BACKGROUND:Encephalitis is a condition of brain dysfunction and parenchymal inflammation with many aetiologies. Guidelines for Australia and Aotearoa New Zealand on diagnosis and management were published in 2015. There have been no recently published local studies of encephalitis. AIMS:This study assessed guideline adherence for recommended investigations and antimicrobial management of suspected community-acquired encephalitis cases. Secondary aims were to compare clinical diagnoses to the International Encephalitis Consortium (IEC) consensus case definition and to provide descriptive epidemiology of encephalitis in Sydney, Australia. METHODS:A retrospective review of medical records was conducted for all adults with a cerebrospinal fluid (CSF) sample collected between 1 July 2018 and 30 June 2019 to investigate suspected community-onset meningoencephalitis or encephalitis at four Sydney metropolitan hospitals. RESULTS:Two hundred and nine suspected cases were reviewed including 35 ultimately diagnosed as encephalitis. Adherence to guideline recommendations was variable but overall better in cases subsequently diagnosed as encephalitis, significantly so for some investigations. Viral polymerase chain reaction testing of non-CSF samples, serology for human immunodeficiency virus and syphilis, repeat herpes simplex virus (HSV) PCR when indicated and anti-N-methyl-D-aspartate receptor antibody testing were areas for improvement. Empiric aciclovir was not given in 30% of suspected cases but was at the appropriate dose and frequency when prescribed. Ten of 35 cases with clinical encephalitis diagnoses did not meet the IEC case definition criteria. The most common infectious aetiology was HSV, while the most common mimics were drug-associated presentations. CONCLUSIONS:Guideline application was variable, with areas identified for improvement. Prospective studies are needed to investigate guideline-adherence barriers.

Abstract Background Vaccination coverage for influenza, SARS-CoV-2 and pneumococcal disease among older Australians remains suboptimal. Hospital admission is an underutilised opportunity for the vaccination of older adults. Methods We conducted a 12-week prospective, single-centre evaluation at a tertiary hospital in Australia (August–November 2024). Inpatients aged ≥ 65 years admitted under cardiology, geriatrics, geriatric rehabilitation, respiratory and infectious diseases were screened for eligibility for National Immunisation Program (NIP)-recommended vaccines (influenza, SARS-CoV-2, conjugate pneumococcal). Stage 1 (weeks 1–6) involved academic detailing of medical officers (including education on the clinical benefit and standard of care for older adult immunisation) and weekly reminders to vaccinate as a part of routine care. During Stage 2 (weeks 7–12), we stopped giving reminders to medical officers, and a part-time vaccine prescriber (5 h/week) screened, consented and prescribed vaccines. Barriers to vaccination were recorded during both stages. We compared vaccination uptake between Stage 1 and Stage 2. Results Of the 851 inpatients screened, 649 were eligible for 1,410 vaccines (76.3%), and 73 vaccinations were administered (5.2%). Overall uptake increased from 19/710 (2.7%) vaccinations during Stage 1, to 54/700 (7.7%) vaccinations during Stage 2 (OR 3.04, 95% CI 1.75–5.49; p < 0.001). An increase in vaccination uptake was observed for SARS-CoV-2 (Stage 1: 1/286, 0.3%; Stage 2: 12/280, 4.3%; OR 12.7, 95% CI 1.86–546.03) and pneumococcal vaccination (Stage 1: 8/247, 3.2%; Stage 2: 30/253, 11.9%; OR 4.0, 95% CI 1.75–10.34), but not for influenza (Stage 1: 10/177, 5.6%; Stage 2: 12/167, 7.2%; OR 1.29, 95% CI 0.5–3.44). Conclusions Academic detailing and regular reminders for medical officers to vaccinate was associated with lower vaccination uptake of older adult inpatients than the use of a part-time vaccine prescriber.

BACKGROUND:Vaccination is effective at preventing severe illness related to influenza, pneumococcal disease and coronavirus disease 2019 COVID-19. Vaccine coverage among older Australians is incomplete, and hospitals currently administer very few vaccine doses. AIMS:This study investigated vaccination coverage for influenza, pneumococcal disease and COVID-19 among inpatients aged 65 years and over and patient-reported likelihood of accepting these vaccinations during hospitalisation. METHODS:A patient survey and audit of the Australian Immunisation Register were performed on 2 days in 2023 at Prince of Wales Hospital in Sydney, Australia. All inpatients aged 65 years and over on the identified days (n = 506) were included in the audit. A total of 447 patients were offered surveys, with 311 (69.6%) responses. The likelihood of accepting vaccinations was self-reported on a 5-point scale. Audit and survey data were not linked. RESULTS:Survey-reported vaccination coverage was 39.2% for COVID-19 in the last 6 months, 68.2% for influenza in 2023 and 32.1% for pneumococcal vaccination ever. The proportion of patients 'likely' or 'very likely' to accept inpatient vaccination was 58.2% for COVID-19, 62.7% for influenza and 61.1% for pneumococcus. The median likelihood score was higher among respondents who reported to be vaccinated than unvaccinated (4 vs. 3; P < 0.0001). Audit vaccination coverage was 21.1% for COVID-19 in the preceding 6 months, 60.5% for 2023 influenza vaccine and 20.6% for the recommended pneumococcal vaccine. CONCLUSIONS:The study demonstrated incomplete vaccination coverage for COVID-19, influenza and pneumococcal disease among older inpatients and patient interest in an inpatient vaccination programme.

