum cryptococcal antigen (CRAG) was positive 1:1280. MRI Brain excluded a space-occupying lesion. Lumbar puncture (LP) demonstrated elevated opening pressure (OP) of 25cm H2O, white cell count of 127 cells/ mm3 (range 0-5cells/mm3, 95% mononuclear) and CSF CRAG 1:160. Cryptococcus neoformans was cultured.
Liposomal Amphotericin-B (LAB) and flucytosine were commenced. Serial LPs were done until OP was 15cm H2O. Flucytosine was discontinued early due to thrombocytopenia. CSF culture was repeated on day 14 and LAB continued until these cultures were confirmed negative (day 21). The cryptococcus neoformans isolate had an MIC of 8.0mg/L for fluconazole so 1200mg of fluconazole daily was chosen for consolidation. Antiretroviral therapy started on day 26. By day 34 the patient had developed intractable nausea and vomiting, acute kidney injury, and QT prolongation. MRI Brain FLAIR sequence identified a new cryptococcoma in the setting of IRIS which was treated with LAB re-induction and steroids. Given toxicity with fluconazole, isavuconazole (MIC 0.125mg/L) was chosen as an alternative for consolidation/maintenance and therapeutic drug monitoring was initiated. The cryptococcoma completely resolved radiologically 143 days post discovery. The patient is currently week 29 of therapy with a view to stopping at 1 year.
This case illustrates the potential for fluconazole toxicity at high doses and the need for oral alternatives for CM treatment with acceptable safety and tolerability profiles such as isavuconazole.
Barriers to isavuconazole use in resource-limited settings with highest CM incidence include cost, inaccessibility, and the need for therapeutic drug monitoring. This case demonstrates successful use of isavuconazole in a resource-rich setting for the continuation and maintenance phases of CM management.Download #2021059 (555.5 KB)
"A Single Centre Experience of Prosthetic Joint Infections (PJI) Management and Outcomes with Outpatient Parenteral Antimicrobial Therapy (OPAT)"
Principal Presenter: Abdubadie Kutubi
Background and Aims
Treatment of prosthetic joint infections (PJIs) usually involves surgical intervention and long-term antimicrobial therapy which is increasingly being facilitated by outpatient parenteral antimicrobial therapy (OPAT) program for suitable patients. The aim of this study was to assess the clinical outcomes, readmission rates and bed days saved for these subjects.
Retrospective chart review was undertaken for PJIs managed via OPAT between 2015-2020. Data was collected after local ethics committee approval in line with GDPR. Data analysis was performed using IBM-SPSS.
41 subjects with PJIs were managed via OPAT at our institute over five years. There were 31 male subjects (75.6%). Median age was 71.6 years (24.9-91.1). Pathogenic organisms: Staphylococcus species: 26 (63.4%), Streptococcus species: 6 (14.6%), Neisseria Meningitidis: 1 (2.4%), Enterococcus species: 2 (4.9%), Mixed organisms: 1 (2.4%), organism unidentified: 5 (12.2%). Comorbidities included CCF: 1 (2.4%), CKD: 2 (4.9%), CAD: 8 (19.5%), Immunocompromised/immunosuppressed: 5 (12.2%), T2DM: 6 (14.6%). Joints involved included knee: 23 (56.1%), hip: 12 (29.3%), elbow: 3 (7.3%), shoulder: 2 (4.9%), ankle: 1 (2.4%). Median duration of OPAT was 32 days (range 5-53). Infection outcome after OPAT was curative in 1 case (2.4%), improvement in 38 cases (92.7%) and failure in 2 cases (4.9%). Readmission occurred in 14 cases (34%), 9.7% within 30 days, 7.3% within 60 days, 7.3% within 90 days and 9.7% after more than 90 days. Reasons for readmission included progression of infection in 9 (64.3%), unplanned reoperation in 3 (21.4%) and planned admission for joint revision in 2 (14.3%). Per subject, a median of 32 bed days were saved (Range 0-81). In total, 1127 bed days were saved which equated to an estimated €963,585. After adjustment for age and gender, Type 2 Diabetes Mellitus (T2DM) was associated with unplanned readmission OR 8.5 (CI 95% 1.1-67.6).
The overall readmission rate in this study is comparable to international data looking at PJIs (1), however is above the Irish national target of <5% for all OPAT discharges (2). Majority of readmissions were related to primary infection n= 26 (64.3%) in this cohort and not OPAT-specific complications. The data indicates that PJI can be safely managed via OPAT. Our study also points to T2DM as a factor associated with readmission. Larger studies on these patients are needed to further assess and optimise the factors associated with readmissions and treatment failures.Download #2021058 (462.53 KB)
"NO EFFECT OF HIV INFECTION ON APOLIPOPROTEIN LEVELS IN A CONTEMPORARY COHORT OF PWH"
Principal Presenter: Stefano Savinelli
Dyslipidaemia is common in people with HIV (PWH), with viral factors and antiretroviral treatment (ART) potentially contributing to changes in lipid parameters and apolipoprotein (Apo) composition, increasing risk of cardiovascular disease (CVD). Apo in PWH have mostly been studied with older ART regimens and uncontrolled HIV infection. The aim of our study was to compare lipid and Apo profiles between ART-treated PWH and healthy controls (HC).
We recruited PWH and HC from the UPBEAT multicentre prospective cohort. Data from year 5 (January 2017-January 2019) were analysed. Apo levels [ApoB, ApoA1, Lp(a)] were analysed by immunoturbidimetry on plasma samples. Lipids (total cholesterol, LDL, HDL), clinical and demographic data were collected. Between-group differences in Apo and lipid levels were assessed with Mann Whitney U test, and association between Apo levels and clinical and demographic factors were analysed using linear regression. Data reported are median [IQR].
We included 108 PWH on ART and 96 HC. Male gender (72.2% vs 51%), younger age (47 [41, 54] vs 51 [44, 57]), obesity (34.3% vs 27.1%), African ethnicity (30.6% vs 9.4%), current smokers (29.6% vs 11.5%), CVD (4.6% vs 0%), hypertension (HTN 29.6% vs 7.3%), diabetes (11.1% vs 3.1%) and statin use (39.8% vs 5.2%) were more represented in PWH. Prevalence of dyslipidaemia was similar in PWH (66.7%) vs HC (62.5%). PWH were mostly virologically suppressed (93.5%); duration of HIV infection 8.86 years [6.53, 11.14]; CD4 count 693 [514, 891]; HIV risk 38% MSM, 46.3% heterosexual, 15.7% PWID; ART use TDF 48.1%, TAF 37%, NNRTI 33.3%, PI 20.4%, INSTI 41.7%. ApoB, TC, HDL and LDL were significantly lower in PWH (ApoB 1.15 [0.96, 1.41] vs 1.37 [0.96, 1.62]; TC 1.37 [0.96, 1.62] vs 5.35 [4.7, 5.9]; HDL 1.26 [1.06, 1.4] vs 1.45 [1.17, 1.73]; LDL 2.85 [2.25, 3.35] vs 3.4 [2.7, 3.8]). Results were unchanged after excluding subjects on statins. Male gender remained independently associated with lower ApoB levels in a multivariable linear regression model (Table 1). No associations with HIV-specific factors were observed. There was no difference in ApoA1 or Lp(a).
Although ApoB levels in PWH on ART were lower than HC, HIV was not associated with ApoB after adjustment for other co-variables in this cohort of PWH on contemporary ART. Only male gender was associated with lower ApoB, suggesting that previously reported associations with ApoB levels and HIV may have been a factor of untreated HIV or older ART.
"‘I’m like a fungus; you can’t get rid of me’ or can you? An Audit of Candidaemia Management Over One Year in an Irish Tertiary Care University Hospital"
Principal Presenter: Luke O'Brien
Keywords: Candida, Candidaemia, Fungal
Candidaemia is the most common manifestation of invasive candidiasis. Considering its associated morbidity and mortality, we conducted a retrospective audit of cases diagnosed with candidaemia over the previous twelve months at our institute. The aim of our study was to assess compliance with local and international candidaemia management guidelines and to ascertain the clinical outcomes for patients
A retrospective medical record review was conducted for all patients diagnosed with candidaemia from September 2019 to September 2020 inclusive. Local hospital guidelines and international guidelines for the Management of Candidiasis were used as the audit standard.
A total of 17 patients were diagnosed with candidaemia over the study period, only 15 patients were included in the analysis as two patients died before Candida was isolated from their blood cultures. Infection was primarily hospital-acquired (80%, n=12). Source of infection varied from intra-abdominal (46.7%, n=7), to intravenous (IV) line associated (40%, n=6) and genitourinary (13.3%, n=2). Early IV treatment with an echinocandin or an acceptable alternative was initiated for all patients with all receiving appropriate definitive antifungals. For patients with IV-line-associated candidiasis, the line was removed in all cases; and for those with an intra-abdominal source, 57.1% (n=4) had appropriate interventions to achieve source control. Follow-up cultures were repeated in 93.3% (n=14) appropriately. An echocardiogram and ophthalmological exam were performed for 86.6% of patients (n=13). Treatment was continued for minimum of two weeks after negative cultures in 80% (n=12). Two patients unfortunately died during their course of treatment due to consequences of their underlying disease process, while all active management was withdrawn in the other. Mortality within 1-month of diagnosis was 26.7% (n=4) and within 1-year was 46.7% (n=7).
Overall, we found that compliance with local and international standards in the management of candidaemia at our institute was optimal, with most patients receiving appropriate treatment and therapeutic interventions. Overall mortality associated with the diagnosis of candidaemia on longitudinal follow-up was high, underscoring the seriousness of this diagnosis. Further interventions to promote effective management of this important condition will be implemented in our institute in collaboration with our local clinical audit department and re-audited.Download #2021056 (321.19 KB)
"Getting Home, Staying Home and Staying Safe: OPAT Discharges during the COVID-19 Pandemic"
Principal Presenter: Dr Susannah Staunton
Keywords: OPAT, Discharge, PICC
Outpatient parenteral antimicrobial therapy (OPAT) facilitates earlier discharge of hospital inpatients and is an important antimicrobial stewardship tool. Delays to the discharge of OPAT appropriate patients often exist, adding unnecessary hospital bed occupancy and cost to the healthcare system. This is important in light of the current COVID-19 pandemic and its associated surge in admissions that can overwhelm hospital bed capacity.
Following clinical audit department approval, a prospective audit was conducted of all patients referred for OPAT from 08/10/2020 to 08/01/2021. Data was collected and analysed on Microsoft Excel confidentially in line with GDPR. Discharge was defined as delayed if occurring over 24 hours after the patient was considered suitable for OPAT. Compliance with the IDSI OPAT Guidelines1 and the European Appropriateness Evaluation Protocol2 was assessed.
53 inpatients were referred for OPAT during the study period. The majority were suitable for OPAT and ultimately discharged to OPAT (n=37, 70%). Most patients experienced delayed discharges (n=21, 57%). The most frequent factor delaying discharge was lack of capacity in community OPAT services (n=10, 48%). The second most common factor was delay in peripherally inserted central catheter (PICC) insertion (n=8, 38%). The mean time from PICC request to PICC insertion was 4.2 days (range 0-12). The mean time from being deemed OPAT suitable to discharge was 2.8 days (range 0-11). A total of 89 additional bed days were attributed to delays, with an estimated cost of €76,095.
4 outpatients were referred for OPAT during the study period. All were suitable for OPAT and avoided admission.
Many patients experience delays in discharge to OPAT services despite being suitable for OPAT. The most common contributors were lack of capacity in community OPAT services and delay in PICC insertion. Interventions will be undertaken to improve these factors prior to re-audit.Download #2021055 (57.91 KB)
"Short course Alendronate for the Prevention of ART associated bone loss , the APART study"
Principal Presenter: Elena Alvarez
Antiretroviral therapy (ART) initiation encompasses a period of accelerated BMD loss in people with HIV (PWH). We aimed to evaluate if short-term use of the oral, generic bisphosphonate alendronate (ALN) could prevent BMD loss at ART initiation.
Multisite, double blinded, placebo-controlled phase 4 clinical trial. ART-naïve, PWH initiating ART comprising tenofovir disproxil fumarate / emtricitabine and a third agent were randomized to 14 weeks of calcium / vitamin D3 supplementation combined with either generic, oral ALN 70mg weekly or placebo (PL), for 2 weeks prior to ART initiation and for a total of 14 weeks. Clinical, laboratory, safety and BMD at lumbar spine (LS) and total hip (TH) were assessed at weeks 0, 14, 26 and 50. Primary endpoint was between group % change in BMD from baseline to week 50, compared using Wilcoxon rank tests. Secondary endpoints included % change from baseline at weeks 14 and 26.
Of the 50 subjects randomized (ALN N=24, PL N=26) 86% were male, 46% Caucasian, 34% African and 20% Hispanic, median age was 35 (32, 40) years and BMI was 24 (22.3, 26.9) kg/m2 . Third agent use comprised integrase inhibitors in 94%. Baseline BMD was not significantly different between groups. At week 50, subjects in the ALN group experienced a median 0.50% (-3.10, 1.80) increase in TH BMD compared to a 2.7% (-4.3, -2.05) decrease in the PL group (P=0.02). At the LS, the ALN group had a 1.4% (-4.10, 3.13) loss compared to 3.69% (-4.82, -1.7) loss in the PL group (P=0.10). TH BMD between-group differences were evident early at week 14 (+1.88% (-0.7, 2.81) with ALN versus -0.65% (-2.65, 1.13) with PL, P=0.036) and persisted to week 50. In contrast, at the LS, between group differences although evident at weeks 14 (+1.24% (-0.04, 3.02) with ALN versus -0.96% (-3.10, 0.78) with PL, P=0.013) and 26 (+0.05% (-3.04, 3.3) with ALN versus -2.48% (-4.65, -0.24) with PL, P=0.033) did not persist to week 50. ALN was well tolerated with no discontinuations post randomization and no significant differences in adverse events between the groups.
Short course oral alendronate for 14 weeks, commenced prior to ART initiation, had a sustained impact on prevention of bone loss at the TH, while the effect at LS was limited to the first 24 weeks.
"Inflammatory Phenotypes characterised by Immuno-dysregulation and systemic inflammation predict Subclinical Coronary Artery Disease in CAD risk matched cohort"
Principal Presenter: Padraig McGettrick
Inflammation has been implicated in increased risk of coronary artery disease (CAD) in individuals with HIV (PWH). The immune or inflammatory pathways that contribute to CAD are not well defined.
The HIV UPBEAT CAD substudy enrolled PWH >40 years old on effective antiretroviral therapy (ART) and uninfected controls propensity matched for CVD risk. We used coronary computed tomography angiography (CCTA) to estimate subclinical CAD and performed chemiluminescence immunoassays to evaluate 28 biomarkers of systemic, innate and vascular inflammation and 10 T-cell immune markers by flow cytometry. Principal component (PC) analysis was used to reduce data dimensionality followed by PC-based unsupervised hierarchical clustering to partition participants into biomarker-derived clusters. Associations between clusters and subclinical CAD were explored using logistic regression, with additional adjustment for HIV status. Data are median (interquartile range) unless stated.
Of 101 participants (51% PWH), 72% were male, 75% Caucasian and median age 49 (45, 55) years. 35.6% had subclinical CAD.
We identified three clusters: Cluster 1 (n=41, 32% PWH) characterised by lower T-cell senescence and activation, TNF, TNF R1/2, IL1ra; Cluster 2 (n=40, 72% PWH) characterised by higher T-cell senescence and exhaustion, TNFR1/2, MIP, but lower IL2, IL12 and IFNg; and Cluster 3 (n=19, 52% PWH) characterised by higher inflammation (higher IL2, Il12, IFNg, IL4, IL10, TNF, IL6, IL1b, IL1ra, IFABP). With the exception of HIV status, demographics were similar between clusters.
Compared to Cluster 1, those in Cluster 2 and 3 had greater presence of [Odds Ratio (95% confidence interval)]: any coronary plaque [Cluster 2: 2.22 (0.9, 5.9); Cluster 3: 2.2 (0.68, 7.04)] , partially calcified [cluster 2: 8.1 (2.0, 55.1); cluster 3: 8.8 (1.8, 65.2)] and calcified plaque [cluster 2: 2.3 (0.9, 6.3); cluster 3: 1.6 (0.4, 5.4)], an association which for cluster 2 strengthened significantly after adjustment for HIV status. In contrast, participants in Cluster 3 had higher calcification scores [Agatson score >100, Calcium volume score >100] which persisted in adjusted analyses [4.0 (0.9, 19.4), 4.6 (1.1,21.0) respectively].
In a cohort of CAD risk-matched individuals with and without HIV, we identified two clusters associated with distinct characteristics of subclinical CAD, one characterised by T cell senescence and exhaustion, the other by systemic inflammation. Biological phenotyping may help to better predict those at risk of long term comorbidities common in ART treated PWH.
