This multi-arm, parallel group, single-blinded randomised controlled trial aimed to assess three commercially available mouthwashes effectiveness against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The manuscript has been written in accordance with the CONSORT statement. Methods Eligible participants were SARS-CoV-2 positive with a positive test in the last 72 hours. All participants had mild to moderate symptoms and could provide 5 saliva samples over a 60-minute period. Participants delivered a baseline saliva sample and then used a mouthwash as per manufacturer’s instructions. They provided further saliva samples at minute 1, 10, 30 and 60. Participants were randomised to one of four groups; OraWise+, Total Care Listerine, Cool Mint Listerine and water (control). The lab-based research team were blind to the intervention. The research question was: Can SARS-CoV-2 be rendered inactive in saliva by using a mouthwash and how long does this effect last? The primary outcome was the amount of viable infectious SARS-CoV-2 virus in the sample, compared to the baseline sample. The secondary outcome measure was the amount of genetic material from the SARS-CoV-2 virus in the sample, measured via PCR testing. Results In total 100 participants were recruited (25 per group). Eight participants did not receive the allocated intervention and did not have saliva samples collected. There were no adverse events. In total 42 of the 92 participants had viable virus which could be cultured at baseline. Statistical analysis of the primary outcome was not advised due to the reduced level of viable virus at baseline and the positive skewness present in the distribution of log10(titre) data. Observational data of the primary outcome measure is presented. Analysis of the secondary outcome PCR measure showed that there was strong evidence for a decrease in SARS-CoV-2 RNA levels compared to water for all mouthwashes after 1 minute, OraWise+ -0.49 (-0.92, -0.05) p-value 0.029, Cool Mint Listerine -0.81 (-1.25, -0.38) p-value <0.001, Total Care Listerine -1.05 (-1.48, -0.62) p-value <0.001. For the remaining timepoints there was generally no evidence of virus level reduction compared to water although there is weak evidence for a decrease at ten minutes using Total Care Listerine -0.44 (-0.88, 0.01), p-value 0.053. Conclusion The three mouthwashes included in this trial observationally demonstrated a reduction in virus titre level 1 minute after use, with virus levels normalising up to 60 minutes compared to the control. Although an interesting observation, this result could not be statistically analysed. Using the secondary outcome PCR measure all three included mouthwashes reduced virus levels compared to water at 1 minute and these results were statistically significant. Clinically this result does not support the use of the included mouthwashes to reduce SARS-CoV-2 levels in saliva.

Background:Fosfomycin has retained activity against many multi-drug resistant (MDR) Gram-negatives, and may be useful against extended spectrum beta-lactamase (ESBL) producing and carbapenem-resistant Enterobacteriaceae. There are few data from the UK on the susceptibility of invasive Gram-negative isolates to fosfomycin, especially in the era of increasing use of oral fosfomycin for UTIs. Materials/methods: 1. We evaluated, in 100 consecutive Gram-negative bloodstream infections (BSI), the in-vitro activity of fosfomycin. Disc diffusion and MIC test strip methods applying revised EUCAST guidelines for fosfomycin were used. 2. A secondary objective was testing for synergy in combination with 10 further antibiotics. Isolates were selected if: a) Fosfomycin resistant b) AMP-C/ESBL/carbapenemase producers (or carbapenem resistant) c) ‘MDR’: defined as ‘resistance to ≥3 classes of antibiotics’ (based on prior routine sensitivity testing). For eligible isolates, MICs were determined individually, and subsequently in combination using the MTS ‘cross’ synergy method. Results:96/100 isolates were susceptible to fosfomycin by MIC test strip. 30/100 isolates were eligible for synergy testing. Synergy was most commonly detected between fosfomycin and piperacillin/tazobactam (32.1%), ceftazidime/avibactam (30%), and temocillin (28.5%). An additive effect was most commonly detected with aztreonam (85.7%) and meropenem (82.1%), but 100% indifference was found with tigecycline. No antagonism was identified. Conclusions:Synergistic or additive effects were detected for beta-lactam/fosfomycin combinations in a high proportion of isolates; >80% for all suggesting such combinations should be preferred when using fosfomycin combination therapy. Agents with a different site of antibiotic action, were more likely to result in indifference.