Following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the complement pathway becomes activated, generating the stable split product C3d. Although C3d can modulate B cell responses through complement receptor 2 (CR2) in experimental systems, it remains unclear how circulating C3d relates to antibody responses after SARS-CoV-2 infection in humans. Here, we examined plasma C3d levels and their associations with SARS-CoV-2-specific antibody responses and clinical characteristics in convalescent adults and children. In adults, older age, male sex, and a history of severe COVID-19 were independently associated with higher C3d levels. C3d concentrations positively correlated with receptor-binding domain (RBD)-specific antibody-dependent cellular phagocytosis (ADCP), neutralizing antibody (nAb) titer, and anti-spike IgM, IgG, IgG1, and IgG3 levels. In children, C3d levels were significantly lower than in adults and correlated with anti-spike and anti-RBD IgG titers. These findings demonstrate that systemic complement activation, reflected by circulating C3d, is positively associated with SARS-CoV-2 antibody responses in both age groups. As this cross-sectional study cannot determine causality, further mechanistic and longitudinal studies are needed to define the role, if any, of C3d in shaping adaptive immunity to SARS-CoV-2.

OBJECTIVES:To evaluate the influence of remote patient monitoring (RPM) for managing people with acute coronavirus disease 2019 (COVID-19) on 28-day mortality and hospital use in Australia. STUDY DESIGN:Retrospective observational cohort study; analysis of deterministically linked NSW Notifiable Conditions Information Management System and hospital, emergency department, and non-admitted patient data. SETTING, PARTICIPANTS:South Eastern Sydney Local Health District catchment area residents aged 15 years or older for whom positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test results (polymerase chain reaction or rapid antigen testing) during 26 November 2021 - 30 June 2022 were recorded. MAIN OUTCOME MEASURES:Primary outcome: All-cause mortality within 28 days of positive SARS-CoV-2 test result. SECONDARY OUTCOMES:Hospital length of stay, and numbers of emergency department presentations, hospital admissions, and intensive care unit admissions within 14 days of positive test results. All analyses were undertaken for the unadjusted data (original cohort analysis) and after propensity score matching and inverse probability treatment weighting. RESULTS:Of 276 236 people aged 15 years or older with positive SARS-CoV-2 test results and complete demographic information, 4399 (1.6%) participated in RPM. Twenty-eight-day mortality was lower for the RPM group than the usual care group (propensity score-matched: adjusted odds ratio [aOR], 0.19; 95% confidence interval [CI], 0.08-0.43; inverse probability treatment-weighted: aOR, 0.21; 95% CI, 0.10-0.46). The 14-day likelihood of intensive care unit admission and emergency department presentation was similar for both groups; the likelihood of hospital admission was higher for the RPM group (propensity score-matched: aOR, 1.42; 95% CI, 1.12-1.78; inverse probability treatment-weighted: aOR, 1.51; 95% CI, 1.28-1.78), but the mean hospital length of stay was shorter (adjusted mean difference, original cohort: -2.01 [95% CI, -2.81 to -1.21] days; propensity score-matched: -3.54 [95% CI, -6.39 to -0.69] days; inverse probability treatment-weighted: -3.26 [95% CI, -6.01 to -0.50] days). CONCLUSION:RPM was associated with greater 14-day likelihood of hospital admission, but also with shorter mean length of stay and lower 28-day mortality, which may indicate that clinical deterioration was detected and treated earlier than with usual care. The benefit of RPM for managing other acute health conditions in the community, particularly infectious diseases, should be examined.

