Diagnostics are increasingly touted as a tool to combat antimicrobial resistance. However, relatively little is known about how microbiology results are utilised in practice and the impact on antimicrobial stewardship. This is true for urinary tract infections (UTIs) where culture is the gold standard diagnostic test despite well-recognised imperfections in accuracy. Given the burden of UTIs in primary care, the aim of this study was to understand how primary care practitioners (PCPs) interpret and respond to culture results. Thirteen participants undertook semi-structured interviews exploring the requesting of tests, processing of results and attitudes to diagnostics in UTI. Participants were posed with five hypothetical clinical scenarios to explore analysis and interpretation of urine culture results. Anonymised transcripts were coded and thematic analysis utilised. Participants were familiar with testing strategies and felt confident interpreting results although areas of less certainty were identified. Amongst hypothetical scenarios posed, considerable variation was observed resulting in heterogenous onward prescribing decisions. Participants felt that culture results altered patient management in approximately 10–20% of cases but identified other less tangible benefits of testing such as prescriber reassurance. Prolonged laboratory turn-around times was frequently cited as the reason antibiotics were not amended or stopped when results became available supporting that improved diagnostic methods are required. This study confirmed urine culture does have value to PCPs, but the impact on patient management was perceived to be small. Further research is needed to evaluate the relationship between patients, prescribing and laboratory results at scale.
We present three cases (one of EBV and two of influenza) of paediatric encephalitis that presented with febrile illness and seizures and/or altered consciousness, with other acute neurological signs. EBV DNA was detected in the CSF of one case, and influenza A RNA was detected in the respiratory samples of the other two cases. All had MRI findings consistent with a diagnosis of viral encephalitis. Specifically, one of the influenza cases was diagnosed with A(H1N1) acute necrotizing encephalitis resulting in severe long-term disability and a likely evolving cerebral palsy. The other two patients eventually made a full recovery. All patients received some form of empirical antiviral treatment and/or immune-modulating therapy. Earlier recognition, diagnosis and treatment of such cases may reduce the severity of clinical disease and, potentially, any longer-term disability.
The invasive fungal disease histoplasmosis poses a significant diagnostic challenge in non-endemic settings like the United Kingdom (UK). Once considered endemic only in the Americas, histoplasmosis is now recognised to be widespread across large parts of Africa, Asia and parts of Oceania, as well as pockets of southern Europe. This likely reflects improved diagnostic capacity and the introduction of Histoplasma-specific antigen testing in research settings, rather than true geographic expansion. In non-endemic settings like the UK, histoplasmosis may be overlooked or mistaken for more commonly encountered diseases such as tuberculosis, leading to delays in initiating appropriate antifungal therapy. This diagnostic challenge is compounded by the highly variable clinical manifestations of histoplasmosis, which depend on exposure burden and host immune status, ranging from localised pulmonary disease to severe disseminated, multi-organ infection that may present years to decades after exposure. In non-endemic settings, diagnostic pathways for histoplasmosis are hampered by limited clinical awareness among healthcare providers, non-specific clinical and radiological manifestations, the poor sensitivity and prolonged turnaround time of culture-based methods, and restricted availability of rapid Histoplasma-specific serological tests (Histoplasma antibody and antigen tests currently available at one and two laboratories in the UK, respectively). These challenges have significant clinical consequences: delay to diagnosis and initiation of antifungal therapy are associated with high mortality from disseminated histoplasmosis. This review provides an overview of histoplasmosis for clinicians, particularly those practicing in the UK and other non-endemic settings, encompassing epidemiology, pathogen biology, clinical presentations, and recommended diagnostic and management approach.