ABSTRACTInfectious SARS-CoV-2 can be recovered from the oral cavities and saliva of COVID-19 patients with potential implications for disease transmission. Reducing viral load in patient saliva using antiviral mouthwashes may therefore have a role as a control measure in limiting virus spread, particularly in dental settings. Here, the efficacy of SARS-CoV-2 inactivation by seven commercially available mouthwashes with a range of active ingredients were evaluated in vitro. We demonstrate ≥4.1 to ≥5.5 log10 reduction in SARS-CoV-2 titre following a one minute treatment with commercially available mouthwashes containing 0.01-0.02% stabilised hypochlorous acid or 0.58% povidone iodine, and non-specialist mouthwashes with both alcohol-based and alcohol-free formulations designed for home use. In contrast, products containing 1.5% hydrogen peroxide or 0.2% chlorhexidine gluconate were ineffective against SARS-CoV-2 in these tests. This study contributes to the growing body of evidence surrounding virucidal efficacy of mouthwashes/oral rinses against SARS-CoV-2, and has important applications in reducing risk associated with aerosol generating procedures in dentistry and potentially for infection control more widely.

Abstract Background Lower Clostridium difficile spore counts in feces from C difficile infection (CDI) patients treated with fidaxomicin versus vancomycin have been observed. We aimed to determine whether environmental contamination is lower in patients treated with fidaxomicin compared with those treated with vancomycin/metronidazole. Methods The CDI cases were recruited at 4 UK hospitals (Leeds, Bradford, and London [2 centers]). Environmental samples (5 room sites) were taken pretreatment and at 2–3, 4–5, 6–8, and 9–12 days of treatment, end of treatment (EOT), and post-EOT. Fecal samples were collected at diagnosis and as often as produced thereafter. Swabs/feces were cultured for C difficile; percentage of C difficile-positive samples and C difficile bioburden were compared between different treatment arms at each time point. Results Pre-EOT (n = 244), there was a significant reduction in environmental contamination (≥1 site positive) around fidaxomicin versus vancomycin/metronidazole recipients at days 4–5 (30% vs 50% recipients, P = .04) and at days 9–12 (22% vs 49%, P = .005). This trend was consistently seen at all other timepoints, but it was not statistically significant. No differences were seen between treatment groups post-EOT (n = 76). Fidaxomicin-associated fecal positivity rates and colony counts were consistently lower than those for vancomycin/metronidazole from days 4 to 5 of treatment (including post-EOT); however, the only significant difference was in positivity rate at days 9–12 (15% vs 55%, P = .03). Conclusions There were significant reductions in C difficile recovery from both feces and the environment around fidaxomicin versus vancomycin/metronidazole recipients. Therefore, fidaxomicin treatment may lower the C difficile transmission risk by reducing excretion and environmental contamination.

Background: The National Health Service in England advises hospitals collect data on hospital-onset diarrhoea (HOD). Contemporaneous data on HOD are lacking. Aim: To investigate prevalence, aetiology and management of HOD on medical, surgical and elderly-care wards. Methods: A cross-sectional study in a volunteer sample of UK hospitals, which collected data on one winter and one summer day in 2016. Patients admitted >= 72 h were screened for HOD (definition: >= 2 episodes of Bristol Stool Type 5-7 the day before the study, with diarrhoea onset >48 h after admission). Data on HOD aetiology and management were collected prospectively. Findings: Data were collected on 141 wards in 32 hospitals (16 acute, 16 teaching). Point-prevalence of HOD was 4.5% (230/5142 patients; 95% confidence interval (CI) 3.9-5.0%). Teaching hospital HOD prevalence (5.9%, 95% CI 5.1-6.9%) was twice that of acute hospitals (2.8%, 95% CI 2.1-3.5%; odds ratio 2.2, 95% CI 1.7-3.0). At least one potential cause was identified in 222/230 patients (97%): 107 (47%) had a relevant underlying condition, 125 (54%) were taking antimicrobials, and 195 (85%) other medication known to cause diarrhoea. Nine of 75 tested patients were Clostridium difficile toxin positive (4%). Eighty (35%) patients had a documented medical assessment of diarrhoea. Documentation of HOD in medical notes correlated with testing for C. difficile (78% of those tested vs 38% not tested, P<0.001). One-hundred and forty-four (63%) patients were not isolated following diarrhoea onset. Conclusion: HOD is a prevalent symptom affecting thousands of patients across the UK health system each day. Most patients had multiple potential causes of HOD, mainly iatrogenic, but only a third had medical assessment. Most were not tested for C. difficile and were not isolated. (C) 2019 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Combining epidemiological, clinical, and genomic data for Clostridium difficile cases offers fresh insight into characteristics associated with transmission and outcome. C. difficile lineages may have different reservoirs and modes of transmission, and recent strain acquisition is associated with poorer outcomes.