"An Audit of Electronic Prescribing and Monitoring of Amikacin in a large Dublin Hospital"
Principal Presenter: Sarah Kenny
Keywords: Amikacin, Electronicprescribing, Antimicrobials
Amikacin is the first line aminoglycoside at St James’s Hospital for empiric use in sepsis and serious infections caused by Gram negative bacilli. Weight-based dosing and therapeutic drug monitoring is essential to ensure therapeutic efficacy and to avoid toxicities such as nephrotoxicity and ototoxicity. E-prescribing using the electronic patient record (EPR) was introduced into St James’s hospital in 2019. The aim of this audit was to identify if amikacin dosing and monitoring was in line with local antimicrobial guidelines and if there was an improvement in with the introduction of e prescribing. A similar audit of 25 patients was completed in 2017 prior to the introduction of e-prescribing.
Retrospective data was collected from the Electronic Patient Record (EPR ) from 120 patients who were admitted in the last quarter of 2020, excluding ICU patients. Data was collected as follows: gender, weight, serum creatinine, indication, duration of therapy and whether trough levels were taken. Each patient's creatinine clearance was calculated using the Cockgroft-Gault equation. Appropriateness of dosing regimen and monitoring was compared with local hospital guidelines.
120 patient records were reviewed. The mean age of patients was 68 (median 71.5 range age 28 -93) and 51.7% were male. The mean creatinine clearance was 63.7 ml/ min (median 59.4 ml/min; range 10-223 ml/min). The indication for amikacin was urosepsis/pyelonephritis in 19.2%, genitourinary infections 16.7%, sepsis 14.2%, hospital/ community onset pneumonia 17.5 %, intra-abdominal 10.8%, neutropenic sepsis 8.3%, and ‘other’ in 8.3%.
32.5% of patients received greater than one dose. Of these patients who had > 1 dose, 10.2% did not have a trough level taken or was taken at an inappropriate time. Initial trough levels were within the recommended range in 87.9% patients.
The initial target dose was charted 15 mg/kg in 57.5% of patients, 10 mg/kg in 30.8% of patients, 4 mg/kg in 5.8% of patients, 2 mg/kg in 2.5%. 2.4% were not prescribed initial weight based doses. Allowing for weight and creatinine clearance the correct dose was prescribed in 78.3% of patients.
In the 2017 audit, amikacin doses were correctly prescribed in 61.5% of patients and 15% did not have trough levels or were taken at an inappropriate time.
This audit showed promising results in amikacin prescribing with the introduction of e-prescribing. E-prescribing is safe in both terms of calculating correct doses and also in terms of therapeutic drug monitoring. It has also highlighted the importance of correct weight documentation on admission, in order that correct initial doses are prescribed in line with protocol.Download #2021052 (645.3 KB)
"A Pair of Non-HIV, Non-Transplant Cryptococcal Meningitis Cases"
Principal Presenter: Eimear McCrohan
Keywords: Cryptococcal Meningitis, Immunosuppression, Non-HIV
Non-HIV, Non-Transplant Cryptococcal Meningitis accounts for a significant burden of Cryptococcal Meningitis cases, with high mortality rates in the developed world. It is a challenging diagnosis to make and often goes unrecognized or has a delayed diagnosis. This translates to worse outcomes in this patient cohort.
We present two cases of Non-HIV, Non-Transplant Cryptococcal Meningitis under our care in Beaumont Hospital in February 2021. We reviewed their clinical notes and investigations and performed a literature review of Non-HIV Cryptococcal Meningitis for the purposes of this case presentation.
Patient A, a 79 year old male presented to ED with a two week history of headache, confusion and falls. Of note, he had no previous history of immunosuppression. CT brain was normal. CSF was CRAG positive and Cryptococcus Neoformans was grown on CSF culture. His HIV test was negative. He was commenced on induction therapy with ambisome and flucytosine. He required frequent therapeutic lumbar punctures and neurosurgical consultation due to persistently raised ICP throughout admission. He was worked up for a diagnosis of sarcoid based on CT Thorax findings of multiple upper lobe predominant nodules and enlarged partially calcified mediastinal nodes with biopsy histology showing non-necrotising granulomas most consistent with sarcoid. After four weeks of induction therapy he started on high dose fluconazole as part of the consolidation phase of treatment.
Patient B, a 51 year male was diagnosed with Non HIV Cryptococcal Meningitis after presenting with extreme fatigue, drowsiness and intermittent headaches over the past year. Unlike Patient A, he had multiple risk factors for immunosuppression including Splenic Lymphoma treated with Rituximab and Bendamustine, Cardiac Sarcoidosis on maintenance steroids, Panhypogammaglobulinaemia and T-cell lymphopenia. After a 12 day ICU admission, he unfortunately passed away due to respiratory failure secondary to Covid Pneumonitis.
Both these cases demonstrate the complexities of managing Non-HIV Cryptococcal Meningitis and the high morbidity and mortality associated with it. Lack of clinical experience, severe co-morbidities, age and irreversibility of immunosuppression are factors which likely contribute to delayed diagnosis in Non-HIV patients. There remains little understanding of the mechanisms of susceptibility for disease in Non-HIV Cryptococcal Meningitis and further immune studies are needed. The current guidelines are heavily weighted towards HIV Cryptococcal Meningitis and further prospective research is needed to identify the hallmarks of Non-HIV cases which would help facilitate early identification and intervention.Download #2021051 (152.9 KB)
"Osteomyelitis of the Skull and Skull Base; a Four Year Retrospective Review in Beaumont Hospital, RCSI Group."
Principal Presenter: Bearach Reynolds
Keywords: Osteomyelitis, Skull base, OPAT
Skull osteomyelitis including Skull Base Osteomyelitis (SBO) is an uncommon but serious condition, associated with significant morbidity for patients. We aim to determine the extent of this condition in our patient cohort and describe its characteristics.
We reviewed the last four years of OPAT data to establish how many cases had been treated by the Infectious Disease Department in Beaumont Hospital.
We identified five cases, fitting into two distinct subgroups of infection. Osteomyelitis associated with surgical intervention and SBO.
There were two patients treated for post-operative skull osteomyelitis. Both of these patients were females between the age of 30-40. These patients presented with signs and symptoms consistent with infection, including pain, erythema and fever. Both patients had a history of oncological surgery with complex skull reconstruction. MRI imaging favoured osteomyelitis however osteonecrosis secondary to radiation was also considered. Critical specimens were available in both cases. One case demonstrated heavy growth of Methicillin Sensitive Staphylococcus Aureus and moderate growth of anaerobes from scalp biopsy. This was treated with prolonged course of ceftriaxone and metronidazole prior to oral switch to flucloxacillin and metronidazole. Hyperbaric oxygen therapy was used as an adjuvant therapy. The second patient cultured MSSA from critical specimens. After surgical re-intervention Pseudomonas Aeruginosa, Staphylococcus Epidermidis and Candida Albicans were isolated with resistance patterns requiring prolonged treatment with meropenem, daptomycin and oral fluconazole.
Three cases of Skull Base Osteomyelitis were identified over the last 4 years. All cases occurred in males over the age of 80. One had a previous history of nasopharyngeal carcinoma treated with chemoradiotherapy. No other patients had documented risk factors for SBO. Two of the cases presented acutely with pyrexia, pain and in one case facial nerve palsy. The other case was detected incidentally on CT brain, performed for worsening mobility. All cases had MRI performed as part of initial investigations. Radiology was only deemed diagnostic in one instance, with the differential in the other cases favouring nasopharyngeal malignancies. This is in keeping with the well documented diagnostic challenge associated with SBO. Critical specimen biopsies were performed in all three cases, with no malignant cells seen. One case grew MSSA and was managed with flucloxacillin. The other two cases had more complicated growth patterns including Pseudomonas and required prolonged OPAT with Piperacillin-Tazobactam. Surgical treatment was not pursued as a treatment strategy in any case.
We identified two subgroups in our Skull Osteomyelitis population. Skull osteomyelitis related to surgery tended to occur in younger patients while SBO tended to present in older males. Critical specimens were available in 100% of cases and were essential in tailoring antimicrobial therapyDownload #2021050 (544.27 KB)
"More than a Bite. The Importance of 16SPCR in the Diagnosis of Culture Negative Infective Endocarditis."
Principal Presenter: Julie-Anne Houlihan
Keywords: Infective endocarditis, Capnocytophaga canimorsus, 16SPCR
A 33 year old male presented to hospital with acute shortness of breath that had gradually worsened over months. A TOE revealed vegetations, severe aortic regurgitation and the patient underwent an urgent mechanical aortic valve replacement. The patient had an episode of illness three months earlier after a bite to his finger from a dog. Blood cultures prior to antibiotics were culture negative. Aortic valve tissue from surgery failed to grow an organism and was sent for 16SPCR which identified an unusual & fastidious organism. Identification of the implicating organism allowed the patient’s antibiotic regimen to be tailored and rationalised as a prolonged treatment course was required.Download #2021049 (155.06 KB)
"COVID-19 vaccine uptake in people living with HIV- a retrospective review of patients attending for outpatient clinic review at the beginning of the COVID-19 national vaccination rollout"
Principal Presenter: Rhea O' Regan
Keywords: vaccine hesitancy, COVID-19, PLWH
The vaccine rollout programme for COVID-19 in Ireland began in January 2021. As per both BHIVA and EACS latest guidelines, PLWH should receive one of the recommended vaccinations available against COVID-19. HSE data indicates that vaccine uptake among the general population is high. We aimed to review the various factors influencing vaccine uptake and hesitancy is a subset of patients attending our HIV clinic service.
We retrospectively reviewed 40 medical records of patients attending the HIV outpatient clinic in Beaumont Hospital in April 2021. We collected information including demographic, ethnicity, occupational and previous COVID infection history from all charts reviewed. Data was analysed using STATA software.
In terms of demographics, 21 (53%) patients were male and 19 (47%) were female. 20 (50%) identied as Black African, 18 (45%) as Caucasian and 2 (5%) as Other. Age range was between 28 and 62 years with mean age being 42 years old.
16 (40%) patients reported being unemployed with 24 (60%) being employed. This included 4 (17%) HCWs.
22 (55%) patients had a documented chronic illness other than HIV. When we looked at HIV infection, the majority of patients were virally suppressed with one patient having a detectable viral load. 37 (93%) patients had a CD4 count of >400cells/uL taken within last six months.
4 (10%) patients reported having experienced previous confirmed COVID infection. Of those, 100% had either received first dose of vaccine or were awaiting appointment. 28 (70%) patients in total were willing to receive or had received 1st dose of available COVID vaccine. 12 (30%) stated they had declined or would decline a vaccination when it was offered. Of those, 7 (58%) had previously declined other vaccinations in our clinic and 9 (75%) were unemployed. 7 (58%) patients were Irish and 5 (48%) were Black African.
Our review demonstrated that vaccine hesitancy is a concern among PLWH attending our clinic. Of those that were unwilling to take an available vaccine, the majority were unemployed, Irish and male. Factors which may impact vaccine hesitancy in these groups include low education level and the influence of social media. Increased focus on patient education and alleviating concerns should be prioritised at outpatient clinic settings in order to overcome this barrier to maintaining high vaccination uptake among vulnerable population groups.Download #2021048 (294.98 KB)
"Dynamic Change and Clinical Relevance of SARS-CoV-2 Antibody Responses"
Principal Presenter: Grace Kenny
Although reports suggest that most individuals with COVID-19 infection develop detectable antibodies post infection, the kinetics, durability, and relative differences between IgM and IgG responses remain poorly understood beyond the first few weeks after symptom onset.
Within a large, well-phenotyped, diverse, prospective cohort of subjects with and without SARS-CoV-2 PCR-confirmed infection and historical controls derived from cohorts with high prevalence of viral coinfections and samples taken during prior flu seasons, we measured SARS-CoV-2 serological responses (both IgG and IgM) using three commercially available assays. We calculated sensitivity and specificity, relationship with disease severity and mapped the kinetics of antibody seropositivity and antibody levels over time using generalised additive models.
We analysed 1,001 samples (327 confirmed SARS-CoV-2, of whom 30% developed severe disease) from 752 subjects spanning a period of 90 days from symptom onset. Overall sensitivity was lower (44.1-47.1%) early (<10 days) after symptom onset but increased to >80% after 10 days. IgM positivity increased earlier than IgG-targeted assay but positivity peaked between day 32 and 38 post onset of symptoms and declined thereafter, a dynamic that was confirmed when antibody levels were analysed and was more rapid with IgM. Early (<10 days) IgM but not IgG levels were significantly higher in those who subsequently developed severe disease (signal / cut-off 4.20 (0.75-17.93) versus 1.07 (0.21-5.46), P=0.048).
This study suggests that post-infectious antibody responses in those with confirmed COVID-19 infection begin to decline relatively early post infection and suggests a potential role for higher IgM levels early in infection predicting subsequent disease severity.
"From Kenya to Connolly: A rare case of P. ovale infection during the COVID Pandemic"
Principal Presenter: Aishah Al Yamahi
P. ovale accounts for between 0.5 and 10.5% of all malaria cases, with geographical distribution in sub-Saharan Africa, the Western Pacific, Timor, and Indonesia. Infections due to P. ovale are likely underestimated compared with those of other Plasmodiumspecies, due to frequently low parasitaemia burden demonstrated on blood film and having morphologic similarities with P.vivax.
P. falciparum is still the leading cause of severe malaria while P. ovale is usually associated with low morbidity and mortality. However, P. ovale can cause severe complications and death.
Previous studies have reported that the severe complications of P.ovale infections include acute respiratory distress syndrome (ARDS), renal impairment, jaundice, and hypotension.
Here, we report the case of a previously healthy 48 year old Caucasian female presenting to a peripheral Dublin hospital in March 2020 with a one week history confusion, severe back pain, oliguria and fever, following travel to Kenya eight months previously.
Initial blood tests demonstrated evidence of severe hemolysis, thrombocytopenia and acute renal failure and patient was immediately transferred to intensive care unit in neighbouring tertiary referral centre for emergency dialysis.
Blood film subsequently revealed schistocytes. Malaria blood smear demonstrated trophozoites of an undifferentiated malaria species with low parasitaemia level. CT scan was significant for multiple liver lesions and splenomegaly in keeping with presumed malarial infection. Patient was commenced on IV artesunate and doxycycline. Thrombotic Thrombocytopenic Purpura or an atypical Haemolytic Uraemic Syndrome were also considered as possible differential diagnoses to account for severe presentation and patient underwent one session of plasma exchange until ADAMSTS level returned normal. Intravenous artesunate treatment was followed by oral artemether/lumefantrine and she was subsequently given fourteen days of primaquine therapy for parasite clearance. Molecular diagnostics carried out at the National Parasitology Reference Laboratory at Public Health England confirmed P. ovale species.
Patient’s renal function slowly improved and she was independent of dialysis on discharge four weeks later.
This case serves as an important reminder to clinicians to take an accurate travel history, even in the midst of a COVID-19 pandemic. It also highlights the need to consider P.ovale species in patients presenting with severe malarial infection. Low level parasitaemia, coupled by poorer sensitivity of RDTs in detecting this species may lead to delay in diagnosis and subsequent treatment of this particular species of infection.Download #2021046 (1.26 MB)
"An unusual case of Kaposi’s Sarcoma driven by Hepatitis B co-infection"
Principal Presenter: Rhea O'Regan
Keywords: Kaposi's Sarcoma, HBV, Oncogenic viruses
Kaposi’s Sarcoma caused by the herpes virus HHV-8 is well described in the literature in the context of advanced HIV co-infection. However, there is a paucity of data relating to co-infection with Hepatitis B and the complex interplay between these two oncogenic viruses.
Here, we describe the case of a 56 year old African gentleman presenting to the Infectious Diseases service with a six year history of worsening lower limb skin changes and associated pain.
Skin biopsies taken with immunohistochemical staining demonstrated CD31, CD34 and HHV-8 and a diagnosis of disseminated Kaposi’s Sarcoma was made. Subsequent viral screen revealed Hepatitis B positive serology. Patient was commenced on chemotherapy with concomitant use of Entecavir to reduce risk of Hepatitis B flare-up.
This case demonstrates a rare yet clinically significant case of non-HIV associated disseminated Kaposi’s Sarcoma and undiagnosed Hepatitis B co-infection in a non-endemic setting. It highlights the need for increased awareness among healthcare providers of non-HIV associated endemic KS and provides an overview of the literature available in treating this disease entity with co-infected Hepatitis B as well as the less well known yet complex interplay between these two oncoviruses.
Download #2021045 (382.55 KB)
"“Time is Brain” Management of Suspected Meningitis In a Tertiary Care University Hospital."
Principal Presenter: Maeve Murphy
Background: Meningitis is a medical emergency with a critical mortality rate which requires immediate intervention. Delay in treatment per hour is associated with a 30% relative increase in mortality.
Aim: The aim of this study was to assess adherence with hospital meningitis management guidelines. A secondary aim was to compare our results with current literature to provide recommendations for optimal compliance and patient outcome.
