Feasey, NA; Hadfield, J; Keddy, KH; Dallman, TJ; Jacobs, J; Deng, X; Wigley, P; Barquist Barquist, L; Langridge, GC; Feltwell, T; +37 more... Harris, SR; Mather, AE; Fookes, M; Aslett, M; Msefula, C; Kariuki, S; Maclennan, CA; Onsare, RS; Weill, FX; Le Hello, S; Smith, AM; McClelland, M; Desai, P; Parry, CM; Cheesbrough, J; French, N; Campos, J; Chabalgoity, JA; Betancor, L; Hopkins, KL; Nair, S; Humphrey, TJ; Lunguya, O; Cogan, TA; Tapia, MD; Sow, SO; Tennant, SM; Bornstein, K; Levine, MM; Lacharme-Lora, L; Everett, DB; Kingsley, RA; Parkhill, J; Heyderman, RS; Dougan, G; Gordon, MA; Thomson, NR; (2016) Distinct Salmonella Enteritidis lineages associated with enterocolitis in high-income settings and invasive disease in low-income settings. Nature genetics. ISSN 1061-4036 DOI: https://doi.org/10.1038/ng.3644

SUMMARYMany cases of giardiasis in the UK are undiagnosed and among other things, diagnosis is dependent upon the readiness of GPs to request a specimen. The aim of this study is to assess the rate of specimens requested per GP practice in Central Lancashire, to examine the differences between GP practices and to estimate the pattern of unexplained spatial variation in the practice rate of specimens after adjustment for deprivation. To achieve this, we fitted a set of binomial and Poisson regression models, with random effects for GP practice. Our analysis suggests that there were differences in the rate of specimens by GP practices (P < 0·001) for a single year, but no difference in the proportion of positive tests per specimen submitted or in the rate of positive specimens per practice population. There was a difference in the cumulative rate of positive specimens per practice population over a 9-year period (P < 0·001). Neither the specimen rate per practice for a single year nor the cumulative rate of positive specimens over multiple years demonstrated significant spatial correlation. Hence, spatial variation in the incidence of giardiasis is unlikely to be confounded by variation in GP rate of specimens.

SUMMARYA community outbreak of legionellosis occurred in Barrow-in-Furness, Cumbria, during July and August 2002. A descriptive study and active case-finding were instigated and all known wet cooling systems and other potential sources were investigated. Genotypic and phenotypic analysis, and amplified fragment length polymorphism of clinical human and environmental isolates confirmed the air-conditioning unit of a council-owned arts and leisure centre to be the source of infection. Subsequent sequence-based typing confirmed this link. One hundred and seventy-nine cases, including seven deaths [case fatality rate (CFR) 3·9%] were attributed to the outbreak. Timely recognition and management of the incident very likely led to the low CFR compared to other outbreaks. The outbreak highlights the responsibility associated with managing an aerosol-producing system, with the potential to expose and infect a large proportion of the local population and the consequent legal ramifications and human cost.

The standard approach for norovirus control in hospitals in the UK, as outlined by the Health Protection Agency guidance and implemented previously by Lancashire Teaching Hospitals, involves the early closure of affected wards. However, this has a major impact on bed-days lost and cancelled admissions. In 2008, a new strategy was introduced in the study hospital, key elements of which included closure of affected ward bays (rather than wards), installation of bay doors, enhanced cleaning, a rapid in-house molecular test and an enlarged infection control team. The impact of these changes was assessed by comparing two norovirus seasons (2007–08 and 2009–10) before and after implementation of the new strategy, expressing the contrast between seasons as a ratio (r) of expected counts in the two seasons. There was a significant decrease in the ratio of confirmed hospital outbreaks to community outbreaks (r=0.317, P=0.025), the number of days of restricted admissions on hospital wards per outbreak (r=0.742, P=0.041), and the number of hospital bed-days lost per outbreak (r=0.344, P<0.001). However, there was no significant change in the number of patients affected per hospital outbreak (r=1.080, P=0.517), or the number of hospital staff affected per outbreak (r=0.651, P=0.105). Closure of entire wards during norovirus outbreaks is not always necessary. The changes implemented at the study hospital resulted in a significant reduction in the number of bed-days lost per outbreak, and this, together with a reduction in outbreak frequency, resulted in considerable cost savings.

Blood culture is a vital investigation and can be the first step in obtaining a definitive diagnosis in a patient with presumed sepsis, but can also have serious adverse consequences for the patient. The aim of this study was to evaluate the extent of the blood culture contamination problem at the Lancashire Teaching Hospitals (LTH) and to assess the impact of the introduction of a new blood culture collection kit on the contamination rate. Blood culture contamination rate at the LTH before the introduction of the blood culture collection kit was 9.2%. A fall in contamination rate was observed after kit introduction, to 3.8%, a proportion approaching the American Society of Microbiologists’ recommended standard of ≤3%. The reduction in contamination was associated with an unintended, yet sustained, reduction in the total number of blood culture sets collected and an unwanted reduction in the number of genuine Gram-negative bacteraemias. This reduction may reflect education and training issues at the time of the introduction. In the era of ‘route cause analyses’, it may also reflect fears by junior colleagues of the consequences of being found responsible for a blood culture contaminant. The study recommended continuing with the blood culture kit, but ensuring regular training and education sessions, carried out in a non-blame manner.