Severe community-acquired pneumonia (CAP) remains difficult to manage when empirical treatment must be started before conventional microbiology yields results. This cross-sectional study characterized microorganisms detected by sputum multiplex real-time PCR in adults with severe CAP at Can Tho Central General Hospital, Vietnam, and explored selected associated factors. Adults admitted between December 2024 and May 2025 who met ATS/IDSA severe CAP criteria were enrolled by convenience sampling. Only Gram-screened sputum specimens considered reliable (≥ 25 polymorphonuclear leukocytes and ≤10 squamous epithelial cells per field) underwent nucleic acid extraction and testing using a 75-target multiplex real-time PCR panel. General pathogens were considered positive at ≥ 100,000 copies/mL, while viruses and atypical bacteria were considered positive at ≥ 5000 copies/mL. Among 51 patients, 47 (92.2%) had at least one detected microorganism. Bacterial detection occurred in 35 (68.6%), viral detection in 45 (88.2%), and fungal detection in 26 (51.0%). All monomicrobial detections were viral (8/51, 15.7%), while 23/51 (45.1%) showed concurrent bacterial, viral, and fungal detections. The leading bacterial detections were Klebsiella pneumoniae (23.5%), Acinetobacter baumannii (21.6%), Streptococcus pneumoniae (19.6%), Escherichia coli (17.6%), and Haemophilus influenzae (11.8%). The most frequent viral detections were Epstein–Barr virus (62.7%), cytomegalovirus (33.3%), SARS-CoV-2 (11.8%), and rhinovirus (9.8%). Candida albicans was the dominant fungal detection (51.0%). In exploratory analyses, viral detection was more frequent in patients with radiographic lung abnormalities than in those without documented abnormalities (93.5% vs 40.0%; OR 21.5, 95% CI 2.5–182.4; p = 0.009); no other factor reached statistical significance. Severe CAP in this tertiary Vietnamese cohort showed extensive mixed microbial detection, including frequent Gram-negative signals and occasional unexpected pathogens such as Mycobacterium tuberculosis and Pneumocystis jirovecii. Sputum multiplex PCR may support early diagnostic orientation, isolation, and targeted diagnostic reassessment, but without susceptibility data it should complement – not replace - culture-based stewardship. Detections - particularly K. pneumoniae, A. baumannii, E. coli, EBV, CMV, and Candida spp. - require careful clinical adjudication in sputum.
In this retrospective study, we compared the cause of death among hospitalized patients who died with a diagnosis of COVID-19 across two periods of the pandemic two years apart: an early period (admissions June to October 2020), when the population was immunologically naïve, and a later period (admissions April to October 2022), when an estimated 96% of the population had immunity from prior infection, vaccination, or both. Two investigators independently reviewed the medical records of 100 in-hospital deaths (50 per period) and classified each death as COVID-19 related, uncertain, or not COVID-19 related, using logistic regression to compare the two periods. Deaths during the early period were more likely to reflect a direct consequence of COVID-19 infection than deaths in the later period (adjusted odds ratio 0.25 for the later vs. early period; 95% CI 0.10 to 0.64; p = 0.004). This difference was largely attenuated when vaccination status was added to the model, suggesting a protective effect of vaccination against COVID-19 related mortality.
Background Scurvy, a clinical manifestation of severe ascorbic acid (AA) deficiency, is thought to be rare in high-income countries, including New Zealand. At the same time, pyroglutamic acidosis (PGA) is not often considered in patients with high anion gap metabolic acidosis (HAGMA). We report a patient with sepsis and Staphylococcus aureus (S. aureus) bacteraemia who developed both of these presentations, which are often under-recognised in clinical practice. Case presentation A patient in his 60s was admitted to the hospital with septic shock due to disseminated S. aureus infection requiring prolonged critical care admission. He developed HAGMA due to PGA from concurrent use of high dose flucloxacillin and paracetamol. Withdrawal of these offending agents resulted in complete resolution of his acid base disturbance. He also suffered from life-threatening complications of AA deficiency manifesting as scorbutic haemopericardium leading to cardiac tamponade, as well as other clinical signs of scurvy including oromucosal bleeding, skin rash, and wound dehiscence. His initial serum AA level prior to replacement was 1 (reference range 26–85) μmol/L. Replacement with high dose AA intravenously led to resolution of his symptoms and normalisation of his serum AA level. Conclusion This case highlights the importance of considering scurvy in hospitalised patients with sepsis and risk factors for AA deficiency. Furthermore, clinicians should be alert about potential complication from flucloxacillin and paracetamol co-prescription causing PGA.
Cefazolin, a first-generation cephalosporin, has been used for decades for surgical site infection prophylaxis as well as for treatment for a variety of infections. Little data is available on dosing in obese individuals or those weighing ≥120 kg. The objectives of this analysis were to obtain a better understanding of cefazolin in these patients by conducting a literature search to gather available information on the safety and pharmacokinetics (PK) of high doses of cefazolin in obese individuals. Additionally, a previously-developed population PK model was assessed using the data from patients enrolled in a Phase 1 study who weighed ≥120 kg. Model-based simulations were also conducted to confirm the appropriateness of a 3 g dose in those weighing ≥120 kg. The literature search revealed that cefazolin was well-tolerated at high doses, and that patients weighing ≥120 kg demonstrated PK differences in protein binding, clearance, and volumes of distribution compared to those <120 kg. The previously-developed 2-compartment population PK model required no refinements and provided a robust fit to the data. The model-based simulations indicate that a 3 g dose in patients weighing ≥120 kg provides more consistent exposure than a 2 g dose relative to observed and simulated normal weight (60–120 kg) patients administered 2 g. These results suggest that a 3 g dose, recently approved by the FDA, is more appropriate than the FDA-approved 2 g dose for surgical prophylaxis in patients with body weight ≥ 120 kg in both adults and children aged 10 to 17 years.