Methods: A prospective observational study on the management of suspected meningitis was undertaken over four months. Medical notes, imaging, laboratory results and inpatient prescriptions were reviewed against local guidelines. Data was collected and analysed on MS excel in line with GDPR. Indications for lumbar puncture, antimicrobial compliance and timelines for all of the above were recorded.
38 patients underwent LP for suspected meningitis. 51% of patients were male. The mean age (SD) was 40 +/-17 years. The most commonly suspected diagnosis was viral encephalitis (n=35, 92%), bacterial meningitis (21%, n=8) and other infective meningoencephalitides (23%, n=9). 18 patients (47%) had blood cultures taken. 89% of patients (n=34) had neuroimaging (94% CT Brain). 94% (n=32) were performed prior to LP. Abnormal level of consciousness was the most common indication.
The median time to LP was 26.5 hours [Range 30 minutes to 14 days]. The median time to antimicrobial administration was 10 hours [Range 50 minutes to 14 days]. Three patients (7.89%) received antimicrobials within 1 hour of suspected diagnosis. Six patients (15.8%) received dexamethasone simultaneously with antimicrobials. 58% (n=22) of those who underwent LP had antimicrobials prescribed with 76% being prescribed empiric antivirals. 52% (n=20) were prescribed antimicrobials and antivirals concurrently. 59% (n=13) were prescribed according to local guidelines. Of those who had alternate antimicrobials prescribed (41%, n= 9) a diagnosis other than meningitis was considered in 56% (n=6).
Three patients were diagnosed with aseptic meningitis and two patients with viral meningitis. From the data at day 10 post admission, 34% (n=13) were discharged, 34% (n=13) had improved clinically, 5% (n=2) had died and 2.5% (n=1) was diagnosed with multiple sclerosis.
Adherence to hospital guidelines on the management of suspected meningitis can be improved. 8% of patients with suspected meningoencephalitides received antimicrobial treatment within one hour. Interventions will be undertaken to improve adherence to the local guidelines.Download #2021044 (552.74 KB)
"The Durability of Bictegravir/Tenofovir Alafenamide/Emtricitabine Single Tablet Combination in HIV Patients with M184V Mutation"
Principal Presenter: Dr. Joanne Byrne
Keywords: HIV, Anti-Retroviral Therapy, Viral Resistance
Background: The central tenet of HIV antiretroviral therapy(ART) is the enduring efficacy of triple therapy with two nucleot(s)ide reverse transcriptase inhibitor (NRTI) backbone plus either; a non-nucleotide reverse transcriptase inhibitor(NNRTI), a protease inhibitor(PI) or an integrase strand transfer inhibitor(INSTI) to achieve sustained viral suppression. In recent times, dual therapy treatment strategies have been shown to be effective in treatment naïve patients, and for switch of therapy to achieve/maintain viral suppression. The aim of this study is to explore the efficacy of Bictegravir/Emtricitabine/Tenofovir Alafenamide Fumarate (BIC/FTC/TAF), a single tablet regimen in maintaining viral suppression in patients who have a virus with an M184V mutation which confers resistance to lamivudine (3TC) and FTC.
Methods: We conducted an observational, retrospective single centre analysis on patients commenced on BIC/FTC/TAF between January 2019 and January 2021. Patient characteristics including age, sex, viral resistance genotype and reason for ART switch were collected. Electronic patient records were scrutinized for the presence of an M184V mutation. HIV viral load(VL) was noted at the commencement of BIC/FTC/TAF and at 3,6, and 12 months when available for each patient with an M184V mutation. Data was anonymised and collected on Microsoft Excel® 2019. The analysis is descriptive.
Results: In total 242 patients were commenced on BIC/FTC/TAF during this period, 25 of whom have a documented M184V mutation. Of these 25 patients 17(68%) were male with a median age of 53 (range 38-68). Avoidance of drug-drug interactions and simplification of therapy were the main reasons for ART switch. All patients were established on ART at the time of switch, 19(76%) of whom were virally suppressed. Of the six(24%) of patients that were not suppressed at switch, the median VL was 299 copies/ml (range 84-4843 copies/ml), five(83.3%) achieved suppression at six months. Overall viral suppression was proven in 22(84.6%) at 3 months, 16(64%) at 6 months, and 14(56%) at 1 year. Viral escape was seen in 3(12%) patients with M184V mutations at 1 year, all of whom had been suppressed at 6 months and have documented difficulties with compliance to ART.
Conclusion: In conclusion BIC/FTC/TAF appears to be efficacious in maintaining viral suppression and achieving viral suppression in those with suppressed or unsuppressed HIV virus at time of its commencement in patients with an M184V mutation. The study is limited by its small sample size.Download #2021043 (150.79 KB)
"Does severity of liver disease affect quality-of-life in patients living with Hepatitis C? Baseline results from the TRACER study."
Principal Presenter: Therese Herlihy
Keywords: liver stiffness, fibrosis, health status indicators
Health-related quality-of-life (QoL) can be used to assess the impact of chronic disease on patients' health and wellbeing. Liver stiffness measurements (LSM) are used as a marker for liver health and correlate with METAVIR fibrosis staging. This analysis aimed to describe the QoL of patients living with chronic hepatitis C (HCV) and to investigate whether liver disease severity as indicated by LSM is associated with decreased QoL.
Individuals recruited to the Chronic Hepatitis C Treatment Radiographic and Clinical Outcomes (TRACER) study had LSM acquired with FibroScan and completed the SF‐36 Health Survey V2 which assesses health on eight domains used to calculate a Physical Component Summary score (PCS; physical functioning (PF), physical role (PR), bodily pain (BP), general health (GH)) and Mental Component Summary score (MCS; vitality (VT), emotional role (ER), social functioning (SF), and mental health (MH)). Patients were grouped into three fibrosis stages (F0/F1:<8.5kPa, F2/F3: 8.5-12.5kPa and F4:>14.5kPa). QoL scores for each indicator ranged from zero (worst health) to 100 (best health) and were scaled relative to those of the United States population (mean=50 [standard-deviation = 10]).
94.3% (83/88) of patients recruited to the study had a LSM; 73.5% male, with a mean age of 47 (IQR 40, 54). Of those, 41.0%, 24.1% and 34.9% were in fibrosis stages F0/F1, F2/F3 and F4, respectively. Overall, patients scored lower in all domains (PF: 47.8 [10.5], RP: 45.5 [11.8], GH: 45.6 [11.1], VT: 47.0 [11.3], SF: 47.2 [11.8], RE: 42.0 [13.9], MH: 44.4 [10.6]) when compared to the reference population. Summary PSC score was similar to the reference population (49.5 [10.5]), but mean MCS score was significantly lower compared to the reference population (43.5 [12.7]). When stratifying summary scores by fibrosis stage, PCS score was higher in the F0/F1 and F2/F3 group compared to the F4 group (F0/F1: 52.8[8.9], F2/F3:51.3[10.1], F4:44.2[10.8]). In contrast, individuals in all fibrosis stages had a low MCS score (F0/F1: 44.4[14.2], F2/F3:43.5[11.7], F4:42.0[11.4]).
In a cohort of people with HCV, lower mental health scores were reported while physical health scores were similar to the reference population. As liver disease severity increased, patients' QoL decreased. We advocate that mental health supports should be an integrated care component for HCV patients.Download #2021042 (320.02 KB)
"Pasturella Multocida Cervical Discitis with Spinal Cord Compression"
Principal Presenter: Caroline Kehoe
Keywords: Pasturella, multocida, spine
Pasturella multocida is a gram negative, anaerobic coccobacilli commonly found in the oropharynx of healthy cats and dogs. Pasturella infection in humans is almost always associated with an animal bite or scratch, although cases where no animal contact had occurred have also been described.
A 51-year-old female presented to the Emergency Department with a 2-week history of progressive loss of power in her lower limbs bilaterally and increasing paraesthesia of her left upper limb. She reported neck pain, profuse sweating, constipation, intermittent difficulty with urination and peri genital numbness. On arrival to the emergency department she was vitally stable and apyrexic. On examination, the patient was tender over C7 on posterior palpation of the neck and was found to have gross neurological abnormalities including; decreased power and altered sensation in upper limbs bilaterally, right-sided hyper-reflexia, Babinski positive bilaterally and a new-onset heel-to-toe gait. She underwent an MRI C-Spine, demonstrating discitis at C6-C7 with white signal change to the vertebral bodies of C6 and C7.
The patient underwent several sets of blood cultures, all of which were negative for bacterial growth. Given the extent of cord compression identified, she underwent discectomy at C6-7 and corpectomy at C5-6 with metalwork sited for stability. Bone, disc and exudate samples were sent from theatre for culture and sensitivity, all of which were positive for a penicillin-sensitive Pasturella Multocida.
Discitis and vertebral osteomyelitis due to Pasturella Multocida infection, appears to have been first described in 1979 by Byrne et al with few reports since . Antibiotic resistance is less of an issue than with other bacterial species, with Pasturella typically sensitive to penicillin. Of note, there has been reports of beta-lactamase-producing isolates, and so empiric treatment with combination drugs, such as amoxicillin/clavulanic, is recommended .
1. Byrne, F., Thrall, T. and Wheat, L., 1979. Hematogenous vertebral osteomyelitis. Pasteurella multocida as the causative agent. Archives of Internal Medicine, 139(10), pp.1182-1183.
2. Christenson, E., Ahmed, H. and Durand, C., 2015. Pasteurella multocida infection in solid organ transplantation. The Lancet Infectious Diseases, 15(2), pp.235-240.Download #2021041 (844.17 KB)
"A comparison of Transient Elastography (TE) with Acoustic Radiation Force Impulse Elastography (ARFI) for the assessment of liver health in patients with Chronic Hepatitis C; baseline results from the TRACER study."
Principal Presenter: Therese Herlihy
Keywords: liver stiffness, fibrosis, ultrasound
Liver stiffness measurements (LSM) are widely used as a marker for liver health and correlate strongly with METAVIR fibrosis staging. LSM can be acquired with TE using a FibroScan machine and can also be acquired with ARFI imaging which is used with conventional B-mode ultrasound. ARFI measurements can be acquired at different liver locations and is less limited by patient size. The aim of this analysis was to describe LSM scores using FibroScan and ARFI in a cohort of people with chronic hepatitis C and to explore how the scores correlated and what factors influenced this correlation.
Individuals recruited to the Chronic Hepatitis C Treatment Radiographic and Clinical Outcomes (TRACER) study had LSM acquired with FibroScan and ARFI at their baseline visit. Spearman’s correlation test was performed in order to identify the correlation between FibroScan and ARFI measurements and a Bland-Altman plot was used to evaluate bias between the mean differences of the ARFI and FibroScan scores. Univariable and multivariable analysis were used to assess the influence of factors such as BMI, APRI score and FIB 4 score on the correlation between LSMs.
88 patients were recruited to the study; 72.7% male with a median age of 47 (IQR 41, 53.5). We achieved ARFI scores in all patients and FibroScan® scores in 94.3% (83/88). FibroScan scores showed 38.6%, 18.2%, 3.4% and 34.1% were in fibrosis stages F0/F1, F2, F3 and F4 respectively and ARFI scores were converted to KPa and showed 36.4%, 14.8%, 5.7% and 43.2% were in fibrosis stages F0/F1, F2, F3, F4 respectively. The five patients where we only achieved ARFI scores all measured in the F4 category. Overall, there was good correlation between the FibroScan and ARFI scores r (95% CI) of 0.87 (0.80, 0.91) – p<0.001. Average (95% CI) difference between the two scores was 1.65 (-0.34, 3.64) kPa, p=0.10. Multivariable analysis showed BMI as the biggest influencing factor on differences between ARFI and FibroScan scores; every 5kg BMI increase BMI led to higher disagreement between scores (r= 0.12 [0.01, 0.23], p=0.05).
ARFI had similar predictive value to FibroScan for the non-invasive assessment of liver fibrosis. BMI adversely affected readings and BMI increases caused greater disagreement between FibroScan and ARFI scores. We suggest that ARFI is more widely adopted in clinical use, especially for patients with raised BMI.Download #2021040 (347.08 KB)
"Weight Changes Associated with Initiation of Bictegravir/Emtricitabine/Tenofovir Alafenamide Fumarate"
Principal Presenter: Dr. Joanne Byrne
Keywords: HIV, Anti-Retroviral Therapy, Integrase Inhibitor
Weight gain and obesity disproportionately affect people living with HIV (PLWH). Antiretroviral therapy (ART) may contribute to this. There is increasing evidence that integrase strand transfer inhibitors (INSTI) are associated with more weight gain than other classes of antiretrovirals. In 2018, the FDA approved a single tablet regimen - Bictegravir/Emtricitabine/Tenofovir Alafenamide Fumarate (BIC/FTC/TAF) containing the second generation INSTI Bictegravir. The primary aim of this study was to evaluate weight changes over 1 year following commencement of BIC/FTC/TAF in treatment naïve and experienced PLWH. The secondary aim was to compare weight changes by gender and evaluate changes in lipid profiles and HBA1C.
We conducted an observational, retrospective single centre analysis on PLWH who commenced BIC/FTC/TAF within the calendar year 2019. Patients with weight recorded prior to commencing BIC/FTC/TAF and at 6 months and/or 12 months afterwards were eligible for the study. Weight, lipids and HBA1C were recorded at 0 and 12 months along with each patient’s demographic and clinical data. A Wilcoxin signed rank test was used to analyse weight changes at 6 and 12 months.
242 patients were commenced on BIC/FTC/TAF over this time period. 67 patients were eligible for the study. 45 patients had a weight recorded at 0 and 6 months, 34 had a weight recorded at 0 and 12 months and 12 patients had a weight recorded at 0, 6 and 12 months. 46 (68.7%) patients were male and 21 (31.3%) patients were female. 5 patients were ART-naïve, 1 patient restarted ART and 61 patients switched therapy. 40 patients had a non-detectable viral load and 27 patients had a detectable viral load at initiation. The median weight was higher at 6 months: 74.4kg (55.4; 133.5) to 77.2kg (56.5; 132) p0.00002 and 12 months: 82.5kg (58.4; 126) to 87.3kg (55.2; 129), p0.032. Female patients were associated with a higher median weight gain of 3.8kg (+1.9; +11.8kg) at 12 months compared to male patients with a median weight gain of 1.7kg (-13.5; +19.4kg) at 12 months. No significant change was noted in lipid profiles or HBA1c from 0 to 12 months.
Commencement of BIC/FTC/TAF resulted in a significant median weight gain at 6 and 12 months, with increased weight gain noted in female patients. There was no significant impact on lipid profile or HBA1c. Although INSTI based regimens are highly efficacious, they appear to cause more weight gain than other regimens. Further research is needed to explore the pathogenesis and associated factors of weight gain in order to individualise therapy.Download #2021039 (315.11 KB)
"Modified Point Prevalence Study of Antifungal use Among Children"
Principal Presenter: Aisha Alkhaaldi
Keywords: antifungals, paediatrics, immunocompromised
Background: The incidence of invasive fungal infections (IFI) in adult and paediatric patients have increased, particularly among immunocompromised patients with mortality ranging from 30-40% for yeast infections and up to 70% for mold infections. Antifungals are treated as “Restricted agents” within Children’s Health Ireland (CHI) but frequently used as part of haematology, oncology and cystic fibrosis protocols. There is currently no formal Antifungal Stewardship (AFS) Program established. Our primary objectives were to record the prevalence and pattern of anti-fungal prescribing, to document the indications for use, to record therapeutic drug monitoring (TDM) levels and to note drug interactions where clinically significant.
Methods: Prospective, modified single-day point prevalence study (mPPS) of antifungal use over 12 consecutive weeks (July 2020 and October 2020). This data was collected as part of a submission to a European-wide study (CALYPSO) across 23 paediatric/neonatal sites. All inpatients <18 years present at 8 a.m. on the day of survey who were receiving systemic antifungal agents were included. Patient data was recorded, anonymised and entered into a study-specific online portal (REDCap) in adherence to GDPR requirements Each patient was followed-up weekly and the status of the prescription recorded.
Results: 38 patients were included in the study; 60.5% male (n= 23), 39.5% female (n=15). During the 12 weeks, the overall rate of antifungal use in CHI was 6.7%. The main underlying condition recorded was cancer (63%, n= 24), 5 of which were post bone-marrow transplant.
A total of 56 antifungal prescriptions were recorded; 64.3% (n= 36) recorded as prophylaxis and 35.7% (n=20)as treatment. Liposomal Amphotericin B accounted for 41% of prescriptions, fluconazole 28.6%, voriconazole 14.3%, posaconazole 8.9%, and caspofungin and itraconazole 3.6% each. At the end of the study period, 86.7% of the prescriptions were ongoing for prophylaxis or completion of treatment.
Conclusion: Antifungal prescribing was appropriately focused on high-risk paediatric patients. It is recognizedthat there is a significant cost associated with liposomal amphotericin B (AmBisome®). Its use as a prophylactic agent in low risk haematology/oncology patients is an area for future discussion. The establishment of a multi-disciplinary Antifungal Stewardship program offers increased oversight of how antifungal agents are prescribed, reducing in appropriate use and maximizing clinical benefits while minimizingside-effects. An effective AFS program offers significant cost-savings, in particular with AmBisome®.Download #2021038 (678.36 KB)
"Castleman’s Disease- Incidental or Instrumental?"
