BACKGROUND:Guidance on the use of fluid-resistant surgical masks (FRSMs) and filtering facepiece protection level 3 (FFP3) respirator masks by healthcare staff in England is produced nationally and applied locally by hospital trusts. In April 2022, national infection prevention and control guidance was updated with reference to the importance of local risk assessment when considering the use of FFP3 respirator masks. AIM:Our aim was to evaluate local hospital policies for use of face masks and risk assessment for healthcare staff. METHODS:A cross-sectional online survey (February-March 2023) of National Health Service trusts in England was conducted. Responses were analysed using Fisher's exact tests and the framework approach. RESULTS:Fifty nine percent (109/186) of eligible hospital trusts responded. All trusts required staff to wear FRSMs or FFP3 respirator masks when providing direct care to patients with suspected respiratory viral infection (RVI), 87% (95/109) and 13% (14/109), respectively. FFP3 respirator masks were required by 13% of trusts (14/109) when providing direct care to individuals with suspected RVI and by 9% of trusts (10/109) when present in a bay/ward with patients with suspected RVI. Over half of the trusts used locally developed risk assessment tools. CONCLUSIONS:There was clear variation in policies for use of face masks and use of workplace and individual risk assessments across hospital trusts. There was also variation in application of mask use, fit testing and audit of adherence. Further work is required to explore whether development of further guidance and national implementation tools could reduce unwarranted variation.

Invasive fungal infection is a life-threatening complication of chemotherapy and neutropaenia in the haematology population. Trichoderma species rarely cause human disease but have been reported to cause invasive infection in the immunosuppressed. We present a case of invasive Trichoderma longibrachiatum pulmonary infection with fatal outcome in a neutropaenic patient with acute myeloid leukaemia. 2012 Elsevier Ltd. All rights reserved.

BACKGROUND:People who inject drugs (PWID) are at increased risk of community-acquired Staphylococcus aureus bacteremia (CA-SAB), but little is known about clinical outcomes of CA-SAB in PWID compared with the wider population of patients with CA-SAB. METHODS:Three national datasets were linked to provide clinical and mortality data on patients hospitalized with CA-SAB in England between 1 January 2017 and 31 December 2020. PWID were identified using the International Classification of Diseases, Tenth Revision code for "mental health and behavioral disorder due to opioid use" (F11). Multivariable logistic regression was used to estimate adjusted odds ratios (aORs) for associations of PWID with 30-day all-cause mortality and 90-day hospital readmission. RESULTS:In 10 045 cases of CA-SAB, 1612 (16.0%) were PWID. Overall, 796 (7.9%) patients died within 30 days of CA-SAB admission and 1189 (11.8%) patients were readmitted to hospital within 90 days of CA-SAB. In those without infective endocarditis, there was strong evidence of lower odds of mortality among PWID compared with non-PWID (aOR, 0.47 [95% confidence interval {CI}: .33-.68]; P < .001), whereas there was no association in CA-SAB case fatality with endocarditis (aOR, 1.40 [95% CI: .87-2.25]; P = .163). PWID were less likely to be readmitted within 90 days of CA-SAB (aOR, 0.79 [95% CI: .65-.95]; P = .011). CONCLUSIONS:In this large cohort study of patients with CA-SAB in England, PWID had lower odds of death in the absence of endocarditis and lower odds of readmission within 90 days compared to non-PWID patients. This study highlights the overrepresentation of PWID among patients with CA-SAB nationally.

