Oral Presentations

(in order of programme)

Friday, 17^thMay,  12.40 – 13.10

#1
A retrospective evaluation of Central Nervous System Tuberculous Disease in Beaumont Hospital over a ten year period; case definitions, adherence to treatment guidelines and patient outcomes

• Allen,C. McNally, S. McConkey, E. de Barra
  Beaumont Hospital, Dublin

Background:  Tuberculous Meningitis (TBM) remains a diagnostic and management challenge and clinical outcomes are poor. The Infectious Disease Department in our tertiary referral hospital - also a national Neurosurgical Centre- have recently set up a dedicated TB outpatient clinic. The aim of this study was to describe clinical characteristics, treatment and outcomes in order to identify areas for improvement.

Methods:  All patients with a discharge diagnosis of tuberculous meningitis (TBM) from Beaumont Hospital from 2007 to 2017 were identified from the Hospital Inpatient Enquiry (HIPE) system. Demographic, clinical, microbiological and radiological data were collected using patient paper and . Frequencies of clinical characteristics were stratified by outcome, and differences were assessed using Fisher exact test.

Results:  Twenty-one patients were included; 12 confirmed, 5 probable and 4 possible cases. 15/21 (71.4%) were female, median age 37, IQR 30-47. Areas of origin:  Ireland (10), Indian subcontinent (7), Sub-Saharan Africa (4). Presenting features included headache- 16/21 (76.2%), vomiting- 9/21(42.9%), fever- 8/21(38.1%), limb weakness- 7/21(33.3%), confusion- 7/21(33.3%) and weight loss- 7/21(33.3%). MRC grade at presentation was ≥2 in 7/21 (33.3%). Focal neurological signs were found in 7/2 (33.3%). 4/21presented with meningism. Lymphocytic meningitis with raised protein (median 970mg/dl, IQR 289mg/dl – 1870mg/dl) was found in all cases where CSF was sampled (16/21). MTB was cultured from CSF in 4/16 (25%); all pan-sensitive isolates. 11/21 (52.4%) patients presented with hyponatraemia. 6/21 (28.6%) patients presented with hydrocephalus. Baseline radiological findings were normal in 2 patients. Median time from presentation to initiation of treatment was 10 days, range 1-90. Therapies comprised of 4 anti-tuberculous drugs in 13/21(61.9%), 5 drugs in 8/21 and steroids in 19/21(90.5%). 6/19 (31.6%) had a steroid course of >8 weeks. Steroid-related psychosis occurred in 2/6; 1 life-threatening. 12 patients had an adverse reaction to at least one anti-tuberculous drug. 4 patients had life-threatening treatment complications; stroke (2), blocked VP shunt (1), steroid-related psychosis (1). Inpatient stay ranged from 5-135 days. Of the 17 patients for whom outcome data were available, 15/17 (88.2%) were alive one year after treatment completion. 7/15 (46.7%) had a Modified Rankin Score of ≥3, indicating significant disability. No statistical association was found between individual clinical characteristics and patient outcomes.

Conclusion:  TBM has a range of clinical presentations and can have normal neuro-imaging at baseline. Lymphocytic meningitis with markedly elevated protein remains a hallmark. Negative culture on CSF is common. Hyponatraemia may be a presenting feature. All efforts should be made to confirm the diagnosis microbiologically, without leading to delays in treatment initiation. Adjunctive steroid therapy is recommended for all patients and care should be taken to taper appropriately according to internationally recognised guidelines.

---

#2
Tuberculosis Hospitalizations in Ireland over a 4 Year Period: A Descriptive Study

• James O’Connell, Eoghan de Barra, Sam McConkey
  Dept. of International Health and Tropical Medicine, Royal College of Surgeons in Ireland, Dublin

Background:Ireland has a low incidence of tuberculosis (TB). Understanding the nature of hospital admissions may help efforts to improve services and meet WHO End TB targets. The aim was to describe demographic and clinical characteristics of TB inpatient admissions.

Methods: The National Quality Assurance and Improvement System was searched for discharges where TB was the primary diagnosis from 1/1/15-31/12/18. Secondary diagnoses of TB admissions were searched for risk factors.

Results: 1182 discharges compromising of 909 patients where TB was the primary diagnosis. These compromised of 909 patients with TB. There was no significant decline in discharges across 4-years. 799 (67.6%) were emergency admissions. 732 (91.6%) of emergency admissions required admission for at least one night (referred to as EAOs here onward).The median age of patients admitted was 42 years (IQR=28-58). 28/560 (5%) were aged under 16 years. Males made up 62-67% of admissions. 36/732 (4.9%) required ICU admission. The median length of stay for EAOs was 11 days (IQR=6-21) and was similar over the 4 years. 387/732 admissions (52.9%) were to 9 level 4 hospitals. 306/732 (41.8%) of admissions were to 19 level 3 hospitals. 107/732 (14.1%) of admissions were through an assessment unit.  389/560 (69.5%) had neither a medical card nor health insurance.  233/560 (41.6%) of patients requiring EAO were from Dublin. This remained unchanged over time. However, an increase in the number of EAO admissions to Dublin level 3 and 4 hospitals was seen over time. 104/560 (18.6%) patients were from Cork. The number of patients from Cork and EAOs to Cork level 3 and 4 hospitals had declined each year. 402/732 (43.9%) patients were admitted under 20 specialties. The remainder were admitted under respiratory or infectious diseases. 71/732 (9.7%) of admissions were readmitted within 30 days. 17/560 (3%) patients who required EAO died. Risk factor prevalence was: diabetes 46/909(5.1%), HIV 28/909 (3.1%), chronic kidney disease 25/909 (2.8%), smoking 325/909 (35.8%), homelessness 13/909 (1.4%), illicit drug use 15/909 (1.7%), harmful alcohol use/alcoholic liver disease 36/909 (4%). 109/732 (14.9%) required isolation.

Discussion and Conclusion: A high proportion of TB cases require emergency admission given that a total of 1251 cases were notified over the same period. The relatively low proportion requiring isolation suggests that most admissions were not thought to be at risk of infecting others. Cases are managed in many hospitals and under many specialties. The introduction of a national TB lead, national multidisciplinary team, hospital group TB leads and a cohort review process should be considered.

---

#3
A Clinical Review of Tuberculosis in the West of Ireland

• Grant C., McHugh JW, Ryan C, Tuite H, O’Regan A. Fleming C.
  Galway University Hospital

Background:  Despite declining rates of MTB infection in Ireland, diagnosis and treatment remains challenging. Galway University Hospital (GUH) has a dedicated TB clinic co-staffed by ID and Respiratory and is the local referral centre for TB management.

Aims:  To describe demographics, clinical presentation and course of TB in patients attending the GUH TB clinic, comparing younger and older patients, Irish-born (IB) and Non Irish born (NIB), and  pulmonary (P) versus extra-pulmonary TB (EP).

Methods:  A retrospective chart and laboratory review was performed for all patients diagnosed with TB in GUH from 2014 to 2018. Univariate and stratified analysiswas performed, stratifying for age, place of birth and infection site.