Principal Presenter: Eibhlin Higgins
Keywords: prosthetic joint infection, ortho ID
Castleman’s Disease- Incidental or Instrumental?
Higgins, E.1, Gallagher, D.1, Holmes, A.1, Tuite, H.1, Fleming, C.1
1. Department of Infectious Diseases, Galway University Hospital
Castleman’s Disease refers to a group of lymphoproliferative disorders which share a series of histopathological features but have varying aetiologies, clinical features and outcomes1. It may be classified as unicentric or multicentric depending or whether a single or multiple lymph node regions are involved. Castleman’s disease in association with HHV-8 is well described. The pathogenesis of HHV-8 negative Castleman’s disease is poorly understood and there are no known infective precipitants.
A 54 year old man was referred to outpatient clinic 12 months post revision of a left total hip replacement. He reported left hip pain and had bulky left inguinal adenopathy on examination. His C reactive protein was mildly elevated at 23.8. An aspirate of the hip was culture negative. 16s PCR (polymerase chain reaction) as well as specific staphylococcal and streptococcal PCR were negative but mecA gene was detected in the sample. He underwent a further aspirate which again was culture negative and all PCR testing was negative. In the absence of definitive evidence of prosthetic joint infection he proceeded to undergo a lymph node biopsy. This demonstrated changes consistent with HHV-8 negative, plasma cell variant Castleman’s.
The patient was subsequently reviewed by haematology and commenced on siltuximab- a chimeric monoclonal antibody which binds to interleukin-6. Despite treatment, the patient developed worsening left hip pain and was admitted for further evaluation.
HHV-8 negative unicentric Castleman’s is a rare entity and there are no published case reports of it presenting post operatively. Its pathogenesis is not known to have an infective trigger. This gentleman has histopathological findings consistent with Castleman’s but persistent symptoms despite treatment and imaging findings concerning for prosthetic joint infection of his left hip.
1. Dispenzieri A, Fajgenbaum DC. Overview of Castleman disease. Blood. 2020;135(16):1353-1364. doi:10.1182/blood.2019000931Download #2021037 (1.44 MB)
"A quality improvement initiative for peripheral vascular catheter related infections"
Principal Presenter: David Moynan
Keywords: healthcare associated infection, peripheral cannula, Staphylococcus aureus
Hospital associated infections (HAI) contribute significant morbidity and mortality. The European Centre for Disease Prevention and Control’s point prevalence survey in 2017 placed Ireland’s prevalence of HAI above the European average. Furthermore, Ireland ranked 4th in Europe for hospital acquired bloodstream infections, 25% of which were vascular catheter related (1). At our institution, rates of peripheral line associated Staphylococcus aureus bacteraemia are increasing. A quality improvement project was established to identify potential causes, determine healthcare worker (HCW) attitudes to potential interventions and increase the awareness of peripheral vascular catheter (PVC) infections among hospital staff.
This project was selected as part of the Saolta hospital group’s quality improvement initiative. A point prevalence study was performed to identify the status of PVCs among hospitalised patients including age, indication and compliance with current guidance on care. In tandem, an anonymous survey was disseminated among staff to evaluate attitudes towards PVC care, familiarity with PVC infections and whether or not there was agreement towards a policy change for their routine removal at 72 hours. Teaching sessions were targeted at interns and senior house officers (SHO).
The point prevalence survey examined 85 inpatients from three acute medical and surgical wards. 65% (58/85) had a PVC in situ, of whom 69% (40/58) had a PVC care bundle that was reviewed twice daily. 23% (14/58) of those with a PVC were on no intravenous medication. The median age of the PVC was 2 days (range 1 – 8 days). Data from the HCW survey was collected from 116 members of staff, including interns, SHOs, registrars and nurses. 80% (93/116) reported having previously encountered a PVC infection, though 53% reported they never/rarely examined their patients’ PVCs. 60% of HCWs surveyed were not in agreement with the introduction of a policy for the routine removal of PVC at 72 hours, though HCW buy in for such a policy increased significantly if concessions for those with difficult vascular access could be implemented concurrently.
This project highlights a lack of awareness in PVC care, particularly among medical staff. The majority of HCWs surveyed do not routinely examine their patients’ PVCs and many remain in situ when no longer clinically indicated. A change in current practice to a policy for the routine removal at 72 hours was not favoured by the majority of HCWs surveyed. These results highlight the importance of identifying key stakeholders in any quality improvement initiative to ensure buy-in is achievable.
1. Murchan S, Murphy H, Burns K. Point Prevalence Survey of Hospital-Acquired Infections and Antimicrobial Use in European Acute Care Hospitals: May 2017.; 2017. www.hpsc.ie.Download #2021036 (1.06 MB)
"The Mater Hospital’s Post-COVID Clinic: a Service Evaluation"
Principal Presenter: Aoife Heeney
The long-term effects of SARS-CoV-2 infection and optimal approach for following up patients are not well-recognised. The Mater Misericordiae University Hospital, Dublin established a post-COVID clinic after the first wave of the pandemic. The purpose of the clinic was to screen for long-term effects of SARS-CoV-2 infection, provide necessary medical care, and improve access to the multidisciplinary team. This study describes the characteristics of our patient cohort and the operations and outcomes of the clinic.
All SARS-CoV-2 patients who tested positive between March 10th and June 14th 2020 were telephone-triaged as red, amber or green based on ongoing symptoms and a clinic appointment was scheduled according. All visits were face-to-face with a member of the infectious diseases medical team. Data was collected retrospectively and included data on demographics, severity of initial illness, clinical status at time of clinic visit, and follow up appointments. A descriptive analysis on patients who attended the clinic was performed.
311 patients attended the post-COVID clinic. The median time from illness to clinic appointment was 95 days (IQR 77-105.5). 204 patients (66%) were female, 192 (62%) were hospital staff, and the median age was 43 years (IQR 31-53). 138 patients (44%) had required hospital admission with a median length of admission of 6 days (IQR 2-10). 12% of these patients (N=17) required critical care admission, 69 patients in our cohort (22%) required oxygen therapy.
At their first clinic visit 219 patients (70%) had ongoing symptoms. A further visit was required for 62 patients (20%) and 34 patients (11%) were discussed at a COVID MDT meeting. 55 patients (18%) required onward referral to another specialist service. 231 patients (74%) did not require any form of follow up.
85% of those triaged as green and 73% triaged as amber did not require further follow up after one clinic visit. 61% of those triaged as red required further post-COVID clinic follow up, specialist referral or discussion at a COVID MDT meeting.
The long-term effects of COVID-19 are significant with 70% of our cohort experiencing ongoing symptoms at time of first clinic visit. This study suggests that a traffic light telephone-triage service followed by a face-to-face medical-led clinic is an effective way of identifying patients who require further management.
"Persistent COVID-19 Pneumonia in a Patient on Long-term Rituximab Therapy"
Principal Presenter: Aoife Heeney
Keywords: COVID, PNEUMONIA, RITUXIMAB
The viral dynamics and clinical course of SARS-CoV-2 infection in patients previously treated with immunomodulatory therapies remain unclear. We describe an unusual case of persistent COVID-19 pneumonia in a patient who had received prolonged rituximab therapy.
The medical record relating to the patient’s hospital admission was reviewed. This was followed by a systematic literature review of COVID-19 in the context of rituximab therapy.
A 59-year-old woman presented in February 2021 with a 2-week history of fevers. She had been diagnosed with COVID-19 a month previously and had experienced mild upper respiratory tract symptoms for 1 week. Her medical history was significant for low grade B-cell lymphoma diagnosed in 2016 for which she received 2 monthly rituximab infusions for the past 2 years. The last dose of rituximab was given 1 month prior to acquisition of SARS-CoV-2.
On admission she had a positive nasopharyngeal swab (NPS) for SARS-CoV-2 with a high cycle threshold (Ct) of 36.6. Based on this she was deemed non-infectious and was not isolated.
She was investigated as a pyrexia of unknown origin. CT imaging showed bilateral pneumonitis consistent with known recent COVID-19. All other investigations for infection, connective tissue disease, and malignancy were negative. Multiple repeat NPS for SARS-CoV-2 were negative. She did have hypogammaglobulinemia with decreased IgG, IgA, and IgM.
PET-CT showed ground-glass attenuation in both lungs which was more extensive than previous imaging, reflecting active pneumonitis. A bronchoscopy was performed and bronchoalveolar lavage fluid was positive for SARS-CoV-2 with a Ct value of 28.7 suggesting possible active viral replication.
The patient’s pyrexia was attributed to persistent SARS-CoV-2 infection in the lower respiratory tract. She defervesced after 8 weeks of high-grade fevers and 10 weeks following her diagnosis of COVID-19. At week 10 she had no antibodies detectable to either SARS-CoV-2 spike or nucleocapsid proteins.
Patients undergoing rituximab therapy are at risk of prolonged SARS-CoV-2 shedding due to B-cell depletion. This can lead to delayed, atypical or prolonged symptoms creating diagnostic challenges as seen in this case. It is less clear whether this may also prolong infectivity, raising difficult infection control questions. B-cell depletion also decreases formation of protective antibodies leading to increased risk of reinfection and possible impaired vaccination response.Download #2021034 (316.14 KB)
"A Family Affair: The Role of Whole Genome Sequencing in the Investigation of a Fatal MRSA Infection"
Principal Presenter: Aia Mohamed
Keywords: MRSA, Infection Control, Whole Genome Sequencing
We would like to present the case of an outbreak investigation into a family cluster of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA).
Initially, an 80 year old gentleman presented secondary to a fall and intracranial haemorrhage [Index patient]. He subsequently developed an MRSA bloodstream infection secondary to a necrotising pneumonia and multi-organ failure which led to an ICU admission and subsequent death.
The initial clinical impression at the time was that the MRSA infection was hospital acquired as admission MRSA screens were negative
An outbreak committee was formed and an investigation was performed to determine the risk of MRSA infection amongst patients and to determine if the source of infection could be identified.
MRSA screening was performed for other patients, staff members and household contacts. Further whole genome sequencing of the MRSA isolate [Index case] noted pvl+ spa type t127 type V on national MRSA data base. A similar MRSA strain was isolated from 2 direct family contacts.
Interestingly, the index patient’s wife and daughter developed multiple invasive MRSA infections including an empyema, and multiple skin and soft tissue infections including gluteal abscesses, vulval abscess, axillary abscess and breast abscesses.
Staphylococcus aureus is still a leading cause of hospital-acquired and community-associated infection worldwide. The burden of disease is exacerbated by the emergence of virulent strains with reduced susceptibility to commonly used antibiotics and their dissemination in healthcare settings and in the community.
Furthermore, community-associated MRSA is now displacing previously dominant health-care-associated MRSA lineages. One implication of the blurring between health-care-associated and community-associated MRSA is that for the purpose of understanding the transmission dynamics of MRSA, hospitals and the community should no longer be regarded as separate entities.
In our outbreak investigation, it was the use of whole genome sequencing [WGS] that allowed confirmation the MRSA carriage by family members had been implicated in the transmission to our index patient as opposed to hospital related transmission.
Whole-genome sequencing is crucial for rapid, accurate, and comprehensive identification of bacterial transmission pathways in hospital and community settings, with concomitant reductions in infections, morbidity, and costs.
"Malignancies in HIV Infection: A 5 Year Retrospective Analysis"
Principal Presenter: Rachel Dillon
People with HIV (PWH) have a greater risk of malignancies compared to the general population. Malignancies are now a leading cause of death with national data regarding diagnoses and outcomes limited. In this study, we identify PWH presenting to a large Dublin University hospital with an underlying malignancy in the last 5 years and assess population demographics, malignancy type, outcomes and predictors of mortality.
Using discharge coded HIPE data, we identified PWH with an underlying malignancy admitted to the Mater Misericordiae University Hospital (day-ward and long-stay) from January 2015 to September 2020. Electronic records were used to assess patient demographics and malignancy data in addition to HIV treatment history and immunological data. Between group differences were assessed using Mann-Whitney U and Chi-Square tests, while logistic regression was used to assess predictors of mortality. Data are median (IQR) unless stated.
Over 5 years, there were 1362 admissions of PWH to MMUH, comprising 568 individuals. 41 (7.2%) had an underlying malignancy; 58.5% female, 46 (39,54) years of age, 80.5% Caucasian, 65.9% smokers and 48.8% had a history of intravenous drug use (IVDU). 48.6% had a detectable HIV viremia at diagnosis with median CD4 count of 205 (140,657) cells/ml and CD4+CD8+ ratio 0.37 (0.17,0.76). 63.4% of malignancies in our group were non-AIDS defining cancers, however the most frequent cancers were Kaposi Sarcoma (17%) and Non-Hodgkin’s lymphoma/leukemia (17%). Most presented at an advanced stage of cancer with 17% stage 3 and 51.2% stage 4. 19 patients (46.3%) have since died. Those who died were more likely older [47 (45,56) versus 40 (37,48) years, p=0.031], Caucasian [18 (94.7%) versus 15 (68.2%), p=0.032] and IVDU [13 (68.4%) versus 7 (31.8%), p=0.047]. There was no significant difference between malignancy stage, CD4 count, CD4/CD8 ratio and viral load between the groups. On regression analysis, older age [OR 1.07 (95%CI 1.0,1.1)] and a history of IVDU [OR 3.8 (95%CI 1.0,14.5)] were significantly associated with cancer death.
7.2% of PWH presenting to MMUH had an underlying malignancy diagnosis with 46.3% deceased at the time of study censure. 68.2% presented at an advanced stage of their diagnosis with older age and IVDU significant predictors of mortality. Further studies are needed to assess benefit of targeted screening programmes in this vulnerable population to reduce malignancy morbidity and mortality.
"SARS-CoV-2 lineage B.1.1.7 in Ireland: December 2020 to April 2021"
Principal Presenter: Ciara Conlan
Ireland experienced a significant surge in SARS-CoV-2 activity in January 2021, with case numbers peaking at around 8,000 cases per day in week 1 of 2021. This surge appeared to coincide with the arrival in Ireland of the SARS-CoV-2 variant of concern, lineage B.1.1.7, first reported by the United Kingdom in December 2020.
The ThermoFisher TaqPath (TFTP) RT-PCR COVID-19 assay targets three regions of the coronavirus genome: orf-1ab, and the genes for the S (spike) and N (nucleocapsid) proteins. Due to a deletion at position 69/70 in the S protein, lineage B.1.1.7 shows a distinct profile on this assay. This presents as S-gene target failure (SGTF), while the other two targets report as detected. While this profile is not exclusive to B.1.1.7, it is the most prevalent human lineage with this deletion.
We reviewed data from all samples tested on the TFTP assay at the National Virus Reference Laboratory between November 2020 and April 2021. We collated: the number of samples tested; the number of samples in which SARS-CoV-2 RNA was detected; and of those, the proportion per week demonstrating SGTF. These data were used to extrapolate the real-time spread of the B.1.1.7 variant throughout Ireland, with findings confirmed by whole genome sequencing.
The first SGTF in Ireland was detected in week 45 of 2020, and accounted for 2% of RNA detected cases, albeit by retrospective analysis, and with a small sample size. By week 51, 7.5% of RNA detected samples exhibited SGTF, increasing thereafter to 16% in week 52, 26% in week 53, 46% in week 1 2021, 58% in week 2, 70% in week 3 (January 18-24), and peaking at 96% in week 8 (February 22-28). Of note, the growth rate was consistent with the increased transmissibility of lineage B.1.1.7 reported in the UK.
SARS-CoV-2 lineage B.1.1.7 rapidly became the dominant SARS-CoV-2 lineage in Ireland in January 2021. This was apparent in real time due to its profile on the TFTP assay. However, given the disconnect between the peak in SARS-CoV-2 case numbers (week 1) and the peak in the prevalence of lineage B.1.1.7 (week 8), these data suggest that lineage B.1.1.7 was not solely responsible for the post-Christmas surge in SARS-CoV-2 activity.
"Persistence of SARS-CoV-2 IgG in Healthcare workers (HCWs) diagnosed with COVID-19 in the first wave of the pandemic"
Principal Presenter: Aimee McGreal-Bellone
Keywords: SARS-CoV-2, Antibodies, anti-nucleocapsid IgG
Introduction: Duration and protection afforded by the humoral immune response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains to be determined. The aim of this study was to investigate persistence of SARS-CoV-2 IgG in HCWs >6 months following reverse transcriptase polymerase chain reaction (RT-PCR) confirmed COVID-19 infection.
Methods: A single-centre, prospective cohort study was undertaken in Cork University Hospital. HCWs who had previously tested positive for SARS-CoV-2 by RT-PCR had serum tested for SARS-CoV-2 IgG using the Abbott anti-nucleocapsid IgG CMIA assay at baseline and at >6 months following enrolment.