Background The role of symptomatic patients who are toxigenic strain positive (TS+) but fecal toxin negative (FT-) in transmission of Clostridium difficile is currently unknown. Methods We investigated the contribution of symptomatic TS+/FT- and TS+/FT+ patients in C. difficile transmission in 2 UK regions. From 2-step testing, all glutamate dehydrogenase (GDH)-positive specimens, regardless of fecal toxin result, from Oxford (April 2012 through April 2013) and Leeds (July 2012 through April 2013) microbiology laboratories underwent culture and whole-genome sequencing (WGS), using WGS to identify toxigenic strains. Plausible sources for each TS+/FT+ case, including TS+/FT- and TS+/FT+ patients, were determined using WGS, with and without hospital admission data. Results A total of 1447 of 12772 (11%) fecal samples were GDH positive, 866 of 1447 (60%) contained toxigenic C. difficile, and fecal toxin was detected in 511 of 866 (59%), representing 235 Leeds and 191 Oxford TS+/FT+ cases. TS+/FT+ cases were 3 times more likely to be plausibly acquired from a previous TS+/FT+ case than a TS+/FT- patient. Fifty-one of 265 (19%) TS+/FT+ cases diagnosed >3 months into the study were genetically related (≤2 single-nucleotide polymorphisms) to ≥1 previous TS+/FT+ case or TS+/FT- patient: 27 (10%) to only TS+/FT+ cases, 9 (3%) to only TS+/FT- patients, and 15 (6%) to both. Only 10 of 265 (4%) were genetically related to a previous TS+/FT+ or TS+/FT- patient and shared the same ward simultaneously or within 28 days. Conclusions Symptomatic TS+/FT- patients were a source of C. difficile transmission, although they accounted for less onward transmission than TS+/FT+ cases. Although transmission from symptomatic patients with either fecal toxin status accounted for a low overall proportion of new cases, both groups should be infection control targets.

Spector and Knight highlight the potential role of faecal transplantation in the management of Clostridium difficile infection.1 We agree that prolonged follow-up data are needed, given the unknown long term adverse consequences, but we wish to clarify come of their statements. Firstly, Spector and Knight quote a recurrence rate of 25% after initial mild infection but recurrence …

Introduction: Bursitis is a rare complication of brucellosis that has only once been described in a country where disease has been eradicated in domestic animals. Case Presentation: A 63-year-old diabetic man presented with an 11-year history of painless swelling over his right knee. Magnetic resonance imaging (MRI) showed a large, multiloculated cyst overlying the knee joint. The patient underwent bursectomy which revealed caseous necrosis. Operative samples cultured Brucella abortus . The patient was treated with a combination of surgery and antimicrobials (doxycycline, rifampicin and gentamicin). His only risk factor for acquiring Brucella was drinking unpasteurized milk during childhood. Fifty eight cases of Brucella bursitis have been described in the English-language medical literature. Half have involved the prepatellar bursa. Only one case, from Australia, occurred in a country that has eradicated brucellosis in domestic animals. Although symptoms are often prolonged, local features of inflammation are usually absent. Diagnosis is primarily by bursal fluid culture. Treatment involves antimicrobials with or without aspiration or excision of the bursa. As the diagnosis was unexpected, several laboratory workers were exposed to the Brucella isolate before its identification. Follow up according to UK guidelines revealed no cases of occupationally acquired infection. Conclusion: Bursitis is an unusual manifestation of brucellosis. It is extremely rare outside countries where the infection is endemic, but the chronicity of symptoms and increase in global travel mean that patients with the condition may present in non-endemic settings. Clinicians should therefore consider the diagnosis in cases of unexplained chronic bursitis.