Results:  85cases of TB presented between 2014 and 2018. 10 were clinical diagnoses, 75 lab-confirmed; 1 was M.Bovis culture positive; 2 were HIV co-infected.  Mean patient age was 41.4 years (median33.5, range 15-90). 54% of patients were male, 62% were IB. For NIB patients, the median years in Ireland at diagnosis was 6 (range 0-15). The mean age of IB patients was 46 vs. 32 years in NIB (p=0.003).  10/85 (12%) patients had multi-site TB. Single-site cases included: Pulmonary 44/75 (59%); Lymph node 12/75 (16%); Musculoskeletal 7/75 (9%); Pleural 4/75 (5%); Genitourinary (3/75); Ocular (2/75); Nasal (1/75). Site of infection was not affected by age or place of birth. 4/85 patients had previous diagnosis of latent TB; 3 treated.

Average duration of symptoms was 139 days prior to first hospital presentation, and 65 days from date of first hospital presentation to commencement of TB treatment. The average number of days from symptom onset to treatment was significantly longer for patients ≥34 years vs. those <34 (265 vs. 126 days, p=0.008). EP cases had symptoms for an average 240 days prior to commencing treatment, compared with 162 in P disease (p=0.088). Time to diagnosis was not affected by place of birth (IB vs. NIB: 200 vs. 178 days, p=0.692)

Drug resistance was identified in 2/53 (4%) IB vs. 6/30 (20%) NIB (p=0.017). Patients spent 17 days on average as inpatients on treatment and attended 11 TB clinic appointments. This was not affected by age, place of birth or site of infection.  22 patients experienced 33 treatment interruptions. IB patients more frequently experienced treatment-interruptions vs. NIB (47.17% vs. 16.67%, p=0.006). Readmission rate was 39/100 treatment courses; 0.56 among patients ≥34 years and 0.2 among younger patients (p=0.05). 4/85 (4.7%) patients died; partially attributable to TB in 2/4.

Conclusion:  Patients with TB are young, diverse, with a wide variety of disease sites and have symptoms on average for 4 months at presentation. The delay in symptom recognition should be addressed by increased awareness and possibly by screening for latent infection in NIB. The data supports national trends in increasing resistance among NIB patients and emphasizes the complexity of care with high readmission rates. TB disease remains a significant challenge and requires a coordinated national management programme.

---

Friday, 17^thMay, 16.00 – 17.00

#4
Impact of Renal Tubular Function on Bone Mineral Density in Older People with HIV

• Elena Alvarez, Lucy Campbell, Keith Burling, Sebastian Noe, Mingjin Yan, Hiba Graham, Martin Rhee, Patrick W. Mallon, Frank Post                                                                                                                                             University College Dublin, Catherine McAuley Centre

Background:Whether renal tubule dysfunction (RTD), common in people living with HIV (PLWH), contributes to low bone mineral density (BMD) remains controversial. We studied the relationship between RTD and BMD in a cross-sectional study (GS-US-104-0423) in a group of older (men >50 years and post-menopausal women) PLWH on stable antiretroviral therapy (ART) that had always or never contained tenofovir (TDF), with or without exposure to protease inhibitors (PI) within the previous three years.

Methods: We analysed stored urine for total protein (PCR), albumin (ACR) and retinol-binding protein (RBPCR) expressed as a ratio to urine creatinine, and fractional excretion of phosphate (FE-PO4) and urate (FE-urate). BMD at the lumbar spine (LS) and femoral neck (FN) was measured by dual X-ray absorptiometry (expressed in g/cm2). ART exposure was stratified into four groups (no-TDF/no-PI, no-TDF/PI, TDF/no-PI, TDF/PI). Associations between tubular markers and BMD were assessed using multivariable linear regression models adjusted for demographic factors, clinical characteristics and ART exposure.

Results: 247 individuals (median (IQR) age 57 (53, 65) years, 47% female, 13% of Black ethnicity, time on ART 10 (6-16) years), CD4 643 (473, 811) cells/mm3 and 98% with HIV RNA<200c/mL) contributed to the analysis.  The prevalence of osteoporosis (T-score<-2.5) at LS and FN ranged from 21-30% and 14-28% in the four ART exposure groups respectively (p=0.24 and p=0.08). Of the renal parameters evaluated, only RBCR was associated with reduced BMD at the FN (β -0.014 [95% CI -0.025, -0.002], p<0.0001) and none were associated with BMD at the LS. In addition, both female gender and lower BMI were associated with lower BMD at FN and LS. The association between RBPCR and BMD_FN remained after controlling for age, gender and ethnicity (Table 1, model 1). The observed association lessened with the inclusion of BMI in the model (model 2). Further adjustment for ART exposure group largely attenuated the relationship between RBPCR and BMD at the FN; using no-TDF/no-PI as the ART reference group, exposure to TDF (with or without PI) was associated with lower BMD at the FN (model 3).

Conclusions: In this cohort of older PLWH with high prevalence of osteoporosis, RBPCR was the only marker of RTD associated with reduced BMD. This association was attenuated after adjustment for BMI and fully abrogated after additional adjustment for ART exposure. TDF exposure was an independent risk factor for reduced BMD at the FN.

Table 1. Mean effect (coefficient β) and 95% confidence interval (95% CI) derived from series of multivariable linear regression models

Multivariable Models	Mean effect on BMD_FN (95% CI)	p
MODEL 1: Adjusted for demographic factors
RBPCR (log transformed)	-0.013 (-0.025, -0.001)	0.029
MODEL 2: Further adjustment for BMI
RBPCR (log transformed)	-0.008 (-0.016, 0.006)	0.166
BMI (per 1 unit)	0.011 (0.007, 0.015)	<0.0001
MODEL 3: Further adjustment for ART group
RBPCR (log transformed)	-0.003 (-0.015, 0.009)	0.647
BMI (per 1 unit)	0.013 (0.009, 0.017)	<0.0001
No-TDF/No-PI	1
No-TDF/PI	-0.047 (-0.098, 0.004)	0.071
TDF/No-PI	-0.072 (-0.121, -0.023)	0.004
TDF/PI	-0.065 (-0.117, -0.013)	0.015

 

---

#5
Immunosenescence in HIV is associated with CMV status and lower CD4:CD8 ratio

Tara McGinty1,  Sarah Miles1, Willard Tinago 1, Caroline A. Sabin,3 Alan Landay 4, Jeffrey Martinson4, Charlotte Prior 2, Brenda Doak2, Cillian DeGascun5, Deirdre Burke5, Alan Macken1, Gerard Sheehan, 1,2 John Lambert 1,2, Aoife G. Cotter,1,2 Patrick W.G. Mallon1,2 on behalf of the HIV UPBEAT (Understanding the Pathology of Bone Diseases in HIV-infected Subjects) Study Group 1.     HIV Molecular Research Group, School of Medicine, University College Dublin, Ireland 2.     Mater Misericordiae University Hospital, Dublin, Ireland 3.     Institute for Global Health, UCL, London 4.     Research Immunology, Rush University Medical Centre, Chicago, USA 5.     National Virus Reference Laboratory, University College Dublin, Ireland