In 2022, there were global reports of increased numbers of acute hepatitis not explained by hepatitis A-E virus infection in children. This manuscript summarises histopathology results from 20 patients in the United Kingdom who underwent liver transplant or had a liver biopsy as part of aetiological investigations. All available histopathological samples were reviewed centrally as part of the outbreak investigation. A working group comprised of infection specialists, hepatologists and histopathologists met virtually to review the cases, presentation, investigations and histopathology. All 20 liver samples had evidence of inflammation without significant interface activity, and submassive confluent pan-lobular or multilobular hepatocellular necrosis. Overall, the predominant histopathological findings were of acute nonspecific hepatitis with submassive hepatic necrosis and central vein perivenulitis and endothelitis. Histopathological findings were a poor indicator of aetiology. This review describes the centralised approach to histopathological examination and summarises the findings. Whilst adenovirus was frequently detected in blood or stool, histopathological examination could not support it as a causative factor. center dot center dot center dot What is Known image Adenovirus is implicated in the outbreak of acute hepatitis in children. Genomic studies have found high levels of adeno-associated virus 2 DNA in the blood and liver of a high proportion of cases. Of histopathology findings that have previously been published, there has not been evidence of adenovirus in hepatocytes.What is New Whilst adenovirus was frequently detected in blood or stool, histopathological examination could not confirm it as a causative factor. Histopathological findings were of acute nonspecific hepatitis with submassive hepatic necrosis and central vein perivenulitis and endothelitis. Immediate access to the relevant information about the histopathological features observed in this hepatitis outbreak.

Background Ensuring vaccination coverage reaches established herd immunity thresholds (HITs) is the cornerstone of any vaccination programme. Diverse migrant populations in European countries have been associated with cases of vaccine-preventable diseases (VPDs) and outbreaks, yet it is not clear to what extent they are an under-immunized group.Methods We did a systematic review and meta-analysis to synthesize peer-reviewed published primary research reporting data on the immune status of migrants in EU/EEA countries, the UK and Switzerland, calculating their pooled immunity coverage for measles, mumps, rubella and diphtheria using random-effects models. We searched on Web of Science, Embase, Global Health and MEDLINE (1 January 2000 to 10 June 2022), with no language restrictions. The protocol is registered with PROSPERO (CRD42018103666).Findings Of 1103 abstracts screened, 62 met eligibility criteria, of which 39 were included in the meta-analysis. The meta-analysis included 75 089 migrants, predominantly from outside Europe. Pooled immunity coverage among migrant populations was well below the recommended HIT for diphtheria (n = 7, 57.4% [95% confidence interval (CI): 43.1-71.7%] I2 = 99% vs HIT 83-86%), measles (n = 21, 83.7% [95% CI: 79.2-88.2] I2 = 99% vs HIT 93-95%) and mumps (n = 8, 67.1% [95% CI: 50.6-83.6] I2 = 99% vs HIT 88-93%) and midway for rubella (n = 29, 85.6% [95% CI: 83.1-88.1%] I2 = 99% vs HIT 83-94%), with high heterogeneity across studies.Interpretation Migrants in Europe are an under-immunized group for a range of important VPDs, with this study reinforcing the importance of engaging children, adolescents and adults in 'catch-up' vaccination initiatives on arrival for vaccines, doses and boosters they may have missed in their home countries. Co-designing strategies to strengthen catch-up vaccination across the life course in under-immunized groups is an important next step if we are to meet European and global targets for VPD elimination and control and ensure vaccine equity.

Background Public health guidance recommending isolation of individuals with group A streptococcal (GAS) infection or carriage for 12–24 h from antibiotic initiation to prevent onward transmission requires a strong evidence base. Aim To estimate the pooled proportion of individuals who remain GAS culture-positive at set intervals after initiation of antibiotics through a systematic literature review (PROSPERO CRD42021290364) and meta-analysis. Methods We searched Ovid MEDLINE (1946–), EMBASE (1974–) and Cochrane library. We included interventional or observational studies with ≥ 10 participants reporting rates of GAS throat culture positivity during antibiotic treatment for culture-confirmed GAS pharyngitis, scarlet fever and asymptomatic pharyngeal GAS carriage. We did not apply age, language or geographical restrictions. Results Of 5,058 unique records, 43 were included (37 randomised controlled studies, three non-randomised controlled trials and three before-and-after studies). The proportion of individuals remaining culture-positive on day 1, day 2 and days 3–9 were 6.9% (95% CI: 2.7–16.8%), 5.4% (95% CI: 2.1–13.3%) and 2.6% (95% CI: 1.6–4.2%). For penicillins and cephalosporins, day 1 positivity was 6.5% (95% CI: 2.5–16.1%) and 1.6% (95% CI: 0.04–42.9%), respectively. Overall, for 9.1% (95% CI: 7.3–11.3), throat swabs collected after completion of therapy were GAS culture-positive. Only six studies had low risk of bias. Conclusions Our review provides evidence that antibiotics for pharyngeal GAS achieve a high rate of culture conversion within 24 h but highlights the need for further research given methodological limitations of published studies and imprecision of pooled estimates. Further evidence is needed for non-beta-lactam antibiotics and asymptomatic individuals.