Results: Of 99 HCWs (age range 20-65 years (IQR 30-47 years), 76% female, 43% nursing, 18% medical) who had SARS-CoV-2 RNA detected on nasopharyngeal swab during the first wave, 72 (73%) had SARS-CoV-2 IgG seropositivity at baseline. 86 of 99 HCWs (age range 20-65 years, 80% female, 14% medical, 46% nursing) attended for interval testing at >6 months. 54 (63%) demonstrated persistence of SARS-CoV-2 IgG at >6 months.
Conclusion: Almost 10% of HCWs became seronegative for SARS-CoV-2 at >6 months post enrolment. Further work is underway to measure neutralising antibody titres in this cohort. The clinical significance of these findings, in relation to immunity and protection, remains to be determined.Download #2021030 (114.04 KB)
"CantBeatALactam – De-Labelling Self-Reported Penicillin Allergy – a Quality Improvement Initiative"
Principal Presenter: Ksenia Davenport
Background: Penicillin allergy is the most commonly reported drug allergy with up to 15-20% of hospitalised patients self-identifying as penicillin allergic. A significant proportion of the reported reactions, however, represent drug side-effects or manifestations of underlying disease as opposed to genuine allergy. Differentiation between true and perceived antimicrobial allergies, and integration of antimicrobial allergy de-labelling into clinical stewardship practice have been shown to reduce the use of broad-spectrum antimicrobials and development of antimicrobial resistance, improve patient safety and treatment outcomes, as well as decrease hospital length of stay and overall healthcare cost. In this project, we set out to de-label two thirds of the medically admitted patients in Galway University Hospital self-identifying as penicillin allergic by July 2021 by integrating allergy evaluation into the routine hospital admission process.
Methods: Patient-reported penicillin allergies were critically evaluated by a multidisciplinary team incorporating medical, nursing and pharmacy specialists. Appropriate de-labelling strategies, including direct oral challenge and skin testing, were applied after careful history acquisition and risk stratification acknowledging patients’ co-morbidities and clinical need for antimicrobials. Penicillin allergy was reinforced when necessary, and recommendations pertaining to future cephalosporin use were given whenever possible.
Results: In the 6 months of its operation this Quality Improvement initiative identified 125 patients self-reporting a penicillin allergy. Of these, 44 (35%) patients were de-labelled based on history alone, 12 (10%) patients were deemed suitable for a direct oral challenge (negative for 7 patients, not undertaken by primary team for 5 patients), and 17 (14%) patients were referred for skin testing (2 completed and negative including an oral challenge). Penicillin allergy was reinforced in 24 (19%) patients due to delayed reaction (n=13), old age/co-morbidities (n=10) and recent anaphylaxis (n=1). Additional 6 (5%) patients refused input, and 22 (18%) patients were not seen as they were discharged prior to assessment (n=21) or deemed unsuitable for interviewing (n=1).
Conclusions: A total of 53 out of 125 assessed patients (42%) self-reporting a penicillin allergy were successfully de-labelled after critical multidisciplinary evaluation demonstrating feasibility of such initiatives in the hospital setting. Through pro-active detailed history taking and careful risk stratification of allergy-reporting patients, all healthcare providers can play a major role in reducing adverse health outcomes, improving antimicrobial stewardship and decreasing healthcare cost in this population.
"The Impact of SARS-CoV-2 on Emergency Presentations and Admissions among Older Patients"
Principal Presenter: Fergal Howley
The outbreak of Acute Respiratory Syndrome Coronavirus 2 (Covid-19) in Ireland prompted significant changes in the provision of healthcare. Suspension of outpatient and day-hospital services, coupled with public health advising elderly people to ‘cocoon’, may have reduced exposure to Covid-19 among this vulnerable cohort, but left many prone to other medical conditions.
This study analyses trends in presentations to an Irish teaching hospital’s emergency department (ED) among elderly patients, commencing with the initial outbreak of Covid-19, compared with previous years. We wished to analyse the impact of lockdown on presentations and admissions among elderly patients, and whether there was a subsequent ‘rebound’ in presentations as restrictions were lifted. We also assessed the impact of the Covid-19 outbreak and lockdown measures on the types of presentations to ED, and the average triage category among this cohort (as a surrogate marker of severity/acuity of illness).
All patients aged >70 years presenting to the ED of an Irish teaching hospital from March-August 2020, 2019 and 2018 inclusive were reviewed retrospectively. Data regarding number of presentations each month, demographics, Manchester Triage Score, presenting complaint, and admission decision were collated. Data were analysed using Stata version 14.1 (Stata®, College Station, TX).
From March-August 2020 there was a 16% reduction in acute presentations among >70 year-olds compared to the 2018/2019 average (4,146 vs 4,922). Much of this reduction was concentrated in late March/April, the initial period of ‘lockdown’, with a 35% reduction in presentations per day throughout March. As restrictions eased, a 2% increase in presentations was noted for June 2020 compared to the 2018/2019 average. Respiratory presentations were down 8% overall (701 vs 769), and there was a marked reduction in stroke/cardiac presentations in the 2020 cohort. An initial decline in presentations with delirium, orthopaedic injuries and falls was followed by a rise when elderly people were advised they could leave their house again in June. Older patients presenting from March-August 2020 were more likely to be admitted compared to 2018/2019 (57% vs 55%, p=0.022). This occurred despite a lower mean triage category for the 2020 cohort.
Presentations to ED among elderly patients declined during the first 6 months of the Covid-19 outbreak in Ireland compared to previous years. Total admissions were also reduced, though the mean admission rate increased slightly. Presentations increased slightly following easing of restrictions, with marked increases in presentations with falls, delirium and orthopaedic problems. This data should inform the distribution of resources across healthcare services in the case of future lockdowns and healthcare crises.
"A 9 Year Retrospective Review of Candida Blood-stream Infections in a Large Model 4 Hospital"
Principal Presenter: Dr. Joanne Byrne
Candida blood-stream infections (CBSI) are the most common invasive fungal infection amongst hospitalised patients and are associated with significant morbidity and mortality. The increased use of intravascular catheters, expansion of elderly population, widespread use of immunosuppressive therapy, broad-spectrum antibiotics, and antifungal prophylaxis have all had a leading role in the changing epidemiology of CBSI. Furthermore, a change in Candida species distribution has been seen globally with a shift towards non-albicans species. The IDSA and ESCMID have published guidelines on the management of CBSI. In 2018, the ECMM developed the Candida EQUAL score which weighs and aggregates factors recommended for the ideal management of CBSI and provides a tool for antifungal stewardship as well as for measuring guideline adherence.
A 9 year retrospective audit was performed which included all Candida bloodstream infections in St. James’s Hospital from 2012-2020. Our aim was to review the epidemiology, diagnosis, management and outcome of candidaemia and assess compliance with the ESCMID and IDSA guidelines utilising the Candida EQUAL score which comprises of 10 quality indicators. The data collected included patient demographics, epidemiology (Candida species and susceptibility results), management and outcome.
246 episodes of Candida bloodstream infections in 228 patients were reported over the time period 2012-2020. 7 patients had multiple episodes of CBSI. The median age of the patients was 66.5 (18; 92). 60% of the patients were male. The number of infections per year ranged from 15 to 50 with a trend towards increasing incidence since 2012 noted. Regarding Candida species distribution, C. albicans remains the predominant Candida species isolated (41.5%) followed by C. parapsillosis (25.8%) and C. glabrata (20.8%). Ongoing trend of increasing non-albicans species since 2012 was noted. Intra-vascular catheters were the identified as the source in 65.9% of episodes. The crude thirty-day mortality of patients was 25.9%. The mean EQUAL score of CVC related infections was 19/22 and the mean score of non-CVC related infections was 16/19.
C. albicans remains the most common species causing CBSI with increasing prevalence of non-albicans Candida spp. such as C. parapsillosis and C. glabrata. Overall good compliance with the Candida EQUAL score was noted. Areas for improvement include ophthalmology review, prompt intravascular catheter removal and appropriate anti-fungal de-escalation post sensitivities. Ongoing Candida surveillance to assess species trends, anti-fungal resistance, source investigation and guidelines adherence is needed. Further education of clinical teams regarding risk factors, early diagnosis and management of CBSI is required.
"An Unusual Case of Acute Disseminated Encephalomyelitis (ADEM) and the Diagnostic Challenges Involved in Managing Patients with Human Immunodeficiency Virus"
Principal Presenter: Dr. Caoimhe Ryan
Keywords: HIV, ADEM, Diagnosis
People living with HIV (PWH) are at increased risk of neurological co-morbidities compared to the general population despite treatment with effective anti-retroviral treatment (ART).
We present a case highlighting the diagnostic challenges arising from a rare debilitating neurological condition in an individual with HIV.
A 67-year-old man living with HIV for 17 years on effective ART but with sub-optimal immunological response (CD4+ cell count<200 copies/ml) presented to a Dublin hospital with abdominal pain, constipation, and urinary retention. He had a previous history of diffuse large B-cell lymphoma (2018) and idiopathic thrombocytopenic purpura. Initial CT Brain was normal, however over 3 days he became encephalopathic and aggressive, dropping his GCS, requiring intubation and transfer to critical care in the Mater Hospital. MRI showed extensive, non-enhancing T2 hyper-intensive foci within the cerebral white matter, brain stem, and right cerebellar hemisphere in addition to multiple foci in the cervical and thoracic spinal cord. Lumbar puncture had normal opening pressure, cell count, and biochemical parameters. Investigations for an infective cause were unremarkable including a normal cryptococcal antigen (serum and CSF), CSF HIV, JC virus and Toxoplasma PCR, CSF gene Xpert for MTB and TB culture, in addition to broad range 16s and 18s PCR. Treponema Palladium serology was positive with a known history of treated infection, and despite negative testing on CSF, empiric treatment for neurosyphilis was completed with little response. CT thorax, abdomen, and pelvis were unremarkable with repeated large volume CSF cytometry showing no evidence of lymphoma recurrence. Following the above investigations and in consultation with Neurology colleagues a final working diagnosis of Acute disseminated encephalomyelitis (ADEM) was reached. Following courses of intravenous immunoglobulin and high dose dexamethasone, there was significant clinical improvement allowing extubation followed by improvement in GCS and ICU discharge after 21 days. Repeat MRI showed significant improvement in both the size and intensity of the white matter foci. He subsequently underwent inpatient rehabilitation.
ADEM is a rare immune-mediated inflammatory, demyelinating CNS disorder, commonly preceded by infection (1). Although more common in children, ADEM occurs in adults and has been described in HIV infection often presenting in an atypical fashion (2). Given the broad differential of CNS pathology in immunosuppressed PWH and the atypical features of ADEM in this population, the diagnosis of ADEM can be challenging and is often delayed. Clinicians must maintain a broad diagnostic differential when PWH present with neurological conditions.
Alper G. Acute disseminated encephalomyelitis. J Child Neurol. 2012 Nov;27(11):1408-25. doi: 10.1177/0883073812455104. Epub 2012 Aug 21. PMID: 22914374
Naidoo A et al. Atypical presentations of acute disseminated encephalomyelitis (ADEM) in HIV infection. J. Neurovirol. (2017) 23:160–170. DOI 10.1007/s13365-016-0481-0Download #2021026 (423.74 KB)
"“Influenza Vaccination – Still Relevant in 2020”: Simultaneous Influenza Vaccine Availability Improved Uptake Amongst Dialysis Patients in an Irish University Hospital."
Principal Presenter: Amy O'Farrell-Tyler
The Irish guidelines recommend quadrivalent influenza vaccine for patients with chronic kidney disease (CKD) to reduce morbidity and mortality. An audit cycle was completed to improve the vaccination uptake in patients with CKD undergoing dialysis.
An initial prospective cross-sectional audit was undertaken in November 2019. Data was collected from patients undergoing dialysis sessions in St Vincent’s University Hospital (SVUH), on a questionnaire using convenience sampling. Demographic information, reasons for non-vaccination, patients’ knowledge about vaccination, place where they received the vaccination information and location of previous vaccinations were recorded. After the initial audit, the influenza vaccine was made available in the Dialysis Unit. In November 2020, a re-audit was undertaken to assess the impact of this intervention, with an additional question regarding the impact of COVID-19 on patients’ attitude to vaccination.
A total of forty-eight patients were included in the re-audit, versus forty-six in the 2019 audit. The percentage of dialysis patients vaccinated in 2020 increased from 69.9% (n=32) to 89.9% (n=44). The majority of participants in 2020 were vaccinated in the Dialysis Unit 79.5% (n=35). Results also demonstrated improvement in the conversations around vaccination in the hospital, as contrasted to 2019 where most patients got vaccination information exclusively from their primary care doctor.
The rate of non-vaccination due to concerns re side effects were similar over two years, 6.25% (n=4) in 2020 vs 8.69% (n= 6) in 2019. The same three patients who reported reluctance to vaccination due to concerns regarding side effects in 2020, were the only three patients in the re-audit to report that the impact of COVID-19 decreased their likelihood of being vaccinated.
The study showed positive shifts in the attitudes and uptake of the influenza vaccine due to the availability of the flu vaccine in the Dialysis Unit. It indicates the benefit of having easy access and availability to the vaccine in a vulnerable group of patients. Similar interventions should be considered in other dialysis units to improve the influenza vaccination uptake, and possibly for COVID-19 vaccination uptakes in future as they become available.
"A Survey of the Potential Acceptance of a SARS-CoV-2 Vaccine Among People Living with HIV in Ireland"
Principal Presenter: Seán Donohue
Keywords: SARS-CoV-2, Vaccine, COVID-19
To date there have been over 240,000 cases of, and 4,800 deaths from COVID-19 in Ireland. Several SARS-CoV-2 vaccines have been developed. A large international survey by Lazarus et al showed 71.5% of the general population would accept a COVID-19 vaccine. Earlier studies had suggested that people living with HIV (PLWH) were not at increased risk of severe COVID-19 infection, but more recently ISARIC and OpenSAFELY have suggested otherwise. Given the potential for increased severity of infection in PLWH, achieving a high rate of vaccination in this group is important. Our survey aimed to assess the level of vaccine acceptability among PLWH.
An anonymous survey was carried out among PLWH from 10/12/2020 until 1/4/2021. The survey was available via a link to the SurveyMonkey platform advertised locally in our HIV clinic and on social media sites of organisations representing PLWH. A paper version was also available locally. The survey used multiple choice questions to assess sex, age, HIV control, comorbidities, years since diagnosis, annual influenza vaccination acceptance and if the patient or a family member had COVID-19 previously. A five-level Likert scale was used to assess participants’ level of agreement with current government restrictions, and willingness to accept a SARS-CoV-2 vaccine. Chi-Square and Fisher’s exact tests were used to assess for interactions between categorical variables.
48 people responded to the survey. 45/48 (93.8%) indicated they were either completely or somewhat in agreement with receiving a SARS-CoV-2 vaccine, with the remaining 3/48 (6.2%) in some or complete disagreement. Similarly, 46/48 (95.8%) were in some or complete agreement with government restrictions. 45/48 (93.8%) also indicated that they accepted the annual influenza vaccine. Given the small numbers of participants who indicated they would not accept a SARS-CoV-2 vaccine there were no statistically significant associations between this view and the other measured characteristics.
This survey demonstrates an overwhelming level of acceptability of COVID vaccination among our cohort at 93.8%, which is considerably higher than that found in surveys examining the general population. A potential limitation of the study is the risk for sampling bias, and those people more likely to accept vaccination may have been more likely to respond to the survey. Nevertheless, the results are encouraging for the success of the vaccine rollout among this patient population.Download #2021024 (182.18 KB)
"Can we improve case finding of MDR-TB in South Kivu in Democratic Republic of the Congo?"
Principal Presenter: Conor Moran
South Kivu is an impoverished, rural province in Eastern Democratic Republic of Congo (DRC) with high rates of tuberculosis (TB). There are increasing numbers of drug-resistant TB cases particularly among young males working in this heavy artisinal mining province. Diagnosis of drug-resistant TB can be challenging. Currently sputum microscopy is used to diagnose symptomatic TB cases. GeneXpert is utilised only for retreatment cases and those failing therapy. TB culture relies on sending samples abroad to reference labs which is not applicable for routine diagnosis. We sought to compare our rate of drug-resistant TB with published data and evaluate whether expanding geneXpert testing could increase case finding.
We analysed paper and electronic records of all patients treated for TB by Médecins Sans Frontières (MSF) in South Kivu, DRC between 2006-2019. We compared the rates of diagnosis of drug-resistant TB in our cohort to national and international published rates of drug-resistant TB.
In South Kivu, DRC, between 2006-2019, MSF treated 6,412 patients for TB, of these 73 (1.14%) were diagnosed with Rifampicin-resistant tuberculosis (RR-TB). There was often a long delay in diagnosis of drug resistant TB. 18/73 (25%) of RR-TB cases had no known prior history of TB. The majority of drug resistant cases were associated with mining. For comparison, a study in Clinical Infectious Diseases (Andre et al, CID 2019), looked at cases of RR-TB in South Kivu: Of 1535 patients geneXpert-positive for MTB, 11% had RR-TB. 45% had never been treated for TB before. The World Health Organisation (WHO) estimates that globally 3.4% of new and 18% of previously treated patients globally have MDR/RR-TB. Thus, we can see that in comparison to published data, RR/MDR TB is being under-diagnosed in South Kivu.