BACKGROUND:The introduction by the World Health Organization of specific International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) clinical codes for coronavirus disease 2019 (COVID-19) in early 2020 was key to standardising disease reporting and supporting global public health efforts. However, the concordance between these clinical codes and laboratory-confirmed COVID-19 cases based on Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) results remains largely unexamined in Australia. OBJECTIVE:This study evaluated the concordance between ICD-10 Australian Modification (ICD-10-AM) code U07.1 (COVID-19, virus identified) and SARS-CoV-2 PCR test results in admitted patient records, to improve case identification. METHOD:This retrospective study analysed routinely collected electronic medical record data from 13 public hospitals in New South Wales, Australia. Clinical coding of ICD-10-AM U07.1 was assessed using SARS-CoV-2 PCR results as the reference standard. Sensitivity, specificity, positive predictive value and negative predictive value were calculated. A mixed-effects logistic regression model was used to assess diagnostic concordance, adjusting for patient demographics. RESULTS:Among 25,724 admissions with a SARS-CoV-2 PCR test, 39.4% were confirmed COVID-19 cases based on positive SARS-CoV-2 PCR test results. The ICD-10-AM clinical coding of U07.1 demonstrated excellent accuracy, with a sensitivity of 91.5% (95% CI: 90.8-92.2%) and 94.1% (95% CI: 93.6-94.6%) compared to conventional and rapid PCR-confirmed cases, respectively. CONCLUSION:The ICD-10-AM code U07.1 aligns well with SARS-CoV-2 PCR-confirmed cases, supporting its use as a reliable marker for COVID-19 in hospital data for surveillance and research purposes.Implications for health information management practice:Ongoing improvements in clinical coding practices are necessary to minimise misclassification and enhance accuracy for public health planning.

Extra-genital gonococcal infection is a rare complication of sexually transmitted Neisseria gonorrhoeae infection. We report a case of gonococcal infection presenting post insertion of a Kirschner wire (K-wire) several decades after previous treatment for pelvic gonococcal infection. The diagnosis was made after removal of the hardware, with good outcome. Few cases of gonococcal osteomyelitis or prosthetic material infection are reported in the literature. The duration of antimicrobial treatment is not defined.

Background: Some individuals have a persistence of symptoms following both COVID-19 (post-acute COVID-19 syndrome; PACS) and other viral infections. This study used prospectively collected data from an international trial to compare symptoms following COVID-19 and non-COVID-19 respiratory illness, to identify factors associated with the risk of PACS, and to explore symptom patterns before and after COVID19 and non-COVID-19 respiratory illnesses. Methods: Data from a multicentre randomised controlled trial (BRACE trial) involving healthcare workers across four countries were analysed. Symptom data were prospectively collected over 12 months, allowing detailed characterisation of symptom patterns. Participants with COVID-19 and non-COVID-19 respiratory illness episodes were compared, focussing on symptom severity, duration (including PACS using NICE and WHO definitions), and pre-existing symptoms. Findings: Compared to those with a non-COVID-19 illness, participants with COVID-19 had significantly more severe illness (OR 7.4, 95%CI 5.6-9.7). Symptom duration meeting PACS definitions occurred in a higher proportion of COVID-19 cases than non-COVID-19 respiratory controls using both the NICE definition (2.5% vs 0.5%, OR 6.6, 95%CI 2.4-18.3) and the WHO definition (8.8% vs 3.7%, OR 2.5, 95%CI 1.4-4.3). When considering only participants with COVID-19, age 40-59 years (aOR 2.8, 95%CI 1.3-6.2), chronic respiratory disease (aOR 5.5, 95%CI 1.3-23.1), and pre-existing symptoms (aOR 3.0, 95%CI 1.4-6.3) were associated with an increased risk of developing PACS. Symptoms associated with PACS were also reported by participants in the months preceding their COVID-19 or non-COVID-19 respiratory illnesses (32% fatigue and muscle ache, 11% intermittent cough and shortness of breath). Interpretation: Healthcare workers with COVID-19 were more likely to have severe and longer-lasting symptoms than those with a non-COVID-19 respiratory illness, with a higher proportion meeting the WHO or NICE definitions of PACS. Age, chronic respiratory disease, and pre-existing symptoms increased the risk of developing PACS following COVID-19. (c) 2024 The Author(s). Published by Elsevier Ltd on behalf of The British Infection Association. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Background:Bacille Calmette-Guérin (BCG) vaccination has off-target (non-specific) effects that are associated with protection against unrelated infections and decreased all-cause mortality in infants. We aimed to determine whether BCG vaccination prevents febrile and respiratory infections in adults. Methods:This randomised controlled phase 3 trial was done in 36 healthcare centres in Australia, Brazil, the Netherlands, Spain, and the United Kingdom. Healthcare workers were randomised to receive BCG-Denmark (single 0.1 ml intradermal injection) or no BCG in a 1:1 ratio using a web-based procedure, stratified by stage, site, age, and presence of co-morbidity. The difference in occurrence of febrile or respiratory illness were measured over 12 months (prespecified secondary outcome) using the intention-to-treat (ITT) population. This trial is registered with ClinicalTrials.gov, NCT04327206. Findings:Between March 30, 2020, and April 1, 2021, 6828 healthcare workers were randomised to BCG-Denmark (n = 3417) or control (n = 3411; no intervention or placebo) groups. The 12-month adjusted estimated risk of ≥1 episode of febrile or respiratory illness was 66.8% in the BCG group (95% CI 65.3%-68.2%), compared with 63.4% in the control group (95% CI 61.8%-65.0%), a difference of +3.4 percentage points (95% CI +1.3% to +5.5%; p 0.002). The adjusted estimated risk of a severe episode (defined as being incapacitated for ≥3 consecutive days or hospitalised) was 19.4% in the BCG group (95% CI 18.0%-20.7%), compared with 18.8% in the control group (95% CI 17.4%-20.2%) a difference of +0.6 percentage points (95% CI -1.3% to +2.5%; p 0.6). Both groups had a similar number of episodes of illness, pneumonia, and hospitalisation. There were three deaths, all in the control group. There were no safety concerns following BCG vaccination. Interpretation:In contrast to the beneficial off-target effects reported following neonatal BCG in infants, a small increased risk of symptomatic febrile or respiratory illness was observed in the 12 months following BCG vaccination in adults. There was no evidence of a difference in the risk of severe disease. Funding:Bill & Melinda Gates Foundation, Minderoo Foundation, Sarah and Lachlan Murdoch, the Royal Children's Hospital Foundation, Health Services Union NSW, the Peter Sowerby Foundation, SA Health, the Insurance Advisernet Foundation, the NAB Foundation, the Calvert-Jones Foundation, the Modara Pines Charitable Foundation, the UHG Foundation Pty Ltd, Epworth Healthcare, the National Health and Medical Research Council, the Swiss National Science Foundation and individual donors.