Whilst healthcare workers (HCWs) are at high risk of contracting COVID-19, measures can be put in place to reduce the spread of COVID-19 and other respiratory infections in healthcare settings. These currently include the use of masks: fluid-resistant surgical masks and respiratory protective equipment. However, for mask policies to be effective, compliance with their use must be high. This study interviewed 12 HCWs from a variety of backgrounds to understand their experiences of mask use. We explored factors associated with compliance with mask use and potential impacts on HCW wellbeing. Overall, participants reported good understanding of the benefits of masks and high compliance levels with policy. However, factors that reduced their compliance with mask policy and impacted their ability to carry out their role were highlighted. These included wearing masks for longer durations, policy being perceived as out of proportion with risk, communication challenges, and discomfort. This study highlights the importance of clear communication of guidance, particularly when it has changed, ensuring staff are familiar with up-to-date research on efficacy of masks, and ensuring guidance aligns with risk. Furthermore, this study highlights the importance of masks being required for an appropriate duration (based on risk).

Introduction. Panton-Valentine leucocidin (PVL) toxin is a potential determinant of virulence associated with S. aureus infection.Gap Statement. The contribution of PVL to S. aureus pathogenicity remains unclear.Aim. To compare clinical outcomes in hospitalized patients with PVL-positive and PVL-negative community-acquired (CA) S. aureus bacteraemia.Methods. Three national datasets were combined to provide clinical and mortality data for patients with CA S. aureus blood culture isolates sent to the UK reference laboratory for PVL testing, August 2018 to August 2021. Multivariable logistic regression models were built for the effect of PVL positivity on 30 day all-cause mortality and 90 day readmission.Results. In 2191 cases of CA S. aureus bacteraemia, there was no association between PVL and mortality (adjusted odds ratio, aOR: 0·90, 95 % confidence interval, CI: 0·50-1·35, P=0·602) and no difference in median LOS (14 versus 15 days, P=0.169). PVL-positive cases had lower odds of readmission (aOR 0·74, CI 0·55-0.98, P=0·038). There was no evidence that MRSA status modified this effect (P=0·207).Conclusions. In patients with CA S. aureus bacteraemia PVL toxin detection was not associated with worse outcomes.

Objectives A global outbreak of mpox (monkeypox) has been ongoing since 2022, with most cases in the UK detected in gay, bisexual and other men who have sex with men (GBMSM). Asymptomatic and pauci-symptomatic mpox infection has been reported outside of the UK. We aimed to investigate whether mpox could be detected in specimens from GBMSM in England who were attending sexual health services (SHSs) for asymptomatic sexually transmitted infection screening. Methods Anonymised, residual clinical specimens from GBMSM undertaking routine asymptomatic screening for gonorrhoea ( Neisseria gonorrhoeae (NG)) and chlamydia ( Chlamydia trachomatis (CT)) infection were tested for the presence of mpox virus. Specimens were collected between 1 August and 7 October 2022 from three SHSs in high-mpox incidence areas in England. Testing was performed using a dual-clade, mpox virus-specific real-time PCR. Results During the collection period, 2927 clinical specimens (951 pharyngeal swabs, 1022 urine specimens and 954 rectal swabs) were obtained from 1159 GBMSM. Mpox virus was detected in four specimens from two participants who attended the same SHS at different times (the first during the week 8–12 of August, the second during the week 19–23 of September). One participant was positive in the urine specimen only, while the other tested positive at all three sites. Conclusions A very low prevalence (2 of 1159, 0.17%) of mpox infection was detected in GBMSM attending SHS in England for asymptomatic NG/CT screening, suggesting that undetected infection in this population was unlikely to be a main driver of transmission. Confirmed mpox cases in the UK declined from over 1100 per month in June and July to 764 cumulatively during the collection period. These data give reassurance that the observed reduction in cases during the collection period was not due to undetected infection or changes in presentation among SHS attendees. Currently, there is insufficient evidence to support routine testing of asymptomatic GBMSM for mpox infection in England.

