Despite this, one constant remains. At the core of medical professionalism is the social contract granting a privilege to provide services, underpinned by expert knowledge and skills, ethical conduct and self-regulation. However, professionalism is also a personal thing, and nothing tests a doctor’s professionalism more than the tension between self-interest and the patient’s best interests — in short, altruism.

Objective: To describe antimicrobial resistance and molecular epidemiology of methicillin‐resistant Staphylococcus aureus (MRSA) isolated in community settings in Australia.

An 8-year-old boy presented with fulminant necrotizing infection resembling gas gangrene following penetrating trauma from a tree branch. Bacillus cereus was isolated from tissue specimens, showing that unexpected pathogens can be isolated. It is essential to submit specimens for culture, as this organism is typically resistant to beta-lactam antibiotics and metronidazole, the empiric choice for gas gangrene.

Medical Journal of AustraliaVolume 182, Issue 5 p. 249-249 Letter Severe childhood pneumonitis caused by the Queensland strain of community-acquired methicillin-resistant Staphylococcus aureus Bradley T Martin, Corresponding Author Bradley T Martin Respiratory Fellow (currently bradleym@chw.edu.au Department of Respiratory Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145)Correspondence: bradleym@chw.edu.auSearch for more papers by this authorPamela Palasanthiran, Pamela Palasanthiran Infectious Diseases Specialist Department of Respiratory Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145)Search for more papers by this authorIain B Gosbell, Iain B Gosbell Infectious Diseases Fellow Department of Respiratory Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145)Search for more papers by this authorThelma Barbagiannakos, Thelma Barbagiannakos Director Sydney Children's Hospital, Sydney, NSWSearch for more papers by this authorEmma J Best, Emma J Best Hospital Scientist SWAPS Staphylococcal Reference Facility, South Western Area Pathology Service, Sydney, NSWSearch for more papers by this authorRichard L Henry, Richard L Henry Head of School of Women's and Children's Health and Senior Associate Dean Faculty of Medicine, University of New South Wales, Sydney, NSW.Search for more papers by this author Bradley T Martin, Corresponding Author Bradley T Martin Respiratory Fellow (currently bradleym@chw.edu.au Department of Respiratory Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145)Correspondence: bradleym@chw.edu.auSearch for more papers by this authorPamela Palasanthiran, Pamela Palasanthiran Infectious Diseases Specialist Department of Respiratory Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145)Search for more papers by this authorIain B Gosbell, Iain B Gosbell Infectious Diseases Fellow Department of Respiratory Medicine, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145)Search for more papers by this authorThelma Barbagiannakos, Thelma Barbagiannakos Director Sydney Children's Hospital, Sydney, NSWSearch for more papers by this authorEmma J Best, Emma J Best Hospital Scientist SWAPS Staphylococcal Reference Facility, South Western Area Pathology Service, Sydney, NSWSearch for more papers by this authorRichard L Henry, Richard L Henry Head of School of Women's and Children's Health and Senior Associate Dean Faculty of Medicine, University of New South Wales, Sydney, NSW.Search for more papers by this author First published: 07 March 2005 https://doi.org/10.5694/j.1326-5377.2005.tb06678.xCitations: 4Read 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 onFacebookTwitterLinkedInRedditWechat Citing Literature Volume182, Issue5March 2005Pages 249-249 RelatedInformation

OBJECTIVES:Oral treatment regimens for multiresistant methicillin-resistant Staphylococcus aureus (MRSA) infections are limited. In Australia, rifampicin plus fusidic acid is the usual treatment regimen following glycopeptide therapy but many patients are intolerant of this; some isolates are resistant; new oxazolidinones are expensive for routine use. Pristinamycin is a possible alternative and we report our experience with this agent.METHODS:The Department of Microbiology and Infectious Diseases, South Western Area Pathology Service treats patients drawn from the South Western Sydney Area Health Service that houses approximately 800,000 people and contains approximately 2000 acute care public hospital beds. Patients prescribed pristinamycin between 1 September 2000 and 31 January 2000 were identified from hospital pharmacy records. A retrospective chart review was performed. Accepted clinical definitions of osteomyelitis and septic arthritis were used.RESULTS:Twenty-seven patients were identified with osteoarticular infections. Twenty-four cases involved Staphylococcus aureus (multiresistant MRSA in 21 cases); three involved Staphylococcus epidermidis sensu stricto; four cases involved multiple organisms. Nineteen cases received pristinamycin monotherapy; the others received various combinations (fusidic acid with five; other antibiotics with three). Therapy was generally well tolerated; no haematological or biochemical toxicity was detected. Seven patients had minor gastrointestinal disturbance; and one developed rash. Four patients required dose reduction. Only four patients ceased pristinamycin due to intolerance. Treatment outcome was evaluated in 23 cases; cure was effected in 16 cases, five were successfully suppressed and two failed. There were no deaths.CONCLUSIONS:Oral pristinamycin is well tolerated and an important additional agent to treat osteoarticular infections with multiresistant MRSA and other staphylococci.