BACKGROUND:The optimal selection process for basic physician trainees (BPTs) is unclear. AIMS:To assess an adult BPT selection process, including a standardised recruitment interview assessing clinical decision-making and situational judgement. METHODS:A retrospective multi-year cohort study of applicants who were selected for interview during the annual recruitment for 2011-2015 clinical years in an adult basic physician training network in NSW. The predictive capacity of the final recruitment assessment score was compared with success in the Royal Australasian College of Physicians (RACP) adult medicine clinical examination within 2 years. RESULTS:Four hundred thirty-six applicants were selected for interview (84-91 in each year). Summary mean post-interview scores ranged from 1.25 to 10, with the median ranging between 7 and 8. Median scores were higher in those who passed the examination than those who did not (7.75 vs 6.43, P < 0.0001). Those who did not sit for the examination in the relevant year or never sat for the examination had similar median scores (7 vs 6.75, P = 0.11). Those not deemed eligible for recruitment were less likely to pass the clinical examination within 2 years than those on the eligibility list (odds ratio (OR) = 0.38, 95% confidence interval (CI) = 0.25-0.57). Applicants with mean scores lower than 8 were less likely to pass than those in the top band (8.1-10); scores between 6.1 and 8 OR 0.42 (95% CI = 0.26-0.68), 4.1-6 OR 0.23 (95% CI = 0.13-0.41) and 2.1-4 OR 0.24 (95% CI = 0.10-0.60). CONCLUSION(S):The predictive capacity of the selection process for success in the RACP clinical examination within the minimum time period is high.

Objectives: To examine how regulatory structures and processes focused on antimicrobial stewardship and antimicrobial resistance are experienced by hospital managers and clinicians. Methods: Forty-two hospital managers and clinicians working within accreditation and antimicrobial stewardship teams in three Australian hospitals participated in individual in-depth interviews. Thematic analysis was performed. Results: Thematic analysis revealed participants' experiences of hospital antimicrobial regulation and their perceptions of what would be required for meaningful antimicrobial optimisation. Theme 1: Experience of regulation of antimicrobials within hospitals: Participants described an increased profile of antimicrobial resistance with inclusion in regulatory requirements, but also the risks of bureaucratic manoeuvring to meet standards rather than governance-inducing systemic changes. Theme 2: Growth of accreditation processes and hospitals over time: Both regulatory requirements and hospitals were described as evolving over time, each manoeuvring in response to each other (e.g. development of short notice accreditation). Theme 3: Perceived requirements for change: Participants perceived a need for top-down buy-in, resource prioritisation, complex understanding of power and influence on clinician behaviour, and a critical need for medical engagement. Conclusions: This study around antimicrobials shows the tension and dynamic relationship between regulatory processes and hospital responses, bringing to light the enduring balance of a system that positions itself to meet regulatory requirements and emerging "demands", without necessarily addressing the key underlying concerns. Antimicrobial resistance-related solutions are perceived as likely to require further resourcing and buy-in across multiple levels, engagement across professional streams and require strategies that consider complex systems change in order for regulatory structures to have potency. (c) 2023 The Author(s). Published by Elsevier B.V. on behalf of Australasian College for Infection Prevention and Control. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