Introduction:  It remains unclear whether increased immunosenescence observed in people living with HIV (PLWH) is driven by high rates of cytomegalovirus (CMV) co-infection or underlying immune dysfunction. We investigate relationships between immune function, CMV IgG positive status (CMV+) and immunosenescence in PLWH and HIV- control subjects. Methods:  Using cryopreserved PBMC from subjects in HIV UPBEAT, a cohort of PLWH and HIV- controls from similar demographic backgrounds, we measured CD4 and CD8 T-cell immunosenescence by flow cytometry, defined as CD4+/CD8+, CD28- CD57+ T-cells. We used linear regression to explore associations between immunosenescence, HIV status, demographics, CMV+, CMV IgG titres and CD4:CD8 ratio. Data are median (interquartile range) or model estimate (ME) [95% confidence interval (CI)] unless stated. Results:  Of 219 subjects, 107 (48.8%) were PLWH (68% male, 34% African, age 47 [39-53] years, 30% smokers) and 112 were HIV- (48% male, 17% African, age 50 [44-56] years, 15% smokers). PLWH had lower CD4:CD8 ratios (0.89 [0.65-1.19] vs 2.3 [1.63-3.18], P<0.001), higher % of senescent CD4+ and CD8+ T-cells (4.2 [1.4-7.6] vs 0.5 [0.1-2.1] and 34 [21.0-45.4] vs 22.6 [14.4-35.0] respectively, both P<0.001) and were more likely to be CMV+ (89% v 40%, P<0.001). In univariate analyses, HIV status, lower CD4:CD8 ratio and CMV+ were associated with higher CD4+ and CD8+ senescence. In analyses adjusted for age, gender, ethnicity and smoking, HIV infection remained significantly associated with higher CD4+ (ME [95%CI) 1.668 [1.168-2.168], P<0.001) and CD8+ (0.306 [0.115-0.497], P=0.002) T-cell senescence. Additional adjustment for CD4:CD8 ratio or CMV+ attenuated this association (table1), with both lower CD4:CD8 ratio and CMV+ associated with increased CD4+ and CD8+ senescence. When both were included in the model, CD4:CD8 ratio and CMV+ remained independently associated with increased T-cell senescence.  CMV+ was similarly associated with CD4+ and CD8+ senescence in PLWH and HIV- subjects (interaction p=0.27 for each) but associations with CD4:CD8 ratio were slightly weaker among PLWH (interaction p=0.002 and p=0.001, respectively). Replacing CMV+ with CMV IgG titres did not alter these findings. Conclusions:  Increased CD4+ and CD8+ senescence in PLWH can be attributed to both immune dysfunction, reflected in lower CD4:CD8 ratios, and CMV status. Future research should focus on immunosenescence and its impact on clinical outcomes in PLWH. Table 1: Association between HIV, log CD4:CD8 ratio and CMV positivity with CD4+ and CD8+ T-cell senescence* *All models adjusted for age, gender, ethnicity and smoking status. Effect on log CD4+ T-cell senescence Model (i)     Model (ii)     Model (iii)       ME 95% CI P ME 95% CI P ME 95% CI P                     HIV+ vs HIV - 0.665 0.075; 1.256 0.03 0.422 -0.022; 0.866 0.062 -0.206 -0.698; 0.287 0.41 log CD4:CD8 ratio -0.999 -1.357; -0.642 <0.001 - - - -0.713 -1.001; -0.425 <0.001 CMV IgG: Positive vs Negative       2.786 2.317; 3.254 <0.001 2.591 2.139; 3.043 <0.001                     Effect on CD8+ T-cell senescence ME 95% CI P ME 95% CI   P ME 95% CI P HIV+ vs HIV - -0.087 -0.312; 0.138 0.45 -0.053 -0.245; 0.139 0.59 -0.328 -0.541; -0.116 0.003 log CD4:CD8 ratio -0.392 -0.529; -0.256 <0.001 - - - -0.313 -0.437; -0.189 <0.001 CMV IgG: Positive vs Negative - - - 0.803 0.6; 1.005 <0.001 0.717 0.522; 0.913 <0.001

 

---

#6
Inflammatory Phenotypes Predict Pulse Wave Velocity Change on ART in Malawian Adults

Christine Kelly¹, Willard Tinago², Alejandro Garcia Abner²,  Ralph Kamngona³,  Patrick Mallon²,  Henry Mwandumba⁴, Sarah Walker⁵, Saye Khoo⁶, Nigel Klein⁵

1. St. James’s Hospital, 2. University College Dublin, 3. Malawi Liverpool Wellcome Trust Clinical Research Program, Malawi, 4. University of Malawi, Malawi, 5. University College London,  6. University of Liverpool

Background:  Inflammation has been linked to vascular dysfunction and increased risk of cardiovascular disease. In low-income settings, drivers of inflammation are multiple, with infectious and environmental factors contributing. We hypothesise that adult people living with HIV (PLWH) in sub-Saharan Africa starting ART with advanced immunosuppression can be stratified into inflammatory phenotypes that predict changes in vascular dysfunction on ART, as measured by pulse wave velocity(PWV).

Methods:  We recruited PLWH with CD4<100 cells/ul two weeks after starting ART in the REALITY trial (NCT01825031). PWV was recorded 2, 10, 24 and 42 weeks post ART. We measured markers of cell surface immune activation by flow cytometry and plasma inflammation markers by electrochemiluminescence at week 2. We identified inflammatory phenotypes using principle components analysis of 22 different markers, using linear mixed models to explore associations between inflammation clusters and change in PWV with ART.

Results:  In 260 of 279 PLWH with available biomarker data we identified three clusters representing 59 (cluster 1), 194 (cluster 2) and 7 (cluster 3) subjects (Figure 1A). Cluster 1 showed markedly higher CD4 and CD8 T cell expression of HLADR and PD1 vs clusters 2 and 3 (HLADR: CD4 86% vs 69%, CD8 84% vs 72%; PD1: CD4 69% vs 39%, CD8 54% vs 33% respectively; all p<0.0001). Although small, subjects in cluster 3 had significantly higher levels of inflammatory cytokine pathways (IL6, IFNɣ, IP10, IL1RA, IL10), chemotaxis (IL8), systemic and vascular inflammation (CRP, ICAM1, VCAM1) and SAA (all p<0.001); and marginally lower pre-ART CD4 (17 vs 42 cells/mm3, p=0.08). Baseline PWV was statistically lower in cluster 3 (6.3m/s vs 7.6, p=0.009), but increased over 42 weeks (log change 0.1m/s vs -0.5, p=0.07, Fig 1B). In mixed models, IL1RA was independently associated with lower baseline PWV (log -0.32m/s per pg/ml higher, p=0.02) and attenuated decline in PWV by week 24 (change in log slope +0.39m/s per pg/ml higher, p=0.01). Cluster 3 also had lower adjusted baseline PWV (log -0.13m/s, p=0.005) but no adjusted change in PWV over time (log +0.23m/s, p=0.13).

Conclusions:  In PLWH from low income settings with high pre-ART T cell activation, PWV improves (declines) on ART. However, we identified a cluster with a hyper-inflamed biological profile in whom PWV increased, with IL1RA a potential marker of this hyper-inflamed state and increasing PWV. The clinical implications of this phenotype require further research.

---

#7
Hepatic steatosis, Ageing and MEtabolic Syndrome in HIV patients (The HAMES-HIV study)

Murphy, M¹,  Almusa Z¹, Farrell G¹, Murray C¹, Broderick M¹, Norris S², Bergin C¹

1. Department of Genito Urinary Medicine & Infectious Diseases, St James’s Hospital, Dublin 2. Department of Hepatology, St James’s Hospital, Dublin

Background:   HIV patients are now living longer and liver disease has emerged as one of the leading causes of morbidity and mortality (1). Metabolic syndrome, ageing, HIV infection, viral hepatitis and antiretroviral therapy all affect the liver in unknown quantities. The prevalence of non-alcoholic fatty liver disease (NAFLD) is higher in the patients living with HIV than the general population (2). NAFLD covers the spectrum of conditions that begin with hepatic steatosis (accumulation of fat in the liver) which can progress to steatohepatitis, fibrosis and cirrhosis.  Guidelines recommend liver imaging in patients with suspected NAFLD and metabolic syndrome. The NAFLD Fibrosis score has been developed to identify those that would benefit from further liver investigations. The aim of this pilot study was to assess the prevalence of metabolic syndrome and hepatic steatosis in HIV patients over 50 years.