PURPOSE OF REVIEW:Biological therapies for Clostridium difficile infection (CDI) include probiotics and faecal microbiota transplant (FMT). There is significant interest in their use in treating refractory/recurrent CDI. This review summarizes the latest evidence for these approaches.RECENT FINDINGS:The small number of randomized controlled trials (RCTs) using probiotics in CDI have produced variable results; the most recent showed no benefit in preventing disease. However, several meta-analyses published in the last year have suggested benefit in their use, but these conclusions are limited by the poor quality of many of the primary studies, and lack of standardization of the probiotic administered. In contrast, FMT appears highly effective for the treatment of CDI. In the only published RCT, the cure rate was 81%, which is close to the rate shown by meta-analyses of previous case series. The use of artificially produced bacterial mixtures in place of faecal samples is now under investigation.SUMMARY:Biological therapies for CDI, especially FMT, will continue to attract attention. Further, large-scale RCTs are required to identify which patients are most likely to benefit from these therapies in the future.

Anaerobic bacteria are a rare cause of mycotic aortic aneurysm (MAA). One reason for this may be that the organisms are often fastidious and do not grow well on standard laboratory media. The advent of molecular techniques such as the identification of RNA from the 16S ribosomal subunit of bacteria by polymerase chain reaction (16S PCR) has offered the opportunity to identify organisms from clinical specimens that are culture negative. This allows better management of patients with difficult or unusual infections, including those caused by anaerobic organisms. We report the first case of Anaerococcus lactolyticus causing MAA. The organism was identified using 16S PCR. It is normally sensitive to β-lactams (including penicillin) and metronidazole, but management of infections caused by Anaerococcus species is not well described. In addition there is limited published data on the optimum treatment of MAA. In this case the patient responded to a seven week course of β-lactams and metronidazole.

We report a case of Buruli ulcer in a tourist from the United Kingdom. The disease was almost certainly acquired in Brazil, where only 1 case had previously been reported. The delay in diagnosis highlights the need for physicians to be aware of the disease and its epidemiology.