An annual survey of antimicrobial resistance in clinical isolates of Staphylococcus aureus was conducted in 21 Australian teaching hospital microbiology laboratories in eight major cities from 1989 to 1999. A total of 19,000 isolates were tested for susceptibility to 18 antimicrobials, with 3795 being methicillin-resistant (MRSA). Resistance to ciprofloxacin in MRSA increased from 4.9% to 75.9%. The proportion of MRSA resistant to erythromycin decreased significantly (99.0%-88.9%), as did that to trimethoprim (98.4%-82.4%) and to tetracycline (96.5%-80.1%). The proportion of MRSA isolated increased in Sydney, Melbourne, Canberra, Adelaide, Perth, and Darwin, but not in Brisbane. The proportion in Hobart peaked in 1994. MRSA in Perth were predominantly non-multiresistant (nmMRSA) throughout the survey (i.e., resistant to less than three of eight indicator antibiotics) due mainly to local strains that originated in the community. The proportion of nmMRSA increased to modest levels in the other cities. In eastern cities, this was due to the appearance of strains closely related to nmMRSA seen in other countries of the southwestern Pacific.

One of the workers in our laboratory developed a proven infection with endemic methicillin-resistant Staphylococcus aureus (EMRSA)-15. Is colonization or infection with EMRSA-15 an issue for laboratory workers?

Beta-lactam resistance in Salmonella isolates is increasing. This paper describes the combination of three different beta-lactamases, OXA-30, SHV-9 and CMY-7, expressed by an isolate of Salmonella enterica serotype Typhimurium. This is the first report of an isolate of Salmonella having both an extended-spectrum beta-lactamase and an AmpC beta-lactamase.

Sir, Herrick first described pericarditis due to Neisseria meningitidis in 1918. Two forms, early and late, have been described. Early purulent pericarditis (often described in the literature as primary meningococcal pericarditis) is thought to be caused by meningococci invading the pericardium, and is rarely described in the literature. Twenty cases have been previously described in the English language literature. Late meningococcal pericarditis is thought to be immunological in aetiology and much more common. We describe a case of early purulent pericarditis which was diagnosed using DNA polymerase chain reaction (PCR). Early purulent meningococcal pericarditis is usually associated with serogroup C meningococci, and the strain described here belonged to sequence type (ST) 11 which had previously been reported to be characteristic of ET-37 complex meningococci. In addition, the isolate’s phenotype was unusual, being C:2a:P1.4 and, on sequencing, the porA gene was found to be P1.7b,4. A previously well 41-year-old man presented with fever and chest pain. He was in shock and exhibited a purpuric rash. There was no meningism or other neurological signs. Antibiotics were commenced. The jugular venous pressure was raised to the angle of the jaw, the apex beat was impalpable, the heart sounds were faint and no rub was audible. The chest X-ray showed a small, globular heart, and the electrocardiogram showed widespread ST elevation, consistent with pericarditis. Echocardiography revealed a pericardial effusion. Neisseria meningitidis was identified from blood cultures taken on admission. A sample of EDTA blood from the date of admission demonstrated the presence of Neisseria meningitidis serogroup C by PCR, detecting IS1106 and ctrA as previously described. The patient developed bilateral pleural effusions. Culture and PCR of pleural fluid for Neisseria meningitidis were negative. On day 4, the patient developed signs of tamponade, confirmed on echocardiography. Pericardiocentesis yielded 830 ml of straw-coloured fluid. The pericardial fluid failed to grow bacteria, but PCR was positive for Neisseria meningitidis serogroup C. Fevers and neutrophilia persisted. CT scan of the thorax (Fig. 1) and transthoracic echocardiogram showed large pleural and pericardial effusions. Pericardectomy was performed on day 19. The pericardium was 3 cm thick and contained buttery exudate, which was excised with the pericardium. Culture of