Drug resistant TB is an increasing problem, particularly in areas with heavy artisanal mining. Resource limited settings like South Kivu in DRC rely on sputum microscopy for diagnosis of tuberculosis. GeneXpert offers a promising, relatively cheap and rapid means of detecting RR-TB. Based on the results of our audit, we changed our diagnostic algorithm in South Kivu, to include geneXpert at initial diagnosis for all patients, this will allow early detection and treatment of drug-resistant TB. Reaudit will be needed to see if this change improves case finding of drug-resistant TB.
"Antibiotic prescribing patterns in patients hospitalized with COVID-19, lessons from the first wave"
Principal Presenter: Brendan O'Kelly
Keywords: COVID-19, antibiotic prescribing patterns, antimicrobial stewardship
Background: Antimicrobial consumption has increased since the beginning of the COVID-19 pandemic in hospitalized patients with COVID-19 despite evidence to show low levels of true bacterial co-infection.
Methods: A retrospective cohort study examining antibiotic prescribing patterns of 300 sequentially admitted patients with COVID-19. Patients were grouped into 3 sub-cohorts: group 1 – received no antibiotics, group 2 – received antibiotics for microbiologically confirmed infection, group 3 – received antibiotics for presumed but not proven bacterial pneumonia. The primary aim was to identify factors that influenced prescription and continuation of antibiotics in group 3. Secondary aims were to examine differences in outcomes between groups.
Results: In total 292 patients were included (63 group 1, 35 group 2, 194 group 3), median age was 60 years (IQR 44-76) and the majority were ethnically Irish (62%). The median duration of antibiotics was 7 days (IQR 5-10). In group 3, factors associated with decision to prescribe intravenous antibiotics on admission were; raised CRP (p=0.024), increased age (p=0.023), higher qSOFA (p=0.016) score and fever >37.5C (p=0.011). Factors associated with duration of antibiotic course were duration of hypoxia (p<0.001) and maximum respiratory support requirement (p=0.013). Twenty-one patients in group 3 had one or antibiotic escalation events, most (n=139) had no escalation or de-escalation of therapy.
Conclusion: Duration of hypoxia and need for respiratory support may have acted as surrogate measures of improvement where usual response measures (CRP, neutrophilia, culture clearance) were absent. Continuous review of antibiotic prescriptions should be at the forefront of clinical management of hospitalized patients with COVID-19.Download #2021022 (351.7 KB)
"Hospital Antimicrobial Point Prevalence Survey (PPS) in Ireland: 2020"
Principal Presenter: Rebecca Breslin and Sarah Fenton
Keywords: Antimicrobial, PPS, stewardship
The national hospital antimicrobial (AM) point prevalence survey (PPS) provides information on antimicrobial prescribing practices at a particular point in time. It is performed annually by antimicrobial stewardship teams across Ireland. Review of PPS findings over time demonstrates trends, areas for intervention and impacts of interventions.
Following a comprehensive review of the protocol and data entry form, the AM PPS was carried out in Irish hospitals in September and October 2020. Data from 2020, 2019 and 2018 were analysed by the Health Protection Surveillance Centre (HPSC) and reported to participating hospitals.
In total, 48 hospitals participated in PPS 2020 (2019: 45, 2018: 44), with 8,458 patients included. The median prevalence of antimicrobial use was 40% (2019: 40%, 2018: 39%). Co-amoxiclav and piperacillin / tazobactam together constituted 38% of all prescribed AMs, with a small increasing trend in prescribing of the broad-spectrum agents piperacillin–tazobactam, meropenem and ceftriaxone over the three years.
Compliance with indicators of good antimicrobial prescribing remains high and continues to show improvement. The compliance of the antimicrobial agent with hospital guidelines or Microbiology/ Infectious Disease recommendation was 85% (2019: 84%, 2018: 82%). Dose and duration were appropriate in 96% and 89% prescriptions respectively in 2020. Ninety one per cent of prescriptions had a documented indication (2019: 92%, 2018: 89%). An increase in the proportion of prescriptions with a documented stop or review date to 45% was observed (2019: 42%, 2018: 34%).
Community and hospital associated infections accounted for 54% and 24% prescriptions respectively. Respiratory, intra-abdominal and skin/soft tissue infections (SST) were the most common body sites in all three years. Surgical antimicrobial prophylaxis (SAP) accounted for 10% of all prescriptions, with a welcome reduction in the proportion extending beyond 24 hours (2020: 28% 2019: 27%, 2018: 37%).
Despite the COVID-19 pandemic, the 2020 AM PPS had the highest number of participating hospitals to date. At 40%, the median prevalence of antimicrobial use was similar to that observed in previous PPS. Broad spectrum penicillins continue to be the most commonly prescribed antimicrobials.
A reduction in SAP extending beyond 24 hours duration was observed, but remains high, contrary to evidence-based practice. Stewardship targets for improvement in 2021 will focus on SAP duration, promotion of IV to oral switch and increasing documentation of review or stop date.Download #2021021 (581 KB)
"Acute Bacterial Gastroenteritis: A Retrospective Review of the Clinical Features and Management in a Tertiary Hospital"
Principal Presenter: Daragh McGee
Keywords: gastroenteritis, enterics, diarrhea
A faeces molecular screen for Salmonella spp, Shigella spp, Campylobacter spp and VTEC can be ordered within three days of presentation to the Mater hospital with diarrhea. The aim of the study was to differentiate organisms based on presentation and laboratory data, and to review appropriate investigation and treatment.
We collated all admitted patients with a positive enteric molecular screen from January to December 2019. Patient demographic, presentation, laboratory, radiology and endoscopy data were accessed via the electronic patient record system. Acuity of presentation was measured using a validated clinical assessment tool: Early Warning Score (EWS). Data was analysed using SPSS.
57 patients were included in the analysis aging from 17-93 years with a mean of 45 years. Case split by organism: Campylobacter 63.2%, Salmonella 19.3%, Shigella 10.5%, and VTEC 8.8%. There was no statistical significant difference in symptoms including diarrhea, vomiting, abdominal pain, PR bleeding and fever between groups. The Shigella group had the highest mean EWS (2.6±1.6, p=0.616), the highest mean CRP (131.4mg/L±162.5mg/L, p=0.802) and highest mean haemoglobin (15.5±0.6g/dL, p<0.001). 22.8% had an acute kidney injury at presentation, this was highest in the VTEC group (60%, p=0.025). 50.90% were prescribed antimicrobials, of which 60.7% were indicated and 53.6% in line with local guidelines. 15.8% patients had lower GI endoscopy during admission or within 6 months of discharge and 28.1% of patients had a CT abdomen.
Although the Shigella group presented with the highest acuity and highest inflammatory markers, more data is needed to draw accurate conclusions. VTEC should be considered as the causative organism in patients with AKI on presentation. A significant amount of antimicrobials prescribed were not indicated and out of line with local guidelines, and a significant amount of investigations were undertaken including invasive endoscopies. Early stool culture could avoid unnecessary investigations in patients presenting with diarrhea.Download #2021020 (376.09 KB)
"Documentation of Do-Not-Attempt-Cardiopulmonary-Resuscitation Orders amid the COVID-19 Pandemic"
Principal Presenter: David Connellan
Keywords: COVID-19, Do-Not-Attempt-Cardiopulmonary-Resuscitation, Advanced Care Planning
The COVID-19 pandemic has brought the decision-making process regarding cardiopulmonary resuscitation (CPR) into focus. The aim of this study was to compare rates of Do-Not-Attempt CPR (DNACPR) documentation in older hospitalised patients before and during the COVID-19 pandemic.
This was a retrospective repeated cross-sectional study. Data including co-morbidities and resuscitation status was collected on 300 patients with COVID-19 hospitalised from March 1st to May 31s t 2020. DNACPR documentation rates in patients aged ≥65 years with a diagnosis of COVID-19 were compared to those without COVID-19 admitted during the same period and also compared to documentation rates pre-COVID-19 pandemic (March 1st to May 31s t 2019).
Of 300 COVID-19-positive patients, 28% had a DNACPR order documented during their admission. Of 131 older (≥65 years) patients with COVID-19, 60.3% had a DNACPR order compared to 25.4% of 130 older patients without COVID-19 (p<0.0001). During a comparable time period pre-pandemic, 15.4% of 130 older patients had a DNACPR order in place (p<0.0001). Fifty percent of DNACPR orders were recorded within 24 hours of a positive swab result for SARS-CoV-2. Of older COVID-19-positive patients, 39.2% were referred to palliative care services and 70.2% survived.
The COVID-19 pandemic has prompted more widespread and earlier decision-making regarding resuscitation status. Although case-fatality-rates were higher for older hospitalised patients with COVID-19, many older patients survived the illness. Advance care planning should be prioritised in all patients and should remain good clinical practice despite the pandemic.Download #2021019 (352.74 KB)
"Prospective audit of compliance with antimicrobial guidelines and antimicrobial stewardship interventions in Galway University Hospital (GUH) in Q1 2021 in covid and non-covid wards"
Principal Presenter: Katie McDonough
Keywords: Covid, Antimicrobial, Audit
Background: Antimicrobial resistance (AMR) is a growing problem accelerated by misuse and overuse of antimicrobial drugs that can contribute to increased mortality worldwide. The COVID-19 pandemic has put pressure on healthcare systems, and data suggests antimicrobials are being overprescribed in COVID patients despite low rates of bacterial or fungal co-infection. Antimicrobial stewardship teams (AST) are one of the main implementations in healthcare dedicated to optimising the use of antimicrobials thereby contributing to the reduction in AMR through education, antimicrobial prescribing guidelines and restricted antimicrobial policies
Aim: To examine and compare antimicrobial prescribing trends (prevalence, duration and indication documentation, IV to Oral switching and guideline compliance) on both COVID-positive (Red) and COVID-negative (Green) wards at Galway University Hospital (GUH) in the first quarter (Q1) of 2021.
Methods: Two data forms were used for collecting and analysing data; an anonymised patient data collection form used on wards by the AST and a Microsoft Excel sheet for data analysis. A 4-week pilot of the data collection form was conducted, and an audit approval form submitted prior to project commencement. Analysis of compliance to GUH prescribing guidelines, comparison between Red and Green wards and trends in COVID patients were analysed using Microsoft Excel.
Results: Average prevalence of antimicrobial prescribing in Red wards was 47% compared to 40% in Green wards in Q1 2021. Piperacillin and beta-lactamase inhibitors, Amoxicillin and beta-lactamase inhibitors and Ceftriaxone were the most prescribed antimicrobials in Red wards. 70% of COVID-positive patients on antimicrobials had a documented diagnosis of pneumonia. 98% of all antimicrobial agents in Red wards were deemed in line with guidelines or had microbiology/infectious disease approval compared to 85% on Green wards. 100% of restricted agent use in Red wards were in line with local restriction policies compared to 50% on green wards.
Discussion: Results show that the majority of AST standards were upheld in GUH during the COVID pandemic in Q1 2021, including documentation of treatment indication and adherence to restrictive policies. However, antimicrobial prescribing was high compared to an average prevalence of 40% from the GUH point-prevalence survey 2020. Increased usage of Ceftriaxone continues for COVID-positive patients, which was also seen in Q2 2020. ASTs continue to have an important role in ensuring appropriate antimicrobial treatment of COVID-positive patients while minimising overuse of antimicrobials as the pandemic progresses.Download #2021018 (547.36 KB)
"It’s Not Always Infection: A Case of Sulfasalazine-induced Hypersensitivity Syndrome"
Principal Presenter: Aisling Nolan
Keywords: Drug Reaction, Fever, Rash
Sulfasalazine is an anti-inflammatory drug used in the treatment of various inflammatory diseases. Common side effects include headache, nausea, fever and rash. Rarely, patients may develop complications including hepatitis, pneumonitis, haemolysis and Steven’s Johnson Syndrome. Severe adverse reactions from this drug are typically delayed.
A 52-year-old lady presented to the Emergency Department with an eight day history of fevers and nausea. One day prior to admission the patient noted a new diffuse, maculopapular rash on the limbs and trunk with increasing dyspnoea. There was no mucosal involvement. At presentation the patient was systemically unwell, with a tachycardia of 110 beats per minute and a fever of 39.5 degrees Celsius. Empiric intravenous antimicrobials were commenced. Blood results demonstrated a significant hepatitis, with ALP 381iu/L, ALT 903iu/L and GGT 342iu/L. The patient’s viral and autoimmune liver screens were not significant.
On re-questioning, the patient reported a new prescription of sulfasalazine four weeks pre-admission for a new diagnosis of rheumatoid arthritis, stopping the drug after only one week owing to illness. Sulfasalazine was restarted one day prior to the new symptom onset, resulting in hospitalisation. Interestingly, despite the patient’s initial improvement, a deterioration occurred following the administration of furosemide for presumed pulmonary oedema. The patient’s pneumonitis progressed clinically. Diuresis was stopped and the patient was started on high dose corticosteroids, making a full recovery.
This case is remarkable for its demonstration of a severe drug induced hepatitis with fever, identifiable only through a thorough patient history and awareness of the non-infectious aetiologies of fever. It highlights the well-documented temporality of re-exposure to sulfasalazine inducing a hypersensitivity reaction1. Notably, receipt of furosemide, another non-antimicrobial sulfonamide, resulted in a further clinical deterioration while in hospital. Future avoidance of sulfonamides has been advised, though the cross-reactivity of antimicrobial and non-antimicrobial sulfonamides remains debated.2,3
1. J W, L L, SM B, M M. Case of relapsing sulfasalazine-induced hypersensitivity syndrome upon re-exposure. BMJ Case Rep. 2020;13(9). doi:10.1136/BCR-2020-235803
2. A Z, P L, A B, WJ P. Cross-reactivity in drug hypersensitivity reactions to sulfasalazine and sulfamethoxazole. Int Arch Allergy Immunol. 2010;153(2). doi:10.1159/000312632
3. BL S, R S, AJ A, et al. Absence of cross-reactivity between sulfonamide antibiotics and sulfonamide nonantibiotics. N Engl J Med. 2003;349(17). doi:10.1056/NEJMOA022963Download #2021017 (357.45 KB)
"MMUH Infectious Diseases HPV Vaccination Uptake Audit"
Principal Presenter: Padraig Mcgetrrick
Keywords: audit, HPV, HPV vaccine
MMUH Infectious Diseases HPV Vaccination Uptake Audit
Authors: Luzviminda Magalona, Dr. Padraig McGettrick, Prof. John Lambert
BACKGROUND: Human Papiloma Virus (HPV) is the most common sexually transmitted infection worldwide. Gardasil is a vaccine directed against HPV serotypes that causes genital warts (serotypes 6 and 11) and cervical, anal and penile cancer (serotypes 16 and 18). Gardasil is currently offered by national guidelines to high-risk groups such as Men who have sex with Men (MSM) < 45 years of age and both men and women living with HIV <25 years of age in order to reduce the burden of HPV related disease. Despite availability, vaccine uptake within our Infectious diseases (ID) and sexual health (STI) clinics has traditionally been low. We aimed to assess HPV vaccine uptake before and after the appointment of a vaccine nurse specialist to assess the benefit of a dedicated nurse specialist in vaccinating high risk groups.
METHODS: Retrospective data was collected from electronic medical records (EMR), medical notes and pharmacy records. Numbers of eligible individuals presenting to and receiving Gardasil vaccine in the ID and STI clinics in the Mater Misericordiae University hospital (MMUH) was assessed for 4 weeks prior to, and after the appointment of a dedicated nurse specialist. Time periods were selected in which there was no limitation to Gardasil supply and when services were running at maximum capacity and not affected by Covid 19 restrictions.
RESULTS: In January 2020, 11.2% of patients attending the ID services were eligible for HPV vaccine [eligibility: STI clinic n=8 (11.3%); HIV clinic n= 73 (11.2%)]. 98.7% were MSM. 33 (41%) individuals received HPV vaccination. Following appointment of vaccine nurse specialist (December 2020) this was re-audited. 171 individuals (27.6%) who attended the MMUH ID services were eligible for HPV vaccine [eligibility: STI clinic n= 42 (44.3%); HIV clinic n=89 (18.4%), Prep clinic n=40 (100%)]. Of those eligible, 151 (89%) received HPV vaccination resulting in a 48% increase in HPV vaccine uptake following appointment of Vaccine nurse specialist.
This audit of vaccine services in the MMUH ID clinics clearly shows the benefit of a dedicated vaccine nurse to increase the vaccine administration and uptake in a vulnerable population attending the MMUH ID services. Future targeted vaccination programs should be arranged to ensure adequate vaccine provision to attendees of the MMUH ID services.