The United Kingdom's cases of malaria infection are primarily acquired in sub-Saharan Africa, with the majority of infections presenting in London.1 When patients go to a hospital with malaria, there is a screening opportunity for other geographically associated chronic infections. We identified patients who were diagnosed with malaria after presenting to our emergency department in London over a 2-year period, to assess whether there may be clinical benefit in screening for chronic viral (hepatitis B, hepatitis C, HIV) or parasitic (schistosomiasis, strongyloidiasis) infection in this cohort. Over this period, 131 patients were diagnosed with malaria. Crude seropositivity rates for HIV, hepatitis B, and strongyloidiasis were higher than expected compared with local population estimates, 7 and 28 times higher for HIV and hepatitis B, respectively. Those patients with previously unidentified cases were offered appropriate treatment. These findings support the potential clinical and public health benefits of screening for other infectious diseases in the context of a malaria diagnosis.

BACKGROUND:Acute myopericarditis can be caused by a myriad of infectious and non-infectious aetiologies, however, it is often considered to be due to self-limiting viral infection. Salmonella spp. myopericarditis is rare and the few cases in the literature suggest significant associated morbidity and mortality. CASE SUMMARY:A 44-year-old man presented with fever, dyspnoea, and chest pain. He was found to have a large pericardial effusion with clinical signs of tamponade and sepsis. Therapeutic pericardiocentesis was performed and ceftriaxone and levofloxacin were administered. Fully sensitive Salmonella enterica serovar Enteritidis (S. Enteritidis) was isolated in his pericardial fluid and he made a full recovery after a 4-week course of ciprofloxacin. A new diagnosis of type 2 diabetes mellitus was made on admission. A follow-up cardiac magnetic resonance (CMR) scan was suggestive of myocarditis which was unexpected given a normal Troponin T level on presentation. DISCUSSION:We report a rare case of S. Enteritidis myopericarditis. Our case is notable as the patient was immunocompetent apart from newly diagnosed diabetes. This case highlights the value of CMR imaging in assessing for myocarditis and ventricular function.

Background: Standard of care for management of Staphylococcus aureus bacteraemia (SAB) is 2-4 weeks intravenous (IV) flucloxacillin or glycopeptide. Ceftriaxone (CRO) is used to facilitate management of SAB under out-patient antimicrobial therapy (OPAT) services once patients are medically stable, however published data on this approach are limited. Methods: Retrospective review of SAB cases at Homerton Hospital: 1st August 2015 to 31st July 2018. Cases were identified from the microbiology database and clinical data retrospectively collected from electronic patient records. Results: 83 cases of SAB were included. Median age was 56 years (IQR 45-74); 53 (63.9%) were male. 70 (84.3%) had complicated SAB, 4 (4.8%) had MRSA bacteraemia and 11/80 (13.8%) were PVL positive. After excluding patients who died or were transferred whilst on IV therapy; 8/11 (72.7%) uncomplicated SAB patients and 29/55 (52.7%) complicated SAB patients received the standard duration of IV anti-staphylococcal therapy. Median length of stay (LOS) was 32 days (IQR 16-52.5). 30-day mortality was 9.6%; in hospital mortality was 14.5%. Eight (8/83, 9.6%) patients switched to CRO prior to completion of standard IV flucloxacillin therapy to facilitate OPAT. Median length of IV flucloxacillin in this group was 12 days (IQR 7-16). Ceftriaxone MIC was performed on 1/8 isolates (3mg/L). 7/8 had complicated SAB. Median LOS was 13 days (IQR 9-17). There were no deaths or relapsed infections. 1 patient developed C. difficileinfection on CRO. Conclusion: In this cohort ceftriaxone was a safe and effective follow-on therapy from flucloxacillin for management of SAB and allowed reduced LOS.