Community-acquired oxacillin-resistant Staphylococcus aureus (ORSA) infections are an emerging problem in the 1990s in Sydney, Australia. Laboratory data pertaining to all specimens that grew S. aureus between 1/1/1990 and 31/12/1999 were analysed. A total of 12,909 isolates of S. aureus were obtained. The proportions that were nonmultiresistant oxacillin-resistant S. aureus (NORSA) increased from 0.09% in 1990 to 5.5% in 1999. Resistance of NORSA strains to erythromycin was 8.5%, ciprofloxacin 8.4%, tetracycline 13%, rifampicin 0.7%, and fusidic acid 5.3%. A chart review was performed for cases of NORSA infection which occurred 1/1/1998-3/5/1998. Isolates from these cases underwent E-test oxacillin MIC testing, mecA determinant PCR, phage typing and pulsed-field gel electrophoresis. All nine of the patients with NORSA were Polynesians, and all had serious soft tissue infections. Bacteraemia was not seen. Only one patient received vancomycin yet all recovered. Isolates from all nine patients contained the mecA determinant. Oxacillin MICs were 1-8 mg/l. Strain differentiation with phage typing and pulsed-field gel electrophoresis showed isolates from eight patients were closely related and were similar to New Zealand WSPP1 and WSPP2 strains. Medical practitioners should take specimens for culture and sensitivity from lesions where infection with S. aureus is likely. Empirical treatment of staphylococcal infections in Polynesians needs to cover NORSA. Methods to detect oxacillin resistance need to be robust.

Objective: To survey Staphylococcus aureus strains isolated from patients presenting from the community, comparing clinical features and antibiotic sensitivity profiles between multiresistant and non-multiresistant methicillin-resistant and methicillin-sensitive isolates.Design: Retrospective case series.Participants and setting: Patients who presented to emergency or dermatology departments in hospitals served by the South Western Sydney Area Health Service between 1 May 1998 and 30 April 1999, All patients with methicillin-resistant S, aureus (MRSA) and the first 100 with methicillin-sensitive S. aureus were eligible,Main outcome measures: Patient demographic characteristics; risk factors; clinical presentation; treatment; outcome; and isolate antibiotic susceptibility.Results: 139 patients were eligible, and 122 had clinical records available. Ten of these 122 (8%) had multiresistant MRSA, 26 (21%) non-multiresistant MRSA and 86 (70%) methicillin-sensitive S. aureus, Among patients with non-multiresistant MRSA, 29% (7/24) were born in New Zealand, Samoa or Tonga, a higher proportion than among those with multiresistant MRSA or methicillin-sensitive S. aureus (P=0.03). Nearly half (44%) of non-multiresistant MRSA strains were community-acquired in patients with no risk factors. Two-thirds of patients with non-multiresistant MRSA (17/26) presented with cellulitis or abscess, and 58% (11/19 evaluable patients) required surgical treatment.Conclusions: Non-multiresistant MRSA strains are common, especially among people born in New Zealand, Samoa or Tonga, and are usually community acquired. Medical practitioners should routinely swab all staphylococcal lesions for culture and sensitivity.

The MRSA-Screen Test (Denka Seiken Co., Japan), a latex agglutination test to detect penicillin-binding protein 2a, was compared with PCR for the detection of oxacillin resistance in Staphylococcus aureus. A total of 77 oxacillin-sensitive and 269 oxacillin-resistant (ORSA) isolates were evaluated. Of the ORSA isolates, 186 were non-multiresistant (NORSA), defined as being resistant to two or fewer antibiotics other than beta -lactams. Eighty-three were multiresistant ORSA (MORSA) strains. If PCR is considered the gold standard test, then the sensitivity, specificity positive and negative predictive values of the MRSA-Screen Test were 100, 99, 99 and 100%, respectively. The endpoint was hard to read with NORSA strains that took longer than 60 s to react. MORSA strains took a median 12 s (range 5-60 s) to give a positive reaction with the MRSA-Screen Test, whereas NORSA strains took a median 30 s (range 5-180 s), a difference which was significantly different (P<0.0001, two-tailed Mann-Whitney unpaired two sample test). NORSA strains had an MIC50 of 128 mg/l and MIC90 of 256 mg/l, whereas MORSA strains had an MIC50 and MIC90 of >256 mg/l. The time that the MRSA-Screen Test took to agglutinate with ORSA strains correlated weakly with the MIC (r(2)=0.26). Detection of methicillin resistance cost AUD$9 per isolate with the MRSA-Screen Test, compared with AUD$13 per isolate with mecA PCR. The MRSA-Screen Test gave excellent sensitivity and specificity, and was quicker and cheaper than PCR. The full 3 min should be allowed to elapse before calling a test negative. Organisms giving indeterminate reactions should be tested for the mecA gene by PCR.