CNS Infectious Diseases (Vaccination), Mater Misericordiae University Hospital
ID SPR Infectious Diseases, Mater Misericordiae University Hospital
Professor of Medicine UCD, ID Consultant Infectious Diseases, Mater Misericordiae University HospitalDownload #2021016 (473.1 KB)
"The quality of email consult requests to the Infectious Diseases Department in St. Vincent's University Hospital over 12 months."
Principal Presenter: Irene O'Dea
Keywords: Health Care Quality Assurance, Referral, Infectious Diseases
The Infectious Diseases consult service in St Vincent's University Hospital transitioned to an email-based referral pathway in December 2019. In the following 12 months the service received a high volume of referrals.
Information included in consult requests aids in correctly identifying patients and triaging requests based on priority. An audit aims to identify whether the necessary information was included to enable safe referral.
A minimum acceptable set of information was identified together with relevant stakeholders and by consulting relevant HIQA and HSE guidance. A total of 281 email requests were received from 20 specialist teams.The referring speciality, grade of referring doctor and reason for request were also recorded.
30.2% (n=85) of referrals were received from the Vascular surgery team. The majority (65.8%, n=185) of emails were sent by interns. Requests for OPAT represented 28.5% of referrals (n=80). In terms of patient identifiers MRNs were included in 95.4% (n=268) of cases and Date of Birth was included in 85.8% (n=241) of cases. Referrer contact details were included in 53.7% (n= 151) of cases and 60.9% (n=171) of referrals included patient location. The urgency of referral was indicated in only 11.4% of cases (n=32). Patient demographics were included in 94.3% (n=265) of cases. In addition, 46.6% of emails included examination findings (n =131), 43.8% reported Microbiology results (n=123) and 55.2% referred to relevant past medical history (n=155). Current antimicrobials were recorded in 75.8% (n=213) of referrals. Working diagnosis was indicated in 76.9% (n=216) of emails. 75.8% (n=213) of requests asked a specific question of the team.
From the above we can see that inclusion of unique patient identifiers was nearly universal. Results suggest that improvements could be made in the inclusion of referrer contact details. Notably, less than half of referrals included microbiology results. Very few referrals included indication of a timeframe for urgency of referrals.
As most referrals were submitted by interns this is a key group to involve in improving the consult requests. Interventions would be undertaken in the form of educational sessions for the intern group, creation of a proforma to prompt referrers and regular meetings with the most frequent referring specialties to improve the quality of consult requests.Download #2021015 (309.69 KB)
"A Review of Antimicrobial Stewardship Interventions at a Tertiary Hospital Centre – A MEG-a Undertaking"
Principal Presenter: Saied Ali
Keywords: Antimicrobial Stewardship, Prescribing, Antibiotics
Hospital antimicrobial stewardship (AMS) programs are an integral part of clinical governance strategies as they aim to promote judicious use of antimicrobials. The MEG Auditing Tool was employed in June 2020 at our hospital site which allowed real-time capture of antimicrobial prescriptions and recommendations whilst on stewardship rounds.
To review all interventions captured by the MEG Auditing Tool in an effort to improve prescribing patterns of antimicrobials through sharing of findings.
All interventions from June 2020 to December 2020 inclusive were electronically reviewed and spreadsheets exported to ascertain trends and outcomes.
A total of 199 interventions were made throughout the outlined period. Majority of antimicrobials were prescribed for respiratory and genitourinary infections, 30.7% (n=61) and 20.6% (n=41) respectively; with co-amoxiclav being the most commonly prescribed antibiotic (31.3%, n=80) followed by piperacillin-tazobactam (23.4%, n=60). Correct dosing was observed in 98% (n=195) while documentation of indication and stop/review dates noted in 42% (n=83) and 7% (n=13) respectively. Overall, administration of antimicrobials was found to be compliant with local prescribing guidelines in 45% (n=89). Of the interventions, recommendations regarding duration were given the most (41.7%, n=83) followed by discontinuation of all antimicrobials (29.1%, n=58), switch to an oral formulation (14.6%, n=29) and de-escalation to an alternative agent (13.6%, n=27). Advice was also given regarding dosing (6.5%, n=13), discontinuation of some antimicrobials (4.5%, n=9), suggestion of different agents (11.1%, n=22) and investigations (7.5%, n=15).
There is room for improvement of prescribing practices. Algorithms for the antimicrobial management of lower respiratory and urinary tract infections have since been developed and circulated, together with “Antimicrobial of the Month” e-posters. Prescribing education is ongoing to improve documentation, with the consideration of the employment of stickers to aid physicians in remembering to de-escalate, be aware of restricted antimicrobials and consider switching to oral formulations. We also continue to work towards the introduction of electronic prescribing. Unfortunately, we failed to document the number of kardexes reviewed where no intervention was required, which we hope to outline going forward as a marker of good quality prescriptions and antimicrobial use.Download #2021014 (193.06 KB)
"The Management of Patients with Colonization and Infection with Extended-Spectrum β-Lactamase-Producing Enterobacterales and Associated Risk Factors and Patient Outcomes."
Principal Presenter: Stjohn Kelliher
Keywords: ESBLs, Enterobacterales, Infection
The Management of Patients with Colonization and Infection with Extended-spectrum β-Lactamase-Producing Enterobacterales and Associated Risk Factors and Patient Outcomes.
1. School of Medicine, University College Cork
Extended-spectrum beta-lactamase (ESBL)–producing Enterobacterales provide a significant threat to health-care systems around the world, and are associated with worse patient-outcomes, longer hospitalizations and greater mortality. The principle reason for the development of antimicrobial resistance is the over-use of antibiotics. In the past decade, infection control and antibiotic stewardship measures have been introduced to provide a systematic approach to prevent the rapid spread of resistant bacteria. This study assessed the management of patients with colonization and infection with ESBL-producing Enterobacterales and associated patient characteristics, risk factors and clinical outcomes in the Mercy University Hospital (MUH), Cork.
A retrospective, cross-sectional observational study was performed on all patients who had ESBL-producing Enterobacterales grown on the appropriate culture during their MUH admission over a two year period from September 2017 to December 2019. Patient charts and electronic data were analysed to determine the appropriateness of antibiotic therapy, input from the microbiology or infectious diseases team, ESBL documentation, patient characteristics, associated risk factors and clinical outcomes.
Data was collected from 158 patients. All infected patients received appropriate antimicrobial therapy (n=46, 100%). 79 patients (81.4%) received input from the microbiology or infectious diseases team. 85 patients (90.4%) had their ESBL-positive result documented. Associated risk factors included age ≥ 65 years (n=119, 75.3%), male gender (n=87, 55.1%), residency of a long-term care facility (LTCF) (n=9, 6.2%), recent antibiotic-use (n=48, 36.6%), hypertension (n=54, 40.6%), malignancy (n=38, 28.6%), diabetes (n=24, 18.0%) and COPD (n=23, 17.3%). Residency of a LTCF was more associated with infection than colonization (p=0.034). Urinary catheterisation was associated with urinary tract growth (n=19, 61.29%). The mean number of hospital admissions in the previous 12 months was 2.2 times and in the subsequent 6 months was 1.35 times. The median length of hospital stay was 7 days (0.75,19), and 8 patients (15%) died due to the infection.
Results indicate that ESBL-positive patients in the MUH received appropriate antimicrobial therapy in accordance with local guidelines and laboratory results, with most having documentation of the positive result in the patient chart and input from the microbiology and infectious diseases team. To conclude, a multidisciplinary team approach and regular assessment of antimicrobial management is instrumental in the implementation of antimicrobial stewardship measures to combat the growth of resistance.Download #2021013 (251.49 KB)
"Localised Treatment of Renal Fungal Balls"
Principal Presenter: Siobhan Quirke
Keywords: fungal renal disease, fungal ball
The formation of fungal balls is rare and difficult to treat. We discuss an alternative and poorly studied treatment modality. The use of localised fluconazole by instillation through nephrostomy has been described in case report evidence only. We provide additional case based evidence to support trial of this treatment modality in invasive fungal infection for those who have failed first-line systemic therapy.
We present the case of a 78 year old female with a past medical history of type II diabetes mellitus, stage 4 chronic kidney disease and hypertension. Additionally she has recurrent extended spectrum beta lactamase (ESBL) urinary tract infections and candiduria as well as extensive radiation related retroperitoneal fibrosis.
In the months prior to admission CT imaging showed urinary obstruction which had caused a deterioration in renal function. Ureteroscopy performed by urology colleagues revealed friable tissue in the renal pelvis and a biopsy showed abundant fungal scores and hyphae consistent with candida. A diagnosis of a fungal focus (or fungal ball) within the renal pelvis was made. She was treated with 28 days of oral fluconazole but failed to improve. She presented to the emergency department with haematuria and repeat imaging revealed progressive and now bilateral urinary obstruction.
We treated her with localised fluconazole instillation through nephrostomy tubes. A dose of 50mg in 500mls NaCl 0.9% was administered over 12 hours for seven days. This treatment was tolerated well and achieved clinical, microbiological and radiological improvement for our patient.
Invasive fungal renal disease is rare, complex and difficult to eradicate. There is lack of clinical trial evidence available to comment on the efficacy and outcomes of the use of this treatment modality but it is described in the literature in a number of case reports and may serve as an alternative modality in these complex patients.Download #2021012 (590.74 KB)
"Audit of LTBI/TB Screening in Newly Diagnosed and Transferred HIV Patients Attending an Urban HIV Clinic"
Principal Presenter: Laura O'Doherty
Keywords: Tuberculosis, HIV, Screening
The European AIDS Clinical Society (EACS) guidelines recommend tuberculosis (TB)/latent TB infection (LTBI) screening for all HIV patients at initial assessment with a chest X-ray (CXR) and an interferon-gamma release assay or Mantoux test. We sought to audit our practice of TB/LTBI screening in the year 2018.
A retrospective electronic patient record review for all HIV patients newly registered at our clinic in the year 2018 was carried out. Variables extracted included basic demographics, history of prior TB/LTBI disease/treatment, baseline and nadir CD4 counts, CXR results, IGRA results, Mantoux test results and whether the patient’s first appointment was with a doctor or clinical nurse specialist (CNS).
243 patients were newly registered to the HIV in 2018 (94 newly diagnosed patients (1 died before being seen) and 149 patients who transferred care with known diagnosis.) 212 were male, mean age 36.
39.8% (37 of 93) of newly diagnosed HIV patients who attended our clinic had an IGRA as compared to 18% (27 of 149) of transferred patients (p = 0.0002). 72% (67 of 93) of newly diagnosed patients had a CXR, as compared with 51.68% (77 of 149) of transferred patients (p = 0.0018). No patients had a Mantoux test. Of newly diagnosed patients 1 was diagnosed and treated for LTBI and 2 for TB. 1 patient (nadir CD4 159) who's initial CXR was normal, had an abnormal CXR 8 weeks later and was diagnosed with multidrug-resistant TB, and probable CNS TB. This patient died despite therapy. Of transferred patients 3 were diagnosed and treated for LTBI.
For newly diagnosed patients, doctors and CNS were just as likely to request an IGRA (42.9% vs. 41.6%, p = 0.94) and CXR (71.4% vs. 72.7%, p = 0.92). CNS were more likely than doctors to request a baseline CXR for transferred patients (64.9% vs. 32.8%, p = 0.0001).
Although the majority of newly diagnosed HIV patients registered at our clinic have origins in countries with high TB prevalence, over 60% were not screened for LTBI with IGRA, and 28% did not have a CXR. Interventions have been implemented to align our practices to EACS guidelines. We plan to re audit our new changes in practices in future.Download #2021011 (234.2 KB)
"Prosthetic Joint Infection: Clinical Outcomes of a Multidisciplinary Approach in a Tertiary Care Centre"
Principal Presenter: Seán Donohue
Keywords: prosthetic joint infection, PJI, DAIR
Prosthetic joint infection (PJI) is a serious complication of joint replacement. Galway University Hospital has a combined ID and orthopaedic programme treating PJI according to IDSA guidelines. There is little data on clinical outcomes of this approach.
Single-centre retrospective study of patients with first-episode PJI from 01/01/2015 to 21/12/2019. Clinical, microbiological and outcome data were collected. Successful treatment was defined as infection-free with/without suppressive antimicrobials at time of data collection.
91 cases identified by HIPE search. 24 excluded as didn’t fulfil IDSA definition, revision surgery performed elsewhere or lost to follow-up. 47/67 (70.1%) were male, median age 69 (range 32-91). 23.9% (16/67) had underlying inflammatory arthritis. 52/67 (77.6%) cases involved the hip, 15/67 (22.4%) the knee. 22.4% (15/67) were early infections (<1 month surgery), 77.6% (52/67) were late. Median hospital stay was 42 days (range 10-183). Median duration of IV antimicrobials was 42 days (range 0-90). Median follow-up 44 months (range 15-85).
The commonest microorganisms were MSSA (early 4/15,26.7%; late 17/5,32.7%) and coagulase-negative staphylococci (early 4/15,26.7%; late 15/52,28.8%). 23.9% (16/67) were bacteraemic, of these S.aureus accounted for 75.0% (12/16).
Debridement, antibiotics and implant retention (DAIR) was the commonest treatment for early PJI (7/15,46.7%). Two-stage exchange was commonest for late PJI (28/52,53.8%).
62.7% (42/67) were infection-free at follow-up. Relapse occurred in 19.4% (13/67), 10.4%(7/67) were reinfected with a different organism. There was one death from PJI (1.6%), and 4 from other causes (5.9%).
In early PJI, DAIR was successful in 71.4% (5/7), 28.6% (2/7) relapsed. Two-stage exchange was successful in 71.4% (20/28) of late PJI, 10.7% (3/28) relapsed, 14.3% (4/28) reinfected. Age, sex, inflammatory markers, microorganism or comorbidities did not predict outcome.
PJI is associated with long length of hospital stay and antimicrobial treatment. Of interest, we found a high prevalence of inflammatory arthritis in our cohort.
In a real-world setting DAIR can be successful in appropriately selected patients with early PJI. Two-stage exchange has low rates of relapse in late PJI. We advocate for a multidisciplinary approach to the management of this complex infection with involvement of orthopaedic and ID specialists in order to achieve high success rates at first intervention.Download #2021010 (224.14 KB)
"Renal Function Monitoring of Patients Living with HIV on Efavirenz/Emtricitabine/Tenofovir disoproxil (EFV/FTC/TDF) at an Ambulatory HIV Clinic"
Principal Presenter: Rehab Wali
Keywords: tenofovir, eGFR, HIV
Regular assessment of renal function is increasingly important in the care of patients living with HIV, an ageing cohort with a range of comorbidities that can compound their risk of kidney injury. The newer TAF (tenofovir alafenamide) containing regimens have been shown in some studies to be relatively safer.
Primary aim: Identify any association between this tenofovir combination medication and renal function decline while accounting for normal ageing, and specifically determine whether it is significant enough to consider switching to a TAF regimen.
Secondary aim: Audit clinic compliance with EACS guidelines for monitoring of renal function.
A list of patients on the tenofovir combination pill in UHL HIV OPD was compiled by pharmacy.
The following data was collected from clinic flowsheets: eGFR, viral load, CD4 count and urinalysis results.
Charts and OPD letters were reviewed to determine start and end dates of this regimen and, if available, date of diagnosis and any treatment received.
From initiation of medication to the end of time interval studied, a median of 7.2 years to a maximum of 15.3 years, eGFR did not significantly change in any patient outside of the expected ranges associated with normal ageing, i.e. by significantly more than 1 ml/min/1.73m2 per year.
We identified a need to involve other medical specialties when reasons for renal function decline were identified that were not causally related to medication or HIV complications.
Clinic was compliant with EACS guidelines in terms of frequency and timing of monitoring of renal function.
Opinion: no need to switch from EFV/FTC/TDF to newer TAF containing drugs in our stable patients.Download #2021009 (681.04 KB)
"Best Practice Guidance for Digital Contact Tracing Apps: A Cross-Disciplinary Review of the Literature."
Principal Presenter: James O'Connell
Digital contact tracing apps (DCTAs) have the potential to augment contact tracing systems and disrupt Coronavirus 2019 transmission. The aim of the research was to derive and summarize best practice guidance for the design of the ideal digital contact tracing app (IDCTA).
A collaborative cross-disciplinary approach was used to derive best practice guidance for designing the IDCTA. A search of the indexed and grey literature was conducted to identify articles describing or evaluating DCTAs. Medline was searched using a combination of free-text terms and MeSH search terms. Grey literature sources searched were the World Health Organisation Institutional Repository for Information Sharing, the European Centre for Disease Control publications library and Google, including the websites of many health protection authorities. Articles that were acceptable for inclusion in our evidence synthesis were peer-reviewed publications cohort studies, randomised trials, modelling studies, technical reports, white papers, and media reports related to digital contact tracing.