Objectives: Bacille Calmette-Gu & eacute;rin (BCG) vaccine has immunomodulatory effects that may provide protection against unrelated infectious diseases. We aimed to determine whether BCG vaccination protects adults against COVID-19. Design: Phase III double-blind randomised controlled trial. Setting: Healthcare centres in Australia, Brazil, the Netherlands, Spain, and the United Kingdom during the COVID-19 pandemic. Participants: 3988 healthcare workers with no prior COVID-19 and no contraindication to BCG. Intervention: Randomised 1:1 using a web-based procedure to receive a single 0.1 mL intradermal dose of BCG-Denmark (BCG group, n = 1999) or saline (placebo group, n = 1989). Main outcome measures: Difference in incidence of (i) symptomatic and (ii) severe COVID-19 during the 12 months following randomisation in the modified intention to treat (mITT) population (confirmed SARSCoV-2 na & iuml;ve at inclusion). Results: Of the 3988 participants randomised, 3386 had a negative baseline SARS-CoV-2 test and were included in the mITT population. The 12-month adjusted estimated risk of symptomatic COVID-19 was higher in the BCG group (22.6%; 95% confidence interval [CI] 20.6 to 24.5%) compared with the placebo group (19.6%; 95% CI 17.6 to 21.5%); adjusted difference +3.0% points (95% CI 0.2 to 5.8%; p = 0.04). The 12- month adjusted estimated risk of severe COVID-19 (mainly comprising those reporting being unable to work for >= 3 consecutive days) was 11.0% in the BCG group (95% CI 9.5 to 12.4%) compared with 9.6% in the placebo group (95% CI 8.3 to 11.1%); adjusted difference +1.3% points (95% CI -0.7 to 3.3%, p = 0.2). Breakthrough COVID-19 (post COVID-19 vaccination) and asymptomatic SARS-CoV-2 infections were similar in the two groups. There were 18 hospitalisations due to COVID-19 (11 in BCG group, 7 in placebo group; adjusted hazard ratio 1.56, 95% CI 0.60 to 4.02, p = 0.4) and two deaths due to COVID-19, both in the placebo group. Conclusions: Compared to placebo, vaccination with BCG-Denmark increased the risk of symptomatic COVID-19 over 12 months among healthcare workers and did not decrease the risk of severe COVID-19 or post-vaccination breakthrough COVID-19. (c) 2024 The Authors. Published by Elsevier Ltd on behalf of The British Infection Association. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Background Approximately 10% of people with HIV in Australia had active hepatitis C virus (HCV) infection prior to availability of government-subsidized direct-acting antiviral (DAA) therapy in 2016. This analysis evaluated progress toward HCV elimination among people with HIV in Australia between 2014 and 2023.Methods The CEASE cohort study enrolled adults with HIV with past or current HCV infection (anti-HCV antibody positive) from 14 primary and tertiary clinics. Biobehavioral, clinical, and virologic data were collected at enrollment (2014-2016), follow-up 1 (2017-2018), and follow-up 2 (2021-2023). HCV treatment uptake, outcome, and HCV RNA prevalence (current infection) were evaluated. Death and HCV reinfection incidence and risk were assessed.Results Of 402 participants, 341 (85%) had current HCV infection (RNA positive) at enrollment. Among the sample, 83% were gay and bisexual men, 13% had cirrhosis, and 80% had a history of injecting drug use (42%, past 6 months). DAA treatment was scaled up rapidly, with cumulative treatment uptake increasing from 12% in 2014 to 2015 to 92% in 2022 to 2023. HCV RNA prevalence declined from 85% (95% CI, 81%-88%) at enrollment (2014-2016) to 8% (95% CI, 6%-12%) at follow-up 1 (2017-2018) and 0.5% (95% CI, 0%-3%) at follow-up 2 (2020-2023). Sixteen reinfections occurred (incidence, 1.41 per 100 person-years; 95% CI, .81-2.29) as well as 30 deaths (incidence, 1.64 per 100 person-years; 95% CI, 1.11-2.34). HCV reinfection incidence declined over time while mortality remained stable.Conclusions Universal access and rapid DAA uptake were associated with a dramatic reduction in HCV prevalence and reinfection incidence among people with HIV to levels consistent with microelimination. Registration: NCT02102451 (ClinicalTrials.gov).Conclusions Universal access and rapid DAA uptake were associated with a dramatic reduction in HCV prevalence and reinfection incidence among people with HIV to levels consistent with microelimination. Registration: NCT02102451 (ClinicalTrials.gov). Universal treatment access and rapid direct-acting antiviral uptake were associated with a dramatic reduction in hepatitis C virus prevalence and reinfection incidence among people with HIV in Australia to levels consistent with microelimination.