Methods:  St James’s Hospital has the largest cohort of HIV patients in Ireland. HIV Patients ≥50 years were identified and relevant data was extracted from the electronic patient record. Metabolic syndrome is defined as ³3 of the following features which are associated with insulin resistance: hypertension, body mass index (BMI) ³30kg/m², low HDL, hypertriglyceridemia and type 2 diabetes. The NAFLD Fibrosis score was calculated using alanine/aspartate aminotransferase level, albumin, platelet counts, BMI, diabetes history and age;a score of >0.675 is suggestive of liver fibrosis. Statistical analysis was conducted using STATA v15.1.

Results:  There were 456 patients ≥50 years identified, from a cohort of ~2,400. The majority were HIV mono-infected (85.5%, n=390). 11.4% (n=52) were co-infected with HCV (of these 25% were genotype 3). Where available data was captured (58.6%, n=267), 52 patients had metabolic syndrome (19.5%). Liver ultrasound imaging was performed in 16 of these patients (30.8%), the majority had steatosis confirmed (62.5%, n=10). The majority of patients with metabolic syndrome had normal liver function tests (84.6%, n=44). The absence of metabolic syndrome was associated with low NAFLD fibrosis scores (p=0.045). From ultrasound imaging, higher rates of hepatic steatosis were noted in HIV mono-infection (37.2%, n=32) compared to patients co-infected with viral hepatitis (15.5%, n=9).

Conclusion:  High rates of liver morbidity identify the need to develop a screening programme for the identification and subsequent management of hepatic steatosis in patients living with HIV. This pilot data suggests that hepatic steatosis in HIV mono-infection is potentially more concerning than previously realised.

References

1. Chan, A.W. et al. Aging of the Liver: What This Means for Patients with HIV. Curr HIV/AIDS Rep (2016) 13: 309.

Maurice JB et al. Prevalence and risk factors of nonalcoholic fatty liver disease in HIV-monoinfection. AIDS (2017) 31: 1621-32.

---

#8
Elite Controllers requiring elite Management Decisions in the Test and Treat era.

Christine Kelly
St. James’s  Hospital, Dublin

The management of people living with HIV who are long term non-progressors is controversial. Data is accumulating that the risk of co-morbidities are increased in this group of patients, but guidelines remain unclear on whether ART should be initiated. We present two patients who are long term non-progressors as examples of the clinical issues involved.

The first is a 34-year old lady diagnosed with HIV in 2004. She had one detectable VL of 247 copies/mL in 2008 but all other viral loads since diagnosis have been undetectable. CD4 counts have always been maintained well above 500 cells/uL. CD4/CD8 ratio is 1.86. BMI is 19 and there is no history of smoking, dyslipidaemia, diabetes, hypertension or family history of heart disease. She is not currently on any ART and there is no clear guidance on whether she should start, given potential side effects of life long ART.

On the other hand, the second lady is a 51-year old lady diagnosed with HIV in 1984. She has persistently had detectable viral loads around 200 copies/mL since diagnosis but was commenced on ART in 2014. At the point of ART initiation, CD4/CD8 ratio was 0.5. She is an active smoker with poorly controlled diabetes, dyslipidaemia and hypertension. Her brother died age 33 from an MI. She was admitted to hospital in November 2018 with dusky, painful, numb fingers on her left hand. She was found to have a 20% stenosis in her left subclavian artery and was commenced on aspirin. However, she was then admitted again in January 2019 with worsening symptoms in her hand and a fixed deformity in her left 4^thdigit. A repeat CT angiogram revealed a 70% stenosis of the left subclavian artery and urgent subclavian stenting was undertaken.

These cases highlight the issues involved in managing patients who are long term non-progressors. There is an urgent need for more data, including clinical biomarkers of immune activation, to help inform optimal management. They also represent an interesting cohort of patients to inform us about the non-infectious complications of low level HIV viraemia and the particular endovascular clinical phenotypes that may emerge in these populations.

---

#9
An Assessment of Prescriber's Attitudes to the Introduction of Preferred Regimens of Highly Active Antiretroviral Therapy (HAART) at a Local and National Level

Kelly M^1,2,Barbosa T³, Kelly S^1,2, Moriarty M ^1,2, Melanophy G¹,Bergin C².

¹Pharmacy Department, St. James’s Hospital, ²Department of GU Medicine and Infectious Diseases (GUIDE), St. James’s Hospital, ³University College Cork

Introduction:  The evolution of HIV from a terminal illness to a chronic condition has been driven by early diagnosis and effective management with highly active antiretroviral therapy (HAART). Patients living with HIV (PLWH) now have a life expectancy nearing that of HIV negative patients. The management of an ageing HIV population and the sustainability of HIV care remain major challenges (1). There are presently no restrictions to HAART regimen choice in Ireland, each individual centre is responsible for their own procurement and prescribing.

Aim:  To assess the attitude of prescribers to the introduction of preferred HAART regimens at a local and national level.

Methods: This study design involved semi-structured interviews of ten prescribers (six consultants and four specialist registrars). A topic guide was prepared, consent was obtained in writing from all prescribers and all interviews were recorded. Thematic analysis was used to analyse the interview. Ethical approval was obtained.

Results:  The prescriber interviews showed that 9/10 prescribers would be in favour of an internal GUIDE preferred regimens algorithm, with 6/10 in favour of this system nationally. The main themes that emerged from anyalysis of the interviews were patient factors that influence prescribing and disease factors that influence prescribing. Patient factors were sub-divided into patient characteristics and patient co-morbidities. Disease factors were sub-divided into HIV disease status, co-morbidities and potential side effects. Concerns at a local level include loss of autonomy, a possible compromise to patient care and the structure around the creation of a preferred regimens algorithm. Concerns at a national level include having one algorithm for varied patient cohorts and a financial focus and loss of clinical Involvement.

Conclusions:  The prescriber concerns highlighted the requirement for clinician involvement in any system of preferred regimens. All prescribers said that an incentive-based system would drive cost saving innovations within the department. 

References

1. UNAIDS. 90-90-90: an ambitious treatment target to help end the AIDS epidemic. UNAIDS Geneva; 2014.

 

---

#10  (Linked to O9 Oral in Presentation).
Prescribing Pattern of Highly Active Anti-Retroviral Therapy (HAART) in an Outpatient Genitourinary and Infectious Disease (GUIDE) Department

Kelly M^1,2,Barbosa T³, Kelly S^1,2, Moriarty M ^1,2, Melanophy G¹,Bergin C².

¹Pharmacy Department, St. James’s Hospital, ²Department of GU Medicine and Infectious Diseases (GUIDE), St. James’s Hospital, ³University College Cork

Introduction:  The evolution of HIV from a terminal illness to a chronic condition has been driven by early diagnosis and effective management with HAART. The GUIDE department at St James’s Hospital (SJH) provides care to more than 2500 HIV positive patients. International best practice guidance advises using a dual NRTI (nucleoside reverse-transcriptase inhibitors) backbone and a third agent as standard HAART, there are presently no restrictions to HAART regimen choice in Ireland (1, 2). The increase in new pharmaceutical therapies has meant there are a plethora of treatment choices for HIV clinicians.