Veterinary RecordVolume 164, Issue 6 p. 186-186 Letter Weil's disease associated with the adoption of a feral rat Benjamin W. Strugnell, Benjamin W. Strugnell VLA — Thirsk, West House, Station Road, Thirsk, North Yorkshire, YO7 1PZSearch for more papers by this authorCharlotte Featherstone, Charlotte Featherstone VLA — Thirsk, West House, Station Road, Thirsk, North Yorkshire, YO7 1PZSearch for more papers by this authorMike Gent, Mike Gent West Yorkshire Health Protection Unit, HPA Laboratories, Bridle Path, York Road, Leeds, LS15 7TRSearch for more papers by this authorPatricia Lister, Patricia Lister West Yorkshire Health Protection Unit, HPA Laboratories, Bridle Path, York Road, Leeds, LS15 7TRSearch for more papers by this authorGail Evans, Gail Evans West Yorkshire Health Protection Unit, HPA Laboratories, Bridle Path, York Road, Leeds, LS15 7TRSearch for more papers by this authorEbere Okereke, Ebere Okereke West Yorkshire Health Protection Unit, HPA Laboratories, Bridle Path, York Road, Leeds, LS15 7TRSearch for more papers by this authorDamian Mawer, Damian Mawer Department of Infection and Travel Medicine, St James's University Hospital, Beckett Street, Leeds, LS9 7TFSearch for more papers by this authorHugh McGann, Hugh McGann Department of Infection and Travel Medicine, St James's University Hospital, Beckett Street, Leeds, LS9 7TFSearch for more papers by this authorRebecca Marchewka, Rebecca Marchewka Yorkshire Vets, 515 Bradford Road, Thornbury, Bradford, BD3 7BASearch for more papers by this authorJane Errington, Jane Errington VLA — Penrith, Merrythought, Calthwaite, Penrith, Cumbria, CA11 9RRSearch for more papers by this authorJackie Fenner, Jackie Fenner Department of Food and Environmental Safety, VLA — Weybridge, New Haw, Addlestone, Surrey, KT15 3NBSearch for more papers by this authorGeoff Pritchard, Geoff Pritchard VLA — Bury St Edmunds, Rougham Hill, Bury St Edmunds, Suffolk, IP33 2RXSearch for more papers by this author Benjamin W. Strugnell, Benjamin W. Strugnell VLA — Thirsk, West House, Station Road, Thirsk, North Yorkshire, YO7 1PZSearch for more papers by this authorCharlotte Featherstone, Charlotte Featherstone VLA — Thirsk, West House, Station Road, Thirsk, North Yorkshire, YO7 1PZSearch for more papers by this authorMike Gent, Mike Gent West Yorkshire Health Protection Unit, HPA Laboratories, Bridle Path, York Road, Leeds, LS15 7TRSearch for more papers by this authorPatricia Lister, Patricia Lister West Yorkshire Health Protection Unit, HPA Laboratories, Bridle Path, York Road, Leeds, LS15 7TRSearch for more papers by this authorGail Evans, Gail Evans West Yorkshire Health Protection Unit, HPA Laboratories, Bridle Path, York Road, Leeds, LS15 7TRSearch for more papers by this authorEbere Okereke, Ebere Okereke West Yorkshire Health Protection Unit, HPA Laboratories, Bridle Path, York Road, Leeds, LS15 7TRSearch for more papers by this authorDamian Mawer, Damian Mawer Department of Infection and Travel Medicine, St James's University Hospital, Beckett Street, Leeds, LS9 7TFSearch for more papers by this authorHugh McGann, Hugh McGann Department of Infection and Travel Medicine, St James's University Hospital, Beckett Street, Leeds, LS9 7TFSearch for more papers by this authorRebecca Marchewka, Rebecca Marchewka Yorkshire Vets, 515 Bradford Road, Thornbury, Bradford, BD3 7BASearch for more papers by this authorJane Errington, Jane Errington VLA — Penrith, Merrythought, Calthwaite, Penrith, Cumbria, CA11 9RRSearch for more papers by this authorJackie Fenner, Jackie Fenner Department of Food and Environmental Safety, VLA — Weybridge, New Haw, Addlestone, Surrey, KT15 3NBSearch for more papers by this authorGeoff Pritchard, Geoff Pritchard VLA — Bury St Edmunds, Rougham Hill, Bury St Edmunds, Suffolk, IP33 2RXSearch for more papers by this author First published: 07 February 2009 https://doi.org/10.1136/vr.164.6.186Citations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume164, Issue6February 2009Pages 186-186 RelatedInformation

A 27 year old British man presented with a painless, slowly enlarging ulcer on the lateral aspect of his left knee. The lesion had begun during a wildlife tour in the Pantanal region of Brazil and the Southern Peruvian Amazon. At presentation it measured 11 x 6 cm and was characterised by deeply undermined edges and a dense adherent eschar. It was debrided with larval therapy and then biopsied. Histology revealed numerous, atypical acid-alcohol fast bacilli and inflammation of the dermal tissue with necrosis of the subcutaneous fat. Mycobacterial culture did not yield any significant isolates. Polymerase chain reaction for Leishmania species was negative on two occasions. The patient was subsequently treated with 6 weeks of clarithromycin monotherapy for presumed Mycobacterium marinum infection but the lesion continued to enlarge. In consequence he was referred to the regional Infection and Travel Medicine department. A further diagnostic procedure was performed and the patient commenced on appropriate therapy with subsequent clinical improvement. This condition is rarely seen in South America and this is the first reported case of infection in a traveller returning to the UK.