Background: Prosthetic joint infections (PJIs) cause substantial morbidity to patients and are extremely challenging for clinicians. Their management can include multiple operations, antibiotics, and prolonged hospital admissions. Multidisciplinary team meetings (MDTM) are increasingly used for collaborative decision-making around the management of PJIs, but thus far there has been no examination of the role of MDTM in decisions and management. This study aimed to examine interactions in a PJI MDTM to identify the dynamics in decision-making, and inter-specialty relationships more broadly. Methods: Twelve MDTMs over 7 months at an Australian tertiary referral hospital were video recorded, transcribed, and thematic analysis was performed. Results: Thematic analysis revealed four key areas of collaborative discussion 1. Achieving Inter-specialty Balance: The role of the multidisciplinary team discussion in providing balance between specialty views, and traversing the barriers between specialty interactions. 2. Negotiating Grey zones: there was frequent discussion of the limits of tests, interpretation of symptoms, and the limits of proposed operative strategies, and the resultant tensions of balancing ideal care vs pragmatic decision-making, and divergent goals of care. 3. Tailoring Treatment: identification of individual patient factors (both physiological and behavioural) and risks into collaborative decision-making. 4. Affording Failure: creating affordances in communication to openly discuss 'failure' to eliminate infection and likely negative outcomes. Conclusions: MDTM in the management of prosthetic joint infections serve multiple functions including: achieving interdisciplinary balance; effective grey zone management, tailoring reconfigured care; and most critically, recognition of 'failure' to eliminate infection, a communicative affordance most likely leading to better care. (c) 2023 Australasian College for Infection Prevention and Control. Published by Elsevier B.V. All rights reserved.

Introduction Coronavirus disease 2019 is an acute respiratory illness caused by severe acute respiratory syndrome coronavirus 2. The coronavirus disease 2019 pandemic upended the traditional paradigm of face-to-face provision of healthcare in the Australian context; as such, a telehealth model of active case management was implemented in our public health system, even though there was little supporting data for the safety of delivering patient care remotely to home-isolation patients in the setting of a highly infectious and potentially fatal illness. Methods A retrospective, single-centre, observational cohort study was performed over 6 weeks commencing 12 March 2020, including patients with coronavirus disease 2019 undergoing home isolation and being actively monitored by a coronavirus disease 2019 telephone assessment clinic. Outcomes assessed comprised: duration of active case follow-up, average number of telephone calls per patient, average number of hours managing each patient, treatment required including presentation to the emergency department or admission to hospital, patient characteristics and utilisation of other health services. Results Of 5223 severe acute respiratory syndrome coronavirus 2 tests performed, 170 individuals (3.25%) tested positive. A total of 158 were included: 76 (47.5%) male and median age 31 years (range 18-94). Median symptom duration was 13 days (interquartile range 6, range 2-34). Median length of coronavirus disease 2019 telephone assessment clinic admission was 10 days (interquartile range 7, range 3-32). A total of 1151 telephone patient encounters were undertaken, with a median of six phone calls made to each patient (interquartile range 5, range 1-20). Ten patients required repeat clinic review; all but one returned home. Six presented to emergency department, with three of these being admitted. In total, there were six admissions: one from the clinic, three from the emergency department and two direct from home (bypassing emergency department). Only four of the six admissions (or 2.5% of all patients) required low-flow oxygen therapy; none required high-flow oxygen or assisted ventilation. The remaining 140 patients (88.6%) were safely managed at home without complications. Discussion A telehealth model of care is safe, efficient and cost-effective for the management of mild-to-moderate coronavirus disease-19 and facilitates home isolation, especially of a low-risk population, thus providing reassurance that this model is sound and suitable for ongoing use.

The long-term health consequences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are still being understood. The molecular and phenotypic properties of SARS-CoV-2 antigen–specific T cells suggest a dysfunctional profile that persists in convalescence in those who were severely ill. By contrast, the antigen-specific memory B-cell (MBC) population has not yet been analyzed to the same degree, but phenotypic analysis suggests differences following recovery from mild or severe coronavirus disease 2019 (COVID-19). Here, we performed single-cell molecular analysis of the SARS-CoV-2 receptor-binding domain (RBD)–specific MBC population in three patients after severe COVID-19 and four patients after mild/moderate COVID-19. We analyzed the transcriptomic and B-cell receptor repertoire profiles at ~2 months and ~4 months after symptom onset. Transcriptomic analysis revealed a higher level of tumor necrosis factor-alpha (TNF-α) signaling via nuclear factor-kappa B in the severe group, involving CD80 , FOS , CD83 and TNFAIP3 genes that was maintained over time. We demonstrated the presence of two distinct activated MBCs subsets based on expression of CD80 hi TNFAIP3 hi and CD11c hi CD95 hi at the transcriptome level. Both groups revealed an increase in somatic hypermutation over time, indicating progressive evolution of humoral memory. This study revealed distinct molecular signatures of long-term RBD-specific MBCs in convalescence, indicating that the longevity of these cells may differ depending on acute COVID-19 severity.

