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ItemDelays in presentation and diagnosis of pulmonary tuberculosis: a retrospective study of a tertiary health service in Western Melbourne, 2011-2014(WILEY, 2018-02)BACKGROUND: Effective tuberculosis (TB) control relies on early diagnosis and prompt treatment commencement. AIM: To investigate delays in presentation and diagnosis of pulmonary TB (PTB) in a low incidence setting in Western Melbourne. METHODS: A single-centred retrospective observational cohort study of symptomatic patients ≥ 18 years newly diagnosed with PTB that were commenced on treatment between 1 December 2011 and 1 December 2014 at a tertiary teaching hospital in Western Melbourne. Main outcome measures included median duration of patient, health system and total delays to diagnosis of PTB and clinical factors associated with prolonged patient (>35 days) and health system (>21 days) delay. RESULTS: A total of 133 patients were included. The median (range) duration of patient, health system and total delay to diagnosis were 28 (0-610), 18 (0-357) and 89 (1-730) days respectively. Prolonged patient delay was associated with being from a country with an annual TB incidence of <50/100 000 (odds ratio (OR) 5.98, 95% confidence interval (CI) 1.19, 29.98) and diabetes mellitus (OR 3.02, 95% CI 1.04, 8.78) in multivariate analysis. Being Australian-born or a resident of Australia ≥6 years (OR 0.03, 95% CI 0.12, 0.74; OR 0.30, 95% CI 0.00, 0.033 respectively) was associated with reduced patient delay. CONCLUSIONS: In this low-incidence, high-resource setting, patient delays contribute most to total delay in PTB diagnosis. Strategies addressing this aspect of the TB diagnosis pathway, such as health literacy and promotion programmes for new migrants and raised primary healthcare awareness, could have the largest impact on reducing total PTB diagnosis delays.
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ItemNo Preview AvailableDiagnosing swine flu: the inaccuracy of case definitions during the 2009 pandemic, an attempt at refinement, and the implications for future planning(WILEY-BLACKWELL, 2013-05)BACKGROUND: At the onset of the pandemic H1N1/09 influenza A outbreak in Australia, health authorities devised official clinical case definitions to guide testing and access to antiviral therapy. OBJECTIVES: To assess the diagnostic accuracy of these case definitions and to attempt to improve on them using a scoring system based on clinical findings at presentation. PATIENTS/METHODS: This study is a retrospective case-control study across three metropolitan Melbourne hospitals and one associated community-based clinic during the influenza season, 2009. Patients presenting with influenza-like illness who were tested for H1N1/09 influenza A were administered a standard questionnaire of symptomatology, comorbidities, and risk factors. Patients with a positive test were compared to those with a negative test. Logistic regression was performed to examine for correlation of clinical features with disease. A scoring system was devised and compared with case definitions used during the pandemic. The main outcome measures were the positive and negative predictive values of our scoring system, based on real-life data, versus the mandated case definitions'. RESULTS: Both the devised scoring system and the case definitions gave similar positive predictive values (38-58% using ascending score groups, against 39-44% using the various case definitions). Negative predictive values were also closely matched (ranging from 94% to 73% in the respective score groups against 83-84% for the case definitions). CONCLUSIONS: Accurate clinical diagnosis of H1N1/09 influenza A was difficult and not improved significantly by a structured scoring system. Investment in more widespread availability of rapid and sensitive diagnostic tests should be considered in future pandemic planning.
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ItemOseltamivir Resistance in Adult Oncology and Hematology Patients Infected with Pandemic (H1N1) 2009 Virus, Australia(CENTERS DISEASE CONTROL, 2010-07)We describe laboratory-confirmed influenza A pandemic (H1N1) 2009 in 17 hospitalized recipients of a hematopoietic stem cell transplant (HSCT) (8 allogeneic) and in 15 patients with malignancy treated at 6 Australian tertiary centers during winter 2009. Ten (31.3%) patients were admitted to intensive care, and 9 of them were HSCT recipients. All recipients of allogeneic HSCT with infection <100 days posttransplantation or severe graft-versus-host disease were admitted to an intensive care unit. In-hospital mortality rate was 21.9% (7/32). The H275Y neuraminidase mutation, which confers oseltamivir resistance developed in 4 of 7 patients with PCR positive for influenza after > or = 4 days of oseltamivir therapy. Three of these 4 patients were critically ill. Oseltamivir resistance in 4 (13.3%) of 30 patients who were administered oseltamivir highlights the need for ongoing surveillance of such resistance and further research on optimal antiviral therapy in the immunocompromised.