Objectives Hospital acquired infection (HAI) is a significant concern for patients and healthcare systems with patients in intensive care units (ICU) at higher risk. Proton pump inhibitors (PPI) are used for stress ulcer prophylaxis and studies reported mixed results on its relationship with risk of infections. This systematic review assessed the association between PPI use and HAI and its impact on infection in ICU. Design Studies were identified through electronic searches of PubMed, Web of Science, Scopus, and Google Scholar between Inception and January 2025. Included studies were those conducted in hospital intensive care unit settings and examined PPI use. Studies that included patients with infection prior PPI use and those without ICU settings confirmed were excluded. Quantitative synthesis and random effect meta-analyses were performed in RevMan 5.4.1. Results The review yielded 16 studies among which Clostridioides difficile was the most frequently reported infection. Across studies, concomitant antibiotic exposure consistently emerged as an important factor associated with infection risk. There was statistically and clinically significant association between PPI use and increased risk of HAIs in ICU patients, while a smaller number reported null or mixed associations. Conclusions These findings underscore the importance of judicious PPI prescribing in ICU settings.
The 2026 cruise-linked Andes virus (ANDV) outbreak represents a rare but high-consequence travel-associated zoonotic event, combining likely land-based acquisition before embarkation, limited onboard human-to-human transmission, delayed clinical recognition, and multinational public health coordination. This narrative review synthesizes current evidence on the outbreak, ANDV biology, transmission dynamics, clinical presentation, diagnostics, management, and implications for maritime and expedition travel medicine. As of 2 July 2026, the World Health Organization (WHO) had reported 13 cases linked to the motor vessel (M/V) Hondius outbreak, including 12 laboratory-confirmed infections, one probable case, and three deaths. Following completion of the 42-day follow-up period for all identified contacts without additional secondary cases, WHO considered transmission interrupted and the outbreak contained. Available evidence supports likely land-based acquisition before embarkation followed by limited onboard human-to-human transmission, without sustained spread. Severe hantavirus cardiopulmonary syndrome may begin with nonspecific fever, malaise, myalgia, gastrointestinal symptoms, or respiratory complaints, then progress abruptly to pulmonary oedema, shock, and fatal cardiopulmonary collapse. Because no licensed antiviral therapy or vaccine is available, early recognition, cautious fluid management, intensive supportive care, ventilatory support, and timely transfer to intensive care or extracorporeal membrane oxygenation-capable centres remain central. The outbreak highlights critical preparedness gaps in shipboard triage, contact tracing, specimen transport, genomic surveillance, risk communication, and cross-border follow-up. Strengthening One Health-informed pre-travel counseling, post-travel symptom surveillance, and maritime outbreak protocols is essential for future expedition-associated zoonotic threats.
Hantavirus infection in humans presents in two distinct clinical forms cardiopulmonary syndrome and haemorrhagic fever with renal syndrome. These clinical manifestations are influenced by geographical distribution, which is associated with specific hantavirus species. Human infection occurs by direct or indirect contact with rodent excreta. We present a case of haemorrhagic fever with renal syndrome secondary to hantavirus infection, characterised by fever, diarrhoea, and renal and hepatic dysfunction. The infection was acquired in the United Kingdom following direct exposure to domesticated and wild rodents. Confirmation of Seoul hantavirus infection was obtained through molecular and serological testing at the Rare and Imported Pathogens Laboratory. The patient improved with conservative management, and ribavirin was not used. Although hantavirus infection is rare in the United Kingdom, it should be considered in patients with fever, renal impairment, and a history of rodent exposure. A comprehensive social history and high index of suspicion are essential to avoid missing the diagnosis.
Histoplasmosis is a fungal infection caused by Histoplasma capsulatum. Immunosuppression can result in disseminated infection with high mortality. We describe a patient from Ghana with advanced HIV who presented with a buccal ulcer. He was diagnosed with disseminated histoplasmosis with oral, lymph node, pulmonary, adrenal and central nervous system involvement and subsequently developed haemophagocytic lymphohistiocytosis. The last travel to an endemic region was nine years beforehand, so that and prolonged travel history is often required in the case of significant immunosuppression.
