Hepatitis C Virus tutorial JSD JF Sep 2020 Drs J Ferguson and J Davis
Cumulative antibiograms summarise the collective susceptibility of bacterial isolates against various antibiotics. Prepared by Drs Jacklyn Joseph and John Ferguson, August 2019. Isolates were cultured from PMGH inpatients and outpatients served by the PMGH Laboratory. Outpatients came from clinic locations from around the National Capital District.
There is selection bias inherent in the samples included in hospital antibiograms and great care must be taken with its interpretation. Treatment guideline review and modification in the light of this antibiogram needs to take into account specific clinical data that assesses the response to treatment of both culture positive and negative infections across the different patient groups (paediatric, adult) and locations (intensive care, non intensive care, outpatient). Susceptibility rates at other institutions may differ significantly.
Where possible isolates derived from inadequate specimen types such as urinary catheter or endotracheal tube tips, have been excluded from analysis. However it is probable that many urine cultures may not have been collected for the correct reason or in the correct manner leading to the possibility of error due to contamination or sampling of patients with asymptomatic bacteriuria.
Guest posting: Dr Holly Jordan, Physician Trainee, John Hunter Hospital, Newcastle, NSW.
- Case 1: 76F presents with headache, lethargy and behavioural changes 1 week post developing unilateral vesicular rash of the upper limb.
- Case 2: u73F presents with 3-4 days history of unilateral (R) frontal headache, associated with (R) ocular pain followed by rash on (R) forehead + inability to open her (R) eye.
- Case 3: u88M found to have multiple (R) hemispheric acute lacunar infarctions following a slow deterioration post fall 3 months prior.
- Albrecht et al. Epidemiology, clinical manifestations, and diagnosis of herpes zoster: UpToDate
- Skripuletz et al. Varicella zoster virus infections in neurological patients: a clinical study BMC Infectious Diseases (2018) 18:238
- Beaman MH. Community-acquired acute meningitis and encephalitis: a narrative review. MJA. 2018.
- Haanpaa M et al. CSF and MRI findings in patients with acute herpes zoster. Neurology. 1998; 51(5):1405-11.
- Herpes zoster ophthalmicus: Therapeutic Guidelines (Australia); 2019
- Nagel MA. Varicella zoster virus vasculopathy: UpToDate
A recent seminar on orthopaedic infections took place organised by the Pacific Islands Orthopaedic Association. Here is the presentation: Zoom tutorials – Spine TB Ferguson 2020 final_cb. References are within the presentation. Some take home messages:
- High burdens of latent TB infection in Pacific Nations
- Need for clinical vigilance for active TB, especially in those with risk factors (Age, systemic steroids, HIV, smokers, alcohol, diabetes, vitamin D deficiency (active treatment of latent TB optimal)
- Drug resistant TB is emerging and already at a significant level in PNG
Diagnosis and confirmation
- Direct molecular detection (sputum and other) of TB and MDR is now the standard of care
- Special diagnostic considerations for children and those with HIV
- Local clinical expertise required – patient education, close monitoring and drug management (side effects, MDR)
- Don’t neglect MDR-TB management- must embrace local detection & control
- Emerging shortened course management regimens for MDR
- Global TB Report (WHO) 2019
- THE DUAL EPIDEMIC OF TB AND DIABETES (WHO) 2015
- Recent update on TB diagnostic techniques – GenXpert MTB/RIF Ultra (9 Apr 2018 Ian Marr)
- WHO Rapid Communication: Molecular assays as initial tests for the diagnosis of
tuberculosis and rifampicin resistance (11 Jan 2020)
- WHO Rapid Communication: Key changes to treatment of multidrug- and
rifampicin-resistant tuberculosis (10 Oct 2018)
- WHO operational handbook on tuberculosis: module 1: prevention: tuberculosis preventive treatment (22 Mar 2020)
These presentations are targeted to new medical micro lab users, especially those within Fleming Fund LMIC countries.
Lecture 1: Principles of MALDI-TOF – Tuesday 16th June 1200-1300hr, AEST, Dr Tony Elias, Senior Microbiology Registrar, Pathology NSW
Overview of the theory and process of MALDI-TOF, a method capable of rapid identification of micro-organisms, revolutionising diagnostic microbiology.
Lecture 2: Practicalities of MALTI-TOF – Tuesday 23rd June 1200-1300hr, AEST
Discussion of reporting, QC, troubleshooting and further applications
- This short youtube video is a nice summary of how the process works.
Guest posting from Dr John D. Brannan PhD, Scientific Director , Dept Respiratory & Sleep Medicine, JOHN HUNTER HOSPITAL, NSW, Australia
Spirometry theory and practice from someone who really knows! Accurate measurement the key to diagnosis and treatment- lots of potential traps.
Guest posting: Professor Peter Wark, University of Newcastle
These presentations highlight the important issues for clinicians concerning these common conditions. Note the limited role for antibiotics in the management of acute exacerbations of these conditions.
Under construction (May 2020)
SECOND CLINICIAN CALL: Confirmed culture identification with susceptibility available
- Prior to calling, check the isolate antibiogram to see that species and susceptibility are consistent with each other – see EUCAST Expert rules which provide intrinsic resistance characters by species, including unusual phenotypes.
- If possible speak to the same clinician who you initially contacted about the Gram stain result (look at your diary record !). Make sure your interaction has an proper formality about it – this is essential for building clinician respect for the laboratory service. See previous posting concerning ISBAR process.
- Document additional clinical data required for completion of an Bloodstream infection event record after your contact (refer to this example template for these records with definitions of key data items).
Specific advice by organism:
Enteric Gram negative – an Enterobacterales species – e.g. E. coli, Klebsiella species, Enterobacter species Continue reading
- Presentation 1- Dr J Ferguson, 6/5/2020: Blood cultures 2020 PRIDA Course Ferguson , Recording of session (45 minutes)
- Presentation 2- Dr J Ferguson, 8/5/20: Blood cultures 2nd 2020 PRIDA Ferguson Recording (also includes a journal club from Dr Sophen on this COVID19 reference.
- Gram stain appearance and implications ver 2 2020 Ferguson
- Essential clinical care of patients with Staphylococcus aureus bloodstream infection – 9 key steps
- Blood culture collection tutorial notes 25 Aug 2019
- Blood culture collection procedure version 3 24 Aug 2019 (PMGH 2019)
- Excellent LMIC blood culture review – great reference !
- Gratten, PNG Medical Journal 1983. Blood cultures – description of manual method
systems for blood culture PMJMJ 1983 Gratten Blood culture method
- Blood cultures overview- question guide to key issues 2015
Updated summary of Gram stain appearances, microbiological and clinical implications. Updated blood culture collection and liaison approach.
- Always note down all clinician discussions in a large personal diary or preferably on the electronic pathology record for the patient’s sample if this exists.
- Categorise and record the clinical relevance of the positive culture – a standard template to be shared soon.
Improve blood culture collection practice
- Ensure that your clinicians know how to collect blood cultures correctly – pathology registrars/ residents can get involved with training . See this collection instruction as a guide: Blood culture collection procedure version 3 24 Aug 2019
- Check out this guide before you start a collection training program – Blood culture collection tutorial notes 25 Aug 2019
- Calculate your blood culture contamination rates regularly and identify locations that require followup training (if rate of contamination > 5%)
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