OBJECTIVES:To describe demographic features, clinical outcomes and diagnostic delay amongst patients with extra-spinal articular tuberculosis (TB) in a low-incidence setting. METHODS:Cases of TB treated at our institution between 2004 and 2014 were identified via the London TB register (LTBR). Demographic features of extra-spinal articular TB cases were compared to controls with TB at all other sites. For articular cases (excluding individuals <16 years or with spinal TB without peripheral joint involvement) clinical data were retrospectively collected. RESULTS:6,146 TB patients were identified over the study period; 146 (2.4%) cases had extra-spinal articular infection. There was no difference in median age between extra-spinal articular TB cases and controls with TB at other sites (31 vs 32 years, p = 0.57). Articular cases were more likely to be male (70.6% vs 59.5%, p = 0.007), Bangladeshi (28.7% vs 18.0%) or Pakistani (24.0% vs 16.1%) and were less likely to be Black-African (9.5% vs 19.8%) (p < 0.001). 93 cases were included in the case series; 85 (88.5%) were migrants and 83 (89.2%) were South Asian. Knee and elbow joints were affected in 22 (23.7%) and 18 (19.4%) cases respectively. The median durations of pre-healthcare and healthcare associated delay were 16 and 6 weeks respectively. Where mycobacterial culture was performed, 57/75 (76%) were positive for Mycobacterium tuberculosis. 86 (92.5%) cases received standard quadruple therapy for a median of 6 months (IQR 6-9). Recurrence of TB infection occurred in 4 (4.3%) cases and there were no TB related deaths. Seven (7.6%) cases required surgical intervention. CONCLUSIONS:Extra-spinal articular TB more commonly affected men and people of South Asian ethnicity. Significant diagnostic delays were identified, including avoidable healthcare-associated delays.

A 24-year-old previously well female presented with a discharging thigh abscess after travel to Ghana. She reported malaise but was otherwise systemically well. Further history revealed 2 years of intermittent left thigh pain, which had been attributed to a large trochanteric bursa identified on ultrasound in 2017. On examination she was afebrile with a deep, undermined ulcer discharging pus in the left antero-lateral thigh. Femoral X-ray was unremarkable. She underwent surgical debridement and intra-operatively infection was found to track to the greater trochanter. Tissue specimens grew Gemella morbillorum, Klebsiella pneumoniae, Enterobacter cloacae, Streptococcus anginosus and mixed anaerobes. She responded well to 4 weeks of ciprofloxacin, metronidazole and amoxicillin. Histological examination of the ulcer edge revealed non-necrotising granulomata (Ziehl-Neelsen stain negative).Mycobacterium tuberculosis(MTB) was subsequently isolated on mycobacterial culture from the same site. MRI demonstrated osteomyelitis of the greater trochanter with a 2cm intramedullary abscess and an adjacent soft tissue collection. Macroscopically caseous material was found on further debridement and tissue samples were AAFB smear negative but MTB complex was detected by PCR and culture of intra-medullary bone. This case demonstrates that bacteria and mycobacteria may be co-pathogens, and that M. tuberculosis bone infection may present with no systemic symptoms. It is a reminder of the importance of cross-sectional imaging and mycobacterial culture in deep soft tissue infections with a long or unusual history.