Background Epstein-Barr virus (EBV) is a double-stranded DNA virus and a member of the Herpesviridae family. Acute EBV infection in immunocompetent adults typically presents as infectious mononucleosis, which is characterised by fever, tonsillar enlargement and cervical lymphadenopathy. Here, we present an unusual case of primary EBV infection which was complicated by pneumonitis, a rare manifestation of the disease in immunocompetent individuals. Case report A 20-year-old male university student with no significant medical history attended the emergency department with a one week history of fever, dry cough and shortness of breath. The patient had developed a sore throat one week prior which had been treated with phenoxymethylpenicillin V, and subsequently, doxycycline, neither of which improved his symptoms. On arrival, the patient was febrile, tachycardic and hypoxic, with mild cervical lymphadenopathy and bibasal lung crepitations. Admission blood results were significant for a lymphocytosis and raised C-reactive protein (CRP). Chest x-ray showed bilateral patchy consolidation and bronchial dilatation, more notable on the left. Computed tomography pulmonary angiogram (CTPA) showed bronchial wall thickening and florid solid and ground glass centrilobular nodularity and areas of nodular consolidation in keeping with infection. Sputum culture did not yield any significant growth and no respiratory viruses were detected by polymerase chain reaction of nose and throat swab. IgM and IgG antibodies against EBV viral capsid antigen (VCA) were both detected on serological testing, confirming the diagnosis of acute EBV infection. Results The patient was commenced on oral prednisolone and discharged home 48 h later once no longer requiring supplemental oxygen. His recovery was complicated by another episode of EBV tonsillopharyngitis requiring a further course of oral steroid therapy. Conclusion While rare, EBV should be considered as a potential cause of pneumonitis in immunocompetent patients where other, more common, infective causes have been considered and excluded.
Objectives Pyogenic liver abscesses (PLAs) remain a serious infectious condition associated with significant morbidity, mortality, and healthcare utilisation. This study aimed to evaluate contemporary trends in the epidemiology, microbiology, antimicrobial resistance, management, and clinical outcomes of PLA in an Irish tertiary referral centre over a 14-year period. Methods A retrospective observational study was conducted at Beaumont Hospital, Dublin, Ireland, reviewing all patients discharged with a diagnosis of PLA between January 2009 and December 2023. Clinical, radiological, microbiological, and antimicrobial prescribing data were collected from hospital records and laboratory information systems. Duration of patient admission, instances of readmission within 30 days post discharge and mortality rate were measured. Statistical analyses included Poisson regression for temporal trends, Fisher's exact test for categorical variables, and Mann–Whitney U testing for length-of-stay comparisons. Results A total of 176 patients were identified, with a median age of 68 years (range 18–96 years); 66% (n = 117) were male. Case incidence increased significantly over time, with an estimated annual increase of 5.1% (IRR 1.05, 95% CI 1.02–1.09; p = 0.005). Biliary disease was the predominant aetiology (60%; n = 105), followed by acute diverticulitis (11%; n = 20). Computed tomography was the principal diagnostic modality (82%; n = 145). Aspiration or drainage was performed in 64% of patients, predominantly through interventional radiology-guided procedures. Escherichia coli and streptococcal species were the most frequently isolated pathogens. Multidrug-resistant organisms were identified in 5% of cases, including extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales and carbapenem-resistant organisms. Co-amoxiclav resistance among E. coli isolates was high (76%; n = 31). Most patients received prolonged antimicrobial therapy for four to six weeks, and oral step-down therapy was feasible in 48% of cases. In-hospital mortality was 7%, 40 patients were discharged on OPAT, while 12% (n = 20) of discharged patients required readmission within 30 days for repeat aspiration due to incomplete radiological resolution. Conclusion The incidence of PLA increased significantly over the study period, reflecting a growing clinical and healthcare burden. Biliary disease remained the leading underlying source, while emerging antimicrobial resistance highlights the importance of ongoing microbiological surveillance and antimicrobial stewardship. Image-guided drainage combined with prolonged antimicrobial therapy remains central to management, although substantial morbidity and mortality persist with prolonged hospitalisation, and high readmission rates. Continued multicentre surveillance and optimisation of diagnostic and management pathways are required to improve patient outcomes.