Ethical, user experience, privacy and data protection, technical, clinical and societal, and evaluation considerations were identified from the literature. The IDCTA should be voluntary and should be equitably available and accessible. User engagement could be enhanced by small financial incentives, enabling users to tailor aspects of the app to their particular needs and integrating DCTAs into the wider public health information campaign. Adherence with the principles of good data protection and privacy by design are important to convince target populations to download and use DCTAs. Bluetooth Low Energy is recommended for DCTA contact event detection, but combining it with ultrasound technology may improve DCTA accuracy. A decentralised privacy-preserving protocol should be followed to enable DCTA users to exchange and record temporary contact numbers during contact events. The IDCTA should define and risk-stratify contact events according to proximity, duration of contact, and the infectiousness of the case at the time of contact. Evaluating DCTAs requires data to quantify app downloads, use among COVID-19 cases, successful contact alert generation, contact alert receivers, contact alert receivers that adhere to quarantine and testing recommendations, and the number of contact alert receivers who subsequently are tested positive for COVID-19. The outcomes of DCTA evaluation should be openly reported to allow for wider public evaluation of the app.
In conclusion, key considerations and best practice guidance for the design of the ideal digital contact tracing app were derived from the literature.
"Potent Antiviral Activity of lenacapavir in Phase 2/3 in Heavily ART-experienced PLWH"
Principal Presenter: Ross Hamilton-Shaw
Keywords: lenacapavir, safety, efficacy
Lenacapavir (LEN, GS-6207), the long-acting first-in-class HIV capsid inhibitor, is in clinical development for the treatment and prevention of HIV-1 infection. With its novel mechanism of action, LEN is fully active in vitro against HIV-1 strains resistant to the major antiretroviral (ARV) classes.
We conducted a Phase 2/3, randomised, double-blind, placebo (PBO)-controlled study in heavily treatment-experienced (HTE) people living with HIV (PWLH) failing their current regimen with HIV-1 RNA (VL) ≥ 400 c/mL and documented resistance to ≥ 2 agents from ≥ 3 of the 4 major ARV classes. Participants were randomised (2:1) to add LEN or PBO to their failing regimen for 2 weeks. During this functional monotherapy period, LEN or PBO was given orally (600 mg on Day [D] 1 and 2 and 300 mg on D8). The primary efficacy endpoint was the proportion of participants with at least 0.5 log10 c/mL decline in VL by D15. At D15, those on oral LEN received subcutaneous (SC) LEN 927 mg (Q6 month), while those on PBO started the LEN 2-week oral lead-in, followed by Q6month SC. All participants initiated an investigator-selected, optimised background regimen (OBR) at D15.
36 participants were randomised: 28% were female and 46% Black. Median age was 54 years. Mean baseline VL was 4.27 log10 c/mL. At D15, 88% of participants on LEN (21 of 24) had at least 0.5 log10 c/mL decline compared to 17% on PBO (2 of 12) (difference: 71%, 95% CI 35 to 90%, p<0.0001). The median (range) change in VL (log10 c/mL) was -2.00 (-3.29 to - 0.29) vs -0.08 (-1.93 to 0.31). During the LEN + OBR period at 4 weeks after SC dosing, 58% (21 of 36) had VL <50 c/mL. The median (range) duration of follow up on LEN was 26 (7-46) weeks. There were no serious adverse events (AEs) related to study drug, discontinuations due to AEs, or deaths. The most frequent AEs (any grade) were injection site swelling (28%) and nodule (25%). Injection site reactions related to LEN (50%) were all mild or moderate. Longer term data will be reported.
LEN led to a rapid and clinically relevant decline in VL when added to a failing regimen in HTE PWLH. LEN was generally safe and well-tolerated. These results support the ongoing evaluation of LEN for the treatment and prevention of HIV-1 infection.Download #2021007 (1.06 MB)
"Four Year Outcomes of B/F/TAF in Treatment-Naïve Adults"
Principal Presenter: Cindy Elliott
Keywords: Bictegravir, outcomes, long-term
Background: Bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) is a guidelines- recommended single-tablet regimen for people living with HIV-1 (PWLH). We present cumulative outcomes from open-label extension (OLE) that followed 144 Weeks (W) of blinded treatment in phase 3 studies in treatment-naïve PLWH.
Methods: We conducted 2 randomised, double-blind, phase 3 studies of B/F/TAF in treatment- naïve adults – Study 1489: B/F/TAF vs dolutegravir/abacavir/lamivudine (DTG/ABC/3TC) and Study 1490: B/F/TAF vs DTG+F/TAF. After completing 144W of blinded treatment, participants were offered to continue on B/F/TAF for 96W in the OLE. Efficacy was assessed as the proportion with HIV-1 RNA <50 copies/mL at each visit after starting B/F/TAF using missing=excluded (M=E) analysis; safety by adverse events (AEs) and laboratory results. Bone mineral density (BMD) in OLE was measured in those randomised to B/F/TAF in Study 1489. We present cumulative results for all participants treated with B/F/TAF in the randomised or OLE phases through a maximum of 192 weeks of follow up (i.e. OLE W48). The final phase of this study will complete once all participants reach a total of 240 weeks (i.e. OLE W96).
Results: In Study 1489, 314 participants were randomised to B/F/TAF and 315 to DTG/ABC/3TC; 252 and 254 entered the OLE. In Study 1490, 320 were randomised to B/F/TAF and 325 to DTG+F/TAF; 254 and 265 entered the OLE. Efficacy was >98% after W48 at each study visit through W192 in both studies. Across both studies, only one participant experienced an AE that led to drug discontinuation during the OLE analysis window. Grade 3 or 4 drug-related AEs were rare (Table). There were no discontinuations due to renal AEs. In participants initially randomised to B/F/TAF, the median change in weight from baseline to W192 was 4.6 kg in Study 1490 and 5.0 kg in Study 1490. The mean percent changes (SD) in hip and spine BMD through W192 were -1.5% (4.9) and -0.9% (5.2), respectively. 13% of participants with baseline osteopenia in hip and 3% with osteopenia of the spine improved to normal at W192, 4% with normal baseline hip and 6% with normal baseline spine BMD progressed to osteopenia and none developed osteoporosis.
Conclusion: Over 4 years of follow-up in treatment-naïve participants, B/F/TAF was safe and highly efficacious. Similar outcomes were demonstrated in participants who switched from DTG-containing regimens to B/F/TAF. These results confirm long term safety and efficacy of B/F/TAF.Download #2021006 (1.22 MB)
"Largest prison outbreak of tuberculosis in Western Europe investigated using whole genome sequencing: recommendations for future prevention"
Principal Presenter: Dr David Mark Kelly
The transient movement of prison subpopulations presents a public health challenge to the control of tuberculosis (TB). We highlight the dual role of public health interventions and laboratory-based molecular epidemiology in mapping and control of a prison outbreak of TB. We recommend a national TB control strategy for prison settings based on this experience and a review of the literature.
In March 2011, the Department of Public Health East were notified of a case of laryngeal TB and one of pulmonary TB, in two prisoners sharing a prison cell. We define the resulting outbreak and the outbreak control response. Cases were identified through either clinical presentation, contact tracing, a case finding exercise or enhanced laboratory surveillance. M. tuberculosis isolates underwent genotyping and whole genome sequencing at the Irish Mycobacteria Reference Laboratory.
Over a nine year period, 34 cases of TB were linked to the outbreak: 27 prisoners (79%), 4 prison officers (12%) and 3 community cases (9%). Nineteen cases (56%) had smear positive TB. M. tuberculosis was isolated from 31 cases (culture positivity 91%). A maximum of six single nucleotide polymorphisms (SNPs) separated the isolates, with 22 being identical (zero SNP differences); suggestive of a highly infectious ‘super-spreader’ within the prison. Isolates belonged to the Beijing sub-lineage and were pan-sensitive to first-line anti-tuberculous agents. A case-finding exercise incidentally detected a prisoner with multidrug-resistant TB (MDR-TB). Of the 143 prison officers screened, 52% had latent TB infection. Litigation costs from the outbreak exceeded five million euros.
WHO guidelines on TB prevention and control in prisons (2014) recommend periodic screening of prisoners as a key aspect of TB control. The 2019 update from the National Tuberculosis Controllers Association recommends baseline TB education and screening using tuberculin skin test or interferon-gamma release assay for health care personnel, as well as periodic screening of those working in settings with potential for ongoing TB transmission.
This study constitutes the largest prison outbreak of TB in Western Europe investigated using WGS, and extending to the community. A national prison entry TB screening and education programme for prisoners and prison officers is required to effect better TB control, prevent prison outbreaks of MDR-TB and limit attendant litigation in Ireland.
"Initial Experiences: The Mater COVID Virtual Clinic Project"
Principal Presenter: Dr Stephen Connolly
The COVID19 pandemic has necessitated innovative ways to provide safe healthcare remotely for large numbers of infected patients. We implemented a COVID Virtual Clinic (CVC) in a tertiary referral centre allowing such patients to be monitored in the community. This study describes the CVC’s remote monitoring experience and explores the predictors of need for specialist intervention.
We included all patients enrolled in the CVC at the Mater Misericordiae University Hospital, Dublin between March 1st and June 1st 2020. Patients received a Bluetooth-enabled pulse oximeter and smartphone application (Patient-M-Power®) and uploaded twice-daily SpO2 readings, heart rate and dyspnoea score (1-10). A team of two-to-four healthcare providers monitored results. Abnormal or absent data triggered calls from the CVC, with assessments and/or admission as required. We collected data on demographics, calls received from/made to patients, outcomes and readmissions. Descriptive analysis of the CVC was performed as well as simple logistic regression to explore factors associated with the likelihood of readmission.
Results: 502 patients were included (179 [36.4%] male, median age 39 [IQR 50-3] years, 360 [73.2%] staff). Outcomes are illustrated in Figure 1. Median time in CVC was 12 days (IQR 13-10). 1902 calls were made to patients by CVC staff prompted by abnormal data: dyspnoea (41 patients, 8.2%), low SpO2 (133, 26.5%), tachycardia, (99, 19.7%), technical issues (81, 16.1%), absent results (255, 50.1%).
This resulted in 45 (9%) patients requiring re-assessment and 42 (8.4%) being readmitted. Of those readmitted, three (7%) required critical care admission. Median length of stay was two (IQR 6.75-1) days. Those readmitted were more likely to be older (odds ratio [OR] per year older 1.03 [1.01, 1.05], P=0.0050, have an abnormal SpO2 (<94%, OR 5.43 [2.93, 11.1], P<0.001) and, a high dyspnoea score (>7, OR 4.33 [2.04, 9.3], P<0.001). Neither gender nor abnormal HR were associated with higher likelihood of readmission. 22.2% of presenting patients were hypoxic in the absence of dyspnoea, of which 70% required admission and one patient required intensive care.
We describe the largest remotely monitored cohort of COVID19 patients to date. The low frequency of readmissions and value of SpO2 monitoring and dyspnoea scores as predictors of readmission highlights the value of this model in providing safe care whilst minimising unnecessary admissions.
"Antimicrobial Stewardship: Quality Indicators are Key"
Principal Presenter: Nora Dwyer
Under the “Recommendations for Implementation of Key Performance Indicators (KPIs) for Antimicrobial Stewardship (AMS) in Acute Hospitals in Ireland” published by the HSE, it is recommended that all acute hospitals develop and routinely audit AMS KPIs. The process of selecting AMS KPIs for St Michael’s Hospital (SMH), audit of KPIs, intervention by means of education sessions and re-audit are described in this study.
An expert consensus group was formed to define AMS KPIs for SMH. Members of the consensus group included a consultant microbiologist and two senior pharmacists. The MEG Audit application was used to audit these defined KPIs before and after education initiatives. An AMS quick reference sheet was developed for pharmacists to highlight key areas of AMS intervention.
Four in-patient medical wards were included in the audits. The following KPIs, having been defined, were audited; ‘Allergy section completed on medication chart’, ‘Antimicrobial prescribed appropriate for allergy documented’, ‘Antimicrobial choice in line with local guideline/ Microbiology/ID approved’, ‘Review or stop date specified’, ‘Indication documented in medication chart’, ‘Indication documented in medication record’, ‘Patients on IV therapy suitable for PO switch’, ‘Restricted antimicrobial compliant with local policy’. The first audit was completed over a two-week period in November 2019 and re-audited February 2020. The first audit was undertaken on 105 antimicrobial prescriptions (n=105) for a total of 77 patients. The second audit was undertaken on 108 antimicrobial prescriptions (n=108), prescribed for a total of 77 patients. Statistical analysis carried out using a Z- Test of Two Proportions.
Improvements were seen in 6 of 8 KPIs post intervention, with 5 KPIs reaching their target. One KPI showed a statistically significant improvement ‘Patients on IV therapy suitable for PO switch’, (P-value=0.006) improving from 18% to 2%, where the KPI target was ≤30%. The worst performing KPI was ‘Review or stop date specified’. Whilst this KPI improved from 20% to 27%, it remained well below the KPI target set at ≥50%.
The development of AMS KPIs for SMH and subsequent audit, followed by education initiatives and re-audit, highlighted areas of AMS that are performing well - ‘Patients on IV therapy suitable for PO switch’, and also those areas needing improvement - ‘Review or stop date specified’. AMS education to staff and the development of AMS pharmacist reference sheets aided the overall improvement of AMS in SMH.
"Can stable HIV be monitored effectively by telephone? A clinical audit of outpatient HIV monitoring by telephone"
Principal Presenter: Dr. Caoimhe Ryan
The onset of the COVID-19 pandemic necessitated many changes in the delivery of healthcare. Since March 2020 there have been restrictions on outpatient attendances in Irish hospitals with only urgent and necessary attendances permitted; challenging the HIV care continuum. This audit aims to determine if clinics can be conducted via telephone to acceptable standards in concordance with international guidelines.
All telephone appointments from one HIV clinic in August 2020 were included. Data were audited against the EACS guidelines. The following definitions were utilised: always documented(100%), almost always(≥85%), frequently(≥60-85%), usually(≥50-60%), infrequently(≥15-50%), almost never(<15%) and never(0%).
26/34 charts from patients with telephone appointments were reviewed. The following parameters were always documented: all current medications, HIV viral load and CD4 count. Parameters almost always documented; past(96.15%) and current(92.3%) medical history. S.pneumoniae vaccination(76.92%), cervical smear(75%), and renal function(73.07%) were frequently documented. Hepatitis B vaccination(57.69%), liver function(57.69%), lipid profile(57.69%), bone profile(53.84%), and full blood count(53.84%) were usually documented. Influenza(38.46%), and Hepatitis A(26.92%) vaccination, sexual history(26.92%), HbA1c(23.07%), and smoking status(19.23%) were infrequently documented. Cardiac risk assessment(3.84%), and alcohol use(7.69%) were almost never documented. Drug use, psychiatric history, and bone health assessment were never documented.
This audit highlights the potential for outpatient monitoring of stable HIV to be conducted via telephone and identifies areas where practice can be improved and where in-person assessment may be more appropriate.
"Prevalence of Antibodies to SARS-CoV-2 in Irish Hospital Healthcare Workers"
Principal Presenter: niamh allen
Hospital healthcare workers (HCW), and those they live with, are at increased risk
of contracting COVID-19 infection. In October 2020, two tertiary hospitals in Irish cities with
diverging community incidence and seroprevalence were identified. COVID-19 had been
diagnosed in 10.2% and 1.8% of staff of Hospital 1 and 2 respectively. We aimed to improve
understanding of HCW risk factors for SARS-CoV-2 infection and to help health services to
prepare for further waves of the pandemic.
This is a cross-sectional seroprevalence study of antibodies to SARS-CoV-2. All staff
of both hospitals (N=9038) were invited to participate in an online questionnaire and blood
sampling for SARS-CoV-2 antibody testing in October 2020. Frequencies and percentages for
positive SARS-CoV-2 antibody were calculated and adjusted relative risks (aRR) for participant
characteristics were calculated using multivariable regression analysis.
In total, 5,788 HCW participated (64% response rate). Seroprevalence of antibodies to
SARS-CoV-2 was 15% in Hospital 1 and 4.1% in Hospital 2. Ninety-five percent of participants
who reported a previous PCR-confirmed infection had detectable antibodies. Thirty-nine percent
of infections had been previously undiagnosed and 16% were asymptomatic. The
highest seroprevalence was found in healthcare assistants (HCA) at 18%, followed by 13% in
nurses. Adjusted relative risk (aRR) for seropositivity was higher for HCA (aRR 2.0,
95%CI 1.4 – 3.0), nurses (aRR 1.6, 95%CI 1.1 – 2.2), daily exposure to patients with COVID-19
(aRR 1.6, 95% CI 1.2-2.1), age 18-29 years (aRR 1.4, 95%CI 1 1-1.9), living with other HCW
(aRR 1.3, 95%CI 1.1 – 1.5), Asian background (aRR 1.3, 95%CI 1.0-1.6), and male sex (aRR
1.2, 95%CI 1.0-1.4).
One of the main risks for infection in HCWs is the community incidence. The HCW
seroprevalence was six times the community seroprevalence. Risk was higher for those with
close patient contact. The proportion of undiagnosed infections call for robust infection control
guidance, easy access to testing and consideration of screening in asymptomatic HCW. With
emerging evidence of reduction in transmission from vaccinated individuals, the authors strongly
endorse rapid vaccination of all HCW.