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ItemAn effective strategy for influenza vaccination of healthcare workers in Australia: experience at a large health service without a mandatory policy(BMC, 2015-02-06)BACKGROUND: Annual influenza vaccination of healthcare workers (HCWs) is recommended in Australia, but uptake in healthcare facilities has historically been low (approximately 50%). The objective of this study was to develop and implement a dedicated campaign to improve uptake of staff influenza annual vaccination at a large Australian health service. METHODS: A quality improvement program was developed at Alfred Health, a tertiary metropolitan health service spanning 3 campuses. Pre-campaign evaluation was performed by questionnaire in 2013 to plan a multimodal vaccination strategy. Reasons for and against vaccination were captured. A campaign targeting clinical and non-clinical healthcare workers was then implemented between March 31 and July 31 2014. Proportional uptake of influenza vaccination was determined by campus and staff category. RESULTS: Pre-campaign questionnaire responses were received from 1328/6879 HCWs (response rate 20.4%), of which 76% were vaccinated. Common beliefs held by unvaccinated staff included vaccine ineffectiveness (37.1%), that vaccination makes staff unwell (21.0%), or that vaccination is not required because staff are at low risk for acquiring influenza (20.2%). In 2014, 6009/7480 (80.3%) staff were vaccinated, with significant improvement in uptake across all campuses and amongst nursing, medical and allied health staff categories from 2013 to 2014 (p < 0.0001). CONCLUSIONS: A non-mandatory multimodal strategy utilising social marketing and a customised staff database was successful in increasing influenza vaccination uptake by all staff categories. The sustainability of dedicated campaigns must be evaluated.
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ItemMorbidity from in-hospital complications is greater than treatment failure in patients with Staphylococcus aureus bacteraemia(BMC, 2018-03-05)BACKGROUND: Various studies have identified numerous factors associated with poor clinical outcomes in patients with Staphylococcus aureus bacteraemia (SAB). A new study was created to provide deeper insight into in-hospital complications and risk factors for treatment failure. METHODS: Adult patients hospitalised with Staphylococcus aureus bacteraemia (SAB) were recruited prospectively into a multi-centre cohort. The primary outcome was treatment failure at 30 days (composite of all-cause mortality, persistent bacteraemia, or recurrent bacteraemia), and secondary measures included in-hospital complications and mortality at 6- and 12-months. Data were available for 222 patients recruited from February 2011 to December 2012. RESULTS: Treatment failure at 30-days was recorded in 14.4% of patients (30-day mortality 9.5%). Multivariable analysis predictors of treatment failure included age > 70 years, Pitt bacteraemia score ≥ 2, CRP at onset of SAB > 250 mg/L, and persistent fevers after SAB onset; serum albumin at onset of SAB, receipt of appropriate empiric treatment, recent healthcare attendance, and performing echocardiography were protective. 6-month and 12-month mortality were 19.1% and 24.2% respectively. 45% experienced at least one in-hospital complication, including nephrotoxicity in 19.5%. CONCLUSIONS: This study demonstrates significant improvements in 30-day outcomes in SAB in Australia. However, we have identified important areas to improve outcomes from SAB, particularly reducing renal dysfunction and in-hospital treatment-related complications.
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ItemStaphylococcus aureus bacteraemia: evaluation of the role of transoesophageal echocardiography in identifying clinically unsuspected endocarditis(SPRINGER, 2013-08)Staphylococcus aureus bacteraemia (SAB) is an important cause of community and nosocomial sepsis, with a significant mortality rate. Infective endocarditis (IE) is a serious complication, occurring in up to 25 % of cases. Transoesophageal echocardiography (TOE) significantly improves the sensitivity of diagnosis. We compared the sensitivity and specificity of clinical evaluation alone in diagnosing IE. We evaluated all adult patients with SAB at our centre from 1998 to 2006 in order to determine what proportion of clinically unsuspected cases were diagnosed with IE on TOE. IE was defined according to modified Duke criteria. The median age of the patients was 68 years, 77 % were male and the majority of cases did not have a known pre-existing condition. Twenty-one percent were methicillin-resistant Staphylococcus aureus (MRSA). Intravascular device was the most common cause of bacteraemia. TOE was performed in 144 (100 %) of the cases. IE was suspected clinically in 15 % of cases, and the overall prevalence of possible or definite IE on TOE-inclusive Duke criteria was 29 % (n = 41). Following TOE, 22 (15 %) cases were reclassified as either possible or definite endocarditis. TOE detected a vegetation in 37 (90 %) of the 41 cases of IE. Nineteen (46 %) were not suspected clinically by Duke criteria. Sensitivity improved in the presence of pre-existing valve lesion or community acquisition. The overall in-hospital mortality was 10 %. There is a high incidence of endocarditis in SAB and a large percentage of cases are not evident on clinical grounds. TOE evaluation is indicated for all medically suitable adult patients with SAB in order to improve the detection of endocarditis.