Background The association between diabetes and Strongyloides stercoralis remains controversial. We conducted a case-control study examining the association between diabetes and Strongyloides seropositivity in a large UK centre. Methods Between January 2013 and October 2016, cases and controls were identified by positive and negative Strongyloides serology, respectively. Demographic, clinical and microbiological data were retrospectively collected. Multivariate logistic regression analysis was performed. Results Over the study period, 532 samples were serologically tested for Strongyloides. After exclusion of duplicates and cases with missing data, 100 (22.3%; 95% CI 18.5-26.4%) out of 449 tested positive. Of seropositive cases, the mean age was 57 years (SD 16), 71 (71%) were male, 94 (94%) were migrants and 92 (92%) had eosinophilia. Univariate logistic regression analysis demonstrated a significant association between Strongyloides seropositivity and age (OR 1.04, 95% CI 1.02-1.05), male sex (OR 2.22, 95% CI 1.37-3.59), migration (OR 5.36, 95% CI 2.27-12.67), eosinophilia (OR 4.36, 95% CI 2.04-9.33) and diabetes (OR 3.52, 95% CI 2.19-5.66). In multivariate analysis, there remained a significant association between diabetes and Strongyloides seropositivity (OR 1.81, 95% CI 1.04-3.16). Conclusions We demonstrated a high rate of Strongyloides seropositivity in our East London cohort and a significant association with diabetes.

SETTING:Breast tuberculosis (TB) is rare in Western Europe, and its diagnosis may be delayed through lack of awareness of presenting features. Our institution serves a large East London population with a high incidence of TB.OBJECTIVE:To characterize presenting features and avoidable diagnostic delay in breast TB patients.DESIGN:We conducted a 13-year retrospective study of breast TB patients treated at our institution including demographic, clinical, microbiology, and pathology data.RESULTS:Forty-seven cases were included; 44 (94%) were female, with a median age of 33 years (IQR 28.5-39.5). The main presenting feature was a breast lump in 41 cases (87%); which were predominantly solitary unilateral lesions (25, 61%) and frequently located in the upper outer quadrant (28, 68%). Where performed, Mycobacterium tuberculosis was cultured in 15/36 (42%) cases. Granulomata were present on biopsy or aspirate in 21 (47%) and 17 (36%) cases, respectively. The median duration between symptom onset and treatment was 20 weeks (IQR 15-30). Forty-six (98%) completed treatment successfully and one relapsed.CONCLUSION:A high index of suspicion for TB is required for individuals presenting with breast symptoms from countries where TB is endemic. Development of standardized pathways may improve detection and management of breast TB may reduce diagnostic delay.

Migrant populations in the EU/EEA are increasingly being associated with outbreaks of vaccine-preventable diseases (VPDs), including the large-scale measles outbreak currently ongoing across Europe; however, it is unclear to what extent migrants represent an under-immunised group in the European context and implications for VPD control. Ensuring high levels of vaccination coverage is a key priority for all countries through the European Vaccine Action Plan, with EU/EEA Member States committed to eliminating measles and rubella, sustaining polio-free status, and controlling hepatitis B infection. We synthesised existing EU/EEA data to assess under-immunisation in migrants (defined as foreign born) residing in EU/EEA countries. We did a systematic review and meta-analysis (PROSPERO CRD42018103666) in accordance with PRISMA guidelines. Inclusion criteria were primary research studies pertaining to vaccination status (measles, mumps, rubella, diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type b [Hib]) in migrants residing in all EU/EEA countries. Pooled prevalence (95% CIs) were calculated for the meta-analysis using a random effects model. 56 studies met our criteria (14 EU/EEA countries); 36 studies, which included data from 80,432 migrants, were included in the meta-analysis. Vaccination status of migrants for key VPDs varied substantially, with pooled immunisation coverage well below the herd immunity threshold (HIT) targets for measles 80% (95% CI: 73-87%; HIT 92-95%), mumps 65% (95% CI: 48-82%; HIT 75-86%), and diphtheria 51% (95% CI: 29-73%; HIT 83-86%). Polio type 1 and 2 coverage was high (97% [95% CI: 95-98%]; 95 [95% CI: 92-97%], respectively). Migrants represent an under-immunised group in Europe, thus a high priority group for catch-up vaccination. Innovative strategies to engage them in vaccine uptake will be critical if we are to make European targets for the elimination and/or control of key VPDs. Migrants represent an under-immunised group in Europe and a high priority group for catch-up vaccination campaigns. Innovative strategies to engage them in vaccine uptake will be critical if we are to make European targets for the elimination and control of vaccine-preventable diseases.