Aim:  To identify prescribing trends for patients on HAART in an outpatient GUIDE clinic.

Methods:  A point prevalence study was undertaken in SJH GUIDE clinic. All patients who attended HIV clinics from 30^th April-30^th May 2018 were included in the study unless they met the exclusion criteria. Ethical approved was obtained.

Results:  Data from a total of 521 HIV patients was collected. The study population had similar patient demographics to the wider GUIDE population; men who have sex with men (MSM) (53.5%, n=279), people who inject drugs (PWID) (6.75% n=35), male (73.7%, n=384) with an average age of 42 years. While 92% of the patient cohort were virally suppressed, this was 82% in people who inject drugs (PWID). In total 63 different HAART combinations were used. There were 484 (92.89%) patients taking standard HAART regimen with two NRTI backbone drugs and a third agent. Tenofovir disoproxil fumarate (TDF) was the most utilised NRTI backbone (42.56%), with integrase inhibitors the most popular choice for third agent (43%). There were 53% (n=260) of patients taking a single tablet regimen (STR). Analysis of the switch cohort (5.75%; n=30) showed a trend towards prescribing STRs, tenofovir alafenamide (TAF) and integrase inhibitors. The main drivers for switch were toxicity and simplification.

Conclusions:  Viral suppression rates indicate that the GUIDE clinic in SJH is on track to meet the UNAIDs 90:90:90 targets. However, guidance targeting the PWID cohort could improve adherence and outcomes in this population. This study shows a movement towards prescribing STRs, TAF containing regimens and integrase inhibitors, with a decline in NNRTI use. All current prescribing meets international best practice guidance but an increase in choice means that prescribing has become more variable.

References

1.     Waters L, Ahmed N, Angus B, Boffito M, Bower M, Churchill D, Dunn D, Edwards S, Emerson C, Fidler S, Fisher M. BHIVA guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2015 (2016 interim update). BHIVA) BHA, ed. London, UK: BHIVA. 2016.

2.     Ryom L, Boesecke C, Bracchi M, Ambrosioni J, Pozniak A, Arribas J, Behrens G, Mallon PG, Puoti M, Rauch A, Miro JM. Highlights of the 2017 European AIDS Clinical Society (EACS) Guidelines for the treatment of adult HIV‐positive persons version 9.0. HIV medicine. 2018 May;19(5):309-15.

3.     UNAIDS. 90-90-90: an ambitious treatment target to help end the AIDS epidemic. UNAIDS Geneva; 2014.

4.     Hughes G, Bergin C. The prevalence, drivers and outcomes of switches in highly active antiretroviral therapy (HAART) in HIV positive patients attending outpatient clinics at St James;s Hospital Dublin. 2015.

---

Saturday, 18^thMay, 09.00 – 10.00

#11
Demographics and Treatment Outcomes of Patients with Chronic Hepatitic C Infection Attending a Tertiary Level Hospital in the Era of Unrestricted Access to Direct-Acting Antivirals

K Davenport, J Farrell, E O’Connor, T McGinty, EG Muldoon, AG Cotter, G Sheehan, PW Mallon, JS Lambert
Department of Infectious Diseases, Mater Misericordiae University Hospital, Dublin

Background: Direct-acting antivirals (DAAs) have revolutionized management of chronic hepatitis C virus (HCV) infection. We sought to establish the demographic characteristics and treatment outcomes in HCV-infected patients attending the Mater Misericordiae University Hospital in the era of unrestricted access to DAAs.

Methods: Retrospective chart review of patients treated for HCV infection 01/04/2017-31/12/2018 gathering information on gender, age, mode of transmission, country of origin, co-infections, HCV genotype, degree of liver damage as assessed by transient elastography (Fibroscan), previous treatment history, and DAA treatment outcomes (early treatment response, ETR, i.e. HCV viral load  undetectable/<12copies/ml at week 4 of treatment; end-of-treatment, EOT, i.e. HCV viral load undetectable/<12copies/ml at the time of completion of treatment; sustained virologic response, SVR, i.e. HCV viral load  undetectable or <12copies/ml at 12 weeks after completion of treatment). Descriptive column statistics were used to analyze data.

Results:  Of 145 treated patients, 104 (71.7%) were male and intravenous drug use was the most likely mode of transmission in 109 (75.2%) cases. Remaining cases were attributed to: 7 (4.8%) men having sex with men, 1 (0.7%) each to tattoos/blood transfusion/vertical transmission, and 26 (17.9%) had no indentifiable risk. Irish-born patients totalled 103 (71.0%) cases, 9 (6.2%) were from other European countries, 23 (15.9%) from countries of the former Soviet Union, 4 (2.8%) from Sub-Saharan Africa, 3 (2.1%) from Asia, 2 (1.4%) from Middle East and 1 (0.7%) from South America. Of the non-Irish patients, 15 (35.7%) were asylum-seekers. Co-infection with HIV and HBV was present in 38 (26.2%) and 1 (0.7%) of cases, respectively. Fibroscan score was 6.5±0.6kPa (mean±standard error of mean) for the non-cirrhotic patients (n=116, 80%) and 23.7±4.4kPa for the cirrhotic patients. History of previously failed treatment was present in 9 (6.2%) cases, including 2 (1.4%) DAA failures. Genotype distribution was as follows: 65 (44.8%) G1a, 57 (39.3%) G3, 13 (9.0%) G1b, 5 (3.5%) G4, 1 (0.7%) G2, 1 (0.7%) G1e. Dual genotypes were identified in 3 (2.1%) patients. Treatment duration was 8 weeks in 24 (16.6%), 12 weeks in 118 (81.4%), and 24 weeks in 3 (2.1%) cases. ETR was achieved by 93 (64.1%) and EOT by 135 (93.1%) patients. Of 83 patients for whom SVR data are available, 80 (96.4%) achieved SVR.

Conclusion:  Our DAA treatment outcomes are comparable with those previously reported. While traditional risk groups remain overrepresented among those infected with HCV, new patient groups are emerging and pose new challenges to care.

---

 

#12
Hepatitis B Genotype Distribution and Drug Resistance Mutations in Ireland, 2016-2018

Doireann Waldron O’Loughlin, Anne Conroy, Jonathan Dean, Cillian F. de Gascun
National Virus Reference Laboratory, University College Dublin

Background: Hepatitis B virus (HBV) infection is a leading global cause of morbidity and mortality. Recent WHO estimates suggest that 257 million individuals worldwide are chronically infected.  HBV can be classified into 10 genotypes (A-J), each containing several subgenotypes, with associated geographical distribution and clinical manifestations. Comparable to other northern European countries (0.1-0.7%), the prevalence of HBV in Ireland is low (<1%), but little is known of the HBV genotypic distribution in Ireland. Likewise, even though resistance to antiviral drugs can significantly affect the clinical outcome of HBV infection, little is known about the prevalence of resistance-conferring mutations in the Irish HBV patient cohort.  This report summarises the genotypic distribution of HBV in Ireland from 2016 to present.  Collating these data will inform national policy for the prevention and control of HBV in Ireland.