SUMMARYA total of 969 isolates of Campylobacter jejuni originating in the Preston, Lancashire postcode district over a 3-year period were characterized using multi-locus sequence typing. Recently developed statistical methods and a genetic model were used to investigate temporal, spatial, spatio-temporal and genetic variation in human C. jejuni infections. The analysis of the data showed statistically significant seasonal variation, spatial clustering, small-scale spatio-temporal clustering and spatio-temporal interaction in the overall pattern of incidence, and spatial segregation in cases classified according to their most likely species-of-origin.

The natural history of untreated gonorrhoea is spontaneous resolution after weeks or months, during which, dissemination can occur in 1–3% of patients (Barr and Danielsson 1971). Disseminated gonoc...

Objective: To gain insight into the beliefs and attitudes of Junior Doctors towards hand hygiene in the hospital environment, as well as their reported use of hand decontamination in practice.

While the prudent use of antimicrobials is accepted as a key issue in reducing healthcare associated infections and the emergence of multi-resistant microorganisms, the optimal way of achieving this remains uncertain. At Lancashire Teaching Hospitals (LTH) a joint ward round with a Medical Microbiologist and Antibiotic Pharmacist attending was initiated in 2004.

A study to assess the level of bacterial contamination of blood pressure cuffs in use on hospital wards was performed. Viable organisms were recovered from all the 24 cuffs sampled at a density of between 1000 and >25 000 colony-forming units/100 cm2. Potential pathogens were isolated from 14 cuffs (58%). Eleven cuffs grew a single pathogen and three cuffs grew a mixture, yielding a total of 18 isolates. Meticillin-susceptible Staphylococcus aureus was isolated from eight (33%) cuffs, meticillin-resistant S. aureus was isolated from two (8%) cuffs and Clostridium difficile was isolated from eight (33%) cuffs. This study serves as a reminder that hands are not the only fomite to go from patient to patient on hospital wards, and that measures should be taken to reduce the risks posed by blood pressure cuffs.

SUMMARYSpecimens of human faeces were tested by a rapid strategy for detection ofCampylobacter jejunilineages by the presence of specific single nucleotide polymorphisms (SNPs) based on theC. jejunimulti locus sequence typing (MLST) scheme. This strategy was derived from analysis of the MLST databases to identify clonal complex specific SNPs followed by the design of real-time PCR assays to enable identification of six majorC. jejuniclonal complexes associated with cases of human infection. The objective was to use the MLST SNP-based assays for the direct detection ofC. jejuniby clonal complex from specimens of human faeces, and then confirm the accuracy of the clonal complex designation from the SNP-based assays by performing MLST on the cultured faecal material, this targeted at determining the validity of direct molecular specimen identification. Results showed it was possible to identify 38% of the isolates to one of the six major MLST clonal complexes using a rapid DNA extraction method directly from faeces in under 3 h. This method provides a novel strategy for the use of real-time PCR for detection and characterization beyond species level, supplying real-time epidemiological data, which is comparable with MLST results.

We present a case of post-operative wound infection with Clostridium novyi in a non-intravenous drug user. Clinical features included progressive cellulitis despite being on antibiotics, accompanied by hypotension, marked leucocytosis and oedema but minimal fever. While established infection with this organism is associated with high mortality, our patient survived. The administration of clindamycin and intravenous immunoglobulin in addition to early surgical assessment and aggressive debridement of affected tissue may have contributed to this successful outcome. To our knowledge, this is the only reported post-operative wound infection due to this pathogen.

An outbreak of infection with Escherichia coli O157 Phage Type 21/28 occurred between the 23rd November 2001 and the 7th December 2001 in Eccleston, Lancashire. There were 30 confirmed cases (23 with positive faecal isolates and seven serologically positive). Eccleston is a village of approximately 5,000 inhabitants with a single medical practice where many of the cases were patients. Initial investigations identified the suspected source as a butcher's counter, operated as a franchise, in a supermarket in Eccleston. The butcher closed voluntarily on the 24th November. The median age of cases was 60 with a mean of 56 and a range of 2-91 years. Of the 30 confirmed cases, 22 were admitted to hospital. Two patients developed serious complications but all 30 made a full recovery. Microbiological investigations confirmed the butcher's counter as the source of the outbreak. The epidemiological evidence implicated cooked meats and microbiological evidence confirmed that contamination had occurred between raw and cooked meats. The deficiencies in meat hygiene practice that were identified could have led to the cross contamination. This outbreak illustrates the risk associated with the handling of raw and cooked meats in the same shop. Complete physical separation of raw and cooked meat operations reduces the risk of such outbreaks.

The impact of changes in antibiotic policy on Clostridium difficile-associated diarrhoea (CDAD), over a five-year period between 1995 and 2000, were studied in the Preston Acute Hospitals Trust. In 1996 the policy was changed in the Preston Acute Hospitals Trust from cefotaxime to ceftriaxone for initial treatment of severe sepsis or pneumonia in medical patients. Over the next nine months the average number of patients with C. difficile toxin-positive stools per quarter increased from 16 to 39. The predicted use of ceftriaxone exceeded by 65% an estimate based on prior use of cefotaxime. A policy of restricted duration of ceftriaxone was introduced, and although this reduced usage by over 50%, CDAD continued at an average of 9.2 cases per month, despite withdrawal of oral cephalosporins in December 1998. In August 1999 levofloxacin was substituted for ceftriaxone in the policy. The incidence of CDAD fell progressively to five cases per month by 2000. It would appear that a short (typically three dose) course of third-generation cephalosporin poses a similar risk for CDAD as a more prolonged course. The six-month delay in the decline of CDAD after virtual withdrawal of cephalosporins may reflect a slowly diminishing environmental reservoir.