A live male infant was born at 37 weeks' gestation after a normal pregnancy to a 34-year-old mother. The baby developed bacteraemia with Streptococcus pneumoniae and recovered completely following treatment with antibiotics. The mother simultaneously developed bacteraemia with the same organism and died from septic shock. Blood culture isolates from mother and child were both serogroup 23F, and were shown to be identical by DNA fingerprinting. The literature reports rare cases of vaginal carriage and/or endometritis with this organism resulting in neonatal sepsis. Transmission to the neonate may have been ascending or haematogenous. A postmortem examination was refused.

Medical Journal of AustraliaVolume 173, Issue 9 p. 500-501 Letter Toxicities of flucloxacillin and dicloxacillin — is there really a difference? Hugh P Aders, Hugh P Aders Medicolegal Adviser haders@unitedmp.com.au Medical Defence Union, Level 21, 201 Kent Street, Sydney, NSW, 1044Search for more papers by this author Hugh P Aders, Hugh P Aders Medicolegal Adviser haders@unitedmp.com.au Medical Defence Union, Level 21, 201 Kent Street, Sydney, NSW, 1044Search for more papers by this author First published: 01 November 2000 https://doi.org/10.5694/j.1326-5377.2000.tb139306.xAboutPDF 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 onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume173, Issue9November 2000Pages 500-501 RelatedInformation

We report the emerging drug-resistance in Streptococcus pneumoniae seen by the South Western Area Pathology Service (SWAPS) from 1 January 1990 to 31 July 2000. SWAPS performs all the pathology testing for the public hospitals in the South Western Sydney Area Health Service, which serves a population of 700,000; 120,000 separations occur at these hospitals annually. In all, 2,265 patients submitted specimens yielding S. pneumoniae. These included respiratory tract specimens, blood cultures, eye swabs and cerebrospinal fluid (CSF). Resistance to penicillin, cefotaxime, and non-beta-lactam antibiotics, especially cotrimoxazole, has emerged over the 1990s. From 1997 onwards, around 10 per cent of CSF and blood culture isolates demonstrated penicillin-resistance and 5 per cent showed cefotaxime-resistance. In 2000, 35 per cent of pneumococci from sites other than CSF and blood exhibited resistance to penicillin and 15 per cent showed resistance to cefotaxime. Resistance to other agents also increased over the decade. In 2000, 76 per cent of all isolates were resistant to cotrimoxazole, 26 per cent to erythromycin and 24 per cent to tetracyclines. Rifampicin-resistance was negligible over the decade, and vancomycin-resistance was absent. Antibiotics currently used for empirical treatment of certain S. pneumoniae infections may now need to be reviewed.

Endophthalmitis occurs in five to 10% of injuries involving intraocular foreign bodies. A 52 year old abattoir worker sustained such penetrating ocular trauma and developed fulminant endophthalmitis. Clostridium beijerinckii was isolated from the vitreous humor. Intravitreal vancomycin and amikacin and intravenous penicillin and clindamycin were given. Despite therapeutic vancomycin and amikacin levels in the vitreous, vision was lost and enucleation was ultimately required.