Objectives. SARS-CoV-2 infection causes a spectrum of clinical disease presentation, ranging from asymptomatic to fatal. While neutralising antibody (NAb) responses correlate with protection against symptomatic and severe infection, the contribution of the T-cell response to disease resolution or progression is still unclear. As newly emerging variants of concern have the capacity to partially escape NAb responses, defining the contribution of individual T-cell subsets to disease outcome is imperative to inform the development of next-generation COVID-19 vaccines. Methods. Immunophenotyping of T-cell responses in unvaccinated individuals was performed, representing the full spectrum of COVID-19 clinical presentation. Computational and manual analyses were used to identify T-cell populations associated with distinct disease states. Results. Critical SARS-CoV-2 infection was characterised by an increase in activated and cytotoxic CD4(+) lymphocytes (CTL). These CD4(+) CTLs were largely absent in asymptomatic to severe disease states. In contrast, non-critical COVID-19 was associated with high frequencies of naive T cells and lack of activation marker expression. Conclusion. Highly activated and cytotoxic CD4(+) T-cell responses may contribute to cell-mediated host tissue damage and progression of COVID-19. Induction of these potentially detrimental T-cell responses should be considered when developing and implementing effective COVID-19 control strategies.

The aim of this study was to evaluate the role of viral polymerase chain reaction (PCR) testing in patients with aseptic meningitis and identify opportunities for improvement in clinical management. All cerebrospinal fluid samples collected in 1 year from four teaching hospitals in Sydney, Australia, were reviewed. Patients with aseptic meningitis were selected, and clinical and diagnostic features, hospital length of stay (LOS), and treatment were analyzed. Identifying a cause by viral PCR did not reduce hospital LOS (median 3 days) or antibiotic use (median 2 days), but the turnaround time of the PCR test correlated with LOS (Rs = 0.3822, p = 0.0003). Forty-one percent of patients received intravenous acyclovir treatment, which was more frequent in patients admitted under neurologists than infectious diseases physicians (56% vs. 24%; p = 0.013). The majority of patients did not have investigations for alternative causes of aseptic meningitis such as human immunodeficiency virus and syphilis if the viral PCR panel was negative. The benefit of PCR testing in aseptic meningitis in adults in reducing LOS and antibiotic use is unclear. The reasons for unnecessary aciclovir use in meningitis syndromes require further assessment.