Method:  In 2016, the National Virus Reference Laboratory (NVRL) switched from the INNO-LiPA® line probe assay to hemi-nested PCR and Sanger sequencing for HBV genotyping and drug resistance testing.  A 1.1kb fragment of the HBV polymerase gene, incorporating partial S1 and entire S2 and S genes, was amplified from clinical specimens received between 2016 and 2018 (n=463 patients), and including both acute and chronic HBV infections.  Sanger sequencing was performed on the amplified product and consensus sequences analysed, with analysis of amino acid substitutions performed using the online genotyping tool Geno2Pheno_[HBV].

Results: Hepatitis B genotype D was the most prevalent at 30.52% (n= 141), closely followed by genotype A (28.35%; n=131), E (16.88%; n=78), C (12.99%; n=60) and B (10.17%; n=47). As expected, genotypes F and H were identified in low numbers (0.65% and 0.22% respectively; n=3, n=1). One putative dual/mixed (C/D) infection was identified, but has yet to be confirmed.  One or more drug resistant mutations were identified in 10 patients (2.16%). Mutations at codons 180 and 204 were seen most frequently, detected in 6 patients each. The mutations conferred resistance to Telbivudine, Lamivudine, Entecavir, Adefovir and Tenofovir. In each case, the mutations appear to have arisen whilst the patient has been receiving antiviral treatment for HBV.  None of the cases identified as acute infection possessed resistance mutations.

Conclusions:  HBV antiviral drug resistance is uncommon in Ireland, but the ability to determine both genotype and drug resistance profiles in a single assay allows for detection of resistance mutations in real-time, even in patients not suspected of harbouring resistant virus, and/or cases of transmitted drug resistance.

---

#13
Compliance of Hepatitis B Management at a single site with European Guidelines

Liam Townsend,GillianFarrell, Marian Broderick, Catherine Murray, Colm Bergin
St. James’s Hospital, Dublin

Background:  The European Association for the Study of the Liver (EASL) have guidelines for management of hepatitis B (HBV). We audited our compliance with these guidelines in the St James’s Hospital GUIDE Department.

Methods:  We evaluated clinical notes and electronic records of all HBV patients listed as attending the GUIDE department. We evaluated our compliance with EASL guidelines regarding:

• Initial HBV assessment
• HBV surveillance
• Treatment initiation
• Cirrhosis follow up

Results:  265 patients attended GUIDE for HBV evaluation.

 

Guideline	Concordance (n=265)
Baseline liver biochemistry	265 (100%)
HBV Viral Load	264
Imaging (US/Fibroscan)	217
Hepatitis A status - HAV immune - non immune and received vaccination - non immune but did not receive vaccination	231 190 28 13

Regarding comorbidities, there were 61 HIV co-infected, 10 HCV co-infected, and 4 HDV co-infected. Non-infectious comorbidities include 20 with alcohol excess, 8 with diabetes, and 60 with increased BMI.

65 have been lost to follow up, with 200 retained in care. Of those retained in care, 161 had a partner:

• 151 partners tested
• 16 showed previous HBV exposure
• 122 of those underwent vaccination

Of those retained in care:

Guideline	Concordance
Requiring Treatment -commenced on treatment	109 102
Viral suppression on treatment (VL < E+3)	96
Loss of sAg	12
Annual Surveillance
Imaging within 6/12 -imaging ordered within 6/12	106 58
Liver biochemistry & αFP within 6/12	186
Viral Load within 3 years	186

9 patients are cirrhotic; three have undergone endoscopic variceal surveillance.

Conclusion:  HBV management is broadly in line with EASL guidelines. 93% of those eligible for treatment have received same, and of those on treatment all are suppressed, with recent starts the only exception. We are achieving high levels of radiological surveillance (82% engaged in ultrasound surveillance).  The main shortcoming in our service is immunisation for other co-infections. 13% have never had their HAV status assessed. Of those that were found to be non-immune, 32% have not been vaccinated. The low testing for HDV in our cohort is not in keeping with guidelines for testing for same, and will need to be addressed.  There are a small number of cirrhotic patients (4.5%); however, only one third of these have had endoscopic variceal surveillan

---

#14
Association between Integrase Strand Transfer Inhibitors and serum magnesium levels

Kai Fung K, O’Broin C, McGettrick P, Savinelli S, Tinago W, Muldoon E, Lambert J, Sheehan GS, Fitzgibbon M, Mallon P
HIV Molecular Research Group, University College Dublin

Background:  Concerns surround potential links between the Integrase Strand Transfer Inhibitor (InSTI) dolutegravir and neural tube birth defects (NTDs) in cohort studies. That low gestational magnesium (Mg++) is associated with NTDs in rodents and NTDs produced by depletion of the bifunctional protein TRPM7 can be prevented through Mg++ supplementation, indicates a role for Mg++ in neural tube closure. Low maternal Mg++ levels have been associated with NTDs in humans, although causality has not been established. Dolutegravir binds strongly to a magnesium moiety at the HIV integrase enzyme active site. The aim of this study was to explore associations between use of InSTI and dolutegravir in particular, with magnesium levels.

Methods:  Adult ART-treated subjects living with HIV recruited to the University College Dublin Infectious Diseases Cohort provided demographic and clinical data  alongside routine measurement of albumin, folic acid and serum electrolytes, including total and ionized magnesium. Unadjusted and adjusted differences between groups in magnesium parameters were assessed using the Wilcoxon rank sum test and linear regression respectively. Data are median (IQR) unless stated.

Results:  149 subjects provided data, the median (IQR) age was 41
(36-47) years, 58% were male, 45% Caucasian and 45% African. HIV transmission risk was through heterosexual contact (55%), men who have sex with men (20%), intravenous drug users (16%). 60% of patients were on InSTI ART. 90% had viral RNA <40 copies/ml.
Mg++ levels were not significantly different between those on INSTI regimens versus non-INSTI regimens (0.82 (0.77-0.86) mmol/L vs 0.84 (0.79-0.87) mmol/L, p=0.09), Mg++ levels were significantly lower in those on DTG regimes versus non-DTG  regimens (0.81 (0.76-0.87)mmol/L vs 0.84 (0.79-0.87) mmol/L, p=0.01). Corrected for age, gender and ethnicity, there remained significantly lower total magnesium levels (-0.026 mmol/L, p=0.05) in those on DTG regimens compared to those on non-DTG regimens. There were no significant differences in ionized magnesium levels between groups.

Conclusions:  Current dolutegravir use was associated with a statistically significant but small reduction in total Mg++ levels, which remained significant after correction. Given the role of magnesium in development of NTDs, these data support the need for further, larger studies in this area.

---

#15
An Audit of Staphylococcus aureusBacteraemia Clinical Management in a Large Model 4 Teaching Hospital, 2018

N Wrigley Kelly,A Mohamed, C Conlan, B O’Connell, C Bergin
St. James’s Hospital, Dublin

Background:A number of quality-of-care indicators (QCIs) have been demonstrated to reduce mortality in Staphylococcus aureus bacteraemia(SAB): follow-up cultures 48-96 hours after starting antimicrobial therapy, early source control, echocardiography in those with clinical indications, early IV cloxacillin, adjustment of vancomycin to troughs and treatment duration according to infection complexity.

Materials/methods: All cases of SAB managed in St James’s Hospital for 2018 were examined. Data was collected using the Electronic Patient Record system, microbiology and medical records.

Results: There were 68 patient episodes of SAB.62 (91%) were methicillin-sensitive S. aureus(MSSA) versus 6 (9%) methicillin-resistant S. aureus(MRSA). 28 were community-acquired (41%). An IV/IA line was the source in 32 cases (47%).