Australian Veterinary JournalVolume 77, Issue 8 p. 511-513 Chlamydia psittaci infection and reinfection in a veterinarian IB GOSBELL, IB GOSBELL Department of Microbiology and Infectious Diseases, South Western Area Pathology Service, PMB 90, Liverpool, New South Wales 2170Search for more papers by this authorAD ROSS, AD ROSS NSW Agriculture, Elizabeth Macarthur Agricultural Institute, PMB 8, Camden, New South Wales 2570Search for more papers by this authorIB TURNER, IB TURNER Camden District Hospital, Camden, New South Wales 2570Search for more papers by this author IB GOSBELL, IB GOSBELL Department of Microbiology and Infectious Diseases, South Western Area Pathology Service, PMB 90, Liverpool, New South Wales 2170Search for more papers by this authorAD ROSS, AD ROSS NSW Agriculture, Elizabeth Macarthur Agricultural Institute, PMB 8, Camden, New South Wales 2570Search for more papers by this authorIB TURNER, IB TURNER Camden District Hospital, Camden, New South Wales 2570Search for more papers by this author First published: 10 March 2008 https://doi.org/10.1111/j.1751-0813.1999.tb12121.xCitations: 17Read 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 Citing Literature Volume77, Issue8August 1999Pages 511-513 RelatedInformation

Traditional tests for detection of syphilis are labour intensive and costly. Enzyme immunoassays (EIAs) are readily automated and cost effective if large numbers of tests are performed. Four experiments were devised to evaluate a syphilis EIA test kit where resources are limited: (1) testing antenatal patients; (2) testing refugees; (3) testing a high prevalence population; and (4) testing "problem sera" (containing autoantibodies or antibodies to other infective agents). Forty-one available syphilitic sera from antenatal patients were tested to evaluate sensitivity. Specificity was determined through testing sera determined to be nonreactive with rapid plasma reagin and Treponema pallidum hemagglutination tests, calculating the sample size (456) on the confidence interval (CI) required. Two runs were performed on antenatal sera, giving sensitivities of 32% (95% CI: 20%, 47%) and 37% (95% CI: 24%, 52%) and specificities of 92% (95% CI: 89%, 94%) and 90% (95% CI 87%, 92%), respectively. We present a method to evaluate a serological test where resources are limited. Unexpectedly, the test kit performed poorly as a screening test. New serological tests need to be evaluated in-house prior to adoption.

Background: Blood culture results have profound implications for patients. Comprehensive overviews of blood cultures have been uncommon, and focused on tertiary referral hospitals.Aim: To present a review of blood culture results from a laboratory servicing community hospitals in Sydney, Australia.Methods: Retrospective chart review of patients with positive blood cultures from 1 June 1993 to 31 May 1994.Results: During the survey period there were 107,382 hospital admissions; 12,109 blood culture sets from 9292 patients were processed. Of these 1197 sets were positive, representing 974 febrile episodes in 923 patients. There were 476 episodes of contamination. Of the episodes of true bacteraemia, Escherichia coli was isolated in 139, Staphylococcus aureus in 91 (22 methicillin-resistant), other enterobacteriaceae in 60, and Streptococcus pneumoniae in 51. The diagnoses attributable to bacteraemia included intravenous catheter-related sepsis (122 episodes), urinary tract infection (88), bacteraemia from unknown source (79), intra-abdominal and biliary sepsis (91), pneumonia (35), and meningitis (21). Sixty-eight patients died directly due to bacteraemia. Multivariate analysis showed underlying disease (OR 3.97) or shock (OR 28.1) predicted death. Blood cultures confirmed clinical diagnoses in 258 episodes, but made a de novo diagnosis in 205 episodes.Conclusions: This study describes the clinical and laboratory features of bacteraemias occurring in smaller public hospitals, as distinct from tertiary referral centres. It demonstrated that intravenous catheter-related sepsis was very common in smaller hospitals. The clinical diagnosis was frequently confirmed, and a de novo diagnosis was often established by a positive blood culture. Unfortunately nearly half the positive blood cultures represented contamination.

Clostridium tertium bacteremia is unusual, seen most often with gastrointestinal disease and/or neutropenia. Two cases are described. The first was a 19-yr-old female with acute leukemia, who developed gastrointestinal symptoms and C. tertium bacteremia while neutropenic. The second was a 57-yr-old female with quiescent ulcerative colitis, who presented with fever, rigors and epigastric pain. Four organisms including C. tertium were isolated from blood cultures. This patient responded to broad spectrum antimicrobial therapy, whereas the first patient required the addition of specific agents to recover. C. tertium is aerotolerant and thus can be misidentified as a Bacillus or Corynebacterium spp. Our isolates had a distinctive Gram stain morphology, were catalase negative and failed to sporulate aerobically--this aided in the recognition of this significant Gram-positive bacillus.