Internal Medicine JournalVolume 53, Issue 1 p. 150-151 Letter to the Editor Case of Mycobacterium chimaera vertebral osteomyelitis diagnosed 7 years after cardiac surgery Correction(s) for this article Corrigendum Volume 53Issue 5Internal Medicine Journal pages: 882-882 First Published online: May 20, 2023 Alyssa Pradhan, Alyssa Pradhan orcid.org/0000-0001-9499-0292 Department of Infectious Diseases, Prince of Wales Hospital, Sydney, New South Wales, Australia Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorElena Martinez, Elena Martinez Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia New South Wales Health Pathology, Sydney, New South Wales, AustraliaSearch for more papers by this authorVitali Sintchenko, Vitali Sintchenko Sydney Institute for Infectious Diseases, University of Sydney, Sydney, New South Wales, Australia Centre for Infectious Diseases and Microbiology-Public Health, Westmead Hospital, Sydney, New South Wales, Australia Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Sydney, New South Wales, AustraliaSearch for more papers by this authorJeffrey Post, Jeffrey Post Department of Infectious Diseases, Prince of Wales Hospital, Sydney, New South Wales, Australia School of Clinical Medicine, UNSW Medicine & Heath, Sydney, New South Wales, AustraliaSearch for more papers by this authorKristen Overton, Kristen Overton orcid.org/0000-0001-6726-5722 Department of Infectious Diseases, Prince of Wales Hospital, Sydney, New South Wales, Australia School of Clinical Medicine, UNSW Medicine & Heath, Sydney, New South Wales, AustraliaSearch for more papers by this author Alyssa Pradhan, Alyssa Pradhan orcid.org/0000-0001-9499-0292 Department of Infectious Diseases, Prince of Wales Hospital, Sydney, New South Wales, Australia Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, AustraliaSearch for more papers by this authorElena Martinez, Elena Martinez Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia New South Wales Health Pathology, Sydney, New South Wales, AustraliaSearch for more papers by this authorVitali Sintchenko, Vitali Sintchenko Sydney Institute for Infectious Diseases, University of Sydney, Sydney, New South Wales, Australia Centre for Infectious Diseases and Microbiology-Public Health, Westmead Hospital, Sydney, New South Wales, Australia Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Sydney, New South Wales, AustraliaSearch for more papers by this authorJeffrey Post, Jeffrey Post Department of Infectious Diseases, Prince of Wales Hospital, Sydney, New South Wales, Australia School of Clinical Medicine, UNSW Medicine & Heath, Sydney, New South Wales, AustraliaSearch for more papers by this authorKristen Overton, Kristen Overton orcid.org/0000-0001-6726-5722 Department of Infectious Diseases, Prince of Wales Hospital, Sydney, New South Wales, Australia School of Clinical Medicine, UNSW Medicine & Heath, Sydney, New South Wales, AustraliaSearch for more papers by this author First published: 24 January 2023 https://doi.org/10.1111/imj.15982Read 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 No abstract is available for this article. References 1Overton K, Mennon V, Mothobi N, Nield B, Martinez E, Masters J et al. A cluster of invasive Mycobacteria chimaera infections following cardiac surgery – epidemiology, clinical features, infection control and sequence analysis. Intern Med J 2018; 48: 1514– 20. 2Stokes G, Overton K, Post J. Update on cluster of invasive Mycobacterium chimaera infections following cardiac surgery. Intern Med J 2020; 50: 889– 90. 3Vendramin I, Peghim M, Tascini C, Livi U. Longest incubation period of Mycobacterium chimaera infection after cardiac surgery. Eur J Cardiothorac Surg 2021; 59: 506– 8. 4Rudikoff AG, Ganocy TK, Kansagra K, Torres FA, Humphries BD, Conte AH. Thoracolumbar osteomyelitis secondary to systemic Mycobacterium chimaera infection status post aortic valve replacement. J Cardiothorac Vasc Anesth 2019; 33: 1704– 9. 5Chand A, Lamagni T, Kranzer K, Hedge J, Moore G, Parks S et al. Insidious risk of severe Mycobacterium chimaera infection in cardiac surgery patients. Clin Infect Dis 2017; 64: 335– 42. 6Scriven JE, Scobie A, Verlander NQ, Houston A, Collyns T, Cajic V et al. Mycobacterium chimaera infection following cardiac surgery in the United Kingdom: clinical features and outcome of the first 30 cases. Clin Microbiol Infect 2018; 24: 1164– 70. 7Sax H, Bloemberg G, Hasse B, Sommerstein R, Kohler P, Achermann Y et al. Prolonged outbreak of Mycobacterium chimaera infection after open-chest heart surgery. Clin Infect Dis 2015; 61: 67– 75. 8Haller S, Holler C, Jacobshagen A, Hamouda O, Sin MA, Monnet DL et al. Contamination during production of heater-cooler units by Mycobacterium chimaera potential cause for invasive cardiovascular infections: results of an outbreak investigation in Germany, April 2015 to February 2016. Euro Surveill 2016; 21: 17. 9Lecorche E, Pean de Ponfilly G, Mougari F, Benmansour H, Poisnel E, Janvier F et al. Disseminated Mycobacterium chimaera following open-heart surgery, the heater–cooler unit worldwide outbreak: case report and minireview. Front Med 2020; 7: 243. Volume53, Issue1January 2023Pages 150-151 ReferencesRelatedInformation

The long-term health consequences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are still being understood. The molecular and phenotypic properties of SARS-CoV-2 antigen-specific T cells suggest a dysfunctional profile that persists in convalescence in those who were severely ill. By contrast, the antigen-specific memory B-cell (MBC) population has not yet been analyzed to the same degree, but phenotypic analysis suggests differences following recovery from mild or severe coronavirus disease 2019 (COVID-19). Here, we performed single-cell molecular analysis of the SARS-CoV-2 receptor-binding domain (RBD)-specific MBC population in three patients after severe COVID-19 and four patients after mild/moderate COVID-19. We analyzed the transcriptomic and B-cell receptor repertoire profiles at similar to 2 months and similar to 4 months after symptom onset. Transcriptomic analysis revealed a higher level of tumor necrosis factor-alpha (TNF-alpha) signaling via nuclear factor-kappa B in the severe group, involving CD80, FOS, CD83 and TNFAIP3 genes that was maintained over time. We demonstrated the presence of two distinct activated MBCs subsets based on expression of CD80(hi) TNFAIP3(hi) and CD11c(h)(i) CD95(hi) at the transcriptome level. Both groups revealed an increase in somatic hypermutation over time, indicating progressive evolution of humoral memory. This study revealed distinct molecular signatures of long-term RBD-specific MBCs in convalescence, indicating that the longevity of these cells may differ depending on acute COVID-19 severity.