1. Follow-up blood cultures
   68% of patients had repeat cultures within 48 hours; 19% between 48 and 96 hours. Therefore the QCI for follow-up blood cultures was met in 87% of cases.
2. Source control
   Line removal was performed in all 32 cases in which it was the source. 16 patients (24%) had soft tissue abscesses; 6 were drained. 20 patients (29%) had prosthetic material other than a line. It was implicated as the source in 6 cases and removed in 3.
3. Echocardiography
   61 patients had echocardiography (90%). 24/28 patients with community-acquired SAB (86%) had an echo; 31/32 patients with line-associated SAB did (97%).
4. Early IV cloxacillin
   Flucloxacillin was the most commonly used antibiotic (76%). Otherwise, prescribers used vancomycin (7%), daptomycin (7%), cefazolin (6%). Of the 11 cases (7%) in which an antibiotic other than flucloxacillin/cefazolin was used, 5 had penicillin allergy and 5 had MRSA bacteraemia. One patient was discharged on oral ciprofloxacin.
5. Adjustment of vancomycin dose to troughs
   Of the 5 cases in which vancomycin was used, 2 maintained the majority of troughs within target range (15-20mg/L). Doses were adjusted to troughs in all cases.
6. Treatment duration according to infection complexity
   In the community-acquired group, 18 of the 28 patients (64%) received at last 4 weeks IV antibiotics. Of the 30 patients with hospital-acquired, line-associated infection, 20 (66%) received 2 weeks IV therapy.

Conclusions: This data demonstrates high rates of timely follow-up cultures, adjustment of vancomycin dose to troughs and early IV cloxacillin. The rate to which source control was achieved varied according to its nature. High echocardiography rates were seen, although it was perhaps over utilised in uncomplicated cases. In a significant minority of cases, antibiotic duration did not correspond to infection complexity. We suggest that a bundle focused on improving adherence to QCIs with infection services taking over patient care might improve practice.

---

 

#16
Outpatient Antimicrobial Therapy for Endovascular Aortic Repair Infection; a Five Year Retrospective Evaluation

Mohamed  Eltayeb,  Grace O’Regan ,  Aoife Seery, Niamh Allen, Cora Mc Nally, Samuel McConkey, Eoghan de Barra

Background:  An estimated 1% of endovascular aortic repair (EVAR) devices become infected, carrying a high mortality rate. Few published data exist around patient outcomes. We examined our cohort retrospectively to add to the understanding of these complicated infections and their management.

Methods:  Using the Hospital Out-Patient Antimicrobial Therapy (OPAT) database we identified all patients who received at least one course of OPAT for infected EVAR over a 5-year period from 2014-2018 inclusive.  Patient medical and electronic records were used to collect demographics, clinical, microbiological and radiological data. Management of Aortic Graft Infection Collaboration (MAGIC) case definitions were applied and management and patient outcomes are described.

Results:  Eleven cases were identified; 10/11 (91%) male, median age 76, range 65-85. Index indication for graft insertion was; aneurysm size- 6/11 (54.5%), symptoms- 3/11 (27.3%) and rupture- 2/11 (18.2%). 3/11 were emergency procedures, 6/11 elective, 2/11 semi-elective. Post-operative complications occurred in 7/11 (63.6%) (five endo-leak (one type 1, two type 2, two type 3), one haematoma and one wound infection). Median time to presentation with aortic graft infection (AGI) post deployment was 229.5 days, range 0-2670. 4/11 (36.4%) had undergone re-intervention prior to presentation with infection. Symptoms included: fever- 6/11 (54.5%); anorexia 6/11 (54.5%); abdo/groin pain 5/11(45.5%); back pain 3/11 (27.3%); bleeding 2/11 (18.2%). 2/11 (18.2%) had leucocytosis. 6/11(54.5%) had probable or confirmed aorto-enteric fistula. 7/11 (63.6%) were late infections (presentation >4 months post stent deployment). Causative organisms were identified in 5/11 (45.5%) cases (blood cultures 3/11, sac aspirate 1/11; endograft culture 1/11). 3/6 (50.5%) were polymicrobial infections.  8/11(72.8%) met criteria for definite infection, 3/11 suspected. 9/11 (81.2%) were re-admitted to hospital at least once, median 3.5, range 0-5, median bed days 67, range 0-193. Median number of days on OPAT was 46.5, total 864. 2/11 had surgical explantation.  4/11 (36.4%) reached primary outcome of death (at 5, 10, 27 and 72 months). Palliative care referral was offered to 3/11.

Conclusion:  AGI occurs most commonly in the first year post deployment. Common presenting features include pain, fever and anorexia. Normal leucocyte count and negative blood cultures do not exclude infection. Where causative organisms are determined, infections are often poly-microbial. This should be considered when treating empirically. Patients require prolonged antibiotic therapy, have lengthy hospital stays, multiple re-admissions and high mortality rates. The role and optimal timing of surgical explanation is unclear.  Given the high mortality rate OPAT for EVAR infection could be considered a palliative intervention and services should plan appropriately.

---

#17
A Retrospective Evaluation of Malaria in Beaumont Hospital Over a Ten Year Period from 2008-2018; Diagnosis and Management, Adherence to Treatment Guidelines and Patient Outcomes

Kerri O’Hare, Ciara Anderson, Cora McNally
Beaumont Hospital/Department of Tropical Medicine, Royal College of Surgeons in Ireland

Background:  Malaria should be suspected in returned travellers or anyone originating from a malaria-endemic area with an influenza-like illness (fever, headache, myalgia, and arthralgia) or pyrexia. Severe malaria is usually caused by P. falciparumand is generally fatal in the absence of a reasonable standard of medical care. Suspected malaria in Ireland is a medical emergency and should be immediately referred to the Emergency Department, as delayed diagnosis and management results in poorer outcomes. This audit aims to review Beaumont Hospital’s adherence to diagnosis and treatment guidelines.

Methods:  A retrospective chart review was performed on patients who attended Beaumont Hospital (a Dublin medical tertiary care centre) between December 1^st2008 and December 1^st2018 and with a subsequent diagnosis of malaria. HIPE coding (ICD-10-am) was used to identify all patients with a malaria diagnosis. Patient charts and electronic records were then reviewed to establish information pertinent to the audit purpose. Particular data of interest included patient demographics, malaria prophylaxis, country of travel, presenting symptoms, confirmatory diagnostics, time to diagnosis and time to treatment.

Results:  In total, 41 patients were identified as being admitted through the Emergency Department with malaria (for 1 patient full data could not be obtained). This included 24 males, and 17 females. The primary diagnosis was P. falciparum in 35 cases. There was also 1 case of P. vivaxand 4 cases of P. ovaleinfections. No patient had correctly taken travel prophylaxis. 29 patients had travelled from countries on the African continent where malaria is endemic. The two commonest symptoms at presentation were fever (presenting complaint in 35 of 40 cases) and headache (14/40). The average time from review by a doctor to diagnosis was 3.9 hrs (with the general turnaround time of malaria testing taking approx 1.5 hrs) (Times varying from 0 – 23 hrs). Time to treatment was varied and categorised as <2hrs from confirmatory bloods (32 patients; 80%), < 12 hrs from confirmatory bloods (3; 7.5%) and >12hrs from confirmatory bloods (5; 12.5%).

Conclusion:  A high index of suspicion is needed to ensure that a diagnosis of malaria is not missed. There have been delays reported in our diagnosing and treatment of malaria, although patients are often presenting with classic symptoms and a history of travel to endemic areas. Malaria therapies are not commonly stored in our emergency department drug dispensary, which may be delaying treatment as staff have to wait until sourced from outside the department. 

---

 

#18
Audit of Meningitis Management at Mater Misericordiae University Hospital

Rhea O’Regan,Tee Keat Teoh, Eavan Muldoon
Mater Misericordiae University Hospital, Dublin

Background:  The incidence of bacterial meningitis is decreasing in Ireland, however mortality remains high.  Studies have suggested that adherence to management guidelines improves outcomes in patients diagnosed with meningitis. Current national guidelines for the initial diagnosis and management of bacterial meningitis in Ireland are based on HPSC guidelines published in 2016. 

This audit aims to assess concordance with the national guidelines on patients admitted to the Mater Misericordiae University Hospital (MMUH) with meningitis during 2017. This is part of a larger audit being conducted by the University of Liverpool and sponsored by NITCAR, British Infection Association and Meningitis Research Foundation to assess the management of meningitis.

Methods:  All patients, 16years or older, admitted to the MMUH with meningitis in 2017 were included. Patients were identified using ICD10 codes based on HIPE coding. 

Meningitis was defined as a CSF WCC>4x10cells/L (regardless of pathogen identification) and a clinical suspicion of meningitis or, in the case of bacterial meningitis, symptoms and signs of meningitis with a significant pathogen in the CSF (culture or PCR) or blood, regardless of CSF leukocyte count. Tuberculous, cryptococcal, nosocomial meningitis, and encephalitis were excluded.

Clinical data was extracted from patient records and CSF cell counts and microbiological results from CSF and blood were recorded.

Results:  14 cases of meningitis were diagnosed and treated at MMUH during 2017.  Of these, 12 sets of notes were available for analysis.  4/12 (33%) were confirmed cases of bacterial meningitis. 

6/12 (50%) of patients had blood cultures drawn, only 3/6 being within one hour of suspected diagnosis.  Lumbar puncture was carried out in all cases; only one was performed within the recommended 1 hour.  All 12 patients had a CT brain performed before lumbar puncture (LP). Opening pressure was not recorded in any case. 

9/12 (75%) received antibiotics; one patient received parenteral antibiotics prior to hospital admission.  6/12 (50%) received dexamethasone. Input from Infectious Diseases specialists was sought in all cases.  3/12 (25%) of CSF samples had positive Gram stains, and 3 had positive cultures. All patients had CSF viral PCRs sent. There were no confirmed deaths during admission or at 3 months. 

Conclusion:  While the audit demonstrates some areas of good practice, there are a number of changes which could be implemented to improve the recognition, diagnosis and subsequent management of bacterial meningitis.   Further steps will focus on identifying barriers to guideline compliance, and staff education.  

 

#19
Patient Satisfaction Survey for HIV Ambulatory Care in University Hospital Limerick (UHL)

A.Gadir Abdalla,S. Suleman, E. Cunningham, S. O’Connell
University Hospital Limerick

Background:  With recent developments in HIV ambulatory care, we aim to achieve a high patient satisfaction rate. Our objective was to assess patient satisfaction with care received at the ambulatory HIV clinic in UHL.

Methods:  The Standardized Patient Satisfaction Survey for HIV Ambulatory Care was administered directly to all adults who attended the clinic in period from November 2018 to January 2019. This questionnaire was adapted from New York State Department of Health AIDS Institute. Data including patient demographics, access to HIV care, waiting times and referral to appropriate services were collected.

Results:  A total of 52 cases gave consent to complete the questionnaire. 36.5% (19) of respondents were male, 55.8% (29) were females. 55.8% (29) were heterosexual, 2.8 (15) were homosexual, 3.8% (2) were bisexual, 1.9% (1) was unsure. 34.6% (18) were black, 7.7% (4) were Hispanic, 5.8% (3) were Latino, 40.4% (21) were Asian, and 3.8 (2) were others. 42.3% (22) rated their health as very good, 36.5% (19) rated health as excellent and no one rate his health as poor.

Access to HIV Care:  53.8% (28) reported they found it possible to schedule an appointment when required. 94.2% (49) answered that their care provider always advised them about the importance of follow up. 30.8 (16) reported that their medical queries were always answered.

Appointment waiting-time:  At the clinic visit, 75% (39) declared were met by friendly staff, while 17.3% (9) were not. 80.7% (42) received educational material while waiting and 9.6% (5) never received it. 76.9% (40) were happy at their waiting time, while 9.6% (5) were not satisfied with the waiting time.

Quality of clinical care:  84.6% (44) of respondents reported their visit was not interrupted, while 5.7% (3) reported it was. All participants 100% (52) reported that providers made sure they understood their laboratory results. 42.3% (22) did not want more time with their provider while 32.7% (17) need more time than what was given. 84.6% (44) found their provider accepting and non-judgmental. 84.6% (44) reported their provider explained anti-retroviral side effects. 28.8 (15) were asked by providers about living situation. 50% (26) were offered support around disclosure, 57.7% (30) were asked and offered support about Drug and Alcohol use.

Conclusion:  Results show that the ambulatory clinic in UHL achieved high standards on provider care but much work is required to improve patient satisfaction rates, including the provision of multi-disciplinary support services to address patient care needs.

 

---

#20
Service disparity within the National OPAT programme

Eileen Sweeney, Eavan Muldoon
National OPAT Programme Clinical working group, Mater Misericordiae University Hospital, Dublin

Background:  The national OPAT programme was established in 2013 and has been demonstrated to be a safe and cost-effective method of treating patients with parenteral antibiotics at home. The aim of this review was to determine the availability of OPAT programme nationwide, to identify areas for service development.

Methods:  A retrospective review was carried out on all OPAT referrals made to the national Management Control Centre (MCC) for the year 2018. Variables collected included referral centre and patient address. As the focus was on patient’s address, those who had more than one OPAT course, or multiple antibiotic changes in the study period were only included once. Patients with Cystic Fibrosis and referrals from Maternity and Paediatric hospitals were excluded. Statistical analysis was performed using Microsoft excel.

Results:  For the year 2018, a total of 1520 patient referrals were made to the National OPAT programme; 1305 referrals met the inclusion criteria. 503/1305 (38.5%) of these patients resided in Dublin. Recent CSO figures indicate that this region makes up 28.3% of the population. 123/1305 (9.4%) of patients resided in Cork, 63/1305 (4.8%) in Galway and 54/1305 (4.1%) in Limerick. 17/1305 (1.3%) of referrals were made for the Northwest (Cavan, Donegal, Monaghan and Sligo) which makes up 8.3% of the population. Nationally 966/1305 (76%) were H-OPAT, 339/1305 (26%) were S-OPAT. For Dublin a larger proportion of patients could avail of HOPAT 421/503 (84%) whereas in the Northwest 5/17 (29%) of patients were treated with HOPAT. 72% of OPAT referrals were made through a hospital with an Infectious Diseases physician. Distance travelled for the round trip for weekly follow up was also investigated with a wide range noted from under 1km to 622km.

Conclusion:  This review identifies the significant disparity of OPAT availability to patients according to their county of residence. A significant proportion of urban dwellers, even while considering population density avail of the service and H-OPAT when compared to their rural counterparts. Other factors precluding rural residents from being considered for OPAT is the need for SOPAT due to lack of CIT services, and the need to travel in some instances very long distances, for their weekly clinic review.